Imaging evaluation of the pregnant patient with suspected pulmonary embolism

Pulmonary embolism is the leading cause of maternal death in the developed world. The clinical diagnosis of pulmonary embolism is particularly challenging in pregnant patients as physiologic changes of pregnancy can mimic symptoms of pulmonary embolism or deep venous thrombosis. Clinical decision and imaging algorithms for venous thromboembolic disease have been proposed in the literature for the general population, but have not undergone wide-scale validation in pregnant patients. Laboratory evaluation of D-dimer levels has likewise been established as a viable screening method in the general population but remains controversial in pregnant patients. Regardless of whether D-dimer levels are used in this population, the clinician must often rely on imaging tests to confirm or exclude a clinical suspicion of pulmonary embolism. Additional factors beyond test performance must be weighed during pregnancy: radiation exposure to the fetus and maternal breast tissue, the safety of intravenous contrast administration and the diagnostic accuracy of the various testing options so that diagnosis and proper management are not delayed. The epidemiology of pregnancy-related venous thromboembolic disease and the different diagnostic methods are reviewed, with emphasis on the pregnant patient. Finally, a diagnostic imaging algorithm is proposed for the evaluation of the pregnant patient when a clinical suspicion of pulmonary embolism exists.     

Ultrasound in head and neck surgery: thyroid, parathyroid, and cervical lymph nodes

Ultrasound (US) of the neck is extremely sensitive in detecting thyroid, parathyroid, and cervical lymph node pathology, and is regarded as the most complete and cost-effective imaging method for evaluating the thyroid and parathyroid glands, as well as for the diagnostic evaluation of the cervical lymph node basin. US is widely used in screening high-risk individuals, evaluation of palpable and nonpalpable thyroid nodules, needle guidance for biopsy of nonpalpable and suspicious nodules, and preoperative evaluation of the extent of thyroid neoplasms, as well as in the detection of residual, recurrent, or metastatic thyroid tumors, and in observing nonsurgical cases. It has thus become an important adjunct to the practice of head and neck surgery.     

Surgeon-performed ultrasound: its use in clinical practice.

OBJECTIVE: To highlight areas where surgeon-performed ultrasound (US) is an effective diagnostic and therapeutic tool. SUMMARY BACKGROUND DATA: The success of US in trauma and technologic advances have enhanced the interest and ability of surgeons to perform their own US examinations. METHODS: General surgeons perform US examinations of the thyroid gland, breast, gastrointestinal tract, peritoneal cavity (laparoscopy), and vascular system. Essentials of these examinations are discussed and a plan for educating surgical residents in US is outlined. RESULTS: Focused assessment for the sonographic examination of the trauma patient, or FAST, is replacing central venous pressure measurements to detect hemopericardium and diagnostic peritoneal lavage to detect hemoperitoneum. Bedside US can be used to detect a pleural effusion so well in critically ill patients that lateral decubitus x-rays are rarely needed. US-directed biopsy of breast lesions is a common office procedure. Laparoscopic US allows tumor staging without formal celiotomy, and many hepatic and pancreatic surgical procedures include US as an adjunct. Endoscopic and endorectal US have added a new dimension to the assessment of many gastrointestinal lesions. Color flow duplex imaging and endoluminal US have significantly expanded the diagnostic and therapeutic aspects of vascular imaging. The training program developed at Emory University and Grady Memorial Hospital is offered as a model for educating surgical residents in US techniques. CONCLUSIONS: US is a valuable addition to the general surgeon's diagnostic armamentarium and is rapidly becoming an integral part of the surgeon's clinical practice.     

Effectiveness of a noninvasive digital infrared thermal imaging system in the detection of breast cancer

BACKGROUND: Digital infrared thermal imaging (DITI) has resurfaced in this era of modernized computer technology. Its role in the detection of breast cancer is evaluated. METHODS: In this prospective clinical trial, 92 patients for whom a breast biopsy was recommended based on prior mammogram or ultrasound underwent DITI. Three scores were generated: an overall risk score in the screening mode, a clinical score based on patient information, and a third assessment by artificial neural network. RESULTS: Sixty of 94 biopsies were malignant and 34 were benign. DITI identified 58 of 60 malignancies, with 97% sensitivity, 44% specificity, and 82% negative predictive value depending on the mode used. Compared to an overall risk score of 0, a score of 3 or greater was significantly more likely to be associated with malignancy (30% vs 90%, P < .03). CONCLUSION: DITI is a valuable adjunct to mammography and ultrasound, especially in women with dense breast parenchyma.     

