Normal Ultrasonography Research Articles

MRI for the pre-operative workup of invasive lobular breast cancer: Change in diagnosis

MRI for the pre-operative workup of invasive lobular breast cancer: Change in diagnosis

Ultrasound in sialadenitis

The salivary glands are located superficially and are therefore easily accessible to ultrasound (US) examination, particularly if a high-frequency probe designed for small parts is used. Hence, US examination of these organs is widely applied particularly in non-neoplastic pathologies. In this way, it is possible to obtain adequate images without the use of ionizing radiation or complex instrumentation such as magnetic resonance imaging. However, US examination requires an expert clinical knowledge and familiarity with the normal and pathological US anatomy of the area. Limitations and pitfalls linked to US examination of this area should also be kept in mind.

Long-Term Follow-Up of TIPS Created with Expanded Poly-Tetrafluoroethylene Covered Stents

Transjugular intrahepatic portosystemic shunts (TIPS) created with expanded poly-tetrafluoroethylene-covered stents have largely replaced bare metal stents. Short-term shunt patency is typically assessed with protocol Doppler ultrasound (US), while little information exists with regard to long-term patency. We investigated the value of Doppler US in assessing TIPS patency as well as long-term clinical outcomes. A retrospective analysis of 59 patients with covered stents used for TIPS between January 2001 and December 2011 was performed. Fifty-four patients had early (median 9days) Doppler US follow-up. Seven of eight patients with an abnormal baseline US required stent revisions. None of the 46 patients with normal baseline Doppler US required revisions within the first 6months; six of these patients subsequently had a portogram because of symptoms, but all TIPS were patent. Fifty-two patients survived for long-term (>6months) follow-up, averaging 654days and three Doppler US exams. Five of six patients with abnormal follow-up Doppler US required revisions, whereas none of the 46 patients with normal follow-up US had revisions. The recurrence of symptoms of portal hypertension and/or hepatic encephalopathy (HE) was low (4/52 patients). No significant predictors of long-term stenosis were identified. Post-TIPS HE was independent of pre-TIPS HE or Child-Pugh score. Short-term patency and that at approximately 2years after TIPS placement was 87 and 77%, respectively. We conclude that Doppler US at least 1week after TIPS is warranted, but repeated Doppler US follow-up is probably not necessary in the absence of clinical symptoms.

Safety and Feasibility of a Diagnostic Algorithm Combining Clinical Probability, D-Dimer and Ultrasonography in Suspected Upper Extremity Deep Vein Thrombosis: A Prospective Management Study

