Implementing a Radiology Residency Quality Curriculum to Develop Physician Leaders and Increase Value for Patients.

Diagnostic and interventional radiology residency programs must educate trainees on quality and patient safety topics to meet board requirements and prepare residents to become effective physician leaders. A quality curriculum should encompass process improvement methodology as well as instruction about crucial patient safety subjects. The authors have developed a standardized and structured approach to fulfill this need using didactic and experiential learning. The educational format includes short lectures, peer-to-peer instruction, and self-study, with the value of presented information reinforced by physician leaders and process improvement specialists. Equally important is a structured experience in departmental quality improvement wherein trainees learn the collaborative nature of effective durable process change in areas of interest to them. This curriculum is implemented during the 3rd year of radiology residency to leverage residents' knowledge and experience with radiology workflows and proximity to the American Board of Radiology Core Exam. Feedback from educators and trainees as well as objective examination data support this approach. This article shares guidance and lessons learned from the authors' radiology residency educational efforts and offers a framework for successful implementation of a comprehensive quality curriculum at any residency training program. This curriculum serves the dual purpose of developing skilled future physician leaders and promoting value for patients. ©RSNA, 2020.

A Validated Nomogram to Predict Upstaging of Ductal Carcinoma in Situ to Invasive Disease.

BACKGROUND: Approximately 8-56% of patients with a core needle biopsy (CNB) diagnosis of ductal carcinoma in situ (DCIS) will be upstaged to invasive disease at the time of excision. Patients with invasive disease are recommended to undergo axillary nodal staging, most often requiring a second operation. We developed and validated a nomogram to preoperatively predict percentage of risk for upstaging to invasive cancer. METHODS: We reviewed 834 cases of DCIS on CNB between January 2004 and October 2014. Multivariable analysis was used to evaluate CNB and imaging factors to develop a nomogram to predict the risk of upstaging from DCIS to invasive cancer. This nomogram was validated with an external dataset of 579 similar patients between November 1998 and September 2016. An area under the receiver operating characteristic curve was constructed to evaluate nomogram discrimination. RESULTS: The rate of upstaging to invasive disease was 118/834 (14.1%). On multivariable analysis, grade on CNB and imaging factors, including mass lesion, multicentric disease, and largest linear dimension, were associated with upstage to invasive disease, and was used to develop a nomogram (c-statistic 0.71). In the external validation dataset, 62/579 (10.7%) patients were upstaged to invasive disease. Our nomogram was validated in this dataset with a c-statistic of 0.71. CONCLUSION: For patients with a CNB diagnosis of DCIS, our validated nomogram using DCIS grade on biopsy, and imaging factors of mass lesion, multicentric disease, and largest linear dimension, may be used for preoperative assessment of risk of upstaging to invasive disease, allowing patient counseling regarding axillary staging at the time of definitive surgery.

Identifying a subset of patients with DCIS who have a low likelihood of residual disease at surgical excision following a core needle biopsy.

BACKGROUND AND OBJECTIVES: Current randomized controlled trials are investigating the outcomes of non-surgical treatment for patients with ductal carcinoma in situ (DCIS). We sought to evaluate pre-operative factors associated with no residual disease at definitive resection following a core needle biopsy (CNB) diagnosis of DCIS. METHODS: Eight hundred and thirty-four operations for DCIS were performed at our institution between January 2004 and October 2014. We evaluated patient and biopsy tumor characteristics to determine pre-operative factors associated with no residual disease at surgical resection using uni- and multivariable analyses. RESULTS: Sixty-nine patients (8%) had no residual disease on final pathology. On multivariable analysis, low- or intermediate-grade lesions, <1 cm in size on mammography, and lesions where ≥90% of calcifications were removed correlated with finding no residual disease on final pathology, c-statistic 0.84. Of the 14 patients with all three low-risk factors, 36% had no residual disease on final pathology. CONCLUSIONS: Although our multivariable analysis performed well, its clinical utility would be limited as we were unable to identify a subset of patients with DCIS in whom the probability of finding no residual disease is low enough to consider routine use of non-surgical management.

A perspective on how to optimize breast imaging rotations for medical students.

As educators we try to acquire and retain the attention of medical students who rotate through radiology in hopes to improve recruitment. There are various ways to optimize a medical student rotation in breast imaging. We review our methods of identifying their medical interest, highlighting the steps in breast intervention, selecting key cases for review, and providing meaningful feedback.

