Paraovarian adrenal rest with MRI features characteristic of an adrenal adenoma.

We report MR and sonographic imaging features of an incidentally detected paraovarian adrenal rest in a 44-year-old woman who was being evaluated for menorrhagia. This is the first report of chemical shift imaging identifying the presence of lipid within an adrenal rest as well as rapid washout of contrast. Both of these MR characteristics are typically seen with an adrenal adenoma.

Feasibility of performing a virtual patient examination using three-dimensional ultrasonographic data acquired at remote locations.

OBJECTIVE: To evaluate the feasibility of performing three-dimensional ultrasonographic studies that meet American Institute of Ultrasound in Medicine and American College of Radiology ultrasonographic examination guidelines with review off-line and at remote locations. METHODS: One hundred patients were studied at 2 institutions using high-end two-dimensional clinical ultrasonographic scanners and commercially available three-dimensional ultrasonography for a variety of organ systems (first- and second-trimester fetus, abdomen, and female pelvis). We evaluated several parameters, including measurements, completeness of organ visualization, abnormalities identified, image quality, number of volumes required, and discrepancies between interpretations. RESULTS: Overall, three-dimensional ultrasonography could produce diagnostic-quality results comparable with those of two-dimensional ultrasonography. Three-dimensional ultrasonographic image quality was lower than that of two-dimensional ultrasonography. Two- and three-dimensional ultrasonographic measurements were comparable (<5% difference), as was the extent of organ visualization, although some structures were challenging for both two- and three-dimensional ultrasonography. In general, organs completely imaged in the scanner field of view required 1 to 1.5 volumes, whereas larger organs required between 3 and 6 volumes. Differences among reviewers' interpretations highlighted the need for standardization of acquisition and reviewing protocols for sonographers and physicians. CONCLUSIONS: Our results show that it is clinically feasible to acquire three-dimensional ultrasonographic data at one site and to obtain accurate interpretation by off-line review at another within the context of providing high-quality clinical diagnostic studies.

Intraoperative sonographic localization of breast masses: success with specimen sonography and surgical bed sonography to confirm excision.

OBJECTIVE: To assess the use of intraoperative sonography for localization of breast masses at excisional biopsy, with specimen and surgical bed sonography to confirm excision. METHODS: A computer search of the 5-year period from January 1993 through January 1998 revealed 138 consecutive women referred for sonographically guided excisional biopsy of 148 masses; 35 masses were excluded because they had no postoperative mammograms. One hundred thirteen masses constituted the study group. Specimen sonography (n = 60) or surgical bed sonography (n = 53) was performed as the initial evaluation to confirm excision, but ultimately, surgical bed sonography may have been necessary after specimen sonography, and specimen sonography may have been necessary after surgical bed sonography. The miss rates determined by postoperative imaging were calculated for each group and compared with those of mammographically guided needle localization series from the literature. RESULTS: Follow-up physical examination and mammography showed no residual mass in the region of surgery in any patient. However, follow-up sonography had 1 miss in the initial specimen sonogram group (1 [1.7%] of 60) and 1 miss in the initial surgical bed group (1 [1.9%] of 53). As shown by the Fisher exact test, there was no significant difference between the miss rates of the 2 initial methods of confirming lesion excision or between the miss rates of these initial methods, both groups combined, and 6 mammographic localization series from the literature. CONCLUSION: Intraoperative breast sonography, using specimen sonography and scanning the surgical bed, has miss rates comparable with those of mammographic needle localization. Follow-up sonography must be performed if there is any doubt of complete excision.

Comparison of unenhanced and contrast-enhanced spiral CT for assessing interval change in patients with colorectal liver metastases.

