Effect of Decreasing the ACR TI-RADS Point Assignment for Punctate Echogenic Foci When They Occur in Mixed Solid and Cystic Thyroid Nodules.

OBJECTIVE. Using the American College of Radiology (ACR) Thyroid Imaging Reporting and Data System (TI-RADS), this study sought to determine whether decreasing the point assignment for punctate echogenic foci in mixed solid and cystic nodules would reduce the number of benign mixed solid and cystic nodules that were biopsied and would not substantially increase the number of missed mixed carcinomas MATERIALS AND METHODS. A multiinstitutional database of 3422 pathologically proven thyroid nodules was evaluated to identify all mixed solid and cystic nodules with punctate echogenic foci. We determined the numbers of mixed benign and malignant nodules that would receive ACR TI-RADS recommendations of fine-needle aspiration, follow-up, and no further evaluation if the points assigned to punctate echogenic foci were changed from 3 points to 1 or 2 points. RESULTS. A total of 287 mixed nodules were adequately characterized for evaluation. When the number of points assigned to punctate echogenic foci was changed from 3 points to 1 point, the point categories changed for 198 mixed nodules. Seven carcinomas would not undergo biopsy, but six of those seven would receive follow-up, and 44 benign nodules would not undergo biopsy. When 2 points were assigned to punctate echogenic foci, the point categories changed for 66 mixed nodules. Three carcinomas would not undergo biopsy, but all three of these would receive follow-up, and eight benign nodules would not undergo biopsy. CONCLUSION. Consideration should be given to decreasing the number of points assigned to punctate echogenic foci in mixed solid and cystic thyroid nodules, given the substantial decrease in the number of benign nodules requiring biopsy and the recommendation of follow-up for any carcinoma 1 cm or larger that did not undergo biopsy.

Inclusion of Thyroid Nodule Location in American College of Radiology TI-RADS Scoring: Impact on System Performance.

Emerging data suggest that the location of thyroid nodules influences malignancy risk. The purpose of this study was to explore the impact of including location in American College of Radiology Thyroid Imaging Reporting and Data System (ACR TI-RADS) scoring. Four of five revised scoring algorithms that added 1 or 2 points to higher-risk locations were associated with lowered accuracy due to lower specificity. However, an algorithm that added 1 point to isthmic nodules did not differ significantly from ACR TI-RADS in accuracy; one additional isthmic cancer was diagnosed for each 10.3 additional benign nodules recommended for biopsy.

Analysis of Malignant Thyroid Nodules That Do Not Meet ACR TI-RADS Criteria for Fine-Needle Aspiration.

OBJECTIVE. Compared with other guidelines, the American College of Radiology (ACR) Thyroid Imaging Reporting and Data System (TI-RADS) has decreased the number of nodules for which fine-needle aspiration is recommended. The purpose of this study was to evaluate the characteristics of malignant nodules that would not be biopsied when the ACR TI-RADS recommendations are followed. MATERIALS AND METHODS. We retrospectively reviewed a total of 3422 thyroid nodules for which a definitive cytologic diagnosis, a definitive histologic diagnosis, or both diagnoses as well as diagnostic ultrasound (US) examinations were available. All nodules were categorized using the ACR TI-RADS, and they were divided into three groups according to the recommendation received: fine-needle aspiration (group 1), follow-up US examination (group 2), or no further evaluation (group 3). RESULTS. Of the 3422 nodules, 352 were malignant. Of these, 240 nodules were assigned to group 1, whereas 72 were assigned to group 2 and 40 were included in group 3. Sixteen of the 40 malignant nodules in group 3 were 1 cm or larger, and, on the basis of analysis of the sonographic features described in the ACR TI-RADS, these nodules were classified as having one of five ACR TI-RADS risk levels (TR1-TR5), with one nodule classified as a TR1 nodule, eight as TR2 nodules, and seven as TR3 nodules. If the current recommendation of no follow-up for TR2 nodules was changed to follow-up for nodules 2.5 cm or larger, seven additional malignant nodules and 316 additional benign nodules would receive a recommendation for follow-up. If the current size threshold (1.5 cm) used to recommend US follow-up for TR3 nodules was decreased to 1.0 cm, seven additional malignant nodules and 118 additional benign nodules would receive a recommendation for follow-up. CONCLUSION. With use of the ACR TI-RADS, most malignant nodules that would not be biopsied would undergo US follow-up, would be smaller than 1 cm, or would both undergo US follow-up and be smaller than 1 cm. Adjusting size thresholds to decrease the number of missed malignant nodules that are 1 cm or larger would result in a substantial increase in the number of benign nodules undergoing follow-up.

