Predictors of pain development for contralateral asymptomatic degenerative rotator cuff tears based on features of an ipsilateral painful cuff tear: a prospective longitudinal cohort study

BACKGROUND

Prior rotator cuff disease natural history studies have focused on tear-related factors that predict disease progression within a given shoulder. The purpose of this study was to examine both patient- and tear-related characteristics of a painful rotator cuff tear that predict future pain development and functional impairment in a shoulder with a contralateral asymptomatic cuff tear.

METHODS

This was a prospective longitudinal cohort study of patients aged ≤65 years who underwent surgery for a painful degenerative rotator cuff tear and possessed an asymptomatic contralateral tear. Patients were followed up prospectively by shoulder ultrasound, physical examination, and functional score assessment. The primary outcome was change in the American Shoulder and Elbow Surgeons (ASES) score at 2 years. Secondary outcomes included the Western Ontario Rotator Cuff Index (WORC) score, Patient-Reported Outcomes Measurement Information System (PROMIS) score, Hospital Anxiety Depression Scale (HADS) depression and anxiety scores, and Veterans RAND-12 (VR-12) mental component score (MCS).

RESULTS

Sixty-five patients were included, with a mean follow-up period of 37 months (range, 24-42 months). In 17 patients (26%), contralateral shoulder pain developed at a median of 15.2 months (interquartile range [IQR], 10.5 months). No difference in age, sex, Charlson Comorbidity Index, or occupational demand was noted between patients in whom pain developed and those in whom pain did not develop. In the presenting painful shoulder, there was no difference in baseline tear size, muscle degeneration, or biceps pathology between groups. The mean baseline tear length (8.6 mm vs. 3.8 mm, P = .0008) and width (8.4 mm vs. 3.2 mm, P = .0004) were larger in asymptomatic shoulders in which pain subsequently developed compared with those in which pain did not develop. However, there was no difference in mean tear enlargement (P = .51 for length and P = .90 for width). There were no differences in baseline ASES, WORC, Patient-Reported Outcomes Measurement Information System (PROMIS), or HADS depression and anxiety scores between shoulders in which pain developed and those in which pain did not develop; however, patients in whom pain developed reported a lower baseline VR-12 MCS (53.3 vs. 57.6, P = .04). Shoulders in which pain developed had higher visual analog scale pain scores (2.9 [standard deviation (SD), 2.5] vs. 0.6 [SD, 1.0]; P = .016), lower ASES scores 75 [SD, 33] vs. 100 [SD, 11.6]; P = .001), and significant changes in all WORC scales with pain onset compared with those that remained asymptomatic. The study showed no significant difference in changes in the HADS anxiety and depression scores but found a significant increase in the VR-12 MCS in patients in whom pain developed (7.1 [interquartile range, 12.6] vs. -1.9 [interquartile range, 8.7]; P = .036).

CONCLUSION

In one-quarter of patients with painful cuff tears, pain developed in a contralateral asymptomatic cuff tear that resulted in a measurable decline in function within 3 years. Our analysis showed that only the baseline tear size of the asymptomatic shoulder was predictive of pain development. There were no tear-related features of the presenting painful rotator cuff tear or indices of mental health and physical function or occupational demand that were predictive of future pain development at short-term follow-up.

Spatiotemporal development of the human T follicular helper cell response to Influenza vaccination

We profiled blood and draining lymph node (LN) samples from human volunteers after influenza vaccination over two years to define evolution in the T follicular helper cell (TFH) response. We show LN TFH cells expanded in a clonal-manner during the first two weeks after vaccination and persisted within the LN for up to six months. LN and circulating TFH (cTFH) clonotypes overlapped but had distinct kinetics. LN TFH cell phenotypes were heterogeneous and mutable, first differentiating into pre-TFH during the month after vaccination before maturing into GC and IL-10+ TFH cells. TFH expansion, upregulation of glucose metabolism, and redifferentiation into GC TFH cells occurred with faster kinetics after re-vaccination in the second year. We identified several influenza-specific TFH clonal lineages, including multiple responses targeting internal influenza proteins, and show each TFH state is attainable within a lineage. This study demonstrates that human TFH cells form a durable and dynamic multi-tissue network.

SARS-CoV-2 Omicron boosting induces de novo B cell response in humans

The primary two-dose SARS-CoV-2 mRNA vaccine series are strongly immunogenic in humans, but the emergence of highly infectious variants necessitated additional doses and the development of vaccines aimed at the new variants1-4. SARS-CoV-2 booster immunizations in humans primarily recruit pre-existing memory B cells5-9. However, it remains unclear whether the additional doses induce germinal centre reactions whereby re-engaged B cells can further mature, and whether variant-derived vaccines can elicit responses to variant-specific epitopes. Here we show that boosting with an mRNA vaccine against the original monovalent SARS-CoV-2 mRNA vaccine or the bivalent B.1.351 and B.1.617.2 (Beta/Delta) mRNA vaccine induced robust spike-specific germinal centre B cell responses in humans. The germinal centre response persisted for at least eight weeks, leading to significantly more mutated antigen-specific bone marrow plasma cell and memory B cell compartments. Spike-binding monoclonal antibodies derived from memory B cells isolated from individuals boosted with either the original SARS-CoV-2 spike protein, bivalent Beta/Delta vaccine or a monovalent Omicron BA.1-based vaccine predominantly recognized the original SARS-CoV-2 spike protein. Nonetheless, using a more targeted sorting approach, we isolated monoclonal antibodies that recognized the BA.1 spike protein but not the original SARS-CoV-2 spike protein from individuals who received the mRNA-1273.529 booster; these antibodies were less mutated and recognized novel epitopes within the spike protein, suggesting that they originated from naive B cells. Thus, SARS-CoV-2 booster immunizations in humans induce robust germinal centre B cell responses and can generate de novo B cell responses targeting variant-specific epitopes.

Evaluation of Survivorship of Asymptomatic Degenerative Rotator Cuff Tears in Patients 65 Years and Younger: A Prospective Analysis with Long-Term Follow Up

BACKGROUND

The purpose of this prospective study is to describe the mid to long-term natural history of untreated asymptomatic degenerative rotator cuff tears in patients 65 years and younger.

METHODS

Subjects with an asymptomatic rotator cuff tear in one shoulder and a contralateral painful cuff tear age 65 years or younger were enrolled in a previously described prospective longitudinal study. Annual physical and ultrasonographic evaluations and surveillance for pain development were performed utilizing independent examiners for the asymptomatic shoulder.

RESULTS

Two hundred twenty-nine subjects (mean age 57.1 years) were followed for a median of 7.1 (range 0.3-13.1) years. Tear enlargement occurred in 138 (60%) shoulders. Full-thickness tears were at greater risk for enlargement compared to partial-thickness (HR=2.93, 95%CI 1.71-5.03, p<0.0001) and control shoulders (HR=18.8, 95%CI 4.63-76.1, p<0.0001). Mean survival rates from Kaplan-Meier analyses indicate that full-thickness tears enlarged earlier (mean 4.7, 95%CI 4.1-5.2 years) than partial-thickness (mean 7.4, 95%CI 6.2-8.5 years) and control shoulders (mean 9.7, 95%CI 9.0-10.4 years). Tear presence in the dominant shoulder was associated with a greater enlargement risk (HR=1.70, 95%CI 1.21-1.39, p=0.002). Patient age (p=0.37) and gender (p=0.74) were not associated with tear enlargement. The 2,5 and 8-year survivorship free of tear enlargement for full-thickness tears was 74%, 42% and 20%, respectively. Shoulder pain developed in 131 (57%) shoulders. Pain development was associated with tear enlargement (HR=1.79, 95%CI 1.24-2.58, p=0.002) and was more common in full-thickness tears compared to controls (p=0.0003) and partial tears (p=0.01). An analysis of progression of muscle degeneration was performed 138 shoulders with full-thickness tears. Tear enlargement was seen in 104 of 138 (75%) of these shoulders during follow-up (median 7.7 [6.0] years). Progression of muscle fatty degeneration was seen in the supraspinatus in 46 (33%) and the infraspinatus in 40 (29%) shoulders. Adjusting for age, both the presence of fatty muscle degeneration and the progression of muscle changes for both the supraspinatus (p<0.0001) and infraspinatus (p<0.0001) muscles were associated with tear size. For both the supraspinatus (p=0.03) and infraspinatus (p=0.03) muscles, tear enlargement was significantly associated with progression of muscle fatty degeneration. Anterior cable integrity was significantly associated with the risk of muscle degeneration progression for both the supraspinatus (p<0.0001) and the infraspinatus (p=0.005) muscles.

CONCLUSIONS

Asymptomatic degenerative rotator cuff tears progress in patient 65 years and younger. Full-thickness rotator cuff tears have a higher risk of continued tear enlargement, progression of fatty muscle degeneration and pain development than partial-thickness tears.

Persons with HIV Develop Spike-Specific Lymph Node Germinal Center Responses following SARS-CoV-2 Vaccination

COVID-19 disproportionately affects persons with HIV (PWH) in worldwide locations with limited access to SARS-CoV-2 vaccines. PWH exhibit impaired immune responses to some, but not all, vaccines. Lymph node (LN) biopsies from PWH demonstrate abnormal LN structure, including dysregulated germinal center (GC) architecture. It is not clear whether LN dysregulation prevents PWH from mounting Ag-specific GC responses in the draining LN following vaccination. To address this issue, we longitudinally collected blood and draining LN fine needle aspiration samples before and after SARS-CoV-2 vaccination from a prospective, observational cohort of 11 PWH on antiretroviral therapy: 2 who received a two-dose mRNA vaccine series and 9 who received a single dose of the Ad26.COV2.S vaccine. Following vaccination, we observed spike-specific Abs, spike-specific B and T cells in the blood, and spike-specific GC B cell and T follicular helper cell responses in the LN of both mRNA vaccine recipients. We detected spike-specific Abs in the blood of all Ad26.COV2.S recipients, and one of six sampled Ad26.COV2.S recipients developed a detectable spike-specific GC B and T follicular helper cell response in the draining LN. Our data show that PWH can mount Ag-specific GC immune responses in the draining LN following SARS-CoV-2 vaccination. Due to the small and diverse nature of this cohort and the limited number of available controls, we are unable to elucidate all potential factors contributing to the infrequent vaccine-induced GC response observed in the Ad26.COV2.S recipients. Our preliminary findings suggest this is a necessary area of future research.

