US-guided Aspiration Research Articles

Management of splenic abscess: report on 16 cases from a single center

Splenic abscess is an uncommon disease, with a reported incidence of 0.14-0.7% in autoptic series. The best treatment option remains unclear. We report our experience of percutaneous drainage of splenic abscess under ultrasound (US) guidance. From 1979 to 2005, 16 consecutive patients (12 male and four female; mean age 39.9 years, range 16-72 years) were diagnosed with splenic abscess by means of US, and were treated with medical therapy alone or combined with US-guided percutaneous aspiration or catheter drainage. Ten of 16 patients had bacterial abscesses (including one case of tubercular abscess), two had an amebic abscess, and four had fungal abscesses. Seven of ten patients with bacterial abscesses were successfully treated with fine needle aspiration alone, one patient was successfully treated with fine needle aspiration for one abscess and catheter drainage for another, and one patient, who subsequently required a splenectomy for an abdominal trauma, successfully underwent percutaneous catheter drainage alone. Four patients with fungal lesions were treated with medical therapy alone, and two patients later required a splenectomy. One patient with a bacterial abscess due to endocarditis was treated with medical therapy alone, and his recovery was uneventful. US-guided percutaneous aspiration of splenic abscesses is a safe and effective procedure. It can be used as a bridge to surgery in patients who are critically ill or have several comorbidities. Percutaneous aspiration may allow complete non-operative healing of splenic abscesses or temporize patients at risk for surgery.

Letters to the Editor

Letters to the Editor

Treatment of breast abscesses with ultrasound-guided aspiration and irrigation in the emergency setting

The purpose of our study was to describe the efficacy of ultrasound (US)-guided aspiration and intracavitary irrigation of breast abscesses in the emergency setting. Ten cases of mastitis clinically suspected of having a breast abscess were referred from the emergency department for breast ultrasound. Eleven abscesses depicted at US were treated with US-guided aspiration and intracavitary irrigation. All patients were given antibiotics, and the success of US-guided treatment was determined. Three abscesses that were smaller than 3 cm were treated with single aspiration and irrigation. Ninety-one percent of patients were cured with US-guided aspiration and irrigation requiring no further surgical intervention. One case of chronic mastitis fistulized to the skin and was drained surgically. No recurrences were observed in the follow-up period. US-guided percutaneous aspiration and irrigation is a successful method for treatment of breast abscesses in the emergency setting. This method is more successful in abscesses with a maximum dimension smaller than 3 cm and should be preferred to the surgical drainage.

Percutaneous drainage as the treatment of choice for neonatal ovarian cysts

Involution of neonatal ovarian cysts occurs usually by 12 months. Persisting cysts larger than 4 cm are prone to torsion. Two modes of therapy are advocated: surgery and percutaneous US-guided cyst aspiration. To compare ovarian preservation following the use of US-guided aspiration or conventional surgery for the treatment of large asymptomatic neonatal ovarian cysts, and to suggest alternative treatment when intrauterine ovarian torsion occurs. The study population comprised 25 baby girls with an ovarian cyst, 5 with a simple cyst and 20 with a complex cyst. Of these 25 infants, 8 had surgery and 17 had US-guided cyst aspiration. In the surgical group of 8, 6 underwent oophorectomy, and in 2 the ovary was saved. In the aspirated group of 17, the ovary was saved in 10, and was lost in 5. At the time of this report one patient was still in the follow-up period, and one was lost to follow-up. US-guided aspiration of large neonatal cysts preserves ovarian tissue in a higher percentage of patients than surgery. It is safe, effective, and repeatable. We recommend US-guided aspiration of asymptomatic large ovarian cysts for salvage or for decompression if intrauterine ovarian torsion occurs. Surgery should be reserved for patients with acute torsion, intestinal obstruction and intestinal volvulus.

