WFUMB Blog
Caio Batalha Pereira, Simone Uezato Ota, Marcelo Schelini, Julia Diva Zavaris, Wagner Iared, Maria Cristina Chammas
- Centro de Aperfeiçoamento e Pesquisa em Ultrassonografia Prof. Dr. Giovanni Guido Cerri, DASA, São Paulo, Brazil.
Clinical History:
A 23-year-old womanfrom the countryside of São Paulo came to our clinicfora routine gynecologic examination. She had no known comorbidity.
The figures represent:
Presence of ill-defined nodular formation, hyperechogenic, without Doppler flow, in the right ovary, measuring approximately 0.8 x 0.7 x 0.6 cm. Volume: 0.3 cm³.
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Question: Which diagnosis is most likely for the case?
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CORRECT ANSWER EXPLAINED BELOW Correct answer is: Dermoid cyst
Dermoid cysts account for 15% of all ovarian neoplasms and predominate in young women, being the most common ovarian neoplasm in patients younger than 20 years. Ultrasound is the preferred imaging modality. Typically, an ovarian dermoid is seen as a unilocular cystic adnexal mass with some mural components. The spectrum of sonographic features includes: a diffusely or partially echogenic mass with posterior sound attenuation owing to sebaceous material and hair within the cyst cavity; an echogenic interface at the edge of the mass that obscures deep structures (the tip of the iceberg sign); mural hyperechoic or Rokitansky nodule (dermoid plug); echogenic shadowing calcific or dental (tooth) components; fluid-fluid levels; multiple thin echogenic bands caused by the hair in the cyst cavity; the dot-dash pattern (dermoid mesh); no internal vascularity on color Doppler; intracystic floating balls sign (uncommon, but characteristic).
Discussion
Among the alternatives, the diagnosis of dermoid cyst should be considered because ovarian serous or mucinous cystadenoma/cystadenocarcinoma is usually only a serious consideration if the typical features of dermoid cyst are absent. Carcinoma also tends to occur in an older age group than dermoid cysts. Ovarian dysgerminomas are rare ovarian tumors that occur predominantly in young women in the 2nd to 3rd decades. Approximately 10-20% of cases occur in pregnancy. On ultrasound, they may be seen as a septated ovarian mass with varying echotexture. Color Doppler ultrasound may show prominent flow signal within the fibrovascular septa. Fibromas occur at all ages but are most frequently seen in middle-aged women, and on ultrasound manifest as solid, hypoechoic masses with ultrasound beam attenuation. As such, they may appear similar to a pedunculated subserosal uterine fibroid. However, the sonographic appearance can be variable, and some tumors can have cystic components, although rarely.
Take home message
Knowing the ultrasound aspects of dermoid cysts is important because they are benign lesions that grow slowly (1-2 mm per year) and, therefore may not need surgery. The most common complication is ovarian torsion, which occurs in 3-16% of dermoid cysts. Many recommend annual follow-up for lesions <7 cm to monitor growth. Tumors larger than 7 cm should be resected.
References
- Outwater EK, Siegelman ES, Hunt JL. Ovarian teratomas: tumor types and imaging characteristics. Radiographics. 21 (2): 475-90
- Adusumilli S, Hussain HK, Caoili EM et-al. MRI of sonographically indeterminate adnexal masses. AJR Am J Roentgenol. 2006;187 (3): 732-40.
- Gürel H, Gürel SA. Ovarian cystic teratoma with a pathognomonic appearance of multiple floating balls: a case report and investigation of common characteristics of the cases in the literature. Fertility and sterility. 90 (5): 2008.e17-9.
- Acién P, Ruiz-Maciá E, Acién M, Martín-Estefanía C. Mature ovarian teratoma-associated limbic encephalitis. Journal of obstetrics and gynaecology : the journal of the Institute of Obstetrics and Gynaecology. 35 (3): 317-9.
- Patel MD, Feldstein VA, Lipson SD et-al. Cystic teratomas of the ovary: diagnostic value of sonography. AJR Am J Roentgenol. 1998;171 (4): 1061-5
- Park SB, Kim JK, Kim KR et-al. Imaging findings of complications and unusual manifestations of ovarian teratomas. Radiographics. 28 (4): 969-83.
- Moomjian LN, Clayton RD, Carucci LR. A Spectrum of Entities That May Mimic Abdominopelvic Abscesses Requiring Image-guided Drainage. (2018) Radiographics : a review publication of the Radiological Society of North America, Inc. 38 (4): 1264-1281.
Incorrect
CORRECT ANSWER EXPLAINED BELOW Correct answer is: Dermoid cyst
Dermoid cysts account for 15% of all ovarian neoplasms and predominate in young women, being the most common ovarian neoplasm in patients younger than 20 years. Ultrasound is the preferred imaging modality. Typically, an ovarian dermoid is seen as a unilocular cystic adnexal mass with some mural components. The spectrum of sonographic features includes: a diffusely or partially echogenic mass with posterior sound attenuation owing to sebaceous material and hair within the cyst cavity; an echogenic interface at the edge of the mass that obscures deep structures (the tip of the iceberg sign); mural hyperechoic or Rokitansky nodule (dermoid plug); echogenic shadowing calcific or dental (tooth) components; fluid-fluid levels; multiple thin echogenic bands caused by the hair in the cyst cavity; the dot-dash pattern (dermoid mesh); no internal vascularity on color Doppler; intracystic floating balls sign (uncommon, but characteristic).
Discussion
Among the alternatives, the diagnosis of dermoid cyst should be considered because ovarian serous or mucinous cystadenoma/cystadenocarcinoma is usually only a serious consideration if the typical features of dermoid cyst are absent. Carcinoma also tends to occur in an older age group than dermoid cysts. Ovarian dysgerminomas are rare ovarian tumors that occur predominantly in young women in the 2nd to 3rd decades. Approximately 10-20% of cases occur in pregnancy. On ultrasound, they may be seen as a septated ovarian mass with varying echotexture. Color Doppler ultrasound may show prominent flow signal within the fibrovascular septa. Fibromas occur at all ages but are most frequently seen in middle-aged women, and on ultrasound manifest as solid, hypoechoic masses with ultrasound beam attenuation. As such, they may appear similar to a pedunculated subserosal uterine fibroid. However, the sonographic appearance can be variable, and some tumors can have cystic components, although rarely.