SARS-CoV-2 mRNA Vaccination Causes Prolonged Increased Cortical Thickening and Vascularity in Ipsilateral Axillary Lymph Nodes

OBJECTIVES

To describe the serial grey-scale and color Doppler appearance of ipsilateral axillary lymphadenopathy in response to the Pfizer-BioNTech Severe Acute Respiratory Syndrome Coronavirus (SARS-CoV-2) messenger RNA (mRNA) vaccine over 24 to 28 weeks.

METHODS

The data for this study were collected during an observational study to determine whether mRNA vaccination induced a germinal center B cell reaction in blood and draining axillary lymph nodes. The current study evaluated the serial color Doppler and grey-scale sonographic appearance of these lymph nodes. Ten participants who each underwent 6 sonograms and FNAs over 24 to 28 weeks were included in the study. A total of 11 lateral lymph nodes were identified. Cortical thickness was measured and absence or presence of color Doppler flow in the hilum and lymph node cortex was graded (scale: 0-2).

RESULTS

Eleven lateral axillary lymph nodes were biopsied over 24 to 28 weeks. Mean thickness varied through time (P < .001) and was greater weeks 2 to 7 compared to weeks 24 to 28 (mean differences of 2.6 to 1.3; P < .006), but weeks 14 to 17 mean thickness was not different from weeks 24 to 28 (0.57; P = .15). Cortical vascularity was increased in all 11 lymph nodes by week 5. Mean vascularity varied through time (P < .001) and was greater weeks 2 to 14 compared to weeks 24 to 28; mean differences ranged from 1.7 to 0.83 (P < .001).

CONCLUSIONS

Serial grey-scale and color Doppler appearance of ipsilateral axillary lymph nodes after mRNA vaccination manifest as increased and prolonged cortical thickening and vascularity that diminishes and approaches normal by 24 to 28 weeks.

SARS-CoV-2 Omicron boosting induces de novo B cell response in humans

The primary two-dose SARS-CoV-2 mRNA vaccine series are strongly immunogenic in humans, but the emergence of highly infectious variants necessitated additional doses of these vaccines and the development of new variant-derived ones 1-4 . SARS-CoV-2 booster immunizations in humans primarily recruit pre-existing memory B cells (MBCs) 5-9 . It remains unclear, however, whether the additional doses induce germinal centre (GC) reactions where reengaged B cells can further mature and whether variant-derived vaccines can elicit responses to novel epitopes specific to such variants. Here, we show that boosting with the original SARS- CoV-2 spike vaccine (mRNA-1273) or a B.1.351/B.1.617.2 (Beta/Delta) bivalent vaccine (mRNA-1273.213) induces robust spike-specific GC B cell responses in humans. The GC response persisted for at least eight weeks, leading to significantly more mutated antigen-specific MBC and bone marrow plasma cell compartments. Interrogation of MBC-derived spike-binding monoclonal antibodies (mAbs) isolated from individuals boosted with either mRNA-1273, mRNA-1273.213, or a monovalent Omicron BA.1-based vaccine (mRNA-1273.529) revealed a striking imprinting effect by the primary vaccination series, with all mAbs (n=769) recognizing the original SARS-CoV-2 spike protein. Nonetheless, using a more targeted approach, we isolated mAbs that recognized the spike protein of the SARS-CoV-2 Omicron (BA.1) but not the original SARS-CoV-2 spike from the mRNA-1273.529 boosted individuals. The latter mAbs were less mutated and recognized novel epitopes within the spike protein, suggesting a naïve B cell origin. Thus, SARS-CoV-2 boosting in humans induce robust GC B cell responses, and immunization with an antigenically distant spike can overcome the antigenic imprinting by the primary vaccination series.

SARS-CoV-2 mRNA vaccination elicits a robust and persistent T follicular helper cell response in humans

SARS-CoV-2 mRNA vaccines induce robust anti-spike (S) antibody and CD4+ T cell responses. It is not yet clear whether vaccine-induced follicular helper CD4+ T (TFH) cell responses contribute to this outstanding immunogenicity. Using fine-needle aspiration of draining axillary lymph nodes from individuals who received the BNT162b2 mRNA vaccine, we evaluated the T cell receptor sequences and phenotype of lymph node TFH. Mining of the responding TFH T cell receptor repertoire revealed a strikingly immunodominant HLA-DPB1∗04-restricted response to S167-180 in individuals with this allele, which is among the most common HLA alleles in humans. Paired blood and lymph node specimens show that while circulating S-specific TFH cells peak one week after the second immunization, S-specific TFH persist at nearly constant frequencies for at least six months. Collectively, our results underscore the key role that robust TFH cell responses play in establishing long-term immunity by this efficacious human vaccine.

Germinal centre-driven maturation of B cell response to mRNA vaccination

Germinal centres (GC) are lymphoid structures in which B cells acquire affinity-enhancing somatic hypermutations (SHM), with surviving clones differentiating into memory B cells (MBCs) and long-lived bone marrow plasma cells^1-5 (BMPCs). SARS-CoV-2 mRNA vaccination induces a persistent GC response that lasts for at least six months in humans^6-8. The fate of responding GC B cells as well as the functional consequences of such persistence remain unknown. Here, we detected SARS-CoV-2 spike protein-specific MBCs in 42 individuals who had received two doses of the SARS-CoV-2 mRNA vaccine BNT162b2 six month earlier. Spike-specific IgG-secreting BMPCs were detected in 9 out of 11 participants. Using a combined approach of sequencing the B cell receptors of responding blood plasmablasts and MBCs, lymph node GC B cells and plasma cells and BMPCs from eight individuals and expression of the corresponding monoclonal antibodies, we tracked the evolution of 1,540 spike-specific B cell clones. On average, early blood spike-specific plasmablasts exhibited the lowest SHM frequencies. By contrast, SHM frequencies of spike-specific GC B cells increased by 3.5-fold within six months after vaccination. Spike-specific MBCs and BMPCs accumulated high levels of SHM, which corresponded with enhanced anti-spike antibody avidity in blood and enhanced affinity as well as neutralization capacity of BMPC-derived monoclonal antibodies. We report how the notable persistence of the GC reaction induced by SARS-CoV-2 mRNA vaccination in humans culminates in affinity-matured long-term antibody responses that potently neutralize the virus.

Germinal centre-driven maturation of B cell response to SARS-CoV-2 vaccination

Germinal centres (GC) are lymphoid structures where vaccine-responding B cells acquire affinity-enhancing somatic hypermutations (SHM), with surviving clones differentiating into memory B cells (MBCs) and long-lived bone marrow plasma cells (BMPCs) 1-4 . Induction of the latter is a hallmark of durable immunity after vaccination 5 . SARS-CoV-2 mRNA vaccination induces a robust GC response in humans 6-8 , but the maturation dynamics of GC B cells and propagation of their progeny throughout the B cell diaspora have not been elucidated. Here we show that anti-SARS-CoV-2 spike (S)-binding GC B cells were detectable in draining lymph nodes for at least six months in 10 out of 15 individuals who had received two doses of BNT162b2, a SARS-CoV-2 mRNA vaccine. Six months after vaccination, circulating S-binding MBCs were detected in all participants (n=42) and S-specific IgG-secreting BMPCs were detected in 9 out of 11 participants. Using a combined approach of single-cell RNA sequencing of responding blood and lymph node B cells from eight participants and expression of the corresponding monoclonal antibodies, we tracked the evolution of 1540 S-specific B cell clones. SHM accumulated along the B cell differentiation trajectory, with early blood plasmablasts showing the lowest frequencies, followed by MBCs and lymph node plasma cells whose SHM largely overlapped with GC B cells. By three months after vaccination, the frequency of SHM within GC B cells had doubled. Strikingly, S + BMPCs detected six months after vaccination accumulated the highest level of SHM, corresponding with significantly enhanced anti-S polyclonal antibody avidity in blood at that time point. This study documents the induction of affinity-matured BMPCs after two doses of SARS-CoV-2 mRNA vaccination in humans, providing a foundation for the sustained high efficacy observed with these vaccines.

SARS-CoV-2 mRNA vaccines induce persistent human germinal centre responses

SARS-CoV-2 mRNA-based vaccines are about 95% effective in preventing COVID-191-5. The dynamics of antibody-secreting plasmablasts and germinal centre B cells induced by these vaccines in humans remain unclear. Here we examined antigen-specific B cell responses in peripheral blood (n = 41) and draining lymph nodes in 14 individuals who had received 2 doses of BNT162b2, an mRNA-based vaccine that encodes the full-length SARS-CoV-2 spike (S) gene1. Circulating IgG- and IgA-secreting plasmablasts that target the S protein peaked one week after the second immunization and then declined, becoming undetectable three weeks later. These plasmablast responses preceded maximal levels of serum anti-S binding and neutralizing antibodies to an early circulating SARS-CoV-2 strain as well as emerging variants, especially in individuals who had previously been infected with SARS-CoV-2 (who produced the most robust serological responses). By examining fine needle aspirates of draining axillary lymph nodes, we identified germinal centre B cells that bound S protein in all participants who were sampled after primary immunization. High frequencies of S-binding germinal centre B cells and plasmablasts were sustained in these draining lymph nodes for at least 12 weeks after the booster immunization. S-binding monoclonal antibodies derived from germinal centre B cells predominantly targeted the receptor-binding domain of the S protein, and fewer clones bound to the N-terminal domain or to epitopes shared with the S proteins of the human betacoronaviruses OC43 and HKU1. These latter cross-reactive B cell clones had higher levels of somatic hypermutation as compared to those that recognized only the SARS-CoV-2 S protein, which suggests a memory B cell origin. Our studies demonstrate that SARS-CoV-2 mRNA-based vaccination of humans induces a persistent germinal centre B cell response, which enables the generation of robust humoral immunity.

