Ultrasonography of intrascrotal torsed appendages: size and interval between symptom onset and the ultrasonographic examination according to echogenicity

Purpose@#This study investigated the size of torsed appendages and the interval between symptom onset and the ultrasonographic examination according to the echogenicity of the torsed appendages. @*Methods@#This was a retrospective analysis of 54 cases in 46 patients with torsion of the testicular appendages between December 2008 and July 2021. Eight patients received follow-up ultrasonography 7-48 days after initial ultrasonography. The echogenicity of torsed appendages was classified into three groups: hypoechoic, hyperechoic, or isoechoic. @*Results@#The 54 torsed appendages were hypoechoic (n=40), hyperechoic (n=9), or isoechoic (n=5). The size of the torsed appendages ranged from 4 to 14 mm (8.0±3.1 mm) in hypoechoic torsed appendages and from 2.6 to 5.0 mm (3.7±0.9 mm) in hyperechoic torsed appendages. The interval between symptom onset and the ultrasonographic examination ranged from 0 to 17 days (4.2±4.4 days) in hypoechoic torsed appendages and from 8 to 48 days (29.8±16.0 days) in hyperechoic torsed appendages. The hyperechoic torsed appendages were smaller and had longer intervals between symptom onset and the ultrasonographic examination than the hypoechoic torsed appendages (P<0.05). Three hypoechoic torsed appendages and a single isoechoic torsed appendage on initial ultrasonography became hyperechoic on follow-up ultrasonography. @*Conclusion@#The size of the torsed appendages and the interval between symptom onset and the ultrasonographic examination varied according to the echogenicity of the torsed appendages. The hyperechoic torsed appendages were smaller and had longer intervals until the examination than the hypoechoic torsed appendages.

Various Intratesticular Hypoechoic Lesions on Scrotal Sonography

Sonography with a high-frequency transducer is the modality of choice for imaging the scrotum. Most intratesticular lesions are hypoechoic. Differentiation of intratesticular hypoechoic lesions as either malignant or benign is important because the treatment of these lesions vary. In this paper, we review the sonographic features of different types of intratesticular hypoechoic lesions, such as testicular cysts, testicular tumors, testicular inflammatory lesions, segmental testicular infarction, and testicular trauma.

Small testes: clinical characteristics and ultrasonographic findings

The purpose of this pictorial essay is to describe the ultrasonographic and clinical findings of patients with small testes due to a wide range of causes. We retrospectively reviewed the ultrasonographic and clinical findings of various causes of small testes. We present various causes of small testes on ultrasonography including Klinefelter syndrome, testicular torsion, mumps orchitis, inguinal hernia, cryptorchidism, varicocele, and trauma. On ultrasonography, small testes in patients with testicular torsion, mumps orchitis, and trauma usually showed heterogeneous echogenicity. Atrophic testes were homogeneously hypoechoic in patients with cryptorchidism and inguinal hernia and were isoechoic to the normal testis in patients with varicocele. Klinefelter syndrome patients had small hyperechoic or hypoechoic nodules, but the echogenicity of the remnant portion of the testes was homogeneous. Ultrasonography is helpful for detecting small testes and for the differential diagnosis of the various possible causes of small testes.

Testicular atrophy after mumps orchitis: ultrasonographic findings

Purpose@#The purpose of this study was to describe the ultrasonographic findings of testicular atrophy after mumps orchitis. @*Methods@#We retrospectively reviewed the case files of eight patients (14 to 24 years old; mean, 17 years) with mumps orchitis and testicular atrophy who were treated between January 2011 and September 2017. On gray-scale and color Doppler, the ultrasonographic features of volume, shape, echogenicity, and degree of blood flow in the testes were analyzed as part of both initial and follow-up ultrasonography. The duration between the initial diagnosis of mumps orchitis and the ultrasonographic diagnosis of testicular atrophy after mumps orchitis ranged from 25 to 230 days (mean, 95.9 days). @*Results@#Of the eight patients with testicular atrophy after mumps orchitis, the testes were affected unilaterally in seven patients (6 right-sided and 1 left-sided) and bilaterally in one patient. The affected testes (n=9) were 23%-55% (mean, 44.7%) smaller in volume (mean, 6.3±2.0 mL) than the contralateral normal testes (n=7) (mean, 10.8±2.3 mL) on follow-up ultrasonography (P=0.001). The shape of the atrophic testes was oblong in seven cases and elliptical in two cases. The atrophic testes were either heterogeneously hypoechoic with multiple hyperechoic islands (n=7) or heterogeneously hyperechoic (n=2). On follow-up color Doppler ultrasonography, the degree of vascularity of the atrophic testis was either similar to (n=3) or lower than (n=6) that of the contralateral testis. @*Conclusion@#On ultrasonography, atrophic testes after mumps orchitis tended to exhibit an oblong shape, heterogeneous low echogenicity with multiple hyperechoic islands, and decreased vascularity.