US-guided Needle Aspiration Treatment of Nonpuerpernal Breast Abscesses in Adolescents

US-guided Needle Aspiration Treatment of Nonpuerpernal Breast Abscesses in Adolescents

Abdominal spilled stones: ultrasound findings

Laparoscopic cholecystectomy (LC) is the treatment of choice for uncomplicated symptomatic gallstones. Spillage of stones due to gallbladder rupture has been reported in up to 33% of all LCs, but clinical sequelae caused by dropped gallstones are uncommon. We recently observed two patients with retained stones after LC. Correct diagnosis was made by abdominal ultrasonography (US) in both cases. In the first patient, who presented with fever, malaise, and weight loss 18 months after LC, abdominal US revealed hypoechoic focal lesions containing hyperechoic images with posterior shadowing of the liver and spleen. US-guided aspiration biopsies of these lesions yielded purulent material, and the injection and aspiration of saline solution provoked rolling movements of the hyperechoic images. Laparotomy confirmed the diagnosis of abscess-containing spilled gallstones. In the second patient, multiple hyperechoic images with posterior shadowing were observed in the Morison pouch during a routine US examination. The diagnosis of retained stones was consistent with the history of gallstone spillage during LC performed 2 months previously and was confirmed by computed tomographic findings of hyperdense images in the Morison pouch. The patient was asymptomatic, and treatment was thus deferred. Our experience suggests that US can be very useful in the detection of gallstones spilled during LC.

Interventional Procedures in Superficial Lesions: The Value of 2D with Additional Coronal Reformatted 4D Ultrasonography Guidance

ObjectiveWe wanted to assess the usefulness of four-dimensional (4D) ultrasonography (US), i.e., real-time three-dimensional US, as an adjunct for performing various US-guided interventional procedures in superficial lesions.Materials and MethodsThirty-three patients were referred for US-guided interventional procedures for superficial lesions, including core biopsy in 19, fine-needle aspiration in eight, therapeutic drug injection in four and needle puncture in two. The procedures were performed under 4D US guidance. We reviewed the pathologic/cytologic results of the core biopsies or needle aspirations, and also the outcomes of drug injection or needle puncture.ResultsFor all the patients who underwent 4D US-guided core biopsy, the specimens were adequate for making the pathological diagnosis, and specimens were successfully obtained for those patients who underwent 4D US-guided aspiration. The patients treated with 4D US-guided therapeutic drug injection or needle puncture had a good response. No major procedure-related complications occurred. The procedural times were similar to those procedural times with using two-dimensional US.ConclusionCombining the two dimensional and 4D US techniques aids the physician when performing US-guided interventional procedures for the superficial lesions.

Management of Ovarian Cysts with Aspiration and Methotrexate Injection

To evaluate prospectively ultrasonography (US)-guided cyst aspiration and methotrexate injection in the management of simple and endometriotic ovarian cysts in selected patients. Authors obtained informed patient consent and approval from hospital ethics committee. Study included 162 female patients (aged 15-77 years) with simple or endometriotic ovarian cysts (3.0-10.6 cm) at a tertiary hospital. Criteria for inclusion in the study were (a) persistence of the cyst for at least 6 months, (b) benign appearance of the cyst at US, and (c) normal serum CA-125 level measurement before the procedure. Authors performed transabdominal aspiration of the cysts with direct US guidance and injection of methotrexate (30 mg). Cytologic examination was performed in all cases. Follow-up US was performed at 1, 3, and 6 months. If the cyst persisted, the procedure could be repeated. Main outcome measure was resolution or persistence of cysts. chi(2) Test or Mantel-Haentszel chi(2) tests for univariate analysis and multiple logistic regression were used for multivariate statistical analysis. Of 162 patients, 148 were available for follow-up. Malignant cells were not found in any of the cases at cytologic examination. At follow-up US, cysts had disappeared in 124 patients (83.8%) and persisted in 24 (16.2%). Cyst diameter proved to be a significant prognostic factor for cyst resolution (P = .01). No major complications were observed. Patients received neither analgesia nor antibiotics. US-guided transabdominal aspiration of cyst fluid and subsequent methotrexate injection appears to be an alternative treatment for both simple and endometriotic ovarian cysts in selected cases.