Comparison of Performance Characteristics of American College of Radiology TI-RADS, Korean Society of Thyroid Radiology TIRADS, and American Thyroid Association Guidelines.

OBJECTIVE: The American College of Radiology (ACR) Thyroid Imaging Reporting and Data System (TI-RADS) provides guidelines to practitioners who interpret sonographic examinations of thyroid nodules. The purpose of this study is to compare the ACR TI-RADS system with two other well-established guidelines. MATERIALS AND METHODS: The ACR TI-RADS, the Korean Society of Thyroid Radiology (KSThR) Thyroid Imaging Reporting and Data System (TIRADS), and the American Thyroid Association guidelines were compared using 3422 thyroid nodules for which pathologic findings were available. The composition, echogenicity, margins, echogenic foci, and size of the nodules were assessed to determine whether a recommendation would be made for fine-needle aspiration or follow-up sonography when each system was used. The biopsy yield of malignant findings, the yield of follow-up, and the percentage of malignant and benign nodules that would be biopsied were determined for all nodules and for nodules 1 cm or larger. RESULTS: The percentage of nodules that could not be classified was 0%, 3.9%, and 13.9% for the ACR TI-RADS, KSThR TIRADS, and ATA guidelines, respectively. The biopsy yield of malignancy was 14.2%, 10.2%, and 10.0% for nodules assessed by the ACR TI-RADS, KSThR TIRADS, and ATA guidelines, respectively. The percentage of malignant nodules that were biopsied was 68.2%, 78.7%, and 75.9% for the ACR TI-RADS, the KSThR TIRADS, and the ATA guidelines, respectively, whereas the percentage of malignant nodules that would be either biopsied or followed was 89.2% for the ACR TI-RADS. The percentage of benign nodules that would be biopsied was 47.1%, 79.7%, and 78.1% for the ACR TI-RADS, the KSThR TIRADS, and the ATA guidelines, respectively. The percentage of benign nodules that would be either biopsied or followed was 65.2% for the ACR TI-RADS. CONCLUSION: The ACR TI-RADS performs well when compared with other well-established guidelines.

Multiinstitutional Analysis of Thyroid Nodule Risk Stratification Using the American College of Radiology Thyroid Imaging Reporting and Data System.

OBJECTIVE: Guidelines for managing thyroid nodules are highly dependent on risk stratification based on sonographic findings. The purpose of this study is to evaluate the risk stratification system used by the American College of Radiology Thyroid Imaging Reporting and Data System (TIRADS). MATERIALS AND METHODS: Patients with thyroid nodules who underwent sonography and fine-needle aspiration were enrolled in a multiinstitutional study. The sonographic nodule features evaluated in the study were composition, echogenicity, margins, and echogenic foci. Images were reviewed by two radiologists who were blinded to the results of cytologic analysis. Nodules were assigned points for each feature, and the points were totaled to determine the final TIRADS level (TR1-TR5). The risk of cancer associated with each point total and final TIRADS level was determined. RESULTS: A total of 3422 nodules, 352 of which were malignant, were studied. The risk of malignancy was closely associated with the composition, echogenicity, margins, and echogenic foci of the nodules (p < 0.0001, in all cases). An increased aggregate risk of nodule malignancy was noted as the TIRADS point level increased from 0 to 10 (p < 0.0001) and as the final TIRADS level increased from TR1 to TR5 (p < 0.0001). Of the 3422 nodules, 2948 (86.1%) had risk levels that were within 1% of the TIRADS risk thresholds. Of the 474 nodules that were more than 1% outside these thresholds, 88.0% (417/474) had a risk level that was below the TIRADS threshold. CONCLUSION: The aggregate risk of malignancy for nodules associated with each individual TIRADS point level (0-10) and each final TIRADS level (TR1-TR5) falls within the TIRADS risk stratification thresholds. A total of 85% of all nodules were within 1% of the specified TIRADS risk thresholds.

