0:02

Hello and welcome to Noon Conference, hosted by modality

0:05

Noon Conference connects the global radiology community

0:08

through free live educational webinars that are accessible

0:11

for all and is an opportunity

0:13

to learn alongside top radiologists from around the world.

0:16

You can access the recording of today's conference

0:18

and previous noon conferences by creating a free account.

0:22

Today we are honored to welcome Dr.

0:24

Deborah Baumgarten

0:25

for a lecture entitled Ultrasound Evaluation

0:28

of Palpable Lesions.

0:30

Dr. Baumgarten completed medical school

0:32

and all of her radiology training at Emory University.

0:35

She was on staff at Emory for over 24 5 years

0:38

before moving to the Mayo Clinic in Jacksonville, Florida,

0:41

where she specializes in abdominal imaging

0:44

with a special interest in ultrasound and GU imaging.

0:48

At the end of the lecture, please join Dr.

0:50

Debra Baumgarten in a q

0:52

and a session where she will address questions

0:53

you may have on today's topic.

0:55

Please remember to use the q

0:57

and a feature to submit your questions so we can get to

0:59

as many as we can before our time is up.

1:02

With that, we are ready to begin today's lecture. Dr.

1:04

Baumgarten, please take it from here.

1:07

Thank you very much and I'm going

1:09

to assume you can see my screen okay

1:11

because we practice beforehand.

1:13

So this is me and I, a very informal setting.

1:16

Um, hopefully you all are, are comfortably sitting

1:19

and we'll get something out of this lecture.

1:21

I'm going to say at first though,

1:23

we talk about palpable lesions.

1:25

I am not a musculoskeletal radiologist,

1:27

so I'm not gonna really be talking about things

1:30

around joints and bones,

1:32

but mostly things that aid general

1:35

practice ultrasound person, somebody in abdomen might see.

1:39

I don't have any financial disclosures that are relevant

1:41

to this presentation.

1:43

I am a section editor for UpToDate

1:45

and I am on the editorial board for radiology

1:48

and radiology imaging cancer.

1:51

So today's learning objectives I'm going

1:54

to showcases that'll give you an idea of

1:56

how we approach lesions that are palpable.

2:00

Um, ultrasound is a great first line test for these lesions

2:04

and I'm gonna highlight some of the following things,

2:06

but not necessarily in this order.

2:08

Some of the technical factors you might think about,

2:11

what are the ultrasound characteristics

2:13

of some of these masses?

2:15

How important it is to interact with the patient, whether

2:18

that's you directly

2:19

or your technologist interacting with the patient

2:22

and passing information on to you.

2:25

The use of some dynamic maneuvers

2:27

that are very common in ultrasound, including compression

2:31

of a lesion and a Val Salva maneuver

2:34

or having the patient take a deep breath and hold it

2:36

and squeeze the use of doppler.

2:40

And then when we like to A, to go on to some other imaging,

2:43

mostly MRI for soft tissue lesions,

2:46

occasionally CT when a biopsy might be appropriate.

2:50

Now we did mention that there'll be q and a at the end,

2:53

but I'm also happy if people type questions either into the

2:56

chat or the q and a section, if I notice them

2:59

and I can answer them as we're going along.

3:01

I will try my best to do that as well.

3:04

I may also ask you to type what you think a lesion might be

3:08

in the chat session and I've got some cases that I'll go

3:11

through, kind of more didactically,

3:12

but then at the end I have some cases that I've reserved

3:14

that are gonna be more unknowns

3:16

and you'll let me know what you think they are.

3:21

So the first case is a 67-year-old female who presented

3:25

with a lump along her right jawline.

3:30

And what we can see here is a very well circumscribed,

3:35

relatively hypoechoic lesion.

3:38

It's in the subcutaneous tissues

3:40

and we can see that it's below the dermis,

3:42

which is this very bright line anteriorly.

3:45

We have some, uh, gel here, a lot of gel actually

3:49

with some artifact from little bubbles of air

3:51

that might be in the gel so that we can get good contact

3:54

with the skin and be able to see this lesion.

3:56

Well. We could also use what's called a standoff pad

4:00

or a gel pad placed on the skin and scanning through that.

4:04

Uh, and that might also help you see the lesion better.

4:08

This mass has some internal complexity.

4:10

It's not completely homogeneous,

4:12

but if you'll notice on our doppler picture here,

4:15

we can see some color around it,

4:17

but there's no no color flow in the lesion itself.

4:21

Here we can see if we look very, very closely,

4:24

we can see there's a little tract leading past the dermis

4:27

to the skin surface over, you know, to the gel

4:29

that we have anteriorly here.

4:32

So I have very nicely described

4:35

what is called an epidermal inclusion cyst,

4:38

and this is a benign subcutaneous lesion.

4:41

It's in the subcutaneous fat layer below the dermis.

4:44

It's uh, typically happens where we have hair growth.

4:47

They're more common in areas where there's hair.

4:51

Um, they're filled with keratin debris, which is

4:53

what gives it the internal complexity,

4:55

but nothing vascular about it.

4:57

And these are benign and they're very common.

5:00

Here's another example of a lesion along the jaw

5:03

of a 30 5-year-old male

5:06

and this demonstrates another fairly common feature

5:08

of epidermal inclusion cysts, which is this area

5:11

of posterior acoustic enhancement.

5:15

So this is another example of one of these

5:17

and it has this internal debris within it.

5:20

And again, no vascularity.

5:25

This is a final example of this particular, uh, entity.

5:30

And this is a 24-year-old who presented

5:33

with a mass along Herman's pubis.

5:35

Again, another place where we have hair.

5:38

And these are sometimes referred to when they're large,

5:41

especially this one was over three centimeters

5:44

as having a pseudo testis appearance

5:46

'cause it, it almost looks like a a normal testis

5:49

but it's not clearly.

5:52

Um, this is another epidermal inclusion cyst

5:55

and for this case we've highlighted some of the important

5:59

features of this being in a very superficial subcutaneous

6:03

ification, finding that little track to the skin.

6:06

And sometimes the easiest way for that

6:08

to be demonstrated is on a cine clip

6:10

where the technologist will scan back

6:12

and forth across the lesion

6:13

and you might be able to see that that small tract, the lack

6:17

of blood flow within it,

6:19

and again, it tending to happen in hair bearing regions.

6:24

Now what about this one who presented with a female

6:27

who was 59 with a left occipital lump?

6:29

So this was also under her hairline, so under her hair.

6:33

So not a bad location for an epidermal inclusion cyst.

6:36

It is hypoechoic, it has what looks like some debris in it.

6:40

This one was sub centimeter.

6:43

We could see that there actually looked like there

6:45

was a track to the skin.

6:47

So we're looking like,

6:49

well maybe this is another epidermal inclusion cyst.

6:53

And then we turn the color on

6:55

and this lesion is very different.

6:57

This one has not only some internal flow here

7:00

but a lot of flow around it.

7:03

Well, due to the vascularity

7:04

and it's, you know, small size, it was kind of a, a lump

7:06

that was kind of bothering the patient a little bit.

