Seminar 7 Ultrasonography of the gastrointestinal tract ... · gastrointestinal tract, liver,...
Transcript of Seminar 7 Ultrasonography of the gastrointestinal tract ... · gastrointestinal tract, liver,...
Seminar 7
Ultrasonography of the
gastrointestinal tract, liver, pancreas
and abdominal lymphnodes
European Veterinary Diagnostic Imaging
Annual Scientific Conference 2010
July 20th
Giessen, Germany
Ultrasonography of the gastrointestinal tract, liver, pancreas and
abdominal lymphnodes
Date: Tuesday, 20.07.2010
Time: 8.00 am に 3.30 pm
Lecturer: Prof. Dr. Dominique Penninck
Cummings School of Veterinary Medicine at Tufts University, North
Grafton, USA
Dr. Federica Rossi
Clinica Veterinaria dell`Orologio, Sasso Marconi, Bologna, Italy
Prof. Dr. Jimmy Saunders
University of Gent, Belgium
Program:
8.00 am に 8.15 am Reception and welcome.
8.15 am に 9.30 am Gastro-intestinal ultrasonography.
J. Saunders
9.30 am に 10.15 am Ultrasonography of the liver.
F. Rossi
10.15 am に 10.30 am coffee break
10.30 am に 12.00 pm Practical exercises.
12.00 pm に 1.00 pm lunch
1.00 pm に 1.30 pm Ultrasonography of the pancreas.
D. Penninck
1.30 pm に 2.00 pm Ultrasonography of abdominal lymphnodes.
J. Saunders
2.00 pm に 2.15 pm coffe break
2.15 pm に 3.15 pm Practical exercises.
3.15 pm に 3.30 pm Evaluation and closure of the seminar.
Gastro-intestinal
Ultrasonography
Jimmy Saunders
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Gastro-intestinal
ultrasonography
Jimmy H. Saunders
Ghent University, Belgium
Crico-pharyngeal dysphagia, motility disorders esophagus,
Hiatal hernia, pyloric stenosis
Qualitative comparison of detection rates of various common
gastrointestinal abnormalities by radiography and
ultrasonography - Lamb 1999
Modality
Lesion Survey
Radiography
Contrast
Radiography
Ultrasonography
Gastric lesion
Delayed gastric emptying
Intestinal hemorrhage
Dilated intestine
Intestinal foreign body
Thickened intestinal wall
Intussusception
Intestinal mass
Pancreatic lesions
Lymphadenopathy
-
+
-
++
++
+
+
+
+
+
++
+++
-
+++
+++
++
++
++
+
+
+
++
-
++
++
+++
+++
+++
++
++
+ = limited information; ++ = useful information; +++ = detailed assessment, with accurate
diagnosis often possible
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Computed tomography ?
Yes for stomach but not so good for bowel
Endoscopy ?
Emergence of ultrasonography
%
Year
1999 2003 20042002200120001998
RX
RX + US
US
60
50
40
30
20
10
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Materials and Methods
RX and US abdomen dogs
191 reports
From 01/11/2003 until
01/04/2005
No final diagnosis in
record file (60%)
No radiographs, bad
positioning or exposure (40%)
68 reports
Results
SYSTEM Number % (> 100)
Gastro-intestinal 38 56
Urinary 19 28
Reticulo-endothelial 14 21
Female reproductive tract 6 9
Male reproductive tract 6 9
General aspect (adrenals, peritoneum, perineal
hernia, ascites, abdominal neoplasia)
11 17
Is it justified ?
Results
SYSTEM LESIONS
Gastro-intestinal-FB (10)
-Acute gastroenteritis (7)
-Lymphocytic-plasmocytic enteritis (5), eosinophilic enteritis
(2), parasitic gastro-enteritis (2), E Coli enteritis(1)
-Gastritis/Atrophic gastritis (3)
-Stomach dilatation (1)
Urinary-Nephro-urolithiasis (5)
-Cystitis (4), pyelonephritis (1)
-Acute renal failure (5)
-Transitional cell carcinoma (2)
Reticulo-endothelial-Spleen: neoplasia (5), rupture (1)
-Liver: hepatitis (4), neoplasia (3), PSS (2), DGN (1)
Female reproductive tract-Pyometra (5)
-Ovarian cysts (1)
Male reproductive tract-PBH/Prostatis (3)
-Paraprostatic cysts (1)
General aspect-Peritonitis (3), hernia perinealis (1), hypoadrenocorticism (1),
carcinomatosis (1), abdominal neoplasia (1), lymphoma (1)
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Results
68 cases
US > RX
41 (60%)
US = RX
24 (35%)
RX > US
3 (5%)
US*
7 (11%)
US°
17 (24%)
US* = US confirmed or proved the organ but without providing a
final diagnosis
US° = US did not provide more information than RX
RX > US: 3x gastro-intestinal (2x stomach, 1x
duodenum), 3x foreign body (total 10 GI FB)
Main concern: gas artefact
• Excessive gas in the GI tract may interfere with transmission of
the ultrasound beam
• However, in most dogs and cats, gas does not cause a problem
Multiple positions of the patient and movement of the
transducer allow mostly to find an adequate acoustic window
Use of any luminal fluid to enhance ultrasound transmission
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Positioning
Specific positioning for specific region:
• Left recumbency: fundus
• Right recumbency: pylorus, duodenum
• Standing: pylorus, ventral aspect body
Dorsal recumbency
Depends of dog’s conformation and patient cooperation
Material
Ultrasound transducers:
• Linear with a frequency >7 MHz
•Microconvex (curvilinear) > 5MHz (below
and between ribs)
Ultrasound machine: preferably new
US has a high sensitivity (81%) en specificity (71%)
for detection of stomach tumors.
Sensitivity and specificity are highly dependent of the
experience and technical skills of the radiologist.
Learning curve: the sensitivity increases from 40%
detection to 81% detection after 2 years of training.