AbstractAbstract 391 IntroductionTraditionally, the focus of VTE diagnostic is on deep vein thrombosis (DVT) of the leg and pulmonary embolism. Until recently, upper extremity DVT (UEDVT) was regarded as an uncommon and relatively benign presentation of venous thromboembolism; however, the more widespread use of central venous catheters has caused a significant increase in its incidence. Moreover, recent data indicate that 10–25% of these patients may have pulmonary embolism. Therefore, effective and safe diagnostic strategies are needed. The use of an algorithm combining a clinical decision score, D-dimer and ultrasonography is well-established for suspected lower limb DVT, but has not been evaluated in suspected UEDVT. This diagnostic management study assessed the safety and feasibility of a new diagnostic algorithm in patients with clinically suspected UEDVT. MethodsIn- and outpatients with suspected UEDVT were recruited from January 2010 until July 2012 in 17 hospitals in Europe and the United States. To confirm an acceptable failure rate of excluding UEDVT (upper 95% confidence interval below 3%), approximately 400 patients needed to be included. Main exclusion criteria were previous UEDVT and the use of therapeutic doses of anticoagulants. Informed consent was obtained from all participants. The algorithm consisted of the sequential application of the Constans' clinical decision score (Constans et al, Thromb Haemost 2008), D-dimer testing and compression ultrasonography. Patients were first categorized as UEDVT likely or unlikely by the Constans' score. In the patients with an unlikely score and a normal D-dimer, UEDVT was considered excluded and no further testing was done. All other patients underwent compression ultrasonography, which first assessed the deep veins for the presence of UEDVT and then the superficial veins for the presence of superficial vein thrombosis (SVT). Ultrasonography was repeated in case of an indeterminate ultrasonography result, or in patients with a high probability score, abnormal D-dimer and a normal ultrasonography. The primary outcome was the 3-month incidence of symptomatic UEDVT and pulmonary embolism in patients with a diagnostic work-up excluding both UEDVT and SVT. ResultsThe study population comprised of 356 consecutive patients with suspected UEDVT. The algorithm was feasible and completed in 96% (Figure). Of the 356 patients, 181 had a low probability score and D-dimer was measured. In 78 patients (22%) a normal D-dimer combined with a low probability score excluded UEDVT without any imaging, and these patients all had an uneventful 3 month follow up. An abnormal D-dimer test result was found in 100 patients, who underwent ultrasonography. In 3 patients, D-dimer measurement was not done, and these patients received ultrasonography right away. Of all patients with a low probability score, 15 patients had UEDVT, 24 patients had SVT, while thrombosis (both deep and superficial) was excluded in 141 patients. One remaining patient died of progressive cancer before ultrasonography could be done. All 175 patients with a high probability score underwent compression ultrasonography right away, which was repeated if indicated. Of these patients with a high probability score, 82 had UEDVT and 22 had SVT. In 71 patients, thrombosis was excluded, including 11 patients in whom the protocol was not followed completely. To summarize, of the 356 included patients, 97 patients had UEDVT (27%), 46 had SVT (13%) and in 212 patients the algorithm excluded UEDVT and SVT (60%). Of all patients in whom the algorithm excluded UEDVT and SVT, one patient developed UEDVT during follow-up for an overall failure rate of 0.47% (95%CI: 0.0–2.6%). Final results of the definitive study population of 407 patients will be presented. ConclusionsA new diagnostic algorithm which combines a clinical decision score, D-dimer and ultrasonography can safely and effectively exclude venous thrombosis of the upper extremity. This approach is attractive as it is simple, quick and non-invasive, and very similar to the well established algorithm for suspected DVT of the leg which could facilitate its implementation in clinical practice. [Display omitted] Disclosures:No relevant conflicts of interest to declare.

Abdominal ultrasonography of the normalSt.Kitts vervet monkey (Chlorocebus sabaeus)

Normal ultrasonography of non-reproductive abdominal and male reproductive anatomy in the vervet monkey were prospectively assessed. This has not been previously reported. Ten non-sexually active male and 10 non-gravid female clinically healthy vervet monkeys between 5 and 12 years of age and weighing between 3.13 and 6.85 kg were evaluated with ultrasound. Individuals were randomly divided by gender groups into one of two immobilization protocols and scanned at 18.0 MHz. High-quality images of the liver, gallbladder, kidneys, urinary bladder, spleen, adrenal glands, gastrointestinal tract, and testes were acquired. The prostate was never visualized. Abdominal lymph nodes other than an ileocolic, the pancreas, and the female reproductive tract were not evaluated. Gastric and duodenal motility were significantly different between immobilization protocols (P<0.05). Abdominal sonographic anatomy was successfully characterized and normal size parameters for non-reproductive abdominal viscera and the testes were established.

Ultrasonography Should Not Guide the Timing of Thyroidectomy in Pediatric Patients Diagnosed with Multiple Endocrine Neoplasia Syndrome 2A through Genetic Screening