Pure lobular carcinoma of the breast presenting as a hyperechoic mass: incidence and imaging characteristics.

OBJECTIVE: The purpose of this study was to determine the proportion of invasive lobular carcinomas with increased sonographic echogenicity. MATERIALS AND METHODS: A retrospective review of mammographic and sonographic findings included cases of pure invasive lobular carcinoma with available images from January 1998 to June 2010. We assessed ultrasound images for the presence of a mass, internal echogenicity, margin characteristics, and attenuation effects. In hyperechoic tumors, more than 90% of the mass had increased echogenicity compared with surrounding fat. In heterogeneously echogenic tumors, the echogenic component constituted 20-90% of the tumor. Findings at mammography, MRI, and surgery were correlated with sonographic findings. A breast pathologist reviewed histologic findings and confirmed the diagnosis of pure invasive lobular carcinoma. RESULTS: Of 509 invasive lobular carcinomas, 27 (5%) were hyperechoic, of which 13 (48%) were associated with posterior acoustic shadowing. Heterogeneously echogenic cancer was seen in 57 (11%) cases. The most common sonographic finding was a hypoechoic, irregular mass with or without posterior shadowing (n = 323; 63%). In 66 (13%) lesions, focal shadowing was seen without a discrete mass. Fourteen (3%) lesions were isoechoic with respect to surrounding normal adipose tissue without acoustic shadowing. Twenty-two (4%) of the malignant tumors were not identified sonographically. Of these, 15 (68%) had mammographic abnormalities, one (5%) was seen at MRI, and six (27%) presented as palpable masses that were surgically excised. CONCLUSION: Pure invasive lobular carcinomas can present as a hyperechoic mass or with substantial hyperechoic component. All sonographic lesion characteristics should be evaluated and biopsy recommended when there are suspicious features, even in a lesion that is predominantly hyperechoic.

Can digital breast tomosynthesis replace conventional diagnostic mammography views for screening recalls without calcifications? A comparison study in a simulated clinical setting.

OBJECTIVE: This study evaluated digital breast tomosynthesis (DBT) as an alternative to conventional diagnostic mammography in the workup of noncalcified findings recalled from screening mammography in a simulated clinical setting that incorporated comparison mammograms and breast ultrasound results. SUBJECTS AND METHODS: One hundred forty-six women, with 158 abnormalities, underwent diagnostic mammography and two-view DBT. Three radiologists viewed the abnormal screening mammograms, comparison mammograms, and DBT images and recorded a DBT BI-RADS category and confidence score for each finding. Readers did not view the diagnostic mammograms. A final DBT BI-RADS category, incorporating ultrasound results in some cases, was determined and compared with the diagnostic mammography BI-RADS category using kappa statistics. Sensitivity and specificity were calculated for DBT and diagnostic mammography. RESULTS: Agreement between DBT and diagnostic mammography BI-RADS categories was excellent for readers 1 and 2 (κ = 0.91 and κ = 0.84) and good for reader 3 (κ = 0.68). For readers 1, 2, and 3, sensitivity and specificity of DBT for breast abnormalities were 100%, 100%, and 88% and 94%, 93%, and 89%, respectively. The clinical workup averaged three diagnostic views per abnormality and ultrasound was requested in 49% of the cases. DBT was adequate mammographic evaluation for 93-99% of the findings and ultrasound was requested in 33-55% of the cases. CONCLUSION: The results of this study suggest that DBT can replace conventional diagnostic mammography views for the evaluation of noncalcified findings recalled from screening mammography and achieve similar sensitivity and specificity. Two-view DBT was considered adequate mammographic evaluation for more than 90% of the findings. There was minimal change in the use of ultrasound with DBT compared with diagnostic mammography.

ACR Appropriateness Criteria® Newly Diagnosed Palpable Scrotal Abnormality.

Palpable scrotal abnormalities are caused by a variety of disorders, ranging from indolent benign conditions to aggressive tumors, and infectious and vascular processes. In these patients the diagnostic workup typically begins with a complete clinical, history, and physical examinations, including analysis of risk factors. If imaging is required, ultrasound examination is the diagnostic modality of choice. In few select patients with very large scrotal masses, MRI may be appropriate. However, the use of gadolinium-based contrast should be evaluated critically depending on specific patient factors. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

ACR Appropriateness Criteria® Pelvic Floor Dysfunction in Females.