Take home message
Knowing the ultrasound aspects of dermoid cysts is important because they are benign lesions that grow slowly (1-2 mm per year) and, therefore may not need surgery. The most common complication is ovarian torsion, which occurs in 3-16% of dermoid cysts. Many recommend annual follow-up for lesions <7 cm to monitor growth. Tumors larger than 7 cm should be resected.
References
- Outwater EK, Siegelman ES, Hunt JL. Ovarian teratomas: tumor types and imaging characteristics. Radiographics. 21 (2): 475-90
- Adusumilli S, Hussain HK, Caoili EM et-al. MRI of sonographically indeterminate adnexal masses. AJR Am J Roentgenol. 2006;187 (3): 732-40.
- Gürel H, Gürel SA. Ovarian cystic teratoma with a pathognomonic appearance of multiple floating balls: a case report and investigation of common characteristics of the cases in the literature. Fertility and sterility. 90 (5): 2008.e17-9.
- Acién P, Ruiz-Maciá E, Acién M, Martín-Estefanía C. Mature ovarian teratoma-associated limbic encephalitis. Journal of obstetrics and gynaecology : the journal of the Institute of Obstetrics and Gynaecology. 35 (3): 317-9.
- Patel MD, Feldstein VA, Lipson SD et-al. Cystic teratomas of the ovary: diagnostic value of sonography. AJR Am J Roentgenol. 1998;171 (4): 1061-5
- Park SB, Kim JK, Kim KR et-al. Imaging findings of complications and unusual manifestations of ovarian teratomas. Radiographics. 28 (4): 969-83.
- Moomjian LN, Clayton RD, Carucci LR. A Spectrum of Entities That May Mimic Abdominopelvic Abscesses Requiring Image-guided Drainage. (2018) Radiographics : a review publication of the Radiological Society of North America, Inc. 38 (4): 1264-1281.
Visit the FLAUS web site for more information coming soon on this event https://www.flaus-us.org
Multiparametric Liver Ultrasound – noninvasive tissue characterisation
We are pleased to announce a joint EFSUMB / WFUMB Webinar event, sponsored by Bracco. ‘Multiparametric Liver Ultrasound – noninvasive tissue characterisation’ with the following speakers of approximately 20 min presentations, discussions and a Q&A session to close.
Register Here for this Event >
- This EFSUMB / WFUMB Webinar event is sponsored by Bracco.
- Once registered your information will be shared with Bracco so they can keep you informed of future webinar events you may be interested in. If you do not wish for your information to be shared please contact us.
- The Webinar is run by EFSUMB.
- Once registered, EFSUMB will email you with the link to join the webinar.
- Each Webinar participant is entitled to an EFSUMB / WFUMB certificate of attendance if the participant joins the webinar for the required minimum period. This time period is monitored by Samsung.
- Each EFSUMB / WFUMB Webinar Event has a maximum of 1000 participants to ensure a good quality of presentation is available for all.
- The webinar event is recorded and all presentations will available on the EFSUMB & WFUMB websites after the event takes place.

WINFOCUS Webinar: “Point-of-Care Ultrasound: Challenges and opportunities in teaching modern learners”
This webinar will look at approaches to teaching POCUS to medical trainees around the world pre- and peak-pandemic.
We will reflect on lessons learned from a decade of teaching the newest generation of medical students vs. life-long learners.
It will take the form of a candid conversation about one sonologist’s journey navigating the ups and downs of building a large academic program with hands-on and virtual training environments.
Thursday 11th March
10:30h EDT (New York, USA)
16:30h CEST (Rome, Italy)
21:00h IST (Delhi, India)
22:30h ICT (Bangkok, Thailand)
23:30h CST (Beijing, China)
07:30h PDT (San Francisco, USA)
09:30h CDT (Mexico City, Mexico)
12:30h CDT (Buenos Aires, Argentina)
Presented by:
Dr. Wilma Chan, MD/EdM, FACEP
Philadelphia, USA
University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA Director, Ultrasound in Undergraduate Medical Education Assistant Professor, Clinical Emergency Medicine Attending Physician, Hospital of the University of Pennsylvania and Penn-Presbyterian Hospital.
Moderated by:
Dr. Gregor Prosen, MD, PhD, FEBEM
Maribor, Slovenia
University Clinical Centre Emergency department Consultant in EM Winfocus Board Member.
In order to participate you need to sign up first and fill out the registration form after.
SIGN UP HERE >>
Caio Batalha Pereira, Simone Uezato Ota, Marcelo Schelini, Wagner Iared, Maria Cristina Chammas
- Centro de Aperfeiçoamento e Pesquisa em Ultrassonografia Prof. Dr. Giovanni Guido Cerri, DASA, São Paulo, Brazil.
Clinical History:
A 67-year-old woman from the countryside of São Paulo came to our clinic with complaints of mild right upper quadrant abdominal pain and slightly elevated serum liver enzymes. She had heart failure as comorbidity.
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Question: Which diagnosis is most likely for the case?
Correct
CORRECT ANSWER EXPLAINED BELOW Correct answer is: Passive hepatic congestion.
Discussion
The figures show a slightly enlarged liver with regular contours and blunt edges. The liver echogenecity is homogeneous. There are no focal lesions. Enlarged hepatic veins, measuring 1.3 to 2 cm near the IVC. Enlarged portal vein with a diameter of 1.5 cm and without thrombi.
Passive hepatic congestion, also known as congested liver in cardiac disease, describes the stasis of blood in the hepatic parenchyma, due to impaired hepatic venous drainage, which leads to the dilation of the central hepatic veins and hepatomegaly. Passive hepatic congestion is a well-studied result of acute or chronic right-sided heart failure.
The spectrum of sonographic features includes enlargement of the right hepatic lobe and the right hepatic vein measures about 9 mm (normal caliber < 6 mm), increases up to 13 mm with pericardial effusion, dilated IVC/hepatic veins, hepatomegaly, ± ascites.