Investigating the Effect of Thyroid Nodule Location on the Risk of Thyroid Cancer

Background: Thyroid nodules are routinely evaluated with ultrasound. Our aim was to determine if thyroid nodule location was a useful feature to predict thyroid cancer. Materials and Methods: Retrospective review of patients with thyroid nodules from six referral centers from 2006 to 2010. A total of 3313 adult patients with thyroid nodules and confirmed benign or malignant thyroid diagnoses were included. Results: Mean patient age was 54.2 (18-97) years, and the majority were women (n = 2635, 79.8%). A total of 3241 nodules were analyzed, 335 (10.3%) of which were malignant. Thyroid nodule location was an independent risk factor in predicting thyroid cancer (p = 0.005). Thyroid cancer odds were highest in the isthmus (odds ratio [OR] = 2.4, 95% confidence interval [CI] 1.6-3.6, p < 0.0001). In a multivariate regression model adjusting for age, sex, family history of thyroid cancer, radiation exposure, nodule size, and American College of Radiology (ACR) TI-RADS (Thyroid Imaging Reporting and Data System) score, the isthmus nodules had the highest risk of malignancy (OR = 2.4 [CI 1.5-3.9], p = 0.0007), followed by upper thyroid nodules (OR = 1.8 [CI 1.2-2.7], p = 0.005) and then middle thyroid nodules (OR = 1.5 [CI 1.1-2.0], p = 0.01) compared with lower thyroid nodules. Isthmus nodules were significantly smaller in size compared with middle (p < 0.0001) and lower (p = 0.0004), but not upper nodules (p = 0.25), with a mean size of 15.5 mm (±10.7). Conclusions: Thyroid nodule location is an independent risk factor in predicting the risk of thyroid cancer. Isthmic nodules carry the highest risk of cancer diagnosis and lower lobe nodules carry the lowest risk.

Reduction in Thyroid Nodule Biopsies and Improved Accuracy with American College of Radiology Thyroid Imaging Reporting and Data System

RSNA, 2018 Online supplemental material is available for this article.

Progression of Fatty Muscle Degeneration in Atraumatic Rotator Cuff Tears

BACKGROUND

The purpose of this prospective study was to examine the progression of fatty muscle degeneration over time in asymptomatic shoulders with degenerative rotator cuff tears.

METHODS

Subjects with an asymptomatic rotator cuff tear in 1 shoulder and pain due to rotator cuff disease in the contralateral shoulder were enrolled in a prospective cohort. Subjects were followed annually with shoulder ultrasonography, which evaluated tear size, location, and fatty muscle degeneration. Tears that were either full-thickness at enrollment or progressed to a full-thickness defect during follow-up were examined. A minimum follow-up of 2 years was necessary for eligibility.

RESULTS

One hundred and fifty-six shoulders with full-thickness rotator cuff tears were potentially eligible. Seventy shoulders had measurable fatty muscle degeneration of at least 1 rotator cuff muscle at some time point. Patients with fatty muscle degeneration in the shoulder were older than those without degeneration (mean, 65.8 years [95% confidence interval (CI), 64.0 to 67.6 years] compared with 61.0 years [95% CI, 59.1 to 62.9 years]; p < 0.05), and the median size of the tears at baseline was larger in shoulders with degeneration than in shoulders that did not develop degeneration (13 and 10 mm wide, respectively, and 13 and 10 mm long; p < 0.05). Tears with fatty muscle degeneration were more likely to have enlarged during follow-up than were tears that never developed muscle degeneration (79% compared with 58%; odds ratio, 2.64 [95% CI, 1.29 to 5.39]; p < 0.05). Progression of fatty muscle degeneration occurred more frequently in shoulders with tears that had enlarged (43%; 45 of 105) than in shoulders with tears that had not enlarged (20%; 10 of 51; p < 0.05). Additionally, tears with enlargement and progression of muscle degeneration were more likely to extend into the anterior supraspinatus than were those without progression (53% and 17%, respectively; p < 0.05); however, this relationship was lost when controlling for tear size (p = 0.56). The median time from tear enlargement to progression of fatty muscle degeneration was 1.0 year (range, -2.0 to 6.9 years) for the supraspinatus and 1.1 years (range, -1.8 to 8.5 years) for the infraspinatus muscle (p = 0.98).

CONCLUSIONS

Progression of fatty muscle degeneration is more common in tears that are larger at baseline, enlarge over time, and undergo a larger magnitude of enlargement. Our study findings also suggest that an often rapid progression of muscle degeneration occurs in relation to a clinically relevant increase in tear size in some degenerative cuff tears.

LEVEL OF EVIDENCE

Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

ACR Thyroid Imaging, Reporting and Data System (TI-RADS): White Paper of the ACR TI-RADS Committee

classification that is widely used in breast imaging, their authors chose to apply the acronym TI-RADS, for Thyroid Imaging, Reporting and Data System. In 2012, the ACR convened committees to (1) provide recommendations for reporting incidental thyroid nodules, (2) develop a set of standard terms (lexicon) for ultrasound reporting, and (3) propose a TI-RADS on the basis of the lexicon. The committees published the results of the first two efforts in 2015. In this article, the authors present the ACR TI-RADS Committee's recommendations, which provide guidance regarding management of thyroid nodules on the basis of their ultrasound appearance. The authors also describe the committee's future directions.

Patterns of tear progression for asymptomatic degenerative rotator cuff tears

BACKGROUND

The purpose of this study was to examine patterns of rotator cuff tear size progression in degenerative rotator cuff tears and to compare tear progression risks for tears with and without anterior supraspinatus tendon disruption.

METHODS

Asymptomatic full-thickness rotator cuff tears with minimum 2-year follow-up were examined with annual shoulder ultrasound examinations. Integrity of the anterior 3 mm of the supraspinatus tendon determined classification of cable-intact vs. cable-disrupted tears. Tear enlargement was defined as an increase of 5 mm or more in width. Tear propagation direction was calculated from measured changes in tear width in reference to the biceps tendon on serial ultrasound examinations.

RESULTS

The cohort included 139 full-thickness tears with a mean subject age of 63.3 years and follow-up duration of 6.0 years. Ninety-six (69.1%) of the tears were considered cable intact. Cable-disrupted tears were larger at baseline (median, 19.0 mm vs. 10.0 mm; P < .0001) than cable-intact tears. There was no difference in the risk of enlargement (52.1% vs. 67.4%; P = .09) or time to enlargement (3.2 vs. 2.2 years; P = .37) for cable-intact compared with cable-disrupted tears. There was no difference in the magnitude of enlargement for cable-intact and cable-disrupted tears (median, 7.0 mm vs.9.0 mm; P = .18). Cable-intact tears propagated a median of 5 mm anteriorly and 4 mm posteriorly, whereas cable-disrupted tears propagated posteriorly.

CONCLUSIONS

The majority of degenerative rotator cuff tears spare the anterior supraspinatus tendon. Although tears classified as cable disrupted are larger at baseline than cable-intact tears, tear enlargement risks are similar for each tear type.

Submandibular venous hemangioma: Case report and review of the literature

Hemangiomas of the submandibular space are very rare. Only 11 cases have been reported in the English literature, all of which were cavernous hemangiomas. In this report, we describe the case of a venous hemangioma in a 70-year-old woman. Ultrasound examination revealed a lobulated, homogeneous, hypoechoic mass, and minimal flow was detected on power Doppler evaluation. The mass and the submandibular gland were surgically excised, and the endothelium was found to be positive for CD31 and D2-40 markers, consistent with venous hemangioma. To our knowledge, this is the first reported case of a venous hemangioma in the submandibular space.

Thyroid Ultrasound Reporting Lexicon: White Paper of the ACR Thyroid Imaging, Reporting and Data System (TIRADS) Committee

Ultrasound is the most commonly used imaging technique for the evaluation of thyroid nodules. Sonographic findings are often not specific, and definitive diagnosis is usually made through fine-needle aspiration biopsy or even surgery. In reviewing the literature, terms used to describe nodules are often poorly defined and inconsistently applied. Several authors have recently described a standardized risk stratification system called the Thyroid Imaging, Reporting and Data System (TIRADS), modeled on the BI-RADS system for breast imaging. However, most of these TIRADS classifications have come from individual institutions, and none has been widely adopted in the United States. Under the auspices of the ACR, a committee was organized to develop TIRADS. The eventual goal is to provide practitioners with evidence-based recommendations for the management of thyroid nodules on the basis of a set of well-defined sonographic features or terms that can be applied to every lesion. Terms were chosen on the basis of demonstration of consistency with regard to performance in the diagnosis of thyroid cancer or, conversely, classifying a nodule as benign and avoiding follow-up. The initial portion of this project was aimed at standardizing the diagnostic approach to thyroid nodules with regard to terminology through the development of a lexicon. This white paper describes the consensus process and the resultant lexicon.

A prospective evaluation of survivorship of asymptomatic degenerative rotator cuff tears

BACKGROUND

The purpose of this prospective study was to report the long-term risks of rotator cuff tear enlargement and symptom progression associated with degenerative asymptomatic tears.