RATIONALE AND OBJECTIVES: The purpose of this study was to determine whether the interval change in hepatic colorectal metastases as assessed with serial computed tomographic (CT) scans without contrast material enhancement differs from that as assessed using serial, portal dominant phase, contrast-enhanced CT scans. MATERIALS AND METHODS: Unenhanced and contrast-enhanced abdominal CT scans were obtained in 28 patients. Three radiologists separately reviewed serial unenhanced and contrast-enhanced studies to assess the interval change in liver metastases. These radiologists recorded total number of lesions, bidimensional measurements of the largest lesions (as many as three), and overall impressions regarding the interval change (none, worse, or better). RESULTS: Among the 84 judgments (28 patients x 3 radiologists), comparisons of unenhanced and contrast-enhanced CT studies were concordant in 60 assessments (71%). Nineteen (23%) showed mild disagreement. Of these, contrast-enhanced CT studies demonstrated disease stability when unenhanced CT studies demonstrated otherwise in 11 judgments, whereas unenhanced CT studies demonstrated stability when contrast-enhanced CT studies demonstrated otherwise in eight assessments. Furthermore, of the five marked disagreements, two resulted from a conclusion of interval improvement on unenhanced CT studies and a conclusion of interval worsening on contrast-enhanced CT studies, whereas three demonstrated the opposite. Neither set of serial CT studies systematically resulted in under- or overestimation of disease progression (McNemar Q test, P < .25). CONCLUSION: The authors found no consistent pattern to demonstrate that serial unenhanced or contrast-enhanced CT studies resulted in over- or underestimation of disease progression.

Sonographically guided renal mass biopsy: indications and efficacy.

PURPOSE: To review the clinical indications, pathologic results, and success rate of all our sonographically guided solid renal mass biopsies over a 5-year period. METHODS: Between 1993 and 1998, 44 consecutive patients underwent sonographically guided percutaneous biopsy of a solid renal mass. Indications included prior history of nonrenal malignancy, metastatic disease of unknown primary origin, previous contralateral nephrectomy for a renal cell neoplasm, a renal transplant mass, suspected renal lymphoma, history of tuberous sclerosis, and poor surgical candidacy. Aspiration biopsies were initially performed with 22- to 18-gauge spinal needles. If the initial cytologic evaluation findings were nondiagnostic, core biopsies were then performed with 20- to 18-gauge core biopsy guns. Dictated sonographic reports of the biopsies were reviewed to determine the following: indication for biopsy, location and size of the renal mass, needle gauge and type, number of needle passes, and complications. Final cytologic and surgical pathologic records were reviewed. RESULTS: Thirty-six (82%) of the 44 biopsy specimens were diagnostic. Aspirated smears were diagnostic in 24 (67%) of these cases, with the diagnosis made on the basis of cell block alone in an additional 2 (6%). A definitive diagnosis came from core biopsy alone in 10 cases (28%). The 18-gauge core needle yielded diagnostic results more reliably than the 20-gauge core needle, and a significant correlation was seen between core biopsy needle size and the rate of diagnostic core samples (P = .017). Pathologic diagnoses included renal cell carcinoma (n = 18), lymphoma (n = 4), oncocytic neoplasm (n = 4), transitional cell carcinoma (n = 2), angiomyolipoma (n = 1), papillary cortical neoplasm (n = 1), and metastatic carcinoma (n = 6). Complications were seen in 4 (9%) of 44 cases; all were treated conservatively. CONCLUSIONS: For specific clinical indications, sonographically guided fine-needle aspiration and core biopsy of a solid renal mass can be performed safely. In many cases, a definitive diagnosis can be made on the basis of fine-needle aspiration alone. However, diagnosis may ultimately require core biopsy, for which 18-gauge core needles would be more reliably diagnostic than 20-gauge needles.

Three-dimensional multiplanar sonohysterography: comparison with conventional two-dimensional sonohysterography and X-ray hysterosalpingography.

The objective of this study was to assess the value of combining transvaginal sonohysterography with three-dimensional multiplanar ultrasonography to optimize assessment of the uterus. To make this assessment, we compared findings on three-dimensional sonohysterography with those on two-dimensional sonohysterography and X-ray hysterosalpingography. Of 20 women who underwent three-dimensional sonohysterography for various indications, 13 also underwent two-dimensional sonohysterography, and 12 had X-ray hysterosalpingography. We reviewed the 3 types of examinations separately and compared the standard techniques with three-dimensional sonohysterography to determine whether three-dimensional sonohysterography provided additional information. In 9 (69%) of 13 comparisons between three-dimensional sonohysterography and two-dimensional sonohysterography and in 11 (92%) of 12 comparisons between three-dimensional sonohysterography and X-ray hysterosalpingography, three-dimensional sonohysterography was advantageous. The coronal plane was most useful for displaying the relationship between lesions and the uterine cavity. Three-dimensional sonohysterography provided additional information compared with standard accepted techniques in the vast majority of women.

