A p p ro a c h t o E v a l u a t i n g

Superficial Soft Tissue

M a s s e s b y Ul t r a s o u n d
Pamela Garza-Báez, MDa, Sandra J. Allison, MDb,c,
Levon N. Nazarian, MDa,*

KEYWORDS
 Ultrasound  Soft-tissue lesion  Soft-tissue tumor

KEY POINTS
 This article presents a systematic approach to the ultrasound (US) evaluation of superficial soft tis-
sue masses.
 The clinical history, the location of the lesion and its detailed characterization by US usually leads to
a confident diagnosis.
 If there are inconclusive or suspicious findings by US, correlative imaging or a percutaneous biopsy
should be performed.

Video content accompanies this article at http://www.radiologic.theclinics.com.

INTRODUCTION placed on the patient, the first step is to take a thor-

ough history about the mass. If the mass is
Sonographic evaluation of superficial soft tissue palpable, have the patient point to the area of inter-
masses is a common diagnostic challenge in clin- est. Examine the area of the mass for skin color
ical practice. A systematic approach to these changes, dilated vessels, or other findings in a
masses enables effective diagnosis and minimizes well-illuminated environment. If the mass is not
errors. This article presents the authors’ preferred palpable, consult the correlative imaging that trig-
approach based on lesion location, grayscale gered the US such as computed tomography,
appearance and Doppler features. In many cases MRI, or PET. It is important to know whether the
a specific diagnosis is possible, but when US find- mass is painful and whether it is growing or stable
ings are inconclusive, US-guided biopsy provides in size. Gather potentially relevant medical history,
a safe and accurate way to establish the etiology including prior malignancy, trauma, surgery, antico-
of the mass. agulation, or systemic diseases.
GENERAL APPROACH TO A SUSPECTED SOFT
TISSUE MASS IMAGING TECHNIQUE
For US imagers as in all of medicine, clinical history US scanning should utilize a high-frequency linear-
is of utmost importance. Before the transducer is array transducer, typically operating within a
radiologic.theclinics.com

a
Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA; b Georgetown
University School of Medicine, Washington, DC, USA; c Washington Radiology, Washington, DC, USA
* Corresponding author. Department of Radiology, Hospital of the University of Pennsylvania, 3737 Market
Street, Mailbox #4, Philadelphia, PA 19104.
E-mail address: levon.nazarian@pennmedicine.upenn.edu

Radiol Clin N Am 63 (2025) 109–122

https://doi.org/10.1016/j.rcl.2024.08.004
0033-8389/25/Ó 2024 Elsevier Inc. All rights are reserved, including those for text and data mining, AI training,
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110 Garza-Báez et al

frequency range of 12 to 24 MHz. Deeper masses Once the mass is identified, it should be
may require a curved linear transducer in the 5 to measured in 3 dimensions. The longest axis of
9 MHz range to enable better penetration. Gener- the mass—which may not necessarily corre-
ally, the transmit frequency should be set to the spond to the long axis of the body—should be
highest level which ensures clear visualization of measured first followed by the orthogonal dimen-
the complete lesion and its surrounding tissues. sion on the same image. The transducer should
For larger masses, extended field-of-view technol- then be rotated 90 and the width measured. Us-
ogy may be helpful to include the entire mass on a ing the same measurement technique each time
single image to show the relationship of the mass will facilitate a comparison of the mass size on
to adjacent structures and enable more precise any subsequent studies. If the mass is not
measurements (Fig. 1). Most imaging can be per- measured the same way each time, the examiner
formed with a standard acoustic coupling gel. For may receive a false impression of either stability
very superficial masses a gel stand-off pad can be or growth.
used, but it is the authors’ preference to float the
transducer on a large dollop of gel. DIAGNOSTIC PATHWAY
The depth of the US image should be minimized
while still including the mass and surrounding tis- The first step in determining the etiology of the
sues. If applicable, focal zone(s) should be set at mass is localizing it to its compartment(s) of
the level of the mass. The gain and time gain origin—skin, subcutaneous tissues, muscle,
compensation curve should be set appropri- bone—as well as determining whether the mass
ately—the gain should be low enough to minimize arises from a specific musculoskeletal structure
artifacts but high enough so that low-level echoes such as joint, bursa, nerve, tendon, ligament, or
in the mass are not missed. Once the grayscale fibrocartilage such as labrum or meniscus. Placing
characteristics of the mass have been evaluated, the mass in a compartment requires paying atten-
the next step is to assess the vascularity in and tion to the anatomic layers visible on a US image
around the lesion by Doppler. Number and pattern (Fig. 2). The beam first encounters the epidermis
of blood vessels should be assessed by color and/ which creates a specular reflection but is difficult
or power Doppler, which should be optimized as to resolve with routine scanning frequencies. The
follows: depth should be minimized as for gray- first discernible layer is generally the dermis which
scale imaging; the color box should be the small- is hyperechoic to subcutaneous fat, which is the
est that still includes the mass; color gain should next layer. The subcutaneous fat layer is of varying
be set by increasing the gain until there is color thickness, is normally hypoechoic relative to the
noise, then dialing it down slowly until noise first dermis and muscle, and often has hyperechoic
appears; and if applicable, focal zone(s) should septations.1 It is a common misconception that
be placed at the level of the mass. To optimize fat is hyperechoic on US, but there is nothing
detection of slow flow, the scale and wall filter intrinsically echogenic about fat. Echoes are
should be at the lowest level that does not cause created by interfaces between tissues of differing
unacceptable color noise. Spectral Doppler is an acoustic impedances. Since subcutaneous fat is
important adjunct to confirm the presence of flow relatively homogenous, normal fat contains few
within the mass and determine whether it is arterial echoes. Separating the fat from the muscle is
and/or venous. hyperechoic fascia of varying thickness. Deep to