Groin abnormalities: ultrasonographic and clinical findings

Groin lesions can be classified as neoplastic or non-neoplastic. Neoplastic lesions include lipoma, epidermoid cyst, angiomyofibroblastoma-like tumor, liposarcoma, and synovial sarcoma, as well as metastases from lymphoma, neuroendocrine carcinoma, and carcinomas of the lung, breast, urinary bladder, ovary, vulva, and colon. Non-neoplastic lesions include hernias, round ligament varices, endometriosis, Kimura disease, Castleman disease, hematoma, and inflammation. Because the clinical implications and therapeutic strategies for groin lesions vary depending on the cause, the ability to noninvasively differentiate among etiologies is very important. Although there is substantial overlap in ultrasonographic findings across various groin lesions, some ultrasonographic features, along with clinical characteristics, may suggest a specific diagnosis. Familiarity with the ultrasonographic and clinical features of various groin lesions facilitates accurate diagnosis and treatment.

Predictive Performance of Ultrasound-Determined Non-Alcoholic Fatty Pancreas Disease Severity for Intermediate and High Risk of Coronary Heart Disease

PURPOSE@#To evaluate non-alcoholic fatty pancreas disease severity on ultrasound (US-determined NAFPD) as a risk factor for coronary heart disease (CHD) and to evaluate its predictive value for intermediate/high CHD risk compared with US-determined non-alcoholic fatty liver disease (US-determined NAFLD) severity.@*MATERIALS AND METHODS@#A retrospective analysis of 544 young adults, aged 18–40 years, was performed. NAFPD and NAFLD were classified as absent, mild, moderate, and severe. CHD risk was calculated using the Framingham Risk Score (FRS). Correlation, multivariate logistic regression, and receiver operating characteristic curve analyses were used to compare the predictive performance.@*RESULTS@#FRS increased with increasing US-determined NAFPD severity (r = 0.624, p < 0.001), with a concomitant increase in the odds ratio for intermediate/high CHD risk. There was no difference between the predictive performance of US-determined NAFLD and NAFPD severities for intermediate/high CHD risk (p = 0.17). The combination of US-determined NAFPD and NAFLD severities significantly improved the differentiation between intermediate and high CHD risk (predictive value, 0.807; p < 0.001).@*CONCLUSION@#US-determined NAFPD severity was well-correlated with FRS and associated with the prevalence of intermediate/high CHD risk. The combination of US-determined NAFPD and NAFLD severities may be useful for predicting CHD risk.

Principles for evaluating the clinical implementation of novel digital healthcare devices

With growing interest in novel digital healthcare devices, such as artificial intelligence (AI) software for medical diagnosis and prediction, and their potential impacts on healthcare, discussions have taken place regarding the regulatory approval, coverage, and clinical implementation of these devices. Despite their potential, ‘digital exceptionalism’ (i.e., skipping the rigorous clinical validation of such digital tools) is creating significant concerns for patients and healthcare stakeholders. This white paper presents the positions of the Korean Society of Radiology, a leader in medical imaging and digital medicine, on the clinical validation, regulatory approval, coverage decisions, and clinical implementation of novel digital healthcare devices, especially AI software for medical diagnosis and prediction, and explains the scientific principles underlying those positions. Mere regulatory approval by the Food and Drug Administration of Korea, the United States, or other countries should be distinguished from coverage decisions and widespread clinical implementation, as regulatory approval only indicates that a digital tool is allowed for use in patients, not that the device is beneficial or recommended for patient care. Coverage or widespread clinical adoption of AI software tools should require a thorough clinical validation of safety, high accuracy proven by robust external validation, documented benefits for patient outcomes, and cost-effectiveness. The Korean Society of Radiology puts patients first when considering novel digital healthcare tools, and as an impartial professional organization that follows scientific principles and evidence, strives to provide correct information to the public, make reasonable policy suggestions, and build collaborative partnerships with industry and government for the good of our patients.