7:08

This one actually got resected

7:11

and this was an unusual type tumor called a pma.

7:17

And these are usually painless.

7:19

They're a little more firm than epidermal inclusion cysts.

7:23

They're very slow growing.

7:24

They are a neoplasm, although they are benign

7:27

and they derive from the hair follicle matrix cells,

7:31

which is why they're called a matrix.

7:33

Oma and pilo referring to the hair follicle,

7:36

they're typically found um, kind of in the head area,

7:40

the neck, the cheek.

7:42

They can be around the orbit

7:43

or in the scalp as in this case.

7:46

Uh, most of these cases

7:48

actually occur occurring in younger patients,

7:49

in children and adolescents.

7:51

This one was a little unusual because it was an older woman,

7:54

but again, a benign neoplasm.

7:57

If you see color in something that you

7:59

otherwise think might be an epidermal inclusion cyst.

8:02

So think about py matric

8:04

and also think about whether you're inclusion cyst has

8:07

somehow become infected, which case you might see edema

8:11

around it flow in the surrounding tissues,

8:13

but you should still not see flow within the bulk

8:16

of the lesion itself if it's truly an

8:18

epidermal inclusion cyst.

8:21

Okay, we're gonna move on to a 56-year-old female

8:25

who had a submandibular lump that she noticed

8:29

was slowly growing and starting to bother her.

8:33

So here I have a series of images.

8:36

We have a lesion, this is our target lesion here that's next

8:40

to the submandibular gland,

8:41

which our technologist has nicely labeled for us

8:44

as SMG in case we didn't know what this was.

8:47

This is actually a normal subular gland here

8:50

and this is a very much more hypoechoic ovoid lesion.

8:54

It has an area of central necrosis

8:58

and it also has some areas of predominantly peripheral flow.

9:03

So this is a really good place for a lymph node,

9:06

but this doesn't look like any normal lymph node

9:09

that I've ever diagnosed.

9:12

So let's first look at the features

9:14

of more normal lymph nodes.

9:16

So this is a lymph node

9:17

that was also in the neck of a different patient.

9:21

You can see that there's a fatty hilum,

9:23

which is this echogenic area centrally.

9:26

There's a hypoechoic cortex, it's shaped kind

9:29

of like a kidney elongated

9:32

and the flow is coming in through the hilum.

9:34

Now depending upon how you set your gain settings,

9:37

you may look, make it look like there's a lot of flow.

9:39

This one also can have a lot

9:41

of flow if these nodes are reacting

9:43

to something like a upper to re respiratory infection

9:46

or something else going on near it.

9:50

This is another example.

9:51

This was in the groin of another patient.

9:53

You can again see that nice fatty hilum

9:56

and the flow coming in through the hilum

9:58

and distributing itself through the node.

10:01

And these are both just examples of reactive nodes.

10:04

So these are benign. But what about this case?

10:09

So this again is a good spot for a node

10:12

but doesn't look like a normal node.

10:14

And this one was biopsied

10:16

and turned out to be a squamous cell carcinoma metastasis

10:20

from a laryngeal primary

10:22

that the patient did not at the time know that she had.

10:26

Now squamous cell carcinomas are one of the uh, head

10:30

and neck cancers that when they metastasize

10:32

to nodes can often have these areas of central necrosis.

10:36

So that's something to think about

10:38

when you see a node like this.

10:43

Alright, we have another 67-year-old female

10:46

who has a painful left occipital lump.

10:49

So again, another lump on her scalp but this one is painful.

10:55

And here we have an example here

10:57

of a another hypoechoic sort of ovoid lesion.

11:01

It's otherwise relatively featureless on long

11:04

and transverse, but this did correspond to her area of pain.

11:09

This is the dermis here anteriorly

11:11

and we were in the subcutaneous layer here,

11:14

but this case has another feature that you might want

11:18

to note which is this little linear area

11:22

extending from this ovoid lesion.

11:24

And if we look closely, there's probably another little

11:27

linear area coming off the opposite side.

11:30

You can see it here on transverse.

11:33

So this we call a little tail and this is actually a nerve

11:38

and this is a bump in that nerve

11:40

or this little tumor is a rising from this nerve

11:43

and this little tail is a clue in addition to the fact

11:46

that the patient has pain,

11:48

that this is a neuroma in this case in the occipital region.

11:52

So an occipital neuroma, if you were unsure what this was

11:56

and tried to biopsy it,

11:57

this would cause exquisite pain in this lesion

12:01

and it might also feel like it was um, almost like tingling

12:06

or, or or traveling along the nerve that it's coming from.

12:09

So it might have referred pain as well.

12:13

These can current areas that have had previous trauma.

12:16

So we often see these after.

12:18

For example, a patient has had a thyroid cancer

12:22

and had a thyroidectomy

12:23

and in an in an area

12:25

of scarring we might see a lesion like this

12:27

and we wanna make sure that it wasn't a recurrence

12:29

of the thyroid cancer.

12:31

And again that tail can help

12:33

but they are usually again painful.

12:36

This is another example here we can see the little tail

12:40

coming off it and they tend to be relatively avascular.

12:46

So this again was another neuroma.

12:49

Okay, our next case is a 22-year-old male

12:53

and he just decided that his left neck looked swollen

12:57

and to him it just felt full.

13:00

So we put an ultrasound probe down in the area

13:02

that he indicated was bothering him

13:05

and all we could see was his

13:07

sternocleidomastoid muscle here.

13:12

So what's often helpful is if the patient has an opposite

13:16

side that you can compare to is to get images

13:19

of that opposite side.

13:21

So here's the patient's right neck

13:24

and I think if you look really closely

13:26

and especially if I provide arrows here, you can see

13:28

that the right sternocleidomastoid muscle is not as robust

13:32

as the left sternocleidomastoid muscle.

13:34

So the patient did indeed have left neck swelling,

13:38

however it was just a normal structure

13:41

and for some reason his left side was a little bit more

13:44

hypertrophied than the right side.

13:49

I'm gonna illustrate the use of

13:50

of comparing the patient in this case as well.

13:53

This is a 62-year-old male who thought

13:56

that his right supraclavicular region was swollen

14:01

and the technologist brought me these pictures

14:04

and there was uh, markers on them labeling this as something

14:08

that they could measure and it was around six centimeters.

14:11

And I'm looking at this

14:13

and thinking doesn't look particularly discreet to me could

14:17

but could it be like something like a lipoma

14:19

and we'll talk more about lipomas in another case

14:23

we put the flow on and there's flow

14:25

and lipomas don't tend to have flow

14:28

and I thought maybe this was just, you know,

14:30

some kind of normal tissue.

14:32

So I asked the technologist to get the patient back,

14:35

he was still in the clinic, he'd left our our department

14:37

but was still wandering around.

14:39

So we brought him back in

14:41

and I asked her to get some images

14:42

of the opposite side for comparison.

14:46

So here is right and the comparative left

14:50

and again right in the comparative left and moving along

14:54

and long and right and left and right and left.

14:57

And honestly I could tell no

14:59

difference between the two sides.

