Derya Tureli

Is any landmark reliable in vertebral enumeration? A study of 3.0-Tesla lumbar MRI comparing skeletal, neural, and vascular markers

PURPOSE This study aimed to determine the reliability of the iliolumbar ligament (ILL), 12th costa, aortic bifurcation (AB), right renal artery (RRA), and conus medullaris (CM) for numbering of vertebral segments. SUBJECTS AND METHODS Five hundred five patients underwent routine lumbar MRI examinations including a cervicothoracic sagittal scout and T1 and T2-weighted sagittal and axial turbo spin echo images. Images were evaluated by two radiologists separately. RESULTS The identifiability of ILL and 12th costa were 85.7% and 48.1%. AB, RRA, and CM were located more caudally in lumbarized S1 and more cranially in sacralized L5 cases. CONCLUSION Landmarks suggested by previous studies are not reliable alternatives to cervicothoracic scout images due to wide ranges of distribution and inconsistencies in identification.

Volume Navigation Technique for Ultrasound-Guided Biopsy of Breast Lesions Detected Only at MRI

OBJECTIVE The purpose of this study is to assess the utility of a volume navigation technique (VNT) for ultrasound-guided biopsy of MRI-detected, but sonographically ambiguous or occult, breast lesions. SUBJECTS AND METHODS Within a recruitment period of 13 months (January 1, 2014, through February 1, 2015), 22 patients with 26 BI-RADS category 4 or 5 lesions that were detected at MRI but missed at second-look ultrasound were reimaged using a rapid sequence and a flexible body coil in a 3-T MRI scanner. Patients were supine, with three skin markers placed on the breasts. MRI volume data were coregistered to real-time ultrasound in a dedicated platform, and MRI-detected lesions (six masses, 11 nonmass enhancements, eight foci, and one architectural distortion) were sought using VNT-guided ultrasound. Five needle biopsy specimens were obtained either from each sonographically detected lesion (n = 11) or from VNT-guided sonographically localized breast volume corresponding to the MRI-detected, but still ultrasound-occult, lesions (n = 15). RESULTS Histopathologic analysis revealed 18 benign and six malignant lesions. The remaining two lesions, both of which appeared as masses at MRI, were high risk and were upgraded to carcinoma after excisional biopsy. All malignant lesions underwent curative surgery; the final histopathologic diagnoses remained unchanged. Of the six malignant lesions, one was a mass, three were nonmass enhancements, and two were enhancing foci at MRI. Three malignant lesions were occult at ultrasound, and three were discerned as subtle hypoechoic changes. No benign lesion was sonographically visualized as a mass, and none progressed, with 56% disappearing at MRI performed during the follow-up period (mean, 14 months). CONCLUSION Coregistration of MRI and real-time ultrasound enables sonographic localization of breast lesions detected at MRI only. VNT is a feasible alternative to MRI-guided biopsy of ultrasound-occult breast lesions.

Use of a Volume Navigation Technique for Combining Real-Time Ultrasound and Contrast-Enhanced MRI: Accuracy and Feasibility of a Novel Technique for Locating Breast Lesions

OBJECTIVE The objective of this study was to evaluate the accuracy of the volume navigation technique for combining real-time ultrasound and contrast-enhanced MRI (CE-MRI) of breast lesions. SUBJECTS AND METHODS Thirty-eight women with single breast lesions underwent 3-T MRI. A 3.5-minute CE-MRI sequence was used, as was a flexible body coil. Patients underwent imaging in the supine position, with three markers placed on their breasts. Real-time sonographic images were coregistered to the preloaded breast CE-MRI volume by coupling skin markers, with the use of an electromagnetic transmitter positioned next to the subjects. The transmitter detected the spatial positions of the two electromagnetic sensors mounted on the transducer bracket. After this fusion process in 3D space was completed, divergences in the location of the center of each lesion on CE-MRI and ultrasound images were analyzed. RESULTS The mean lesion size was 17.4 mm on ultrasound and 17.9 mm on MRI, whereas the mean (± SD) misalignment of the lesion centers on CE-MRI and ultrasound was 3.9 ± 2.5 mm on the x-axis (mediolateral view), 3.6 ± 2.7 mm on the y-axis (anteroposterior view), and 4.3 ± 2.6 mm on the z-axis (craniocaudal view). No lesion had a misalignment greater than 10 mm on any of three axes. The accuracy of volume navigation was independent of patient age and the lesion size, location, and histopathologic findings (p > 0.05). Intermediate lesions, which had a depth of center of 11-20 mm on ultrasound had a mean misalignment of 2.6 ± 1.9 mm, compared with 5.5 ± 2.2 mm for deep lesions, which had a depth of center greater than 20 mm (p = 0.049). CONCLUSION The volume navigation technique is an accurate method for coregistration of CE-MRI and sonographic images, enabling lesion localization within a limited volume.