Alignment of sources and detectors on breast surface for noncontact diffuse correlation tomography of breast tumors.

Noncontact diffuse correlation tomography (ncDCT) is an emerging technology for 3D imaging of deep tissue blood flow distribution without distorting hemodynamic properties. To adapt the ncDCT for imaging in vivo breast tumors, we designed a motorized ncDCT probe to scan over the breast surface. A computer-aided design (CAD)-based approach was proposed to create solid volume mesh from arbitrary breast surface obtained by a commercial 3D camera. The sources and detectors of ncDCT were aligned on the breast surface through ray tracing to mimic the ncDCT scanning with CAD software. The generated breast volume mesh along with the boundary data of ncDCT at the aligned source and detector pairs were used for finite-element-method-based flow image reconstruction. We evaluated the accuracy of source alignments on mannequin and human breasts; largest alignment errors were less than 10% in both tangential and radial directions of scanning. The impact of alignment errors (assigned 10%) on the tumor reconstruction was estimated using computer simulations. The deviations of simulated tumor location and blood flow contrast resulted from the alignment errors were 0.77 mm (less than the node distance of 1 mm) and 1%, respectively, which result in minor impact on flow image reconstruction. Finally, a case study on a human breast tumor was conducted and a tumor-to-normal flow contrast was reconstructed, demonstrating the feasibility of ncDCT in clinical application.

Preoperative ultrasound is not useful for identifying nodal metastasis in melanoma patients undergoing sentinel node biopsy: preoperative ultrasound in clinically node-negative melanoma.

BACKGROUND: Sentinel lymph node biopsy (SLNB) is widely used in melanoma. Identifying nodal involvement preoperatively by high-resolution ultrasound may offer less invasive staging. This study assessed feasibility and staging results of clinically targeted ultrasound (before lymphoscintigraphy) compared to SLNB. METHODS: From 2005 to 2009, a total of 325 patients with melanoma underwent ultrasound before SLNB. We reviewed demographics and histopathologic characteristics, then compared ultrasound and SLNB results. Sensitivity, specificity, and positive and negative predictive value were determined. RESULTS: A total of 325 patients were included, 58% men and 42% women with a median age of 58 (range 18-86) years. A total of 471 basins were examined with ultrasound. Only six patients (1.8%) avoided SLNB by undergoing ultrasound-guided fine-needle aspiration of involved nodes, then therapeutic lymphadenectomy. Sixty-five patients (20.4%) had 69 SLNB positive nodal basins; 17 nodal basins from 15 patients with positive ultrasounds were considered truly positive. Forty-five SLNB positive basins had negative ultrasounds (falsely negative). Seven node-positive basins did not undergo ultrasound because of unpredicted drainage. A total of 253 patients with negative SLNBs had negative ultrasounds in 240 nodal basins (truly negative) but falsely positive ultrasounds occurred in 40 basins. Overall, sensitivity of ultrasound was 33.8%, specificity 85.7%, positive predictive value 36.5%, and negative predictive value 84.2%. Sensitivity and specificity improved somewhat with increasing Breslow depth. Sensitivity was highest for the neck, but specificity was highest for the groin. CONCLUSIONS: Routine preoperative ultrasound in clinically node-negative melanoma is impractical because of its low sensitivity. Selected patients with thick or ulcerated lesions may benefit. Because of variable lymphatic drainage patterns, preoperative ultrasound without lymphoscintigraphic localization will provide incomplete evaluation in many cases.

Xantho-granulomatous mastitis preceded by cysts on ultrasound: Two cases with review of literature.

Xantho-granulomatous mastitis (XGM) is a rare entity, only recently described in 2005. These lesions are often biopsied due to their clinical and radiological resemblance to breast cancer. With limited clinical experience, the etiopathogenesis and natural history of XGM remains unknown. We present two cases of pathologically proven XGM that were imaged at two time-points, with the findings alluding to the possibility of a precursor stage of cyst formation. In addition, we present a thorough review of all cases published to date and discuss the differential considerations and management implications of XGM.

Elastography for the characterization of breast lesions: initial clinical experience.