15:01

So these cases, the comparing the patient to himself

15:05

or herself as their own control is a very important

15:09

thing When you're looking at at areas that the patient feels

15:13

is subjectively full or they think they feel something

15:17

and you really don't see anything that's discreet

15:19

or measurable, it's often very helpful to compare

15:22

to the opposite side and just reassure the patient that

15:25

what they're feeling is just normal tissue.

15:28

And in this case it was just normal fat

15:30

in the supraclavicular space.

15:36

Okay, here we've got a 26-year-old female who presented

15:39

with a painful lump on the left side of her chin

15:44

and we put our ultrasound probe down

15:47

and we saw this very large area here

15:51

turned the color on

15:52

and there's a lot of color in it, maybe some area of central

15:57

fluid or necrosis.

16:00

We can compare the right side of her chin with the left side

16:03

of her chin and see

16:05

that clearly this side is swollen and is more vascular.

16:10

The other thing that would be helpful in this case is

16:12

to know does the patient have anything else going on?

16:15

Do they have a fever? What does the skin

16:17

overlying this lesion look like?

16:19

Is it red? Is is how long has the swelling been going on?

16:24

Was there a pimple

16:26

or something that the patient may have played with

16:28

or done something to?

16:29

Was there trauma in this area?

16:32

So all of those things are important to know

16:34

and this turned out to be a chin abscess

16:37

with overlying cellulitis

16:39

and the fact that the technologists could come to me

16:41

and say, yeah, this was kind of like mushy a little bit

16:45

and there was redness there

16:47

and the patient said it had only been going on

16:49

for about a week And the I, to be honest with you,

16:52

the patient had a lot of acne and that sort of thing.

16:54

So it, it's helpful to also have some idea

16:57

of the physical exam and I'm gonna show you some cases later

17:00

where the technologist has

17:01

with the patient's permission taken an image of the area

17:05

that they are scanning

17:06

and knowing what it looks like on the

17:08

outside can be very helpful.

17:11

So this actually required an incision and drainage.

17:14

So the patient was sent back to the physician,

17:16

they actually um, made a little incision,

17:19

got the purulent material out

17:21

and then the patient was placed on antibiotics.

17:26

Okay, I'm gonna move away from the head right now and

17:28

and move down the body a little bit.

17:30

And this was a 62-year-old inpatient

17:33

and she had been in the hospital for a few days

17:35

and noticed that there was a lump in her

17:38

anterior lower abdomen.

17:40

So we got an ultrasound and this is what we found.

17:45

So here again, um, we're very superficial

17:50

and we see this little discreet lesion.

17:52

It was about 15 millimeters.

17:54

We put the color on which is also a very important feature

17:58

and there is no color within this.

18:01

It's also superficial to the peritoneal cavity.

18:04

So we can see what's the peritoneal cavity is here,

18:07

this is a bowel loop, there's a little bit of ascites

18:09

and let me show you this.

18:10

Next is a movie and you can see the lesion is here

18:14

and you can see the fascial planes are intact

18:17

and there's bowel loops here

18:19

and a little bit of ascites in the

18:20

underlying peritoneal cavity.

18:22

So this lesion is not communicating

18:24

with the peritoneal cavity,

18:25

which is also something very important.

18:30

So we asked the patient a couple of extra questions like

18:33

what else is going on with her?

18:35

Did she remember any, remember any trauma in this region?

18:38

And it turned out because she's an inpatient,

18:40

they put her on uh, subcutaneous Lovenox so

18:44

that she wouldn't have risk

18:46

for deep venous thrombosis by being in bed.

18:49

So we concluded this, this was just a small hematoma,

18:52

again an avascular lesion,

18:55

but we have to be careful when we're diagnosing hematomas

18:59

we have to have an appropriate history.

19:01

There should be some element of trauma that we could point

19:04

to, even if it's iatrogenic as it was in this case.

19:08

And the sonographic features

19:10

of hematoma can overlap with other entities.

19:12

So you wanna make sure you follow these patients up

19:14

and make sure that these lesions are resolving.

19:17

And this one did ultimately resolve on a follow-up visit

19:20

that she had after she had left the hospital.

19:26

So here's another patient.

19:29

We can see this little lesion here in the subcutaneous

19:31

tissues overlying the left chest wall.

19:35

And this was a 78-year-old male.

19:38

He had a diagnosis of B-cell lymphoma.

19:41

So we already have a malignancy

19:43

that's known in this patient,

19:45

but he noticed that there was a little bit

19:46

of discoloration over his chest and he had some yellow

19:50

and purple discoloration.

19:52

But there was this little area which was more

19:54

firm and a little bit mobile.

19:58

There's a mixed echogenicity here, um,

20:01

but it is in the subcutaneous space.

20:04

And I'll show you a few still pictures here.

20:07

We could measure it. It was about two centimeters.

20:10

A little bit of area in the center was a little more

20:12

hypoechoic we can turn color on.

20:17

You can see color in the underlying

20:18

tissues but none in here.

20:21

Um, again, you know, given the purple

20:24

and yellow discoloration around it, we thought

20:27

that there was probably trauma

20:29

and maybe a little hematoma here,

20:32

but the patient didn't really remember any trauma

20:34

and there wasn't normal platelet count.

20:36

But we advised the patient

20:38

to have the lesion looked at again clinically

20:41

and it went away by a two week follow up.

20:43

So again, you have

20:44

to be very cautious when you diagnose a hematoma

20:48

to make sure that that's actually what it turns out to be

20:51

and not something else even though there are certain

20:54

features that lead you in that direction.

20:55

And just make sure the patient follows up.

20:58

So we've highlighted the features of the hematoma,

21:00

their avascular, they can have very variable echogenicity

21:03

based on their age

21:05

and in the absence of any history of trauma, then we need

21:08

to make sure that there's clinical follow up.

21:11

Something that I read about in preparing for this talk is

21:14

that when sarcomas are misdiagnosed,

21:16

you have a malignant sarcoma.

21:19

Hematoma is the leading wrong diagnosis.

21:23

So maybe our settings are off

21:24

and we're not seeing the area of flow

21:27

or the sarcoma is relatively high grade and has necrosis.

21:31

So just keep that in mind

21:32

that when sarcomas are misdiagnosed,

21:35

hematoma is the most likely thing

21:36

that somebody has called it.

21:38

So you need to make sure that the patient has follow up

21:41

because hematomas will go away.

21:46

Okay, our next case also in the abdomen, the patient

21:49

who is a 57-year-old female noticed a lump

21:54

and we can see that there's a lesion here

21:57

in the subcutaneous tissues

22:00

and we can see that it looks like there's a little, um,

22:04

communication here, maybe, maybe not,

22:06

or a little gap here in the fascial plane.

22:09

That's about a 10 millimeter defect here.

22:12

So let me show you something else here.

22:16

This is that same patient

22:18

and you'll notice this is labeled left to midline long

22:23

with valves or val Salva in her palpable area.

22:28

So as the patient squeezes, we can see that there's tissue

22:32

that is moving through that fascial defect

22:35

out into the subcutaneous fat

22:38

and that's when she can feel it.