Fig. 1. Subcutaneous lipoma in the shoulder on standard (A) and (B) extended field of view (EFOV) sonography.
The EFOV image allows the entire mass to be depicted, so that it can be more accurately measured and its rela-
tionship to the regional anatomy better defined.

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 Approach to Evaluating Soft Tissue Masses 111

Fig. 2. Normal soft tissues on sonogra-

phy of the back. D, Dermis; F, Fascia; M,
Muscle; SQ, Subcutaneous tissue.

this fascia is muscle which has a typical pattern is at least partially solid (Fig. 4B), whereas flow
of hypoechoic muscle bundles separated by may not be detectible within a solid mass if the
hyperechoic fibroadipose septa in a pennate flow is too slow, the internal vessels are too small,
pattern.2 and/or the Doppler technique is suboptimal.4
The echogenicity of the mass should then be Spectral Doppler will confirm the types of flow
characterized as hypoechoic, isoechoic, hypere- within the mass, arterial and/or venous. However,
choic, or mixed. Because these terms are relative, the shape of the arterial waveform has no predic-
there needs to be a standard of reference. The au- tive value regarding whether the mass is benign
thors recommend comparing the echogenicity to or malignant (Fig. 4C; Fig. 8B).5
muscle since a regional muscle can almost always A crucial fact to understand about soft tissue
be imaged in the same field of view. Next, the bor- masses is that acoustic enhancement does not
ders should be assessed: are the borders well- mean the mass is cystic. Because acoustic
defined or do they blend in almost imperceptibly enhancement is commonly used to differentiate
with surrounding tissues? It should also be noted cystic from solid masses in organs such as the
whether the mass attenuates the US beam, has kidneys, liver, and ovaries, many radiologists
no perceptible effect on the beam, or causes incorrectly assume that this finding is also appli-
acoustic enhancement. cable to superficial masses. Unfortunately, that
is not the case. In fact, in one series of superficial
IS THE MASS CYSTIC OR SOLID? metastases from melanoma, 71% of the lesions
had acoustic enhancement.3 Homogenous solid
One of the most important functions of US is to masses often attenuate the US beam less than
determine whether a mass is cystic or solid. the more heterogeneous adjacent soft tissues.
Although this task sounds straightforward, it can Thus, acoustic enhancement must never be
be tricky. The first thing to do is to evaluate the used to differentiate cystic from solid masses
grayscale appearance. On average, cystic lesions (Fig. 6).3
tend to be relatively less echogenic than solid
masses, but there are many important exceptions.
Cystic masses can have echoes within them
because of contents such as hemorrhage, pus,
or keratin (Fig. 3). Conversely, solid masses can
be relatively hypoechoic or even anechoic if their
cellular content is homogeneous with few acoustic
interfaces (Fig. 4A).3 Because the grayscale
appearance alone is unreliable, we may need to
rely on other clues. Compression should be
applied by the transducer in real time. A mass
that changes its morphology with compression
may be fluid-containing, especially if the internal
echoes swirl in real time (Fig. 5, Video 1). The Fig. 3. Epidermoid cyst in the calf. Sonography dem-
next piece of data is the Doppler evaluation. onstrates diffuse internal echoes due to keratin accu-
Doppler flow is more helpful if it is present than if mulation, the so-called “pseudotestis” appearance.
it is absent: internal flow confirms that the mass There was no internal flow on color Doppler.

