Beverly G. Coleman

Management of asymptomatic ovarian and other adnexal cysts imaged at US: Society of Radiologists in Ultrasound Consensus Conference Statement.

The Society of Radiologists in Ultrasound convened a panel of specialists from gynecology, radiology, and pathology to arrive at a consensus regarding the management of ovarian and other adnexal cysts imaged sonographically in asymptomatic women. The panel met in Chicago, Ill, on October 27-28, 2009, and drafted this consensus statement. The recommendations in this statement are based on analysis of current literature and common practice strategies, and are thought to represent a reasonable approach to asymptomatic ovarian and other adnexal cysts imaged at ultrasonography.

Strategy for Repeat Biopsy of Patients with Prostatic Intraepithelial Neoplasia Detected by Prostate Needle Biopsy

PURPOSE We evaluated the strategy for repeat biopsy of patients with prostatic intraepithelial neoplasia without concurrent carcinoma detected on prostate needle biopsy. MATERIALS AND METHODS Of 1,275 consecutive patients undergoing prostate needle biopsy 61 were identified with prostatic intraepithelial neoplasia but without concurrent prostate carcinoma. Of the 61 patients 53 had undergone repeat biopsy. The medical records, transrectal ultrasound, and operative and pathological reports of these patients were reviewed. RESULTS Repeat biopsy was done in 53 patients with prostatic intraepithelial neoplasia, yielding carcinoma in 15, prostatic intraepithelial neoplasia without carcinoma in 8 and benign tissue in 30. The yield of carcinoma from repeat biopsy of a prostatic intraepithelial neoplasia site was 8.3% (7 of 84 sites). A total of 18 sites of carcinoma was detected by repeat biopsy of a previous random biopsy site (8), a prostatic intraepithelial neoplasia site only (5), a transrectal ultrasound nodule (3), a palpable nodule and prostatic intraepithelial neoplasia site (1), and a transrectal ultrasound nodule and prostatic intraepithelial neoplasia site (1). Carcinoma was as frequently detected by repeat biopsy of a prostatic intraepithelial neoplasia site (6 patients) as by random repeat biopsy (6 patients). CONCLUSIONS Repeat prostate needle biopsy of patients with prostatic intraepithelial neoplasia should include random repeat biopsy and repeat biopsy of transrectal ultrasound abnormalities as well as previous sites of prostatic intraepithelial neoplasia.

Multidisciplinary consensus on the classification of prenatal and postnatal urinary tract dilation (UTD classification system)

OBJECTIVE Urinary tract (UT) dilation is sonographically identified in 1-2% of fetuses and reflects a spectrum of possible uropathies. There is significant variability in the clinical management of individuals with prenatal UT dilation that stems from a paucity of evidence-based information correlating the severity of prenatal UT dilation to postnatal urological pathologies. The lack of correlation between prenatal and postnatal US findings and final urologic diagnosis has been problematic, in large measure because of a lack of consensus and uniformity in defining and classifying UT dilation. Consequently, there is a need for a unified classification system with an accepted standard terminology for the diagnosis and management of prenatal and postnatal UT dilation. METHODS A consensus meeting was convened on March 14-15, 2014, in Linthicum, Maryland, USA to propose: 1) a unified description of UT dilation that could be applied both prenatally and postnatally; and 2) a standardized scheme for the perinatal evaluation of these patients based on sonographic criteria (i.e. the classification system). The participating societies included American College of Radiology, the American Institute of Ultrasound in Medicine, the American Society of Pediatric Nephrology, the Society for Fetal Urology, the Society for Maternal-Fetal Medicine, the Society for Pediatric Urology, the Society for Pediatric Radiology and the Society of Radiologists in Ultrasounds. RESULTS The recommendations proposed in this consensus statement are based on a detailed analysis of the current literature and expert opinion representing common clinical practice. The proposed UTD Classification System (and hence the severity of the UT dilation) is based on six categories in US findings: 1) anterior-posterior renal pelvic diameter (APRPD); 2) calyceal dilation; 3) renal parenchymal thickness; 4) renal parenchymal appearance; 5) bladder abnormalities; and 6) ureteral abnormalities. The classification system is stratified based on gestational age and whether the UT dilation is detected prenatally or postnatally. The panel also proposed a follow-up scheme based on the UTD classification. CONCLUSION The proposed grading classification system will require extensive evaluation to assess its utility in predicting clinical outcomes. Currently, the grading system is correlated with the risk of postnatal uropathies. Future research will help to further refine the classification system to one that correlates with other clinical outcomes such as the need for surgical intervention or renal function.