Penninck et al., 1997
Learning curve
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Ultrasonographic criteria
Motility
Layering
Wall thickness
Luminal content
Wall layers / Echogenicity
Wall layers (inner to outer) Echogenicity
Mucus/ Lumen content Hyperechoic unless fluid (hypo-)
Mucosa Hypoechoic
Sub-mucosa Hyperechoic
Muscularis Hypoechoic
Serosa Hyperechoic
Wall layers / Echogenicity
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Wall thickness
Wall thickness Dog (mm) Cat (mm)
Stomach 2-5 1.7-3.6
Duodenum 3-6 2.0-2.5
Jejunum 2-5 2.0-2.5
Ileum 2-4 2.5-3.2
Colon 2-3 1.4-2.5
Motility
4-5 contractions / minute
BUT extremely variable ....
THUS mostly not useful
Luminal content
Food, mucus, fluid, gas
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1
2
3
4
Which one is the dog ?
THE STOMACH
Radiography
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Contrast radiography
Anatomy
1: esophagus; 2. pars cardiaca; 2’. cardiasphincter; 3. fundus ventriculi; 4. corpus
ventriculi; 5. pars pylorica; 6. pars cranialis duodeni
2
4
1
3
5
6
2’2’
2
4
1
3
5
6
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•Volume of the stomach depends on its content and on the size of the dog
• Large volumes of foot in short period of time
consequences for US: fast of 12-18 hours to reduce gastric contents
Gastric emptying:
• Liquids are emptied in an exponential pattern without evidence of a
lag phase
• Solid food is emptied with a lag phase of varying length (depending
on the composition of the ingesta, temperature) and follows a more
linear pattern afterwards
Consequences on US:
• No fluid in the stomach
• Foot depends on time and content of last meal
Specificities in cats
Stomach:
Fat in the gastric submucosa
From Heng HG, Wrigley HR, Kraft SL, Powers BE. Fat is responsible for an intramural
radiolucent band in the feline stomach wall. Vet Radiol Utrasound 2005;46:54-56.
Ileum:
Prominent submucosa & musculature
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Wall thickness:
< 5 mm (may be difficult to measure)
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Carcinoma
Gastric ulcer
US signs:
•mucosal defect, loss of layer, hyperechoic center (crater), clear
demarcation normal versus affected segment
• decreased gastric motility, fluid accumulation
Gastric wall edema
• mostly underlying inflammation and ulceration
• altered layering (DDX: neoplasia) !!!!
• thin inner hypoechoic border
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THE SMALL INTESTINE
Anatomy
1
2
3
4
jejunal
lymph node
ommentum
1. stomach; 2. duodenum; 3. jejunum;
4. ileum; 5. cecum; 6. colon
1
2
3
4
1
2
3
3
3
4
5
6
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Canine 2-5m; feline: 0,8 -1,3m (3,5 x body length)
• Duodenum: peyer plates
• Jejunum: 6-8 spirals, very moveable
• Ileum: merge not in het caecum but in the colon ascendens
3
4
1. stomach; 2. duodenum; 3. pancreas; 4. spleen
1
2
1
4
3
2
1
2
3
4
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US - Histology
Level of the duodenum
1: pylorus, 2: pars cranialis duodeni, 3: villi
A. Mucosa B. Submucosa (strong vascularisation) C. Muscularis D. Serosa
2
1
3
A
B
CD
Intestinal villi at the level of the duodenum
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L 0.45 cm
2004: > 5 mm jejunum
> 6 mm duodenum
Intussusception
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Acute obstruction
• Foreign body NOT SUFFICIENT
• Dilation small intestine (gas):
• dog: - 1.6 x high body L5
• cat: > 12 mm
• Displacement or folds
Foreign bodies
• Great variation in size, shape and echogenicity
• Bright interface associated with strong shadowing highly
suggestive of a FB (= feces in colon !)
• Some are easily identified (balls), others are not
• GI parasites may mimic a FB
• Fluid accumulation, useful indicator
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Normal or ileus ?
If ileus: Mechanical or Functional ?
Chronic obstruction: mostly normal• Minimal to moderate intestine dilation (more fluid)
• Gravel sign
• Decreased serosal detail not always easy
• Free peritoneal gas
Dilation Normal
What happens in between ?
?
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Enteritis Neoplasia
- Diffuse
- Symmetrical
- Reactional lymph nodes
- Focal
- Asymmetrical
- Tumoral lymph nodes
Loss of parietal layers = excellent positive predictive value
0.82 cm
0.66 cm
• Thickened wall
Enteritis
•Mildly thickened wall
•Mucosa: increased echogenicity
L 0.65 cm
Enteritis
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• Thickening wall: > 5 mm
• Thickened muscularis
L 0.69 cm
Enteritis ?
Mucosal fibrosis in cats
From Penninck D. et al. Vet Radiol Ultrasound 2010
Lymphangiectasia
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Corrugated intestinal wall
• Pancreatitis (50%)
• Peritonitis/ Perforation
• Enteritis
• Neoplasia
• Entrapment
• Incidental
Leiomyosarcoma
L 1.49 cm
Intra-mural, focal massa
Lymphoma
• Thickened and symmetrical
hypechogenic wall
• Loss of layers
Sonography of the liver
Federica Rossi
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Sonography of the liver
Federica Rossi
SRV, Dipl. ECVDI
Sasso Marconi (BO) - Italy
SonographicSonographic keykey--pointspoints
�� locationlocation
�� sizesize
�� shapeshape, , marginsmargins
�� echogenicityechogenicity
�� echotextureechotexture//architecturearchitecture of the of the parenchymaparenchyma
�� hepatobiliaryhepatobiliary systemsystem
�� vesselsvessels
Location Location
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LiverLiver sizesize
�� subjectivesubjective
assessmentassessment
�� distancedistance betweenbetween
stomachstomach and and diaphragmdiaphragm increasedincreased
�� extensionextension ventralventral toto
the the stomachstomach
�� roundingrounding marginsmargins
LiverLiver sizesize
Bolognese, 5 KgBolognese, 5 Kg MixedMixed breedbreed dog, 7 Kgdog, 7 Kg
3
LiverLiver sizesize
HowHow muchmuch liverliver parenchymaparenchyma
surroundssurrounds the the gallbladdergallbladder??