Thyroid fine needle aspiration biopsy: Do we really need an on-site cytopathologist?

PURPOSE The aim of this single center study is to evaluate the effectiveness of performing ultrasound-guided thyroid fine-needle aspiration biopsies (FNAB) performed by the radiologist alone without an on-site cytopathologist. MATERIALS AND METHODS In this prospective randomized study, 203 patients with single nodules measuring 10mm or more underwent ultrasound-guided FNAB: 102 patients underwent FNAB performed by the radiologist accompanied by a cytopathologist (control group); 101 patients underwent FNAB by the radiologist alone (study group). In both groups biopsy time, specimen adequacy ratio, total aspiration number, cytopathologists cytological diagnosis time (t1), cytopathologists total time consumption (t2) were evaluated. RESULTS Mean total biopsy time was 8.74 ± 2.31 min in the study group and was significantly shorter than the control groups 11.97 ± 6.75 min (p=0.004). The average number of aspirations per patient in the study group was 4.00 ± 0; compared to the control groups 3.56 ± 1.23 this was significantly higher (p=0.001). t1 of the study group was 307.48 ± 226.32s; compared to 350.14 ± 247.64 s in the control group, there was no statistically significant difference (p=0.137). t2 of the study group was 672.93 ± 270.45 s; compared to the control group (707.03 ± 258.78 s) there was no statistically significant difference (p=0.360). Diagnostic adequacy of aspirated specimens was reassessed in the pathology laboratory. In the study group, 84 out of 101 aspirations and in the control group 89 out of 102 aspirations was determined as adequate with no statistically significant difference (p=0.302). CONCLUSIONS We believe that in centers where a cytopathologist is not available, ultrasound-guided thyroid FNAB can be adequately performed by an experienced radiologist who was effectively trained in smear preparation.

Magnetic resonance enterography in refractory iron deficiency anemia: a pictorial overview.

AIM To highlight magnetic resonance enterography (MRE) for diagnosis of patients with refractory iron deficiency anemia and normal endoscopy results. METHODS Fifty-three patients diagnosed with iron deficiency anemia refractory to treatment and normal gastroscopy and colonoscopy results were admitted to this prospective study between June 2013 and December 2013. All patients underwent a standardized MRE examination with a 1.5 Tesla magnetic resonance imaging system using two six-channel phased-array abdominal coils. Adequate bowel distention and fast imaging sequences were utilized to achieve diagnostic accuracy. All segments of the small bowel, duodenum, jejunum, and ileum were examined in detail. All cases were examined independently by two radiologists with > 5 years of experience in abdominal magnetic resonance imaging. A consensus reading was performed for each patient following image examination. Both radiologists were blinded to patient history, laboratory findings, and endoscopy results. RESULTS Twenty (37.7%) male and 33 (62.3%) female patients were included in the study. The mean age of the patients was 52.2 ± 13.6 years (range: 19-81 years, median 51.0). The age difference between the male and female patient groups was not statistically significant (54.8 ± 16.3 years vs 50.7 ± 11.7 years). MRE results were normal for 49 patients (92.5%). Four patients had abnormal MRE results. One patient with antral thickening was diagnosed with antral gastritis in the second-look gastroscopy. One patient had focal wall thickening in the 3(rd) and 4(th) portions of the duodenum. The affected areas were biopsied in a subsequent duodenoscopy, and adenocarcinoma was diagnosed. One patient had a fistula and focal contrast enhancement in the distal ileal segments, consistent with Crohns disease. One patient had focal wall thickening with luminal narrowing in the mid-jejunum that was later biopsied during a double-balloon enteroscopy, and lymphoma was diagnosed. CONCLUSION MRE is a non-invasive and effective alternative for evaluating possible malignancies of the small intestines and can serve as a guide for a second-look endoscopy.