METHODS

Subjects with an asymptomatic rotator cuff tear in one shoulder and pain due to rotator cuff disease in the contralateral shoulder enrolled as part of a prospective longitudinal study. Two hundred and twenty-four subjects (118 initial full-thickness tears, fifty-six initial partial-thickness tears, and fifty controls) were followed for a median of 5.1 years. Validated functional shoulder scores were calculated (visual analog pain scale, American Shoulder and Elbow Surgeons [ASES], and simple shoulder test [SST] scores). Subjects were followed annually with shoulder ultrasonography and clinical evaluations.

RESULTS

Tear enlargement was seen in 49% of the shoulders, and the median time to enlargement was 2.8 years. The occurrence of tear-enlargement events was influenced by the severity of the final tear type, with enlargement of 61% of the full-thickness tears, 44% of the partial-thickness tears, and 14% of the controls (p < 0.05). Subject age and sex were not related to tear enlargement. One hundred subjects (46%) developed new pain. The final tear type was associated with a greater risk of pain development, with the new pain developing in 28% of the controls, 46% of the shoulders with a partial-thickness tear, and 50% of those with a full-thickness tear (p < 0.05). The presence of tear enlargement was associated with the onset of new pain (p < 0.05). Progressive degenerative changes of the supraspinatus muscle were associated with tear enlargement, with supraspinatus muscle degeneration increasing in 4% of the shoulders with a stable tear compared with 30% of the shoulders with tear enlargement (p < 0.05). Nine percent of the shoulders with a stable tear showed increased infraspinatus muscle degeneration compared with 28% of those in which the tear had enlarged (p = 0.07).

CONCLUSIONS

This study demonstrates the progressive nature of degenerative rotator cuff disease. The risk of tear enlargement and progression of muscle degeneration is greater for shoulders with a full-thickness tear, and tear enlargement is associated with a greater risk of pain development across all tear types.

LEVEL OF EVIDENCE

Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Clinical and radiographic outcomes of failed repairs of large or massive rotator cuff tears: minimum ten-year follow-up

INTRODUCTION

Little information exists regarding the long-term outcome after structural failure of rotator cuff repair. We previously reported clinical improvement, despite a 94% rate of failure of healing, at two years of follow-up in a cohort of eighteen patients who had undergone arthroscopic repair of massive rotator cuff tears. The purpose of the present study was to evaluate the ten-year results for these patients with known structural failures of rotator cuff repairs.

METHODS

Fifteen (83%) of eighteen patients were available for follow-up at ten years. Patients were evaluated with use of the American shoulder and elbow surgeons (ASES) score, the simple shoulder test (SST), a visual analog scale pain score, and the constant score. Radiographs and sonograms were assessed.

RESULTS

The average age was 74.6 years at the time of the latest follow-up. The average ASES score was 79.4 points (range, 50 to 95 points) and the average visual analog scale pain score was 2.2 points (range, 1 to 4 points); both scores were unchanged from those at two years. The average SST score was 9.2 points (range, 6 to 12 points), and the average age-adjusted Constant score was 73.2 points (range, 58.7 to 89.7 points). Of the patients with structurally failed repairs, all but one had radiographic signs of proximal humeral migration or cuff tear arthropathy: three had Hamada grade-2 changes, five had grade-3 changes, and three had Grade-4 changes (with two having grade-4a changes and one having grade-4b changes). Ultrasound confirmed the persistence of all tears that had been seen at two years.

CONCLUSIONS

Clinical improvements and pain relief after arthroscopic rotator cuff repair of large and massive tears are durable at the time of long-term (ten-year) follow-up, despite early structural failure of repair. Shoulders had a high rate of progression of radiographic signs associated with large rotator cuff tears. These results demonstrate that healing of large rotator cuff tears is not critical for long-term satisfactory clinical results in older patients.

Imaging algorithms for evaluating suspected rotator cuff disease: Society of Radiologists in Ultrasound consensus conference statement

The Society of Radiologists in Ultrasound convened a panel of specialists from a variety of medical disciplines to reach a consensus about the recommended imaging evaluation of painful shoulders with clinically suspected rotator cuff disease. The panel met in Chicago, Ill, on October 18 and 19, 2011, and created this consensus statement regarding the roles of radiography, ultrasonography (US), computed tomography (CT), CT arthrography, magnetic resonance (MR) imaging, and MR arthrography. The consensus panel consisted of two co-moderators, a facilitator, a statistician and health care economist, and 10 physicians who have specialty expertise in shoulder pain evaluation and/or treatment. Of the 13 physicians on the panel, nine were radiologists who were chosen to represent a broad range of skill sets in diagnostic imaging, different practice types (private and academic), and different geographical regions of the United States. Five of the radiologists routinely performed musculoskeletal US as part of their practice and four did not. There was also one representative from each of the following clinical specialties: rheumatology, physical medicine and rehabilitation, orthopedic surgery, and nonoperative sports medicine. The goal of this conference was to construct several algorithms with which to guide the imaging evaluation of suspected rotator cuff disease in patients with a native rotator cuff, patients with a repaired rotator cuff, and patients who have undergone shoulder replacement. The panel hopes that these recommendations will lead to greater uniformity in rotator cuff imaging and more cost-effective care for patients suspected of having rotator cuff abnormality.

Diagnostic performance and reliability of ultrasonography for fatty degeneration of the rotator cuff muscles

BACKGROUND

Diagnostic evaluation of rotator cuff muscle quality is important to determine indications for potential operative repair. Ultrasonography has developed into an accepted and useful tool for evaluating rotator cuff tendon tears; however, its use for evaluating rotator muscle quality has not been well established. The purpose of this study was to investigate the diagnostic performance and observer reliability of ultrasonography in grading fatty degeneration of the posterior and superior rotator cuff muscles.

METHODS

The supraspinatus, infraspinatus, and teres minor muscles were prospectively evaluated with magnetic resonance imaging (MRI) and ultrasonography in eighty patients with shoulder pain. The degree of fatty degeneration on MRI was graded by four independent raters on the basis of the modified Goutallier grading system. Ultrasonographic evaluation of fatty degeneration was performed by one of three radiologists with use of a three-point scale. The two scoring systems were compared to determine the diagnostic performance of ultrasonography. The interobserver and intraobserver reliability of MRI grading by the four raters were determined. The interobserver reliability of ultrasonography among the three radiologists was determined in a separate group of thirty study subjects. The weighted Cohen kappa, percentage agreement, sensitivity, and specificity were calculated.

RESULTS

The accuracy of ultrasonography for the detection of fatty degeneration, as assessed on the basis of the percentage agreement with MRI, was 92.5% for the supraspinatus and infraspinatus muscles and 87.5% for the teres minor. The sensitivity was 84.6% for the supraspinatus, 95.6% for the infraspinatus, and 87.5% for the teres minor. The specificity was 96.3% for the supraspinatus, 91.2% for the infraspinatus, and 87.5% for the teres minor. The agreement between MRI and ultrasonography was substantial for the supraspinatus and infraspinatus (kappa = 0.78 and 0.71, respectively) and moderate for the teres minor (kappa = 0.47). The interobserver reliability for MRI was substantial for the supraspinatus and infraspinatus (kappa = 0.76 and 0.77, respectively) and moderate for the teres minor (kappa = 0.59). For ultrasonography, the interobserver reliability was substantial for all three muscles (kappa = 0.71 for the supraspinatus, 0.65 for the infraspinatus, and 0.72 for the teres minor).

CONCLUSIONS

The diagnostic performance of ultrasonography in identifying and grading fatty degeneration of the rotator cuff muscles was comparable with that of MRI. Ultrasonography can be used as the primary diagnostic imaging modality for fatty changes in rotator cuff muscles.

Factors affecting healing rates after arthroscopic double-row rotator cuff repair

BACKGROUND

Double-row arthroscopic rotator cuff repairs were developed to improve initial biomechanical strength of repairs to improve healing rates. Despite biomechanical improvements, failure of healing remains a clinical problem.

PURPOSE

To evaluate the anatomical results after double-row arthroscopic rotator cuff repair with ultrasound to determine postoperative repair integrity and the effect of various factors on tendon healing.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Forty-eight patients (49 shoulders) who had a complete arthroscopic rotator cuff repair (double-row technique) were evaluated with ultrasound at a minimum of 6 months after surgery. Outcome was evaluated at a minimum of 1-year follow-up with standardized history and physical examination, visual analog scale for pain, active forward elevation, and preoperative and postoperative shoulder scores according to the system of the American Shoulder and Elbow Surgeons and the Simple Shoulder Test. Quantitative strength was measured postoperatively.

RESULTS

Ultrasound and physical examinations were performed at a minimum of 6 months after surgery (mean, 16 months; range, 6 to 36 months) and outcome questionnaire evaluations at a minimum of 12 months after surgery (mean, 29 months; range, 12 to 55 months). Of 49 repairs, 25 (51%) were healed. Healing rates were 67% in single-tendon tears (16 of 24 shoulders) and 36% in multitendon tears (9 of 25 shoulders). Older age and longer duration of follow-up were correlated with poorer tendon healing (P < .03). Visual analog scale for pain, active forward elevation, American Shoulder and Elbow Surgeons scores, and Simple Shoulder Test scores all had significant improvement from baseline after repair (P < .0001).

CONCLUSION

Increased age and longer duration of follow-up were associated with lower healing rates after double-row rotator cuff repair. The biological limitation at the repair site, as reflected by the effects of age on healing, appears to be the most important factor influencing tendon healing, even after maximizing repair biomechanical strength with a double-row construct.

