Pre-biopsy psychological factors predict patient biopsy experience.

BACKGROUND: Excisional/surgical breast biopsy has been related to anticipatory emotional distress, and anticipatory distress has been associated with worse biopsy-related outcomes (e.g., pain, physical discomfort). PURPOSE: The present study was designed to investigate (a) whether anticipatory distress before an image-guided breast biopsy would correlate with biopsy-related outcomes (pain and physical discomfort during the biopsy) and (b) whether type of distress (i.e., general anxiety, worry about the procedure, worry about biopsy results) would differentially relate to biopsy-related outcomes. METHODS: Fifty image-guided breast biopsy patients (mean age = 44.4 years) were administered questionnaires pre- and post-biopsy. Pre-biopsy, patients completed the Profile of Mood States-tension/anxiety subscale and two visual analog scale items (worry about the biopsy procedure, worry about the biopsy results). Post-biopsy, patients completed two visual analog scale items (pain and physical discomfort at their worst during the procedure). RESULTS: The following results were gathered: (1) Pre-biopsy worry about the procedure was significantly related to both pain (r = 0.38, p = 0.006) and physical discomfort (r = 0.31, p = 0.026); (2) pre-biopsy general anxiety was significantly related to pain (r = 0.36, p = 0.009), but not to physical discomfort; and (3) Pre-biopsy worry about the biopsy results did not significantly relate to pain or physical discomfort. CONCLUSIONS: Worry about the procedure was the only variable found to be significantly correlated with both biopsy-related outcomes (pain and physical discomfort). From a clinical perspective, this item could be used as a brief screening tool to identify patients who might be at risk for poorer biopsy experiences and who might benefit from brief interventions to reduce pre-biopsy worry.

Painless transient bone marrow edema syndrome in a pediatric patient.

Transient regional migratory osteoporosis, considered to be part of the spectrum of bone marrow edema syndrome, is a rare condition with an unknown etiology. Patients usually present with lower extremity pain, most commonly in the 4th-5th decades of life. We describe a 15-year-old male patient with type 1 Gaucher disease who presented with transient bone marrow edema syndrome with features most closely resembling regional migratory osteoporosis. The patient presented with bone marrow edema of the lateral tibial epiphysis of his right knee that was incidentally seen on routine surveillance MRI that was performed as protocol for patients with type 1 Gaucher disease on enzyme replacement therapy. At this time, the patient had no pain and physical examination was normal. Follow-up MRI of the right knee 4 months afterward showed complete resolution of the signal abnormality in the right tibial epiphysis, and repeat study 8 months later displayed a new focus of painless migratory edema of the medial tibial epiphysis of the same knee. These changes completely resolved as well. Marrow signal abnormalities in children with Gaucher disease can have a broad differential, including infection, marrow infiltration, trauma, osteonecrosis, and bone marrow edema syndrome, amongst others. Correct diagnosis of bone marrow edema syndrome is critical, as this disease process most often resolves on conservative measures. The unusual presentation of transient bone marrow edema syndrome with regional migratory osteoporosis features in a young patient with Gaucher disease is described.

Migrated herniated disc mimicking a neoplasm.

Disc sequestration is defined as migration of a herniated disc fragment into the epidural space such that it is completely separated from the parent disc. We report a case of a migrated herniated disc that was initially pathologically diagnosed as a cartilage neoplasm. In addition to confounding morphological features, this interpretation may have been influenced by an initial radiological interpretation that did not include herniated disc in the differential diagnosis of a spinal lesion with prominent peripheral contrast enhancement. MR imaging is most helpful in considering other lesions in the differential diagnosis including abscess, hematoma, and primary or metastatic neoplasms. Pathologically, degenerative changes in herniated discs, including clustering of chondrocytes and neovascularization, may be severe resulting in a pseudoneoplastic appearance. Increased awareness of the radiological and pathological features of migrated herniated disc should limit confusion with other tumors.

Focal tuberculous osteomyelitis of the calcaneus secondary to direct extension from an infected retrocalcaneal bursa.

