Bret F. Coughlin

Complex Cystic Breast Masses: Diagnostic Approach and Imaging-Pathologic Correlation

Complex cystic breast masses demonstrate both anechoic (cystic) and echogenic (solid) components at ultrasonography (US). US is used to identify and characterize such masses and to guide percutaneous biopsy. Numerous pathologic entities may produce complex cystic breast lesions or may be associated with them, and biopsy is usually indicated. Common benign findings include fibrocystic changes, intraductal or intracystic papilloma without atypia, and fibroadenoma. Common atypical findings include atypical ductal hyperplasia, atypical papilloma, atypical lobular hyperplasia, and lobular carcinoma in situ. Malignant findings include ductal carcinoma in situ, infiltrating ductal carcinoma, and infiltrating lobular carcinoma. If the biopsy approach is tailored to the individual patient and if the imaging features are closely correlated with findings at pathologic analysis, US-guided percutaneous biopsy may be used effectively to diagnose and to guide management of complex cystic masses.

Routine Chest Roentgenography Is Unnecessary in the Work-Up of Stage I and II Breast Cancer

PURPOSE Clinical practice guidelines of many professional societies call for routine staging chest x-rays (SCXR) for all patients with invasive cancer. Given the estimated 157,000 patients annually for whom this recommendation pertains, this screening examination represents a considerable health care expenditure. If it were shown that SCXR rarely changed the management of low-risk subsets of this population, it might be possible to selectively omit this practice from the care of these patients with substantial resultant cost savings. PATIENTS AND METHODS All patients with clinical stage I and II breast cancer presenting to the Baystate Medical Center from 1989 through 1997 were identified through the Tumor Registry. Their hospital records were reviewed for clinical presentation and documentation of SCXR. RESULTS One thousand four hundred ninety-four patients were identified with clinical stage I and II disease. SCXR were available for review on 1,003 patients. Only one asymptomatic patient was upstaged to stage IV based on a SCXR. Two patients with primary lung tumors were also identified. These data demonstrate an asymptomatic pulmonary metastasis detection rate of 0. 099% (95% confidence interval, 0.0% to 0.6%). The total charges of SCXR for this group approached

Reduced Z-axis coverage multidetector CT angiography for suspected acute pulmonary embolism could decrease dose and maintain diagnostic accuracy

180,000. CONCLUSION These data demonstrate the low diagnostic yield and high cost of routine SCXR in the management of asymptomatic patients with clinical stage I and stage II breast cancer. Because other studies have shown that SCXR changes neither quality of life nor overall survival, SCXR should be limited to symptomatic patients in whom metastatic disease is suspected.

MRI diagnosis of spontaneous uterine rupture of an unscarred uterus

Multidetector computed tomographic angiography (MDCTA) is the method of choice for evaluation of suspected acute pulmonary embolism (PE) in most patients because it is accurate and widely available. The use of computed tomography, including MDCTA for PE, has risen dramatically over the last several years with an attendant rise in radiation exposure. Many methods currently employed to reduce radiation dose may affect image quality and potentially affect diagnostic accuracy. Reducing Z-axis coverage would decrease radiation dose without any effect on image quality. This study was performed to assess the effect on the accuracy of MDCTA for suspected acute PE if the Z-axis coverage was reduced to the anatomic range from the top of the aortic arch through the heart. Two hundred ninety-five examinations were performed on a 64-detector-row MDCT and interpreted as positive for PE from July 2005 to February 2008. When the anatomic range of these data sets were retrospectively reduced and reinterpreted for PE, no case was interpreted as negative for PE. The Z-axis coverage was reduced by 37%. In the interest of keeping radiation doses as low as reasonably achievable, further research in this area is warranted.

Touch-preparation cytologic examination of breast core biopsy specimens: Accuracy in predicting benign or malignant core histologic results

Spontaneous uterine rupture is a rare, potentially catastrophic complication of pregnancy, and its prompt diagnosis and treatment are essential in limiting morbidity and mortality. Clinical diagnosis is difficult and relies heavily on diagnostic imaging. Radiological diagnosis is also often difficult with most documented cases involving the use of ultrasound and computed tomography. Although magnetic resonance imaging (MRI) is being used more frequently to assess patients, there are few reports illustrating the utility of MRI and its advantages over other imaging modalities in the diagnosis of uterine rupture. This report documents a case of spontaneous uterine rupture diagnosed by MRI in a postpartum patient with an unscarred uterus.

Testicular Cooling Associated With Testicular Torsion and its Detection by Infrared Thermography: An Experimental Study in Sheep

RATIONALE AND OBJECTIVES The purpose of this study was to determine the accuracy of touch-preparation cytologic examination of breast core biopsy specimens in predicting benign or malignant core histologic results. MATERIALS AND METHODS One hundred two core biopsies were performed on 88 women with stereotactic or ultrasonographic (US) guidance. Slides were prepared by smearing one core sample on each slide, spraying the slides with fixative, and staining them with the Papanicolaou technique. Slides were blindly reviewed by a cytopathologist. Cytologic results were categorized as positive for malignancy, not diagnostic for malignancy, or insufficient for diagnosis. Results were correlated with histologic results from all specimens obtained during the core biopsy. RESULTS Imaging depicted the lesions sampled for biopsy as masses (n = 70), clustered calcifications (n = 29), focal asymmetries (n = 2), or architectural distortion (n = 1). Touch-preparation slides of 87 (85%) lesions contained sufficient material for diagnosis. Cytologic results correctly identified 12 of 16 (three of five intraductal and nine of 11 invasive) malignancies in 10 of 13 masses and two of three clusters of calcifications. Two false-positive results occurred, both with fibroadenomas. Overall, touch-preparation studies produced 69 true-negative and four false-negative results. Excluding slides with insufficient material, the sensitivity, specificity, and accuracy of touch-preparation results were 75%, 97%, and 93%, respectively. Including insufficient samples, accuracy was 79%. CONCLUSION Although touch-preparation cytologic examination of breast core biopsy specimens is fairly accurate in prediction of benign or malignant core histologic results, its correlation with histologic results is not sufficient to justify routine use in immediate counseling and treatment planning.

