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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5780_Библиотеки_им_академика_М_И_Перельмана.pdf
21.1 Principal Signs and Symptoms
Schmidt, Ultrasound © 2007 Thieme
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Ascites, Pleural Effusion
..............................................................................................................
n
Definition: collection of serous fluid in the capillary space between the visceral
and parietal layers of the peritoneum or in the pleural space (exudate or transudate). For the differentiation of benign and malignant ascites, see p. 155.
n
Occurrence:
x
Peritoneal carcinomatosis: see Table 79.
x
Pleural metastases, pleural carcinomatosis (Figs. 659 and 660)
x
Mesothelioma (Fig. 661): benign or malignant pleural or peritoneal tumor
Table 79.Signs of peritoneal carcinomatosis (after Rioux)
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Omental thickening (in 97 %)
Peritoneal mass (in 19 %)
Peritoneal discontinuity (in 16 %)
Mesenteric adhesions (in 16 %)
Hepatic metastases (in 38 %)
Lymph node metastases (in 24 %)
Ascites (in 49 %)
ab
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Fig. 659a, b Pleural effusion. a Neoplastic pleural thickening (arrows) as a direct
cause of effusion (E). S = spleen. b Result of ultrasound search for a primary tumor:
malignant pancreatic tumor (P) infiltrating the antrum (A) and duodenum. Arrows:
tumor extensions (same patient as in a)
Fig. 660 Malignant pleural effusion (E)
in peritoneal carcinomatosis: thickening
of the parietal pleura (arrows). The
echogenic line behind the parietal pleura
is an entry echo from the aerated lung
(LU)
439
21.1 Principal Signs and Symptoms
Schmidt, Ultrasound © 2007 Thieme
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a
c
b
Fig. 661a–c Malignant pleural
mesothelioma (histology: small-cell
malignant tumor). a Pleural effusion
with low-level internal echoes. b CDS:
massive hypoechoic neoplastic thickening of the diaphragmatic pleura with
spot-like vessels. L = liver, T = tumor.
c Upper abdominal longitudinal scan:
tumor masses (T) about the diaphragm
x
Meigs tumor (see Fig. 210, p. 162): benign ovarian tumor with ascites or
unilateral pleural effusion
Diarrhea, Constipation
..............................................................................................................
n
Occurrence:
x
Hormone-producing gastrointestinal tumors:
– Carcinoid (Fig.
440
662): diarrhea in 70–90 %
Fig. 662 Metastatic carcinoid in the
liver (cursors): almost completely anechoic mass with a small, echogenic tumor
margin—typical appearance of metastatic carcinoid
21.1 Principal Signs and Symptoms
Schmidt, Ultrasound © 2007 Thieme
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– Gastrinoma (pancreatic tumor with Zollinger–Ellison syndrome)
– Vipoma (pancreatic tumor with Verner–Morrison syndrome, very rare):
“pancreatic cholera.”
n
Rectal carcinoma: episodes of diarrhea (with bright red blood), constipation
n
Colon carcinoma (see Fig. 663b, p. 441): constipation or bowel obstruction
Thrombosis
..............................................................................................................
n
Definition: intravital and intravascular coagulation with thrombus formation
663) or a tumor thrombus (Fig. 664) in the setting of a paraneoplastic syn-
(Fig.
drome (caused by ectopical ly produced hormones or hormonally active peptides
and polypeptides, also tumor markers).
n
Occurrence:
x
Superficial and deep (lower-extremity) venous thrombosis (Figs. 663 and 664)
x
Portal vein thrombosis (see Fig. 370, p. 261)
x
Vena cava or renal vein thrombosis (see Fig. 101, p. 74)
b
Fig. 663a, b Deep vein thrombosis
in paraneoplastic syndrome. a CDS:
a
thrombosis (TH). b Cause: local metas-
tased carcinoma of the sigmoid colon.