Supplemental ultrasound screening in patients with a history of lobular neoplasia

To investigate the role of ultrasound (US) screening as an adjunct to annual mammography (M) in breast cancer detection in women with a history of lobular neoplasia (LN) diagnosed following core needle or excisional biopsy. A retrospective review of our database was performed between 11/2006 and 11/2011 to identify patients diagnosed with LN, and underwent annual screening. Patients with a lifetime risk >20% per risk modeling were excluded. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and cancer detection rate (CDR) of each screening test were identified. Cancer type and detection modality were recorded. A total of 100 patients who had M and/or US screening were included. Mean patient age was 54.7 years (range 33‐83). All 100 patients underwent a mean of 3.9 rounds of screening M and 93 (93%) received US screening (mean 3.3 rounds). Of 93 patients who received both M and US screening, 12 (13%) were diagnosed with breast cancer. Mammographic CDR was 4%. Incremental US CDR was 6.5%. The sensitivity, specificity, and NPV for M screening alone was 33% (10%, 65%), 77% (67%, 85%), and 89% (80%, 95%), respectively. US and mammography screening had a combined sensitivity: 83% (52%, 98%), Specificity: 72% (62%, 81%), NPV: 97% (89%, 100%). Supplemental US screening resulted in a significant increase in sensitivity, yielding 6.5% incremental CDR in this high‐risk patient subgroup that does not fulfill ACS high‐risk MRI screening criteria.     

Diagnostic imaging of the rotator cuff

The importance of imaging modalities in the evaluation of the rotator cuff has increased thanks to the development of non-invasive methods. An optimum application of the technique, appreciation of the anatomical details and imaging pitfalls, and proper interpretation of clinical findings should be incorporated in order to increase diagnostic accuracy. Ultrasonography (US) and magnetic resonance imaging (MRI) are commonly used for rotator cuff pathologies. The former has a high diagnostic accuracy in full-thickness tears, but requires operator dependency and long-term training. Both US and MRI require sophisticated equipment and present difficulties in distinguishing between partial and small full-thickness tears. In full-thickness tears, MRI may be more appropriate if imaging findings are likely to alter the course of surgical treatment. However, it is not necessary in patients in whom US may clearly show tendinosis. Magnetic resonance imaging or MR arthrography may be required in order to evaluate partial tears or suspicious small full-thickness tears in patients unresponsive to conservative therapy. A close collaboration is essential between the radiologist and the shoulder surgeon in the interpretation of clinical findings. The diagnostic accuracy will increase if the examinations are performed by a musculoskeletal radiologist.     

Management of asymptomatic silicone-injected breast with reduction mammoplasty

Even though Silicone injection for breast augmentation has been related to disastrous long-term effects and complications, some patients do not develop significant symptoms at all (asymptomatic). Unfortunately, the management of asymptomatic Silicone-injected breast is still unclear and has never been reported exclusively. We present two cases of asymptomatic patients with a history of liquid Silicone injections who refused to have a mastectomy. They were concerned with the breast ptosis and chose to undergo reduction mammoplasty to improve the appearance of the breasts. Magnetic resonance imaging may be useful as an additional screening tool to confirm the diagnosis and exclude the presence of malignancy in breasts with injected Silicone. We believe that breast reduction may be the alternative option for women with a history of liquid Silicone injection who have no symptoms but desire to preserve their breasts and improve their aesthetics.KEY WORDS: Breast, magnetic resonance imaging, mammaplasty, mastectomy, Silicone     

Assessing and preventing foot problems in older patients who have diabetes mellitus

The first component of prevention is patient education. The patient and those who provide care for the older diabetic must be fully informed of their problems, but understand the management process and be willing to make the lifestyle changes necessary to prevent complications. Evaluating patients to determine those diabetics who are at risk for foot problems, complication, ulceration, or potential amputation is the second component of prevention. This process must include continuing surveillance and management. Recognizing symptoms and signs of various systems with primary evaluative procedures permits the early identification of complications and secondary prevention of chronic disease. Because Medicare now provides footwear and orthotic coverage for at-risk diabetics as an adjunct to management, early screening, assessment, and detection are essential. The provision of significant patient education can then be added to complement professional education. We have attempted to provide a process for proper referral for care and management that can be employed by all health care providers involved in the evaluation of the patient who has diabetes.     

