have distinct delineation (hydatid cyst), lack of vascularization or show a characteristic in many centers considers that any new lesion revealed in a cirrhotic patient should be Cyst-adenocarcinoma metastases due to semifluid content may have a tumor is asymptomatic but may be associated with right upper quadrant pain in case of presence of venous type Doppler flow which reflects the portal venous nutrition of the 4 Finally, the nodular pattern is thought to represent changes related to hepatic fibrosis; it is present in approximately 10% of CFLD patients. therapeutic efficacy as early as possible. Twenty-one of these patients had normal liver echoes on ultrasound, 5 exhibited increased echogenicity and 5 had heterogeneous echogenicity. types of benign liver tumors. In case of highgrade its ability to enhance intra-lesion microcirculation, has proved its utility in monitoring On the left a typical FNH with a central scar that is hypodens in the portal venous phase and hyperdens in the equilibrium phase. Some cholangiocarcinomas have a glandular stroma. phase and seeing metastases in contrast to normal liver parenchyma during the sinusoidal The absence of Checking a tissue sample. Doppler circulation signal. It occurs in dyslipidemic or alcohol intake patients with normal physical and biological status. Among ultrasound treatment of hypervascular liver metastases. Although adenomas are benign lesions, they can undergo malignant transformation to hepatocellular carcinoma (HCC). Echogenity is variable. are represented by the presence of portal venous signal type or arterial type with normal RI Brancatelli G., Baron RL, Peterson MS, Marsh W. Helical CT screening for HCC in patients with Cirrhosis: Frequency and causes of False-Positive interpretation. These masses may be benign genetic differences or a result of liver disease. and requires other imaging procedures, follow up and measurements of the tumor at To this the risk of confusion between hypervascular Richard Baron is Chair of Radiology at the University of Chicago and well known for his work on hepatobiliary diseases. CEUS examination is It can be a constricting or an expanding lesion, because it can have a fibrous or a glandular stroma. The lesion is hyperdense in the equilibrium phase indicating dens fibrous tissue. Routine use of CEUS examination to [citation needed], It develops on non cirrhotic liver. For a lesion diameter below 10mm US accuracy is insufficient, requiring morphologic diagnostic procedures, use of other diagnostic imaging heterogeneous echo pattern. Clinically, HCC overlaps with advanced liver cirrhosis Currently, CEUS and MRI are Some authors indicate the Most hemangiomas are detected with US. validated indications at this time, but with proved efficacy in extensive clinical trials . measurement of the tumor diameter (RECIST criteria) is not enough for therapy assessment. CT will show hemangiomas as sharply defined masses with the same density as the vessels on NECT and CECT. These early HCC's are very different from the large ones that we see in the non-cirrhotic patients. evolution degrees, so that regenerative nodules, dysplastic nodules and even early ducts (which may be dilated) and the liver vessels. During late phase the appearance is isoechoic or i'd talk to your doc, whoever ordered the test. parenchymal hyperemia. 20%. [citation needed], B-mode ultrasonography is unable to distinguish between regenerative nodules and (long evolution, repeated vascular and parenchymal decompensation, sometimes bleeding due to variceal leakage) in addition to accelerated weight loss in the recent past and lack of arterial phase, with washout during the portal venous phase and hypoechoic pattern (radiofrequency, laser or microwave ablation). Ultrasound revealed a hypertrophic, heterogeneous liver and a large shunt between a patent umbilical vein and the left branch of the portal vein. especially in smaller tumors. He has been president of the Society of Computed Body Tomography and Magnetic Resonance. During the portal venous phase there is a specific "wash out" of ultrasound contrast agent (UCA) and the tumor appears hypoechoic during the late phase. CT will show most adenomas as a lesion with homogeneous enhancement in the late arterial phase, that will stay isodense to the liver in later phases. well defined, un-encapsulated area, with echostructure and vasculature similar to those of The imaging findings will be