Application of three-dimensional ultrasonography in the evaluation of the fetal heart.

The objectives of this study were to determine whether three-dimensional ultrasonography can provide more cardiac views than two-dimensional ultrasonography and to develop a standard technique. Eighteen women, 16 to 26 weeks' gestation, were scanned with two-dimensional ultrasonography for 10 minutes or less to obtain fetal heart views. Three-dimensional ultrasonography was used (< or =10 minutes) to obtain up to 4 acquisitions of the fetal heart: 4-chamber view, left parasagittal, transverse, and longitudinal nonstandard. Views were later extracted from saved volume data, comparing the yields of two- and three-dimensional ultrasonography. The 4-chamber view was obtained in 15 (93%) of 16 cases on both two- and three-dimensional ultrasonography. On two-dimensional ultrasonography, the left outflow tract was obtained in 68% of the cases; on three-dimensional ultrasonography, the left outflow tract was obtained in 46% from the 4-chamber view acquisition and in 100% from the left parasagittal acquisition. On two-dimensional ultrasonography, the right outflow tract was obtained in 68% of the cases; on three-dimensional ultrasonography, the right outflow tract was obtained in 86% from the 4-chamber view acquisition and in 71% from the left parasagittal acquisition. Aortic and ductal arches were obtained in 12% and 18%, respectively, on two-dimensional ultrasonography. On three-dimensional ultrasonography the aortic and ductal arches were obtained in 66% and 86%, respectively, from the 4-chamber view acquisition and in 57% and 71%, respectively, from the left parasagittal acquisition. Three-dimensional ultrasonography permitted a greater number of cardiac views to be extracted from volume data than did two-dimensional ultrasonography.

Safety and efficacy of sonographically guided random core biopsy for diffuse liver disease.

Sonographic guidance is commonly used in the biopsy of focal hepatic lesions, but biopsy for diffuse disease is often non-image-guided. We evaluated the safety and efficacy of real-time sonographically guided random core biopsy in the assessment of diffuse liver disease in 210 patients. The two most common indications for biopsy were viral hepatitis (in 113 patients) and elevated liver function test results of unknown cause (in 54 patients). Ultrasonography and pathology reports were reviewed retrospectively to determine number of needle passes and final diagnoses. Adequate tissue was obtained in all 210 patients, with 259 of 269 (96%) passes having been successful. Specimens were submitted for light microscopy and other tests as indicated. No difference in success rates was found for right and left lobe biopsies. No major complications occurred. Minor complications occurred in 10 of 210 (4.8%) patients and were self-limited. Sonographically guided core liver biopsy is a safe and effective method for the diagnosis of liver disease.

Artifacts and the visualization of fetal distal extremities using three-dimensional ultrasound.

OBJECTIVES: To demonstrate that acoustic shadowing in 3D US may give rise to artifacts simulating limb defects and provide a solution to eliminate its occurrence. METHODS: Twenty second trimester fetuses (gestational age 15-24 weeks) were scanned with three-dimensional ultrasound (3D US) using a sagittal acquisition plane. Fetal tibia/fibula and radius/ulna pairs were assessed for completeness of imaging. A further 20 fetuses (gestational age 20-26 weeks) were scanned in both axial and sagittal planes and the results compared to verify clear visualization of both bones. RESULTS: Shadowing from adjacent structures produced an apparent limb defect in 55% of the first 20 fetuses imaged only sagittally (18% of limb pairs). Acquiring data from more than one orientation avoided this artifact. CONCLUSIONS: The 3D US is subject to the same artifacts as two-dimensional (2D US) in terms of acoustic shadowing, although their presentation may be different. Awareness of this fact is essential for correct interpretation of 3D US studies. Three-dimensional scanning protocols should be modified to ensure that fetal structures are adequately visualized by acquiring volume data in more than one acquisition orientation.

