Carol B. Benson

Long-term Assessment of a Multidisciplinary Approach to Thyroid Nodule Diagnostic Evaluation

The diagnostic evaluation of patients with thyroid nodules is imprecise. Despite the benefits of fine‐needle aspiration (FNA), most patients who are referred for surgery because of abnormal cytology prove to have benign disease. Recent technologic and procedural advances suggest that this shortcoming can be mitigated, although few data confirm this benefit in unselected patients.

Usefulness of Ultrasonography in the Management of Nodular Thyroid Disease

Thyroid nodules are a common diagnostic challenge encountered in clinical medicine. Approximately 4% to 7% of adults have palpable thyroid nodules, and up to 70% have thyroid nodules visible on ultrasonography, many of which are less than 1 cm in diameter (1-5). Fine-needle aspiration biopsy is the standard diagnostic test for evaluating a palpable thyroid nodule in euthyroid patients. Previous studies have shown that the diagnostic accuracy of fine-needle aspiration biopsy is improved with ultrasonography guidance compared with palpation alone (6-9). In addition, ultrasonography guidance is required for aspiration of nonpalpable thyroid nodules (10-12). The objective of our study was to determine whether the routine use of ultrasonography in all patients with suspected thyroid nodules changed clinical management compared with palpation alone. Methods Patients The study sample consisted of all patients referred to the Brigham and Womens Hospital dual-discipline (endocrinology and radiology) Thyroid Nodule Clinic (Boston, Massachusetts) for suspected nodular thyroid disease or suspected recurrent thyroid cancer between October 1995 and March 1997. Clinicians were instructed to refer patients with suspected or diagnosed nodular thyroid disease and a normal serum thyrotropin level to the Thyroid Nodule Clinic. If patients had a suppressed thyrotropin level and were not taking thyroid hormone, a radionuclide scan was suggested. The clinic visit included thyroid ultrasonography performed by a radiologist, an evaluation by an endocrinologist, and ultrasonography-guided fine-needle aspiration biopsy of all nodules measuring at least 1 cm in maximum diameter (up to a maximum of four nodules). A cutoff of 1 cm was selected on the basis of recommendations in the literature (13). For patients seen more than once, only the initial visit was analyzed. Measurements Medical records were reviewed for the specialty of the referring clinician, the referring clinicians examination of the thyroid before referral, and the indication for referral. Sonography was performed by using 5- to 10-MHz transducers. Nodules were measured in three dimensions. Fine-needle aspiration was performed with a 25-gauge needle. Ultrasonography guidance was used to confirm placement of the needle in the nodule or to direct sampling into solid portions of partially cystic nodules. Four to six passes were made per nodule. The needles were rinsed and pooled in a single vial containing CytoLyt solution (CytoLyt Corp., Boxborough, Massachusetts). Two ThinPrep slides (Cytyc Corp., Marlborough, Massachusetts) were stained by using a modified Papanicolaou method and were read by a cytopathologist at the Brigham and Womens Hospital as benign, atypical, suspicious for a follicular or Hrthle cell neoplasm, suspicious or positive for papillary cancer, or nondiagnostic. Aspirates were considered nondiagnostic if they contained fewer than six groups of benign follicular cells. The atypical category was applied to cases in which a mild degree of cellular or architectural atypia precluded a benign diagnosis but was insufficient for a suspicious or positive diagnosis. Cytology reports were reviewed for all patients who had fine-needle aspiration biopsy, and histologic reports were reviewed for all patients who had surgery. Two endocrinologists reviewed the charts to compare the referring physicians findings on thyroid physical examination with the ultrasonography findings. If a discrepancy existed between the referring physicians clinical thyroid examination and the number of nodules requiring fine-needle aspiration biopsy based on ultrasonography ( 1 cm), ultrasonography was considered to have altered the clinical management. Role of the Funding Sources The funding sources had no role in the collection, analysis, and interpretation of the data or in the decision to submit the paper for publication. Results Characteristics of the Study Group A total of 223 patients (203 women and 20 men [mean age, 46.3 15.3 years]) were evaluated at the Thyroid Nodule Clinic between October 1995 and March 1997. Sixty-one percent were referred by primary care physicians, 37% were referred by endocrinologists, and 2% were referred by surgeons. The indication for referral was abnormal findings on thyroid physical examination in 173 of 223 patients (78%); 114 were referred for a suspected solitary nodule, 33 were referred for diffuse or asymmetric goiter, and 26 were referred for multinodular goiter (Table 1). Ultrasonography-guided fine-needle aspiration biopsy was performed on 209 nodules in 156 patients. Sixty-seven patients had no aspirations, 112 had one aspiration, and 44 had two or more aspirations. Table 