Whole-slide imaging: routine pathologic diagnosis

Digital pathology systems offer pathologists an alternate, emerging mechanism to manage and interpret information. They offer increasingly fast and scalable hardware platforms for slide scanning and software that facilitates remote viewing, slide conferencing, archiving, and image analysis. Deployed initially and validated largely within the research and biopharmaceutical industries, WSI is increasingly being implemented for direct patient care. Improvements in image quality, scan times, and imageviewing browsers will hopefully allow pathologists to more seamlessly convert to digital pathology, much like our radiology colleagues have done before us. However, WSI creates both opportunities and challenges. Although niche applications of WSI technology for clinical, educational, and research purposes are clearly successful, it is evident that several areas still require attention and careful consideration before more widespread clinical adoption of WSI takes place. These include regulatory issues, development of standards of practice and validation guidelines, workflow modifications, as well as defining situations where WSI technology will really improve practice in a cost-effective way. Current progress on these and other issues, along with improving technology, will no doubt pave the way for increased adoption over the next decade, allowing the pathology community as a whole to harness the true potential of WSI for patient care. The digital decade will likely redefine how pathology is practiced and the role of the pathologist.     

The value of ultrasonography in the diagnosis of adnexal masses

Seventy patients with palpable adnexal masses were subjected to ultrasonographic examination. Three patients with negative ultrasound and no disease were excluded from the final analysis. Correct diagnosis was obtained in 58.2% patients; contributory information in 16.4%. Ultrasonography is valuable in diagnosing functional and benign ovarian neoplasms. It is also useful in suspecting malignant ovarian neoplasms and confirming diagnosis of ectopic pregnancy, if correlated with the clinical findings.     

Selected adnexal cystic masses in postmenopausal women can be safely managed by laparoscopy

The aim of this study was to assess the efficacy and safety of laparoscopic treatment for adnexal cystic masses that were predicted to be benign in postmenopausal women. Postmenopausal women found to have an adnexal cystic mass were retrospectively evaluated with transvaginal ultrasonography, and serum CA-125 levels. The selection criteria were adnexal cystic masses greater than 3 cm but less than 10 cm, the masses were in the benign range (4-8) of Sassone's scoring system for transvaginal ultrasonography, and the patients had serum CA-125 levels less than 65 IU/mL. Two hundred nineteen women fulfilled the criteria and underwent operative laparoscopy. Almost all the masses (99.5%) were accurately predicted to be benign except for one borderline ovarian tumor. Two hundreds thirteen (97.3%) women were successfully managed by operative laparoscopy and six (2.7%) required laparotomy. For the patients managed by laparoscopy, the mean operative time was 51.3 min; the mean hospital stay was 2.5 days. There was no significant morbidity and surgery-related mortality. The combination of the Sassone's scoring system for transvaginal ultrasonography and serum CA-125 level can accurately predict benign cystic masses, and operative laparoscopy is technically feasible and safe for the management of adnexal mass in postmenopausal women.     

Differential diagnosis of adrenal masses by chemical shift and dynamic gadolinium enhanced MR imaging

Chemical shift MRI is widely used for identifying adenomas, but it is not a perfect method. We determined whether combined dynamic MRI methods can lead to improved diagnostic accuracy. Fifty-seven adrenal masses were examined by chemical shift and dynamic MR imaging using 2 MR systems. The masses included 38 adenomas and 19 non-adenomas. In chemical shift MRI studies, the signal intensity index (SI) was calculated, and the lesions classified into 5 types in the dynamic MRI studies. Of the 38 adenomas studied, 37 had an SI greater than 0. In the dynamic MRI, 34 of 38 adenomas showed a benign pattern (type 1). If the SI for the adenomas in the chemical shift MRI was considered to be greater than 0, the positive predictive value was 0.9, and the negative predictive value was 0.94 and kappa = 0.79. If type 1 was considered to indicate adenomas in the dynamic MRI, the corresponding values were 0.94, 0.81 and kappa = 0.77 respectively. The results obtained when the 2 methods were combined were 1, 0.95 and kappa = 0.96 respectively. The chemical shift MRI was found to be useful for identifying adenomas in most cases. If the adrenal mass had a low SI (0 < SI < 5), dynamic MRI was also found to be helpful for making a differential diagnosis.     

