- •Contents
- •Preface
- •Contributors
- •1 Vessels
- •1.1 Aorta, Vena Cava, and Peripheral Vessels
- •Aorta, Arteries
- •Anomalies and Variant Positions
- •Dilatation
- •Stenosis
- •Wall Thickening
- •Intraluminal Mass
- •Perivascular Mass
- •Vena Cava, Veins
- •Anomalies
- •Dilatation
- •Intraluminal Mass
- •Compression, Infiltration
- •1.2 Portal Vein and Its Tributaries
- •Enlarged Lumen Diameter
- •Portal Hypertension
- •Intraluminal Mass
- •Thrombosis
- •Tumor
- •2 Liver
- •Enlarged Liver
- •Small Liver
- •Homogeneous Hypoechoic Texture
- •Homogeneous Hyperechoic Texture
- •Regionally Inhomogeneous Texture
- •Diffuse Inhomogeneous Texture
- •Anechoic Masses
- •Hypoechoic Masses
- •Isoechoic Masses
- •Hyperechoic Masses
- •Echogenic Masses
- •Irregular Masses
- •Differential Diagnosis of Focal Lesions
- •Diagnostic Methods
- •Suspected Diagnosis
- •3 Biliary Tree and Gallbladder
- •3.1 Biliary Tree
- •Thickening of the Bile Duct Wall
- •Localized and Diffuse
- •Bile Duct Rarefaction
- •Localized and Diffuse
- •Bile Duct Dilatation and Intraductal Pressure
- •Intrahepatic
- •Hilar and Prepancreatic
- •Intrapancreatic
- •Papillary
- •Abnormal Intraluminal Bile Duct Findings
- •Foreign Body
- •The Seven Most Important Questions
- •3.2 Gallbladder
- •Changes in Size
- •Large Gallbladder
- •Small/Missing Gallbladder
- •Wall Changes
- •General Hypoechogenicity
- •General Hyperechogenicity
- •General Tumor
- •Focal Tumor
- •Intraluminal Changes
- •Hyperechoic
- •Hypoechoic
- •Nonvisualized Gallbladder
- •Missing Gallbladder
- •Obscured Gallbladder
- •4 Pancreas
- •Diffuse Pancreatic Change
- •Large Pancreas
- •Small Pancreas
- •Hypoechoic Texture
- •Hyperechoic Texture
- •Focal Changes
- •Anechoic Lesion
- •Hypoechoic Lesion
- •Isoechoic Lesion
- •Hyperechoic Lesion
- •Irregular (Complex Structured) Lesion
- •Dilatation of the Pancreatic Duct
- •Marginal/Mild Dilatation
- •Marked Dilatation
- •5 Spleen
- •Nonfocal Changes of the Spleen
- •Diffuse Parenchymal Changes
- •Large Spleen
- •Small Spleen
- •Focal Changes of the Spleen
- •Anechoic Mass
- •Hypoechoic Mass
- •Hyperechoic Mass
- •Splenic Calcification
- •6 Lymph Nodes
- •Peripheral Lymph Nodes
- •Head/Neck
- •Extremities (Axilla, Groin)
- •Abdominal Lymph Nodes
- •Porta Hepatis
- •Splenic Hilum
- •Mesentery (Celiac, Upper and Lower Mesenteric Station)
- •Stomach
- •Focal Wall Changes
- •Extended Wall Changes
- •Dilated Lumen
- •Narrowed Lumen
- •Small/Large Intestine
- •Focal Wall Changes
- •Extended Wall Changes
- •Dilated Lumen
- •Narrowed Lumen
- •8 Peritoneal Cavity
- •Anechoic Structure
- •Hypoechoic Structure
- •Hyperechoic Structure
- •Anechoic Structure
- •Hypoechoic Structure
- •Hyperechoic Structure
- •Wall Structures
- •Smooth Margin
- •Irregular Margin
- •Intragastric Processes
- •Intraintestinal Processes
- •9 Kidneys
- •Anomalies, Malformations
- •Aplasia, Hypoplasia
- •Cystic Malformation
- •Anomalies of Number, Position, or Rotation
- •Fusion Anomaly
- •Anomalies of the Renal Calices
- •Vascular Anomaly
- •Diffuse Changes
- •Large Kidneys
- •Small Kidneys
- •Hypoechoic Structure
- •Hyperechoic Structure
- •Irregular Structure
- •Circumscribed Changes
- •Anechoic Structure
- •Hypoechoic or Isoechoic Structure
- •Complex Structure
- •Hyperechoic Structure
- •10 Adrenal Glands
- •Enlargement
- •Anechoic Structure
- •Hypoechoic Structure
- •Complex Echo Structure
- •Hyperechoic Structure
- •11 Urinary Tract
- •Malformations
- •Duplication Anomalies
- •Dilatations and Stenoses
- •Dilated Renal Pelvis and Ureter
- •Anechoic