1. Indication for Referral to the Thyroid Nodule Clinic in 223 Patients Sonographic Findings Ultrasonography revealed solitary nodules in 33% of patients, a multinodular goiter (>1 nodule on ultrasonography) in 50%, and no nodules in 17% (excluding those with a history of thyroid cancer). Ultrasonography findings in the 173 patients referred for abnormal findings on thyroid physical examination are given in Table 2. Table 2. Sonographic Findings in 173 Patients Referred to the Thyroid Nodule Clinic for Abnormal Results on Physical Examination Management of Nodular Thyroid Disease Ultrasonography changed management in 44% (50 of 114) of the patients referred for a solitary nodule on physical examination. In 27 patients, an additional nonpalpable nodule at least 1 cm in diameter was found on ultrasonography and more than one nodule required aspiration. Eighteen patients had no nodules, and 5 patients had only small nodules (<1 cm); therefore, despite the results of the physical examination, no aspiration was required. For the remaining 64 patients referred for a solitary nodule (46 with a solitary nodule 1 cm and 18 with multiple nodules but only one nodule 1 cm), clinical management was not affected because the palpated nodule was the only nodule that was at least 1 cm in diameter on ultrasonography. Among the 33 patients referred for a diffuse or asymmetric goiter, 55% (18 of 33) had one or more nodules at least 1 cm in diameter on ultrasonography, which suggests that the examining physician recognized an abnormality but could not detect a discrete nodule. Among the 26 patients referred for a multinodular goiter, 5 did not require an aspiration based on the ultrasonography findings and 21 required one or more aspirations for discrete nodules at least 1 cm in diameter. In summary, ultrasonography altered clinical management in 109 of the 173 patients (63%) referred for abnormal findings on physical examination. It was needed for guidance of nonpalpable nodules that were at least 1 cm in diameter in 66 patients (27 referred for a solitary nodule with additional nodules 1 cm on ultrasonography, 21 referred for a multinodular goiter, and 18 referred for a diffuse or asymmetric goiter with discrete nodules 1 cm on ultrasonography) and documented no nodules that were at least 1 cm in diameter in 43 patients. In the 48 patients referred for other indications, ultrasonography helped 1) evaluate growth in patients with previous benign cytologic findings, 2) direct sampling of lymph nodes in patients with thyroid cancer, 3) direct sampling of nonpalpable nodules found incidentally on other radiology studies, and 4) screen for nodules in patients with previous exposure to radiation. Cytologic Findings after Fine-Needle Aspiration In the 153 patients with no history of thyroid cancer who had fine-needle aspiration, 130 of the 205 nodules aspirated (63%) were benign. Seven nodules (3%), all confirmed histologically, were positive for papillary cancer. Nine (4%) were suspicious for papillary cancer. Five of these (56%) were histologically confirmed as papillary cancer, and 2 were benign. One patient with 2 suspicious nodules sought a second opinion and was lost to follow-up. Seventeen nodules (8%) were suspicious for follicular or Hrthle cell neoplasm, of which 9 were excised; 1 was a follicular carcinoma and the others were benign. Nine nodules (4%) were characterized as atypical. Of these, 2 were found to be benign after surgery. Thirty-three nodules (16%), of which 13 were more than 50% cystic, had nondiagnostic cytologic characteristics. In 1 patient, surgery for papillary carcinoma in 1 nodule revealed papillary carcinoma in a second nodule whose cytologic characteristics were nondiagnostic. The occurrence of malignancy was similar in patients with solitary nodules and those with multiple nodules. Cancer was found in 4 of 60 patients with solitary nodules (6.7%) and 8 of 90 patients with multiple nodules (8.9%). In 4 of the 12 patients who received a diagnosis of thyroid cancer, the malignant nodule was not palpated by the referring physician. One patient was referred for a solitary palpable nodule, which was benign, but a nonpalpable malignant nodule in the contralateral lobe was detected on ultrasonography. In another patient, who was referred for follow-up of a benign nodule, a second nonpalpable nodule was found to be malignant. The malignant nodule was also nonpalpable in the other 2 patients who had either a multinodular or diffuse goiter on the referring clinicians examination. Fine-needle aspiration biopsies of 4 nonpalpable lymph nodes in the 3 patients with a history of thyroid cancer were all positive for recurrent papillary cancer. Discussion We routinely use ultrasonography and ultrasonography-guided fine-needle aspiration in patients referred to our Thyroid Nodule Clinic for suspected thyroid nodules. Almost half of the patients referred for a solitary nodule on physical examination (a group previously not thought to benefit from ultrasonography) were found to have multiple nodules, and many (27 of 48) required additional aspiration of a nonpalpable nodule. More than 50% of patients (18 of 33) with suspected diffuse or asymmetric goiter had discrete nodules requiring fi

