Department of Radiology, Riley Hospital for Children, Indiana University School of Medicine, ... ultrasound will generate a good differential diagnosis and aid.
1983, The British Journal of Radiology, 56, 527-530
AUGUST
1983
Ultrasound diagnosis of liquid-filled lesions in children By Mervyn D. Cohen, M.B., Ch.B., John A. Smith, M.D., and Gordon F. Greenman, M.D. Department of Radiology, Riley Hospital for Children, Indiana University School of Medicine, 1100 West Michigan Street, Indianapolis, IN 46223 (Received December 1982)
Ultrasound studies were performed on Xonics or ATL real-time ultrasound units. Liquid-filled lesions were diagnosed by the conventional criteria of echo freedom and posterior enhancement. The accuracy of ultrasound in detecting the anatomical site of the lesion was scored as 1 point for correct, 0 points for wrong. In some situations a half point was scored; e.g., for cystic hygromas, ultrasound showed a soft tissue lesion but could not accurately define the origin from lymphatic channels, but taken with the clinical history of a non-inflamed neck mass in Ultrasound may be useful in the evaluation of mass lesions a newborn, a reasonably accurate prediction of detected clinically (Gricom et al, 1977; Haller et al, anatomical site (other than just soft tissue) could be 1978; Wicks et al, 1978; Neuenschwander et al, 1981) or made. abnormalities seen on chest radiograph (Haller et al, Pathological prediction was rated on a score of 0 to 1980; Kangarloo et al, 1977). This study documents the 3. Three points were given for a completely accurate accuracy of ultrasound in identifying liquid-filled lesions, prediction and 0 for a completely wrong prediction of locating them anatomically and predicting their pathology. Two points were scored for giving a short pathology. The utility of other imaging modalities is differential diagnosis of two or three disorders and 1 evaluated. point for a large differential. ABSTRACT
The ultrasound studies and clinical records of 93 children with cystic lesions have been reviewed. Ultrasound is extremely accurate in identifying the cystic nature of the lesions. Where precise anatomical localisation is possible the prediction of pathology is most accurate. Where anatomical localisation (e.g., in soft tissues, some abdominal sites) is more difficult the ultrasound will generate a good differential diagnosis and aid in planning additional investigations. Review of other investigations done showed that CT in 16 cases rarely yielded new information.
METHODS
During the last three years, 97 children seen at the James Whitcomb Riley Hospital have been diagnosed by ultrasound as having liquid-filled lesions (other than hydrocephalus). Four children were excluded from the study because no final clinical or pathological diagnosis was reached. The clinical records, ultrasound studies and other investigations performed on the remaining 93 children were reviewed retrospectively.
RESULTS
Table I summarises the results of ultrasound prediction of anatomical location and pathology of the abnormality. Table II gives the accuracy for prediction of pathology by ultrasound for specific renal lesions. Tables III and IV give the results of studies, other than ultrasound, performed on patients with genitourinary disease and lesions in other sites.
TABLE I ACCURACY OF ULTRASOUND IN PREDICTING ANATOMICAL SITE AND PATHOLOGY OF CYSTIC LESIONS IN 93 CHILDREN
Site of lesion
No. of cases
Pleura/peritoneum Lung/mediastinum Neck Limbs Pancreas Liver/gall bladder Ovary Miscellaneous abdomen Urogenital sinus Renal tract
8 4 6 5 3 11 5 8 3 40
Prediction of site by ultrasound Points scored Maximum % scored 8 3 3 3
2 10 1.5 5 2.5 37.5
100 75 50 60 66 91 30 63 83 94
8 4 6 5 3 11 5 8 3 40
527
Prediction of pathology by ultrasound Points scored Maximum % scored
7.5 13.5 10 6.5 26 8.5 16.5 8.5
91
12 18 15 9 33 15 24 9 120
63 75 66 72 79 57 68 94 76
