Abstract
Day 1 Wednesday 6 December
General Imaging
What to do with incidental renal lesions
Hammersmith Hospital, London, UK
Abstract
Ultrasound (US) is often the initial imaging modality used in the evaluation of renal diseases and detects many incidental lesions. Traditionally these would be further characterised using CT and MR. Despite improvements in B-mode and Doppler imaging, US still has limitations in the assessment of focal renal masses and complex cysts as well as the microcirculation. Imaging with contrast-enhanced US (CEUS) with microbubbles has overcome many of these problems with an increasing number of renal applications and guidelines underpinning their importance. This talk describes microbubble contrast agents and their role in renal imaging. Microbubbles are extremely safe and well tolerated pure intravascular agents that can be used in renal failure and obstruction where CT and MR contrast agents may have deleterious effects. Their intravascular distribution allows quantitative perfusion analysis of the microcirculation, diagnosis of vascular problems and qualitative assessment of tumour vascularity and enhancement patterns. Low acoustic power real-time imaging can be performed without exposure to ionising radiation and at lower cost than CT or MR. CEUS can accurately distinguish pseudotumours from true tumours. CEUS has been shown to be more accurate than unenhanced US, rivals CT in aiding diagnosis of malignancy in complex cystic renal lesions, and can be used to stage Bosniak-type cysts. CEUS is useful in the characterisation of indeterminate renal masses and focal inflammatory lesions in native and transplant kidneys.
Contrast enhanced ultrasound in the assessment of renal lesions
Radiology Department, Plymouth Hospitals NHS Trust, Plymouth, UK
Abstract
Contrast enhanced ultrasound (CEUS) is being increasingly used as a problem-solving tool in the assessment of atypical or difficult to characterise renal lesions. It is relatively quick and easy to perform and can avoid the need for ionising radiation. It is able to accurately detect if there is intra-lesional blood flow which may indicate underlying malignancy. There are limitations to CEUS, particularly in the assessment of small lesions, typically less than 1 cm in size where enhancement can be difficult to confidently assess. We have reviewed the use of CEUS at a tertiary referral centre in the South-West of England. Over a two-year period between June 2015 and June 2017, a total of 454 CEUS examinations were performed. Of these, 141 examinations were for the assessment of a renal lesion. Referrals for CEUS included lesions identified via conventional ultrasound and computed tomography (CT) that required further assessment. We have found that CEUS is able to accurately confirm the presence of benign lesions such as hyperdense cysts and anatomical variants including a column of Bertin. In these cases, patients have avoided further ionising radiation exposure and unnecessary worry through this investigation. If a lesion is deemed suspicious for malignancy following CEUS, it is inevitable the patient will require further investigation with CT, thus ionising radiation is not entirely avoided. We present our local experience of CEUS and an educational review of the beneficial role CEUS has in clinical practice.
Early post-operative ultrasound for renal transplant: What not to miss
1Peninsula Radiology Academy, Plymouth, UK
2Radiology Department, Derriford Hospital, Plymouth, UK
Abstract
Ultrasound (US) is the preferred imaging modality for evaluation of renal transplants in the immediate post-operative period and long-term follow-up. This is namely due to its accessibility, inexpensive and non-invasive qualities. Furthermore, patients can remain monitored on the hospital ward with the scanning performed portably if necessary. Upwards of 3300 renal transplants were performed in the U.K. in the last financial year: 1009 living, 1404 Donation after brain death (DBD) and 934 donation after circulatory death (DCD) with an estimated 5000 or more patients on the waiting list.1,2 At Derriford Hospital, as the tertiary referral centre for the South West, a total of 57 renal transplants were performed within the same time period: 17 living, 18 Donation after brain death (DBD) and 22 donation after circulatory death (DCD). Twenty-one patients (39%) underwent renal ultrasound prior to hospital discharge. If there are concerns in the early post-operative period, ultrasound may be used to evaluate and diagnose complications. The principal aim is to identify those complications which may benefit from urgent surgical intervention. These include renal vein thrombosis, renal artery thrombosis, arterial kink and large perinephric collections. This paper demonstrates typical post-surgical sonoanatomy and identifies common early complications of renal transplant that can be depicted sonographically and are essential not to miss.
References
Sonographic appearances of mid and long term renal transplant complications
1Radiology Peninsula Radiology Academy, Plymouth, UK
2Radiology Derriford Hospital, Plymouth, UK
Abstract
Ultrasound (US) is the preferred imaging modality for evaluation of renal transplants in the immediate post-operative period and long-term follow-up. This is namely due to its accessibility, inexpensive and non-invasive qualities. Upwards of 3100 renal transplants were performed in the U.K in the last financial year. An estimated 5000 or more patients remain on the waiting list.1,2 During the mid and late post-operative period and at routine follow-up, ultrasound may be used to evaluate the transplant and diagnose complications. It is important to understand that different complications occur at different stages following a transplant. The complications seen at this stage are often managed medically or with the assistance of interventional radiology. These include rejection, peri-nephric collections, vascular stenosis, ureteric stenosis, renal calculi, malignancy and recurrence of original pathology. In this imaging review we aim to demonstrate typical post-surgical sonoanatomy and identify common mid and late urological, vascular and neoplastic renal transplant complications seen in the follow-up period.
References
Endocavitary contrast enhanced ultrasound (CEUS): A novel technique for problem solving
Radiology Department, King’s College Hospital, London, UK
Abstract
Contrast enhanced ultrasound (CEUS) is a technique that has developed as an adjunct to conventional ultrasound. CEUS offers a number of benefits over conventional axial imaging with computerised tomography and magnetic resonance imaging, primarily as a ‘beside’ test, without ionising radiation or the safety concerns associated with iodinated/gadolinium-based contrast agents. Intravascular use of ultrasound contrast agents (UCA) is widespread with extensive evidence for effective use. Despite this, the potential utility of UCA in physiological and non-physiological cavities has not been fully explored. The possibilities for endocavitary uses of CEUS are described in this review based on a single centre experience including CEUS technique and utility in confirming drain placement, as well as within the biliary system, urinary system, gastrointestinal tract and intravascular catheters.
Donald MacVicar Brown Keynote Lecture
Future reverberations from past reflections: A glimpse at the full capabilities of ultrasound
Joint Department of Physics and Division of Radiotherapy and Imaging, Institute of Cancer Research and Royal Marsden NHS Foundation Trust, Sutton, UK
Abstract
Compared with other mainstream medical imaging technologies, ultrasound is low cost, transportable, high throughput, safe and comfortable for the patient. It offers excellent 3D soft tissue visibility, good blood flow and other functional information, and high frame rate. Since its commercialisation in the 1960s, it has made enormous contributions to medicine but the potential for further impact is truly exciting. This lecture draws on the author’s work and experience in cancer research to look at recent technical progress in medical ultrasound, and considers some of the physical possibilities as well as technically achievable goals for the next decade. An area that continues to show promise is mechanical property imaging, known as elastography. Different types of mechanical wave travel in tissue at different speeds, and each provides importantly different information about tissue composition and function. Pressure waves (ultrasound) are used to watch the progress of a shear wave and make images of its speed, or to image the tissue strain created by a hand-induced or a physiologically generated stress. It is proving important for diagnosis and assisting treatment of an astonishingly wide range of diseases. In an emerging form of elastography (of which there are many) the methods are combined; the tissue is held under gentle pressure while elastography is used to watch it change over time as fluid between the cells is squeezed out. This allows assessment of the microscopic pores (gaps) in tissue through which fluid can squeeze. Applications include assessment of cancer and conditions such as lymphoedema. Elastography is just one method that takes advantage of new capabilities for transducer arrays, electronics, computers and software for image reconstruction and data processing. These capabilities enable, for example, plane wave imaging at thousands of frames per second, observation of electromechanical wave propagation in the heart, multi-wave assistance of drug delivery, exquisite super-resolution of deep microscopic blood vessels, and optoacoustic imaging which reveals optical pigments such as haemoglobin or melanin, or dyes or nanoparticles introduced intravenously, because they emit sound waves when illuminated by a short (<10 ns) laser pulse. Furthermore, using reconstruction methods that incorporate the physics of ultrasound wave propagation, high-resolution quantitative images may be reconstructed of ultrasound speed, attenuation and scattering. These images hold potential for cancer screening, diagnosis and monitoring, and even quantifying the risk of developing cancer.
MSK Fundamental
Case report: Plantar fibromatosis: Getting to the foot of the problem
1Radiology Department, Saint James’s Hospital, Dublin, Ireland
2Radiography and Diagnostic Imaging, School of Medicine, University College Dublin, Dublin, Ireland
Abstract
Plantar fibromatosis, also known as Ledderhose disease, is a rare, benign, hyperproliferative condition, in which slow growing nodules develop within the plantar fascia. Patients typically present with a palpable lump and associated foot pain. This paper describes the case of a 36-year-old female who presented to the emergency department with a sudden onset of sharp right foot pain when weight bearing and a palpable lump on the plantar aspect of her foot. An ultrasound examination was performed to image the lump. The ultrasound examination revealed a firm, well defined, heterogenous and hypoechoic nodule, measuring 10.7 mm × 3.1 mm. The nodule demonstrated no internal vascularity and had direct involvement with the plantar fascia. This ultrasound examination resulted in a definitive diagnosis of plantar fibromatosis; no further imaging was required. The ultrasound features identified were used to distinguish this lesion from differential pathologies, such as a ganglion cyst or fibrosarcoma. Plantar fibromatosis can cause persistent foot pain, therefore prompt diagnosis is essential to allow treatment to commence. Ultrasound is cheap, efficient and readily available, it is recognised as the gold standard for first-line imaging in the investigation of palpable plantar lumps. It offers high-resolution imaging, often making a definitive diagnosis of plantar fibromatosis, as in this case. When suspicious image features are seen, further imaging and biopsy is recommended, to rule out a lesion of neoplastic nature.
Ultrasound evaluation of rectus abdominis and lumbar multifidus muscles in individuals with postural changes
Medical Imaging and Radiotherapy Department, IPC, Coimbra Health School, Coimbra, Portugal
Abstract
Postural changes are well present in society. These pathologies, when not congenital, come from the practice of bad posture habits and lack of physical exercise. The cases of hyperlordosis, kyphosis and scoliosis are often diagnosed in adulthood when they are in a more advanced state. When detected early, they can be applied or treated surgically. The postural muscles are muscles responsible for stabilisation and the various actions of the spine. MRI is the best method of muscle evaluation; however, ultrasound is a method less expensive and also has a great ability to assess muscle characteristics. The aim of this study is to characterise the muscular echography of two postural muscles in healthy individuals and in individuals with postural alterations (namely hyperlordosis). Thirty young adults were submitted to an ultrasound evaluation of the rectus abdominis and multifidus lumbar muscles in rest and contraction and an angle measurement of the lumbar spine through photometry equipment. They were divided in two groups: one of control and other with non-congenital posture, with a sample composed of 11 participants with postural deviations, and 19 without. A total of 360 images were analysed with Image J software to obtain muscle thickness and echo intensity values from the two muscles in two conditions and the angle of the lumbar spine was calculated also for all participants. There were significant differences between the rest and contraction on muscle thickness and echo-intensity of both muscles. There were no significant differences between the two groups of participants and there was no correlation between the angle and the ultrasound measurements. The postural deviations do not influence the ultrasound characteristics of the studied muscles. However, more studies must be performed to analyse the relation between the lumbar and abdominal muscles and postural changes.
Professional Issues
Optimising your existing radiology service
Lesley Wright Improvement, Leeds, UK
Abstract
There has never been greater pressure on Radiology and Ultrasound services. Radiology and Sonography staff are coping with a combination of workforce shortages and conflicting lead-time targets for different priorities of patients including: 1-hour stroke, two-week wait for cancer, 31/62 cancer pathway, new 28-day NICE cancer diagnosis, six-week diagnostics for 18-week pathway, 4-hour emergency care and the need to keep in-patient stays as short as possible. We make significant investment in continuous professional development to ensure staff have the most up to date training to diagnose a variety of conditions for our patients, but do we put enough investment into developing staff to diagnose the long waiting times in radiology? Radiology staff are understandably ‘firefighting’ to reschedule previously ‘scheduled’ patients and current ‘emergency or urgent’ patients. Consequently, many patients experience long lead times (waiting times). Faced with an overwhelming backlog and long waiting times, it is easy to understand why radiology staff believe there is ‘lack of capacity’ in their system.1,2 Therefore, it is important that we diagnose the reason for the backlog and long waiting times. If we are to get support for developing services, demonstrating that we have addressed service optimisation is key and will help develop your business case. This presentation will identify how to optimise your current service and understand the cause of the constraints.
References
Ultrasound referrals: Good, bad, does it matter?
1Ultrasound, Hull and East Yorkshire Hospitals NHS Trust, Hull, UK
2Diagnostic Imaging, University of Leeds, Leeds, UK
Abstract
Diagnostic imaging is one of the fastest expanding services with a rise in demand of 40% within the last decade. Sources report that up to 40% of radiological examinations are unnecessary and radiology services are generally overused by GPs. In a service which is already under strain, departments are often not keeping up with demand. In 2015, BMUS released referral guidelines in attempt to support better use of ultrasound services. The aim of this audit was to determine whether GP referrals for abdominal ultrasound scans are appropriate according to BMUS guidelines. The objectives were (1) to demonstrate whether the BMUS guidelines had any implications for volume and detection of clinical findings; (2) to assess agreement between sonographers using the BMUS guidelines. Three hundred referrals were reviewed using retrospective cohort analysis. Data collected included referral details and quality assessment scores. Each referral was individually evaluated by three observers with variable experience (range 2–22 years). The audit showed that 27.9% of referrals were deemed inappropriate. Of these, 19% were rejected as inappropriate for imaging, 44% were redirected to a more appropriate modality and 37% were rejected with no clinical question. Inter-observer percentage agreement ranged from 57.9 to 69.9%. 45.3% of examinations produced a clinical finding. Most referrals in this study were appropriate. Almost half of inappropriate referrals were because another imaging investigation would be optimum. Approximately one-third of referrals did not directly ask a clinical question; better-quality decision making is needed. Moderate agreement between observers is demonstrated, supporting the notion that the BMUS guidelines can be used when vetting referrals. Little association between referral quality and diagnostic outcome is seen in this study. The guidelines will reduce demand but it cannot be guaranteed that this will not be at the expense of missing serious clinical findings. Proper channels of communication between ultrasound departments and GPs are essential.
Physics
A simple method for measuring ultrasound beam slice thickness with depth to assess changes in lens properties
Christie Medical Physics and Engineering, Christie NHS Foundation Trust, Manchester, UK
Abstract
Any difference in slice thickness with depth between two ultrasound probes may not be visible in standard in-plane phantom testing but may have an impact upon what is clinically visible. The aim of this study was to demonstrate a simple, reproducible method for assessing slice thickness with depth using a standard phantom. The intention was not to provide a definitive slice profile but a reference to assess time-based changes in slice thickness profile due to wear. A linear array probe was drawn across a Gammex 403 GS phantom orientated such that wires of known depths are either present or absent in the field of view depending on the slice thickness of the beam at that depth. The probe was manipulated using a bespoke jig with a screw thread mechanism that allowed 0.5 mm positional resolution. Images acquired every 0.5 mm were exported for offline analysis. A MATLAB script was written to plot the received signal intensity from each wire against relative probe position and fit a curve to each plot. The FWHM of each fitted curve was assumed to be a robust estimate of the slice thickness at each wire depth. Slice thickness profiles were calculated from an average of three measurements on several machines in separate sessions. The results obtained demonstrated good reproducibility of the method at all available wire depths, both between individual measurements in a single session and between repeat sessions performed with the same equipment on different days. Obtaining, exporting and analysing the images required around 20 minutes. The study demonstrated proof of principle that ultrasound beam slice thickness profile with depth can be reproducibly measured using the described method. The test duration and simplicity is suitable to be incorporated into acceptance testing of ultrasound probes as it involves a standard phantom and simply engineered jig.
Elastography in carotid disease
University Hospitals of Leicester NHS Trust, Leicester, UK
Abstract
It has been well established that ageing and diseases such as stroke, hypertension, diabetes mellitus and cardiovascular disease can affect carotid artery elasticity. Various ultrasound techniques including dynamic B-mode, tissue Doppler and elastography imaging have been used to assess biomechanical characteristics. Strain-based elastography techniques have predominately been applied to assess carotid plaques and studies have compared against histological and B-mode characterisation. This talk will provide an overview of different elastography techniques and focus on the application of a state-of-the-art Supersonic Shear Wave Elastography (SSWE) technique for identification of the unstable carotid plaque. Although many studies have demonstrated the clinical benefit of SSWE for a variety of applications, particularly the liver, breast and thyroid, there are only a few recent studies on vascular applications. Carotid plaque imaging is a challenging clinical application considering the small heterogeneous tissue size, the dynamic environment due to pulsatile blood flow, thin vessel walls, non-linear tissue elasticity and shear wave propagation model assumptions which may not be valid. Despite these challenges, we hypothesised that SSWE imaging of carotid plaque can help identify the unstable plaque. Our clinical and experimental studies in Leicester have demonstrated the feasibility of SSWE for assessing Young’s modulus of carotid plaque. We highlight the clinical potential of SSWE imaging and suggest that SSWE may be superior to B-mode greyscale median (GSM) for identification of carotid plaque vulnerability. There are exciting developments in ultrasound technology which are relatively easy to implement in the vascular clinic and provide new information to address important clinical questions.
The reliability of echocardiographic measurements in clinical research
Leeds Teaching Hospitals NHS Trust, Leeds, UK
Abstract
The reliability and validity of an instrument determines the confidence that can be placed in the measurements produced. Validity is an assessment of whether an instrument measures what it aims to measure; reliability is the ability of the instrument to consistently reproduce a measurement. Intra-class correlation coefficients (ICC) assess the consistency between quantitative measurements, in terms of reliability, reproducibility and validity. Echocardiography is routinely used to assess and monitor LV size and function, but may be less accurate than other methods. The aims of this study were (1) to critically assess intra- and inter-observer variability in the analysis of clinical research echocardiograms; (2) to demonstrate the validity of the measurements used. Echocardiogram data used in a clinical research study were reanalysed to check intra-observer variability, with an interval of one week between analyses. Data were also analysed by a second experienced and accredited cardiac physiologist who was also blinded to the patient, date and intervention. ICC for intra-observer variability was 0.957 (95% confidence interval 0.824–0.989). ICC for inter-observer variability was 0.989 (95% confidence interval 0.971–0.996). These results indicate a good level of consistency for both intra- and inter-observer measurements.
Day 2 Thursday 7 December
Obstetrics
Assessing the accuracy of ultrasound estimation of gestational age during routine antenatal care in in vitro fertilisation (IVF) pregnancies
Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
Abstract
The objective of this study was to assess the accuracy of the current standard Crown Rump Length (CRL) reference range used locally to estimate gestational age in early routine antenatal care. Routinely collected retrospective data from 178 IVF pregnancies seen for antenatal care at the Royal Devon and Exeter NHS Foundation Trust over the period 1 January 2006 to 1 January 2016 were identified. We compared ultrasound calculated CRL Gestational Age (GA) taken at the routine First Trimester Screening Clinic (FTSC) with the ‘true’ GA calculated from the known IVF fertilisation date. The results demonstrate a systematic overestimation of GA by ultrasound using the Robinson and Fleming ultrasound reference chart (as recommended by British Medical Ultrasound Society and UK national screening committee/Fetal anomaly screening programme) when compared to IVF GA. The mean overestimation was 3.0 days (95% CI: 2.7–3.4), p < 0.0001. A range of alternative ultrasound reference charts also generated a systematic overestimation, ranging from 1.6 to 2.9 days, p < 0.001, p < 0.0001 for each. The current CRL reference chart used in routine clinical practice would appear to systematically overestimate GA by an average of three days when assessed in IVF pregnancies. This finding was repeated in alternative available reference charts. While these differences may appear slight, the systematic error we identified may have potential implications on the accuracy of GA estimation in routine antenatal care, particularly when related to those pregnancies at risk of pre-term delivery or growth retardation. Further research is needed to confirm our findings in larger, non-IVF cohorts and may lead to the need for a new CRL reference chart to be developed.
Identifying factors which influence the antenatal detection of congenital heart defects
1Antenatal Clinic, North Bristol Trust, Bristol, UK
2Medical Ultrasound, University of the West of England, Bristol, UK
Abstract
Early identification of Congenital Heart Disease (CHD) provides significant benefits for babies and their families. This study aimed to evaluate the Trust’s detection rates of congenital heart disease (CHD), to explore factors that may affect these rates and finally to explore the sonographers attitudes towards scanning the fetal heart. This triangulation method provided a more holistic picture of the current service and identified future training needs of the department. All pregnancies affected with CHD between 1 January 2009 and 31 December 2014 were identified and data obtained on those diagnosed in the antenatal period and those diagnosed only in the postnatal period. The detection rates for all types of heart defect were recorded with the main focus being on the four specific conditions that make up the FASP serious cardiac anomaly group: HLHS, AVSD, TGA, TOF. Sonographers’ attitudes towards assessing the fetal heart were explored by means of a survey. Ethics approval was obtained. There were a total of 355 cases of CHD reported after exclusions. The overall antenatal detection rate increased significantly over the study period from 45 to 63%. Detection rates were considerably higher rising from 70 to 93% for the four FASP cardiac auditable conditions. There was a response rate of 79% from the online survey. Themes identified were issues of individual litigation, difficulties in scanning women with raised Body Mass Index (BMI), sonographer’s confidence and training. There is a clear improvement in the antenatal detection which exceeds the minimum 50% target required by FASP. Factors such as the time of day for the scan, the variation in the machine used and high maternal BMI did not adversely affect the antenatal detection rates. The study has also highlighted the importance of continual professional development, feedback, ongoing training and audit. The role of cardiac champions was also well recognised by the sonographers.