22:42

So this is a small fat containing hernia.

22:46

If this con hernia contained bowel, we would expect

22:49

to see some maybe air bowel loops with fluid in them.

22:53

But this was just a little bit of of fat moving in and out.

22:57

Now it turned out that this patient had an MRI abdomen

23:01

coincidentally for a completely unrelated reason

23:04

and you can see that little fat containing hernia there

23:07

with a little defect in the fascia.

23:10

So this case highlights the ability of ultrasound

23:13

to allow us to do one of our most favorite dynamic

23:16

maneuvers, which is of Salva,

23:20

which allows us more confidently to diagnose hernias.

23:27

Alright, this 46-year-old female had had a right axillary

23:31

lymph adenectomy and she came back in

23:34

because she could feel fullness

23:35

and swelling in the area of her surgery.

23:39

And this is a, an example of

23:41

what these pictures look like when the patients are are

23:44

brought in and we can take a picture,

23:46

we have a few iPads in our department for this purpose.

23:50

You can see where she's had an incision here

23:53

and it looks a little bit red around the incision,

23:56

maybe a little bit more full than you'd

23:58

expect an axilla to be.

23:59

This is airy. Here is probably her, um, bra

24:02

or her her tank top or whatever she's wearing.

24:04

This is the crease of her axilla. Her arm is above here.

24:10

So this is what we found when we started looking around in

24:13

that area on long and transverse.

24:18

And what we see is a very large hypo coic collection

24:22

with multiple areas of septation.

24:25

It looks like there's an area

24:27

that extends more superficially,

24:29

which you'll see coming out here,

24:31

maybe going toward her incision.

24:33

And this was in that region of redness and swelling.

24:37

Now it's very important here is the clinical history

24:39

because we know the patient's had recent surgery.

24:44

So this turned out to be a large seroma.

24:47

Now how can we tell a seroma from say an abscess?

24:51

Well some of that is gonna be a little bit subjective

24:54

in terms of of what they look like.

24:55

They look fairly similar,

24:57

but in this case there is no hyperemia around it.

25:00

These are color images here.

25:02

An abscess, you'd expect to have more inflammation and

25:06

therefore recruiting blood flow to the area.

25:09

So you'd expect there to be color flow around it.

25:12

The fluid internally may be a little more complex,

25:16

but you're also gonna have

25:17

to ask the patient about her symptoms.

25:20

Abscesses are more likely to have

25:22

constitutional symptoms like the patient may present

25:24

with fever, there may also be more redness in the overlying

25:27

skin or they may tell you

25:29

that their incision is draining some purulent material

25:32

but it's not all out.

25:34

And you can see that the technologist here is labeled scar.

25:38

So this is leading toward the patient's scar.

25:41

So in order for this to be drained,

25:43

it may simply require the physician to just open

25:45

that scar up a little bit

25:47

and have this material have a way of of getting out.

25:51

We can also switch to a non-linear.

25:55

So this is a linear transducer.

25:57

We can switch to a curved transducer that has a larger field

26:00

of view if we wanna give um, ourselves a better opportunity

26:04

to see the entire extent of the lesion

26:06

and give the referring physician a more accurate measurement

26:09

of what the lesion actually looks like.

26:14

Okay, moving down the arm in an 80-year-old female,

26:18

she's had a mass on her forearm,

26:20

she thinks it's been there at least a year,

26:22

but is wondering if it's recently increased in size.

26:27

So here's the mass, it's a little bit difficult

26:31

to separate from the surrounding subcutaneous fat.

26:34

Here's our dermis here in the anteriorly,

26:36

but if I put markers on it,

26:38

it makes it a little bit more discreet.

26:41

It's very smoothly marginated.

26:44

It has these linear, wavy internal areas

26:50

and if I put color flow on it really don't see much color

26:53

flow here at all in this lesion.

26:56

And these are characteristics that are very typical

27:00

of a benign lipoma,

27:03

especially since this patient describes this

27:05

as being there at least a year,

27:07

probably more not growing very quickly.

27:09

Maybe grow grew a little bit

27:11

so it doesn't have a very aggressive, aggressive history.

27:15

So subcutaneous lipomas are frequently iso coic.

27:18

They may be a little bit hypoechoic to the surrounding fat.

27:23

Occasionally they may be a little bit more echogenic than

27:26

the surrounding fat, but most of the ones I've seen

27:30

are very difficult to differentiate from surrounding fat.

27:34

Now one of the other features that helps us

27:36

diagnose a lipoma is that they're squishy lesions.

27:39

They're very soft 'cause they're just made of fat.

27:42

So here we have the technologist applying pressure

27:45

to the lesion and you can see it deforming.

27:47

It's getting smaller as she presses on it.

27:53

So that is another way that we can help diagnose the lipoma

27:57

'cause it will easily deform.

28:03

So here's another example.

28:05

This is a 56-year-old male who is complaining of a lesion

28:09

along his posterior right neck.

28:11

And again, we see fairly typical features of a lipoma.

28:14

In this case it's a little bit hypo coic

28:17

to the surrounding fat, which makes it a little

28:19

bit easier to see.

28:20

Again, it's doesn't have any flow when we turn color on.

28:26

It turns out that the patient had an older CT scan

28:30

and if you compare the right

28:31

and the left in the region that the patient was complaining,

28:35

we can see that there's a fatty lesion here that corresponds

28:39

to the lesion that we were seeing at ultrasound.

28:42

So we could probably have saved this patient in ultrasound

28:44

if somebody had thought to go back and look at the ct.

28:48

It's unknown unclear.

28:50

I I didn't see, uh, this was an outside CT

28:52

that was scanned into our, our archive.

28:55

I don't have any idea if anybody described the lipoma,

28:58

but it, I think it would be very easy to just pass by

29:00

that seeing that there's just fat there

29:02

and not describe it at all.

29:04

So it may not have been in the patient's medical record,

29:07

but again, another typical lipoma.

29:11

But what about this lesion?

29:14

Here we have one that's a little hyper coic

29:16

to the surrounding fat in a 59-year-old female.

29:19

And she did note that this lesion was becoming a little bit

29:23

more uncomfortable and this was on her mid abdomen.

29:27

So this was along her anterior abdominal wall.

29:32

This particular lesion has a tiny little bit of flow in it.

29:37

So this is a variant of lipoma

29:40

and this is called an angio lipoma.

29:43

And you should consider angio lipoma in your

29:46

differential for a lipoma.

29:48

When the patient complains

29:49

that these lesions are a little bit uncomfortable, um,

29:54

lipomas are generally asymptomatic

29:56

other than they're just palpable.

29:59

Um, they also can have a little bit of flow in them,

30:02

hence the angio part of the angio lipoma.

30:06

So often these are resected because they are uncomfortable.

30:09

And so that's what happened in this case

30:11

to confirm the diagnosis of an angio lipoma.

30:14

The patient complained that if she bumped into something,

30:17

or especially if she'd been standing for a while,

30:19

it was uncomfortable.

30:22

Okay, well this one looks a little bit like the

30:24

last one I just showed you.