Principles for evaluating the clinical implementation of novel digital healthcare devices

With growing interest in novel digital healthcare devices, such as artificial intelligence (AI) software for medical diagnosis and prediction, and their potential impacts on healthcare, discussions have taken place regarding the regulatory approval, coverage, and clinical implementation of these devices. Despite their potential, ‘digital exceptionalism’ (i.e., skipping the rigorous clinical validation of such digital tools) is creating significant concerns for patients and healthcare stakeholders. This white paper presents the positions of the Korean Society of Radiology, a leader in medical imaging and digital medicine, on the clinical validation, regulatory approval, coverage decisions, and clinical implementation of novel digital healthcare devices, especially AI software for medical diagnosis and prediction, and explains the scientific principles underlying those positions. Mere regulatory approval by the Food and Drug Administration of Korea, the United States, or other countries should be distinguished from coverage decisions and widespread clinical implementation, as regulatory approval only indicates that a digital tool is allowed for use in patients, not that the device is beneficial or recommended for patient care. Coverage or widespread clinical adoption of AI software tools should require a thorough clinical validation of safety, high accuracy proven by robust external validation, documented benefits for patient outcomes, and cost-effectiveness. The Korean Society of Radiology puts patients first when considering novel digital healthcare tools, and as an impartial professional organization that follows scientific principles and evidence, strives to provide correct information to the public, make reasonable policy suggestions, and build collaborative partnerships with industry and government for the good of our patients.

Ultrasonographic diagnosis of ovary-containing hernias of the canal of Nuck

PURPOSE: The purpose of this study is to describe the ultrasonographic findings of ovary-containing hernias of the canal of Nuck. METHODS: This was a retrospective analysis of 22 hernia cases of the canal of Nuck. The following gray scale and color Doppler ultrasonographic features were analyzed: the site and the size of the hernia, the texture of the hernia contents, and the presence or absence of blood flow in the hernia contents. RESULTS: All of the patients had swelling of the right inguinal region (n=10), left inguinal region (n=8), or both (n=2). On ultrasonography, the hernias appeared as either solid masses (n=17) or solid masses containing cysts (n=5). The mean anteroposterior diameter of the hernia sac of the canal of Nuck was 9.1 mm (range, 5 to 18 mm). The mean anteroposterior diameters of the hernia sac were 11.6 mm (range, 7.6 to 18 mm) for hernias containing an ovary, and 8.3 mm (range, 5 to 13 mm) for hernias containing omental fat. During surgery, among the 17 cases with solid-appearing hernia contents on ultrasonography, omental fat was identified in the hernia sac in four cases, but no structure was identified in 13 cases. All five cases that appeared as solid masses containing cysts on ultrasonography contained ovary tissue in the hernia sac. Among the four cases of ovary-containing hernias, color Doppler ultrasonography identified blood flow within the ovary in three cases, but no flow signal was seen in one case of incarcerated hernia. CONCLUSION: Ultrasonography may be helpful for the diagnosis of ovary-containing hernias of the canal of Nuck by detecting solid masses containing small cysts.

The challenges related to a new medical insurance policy for ultrasounds and their solutions

In the Republic of Korea, medical insurance coverage for ultrasounds began on October 1, 2013 for four major categories of illness: cancer, heart disease, cerebrovascular disorders, and rare and incurable diseases. However, several problems associated with this ultrasound insurance coverage have arisen: broad classification of ultrasound examination procedures, small and distorted insurance fees, and inappropriate insurance fee calculation methods. In order to prevent the deterioration of medical quality as well as confusion in the medical field, it is necessary that the Ministry of Health and Welfare, the Korean Medical Association, and other ultrasound-related academic societies cooperate to subdivide the classification of ultrasound examination procedures, modify the insurance fee, and properly calculate the ultrasound insurance fee.

