42nd Korean Society of Ultrasound in Medicine 2011 May 20(Fri) - 21(Sat), 2011 Hall E, Coex, Seoul, Korea

Transcription

1 42nd Korean Society of Ultrasound in Medicine 2011 May 20(Fri) - 21(Sat), 2011 Hall E, Coex, Seoul, Korea

2 Contents 1 Welcome Message 2 Organizing Committee 3 Program at a Glance 4 Invited Speakers 7 Congress Information Registration Desk Preview Room & Internet Lounge Practical Workshop of KSUM Interactive Case Review Scientific Exhibition & Case of the Day Congress Dinner Coffee Breaks Rest Area Secretariat Office 9 General Information 12 Sponsors 13 Technical Exhibition 14 Photo Contest 15 Scientific Programs 31 Abstracts 233 Author Index

3 42nd Korean Society of Ultrasound in Medicine 2011 Open 1 Welcome Message Cheol Min PARK, M.D. Dear Colleagues and Friends, On behalf of the Organizing Committee and the Korean Society of Ultrasound in Medicine (KSUM), I am delighted to extend my warm welcoming to all colleagues participating in the 42nd Korean Society of Ultrasound in Medicine 2011 Open to be held in Seoul, Korea. Following the success of KSUM 2010, we have been continuing our efforts for globalization and the introduction of innovation with enthusiasm in ultrasound in medicine. Under the theme of KSUM Open, we have put together a very comprehensive program aimed at enhancing basic and up-to-date knowledge for various topics. 'KSUM Open' means an occasion that signaled the transition of the KSUM from a domestic meeting to an international congress and now open to all friends from abroad. Hence, this year, the scientific program is further expanded with diverse educational courses regarding recent Ultrasound in Medicine and is anticipated to attract large crowds. Especially, full-english educational sessions and special focused lectures have scheduled to be delivered by excellent speakers from various countries for KSUM 2011 Open. We would not be what we are today, without the continuing support and high quality scientific contributions from our many colleagues. I hope that you will join us at KSUM 2011 Open in beautiful Korean Spring time to renew your knowledge and find the joy of learning again. I am very confident that you will enjoy KSUM 2011 Open in Seoul. Cheol Min PARK, M.D. President of the Korean Society of Ultrasound in Medicine

4 2 42nd Korean Society of Ultrasound in Medicine 2011 Open Organizing Committee President Vice-President Chair, Board of Directors Secretary Treasurer Chair, Scientific Committee Chair, Publication Committee Chair, Planning Committee Chair, Information & Communication Committee Chair, Medical Affair Committee Chair, Insurance and Accreditation Committee Chair, International Liaison Committee Chair, Public Relation Committee Chair, Education Committee Chair, Compilation Committee Director at Large Auditor Cheol Min PARK, M.D. (Korea University) Seung Hyup KIM, M.D. (Seoul National University) Ho Jung YOUN, M.D. (Seoul St. Mary's Hospital) Am KIM, M.D. (University of Ulsan) Jae Young BYUN, M.D. (Seoul St. Mary's Hospital) Won Jae LEE, M.D. (Sungkyunkwan University) Hae Jeong JEON, M.D. (Konkuk University) Jeong Yeon CHO, M.D. (Seoul National University) Eun-Kyung KIM, M.D. (Yonsei University) Kyung Nam RYU, M.D. (Kyung Hee University) Kyoung Won KIM, M.D. (University of Ulsan) Dal Mo YANG, M.D. (Kyung Hee University) Joon-Il CHOI, M.D. (Seoul St. Mary's Hospital) Jae Young LEE, M.D. (Seoul National University) Jae Joon CHUNG, M.D. (Yonsei University) Seung Eun JUNG, M.D. (Seoul St. Mary's Hospital) Dongil CHOI, M.D. (Sungkyunkwan University) Hae Ok JUNG, M.D. (Seoul St. Mary's Hospital) Hye-Sung WON, M.D. (University of Ulsan) Joon Koo HAN, M.D. (Seoul National University) Hee Jung LEE, M.D. (Keimyung University) Jung Hwan BAEK, M.D. (University of Ulsan) Dong Ho LEE, M.D. (Kyung Hee University) Kyung Jin NAM, M.D. (Dong-A University)

5 42nd Korean Society of Ultrasound in Medicine 2011 Open 3 KSUM 2011 Open Program at a Glance Time Day 1, May 20 (Fri) Day 2, May 21 (Sat) Time 07:00 Hall E1-4 Hall E5 Hall E6 Room 300 Hall E1-4 Hall E5 Hall E6 Room :00 08:00 08:00 08:30 08:30 09:00 09:30 Categorical Course (AB) Categorical Course (PD) Categorical Course (GU) Categorical Course (PHY) Categorical Course (BR) Categorical Course (MS) 09:00 09:30 10:00 10:30 Coffee Break Coffee Break 10:00 10:30 11:00 11:30 12:00 12:30 13:00 13:30 14:00 14:30 Registration & Technical Exhibition Special Focus Session (AB) Luncheon Session I Scientific Session (YIA/AB) Scientific Session (PD/GU) Luncheon Session II Special Focus Session (PD) Special Focus Session (IR) Special Focus Session (GU) Registration & Technical Exhibition Scientific Session (H&N/THY) Luncheon Session III Special Focus Session (H&N) Special Focus Session (BR) Luncheon Session IV Scientific Session (BR/MS) Special Focus Session (MS) Special Focus Session (CV) Practice Workshop_KSUM (How to Make Good Ultrasound Images?) 11:00 11:30 12:00 12:30 13:00 13:30 14:00 14:30 15:00 Coffee Break Coffee Break 15:00 15:30 15:30 16:00 16:30 Jisan Lecture Categorical Course (THY) Categorical Course (CV) 16:00 16:30 17:00 17:30 Interactive Case Review Scientific Session (THY) 17:00 17:30 18:00 18:00 18:30 18:30 19:00 19:00 19:30 20:00 Congress Dinner 19:30 20:00 20:30 21:00 20:30 21:00

6 4 42nd Korean Society of Ultrasound in Medicine 2011 Open Invited Speakers Bae Young Lee Bo Kyoung Seo Bong joo Kang Byung Kwan Park Chan Kyo Kim Korea Korea Korea Korea Korea Chong Hyun Yoon Dong Woo Park Eun Young Ko Eun-Kyung Kim Gervais Wansaicheong Korea Korea Korea Korea Singapore Harvey Teo Hee Sun Park Hong-Jen Chiou HYE-SUNG WON Hyoung Jung Kim Singapore Korea R. O. China Korea Korea Hyun Sook Hong In-One Kim Jae Young Lee Jang-Ho Bae Jeong Hyun Lee Korea Korea Korea Korea Korea

7 42nd Korean Society of Ultrasound in Medicine 2011 Open 5 Jeong Seon Park Ji-hoon Kim Jin Ho Chang Jin Wei Kwek Jin Young Kwak Korea Korea Korea Singapore Korea Jong Seob Jeong Jongbum Seo Joo Han Oh Joon-Il Choi Jung Hwan Baek Korea Korea Korea Korea Korea Jung-Ah Choi Jung-Eun Cheon Ki Seok Choo Kil-Ho Cho Kwang Nam Jin Korea Korea Korea Korea Korea Kyu Ran Cho Llewellyn Sim Masatoshi Kudo Min Hoan Moon Min Woo Lee Korea Singapore Japan Korea Korea Minju Kim Na Ra Kim Nariya Cho Nathalie Lassau Nitin G Chaubal Korea Korea Korea France India

8 6 42nd Korean Society of Ultrasound in Medicine 2011 Open Paul S. Sidhu Sang Il Choi Sang-Wook Yoon Seung Eun Jung Seung Ja Kim United Kingdom Korea Korea Korea Korea Simon Elliott So Lyung Jung Soo Ah Im Soo Mee Lim So-young Yoo United Kingdom Korea Korea Korea Korea Su Lim Lee Sung Il Hwang Sung Kyoung Moon Whal Lee Won-Jin Moon Korea Korea Korea Korea Korea Woo Sun Kim Xiaoye Hu Yangmo Yoo Young Hen Lee Young Mi Park Korea P. R. China Korea Korea Korea Yun Sun Choi Korea

9 Congress Information 42nd Korean Society of Ultrasound in Medicine 2011 Open 7 Registration Place Lobby, Hall E (3F) Operating Hours May 20(Fri) 07:00-18:30 May 21(Sat) 07:30-18:00 Name Badges The name badges will be used as passed. You are kindly requested to wear your name badge throughout the Meeting. Please note that only registered participants wearing their badges are allowed admission to the scientific session rooms and exhibitions. Registration Fee Category On-site Registration Full Membership KRW 80,000 Full Membership(Annual Fee Unpaid) KRW 100,000 Associate Member KRW 50,000 Non-member KRW 140,000 One-day Participant KRW 50,000 Applicants who enroll in Korean Society of Ultrasound in Medicine can make the on-site registration of KSUM 2011 Open with discounted registration fee. Application of KSUM is also available at the KSUM Head-office booth at the Registration Desk Area. Congress Kit Congress Kit coupon attached along the name tag will be given to each participant on registration and the coupon is available at Kit Desk. It contains Abstract Book. Preview Room & Internet Lounge Place Foyer, Hall E5 (3F) Operating Hours May 20(Fri) - 21(Sat) 07:30-18:00 - The speakers are required to check-in at the Preview Room to review their slide(s) and save the final versions. Final presentation file(s) must be uploaded at least an hour before the start of their session. - Participants are able to use the internet in the Internet Lounge during the congress Practical Workshop of KSUM ( 연수강좌 ) Place Room no. 300(3F) Operating Hours May 21(Sat) 08:30-16:50 Practice Workshop will be proceeded in Korean.

10 8 42nd Korean Society of Ultrasound in Medicine 2011 Open Interactive Case Review Place Hall E1-4 Operating Hours May 20(Fri) 16:40-18:20 Please challenge to the answer, you can be the winner for Amazing Prize. Challenger will get a prize during a session. Scientific Exhibition (Electronic poster display only) & Case of the Day Place Foyer, Hall E (3F) Operating Hours May 20(Fri) - 21(Sat) 08:30-18:00 The Case of the Day Committee will present 14 cases on May 20 (Fri) in the E-poster Area, Foyer of Hall E (3F). Cases will be displayed on the board, and please submit your sheet in the Answer Box. The winner will be awarded at the Congress Dinner (19:00, May 20, 2011). Congress Dinner Place Diamond Hall (B1F), InterContinental Seoul Coex Operating Hours May 20(Fri) 19:00 Only pre-reserved participants on their on-line registration and invited guests are able to join for a chance to relax and enjoy a delightful evening of delicious food and exciting entertainment. Coffee Breaks Place Lobby, Hall E (3F) Operating Hours May 20(Fri) - 21(Sat) 10:00-10:30, 14:50-15:20 All registered participants are able to have free access to the coffee breaks which will be provided daily at the Lobby of Hall E from May 20 to May 21. Rest Area Place Lobby, Hall E (3F) Operating Hours May 20(Fri) - 21(Sat) 08:30-18:00 The Rest area will be opened during the Congress Secretariat Office Place Room no. 303 (3F) Operating Hours May 20(Fri) - 21(Sat) 07:30-18:30 Contact the person in charge - Scientific Sessions & General Affairs: Min-kyoung Kim (Ms. Renee Kim / Manager) - Technical Exhibition & Photo Contest: Jihwan Kim (Mr. Peter Kim) - Registration: Sooyeon Lee (Ms. Christine Lee)

11 42nd Korean Society of Ultrasound in Medicine 2011 Open 9 General Information * Currency Exchange The KRW(\) is the Korean currency. It consists of fifty thousand, ten thousand, five thousand, and one thousand Won notes, and five hundred, one hundred, fifty, and ten Won coins. The exchange rate is approximately 1US$ to \1,100 as of May Foreign bank notes and traveler s checks can be converted into Korean Won at banks, bureau de change at the airport, and major hotels. Internationally recognized credit cards are also accepted at most hotels, shops, and restaurants. * Tax Any product with the Tax Free Shopping signed will give you a refund on the VAT. You must depart Korea within 3 months of the purchase. VAT Refund Information - Minimum purchase amount: KRW Period for obtaining a valid customs stamp: 3 months from the issuing date. - Cheque Validity: With a valid customs stamp 3 months from the issuing date. - Receipt/Invoice: No need to be attached. - Customs stamp: An official Korean customs stamp. For more information, please contact: Taxfree.kr@global-blue.com Tel: Fax: * Tipping Tipping is not customary in Korea. A 10% service charge is already added to the bill at all tourist hotels and some restaurants. * Telephone Calls In Korea To make a local call in the same area or city, just dial the telephone number. If you are in a different area of city, first dial the area code and then the telephone number you wish to call. International Calls To make a direct international call from Korea, first dial the international access code 001, 002, 008 or plus the country code, the area code and the recipient s number. * Time Difference Korea s standard time zone is GMT +9 hours. * Liability and Insurance The Organizing Committee will take no liability for personal injuries sustained by or for loss or damage to property belonging to congress participants, either during or as a result of the congress. It is, therefore, advised that participants arrange their own personal health, accident, and travel insurance.

12 10 42nd Korean Society of Ultrasound in Medicine 2011 Open Tourist Points Bongeunsa (5 mins by walk from Coex) Bongeunsa is a Buddhist temple in Gangnam-gu, Seoul. It was built in 794 during the reign of King Wonseong in Koryo Dynasty by the monk Yeon-hoe, then the highest ranking monk of Silla, and originally named Kyongseoungsa. It is located on the slope of Sudo Mountain in Samseong-dong, across the street from the Coex Mall. The temple is also a notable tourist destination, offering a Temple Stay Program in which visitors can lead the life of a monk for a few hours. Temple Stay Program for Foreigners Every Thursday, special Temple Stay program opens for Foreigners. Inquiries Hotline: 02) (Korean) 02) (Foreigner) bongeunsa@templestay.com Coex Mall (Directly connected from Coex) As the largest underground shopping mall in Asia, Coex Mall has a lot to offer. Here you can enjoy not only shopping, entertainment and fine dining but also a variety of cultural activities. There are about 200 stores with both national and international brands. Visit the 16-screen multiplex cinema, Megabox, the Aquarium, and the Kimchi Museum. Entrances of Hyundai Department store, one of the most famous one in Korea are connected to Coex Mall, so the visitors can easily access and forth of these fantastic places for shopping.

13 42nd Korean Society of Ultrasound in Medicine 2011 Open 11 Dongdae-mun Fashion Town Dongdae-mun Fashion Town is the biggest fashion industry complex where traditional market and modern shopping mall exists around Choneggyecheon(stream), an new cultural space and old Dongdaemun stadium. About 30,000 stores in 30 shopping malls are densely populated here, boasting of the biggest size in Korea and can be regarded as the world biggest fashion town with a daily flowing population of about 1 million visitors. # Main Shopping Towns Doota, Milgliore, Designers Club, Pyeonghwa Market, Gwanghee Fashion Mall, Nam Pyeonghwa Market, Jeil Pyeonghwa Market, Dong Pyeonghwa Market, TheOT, U:US # Location Areas around Dongdaemun History & Culture Park and traditional markets(dongdaemun History & Culture Park station, Subway Line 2, 4, 5). # The Shortest Way to Visit From Coex Subway (About 35 mins) Samseong(Line 2) - Dongdaemun History and Culture park(line 2)

14 12 42nd Korean Society of Ultrasound in Medicine 2011 Open Sponsors The Organizing Committee of KSUM 2011 Open gratefully acknowledges the sponsorship by following companies. Gold Silver Bronze

15 42nd Korean Society of Ultrasound in Medicine 2011 Open 13 Technical Exhibition All participants will have opportunity throughout the meeting to visit the industrial exhibition. The exhibition will be located at Lobby of Hall E. Place Lobby, Hall E (3F) Operating Hours May 20(Fri) - 21(Sat) 08:00-18:00 Exhibition layout E-poster & Case of the Day Main Session Hall Technical Exhibition Preview Room & Internet Lounge Rest Area Photo Contest & Photo Zone Registration Desk Practical Workshop Booth No. Company Name Booth No. Company Name 1 ALOKA KOREA CO., LTD. 19 Dong-Kook Pharmaceutical Co., Ltd. 2 InSightec Ltd Guerbet Korea Ltd. 3 Win International Co., LTD Bayer Korea Co., Ltd. 4 Siemens Healthcare Bracco Imaging Korea, Ltd. 5-6 SAMSUNG MEDISON Co., Ltd. 26 Reyon & Covidien 7-8 Philips 27 Covidien Korea, Inc GE Healthcare 28 ACCUZEN TI Medical Systems Inc. 29 DongSeo Medicare Co., Ltd Central Medical Service 30 Withhealthcare. Co., Ltd. 15 HANDOK Pharmaceuticals Co., LTD. 31 LG Life Sciences 16 Gabon Medical Book Service 32 ALPINION Medical Systems 17 JW MEDICAL CORPRATION 33 Ah Sung Medical 18 Daewoong pharmaceutical.co., LTD. 34 SI healthcare Ltd.

16 14 42nd Korean Society of Ultrasound in Medicine 2011 Open Photo Contest Photography offers a very good opportunity to understand the interest of colleagues and communicate with each other. The selected photos will be exhibited in the corner of Hall E Lobby Award Section Prize Grand Prix 1 Winner KRW 500,000 Gold 1 Winner KRW 300,000 Silver 2 Winners KRW 200,000 Bronze 3 Winners KRW 100,000 Honorary Mentions 10 Winners Gift Award Ceremony The Grand Prix will be awarded at the Congress Dinner (19:00, May 20, 2011). Winners of the Gold, Silver and Bronze Prizes and Honorary Mentions may receive their awards at the Registration (KSUM Head-office) Desk during event. Return of Photos Awardees can pick up their exhibited photos from 16:00 on May 21(Sat), 2011.

17 42nd Korean Society of Ultrasound in Medicine 2011 Scientific Program & Abstracts

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19 42nd Korean Society of Ultrasound in Medicine 2011 Open 17 Day 1 (Friday, 20 May) Categorical Course (CC) Abdomen 08:30-10:00 Hall E1-4 Chairperson(s): Chul Soon Choi Kangdong Sacred Heart Hospital, Korea Jae Young Lee Seoul National University Hospital, Korea 08:30-08:50 CC1 AB-01 Challenges and Pitfalls in Abdominal US 31 Min Ju Kim Department of Radiology, Anam Hospital, Korea University College of Medicine, Korea 08:50-09:10 CC1 AB-02 Ultrasonography of Diffuse Liver Disease 32 Hee Sun Park Department of Radiology, Konkuk University Medical Center, Korea 09:10-09:30 CC1 AB-03 US Findings of Benign Focal Liver Lesions 35 Hyoung Jung Kim Department of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Korea 09:30-09:50 CC1 AB-04 US Findings of Malignant Focal Lesions of the Liver 37 Joon-Il Choi Department of Radiology, Seoul St. Mary s Hospital, The Catholic University of Korea, Korea 09:50-10:00 Discussion Pediatric 08:30-10:00 Hall E5 Chairperson: Gye Yeon Lim The Catholic University of Korea, St. Mary s Hospital, Korea 08:30-09:00 CC2 PD-01 Ultrasound of the Pediatric Urinary Tract 40 Hyun Sook Hong Department of Radiology, Soonchunhyang University Hospital, Bucheon, Korea 09:00-09:30 CC2 PD-02 US of the Pediatric Gynecologic Diseases 46 So-Young Yoo Department of Radiology, Sungkyunkwan University, Korea 09:30-10:00 CC2 PD-03 US of Pediatric Scrotum 49 Soo Ah Im Department of Radiology, Seoul St. Mary s Hospital, The Catholic University of Korea, Korea Genitourinary 08:30-10:00 Hall E6 Chairperson: Kyoung Sik Cho Asan Medical Center, Korea 08:30-08:50 CC3 GU-01 US of Medical Renal Diseases and Transplanted 56 Kidney Chan Kyo Kim Department of Radiology, Samsung Medical Center, Sungkyunkwan University, Korea 08:50-09:10 CC3 GU-02 US Differential Diagnosis of Renal Masses 62 Gervais Wansaicheong Department of Radiology, Tan Tock Seng Hospital, Singapore 09:10-09:30 CC3 GU-03 US and Biopsy of the Prostate 64 Sung Il Hwang Department of Radiology, Seoul National University Bundang Hospital, Korea 09:30-09:50 CC3 GU-04 US of the Testis 65 Paul S. Sidhu Department of Radiology, King s College London, United Kingdom 09:50-10:00 Discussion Special Focus Session Abdomen 10:30-12:00 Hall E1-4 Chairperson(s): Hae Jeong Jeon Konkuk University, Korea Masatoshi Kudo Kinki University, School of Medicine, Japan 10:30-10:50 SF1 AB-01 Abdominal Application of Shear Wave-Based 115 Elastography Jae Young Lee Department of Radiology, Seoul National University Hospital, Korea 10:50-11:10 SF1 AB-02 Monitoring Effect of Antiangiogenic Treatments by 118 DCE-US Nathalie Lassau Imaging Department-Ultrasonograph Unit, Institut Gustave Roussy, France 11:10-11:30 SF1 AB-03 Update on Endoscopic USG: 120 How Much for Imaging, Needling, or Therapy? Masatoshi Kudo Department of Gastroenterology and Hepatology, Kinki University, School of Medicine, Japan 11:30-11:50 SF1 AB-04 Real-time Image US Fusion and Navigation 122 Technique with CT or MRI Min Woo Lee Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Korea 11:50-12:00 Discussion

20 18 42nd Korean Society of Ultrasound in Medicine 2011 Open Intervention 10:30-12:00 Hall E6 Chairperson(s): Won Hong Kim Inha University Hospital, Korea Sang-Wook Yoon CHA Bundang Medical Center, CHA University, Korea 10:30-10:50 SF2 IR-01 Therapeutic Effects of High-Intensity Focused 123 Ultrasound Ablation on Uterine Leiomyomas: A 147- Case Study Xiaoye Hu Department of Oncology, Second Affiliated Hospital, Zhejiang University School of Medicine, China 10:50-11:10 SF2 IR-02 HIFU Therapy of Pancreas Cancer 124 Seung Eun Jung Department of Radiology, Seoul St. Mary s Hostpial, The Catholic University of Korea, Korea 11:10-11:30 SF2 IR-03 HIFU/MRgFUS of Uterine Diseases 127 Sang-Wook Yoon Department of Diagnostic Radiology, CHA Bundang Medical Center, CHA University, Korea 11:30-11:50 SF2 IR-04 Experience in MR Guided Focused Ultrasound 128 Surgery (MRgFUS) of Early Prostate Cancer Kwek JW, Cheng CWS, Thng CH, Lau W, Khoo J Department of Oncologic Imaging, National Cancer Centre, Singapore 11:50-12:00 Discussion Pediatric 13:20-14:50 Hall E5 Chairperson: Young Seok Lee Dankook University Hospital, Korea 13:20-13:50 SF3 PD-01 Ultrasound of the Neonatal Brain 129 Harvey Teo Department of Diagnostic Imaging, Kandang Kerbau Women s and Children s Hospital, Singapore 13:50-14:20 SF3 PD-02 Ultrasonography of Neonatal Hepatobiliary Disease 130 Woo Sun Kim Department of Radiology, Seoul National University Children s Hospital, Korea 14:20-14:50 SF3 PD-03 Ultrasound of Neonatal GI Tract Anomalies 132 Chong Hyun Yoon Department of Pediatric Radiology, Children s Hospital Asan Medical Center, Seoul, Korea Genitourinary 13:40-14:00 SF4 GU-02 US of Male Infertility 144 Min Hoan Moon Department of Radiology, Seoul Metropolitan Boramae Medical Center, Seoul National University College of Medicine, Korea 14:00-14:20 SF4 GU-03 CEUS in GU 145 Gervais Wansaicheong Department of Radiology, Tan Tock Seng Hospital, Singapore 14:20-14:40 SF4 GU-04 Ultrasound (US) Elastography in the Evaluation of 146 Kidney Disease Sung Kyoung Moon Department of Radiology, Kyung Hee University Hospital, Korea 14:40-14:50 Discussion Luncheon Session PHILIPS Hall E1-4 Chairperson: Ki Whang Kim Severance Hospital, Yonsei University, Korea 12:00-13:20 LS-01 xmatrix Ultrasound: the Power of CT/MR in 167 Your Hand Simon Elliott Department of Radiology, Freeman Hospital, Newcastle Upon Tyne, United Kingdom BRACCO Hall E5 Chairperson: Jae Young Byun The Catholic University of Korea, Seoul St. Mary s Hospital, Korea 12:00-13:20 LS-02 Dynamic Contrast Enhanced Ultrasonography 168 Nathalie Lassau Imaging Department-Ultrasonography Unit, Institute Gustave Roussy, France Jisan Lecture 15:20-16:40 Hall E1-4 Chairperson: Cheol Min Park Korea University Guro Hospital, Korea 15:20-16:00 JL-01 Neurosonography 171 In-One Kim Department of Radiology, Seoul National University College of Medicine, Korea 16:00-16:40 JL-02 USG in Infectious Tropical Diseases 176 Nitin Chaubal Department of Ultrasound, Thane Ultrasound Centre, Thane and Jaslok Hospital & Research Centre, Mumbai, India 13:20-14:50 Hall E6 Chairperson(s): Byung Kwan Park Samsung Medical Center, Korea Jeong Yeon Cho Seoul National University Hospital, Korea 13:20-13:40 SF4 GU-01 3D/4D fetal US 143 Hye-Sung Won Department of Obstetrics & Gynecology, University of Ulsan College of Medicine, Asan Medical Center Country, Korea

21 42nd Korean Society of Ultrasound in Medicine 2011 Open 19 Interactive Case Review 16:40-18:20 Hall E1-4 Chairperson: Jung Hwan Baek Ulsan College of Medicine, Asan Medical Center, Korea 16:45-17:00 ICR-01 Thyroid / Neck Jung Hwan Baek Ulsan College of Medicine, Asan Medical Center, Korea 17:00-17:15 ICR-02 Abdomen Joon-Il Choi Seoul St. Mary's Hospital, The Catholic University of Korea, Korea 17:15-17:30 ICR-03 Genitourinary Byung Kwan Park Samsung Medical Center, Korea 17:30-17:45 ICR-04 Breast Nariya Cho Seoul National University Hospital, Korea 17:45-18:00 ICR-05 Pediatric Jung-Eun Cheon Seoul National University Children's Hospital, Korea 18:00-18:15 ICR-06 Musculoskeletal Jung-Ah Choi Seoul National University, Bundang Hospital, Korea Scientific Sessions Pediatric 10:30-11:30 Hall E5 Chairperson(s): Kwanseop Lee Hallym University Sacred Heart Hospital, Korea Hyun Sook Hong Soonchunhyang University Bucheon Hospital, Korea SS 1 PD-01 10:30 Lenticulostriate Vasculopathy on 177 Ultrasonography, Doppler, and MRI with Associated Clinical Conditions and Results Mi-Jung Lee 1, Myung-Joon Kim 1, Seung-Koo Lee 1, Ran Namgung 2, Kook In Park 2 1 Department of Radiology and Research Institute of Radiological Science, Yonsei University, Severance Hospital, Korea 2 Department of Pediatrics, Yonsei University, Severance Children s Hospital, Korea SS 1 PD-02 10:40 Sonographic Features of Extracranial 177 Cytomegalovirus Infection in Children Chan Sun Kim, Sang Kwon Lee, Byung Hak Lee, Hee Jung Lee Department of Radiology, Keimyung University Dongsan Hospital, Korea SS 1 PD-03 10:50 Role of Real-time Sonoelastographic Evaluation 178 in Spastic Cerebral Palsy Dong Rak Kwon, Gi Young Park, Sung Uk Lee Department of Rehabilitation Medicine, Catholic University of Daegu School of Medicine, Korea SS 1 PD-04 11:00 Ultrasonographic Diagnosis of Gastric or 178 Duodenal Ulcer in Children Hyun Jung Lee, Kwanseop Lee, Hyeon Hwan Jo, In Jae Lee, Min Jung Kim Department of Radiology, Hallym University Hospital, Korea SS 1 PD-05 11:10 Small Bowel Ultrasound Characteristics Among 179 the Undernourished Children with Disseminated Tuberculosis Maria Goretti Ametembun Saumlaki Public Health Centre, West of South-East Moluccas, East Part of Indonesia, Indonesia SS 1 PD-06 11:20 Ultrasound value of Renal Length and Volume in 179 Healthy Korean Children and Simple Equations with Height and Weight Mi-Jung Lee 1, Myung-Joon Kim 1, Sok Hwan Lim 2 1 Department of Radiology and Research Institute of Radiological Science, Yonsei University, Severance Hospital, Korea, 2 Department of Radiology, Yonsei University, Severance Children s Hospital, Korea Genitourinary 11:30-12:00 Hall E5 Chairperson: Sung Il Jung Konkuk University Medical Center, Korea SS 2 GU-07 11:30 Diagnostic Sensitivity of Gray-Scale Sonographic 180 Findings for the Detection of Acute Pyelonephritis Hui Jin Lee, Sung Il Jung, Yonung Jun Kim, Hee Sun Park, Haejeong Jeon Department of Radiology, Konkuk University Medical Center, Konkuk University School of Medicine, Korea SS 2 GU-08 11:40 Comparison of Diagnostic Yields of Variable 180 Systematic Randomized Prostate Biopsy Protocols Using Prostate Phantoms with Devil s Tongue Jelly Sung Il Hwang, Hak Jong Lee, Ja Yeon You, Yong Hyun Joo, Gheeyoung Choe Department of Radiology, Seoul National University Bundang Hospital, Korea SS 2 GU-09 11:50 US & CT Findings of Exophytic Uterine 181 Lipoleiomyoma Jongchul Kim Department of Radiology, Chungnam National University Hospital, Korea

22 20 42nd Korean Society of Ultrasound in Medicine 2011 Open YIA 13:20-13:50 Hall E1-4 Chairperson(s): Jae-Joon Chung Yonsei University, Korea Dal Mo Yang Kyung Hee University, Korea SS 2 YIA-01 13:20 Relationship Between Beam-flow Angle and 181 Doppler Ultrasound Velocity Measurements Michael Yong Park, Seung Eun Jung, Jae Young Byun Department of Radiology, The Catholic University of Korea, Korea SS 2 YIA-02 13:30 Quantification of the Kidney Fibrosis Using 182 Supersonic Shear Wave Imaging: Experimental Study with Rabbit Model Sung Kyoung Moon 1, Dong Ho Lee 1, Sang Youn Kim 2, Jeong Yeon Cho 2, Seung Hyup Kim 2, Kyung-Chul Moon 3 1 Department of Radiology, Kyung Hee University Medical Center, Korea, 2 Department of Radiology, Seoul National University Hospital, Korea, 3 Department of Pathology, Seoul National University Hospital, Korea SS 2 YIA-03 13:40 Young s Modulus Measurement Using Core 182 Biopsy Sample of Breast Tissue and Phantom Model: Ultrasound-Elastographic Correlation Suhyun Lee, Nariya Cho, Woo Kyung Moon, Jung Min Chang, Kee Hyun Chang Department of Radiology, Seoul National University Hospital, Korea Abdomen 13:50-14:50 Hall E1-4 Chairperson(s): Jae-Joon Chung Yonsei University, Korea Dal Mo Yang Kyung Hee University, Korea SS 2 AB-04 13:50 Differentiation of Adenomyomatosis and Wall 183 Thickening Type Gallbladder Cancer on High Resolution Ultrasonography Ijin Joo, Jae Young Lee, Jung Hoon Kim, Soo Jin Kim, Joon Koo Han, Byung Ihn Choi Seoul National University Hospital, Korea SS 2 AB-05 14:00 US Elastography in Evaluation of Rejection after 183 Liver Transplantation Jeong-Hee Yoon 1, Jae-young Lee 1, Mihye Yoo 1, Sung-kyung Moon 2, JK Han 1, Byung Ihn Choi 1 1 Department of Radiology, Seoul National University Hospital, Seoul, Korea 2 Department of Radiology, Kyung Hee University Hospital, Seoul, Korea SS 2 AB-06 14:10 Volume Navigation-Guided Percutaneous 184 Radiofrequency Ablation of Hepatocellular Carcinoma with Poor Lesion Conspicuity on Conventional Sonography: Initial Experience Min Woo Lee, Hyunchul Rhim, Dongil Choi, Young-sun Kim, Young Kon Kim, Min Jung Park, Hyo K. Lim Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Korea SS 2 AB-07 14:20 Radiofrequency Ablation of Hepatic Metastases 184 after Curative Resection of Pancreatic Adenocarcinoma Jin Hyung Kim, Yong Moon Shin, Hyung Jin Won, Pyo Nyun Kim, Moon Gyu Lee Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Korea SS 2 AB-08 14:30 Preclinical Evaluation of the Effect of Combined 185 HIFU and Gemcitabine Treatment on the Animal Xenograft Model of Human Pancreatic Cancer Kyung Won Kim, Jae Young Lee, Harry Kim, Ji Suk Park, Eun Sun Lee, Joon Koo Han, Byung Ihn Choi Department of Radiology, Seoul National University Hospital, Korea SS 2 AB-09 14:40 Planning Ultrasonography for Fiducial Marker 185 Implantations before CyberKnife Radiation Therapy: Is It Predictable Technical Failure? Hyun Jeong Park, Seong Sook Hong, Sung Tae Park, Kui Hyang Kwon, Deuk Lin Choi Department of Radiology, Soonchunhyang University Hospital, Seoul, Korea

23 42nd Korean Society of Ultrasound in Medicine 2011 Open 21 Day 2 (Saturday, 21 May) Categorical Course (CC) Physics 08:30-10:00 Hall E1-4 Chairperson: Yangmo Yoo Sogang University, Korea 08:30-08:50 CC4 PHY-01 Basic Principles of Ultrasound Imaging 66 Jin Ho Chang Medical Solutions Institute, Sogang Institute of Advanced Technolgy, Sogang University, Korea 08:50-09:10 CC4 PHY-02 Signal and Image Processing Techniques for 67 Medical Ultrasonic Imaging Jong Seob Jeong Medical Biotechnology, College of Life Science and Biotechnology, Dongguk University, Korea 09:10-09:30 CC4 PHY-03 New Imaging Modes and Algorithms in Medical 68 Ultrasound Imaging Yang Mo Yoo Department of Electronic Engineering and Interdisciplinary Program of Integrated Biotechnology, Sogang University, Korea 09:30-09:50 CC4 PHY-04 Cancer Treatment with Ultrasound: 69 Technical Trends of HIFU Jong Bum Seo Biomedical Engineering, Yonsei University, Korea 09:50-10:00 Discussion Breast 08:30-10:00 Hall E5 Chairperson: Eun-Kyung Kim Severance Hospital Yonsei University, Korea 08:30-08:50 CC5 BR-01 Breast US: Equipment and Techniques 70 Seung Ja Kim Department of Radiology, Seoul National University, Boramae Medical Center, Korea 08:50-09:10 CC5 BR-02 BIRADS in Interpretation of Breast US 73 Bong Joo Kang Department of Radiology, Seoul saint Mary s Hospital, Korea 09:10-09:30 CC5 BR-03 Mammographic-Ultrasound Correlation 76 Llewellyn Sim Department of Diagnostic Radiology, Singapore General Hospital, Singapore 09:30-09:50 CC5 BR-04 Ultrasound (US)-guided Procedures 77 Young Mi Park Department of Radiology, Busan Paik Hospital Inje University, Korea 09:50-10:00 Discussion Musculoskeletal 08:30-10:00 Hall E6 Chairperson(s): Kyung Nam Ryu Kyung Hee University Medical Center, Korea Kil-Ho Cho Yeungnam University Medical Center, Korea 08:30-08:50 CC6 MS-01 Ultrasound of the Shoulder: Anatomy 82 Kil-Ho Cho Department of Radiology, Yeungnam University Hospital, Daegu, Korea 08:50-09:10 CC6 MS-02 Ultrasound Evaluation of Rotator Cuff Tear 84 Jung-Ah Choi Department of Radiology, Seoul National University College of Medicine, Korea 09:10-09:30 CC6 MS-03 Treatment of the Rotator Cuff Tear 85 Joo Han Oh Orthopedic Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Korea 09:30-09:50 CC6 MS-04 Postoperative US of the Shoulder 94 Na Ra Kim Department of Radiology, Konkuk University School of Medicine, Korea 09:50-10:00 Discussion Thyroid 15:20-16:50 Hall E1-4 Chairperson: Dong Gyu Na Human Medical Imaging and Intervention Center, Korea 15:20-15:40 CC7 THY-01 Current Guideline of FNA in Thyroid Nodule Based 95 on the Recommendations of KSThR Won-Jin Moon Department of Radiology, Konkuk University Medical Center, Korea 15:40-16:00 CC7 THY-02 How I Should fu Thyroid Nodule after FNAB? 96 Jin Young Kwak Department of Radiology, Yonsei University Gangnam Severance Hospital, Korea 16:00-16:20 CC7 THY-03 Preop. & Postop. Evaluation in the Patient with 101 Thyroid Cancer Jeong Seon Park Department of Radiology, Hanyang University Hospital, Korea 16:20-16:40 CC7 THY-04 Interventional Management of Thyroid Disease 104 (PEIT & RFA) So Lyung Jung Department of Radiology, Seoul St. Mary s Hospital, The Catholic University of Korea, Korea 16:40-16:50 Discussion

24 22 42nd Korean Society of Ultrasound in Medicine 2011 Open Cardiovascular 15:20-16:50 Hall E6 Chairperson: Whal Lee Seoul National University Hospital, Korea 15:20-15:50 CC8 CV-01 Doppler Ultrasound for Arteriovenous Fistular for 108 Hemodialysis Kwang Nam Jin Department of Radiology, SMG-SNU Boramae Medical Center, Korea 15:50-16:20 CC8 CV-02 Diagnosis (US) of Peripheral Occlusive Disease of 109 Lower Extremity Ki Seok Choo Department of Radiology, Pusan National University Yangsan Hospital, Korea 16:20-16:50 CC8 CV-03 Diagnosis of Deep Vein Thrombosis 112 Bae Young Lee Department of Radiology, Seoul St. Mary s Hospital, The Catholic University of Korea, Korea Special Focus Session Breast 10:30-12:00 Hall E5 Chairperson: Seong Ku Woo Keimyung University Dongsan Medical Center, Korea 10:30-10:50 SF5 BR-01 US Screening of Breast Cancer 147 Eun-Kyung Kim Department of Radiology, Yonsei University, College of Medicine, Korea 10:50-11:10 SF5 BR-02 Preoperative Evaluation of Breast Cancer 148 Eun Young Ko Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Korea 11:10-11:30 SF5 BR-03 Postoperative Evaluation of Breast Cancer 149 Bo Kyoung Seo Department of Radiology, Korea University Ansan Hospital, Korea 11:30-11:50 SF5 BR-04 Introducing Breast Elastography into Clinical Practice 153 Llewellyn Sim Department of Radiology, Singapore General Hospital, Singapore 11:50-12:00 Discussion Musculoskeletal 10:30-12:00 Hall E6 Chairperson(s): Young Cheol Yoon Samsung Medical Center, Korea Mi Sook Sung The Catholic University of Korea, Bucheon St. Mary s Hospital, Korea 10:30-10:55 SF6 MS-01 US of Achilles Tendon 154 Hong-Jen Chiou Department of Radiology, Taipei Veterans General Hospital & National Yang-Ming University, R.O. China 10:55-11:20 SF6 MS-02 US of Peroneal Tendon 155 Hong-Jen Chiou Department of Radiology, Taipei Veterans General Hospital & National Yang-Ming University, R.O. China 11:20-11:45 SF6 MS-03 US Evaluation of the Sole Pain 156 Yun Sun Choi Department of Radiology, Eulji University, Korea 11:45-12:00 Discussion Head and Neck 13:20-14:50 Hall E1-4 Chairperson: Hyung-Jin Kim Samsung Medical Center, Korea 13:20-13:50 SF7 H&N-01 Everything That You Should Know for the 159 Ultrasonographic Differentiation Between Benign and Malignant Lymph Nodes Ji-hoon Kim Department of Radiology, Seoul National University Hospital, Korea 13:50-14:20 SF7 H&N-02 Ultrasonographic Diagnosis of Cystic or Cyst-like 160 Masses Young Hen Lee Department of Radiology, Ansan Hospital, Korea University College of Medicine, Korea 14:20-14:50 SF7 H&N-03 Ultrasonographic Diagnosis of Salivary Gland 161 Disease Dong Woo Park Department of Radiology, College of Medicine Hanyang University, Korea Cardiovascular 13:20-14:50 Hall E6 Chairperson: Sang Il Choi Seoul National University, Bundang Hospital, Korea 13:20-13:50 SF8 CV-01 Practical Guideline for Carotid Doppler 164 Sang Il Choi Division of Cardiovascular Imaging, Department of Radiology, Seoul National University Bundang Hospital, Korea 13:50-14:20 SF8 CV-02 Carotid IMT: What Can We Know 165 Jang-Ho Bae Department of Internal Medicine, Konyang University Hospital, Korea 14:20-14:50 SF8 CV-03 Spectral Analysis of Carotid Doppler 166 Nitin G Chaubal Thane Ultrasound Centre, Thane and Jaslok Hospital & Research Centre, Mumbai, India