We report a case of focal tuberculous involvement of the posterior margin of the calcaneus with preservation of the articular margin. The route of infection was direct extension through tuberculous retrocalcaneal bursitis, a rare and atypical pathogenesis. Magnetic resonance imaging was helpful in ruling out neoplasm and in limiting the diagnosis to an inflammatory infectious process.

Mycobacterium kansasii causing chronic monoarticular synovitis in a patient with HIV/AIDS.

Mycobacterium kansasii is a nontuberculous mycobacterium that primarily causes pulmonary disease in AIDS patients, however it has also been known, rarely, to result in skeletal infection. When skeletal infection occurs, the time from onset of symptoms to diagnosis is up to 5 years in previously reported cases. We describe a 48-year-old woman with HIV/AIDS who presented with chronic, isolated left knee pain and swelling of over two decades which had recently worsened. Radiographs and magnetic resonance imaging demonstrated marked subarticular erosions, synovial thickening, and bone marrow edema, which had progressed compared with prior imaging done seven years earlier. Synovial biopsy grew Mycobacterium kansasii. Following the presentation of our case, clinical and imaging findings, including the differential diagnosis, of monoarticular arthritis caused by Mycobacterium kansasii are reviewed and discussed.

Mammographically Occult Breast Cancers.

A small percentage of breast cancers are not visible on mammography. Since mammographically occult malignancies may be more difficult to diagnose, we hypothesized that the lack of visualization would cause a delay in detection, more aggressive surgical and adjuvant therapy, and poorer outcome. Patients with mammographically occult malignancies were compared to patients with cancers visible on mammogram. The significance of mammographic visibility for treatment and local and distant recurrence rates were evaluated. Ninety-one of the 813 (11%) cancers were mammographically occult. Patients with mammographically occult malignancies were significantly younger, of lower body weight, and had fewer pregnancies than patients with cancers visible on mammography: age, body weight, and parity were statistically significant (p < 0.001) in stepwise logistic regression. Ductal carcinoma in situ was significantly more frequently diagnosed in patients with mammographically visible malignancies (14% versus 4%, p = 0.0163) and nodal involvement was significantly more frequent in patients with mammographically occult malignancies (35% versus 24%, p = 0.0391). Diagnostic delays exceeding 3 months were experienced by 24% of patients with mammographically occult malignancies compared to 13% of patients with tumor visible on mammography (p < 0.0001). Adjuvant chemotherapy was given to 63% of patients with occult malignancies compared to 41% of patients with mammographically visible cancers (p = 0.0027). The use of breast-conserving therapy and adjuvant radiation and tamoxifen were comparable. Survival free of local recurrence and distant metastases for the 403 patients followed for 5 years or more was not related to mammographic visibility.

Endovascular Techniques and Peripheral Vascular Surgery.

Endovascular is an increasingly popular term that describes the use of catheter-based instruments to diagnose and treat vascular disease. Implicit in this terminology is its association with techniques that are less invasive to the patient than traditional surgical techniques. Endovascular techniques began in 1963 with the advent of the Fogarty arterial embolectomy catheter for removal of clotted blood from the peripheral arterial circulation. Shortly thereafter, radiologist Charles Dotter introduced the concept of arterial dilatation which was popularised a decade later by cardiologist Andreas Gruntzig with the use of a non-dispensible plastic balloon catheter. During the next two decades, endovascular techniques proliferated in the growing fields of interventional cardiology and interventional radiology, yet were embraced more slowly by the surgical community.

A porcine model for endolaparoscopic abdominal aortic repair and endoscopic training.

