Ultrasound

It is the breast examination by means of the ultrasounds, with high resolution probe ( > 7,5 MHz) and with a 4 cm penetration; the interposition material or the focalization material and the multiple frequencies are used.

It is the primary intention method in the following cases:

• women under 40 years old
• pregnant or breastfeeding women
• breast prosthesis
• the evaluation of the immediate postoperative complications

It is the complementary method: in case of women over 40 years old for whom the mammography becomes the primary intention technique, the ultrasound enabling the differentiation between the cyst and the solid nodule; furthermore, it brings in morphological elements in the characterization of benign or malignant tumor formations, enables the guiding of the percutaneous breast punctures, highlights the cutaneous changes associated to the injury, enables the evaluation of the dense breast (opaque breast)- BIRADS 3-4 code, enables the examination of the axilla by determining the absence or presence of the adenopathies.

The color Doppler ultrasound is important for the characterization of the intralesional vascularization: the cyst is avascular (without vascularization, the benign tumor formations are hipovasculerized (low vascularization), the malignant tumor formations are hypervascularized (high vascularization) with abnormal flows and speeds that are higher in cancers than in benign tumors; the normal axillary lymph nodes have no color doppler signal and the adenopathies show constant vascularization. In case of doppler evaluation of the lymph nodes the appearance should be correlated with other signs.

In conclusion, the breast ultrasound has the following characteristics:

• is non-irradiating
• is noninvasive
• can be repeated if necessary
• is the primary intention method in the well chosen cases
• is complementary to the mammography in case of women over 40
• does not show the small calcifications
• is not the screening method of breast cancer
• is not used for the monitoring of the malignant tumor breast that was conservatively treated (chemo/radio treated)

The elastography is an imaging method that measures the elasticity of an injury compared to the healthy adjacent tissue. It is performed by using the ultrasound scanner which must be equipped with the elastography application by using the same transducer of the conventional ultrasound, by exerting a minimum compression in the area of interest by means of the transducer. The malignant tumor formations are hard, rigid and do not move so much and the benign tumor formations are elastic, soft and tend to move more than the others.

In our clinic the elastography is performed by the ACUSON S 2000 ultrasound scanner and the quantification of the rigidity is determined by means of the e Sie Touch elasticity imaging, the technique that enables a dual mode simultaneous view of the standard image – the B-mode (composition of the tissue) and the elastography (relative rigidity) are viewed together in the same time.

The elastography ensures a qualitative view of the rigidity of the tissue by obtaining a white/black map or a colored map. In case of the white/black map the white color indicates the softer tissue, and the black color indicates the hard tissue. In case of the color map 1 a red-green-blue map is displayed where the very hard tissues are colored in red, the intermediate in shades of yellow, the soft tissues are colored in green and very soft tissues in blue. In case of the color map 2, the very hard tissues are colored in blue and the elastic tissues in green and red. Furthermore, the technique enables the determination of a QF quality factor which value indicates to be > 60 which means a minimum error of the image; furthermore, it enables the determination of the ratio of the tissue pressure.

The value of the pressure is lower in case of a malignant lesion less compressible compared to the normal tissue or a benign lesion. Two ROIs are chosen, one placed on the lesion and the other one on the normal tissue and the index of the ratio is immediately calculated.

The breast elastography has the following characteristics:

• is noninvasive
• is painless
• enables a good characterization of small formations and cysts
• brings information for the differentiation between the benign and malignant nodule, especially in case of the nodular lesions with BIRADS 3 and 4 a score.
• can differentiate the complicated cyst of the solid nodule
• decreases the number of biopsies

The breast elastography is not indicated:

• in the evaluation of the large dimension tumor formations
• in the evaluation of a fibrous breast
• in breast hematoma
• in case of a breast implant
• in the evaluation of the postoperative changes of the breast

In conclusion: 

the breast elastography remains the complementary imaging technique that does not exclude the mammography, the standard ultrasound and the breast MRI.

It is a primary intention imaging method for the investigation of the thyroid gland; it is performed by the ultrasound scanner with high resolution linear transducer (7-18 MHz). The procedures enable the determination of the thyroid gland size, of the thyroid parenchyma structure and vascularization, highlights the focal or diffuse lesions, makes the difference between the cyst and the solid lesions, as well as between the benign and malignant thyroid nodule, highlights the local adenopathies, makes the difference between a thyroid nodule and a cervical mass of a different origin. It is non-irradiating, noninvasive, it can be repeated, enables the fine needle biopsy, is useful in postoperative monitoring of the recurrence in patients with thyroid cancer surgery.