25 42nd Korean Society of Ultrasound in Medicine 2011 Open 23 Luncheon Session SIEMENS Hall E1-4 Chairperson: Dong Ho Lee Kyung Hee University, Medical Center, Korea 12:00-13:20 LS-03 Acoustic Radiation Force Imaging (ARFI) and 169 Elastography: Principles and Applications Paul S. Sidhu Department of Radiology, King s College London, United Kingdom INSIGHTEC Hall E5 Chairperson: Seung Hyup Kim Seoul National University Hospital, Korea 12:00-13:20 LS-04 MR Guided Focused Ultrasound Surgery (MRgFUS): 170 Principles and Applications Jin Wei Kwek Department of Oncologic Imaging, National Cancer Centre, Singapore Scientific Sessions Head&Neck 10:30-12:00 Hall E1-4 Chairperson(s): Jinna Kim Yonsei University Severance Hospital, Korea Jeong Hyun Lee Seoul Asan Medical Center, Korea SS 3 H & N-01 10:30 High Resolutional Ultrasonographic Imaging of 186 Augmented Rhinoplasty Including Foreign Body Injection: Correlation with Clinical Findings Yu Jin Oh, Ik Yang, Ah Young Jung, Ji Young Woo, Hye Suk Hong, Su Kyung Jeh, Ji Young Hwang, Yul Lee Department of Radiology, Kangnam Sacred Heart Hospital, Hallym University, Korea SS 3 H & N-02 10:40 Sonographic Findings of Biopsy Proven Kikuchi 187 Disease Jung Lim Yoo 1, Sang-il Suh 1, Kyoung Min Kim 1, Young Hen Lee 1, Hyung Suk Seo 1, Bong Kyung Shin 2, Joon Young Song 3, Hae Young Seol 1 Departments of 1 Radiology, 2 Pathology, 3 Infectious Diseases, Guro Hospital, College of Medicine, Korea University, Seoul, Korea SS 3 H & N-03 10:50 Efficacy of US Guided FNAC of Nonpalpable 187 Supraclavicular Lymph Node as Substitute for Difficult Infraclavicular Abnormalities Asif Momin, Shenaz Saifi, Vaseem Ansari Department of Imaging, Prince Aly Khan Hospital, Mumbai, India SS 3 THY-04 11:00 Ultrasound Diagnosis of Head and Neck Infective 188 Lesions Shenaz Saifi, Asif Momin Department of Radiology, B Y L Nair Hospital and T N Medical College, Mumbai, India SS 3 THY-05 11:10 Thyroid Imaging Reporting and Data System for 188 Ultrasound Features of Thyroid Nodules Hyun Gi Kim, Eun-Kyung Kim, Hee Jung Moon, Eun Ju Sohn, Jung Hyun Yoon, Ji Soo Choi, So Hee Park, Hyun Kyung Jung Department of Radiology, Yonsei University Gangnam Severance Hospital, Korea SS 3 THY-06 11:20 Diagnostic Performance and Interobserver 189 Agreement in Assessing Thyroid Nodules with Threedimensional Sonography Soo chin Kim, Ji-hoon Kim, Tae Jin Yun, Seung Hong Choi, Chul-Ho Sohn, Kee-Hyun Chang, Moon Hee Han Department of Radiology, Seoul National University College of Medicine, Korea SS 3 THY-07 11:30 18 F-Fluorodeoxyglucose Positron Emission 189 Tomography for Primary Thyroid Cancer: Clinical, Pathologic and Sonographic Finding Correlation Kyung Eun Kim, Eun-Kyung Kim, Hee Jung Moon, Jin Young Kwak Department of Radiology, Yonsei University Gangnam Severance Hospital, Korea SS 3 THY-08 11:40 Assessment of the Nondiagnostic Result of 190 Repeated Ultrasound-guided Fine-needle Aspiration of Thyroid Nodules Yoon Seong Choi, Hee Jung Moon, Jin Young Kwak, Eun-Kyung Kim Department of Radiology, Yonsei University Severance Hospital, Korea SS 3 THY-09 11:50 Locoregional Control of Recurrent Well 190 Differentiated Thyroid Cancer in the Neck by Ultrasonography-Guided Radiofrequency Ablation Jung Hwan Baek, Yoon Suk Kim, Jin Yong Sung, Hoon Choi, Jeong Hyun Lee Department of Radiology, Daerim Saint Mary Hospital University of Ulsan College of Medicine, Asan Medical Center, Korea Breast 13:20-14:20 Hall E5 Chairperson(s): Boo Kyung Han Samsung Medical Center, Korea Nariya Cho Seoul National University Hospital, Korea SS 4 BR-01 13:20 How is Pleomorphic Variant of Invasive Lobular 191 Carcinoma Different from Classic Invasive Lobular Carcinoma of the Breast? Hye Na Jung, Jung Hee Shin, Boo-Kyung Han, Eun Young Ko, Eun Sook Ko Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Korea SS 4 BR-02 13:30 Targeted US for the MR-detected Lesions on 191 Preoperative Breast MRI Ji-Eun Kim, Eun Young Ko, Jung Hee Shin, Boo-Kyung Han Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Korea SS 4 BR-03 13:40 Role of Elastography in Breast Imaging 192 Anugayathri Makudamudi Chennai Breast Centre, India SS 4 BR-04 13:50 Ultrasound Elastography in Diagnostic 192 Assessment of Axillary Lymph Nodes Llewellyn Sim, Lester Leong Department of Diagnostic Radiology, Singapore General Hospital, Singapore

26 24 42nd Korean Society of Ultrasound in Medicine 2011 Open SS 4 BR-05 14:00 Is US-guided Core Needle Biopsy (CNB) enough 193 in Probably Benign Nodules with Interval Growth? Jung Hyun Yoon 1, 2, Eun-Kyung Kim 1, Jin Young Kwak 1, Min Jung Kim 1, Hee Jung Moon 1 1 Department of Radiology, Research Institute of Radiological Science, Severance Hospital, Yonsei University, College of Medicine, Korea, 2 Department of Radiology, Bundang CHA Medical Center, CHA University, College of Medicine, Korea SS 4 BR-06 14:10 US-Guided Optical Tomography: Correlation with 194 Clinicopathologic Variables in Breast Carcinomas Ji Soo Choi, Min Jung Kim, Hee Jung Moon, Jin Young Kwak, Eun-Kyung Kim Department of Radiology, Research Institute of Radiological Science, Yonsei University College of Medicine, Korea Musculoskeletal 14:20-14:50 Hall E5 Chairperson IK Yang Hallym University Sacred Heart Hospital, Korea SS 4 MS-07 14:20 Ultrasonography and Real-time Sonoelatography 194 of Myofascial Trigger Points in Upper Trapezius Muscle Gi-Young Park 1, Sang Hee Im 2, Dongrak Kwon 1 1 Department of Rehabilitation Medicine, Catholic University of Daegu School of Medicine, Korea 2 Department of Rehabilitation Medicine, Kwandong University School of Medicine, Korea SS 4 MS-08 14:30 Sonographic Appearances of Morton s Neuroma: 195 Differences from Other Interdigital Soft Tissue Masses Hee-Jin Park, Myung-Ho Rho, Hyun-Pyo Hong, So-Yeon Lee Department of Radiology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Korea SS 4 MS-09 14:40 The Usefulness of Ultrasound for the Detection of 195 Lymph Node Metastasis in Malignant Soft Tissue Tumor Jina Kim, Sanghoon Lee, Myungjin Shin, Hyewon Chung, Minhee Lee Department of Radiology, Asan Medical Center, Korea Thyroid 16:50-17:50 Hall E1-4 Chairperson(s) Dong Wook Kim Inje University Busan Paik Hospital, Korea Jung Hee Shin Samsung Medical Center, Korea SS 5 THY-10 16:50 US Elastography of Thyroid Nodule: Is Adding 196 Strain Ratio to Color Mapping Better? Ji-Eun Kim, Jung-Hee Shin, Boo-Kyung Han, Eun Young Ko, Eun Sook Ko Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea SS 5 THY-11 17:00 Mixed Echoic Thyroid Nodules on Ultrasound: 196 Approach to Management Yu-Mee Sohn 1, 2, Jung Hyun Yoon, Hee Jung Moon, Eun-Kyung Kim, Jin Young Kwak 1 Department of Radiology, Research Institute of Radiological Science, Yonsei University College of Medicine, Korea, 2 Department of Radiology, Kyung Hee University Medical Center, College of Medicine, Kyung Hee University, Korea SS 5 THY-12 17:10 BRAF Mutation Analysis and Ultrasonography as 197 Adjuncts to Fine Needle Aspiration Cytology in Papillary Thyroid Carcinoma: Their Relationships and Roles Won-Jin Moon 1, Nami Choi 1, Jin Woo Choi 1, Suk Kyeong Kim 2, Tae Sook Hwang 3 1 Department of Radiology, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea, 2 Department of Internal Medicine, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea, 3 Department of Pathology, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea SS 5 THY-13 17:20 Diagnostic Value of BRAF V600E Mutation 197 Analysis of Thyroid Nodules According to Ultrasonographic Features and the Time of Aspiration Hee Jung Moon 1, Eun-Kyung Kim 1, Woong Youn Chung 2, Jong Rak Choi 3, Jung Hyun Yoon 1, Jin Young Kwak 1 1 Department of Radiology, Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul, Korea, 2 Department of Surgery, Yonsei University College of Medicine, Seoul, Korea, 3 Department of Laboratory Medicine, Yonsei University College of Medicine, Seoul, Korea SS 5 THY-14 17:30 Role of US Diagnosis in Assessing and Managing 198 Thyroid Nodules with Inadequate Cytology Dong Wook Kim, Jin Young Park Department of Radiology, Busan Paik Hospital, Inje University College of Medicine, Busan, Korea SS 5 THY-15 17:40 What to Do with Inadequate Cytology in Thyroid 198 Nodules? Should We Repeat Aspiration or Follow-up? Jung Hyun Yoon 1, 2, Hee Jung Moon 1, Eun-Kyung Kim 1, Jin Young Kwak 1 1 Department of Radiology, Research Institute of Radiological Science, Severance Hospital, Yonsei University, College of Medicine, Korea, 2 Department of Radiology, Bundang CHA Medical Center, CHA University, College of Medicine, Korea

27 42nd Korean Society of Ultrasound in Medicine 2011 Open 25 Scientific Exhibits Thyroid SE 01 How to Effectively Aaspirate Symptomatic Thyroid 199 Colloid Cysts Using Saline Jung Hee Shin 1, Boo-Kyung Han 1, Eun Young Ko 1, Jin Yong Sung 2 1 Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Korea, 2 Department of Radiology, Thyroid Center, Daerim St. Mary s Hospital, Korea SE 02 US and Clinical Features of Cribriform-Morular 199 Variant of Papillary Thyroid Carcinoma Sanghee Lee 1, Jung Hee Shin 1, Ji-Eun Kim 1, Boo-Kyung Han 1, Eun Young Ko 1, Young Lyun Oh 2 1 Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Korea, 2 Department of Pathology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Korea SE 03 Contribution of Computed Tomography to 199 Ultrasound in Predicting Lateral Lymph Node Metastasis in Patients with Papillary Thyroid Cancer Jung Hyun Yoon 1, 2, Hee Jung Moon 1, Ji Hyun Youk 1, Eun Joo Son 1, Eun-Kyung Kim 1, Jin Young Kwak 1 1 Department of Radiology, Research Institute of Radiological Science, Severance Hospital, Yonsei University, College of Medicine, Korea, 2 Department of Radiology, Bundang CHA Medical Center, CHA University, College of Medicine, Korea SE 04 Malignant US features in Long-term Follow-up of 200 Cystic and Predominantly Cystic Thyroid Nodules after Successful Ethanol Ablation Dong Wook Kim 1, Ji Sung Park 1, Seung Min Nam 1, Noh Hyuck Park 2 1 Department of Radiology, Busan Paik Hospital, Inje University College of Medicine, Korea, 2 Department of Radiology, Kwandong University College of Medicine, Myongji Hospital, Korea SE 05 Preoperative US-Guided Hook-Needle Localization 200 for Nonpalpable Cervical Masses: A Help for Surgeon Ji Yeon Park, Noh Hyuck Park, Hee-Jin Park, Mi Sung Kim, Chan Sup Park Department of Radiology, Kwandong University College of Medicine, Myongji Hospital, Korea SE 06 US-Guided Ethanol Ablation of Predominantly 201 Solid Thyroid Nodules: The Efficacy and Factors Predicting the Outcome Dong Wook Kim 1, Myung Ho Rho 2 1 Department of Radiology, Busan Paik Hospital, Inje University College of Medicine, Korea, 2 Department of Radiology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Korea SE 07 Ultrasound-Guided Fine-Needle Aspiration 201 Cytology for Thyroid Nodules: An Emphasis on One- Sampling and Biopsy Techniques Dong Wook Kim Department of Radiology, Busan Paik Hospital, Inje University College of Medicine, Korea SE 08 Diagnostic Role of Conventional Ultrasound and 201 Ultrasound Elastography in Asymptomatic Patients with Hashimoto Thyroiditis Injoong Kim, Jung Hyun Yoon, Eunju Son, Hee Jung Moon, Eun-Kyung Kim, Jin Young Kwak Department of Radiology, Research Institute of Radiological Science, Yonsei University College of Medicine, Korea SE 09 Clinical Significance of Vagus Nerve Variation in 202 Radiofrequency Ablation of Thyroid Nodules Eun Ju Ha 1, Jung Hwan Baek 1, Jeong Hyun Lee 1, Jae Kyun Kim 2, Young Kee Shong 3 1 Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Korea, 2 Department of Radiology, Chung- Ang University College of Medicine, Korea, 3 Department of Endocrinology and Metabolism, University of Ulsan College of Medicine, Asan Medical Center, Korea SE 10 Malignancy-Mimicking Morphologic Change on 202 Ultrasound after Fine Needle Aspiration Biopsy in a Thyroid Nodule with Initially Benign Ultrasound and Cytologic Result Sun Jin Herh, Jin Young Kwak, Hee Jung Moon, Eun-Kyung Kim Department of Radiology, Severance Hospital, Yonsei University College of Medicine, Korea SE 11 Differentiation of Benign and Malignant Solid 202 Thyroid Nodules Using an US Classification System Dong Wook Kim Department of Radiology, Busan Paik Hospital, Inje University College of Medicine, Busan, Korea SE 12 Neck Ultrasonography for the Evaluation of 203 Hyperparathyroidism : From Diagnosis to Treatment Seunah Lee 1, Sangil Suh 1, Youngjoo Kwon 2, Jaebok Lee 3, Younghen Lee 1, Hyungseok Seo 1, Hae Young Seol 1 Departments of 1 Radiology, 2 Internal Medicine, 3 General Surgery, Korea University Hospital, Korea University College of Medicine, Seoul, Korea SE 13 Development of Automated Thyroid Ultrasound 203 Scanning System Hanyong Chun 1, Hyunchul Jung 1, Jihoon Kim 2, Kwanggi Kim 1, Heonsoo Shin 1 1 Biomedical Engineering Branch, National Cancer Center, Korea, 2 Department of Radiology, Seoul National University Hospital, Korea SE 14 Papillary Thyroid Cancers Diagnosed During 204 Ultrasonography Follow Up Yoo Jin Lee, Eun Young Ko, Boo-Kyung Han, Jung Hee Shin, Yoo Jin Lee, Eun Sook Ko Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Korea SE 15 Ultrasonography-Guided Core Needle Biopsy for 204 the Thyroid Nodule: The Procedure has Benefit for the Diagnosis when FNAC Analysis Shows Inconclusive Results? Yoo Jin Lee, Jung Hee Shin, Boo-Kyung Han, Eun Young Ko, Eun Sook Ko Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Korea SE 16 Sonographically Guided Core Needle Biopsy of 204 Salivary Gland Mass So Lyung Jung Department of Radiology, St. Mary s Hospital, The Catholic of Korea, Seoul, Korea Musculoskeletal SE 17 Ultrasonography of Rotator Cuff and Non Rotator 205 Cuff Disorder: MR Correlation Dal Soo Park 1, Jung Ho Kang 2, Jung Hee Oh 2, Young Jin Son 2, Sang Soo Kim 2 1 Department of Radiology, 2 Department of Orthopedic Surgery, S-Seoul Hospital, Korea SE 18 Imaging Findings of Subacromial Subdeltoid 205 Calcific Bursitis: A Case Report Gi-Young Park, Dong-Rak Kwon, Sung-Uk Lee Department of Rehabilitation Medicine, School of Medicine, Catholic University of Daegu, Korea

28 26 42nd Korean Society of Ultrasound in Medicine 2011 Open SE 19 Intrasheath Subluxation of the Peroneal Tendons: 205 Usefulness of Dynamic Ultrasonography Sungmoon Lee 1, Sihyung Kim 1, Heejung Lee 1, Sungku Woo 1, Kwangsoon Song 2 1 Department of Radiology, Keimyung University Dongsan Hospital, Daegu, Korea, 2 Department of Orthopedics, Keimyung University Dongsan Hospital, Daegu, Korea SE 20 Ultrasonography of the Hands: Pictorial Review 206 Hye Jung Choo 1, Junggeun Ha 1, Sun Joo Lee 1, Chaekyung Lee 2, Tae Eun Kim 3 1 Department of Radiology, Inje University Pusan Paik Hospital, Busan, Korea, 2 Department of Radiology, Pohang St. Mary s Hospital, Pohang, Korea, 3 Department of Radiology, Daegu Fatima Hospital, Daegu, Korea SE 21 Water-bath Method for Sonographic Evaluation of 206 Superficial Structures in Children Jeong Hyun Yoo 1, Rajesh Krishnamurthy 2 1 Department of Radiology, Mokdong Hospital, Ewha Womans University School of Medicine, Korea, 2 Diagnostic Imaging, Texas Childrens Hospital, Houston. USA SE 22 The Feasibility of Ultrasound-Guided Gun Biopsy 207 for Evaluating Inguinal Lymph Node Sun Ji Kang, Myung Jin Shin, Sang Hoon Lee, Hye Won Chung, Min Hee Lee Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Korea SE 23 A Case of Distal Sural Neuropathy: 207 Electrophysiologic, Ultrasonographic and MRI Findings Dong Hwee Kim 1, Nan Hee Kim 2 1 Department of Physical Medicine & Rehabilitation, 2 Division of Endocrinology, Ansan Hospital, Korea University College of Medicine, Korea SE 24 Ultrasonography for Evaluation of Nasal Bone 208 Fracture: Comparison with Plain Radiograph, CT and Surgery In Sook Lee 1, Jong Woon Song 2 1 Department of Radiology, Pusan National University Hospital, Korea, 2 Department of Radiology, Inje Haeundae Paik Hospital, Korea SE 25 Pictorial Essay of Ultrasound Findings in a Variety 208 of Superficial Soft Tissue Lesions That Could be Encountered During a Musculoskeletal Ultrasound Session Wei Yang Lim, Gervais Wansaicheong Department of Radiology, Tan Tock Seng Hospital, Singapore Abdomen SE 26 Establishing the Cut-off Values for a Quality 209 Assurance Test using an US Phantom for Screening US Examinations for Hepatocellular Carcinoma: An Initial Report of a Nationwide Survey in Korea Joon-Il Choi 1, Pyo Nyun Kim 2, Woo Kyoung Jeong 3, Hyun Cheol Kim 4, Dal Mo Yang 4, Sang Hoon Cha 5, Jae-Joon Chung 6 1 Department of Radiology, Seoul St. Mary s Hospital, The Catholic University of Korea, Seoul, Korea, 2 Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Seoul, Korea, 3 Department of Radiology, Hanyang University Guri Hospital, Hanyang University College of Medicine, Korea, 4 Department of Radiology, Kyung Hee University Hospital at Gangdong, Seoul, Korea, 5 Department of Radiology, Ansan Hospital, College of Medicine Korea University, Korea, 6 Department of Radiology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea SE 27 US and Contrast-Enhanced US for the Focal 209 Lesion in the Liver and Kidney Jung-Hee Yoon, Seong-Ho Kim, Ok Hwa Kim, Ji Hwa Ryu, Suk-Jung Kim, Choong-Ki Eun Department of Radiology, Haeundae Paik Hospital, Inje University College of Medicine, Korea SE 28 Congenital Anomalies of the Inferior Vena Cava 209 Associated with Intrahepatic Vascular Shunts: Sonographic and MR Imaging Findings D.J. Theodorou, S.J. Theodorou, Y. Kakitsubata, M. Shibata, M. Yuge, Y. Yuki, T. Tanaka Department of Radiology, Miyazaki Social Insurance Hospital, Miyazaki, Japan SE 29 Ultrasound Diagnosis on Gall Bladder Stone 210 Disease Batmagnai Damdinsuren Khan-Uul district General Hospital, 2P.N. Shastin Central Clinics Hospital, Mongolia SE 30 Common Bile Duct Wall Thickening in Acute 211 Hepatitis A Patients: A Prospective Study Chul Soon Choi, Eun Joo Yun, Young Lan Seo, Dae Young Yoon, Kyoung Ja Lim, Sang Hoon Bae Department of Radiology, Kangdong Sacred Heart Hospital, Korea SE 31 Value of Color Doppler Twinkling Artifacts from 211 Gallbladder Adenomyomatosis Mi Hye Yu, Jae Young Lee, Se Hyung Kim, Jeong Min Lee, Jung Hoon Kim, Joon Koo Han, Byung-Ihn Choi Department of Radiology, Seoul National University Hospital, Korea SE 32 US Findings of Biliary Cast Syndrome in Non Liver 212 Transplant Patient : A Case Report Sangsuk Han, Hyunseok Jung, Seongsook Cha Department of Radiology, Inje University Busan Paik Hospital, Korea SE 33 Measurement of Liver Stiffness by Shear Wave 212 Elastography (SWE): Comparison of Median Values of 5-times Measurement to 10-Times Measurement Wookyoung Jeong 1, Yongsoo Kim 1, Minyeong Kim 1, Soonyoung Song 2, Byunghee Koh 2, Onkoo Cho 2 Department of Radiology, Hanyang University 1 Guri and 2 Seoul Hospital, Korea SE 34 Intraoperative Ultrasonography and 213 Radiofrequency Ablation of Hepatic Tumors: Its Role and Technical Effectiveness Heon-Ju Kwon 1, Hye Jin Kim 1, 2, Hyung Jin Won 1, Yong Moon Shin 1, Pyo Nyun Kim 1, Moon-Gye Lee 1 1 Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Korea, 2 Department of Radiology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Korea SE 35 Acute Rejection after Right lobe Living Donor 213 Liver Transplantation: Percentage Interval-change of Venous Pulsatility Index at Doppler Ultrasound - Receiver Operating Characteristic Analysis So Jung Lee 1, Kyoung Won Kim 1, Jin Hee Kim 1, So Yeon Kim 1, Gi-Won Song 2, Shin Hwang 2, Sung-Gyu Lee 2 Departments of 1 Radiologyand Liver Transplantation 2 Surgery, Asan Medical Center, University of Ulsan College of Medicine, Korea SE 36 Macrocystic Serous Cystadenoma of the 214 Pancreas: Varied Imaging Presentations D.J. Theodorou, S.J. Theodorou, Y. Kakitsubata, Y. Miyata, Y. Ito, Y. Yuki, K. Shirao Departments of Radiology and Surgery, Miyazaki Konan Hospital, Miyazaki, Japan

29 42nd Korean Society of Ultrasound in Medicine 2011 Open 27 Genitourinary SE 37 The Effects of Single Dose of GnRH Agonist Prior 214 to Magnetic Resonance-guided Focused Ultrasound Surgery of Uterine Fibroids Sang Wook Yoon, Kyoung Ah Kim, Jong Tae Lee Department of Radiology, CHA University College of Medicine, Korea SE 38 Current Reemphasis of Transrectal Ultrasound for 215 Prostate Cancer Diagnosis in Men with Serum Prostate Specific Antigen Levels Less Than 10 ng/ml Sang Su Kim Department of Radiology, Busan Paik Hospital, Inje University School of Medicine, Korea SE 39 Urachal Remnant Diseases: Radiologic Findings 215 of US and CT Hyoun Cho, Hyun Young Han, Kyu Soon Kim, Dong Jin Jeon Department of Radiology, Eulji University Hospital, Korea SE 40 A Case of Left Renal Angiomyolipoma with 216 Inferior Vena Cava Extension: US and CT and MR Findings Bo Reum Yoo, Hyun Young Han Department of Radiology, Eulji University Hospital, Korea SE 41 Adenofibroma of the Endometrium Protruding 216 into the Vaginal Cavity: US and MRI Findings Sung Eun Rha, Hyun Jung Kim, Seung Eun Jung, Jae Young Byun Department of Radiology, Seoul St. Mary s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea SE 42 The Application of 3D Volumetric US in Patients 216 with Bladder Cancer and Its Mimickers Hyun Jeong Park, Seong Sook Hong, Sung Tae Park, Kui Hyang Kwon, Deuk Lin Choi Department of Radiology, Soonchunhyang University Hospital, Seoul, Korea SE 43 US Evaluation of Inguinal Lesions 217 Sung Bin Park, Mi Jin Song, Young Ho Lee, Myung Sook Lee, Hyeun Cha Cho Department of Radiology, Cheil General Hospital & Women s Healthcare Center, Kwandong University College of Medicine, Seoul, Korea SE 44 US of Decidualized Endometriosis 217 Sung Bin Park 1, Young Ho Lee 1, Mi Jin Song 1, Myung Sook Lee 1, Hyeun Cha Cho 1, Tae Jin Kim 2, Ji Young Kim 3, Sung Ran Hong 3 1 Department of Radiology, 2 Department of Obstetrics and Gynecology, 3 Department of Pathology, Cheil General Hospital and Women s Healthcare Center, Kwandong University College of Medicine, Korea SE 45 Prenatal and Postnatal Findings of Fetal Face and 217 Neck Anomalies Inseon Ryoo 1, Jeong Yeon Cho 1, Sung Kyoung Moon 1, Sang Yoon Kim 1, Seung Hyup Kim 1, Min Hoan Moon 2 1 Department of Radiology, Seoul National University Hospital, Korea, ²Department of Radiology, Cheil General Hospital, Korea SE 46 HIFU Treatment for Abnormal Vaginal Bleeding 218 Secondary to Uterine Myoma Jung Hyun Lim 1, Dong Jin Chung 2, Young Tec Lim 3, Sae Hyun Choi 4, Seong-Tae Hahn 5 Department of Radiology, St. Mary s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea SE 47 Evaluation of the Fetal Urinary Bladder and 218 Associated Genitourinary Anomalies Sang Youn Kim 1, Jeong Yeon Cho 1, Seung Hyup Kim 1, Young Ho Lee 2, Mi Jin Song 2, Jeong Ah Kim 2, Min Hoan Moon 3, Sung Il Jung 4 1 Department of Radiology, Seoul National University Hospital, Korea, 2 Department of Cheil General Hospital, Korea, 3 Department of Radiology, Seoul National University Bundang Hospital, Korea, 4 Department of Radiology, Konkuk University Hospital, Korea SE 48 Ultrasonography of Groin: Common and Rare 218 Diseases Boem-Ha Yi 1, Hae-Kyung Lee 1, Min-Hee Lee 1, Hyun Sook Hong 1, Tae Hee Kim 2, Min Eui Kim 3, Kyu Suk Cho 4 1 Department of Diagnostic Radiology, Soonchunhyang University Bucheon Hospital, Korea, 2 Department of Obstetrics and Gynecology, Soonchunhyang University Bucheon Hospital, Korea, 3 Department of Urology, Soonchunhyang University Bucheon Hospital, Korea, 4 Department of Surgery, Soonchunhyang University Bucheon Hospital, Korea SE 49 Ultrasound Imaging of Scrotal Tumor & 219 Pseudotumor: A Pictorial Review Sae Ah Lee, You Me Kim Department of Radiology, Dankook University Hospital, Korea SE 50 IgG4-related Sclerosing Disease Involving the 219 Urethra: A Case Report Jin Woo Choi, Sang Youn Kim, Jeong Yeon Cho, Seung Hyup Kim Departement of Radiology, Seoul National University Hospital, Korea Pediatric SE 51 Ultrasound of the Soft Tissue Masses in Children: 219 How to Narrow the Differential Diagnosis Sae Ah Lee 1, Young Seok Lee 1 Department of Radiology, Dankook University Hospital, Korea SE 52 Serial Sonoelastographic Evaluation of 220 Gastrocnemius Muscles after Botulinum Toxin A Injection in Spastic Cerebral Palsy Dong Rak Kwon, Gi Young Park Department of Rehabilitation Medicine, Catholic University of Daegu School of Medicine, Korea SE 53 US Spectrum of Tumors and Tumor-Like Lesions 220 in the Pediatric Liver Youn Ah Choi, So-young Yoo, Ji Hye Kim, Hong Eo, Tae Yeon Jeon Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea SE 54 The Superficial Perisutural Echogenic Lesions 220 Involving Both Brain Parenchyma and Leptomenigeal Space in Neonatal Cranial Ultrasonography: Imaging Findings and the Significance Byoung Hee Han 1, Sung Bin Park 1, Kyung Sang Lee 1, Kyung Ah Kim 2, Sun Young Ko 2, Yeon Kyung Lee 2, Su Bin Son 2 Departments of 1 Radiology, 2 Pediatrics, Kwandong University College of Medicine, Cheil General Hospital & Women s Healthcare Center, Korea SE 55 Neonatal Brain Ultrasound: Stepwise Approach 221 Not to Miss Congenital Anomalies Hye-Kyung Yoon, Young Ah Cho, Jae-Yeon Hwang, Cherry Kim, Gil-Sun Hong, Chong Hyun Yoon Department of Radiology, Ulsan University College of Medicine, Asan Medical Center, Korea

30 28 42nd Korean Society of Ultrasound in Medicine 2011 Open SE 56 Comparison of the Reliability Between the 221 Hydronephrosis Grading System: Society for Fetal Urology Grading System vs. Onen s Grading System Mi-Jung Lee 1, Myung-Joon Kim 1, Choon-Sik Yoon 2, Mu Sook Lee 1 1 Department of Radiology and Research Institute of Radiological Science, Severance Children s Hospital, Yonsei University, College of Medicine, Korea, 2 Department of Radiology, Gangnam Severance Hospital, Yonsei University, College of Medicine, Korea SE 57 Sonographic Findings of Neonatal 222 Pneumomediastinum Ah Young Jung, Hee Sun Ko, Ik Yang, Ji Young Woo, Hye Suk Hong, Su Kyung Jeh Department of Radiology, Kangnam Sacred Heart Hospital, Korea SE 58 Congenital Intrahepatic Portosystemic Shunt: 222 Imaging Features and Outcomes Jung-Eun Cheon, Woo Sun Kim, Su-Mi Shin, Young-Hun Choi, In-One Kim Department of Radiology, Seoul National University Children s Hospital, Korea SE 59 Genitourinary Anomaly with Ipsilateral Renal 222 Maformation in Children Young ah Cho 1, Hye-kyung Yoon 1, Jae Yeon Hwang 1, Chong hyun Yoon 1, Ji eun Lee 2, Kyu Heung Lee 3 1 Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Korea, 2 Department of Radiology, 3 Department of Pediatric, CHA Bundang Medical Center, CHA University, Korea SE 60 Ultrasonogaphy of Normal and Abnormal 223 Appendix in Children Noh Hyuck Park 2, Hwa Eun Oh 2, Hee Jin Park, Ji Yeon Park 1 Department of Radiology, Kwandong University College of Medicine, Myongji Hospital, Korea, 2 Department of Pathology, Kwandong University College of Medicine, Myongji Hospital, Korea SE 61 Sonographic Types of Reactive Lymph Node 223 Hyperplasia in Children: Histopathologic Correlation Heejung Lee 1, Haera Jung 2, Sangkwon Lee 1 Department of Radiology, 2 Department of Pathology, Keimyung University School of Medicine, Korea SE 62 The Preoperative Ultrasound and Intraoperative 223 Findings of Inguinal Hernia in Children Mohammad Kazem Tarzamni 1, Saeid Aslanabadi 2, Nazanin Eshraghi 3 1 Department of Radiology, Tabriz University of Medical Sciences, 2 Department of Pediatric, Tabriz University of Medical Sciences, Iran SE 63 US of the Pediatric Spine: Technique, Normal 224 Variants, and Pathologic Condition Tae Yeon Jeon, So-Young Yoo, Hong Eo, Ji Hye Kim Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Korea Cardiovascular SE 64 Imaging of Venous Diseases According to Image 224 Modalities Focusing on Deep Vein Thrombosis and Varicose Veins Kyongmin Beck, Bae Young Lee, Hyeon Sook Kim, Kyung Sup Song Department of Radiology, St. Paul Hospital, College of Medicine, The Catholic University of Korea, Korea Breast SE 65 Radiologic Findings of Sclerosing Adenosis 224 Bo Bae Choi 1, Kwang Sun Shu 2 Departments of 1 Radiology, 2 Pathology, Chungnam National University Hospital, Korea SE 66 Pictorial Review of Echogenic Breast Mass on 225 Ultrasonography: Imaging and Pathologic Correlation Eun Sun Oh, Yun-Woo Chang, Hyun Joo Kim, Seong Sook Hong, Jung Wha Hwang, Kui Hyang Kwon, Dong Wha Lee Department of Radiology, Soonchunhyang University Hospital, Korea SE 67 US of the Axilla: Normal Anatomy and Pathology 225 Eugene Kang, Hye-Won Kim, Moo-Sang Kim, Seon-Kwan Juhng Department of Radiology, Wonkwang University Hospital, Korea SE 68 The Ultrasonographic Findings of Breast 225 Sparganosis Jung Lim Yoo 1, Ok Hee Woo 1, Kyoung Eun Lee 1, Kyu Ran Cho 2, Hwan Seok Yong 1, Bo Kyoung Seo 3, Eun-young Kang 1 1 Department of Radiology, Korea University Guro Hospital, 2 Korea University Anam Hospital, 3 Korea University Ansan Hospital, Korea SE 69 Radiologic Features of High-Risk Lesions in 226 Breast and Strategies in Management Seung-hee Choi, Ok Hee Woo, Kyoung Eun Lee, Yoon Kyung Kim, Kyu Ran Cho, Hwan Seok Yong, Bo Kyoung Seo, Eun-young Kang Department of Radiology, Korea University Guro Hospital, Korea University Anam Hospital, Korea University Ansan Hospital, Korea SE 70 Panoramic Ultrasound Imaging(PUI) of the Breast: 226 Advantages and Limitations Ik Yang, Hee Sun Ko, Ji Young Hwang, Su Kyung Jeh, Ah Young Jung, Ji Young Woo, Hye Suk Hong, Yul Lee Department of Radiology, Kangnam Sacred Heart Hospital, Hallym University, Korea SE 71 Hyperechoic Breast Lesion on Usg: A Review of Cases with Mammographic Finding and Pathologic Correlation Ji Won Park, Hye Jung Kim, Gab Chul Kim Department of Radiology, Kyungpook National University Medical Center, Korea SE 72 Metastatic Tumor to the Breast: A Variety of 227 Image Findings Young Hun Lee 1, Jang Hee Lee 1, Ji Sung Park 1, Young Mi Park 1, Suk Jung Kim 1, Hyun Kyoung Jung 2, Seok Jin Choi 1, Sang Suk Han 1 1 Department of Radiology, Inje University College of Medicine, Busan Paik Hospital, Korea, 2 Department of Radiology, Inje University College of Medicine, Haeundae Paik Hospital, Busan, Korea SE 73 Extra-mammary Lesions Detected on Breast 228 Sonography: What Radiologists Need to Know Ji Sung Park 1, Sang Su Kim 1, Young Mi Park 1, Suk Jung Kim 2, Hyun Kyoung Jung 2, Yoo Na Seo 3, Sang Suk Han 1, Seok Jin Choi 1 1 Department of Radiology, Inje University College of Medicine, Busan Paik Hospital, Korea, 2 Department of Radiology, Inje University College of Medicine, Haeundae Paik Hospital, Korea, 3 Department of Radiology, Busan St. Marys Medical Center, Busan, Korea

31 42nd Korean Society of Ultrasound in Medicine 2011 Open 29 SE 74 Delayed Diagnosed Invasive Lobular Carcinoma 228 Precede Presenting as Primary Poorly Differenctiated Gastric Carcinoma or Krukenberg Tumor Ji-Young Hwang 1, 2, Eun Sook Cha 1, Jee-Eun Lee 1 1 Department of Radiology, School of Medicine, Ewha Womans University, Korea, 2 Department of Radiology, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Korea SE 75 Clinical Application of Shear Wave Elastography 228 (SWE) in the Diagnosis of Benign and Malignant Breast Diseases Jung Min Chang, Woo Kyung Moon, Nariya Cho, Ann Yi, Hye Ryoung Koo Department of Radiology, Seoul National University Hospital, Korea SE 76 Mammographic and Ultrasonographic Features of 229 Metastatic Signet-Ring Cell Gastric Carcinoma to the Breast Joon Ho Kwon, Hee Jung Moon, Eun-Kyung Kim, Jin Young Kwak, Min Jung Kim Department of Radiology, Yonsei University College of Medicine, Korea SE 77 Various Sonographic Features of Lymphoma and 229 Leukemia Sung Eun Song 1, Bo Kyoung Seo 1, Kyu Ran Cho 2, Kyu-won Hwang 2, Ok Hee Woo 3, Kyoung Eun Lee 3, Sang Hoon Cha 1 1 Department of Radiology, Korea University Ansan Hospital 2 Department of Radiology, Korea University Anam Hospital 3 Department of Radiology, Korea University Guro Hospital, Korea SE 78 Vanishing Lesion During US Guided Core Needle 230 Biopsy: Can We Exclude Malignancy? SY Moon, NH Park, JY Park, CS Park, MS Kim, HJ Park, BJ Kwon Department of Radiology, Myongji Hospital, Korea SE 79 Primary and Metastatic Signet Ring Cell 230 Carcinoma of the Breast Jinkyung An 1, Jeongjoo Woo 1, Jaehee Kang 2, Jongeun Joo 3, Eunkyung Kim 3 1 Department of Radiology, Eulji Hospital, Eulji University, 2 Department of Surgery, Eulji Hospital, Eulji University, 3 Department of Pathology, Eulji Hospital, Eulji University, Korea SE 80 Surgical Mesh Reconstruction in Patients with 230 Breast Conserving Surgery: Sonographic Findings Hye-Won Kim, Eugene Kang, Hye-Seon Shin Department of Radiology, Wonkwang University Hospital, Korea SE 81 Tips for Obtaining Good Image Quality in Breast 230 Ultrasound Examination Sung Eun Song 1, Bo Kyoung Seo 1, Kyu Ran Cho 2, Kyu Won Hwang 2, Sang Hoon Cha 1, Seung Wha Lee 1 1 Department of Radiology, Korea University Ansan Hospital, Korea, 2 Department of Radiology, Korea University Anam Hospital, Korea SE 82 A Retrospective Review of Diabetic Mastopathy: 231 A Benign Sonographic Mimic of Breast Malignancy Chun Yat Law, Kwok Chun Wong, Yiu Ching Chu Department of Radiology, Kwong Wah Hospital, Hongkong Others SE 83 Ultrasound-Guided Fiducial Marker Implantation 231 for CyberKnife Radiation Therapy: What Radiologist Should Know Seong Sook Hong, Jae Hyun Kim, Hyun Jeong Park, Kui Hyang Kwon Department of Radiology, Soonchunhyang University Hospital, Korea SE 84 Ultrasonography Practice in Fiji: Challenges and 231 Trends Sanjalesh Kumar College of Medicine, Nursing and Health Science, Fiji National University, Fiji

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33 Categorical Course 31 CC1 AB-01 Abdomen 08:30-08:50 Hall E1-4 Chairperson(s): Chul Soon Choi Kangdong Sacred Heart Hospital, Korea Jae Young Lee Seoul National University Hospital, Korea Challenges and Pitfalls in Abdominal US Minju Kim Department of Radiology, Anam Hospital, Korea University, Korea Categorical Course 20, Friday (Hall E1-4) Ultrasound has been a valuable method of imaging the body for many years. Abdominal ultrasound can provide clinically useful information with lack of ionizing radiation, real-time nature examination, and multi-planar imaging capability. The portable nature of the equipment is another advantage that ultrasound has over other cross-sectional modalities such as computed tomography (CT) and magnetic resonance imaging (MRI). Even many advantages of ultrasound, there are several pitfalls in abdominal ultrasound. The operator must be aware of the special scanning techniques, artifacts encountered, and equipment malfunctions to be able to produce consistently high-quality scans. We can make variable diagnostic errors (false-negative or false-positive) during abdominal ultrasound. These errors are classified as followings: 1) Technical factor-related pitfalls, 2) Poor sonic window-related pitfalls, 3) Pseudo lesions, and 4) Misinterpretation-related pitfalls. We should know the solutions of these pitfalls and limitations of ultrasound. Although the ultrasound is an initial useful tool for the abdominal solid organ, visualization of the gastrointestinal tract with ultrasound may be difficult because intraluminal air is echogenic. When necessary, ultrasound can be performed after ingestion of water to improve evaluation of the stomach and proximal small bowel. Recent technical advance such as harmonic imaging and spatial compounding, extended-filed-of view imaging, and three-dimensional ultrasound imaging have improved detection of the abdominal lesions. In this lecture, we focus on introduction of new advanced technology including contrast-enhanced ultrasound (CEUS) and hybrid ultrasound imaging techniques (fusion imaging). CEUS is helpful for the problems in the following clinical situations; 1)incidental findings on routine ultrasound, 2) lesions or suspected in chronic hepatitis or liver cirrhosis, 3) lesions or suspected lesion in patient with a known history of malignancy, 4) patient with inconclusive MRI/CI or cytology/histology results, and 5) characterization of portal vein thrombosis. Real-time virtual sonography combined with CT/MRI led to the discovery of small or poorly-defined focal lesions and interventional treatment is easier to perform under ultrasound-guidance.