LiverLiver sizesize
DecreasedDecreased
�� ChronicChronic hepatichepatic
diseasesdiseases evolvingevolving
toto hepatichepaticfibrosisfibrosis//cirrosiscirrosis
�� ShuntsShunts
IncreasedIncreased
�� MostMost hepatichepatic
disordersdisorders are are
associatedassociated withwithhepatomegalyhepatomegaly
NormalNormal hepatichepatic sizesize doesdoes notnot excludeexclude hepatichepatic diseasedisease
EchogenicityEchogenicity -- changeschanges
diffusediffuse changeschanges of of liverliver echogenicityechogenicity
compare compare toto::
falciformfalciform fatfat
renalrenal cortexcortex
spleenspleen
FocalFocal//multifocalmultifocal
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HepatomegalyHepatomegaly -- DDDD
�� VenousVenous congestioncongestion ++++++
�� LLymphomaymphoma, , leukemialeukemia, , histiocytichistiocytic neoplasia +++neoplasia +++
�� Acute Acute hepatitishepatitis ++++
�� AmiloidosisAmiloidosis ++
HEPATOMEGAL Y + HEPATOMEGAL Y + HYPOHYPO--ECHOGENIC LIVERECHOGENIC LIVER
VenousVenous congestioncongestion
�� HepatomegalyHepatomegaly withwith hypoechogenichypoechogenic liverliver
�� EnlargedEnlarged hepatichepatic veinsveins withwith abnormalabnormal flowflow
�� Free Free abdominalabdominal fluidfluid
�� PortalPortal congestioncongestion –– splenicsplenic congestioncongestion
�� HeartHeart murmuremurmure (right (right heartheart diseasesdiseases, , pericardialpericardial diseasesdiseases, VCC , VCC compressioncompression or or
inv asioninv asion))
VenousVenous congestioncongestion
HVHV
CVV
FF
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LYMPHOMALYMPHOMA
HepatomegalyHepatomegaly and :and :
1. 1. NormalNormal echogenicityechogenicity
2.2. Diffuse Diffuse hypoechogenicityhypoechogenicity
3.3. Diffuse Diffuse hyperechogenicityhyperechogenicity
4.4. FocalFocal or or multifocalmultifocal hypoechoichypoechoic lesionslesions
+ + lymphadenomegalylymphadenomegaly and and extrahepaticextrahepatic lesionslesions
(spleen)(spleen)
LYMPHOMA
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Left kidney spleen
Mesenteric ln
Acute Acute hepatitishepatitis
UsUs usefuluseful toto excludeexclude otherother hepatichepatic diseasesdiseases and and toto
obtainobtain cytologicalcytological samplessamples
Maltese m 8 a
7
AmiloidosisAmiloidosis
�� ToTo bebe includedincluded in the DDin the DD
�� HystopathologicalHystopathological diagnosisdiagnosis
HepatomegalyHepatomegaly -- DDDD
�� NonNon--neoplastic neoplastic infiltrativeinfiltrative diseasesdiseases
((fattyfatty or or glicogenglicogen infiltrationinfiltration):):
1. 1. DiabetesDiabetes mellitusmellitus
2. 2. SteroidSteroid hepatopathyhepatopathy
3. 3. HepaticHepatic lipidosislipidosis ((catscats), ), obesityobesity
�� Neoplastic diffuse Neoplastic diffuse diseasedisease: : lymphomalymphoma, , mastmast cellcell tumourtumour (dog)(dog)
HEPATOMEGAL Y + HEPATOMEGAL Y +
HYPERHYPER--ECHOGENIC LIVERECHOGENIC LIVER
VacuolarVacuolar hepatopathieshepatopathies
1.1. HepatomegalyHepatomegaly
2.2. HyperechogenicHyperechogenic liverliver
HepatomegalyHepatomegaly -- DDDD
3. 3. IncreasedIncreased distaldistal
beambeam attenuationattenuation
((absorptionabsorption))
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dog - diabetes
Cat – lipidosis DD obese c at!
DD: Dia, DD: Dia, LipLip, , CusCus, , LymLym
Look the Look the adrenalsadrenals!!!!!!!!