30:27

A three centimeter, almost three centimeter lesion.

30:29

This was in an 83-year-old male.

30:32

This was down in the region of his groin.

30:34

However, unlike most lipoma histories,

30:38

this patient just noted this the week

30:40

before while he was showering.

30:42

So that's a little unusual.

30:44

We don't often have a history

30:46

of something only being there about a week

30:48

and then making a diagnosis of lipoma.

30:51

So the patient had had, um, bilateral hernia repair,

30:55

you know, 10 years previously.

30:57

He was, um, having some sharp pain

30:59

and he's actually thought he had a recurrent limb, uh,

31:02

hernia when he felt this.

31:06

We can put color on it

31:07

and power doppler not a whole lot of flow

31:10

that we're picking up with a doppler,

31:13

but it is a little bit heterogeneous.

31:15

And if you look carefully, the edges

31:17

of this lesion are not particularly well-defined.

31:20

They're a little bit wavy,

31:22

sometimes a little bit hard to define at all.

31:25

So this is a a, a case that could easily have been blown off

31:29

as a lipoma or an angio lipoma,

31:32

but the history really doesn't fit at all.

31:35

There is no lipoma again that I've encountered

31:40

where someone says it wasn't there

31:42

and then suddenly it's there.

31:45

So in this case, this is one of the times

31:46

where we might wanna go to additional imaging

31:49

and this patient had an MRI

31:52

and you can see non-contrast images here

31:55

we've given contrast and this lesion is enhancing.

31:59

It also shows restricted diffusion.

32:02

And this turned out to be what's called an angio fibroma.

32:07

And this is a rare neoplasm.

32:09

It is a benign neoplasm,

32:11

but they can be, um, infiltrative, they tend

32:15

to have to be resected.

32:18

They occur almost exclusively in either the um, vul, vulvar

32:23

or vaginal area in a woman or in the inguinal area

32:26

or scrotal region in a man.

32:29

Um, occasionally they may have atypical features on

32:33

resection or have sarcomatoid features,

32:35

but that is extremely la rare.

32:37

The majority of these are benign.

32:40

So although lipomas have very typical features,

32:44

the differential is you can have a differential one if it's

32:48

painful or there's a little bit of vascularity,

32:50

you should consider an angio lipoma.

32:52

And if the lesion lesion looks like a lipoma but is new

32:55

or rapidly enlarging, consider an angio fibroma,

32:59

especially if it's again

33:00

around the groin region of a male or female.

33:03

If you see something like this

33:05

but it's in another area that's not the groin, then you need

33:08

to consider that it could be a sarcoma if it's new

33:11

and rapidly changing.

33:15

Okay, here's another patient. She's 43.

33:18

She described that she'd had one mass on her wrist

33:21

for about 10 years, but then she noticed

33:24

that there was a new area of swelling that's only been there

33:27

for about the last two months.

33:29

So here's the lesion that had been stable for 10 years

33:33

and we can see what we've described

33:35

as pretty typical for a lipoma.

33:38

We have a lesion that is almost indiscernible from the

33:40

subcutaneous fat,

33:42

but again, when you put markers

33:43

around it, it makes it a little easier.

33:45

It's avascular, it has those typical wavy lines in it.

33:50

So this is the stable lesion

33:51

and we can feel comfortable calling that a lipoma.

33:56

This is the other lesion that that patient had

34:03

very different lesion, again, palpable for two months.

34:07

It has a lot of vascularity.

34:09

We could actually even get a pulse on it.

34:11

It's irregularly shaped.

34:14

This is an underlying bone of her wrist.

34:17

It is in the same space just about

34:19

as the, as the other lesion.

34:21

But this is not a lipoma.

34:24

And this turned out to be a 10 oh synovial giant cell tube.

34:28

And these are benign tumors,

34:30

but again, certain benign tumors can be very infiltrative

34:34

and they can grow and destroy surrounding tissues even

34:37

though they don't metastasize.

34:39

So they do need to be resected.

34:42

So again, it's very important to know the history

34:45

and know which lesion you're looking at has been there

34:48

longer benign lipoma feel good about it

34:51

and which lesion is new, looks more aggressive.

34:55

Um, this was again just resected.

34:56

If we were unsure whether this was like a sarcoma

34:59

or something, this patient could have gone on to have a,

35:02

a wrist MRI first to look at its features and its extent.

35:05

But this was just resected knowing it had to come out meld.

35:11

So somebody asked a question,

35:13

how much differentiation is there between lipoma

35:15

and lipos sarcoma and ultrasound?

35:18

And I have to say I've never made a primary diagnosis

35:21

of a lipos sarcoma on ultrasound.

35:24

So I I can't tell you that I know for sure except to say

35:27

that lipomas,

35:29

because they're homogeneous fat again,

35:32

will be very homogeneous with those wavy lines.

35:35

Lipos sarcoma should have areas

35:37

of soft tissue differentiation often

35:40

and they will have areas of therefore vascularity.

35:43

But again, the history is gonna be important there too.

35:45

A lipos sarcoma may grow slowly but should be increasing.

35:49

And again, if you're ever unsure,

35:51

you can always go onto advanced imaging.

35:55

Um, a couple of other questions.

35:57

I think I wanna just take the time to answer now.

35:59

Um, somebody asked, do we need a biopsy,

36:01

an epidermal inclusion cyst to confirm that?

36:03

I don't think we do. If it's completely avascular

36:07

and you can see the little track to the skin

36:08

and has that debris inside,

36:10

I think we can be very comfortable with that,

36:12

especially if it's just an

36:14

otherwise asymptomatic palpable lump.

36:16

We see them often in the subcutaneous fat on CT scans

36:19

as well and they are non enhancing little rounded lesions

36:23

and we call them epidermal inclusion system move on.

36:27

If however, the patient comes in

36:28

and says this is rapidly increasing, it's increasing

36:31

or it has pain, then we may need to do something else to

36:35

um, confirm that.

36:39

How do we confirm it in the absence of attract again, hard.

36:43

But if it has the other features,

36:45

I think we can be fairly confident through transmission.

36:49

The internal keratin debris.

36:51

Can we see a pal matri oma in the axilla?

36:53

Yes, you can, you can see it anywhere.

36:55

There's hair growth and let's see,

37:00

have I ever had a small lenticular lesion

37:02

that was called a lipoma turn out to be something else?

37:05

And they ones that are so small

37:06

that they really don't squish?

37:08

Um, most of them if they, they've turned out maybe

37:11

to be an angio lipoma.

37:14

Again, I haven't had very many where I've called it a lipoma

37:18

and then been surprised

37:19

that it turned out to be something else.

37:21

We did not call that gentleman

37:22

with a groin lesion, a lipoma.

37:24

It just didn't fit completely either.

37:26

And what's the difference between a sebaceous cyst

37:29

and an epidermal inclusion cyst?

37:30

Sebaceous cyst is what we used to call them.

37:32

So it's, it's basically the same thing.

37:35

So I, I just, I think that the

37:37

approved term now is epidermal inclusion cyst.