non-specific. The role of US is Metastases can look like almost any lesion that occurs in the liver. [citation needed], The substrate on which the tumor condition develops (if the liver is normal or if there is evidence of diffuse liver disease) and All these areas of enhancement must have the same density as the bloodpool. with advanced liver disease (Child-Pugh class C). On MRI metastases are usually hypointense on T1WI and hyperintense on T2WI. arterio-venous shunts. Typically, these tumors are more difficult to see than fatty deposits because the difference between the cells in the tumor and regular liver cells may not be obvious on a CT scan. Calcification can be seen in metastases of colon, stomach, breast, endocrine pancreatic ca, leiomyosarcoma, osteosarcoma and melanoma. The caudate lobe extends to the right kidney. HCC and Portal Vein thrombosis hyperenhancement during arterial phase close to the lesion, this being suggestive of a liver At the time the article was created Yuranga Weerakkody had no recorded disclosures. Early HCC needs to be differentiated from other hypervascular lesions, that will be hyperdense in the arterial phase. area showing a peripheral homogeneous hyperenhanced rim due to post-procedure Posterior from the lesion the During the portal venous and late phase, the appearance is persistently isoechoic. In these metastases the halo is most probably related to a combination of compressed normal hepatic parenchyma around the mass and a zone of cancer cell proliferation. [citation needed], These lesions are well defined, with isoechoic or hypoechoic appearance and sizes less than If the liver is hyperechoic due to steatosis, the hemangioma can appear hypoechoic (figure). HCC may be solitary, multifocal or diffusely infiltrating. They are best seen in the late arterial phase at 35 sec after contrast injection. Another common aspect is "bright In addition, discrimination of synchronous lesions that have a Differential diagnosis [citation needed], 2D ultrasound, Doppler ultrasound and especially CEUS can play an important role in pretherapeutic Findings of heterogeneous liver echogenicity and irregular surface correlated to liver cirrhosis with a sensitivity of 70.6%, specificity of 100%, positive and negative predictive values of 100% and 82.1% respectively, and accuracy of 87.5%. Hemangioma is the most common benign liver tumor. For a recently developed nodule the dimensional criteria will be taken into account. Early therefore CEUS appearance is hypoechoic). normal liver (metastases). The lesion definitely has some features of a hemangioma like nodular enhancement in the arterial phase and progressive fill in in the portal venous and equilibrium phase. Small HCC and hypervascular metastases may mimic small hemangiomas because they all show homogeneous enhancement in the arterial phase. ** TECHNIQUE **: Ultrasound images of the liver acquired. stages, which include very early stage (single nodule <2cm), curable by surgical resection However in 20% of patients the scar is hypointense. Conventional US appearance of metastases is uncharacteristic, consisting So we have a HCC in the right lobe on the upper images and a hemangioma in the left lobe on the lower images. contraindicated. There are The efficiency of 2D ultrasound is low in assessing the effects of HCC or metastasis therapy, 3 Left untreated, continued fibrotic changes can lead to multilobular cirrhosis. remaining liver parenchyma has a dual vascular intake, predominantly portal. A similar procedure is Limitations of the method are those method for early detection and treatment monitoring for this type of tumor The presentation of liver abcesses is very much dependend on the way the bacteria have entered the liver. Rarely, HCC may appear isoechoic, consist of a tumor type with a higher degree of They typically displace normal liver vessels but no vascular or biliary invasion liver parenchyma of the cirrhotic patient. tumor may appear more evident. enhancement is slow, during several minutes, depending on the size of hemangioma and a different size than the majority of nodules. lemon juice etc. the developing context (oncology, septic) are also added. First look at the images on the left and try to find good descriptive terms for what you see. [citation needed], Generally, RN is not distinct from the surrounding parenchyma. A The most common organs of origin are: colon, stomach, pancreas, breast and lung. precapillary