Pelvic floor disorders including pelvic organ prolapse (POP), urinary dysfunction, defecatory dysfunction, and complications after pelvic floor surgery are relatively common in the female population. Imaging tests are obtained when the initial clinical evaluation is thought to be incomplete or inconclusive or demonstrates findings that are discordant with patients' symptoms. An integrated imaging approach is optimal to evaluate the complex anatomy and dynamic functionality of the pelvic floor. Fluoroscopic cystocolpoproctography (CCP) and MR defecography are considered the initial imaging tests of choice for evaluation of POP. Fluoroscopic voiding cystourethrography is considered the initial imaging test for patients with urinary dysfunction. Fluoroscopic CCP and MR defecography are considered the initial imaging test for patients with defecatory dysfunction, whereas ultrasound pelvis transrectal is a complementary test in patients requiring evaluation for anal sphincter defects. MRI pelvis without and with intravenous contrast, MRI pelvis with dynamic maneuvers, and MR defecography are considered the initial imaging tests in patients with suspected complications of prior pelvic floor surgical repair. Transperineal ultrasound is emerging as an important imaging tool, in particular for screening of pelvic floor dysfunction and for evaluation of midurethral slings, vaginal mesh, and complications related to prior pelvic floor surgical repair. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Magnetic resonance-guided focused ultrasound of uterine leiomyomas: review of a 12-month outcome of 130 clinical patients.

PURPOSE: To assess 12-month outcomes and safety of clinical magnetic resonance (MR)-guided focused ultrasound (US) treatments of uterine leiomyomas. MATERIALS AND METHODS: Between March 2005 and December 2009, 150 women with symptomatic uterine leiomyomas were clinically treated with MR-guided focused US at a single institution; 130 patients completed treatment and agreed to have their data used for research purposes. Patients were followed through retrospective review of medical records and phone interviews conducted at 3-, 6-, and 12-month intervals after treatment to assess additional procedures and symptom relief. Outcome measures and treatment complications were analyzed for possible correlations with the appearance of the tumors on T2-weighted imaging. RESULTS: The cumulative incidence of additional tumor-related treatments 12 months after MR-guided focused US was 7.4% by the Kaplan-Meier method. At 3-, 6-, and 12-month follow-up, 86% (90 of 105), 93% (92 of 99), and 88% (78 of 89) of patients reported relief of symptoms, respectively. No statistically significant correlation between tumor appearance on T2-weighted imaging and 12-month outcome was found. Treatment-related complications were observed in 17 patients (13.1%): 16 patients had minor complications and one had a major complication (deep vein thrombosis). All complications were resolved within the 12-month follow-up period. CONCLUSIONS: MR-guided focused US is a noninvasive treatment option that can be used to effectively and safely treat uterine leiomyomas and delivers significant and lasting symptom relief for at least 12 months. The incidence of additional treatment during this time period is comparable with those in previous reports of uterine artery embolization.

ACR Appropriateness Criteria® Postmenopausal Acute Pelvic Pain.

Acute pelvic pain is a common presenting complaint in both the emergency room and outpatient settings. Pelvic pain of gynecologic origin in postmenopausal women occurs less frequently than in premenopausal women; however, it has important differences in etiology. The most common causes of postmenopausal pelvic pain from gynecologic origin are ovarian cysts, uterine fibroids, pelvic inflammatory disease, and ovarian neoplasm. Other etiologies of pelvic pain are attributable to urinary, gastrointestinal, and vascular systems. As the optimal imaging modality varies for these etiologies, it is important to narrow the differential diagnosis before choosing the initial diagnostic imaging examination. Transabdominal and transvaginal ultrasound are the best initial imaging techniques when the differential is primarily of gynecologic origin. CT with intravenous (IV) contrast is more useful if the differential diagnosis remains broad. MRI without IV contrast or MRI without and with IV contrast, as well as CT without IV contrast may also be used for certain differential considerations. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Thyroid follicular carcinoma: sonographic features of 50 cases.

