Category: Podcasts

Ultrasound of Epidermal Inclusion Cyst

In this radiology lecture, we review the ultrasound appearance of epidermal inclusion cyst!

Key teaching points include:

  • Epidermal inclusion cyst is the most common cutaneous cyst.
  • Can occur anywhere: Head, neck, trunk, extremities.
  • Benign, keratin-containing cyst lined by a wall of stratified squamous epithelium.
  • On ultrasound, appears as a well-circumscribed, round to oval mass with broad (50%) contact with dermis, nonvascular and with posterior acoustic enhancement.
  • Hypoechoic to minimally hyperechoic with internal linear echogenic and anechoic debris = “Pseudotestis.”
  • Presence of a focal hypoechoic tract extending towards epidermis adds specificity = “Submarine sign.” May see overlying punctum on skin surface = Small, dark-colored opening.
  • Epidermal inclusion cysts are different from sebaceous cysts. Sebaceous cysts originate from sebaceous glands, contain sebum and are less common.
  • Epidermal inclusion cysts contain keratin, not sebum, but are often incorrectly referred to as sebaceous cysts.
  • Epidermal inclusion cyst vs. epidermoid cyst. Epidermoid cyst is a non-neoplastic cyst lined only by squamous epithelium. Epidermal inclusion cyst is a specific type of epidermoid cyst caused by implantation of epidermal elements in the dermis. All epidermal inclusion cysts are epidermoid cysts, but not all epidermoid cysts are epidermal inclusion cysts.
  • Can become ruptured or infected: Ill-defined or lobular margins, internal blood flow, peri-lesional soft tissue inflammation, adjacent fat focally hyperechoic or hyperemic. DDx for complicated epidermal inclusion cyst: Neurogenic tumors and other neoplasms.
  • Uncomplicated cysts typically do not require treatment, but if infected may require I&D or excision. Growing cysts may also require excision.
  • Rare (1%) malignant degeneration to squamous cell carcinoma, less commonly basal cell carcinoma.

References:
Jacobson JA, Middleton WD, Allison SJ, et al. Ultrasonography of Superficial Soft-Tissue Masses: Society of Radiologists in Ultrasound Consensus Conference Statement. Radiology 2022; 304:18-30. https://pubs.rsna.org/doi/full/10.1148/radiol.211101

To learn more about the Samsung RS85 Prestige ultrasound system, please visit: https://www.bostonimaging.com/rs85-prestige-ultrasound-system-4

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Ultrasound of Torsion of the Appendix Testis

In this radiology lecture, we review the ultrasound appearance of torsion of the appendix testis and appendix epididymis!

Key teaching points include:

  • Appendix testis is a vestigial appendage usually located between upper pole of testis and head of epididymis.
  • AKA hydatid of Morgagni, the appendix testis is commonly present as a normal finding.
  • Appendix epididymis typically arises from epididymal head.
  • Both scrotal appendages are often pedunculated which increases risk of torsion.
  • Torsion occurs when appendage twists, occluding blood supply.
  • Torsion of the appendix testis is one of most common causes of acute scrotal pain in prepubertal children.
  • Peak age 7-12 years old, but can occur at any age.
  • Normal appendix testis: Oval-shaped, less than 6 mm in size, homogeneously isoechoic to epididymis, and demonstrates little to no blood flow on color Doppler.
  • Torsed appendix testis: 6 mm or larger in size, variable echogenicity, hypoechoic before 24 hours, hyperechoic or heterogeneous after 24 hours.
  • In setting of appendix torsion, hyperemia of surrounding structures with hydrocele and scrotal wall thickening often present.
  • Torsed appendage can detach and become free floating in scrotum.
  • Patients may present with pain localized to upper pole of testis or epididymis.
  • Physical examination may yield the “blue dot” sign: Small, palpable nodule at superior aspect of testis with bluish discoloration of overlying skin due to ischemic appendix.
  • Cremasteric reflex typically intact, and testicle not high riding (unlike testicular torsion).
  • Hyperemia of surrounding structures can be difficult to differentiate from bacterial epididymitis.
  • However, in children, epididymitis usually secondary to inflammation from direct trauma, torsion of a scrotal appendage, or urine reflux into epididymis. Urine dipstick/urinalysis helpful to differentiate from infection.
  • Treatment: Pain management with analgesics, ice, rest. If not recognized, may be treated unnecessarily with antibiotics. Scrotal exploration may be necessary if testicular torsion cannot be excluded.

