Acellular Dermal Matrix: Imaging Features With Histopathology Correlation.

Acellular dermal matrix (ADM) is an immunologically inert graft, typically from cadaveric skin, often used in postmastectomy breast reconstruction. Created from decellularized dermal tissues that have been treated to remove DNA and antigenic donor cells (leaving extracellular matrix), ADM is often used as a structural scaffold or sling to reinforce and support the structure and position of a breast implant during postoperative integration in implant-based breast reconstruction; ADM can also be used to fill cosmetic defects. Advantages of ADM use include improved cosmesis and reduced capsular contracture rates. On US, ADM can be seen as a subtle band with variable echogenicity adjacent to the implant. When folded on itself or redundant, ADM may present as a palpable oval mass with indistinct or circumscribed margins and variable echogenicity. On mammography, ADM can be seen as a circumscribed oval equal density mass when redundant and folded on itself; a layered appearance may be evident on tomosynthesis. On MRI, presence and absence of enhancement have been documented. Imaging findings likely vary depending on the degree of host tissue remodeling and incorporation, and when biopsied, histopathologically, ADM may be difficult to distinguish from scarring. Successful imaging diagnosis of ADM is aided by clinical knowledge of the intraoperative use and configuration of ADM, which may help differentiate ADM from new or recurrent malignancy and avoid unnecessary biopsy.

Breast Hemangiomas: Imaging Features With Histopathology Correlation.

Breast hemangiomas are rare benign vascular lesions. In a previously performed review of approximately 10,000 breast surgical pathology results, roughly 0.15% (15/~10 000) were hemangiomas. Hemangiomas are more frequent in women and have a documented age distribution of 1.5 to 82 years. They are most often subcutaneous or subdermal and anterior to the anterior mammary fascia but may rarely be seen in the pectoralis muscles or chest wall. On imaging, breast hemangiomas typically present as oval or round masses, often measuring less than 2.5 cm, with circumscribed or mostly circumscribed, focally microlobulated margins, equal or high density on mammography, and variable echogenicity on US. Calcifications, including phleboliths, can be seen. Color Doppler US often shows hypovascularity or avascularity. MRI appearance can vary, although hemangiomas are generally T2 hyperintense and T1 hypointense with variable enhancement. Pathologic findings vary by subtype, which include perilobular, capillary, cavernous, and venous hemangiomas. If core biopsy pathology results are benign, without atypia, and concordant with imaging and clinical findings, surgical excision is not routinely indicated. Because of histopathologic overlap with well-differentiated or low-grade angiosarcomas, surgical excision may be necessary for definitive diagnosis. Findings that are more common with angiosarcomas include size greater than 2 cm, hypervascularity on Doppler US, irregular shape, and invasive growth pattern.

Comparing Ultrasound with Magnetic Resonance Imaging in the Evaluation of Subungual Glomus Tumors and Subungual Myxoid Cysts.

Introduction: Subungual myxoid cysts and subungual glomus tumors demonstrate characteristic features on magnetic resonance imaging (MRI) and ultrasound (US). It is not yet well-established whether US is congruent to MRI in diagnostic evaluation of these subungual lesions. Methods: Participants with clinical suspicion for subungual glomus tumors or subungual myxoid cysts were recruited. After clinical evaluation, participants underwent radiography, MRI, and US plus biopsy, aspiration, or excision where possible. Differential diagnoses were revised after review of imaging, and imaging findings were compared to definitive diagnosis by pathology, aspiration, or clinical course. Results: All lesions were visible on both US and MRI and size estimates agreed between the two modalities. US and MRI findings of subungual glomus tumors and subungual myxoid cysts agreed with their known respective imaging characteristics. Conclusions: Diagnosis of subungual myxoid cysts and subungual glomus tumors agreed between US and MRI. We provide sample MRI and US imaging parameters for optimal evaluation of subungual myxoid cysts and glomus tumors. We demonstrate that subungual MRI evaluation can be performed without special equipment, allowing for evaluation by most radiology departments. Lastly, US is user-dependent and may be non-inferior for a sonographer familiar with subungual US.

Barriers and Facilitators of Palliative Care and Advance Care Planning in Adults With Congenital Heart Disease.

Palliative care has potential to improve quality of life and goal-concordant care for patients with adult congenital heart disease (ACHD). However, it is rarely employed prior to critical illness because the best methods for implementation are not well-defined. We qualitatively evaluated ACHD patients' understanding of and opinions regarding palliative care and advance care planning (ACP) to better define the needs of this population. We conducted a thematic analysis of 25 semistructured interviews with patients with ACHD in which we assessed participants' perspectives on the need for, and barriers and facilitators to, the use of palliative care and ACP. In a group of participants with ACHD (mean age 38, 48% male) classified as simple (24%), moderate (32%), or complex (44%), we identified 4 major themes: (1) using knowledge to combat future uncertainties; (2) unfamiliarity with and limited exposure to palliative care and ACP; (3) facilitators and barriers to engaging in palliative care and ACP; and (4) importance of timing and presentation of ACP discussions. In conclusion, participants expressed a desire for knowledge about ACHD progression and treatment. They supported routine incorporation of palliative care and ACP and identified related facilitators and barriers to doing so. Importantly, timing and format of these discussions must be individualized using shared decision-making between clinicians, patients, and their families.