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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5765_Библиотеки_им_академика_М_И_Перельмана.pdf
3.2 Solid Lesions
69
d
Fig. 3.22 (Continued)
e
70
3 Ultrasound ofCommon Non-vascular Benign Cutaneous Lesions
a
b
Fig. 3.23 Dermatobroma. (a) Clinical photograph of the lesion in the
left forearm of a female patient. (b) Dermatoscopic photograph of the
same lesion. (c) Ultrasound (greyscale) shows a 9.0-mm (transverse)× 5.2-mm (thickness), ill-dened, hypoechoic dermal structure
that extends into the upper hypodermis, displaces the epidermis upward,
and shows a pseudonodular, more intense hypoechoic center (double
asterisks). (d) Color Doppler ultrasound presents a few vessels at the
periphery of the lesion (asterisk).
3.2 Solid Lesions
71
c
d
Fig. 3.23 (Continued)
72
3 Ultrasound ofCommon Non-vascular Benign Cutaneous Lesions
3.2.4 Nodular Fasciitis
3.2.4.1 Denition
Fibrous reactive process of unknown cause; it is most commonly seen in the forearms of young adults but may affect
other corporal regions. On histology, it presents spindle cells
within myxoid and collagen stroma, inammatory cells, vessels, and inner hemorrhage [2, 35].
3.2.4.2 Synonym
Pseudosarcomatous bromatosis.
a
3.2.4.3 Key Sonographic Signs
• The most common forms of presentations are an ill-dened
hypoechoic structure and a hypoechoic hypodermal nodule with some parts showing irregular contour [2, 35, 36].
• The most common location is the deep hypodermis, and
frequently these lesions contact the fascial layer at some
point (Fig.3.24).
• Panniculitis signs can be detected in the periphery such as
increased thickness and echogenicity of the fatty lobules
of the hypodermis, and a variable amount of anechoic or
hypoechoic uid between the fatty lobules.
• On color Doppler, these lesions can show hypovascularity
or prominent vascularity in the periphery or within the
structure [2].
3.2.4.4 Tip
Look for the contact of the lesion with the underlying
fascia.
Fig. 3.24 Nodular fasciitis.
(a and b), Ultrasound (a,
greyscale; b, panoramic view
with color lter) shows a
hypoechoic nodule in the
deep hypodermis, with some
irregular contours and
attachment to the fascia
(arrow). (c) Color Doppler
demonstrates increased
vascularity in the periphery
of the lesion.
3.2 Solid Lesions
73
b
c
Fig. 3.24 (Continued)
74
3 Ultrasound ofCommon Non-vascular Benign Cutaneous Lesions
3.2.5 Neurobromas
3.2.5.1 Denition
Tumors derived from the nerve sheath. These can be single
or multiple and can be associated with neurobromatosis
type I (von Recklinghausen’s disease). The most common
forms of presentations are diffuse, localized, and plexiform [2].
3.2.5.2 Key Sonographic Signs
The forms of presentations of neurobromas show different
types of sonographic patterns (Fig.3.25) [2, 37–42]:
• Diffuse type commonly appears as ill-dened dermal and/or
hypodermal structures or plaque-like regions with mixed
echogenicity that can show hypoechoic and hyperechoic
areas, some hypoechoic tortuous tracts, and hypoechoic nodules (Figs. 3.25c, 3.26, and 3.27; Videos 3.8 and 3.9). In
some cases, these structures can present lobulated contours.
• Localized type usually appears as well-dened,
hypoechoic single or multiple nodules located beneath the
fascial layer (Fig.3.25d). Occasionally, these can present
centrally located afferent and efferent hypoechoic tracts.
• Plexiform type frequently appears as multiple thick,
hypoechoic neural bundles or nodules that follow the axis
of the main nerves and their branches, including the hypodermal neural tracts. This form of presentation has been
called “bag of worms” (Fig.3.25e).
• These forms of presentation can be present in the same
patient in the corporal region or in different body locations of the patient.
• On color Doppler, vascularity has been reported to vary
from hypovascular to hypervascular.
• Rarely, neurobromas can present hemorrhage and produce a
sudden lump. In these cases, ill-dened heterogeneous structures may be detected in the dermis and hypodermis [2, 41].
a
Fig. 3.25 Neurobromatosis type I with diffuse, localized, and plexiform
variants in the same patient. (a) Clinical image of a lesion on the left thigh.
(b) Diffuse lesions. Ultrasound (greyscale, transverse view; left thigh)
shows three neighboring hypoechoic dermal lesions that with a plaque-like
structure that measures 3.59cm (transverse)×0.33cm (thickness) and protrudes into the upper hypodermis. (c) Diffuse lesion. Color Doppler ultrasound (longitudinal view; left thigh) shows inner vascularity within the
structure. (d) Localized lesion. Color Doppler ultrasound at the left groin
region (longitudinal view) demonstrates well-dened, oval-shaped nodule
underlying the fascial layer, with some vessels in the periphery. (e)
Plexiform type. Ultrasound (greyscale, longitudinal view; proximal and
lateral part of the left leg) shows three well-dened nodules that measure
3.7, 3.8, and 8.7mm, following the path of the left common peroneal nerve.
3.2 Solid Lesions
75
b
c
Fig. 3.25 (Continued)
d
76
Fig. 3.25 (Continued)
3 Ultrasound ofCommon Non-vascular Benign Cutaneous Lesions
e
a
Fig. 3.26 Neurobromatosis diffuse type I. (a) Clinical image of a
lesion in the mandibular region. (b) Photograph of café-au-lait spots in
the abdominal wall of the same patient. (c and d) Ultrasound of the
mandibular region (c, greyscale, transverse view; d, panoramic view
with color lter) shows 2.22-cm (transverse)×0.79-cm (thickness) illdened, plaque-like dermal and hypodermal structure with heteroge-
neous echogenicity. This lesion shows hypoechoic tracts that involve
the hair follicles and hyperechoic areas that affect the dermis and hypodermis. (e) Color Doppler of the mandibular region (longitudinal view)
presents prominent vascularity within the structure. (f) The mandibular
lesion (asterisk) in three-dimensional view. See Video 3.8.
3.2 Solid Lesions
77
b
c
Fig. 3.26 (Continued)
78
3 Ultrasound ofCommon Non-vascular Benign Cutaneous Lesions
d
e
Fig. 3.26 (Continued)
f