Littoral Cell Angioma Presenting as Metastatic Thyroid Carcinoma to the Spleen

Papillary thyroid carcinoma (PTC) commonly metastasizes to cervical lymph nodes. Distant metastases are unusual with the lungs most frequently involved. Well-differentiated thyroid carcinoma very rarely presents with metastases to the spleen. This is the case of a 25-year-old man with a history of PTC (1.4 cm primary; no capsular invasion and negative lymph node metastases). One year after initial surgery, recurrent disease was found in multiple neck nodes by central neck dissection. Whole body scan (WBS) following a therapeutic ablation dose of 150 mCi I(131) revealed mediastinal metastases. Computerized axial tomography (CT) of the chest one year later showed no gross mediastinal or pulmonary disease. However, multiple large splenic lesions were incidentally noted. Evaluation by ultrasound (US) showed lesions to be solid echogenic masses without remarkable Doppler characteristics to suggest vascular tumors. US-guided percutaneous fine-needle aspiration biopsy (FNAB) of one lesion was nondiagnostic. After withdrawal from Levothyroxine, serum TSH was >100 mU/L with a thyroglobulin of 9.4 ng/mL and negative anti-thyroglobulin antibodies. Diagnostic WBS revealed faint splenic uptake but was otherwise unremarkable. Following treatment with 192 mCi I(131), WBS demonstrated increased activity in the mediastinum as well as in the spleen suggesting mediastinal and splenic metastases. Contrast CT of the abdomen showed multiple low-attenuated heterogeneously enhancing splenic masses, normal liver and no intra-abdominal lymphadenopathy. The largest mass (4.5 x 3.5 cm) was exophytic and in close proximity to the splenic capsule. Despite the serum thyroglobulin of only 9.4 ng/mL, the finding of I(131) accumulation within solid splenic masses led to a preoperative diagnosis of thyroid carcinoma metastases. To establish the diagnosis and to remove the risk for splenic rupture, a laparoscopic splenectomy was performed. Histopathologic analysis showed large littoral cell angiomas (LCA). False-positive radioiodine scintigraphy in the setting of PTC involving a vertebral hemangioma has been reported. To our knowledge, this is the first case that describes multiple angiomas mimicking metastatic thyroid carcinoma to the spleen. In one-third of all cases reported, LCA co-exists with various visceral organ cancers or malignant lymphoma. This is the first report of an association between LCA and thyroid carcinoma.

Clinical Significance of Ductal Dilatation on Breast Ultrasonogram

With the advent of high-resolution ultrasound (US), dilatation of the lactiferous ducts can be easily demonstrated at routine breast US examination. The purpose of this study was to prospectively evaluate the clinical significance of ductal dilatation detected on breast US study. During a period of 12 months, we examined 16,336 nonlactating women referred for breast US; about 2.5% of them had a known history of nipple discharge. Routine whole breast US examinations were performed by using high-resolution US scanners. More attention was paid to detect and document the dilated ducts in the breasts. Among the 16,336 nonlactating women, 478 (2.9%) had duct dilatation (defined as duct diameter > 2.0 mm). Patients with dilated ducts were either followed-up for at least 2 years or were aspirated or biopsied according to their US findings. Of the 478 women with duct dilatation, 387 (81.0%) had no significant internal echoes in the dilated ducts, 48 (10.0%) had low-level internal echoes inside the ducts, and 39 (8.2%) had medium-level to relatively high-level internal echoes. Solid nodules in the ducts were demonstrated in 26 (5.4%) women, and calcified material in five (1.0%). For patients with intraductal echoes, US-guided aspiration or biopsy was performed to determine the duct contents; 18 of 26 intraductal nodules were shown to be intraductal papilloma cytologically and/or histopathologically, two were shown to be intraductal carcinoma in situ, and five were epithelial hyperplasia or atypical ductal hyperplasia. The majority of the other 61 women with internal echoes were found to have inspissated secretions (50/61, 82.0%), while the remaining 11 showed no cellular component inside, but the findings were inconclusive. Multiple dilated ducts depicted on US are rarely associated with intraductal tumors (p < 0.001). If US can demonstrate solid nodules in the dilated duct, the possibility of intraductal tumor, especially papilloma, should be considered first. Routine and cautious evaluation of the dilated duct may depict intraductal tumor even in women without nipple discharge, and may facilitate surgical intervention without unnecessary delay.

