Mixed Echogenicity Research Articles

A Rare Case of Oriental Cholangiohepatitis

Introduction: Oriental cholangiohepatitis is commonly seen in Asian with prevalence of < 1% in Western countries. It is thought to be secondary to parasitic infection of bile system with concomitant biliary infection that leads to production of beta-glucuronidase that play key roles in bilirubin precipitation, stone and stricture formation. Case: A 73 year-old caucasian female with history of diabetes mellitus presented with nausea, vomiting, epigastric abdominal pain, diarrhea for 1 week. Reported 70-lb weight loss over past year. CT scan was concerning for possible pancreatic mass, omental metastasis, numerous tumor nodules in mesentery and possible thrombus in portal vein. Labwork showed ALP 230, albumin 1.6, CA 19/9 45.2. US Liver showed moderate intrahepatic biliary dilation, dilated proximal common duct measuring 1.4cm. MRCP showed moderate intra and extrahepatic biliary ductal dilatation with multiple large filling defects within both intrahepatic and extrahepatic bile ducts, consistent with stones (Fig 1). EUS was done which showed normal visual exam, diffuse pancreas with mixed echogenicity. FNA of pancreatic head/body negative for malignancy. ERCP showed CBD of 1.8 cm with atleast 4 (˜1cm stones) with largest being ˜1.2cm (Fig 2). Biliary sphincterotomy was performed followed by mechanical lithotripsy, balloon extraction. A 10 Fr 9cm plastic biliary stent was placed in CBD proximal to retained stones. Repeat ERCP was done in OR with laser lithotripsy and residual stone removal in 2-3 weeks.Figure 1Figure 2Discussion: It is a serious condition owing to its intractability, frequent recurrence and predisposition of cholangiocarcinoma. Presenting symptoms include abdominal pain, jaundice, cholangitis and can lead to production of strictures and liver abscesses. US liver is first diagnostic modality as it can clearly show intrahepatic stones and biliary dilation. MRCP is the best non-invasive imaging that shows intrahepatic stones, biliary strictures and hepatic abscess. Direct cholangiography remains the gold standard with sensitivity of almost 100% in the detection of obstruction. The goals of treatment include treating cholangitis (fluids/antibiotics), preventing recurrence, clearance of stones, correction of strictures, restoration of biliary drainage and to stop the progression of the disease. There is no definitive treatment owing to the complicated nature of the disease. Urgent endoscopic biliary decompression prevents patient from going into shock. Hepatic resection has shown to reduce the risk of recurrence of stones, since it removes not only intrahepatic stones but also the associated pathological bile ducts damaged by strictures. Liver transplantation is usually the only treatment option in cases of diffuse liver parenchyma involvement and development of cirrhosis.Table 1: Grading the severity of hepatolithiasis

Diagnosis of urinary bladder diseases in dogs by using two-dimensional and three-dimensional ultrasonography.

Aim:The objective of this study was to obtain and compare two-dimensional (2D) and three-dimensional (3D) ultrasonographic images of the urinary bladder in different disease conditions.Materials and Methods:The present study was conducting on total 10clinical cases of the urinary bladder in dogs. The ultrasound (US) machine used for this study was 3D US machine (Nemio-XG: Toshiba, Japan) having a four-dimensional volumetric probe.Results:In the present study, the inflamed thickened wall was clearly visible with the distinction of different layers of the urinary bladder wall in some of the cases of cystitis using 2D ultrasonography. In 3D sonogram, the urinary bladder was visualized as a large anechoic structure with no distinction of different layers of the bladder wall. The cystoliths were clearly visible as hyperechoic structures with distal acoustic shadow in 2D sonogram and appeared as a bright echogenic area in 3D sonogram. In case of urinary bladder neoplasia in 2D ultrasonogram, the bladder lumen was found to be occluded with a large growth imaged as focal anechoic areas in the tissue of mixed echogenicity with small hyperechoic dots in this tissue parenchyma. In 3D ultrasonogram, a tissue of mixed echogenicity of pus was also observed.Conclusion:From the present study it was concluded that 2D and 3D ultrasonography is very helpful for diagnosis of different clinical conditions of the urinary bladder such as cystitis, cystoliths, and urinary bladder neoplasia. The cavity of urinary bladder was more clearly visualized in 3D ultrasonography, but the distinction of different layers of the bladder wall was visualized only in 2D ultrasonography. The distinct shadow of pus and cystoliths were visible in 2D ultrasonogram. The visualization of pus in 3D ultrasonography was done for the first time in present study.