The patient had a 3-week history of recurrent pneumonia and fever, initially
diagnosed as postinfarction pneumonia. The tumor was not diagnosed until deep
venous thrombosis developed, prompting an ultrasound tumor search
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Fig. 664 Tumor thrombosis of the internal
jugular vein (JV): highlevel intraluminal echoes
(TU, TH) with internal
vascularity. CDS with
spectral analysis shows
aberrant arterial vessels
that confirm a malignant
tumor thrombus. Primary
tumor: renal cell carcinoma that metastasized
to the thyroid gland
441
21.2 Sonographic Criteria for Malignancy
Schmidt, Ultrasound © 2007 Thieme
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Abnormal Laboratory Values
..............................................................................................................
n
Look for anemia, lymphocytosis, thrombocytosis, hemoblastosis, hypercalcemia,
elevated ESR, etc.
n
Occurrence in:
x
Acute leukemia, chronic lymphatic leukemia
x
Plasmacytoma
x
Gastrointestinal tumors
x
Metastasizing tumor
21.2 Sonographic Criteria for Malignancy
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Basic Principles
..............................................................................................................
n
Sonographic definition of tumors: Primary organ tumors and metastases appear
as circumscribed lesions whose shape and echo pattern are characteristic of
tumors. The normal architecture and echo pattern of the affected organ is altered
or destroyed.
n
Sonographic appearance of tumors:
x
Benign and malignant tumors may have different malignancy criteria in different organs (e.g., an echopenic halo suggests metastasis in the liver but suggests
a benign nodule in the thyroid gland).
x
Calcification and liquefaction may occur in both malignant and benign tumors.
x
Many types of tumor lack reliable criteria for malignancy.
n
Sonographically detectable organ changes: Some tumors are difficult to define
directly with ultrasound but may still be detected indirectly by their effects on
the host organ. The changes in the host organ relate mainly to organ contours
and echo patterns but may also involve blood vessels and tubular structures.
n
Associated findings: Tumors occasionally assume importance not by their pri-
mary site of occurrence or their host-organ effects but by their relationship to
and effects on surrounding structures. They may produce clinical manifestations
by the alteration of dynamic processes (e.g., intestinal peristalsis), the formation
of abnormal fluids, the obstruction of blood flow or canalicular pathways, or by
infiltrating adjacent organs.
n
Overview: See Table 80.
Table 80.Sonographic criteria for malignancy
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Tumor appearance Shape
Internal echo pattern
Arrangement
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Vascularization pattern (p. 445)
Regressive changes
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Spot-like pattern
Wheel or basket pattern
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Organ changes (p. 447)
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Associated findings (p. 447)
Branching pattern
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Contours
Echo pattern
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Functional disorders
Abnormal fluid collections
442
Displacement, fixation, infiltration
21.2 Sonographic Criteria for Malignancy
Schmidt, Ultrasound © 2007 Thieme
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Appearance of Tumors
..............................................................................................................
n
Shape:
x
Scalloped (pancreatic carcinoma; see Fig. 442, p. 304)
x
Round (HCC; see Fig. 351, p. 249)
x
Patchy (CCC; see Fig. 352, p. 250)
x
Polygonal, band-shaped, or target-shaped (colorectal carcinoma; see Fig. 663b,
p. 441)
n
Echogenicity, arrangement:
x
Metastases are generally round and hypoechoic, but multiple metastases have a
tendency to coalesce (e.g., hepatic metastases; see Fig.
x
Colorectal metastases are usually hyperechoic, often have a hypoechoic halo,
and are more likely to be multiple than solitary (Fig.
x
Hemangiomas often have an identical appearance to metastases. A feeding vessel or intratumoral vessel can often be detected (but not in metastases;
Fig.
665b).
665).
665a).
ab
Fig. 665a, b Metastases. a Hyperechoic hepatic metastases from colon carcinoma, one with central liquefaction (anechoic regressive cystic transformation,
incipient bull’s-eye sign), no halo. b Hemangioma (H): cloudy hyperechoic pattern,
peripheral halo (arrow). L = liver
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n
Regressive changes:
x
Liquefaction: Foci of liquefaction may occur in benign and malignant tumors
such as colorectal metastases (see Fig.
metastases from breast carcinoma. Carcinoid metastases can even be identified
by their extensive central anechoic zones and hyperechoic rim (see Fig.
p. 440).
x
Calcifications:
– Microcalcifications: may form in older hepatic metastases (Fig.
Fig.
665a) and in testicular and prostatic carcinomas (see Fig. 581, p. 391,
585, p. 393).
and Fig.
– Macrocalcification: may form in colorectal metastases, renal carcinoma, pri-
mary hepatocellular carcinoma (Fig.
