Percutaneous testicular biopsy for indeterminate testicular lesions.

Ultrasound forms an important part of the assessment of the testicle. Nevertheless, there are a number of situations in which clinical and radiological assessment is unable to provide a definitive diagnosis of a testicular lump. In these situations, historically, either open biopsy or orchidectomy has been performed. Ultrasound-guided percutaneous testicular biopsy is an alternative, less invasive method of obtaining histological diagnosis. Here we describe the rationale, technique and potential uses of the technique.

Ultrasound of the male anterior urethra.

Imaging of the anterior male urethra has traditionally been performed by fluoroscopic contrast urethrography. While providing easily interpretable images, this technique has a number of disadvantages associated with it. An alternative approach is to use ultrasound to assess the lumen of the urethra and the periurethral tissues. Here we describe the development of urethral ultrasound and the ascending and descending urethral ultrasound techniques employed in our institution with reference to commonly and uncommonly encountered pathologies. We also identify common pitfalls and how to avoid them.

Ultrasound-guided core needle biopsy of parotid gland swellings.

OBJECTIVE: To determine whether ultrasound-guided core needle biopsy is a safe and reliable investigation in cases of parotid swelling in which fine needle aspiration cytology has failed to give a definitive diagnosis. DESIGN: Analysis of 66 ultrasound-guided core biopsy specimens of the parotid gland (the largest series reported thus far) sample number refers to histological samples throughout the paper. SUBJECTS: All the 184 cases of parotid surgery with a histological diagnosis were included. MAIN OUTCOME MEASURES: The sensitivity, positive predictive value and diagnostic accuracy of fine needle aspiration cytology and ultrasound-guided core needle biopsy, as compared with the final histological analysis. RESULTS: Of a total of 184 patients, 89.1 per cent (164/184) had benign parotid lesions excised. The sensitivity, positive predictive value and diagnostic accuracy of fine needle aspiration cytology for benign lesions were 76.2, 84.2 and 87.5 per cent, respectively, and those of ultrasound-guided core needle biopsy were 91.7, 98.2 and 96.4 per cent, respectively. Twenty of 184 patients (10.9 per cent) had malignant lesions. The sensitivity, positive predictive value and diagnostic accuracy of fine needle aspiration cytology for detection of malignant lesions were 60, 75 and 75 per cent, respectively, while those of ultrasound-guided core biopsy were 89, 100 and 100 per cent, respectively. Non-diagnostic rates were 25.8 per cent for fine needle aspiration cytology and 4.5 per cent for ultrasound-guided core biopsy. Only one case of complications (a sub-clinical haematoma) occurred in the ultrasound-guided core biopsy group. CONCLUSION: We propose ultrasound-guided core needle biopsy as a very safe and effective tool in cases of parotid swelling in which fine needle aspiration cytology has failed to give a definitive diagnosis.

Spatial mapping of the brachial plexus using three-dimensional ultrasound.

Imaging of the brachial plexus with MRI and standard two-dimensional (2D) ultrasound has been reported, and 2D ultrasound-guided regional anaesthetic block is an established technique. The aim of this study was to map the orientation of the brachial plexus in relation to the first rib, carotid and subclavian arteries, using three-dimensional (3D) ultrasound. A free-hand optically tracked 3D ultrasound system was used with a 12 MHz transducer. 10 healthy volunteers underwent 3D ultrasound of the neck. From the 3D ultrasound data sets, the outlines of the brachial plexus, subclavian artery and first rib were manually segmented. A surface was interpolated from the series of outlines to produce a spatially orientated 3D reconstruction of the brachial plexus. The brachial plexus could be mapped in all volunteers, although a variation in image resolution between individuals existed. Anatomical variations were demonstrated between the 10 volunteers; the most notable and clinically relevant was the alignment of the plexus divisions. 3D reconstructions illustrated the plexus, changing its orientation from a vertical alignment in the interscalene region to a more horizontal alignment in the supraclavicular fossa. Spatial mapping of the brachial plexus is possible with 3D ultrasound using the subclavian artery and first rib as landmarks. There is a deviation from the conventionally described anatomy and this may have implications for the administration of regional anaesthesia.