Gastric teratoma in children: Our experience

Summary Background/Introduction Gastric teratoma is an extremely rare tumor, almost exclusively benign, accounting for Purpose/Aim This work aimed to study the clinical presentation, investigation modalities, intraoperative findings, histopathological types, and surgical outcome of gastric teratoma in children. Methods A retrospective study was performed from 1993 to 2013 in two pediatric institutes. Results There were eight patients with gastric teratoma and all of them were male. Seven (87.5%) patients presented in infancy, out of which four (50%) patients were neonates, while one (12.5%) patient was a toddler. The manifestations were as follows: a palpable abdominal mass in seven (87.5%), abdominal distension in five (67.5%), anemia in four (50%), respiratory distress in three (37.5%), gastric outlet obstruction with recurrent vomiting in three (37.5%), and abdominal pain, anorexia, and melena in one (12.5%) each. Ultrasonography showed a solid cystic mass with mixed echogenicity in all the patients, while calcification was seen in seven (87.5%) cases. Computed tomography, which was performed in four (50%) patients, clinched the preoperative diagnosis. A growth was present on the posteroinferior wall near the greater curvature in seven (87.5%) cases, while in one (12.5%) patient, it was arising from the lesser curvature. Excision of the tumor was performed in all patients. Histopathology was mature type in six (75%) cases, and immature Grade 1 and 2 in one (12.5%) each. Complications were seen in five (62.5%) cases, and one (12.5%) mortality was observed in our series. All other patients were doing well in the postoperative period. Conclusion Gastric teratoma is almost always benign and has predilection for male sex. It commonly presents as a palpable abdominal mass. Complete surgical excision is curative. Close observation is recommended for Grade 2 and 3 immature teratomas. The prognosis is excellent.

An incidental prostatic leiomyoma in a dog

A 12-year-old entire male cocker spaniel presented for re-evaluation of mitral valve disease. Abdominal palpation revealed a large mass caudally. Abdominal ultrasonography identified a large, heterogeneous, mixed echogenicity mass adjacent...

Primary Leiomyosarcoma of inferior vena cava: a Case of Rare Malignancy

Vascular leiomyosarcoma is a rare tumor, only about 200 cases have been reported worldwide. It commonly arises from inferior vena cava (IVC). There is a strong predilection for females and middle segment of IVC is most commonly affected. The diagnosis is often challenging as patients present with non-specific complaints such as dyspnoea, abdominal discomfort, or back pain. Computed tomography (CT) and Magnetic resonance imaging (MRI) individually or in combination with cavography, ultrasonography (US) and echocardiography, allow an early preoperative diagnosis. Here in, we present a rare case report of leiomyosarcoma of IVC in a 70 year old male patient who presented with vague abdominal discomfort. Ultrasound of abdomen detected a mass in retro peritoneum with mixed echogenicity. CT scan revealed a 10.5 x 6 x 6 cm lobulated, heterogeneously enhancing luminal mass with necrotic changes in supra-renal segment of IVC. Diagnosis of primary Vena caval tumor was made. En bloc resection of the tumor with 1 cm cuff of IVC with closure of the lower end of IVC was performed with excision of a cuff of the liver which was adherent to the IVC. Specimen grossly revealed a soft tissue mass adherent to vessel measuring 10 x 6.5 x 6 cm. External surface was smooth and bosselated. Cut section was nodular, grey white and firm in consistency. Microscopically diagnosis of Leiomyosarcoma was made. IHC study revealed positivity for Smooth muscle actin and desmin and Ki 67 positivity in 12-15 % of tumor cells and was consistent with diagnosis of Leiomyosarcoma. Key words: Desmin, Inferior vena cava, Leiomyosarcoma, Smooth muscle actin, Vascular tumor.

Angiosarcoma of the breast masquerading as hemangioma: exploring clinical and pathological diagnostic challenges.

Angiosarcoma of the breast masquerading as hemangioma: exploring clinical and pathological diagnostic challenges.