Head and Neck
Case report: Ultrasound detection of a left supraglottic tumour
Hull and East Yorkshire NHS Trust, Hull, UK
Abstract
A 68-year-old male was referred by his GP for an ultrasound examination of his neck with the presenting symptoms of tender left mid anterior triangle lymph node palpable. Additional information: the patient is a smoker, has been experiencing left ear pain and is long-term hypothyroid. The patient had a high frequency ultrasound examination of the neck performed using the standard 7 sweep technique. Ultrasound revealed an ill-defined mass arising from within the larynx. This mass was hypoechoic and measured 19 × 15 × 19 mm and appeared to be closely related to the left false vocal cord. Appearances were highly suspicious of malignancy. There was no abnormal lymphadenopathy demonstrated within the neck. No masses or suspicious features were seen in the area of concern. The patient was informed that there was an area within his larynx that would need further investigations and that an urgent referral to ENT would be advised to the GP. The patient had a staging CT of the neck and chest performed. The conclusion of the CT report read: ‘The imaging appearances remain highly suspicious for a left-sided supraglottic tumour with no lymphadenopathy or distant metastatic disease identified. If malignancy is proven suggested radiological staging would be T3 N0 M0.’ The patient underwent a microlaryngoscopy; biopsy revealed carcinoma in situ of the left false cord. This cancer has been staged as T4aN0M0. The patient is to have radical chemoradiotherapy to both sides of the neck; he has a RIG in situ. Ultrasound is not routinely used to assess the larynx; however, this case shows that using the standard 7 sweeps of the neck for ultrasound examination of the neck can reveal incidental cancers of the larynx.
MSK Advanced
A framework for requesting, performing and reporting shoulder diagnostic ultrasound scans, incorporating a novel approach to quantifying tendinopathic findings
1School of Healthcare Sciences, Cardiff University, Cardiff, UK
2Research Institute for Primary Care and Health Sciences, Keele University, Keele, UK
Abstract
Ultrasound scanning of the shoulder can provide valuable diagnostic information to guide the management of the patient with shoulder pain. However, this is partially dependent upon (i) well-reasoned integration of the scan findings into the patient care pathway and (ii) images being generated, evaluated and interpreted in a systematic manner, including more subjective elements such as tendinopathic findings. This abstract outlines a framework designed to address these challenges. Framework part 1: The referral form is designed to enable the referring clinician to support the sonographer with undertaking a clinically meaningful scan. It (i) provides a brief precis of the indications for (and not for) requesting a shoulder ultrasound scan and (ii) prompts for relevant clinical information pertinent to the suspected pathology. Framework part 2a and 2b: Part 2a is based upon the ESSR shoulder guidelines1 and was adapted from the shoulder ultrasound training and assessment paper by Smith et al.2 It provides the sonographer with a recommended checklist to guide performance of the scan, including key pathological characteristics and their definitions. As such it supports the sonographer with arriving at a well-reasoned differential sonographic diagnosis. It also proposes a novel algorithm for characterising tendinopathic change comprising tendon thickness, echogenicity and echotexture with the contralateral shoulder used as a pseudo-comparator. This form aligns with the subsequent scan recording pro forma (part 2b), whereby mirroring of the terminology and structure help to ensure consistency. Framework part 3: The scan reporting pro forma mirrors part 2b, but also enables the sonographer to place the findings in context of the clinical information provided in Framework part 1, along with providing feedback regarding future scan requests. It is hoped that this framework will facilitate referring clinicians and sonographers to support each other in providing optimal patient care alongside finite imaging resources.
References
Case report: Adult meningocele – an uncommon ultrasound finding
1University College Dublin, Dublin, Ireland
2Radiology, Connolly Hospital Blanchardstown, Dublin, Ireland
Abstract
Meningoceles are herniations of meninges, through an embryological defect in the neural arches of the vertebrae. Classified as spina bifida cystica, meningoceles are a rare type of closed neural tube defect, which is covered by skin. This case study demonstrates the possible ultrasound findings of an adult meningocele. A 39-year-old male presented at the emergency department with a palpable, tender mass on his left lateral chest wall. He stated that this was a new swelling and complained of unexplained weight loss over the last six months. He has a history of spina bifida. Ultrasonography revealed a complex cystic mass with internal septation and soft tissue components. Colour Doppler interrogation demonstrated minimal vascularity within the soft tissue components and pulsation artefacts within cystic portions of the mass. Additionally, a solid finger-like projection was identified at the inferior aspect of the mass. Due to posterior shadowing from the spine, the deep extension of the mass could not be fully evaluated. A previous renal computed tomography scan reported an incidental finding of a meningocele five years prior. Most meningoceles are detected and surgically treated in the antenatal or perinatal stages. Adult meningoceles are much rarer and patients often present with pain or neurological symptoms. Ultrasound is useful for assessing cyst contents which may include fibrous bands, aberrant nerve roots or glial nodules. Sonographers should be aware of normal pulsations of cerebrospinal fluid which can differentiate meningoceles from other complex cystic lesions. While ultrasound can be useful here, it is difficult to assess the entire extent of the mass. In addition to plain spine radiographs, magnetic resonance imaging is often recommended for its superior anatomical visualisation and would contribute to a more definitive diagnosis. Surgical treatment for adults is considered when there are severe symptoms of paraparesis or bladder dysfunction.
Case report: Soft tissue sarcoma masquerading as a haematoma
Sheffield Teaching Hospitals, Sheffield, UK
Abstract
Patients presenting with a soft tissue lump are commonly encountered in clinical practice. The vast majority of these are benign with one study reporting 95% of patients from primary care referred for imaging of a potential sarcoma had either benign or non-cancerous lesions.1 Sarcomas account for around 1% of all primary adult soft tissue masses.2 Although relatively rare, there were 3298 new diagnoses of soft tissue sarcomas and 531 new diagnoses of bone sarcomas in the UK in 2010 with the overall incidence of sarcomas increasing from 35 per million to 45 per million in the period from 1996 and 2010.3 This case study reports on a soft tissue sarcoma that was initially reported as a haematoma. The patient presented to their GP with a three-month history of a soft tissue thigh lump following trauma that was not painful or increasing in size. An initial ultrasound scan reported the superficial soft tissue mass as a probable haematoma and recommended a rescan in six weeks. This showed no interim changes. The patient presented back to their GP eight months later with the same lump increasing in size and painful. A further ultrasound reported an irregular, hypervascular soft tissue mass and an MRI scan discovered a soft tissue mass with peritumeral oedema suspicious of a malignancy. The patient was referred to the local Sarcoma MDT with an ultrasound-guided biopsy confirming the diagnosis of a myxofibrosarcoma. The patient had this subsequently excised. Despite the ultrasound findings correlating with the clinical details, this case demonstrates that the diagnosis of a haematoma can be difficult and other differential diagnoses such as soft tissue sarcomas should also be considered.
References
Case report: A simple lipoma - Not so simple after all!! A case of myxoid liposarcoma
Radiography and Diagnostic Imaging, School of Medicine, University College Dublin, Dublin, Ireland
Abstract
A 24-year-old male was referred to the imaging department due to the presence of a soft tissue mass growing on the inner left thigh. The patient had become increasingly aware of the lump due to pain. Focal localised scanning was undertaken of the soft tissue mass and its surrounding area. The ultrasound examination demonstrated a well-defined, smooth, heterogenous lesion with linear septations 8 cm × 6.8 cm × 3.9 cm located between the deep subcutaneous tissue and the muscle. Internal vasculature was detected but no gross hyperaemia. The findings were suspicious of malignant degeneration in a pre-existing lipomatous lesion so the patient was immediately referred for further investigations. MRI imaging of both thighs was performed and again the suspicious lesion was identified. Surgical biopsy was performed which identified the lesion as a high-grade myxoid liposarcoma. Pre-operative radiotherapy was performed on the lesion which was subsequently surgically removed. Sonography is usually the diagnostic imaging method of choice in the initial assessment of soft tissue lesions whose origin and nature are not fully understood. The primary goal for the imaging referral was to confirm the presence of a mass and to assess its extent in preparation for possible intervention and treatment. Ultrasound can contribute to effective management of such cases when combined with MRI, laboratory and histological assessment.
Vascular
Future of carotid disease assessment
1IVS Ltd, Manchester University NHS FT, Manchester, UK
2Academic Surgery Unit, University of Manchester, Manchester, UK
Abstract
The velocity criteria endorsed by the Vascular Surgical Society and the Society for Vascular Technology for the assessment of carotid disease are now 10 years old. Our knowledge of carotid artery disease has progressed significantly since 2007 yet, the criteria have remained unchanged. Are we now at the point of needing new criteria? Current European Society of Vascular Surgery (ESVS) guidelines recommend carotid endarterectomy (CEA) for a symptomatic severe carotid stenosis (>70%; NASCET criterion). However, in asymptomatic patients, the severity of carotid stenosis is a poor predictor of stroke, with a <2% risk of ipsilateral stroke per year. Despite these differences, we assess symptomatic and asymptomatic carotid disease using the same stenosis velocity criteria, which potentially may be doing some patients a disservice. A proportion of symptomatic patients may have unnecessary surgery as their actual risk of a further ischaemic event could be lower than the risk associated with a high-grade stenosis. Conversely, an asymptomatic patient may have significant risk of an ischaemic event as they firmly fall within that 2% of patients. Therefore, there is a need for personalised risk assessment. In recent publications, groups have focused on assessing the vulnerability of the carotid plaque. Techniques documented include, plaque volume, grey scale median, juxta-luminal black area, neovascularisation and elastography. This talk will present the current state of research and perhaps outline the future for carotid disease assessment.
Doppler velocity accuracy
United Lincolnshire Hospitals NHS Trust, Lincoln, UK
Abstract
The implementation of Doppler QA is patchy. This may be due to the availability of expertise and the expensive test equipment required. However, the accuracy and linearity of Doppler velocity estimation is critical to patient management. The aim of this work was to explore the options for assuring Doppler velocity accuracy. The Medical Devices Directive requires manufacturers to provide accurate and stable measurements, taking account of the intended purpose and to state the limits of accuracy. Suppliers were therefore asked for measurement accuracy specifications and methods of assurance. Measurements were made in the field using a flow phantom and a string phantom. No suppliers were able to supply the requested information on first demand; at the time of writing we are still awaiting responses from some suppliers; one supplier has refused to supply information. Current responses include velocity accuracy specifications ranging from ±5% to ±15% and assurance methods using a variety of phantoms. Some suppliers claimed accuracies well within specification (2–3%) during their own testing. Testing is performed at relatively low velocities compared to those encountered in clinical practice and no testing of linearity was reported. Tests with both phantoms showed good agreement with set mean velocities. It is concerning that suppliers are largely unable to provide assurance of Doppler velocity accuracy on demand, one implication being that customers are not asking for this information at the procurement stage. Manufacturers’ assurance methods are not standardised, so that Doppler velocity accuracy may vary between them, having potentially serious implications for patients. String and flow phantoms differ in the characteristics of the resulting Doppler spectra and care is required in using them to assess accuracy.
Ultrasound shear-wave elastography (SWE) of the carotid arteries in patients with spontaneous coronary artery dissection (SCAD) versus healthy volunteers
University of Leicester, Leicester, UK
Abstract
Spontaneous coronary artery dissection (SCAD) is a rare but potentially life-threatening condition, mainly affecting women, sometimes around the time of pregnancy. The aim of this study was to evaluate the Young’s modulus (YM) of the common carotid artery (CCA) wall using shear wave elastography (SWE) in SCAD patients and healthy volunteers to assess whether SWE could be used as a novel biomarker for SCAD. Following Medical Ethics approval and informed consent, 127 women (89 SCAD and 38 healthy volunteers) underwent SWE scanning of the CCA using a Supersonic Imagine Aixplorer ultrasound scanner and L15-4 probe. Cine-loop data were analysed by a blinded observer, who measured mean YM in five consecutive frames within 2 mm ROIs; two positioned on the anterior wall and two on the posterior wall. Mean YM estimates were compared between SCAD patients and volunteers, and between measurements from the anterior and posterior vessel walls. Intra-frame variability was assessed by calculating the co-efficient of variation (CV). There was no significant difference in YM between SCAD patients (YM = 54 kPA 95% Confidence Interval 49–59) and healthy volunteers (YM = 56 kPa, 95% CI 51–61; p = 0.60). The YM for the anterior wall was 6.5 kPa (9.9%) higher than the posterior wall. The inter-frame CV for the anterior wall estimates (CV = 23%) was lower than for the posterior wall (CV = 30%). The YM of the CCA in SCAD patients is similar to those in healthy volunteers suggesting that changes in arterial compliance are not a major factor in the pathogenesis of SCAD. The difference in YM between the anterior and posterior wall is attributed to an artefact of the SWE technique that has not previously been reported and requires further investigation. Variability of YM estimates was satisfactory, confirming the clinical feasibility of SWE for assessment of vessel elasticity.
Illiac endothelial fibrosis
St George’s Vascular Institute, St George’s University Hospital NHS Trust, London, UK
Abstract
Endofibrosis (EF) of the iliac arteries is a flow-limiting condition typically seen in highly trained endurance athletes with cyclists being the most affected category. The data to inform everyday clinical management are weak and therefore we have formed an international group of experts (INSITE) to explore areas of consensus and disagreement concerning the diagnosis and management of patients with suspected EF. The results of a first consensus highlighted that an exercise test (measuring pre- and post-exercise ankle-brachial pressure index (ABPI)) was the most appropriate way to confirm or exclude EF. Ultrasound may be a useful tool for the diagnosis of EF; however, established diagnostic criteria are lacking. We performed a prospective study to define the role of ultrasound in the diagnosis of EF. Thirty-seven athletes (74 limbs) were referred to our department with suspected EF. All patients had a pre- and post-exercise colour Doppler ultrasound (CDU) of the iliac arteries and ABPI. Doppler waveform, peak systolic velocity (PSV) and end-diastolic velocity (EDV) were assessed pre- and post-exercise. EF was diagnosed with CDU in 24 athletes (29 limbs). Arterial wall and course abnormalities were detected at rest in 20 (67%) symptomatic limbs of athletes with EF and four (22%) symptomatic limbs of athletes without EF. Post-exercise abnormal waveforms of the stenotic/damped type were seen in the iliac arteries in all 29 limbs of athletes diagnosed with EF. These waveform changes were accompanied by high PSV (>350 cm/s) and EDV (>150 cm/s), with (n = 10; 34%) or without (n = 19; 66%) evidence of reduced arterial lumen calibre. Some 17 athletes with EF underwent surgery with endarterectomy and patch angioplasty. Intraoperative findings confirmed the ultrasound findings. Colour Doppler ultrasound can be used to detect EF. Larger studies are needed to confirm suggested diagnostic criteria.
Case report: Budd-Chiari Syndrome: A rare but important cause of raised liver function tests
1Diagnostic Imaging, School of Medicine, University College Dublin, Dublin, Ireland
2Radiology, Cork University Hospital, Cork, Ireland
Abstract
A 25-year-old female patient presented to the emergency department. The patient had known primary sclerosing cholangitis on a background of ulcerative colitis. On this presentation there was an acute elevation in her liver enzymes. The patient was also vomiting and experiencing tender right upper quadrant (RUQ) pain. The patient was referred for ultrasound to assess for an acute cause of hepatitis. The lumen of the right and middle hepatic veins was echogenic and demonstrated no flow indicating thrombosis of these vessels. The left hepatic vein demonstrated some flow but eccentric thrombus was noted. Non-occlusive thrombus was also noted in the portal vein. There was no evidence of portal hypertension or collateral formation. The echotexture of the liver was heterogenous and there was ascites present. A diagnosis of Budd–Chiari syndrome was given based on these ultrasound findings. This was confirmed by CT. This was an acute form of Budd–Chiari and for this reason there was no evidence of collateral vessels, which are very defining of Budd–Chiari. However, the patient was symptomatic and had ascites and a heterogenous liver, which are not specific to Budd–Chiari but closely relate to an acute onset. Given the patients history of ulcerative colitis, a thrombogenic diathesis, particularly in acute flare up is the most likely underlying cause of the patient’s Budd–Chiari. The patient commenced anticoagulation therapy and a full resolution of hepatic vein patency was noted on MRI one week post-commencement. Ultrasound was able to definitively diagnose Budd–Chiari in this patient in a timely manner. Given the importance of timely intervention for a good prognosis, it is imperative that hepatic vein patency is interrogated in all patients presenting with raised LFTs when no other causative factor is identified.
Young Investigator
3D spatial compounding improves ultrasound image quality in gynaecological image-guided radiotherapy
Joint Department of Physics and Imaging, Institute of Cancer Research and Royal Marsden NHS Foundation Trust, Sutton, UK
Abstract
The poor image quality of current online imaging methods makes it challenging to localise the uterus during radiotherapy. A novel method using commercially available transducer-tracking technology to create spatially compounded 3D ultrasound (US) images was developed. Image quality was evaluated as a function of the number of US images used to create a compounded image in a phantom and in vivo. 3D-US images were acquired from different positions in an US quality assurance phantom (seven images), and transabdominally of the uterus from four volunteers (six images/imaging session/volunteer; 21 total sessions), and from four cervical cancer patients (four images/fraction/patient; 15 total fractions). Images were transferred onto a common frame of reference. Compounded images (imCs) were created by averaging two, three, four, five, six or seven individual images. For the phantom study, differences in (1) contrast-to-noise ratio (CNR) in four grey-scale targets and (2) spatial resolution was determined between the non-compounded image and each imC using ANOVA. For the in vivo study, three observers independently ranked randomised sets of images (non-compounded and imCs) for image quality of the uterus (1 representing poorest image quality). A Wilcoxon signed-rank test was used to measure differences in mean rank (MR) of three observers between the compounded and non-compounded images. In the phantom study, the CNR of imCs was significantly greater by a range of 35–104%, depending on the number of individual images in the ImC and grey-scale target assessed. Spatial resolution was unchanged compared with non-compounded images. In the in vivo study, the non-compounded image had significantly poorer MR than all imCs, with mean (range) MR of 1.3 (1–2.67) and 1.6 (1–2.33), respectively. MR increased significantly with increasing number of 3D-US images used up to three images and five images for patient and volunteers, respectively. Three-dimensional spatial compounding improves US image quality compared with non-compounded images in both the phantom and in vivo.
Optic nerve sheath evaluation by ultrasound
Medical Imaging and Radiotherapy Department, IPC, Coimbra Health School, Coimbra, Portugal
Abstract
The human eye is one of the most complex organs in our body. The eyeball is located in the anterior region of the orbit. The lens divides the globe into two segments: anterior and posterior. The sheath of the optic nerve passes from the posterior globe to the brain. The fact that the eye is a liquid-filled, superficial structure allows an optimal appreciation of the ocular structures on ultrasound. There has been an increase in the use of this modality in the evaluation of the diameter of the optic nerve sheath (ONSD). The purpose of this study was to analyse the reproducibility of measurements of the diameter of the sheath of the optic nerve, characterise the nerve sonographically, verifying that without the existence of associated symptomatology, whether this measurement is affected or not, throughout the variation of the body mass index, by the values of blood pressure or blood glucose. A total of 370 ONSD images were collected from 84 individuals, divided into two groups. The ICC was obtained to evaluate the reproducibility of the measurements. The correlation of variables and samples was also evaluated with the Pearson test and the Student’s t-test for independent samples. The left ONSD ICC showed satisfactory reproducibility (0.73). BMI and age showed a positive correlation with AP (p < 0.05). No significant differences were found between the group with pathology (myopia, astigmatism or hypermetropia) and without pathology. Ultrasonography can be used to assess the ONSD, because the left ONSD ICC shows satisfactory reproducibility and can help in new ocular diseases evaluation.
Brain tissue pulsation measurements for diagnosis of acute stroke: A pilot study
1Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
2National Institute for Health Research, Leicester Biomedical Research Centre, University of Leicester, Leicester, UK
3Department of Medical Physics, University Hospitals of Leicester NHS Trust, Leicester, UK
4University of Washington, Seattle, USA
5Nihon Kohden, Tokyo, Japan
6Broadview Laboratories, Seattle, USA
Abstract
Normal brain tissue pulsates with the cardiac cycle, but whether ultrasound measurement of tissue pulsations could provide a non-invasive biomarker for intracranial pathology has yet to be explored. Here we compare Doppler ultrasound brain tissue pulsation measurements from healthy volunteers and stroke patients to assess whether changes in intracranial pulsatility are observed in acute stroke. Brain tissue motion was measured using Doppler ultrasound through the forehead and temporal bone window for 30 depths within the brain ranging from 2 to 8 cm. Healthy volunteer pulsation measurements were then used to develop a generalised additive model describing the expected healthy range of pulsations for each depth and probe position (temporal versus forehead) as a function of age, sex and heart rate (HR), while accounting for correlations between measurements within subjects. Test data from stroke patients were then compared with the model-derived expected healthy pulsations to identify subjects experiencing abnormal pulsations. Brain tissue motion was measured in 24 healthy volunteers and 14 acute stroke patients (12 ischaemic and 2 haemorrhagic). Pulsations in healthy subjects were well described by the model, including correlations in pulsation between adjacent depths, an overall increase in pulsation with depth, differences due to probe position and variations in pulsation magnitude with age and HR. The model was tested using 25 pulsation measurements from the stroke and non-stroke hemispheres of patients. Pulsations in stroke patients significantly deviated from the model, with a higher proportion of depths exhibiting pulsations outside of the normal expected range. On this basis, the fitted model correctly classified stroke subjects with 85% sensitivity and 85% specificity based on a single 8 second pulsation recording. With further refinement of this technique, portable ultrasound measurement of brain tissue pulsations may prove useful for hyper-acute assessment of stroke.