Simple adnexal cysts in postmenopausal women: conservative management

Objective: To evaluate the expectant management of asymptomatic small, anechoic, simple ovarian cysts diagnosed by echography in postmenopausal women. To gain insight in the natural history of these cysts. Method: Thirty six postmenopausal women with asymptomatic ovarian cysts (from 1.5 to 5.0 cm) diagnosed by ultrasonography and with a CA 125 serum level within the normal range and a non-suspicious color Doppler were followed conservatively. Visits were scheduled at 8–10 weeks of the diagnosis, at 6-month intervals twice and annually thereafter. Results: The follow-up period extended from 4 to 70 months with an average of 31.5 months. There were no cases of cyst enlargement. The cysts remained unchanged in 29 cases (80.5%), decreased in size in four cases (11.1%) and disappeared in three cases (8.3%). Conclusion: We think that the possibility of malignant transformation of one of these cysts is remote and the benefits of conservative management greatly outweighs its risks.     

Cytotechnologist-attended on-site adequacy evaluation of thyroid fine-needle aspiration: comparison with cytopathologists and correlation with the final interpretation

Recent increases in the number of thyroid fine-needle aspiration (FNAs) biopsies and the popularity of on-site evaluation for adequacy (OSEA) have led many practices, including ours, to rely on cytotechnologists for performing OSEA. We retrospectively analyzed the accuracy of a cytotechnologist against that of a cytopathologist in performing OSEA and making the final diagnosis. Of 2,261 thyroid FNA specimens evaluated over a 33-month period under ultrasound guidance with OSEA, the cytotechnologist attended 64.7% (1,462/2,261) of the procedures whereas the cytopathologist attended 35.3% (799/2,261). There was no difference in the adequacy downgrade rate for cytotechnologists compared with that for cytopathologists during this study period (4.1% vs 5.0% downgrade rate, P = .33). Regardless of who rendered the OSEA, subadequate specimens had a higher rate of indeterminate diagnosis (25.2%) than those specimens deemed adequate at the time of OSEA (11.9%, P = .00001). These results indicate that the accuracy of cytotechnologists is comparable with that of cytopathologists in conducting OSEA of the thyroid.     

Diagnostic spectrum of ovarian masses in women with breast cancer; magnetic resonance imaging: histopathology correlation

This study addresses the clinical problem of the patient with breast cancer that has been operated on for an ovarian mass. It specifies the spectrum of histopathologic diagnoses and the differentiating magnetic resonance imaging (MRI) features of ovarian masses with correlations between clinical features, histopathologic, and MRI findings. Sensitivity and specificity of MRI vs histopathology in diagnosing malignancy are estimated. The study included 53 women with breast cancer who underwent surgery for an ovarian mass. Complete medical records, US and MRI images for the ovarian mass, and histopathology slides of both breast and ovarian resection specimens were reviewed and analyzed retrospectively. Thirty-six (67.9 %) patients had benign masses, and 17 (32.1%) had malignant masses, of which 8 (15.1%) were primary ovarian malignancies and 9 (17%) were metastatic from breast carcinomas. There was a significant association between benign and primary malignant ovarian masses and stage II breast cancer (P = .00). There was a significant association between metastatic ovarian masses and stage III to IV breast disease (P = .00) and negative estrogen receptor status (P = .05). Magnetic resonance imaging had a specificity of 91.7% and a sensitivity of 94.1% in diagnosing malignant ovarian masses. In conclusion, the spectrum of ovarian masses diagnosed in patients with breast cancer is broad, including benign lesions, primary ovarian malignancies, and breast metastases. Knowledge of the imaging features may allow a specific diagnosis aiding in surgical planning. Despite the high specificity and sensitivity of MRI to differentiate benign from malignant lesions, the unique ability to differentiate between primary and metastatic malignancies is conserved to histopathology.     

Transvaginal sonographic characterization combined with cytologic evaluation in the diagnosis of ovarian and adnexal cysts