- •Hypoechoic
- •Hypoechoic
- •Hyperechoic
- •Large Bladder
- •Small Bladder
- •Altered Bladder Shape
- •Intracavitary Mass
- •Hypoechoic
- •Hyperechoic
- •Echogenic
- •Wall Changes
- •Diffuse Wall Thickening
- •Circumscribed Wall Thickening
- •Concavities and Convexities
- •12.1 The Prostate
- •Enlarged Prostate
- •Regular
- •Irregular
- •Small Prostate
- •Regular
- •Echogenic
- •Circumscribed Lesion
- •Anechoic
- •Hypoechoic
- •Echogenic
- •12.2 Seminal Vesicles
- •Diffuse Change
- •Hypoechoic
- •Circumscribed Change
- •Anechoic
- •Echogenic
- •Irregular
- •12.3 Testis, Epididymis
- •Diffuse Change
- •Enlargement
- •Decreased Size
- •Circumscribed Lesion
- •Anechoic or Hypoechoic
- •Irregular/Echogenic
- •Epididymal Lesion
- •Anechoic
- •Hypoechoic
- •Intrascrotal Mass
- •Anechoic or Hypoechoic
- •Echogenic
- •13 Female Genital Tract
- •Masses
- •Abnormalities of Size or Shape
- •Uterus
- •Abnormalities of Size or Shape
- •Myometrial Changes
- •Intracavitary Changes
- •Endometrial Changes
- •Fallopian Tubes
- •Hypoechoic Mass
- •Anechoic Cystic Mass
- •Solid Echogenic or Nonhomogeneous Mass
- •14 Thyroid Gland
- •Diffuse Changes
- •Enlarged Thyroid Gland
- •Small Thyroid Gland
- •Hypoechoic Structure
- •Hyperechoic Structure
- •Circumscribed Changes
- •Anechoic
- •Hypoechoic
- •Isoechoic
- •Hyperechoic
- •Irregular
- •Differential Diagnosis of Hyperthyroidism
- •Types of Autonomy
- •15 Pleura and Chest Wall
- •Chest Wall
- •Masses
- •Parietal Pleura
- •Nodular Masses
- •Diffuse Pleural Thickening
- •Pleural Effusion
- •Anechoic Effusion
- •Echogenic Effusion
- •Complex Effusion
- •16 Lung
- •Masses
- •Anechoic Masses
- •Hypoechoic Masses
- •Complex Masses
- •Index
Decreased Size
Testis, Epididymis
Diffuse Change
Enlargement
Decreased Size
Circumscribed Lesion
Epididymal Lesion
Intrascrotal Mass
Anorchism, Cryptorchidism
Hypogonadism
Atrophy
Anorchism, Cryptorchidism
Unilateral or bilateral testicular aplasia is easy to diagnose with ultrasound. In cryptorchidism, ultrasound shows an ectopic, undescended testis in the groin or abdomen (e. g., iliac region). The testis in these cases is hypoplastic.
Hypogonadism 
Small testes occur as an ontogenic condition in intersexuality, Klinefelter syndrome, prepubertal and postpubertal hypopituitarism (hypogonadotropic eunuchoidism, organic pituitary disease), and various other syndromes. The small size of the testes is demonstrated by ultrasound.
Atrophy 
Testicular atrophy can result from insults such as testicular torsion or radiation therapy. The diagnosis is made from the underlying disorder, and ultrasound can confirm the clinical suspicion.
■ Circumscribed Lesion
Anechoic or Hypoechoic
Testis, Epididymis
Diffuse Change
Circumscribed Lesion
Anechoic or Hypoechoic
Irregular/Echogenic
Epididymal Lesion
Intrascrotal Mass
Testicular Cyst
Hematoma
Abscess
Testicular Infarction
Testicular Tumor
Testicular Cyst
Testicular cysts occur as simple cysts without a |
interior with a rounded border and distal |
cyst wall and in the form of very rare epider- |
acoustic enhancement with absence of color |
moid cysts. Simple testicular cysts display typ- |
Doppler signals. Epidermoid cysts may contain |
ical cystic features on ultrasound: an anechoic |
distinct internal echoes. |
12
Circumscribed Lesion
431
12
Prostate, Seminal Vesicles, Testis, Epididymis
Hematoma
Post-traumatic hematoma can appear as a predominantly anechoic lesion, depending on its stage (Fig.12.29). High-level internal echoes with reverberations represent bubbles produced by gas-forming bacteria.