OBJECTIVE: The purpose of our study was to retrospectively evaluate sonography of thyroid follicular neoplasms for features that would aid in distinguishing follicular carcinoma from follicular adenoma and for any imaging features that distinguish the Hürthle-cell variant of follicular carcinoma from classic follicular carcinoma. MATERIALS AND METHODS: The study cohort consisted of patients with the diagnosis of follicular carcinoma and patients with the diagnosis of follicular adenoma. Fifty patients (25 men and 25 women; median age, 59.5 years) with a diagnosis of follicular carcinoma (27 with classic follicular carcinoma, 22 with Hürthle-cell variant of follicular carcinoma, and one insular variant) in a 6-year period were included. Fifty-two control patients (10 men and 42 women; median age, 46.5 years) were selected from a random sampling of all cases of follicular adenoma during the same time period. Sonograms were reviewed in consensus by four radiologists for various features. All study patients and control patients underwent surgical resection and pathologic analysis of their thyroid follicular neoplasm. The chi-square or Fisher's exact test was used for categorical variables; the Wilcoxon's rank sum test was used for continuous variables. RESULTS: Hypoechoic appearance (82% of follicular carcinoma patients vs 50% of follicular adenoma patients; p<0.005; odds ratio [OR]), 0.5; 95% CI, 0.3-0.7), absence of halo (64% of follicular carcinoma patients vs 42% of follicular adenoma patients; p<0.05; OR, 0.4; 95% CI, 0.2-0.9), absence of cystic change (90% of follicular carcinoma patients vs 69% of follicular adenoma patients; p<0.05; OR, 0.2; 95% CI, 0.1-0.7), greater patient age (median age of 59.5 years for follicular carcinoma patients vs 46.5 years for follicular adenoma patients; p<0.05), size of the tumor (median size of 11.75 mL for follicular carcinoma patients vs 5.95 mL for follicular adenoma patients; p<0.05), and male sex (50% of follicular carcinoma patients vs 19.2% of follicular adenoma patients; p<0.005; OR, 3.7; 95% CI, 1.6-8.9) were more frequently associated with follicular thyroid cancer than with benign adenoma. No significant difference in the prevalence of refractive shadowing, echotexture, visible invasion, lymph node enlargement, adjacent nonfollicular suspicious lesions, vascularity subtype, and calcifications was observed between the two groups. Within the follicular carcinoma subgroup, homogeneous or predominantly homogeneous echotexture (67% of classic follicular carcinoma patients vs 36% of Hürthle-cell variant of follicular carcinoma patients; p<0.05; OR, 3.5; 95% CI, 1.1-11.4) and the presence of calcifications (22% of classic follicular carcinoma patients vs 4% of Hürthle-cell variant of follicular carcinoma patients [multivariate analysis including age]; p < 0.05; OR, 22.9; 95% CI, 2.0-261.9) were associated with classic follicular carcinoma. Greater patient age (median age of 53 years for classic follicular carcinoma patients vs 64.5 years for Hürthle-cell variant of follicular carcinoma patients; p<0.05) was associated with Hürthle-cell variant follicular carcinoma. There was no association between tumor volume, sex, sonographic halo, refractive shadowing, echogenicity, visible invasion, lymph node enlargement, adjacent nonfollicular suspicious lesions, vascularity subtype, and cystic change between the subgroups of follicular carcinoma. CONCLUSION: The sonographic features of follicular adenoma and follicular carcinoma are very similar, but larger lesion size, lack of a sonographic halo, hypoechoic appearance, and absence of cystic change favored a follicular carcinoma diagnosis. Increased patient age and male sex are associated with malignancy. Within the follicular carcinoma subgroup, Hürthle-cell variant of follicular carcinoma is more often seen in older patients with nodules having a heterogeneous appearance and lacking internal calcifications.

Cystic change in thyroid carcinoma: Prevalence and estimated volume in 360 carcinomas.

PURPOSE: The aim of this study was to determine the prevalence and amount of cystic change in thyroid cancer. This study also examined associated sonographic characteristics of cystic malignant thyroid nodules to help recognize these clinically important nodules. METHODS: This study was a retrospective review of 360 malignant thyroid nodules surgically removed at our institution between January 1, 2002 and December 31, 2004. All patients had signed research authorization. All patients had preoperative sonograms and surgical pathologic proof of their thyroid malignancy. The 360 malignant nodules were found in 307 patients. All scans were performed using 7- to 15-MHz transducers, and most studies included a digital video clip of the cancer. The preoperative ultrasound examinations were retrospectively reviewed by three radiologists and a sonographer. An estimate of cystic component percentage was derived by consensus. The presence of a mural nodule, thick irregular wall, microcalcifications, and prominent vascularity was also recorded. RESULTS: Of the 360 carcinomas, 318 (88.3%) were solid to minimally (less than 5%) cystic, 33 (9.2%) were 6-50% cystic, 9 (2.5%) were 51-100% cystic. Of the nine (2.5%) malignancies that were greater than 50% cystic, all had other suspicious findings including mural nodules, microcalcifications, increased vascularity, and/or a thick irregular wall about the cystic portion. CONCLUSION: The vast majority (88%) of thyroid cancer is uniformly solid or has minimal (1-5%) cystic change by sonography. Marked cystic change (>50% of the nodule) occurred in only 2.5% of cancers, which had other sonographic findings worrisome for malignancy.