Does Cerebellar Injury in Premature Infants Contribute to the High Prevalence of Long-term Cognitive, Learning, and Behavioral Disability in Survivors?

OBJECTIVE. Although cerebellar hemorrhagic injury is increasingly diagnosed in infants who survive premature birth, its long-term neurodevelopmental impact is poorly defined. We sought to delineate the potential role of cerebellar hemorrhagic injury in the long-term disabilities of survivors of prematurity. DESIGN. We compared neurodevelopmental outcome in 3 groups of premature infants (N = 86; 35 isolated cerebellar hemorrhagic injury, 35 age-matched controls, 16 cerebellar hemorrhagic injury plus supratentorial parenchymal injury). Subjects underwent formal neurologic examinations and a battery of standardized developmental, functional, and behavioral evaluations (mean age: 32.1 ± 11.1 months). Autism-screening questionnaires were completed. RESULTS. Neurologic abnormalities were present in 66% of the isolated cerebellar hemorrhagic injury cases compared with 5% of the infants in the control group. Infants with isolated cerebellar hemorrhagic injury versus controls had significantly lower mean scores on all tested measures, including severe motor disabilities (48% vs 0%), expressive language (42% vs 0%), delayed receptive language (37% vs 0%), and cognitive deficits (40% vs 0%). Isolated cerebellar hemorrhagic injury was significantly associated with severe functional limitations in day-to-day activities. Significant differences were noted between cases of cerebellar hemorrhagic injury versus controls on autism screeners (37% vs 0%) and internalizing behavioral problems (34% vs 9%). Global developmental, functional, and social-behavioral deficits were more common and profound in preterm infants with injury to the vermis. Preterm infants with cerebellar hemorrhagic injury and supratentorial parenchymal injury were not at overall greater risk for neurodevelopmental disabilities, although neuromotor impairment was more severe. CONCLUSIONS. Cerebellar hemorrhagic injury in preterm infants is associated with a high prevalence of long-term pervasive neurodevelopment disabilities and may play an important and underrecognized role in the cognitive, learning, and behavioral dysfunction known to affect survivors.