BACKGROUND: While breast biopsy remains the gold standard for diagnosis of suspicious lesions, a large proportion of biopsy specimens reveal a benign result. Therefore, a noninvasive and reliable method to identify low-risk lesions would be a valuable tool. METHODS: We assessed the application and diagnostic performance of elastography for the characterization of breast lesions in patients referred for biopsy. Subjects referred for ultrasound-guided biopsy of sonographically apparent breast lesions were included in this study. The Hitachi Hi-Vision 900 ultrasound was used to generate index test results for elastography scoring (ES) and for strain ratio (SR) measurement. Sensitivity, specificity, and positive and negative predictive values were determined using pathologic results from 14-gauge core needle biopsy as the reference standard. RESULTS: A total of 310 lesions in 288 patients were included in this series. Of these 310 lesions, 223 (72%) were benign and 87 (28%) were malignant. Sensitivity was 0.76 for ES and 0.79 for SR. Specificity was 0.81 for ES and 0.76 for SR. Positive predictive value was 0.60 for ES and 0.57 for SR. Negative predictive value was 0.90 for ES and 0.90 for SR. SR values for malignant lesions were significantly higher (median ratios 10.5 and 2.7, respectively, P < .001). CONCLUSIONS: While the initial clinical performance of elastography imaging shows potential to reduce biopsy of low-risk lesions, a large-scale trial addressing appropriate patient selection, diagnostic parameters, and practical application of this technique is necessary prior to widespread clinical use.

Hashimoto thyroiditis: Part 1, sonographic analysis of the nodular form of Hashimoto thyroiditis.

OBJECTIVE: The purpose of this article is to analyze the sonographic appearance of nodular Hashimoto thyroiditis. SUBJECTS AND METHODS: As part of an ongoing multiinstitutional study, patients who underwent ultrasound examination and fine-needle aspiration of one or more thyroid nodules were analyzed for multiple predetermined sonographic features. Patients completed a questionnaire, including information about thyroid function and thyroid medication. Patients (n = 61) with fine-needle aspiration cytologic results consistent with nodular Hashimoto thyroiditis (n = 64) were included in the study. RESULTS: The mean (+/- SD) diameter of nodular Hashimoto thyroiditis was 15 +/- 7.33 mm. Nodular Hashimoto thyroiditis occurred as a solitary nodule in 36% (23/64) of cases and in the setting of five or more nodules in 23% (15/64) of cases. Fifty-five percent (35/64) of the cases of nodular Hashimoto thyroiditis occurred within a sonographic background of diffuse Hashimoto thyroiditis, and 45% (29/64) of cases occurred within normal thyroid parenchyma. The sonographic appearance was extremely variable. It was most commonly solid (69% [42/61] of cases) and hypoechoic (47% [27/58] of cases). Twenty percent (13/64) of nodules had calcifications (seven with nonspecific bright reflectors, four with macrocalcifications, and three eggshell), and 5% (3/64) of nodules had colloid. Twenty-seven percent (17/64) of nodules had a hypoechoic halo. The margins were well defined in 60% (36/60) and ill defined in 40% (24/60) of nodules. On Doppler analysis, 35% (22/62) of nodules were hypervascular, 42% (26/62) were isovascular or hypovascular, and 23% (14/62) were avascular. CONCLUSION: The sonographic features and vascularity of nodular Hashimoto thyroiditis were extremely variable.

Hashimoto thyroiditis: Part 2, sonographic analysis of benign and malignant nodules in patients with diffuse Hashimoto thyroiditis.

OBJECTIVE: The purpose of this article is to compare sonographic features of benign and malignant nodules in patients with diffuse Hashimoto thyroiditis. SUBJECTS AND METHODS: As part of an ongoing multiinstitutional study, patients who underwent ultrasound and fine-needle aspiration of one or more thyroid nodules were analyzed for a variety of predetermined sonographic features. Patients with a sonographic appearance consistent with diffuse Hashimoto thyroiditis and with coexisting nodules that could be confirmed to be benign or malignant by fine-needle aspiration or surgical pathologic analysis were included in the study. RESULTS: Among nodules within diffuse Hashimoto thyroiditis, 84% (69/82) were benign (35 nodular Hashimoto thyroiditis, 32 nodular hyperplasia, and two follicular adenoma), and 16% (13/82) were malignant (12 papillary carcinoma and one lymphoma). Malignant nodules were more likely to be solid and hypoechoic (62% vs 19%). All types of calcifications were more prevalent among malignant nodules, including microcalcifications (39% vs 0%), nonspecific tiny bright reflectors (39% vs 6%), macrocalcifications (15% vs 3%), and eggshell (15% vs 2%). Benign nodules were more likely to be hyperechoic (46% vs 9%), to have a halo (39% vs 15%), and to lack calcifications (88% vs 23%). Benign nodules more often had ill-defined margins (36% vs 8%). CONCLUSION: Sonographic features of benign and malignant nodules within diffuse Hashimoto thyroiditis are generally similar to the features typical of benign and malignant nodules in the general population. If calcifications of any type are added to the list of malignant sonographic features, the decision to biopsy a nodule in patients with diffuse Hashimoto thyroiditis can be based on recommendations that have been published previously.