Magnetic resonance imaging (MRI)/ultrasonography (US) fusion-guided transrectal biopsy is equally effective with MRI/US fusion-guided transperineal biopsy in detecting anteriorly located prostate cancer
Radiology, Hull and East Yorkshire Hospitals, Hull, UK
Abstract
Transperineal template biopsy has been shown to be effective in detecting anteriorly located prostatic cancer and is often performed under a general anaesthetic. In this study we have evaluated the effectiveness of MRI/US fusion-guided transrectal biopsy in detecting anteriorly located prostatic cancer. This may be a more cost-effective approach compared with the transperineal approach and can be performed under local anaesthesia. A total of 148 patients underwent multiparametric MRI and biopsy for suspected prostate cancer in a single centre over a 13-month period (2015–2016) and were analysed retrospectively. Computer records were reviewed to determine location of suspected tumour, type of biopsy (standard TRUS and fusion-guided transrectal biopsy under local anaesthesia or transperineal biopsies under general anaesthesia) and histology results from biopsy and prostatectomy. Of the 148 patients, 17 (12%) had a suspected anterior lesion in MRI (AL) and 131 (88%) patients had a MRI without a suspected anterior lesion (NAL). In the AL group, 81% of the patients had a PIRAD 4 or 5 lesion and 53% of them a benign DRE. In the NAL group 34% of patients had a PIRAD 4 or 5 lesion and 62% a benign DRE. In the AL, 12 (71%) patients had fusion biopsies and in 11 (92%) of them prostate cancer was detected, with eight (67%) positive targeted cores. In the NAL group, 40 (31%) patients had fusion biopsies, and in 30 (75%) of patients prostate cancer was detected, with 24 (60%) positive targeted cores. Seventeen (41%) patients in total had a radical prostatectomy and anteriorly located prostatic cancer was detected in 11 (65%). The results showed that fusion-guided transrectal biopsy is equally effective in detecting anteriorly located prostatic cancer compared with fusion-guided transperineal biopsy. The obvious advantage is that transrectal fusion biopsies can be performed under local anaesthesia.
Combined focused ultrasound and radiotherapy for the treatment of hypoxic tumours, using photoacoustic imaging as a planning tool
Joint Department of Physics and Division of Radiotherapy and Imaging, Institute of Cancer Research and Royal Marsden NHS Foundation Trust, Sutton, UK
Abstract
Tumours with significant regions of hypoxia respond poorly to radiotherapy (RT). There is therefore a clinical need for treatment strategies that address this. We here propose the combination of high intensity focused ultrasound (HIFU) ablation of hypoxic regions and radiotherapy. We have investigated this approach in human head and neck cancer xenograft tumours grown subcutaneously in the flanks of immunocompromised mice. A preliminary study assessed their radiation response to X-rays (SARRP, X-Strahl) over a 60-day follow-up period. Tumour control was seen in 46% of subjects exposed to a single 10 Gy fraction, in 73% for 20 Gy and 92% for 30 Gy. Ten gray was therefore chosen for combined treatments in order to maximise the scope for improvement in outcome. Tumour regions that were likely to be hypoxic were identified non-invasively, using photoacoustic imaging (MSOT inVision256TF, iThera Medical) to provide a map of the blood oxygen saturation. The ultrasound-guided HIFU treatments (VIFU-2000, Alpinion) comprised 6 × 10 second exposures at a focal peak intensity of 1200 ± 240 W/cm2, delivered in a spiral pattern (diameter 3 mm, exposure spacing 1 mm). HIFU exposure of a single hypoxic region, in the absence of RT resulted in a tumour growth delay of up to 13 days. HIFU immediately before or after 10 Gy RT resulted in tumour control rates over 60 days of 76 and 86%, respectively, similar to 20 and 30 Gy alone treatments. This was a highly significant (p-value < 0.05) improvement in treatment outcome. This novel study has allowed investigation of the potential of HIFU ablation of regions of tumours believed to be hypoxic, to permit a reduction in radiation dose (to 10 Gy) whilst achieving the same efficacy as higher RT doses (20–30 Gy). This approach holds potential for decreasing cytotoxic side effects of radiation treatments in normal tissues.
Use of small bowel ultrasound to identify small bowel Crohn’s disease compared with magnetic resonance enterography
Gastrointestinal Imaging Group, University Hospitals of Leicester, Leicester, UK
Abstract
Imaging is central to the diagnosis and monitoring of patients with Crohn’s disease (CD). The advent of faecal calprotectin measurement in primary care has led to increasing numbers of patients being referred for imaging assessment of possible CD. It is generally accepted that colonoscopy with terminal ileal biopsies and MR enterography (MRE) are the gold standard investigations for diagnosis and mapping of CD. However, from a cost and service provision perspective this is an expensive, labour-intensive approach with significant impact on MRI provision. Our local practice of focused small bowel ultrasound (SBUS) predates the introduction of MRE. We assess our use of SBUS in lieu of baseline MRE and evaluate SBUS findings against MRE. We retrospectively reviewed all adult patients who had a SBUS followed by a MRE within four months from 2012 to 2016 in a single institution for concordance of imaging findings using the MRE as gold standard. One hundred and ninety-five patients were identified, average age 31 years, with 126 females. Sensitivity of SBUS to identify macroscopic small bowel inflammation was 98.5%, specificity of 95%, PPV of 95% and a NPV 98.5%. Review of all false negative discordant cases revealed that the discrepancy was due to isolated jejunal disease in all cases. On review of false positive cases, all had macroscopic ileitis on retrospective SBUS review which had resolved/was not present on subsequent MRE. SBUS is a useful, sensitive and specific investigation in assessment of small bowel inflammation and Crohn’s disease in the correct operator hands. If there is clinical concern of isolated jejunal disease after a normal SBUS, our local practice is to investigate further with small bowel barium studies and capsule endoscopy once strictures have been excluded.
The effect of 4-hour SkinSuit induced partial axial reloading upon stature elongation and anterior intervertebral disc height as assessed by ultrasound after 8-hour hyper-buoyancy flotation
1Centre for Human and Aerospace Physiological Sciences, King’s College London, London, UK
2Women’s Health, King’s College London, London, UK
3King’s College London, London, UK
Abstract
Astronauts experience significant stature elongation in space which may contribute to a four-fold increased risk of intervertebral disc (IVD) herniation. Lumbar herniation risk is attributed to prolonged IVD swelling, though risk factors for cervical herniation remain unidentified. An ultrasound protocol assessing IVD height was trialled in space, but no data were reported. The European Space Agency’s Mk VI SkinSuit, which imparts (∼20% bodyweight) axial loading shoulder foot, has been shown to mitigate elongation experienced from overnight unloading. Its ability to reload the IVDs, however, requires further assessment. Therefore, this study investigated the effect of 8-hour hyper-buoyancy flotation (HBF) followed by 4-hour Mk VI SkinSuit reloading upon IVD height using the NASA in-orbit ultrasound protocol. Eight healthy males (27 ± 5 y; 1.78 ± 0.07 m; 70.6 ± 10.4 kg) lay for 8 hours overnight on the HBF in normal clothes, followed by a further 4 hours having donned the SkinSuit. Cervical (C4/C5–C7/T1) and lumbar (L2/L3–L5/S1) anterior disc spaces (mm) were measured using ultrasound (6–13 MHz linear and 2–5 MHz convex transducers, respectively) on the HBF at the start/end of the 8-hour unloading and 4-hour reloading periods, in addition to stature. Significant stature elongation (177.1 ± 7.5 versus 179.2 ± 7.7 cm) was induced following 8-hour HBF. SkinSuit reloading immediately reduced stature elongation by 1 cm (178.2 ± 7.8 cm), which was maintained throughout the 4 hours reloading. Eight-hour HBF unloading induced significant increments in C4/C5 (1.0 ± 1.0 mm), C6/C7 (0.8 ± 0.7 mm), C7/T1 (0.4 ± 0.5 mm) and L5/S1 (2.1 ± 2.0 mm) IVD height. Reloading initially reduced L5/S1 (0.5 ± 0.7 mm) IVD height whereas L2/L3 (1 ± 1.1 mm) and L4/L5 (0.4 ± 1.2 mm) increased further. Eight-hour HBF unloading induced significant stature elongation and for the first time, using the NASA in-orbit ultrasound protocol, parallel anterior IVD height increments were identified. Reloading produced an immediate reduction in stature but variable lumbar anterior IVD height changes. Therefore, further evaluation of the inter-relationship between Gz loading, stature and IVD heights across the vertebral column is warranted.
Professional Issues
Case report: Direct entry undergraduate education for sonographers
Radiography, Birmingham City University, Birmingham, UK
Abstract
It is a challenging time within the national ultrasound workforce. Staffing shortages are directly impacting on patient waiting lists and the ability to facilitate education of the next generation of sonographers. The ageing of the existing workforce means that exit rates are predicted to be higher than entry rates, resulting in a range of solutions having been consulted and developed. Much discussion has, therefore, been held on additional routes through ultrasound education. Current models involve the need for shortage professions such as diagnostic radiography and midwifery to be further reduced through these professionals pursuing training as advanced practitioner sonographers, emphasising the need for action now rather than when it is too late in order to protect service delivery standards. This case study presents an innovative new model leading to the development of the future of ultrasound education: the direct entry BSc (Hons) Medical Ultrasound plus PgCert Medical Ultrasound (preceptorship) programme being delivered at Birmingham City University. The experiences gained through the discussion, the development, delivery and continuous evaluations of the programme will be shared. An overview of the recruitment and selection of students and their backgrounds will be provided. With the second intake now recruited, the team are in a strong position to present the highs and lows of the journey so far, particularly emphasising areas that have been further examined and reconsidered, as well as those requiring further ongoing professional discussion. Presenting the University, the student and clinical perspectives, this presentation offers unique insights into the considerations that need to be allowed for when contemplating the design of education for sonographers in this manner.
Satellite Session: Therapy Ultrasound Group
Speckle-free soft tissue attenuation estimation and compensation in passive acoustic mapping
Institute of Biomedical Engineering, University of Oxford, Oxford, UK
Abstract
A variety of passive and active techniques have been developed to detect, localise and quantify cavitation activity during therapeutic ultrasound procedures. Much of the prior development work has been performed in lossless in vitro systems or in small animal models where attenuation effects are minimal. As a further step towards clinical application of passive cavitation monitoring (PAM), we present methods for attenuation estimation and compensation that can be implemented in real time. Attenuation is estimated using cavitation signal spectra received on a conventional diagnostic ultrasound array that has been calibrated both for sensitivity and directivity. The proposed method is independent of speckle scattering, requires no reference measurement or array model (as in backscatter methods), requires no additional data collection beyond what is already done for PAM and is implemented unilaterally (without need for a through-transmission measurement). Simulations and soft tissue phantom validation experiments demonstrated the ability to closely estimate frequency-dependent attenuation and to use the resulting values to recover the radiated cavitation energy as if the propagation medium had been lossless. These results indicate the potential to significantly enhance the quantitative capabilities of PAM for ensuring therapeutic safety and efficacy, while offering the ability to non-invasively monitor a critical tissue property over the course of a therapeutic treatment.
A disturbance-free device for the exposure of cells – Preliminary study
Ultrasound and Underwater Acoustics, National Physical Laboratory, Teddington, UK
Abstract
The number of medical applications of ultrasound has experienced exponential growth in the last decade. In particular, there is a growing interest in the observation of the behaviour of cells under the effect of an acoustic pressure field. However, the challenge of exposing cells to a known acoustic pressure field is significant and still unresolved. Currently, cells are exposed in petri dishes, multiwell plates or in large water tanks designed for, e.g. pressure mapping. Furthermore, it could be of interest to decouple the thermal and the mechanical effects, to better tune the acoustic parameters to deliver the maximum impact while reducing the risk of unwanted side effects. A first prototype of a disturbance free chamber for evaluating the effects of a mechanical stimulation of living cells has been designed and embedded with thermal and pressure sensors. Results using two transducers (1 and 2.25 MHz) demonstrated an echo reduction compared to petri dishes of around 98%, minimal temperature rises and an agreement between free field and in situ pressure measurements up to 90%. A second prototype, in the form of a multiwall plate with nine chambers will is under tests to assess cell viability, ensure sterilisation and assess the risks of cross contamination. Such a device could be used to enhance some of the bio-effects of ultrasound observed in vivo (e.g. angiogenesis, cell proliferation, cellular barrier opening and drug intake), through the optimisation of the exposure parameters. Furthermore, the bio-effects of diagnostic ultrasound can be studied at a different level, to assess the safety of exposure for new diagnostics techniques, in particular for early pregnancy scans.
Time reversal based beamforming of a modular 3D HIFU array for targeting of intervertebral discs
Institute of Biomedical Engineering, University of Oxford, Oxford, UK
Abstract
Chronic low back pain associated with degeneration of the intervertebral discs is currently treated with highly invasive methods that also demonstrate low long-term success rates. An alternative minimally invasive proposed method involves the use of high intensity focussed ultrasound to mechanically fractionate the degenerated disc. However, accurate focussing of ultrasound in the region of interest and delivery of the required acoustic energy without damaging sensitive nearby structures is challenging due to interference from the surrounding vertebral bodies. To address this challenge, a patient-specific strategy is employed that involves the use of a modular array of transducers, arranged at an optimal configuration determined by CT scans, along with beamforming on transmit, based on time reversal. The aim is to accurately and tightly focus at multiple locations within the disc, ensuring both safety and efficacy of the treatment. Initial numerical simulations and in vitro experimentation involving 3D-printed spine model derived from human CT scans were performed, and the outcomes were compared to determine the focussing and steering capability of the array. Prior to experimentation, calibration of each array configuration is performed to determine the positions of all transducers and the free-field acoustic pressure at the focus. Then, by placing a hydrophone at a target location, the phases of all elements required for focussing are calculated. Finally, electronic steering of the focus at multiple locations surrounding the location of the hydrophone is performed by exploiting the calculated transducers positions. Two-dimensional scans of the acoustic field along all three dimensions demonstrate the ability of the array to tightly focus at the initial target location, as well as the steering locations. Finally, good agreement between acoustic measurements and simulated acoustic field was observed, suggesting that numerical simulations could enable accurate treatment planning.
Focused ultrasound mediated hyperthermia in vitro – Design, optimisation and calibration of an experimental set-up
Joint Department of Physics, The Institute of Cancer Research and Royal Marsden NHS Foundation Trust, Sutton, UK
Abstract
For treatment planning purposes, understanding, quantifying and modelling of the biological effects of focused ultrasound (FUS) is essential. In particular, the differences of mechanical and thermal effects have not been fully characterised. This may partly be due to experimental difficulties to treat cells with FUS in vitro. We present an experimental set-up allowing for the analysis and quantification of the in vitro response of cancer cell lines under tissue mimicking FUS exposure conditions. The experiments are carried out on cells in a tissue-mimicking material which provides acoustic and biological properties in the range of human tissues. HCT116 cells (human colorectal carcinoma) were embedded in a thin (several 100 µm), tissue-mimicking collagen gel which provides the biological matrix. The collagen gel was sandwiched between two disks of acoustically absorbing polyvinyl alcohol cryogel (PVA). The sandwich was placed in a sterile sample holder filled with degassed medium within a water tank. To achieve a heated volume significantly larger than the geometric focus, a single element focused transducer (Sonic Concepts, Bothell, USA, 1.66 MHz) was moved at constant speed in a circular trajectory (6–8 mm diameter, period of 1 Hz). The majority of the heated cells were therefore not exposed to FUS directly but were heated by diffusion of thermal energy into the circle’s centre. A number of different exposure parameters (acoustic power, rotation diameter and speed) and gel samples of varying polymer content were tested. Cells containing collagen gels were analysed post-treatment for the spatial distribution of viable cells using the MTT call viability assay or fluorescent microscopy. Thermal doses in the therapeutic range (20–250 CEM) were achieved in the cell layer within the heated circular area for a 10% w/w PVA gel with 5% of cellulose added for a free field spatial peak temporal peak intensity of 1100–1400 W/cm2. However, time–temperature distributions varied for different samples of the same gel batch making an online monitoring of the thermal dose accumulated necessary. In the optimised set-up a variation in cell viability was observed across the heated sample. Fluorescent microscopy confirmed that cells were firmly trapped in the collagen layer and were not displaced by FUS. Samples heated with FUS were compared with collagen gels containing cells heated in a thermal cycler to compare the influence of the heating technique used and to see potential additional cell kill due to the mechanical effects of FUS. The experimental arrangement described may now be applicable to study the biological effects of FUS as a function of a number of exposure conditions.
Modelling large-volume hyperthermia in the liver for ultrasound-enhanced drug delivery from thermosensitive carriers
Institute of Biomedical Engineering, Department of Engineering Science, University of Oxford, Oxford, UK
Abstract
Ultrasound-mediated mild hyperthermia in the range of 39–42°C is a promising technique for non-invasive targeted release of thermally sensitive carriers in cancer therapy. The need to sustain a temperature rise of a few degrees evenly throughout a large volume currently limits this therapy to regions with a large accessible acoustic window. Furthermore, the need to continuously scan clinically available highly focused therapeutic ultrasound transducers typically used for ablation limits the volume that can be maintained at this temperature for tens of minutes and greatly extends treatment time per unit volume. In addition, bone structures, such as the ribs, significantly restrict accessible target locations in areas such as the liver and play a significant role in preventing this therapy from entering into clinical practice. In order to model propagation to the liver, including the ribs, a 3D full wave finite element approach was employed to simulate ultrasound-mediated mild hyperthermia induced by a small focused therapeutic transducer. An increase in therapeutic focal volume was achieved without mechanical scanning, rather a 3D printed lens was designed which spreads the focus of the transducer. Using a 3D printed lens allows for patient-specific adjustments to be implemented to reduce phase aberration in the prefocal path. This work was supported by the RCUK Digital Economy Programme, grant number EP/G036861/1 (Oxford Centre for Doctoral Training in Healthcare Innovation).
Improved drug distribution to the brain in vivo using Rapid Short-Pulse (RaSP) sequences
1Noninvasive Surgery and Biopsy Laboratory, Department of Bioengineering, Imperial College London, London, UK
2Department of Chemistry, Imperial College London, London, UK
Abstract
Focused ultrasound combined with microbubbles has been shown to locally and non-invasively open the blood–brain barrier, allowing drugs to enter the brain. Despite encouraging results in human patients, several performance and safety features, such as poor drug distribution, high drug accumulation along vessels and small sites of red blood cell extravasation, have been unavoidable. We have recently developed a new rapid short-pulse (RaSP) ultrasound sequence designed to reduce these adverse features by promoting safer modes of cavitation activity throughout the capillaries. In our RaSP sequences, low-pressure short ultrasonic pulses are emitted at kHz pulse repetition frequencies (PRF) and grouped into bursts. We have shown in vitro that RaSP sequences prolong microbubble lifetime and increase their mobility, enhancing the distribution of acoustic cavitation activity. Here we evaluate the ability of RaSP sequences to improve the in vivo performance and safety of ultrasound-mediated drug delivery to the brain. The left hippocampus of mice was exposed to 1 MHz focused ultrasound after systemically administering SonoVue® microbubbles and fluorescent 3 kDa dextran. The mice were exposed to RaSP sequences (pulse length (PL): five cycles; PRF: 1.25 kHz; burst length: 30 ms) or standard ms-long sequences (PL: 10,000 cycles; PRF: 0.5 Hz; burst length: 10 ms) at non-derated 400 kPapk-neg. A 7.5 MHz passive cavitation detector was used to capture the microbubble acoustic emissions. Brains were sectioned into 30 µm slices and imaged by fluorescence and confocal microscopy. Despite emitting 150 times less acoustic energy, RaSP sequences delivered a similar drug dose and produced a more uniform drug distribution compared to standard long-pulse sequences. RaSP sequences resulted in less dextran accumulation along arteries, suggesting that these sequences reduce the likelihood of unnecessary arterial treatment. For both sequences, neuronal uptake of dextran was observed in areas where high doses of dextran were present in the parenchyma. Acoustic emissions, which relate to the magnitude and duration of the cavitation activity, were more stable for RaSP sequences than for the long pulses. These results indicate that low-pressure RaSP sequences could deliver a more efficient and safe drug dose to treat brain diseases such as Alzheimer’s and glioblastoma.
Results of a phase I clinical trial of ultrasound-guided and ultrasound-triggered targeted drug delivery from thermosensitive liposomes in liver tumours (TARDOX)
1Nuffield Department of Surgical Sciences, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
2Department of Radiology, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
3Institute of Biomedical Engineering, University of Oxford, Oxford, UK
4Oxford Institute for Radiation Oncology, University of Oxford, Oxford, UK
5Nuffield Department of Anaesthesia, Oxford University, Hospitals Foundation NHS Trust, Oxford, UK
6Centre for Pathology, Faculty of Medicine, Imperial College London, London, UK
7Department of Oncology, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
Abstract
The TARDOX study (Oxford, UK, NCT02181075) is a 10-patient Phase I first-in-man proof-of-concept study which aims to demonstrate the safety and feasibility of targeted drug delivery using lyso-thermosensitive liposomal systems in combination with mild hyperthermia delivered non-invasively using ultrasound-guided focused ultrasound (FUS). The primary endpoint of the study concerns demonstration of enhanced intratumoural delivery of doxorubicin to liver tumours for the same systemic dose of the drug, when given in liposomal form (Lyso-Thermosensitive Liposomal Doxorubicin, LTLD, ThermoDox®) and released locally by FUS hyperthermia. Each treatment was performed under a general anaesthetic with the patient supine on a CE-marked ultrasound-guided FUS system (JC200, Chongqing HAIFU). An 18-gauge co-axial needle was placed under ultrasound guidance into the target tumour, allowing insertion of a clinically approved thermistor or a core biopsy needle according to the treatment protocol. Shortly following the 30-minute intravenous ThermoDox® infusion, the JC200 beam was moved transcostally through the target tumour volume, containing the thermistor, in an automated plan to induce hyperthermia of 40–44°C, monitored using the implanted thermistor. Core tumour biopsies were taken (a) prior to drug infusion; (b) following completion of drug infusion and (c) following FUS, for analysis of intratumoral doxorubicin concentration and microscopy studies. Dynamic contrast enhanced (DCE) MRI, perfusion CT and 18F-FDG PET-CT scans were performed the day prior to treatment and at approximately two and four weeks post-treatment with clinical review. An additional MRI was performed the day following treatment. Response evaluation was performed using principles of RECIST & CHOI and the SUVmax metric for the target tumour. Thermometry, pharmacokinetic and HPLC data for the 10 patients treated demonstrate that the use of LTLD with extra-corporeal FUS hyperthermia for targeted drug delivery in human liver tumours is feasible, safe and can enhance intratumoral delivery of doxorubicin for a given systemic dose relative to LTLD alone.
