Maria E. Sellars

Ultrasound appearances of the testicular appendages: pictorial review.

Abstract. Five testicular appendages are formed during development of the male genito-urinary tract, which are the remnants of the degenerating mesonephric and paramesonephric ducts. The testicular and epididymal appendages, found at the upper pole of the testis and at the head of the epididymis respectively, are the most common and have a range of appearances on ultrasound. These appendages have the ability to undergo torsion, an important differential diagnosis in the child who presents with an acute scrotum. The varying ultrasound appearances of the testicular appendages are described and illustrated. Ultrasound features of appendiceal torsion are also demonstrated.

Survival of patients with ALS following institution of enteral feeding is related to pre‐procedure oximetry: A retrospective review of 98 patients in a single centre

A retrospective review was carried out on the influence of pre‐procedure respiratory assessment on survival of patients with amyotrophic lateral sclerosis (ALS) requiring nutritional support with either a gastrostomy or a nasogastric feeding tube. Over a five‐year period 98 patients (49 male, 49 female; median age 61 years, range 26–86 years) with ALS were referred for enteral feeding with either radiological inserted gastrostomy (RIG), percutaneous endoscopic gastrostomy (PEG) or nasogastric tube (NG). Case notes review was performed to record patient age, sex, pre‐procedure respiratory assessment, method of enteral feeding and survival post‐procedure. Kaplan‐Meier survival curves were constructed for each group, with Cox regression analyses performed in order to establish the effect of each variable on outcome. Median survival (with 95% confidence intervals) following RIG, PEG and NG was 6.31 months (4.58–8.04 months), 7.13 months (4.81–9.45 months) and 0.95 months (0.00–2.77 months), respectively. The survival advantage between RIG and PEG was not statistically significant (p = 0.50), but for NG versus RIG and PEG groups combined, there was a significant difference (p = 0.03). For patients with normal overnight oximetry, median survival was 8.54 months (3.88–13.21 months), compared to 4.80 months (1.20–8.39 months) in the abnormal oximetry group (p = 0.03; relative risk 1.97). It is concluded that RIG and PEG are equivalent in terms of post‐procedure survival. Abnormal oximetry prior to the procedure is a significant indicator of post‐procedure survival.

Features of testicular epidermoid cysts on contrast-enhanced sonography and real-time tissue elastography.

A series of 7 testicular epidermoid cysts were imaged by contrast‐enhanced sonography to assess internal vascularity and by real‐time tissue elastography to grade stiffness by a visual and strain ratio quantification scoring system. No internal vascular enhancement was seen on contrast‐enhanced sonography; the 3 largest lesions showed rim enhancement. On the real‐time elastographic color display, all lesions were predominantly blue (“hard”), and the lesions analyzed for the strain ratio had a mean value of 43.57. Contrast‐enhanced sonography depicts the absence of vascular flow, and real‐time elastography shows that the epidermoid cysts are hard. This combination of information will help further characterize these lesions.

Impalpable testis cancer

Sir I was impressed with the comments in the recent issue by Blaivas [1] and his editorial elsewhere [2]. He pointed out the ambiguity of the definition of the overactive bladder (OAB) compared with Down’s syndrome [1]. He also indicated the ambiguity of the exclusion criteria of OAB ‘if there is no proven infection or other obvious pathology’ [2]. He asked whether the patients with BPH (obvious pathology) have OAB. I would like to offer a suggestion about the exclusion criteria for OAB. As is well-known, there is a similar symptom-based syndrome of evacuation or excretion, the ‘irritable bowel syndrome’ (IBS). In the definition of IBS the exclusion criteria are clearly stated descriptively as ‘red flags’ in the diagnosis of IBS, i.e. occult blood in stool, weight loss, arthritis or dermatitis on physical examination, etc. [3]. Thus we need ‘red flags’ also for the differential diagnosis of OAB. I wonder why the International Continence Society Terminology Committee [4] refer to such a syndrome? They should be able to make more descriptive exclusion criteria like ‘occult blood in urine’ to exclude malignancies. I ‘urge’ the committee to make descriptive exclusion criteria to relieve physicians from the confusion. Otherwise, the symptom-based OAB definition is not a patientor primary care-friendly diagnosis as it is, but rather only a pharmaceutical industry-friendly one.