Balloon Dilation of Severe Aortic Stenosis in the Fetus Potential for Prevention of Hypoplastic Left Heart Syndrome: Candidate Selection, Technique, and Results of Successful Intervention

Background—Preventing the progression of fetal aortic stenosis (AS) to hypoplastic left heart syndrome (HLHS) requires identification of fetuses with salvageable left hearts who would progress to HLHS if left untreated, a successful in utero valvotomy, and demonstration that a successful valvotomy promotes left heart growth in utero. Fetuses meeting the first criterion are undefined, and previous reports of fetal AS dilation have not evaluated the impact of intervention on in utero growth of left heart structures. Methods and Results—We offered fetal AS dilation to 24 mothers whose fetuses had AS. At least 3 echocardiographers assigned a high probability that all 24 fetuses would progress to HLHS if left untreated. Twenty (21 to 29 weeks’ gestation) underwent attempted AS dilation, with technical success in 14. Ideal fetal positioning for cannula puncture site and course of the needle (with or without laparotomy) proved to be necessary for procedural success. Serial fetal echocardiograms after intervention demonstrated growth arrest of the left heart structures in unsuccessful cases and in those who declined the procedure, while ongoing left heart growth was seen in successful cases. Resumed left heart growth led to a 2-ventricle circulation at birth in 3 babies. Conclusions—Fetal echocardiography can identify midgestation fetuses with AS who are at high risk for developing HLHS. Timely and successful aortic valve dilation requires ideal fetal and cannula positioning, prevents left heart growth arrest, and may result in normal ventricular anatomy and function at birth.

Can Color Doppler Sonography Aid in the Prediction of Malignancy of Thyroid Nodules

Objective. To determine whether color Doppler interrogation of a thyroid nodule can aid in the prediction of malignancy. Methods. We obtained color Doppler images of thyroid nodules undergoing sonographically guided fine‐needle aspiration. The color Doppler appearance of each nodule was graded from 0 for no visible flow through 4 for extensive internal flow. The size, sonographic appearance, results of fine‐needle aspiration, and surgical pathologic findings, if available, were recorded for each nodule. Results. There were 254 nodules sampled, of which 32 were malignant (all confirmed at surgery) and 177 were benign. Fourteen (43.8%) of the 32 malignant nodules were color type 4, compared with only 26 (14.7%) of the 177 benign nodules (P = .0004, Fisher exact test). Thirteen (40.1%) of the 32 malignant nodules were solid, as were 18 (10.2%) of the 177 benign nodules (P = .006, Fisher exact test). Among solid nodules, the prevalence of malignancy was greater when the nodule was hypervascular (13 [41.9%] of 31) than when the color type was less than 4 (11 [14.7%] of 77; P = .004, Fisher exact test). Conclusions. Solid hypervascular thyroid nodules have a high likelihood of malignancy (nearly 42% in our series). The color characteristics of a thyroid nodule, however, cannot be used to exclude malignancy, because 14% of solid nonhypervascular nodules were malignant