Symptomatic progression of asymptomatic rotator cuff tears: a prospective study of clinical and sonographic variables

BACKGROUND

The purposes of this study were to identify changes in tear dimensions, shoulder function, and glenohumeral kinematics when an asymptomatic rotator cuff tear becomes painful and to identify characteristics of individuals who develop pain compared with those who remain asymptomatic.

METHODS

A cohort of 195 subjects with an asymptomatic rotator cuff tear was prospectively monitored for pain development and examined annually for changes in various parameters such as tear size, fatty degeneration of the rotator cuff muscle, glenohumeral kinematics, and shoulder function. Forty-four subjects were found to have developed new pain, and the parameters before and after pain development were compared. The forty-four subjects were then compared with a group of fifty-five subjects who remained asymptomatic over a two-year period.

RESULTS

With pain development, the size of a full-thickness rotator cuff tear increased significantly, with 18% of the full-thickness tears showing an increase of >5 mm, and 40% of the partial-thickness tears had progressed to a full-thickness tear. In comparison with the assessments made before the onset of pain, the American Shoulder and Elbow Surgeons scores for shoulder function were significantly decreased and all measures of shoulder range of motion were decreased except for external rotation at 90° of abduction. There was an increase in compensatory scapulothoracic motion in relation to the glenohumeral motion during early shoulder abduction with pain development. No significant changes were found in external rotation strength or muscular fatty degeneration. Compared with the subjects who remained asymptomatic, the subjects who developed pain were found to have significantly larger tears at the time of initial enrollment.

CONCLUSIONS

Pain development in shoulders with an asymptomatic rotator cuff tear is associated with an increase in tear size. Larger tears are more likely to develop pain in the short term than are smaller tears. Further research is warranted to investigate the role of prophylactic treatment of asymptomatic shoulders to avoid the development of pain and loss of shoulder function.

Location and initiation of degenerative rotator cuff tears: an analysis of three hundred and sixty shoulders

BACKGROUND

It has been theorized that degenerative rotator cuff tears most commonly involve the supraspinatus tendon, initiating at the anterior portion of the supraspinatus insertion and propagating posteriorly. The purposes of this study were to determine the most common location of degenerative rotator cuff tears and to examine tear location patterns associated with various tear sizes.

METHODS

Ultrasonograms of 360 shoulders with either a full-thickness rotator cuff tear (272) or a partial-thickness rotator cuff tear (eighty-eight) were obtained to measure the width and length of the tear and the distance from the biceps tendon to the anterior margin of the tear. Tears were grouped on the basis of their size (anteroposterior width) and extent (partial or full-thickness). Each tear was represented numerically as a column of consecutive numbers representing the tear width and distance posterior to the biceps tendon. All tears were pooled to graphically represent the width and location of the tears within groups. Frequency histograms of the pooled data were generated, and the mode was determined for each histogram representing various tear groups.

RESULTS

The mean age (and standard deviation) of the 233 subjects (360 shoulders) was 64.7 +/- 10.2 years. The mean width and length of the tears were 16.3 +/- 12.1 mm and 17.0 +/- 13.0 mm, respectively. The mean distance from the biceps tendon to the anterior tear margin was 7.8 +/- 5.7 mm (range, 0 to 26 mm). Histograms of the various tear groups invariably showed the location of 15 to 16 mm posterior to the biceps tendon to be the most commonly torn location within the posterior cuff tendons. The histograms of small tears (a width of <10 mm) and partial-thickness tears showed similar distributions of tear locations, indicating that the region approximately 15 mm posterior to the biceps tendon may be where rotator cuff tears most commonly initiate.

CONCLUSIONS

Degenerative rotator cuff tears most commonly involve a posterior location, near the junction of the supraspinatus and infraspinatus. The patterns of tear location across multiple tear sizes suggest that degenerative cuff tears may initiate in a region 13 to 17 mm posterior to the biceps tendon.

Relationship of tear size and location to fatty degeneration of the rotator cuff

BACKGROUND

Fatty degeneration of the rotator cuff muscles may have detrimental effects on both anatomical and functional outcomes following shoulder surgery. The purpose of this study was to investigate the relationship between tear geometry and muscle fatty degeneration in shoulders with a deficient rotator cuff.

METHODS

Ultrasonograms of both shoulders of 262 patients were reviewed to assess the type of rotator cuff tear and fatty degeneration in the supraspinatus and infraspinatus muscles. The 251 shoulders with a full-thickness tear underwent further evaluation for tear size and location. The relationship of tear size and location to fatty degeneration of the supraspinatus and infraspinatus muscles was investigated with use of statistical comparisons and regression models.

RESULTS

Fatty degeneration was found almost exclusively in shoulders with a full-thickness rotator cuff tear. Of the 251 shoulders with a full-thickness tear, eighty-seven (34.7%) had fatty degeneration in either the supraspinatus or infraspinatus, or both. Eighty-two (32.7%) of the 251 full-thickness tears had a distance of 0 mm between the biceps tendon and anterior margin of the tear. Ninety percent of the full-thickness tears with fatty degeneration in both muscles had a distance of 0 mm posterior from the biceps, whereas only 9% of those without fatty degeneration had a distance of 0 mm. Tears with fatty degeneration had significantly greater width and length than those without fatty degeneration (p < 0.0001). Tears with fatty degeneration had a significantly shorter distance posterior from the biceps than those without fatty degeneration (p < 0.0001). The distance posterior from the biceps was found to be the most important predictor for supraspinatus fatty degeneration, whereas tear width and length were found to be the most important predictors for infraspinatus fatty degeneration.

CONCLUSIONS

Fatty degeneration of the rotator cuff muscles is closely associated with tear size and location. The finding of this study suggests that the integrity of the anterior supraspinatus tendon is important to the development of fatty degeneration. Patients with full-thickness tears that extend through this area may benefit from earlier surgical intervention if fatty degeneration has not already occurred. Additionally, the findings suggest the importance of secure fixation and healing of the anterior aspect of the supraspinatus with surgical repair.

Revision arthroscopic rotator cuff repair: repair integrity and clinical outcome

BACKGROUND

Literature regarding the outcomes of revision rotator cuff repair is limited. The purposes of the present study were to report the tendon repair integrity and clinical outcomes for a cohort of patients following revision arthroscopic rotator cuff repair and to examine factors related to tendon healing and the influence of healing on clinical outcomes.

METHODS

Twenty-one of twenty-nine consecutive revision arthroscopic rotator cuff repairs with a minimum of two years of postoperative follow-up were retrospectively reviewed. Outcomes were evaluated on the basis of a visual analog pain scale, the range of motion of the shoulder, the Simple Shoulder Test, the American Shoulder and Elbow Surgeons score, and the Constant score. Ultrasonography was used to examine repair integrity at a minimum of one year following surgery. Ten shoulders underwent arthroscopic repair of a recurrent single-tendon posterior rotator cuff tear, whereas eleven shoulders had repair of both the supraspinatus and infraspinatus.

RESULTS

The mean age of the twenty-one subjects was 55.6 years; thirteen subjects were male and eight were female. Complete preoperative and postoperative clinical data were available for nineteen subjects after an average duration of follow-up of thirty-three months. Significant improvements were seen in terms of postoperative pain (p < 0.05), the Simple Shoulder Test score (p < 0.05), the American Shoulder and Elbow Surgeons function (p < 0.05) and total scores (p < 0.05), active forward elevation (p < 0.05), and active external rotation (p < 0.05). Postoperative ultrasound data were available for all twenty-one shoulders after a mean duration of follow-up of twenty-five months. Ten (48%) of the twenty-one shoulders had an intact repair. Seven (70%) of the ten single-tendon repairs were intact, compared with three (27%) of the eleven supraspinatus/infraspinatus repairs (p = 0.05). Patient age (p < 0.05) and the number of torn tendons (p = 0.05) had significant effects on postoperative tendon repair integrity. Shoulders with an intact repair had better postoperative Constant scores (p < 0.05) and scapular plane elevation strength (p < 0.05) in comparison with those with a recurrent tear.

CONCLUSIONS

Revision arthroscopic rotator cuff repair results in reliable pain relief and improvement in shoulder function in selected cases. Approximately half of the revision repairs can be expected to be intact at a minimum of one year following surgery. Patient age and the number of torn tendons are related to postoperative tendon integrity. The postoperative integrity of the rotator cuff can have a significant influence on shoulder abduction strength and the Constant score.

High-resolution sonography of the normal extrapelvic vas deferens

OBJECTIVE

The purpose of this study was to determine the reliability of sonographic visualization of the normal extrapelvic vas deferens and to analyze its appearance and dimensions.

METHODS

Scans of the scrotum and spermatic cords were obtained in 25 fertile volunteers. Identification of the vas deferens was attempted bilaterally in the scrotal, suprascrotal, and prepubic segments in all volunteers. When possible, the total thickness and the diameter of the lumen were measured. Visualization and dimensions were correlated with the body mass index (BMI) and abstinence interval.

RESULTS

All segments of the vas deferens were identified bilaterally in all volunteers. In all cases, it appeared as an anechoic or very hypoechoic tubular structure that was noncompressible and contained no detectable blood flow. It was convoluted inferiorly and became straight as it progressed from the scrotum to the suprascrotal and prepubic segments. The lumen was seen in the suprascrotal segment in all of the volunteers except the one with the highest BMI. The total thickness of the vas ranged from 1.5 to 2.7 mm (mean, 1.89 mm). The lumen of the vas ranged from 0.2 to 0.7 mm (mean, 0.43 mm). There was no correlation between the luminal diameter and the abstinence interval.

CONCLUSIONS

The extrapelvic portion of the vas deferens is reliably visualized sonographically. Its appearance is characteristic and reproducible. The lumen can be measured in almost all cases.