Contrast Enhanced Ultrasound (CEUS) Characterization of Grey-scale Sonographic Indeterminate Focal Liver Lesions in Pediatric Practice

PURPOSE To determine the usefulness of contrast-enhanced ultrasound (CEUS) in characterizing grey-scale sonographic indeterminate focal liver lesions (FLL) in pediatric practice. MATERIALS AND METHODS Local Ethics Board approval waiver was attained. Consent for CEUS examinations was acquired from parents. Forty-four children referred for CEUS assessment of grey-scale sonographic indeterminate FLL over a 5-year period underwent standard multiphase CEUS performed by experienced operators. A phospholipid microbubble agent was used and low mechanical index ultrasound imaging techniques employed. Interpretation by consensus of the CEUS examination was compared to consensus interpretation of other imaging and to histology. Follow-up imaging was used to confirm stability of benign abnormalities. Any contrast reactions were recorded. RESULTS The CEUS examination interpretation agreed with reference imaging in 29/34 (85.3 %) of cases. In discordant cases, reference imaging showed no abnormality (n = 5), with fatty change (n = 4) and regenerating nodules (n = 1) on CEUS and follow-up sonography. Where reference imaging was not performed (n = 10), histology (n = 7) or follow-up sonography (n = 3) confirmed the diagnosis. In one discordant case, all imaging modalities showed concordance identifying a malignant lesion; however histology demonstrated a benign hepatocellular adenoma. The specificity was 98.0 % (95 % CI; 86 - 100 %) and the negative predictive value was 100 %. No adverse effects to the contrast material were noted. CONCLUSION These findings demonstrate the usefulness of CEUS in characterizing indeterminate grey-scale sonography FLL in pediatric patients with the potential to reduce exposure to ionizing radiation.

Splenogonadal Fusion B-Mode and Color Doppler Sonographic Appearances

Splenogonadal fusion is a rare abnormality. We report the B-mode and color Doppler sonographic appearances of a superior testicular pole splenogonadal fusion and describe the pattern of vascularity present in this rare benign abnormality.

Contrast-Enhanced Ultrasound in the Evaluation of Focal Testicular Complications Secondary to Epididymitis

OBJECTIVE The purpose of this study is to determine the effectiveness of contrast-enhanced ultrasound in evaluating incidental focal testicular lesions in epididymitis. MATERIALS AND METHODS Intratesticular lesions ipsilateral to epididymitis were subject to B-mode color Doppler ultrasound and contrast-enhanced ultrasound, with their appearances reviewed in consensus. Final interpretation was by histologic analysis or follow-up ultrasound. RESULTS Over 28 months, 16 focal testicular lesions (median lesion size, 24 mm; range, 14-48 mm) in 14 patients (median age, 49 years; range, 18-81 years) were examined. Lesions were oval (n = 14), wedge shaped (n = 1), or involved the entire testis (n = 1). Lesions were isoechoic (n = 1), hypoechoic (n = 4), or of mixed echogenicity (n = 11). Color Doppler ultrasound flow was not clearly depicted in 13 lesions but was present in three lesions, with contrast-enhanced ultrasound concordant with color Doppler ultrasound, showing unequivocal absence of vascularity and increased flow, respectively. In the avascular lesions, rim enhancement (n = 6), vascular projections (n = 4), and irregular (n = 10) and smooth (n = 2) borders were documented. The observers identified infarction (n = 9), abscess (n = 4), orchitis (n = 1), and tumor (n = 2). Histologic examination (seven lesions in five patients) confirmed infarction, abscess formation, and seminoma; follow-up ultrasound confirmed resolution for eight patients. CONCLUSION Contrast-enhanced ultrasound is a useful adjuvant to color Doppler ultrasound examination of a focal lesion in the testis ipsilateral to epididymitis to improve the characterization of nonvascularized tissue.