Correlation of the Speed of Enhancement of Hepatic Hemangiomas with Intravoxel Incoherent Motion MR Imaging

PURPOSE: To evaluate the relationship between the speed of enhancement of hepatic hemangiomas on gadolinium-enhanced MRI and ADC values by using various parameters, including the D, f, D* and ADC(fit) on intravoxel incoherent motion (IVIM) MR Imaging. MATERIALS AND METHODS: The institutional review board approved this retrospective study. A total of 47 hepatic hemangiomas from 39 patients were included (20 men and 19 women). The hemangiomas were classified into three types according to the enhancement speed of the hepatic hemangiomas on gadolinium-enhanced dynamic T1-weighted images: rapid (Type A), intermediate (Type B), and slow (Type C) enhancement. The D, f, D* and ADC(fit) values were calculated using IVIM MR imaging. The diffusion/perfusion parameters and ADC values were compared among the three types of hemangiomas. RESULTS: Both the ADC(fit) and D values of type C were significantly lower than those of type A (P = 0.0022, P = 0.0085). However, for the f and D*, there were no significant differences among the three types. On DWI with all b values (50, 200, 500 and 800 sec/mm2), the ADC values of type C were significantly lower than those of the type A (P < 0.012). For b values with 800 sec/mm2, the ADC800 values of the type C hemangiomas were significantly lower than those of type B (P = 0.0021). We found a negative correlation between hepatic hemangioma enhancement type and ADC50 (rho= -0.357, P = 0.014), ADC200 (rho= -0.537, P = 0.0001), ADC500 (rho= -0.614, P = 0.0001), and ADC800(rho= -0.607, P = 0.0001). Therefore, four ADC values of ADC50, ADC200, ADC500, and ADC800 were decreased with decreasing enhancement speed. CONCLUSION: Hepatic hemangiomas had variable ADCs according to the type of enhancement, and the reduced ADCs in slowly enhancing hemangiomas may be related to the reduced pure molecular diffusion (D).

Retroperitoneal Synovial Sarcoma Manifested by Obstructive Jaundice in an Elderly Woman: Case Report

Synovial sarcoma is a rare type of soft tissue sarcoma that arises in tissues containing synovial fluid, usually in the extremities. It has only rare occurrence in the retroperitoneal space. Early detection of retroperitoneal synovial sarcoma is difficult, since the retroperitoneal space is highly expandable and deeply hidden. Furthermore, the presenting symptoms are often vague and nonspecific, and are related to the pressure on adjacent structures. In this study, we present an unusual case of retroperitoneal synovial sarcoma with obstructive jaundice due to intrabiliary blood clots caused by invasion of bile duct by tumor. The obstructive jaundice was relieved through endoscopic removal of the blood clots and insertion of a biliary stent.

Sonography of Kimura's Disease in the Groin

Kimura's disease is a rare chronic inflammatory disorder mimicking a malignant tumor. It usually occurs in the head and neck regions, but occasionally shows up in the groin. A gray-scale groin sonograph showed a lobulated hypoechoic mass. Color Doppler sonography revealed the paucity of blood vessels within the mass.

Imaging Findings of Scrotal Tumors in Children: A Pictorial Essay

The diagnosis of scrotal tumors in children can be challenging because of the rarity, vague symptoms, and varied imaging features of the tumors. The pathology and frequency of scrotal tumors that occur in children are different from tumors that arise in adults. In this pictorial essay, we illustrate the imaging findings of scrotal tumors in children with pathological correlations. In addition, we present the clinical manifestations that are valuable for a differential diagnosis. Familiarity with the imaging findings and clinical manifestations of pediatric scrotal tumors may be helpful in making an accurate diagnosis and providing proper patient management.