American Thyroid Association (ATA) guidelines suggest that thyroidectomy can be delayed in some children with multiple endocrine neoplasia syndrome 2A (MEN2A) if serum calcitonin (Ct) and neck ultrasonography (US) are normal. We hypothesized that normal US would not exclude a final pathology diagnosis of medullary thyroid cancer (MTC). We retrospectively queried a MEN2A database for patients aged<18 years, diagnosed through genetic screening, who underwent preoperative US and thyroidectomy at our institution, comparing preoperative US and Ct results with pathologic findings. 35 eligible patients underwent surgery at median age of 6.3 (range 3.0-13.8) years. Mean MTC size was 2.9 (range 0.5-6.0) mm. The sensitivity of a US lesion≥5 mm in predicting MTC was 13% [95% confidence interval (CI) 2%, 40%], and the specificity was 95% [95% CI 75%, 100%]. Elevated Ct predicted MTC in 13/15 patients (sensitivity 87% [95% CI 60%, 98%], specificity 35% [95% CI 15%, 59%]). The area under the receiver operating characteristic curve (AUC) for using US lesion of any size to predict MTC was 0.50 [95% CI 0.33, 0.66], suggesting that US size has poor ability to discriminate MTC from non-MTC cases. The AUC for Ct level at 0.65 [95% CI 0.46, 0.85] was better than that of US but not age [AUC 0.62, 95% CI 0.42, 0.82]. In asymptomatic children with MEN2A diagnosed by genetic screening, preoperative thyroid US was not sensitive in identifying MTC of any size and, when determining the age for surgery, should not be used to predict microscopic MTC.

Value of Diagnostic Radioiodine Whole-Body Scanning After Initial Therapy in Patients with Differentiated Thyroid Cancer at Intermediate and High Risk for Recurrence

Diagnostic radioiodine whole-body scanning (DxWBS) in combination with stimulated thyroglobulin (Tg) (i.e., measurement after levothyroxine [L-T4] withdrawal or recombinant human TSH administration) continues to be recommended for patients with differentiated thyroid carcinoma (DTC) at high or intermediate risk for recurrence with negative basal Tg and ultrasonography (US) after ablation. However, the value of DxWBS has been questioned, even in these cases. The objective of this prospective study was to evaluate the value of DxWBS in these patients. The study consisted of 318 patients who had total thyroidectomy with apparent complete tumor resection for DTC. Further, per inclusion criteria, they had the following characteristics (i) a post-therapy radioiodine whole-body scan (RxWBS) showing no metastases and uptake in the thyroid bed of ≤2%, (ii) classification as high or intermediate risk for recurrence based on the large tumor size, tumor extension beyond the thyroid capsule, and lymph node metastases, (iii) Tg during L-T4 therapy (TgT4) of <1 ng/mL, (iv) negative anti-Tg antibodies (TgAb), and (v) normal US performed 8-12 months after ablation. Tg stimulation combined with DxWBS was performed in all patients. Patients without apparent disease in the initial assessment were followed up for 24 to 96 months. In the initial assessment, stimulated Tg continued to be <1 ng/mL in 253 (79.5%) patients and converted to levels >1 ng/mL in 65 (20.4%). None of the patients had metastases on DxWBS, and 46 (14.4%) had discrete uptake (<0.5%) only in the thyroid bed. (18)F-fluorodeoxyglucose positron-emission tomography and computed tomography (FDG-PET/CT) revealed metastases in three patients with elevated stimulated Tg. Fourteen (4.4%) patients without initially apparent disease relapsed during follow-up, including five (2%) with initial stimulated Tg < 1 ng/mL. There was no disease-related death. Thyroid bed uptake on DxWBS had no prognostic value for recurrence, irrespective of stimulated Tg levels. DxWBS can be avoided in patients with large tumors or extensions beyond the thyroid capsule or lymph node metastases, but who show no apparent disease upon initial RxWBS and US and whose serum TgT4 of <1 ng/mL and negative TgAb after thyroidectomy and ablation.

Teaching and learning normal gynecological ultrasonography using simple virtual reality objects: a proposal for a standardized approach

Teaching and learning normal gynecological ultrasonography using simple virtual reality objects: a proposal for a standardized approach

Does 3D Ultrasound Enhance the Diagnosis of Bladder Tumours in Patients with Haematuria?

Purpose. Bladder cancer is a frequent cause of haematuria in elderly patients, and bladder ultrasound (US) is a valuable tool in diagnosing these malignancies. We examined the accuracy of 3D bladder US in diagnosing bladder tumors in patients with haematuria. Patients and Methods. Twenty-one patients observed in the emergency department for haematuria underwent a kidney and bladder US. Patients with normal or uncertain bladder US findings underwent a 3D US and a cystoscopy. Results. In 5 (23.8%) patients, the 3D US detected bladder tumours not seen in 2D US. All these patients were found to have bladder tumours on cystoscopy. Another 5 (23.8%) patients with uncertain findings on 2D US had normal 3D US and cystoscopy. 3D US showed a sensitivity of 83.3% and a specificity of 100% with a positive predicted value and negative predictive values of 100% and 93.8%, respectively. Conclusion. 3D US was more sensitive than 2D US in diagnosing bladder tumours in patients with haematuria.