The thyroid ultrasound is used in the percutaneous treatment with ethanol in case of the toxic adenomatous thyroid nodules. It is useful to diagnose the thyroid colloid cysts, thyroid goiter, thyroid cancer, acute, subacute or chronic thyroid, autoimmune or non-autoimmune thyroid.

Thyroid ultrasound indications according to the American Association of Endocrinologists

• for patients with enlarged, multinodular or palpable nodule thyroid
• for patients with high risks of thyroid cancer, family history of thyroid cancer, those diagnosed with type II MEN (multiple endocrine neoplasia) (patients with medullary thyroid carcinoma, unilateral or bilateral pheochromocytoma and endocrine tissue hyperplasia or neoplasia)
• for patients diagnosed with palpable laterocervical and potentially neoplastic adenopathies
• Color Doppler ultrasound views the peri/intralesional vascularization by helping to make the difference between the benign and malignant node – in case of the malignant node, the peri and intranodular tortuous vessels and the central vascularization are highlighted. The thyroid cyst is avascular (without vascularization), the benign nodular formations are hypovascularized (low vascularization), mostly peripheral vascularization.
• Thyroid ultrasound brings further information on the differentiation between the benign and malignant nodule, makes the difference between the cyst and the solid nodule –see breast elastography for technical details and lesional semiology.

In conclusion:

the thyroid ultrasound is the primary intention technique for the investigation of the thyroid gland. Noncystic tumor lesiosns of the thyroid gland are evaluated by complex imaging techniques, such as cervical region MRI and CT.

It is the imaging method that uses the ultrasounds to view the abdominal organs (gallbladder, liver, biliary tract, kidney, spleen, retroperitoneum). It is performed by the ultrasound scanner, by using a 3.5-5 MHz frequency transducer. The gallbladder investigation must be performed a jeun (at least 8 hours), by refraining from drinking coffee and soda.

It is the primary intention method for the investigation of the abdomen, is non-irradiating, noninvasive, can be repeated if needed, it is useful to diagnose gallstones (cholelithiasis) and kidney stones (renal lithiasis), vesicular polyps, vesicular carcinoma, postcholecystectomy syndrome, acute or chronic liver diseases, hepatic steatosis, liver cirrhosis, highlights liver cystic formations (biliary cyst, polycystic liver, hydatid cyst), can diagnose the benign liver tumor formations (hemangioma, FNH and hepatic adenoma) or primitive or secondary malignant tumor formations, hepatic abscess, acute or chronic pancreatitis, benign or malignant pancreatic tumor formations, abdominal trauma, benign or malignant tumor formations of the spleen and kidneys, polycystic kidney disease/simple or complicated renal cyst/ multiycystic kidney, it highlights the abdominal aortic aneurysm, the portal vein thrombosis or VCI, retroperitoneal adenopathies, retroperitoneal tumors.

The abdominal ultrasound enables fine needle biopsies, ultrasound-guided percutaneous treatment (ultrasound-guided percutaneous alcoholization and radiofrequency ablation) in case of primitive or secondary liver tumors. It is the screening method for patients with liver carcinoma risk – the performance of the standard ultrasound and the dosing of the alpha-fetoprotein each 6 months.

The benign or malignant tumor formations discovered during the standard ultrasound, need further superior investigation, such as abdominal MRI (N+SDC), abdominal CT (N +SDC) or CEUS (contrast-enhanced ultrasound).

It is the imaging method that uses the ultrasounds in order to view the pelvic organs (bladder, uterus and accessory women’s organs and men’s seminal vesicles). It is performed by the ultrasound scanner using a 3.5-5MHz frequency transducer by means of transabdominal investigation. For the evaluation of the women’s pelvis, it is recommended to drink 2l liters of fluids before the examination. The ultrasound investigation of the female pelvis may be performed by the gynecologists by means of an endovaginal probe. The prostate ultrasound may be performed by the urologists by means of an endorectal probe.

The pelvic ultrasound is the primary intention method for the examination of the pelvis, is non-irradiating, noninvasive, it can be repeated if needed, is useful to diagnose and monitor the evolution of pregnancy in pregnant women, it can diagnose the bladder stones, intrapelvic benign or malignant tumor formations, inflammatory ortraumatic intrapelvic injuries.

The benign or malignant tumor formations discovered during the ultrasound need further superior investigations, such as pelvic MRI (N and with SDC), pelvic CT (N and with SDC) or CEUS (contrast-enhanced ultrasound).