Shoulder strength in asymptomatic individuals with intact compared with torn rotator cuffs

BACKGROUND

Normative data are essential to the evaluation of shoulder function. The purposes of this study were to establish a normative database of isometric shoulder strength measured in asymptomatic individuals verified to have intact rotator cuffs and to determine the effect of asymptomatic rotator cuff tears on shoulder strength.

METHODS

Two hundred and thirty-seven volunteers with no shoulder pain or history of shoulder injury were screened with ultrasonography bilaterally for rotator cuff tears and then underwent isometric strength measurements for abduction in the scapular plane and external rotation. Statistical analysis was performed to evaluate the effect of age, body habitus, hand dominance, and the presence of a rotator cuff tear on shoulder strength.

RESULTS

Of the 237 volunteers, forty-one were found to have a torn rotator cuff in at least one shoulder. The prevalence of rotator cuff tears was 0% for the subjects between forty and forty-nine years old; 10%, between fifty and fifty-nine years old; 20%, between sixty and sixty-nine years old; and 40.7% for those seventy years old or older. Both abduction strength and external rotation strength in the male subjects showed an age-dependent decrease, whereas only abduction strength showed an age-dependent decrease in the female subjects. In multiple regression analysis, age and weight were the most important predictors of abduction strength and external rotation strength, respectively. In the shoulders with a large-to-massive full-thickness rotator cuff tear, abduction strength was significantly decreased (p = 0.007). Additionally, the ratio of abduction strength to external rotation strength was significantly decreased in the shoulders with a large-to-massive full-thickness tear compared with the shoulders with an intact rotator cuff (p < 0.001).

CONCLUSIONS

There is a high prevalence of rotator cuff tears in elderly asymptomatic individuals. Asymptomatic shoulders with a large-to-massive full-thickness rotator cuff tear have significantly decreased abduction strength. When there is a substantial decrease in abduction strength in relation to external rotation strength, the presence of an asymptomatic full-thickness tear should be suspected in that shoulder. Previous studies establishing normative values for isometric shoulder strength may have been skewed by the presence of asymptomatic rotator cuff tears in elderly subgroups.

Ultrasound-guided Chest Biopsies

Pulmonary nodules that are surrounded by aerated lung cannot be visualized with sonography. Therefore, percutaneous biopsy must be guided with computed tomography or fluoroscopy. Although this restriction only applies to central lung nodules, it has permeated referral patterns for other thoracic lesions and has retarded the growth of ultrasound-guided interventions. Nevertheless, sonography is an extremely flexible modality that can expeditiously guide many biopsy procedures in the thorax. Peripheral pulmonary nodules can be successfully biopsied with success rates exceeding 90% and complications rates of less than 5%. Orienting the probe parallel to the intercostal space facilitates biopsies of peripheral pulmonary nodules. Anterior mediastinal masses that extend to the parasternal region are often easily approachable provided the internal mammary vessels, costal cartilage, and deep great vessels are identified and avoided. Superior mediastinal masses can be sampled from a suprasternal or supraclavicular approach. Phased array probes or tightly curved arrays may provide improved access for biopsies in this location. Posterior mediastinal masses are more difficult to biopsy with ultrasound guidance because of the overlying paraspinal muscles. However, when posterior mediastinal masses extend into the posterior medial pleural region, they can be biopsied with ultrasound guidance. Because many lung cancers metastasize to the supraclavicular nodes, it is important to evaluate the supraclavicular region when determining the best approach to obtain a tissue diagnosis. When abnormal supraclavicular nodes are present, they often are the easiest and safest lesions to biopsy.

The demographic and morphological features of rotator cuff disease. A comparison of asymptomatic and symptomatic shoulders

BACKGROUND

Very little comparative information is available regarding the demographic and morphological characteristics of asymptomatic and symptomatic rotator cuff tears. This information is important to provide insight into the natural history of rotator cuff disease and to identify which factors may be important in the development of pain. The purpose of the present study was to compare the morphological characteristics and prevalences of asymptomatic and symptomatic rotator cuff disease in patients who presented with unilateral shoulder pain.

METHODS

Five hundred and eighty-eight consecutive patients in whom a standardized ultrasonographic study had been performed by an experienced radiologist for the assessment of unilateral shoulder pain were evaluated with regard to the presence and size of rotator cuff tears in each shoulder. The demographic factors that were analyzed included age, gender, side, and cuff thickness. All of these factors were evaluated with regard to their correlation with the presence of pain.

RESULTS

Of the 588 consecutive patients who met the inclusion criteria, 212 had an intact rotator cuff bilaterally, 199 had a unilateral rotator cuff tear (either partial or full thickness), and 177 had a bilateral tear (either partial or full thickness). The presence of rotator cuff disease was highly correlated with age. The average age was 48.7 years for patients with no rotator cuff tear, 58.7 years for those with a unilateral tear, and 67.8 years for those with a bilateral tear. Logistic regression analysis indicated a 50% likelihood of a bilateral tear after the age of sixty-six years (p < 0.01). In patients with a bilateral rotator cuff tear in whom one tear was symptomatic and the other tear was asymptomatic, the symptomatic tear was significantly larger (p < 0.01). The average size of a symptomatic tear was 30% greater than that of an asymptomatic tear. Overall, patients who presented with a full-thickness symptomatic tear had a 35.5% prevalence of a full-thickness tear on the contralateral side.

CONCLUSIONS

There is a high correlation between the onset of rotator cuff tears (either partial or full thickness) and increasing age. Bilateral rotator cuff disease, either symptomatic or asymptomatic, is common in patients who present with unilateral symptomatic disease. As the size of a tear appears to be an important factor in the development of symptoms, we recommend surveillance at yearly intervals for patients with known rotator cuff tears that are treated nonoperatively.

Development of Nonobstructive Intraarterial Thrombi After Injection of Thrombin into Pseudoaneurysms

OBJECTIVE

Our objective was to describe the development of nonobstructive, localized intraarterial thrombi after percutaneous injection of thrombin into femoral pseudoaneurysms.

CONCLUSION

Partial extension of thrombi into the arterial lumen may occur after injection of thrombin into small pseudoaneurysms with short necks. In our experience, this is an asymptomatic and self-limited complication of the procedure.

The efficacy of ultrasound in the diagnosis of long head of the biceps tendon pathology

The use of shoulder ultrasound as an imaging modality has recently gained widespread attention; however, the ability of ultrasound to diagnose long head of the biceps tendon pathology accurately still remains unclear. The biceps tendons in 71 patients were prospectively evaluated by comparison of standard ultrasonographic and arthroscopic examinations. Arthroscopic examination was used as the gold standard comparison. Ultrasound showed a 100% specificity and 96% sensitivity for subluxation or dislocation. Ultrasound detected all complete ruptures of the biceps tendon but detected none of the 23 partial-thickness tears. Overall, ultrasound diagnosed 35 of 36 normal biceps tendons (specificity, 97%) and 17 of 35 abnormal biceps tendons (sensitivity, 49%). Ultrasound can reliably diagnose complete rupture, subluxation, or dislocation of the biceps tendon. It is not reliable for detecting intraarticular partial-thickness tears.

Detection and measurement of rotator cuff tears with sonography: analysis of diagnostic errors

OBJECTIVE

The purpose of this study was to analyze the causes of errors in the detection and measurement of rotator cuff tears in our patient population.

SUBJECTS AND METHODS

Seventy-one consecutive patients with shoulder pain who were prospectively studied with sonography had subsequent arthroscopy that showed a full-thickness or partial-thickness tear or intact cuff. For sonography and arthroscopy, the length or degree of retraction and width of a tear, when present, was recorded. When there were discrepant findings, representative images were jointly evaluated by the radiologist and orthopedic surgeon to determine the cause of the error.

RESULTS

Fifteen detection errors were found, including five misses (three < 5-mm subscapularis and two small partial-thickness tears), four errors inherent with the test (distinguishing large bursal side or extensive partial-thickness from full-thickness tears and tendinopathy from partial-thickness tears), three errors of an unknown cause, two due to misinterpretation, and one error inherent with the patient. Seventeen measurement errors occurred with full-thickness tears, 15 of those in patients with large or massive tears. Bursal thickening (n = 4), non-visualization of the torn tendon end (n = 2), nonretracted tear (n = 2), and complex tear (n = 1) contributed to the errors. Eight measurement errors occurred with partial-thickness tears. Difficulty distinguishing tendinopathy from partial-thickness tears (n = 3) and complex tears (n = 3) accounted for six errors.

CONCLUSION

Although infrequent, detection errors were due to limitations inherent with the test or misses. Limitations inherent with the patient and misinterpretation of the findings were rare. Most measurement errors occurred in patients with large or massive cuff tears.

Diagnosis and treatment of iatrogenic femoral artery pseudoaneurysms

Color Doppler is the procedure of choice for the diagnosis of iatrogenic femoral artery pseudoaneurysms. Although surgery is still necessary in a limited number of patients, most can be treated with ultrasound-guided thrombin injection. Success exceeds 90% and complications are much lower than surgery. Although rare, the major complication is embolization into the femoral artery. This can be minimized by using as little thrombin as possible, and by avoiding small pseudoaneurysms with short necks.

Sonography and MRI of the shoulder: comparison of patient satisfaction

OBJECTIVE

MRI and sonography are both used to evaluate patients with painful shoulders. This study was conducted to compare patients' perceptions and satisfaction with both tests.

SUBJECTS AND METHODS

One hundred eighteen patients with shoulder pain and a clinically suspected rotator cuff tear underwent both MRI and sonography and filled out satisfaction surveys after both tests. Patients were asked the following questions: Did the test cause pain? If it did, they were asked to grade the pain on a scale of 1-10 (1, minimal pain; 10, severe pain). Did the test take too long? Would they be willing to undergo the test again? How would they grade their overall satisfaction with the test (1, poor; 2, fair; 3, good; 4, very good; and 5, excellent)? Which test did they prefer if both were equally accurate?

