Expertddx: Ultrasound

523 Pages·2010·97.15 MB·English

by  Anil T. Ahuja

Anil T.Ahuja, MD, FRCR Winnie C.W. Chu, MBChB, FRCR
Professor Professor
Department of Diagnostic Radiology & Organ h;naging Department of Diagnostic Radiology & Organ Imaging
The Chinese University of Hong Kong The Chinese University of Hong Kong
Hong Kong, China Hong Kong, China
James F.Griffith, MBBCh, FRCR Deborah levine, MD
Professor Associate Radiologist-in-Chief of Academic Affairs
Department of Diagnostic Radiology & Organ Imaging Co-Chief of Ultrasound
The Chinese University of Hong Kong Director of Ob/Gyn Ultrasound
Hong Kong, China Beth Israel Deaconess Medical Center
Professor of Radiology
Harvard Medical School
Gregory E.Antonio, MD, FRANZCR Boston, Massachusetts
Honorary Professor
Department of Diagnostic Radiology & Organ Imaging Stella S.Y.Ho, PhD, ROMS
The Chinese University of Hong Kong
Adjunct Associate Professor
Hong Kong, China
Department of Diagnostic Radiology & Organ Imaging
The Chinese University of Hong Kong
Hong Kong, China
K.T.Wong, MBChB, FRCR
Honorary Clinical Associate Professor Bhawan K. Paunipagar, MO, ONB
Department of Diagnostic Radiology & Organ Imaging
Clinical Tutor
The Chinese University of Hong Kong
Department of Diagnostic Radiology & Organ Imaging
Hong Kong, China
The Chinese University of Hong Kong
Hong Kong, China
Yolanda Y.P.lee, MBChB, FRCR
Simon S.M. Ho, MBBS, FRCR
Honorary Clinical Assistant Professor
Honorary Assistant Professor
Department of Diagnostic Radiology &Organ Imaging
Department of Diagnostic Radiology &Organ Imaging
The Chinese University of Hong Kong
The Chinese University of Hong Kong
Hong Kong, China
Hong Kong, China
,.
AMIRSYS"
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AMIRSYS®
Names you know. Content you trust.@
First Edition
Copyright 2010 Amirsys, Inc.
Allrights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or media
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Composition by Amirsys, Inc., Salt Lake City, Utah
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ISBN: 978-1-931884-14-3
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Library of Congress Cataloging-in-Publication Data
Expertddx. Ultrasound / [edited by] Ani! T.Ahuja. --1st ed.
p.; cm.
Includes index.
ISBN978-1-931884-14-3
1. Diagnostic ultrasonic imagingnAtlases. 2. Diagnosis, Differential--Atlases. I.Ahuja, Ani! T.II.Title: Ultrasound.
[DNLM: 1. UltrasonographynHandbooks. 2. Diagnosis, Differential--Handbooks. WN 39 £96 2009]
RC78.7.U4E972009
616.07'S43--dc22
2009019984
CONTRIBUTING AUTHORS
Chander Lulla, MO, OMRO
Consultant Sonologist
RIAClinic
Mumbai, India
Vivian Y.F.Leung, PhO, ROMS
Adjunct Associate Professor
Department of Diagnostic Radiology &Organ Imaging
The Chinese University of Hong Kong
Hong Kong, China
Eric K.H. Liu, PhO, ROMS
Adjunct Assistant Professor
Department of Diagnostic Radiology &Organ Imaging
The Chinese University of Hong Kong
Hong Kong, China
Nicole Roy,MO
Associate Professor of Breast and Body Imaging
University of Utah School of Medicine
Salt Lake City, Utah
vii
Once the appropriate technical protocols have been delineated, the best quality images obtained,
and the cases queued up on PACS,the diagnostic responsibility reaches the radiology reading room. The
radiologist must do more than simply "lay words on" but reach a real conclusion. Ifwe cannot reach a
definitive diagnosis, we must offer a reasonable differential diagnosis. Alist that's too long isuseless; a list
that's too short may be misleading. Tobe useful, a differential must be more than a rote recitation from
some dusty book or a mnemonic from a lecture way back when. Instead, we must take into account key
imaging findings and relevant clinical information.
With these considerations in mind, we at Amirsys designed our Expert Differential Diagnoses series-
EXPERTddxfor short. Leading experts in every subspecialty of radiology identified the top differential
diagnoses in their respective fields, encompassing specific anatomic locations, generic imaging findings,
modality-specific findings, and clinically based indications. Our experts gathered multiple images, both
typical and variant, for each EXPERTddx. Each features at least eight beautiful images that illustrate the
possible diagnoses, accompanied by captions that highlight the pertinent imaging findings. Hundreds
more are available in the eBook feature that accompanies every book. Inclassic Amirsys fashion, each
EXPERTddxincludes bulleted text that distills the available information to the essentials. You'll find
helpful clues for diagnoses, ranked by prevalence as Common, LessCommon, and Rarebut Important.