Does undetectable basal Tg measured with a highly sensitive assay in the absence of antibodies and combined with normal ultrasonography ensure the absence of disease in patients treated for thyroid carcinoma?

It has been proposed that, in patients treated for well-differentiated thyroid carcinoma, undetectable basal thyroglobulin (Tg) levels measured with a highly sensitive assay in the absence of anti-thyroglobulin antibodies (TgAb) and combined with negative neck ultrasonography (US) ensured the absence of disease. We report a series of five patients with well-differentiated (papillary) carcinoma submitted to total thyroidectomy with apparently complete tumor resection, followed by remnant ablation with (131)I (100-150 mCi), who had no distant metastases upon initial post-therapy whole-body scanning. When tumor recurrence or persistence was detected, these patients presented undetectable basal Tg (0.1 ng/mL) in the absence of TgAb, and US showed no anomalies. Two patients had lymph node metastases, one had mediastinal metastases, bone involvement was observed in one patient, and local recurrence in one. We conclude that further studies are needed to define in which patients undetectable basal Tg (negative TgAb) combined with negative US is sufficient, and no additional tests are required.

Cranial ultrasonography and transfontanellar Doppler in premature neonates (24–32 weeks of gestation): Dynamic evolution and association with a severe adverse neurological outcome at hospital discharge in the Aquitaine cohort, 2003–2005

ObjectiveTo correlate the short-term neurological outcome of early cerebral abnormalities using cranial ultrasonography (US) in premature newborns at their hospital discharge. MethodsEach newborn born<33 weeks of gestational age (GA) included in a prospective cohort benefited of 3 US: two early in the first week of life (D3 and D8) and one later (Months 1–2) standardized US pulsed Doppler. A US abnormality was ≥one morphologic abnormality (moderate: intra-ventricular hemorrhage (IVH) grades 1–2; severe: IVH 3–4, periventricular leukomalacia, persistent flares). Correlates of having a severe adverse neurological outcome were analyzed using a stepwise backward logistic regression adjusted model with gestational age, early cerebral abnormality at Days 3–8, velocity and with variables with correlation probabilities with p<0.25 in the univariate analysis among occurring co-morbidity events previously defined. Two adjusted logistic regression analyses were conducted including or not velocity data because of missing information. ResultsAmong 452 premature included, 11.3% did not have an early US, 74.8% had a normal early US, 13.9% ≥one early morphological US abnormality (10.0% moderate, 3.9% severe). At hospital discharge, 40% were still alive with a normal late US, 33% alive with ≥one late morphological US abnormality (10% moderate, 23% severe), and 10% died. Adjusted correlates of a late US severe abnormality or a neurological related death at hospital discharge were: early US abnormality (aOR: 8.7, 95% CI: 2.3–33.6), GA<29 weeks (aOR: 2.8 95% CI: 1.4–5.4). ConclusionThis study shows that early US morphological abnormalities increase significantly when the GA decreases and is highly predictive of the occurrence of a further late US severe abnormality or neurological related death at hospital discharge.

425: Improved detection of anomalies by CVS with fish analysis prior to multifetal reduction (MFPR)