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112 Garza-Báez et al

Fig. 4. Soft tissue lymphoma presenting as a subcutaneous thigh mass. Grayscale appearance (A) is hypoechoic
with low level internal echoes. (B) Extensive flow on color Doppler confirms solid nature of the mass. (C) Arterial
waveform obtained on spectral Doppler. Note the high resistance flow despite the malignant nature of the mass.

DOES THE MASS CONTAIN FAT? Fat necrosis can present as a palpable subcu-
taneous nodule virtually anywhere in the body.
For solid masses the next step is to decide The nodule may or may not be painful. There is
whether the mass is fatty because lipomas are often a history of blunt trauma, surgery, or local in-
so common, especially in the subcutaneous tis- jections.9 On US, subcutaneous fat necrosis has a
sues. The echogenicity of lipomas ranges from variable appearance—it can appear uniformly
hyperechoic to isoechoic to hypoechoic with hyperechoic or have a hypoechoic center with pe-
respect to muscle depending on how many inter- ripheral hyperechogenicity (Fig. 9). The borders
faces are created by other components such as are ill-defined and blend in with the adjacent sub-
fibrous tissue.6 Lipomas characteristically contain cutaneous fat. There is typically no significant
linear echogenic septations that are oriented along vascularity on color Doppler. Compared to li-
the long axis of the lipoma, usually parallel to the pomas, there tends to be less mass effect on the
skin (Fig. 7). There may be a defined capsule adjacent soft tissues.
around the lipoma, or the borders may blend in
with the adjacent soft tissues and be difficult to
DOES THE MASS ARISE FROM A
delineate. When applicable, bilateral comparison
MUSCULOSKELETAL STRUCTURE?
can be helpful to differentiate a normal lobulation
of fat from a lipoma. Note that on color Doppler li- The examiner should scrutinize the mass for any
pomas tend to have little or no flow.6,7 However, connection to a musculoskeletal structure since
there may be exceptions in which a lipoma dem- that connection may be the key to the diagnosis.
onstrates an atypical amount of increased flow Common examples include the following.
(Fig. 8). Although the vast majority of fatty masses
are lipomas, well-differentiated liposarcomas may Joints/Bursae
look similar to lipomas. Features raising suspicion
of liposarcoma include recent rapid growth, deep Popliteal (Baker’s) cyst
location (ie, not subcutaneous), and prominent, Baker’s cyst is a distended bursa that occurs at
irregularly branching vessels on color Doppler.8 the medial posterior aspect of the popliteal fossa.
To avoid diagnostic errors, it is important to call a

Fig. 5. Infected subcutaneous hema-

toma in a hockey player who was hit
by a puck in the leg. Hypoechoic
collection with peripheral color
Doppler flow and increased echoge-
nicity of the subcutaneous fat likely re-
flecting edema.

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 Approach to Evaluating Soft Tissue Masses 113

Fig. 6. 2 solid masses that exhibit increased acoustic through transmission. (A) Schwannoma in the hand and (B)
Subcutaneous melanoma metastasis in the thigh.

Fig. 7. Subcutaneous lipoma in the

supraclavicular space. There was no in-
ternal flow on color Doppler.

Fig. 8. Lipoma within the biceps brachii muscle. (A) Longitudinal sonogram shows a slightly hyperechoic intra-
muscular mass with the parallel echogenic lines typical of lipoma. (B) Low resistance arterial flow within the
mass on Doppler. Because of the intramuscular location and internal flow, the mass was removed and was benign.
L, Lipoma, B, Biceps brachii.

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114 Garza-Báez et al

differential diagnosis. However, a popliteal fossa

mass without the typical morphology needs to be
regarded with suspicion (Fig. 11).