RESULTS

Sonography caused pain above the baseline in 39 patients, with an average pain score (mean +/- SD) of 5.4 +/- 2.3, and MRI caused pain above the baseline in 40 patients, with an average pain score of 6.1 +/- 2.7 (p = 0.36). Two patients thought the sonography examination took too long, and 28 patients though the MRI examination was too long (p < 0.001). The average satisfaction level for sonography was 4.3 +/- 0.7 and for MRI, 3.6 +/- 1.2 (p < 0.001). The satisfaction score was higher for sonography in 54 patients, higher for MRI in 13 patients, and the same for both in 50 patients (p < 0.001). All patients were willing to repeat the sonography, but 10 patients were unwilling to repeat the MRI (p = 0.002). Ninety-three patients preferred sonography, eight patients preferred MRI, and 17 patients had no preference (p < 0.001).

CONCLUSION

Most patients with shoulder pain prefer sonography to MRI.

Sonography of the Rotator Cuff:Analysis of Interobserver Variability

OBJECTIVE

The purpose of our study was to determine the interobserver variability in the sonographic evaluation of the rotator cuff.

SUBJECTS AND METHODS

Two radiologists independently scanned 61 patients with shoulder pain. Each radiologist categorized the rotator cuff as normal, partially torn, or fully torn. When a tear was present, the tendons involved were specified. All diagnoses were made prospectively without knowledge of the findings of the other radiologist.

RESULTS

The radiologists were in full agreement in the categorization of 92% (56/61) of the patients. In four of the five discrepant cases, the disagreement was whether there was a full-thickness or a partial-thickness tear. The radiologists were in agreement concerning which tendons were involved in 80% (41/51) of the patients in whom a tear was detected by both observers. In all 10 discrepant cases, the disagreement was whether a tear involved both the supraspinatus and infraspinatus tendons or was isolated to one or the other of these tendons.

CONCLUSION

The level of interobserver variability in the sonographic detection and characterization of rotator cuff tears is low.

Giant Cell Tumors of the Tendon Sheath: Analysis of Sonographic Findings

OBJECTIVE

The purpose of this study was to analyze the sonographic characteristics of giant cell tumors of the tendon sheath.

CONCLUSION

Giant cell tumors of the hand typically appear as solid, homogeneous hypoechoic masses with detectable internal vascularity that are associated with the flexor tendons of the fingers.

The accuracy of high-resolution ultrasound for evaluating focal lesions of the hand and wrist

PURPOSE

Although several articles have described the sonographic features of solid and cystic lesions of the hand and wrist, few have investigated its accuracy for diagnosing such lesions. The purposes of this retrospective study were to determine the accuracy of sonography for diagnosing focal lesions of the hand and wrist against the standard of histologic examination of the resected specimen and to compare the accuracy of sonography against the recorded initial clinical impression.

METHODS

A medical record search for all sonographic studies of the hand and wrist at our institution was performed. Eighty-four patients had correlative surgery and made up the study group. All sonogram reports were reviewed for the absence or presence of focal lesions and specific diagnoses and all medical records were reviewed for the initial clinical impression. Both were compared with histologic findings and tested for agreement with the kappa statistic and for significant differences with the McNemar test

RESULTS

Seventy-six of the 84 patients had focal lesions of the hand and wrist and 8 had normal sonograms. Overall, ultrasound correctly diagnosed 83% of the lesions and the initial clinical impression was correct in 54%. Of the 76 lesions ultrasound correctly diagnosed 87% of cystic lesions, 73% of solid lesions, 75% of tenosynovitis cases and the single-vessel thrombosis. The initial clinical impression was correct in 67% of cystic lesions and 75% of tenosynovitis cases. The solid or cystic nature of the 15 solid lesions and the single-vessel thrombosis could not be determined by history or physical examination alone. Of the 35 cases in which the recorded clinical impression was incorrect or not recorded ultrasound provided the correct diagnoses in 71% of these cases. Agreement with the kappa statistical analysis was only fair and the recorded initial clinical impression was less accurate than ultrasound.

CONCLUSIONS

Ultrasound was statistically more accurate than the initial clinical impression for distinguishing solid from cystic lesions of the hand and wrist. Ultrasound was very accurate for specifically diagnosing ganglions and slightly less for solid lesions and tenosynovitis.

Detection and quantification of rotator cuff tears. Comparison of ultrasonographic, magnetic resonance imaging, and arthroscopic findings in seventy-one consecutive cases

BACKGROUND

Although many investigators have evaluated the accuracy of ultrasonography and magnetic resonance imaging for the detection of full and partial-thickness rotator cuff tears, few have directly compared the two tests. The purpose of our study was to compare the accuracy of the two tests for detection and measurement of the size of rotator cuff tears, with arthroscopic findings used as the standard.

METHODS

One hundred and twenty-four consecutive patients with shoulder pain were prospectively studied with ultrasonography and magnetic resonance imaging. Seventy-one had subsequent arthroscopy, and they formed the study group. The arthroscopic diagnosis was a full-thickness tear in forty-six patients, a partial-thickness tear in nineteen, and no tear in six. The presence or absence of a full or partial-thickness tear and the tear size as demonstrated by each imaging test and at the time of arthroscopy were recorded. The findings of the imaging tests and arthroscopy were then compared for each parameter.

RESULTS

Ultrasonography correctly identified forty-five of the forty-six full-thickness tears and magnetic resonance imaging, all forty-six. Ultrasonography correctly identified thirteen of the nineteen partial-thickness rotator cuff tears and magnetic resonance imaging, twelve of the nineteen. The overall accuracy for both imaging tests was 87%. Ultrasonography correctly predicted the degree of retraction of 73% of the full-thickness tears and the length of 85% of the partial-thickness tears, and magnetic resonance imaging correctly predicted the retraction and length of 63% and 75%, respectively. Ultrasonography correctly predicted the width of 87% of the full-thickness tears and 54% of the partial-thickness tears, and magnetic resonance imaging correctly predicted the width of 80% and 75%, respectively. No significant differences between ultrasonography and magnetic resonance imaging were demonstrated (p > 0.05).

CONCLUSIONS

Ultrasonography and magnetic resonance imaging had comparable accuracy for identifying and measuring the size of full-thickness and partial-thickness rotator cuff tears. When an investigator has comparable experience with both imaging tests, the decision regarding which test to perform for rotator cuff assessment does not need to be based on accuracy concerns. The choice can be based on other factors, such as the importance of ancillary clinical information (regarding lesions of the glenoid labrum, joint capsule, or surrounding muscle or bone), the presence of an implanted device, patient tolerance, and cost.

The outcome and repair integrity of completely arthroscopically repaired large and massive rotator cuff tears

BACKGROUND

The impact of a recurrent defect on the outcome after rotator cuff repair has been controversial. The purpose of this study was to evaluate the functional and anatomic results after arthroscopic repair of large and massive rotator cuff tears with use of ultrasound as an imaging modality to determine the postoperative integrity of the repair.

METHODS

Eighteen patients who had complete arthroscopic repair of a tear measuring >2 cm in the transverse dimension were evaluated at a minimum of twelve months after surgery and again at two years after surgery. The evaluation consisted of a standardized history and physical examination as well as calculation of the preoperative and postoperative shoulder scores according to the system of the American Shoulder and Elbow Surgeons. The strength of both shoulders was quantitated postoperatively with use of a portable dynamometer. Ultrasound studies were performed with use of an established and validated protocol at a minimum of twelve months after surgery.

RESULTS

Recurrent tears were seen in seventeen of the eighteen patients. Despite the absence of healing at twelve months after surgery, thirteen patients had an American Shoulder and Elbow Surgeons score of >/=90 points. Sixteen patients had an improvement in the functional outcome score, which increased from an average of 48.3 to 84.6 points. Sixteen patients had a decrease in pain, and twelve had no pain. Although eight patients had preoperative forward elevation to <95 degrees, all eighteen regained motion above shoulder level and had an average of 152 degrees of elevation. At the second evaluation, a minimum of twenty-four months after surgery, the average score, according to the system of the American Shoulder and Elbow Surgeons, had decreased to 79.9 points; only nine patients had a score of >/=90 points, and six patients had a score of </=79 points. The average forward elevation decreased to 142 degrees.

CONCLUSIONS

Arthroscopic repair of large and massive rotator cuff tears led to a high percentage of recurrent defects. The minimum twelve-month evaluation showed excellent pain relief and improvement in the ability to perform activities of daily living despite the high rate of recurrent defects; however, at a minimum follow-up of two years, the results deteriorated with only twelve patients who had an American Shoulder and Elbow Surgeons score of >/=80.

Accuracy of ultrasound imaging of the rotator cuff in shoulders that are painful postoperatively

BACKGROUND

Evaluation of the rotator cuff in a shoulder that has been persistently painful postoperatively could be challenging. Magnetic resonance imaging has been the preferred imaging method, but accuracy rates have been lower for those shoulders than for shoulders that have not been operated on; also, magnetic resonance imaging is susceptible to suture anchor artifact. The purpose of this study was to evaluate the diagnostic accuracy of ultrasound for evaluating the rotator cuff in shoulders that are painful postoperatively.

METHODS

The records of forty-four consecutive patients who had undergone both a high-resolution ultrasound examination and subsequent shoulder arthroscopy were retrospectively reviewed. Thirty-four patients underwent rotator cuff repair at the time of the arthroscopy, and ten had subacromial decompression or another procedure without cuff repair. The results of the ultrasound examination were compared with the intraoperative findings of the arthroscopic examination (the "gold standard").

