0404: Sonography of Neck Nodes
1
(2) Provide real time imaging guidance for fine needle aspiration cytology (FNAC) / biopsy; (3) Follow-up patients post-operatively to exclude local or regional tumor recurrence; (4) Evaluate nodal status to accurately stage thyroid cancer This presentation will review the ultrasound features of the commonly encountered thyroid lesions. 0403 3D in Small Parts: Thyroid, Parathyroid and Parotids Leandro Fernandez, Instituto Medico La Floresta, Venezuela 3DUS can be used in ultrasonography for Small Parts, among other medical areas. The assessment of the parotid, thyroid and parathyroid glands is properly achieved. The Multiplanar presentation and Niche Mode are quite useful to determine the extension -inside or outside the organs-, of nodules, cysts or tumors. The VOCAL® makes it possible to obtain a proper after-treatment follow-up of focal disorders in these small organs. Neovascularization is clearly viewed with 3DUS and probably can suggest malignant origin of a neoplasm. 3DUS offers a more comprehensive image of anatomical structures and pathological conditions and also permits to observe the exact spatial relationships. According our previous published results, 3DUS in Small Parts has an excellent conspicuity in 86.4%, moderate in 9.8% and poor in 3.8%. The feasibility was very easy in 65.2%, easy in 32.8% and difficult in 2% of the cases. We are very aware more studies are needed to demonstrate specificity and sensibility of 3DUS in particular clinical conditions, not only in small parts but also in some other non-Ob/Gyn applications. 0404 Sonography of Neck Nodes Anil Ahuja, The Chinese University of Hong Kong, Hong Kong Lymph node enlargement is the commonest cause of a neck lump. High-resolution ultrasound (US) combined with fine needle aspiration cytology (FNAC) has a high sensitivity & specificity in the assessment of cervical lymph nodes. Grey scale sonography helps to evaluate the morphology of cervical nodes, whereas power Doppler sonography assesses nodal vasculature. Grey scale sonographic features such as internal architecture, presence of intranodal necrosis, echogenic hilus, and calcification help to distinguish between the various causes of cervical lymphadenopathy. The presence of adjacent soft tissue edema and matting of nodes are additional useful features to identify tuber- culous lymphadenitis. Power Doppler sonography evaluates the vascu- lar pattern of the lymph nodes and further improves the diagnostic accuracy of sonography in differentiating benign from malignant nodes. Metastatic nodes exhibit disorganized peripheral vessels, lym- phomatous nodes are invariably hypervascular with chaotic internal vascularity while tuberculous nodes are avascular or hypovascular with displaced hilar vessels. Apart from the role in diagnosis, ultrasound helps in the surveillance of the post-treatment neck for presence of nodal recurrence and to monitor treatment response in patients undergoing chemotherapy or radiother- apy. The increasing use of ultrasound contrast further enhances the role of sonography in these areas. This presentation aims to provide an overview of sonographic evalua- tion of cervical lymph nodes and its use in the post-treatment neck. 0406 Blood Flow in the Liver David Cosgrove, Imperial College, Hammersmith Hospital, United Kingdom The double vascular supply to the liver means that special care must be taken when scanning patients with vascular liver problems. Both supply vessels as well as the hepatic veins and sites for porto-systemic shunts must be scrutinised. Arterial abnormalities are rare, though variants such as a dual supply are very common and important in liver surgery, especially for partial live-related transplantation. Occlusion is only encountered after liver transplantation. The anatomy of the portal vein is very constant but anomalies of the hepatic veins are common, especially accessory veins draining the right liver (segments 7 and sometimes 6) as well as the caudate lobe (segment 1). They are important in liver surgery and need to be mapped out as part of surgical planning using CT or ultrasound. Portal hypertension can be caused by narrowings at different levels, the commonest being intrahepatic and resulting from cirrhosis. Pre-hepatic portal hypertension results from stenosis of the main portal vein or its tributaries and is a complication of carcinoma of the head of the pancreas and of splenectomy. Post-hepatic hypertension is seen in the Budd Chiari syndrome. Each produces different patterns of abnormal Doppler changes which are characteristic, with reduced or reversed flow in the main portal vein and marked increases in hepatic arterial flow, which