3D reconstruction of the skeletal anatomy of the normal neonatal foot using 3D ultrasound.

Currently imaging plays a limited role in the assessment of the neonate with a foot deformity. The aim of this study was to establish a technique for examining the neonatal foot with three-dimensional ultrasound (3D US). 3D US was attempted on the normal feet of 20 infants (9 male, 11 female) under 6 weeks old (range 35-41 days). The data sets were obtained whilst the infants were feeding or asleep to minimize movement artefact. A high-resolution optically tracked freehand 3D US system (Diasus, 16 MHz transducer) was used with Stradx software to acquire and analyse the data sets. Manual segmentation of the non-ossified tarsi from the data sets was performed. Five infants were too restless to be examined. 107 data sets were recorded from 22 feet of the remaining 15 infants. 21 of the data sets were discarded due to movement artefact. 86 were suitable for manual segmentation. Surface interpolation of the segmented data sets produced surface rendered reconstructions illustrating the complex 3D anatomy of the foot. This new technique may offer a method of examining the deformed foot, e.g. congenital talipes equinovarus.

A case of endometrial carcinoma detected using transrectal ultrasound.

Transvaginal ultrasound is commonly used in the investigation of postmenopausal bleeding. In this article, we report the use of transrectal ultrasound in the assessment of postmenopausal bleeding and detection of an endometrial carcinoma, where other methods of assessment were unsuccessful.

Two- and three-dimensional ultrasound in the development of a needle-free injection system.

Ultrasound was used to assess a needle-free injection device for both intradermal and subcutaneous injections. The aim of this study was, first, to differentiate intradermal from subcutaneous injections, both in vivo and in vitro using 2D ultrasound, and second, to quantify the amount of injectate that actually arrives within the dermis or subcutaneous tissues using volume measurements derived from high-resolution 3D ultrasound data sets, using a freehand system (Stradx), developed by the Cambridge University Departments of Engineering and Radiology. For the in vitro study the devices were filled with dye and injected into a pig preparation. The injection site was examined with high-resolution ultrasound and subsequently dissected to locate the injected dye with respect to the dermis. For the in vivo study, 8 volunteers received needle-free injections of normal saline. High-resolution 2D images and 3D data sets were obtained of the injected sites. Proprioceptive information for the 3D data sets was produced using an optically tracked freehand system. Segmentation of the 3D data sets gave an estimation of the volume of injected material (injectate) within the dermis. The results demonstrated that 2D ultrasound could identify the location of the injectate in the in vitro experiments and successfully distinguished an intradermal from a subcutaneous injection. In the in vivo study, 2D ultrasound clearly demonstrated the injectate location within the volunteers' dermis but was less able to demonstrate the dispersion of injectate within the subcutaneous tissues.

Descending urethral ultrasound of the native and reconstructed urethra in patients with hypospadias.

A retrospective study, over a 7 year period, examining the use of descending urethral ultrasound in corrected and uncorrected hypospadias was performed. 15 examinations were performed on 14 patients; 12 patients had undergone previous surgery for hypospadias, ranging from urethral reconstruction to stricture dilatation. Eight strictures, four irregular urethras, two normal post-operative urethras and one urethral valve were demonstrated. All the clinically significant abnormalities (those which impaired the flow of urine) demonstrated by ultrasound were confirmed with subsequent urethroscopy or contrast urethrography. This small series illustrates the application of descending urethral ultrasound in patients with hypospadias who are difficult to examine with more conventional radiographic techniques.

Management of neck lumps--a triage model.