37:41

Okay, I'm gonna move on to a woman who came in

37:43

with finger pain and this is the area

37:45

that she indicated was painful

37:47

and you can see there's actually some swelling,

37:49

a little lump there before her joint.

37:53

And this is what that hand looked like.

37:56

Now I told you I'm not MSK

37:57

and I wasn't gonna do much in terms of of joints and things,

38:01

but this was a superficial lesion,

38:02

it was superficial to the bone.

38:06

So here we've measured a thing inside this area

38:10

of fluid inside that swelling.

38:13

So does anybody wanna venture a guess as to what this is?

38:21

It's okay if you don't. This was a seven millimeter

38:25

piece of what turned out to be a palm frond.

38:30

It turned out that this patient had been gardening

38:32

and was trimming a palm tree

38:35

and didn't really notice at the time

38:37

that she might have gotten punctured,

38:39

but it, afterwards she was a little painful

38:41

and then it started to swell a little bit.

38:43

You get a little reactive fluid around this thing

38:45

and they had to go in in there and just take this out.

38:47

So this is the equivalent of like a splinter

38:49

that got stuck in there, but it was from a palm fron

38:52

and they can be very, they can be very um,

38:56

sharp and can do that.

38:58

Alright, we're gonna go on to some quiz cases

39:02

and we'll we'll highlight some other features

39:04

of ultrasound as we go through these.

39:07

So our first case is a 57-year-old male

39:10

and he had a palpable area on his arm

39:12

and he said it was starting to get painful.

39:15

So he's pointing to the area there

39:17

and I'll, I'll just show you a close up here,

39:20

not a very large area

39:21

and the skin overlying it looks pretty normal.

39:24

And this is what we got when we first put the probe on here.

39:27

So I want you to let me know what you're,

39:29

what you're thinking.

39:43

Okay, so a couple of you said lipoma great

39:45

and one person said angio lipoma.

39:48

All right, well I did tell you

39:49

that the patient said it was becoming painful.

39:52

So here we've measured it.

39:53

So it's about four centimeters by eight millimeters

39:56

by two centimeters and here it is with color flow on it.

40:02

So it's a little bit more genic than the fat.

40:05

It's painful and it has color flow.

40:08

So for you all who said atypical lipoma

40:12

or angio lipoma, excellent.

40:14

This turned out to be an angio lipoma.

40:15

And again, because it was bothering the patient,

40:18

it was resected.

40:20

Now could this be a sarcoma I suppose

40:25

but the patient had said it had been there a while,

40:27

it just had gotten more painful.

40:29

But again, so if the features

40:31

of typical lipoma are not all there

40:33

and in this case the pain, the little bit of flow

40:37

and the fact that it was a little bit hypo hyper, excuse me,

40:40

hyper coic to the surrounding fat might be an indication

40:43

to just take these out regardless

40:45

of whether you think it may be just a benign angio lipoma

40:48

or something more ominous.

40:50

The other thing that can happen is there are very good

40:52

pathology tests these days

40:54

to differentiate lipoma from lipos sarcoma based on biopsy.

40:59

So you could, if the patient didn't wanna go

41:01

for a resection right away, do a biopsy of the lesion first,

41:05

send it for all the pathologic

41:06

tests that they now have available.

41:08

And that might inform whether you need a

41:09

biopsy immediately or not.

41:12

Okay, here's another one.

41:13

Patient came in with left foot pain and swelling.

41:17

And so this is what the foot looked like here

41:23

and I'm gonna show you this.

41:38

How about this one? Yep,

41:45

somebody wrote palm frond again

41:48

and this is what it looked like.

41:51

And indeed this person had stepped on a palm frond

41:56

by accident instead of, of having it in their hands.

41:58

So yes, this was another, this foreign body

42:00

with reaction around it.

42:02

We can see that fluid around it kind

42:04

of body is kind of walled it off.

42:07

There's a little bit of flow in the surrounding tissues when

42:10

I showed you that it looked a little bit red and swollen.

42:12

So this is on the way to becoming, you know,

42:15

an infection if this is gonna be left in there long enough.

42:17

But this had to be removed and the fluid drained

42:20

and then they were fine.

42:22

Um, we can sometimes see glass, so that is something else

42:25

that ultrasound can help, uh, differentiate.

42:29

Um, that would other kinds of, of foreign bodies

42:33

or sometimes easier to see on ultrasound than they are

42:36

with plain films, especially if they're not metallic.

42:41

Alright, another patient who came in

42:44

with right leg pain and swelling.

42:46

I don't think I have a picture of this person,

42:48

but this is the area this is described as as being

42:53

behind the knee and going down into the calf.

42:57

And we have in the

43:02

subcutaneous space this area here

43:07

with some septations.

43:12

Okay, we've, we've got a diagnosis of a ruptured baker cyst,

43:18

a seroma, a hematoma, some kind of cystic lesion,

43:22

a dissecting baker cyst.

43:23

All those are great thoughts.

43:25

So a key feature of a baker cyst is you kind of have

43:28

to see it going through the muscle bundles and toward the,

43:31

and into the, uh, joint space.

43:33

Um, their curve, linear shape.

43:35

We see them quite often when we're doing DVT studies.

43:38

For example, this one we couldn't actually get to uh,

43:42

communicate with the joint space when we took it all

43:45

the way up toward the knee.

43:46

This was kind of dissecting more into the calf.

43:50

And on some questioning here, I'm gonna show you another,

43:54

this is the same patient here.

43:56

We did a composite so we can get a, a really great idea of

44:00

how large this area actually was.

44:03

Again, it's, it's avascular.

44:05

There's some vascularity in the surrounding tissues

44:08

and it turned out that this patient, um, he had been walking

44:11

and it felt a pop and then he got some swelling after that

44:15

and then he finally came in

44:17

'cause the swelling didn't go down.

44:19

And we diagnosed this as a, a hematoma that had

44:23

from a torn muscle of some sort and it was lysing.

44:26

So when you have hematomas acutely they can be very

44:30

echogenic as they start to lice

44:32

and start the body starts breaking them down, you end up

44:35

with a more fluid looking structure with

44:38

that can have some complexity in it, complexity in it,

44:40

some areas of of that look like

44:43

septations fibrin bands and such.

44:46

So this eventually went away.

44:49

You could also consider draining it if it was really

44:51

bothersome to the patient, you could stick a needle in it

44:54

to confirm that it wasn't infected

44:56

and in fact was just, uh, blood products.

45:01

Okay, we have a patient

45:06

here 52 with a right back lump

45:08

and our technologist has taken a picture

45:10

and put a little arrow here

45:11

and you can see a little skin discoloration here in

45:13

the area of the lump.

45:15

And so here we are in the right lower back

45:28

and we have here.

45:31

And as it goes through here you can see the lesion

45:36

and I'm gonna show you some still pictures

45:41

so the right lower back we can put some calipers on it,

45:45

which might make it a little bit easier to see.

45:48

I can also show you here, there's no vascularity

45:53

and actually the technologist went from the left side

45:56

to the right side and you can see there really is something

45:59

going on here compared to the opposite side.