Effects of nodule characteristics on sampling number and duration of thyroid fine-needle aspiration biopsy: size does not matter, but cystic degeneration ratio does

Background Ultrasound-guided fine needle aspiration biopsy (FNAB) of thyroid nodules, though the most accurate method to rule out malignancy, still has an inherent risk of yielding non-diagnostic specimens despite immediate assessment of specimen adequacy by an on-site cytopathologist. Purpose To evaluate the effects of nodule volume and extent of cystic degeneration on total biopsy time and number of aspirations required for obtaining an adequate specimen. Material and Methods A total of 510 patients underwent FNAB by a single radiologist accompanied by a cytopathologist who immediately assessed each sample for specimen adequacy. All sampled nodules were single and had one maximum diameter > 10 mm. Nodule volumes and cystic degeneration ratios were calculated prior to the intervention. Aspirations were repeated until the cytological material was deemed adequate by the cytopathologist; the number of aspirations and total biopsy time were then recorded. Results Nodule volumes did not have significant effect on neither number of aspirations necessary for achieving specimen adequacy (P > 0.05) nor total biopsy time (r = −0.148 with P = 0.001). Predominantly cystic nodules, compared to predominantly solid nodules, required more sampling per nodule (4.58 ± 1.11 vs. 3.44 ± 1.19 aspirations, P = 0.001) and longer total biopsy time (16.40 ± 6.19 vs. 11.15 ± 6.18 min, P = 0.001). Conclusion Predominantly cystic nodules require allocation of more time for biopsy. To ensure specimen adequacy when immediate specimen evaluation by an on-site cytopathologist is not possible, four samples from predominantly solid nodules and five passes through predominantly cystic nodules are required.

Thyroid fine needle aspiration biopsy: do nodule volume and cystic degeneration ratio affect specimen adequacy and cytological diagnosis time?

Background A fine needle aspiration biopsy (FNAB) of thyroid nodules – the least invasive and most accurate method used to investigate malignant lesions – may yield non-diagnostic specimens even under ultrasonographic guidance. Purpose To evaluate the effects of thyroid nodule volume and extent of cystic degeneration on both the non-diagnostic specimen ratio as well as cytopathologist’s definitive cytological diagnosis time. Material and Methods In this single center study, FNAB was performed on 505 patients with single thyroid nodules greater than 10 mm. Nodule volume was calculated prior to FNAB and cystic degeneration ratio was recorded. All biopsies were performed by a single radiologist who also prepared specimen slides. Specimen adequacy and final diagnosis were made in the pathology laboratory by a single-blinded cytopathologist based on the Bethesda system. Definitive cytological diagnosis time was recorded upon reaching a definitive diagnosis. Results The specimen adequacy ratio was 85.3%. The mean nodule volume of adequate specimens was larger than those of non-diagnostic samples (6.00 mL vs. 3.05 mL; P = 0.001). There was no correlation between nodule volume and cytopathologist’s definitive cytological diagnosis time (r = 0.042). Biopsy of predominantly solid nodules yielded better specimen adequacy ratios compared to predominantly cystic nodules (87.8% vs. 75.3%; P = 0.028). Definitive cytological diagnosis times were longer in predominantly cystic nodules compared to predominantly solid nodules (376 s vs. 294 s; P = 0.019). Conclusion Predominantly cystic nodules are likely to benefit from repeated nodular sampling until the specimen is declared adequate by an on-site cytopathologist. If a cytopathologist is not available, obtaining more specimens per nodule may achieve desired adequacy ratios.

