Multimethod imaging, staging, and spectrum of manifestations of metastatic melanoma.

The incidence of melanoma has been steadily increasing. Imaging plays an important role in tumour assessment as metastatic melanoma can involve multiple organs. Computed tomography (CT) is currently the most widely used technique for tumour staging, surveillance and assessment of therapeutic response, but ultrasound, magnetic resonance imaging (MRI) and positron-emission tomography (PET)-CT also play important roles in the imaging of this tumour. In this article, we review the pathways of spread, staging according to the recently updated TNM classification, pathology, typical and atypical imaging features at common and uncommon sites, and treatment of metastatic melanoma.

Plantar fibromatosis: most common sonographic appearance and variations.

PURPOSE: The aim of this study was to describe the most common sonographic appearances of plantar fibromatosis, thus enabling sonographic diagnosis of this benign, focally invasive fibrous neoplasm. METHODS: The medical records, pathologic reports, and sonographic reports and images of 22 patients with palpable plantar masses were reviewed retrospectively. The sonographic findings were used to characterize those masses with respect to location, shape, size, and echogenicity. Sixteen patients were included in this study because of the proximity of their lesions to the plantar fascia; 6 patients were excluded because their lesions were metatarsophalangeal bursae or ganglia. RESULTS: The 20 feet examined in the 16 patients studied contained 43 distinct lesions, all located on the surface of the plantar fascia. Thirty-seven (86%) of the 43 were 20 mm long or less. Thirty-seven (86%) of the 43 lesions were elongated; the remaining 6 (14%) were round or oval. Twenty-five (68%) of the 37 elongated lesions had tapered ends, and the other 12 (32%) had rounded ends. Thirty-one (72%) of the 43 lesions were hypoechoic; 25 (81%) of these 31 measured as long as 10 mm. Ten (83%) of the 12 lesions that had mixed echogenicity were longer than 10 mm. CONCLUSIONS: The lesions of plantar fibromatosis were characteristically located on the surface of the plantar fascia, sagittally elongated, most often less than 20 mm long, fusiform, and hypoechoic. Lesions longer than 10 mm often exhibited mixed echogenicity. The superficial location and appearance should strongly suggest plantar fibromatosis, although careful examination is required to exclude other possibilities, such as sarcoma.

Ultrasound-guided fine-needle aspiration biopsy of the thyroid bed.

BACKGROUND: Ultrasound (US) has been shown to be a sensitive technique for monitoring patients for recurrent thyroid carcinoma in the thyroid bed after total thyroidectomy. However, the role of US-guided fine-needle aspiration biopsy (FNAB) in the confirmation of sonographically indeterminate or suspicious masses has not been adequately addressed. The purposes of this study were to determine the sensitivity and specificity of US-guided FNAB of the thyroid bed for diagnosing recurrent carcinoma after total thyroidectomy and to highlight potential diagnostic pitfalls. METHODS: Twenty-one patients with a history of total thyroidectomy and histologically confirmed thyroid carcinoma who had undergone US-guided FNAB of hypoechoic lesions in the thyroid bed were included in this retrospective study. Fifteen of the 21 had papillary carcinoma (PC), 5 had medullary carcinoma (MC), and 1 had Hürthle cell carcinoma (HTC). The cytologic features of the aspirates were compared with histopathologic findings of pre- and post-FNA surgery. Immunohistochemical staining for thyroglobulin, calcitonin, and parathyroid hormone was performed in four cases. RESULTS: The cytologic diagnosis from the US-guided FNABs was conclusive in 20 of 21 cases. Fifteen cases were diagnosed as recurrent tumor (12 PC, 2 MC, and 1 HTC), and 13 of the 15 were confirmed subsequently by histology. Five cases were diagnosed as benign (two residual benign thyroid tissue, one parathyroid gland [PG] tissue, and two reparative changes) and hence were not resected. There was one false-positive diagnosis in which PG was misdiagnosed as PC. Immunohistochemical studies helped to confirm the diagnosis of PG tissue in two cases and of MC in two cases. The sensitivity of US-guided FNA for diagnosing recurrent carcinoma in the thyroid bed after total thyroidectomy was 100% and the specificity was 85.7%. CONCLUSIONS: US-guided FNAB was found to be a sensitive and specific test for diagnosing sonographically indeterminate lesions in the thyroid bed. One potential diagnostic pitfall was the misdiagnosis of normal residual thyroid or PG tissue as recurrent tumor. Careful attention to cytologic details and the use of selected immunohistochemical staining may help to prevent these misdiagnoses.

US-guided implantation of metallic markers for permanent localization of the tumor bed in patients with breast cancer who undergo preoperative chemotherapy.