sphincter made up of smooth musculatures. However if you look at the delayed phase, you will notice that this area enhances. They are applied in order to obtain a full When increased, they can compress the bile The prevalence of echogenic liver is approximately 13% to 20%. CEUS represents a useful method in clinical practice for differentiating between malignant and benign FLLs detected on standard ultrasonography, and the results are in concordance with previous multicenter studies: DEGUM (Germany) and STIC (France). The incidence is compared PC-LB and EUS-LB methods in terms of diagnostic outcomes including accuracy and safety for both focal and parenchymal liver diseases . Low density, so it may be cystic i.e fluid containing. 1).Features include increased echogenicity of the liver parenchyma, poor or non-visualisation of the diaphragm, intrahepatic vessels and posterior part of the right hepatic lobe. In the arterial phase we see a hyperdense structure in the lateral segment of the left lobe of the liver. A similar appearance has been described with liver abscesses.Calcified metastases may shadow when they are densely echogenic (figure). The risk of significant bleeding from the tumor is as high as 30%. detect liver metastases is recommended when conventional US examination is not Calcification is rare and seen in less than 10%, usually in the central scar of giant hemangioma. [2], Tumor characterization is a complex process based on a sum of criteria leading towards tumor nature definition. radial vessels network develops from this level with peripheral orientation. US will show a FNH as a non specific ill-defined lesion. to the experience of the examiner. confirmation is made using CEUS examination which proves a normal circulatory bed similar These are two common findings and they can be coincidental. required. addition, the method can incidentally detect metastases in asymptomatic patients. Diagnosis and characterization of liver tumors require a distinct approach for each group of It means that the liver isn't homogeneous. Vascular complications include thrombosis and stenosis of the hepatic artery, portal vein, or inferior vena cava, as well as hepatic artery pseudoaneurysms and celiac artery stenosis. potential post-intervention complications (e.g. Hepatobiliary and Pancreatic Radiology: Imaging and Intervention. Although a liver ultrasound is intended to identify liver conditions specifically, an abdominal ultrasound in general can diagnose a variety of abdominal organ conditions, such as: 1 Abdominal pain. be cost-effective, it should be applied to the general population and not in tertiary hospitals. 3 Abnormal function of the liver. categories of cirrhotic liver nodules: regenerative, dysplastic (considered as premalignant curative or palliative therapies have been considered. CEUS exploration, by The spatial distribution of the vessels is irregular, disordered. The pathogenesis is believed to be related to a generalized vascular ectasia that develops due to exposure of the liver to oral contraceptives and related synthetic steroids. increases with the tumor size. At conventional B-mode ultrasound, diffuse fatty infiltration results in increased echogenicity of the liver when compared to other organs such as the renal cortex (Fig. You have to look at all the other images, because they give you the clue to the diagnosis. They are single or multiple (especially metastases), have a is therefore mandatory to analyze all these three phases of CEUS examination for a proper areas. Malignant lesions however have a tendency to loose their contrast faster than the surrounding liver, so they may become relatively hypodense in later phases. differentiation and therefore with slower development. of hemangioma, ultimately prove to be hepatocellular carcinoma. There are three CEUS examination cannot completely replace the other imaging [citation needed], Ultrasound exploration can be an effective procedure for the assessment of liver tumors . and hypoechoic appearance during late phase. The nodule's vasculature completely disappearing. Characteristic 2D ultrasound appearance is that of a very and a normal resistivity index. [citation needed], They are intravenously administered and are indicated in advanced stages of liver tumor Sensitivity is conditioned by the size and TACE therapeutic results by contrast imaging techniques is performed as for ablative Does this help you? Thus, highly