34 32 42nd Korean Society of Ultrasound in Medicine 2011 Open CC1 AB-02 Abdomen 08:50-09:10 Hall E1-4 Chairperson(s): Chul Soon Choi Kangdong Sacred Heart Hospital, Korea Jae Young Lee Seoul National University Hospital, Korea Ultrasonography of Diffuse Liver Disease Hee Sun Park Department of Radiology, Konkuk University Medical Center, Korea 1. Chronic Liver Disease 2. Cirrhosis Although ultrasound is widely used in the assessment of patients with liver disease, in common with other imaging tests it is unreliable as an accurate means of grading diffuse disease severity. Currently liver biopsy remains the gold standard, but it is invasive, holds sampling error and interpretation variability. A number of Doppler based methods have been developed, mainly to measure the relative flow or velocity in the hepatic vessels. However, there is controversy with regard to the reproducibility, and no current Doppler test is regarded as sensitive or specific enough to replace biopsy. An alternative method in which the relative transit time through the splanchnic bed of a bolus of microbubbles is measured has recently been described. Hepatic vein transit time (HVTT) is a highly sensitive marker of cirrhosis using microbubbles as a tracer according to the studies, and that enabled grading of pre-cirrhotic disease due to HCV. One of other noninvasive methods is to measure the liver stiffness, using sonographic transient elastography and acoustic radiation force impulse (ARFI). In patients with chronic hepatitis C, sonographic elastography allows for noninvasive assessment of hepatic fibrosis that does not vary with the sites. Also, ARFI sonoelastography enables a rapid and noninvasive detection of fibrosis in patients with nonalcoholic fatty liver disease. US of Cirrhosis Volume redistribution Coarse echotexture Nodular surface Regenerative/Dysplastic nodules Portal hypertension: ascites, splenomegaly, varices Doppler US Two abnormal patterns in compensated cirrhosis are decreased amplitude of phasic oscillations with loss of reversed flow and a flattened waveform. These abnormal patterns also have been found in patients with fatty liver. As cirrhosis progresses, luminal narrowing of the hepatic veins may be associated with flow alterations visible on color and spectral Doppler ultrasound. High-velocity signals through an area of narrowing produce color aliasing and turbulence. Hepatic artery waveform also shows altered flow dynamics in cirrhosis and chronic liver disease, in which the normal increase in postprandial resistive index is blunted. 3. Portal Hypertension Sonographic findings of portal hypertension include the secondary signs of splenomegaly, ascites, and portosystemic venous collaterals. When the resistance to blood flow in the portal vessels exceeds the resistance to flow in the small communicating channels between the portal and systemic circulations, portosystemic collaterals form. Thus, although the caliber of the portal vein initially may be increased (>1.3 cm) in portal

35 hypertension, with the development of portosystemic shunts, portal vein caliber with decrease. Portosystemic Venous Collaterals: Major Sites Identified on US Gastroesophageal junction Paraumbilical vein in falciform ligament Splenorenal and gastrorenal veins Intestinal-retroperitoneal anastomoses Hemorrhoidal veins Doppler US As portal hypertension progresses, portal venous flow loses its undulatory pattern and becomes monophasic, and then biphasic, and finally hepatofugal (away from the liver). Intrahepatic arterioportal shunt may also be seen. Categorical Course Fatty Liver US of Diffuse Steatosis Mild Minimal diffuse increase in hepatic echogenicity Normal visualization of intrahepatic vessel borders and diaphragm Moderate Moderate increase in echogenicity Slightly impaired visualization of intrahepatic vessels and diaphragm Severe Marked increase in echogenicity Poor penetration of posterior liver Poor or no visualization of hepatic vessels and diaphragm Categorical Course 20, Friday (Hall E1-4) 4. Portal Vein Thrombosis Sonographic findings include echogenic thrombus within the vessel lumen, portal vein collaterals, vessel caliber extension, and cavernous transformation. Cavernous transformation of the portal vein refers to numerous wormlike vessels at the porta hepatis, which represent periportal collateral circulation. This pattern is observed in longstanding thrombosis requiring up to 12 months to occur, and this is more likely to develop with benign disease. Malignant portal vein thrombosis has a high association with HCC and is often expansive. Doppler US Doppler US is useful in distinguishing between benign and malignant portal vein thrombi in cirrhotic patients. Both bland and malignant thrombi may demonstrate continuous blood flow, but pulsatile flow was found to be highly specific for the diagnosis or malignant thrombosis. US of Focal Fatty Change Rapid change with time, both in appearance and resolution No alteration of course or caliber of regional vessels No contour abnormality or mass effect Geographic margins, round, or interdigitated with normal tissue Preferred site for focal fat sparing Anterior to portal vein at porta hepatis (S4) Gallbladder fossa Liver margins Preferred site for focal fat Anterior to portal vein at porta hepatis (S4) Contrast-enhanced ultrasound (CEUS) is valuable in the differentiation of fatty change from neoplasia, because the fatty or spared regions will appear isovascular. References 1. Blomley MJ, Lim AK, Harvey CJ, et al. Liver microbubble transit time compared with histology and Child-Pugh score in diffuse liver disease: a cross sectional study. Gut 2003;52: Lim AK, Taylor-Robinson SD, Patel N, et al. Hepatic vein transit times using a microbubble agent can predict disease severity non-invasively in patients with hepatitis C. Gut 2005;54:

36 34 42nd Korean Society of Ultrasound in Medicine 2011 Open 3. Koizumi Y, Hirooka M, Kisaka Y, et al. Liver fibrosis in patients with chronic hepatitis C: noninvasive diagnosis by means of real-time tissue elastography-establishment of the method for measurement. Radiology 2011;258: Castera L, Pinzani M. Biopsy and non-invasive methods for the diagnosis of liver fibrosis: does it take two to tango? Gut 2010;59: Bonekamp S, Kamel I, Solga S, et al. Can imaging modalities diagnose and stage hepatic fibrosis and cirrhosis accurately? J Hepatol 2009;50: Martinez SM, Crespo G, Navasa M, et al. Noninvasive assessment of liver fibrosis. Hepatology 2011;53: Yoneda M, Suzuki K, Kato S, et al. Nonalcoholic fatty liver disease: US-based acoustic radiation force impulse elastography. 8. Vilgrain V. Ultrasound of diffuse liver disease and portal hypertension. Eur Radiol 2001;11: Tchelepi H, Ralls PW, Radin R, et al. Sonography of diffuse liver disease. J Ultrasound Med 2002;21: Kim SH, Lee JM, Kim JH, et al. Appropriateness of a donor liver with respect to macrosteatosis: application of artificial neural networks to US images-initial experience. Radiology 2005;234: Stephanie RW, Cynthia EW. The liver, In: Carol RM, et al. Diagnostic Ultrasound. 4th ed. Philadelphia, PA: Elsevier Mosby, 2011;

37 Categorical Course 35 CC1 AB-03 Abdomen 09:10-09:30 Hall E1-4 Chairperson(s): Chul Soon Choi Kangdong Sacred Heart Hospital, Korea Jae Young Lee Seoul National University Hospital, Korea US Findings of Benign Focal Liver Lesions Hyoung Jung Kim Department of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Korea Categorical Course 20, Friday (Hall E1-4) An important role of radiologists is to determine the clinical significance of focal hepatic lesions that are detected with ultrasonography. The most important decision to be made is whether a mass is clinically insignificant (meaning the work-up usually ends) or is clinically significant (meaning the work-up usually proceeds). Critical information used to make this decision includes the followings. a. The ultrasonography appearance of the mass itself: either the finding of hypoechoic mass or the finding of a peripheral hypoechoic halo around a mass that is hyperechoic or isoechoic almost always indicates a clinically significant lesion. b. The number of masses: multiple masses usually indicate clinically significant lesions. c. The clinical history: a new lesion or a history of significant malignancy or cirrhosis often indicates clinically significant lesions. Benign Hepatic Tumors 1. Hepatic cyst Simple hepatic cysts are the most common liver lesion. Pathologically, simple hepatic cyst is defined as a single, unilocular cyst lined by a single layer of cuboidal bile duct epithelium. Asymptomatic cysts are not usually treated until complicated by hemorrhage or infection. They generally display the three classic sonographic criteria of (a) an anechoic lumen, (b) a well-demarcated thin wall, and (c) increased through transmission. Many hepatic cysts may have a partial septum or puckering of the wall that disturbs the normally smooth contour of the uncomplicated cysts. These appearances should not raise additional concern about malignancy. Cysts are considered complicated if they have internal echoes, thick wall, septa that are numerous or thick, solid element, or calcification. The differential diagnosis includes hemorrhagic or infected cysts, cystic metastases, and hemorrhagic or necrotic tumors. 2. Hemangioma Hemangiomas occur primarily in women (female/male = 5:1) and they may be multiple in up to 50% of cases. Pathologically, hemangioma is defined as a tumor composed of multiple vascular channels lined by a single layer of endothelial cells supported by a thin fibrous stroma. The channels are separated by thin fibrous septa, which may form finger like projection into the channels. The typical ultrasonographic features of a hemangioma is small (less than 3 cm in diameter), homogeneous, and echogenic mass that does not have a hypoechoic halo in the periphery. Faint posterior acoustic enhancement may be a characteristic finding, but it is not consistently seen. Multiple microscopic vascular channels of hemangiomas act as numerous acoustic interfaces, yielding the hyperechoic appearance on ultrasonography. Atypical ultrasonographic features of a hemangioma are commonly encountered. They include the followings: scalloped border, focal hypoechoic central area, punctuate calcifications, and thin or thick echogenic rim. When a typical hemangioma is incidentally discovered in patients without liver cirrhosis or known history of malignancy, further work-up is usually not necessary, or at most a repeat ultrasonography is performed in 3 to 6 months to document lack of change. Small hepatocellular carcinoma and metastasis form a colon cancer or neuroendocrine tumor may mimic hemangioma.

38 36 42nd Korean Society of Ultrasound in Medicine 2011 Open 3. Focal nodular hyperplasia Pathologically, focal nodular hyperplasia is defined as a tumor-like condition characterized by a central fibrous scar with surrounding nodules of hyperplastic hepatocytes and small bile ductules. The bile ductules seen in central scar do not connect to the biliary tree. On cut section, it is well-demarcated mass that is often located on the surface of the liver. Although the margin is sharp, there is no capsule. Hemorrhage and necrosis are rare. Focal nodular hyperplasia is common in women and usually solitary mass (80%). It is hard to detect focal nodular hyperplasia initially with ultrasonography. Although the appearance of focal nodular hyperplasia varies at ultrasonography, most of the tumors are nearly isoechoic to hepatic parenchyma. This makes sense because their cellular composition is similar to normal hepatocytes, and it explains why many cases of focal nodular hyperplasia undetected at ultrasonography. Therefore, subtle contour abnormalities and displacement of vascular structures should raise the suspicion of focal nodular hyperplasia. The central scar, which is frequently seen at CT and MR imaging, is uncommonly seen at conventional US examination. However, a pattern of blood vessels radiating peripherally from a central feeding artery may be displayed with color Doppler imaging. 4. Hepatic adenoma Pathologically, hepatic adenoma is defined as a tumor composed of slightly atypical hepatocytes. The tumor lacks portal tracts and terminal hepatic veins; consequently, necrosis, hemorrhage, and rupture commonly occur in large tumors. Large blood vessels run through the surface of hepatic adenomas. Hepatic adenoma is clinically significant tumor because of its spontaneous hemorrhage, pain, and risk of malignant degeneration. For these reasons, surgical resection is recommended. On ultrasonography, most hepatic adenomas appear either as hypoehoic masses or as heterogeneous echoic masses with or without a peripheral hypoechoic halo. Therefore, hepatic adenomas appear similar to most other clinically significant liver tumors, including metastases and hepatocellular carcinoma. Others characteristic abnormalities at sonography. Fatty infiltration most often manifests in a diffuse distribution and results in uniform increased echogenecity of the liver. In many cases, focal areas of spared normal liver parenchyma will appear hypoechoic with respect to the fatty infiltrated parenchyma. If the fatty infiltration is not recognized, the spared areas of normal parenchyma may be mistaken for focal hypoechoic lesions. Fortunately, the spared parenchyma is usually located in front of the portal bifurcation or around the gallbladder. The combination of these typical locations, geographic shape, and normal course of hepatic vessels without alternation generally allows for a confident diagnosis of focal fatty sparing at ultrasonography. When fatty infiltration is focal, it usually appears as hyperechoic region. The hyperechoic area may have a geographic pattern, where the boundaries are sharp and map-like and they don t alter the course of the hepatic vessels. The appearance is usually diagnostic, and no further imaging work-up is required. It is most often seen in front of the portal bifurcation and adjacent to the gallbladder. Focal fatty infiltration may simulate the appearance of a hemangioma at ultrasonography. 2. Pyogenic hepatic abscess Pyogenic hepatic abscesses show extremely variable ultrasonographic features. On ultrasonography, they are usually spherical or ovoid. Mural thickness is variable, and the wall is typically irregular and hypoechoic. They appear complex fluid collections with a mixed echogenecity. Septa, fluid-fluid levels, internal debris, and posterior acoustic enhancement may also be seen. Early lesions tend to be echogenic and poorly demarcated. They may evolve into well-demarcated, nearly anechoic lesions. Abscess may calcify with healing. If gas is present in an abscess, brightly echogenic regions with shadowing may be noted. The presence of through transmission and clinical findings will often provide a clue to the diagnosis of pyogenic hepatic abscess. Sonographic differential diagnosis includes amebic or hydatid infection, a necrotic or cystic neoplasm, hematoma, complicated biloma, and simple cyst with infection. 1. Focal fat deposition or sparing Fatty infiltration of the liver causes a variety of

39 Categorical Course 37 CC1 AB-04 Abdomen 09:30-09:50 Hall E1-4 Chairperson(s): Chul Soon Choi Kangdong Sacred Heart Hospital, Korea Jae Young Lee Seoul National University Hospital, Korea US Findings of Malignant Focal Lesions of the Liver Joon-Il Choi Department of Radiology, Seoul St. Mary s Hospital, The Catholic University of Korea, Korea Categorical Course 20, Friday (Hall E1-4) Among the myriads of its clinical roles, evaluation of the malignant focal lesions of the liver is one of the most common and effective usage of ultrasound (US) examination. Though there are some rare tumors such as lymphomas or epithelioid hemangiomendothelioma, the most common malignant focal lesions of the liver includes hepatocellular carcinomas (HCC), metastases, intrahepatic cholangiocarcinomas. Hepatocellular Carcinomas HCC is the most common primary malignancy of the liver, most of which occurs on a background of liver cirrhosis. Liver cancer including HCC is the fifth common malignancy in Korea (1). The survival benefit of US for the surveillance of HCC for the risk group (carriers of HCV or HBV, cirrhosis of other causes) was demonstrated by a large, prospective, randomized trial (2) and experts groups of USA, Europe, Korea and Japan recommended regular check-up US for the surveillance of HCC (3-6). Gray-scale US findings of HCC is diverse and depend on variable factors including the size, growth pattern, degree of fatty metamorphosis and necrosis, and underlying liver parenchymal disease. Small tumors less than 2 cm without fatty metamorphosis usually shows low ehogenicity but the echo pattern tends to become more complex as the size increases due to the complexity of cellular components including necrosis, hemorrhage and fibrosis. Small tumors with fatty metamorphosis or sinusoidal dilation may appear homogeneously hyperechoic, indistinguishable from hemangiomas. As of CT or MRI, mosaicism (nodule-in-nodule appearance) is highly suggestive of a malignant focus (7, 8). Low echoic halo is another US finding of HCC and posterior enhancement could be observed in solid, homogenous tumors but is not specific finding (8, 9). On Doppler US, HCC showed basket pattern (the network of peripheral vessels surrounding tumor nodule) and vessels within the tumor pattern (blood flow that runs into and branched within the tumor) (10). Infiltrative HCC appears as an area of heterogeneity and is often difficult to recognize as a tumor especially on the background of cirrhosis. Therefore, it is important to evaluate portal veins within any suspicious heterogeneous area on US because portal venous thrombosis is frequently associated with infiltrative HCC. Tumor thrombosis is mostly contiguous with the parenchymal tumor of a similar echogenicity and dilated diameter of portal veins is another clue. On color Doppler US, vascularity in portal vein thrombus implies tumor thrombus. The stepwise development of HCC from a regenerative nodule (RN) through dysplastic nodule (DN) is now well recognized. The evaluation of blood supply is essential to characterize a hepatocellular nodule. As a DN evolves toward malignancy, abnormal neoplastic arterial supply increases and normal arterial and portal supply decrease. Early HCC or well-differentiated HCC have variable degrees of arterial and portal venous supply and significant overlap with DNs. Clinical use of US contrast agents can help to make a diagnosis of HCC. The most powerful advantage of CEUS in diagnosing HCC is its temporal resolution. Current real-time low mechanical index (MI) imaging techniques with second generation contrast agents has remarkably improved the capability of contrast enhanced ultrasound (CEUS) in detection and characterization of focal liver lesions. Typical CEUS findings of HCCs are positive enhancement during the hepatic arterial phase and washout during the portal venous phase or delayed phase. However, atypical CEUS

40 38 42nd Korean Society of Ultrasound in Medicine 2011 Open findings such as isoechoic pattern on portal venous or delayed phase and no arterial phase enhancement could be found (11-13). Recently, Kudo et al. reported the usefulness of newly developed US contrast agent, sonazoid, which make it possible to obtain Kupffer phase image on detection and characterization of HCC (14). Metastases Excluding lymphatic system, liver is the most frequently involved organ by metastatic disease. Also, benign lesions such as hemangiomas and cysts are very common. Therefore, both detection and characterization is very important in the diagnosis of hepatic metastases and imaging test with both high sensitivity and specificity is needed. Gray scale and Doppler US is reported as a limited tool for the detection of hepatic metastases (15, 16), though sensitivity of CEUS was satisfactory (17). However, intraoperative US showed very high sensitivity and specificity (18, 19), and US is also very useful for differentiating cysts from solid nodules and targeting of various interventional treatment for hepatic metastases (14). US appearance of metastases reflects the pathological characteristics of primary tumors and is similar to that of primary malignancies. Hypoechoic lesions are the most frequently encountered lesions, but various US findings can be observed. Table 1 summarized US findings of hepatic metastases. Intrahepatic Cholangiocarcinomas Intrahepatic cholangiocarcinomas (ICC) arises from intrahepatic bile duct branches smaller than second order branches. Histology reveals a glandular adenocarcinoma with extensive intralesional fibrosis. ICC can be classified into mass-forming, periductal infiltrative and intraductal papillary growth types, as other types of cholangiocarcinomas. Differentiating mass-forming ICC from metastatic adenocarcinoma is challenging for both radiologists and pathologists. Compared to metastases, ICC is more likely to be solitary, large, with occasional association with peripheral ductal dilatation. On gray scale US, echogenicity of mass-forming type ICC is various and nonspecific. However, high echoic masses with lobulated contour and absence of capsule is typical. Peripheral ductal dilatation and retraction of adjacent hepatic contour can be noted, also. Echogenicity of the mass depends on the presence of fibrosis, calcifications and amount of mucin. Periductal infiltrative type ICC can show narrowing and stricture of bile ducts with peripheral dilatation, and soft tissue masses invading hepatic parenchyma when tumors progress. Intraductal papillary growth type tumors shows ductal dilatation with multiple, small, high echoic nodular lesions in bile ducts. On CEUS, early arterial enhancement and washout of contrast material is reported for massforming ICC, and this finding is somewhat different from that of CT or MRI. This finding might be caused by the characteristics of US contras agents that stays in intravascular space only (13). Table 1. US Appearance of Hepatic Metastases US Appearance Hypoechoic metastases Hyperechoic metastases Target pattern Origin of Hepatic Metastases Breast, lung cancer, pancreas cancer, lymphoma Colon cancer, RCC, pancreas islet cell tumor, carcinoid, cholangiocarcinoma Most common in lung cancer. GI origin tumors (halo sign, Bull s eye) Cystic metastases Mucin-producing tumors (colon, ovary, IPMN) Necrosis: sarcoma, GIST Calcified metastases Mucin-producing tumors (colon, ovary, breast, stomach) Carcinoid, thyroid medullary carcinoma, osteosarcoma Infiltrative Breast, lung cancer, melanoma

41 Categorical Course 39 References 1. Annual report of cancer statistics in Korea in National Cancer Control Institute of National Cancer Center Korea. 2. Zhang BH, Yang BH, Tang ZY. Randomized controlled trial of screening for hepatocellular carcinoma. J Cancer Res Clin Oncol 2004;130: Bruix J, Sherman M. Management of hepatocellular carcinoma. Hepatology 2005;42: Park JW, Choi JY, Seo KS, et al. Practice guidelines for management of hepatocellular carcinoma Seoul:Jingihoek. 2009; Bruix J, Sherman M, Llovet J, et al. Clinical management of hepatocellular carcinoma. Conclusions of the Barcelona EASL conference. J Hepatol 2001;35: Kudo M, Okanoue T. Management of hepatocellular carcinoma in Japan: Consensus-based clinical practice manual proposed by the Japan society of hepatology. Oncology 2007;72(suppl 1): Jang HJ, Yu H, Kim TK. Imaging of focal liver lesions. Semin Roentgenol 2009; 44(4): Choi BI, Takayasu K, Han MC. Small hepatocellular carcinomas and associated nodular lesions of the liver: pathology, pathogenesis, and imaging findings. AJR 1993;160: Okuda K. Hepatocellular carcinoma: recent progress. Hepatology 1992;15: Tanaka S, Kitamura T, Fujita M, Nakanishi K, Okuda S. Color Doppler flow imaging of liver tumors. AJR 1990;154: Piscaglia F, Lencioni R, Sagrini E, et al. Characterization of focal liver lesions with contrast-enhanced ultrasound. Ultra Med Biol 2010;36(4): Giorgio A, De Stefano G, Coppola C, et al. Contrast-enhanced sonography in the characterization of small hepatocellular carcinomas in cirrhotic patients: Comparison with contrast-enhanced ultrafast magnetic resonance imaging. Anticancer Res 2007;27: Jang HJ, Kim TK, Wilson SR. Imaging of malignant liver masses: Characterization and detection. Ultrasound Q 2006;22: Kudo M, Hatanaka K, Maekawa K. Newly developed novel ultrasound technique, defect reperfusion ultrasound imaging, using sonazoid in the management of hepatocellular carcinoma. Oncology 2010;78 Suppl 1; Scholmerich J, Volk BA, Gerok W. Value and limitations of abdominal ultrasound in tumour staging - liver metastasis and lymphoma. Eur J Radiol 1987;7(4): Machi J, Isomoto H, Kurohiji T, et al. Accuracy of intraoperative ultrasonography in diagnosing liver metastasis from colorectal cancer: Evaluation with postoperative follow-up results. World J Surg 1991;15(4):551-6; discussin Piscaglia F, Corradi F, Mancini M, et al. Real time contrast enhanced ultrasonography in detection of liver metastases from gastrointestinal cancer. BMC Cancer 2007;7: Conlon R, Jacobs M, Dasgupta D, Lodge JP. The value of intraoperative ultrasound during hepatic resection compared with improved preoperative magnetic resonance imaging. Eur J Ultrasound 2003;16(3):211-6 Categorical Course 20, Friday (Hall E1-4)

42 40 42nd Korean Society of Ultrasound in Medicine 2011 Open CC2 PD-01 Pediatric 08:30-09:00 Hall E5 Chairperson: Gye Yeon Lim The Catholic University of Korea, St. Mary s Hospital, Korea Ultrasound of the Pediatric Urinary Tract Hyun Sook Hong Department of Radiology, Soonchunhyang University Hospital, Bucheon, Korea Ultrasound (US) has been the initial imaging modality for the evaluation of children with a suspected urinary tract abnormality because it is painless, involves no radiation exposure, and provides excellent anatomic details of the urinary system. The results of US usually determine what further evaluation is required. Diuresis renography has been one of the most important diagnostic tools in the evaluation of neonates with hydroureteronephrosis. Voiding cystourethrography (VCUG) has been essential for the evaluation of the anatomy and abnormalities of the bladder and urethra and has been suggested to precede other examinations (IVU, MR imaging). Sonography is followed by CT or MRI for the staging of the tumor. In particular, MRI has been useful given that tumors can extend into the spinal canal and cause neurologic symptoms. Normal Anatomy and Variations The renal sonographic appearance and anatomy of pediatric patients depends on age. Normal neonatal and infant kidneys have been demonstrated to exhibit several features that differ from those of normal adults. In premature infants, the normal renal cortex can be hyperechoic relative to the adjacent liver. In normal term infants, renal cortical echogenicity often has exhibitied the same echogenicity as the adjacent normal liver, whereas in the older children and adults, the renal cortex has been less echogenic than the liver. Further, the medullary pyramids in infant have been demonstrated to be relatively larger and have tended to appear more prominent. Additionally, the corticomedullary differentiation has been greater in an infant s and child s kidney, possibly because of increased resolution from higher-frequency transducer and less overlying body fat tissue. This also may have resulted from differences in the cellular composition and volume of glomeruli. By six months of age, the pyramids have been shown to demonstrate an adult pattern. Finally, the central echo complex has been much less prominent because of less peripelvic fat in the infants. Other normal anatomical structures that have been seen in the neonate are arcuate and interlobular arteries, columns of Bertin, junctional parenchymal defects, and interrenicular septa. Junctional parenchymal defects and the interrenicular septa represent a plane of fusion between fetal renal lobes. They have been seen in the center of a column of Bertin. Junctional parenchymal defects have appeared as an echogenic triangular focus in the anterosuperior or posteroinferior margin of the kidney, running from the junctional defect to the renal hilum. Both junctional parenchymal defects and interrenicular septa are three times more frequent on the right side. One must take care not to mistake junctional defects for renal scars. Indentations have been noted between pyramids, whereas scars are indentations within pyramids and not on the edge and have been associated with parenchymal thinning. Stasis nephropathy has been frequently seen in newborns, and represents a transient, self-limited condition. Whether this has been due to Tamm-Horsfall proteins casts or uric acid precipitation or both has not been clear. Other causes of hyperechoic renal pyramids, including nephrocalcinosis, would be unusual in a neonate during the first days of life Congenital Anomalies Congenital anomalies have been classified as abnormalities in number (renal agenesis), position (ptosis or ectopia) or fusion (horseshoe kidney and crossed

43 fused ectopia) of the kidney. Abnormal position In utero, the kidney has been demonstrated to arise in the pelvis and then migrate cranially. Ectopic kidney usually occurs when there is failure of ascent. Crossed ectopia is a form of renal ectopia in which the kidney lies on the opposite side of the retroperitoneum with its ureter occupying a normal postion in the bladder. Ninety percents of crossed ectopic kidneys have been fused to the normal ipsilateral kidney, usually side by side longitudinally, the resultant renal mass usually appears dysmorphic with a sigmoid or s shape. Patients with ectopic kidneys have been reported to be at increased risk for developing complications such as hydronephrosis, infection, and calculus formation. The sonographic findings of simple crossed - fused ectopia have included a mass with a reniform contour and two renal sinuses and the absence of the kidney in the contralateral renal fossa. The fused lower pole unit has been shown to position medillay, extending anteriorly to the spine. Horseshoe kidneys have been the most common fusion anomaly with an incidence from 1 in 600 to 1 in With this anomaly, there is fusion of the lower poles of the kidneys producing a parenchymal or fibrous isthmus across the midline. The ureters typically cross in front of the isthmus, descending from anteriorly positioned renal pelvis. Associated anomalies of the genitourinary, cardiovascular, or skeletal systems and the gastrointestinal tract have occurred in about one-third of patients. As in ectopia, an increased risk of hydronephrosis, infection, and stones has been identified. Hydronephrosis usually is the result of ureteral obstruction at the ureteropelvic junction caused by a crossing vessel. Rare complications have included Wilms tumor, and renal cell carcinoma. The sonographic findings of horseshoe kidneys have included a normal retroperitoneal position of the kidneys, medially-oriented inferior poles, and the isthmus of tissue crossing the midline. Renal agenesis and hypoplasia Renal agenesis results from an early insult to the developing ureteral bud, which prevents renal organogenesis from progressing normally. This event has been shown to occur between the 5th and 7th week of gestation and may be bilateral or unilateral. Categorical Course 41 Bilateral renal agenesis is invariably fatal, with infants dying of pulmonary hypoplasia, resulting from oligohydramnios and uterine compression of the fetal thorax. On sonoraphy, the kidneys and renal arteries have been demonstrated to be absent, and the bladder often has been shown to be small. Further, the adrenal glands usually are present but typically elongated. Unilateral renal agenesis has been reported to occur in 1 in 1000 to 1 in 5000 births. Associated anomalies of the cardiovascular, gastrointestinal, or skeletal systems have occurred in up to 25% of affected individuals. Genital anomalies also have been common; these have included duplicated uterus or vagina in girls and hypospadias, undescended testes, seminal vesicle cysts, and absent vas deferens in boys. Typically, the solitary kidney has been shown to be of normal size and morphology at birth, but within 6 to 12 months of life, compensatory renal hypertrophy frequently have been noted. Renal hypoplasia refers to a congenitally small kidney that shows no pathological evidence of dysplasia. This condition is usually unilateral and has been characterized by a decreased number of renal lobules, pyramids, and calyces. On sonography, the kidney has been revealed to be present in the renal fossa and is small in size. There is compensatory hypertrophy of the normal contralateral kidney. Duplication In complete duplication, two pelvises and two separate ureters have been demonstrated to drain the kidney. The lower pole collecting system usually inserts into the bladder at the normal site; however, the intramural portion has been shown to be shorter than usual, and thus, vesicoureteral (VU) reflux has resulted. The upper pole system often inserts ectopically, inferomedial to the site of the normal ureteral insertion (Weigert-Meyer rule). Its orifice has been suggested to be stenotic and obstructed. Ballooning of the submucosal portion of this upper pole ureter has caused ureterocele. Patients with unobstructed duplications have no further clinical problems; however, patients with complicated renal duplications may present with urinary tract infections, failure to thrive, abdominal mass, hematuria, or symptoms of bladder outlet obstruction from a ureterocele. With obstructon of an upper pole moiety, dilatation of the upper pole collection system and its entire Categorical Course 20, Friday (Hall E5)

44 42 42nd Korean Society of Ultrasound in Medicine 2011 Open ureter has been observed. The renal parenchyma may be thinned over this upper pole collectiong system. If the obstruction has been associated with a simple ureterocele, bladders may demonstrate the ureterocele as a curvilinear structure within the bladder, in addition to the dilated distal ureter adjacent to the bladder. A large ureterocele may cross the midline and obstruct the contralateral ureter or bladder outlet and cause bilateral hydronephrosis. With reflux in the lower pole moiety, the lower pole collection system and its ureter will be dilated to varying degrees. If reflux is mild, there may be no lower pole dilatation During the development, if the ureteral bud fails to separate from the Wolffian duct, it may be carried into a more caudal position than normal. Consequently, the opening of the ureter becomes caudally ectopic and, in the female, inserts into the lower bladder, urethra, vestibule, or vagina. More rarely, it has been shown to empty into the uterus or a Wolffian duct remnant. In males, it empties into the lower bladder, posterior urethra, seminal vesicle, vas deferens, or ejaculatory duct. In very rare instances, it can empty into the rectum. The fundamental difference between ureteral ectopia in females and in males is that in females, ectopic ureters can terminate at a level distal to the continence mechanisms of the bladder neck and external sphincter and thus, may be associated with incontinence. An ectopic ureter can drain a single kidney, however, about 70% have been associated with complete ureteral duplication. Ureterocele Ureteroceles represent cystic dilatation of the intravesical segment of the ureter. Ureteroceles have been associated with either a single or a duplex ureter. The congenital defect has been shown to be the obstruction of the meatus, with the ureterocele simply a hyperplastic response to this obstruction. The outer wall has been revealed to be composed of bladder epithelium and the inner wall of ureteral epithelium, with connective tissue and muscle fiber in between. Ureteral duplication has been present in about 75% of patients with ureteroceles. On US, the ureterocele has been identified as a cystic intravesical mass, contiguous with a dilated ureter and arising from a normally positioned ureteral orifice near the lateral margin of the trigone. The wall of the ureterocele has been visualized as a rounded echogenic structure located near the lateral margin of the trigone. Cecoureterocele has been identified as an uncommon form of ectopic ureterocele in which the intravesical portion dissects submucosally below the trigone and urethra. Hydronephrosis Dilatation of the renal collecting systemhydronephrosis- is a fairly common problem. Dilatation may be caused by obstruction, reflux, or abnormal muscle development. A cystogram and nuclear renogram with furosemide often have been performed for complete evaluation. When intrauterine hydronephrosis is diagnosed, a postpartum examination has been suggested to confirm the diagnosis; however, initial postpartum sonograms should not be performed until 4- to 5 days after delivery. That is, a renal sonogram performed earlier may provide false negative results or can underestimate the severity of hydronephrosis, probably due to the relative state of dehydration and decreased glomerular filtration rate immediately after delivery. Ureteropelvic junction obstruction Ureteropelvic junction (UPJ) obstruction has been identified as the most common cause of childhood upper urinary tract obstruction. The cause has been controversial, but it is believed to be congenital in origin and the result of intrinsic stenosis or extrinsic compression from a band, adhesion, or aberrant vessel. Occasionally, the obstruction may be functional because of abnormal development of the muscle fibers at the UPJ. Characteristic sonographic findings have included multiple cystic structures of uniform size, communication between the cysts, a moderate or large renal pelvis, visible renal parenchyma, and lack of visualization of a distal ureter. The renal parenchyma has been shown to either increase echogenicity or to contain cysts corresponding to histologic areas of the renal dysplasia. With severe obstruction, the renal collecting system can rupture, and urine can collect in the perirenal space. Rarely, ipsilaterl ureteral dilatation has been present secondary to coexisting VU reflux or distal ureteral obstruction. False-negative sonograms have been seen in patients who have mild degrees of dilatation, being confused with an extrarenal pelvis. Thus, scintigram have been neces-

45 sary to determine function. Megaureter Megaureter refers to ureteral dilation. In practice, a ureter with a diameter of 7 mm or more has been considered a megaureter. The condition has been divided into three types: a) nonobstructive, nonrefluxing megaureter b) obstructive megaureter, and c) refluxing megaureter. Primary nonobstuctive, nonrefluxing megaureters have been demonstrated to be caused by idiopathic ureteral dilatation. No juxtavesical obstruction, reflux or outlet obstruction has been identified. The dilatation has been shown to involve either the entire ureter, or occur segmentally. Upper tract drainage usually has not been significantly abnormal. The diagnosis of this anomaly has been one of exclusion. Secondary nonrefluxing, nonobstructive megaureters can be the result of a urinary infection or a high urine flow and volume, such as that occurring in diabetes insipidus. Primary obstructive megaureter has been revealed to be congenital obstructions of the juxtavesical ureter, the possible causes of which have included ureteral stenosis, stricture, or valves or an aperistatic distal ureteral segment. In the latter form of obstructive megaureter, termed primary megaureter, the most distal 0.5 to 4 cm of ureter has been shown to narrow and thus, to be unable to conduct a peristaltic wave, producing a functional rather than an anatomical obstruction. Primary Vesicoureteral Reflux Vesicoureteral reflux (VUR) is an abnormal flow of urine from the bladder into the upper urinary tract. In the majority of cases, it occurs as a result of a primary maturation abnormality of the vesicoureteral junction or a short distal ureteric submucosal tunnel in the bladder, altering the function of the valve mechanism. VUR has been suggested either to be an isolated anomaly or associated with other congenital anomalies such as posterior urethral valves or complete duplication of the urinary tract. Reflux has been the most common cause of antenatal hydronephrosis, being responsible for 40% of intrauterine cases. VCUG should be used to document the presence of VUR and to determine the grade of reflux and whether reflux occurs during micturation or during bladder filling. Data has shown that cystosonography depicts not only more refluxing units but also higher grade VUR than does VCUG. The main limitation of cystosonography is that it has been incapable of adequately depicting the urethra, although this may be less of a consideration in female patients. US has been used to assess the renal parenchyma, the collecting system, and any associated abnormalities. Thickening of the wall of the renal collecting system has been described upon US in patients with VUR, an occurrence likely due to intermittent dilatation of the collecting system during periods of VUR and one that can be attributed to infolding of the epithelium when a dilated upper urinary tract is in an empty contracted state. Urachal Anomalies Categorical Course 43 The fetal urachus is a tubular structure extending from the umbilicus to the bladder. It normally closes by birth, with the urachal remnant being visible as a hypoechoic elliptical-shaped mass on the anterosuperior aspect of the bladder. It has been shown to remain patent, and urine may leak from the umbilicus. If part of the urachus closes, patent parts may form urachal cysts, which may become infected. The proximal portion of the urachus may remain open, producing a diverticulum-like structure from the dome of the bladder. These anomalies may be associated with Prune-belly syndrome. Urachal abnormalities have been evaluated with cystography in the lateral projection and with US. Further, US has been useful in demonstrating urachal cysts and masses near the abdominal wall, along the site of the urachal tract. Renal cystic disease Renal cystic disease has been a complex subject, with overlapping classifications. Autosomal recessive polycystic kidney disease (ARPKD; Potter type I) is a phenotypically variable disorder with varying degrees of nonobstructing renal collecting duct ectasia, biliary duct ectasia, and fibrosis of the liver and kidneys. In ARPKD, kidney has been characterized by dilated collecting ducts, seen as radially arranged, fusiform cysts that are most prominent in the medullary portions of the kidney. This disease has a spectrum of severity and a reciprocal relation with liver involvement (periportal fibrosis with proliferation and variable dilatation of ducts). On US, the Categorical Course 20, Friday (Hall E5)

46 44 42nd Korean Society of Ultrasound in Medicine 2011 Open kidneys are hyperechogenic and greatly enlarged, often with a hypoechoic outer rim, which probably represents the cortex compressed by the greatly expanded pyramids. High resolution US has shown a spectrum of abnormalities, including dilatated tubules, cysts and hyperechoic foci. On Intravenous urography (IVU), enlarged kidney have shown a striated, increasingly dense nephrogram and poor visualization of the collecting system. If patients survive, kidneys echogenicity is increased and shows larger cysts. Patients with Autosomal dominant polycystic kidney (ADPKD, Potter type 3) have revealed a gene locus on the short arm of chromosome 16 (>90%), with varying disease severity. Typical presentation has been between 30 and 40 years of age, at which time hypertension or azotemia is present. About 25% of patients have a negative family history. ADPKD has been characterized by a weakness in basement membrane, likely because of generalized defects in collagen formation. All parts of the nephron are affected, although only 5-10% of the nephrons are involved. Cysts therefore have occured anywhere and usually have been macroscopic and of varying size. About 10% of patients with ADPKD have hepatic cysts, with a much lower incidence of splenic, pancreatic, and pulmonary cysts. Patients may also have cerebral aneurysms, colonic diverticulosis, and cysts in the ovaries, seminal vesicles, and brain. However, extrarenal cysts have been rare in children. Multicystic dysplastic kidney (MCDK, Potter type 2) is the most common form of cystic disease in infants and has been associated with an increased incidence of abnormalities in the contralateral kidney, including UPJ stenosis, MCDK, primary megaureter, and VU reflux. Large cysts of varying size have been shown to arrange like a bunch of grapes, with no recognizable renal pelvis. Ureteral obliteration causes renal function to diminish and then cease. When MCDK cysts resemble the dilated calices of severe UPJ stenosis, scintigraphy has been useful to detect any remaining renal function. The calices in severe hydronephrosis from UPJ stenosis communicate, whereas MCDK cysts do not. Periodic follow-up sonography has shown a decrease in the size of the cysts as urine production stops, to the points that the kidney may no longer be visible. Renal tumors Wilms tumor (nephroblastoma) is the most common intra-abdominal malignant tumor to occur in children. Its incidence has been reported to peak between 2 and 5 years of age. Wilms tumor has been shown to be usually bulky and expanding within the renal parenchyma, resulting in distortion and displacement of the collecting system and capsule. It is usually sharply marginated and typically, a large solid mass distorting the sinus, pyramids, cortex, and contour of the kidney is outlined with sonography. Although usually quite hyperechoic and homogeneous, hypoechoic areas that represent hemorrhage and necrosis have been identified. 5-10% of patients display bilateral tumors, and nephroblastomatosis can be present in both kidneys. Wilms tumor has been reported to spread through direction extension into the renal sinus and peripelvic soft tissues, the lymph nodes in the renal hilum, and the para-aortic areas. Because extension is possible into the renal vein, inferior vena cava, right atrium and liver, these areas should also be examined. Both CT and MRI have been commonly performed for further work-up and staging. Mesoblastic nephroma or fetal renal hamartoma is the most common neonatal renal neoplasm in the first few months of life and sometimes has been detected in the fetus. It has been characterized as a benign tumor, but can spread by local invasion. Sonography has demonstrated a mass arising within the kidney appearing similar to a Wilms tumor. The young age of the patient, the tumor s benign biologic behavior, and its more favorable outcome have helped to differentiate mesoblastic nephroma from Wilms tumor Angiomyolipoma is a form of hamartoma that can cause symptoms related to hemorrhage and rupture. In children, these tumors are usually multiple and are associated with tuberous sclerosis. Sonography typically shows multiple masses of varying echogenicity and because of the fat content, some masses may be hyperechogenic. There may associated cysts within the kidney Multilocular renal cyst (cystic nephroma) is a rare lesion that has been generally considered benign. It is uncommon in children younger than 2 years and has been difficult to distinguish from cystic, well differentiated Wilms tumor, with nephroblastoma compo-

47 Categorical Course 45 nents in the walls of the cysts. Sonography has demonstrated a well-circumscribed, multiloculated cystic mass with septations. Lymphomatous involvement of the kidney is usually a secondary process and has been seen on sonography as single or multiple, relatively hypoechoic or weakly echogenic masses within the kidney. The kidney may be enlarged and lobulated in outline and diffuse infiltration of the kidney has been demonstrated to occur. Renal cell carcinoma, rare in childhood, occurs later (mean age 12 years) than Wilms tumor. Differentiation between adrenal hemorrhage and a neonatal neuroblastoma is important. Follow- up demonstrating decreases in size and eventual resolution of masses confirms the diagnosis of an adrenal hemorrhage. Prenatal detection, the presence of calcification on initial images, vascularity in the septum or outer wall on color Doppler US, and evolution to a more complex mass may all favor the diagnosis of neuroblastoma. References 1. Kuhn JP, Slovis TL, Haller JO. Caffey s pediatric diagnostic imaging 11th ed. Philadelphia, Mosby Donnelly LF. Diagnostic Imaging Pediatrics. Amirsys/Elsevier Lowe LH, Isuani BH, Heller RM, et al. Pediatric renal masses: Wilms tumor and beyond Radiographics 2000;20: Yu JS, Kim KW, Lee HJ, Lee YJ, Yoon C, Kim M. Urachal remnant disease: spectrum of CT and US findings Radiographics 2001; 21: Lonergan GJ, Rice RR, Suare ES. Autosomal Recessive Polycystic Kidney Disease: Radiologic-Pathologic Correlation. Radiographics 2000; 20: Eo H, Kim JH, Jang KM, Yoo S, Lim G, Kim M, et. al. Comparison of Clinico-Radiological Features between Congenital Cystic Neuroblastoma and Neonatal Adrenal Hemorrhagic Pseudocyst. Korean J Radiol 2011;12:52-58 Categorical Course 20, Friday (Hall E5)