A transvaginal sonographic (TVS) scoring system using morphologic features has been developed at our institution to maximize discrimination between benign and malignant ovarian and adnexal cysts. Low (4–7) or intermediate (8–9) scores have been found to correlate with benignity, hence TVS-guided or laparo-scopically directed needle aspiration of low-scoring lesions may safely be performed. High-scoring lesions (10–14) are often malignant, therefore in situ needle aspiration of such lesions is not recommended. The aim of our study was to correlate the results of TVS characterization of ovarian and adnexal cysts with the aspiration cytologic evaluation. Twenty-three of the 43 cysts studied were aspirated in situ from the patient; 20 were aspirated from resected surgical specimens. Thirty-six benign cysts had TVS scores ranging from 4 to 12, with a median score of 7. All 25 cysts that were benign by TVS and/or histology were also cytologically benign as well as an additional 11 cysts that were not resected (TVS scores: 4 to 9). Seven cytologically and histologically malignant cysts had high TVS scores (TVS scores 10–14; median = 12). The combination of TVS and needle aspiration cytology is valuable, particularly in the diagnosis of cysts having low or intermediate TVS scores and benign cytology. Aspiration of cysts or masses with high TVS scores is not recommended. This combined evaluation may allow a more limited surgical approach, such as operative laparoscopy, or, in some cases, obviate the need for operative treatment altogether. © 1994 Wiley-Liss, Inc.     

Serial anatomy of the auditory tube: correlation to CT and MR imaging

Summary Serial anatomy of the auditory tube (AT), was studied in nine anatomical specimens, according to transverse, coronal and specific oblique planes and was correlated to computed tomography and magnetic resonance imaging. In order to assess the orientation of the oblique plane, parallel to the AT, 30 AT specimens were catheterized: the mean angle between the AT and the Virchow plane or the bony palate was 34°. The bony portion is better explored with CT, whereas the cartilaginous portion is better studied with MR. The cartilage, posterior and medial, is closed anteriorly and inferiorly by a fibrous membrane (lamina membranacea), which is not seen on CT or MR images. The AT is closely related to the tensor veli palatini muscle (TVPM) anterolaterally, and the levator veli palatini muscle inferiorly (LVPM); both are well imaged on the oblique plane. They are bounded by fascias: the submucosal fascia (tela submucosa) is medial, the pharyngobasilar fascia runs between the TVPM and the LVPM and the auditory tube; the fascia of Weber-Liel is lateral to the TVPM. Fascias are difficult to distinguish from the surrounding fatty tissue and the adjacent muscles. The auditory tube and its muscles, forming the lateral wall of the nasopharynx, are well studied by CT and MR imaging, using the transverse or, preferably oblique plane, together with coronal plane.

---

Anatomie sérielle de la trompe auditive : correlation à l'imagerie tomodensitométrique et par résonance magnétique

Résumé L'anatomie sérielle de la trompe auditive (TA), étudiée chez neuf sujets anatomiques selon les plans de coupe transversal, coronal et selon un plan de coupe oblique spécifique, a été corrélée à l'imagerie tomodensitométrique et par résonance magnétique. Afin de déterminer l'orientation du plan oblique, parallèle à la TA, la TA de 30 sujets anatomiques a été cathétérisée : l'angle moyen de la TA avec le plan de Virchow ou le plan du palais osseux est de 34°. La partie osseuse de la TA est mieux étudiée par le scanner, tandis que la partie cartilagineuse est mieux étudiée par l'IRM. Le cartilage, postéro-médial, est fermé en avant et en bas par une membrane fibreuse (lame membranacée), qui n'est pas visible en scanner et en IRM. La TA est en rapport étroit avec le muscle tenseur du voile du palais (MTVP) en avant et latéralement, et avec le muscle élévateur du voile du palais (MEVP) en bas ; ces deux muscles sont bien étudiés par le plan oblique. La TA et ses muscles sont accompagnés par des fascias : le fascia sous-muqueux (tela submucosa) est médial ; le fascia pharyngobasilaire chemine entre le MTVP d'une part et le MEVP et la TA d'autre part ; le fascia de Weber-Liel reste en dehors du MTVP. Les fascias sont difficiles à distinguer du tissu graisseux, qui les entoure, et des muscles adjacents. La TA et ses muscles, qui forment la paroi latérale du nasopharynx, sont bien étudiés par le scanner et l'IRM, en utilisant le plan transversal, ou plutôt le plan oblique, associé au plan coronal.