ACR Appropriateness Criteria® Abnormal Uterine Bleeding.

This publication summarizes the relevant literature for the imaging of patients with symptoms of abnormal uterine bleeding, including initial imaging, follow-up imaging when the original ultrasound is inconclusive, and follow-up imaging when surveillance is appropriate. For patients with abnormal uterine bleeding, combined transabdominal and transvaginal ultrasound of the pelvis with Doppler is the most appropriate initial imaging study. If the uterus is incompletely visualized with the initial ultrasou2nd, MRI of the pelvis without and with contrast is the next appropriate imaging study, unless a polyp is suspected on the original ultrasound, then sonohysterography can be performed. If the patient continues to experience abnormal uterine bleeding, assessment with ultrasound of the pelvis, sonohysterography, and MRI of the pelvis without and with contrast would be appropriate. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

ACR Appropriateness Criteria® Female Infertility.

The most common known causes of female infertility are male factor (26%), ovulatory failure (21%), and tubal damage (14%), while in 28% a couple's infertility remains unexplained. Female-specific causes of infertility include deterioration of oocyte quality with increasing maternal age; ovulatory disorders, most notably polycystic ovarian syndrome; history of salpingitis such as that caused by chlamydia infection; endometriosis; and uterine cavity abnormalities interfering with implantation causing inability to become pregnant or causing recurrent pregnancy loss. These potential causes of female infertility are discussed in this document and the appropriate imaging recommendations for each variant are provided. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

ACR Appropriateness Criteria® Postpartum Hemorrhage.

Postpartum hemorrhage (PPH) can be categorized as primary or early if occurring in the first 24 hours after delivery, whereas late or delayed PPH occurs between 24 hours and 6 weeks. Most of the causes of PPH can be diagnosed clinically, but imaging plays an important role in the diagnosis of many causes of PPH. Pelvic ultrasound (transabdominal and transvaginal with Doppler) is the imaging modality of choice for the initial evaluation of PPH. Contrast-enhanced CT of the abdomen and pelvis and CT angiogram of the abdomen and pelvis may be appropriate to determine if active ongoing hemorrhage is present, to localize the bleeding, and to identify the source of bleeding. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Ovarian stromal hyperthecosis: sonographic features and histologic associations.

OBJECTIVE: Ovarian stromal hyperthecosis (SH) has variable clinical importance but can cause hyperandrogenism, particularly in premenopausal women. Sonography is often used to evaluate the ovaries of women with hyperandrogenism, but there is little published regarding the sonographic appearance of SH. The primary purpose of this study was to describe the sonographic features of SH. METHODS: A computerized search of our institution's pathology and imaging databases from 1996 through 2007 was performed to identify patients with histologically proven SH who had pelvic sonography before surgery. Sonograms and histologic findings were reviewed in each case. RESULTS: Twenty ovaries with SH were identified, occurring in 14 patients with a mean age of 59.8 years (range, 36-83 years). The SH was bilateral in 6 patients, unilateral in 6, and of uncertain laterality in 2 with a unilateral oophorectomy. Sonographic findings were as follows: 5 normal, 1 with a hemorrhagic cyst (later resolved) and otherwise normal, 3 enlarged but otherwise normal, 1 with a solid mass due to the nodular form of SH, 1 with a solid mass due to a fibroma, 2 with polycystic ovaries, and 7 not seen. Six of the 14 patients (43%) also had an ovarian fibrothecoma. CONCLUSIONS: Ovarian SH has variable sonographic features. Most commonly, the affected ovaries are either normal or slightly enlarged. A solid mass may infrequently be visible, and polycystic ovary syndrome changes may coexist with SH. A possible association of SH with fibrothecoma was also noted, which to our knowledge has not been previously reported.