Distended iliopsoas bursa

Analogous to the Baker’s cyst in the knee, the
iliopsoas bursa commonly communicates with
the hip joint and can present as a palpable
mass.13 This bursa also has a typical location:
when distended the bursa extends posterior to
the common femoral artery and vein at the level
of the acetabulum (Fig. 12).14 More inferiorly the
bursa can track along the iliopsoas tendon down
Fig. 9. Fat necrosis presenting as a painless nodule in to its insertion on the lesser trochanter, where
the arm of a patient with acute myelogenous leuke- the bursa abruptly ends. Similar to the Baker’s
mia. Note that the area is mainly hyperechoic with a cyst the distended iliopsoas bursa is typically
hypoechoic component (arrows), and the margins anechoic, but can also be filled with thick, echo-
blend seamlessly in with the adjacent subcutaneous genic material (see Fig. 12). It can even become
fat. Because of the history, the nodule was removed, so large that it presents as a palpable mass. A dis-
and fat necrosis confirmed histologically.
tended iliopsoas bursa is generally associated
with hip arthritis or iliopsoas tendon pathology,
Baker’s cyst only if it arises between the medial especially in patients who have had a hip
head of the gastrocnemius and the semimembra- replacement.13,15
nosus tendon10 (Fig. 10). Baker’s cysts communi-
cate with the knee joint over 50% of the time, so Ganglion cysts or synovial cysts
any process that occurs in the knee joint can Ganglion cysts are common in the wrist/hand and
extend into the Baker’s cyst including joint ankle/foot but can occur anywhere in the body.
effusions, synovitis, intraarticular bodies, or, Ganglion cysts present as firm nodules that can
rarely, infection.11,12 A palpable mass in the medial wax and wane in size and may or may not be pain-
popliteal fossa with typical morphology has no ful. When they arise from the volar wrist they can
even present as a pulsatile mass if they are deep
to the radial artery. Ganglion cysts are most
commonly anechoic, either unilocular or multilocu-
lar. When a ganglion cyst contains internal echoes,
it may be difficult to distinguish from a hypoechoic
solid nodule. In such cases, establishing commu-
nication to an adjacent joint space or tendon
sheath can confirm the diagnosis and help guide
surgical resection (Figs. 13 and 14). Synovial cysts
are similar in appearance to ganglion cysts but
differ in their wall composition and in their con-
tents.16 Ganglion cysts are filled with a thick, gelat-
inous material and are relatively non-
compressible, while synovial cysts are filled with
less viscous fluid extending from the nearby joint
and tend to be more compressible.16 Because
they can look identical, whether a cyst is a synovial
cyst or ganglion cyst can sometimes be deter-
mined by ease of aspiration. There are also char-
acteristic locations where synovial cysts occur,
for example, superficial to the acromioclavicular
joint (Fig. 15). Cysts can also arise in relation to
Fig. 10. Baker’s cyst in the knee. Axial sonogram
tears of fibrocartilaginous structures, most com-
shows the origin between the medial head of the mon being labral tears in the hip or shoulder or
gastrocnemius and the semimembranosus tendon. meniscal tears in the knee and are referred to as
MG, Medial gastrocnemius; SM, Semimembranosus paralabral or parameniscal cysts, respectively
tendon. (Fig. 16A, B).

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 Approach to Evaluating Soft Tissue Masses 115

Fig. 11. Recurrent lymphoma in the popliteal space. (A) Axial sonogram. Although Baker’s cyst can have internal
echoes, this mass is in the wrong location. It is lateral in the popliteal fossa instead of medial, and it does not have
the typical anatomy shown in Fig. 10. (B) Coronal PET/CT confirms the hypermetabolic nature.

Fig. 12. Distended iliopsoas bursa. Axial sonogram with color Doppler at the level of the right acetabulum shows
the distended bursa with diffuse internal echoes. The bursa is in its typical location posterior to the neurovascular
bundle. A, Common femoral artery; IP, Iliopsoas tendon; N, Common femoral nerve; V, Common femoral vein.

Fig. 13. Volar wrist ganglion with communication to the underlying radioscaphoid joint. R, Radial head; S,
Scaphoid.

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116 Garza-Báez et al

Fig. 14. Ganglion at the volar aspect

of the fourth finger arising from the
flexor tendon sheath (arrow).