Expected findings related to alternative answers
Among the alternatives, the diagnosis of congestive hepatic congestion should be considered by the patient history and the imaging findings. Budd-Chiari syndrome refers to the clinical picture that occurs when there is partial or complete obstruction of the hepatic veins. It is characterized on imaging by ascites, caudate hypertrophy, peripheral atrophy and prominent collateral veins. Hepatic veno-occlusive disease (VOD), also known as sinusoidal obstruction syndrome (SOS), is a condition arising from occlusion of the hepatic venules. Ultrasound is the imaging modality of choice which may show: hepatomegaly; portal vein abnormalities, such as portal vein dilatation, portal venous pulsatility, hepatofugal portal venous flow; gallbladder wall thickening (> 6-8 mm); and ascites. Acute hepatitis is a clinical diagnosis and the spectrum of sonographic features includes hepatomegaly (most sensitive sign) >15.5 cm at the midclavicular line; starry sky appearance; gallbladder wall thickening; periportal edema; accentuated brightness of the portal veinous walls; overall decreased echogenicity.
Take home message
Knowing the ultrasound aspects of hepatic congestion is important because it allows the clinician to direct the treatment to the basic cause – the heart failure.
References
- Zakim D, Boyer TD. Hepatology. Saunders. ISBN:0721648363.
- McNaughton DA, Abu-Yousef MM. Doppler US of the liver made simple. RadioGraphics 2011; 31(1): 161–188.
- Gore RM, Mathieu DG, White EM et-al. Passive hepatic congestion: cross-sectional imaging features. AJR Am J Roentgenol. 1994;162 (1): 71-5.
- Murphy FB, Steinberg HV, Shires GT et-al. The Budd-Chiari syndrome: a review. AJR Am J Roentgenol. 1986;147 (1): 9-15
- Bayraktar UD, Seren S, Bayraktar Y. Hepatic venous outflow obstruction: three similar syndromes. World J. Gastroenterol. 2007;13 (13): 1912-27
- Brancatelli G, Vilgrain V, Federle MP et-al. Budd-Chiari syndrome: spectrum of imaging findings. AJR Am J Roentgenol. 2007;188 (2): W168-76
Incorrect
CORRECT ANSWER EXPLAINED BELOW Correct answer is: Passive hepatic congestion.
Discussion
The figures show a slightly enlarged liver with regular contours and blunt edges. The liver echogenecity is homogeneous. There are no focal lesions. Enlarged hepatic veins, measuring 1.3 to 2 cm near the IVC. Enlarged portal vein with a diameter of 1.5 cm and without thrombi.
Passive hepatic congestion, also known as congested liver in cardiac disease, describes the stasis of blood in the hepatic parenchyma, due to impaired hepatic venous drainage, which leads to the dilation of the central hepatic veins and hepatomegaly. Passive hepatic congestion is a well-studied result of acute or chronic right-sided heart failure.
The spectrum of sonographic features includes enlargement of the right hepatic lobe and the right hepatic vein measures about 9 mm (normal caliber < 6 mm), increases up to 13 mm with pericardial effusion, dilated IVC/hepatic veins, hepatomegaly, ± ascites.
Expected findings related to alternative answers
Among the alternatives, the diagnosis of congestive hepatic congestion should be considered by the patient history and the imaging findings. Budd-Chiari syndrome refers to the clinical picture that occurs when there is partial or complete obstruction of the hepatic veins. It is characterized on imaging by ascites, caudate hypertrophy, peripheral atrophy and prominent collateral veins. Hepatic veno-occlusive disease (VOD), also known as sinusoidal obstruction syndrome (SOS), is a condition arising from occlusion of the hepatic venules. Ultrasound is the imaging modality of choice which may show: hepatomegaly; portal vein abnormalities, such as portal vein dilatation, portal venous pulsatility, hepatofugal portal venous flow; gallbladder wall thickening (> 6-8 mm); and ascites. Acute hepatitis is a clinical diagnosis and the spectrum of sonographic features includes hepatomegaly (most sensitive sign) >15.5 cm at the midclavicular line; starry sky appearance; gallbladder wall thickening; periportal edema; accentuated brightness of the portal veinous walls; overall decreased echogenicity.
Take home message
Knowing the ultrasound aspects of hepatic congestion is important because it allows the clinician to direct the treatment to the basic cause – the heart failure.
References
- Zakim D, Boyer TD. Hepatology. Saunders. ISBN:0721648363.
- McNaughton DA, Abu-Yousef MM. Doppler US of the liver made simple. RadioGraphics 2011; 31(1): 161–188.
- Gore RM, Mathieu DG, White EM et-al. Passive hepatic congestion: cross-sectional imaging features. AJR Am J Roentgenol. 1994;162 (1): 71-5.
- Murphy FB, Steinberg HV, Shires GT et-al. The Budd-Chiari syndrome: a review. AJR Am J Roentgenol. 1986;147 (1): 9-15
- Bayraktar UD, Seren S, Bayraktar Y. Hepatic venous outflow obstruction: three similar syndromes. World J. Gastroenterol. 2007;13 (13): 1912-27
- Brancatelli G, Vilgrain V, Federle MP et-al. Budd-Chiari syndrome: spectrum of imaging findings. AJR Am J Roentgenol. 2007;188 (2): W168-76
Warmest greetings from the Organizing Committee of the 52nd Annual Congress of Korean Society of Ultrasound in Medicine (KSUM 2021)!
On behalf of the Organizing Committee, it is our great pleasure to inform you that KSUM 2021 will be held on May 13-14, 2021 at COEX, Seoul, Korea.
Under the current COVID-19 situation, we anticipate that foreign participants will experience difficulty in freely entering Korea. As such, the Organizing Committee is preparing a hybrid format that will propose sessions both online and onsite, which participants may attend safely the conference.
The KSUM 2021 Hybrid Congress will cover the latest findings in the field of ultrasound in medicine and biology, and provide you with the chance to share your thoughts and ideas and hear renowned speakers and delegates.
Title: The 52nd Annual Congress of Korean Society of Ultrasound in Medicine (KSUM 2021)
▪ Date: May 13 (Thu) – 14 (Fri), 2021
▪ Venue: Hybrid (Online & Onsite)
▪ Official Language: English
▪ Organized by: Organizing Committee of KSUM 2021
▪ Hosted by: Korean Society of Ultrasound in Medicine (KSUM)
▪ Website: http://2021.ksum.or.kr
▪ Important Dates:
– Abstract Submission Due Date: March 22 (Mon), 2021
– Abstract Acceptance Notice: April 5 (Mon), 2021
– Pre-registration Due Date: May 3 (Mon), 2021
Matthew Gourlay
- Fowler Simmons Radiology. Adelaide, South Australia
Clinical History:
57 year old female runner. Recent increase in running load with increasing medial knee pain.