Investigation of the ability of gas-filled nanobubbles to deliver drug mimics to the brain by disruption of the blood–brain barrier using focused ultrasound
1Centre for Cardiovascular Science, Queen’s Medical Research Institute, University of Edinburgh, Edinburgh, UK
2Department of Drug Chemistry and Technologies, Sapienza Universita di Roma, Roma, Italy
Abstract
The aim of this project is to investigate the use of focused ultrasound (FUS) to temporarily and non-invasively disrupt the blood–brain barrier (BBB) and thereby allow drugs and therapies to enter the brain. Microbubbles (SonoVue, Bracco) (0.3 µl/g) were delivered via tail vein injection into the vasculature in solution with Evan’s Blue dye (3 µl/g). To target the BBB, an ultrasonic transducer (3.5 MHz) was suspended 45 mm above the head and focused through coupling gel onto the brain through an intact skull. The optimisation of this technique required determination of the focal position of the 3.5 MHz transducer at 45 mm with a peak negative pressure of 2.1 MPa (single pulse) at 35,000 cycles over a 10 ms burst with a pulse repetition frequency of 10 Hz. In addition, measurement of the attenuation of the ultrasound beam through ex vivo mouse skulls was calculated at 5.13 db/mm (±SD – 1.56), averaged across five regions of five different skulls. Using FUS the delivery of Evans Blue dye into the brain showed no measurable damage confirming disruption to the BBB. This enabled the passage of an adeno-associated virus expressing GFP into the brain (n = 6 for each cohort including control) – indicating that the virus requires the ultrasound and microbubbles to facilitate its movement into the brain. Next, the role of contrast agents used in the opening and disruption of the BBB was investigated to compare composition and size of the contrast agents. Microbubbles (2–3 µm) and nanobubbles (∼200 nm) were compared showing that microbubbles can open the BBB at a lower acoustic pressure than nanobubbles (1.74 MPa versus 2.2 MPa) and that the BBB recloses between 9 and 12 hours for nanobubbles, but is still open at the 12-hour time point for microbubbles. When comparing surfactant membrane nanobubbles to phospholipid nanobubbles at stock concentration of 5 × 1013 microbubbles/ml, no damage was caused by the surfactant nanobubbles; however, there was some limited red blood cell extravasation in the phospholipid nanobubble cohort. Lastly, using FUS, the hydrophilic drug mimic calcein was delivered into the brain (n = 5 non-ionic surfactant nanobubble, n = 5 lipid nanobubble). Results indicated that the delivery of calcein is most efficient when using non-ionic surfactant nanobubbles as opposed to lipid nanobubbles – with a greater volume of the drug being delivered into the brain. In conclusion, we have shown that it is possible to deliver drug mimics and viruses into the brain using focused ultrasound.
Patient specific models for renal tumour ablation
Institute of Biomedical Engineering, University of Oxford, Oxford, UK
Abstract
High intensity focussed ultrasound (HIFU) is emerging as a non-invasive treatment for multiple cancer types. Of these, localised renal tumours represent a good target for HIFU, because they are accessible to the ultrasound beam. However, challenges remain in the delivery of the treatment to tumours at depth, with clinical results showing a variation in the ablation efficacy. One clinical trial conducted in the Churchill hospital to investigate the applicability of HIFU for renal tumour ablation found that in 4/10 patients <50% of the tumour volume was ablated successfully. Previous simulation analysis suggests that fat layers result in defocussing of the HIFU field and may be responsible for the poor outcomes in these patients. The role of the fat layers on clinical outcomes has been studied here by importing CT scans of patients in the trial and segmenting them into different tissue types. Full three-dimensional ultrasound simulations are being carried out using k-Wave (an open source Matlab toolbox) in order to confirm the role of fat in beam defocussing and attenuation. For a fixed transducer pressure, thermal simulations are used to compare the temperature rises induced across the different patient models.
Therapeutic ultrasound increases the infiltration of pancreatic tumours by CD8+ lymphocytes
Joint Department of Physics, The Institute of Cancer Research: Royal Marsden NHS Foundation Trust, Sutton, UK
Abstract
Advances in cancer immunotherapy have improved our understanding of the power of the immune system and its optimisation to help against the disease. Therapy ultrasound can both induce necrosis in target tissues by raising the temperature to ablative levels and create cavitation which can result in mechanical disruption of stroma surrounding cancer cells. Both these processes may increase the immunogenicity of tumours, and there is anecdotal clinical evidence to that effect. In a pre-clinical study, pancreatic orthotopic tumours have been subjected to a number of different therapy ultrasound exposure regimes (hyperthermic and cavitational) to explore whether there is increased T cell infiltration and immune cell activity in the area of the tumour. Our results show that therapeutic ultrasound induces an immune response which is associated with an increased percentage of CD8+ lymphocytes in the tumour, spleen and blood of treated subjects.
Development of a device for large volume sonication of the brain
1Institute of Biomedical Engineering, University of Oxford, Oxford, UK
2Department of Oncology, University of Oxford, Oxford, UK
Abstract
Brain metastases occur in approximately 15% of cancer patients and appear to be increasing in incidence. Treatment options are still very limited, and survival is usually measured in months. The aim of this project is to develop phase change nanodroplets that can selectively bind to the sites of very small brain metastases. As part of a treatment involving these droplets, it is desirable to expose the entire brain to ultrasound, in order to vaporise and cavitate these droplets regardless of the location of the brain metastases. Unfortunately, existing therapeutic ultrasound systems are not well suited for large volume exposure. We present simulations and ex vivo measurements of sound propagation through the skull, including analysis of how shear waves contribute to ultrasound transmission. Based on these results, we investigate creating an optimised ultrasound field using acoustic lenses and a prototype ultrasound transducer.
Day 3 Friday 8 December
Gynaecology
Case reports: Mimics of ovarian masses
York NHS Teaching Hospital, York, UK
Abstract
Pelvic masses from non-gynaecological origin can mimic ovarian or uterine pathology. We present three patients with gynaecological related symptoms and pelvic masses on ultrasound that were proven subsequently to be derived from the gastrointestinal tract. All patients were referred from primary care with gynaecological symptoms and had initial imaging with TA and TV ultrasound. Case 1 was a 75-year-old woman with post-menopausal bleeding. Ultrasound demonstrated an incidental complex cyst with linear internal echoes thought to be an ovarian cyst. MRI and CT demonstrated a tubular cyst connecting to the appendix, diagnostic of a mucocele appendix, confirmed at operation. Ultrasound findings of the classic onion ring sign of mucocele appendix are described. Case 2 was a 54-year-old woman with pelvic heaviness. Ultrasound revealed a 12 cm cystic/solid right adnexal mass with vascularity, suspicious of malignant ovarian tumour. MRI demonstrated similar findings and central MDT advised removal. At operation, the ovaries appeared normal and the tumour was arising from the small bowel. Histology confirmed a malignant small bowel GIST. Case 3 was a 52-year-old woman with bloating and mildly raised CA 125. A 3.5 cm solid but avascular left adnexal mass on ultrasound was thought to be pedunculated fibroid or ovarian fibroma but suggested a bowel origin as an alternative. CT demonstrated a large sigmoid polyp that accounted for the ultrasound findings and colposcopy was advised. We conclude that non-gynaecological causes should be considered in the differential of pelvic masses, particularly when the findings are unusual. Other imaging modalities can be helpful in discriminating their origin, though not always, due to the close proximity of pelvic organs and bowel.
Case report: An unusual ovarian lesion: Benign versus malignant
1University College Dublin, Dublin, Ireland
2Midlands Regional Hospital, Portlaoise, Laois, Ireland
Abstract
A 57-year-old nulliparous lady with a six-month history of bloating, being treated for water retention by her GP was referred for pelvic ultrasound to assess uterus and ovaries pathology. The GP indicated this lady was virgo-intacta so transvaginal scanning was not an option. Ultrasound revealed diffuse abdominal and pelvic ascites present making the examination technically challenging. A 8.6 cm × 5 × 5 cm mildly heterogenous, predominantly solid, mass like lesion was seen posterior to the uterus towards the right adnexal region, suspicious for ovarian malignancy. The lesion displayed internal vascularity but no gross hyperaemia was seen. The uterus appeared normal measuring 5.2 cm × 2 cm with an endometrial stripe thickness of 5 mm. The left ovary was not identified. Kidneys were normal in size, shape and echotexture. A CT scan was advised for further assessment According to IOTA guidelines, this ovarian lesion displayed at least three malignant features which warranted further imaging. CT and MRI scans of the lesion were also concerning for malignancy. Ascitic fluid cytology was negative but CA 125 was significantly raised at 1145 µ/ml (normal range 0–35 µ/ml). All other bloods were unremarkable. Patient underwent total abdominal hysterectomy with bilateral salpingo-oophorectomy, omentectomy, appendicectomy and lymphadenectomy. Pathology results revealed a proliferative oxyphilic struma ovarii of the right ovary. Struma ovarii is a rare ovarian neoplasm consisting almost exclusively of mature thyroid tissue (>50%) derived from germ cell in a mature teratoma. However, in this case there was no evidence of stromal carcinoid or typical stroma derived thyroid carcinoma. As a result no further treatment was required. This case reinforces the importance of ultrasound as an initial screening tool for gynaecological investigations. Even though the patient was not suitable for TV imaging, ultrasound still provided a large amount of valuable information that aided rapid diagnosis and treatment.
Early Pregnancy
Case report: A live unilateral dichorionic twin ectopic pregnancy – A rare entity
1University College Dublin, Dublin, Ireland
2Regional Hospital Mullingar, Mullingar, Ireland
Abstract
The incidence of ectopic pregnancy is increasing, possibly related to a rise in assisted reproduction and better diagnosis using high-resolution transvaginal ultrasound. A 36-year-old woman, with a history of a left laparoscopic salpingo-oophorectomy (previous ectopic pregnancy) presented with painless vaginal bleeding at nine weeks post-LMP and a positive pregnancy test and BhCG of 92,000 IU/l. Transvaginal ultrasound showed two separate right-sided adnexal masses. Each mass had a gestational sac, each with its own yolk sac and embryo. Cardiac activity was identified in both embryonic poles and further demonstrated on M-mode and colour Doppler, confirming a live twin ectopic pregnancy. Ultrasound findings of two suspected adnexal masses, no interuterine pregnancy, along with an increased BhCG level, especially with associated risk factors, can help the early diagnosis of an ectopic pregnancy and reduce the related mortality and morbidity.
Professional Issues
Case report: Peer review – Underpinning safe practice
Diagnostic Imaging, St Mary’s Hospital, Newport, Isle of Wight, UK
Abstract
The BMUS Peer Review audit tool was introduced into our practice in November 2015. Regular peer review proved difficult due to increasing workload and long-term sickness but the team unanimously agreed that it was beneficial to practice in terms of quality review and to standardise good practice. In 2016, long-term sickness resulted in little or no peer review being undertaken for several months. In February 2017, a case was reviewed following input from the requesting consultant and an error was found in the report. Further cases for the sonographer were reviewed and multiple errors discovered in report content. An incident form was completed, a SIRI declared and a Clinical Advisory Group convened to investigate the extent of the incident, the degree of harm and any associated Duty of Candour for patients. A review of the previous year’s work identified a mean error rate of 25%. The errors in the most recent nine-month cohort were reviewed by referrer for a decision to rescan. A small number of patients were rescanned and updated reports issued. Insufficient peer review contributed to these errors not being identified through this process. The importance of adequate time for peer review, CPD and continual learning for the sonographer role must not be underestimated. This conflicts with examination capacity but needs to be recognised as an essential aspect of safe ultrasound practice. The findings resulted in the following actions:
• Time for peer review and CPD embedded into practice
• Support for sonographer and manager involved sourced from local colleagues, the HR team and BMUS
• Structured retraining period planned
• Competency assessment planned prior to resuming independent practice.
A clinical audit to establish if Salisbury District Hospital is complying with its chaperone policy for testicular ultrasound
Clinical Radiology, Salisbury District Hospital, Salisbury, UK
Abstract
Testicular ultrasound is an intimate examination and all patients should be offered a chaperone. The objective of this work was to establish if testicular ultrasound scans at Salisbury District Hospital meet the hospital’s chaperone policy. To determine this, criteria and standards must be set. The performance needs to be assessed against the set criteria and standards and identification must be made as to what standards have been met. All patients who attended the ultrasound department for a testicular ultrasound between 1 January and 31 December 2016 who met the specific inclusion and exclusion criteria were audited. Data were collected retrospectively from Salisbury District Hospital in the form of a clinical audit. The study population included 699 patients who met the inclusion and exclusion criteria. The department failed to meet the 100% criterion in offering every patient a chaperone and achieved 37% compliance. In all the reports of the patients who received a chaperone, the name and position were correctly identified in 100%. However, it was not identified in any of the reports that had a female chaperone that only a female was available. In the 3% of patients who declined a chaperone, this was documented accurately in 100% of the reports. The Ultrasound Department is failing to offer all testicular ultrasound patients a chaperone. Documentation within the reports regarding name and identity of chaperone is always correct but information regarding whether the opposite sex of chaperone was available is not present. Recommendations include holding a meeting to discuss results and briefing staff about the chaperone and its requirements. It would be recommended that practice is altered to have specific set testes lists on set days per week so that it can be appropriately staffed with two members of the team. A chaperone pro forma for reports would be suggested and discussed.
The role of preceptorship in the development of a newly qualified sonographer
Tameside and Glossop Integrated Care Hospital NHS Foundation Trust, Ashton-under-Lyne, UK
Abstract
The aim of this study is to understand the educational role of preceptorship in the development of a newly qualified sonographer. All gynaecology examinations performed and reported by a newly qualified sonographer over their initial six-month preceptorship period were marked before verification by a single consultant practitioner. The report marking options that could be selected were ‘agree’, ‘disagree with wording’, ‘disagree with meaning (no impact on patient)’ and ‘disagree with meaning (impact on patient)’. One hundred and sixty-six gynaecology examinations were performed over a six-month period. The consultant practitioner selected ‘agree’ on a total of 107 reports, ‘disagree with wording’ on 11, ‘disagree with meaning (no impact on patient)’ on 17 and ‘disagree with meaning (impact on patient)’ on 31. A record was kept of the different pathologies encountered, the number of patients that had to be recalled for further examination before verification of the report and the number of patients that had follow-up scans/further alternative imaging as a result of the scan findings and report produced by the preceptee. Any discrepancies in the report were highlighted by the consultant practitioner and discussed with the preceptee. Through this record of examinations and through use of current literature, the preceptee could, on a month-by-month basis, identify key learning points and areas for development, examples of which include improvements made to wording of reports. Furthermore, over the preceptorship period, the preceptee felt more confident identifying and reporting pathology and as a result, fewer report corrections needed to be made. This study demonstrates the educational value of preceptorship. By recording and analysing these results and through use of current literature, key learning points could be identified and a greater understanding gained of the educational benefit of the preceptorship process to the preceptee.
General Imaging
Ultrasound management of the splenic lesion
Derriford Hospital, Plymouth Hospitals NHS Trust, Plymouth, UK
Abstract
The spleen has been called ‘the forgotten organ’ because splenic pathology is relatively uncommon and frequently clinically silent. Splenic abnormalities will, however, be encountered by all ultrasound practitioners who scan the abdomen, particularly if the spleen is evaluated carefully rather than just a cursory measurement of splenic size, these abnormalities will often be clinically important. The aim of this lecture is to suggest an approach to the sonographic evaluation of non-traumatic splenic pathology. We will discuss the differential diagnosis for cystic, echogenic and echo-poor solid lesions. The immense value of contrast-enhanced ultrasound (CEUS) in detection and characterisation will be reviewed, particularly its role in the triage of patients to observation, further imaging or biopsy. The latest recommendations on the use of CEUS from EFSUMB guidelines will be presented. Potential pitfalls in diagnosis due to ectopic splenic tissue that might lead to over-investigation and treatment will be shown. The role of complementary imaging (particularly PET CT) and biopsy will also be considered. At the end of this lecture I hope that participants will have a framework to help them evaluate non-traumatic splenic pathology. Even when it is not possible to make definitive diagnosis based on ultrasound appearances, a report can be issued that is clinically valuable and gives a useful opinion on the likely significance of the abnormality encountered and, where necessary, advice on further management.
Paediatrics
A retrospective analysis of safety and cost implications of paediatric contrast-enhanced ultrasound at a single centre
Radiology, King’s College Hospital, London, UK
Abstract
Because of concern over medical ionising radiation exposure of children, contrast-enhanced ultrasound (CEUS) has generated interest as an inexpensive, ionising radiation-free alternative to CT and MRI. CEUS has received approval for paediatric hepatic use but remains off-label for a range of other applications. The purposes of this study were to retrospectively analyse adverse incidents encountered in paediatric CEUS and to assess the financial benefits of reducing the number of CT and MRI examinations performed. All paediatric (patients 18 years and younger) CEUS examinations performed between January 2008 and December 2015 were reviewed. All immediate reactions deemed due to contrast examinations were documented in radiology reports. Electronic patient records were examined for adverse reactions within 24 hours not due to an underlying pathologic condition. With tariffs from the U.K. National Institute of Clinical Excellence analysis, CEUS utilisation cost ($94) was compared with the CT ($168) and MRI ($274) costs of the conventional imaging pathway. The records of 305 paediatric patients (187 boys, 118 girls; age range, 1 month–18 years) undergoing CEUS were reviewed. Most of the studies were for characterising liver lesions (147/305 (48.2%)) and trauma (113/305 (37.1%)); the others were for renal, vascular and intracavitary assessment (45/305 (14.8%)). No immediate adverse reactions occurred. Delayed adverse reactions occurred in two patients (2/305 (0.7%)). These reactions were transient hypertension and transient tachycardia. Neither was symptomatic, and both were deemed not due to the underlying disorder. The potential cost savings of CEUS were $74 per examination over CT and $180 over MRI. Paediatric CEUS is a safe and potentially cost-effective imaging modality. Its use allows reduction in the ionising radiation associated with CT and in the gadolinium contrast administration, sedation and anaesthesia sometimes required for MRI.
The application of contrast enhanced ultrasound (CEUS) in tertiary paediatrics
Great Ormond Street Hospital, London, UK
Abstract
Although childhood malignancy is uncommon, it remains the most frequent cause of death in under 14s.1 For example, hepatic lesions account for only 6% of intra-abdominal masses; however, two in three will be malignant,2 with a timely diagnosis essential. CEUS is a recognised imaging modality for characterising indeterminate lesions, together with other recommended applications such as trauma. Despite its documented success, use of CEUS remains off licence in paediatrics,3 meaning many centres will not routinely adopt this practice as a first-line investigation. At Great Ormond Street, the service is evolving and auditing will enable service providers to analyse current data for future development. The aim of this audit was to assess the application, technique and findings of CEUS in tertiary paediatrics in comparison to the EFSUMB recommendations and guidelines. This audit is necessary to evaluate the current service to enable progression and development. It included analysis of patient demographics, clinical indications, technique (probe selection, contrast given), organ assessed/region of interest, adverse reactions, diagnosis and patient management as a consequence of findings. Thirty-seven examinations were performed over three years with patient age ranging from four months to 16 years. Indications were varied with 10 patients having a history of malignancy. The examinations were categorised into organs; 25 hepatic, six renal, four splenic, one bowel and one polytrauma. All examinations were performed alongside other imaging modalities. A diagnosis was established in 29 patients with the remaining eight requiring additional examinations (individual diagnoses will be provided). All CEUS performed were justified, contributing to diagnosis and management. Applications are in line with recommended EFSUMB guidelines. Examinations performed were based on solid clinical history and there was good documentation of lesion characteristics. Improvement is necessary in discussing/documenting off-label usage and better awareness/being prepared for adverse reactions.
References
Poster Exhibition 2017
MSK
Is there a link between shoulder pain, shoulder capsule width and rotator cuff (RTC) pathology?
European School of Osteopathy, Boxley, UK
Abstract
Shoulder stability is dependent on active (RTC) and passive (capsule) stabilisers; pathology of one of them must affect the other. Aside from secondary adhesive capsulitis, there is a paucity of studies investigating the pathogenic relationship between these structures and shoulder pain. The objective of this study was to investigate whether there is a link between the capsule width, shoulder pain and RTC pathology. This was an observational cross-sectional study. Participants were recruited from the Musculoskeletal Ultrasound Department of the European School of Osteopathy (ESO) clinic and ESO students, who met the inclusion and exclusion criteria. The outcome measures were inferior glenohumeral ligament (IGHL) width, Oxford Shoulder Score (OSS) and Shoulder Pain and Disability Index (SPADI). The 13-point RTC scan was used to determine the severity of the pathologies. Data were analysed using Analyse-It; First Normality and variance were tested. Then all the data were analysed to determine whether they could be correlated for significance between the groups. The groups compared were symptomatic shoulder with contralateral control shoulder and a group with RTC tears compared to a group with no RTC tears but RTC pathology. A total of 24 participants were recruited, of which seven dropped out through the process and 17 completed the study. Spearman’s test showed a correlation between IGHL versus OSS (rs = −0.43, p = 0.01), IGHL versus SPADI (rs = 0.37, p = 0.03) and OSS versus SPADI (rs = 0.97, p < 0.0001). Wilcoxon–Mann–Whitney test showed statistical significance difference between IGHL in the symptomatic group compared with the control group (p = 0.02). However, no statistical difference was found between the group with RTC tear and the group with no RTC tear but RTC pathology (p = 0.19). The results of this study support the idea that there is a possible link between shoulder pain, IGHL width and RTC pathology. Further research could give insight into the predictive value of a simple ultrasound metric diagnostically aiding the primary assessment of the ‘problem shoulder’.