Post-traumatic liver and splenic pseudoaneurysms in children: Diagnosis, management, and follow-up screening using contrast enhanced ultrasound (CEUS)

BACKGROUND Pseudoaneurysm (PA) formation following blunt and penetrating abdominal trauma is a recognized complication in solid organ injury, usually diagnosed by contrast-enhanced CT (CECT) imaging. Delayed rupture is a potentially life-threatening event, although its frequency is not known in pediatric trauma. Contrast enhanced ultrasound (CEUS) is a novel radiation-free alternative to CECT with the potential to identify PA. METHODS A retrospective review of consecutive cases of significant liver and splenic injuries admitted to single institution (tertiary and quaternary referrals) over more than a 12year period was performed. From 2011, CEUS was performed routinely postinjury (5-10days) using SonoVue™ as contrast. Initially, CECT and CEUS were performed in tandem to ensure accurate correlation. RESULTS From January 2002-December 2014, 101 (73M) children [median age was 14.2 (1.3-18)years] with liver and splenic injuries were admitted. Injuries included: liver [n=57, grade 3 (1-5)], splenic [n=35, grade 3 (1-5)], and combined liver/spleen [n=8, (1-4)]. Median Injury Severity Score (ISS) was 13 (2-72). The predominant mechanisms of injury were blunt trauma n=73 (72%) and penetrating trauma n=28 (28%). Seventeen children (17%) developed PA. Six children became symptomatic (35%), and five went on to have embolization [at 7 (3-11)days]. These were detected by CECT (n=4) and CEUS (n=2). Eleven children remained asymptomatic [detected by CECT (n=8) and CEUS (n=3) at median 5 (4-8)days]. One underwent embolization owing to evidence of interval bleeding. Sensitivity of CEUS at detection of PA was 83%, with specificity of 92% (PPV=71%, NPV=96%). There was no association between grade of injury and presence of PA in either liver or splenic trauma (P=0.4), nor was there an association between size of PA and symptoms (P=0.68). Children sustaining splenic PA were significantly younger than those with hepatic PA (P=0.03). Follow-up imaging confirmed resolution of PA in 16 cases. One child was lost to follow-up. CONCLUSIONS The incidence of PA is higher than previously reported in the pediatric literature (<5%). Postinjury imaging appears mandatory, and CEUS appears to be highly sensitive and specific for diagnosis and follow-up.

Re: New ultrasound techniques for imaging of the indeterminate testicular lesion may avoid surgery completely

SirdWe read with interest the article by Kirkham et al.1 The authors recommend targeted testicular excision biopsy with histological analysis of frozen samples as the investigation of choice for “indeterminate” intra-testicular lesions. In our experience, with recent advances in ultrasound technology, there are a number of investigations in the radiologists armamentarium that need to be exhausted before a lesion is deemed “indeterminate” and the patient is subjected to an excision biopsy. The most important ultrasound technique for the interrogation of a focal indeterminate testicular lesion is colour Doppler ultrasound, with all types of primary testicular tumours (both germ cell and non-germ cell tumours)

Intrahepatic duct dilatation in type 4 choledochal malformation: pressure-related, postoperative resolution

BACKGROUND Type 4 choledochal malformations (CMs) may be defined as those with both intrahepatic and extrahepatic bile duct dilatation. The aims of this study were to investigate possible causes of intrahepatic duct (IHD) dilatation in CM and to define the effect of surgery over time. METHODS This study was a single-center retrospective review of a database of all children with CM undergoing surgery (excision of extrahepatic bile duct dilatation and hepaticojejunostomy) and identified as type 4 (on imaging and at surgery). Data included intraoperative choledochal pressure measurements and biliary amylase content and were expressed as median (interquartile range [IQR]). All comparisons used nonparametric statistical tests. P ≤.05 was regarded as significant. RESULTS Twenty children were identified as type 4 CM (age, 4.3 years; range, 2.7-10.4 years) with preoperative IHD dilatation (right duct: diameter [range], 8.5 [4.5-14] mm; left: 8 [4-14.5] mm). Median intraoperative choledochal pressure was 17 (8-27) mm Hg (normal, <5 mm Hg), and intraoperative bile amylase was 3647 (range, 500-58,000) IU/L (normal, <100 IU/L). Preoperative IHD diameter correlated with choledochal pressure (right: r(s)=0.46, P = .03; left: r(s)=0.34, P = .07) but not with biliary amylase (P = .28 and P = .39, respectively). At 1 year postsurgery, median (range) IHD diameter had decreased to 1 (1-2.5) mm for right duct (P = .0002) and 1.5 (1-3) mm for left duct (P = .0006) and remained stable for up to a 10-year follow-up. CONCLUSION Our data suggest that IHD dilatation is related to sustained increased intrabiliary pressure rather than any intrinsic intrahepatic CM. Effective surgery invariably reduces measured IHD toward normal values.