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Question: What is the likely diagnosis?
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CORRECT ANSWER EXPLAINED BELOW Correct answer is: Medial tibial plateau stress fracture.
Discussion
Stress fractures of the lower limb are not an uncommon finding in runners. This may be due to an increase in load or training errors. They may also occur due to decreased bone density of individuals without necessarily any increase in loading.
Our patient indicated an increase in loading along with tenderness over medial tibial plateau. On ultrasound assessment oedema of the fat layer overlying bone was noted along with periosteal haematoma which is shown as a hypoechoic line overlying the bone cortex (this is nicely shown in video 1 and Image 4). Swelling and oedema of the overlying fat can be noted on Image 1 between the medial collateral ligament and tibia. Clinical history and examination along with ultrasound findings are strongly indicative of stress fracture.
Image 4- Medial tibial plateau transverse view. Tibia (open white arrow), deep fascia (white arrow), periosteal haematoma (black arrow). Associated fat oedema can be noted overlying periosteal haematoma.
Image 3- PDFS MRI sequence showing bone marrow oedema of tibial plateau consistent with stress fracture.
Expected findings related to alternative answers
- A) Pes anserine bursitis-very rare to occur in isolation and swelling in this region can usually be attributed to one of the other 3 possible answers.
- B) Medial meniscal tear-clinically would present with pain and tenderness centred more over medial joint line rather than pes anserine region. Fluid and oedema uncommonly seen tracking down towards the pes anserine region due to a related meniscal cyst with or without rupture. Periosteal haematoma would not be present.
- D) Pes anserine bursitis may occur in patients with systemic arthropathy. This would result in localised swelling of tissues between medial collateral ligament (MCL) and pes anserine (unlike our current case which shows swelling under MCL).
Incorrect
CORRECT ANSWER EXPLAINED BELOW Correct answer is: Medial tibial plateau stress fracture.
Discussion
Stress fractures of the lower limb are not an uncommon finding in runners. This may be due to an increase in load or training errors. They may also occur due to decreased bone density of individuals without necessarily any increase in loading.
Our patient indicated an increase in loading along with tenderness over medial tibial plateau. On ultrasound assessment oedema of the fat layer overlying bone was noted along with periosteal haematoma which is shown as a hypoechoic line overlying the bone cortex (this is nicely shown in video 1 and Image 4). Swelling and oedema of the overlying fat can be noted on Image 1 between the medial collateral ligament and tibia. Clinical history and examination along with ultrasound findings are strongly indicative of stress fracture.
Image 4- Medial tibial plateau transverse view. Tibia (open white arrow), deep fascia (white arrow), periosteal haematoma (black arrow). Associated fat oedema can be noted overlying periosteal haematoma.
Image 3- PDFS MRI sequence showing bone marrow oedema of tibial plateau consistent with stress fracture.
Expected findings related to alternative answers
- A) Pes anserine bursitis-very rare to occur in isolation and swelling in this region can usually be attributed to one of the other 3 possible answers.
- B) Medial meniscal tear-clinically would present with pain and tenderness centred more over medial joint line rather than pes anserine region. Fluid and oedema uncommonly seen tracking down towards the pes anserine region due to a related meniscal cyst with or without rupture. Periosteal haematoma would not be present.
- D) Pes anserine bursitis may occur in patients with systemic arthropathy. This would result in localised swelling of tissues between medial collateral ligament (MCL) and pes anserine (unlike our current case which shows swelling under MCL).

WFUMB Course Book
Chapter: 8.0 Pancreas
Video: 8.2.
Giovanna G. B. Motta, Alessandra RodriguesSilva Chiovatto*, Eduardo Davino Chiovatto, Maria Cristina Chammas, Wagner Iared
- Centro de Aperfeiçoamento e Pesquisa em Ultrassonografia
- Prof. Dr. Giovanni Guido Cerri, DASA, São Paulo, Brazil.
*Corresponding author: arrsilva@gmail.com
Clinical History:
A 15-days-old white female infant was referred to our clinic with a history of breech presentation. She was delivered by cesarean without evident clinical issues. Ultrasound of the hip was performed as a screening due to the breech presentation.
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WFUMB Webinar: COVID era lung ultrasound advances
Took place on Tuesday, February 23, 2021. 2:00 PM CET
The webinar consisted of Introduction, 3 lectures & summary, with Q&A’s and feedback.
Lung ultrasound of COVID-19 and its complications and differential diagnosis will be discussed in the presentations. Also included is the use of contrast enhanced ultrasound, the knowledge of clinical symptoms and past medical history. The objective is to understand Viral pneumonia of other origin, bacterial pneumonia, pulmonary embolism and congestive heart failure (B-line artifacts without pleural changes).
Introduced and chaired by Fabio Piscaglia, presentations for this webinar are below …



Question & Answer Session
Fabio Piscaglia, Christoph Dietrich, Joanna Jaworska & Mike Blaivas
Echoes Issue No. 23
[JUNE 2020]
3 mm. Distal posterior tibial artery
With thanks to Leandro Fernandez, MD, for this contribution
WFUMB Webinar: Hepatocellular carcinoma (HCC)
Took place on Tuesday, January 19, 2021. 1:00 PM – 2:00 PM GMT
The webinar consisted of Introduction, 3 lectures & summary, with Q&A’s and feedback.
A Webinar on Hepatocellular Carcinoma with experts from Italy, USA and China, and chaired by Byung Choi. Aims were:
- which are the subjects deserving surveillance for HCC
- which imaging techniques are accepted for HCC diagnosis
- how to classify CEUS appearance of lesions at risk for HCC
- which is the recommended flow chart to characterise a focal liver lesion at risk for HCC
Please ask to receive a WFUMB certificate of attendance.
