Purpose: The aim of this study was to investigate the incidence of fine strong echoes in benign and malignant thyroid nodules and their causative substances, as well as whether it was possible to ultrasonographically distinguish them. Subjects and Methods: A total of 144 resected nodules were used, including 56 cases of papillary carcinoma (PC), four cases of follicular carcinoma (FC), 57 cases of follicular adenoma (FA), and 27 cases of adenomatous goiter (AG). We compared and examined ultrasonographic and histologic findings for each histological type, with a particular focus on the features of fine strong echoes, their causative substances, and the correlation between them. Results: Fine strong echoes were observed in PCs with a significantly high incidence of 69.6% (39 cases, p＜0.0001), but also in 21.1% of FA (12 cases) and 25.9% of AG (7 cases). In the 58 positive cases, one or two of five microstructures (psammoma bodies, irregular-shaped microcalcifications in fibrous stroma, calcium oxalate crystal, cholesterol crystals, and psammoma body-like structures) were histologically observed, while they were absent in 76 of the 86 negative cases. Discussion: The presence or absence of fine strong echoes was coincident with the presence or absence of the five microstructures in 93.1% of cases. Fine strong echoes on ultrasound images were considered to reflect these microstructures. Fine strong echoes due to the microstructures looked like each other, but taking incidental findings into account, ultrasonographic estimation of the microstructures may be possible. In anechoic nodules, slow-moving fine strong echoes with comet signs and fixed ones are likely to be cholesterol crystals and calcium oxalate crystals, respectively. Conclusion: Fine strong echoes were observed in 22.6% of benign thyroid nodules. Their causative substances were four types of microstructures other than psammoma bodies. Calcium oxalate crystals and cholesterol crystals in the anechoic nodules may be estimated based on ultrasound images, although it seems difficult to distinguish them in most cases.
A woman in her 70s was admitted to our hospital with bilateral leg edema and dyspnea on exertion persisting for several months. Pericardial effusion was suspected based on echocardiography performed by her previous doctor. On admission, continuous heart murmur, atrial fibrillation on ECG, and cardiomegaly on chest X-p were observed. Transthoracic echocardiography showed pericardial luminal structures with color flow signals inside on Doppler echocardiography, instead of pericardial effusion. The luminal structures showed a rosary shape, and the flow drained to the enlarged coronary sinus and right atrium. Tortuous coronary dilatation started from the enlarged left coronary ostium, and a giant coronary aneurysm at the left circumferential coronary artery was observed. Cardiac computed tomography showed the same findings as echocardiography. Aorto-coronary bypass and surgery for the coronary aneurysm were performed. Here, we report a rare case of coronary arterial fistula with a giant coronary aneurysm precisely detected by transthoracic echocardiography.
Total anomalous pulmonary drainage (TAPVD) is a congenital anomaly that is extremely difficult to diagnose in the prenatal phase. However, it is essential that TAPVD is diagnosed during the prenatal period as some types of TAPVD require surgery soon after birth; moreover prompt treatment can affect the neonatal prognosis. In this article, we report our experience of prenatal diagnosis of isolated TAPVD type IIa with a dilated coronary sinus at 2nd trimester fetal ultrasound screening, along with a brief review of the literature. The patient was a 25-year-old primigravida without any medical or family history. At 20 weeks of gestation, 2nd trimester fetal ultrasound screening was performed. A partial atrioventricular septal defect (AVSD) was suspected. A partial midline defect in the heart was suspected, and the level of the atrioventricular valve appeared to be at nearly the same position in both ventricles. The images of other cardiac features were normal; when looking at the pulmonary vein for the first time, a connection to the left atrium (LA) was observed, at least in each of the right and left pulmonary venous connections. At 20 weeks of gestation, it was difficult to judge the direction of the blood flow. Thus, we decided to check it again after the fetus had grown. At 26 weeks of gestation, we found that the blood flow direction was from left to right, which is an unusual direction. The suspicion of partial AVSD was then rejected. The “septal defect” on the ultrasound image was actually a dilated coronary sinus. No features of persistent left superior vena cava (PLSVC), which is the most common anomaly when there is a dilated coronary sinus., were seen. Additionally, the pulmonary vein merged into the dilated coronary sinus. Based on these findings, we concluded that this was a case of isolated TAPVD type IIa. Therefore, we referred the patient to a tertiary hospital. In this case, a midline defect initially raised the suspicion of partial AVSD. After careful observation, however, we detected an unusual direction of the blood flow, and the resulting rejection of PLSVC led to a diagnosis of type IIa TAPVD.
Fetal huge hepatic hemangioma causes high-output cardiac failure due to arteriovenous shunting that requires assessment of fetal cardiovascular function. The ratio of umbilical venous flow volume (UVFV) to combined cardiac output (CCO) is reported to be an indicator of placental circulation. We report a case of fetal huge hepatic hemangioma with assessment of fetal cardiovascular function using the ratio of UVFV to CCO (UVFV/CCO). At 27 weeks of gestation, cardiomegaly (cardiothoracic area ratio (CTAR) 48.5%) and mild mitral and tricuspid valve regurgitation were detected on fetal ultrasonography. Increased CCO (1,214 ml/min) and UVFV (350 ml/min) but normal UVFV/CCO (28.9%) were observed. The amniotic fluid volume was normal with no sign of hydrops. At 30 weeks +1 day of gestation, the CTAR (62.9%) and CCO (1,620 ml/min) were increased, and UVFV (236 ml/min) was decreased, resulting in low UVFV/CCO (14.6%). Although there was no sign of hydrops, oligohydramnios was seen, and the biophysical profiling score (BPS) was 2/10 points. At 30 weeks +4 days of gestation, emergency cesarean section was performed because of decreased baseline variability on cardiotocography (CTG). The birth weight of the male newborn was 2,340 g, the pH of the umbilical arterial blood was 7.254, and the Apgar scores at 1 and 5 minutes were 1 and 5 points, respectively. Although coil embolization of the right hepatic arteries was performed at 1 and 5 days of age, the size of the hemangioma did not decrease. He died at 70 days of age due to sepsis caused by Gram-positive cocci. The UVFV/CCO decreased along with deterioration of fetoplacental circulation in a case of fetal huge hepatic hemangioma.