46:01

It is definitely, but not the,

46:04

but of course we could see it on the skin as well.

46:07

So we have a couple votes for a lipoma,

46:11

multiple votes for a lipoma.

46:13

Good. And that's what this was avascular

46:18

relatively high, uh, iso coic

46:20

to the surrounding soft tissues.

46:22

Again, good to know how long it had been there.

46:24

I didn't give you that information.

46:25

But querying the patient you could find out if it had been

46:28

there for years or it was relatively new.

46:30

This one had been there. Um, we often find

46:33

that patients who've not been

46:34

to the doctor in a while come to see their doctor.

46:36

They end up getting all kinds of things worked up that may

46:39

or may not be appropriate to look, work up,

46:41

but that's all right.

46:44

Somebody asked why the skin should change along

46:46

the back of a lipoma.

46:47

It's possible because it's more swollen there

46:49

that she had some rubbing of clothing or something on there.

46:52

Otherwise, I, I really don't know the answer to

46:54

that question, why there should be some skin changes there.

46:57

I wouldn't honestly think there would be other than if it

47:00

was just irritated from being a little bit, uh,

47:03

swollen there compared to the opposite side.

47:07

Somebody also asked if I could differentiate a

47:09

and the angio from a lipoma.

47:11

Um, I'm not sure I I have, I have tried

47:15

to make the diagnosis of a hemangioma on some patients.

47:17

We occasionally are referred mostly children to rule out

47:22

that something that's swollen is a hemangioma

47:25

but we get them so infrequently.

47:26

And I, I don't do pediatrics that I, I don't know

47:29

that I could confidently answer that question.

47:31

So unfortunately I'm going to punt that one

47:36

and we're gonna move on to this patient who's 39

47:38

who noticed a right thigh lump.

47:39

And this had not been there for a long time.

47:42

It had been slowly growing

47:43

but it it'd been more like in the months,

47:46

not years sort of thing.

47:49

And this is what we saw when we first put

47:51

our transducer down.

47:54

It was kind of a regular looking lesion.

47:57

It's about four centimeters by four

47:59

and a half centimeters by two centimeters.

48:10

And here is sort of the key image

48:14

that's gonna let you know

48:17

that this is something you probably wanna be worried about.

48:20

The history is a problem

48:21

because it hadn't been there very long.

48:23

The fact that there's an area that looks like it's necrosis

48:26

and there's a lot of flow in it.

48:29

So the prob appropriate thing to do in this case,

48:33

and a lot of you said sarcoma, which is great, is

48:38

to do advanced imaging

48:41

and it's this area here

48:44

and it's a soft tissue sarcoma.

48:48

So that's really unfortunate.

48:50

What is fortunate for this patient is

48:52

that it was relatively superficial.

48:55

It had looked like it's going

48:56

through the tissue planes here a little bit,

48:59

but he, they were able to resect this without a huge amount

49:02

of deformity in this patient.

49:04

It's also very important never

49:06

to put a needle into something that you think is a sarcoma

49:09

until you talk to the surgeon about

49:11

what their approach is going to be

49:13

for resection of the lesion.

49:16

So this is relatively superficial,

49:18

so going directly in the lesion is probably appropriate

49:21

'cause they're going to resect the entire thing

49:23

with the overlying skin.

49:25

But for example, if this had been a little bit deeper,

49:27

you never wanna go completely through another compartment

49:31

into that lesion because you can seed another

49:33

compartment of the thigh.

49:35

You wanna take the, the shortest distance that will not, uh,

49:40

change the surgery for that patient.

49:43

So be very careful before you just stick needles into things

49:45

you think are sarcomas.

49:48

Alright, we have a 20-year-old male.

49:52

He complained that he had a left upper neck mass.

49:55

Happened to mention he had a recent covid infection.

49:58

So this is what he looked like when he first came in.

50:01

And this was on 8 6 20 24.

50:05

And so I'll show you a c clip here that's going

50:09

through this area and you can see there's a couple

50:14

of rounded structures here and here.

50:17

Lot of flow described

50:20

as the upper neck in the area of concern.

50:24

So adenopathy, lymph nodes, hyperplastic, reactive nodes.

50:29

Great. Yes, all of those are true.

50:32

Um, it looks like the flow is is coming in from a

50:35

hilum and branching out.

50:36

It's a young person. They were,

50:39

it's a relatively recent occurrence

50:40

and the patient had a recent infection.

50:43

Excellent. Well the patient came back again

50:49

and this was, that first time was on eight six,

50:52

they came back three weeks later

50:54

and this is what that same area now looks like.

51:00

And here we're using, uh, ultrasound to compress this area.

51:05

So what do you think has gone on now?

51:10

An uh, abscess, necrotic lymph node and abscess separative.

51:13

Lymphadenitis. Excellent. Exactly. This is what happened.

51:17

You can see we're using the probe to show that this debris

51:21

and fluid is moving around it's mobile inside of there.

51:24

We can see that the lesion is vascular including a rounding

51:29

around it, excuse me, as well as some

51:31

of the areas internally.

51:34

And the patient ended up with a neck ct

51:37

and this is that area here.

51:40

So basically we have lymph nodes that became abscessed

51:45

and this had to be, uh, incised and drained

51:47

and the patient was placed on antibiotics,

51:49

continued on antibiotics I should say the fluid

51:52

that was in here never actually grew out anything.

51:55

Um, but he was put on presumptive, uh, antibiotics

52:00

for, you know, typical skin flora

52:03

and did eventually get better.

52:08

All right, we've had 71-year-old female,

52:11

she's had a thigh lump

52:12

and she says it's been there for a long time, as long

52:16

as she could remember 40 years or more.

52:18

But she thinks it's growing

52:19

and now it's become kind of painful.

52:22

And this is a picture of what it looked like here,

52:24

this little lump here, little skin discoloration over it.

52:29

And this is what it looked like when we put our

52:32

ultrasound probe on.

52:34

You can see it's deforming the skin and this is gel

52:38

and then this is what it looked like here

52:44

and in the other plane kinda lobular.

52:51

And this is what it looks like with color flow.

52:55

So I'm gonna tell you, you're probably not gonna know

52:57

what this is 'cause I had never heard

52:58

of this diagnosis either.

53:00

However, it's something

53:04

that's been there a really long time

53:06

but just recently started to bother her.

53:08

So the fact that it's been there more than 40 years,

53:11

the fact that there's flow in it doesn't bother me so much.

53:14

If she had said, I noticed this three months ago

53:17

and now it's getting larger and painful.

53:19

The flow is definitely a problem,

53:21

but the fact that it's been there a really long time is,

53:24

is not as big an issue.

53:26

And like I said, you're not gonna know what this is.

53:30

Somebody says neurofibroma, MFH lipo.

53:35

This turned out to be what's called an rine. SPI adenoma.

53:39

This is a very rare benign tumor. It's usually asymptomatic.

53:43

But what the patient described was that

53:45

because of its location when she went to cross her legs like

53:49

to to sit with her legs crossed it, would it,

53:51

she would bump into it, it would bother her.