Ultrasound in rheumatology: A practical guide
1Leeds Biomedical Research Centre, Leeds Teaching Hospitals, Leeds, UK
2Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
Abstract
Rheumatoid arthritis (RA) is a common, chronic disabling inflammatory arthritis. The accurate early identification of inflammation, for both diagnosis and disease monitoring, is imperative in order to reduce structural damage and to maintain joint function.1 Traditional methods of evaluating joints such as clinical examination and X-ray are limited with respect to sensitivity and specificity.2 Consequently, ultrasound is increasingly being employed by clinicians to assess and to quantify joint inflammation (synovitis, tenosynovitis) and damage (bone erosion) in RA.3 This poster introduces the current EULAR ultrasound definitions and semiquantitative scoring systems employed at Leeds Biomedical Research Centre, including images and scanning planes utilised, with a view to educating other health professionals and the standardisation of procedures. Hands, wrists and feet are commonly assessed for signs of abnormal intra-articular tissue to make/exclude the diagnosis of synovial hypertrophy (SH) with or without power Doppler (PD).4 A recommended approach for scoring SH is a semiquantitative (SQ) grading of severity on a scale from 0 to 3, for both greyscale (GS) and PD imaging.3 Tenosynovitis is one of the key features of the clinical pattern in patients with rheumatoid arthritis (RA), with the Extensor Carpi Ulnaris (ECU) and flexor tendons being commonly involved.5 Established tenosynovitis may end in tendon damage resulting in tendon rupture with consequent disability.6 A SQ grading of severity on a scale from 0 to 3 allows for monitoring.7 Bone erosions are commonly found in RA and are considered one of the characteristic findings, and they appear in distinctive sites. They signify the destructive outcome of untreated synovitis.8 A SQ grading of severity on a scale from 0 to 3 allows monitoring.1 The learning outcome of this poster will be to define and quantify inflammatory and structural pathology seen in RA to facilitate the early diagnosis and accurate monitoring of disease. It will also highlight high risk areas in joints for ultrasound evaluation.
References
Case report: Ultrasound assessment of a common cause of forefoot pain: Plantar plate tear of the 2nd–5th metatarsophalangeal joints
Radiology, Weston General Hospital, North Somerset, UK
Abstract
The plantar plate is a fibrocartilaginous structure which stabilises the plantar aspect of the metatarsophalangeal joint, preventing dorsi-extension of the toe. It is susceptible to partial or complete tears due to chronic overload, age or trauma. Tears typically present with burning, throbbing or tingling and are commonly misdiagnosed as a Morton’s neuroma, stress fracture or arthropathy. Untreated tears can cause persistent pain and may progress to substantial deformity and dysfunction. Treatment involves strapping and NSAIDs, with surgery reserved for persistent symptoms. A 66-year-old female with metatarsalgia in the region of the second toe was referred for ultrasound; a steroid injection was requested if a Morton’s neuroma was detected. A clinical examination was first performed using three specific tests for plantar plate tears, testing positive for medial toe drift, reduced plantar purchase and a positive dorsal drawer test. Ultrasound identified a hypoechoic defect on the lateral aspect of the plantar plate, consistent with a partial tear. There was also co-existing capsular disruption and osteoarthritis of the metatarsophalangeal joint. Studies evaluating ultrasound in detecting plantar plate tears show it to be more sensitive than MRI and this, together with its low cost and flexibility, suggests that ultrasound is suitable as the first-line test. Ultrasound does, however, have a poorer specificity than MRI, which may be too low to rely on for surgical planning, and follow-up MRI imaging may be required. Ultrasound performs well at identifying concomitant or other causes of metatarsalgia especially interspace lesions, notably Morton’s neuromas. Accurate differentiation, particularly between a tear and a neuroma is advantageous as it indicates the correct treatment option and, in particular, it avoids the inappropriate administration of a steroid injection when the pathology is a tear.
Can Swindon foot and ankle questionnaire (SFAQ) be used to screen ultrasound requests?
Great Western NHS Foundation Trust, Swindon, UK
Abstract
Pressures on radiology ultrasound services include increasing requests from rheumatologists to confirm early rheumatoid arthritis (RA). Feet pose particular problems. They are often affected in RA but are excluded from the current standard clinical score DAS28CRP. We developed a simple scoring system for feet and ankles in inflammatory arthritis (SFAQ), validated against clinical measures,1 but not ultrasound (US). We compared US findings in early RA with SFAQ and looked at changes in early disease. Early inflammatory arthritis patients completed the SFAQ and DAS28CRP. Ultrasound (US) assessment of the feet and ankles was performed by consultant musculoskeletal (MSK) radiologist, blinded to the clinical score. These tests were repeated at six months. SFAQ scores >6 were considered high. DAS28CRP scores were stratified: high >5.1, moderate 5.1–3.2, low <3.2. Fifteen patients took part. On US scan, 5/15 (33%) had active synovitis. Of these 3/5 had high SFAQ (p-0.064) and 4/5 had high DAS28CRP. Of 10 patients with no synovitis, 6/10 had high SFAQ and 3/10 had high DAS28CRP. Five of 15 patients attended at six months. 2/5 had initial US synovitis and high SFAQ in the first assessment. At second assessment: none had active synovitis; SFAQ and DAS28CRP scores were all normal. We showed correlation between active synovitis on US and high SFAQ score. With increasing demand and pressure on the MSK US service, SFAQ could be used for stratification of active synovitis in foot and ankle, thus reducing the need for ultrasound scanning. Statistical significance is not achieved due to small numbers. Larger studies are needed.
Reference
Is it possible to predict the eventual outcome of a Graf Type IIa hip by graphical extrapolation?
Princess Anne Hospital, Southampton, UK
Abstract
For a Graf Type IIa hip that has not matured to a Graf Type 1 after two ultrasound scans, assuming a linear progression of maturation, is it possible to predict the eventual outcome by graphical extrapolation? The purpose of the study was to investigate whether it is possible to reduce the number of follow-up ultrasound scans for monitoring Developmental Dysplasia of the Hip (DDH). Two hundred and forty-four infants with high-risk factors for DDH referred for hip sonography in a six-month period were included in this study. Sonographic examinations were performed using the Graf technique. Both hips were measured and the Graf classification determined. One hundred and forty-nine infants had Graf Type I hips at the first scan. Ninety-three infants were referred for a follow-up ultrasound scan of which 72 matured to a Graf Type I and 11 were referred for treatment. Ten were referred on for a third scan, of which nine matured to a Graf Type I and one referred for treatment. The results for the 10 infants that required three scans were used to test graphical extrapolation techniques. The analysis showed that in general there is a linear maturation of the hip. This means that it is possible to predict the outcome from two scans using graphical extrapolation. In this study, 100% agreement between the extrapolated prediction and the clinical decision was demonstrated when the result from the first and third scan was used. However, only 85% agreement was demonstrated when the first and second scans were used. The study shows that it is possible to predict the eventual outcome for a Type IIa hip. The study also shows that follow-up scans can be reduced.
Case report: The role of ultrasound in the differential diagnosis of palpable abdominal wall lesions
Radiology, York Hospital, York, UK
Abstract
Ultrasound is an important tool in assessing abdominal wall lesions. High frequency linear transducers allow detailed assessment of anatomy and high-quality imaging of superficial pathology. The exact location of lesions with respect to the layers of the abdominal wall can be determined and dynamic Valsalva manoeuvre is particularly useful in the assessment of hernias. We present a pictorial review encompassing the spectrum of palpable abdominal wall lesions encountered in our District General Hospital. Abdominal wall masses can develop insidiously or acutely and as such present to primary care or a variety of secondary care specialties. Ultrasound is often the first-line investigation and in many cases the only imaging modality undertaken. Rectus sheath haematoma often presents with pain, bruising and a rapidly enlarging abdominal mass. While some patients have a predisposition such as bleeding disorders or anticoagulant medication, others occur spontaneously. We will include the imaging findings of several abdominal wall haematomas seen in our department recently and outline the key anatomical landmarks. We present a pictorial review of the important alternative painful diagnoses including infection, abdominal wall hernias including postoperative appearances, endometriosis and fat necrosis. Other non-painful abdominal wall lesions such as lipomas, haemangiomas, pilomatrixomas and abdominal wall desmoids will also be depicted. Ultrasound is often the first-line investigation for abdominal wall masses. Its role in characterising masses and determining whether further imaging is required is becoming increasingly useful. We present several cases of rectus sheath haematoma, outline the imaging and demonstrate the potential differential diagnoses as a pictorial review.
Ultrasound detection of hamstrings tears (a less usual cause for hip pain)
1Radiology Department, Darent Valley Hospital NHS Trust, Dartford, UK
2Imaging Department, Kings College Hospital NHS Foundation Trust, London, UK
Abstract
The aims of this study were to demonstrate the value of ultrasound in detecting full thickness and partial thickness tears of the hamstrings attachment on the ischial tuberosities and to demonstrate the value of ultrasound as an adjunct to guided intervention. One hundred and ninety-one (n = 191) patients were evaluated for hip pain complaints within a six-month period in our two hospitals, using ultrasound, by four dedicated musculoskeletal radiologists. One hundred and twelve (k1 = 112) were female patients and 79 (k2 = 79) were male patients. The age range was between 49 and 91, with a preponderance of patients in their sixth and seventh decades. The referring diagnosis was in most cases trochanteric bursitis, muscle tears, haematomas or joint effusion. Several patients were referred with hip pain following hip joint replacements. Post-operative collections or muscle tears were suspected. Thirty-five patients (r = 35) had unsuspected tears of the hamstrings. Two (r1 = 2) patients were found to have full thickness tears of the hamstrings. Both patients presented following falls after hip replacement surgery. Thirty-three (r2 = 33) patients presented with unsuspected deep surface partial tears of the hamstrings. Of these patients seven (b = 7) had bilateral partial tears of the hamstrings. In our study cohort we have shown that both full thickness and partial thickness tears can be demonstrated with high-resolution ultrasound. Ultrasound evaluation is particularly helpful in the post-operative setting (no artefact as compared to MRI), can be less time consuming and can guide intervention. Our study is limited by the small numbers included in the study cohort and by the limitations of ultrasound in patients with high BMI, in whom studies are difficult to perform.
Acute medial Gastrocnemius tear with associated deep vein thrombosis: A case series and review of the literature
1Radiology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
2Sports Medicine, Southampton Football Club, Southampton, UK
3Sports Medicine, Nuffield Health, Epsom, UK
Abstract
Acute exercise related medial calf pain is a common clinical problem and often presents in middle-aged patients following sporting activity including tennis, badminton, netball, etc. The symptoms frequently relate to an acute tear of the medial head of gastrocnemius; however, the differential diagnosis includes other muscle injuries involving soleus or plantaris, rupture of a Bakers’ cyst and deep vein thrombosis. Ultrasound is often the diagnostic modality of first choice and can help distinguish between the main differential diagnoses. In the presence of an acute muscle tear, ultrasound can be used to assess the grade of injury and associated complications including haematoma formation. We present three cases of medial gastrocnemius tears in middle-aged athletes (mean age 52 years) diagnosed by ultrasound with simultaneous demonstration of an associated intramuscular deep vein thrombosis. None of these cases demonstrated proximal propagation into the popliteal vein. The clinical features, imaging findings and management are presented in this case series along with a review of the published literature. We suggest that the presence of a medial gastrocnemius tear should routinely prompt ultrasound assessment of the adjacent deep calf veins to exclude intercurrent DVT.
Paediatrics
The ultrasound features of necrotic bowel in children: A pictorial essay
Diagnostic Imaging and Intervention, KK Women’s and Children’s Hospital, Singapore, Singapore
Abstract
Bowel necrosis (BN) is death of part of the intestines due to its blood supply being cut off. Although patients are invariably septic and very ill, it is a difficult diagnosis to make clinically. Ultrasound is a relatively inexpensive, portable and readily available modality that is useful in the diagnosis of BN. This pictorial essay will illustrate the ultrasound features of BN and highlight some of the causes in children. Correlation with plain radiographs, CT and pathological specimens will be shown. Necrotising enterocolitis, malrotation with small bowel volvulus and incarcerated inguinal hernias are common causes of BN in the neonatal period. Intussusception, complications of Meckel’s diverticulum, post-surgical adhesions, internal hernias and vasculitic causes are more common in older children. The ultrasound features of BN include persistent dilated loops of thick-walled bowel, intramural gas appearing as echogenic specks, bubbles of gas within the portal vein, absent intra-mural colour Doppler signs and pneumoperitoneum. The diagnosis of BN can be made earlier on ultrasound than on abdominal radiographs. This pictorial essay will familiarise the reader with a wide range of conditions that may cause BN in children. The reader will also learn to recognise the imaging features of BN on various imaging modalities with an emphasis on ultrasound. Knowledge of these findings will help the radiologist diagnose the condition early, possibly preventing severe complications later on.
The neonatal spine: Ultrasound technique and pathology
Great Ormond Street Hospital for Children, London, UK
Abstract
We present an educational poster of ultrasound scanning techniques and imaging examples of both normal and abnormal neonatal spinal pathology encountered at a quaternary paediatric referral centre. Great Ormond Street NHS hospital, London (GOSH) is a quaternary paediatric referral centre which sees a wide variety of patients and pathologies. Ultrasound is frequently used at GOSH as a first-line investigation of the spine and is particularly useful as a screening tool for most suspected neonatal spine abnormalities within the first few hours of life. It is an effective, non-invasive technique with high sensitivity and specificity. The pitfalls, however, are that it is highly operator dependent and requires a sound knowledge, systematic approach and confidence in usage of the equipment. We analysed imaging of patients referred to our institution over the last five years (which included 300 patients) for an ultrasound of their spine. We present our ultrasound scanning techniques and protocols used to enhance imaging and reduce inter-observer variability. We highlight the variety of clinical presentations requiring specialist spinal imaging that lead to a quaternary centre referral. These commonly include abnormalities seen in utero, myelomeningocele, skin discolouration of the lumbar region, sacral dimpling, bladder abnormalities and congenital abnormalities with spine association. We present a pictorial review of the variety of pathology encountered using ultrasound alongside any cross-sectional imaging correlates, drawing reference from normal anatomy. These include myelomeningocele, cord tethering, sacrococcygeal teratoma and vertebral anomalies. Spinal pathology is a commonly encountered entity, however, often met with a degree of trepidation when ultrasound is used as an imaging modality. We have shown the techniques employed at a quaternary paediatric centre alongside both normal anatomy and examples of pathology with cross-sectional imaging correlates.
Vascular anomalies – The key role of ultrasound in making the diagnosis
Great Ormond Street Hospital for Children, London, UK
Abstract
Vascular anomalies are richly varied in their clinical presentation and can be a diagnostic challenge for those without experience in this field. The classification of vascular anomalies is explained, with examples of the characteristic sonographic features of each subtype. The poster emphasises why it is also crucial to take a comprehensive clinical history and examine the patient to ensure the correct diagnosis. The poster includes examples of all the vascular anomaly subtypes encountered at a specialist paediatric vascular anomalies referral centre and aims to simplify this diagnostic field for the sonographer. Vascular anomalies are common, with haemangiomas occurring in approximately one in 22 children. The clinical spectrum of vascular anomalies is diverse and imaging features vary according to the age of the child. Ultrasound is an efficient, non-invasive and highly effective imaging modality for characterisation of these anomalies but an understanding of the medical history and clinical findings is key to making a definitive diagnosis and advising on subsequent management. Over 500 soft tissue ultrasound scans have been reviewed in order to demonstrate: (1) the variety of clinical presentations of vascular anomalies in childhood, (2) recommended scanning techniques and ultrasound protocols for compartmentalising the main VA subtypes, (3) how to differentiate between a vascular malformation and a haemangioma or other benign vascular tumour and (4) the value of ultrasound in directing further investigation and management of vascular anomalies. Vascular anomalies are richly varied in their clinical presentation and can be a diagnostic challenge for those without experience in this field. This poster gives an overview of the lesion subtypes and highlights aspects of the clinical history, examination and ultrasound study which are critical in making a correct and confident diagnosis.
Case report: Hepatocellular carcinoma on top of cystic fibrosis related liver disease: A deadly combination
Radiology, Crumlin Children’s Hospital, Dublin, Ireland
Abstract
Cystic fibrosis is defined as an autosomal recessive disorder caused by a defect in the cystic fibrosis transmembrane conductance regulator (CFTR) protein. It is a progressive disease process resulting in irreversible respiratory damage. Cystic fibrosis associated liver disease (CFLD) is progressive liver disease in these patients. It is presumed the CFTR protein on the surface of cholangiocytes is impaired resulting in inspissated bile. This ultimately leads to biliary obstruction resulting in fibrosis and cirrhosis of the liver. A 16-year-old female patient with trisomy 21 and cystic fibrosis attended the ultrasound department. The patient had no surveillance scan performed since 2012, even though there were extensive hepatobiliary manifestations of the disease previously documented. Using a curvilinear 5-1 MHz transducer in conjunction with a linear 13-5 MHz, an abdominal scan was performed. Ultrasonography of the liver revealed a coarse, heterogeneous echotexture associated with a nodular capsule and periportal fibrosis. Doppler studies illustrated portal hypertension in conjunction with recanalisation of the para umbilical vein. A suspicious hyperechoic lesion measuring 14.3 cm × 13 cm was detected within the right lobe. As a result of the sonographic findings, an MRI liver and CT thorax were subsequently performed, which revealed a 4 cm × 4 cm lung lesion. A CT-guided lung biopsy was carried out. Based on histology results, the patient was diagnosed with metastatic HCC and her condition was palliative. Ultrasound can be used as a baseline tool to diagnose and monitor progression of CFLD. A coarse, heterogeneous nodular liver leads to difficulties in the detection of hepatocellular carcinoma. It is relatively cheap, quick and easy to perform but with the known limitation of operator dependency. Published guidelines recommend annual ultrasound surveillance for CF patients to detect hepatobiliary manifestations. However, a lack of interval ultrasound imaging led to a very poor prognosis for this patient.
Musculoskeletal ultrasound in children – Some of the challenges and pitfalls
Radiology, York Hospital, York, UK
Abstract
Use of ultrasound in both children and MSK imaging is well established. Our District General Hospital (DGH) performs about 1600 paediatric US per year, the majority being renal, abdominal and screening hip examinations by paediatric radiologists and sonographers. Over the past few years the exponential use of ultrasound for assessing superficial lumps and bumps and musculoskeletal problems in children has meant a steep learning curve for our MSK radiologists, predominantly trained in adult imaging. We would like to share some strategies we have learned. There are many challenges associated with scanning a child; some of the more important are practical involving actually getting to scan the child and keeping them still for the duration. Our pictorial discussion reviews the tricks and stratagems we use to persuade the child into the room and onto the bed. We show some of the parental holds and distraction techniques we employ in an effort to keep the child still. Young children may not accurately localise or communicate the site of symptoms, requiring flexibility of approach. Although scan technique is similar in adults and children, the anatomy may be unfamiliar and changes markedly over a relatively short period of time as cartilaginous parts of joints progressively ossify. We provide examples of joints at different ages and stages of maturation. One of the main pitfalls can be differentiating cartilage from joint effusion or synovitis. We use cases to illustrate some of the techniques we have found useful in avoiding misinterpretation. Some conditions and injuries encountered are specific to children, the history may be unclear and in infants the possibility of infection, non-accidental injury or developmental anomalies with deeper communication must be considered. Ultrasound is excellent for children in MSK but has associated challenges and pitfalls. We discuss how some of these may be overcome.
Case report: Application of bowel ultrasound in comparison to MRI
Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
Abstract
Crohn’s disease (CD) is an inflammatory disorder affecting any part of the gastrointestinal tract. The incidence and prevalence of CD is rising.1 Imaging is pivotal in diagnosis and in monitoring disease activity. Although several imaging modalities are used, MR enterography is often preferred due to the high resolution of both bowel and relevant extra-intestinal sites. However, drawbacks include lack of availability, patient preparation and examination length which may be challenging for infants. Ultrasound offers advantages of being non-invasive, generally well tolerated and providing a dynamic assessment of the bowel.2 A 14-year-old boy of Hungarian origin with known CD, asymptomatic on maintenance treatment, was found on examination at a routine appointment to have an 8–10 cm mass palpable in the right iliac fossa. An ultrasound scan was arranged which showed presence of a grossly abnormal mass of bowel loops with at least three interloop fistulae and markedly abnormal vascularity of surrounding mesentery. The terminal and distal ileum were thick walled, with dilatation of the mid-ileum suggesting a stricture. An MRI small bowel study corroborated these findings. He was commenced on biologic treatment and underwent an ileocaecal resection. Further cases are demonstrated in our presentation. This case, alongside other examples in our presentation, highlights potential advantages of using ultrasound as an adjunct to MRI in the surveillance of CD. Sonographic assessment is reliable in detecting inflammatory changes within the colon and distal ileum – with our case clearly depicting interloop bowel fistulae – and may be particularly useful to confirm equivocal or unusual findings seen in other imaging modalities.