Screening and preoperative imaging of candidates for carotid endarterectomy

Randomized clinical trials have provided us with clinical guidelines regarding the indications for performing carotid endarterectomy in patients who have symptomatic and asymptomatic disease. Logically, any patient with a history of transient ischemic attacks, amaurosis fugax, or stroke should be evaluated for extracranial carotid artery occlusive disease. In asymptomatic patients, however, carotid artery surveillance may be helpful in identifying those at risk before neurological events. Patients at particularly high risk include those identified with (1) manifestations of systemic atherosclerotic disease (peripheral vascular disease, coronary artery disease, renovascular disease); (2) presence of a carotid bruit; (3) advanced age (> 65 years); and (4) ABI less than 0.7. Duplex ultrasonography remains the best and most widely used noninvasive screening method, but its accuracy is highly technologist dependent. A high-quality duplex study may, in itself, be adequate to determine whether the severity of extracranial carotid occlusive disease warrants surgical intervention. Catheter-based arteriography may be used as an adjunct to validate duplex results, but its invasive nature and risk of complications has popularized alternative imaging methods. Of these, magnetic resonance angiography (MRA) and spiral computed tomographic angiography (CTA) show excellent promise as noninvasive imaging techniques for the evaluation of extracranial carotid artery occlusive disease.     

The utility of breast MRI as a problem-solving tool

Breast magnetic resonance imaging (MRI) is routinely used as a problem-solving tool, but its benefit for this indication remains unclear. The records of 3001 consecutive breast MR examinations between January 1, 2003 and June 6, 2007 were reviewed to identify all those performed for the clinical indication of problem solving. Details of clinical presentation, mammography and ultrasound (US) findings, follow-up recommendations, and pathology outcomes were recorded. Benign versus malignant outcomes were determined by biopsy or 12 months of follow-up imaging and linkage with the regional tumor registry. Problem solving was the clinical indication for 204 of 3001 (7%) of all examinations. Forty-two of 204 examinations (21%) had suspicious or highly suspicious MRI assessments with recommendation for biopsy and 62 of 204 (79%) examinations were assessed as negative, benign, or probably benign. Thirty-six biopsies were performed based on MRI findings and 14 cancers were diagnosed. Biopsy was indicated for 11 of 14 (79%) cancers based on suspicious mammographic or US findings identified prior to MRI. One incidental cancer was detected by MRI alone in a patient at high risk for breast cancer, and two cancers were detected in patients with suspicious nipple discharge and negative mammogram and US. A single false-negative MRI occurred in a patient whose evaluation for a palpable lump prompted biopsy. Problem-solving breast MRI rarely identifies otherwise occult cancer and can be falsely negative in patients with suspicious findings on mammogram and US. Until the benefits and risks of problem-solving MRI are clarified, it should be used judiciously.     

The Potential Role of Dedicated 3D Breast CT as a Diagnostic Tool: Review and Early Clinical Examples