Hyaline-vascular castleman disease: a rare cause of solitary subcutaneous soft tissue mass.

Castleman disease (CD) is a rare lymphoproliferative disorder that primarily affects mediastinal, retroperitoneal, and cervical lymph nodes. Clinically, these lesions occur as a localized (unicentric) or less frequently as a systemic (multicentric) disease. Two main distinct histologic variants are recognized, the more common hyaline-vascular (HV) type and the plasma cell (PC) type. Extranodal Castleman disease, HV type (HVCD) is even less common. We describe a case of subcutaneous HVCD in a 57-year-old woman with a palpable chest mass and without systemic symptoms. Although the histologic findings are similar to those of HVCD in lymph nodes and other sites, a plethora of differential diagnosis is raised particularly with the more commonly occurring lymphoproliferative lesions in this location. This is one of the few bona fide cases of HVCD in subcutaneous location published to date. A review of the literature with an emphasis on pathogenesis of the disease subtypes is presented.

Challenges faced by women in radiology during the pandemic - A summary of the AAWR Women's Caucus at the ACR 2020 annual meeting.

The COVID-19 pandemic has dramatically altered the professional and personal lives of radiologists and radiation oncologists. This article summarizes the 2020 American Association for Women in Radiology (AAWR) Women's Caucus at the American College of Radiology (ACR) Annual Meeting. The caucus focused on the major challenges that women in radiology have faced during the pandemic.

Promoting Greater Diversity and Inclusion in Radiology Research: A Survey of the American Association for Women Radiologists.

OBJECTIVES: To assess perceived challenges to radiology research and publication by female radiologists, as well as possible strategies for overcoming these challenges. METHODS: An electronic survey was conducted of female nontrainee members of the American Association for Women Radiologists in September and October, 2017. Respondents were recruited by e-mail. Responses were assessed descriptively. RESULTS: The response rate was 31.8% (89/280). 61.4% of respondents were interested in conducting radiology research. 60.2% were expected by their departments to pursue research versus 80.7% expected to pursue educational activities. 56.8% felt that their research success is valued by their department. 47.7% felt that they receive appropriate credit for their research from their departments. 22.7% felt that they receive sufficient time for research. 23.9% felt that their department makes deliberate efforts to support women's research efforts. 41.6% versus 70.8% ever had a female versus a male research mentor, respectively. Among seven provided options, the three items most commonly selected as being most helpful to enhancing research success were dedicated research time (40.4%), personal research mentors (23.6%), and earlier career training in research methodology (21.3%). Additional relevant themes identified by a free-response survey item included: family/child-care issues (n = 5), unconscious bias at the departmental/chair level (n = 5), exclusion of women from research activities by male researchers (n = 2), and concern of being perceived as "aggressive" (n = 2). CONCLUSION: Initiatives targeting the identified challenges to radiology research could help promote greater diversity and inclusion among radiologist researchers, which in turn has implications for improving the quality of such research.

Evaluation of Margin Status of a Breast Lumpectomy Specimen: What the Radiologist Should Know.

Breast Conserving Therapy (BCS) or lumpectomy has been an established treatment option for women with early-stage invasive breast cancers. Surgical margin status has a significant impact on local recurrence. However, there is much complexity in achieving a negative lumpectomy margin. There are multiple risks and predictors of positive surgical margins that the radiologist needs to be familiar with. When working as a member of a multidisciplinary team, it is important to be cognizant of the pathologist's and surgeon's roles in reducing the number of failed breast conserving surgeries. Despite the common use of imaging to help avoid positive surgical margins, it is important to remember the limitations of standard intraoperative specimen radiographs. A negative resection margin is the goal of BCS ensuring decrease of local recurrence, increased cosmesis, and improved long-term survival.