– Regressive changes: may produce a “target sign” (hypoechoic–hyperechoic–
hypoechoic, Fig.
sign” (Fig.
adenomas, and renal carcinomas.
668), whereas central liquefaction produces a “bull ”s eye
665a, p. 443); may also occur in large hemangiomas, hepatic
665a), atypical hemangiomas, and
667), and hemangiomas.
662,
666; see also
443
21.2 Sonographic Criteria for Malignancy
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a
identified by their acoustic shadows (S). b Hemangioma (cursors): microcalcification casting a faint acoustic shadow
Fig. 666a, b Microcalcifications.
a Hyperechoic hepatic metastases from
rectal carcinoma. Microcalcifications are
Fig. 667 Microcalcification (arrow)
with an acoustic shadow (S) in a primary hepatocellular carcinoma plus
another tumor (cursors)
x
Differential diagnosis:
– Echogenic gas bubbles with acoustic shadows or reverberations (can mimic
calcifications)
– Echogenic abscess calcification with distal acoustic shadowing
n
Benign tumors with a halo (see Figs. 348 and 349, p. 248, 249):
x
Hepatic adenoma, focal nodular hyperplasia, hemangioma: a pseudocapsule may
be formed by tissue and vascular displacement; rare but possible
x
Abscess: hyperechoic pyogenic membrane. Rarely, abscesses may have a hypoechoic halo.
n
Malignant tumo rs with a halo:
x
Primary organ carcinoma:
– Hepatocellular carcinoma: A hypoechoic halo is somewhat unusual.
– Renal cell carcinoma (Fig.
Fig. 668 Hepatic metastasis from a
carcinoma of the small intestine (arrows):
target sign. Associated finding:
echogenic gallbladder (GB)
669): peripheral vascular rim, also internal vessels
444
21.2 Sonographic Criteria for Malignancy
Schmidt, Ultrasound © 2007 Thieme
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Fig. 669 Renal cell carcinoma
(T): delineated from the rest of
the renal parenchyma (K) by a
peripheral vascular rim. The
combination of peripheral and
internal vessels is suggestive of
malignancy
x
Metastasis: A hypoechoic halo is consistently present (“halo sign”), representing
a zone of intense tumor-cell proliferation (see Fig.
metastases may occasionally show a changeable halo sign; this is not useful
for differentiating colorectal metastasis from hemangioma (see Fig.
Vascularity
..............................................................................................................
n
There are still no definitive sonographic criteria for the reliable benign–malignant
differentiation of tumors. This probably relates to varying patterns of tumor angioneogenesis and changes in the original organ vascularity. Attempts have been
made to define typical malignancy criteria for specific organ tumors. To date, it
has been possible to establish definite malignancy criteria for only a few tumor
types. Examples are renal tumors and lymph nodes (see below).
n
Vascularization patterns in benign tumors:
x
Hepatic adenoma : hypervascular (see Fig. 349, p. 248)
x
Focal nodular hyperplasia: hypervascular with a typical spoked-wheel pattern
(see Fig.
x
348, p. 248)
Leiomyomas, GIST tumors: no detectable intratumoral vessels (Fig. 670)
332, p. 240). Colorectal
665, p. 443).
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Fig. 670 Tumor of the gastric wall (T):
benign? malignant? CDS shows no
peripheral or intratumoral vessels. FNAB
and histology : leiomyoma. L = liver
n
Vascularization patterns in malignant tumors: depend on the tumor type and
affected organ. There are no patterns of vascularity that are specific for a particular
tumor (although hepatic tumors may show typical patterns in the various phases
of contrast-enhanced sonography: early arterial, arterial, venous, and portal
venous). Nevertheless, three vascularization patterns have been identified that
are commonly associated with malignant tumors (after Tanaka):
x
Branching pattern (Figs. 671 and 672): observed in HCC and other tumors
(e.g., lymph nodes, where the wheel pattern is also common)
x
Basket or wheel pattern (Fig. 672a): illustrated by hepatocellular carcinoma
with peripheral vascularity
445
21.2 Sonographic Criteria for Malignancy
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x
Spot-like pattern (Fig. 673; see also Fig. 661b, p. 440): This is the most com-
monly seen pattern of angioneogenesis and is strongly suggestive of a malignant process.
x
Only arterial tumor vessels are indicative of malignancy.