fish analysis prior to multifetal reduction (MFPR) Mara Rosner, Eugene Pergament, Stephanie Andriole, Pe’er Dar, Rachel Greenbaum, Mark Evans Montefiore Medical Center/Albert Einstein College of Medicine, Obstetrics & Gynecology and Women’s Health, Bronx, NY, Northwestern Reproductive Genetics PC, Genetics, Chicago, IL, Comprehensive Genetics, Genetic Counseling, New York, NY, Albert Einstein College of Medicine/ Montefiore Medical Center, Obstetrics & Gynecology and Women’s Health, Bronx, NY, Comprehensive Genetics, Ultrasound, New York, NY, Comprehensive Genetics & Mt. Sinai School of Medicine, Obstetrics & Gynecology, New York, NY OBJECTIVE: Over 50% of patients undergoing IVF in the USA are 35 years of age. When multiples, PGD, and ICSI are added, over 70% are at increased risk, yet most patients are not offered CVS prior to MFPR. We routinely offer CVS prior to MFPR. STUDY DESIGN: We retrospectively reviewed our last 470 CVS/MFPR patients. Abnormalities were categorized as structural, FISH, and abnormal karyotype. Our approach is generally not to test fetuses that are clearly abnormal and reduced such that the overall cytogenetic abnormality rate is artificially lowered. RESULTS: 94/470(20%) pregnancies and 96/1339(7.2%) fetuses had anomalies. 62/94(66%) were referred in the 1st trimester of which 24/62(39%) were identified or suggested by ultrasound(US). 27/ 62(43.5%) had an abnormal FISH that dictated MFPR. 21/27(77.7%) of the cytogenetic abnormalities had normal US. 5/21(24%) were T21, 2/21(10%) were T18/13, 13/21(62%) were sex chromosome mosaics, and one was a trisomy 13 mosaic. When final karyotype was available, FISH agreed with the karyotype in 702/728(96.4%) fetuses. Of the 26 discrepancies between FISH and karyotype, 18/26(69%) were sex chromosomes suggesting cross contamination or known innocuous findings such as tetraploidy or inherited inversions. Ultimately, there were 8/728(1%) potentially concerning karyotypic abnormalities discordant from FISH which included mosaic trisomies, one trisomy 8 and one chromosome 15p 7/8 of which were confined placental mosaicisms. Final karyotype and subsequent amniocentesis confirmed one 46XX/46XY mosaic not seen on FISH. CONCLUSION: In our cohort, US alone identified only 39% of 1st trimester anomalies before MFPR. FISH identified another 32.8% and added value beyond US for 15/351 (4.3%) patients. 8/728(1%) required follow up amniocentesis for discrepancies. Given the risks of carrying multiples and published mistakes in reducing the wrong fetus by waiting for karyotype, our data suggest CVS, next day FISH and then MFPR as the optimal strategy. As a by-product, patients can then consider fetal sex when there are no other abnormalities. 426 Adolescent cognitive and anxiety behavior in offspring following in utero exposure to increased trans unsaturated fatty acids through maternal diet Mark Alanis, Claudia Umphlet, Heather Boger, Ann-Charlotte Granholm Medical University of South Carolina, Obstetrics and Gynecology, Charleston, SC, MUSC, Neurosciences, Charleston, SC OBJECTIVE: The developing brain is potentially susceptible to inflammatory diets, such as trans unsaturated fatty acids (TFA). STUDY DESIGN: Fisher 344 virgin rats were randomized to isocaloric experimental (TFA) or study (AIN93) diets for 4 weeks, mated, and then maintained on their study diets until weaning. On postnatal day 23 (P23) offspring were further randomized into 1 of 4 prenatal/postnatal dietary arms (N 16 litters): TFA/TFA, TFA/AIN, AIN/AIN, and AIN/TFA. Adolescent male and female rats (P36-38) underwent anxiety assessment using the elevated plus maze paradigm. Decreased % time and entry into open arms indicate increased anxiety. Adolescent male rats (P40-45) underwent cognitive behavioral performance testing using the water radial arm maze (WRAM) over 12 consecutive days. Spatial working and reference memory errors were averaged across litters during learning (days 1-3) and asymptotic phases (days 4-7, 6-9, and 10-12). Group comparisons were performed using 2-way analysis of variance (ANOVA) with repeated measures. Equality of variance was assessed by the F-test. Two-tailed p values .05 were considered significant. RESULTS: Females demonstrated greater anxiety than males based on the number of entries into open arms (10.5 0.9 versus 16.9 1.6, p .001), but not % open time (40% versus 53% open time, respectively, p .05). Diet did not demonstrate a significant relationship with anxiety (p .52). Rats in all 4 diet arms showed similar improvement over the 12 day WRAM test (Figure). When collapsing the analysis to 2 groups (prenatal TFA versus AIN), prenatal TFA rats committed more total working memory errors compared to prenatal AIN rats during the day 10-12 phase (6.1 .6 vs. 3.3 1.2 errors, respectively; p .03). Variance was not significantly different between the 4 groups (p .05 for all F-tests). CONCLUSION: Prenatal and postnatal dietary exposure of TFA did not demonstrate a major impact on either anxiety or hippocampal-dependent cognitive behavior, which may be explained by a true absence of effect or variance in the sample set (Type II error).