differentiated HCC illustrates the phenomenon of The two most common liver lesions causing hepatic hemorrhage are HA and HCC. A high content of fat in the liver is indicative of fatty liver disease. compare the tumor diameter before therapy with the ablation area. Only when you have a population with livertransplants, bilomas in an infarcted area would look the same. Barbara Beuscher-Willems (Contributor), M. W. Max Brandt (Contributor), Christian Goerg (Contributor). In most cases, a finding of heterogeneous liver is followed by further medical testing to determine the cause of the heterogeneity. all cause this ultrasound picture. certain patterns of hyperechoic or isoechoic metastases that can be overlooked or can mimic mass with irregular shapes, fringed, with fluid or semifluid content, with or without air inside. This capsule will only show enhancement on delayed scans. clarify the diagnosis. The typical risk factors for HCC such as cirrhosis, elevated alphafetoprotein, viral hepatitis, alcohol abuse are absent. While FNH is always very homogeneous, FLC is usually heterogeneous following contrast administration. In this pattern, the liver has a heterogeneous appearance with focal areas of increased periportal echogenicity. The size varies from a few millimeters to more than 10 cm (giant hemangiomas). Adenomas typically measure 8-15 cm and consist of sheets of well-differentiated hepatocytes. [citation needed], Cirrhotic liver is characterized by the occurrence of nodules with different sizes and The diagnosis of FNH is based on the demonstration of a central scar and a homogeneous enhancement. Hypervascular metastases have to be differentiated from other hypervascular tumors that can be multifocal like hemangiomas, FNH, adenoma and HCC. If you take a cohort of patients with hepatitis C and you follow them for 10 years, 50% of them will have end stage liver disease and 25% will have HCC. It is very important to make the distinction between just thrombus and tumor thrombus. In otherwise healthy young women using oral contraceptives, adenoma is favored. ablation to confirm the result of the therapy. Moreover a central scar may be found in some patients with fibrolamellar hepatocellular carcinoma, hepatic adenoma and intrahepatic cholangiocarcinoma. Mortel K, Segatto E, Ros P. The Infected Liver: Radiologic-Pathologic Correlation. 10% of HCC are hypodense compared to liver. They contrast enhancement of a nodule within 12cm developed on a cirrhotic liver is sufficient different nature is also important knowing that up to 2550% of liver lesions less than 2cm It is a heterogeneous disease encompassing a broad spectrum of histologic states characterized universally by macrovesicular hepatic steatosis. nodule, with distinct pattern, developed on cirrhotic liver. the tumor as an eccentric area behaving as the original tumor at CEUS examination, with 1).Features include increased echogenicity of the liver parenchyma, poor or non-visualisation of the diaphragm, intrahepatic vessels and posterior part of the right hepatic lobe. performance are: excessive obesity, fatty liver disease, hypomobility of the diaphragm, and On CEUS examination both RN and DN may have quite a variable enhancement pattern. It has an incidence of 0.03%. An echogenic liver is defined as increased echogenicity of the liver parenchyma compared with the renal cortex. CFM exploration identifies a chaotic vessels pattern. Notice that the enhancing parts of the lesion follow the bloodpool in every phase, but centrally there is scar tissue that does not enhance. If you only had the portal venous phase you surely would miss this lesion. 2010). Heterogeneous Liver on Research Ultrasound Identifies Children with Cystic Fibrosis at High Risk of Advanced Liver Disease: Interim Results of a Prospective Observational Case-Controlled Study Marilyn J. Siegel MD 1 , A. Jay Freeman MD 2 , Wen Ye PhD 3 , Joseph J. Palermo MD 4 , Jean P. Molleston MD 5 , Shruti M. Paranjape MD 6 , Janis Stoll MD 7 , In some cases this accumulation can An ultrasound scan of a liver with hyperechoic parenchyma that is also hyperattenuating (reduced echogenicity in the deep field). the procedure increases its performance even if it does not have a decisive contribution to It can be located anywhere in the intrahepatic bile ducts or common bile duct. options. Residual tumor has poorly defined edges, irregular shape, phase there is a centripetal and inhomogeneous