Clustered Microcysts at Breast US: Outcomes and Updates for Appropriate Management Recommendations.

Background Clustered microcysts are common, especially in perimenopausal women, and are seen in up to 6% of US examinations. However, there are limited published data on appropriate assessment and management recommendations for clustered microcysts on breast US images. Purpose To determine outcomes of lesions identified as clustered microcysts on breast US images to help guide appropriate management recommendations. Materials and Methods Lesions classified as clustered microcysts at breast US were retrospectively identified in women at two hospitals (a large tertiary care academic hospital and a National Comprehensive Cancer Network-designated comprehensive cancer center) within one metropolitan health system from 2005 through 2015. If US-guided tissue sampling was performed, results were obtained from the pathology or cytology reports. If sampling was not performed, only lesions with at least 24 months of imaging follow-up or any imaging follow-up with interval resolution or decrease in size were included in the study. Data were evaluated using standard statistics, Fisher exact tests, and Wilcoxon rank sum tests. Results A total of 189 women (median age, 52 years [interquartile range, 46-59 years]) with 196 lesions classified as clustered microcysts on US images were included in this study. During the surveillance period of at least 24 months and at tissue diagnosis, malignancy was not found in any of the 196 lesions (0%) (95% confidence interval: 0.0%, 1.9%). A total of 158 of 196 (80%) lesions were followed with imaging, and 38 of 196 (20%) lesions underwent percutaneous sampling. During the follow-up period, 28 of 158 (18%) lesions spontaneously resolved, 13 of 158 (8%) decreased in size, and one of 158 lesions (0.6%) increased at 18-month follow-up but then became stable. One hundred sixteen of 158 lesions (73%) demonstrated no change at follow-up imaging, 38 of 196 (19%) lesions underwent percutaneous sampling, and 38 of 38 (100%) revealed benign results. Conclusion No malignancies were identified in this series. These results further support the existing literature that lesions characterized as clustered microcysts demonstrate a very low risk of malignancy and can be classified as benign. Biopsy may be safely avoided. © RSNA, 2020 See also the editorial by Berg in this issue.

The Spectrum of Rib Neoplasms in Adults: A Practical Approach and Multimodal Imaging Review.

OBJECTIVE. Adult neoplasms of the ribs are a heterogeneous group consisting of both benign and aggressive entities. Rib neoplasms have a variety of overlapping imaging features, with much of the imaging data disjointed across the musculoskeletal, thoracic, and oncologic imaging literature. Arrival at accurate diagnosis can therefore be quite challenging. This article consolidates this information and introduces the reader to an algorithmic approach to rib lesion evaluation based on imaging. CONCLUSION. Rib neoplasms are a diverse group of benign and malignant entities, which often makes determining an accurate diagnosis challenging. Evaluation requires a multipronged approach that incorporates radiographic imaging features, nonradiographic imaging findings, lesion location, and clinical data.

Rosai-Dorfman disease of the breast: A potential marker of systemic disease.

Rosai-Dorfman disease (RDD) is a rare idiopathic benign proliferative disorder of histiocytes. RDD typically presents with cervical lymph node involvement; however, extranodal sites such as the breast can also be involved and should prompt evaluation for additional sites of disease.

Ulnar focal cortical indentation: a progressive, deforming variant of focal fibrocartilaginous dysplasia.

BACKGROUND: Focal fibrocartilaginous dysplasia is a rare growth disturbance of bone resulting in deformity. In the ulna, focal fibrocartilaginous dysplasia is particularly rare, and the characteristic fibroligamentous tether can result in progressive deformity with progressive dislocation of the radial head. The fibroligamentous tether is similar in appearance and function to the Vickers ligament seen in Madelung deformity. The imaging features of ulnar focal fibrocartilaginous dysplasia include a unilateral angular deformity in the ulna with a radiolucent cortical defect and surrounding sclerosis, with secondary radial bowing or radial head dislocation. Focal fibrocartilaginous dysplasia of the ulna has been described using the term ulnar focal cortical indentation. OBJECTIVE: To review the clinical and radiologic features of four cases of ulnar focal cortical indentation occurring in pediatric patients. MATERIALS AND METHODS: We retrospectively reviewed picture archiving and communication system and electronic medical record imaging findings with surgical correlation of ulnar focal cortical indentation at two large specialty pediatric hospitals. RESULTS: Ulnar focal cortical indentation lesions typically arise in the ulnar metaphysis and result in angular forearm deformities with progressive radial deformity including radial head dislocation. Early surgical intervention prevents progression of the deformity and retains range of motion. CONCLUSION: Ulnar focal cortical indentation, although rare, is likely a progressive form of focal fibrocartilaginous dysplasia resulting in significant deformity and disability. Early recognition of the characteristic imaging features is important for early surgical intervention to preserve range of motion and prevent radial head dislocation.