See Presentations below
Introduction- Byung Ihn Choi, MD
US Surveilance and Diagnosis – Fabio Piscaglia, MD
CEUS LI-RADS – Yuko Kono, MD
Treatment by US Intervention – Xiaoyan Xie, MD
Sirine Dehmani 1, Christoph F Dietrich 2
- Kliniken Hirslanden Beau Site, Salem und Permanence, Bern, Switzerland, Sirine.Dehmani@hirslanden.ch
- *Kliniken Hirslanden Beau Site, Salem und Permanence, Bern, Switzerland, ChristophFrank.Dietrich@hirslanden.ch
* Correspondence: ChristophFrank.Dietrich@hirslanden.ch
Clinical History:
A 56-year-old-male with a history of previous cough and dyspnea on exercise was admitted to our clinic for evaluation and CoViD testing. At the time of the US examination he had no dyspnea or other symptoms.
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CORRECT ANSWER EXPLAINED BELOW Correct answer to Q1 is:
- B-line artefacts
- Irregular pleural line and very small amount of free fluid located peripherally
- Multiple small consolidations in all lung regions
Correct answer to Q2 is:
- SARS-CoViD-19 infection
Discussion:
Since COVID-19 infection is primarily a respiratory disease the expectation would be that lung imaging would be essential for the diagnosis (1,2). The typical sonographic signs using lung US (LUS) identified in the course of COVID-19 infections include features of the pleura and pleural space (1), findings of interstitial pneumonia (2) and specific artefacts (3) (1,3-5). The signs are specific when there is a very high “a priori” probability of COVID-19 with cough and dyspnea (1). The initial lung involvement often posterior-basal may become extensive with involvement of the entire lung as shown in this patient. In later stages mixed and much less specific image patterns can be observed including the so-called white lung and bacterial pneumonia superinfection. US also allows detection of complications including pneumothorax, not only in ventilated patients, and pulmonary embolism (5).
Ultrasound signs and differential diagnoses
Pleura
- Thickened, irregular (coarse) and fragmented pleural line.
- Small amount of superficially located pleural fluid (sign of severity). More extensive pleural effusions are not typical.
Lung
- Consolidations, multiple. Very small consolidations often posterobasally, initially. Later in various distributions and possibly involving the entire lung.
Artefacts
- B-lines (initially discrete, later multifocal and confluent), alveolar-interstitial syndrome, so-called „white lung“ (ARDS).
- Respiratory dependent lung sliding (A-artefact), combined with B-line artefacts (mixing A and B patterns).
Differential diagnoses and complications
- Chronic heart insufficiency (BLA, larger pleural effusion than in CoViD-19).
- Bacterial pneumonia (typically larger consolidations than in CoViD-19).
- Pulmonary embolism (initially no vascularity)
Conflicts of interest
“The authors declare no conflict of interest.”
Image(s): Confluent curtain like B-line artefacts (BLA) intercostally using 5 MHz curved array transducer (a). Thickened and irregular pleura line and tiny amount of pleural fluid using 5 MHz curved array transducer (b) and 10 MHz transducer revealing much more details (c). The corresponding computed tomography image is also shown (d). C: Consolidation. FF: free fluid. White arrow: Pneumo-alveolo-bronchogram.
References
- Piscaglia F, Stefanini F, Cantisani V, Sidhu PS, Barr R, Berzigotti A, Chammas MC, et al. Benefits, Open questions and Challenges of the use of Ultrasound in the COVID-19 pandemic era. The views of a panel of worldwide international experts. Ultraschall Med 2020;41:228-236.
- Zhu N, Zhang D, Wang W, Li X, Yang B, Song J, Zhao X, et al. A Novel Coronavirus from Patients with Pneumonia in China, 2019. N Engl J Med 2020;382:727-733.
- Dietrich CF, Mathis G, Cui XW, Ignee A, Hocke M, Hirche TO. Ultrasound of the pleurae and lungs. Ultrasound Med Biol 2015;41:351-365.
- Dietrich CF, Mathis G, Blaivas M, Volpicelli G, Seibel A, Atkinson NS, Cui XW, et al. Lung artefacts and their use. Med Ultrason 2016;18:488-499.
- Dietrich CF, Mathis G, Blaivas M, Volpicelli G, Seibel A, Wastl D, Atkinson NS, et al. Lung B-line artefacts and their use. J Thorac Dis 2016;8:1356-1365.
- 1
- 2
- Answered
- Review
-
Question 1 of 2
1. Question
Question 1: Which of the following US signs can you identify (more than one is possible)?
Correct
CORRECT ANSWER EXPLAINED BELOW Correct answer to Q1 is:
- B-line artefacts
- Irregular pleural line and very small amount of free fluid located peripherally
- Multiple small consolidations in all lung regions
Correct answer to Q2 is:
- SARS-CoViD-19 infection
Discussion:
Since COVID-19 infection is primarily a respiratory disease the expectation would be that lung imaging would be essential for the diagnosis (1,2). The typical sonographic signs using lung US (LUS) identified in the course of COVID-19 infections include features of the pleura and pleural space (1), findings of interstitial pneumonia (2) and specific artefacts (3) (1,3-5). The signs are specific when there is a very high “a priori” probability of COVID-19 with cough and dyspnea (1). The initial lung involvement often posterior-basal may become extensive with involvement of the entire lung as shown in this patient. In later stages mixed and much less specific image patterns can be observed including the so-called white lung and bacterial pneumonia superinfection. US also allows detection of complications including pneumothorax, not only in ventilated patients, and pulmonary embolism (5).
Ultrasound signs and differential diagnoses
Pleura
- Thickened, irregular (coarse) and fragmented pleural line.
- Small amount of superficially located pleural fluid (sign of severity). More extensive pleural effusions are not typical.
Lung
- Consolidations, multiple. Very small consolidations often posterobasally, initially. Later in various distributions and possibly involving the entire lung.
Artefacts
- B-lines (initially discrete, later multifocal and confluent), alveolar-interstitial syndrome, so-called „white lung“ (ARDS).
- Respiratory dependent lung sliding (A-artefact), combined with B-line artefacts (mixing A and B patterns).
Differential diagnoses and complications
- Chronic heart insufficiency (BLA, larger pleural effusion than in CoViD-19).
- Bacterial pneumonia (typically larger consolidations than in CoViD-19).
- Pulmonary embolism (initially no vascularity)
Conflicts of interest
“The authors declare no conflict of interest.”