Three-dimensional multiplanar ultrasound for fetal gender assignment: value of the mid-sagittal plane.

OBJECTIVE: To evaluate the feasibility and accuracy of fetal gender assignment from three-dimensional ultrasound (3D US) data at 10-24 weeks' gestation. METHODS: Three-dimensional ultrasound volume data on 47 fetuses were reviewed and divided into groups: 10-14, 15-18, and 19-24 weeks. Fetal genitalia were studied in axial and sagittal planes for gender assignment, using published criteria. The most valuable plane for assignment was noted. Gender assignment was compared with gender at birth. RESULTS: Gender assignment was possible in 44 of 47 fetuses; 25 assigned male and 19 female. Between 10 and 14 weeks the mid-sagittal plane alone was diagnostic for all fetuses. Accuracy of assignment between 11 and 14 weeks was 100%. Between 15 and 18 and 19 to 24 weeks, male assignment was 100% accurate. Female assignment was 100% accurate between 15 and 18 weeks. Accuracy decreased to 60% in the 19 to 24 week group, however, in two of the five cases in which gender was wrongly assigned to be male, the assignment was prospectively considered doubtful due to poor resolution of volume data. Excluding these two cases, accuracy for female assignment in the 19-24 week group was 100%. CONCLUSION: Using 3D US, gender assignment was possible in 44 of 47 of fetuses, as early as 11 weeks' gestation. In early gestation, 11-14 weeks, accuracy of male and female gender assignment was 100%.

Three-dimensional multiplanar transvaginal ultrasound of the cervix in pregnancy.

OBJECTIVES: To develop a standard technique for using three-dimensional ultrasound (3D US) to study and evaluate the cervix in pregnant women at high risk for premature delivery, comparing the findings on 3D US with those on conventional two-dimensional ultrasound (2D US). STUDY DESIGN: Twenty-one pregnant women at high risk for premature delivery had a total of 37 transvaginal 2D and 3D US examinations of the cervix between 11 and 32 weeks' gestation. A 3D US vaginal probe (5.0-8.0 MHz, Voluson 530D, Medison, Pleasanton, CA, USA) was used. Measurements made from the 2D and 3D US were compared. RESULTS: Of the 37 cervical length measurements in 3D US sagittal plane, seven were shorter and three were longer than on 2D US (varying by 5-15 mm) indicating that the true mid-sagittal plane was not obtained in ten (27%) of the 37 2D US examinations. Of 21 examinations showing funneling, funneling was seen on both 2D and 3D US in 15, but was seen only on 3D US in six. There was a significant (P < 0.05) difference between funnel width as measured in the coronal 3D plane versus 2D US, as well as between funnel width in the coronal 3D US plane versus sagittal 3D US plane (P < 0.05). The cerclage was seen in its entirety in nine of 10 examinations; the 3D US axial plane was most valuable for imaging the cerclage. CONCLUSIONS: 3D US appears to offer a more complete assessment of the cervix than 2D US. Multiplanar correlation shows that the standard 2D US sagittal view may under- or over-estimate cervical length. Our preliminary data suggest that 3D US has the potential to improve our understanding of cervical morphology.

Diagnosis of conjoined twins at 10 weeks using three-dimensional ultrasound: a case report.

A case report is presented of the prenatal diagnosis of conjoined twins at 10 weeks and 2 days' gestation using three-dimensional ultrasound (3D US). The multiplanar display coupled with 3D US surface rendering clearly confirmed the presence of craniopagus. The twins were facing in opposite directions with the left occipital region of one embryo fused with the left parietal-temporal region of the other. Additional multiplanar analysis above the level of the biparietal diameter demonstrated brain sharing.

Size of colorectal liver metastases at abdominal CT: comparison of precontrast and postcontrast studies.