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ab
Fig. 671a, b Well-differentiated primary hepatocellular carcinoma. a B-mode
image: elliptical tumor (arrows). Harmonic imaging. b CDS: spot-like and branching
patterns of increased vascularity. T = tumor
ab
Fig. 672a, b Malignant lymphadenopathies. a Malignant cervical lymph node
(endometrial carcinoma). CDS: elliptical tumor with multiple intratumoral vessels
and avascular foci; subcapsular vessels (wheel pattern). b Malignant cervical lymph
node (acute lymphatic leukemia). CDS : branching pattern (arterial vessels only)
ab
Fig. 673a, b Large bowel obstruction due to a tumor stricture (T). a B-mode
image: nonhomogeneous mass filling the bowel lumen, with prestenotic dilatation
and thickening of the bowel walls (BW). b CDS: spot-like pattern of aberrant tumor
vessels
446
21.2 Sonographic Criteria for Malignancy
Schmidt, Ultrasound © 2007 Thieme
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Organ Changes
..............................................................................................................
n
Contour changes :
x
Protuberances
x
Irregularities
n
Alteration of tubular structures:
x
Tumor invasion, obstruction, or displacement (e.g., blood vessels, bile ducts)
x
Prestenotic dilatation (e.g., bile duct dilatation)
Deformation or infiltration of vessels (Fig. 674; see also Fig. 371, p. 261) :
x
Portal vein with portal hypertension
x
Hepatic veins in Budd–Chiari syndrome
ab
Fig. 674a, b Budd–Chiari syndrome. a Acute Budd–Chiari syndrome: lymph node
metastases (L) from ovarian carcinoma, completely infiltrating the vena cava (VC)
at the termination of the hepatic veins. b Chronic secondary Budd–Chiari syndrome: diffuse hepatic metastasis from bronchial carcinoma. The hepatic veins are
obliterated as far as the vena cava (VC), which is still patent
Associated Findings
..............................................................................................................
n
Functional impairment (see Fig. 656, p. 437, and Fig. 673, p. 446):
x
Biliary tract obstruction (biliary tumor, pancreatic tumor, gastric tumor)
x
Urinary tract obstruction (gynecologic tumors, intestinal tumors, urothelial
carcinoma)
x
Obstruction of the vena cava
x
Obstruction of the pancreatic duct (pancreatic carcinoma, benign microcystic
cystadenoma)
x
Partial or complete bowel obstruction (urogenital tumors, gastrointestinal
tumors, pancreatic involvement by intra-abdominal metastasis, infiltration or
peritoneal carcinomatosis)
x
Locoregional metastasis
n
Abnormal accumulations of fluid:
x
Pleural effusion (pleural metastases, see Fig. 659, p. 439)
x
Ascites:
– Generalized: with peritoneal carcinomatosis, hepatic metastases
– Circumscribed: with advanced gallbladder tumors, urogenital tumors, or
intestinal tumors
x
Differentiation of benign and malignant ascites: see Figs. 675 and 676 , Table 81
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447
21.2 Sonographic Criteria for Malignancy
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Fig. 675 Characteristic
features of benign (left)
and malignant (right)
ascites (after Meckler)
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ab
Fig. 676a, b Benign and malignant ascites. a Benign ascites : smooth peritoneum
and free-floating small bowel loops (“sea anemone sign”) in a patient with
decompensated hepatic cirrhosis. b Malignant ascites: internal echoes and marked
mesenteric retraction consistent with malignant ascites
Table 81.Sonographic features of benign and malignant ascites
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Benign ascites Malignant ascites
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Anechoic (internal echoes, septa)
Free-flowing Confined (loculated, encapsulated)
Smooth, regular peritoneum Irregular peritoneum, mass
Thin greater omentum Thick, rigid greater omentum
Unconstrained mesentery Retracted mesentery
“Sea anemone” pattern (Fig. 676) Matted loops of small bowel
Thin, mobile bowel wall Thickened, rigid bowel wall
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Occurrence
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Hepatic cirrhosis, pancreatitis,
right heart failure
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
(Anechoic), internal echoes, septa
Adhesions between the bowel and abdominal wall
Nodal and hepatic metastases
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Metastases and tumors of the bowel, pancreas,
uterus, and ovaries
448