Image(s): Confluent curtain like B-line artefacts (BLA) intercostally using 5 MHz curved array transducer (a). Thickened and irregular pleura line and tiny amount of pleural fluid using 5 MHz curved array transducer (b) and 10 MHz transducer revealing much more details (c). The corresponding computed tomography image is also shown (d). C: Consolidation. FF: free fluid. White arrow: Pneumo-alveolo-bronchogram.
References
- Piscaglia F, Stefanini F, Cantisani V, Sidhu PS, Barr R, Berzigotti A, Chammas MC, et al. Benefits, Open questions and Challenges of the use of Ultrasound in the COVID-19 pandemic era. The views of a panel of worldwide international experts. Ultraschall Med 2020;41:228-236.
- Zhu N, Zhang D, Wang W, Li X, Yang B, Song J, Zhao X, et al. A Novel Coronavirus from Patients with Pneumonia in China, 2019. N Engl J Med 2020;382:727-733.
- Dietrich CF, Mathis G, Cui XW, Ignee A, Hocke M, Hirche TO. Ultrasound of the pleurae and lungs. Ultrasound Med Biol 2015;41:351-365.
- Dietrich CF, Mathis G, Blaivas M, Volpicelli G, Seibel A, Atkinson NS, Cui XW, et al. Lung artefacts and their use. Med Ultrason 2016;18:488-499.
- Dietrich CF, Mathis G, Blaivas M, Volpicelli G, Seibel A, Wastl D, Atkinson NS, et al. Lung B-line artefacts and their use. J Thorac Dis 2016;8:1356-1365.
Incorrect
CORRECT ANSWER EXPLAINED BELOW Correct answer to Q1 is:
- B-line artefacts
- Irregular pleural line and very small amount of free fluid located peripherally
- Multiple small consolidations in all lung regions
Correct answer to Q2 is:
- SARS-CoViD-19 infection
Discussion:
Since COVID-19 infection is primarily a respiratory disease the expectation would be that lung imaging would be essential for the diagnosis (1,2). The typical sonographic signs using lung US (LUS) identified in the course of COVID-19 infections include features of the pleura and pleural space (1), findings of interstitial pneumonia (2) and specific artefacts (3) (1,3-5). The signs are specific when there is a very high “a priori” probability of COVID-19 with cough and dyspnea (1). The initial lung involvement often posterior-basal may become extensive with involvement of the entire lung as shown in this patient. In later stages mixed and much less specific image patterns can be observed including the so-called white lung and bacterial pneumonia superinfection. US also allows detection of complications including pneumothorax, not only in ventilated patients, and pulmonary embolism (5).
Ultrasound signs and differential diagnoses
Pleura
- Thickened, irregular (coarse) and fragmented pleural line.
- Small amount of superficially located pleural fluid (sign of severity). More extensive pleural effusions are not typical.
Lung
- Consolidations, multiple. Very small consolidations often posterobasally, initially. Later in various distributions and possibly involving the entire lung.
Artefacts
- B-lines (initially discrete, later multifocal and confluent), alveolar-interstitial syndrome, so-called „white lung“ (ARDS).
- Respiratory dependent lung sliding (A-artefact), combined with B-line artefacts (mixing A and B patterns).
Differential diagnoses and complications
- Chronic heart insufficiency (BLA, larger pleural effusion than in CoViD-19).
- Bacterial pneumonia (typically larger consolidations than in CoViD-19).
- Pulmonary embolism (initially no vascularity)
Conflicts of interest
“The authors declare no conflict of interest.”
Image(s): Confluent curtain like B-line artefacts (BLA) intercostally using 5 MHz curved array transducer (a). Thickened and irregular pleura line and tiny amount of pleural fluid using 5 MHz curved array transducer (b) and 10 MHz transducer revealing much more details (c). The corresponding computed tomography image is also shown (d). C: Consolidation. FF: free fluid. White arrow: Pneumo-alveolo-bronchogram.
References
- Piscaglia F, Stefanini F, Cantisani V, Sidhu PS, Barr R, Berzigotti A, Chammas MC, et al. Benefits, Open questions and Challenges of the use of Ultrasound in the COVID-19 pandemic era. The views of a panel of worldwide international experts. Ultraschall Med 2020;41:228-236.
- Zhu N, Zhang D, Wang W, Li X, Yang B, Song J, Zhao X, et al. A Novel Coronavirus from Patients with Pneumonia in China, 2019. N Engl J Med 2020;382:727-733.
- Dietrich CF, Mathis G, Cui XW, Ignee A, Hocke M, Hirche TO. Ultrasound of the pleurae and lungs. Ultrasound Med Biol 2015;41:351-365.
- Dietrich CF, Mathis G, Blaivas M, Volpicelli G, Seibel A, Atkinson NS, Cui XW, et al. Lung artefacts and their use. Med Ultrason 2016;18:488-499.
- Dietrich CF, Mathis G, Blaivas M, Volpicelli G, Seibel A, Wastl D, Atkinson NS, et al. Lung B-line artefacts and their use. J Thorac Dis 2016;8:1356-1365.
-
Question 2 of 2
2. Question
Question 2: Which of the following diseases is most probable (only one answer is correct)?
Correct
CORRECT ANSWER EXPLAINED BELOW Correct answer to Q1 is:
- B-line artefacts
- Irregular pleural line and very small amount of free fluid located peripherally
- Multiple small consolidations in all lung regions
Correct answer to Q2 is:
- SARS-CoViD-19 infection
Discussion:
Since COVID-19 infection is primarily a respiratory disease the expectation would be that lung imaging would be essential for the diagnosis (1,2). The typical sonographic signs using lung US (LUS) identified in the course of COVID-19 infections include features of the pleura and pleural space (1), findings of interstitial pneumonia (2) and specific artefacts (3) (1,3-5). The signs are specific when there is a very high “a priori” probability of COVID-19 with cough and dyspnea (1). The initial lung involvement often posterior-basal may become extensive with involvement of the entire lung as shown in this patient. In later stages mixed and much less specific image patterns can be observed including the so-called white lung and bacterial pneumonia superinfection. US also allows detection of complications including pneumothorax, not only in ventilated patients, and pulmonary embolism (5).
Ultrasound signs and differential diagnoses
Pleura
- Thickened, irregular (coarse) and fragmented pleural line.
- Small amount of superficially located pleural fluid (sign of severity). More extensive pleural effusions are not typical.
Lung
- Consolidations, multiple. Very small consolidations often posterobasally, initially. Later in various distributions and possibly involving the entire lung.