References:
Baldisserotto M, Ketzer de Souza JC, Pertence AP, Dora MD. Color Doppler sonography of normal and torsed testicular appendages in children. AJR 2005; 184:1287–1292

To learn more about the Samsung RS85 Prestige ultrasound system, please visit: https://www.bostonimaging.com/rs85-prestige-ultrasound-system-4

Click the YouTube Community tab or follow on social media for bonus teaching material posted throughout the week!

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Ultrasound of Acute Appendicitis

In this radiology lecture, we review the ultrasound appearance of acute appendicitis with three unique cases!

Key teaching points include:

  • Ultrasound is the first-line imaging modality in pediatric and pregnant patients due to lack of ionizing radiation: Sensitivity/specificity approximately 80%.
  • Technique: Linear transducer with graded compression at site of maximal tenderness using gradual increased pressure to displace normal bowel gas.
  • Inflamed appendix appears as a noncompressible, blind-ending tubular structure arising from cecum.
  • Outer appendiceal diameter with compression: Less than 6 mm almost always normal, 6-8 mm borderline, greater than 8 mm highly suspicious.
  • Thickened appendiceal wall (greater than 2 mm).
  • Wall hyperemia: “Dot flow” normal, continuous linear/curvilinear flow highly suspicious.
  • Increased echogenicity and expansion of peri-appendiceal fat due to infiltration by inflammatory cells and edema.
  • Hyperechoic appendicolith with posterior acoustic shadowing supportive.
  • Identify terminal ileum separate from appendix to differentiate from ileitis, Meckel’s diverticulum, or other small bowel abnormality.
  • Appendix does not exhibit peristalsis.
  • Right lower quadrant free fluid and lymphadenopathy supportive, but nonspecific in isolation.
  • Loss of wall stratification suspicious for necrotic/gangrenous appendicitis, and color Doppler flow may be absent.
  • Gas in appendix appears as dirty shadowing and ring-down artifact. Intraluminal gas sometimes helpful to exclude appendicitis, but can also be seen with gangrenous complication.
  • Peri-appendiceal gas-containing collections highly suspicious for perforation. CT may be needed for clarification.

References:
1) Madhuripan N, Jawahar A, Jeffrey RB, Olcott EW. The Borderline-Size Appendix: Grayscale, Color Doppler, and Spectral Doppler Findings That Improve Specificity for the Sonographic Diagnosis of Acute Appendicitis. Ultrasound Q. 2020;36(4):314-320.
2) Fallon SC, Orth RC, Guillerman RP, et al. Development and validation of an ultrasound scoring system for children with suspected acute appendicitis. Pediatr Radiol. 2015;45(13):1945-1952.

To learn more about the Samsung RS85 Prestige ultrasound system, please visit: https://www.bostonimaging.com/rs85-prestige-ultrasound-system-4

Click the YouTube Community tab or follow on social media for bonus teaching material posted throughout the week!

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Ultrasound of Thyroglossal Duct Cyst

In this radiology lecture, we review the ultrasound appearance of thyroglossal duct cyst with two unique cases!

Key teaching points include:

  • Thyroglossal duct cyst is the most common congenital neck cyst.
  • Most present before age 18 as a midline, fluctuant neck mass near hyoid bone.
  • Often asymptomatic unless superinfected = Abscess, draining sinus.
  • Epithelial-lined cysts caused by failure of normal involution of thyroglossal duct.
  • Can occur anywhere from foramen cecum of tongue to thyroid gland.
  • Most are infrahyoid, followed by hyoid and suprahyoid.
  • Most are midline, but can be paramedian (more likely if infrahyoid).
  • If infrahyoid, typically embedded in strap muscles.
  • May move with swallowing and elevates with tongue protrusion.
  • Presence of normal thyroid gland should be confirmed.
  • When simple, typically appears as an anechoic midline neck mass near hyoid bone.
  • Cyst complexity usually due to superinfection: Proteinaceous internal debris and septations, thick irregular walls, increased blood flow and surrounding inflammation.
  • Solid components may indicate ectopic thyroid or rarely (less than 1% of cases) thyroid cancer (typically papillary subtype).
  • Tx: Resection of cyst, surrounding tissue along the thyroglossal tract, and midline portion of hyoid bone = Sistrunk procedure.