enhancement. In terms of Focal fatty sparing in a diffusely fatty liver or foci of focal fatty infiltration can simulate metastases. assess the effectiveness of therapy and to detect other nodules. establish a differential diagnosis with hepatocellular carcinoma. staging, particularly when sectional imaging investigations (CT, MRI) provide Doppler examination detects a high speed arterial flow and low impedance index (correlated with described changes in tumor angiogenesis). Doppler exploration reveals no circulatory signal due to very The figure on the left shows such a case. Characteristic 2D ultrasound appearance is that of a very well defined lesion, with sizes of 2-3 cm or less, showing increased echogenity and, when located in contact with the diaphragm, a "mirror image" phenomenon can be seen. detected in cancer patients may be benign . CEUS examination shows hyperenhancement of the lesion during the arterial phase. Hepatocellular adenomas are large, well circumscribed encapsulated tumors. US sensitivity for metastases At US, metastases may appear cystic,hypoechoic, isoechoic or hyperechoic. It can be associated with other Syed Babar (Contributor), Richard C. Beese (Contributor), Richard Edwards (Contributor) et al. The key is to look at all the phases. [citation needed], Spectral Doppler characteristics of early HCC overlap those of the dysplastic nodule, as they Typically adenomas have well-defined borders and do not have lobulated contours. or the appearance of new lesions. On a contrast enhanced CT hypovascular lesions can be obscured if the liver itself is lower in density due to fat deposition. On T2-weighted images the scar appears as hyperintense in 80% of patients, which is very typical. transonic suggesting fluid composition. You will only see them in the arterial phase. Fibrolamellar carcinoma (FLC) has a dark scar on T2WI and FNH has a brigth scar on T2WI in 80% of the cases. This can occur due to a number of reasons which include: Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys. (2002) ISBN: 1588901017. with heterogeneous structure, poorly delineated, often with peripheral location and weak tool in the evaluation of liver enzyme abnormalities is abdominal ultrasound (US), with more in-depth evalua-tion by computed tomography (CT), magnetic resonance imaging (MRI)/magnetic resonance cholangiopancreatog-raphy (MRCP), or cholescintigraphy as detailed later. . What can an ultrasound of the liver detect? Doppler exploration is not enough, CEUS examination will be performed. These therapies are based on the [citation needed], It is a benign tumor made up of normal or atypical hepatocytes. [citation needed], After curative therapies (surgical resection, local ablative therapies) continuing ultrasound [citation needed], Please review the contents of the article and, Pseudotumors and inflammatory masses of the liver, Preneoplastic status. 2000;20(1):173-95. In Part II the imaging features of the most common hepatic tumors are presented. Tumors can range from benign liver tumors to cancerous masses and metastases from cancer elsewhere in the body. metastases). CT scans can detect the additional fatty structures in the liver, which appear on the scan as areas of lighter-colored tissue, according to an article in The Oncologist. [citation needed]. clinical suspicion of abscess. months. anti-angiogenic molecules by quantifying intratumoral perfusion based on the statistical Nevertheless, chronic Budd-Chiari syndrome may be difficult to differentiate from cirrhosis ( 8 ). Although breast cancer metastases can be hypervascular, it was shown that routine use of adding arterial phase imaging, did not show any advantage. Heterogeneous Liver on Research Ultrasound Identifies Children with Cystic Fibrosis at High Risk of Advanced Liver Disease: Interim Results of a Prospective Observational Case-Controlled Study Research liver ultrasound examinations can identify children with CF at increased risk for developing advanced CF liver disease. However, this pattern is not specific for metastases as it can also be seen in primary malignant liver neoplasms (eg, HCC) and benign liver neoplasms (eg, adenoma in glycogen storage disease). Asked for Male, 58 Years. Tumor characterization using the ultrasound method will be based on the following elements: consistency (solid, liquid, mixed), echogenicity, structure appearance (homogeneous or heterogeneous), delineation from adjacent liver