References
Case Report: Soft tissue masses in children: An important differential diagnosis
Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
Abstract
Synovial sarcomas (SS) are malignant tumours arising from mesenchymal cells and account for 10% of all sarcomas.1 They most frequently occur in young adults, commonly within extremities near large joints. SS can invade locally and/or give rise to nodal or distant metastasis. A nine-year-old boy, previously fit and well, presented with a week’s history of atraumatic painless swelling of the inferomedial right thigh. The only relevant history was a strong family history of malignancy including leukaemia and breast cancer. On examination, a soft mass was palpable overlying the right lower femur, with a harder area centrally. Initial ultrasound demonstrated a mixed echogenicity soft tissue mass measuring 11 cm × 6 cm × 5 cm, centred on the posterior compartment of the distal right thigh, displacing the hamstrings posteriorly. Hypoechoic foci were found within, though these did not return Doppler signal to indicate intralesional vessels. Small disorganised arterialised vessels were present in other areas of the mass. A subsequent MRI study demonstrated a lesion with a central solid component and surrounding cystic areas, some of which appeared to be blood filled. At this point, an atypical vascular malformation was in the differential as well as a neoplastic process. Ultrasound-guided needle biopsy confirmed a biphasic SS. PET-CT ruled out nodal and distant metastasis. Chemotherapy was instituted prior to considering surgery, which may include amputation for local control. Synovial sarcomas can be misdiagnosed as benign pathology due to their insidious onset and well-circumscribed appearance. On sonographic assessment, certain features can overlap with those found in vascular malformations or haematomas. It is important to consider SS as a differential diagnosis in children with soft tissue masses, and undertake biopsy where appropriate.
Reference
Head and Neck
Satisfying NICE (quickly) – A sonographer’s experience of a streamlined approach to becoming proficient in ultrasound-guided biopsy in the neck
Radiology, ABMU Health Board, Wales, UK
Abstract
In February 2016 NICE published ‘Cancer of the upper aerodigestive tract: Assessment and management in people aged 16 and over’. This recommended the use of ultrasound-guided biopsy for the assessment of neck lumps. While the role of the neck lump clinic or alternative referral pathways are a source of much debate, there is certainly increased demand for ultrasound-guided neck biopsy. Ultrasound-guided biopsy has been traditionally undertaken by radiologists, but due to increasing demand, availability and portability of ultrasound, and a national shortage of radiologists, this has resulted in other healthcare practitioners increasingly undertaking these procedures. Successful sonographer-led neck lump clinics have been established throughout the United Kingdom based on training schemes adapted to the resources available locally. To date there is no nationally recognised training pathway for sonographers wishing to perform ultrasound-guided neck biopsy. The poster details how an ‘in house’ sonographer training programme was established for head and neck ultrasound-guided FNA in Morriston Hospital, Swansea. Unlike other training schemes in the UK our programme was streamlined, requiring completion of fewer biopsies, focusing instead on multiple work-based assessments performed at regular intervals throughout the training. The assessments, performed by different radiologists, were based on the ‘mini-DOPS’ tools used by the Royal College of Radiologists and are an essential part of the Radiology Trainee’s curriculum. These Direct Observation of Procedural Skills are used as a summative measurement of progress in a particular technique, taking into account not only practical skills, but also communication and cross infection. The poster describes the programme, its advantages and pitfalls, and highlights the multiple assessments that had to be successfully completed prior to moving onto the next. The assessment tools encourage reflective practice. The trainee was also required to keep a separate log book of biopsies performed with periodical reflection on positive and negative experiences. The trainee attended the Head and Neck Oncology MDT and also regularly audited their biopsy success against local and national standards. Through regular assessment, reflection and audit of the trainee’s progress this training pathway offers a reproducible, transparent, efficient and ultimately safe training pathway with the goal of becoming proficient in a much sought after procedure.
Case report: Scrofula – The King’s Evil. Sonographic features of tuberculous cervical lymphadenitis
1Mater Misericordiae University Hospital, Dublin, Ireland
2University College Dublin, Dublin, Ireland
Abstract
Tuberculosis (TB) is on the rise in non-endemic countries. Factors linked with its resurgence include human migration, multi-drug resistance and acquired immunodeficiency syndrome (AIDS). Extrapulmonary TB can manifest as tuberculous cervical lymphadenitis (TCL), historically known as scrofula. This poster describes the application of ultrasound (US) in a case of TCL. A 23-year-old Nepalese woman presented to an Irish hospital with night sweats, neck pain, right-sided supraclavicular swelling and a non-productive cough. Over a period of nine months, ultrasound was used to aid the diagnosis of TCL, assist therapeutic intervention and monitor the effectiveness of anti-microbial treatment. Early sonographic findings demonstrated normal nodal appearances – echogenic fatty hilum with associated vascular elements. Raised clinical suspicion warranted intervention by means of a core needle biopsy. During the procedure, a hypoechoic mass with an inhomogenous echotexture was visualised, likely representing a TB abscess. TCL was confirmed after the detection of heavy acid-fast bacilli during laboratory testing. Ultrasound-guided fine needle aspiration was used to acquire a sample of purulent material for drug sensitivity testing. Follow-up ultrasound imaging demonstrated more pronounced features of cervical adenopathy – hypoechoic rounded nodes, displaced vasculature and posterior acoustic enhancement. A large purulent abscess was also detected. The abscess spontaneously discharged on two occasions. Final ultrasound evaluation demonstrated residual fluid without adenopathy, indicating resolution of TCL. In addition to its role in assisting the diagnosis of scrofula, ultrasound has a part to play in the ongoing monitoring of response to treatment in complex cases of tuberculous cervical lymphadenitis.
A practical approach to the common diagnostic dilemmas encountered in ultrasound examination for thyroiditis
Imaging, UCLH, London, UK
Abstract
Thyroiditis is inflammation of the thyroid gland1 and it is a common presentation in a busy head and neck ultrasound clinic. While there are some typical ultrasound appearances that point to a particular type of thyroiditis, there is a level of overlap and contradiction that can generate confusion. In order to use the ultrasound findings to guide diagnosis, it is important to consider imaging appearances alongside the clinical context. This poster aims to provide a collective overview of the different types of thyroiditis, incorporating clinical features, signs and symptoms and typical ultrasound appearances, with a view to providing a practical and unambiguous approach to formulating an ultrasound report and diagnostic conclusion that positively assists the referring clinician. There is room for a small introductory section that discusses the categories of thyroiditis including some of the physiological mechanisms of how these processes manifest themselves. There is a pictorial section illustrating the various ultrasound appearances that when correlated with hormone and antibody profiles and patient signs and symptoms can direct the ultrasound practitioner towards the categorisation/identification of the type of thyroiditis presenting in the patient. A flow chart is developed that assists the ultrasound practitioner in arriving at their diagnostic conclusion. Optimal report terminology can then be discussed that provides the referring clinician with a useful adage to the array of results used for patient consultation.
Reference
Case report: Clinical role extension for sonographers
Ultrasound, Derriford Hospital, Plymouth, UK
Abstract
Clinical role extension is an essential facet of sonographer practice. Extending clinical roles have the potential to enhance patient pathways by widening access for patients to more specialised ultrasound examinations. For the ultrasound practitioner, properly delegated role extension can help to retain role satisfaction while maintaining a safe, supportive environment. This poster describes a training package for sonographers in head and neck ultrasound, including the performance of invasive tests where needed. We describe the documentation, training, assessment, governance and ongoing CPD which are necessary to ensure that extended practice is safe and well accepted by clinicians within and without the imaging department. It is hoped that our experience may be used as a framework for other sonographers in developing their own extended clinical practice roles.
Reducing non-diagnostic thyroid FNA rates using two-pass technique
Cirencester Radiology Department, Gloucestershire Hospitals NHS Foundation Trust, Gloucester, UK
Abstract
Thyroid Fine Needle Aspiration (FNA) is a low risk technique with non-diagnostic cytology reported in up to 40% of patients in the literature, although the number of needle passes is not usually specified. A study from Brazil in 2012 has suggested that a two-pass needle technique is optimal. An audit of a total of 112 thyroid FNAs was performed by the author between July 2010 and May 2017; 64 used a one-pass technique, and 48 used a two-pass technique. The percentage of non-diagnostic FNAs (Thy1) was 31% with the one-pass technique, reducing to 15% with a two-pass technique. Non-diagnostic FNAs likely to be cysts (Thy1c) were found in 45% using the one-pass technique, reducing to 31% with the two-pass technique. In summary, the two-pass needle technique shows a clear reduction in the rate of non-diagnostic FNAs, therefore, the author will continue to use this technique. Some ultrasound images are presented.
Correlation between the British Thyroid Association ultrasound grading of thyroid nodules and histopathology specimens with assessment of inter-rater agreement: A one-year institutional experience from UCLH
Radiology, University College London Hospitals, London, UK
Abstract
The British Thyroid Association (BTA) guidelines 2014 introduced an ultrasound (US) classification for thyroid nodules (U1-U5) with U1 being normal thyroid, U2 benign, U3 indeterminate, U4 suspicious for malignancy and U5 likely malignant. We retrospectively reviewed thyroidectomy specimens from a 12-month period between 2015 and 2016. One hundred and twenty-one specimens were eligible for inclusion. The U grade given in the original US report was correlated with the histopathology result. In addition, four observers (three consultant radiologists and one sonographer, all with an interest in head and neck imaging) retrospectively allocated a U grade based on the saved US pictures, blinded to the patient information, original reports and any cytology or histopathology results. The rate of malignancy for each U category (as given in the original report) was calculated: U2 = 3%; U3 = 40%; U4 = 79%; U5 = 100%. In addition, we calculated the specificity and sensitivity for diagnosis of malignant thyroid nodules on US for the original report and four further raters. The sensitivity was high (92–98%); however, the specificity was only moderate (43–49%). The inter-rater agreement was calculated for the original reports and four further raters, with a Fleiss Kappa score of 0.51, indicating moderate inter-rater agreement. We conclude that the BTA guidelines U classification has a high sensitivity for detecting malignant thyroid nodules but only a moderate specificity and moderate inter-rater agreement. This is likely to be due to the inherent difficulty in the assessment of thyroid nodules on US but may also be due to the complexity of the scoring system. The next step would be to ascertain whether the BTA guidelines provide any advantage over a simplified three-tier scoring system, e.g. benign, indeterminate, likely malignant. We intend to repeat the study comparing both the BTA 2014 U grading with a simplified three-tier score.
Physics
Evaluation of subjective and objective ultrasound quality assurance sensitivity assessment methods
Joint Department of Physics, Institute of Cancer Research and Royal Marsden NHS Foundation Trust, Sutton, UK
Abstract
Current quality assurance (QA) procedures incorporate subjective tests of system sensitivity, i.e. the ability of the system to detect and display weak echoes. While it is apparent that automated methods could reduce the time intensiveness of QA, it is not clear to what extent automation influences the variance and also which sensitivity method is most reproducible. Two routine system sensitivity tests were evaluated, namely the in-air reverberation distance (AR) (IPEM 102 guidelines) and the depth of penetration (DOP) (AAPM TG1 guidelines) for linear array probes from three ultrasound scanners (SuperSonic Imagine Aixplorer/SL15-4 (S1), Medison Accuvix XQ/L5-12IM (S2) and Zonare Z.one/L10-5 (S3)). Following guidelines, four observers manually performed (×3) the tests and saved images for automated analysis. A computer program was developed to automatically estimate the AR and DOP using observer images. Results were compared statistically (T-test) and by coefficient of variation (COV). Mean inter-user manual and automated AR and DOP distances were either not statistically different (p > 0.05) (S2/S3) or within the tolerance of one reverberation line (AR,∼1 mm) or 1 cm (DOP) presented in guidelines (S1). The mean COV difference between manual and automatic methods was also not significant. The mean COV was lower for both manual and automated estimates of AR (5.3 and 4.0%, respectively) compared to DOP (8.5 and 8.7%). For a single observer and imaging preset, mean (intra-user) COV was <5% for both manual and automated estimates of AR and DOP. AR was more sensitive than DOP to −3 dB reduction in transmit power (mean change in AR was −8.6 ± 6.2% greater). Results support the use of automated and objective estimates of sensitivity. Automatic methods would speed up QA. Automatically reproduced image acquisition settings such as a QA preset could also be employed, due to removal of subjectivity in image interpretation. AR estimates appear to be more sensitive to changes in scanner sensitivity than DOP.
Everything you wanted to know about knobs but were too afraid to ask
Radiology, Derriford Hospital, Plymouth, UK
Abstract
The array of tools available for image optimisation in ultrasound can seem bewildering, and once the initial hurdle of understanding and demonstrating anatomy has been overcome, producing the best quality image becomes the next challenge for any trainee in the field. Whilst image optimisation can help to produce better images, its use requires a good understanding of the underlying physics in order to maximise its potential and avoid introducing artefact. Here, some of the common image optimisation techniques are reviewed together with the physics that underlies them.
In vivo validation of 3D transperineal ultrasound estimates of prostate motion during radiotherapy
1Radiotherapy and Imaging, Institute of Cancer Research, Sutton, UK
2Radiotherapy and Imaging, Royal Marsden Hospital, Sutton, UK
Abstract
Ultrasound is increasingly used for image guidance in radiotherapy (RT).1,2 Good soft-tissue contrast, excellent spatial resolution and non-ionising nature make it an attractive modality for estimating prostate motion during treatment. The Elekta Clarity® ultrasound system is designed for RT guidance applications. Here we present an in vivo validation of the system for monitoring 3D prostate motion during RT fractions. Imaging data from 17 patients across 80 fractions were analysed as follows. Sequences of 3D ultrasound images were acquired during radiotherapy delivery. Simultaneously acquired X-ray portal image sequences were contrast enhanced and reviewed by three observers to manually identify the positions of three intra-prostatic fiducial markers. The Clarity® system’s prostate position monitoring data were compared to marker positions in the portal images. Three observers rated the ultrasound image sequences into four image quality levels. A sequence from each level was selected. Prostate motion was estimated using an in-house automated echo-tracking algorithm3 and by manually tracking anatomical features within the prostate. These estimates were compared to Clarity®. Clarity measurements of prostate position exhibited a 1 mm mean geometric error and 95% uncertainty of 3 mm relative to portal images. Alternative motion estimation methods produced estimates similar to Clarity, independent of image quality. Clarity accurately estimates prostate motion regardless of image quality, demonstrating its potential usefulness in motion compensation strategies during radiotherapy delivery.
References
Measurement of the output of transvaginal probes and correlation with temperature variation in a phantom test
Ultrasound and Underwater Acoustics, National Physical Laboratory, Teddington, UK
Abstract
The Thermal Index (TI) is commonly used as an indicator for the assessment of the thermal hazard. TI definition and the methods for its evaluation are reported in the IEC standard 62359. However, use of TI has been criticised for being too simplistic, not taking into account, for example, the spatial and temporal distribution of heat deposition and transducer self-heating. This latter aspect can be the dominant source of thermal hazard during endocavitary scans. Thirty-two different transvaginal probes from five manufacturers were tested in 17 hospitals. The surface temperature with the probe operating in air was measured using an infrared camera and the acoustic output power was measured using a pyrometer. The results were correlated with temperature variations measured in a phantom, reported in a previous work. When B-mode was activated for gynaecology and obstetrics presets, the average temperature rise at equilibrium for the probe in air was 5.5°C (st. dev. 2.5°C, max 12.5°C). An average output power of 16.1 mW (st. dev. 7.1 mW, max 41 mW) was measured using the pyrometer. When compared with the temperature after a sufficiently long exposure in the phantom experiments, the coefficients of determination R2 for linear regression were 0.70, 0.48 and 0.28 (at the surface and at 7 and 14 mm depth within the phantom, respectively) for the infrared measurements, and 0.30, 0.30 and 0.36 using the acoustic power. R2 was always below 0.1 using the thermal index. Both the probe temperature in air and the acoustic output power measurements were better predictors than the TI for the final temperature after a sufficiently long exposure, based on phantom measurements. Goodness of fit decreases with depth using infrared data and increases when output power is used.
In vivo measurement of temperature variation during transvaginal scans
1Ultrasound and Underwater Acoustics, National Physical Laboratory, Teddington, UK
2Queen Charlotte’s and Chelsea Hospital, London, UK
3Imperial College Healthcare NHS Trust, London, UK
4Imperial College London, London, UK
Abstract
Transvaginal examinations, particularly of the first trimester fetus, are safety critical due to the close proximity of sensitive tissues to the transducer that can produce heat during use. However, knowledge of how heat is generated and transferred to tissues remains limited, and the monitoring of thermal hazards mostly relies on a derived parameter, the thermal index (TI). We carried out a registered Service Evaluation on 24 patients and measured the temperature rise during transvaginal scans, using fine wire thermocouples (75 µm spatial resolution), secured to the surface of the transducer. Two scanners were used (GE Voluson E8 with a RIC 6D transducer and Samsung WS80 with a V5-9 probe). With the thermocouple in place, no imaging artefacts were detected. Where possible, examinations were recorded to DVD. Generated images were anonymised and analysed using custom-developed software, which was able to extract the values of the TI, and the active imaging mode and status. This information was correlated with the recorded temperature. The average duration of the scans was 7 minutes 15 seconds (minimum 3, maximum 18 minutes). The majority of the scans last around 4 minutes. The average peak temperature was 36.3°C, minimum 34.1°C, maximum 38°C, with most of the scans showing a value around 37.5°C, with no significant difference shown between the machines. When the video was available, it was possible to correlate the temperature curves to the active mode and TI. The measured temperature at the probe surface never approached values reported as hazardous in the international standards. For an average body temperature of 36.5°C, the most frequent temperature rise was around 1°C. Results of duration and maximum temperature are in line with previous studies. Doppler modes were often correlated with faster increases in temperature and higher temperatures being achieved.
Professional Issues
Right test, right place, right time: Implementing the BMUS Best Practice Guidelines
Ultrasound, Hull and East Yorkshire Hospitals NHS Trust, Hull, UK
Abstract
All ultrasound service providers want to give the best care to their patients. Quality assessment and peer review can ensure that the patients receive a high-quality examination performed by competent sonographers working in a service underpinned by education and development. However, all services are under pressure. With a year-on-year increase in demand for ultrasound imaging in the region of 7.2% since 2013 making best uses of all resources, be it staffing, appointment capacity or hardware is paramount in the delivery of a cost effective, efficient and effective ultrasound service. Locally, a significant peak in demand of 24% in 2015/16 was realised. At this point action was required as additional resources in terms of staffing and room capacity could not be sourced. It was recognised that implementing the BMUS Best Practice Guidelines to justify referrals may aid in demand management. Following discussion and agreement with the local Clinical Commissioning Group the BMUS guidelines were implemented in February 2017. Since then, any referrals deemed inappropriate are returned to the referrer with advice and guidance of either alternative imaging or more appropriate actions required. Between February and June 2017 11917 GP referrals were received. Of these, 946 were cancelled as inappropriate and 94 changed modality or had subsequent US imaging following further information. This has resulted in a real decrease in imaging activity of 7.5%. This poster outlines the process followed to ensure that educating referrers is at the heart of the demand management. The ultimate goal of this process is to ensure patients receive the right test in the right place at the right time.
Mystery shoppers – A quality review process in radiology
1Ultrasound, Hull and East Yorkshire Hospitals NHS Trust, Hull, UK
2Radiology, Plymouth Hospitals NHS Trust, Plymouth, UK
Abstract
The national Friends and Family Test (FFT), launched in 2013, is an important feedback tool that supports the fundamental principle that people who use NHS services should have the opportunity to provide feedback on their experience. However, the FFT quality assessment tools within radiology often centre around the clinical aspect of the patient pathway rather than evaluating patient experiences of the whole journey from referral to examination. The use of mystery shoppers in the retail sector is widely embraced to assess quality of the customer experience. The same process can be mirrored within radiology to review the quality of the service provided. The idea of using mystery shoppers in radiology was first devised by the radiology accreditation team at Derriford Hospital, Plymouth as a means of quality testing the patient pathway. The process was then introduced within ultrasound of the Hull and East Yorkshire Hospitals NHS Trust. The radiology process from receiving the appointment letter through to being greeted into the examination room by the radiographer or radiologist is reviewed using this process. This poster presents the results of the patient feedback from both hospital sites. The key learning outcomes generated by the feedback are presented. The mystery shopper feedback has proven to be a useful quality assessment process in both centres and the authors recommend its widespread use. Top tips and pitfalls to avoid are presented to aid implementation within other imaging departments.
A simple method for measuring ultrasound slice thickness with depth
Christie Medical Physics and Engineering, Christie NHS Foundation Trust, Manchester, UK
Abstract
Any changes in slice thickness incurred by lens repair or replacement may be clinically relevant. A simple method for measuring ultrasound beam slice thickness with depth has been devised. The technique aims to allow quantification of acoustic lens wear via changes in measured slice thickness at different stages of a transducer’s working life. Proof of principle of the technique has been established, with the theory and method described in an accompanying submission. This poster displays and discusses example images from tests on a range of scanners and transducers. The transducers have been selected such that a cross-section of transducer ages and differing levels of acoustic lens wear are represented. Visual representation of the measured slice thickness is displayed to show the simplicity of interpreting the data acquired by the technique. The newly devised method can give quantitative information about the ultrasound beam slice thickness of a clinical transducer. By comparing repeat measurements over time, quantitative assessment of acoustic lens wear can be performed.
Lump not rump: The value of a sonographer run lump ultrasound service
Radiology, London North West Hospital Trust, London, UK
Abstract
Superficial soft tissue masses are common, occurring in approximately three per 1000 per year of the general adult population with the vast majority of superficial lumps being benign (99%). The value of ultrasound referral is for reassurance and the identification of potentially serious lesions requiring further assessment. The aim of this study is to show the value of an ultrasound triage by sonographers to identify cases needing further assessment. Retrospective audit of prospectively acquired data from GP-referred lump ultrasound performed over an eight-month period by three trained and experienced sonographers was carried out. Sonographers initially had all scans reviewed by consultants, reducing to selective review after four weeks. Standards set locally were >90% of reports made through a structured template identifying cases needing further assessment; images in two planes, with measurements and colour flow in >90%; consultant opinion in >90% of lumps >5 cm, with deep infiltration, irregular margins or suspicious intra-nodular flow. Of the total of 113 cases, 30 patients had no lump at the time of examination. Of the 83 lumps examined, 81/83 (98%) had structured reports through templates; 78/83 (94%) had satisfactory images; 3/83 lumps were regarded as atypical and all of these were double reported by consultants. No malignancies were identified. A timely, sustainable service was provided enabling reassignment of 2–3 consultant lists per week. All standards have been met for the sonographer-led lumps and bumps service. As expected, the pickup rate of serious pathology is very low. We recommend that a sonographer-run lump ultrasound service is feasible, efficient and uniform and will allow consultant sessions to be released for complex cases.