Inflammatory Pseudotumour of Mesentery - A Case Report

Not available.DOI: http://dx.doi.org/10.3329/jpsb.v1i2.19538

The role of VTIQ as a new tissue strain analytics measurement technique in testicular lesions.

Virtual touch tissue imaging quantification (VTIQ) is a newly developed technique for the sonographic quantification of tissue elasticity. It has been used in the assessment of breast lesions. The purpose of this study was to determine the diagnostic performance of VTIQ in indeterminate testicular lesions. Twenty patients with known testicular pathology underwent conventional B-mode sonography with additional VTIQ of the testicular lesions using a Siemens Acuson S2000™ and S3000™ (Siemens Medical Solutions, Mountain View, CA, USA) system. Tissue mechanical properties were analysed in the VTIQ examination. The pathologic diagnosis was established after surgery or in the follow-up examination for suspected benign lesions. Over 36 months, 22 focal testicular lesions (median lesion size, 18 mm; range, 4-36 mm in 20 patients (median age, 43 years; range, 22-81 years) were examined. Lesions were hyperechoic (n = 1), hypoechoic (n = 14), isoechoic (n = 1), of mixed echogenicity (n = 3) or anechoic (n = 3). Histological examination showed one benign lesion (6.25%) with a mean size of 7 mm and 15 malignant lesions (93.75%) with a mean size of 20 mm. Mean shear wave velocity for normal testicular tissue was 1.17 m/s. No shear wave velocity could be measured in cystic lesions. The rest of the benign lesions showed a mean shear wave velocity of 2.37 m/s. The value of the shear wave velocity in germ cell tumours showed a mean shear wave velocity of 1.94 m/s and for seminoma it showed a mean shear wave velocity of 2.42 m/s. VTIQ is a reliable new method for measuring qualitative and quantitative stiffness of testicular lesions and tissue. The qualitative shear-wave elastography features were highly reproducible and showed good diagnostic performance in unclear testicular lesions. The VTIQ technique is also useful in assessing small testicular nodules and pseudolesions.

Index of Suspicion in the Nursery

A 3.7-kg, 6-day-old term infant presents to the emergency department with decreased oral intake, irritability, and respiratory distress. No history of fever, or respiratory or gastrointestinal symptoms are elicited. Prenatal and delivery history are unremarkable, including negative maternal serologies and Group B streptococcus testing. Mother is healthy, but the sibling has rhinorrhea and cough. The infant is intubated for respiratory distress, receives 60 mL/kg of normal saline boluses for poor perfusion, and dopamine is started for hypotension. The infant is noted to have a blanching, maculopapular erythematous rash involving the axilla and trunk, but otherwise has a nonfocal physical examination. A sepsis evaluation is performed, including blood, urine, and cerebrospinal fluid (CSF) cultures. Empirical antimicrobial therapy with ampicillin, gentamicin, and acyclovir is administered, and the infant is transferred to the NICU for further management. A 6-week-old healthy boy presents with bilateral painless scrotal swelling. He was born at term via normal vaginal delivery following an uneventful pregnancy; antenatal ultrasound scans were normal. The scrotal mass had been present since birth and initially was believed to be a hydrocele but it had become firmer over a course of 6 weeks. On physical examination, it consisted of two small, grape-size swellings, one above the left testis and one below the right testis. There was no history of delayed passage of meconium or any sign of bowel obstruction. Plain abdominal radiograph was performed and did not show intra-abdominal calcifications. An ultrasound scan demonstrated that both testes were normal in size, shape, and echodensity. Within the right and left scrotum there were paratesticular masses of mixed echogenicity. Both masses could be traced toward the inguinal canal, as shown in Fig 1. There were no abdominal calcifications. Sweat test and tissue culture were performed to exclude cystic fibrosis and tuberculosis, respectively, and were negative. …

Rheumatoid nodules in the thyroid bed following total thyroidectomy: a case report