48 46 42nd Korean Society of Ultrasound in Medicine 2011 Open CC2 PD-02 Pediatric 09:00-09:30 Hall E5 Chairperson: Gye Yeon Lim The Catholic University of Korea, St. Mary s Hospital, Korea US of the Pediatric Gynecologic Diseases So-Young Yoo Department of Radiology, Sungkyunkwan University, Korea The pediatric gynecological diseases are vastly different from those that commonly affect adults and some affect specific age groups of children. US is the primary imaging modality for evaluation of the pediatric gynecologic abnormality, often enabling a definitive diagnosis for some disorders such as nonneoplastic ovarian cysts, ambiguous genitalia and precocious puberty. The evaluation of the pediatric female pelvis requires the knowledge of the developmental changes occurring in the various stages of pediatric life. Transabdominal US requires adequate bladder filling for easier visualization of uterus and ovaries. A sector or curved transducers is required in older children and high frequency linear probe is suitable for neonates and young infants. CT and MR are generally second-line modalities and have important roles especially in the global assessment in a neoplasm or an inflammatory process that extend beyond the scope of US. MR is also useful for evaluation of complex urogenital anomalies. US findings of the commonly encountered gynecologic diseases in children as well as the developmental changes of the genital tracts will be discussed. Normal US Findings Uterus Neonate: prominent with echonic endometrial stripe spade-shaped with cervix thicker than fundus decrease in size with declining level of maternal hormone Prepubertal: tubular shape with little change in size until 7 years of age endometrial canal usually not visualized Postpubertal: pear shape (fundus: cervix= 2:1 to 3:1) endometrial lining varying with the phase of menstrual cycle Ovary Location: anywhere along embryologic course from the inferior border of kidney down to the broad ligament rarely, herniated into the inguinal canal Size: volume measurement by 0.5 X width X thickness X length (neonate~1 yr : 1~3.6 cm 3, 1~5 yr :<1 cm 3, prepubertal: 1~4 cm 3, postmenarchal: 4~ 8 cm 3 ) Follicles: usually less than 9 mm in diameter larger follicular cysts in neonates and young infants due to maternal stimulation Neonatal Ovarian Cyst - Most common pelvic mass in the female neonate - Of follicular origin by excessive maternal hormonal stimulation in utero - May be large and extend into upper abdomen - Usually spontaneous regression with decrease in size - Complication: torsion, hemorrhage, intestinal obstruction, perforation. - US: variable depending on the presence of complication complicated cyst may contain a fluid-debris level, septae or a retracting hematoma Functional Ovarian Cyst of Postmenarchal Girls Resulting from failure of a mature follicle to rupture (follicular cyst) or uninvoluted corpus luteum (corpus luteal cyst) in adolescent girls - Usually incidentally detected, but can be symptomatic with complication - Size ranging from 3 to 8 cm, regressing sponta-

49 neously - US - nonhemorrhagic cyst: anechoic, thin walled unilocular cyst - hemorrhagic cyst: variable according to the age of blood usually complex masses with internal echo, septa, and fluid-debris level - DDx: cystic neoplasm, tuboovarian or appendiceal abscess, ectopic pregnancy Adnexal Torsion - Twisting of the the ovary or/and fallopian tube causing ischemia or hemorrhagic infarction - Torsion of normal adnexa is more common in children than adults because of excessive ovarian mobility. - Occur more often in patients with preexisting adnexal masses (teratoma m/c) - US: - varying depending on duration, degree of vascular compromise and a coexistent mass within the affected ovary - unilateral enlarged ovary with peripheral cysts or complex cystic mass - fallopian tube thickening, pelvic free fluid - color Doppler: lack of arterial and venous flow, twisted vascular pedicle * Presence of color flow does not exclude torsion but instead suggests that the ovary may be viable. - CT/MR: better visualization of torsion knot (twisted vascular pedicle) Ovarian Neoplasm Germ cell tumor - Two-thirds of all ovarian tumors in children - Mature teratoma : m/c, cystic mass with echogenic mural nodule - Immature teratoma: larger and more solid than mature teratoma - Dysgerminoma: mainly solid tumor with lobules divided by fibrovascular septa - Endodermal sinus tumor (yolk sac tumor):highly malignant, mainly solid tumor, AFP Epithelial tumor - Rare in children, 10-20% of all ovarian tumors - Cystadenoma/adenocarcinoma: serous type >mucinous type - US: large multiseptated cystic mass - Malignant tumors tend to have more solid portions as papillary projections. Sex cord-stromal tumor - Rare, 10% of ovarian tumors Juvenile granulosa cell tumor (JGCT) - estrogen-producing tumor causing a pseudoprecocious puberty - varying imaging findings from solid to multilocular cystic masses - uterine enlargement and thick endometrium Sertoli-Leydig cell tumor -virilization in one-third, usually solid or solid and cystic mass Secondary tumors - Burkitt lymphoma, leukemia, neuroblastoma - Mainly solid mass Vaginal Obstruction Categorical Course 47 In neonate - usually associated with cloacal malformation or persistent urogenital sinus - manifest as hydrometrocolpos by accumulation of vaginal secretions secondary to maternal hormonal stimulation In adolescent - commonly associated with imperforate hymen and less frequently by vaginal atresia, stenosis or transverse septum - present with amenorrhea, cyclic pain, or palpable abdominal mass US findings - a tubular, fluid-filled, midline pelvic mass representing a dilated vagina - a fluid-filled uterus c/s internal echoes Congenital Uterine Anomalies Classification of congenital uterine anomalies Arrested müllerian duct development: uterine agenesis/hypoplasia, unicornuate uterus Categorical Course 20, Friday (Hall E5)

50 48 42nd Korean Society of Ultrasound in Medicine 2011 Open Total/partial failure of müllerian duct fusion: uterine didelphys, bicornuate uterus Nonresorption of uterine septum: septate uterus, arcuate uterus * Search for associated abnormalities in urinary tract Ambiguous Genitalia (Intersex Disorder) Classification of intersex disorders with ambiguous genitalia 1. Female pseudohermaphroditism: 46 XX, ovary (+), uterus (+) congenital adrenal hyperplasia/ Maternal androgen effect 2. Male pseudohermaphroditism: 46 XY, testis (+), uterus (-) decreased testosterone synthesis/ testicular feminization 3. Dysgenetic male pseudohermaphroditism and XY gonadal agenesis: streak testis 4. True hermaphroditism: 46 XX or XY, mosaic type, ovary and testis/ovotestis Classification - Central type (gonadotropin-dependent, complete or true) idiopathic (85-90%), CNS lesions such as tuber cinereum hamartoma - Peripheral type (gonadotropin-independent, incomplete or pseudoprecocious) due to excessive estrogen from ovaries (autonomous cyst or estroten-producing tumor) or adrenal gland (estrogen secreting adrenal tumors) Imaging work-up Bone age: commonly advanced in true precocious puberty Pelvic US : determine ovarian and uterine size and evaluate the effect of treatment in central type, uterine and bilateral ovarian enlargement in peripheral type, unilateral ovarian cyst or tumor Delayed puberty chronic systemic illness, hypogonadotropic/ hypergonadotropic hypogonadism Role of imaging US- identification of uterus and gonad, evaluation of adrenal gland Genitography or VCUG- detailed anatomy of lower GU tract including demonstration of the vagina, its relation with the urethra and type of urethra for surgical reconstruction MR- helpful in the situations with complex anatomy Disorders of Puberty Precocious puberty Definition: appearance of external signs of adolescence before 8 year Suggested readings 1. Stranzinger E, Strouse PJ. Ultrasound of the pediatric female pelvis. Semin Ultrasound CT MR 2008;29: Servaes S, Victoria T, Lovrenski J, et al. Contemporary pediatric gynecologic imaging. Semin Ultrasound CT MRI 2010;31: Ziereisen F, Guissard G, Damry N, et al. Sonographic imaging of the paediatric female pelvis. Eur Radiol 2005;15: Siegel MJ: Female pelvis. In: Siegel MJ, 3rd ed. Pediatric sonography. Philadelphia, Lippincott Williams &Wilkins, 2002; pp Garel L, Dubois J, Grignon A, et al. US of the pediatric female pelvis: A clinical perspective. Radiographics 2001;21:

51 Categorical Course 49 CC2 PD-03 Pediatric 09:30-10:00 Hall E5 Chairperson: Gye Yeon Lim The Catholic University of Korea, St. Mary s Hospital, Korea US of Pediatric Scrotum Soo Ah Im Department of Radiology, Seoul St. Mary s Hospital, The Catholic University of Korea, Korea Categorical Course 20, Friday (Hall E5) Protocol for Scrotal US Scrotal US is performed with the patient in the supine position and the scrotum supported by a towel placed between the thighs. A large amount of warm gel is used to minimize pressure on the scrotal skin. High-frequency linear-array transducers are recommended for performing the study: 15-8 MHz for neonates and infants and 8-5 MHz for prepubertal and pubertal boys. Because of the superficial position of the organ, we use the fundamental mode and scan each hemiscrotum in the transverse and longitudinal planes. Study of the spermatic cord is an important part of the examination, particularly in patients with varicocele and suspected testicular torsion. The cord is identified in the inguinal canal, and its course is followed up to the posterosuperior border of the testis. Testicular size can be determined by measuring the anteroposterior diameter on comparable transverse images of the left and right sides or by calculating testicular volume with the formula for an ellipsoid: V = L X W X H X 0.52, where V = volume, L= length, W = width, and H = height. Although these measurements are not acquired routinely, they should be obtained in patients with varicocele, testicular atrophy, or acute scrotum to assess changes in testicular size. Testicular volume is approximately 1-2 cm 3 before the age of 12 years and reaches 4 cm 3 in pubertal males. In the peripubertal period, a difference of 3 mm in anteroposterior diameter is significant. Color Doppler imaging is performed in all cases to investigate extratesticular vascularization and testicular perfusion, with parameters optimized to display low flow velocities (low wall filter [100 khz], low pulse repetition frequency [1-2 Hz], and 70-90% color gain output settings). We add power Doppler imaging in some cases of suspected testicular torsion or tumors to supplement conventional color Doppler imaging. In power Doppler imaging, the color map displays the integrated power of the color signal to depict the presence of blood flow instead of its mean Doppler frequency shift, as in the color Doppler display. Normal Scrotal Anatomy at US It is fundamental to be familiar with the normal sonographic anatomy of the spermatic cord to detect its torsion. On grey-scale US, the normal spermatic cord is seen as a slightly hypoechoic tubular structure. On color Doppler sonography, the spermatic cord has straight or slightly tortuous, but continuous vessels that extend towards the testis. Both testes and epididymides should have similar volume, texture, echogenicity and shape on grey-scale US and similar blood flow on color Doppler studies; any minor change should raise suspicion of pathology. The testis is an ovoid structure; its echogenicity in younger children is low, and increases to medium with age. In normal testes smaller than 1 cm 3, the ability of color Doppler US to detect flow is low (69%); in testes larger than 1 cm 3, all capsular and centripetal arteries can be identified. In the younger child, only the epididymal head is identified, lying on the upper pole of the testis; in the older child, the whole epididymis - head, body and tail - is seen. The epididymis is a tortuous tubular structure, usually located posterior and lateral to the testis; its head has a pyramidal shape when scanned in longitudinal section. The echogenicity of the epididymis is equal to or slightly greater than that of the testis. The echotexture of the testis and the epididymis is homoge-

52 50 42nd Korean Society of Ultrasound in Medicine 2011 Open neous. The normal epididymis may have minimal or no flow. The mediastinum testis may be seen as a central linear and echogenic band and is usually visible in older children. A small amount of scrotal fluid may be present. Processus Vaginalis-related Disorders The processus vaginalis appears at about 13 weeks of fetal development as an outpouching of the parietal peritoneum, through which the testis descends from the abdomen to the scrotum between the 7th and 9th months of fetal life. After testicular descent, the processus vaginalis is obliterated and the scrotal portion of this processus remains as a peritoneum-lined cavity, the tunica vaginalis, surrounding the anterior surface of the testis. Failure of the testis to descend into the scrotum and patency or anomalous closure of the processus vaginalis result in the following conditions: cryptorchidism, inguinoscrotal hernia, and hydrocele. 1. Cryptorchidism Failure of the intraabdominal testes to descend into the scrotal sac is known as cryptorchidism. The testes originate within the retroperitoneum and migrate downward through the internal inguinal ring, inguinal canal, and external inguinal ring to the scrotum. The cryptorchid testis may be located at any point along the descent route. The prevalence of this condition is % in premature infants and % in fullterm infants. Sonography is useful only for identifying testes in the inguinal canal (the most frequent location [70% of cases]) or the prescrotal region just beyond the external inguinal ring (20%) and should be the initial imaging procedure. The cryptorchid testis is usually smaller and isoechoic or hypoechoic relative to the normally located testis. 2. Inguinal-Scrotal Hernia Inguinal-scrotal hernia is defined as the passage of intestinal loops and/or omentum into the scrotal cavity. The prevalence of inguinal hernia is higher in preterm neonates, especially at 32 weeks gestation. The hernia is more frequently located on the right side, since the right processus vaginalis closes later than the left. Physical examination is sufficient to enable diagnosis in most cases. Nevertheless, US examination (which has replaced plain radiography) is indicated in patients with inconclusive physical findings, in patients with acute scrotum, and to investigate contralateral involvement in patients in whom only a unilateral hernia is clinically evident. At gray-scale US, the scrotum is partially occupied by one or more round structures containing air bubbles or fluid. The diagnosis of hernia is achieved by visualization of air bubble movement and/or intestinal peristalsis during the real-time examination. The herniated omentum is seen as a highly echogenic structure. US examination should include both inguinal canals, since a clinically inapparent contralateral hernia can be found in 88% of cases. Inguinal rings larger than 4 mm are an indication for prophylactic herniorrhaphy. Color or power Doppler imaging is routinely used in inguinal-scrotal hernia to investigate intestinal and testicular perfusion. Urgent surgery is indicated in patients with an akinetic dilated bowel loop (a sign of strangulation) or impaired testicular perfusion, which occurred in 2.5%. 3. Hydrocele Hydrocele, an abnormal collection of fluid between the visceral and parietal layers of the tunica vaginalis and/or along the spermatic cord, is the most common cause of painless scrotal swelling in children. In the normal scrotum, 1-2 ml of serous fluid may be observed in the potential tunica vaginalis cavity and should not be mistaken for hydrocele. Virtually all hydroceles are congenital in neonates and infants and associated with a patent processus vaginalis, which allows peritoneal fluid to enter the scrotal sac. In older children and adolescents, hydroceles are usually acquired and are the result of an inflammatory process, testicular torsion, trauma, or a tumor. At sonography, congenital hydrocele appears as an anechoic fluid collection surrounding the anterolateral aspects of the testis and sometimes extending to the inguinal canal or as a fluid collection with low-level swirling echoes, which are related to protein aggregation or deposition of cholesterol crystals. Closure of the processus vaginalis above the testis and below the internal inguinal ring leads to a less common type of hydrocele, also known as spermatic cord cyst, which appears as a fluid collection in the

53 spermatic cord. Another type, referred to as abdominoscrotal hydrocele, is a highly uncommon entity, with only some 80 reported pediatric cases. These are large inguinoscrotal hydroceles that protrude through the internal inguinal ring into the abdominal cavity and manifest clinically as a communicating abdominal-scrotal mass. The exact mechanism by which peritoneal fluid is forced into the abdominal cavity remains speculative. Most congenital hydroceles (80%) resolve spontaneously before the age of 2 years. However, surgical treatment is usually applied in spermatic cord and abdominoscrotal hydroceles. Acute Scrotum Categorical Course 51 the scrotal wall, and allows rotation of the spermatic cord. It is bilateral in 12% of patients. Some clinical features of this type of torsion are sudden onset scrotal pain, nausea and vomiting. The physical examination usually reveals scrotal edema on the affected side as well as erythema and loss of the cremasteric reflex. The testis is painful to palpation and may be transversely oriented inside the scrotal sac. The viability of the testis, as well as changes detected sonographically, are primarily dependent on time since torsion. In general, testis salvage rate is greater than 90% if detected and treated up to 4 h after torsion, and the success rate decreases after this time. Detorsion and orchidopexy 24 h after onset results in testicular atrophy in practically 100% of patients. Categorical Course 20, Friday (Hall E5) The term acute scrotum refers to a clinical picture of sudden-onset scrotal pain, redness, and swelling, most frequently caused by acute epididymoorchitis, torsion of the testicular appendages, or testicular torsion. Since scrotal involvement is usually unilateral, we start the examination on the asymptomatic side to have a basis for comparison. Color Doppler imaging, adjusted to visualize low flow velocities, or power Doppler imaging should always be added to the gray-scale study. Pulsedwave Doppler imaging is not absolutely necessary. Comparable transverse Doppler scans of both testes are essential to study testicular perfusion discrepancies. Patients with absent or clearly decreased blood flow signal should be treated surgically. In cases with inconclusive Doppler perfusion findings, nuclear medicine or MR imaging can assist in the diagnosis and management decisions. 1. Testicular torsion Testicular torsion is the cause of an acute scrotum that has the highest morbidity because delay in its diagnosis may result in loss of a testis. Two types of torsion are described here: intra- and extravaginal. (1) Intravaginal torsion Intravaginal torsion of the testis or the spermatic cord is the most common type of torsion; it is most frequent in puberty, although it may also occur at other ages. The bellclapper deformity is a predisposing factor. Here the tunica vaginalis surrounds the entire testis and epididymis, prevents their fixation to - Gray-scale and color Doppler US findings The most important finding in these cases is the direct sonographic identification of the torsion knot in the spermatic cord located in the inguinoscrotal region above the testis and epididymis. Different terms have been used to describe this sign of torsion: snail shell shaped, whirlpool sign, knot sign or a mass measuring 7-33 mm. Color Doppler US shows spiralling (whirlpool) or twisted vessels in the topography of the spermatic cord, but intratesticular blood flow may be absent, reduced, or even normal. A finding of absent or reduced intratesticular blood flow has a sensitivity of 76-88%. The identification of a twisted cord with intratesticular blood flow is a sign that the testis is viable and may be salvaged after reduction and orchidopexy. Immediately after torsion (up to 3 h), testis volume and echogenicity may be normal. Later, an increase in testicular volume and hypoechogenicity or heterogeneous echogenicity, or both, may be detected. Cystic areas may be seen in the late phase, but these findings are nonspecific. After spontaneous or manual detorsion, color Doppler US shows that blood flow in the testis is normal or increased, and that the spermatic cord is normal (postischaemic hyperreactivity). Spontaneous detorsion may mimic epididymoorchitis and, in this case, the child s report of spontaneous clinical improvement of pain before the examination is an indication that the diagnosis is correct. Associated findings may include changes in the normal orienta-

54 52 42nd Korean Society of Ultrasound in Medicine 2011 Open tion of the testis axis in the scrotal sac, reactive hydrocele, scrotal wall edema, and edema or hyperaemia of the epididymis. (2) Extravaginal torsion This type of torsion is often found in the neonatal period due to deficient fixation of the spermatic cord. It accounts for about 10% of all cases of testicular torsion. It is often intrauterine, in which case the testis is usually lost, or postnatal, when immediate surgical intervention may salvage the testis. In some cases, extravaginal testicular torsion is bilateral. Complicated pregnancies and vaginal deliveries seem to be predisposing factors for extravaginal torsion. - Gray-scale and color Doppler US findings US features of recent extravaginal torsion include an enlarged globular testis, parenchyma with heterogeneous echogenicity, and no intratesticular blood flow on color Doppler studies. Hydrocele, occasionally with debris, and thickening of paratesticular structures are associated findings. In the later phase the testis may have a normal or even reduced size with peripheral hyperechoic areas that correspond to areas of calcification. Color Doppler US shows absence of blood flow. 2. Torsion of the appendix testis Although testicular torsion has a greater morbidity than torsion of the appendix testis, it is the latter that most frequently causes an acute scrotum. In children with an acute scrotum the prevalence of torsion of the testicular appendage ranges from 31% to 57%, and of torsion of the testis, from 11.7% to 46.0%. Physical examination of the scrotum may reveal the blue dot sign, a bluish change in the color of the skin on the affected side due to ischaemia of the appendix testis. The blue dot is a highly specific sign of torsion, although it is only seen in 21% of patients. - Gray-scale and color Doppler US findings Grey-scale and color Doppler US of a torsed appendix testis show a hyperechoic avascular nodule at the upper pole of the testis, usually medial to the head of the epididymis in the transverse plane and in the epididymistesticular recess in the longitudinal plane. In the later phase, cystic areas may appear in the appendix. However, the detection of the appendix testis on grey-scale US alone is not pathognomonic for torsion because it may also be identified in children without torsion. A torsed appendix testis is usually larger than normal with a diameter greater than 5 mm, and is always associated with reactive noninfectious epididymoorchitis. The epididymis often involves the torsed appendix testis, and color Doppler US is useful to differentiate both structures. However, the differentiation of torsed from normal appendix testes using color Doppler US is difficult because flow in the normal appendix testis is not easily detected. Epididymoorchitis of the torsed appendix testis should be differentiated from bacterial epididymoorchitis in order to avoid the unnecessary use of antibiotics. In this situation, laboratory findings, in addition to the detection of a nodule in the upper pole of the testis by US, will help to define the right diagnosis. 3. Epididymitis and epididymoorchitis Epididymoorchitis, with a prevalence of 14-28%, is one of the most important causes of an acute scrotum in children. The scrotum may be affected by hamatogenous epididymoorchitis, particular in cases of sepsis caused by Escherichia coli or Neisseria meningitides. In patients with mumps and subclinical involvement of the parotid, epididymoorchitis may mimic torsion of the testis. In younger children, epididymitis may be associated with congenital anomalies of the urogenital tract, such as urethral abnormalities, ectopic ureter, ectopic vas deferens, Müllerian duct cyst, neurogenic bladder, bladder exstrophy, sphincter dyssynergia, or vesicoureteral reflux. Therefore, the US examination of these patients should evaluate regions beyond the scrotum: bladder, kidneys and perineal region. If an anomaly is suspected, it is important to complement the examination with other imaging studies of the urinary tract. The results of laboratory tests may show a WBC >10,000 cells/μl; urinalysis may show pyuria; urine culture may be useful to identify the bacterium; blood culture should be obtained in patients with systemic symptoms. - Gray-scale and color Doppler US findings In epididymitis, the epididymis is totally or partially enlarged, more markedly at its head; in epididymoorchitis, the testis may be enlarged. Color Doppler US reveals increased blood flow in the epididymis, and,

55 in epididymoorchitis, also in the testis. However, such findings are also seen in torsion of the spermatic cord or of the appendix testis. The detection of the normal spermatic cord and the lack of an avascular nodule next to the upper pole of the testis are signs that rule out the diagnoses of torsion of the testis and appendix testis, and suggest, together with clinical and laboratory findings, the diagnosis of epididymitis or bacterial epididymoorchitis. Other signs, such as hydrocele with or without lumps, and thickening of the scrotal wall, are often found. Bacterial or viral epididymoorchitis should be differentiated from spontaneous detorsion of the spermatic cord in which there is reactive inflammation of testis and epididymis. A very characteristic feature of these cases is the acute relief of scrotal pain reported by patients with spontaneous spermatic cord detorsion. 4. Testicular trauma Testicular trauma of any nature, including physical abuse, may result in simple contusion, testicular hemorrhage, epididymal hemorrhage, testicular fracture, or testicular rupture, the most serious of these conditions. When there is an obvious clinical history of scrotal trauma, US may be used to exclude secondary torsion or to stage the trauma. As an accurate history is difficult to obtain from children, particularly younger children, the findings on US may be the first indication of trauma. - Gray-scale and color Doppler US findings Sonography has an important role in detecting traumatic lesions. In a hematocele there is usually fluid and lumps in the scrotal sac. In testicular fracture, intratesticular hypoechoic areas are seen. In testicular rupture, the echogenic tunica albuginea is discontinuous, a finding with a sensitivity of 100% and specificity of 65%. Surgery is indicated for testicular rupture, and its early detection may result in salvage of the testis in 80-90% of patients. Testicular torsion and hernias may also be detected after trauma. In traumatic epididymitis without any other lesion, the differential diagnosis from bacterial epididymitis may be difficult, particularly in younger children because an adequate clinical history may be difficult to obtain. Categorical Course 53 Scrotal Tumors The prevalence of scrotal tumors is estimated at cases per 100,000 boys. Scrotal tumors usually manifest as painless scrotal swelling. Owing to its excellent spatial resolution, US is nearly 100% sensitive for identifying scrotal masses. The technique allows differentiation between cystic and solid tumors and classification as intra- or extratesticular. The term paratesticular refers to a group of extratesticular lesions that are not easily identified as originating from a particular tissue. 1. Extratesticular Tumors The most frequent extratesticular tumor is paratesticular rhabdomyosarcoma, which originates in the spermatic cord or scrotal tunics. The majority occur in the first two decades of life and belong to the embryonal histopathologic subtype. At US, paratesticular rhabdomyosarcoma is seen as a hypo- or hyperechoic solid mass that may envelop or invade the epididymis and testis, with hypervascularity at color Doppler imaging. Tumors of the epididymis are usually benign. Epididymal cysts, although not true tumors, usually manifest as a palpable mass and are of lymphatic origin. Because they contain clear serous fluid, they are seen as an anechoic, well-defined mass with increased through transmission. Epididymal cysts cannot be differentiated from spermatoceles, which are secondary to obstruction and dilatation of the efferent ductal system. However, the latter occur exclusively in postpubertal boys. Adenomatoid tumor is rare in children and arises from the poles of the epididymis. At US, this tumor is seen as a smooth, round, well circumscribed echogenic mass. However, the appearance is not specific and it should be differentiated from granulomatous epididymitis, a chronic form of epididymitis that manifests as a painful palpable mass. At color Doppler imaging, vessels are observed within the adenomatous tumor, whereas usually no vessels are seen in granulomatous epididymitis. Primary malignant tumors of the epididymis are very rare in children; epididymal involvement is mainly due to metastatic spread from B-cell acute lymphoblastic leukemia and B-cell non-hodgkin lymphoma. Categorical Course 20, Friday (Hall E5)

56 54 42nd Korean Society of Ultrasound in Medicine 2011 Open 2. Testicular Tumors Testicular tumors account for 1% of all pediatric solid tumors. They have two peaks of prevalence, before 3 years of age and in the postpubertal period, and usually manifest as a painless scrotal mass. Nevertheless, in approximately 10% of patients, testicular tumor is associated with pain due to hemorrhage or infarction, mimicking torsion or epididymitis. Testicular tumors are subdivided into two groups: germ cell tumors and non-germ cell tumors. (1) Germ Cell Tumors Germ cell tumors result from the transformation of primitive germ cells. These pluripotential cells can remain nondifferentiated (seminomas), become slightly differentiated (embryonal carcinoma), or transform into differentiated embryonal (mature or immature teratomas) or extraembryonal (choriocarcinoma) structures. Yolk sac tumor, also known as endodermal sinus tumor, is the most common germ cell tumor, with most cases occurring before the age of 2 years. Levels of serum markers such as lactate dehydrogenase (the least specific) and a-fetoprotein are elevated in more than 90% of patients. These markers are also useful in follow-up to check for regression or recurrence of the tumor. The US findings are nonspecific, usually showing a solid mass replacing the entire testis. The presence of hypoechoic areas within the tumor, which indicates areas of necrosis, is a frequent finding in our experience. As with all germ cell tumors, spread is predominantly via the lymphatic system; hence, the lymphatic pathway should be included in the initial work-up. The second most common germ cell tumor is teratoma, which is classified as mature or immature. Teratoma may appear as a cystic lesion with peripheral solid components or a complex mass with cystic components, calcifications, and echogenic intratumor fat. These tumors are usually benign in prepubertal children, so tissue sparing surgery may be possible; however, in adolescents they are often malignant and require orchidectomy. Testicular epidermoid cyst is the most common benign testicular tumor with no malignant potential. The cyst contains cheesy material and may resemble a solid tumor at US. Several sonographic patterns have been described: anechogenic lesion surrounded by a hypoechoic or echogenic rim, a target appearance, and an onion ring configuration with alternating echogenic and anechoic areas within the lesion. The presence of well-delineated borders and avascularity at color Doppler imaging favors the diagnosis. (2) Non-Germ Cell Tumors Non-germ cell tumors, which are less frequent than germ cell tumors, can develop from the gonadal stroma (Leydig cell tumor), sex cord cells (Sertoli cell tumor), or sex cord cells plus stroma (gonadoblastoma). Strictly speaking, gonadoblastoma is not actually a tumor but instead is a dysgenetic lesion occurring in the setting of gonadal dysgenesis and intersex syndromes. Leydig cell tumor secretes hormones (androgens or estrogens); hence, one-third of patients present with endocrinopathy. At US, the tumor is seen as a smoothly demarcated, echopoor, homogeneous mass. Sertoli cell tumor is less hormonally active than Leydig cell tumor, although some patients may show gynecomastia. A subtype of Sertoli cell tumor associated with Peutz-Jeghers syndrome typically occurs in children. Testicular lesions in these patients are usually bilateral and are visualized at US as burned-out tumors (ie, with dense echogenic foci that represent calcified scars). (3) Other Testicular Tumors Primary follicular lymphoma of the testis is exceptional, with few reported cases. However, secondary involvement is common in patients with acute lymphoblastic leukemia and non-hodgkin B-cell lymphoma. At US, there are two types of involvement, which are seen in both leukemia and lymphoma: the more common diffuse type, in which the testis is enlarged and hypoechoic, and the focal type, which demonstrates multiple hypoechoic nodules. Increased blood flow is seen on color Doppler images, simulating an inflammatory lesion. Metastasis of other solid tumors, such as Wilms tumor, neuroblastoma, and retinoblastoma, may also affect the testis. Systemic Diseases with Scrotal Involvement Several systemic diseases can occur with scrotal involvement. The testes are affected in 15-37% of patients with Henoch-Schonlein purpura. In this disease, scrotal symptoms may precede other manifestations. US findings include scrotal wall thickening, epi-

57 Categorical Course 55 didymal enlargement, and reactive hydrocele. Involvement is bilateral in the vast majority of cases; hence, this entity should be considered when bilateral US findings similar to those of inflammatory epididymitis are visualized. Scrotal involvement can also occur in acute hemorrhagic edema of infancy. US findings are similar to those seen in Henoch- Schonlein purpura, and differentiation between the two conditions is based on clinical features. Acute hemorrhagic edema of infancy affects very small children (5 months-2 years of age), and the gastrointestinal tract, kidneys, and joints are preserved. The condition known as acute idiopathic scrotal edema of possible allergic origin is characterized by sudden onset of nonhemorrhagic edema and redness of the scrotal wall. The age at presentation varies from 4 months to 18 years. Clinical discomfort is minimal, and the edema usually resolves between 72 hours and 4 days with conservative treatment. The US findings, which include thickening of the scrotal walls and hypervascularity, are characteristic. Conclusions Gray-scale and color Doppler US is the primary imaging modality for the study of scrotal diseases in children. Together with the results of clinical and physical examination, the information obtained with this method is sufficient to enable diagnosis in most cases. When US findings are inconclusive, MR imaging can provide additional information. Knowledge of the US features of the conditions described and illustrated in this article is fundamental for the management of scrotal lesions in children. References 1. Clinical and sonographic criteria of acute scrotum in children: a retrospective study of 172 boys. Pediatr Radiol 2005;35: Gray-Scale and Color Doppler Sonography of Scrotal Disorders in Children: An update. Radiographics 2005;25: Scrotal emergencies. Pediatr Radiol 2009;39: Categorical Course 20, Friday (Hall E5)

58 56 42nd Korean Society of Ultrasound in Medicine 2011 Open CC3 GU-01 Genitourinary 08:30-08:50 Hall E6 Chairperson: Kyoung Sik Cho Asan Medical Center, Korea US of Medical Renal Diseases and Transplanted Kidney Chan Kyo Kim Department of Radiology, Samsung Medical Center, Sungkyunkwan University, Korea Renal Parenchymal Diseases (OR Medical Renal Diseases) is an inflammatory disease of the tubules and interstitium of various causes and different mechanism of tissue damage. Renal parenchymal disease refers to a disease affecting the renal parenchyma: glomeruli, tubules, interstitium, and blood vessels. It can be classified into three categories: glomerular, tubulointerstitial, and vascular. This approach is useful, because the early manifestations of disease affecting each of four basic morphologic components tend to be distinct. It also includes the systemic disease that involves the kidney. Glomerular diseases Glomerular diseases constitute some of the major problems in nephrology; indeed, chronic glomerulonephritis is one of the most common causes of chronic kidney disease in humans. The pathologic process is confined to the kidney (primary glomerulopathies) or associated with systemic or hereditary diseases (secondary glomerulopathies). Tubulointerstitial diseases Most forms of tubular injury involve the interstitium as well. Tubulointerstitial diseases include two major groups of processes: 1) ischemic or toxic tubular injury, leading to acute kidney injury (AKI) and acute renal failure (ARF), and (2) inflammatory reactions of the tubules and interstitium (tubulointerstitial nephritis). AKI that is also called acute tubular necrosis (ATN) is the most common cause of acute renal failure and is a reversible tubular damage caused by either ischemia or toxins. Tubulointerstitial nephritis is characterized by histologic and functional alterations that involve predominantly the tubules and interstitium. It Vascular diseases Nearly all diseases of the kidney involve the renal blood vessels secondarily. Systemic vascular diseases, such as various forms of vasculitis, also affect renal vessels. Benign and malignant nephrosclerosis, renal artery stenosis, renal vein thrombosis, and atheroembolic disease are the main components. US findings of renal parenchymal diseases Although the diagnosis of renal parenchymal diseases still mainly relies on renal biopsy, imaging studies have important roles in evaluating the patients. Renal US is usually the first imaging modality for the evaluation of renal diseases. It is used routinely in patients with azotemia to exclude possible obstructive uropathy, to measure the size of the kidneys, and to evaluate renal parenchymal echogenicity, particularly with respect to cortical echogenicity and the distinctness of the corticomedullary differentiation. Renal size, either renal length or renal parenchymal thickness, is a useful index of chronicity of the renal disease. For measurement of renal size, US is a reliable technique and renal length is most commonly used. The length of kidney is considered normal when it is comprised 9-13 cm. Normally, renal margins are smooth, except in some normal variants such as fetal lobulations or junctional parenchymal defects. Mean normal value of renal parenchymal thickness is cm, avoiding renal pyramids. The change in renal parenchymal echogenicity is the most common clue for the US diagnosis of renal parenchymal disease. Renal cortical echogenicity is normally lower than that of liver, spleen and renal

59 sinus in adults. If renal cortical echogenicity is higher than that of the liver or spleen in adults, it is assumed that renal parenchymal disease is present. When it is equal to the liver, the renal function is normal in 70% of cases. Renal cortical echogenicity is correlated to the severity of histopathological changes in renal parenchymal diseases such as glomerular sclerosis, focal tubular atrophy and hyaline casts per glomerulus. Renal corticomedullary differentiation is another important parameter in the US evaluation of the kidney. Renal medullary echogenicity is normally slightly lower than that of the renal cortex. However, renal corticomedullary differentiation is seen only in about 50% of adults with normal renal function. Thus, in cases of renal parenchymal disease, it may be preserved, obliterated, or accentuated. Doppler US is an easy and noninvasive technique for the evaluation of renal blood vessels and the hemodynamic changes of the kidney. Power Doppler US is known to be superior to color Doppler US in the visualization of fine intrarenal vasculature. Assessment of renal vascular resistance is obtained by Doppler waveform analysis, obtaining resistive index (RI) which corresponds to peak systolic velocity minus end-diastolic velocity divided by peak systolic velocity. The RI is the most commonly used index. Interlobar or arcuate arteries are commonly used to obtain Doppler spectra, but interlobar arteries are preferred to arcuate arteries because the Doppler signals are stronger due to smaller Doppler angles, particularly in the interpolar areas of the kidney. Doppler spectra are obtained at least in three regions (upper polar, lower polar, and interpolar regions) of each kidney and the average value is taken. The RI measured on segmental, interlobar and arcuate arteries are normally <0.7, and decrease progressively from segmental to interlobular arteries. Several factors such as age or systemic BP may affect the RI of the intrarenal arteries. Studies that correlate RI with biopsy findings in various renal parenchymal diseases have reveals that kidneys with active disease in tubulointerstitial or vascular compartment present elevated RI (>0.8), while kidneys with glomerular diseases present more often normal RI. Diabetic nephropathy, hepatorenal syndrome, and hemolytic uremic syndrome are examples in which elevated RI was reported to correlate well Categorical Course 57 with the severity of the disease. Doppler US may also be helpful in predicting the prognosis of certain renal diseases. In patients with lupus nephritis, a normal RI may predict a better renal outcome, and in patients who undergo liver transplantation, an elevated RI without azotemia indicates a greater change of subsequent renal dysfunction. For patients with ARF, Doppler US findings may reflect the status of renal hemodynamics, which is different among the types of ARF. DM nephropathy Diabetic nephropathy is the single most important disorder leading to renal failure in adults. It develops in 40-50% of insulin-dependent patients and 20% of non-insulin-dependent diabetic patients. DM is one of the common causes of bilaterally enlarged kidneys. Imaging studies may reveal renal enlargement in the early stage of diabetic nephropathy and shrunken kidneys in the late stage. For detection of changes in renal size, US is the best imaging modality available. In the early stage, US may show an enlarged kidney with normal parenchymal echogenicity. In diabetic patients undergoing hemodialysis renal length is decreased. In advanced stage, US may show a shrunken kidney with increased echogenicity and variable corticomedullary differentiation which is not different from the findings of end-stage renal disease due to other causes. The RI is typically elevated in advanced stage, while RI is often normal in early stage. The RI is highly correlated with serum creatinine concentration and creatinine clearance rate, while an elevated RI ( 0.7) is associated with impaired renal function, increased proteinuria and poor prognosis. Acute and chronic renal failure ARF is a syndrome characterized by rapid decrease in glomerular filtration rate (GFR) and retention of nitrogenous waste products. It may be determined by renal hypoperfusion (prerenal), renal parenchymal diseases (renal) or by acute obstruction (postrenal). Among these, renal parenchymal disease is the most common cause of ARF. US is commonly used in evaluating kidneys in ARF. The primary role of US is to rule out urinary tract Categorical Course 20, Friday (Hall E6)

60 58 42nd Korean Society of Ultrasound in Medicine 2011 Open obstruction. In ARF due to primary renal parenchymal disease, gray-scale US may reveal globular renal enlargement. Renal parenchymal echogenicity is various but is frequently hypoechoic due to edema. The degree of renal corticomedullary differentiation is also various. Renal medulla is often prominent and hypoechoic resulting in increased corticomedullary differentiation. In prerenal ARF, RI of <0.7 is related to complete recovery after fluid restoration, whereas RI of >0.7 indicates a progression towards ischemic ATN and worse prognosis. In renal ARF, RI is usually >0.7. On Doppler US, most patients with prerenal ARF have normal parenchymal flow, whereas patients with ATN reveal higher RI with reduction of parenchymal perfusion. Doppler US is also a useful tool in followup of prerenal and renal ARF during medical treatment and normalization of renal RI frequently advances recovery of renal function. In postrenal ARF, urinary tract obstruction must be bilateral or unilateral in patients with one kidney or with preexisting impaired renal function. US is accurate in detecting hydronephrosis. Renal vasoconstriction is the key factor in the pathophysiological course of acute and chronic obstruction and increased RI result. A mean RI >0.7 and a difference > between the average RIs of two kidneys is considered diagnostic of obstruction. Generally, there should be a rapid return to normal RI if obstruction is relieved within 5 hours, whereas RI may take days or even weeks to return to baseline levels if obstruction is present for at least hours. Chronic renal failure refers to irreversible loss of renal function. Radiologically, it is characterized by bilaterally small kidneys. On US, parenchymal echogenicity may be various depending on the etiology of renal failure but most often is diffusely increased. Renal length does not correlate with renal decreased function, whereas it correlates, as does cortical echogenicity, with severity of pathological changes, such as global sclerosis, focal tubular atrophy and numerous hyaline casts per glomerulus. US follow-up of native scarred kidneys is indicated in patient with CRF treated with dialysis or renal transplantation, since they develop acquired polycystic kidney diseases with a significantly increased risk of solid and cystic malignancies. Transplanted Kidney Renal transplantation has emerged as the most costeffective and patient-supportive way, with 90-95% graft survival rate. The complications can be divided into four categories: renal, vascular, and urologic complications, and fluid collections. The main role of imaging studies is to distinguish vascular and urologic complications from renal complications that require renal biopsy. Owing to its high sensitivity and wide availability, color Doppler US is most commonly used. Imaging of transplant kidney Early complications Early complications are numerous and various, and include ATN, acute rejection, vascular occlusion, obstruction, hemorrhage, urinary leak, collections, cyclosporine toxicity, and infection. Many of these complications can be differentiated on a basis of clinical history, Laboratory and US findings. A differentiation between ATN and AR can be difficult clinically as symptoms are often absent. Since both entities require different approaches, early and accurate diagnosis is essential. Doppler US can be used to differentiate between two entities, but it has been impossible to distinguish these two entities. Eventually, renal biopsy is needed. Acute tubular necrosis (ATN) ATN usually occurs immediately after transplantation, most often within the first 48 hours, and is caused by ischemia of the transplanted kidney. Its causes include prolonged ischemia (cold or warm) and reperfusion injury. ATN is initially present in most cadaveric grafts and resolves spontaneously over the first 2 weeks, depending on the degree of ischemic insult. On US, the kidney may be swollen and have globular shape. Acute rejection The gold standard of diagnosing acute rejection is biopsy. Graft rejection is often classified into five categories according to the onset of the disease: hyperacute, accelerated acute, acute, chronic, and acute superimposed on chronic. Because of difference in

61 treatment, it is essential to differentiate graft rejection from other causes of graft dysfunction. Hyperacute rejection is mediated by humoral antibodies and frequently occurs during surgery or a few hours following transplantation. The affected graft is usually unsalvageable and should be removed immediately by transplant nephrectomy. Accelerated acute rejection is mediated by antibodyand cell-mediated rejection and usually occurs in 2 or 3 days following transplantation. Diagnosis can be made when rejection occurs in the first week of transplantation. Acute rejection is cell-mediated process and characterized by oliguria, rapid increase in serum creatinine, graft swelling, tenderness and fever. It needs to be differentiated from acute pyelonephritis and urine analysis can be helpful to distinguish them. Diagnosis can be made by biopsy. Acute rejection can be divided into interstitial and vascular rejection. Histologically, it is characterized by mononuclear cellular infiltration, tubulitis and vasculitis, and Banff classification is currently used as standard scheme to diagnose acute rejection. Acute rejection usually presents within 1-4 weeks. US findings are as follows. Hyperacute rejection usually occurs in operation room and imaging studies are not necessary. It is characterized by marked reduction or absence of parenchymal perfusion on Doppler US. In acute rejection, gray-scale US may demonstrate swelling of the transplanted kidney, decreased echogenicity of renal cortex and medullary pyramids, diminished echogenicity of the renal sinus, thickening of the wall of renal pelvis and ureter, and decrease in corticomedullary differentiation. On color Doppler US, RI of >0.9 is relatively specific for acute rejection. However, other diseases including renal artery stenosis, renal vein thrombosis, acute severe ureteral obstruction, severe ATN, acute cyclosporine nephrotoxicity, pyelonephrtitis and compression of kidney by perirenal fluid collection may reveal elevated RI. Because the RI is nonspecific, serial changes of the RI are more helpful. The baseline and serial follow-up Doppler studies may improve accuracy in assessing allograft dysfunction. Categorical Course 59 graft normally in association with an abrupt cessation of renal function and urine output. A typical patient would be normally between postoperative days 3 and 8. US findings include enlarged hypoechoic kidney, presence of echogenic material and absence of low within renal vein, high RI with reversed plateau of diastolic flow or no diastolic flow in renal artery on Doppler US. In cases of incomplete renal vein thrombosis, a low-amplitude pulsus parvus and tardus waveform may be shown. Cyclosporin/Tacrolimus nephrotoxicity Cyclosporine has the greatest nephrotoxic potential, with its vasoconstrictive effect on the afferent glomerular arterioles. It usually occurs in 1-3 months following the transplantation. Nephrotoxicity may be divided into acute, subacute, and chronic. Acute and subacute nephrotoxicity can be improved with reduction of dose, while chronic nephrotoxicity is irreversible. Obstruction Early obstruction within the first 3 days following operation is normally due to either ureteric or vesical blood clot. Thereafter obstruction may represent a distal ureteric stenosis or external compression of the ureter. Although hydronephrosis can be easily detected by US, these appearances must always be interpreted in conjunction with biochemical data. It is also important to consider hydronephrosis as a cause of an elevated RI in the early transplant period. Lymphoceles (lymphocysts) Lymphoceles tend to form later, beginning several weeks after surgery. The lymph derives from the transplanted kidney: lymphatics are too small to be anastomosed, and so the abundant drainage from the transplant pours into the retroperitoneal space in the iliac fossa where it is usually absorbed completely. If it collects, it forms an echo-free space close to the kidney. As with hematomas, they usually do not obstruct the collecting system. Late renal complications Categorical Course 20, Friday (Hall E6) Renal vein thrombosis Venous thrombosis is more common than arterial occlusion and causes acute pain and swelling of the Arterial stenosis Renal artery stenosis is the most common vascular complication of transplantation, reported in up to

62 60 42nd Korean Society of Ultrasound in Medicine 2011 Open 10% of patients. Evaluation for renal artery patency should be performed in patients with severe hypertension refractory to medical therapy or with hypertension combined with either an audible bruit or unexplained graft dysfunction. Color Doppler US can be difficult due to the numerous twists and turns of the transplant artery, as the requirement for accurate angle correction for precise spectral Doppler quantification is of paramount importance. In addition it can be difficult to distinguish between a focal stenosis and a tortuous renal artery. Stenoses usually occur at the anastomosis or at the proximal donor artery and are directly related to surgical technique. Doppler criteria for significant stenosis include: (a) velocities of greater than m/sec or focal frequency shift of greater than 7.5 KHz (when a 3-MHz transducer is used), (b) a velocity gradient between stenotic and prestenotic segments of more than 2:1, and (c) marked distal turbulence (spectral broadening). An observation of tardus and parvus waveforms may be helpful in transplanted kidney, but they are variably present. Arteriovenous fistula (AVF) AVF normally occur secondary to renal biopsy, with the incidence of 10%. US findings include a focal pool of color flow containing both arterial and venous components on spectral Doppler analysis. This area can often be differentiated from high flow in other parts of the kidney by increasing the pulse repetition frequency (PRF) to a level that results in nonvisualization of the normal intrarenal vasculature. At this level of PRF, only pathologic flow within the fistula is observed. This maneuver almost in itself is diagnostic. Spectral analysis of the arterial waveform will show increased systolic and diastolic flow within the affected area, and as a result the PI or RI ratio may be normal or reduced in comparison with that of the surrounding vessels. Venous flow can be normal but may also be turbulent in up to one third of cases. A large draining vein may also be visualized. Chronic rejection Chronic rejection is antibody-mediated process. It usually occurs months to years after surgery. Histologically, it is characterized by fibrous intimal thickening with interstitial fibrosis and tubular atrophy. The affected patients may present with progressive azotemia and hypertension. The changes are usually irreversible. Predisposing episodes of acute rejection represent the most consistent predisposing factors. As there is no effective treatment, all efforts are concentrated toward preventing episodes of acute rejection as a method of reducing chronic rejection. US findings include increased transplant echogenicity and reduction in the number of intrarenal vessels. However, the role of US is limited. Long-term complications Recurrent disease in transplanted kidney is more commonly encountered in long-term recipients with DM, amyloidosis and cystinosis. US findings are nonspecific. Increased morbidity and mortality following transplantation are normally due to cardiovascular disease, malignancy, or infection secondary to the immunosuppressive regimen. The most common malignancies following transplantation are skin-related cervical cancer, non-hodgkin lymphoma and renal cell carcinoma. Conclusion In renal parenchymal disease, morphologic and functional evaluations using US do not provide excellent sensitivity and specificity, because different renal parenchymal diseases may demonstrate the same US findings, or the same renal parenchymal disease may give different US findings according to the stage of renal disease and to clinical condition. But, renal parenchymal diseases may demonstrate some characteristic features on US. Doppler US is a useful tool in renal parenchymal diseases and ARF follow-up, during and after treatment. In transplanted kidney, US is the best tool to monitoring the transplanted kidney. US is very good at measuring renal size, detecting dilatation of collecting system, following perinephric collections, assessing arterial and venous occlusions, and in detecting new pathology of transplanted kidney. It is also the best means of guiding transplant biopsies and insertion of nephrostomy catheters. Moreover, it can detect AVF and end-stage features of the failed transplant, usually due to chronic rejection.

