Use of the probably benign (BI-RADS category 3) assessment for masses on breast MRI: Is it transferable to general clinical practice?

The purpose of this study was to identify potential BI-RADS 3 mass descriptors on breast magnetic resonance imaging by systematically defining positive predictive values (PPV). In a blinded retrospective review of BI-RADS 4 masses, reader 1 identified 132 masses and reader 2 identified 76 masses. PPV for mass descriptors and for descriptor combinations was determined. No mass descriptor resulted in a PPV ≤2% (BI-RADS 3 threshold). Descriptors with the lowest PPVs were circumscribed margin (8%), rim internal enhancement and persistent kinetics (13% each), and oval shape (15%). The results demonstrate the difficulty in transferring the theoretical concept of lesion surveillance to systematic clinical use.

The fetal urinoma revisited.

The fetal urinoma is a rare but important diagnosis, as it indicates substantial underlying obstruction with implications for the functionality of the affected kidney. This case series describes a single center's experience with the diagnosis and management of fetal urinomas. All 25 cases were diagnosed or referred to our medical center over an 11-year period. Most cases were secondary to either posterior urethral valves or ureteropelvic junction obstruction. Fetal interventions, including percutaneous drainage of the urinoma and cystoscopic alleviation of bladder outlet obstruction, were performed in 4 cases.

Agreement of mammographic measures of volumetric breast density to MRI.

BACKGROUND: Clinical scores of mammographic breast density are highly subjective. Automated technologies for mammography exist to quantify breast density objectively, but the technique that most accurately measures the quantity of breast fibroglandular tissue is not known. PURPOSE: To compare the agreement of three automated mammographic techniques for measuring volumetric breast density with a quantitative volumetric MRI-based technique in a screening population. MATERIALS AND METHODS: Women were selected from the UCSF Medical Center screening population that had received both a screening MRI and digital mammogram within one year of each other, had Breast Imaging Reporting and Data System (BI-RADS) assessments of normal or benign finding, and no history of breast cancer or surgery. Agreement was assessed of three mammographic techniques (Single-energy X-ray Absorptiometry [SXA], Quantra, and Volpara) with MRI for percent fibroglandular tissue volume, absolute fibroglandular tissue volume, and total breast volume. RESULTS: Among 99 women, the automated mammographic density techniques were correlated with MRI measures with R(2) values ranging from 0.40 (log fibroglandular volume) to 0.91 (total breast volume). Substantial agreement measured by kappa statistic was found between all percent fibroglandular tissue measures (0.72 to 0.63), but only moderate agreement for log fibroglandular volumes. The kappa statistics for all percent density measures were highest in the comparisons of the SXA and MRI results. The largest error source between MRI and the mammography techniques was found to be differences in measures of total breast volume. CONCLUSION: Automated volumetric fibroglandular tissue measures from screening digital mammograms were in substantial agreement with MRI and if associated with breast cancer could be used in clinical practice to enhance risk assessment and prevention.

Recognizing artifacts and optimizing breast MRI at 1.5 and 3 T.

OBJECTIVE: This article will discuss routine 1.5 and 3 T MRI of the breast as well as illustrate several examples of patient-related and technical artifacts one might encounter. Suggestions to help eliminate these artifacts and optimize images will be provided. CONCLUSION: Artifacts seen on breast MR images can degrade image quality and obscure important findings. Recognizing artifacts and understanding how to address and troubleshoot them is essential for any radiologist interpreting breast MRI.

Preliminary clinical experience at 3 T with a 3D T2-weighted sequence compared with multiplanar 2D for evaluation of the female pelvis.

OBJECTIVE: The purpose of this article is to compare 3D T2-weighted sampling perfection with application-optimized contrast with different flip-angle evolutions (SPACE) with three-plane 2D turbo-spin echo (TSE) sequences for female pelvic imaging at 3 T. MATERIALS AND METHODS: Twenty women were imaged with 2D TSE and 3D SPACE sequences. Three radiologists independently assessed image quality, diagnostic quality, and artifacts; measured normal anatomic structures; evaluated pathologic abnormalities; and recorded interpretation time. Readers subsequently performed a side-by-side comparison, and their preferences were graded according to overall interpretation, sharpness of lesion edges, motion and other artifacts, uterine and cervical zonal anatomy distinction, identification of adnexal pathologic abnormalities, and distinction between fat and fluid. Quantitative comparison of relative signal intensity and relative tissue contrast was performed. RESULTS: The mean acquisition time of 3D SPACE was significantly shorter than that of 2D TSE (6 minutes 35 seconds vs 8 minutes 50 seconds; p < 0.005). Intrareader agreement between interpretations of 2D and 3D sequences was excellent. There were no significant differences among readers in detecting artifacts, normal structures, and pathologic abnormalities or in determining endometrial thickness, image quality, or interpretation time (p > 0.05). Except for distinctions between fat and fluid, the average reader score indicated a slight preference for the 3D sequence. Three-dimensional multiplanar reconstructions were helpful but not considered essential. Relative agreement between readers was moderate (r ≥ 0.4) to strong (r ≥ 0.7). The relative signal intensity was higher for fat and bladder fluid on the 3D sequence than on the 2D sequence (p = 0.014 and p = 0.018, respectively). Relative tissue contrast was higher for the 3D sequence (p < 0.05), with no significant difference in bladder or fat contrast (p = 0.31) but a trend toward more superior contrast on the 2D sequence. CONCLUSION: At 3 T, 3D SPACE has similar image quality and diagnostic quality with shorter scan time when compared with 2D TSE but with reduced contrast between fat and fluid.