ACR Appropriateness Criteria® Growth Disturbances-Risk of Fetal Growth Restriction.

Fetal growth restriction, or an estimated fetal weight of less than the 10th percentile, is associated with adverse perinatal outcome. Optimizing management for obtaining the most favorable outcome for mother and fetus is largely based on detailed ultrasound findings. Identifying and performing those ultrasound procedures that are most associated with adverse outcome is necessary for proper patient management. Transabdominal ultrasound is the mainstay of initial management and assessment of fetal growth. For those fetuses that are identified as small for gestational age, assessment of fetal well-being with biophysical profile and Doppler velocimetry provide vital information for differentiating those fetuses that may be compromised and may require delivery and those that are well compensated. Delivery of the pregnancy is primarily based upon the gestational age of the pregnancy and the ultrasound findings. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

A clinical review of focused ultrasound ablation with magnetic resonance guidance: an option for treating uterine fibroids.

Uterine fibroids are common smooth muscle tumors, which can result in substantial symptoms affecting the quality of life of women. Whereas patients have several options available for treatment, focused ultrasound ablation is one of the least invasive treatment options outside medical therapy. Magnetic resonance-guided focused ultrasound (MRgFUS) ablation combines therapy delivered by an ultrasound transducer with imaging, guidance for therapy, and thermal feedback provided by magnetic resonance imaging. In 2004, the MRgFUS system ExAblate 2000 (InSightec, Haifa, Israel) was approved by the United States Food and Drug Administration for clinical treatments of uterine fibroids. Since its approval, our institution has performed more than 140 treatments. This paper provides an overview of our site's clinical experience with MRgFUS, including a brief description of the treatment system, pertinent features to review on screening magnetic resonance imaging, how the procedure is performed, and risks and benefits of the treatment. Some potential clinical applications of the technology are also briefly reviewed.

ACR Appropriateness Criteria® First Trimester Vaginal Bleeding.

Vaginal bleeding is not uncommon in the first trimester of pregnancy. The majority of such patients will have a normal intrauterine pregnancy (IUP), a nonviable IUP, or an ectopic pregnancy. Ultrasound (US) is the primary imaging modality in evaluation of these patients. US, along with clinical observations and serum human chorionic gonadotropin levels, can usually distinguish these causes. Although it is important to diagnose ectopic pregnancies and nonviable IUPs, one should also guard against injury to normal pregnancies due to inappropriate treatment with methotrexate or surgical intervention. Less common causes of first trimester vaginal bleeding include gestational trophoblastic disease and arteriovenous malformations. Pulsed methods of Doppler US should generally be avoided in the first trimester when there is a normal, or a potentially normal, IUP. Once a normal IUP has been excluded, Doppler US may be useful when other diagnoses such as retained products of conception or arteriovenous malformations are suspected. MRI may occasionally be helpful as a problem-solving tool. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Ability of Intraoperative Pathologic Analysis of Ductal Carcinoma In Situ to Guide Selective Use of Sentinel Lymph Node Surgery.

For patients with ductal carcinoma In Situ (DCIS), sentinel lymph node (SLN) surgery is generally reserved for patients at high risk of being upstaged to invasive disease. The use of frozen section (FS) pathologic analysis of the primary tumor may allow for selective surgical nodal staging within one procedure. We sought to define the reliability of FS for detection of upstaging. Eight hundred and twenty-seven patients were identified with DCIS on core needle biopsy that underwent 834 operations at our institution between January 2004 and October 2014. We calculated the rate of upstage from DCIS to invasive cancer on both intraoperative FS and final pathology to determine the performance of FS. Upstage rate on final pathology was 118/834 (14.1%) 95 per cent confidence interval 11.8 to 16.7 per cent. FS identified 88/118 (74.6%) of the upstages. Specificity was 99.3 per cent (711/716). Overall accuracy was 95.8 per cent (799/834) and the positive predictive value was 96.0 per cent (711/741 patients). Mean size of invasive cancers identified on FS was 5.6 mm, versus 3.5 mm for those identified only on permanent section, P = 0.11. Intraoperative FS analysis of DCIS is useful for identification of upstage to invasive disease. This may facilitate a selective approach to SLN surgery that both decreases unnecessary SLN surgery and the need for a second operation.