IntroductionRheumatoid nodules occur in 30 percent of patients with active rheumatoid arthritis. Common sites include the buttocks or the extensor surface of the forearm, with one group documenting their presence in the thyrohyoid membrane. To the best of our knowledge, rheumatoid nodules have not been described in the thyroid bed.Case presentationWe present the case of a 46-year-old Caucasian woman with active rheumatoid arthritis and Hashimoto's thyroiditis who presented with compressive neck symptoms. An ultrasound scan revealed that both lobes of her thyroid were enlarged. The right lobe measured 7.9×3.4×3.3cm and the left 8.3×3.3×3.1cm. A solitary 1.0×0.6×0.8cm nodule was seen in the right lower lobe. Her thyroid-stimulating hormone level was 4.22uU/mL (0.34 to 5.60). A total thyroidectomy was performed due to her symptoms and the possible growth of a nodule when on levothyroxine. A postoperative ultrasound scan showed no remaining thyroid tissue. The pathology revealed several small neoplasms ranging from a well-encapsulated adenoma to highly atypical follicular and papillary Hurthle cell lesions in the setting of Hashimoto’s thyroiditis. Low-dose radioactive iodine (33.4mCi) was given. Four months later, our patient complained of a feeling of fullness in her neck. A solid nodule of mixed echogenicity (5.6×3.3×2.3cm) was seen in the right level VI of the neck, and solid tissue of mixed echogenicity (2.9×2.3×1.7cm) on the left. Following repeat surgery, the pathology from the right specimen showed Hashimoto’s thyroiditis. The left specimen had areas of granuloma formation with fibrinoid necrosis and palisading histiocytes, consistent with the histology of rheumatoid nodules. No evidence of malignancy was seen. The patient continues to do well and remains disease-free.ConclusionsRheumatoid nodules have not been reported in the thyroid bed. Their pathogenesis is not clear. Postoperative release of tumor necrosis factor alpha and local vascular damage may have triggered the nodule formation in this case. Rheumatoid nodules must be kept in the differential diagnosis of an enlarging thyroid in the setting of active rheumatoid arthritis. A fine-needle aspiration biopsy may show granuloma formation and be the most cost-effective initial diagnostic step, especially if there is a concern for malignancy. Early identification of these nodules will help decrease morbidity from unnecessary interventions and result in treatment that is both timely and appropriate.

P16.06: Cesarean scar pregnancy: diagnosis, treatment and sonohysterography follow up. A case report

31 years old patient, Grav 3, was admitted at 7th week of pregnancy with the history of spotting for 3 weeks. She had had one Cesarean section and one D&C because of missed abortion in the past; 10 and 6 years before respectively. Transvaginal ultrasound examination (TVUS) at the admission revealed empty uterine cavity and the gestational sac localized within the Cesarean scar with the viable fetus (CRL 8.8 mm). TVUS performed next day confirmed Cesarean scar pregnancy. Serum beta-HCG was 63861mIU/ml. Methotexate 100mg im treatment was started and repeated in two days. Every day TVUS supervision was carried out and at the day 7 after admission fetus was still viable with the serum beta-HCG 95274 mIU/ml. Intravaginal misoprostol was applied and repeated next day followed with D&C. Throughout next two days patient presented intermittent bleeding of variable intensity. TVUS revealed blood, clots and possible residual tissues at the site of ceserean scar. Beta-HCG was 13675mIU/ml. On day 11 another D&C was performed because of increased bleeding with the good result. Patient was discharged home 14 days after admission. No blood tranfusion was performed. 10 weeks after discharge TVUS showed typically looking uterus with the area 8,9x4,8x11mm of mixed echogenicity at the site of Cesarean scar suggesting scar defect. Saline sonohysterography revealed large (9,6x10,0x18mm) scar defect with the residual myometrial thicknes 1,8mm. This case of CSSP shows treatment difficulties with the need for the repated operative procedures, prolonged hospital stay and limited value of transvaginal ultrasound vs sonohysterography is the assessment of Cesarean scar defects.

Granulosa cell tumour in a female dromedary camel

A 14-year-old female dromedary camel was examined for failure of conception. Ultrasonography revealed a mass of mixed echogenicity involving the left ovary, which was later surgically removed. The cut surface was multilocular. Upon microscopic examination, a mature granulosa cell tumour (GCT) was found. Laboratory examination revealed neutrophilia, increased albumin and blood urea nitrogen and decreased globulin, calcium, phosphorus and magnesium. Oestrogen, progesterone, and testosterone were within the normal values. This appears to be the first description of GCT in dromedary camels.