Noncontact diffuse correlation tomography of human breast tumor.

Our first step to adapt our recently developed noncontact diffuse correlation tomography (ncDCT) system for three-dimensional (3-D) imaging of blood flow distribution in human breast tumors is reported. A commercial 3-D camera was used to obtain breast surface geometry, which was then converted to a solid volume mesh. An ncDCT probe scanned over a region of interest on the mesh surface and the measured boundary data were combined with a finite element framework for 3-D image reconstruction of blood flow distribution. This technique was tested in computer simulations and in vivo human breasts with low-grade carcinoma. Results from computer simulations suggest that relatively high accuracy can be achieved when the entire tumor is within the sensitive region of diffuse light. Image reconstruction with a priori knowledge of the tumor volume and location can significantly improve the accuracy in recovery of tumor blood flow contrasts. In vivo imaging results from two breast carcinomas show higher average blood flow contrasts (5.9- and 10.9-fold) in the tumor regions compared to the surrounding tissues, which are comparable with previous findings using diffuse correlation spectroscopy. The ncDCT system has the potential to image blood flow distributions in soft and vulnerable tissues without distorting tissue hemodynamics

Clinical evaluation of a new digitizing device for improved film mammography.

RATIONALE AND OBJECTIVES: The study was designed to evaluate a new digitizing device, the iView (Maxxvision, LLC, Gainesville, FL), which aims to replace the magnifying glass in mammography with real-time film digitization, display, and processing. MATERIALS AND METHODS: A receiver operating characteristic (ROC) experiment was performed with 5 certified mammographers and 114 mammograms that were read with and without the iView. A satisfaction survey was also conducted on the system's features and usefulness. RESULTS: Data analysis suggested that (1) Cancer sensitivity could improve with the use of the iView system. ROC area differences showed improvements from 2% to 24% although these were not always statistically significant. At a false positive rate of 0.2, the true positive rate increased up to 60% depending on the set of cases and the observer's experience. (2) Specificity could also be improved. At a true positive rate of 0.9, the false positive rate decreased by as much as 55%. (3) Most observers felt more confident in their decisions when using the iView, although the prototype's ergonomic problems did not allow full utilization of its capabilities. CONCLUSION: Our pilot clinical study showed that the iView has the potential to improve mammogram interpretation. In addition, the system could broaden the applicability of electronic information and provide wider access to digital technology through a relatively simple and cost-effective approach. Observers recommended several improvements in the ergonomics and default display of the system that are currently implemented by the company. A larger clinical study of the improved system is necessary to clearly demonstrate its clinical value for mammography.

Case report: PET scan detects prostate cancer in a patient with Hodgkins lymphoma.

Positron emission tomography (PET) is routinely used in the management of cancers such as lung, colorectal, esophageal, breast, lymphoma, and melanoma. In urologic oncology, the role of PET has been less well defined and is currently under investigation. We report the first case of PET scan detection of prostate cancer in a patient with Hodgkins lymphoma.

Simultaneous measurement of deep tissue blood flow and oxygenation using noncontact diffuse correlation spectroscopy flow-oximeter.

We report a novel noncontact diffuse correlation spectroscopy flow-oximeter for simultaneous quantification of relative changes in tissue blood flow (rBF) and oxygenation (Δ[oxygenation]). The noncontact probe was compared against a contact probe in tissue-like phantoms and forearm muscles (n = 10), and the dynamic trends in both rBF and Δ[oxygenation] were found to be highly correlated. However, the magnitudes of Δ[oxygenation] measured by the two probes were significantly different. Monte Carlo simulations and phantom experiments revealed that the arm curvature resulted in a significant underestimation (~-20%) for the noncontact measurements in Δ[oxygenation], but not in rBF. Other factors that may cause the residual discrepancies between the contact and noncontact measurements were discussed, and further comparisons with other established technologies are needed to identify/quantify these factors. Our research paves the way for noncontact and simultaneous monitoring of blood flow and oxygenation in soft and vulnerable tissues without distorting tissue hemodynamics.