Nerves can also present as a palpable mass. The patient

may or may not recall the injury. In our experience,
Nerve sheath tumors such as neurofibromas or
the mass is usually due to the patient or physician
schwannomas characteristically appear as hypoe-
palpating the healthy, normally contractile muscle
choic, relatively homogeneous solid masses of
that forms a “hill’ next to the “valley” which is
varying vascularity. The key to the diagnosis is
composed of scarred, atrophic muscle represent-
observing nerve fibers entering and exiting the
ing the chronic injury (Fig. 21).
long axis of the mass, either centrally or eccentri-
The major differential diagnosis for muscle he-
cally (Fig. 17). The nerve fibers should be traced
matoma is a muscle neoplasm. A history of recent
to determine which nerve the mass is arising
trauma suggests hematoma, but occasionally the
from, understanding that tiny cutaneous nerves
trauma history is incidental, that is, the trauma
may be difficult to trace.17
draws attention to a pre-existing mass. Neo-
plasms tend to be better defined than acute mus-
Muscles
cle hematomas on grayscale and can contain
Muscle injuries can present as palpable masses increased vascularity on color Doppler (Fig. 22).
either acutely or chronically. Palpable masses at In contrast, acute muscle hematomas are more
the time of the injury usually represent intra- and/ likely to blend in with the adjacent edematous
or intermuscular hematomas. Acute hematomas muscle fibers, and if increased Doppler flow is pre-
tend to be isoechoic to muscle, but as the hema- sent it tends to be in the adjacent soft tissues, not
toma liquefies it becomes more hypoechoic (Figs. centrally within the hematoma itself. When differ-
18 and 19). With time, a hematoma can reabsorb, entiation between hematoma and muscle
evolve into a seroma, organize and become fibrotic neoplasm is difficult, follow-up US imaging should
or less commonly ossify, known as myositis ossifi- be performed since hematomas decrease in size
cans18 (Fig. 20). Chronic high-grade muscle tears and evolve in appearance over time. Correlation

Fig. 15. Synovial cyst (asterisk) arising from the right acromioclavicular joint. The cyst presented as a painless
palpable mass. C, Clavicle; A, Acromion; Arrow, Synovial thickening in AC joint.

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 Approach to Evaluating Soft Tissue Masses 117

Fig. 16. Parameniscal cyst (A) presenting as a large mass in at the medial knee (between cursors). In (B) the
connection to the medial meniscus is demonstrated. T, tibia, F, Femur, MM, Medial meniscus, MCL, Medial collat-
eral ligament.

Fig. 17. Sural nerve schwannoma. Note the nerve fibers entering and exiting the nerve (arrows).

Fig. 18. Acute traumatic hematoma in

the soleus muscle (arrows). Note that
the hematoma is mainly hyperechoic
to the normal muscle fibers, with small
isoechoic and hypoechoic components.

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118 Garza-Báez et al

Fig. 19. Subacute hematoma in the

gastrocnemius muscle secondary to a
muscle tear. The sonogram was per-
formed approximately 2 weeks after
the injury. The hematoma is more hy-
poechoic and well defined than in
Fig. 18, and the associated muscle
tear is evident (arrow).

Fig. 20. Myositis ossificans presenting as a biceps femoris mass in this 73-year-old man. (A) Longitudinal sono-
gram shows the echogenic ossification (between arrows) with acoustic shadowing. (B) Radiograph confirms
the diagnosis (arrows). F, Femur.

Fig. 21. Chronic rectus femoris tear in this 22-year-old female soccer player with a history of pulled muscle in the
thigh. The patient presented for evaluation of a painless mass. (A) Longitudinal sonogram shows a contracted
hyperechoic scar tissue from prior injury (arrow). The palpable “mass” (M) represents the normally contractile
muscle fibers at the cephalad edge of the tear (arrow) accentuated by muscle contraction against resistance (B).

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 Approach to Evaluating Soft Tissue Masses 119

Fig. 22. Biceps sarcoma mistaken clinically for a biceps muscle tear because of arm swelling (A) Longitudinal
extended field of view sonogram demonstrates a well-defined hypoechoic intramuscular mass. The mass was
nontender. (B) Color Doppler shows irregular internal vascularity.

Fig. 23. Muscle hernia (asterisk) presenting as a painless calf mass. Longitudinal sonogram shows muscle fibers
protruding through a fascial defect (between arrows).