Artefacts
- B-lines (initially discrete, later multifocal and confluent), alveolar-interstitial syndrome, so-called „white lung“ (ARDS).
- Respiratory dependent lung sliding (A-artefact), combined with B-line artefacts (mixing A and B patterns).
Differential diagnoses and complications
- Chronic heart insufficiency (BLA, larger pleural effusion than in CoViD-19).
- Bacterial pneumonia (typically larger consolidations than in CoViD-19).
- Pulmonary embolism (initially no vascularity)
Conflicts of interest
“The authors declare no conflict of interest.”
Image(s): Confluent curtain like B-line artefacts (BLA) intercostally using 5 MHz curved array transducer (a). Thickened and irregular pleura line and tiny amount of pleural fluid using 5 MHz curved array transducer (b) and 10 MHz transducer revealing much more details (c). The corresponding computed tomography image is also shown (d). C: Consolidation. FF: free fluid. White arrow: Pneumo-alveolo-bronchogram.
References
- Piscaglia F, Stefanini F, Cantisani V, Sidhu PS, Barr R, Berzigotti A, Chammas MC, et al. Benefits, Open questions and Challenges of the use of Ultrasound in the COVID-19 pandemic era. The views of a panel of worldwide international experts. Ultraschall Med 2020;41:228-236.
- Zhu N, Zhang D, Wang W, Li X, Yang B, Song J, Zhao X, et al. A Novel Coronavirus from Patients with Pneumonia in China, 2019. N Engl J Med 2020;382:727-733.
- Dietrich CF, Mathis G, Cui XW, Ignee A, Hocke M, Hirche TO. Ultrasound of the pleurae and lungs. Ultrasound Med Biol 2015;41:351-365.
- Dietrich CF, Mathis G, Blaivas M, Volpicelli G, Seibel A, Atkinson NS, Cui XW, et al. Lung artefacts and their use. Med Ultrason 2016;18:488-499.
- Dietrich CF, Mathis G, Blaivas M, Volpicelli G, Seibel A, Wastl D, Atkinson NS, et al. Lung B-line artefacts and their use. J Thorac Dis 2016;8:1356-1365.
Incorrect
CORRECT ANSWER EXPLAINED BELOW Correct answer to Q1 is:
- B-line artefacts
- Irregular pleural line and very small amount of free fluid located peripherally
- Multiple small consolidations in all lung regions
Correct answer to Q2 is:
- SARS-CoViD-19 infection
Discussion:
Since COVID-19 infection is primarily a respiratory disease the expectation would be that lung imaging would be essential for the diagnosis (1,2). The typical sonographic signs using lung US (LUS) identified in the course of COVID-19 infections include features of the pleura and pleural space (1), findings of interstitial pneumonia (2) and specific artefacts (3) (1,3-5). The signs are specific when there is a very high “a priori” probability of COVID-19 with cough and dyspnea (1). The initial lung involvement often posterior-basal may become extensive with involvement of the entire lung as shown in this patient. In later stages mixed and much less specific image patterns can be observed including the so-called white lung and bacterial pneumonia superinfection. US also allows detection of complications including pneumothorax, not only in ventilated patients, and pulmonary embolism (5).
Ultrasound signs and differential diagnoses
Pleura
- Thickened, irregular (coarse) and fragmented pleural line.
- Small amount of superficially located pleural fluid (sign of severity). More extensive pleural effusions are not typical.
Lung
- Consolidations, multiple. Very small consolidations often posterobasally, initially. Later in various distributions and possibly involving the entire lung.
Artefacts
- B-lines (initially discrete, later multifocal and confluent), alveolar-interstitial syndrome, so-called „white lung“ (ARDS).
- Respiratory dependent lung sliding (A-artefact), combined with B-line artefacts (mixing A and B patterns).
Differential diagnoses and complications
- Chronic heart insufficiency (BLA, larger pleural effusion than in CoViD-19).
- Bacterial pneumonia (typically larger consolidations than in CoViD-19).
- Pulmonary embolism (initially no vascularity)
Conflicts of interest
“The authors declare no conflict of interest.”
Image(s): Confluent curtain like B-line artefacts (BLA) intercostally using 5 MHz curved array transducer (a). Thickened and irregular pleura line and tiny amount of pleural fluid using 5 MHz curved array transducer (b) and 10 MHz transducer revealing much more details (c). The corresponding computed tomography image is also shown (d). C: Consolidation. FF: free fluid. White arrow: Pneumo-alveolo-bronchogram.
References
- Piscaglia F, Stefanini F, Cantisani V, Sidhu PS, Barr R, Berzigotti A, Chammas MC, et al. Benefits, Open questions and Challenges of the use of Ultrasound in the COVID-19 pandemic era. The views of a panel of worldwide international experts. Ultraschall Med 2020;41:228-236.
- Zhu N, Zhang D, Wang W, Li X, Yang B, Song J, Zhao X, et al. A Novel Coronavirus from Patients with Pneumonia in China, 2019. N Engl J Med 2020;382:727-733.
- Dietrich CF, Mathis G, Cui XW, Ignee A, Hocke M, Hirche TO. Ultrasound of the pleurae and lungs. Ultrasound Med Biol 2015;41:351-365.
- Dietrich CF, Mathis G, Blaivas M, Volpicelli G, Seibel A, Atkinson NS, Cui XW, et al. Lung artefacts and their use. Med Ultrason 2016;18:488-499.
- Dietrich CF, Mathis G, Blaivas M, Volpicelli G, Seibel A, Wastl D, Atkinson NS, et al. Lung B-line artefacts and their use. J Thorac Dis 2016;8:1356-1365.
By Osmar Saito, MD and Maria Cristina Chammas MD, Director of Ultrasound
Clinicas Hospital, Department of Radiology, School of Medicine, University of São Paulo, São Paulo, Brazil
Clinical History:
A 36-year-old male with a history of intermittent pain in his right testicle was admitted to the emergency radiology ward with a fast enlarging testicle, without previous trauma. He had also lost weight. Physical examination revealed an enlarged firm testicle without pain on the right side and a normal left testicle. The patient had no fever, no trauma, no chronic disease and denied any sexually transmitted diseases. After some time the patient remembered that 6 years previously he had had leukemia and had underwent a bone marrow transplant.