Fig. 12.29 Post-traumatic testicular hematoma. LI = left. |
b Color Doppler shows an absence of vascularity in the |
a B-mode demonstrates an anechoic mass. |
hematoma. |
Abscess
Most abscesses are anechoic, but occasionally a cloudy internal structure is seen. The margins are irregular (Fig.12.30). The diagnosis is established by the clinical presentation and if necessary by ultrasound-guided needle aspiration. Given the variable appearance of abscesses, there are cases in which the diagnosis can be confirmed only by demonstrating bacterial gas formation.
Fig. 12.30 Testicular abscess: anechoic to hypoechoic mass within the testis (HO) and scrotum. Color Doppler shows no blood flow within the mass. Patient presented clinically with septic temperatures and an infected hematoma.
Testicular Infarction
On the whole, testicular infarctions are very rare. They have been characterized as hypoechoic as well as hyperechoic lesions that are virtually indistinguishable from tumors.10
Testicular Tumor
Many different tumors can occur in the testes, showing a peak incidence during adolescence. They can be classified by histological and genetic criteria into seminomas, nonseminomatous tumors (embryonic carcinoma, yolk sac tumor, choriocarcinoma), gonadal stromal tumors (Leydig cell tumor, Sertoli cell tumor), and malignant lymphomas.
Most testicular tumors (90–95%) are derived from germ cells (seminomatous [= 50%] and nonseminomatous tumors). Non–germ-cell tumors (Leydig cell tumor, Sertoli cell tumor, and
other very rare stromal tumors) represent only about 4%. The remaining tumors are lymphomas and leukemic infiltration, mesenchymal tumors and metastases.
Malignant tumors are mainly hypoechoic; some tumors also present a heterogeneous appearance.
Gray-scale ultrasonography with a high-res- olution probe (5–12 MHz) is almost 100% sensitive for detection of testicular tumors. CDS demonstrates increased vascularity in the majority of malignant tumors.
There are also a variety of benign intratesticular processes that mimic testicular malignancy. Benign lesions are more frequent: they represent cysts, epidermoid cysts, tubular ectasia, intratesticular spermatocele or varicocele, and calcifications. Epidermoid cysts show often irregular structure, cyclic calcifications, or onion-ring appearance. The sonomorphological features described by Schwerk and Schwerk10 are listed in Table 12.3; see also
Fig.12.31.
Table 12.3 Sonomorphological features of testicular tumors10
●One or more foci disrupting the testicular echo texture
●Tumor outline smooth or irregular
●Great majority of tumors (approximately 90%) are hypoechoic; a few are isoechoic or hyperechoic
●Homogeneous or heterogeneous tumor structure, in some cases with focal calcifications and/or (pseudo)cystic areas
432
Fig. 12.31 Testicular tumor (TU). |
b Color Doppler: hypervascular periphery. |
a Testicular carcinoma: nonhomogeneous, hypoechoic |
|
mass with small anechoic cysts. |
|
12
Circumscribed Lesion
c Seminoma: hypoechoic masses (image courtesy of Professor C. Goerg, University Hospital Giessen and Marburg, Marburg, Germany).
Irregular/Echogenic
Epididymis |
|
|
Diffuse Change |
|
|
|
|
||
|
|
|
Circumscribed Lesion |
|
|
|
|
||
|
|
|
|
Anechoic or Hypoechoic |
|
|
|
|
Irregular/Echogenic |
|
|
|
|
|
Testis, |
|
|
Epididymal Lesion |
|
|
||||
|
|
Intrascrotal Mass |
||
|
|
|
||
Nonseminatous tumors often present an inhomogeneous echo texture, with parts that may be cystic (necrosis, dilated seminiferous ducts)
Testicular Microlithiasis
or echogenic (hemorrhage, fibrosis). Nevertheless, all of the focal lesions described above can also assume a heterogeneous structure. In or-
chitis, this is seen mainly with atypical granulomatous inflammations.
Testicular Microlithiasis
Testicular microlithiasis or calcifications can occur in association with inflammatory as well as neoplastic testicular lesions.
Testicular microlithiasis is caused by degenerated myofibroblasts within the seminiferous tubules with intramural fibrosis. They appear as multiple echogenic foci measuring 2–3 mm without shadowing. Microlithiasis testis has been associated with a high incidence of testicular neoplasia (average 45%), therefore annual ultrasound follow-up is recommended for at least several years after the diagnosis. Nevertheless there is no evidence of a premalignant condition or causative agent in testicular neoplasia (Fig.12.32). Differentiation in these cases can be accomplished histologically or by reference to the history and clinical presentation (trauma, fever with inflammatory swelling, underlying disease).
Fig. 12.32
a “Starry sky” calcifications in the right testis (testicular microlithiasis) following a left orchiectomy for a germ cell tumor. Microlithiasis is an uncommon generally bilateral condition and has been associated with testicular neoplasia.
b Tumor-associated macrocalcification with shadowing in a metastatic germ cell carcinoma (FL= fluid collection).
433