Our EXPERTddxseries is designed to help radiologists reach reliable-indeed, expert-conclusions.
Whether you are a practicing radiologist or a resident/fellow in training, we think the EXPERTddxseries
will quickly become your practical "go-to" reference.
Anne G. Osborn, MD
Executive Vice President and Editor-in-Chief, Amirsys, Inc.
Paula]. Woodward, MD
Executive Vice President and Medical Director, Amirsys, Inc.
H. RicHarnsberger, MD
CEO, Amirsys, Inc.
ix
PREFACE
Despite the advances of teleradiology, in most cases ultrasound diagnosis is made on real-time
examination. Because of its real-time nature, ultrasound demands a high level of skill and meticulous
attention to detail.
EXPERTddx: Ultrasound is the third Amirsys book designed specifically for the practicing sonologist.
Our first book, Diagnostic Imaging: Ultrasound, discussed the sonographic appearances of conditions
commonly encountered in clinical practice. The second, Diagnostic and Surgical Imaging Anatomy:
Ultrasound, covered key anatomy that should be familiar to any sonologist.
In EXPERTddx: Ultrasound, we focus on the building blocks of ultrasound diagnosis. The book looks at
the discrete sonographic characteristics of a mass or lesion. Isit hypoechoic, calcified, vascular, or solid?
The presence and arrangement of these discrete sonographic features enables the characterization of
involved tissues, making it possible to arrive at a sonographic diagnosis/differential diagnosis. Relating this
sonographic diagnosis to the clinical presentation then provides the most likely final diagnosis.
It is important to realize that a diagnosis is rarely based on one sonographic characteristic alone.
Typically, any lesion shows a plethora of sonographic features, each of which provides a clue to the nature
of the tissue being examined. For example, a liver mass may be hypoechoic, noncalcified, vascular, and
solid all at the same time. This combination of features leads us to a differential diagnosis that includes
hepatocellular carcinoma. The presence of cirrhosis, ascites, weight loss, and elevated alpha-fetoprotein
narrows the possible diagnosis to hepatocellular carcinoma.
When you read EXPERTddx: Ultrasound, please consider each feature as a starting point in a chain
of thought. Very soon you will put these features and thoughts together to rapidly arrive at a definitive
diagnosis.
Although dedicated to ultrasound, this book also includes images from other modalities. This isto
emphasize that ultrasound is not a standalone modality. Information gained by ultrasound can frequently
complement or be supported by information obtained from other imaging modalities. Please note that this
book does not discuss obstetric ultrasound, as the topic has been covered in a separate book in the same
series.
Iam grateful to Drs. RicHarnsberger, Anne Osborn, and Paula Woodward for giving me the
opportunity to work on this project and patiently guiding me along the process. Iremain humbled by
their continuing patience and faith. The production team at Amirsys has been great and contributed
significantly toward the completion of this book.
Finally, a book such as this would not have been possible without the contribution of all members
of the department. Once again, Ihave been fortunate to work with a wonderful group of colleagues
interested in ultrasound. Despite their significant clinical and academic duties, they have worked hard on
this project and contributed their cases, knowledge, and time. Iremain forever grateful.
The journey has been hard work but also good fun. The effort has been more than compensated by
the privilege of working with friends and learning from them. Ihope this book will help you in your daily
clinical practice.