Vascular
EVAR stent graft: Ultrasound characteristics
Vascular Studies Unit, University of South Manchester NHS Trust, Manchester, UK
Abstract
Management of Abdominal Aortic Aneurysms via Endovascular Aneurysm Repair (EVAR) has become common practice. EVAR choice is partly governed by specific stent graft features that lend themselves to best treatment for that aneurysm. Multiple stent graft types exist within post EVAR ultrasound (US) surveillance. This poster identifies the various stent models that are frequently being used by vascular surgeons today and highlights common pitfalls that US practitioners must be aware of to avoid misdiagnosis. Device images have been obtained with permission from EVAR manufacturers including Vascutek, Trivascular Endologix, Medtronic, Lombard and Cook Medical. A selection of US images was obtained with the aims of demonstrating common pitfalls and highlighting the potential risks of misdiagnosis as a result of common EVAR device characteristics. Different stent graft device characteristics can be visualised on 2D US. Endobags in Nellix devices can be mistaken for thrombus/dissection. Altura with a unique bilateral ‘D’ shape stent design lacks a single neck which can be perceived as a dissection. Ovation stent graft consists of sealing rings and therefore type 1a endoleak misdiagnosis from pooled blood at the two polymer rings can occur. Anaconda devices have a saddle shape configuration designed for aneurysm with highly angulated necks and are commonly misdiagnosed as a kinked/fractured stent graft. Conventional devices include Cook which uses anchoring barbs and Endurant with endoanchors. Both are visualised as echogenic walled structures and pose low risk of misdiagnosis despite little evidence on endoanchors until the ANCHOR trial is complete. The multitude of stent grafts adopted in EVAR surgery has increased the occurrence of new stent types within EVAR surveillance. Communication between the surgical team and surveillance team is ever more important. A good understanding of the device characteristics by US practitioners is essential to prevent misdiagnosis.
Case report: Sonographic findings of a recannalised femoral pseudoaneurysm: What happened next?
University College, Dublin, Ireland
Abstract
A femoral pseudoaneurysm is one of the most common complications following cardiac catheterisation. In this case a 90-year-old lady presented to the ultrasound department for a four-week follow-up of a left superficial femoral artery (SFA) pseudoaneurysm. This developed as a complication of a coronary angiogram and was treated initially with ultrasound-guided thrombin injection which appeared to result in complete thrombosis of the pseudoaneurysm. The ultrasound examination incorporated a B-mode, colour Doppler and spectral Doppler assessment of the left SFA. An echolucent sac adjacent to the SFA was identified on B-mode. Colour Doppler identified a tract connecting the pseudoaneurysm chamber to the SFA. The ‘yin-yang’ sign was also visualised within the chamber, indicating bidirectional flow. Spectral Doppler demonstrated a ‘to-and-fro’ waveform in the communicating neck between the SFA and the pseudoaneurysm chamber, indicating blood entering and exiting during systole and diastole, respectively. Ultrasound findings indicated a recannalised pseudoaneurysm due to a persistent defect in the proximal SFA. Surgical correction was deemed necessary for the patient. In anticipation of this, a computed tomography lower limb angiogram was performed. This demonstrated a haematoma anterior to the proximal SFA with no visible arterial flow, indicating that the pseudoaneurysm had spontaneously thrombosed. Therefore, no further intervention was required. This case study demonstrates an unusual outcome in the management of a femoral pseudoaneurysm. Although ultrasound-guided thrombin injection was successful initially, the pseudoaneurysm recannalised. Additionally, the recannalised pseudoaneurysm spontaneously thrombosed. Ultrasound plays an essential role in the diagnosis and monitoring of a pseudoaneurysm. Diagnostic confidence is achieved when the triad of classical ultrasound findings are identified, including an echolucent sac adjacent to a vessel on B-mode, the ‘yin-yang’ sign on colour Doppler and the ‘to-and-fro’ waveform on spectral Doppler.
General Imaging
What is the impact of changing body position on liver stiffness estimates obtained using point shearwave elastography in fasted healthy volunteers?
1Philips Healthcare, Guildford, UK
2University of Leeds, Leeds, UK
Abstract
The aim of this study was to investigate the effect of changing posture on liver stiffness elastography measurements (LSEM) obtained using Point Shear-wave Elastography (PSWE) in healthy volunteers. Sixteen self-selecting healthy volunteers with BMI < 30 kg/m2 were fasted for at least 3 hours before being examined by a single operator using an Affiniti 70 Philips® system with C5-1 curvilinear transducer. Ten LSEM (kPa) were performed with participants in standard supine (control), left lateral decubitus (LLD) (experimental 1) and semi-erect (SE) (experimental 2) positions. The right lobe of liver was accessed intercostally on neutral breath hold. Data analysis of the mean LSEM using both Bland Altman assessment for agreement and paired sample t-tests to compare control values with each of the two experimental positions was performed. The patient characteristics were as follows: median age 37 years (range 22–61) and median BMI 22.2 kg/m2 (range 17–28). LSEM results were as follows: mean (SD) and median (range) in kPa: Supine: 4.66 (0.85), 4.66 (3.22–6.95); LLD: 4.80 (1.06), 4.65 (3.40–6.95); semi-erect: 5.26 (1.42), 5.23 (2.87–7.68). Experiment 1 resulted in a mean difference of 0.14, p = 0.593 (95% CI −0.41 to 0.69). Experiment 2 showed a mean difference of 0.59, p = 0.027 (95% CI 0.07–1.11). Bland Altman analysis indicates 95% limits of agreement (LoA) for experiment 1 of 2.22 to −1.98 and experiment 2 of 2.5 to −1.3. Both experimental postures showed increased variability in LSEM relative to supine control. No statistically significant difference for supine v LLD suggests these postures are interchangeable in clinical practice; the statistically significant difference for SE posture suggests this could lead to higher liver stiffness grading, up to 1 kPa. Although mean differences were small, the wide LoA (approximately 2 kPa) for both experimental postures could have clinical impact, particularly in mild/moderate fibrosis categories due to narrower cut-off ranges. Results suggest measurements should be performed in supine posture where possible, or the same posture maintained for patients undergoing serial surveillance scans.
Case report: Exposition of a renal cell carcinoma (RCC) with an associated pelvis mass on ultrasound
Radiology, Sheffield Teaching Hospitals NHS Trust, Sheffield, UK
Abstract
Renal cell carcinoma (RCC) is the most common type of adult kidney cancer, accounting for 90% of cases.1 Common metastases include ovarian and pelvic tumours; however, an incidental finding of a solitary tumour is the most likely presentation. Prognosis largely depends on the stage of the cancer upon discovery, with survival rates decreasing significantly if the cancer has metastasised,2 highlighting the importance of early diagnosis, of which ultrasound (US) is an acknowledged part. This case study will focus on US in a patient with RCC and an associated pelvic mass. US arguably has the largest role to play in the diagnosis of this RCC. Its initial diagnostic value is huge, owing to it being the first imaging modality for most abdominal complaints. Furthermore, US is not solely limited to diagnosis through B-mode visualisation. In addition, recent developments such as CEUS, elastography and fusion imaging in conjunction with guided percutaneous biopsies make it difficult to perceive a more complete modality for RCC assessment. This work makes recommendations for future practice, deeming it necessary to improve the assessment of iliac venous velocities in lower limb Doppler studies. It may also be beneficial to extend a negative Doppler scan further to assess the pelvis, as adnexal scanning was proved integral. However, US as a staging modality is not advocated, due to lack of sensitivity, specifically in IVC assessment in this case. Furthermore, huge diagnostic and management benefits would likely be granted to this patient if CEUS and fusion imaging were commonly used, alongside a ‘one stop’ scan and biopsy clinic for kidney lesions. This work has highlighted throughout how US use is fundamental to earlier and accurate diagnosis, treatment and management.
References
Case report: Goblet cell carcinoma of the appendix
Ultrasound, Leicester Royal Infirmary, University Hospitals of Leicester, Leicester, UK
Abstract
A 50-year-old male presented for urinary tract ultrasound. Symptoms included dysuria, frequency and lower abdominal pain, persisting for several months with no known infective cause. Ultrasound was requested to rule out bladder stones. There was no previous relevant imaging. Ultrasound showed an avascular, hypoechoic mass (9 cm × 3 cm × 4 cm), which contained several hyperechoic, shadowing foci, indenting on the external bladder wall from the right iliac fossa. CT reported a focal, thick walled, enhancing collection related to the superior aspect of the urinary bladder. There was a contiguous, enhancing soft tissue mass tethered and involved the urinary bladder, terminal ileum, distal ileum and appendix in a stellate configuration. No fistula was identified. Appearances were of primary appendiceal pathology. In view of the enhancing soft tissue mass, surgical excision was advised. Histology showed a diffusely infiltrative Goblet Cell Carcinoma (GCC) of the appendix. Goblet cells are glandular cells which excrete mucins to protect associated mucous membranes. GCC occurs when there is excessive proliferation of both goblet and neuroendocrine cells. Goblet cell carcinoma accounts for 5% of neoplasms of the appendix, with an annual incidence of 0.12 per million. GCCs are rare and share characteristics with adenocarcinoma and carcinoid tumours. They almost exclusively involve the appendix. Symptoms often present in fifth and sixth decade with no gender preference. Clinical presentations are varied, most commonly acute appendicitis, pain and mass. Other symptoms include bowel obstruction, intussusception and gastrointestinal bleeding. Imaging findings include ill-defined nodular thickening of the appendix (most commonly at the tip) with a diffuse pattern of infiltration. The majority of GCCs are >2 cm and demonstrate longitudinal growth patterns. In 3% of patients with GCC, findings are incidental. Treatment requires en bloc resection, possibly followed by chemotherapy, systemic or hyperthermic intraperitoneal chemotherapy (HIPEC) for recurrent peritoneal disease.
Case report: Ultrasound in diagnosing acute calculous cholecystitis
1Radiology, Sheffield Teaching Hospital, Sheffield, UK
2University of Leeds, Leeds, UK
Abstract
Acute cholecystitis affects about one in 10 adults in the United Kingdom.1 This case study identifies a patient with suspected gallstone disease and the role of ultrasound in the diagnosis and outcome. A 44-year-old female presented to the Accident and Emergency (A&E) department with an acutely tender upper abdomen. A previous ultrasound examination reported a solitary, mobile gallstone. The ultrasound examination revealed a solitary, immobile gallstone in the neck of the gallbladder, smaller mobile gallstones in the fundus and biliary debris. The gallbladder wall appeared thickened and oedematous with hyperaemic vascularity. The patient also displayed a positive Murphy’s sign. Using the clinical signs and ultrasound a diagnosis of acute calculous cholecystitis was made. The patient had a laparoscopic cholecystectomy and made a full recovery. Early diagnosis is imperative to relieve pain and plan for surgical management for patients with acute calculous cholecystitis. The accuracy of ultrasound in diagnosing acute calculous cholecystitis has been described as imperfect; its sensitivity is widely varied between studies. However, ultrasound has a high sensitivity and specificity in detecting cholelithiasis, which is one of the main findings in acute cholecystitis and in this case. Other imaging characteristics in this case such as wall thickening, pericholecystic fluid and specifically a positive Murphy’s sign, improve ultrasound’s ability alone to diagnose acute calculous cholecystitis. This patient underwent a laparoscopic cholecystectomy within five days as recommended by NICE.2 There is much discussion into the advantages and disadvantages of both laparoscopic surgery and open surgery and much depends on the severity of the inflammation. This case was successfully treated using laparoscopic methods, which are less invasive. In this case ultrasound alone was able to efficiently conclude and diagnose acute calculous cholecystitis.
References
Case report: An unusual presentation of urachal tumour
Portsmouth Hospitals NHS Trust, Portsmouth, UK
Abstract
There are only around 350 cases of urachal cancer described in the medical literature to date, accounting for 0.2% of all bladder cancers. Urachal cancer is a rare type of cancer arising from the urachus or its remnants. It is often difficult to diagnose and requires a multidisciplinary approach. Patients who present with early confined disease have a good prognosis, whereas those with advanced disease have less promising outcomes. We report a case of a 40-year-old woman with no previous history, complaining of unprovoked right shoulder pain. Following an initial x-ray which demonstrated diffuse permeative disease, further imaging tests including ultrasound ultimately made the rare diagnosis of metastatic urachal malignancy, which was confirmed by biopsy. Advanced ultrasound practitioners should be aware of the role of ultrasound in the management of indeterminate pelvic masses. As ultrasound is often a first-line imaging tool it is important to be aware of the appearances and be able to differentiate pelvic masses to exclude the rare diagnosis of urachal malignancy.
Case report: Appendix mucocele
Queen Alexandra Hospital, Portsmouth, UK
Abstract
Appendix mucoceles are a rare finding presenting in 0.2–0.3% of surgical appendectomy specimens. There are four main types: mucosal hyperplasia, mucinous neoplasm of the appendix, appendiceal carcinoid and an adjacent caecal tumour. The result is obstruction of the appendiceal lumen and accumulation of mucous. The discovery of a mucocoele is usually incidental as patients are asymptomatic and prognosis is usually positive if no mucous cells are noted within the peritoneum. This report reviews a 70-year-old patient with a palpable mass within the right adnexa and no previous significant clinical history. She was known to have fibroids and the initial assessment with ultrasound was requested through her gynaecologist. The ultrasound demonstrated a 10 cm tubular heterogeneous structure seen separate to the right ovary and extending from the caecum. While the patient was in the department she was reviewed by a specialist GI sonographer. Appearances were concluded to be in keeping with an appendiceal mucocoele and review with CT and colorectal opinion was recommended. Advanced ultrasound practitioners need to be able to appreciate findings of indeterminate pelvic mass as timely management can have improved prognosis for the patient in rare cases. As this is the common modality of choice for initial assessment, advanced ultrasound practitioners need to be able to assess findings even if they are outside their scope of their practice.
Gynaecology
Is a full bladder still necessary for pelvic ultrasound?
Radiology, Plymouth Hospital NHS Trust, Plymouth, UK
Abstract
Despite some evidence that it is not necessary, female patients are often asked to arrive with a full bladder for initial transabdominal ultrasound views, prior to a transvaginal ultrasound. The rationale is to provide a good ultrasound ‘window’ to assess the uterus and ovaries. However, in our centre, the vast majority of patients go on immediately to have a transvaginal ultrasound anyway, during which better views are usually obtained. Therefore, we postulated that asking patients to arrive with a full bladder was unnecessary, and led to delays whilst the patient left the ultrasound room to void. We reviewed all the images acquired for 20 consecutive patients, to determine whether adequate views were obtained transabdominally, and then transvaginally. We also wished to determine, via a patient satisfaction survey, whether patients had any discomfort from the pressure of the ultrasound probe on the abdomen, if they had a full bladder, or whether they were in discomfort in the waiting area, with a feeling of needing to void. The total time taken to complete the clinical encounter was also recorded, to determine if asking patients to arrive with a full bladder and then sending them out of the ultrasound room to void resulted in significantly longer appointment times. The study was therefore undertaken at two centres, one which asked patients to arrive with a full bladder via a letter sent out with the appointment time, and one which did not. The results were compared.
Solid Adnexal Masses – All you need to know
1Peninsula Radiology Academy, Plymouth, UK
2Imaging, Plymouth Hospital NHS Trust, Plymouth, UK
Abstract
Pelvic ultrasound is the most common technique used to assess adnexal masses and it is important for all practitioners to understand the sonographic features used to characterise adnexal masses. Benign adnexal masses are predominantly cystic although some, e.g. dermoids and cystadenomas may have a solid component. Malignant epithelial neoplasms are usually largely cystic with a variable amount of solid tissue. Predominantly solid adnexal masses may be benign (e.g. fibroma) but include rare malignancies such as sex cord stromal tumours, malignant germ cell tumours and metastases. Solid extra-ovarian masses may also mimic ovarian pathology in the adnexa. Understanding the key identifying features of solid adnexal masses and potential pitfalls is therefore extremely valuable in everyday pelvic ultrasound. We present a pictorial review of predominantly solid adnexal masses and how their sonographic appearances are used to aid diagnosis.
Case report: Ovarian dysgerminoma – Lessons learnt
Obstetrics and Gynaecology Ultrasound, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
Abstract
A 28 year old presented at the Early Pregnancy Assessment Unit (EPAU) believed to be pregnant with suboptimal Beta-Human Chorionic Gonadotropin (bHCG) levels. On ultrasound scan there was no evidence of an intrauterine pregnancy. However, a bulky right ovary was reported containing a ‘39 mm cystic area with several septa and the appearance of some solid elements with no associated vascularity’. The ultrasound appearances were interpreted by clinicians as suspicious for ectopic pregnancy. The patient’s bHCG levels were then monitored. Over a period of three months the patient’s bHCG levels fluctuated and a second ultrasound scan was performed by a specialist nurse practitioner where a bulky right ovary was reported, but nil else. The case was then referred to the Trust’s gynaecology diagnostic multidisciplinary team (MDT) meeting where images from both ultrasound scans were reviewed by a consultant radiologist and specialist sonographer. The outcome from the meeting was that a further ultrasound scan would be performed by the specialist sonographer as appearances of the right ovary from both ultrasound scans did not appear normal. At this ultrasound scan appearances of the right ovary were highly suspicious for a lesion. Pathology confirmed ovarian dysgerminoma. Many lessons were learnt from this case and recommendations included standardisation of ultrasound reports on EPAU, interpretation of ultrasound reports and who should review reports, together with the remit of specialist nurse practitioner focused scanning. Positive outcomes from the case highlighted the value of a gynaecology diagnostic MDT meeting and the role of the specialist sonographer working closely with a consultant radiologist and gynaecologists.
Exposition of an endometrial polyp on ultrasound
Radiology Sheffield Teaching hospitals NHS Trust, Sheffield, UK
Abstract
An Endometrial Polyp (EP) is a mass situated within the lining of the endometrium, affecting premenopausal and postmenopausal women, specifically those treated with tamoxifen.1,2 It is estimated that around 25% of women have an EP,3 which are a predominately benign overgrowth of endometrial cells, however, a malignant risk exists (1–3%).4,5 Commonly, endometrial polyps may be difficult to differentiate between endometrial hyperplasia, prolapsed submucosal fibroids and endometrial carcinoma.6 Malignancy risk, alongside symptoms such as menorrhagia and infertility, categorise EPs as a pathology that requires an early diagnosis to aid best treatment. Ultrasound (US) is the first-choice modality for assessment of suspected EPs and pelvic abnormalities,7 with large studies proving it highly sensitive.8 This work focuses on US in a patient with an EP and how US imaging, plus recent US developments can help to aid diagnosis and improve management. Overall, US is arguably the most complete imaging modality for endometrial assessment and with current technological developments, supported by future research and proactive changes to the current tentative treatment pathway, US can become undeniably valuable. Additionally, this work draws a basic conclusion on the treatment and management of this patient whilst also analysing the use of other appropriate imaging adjuncts.
References
Case report: Ultrasound in diagnosing a dermoid cyst
Radiology, Sheffield Teaching Hospitals, Sheffield, UK
Abstract
Dermoid cysts are the most common benign ovarian germ cell tumour and make up 10–20% of ovarian neoplasms.1 This case report illustrates the use of gynaecological ultrasound in the diagnosis of a dermoid cyst in a young, premenopausal female with abdominal pain. A nulliparous, premenopausal, 21-year-old female attended the ultrasound department for a pelvic scan as requested by her General Practitioner (GP). The request read: ‘Lower abdominal pain, very tender. History of ovarian cysts in home country of Albania’. The patient was a victim of human trafficking and was unable to communicate her symptoms and history. There were no prior biochemical tests. The transabdominal scan revealed there was a complex, unilocular mass of mixed echogenicity measuring 22 mm in the right ovary. The transvaginal examination verified the right ovarian mass consisted of solid components and hyperechoic stranded echoes and demonstrated acoustic shadowing. The right ovarian mass was reported as a dermoid cyst and a gynaecological referral was recommended. The dermoid cyst was not causing any acute symptoms at the time and the patient is currently undergoing expectant management. Ultrasound has a high sensitivity in diagnosing dermoid cysts. Despite this, dermoid cysts can have a varied appearance which makes the diagnosis challenging. The images demonstrated multiple, thin echogenic striations within which may represent hair and posterior acoustic shadowing likely caused by calcified components within the mass. These appearances have previously been described as typical ultrasound characteristics of a dermoid cyst. Using the IOTA simple rules also deterred suspicions of malignancy. Whilst laparoscopic surgery is the preferred management, conservative management for smaller dermoid cysts is accepted. In this case ultrasound alone was able to efficiently conclude and diagnose a dermoid cyst.
Reference
Obstetrics
Cervical length measurement – A pictorial review
1Ultrasound Department, Nottingham University Hospitals NHS Trust, Nottingham, UK
2University of Derby, Derby, UK
Abstract
Preterm birth is one of the largest causes of neonatal morbidity. The cervical length measurement can be used during pregnancy to act as a predictor for the likelihood of preterm labour and can act as a tool for surveillance of the cervix to enable clinicians to guide any intervention or treatment in a timely fashion. The measurement of cervical length is an advanced technique which is inherently difficult for trainee and newly qualified sonographers to become competent and confident in performing. Cervical length scanning is frequently performed by feto-maternal medicine specialists and obstetricians at Nottingham University Hospitals NHS Trust with specific preterm birth clinics now being undertaken. Consequently, the number of cervical length scans performed by the obstetric ultrasound department is not as large, which impacts on staff confidence in performing the technique. The aim of this pictorial review is to outline the cervical anatomy which is visualised when performing a cervical length ultrasound examination. The optimum technique is discussed alongside common pitfalls of the cervical length examination and how to overcome these. This review aims to act as a useful guide in the technique of performing the cervical length scan to aid the confidence of obstetric sonographers.