P3-07-22: Combined Approach for Staging the Axilla in Breast Cancer Patients with Clinically (−)Nodes Versus Sentinel Node Biopsy Alone.

Abstract Background Prognostic information and local control for managing the majority of clinically node (−) breast cancer patients may be achieved by sentinel node biopsy (SNB) alone and/or limited axillary dissections (LAD). Currently, 20 - 30% of clinically node (−) patients have unnecessary surgery. This study compares the results from staging the axilla using SNB alone versus using the combined approach shown below. Methods: Clinically node (−) patients (n=176) were subclassified according to their primary tumor histology, axillary ultrasound (US) data, and US guided Fine Needle Aspiration (US-FNA) results, as follows: Low Risk (LR) for axillary metastasis (n = 62); High Risk (HR) with normal axillary US (n = 17); HR with US suggesting minimal N1a disease (n = 23); HR with US suggesting N1a disease (n = 52); HR with US suggesting N2-3 disease (n = 22). All patients with (+) SNB or (+) US-FNA had Axillary Lymph Node Dissections (ALND). The number of (+) Sentinel Nodes (SN), Non Sentinel Nodes (NSN) and (+) LN after a (+) US-FNA from each patient category was correlated with corresponding preoperative data. HR patients were defined as having grade II tumors ≥ 1.5 cm and grade III tumors &amp;gt; 1.0 cm. US abnormalities in the axilla were interpreted as follows: minimal N1a disease equivalent to cortical defects &amp;lt; 5mm in 1–3 LN; N1a disease, cortical defects &amp;gt; 5mm in 1–3 LN and N2-3 disease, complete nodal replacement in ≥ 1 LN. LAD refers to level I dissections (1-5 LN). Results: Three subgroups of patients were identified: Group A, patients not requiring ALND (128/176 = 72%); Group B, patients requiring ALND bypassing SNB (22/176 =13%) and Group C, patients requiring LAD (26/176 = 15%). Preoperatively these 3 groups were categorized as follows: Group A included patients at LR for axillary metastasis, HR patients with normal axillary US, HR patients with axillary US suggesting minimal N1a disease and HR patients with axillary US suggesting N1a disease with (−) US-FNA; Group B included HR patients with axillary US suggesting N2-3 disease and (+) US-FNA; Group C included HR patients with axillary US suggesting N1a disease and (+) US-FNA. The post ALND characteristics for these 3 groups are summarized as follows: all Group A patients had N1a disease represented by ≤ 2 (+) LN, 94% (17/18) were SN (+) only, 85% (15/18) with 1 (+) LN and 15% with 2 (+) LN; in Group B, 20 patients had N2-3 disease and 2 patients had N1a disease, all Group B patients had &amp;gt; 2 (+) LN; in group C, 20 patients had N1a disease and 2 patients had N2 disease, and 77% had single (+) node disease. Conclusion: By following this approach a more patient oriented method for staging the axilla can be implemented as follows: 1. SNB alone for LR patients and for HR patients with axillary US findings suggesting no axillary disease, minimal N1a disease and/or N1a disease with (−) US-FNA; 2. ALND for HR patients with axillary findings suggesting N2-3 disease and a (+) US-FNA; 3. LAD for HR patients with US findings suggesting N1a disease and (+) US-FNA. This approach would result in a 38% (48/176) reduction in the number of SNB and a 30% (22/66) reduction in the number of ALND. This translates in to $200,000 (30-40%) in procedure-associated savings. Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P3-07-22.