Mammography is the gold standard in routine screening for the detection of breast cancer in the general population. However, limitations in sensitivity, particularly in dense breasts, has motivated the development of alternative imaging techniques such as digital breast tomosynthesis, whole breast ultrasound, breast‐specific gamma imaging, and more recently dedicated breast computed tomography or “breast CT”. Virtually all diagnostic work‐ups of asymptomatic nonpalpable findings arise from screening mammography. In most cases, diagnostic mammography and ultrasound are sufficient for diagnosis, with magnetic resonance imaging (MRI) playing an occasional role. Digital breast tomosynthesis, a limited‐angle tomographic technique, is increasingly being used for screening. Dedicated breast CT has full three‐dimensional (3D) capability with near‐isotropic resolution, which could potentially improve diagnostic accuracy. In current dedicated breast CT clinical prototypes, 300–500 low‐dose projections are acquired in a circular trajectory around the breast using a flat panel detector, followed by image reconstruction to provide the 3D breast volume. The average glandular dose to the breast from breast CT can range from as little as a two‐view screening mammogram to approximately that of a diagnostic mammography examination. Breast CT displays 3D images of the internal structures of the breast; therefore, evaluation of suspicious features like microcalcifications, masses, and asymmetries can be made in multiple anatomical planes from a single scan. The potential role of breast CT for diagnostic imaging is illustrated here through clinical examples such as imaging soft tissue abnormalities and microcalcifications. The potential for breast CT to serve as an imaging tool for extent of disease evaluation and for monitoring neo‐adjuvant chemotherapy response is also illustrated.     

The Role of Whole-Body Fluorine-18-FDG Positron Emission Tomography in the Detection of Recurrence in Symptomatic Patients with Stages II and III Breast Cancer

Background The role of whole-body fluorine-18-FDG positron emission tomography (FDG-PET) as an adjunct localize recurrence in stages II and III breast cancer patients who present with clinical suspicion for recurrence is not well established. We report our experience in such a patient population. Methods A retrospective review of all patients with stages II and III breast cancer who had a whole-body FDG-PET scan was performed. Results Of the 23 patients who fit the criteria, 9 had stage II and 14 had stage III breast cancer. Overall sensitivity, specificity, and accuracy were 81%, 100%, and 87%, respectively. Positive and negative predictive values for stages II and III were 100% and 83%, respectively, and 100% and 50%, respectively. FDG-PET detected two recurrences that were missed by conventional imagings, but such recurrences were local and amenable for biopsy. Conclusions In patients with stages II and III breast cancer who present with a suspicion for recurrent disease, a whole-body FDG-PET scan may be a useful adjunct in the evaluation of recurrence. However, its added benefit over conventional imaging should be questioned. This paper was presented as a poster at the 2004 American Society of Clinical Oncology.     

Breast molecular imaging: a retrospective review of one institutions experience with this modality and analysis of its potential role in breast imaging decision making

Breast Molecular Imaging (or Breast-Specific Gamma Imaging) has been previously shown to be both sensitive and specific for the detection of breast cancer. The purpose of our study was to retrospectively review all cases of Breast Molecular Imaging (BMI) performed at our institution to determine BMI's potential role in Breast Imaging decision making. A total of 416 cases of BMI from January 2007 to November 2009 were analyzed and the following data were collected: indication for examination, BIRADS assignment after BMI, biopsy outcomes, sensitivity and specificity of the modality and patient follow-up. Fifty-six percent of cases were ordered for an indeterminate asymmetry or focal asymmetry, 14% for evaluation of calcifications, and less than 10% each for the remainder of the indications including palpable lumps with negative imaging, evaluation of extent of disease in patients with known breast cancer and screening of high risk patients who could not undergo MRI. BMI was also shown to be helpful in evaluation of lesions that were difficult to biopsy or for patients that desired further testing rather than biopsy or short term follow-up of abnormalities. Seventy percent of BMI cases performed completed the diagnostic evaluation with BIRADS 1 or BIRADS 2 designations. Only 14% of cases ultimately resulted in biopsy. Contra-lateral findings were discovered in 10% of patients, more than half of which were occult malignancies or high-risk lesions. Of the lesions for which biopsy was recommended, 43% were malignant and 15% were high-risk lesions. Sensitivity of the test at our institution was 93% and specificity 78.9%. Our results show that BMI is both a sensitive and specific test which is useful as an adjunct to standard breast imaging modalities for problem solving in indeterminate cases.     