eventually becomes the sole supply to the liver. In all types, extra hepatic porto-systemic shunts may form and the typical sites (gall bladder bed, retroperitoneum at the head of the pancreas, spleno-renal and spleno-gastric) need to be examined systematically with a view to understanding the altered haemodynamics. Except in the pre-hepatic types, the fetal umbilical vein may recanalise and decom- press the portal system; it is seen as a channel in the position of the ligamentum teres and can be traced away from the liver passing inferiorly in the direction of the umbilicus. Here, varices may empty into subcutaneous veins that either take flow superiorly to anastomose with the superior epigastric veins or, more commonly, pass inferiorly into the pelvis and empty into retroperitoneal veins. In this situation, portal vein flow is faster than normal and there may be reversed flow in the right portal branch. If the portal vein occludes, flow may be restored via recanalisation or new vessels that open around the original portal vein, so-called cavernous transformation. The Doppler findings are complex, with numerous tortuous vascular channels in the porta hepatis. The intrahepatic arterio-venous shunts that are so important in cirrhosis are usually microscopic and cannot be imaged with ultrasound. How- ever, the rapid transit of blood from the hepatic artery to the hepatic veins can be tracked by using a bolus of a microbubble contrast agent as a tracer. In the normal, there is a substantial delay ( 12 secs) but this is much shorter in cirrhosis. This non-invasive test separates mild from severe chronic hepatitis and from frank cirrhosis and can be used to monitor these patients. Metastases produce a similar shift of the liver’s blood supply in favour of the artery. Surgical stents to shunt the blood from the portal to the systemic circulation may be inserted, the usual version being the transjugular intrahepatic porto-systemic shunt, which is highly echogenic on ultra- sound. This may make Doppler evaluation difficult and there is always some degree of flow disturbance at the portal end of the shunt. Usually Doppler can be used to establish that the shunt is patent, but assessing restenosis is difficult because the flow may accelerate (across a steno- sis) or slow (if the stenosis becomes haemodynamically significant). This confusing situation has led to angiography with pressure measure- ments being used instead of ultrasound. Pathology of the hepatic veins is relatively uncommon, but occlusion occurs in the Budd-Chiari syndrome, which may be caused by mem- branous flaps in the upper IVC or occur in hypercoagulable states. Occasionally a tumour, such as a metastasis compresses one of the veins, leading to occlusion. If the occlusion is complete and of rapid onset, acute liver failure ensues and is usually rapidly fatal. Partial or incomplete forms lead to portal hypertension and Doppler can be used S52 Ultrasound in Medicine and Biology Volume 35, Number 8S, 2009
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Transcript of 0404: Sonography of Neck Nodes
S52 Ultrasound in Medicine and Biology Volume 35, Number 8S, 2009
(2) Provide real time imaging guidance for fine needle aspirationcytology (FNAC) / biopsy;(3) Follow-up patients post-operatively to exclude local or regionaltumor recurrence;(4) Evaluate nodal status to accurately stage thyroid cancerThis presentation will review the ultrasound features of the commonlyencountered thyroid lesions.
0403
3D in Small Parts: Thyroid, Parathyroid and ParotidsLeandro Fernandez, Instituto Medico La Floresta, Venezuela
3DUS can be used in ultrasonography for Small Parts, among othermedical areas. The assessment of the parotid, thyroid and parathyroidglands is properly achieved. The Multiplanar presentation and NicheMode are quite useful to determine the extension -inside or outside theorgans-, of nodules, cysts or tumors. The VOCAL® makes it possibleto obtain a proper after-treatment follow-up of focal disorders in thesesmall organs. Neovascularization is clearly viewed with 3DUS andprobably can suggest malignant origin of a neoplasm. 3DUS offers amore comprehensive image of anatomical structures and pathologicalconditions and also permits to observe the exact spatial relationships.According our previous published results, 3DUS in Small Parts has anexcellent conspicuity in 86.4%, moderate in 9.8% and poor in 3.8%.The feasibility was very easy in 65.2%, easy in 32.8% and difficult in2% of the cases.We are very aware more studies are needed to demonstrate specificityand sensibility of 3DUS in particular clinical conditions, not only insmall parts but also in some other non-Ob/Gyn applications.