53:54

They are um, they arise from the rin sweat glands.

53:57

I don't know why she'd have it there.

53:59

That's generally where it is.

54:00

I mean, I guess we have sweat glands all over our body.

54:03

Um, but again, very rare mesenchymal tumor.

54:07

Again, I've never seen another one of these.

54:09

I probably won't see another one of these.

54:11

Um, but it was resected mostly for the symptoms

54:13

and not so much because we thought it

54:15

was something malignant.

54:20

Now we have an a 58-year-old female.

54:22

She has a history of diabetes

54:24

and she had a painful axillary lump

54:27

and this is what her axillary lump looked like.

54:30

Here's a still picture. Here's

54:32

with color flow I can show you.

54:34

Uh, going through her axilla

54:39

and a picture staying kind of in one place,

54:41

moving a little bit back and forth with color flow,

54:45

not a very well-defined lesion.

54:48

Kind of more infiltrative areas here

54:51

that are are more liquidy looking or debris laden.

54:59

Yeah, somebody saying axillary abscess.

55:01

Adeno cellulitis, yes. Great.

55:10

And this indeed did turn out

55:11

to be an abscess in this patient.

55:15

So again, history is important.

55:17

I mean, all I gave you was the diabetes

55:19

and the fact that she had a lump there.

55:21

Um, we'd wanna look at the overlying skin to make sure

55:23

that it, it didn't look like there was any areas of,

55:26

you know, cellulitis that would also lead us in that area.

55:29

The diabetes history is a little helpful.

55:31

I mean, diabetics are more prone to getting infections

55:33

and even a small, um, little bit of trauma in the axi.

55:38

Maybe she nicked herself when she was shaving.

55:40

Something like that could end up causing more issues.

55:43

Or an ingrown hair can end up causing more issues in a

55:46

diabetic than it would in a, in a uh,

55:48

patient without diabetes.

55:50

Okay, I've got a couple more cases.

55:52

This was a 30 5-year-old male who noted painful shin.

55:57

Um, and she had a little bit of swelling on his shin

55:59

and the area that was in question was along here.

56:03

So we put our ultrasound probe on

56:07

and we can measure this little lesion here.

56:13

And I, I love our text

56:15

'cause they're lateral left lower, she

56:16

and area of palpation pain.

56:18

They give us all kinds of information.

56:21

Ah, somebody got it right away.

56:23

Muscle hernia, muscle hernia, muscle hernia, fat hernia.

56:27

Excellent. So this is the money shot here.

56:32

Here we have the technologist applying pressure on the area.

56:40

Actually I take that back. The patient is,

56:42

is moving his foot back and forth.

56:44

She's not putting pressure.

56:46

The patient is moving his muscles

56:48

and you can see that there's a little

56:51

break here in the fascial plane

56:53

and there's tissue that's going in and out of that area.

56:57

And this turned out to be an anterior tibialis hernia.

57:00

So those of you said muscle, um, hernia.

57:05

Excellent. Um, I haven't seen very many of these, um,

57:08

but when you do see this

57:10

and you're able to see the fascial plane being disrupted

57:14

and the tissue going in

57:15

and out, it's extremely satisfying to be able

57:18

to make that diagnosis.

57:22

So those are all the cases I have.

57:24

Um, I wanted to talk about a,

57:25

a little bit of of things here.

57:27

Um, interacting with the patient is really hi important.

57:30

You really need to know the history.

57:32

How long has the lesion been there?

57:33

Is it painful or not painful?

57:35

Are there any associated changes in the overlying skin?

57:38

Does the patient have any other symptoms like fever?

57:42

Was there precipitating trauma

57:44

or did they pick out a pimple?

57:46

Did they have an ingrown hair? Anything like that.

57:49

Ultrasound maneuvers are helpful. Compression Valsalva.

57:52

In that last case, we saw the patient flexing his foot

57:56

and allowing the muscles to move back and forth

57:59

and showing how that defect was, uh, was happening.

58:03

Also, characteristics of the lesion.

58:06

Is there blood flow in it or around it?

58:09

How does it look compared

58:10

to the surrounding SU structures and what are its borders?

58:13

Does it communicate with the skin?

58:15

Superficial things tend to be a little bit more likely

58:18

to be, uh, benign, deeper things.

58:21

You may not see the full extent of the lesion

58:23

and you may need to get advanced imaging just to be able

58:26

to know that you're seeing the entire lesion

58:29

and all of its characteristics, whether it's larger or not.

58:32

Again, the larger the lesion, the more difficult it is

58:35

to see the entire thing with ultrasound.

58:38

And you may need to go on to other kinds of imaging.

58:41

So again, advanced imaging is important when the lesion has

58:44

not been there very long and is growing or is, um, vascular.

58:49

And again for also surgical planning to look for metastases

58:54

to see about biopsies.

58:55

All of these things can help you determine whether

58:57

something's benign or malignant.

59:00

So I thank you. So let me see about

59:04

if there's any other questions here

59:05

that I can answer in the last 30 seconds here.

59:08

Um, why do we need a biopsy sarcoma? Does it spread?

59:12

So sarcomas, we, we might wanna biopsy a lesion

59:18

preoperatively so that the physician

59:21

who is resecting it knows how much tissue they need

59:23

to take out and whether they need

59:24

to do a lymphadenectomy at the

59:26

same time, that kind of thing.

59:27

It might be more for surgical planning.

59:28

Sometimes we, we very much strongly suspect a sarcoma based

59:32

on its characteristics on, uh, ultrasound

59:35

and also advanced imaging.

59:37

Um, so sometimes we do those biopsies.

59:40

Sometimes they just do an basically an excisional biopsy.

59:42

They, they know the lesion has to come out

59:44

and they just take the thing out.

59:46

Um, but it's also nice to know ahead

59:48

of time if something is a sarcoma

59:50

because they might also consider radiation

59:53

or chemotherapy ahead of time

59:55

if the lesion is very infiltrative

59:57

and might be involving structures

59:59

that the patient might like to preserve.

60:02

Um, I think I've gotten most of the questions here.

60:06

Um, if I didn't get to your question, I'm really sorry.

60:08

Um, but it's one o'clock

60:10

and I need to let you guys get back to, uh,

60:12

your day. So thank you very much.

60:14

Oh, thank you so much, uh, for everything today, Dr.

60:17

Baumgarten. Uh, thank you for a great case review.

60:20

And thank you so much for everyone

60:22

who participated in our noon conference

60:24

and asking such great questions.

60:26

You can access the recording of today's conference

60:28

and all our previous noon conferences

60:30

by creating a free account.

60:32

We'll also email out a link to the replay later today.

60:36

Be sure to join us on Thursday,

60:38

February 27th at 12:00 PM Eastern, where Dr.

60:41

Alka Singal will deliver a case review entitled Parathyroid

60:45

Ultrasound, how to Identify

60:47

and Differentiate from Other Neck Pathology.

60:50

You can register for it@mrionline.com

60:53

and follow us on social media

60:54

for updates on future noon conferences.

60:57

Thanks again and have a great day.