LiverLiver sizesize
DecreasedDecreased
�� ChronicChronic hepatichepatic
diseasesdiseases evolvingevolving
toto hepatichepaticfibrosisfibrosis//cirrhosiscirrhosis
�� ShuntsShunts
IncreasedIncreased
�� MostMost hepatichepatic
disordersdisorders are are
associatedassociated withwithhepatomegalyhepatomegaly
NormalNormal hepatichepatic sizesize doesdoes notnot excludeexclude hepatichepatic diseasedisease
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CHRONICCHRONICHEPATITISHEPATITIS
�� LiverLiver sizesize fromfrom normalnormaltoto reducedreduced
�� IrregularIrregular marginsmargins
�� IncreasedIncreased echogenicit yechogenicit y
withwith mineralizationsmineralizations
�� attenuationattenuation of of periperi--portalportal echoesechoes
�� regenerativeregenerative nodulesnodules
FIBROSIS - CIRRHOSIS
Jack Russel f 1a
CIRRHOSIS
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PSSPSS
LiverLiver sizesize
DecreasedDecreased
�� ChronicChronic hepatichepatic
diseasesdiseases evolvingevolving
toto hepatichepaticfibrosisfibrosis//cirrhosiscirrhosis
�� ShuntsShunts
IncreasedIncreased
�� MostMost hepatichepatic
disordersdisorders are are
associatedassociated withwithhepatomegalyhepatomegaly
NormalNormal hepatichepatic sizesize doesdoes notnot excludeexclude hepatichepatic diseasedisease
West West HighlandHighland male 2 ymale 2 y
Liver biopsy: Cu hepatopathy
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FOCALFOCAL-- MULTIFOCAL MULTIFOCAL
HEPATIC LESIONSHEPATIC LESIONS
CystCyst ++++
CalcificationCalcification ++++
NodularNodular hyperplasiahyperplasia ++++++++
PrimaryPrimary or or metastaticmetastatic neoplasia +++neoplasia +++
HematomaHematoma ++
NecrosisNecrosis ++
AbscessAbscess, granuloma, granuloma ++
ANAN--
HYPERHYPER--
HYPOHYPO--, , HYPERHYPER--, ,
MIXEDMIXED
HEPATIC CYSTSHEPATIC CYSTS
SONOGRAPHIC SONOGRAPHIC FEATURESFEATURES
�� round round toto ovaloval
�� anhechoicanhechoic contentcontent
�� thinthin and regular and regular wallwall
�� distaldistal acousticacoustic
enhancementenhancement
HEPATIC CYSTSHEPATIC CYSTS
OftenOften are are incidentalincidental findingsfindings��frequentfrequent in in catscats((policysitcpolicysitc diseasedisease, , cystadenomacystadenoma))
DD: GBDD: GB
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CYSTADENOMA (cat)
Gatto Persiano m 9a
HEPATIC CALCIFICATIONHEPATIC CALCIFICATION
SONOGRAPHIC SONOGRAPHIC FEATURESFEATURES
�� wellwell defineddefinedhyperechoichyperechoic areasareas
�� variousvarious shapeshape and and sizesize
�� distaldistal shadowingshadowing
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NODULAR HYPERPLASIANODULAR HYPERPLASIA
BenignBenign processprocess due due toto
accumulationaccumulation of of
�� regen erat edregen erat ed hepati chepati c cellscells
�� necro ticnecro tic and and at rophicat rophic
hepatichepatic p arench ymap arench yma
�� fatfat
�� dilateddilated hepati chepati c sinusoidssinusoids
SONOGRAPHIC SONOGRAPHIC FEATURESFEATURES
FocalFocal or or multifocalmultifocal::
�� hypoechoichypoechoic ++++++
�� isoechoicisoechoic ++++
�� hyperechoichyperechoic ++++
�� complexcomplex mass +mass +
Up Up toto 70 % of old 70 % of old animalsanimals affectedaffected
HEMATOMA, NECROSIS, HEMATOMA, NECROSIS, ABSCESSABSCESS
SonographicSonographic featuresfeatures are are variablevariable and can and can bebe similarsimilar: :
1. acute 1. acute hemorragehemorrage: : hyperhyper--
2. 2. recentrecent hematomahematoma or or abscessabscess: : hypohypo-- or or anhechoicanhechoic
3. old 3. old hemorragehemorrage, , chronicchronic abscessabscess, , necrosisnecrosis: : mixedmixed//complexcomplex
HYSTORY, LAB WORK, FOLLOW UPHYSTORY, LAB WORK, FOLLOW UP
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HEMATOMAHEMATOMA
H
coagulopathy
HEPATIC ABSCESSHEPATIC ABSCESS
Irregular external capsule and fluid content
F
F
CHRONIC HEPATITIS WITH CHRONIC HEPATITIS WITH
NECROSISNECROSIS
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Hepatomegaly and hypoechoic
peripheral infarct in dog with IMHA
HEPATIC NEOPLASIAHEPATIC NEOPLASIA
PRIMARYPRIMARY
HEPITELIALHEPITELIAL::
�� HepatocellularHepatocellular: : adenoma, adenoma, ACAC
�� BiliarBiliar: adenoma, : adenoma, ACAC
MESENCHYMALMESENCHYMAL::
�� HemangiomaHemangioma, , hemangiosarcomahemangiosarcoma
�� Fibroma, fibrosarcomaFibroma, fibrosarcoma
�� OtherOther sarcomassarcomas((LeiomioLeiomio-- osteoosteo……))
METASTATICMETASTATIC
DOG:DOG:
�� CarcinomaCarcinoma: : gastricgastric, , pancreaticpancreatic, , intestinalintestinal, , mammarymammary
�� SplenicSplenic hemangiosarcomahemangiosarcoma
�� LymphomaLymphoma, mastocitoma, mastocitoma
CAT:CAT:
�� CarcinomaCarcinoma: : pancreaticpancreatic, , intestinalintestinal, , renalrenal
�� LymphomaLymphoma
HEPATIC NEOPLASIA HEPATIC NEOPLASIA ––
sonographicsonographic featuresfeatures
FOCALFOCAL
MULTIFOCALMULTIFOCAL
hypoechoichypoechoic
complexcomplex
hyperechoichyperechoic or or mixedmixed
multifocalmultifocal (carcinoma)(carcinoma)
solitarysolitaryh yperechoich yperechoiclessless likelylikely
DIFFUSEDIFFUSE
inhomogeneousinhomogeneous
parenchymaparenchyma
abnormalabnormal echostructureechostructure
sometimessometimes onlyonlychangechange
in in echogenicityechogenicity((lymphomalymphoma) )
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HEPAT OCE LL ULA R C ARCI NO MA
HEMANGIOSARCOMA
LYMPHOMA
METASTATIC SARCOMA
SizeSize-- shapeshape-- echogenicityechogenicity
�� hepatomegalyhepatomegaly or or microepatiamicroepatia
�� regular or regular or irregularirregular marginsmargins
�� diffuse or diffuse or focalfocal changeschanges in in echogenicityechogenicityand and architecturearchitecture
�� otherother abdominalabdominal organsorgans
�� lymphlymph--nodesnodes
�� correlationcorrelation withwith clinicalclinical signssigns and and laboratorylaboratory resultsresults
UsUs findingsfindings are are notnotpatognomonicpatognomonic
list of DD list of DD diagnosisdiagnosis
FNA or FNA or biopsybiopsy
1
HEPATOBILIARY SYSTEMHEPATOBILIARY SYSTEM
SonographySonography isis the the preferredpreferred initialinitialimagingimaging techniquetechnique toto evaluateevaluate
diseasesdiseases of the of the hepatobiliaryhepatobiliary systemsystem
NORMAL GALLBLADDERNORMAL GALLBLADDER
��variable variable sizesize ((fastingfastingtime)time)
��anechoicanechoic contentcontent
��somesome sludgesludge
��thinthin wall (catwall (cat--1 mm, 1 mm, dogdog--2,3 mm)2,3 mm)
GB CATSGB CATS
2
�� GBGB
�� cysticcystic ductduct
�� hepatichepatic ductsducts
�� common bile common bile ductduct
major major duodenalduodenal
papillapapilla
dogdog catcat
BILIARY TRACTBILIARY TRACT
BILIARY TRACT BILIARY TRACT
�� ProximalProximal common bile common bile ductduct(CBD)(CBD)
-- ventralventral toto the the portalportal veinvein
-- easy easy toto foundfound in in catscats (up (up toto 4 mm 4 mm diameterdiameter) )
-- dog dog lessless visiblevisible (< 3 (< 3 mm)mm)
�� IntrahepaticIntrahepatic bile bile ductsducts notnotvisualizedvisualized in in normalnormalanimalsanimals
BILIARY SLUDGEBILIARY SLUDGE
��frequentfrequent findingfinding (old (old dogsdogs))
��originorigin and and significancesignificance notnotclearclear ((biliarybiliary stasisstasis?)?)
