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Objectives: Many studies show that a large portion of medical prescriptions for diagnostic examinations may be not useful for patient's management or unnecessary. Rapid technological advancement has made it possible for magnetic resonance imaging (MRI) to be increasingly used all over the world, particularly for musculoskeletal disorders. The aim of this study was to assess the appropriateness of the knee MRI prescriptions., Materials and Methods: A panel of experts found standard clinical practice guidelines in the management of knee disorders. Secondly, the finalized set of guidelines chosen was compared with the data of 400 patients who underwent previous knee MRIs, which were then reported in a specific questionnaire prepared by the authors. The rate of appropriateness of knee MRI prescriptions was then calculated., Results: Almost 21% of prescriptions were totally inappropriate, 18.8% were uncertain, and 60.2% could be considered totally appropriate. The most frequent prescription indication was for meniscal disorders that account for 26.8% of the total indications., Conclusions: Our results demonstrate that approximately 40% of the total prescriptions were totally inappropriate or uncertain and that most of these were made by general practitioners. In light of these results, the economic impact of inappropriate prescriptions on the Italian healthcare system has to be seriously considered.

Purpose: Our purpose was to assess the potential of ultrasonography (US) in the detection of in-transit or satellite metastases., Materials and Methods: Following a review of the relevant literature, we present the results of a retrospective study based on 2,000 malignant melanoma patients with complete case records. Of these, we selected 600 patients who had a thick melanoma (>1 mm) at presentation but were clinically free of in-transit or satellite melanoma metastases during follow-up. All patients underwent periodic clinical and imaging investigations, as well as US examination of the site of the surgical wound and surrounding soft tissues., Results and Discussion: US raised the suspicion of in-transit or satellite metastases in 63 patients. A total of 95 lesions were identified. Average lesion diameter was 0.7 mm, and only four were larger than 1 cm. All suspected lesions were confirmed by surgery, follow-up or US-guided fine-needle aspiration (FNA) with 22-gauge needles using a freehand technique and exploiting the capillarity principle. In this series, there were apparently no false positive or false negative US results although inclusion criteria precluded correct evaluation of possible false negatives. Minimum lesion diameter allowing sonographic detection appears to be around 0.4 mm. US features of in-transit metastases have been well documented. They usually appear as solid lesions, hypoechoic relative to the surrounding subcutaneous fat and with relatively well-defined and regular contours and good US transmission. Internal structure is fairly homogeneous, and sometimes millimetresized fluid areas can be appreciated inside. Larger metastatic lesions may exhibit internal vascular signals at power Doppler imaging. These findings in dermatological sonography are almost exclusive of metastases but may also be seen in glomangioma, which, however, has intense intralesional vascularity. US-guided FNA plays an important role in diagnosis of metastases from malignant melanoma. Of the 32 nodules that were cytologically sampled, a definitive or most probable diagnosis of metastasis was made for nodules with a mean diameter of 0.7 mm (minimum 0.5 mm)., Conclusions: Sonography of soft tissues surrounding the original site of a malignant melanoma should be more widely used and associated with US-guided FNA biopsy.

Purpose: US is usually considered of little help in studying the ureters because it only shows proximal and distal tracts. The distal ureter is also difficult to study with most of the other imaging methods. Transrectal probes improve depiction of the intramural and pelvic tracts of the ureter, as well as image quality, dramatically providing good results in a short time. The first and, to our knowledge, the only report on this procedure has been Holm's (1994), where the author reported good results though in a small series. For years we have used transrectal US, performed for prostate studies, also to examine intramural ureters and have obtained good results in a short time. Thus we decided to compare the transrectal with the transabdominal approach., Material and Methods: We examined 92 randomly selected male patients with various urologic conditions but no ureter involvement using 3.5 MHz convex and 5.0 MHz biplane transrectal probes. Image quality was rated on an arbitrary scale (0-4) and then submitted to statistical analysis., Results: Transrectal images were clearly superior to transabdominal ones (p = 0.012) and particularly, ureters were depicted in 93% versus 60% of cases, respectively. The amount of urine in the bladder appears to play a major role (the greater the amount the worse the image quality), while ureter depiction is independent of body habit and bladder squeezing., Conclusions: Our results are clearly superior to Holm's. Also, considering that the transrectal examination requires a short time, is cost-effective and little invasive, we believe that this method can play an extremely important role in lower ureter studies.