63 Categorical Course 61 References 1. Cosgrove DO, Chan KE. Renal transplants: what ultrasound can and cannot do. Ultrasound Q 2008; 24:77-87; quiz Baxter GM. Ultrasound of renal transplantation. Clin Radiol 2001; 56: Barry HM, Jordan ML, Conlin, MJ. Renal Transplantation. In: Wein AJ, et al. ed. Campbell-Walsh Urology. Philadelphia: W.B. Saunders, 2007: Choyke PL, Becker JA, Zeissman, HA. Imaging the transplanted kidney. In: Pollack HM, McClennan BL et al. ed. Clinical Urography. Philadelphia: W.B. Saunders, 2000: Kim SH, Kim BH. Renal Parenchymal Disease. In: Pollack HM, McClennan BL et al. ed. Clinical Urography. Philadelphia: W.B. Saunders, 2000: Kim BH. Renal Parenchymal Disease. In: Kim SH, et al. ed. Radiology illustrated Uroradiology. Philadelphia: W.B. Saunders, 2003: Kim BH. Transplanted kidneys. In: Kim SH, et al. ed. Radiology illustrated Uroradiology. Philadelphia: W.B. Saunders, 2003: Quaia E, Bertolotto M. Renal parenchymal diseases: Is characterization feasible with ultrasound? Eur Radiol 2002; 12: Categorical Course 20, Friday (Hall E6)

64 62 42nd Korean Society of Ultrasound in Medicine 2011 Open CC3 GU-02 Genitourinary 08:50-09:10 Hall E6 Chairperson: Kyoung Sik Cho Asan Medical Center, Korea US Differential Diagnosis of Renal Masses Gervais Wansaicheong Department of Radiology, Tan Tock Seng Hospital, Singapore Ultrasound scans are commonly used in the evaluation of the kidneys. It is considered an appropriate examination in the evaluation of Acute onset flank pain - suspicion of stone disease Acute pyelonephritis if complicated Indeterminate renal mass Renovascular hypertension Renal failure Haematuria CT scans are generally preferred but this may be limited by issues of access and economics. It is not considered suitable for the follow up of renal cell carcinoma, evaluation of recurrent lower urinary tract infections in women or acute trauma. There are many diagnostic algorithms that can be used to characterize renal masses detected on sonography. One useful technique is based on the location of the lesion and typical features. The initial step is to decide if the scan shows abnormal findings. It is important to exclude pseudolesions at this point. Common examples of pseudolesions that can mimic masses include Column of Bertin Renal scarring Renal duplication Dromedary hump Prominent pyramids The next step is to decide the epicenter of the lesion or from where it could have arisen. The kidney may be divided into three areas: outside the kidney, the renal cortex and medulla and the renal pelvis. This is similar to the arbitrary division of the thorax into different compartments. Although not based on histology, the likelihood of a particular diagnosis is greater when dealing in one compartment compared to another compartment. Focal masses outside the kidney may include: Perinephric collection - Anechoic Fluid overload - Hypoechoic Blood from trauma Pus Lymphocoele - Multilocular Cystic lymphangioma Although fluid collections often follow the perirenal fascial planes and have a crescent shape, they may also assume a more oval or round shape when imaged at an oblique angle or are complex in appearance. Focal masses within the renal cortex and medulla may be characterized by their predominant echogencity: Cystic - Simple Solitary - Cyst - Calyceal cyst Multiple - Polycystic kidney - Multicystic dysplastic kidney - Complex

65 Multilocular cystic nephroma Cystic disease in chronic renal disease Xanthogranulomatous pyelonephritis Solid - Diffuse Acute pyelonephritis Lymphoma - Focal Hypoechoic - Focal bacterial nephritis - Lymphoma - Metastases - Transitional cell carcinoma Hyperechoic - Renal stone - Papillary necrosis - Angiomyolipoma - Emphysematous pyelonephritis - Renal cell carcinoma Some of the lesions may have variable appearance e.g. renal cell carcinoma. It has been described as being hyperechoic, hypoechoic and isoechoic to renal parenchyma. This can be confusing. However, one key point to remember is that the diagnosis after ultrasound need not be definitive. It is more important to be appropriate in deciding further management. Focal masses in the region of the renal pelvis include Parapelvic cyst Peripelvic cyst Hydronephrosis After analysis of the sonographic features of a renal mass, there are three main options. The first option is to leave it alone as it is of little clinical significance. A simple cyst would fall into this category. The second option is to continue surveillance of the mass. This could be because it can develop complications or has some indeterminate feature that has a low likelihood of malignancy. A large angiomyolipoma or renal abscess may fall into this category. The third option is to ask for additional evaluation with another imaging modality e.g. CEUS, CT scan or MR scan. This is often done as a prelude to surgical excision or other intervention. References Categorical Course 63 ACR Appropriateness Criteria - Urologic Imaging ( Accessed on 1 May 2011) Diagnostic Imaging - Ultrasound. Ahuja et al. (2007) Categorical Course 20, Friday (Hall E6)

66 64 42nd Korean Society of Ultrasound in Medicine 2011 Open CC3 GU-03 Genitourinary 09:10-09:30 Hall E6 Chairperson: Kyoung Sik Cho Asan Medical Center, Korea US and Biopsy of the Prostate Sung Il Hwang Department of Radiology, Seoul National University Bundang Hospital, Korea The indications of prostate ultrasound are not only to detect prostate disease such as cancer, benign hyperplasia, prostatitis and cause of infertility, but to guide biopsy of prostate and drainage of abscess. Digital rectal exam, level of prostate specific antigen and ultrasound are used for the detection of prostate cancer. Ultrasound guided biopsy of the prostate is performed for patients who have abnormal digital rectal exams, increased PSA level, or abnormal ultrasound imaging of prostate. However, the sensitivity and specificity of ultrasound to detect cancer is not so high, therefore systemic randomized biopsy is the method of choice. Transrectal approach is the most commonly used approach for the evaluation of prostate with ultrasound. Transabdominal and transperineal approach can be used in patients for whom the transrectal approach is not possible. Endorectal ultrasound probe with 6-10 MHz is usually used. The prostate should be imaged at least two planes form the apex to base. Volume is usually estimated by prolate ellipse formula (0.523 X AP X transverse X longitudinal dimeter). Presence of focal mass, change of echogenicity, symmetry, continuity of outer margin should be documented during sonography. Increased focal lesion on color/power Doppler US should be included for the target of biopsy. Periprostatic fatty tissue, intraprostatic urethra, bladder abnormalities are also should be evaluated. For the evaluation of seminal vesicles, size, shape, position, symmetry and echogenicity should be checked. The presence of midline cyst is important especially for the patients who are referred for infertility. Patients may feel uncomfortable or pain during the procedure because the size of the rectal probe and the need for anesthesia is required during biopsy because multiple cores are obtained. Periprostatic nerve block is one of commonly used way of anesthesia. Optimal number of biopsy core remains controversial. However, biopsy protocol with at least more than six cores is usually selected in many hospitals. In conclusion, transrectal ultrasound of prostate is an essential tool used to detect prostate pathology and perform biopsies. Increasing incidence of prostate cancer in Korea and wide use of PSA screening will remarkably raise the need of prostate ultrasonography.

67 Categorical Course 65 CC3 GU-04 Genitourinary 09:30-09:50 Hall E6 Chairperson: Kyoung Sik Cho Asan Medical Center, Korea US of the Testis Paul S. Sidhu Department of Radiology, King s College London, United Kingdom Categorical Course 20, Friday (Hall E6) Ultrasound examination of the testis is well established and retains the lead in imaging of the scrotal contents, superior to MR imaging. Importantly ultrasound retains the position of a relatively in-expensive, readily available and repeatable modality without causing patient harm. Over the years testicular ultrasound has aided the clinician with accurate assessment of the disease process, evaluating progression or regression of pathology and providing reassurance. The advances in high-frequency transducers have allowed even more outstanding resolution of the contents of the scrotal sac, with better definition of all types of pathology. Colour Doppler capabilities allow imaging of vascularity in the smallest of lesions, aiding determination of lesion type. The detection of incidental pathology causes a dilemma for the clinician, with problems for the management. This comprehensive review will detail aspects of testicular ultrasound that are established, highlight areas of clinical uncertainty and discuss future imaging techniques such as elastography and contrast-enhanced ultrasound in the management of testicular disease.

68 66 42nd Korean Society of Ultrasound in Medicine 2011 Open CC4 PHY-01 Physics 08:30-08:50 Hall E1-4 Chairperson: Yangmo Yoo Sogang University, Korea Basic Principles of Ultrasound Imaging Jin Ho Chang Medical Solutions Institute, Sogang Institute of Advanced Technology, Sogang University, Korea Medical ultrasound imaging has firmly established its own territory as a diagnostic tool due to its realtime capability, portability, safety, and functional imaging capability. These features are prominent advantages over other imaging modalities such as magnetic resonance imaging (MRI) and computer tomography (CT), thus making it possible for ultrasound imaging to occupy the position of the second most popular modality in the medical imaging market. However, the ultrasound imaging also has drawbacks: low contrast resolution, non-uniformity of spatial resolution, incapability to image bony structures, and patient-dependent image quality. In fact, the beneficial and adverse features of ultrasound imaging stem from inherent characteristics of ultrasound. The aim of this short course is to introduce the essential nature of ultrasound such as reflection, refraction, diffraction, attenuation, and nonlinearity and what these plays a role in ultrasound imaging. Some examples are also presented to demonstrate how these characteristics affect ultrasound image quality and what we can take advantage of from those in the diagnosis of diseases. In addition, the course provides brief information about pivotal parameters related to the spatial resolution of ultrasound images.

69 Categorical Course 67 CC4 PHY-02 Physics 08:50-09:10 Hall E1-4 Chairperson: Yangmo Yoo Sogang University, Korea Signal and Image Processing Techniques for Medical Ultrasonic Imaging Jong Seob Jeong Medical Biotechnology, College of Life Science and Biotechnology, Dongguk University, Korea Categorical Course 21, Saturday (Hall E1-4) In recent years, the medical ultrasonic signal and image schemes have been significantly developed and thus it can provide clinically useful information. The goal of this presentation is to review fundamentals of signal and imaging processing techniques widely used for current ultrasonic systems. The content of this presentation covers topics array beam formation as well as post-processing for ultrasonic B-mode images. More advanced subjects based on the interaction between transmit and receive data will be presented. Especially, the synthetic aperture technique for high resolution imaging, multi-beam acquisition for fast frame rate, and write-zoom method for high definition image will be also discussed. Subsequently, a harmonic imaging capable of providing improved resolution as well as reduced side-lobe artifacts will be presented. The compound imaging methods to reduce the effects of speckle, along with the basic principles and effects will be dealt with in this presentation.

70 68 42nd Korean Society of Ultrasound in Medicine 2011 Open CC4 PHY-03 Physics 09:10-09:30 Hall E1-4 Chairperson: Yangmo Yoo Sogang University, Korea New Imaging Modes and Algorithms in Medical Ultrasound Imaging Yang Mo Yoo Department of Electronic Engineering and Interdisciplinary Program of Integrated Biotechnology, Sogang University, Korea Since its introduction in the 1950s, ultrasound imaging has become one of the most frequently used medical imaging modalities, accounting for almost 25% of all imaging examinations performed around the world. Ultrasound imaging provides high-resolution real-time anatomical and/or physiological images. Moreover, in the past decades, ultrasound image quality and its diagnostic capabilities have been significantly improved with engineering and technological innovations. In this course, the scientific and engineering principles in some of the recent technological advances such as color Doppler imaging, harmonic imaging and elastography will be reviewed. In addition, some examples will be presented to demonstrate how these new imaging modes and algorithms are clinically utilized.

71 Categorical Course 69 CC4 PHY-04 Physics 09:30-09:50 Hall E1-4 Chairperson: Yangmo Yoo Sogang University, Korea Cancer Treatment with Ultrasound: Technical Trends of HIFU Jong Bum Seo Biomedical Engineering, Yonsei University, Korea Categorical Course 21, Saturday (Hall E1-4) High Intensity Focused Ultrasound (HIFU) is a noninvasive surgical method for cancer treatment. Generally, an externally placed high power transducer is operated to create a focused beam at the target volume. Due to the high selectivity of the focus, localized cell necrosis can be achieved without harm to surrounding tissues. Phased array transducer systems provide fast and accurate electronic scanning of focus and multi-foci, so that HIFU becomes more applicable in clinical use. HIFU only can utilize thermal effect according to FDA regulation, hence MR based temperature measurement is widely used as a monitoring means. With the development of advanced focusing algorithm and monitoring means, complete noninvasive surgery is expected to be implemented in the near future.

72 70 42nd Korean Society of Ultrasound in Medicine 2011 Open CC5 BR-01 Breast 08:30-08:50 Hall E5 Chairperson: Eun-Kyung Kim Severance Hospital Yonsei University, Korea Breast US: Equipment and Techniques Seung Ja Kim Department of Radiology, Seoul National University Boramae Medical Center, Korea I. Equipment II. Scanning Techniques and Recording 1. Transducer and Acoustic Standoff For high quality breast ultrasound (US), a linear array transducer with center frequency of 7 MHz or higher is minimum requirement. On occasion, a lower frequency transducer may be advantageous, when breast size and thickness greatly exceed 3 cm (lactating breast, mastitis or inflammatory carcinoma, large silicone implants with capsular contracture, and severe macromastia). If the lesion is superficial and the focal zones cannot be moved electronically, a standoff pad (about 7 mm thick) should be used. 2. Time-gain Compensation, Gain and Focal Zones Deeper structures produce weaker echoes and echo intensity decreases due to the attenuation. The timegain compensation (TGC) process compensates the echo intensities from equally refractive structures to be the same regardless of depth. In the breast, the echogenicity of normal breast fat is the standard against all other normal anatomic tissues and pathologic lesions. Therefore, it is important to set up the time-gain curve so that fat appears to be mildly gray and the fat at all depths of the breast to be of the same echogenicity. In addition, we should adjust gain settings to allow simple cysts to be distinguished from solid masses. Proper placement of focal zones is critical to optimal image quality. The mass is better seen when the focal zones are placed at the level of the mass. 1. Patient Positioning The patient is scanned in contralateral posterior oblique positioning with the ipsilateral arm above her head. When the area of interest is located medially, supine positioning is usually best. This positioning thins the breast and pulls the tissue plane into a horizontal orientation and minimizes the image degradation and shadowing. The sitting position is a helpful adjunct for locating and selectively scanning a lesion that is palpable only when the patient is in an upright position. 2. Compression A variable degree of compression further thins the breast tissue and also tends to force normal breast tissues into a plane parallel to the transducer surface, improving penetration and image quality. Cooper s ligament creates an acoustic shadowing, preventing evaluation of deeper structures and simulates shadowing caused by the desmoplastic reaction associated with invasive malignancy. Moderate compression with the transducer and changing the angle of the incidence beam can push such a Cooper s ligament into a plane that lies parallel to the transducer surface and eradicates the acoustic shadowing it causes. The ductal system within the nipple and subareolar area is difficult to demonstrate by acoustic shadowing. One way to improve visualization of the nippleareolar complex is to compress only the peripheral end of the transducer and push the nipple to the other side, bringing the transducer nearly parallel with the subareolar duct. The compressibility of a lesion can be used in the differential diagnosis of lesions. Glandular tissue and

73 fat are easily deformed, whereas tumors have a firmer consistency and show little or no compressibility. 3. Scanning Planes Because the breast contains few anatomic landmarks, it is necessary to employ a systemic pattern of transducer movement. The scans should be obtained in at least two orthogonal planes and overlapped to achieve complete coverage and ensure that small lesions are detected. Longitudinal and transverse scan planes may be sufficient for a generalized search of the breast. However, for whole breast US survey of the breast, scanning in an antiradial fashion from peripheral to central is efficient. In addition, scanning the breast along normal anatomic-lobar planes improves understanding of the site of lesion origin and helps narrow the differential diagnosis. Therefore, when pathology is identified during surveying in longitudinal and transverse scan planes, the scan should be adjusted to radial and antiradial planes. Radial scanning is needed to evaluate patients with nipple discharge. 4. Larger Field of View (FOV) In several circumstances, split-screen imaging can be important in the breast; compare mirror image locations, document dynamic events, and lesion of interest is wider than the transducer. A low-frequency curved linear transducer can be used in demonstrating large or too deep lesions. Another way to expand the FOV is to phase the beam on either end, creating a trapezoidal shaped beam. Certain equipment has adopted panoramic imaging (extended FOV). 5. Image Documentation Before every examination, the name, identification number, birth date of the patient and examination date should be entered. A brief and reproducible method of reporting lesions is important. There are several descriptors; the side (right or left), a clock face location, the distance from the nipple, the depth of the lesion and a scan plane orientation. The method for describing the sonographic location is important for two reasons. First, it is highly reproducible and enables us to find a lesion again easily. Second, it represents a cryptic, easy-to-type, shorthand method for annotating a lesion location while scanning the Categorical Course 71 patient. A lesion being studied should be viewed in at least two perpendicular projections and the maximal dimensions of a mass should be recorded. Images of the mass with and without measuring calipers may also be taken. When scanning a patient with palpable abnormality, the operator can ensure that the palpable finding is scanned by placing the finger or paper clips on the mass. III. Other Techniques 1. Tissue Harmonic Imaging Tissue harmonic imaging is generated by imaging with two pulses of opposite polarity. Two pulses with inverted phases are emitted, and when the echoes from each of these two pulses are added, the fundamental components of each pulse are canceled out and the harmonic components are amplified, resulting in an improvement in contrast resolution. This technique has been shown to greatly improve image quality and, especially, make solid nodules appear more hypoechoic and fat appear relatively echogenic, which helps to define solid nodules. Also, it helps distinguish artificial internal echoes within cysts from real internal echoes. With harmonics, because of marked reduction in speckle artifact, calcifications may be more apparent sonographically. There are some limitations to the use of harmonics; reduced penetration, reduction in frame rate, and less noticeable benefit in the near field. 2. Spatial Compound Imaging While the conventional image is constructed with a single sweep of the beam, the spatial compound image is constructed with multiple sweeps of the beam with steering. From averaging multiple images with different angles of incidence, the images build up real echoes and average out artifactual echoes. The fibrous pseudocapsule around benign lesions, normal Cooper s ligaments and malignant spiculations are shown better with compound imaging that with conventional imaging. The posterior enhancement deep to cystic lesions is less pronounced and acoustic shadowing deep to desmoplastic carcinomas is decreased. Much like harmonic imaging, it is a method of reducing speckle artifact. Categorical Course 21, Saturday (Hall E5)

74 72 42nd Korean Society of Ultrasound in Medicine 2011 Open Limitations of compounding include a potential decrease in frame rate and sensitivity to motion artifact. 3. Doppler Blood vessels in the breast can be visualized by Doppler ultrasound. High sensitivity for low amplitude and low signal flow detection requires Doppler frequencies above 5 MHz. Power Doppler is more sensitive to low levels of flow than color Doppler and is also less angle dependent than color Doppler. However, it cannot show direction of flow and cannot distinguish between arterial and venous flow without pulsed Doppler spectral analysis. Care should be taken not to apply pressure with the probe as this obliterates the small, low-pressure vessels associated with breast lesions. It was hoped that color Doppler and power Doppler imaging would distinguish cancer from benign breast lesions by showing increased blood flow in breast malignancies. However, they do not always detect increased flow in breast cancer, and there is overlap between benign and malignant blood flow patterns. Other applications of Doppler ultrasound in the breast are to depict the locations of blood vessels when planning breast biopsy needle trajectories, to find a blood vessel in an intracystic mass or a benign looking nodule, to distinguish fat necrosis and scar from recurrent tumor, and to demonstrate inflammatory hyperemia. 4. Three-dimensional Imaging In three-dimensional imaging, a block of tissue volume can be stored with a single sweep of the ultrasound beam across the region of the interest. This allows the entire surface of the mass to be evaluated with dynamic and multi-sectional capabilities. Recent studies have shown that breast cancers show the discontinuous hyperechoic rim and spiculated margin on coronal images. Moreover, real-time three-dimensional (four-dimensional) ultrasound can improve depiction and understanding of the geometric relationship of needle and lesion during ultrasound-guided interventions. The use of contrast agents combined with threedimensional ultrasound has been proposed as a means of increasing the ability of detecting small increases in vascular density. 5. Elastography It is known that breast cancers tend to be harder than benign breast masses, but the difference is subjective and often difficult to assess. Elastography is a method of imaging the hardness of soft tissue. Elastograms are created by comparing ultrasound echo data obtained before and after a slight compression of the tissue. The results are displayed as an image on which hard areas appear dark and soft areas appear bright. The cancers are statistically darker than fibroadenomas and substantially larger on the elastogram than on the sonogram. Elastography may be used to detect iso-echoic breast cancers. 6. Automated Breast US (ABUS) ABUS systems have been proposed as suitable for screening for breast cancer and the current ABUS units, which are equipped with high-frequency broadband transducers, have the advantages of reproducibility, utility (in terms of surveying large areas of the breast), and reduced operator dependence compared to hand-held US (HHUS) devices. Indeed, several studies have concluded that the performances of ABUS and HHUS are equivalent. 7. Volume Navigation US or Real time Virtual Sonography The Fusion tool gives us the remarkable ability to merge real-time ultrasound with previously acquired CT, MR or ultrasound images. Now we can directly compare lesions while taking advantage of the strengths of each imaging modality, easily and with proven accuracy. We can virtually scan the reference volume to match the live image, making a comparison either side by side or by overlaying the images. This tool not only helps in diagnosis, but also in monitoring of interventional procedures.

75 Categorical Course 73 CC5 BR-02 Breast 08:50-09:10 Hall E5 Chairperson: Eun-Kyung Kim Severance Hospital Yonsei University, Korea BIRADS in Interpretation of Breast US Bong Joo Kang Department of Radiology, Seoul saint Mary s Hospital, Korea Categorical Course 21, Saturday (Hall E5) The fourth edition of the BIRADS mammography appeared in 2003 and is now associated with the first editions of the BIRADS ultrasound and MRI. BIRADS is a system of assistance to the drafting of the reports more and more used in the world and soon directly implemented on mammography and ultrasound units. The categories of evaluation of the BIRADS allow a clear synthesis of the descriptive data resulting from the use of the lexicon and invite the radiologist to a reasoned, objective and less intuitive step. They give an action to be taken and responsibility to the radiologist and the referring physicians in the assumption of the patients. homogeneously fatty or fibroglandular, or heterogeneous. It can influence lesion detection sensitivity and should be noted. A fatty echo pattern generates a weak ultrasound contrast and can reduce sensitivity, while a heterogeneous echo pattern can be the cause of false positives. A homogenous fibroglandular echopattern is theoretically an ideal environment for the detection of 1. Role of breast US Increase the specificity of mammography Reveal occult breast cancer in patients with dense breasts Identify non-calcified DCIS, invasive component of DCIS Visualize large (>10-mm) clusters of microcalcifications with a high suspicion for malignancy allow the use of US to guide interventional procedures US can be used to evaluate patients with nipple discharge when ductography is not possible or indeterminate. Limitation of Breast US Highly operator dependent Small FOV Insensitivity to detect microcalcifications, DCIS Overdiagnosis, high false positive rate Cost of the subsequent diagnostic procedures 2. Breast imaging lexicon The background echo pattern of the breast can be

76 74 42nd Korean Society of Ultrasound in Medicine 2011 Open abnormalities. 3. Final assessment category 1) BI-RADS category 0: evaluation is incomplete - further imaging examinations are required. Ex1) when ultrasound is the first exploration Ex2) there is a need for comparison with previous exams, or a need for a mammogram. 2) BI-RADS category 1: Negative examination: normal ultrasound 3) BI-RADS category 2: Benign findings Ex) simple cysts, typical intramammary lymph nodes, implants, stable post-surgical changes, stable possible or biopsy-proven fibroadenomas, well defined fatty lobules in dense echogenic breast tissue 4) BI-RADS category 3: Probably benign lesions (>98%) - short term follow-up is recommended Ex) solid masses with circumscribed margin, oval or gently lobulated shape, parallel orientation (probable fibroadenoma), non-palpable complicated cysts, clustered microcysts. 5) BI-RADS category 4: Suspicious abnormality - Biopsy should be considered 4a - low suspicious (3-10%) 4b - intermediate suspicious (11-50%) 4c - moderate suspicious (51-94%) 6) BI-RADS category 5: Highly suspicious of malignancy - Appropriate action should be taken; almost certainly malignant (> 95%) 7) BI-RADS category 6: Known biopsy-proven malignancy - Appropriate action should be taken (Prior to definite therapies such as surgical excision, RTx, CTx, mastectomy) 3) Type and order of different examinations. 4) Comparison with previous examinations. 5) Correlation with signs, whether clinical, or from mammograms or MRI. 6) Final global evaluation in the BIRADS lexicon for ultrasound categories ) Recommendations as to the course of action to be taken 6. Categorization of the suspicious malignant lesion (Stavros AT). The 10 sonographic features that are suspicious for breast cancer, like sonographic features in other organ systems, can validly be placed into three categoriessurface characteristics, shapes, and internal characteristics (Table 1). The suspicious sonographic features can also be categorized differently. They can be thought of as hard findings that suggest the presence of invasion (Table 2). The soft findings tend to represent in situ (ductal carcinoma in situ[dcis]) components of the lesion. The mixed findings can represent either invasive or DCIS components of the tumor. - BI-RADS 4, 5 category subcategorization (Stavros AT). (1) 1-2 finding, both soft -> C4A 4. Reporting system: The ultrasound report consists in 1) Clinical history and examination information. 2) Analysis of the lesion(s) and sign(s) (shape, margin, orientation, echo pattern) with dimensions and localization. The measure of the dimensions is done in two or three axis. The position and the depth of the lesion have to be defined. The location is determined using a clock face system, indicating right or left side, the anatomical position (quadrant, subareolar, central, axillary), distance from the nipple and depth in relation to the skin.

77 Categorical Course 75 (2) 3-4 finding, one hard -> C4B (3) >5 finding, one more hard->5 References 1. Feig FA. Categorical course in diagnostic radiology: breast imaging. RSNA education. 2005; Bassett LW, Jackson VP, Fu KL, Fu YS. Diagnosis of disease of the breast Elsevier Saunders Feig SA. Categorical course in diagnostic radiology: Breast imaging. RSNA education Mendelson EB. The breast. In: Rumack CM, Wilson SR, Charboneau JW, eds. Diagnostic ultrasound. 2nd ed. St Louis, Mo: Mosby, 1998; Jackson VP. The role of US in breast imaging. Radiology 1990;177: American College of Radiology. Practice guideline for the performance of the breast ultrasound examination. Reston, Va: American College of Radiology, 2002; American College of Radiology. BI-RADS-US. In: ACR BI- RADS Breast Imaging Reporting and Data System breast imaging atlas. Reston, Va: American College of Radiology, Kremkau FW. Diagnostic ultrasound: principles and instruments. Philadelphia, Pa: Saunders, 1998; Kwak JY, Kim EK, You JK, Oh KK. Variable breast conditions: comparison of conventional and real-time compound ultrasonography. J Ultrasound Med 2004;23(1): Stavros AT, Thickman D, Rapp CL, Dennis MA, Parker SH, Sisney GA. Solid breast nodules: use of sonography to distinguish between benign and malignant lesions. Radiology 1995;196(1): Rosen PP. Rosen s breast pathology. 2nd ed. Philadelphia, Pa: Lippincott Williams &Wilkins, 2001; Heywang-Kobrunner SH, Schreer I, Dershaw DD. Diagnostic breast imaging. New York: Thieme Inc Levy L, Suissa M, Chiche JF, Teman G, Martin B.BIRADS ultrasonography. European Journal of Radiology 61 (2007) Raza S, Goldkamp AL, Chikarmane SA, Birdwell RL. US of Breast Masses Categorized as BI-RADS 3, 4, and 5: Pictorial Review of Factors Influencing Clinical Managemen. Radiographics 2010; 30: Categorical Course 21, Saturday (Hall E5)

78 76 42nd Korean Society of Ultrasound in Medicine 2011 Open CC5 BR-03 Breast 09:10-09:30 Hall E5 Chairperson: Eun-Kyung Kim Severance Hospital Yonsei University, Korea Mammographic-Ultrasound Correlation Llewellyn Sim Department of Diagnostic Radiology, Singapore General Hospital, Singapore This lecture serves to review the roles, limitations, principles and technique, image interpretation and clinical application of mammographic-ultrasound correlation in assessment of breast lesions. The following areas will be covered: A. Roles-explain the primary and secondary roles of breast ultrasound B. Limitations-highlight the pitfalls of breast ultrasound C. Principles and Technique-explain how mammographic-ultrasound correlation is used to assess breast lesions D. Image interpretation-describe mammographic and sonographic features of benign and malignant breast lesions E. Clinical application-review of mammographic and ultrasound correlated case studies with histopathology

79 Categorical Course 77 CC5 BR-04 Breast 09:30-09:50 Hall E5 Chairperson: Eun-Kyung Kim Severance Hospital Yonsei University, Korea Ultrasound(US)-guided Procedures Young Mi Park Department of Radiology, Busan Paik Hospital Inje University, Korea Categorical Course 21, Saturday (Hall E5) Percutanous image-guided breast biopsy has been developed largely to solve the diagnostic problem of increasing numbers of breast lesions found through breast examination. Most importantly, core needle biopsy (CNB) has proved to be an acceptable alternative to surgical biopsy. Compared to surgical biopsy, it is a short procedure that does not deform the breast, is associated with minimal residual skin scarring, and importantly, no residual mammographic scarring. Ultrasound (US) is the preferred first-line mode for image-guided breast biopsy. It is well accepted, quick, readily accessible, and less costly than other localization techniques without the need for ionizing radiation. The success of a breast biopsy program depends on both the performance of the procedure and the postbiopsy management. The lecture reviews the current procedures for performing US-guided breast biopsy together with the different types of breast biopsy devices currently available, and post-biopsy management including current controversial issues. Current Procedures Current US-guided procedures include fine needle aspiration biopsy (FNA), and large core needle biopsy (CNB), and localization with skin marking, wire, or charcot. Operators should choice the type and devices of biopsy for specific lesion type. US-guided localization is performed for the nonpalpable lesion that requires surgery. 1. US-guided FNA FNA is the most basic and inexpensive form of sampling using G disposable needles. It is a simple technique, well tolerated by patients, and can be done in almost any setting, with or without image guidance. But, there is a variable frequency of insufficient samples for FNA ranging from 8.5 to 46%. As a result, FNA is no longer recommended as a routine technique for breast diagnosis. Its best application is in differentiating between cystic and solid lesions. It is currently the technique of choice for sampling axillary lymph nodes because of the risks of using core biopsy in the axilla. However, core biopsy of the axilla is now advocated by some centers. FNA of symptomatic simple cysts is commonly performed and the aspirate is discarded if there are no atypical features on imaging or evidence of blood staining of the aspirate. Aspiration of abscesses is more effective using a larger bore needle. 2. US-guided CNB Image-guided CNB of the breast has been widely used following the publication by Parker et al. in Compared to FNA, CNB is performed to characterize the lesion histologically and to obtain information that is important in planning overall oncological management. This includes histological type and grade, basal subtype, hormone and HER2 receptor status, and genetic profiling. Current CNB devices include the (semi)automated large-core (ALC) spring-loaded, and vacuum-assisted (VAD) devices. When using an ALC device, a 14-gauge needle is generally chosen. Although it has been shown that diagnostic accuracy increases significantly with increasing needle size, in everyday practice 14 G needles generally give excellent results. Little preparation is needed for an US-guided biopsy. Once the lesion is identified, the overlying skin is marked, cleansed, and anesthetized. The needle entry site should be adjusted according to the depth of the lesion to enter the lesion without the possibility of pneumothorax. The needle is usually inserted 1 to 2

80 78 42nd Korean Society of Ultrasound in Medicine 2011 Open cm proximal to the edge of the transducer and perpendicular to the plane of the ultrasound beam. The needle tip is advanced to the margin of the lesion, and then fired. Prefire and postfire images documenting the needle traversing the lesion are obtained. Before firing the device, the operator should scan distal to the lesion to the expected postfire position of the needle tip to be certain that no complications will occur. Nowadays, many breast imagers use a coaxial system in which an introducer is inserted proximal to the lesion, and the ALC needle is placed through the introducer to take the biopsy. The introducer is left in place when the ALC needle is removed to place a specimen in the specimen container. Multiple tissue specimens can be obtained, in a way of re-insertion of needle through the introducer. The optimal number of specimens necessary to achieve a reliable histological diagnosis has been debated. For US-visible masses, some reports suggest that greatest accuracy is achieved with three core biopsy specimens. The success rate is largely dependent on the type of lesion being sampled and there will be variability between cases and operators. Specimen radiography is essential to demonstrate the removal of representative calcifications from suspicious microcalcification clusters. A VAD also can be used to perform US-guided CNB. VAD needles range from 14- to 7-gauge. VAD enables multiple samples to be taken by rotating the shaft of the needle after a single insertion. It allows removal of the lesion in a piecemeal fashion through a 2-3 mm skin incision. Relative to CNB, VAD provides larger specimens, offers a higher calcification retrieval rate, is less sensitive to targeting errors ( %), and has lower re-biopsy and underestimation rates (0-36%). In practice, VAD is most commonly used for diagnostic sampling of microcalcification, but can be also used for sampling soft-tissue abnormalities and in cases of equivocal benign ALC biopsy results or in cases of imaging-histology discordance to re-biopsy for a definitive diagnosis as the large volume tissue samples allow the same diagnostic accuracy as open surgery. It also has a role in therapeutic excision of some breast lesions, such as fibroadenomas and papillomas, and can be used for drainage of large complex breast abscesses. Recent studies have suggested that using 11 or 8 G VAD allows complete removal of benign breast lesions, obviating the need for surgical excision. The reported recurrence rates for these lesions after percutaneous excision is 15%. Of note, all of the fibroadenomas that demonstrated recurrence were more than 2 cm at presentation. At the end of the vacuum assisted biopsy (VAB) procedure, a localizing clip can be placed to mark the biopsy site. This is particularly useful for small lesions and microcalcification clusters that have been completely removed at the percutaneous biopsy. Scar formation on subsequent mammograms has been reported in VAB, with rates between 2 and 10.5%, depending on the number of cores excised. The main risks associated with breast biopsy are bleeding and hematoma formation, post-procedure pain or discomfort. Anticoagulants are a relative contraindication and patients are advised to stop them before biopsy is undertaken if this is clinically possible. Post-biopsy Management A successful imaging-guided CNB program requires a strong working relationship between the radiologist and pathologist. All women with breast abnormalities are assessed using the triple diagnostic method. An excisional biopsy should be performed if there is any discordance between clinical, imaging, or pathology findings. Concordant malignant cases are referred to a surgeon for definitive treatment. Concordant benign cases are placed in a follow-up imaging protocol, because CNB has a 2% false-negative rate. But, discordant benign lesion (it reveals suspicious findings radiologically, but pathologic result is benign) should be referred to a surgeon for re-biopsy (surgical biopsy) after careful analysis. In case of discordant malignancy, it should be referred to a surgeon without any delay, and radiologists have to analyze the imaging findings thoroughly whether the important suspicious finding may be overlooked. False-negative rates for ultrasound-guided CB range from 0 to 9%, which is not higher than that of excisional biopsy (range 0-8%). The most common cause of false-negative results is inaccurate tissue sampling. This is dependent on the lesion position, size, mobility, and type; the size and density of the breast; operator experience; and patient compliance. For benign concordant biopsy results, imaging follow-up is recommended to avoid delay in diagnosis of a possible