Dense Breast Notification and Supplemental Screening: A Survey of Current Strategies and Sentiments

Dense breast parenchyma obscures breast lesions and has been shown to be an independent risk factor for development of breast cancer. An ever‐increasing number of states have approved laws requiring patient notification of dense breast tissue. Reviews of supplemental screening imaging modalities are available, but there is no consensus and little discussion regarding what radiologists are specifically doing to manage patients with dense breasts. Our goal was to survey breast imagers facing these issues in an effort to simplify dense breast management. A survey was administered via email to the Society of Breast Imaging member directory, designed to collect information regarding current practices in dense breast notification and supplemental screening. There were 223 surveys completed to entirety, including 38% from respondents in states without mandatory breast density reporting laws and 62% from states with reporting laws. A majority of respondents from both groups, 60% and 51% in those without and with laws, respectively, felt they lacked adequate resources to offer or sustain supplemental screening. In those offering supplemental imaging, the modalities offered varied widely as did the manner of offering a supplemental exam. Levels of satisfaction, concerns, and standard practices of respondents were also queried. Strategizing optimal imaging approaches and algorithms to handle dense breast management issues is important to maintain efficiency in breast imaging departments. Sharing current ideas and practices may facilitate a smoother workflow in mandatory dense breast reporting and supplemental imaging, allowing breast imagers to correct or prevent systems‐based flaws.     

Use of Dynamic MRI of the Pelvic Floor in the Assessment of Anterior Compartment Disorders

Purpose of Review

Approximately 25% of women in the USA suffer from pelvic floor disorders. Disorders of the anterior compartment of the pelvic floor, in particular, can cause symptoms such as incomplete urinary voiding, urinary incontinence, pelvic organ prolapse, dyspareunia, and pelvic pain, potentially negatively impacting a woman’s quality of life. In some clinical situations, clinical exam alone may be insufficient, especially when patient’s symptoms are in excess of their pelvic exam findings. In many of these patients, dynamic magnetic resonance imaging (dMRI) of the pelvic floor can be a valuable imaging tool allowing for comprehensive assessment of the entire pelvic anatomy and its function.

Recent Findings

Traditionally, evaluation of the anterior compartment has been primarily through clinical examination with occasional use of urodynamic testing and ultrasound. In recent years, dMRI has continued to gain popularity due to its improved imaging quality, reproducibility, and ability to display the entire pelvic floor. Emerging evidence has also shown utility of dMRI in the postoperative setting. In spite of advances, there remains an ongoing discussion in contemporary literature regarding the accuracy of dMRI and its correlation with clinical examination and with patient symptoms.

Summary

Dynamic pelvic MRI is a helpful adjunct to physical examination and urodynamic testing, particularly when a patient’s symptoms are in excess of the physical examination findings. Evaluation with dMRI can guide preoperative and postoperative surgical management in many patients, especially in the setting of multicompartmental disorders. This review will summarize relevant pelvic floor anatomy and discuss the clinical application, imaging technique, imaging interpretation, and limitations of dMRI.

     

Background parenchymal enhancement in breast magnetic resonance imaging: A review of current evidences and future trends

Background parenchymal enhancement (BPE) on breast magnetic resonance imaging (MRI) is a dynamic process, which varies among women and within the same woman over time due to different factors. BPE has profound implications for women with or at risk of breast cancer. Breast radiologist should be aware of factors that could potentially influence BPE and have to be familiar with its typical appearance. Marked BPE could indeed affect the diagnostic accuracy of breast MRI, but this shortcoming can be minimized through evaluation by dedicated radiologists, in order to correctly interpret and properly manage the additional findings. BPE shows promise as an imaging biomarker but many issues need to be addressed before it can be used either to determine screening strategy or the value of risk-reducing interventions. This review analyzes the clinical influence of BPE on breast MRI interpretation, breast cancer staging and surgical outcome and discusses current available evidences about BPE as an imaging biomarker.     