Imaging of soft tissue sarcomas of the extremities with radiologic-pathologic correlation.

Soft tissue sarcomas are a rare diverse group of mesenchymal malignancies that can arise in any location in the body and have extremely variable presentations. Liposarcoma, pleomorphic undifferentiated sarcoma, leiomyosarcoma, myxofibrosarcoma, and synovial sarcoma constitute 75% of all soft tissue sarcomas. These along with more uncommon sarcomas will be reviewed with emphasis on the 2013 World Health Organization (WHO) classification. Imaging plays a crucial role in the initial staging, monitoring response to chemotherapy and radiation therapy, and surveillance to detect local or distant recurrence. In this review, the imaging, as well as histopathologic findings of various soft tissue sarcomas will be demonstrated with biomarker correlation. Given the rarity and heterogeneous nature of these tumors, they are generally managed in tertiary care hospitals by a sarcoma tumor board comprised of an oncologist, surgical oncologist, pathologist, radiation oncologist, and radiologist. Overall clinical outcomes are improving due to rapid advances in the understanding of soft tissue sarcomas. We also review imaging features of treatment response and recurrence of these tumors including imaging follow-up guidelines.

Role of Imaging in Bronchoscopic Lung Volume Reduction Using Endobronchial Valve: State of the Art Review.

Chronic obstructive pulmonary disease (COPD) is becoming one of the leading causes of mortality and morbidity throughout the world. The National Emphysema Treatment Trial demonstrated that lung volume reduction surgery can improve pulmonary function, exercise capacity, and quality of life in select subgroups of patients with COPD. In recent years, few bronchoscopic lung volume reduction (BLVR) procedures have undergone clinical trials with the goal of establishing an effective and safe alternative approach for reducing hyperinflation in patients with severe emphysema who are symptomatic despite optimal medical management, but are poor surgical candidates. Of these BLVR procedures, only deployment of 1-way endobronchial valves (EBVs) has the largest pool of scientific data available to date to support its clinical utility. Two EBV systems have been food and drug administration-approved within the last year to meet the clinical demands of this select group of patients with COPD. On the basis of the results of multiple randomized clinical trials, the recommendations of the original 2016 Expert Panel Report on BLVR usage criteria of EBV have been updated in 2019. The outcome of EBV therapy is maximized in certain image-based COPD phenotypes. Imaging plays a major role in patient selection, target lobe identification, and in the management of postprocedural adverse events. With the expected widespread use of EBV therapy in the coming years, knowledge and familiarity of the Role of Imaging in BLVR using EBVs is essential for radiologists attempting to make meaningful contribution toward improving clinical outcomes.

The Utility of Adding a Liquid-Nutrient Meal to Aid Interpretation of Small-Bowel Transit Scintigraphy.

Small-bowel transit scintigraphy (SBTS) evaluates the accumulation of a radiolabeled meal in the terminal ileal reservoir (TIR) 6 h after ingestion. The location of the TIR may be difficult to determine because anatomic information is limited; for equivocal studies, the patient is asked to return the next day to help determine the TIR location by potential transit into the colon. The purpose of this study was to evaluate whether administration of an additional liquid-nutrient meal (LNM) at 6 h can promote movement of the radiolabeled meal to aid in the interpretation of SBTS and eliminate the need for the patient to return. Methods: This retrospective study reviewed 117 SBTS studies from February 2017 to September 2019. Patients were fed a standardized mixed radiolabeled solid-liquid meal for gastric emptying with SBTS according to Society of Nuclear Medicine and Molecular Imaging practice guidelines. An additional LNM was given at 6 h, and post-LNM images were obtained at least 20 min after the LNM. Two board-certified nuclear medicine physicians independently evaluated all images as equivocal or diagnostic at 6 h. Results: Of the 117 patients (71.8% female; median age, 42.0 y) undergoing SBTS, 37 were equivocal cases at 6 h before the LNM (31.6%; 95% CI, 23.3%-40.9%), compared with 12 equivocal cases after the LNM (10.3%; 95% CI, 5.4%-17.2%). Of the equivocal cases, 25 (69.4%; 95% CI, 51.9%-83.7%) had a definitive result after the LNM, whereas 11 (30.6%; 95% CI, 16.4%-48.1%) remained equivocal and 1 showed rapid transit. Among the 23 patients with gastroparesis, only 13 (57%) responded to the LNM, and none of the 3 patients with irritable bowel syndrome responded. Conclusion: The number of equivocal SBTS cases decreased after administration of an LNM at 6 h, converting to a definitive result. This suggests that with use of an LNM, most patients can complete SBTS in 1 d without the need for repeat imaging at 24 h. Administering an LNM appears to be less effective for patients with gastric disorders. However, the clinical significance remains to be explored, and it is unclear whether such patients have both a gastric and a small-bowel disorder, hence reducing any motility-promoting effect of the LNM.