Metallic markers were implanted with ultrasonographic guidance in 51 malignant breast tumors in 49 patients to tag the tumor bed in anticipation of complete or almost complete response to preoperative neoadjuvant induction chemotherapy before breast-conservation surgery. The markers were the only remaining evidence of the original tumor site in 47% (23 of 49) of the patients preoperatively. This technique effectively addresses the problem of preoperative localization of the tumor bed in complete or nearly complete response of breast cancer to neoadjuvant chemotherapy.

Fibromatosis colli of infancy: variability of sonographic appearance.

PURPOSE: We describe the variable sonographic appearances of fibromatosis colli, a disease that presents as a mass-like enlargement of the sternocleidomastoid muscle during the first 8 weeks of life. METHODS: Sonograms and records of 12 infants who presented with a sternocleidomastoid mass or torticollis before they were 12 weeks old were retrospectively reviewed for sonographic features (presence of a mass, diffuse muscle enlargement, and echogenicity), medical history, and follow-up data. RESULTS: Sonographically, 6 infants had only a mass in the sternocleidomastoid muscle, 2 had a mass with fusiform muscle enlargement, and 4 had only muscle enlargement. Five masses were hyperechoic, and 1 mass was of mixed echogenicity. The 2 masses associated with muscle enlargement were hypoechoic. Three cases of diffuse muscle enlargement were of mixed echogenicity, and 1 was hypoechoic. Unusual variations included (1) a mass split longitudinally into 2 components and (2) a diffusely enlarged muscle with a striated pattern of mixed echogenicity. Follow-up in 10 patients at 4 months and in 7 patients at 6 months showed clinical improvement. CONCLUSION: Fibromatosis colli usually appears sonographically as a hyperechoic mass or diffuse sternocleidomastoid enlargement of mixed echogenicity. Variations in its appearance should not prevent the correct diagnosis as long as the abnormality is intramuscular and adjacent soft tissues are normal.

Rupture of the medial collateral ligament of the first metatarsophalangeal joint in a professional soccer player.

Worldwide, more people play soccer than any other team sport. The Federation Internationale de Football Association (FIFA) registered more than 150 million players in 1984. Although foot injuries in soccer range from midfoot sprains to stress fractures to capsulitis of the first metatarsophalangeal joint, we could find no case reports of a rupture of the lateral collateral ligaments of the great toe in soccer players. This is a report of the diagnosis, treatment, and outcome of such an injury in a professional soccer player.

Placenta membranacea, previa and accreta. A case report.

A case of placenta membranacea, previa and accreta was managed conservatively and resulted in delivery of a mature fetus. The diagnosis of placenta membranacea and previa was obtained with ultrasound. The placenta previa and accreta necessitated a cesarean delivery and hysterectomy.

Segmental adenomyomatosis of the gallbladder. A radiologic, sonographic, and pathologic correlation.

Adenomyomatosis is a hyperplastic condition that is occasionally symptomatic. The segmental form of adenomyomatosis can result in marked wall thickening in the waist of the gallbladder, giving a characteristic "hourglass" deformity in both the oral cholecystogram and the ultrasound examination.

Effect of nasal airway positive pressure on upper airway size and configuration.

The effect of nasal airway positive pressure (NAPP) on upper airway size and configuration during wakefulness was studied by computerized tomography in 12 obese subjects with obstructive sleep apnea (OSA), seven weight- and age-matched subjects without OSA, and 12 normal subjects. NAPP of 10 to 12 cm H2O was associated with a significant increase in airway area throughout the upper airway in all three groups. The change in airway area per cm H2O NAPP increased from nasopharynx to hypopharynx. The change in airway area per cm H2O NAPP was significantly smaller in the OSA than in the normal subjects in the region of the soft palate. Electromyographic recordings of the genioglossus and alae nasi muscles with and without NAPP during wakefulness in five of the OSA and five of the normal subjects showed either a decrease or no change in phasic and tonic activity with NAPP. In a separate series of experiments in an additional five OSA and five normal subjects, NAPP of zero, 5, 10, and 15 cm H2O was associated with a linear increase in airway area at a given airway level. These results indicate that (1) the increase in pharyngeal cross-sectional area with application of NAPP during wakefulness is smaller in OSA than in normal subjects in the region of the soft palate and (2) changes in upper airway muscle activity may accompany changes in upper airway size and configuration.

Fibrolamellar carcinoma of the liver: CT, ultrasound and angiography. Case report.

Two cases of fibrolamellar carcinoma (FLC) of the liver reported here illustrate that this rare neoplasm is a distinct variant of the usual hepatocellular carcinoma (HCC). It occurs in younger individuals, is unrelated to liver cirrhosis and has a remarkably better prognosis due to a higher surgical resectability rate. It is sonographically hyperechoic and demonstrates angiographic and computed tomographic features of a very vascular tumor. The differential diagnosis includes focal nodular hyperplasia, hepatic adenoma, hepatocellular carcinoma and hemangioma.