��positionalpositional changingchanging --> > ‚‚snowsnowstormstorm‘‘
��gravitygravity-- dependentdependent
horizontal horizontal „„fluidfluid lineline““betweenbetween bilebile and and corpuscularcorpuscularstructuresstructures
3
BILIARY SLUDGEBILIARY SLUDGE
�� ThickenedThickened and more and more
organizedorganized sedimentsediment: : ““SludgeSludge ballsballs””
�� DD: DD: wallwall massesmasses
BILIARY CALCULIBILIARY CALCULI
GALLBLADDER WALL GALLBLADDER WALL THICKENINGTHICKENING
��hepatitishepatitis, , cholecystitischolecystitis, , cholangiohepatitischolangiohepatitis ((congestioncongestion, , edemaedema))
�� hypoalbuminemiahypoalbuminemia ((dyscrasicdyscrasic edemaedema))
�� right right heartheart failurefailure
�� sepsissepsis
�� neoplasianeoplasia
4
GALLBLADDER WALL GALLBLADDER WALL
THICKENINGTHICKENING
must be differentiated from small amounts of peritoneal effusion
DD: COAGULOPATHY !!DD: COAGULOPATHY !!
FF
COLANGIOHEPATYTISCOLANGIOHEPATYTIS
5
ACUTE COLANGIOHEPATITISACUTE COLANGIOHEPATITIS
CHRONIC COLANGIOHEPATITISCHRONIC COLANGIOHEPATITIS
Sev ere Sev ere fibrosisfibrosis preventprevent distentiondistention of the GB lumenof the GB lumen
MUCOCELEMUCOCELE
�� BiliaryBiliary stasisstasis + + mucinousmucinoushyperplasiahyperplasia
�� gallbladdergallbladder distentiondistention
�� wallwall thickeningthickening
�� hyperechoichyperechoic kiwi kiwi likelikepattern, immobile pattern, immobile contentcontent
�� frequentlyfrequently, , butbut notnot alwaysalwaysassociatedassociated withwith bacterialbacterialinfectioninfection
�� possiblepossible perforationperforation((necrotizingnecrotizing colecystitiscolecystitis))
6
BILIARY OBSTRUCTIONBILIARY OBSTRUCTION
ACUTE OR CHRONICACUTE OR CHRONIC
UsUs veryvery usefuluseful toto identifyidentify the cause of the cause of obstructionobstruction: :
�� colelitiasiscolelitiasis, , sludgesludge
�� inflammationinflammation or neoplasia of the or neoplasia of the biliarybiliarytracttract or or adjacentadjacent structuresstructures ((liverliver, , duodenumduodenum, pancreas, , pancreas, lymphnodeslymphnodes, vena , vena porta)porta)
BILIARY OBSTRUCTIONBILIARY OBSTRUCTION
PROGRESSION OF SONOGRAPHIC PROGRESSION OF SONOGRAPHIC FINDINGS AFTER COMPLETE FINDINGS AFTER COMPLETE
OBSTRUCTION:OBSTRUCTION:
–– first: GB and first: GB and cysticcystic ductductdistentiondistention
–– after 48 after 48 hourshours: CBD : CBD distentiondistention, , extraextra--hepatichepatic ductsducts visiblevisible nearnear the GB the GB neckneck
–– after 5after 5--7 7 daysdays: : dilationdilation of of intraintra--hepatichepatic
bile bile ductsducts
BILIARY OBSTRUCTION
CBD > 5 mm
CBD acute obstruction
DuodenumDuodenum
PortalPortal veinvein
> 1 cm
7
BILIARY OBSTRUCTION
20 y old femal e cat
hepatomegaly
CBD
Duodenum
Duodenum
GB wall
BILIARY OBSTRUCTION
Urs Geissbühler
Mixed breed f 10y
8
BILIARY OBSTRUCTION
extraextra--hepatichepatic ductsducts
visiblevisible nearnear the GB the GB
neckneck (after > 48 (after > 48
hourshours of of obstructionobstruction))
BILIARY OBSTRUCTIONBILIARY OBSTRUCTION
DD of DD of biliarybiliary obstructionobstruction: : �� most common causes in dogs: most common causes in dogs:
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Ultrasonography of the pancreas
Dominique Penninck
Dominique Penninck DVM, PhD, DACVR, DECVDI Tufts Cummings School of Veterinary Medicine USA Ultrasonography of the pancreas in dogs and cats Email:[email protected]
Technique and Normal Pancreas:
The pancreas is a thin, elongated organ made of 3 segments (left and right limbs and body), located along the greater curvature of the stomach and the mesenteric border of the descending duodenum. The anatomic landmarks used to locate the right pancreatic lobe are the right kidney, the descending duodenum with its straight course along the right abdominal wall, and the pancreatico-duodenal vein paralleling the descending duodenum. The right pancreatic lobe can be imaged from a ventral or lateral approach, with a longitudinal scan-plane orientation used to find the descending duodenum and right kidney. The pancreatic body can be imaged from ventrally or from the right side with the animal in a dorsal, left or right lateral recumbent position by moving the scan plane craniomedial to the proximal descending duodenum and caudal to the pyloric antrum. The portal vein represents a useful landmark as it is located just dorsal and to the left of the body of the pancreas. A transverse scan just caudal to the porta hepatis and pylorus may be used to locate this vein and the body of the pancreas. The left pancreatic lobe is more difficult to image in dogs, because