Comparison of diffusion weighted MRI parameters of mediastinal lymph nodes with PET/CT in lung cancer patients

ABSTRACT Objective: We have compared diffusion-weighted magnetic resonance imaging (DW-MRI) properties of mediastinal lymph nodes in lung cancer patients with positron emission tomography/ computed tomography (PET/CT) findings. Patients and Methods: Twenty-one consecutive untreated patients with lung cancer were included. DW-MRI was performed on a 1,5T scanner with b values of 50, 500 and 1000. Additional MR imaging was performed for anatomical correlation. Results: A total of 47 lymph nodes were analyzed. While no correlation was found between minimum apparent diffusion coefficient (ADC) values (ADCmin) of lymph nodes and their maximum standardized uptake values (SUVmax) on PET/CT, ADCmin ratios of lymph nodes to main lesion (ADCmin Node/ Lesion) (r = - 0.407; p = 0.005) and lymph node to cerebrospinal fluid (ADCmin Node/CSF) (r = - 0.364; p = 0.012) were correlated with SUVmax. Cutoff values for DW-MRI parameters were determined using ROC analysis. Six lymph nodes were histopathologically examined. Both methods correctly identified one metastatic and two metastasis negative lymph nodes, while staging one lymph node with granulomatous change as metastasis positive. Two metastasis negative lymph nodes, reported as suspicious on PET/CT, were correctly staged on DW-MRI. Conclusion: Our findings indicate that DW-MRI could be at least as valuable as PET/CT in mediastinal staging of patients with lung cancer.

Evaluation of sacroiliac joint MRI for pelvic venous congestion signs in women clinically suspected of sacroiliitis.

Background Pelvic congestion syndrome (PCS) is a commonly overlooked condition which is a potential cause of chronic pelvic pain. Magnetic resonance imaging (MRI) of the sacroiliac joint (SIJ) may demonstrate unexpected conditions that can mimic sacroiliitis (SI). Awareness of MRI-defined pelvic venous congestion (PVC) may help in identifying PCS, where vascular abnormality may be the sole manifestation of SIJ pain. Purpose To detect incidental MRI-defined PVC in patients who underwent SIJ-MRI for presumed SI and define the variance of its incidence. Material and Methods A total of 870 women who underwent SIJ-MRI were retrospectively evaluated. Incidental findings of PVC and other genitourinary and musculoskeletal system disorders were documented. Results Of the 774 included patients, 37% demonstrated incidentally detected imaging findings related to the genitourinary system, musculoskeletal system, and PVC. The prevalence of MRI-defined PVC signs was higher in patients without SI than with SI. The prevalence of musculoskeletal disorders was higher in patients with SI whereas prevalence for genitourinary disorders was similar. Binary logistic regression analysis revealed a statistically significant correlation between SI–PVC and SI–genitourinary disorders but not between SI–musculoskeletal disorders pairs (P = 0.001, 0.001, and 0.057 > 0.05). The probability of observing SI in SIJ-MRI is positively correlated with the absence of PVC or genitourinary disorders. Conclusion Patients who underwent MRI for presumed SI demonstrated incidental PVC as well as other genitourinary and musculoskeletal findings. An awareness of these imaging findings can help identify PVC and may draw clinicians’ attention to the possibility of PCS.

Outcomes of unconventional utilization of BI-RADS category 3 assessment at opportunistic screening

Background An important difficulty regarding the Breast Imaging Reporting and Data System (BI-RADS) category 3 assessment is the need for extensive diagnostic workup and an additional 6-month follow-up study. Purpose To evaluate the feasibility of the BI-RADS category 3 assessments at opportunistic screening. Material and Methods Mammography charts of 9062 screening patients in a major teaching hospital situated in an urban setting of a developing country were evaluated retrospectively (1997–2010). BI-RADS category 3 patients, called for a 6-month follow-up, which comprised a single-view spot or magnification mammogram. The length of follow-up period, compliance to periodic mammographic surveillance, cancer detection rate, and negative predictive values of category 3 assessments were calculated. Results Of the screened population, 9.2% were assigned BI-RADS category 3, and 31.2% of these cases were lost to follow-up. The mean follow-up period for 606 patients was 36.9 months. The negative predictive values for 6-month, 12-month, and final control studies were 90.9%, 87.5%, and 100%, respectively. Patient compliance for 6 months, 12 months, and any control evaluations beyond 12 months was low (50.0%, 29.8%, and 47.5%, respectively). Cancer detection rate was 0.8%. Conclusion Results of the study supports the feasibility of the BI-RADS category 3 assessments at opportunistic screening without any additional diagnostic workup. The practice of category 3 assessment following screening mammograms may be a more cost-effective method for developing countries with high recall rates and low resources in eliminating the maximum risk with minimum cost within the limits of available resources.