Reply: Remarks on sentinel node biopsy in head and neck cancer

Reply: Remarks on sentinel node biopsy in head and neck cancer

Breast abscess in lactating women: US-guided treatment.

To retrospectively evaluate the use of ultrasonography (US)-guided treatment of breast abscesses in lactating women. One hundred eight consecutive lactating women who were clinically suspected of having a breast abscess were examined with US. Abscesses depicted at US were treated with US guidance, and the success of US-guided treatment was retrospectively determined. Fifty-six abscesses were identified at US in 43 women; all abscesses were treated with US guidance: 23 with needle aspiration and 33 with catheter drainage. Treatment method was determined according to the size of the abscess. Abscesses that were smaller than 3 cm in maximum diameter were treated with needle aspiration, and abscesses that were 3 cm or larger in maximum diameter were treated with catheter insertion. One patient who was treated with needle aspiration subsequently underwent surgical intervention; all others were successfully treated with US intervention. Catheter placement was well tolerated (mean pain score 2.3 in 22 women by using a subjective pain scale of 0-10). US-guided needle aspiration of abscesses smaller than 3 cm and US-guided catheter drainage of abscesses 3 cm or larger are successful means of treating breast abscesses.

Prostatic abscess: transrectal color Doppler ultrasonic diagnosis and minimally invasive therapeutic management

The purpose of this study was to analyze the transrectal ultrasound (US), or TRUS, and color Doppler ultrasonography (CDU) findings and therapeutic strategies with TRUS-guided procedures in 13 patients with prostatic abscess. Over a period of 6 years, 18 prostatic abscesses were diagnosed in 13 patients (mean age: 59 years). Diagnostic workup included TRUS, analysis of midstream urine, and analysis and culture of abscess fluid for leukocytes and pathogens. These patients were treated either conservatively (for abscess cavities < 1 cm in diameter), or by aspiration or draining procedures (cavities ≥ 1 cm). The transrectal CDU findings were correlated to the treatment effects. The predisposing factors were also reviewed. In the 13 patients, the most common clinical symptom and sign were urinary frequency (77%) and pus cell in the midstream urine (92%). Predisposing factors were found in 11 men, with diabetes in 5 of them. In 10 patients, the definitive preinterventional diagnosis was based on the TRUS findings. TRUS with probe palpation demonstrated tiny floating echogenic speckles in the abscess cavity in 4 patients. CDU demonstrated increased color-flow signals at the margin and surrounding tissue of the abscess pockets. Abscesses with poorly defined boundaries had more prominent surrounding color-flow signals and achieved, with relative difficulty, a satisfactory aspiration procedure. Aspiration was done for all 11 abscesses between 1 and 3 cm. A total of 4 larger abscesses (> 3.0 cm) were treated with aspiration or drainage using a 5-French pigtail catheter. No surgical drainage was performed. Transrectal CDU may help in the evaluation of maturity of an abscess pocket. US-guided aspiration with an 18-gauge needle or drainage with a 5-French pigtail catheter significantly shortened the hospital stay. (E-mail: yhchou@vghtpe.gov.tw)

Living donor liver transplantation: complications in donors and interventional management.

To evaluate the incidence of postoperative complications in liver donors and the efficacy of interventional management for treating these complications. The study included 386 consecutive donors: 219 donors underwent right lobectomy or segmentectomy and 167 donors underwent left lobectomy or segmentectomy. Postoperative status, laboratory data, and radiologic images were reviewed for postoperative complications. Interventional management consisted of percutaneous drainage, ultrasonographic (US)-guided aspiration, percutaneous transhepatic biliary drainage (PTBD) and balloon dilation, transcatheter arterial embolization, or portal vein stent placement. Technical success, clinical improvement, and complications were documented following intervention. In 52 (13.5%) donors, 56 postoperative complications were encountered, including pleural effusion (n = 9), biliary leakage (n = 6), biliary obstruction (n = 5), intraperitoneal abscess (n = 5), active bleeding (n = 5), portal vein stenosis or kink (n = 3), biloma (n = 2), and other complications (n = 21). Complications occurred in 41 (18.9%) right lobe and 11 (7.0%) left lobe donors (P <.001). Twenty-seven (48%) complications were treated with interventional management (percutaneous drainage, n = 10; US-guided aspiration, n = 6; PTBD and balloon dilation, n = 4; transcatheter arterial embolization, n = 4; and stent placement, n = 3) and resolved completely. No procedure-related complications occurred. In one donor with venous oozing, arteriographic images did not show an active bleeding focus; thus, bleeding control with interventional management failed. The remaining 29 complications were treated using medical (n = 27) or surgical (n = 2) management. One donor with acute renal failure has thus far been treated with hemodialysis. Although complications from liver donation are not uncommon, most are minor and, with medical or interventional management, have no long-term sequelae. Interventional management seems useful in the treatment of postoperative complications of liver donation.