of gas interference in the adjacent stomach and transverse colon. However, in cats, the left limb is larger and can more easily identified than the right limb. High frequency (>7.5 MHz) sectorial transducers are recommended to evaluate the pancreas, especially in cats and small-to-medium-sized dogs. The normal pancreas is isoechoic to slightly hyperechoic to the adjacent liver lobes, and nearly isoechoic to the surrounding mesenteric fat. There are no reported size ranges in dogs. In cats, the mean thickness measurements for the right pancreatic lobe, body, and left pancreatic lobe were 4.5mm (range 2.8 - 5.9), 6.6mm (range 4.7 - 9.5), and 5.4mm (range 3.4 - 9.0) respectively. The pancreatic duct had a mean diameter of 0.8mm (range 0.5 - 1.3). Pancreatic Disorders: Most pancreatic disorders result in focal or diffuse thickening and decreased echogenicity of the pancreas. Pancreatitis has various ultrasonographic appearances depending on the severity, duration and extent of pancreatic and peripancreatic tissue inflammation. In acute pancreatitis, the pancreas appears enlarged and diffusely hypoechoic while the surrounding fat appears moderately hyperechoic as the result of fat saponification. In dogs, the right limb of the pancreas tends to be most commonly affected while in cats; the changes tend to be more severe in the body and left limb. In cats, pancreatic enlargement, and diffuse change in pancreatic and surrounding fat echogenicity are often less obvious. In severe hemorrhagic, necrotizing pancreatitis, irregular hypoechoic area(s) represent necrosis and hemorrhage of part of the pancreas and peripancreatic tissue. Pancreatic edema appears as numerous hypoechoic stripes demarcating pancreatic lobulation and dissecting the enlarged pancreas. It can be seen in several clinical conditions, including edematous pancreatitis. Focal acute pancreatitis may contain combined areas of pancreatic necrosis, hemorrhage and surrounding inflamed mesentery. The hypoechoic and anechoic areas corresponding to collections of hemorrhage and necrotic tissue may, with chronicity, become more organized and develop into pseudocyst or abscess. In chronic pancreatitis, the pancreas can be within normal range for size and the parenchyma often is inhomogeneous. In cats, chronic pancreatitis is twice more frequent than acute pancreatitis. Pancreatic nodular hyperplasia is occasionally seen in the pancreas of older dogs and cats. Well-defined hypoechoic to isoechoic nodules that can vary in size can be disseminated throughout the pancreas. Pancreatic exocrine tumors such as adenocarcinoma arise from acinar cells or ductal epithelium. Even though these tumors are rare, they are the most common
type of pancreatic neoplasia in small animals. They tend to develop in the central portion of the gland. As they grow, they may compress the common bile duct, invade the adjacent gastric and duodenal segments, and frequently metastasize to the liver. They often are poorly echogenic nodules or masses; at times they are partially mineralized. Insulinomas are the most commonly encountered endocrine tumors in dogs. The ultrasound detection rate varies depending on the size and distribution of the lesions, the equipment quality and the operator’s experience. Insulinomas can present as a solitary nodule, multiple nodules or an ill-defined area of abnormal echogenicity. The size of the pancreatic lesions varies greatly, but a majority of the lesions tends to be small (less than 2 cm) and be poorly echogenic. A few references: Etue S.M., Penninck D.G., Labato M.A., Pearson S., Tidwell A. Ultrasonography of the normal feline pancreas and associated anatomical landmarks: a prospective study of 20 cats. Vet Radiol Ultrasound 2001;42:330-336. Hecht S., Penninck D.G., Mahony O.M., King R., Rand W.M Relationship of pancreatic duct dilation to age and clinical findings in cats. Vet Radiol Ultrasound 2006;47:287-294. Hecht S., Penninck D.G., Keating J.H Imaging findings in pancreatic neoplasia and nodular hyperplasia in 19 cats. Vet Radiol Ultrasound 2007;48:45-50. Lamb C.R., Simpson K.W., Boswood A., Matthewman L.A. Ultrasonography of pancreatic neoplasia in the dog: a retrospective review of 16 cases. Vet Rec 1995;37:65-68. Nyland T.G., Mulvany M.H., Strombeck D.R. Ultrasonic features of experimentally induced, acute pancreatitis in the dog. Vet Radiol Ultrasound 1983:24:260-266. Moon M.L., Panciera D.L., Ward D.L., Steiner J.M., Williams D.A. Age-related changes in the ultrasound appearance of the normal feline pancreas. Vet Radiol Ultrasound 2005;46, 138-142. Murtaugh R.J., Herring D.S., Jacobs R.M., DeHoff W.D.(1985) Pancreatic ultrasonography in dogs with experimentally induced acute pancreatitis. Vet Radiol Ultrasound 26:27-32. Salisbury S.K., Lantz G.C., Nelson R.W., Kazacos E.A. Pancreatic abscess in dogs: Six cases (1978-1986). J Am Vet Med Assoc 1988;193:1104-1108.