To learn more about the Samsung RS85 Prestige ultrasound system, please visit: https://www.bostonimaging.com/rs85-prestige-ultrasound-system-4

Click the YouTube Community tab or follow on social media for bonus teaching material posted throughout the week!

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Ultrasound of Varicocele

In this radiology lecture, we review the ultrasound appearance of scrotal varicocele with three unique cases.

Key teaching points include:

  • Varicocele is abnormal dilatation of pampiniform venous plexus = Peritesticular veins.
  • Seen in up to 15% of adult and adolescent males.
  • Caused by incompetent or absent testicular vein valves.
  • Upper limit of normal for scrotal vein caliber = 2 mm, varicocele when greater than 2-3 mm.
  • Flow in varicocele usually too slow to detect with color Doppler and is typically better seen with Valsalva or with standing position.
  • 85% left sided, 15% bilateral: Left testicular vein drains into left renal vein at 90-degree angle, and superior mesenteric artery compresses left renal vein = Increased pressure and venous backflow. Right vein drains into IVC at acute angle.
  • Symptoms: Scrotal mass, pain, infertility/subfertility.
  • Low grade: Reflux only seen with Valsalva, inguinal canal/supratesticular location, vessels enlarged only in standing position.
  • High grade: Reflux seen at rest, infratesticular location, vessels enlarged in supine position.
  • Solitary right varicocele raises concern for compression of the right testicular vein from a retroperitoneal mass.
  • Ultrasound of upper abdomen should be considered when an isolated right-sided varicocele or asymmetrically large right-sided varicocele found.
  • However, most patients typically present with additional signs and symptoms of malignancy: “No patient in our cohort was found to have an unsuspected malignancy for which isolated right-sided varicocele was the only presenting sign.”*

*Gleason A, Bishop K, Xi Y et al. Isolated Right-Sided Varicocele: Is Further Workup Necessary? AJR 2019; 212:802-807

To learn more about the Samsung RS85 Prestige ultrasound system, please visit: https://www.bostonimaging.com/rs85-prestige-ultrasound-system-4

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Ultrasound of Achilles Tendinosis and Tear

In this radiology lecture, we review the ultrasound appearance of Achilles tendinosis, partial thickness tears and full thickness tears through four unique cases.

Key teaching points include:

  • Achilles tendon is strongest in body. Originates from soleus and gastrocnemius muscles, inserts onto posterior calcaneal tuberosity.
  • Achilles tendon tears = Most common ankle tendon injury.
  • Tendon enlargement greater than 1 cm in AP dimension = Abnormal.
  • Tendinosis appears as fusiform hypoechoic swelling of tendon without fiber disruption with increased blood flow (use power Doppler or microvascular flow).
  • Ultrasound highly sensitive and specific for partial and complete Achilles tears.
  • Partial tear = Hypoechoic/anechoic cleft that disrupts tendon fibers.
  • Full thickness tears = Usually 2-6 cm proximal to calcaneal insertion. Complete tendon fiber disruption and retraction. May see refractive shadowing at tendon stumps. Tendon gap may fill with mixed echogenicity fluid/hemorrhage or portion of adjacent fat pad.
  • Plantaris tendon = Thin tendon at medial aspect of Achilles, may mimic intact Achilles tendon fibers (plantaris usually stays intact with Achilles tear).
  • Dynamic imaging with passive ankle dorsiflexion and plantar flexion helps reveal tendon retraction at tear site.
  • Achilles tendon surrounded by a paratenon as opposed to a true synovial tendon sheath.
  • Paratendinitis = Hypoechoic swelling or anechoic fluid adjacent to tendon.
  • Achilles tendon ossification can occur with prior tendon rupture, surgery, or repetitive microtrauma.
  • Scar tissue in chronic tear can simulate tendon fibers (dynamic maneuvers helpful), and fibrous bridging may occur.