     

急性心肌梗塞的MR灌注成像及延迟扫描：实验研究并与病理对照

目的 探讨首过MR（磁共振）灌注成像和延迟扫描对预测存在梗塞风险的心肌和评价梗塞面积的价值。方法在导管法冠状动脉造影的指导下将凝胶海绵注射入11只比格犬的左前降支（left anterior descending,LAD）的中部阻塞血管,首过法MR灌注成像在LAD阻塞后30min内进行,3d后行MR增强延迟扫描。对心肌切片采用2,3,5,氯化三苯基四氮唑（triphenyltetrazolium chloride,yrc）染色,比较MR延迟扫描和TTC染色切片上心肌梗塞的面积。结果3只犬制作心肌梗塞模型过程中死亡,8只犬存活并完成实验。MR灌注成像30min内即显示阻塞血管供血区低灌注。延迟扫描和TTC染色切片上测量心肌梗塞大小分别为0．281±0．056和0．307±0．070,两者间有相关性（r=0．86,P=0．008）。结论MR灌注成像和延迟扫描可以预测存在梗塞风险的心肌和评价梗塞面积,进而指导临床干预和判断预后。     

Ultrasonography compared with magnetic resonance imaging for the diagnosis of adenomyosis: correlation with histopathology.

BACKGROUND: The objective of this study was to compare the accuracy of transabdominal (TAUS) and transvaginal sonography (TVUS) and magnetic resonance imaging (MRI) for the diagnosis of adenomyosis, and to correlate imaging with histological findings. METHODS: In a prospective study, 120 consecutive patients referred for hysterectomy underwent TAUS, TVUS and MRI. Results of these examinations were interpreted blindly to histopathological findings. RESULTS: Histological prevalence of adenomyosis and leiomyomas was 33.0 and 47.5% respectively. Adenomyotic uteri were accompanied by additional pelvic disorders in 82.5% of cases. Sensitivity, specificity, and positive and negative predictive values of TAUS and TVUS were 32.5 and 65.0%, 95.0 and 97.5%, 76.4 and 92.8%, and 73.8 and 88.8% respectively. Myometrial cyst was the most sensitive and specific TVUS criterion. In MRI, the presence of a high-signal-intensity myometrial spot was as specific but less sensitive than a maximal junctional zone thickness (JZ(max)) >12 mm and a JZ(max) to myometrial thickness ratio >40%. Sensitivity, specificity, and positive and negative predictive values of MRI were 77.5, 92.5, 83.8 and 89.2% respectively. No difference in accuracy was found between TVUS and MRI, but sensitivity was lower with sonography in women with associated myomas. CONCLUSIONS: TVUS is as efficient as MRI for the diagnosis of adenomyosis in women without myoma, while MRI could be recommended for women with associated leiomyoma.     

Detection and management of pathological, non-palpable, cystic adnexal masses

Ten patients with normal bimanual pelvic examinations were found to have small, non-palpable adnexal cysts by transvaginal ultrasound examination. After failing to respond to a course of observation and suppressive therapy with combination oral contraceptives, surgical evaluation was performed. In each case, histological examination returned a pathological diagnosis (endometrioma, serous cystadenoma, mature cystic teratoma, inflammatory cyst). This series suggests that transvaginal ultrasonography may be used to detect adnexal pathology before it is clinically apparent. A scheme for management of this clinical entity is proposed.     

Evaluation of adnexal masses by ultrasound and fine needle aspiration cytology

Forty Eight cases of adnexal masses were subjected to ultrasound and FNAC. In this study, FNAC could differentiate benign and malignant adnexal masses in 98% of cases where as ultrasound was successful in 85% of cases. FNAC is a safe simple, rapid & reliable investigation. The complex adnexal masses present a diagnostic challenge with particular reference to the findings predictive of malignancy.     

MR imaging of renal cell carcinoma: associations among signal intensity, tumor enhancement, and pathologic findings

The purpose of this study was to compare the MR characteristics of renal cell carcinomas against histologic findings and to assess the correlations among signal intensity, tumor enhancement, and pathologic findings. Fifty-four patients (56 lesions) were examined by MR imaging and then underwent partial or radical nephrectomy. The pathologic diagnosis of all lesions was renal cell carcinoma. All MR examinations were performed as dynamic studies using the same 1.5-T scanner. MR characteristics were compared against pathologic findings after resection, and the correlations among signal intensity, tumor enhancement, and pathologic findings were then assessed. A significant correlation was observed between tumor grade and tumor enhancement, with G3 lesions tending to show little enhancement. Regardless of the histologic classification, G3 tumors were found to contain highly heterotypic cancer cells and very few vessels by histopathologic examination. No significant correlations were noted between the other MR characteristics and pathologic findings. Renal cell carcinomas showing little enhancement tend to be highly malignant lesions based on the pathologic findings. Special consideration is required for these tumors with regard to the selection of surgical intervention and follow-up observation.     