OBJECTIVES: The goals of this laboratory model were to evaluate the performance of the surgical team and endolaparoscopic techniques in the porcine model of infrarenal abdominal aortic repair. METHODS: Twenty-four pigs underwent full endolaparoscopic aorto-aortic graft implantation with voice-activated computerized robotics. The first group of 10 pigs (acute) was sacrificed while under anesthesia at 0.5 hours (5 animals) and 2 hours (5 animals). The second group of 14 pigs (survival) were recovered from anesthesia and maintained for 7 hours (5 pigs) and 7 days (9 pigs) prior to sacrifice. Survival animals were observed for evidence of hind limb dysfunction. All grafts were visually inspected at autopsy. RESULTS: All animals survived the operation. All grafts were successfully implanted, and all were patent with intact anastomoses at autopsy. Mean aortic clamp time for each group was as follows: acute, 92.9 +/- 28.04 minutes; survival, 59.6 +/- 13.8 minutes; P=0.0008. Total operative time for each group was as follows: acute, 179 +/- 39.6 minutes; survival, 164.6 +/- 48 minutes; P=0.44 ns. Estimated blood loss for each group was as follows: acute, 214 -/+ 437.8 mL; survival 169.2 +/- 271 mL; P=0.76 ns. from respiratory arrest; 1 animal suffered motor sensory dysfunction of the hind limbs (spinal cord ischemia); significant bleeding occurred in 6 of 24 pigs; 8 of the 9 seven-day survivors required minimal pain medication and had normal hind limb function. CONCLUSIONS: The reduction in aortic clamp time, total operative time, and blood loss as the study progressed indicate the feasibility of this surgical protocol and the maturation of the learning process, which is paramount in prevention of 2 main sources of morbidity: bleeding and spinal cord ischemia. The reduction in aortic clamp time between the acute and survival groups was dramatic and statistically significant. An intensive formal training program combining dry and live surgical laboratories is deemed essential for the development of endoscopic skill sets necessary for this challenging procedure.

Imaging of Gaucher disease.

Gaucher disease is the prototypical lysosomal storage disease. It results from the accumulation of undegraded glucosylceramide in the reticuloendothelial system of the bone marrow, spleen and liver due to deficiency of the enzyme glucocerebrosidase. This leads to hematologic, visceral and skeletal maifestions. Build up of glucosylceramide in the liver and spleen results in hepatosplenomegaly. The normal bone marrow is replaced by the accumulating substrate leading to many of the hematologic signs including anemia. The visceral and skeletal manifestations can be visualized with various imaging modalities including radiography, computed tomography, magnetic resonance imaging (MRI) and radionuclide scanning. Prior to the development of enzyme replacement therapy, treatment was only supportive. However, once intravenous enzyme replacement therapy became available in the 1990s it quickly became the standard of care. Enzyme replacement therapy leads to improvement in all manifestations. The visceral and hematologic manifestations respond more quickly usually within a few months or years. The skeletal manifestations take much longer, usually several years, to show improvement. In recent years newer treatment strategies, such as substrate reduction therapy, have been under investigation. Imaging plays a key role in both initial diagnosis and routine monitoring of patient on treatment particularly volumetric MRI of the liver and spleen and MRI of the femora for evaluating bone marrow disease burden.

Introductory pictorial atlas of 3D tomosynthesis.

Mammography is an essential tool for early detection of breast cancer. Breast imaging based on three-dimensional digital breast tomosynthesis (DBT) is a new method for breast cancer screening and diagnosis that uses three-dimensional digital images to allow separation of overlapping breast structures, which may allow for improved visualization of potentially significant findings. This article will highlight the utility of DBT as a tool for the detection of breast pathology; it will demonstrate normal findings as well as breast pathology on DBT and two-dimensional conventional mammography. DBT is a very promising modality, which may decrease the false-positive rate of mammography and find additional abnormalities not seen on two-dimensional mammography.

Role of nuclear scintigraphy in the characterization and management of the salivary component of Sjögren's syndrome.

The American-European Consensus Group, in its classification criteria of Sjögren's syndrome (SS), consigns dynamic salivary scintigraphy to providing objective evidence of xerostomia, a secondary role. In the current SS therapeutic environment, scintigraphy's ability to differentiate parenchymal damage from neuropathic or other derangements of the salivary apparatus may prove more valuable than its role as a diagnostic modality. The procedure itself is highly process-dependent and its discriminatory power task-dependent. A multiplicity of data collection protocols and interpretative approaches tends to corrode the validity of its diagnostic information. Salivary scintigraphy's clinical utility might be extended by standardization of its test protocol and uniformity in its interpretative algorithms.

Synovial chondromatosis of the lumbar spine with compressive myelopathy: a case report with review of the literature.