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56, No. 668 Mervyn D. Cohen, John A. Smith and Gordon F. Greenman TABLE II
ACCURACY OF ULTRASOUND IN PREDICTING CYSTIC LESIONS OF THE RENAL TRACT IN 4 0 CHILDREN
Prediction of pathology by ultrasound Points scored Maximum % scored
Lesion
Multicystic UPJ obstruction Other hydronephrosis Other cystic Miscellaneous
8 8 9 7 8
24 24 27 21 24
16 17 24 17 17
66 72 88 81 72
TABLE III RESULTS OF OTHER INVESTIGATIONS PERFORMED ON PATIENTS WITH CYSTIC GENITOURINARY ABNORMALITIES
Study
Study gives the same or less information than ultrasound
Study Study gives confusing more information than ultrasound
Voiding cystogram Urogram Antegrade renal Computerised tomography Angiogram
9 10 0 2 1
6 8 5 0 0
2 0 1 0 0
TABLE IV RESULTS OF OTHER INVESTIGATIONS PERFORMED ON PATIENTS WITH CYSTIC NONGENITOURINARY ABNORMALITIES
Study
Computerised tomography Abdominal radiograph Cystogram Urogram Cholangiogram Barium enema Upper GI Angiogram
Study gives the same or less information than ultrasound
Study gives more information than ultrasound
13 10 3 1
1 7 0 0 0 2 1 0
2 1 0 2
echoes, increased through transmission or anterior reverberation artefacts in large lesions (Wicks et al, 1978). Bleeding or debris will cause internal echoes (Thurber et al, 1979; Wilson et al, 1978; Kangarloo et al, 1979), and all chest lesions with lung behind them will show increased posterior echoes (Haller et al, 1980). In all our cases, except one, a cystic lesion was accurately diagnosed. The one error was a gigantic cyst replacing the entire spleen. Low internal echoes were thought to suggest lymphoma. At surgery the spleen was replaced by a cyst with turbid fluid with microscopic crystals. This is similar to cases reported previously (Thurber et al, 1979). There have been many reports of the use of ultrasound in diagnosing cystic lesions. Many are reports of only a few cases, and few attempt to define the accuracy of ultrasound. Ultrasound has been used to aid in the diagnosis of cystic hygromas (Haimovici et al, 1980), splenic cysts (Gricom et al, 1977), duplication cysts (Fried et al, 1977), mesenteric cysts (Haller et al, 1978), liver cysts (Weaver et al, 1978), chest cysts (Wolson, 1976), meconium cysts (Carroll & Moskowitz, 1981), adrenal haemorrhage (Mineau & Koehler, 1979), pleural effusions (Haller et al, 1980), aneurysms (Neiman et al, 1979), mediastinal cysts (Haller et al, 1980), renal cysts and hydronephrosis (Stuck et al, 1982). Pleura and peritoneum Ultrasound is accurate for the diagnosis of pleural effusions (Haller et al, 1980). In our study ultrasound was completely accurate in localising pleural and peritoneal lesions but was of little help in identifying the pathological aetiology of the liquid collection. Ascites was due to cirrhosis in two cases, leukaemia in one and neonatal in one. Pleural effusions were due to trauma (1), infection (1), chylothorax (1), and a haemorrhagic disorder (1). Lung and mediastinum Ultrasound identified the cystic nature of four lesions. Together with plain film findings of calcium, two teratomas could be diagnosed. A bronchogenic cyst was identified as the cause of persistent left lung emphysema in a neonate. A very cystic right middle lobe abscess in a 3-week-old infant was misdiagnosed as a bronchogenic cyst.
DISCUSSION
Ultrasound in most cases will accurately identify the liquid-filled nature of a lesion (Wicks et al, 1978; Friedman et al, 1980). The usual criteria for diagnosing a cyst are a smooth-walled lesion with no internal
Neck Ultrasound has identified a cystic hygroma in utero (Haimovici et al, 1980). Ultrasound accurately identified the cystic nature of six lesions, but could not determine the actual tissue of origin except to exclude an arterial or venous connection. Intrathoracic extension of two cystic hygromas was well seen. On purely ultrasound criteria it was difficult to distinguish four cases of cystic hygroma from two neck abscesses. Fortunately clinical distinction is relatively easy.