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Ultrasound of Uterine Adenomyosis

In this radiology lecture, we review the ultrasound appearance of adenomyosis through three unique cases, including an MRI example.

Key teaching points include:

  • Adenomyosis results from ectopic endometrial tissue in myometrium. Leads to dysfunctional smooth muscle hyperplasia/hypertrophy surrounding ectopic glands.
  • Cause unknown.
  • Common, usually multiparous women of reproductive age.
  • Additional risk factors: Early menarche, short menstrual cycles, high BMI = High estrogen exposure.
  • Rarely seen in postmenopausal patients, unless treated with tamoxifen for breast cancer.
  • Often asymptomatic, but can present with menorrhagia, dysmenorrhea, dyspareunia, and chronic pelvic pain.
  • For diagnosing adenomyosis, transvaginal US much more sensitive and specific (89%) than transabdominal imaging.
  • Most specific US findings: Linear echogenic striations/nodules radiating from endometrium into inner myometrium. Tiny myometrial and subendometrial cysts = Fluid-filled glands.
  • Additional US findings: Enlarged, globular uterus with diffuse myometrial bulkiness, myometrial heterogeneity, irregular endometrial-myometrial interface, hyperechoic islands, and pencil-thin “venetian blind” or “rain shower” shadowing. Cine clips extremely helpful.
  • Adenomyosis can cause asymmetric myometrial thickening.
  • Focal adenomyosis (adenomyoma) has ill-defined margins compared to fibroids, typically elliptical as opposed to rounded in shape.
  • May see abnormal vascular flow: Increased vascularity with tortuous vessels penetrating myometrium. Helps differentiate adenomyosis from fibroids, which tend to displace vessels and show circumferential flow.
  • On US, thickened junctional zone may manifest as a hypoechoic halo surrounding echogenic endometrium.
  • MRI “traditionally” the modality of choice to diagnose adenomyosis, and junctional zone thickened to 12 mm or greater highly specific. May contain punctate T2 hyperintense cystic foci/T1 hyperintense hemorrhage.
  • However, modern TV US shows comparable accuracy to MRI with no statistical significance between sensitivities and specificities: “Transvaginal US should be considered the primary imaging modality for the diagnosis of adenomyosis.”*
  • Treatment: Pain management, tranexamic acid, OCPs, GnRH agonists.
  • If severe, not relieved medically, and no desire for fertility: Hysterectomy.

*Cunningham RK, Horrow MM, Smith RJ, et al. Adenomyosis: A Sonographic Diagnosis. RadioGraphics. 2018; 38:1576-1589

To learn more about the Samsung RS85 Prestige ultrasound system, please visit: https://www.bostonimaging.com/rs85-prestige-ultrasound-system-4

Click the YouTube Community tab or follow on social media for bonus teaching material posted throughout the week!

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Ultrasound of Endometrioma

In this radiology lecture, we review the ultrasound appearance of endometrioma through three unique cases, including an MRI example.

Key teaching points include:

  • Endometriosis = Ectopic endometrial glands and stroma outside of the uterine cavity. Includes endometriomas, extraovarian implants and adhesions.
  • Endometriomas = Endometriotic cysts within ovary.
  • Endometriosis is seen in about 10% of women of reproductive age.
  • Presentation: Pelvic pain, dysmenorrhea, dyspareunia, infertility.
  • Ultrasound: Diffuse, homogeneous low-level echoes (most specific feature) yielding a ground glass appearance. May have posterior acoustic enhancement.
  • Endometriomas may have peripheral punctate echogenic foci. These foci have no internal vascular flow but can see twinkle artifact.
  • Vascular flow may be present in endometrioma septations.
  • Endometrioma vs. hemorrhagic cyst: Hemorrhagic cysts are acute, usually solitary and unilocular, whereas endometriomas are chronic, sometimes multiple and multilocular.
  • Endometriomas can rarely (1%) undergo malignant transformation into endometrioid carcinoma or clear cell carcinoma.
  • MR is the most specific imaging modality for diagnosis of endometrioma = Specificity 98%.*
  • Homogeneous, T1 “light bulb” bright, T2 dark = “T2 shading.”
  • Surgical treatment: Depends on disease severity from laparoscopic cyst aspiration/cystectomy to hysterectomy/oophorectomy.
  • Medical management may be attempted: Oral contraceptives, GnRH agonists

*Reference: Togashi K, Nishimura K, Kimura I, et al. Endometrial cysts: Diagnosis with MR imaging. Radiology. 1991;180:73-78.