Anil T.Ahuja, MD, FRCR
Professor
Department of Diagnostic Radiology & Organ Imaging
The Chinese University of Hong Kong
xi
ACKNOWLEDGMENTS
Text Editing
KellieJ. Heap
Arthur G. Gelsinger, MA
Katherine Riser
Image Editing
Jeffrey J. Marmorstone
Terence Y.W.Lam
Kevin K.W.Leung
Abby Y.T.Tong
Medical Text Editing
Paula]. Woodward, MO
Marc Tubay, MO
Art Direction and Design
Lane R.Bennion, MS
Richard Coombs, MS
Contributors
Alex H.C. Chan
James S.W.Cheung
Carmen Cho, MBChB
Ann King, FRCR
William K.M. Kong
Aniruddha Kulkarni, MO
Pramod Lonikar, MBBS,OMRO
Tom W.K.Lee
AsHMomin, MO, ONB
Oarshana Rasalkar, MBBS,FRCR
Sanjay Vaid
Cina Tong, MBChB
KiWang, FRCR
Simon C.H. Yu,FRCR
Associate Editor
Ashley R.Renlund, MA
Production lead
Melissa A.Hoopes
xiii
SECTIONS
Head and Neck
Thyroid/Parathyroid
Liver
Biliary System
Pancreas
Spleen
Adrenal Gland
Kidney
Abdominal Wall/Peritoneal Cavity
Bladder
Prostate
Scrotum
Female Pelvis
Vascular
Musculoskeletal
Breast
xv
SECTION 1
Head and Neck S_E_CL_iTv_eIOr_N_3 _
----------------------- 11
Midline Neck Mass 1-2 Hepatomegaly 3-2
Yolanda Y.P.Lee,MBChB, FRCR&Ani! T.Ahuja, MD, GregoryE.Antonio, MD, FRANZCR
FRCR
Hyperechoic Liver, Diffuse 3-6
Cystic Neck Mass 1-8 GregoryE.Antonio, MD, FRANZCR
Yolanda Y.P.Lee,MBChE, FRCR&Anil T.Ahuja, MD, EricK.H. Liu, PhD, RDMS &Michael P.Federle,MD,
FRCR FACR
Non-Nodal Solid Neck Mass 1-14 Heterogeneous Liver Echopattern 3-8
Yolanda Y.P.Lee,MEChE, FRCR&Ani! T.Ahuja, MD, GregoryE.Antonio, MD, FRANZCR
FRCR
Simple Anechoic Liver Mass 3-10
Solid Neck Lymph Node 1-20 GregoryE.Antonio, MD, FRANZCR
Yolanda Y.P.Lee,MEChE, FRCR&Anil T.Ahuja, MD,
Complex Cystic Liver Mass 3-14
FRCR
GregoryE.Antonio, MD, FRANZCR &Cina Tong,MEChE
Necrotic Neck Lymph Node 1-26
Hypoechoic Liver Mass 3-18
Yolanda Y.P.Lee,MEChE, FRCR&Anil T.Ahuja, MD,
FRCR GregoryE.Antonio, MD, FRANZCR &Carmen Cho,
MEChB
Diffuse Salivary Gland Enlargement 1-28
Isoechoic Liver Mass 3-22
Yolanda Y.P.Lee,MEChE, FRCR&Anil T.Ahuja, MD,
FRCR GregoryE.Antonio, MD, FRANZCR &Cina Tong,MEChE
Focal Salivary Gland Mass 1-34 Echogenic Liver Mass 3-26
GregoryE.Antonio, MD, FRANZCR
Yolanda Y.P.Lee,MEChE, FRCR&Anil T.Ahuja, MD,
FRCR EricK.H.Liu, PhD, RDMS &Michael P.Federle,MD,
FACR
Target Lesions in Liver 3-32
SECTION 2 GregoryE.Antonio, MD, FRANZCR
Thyroid/Parathyroid Irregular Border Liver Mass 3-34
GregoryE.Antonio, MD, FRANZCR
Multiple Hepatic Masses 3-38
Diffuse Thyroid Enlargement 2-2
GregoryE.Antonio, MD, FRANZCR &Carmen Cho,
Yolanda Y.J~Lee,MEChE, FRCR&Ani! T.Ahuja, MD, MEChE
FRCR
Hepatic Mass with Central Scar 3-42
lso-/Hyperechoic Thyroid Nodule 2-8 GregoryE.Antonio, MD, FRANZCR
Yolanda Y.P.Lee,MEChB, F/~CR&Anil T.Ahuja, MD,
FRCR Hepatic Lesion with Posterior Shadowing 3-44
GregoryE.Antonio, MD, FRANZCR
Hypoechoic Thyroid Nodule 2-10
Yolanda Y.P.Lee,MEChE, F1~CR&Anil T.Ahuja, MD, Periportal Lesion 3-46
FRCR GregoryE.Antonio, MD, FRANZCR
Cystic Thyroid Nodule 2-16 Irregular Hepatic Surface 3-50
Yolanda Y.P.Lee,MEChE, FRCR&Anil T.Ahuja, MD, GregoryE.Antonio, MD, FRANZCR
FRCR
Perihepatic Cyst/Fluid Collection 3-52
Calcified Thyroid Nodule 2-20 GregoryE.Antonio, MD, FRANZCR
Yolanda Y.P.Lee,MBChE, FRCR&Anil T.Ahuja, MD, Portal Vein Abnormality 3-56
FRCR
GregoryE.Antonio, MD, FRANZCR
Enlarged Parathyroid Gland 2-24
Mass in Porta Hepatis 3-58
Yolanda Y.P.Lee,MEChE, FRCR&Anil T.Ahuja, MD,
GregoryE.Antonio, MD, FRANZCR &Carmen Cho,
FRCR
MEChE
XVI