Pelvic ultrasound immediately following MDCT in female patients with abdominal/pelvic pain: is it always necessary?

To determine the added value of reimaging the female pelvis with ultrasound (US) immediately following multidetector CT (MDCT) in the emergent setting. CT and US exams of 70 patients who underwent MDCT for evaluation of abdominal/pelvic pain followed by pelvic ultrasound within 48 h were retrospectively reviewed by three readers. Initially, only the CT images were reviewed followed by evaluation of CT images in conjunction with US images. Diagnostic confidence was recorded for each reading and an exact Wilcoxon signed rank test was performed to compare the two. Changes in diagnosis based on combined CT and US readings versus CT readings alone were identified. Confidence intervals (95%) were derived for the percentage of times US reimaging can be expected to lead to a change in diagnosis relative to the diagnosis based on CT interpretation alone. Ultrasound changed the diagnosis for the ovaries/adnexa 8.1% of the time (three reader average); the majority being cases of a suspected CT abnormality found to be normal on US. Ultrasound changed the diagnosis for the uterus 11.9% of the time (three reader average); the majority related to the endometrial canal. The 95% confidence intervals for the ovaries/adnexa and uterus were 5-12.5% and 8-17%, respectively. Ten cases of a normal CT were followed by a normal US with 100% agreement across all three readers. Experienced readers correctly diagnosed ruptured ovarian cysts and tubo-ovarian abscesses (TOA) based on CT alone with 100% agreement. US reimaging after MDCT of the abdomen and pelvis is not helpful: (1) following a normal CT of the pelvic organs or (2) when CT findings are diagnostic and/or characteristic of certain entities such as ruptured cysts and TOA. Reimaging with ultrasound is warranted for (1) less-experienced readers to improve diagnostic confidence or when CT findings are not definitive, (2) further evaluation of suspected endometrial abnormalities. A distinction should be made between the need for immediate vs. follow-up imaging with US after CT.

Normal or abnormal? Demystifying uterine and cervical contrast enhancement at multidetector CT.

Computed tomography (CT) is not generally advocated as the first-line imaging examination for disorders of the female pelvis. However, multidetector CT is often the modality of choice for evaluating nongynecologic pelvic abnormalities, particularly in emergent settings, in which all the pelvic organs are invariably assessed. Incidental findings of uterine and cervical contrast enhancement in such settings may easily be mistaken for abnormalities, given the broad spectrum of anatomic variants and enhancement patterns that may be seen in the normal uterus and cervix. The authors' review of CT and magnetic resonance (MR) imaging enhancement patterns, augmented by case examples from their clinical radiology practice, provides a solid foundation for understanding the spectrum of normal uterine and cervical appearances and avoiding potential pitfalls in the diagnosis of benign cervical lesions, adenomyosis, infection, malignancy, and postpartum effects. This information should help radiologists more confidently differentiate between normal and abnormal CT findings and, when CT findings are not definitive, offer appropriate recommendations for follow-up ultrasonography or MR imaging.

Commonly encountered foreign bodies and devices in the female pelvis: MDCT appearances.

OBJECTIVE: The objective of this article is to illustrate the MDCT appearances of several commonly encountered foreign bodies and devices in the female pelvis. CONCLUSION: The presence of a foreign body or device in the female pelvis can be a potential source of confusion to radiologists, particularly to the inexperienced reader. Familiarity with the normal appearances and locations of these devices on MDCT allows their accurate identification and detection of associated complications.

Image presentation. Sonographic appearances of benign and malignant male breast disease with mammographic and pathologic correlation.

OBJECTIVE: Imaging of the male breast is most often performed for the evaluation of a clinical abnormality such as breast enlargement or tenderness, a palpable mass, nipple skin changes, or nipple discharge. Most breast lesions encountered in men are benign. Malignant breast lesions are less frequent; breast cancer accounts for less than 1% of all male cancers in the United States. The initial imaging evaluation of a finding in the male breast is performed with mammography. Sonography is frequently used as an adjunct to mammography but is less often used as the primary imaging modality. The objective of this article is to provide readers with a thorough review of the sonographic appearances of benign and malignant male breast disease. METHODS: We reviewed our institution's case database to identify male patients who underwent mammography, sonography, and subsequent biopsy of a breast lesion. These cases were collected and reviewed to select the best imaging examples. RESULTS: A spectrum of benign and malignant male breast disease is presented with corresponding sonographic, mammographic, and pathologic imaging. For each entity, the salient imaging findings and typical clinical presentation are discussed. CONCLUSIONS: Most studies in the literature have reported on the mammographic and sonographic imaging features of primary breast carcinoma in men. However, very little has been reported on the sonographic appearance of benign and malignant male breast conditions. Recognition and correct identification of pathologic male breast entities on sonography is essential to determine appropriate management recommendations and avoid unnecessary biopsies.