81 false-negative CNB. The follow-up imaging modality should be the one that best demonstrates the lesion. For most benign concordant CNB results, a 6-month follow-up is recommended. One-year follow-up is an alternative interval for definite benign results, e.g., imaging indicated typical fibroadenoma, and pathology showed fibroadenoma. In a recent research by Salkowski et al., they found that a 6-month interval imaging examination following a benign concordant biopsy finding did not result in any cancers detected and recommended rebiopsy rates resulting from a 6- month interval imaging study were not significantly different from those with initial follow-up imaging at 12 months. These results suggest that yearly follow-up may be more appropriate. In addition to cost savings, eliminating the 6-month follow-up examination may decrease patient anxiety and unnecessary radiation exposure. In addition, several high risk benign pathology findings have been shown to coexist with carcinoma, and a cancer might be missed because of sampling error. They also require excisional biopsy. Atypical ductal hyperplasia (ADH), lobular neoplasia, radial scar, papillary lesions, and columnar cell lesions are included in this entity. 1. ADH ADH is a proven high-risk lesion with potential for CNB underestimation of disease. ADH shows features that lie midway between usual ductal hyperplasia and ductal carcinoma in situ (DCIS). There are several reasons surgical excision should be performed after a CNB diagnosis of ADH. First, distinguishing advanced ADH from low-grade DCIS can be difficult for the most experienced pathologists. Secondly, DCIS may lie at the periphery of ADH. Therefore, there is consensus that ADH on CNB mandates excisional biopsy. 2. Lobular neoplasia Lobular neoplasia is a spectrum of lesions including lobular carcinoma in situ (LCIS), atypical lobular hyperplasia (ALH), and ductal involvement with cells of ALH. Traditionally, lobular neoplasia is not a direct precursor of malignancy but rather is a marker that identifies women who have an increased risk of developing breast cancer in the future (a three times greater risk for ADH and a ten times greater risk for Categorical Course 79 LCIS); the increased risk is equal for either breast and at any location. Thus, it would be reasonable to recommend excisional biopsy after a CNB with lobular neoplasia. A recent retrospective study by Page and colleagues found that the distribution of cancers that developed after a CNB showing lobular neoplasia was not bilaterally equal. If lobular neoplasia was diagnosed on biopsy, subsequent cancers were three times more likely to develop in the ipsilateral breast. This report suggests that lobular neoplasia is intermediate between a local precursor and a generalized risk factor for breast cancer. 3. Radial scar Radial scar increases the risk of developing breast cancer, and the risk increases with a larger size of the radial scar. Some experts recommend excisional biopsy for all radial scars diagnosed on CNB. According to Brenner et al, multi-institutional study of 157 cases of radial scar diagnosed at CNB found carcinoma in 8% at excision. This percentage increased to 28% if the radial scar was associated with atypia (ADH, ALH, LCIS) and fell to 4% if there was no atypia. Coexisting malignancy was missed in 9% of lesions biopsied with an ALC device but in none of those biopsied with a VAD. The rate of missed cancer fell from 8% to zero when 12 or more specimens were obtained. Thus, diagnosis of benign radial scar by CNB was reliable when there was no atypia and at least 12 VAB specimens. But, Linda et al. reported in a recent article that a percutaneous diagnosis of a radial scar does not exclude associated malignancy at surgical excision. According to the article, mammographic and sonographic features of a lesion diagnosed as a radial scar at percutaneous imaging-guided biopsy do not predict which lesions will have associated malignancy at surgery. Therefore, this report suggests that all patients with percutaneous diagnosis of a radial scar should undergo surgical excision regardless of mammographic and sonographic appearances, until further criteria can be determined. 4. Papillary lesions Papillary lesions include solitary, large central duct papillomas and multiple peripheral papillomas. There are concerns when papillary lesions are diagnosed on CNB. First, there is difficulty in differentiating atypical from malignant papillary lesions on limited, frag- Categorical Course 21, Saturday (Hall E5)

82 80 42nd Korean Society of Ultrasound in Medicine 2011 Open mented material. Secondly, it is uncertain if the CNB specimens represent the most worrisome areas of the papilloma. In a recent article by Youk et al., atypical papilloma diagnosed by US-guided ALC biopsy showed a high upgrade rate after surgical excision (7/30 cases, 23.3%). The authors suggest that atypical papilloma should be excised surgically in any case. In another report written by the same research team, they evaluated the diagnostic accuracy of US-guided 14-gauge ALC biopsy for 160 benign papillomas without atypia and whether clinical and radiologic features could be used to predict an upgrade to malignancy. The rate of upgrade to malignancy after surgical excision was 5.0%. They concluded that imagingpathologic discordance after CNB, as well as patient age of 50 years or older, lesion size of 1 cm or greater, and distance from nipple to lesion of 3 cm or greater, resulted in a significantly increased likelihood of malignancy, which may be helpful in predicting the possibility of upgrade to malignancy. In a prospective study, Chang and colleagues reported on 73 benign papillomas and 12 atypical papillomas diagnosed by US-guided 11-gauge VAB, all of which had surgical excision. Surgical excision revealed the presence of benign papillomas in 34 cases, no residual lesion in 15 cases, atypical papillomas in nine cases, and DCIS in two cases. The upgrade rate was 0% (0 of 49) for benign papillomas and 18.2% (2 of 11) for atypical papillomas. The authors concluded that surgical excision may not be required for lesions with a diagnosis of benign papilloma after US-guided 11-gauge VAB, and a diagnosis of atypical papilloma should prompt excision for a definitive diagnosis. In summary, atypical papillary lesions diagnosed at CNB require surgical excision because the frequency of histologic underestimation is similar to that in other atypical lesions. 5. Columnar cell lesions Columnar cell lesions can be placed into two categories: columnar cell change and columnar cell hyperplasia. Calcifications are reported to be present in 75% of columnar cell lesions. CNB of a columnar cell lesion with atypia shows DCIS or invasive cancer at excisional biopsy in up to 30% of cases. The cancer risk associated with columnar cell lesions that do not fulfill the criteria for ADH or DCIS is unknown and requires follow-up studies. Based on current literature, excisional biopsy should be performed if CNB demonstrates a columnar cell lesion with atypia. Summary US-guided breast biopsy for suspicious imaging findings is the preferred method and the most reliable alternative to surgical biopsy in women who require breast biopsy. US-guided CNB is best for most soft-tissue lesions and FNA plays a role in assessment of some US-visible abnormalities and in assessment of the axilla. The accuracy of diagnosis of breast lesions depends on the correlation of clinical findings, imaging features of a breast lesion, and the results of sampling. References 1. Bassett LW, Mahoney MC, Apple SK. Interventional breast Imaging: current procedures and assessing for concordance with pathology. Radiol Clinics of North America 2007;45: O Flynn EA, Wilson AR, Michell MJ. Image-guided breast biopsy: state-of-the-art. Clin Radiol. 2010;65(4): Sauer G, Deissler H, Strunz K, et al. Ultrasound guided large core needle biopsy of breast lesions: analysis of 962 cases to determine the number of samples for reliable tumour classification. Br J Cancer 2005;92: Kim MJ, Kim EK, Lee JY, et al. Breast lesions with imaging-histologic discordance during US-guided 14G automated core biopsy: can the directional vacuum-assisted removal replace the surgical excision? Initial findings. Eur Radiol 2007;17: Grady I, Gorsuch H, Wilburn-Bailey S. Long-term outcome of benign fibroadenomas treated by ultrasound-guided percutaneous excision. Breast J 2008;14: Bonaventure T, Cormier B, Lebas P, et al. Benign papilloma: is US-guided vacuum-assisted breast biopsy an alternative to surgical biopsy? J Radiol 2007;88: Yazici B, Sever AR, Mills P, et al. Scar formation after stereotactic vacuum-assisted core biopsy of benign breast lesions. Clin Radiol 2006;61: Zagouri F, Sergentanis TN, Kouloucheri D, et al. Vacuumassisted breast biopsy: more cores, more scars? Clin Radiol 2008;63: Salkowski LR, Fowler AM, Burnside ES, Sisney GA. Utility of 6-month follow-up imaging after a concordant benign breast biopsy result. Radiology 2011;258(2): Page DL, Schuyler PA, Dupont WD, et al: Atypical lobular hyperplasia as a unilateral predictor of breast cancer risk: a retrospective cohort study. Lancet ;361(5): Brenner R.J., Jackman R.J., Parker S.H., et al: Percutaneous core needle biopsy of radial scars of the breast: when is excision necessary? AJR Am J Roentgenol ;179(5): Linda A, Zuiani C, Furlan A, et al. Radial scars without

83 Categorical Course 81 atypia diagnosed at imaging-guided needle biopsy: how often is associated malignancy found at subsequent surgical excision, and do mammography and sonography predict which lesions are malignant? AJR Am J Roentgenol 2010; 194(4): Youk JH, Kim EK, Kwak JY, Son EJ. Atypical papilloma diagnosed by sonographically guided 14-gauge core needle biopsy of breast mass. AJR Am J Roentgenol 2010;194(5): Youk JH, Kim EK, Kwak JY, Son EJ, Park BW, Kim SI. Benign papilloma without atypia diagnosed at US-guided 14-gauge core-needle biopsy: clinical and US features predictive of upgrade to malignancy. Radiology 2011;258(1): Chang JM, Han W, Moon WK, et al. Papillary lesions initially diagnosed at ultrasound-guided vacuum-assisted breast biopsy: rate of malignancy based on subsequent surgical excision. Ann Surg Oncol 2011 Mar 3. [Epub ahead of print] Categorical Course 21, Saturday (Hall E5)

84 82 42nd Korean Society of Ultrasound in Medicine 2011 Open CC6 MS-01 Musculoskeletal 08:30-08:50 Hall E6 Chairperson(s): Kyung Nam Ryu Kyung Hee University Medical Center, Korea Kil-Ho Cho Yeungnam University Medical Center, Korea Ultrasound of the Shoulder: Anatomy Kil-Ho Cho Department of Radiology, Yeungnam University Hospital, Daegu, Korea The rotator cuff (RC) is an integral component in the normal movement and function of the shoulder joint. Understanding the cross-sectional anatomy is basic for real-time evaluation of the shoulder with using inherent dynamic capability of ultrasound. Anatomy The RC consists of four tendons of the supraspinatus, infraspinatus, and teres minor muscles that are inserting at the greater tubercle of the humerus in order from above, and subscapularis which inserts at the lesser tubercle. The long tendon of the biceps brachii muscle, although it is not included in RC, is an important landmark in shoulder sonography. In addition, the acromion, the coracoid process, and greater tubercle are bone landmarks in shoulder ultrasound. 1. Anterior: Long biceps and Subscapularis tendons 2. Superior: A-C joint, Supraspinatus tendon and Subdeltoid bursa 3. Posterior: Infraspinatus tendon, Posterosuperior labrum, Gleno-humeral joint, and Spinoglenoid groove 4. Surface of the humeral head Routine Examination The examination is performed usually with a linear array high-frequency (> 10 MHz) transducer. The patient is scanned at least two orthogonal planes, whenever possible, for analysis of the pathologies in 3-dimension. Anterior Aspect At first, the dorsal side of the patient s arm is resting comfortably in his (or her) lap. This is called neutral position of the arm. Examination begins in the anterior aspect of the shoulder by up-and-down movement of the transducer which is placed in the transverse plane. The long biceps tendon contained in the inter-tubercular (or bicipital) groove is visualized as an echoic circle or ellipse (this is the short-axis view of the tendon). The transducer is then turned 90 to examine the tendon in the long-axis view, which appears as an echoic fibrillar band. Again, the transducer is turned 90 in transverse orientation, and is moved upward to the proximal end of the bicipital groove. In this position, examiner evaluates the subscapularis (SUB) tendon, with the patient s arm rotating maximum internally and externally in keeping palm up state. With this maneuver, potential medial dislocation of the biceps long head tendon is also evaluated. Superior Aspect To watch the supraspinatus (SS), transducer is placed in coronal plane superior to the acromio-clavicular joint. Next, the transducer is moved laterally along the bone surface of the acromion. The SS tendon appears as a bird-beak shape inserting onto the superior facet of the greater tubercle of the humeral head. A bright linear echo between the SS tendon and deltoid muscles represents of the subdeltoid bursa and interposed fat. In the neutral position of the arm, much of the SS tendon is hidden beneath the acromion. To correct this, the patient is asked to place the back of his or her hand behind the buttock and to keep the elbow close to the body. This position (with the patient s shoulder in hyperextension and internal rotation) allows the SS tendon to move anteriorly from under-

85 Categorical Course 83 neath the acromion and may helpful to increase the sensitivity of detecting small tear by stretching the tendon. By placing the transducer sagittally on the greater tubercle, the long-axis view of the SS tendon is demonstrated. Next, the transducer is turned 90 to evaluate the tendon in the short-axis view. The footprint part of the SS tendon inserts over anterior mm of the greater tubercle shelf in this position. The remaining posterior part is the infraspinatus insertion. Posterior Aspect By placing the transducer in transverse direction inferior to the scapular spine in neutral position of the patient s arm with keeping patient s hand palm up on the thigh, the infraspinatus (IS) is seen. In this position, examiner evaluates the IS tendon, with the patient s arm rotating maximum internally and externally as like as the maneuver for the supscapularis (SUB) tendon examination. Ancillary Examination For the A-C joint examination, the transducer is placed in coronal plane on the top of the shoulder. The joint is identified by the bone landmarks with interposed joint space. The joint laxity can be detected by patient s hand placing on the opposite shoulder, or by moving the elbow anterior-posterior direction. For SS impingement assessment, the patient put the arm down at the side with the hand pronated. The transducer is placed in coronal-oblique plane in the superior aspect of the shoulder to visualize the SS tendon as a bird-beak shape between the greater tubercle of the humeral head and the lateral margin of the acromion. The patient is asked to raise the arm actively anterolaterally whether the patient s elbow is extended or flexed during this maneuver. Normally, the greater tubercle slides easily under the acromion. In anterior aspect with the transducer placed transversely as for the SUB examination, the patient is asked to rotate the shoulder maximum externally in keeping the 90 flexed elbow close to the body in palm up state. Normally, the external rotation angle is more than 60. The posterior glenoid labrum and the spino-glenoid notch can be evaluated in the posterior aspect of the shoulder by placing the transducer in transverse direction. Categorical Course 21, Saturday (Hall E6)

86 84 42nd Korean Society of Ultrasound in Medicine 2011 Open CC6 MS-02Musculoskeletal 08:50-09:10 Hall E6 Chairperson(s): Kyung Nam Ryu Kyung Hee University Medical Center, Korea Kil-Ho Cho Yeungnam University Medical Center, Korea Ultrasound Evaluation of Rotator Cuff Tear Jung-Ah Choi Department of Radiology, Seoul National University College of Medicine, Korea Rotator cuff tears can be reliably evaluated on ultrasound with reported sensitivity of 95% and specificity of 93% for full thickness tears and sensitivity of 41% and specificity of 91% for partial-thickness tears. It was the disadvantages of operator and equipment dependency and one must be aware of several pitfalls.

87 Categorical Course 85 CC6 MS-03 Musculoskeletal 09:10-09:30 Hall E6 Chairperson(s): Kyung Nam Ryu Kyung Hee University Medical Center, Korea Kil-Ho Cho Yeungnam University Medical Center, Korea Treatment of the Rotator Cuff Tear Joo Han Oh Orthopedic Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Korea Categorical Course 21, Saturday (Hall E6)

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96 94 42nd Korean Society of Ultrasound in Medicine 2011 Open CC6 MS-04 Musculoskeletal 09:30-09:50 Hall E6 Chairperson(s): Kyung Nam Ryu Kyunghee University Medical Center, Korea Kil-Ho Cho Yeungnam University Medical Center, Korea Postoperative US of the Shoulder Na Ra Kim Department of Radiology, Konkuk University School of Medicine, Korea A basic knowledge of the type of surgical intervention performed and its extent is critical for examiner to reach a correct interpretation of the US images. Before the examination, details of the surgical intervention should always be collected from the surgical records. Generally speaking, the main surgical techniques for impingement syndrome and rotator cuff disease involve subacromial decompression and rotator cuff repair or debridement. The postoperative complications include insufficient excision of the acromion, progression of rotator cuff tendinosis, residual or recurrent rotator cuff tears, postoperative infection and adhesion. US has the advantage that it is unaffected by the presence of intraosseous hardwares. Nevertheless, postoperative shoulder US may be challenge, especially if the operative details are not available. The most reliable US signs of a re-torn supraspinatus are: nonvisualization of the cuff because of complete tendon avulsion and retraction under acromion, presence of a focal defect in the rotator cuff, a variable degree of tendon retraction from the surgical trough and detection of sutures floating freely in the fluid. The diagnostic accuracy of US for detection of postoperative rotator cuff tears is similar to that for imaging for shoulders that have not been operated. The most recent series based on newer equipment, current US criteria for tears and complete surgical validation of the results reported 91% sensitivity, 86% specificity and 89% accuracy for US identification of rotator cuff integrity postoperatively. Detachment of the deltoid insertion from the anterolateral acromion is a frequent surgical practice that improves exposure during acromioplasty with an open approach. Postoperative detachment of the deltoid is a potential complication after this procedure. US can identify this condition, which can be repaired surgically if recognized early. The main complications with shoulder arthroplasty are loosening, superior migration, subluxation or dislocation of the humeral head and postoperative rotator cuff tear. US has proved able to provide information about the para-articular soft tissues and the rotator cuff after shoulder arthroplasty, especially in cases of poor postoperative outcome and absence of radiographic signs of loosening and migration. The examiner should remember that the subscapularis tendon has often been taken off the lesser tubercle to allow surgical access. After placement of the prosthesis, the subscapularis tendon is usually reinserted more medially, at the site of humeral head resection rather than at the anatomical insertion site. However, this tendon may retear leading to an anteriorly unstable shoulder. References 1. Bianchi S, Martinoli C. Ed. Ultrasound of the musculoskeletal system. Springer, Berlin; 2007: Crass JR, Craig EV, Feinberg SB. Sonography of the postoperative rotator cuff. AJR 1986;146: Mack LA, Nyberg DA, Matsen FR, Kilcoyne RF, Harvey D. Sonography of the postoperative shoulder. AJR 1988;150: Prickett WD, Teefey SA, Galatz LM, et al. Accuracy of ultrasound imaging of the rotator cuff in shoulders that are painful postoperatively. JBJS 2003;85:

97 Categorical Course 95 CC7 THY-01 Thyroid 15:20-15:40 Hall E1-4 Chairperson: Dong Gyu Na Human Medical Imaging and Intervention Center, Korea Current Guideline of FNA in Thyroid Nodule Based on the Recommendations of KSThR Won-Jin Moon Department of Radiology, Konkuk University Medical Center, Konkuk University School of Medicine, Korea Categorical Course 21, Saturday (Hall E1-4) The detection of thyroid nodules has become more common with the increasing use of ultrasonography (US). US is the mainstay for the detection and differential diagnosis of thyroid nodules as well as for guidance for a biopsy. The Task Force on Thyroid Nodules of the Korean Society of Thyroid Radiology (KSThR) has developed recommendations for the US diagnosis and US-based management of thyroid nodules (1). The recommendations by KSThR have been based on a comprehensive analysis of the current literature, multicenter study results and from consensus of experts. On US of thyroid nodule, the size of the nodule, internal texture, shape, echogenicity, shape, margin, presence of calcification, presence of adjacent structure should be carefully scrutinized. Findings for a suspicious malignant nodule include a taller-thanwide shape, spiculated or microlobulated margin, marked hypoechogenicity, microcalcifications and macrocalcifications. Presence of at least one of the malignant US findings suggests the presence of a malignancy. According to these findings and the resultant category of a nodule, the nodule should be aspirated or followed-up with US or should be clinically observed. Reference 1. Moon WJ, Baek JH, Jung SL, Kim DW, Kim EK, Kim JY, Kwak JY, Lee JH, Lee JH, Lee YH, Na DG, Park JS, Park SW; Korean Society of Thyroid Radiology (KSThR); Korean Society of Radiology. Ultrasonography and the ultrasoundbased management of thyroid nodules: consensus statement and recommendations. Korean J Radiol Jan;12(1):1-14. Figure 1. Flowchart for strategy for follow-up US and US-guided FNA biopsy according to US findings and cytology results of thyroid nodules (1).

98 96 42nd Korean Society of Ultrasound in Medicine 2011 Open CC7 THY-02 Thyroid 15:40-16:00 Hall E1-4 Chairperson: Dong Gyu Na Human Medical Imaging and Intervention Center, Korea How I Should fu Thyroid Nodule after FNAB? Jin Young Kwak Department of Radiology, Yonsei University Gangnam Severance Hospital, Korea

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103 Categorical Course 101 CC7 THY-03 Thyroid 16:00-16:20 Hall E1-4 Chairperson: Dong Gyu Na Human Medical Imaging and Intervention Center, Korea Preop. & Postop. Evaluation in the Patient with Thyroid Cancer Jeong Seon Park Department of Radiology, Hanyang University Hospital, Korea Categorical Course 21, Saturday (Hall E1-4) Thyroid cancer constitutes approximately 1% of malignancies worldwide, and its incidence is increasing in many countries. Ultrasonography (US) is an essential tool in the management of thyroid nodules and the use of US is adding in the revised guidelines worldwide. With the advance of ultrasound (US) techniques, US of the thyroid glands is extremely sensitive in detecting thyroid and cervical lymph nodes (LN). Preoperative ultrasonographic evaluation of thyroid cancer is not applied to the patients who are scheduled to undergo thyroidectomy, but also the careful evaluation is needed for the patients who undergo thyroid US. I. Preoperative Evaluation of Thyroid Cancer Thyroid cancer has unique and largely unexplained tumor biology, characterized by early spread to regional LN and occasional extrathyroidal soft tissue extension, but a low incidence of distant metastases and infrequent death. The disease-specific survival rate of differentiated thyroid carcinoma (DTC) is excellent and may exceed 90% at 10 years, but its recurrence rate is more than 30%. US is becoming widely accepted as the technique of choice for staging papillary thyroid carcinoma as indicated by the several management guidelines, which recommend preoperative US to assess primary lesions in the thyroid and assess lymph node involvement. Despite debate about the extent of surgery, consensus has been reached about when extensive surgery is adequate for treating papillary thyroid carcinoma. If a mass is at least 1cm in diameter, if a mass extends beyond the thyroid, if there is metastasis, or if a combination of these findings is present, total thyroidectomy is advocated. Extrathyroidal invasion and cervical lymph node metastasis are frequently related and are wellknown prognostic factors. Thus, preoperative predictions of tumor size, extrathyroidal invasion, multifocality, and cervical LN metastasis are essential for deciding the extent of the optimal surgical intervention. Although the AJCC TNM staging system (Table 1) is not routinely adopted for the prediction of prognosis in thyroid cancer, we can notice the US features what sonologists should check preoperatively. Preoperative US should include the information as follows; 1. The longest diameter 2. Multifocality, bilaterality of thyroid cancer 3. Extrathyroidal invasion (capsule, strap muscle, larynx, trachea, esophagus, etc.) 4. Regional LNstatus (including central and lateral cervical chains) Table 1. TNM Classification System for Differentiated Thyroid Cancer Primary tumor TX: Primary tumor cannot be assessed T0: No evidence of primary tumor T1: Tumor 2 cm in greatest dimension limited to the thyroid. T1a: Tumor 1 cm, limited to the thyroid. T1b: Tumor >1 cm but 2 cm in greatest dimension, limited to the thyroid.

104 102 42nd Korean Society of Ultrasound in Medicine 2011 Open T2: Tumor >2 cm but 4 cm in greatest dimension, limited to the thyroid. T3: Tumor >4 cm in greatest dimension limited to the thyroid or any tumor with minimal extrathyroid extension (e.g., extension to sternothyroid muscle or perithyroid soft tissues). T4a: Tumor of any size extending beyond the thyroid capsule to invade subcutaneous soft tissues, larynx, trachea, esophagus, or recurrent laryngeal nerve. Intrathyroidal anaplastic carcinoma. T4b: Tumor invades prevertebral fascia or encases carotid artery or mediastinal vessels. Anaplastic carcinoma with gross extrathyroid extension. Regional Lymph Nodes NX: Regional lymph nodes cannot be assessed. N0: No regional lymph node metastasis. N1: Regional lymph node metastasis. N1a: Metastases to Level VI (pretracheal, paratracheal, and prelaryngeal/delphian lymph nodes). N1b: Metastases to unilateral, bilateral, or contralateral cervical (Levels I, II, III, IV, or V) or retropharyngeal or superior mediastinal lymph nodes (Level VII). Distant Metastasis M0: No distant metastasis. M1: Distant metastasis Note. Adapted from the seventh edition of the American Joint Committee on Cancer/International Union Against Cancer (AJCC/UICC) TNM classification system. II. Postoperative Evaluation of Thyroid Cancer Although mortality from DTC is low, the rate of recurrence is considerably higher. The recurrence rates for patients with PTC are approximately 15% to 22% and about 1.8% annually for the first decade after treatment. About 85% of patients with recurrence will have cervical nodal metastases, 32% will have local recurrence in the thyroid bed, and 12% will have distant metastasis. Local recurrence after adequate surgical treatment is generally low; 10-year local recurrence rates of 4% to 7% have been reported. Regional LN recurrence occurs in approximately 10% of patients. Postoperative assessment includes physical examination of the neck, neck US, chest radiography to detect lung metastases, iodine 131 wholebody scanning, tumor markers such as thyroglobulin (Tg) and anti-tg antibody for papillary and follicular carcinoma, and the calcitonin level for medullary carcinoma. Advantages of US include the ability to detect nonpalpable recurrent disease and the ability to perform simultaneous US-guided percutaneous biopsy for diagnosis. US does not rely on the ability of thyroid carcinoma cells to concentrate iodine. The Korean Thyroid Association recommended postoperative US every 6 or 12 month for the evaluation of locoregional recurrence. US is very sensitive in the detection of cervical recurrence in the postoperative patients with DTC. We should scan central and lateral neck LN as well as thyroid beds. The previous reports revealed that thyroidectomy bed recurrence showed hypoechoic appearance, round or oval shape, inhomogeneous pattern, calcifications, and hypervascularity. However, those recurrent cases misdiagnosed as recurrent tumors in the surgical bed included normal residual thyroids, parathyroid glands, suture granuloma, strap muscle, tracheal cartilage, pyramidal lobes, postoperative fibrosis, cysts, and fat necrosis. Regional LN metastasis should be carefully evaluated in the postoperative US, as well as preoperative examination. The US findings suggestive of metastatic LN are cystic change, intranodal calcification, round shape (L/T ratio<1.5), hyperechoic change, loss of echogenic hilum, and abnormal vascularity (eg. peripheral vascularity). In the cases of papillary thyroid cancer, size criteria for cervical lymph node metastasis have yet to be determined. US-guided fine-needle aspiration cytology (FNAC) is the most useful technique for diagnosing nodal metastases, but 5-10% of the samples are non-diagnostic

105 Categorical Course 103 and 6-8% are false negatives. Recently, several studies have reported that the detection of Tg in FNA biopsy washout fluid identifies PTC recurrences/metastases of the neck with higher sensitivity and specificity than FNAC. References 1. Edge, S.B.; Byrd, D.R.; Compton, C.C.; Fritz, A.G.; Greene, F.L.; Trotti, A. American joint committee on cancer. AJCC cancer staging manual. Chicago: Springer, Jeon SJ, Kim E, Park JS, et al. Diagnostic benefit of thyroglobulin measurement in fine-needle aspiration for diagnosing metastatic cervical lymph nodes from papillary thyroid cancer: correlations with US features. Korean J Radiol Mar-Apr;10(2): Park JS, Son KR, Na DG, et al. Performance of preoperative sonographic staging of papillary thyroid carcinoma based on the sixth edition of the AJCC/UICC TNM classification system. AJR Am J Roentgenol Jan;192(1): Kim E, Park JS, Son KR, et al. Preoperative diagnosis of cervical metastatic lymph nodes in papillary thyroid carcinoma: comparison of ultrasound, computed tomography, and combined ultrasound with computed tomography. Thyroid Apr;18(4): Moon HJ, Kim EK, Chung WY, et al. Minimal Extrathyroidal Extension in Patients with Papillary Thyroid Microcarcinoma: Is It a Real Prognostic Factor? Ann Surg Oncol.2011 Jan 26. [Epub ahead of print] 6. Moon WJ, Baek JH, Jung SL, et al.korean Society of Thyroid Radiology (KSThR). Ultrasonography and the ultrasound-based management of thyroid nodules: consensus statement and recommendations. Korean J Radiol Jan;12(1): Sohn YM, Kwak JY, Kim EK, et al. Diagnostic approach for evaluation of lymph node metastasis from thyroid cancer using ultrasound and fine-needle aspiration biopsy. AJR 2010 Jan;194(1): Hahn SY, Shin JH, Han BK, et al. Predictive factors related to the recurrence at US-guided fine needle aspiration in postoperative patients with differentiated thyroid cancer. Clin Endocrinol Feb;74(2): Shin JH, Han BK, Ko EY, et al. Sonographic findings in the surgical bed after thyroidectomy: comparison of recurrent tumors and nonrecurrent lesions. J Ultrasound Med Oct;26(10): Categorical Course 21, Saturday (Hall E1-4)

106 104 42nd Korean Society of Ultrasound in Medicine 2011 Open CC7 THY-04 Thyroid 16:20-16:40 Hall E1-4 Chairperson: Dong Gyu Na Human Medical Imaging and Intervention Center, Korea Interventional Management of Thyroid Disease (PEIT & RFA) So Lyung Jung Department of Radiology, Seoul St. Mary s Hospital, The Catholic University of Korea, Korea Benign thyroid nodules in general are managed by non-surgical methods such as percutaneous ethanol injection ablation (PEIT), laser ablation (LA), radiofrequency ablation (RFA). However, non-surgical treatment may be done in some cases of malignant thyroid nodules with poor surgical condition and in some cases of recurrent well differentiated thyroid cancer. Benign thyroid nodules are generally asymptomatic. However, they may cause neck discomfort and/or dysphagia and tracheal displacement. Non-surgical treatment has been suggested recently in management of the patients with benign thyroid masses causing symptoms. The inclusion criteria for benign thyroid nodules were as follows: (1) the presence of subjective symptoms (foreign body sensation, neck discomfort or pain, compressive symptoms) or cosmetic problems; (2) a poor surgical candidate or refusal to undergo surgery; (3) FNAB and US findings that were compatible with a benign nodule at least two separate times. The exclusion criteria were as follows: (1) follicular neoplasm or malignancy on FNAB; (2) a nodule with the US criteria for a malignancy, although FNAB was a benign result; (3) previous radiation or operation history to the head and neck. 1. Percutaneous Ethanol Injection Therapy (PEIT) The sclerosing properties of ethanol have been recognized for many years and have offered interventional possibilities in the management of various benign as well as malignant lesions. The mechanism of action of ethanol appears to be related to a direct coagulative necrosis, vascular thrombosis, and hemorrhagic infarction. The treated areas are replaced by granulation tissue that causes scarring and progressive shrinkage of the nodules. Ultrasound-guided percutaneous ethanol injection therapy is rapid and performed on an out-patient basis and has now gained wide acceptance due to the accumulating evidence of the efficacy and safety of this therapeutic tool. Several authors have considered the effectiveness of PEIT in the treatment of autonomously functioning nodules, cystic nodules, and benign cold nodules. Treatment efficacy, safety, and cost-effectiveness are still controversial. Side effects caused by ethanol injection are generally few and transient and are related to the injection into solid nodules rather than cysts. Pain during the procedures (cyst < solid nodules), swelling in the neck, transient dysphonia, abscess, hypothyroidism, hypoparathyroidism, or jugular venous thrombosis are reported. At the 5-year follow-up, patients were requested to describe their experience of the procedures as fine (further treatment would be accepted without hesitation), tolerable (the treatment was mildly painful but could be repeated if necessary), or very painful (the pain experienced was severe and surgery would be preferred if a further treatment were needed). Patients with cystic nodules described PEI as fine in 20.7% of cases, tolerable in 75.8% of cases, and very painful in 3.4% of cases. Patients with hyperfunctioning nodules characterized the procedure as fine in 8.9%, tolerable in 60.7%, and very painful in 30.3% of cases. Thyroid cyst: PEIT proved highly effective in the treatment of thyroid cysts and complex thyroid nodules. Although aspiration by itself may cure thyroid cysts, recurrence is common, and surgery is often the final treatment for large recurring lesions. However, now PEIT should be the first line of treatment for recurrent cystic nodules once FNA has ruled out the presence of malignancy because surgery, the only alternative

107 treatment to ethanol injection for recurrent and enlarging thyroid cysts, is more expensive, time-consuming, and liable to produce transient or permanent complications. Guglielmi et al (2004) reported a volume reduction greater than 75% versus baseline in 86.5% at the 5 year evaluation. Cho et al showed volume reduction by 50-99% in 13/22 patients for 10 months. Cure (defined as a cyst volume 1ml at the end of follow up) of recurrent thyroid cysts was obtained in 82%. Autonomously functioning nodule (AFTN) AFTN is a condition in which thyroid nodule secretes thyroid hormones independently of the production of TSH. In these cases, hyperthyroidism is often mild or moderate. Because of the slow course, patients can show borderline symptoms and normal levels of ft3 and ft4 but low TSH levels for a long time. Rapid progression toward thyrotoxicosis has been reported in a few cases. Early treatment is advised in elderly patients with dysrhythmia or cardiac failure and in young patients who may have increased risk of hyperthyroidism. Conventional therapies for hyperfunctioning thyroid nodule include radioiodine & surgery. Both of these treatments are associated with a small but definite risk of hypothyroidism, whereas hypoparathyroidism and vocal cord lesions may occur after surgery. Over the past 16 years, PEIT has been proposed as an alternative therapy to surgery & radioiodine. A complete cure by PEI ablation of hyperfunctioning thyroid nodules is considered posttreatment absence of hyperfunctioning tissue and normal uptake of thyroid parenchyma at scintigraphy. The best results of PEI ablation of hyperfunctioning thyroid nodules have been observed for small to large nodules larger than 40 ml. The longterm efficacy of PEI treatment for 13 years is also good with a complete cure in 93% patients. Cold benign solid thyroid nodule (CBSTN) In cases of nonfunctioning CBSTN, it is difficult to decide the best management for patients. Both surgical and conservative approaches have their drawbacks. Surgery requires hospitalization, and leaves a visible scar on the skin of the anterior neck. By contrast, the conservative approach is not helpful for the patient complaint of an uncomfortable feeling of a lump or cosmetic concerns. Therefore, non-surgical, Categorical Course 105 minimally invasive modalities including PEIT have been performed with good results. Meskhi et al performed PEIT in patients with colloid nodules and adenomatous nodules with more volume reduction in adenomatous nodules (71%). Kim et al treated 25 adenomatous hyperplasia with a total of one to three PEIT at intervals of one or two months. The volume reduction of 56.1% was reported in 4 months followup. Locally recurrent well-differentiated thyroid carcinoma In patients with recurrent cancers, noninvasive, nonsurgical treatment modalities have been attempted, not only to minimize the mortality rate due to local recurrence but also to ovoid the possible morbidity caused by repeat surgery. PEIT may be an alternative treatment option for locally recurrent thyroid carcinomas in properly selected patients or in patient with difficult reoperations. Lim et al reported that 24 recurrent lesions in 16 PTC patients were treated with PEIT in 3-months intervals and the median diameter of lesions was significantly reduced from 9.9mm to 5.3 mm. Four lesions disappeared sonographically. Lewis et al reported that 29 metastatic lymph nodes in 14 patients were treated with PEIT and treated lesions decreased in volume from 492 mm 3 to 76 mm 3 at 1 year and 20 mm 3 at 2 years after treatment. Monchik et al reported that no recurrent disease was detected at the treatment site in all 6 patients treated with PEIT at a mean follow-up of 18.7 months with no complication. 2. Radiofrequency Ablation (RAF) RFA for malignant and benign tumors is a minimally invasive treatment tool with good outcomes and low morbidity and mortality. Over the last 10 years, RFA has increasingly been used to treat liver tumors. In the last five years, the application of RFA has been further extended to organs such as lung, bone, kidney, breast, spleen, thyroid, and tongue because handling is easy and safe and gives excellent consistency and control of the ablation area. RFA of benign thyroid tumors has increased markedly along with the higher incidence of thyroid tumors and shows good outcomes and safety. RFA is applied by inserting a metal needle probe Categorical Course 21, Saturday (Hall E1-4)

108 106 42nd Korean Society of Ultrasound in Medicine 2011 Open into a tumor. The electrodes transmit alterating current that creates intracellular ionic agitation within the adjacent tissues, thereby producing intratumoral hyperthermia and subsequent tumor necrosis. Baek et al has suggested two techniques such as trans-isthmic approach method and moving shot technique for RFA of the thyroid nodules. Good results have been reported in benign nonfunctioning thyroid nodules, benign autonomously functioning thyroid nodules, and recurrent thyroid cancers that were treated using RFA. Jeong et al. treated 302 benign thyroid nodule using RFA. The results of this study showed most of the patients (86%) were treated solitary nodule. About 70% of the nodules were treated in a single session of RFA. The volume reduction at 1, 3 and 6 months after ablation were about 58%, 74% and 85%, respectively. A volume reduction greater than 50% (therapeutic success rate) was observed in 91%, and 28% of index nodules had disappeared on the follow-up US. Baek et al (2010) also reported the prospective randomized study that RFA was effective in predominantly solid thyroid nodules compared with control group. Six month after RFA, patients in RFA group was achieved significant volume reduction (mean volume reduction was 49.1% at 1 month and 79.7% at 6 months) compared with control group. Baek et al.(2008 & 2009) reported the effectiveness of RFA in treatment of the benign autonomously functioning thyroid nodules in volume reduction and improving the symptoms and abnormal thyroid function. The volume reduction was 36.4% at the 1-month and 70.7% at the 6 month follow-up. A significant improvement of mean T3, ft4, and TSH were observed at last follow-up. After ablation, four patients showed a cold or normal thyroid scan and five were improved, but remained as hot nodules. The possible complications are voice change, hematoma, tumor rupture, first degree skin burn, and transient thyrotoxicosis etc. Most common complaint of the patients is pain. During the ablation, most of the patients complain of various degrees of pain at the ablated site, or pain radiating to the head, ear, shoulder, or teeth. The pain decreased when the generator output was reduced or turned-off during ablation and was easily controlled by oral analgesics. All of the complications were recovered spontaneously. References 1. Baek JH, Na DG, Lee JH, Jung SL, Sung JY, Sim J, Kim JH, Shin JH, Bae J, Ko HK, Kim YS, Kim KT, Kim DW, Park J, S. (2009) Korean Society of Thyroid Radiology recommendations for radiofrequency ablation of thyroid nodules. 2. Moon W-J, Baek JH, Jung SL, Kim DW, Kim EK, Kim JY, Kwak JY, Lee JH, Lee JH, Lee YH, Na DG, Park JS, Park SW, Korean Society of Thyroid Radiology (KSThR) KRS, Korea (2011) Ultrasonography and Ultrasound-Based Management of Thyroid Nodules: Consensus Statement and Recommendations. Korean J Radiol 3. Moon W-J, Jung SL, Lee JH, Na DG, Baek J-H, Lee YH, Kim J, Kim HS, Byun JS, Lee DH (2008) Benign and Malignant Thyroid Nodules: US Differentiation-- Multicenter Retrospective Study. Radiology:247: Baek JH, Jeong HJ, Kim YS, Kwak MS, Lee D (2008) Radiofrequency Ablation for an Autonomously Functioning Thyroid Nodule. Thyroid 18: Baek JH, Moon WJ, Kim YS, Lee JH, Lee D (2009) Radiofrequency ablation for the treatment of autonomously functioning thyroid nodules. World J Surg 33: Deandrea M, Limone P, Basso E, Mormile A, Ragazzoni F, Gamarra E, Spiezia S, Faggiano A, Colao A, Molinari F, Garberoglio R (2008) US-guided percutaneous radiofrequency thermal ablation for the treatment of solid benign hyperfunctioning or compressive thyroid nodules. Ultrasound Med Biol 34: Jeong WK, Baek JH, Rhim H, Kim YS, Kwak MS, Jeong HJ, Lee D (2008) Radiofrequency ablation of benign thyroid nodules: safety and imaging follow-up in 236 patients. Eur Radiol 18: Kim YS, Rhim H, Tae K, Park DW, Kim ST (2006) Radiofrequency ablation of benign cold thyroid nodules: initial clinical experience. Thyroid 16: Spiezia S, Garberoglio R, Milone F, Ramundo V, Caiazzo C, Assanti AP, Deandrea M, Limone PP, Macchia PE, Lombardi G, Colao A, Faggiano A (2009) Thyroid nodules and related symptoms are stably controlled two years after radiofrequency thermal ablation. Thyroid 19: Lee JH, Kim YS, Lee D, Choi H, Yoo H, Baek JH (2010) Radiofrequency Ablation (RFA) of Benign Thyroid Nodules in Patients with Incompletely Resolved Clinical Problems after Ethanol Ablation (EA). World J Surg 34: Baek JH, Kim YS, Lee D, Huh JY, Lee JH (2010) Benign predominantly solid thyroid nodules: prospective study of efficacy of sonographically guided radiofrequency ablation versus control condition. AJR Am J Roentgenol 194: Sung JY, Baek JH, Kim YS, Jeong HJ, Kwak MS, Lee D, Moon WJ (2008) One-Step Ethanol Ablation of Viscous Cystic Thyroid Nodules. AJR Am J Roentgenol 191: Baek JH, Kim YS, Sung JY, Choi H, Lee JH (2010) Locoregional Control of Metastatic Well Differentiated Thyroid Cancer in the Neck by Ultrasonography-guided Radiofrequency Ablation AJR Am J Roentgenol in press 14. Cho YS, Lee HK, Ahn IM, Lim SM, Kim DH, Choi CG,

109 Categorical Course 107 Suh DC (2000) Sonographically guided ethanol sclerotherapy for benign thyroid cysts: results in 22 patients. AJR:174; Guglielmi R, Pacella CM, Bianchini A, Bizzarri G et al. (2004) Percutaneous ethanol injection treatment in benign thyroid lesions: role and efficacy. Thyroid:14(2); Bennedbaek FN, Karstrup S, Hegedus L. (1997) Percutaneous ethanol injection therapy in the treatment of thyroid and parathyroid diseases. Euro J of endocrinolog y:136(3); Tarantino L, Giorgio A, mariniello N et al. (2000) Percutaneous ethanol injection of large autonomous hyperfunctioning thyroid nodules. Radiology:214; Zingrillo M, Collura D, Ghiggi MR et al. (2007) Treatment of large cold benign thyroid nodules not eligible for surgery with percutaneous ethanol injection. J Clin Endocrinol and Metabolism 19. Bennedbaek FN, Nielsen LK, Hegedus L. (1998) Effect of percutaneous ethanol injection therapy versus suppressive doses of L-thyroxine on benign solitary solid cold thyroid nodules: a randomized trial. J Clin Endocrinol Metab 83: Bennedbaek FN, Hegedus L (2003) Treatment of recurrent thyroid cysts with ethanol: A randomized double-blind controlled trial. J Clin Endocrinol Metab 88: Monchik JM, Donatini G, Iannuccilli J, Dupuy DE. (2006) Radiofrequency ablation and percutaneous ethanol injection treatment for recurrent local and distant well-differentiated thyroid carcinoma. Ann Surg 244: Lim CY, Yun JS, Lee J et al. (2007) Percutaneous ethanol injection therapy for locally recurrent papillary thyroid carcinoma. Thyroid 17: Lewis BD, Hay ID, Charboneau JW, Mclver B et al. (2002) Percutaneous ethanol injection for treatment of cervical lymph node metastases in patients with papillary thyroid carcinoma. AJR 178: Kim JK, Lee HK, Ahn IM et al. (1998) Treatment of benign cold thyroid nodule : Efficacy and safety of US-guided percutaneous ethanol injection. J Korean Radiol Soc 1998;39: Tarantino L, Francica G, Sordelli I et al. (2008) Percutaneous ethanol injection of hyperfunctioning thyroid nodules: Long-term follow-up in 125 patients. AJR 2008;190: Categorical Course 21, Saturday (Hall E1-4)