Synovial chondromatosis has been rarely reported to occur in the spine with only one case found in the lumbar spine. We describe another case of synovial chondromatosis in the lumbar spine in a 41-year-old man who presented with compressive myelopathy. The tumor was located in the left ventrolateral corner of the epidural space just below the L(4)-L(5) intervertebral space. Besides being extremely rare, our case was unusual in that the juxtaposed facet joint was radiologically normal.

Ossifying chondroid lipoma.

Chondroid lipoma is a rare variant of lipoma that pathologically can mimic liposarcoma or possibly other sarcomas. Variants of lipoma, including chondroid lipoma, may demonstrate radiological evidence of fat within the tumor, but often display heterogeneous features on imaging studies, making a clinical diagnosis difficult. A large collective experience with the imaging characteristics of chondroid lipoma is lacking due to the rarity of this tumor. We present a case of chondroid lipoma of the upper thigh in a 37-year-old woman who had regions of metaplastic bone formation within the tumor. Radiologically, the tumor presented as a large soft tissue mass with calcification and ossification. Although metaplastic bone formation in conventional lipoma is well described, it has been rarely reported to occur in chondroid lipoma and has not been pathologically documented or illustrated. The imaging findings and histopathology of this unusual tumor are presented, along with a review of the literature.

Ultrasound detection of nonpalpable mammographically occult malignancy.

OBJECTIVE: To evaluate the prevalence of occult malignancy with screening breast ultrasound. METHODS: All ultrasound-guided core needle breast biopsies performed between January 1, 1999, and June 30, 2001, were retrospectively reviewed. Lesions were identified during screening breast ultrasound in high-risk women with no mammographic or palpable abnormality in either breast, a unilateral mammographic or palpable abnormality in the contralateral breast, or a unilateral mammographic or palpable abnormality in a different quadrant of the same breast. All ultrasound-detected lesions were histologically verified. RESULTS: Six hundred and fifty-two women with a mean age of 49 years underwent 698 biopsies during the study period. Three hundred and forty-nine of these lesions were detected at screening breast ultrasound. Out of 349, 11 (3.2%) had a mammographically and clinically occult malignancy. Nine cancers were found in women with no mammographic or palpable abnormality. Two cancers were found in the same breast as the mammographic or palpable abnormality. None were found in the breast contralateral to a palpable or mammographic abnormality. CONCLUSION: Screening breast ultrasound of high-risk women has a similar detection rate for occult carcinoma as screening mammography, but has a low positive predictive value in cases where biopsy is performed.

Giant cell tumor complicating Paget disease of long bone.

Giant cell tumor (GCT) is a rare complication of Paget disease of bone. It usually occurs in the skull or pelvic bones of patients with long-standing polyostotic disease. This report describes a 62-year-old patient who presented with monostotic Paget disease of the distal femur complicated by GCT. He had a 2-year history of discomfort and pain in his left knee. Conventional plain films and MRI demonstrated the characteristic bone changes of Paget disease and an associated lytic lesion involving the epiphyseal and metaphyseal regions of the distal femur. A diagnostic curettage showed the characteristic histopathologic features of Paget disease and GCT. There was no evidence of malignancy. The clinicopathologic features of this rare lesion are described and correlated with a review of the literature.

Primary periosteal lymphoma--rare and unusual.

We describe a primary periosteal lymphoma that involved only the periosteum without affecting the adjacent medulla or the regional lymph nodes. No other lymphomatous foci were found in either the distant lymph nodes or viscera. This unusual presentation simulates the imaging appearance of surface lesions of bone, namely benign and malignant tumors, and departs from the typical appearance of primary lymphoma of bone. Therefore, this rare type of lymphoma should be considered in the differential diagnosis of surface bone lesions.

Atypical extraspinal musculoskeletal tuberculosis in immunocompetent patients, a review. Part I: atypical osteoarticular tuberculosis and tuberculous osteomyelitis.