Breast Ultrasound Examination with Video Monitor System: A Satisfaction Survey among Patients

PURPOSE: The purpose of this study is to assess the patients satisfaction with a newly established video-monitor system and the associated basic items for performing breast ultrasound exams by conducting a survey among the patients. MATERIALS AND METHODS: 349 patients were invited to take the survey and they had undergone breast ultrasound examination once during the 3 months after the monitor system has been introduced. The questionnaire was composed of 8 questions, 4 of which were about the basic items such as age, gender and the reason of their taking the breast ultrasound exam, their preference for the gender of the examiner and the desired length of time for the examination. The other 4 question were about their satisfaction with the video monitor. The patients were divided into two groups according to the purposes of taking the exams, which were screening or diagnostic purposes. The results were compared between these 2 groups. The satisfaction with the video monitor system was assessed by using a scoring system that ranged from 1 to 5. RESULTS: For the total patients, the screening group was composed of 124 patients and the diagnostic group was composed of 225. The reasons why the patients wanted to take the examinations in the diagnostic group varied. The questionnaire about the preference of the gender of the examiner showed that 81.5% in the screening group and 79.1% in the diagnostic group preferred a woman doctor. The required, suitable time for the breast ultrasound examination was 5 to 10 minutes or 10 to 15 minutes for about 70% of the patients. The mean satisfaction score for the video monitor system was as high as 3.95 point. The portion of patients in each group who answered over 3 points for their satisfaction with the monitor system was 88.7% and 94.2%, respectively. CONCLUSION: Our study showed that patients preferred 5-15 minutes for the length of the examination time and a female examiner. We also confirmed high patient satisfaction with the video monitor system.

Reviews of Radiation Protection and Shielding for Computed Tomography in Foreign Countries / 의학물리

A computed tomography (CT) is a powerful system for the effectively fast and accurate diagnosis. The CT system, therefore, has used substantially and developed for improving the performance over the past decade, resulting in growing concerns over the radiation dose from the CT. Advanced CT techniques, such as a multidetector row CT scanner and dual energy or dual source CT, have led to new clinical applications that could result in further increases of radiation does for both patients and workers. The objective of this study was to review the international guidelines of the shielding requirements for a CT facility required for a new installation or when modifying an existing one. We used Google Search Engine to search the following keywords: computed tomography, CT regulation or shield or protection, dual energy or dual source CT, multidetector CT, CT radiation protection, and regulatory or legislation or regulation CT. In addition, we searched some special websites, that were provided for sources of radiation protection, shielding, and regulation, RSNA, AAPM, FDA, NIH, RCR, ICRP, IRPA, ICRP, IAEA, WHO (See in Table 1 for full explanations of the abbreviations). We finally summarized results of the investigated materials for each country. The shielding requirement of the CT room design was very well documented in the countries of Canada, United States of America, and United Kingdom. The wall thickness of the CT room could be obtained by the iso-exposure contour or the point source method. Most of documents provided by international organizations were explained in importance of radiation reduction in patients and workers. However, there were no directly-related documents of shielding and patient exposure dose for the dual energy CT system. Based international guidelines, the guideline of the CT room shielding and radiation reduction in patients and workers should be specified for all kinds of CT systems, included in the dual energy CT. We proposed some possible strategies in this paper.

Evaluation of Atherosclerotic Plaque in Patients without Coronary Artery Calcification Using Multidetector Row Computed Tomography: A Preliminary Report of 110 patients

PURPOSE: We analyzed the frequency and characteristics of atherosclerotic plaques in the patients without coronary artery calcification (CAC) by the use of multidetector row CT (MDCT). In addition, we analyzed patients with negative CAC to guarantee the absence of coronary artery disease (CAD). MATERIALS AND METHODS: One hundred-ten patients with a suspicion of CAD and no CAC as detected on 16-slice and 64-slice MDCT were enrolled in this retrospective study. We analyzed the frequency of atherosclerotic plaques. For characterizing the atherosclerotic plaques, location, attenuation, volume, the degree of stenosis, and the remodeling index (RI) were analyzed. RESULTS: Atherosclerotic plaques were detected in 8 patients (7.3%). The plaques were located in the right coronary artery (n=3), left anterior descending artery (n=3), and left main coronary artery (n=2). Attenuation, volume, stenosis and RI were 41.4+/-16.6 HU (range, 20.2 - 69.9 HU), 55+/-55 mm3 (range, 15-179 mm3), 40.7+/-16.3% (range,16.0-68.0%) and 1.35+/-0.13 (range, 1.16-1.50). Lipid rich plaque and significant stenosis were detected in 6 patients and in 2 patients, respectively. CONCLUSION: Despite negative CAC as detected on MDCT, atherosclerotic plaque might have significant stenosis or lipid rich plaque. Therefore, negative CAC does not seem to guarantee the absence of CAD. Coronary CT angiography was recommended for patients with negative CAC.