Introduction: Plantar fibromatosis, or Ledderhose's disease, is a fibrous proliferation arising within the plantar fascia end exhibiting typical clinical nodular features. The lesion appears as a firm single thickening or a nodule, occasionally painful, localized to the medial portion of the sole of the foot. This unusual condition has not been extensively studied with US and very little has been written about it., Material and Methods: In 1998-99, six patients with plantar fibromatosis were submitted to US with 13 MHz linear array and 20 MHz mechanical annular array probes. All patients were examined in prone recumbency with the probe positioned on the sole of the foot. Only some of them were subsequently submitted to surgery., Results: Plantar fibromatosis exhibited an almost pathognomonic pattern and US proved to be a quick, noninvasive and cost-effective technique to confirm clinical diagnosis. The nodule is typically single and isoechoic, with maximum diameter of about 1 cm, inhomogeneous internal structure and few thin hyperechoic septa. The nodular fibrous proliferation adheres with the major axis along the plantar fascia; it exhibits clear-cut margins and US beam transmission is good. No calcifications or fluid collections are seen within the nodule. Color and power Doppler show no flow inside., Conclusions: US is an adequate tool for the study of plantar fibromatosis.

Purpose: We investigated the predictive capabilities of high frequency, high resolution ultrasound (US) in the preoperative assessment of tumor thickness in cutaneous malignant melanomas. This evaluation is a valuable help for correct surgical planning., Material and Methods: December 1997 to August 1998, we studied with US over 120 pigmented skin lesions and collected the data, including the final histologic diagnosis, of 78 of them, which make our series. Sixty-six of 78 lesions were histologically defined as cutaneous malignant melanomas with superficial spread and the other 12 as melanocytic nevi. All examinations were carried out with an Esaotebiomedica AU 5 Harmonic scanner equipped with a 20-MHz annular array probe and a linear 13-MHz probe; B-mode, color and power Doppler images were always acquired., Results: The statistical analysis of the comparative US and histologic measurements of tumor thickness showed very good agreement, with a high Pearson's coefficient (R: .93). However, US frequently underestimated the actual thickness relative to histology, which is in contradiction with previous literature reports. We could study with US the melanoma in situ, which has never been described before. Last but not least, low-thickness melanomas had very few color and power Doppler signals., Conclusions: US is the correct tool for the preoperative assessment of the thickness of cutaneous malignant melanomas because it provides high agreement with histologic data even in lesions thinner than 1 mm.

Introduction: We report the preliminary results of a study on the importance of juxtajugular and supraisthmian lymph node enlargement at US as a sign of occult subacute thyroiditis., Material and Methods: We examined patients submitted to thyroid US for noninflammatory thyroid conditions and for positive familiarity and studied the presence of supraisthmian and juxtajugular lymph node enlargement. The patients were then divided into two groups: the clinical history, antibody titer and symptoms were studied in group A (patients with enlarged lymph nodes) and the antibody titer, symptoms and US findings were studied in group B (patients with a history of thyroiditis)., Results: Fifty-nine of 600 patients were allocated to group A and 25 of 600 to group B. Of the former 59 asymptomatic patients (10% of the total), 29% had supraisthmian and 85% juxtajugular lymph node enlargement, with some patients positive at both sites. Forty-seven patients (80%) had subacute thyroiditis (33 of them with positive antibodies and 23 with a clinical history); we had 12 false positives. Twenty-two of 25 group B patients (91%) had supraisthmian (40%) or juxtajugular (83%) lymph node enlargement: 3 patients with no enlarged lymph nodes had an over 3-year history of low antibody titers., Discussion: Forty-seven of 600 (8%) asymptomatic patients who had been never examined are or were affected with subacute thyroiditis. Ninety-one per cent of all thyroiditis patients had supraisthmian or juxtajugular lymph node enlargement, more frequently the latter than the former., Conclusions: Supraisthmian and/or juxtajugular lymph node enlargement appears to be a very useful US sign of subacute thyroiditis, even though these data need confirmation from larger series of patients.

In the past, several obstacles hindered the study of decubitus calcifications in soft tissues--i.e., poor prognosis, difficult patients investigation due to their poor health and, finally, unsufficient information yielded by conventional radiology. However, special radiographic techniques and US (with 7.5 MHz probes) allowed satisfactory results to be obtained. US permits the more accurate definition of the site of calcifications, better demonstration of the calcifications with poor calcium content and optimal depiction of structural changes of the muscular bundles following denervation or edema and of skin trophism changes. US limitations, besides those strictly related to the method itself, are: gross calcifications with large posterior shadowing not allowing the deep layers to be investigated, the need of an extremely qualified operator and of a detailed description and, finally, the fact that the exam is long, difficult and stressful to the operator and painful to the patient. In conclusion, US provides both the surgeon and the clinician with useful information and can thus be employed as a routine test, with the additional advantage of not employing ionizing radiations.