Congenital high airway obstruction syndrome: MR/US findings, effect on management, and outcome

BackgroundCongenital high airway obstruction syndrome (CHAOS) is a rare disorder defined as any fetal abnormality that obstructs the larynx or trachea. Prompt airway intervention at delivery after accurate prenatal diagnosis may allow survival of this otherwise fatal condition.ObjectiveTo identify prenatal MRI findings in CHAOS, to compare these findings with those of fetal US, to determine if imaging alters diagnosis and management decisions, and to correlate prenatal with postnatal imaging findings.Materials and methodsRecords and MRI scans of ten fetuses with CHAOS were reviewed, and the findings correlated with outside and same-day fetal US and postnatal imaging findings. Fetal lung volumes were measured on MRI scans.ResultsLarge lung volumes were found in 90% of the fetuses. Increased lung signal intensity, inverted diaphragm, and a dilated, fluid-filled lower airway were identified in all. The obstruction level was identified in 90%. MRI changed screening US diagnosis in 70%, but was concordant with the tertiary care US imaging in 90%. Seven fetuses were terminated or died in utero, and three fetuses survived after ex utero intrapartum tracheostomy placement. Autopsy or bronchoscopy performed in 60% confirmed CHAOS. Postnatal chest radiographs and CT showed hyperinflation, while US and fluoroscopy showed diminished diaphragmatic motion.ConclusionMRI demonstrates large lung volumes, increased lung signal intensity, inverted diaphragm, and dilated fluid-filled lower airway, and usually identifies the obstruction level. The degree of correlation between MRI and tertiary prenatal US is high, but CHAOS is frequently misdiagnosed on screening US. Correct diagnosis may enable planned airway management. Voluminous lungs and diaphragmatic abnormalities persist on postnatal imaging.

Nonuniform attenuation in computed tomography study of the cirrhotic liver.

Diffuse hepatocellular processes are not well imaged by most radiologic modalities. At present, CT has not added significantly to the evaluation of hepatocellular disease, particularly in the cirrhotic liver. The CT patterns of cirrhosis previously described are reviewed, and the pathophysiology of cirrhosis is discussed. In 3 cases, a pattern was seen in cirrhotic livers characterized by nonuniform attenuation with varied response to administration of intravenous contrast agents. With further evaluation of fatty infiltration and cirrhosis, CT may prove helpful in understanding these disease processes.

Role of Computed Tomography in the Presurgical Evaluation of Carcinoma of the Cervix

Thirty-six consecutive patients either with primary or recurrent carcinoma of the cervix were evaluated by computed tomography (CT) to assess CTs ability to screen patients prior to radical surgery. Overall accuracy when compared to surgical findings or skinny needle biopsies was 80%. Inaccuracies by CT were the result of inability to assess minimally enlarged lymph nodes, inability to distinguish fibrosis from recurrent tumors, and difficulty in delineating actual tumor invasion versus contiguity of adjacent pelvic organs. Computed tomography proved to be a sensitive indicator in delineating actual tumor bulk and sidewall extension. Information gained by CT compared favorably with that obtained by intravenous urography, barium enemas, lymphangiography, and nuclear medicine bone scans. This comparison indicates that CT can serve as a sensitive imaging modality to assess the surgical candidacy of patients either with initial or recurrent carcinoma of the cervix. An algorithm of studies is proposed based on this preliminary investigation.

Management of asymptomatic ovarian and other adnexal cysts imaged at US Society of Radiologists in Ultrasound consensus conference statement.

The Society of Radiologists in Ultrasound (SRU) convened a panel of specialists from gynecology, radiology, and pathology to arrive at a consensus regarding the management of ovarian and other adnexal cysts imaged sonographically in asymptomatic women. The panel met in Chicago, IL, on October 27-28, 2009, and drafted this consensus statement. The recommendations in this statement are based on analysis of current literature and common practice strategies, and are thought to represent a reasonable approach to asymptomatic ovarian and other adnexal cysts imaged at ultrasonography.