We report our experience in the out-patient triage of 100 patients presenting with a lump in the neck. The out-patient visit consisted of a general history and examination, assessment of the upper air and food passages and, where indicated, ultrasound and core needle biopsy of the lump. Other investigations were performed as appropriate. One hundred neck lump patients were seen in a 9 month period. Ninety-six of these lumps were diagnosed on an out-patient basis, only four requiring admission for formal excision biopsy. Among the diagnoses were eleven lymphomas, nine parotid neoplasms, nine lymph node metastases, five thyroglossal cysts, and four branchial cysts. Almost half the patients seen had either a reactive lymphadenopathy, or no abnormality. The establishment of a tissue diagnosis on an out-patient basis allowed appropriate referrals to be made and management plans to be formulated. The theoretical risk of seeding of malignant cells in the needle tract is acknowledged and discussed.

The use of ultrasound-guided cutting-needle biopsy in paediatric neck masses.

OBJECTIVE: Neck masses are common in children. Although there is a low incidence of therapeutically significant pathology, biopsy is occasionally required for evaluation. Open biopsy or fine needle aspiration may be used to obtain tissue. Open biopsy provides material suitable for histological analysis but requires general anaesthesia. Cytological material obtained by fine needle aspiration is often inconclusive. A core of histological material may also be obtained by percutaneous cutting-needle biopsy, a recognised procedure at other anatomical sites, usually performed under local anaesthesia. MATERIALS AND METHODS: There are few accounts using cutting needles in adult neck masses and no previous paediatric series. We present our experience of ultrasound-guided core biopsies of neck masses in 15 children ranging in age from three months to 16 years. RESULTS: Thirteen biopsies were easily performed without sedation as an outpatient procedure under topical and injected local anaesthetic. In all fifteen cases the procedure was well tolerated and a tissue successfully obtained. CONCLUSION: Ultrasound guided cutting needle biopsies of head and neck masses of children can be performed under local anaesthesia in the majority of cases.

Scrotal trauma: a cause of testicular atrophy.

Scrotal trauma is often mentioned as a cause of testicular atrophy yet there have been few studies documenting the effect of scrotal trauma on testicular size months or years following injury. We performed clinical and sonographic examinations in 10 patients who had suffered blunt scrotal trauma. A significant reduction in volume of the injured testis was observed in 5/10 cases at follow-up sonography. In two cases the affected testis was heterogeneous and colour flow Doppler examination showed reduced flow. In three cases the testis was homogeneous but reduced in volume and in the remaining five cases the affected testis appeared normal. We conclude that testicular atrophy is a sequel of scrotal trauma and occurred in 50% of patients in this study.

Subclavian and internal jugular veins at Doppler US: abnormal cardiac pulsatility and respiratory phasicity as a predictor of complete central occlusion.

In 21 consecutive patients, the authors analyzed changes in venous Doppler waveforms of damped or diminished cardiac pulsatility and respiratory phasicity. Each patient was suspected of having upper limb venous thrombosis, but thrombus was not visible at gray-scale ultrasonography (US) in the subclavian and brachiocephalic veins. US findings were compared with phlebographic findings. The results show that US can be used to establish the presence or absence of thrombosis in the distal portion of the brachiocephalic or subclavian veins, which are inaccessible to direct insonation.

Duplicated superficial femoral veins: a source of error in the sonographic investigation of deep vein thrombosis.

PURPOSE: To determine whether the number of false-negative ultrasound (US) findings of thrombosis is larger when a duplicated femoropopliteal venous system is present. MATERIALS AND METHODS: A retrospective review was performed of 381 venograms obtained after initial US findings were considered negative for thigh or popliteal thrombosis in patients in whom deep vein thrombosis was suspected Venograms were evaluated for the presence of thrombosis and the presence and configuration of duplicated superficial femoral veins. RESULTS: Multiple superficial femoral veins were present on 177 (46%) of the 381 venograms; 149 (84%) were duplex systems. False-negative US findings occurred in four (2%) of 204 patients with single femoral veins and in 10 (6%) of 177 patients with duplicated femoral veins (P = .056, not statistically significant). CONCLUSION: The frequency of missed proximal thrombosis at sonography appears to be increased when duplicated superficial femoral veins are present. Data from clinical and imaging studies are insufficient to support the adoption of a totally noninvasive imaging strategy.