Intrapancreatic ciliated enteric duplication cyst presenting with biliary obstruction

PURPOSE We determined whether experimental testicular torsion results in gonadal cooling and whether testicular temperature changes can be detected by infrared thermography. MATERIALS AND METHODS A nonblinded, randomized, controlled trial was done in 6 anesthetized sheep. Thermocouple probes recorded testicular temperature every 15 minutes for 6 hours after experimental side 720-degree medial testicular torsion with orchiopexy or control side sham procedure with orchiopexy and for 75 minutes after procedure reduction. Color Duplex ultrasound was done to control the experimental assignment. Mean hemiscrotal infrared thermography temperatures were calculated and nonparametric repeated measures analysis was performed to determine whether there were significant changes in temperature as a function of the experimental condition and time. RESULTS Testicular torsion resulted in significant testicular cooling by probe and infrared thermography (p <0.05 and <0.0001, respectively), which was promptly reversed upon the reduction of experimental torsion. Two hours after experimental torsion the median temperature difference (control side minus torsion side) was 2.5C for the probe and 1.7C for infrared thermography. CONCLUSIONS Experimental testicular torsion resulted in significant gonadal cooling that was detectable by infrared thermography of the hemiscrotum. The applicability of these findings to the clinical setting remains to be determined.

Incorporation of a Formalized Emergency Radiology Curriculum to Facilitate Population of a MIRC-based Digital Teaching File

A 46-yr-old man presenting with biliary obstruction from an intrapancreatic tumor underwent pancreaticoduodenectomy. The pathology report showed the tumor to be an enteric duplication cyst. Diagnostic imaging features and operative management are discussed.

Diagnosing appendicitis with CT and ultrasound using prospective patient stratification by body mass index

Teaching files are integral to radiological training. Digital Imaging and Communication in Medicine compatible digital radiological data and technological advances have made digital teaching files a desirable way to preserve and share representative and/or unusual cases for training purposes. The Medical Imaging Resource Community (MIRC) system developed by the Radiological Society of North America (RSNA) is a robust multi-platform digital teaching file implementation that is freely available. An emergency radiology training curriculum developed by the American Society of Emergency Radiology (ASER) was incorporated to determine if such an approach might facilitate the entry, maintenance, and cataloguing of interesting cases. The RSNA MIRC software was obtained from the main MIRC website and installed. A coding system was developed based on the outline form of the ASER curriculum. Weekly reports were generated tallying the number of cases in each category of the curriculum. Resident participation in the entry and maintenance of cases markedly increased after incorporation of the ASER curriculum. The coding schema facilitated progress assessment. Ultimately, 454 total cases were entered into the MIRC database, representing at least 42% of the subcategories within the ASER curriculum (161 out of 376). The incorporation of the ASER emergency radiology curriculum greatly facilitated the location, cataloguing, tracking, and maintenance of representative cases and served as an effective means by which to unify the efforts of the department to develop a comprehensive teaching resource within this subspecialty. This approach and format will be extended to other educational curricula in other radiological subspecialties.

Single Dilated Lactiferous Duct Due to Papilloma Ultrasonographically Guided Percutaneous Biopsy With a Vacuum-Assisted Device

Purpose: To determine the accuracy of CT and ultrasonography (US) in diagnosing appendicitis in adults stratified to either modality on the basis of body mass index (BMI), a measure of body habitus. Methods: Seventy-two adults with suspected appendicitis and demonstrating atypical clinical features were prospectively stratified to either appendiceal CT or US based on BMI. Patients with BMI < 30 underwent US and with BMI ≥ 30 underwent CT. Outcomes were determined by surgery, the medical record, and clinical follow-up after 3 months. Results: Of the 72 patients enrolled, 30 (24 women and 6 men) underwent CT and 42 (35 women and 7 men) underwent US. The average BMI was 34 ± 4 among patients who had CT and 24 ± 3 among patients who had US. Of the patients who had CT scans, 4 had positive scans for appendicitis and all of these were proven at surgery to have appendicitis. The remaining 26 patients had negative CT scans for appendicitis. Twenty-two of these were subsequently proven either by surgery or clinical follow-up not to have appendicitis, while 4 were lost to follow-up. This corresponds to a sensitivity, specificity, positive predictive value, and negative predictive value of 100 %. Twelve ultrasound examinations were positive for appendicitis. Nine of these patients had appendicitis proven at surgery, 1 had a perforated Meckels diverticulum, and 2 did not have appendicitis after clinical follow-up. Twenty-seven patients had negative ultrasound exams for appendicitis. However, 6 of these had appendicitis proven at surgery, 17 did not have appendicitis, and 4 were lost to follow-up. Three patients had ultrasound exams that were equivocal for appendicitis; of these, 1 had appendicitis and 2 did not. For US, this corresponds to a sensitivity of 60 %, specificity of 85 %, PPV of 75 %, and NPV of 74 %. Conclusion: This study suggests that CT is an accurate method of evaluating adults with suspected appendicitis who have BMI ≥ 30. Stratifying patients with BMI < 30 to US did not reproduce the results already reported in the literature.