MR imaging of mediastinal pseudocyst.

Magnetic resonance imaging of a mediastinal pseudocyst clearly demonstrated the entirely intrathoracic location of the pseudocyst.

Renal transplant dysfunction: MR evaluation.

The results of 45 MR examinations were prospectively compared with the clinical course and biopsy results in 38 renal transplant patients to determine the role of MR in evaluating allograft dysfunction. Twenty-six patients underwent allograft biopsy. In eight patients in whom the biopsy was performed more than 48 hr after MR examination and in 19 patients who did not have a biopsy, the subsequent clinical course was sufficiently diagnostic to determine the specific cause of the transplant dysfunction. Corticomedullary differentiation, graded from 0 to 3, was not helpful in separating rejection (n = 20) from acute tubular necrosis (n = 9), drug toxicity (n = 7), pyelonephritis (n = 2), or normal grafts (n = 7) because of overlap between groups (sensitivity =; 60%, specificity = 60%). In the six patients with two or more MR studies, serial changes in corticomedullary differentiation were not consistent and could not be used to diagnose rejection. When any abnormality of allograft sinus fat, size or shape, or corticomedullary differentiation was considered, the sensitivity for the diagnosis of rejection approached 80%; however, specificity was low (48%). We conclude that MR imaging is not sufficiently accurate to replace transplant biopsy and therefore has a limited role in the evaluation of transplant dysfunction.

Pseudocyst following splenectomy: impact of CT and ultrasound on its diagnosis and management.

Three cases of pseudocysts occurring after splenectomy are presented. Sonography and computed tomography were helpful in diagnosing the pseudocysts as well as providing guidance for subsequent drainage. Demonstration of a cystic mass adjacent to the tail of the pancreas following splenectomy suggests the diagnosis of postsplenectomy pseudocyst and has important implications for clinical management.

Potential placenta previa: definition, frequency, and significance.

Sixty-three (5%) of 1239 women studied by sonography during the second trimester of their pregnancies had a diagnosis of placenta previa. Follow-up was available for 51 of the 63 patients; in three of these, the original diagnosis was complete placenta previa, and in the other 48, the first diagnosis was partial or marginal placenta previa. At term, placenta previa was seen in only four patients for an overall frequency of 0.3% (4/1227). In all three of the patients with complete placenta previa, the condition persisted from the second trimester to term; previa persisted in only one of 48 patients with marginal/partial previa. Because of the infrequent persistence of marginal or partial placenta previa to term, we recommend using the term "potential placenta previa" in the second trimester, with follow-up sonography indicated only for vaginal bleeding.

Chronic ectopic pregnancy. A comparison with acute ectopic pregnancy.

An ectopic tubal pregnancy that undergoes repeated minor ruptures instead of a single episode of rapid bleeding frequently develops into a pelvic hematocele. The hematocele, which contains old blood, clots and gestational tissue, is surrounded by adhesions and is misleadingly called a "chronic" ectopic pregnancy. The term "chronic" describes only the appearance of the pelvic mass and does not necessarily imply chronicity of duration. Its incidence was 28% in our series of 149 ectopic pregnancies. Fifty percent of our patients with chronic ectopic pregnancy had a negative serum beta human chorionic gonadotrophin (HCG). This entity has a sonographic appearance distinctly different from acute ectopic pregnancy.

Ruptured uterus: sonographic diagnosis.

Sonography was able to suggest a diagnosis of uterine rupture by demonstrating intra- or extraperitoneal hematoma in the correct clinical setting. A pelvic abscess complicating a uterine rupture was seen in one case. Previous uterine scar, use of prostaglandins for induction of labor, trauma with a currette, and cornual pregnancy were the implicated etiologic factors. Although the rupture site was never directly visualized by sonography, the combination of sonographic and clinical findings was strongly suggestive of the correct diagnosis.

Sonographic demonstration of bladder-flap hematoma.

A bladder-flap hematoma is generally thought of as a blood collection in a potential space located between the urinary bladder and lower uterine segment (vesicouterine space). These collections can also extend over the bladder and uterus beneath the peritoneal reflection. In this study, ten patients with a bladder-flap hematoma were evaluated for fever, mass, or dropping hematocrit after surgery. No one sonographic appearance is specific for bladder-flap hematoma; however, the diagnosis can be made by finding a mass in the extraperitoneal pelvic space in the postoperative patient.

Aneurysmal malformation of the extrahepatic portal vein.

Malformations of the extrahepatic portal vein are quite rare. A 6-cm aneurysmal malformation of the extrahepatic portal vein, thought to be congenital in origin, is described. An English language literature review yielded only six similar cases, each of which was associated with portal hypertension, primary hepatocellular disease, or both. The patient reported herein had cholelithiasis with chronic cholecystitis, but no primary liver disease or vascular disease. We believe this is the first report of such an anomaly.