Review of third trimester abdominal circumference (AC) measurements
Rosie Ultrasound, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
Abstract
The aim of this work is to pilot a method of peer review for obstetric ultrasound. Sonographers are aware of the need for peer review as advocated by both the Royal College of Radiologists and BMUS. Vigorous review processes are in place for nuchal translucency scans. Similar peer review processes are not routine within other areas of obstetric ultrasound. To pilot obstetric peer review we have chosen third trimester growth scans, and specifically AC measurements due to the implementation of the ‘Saving Babies Lives’ care bundle. This relies on serial third trimester growth scans to monitor pregnancies at risk of fetal growth restriction. AC measurements are the best predictor of fetal wellbeing. There is evidence to suggest that the two-diameter method of measurement is more reproducible than an ellipse. Twenty-two growth scans (5% March 2017) were randomly selected. The BMI, amniotic fluid index and gestational age were recorded. Nine sonographers blindly re-measured five AC images using the ellipse and two-diameter methods. The sonographers were given a PowerPoint presentation of 22 measured AC images to assess independently against image criteria based on the Fetal Anomaly Screening Program. The results were then presented and discussed with the sonographers. Preliminary results showed comparable inter-operator variability between ellipse and two-diameter measurements as follows:
• Minimum Difference ellipse = 16.9 mm
• Minimum Difference 2-diameter = 12.7 mm
• Maximum Difference ellipse = 33.7 mm
• Maximum Difference 2-diameter = 35.7 mm
The average retrospect ellipse measurements for each case varied from the original measurement obtained during live scanning by between −9.9 mm and +1 mm; this indicates a possible tendency to over-measure the AC during scans. Individual sonographers are now more aware of their own practice and the potential for bias. The next stage will be to evaluate the interpretation of AC measurements by reviewing reports. We will re-audit in three months’ time and plan to use the same model to review other aspects of obstetric ultrasound.
Potential of new 3D ultrasound-based metric to assess the fetal skull: A pilot study
1Department of Perinatal Imaging and Health, King’s College London, London, UK
2Biomedical Image Analysis Group, Imperial College London, London, UK
Abstract
The purpose of this study was to evaluate the potential of a novel 3D cranial index (3DCI), derived automatically from 3D ultrasound (US) volumes and to compare 3DCI to the usual method for skull shape assessment (cephalic index, CI = BPD/OFD). This retrospective study (NRES ref.num. 14/LO/1806) includes 55 cases (mean gestational age 24.7 weeks, range 20–36) collected during a dedicated US research clinic. All participants had previously had a mid-trimester anomaly scan. Standard 2D scanning planes and 3DUS head volumes were acquired using a Philips Epiq7G scanner with a X6-1 xMatrix transducer. The skull was automatically segmented using a fully convolutional network architecture, and a statistical model of the normal head shape was generated using principal component analysis and leave-one-out cross-validation. The 3DCI was computed as the distance to the mean shape of the skull normalised to the patient’s gestational age. Additionally, a patient-specific 3D distance map was automatically generated showing in detail the spatial distribution of the distance to the expected shape. The CI was obtained from manually annotated 2D scans. The 5th percentile threshold was used to identify potentially abnormal cases in both metrics. The ground truth for fetal assessment of skull shape was established by a sonographer and a fetal medicine specialist, identifying two cases with dolichocephaly. The accuracy, specificity and sensitivity for the abnormal shape identification were 90, 50 and 92% for CI, and 98, 100 and 98% for 3DCI. The new automatic 3DCI significantly outperformed the CI (p-value <0.005 using McNemar’s statistical test). The new automatic and objective US-based 3D biometric has the potential to provide objective and accurate assessment of the fetal head, reducing sonographer subjectivity and showing higher diagnostic power than traditional metrics. Finally, the patient-specific morphological map of the fetal skull could allow more objective and quantitative follow-up of the patient’s evolution.
Case report: Twin reversed arterial perfusion (TRAP) sequence
1Fetal Assessment Unit, Regional Hospital Mullingar, Mullingar, Westmeath, Ireland
2Radiography and Diagnostic Imaging, School of Medicine, University College Dublin, Dublin, Ireland
Abstract
Twin reversed arterial perfusion (TRAP) sequence, unique to monochorionic twins, is where one twin (acardiac) has an absent, rudimentary or non-functioning heart with a normal second (pump) twin. It is hypothesised that the acardiac twin has no direct vascular connection to the placenta, obtaining all of its blood supply through an arterio-arterial communication from the unaffected twin. We report a case of TRAP sequence diagnosed at 13 weeks’ gestation. On ultrasound a monochorionic–monoamniotic twin pregnancy was diagnosed, the second twin inappropriately grown with acardiac amorphous. Colour Doppler displayed reversed arterial blood flow towards the acardiac twin via the umbilical artery. The pump twin delivered at term. The pump twin has a high mortality rate due to cardiac failure. Early and accurate diagnosis in this case facilitated appropriate referral for vital assessment and close monitoring resulting in a good outcome for the pump twin.
Early Pregnancy
Diagnosing caesarean scar pregnancy with transvaginal ultrasound
Radiology, Nottingham University Hospitals, Nottingham, UK
Abstract
Caesarean scar pregnancy (CSP) is the implantation of a pregnancy in a hysterotomy scar. The prevalence is low and the diagnosis is challenging, with 13% of reported cases misdiagnosed.1 Misdiagnosis is significant as untreated CSPs can result in serious complications. In 2016, the RCOG published criteria for diagnosing CSP using transvaginal ultrasound.2 However, these criteria were derived from descriptive studies. A literature review will therefore be conducted to identify the evidence base for diagnosing CSP and evaluate the RCOG’s guidelines. A literature review was conducted with a carefully considered search strategy. Key words from the title were enhanced and used as search terms in high-quality healthcare databases. The results were assessed against inclusion and exclusion criteria, leaving three articles for critical appraisal. The study by Timor-Tritsch et al.3 described seven imaging features for diagnosing CSP with TVUS. These support the RCOG’s diagnostic criteria. However, a small number of cases (n = 26) were used. Also, the study’s conclusions came from practical experience rather than tested evidence. Buresch et al.4 described six ultrasound markers that also support the RCOG’s criteria. However, again these recommendations are based on the experience of the authors and not a trial. Timor-Tritsch et al.1 found an accurate method for diagnosing CSP by assessing the location of the gestation sac relative to the midpoint of the uterus. This was not described by the RCOG. The literature review showed that the RCOG’s diagnostic criteria are supported by current research evidence and can be used in local practice. However, research based on large-scale studies of accuracy was not found. This means that while the results of the literature review agree with the RCOG, validated evidence to support the diagnosis of CSP with TVUS is still lacking.
References
Image quality management in early pregnancy: The case for improved guidance
Medical Physics, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
Abstract
Early pregnancy scans for patients with severe and genuine anxiety over pregnancy loss require sensitive care and quick accurate diagnosis. The quality of early pregnancy ultrasound (EPUS) scanning has recently been under review and as a result a small sample of four EPUS machines was subject to advanced quality testing. The results were suboptimal, supporting the hypothesis that a lack of coordinated professional and management guidelines has been affecting the quality of early pregnancy scanning. Machines are not managed by the imaging department, therefore, quality management controls such as governance and procurement are easily overlooked. Scanning is not covered under ISAS accreditation, or RCR guidelines, and lies outside the remit of FASP. Users have diverse training, from experienced sonographers, to midwives and rotational specialist trainee grade doctors. There are no clear published recommendations for quality assurance testing in early pregnancy. Medical physics testing has shown variable performance across early pregnancy machines, using standard and novel methods. A semi-automated MATLAB script to assess the contrast-to-noise ratio (CNR) in phantom anechoic targets was developed. Preliminary results of Kruskal–Wallis testing showed significance (P < 0.000) between the CNR of clinically ‘failing’ and adequately performing machines. It is recommended that quality assurance testing is undertaken on all early pregnancy machines and national guidelines produced to improve and standardise service provision.
Other
Ultrasound scoring for assessment of soft tissue masses
Department of Radiology, Morriston Hospital, Swansea, Wales
Abstract
Ultrasound scans are frequently used in the initial assessment of suspected soft tissue masses, with underlying concern that the mass may be malignant. This study aimed to develop an ultrasound-based scoring system to identify the benign lesions so as to expedite assessment and subsequent treatment. The British Sarcoma Group guidelines give a number of criteria for assessing whether a lesion should be considered suspicious and these were adapted with ultrasound findings to give a scoring system, each being scored as 0 if negative or 1 for positive, and a total score assigned. Our audit of more than 200 patients showed that majority of patients (∼90%) referred for assessments of soft tissue lesions have a score of 0 or 1. Less than 7% of patients scored 3 or more. The advantage of using this scoring system is that it makes early assessment of lesions relatively straightforward for non-specialised radiologists and sonographers. This means there is easier and quicker triage of patients helping to easily identify lesions that do not need further imaging and specialist input. It also helps to make the services of specialised radiologists quickly available to patients who need specialist assessment and treatment.
Impact of an intensive ultrasound training block on trainee competence
1Imaging, Peninsula Radiology Academy, Plymouth, UK
2Imaging, Plymouth Hospitals NHS Trust, Plymouth, UK
Abstract
Ultrasound training involves a steep learning curve and within the current clinical climate there is ever increasing pressure on departments to optimise the efficiency of their ultrasound service. It is increasingly important, therefore, that we deliver ultrasound training that is effective for trainees, and helps them achieve competence as early in their training as possible, whilst minimising impact on service provision. In our institution ST1 ultrasound training is multifaceted, involving simulator training, small group tutorials and small group clinical cases in addition to clinical supervised scanning, which all run alongside other modality learning. Two years ago we introduced a dedicated intensive month long ultrasound block, which all trainees rotated through during the first year of training. Trainees are assessed utilising a standardised assessment template after 10 months of training when most, but not all trainees have rotated through the block. To assess the impact of introducing a dedicated ultrasound block, we compare the assessment scores from those who have completed their ultrasound block with those who have not. We use the data from these assessments to demonstrate the impact of an intensive ultrasound block on trainee competence.
The role of ultrasound in the assessment of chest pathology – A pictorial review
Ultrasound, Maidstone and Tunbridge Wells NHS Trust, Maidstone, UK
Abstract
The poster aims to visually display examples of thoracic pathology and conditions which can be evaluated with ultrasound either in department or at the bedside. This is a useful tool for the ultrasound practitioner to include in their report to improve the diagnosis and therefore the treatment pathway of the patient.
When the penny drops – Threshold concepts in postgraduate sonographer training and development
Diagnostic Imaging, University of Derby, Derby, UK
Abstract
Meyer and Land present the idea that in most disciplines … ‘there are “conceptual gateways” or “portals” that lead to a previously inaccessible, and initially perhaps “troublesome”, way of thinking about something’.1 These are the ‘penny drop’ moments that lead to transformative and irreversible learning, the dawning realisation of the interconnection of theories and practice experiences that enable students to make sense of profession-specific expectations. Threshold concepts can transform the way students think and challenge their self-identity. Both are key as they move towards autonomy as advanced practitioners. However, these insights may lead to challenge and re-evaluation of their emerging professional role. An informal workshop was used to explore the idea of threshold concepts and skills with ultrasound mentors and consider the key ‘penny drop’ moments in sonographer training. We consider the threshold concepts that underpin key skills (such as scan orientation and effective communication) and the stages of learning when we would expect these to be grasped. We explore the challenges in identifying students who are in a ‘stuck place’ and innovative interventions that can help students progress. We found:
• Mentors focused overwhelmingly on threshold skills rather than underlying concepts;
• Limited consensus on the expected timing of when key concepts should normally be grasped by students;
• More guidance is needed from the University on creative learning opportunities.
Further work is required to identify threshold concepts that are implicit (but not clearly articulated) within the curriculum and discussion of ‘troublesome’ concepts needs to be encouraged. We consider novel ways of enabling students to explore threshold concepts within their own practice. Mentor training needs to include guidance to help them identify students who are in a ‘stuck place’.
Reference
Where’s the baby?
Diagnostic Imaging, University of Derby, Derby, UK
Abstract
In ultrasound training, image orientation and the ability to link 2D image interpretation with 3D anatomy is key. Ultrasound looks easy when performed by an expert. However, the hand–eye coordination and spatial awareness required to complete a scan often come as ‘a bit of a shock’ to novice sonographers. This is particularly true in obstetrics where we image a moving target. This can result in a rapid drop in confidence and significant anxiety. There is evidence that students cope with this uncertainty by mimicking expert behaviours. This may include transducer position, patient position and ‘image grabbing’. This frequently results in feedback from mentors that the student ‘….just doesn’t get it’. Review of work by Meyer and Land1 identifies the importance of threshold concepts in education. Where students fail to grasp key concepts, they may find themselves in a ‘stuck place’ where they are aware that they are failing to progress but are unable to articulate why. We use simulation activities to ‘unpick’ student understanding of image acquisition. This helps them move from image grabbing to a logical and systematic approach building on good 3D spatial awareness rather than mimicking of observed behaviours. We have developed a simple card game that is enables students to identify misconceptions around image scan planes and orientation that may result in an inability to interpret fetal position and situs. Students and mentors report rapid improvement in scan technique and confidence once essential threshold concepts are grasped. This is frequently described by students and their trainers as a ‘penny drop’ moment. This simple, low-cost intervention may help facilitate early identification of students who are struggling with image orientation and fetal lie. A better understanding of threshold concepts enables us to develop targeted learning and assessment activities.
Reference
Peer assisted learning for point of care ultrasound in nursing education
Acute and Emergency Care Centre, Khoo Teck Puat Hospital, Singapore, Singapore
Abstract
Point of care ultrasound (POCUS) is increasingly utilised by the nursing community. Considerable challenges still exist with regards to training nurses in this skill, as this is typically provided by physician faculty or senior nurses. These include limited faculty time, power distance and scheduling conflicts. Peer assisted learning (PAL) has the potential to overcome these barriers. Nevertheless, despite the extensive body of literature on PAL in nursing education, there remains a paucity of data examining the role of PAL for training nurses in POCUS, and in particular the effectiveness of near peer (NP) versus same level peer (SLP) learning. We designed a prospective quasi-experimental research to evaluate the competency of ultrasound novice nurses who learn ultrasound-guided peripheral intravenous cannulation (UG-PIVC) from near peers (NP) versus same level peers (SLP). Competencies are defined as the time to complete the UG-PIVC task on a standardised mannequin. A visual aid was created to scaffold peer learning and teaching. Two senior nurses were trained by a recognised POCUS expert physician to perform UG-PIVC on the mannequin. They were designed as NP and trained a group of eight nurses. After training, these eight nurses were designated as SLP and subsequently trained another group of 12 nurses. The competencies of these two groups of nurses were recorded and compared using the t-test. Nurses who were taught by the NP and SLP completed the UG-PIVC task with a mean of 104.75 seconds (SD 39.59) and 94.25 seconds (SD 34.88), respectively, p = 0.540. There is no statistical significance in the time to task completion for both groups. The result suggests that ultrasound novice nurses could learn UG-PIVC skills from same level peers as effectively, if not more, compared to learning from near peers. PAL has the potential to alleviate faculty teaching pressure in nursing POCUS education.
Diaphragmatic ultrasound: Technique and cases
1Imaging Peninsula Radiology Academy, Plymouth, UK
2Imaging Plymouth Hospitals NHS Trust, Plymouth, UK
Abstract
Diaphragmatic dysfunction is commonly underdiagnosed as a consequence of the non-specific nature of presentation. Symptoms include dyspnoea, asymmetric breathing, paradoxical movement of the epigastrium, recurrent pneumonia or unilateral collapse, and in mechanically ventilated patients slow respiratory weaning. Diaphragmatic paralysis can be caused by direct involvement of the diaphragm (through trauma, surgery or adjacent pathology), or through neuromuscular disorders such as direct phrenic nerve damage, motor neurone disease, central nervous system abnormalities and muscular dystrophies. Prompt diagnosis is important because some causes are amenable to treatment and provision can be made for longer term ventilatory support. There are multiple well-described techniques for evaluation of the diaphragm, including many different modalities and indirect function tests such as pulmonary function tests, transdiaphragmatic pressure measurements, phrenic nerve conductions studies and electromyography. Although each of these has their strengths and weaknesses, ultrasound combines many of the strengths, offering assessment of both structure and function in a non-invasive, real-time manner at a location of choice (bedside or ultrasound room). We present a guide to the technique of ultrasound assessment of the diaphragm and a series of clinical cases illustrating its utility. Although not a new technique, diaphragmatic ultrasound currently lies out with the skill set of many experienced sonographers and radiologists, commonly falling to critical care or respiratory physicians. At a time when clinicians are looking for added value we suggest that diaphragmatic ultrasound is a useful skill to retain within the imaging department.
Transvaginal ultrasound: The musculoskeletal risks for practitioners
Ultrasound, Maidstone and Tunbridge Wells NHS Trust, Maidstone, UK
Abstract
The aim of this study was to identify factors that affect the strain on practitioners when performing transvaginal ultrasound examinations. The positioning for transvaginal examinations was examined to demonstrate factors, which can impact the strain on the practitioners, and provide ergonomic recommendations. The research was completed in two sections. An electronic questionnaire was designed to provide background information on the technique, prevalence and symptoms of Work Related Musculoskeletal Disorders (WRMSD) amongst practitioners performing transvaginal ultrasound. The second part was an observational study involving seven volunteer sonographers who each performed five transvaginal examinations with each scan in a different patient and sonographer position. Each scan was assessed using the Rapid Upper Limb Assessment form, which evaluated the muscular strain and positioning of the sonographer. The study demonstrated that performing transvaginal examinations with the patient’s legs in stirrups with the sonographer seated scored a RULA score of 6.6, indicating this placed the sonographer at the highest risk of muscular strain and work. Performing transvaginal examinations using a wedge with the sonographer standing scored the lowest RULA score of 3 indicating this position resulted in the lowest risk for muscular strain. A total of 742 responses were analysed for the electronic questionnaire, which demonstrated that 96.2% of respondents were suffering from pain and 87.8% stating transvaginal examinations resulted in awkward postures. The results of the questionnaire demonstrated multiple factors that contribute to work related musculoskeletal disorders. The transvaginal ultrasound examination has been demonstrated to be associated with WRMSD and there remains a high prevalence of pain amongst practitioners who perform transvaginal ultrasound. Performing transvaginal examinations whilst standing improved the sonographer’s posture. These results are in concordance with previous literature; these results indicate a significant association between posture and examination positing and the prevalence and severity of musculoskeletal symptoms.
Penile Sonography: Benefits of clinical input with difficult cases
Leeds Teaching Hospital, Leeds, UK
Abstract
Penile sonography is an accessible and invaluable diagnostic tool in characterising lesions, identifying fractures and assessing functional vascularity. It is technically straightforward but the interpretation of penile lesions can be difficult. This pictorial review aims to demonstrate educational points from two cases regarding a superficial and a deep penile lesion and the crucial benefit of involving the referring clinical team in aiding the diagnosis. Case one: A young man who presented with a smooth and mobile lump on the mid-shaft of the penis for the last six weeks. Clinical diagnosis was a superficial cyst. Sonography demonstrated a hypoechoic ellipsoid lesion on the dorsum of the penis, possibly arising from the glans. Foreskin retraction was not performed; may differentiate the lesion from the skin or the glans. Follow up is ongoing. Case two: A young man who presented with penile discharge and a history of phimosis with a clinical suspicion for penile abscess. Sonography was requested to help differentiate whether the abscess was superficial or deep, to determine the patient’s medical or surgical management respectively. The patient had two scans over two days. The first scan reported as a left corporal abscess involving the glans. The clinical team felt the abscess was deeper and a second scan was done with a urologist on site to demonstrate where the abscess was felt clinically. Repeat sonography confirmed a penile abscess in the deep tissue of the corpora cavernosa without foreskin and superficial tissue involvement. These two cases demonstrate the diagnostic dilemma of performing and interpreting penile sonography. The first demonstrates a scenario whereby technique (i.e. retraction of foreskin) may have altered lesion characterisation. The second highlights the importance of clinical input from the referring team. The lessons from these cases may prove to be useful in improving the quality of penile sonography.
The role of ultrasound in the diagnosis and management of jumpers’ knee: A critical review
1Elizabeth Hospital, King’s Lynn, UK
2Canterbury Christ Church University, Canterbury, UK
Abstract
Jumpers’ Knee is a term used to describe tendonitis or tendinopathy of the patellar tendon, as it is most prevalent following participation in sports such as jumping, basketball, football and volleyball.1 The phrase tendonitis has been in decline following the study by Maffulli et al.2 that suggested inflammatory responses had little involvement in tendinopathic changes. Cook and Purdam3 introduced the concept of tendinopathy as a dynamic process, with areas of a single tendon in different stages at any given time. More recently, a large systematic literature review by Dean et al.4 considered the evidence of inflammation in tendinopathy to be ‘increasingly overwhelming in recent years’. Could the theory that surrounds the aetiology and pathogenesis of tendinopathy, therefore, be about to change once more? Ultrasound aids clinical diagnosis by correlating B-mode and Doppler findings to patient symptoms. However, despite some claims, there seems little evidence that ultrasound findings can reliably predict the onset of Jumpers’ Knee at this moment in time. The optimum imaging modality for accurately diagnosing or predicting tendinopathy may be Shear Wave Elastography (SWE), as De Zordo et al.5 found a correlation between tendon stiffness and normal B-mode appearances, whilst Docking et al.6 found a correlation between SWE strain mapping and tendon thickness. More recently, Dirrichs et al.7 performed a prospective study on 112 patients, in which the correlation between symptomatic tendons and low SWE values was found to be highly significant (P < 0.001); however, it remains to be seen if its use can be more reliable in predicting the onset of tendinopathy when compared to B-mode and Doppler ultrasound.