Saunders H.M. Ultrasonography of the pancreas. In: Problems in Veterinary Medicine 1991; 3:583-603. Saunders H.M., VanWinkle T.J., Drobatz K., Kimmel S.E., Washabau R.J. Ultrasonographic findings in cats with clinical, gross pathologic, and histologic evidence of acute pancreatic necrosis: 20 cases (1994-2001) J Am Vet Med Assoc 2002;221:1724-1730. VanEnkevort B.A., O’Brien R.T., Young K.M. Pancreatic pseudocysts in 4 dogs and 2 cats: ultrasonographic and clinicopathologic findings. J Vet Intern Med 1999;13:309-313.
Ultrasonography of abdominal
lymphnodes
Jimmy Saunders
06.07.2010
1
Ultrasonography of the abdominal
lymph nodes
Jimmy H. Saunders
Ghent University
ANATOMY
ANATOMY
From: www.medical-look.com
06.07.2010
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ANATOMY
VISCERAL LYMPH NODES PARIETAL LYMPH NODES
PARIETAL LYMPH NODES
Iliosacral lymphocenter:
- Medial iliac
- Hypogastric
- Sacral (inconsistent)
Lombo-aortic lymphocenter:
- Lombo-aortic
- Renal
LOMBO-AORTIC LYMPH NODES
Location: along the abdominal aorta and cauddal
vena cava from the diaphragm to the deep circumflex
iliac arteries
Number: 12
Size: 1-2cm in the dog (the biggest), 0.5-1.8cm in
the cat
Drainage: muscles, vertebrae, kidneys, bladder,
adrenal glands, ovaries, uterus, testes, more caudal
lymph nodes
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RENAL LYMPH NODES
Location: near the renal vessels (they are part of
the lombo-aortic)
Number: -
Size: 1cm in the dog, 0.5-1.4cm in the cat
Drainage: musculature, urogenital tract, adrenals,
more caudal lymph nodes
MEDIAL ILIAC LYMPH NODES
Location: lateral margins of the caudal aorta and
corresponding external iliac artery (the right one
is more ventral)
Number: 0-2
Size: 2-6cm in the dog, 0.3-2.8cm in the cat
Drainage: dorsal part of the abdomen, caudal part
of the digestive and urogenital tract
Medial iliac lymph node
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HYPOGASTRIC/SACRAL LYMPH NODES
Location: (differentiation is difficult !)
- hypogastric: in the angle between the internal iliac and
the median sacral arteries
- sacral: near the median sacral artery
Number: 1- 3 (sacral only in 50% of dogs)
Size: 1-3cm in the dog, 0.1-2cm in the cat
Drainage:
- hypogastric: bladder, caudal part genital tract, tail,
pelvis, femoral lymph nodes
- sacral: adjacent musculature, tail, caudal uterus
VISCERAL LYMPH NODES
Mesenteric (Cr & Cd) lymphocenter:
- Jejunal
- Colic
- Caudal mesenteric
Celiac lymphocenter:
- Hepatic
- Gastric
- Splenic (inconsistent)
- Pancreatico-duodenal (inconsistent)
HEPATIC LYMPH NODES
Location: adjacent to the portal vein, just caudal the
porta hepatis
- left: lesser omentum dorsal to the common bile duct
- right: adjacent to the pancreatic body
Number: single to multiple
Size: 1-6cm in the dog (Rt < Le), 0.2-3cm in the cat
Drainage: stomach, duodenum, pancreas, liver
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Hepatic lymph node
GASTRIC LYMPH NODES
Location: along the lesser curvature of the stomach
(from cardia to pylorus), embedded in the lesser
omentum - near the right gastric artery
Number: 1-5
Size: 0.5-2.5cm in the dog, 0.1-2cm in the cat
Drainage: esophagus, stomach,, liver, diaphragm,
peritoneum, mediastinum
SPLENIC LYMPH NODES
Location: along the splenic vessels. Between the
hilus of the spleen and the left pancreatic lobe,
close from the junction splenic and portal veins
Number: 1-5
Size: 0.5-4cm in the dog, 0.2-2cm in the cat
Drainage: spleen, esophagus, stomach, pancreas,
liver, omentum, diaphragm, gastric lymph nodes
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Splenic lymph node
PANCREATICO-DUODENAL
LYMPH NODES
Location:
- near the cranial duodenal flexure between pylorus and
right pancreatic lobe
- meeting point of the cranial pancreaticoduodenal and
right gastroepipolic vein
Sometimes: along the right pancreatic lobe (1-2, small)
Number: inconsistent
Size: small in the dog, 0.3-1.5cm in the cat
Drainage: duodenum, pancreas, stomach, omentum
JEJUNAL LYMPH NODES
Location: two elongated structures near the
root of the mesentery
Number: 2
Size: 0,5-20cm in the dog, 0,5-8cm in the cat
Drainage: jejunum, ileum, pancreas
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Jejunal lymph node
COLIC / CAUDAL MESENTERIC
LYMPH NODES
Location: the mesocolon
- near the ascending or transverse lymph nodes (colic) -
near the ileocolic junction (1-2)
- near the descending lymph node (caudal mesenteric, 2-5)
Vascular landmarks: near the ileocolic vein, middle colic
vein
Size: 1-2.5cm in the dog, 0.1-3cm in the cat
Drainage: ileum, cecum, colon, rectum
Sacral lymph nodeColic lymph node
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Lymph node = LN Seen in ... % of cats Size (in mm)
Hepatic LN 70 L=7.6, W=2.9 (normal: L=<20, W=<10)
Gastric LN 30 L=5.1, W=1.9 (normal: L=5-6)
Splenic LN 60 L=8.4, W=3.2 (normal: L=5-20)
Pancreatico-duodenal LN 60 L=8.4, W=4.6 (normal: L=10, W=5)
Jejunal LN 90 L=20.1, W=5.0 (normal: L=<60, W=3-7)