Fig. 24. Arteriovenous malformation in the hand. Sonogram reveals a hypoechoic soft tissue mass with cystic
spaces, a phlebolith, and both arterial (A) and venous (B) flow. P, Phlebolith.

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120 Garza-Báez et al

IS THE MASS VASCULAR IN ORIGIN?

Vascular malformations can look nondescript on
grayscale but should always be considered when
there are prominent vascular spaces and/or phle-
boliths. On physical examination, there may be
bluish or reddish discoloration of the overlying
skin. To guide management, it is important to eval-
uate the amount of flow on color Doppler and to
use spectral Doppler to determine whether the
Fig. 25. Normal cervical lymph node. flow is arterial and/or venous (Fig. 24). Low-flow
vascular malformations include mainly venous,
lymphatic, and mixed malformations, whereas le-
with MRI can also be helpful in making this sions that have arterial waveforms are considered
distinction.12 high-flow malformations. These include arteriove-
Injuries to the fascial envelope over the muscle nous malformations and arteriovenous fistulas.
can lead to muscle hernias, which can present as MRI correlation can be done for a broad overview
masses that may or may not be painful. The key of the vascular extent, the anatomic relationship
to the diagnosis is identifying the discontinuity of with adjacent structures, and confirmation of
the fascial layer and showing the muscle tissue sonographic findings.22
that protrudes through the defect. Muscle hernias
in the lower extremity may only be evident if the
patient stands or contracts their leg muscles. As IS THE MASS A LYMPH NODE?
in hernias elsewhere in the body, the examiner
should try to reduce the muscle hernia with probe Both normal and abnormal lymph nodes can pre-
pressure (Fig. 23, Video 2).19 sent as palpable masses, so it is important to
have a strategy to differentiate benign from malig-
nant lymph nodes. Benign lymph nodes tend to
Skin
have an oval shape, defined by Solbiati as
A wide array of skin lesions can be encountered on a length-to-anteroposterior ratio greater than
US, but a full description is beyond the scope of 2.023 (Fig. 25. The node should have a homoge-
this article. Because the epidermoid cyst is so nous echotexture, uniform thickness, and pre-
common, it should always be considered when served echogenic hilum noting that certain lymph
there is a well-defined mass located in the dermis nodes, particularly in the cervical chain, have a
and subcutaneous tissues. These cysts are typi- small hilum. Color Doppler flow in benign lymph
cally hypoechoic but can be more echogenic and nodes, if present, enters at the hilum and has a
heterogeneous if they contain a large amount of regular branching pattern within the node paren-
keratin, even displaying a “pseudotestis” pattern chyma Conversely, malignant lymph nodes often
(see Fig. 3). There is typically no internal flow on exhibit a rounder appearance, more heterogeneity
Doppler US images.20,21 of the node parenchyma, and/or uneven

Fig. 26. Malignant inguinal lymph

node on (A) grayscale and (B) color
Doppler.

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 Approach to Evaluating Soft Tissue Masses 121

thickening. The echogenic hilum is frequently nar- CLINICS CARE POINTS

rowed or obliterated (Fig. 26A). On color Doppler,
the vessels in malignant nodes often have irregular
branching patterns and uneven distribution within  Key to differential diagnosis: specific anatomic
the node (Fig. 26B). These vessels also tend to location.
enter the node through its periphery rather than  Joint and tendon: benign lesion.
through the hilum.24  Bursa: unilocular and compressible.
 Ganglion: unilocular or multilocular and not
compressible.
SHOULD THE MASS BE BIOPSIED?
 Malignancy: hypoechoic, heterogeneous with
US-guided biopsy is a very important tool because blood flow.
the grayscale and color Doppler characteristics of
masses are often nonspecific. When in doubt,
percutaneous biopsy is a very safe and effective
method for diagnosis.25 DISCLOSURE
Figure: Flow chart of ultrasound evaluation of
soft tissue masses. The authors have nothing to disclose.

SUMMARY SUPPLEMENTARY DATA

US is useful in the differential diagnosis of a wide Supplementary data to this article can be found
array of superficial soft tissue masses. Applying online at https://doi.org/10.1016/j.rcl.2024.08.004.
the systematic approach outlined in this paper
can lead to a confident diagnosis in many cases. REFERENCES
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