Natural History of Benign Solid and Cystic Thyroid Nodules

Context Although benign thyroid nodules are common, we know relatively little about their natural history. Contribution This observational study from a single tertiary care facility used repeated ultrasonography to show that benign thyroid nodules typically increase in volume over a 3- to 5-year period. Solid nodules grew more than cystic nodules, and only 1 of 74 reaspirated nodules was malignant. Implications Nodule growth alone does not predict malignancy. The Editors Thyroid nodules are present in nearly 50% of adults, increasing in prevalence with age (1). The evaluation of thyroid nodules that measure 1 cm or greater in diameter typically includes a screening measure of serum thyroid-stimulating hormone (TSH) levels and fine-needle aspiration (FNA). Most FNA results are benign (90% to 95%), and follow-up examinations are advised. Recommendations include periodic clinical examinations or ultrasonography, with or without suppressive l-thyroxine therapy (1, 2). Nodules that increase in size during follow-up are often regarded as suspicious for malignancy, and repeated FNA or surgery is advised (3-6). Data supporting these recommendations are limited, however, as few reports have evaluated thyroid nodule growth using the most sensitive technique, high-resolution ultrasonography. Furthermore, criteria defining nodule growth are inconsistent; some guidelines use an increase in maximal diameter of greater than 50%, while others suggest an increase in maximal diameter greater than 5 mm or an increase in calculated volume greater than 15% (5-10). We used ultrasonography of thyroid nodules to determine the natural history of cytologically benign thyroid nodules over a 1-month to 5-year follow-up period. Methods We retrospectively reviewed the records of all patients referred to the dual-discipline Thyroid Nodule Clinic at Brigham and Womens Hospital, Boston, Massachusetts, for evaluation of nodular thyroid disease between 1995 and 2000. All patients referred to the clinic underwent ultrasonography of the thyroid by a radiologist and ultrasonography-guided FNA of nodules measuring 1 cm or greater in maximal diameter by an endocrinologist. All ultrasonography evaluations were adequate for review and interpretation. All patients with benign cytology on initial FNA were advised to schedule follow-up ultrasonography 9 to 12 months later. Repeated FNA was performed on the follow-up visit at the discretion of the endocrinologist, usually because of nodule growth. The study sample included all patients with nodules with benign cytologic results on the initial visit who returned for follow-up ultrasonography within the 5-year period. Thyroid ultrasonography was performed by one of three radiologists using a 5- to 15-MHz transducer. The length, width, and depth of each nodule were reported, and each nodule was classified as solid, less than 25% cystic, 25% to 50% cystic, 50% to 75% cystic, or greater than 75% cystic. Nodule volume was calculated by using the formula for a rotational ellipsoid (length width depth /6) (7, 11, 12). Ultrasonography-guided FNA was performed with a 25-gauge needle (three to four aspirations per nodule), and specimens were processed by using the Thin-Prep technique (Cytyc Corp., Boxborough, Massachusetts). All slides were read by a cytopathologist at Brigham and Womens Hospital. Specimens were considered benign when six or more groups of benign follicular cells (each group containing 15 cells) were identified without atypical features. Repeated ultrasonographies were performed, and findings were directly compared with the previous images. Change in nodule size over the interval between examinations was assessed by using three criteria: 1) change in maximal diameter greater than 50% [7, 8, 12, 13]; 2) change in maximal diameter of 3 mm or more; 3) change in calculated volume of 15% or more (11, 14). The latter two criteria are defined by established inaccuracy rates for each method (11, 15). The Investigational Review Board of Brigham and Womens Hospital granted permission to perform this review. Descriptive statistics are presented according to nodule or patient as appropriate. The main outcome for the single-variable and multivariable predictive models was nodule growth, defined as an increase in volume of 15% or greater. Single-variable and multivariable mixed-effects logistic regression was used to predict growth, while accounting for the correlation structure in the data where some patients had more than one nodule (16). Potential predictors were the time between examinations, cystic content (solid, <25% cystic, 25% to 50% cystic, 50% to 75% cystic, or >75% cystic), TSH level (mIU/L), l-thyroxine use, age, and sex. Unadjusted and adjusted odds ratios and 95% CIs were calculated. Time to growth was determined by using life-table methods. Data were analyzed by using SAS software, version 8.2 (SAS Institute, Inc., Cary, North Carolina). The funding sources had