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OCTOBER 2016 – Abdominal (retroperitoneal) lymphadenopathy

Abdominal (retroperitoneal) lymphadenopathy

Dietrich CF, Dong Yi, Kaeb A

Correspondence
Prof. Dr. med. Christoph F. Dietrich
Medizinische Klinik 2
Caritas-Krankenhaus
Uhlandstr. 7
97980 Bad Mergentheim

Tel:+49 7931 58 2201
Email: christoph.dietrich@ckbm.de
2Discussion

This case report illustrates the use of conventional and innovative ultrasound technologies for the differential diagnosis of (retroperitoneal) lymphadenopathy [(6-18)], focal liver lesions [(2;19-24)], and testicular masses [(25-32)] in daily routine [(33)]. The following text mainly refers to the published paper in Endoskopie Heute [(34)]. Testicular tumours account for <2 % of all malignancies in men and are thus considered rare. There is a marked age association with 20 - 40 year old patients (mean age 35) accounting for 20 - 30 % of all cases, and testicular tumours are the most common malignant tumour in this age group. The classic initial symptom in all testicular cancers is the painless, unilateral and slow increase in size of the testis but sometimes also unspecific symptoms elsewhere. Testicular tumours can be divided into germ cell and non-germ cell tumours. The most common histological type of germ cell tumour (and ultimately of all testicular tumours, 40%) is the seminoma. The seminoma appears sonographically as a hypoechoic, relatively sharply defined tumour without calcification or cystic structures. In our patient small calcifications could be seen. Non-seminomatous germ cell tumours include embryonal carcinomas (as in our case) teratocarcinomas, teratomas, choriocarcinoma, and yolk sac tumours. Mixed tumours are rare and show a variety of elastography appearances. Other tumours of the gonadal stroma, metastases and lymphomas have to be ruled out before surgery. Sonographic appearances of the Leydig cell tumour (2 % of all testicular tumours) cannot be differentiated from those of seminoma. The echo pattern is similar to seminomas, the Leydig cell tumour is usually smaller. Differential diagnosis has to take into account haematoma, and focal changes in granulomatous orchitis (anamnestic information). According to testicular imaging we also refer to the already mentioned published literature on imaging [(25-32)]. Other pathological entities include testicular cysts and (micro) calcifications. Microlithiasis is often observed in combination with a malignant testicular tumour in the surrounding parenchyma [(26)]. The value of elastography for early detection and avoidance of biopsy procedures has not been established so far but is promising [(34)]. Lymphatic drainage of the testis is ipsilateral, lateral to the para-aortic lymph nodes, located at the level of the renal vessels on the left, and slightly more caudally on the right. The case illustrates lymph node assessment criteria. For further reading we refer to the recently published literature [(7-9;14;35-37)]. Regarding CEUS of the liver [(24;38;39)], CEUS of non-liver organs [(39)], elastography [(40-44)], and ultrasound guided interventions [(45-53)] we refer to the EFSUMB guidelines [(54)].

3References
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  20. Strobel D, Bernatik T, Blank W, Schuler A, Greis C, Dietrich CF et al. Diagnostic accuracy of CEUS in the differential diagnosis of small (
  21. Strobel D, Seitz K, Blank W, Schuler A, Dietrich CF, von Herbay A et al. Tumor-specific vascularization pattern of liver metastasis, hepatocellular carcinoma, hemangioma and focal nodular hyperplasia in the differential diagnosis of 1,349 liver lesions in contrast-enhanced ultrasound (CEUS). Ultraschall Med 2009; 30(4):376-382.
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  28. Patel KV, Huang DY, Sidhu PS. Metachronous bilateral segmental testicular infarction: multi-parametric ultrasound imaging with grey-scale ultrasound, Doppler ultrasound, contrast-enhanced ultrasound (CEUS) and real-time tissue elastography (RTE). J Ultrasound 2014; 17(3):233-238.
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4Figures
Figure 1:Abdominal (retroperitoneal) lymphadenopathy below the celiac axis using B-mode (a) and contrast enhanced ultrasound (b).
Figure 2: Focal liver lesion using B-mode (a) and contrast enhanced ultrasound (CEUS) in the arterial (b), late phase (c) and CEUS using time intensity curve analysis (TICA) (d). The B-mode ultrasound showed an isoechoic lesion with transducer distal shadowing, somewhat unspectacular. CEUS showed early and slightly hyperenhancing features in the arterial phase and pronounced wash out in the portal venous and late phases indicating metastases and excluding hemangioma [(1)]. The TICA image on the right side of the screen differentiates the initially hyperenhancing lesion (red line) in comparison to the surrounding liver parenchyma (yellow line). In the portal venous phase the red line crosses downward in comparison to the liver parenchyma (yellow line), indicating metastasis [(2-5)].
Figure 3: Imaging of the left testicle using elastography with sharp delineation of the embryonal cell carcinoma with clear stiffer elastographic delineation from the surrounding tissue (a) and CEUS with atypical neoplastic vessels and little perfusion (b).
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