RESULTS

Ultrasound led to a correct diagnosis for forty of the forty-four patients. Twenty-two recurrent rotator cuff tears and twenty-two intact rotator cuffs were found at surgery. Ultrasound correctly identified twenty of the twenty-two rotator cuff tears (true-positive results) and twenty of the twenty-two intact rotator cuffs (true-negative results). Two intact cuffs were identified as having a full-thickness tear (false-positive results), and two cuffs with a full-thickness rotator cuff tear were identified as being intact (false-negative results). The sensitivity and specificity of ultrasound for identifying rotator cuff integrity postoperatively were 91% and 86%, respectively. The accuracy was 89%.

CONCLUSIONS

Ultrasound is a highly accurate imaging study for evaluating the integrity of the rotator cuff in shoulders that have undergone an operation. Its accuracy for operatively treated shoulders appears to be comparable with that previously reported for shoulders that had not been operated on.

Doppler evaluation of transjugular intrahepatic portosystemic shunts

Transjugular intrahepatic portosystemic shunts are becoming an increasingly popular technique for the treatment of portal hypertension and its complications. However, to maintain patency, revisions are periodically required to treat stenosis and thrombosis. At many centers, Doppler sonography is used for routine follow-up. A variety of hemodynamic parameters, including main portal vein velocity, maximum stent velocity, minimum stent velocity, velocity gradient in the stent, temporal changes in stent velocity, flow direction in the intrahepatic portal and hepatic veins, and pulsatility of flow in the stent can be used. Many studies have confirmed that Doppler sonography is a valuable, noninvasive means of detecting stent malfunction, although the criteria vary somewhat at different institutions.

Detection of primary hepatic malignancy in liver transplant candidates: prospective comparison of CT, MR imaging, US, and PET

PURPOSE

To determine and compare the diagnostic performance of computed tomography (CT), magnetic resonance (MR) imaging, ultrasonography (US), and positron emission tomography (PET) in the detection of hepatocellular carcinoma (HCC) or cholangiocarcinoma in liver transplant candidates and to determine interobserver variability between the readers.

MATERIALS AND METHODS

Twenty-five patients were examined prospectively with CT, MR imaging, US, and PET. Each test result was interpreted independently by two radiologists. Explanted liver specimens were examined histologically to determine presence and type of lesion. Results were analyzed on a patient-by-patient basis with marginal homogeneity and effect likelihood ratio tests.

RESULTS

HCC was diagnosed in nine patients. US diagnostic performance was superior to that of CT and MR imaging on a patient-by-patient basis. Sensitivities were higher for US (0.89 for both US readers) than they were for CT (0.67 and 0.56 for readers 1 and 2, respectively), MR imaging (0.56 and 0.50 for readers 1 and 2, respectively), and PET (0 for both readers). None of the differences (within test) between readers were significant (P >or=.32). Ratings by US and MR observers and one CT observer were significantly associated with truth (P <or=.04). One or more imaging tests depicted 68 lesions. Histologic analysis revealed 18 HCC nodules; of these, 13 were correctly identified at CT, 14 at MR imaging, 13 at US, and none at PET. There were nine false-positive diagnoses of HCC with CT, five with MR imaging, and nine with US.

CONCLUSION

Although US had the best diagnostic performance in depicting HCC on a patient-by-patient basis and was substantially better than were MR imaging and CT (which had nearly equivalent diagnostic performances), CT, US, and MR imaging performed similarly on a lesion-by-lesion basis. Small tumor nodules were the most common cause of missed HCCs with all tests. PET did not depict any HCCs.

Sonography of the medial collateral ligament of the elbow: a study of cadavers and healthy adult male volunteers

OBJECTIVE

We assessed the ability of high-resolution sonography to reveal the size and echogenicity of the anterior bundle of the normal medial collateral ligament of the elbow in cadavers and uninjured male volunteers.

MATERIALS AND METHODS

The anterior bundle of the medial collateral ligament in five cadaveric elbows was imaged and injected with contrast material by experienced musculoskeletal radiologists using a 12-MHz linear array transducer. Immediate ligament dissection was performed. The bilateral ligaments in 30 healthy 21- to 34-year-old male volunteers were imaged with gravitational stress. Of these, five randomly selected subjects also received approximately 5 lb (11.3 kg) of applied stress.

RESULTS

Contrast material was injected directly into all five cadaveric ligaments. The anterior bundle of the medial collateral ligament in all 30 asymptomatic male volunteers was hyperechoic in comparison with surrounding muscle and had a fibrillar pattern and fanlike shape. Its mean dimensions were 2.6 +/- 0.31 x 2.2 +/- 0.47 x 4.0 +/- 0.88 mm on the right and 2.6 +/- 0.36 x 2.1 +/- 0.42 x 4.0 +/- 0.86 mm on the left, in longitudinal short, transverse short, and transverse long axes, respectively. Differences in ligament measurements in sidedness, stress application, and hand dominance did not approach statistical (Bonferroni corrected, p > 0.01) or clinical (all differences, <0.2 mm) significance.

CONCLUSION

Radiologists can accurately use sonography to identify and measure the size of the anterior bundle of the normal medial collateral ligament of the elbow. These baseline parameters for the normal ligament may prove useful when evaluating the injured ligament.

Testicular microlithiasis: prospective analysis of prevalence and associated tumor

PURPOSE

To evaluate testicular microlithiasis (TM) prospectively with modern state-of-the-art equipment.

MATERIALS AND METHODS

Information concerning indication for examination, presence and degree of TM, presence of testicular tumor, and patient age was prospectively recorded for all patients referred for scrotal ultrasonography between 1996 and 1999. High-frequency linear transducers (7.5 MHz or higher) were used. TM was divided into classic (CTM) and limited (LTM) on the basis of the presence of five or more microliths on one or more images of the testes. Fisher exact tests were used for determining significant differences in proportions.

RESULTS

Data in 1,079 patients were analyzed. The overall prevalence of TM was 18.1% (195 of 1,079). Forty (3.7%) patients had CTM, and 155 (14.4%) had LTM; 15 (1.4%) had tumors visible at US. Tumors were present in three (8%) of 40 patients with CTM (seminoma in two, embryonal cell in one), nine (5.8%) of 155 with LTM (seminoma in six, mixed germ cell in one, Leydig cell in two), and three (0.3%) of 884 with no TM (seminoma in two, other in one). There was no difference between CTM and LTM (P =.72) in the rate of coexisting tumor. There was a significant difference between no TM and CTM or LTM (P </=.001) in the rate of coexisting tumor. Eighty percent (12 of 15) of patients with tumor at presentation had CTM or LTM.

CONCLUSION

Approximately one of 27 patients had CTM, and one of seven had LTM. Although a majority of patients with testicular tumors had coexistent TM, more than 90% with TM (both CTM and LTM) did not have tumor at presentation.

Usefulness of intraoperative sonography for revealing hepatic metastases from colorectal cancer in patients selected for surgery after undergoing FDG PET

OBJECTIVE

The purpose of this study was to compare the diagnostic performance of preoperative positron emission tomography (PET) with FDG and intraoperative sonography with the standard of histologic examination of resected liver specimens in evaluating patients for curative resection of liver metastases from colorectal cancer.

MATERIALS AND METHODS

We retrospectively identified 47 patients with recurrent colorectal cancer who underwent surgical exploration for possible curative resection of hepatic metastases. All patients underwent CT or MR imaging and FDG PET preoperatively and intraoperative sonography. The performance of the imaging techniques was evaluated through review of the radiologic reports and correlation with surgical and histopathologic findings.

RESULTS

Eighty-seven malignant hepatic lesions were identified by histopathologic analysis of liver specimens, and 23 benign hepatic abnormalities were documented histopathologically or by uroradiologic imaging. For hepatic sections characterized as containing metastases by radiologic imaging, the positive predictive value for FDG PET was 93% (54/58); for intraoperative sonography, 87% (52/60); and for conventional imaging, 83% (43/52). For individual lesions characterized as probably malignant, the positive predictive value for FDG PET was 93% (62/68); for intraoperative sonography, 89% (63/71); and for conventional imaging, 78% (46/59). The findings at intraoperative sonography led to a change in the clinical treatment of only one patient (2%).

CONCLUSION

The results indicate that FDG PET effectively screens potential candidates for curative liver resection. Although intraoperative sonography helps to determine the anatomic location of metastases thus facilitating surgical resection, its adjunctive use in patients screened preoperatively by FDG PET has limited impact on treatment selection.

Utility of staging laparoscopy in subsets of peripancreatic and biliary malignancies

OBJECTIVE

To determine the relative benefit of staging laparoscopy in peripancreatic and biliary malignancies.

SUMMARY BACKGROUND DATA

Staging laparoscopy has been used in a variety of peripancreatic and biliary malignancies. The utility of the technique in subsets of these types of cancer has not been systematically compared.

METHODS

One hundred fifty-seven patients underwent laparoscopy after conventional tumor staging; 89 were also staged with laparoscopic ultrasonography. Diagnostic categories were cancer of the pancreatic head and uncinate process, cancer of the body and tail of pancreas, cancer of the extrahepatic bile duct, cancer of the gallbladder, and cancer of the ampulla of Vater/duodenum.

RESULTS

In patients with cancer of the head of the pancreas, metastatic disease or vascular invasion was discovered frequently by laparoscopy (31%), whereas in ampullary/duodenal cancer it was never found. The laparoscopic findings in cancer of the head of the pancreas had an important influence on treatment decisions, whereas in cancer of the ampulla/duodenum, laparoscopy had no effect on clinical decisions. Laparoscopy also substantially influenced the treatment of gallbladder cancer; in other tumor types, results were intermediate. Laparoscopic ultrasonography was valuable in cancer of the head of the pancreas.

CONCLUSIONS

The utility of staging laparoscopy depends on diagnosis. It is recommended for continued use in pancreatic head and gallbladder cancers but not in ampullary malignancies.