PURPOSE: To investigate whether measurements of hepatic metastases from colorectal carcinoma before contrast material administration are significantly different statistically from measurements after contrast material administration. MATERIALS AND METHODS: Twenty-four patients with hepatic metastases from colorectal carcinoma underwent spiral computed tomography (CT) with 7-mm collimation. The liver was imaged before and in the portal-dominant phase after intravenous contrast material administration. For each scan, one to three discrete liver lesions were selected for measurement (n = 49). Three experienced radiologists performed independent measurements of the selected lesions on both pre- and postcontrast images at a computer workstation. A three-way analysis of variance (ANOVA) was performed: subjects by raters (the three independent radiologists) by pre- or postcontrast status. The dependent variable was the product of bidimensional measurements. RESULTS: Sixty-seven percent (33 of 49) of the lesions were measured as larger on precontrast images; 33% (16 of 49), as smaller. There was high interrater reliability, with an intraclass correlation coefficient greater than 0.9 ANOVA showed significant subject, rater, and contrast material effects (P < .001) for the largest lesions in each liver. Contrast material status was a significant factor for all lesion sizes (P < .003). CONCLUSION: On average, hepatic metastases from colorectal carcinoma are significantly smaller after contrast material administration.

Safety and efficacy of a new oral contrast agent for sonography: a phase II trial.

OBJECTIVE: Our purpose was to study the safety and efficacy of a new orally administered sonographic contrast agent in patients with suspected upper abdominal disorders. SUBJECTS AND METHODS: Ninety-nine patients with signs or symptoms suggestive of upper abdominal disorders were enrolled in a prospective range-of-dose phase II clinical trial at six sites; sonograms of 93 patients were evaluated for efficacy. Patients underwent upper abdominal sonography before and after receiving a randomized dose of the contrast agent (200, 400, 600, 800, or 1000 ml). Safety was monitored by physical examination and laboratory testing. The primary efficacy parameter was additional information provided by the contrast agent when comparing unenhanced and contrast-enhanced sonography. RESULTS: Of the 14 adverse events in 11 patients, only five, which included mild diarrhea and nausea, were considered related to the contrast agent. In 83 of 93 patients, additional information was obtained from the contrast-enhanced images. Visualization of anatomy was improved as follows: the stomach, in 82% of patients; the duodenum, in 63% of patients; the pancreatic head and body, in 61% of patients; and the pancreatic tail, in 67% of patients. CONCLUSION: SonoRx is a safe and well-tolerated contrast agent that improves the sonographic evaluation of the upper abdomen, with significant improvement in imaging the stomach, duodenum, and pancreas.

CT assessment of abdominal hemorrhage in coagulopathic patients: impact on clinical management.

BACKGROUND: To assess how computed tomography (CT) affected clinical management in coagulopathic patients with suspected spontaneous abdominal hemorrhage. METHODS: Fifty-four patients with coagulopathy underwent CT for possible abdominal hemorrhage. Medical records were reviewed retrospectively for pre-CT management strategy, degree of clinical suspicion for abdominal hemorrhage, CT findings, and post-CT management strategy. RESULTS: Abdominopelvic CT demonstrated hemorrhage in 31/54 (57%) of patients; 20/54 (37%) of patients had retroperitoneal hemorrhage, 2/54 (4%) had hemoperitoneum, and 9/54 (17%) had hemorrhage confined to the thigh, groin, and/or abdominal wall. CT directly affected clinical management in 28/54 (54%) cases; 17/31 (55%) CT scans that were positive for hemorrhage had a clinical impact versus 11/23 (48%) negative CT scans. This difference was not statistically significant (p = 0.61). CT scans with a higher pretest suspicion for abdominal hemorrhage were more likely to have hemorrhage detected (p = 0.0046) but not more likely to have a clinical impact (p = 0.73). CONCLUSIONS: CT to assess for abdominal hemorrhage had a direct impact on clinical management in about one-half of coagulopathic patients. Positive and negative CT studies were equally likely to affect management.

Normal splenic volumes estimated using three-dimensional ultrasonography.