One in five subjects with normal thyroid ultrasonography has altered thyroid tests

The relation between thyroid ultrasonography and laboratory, and the relationship of thyroid volume with clinical and anthropometric parameters, are not well clarified. Aim of the study was to investigate normal and hypoechoic-inhomogeneous not nodular thyroid gland in predicting thyroid tests, and to assess the correlation of thyroid volume with several clinical parameters. The series included 434 subjects (244 with normal thyroid ultrasonography, and 190 with hypoechoic-inhomogeneous thyroid) at their first evaluation. Subjects with normal ultrasonography and skewed tests were re-evaluated after one year. All subjects with normal ultrasound showed normal free-T₄, while TSH was elevated in 9.8% of cases and thyroid antibodies were positive in another 9.8%. In patients with hypoechoic-inhomogeneous thyroid, free-T₄ was low in 33.2%, TSH was elevated in 78.4% and thyroid antibodies were positive in 76.3%. Normal ultrasonography matched with normal tests in 81.1% of cases while hypoechoic-inhomogeneous thyroid in 9.5% (p<0.001). The re-evaluation of tests showed no significant difference. In subjects with both normal ultrasonography and tests, thyroid volume was correlated with age (p=0.001), weight (p=0.003), BMI (p=0.04), body surface area (p=0.002). Thyroid laboratory assessment was different between subjects with ultrasonographically normal or hypoechoic-inhomogeneous thyroid. Thyroid volume of thyroid diseases-free subjects was correlated with age, weight, BMI and body surface area, and this should be of interest to investigate the references of normality of thyroid size.

53 Emergency Sonography of the Gallbladder: Is Measurement of the Common Bile Duct Necessary?

53 Emergency Sonography of the Gallbladder: Is Measurement of the Common Bile Duct Necessary?

The role of ultrasound and magnetic resonance cholangiopancreatography for the diagnosis of biliary stricture after liver transplantation

PurposeTo identify the diagnostic value of ultrasound (US) and magnetic resonance cholangiopancreatography (MRCP) in diagnosing biliary strictures after liver transplantation. Materials and methodsSixty patients with clinically suspected biliary strictures after liver transplantation were retrospectively evaluated. All patients underwent US and MRCP before the standard of reference (SOR) procedure: endoscopic retrograde cholangiopancreatography or percutaneous transhepatic cholangiography. Radiological images were analyzed for biliary dilatation and strictures. ResultsBy SOR, biliary dilatation was present in 55 patients, stricture in 53 (44 anastomotic, 4 intrahepatic, 5 both), and dilatation and/or stricture in 58. Dilatation was diagnosed by US and MRCP in 39 and 45, respectively (sensitivity 71% vs. 82%, p=0.18). Stricture was diagnosed by US and MRCP in 0 and 42, respectively (sensitivity 0% vs. 79%, p<0.0001). False positive stricture was diagnosed by MRCP in 2. Dilatation and/or stricture was diagnosed by US in 39 and MRCP in 50 (sensitivity 67% vs. 86%, p=0.01); however, using both techniques, sensitivity increased to 95%. ConclusionsMRCP is superior to US for diagnosing biliary strictures after liver transplantation primarily because MRCP can detect stricture. The combination of US and MRCP seems superior to either method alone. Our data suggest that in patients with normal US and MRCP, direct cholangiography could be avoided.

Normal Transvaginal Sonography Endometrial Thickness Measurements Associated With Endometrial Cancer in the Symptomatic Postmenopausal Patient

Carcinoma of the endometrium is a difficult abnormality to diagnose with sonography alone. In this case, a transvaginal sonogram resulted in unremarkable findings to evaluate a postmenopausal patient with vaginal bleeding. Further testing went on to establish a diagnosis of grade 1 endometroid adenocarcinoma.