MR imaging and electrophysiological evaluation in carpal tunnel syndrome

The objective of this study was to compare the MRI findings of wrists in patients diagnosed with CTS with those of the healthy controls, and to evaluate the correlation between the MRI differences and the electrophysiological findings in the patient group. This study involved 55 wrists, 30 of which were clinically and electrophysiologically diagnosed with CTS and 25 healthy controls. These 55 wrists were evaluated electrophysiologically, and in terms of median nerve diameter, ratio of median nerve diameter at psiform bone level to distal radio-ulnar joint level, the flexor retinaculum bulging ratio and the median nerve intensity by MRI. When the patient group, which were clinically and electrophysiologically diagnosed with CTS, and the healthy control group were compared, a significant difference (p < 0.001) was observed between the two in terms of median nerve diameters (at psiform bone level: 8.47 +/- 1.41mm and 2.91 +/- 1.01 mm, distal radio-ulnar joint level: 4.04 +/- 1.06 mm and 2.42 +/- 0.95 mm), ratio of median nerve diameter at psiform bone level to distal radio-ulnar joint level (2.17 +/- 0.54 and 1.25 +/- 0.12), their flexor retinaculum bulging ratios (26.21 +/- 5.98% and 7.27 +/- 4.53%) and their median nerve intensities. In the patient group, no significant correlation between MRI and the electrophysiological findings was found (p > 0.05). According to the data obtained from the study, we believe that the MRI examination of structural changes that occur in the carpal tunnel, neighboring structures and the median nerve would be useful in the diagnosis of CTS, especially in cases with suspected clinical and electrophysiological diagnosis.     

Transvaginal color Doppler and CA125 as tools in the differential diagnosis of postmenopausal ovarian masses

Objective: To evaluate whether transvaginal color Doppler and CA125 are valid in differentiating malignant from benign postmenopausal ovarian masses. Methods: Sixty-two women with ovarian masses were studied with transvaginal color Doppler ultrasound before surgery. Serum CA125 levels were also measured. Resistance index (RI) and pulsatility index (PI) were calculated from the waveforms generated from blood flow within the ovary. Results: Benign tumors had a significantly higher pulsatility index (mean 1.23 ± 1.02; range 0.65–2.99) and resistive index (mean 0.78 ± 0.22; range 0.5–1.1) than did malignant tumors. However some overlap in individual values for benign and malignant lesions was found. RI and PI sensitivity were significantly higher than those with CA125 (P < 0.05). Blood flow was detectable by color Doppler imaging in 95% of cases with malignant masses. Conclusion: Doppler sonographic evaluation of resistance and pulsatility indexes in the vessels of ovarian masses together with CA125 increased the sensitivity of prediction of malignancy for pelvic masses, but further work is needed before the validity of these factors is proved.     

Focal lesions in cirrhotic liver: comparing MR imaging during arterial portography with Gd-enhanced dynamic MR imaging

The purpose of this study was to document the additional value of MR imaging during arterial portography (MRAP) in patients examined with intravenous contrast-enhanced dynamic MR imaging for the assessment of focal lesions in patients with cirrhosis or chronic viral hepatitis. The MR images of 24 patients with 39 hepatocellular carcinomas and 18 benign hepatocellular nodules examined with dynamic MR imaging and MRAP within a 14-day interval were retrospectively reviewed. For 39 hepatocellular carcinomas, MRAP revealed 37 perfusion defects (95%), while dynamic MR imaging demonstrated 35 occurrences of nodular contrast-enhancement (90%) on arterial dominant phases. Among the 11 benign nodules misinterpreted as hepatocellular carcinoma due to their high signal intensities on arterial-dominant phases of dynamic MR imaging, eight (73%) showed intratumoral portal venous perfusion on MRAP and were regarded as benign nodules. As a result of its high sensitivity and its potential ability to enable differentiation of benign and malignant hepatocellular nodules, MRAP can be added to dynamic MR imaging for planning future management in patients with equivocal hepatocellular nodules in the cirrhotic liver.     

磁共振弥散张量成像在临床诊疗中的应用

磁共振弥散张量成像(diffusion tensor imaging,DTI)作为一种功能磁共振成像(magnetic resonance imaging,MRI),在临床诊疗中发挥了重要作用.本文先介绍了DTI临床应用的各个领域,重点阐述了其在脑部疾病的应用,后指出临床应用中存在的问题,并对其前景进行了展望.