Sonographic Findings after Total Hip Arthroplasty: Normal and Complications

Purpose: The purpose of this study was to determine the efficacy of sonography in the evaluation of normal pseudocapsular morphology and the detection of complications after total hip arthroplasty. Materials and Methods: Between Janvary 1997 and June 2000, 47 patients [35 men and 12 women aged 24 to 84 (mean, 61) years] using real-time linear-array, convex US units with 3.5-MHz and 10-MHz transducers. Normal capsular morphology in 30 with total hip replacements, who had been asymptomatic for at least one year, was studied, and the prosthetic joint infection demonstrated in six of 17 who had experienced was confirmed at surgery or by US-guided aspiration. Results: Sonograms indicated that a normal pseudocapsule lay straight over the neck of the prosthesis or was slightly convex toward the neck, and that the mean bone-to-pseudocapsule distance was 2.9 mm. However, in the 11 symptomatic patients in whom no evidence of infection was revealed by cultures, th mean distance was 4.7 mm; in the remaining six patients, whose joints were infected (a condition strongly suggested by the presence of extracapsular fluid), the mean distance was 5.5 mm, with no significant difference between the two groups. Conclusion: Sonography can be used to evaluate normal caspular morphology after total hip replacement and to diagnose infection around hip prostheses. In all patients in whom sonography revealed the presence of extra-articular fiuid, infection had occurred.

US-guided Needle Aspiration and Catheter Drainage as an Alternative to Open Surgical Drainage for Uniloculated Neck Abscesses

To prospectively evaluate the effectiveness of ultrasound (US)-guided needle aspiration and catheter drainage as an alternative to open surgical drainage of uniloculated neck abscesses. Fifteen consecutive patients (11 female, four male; age range from 18 days to 78 years, mean 42.5 y +/- 22.4) diagnosed with deep neck infections associated with uniloculated neck abscesses were treated. The patients were originally scheduled for surgical incision and drainage after a period of unsuccessful treatment with antibiotics. US-guided needle aspiration (in 10 patients) and US-guided catheter drainage (in five patients) were performed under local anesthesia. Open surgical drainage was performed when US-guided drainage procedures failed. Surgical open drainage was avoided in 13 of the 15 patients (87%). An average of 6 mL of pus was obtained in patients in the needle aspiration group and 140 mL of pus was drained by catheter. One patient had a recurrent pyogenic lymphadenitis at the same location and was treated successfully by repeated needle aspiration. No complications occurred in this study. In a selected group of patients without imminent airway obstruction, most uniloculated neck abscesses may be managed initially by US-guided needle aspiration and catheter drainage before resorting to open surgical drainage.

ABSCESSES OF THE BREAST. US-guided serial percutaneous aspiration and local antibiotic therapy after unsuccessful systemic antibiotic therapy

Purpose: The usual therapeutic approach to acute breast abscesses (ABAs) not responsive to systemic antibiotics is surgical incision and drainage. Our purpose was to assess the efficacy of treating ABAs with serial US-guided percutaneous aspiration and local injection of antibiotics. Material and Methods: Twenty-six patients with 28 ABAs, in whom systemic antibiotic therapy had failed, underwent serial US-guided aspiration with local injection a of large-spectrum antibiotic. The treatment was repeated weekly until complete resolution was observed at clinical and US examination. The volume of the ABAs was calculated before each US-guided aspiration. Follow-up US examinations were performed at 1, 4, and 12 weeks after clinical and US resolution. A comparison betweeen costs of surgical and US-guided treatment of ABAs in our institution was done. Results: In 27 ABAs the treatment was successful: a progressive volume reduction and a complete resolution at clinical and US examination was observed within 1 to 7 weeks. In 1 case only, with a large ABA markedly increased in volume at the second examination, surgical drainage was performed. Conclusion: US-guided aspiration with local antibiotic injection is a safe and effective approach to ABAs, cheaper than surgical drainage of these lesions.