Imaging the urinary tract in children with urinary tract infection

To evaluate whether ultrasonography (US) alone is sufficient in imaging the urinary tract in 1185 children with urinary tract infection (UTI). The reports on US and voiding cystourethrography (VCUG) were reviewed. Initial US was normal in 861/1185 patients (73%). VCUG revealed abnormal findings in 285/861 (33%), of which grade III-V vesicoureteral reflux (VUR) comprised 97 cases (11%). During follow-up, VUR had resolved in 88/97 (91%) patients: in 50/57 (88%) patients without active treatment for VUR, in 27/29 (93%) with endoscopic and in 11/11 (100%) with open surgery for VUR. During follow-up, 11/97 patients (11%) had developed new renal scarring detectable in US, but no renal impairment occurred. Except for VUR, VCUG showed nonobstructive urethral valves in two infant boys with normal initial US. Thus, in 861 children with normal initial US, 40 patients with grade III-V VUR and two patients with significant nonreflux pathology may have benefited from surgical treatment, giving the total number of possibly missed pathological finding in 42/861 (4.9%) cases if VCUG had not been performed. We suggest that children with UTI could be examined using US alone and to use VCUG only after additional indications.

Clinical presentation and metabolic features of overt and occult urolithiasis

Although pediatricians are frequently confronted with patients presenting urolithiasis symptoms without obvious stones, the syndrome of occult urolithiasis may be still viewed with some skepticism. We have compared the clinical and metabolic features of 197 children with obvious calculi, 189 with microcalculi (diameter ≤ 3 mm based on renal sonography), and 114 with symptoms of urolithiasis and normal renal sonography findings. Only microcalculi and normal sonography subjects with a urinary abnormality potentially leading to urolithiasis were included in the study. Age at presentation increased significantly (p = 0.0001) in the groups in the order normal sonography to microcalculi to calculi groups. There was no significant difference among the three groups in terms of family history of urolithiasis, gender distribution, and degree of hypercalciuria, hyperuricosuria, hyperoxaluria, or hypocitraturia. The average frequency of pain attacks of patients with recurrent abdominal pain (RAP) ranged from 3.6 to 4.6 days of pain per month among the three groups, which is four to ninefold lower than that reported for children with functional or organic gastrointestinal RAP. The consistency of many clinical and urinary metabolic characteristics indicates a common underlying disorder in overt and occult urolithiasis. The increase of age at presentation from the normal sonography to microcalculi and calculi groups may reflect progressive crystal accretion leading ultimately to overt stone formation.

Pelvic ultrasound immediately following MDCT in female patients with abdominal/pelvic pain: is it always necessary?

To determine the added value of reimaging the female pelvis with ultrasound (US) immediately following multidetector CT (MDCT) in the emergent setting. CT and US exams of 70 patients who underwent MDCT for evaluation of abdominal/pelvic pain followed by pelvic ultrasound within 48 h were retrospectively reviewed by three readers. Initially, only the CT images were reviewed followed by evaluation of CT images in conjunction with US images. Diagnostic confidence was recorded for each reading and an exact Wilcoxon signed rank test was performed to compare the two. Changes in diagnosis based on combined CT and US readings versus CT readings alone were identified. Confidence intervals (95%) were derived for the percentage of times US reimaging can be expected to lead to a change in diagnosis relative to the diagnosis based on CT interpretation alone. Ultrasound changed the diagnosis for the ovaries/adnexa 8.1% of the time (three reader average); the majority being cases of a suspected CT abnormality found to be normal on US. Ultrasound changed the diagnosis for the uterus 11.9% of the time (three reader average); the majority related to the endometrial canal. The 95% confidence intervals for the ovaries/adnexa and uterus were 5-12.5% and 8-17%, respectively. Ten cases of a normal CT were followed by a normal US with 100% agreement across all three readers. Experienced readers correctly diagnosed ruptured ovarian cysts and tubo-ovarian abscesses (TOA) based on CT alone with 100% agreement. US reimaging after MDCT of the abdomen and pelvis is not helpful: (1) following a normal CT of the pelvic organs or (2) when CT findings are diagnostic and/or characteristic of certain entities such as ruptured cysts and TOA. Reimaging with ultrasound is warranted for (1) less-experienced readers to improve diagnostic confidence or when CT findings are not definitive, (2) further evaluation of suspected endometrial abnormalities. A distinction should be made between the need for immediate vs. follow-up imaging with US after CT.