With the resurgence of pulmonary tuberculosis and musculoskeletal tuberculosis in North America and Europe over the last 20 years, the typical pattern of extraspinal musculoskeletal tuberculosis has been changing; presentation of the disease often mimics that of neoplasia. However, certain radiographic features may offer some clues to the more benign nature of the process and its inflammatory and infectious nature. Although the diagnosis of extraspinal musculoskeletal tuberculosis depends largely on clinical context, it is the radiologist's role to guide the imaging workup to initiate the specific treatment as early as possible. As in classic extraspinal tuberculosis, delayed diagnosis may lead to deformity of the involved joint and permanent disability. This review considers atypical osteoarticular tuberculosis and tuberculous osteomyelitis. We discuss examples of these atypical presentations. All patients were permanent residents in Europe and North America, and all were immunocompetent.

Atypical extraspinal musculoskeletal tuberculosis in immunocompetent patients: part II, tuberculous myositis, tuberculous bursitis, and tuberculous tenosynovites.

Tuberculosis involving the soft tissue from adjacent bone or joint is well recognized. However, primary tuberculous pyomyositis, tuberculous bursitis, and tuberculous tenosynovitis are rare entities constituting 1% of skeletal tuberculosis. Tuberculous tenosynovitis involves most commonly the tendon sheaths of the hand and wrist, and tuberculous bursitis occurs most commonly around the hip. The greater trochanteric bursa and the greater trochanter are the most frequent sites of tuberculous bursitis. Cases of primary tuberculous pyomyositis and tenosynovitis of the tendons of the ankle and foot are seldom reported in the radiology literature. All imaging modalities-plain radiography, bone scan, computed tomography, and magnetic resonance imaging (MRI)--provide information that is helpful in determining therapy. MRI in particular, with its multiplanar capabilities and superb contrast of soft tissue, can demonstrate the extent of the soft tissue mass and access the adjacent bones and joints. However, MRI has no diagnostic specificity in regard to tuberculosis, and in nonendemic areas, biopsy is strongly recommended. All patients in this review were permanent residents of North America or Western Europe and were immunocompetent. Examples of atypical presentations of the above entities are demonstrated.

Glomus tumor of the thigh: confluent with the periosteum of the femur.

True glomus tumor is rare. In the majority of cases it involves the hand, preferring the fingertips or nail beds. We report a patient with glomus tumor of the mid-thigh who presented with severe localized pain and limp. The imaging features are discussed and the English literature reviewed.

Change in final diagnosis on second evaluation of labial minor salivary gland biopsies.

OBJECTIVE: We evaluated the diagnostic accuracy of labial salivary gland specimens from a group of patients with symptoms or signs of dry mouth and/or dry eyes referred for assessment of possible Sjögren's syndrome (SS). METHODS: Fifty-eight individuals (52 women, 6 men; median age 54.5 yrs, range 19-90) had previously undergone one (n = 58) or 2 (n = 2) labial salivary gland biopsies, serologic studies, and objective tests for dry eyes and/or dry mouth to diagnose possible SS. Patients were referred to our institution for a second opinion regarding diagnosis and/or management of SS. All biopsy specimens underwent blinded review to measure aggregate glandular area, identify lymphocytic foci, and calculate focus scores that might verify the submitted diagnoses. Results were classified according to accepted histologic criteria: chronic sialadenitis, focal lymphocytic sialadenitis, indeterminate, insufficient tissue for diagnosis, and within normal limits. Institutional sources of submitted diagnoses included university hospitals (n = 26), university affiliates (n = 9), community hospitals (n = 18), commercial laboratories (n = 6), and a governmental agency (n = 1). RESULTS: Upon reexamination, 32 of 60 accessions (53%) sustained a revision of the initial diagnosis. Application of the focus scoring system combined with clinical features to reveal 12 hitherto undocumented cases of SS and refuted the diagnosis of SS in 8 instances. The principal reason for inaccurate initial interpretation was failure to apply the focus scoring system in 58 of 60 instances. Median diagnostic delay for the 12 SS cases was 302 days (range 55-2821). CONCLUSION: It is possible that widespread cross-institutional failure to apply the focus scoring system in the interpretation of labial salivary gland biopsies may delay the recognition and/or treatment of SS.