Hemangiossarcoma Renal Bilateral Primário Em Cão - Relato De Caso

Reporting of renal neoplasm with aid sonographic image. Canine female, SRD, 12 years, 19 Kg, vomiting and pale anorexia. Mucosas, abdominal swelling, pain on palpation of the hypogastrium right and left side, tachypnea, dehydration and temperature of 38.1°C. Normocytic normochromic anemia, leukocytosis neutrophilic. Elevated serum creatinine and urea. Left kidney with partial loss of architecture, increased echogenicity of the cortical region. Ureter hydronephrosis. Cranial mass with mixed echogenicity in the sagittal plane. Right kidney-increased echogenicity in the cortical region. Perirenal mass with mixed echogenicity with hipoecogênea anecogêneas areas. The histopathologic diagnosis was bilateral renal hemangiosarcoma, without evidence of neoplastic cells in other organs such as spleen, liver and right atrium. Renal neoplasms are rare and may produce local or systemic manifestations signs of renal failure with azotemia, as evidenced in the dog study. The more common in dogs, hemangiosarcoma is in the right atrium and the kidney as metastasis, which was not observed in this study, confirming a case of bilateral renal primary hemangiosarcoma.

Segmental Testicular Infarction

Segmental testicular infarction can mimic testicular carcinoma on sonography and can lead to unnecessary orchiectomy. This case series describes and correlates sonographic and histologic findings of 7 pathologically proven segmental testicular infarction cases. Segmental testicular infarction should be suspected on sonography when a geographic lesion with low or mixed echogenicity has absent or near-absent flow in a patient with scrotal pain. A hyperechoic rim and peripheral hyperemia correspond to interstitial hemorrhage and inflammatory changes. As an infarct evolves, it becomes more discrete and hypoechoic as ghost outlines replace seminiferous tubules. Follow-up or contrast-enhanced magnetic resonance imaging or sonography can increase diagnostic confidence in suspected cases and prevent unnecessary orchiectomy.

A Case of Scrotal Leiomyosarcoma in a Dog

A CASE OF SCROTAL LEIOMYOSARCOMA IN A DOG E. Laloy, S. Chateau-Joubert, M. El Mrini, F. Rakotovao, M. Carlus, E. Reyes-Gomez, V. Delfosse and N. Cordonnier National Veterinary School of Alfort, France Introduction: Scrotal smooth muscle tumours are uncommon in man. They arise from the tunica dartos of the scrotum. They have not been reported in animals. Materials and Methods: A 6-year-old male shar pei dog presented with a single 1-cm diameter mass arising from the left scrotum. Surgical excision was performed and the nodule was fixed in 10% neutral buffered formalin, processed routinely and embedded in paraffin wax. Sections were stained with haematoxylin and eosin. Several sections were subjected to immunohistochemistry. Results: The neoplasm was well circumscribed, but unencapsulated. It showed multifocal contiguity with the dartos smooth muscle bundles. It comprised of short interlacing bundles of plump spindle cells within minimal collagenous stroma. The neoplastic cells had abundant eosinophilic cytoplasm and oval to elongated nuclei. Moderate anisokaryosis and anisocytosis were seen. There were seven mitotic figures per 10 high-power fields ( 40). Small focal areas of necrosis were present. The neoplastic cells were positive for vimentin and smooth muscle actin, while they were negative for melan A, glial fibrillary acidic protein (GFAP) and S100. A few cells were positive for desmin. Conclusions: The histological and immunohistochemical findings were most consistent with a scrotal leiomyosarcoma. This is the first report of scrotal leiomyosarcoma in a dog. MESOTELIOMA OF THE TUNICA VAGINALIS OF THE TESTIS IN THE DOG: AN UNCOMMON NEOPLASM WITH MALIGNANT BEHAVIOUR G.A. Ram irez*, A. Su arez-Bonnet y, A. Espinosa-de-los-Monteros y, J. Altimira* and M. Vilafranca* *HISTOVET Laboratory and yLas Palmas de Gran Canaria University, Spain Introduction: Mesotheliomas of the tunica vaginalis testis are extremely rare. The aim of this work is to describe the clinical, histological and immunohistochemical features as well as the clinical outcome of this neoplasm in the dog. Materials and Methods: Our records were reviewed for dogs with a diagnosis of testicular mesothelioma made between 1995 and 2011. Clinical histories and follow-up information were obtained from referring clinicians. Diagnoses were confirmed by re-review of paraffin wax-embedded specimens. Immunohistochemistry was also performed with a panel of antibodies including cytokeratins, vimentin and CEA. Results: Cases were presented as swelling of the scrotum. Ultrasonography revealed heterogeneous and irregular masses with a mixed echogenicity; anechoic effusion surrounding the affected testicles (hydrocele) was also common. Gross examination often revealed firm, polypoid or papillary, yellow to white masses with a solid cut surface. The tunica vaginalis was thickened, studded with nodules of varying size, and diffusely calcified in one case. Invasion of the spermatic cord was common. Microscopically, the tumours had epithelial features with papillary, tubulopapillary or solid patterns and consistently expressed cytokeratins and vimentin. Post-operative recovery was always uneventful, but worsening of general health was reported in a period of!7 months. Necropsy examination, when performed, confirmed abdominal metastatic disease. Conclusions: Mesothelioma of the tunica vaginalis testis in the dog is a rare malignant neoplasm with an aggressive behaviour and poor outcome.