528
AUGUST
1983
Ultrasound diagnosis of liquid-filled lesions in children Limbs Ultrasound accurately diagnosed one aneurysm. Weber Christian panniculitis, abscess and haematoma could not be accurately differentiated by ultrasound alone. Pancreas In two children with pancreatic pseudocysts, the origin from the pancreas could be accurately defined in one. In the other patients with a clinical history suggestive of pancreatic cyst, a cystic lesion was identified in the region of the pancreas. A pancreatic cystadenoma in the region of the tail of the pancreas could not be differentiated by ultrasound from a pedunculated cystic Wilms' tumour or a necrotic neuroblastoma. Liver and gall bladder Anatomical location was extremely good. The only error was in mistaking a liver cyst with a duct-like protrusion for a choledochal cyst. Two other choledochal cysts and three enlarged gall bladders were accurately diagnosed. Ultrasound could not easily distinguish abscess, haematomas and cystic tumours. Ovary The cystic abnormality was easily identified, but accurate prediction of origin from the ovary proved difficult. This is easiest with small lesions lying adjacent to the uterus but can be impossible with gigantic lesions or lesions in odd sites. We had one neonate with an ovarian cyst in the right upper quadrant. Other abdominal cysts These included meconium pseudocysts, urachal cysts, haematomas and teratomas. In general, in the abdomen cysts not arising from liver, spleen, or kidney were difficult to localise anatomically and thus accurate prediction of pathology was not easy. Identification of calcium was most helpful in diagnosis of teratoma or meconium cyst. Urogenital sinus Ultrasound was very helpful in localising the abnormality and outlining the pathology in three cases of these congenital anomalies.
cystic kidney. This latter report dealt with neonates and older children. Mild primary pelvic hydronephrosis with preserved renal tissue and well-defined calyces may be relatively easy to diagnose. We believe that, in the neonate, multicystic kidney can be very difficult to distinguish from severe hydronephrosis. Even radionuclide studies may occasionally be unhelpful when there is function and filling-in of cystic areas with radionuclide in multicystic kidneys (Siddiqui et al, 1982). Antegrade studies (Babcock et al, 1979; Saxton et al, 1981) may help, but again may be confusing when there is communication between cysts in a multicystic dysplastic kidney (Siddiqui et al, 1982; Saxton et al, 1981). Visualisation of a dilated ureter is extremely helpful in identifying obstruction distal to the pelvi-ureteric junction (Chopra & Teele, 1980). Other investigations In patients with genitourinary pathology micturating cystography was helpful in identifying valves (four cases), a ureterocele (one case) and urethral obstruction (one case). It was of no help in distinguishing primary pelvic hydronephrosis from multicystic kidney. Urography was helpful in showing bilateral hydronephrosis (five cases) and renal function in three cases of primary pelvic hydronephrosis. On six occasions it showed unilateral nonfunction which did not help in distinguishing hydronephrosis from multicystic kidney. It may well be that the intravenous urogram has no strong role in evaluating these cystic renal lesions, as most of the information should be obtainable from radionuclide study. Antegrade studies were helpful in two cases of primary pelvic hydronephrosis, two cases of multicystic kidney and one urinoma. In one case the antegrade study was confusing; communicating cysts mimicked hydronephrosis. CT and angiography were of no help. For nongenitourinary lesions CT was very disappointing. In 13 cases it demonstrated the abnormality but yielded no new information not available from the ultrasound study. Angiography twice yielded the same information as ultrasound. The most helpful additional study was the plain film, when it showed calcification. CONCLUSION
Renal Ultrasound was very good in anatomically identifying renal location of cystic lesions. The only problems were with a gigantic cystic kidney crossing the mid-line and mimicking bilateral involvement, and in differentiating a urinoma from a giant renal pelvis from primary pelvic hydronephrosis. In neonates ultrasound will accurately distinguish cystic from solid neonatal flank masses (Neuenschwander et al, 1981). It has been reported that ultrasound can assist (Rails et al, 1980; Bearman et al, 1976) or accurately differentiate (Stuck et al, 1982) primary pelvic hydronephrosis from multi-
Ultrasound is thus extremely accurate at identifying the liquid-filled nature of a lesion. In the neck, other soft tissues, and some abdominal and pelvic sites it may be difficult to identify the anatomical location of the lesion precisely. This is because the lesion arises from tissue with no distinguishing ultrasound features. Where accurate anatomical location is possible the prediction of pathology is extremely good. Identification of calcium narrows the differential diagnosis considerably. Ultrasound should be used early in the evaluation of mass lesions. With liquid-filled lesions it may be the only study required prior to initiating therapy. If not,
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