Added value of multiplanar reformation in the multidetector CT evaluation of the female pelvis: a pictorial review.

Although computed tomography (CT) is generally not the first-line imaging test of choice for the evaluation of female pelvic disorders, it is often the initial diagnostic examination performed in the emergency setting in patients who present with abdominal pain and nonspecific clinical symptoms. Multidetector CT coupled with reconstruction software permits isotropic voxel acquisition that can be used to generate two-dimensional multiplanar reformatted (MPR) images for evaluation of the female pelvis with no additional radiation exposure. Multidetector CT with MPR allows improved visualization of the normal anatomy and anatomic variants as well as greater diagnostic accuracy in the evaluation of the female pelvis. Although ultrasonography and magnetic resonance imaging remain the primary imaging modalities for the assessment of most female pelvic disorders, more accurate diagnosis of these disorders at multidetector CT may obviate additional imaging tests and allow more appropriate management.

Basal ganglia dopamine loss due to defect in purine recycling.

Several rare inherited disorders have provided valuable experiments of nature highlighting specific biological processes of particular importance to the survival or function of midbrain dopamine neurons. In both humans and mice, deficiency of hypoxanthine-guanine phosphoribosyl transferase (HPRT) is associated with profound loss of striatal dopamine, with relative preservation of other neurotransmitters. In the current studies of knockout mice, no morphological signs of abnormal development or degeneration were found in an exhaustive battery that included stereological and morphometric measures of midbrain dopamine neurons, electron microscopic studies of striatal axons and terminals, and stains for degeneration or gliosis. A novel culture model involving HPRT-deficient dopaminergic neurons also exhibited significant loss of dopamine without a morphological correlate. These results suggest that dopamine loss in HPRT deficiency has a biochemical rather than anatomical basis and imply that purine recycling to be a biochemical process of particular importance to the function of dopaminergic neurons.

Pericardial varices secondary to portal hypertension demonstrated by CT.

Pericardial varices are rarely seen on CT and can be misinterpreted as mediastinal masses or lymph nodes. We report a case of a 38-year-old man who presented for routine liver transplant evaluation. On high-resolution computed tomography (CT), a cluster of varices was seen in the left cardiophrenic angle.

Characterization of normal ileocecal valve density on CT colonography.

The objective of this study was to evaluate normal ileocecal valve (ICV) attenuation and composition on CT colonography (CTC). Two hundred twelve patients who underwent CTC at the authors' institution were retrospectively identified. Two independent readers recorded three region-of-interest (ROI) measurements, which were used to determine mean ICV density. ICV attenuation measurements were compared with age and abdominal body fat using Pearson correlation. A subjective classification system was applied to characterize the relative fat and soft tissue density of the ICV. Mean ICV density was -26.3+/-14 HU (range -60.1 to 18.3 HU). There was no correlation between the fat content of the ICV and age (r=0.06) or body fat (r=-0.47). The majority of valves (83.5%) were classified as heterogeneously low density or heterogeneously high density, whereas a small fraction of valves (6.1%) were categorized as homogeneously low density. The results of this study suggest that ICVs have a varying range of densities, and this feature alone cannot be used to distinguish the ICV from a polyp or neoplastic lesion on CTC.

Primary squamous cell carcinoma of the colon associated with hypercalcemia and hyperleukocytosis. Report of a case.

BACKGROUND/AIMS: Squamous cell carcinoma of the colon is a rare entity. We report a case of a patient who presented with a perforated squamous cell carcinoma of the sigmoid colon. RESULTS: A 45-year-old female presented with a 2-month history of worsening abdominal pain, bloody diarrhea, and vomiting. She underwent an exploratory laparotomy and was found to have keratinizing squamous cell carcinoma of the sigmoid colon that had perforated forming multiple abscess cavities. The postoperative course was complicated by hypercalcemia and persistent hyperleukocytosis, ultimately resulting in the patient's death. CONCLUSIONS: We present the second reported case of squamous cell carcinoma of the colon associated with hypercalcemia and the first reported case of associated hyperleukocytosis.

Effect of thermal treatment during the preparation of aluminum hydroxide adjuvant on the protein adsorption capacity during aging.

Six aluminum hydroxide adjuvants, poorly crystalline aluminum oxyhydroxide (AlOOH) were prepared using different thermal treatments of amorphous aluminum hydroxide (Al(OH)3) in an effort to increase the protein adsorption capacity. All of the adjuvants initially exhibited a higher protein adsorption capacity. However, the protein adsorption capacity decreased during aging at room temperature. X-ray and differential centrifugal sedimentation analysis revealed that complete dehydration of amorphous aluminum hydroxide to aluminum oxyhydroxide is required to produce a stable adjuvant. Any residual amorphous aluminum hydroxide will spontaneously transform to crystalline aluminum hydroxide during aging at room temperature. Since crystalline aluminum hydroxide has a small surface area, the protein adsorption capacity of adjuvants containing amorphous aluminum hydroxide decreased by 30-40% when stored for 6 months at room temperature.