Fetal Therapy State of the Art

Objective. To review our experience with the use of sonography in evaluating potential candidates for in utero fetal therapy performed at The Center for Fetal Diagnosis and Treatment at The Childrens Hospital of Philadelphia. Methods. This review article was designed to discuss open hysterotomy for the 4 fetal surgical procedures that have been performed at our institution. The procedures included surgical repair of myelomeningocele, resection of sacrococcygeal teratoma in fetuses with nonimmune hydrops, resection of an enlarging congenital cystic adenomatoid malformation that is not amenable to thoracoamniotic shunting, and tracheal clip occlusion for severe left congenital diaphragmatic hernia. Results. For each surgical procedure, the use of sonography in the prenatal diagnosis of the congenital anomaly was detailed, as were indications for surgery and surgical procedures, postoperative monitoring and finally delivery, postnatal treatment, and long‐term follow‐up. Three of the procedures have been reasonably successful with rather dramatic results in some cases such that these techniques are still being performed. The 1 exception was open hysterotomy for the tracheal clip procedure for congenital diaphragmatic hernia, which has been abandoned. Conclusions. Fetal therapy is a rapidly evolving specialty, which is being practiced at several centers in this country. Sonography is an integral part of this specialty practice and has been used extensively in the diagnosis of some congenital anomalies that have debilitating or lethal consequences for the fetus. Technologic improvements in both sonography and magnetic resonance imaging have assisted tremendously in the many advances herein reported in the diagnosis and treatment of the above‐described 4 congenital anomalies.

Imaging of the Female Pelvis through the Life Cycle

The appearance of the normal reproductive tract on radiologic images changes dramatically over the female patients life span, reflecting the influence of hormones on these organs. In female children and adolescents, the appearance of the reproductive tract reflects the stage of sexual maturation. In women of reproductive age, physiologic changes such as those occurring in the corpus luteum are routinely imaged and must be distinguished from pathologic conditions. In the postmenopausal years, as reproductive hormone levels diminish, the endometrium and ovaries undergo progressive involution. Imaging findings that might be considered physiologic in younger women may represent pathologic or even neoplastic changes in postmenopausal women. Although postpartum imaging is typically performed in symptomatic patients, including those with greater than expected vaginal bleeding, suspected obstetric trauma, thromboembolic disease, or infectious complications, clinicians who interpret these radiologic results should be familiar with expected findings in asymptomatic patients after childbirth. Familiarity with the spectrum of ultrasonographic, computed tomographic, and magnetic resonance imaging appearances of the normal female reproductive tract from birth through the postmenopausal years will ultimately help clinicians avoid misinterpreting these normal physiologic changes as pathologic conditions.

Abnormal Umbilical Cord Doppler Sonograms May Predict Impending Demise in Fetuses with Sacrococcygeal Teratoma

Objective: To identify factors predictive of fetal demise in fetuses with sacrococcygeal teratoma (SCT). Method: The recent management of monochorionic twins discordant for a large SCT and a singleton with a large SCT was reviewed. Results: Serial fetal echocardiography and ultrasonography with Doppler flow measurements documented rapid growth of the SCT in both cases with a relatively modest increase in combined cardiac output. No placentomegaly or hydrops was observed at any time. In both fetuses with SCT, evolution of abnormal umbilical artery waveforms was observed with the ultimate development of reversed end-diastolic umbilical arterial flow that was followed by sudden fetal demise. Conclusion: Death in these 2 fetuses with large SCTs in the absence of placentomegaly/hydrops or hemodynamic changes suggestive of evolving high-output failure suggests a previously unrecognized mechanism of death in fetuses with large rapidly growing SCTs. In these cases, fetal demise may only be heralded by abnormal umbilical artery waveforms that progress to the premorbid observation of reversed diastolic umbilical artery blood flow. Umbilical artery waveform analysis should be closely monitored with other hemodynamic parameters in fetuses with large SCTs. In such fetuses, depending on the gestational age, abnormalities in umbilical artery waveform should be considered indications for early delivery or in utero intervention to prevent fetal demise.