Mapping the Ultrasound Landscape to Define Point-of-Care Ultrasound and Diagnostic Ultrasound: A Proposal From the Society of Radiologists in Ultrasound and ACR Commission on Ultrasound.

Current descriptions of ultrasound evaluations, including use of the term "point-of-care ultrasound" (POCUS), are imprecise because they are predicated on distinctions based on the device used to obtain images, the location where the images were obtained, the provider who obtained the images, or the focus of the examination. This is confusing because it does not account for more meaningful distinctions based on the setting, comprehensiveness, and completeness of the evaluation. In this article, the Society of Radiologists in Ultrasound and the members of the American College of Radiology Ultrasound Commission articulate a map of the ultrasound landscape that divides sonographic evaluations into four distinct categories on the basis of setting, comprehensiveness, and completeness. Details of this classification scheme are elaborated, including important clarifications regarding what ensures comprehensiveness and completeness. Practical implications of this framework for future research and reimbursement paradigms are highlighted.

Fibrosing Mediastinitis: a Rare Cause of Unilateral Absent Lung Perfusion on a V/Q Scan.

We report a case of a 29-year-old female with a history of asthma, post-partum ARDS, and pulmonary hypertension who presents with severe shortness of breath. The patient describes her shortness of breath as progressive over the past 10 years. Chest radiography and CT angiography of the thorax showed findings consistent with fibrosing mediastinitis with severe stenosis of the left main pulmonary artery. This resulted in appearance of unilateral absent left lung perfusion on quantitative Tc-99-MAA perfusion and Xe-133 ventilation (V/Q) scan.

Aberrant Right Vertebral Artery with a Diverticulum of Kommerell: Review of a Rare Aortic Arch Anomaly.

The normal aortic arch branching pattern is of a three-vessel arch with the vertebral arteries arising from the subclavian arteries. There are a variety of well-known symptomatic and asymptomatic aortic branching patterns widely reported in the literature. An anomalous right vertebral artery with a diverticulum of Kommerell is an extremely rare variant, with few other cases reported in the literature. Herein, we review the embryology of the aortic arch and vertebral artery, the various types of Kommerell's diverticula and the clinical significance of this anomaly.

IUD embedment in the fallopian tube: An unexpected location for a translocated IUD.

Intrauterine devices (IUDs) are the most common form of contraceptive used worldwide. The imaging features of IUDs and their potential complications are crucial to recognize in order to determine adequate positioning and ultimately function of the IUD. Herein, we report a rare case of a copper IUD embedded in the left fallopian tube that required surgical removal. Only a few such cases have been reported in the literature to date.

A Rare Case of Chronic Appendicitis Superimposed on an Incarcerated de Garengeot Hernia Prospectively Identified on Computed Tomography.

The de Garengeot hernia is an uncommon and potentially confounding pathologic process in which the appendix is contained within a femoral hernia. While typically a benign incidental finding, superimposed acute appendicitis is a rare but serious complication. Identification of this entity is crucial to patient management and ultimately outcome with imaging playing a critical role. Cross-sectional imaging, with either CT or MRI, should be performed in all cases of suspected incarcerated de Garengeot hernia to facilitate the appropriate diagnosis and surgical intervention. Herein, we present the fifth case of a prospective CT diagnosis of the de Garengeot hernia in a 61-year-old female who presented with an irreducible right femoral hernia. The patient underwent CT examination which demonstrated the appendix within the femoral hernia sac with an associated periappendiceal fluid collection. The patient was taken for emergent surgical intervention at which time the appendix was found within the hernia sac. The appendix was removed, the defect repaired, and ultimately the patient recovered well.