Bacteriology of infected cavitating lung tumor.

Differentiation between in situ infection and simple tumor necrosis in cavitating lung tumors by means of imaging studies is difficult. In this study, we prospectively investigated the role of ultrasound (US)-guided transthoracic aspiration for bacteriologic examination of infected cavitating lung tumors, and the influence of the culture results on the treatment of patients. Twenty-two patients (18 men and four women) with cavitating lung tumors treated from January 1996 to October 1998 were included. All patients underwent US-guided transthoracic aspiration for bacterial, fungal, and mycobacterial cultures. Microorganisms were isolated from six of seven febrile patients and one of 15 nonfebrile patients. A total of nine pathogens were isolated from seven patients: Klebsiella pneumoniae (n = 3); Haemophilus influenzae (n = 2); Enterococcus faecium (n = 1); Bifidobacterium (n = 1); Shewanella putrefaciens (n = 1); and Mycobacterium tuberculosis (n = 1). Two pathogens were isolated from the aspirate cultures in two patients, while the others had monomicrobial infection. The six febrile patients who had positive lung aspirate cultures were treated with empiric antimicrobial agents before the culture results were available, and the culture results led to adjustment of the antibiotic regimen in five of these. The clinical conditions of the six patients with infected cavitating lung tumors improved after the initiation of individualized antimicrobial treatment. Pneumothorax occurred in one patient, and was the sole procedure-related complication. In conclusion, US-guided transthoracic aspiration is helpful for differentiating infected cavitating lung tumors from simple tumor necrosis. Infection in cavitating lung tumors is common among febrile patients, and the culture results can guide modification of the antimicrobial therapy.

Fascioliasis: US, CT, and MRI findings with new observations.

The purpose of this study is to describe the ultrasonographic (US), computed tomographic (CT), and magnetic resonance imaging (MRI) findings in fascioliasis and to emphasize the impact of radiology in diagnosis. Radiologic findings in 23 consecutive patients with fascioliasis were prospectively recorded. All patients had at least one US and CT examination, and 10 of them were studied by MRI. All diagnoses were confirmed by serologic methods. In the first three cases, initial diagnosis was reached by microscopic demonstration of the parasites' eggs in bile obtained by US-guided gallbladder aspiration. In the hepatic phase of fascioliasis, multiple, confluent, linear, tractlike, hypodense, nonenhancing hepatic lesions were detected by CT. On US, the parasites could be clearly identified in the gallbladder or common bile duct as floating and nonshadowing echogenic particles. MRI showed the lesions as hypo- or isointense on T1-weighted images and as hyperintense on T2-weighted images. CT findings in the hepatic phase and US findings in the biliary phase are characteristic of fascioliasis. Because clinical and laboratory findings of fascioliasis may easily be confused with several diseases, radiologists should be familiar with the specific radiologic findings of the disease to shorten the usual long-lasting diagnostic process.

ULTRASOUND-GUIDED TRANSTHORACIC BIOPSY OF THE CHEST

Recent studies have confirmed that US is a very useful diagnostic tool for various diseases of the chest. The image information provided by US is helpful for etiologic diagnosis and clinical management. US-guided needle biopsy provides a precise and safe approach for transthoracic tissue sampling of lesions. The diagnostic yield is high, and the procedure is relatively easy and very safe. Color Doppler US and amplitude US angiography further extend the diagnostic potential and safety of this invasive procedure. Vascular information can be obtained and the needle shaft can be visualized clearly while conducting a biopsy. US examination and US-guided needle aspiration biopsy have now become indispensable diagnostic tools for various chest diseases.