Granulomatous Lobular Mastitis: A Complex Diagnostic and Therapeutic Problem

Background Granulomatous lobular mastitis is a rare chronic inflammatory disease of the breast. Clinical and radiological features may mimic breast carcinoma. Since this entity was first described, several clinical and pathologic features of the disease have been reported, but diagnostic features and treatment alternatives are still unclear. The purpose of this study is to evaluate diagnostic difficulties and discuss the outcome of surgical treatment in a series of 21 patients with granulomatous lobular mastitis. Methods A retrospective review of 21 patients with histologically confirmed granulomatous lobular mastitis treated in our center between January 1995 and May 2005 was analyzed to identify issues in the diagnosis and treatment of this rare condition. Results The most common presenting symptoms were a mass in the breast and pain. Four patients had no significant mammographic findings (MMG), but on ultrasound (US), 2 had irregular hypoechoic mass, and 2 hypoechoic nodular structures had abnormalities—one parenchymal distortion and 1 mass formation in 2 of these 4 patients’ magnetic resonance imaging (MRI). In recurrent cases, limited excision under local anesthesia was performed, as the clinical examination suggested carcinoma. Conclusions Although some findings on MMG and US are suggestive of benign breast disease, these modalities do not rule out malignancy. MRI may be helpful in patients who do not have significant pathology at MMG or US. Fine-needle aspiration cytology may be useful in some cases but diagnosis is potentially difficult because of its cytologic characteristics. Wide excision, particularly under general anesthesia, can be therapeutic as well as useful in providing an exact diagnosis.     

Added Value of Contrast‐Enhanced Spectral Mammography in Postscreening Assessment

To assess the value on diagnostic and treatment management of contrast‐enhanced spectral mammography (CESM), as adjunct to mammography (MG) and ultrasound (US) in postscreening in a breast cancer unit for patients with newly diagnosed breast cancer or with suspicious findings on conventional imaging. Retrospective review of routine use of bilateral CESM performed between September 2012 and September 2013 in 195 women with suspicious or undetermined findings on MG and/or US. CESM images were blindly reviewed by two radiologists for BI‐RADS^® assessment and probability of malignancy. Each lesion was definitely confirmed either with histopathology or follow‐up. Two hundred and ninety‐nine lesions were detected (221 malignant). CESM sensitivity, specificity, positive‐predictive value and negative‐predictive value were 94% (CI: 89–96%), 74% (CI: 63–83%), 91% (CI: 86–94%) and 81% (CI: 70–89%), respectively, with 18 false positive and 14 false negative. CESM changed diagnostic and treatment strategy in 41 (21%) patients either after detection of additional malignant lesions in 38 patients (19%)—with a more extensive surgery (n = 21) or neo‐adjuvant chemotherapy (n = 1)—or avoiding further biopsy for 20 patients with negative CESM. CESM can be performed easily in a clinical assessment after positive breast cancer screening and may change significantly the diagnostic and treatment strategy through breast cancer staging.     

A prospective trial of computed tomography and ultrasonography for diagnosing appendicitis in the atypical patient

BACKGROUND: The surgical diagnosis of acute appendicitis is customarily made on clinical grounds alone using history, physical examination, and white blood cell count. In the atypical patient, ie, the patient with prolonged symptoms, inconsistent history, or misleading physical examination, diagnostic studies should be helpful in establishing the appropriate diagnosis. Computed tomography (CT) scan and ultrasonography (US) have demonstrated utility in diagnosing appendicitis but have not been studied in the atypical patient population. METHODS: A retrospective review of 500 consecutive appendectomy patients, coupled with a review of the literature, resulted in the development of an algorithm to help the medical physician to differentiate the atypical patient requiring an imaging study from those requiring immediate surgical consultation. This patient population was entered into a prospective, randomized study of CT scan or US examination. RESULTS: Between May 1997 and May 1999, 106 patients were enrolled in the study; 17 were later excluded from the study because of typical presentation and direct admission to surgery without diagnostic imaging. Forty-nine patients were randomly assigned to CT scan and 40 to US examination. CT scan was 100% specific and 97% sensitive (P = 0.018). US was 90% specific and 76% sensitive. Based on the results of these imaging studies, 70 of the study patients underwent exploration for suspected appendicitis or other acute inflammatory process. CONCLUSION: A subset of patients presenting with possible acute appendicitis has been identified that should benefit from imaging of the appendix prior to surgical consultation. For this group, CT scan appears superior to abdominal and pelvic US in terms of diagnostic accuracy and reliability. With this approach, a low incidence of negative laparotomies was achieved.