no role in the design, conduct, or reporting of the study or the decision to publish the manuscript. Results A total of 1009 patients were examined in the Thyroid Nodule Clinic between 1995 and 2000, and 1358 nodules were biopsied. On initial FNA, 854 nodules (in 700 patients) measured 1 cm or greater in maximal diameter with benign cytologic results. Two hundred sixty-eight patients (38%) with 330 benign thyroid nodules (39%) returned for follow-up ultrasonography, with a mean interval of 20 months (range, 1 to 65 months) between examinations (Appendix Figure). The baseline demographic and ultrasonography characteristics of these 268 patients and their nodules were similar to those of the 432 patients who did not return for follow-up (Table 1). Table 1. Demographic and Ultrasonography Characteristics of Patients with a Benign Thyroid Nodule 1 cm in Maximal Diameter Who Returned for Follow-up Ultrasonography as Recommended Compared with Those Who Did Not Change in nodule size over each patients follow-up period was assessed by three methods to facilitate comparison with previous studies. With use of a greater than 50% change in maximal diameter, 14 nodules (4%) were determined to have increased in size upon repeated ultrasonography. With evaluating change in maximal diameter of 3 mm or greater or change in calculated volume (cm3) of 15% or greater, 86 nodules (26%) and 129 nodules (39%), respectively, were determined to have increased in size on follow-up ultrasonography. The time interval between examinations was significantly correlated with nodule growth (r = 0.22; P < 0.001). Table 2 shows mixed-models logistic regression analysis for prediction of thyroid nodule growth (volume change 15%). Time between examinations and lower cystic content remained statistically significant predictors of growth in the final multivariable model. Each year, the background odds of growth increased by 50%. The estimated median time to achieve volume growth of 15% or greater was 35 months (95% CI, 29 to 41 months). The estimated proportion with growth was 53% (CI, 46% to 61%) at 3 years and 89% (CI, 81% to 97%) at 5 years using life-table methods. The patients age, sex, baseline serum TSH concentration, or l-thyroxine use did not predict nodule growth. Table 2. Single-Variable Predictors and Final Multivariable Model To Predict Thyroid Nodule Growth (Volume Increase 15%) Sixty-one patients underwent repeated FNA at the time of the second ultrasonography. The nodules in this group were larger on initial examination (2.7 cm vs. 2.3 cm; P = 0.001) and had increased in volume by an average of 69% during follow-up compared with 14% in those nodules not rebiopsied (P < 0.001). Patient characteristics were similar except for a longer interval between examinations (28 months vs. 18 months) and younger age (43 years vs. 48 years) noted among the rebiopsied group. One of the 74 repeated FNA samples suggested a follicular neoplasm, and the remainder were benign. The nodule was removed; it was a poorly differentiated papillary carcinoma. It had enlarged from 10.1 cm3 to 18.1 cm3 in volume (an 80% increase) over 38 months. Discussion We used ultrasonography to assess the natural history of 330 benign thyroid nodules measuring 1 cm or more in maximal diameter followed for a mean period of 20 months. Although the 268 patients (with 330 nodules) represent only 39% of the benign nodules seen in the Brigham and Womens Hospital Thyroid Nodule Clinic between 1995 and 2000, they appear to be representative of the whole group with respect to demographic and nodule characteristics. Using the most rigorous criteria ( 15% increase in volume), we documented growth in 39% of benign thyroid nodules during follow-up, which indicates that many such nodules grow. Consistent with our findings, Brander and colleagues (10) found that 35% of benign nodules increased in size over 4.9 to 5.6 years. However, the criteria for growth were not defined, and minimal data on repeated FNA were provided (10). Similarly, Papini and colleagues (15) documented an increase in mean nodule volume among patients in the control group of a 5-year randomized study that assessed the efficacy of l-thyroxine suppression therapy for nodular goiter. Our results also support previous conclusions that more cystic nodules are less likely to grow compared with nodules with a greater solid component (5). Current opinion suggests that increasing nodule size has modest but significant power for predicting thyroid cancer (2). Kuma and colleagues found malignancy in 26% of previously unbiopsied nodules that increased in size over a 10- to 30-year period (5). A follow-up study 2 years later reported a malignancy rate of 4.5% among nodules that were previously found to be benign on FNA and subsequently grew (although no definition of growth was provided) (6). In our study, only 1 of 74 rebiopsied nodules was malignant on repeated FNA biopsy. Although only 22% of nodules seen in follow-up were rebiopsied, this group had s