Unusual early-stage pancreatic sarcomatoid carcinoma

Sarcomatoid carcinoma of the pancreas (SCP) is a very rare pathological type of carcinoma that usually has a poor prognosis. Its pathogenesis has not been elucidated. We herein report a case of an early-stage SCP involving successful treatment and a good prognosis. The patient was a 48-year-old Chinese man with a 5-mo history of vague abdominal pain. Ultrasonography revealed a 93 mm × 94 mm × 75 mm mass of mixed echogenicity in the tail of the pancreas. Laboratory test results were within the normal range, with the exception of an obviously increased pretreatment neuron-specific enolase level. The plasma transforming growth factor (TGF)β1 and interleukin-11 levels were obviously increased according to enzyme-linked immunosorbent assay. Microscopically, the excised tumor tissue comprised cancer cells and mesenchymal cells. Immunohistochemical analysis was positive for α-1-antichymotrypsin, pan-cytokeratin, cytokeratin 19, cytokeratin 8/18, and vimentin and negative for CD68 and lysozyme. The pathogenetic mechanism of this case shows that TGFβ1 may regulate the epithelial-to-mesenchymal transition in SCP. With early eradication of the tumor and systemic therapy, this patient has been alive for more than 3 years without tumor recurrence or distant metastasis. This case is also the first to show that TGFβ1 may regulate the epithelial-to-mesenchymal transition in early-stage SCP.

Liposarcoma of the Testis and Spermatic Cord

Primary liposarcoma of the spermatic cord is rare, and preoperative diagnosis is difficult. We report a rare case of well-differentiated liposarcoma in 65-year-old man. The patient’s chief complaint was painless enlargement of a mass in the right inguinal area that had persisted for about two months. The main component of the mass was wrapped around the spermatic cord and several components were around the testis. Ultrasonography of the main component showed mixed echogenicity. CT showed an ovoid fat-containing nodule and several other fat-density masses surrounding the testis. The mass was surgically removed, along with the right testis and spermatic cord. A pathological examination showed a well-differentiated liposarcoma of the right spermatic cord and testis.

Endoscopic Ultrasound in Differentiating Solitary Rectal Ulcer Syndrome from Rectal Cancer

Purpose: Solitary rectal ulcer syndrome is a heterogeneous disorder that can present with a diverse endoscopic appearance, including single and multiple ulcers, hyperemic mucosa, and polypoid lesions. We present a case of solitary rectal ulcer syndrome presenting as a circumferential rectal mass. A 53 year-old man with schizophrenia and a 4 year history of constipation presented to the hospital with 2 months of rectal bleeding and intermittent rectal prolapse for 2 weeks. His exam was notable for prolapse of the rectum, and laboratory studies were unremarkable. Initial colonoscopy showed a circumferential, friable mass in the rectum with distal margin less than 5 cm from the anal verge and proximal margin 10 cm from the anal verge; multiple biopsies were taken. CT scan showed a circumferential rectal mass without evidence of distant metastatic disease. Pathology revealed only necrotic tissue. He was then scheduled for a repeat colonoscopy with endoscopic ultrasound. The subsequent endoscopy was performed 4 days later and showed circumferential hyperemic mucosa with ulceration extending from the dentate line to 10cm in the rectum but no definite rectal mass. Rectal endoscopic ultrasound revealed circumferential thickening of the submucosal layer with areas of mixed echogenicity between the second and third layers. No focal hypoechoic mass lesion was seen. Repeat deep biopsies showed smooth muscle bundles extending between the crypts towards the mucosal surface with immunohistochemistry stain positive for smooth muscle actin confirming the diagnosis of solitary rectal ulcer syndrome Solitary rectal ulcer syndrome can present with a highly variable endoscopic appearance. Misdiagnosis as rectal cancer has been described in the medical literature but is uncommon in clinical practice. Histopathology can confirm the diagnosis in the appropriate clinical setting, but representative samples are not always obtained on initial biopsies. Additionally, cross-sectional imaging findings can be interpreted as a malignant process in solitary rectal ulcer syndrome. When biopsies are inconclusive, endoscopic ultrasound may provide supportive information in this difficult diagnostic situation. High clinical suspicion in the appropriate setting of patients with bowel disturbances or rectal prolapse and appreciation of the diverse presentation of this clinical entity are essential to the timely diagnosis of solitary rectal ulcer syndrome.