Over a 2-year period (1989-90), about 400 cases were examined (out of nearly 2,500 US examinations of the prostate), 244 of which had subsequent bioptic, surgical or autoptic confirmation. This paper reports the anatomic, clinical and pathologic data relative to the seminal vesicles of 244 subjects who underwent transrectal US of the prostate for different clinical indications. Our biometric values were slightly different from those reported in literature, the latter being based on autoptic findings. Agenesis and monolateral ectopia were confirmed to be extremely rare: 4 cases only (1.6%) in our series. A typical finding was the nearly perfect symmetry; in size and structure, of the two seminal vesicles in the same subject; as a matter of fact, a loco-regional pathologic condition was detected in all the patients (14) with asymmetry. A hundred per cent agreement was observed between the US patterns of the seminal vesicles and the prostatic patterns in case of acute/subacute prostatic inflammation involving also the 2 glands: this parameter can be used to follow the clinical course of the inflammatory process.

The authors report on a series of 1,043 fine-needle biopsies of the thyroid performed under US guidance; the patients had been selected for thyroid pathologic conditions. Fifty-two neoplasms were observed (46 papillary carcinomas, 1 medullary carcinoma, 2 follicular carcinomas, and 3 metastases), which had been detected by cytology and confirmed by histology or autopsy. The authors focus on 46 cases of papillary carcinoma: their US features were studied which, through a correlation of variables, allow a quick and "safe" recognition of the type of carcinoma (papillary carcinomas account for nearly 60% of thyroid neoplasms). Tumor echogenicity and outline, and the presence/absence of calcifications were evaluated: in most cases, papillary carcinomas presented as focal lesions (alone or associated with other goiter lesions), with irregular and blurred outline, no hypo/anechoic halo and, in about 1/3 of the cases, with calcifications and colliquative areas. In 17% of papillary neoplasms, metastases to loco-regional nodes were observable at US; in 3 cases the carcinoma did involve a loco-regional node but there were no US signs suggestive of it. The incidence of neoplasms on the total of fine-needle biopsies is 4.9%, while in a previous series of 3,038 fine-needle biopsies, without US guidance, on clinically detectable lesions, the figure was about 2%.

The authors report on a series of 254 consecutive male patients who underwent transrectal US, sometimes combined with uroflowmetry, for the study of micturitonal phase. 170 patients were studied with both techniques. In 118 patients, there was complete agreement between the two methods about presence and degree of flow obstruction; partial disagreement was observed in 48 patients and complete disagreement in 4. On 44/52 patients with partial/complete disagreement diagnostic cystouretrography was performed. Our results demonstrate high agreement between the two techniques, except in case of micturition deficit with columnar hypertrophic bladder and in obstructive pathologic conditions of anterior urethra.

Peyronie disease, or Induratio Penis Plastica, is characterized by the presence of one or more fibrous plaques at the albuginea penis, on the cavernous bodies or on the intercavernous septum. First of all, Induratio Penis Plastica etiology is described, and its clinics and therapy. Past imaging methods are then considered (i.e. conventional radiology, xerography), and current ones (i.e. conventional radiology, cavernosography, CT and US). The authors report on their 4-year (1983-1987) experience with US in 62 males. Various different probes were employed, especially small-part 7.5 MHz probes. The results are similar to those reported in international literature. The use of high frequency probes allows the evaluation of focal hypoechoic lesions even in the early phase of the disease, thus helping make therapy more effective.

In the last three years we performed more than 200 echo-guided prostatic biopsies using different probes. Recently, thanks to the availability of a bi-planar transrectal probe we have developed a technique that resulted simple rapid well accepted by the patients and above all able to center small prostatic nodules. We have studied with this technique 96 patients performing 120 biopsies. For the biopsy we used a 19 G cutting-needle introduced under local anaesthesia parallel to the probe (linear array) when the needle is on the target we turn on the axial view and we check the position with respect to the center of the lesion, then, returning to the sagittal view we perform 1 to 3 biopsies for microhistological and cytological examination. With this method we have reached a better accuracy of diagnosis.

Prostatic lithiasis is a well know phenomenon. It has little clinical significance and is not easily shown by conventional radiography, which has poor sensitivity and specificity. The authors have studied 612 patients with both suprapubic and transrectal US in order to 1) assess US sensitivity and specificity and 2) report the frequency, spatial distribution, number and features of prostatic calcifications with special emphasis on differential diagnosis between prostatic neoplasms and chronic prostatitis. The authors have also studied the relationship between morphology and symptoms and the results agree with those reported in the scanty literature. The authors conclude that the parameters studied are directly related to age, except for a younger group with clear evidence of genital inflammation. The authors emphasize the impossibility to correlate morphology of prostatic calcifications with pathologic conditions: there are no specific symptoms clearly connected with calcification even though the inflammation is often associated with calcifications.