110 SF1 AB-01 Special Focus Session 115 Abdomen 10:30-10:50 Hall E1-4 Chairperson(s): Hae Jeong Jeon Konkuk University, Korea Masatoshi Kudo Kinki University, School of Medicine, Japan Abdominal Application of Shear Wave-Based Elastography Jae Young Lee Department of Radiology, Seoul National University Hospital, Korea At present, we have three commercially available shear wave based elastography (SWBE) including Transient elastography (TE, Fibroscan), acoustic radiation force impulse (ARFI) elastography, and Supersonic Shear Imaging (SSI). In my lecture, I will introduce the principle of SWBE and the clinical results. I. Principles of SWBE Tissue stiffness is measured by a physical quantity called Young s modulus and expressed in pressure units - Pascals, or more commonly kilo Pascals (kpa). Shear waves indicate transverse waves occur with vertical direction to beam propagation when a transducer insonates a longitudinal wave. Longitudinal waves move with a speed of 1540 m/s in tissues whereas shear waves is much lower in velocity with a speed of 1-10 m/s in tissues. Shear waves propagate by creating a tangential sliding force between tissue layers. measuring shear wave propagation speed enables determination of the elasticity of the tissue. 1) Transient elastography (Fibroscan) It is the first elastography technique developed to quantitatively and noninvasively assess soft biological tissue stiffness in vivo. Technically, it consists of a dedicated acquisition platform that includes a single channel ultrasound analog front end to emit and receive ultrasound signals and a mechanical vibrator for generation of a low-frequency elastic wave at 50 Hz. The shear wave can be observed on the elastogram image which represents the strains induced in tissues as a function of time and depth. It is computed from US data acquired at a very high frame rate during the shear wave propagation. Advantages of TE are that it has been extensively validated and well correlated with liver fibrosis stage. Disadvantages of TE are that it does not provide B-mode image which is very helpful for targeting; only right lobe can be measured; and it shows higher measurement failure rate of 5.5~6% mainly due to limiting factors such as obesity and ascites. Special Focus Session 20, Friday (Hall E1-4) Elasticity (Young s modulus, kpa) and shear wave propagation (m/s) are directly linked through the simple formula; E= 3 c 2 where is the density of tissue expressed in kg/m 3. Therefore, since the density of tissues is well known (for example, liver = 1000 kg/m 3 ), 2) Acoustic Radiation Force Impulse (ARFI) Elastography ARFI elastography uses high-intensity, short-duration acoustic pulses to produce shear-wave propagation in the target tissue. Shear-wave velocity is measured by repeating pulse pulses and detection pulses across the region of interest. As advantages of ARFI, elastography can be measure as watching B-mode image because it is integrated into a conventional US platform. It is technically simple and fast to perform. It is extensively being investigated for clinical application. It can be per-

111 116 42nd Korean Society of Ultrasound in Medicine 2011 Open formed regardless of ascites and obesity. Relative disadvantages of ARFI can be that it is not real time measurement; it needs multiple measurement at least more than 3 times because of its small ROI and motion sensitivity; and it can be measured only up to 6cm depth from the skin because of depth limitation in measurement 3) Supersonic Shear Imaging (SSI) SSI is a new US-based technique for real-time visualization of soft tissue viscoelastic properties in all areas in ROI. By successively focusing multiple beams at increasing depths, a quasiplane shear wave is generated. The generated shear waves are captured by ultrafast imaging to acquire raw radiofrequency data at a very high frame rate (up to 5000 frames/s). The ultrafast imaging uses an unfocused plane wave. In this manner, a movie of the particle velocity induce by the shear wave is formed. It was recently introduced in the abdominal diagnostic field, so that it needs extensive validation. II. Abdominal Application of SWBE 1) Liver Fibrosis Invasiveness and sampling errors of liver biopsy have stimulated the development of diverse noninvasive methods for evaluating liver fibrosis. Recently, transient elastography (TE), acoustic radiation force impulse (ARFI) imaging, supersonic shear imaging (SSI), and etc have been introduced as a noninvasive technique for evaluating liver fibrosis. The reproducibility of TE is reportedly excellent and the measurement failure rate is between 5.5 and 6%. Sensitivity and specificity of TE for the diagnosis of cirrhosis was 73-87% and 91-97% respectively(1). However, TE is limited in the evaluation of patients with obesity or the presence of ascites. Additionally, it is limited in that TE does not provide B-mode US image together. Results from ARFI elastography are similar to TE for correlation with histologic fibrosis stage and for diagnosis of moderate fibrosis and cirrhosis(2-4). The most distinct feature of ARFI elastography from TE is that it is integrated into a conventional US platform. In ARFI elastography, the most recommendable site for measurement is S7 and S8 with intercostal approach and 1-3 cm from liver capsule. In nonalcoholic fatty liver disease, ARFI showed good correlation of fibrosis stage(5, 6). In addition, ARFI elastography can be used to get additional information regarding the stiffness of focal liver lesions(7). The SSI technique is under investigation about liver application(8). 2) Hepatic focal lesions Subjective experience of hepatic surgeons says malignant tumors are stiffer than normal liver parenchyma and benign tumors. Tumor rigidity is influenced by elevation in interstitial tissue pressure and solid stress due to altered vasculature and tumor expansion; increase in the elastic modulus of transformed cells mediated by an altered cyto-architecture; and matrix stiffening linked to fibrosis. In a research with MR elastography, elasticity may be a new para- Table. Summary of Published Reports Regarding TE and ARFI Elastography >F0 > F1 > F2 > F3 TE 5.65 kpa 7.1 kpa 9.6 kpa 12.5 kpa Accuracy 79-83% 90-91% 91-97% ARFI 1.23 m/s 1.34 m/s 1.55 m/s 1.86 m/s Sen/Spf 88.9/ / / /94.4 Note. Sen = Sensitivity, Spf = specificity, TE = Transient elastography, ARFI = acoustic radiation force impulse, F = Metavir fibrosis stage

112 Special Focus Session 117 meter for differentiation benign and malignant liver tumors(9). Also, we reported that there is a potential that elasticity measured by ARFI elastography could be a tool for the differentiation(7). However, there is a debate for this issue(10). In fact, hemangiomas show very wide range of elasticity spectrum on elastography. 3) Other abdominal organs ARFI technique allows measurement of pancreas, spleen and kidney as well as the liver by a help of B- mode imaging. In a study, the pancreas showed 0.52 to 4.60 m/s (mean, 1.40 m/s); the spleen, 0.68 to 4.64 m/s (mean, 2.44 m/s); and kidney 0.52 to 4.83 m/s (mean 2.24 m/s) (11, 12). The clinical meaning of the values should be validated with future studies. In our study, with a cutoff value of 3.5 m/s of the spleen on ARFI technique, specificity was 97.6% and PPV was 95.2% for the diagnosis of presence of chronic liver disease (Lee JY, et al, ESGAR 2010). In a study, splenic shear wave velocity cut-off value of 2.73 m/s (AUC 0.82) could differentiate between the patients with LC and non-cirrhotic chronic liver disease(13). ARFI is suggested to be valuable for the diagnosis of renal transplant fibrosis(14, 15). References 1. Nguyen-Khac E, Capron D. Noninvasive diagnosis of liver fibrosis by ultrasonic transient elastography (Fibroscan). Eur J Gastroenterol Hepatol 2006;18(12): Friedrich-Rust M, Wunder K, Kriener S, et al. Liver fibrosis in viral hepatitis: noninvasive assessment with acoustic radiation force impulse imaging versus transient elastography. Radiology 2009;252(2): Sporea I, Sirli RL, Deleanu A, et al. Acoustic Radiation Force Impulse Elastography as Compared to Transient Elastography and Liver Biopsy in Patients with Chronic Hepatopathies. Ultraschall Med Babaev AE, Babaev AA, Yanchevskiy IV. Influence of an oscillating circuit on the radiation of transient acoustic waves by an electroelastic cylinder. J Acoust Soc Am 2010;127(4): Palmeri ML, Wang MH, Rouze NC, et al. Noninvasive Evaluation of Hepatic Fibrosis using Acoustic Radiation Force-Based Shear Stiffness in Patients with Nonalcoholic Fatty Liver Disease. J Hepatol Yoneda M, Suzuki K, Kato S, et al. Nonalcoholic fatty liver disease: US-based acoustic radiation force impulse elastography. Radiology 2010;256(2): Cho SH, Lee JY, Han JK, Choi BI. Acoustic radiation force impulse elastography for the evaluation of focal solid hepatic lesions: preliminary findings. Ultrasound Med Biol 2010;36(2): Muller M, Gennisson JL, Deffieux T, Tanter M, Fink M. Quantitative viscoelasticity mapping of human liver using supersonic shear imaging: preliminary in vivo feasibility study. Ultrasound Med Biol 2009;35(2): Venkatesh SK, Yin M, Glockner JF, et al. MR elastography of liver tumors: preliminary results. AJR Am J Roentgenol 2008;190(6): Heide R, Strobel D, Bernatik T, Goertz RS. Characterization of focal liver lesions (FLL) with acoustic radiation force impulse (ARFI) elastometry. Ultraschall Med 2010;31(4): Gallotti A, D Onofrio M, Pozzi Mucelli R. Acoustic Radiation Force Impulse (ARFI) technique in ultrasound with Virtual Touch tissue quantification of the upper abdomen. Radiol Med 2010;115(6): Goertz RS, Amann K, Heide R, Bernatik T, Neurath MF, Strobel D. An abdominal and thyroid status with Acoustic Radiation Force Impulse Elastometry - A feasibility study Acoustic Radiation Force Impulse Elastometry of human organs. Eur J Radiol Grgurevic I, Cikara I, Horvat J, et al. Noninvasive Assessment of Liver Fibrosis with Acoustic Radiation Force Impulse Imaging: Increased Liver and Splenic Stiffness in Patients with Liver Fibrosis and Cirrhosis. Ultraschall Med Syversveen T, Brabrand K, Midtvedt K, et al. Assessment of renal allograft fibrosis by acoustic radiation force impulse quantification a pilot study. Transpl Int 2011;24(1): Stock KF, Klein BS, Vo Cong MT, et al. ARFI-based tissue elasticity quantification in comparison to histology for the diagnosis of renal transplant fibrosis. Clin Hemorheol Microcirc 2010;46(2-3): Special Focus Session 20, Friday (Hall E1-4)

113 118 42nd Korean Society of Ultrasound in Medicine 2011 Open SF1 AB-02 Abdomen 10:50-11:10 Hall E1-4 Chairperson(s): Hae Jeong Jeon Konkuk University, Korea Masatoshi Kudo Kinki University, School of Medicine, Japan Monitoring Effect of Antiangiogenic Treatments by DCE-US Nathalie Lassau Imaging Department-Ultrasonography Unit, Institut Gustave-Roussy, Villejuif. France New treatments based on antiangiogenic substances are developed in order to destroy tumor vessels and are the object of promising clinical research for cancer treatment. Considering the large number of new targeted drugs under development, there is a great need for early reliable imaging indicators of tumour responses, and identification of a recommended modality of drug administration to guide further steps in the clinical development. The response rate remains the best objective parameter of efficacy of the treatments tested in Phase 1 2, or 3 but this parameter is obtained very late in the clinical development, while the effect on the tumour must be determined as soon as possible in order to optimise the schedule and the dose to be recommended for the late clinical development stage. The early functional evaluation of new treatments is a main goal. At present, technical advances in DCE-ultrasonography using bolus contrast agent (SonoVue, Bracco) and perfusion software allow the detection of microvascularization and perfusion for superficial and deep malignant tumors. Thus, it becomes possible to early evaluate the efficiency of antiangiogenic or antivascular molecules. Treatment response can be early predicted according to modifications of this vascularization before any volume modification. The acquisition of raw linear data affords the precise quantification (peak intensity, time to peak intensity, sloap of wash-in, and area under the curve ) of the perfusion after contrast uptake curves modelization, in particularly using time tracking of region of interest. The results will be focused on GIST, RCC, HCC, and melanoma with different molecules performed in our institution including 117 patients. Reduction in tumor vascularization can easily be detected in responders after 1 or 2 weeks and is correlated with progression-free survival and overall survival in RCC or HCC. DCE-US is supported by the French National Cancer Institute (INCa), which is currently studying the technique in metastatic breast cancer, melanoma, colon cancer, gastrointestinal stromal tumors and renal cell carcinoma, as well as in primary hepatocellular carcinoma, to establish the optimal perfusion parameters and timing for quantitative anticancer efficacy assessments. Currently 530 patients are included in 19 centers and the preliminary results on 400 patients with 1096 DCE-US demonstrated that AUC could be a robust parameter to predict response. References 1. Lassau N, Lamuraglia M, Vanel D et al. Doppler US with perfusion software and contrast medium injection in the early evaluation of isolated limb perfusion of limb sarcomas: prospective study of 49 cases. Ann Oncol Lassau N, Lamuraglia M, Chami L, et al. Gastro-intestinal stromal tumours treated with Imatinib : Monitoring response with contrast enhanced ultrasound. AJR Escudier B, Lassau N, Angevin E, Soria JC, Chami L, Lamuraglia M, Zafarana E, Landreau V, Schwartz B, Brendel E, Armand JP, Robert C. Phase I trial of sorafenib in combination with IFN alpha-2a in patients with unresectable and/or metastatic renal cell carcinoma or malignant melanoma. Clin Cancer Res N Lassau, A Roche. Imaging and angiogenesis: DCE-US (dynamic contrast enhanced-ultrasonography) Bull Cancer N B Lassau, MD, PhD, Villejuif, FRA; J Lacroix, MD; R Aziza; V Vilgrain, MD; S Taieb, MD; S Koscielny French Multicentric Prospective Evaluation of Dynamic Contrastenhanced Ultrasound (DCE-US) for the Evaluation of Antiangiogenic Treatments. RSNA J Pellier, Villejuif, FRANCE; J Chevalier, MSC; S Koscielny; J Bonastre, DSc, MSC; B Benatsou; N B Lassau, MD, PhD. Methodological Study to Assess the Evolution of the Quality of Dynamic Contrast-enhanced Ultrasound in

114 a Large National Multicentric Study. RSNA J Bonastre, DSc, MSC, Villejuif, FRANCE; J Chevalier, MSC; J Pellier; B Benatsou; S Koscielny; N B Lassau, MD, PhD. Dynamic Contrast-enhanced Ultrasound with Quantification to Assess Targeted Treatment Efficacy: Results of a Multi-centric Prospective Cost Study. RSNA Nathalie Lassau, Serge Koscielny, Laurence Albiges, Linda Chami, Baya Benatsou, Mohamed Chebil, Alain Roche, Bernard J. Escudier Metastatic Renal Cell Carcinoma Treated with Sunitinib: Early Evaluation of Treatment Response Using Dynamic Contrast-Enhanced Ultrasonography Clin Cancer Res Feb 15;16(4): Peronneau P, Lassau N, Leguerney I, Roche A, Cosgrove Special Focus Session 119 D. Contrast Ultrasonography: Necessity of Linear Data Processing for the Quantification of Tumor Vascularization. June 24, 2010, Ultraschall in Med 2010; 31: Lassau N, Koscielny S, Chami L, Chebil M, Benatsou B, Roche A, Ducreux M, Malka D, Boige V. Advanced Hepatocellular Carcinoma: Early Evaluation of Response to Bevacizumab Therapy at Dynamic Contrast-enhanced US with Quantification--Preliminary Results. Radiology Jan;258(1): Lassau N, Chami L, Chebil M, Benatsou B, Bidault S, Girard E, Abboud G, Roche A. Dynamic contrast-enhanced ultrasonography (DCE-US) and anti-angiogenic treatments. Discov Med Jan;11(56): Special Focus Session 20, Friday (Hall E1-4)

115 120 42nd Korean Society of Ultrasound in Medicine 2011 Open SF1 AB-03 Abdomen 11:10-11:30 Hall E1-4 Chairperson(s): Hae Jeong Jeon Konkuk University, Korea Masatoshi Kudo Kinki University, School of Medicine, Japan Update on Endoscopic USG: How Much for Imaging, Needling, or Therapy? Masatoshi Kudo Department of Gastroenterology and Hepatology, Kinki University, School of Medicine, Japan Endoscopic ultrasonography (EUS) is superior to all other imaging modalities in detecting small pancreatic cancers because of its high resolution and availability of fine needle aspiration biopsy (FNA). However, its ability to characterize hypoechoic pancreatic masses is limited To characterize such hypoechoic masses, contrast enhancement with intravenous ultrasound contrast agents is needed. The development of second generation ultrasound contrast agents and an EUS system with a broad band transducer now allows microvessels and the parenchymal perfusion in the pancreas to be visualized. This contrast-enhanced harmonic EUS has shown that most pancreatic cancers exhibit hypovascular heterogeneous enhancement with irregular network-like microvessels. Moreover, it can diagnose pancreatic cancers with high sensitivity (89-92%). Abdominal pain is a common and often difficult symptom to manage in patients with pancreatic cancer. EUS-guided Celiac plexus neurolysis (CPN) has demonstrated safety and efficacy through real-time imaging and anterior access to the celiac plexus from the posterior gastric wall, thereby avoiding complications related to the puncture of spinal nerves, arteries and the diaphragm, and is now practiced widely. Furthermore, recently two new EUS-guided neurolyses for abdominal pain of pancreatic cancer have been reported. The first of these is EUS-guided celiac ganglia neurolysis (EUS-CGN) in which EUS facilitates CGN by enabling direct injection into the individual celiac ganglion, and the second is EUS-guided broad plexus-neurolysis (EUS-BPN) that extends over the superior mesenteric artery. Endoscopic ultrasonography-guided choledochoduodenostomy (EUS-CDS) is as an alternative to percutaneous transhepatic biliary drainage (PTBD) in patients with biliary obstruction when endoscopic retrograde biliary drainage (ERBD) is unsuccessful. We reviewed our experience and technique in patients undergoing EUS-CDS. Over a 2-year period to Dec 2008, 15 patients with unsuccessful ERBD underwent EUS- CDS. EUS-guided needle puncture was performed to access the bile duct from the duodenal bulb. After cholangiography, a guidewire is inserted through the needle and directed to the hepatic hilum. The puncture fistula is then dilated with a biliary dilator and a plastic stent was inserted. The technical success rate of EUS-CDS was 93% (14/15 patients), and one patient underwent an EUS-guided rendezvous approach because the choledochoduodenal fistula could not be dilated. Decompression of the bile duct was achieved in all patients. In conclusion, recent development of EUS provides superb contrast-enhanced image, EUS-FNA, EUS- CPN and treatment such as several types of biliary drainage. References 1. Kitano M, Sakamoto H, Matsui U, Ito Y, Maekawa K, Shrenck T V, Kudo M: a novel perfusion imaging technique of the pancreas: contrast-enhanced harmonic EUS (with video). Gastrointest Endscopy 67: , Kitano M, Kudo M, Sakamoto H, Nakatani T, Maekawa K, Mizuguchi N, Ito Y, Miki M, Matsui U, Shrenck T V: Preliminary study of contrast-enhanced harmonic endosonography with second-generation contrast agents. J Med Ultrason 35:11-18, Sakamoto H, Kitano M, Suetomi Y, Maekawa K, Takeyama Y, Kudo M: Utility of contrast-enhanced endoscopic ultrasonography for diagnosis of small pancreatic carcinomas. Ultrasound Med Biol 34: , 2008.

116 Special Focus Session Sakamoto H, Kitano M, Dote K, Chikugo T, Takeyama Y, Kudo M: In situ carcinoma of pancreas diagnosed by EUS- FNA. Endoscopy 40: E15-16, Sakamoto H, Kitano M, Komaki T, Noda K, Chikugo T, Kudo M: Small cell carcinoma of the pancreas: role of EUS- FNA and subsequent effective chemotherapy using carboplatin and etoposide. J Gastroenterol 44: , Sakamoto H, Kitano M, Komaki T, Noda K, Chikugo T, Dote K, Takeyama Y, Das K, Yamao K, Kudo M: Prospective comparative study of the EUS guided 25-gauge FNA needle with the 19-gauge Trucut needle and 22-gauge FNA needle in patients with solid pancreatic masses. J Gastroen Hepatol 24: , Kitano M, Sakamoto H, Komaki T, Kudo M: Present status and future perspective of EUS-guided drainage. Digest Endosc 21: 66-70, Sakamoto H, Kitano M, Komaki T, Imai H, Kamata K, Kimura M, Takeyama Y, Kudo M: Small invasive ductal carcinoma of the pancreas distinct from branch duct intraductal papillary mucinous neoplasm. Case Report. World J Gastroetenrol 15: , Kamata K, Kitano M, Komaki T, Sakamoto H, Kudo M: Transgastric EUS guided gallbladder drainage for acute cholecystitis. Endoscopy 41: E , Kitano M, Sakamoto H, Das K, Komaki T, Kudo M: EUSguided in vivo microdialysis of the pancreas: a novel technique with potential diagnostic and therapeutic application. Gastrointest Endosc 71: , Sakamoto H, Kitano M, Kamata K, El-Masry M, Kudo M: Diagnosis of pancreatic tumors by endoscopic ultrasonography. World J Radiol 2: , Sakamoto H, Kitano M, Kamata K, Komaki T, Imai H, Chikugo T, Taketyama Y, Kudo M: EUS-guided broad plexus-neurolysis over the superior mesenteric artery using a 25 gauge needle. Am J Gastroenterol 105: , Sakamoto H, Kitano M, Kudo M: Diagnosis of subepithelial tumors in the upper gastrointertinal tract by EUS. World J Radiol 2: , Kamata K, Kitano M, Kudo M, Imai H, Sakamoto H, Komaki T: Endoscopic ultrasound (EUS)-guided transluminal endoscopic removal of gallstones. Endoscopy 42:E , Kitano M, Komaki T, Sakamoto H, Imai H, Kamata K, Kudo M: Endoscopic ultrasonography (EUS) and contrastenhanced EUS. Pancreatology, 2011 (in press) 16. Komaki T, Kitano M, Sakamoto H, Imai H, Kamata K, Kudo M: EUS guided biliary drainage. Pancreatology, 2011 (in press) 17. Sakamoto H, Kitano M, Komaki T, Imai H, Kamata K, Kudo M: EUS guided pain cotrol. Pancreatology, 2011 (in press) 18. Kitano M, Kudo M, Yamao K, Takagi T, Sakamoto H, Komaki T, Kamata K, Imai H, Murakami T, Takeyama Y: Characterization of small pancreatic neoplasms by contrast-enhanced harmonic endosonography. Gastrointest Endosc, 2011 (in press) 19. Kamata K, Kitano M, Kudo M, Sakamoto H, Komaki T, Imai H: Transluminal endoscopic removal of gallstones. Endoscopy, 2011 (in press) 20. Sakamoto H, Kitano M, Matsui S, Kamata K, Komaki T, Imai H, Dote K, Kudo M: Estimation of malignant potential of GIST by contrast-enhanced harmonic EUS (with video). Gastrointest Endosc, 2011 (in press) Special Focus Session 20, Friday (Hall E1-4)

117 122 42nd Korean Society of Ultrasound in Medicine 2011 Open SF1 AB-04 Abdomen 11:30-11:50 Hall E1-4 Chairperson(s): Hae Jeong Jeon Konkuk University, Korea Masatoshi Kudo Kinki University, School of Medicine, Japan Real-time Image US Fusion and Navigation Technique with CT or MRI Min Woo Lee Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Korea With the technical development of CT and MRI, we encounter smaller hepatocellular carcinomas (HCCs) more frequently than before. Although radiofrequency ablation (RFA) has been used as a curative treatment option for unresectable HCCs, not all HCCs are suitable for percutaneous US-guided RFA. As an example, HCCs with very small size and subphrenic location are sometimes hard to detect on conventional US. Recently, volume navigation (GE healthcare) was introduced as a one kind of fusion imaging technique for the guidance of abdominal interventional procedure. We have performed volume navigation-guided RFA of HCC with poor lesion conspicuity on conventional US and found that volume navigation was of great help for the accurate targeting of small HCC with poor lesion conspicuity. Volume navigation is a promising technique for guidance of RFA. It can increase operator s confidence, the accuracy of procedures, and thus, results in increased rate of technical success.

118 SF2 IR-01 Special Focus Session 123 Intervention 10:30-10:50 Hall E6 Chairperson(s): Won Hong Kim Inha University Hospital, Korea Sang-Wook Yoon CHA Bundang Medical Center, CHA University, Korea Therapeutic Effects of High-Intensity Focused Ultrasound Ablation on Uterine Leiomyomas: A 147-Case Study Xiaoye Hu Department of Oncology, Second Affiliated Hospital, Zhejiang University School of Medicine, China Objective To evaluate the therapeutic effects of high-intensity focused ultrasound (HIFU) ablation on uterine leiomyomas and related clinical factors. Methods One hundred forty-seven patients with clinically and ultrasonographically diagnosed uterine leiomyomas at the Second Affiliated Hospital, Zhejiang University School of Medicine from June 2003 to September 2010 were recruited in this study. Their clinical outcomes after HIFU treatment were assessed through a 3-month follow up, in which changes of the uterine and leiomyoma volumes were measured by ultrasound or pelvic MRI. Results HIFU ablation was administered to 197 leiomyomas in 147 patients. The average uterine and 70.6% resumed normal menstruation, and symptoms such as abdominal discomfort and bladder and rectal pressure disappeared in 78.7%. The treatment efficacies for leiomyomas with ablation rates less than 20%, ranging from 20% to 80% and greater than 80% were 16%, 52% and 88%, respectively (p < 0.01). For leiomyomas above or below the depth of 9 cm from the skin, the efficacies were 76% and 42%, respectively (p < 0.001); for those with limited or adequate blood supply, the efficacies were 70% and 6%, respectively (p < 0.001). Anesthetic and non-anesthetic procedures had the efficacies of 81% and 61%, respectively (p < 0.05). On the other hand, the leiomyoma size, age and skin thickness were irrelevant to the leiomyoma volumes decreased to cm 3 therapeutic effect (p > 0.05). and cm 3 after three months postoperatively Conclusion HIFU is effective for the treatment from cm 3 and cm 3, uterine leiomyomas. The clinical effects were related respectively (p < 0.01). The total effective rate of individual leiomyomas was 64.4%. Of all the patients, to the ablation rate, depth and blood supply of leiomyomas and types of procedure. Special Focus Session 20, Friday (Hall E6)

119 124 42nd Korean Society of Ultrasound in Medicine 2011 Open SF2 IR-02 Intervention 10:50-11:10 Hall E6 Chairperson(s): Won Hong Kim Inha University Hospital, Korea Sang-Wook Yoon CHA Bundang Medical Center, CHA University, Korea HIFU Therapy of Pancreas Cancer Seung Eun Jung Department of Radiology, Seoul St. Mary s Hostpial, The Catholic University of Korea, Korea Pancreatic cancer is life threatening with a very high fatality rate. Most patients with pancreatic cancer are diagnosed when their disease has reached an advanced stage. More than 80% of patients with pancreatic cancer will die within several months of the diagnosis, while less than 5% are expected to survive beyond five years after the initial diagnosis (1). To date, surgical treatment of pancreatic cancer is the only modality that offers a chance for long-term survival. However, potentially curative surgery is an option for only about 10-15% of patients with pancreatic cancer (2, 3). Even if surgical resection with or without adjuvant therapy is performed, the 5-year survival is less than 20% (4, 5). The median survival time is 6-10 months for patients with locally advanced pancreatic cancer, and 3-6 months for patients with metastatic disease. Although palliative chemoradiation may be used to gain a survival benefit, no effective modality has been demonstrated for the treatment of patients that are not candidates for curative resection (6-9). Systemic chemotherapy for advanced PC to date has failed to provide more than a very modest survival benefit for patients with advanced disease (10, 11). Tumor ablation therapy using high intensity focused ultrasound (HIFU) is a non-invasive method using focused ultrasound energy from an extracorporeal source that is targeted within the body; this method results in thermally induced necrosis and apoptosis (12-15). The primary mechanisms of HIFU are associated with the delivery of energy to the target tissue that causes coagulative necrosis by thermal effects and cavitation. Cavitation is a mechanical effect of the US energy that damages tissue. Because of the depression caused by the negative part of the US wave, intracellular water can enter the gaseous phase and lead to the development of microbubbles. When they reach the size of resonance, these bubbles may suddenly collapse and produce high-pressure shock waves destroying adjacent tissue. The effects of HIFU disrupt the cell membrane; enhancement of the systemic anti-tumor immune response has been confirmed experimentally (18). In the targeted area, all tumor cells are irreversibly destroyed as noted by nuclear pyknosis, debris, and dissolution (19, 20). HIFU therapy has been used to treat a variety of advanced stage solid tumors in different areas of the body (1). HIFU for the treatment of pancreatic cancer may be useful for alleviating pain in patients that have intractable pain; these patients might also benefit from local tumor control. There remains controversial in the efficacy of local tumor control in patients with advanced pancreatic cancer; this is because pancreatic cancer has been considered a systemic disease. Many clinical attempts were failed to demonstrate these efficacies. Recently, the feasibility of HIFU for advanced pancreatic cancer has been reported in small case series (16, 17). Oncologists continue to debate the efficacy of local tumor control in patients with advanced pancreatic cancer; this is because pancreatic cancer has been considered a systemic disease. Though, we have thought that local control with HIFU ablation of the primary tumor may enhance the systemic anti-tumor effects and it could attribute to lengthen the span of overall survival. Theoretically, HIFU is an attractive technique that might achieve local tumor control as well as enhance anti-tumor effects in several aspects. First, cell membrane disruption by HIFU may enhance chemotherapeutic effects by increasing permeability of drugs molecules. Second, HIFU has been shown to activate human immunity and decrease tumor growth (21, 22).

120 Enhanced T-cell immunity may lead to reduction and/or elimination of metastases and prevent local recurrence. Third, the systemic tumor burden may be reduced by ablating the primary focus by the HIFU. This can be supported by that patients undergoing complete HIFU ablation demonstrated a negative conversion of circulating mrna tumor-specific markers (23). However, there were no reports that this effect could attribute to lengthen the span of overall longterm survival. Since 2006, we treated 46 patients with pancreatic carcinoma using a HIFU system (Model-JC, Haifu Technology Co. Ltd., Chongqing, China). Our study was a prospective trial to evaluate the safety and efficacy as well as the long term outcome of HIFU therapy for advanced pancreatic cancer. After one HIFU session, complete tumor necrosis of the targeted lesion was achieved in most patients. In the majority of patients, the HIFU ablated tumor necrotic lesions remained without progression even though extrapancreatic metastases might have occurred. The results of this study are consistent with the earlier research from this group reported in 2007 on 18 patients (30). In addition, HIFU therapy leads to a significant increase in the overall survival. The overall median survival was months in the HIFU treated pancreatic cancer patients; this is significantly improved compared to the outcomes of prior reports of chemotherapy alone and primary chemoradiation therapy with or without maintenance chemotherapy. (6-11, 21-29). On the follow period after HIFU, survival time was not affected whether the chemotherapy was done. The main advantages of the HIFU are that it is noninvasive and conformal. It can induce complete coagulation necrosis of a deep tumor through the intact skin and can ablate large volume tumors. In addition, the real-time targeting process can enhance the accuracy and shape suitability. In our clinical experience, HIFU has been very useful for recurrent, residual, large, and multiple tumors; even tumors located near to the celiac trunk or splenic vascular structures or in a difficult location that is inaccessible by other methods. Therefore, HIFU provides patients with a new therapeutic option with reduced pain, reduced damage to adjacent structures, more rapid recovery and no risk for tumor seeding from an inserted instrument tract. Special Focus Session 125 The limitations of the HIFU are the long procedure time and general anesthesia. In addition, to avoid complications, complete bowel preparation and compression of the bowel loops with water packs are essential. Pancreatic HIFU can be performed regardless of the tumor location, even in the head of the pancreas. However, HIFU should be avoided in cases with marked duodenal invasion or duodenal stenting because these cases revealed high risk of duodenal fistula formation after the HIFU. The purpose of this lecture was to introduce our clinical experiences using HIFU therapy of pancreatic cancer including how to operate HIFU for pancreatic cancer and its complications and discuss the potential benefits for treating patients with advanced pancreatic cancer. References 1. Greenlee RT, Murray T, Bolden S, et al. Cancer statistics CA Cancer J Clin 2000;50: Batidas JA, Poen JC, Niederhuber JE. Pancreas. In: Abeloff MD, Armitage JO, Lichter AS, Niederhuber JE, eds. Clinical oncology. 2nd ed. Philadelphia: Churchill- Livingston; 2000: Cancer Research UK. Cancer statistics. Available at: 4. Goggins M. Molecular markers of early pancreatic cancer. J Clin Oncol 2005;23: Chua YJ, Cunningham D. Adjuvant treatment for resectable pancreatic cancer. J Clin Oncol. 2005;23: Huguet F, Girard N, Guerche CS, et al. Chemoradiotherapy in the management of locally advanced pancreatic carcinoma: a qualitative systematic review. J Clin Oncol 2009;27: Chauffert B, Mornex F, Bonnetain F, et al. Phase III trial comparing intensive induction chemoradiotherapy (60 Gy, infusional 5-FU and intermittent cisplatin) followed by maintenance gemcitabine with gemcitabine alone for locally advanced unresectable pancreatic cancer. Definitive results of the FFCD/SFRO study. Ann Oncol 2008; 19: Sultana A, Tudur SC, Cunningham D, et al. Systematic review, including meta-analyses, on the management of locally advanced pancreatic cancer using radiation/combined modality therapy. Br J Cancer 2007;96: Whittington R, Neuberg D, Tester WJ, Benson 3rd AB, Haller DG. Protracted intravenous fluorouracil infusion with radiation therapy in the management of localized pancreaticobiliary carcinoma: a phase I Eastern Cooperative Oncology Group Trial. J Clin Oncol 1995;13: Mukherjee S, Hudson E, Reza S, et al. Pancreatic cancer within a UK cancer network with special emphasis on locally advanced non-metastatic pancreatic cancer (LANPC). Clin Oncol (R Coll Radiol) 2008;20: Special Focus Session 20, Friday (Hall E6)

121 126 42nd Korean Society of Ultrasound in Medicine 2011 Open 11. Jackson A, The pancreatic subgroup of ACCORN. Survey of current UK practice of pancreatic cancer management by clinical oncologists. In: Proceedings of combined chemo-radiotherapy for GI cancer. London: BIR; Dubinsky TJ, Cuevas C, Dighe MK, et al. High-intensity focused ultrasound: current potential and oncologic applications. AJR Am J Roentgenol 2008;190: Vykhodtseva N, McDannold N, Martin H, et al. Apoptosis in ultrasound-produced threshold lesions in the rabbit brain. Ultrasound Med Biol 2001;27: Wu F, Chen WZ, Bai J, Zou JZ, Wang ZL, Zhu H, Wang ZB. Pathological changes in human malignant carcinoma treated with high-intensity focused ultrasound. Ultrasound Med Biol 2001;27: Leslie TA, Kennedy JE. High intensity focused ultrasound in the treatment of abdominal and gynaecological diseases. Int J Hyperthermia 2007;23: Wu F, Wang ZB, Zhu H, et al. Feasibility of US-guided high-intensity focused ultrasound treatment in patients with advanced pancreatic cancer: initial experience. Radiology 2005;236: Wang X, Sun J. High-intensity focused ultrasound in patients with late-stage pancreatic carcinoma. Chin Med J (Engl) 2002;115: Yang R, Reilly CR, Rescorla FJ, et al. High-intensity focused ultrasound in the treatment of experimental liver cancer. Arch Surg 1991; 126: Lai EC, Fan ST, Lo CM, Chu KM, Liu CL, Wong J. Hepatic resection for hepatocellular carcinoma. An audit of 343 patients. Ann Surg 1995;221: Llovet JM, Burroughs A, Bruix J. Hepatocellular carcinoma. Lancet 2003;362: Cunningham D, Chau I, Stocken DD, et al. Phase III randomized comparison of gemcitabine versus gemcitabine plus capecitabine in patients with advanced pancreatic cancer. J Clin Oncol 2009;27: Herrmann R, Bodoky G, Ruhstaller T, et al. Gemcitabine plus capecitabine compared with gemcitabine alone in advanced pancreatic cancer: a randomized, multicenter, phase III trial of the Swiss Group for Clinical Cancer Research and the Central European Cooperative Oncology Group. J Clin Oncol 2007;25: Wu F, Wang ZB, Jin CB, et al. Circulating tumor cells in patients with solid malignancy treated by high-intensity focused ultrasound. Ultrasound Med Biol. 2004;30: Louvet C, Labianca R, Hammel P, et al. Gemcitabine in combination with oxaliplatin compared with gemcitabine alone in locally advanced or metastatic pancreatic cancer: results of a GERCOR and GISCAD phase III trial. J Clin Oncol 2005;23: Moore MJ, Goldstein D, Hamm J, et al. Erlotinib plus gemcitabine compared with gemcitabine alone in patients with advanced pancreatic cancer: a phase III trial of the National Cancer Institute of Canada Clinical Trials Group. J Clin Oncol 2007;25: Milano MT, Chmura SJ, Garofalo MC, et al. Intensity-modulated radiotherapy in treatment of pancreatic and bile duct malignancies: toxicity and clinical outcome. Int J Radiat Oncol Biol Phys 2004;59: Ben-Josef E, Shields AF, Vaishampayan U, et al. Intensitymodulated radiotherapy (IMRT) and concurrent capecitabine for pancreatic cancer. Int J Radiat Oncol Biol Phys 2004;59: Wilkowski R, Thoma M, Schauer R, et al. Effect of chemoradiotherapy with gemcitabine and cisplatin on locoregional control in patients with primary inoperable pancreatic cancer. World J Surg 2004;28: Shinchi H, Takao S, Noma H, et al. Length and quality of survival after external-beam radiotherapy with concurrent continuous 5-fluorouracil infusion for locally unresectable pancreatic cancer. Int J Radiat Oncol Biol Phys 2002;53: Jung SE, Cho SH, Hahn ST, et al. High-intensity Focused Ultrasound Treatment (HIFU) for the Advanced Pancreatic Cancer. J Korean Radiol Soc 2007;56:

122 SF2 IR-03 Special Focus Session 127 Intervention 11:10-11:30 Hall E6 Chairperson(s): Won Hong Kim Inha University Hospital, Korea Sang-Wook Yoon CHA Bundang Medical Center, CHA University, Korea HIFU/MRgFUS of Uterine Diseases Sang-Wook Yoon Department of Diagnostic Radiology, CHA Bundang Medical Center, CHA University, Korea MR-guided focused ultrasound surgery (MRgFUS) is a totally non-invasive treatment modality. This is a kind of ablation therapy. The difference between RF ablation and focused ultrasound surgery (FUS) is that FUS has clear treatment margin with adjacent tissue comparing with RFA. This feature is directly related with accuracy of treatment area and safety. MRgFUS system is composed of a MRI and a FUS system. MRI is used to visualize patient anatomy, map the volume of tissue to be treated, and control the treatment by monitoring the temperature of the tissue after heating. Focused beam of ultrasound energy, generated by FUS system heats and destroys the tissue using high-intensity sound waves. MRgFUS is now applied to uterine disease such as uterine fibroids(uf) and adenomyosis(adm), breast cancer, pain palliation from bone metastasis, liver tumor, and brain disease such as tumor or functional disorder. In this session, MRgFUS about uterine fibroids and adenomyosis will be mentioned. Objectives: 1. To know the principle of MRgFUS 2. Patient selection criteria in screening MRI for UF and ADM. 3. The benefits of MRgFUS in UF and ADM. 4. Cases Special Focus Session 20, Friday (Hall E6)

123 128 42nd Korean Society of Ultrasound in Medicine 2011 Open SF2 IR-04 Intervention 11:30-11:50 Hall E6 Chairperson(s): Won Hong Kim Inha University Hospital, Korea Sang-Wook Yoon CHA Bundang Medical Center, CHA University, Korea Experience in MR Guided Focused Ultrasound Surgery (MRgFUS) of Early Prostate Cancer Kwek JW, Cheng CWS, Thng CH, Lau W, Khoo J Department of Oncologic Imaging, National Cancer Centre, Singapore Early detection of prostate cancer has led to concerns that while many early prostate cancers now diagnosed posed too little a threat for radical therapy, these men may be reluctant to accept active surveillance. Traditional radical therapies like radical prostatectomy and radiation therapy are associated with complications such as incontinence and impotence. Other whole gland therapies such as transrectal HIFU and cryotherapy also report moderate risk of above complications as well as rectal-related morbidity. Focal therapy in a carefully selected population with early prostate cancer may be associated with minimal morbidity. An ideal focal therapy modality should show preclinical evidence of tumoricidal activity, allow real time treatment monitoring, be non invasive, affects only dominant tumor focus with minimal alteration of structures essential for sexual, urinary and bowel function, not prohibitively expensive, allows re-treatment or subsequent whole gland therapy such as surgery or radiation without excess morbidity. In this lecture, I will share our experience of using MR guided Focused Ultrasound Surgery (MRgFUS) for focal ablation of early prostate cancer at the National Cancer Centre Singapore.