Correlation of sonographic features of invasive ductal mammary carcinoma with age, tumor grade, and hormone‐receptor status

To determine whether presenting sonographic features of invasive ductal carcinomas (IDC) are associated with patient age, tumor histologic grade, and hormonal receptor status. Sonographic features of 101 consecutive cases of IDC seen at ultrasound were retrospectively assessed based on the BI-RADS criteria of posterior acoustic appearance, tumor margins, and echogenicity. Associations between sonographic features and tumor characteristics were statistically evaluated with attention to patient age. IDC with shadowing compared with unchanged posterior acoustic appearance were significantly more likely to be of low histologic grade (Odds Ratio [OR] = 5.00; p < 0.05) and estrogen receptor (ER) -positive (OR = 10.00; p < 0.05). Conversely, posterior enhancement was associated with ER-negative status (OR = 4.45; p < 0.01), particularly among patients younger than 60 years of age (OR = 5.36, p < 0.05). Circumscribed tumors were more often high grade, particularly among older women (p < 0.01), and hormone receptor--negative regardless of age group. Among older women, tumors with mixed echogenicity tended to be high grade and progesterone receptor--negative (p values < 0.05). Noncircumscribed borders were observed for all tumors with posterior shadowing, and 97% of such tumors were also ER positive. Sonographic features were significantly associated with tumor grade and hormone receptor status, with some differences based on patient age. Specifically, the presence of posterior shadowing was associated with lower histologic grade and ER-positive status, especially in older patients. In contrast, we found that posterior acoustic enhancement was more commonly associated with ER-negative status, especially in younger patients.

Contrast-Enhanced Ultrasound in the Evaluation of Focal Testicular Complications Secondary to Epididymitis

The purpose of this study is to determine the effectiveness of contrast-enhanced ultrasound in evaluating incidental focal testicular lesions in epididymitis. Intratesticular lesions ipsilateral to epididymitis were subject to B-mode color Doppler ultrasound and contrast-enhanced ultrasound, with their appearances reviewed in consensus. Final interpretation was by histologic analysis or follow-up ultrasound. Over 28 months, 16 focal testicular lesions (median lesion size, 24 mm; range, 14-48 mm) in 14 patients (median age, 49 years; range, 18-81 years) were examined. Lesions were oval (n = 14), wedge shaped (n = 1), or involved the entire testis (n = 1). Lesions were isoechoic (n = 1), hypoechoic (n = 4), or of mixed echogenicity (n = 11). Color Doppler ultrasound flow was not clearly depicted in 13 lesions but was present in three lesions, with contrast-enhanced ultrasound concordant with color Doppler ultrasound, showing unequivocal absence of vascularity and increased flow, respectively. In the avascular lesions, rim enhancement (n = 6), vascular projections (n = 4), and irregular (n = 10) and smooth (n = 2) borders were documented. The observers identified infarction (n = 9), abscess (n = 4), orchitis (n = 1), and tumor (n = 2). Histologic examination (seven lesions in five patients) confirmed infarction, abscess formation, and seminoma; follow-up ultrasound confirmed resolution for eight patients. Contrast-enhanced ultrasound is a useful adjuvant to color Doppler ultrasound examination of a focal lesion in the testis ipsilateral to epididymitis to improve the characterization of nonvascularized tissue.