To learn more about the Samsung RS85 Prestige ultrasound system, please visit: https://www.bostonimaging.com/rs85-prestige-ultrasound-system-4

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Ultrasound of Testicular Torsion

In this radiology lecture, we review the ultrasound appearance of testicular torsion through three unique cases.

Key teaching points include:

  • Torsion occurs when spermatic cord twists and cuts off blood supply to the testis.
  • Bell-clapper deformity most common etiology: Abnormally high attachment of tunica vaginalis allowing spermatic cord rotation and testicular torsion (intravaginal).
  • Torsion has a bimodal distribution: First year of life (extravaginal), adolescents/young adults (intravaginal).
  • “Whirlpool” sign: Eddy swirl of coiled spermatic cord superior to testis, highly specific but less commonly seen than redundant spermatic cord.
  • Redundant spermatic cord AKA boggy pseudomass, torsion knot, epididymal-cord complex and should be avascular or only minimally vascular (unlike paratesticular neoplasm or acute epididymitis).
  • Testicles normally lie vertically, but horizontal or oblique (diagonal) lie suspicious for torsion.
  • Testicular enlargement, reactive hydrocele and scrotal skin thickening are secondary findings of torsion.
  • Marked testicular heterogeneity = Late torsion and nonviability/necrosis, more likely after 24 hours of symptoms.
  • Treatment: Detorsion and orchiopexy if salvageable, orchiectomy if not.

Reference: Bandarkar AN, Blask AR. Testicular torsion with preserved flow: Key sonographic features and value-added approach to diagnosis. Pediatric Radiology (2018) 48:735–744.

To learn more about the Samsung RS85 Prestige ultrasound system, please visit: https://www.bostonimaging.com/rs85-prestige-ultrasound-system-4

Click the YouTube Community tab or follow on social media for bonus teaching material posted throughout the week!

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Ultrasound & CT of Renal Oncocytoma

In this radiology lecture, the ultrasound and CT appearance of renal oncocytoma is revealed.

Key teaching points include:

  • Oncocytomas are benign, solid tumors.
  • 13% patients have multiple oncocytomas, and 1/3rd have concurrent renal cell carcinoma.
  • Central stellate nonenhancing scar only seen in 1/3rd of cases, and more commonly in larger tumors.
  • Spoke-wheel angiographic pattern may be present, best visualized on ultrasound using microvascular flow, AKA superb microvascular imaging.
  • Often not possible to differentiate from renal cell carcinoma (RCC) with imaging.
  • Both oncocytoma and RCC can have central scar and/or spoke-wheel angiographic pattern.
  • Kim et al.* found segmental enhancement inversion (corticomedullary phase/early excretory phase) characteristic for oncocytoma, but subsequent studies have shown inconsistent results.
  • When evaluating a renal mass, if only have postcontrast and 15-minute delayed phase images, mass deenhancement of 15 HU or more suggests a solid mass, whereas no change is more consistent with a hyperattenuating cyst.**

*Kim JI, Cho JY, Moon KC, et al. Segmental enhancement inversion at biphasic multidetector CT: Characteristic finding of small renal oncocytoma. Radiology 2009;252(2):441–448.

**Macari M, Bosniak MA. Delayed CT to evaluate renal masses incidentally discovered at contrast-enhanced CT: Demonstration of vascularity with deenhancement. Radiology 1999;213:674-680.

To learn more about the Samsung RS85 Prestige ultrasound system, please visit: https://www.bostonimaging.com/rs85-prestige-ultrasound-system-4

Click the YouTube Community tab or follow on social media for bonus teaching material posted throughout the week!

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