The purposes of this study were to determine splenic volumes using three-dimensional ultrasonography and to compare these measurements with two-dimensional splenic indices. Fifty-two healthy volunteers were studied. Two-dimensional volume measurements were based on length, width, and thickness, and the splenic index was calculated using the standard prolated ellipsoid formula (length x width x thickness x 0.523). Three-dimensional volume planar measurements were obtained with a slice by slice technique by manually drawing a region of interest around the spleen from one end of the sweep to the opposite end. These measurements were recorded three times by two observers. In addition, in vitro determination of splenic volume was performed using three cadaveric human spleens in a water bath. No statistically significant interobserver or intraobserver variability was present for either two-dimensional or three dimensional ultrasonography. Three-dimensional sonographic estimations of planar splenic volumes and ellipsoid splenic volumes were consistently smaller than two-dimensional sonographic estimations of splenic volumes. Three-dimensional sonographic splenic volumes calculated in vitro using the planar method were accurate to within 2% of in vitro water displacement volumes. Three-dimensional ultrasonography is potentially superior to two-dimensional sonography for evaluation of irregularly shaped objects, such as the spleen, and can provide improved accuracy over that of traditional two-dimensional techniques.

Clinical impact of sonographically guided biopsy of salivary gland masses and surrounding lymph nodes.

Although fine-needle aspiration biopsy of salivary gland masses has been reported in the otolaryngology literature, the use of sonography to guide the biopsy of nonpalpable masses and masses seen on other cross-sectional imaging studies has not been described. Our goal was to evaluate sonographically guided biopsy of masses and lymph nodes related to the salivary glands. We analyzed the records of 18 patients who had undergone fine-needle aspiration biopsy of a salivary gland mass or lymph node with a 25-, 22-, or 20-gauge needle. A definitive cytologic diagnosis was made for 13 of the 18 patients (72%); cytology was suggestive but not definitive in three patients (17%) and insufficient in two (11%). Definitive diagnoses were made in three cases of reactive lymph node, in two cases each of lymph node metastasis and Warthin's tumor, and in one case each of pleomorphic adenoma, adenoid-cystic carcinoma, schwannoma-neurofibroma, parotid metastasis, parotid lymphoma, and Sjögren's-related lymphoid-epithelial lesion. Sonographically guided biopsy allows for confident needle placement in masses seen on computed tomography and magnetic resonance imaging. Sonography can usually distinguish a perisalivary lymph node from true intrasalivary masses, and it can help the surgeon avoid the pitfall of a nondiagnostic aspiration of the cystic component of masses. We conclude that sonographically guided biopsy of salivary gland masses can provide a tissue diagnosis that can have a direct impact on clinical decision making.

Deep pelvic abscesses: transperineal US-guided drainage.

PURPOSE: To examine the efficacy of transperineal sonographically guided drainage of deep pelvic abscesses. MATERIALS AND METHODS: Twelve drainage procedures were performed in 11 adults with symptoms of infection and cross-sectional images demonstrating a deep pelvic abscess. Eight patients had recently undergone abdominoperineal resection, seven of whom underwent preoperative radiation therapy. Two had chronic osteomyelitis with adjacent fluid collections, and one developed an infected hematoma after trauma. With ultrasound (US) guidance for initial access, catheters were placed for drainage in 11 procedures. One patient was treated with aspiration alone. Patients underwent clinical follow-up and subsequent imaging as necessary. RESULTS: Transperineal needle placement was successful in 12 of 12 patients (100%). In procedures that required catheter placement, 10 of 11 placements (91%) were achieved with the transperineal approach. One patient required fluoroscopic transvaginal catheter placement after opacification of the collection transperineally. Catheter drainage was maintained for 2-146 days (mean, 40 days; median, 21 days). Clinical success was achieved in nine of 10 patients (90%) by means of transperineal drainage. There were no complications, although premature catheter removal occurred in two patients. CONCLUSION: US-guided transperineal abscess drainage may be successfully performed in patients who cannot undergo conventional transabdominal, transvaginal, or transrectal catheter drainage.