parenchyma (capsular, imprecise), elasticity, posterior acoustic enhancement Also they are G. Scott Gazelle (Editor), Sanjay Saini (Editor), Peter R. Mueller (Editor). molecules are currently the subject of clinical trials), followed by embolization of hepatic slow flow speed. The lower images show a lesion that is visible on all images. To accurately assess the effectiveness of treatment it is mandatory to However on nonenhanced scans these regions of fat variation tend to be nonspherical and geographic, with no mass effect or distortion of the local vessels. Lipiodol retention mainly intratumoral, but also diffusely intrahepatic. Complete fill in is sometimes prevented by central fibrous scarring. Residual tumor tissue is evidenced at the periphery of At the time the article was last revised Jeremy Jones had no recorded disclosures. Liver cirrhosis was confirmed in 111 participants; therefore, ultrasound had a 94% sensitivity and 49% specificity for the detection of liver cirrhosis [ 41 ]. vascularity, metastases can be hypovascular (in gastric, colonic, pancreatic or ovarian Clinical correlation in such cases is most helpful. vasculature as a sign of incomplete therapy or intratumoral recurrence. 68F, referred for ultrasound due to recurrent upper abdominal pain. normal parenchyma in a shining liver. shows no circulatory signal. internal bleeding. analysis performed using specific software during post-processing in order to assess circulatory pattern, displace normal liver structures and even neighboring organs (in case of The central scar may be detected as a hyperechoic area, but often cannot be differentiated. arterial phase, with portal and late wash-out. In both cases ultrasound examination identifies a [citation needed], Malignant liver tumors develop on cirrhotic liver (hepatocellular carcinoma, HCC) or diagnostic methods currently in use because of the known limitations of the ultrasound Following are the characteristic features of some splenic neoplasias: ranges between 4080% . Large hemangiomas can have an atypical appearance. Most liver metastases are multiple, involving both lobes in 77% of patients and only in 10% of cases there is a solitary metastasis. sensitivity and specificity of ultrasound in detecting liver metastases, but also by assessing A low-attenuation pseudocapsule can be seen in as many as 30% of patients. (hepatocellular carcinoma and some types of metastases), have a heterogeneous structure borderline lesions such as dysplastic nodules and even early HCC. effect, the relation with neighboring organs or structures (displacement, invasion), vasculature (presence and characteristics on Doppler ultrasonography and contrast-enhanced ultrasound (CEUS). The size varies from a few millimeters to more than 10 cm (giant hemangiomas). 1cm. This is because the lesion is made of these channels containing blood. Characteristic elements of malignant Doppler examination [citation needed], HCC appearance on 2D ultrasound is that of a solid tumor, with imprecise delineation, with heterogeneous structure, uni- or multilocular (encephaloid form). It is the antonym for homogeneous, meaning a structure with similar components. Coarsened hepatic echotexture is a sonographic descriptor used when the uniform smooth hepatic echotexture of the liver is lost. Oliver JH, Baron RL: State of the art, helical biphasic contrast enhanced CT of the liver: Technique, indications, interpretation, and pitfalls. inflammation. radiofrequency ablation (RFA) and liver transplantation. Peripheral enhancement monitoring, CEUS can be used in follow-up protocols, its diagnostic CEUS investigation has real diagnosis value due to the typical behavior (well differentiated HCC) or increased RI (moderately or poorly differentiated HCC). the central fluid is contrast enhanced. When increasing, they can result in central necrosis. located in contact with the diaphragm, a "mirror image" phenomenon can be seen. Had a ultrasound, results said liver is 13.4cm and that there is somewhat heterogeneous appearance but with no definite abnormality r focal finding? Biliary abscesses start small but can progress rapidly. Coarse calcifications are seen in only 5% of patients. Ultrasonography (US) is the initial imaging modality of choice for detection and follow-up of early and delayed complications from all types of liver transplantation. Tumor wash out at the end of the arterial phase allows the The specification of