Predictors of Technical Success and Postnatal Biventricular Outcome After In Utero Aortic Valvuloplasty for Aortic Stenosis With Evolving Hypoplastic Left Heart Syndrome

Background— Aortic stenosis in the midgestation fetus with a normal-sized or dilated left ventricle predictably progresses to hypoplastic left heart syndrome when associated with certain physiological findings. Prenatal balloon aortic valvuloplasty may improve left heart growth and function, possibly preventing evolution to hypoplastic left heart syndrome. Methods and Results— Between March 2000 and October 2008, 70 fetuses underwent attempted aortic valvuloplasty for critical aortic stenosis with evolving hypoplastic left heart syndrome. We analyzed this experience to determine factors associated with procedural and postnatal outcome. The median gestational age at intervention was 23 weeks. The procedure was technically successful in 52 fetuses (74%). Relative to 21 untreated comparison fetuses, subsequent prenatal growth of the aortic and mitral valves, but not the left ventricle, was improved after intervention. Nine pregnancies (13%) did not reach a viable term or preterm birth. Seventeen patients had a biventricular circulation postnatally, 15 from birth. Larger left heart structures and higher left ventricular pressure at the time of intervention were associated with biventricular outcome. A multivariable threshold scoring system was able to discriminate fetuses with a biventricular outcome with 100% sensitivity and modest positive predictive value. Conclusions— Technically successful aortic valvuloplasty alters left heart valvar growth in fetuses with aortic stenosis and evolving hypoplastic left heart syndrome and, in a subset of cases, appeared to contribute to a biventricular outcome after birth. Fetal aortic valvuloplasty carries a risk of fetal demise. Fetuses undergoing in utero aortic valvuloplasty with an unfavorable multivariable threshold score at the time of intervention are very unlikely to achieve a biventricular circulation postnatally.

Evaluation of the woman with postmenopausal bleeding: Society of radiologists in ultrasound-sponsored consensus conference statement

A panel of 14 physicians practicing medicine in the United States with expertise in radiology, obstetrics and gynecology, gynecologic oncology, hysteroscopy, epidemiology, and pathology was convened by the Society of Radiologists in Ultrasound to discuss the role of sonography in women with postmenopausal bleeding. Broad objectives of this conference were (1) to advance understanding of the utility of different diagnostic techniques for evaluating the endometrium in women with postmenopausal bleeding; (2) to formulate useful and practical guidelines for evaluation of women with postmenopausal bleeding, specifically as it relates to the use of sonography; and (3) to offer suggestions for future research projects.

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.

Creation of an Atrial Septal Defect In Utero for Fetuses With Hypoplastic Left Heart Syndrome and Intact or Highly Restrictive Atrial Septum

Background—Infants born with hypoplastic left heart syndrome and an intact or highly restrictive atrial septum face a neonatal mortality of at least 48% despite early postnatal left atrial decompression and palliative surgery. Prenatal left atrial decompression has been suggested as a means of improving these outcomes. This study reports the feasibility of fetal catheterization to create an interatrial communication and describes technical considerations. Methods and Results—Seven fetuses at 26 to 34 weeks’ gestation with hypoplastic left heart syndrome and intact or highly restrictive atrial septum underwent attempted prenatal intervention. Under ultrasound guidance, the atrial septum was approached with a needle introduced percutaneously from the maternal abdominal surface. In 6 of 7 fetuses, the atrial septum was successfully perforated, with balloon dilation of this iatrogenic defect resulting in a small but persistent interatrial communication. There were no maternal complications. One fetus died after the procedure. The remaining fetuses were liveborn at term, although 4 died as neonates. Conclusions—Ultrasound-guided fetal atrial septoplasty consisting of septal puncture and balloon dilation is feasible and can be performed percutaneously to minimize maternal risk. Although we have not demonstrated any positive clinical impact to date, it is our hope that further technical evolution will ultimately enable prenatal left atrial decompression and improvement of outcomes in fetuses with hypoplastic left heart syndrome and intact atrial septum.