Renal LN 50 L=6.1, W=3.5
Cecal LN 40 L=11.8, W=4.1 (normal: L=3-15, W=5-9)
Colic LN 40 L=9.0, W=3.1 (normal: L=12)
Caudal mesenteric LN 10 L=6.0, W=2.1
Aortic lumbal LN 60 L=9.9, W=3.2 (normal: L=5-6, W=3-4)
Medial iliac LN 100 L=13.5, W=4.5 (normal: L=20, W=2.7)
Sacral LN 40 L=9, W=3.1 (normal: L=12)
US IN CATS
US FEATURES
ECHOGENICITY
Subjective evaluation
Uniform, iso- to hypoechoic to the surrounding tissues
Abnormal: non-uniform and hypo- or anechoic
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Normal: slender = length > thickness
Abnormal: plump with rounded edges
Way to evaluate: short to long axis ratio
SHAPE
Border definition = sharpness of the borders of a lymph node
Normal lymph node:
sharp, regular borders
sharpness of the borders depends of the difference in acoustic impedance
Irregular border: may suggest an invasion growth compatible with
malignancy
MARGINS
Transmission of the echoes through a lymph node give clues
about its (abnormal) composition
fluid-filled acoustic enhancement: necrosis, abscess, cyst
dense structure (mineralized) acoustic shadowing: dystrophic
with chronicity (reactive, metastatic)
ACOUSTIC TRANSMISSION
From: Nyman H.T, O’Brien R.T. The sonographic evaluation of lymph nodes. Clin Tech Small Anim Prac 2007;22:128-137
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YOUNG ANIMAL
Till +/- 1 year old
Lymph nodes are bigger than in the adult
Lymph nodes have a hypoechoic halo
THE DISEASED NODE
THE DISEASED NODES
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Aim: demonstrate the amount, distribution and architecture of blood
vessels within the lymph node
Normal: orderly arrangement of branching arteries starting from the hilus
or no vascularisation visible
Metastatic lymph nodes:
Peripheral perfusion pattern due to initial deposition of tumor cells in the
marginal and medullary sinuses inducing aberrant vessels
With tumor progression: periphery + central vessels
Vessel morphology: irregular diameter, branching pattern, intravascular
shunts, blind-ending vessels
COLOR / POWER DOPPLER
COLOR / POWER DOPPLER
From: Nyman H.T, O’Brien R.T. The sonographic evaluation of lymph nodes. Clin Tech Small Anim Prac 2007;22:128-137
Metastasis perianal gland
carcinoma - peripheral
Reactive - hilarLymphoma - mixed
VASCULAR FLOW INDICES
Two indices may be useful when used in combination with the echogenicity,
hilus, short to long axis ratio, blood flow distribution
Resistive index (RI):
peak systolic velocity-end diastolic velocity / peak systolic velocity Pulsatility index (PI):
peak systolic velocity-end diastolic velocity / time-averaged max. velocity
Theory:
Inflamed lymph node: decreased vascular resistance because of vasodilatation
Metastatic lymph node: increased vascular resistance because of compression
by tumor cells or vessels in the lymph node and/or tumor-evoked angiogenesis
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Neoplastic nodes Inflammatory nodes
Shape Round Oval
S/L axis 0.55 0.55
Hilus Narrow or absent Usually present
Echogenicity Often hypoechoic Isoechoic
Border Sharp Varied
Posterior enhancement Often present Often absent
Blood flow distribution Primarily peripheral or mixed Hilar
RI High, 0.65 Low, 0.65
PI High, 1.45 Low, 1.45
(Nyman et al., 2004)
Doppler
B-mode
THE DISEASED NODE
THE DISEASED NODE
Using the size of the lymph node, distribution of vascular flow
within the lymph node, and pulsatility index (PI), a correct
diagnosis can be obtained in:
- 77% of the cases between normal, reactive, lymphoma and
metastatic
- 89% of the cases between benign and malignant
QUALITATIVE EVALUATION
• Increased intranodal vascular signals
• Different patterns for:
• normal lymph nodes
• reactive lymph nodes
• metastatic lymph nodes
• lymphoma
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ENHANCEMENT PATTERNS
NORMAL,
REACTIVE
METASTASES
LYMPHOMA. .. .. ... .
..
..
...
.. ...
. .
BASELINEARTERIAL
PHASE
PARENCHYMAL
PHASE
NORMAL,
REACTIVE
BASELINEARTERIAL
PHASE
PARENCHYMAL
PHASE
REACTIVE: diffuse intense homogeneous enhancement
because of intense vascularisation with a rich cortical
capillary circulation
ENHANCEMENT PATTERNS
METASTASES
BASELINEARTERIAL
PHASE
PARENCHYMAL
PHASE
METASTASES:
• generally less vascularized than the adjacent normal
parenchyma = perfusion defects
• avascular areas of necrosis, sometimes confluent
ENHANCEMENT PATTERNS
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LYMPHOMA. .. .. ... .
..
..
...
.. ...
. .
BASELINEARTERIAL
PHASE
PARENCHYMAL
PHASE
LYMPHOMA: variable appearance
• arterial phase:
• low grade: similar to reactive
• high grade: diffuse, heterogeneous, dotted because of hypertrophic arterial
vessels larger than in other forms of lymphadenopathy
• parenchymal phase: punctiform aspect throughout parenchyma
ENHANCEMENT PATTERNS
Lymph node perfusion (quantitative)
Quantitative study: still experimental
Sentinel lymph node - lymphosonography: still experimental
Subcutaneous injection
Normal Malignant
Under investigation…