these data is important for staging liver tumors and prognosis. detection varies depending on the examiner's experience and the equipment used and have malignant histology and up to 50% of hyperechoic lesions, with ultrasound appearance lobar or generalized. The method tumor periphery during arterial phase followed by wash-out during portal venous phase On a NECT these lesions usually are better depicted (figure). In the portal venous phase however, the enhancement is not as bright as the enhancement of the portal vein. Reference article, Radiopaedia.org (Accessed on 04 Mar 2023) https://doi.org/10.53347/rID-17361, {"containerId":"expandableQuestionsContainer","displayRelatedArticles":true,"displayNextQuestion":true,"displaySkipQuestion":true,"articleId":17361,"questionManager":null,"mcqUrl":"https://radiopaedia.org/articles/coarsened-hepatic-echotexture/questions/2403?lang=us"}, View Yuranga Weerakkody's current disclosures, see full revision history and disclosures, doi:10.1148/radiographics.20.1.g00ja25173, shoulder (modified transthoracic supine lateral), acromioclavicular joint (AP weight-bearing view), sternoclavicular joint (anterior oblique views), sternoclavicular joint (serendipity view), foot (weight-bearing medial oblique view), paranasal sinus and facial bone radiography, paranasal sinuses and facial bones (lateral view), transoral parietocanthal view (open mouth Waters view), temporomandibular joint (axiolateral oblique view), cervical spine (flexion and extension views), lumbar spine (flexion and extension views), systematic radiographic technical evaluation (mnemonic), foreign body ingestion series (pediatric), foreign body inhalation series (pediatric), pediatric chest (horizontal beam lateral view), neonatal abdominal radiograph (supine view), pediatric abdomen (lateral decubitus view), pediatric abdomen (supine cross-table lateral view), pediatric abdomen (prone cross-table lateral view), pediatric elbow (horizontal beam AP view), pediatric elbow (horizontal beam lateral view), pediatric forearm (horizontal beam lateral view), pediatric hip (abduction-internal rotation view), iodinated contrast-induced thyrotoxicosis, saline flush during contrast administration, CT angiography of the cerebral arteries (protocol), CT angiography of the circle of Willis (protocol), cardiac CT (prospective high-pitch acquisition), CT transcatheter aortic valve implantation planning (protocol), CT colonography reporting and data system, CT kidneys, ureters and bladder (protocol), CT angiography of the splanchnic vessels (protocol), esophageal/gastro-esophageal junction protocol, absent umbilical arterial end diastolic flow, reversal of umbilical arterial end diastolic flow, monochorionic monoamniotic twin pregnancy, benign and malignant characteristics of breast lesions at ultrasound, differential diagnosis of dilated ducts on breast imaging, musculoskeletal manifestations of rheumatoid arthritis, sonographic features of malignant lymph nodes, ultrasound classification of developmental dysplasia of the hip, ultrasound appearances of liver metastases, generalized increase in hepatic echogenicity, dynamic left ventricular outflow tract obstruction, focus assessed transthoracic echocardiography, arrhythmogenic right ventricular cardiomyopathy, ultrasound-guided biopsy of a peripheral soft tissue mass, ultrasound-guided intravenous cannulation, intensity-modulated radiation therapy (IMRT), stereotactic ablative radiotherapy (SBRT or SABR), sealed source radiation therapy (brachytherapy), selective internal radiation therapy (SIRT), preoperative pulmonary nodule localization, transjugular intrahepatic portosystemic shunt, percutaneous transhepatic cholangiography (PTC), transhepatic biliary drainage - percutaneous, percutaneous endoscopic gastrostomy (PEG), percutaneous nephrostomy salvage and tube exchange, transurethral resection of the prostate (TURP), long head of biceps tendon sheath injection, rotator cuff calcific tendinitis barbotage, subacromial (subdeltoid) bursal injection, spinal interventional procedures (general), transforaminal epidural steroid injection, intravenous cannulation (ultrasound-guided), inferomedial superolateral oblique projection, breast ultrasound features: benign vs malignant, certain bile duct tumors: will also usually show of accompanying biliary duct dilatation, diffusely infiltrating hepatic metastases, 1.

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