124 Special Focus Session 129 SF3 PD-01 Pediatric 13:20-13:50 Hall E5 Chairperson: Young Seok Lee Dankook University Hospital, Korea Ultrasound of the Neonatal Brain Harvey Teo Department of Diagnostic Imaging, Kandang Kerbau Women s and Children s Hospital, Singapore Ultrasound (US) of the neonatal brain has been performed since the 1970s. With the advent of high-resolution transducers, quick and easy portability of US, it has become the primary and initial mode of evaluating the neonatal brain. Most images are obtained through the anterior fontanelle. Other acoustic windows are the posterior fontanelle, mastoids, temporal bones and foramen magnum. Standard planes in coronal and sagittal sections are obtained through the anterior fontanelle. Normal variants that should be recognized are the appearance of the premature brain, cavi septi pellucid, cavi vergae, periventricular halo, extra-axial fluid spaces and connatal cysts. Intracranial hemorrhage (ICH) is an important complication in the premature patient. ICH can be graded into 4 grades according to the Papile grading system and these are related to the prognosis of the patient. Parenchymal and extra-axial hemorrhages are more common in term infants. Hypoxic-ischemic injury in the premature infant results in periventricular leukomalacia. In the term infant diffuse ischemic injury results in hypoxicischemic encephalopathy with the cortex becoming diffusely echogenic and the gyral-sulcal surfaces becoming poorly defined. The echogenicity of the white matter is also increased and the gray-white matter differentiation becomes more prominent. US of the neonatal brain is also excellent in depicting congenital malformations, hydrocephalus, tumors and infections. Examples of these will be illustrated as well as correlative imaging with MRI. Special Focus Session 20, Friday (Hall E5)

125 130 42nd Korean Society of Ultrasound in Medicine 2011 Open SF3 PD-02 Pediatric 13:50-14:20 Hall E5 Chairperson: Young Seok Lee Dankook University Hospital, Korea Ultrasonography of Neonatal Hepatobiliary Disease Woo Sun Kim Department of Radiology, Seoul National University Children s Hospital, Korea Ultrasonography(US) has been accepted as the initial imaging modality of choice for the evaluation of neonatal jaundice. US can exclude the presence of choledochal cyst or dilatation of the biliary tract due to other causes of obstruction. US is performed after the patient has fasted for at least 4 hours in the neonatal and infantile period. In the evaluation of neonatal jaundice, a high MHz transducer should be used for the examination of the size and shape of GB and the portahepatis. Although there is large variation in the range of normal measurement, GB measures 1.3 to 3.4 cm in length (mean 2.5 cm) in neonates and young infants. The diameter of the common bile duct dose not exceed 1 mm in neonates, 2 mm in infants, 4 mm in children1 to 10 years of age, and 6 mm in adolescents, even though there is exception in some children. Biliary Atresia Two most causes of conjugated hyperbilirubinemia in neonates are biliary atresia and neonatal hepatitis. It is important to identify children with biliary atresia who benefit from early portoenterostomy. Because the two entities have similar clinical and laboratory findings, diagnostic imaging plays an important role in the differential diagnosis. US evaluation of the portahepatis as well as the gallbladder is useful. In biliary atresia, GB is usually small or atretic, although it is 1.5 cm or greater in length in about 10% of patients. In neonatal hepatitis, GB is usually normal. In biliary atresia, an obliterated bile duct remnant in the portahepatis appears as a triangular or tubular, echogenic structure along the anterior aspect of the right portal vein, which has been termed the ultrasonographic triangular cord sign. This sign is reliable for the diagnosis of biliary atresia and has a high specificity and but relatively low sensitivity. In addition to the triangular cord sign, other US findings such as non-visualization of the common bilie duct or an enlarged hepatic artery are useful in the US diagnosis of biliary atresia. The presence of hepatic subcapsular arterial flow at color Doppler US was reported in patients with biliary atresia. Focal cystic dilatation of the extrahepatic bile duct can be found in about 10% of patients with biliary atresia. In patients with this choledochal cyst associated with biliary atresia, cysts are smaller, intrahepatic ducts are not dilated, and gallbladders are small or atretic as compared with those of infants with choledochal cyst in the absence of biliary atresia. In recent articles, combinations of above US findings have showed an excellent performance(accuracy >90%) in the US diagnosis of biliary atresia. And in practice, US can make the diagnosis of biliary atresia in most of the cases. Hepatobiliary scintigraphy using various radiophamaceuticals(99mtc-disida and 99mTc-mebrofenin are commonly used) has been widely performed in the diagnosis of biliary atresia. Visualization of excreted radiophamaceutical in the lumen of the bowel can exclude the diagnosis of biliary atresia. However, patients (neonatal hepatis or biliary atresia) with liver dysfunction frequently have reduced parenchymal extraction of radiophamaceutical and poor or no excretion into the bowel, which makes a differential diagnosis very difficult. Hepatobiliary scintigraphy has high sensitivity, but it has lower specificity than ultrasonography. Although the specificity of the study may increase with premedication with phenobarbital(for more than 5 days), the premedication delays surgical intervention significantly. Because magnetic resonance cholangiography

126 (MRC) permits noninvasive evaluation of the biliary tree in infants, it has developed as an useful imaging modality for the diagnosis of biliary atresia. On heavily T2-weighted single-shot fast spin echo sequences, the demonstration of the extrahepatic bile ducts including the gallbladder, the cystic duct, the common bile duct, and the common hepatic duct can exclude the diagnosis of biliary atresia. MRC has a high accuracy, sensitivity and specificity for diagnosing biliary atresia. False-positive diagnoses of biliary atresia, which might be related to the small size of the bile ducts of infants or motion artifact, have been reported. Because MRC is more expensive than ultrasonography and not available in all hospitals, MRC may be reserved for patients with atypical or equivocal findings at ultrasonography which is the best initial imaging modality. Biopsy and histologic examination of the liver is a reliable diagnostic test for the diagnosis of some causes of neonatal or infantile jaundice,including paucity of interlobular bile ducts(alagille syndrome or nonsyndromic form), progressive familiar intrahepatic cholestasis(byler disease), TPN-induced cholestasis and some infections, which have no specific imaging finding. However, it should be performed only when the results of imaging studies are inconclusive for the diagnosis of biliary atresia because it is invasive and takes a long time to get a report. Intraoperative cholangiography is the gold standard in the diagnosis biliary atresia. Bile Plug Syndrome Bile plug syndrome is an extrahepatic biliary obstruction by bile sludge occurring in full-term Special Focus Session 131 infants with no anatomic abnormalities of the biliary tract. This syndrome may be associated with massive hemolysis, TPN, and some bowel diseases. US shows dilated intrahepatic or extrahepatic bile ducts which contain echogenic material without acoustic shadowing. Bile sludge can also be found in GB. Spontaneous Perforation of the Extrahepatic Bile Duct It affects infants under 3 months of age. Patients usually present with jaundice and ascites. The most common site of perforation is at the junction of the cystic and common hepatic ducts. Common US findings are ascites with echogenic debris or septation, a loculated bile collection in the portahepatis. The biliary tract is not dilated, although calculi may be seen in GB or common duct. Hepatobiliary scintigraphy can confirm the presence of bile leakage into the peritoneal cavity. Conclusions Prompt and accurate differentiation of biliary atresia from other causes of neonatal jaundice by using noninvasive imaging modalities is important. Ultrasonography is not only the initial imaging modality of choice but also an accurate examination for the diagnosis of biliary atresia if multiple ultrasonographic features are carefully evaluated by an experienced operator. When ultrasonographic features are conclusive, prompt surgery is needed without further investigations. MRC or liver biopsy can be performed preoperatively when the findings at ultrasonography are equivocal. Special Focus Session 20, Friday (Hall E5)

127 132 42nd Korean Society of Ultrasound in Medicine 2011 Open SF3 PD-03 Pediatric 14:20-14:50 Hall E5 Chairperson: Young Seok Lee Dankook University Hospital, Korea Ultrasound of Neonatal GI Tract Anomalies Chong Hyun Yoon Department of Pediatric Radiology, Children s Hospital Asan Medical Center, Seoul, Korea

128 Special Focus Session 133 Special Focus Session 20, Friday (Hall E5)

129 134 42nd Korean Society of Ultrasound in Medicine 2011 Open

130 Special Focus Session 135 Special Focus Session 20, Friday (Hall E5)

131 136 42nd Korean Society of Ultrasound in Medicine 2011 Open

132 Special Focus Session 137 Special Focus Session 20, Friday (Hall E5)

133 138 42nd Korean Society of Ultrasound in Medicine 2011 Open

134 Special Focus Session 139 Special Focus Session 20, Friday (Hall E5)

135 140 42nd Korean Society of Ultrasound in Medicine 2011 Open

136 Special Focus Session 141 Special Focus Session 20, Friday (Hall E5)

137 142 42nd Korean Society of Ultrasound in Medicine 2011 Open

138 SF4 GU-01 Special Focus Session 143 Genitourinary 13:20-13:40 Hall E6 Chairperson(s):Byung Kwan Park Samsung Medical Center, Korea Jeong Yeon Cho Seoul National University Hospital, Korea 3D/4D Fetal US Hye-Sung Won Department of Obstetrics & Gynecology, University of Ulsan College of Medicine, Asan Medical Center Country, Korea Nowadays 3D/4D US is essential technique to diagnose the fetal abnormalities. In the first trimester 3D US is useful method to evaluate multiple pregnancy, search the correct midsagital plane(for CRL and FNT) and fetal anomalies(acrania, conjoined twin). In the 2nd and 3rd trimester, 3D US is superior for evaluation of surface anatomy(low set ear, micrognathia, cleft lip & palate, hands and feet anomalies..) using surface rendering mode, and spinal abnormalities using X-ray mode. 3D/4D US in obstetrical field is innovative diagnostic tool. Special Focus Session 20, Friday (Hall E6)

139 144 42nd Korean Society of Ultrasound in Medicine 2011 Open SF4 GU-02 Genitourinary 13:40-14:00 Hall E6 Chairperson(s):Byung Kwan Park Samsung Medical Center, Korea Jeong Yeon Cho Seoul National University Hospital, Korea US of Male Infertility Min Hoan Moon Department of Radiology, Seoul Metropolitan Boramae Medical Center, Seoul National University College of Medicine, Korea Infertility is defined as the case in which there is a failure in pregnancy in spite of unprotected intercourse of 12 months. Infertility is caused by either male factors or female factors. Male factors are found in up to 50% of infertile couples and the sole causes of infertility in 30%. The evaluation of infertile men begins with a detailed clinical history and physical examination and then proceeds to laboratory test including semen analysis, hormonal assays, sperm function test, and genetic test. Imaging studies can be used selectively as part of the comprehensive evaluation of male infertility. In this lecture, we review the spectrum of diseases responsible for male infertility, discuss appropriate imaging modalities to be proven for specific clinical settings, and illustrate characteristic imaging findings that permit specific diagnosis. We also discuss how imaging studies may be used to distinguish defects of sperm production from obstruction of sperm passage. The discussion is divided into three main categories: obstruction in sperm passage, impairment in sperm function, and defect in sperm genesis.

140 SF4 GU-03 Special Focus Session 145 Genitourinary 14:00-14:20 Hall E6 Chairperson(s):Byung Kwan Park Samsung Medical Center, Korea Jeong Yeon Cho Seoul National University Hospital, Korea CEUS in GU Gervais Wansaicheong Department of Radiology, Tan Tock Seng Hospital, Singapore Ultrasound scans are used to differentiate between a simple cyst and solid or complex tumours. This may occur at the initial diagnosis or as part of the evaluation of lesion detected at CT scan or MR scan. Differentiation between benign and malignant lesions can be difficult. This is due to the overlap between the B mode features of such lesions. One critical feature is the vascularity of the lesion. Pulse wave and color Doppler techniques can help to characterize blood flow but are limited due to attenuation, poor sensitivity, blooming and angle dependency. CEUS can overcome many of these limitations. It can be used to evaluate the micro- and macro-circulation, characterize lesions, detect lesions and monitor local treatment. Of note, the ability to use CEUS in patients with renal impairment is important in light of concern with contrast induced nephropathy in CT scans and nephrogenic sclerosing fibrosis in MR scans. It may be viewed as a complementary investigation. The kidneys have a single-phase arterial supply, allowing for rapid contrast enhancement and assessment following contrast administration. The normal kidney enhances in the following fashion: a) Early arterial phase: Renal arteries are welldemonstrated b) Late arterial or cortical phase: Intense and uniform enhancement of the renal cortex c) Medullary phase: Pyramids gradually fill with contrast until they are isoechoic with the cortex Distinguishing between a pseudolesion and true lesion can be helped by CEUS. The former have haemodynamics that are identical to the rest of the kidney. Differentiation of a renal cell carcinoma from renal metastasis, angiomyolipoma, oncocytoma and leiomyoma is not possible. CEUS is helpful in evaluation of echoic material within the collecting system and urinary bladder and in differentiating benign thrombus from tumour extension. In an abscess, there is early rim enhancement and quicker washout. Complex cystic renal lesions can be a challenge to evaluate. CEUS is helpful in such patients as it helps to reduce the need to proceed to a CT scan or MR scan to look for features that are suggestive of malignancy. Follow up may also be done with CEUS. The technique of CEUS has been standardized with the publication of Guidelines and good clinical practice from EFSUMB. It is a relatively simple technique and requires minimal preparation and monitoring. Reference Guidelines and Good Clinical Practice Recommendations for Contrast Enhanced Ultrasound - Update EFSUMB study group. Ultraschall in Med : Special Focus Session 20, Friday (Hall E6)

141 146 42nd Korean Society of Ultrasound in Medicine 2011 Open SF4 GU-04 Genitourinary 14:20-14:40 Hall E6 Chairperson(s):Byung Kwan Park Samsung Medical Center, Korea Jeong Yeon Cho Seoul National University Hospital, Korea Ultrasound (US) Elastography in the Evaluation of Kidney Disease Sung Kyoung Moon Department of Radiology, Kyung Hee University Hospital, Korea Tissue strain imaging - elastography - embodies the tissue viscoelasticity or stiffness, and reflects the degree of tissue fibrosis. It could be considered the same as palpation for estimating the tissue hardness. Ultrasound (US) elastography is the widely-used representative of tissue strain imaging. It has been generally applied to tumor imaging of the palpable and superficial organs such as prostate, breast, and thyroid. In terms of the internal organs, virtual touch or virtual palpation technique can be applied for the evaluation of the focal and diffuse abnormalities. Its core technique is measuring the velocity of shear waves propagating in the target tissue. In harder tissue, shear waves propagate faster than in softer one. It is a noninvasive and reproducible technique for the quantification of tissue stiffness or fibrosis. There were many studies about the usefulness of US elastography in the assessment of hepatic fibrosis in patient with chronic liver disease and focal hepatic lesion and tumor. On the other hand, there are only a few clinical and experimental reports about the application of elastography on kidney disease. However, US elastography can be applied to the kidney and very useful for the evaluation of the renal pathology. There are two major applications of US elastography to the kidney; firstly, it can be applied to the quantification of renal tubulointerstitial fibrosis which is the well-known and important pathology of chronic renal disease; secondly, it can be applied to the differentiation of the renal tumors, especially renal cell carcinoma (RCC) and angiomyolipoma (AML) with minimal fat. We performed the experiment of the quantification of renal tubulointerstitial fibrosis in the rabbit model by using US elastography. It showed the good and positive correlation between viscoelasticitiy measured by US elastography and the histologic degree of renal tubulointerstitial fibrosis. We performed the clinical study about the correlation between viscoelasticity and histopathology in transplanted kidney. This clinical study also demonstrated that US elastography could show the degree of allograft fibrosis and could be the noninvasive monitoring tool for the progression to the chronic allograft nephropathy. In our study about renal tumor, US elastography revealed that the RCCs were usually harder than AMLs. Though most of AML and RCC can be differentiated from each other with US, CT and MR imaging, some small tumors such as non-clear cell type RCC and AML with minimal fat are not easy to make accurate diagnosis. US elastography may have added value in the differential diagnosis of small RCC from AML with minimal fat. In conclusion, US elastography can be the feasible and promising modality for the evaluation of various kidney diseases.

142 Special Focus Session 147 SF5 BR-01 Breast 10:30-10:50 Hall E5 Chairperson: Seong Ku Woo Keimyung University Dongsan Medical Center, Korea US Screening of Breast Cancer Eun-Kyung Kim Department of Radiology, Yonsei University, College of Medicine, Korea Sonography is an attractive supplement to mammography in breast cancer screening because it is relatively inexpensive, requires no contrast, is well tolerated by patients and is widely available for equipment. Especially in women with mammographically dense breast, it has been consistently found that sonography is able to detect additionally a substantial number of cancers at an early stage. Despite these findings, breast sonography has known limitations as a screening tool; operator-dependence, the shortage of skilled operators, the inability to detect microcalcifications, and substantially higher false-positive rates than mammography. Further study of screening sonography is still ongoing and is expected to help establish the role of screening sonography. Special Focus Session 21, Saturday (Hall E5)

143 148 42nd Korean Society of Ultrasound in Medicine 2011 Open SF5 BR-02 Breast 10:50-11:10 Hall E5 Chairperson: Seong Ku Woo Keimyung University Dongsan Medical Center, Korea Preoperative Evaluation of Breast Cancer Eun Young Ko Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Korea Preoperative evaluation of breast cancer patients is important in surgical planning especially in considering of breast conserving surgery, and treatment planning including neoadjuvant chemotherapy. 1. Evaluation of the primary tumor - location, extent - associated findings, ductal extension US findings of primary breast cancer : irregular shape indistinct, speculated, angular, microlobulated margin hypoechoic mass not-parallel orientation But in some cases such as invasive lobular carcinoma (ILC), it is difficult to evaluate on ultrasound (US). Underestimation of extent, multifocality, multicentricity is relatively common. US findings of ILC : negative hypoechoic mass with posterior shadowing ill-defined low echoic area with posterior shadowing or distortion 2. Evaluation of multifocal, Multicentric lesions % of breast cancers (Holland et al.: multifocal in 25-50%, Multicentric in 15-20%, bilaterality in 5-8% of breast cancers) - Increased risk: family history of breast cancer, young age, large size of primary tumor, ILC - US can demonstrate mammographically occult multifocal or multicentric breast cancers especially in the patients with dense breasts. 3. Evaluation of axillary lymph node status - US is superior in evaluating axillary lymph node to mammography, for mammography cannot cover whole axillary area. - Findings suggesting axillary lymph node metastasis are : Asymmetrically enlarged lymph node with thick cortex over 3 mm eccentric or irregular cortical thickening Loss of hilum, Round shape Speculated or indistinct martin suggesting extranodal tumor extension May need fine needle aspiration to skip sentinel lymph node biopsy. References 1. Fisher B, Anderson S, Redmond CK, et al. Reanalysis and results after 12 years of follow-up in a randomized clinical trial comparing total mastectomy with lumpectomy with or without irradiation in the treatment of breast cancer. N Engl J Med 1995;333: Holland R, Veling SH, Mravunac M, et al. Histologic multifocality of Tis, T1-2 breast carcinomas: implications for clinical trials of breast-conserving surgery. Cancer 1985;56: Lagios MD. Multicentricity of breast carcinoma demonstrated by routine serial subgross and radiographic examination. Cancer 1977;40: Moon WK, Noh DY, Im JG. Multifocal, Multicentric, and contralateral breast cancers: bilateral whole-breast US in the preoperative evaluation of patients. Radiology 2002;224: Liberman L. Lymphoscintigraphy fo lymphatic mapping in breast carcinoma. Radiology 2003;228:

144 Special Focus Session 149 SF5 BR-03 Breast 11:10-11:30 Hall E5 Chairperson: Seong Ku Woo Keimyung University Dongsan Medical Center, Korea Postoperative Evaluation of Breast Cancer Bo Kyoung Seo Department of Radiology, Korea University Ansan Hospital, Korea I. Breast Cancer Surgery and Reconstruction 1. Breast cancer surgery A. Breast conservation surgery Breast conservation surgery is defined as the excision of the primary breast tumor and adjacent breast tissue, usually followed by irradiation. Breast conservation surgery also is commonly referred to as lumpectomy, partial mastectomy, and segmental mastectomy. In terms of tumor recurrence, the results of prospective, randomized trials as well as the results of large retrospective non randomized studies from single institutions have demonstrated the equivalence of mastectomy and breast conservation treatment for appropriately selected patients with breast cancer. * Contraindication of breast conservation surgery Absolute contraindications Pregnancy Two or more primary tumors in separate quadrant Diffuse malignant appearing calcifications History or prior radiation to the breast area Persistent positive margins Relative contraindications History of collagen vascular disease Multiple gross tumors or indeterminate calcifications within the same quadrant Breast size to tumor size ratio B. Mastectomy a. Radical mastectomy Resection of breast, pectoralis major, and pectoralis minor muscles with axillary lymph node dissection b. Modified radical mastectomy Resection of breast, pectoralis minor muscle with or without axillary lymph node dissection c. Simple mastectomy Resection of breast with wide skin excision d. Skin-sparing mastectomy Resection of breast with minimal skin excision for reconstruction C. Sentinel lymph node biopsy The sentinel lymph node is the hypothetical first lymph node or group of nodes reached by metastasizing cancer cells from a primary tumor. If the sentinel lymph node does not contain cancer, then there is a high likelihood that the cancer has not spread to any other area of the body. Sentinel lymph node biopsy is performed to predict indication of axillary node dissection. To find out the sentinel lymph node, we use dye (1% isosulfan blue) and radioactive substance ( 99 mtcsulfur colloid). The physician visually inspects the lymph nodes for staining and uses a Gamma Probe to assess which lymph nodes have taken up the radionuclide. One or several nodes may take up the dye and radioactive tracer and the surgeon removes these lymph nodes and sends them to a pathologist for rapid examination under a microscope to look for the presence of cancer. If sentinel nodes are positive for malignancy, axillary node dissection should be performed. D. Axillary lymph node dissection Axillary lymph node dissection usually removes nodes in level I and II. While the procedure is very accurate, it exposes patients to high risk of lymphedema. Special Focus Session 21, Saturday (Hall E5)

145 150 42nd Korean Society of Ultrasound in Medicine 2011 Open 2. Reconstruction Breast reconstruction is performed after mastectomy with autologous tissues or implants. A. Flap surgery Flap surgery is a reconstruction procedure with autologous tissues. The benefits of this method are removal of unwanted fat at unwanted body part, no risk of implant rupture, and good feeling like real breast tissue. Transverse rectus abdominis myocutaneous flap, latissimus dorsi myocutaneous flap, and gluteal flap are used for breast reconstruction in patients. B. Implant insertion There are three general types of breast implant devices, defined by their filler material: saline, silicone, and composite (alternative composition). Implants are placed in subpectoral or subglandular layers. II. Postoperative Complications 1. Recurrent breast cancer The rates of local recurrence following breast conservation surgery and radiation are between 1 and 2% per year, with most of the recurrences occurring in the first 39 months. Follow-up of patients after conservative treatment includes a periodic clinical examination and mammography every 6 months during the first 2 years and every year thereafter. Inadequate treatment of the original cancer, including gross residual tumor, increases the likelihood of recurrence. Posttreatment changes can sometimes mimic malignancy or obscure locally recurrent breast cancer. a. Mammography New suspicious calcifications, new density or mass, enlarging scar or lesion, lymph node enlargement, skin thickening b. Ultrasound New mass or ducal change with malignant feature, lymph node enlargement c. MRI The most accurate imaging modality in diagnosis of tumor recurrence versus scar T1 contrast enhancement is the best technique The majority of scars more than 6 months postoperatively do not enhance significantly while all malignancies enhance significantly. 2. Hematoma and seroma The most hematoma and seroma are gradually decreased in size within 2-3 years after surgery and not necessary to aspirate. a. Mammography Early: Oval or round mass, variable margins, air-fluid levels Late: Decrease in size, architectural distortion, dystrophic calcifications b. Ultrasound Oval or round shaped cystic mass with/without septa Often internal debris Fluid-fluid levels 3. Breast edema Breast edema is usually improved within 2-3 years after surgery. This would be continued in cases with radiation therapy or axillary node dissection because of lymphedema. However, long-standing or newly developed breast edema should be evaluated for detection of tumor recurrence. a. Mammography Skin or/and trabecular thickening b. Ultrasound Skin thickening, lymphatic dilatation, increased echotexture of subcutaneous fat, blurring of normal architecture 4. Fat necrosis Fat necrosis of the breast is a benign inflammatory process that may mimic malignancy clinically, mammographically, and sonographically. Fat necrosis has various imaging findings. a. Mammography Round or oval lucent mass Oil cyst Rim calcifications or dystrophic calcifications Spiculated mass, architectural distortion, retraction Decrease in size on follow-up examinations b. Ultrasound Early: Increased echotexture due to breast edema Subacute: Complex cystic masses Late: Architectural distortion, oil cyst, calcifica-

146 tions 5. Implant rupture a. Mammography Normal: Silicon is denser than saline implant, value and multiple lines in saline implant Intracapsular rupture: Normal finding in most cases Extracapsular rupture: Free silicon, bulging contour, collapsed implant, migration of silicon to axilla, chest wall. b. Ultrasound Normal: Implant shell appears as double parallel echogenic lines, radial folds, reverberation artifacts at anterior aspect Intracapsulre rupture: Stepladder sign (multiple lines within implants), hypoechoic debris Extracapsular rupture: Snowstorm sign (silicon granulomas) c. MRI The best imaging modality for diagnosis of implant rupture Intracapsular rupture: Linguine sign (multiple hypointense lines), keyhole, teardrop or noose sign, subcapsular line Extracapsular rupture: Silicon in breast tissue or axilla III. Follow-up Surveillance Guidelines after Breast Cancer Surgery Breast cancer can recur at any time, but most recurrences occur in the first three to five years after initial treatment. Recurrence rate is 1-2% per year and 13% over 7.5 years. Prognostic indicators to predict tumor recurrence are lymph node involvement, tumor size, hormone receptors, histologic grade, and oncogene expression. The most common sites of recurrence include the lymph nodes, the bones, liver, or lungs. Tumor recurrence is classified as local recurrence (breast), regional recurrence (breast and regional lymph nodes) and distant metastasis % of tumor recurrence cases is distant metastasis and 10-30% is loco-regional recurrence. Table 1 demonstrates Summary of 2006 guideline recommendations for breast cancer surveillance by American Society of Clinical Oncology(ASCO). Based on the guideline, routine periodic breast and pelvic Special Focus Session 151 examinations are recommended. Breast self examination, history and physical examination, mammography should be performed for breast examination. Annual mammography improves survival rate after breast cancer surgery. Breast ultrasound is not routinely recommended according to the guideline. However, breast ultrasound is very useful to detect loco-regional tumor recurrence. In terms of detection of lymph node recurrence, ultrasound is excellent imaging modality to evaluate axillary or supraclavicular lymph nodes. Additionally, lymph node recurrence is a predictor of concurrent or subsequent distant metastasis, thus, the axillary and supraclavicular lymph node areas should be included if US surveillance after breast cancer surgery. In terms of detection of local tumor recurrence, ultrasound is convenient and effective modality in patients with mastectomy. Clinically, various breast imaging modalities have been used in diagnosis of tumor recurrence. MRI is the best method to complement mammography and sonography with the highest sensitivity for the diagnosis of local recurrences in the radiodense breast. MRI is the best method in diagnosis of tumor recurrence after breast conservation surgery or mastectomy References 1. Khatcheressian JL, et al. American Society of Clinical Oncology 2006 Update of the Breast Cancer Follow-up and Management Guidelines in the Adjuvant Setting. J Clin Oncol 2006;24: Orel SG, et al. Breast Cancer Recurrence after Lumpectomy and Radiation Therapy for Early-Stage Disease: Prognostic Significance of Detection Method. Radiology 1993;188: Edeiken BS, et al. Recurrence in Autogenous Myocutaneous Flap Reconstruction after Mastectomy for Primary Breast Cancer: US Diagnosis. Radiology 2003;227: Rissanen TJ, et al. Breast Cancer Recurrence after Mastectomy: Diagnosis with Mammography and US. Radiology 1993;188: Kramer S, et al. Magnetic Resonance Imaging in the Diagnosis of Local Recurrences in Breast Cancer. Anticancer Res 1998;18: Moon HJ, et al. US Surveillance of Regional Lymph Node Recurrence after Breast Cancer Surgery1Radiology 2009:252: 대한유방영상의학회. 유방영상진단학 Berg WA, Birdwell RL. Diagnostic imaging: Breast Spear SL. Surgery of the breast Bland KI, Copeland EM. The breast Special Focus Session 21, Saturday (Hall E5)

147 152 42nd Korean Society of Ultrasound in Medicine 2011 Open Table 2. Summary of 2006 guideline recommendations for breast cancer surveillance Mode of Surveillance Summary of Recommendations Recommended breast cancer surveillance History/physical examination Every 3 to 6 months for the first 3 years after primary therapy; every 6 to 12 months for years 4 and 5; then annually Patient education regarding Physicians should counsel patients about the symptoms of symptoms of recurrence recurrence including new lumps, bone pain, chest pain, abdominal pain, dyspnea or persistent headaches; helpful websites for patient education include and Referral for genetic counseling Criteria include: Ashkenazi Jewish heritage; history of ovarian cancer at any age in the patient or any first- or second-degree relatives; any first-degree relative with a history of breast cancer diagnosed before the age of 50 years; two or more first- or second-degree relatives diagnosed with breast cancer at any age; patient or relative with diagnosis of bilateral breast cancer; and history of breast cancer in a male relative Breast self-examination All women should be counseled to perform monthly breast self-examination Mammography First post-treatment mammogram 1 year after the initial mammogram that leads to diagnosis but no earlier than 6 months after definitive radiation therapy; subsequent mammograms should be obtained as indicated for surveillance of abnormalities Coordination of care Continuity of care for breast cancer patients is encouraged and should be performed by a physician experienced in the surveillance of cancer patients and in breast examination, including the examination of irradiated breasts; if follow-up is transferred to a PCP, the PCP and the patient should be informed of the long-term options regarding adjuvant hormonal therapy for the particular patient; this may necessitate rereferral for oncology assessment at an interval consistent with guidelines for adjuvant hormonal therapy Pelvic examination Regular gynecologic follow-up is recommended for all women; patients who receive tamoxifen should be advised to report any vaginal bleeding to their physicians Breast cancer surveillance testing: not recommended Routine blood tests CBCs and liver function tests are not recommended Imaging studies Chest X-ray, bone scans, liver ultrasound, computed tomography scans, FDG-PET scans, and breast MRI are not recommended Tumor markers CA 15-3, CA 27.29, and carcinoembryonic antigen are not recommended FDG-PET FDG-PET scanning is not recommended for routine breast cancer surveillance Breast MRI Breast MRI is not recommended for routine breast cancer surveillance Khatcheressian JL, et al. Journal of Clinical Oncology 24;5091, 2006

148 Special Focus Session 153 SF5 BR-04 Breast 11:30-11:50 Hall E5 Chairperson: Seong Ku Woo Keimyung University Dongsan Medical Center, Korea Introducing Breast Elastography into Clinical Practice Llewellyn Sim Department of Radiology, Singapore General Hospital, Singapore Breast elastography has a higher sensitivity, specificity and accuracy than conventional ultrasound. Combining both evaluations gives higher specificity, the same accuracy but reduces sensitivity, relative to elastography alone. The use of breast elastography alone or combined with ultrasound provides more accurate diagnosis of breast cancer This lecture serves to review the principles, technique, image interpretation and clinical applications of Breast Elastography. The following areas will be covered: A. Principles - elastography measures relative tissue hardness or softnesss under strain B. Scientific basis - review of basic research done culminating in current types of elastographic technology C. Technique - proprietary imaging technology produces a 2D elastogram using an ultrasound transducer D. Image interpretation - methods of image analysis and criteria for benign and malignant lesions E. Elastogram - Histopathological correlation - review of case studies F. Clinical Research - presentation of local data and conclusions G. Clinical applications - radiological assessment and clinical management of breast lesions using elastography H. Potential benefits - the better performance of breast elastography improves sonographic diagnosis of breast cancer, reduces rates of missed breast cancer, re-inforces a benign ultrasound finding and potentially reduces unnecessary biopsies Special Focus Session 21, Saturday (Hall E5)

149 154 42nd Korean Society of Ultrasound in Medicine 2011 Open SF6 MS-01 Musculoskeletal 10:30-10:55 Hall E6 Chairperson(s): Young Cheol Yoon Samsung Medical Center, Korea Mi Sook Sung The Catholic University of Korea, Bucheon St. Mary s Hospital, Korea US of Achilles Tendon Hong-Jen Chiou Department of Radiology, Taipei Veterans General Hospital & National Yang-Ming University, R.O. China Achilles tendon is the strongest, largest, thickest tendon and approximately 15 cm in length in the human body. The tendon is made of fascicles, with an interfascicular membrane separating the fascicles into bundles which calls peritenon. Surrounding this tendon is a dense connective tissue layer (tightly bound to the tendon) called epitendineum. Loose areolar connective tissue envelops the epitendineum called paratenon. In ultrasonography, normal Achilles tendon usually presents as linear fibrillar echogenic lines which coming from the peritenon and bold echogenic line coming from paratenon. Achilles tendon degeneration could result in fibromatosis or hypoxic, lipoid, osseous or calcific, and myxoid change. In case of sport s injury or overuse, which is very common, tear or rupture could be occurred. Achilles tendinosis generally manifests as secondary hypertrophy and hypoechogenicity which could also occur in intrasubstance tear or mucoid degeneration, sometimes, dystrophic calcification or ossification may be seen in chronic status. Some patients with crystal deposition, such as urate crystal or cholesterol deposition, could resulted in acute or chronic inflammatory change which present as globular echogenic collections with or without variable amounts of posterior acoustic shadowing. Achilles tendon tears generally appear as discretely marginated defects within the tendon, with echo-free or echognic hematoma formation. Achilles tendon tear post surgical repair or conservative treatment could generate the scar or granulation tissue which usually present as heterogeneous echogenicity. Ultrasound could define the continuity of the peritenon to predict the healing status. There are two bursa locate at distal Achilles tendon, retro-calcaneal and pre-achilleal bursa, which could be inflammation associated with Achilles tendinitis or not. They usually present as fluid accumulation and hypervascular in the margin in color Doppler ultrasonography. Ultrasonography is a good modality to demonstrate the pathology of Achilles tendon and provide sufficient information for the treatment planning and clinical follow up.

150 SF6 MS-02 Special Focus Session 155 Musculoskeletal 10:55-11:20 Hall E6 Chairperson(s): Young Cheol Yoon Samsung Medical Center, Korea Mi Sook Sung The Catholic University of Korea, Bucheon St. Mary s Hospital, Korea US of Peroneal Tendon Hong-Jen Chiou Department of Radiology, Taipei Veterans General Hospital & National Yang-Ming University, R.O. China The peroneus tendons run over the posterior surface of the fibular head where there is an adaptive fibrocartilage contact to the peroneal brevis. The superior peroneal retinaculum covers the peroneal tendons and envelops the tendon to the fibula bone. On the lateral surface of the calcaneal bone, the tendons run superficial to the calcaneo-fibular ligament and lateral to the talo-calcaneal ligament. Distal to the calcaneo-fibular ligament the tendons run superior (brevis) and inferior (longus) to the peroneal tubercle on the lateral calcaneal bone, encased by the inferior peroneal retinaculum. The peroneal brevis is inserted into the infero-lateral part of the 5th metatarsal tubercle and the longus tendon inserts into 1st metatarsal base. The function of both tendons acts for ankle plantar flexion which against to the tibialis anterior, subtalar and midtarsal evertion which against to the tibialis posterior tendon. In the US scanning technique, the transducer place posterior-laterally of the lateral malleolus, the peroneal brevis is adjacent to the fibula bone and the longus located superficially. The tendon shows hyperechoic linear fibrillar arrangement with variable anisotropy effect. Peroneal tendon lesion is a relatively uncommon cause of lateral hindfoot pain. The pathology of peroneal tendons could be degeneration, tenosyonovitis, tendinitis,subluxation or tear. Tendon subluxation may be due to tear or detachment of superiorperoneal retinaculum, the brevis tendon usually comes with partial tear. Tear ofperoneal tendon usually occur more on the brevis than longus part. US of peronealtendinopathy could be fluid accumulation in tendon sheath with increased vascularityin tenosynovitis, decreased echogenicity and swelling in peroneal tendinitis, focalintratendon hypoechoic cleft with extend to the periphery in partial tendon tear orhypoechoic cleft in complete tear. In subluxation of the peroneal tendon, dynamicultrasonography could clearly showed sliding of the peroneal tendon cross over thefibula head during dynamic movement of the ankle. Peroneal longus tear usuallyoccurs at the level of inferior peroneal retinaculum (peroneal tubercle) or os perineumregion. Therefore, os perineum fracture could be a sign of peroneal longus tendon tear,which present as echogenic bony fragment with irregular margin and posterioracoustic shadowing and hypoechoic cleft in the tendon. Ultrasound could be a goodimaging modality for the diagnosis of peroneal tendon lesions. Special Focus Session 21, Saturday (Hall E6)

151 156 42nd Korean Society of Ultrasound in Medicine 2011 Open SF6 MS-03 Musculoskeletal 11:20-11:45 Hall E6 Chairperson(s): Young Cheol Yoon Samsung Medical Center, Korea Mi Sook Sung The Catholic University of Korea, Bucheon St. Mary s Hospital, Korea US Evaluation of the Sole Pain Yun Sun Choi Department of Radiology, Eulji University, Korea Ultrasound is commonly used in clinical practice in evaluation of the sole pain. The purpose of this talk is to review causes of the sole pain, to show ultrasound appearances of the various disorders, and to give examples of how to differentiate plantar fasciitis or Morton neuroma from other causes of sole pain. should be distinguished from enthesopathy which may occur in seronegative spondyloarthropathy or from painful heel pad in rheumatoid arthritis. The presence of enthesopathy, tendinopathy, and pre- Achilles bursitis should prompt a diagnosis of seronegative spondyloarthropathy. 1. Plantar Fasciopathy 1) Plantar Fasciitis Plantar fasciitis is the most common cause of heel pain. This condition is a low grade inflammatory disorder of the fascia. Ultrasound offers a quick, noninvasive, and low cost technique to confirm the diagnosis of plantar fasciitis. Ultrasound can visualize fascial thickening ( 5 mm), hypoechoic changes, perifascial fluid collection, and bony spur (Fig. 1). In 40% of patients affected by acute plantar fasciitis, Doppler imaging may reveal hyperemia in the fascia and the adjacent soft tissues. The most common site of pathologic changes is the posterior portion of the fascia, close to its insertion on the medial tubercle. Although the posterior third of the fascia is selectively affected in most patients, some cases show pathologic abnormalities extending to the middle third. Plantar fasciitis 2) Plantar Fascia Tear Plantar fascia tear is located at the posterior insertion of the fascia. This condition is most often observed in sportsmen who have sustained forceful plantar flexion. The US appearance of plantar fascia rupture is similar to that of plantar fasciitis, including focal nodular swelling and a hypoechoic appearance of the fascia. 3) Plantar Fibromatosis (Ledderhose Disease) Plantar fibromatosis is a benign condition characterized by focal nodular enlargement of the plantar aponeurosis due to local proliferation of fibrous tissue. Passive dorsal extension of the toes tightens the apopneurosis and can result in increased local pain. In large lesions, pain may derive from direct compression exerted by the plantar nodule against the medial plantar nerve. 2. Entrapment Neuropathy Fig. 1. Plantar fasciitis Sagittal scan shows a thickened and hypoechoic preinsertional portion of the plantar fascia (arrows). Cal: calcaneus The plantar fascia is innervated by the medial calcaneal nerve and a first branch of the lateral plantar nerve. The symptoms of nerve entrapment may mimic those of plantar fasciopathy. A positive Tinel s sign, which is most commonly between quadrates plantar and abductor hallucis, results in pain or paresthesia in the sensory distribution of the nerve. The condition is sometimes referred to as Baxter s neu-

152 ropathy. On US, neuropathy of nerves may show fatty atrophy of muscles. US-guided injection may be useful as a therapeutic measure. 3. Plantar Vein Thrombosis Plantar vein thrombosis is an uncommon condition of unknown origin that may mimic plantar fasciitis. Ultrasound demonstrates one or more enlarged plantar veins containing hypoechoic non-compressible material, reflecting clots. 4. Metatarsalgia: Morton Neuroma and Intermetatarsal Bursitis Morton neuroma is a painful condition that mainly occurs in middle-aged women and reflects a mechanically induced degenerative neuropathy of a plantar common digital nerve. Morton neuroma is not a true neoplasm as it consists of a perineural fibrotic mass associated with vascular proliferation and axonal degeneration. The plantar digital nerve of the third intermetatarsal space is most commonly affected, although involvement of the second intermetatarsal space is not uncommon. To further increase overall accuracy, pressure can be applied on the medial and lateral aspects of the forefoot while relieving pressure with the transducer on the plantar foot in an attempt to demonstrate the neuroma, squeezed between the metatarsal heads, as it abruptly displaces toward the plantar surface of the foot causing a palpable click, the so-called sonographic Mulder sign. On US, Mortons neuroma appears as a fusiform hypoechoic mass (Fig. 2). The internal echotexture of Morton neuroma may be hypoechoic, anechoic, or mixed. Ultrasound has proved to be an accurate means of Special Focus Session 157 detecting Morton neuroma, with a 100% sensitivity and 83.3% specificity. The intermetatarsal bursa is an attritional bursa. In normal subjects, it contains a small amount of fluid. Intermetatrsal fluid is considered abnormal when the bursa has a transverse diameter of 3 mm. When distended by fluid, the intermetatarsal bursa appears as an echo free structure with posterior acoustic enhancement that lies dorsal and posterior to the neuroma. Compression can displace the bursal fluid and may cause a slight decrease in size of the neuroma as a result of concomitant compression of the adjacent area of mucoid degeneration. 5. Turf Toe Turf toe is a sprain of the first metatarsophalangeal joint in which there is partial or complete disruption of the plantar plate, presenting with persistent hyperextension of the proximal phalanx. Plantar plate injury manifests either as a swollen hypoechoic and discontinuous structure or with disruption of its attachment to the proximal phalanx. Dynamic scanning during flexion and extension of the affected toe can help the diagnosis by opening the gap of the tear within the substance of the plantar plate. 6. Foreign Body Granuloma Foreign body granulomas develop in response to fragments of wood, thorns, glass or plastic objects that have penetrated the soft tissues of the foot. They are almost invariably found in the subcutaneous fat at the plantar aspect of the foot. US scanning should cover a wide tissue area around the wound, as foreign bodies may migrate far away from the penetration site. Special Focus Session 21, Saturday (Hall E6) A B Fig. 2. Morton neuroma in 61-year-old female A. Transverse scan of third intermetatarsal space shows a round, hypoehoic mass (arrow). B. Longitudinal scan shows a mass (arrows) with plantar digital nerve continuity. References 1. Bianchi S, Martinoli C. Ultrasound of the musculoskeletal system. New York: Springer, 2007: Cardinal E, Chhem RK, Beauregard CG. Aubin B, Pelletier M. Plantar fasciitis: sonographic evaluation. Radiology 1996;201: Yoon SJ, Choi YS, Tien KL, Jung HJ, Lee KT, Yoon YK. Sonographic evaluation of plantar fasciitis. J Korean Radiol Soc 1999;40: Bedi DG, Davidson DM. Plantar fibromatosis: most common sonographic appearance and variations. J Clin Ultrasound 2001;29: