S. Alessi

Shear wave elastography in the diagnosis of thyroid nodules: feasibility in the case of coexistent chronic autoimmune Hashimoto’s thyroiditis

Objective  ShearWave™ Elastography (SWE) is real‐time, quantitative and user‐independent technique, recently introduced in the diagnostic work‐up of thyroid nodules. Hashimoto’s thyroiditis (HT), characterized by variable degrees of lymphocytic infiltration and fibrosis, might affect shear wave propagation. The aim of this study was to assess the feasibility of SWE in cytologically benign thyroid nodules within both Hashimoto’s and nonautoimmune thyroid glands. The effect of autoimmunity on the gland stiffness was also evaluated.

Subclinical remodelling of draining lymph node structure in early and established rheumatoid arthritis assessed by power Doppler ultrasonography

OBJECTIVE To investigate the suitability of power Doppler ultrasonography (PD-US) for the assessment of lymph node (LN) status in RA, evaluating the existence of structural and dynamic modifications in well-characterized stages of the disease. METHODS Ten patients with active disease and five patients in clinical remission underwent complete clinical and PD-US examination of hands, wrists, axillary and cervical LNs on the same day. Synovitis and PD were graded 0-3. LN assessment included maximum short axis, cortical hypertrophy (CH) and PD signal distribution. All patients with active disease were re-evaluated prospectively 3 months after initiation of therapy. RESULTS PD-US signs of axillary LN remodelling were observed in 7 out of 10 patients with active disease despite the absence of clinical lymphoadenopathy. Subclinical alterations were detected in both early untreated RA and in established disease. Characteristic structural changes consisted of hypertrophy of the LN cortex and PD signal amplification in cortical and hilar regions. Cervical LNs in active disease and axillary LNs in clinical remission were unaffected. LN PD amplification returned to normal ranges in patients with baseline alterations re-evaluated 3 months after therapy with TNF-α blocking agents and/or MTX. CONCLUSION Draining LNs in RA are subjected to subclinical intra-parenchymal changes and vascular flow modulation detectable by PD-US. Sonographic signs of LN involvement associate with disease activity and are reversible upon treatment. These data point at LN reactivity as a dynamic component of RA inflammatory cascade and an attractive platform to be explored in prognostic and response to therapy evaluations.

Varicocele: Ultrasonographic assessment in daily clinical practice

INTRODUCTION Varicoceles are abnormal dilatations of the pampiniform venous plexus. They are classified as primary or secondary, depending on their cause, and staged clinically on the basis of their extension and on the presence or the absence of spontaneous or induced reversal of blood flow. MATERIALS AND METHODS We examined 95 patients (age range: 3-77 years) using Color Doppler ultrasound with settings optimized for the study of slow flow. All patients found to have varicoceles underwent ultrasonographic assessment of the kidneys and retroperitoneum. Findings were classified with a simplified version of the Sarteschi system. RESULTS 41 (43.1%) of the patients were found to have varicoceles, which were classified as grade 1 in 11 cases, grade 2 in 13, grade 3 in 10, and grade 4 in 7 according to the simplified Sarteschi classification. DISCUSSION Our results are with those reported in the literature. They confirm that varicoceles are a frequent finding and ultrasonography is currently the best imaging technique for its diagnosis and also for the post-surgery follow-up.

Lymphoma of the scrotum in patients with Down’s syndrome: US appearance. Mini-pictorial essay

Downs syndrome is relatively common, and patients who are affected have an increased risk of developing acute leukemia, but not solid tumors. Studies performed in larger patient populations have shown that solid tumors, including lymphomas, are significantly less frequent in Down patients than in children and adults who are not Trisomy 21-affected.Testicular lymphomas are rare and extremely aggressive. Ultrasound (US) combined with color Doppler is essential in the diagnosis and evaluation of treatment results in these lesions. As they are very rare, it was decided to publish this mini-pictorial essay.

Baker's cyst in pediatric patients: Ultrasonographic characteristics

OBJECTIVE Evaluate incidence, etiology, and sonographic features of Bakers cyst in children. MATERIALS AND METHODS We examined 16 pediatric patients, with the clinical diagnosis of Bakers cyst. The possibility to confirm or to exclude the presence of the lesion, assess the structure, presence of bilateralism and joint effusion were considered. Three subjects had known juvenile arthritis, 2 hemophilia, 11 a popliteal swelling in the absence of concomitant diseases. RESULTS In all patients it was possible to confirm (11) or to exclude (5) the presence of Bakers cyst. The idiopathic forms (6) exhibited anechoic structure; in patients with arthritis (3) there was hypertrophic synovium; in hemophilic patients at the presentation (2) anechoic structure with layering (serum and red blood cells); in chronic hemophilia synovial hypertrophy was seen. Joint effusion was constantly present in children with hemophilia and arthritis and in 1 case of idiopathic cyst. CONCLUSION Bakers cysts in children are rare. Ultrasound is able to confirm or to exclude the presence of the lesion and it is able to evaluate characteristics, bilateralism and association with joint effusion.

Ultrasound guided fine-needle aspiration cytology of breast lesions

Breast biopsy consists in the collection of cells or tissue fragments from a breast lesion and their analysis by a pathologist. There are several types of breast biopsy defined on the basis of the type of needle used: fine-needle aspiration and biopsy performed with a spring-based needle. This article focuses on fine-needle aspiration performed under sonographic guidance.It is used mainly to assess cysts that appear to contain vegetations or blood or that are associated with symptoms; lesions and solid nodules that are not unequivocally benign; and axillary lymph nodes that appear suspicious on physical examination and/or sonography.In addition to distinguishing between benign and malignant lesions, ultrasound guided fine-needle aspiration also plays an important role in tumor grading and in immunocytochemical identifying specific tumor markers. This article describes the technique used and the possible causes of false negative and false positive findings. Despite its limitations, fine-needle aspiration has become a fundamental tool for the identification and preoperative management of malignant breast lesions.

Scrotal pain as the first clinical manifestation of testicular seminoma: A case report.

Seminomas are the malignant testicular tumors most commonly diagnosed in young adult males. It consists of undifferentiated cells derived from the embryonic gonad. The tumor presents as a scrotal mass that may or may not be associated with pain. On ultrasonography, the mass appears hypoechoic with well-defined margins and an echo structure that tends to be homogeneous. Color Doppler studies reveal rich vascularization. This report describes a case of seminoma that presented with scrotal pain. The typical findings on ultrasonography and color Doppler were fundamental for correct diagnosis of this tumor.

Testicular ischemia after inguinal hernia repair

Testicular ischemia is a rare complication of inguinal hernia repair. It results from the injury to the vessels that course along the inguinal canal. Typically it is painful at the beginning and asymptomatic later. Ultrasonographic appearance and aspects of testicular ischemia result in diffusely hypoechoic and disomogeneous testis, with complete lack of intratesticular vascular signal on color-Doppler and cremasteric vessels hypertrophy in chronic cases.This report describes a testicular ischemia seen in a patient referred to because of hernia recurrence, without any sign or symptom of acute scrotum. Ultrasound examination showed the most frequent complications after inguinal hernia repair: both hernia recurrence and testicular ischemia.

Ganglioneuroblastoma: Case report and review of the literature

Neuroblastoma are among the most important tumors of extracranial origin in pediatric patients. They arise from embryonal cells involved in the development of the sympathetic nervous system, whose differentiation has been arrested [1,2]. They are the tumors most frequently diagnosed during the first decade of life. Their evolution is unpredictable, ranging from progression to spontaneous regression or maturation, and their location and metastatic potential vary. Little is known about the cause of these tumors and the risk factors associated with their development. This article describes a typical case of ganglioneuroblastoma and provides a review of the literature on this type of tumor.Sommario Il neuroblastoma è uno dei più importanti tumori pediatrici di derivazione extracranica; esso origina dalle cellule embrionali coinvolte nello sviluppo del sistema nervoso simpatico a causa di un blocco nel loro processo di differenziamento [1,2]. È la più frequente neoplasia della prima decade di vita; la sua progressione biologica è imprevedibile, regressione spontanea, maturazione a ganglioneuroma, localizzazione e metastatizzazione variabili. Poco è noto a riguardo dei fattori di rischio e della sua eziopatogenesi. Viene presentato un caso tipico di ganglioneuroblastoma e riesaminata la letteratura su questa neoplasia.

A1.13 Ultrasound-guided assessement of axillary lymph nodes in rheumatoid arthritis: cross-sectional and prospective clinico-pathologic significance

Background and Objectives Joint-draining lymph nodes (LN) and afferent lymphatics are relevant components of the induction-resolution phases of immune responses, acting through the control of cell efflux from the joint and regulation of peripheral inflammation. LN reactivity to exogenous stimuli associates with morphological and vascular flow dynamic changes. While the dynamics of draining LN have been extensively investigated in infectious and neoplastic diseases, much remains to be understood regarding their involvement in human autoimmune conditions. In this study, we have developed of a non-invasive power Doppler ultrasound (PDUS) system for the assessment of human axillary LN blood flow characteristics and investigated its significance in relationship with disease activity and outcome in rheumatoid arthritis (RA). Materials and Methods 101 subjects were recruited in the study: 20 healthy volunteers, 33 RA patients with active disease candidate to biologic therapy and 48 RA patients in stable clinical remission candidate to drug-free follow-up. All patients underwent complete clinical-laboratory evaluations and joint-axillary LN PDUS assessments. LN were evaluated for volume (by ellipsoid formula), cortex hypertrophy and vascular flow distribution. All evaluations were performed at baseline and at 6 months after biologic treatment initiation, and every 3 months following DMARD suspension. Results Vascular flow characteristics were assessed semi-quantitatively according to the degree of PD distribution in LN cortex (0-1 PD signals/2-3/4-5 /≥6). Validation assessments showed good inter-rater agreement (k = 0.86) and strong correlation between the score and overall PD+vascular signal defined by digital image analysis (rho = 0.9, p<0.01). A grading system referring to the maximum observed score was adopted to define a patient-related index. In subjects with detectable LN, the LN PD grade significantly discriminated active RA from controls. RA patients in remission revealed a trend towards reduction in the prevalence of high PD grades compared to active RA, but not a systematic return to normalcy. In active RA a significant correlation was observed between LN PD grade and joint PD score (p<0.05), but not with DAS28, SJC28, TJC28, ESR, CRP. Pilot prospective evaluations following biologic treatment pointed at the axillary LN PD grade as the only predictor of DAS28 remission at 6 months (OR 2.53, 95% CI 1,21-5,31, p = 0.01). Conclusions Non-invasive vascular flow assessment by PDUS of axillary LN seems a feasible, reliable and valid tool to capture clinically-relevant changes of draining LN status. This may be important to better focus invasive procedures for biological studies and as a novel approach for biomarker discovery in RA.