Ultrasound:
B Mode US in the supine position showed a heterogeneous, enlarged testicle (Figure 1, 2 and 3). Color Doppler showed that the right testicle had an increased vascular pattern (Figure 4, 5 and 6).
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Question 1 of 1
1. Question
Question: What is the diagnosis?
Correct
CORRECT ANSWER EXPLAINED BELOW Correct answer is: Leukemia
Image Findings:
The examination revealed an enlarged, heterogeneous right testicle, with a normal epididymis. Also, a small homogenous fluid collection, corresponding to a hydrocele was seen (Figure 1 and 2). The color Doppler study showed a pattern of hypervascularity.
Discussion
Leukemia is a cancer of the body’s blood-forming tissues, such as the bone marrow and the lymphatic system. Leukemia can affect adults and children. In acute lymphocytic leukemia, the brain and the spinal cord and the testes in boys are known as sanctuary sites of cancer. Sanctuary sites are extramedullary anatomic locations that have historically been difficult to penetrate with systemic chemotherapy. In the testes, the finding of an enlarged firm testicle and hyperactivity on color Doppler similar to inflammatory findings, should remind the physician of leukemia of the testis.
Teaching Points
Although an enlarged testicle due to leukemia is a rare ultrasound finding, it is important to remember this diagnosis when dealing with a patient with a previous history of leukemia. The differential diagnoses include inflammatory diseases, but the clinical finding of a painless testicle is very important, as this indicates leukemia more than inflammation.
References
- https://radiopaedia.org/articles/leukaemia-testicular-manifestations-1?lang=us
- Kocakroc E, Bhatt S, Dogra V S; Ultrasound Evaluation of Testicular neoplasms. Ultrasound Clinics (2), 27-44, 2007.
- Dogra V, Gottlieb RH, Oka M et al. Sonography of scrotum. Radiology, 227:18-36, 2003.
- Hortsman WG, Melson GL, Middleton WD et al. Testicular tumors: findings with color Doppler US. Radiology, 185: 733 -37, 1992.
Incorrect
CORRECT ANSWER EXPLAINED BELOW Correct answer is: Leukemia
Image Findings:
The examination revealed an enlarged, heterogeneous right testicle, with a normal epididymis. Also, a small homogenous fluid collection, corresponding to a hydrocele was seen (Figure 1 and 2). The color Doppler study showed a pattern of hypervascularity.
Discussion
Leukemia is a cancer of the body’s blood-forming tissues, such as the bone marrow and the lymphatic system. Leukemia can affect adults and children. In acute lymphocytic leukemia, the brain and the spinal cord and the testes in boys are known as sanctuary sites of cancer. Sanctuary sites are extramedullary anatomic locations that have historically been difficult to penetrate with systemic chemotherapy. In the testes, the finding of an enlarged firm testicle and hyperactivity on color Doppler similar to inflammatory findings, should remind the physician of leukemia of the testis.
Teaching Points
Although an enlarged testicle due to leukemia is a rare ultrasound finding, it is important to remember this diagnosis when dealing with a patient with a previous history of leukemia. The differential diagnoses include inflammatory diseases, but the clinical finding of a painless testicle is very important, as this indicates leukemia more than inflammation.
References
- https://radiopaedia.org/articles/leukaemia-testicular-manifestations-1?lang=us
- Kocakroc E, Bhatt S, Dogra V S; Ultrasound Evaluation of Testicular neoplasms. Ultrasound Clinics (2), 27-44, 2007.
- Dogra V, Gottlieb RH, Oka M et al. Sonography of scrotum. Radiology, 227:18-36, 2003.
- Hortsman WG, Melson GL, Middleton WD et al. Testicular tumors: findings with color Doppler US. Radiology, 185: 733 -37, 1992.
Work Related Musculoskeletal Disorders (WRMSD) Alliance of Organizations is hosting a Virtual Solutions Hack-a-Thon Challenge
Who Can Participate:
Innovative students that are currently enrolled in a higher education setting. We are hoping to welcome those focused in:
Sonography | Physical Therapy |
Engineering | Medicine |
Instructional Design | Health/Fitness |
Architecture | Business |
Sports & Fitness | Health Administration |
Participants will be asked for no more than 10 hours of online participation. Each team will be comprised of students from different fields of study.
The Challenge to Solve:
For many sonographers, physicians, and other medical professionals performing ultrasound scans, pain is a daily reality. Work-related musculoskeletal disorders (WRMSD) limit their ability to live productive lives and care for their patients.
During this virtual Solution Hack-a-Thon Challenge, you and your team will be empowered to explore, discuss, debate and brainstorm on ways to eliminate WRMSD once and for all.
The Grand Prize to Earn:
Each member of the team with the winning solution will receive a $550 USD cash prize and will be invited to participate in the upcoming 2021 WRMSD Design Summit.
Registration and Timeline:
November 2, 2020 – Registration opens here. Please sign-up before November 30, 2020. Register early as participation will be limited.
December 7, 2020 to February 15, 2021 – Teams work at their own pace to complete and submit their presentation. Team collaboration calls start December 28, 2020
March 1, 2020 – Winners announced.
Winner Selection Criteria, Rules & Fine Print:
- Participation is open to residents/students of the US and Canada.
- Participants will commit to no more than 10 hours and will participate online.
- Each team will submit one presentation on their solution. Solutions cannot eliminate the need for an actual sonographer. Presentations should not exceed 5 to 7 minutes in length.
- Judges will be comprised of representatives from members of the WRMSD GC Alliance and industry-related partners. Presentations will be judged for innovation, sustainability, scalability.
- Each selected participant will receive a $25 USD VISA gift card
- Full copy of the Official Rules and Guidelines are available here.
REGISTER NOW TO PARTICIPATE >>
The WRMSD Grand Challenge Alliance of Organizations includes:
- American Institute of Ultrasound in Medicine,
- American Registry for Diagnostic Medical Sonography and Inteleos,
- American Society of Echocardiography,
- Intersocietal Accreditation Commission,
- Joint Review Committee on Education in Cardiovascular Technology,
- Joint Review Committee on Education in Diagnostic Medical Sonography,
- Society for Vascular Ultrasound,
- Society of Diagnostic Medical Sonography.
For more information visit https://www.ardms.org/wrmsd-grand-challenge/