0404
Sonography of Neck NodesAnil Ahuja, The Chinese University of Hong Kong, Hong Kong
Lymph node enlargement is the commonest cause of a neck lump.High-resolution ultrasound (US) combined with fine needle aspirationcytology (FNAC) has a high sensitivity & specificity in the assessmentof cervical lymph nodes. Grey scale sonography helps to evaluate themorphology of cervical nodes, whereas power Doppler sonographyassesses nodal vasculature. Grey scale sonographic features such asinternal architecture, presence of intranodal necrosis, echogenic hilus,and calcification help to distinguish between the various causes ofcervical lymphadenopathy. The presence of adjacent soft tissue edemaand matting of nodes are additional useful features to identify tuber-culous lymphadenitis. Power Doppler sonography evaluates the vascu-lar pattern of the lymph nodes and further improves the diagnosticaccuracy of sonography in differentiating benign from malignantnodes. Metastatic nodes exhibit disorganized peripheral vessels, lym-phomatous nodes are invariably hypervascular with chaotic internalvascularity while tuberculous nodes are avascular or hypovascular withdisplaced hilar vessels.Apart from the role in diagnosis, ultrasound helps in the surveillance ofthe post-treatment neck for presence of nodal recurrence and to monitortreatment response in patients undergoing chemotherapy or radiother-apy. The increasing use of ultrasound contrast further enhances the roleof sonography in these areas.This presentation aims to provide an overview of sonographic evalua-tion of cervical lymph nodes and its use in the post-treatment neck.
0406
Blood Flow in the LiverDavid Cosgrove, Imperial College, Hammersmith Hospital, United
KingdomThe double vascular supply to the liver means that special care must betaken when scanning patients with vascular liver problems. Both supplyvessels as well as the hepatic veins and sites for porto-systemic shuntsmust be scrutinised.Arterial abnormalities are rare, though variants such as a dual supplyare very common and important in liver surgery, especially for partiallive-related transplantation. Occlusion is only encountered after livertransplantation. The anatomy of the portal vein is very constant butanomalies of the hepatic veins are common, especially accessory veinsdraining the right liver (segments 7 and sometimes 6) as well as thecaudate lobe (segment 1). They are important in liver surgery and needto be mapped out as part of surgical planning using CT or ultrasound.Portal hypertension can be caused by narrowings at different levels, thecommonest being intrahepatic and resulting from cirrhosis. Pre-hepaticportal hypertension results from stenosis of the main portal vein or itstributaries and is a complication of carcinoma of the head of thepancreas and of splenectomy. Post-hepatic hypertension is seen in theBudd Chiari syndrome. Each produces different patterns of abnormalDoppler changes which are characteristic, with reduced or reversedflow in the main portal vein and marked increases in hepatic arterialflow, which eventually becomes the sole supply to the liver. In alltypes, extra hepatic porto-systemic shunts may form and the typicalsites (gall bladder bed, retroperitoneum at the head of the pancreas,spleno-renal and spleno-gastric) need to be examined systematicallywith a view to understanding the altered haemodynamics. Except in thepre-hepatic types, the fetal umbilical vein may recanalise and decom-press the portal system; it is seen as a channel in the position of theligamentum teres and can be traced away from the liver passinginferiorly in the direction of the umbilicus. Here, varices may emptyinto subcutaneous veins that either take flow superiorly to anastomosewith the superior epigastric veins or, more commonly, pass inferiorlyinto the pelvis and empty into retroperitoneal veins. In this situation,portal vein flow is faster than normal and there may be reversed flowin the right portal branch. If the portal vein occludes, flow may berestored via recanalisation or new vessels that open around the originalportal vein, so-called cavernous transformation. The Doppler findingsare complex, with numerous tortuous vascular channels in the portahepatis.The intrahepatic arterio-venous shunts that are so important in cirrhosisare usually microscopic and cannot be imaged with ultrasound. How-ever, the rapid transit of blood from the hepatic artery to the hepaticveins can be tracked by using a bolus of a microbubble contrast agentas a tracer. In the normal, there is a substantial delay (� 12 secs) butthis is much shorter in cirrhosis. This non-invasive test separates mildfrom severe chronic hepatitis and from frank cirrhosis and can be usedto monitor these patients. Metastases produce a similar shift of theliver’s blood supply in favour of the artery.Surgical stents to shunt the blood from the portal to the systemiccirculation may be inserted, the usual version being the transjugularintrahepatic porto-systemic shunt, which is highly echogenic on ultra-sound. This may make Doppler evaluation difficult and there is alwayssome degree of flow disturbance at the portal end of the shunt. UsuallyDoppler can be used to establish that the shunt is patent, but assessingrestenosis is difficult because the flow may accelerate (across a steno-sis) or slow (if the stenosis becomes haemodynamically significant).This confusing situation has led to angiography with pressure measure-ments being used instead of ultrasound.Pathology of the hepatic veins is relatively uncommon, but occlusionoccurs in the Budd-Chiari syndrome, which may be caused by mem-branous flaps in the upper IVC or occur in hypercoagulable states.Occasionally a tumour, such as a metastasis compresses one of theveins, leading to occlusion. If the occlusion is complete and of rapidonset, acute liver failure ensues and is usually rapidly fatal. Partial or
incomplete forms lead to portal hypertension and Doppler can be used