Ultrasonographic Features of a Colovesical Fistula Arising Secondary to Sigmoid Colon Diverticulitis: A Case Report

Colovesical fistulae secondary to diverticulitis usually manifest themselves as non-specific lower abdominal discomfort and urologic symptoms. CT is known to be the most sensitive modality for diagnosing this entity. Ultrasonography is the initial diagnostic tool used for evaluating patients with these symptoms, but there have been no reports describing the ultrasonographic findings of colovesical fistulae in Korea. Therefore, we present a case of an ultrasonographically diagnosed colovesical fistula complicating sigmoid diverticulitis. Color Doppler ultrasonography was used in conjunction with lower abdominal compression in order to determine if the fistulous tract was open or obliterated.

Which Factors Influence the Detection of an Inflamed Appendix: Comparative Assessment of Ultrasonography and CT

PURPOSE: To compare and assess factors influencing the detection of an inflamed appendix by both ultrasonography (US) and CT. MATERIALS AND METHODS: We retrospectively analyzed US and CT findings of 58 patients with confirmed acute appendicitis (42 patients with perforation and 16 patients without perforation), in which both preoperative US and CT scans were performed. We compared the use of US and CT for the diagnostic accuracy of acute appendicitis, and determined the detection rate for an inflamed appendix. According to the location of the appendix, the amount of mesenteric fat content in lower abdominal cavity, the presence of cecal wall thickening, and the presence of pericecal fluid or an abscess, the use of US and CT were compared for the determination of the detection rate of an inflamed appendix. RESULTS: The diagnostic accuracies for US and CT for acute appendicitis in our study group were both 93.1%, and there was no difference between the use of the two modalities. Although the detection rate of an inflamed appendix was slightly higher for US (93.1%) than for CT (84.5%), the difference between the use of the two modalities was not significant (p > 0.05). There was no significant difference in the detection rate of an inflamed appendix between the use of US and CT according to location of appendix, the amount of mesenteric fat content and the presence of cecal wall thickening. A pelvic location of the inflamed appendix and the presence of pericecal fluid or an abscess, were factors that significantly increased the detection rate for US than for CT (p < 0.05). CONCLUSION: The use of US for diagnosis of acute appendicitis is as useful as the use of CT. US is especially useful to detect an inflamed appendix more effectively than CT in cases where the appendix is in a pelvic location and presents with pericecal fluid or an abscess.

Usefulness of Abdominal Aortic Calcification for Screening of Peripheral Vascular Disease

PURPOSE: We wanted to evaluate the value of abdominal aortic calcification (AAC), as detected on CT, as a predictor of atherosclerotic stenotic disease of the lower extremity arteries. MATERIALS AND METHODS: One hundred three patients who had CT angiography performed for the evaluation of peripheral vascular disease were enrolled in this retrospective study. The volume (mm3) of the AAC was measured on CT. Each lower extremity was divided into 8 segments. The extent of stenosis of the lower extremity artery was manifested as the sum of the stenosis scores for 16 segments (total stenosis score: TSS). The significant stenosis scores (SSS-50 and SSS-75) were defined as the sum of scores for the lower extremity artery segments that had significant stenosis of more than 50% and 75%, respectively. AAC was correlated to the TSS, SSS-50 and SSS-75 with using Spearman's correlation coefficient. The diagnostic performance of AAC for stenosis of a lower extremity artery of more than 50% and 75%, respectively, was evaluated by using the receiver operating characteristic (ROC) curve RESULTS: The Spearman's correlation coefficients were 0.728 (AAC vs. TSS), 0.662 (AAC vs. SSS-50), and 0.602 (AAC vs. SSS-75), respectively. For significant stenosis more than 50% and 75%, the areas under the ROC curve were 0.898 and 0.866, respectively. The cutoff value, sensitivity, specificity, positive predictive value, negative predictive value and accuracy were 1030 mm3, 87%, 88%, 89%, 86% and 87% for stenosis more than 50% and 1030 mm3, 87%, 80%, 79%, 88% and 84% for stenosis more than 75%, respectively. CONCLUSION: Abdominal aortic calcification detected on CT may be a useful predictor of atherosclerotic stenotic disease of lower extremity arteries.