Hanaa Al-Khawari

Radiologic Features of Granulomatous Mastitis

Abstract: Granulomatous mastitis (GM) is a recognized, but an uncommon cause of breast mass. Awareness of this condition is important, because it can clinically as well as radiologically mimic breast carcinoma. In this study, we present the imaging features of a series of 10 cases with proved diagnosis of granulomatous mastitis with emphasis on magnetic resonance (MR) findings. All those patients who were histologically proven to have GM of the breast were analyzed. Their files were reviewed and data recorded for demographic, clinical presentation and imaging appearances. The imaging features of the lesions by mammography, ultrasound, and magnetic resonance imaging were analyzed. Of the 305 patients who were surgically treated, 10 (3%) cases proved to have GM. All the patients were females with age ranging from 27 to 53 years (average 38 years and median age 36 years). Guided core biopsy was performed in all cases for confirmation of diagnosis followed by either excision biopsy (in five cases) or lumpectomy (in five cases). The final histopathologic results were chronic granulomatous inflammation consistent with tuberculosis in four cases and GM with acute inflammation, but unknown etiology in four cases and GM due to duct ectasia in two cases. GM, a rare breast condition, should be considered in the differential diagnosis of patients with a breast mass associated with inflammatory change. Routine breast imaging with US, MG, or MRI, the condition from malignant lesions and biopsy, still remains the only method of definite diagnosis.

Role of Magnetic Resonance Imaging in the Assessment of Perianal Fistulas

Objective: This study was carried out to evaluate the role of magnetic resonance imaging (MRI) in preoperative assessment of fistula-in-ano. Subjects and Methods: Twenty-six patients (21 male and 5 female, age 19–65 years) were prospectively studied from July 1999 to December 2001 using a 1.0-tesla superconducting magnet. T1-weighted fast spin echo (T1W FSE) images before and after gadolinium injection and fat suppressed T2-weighted fast spin echo (T2W FSE) images were obtained in transverse and coronal planes. MRI findings were correlated with surgical findings. Results: Twenty-one of the 26 patients demonstrated active fistulas. The MRI findings were in accordance with the examination findings under anesthesia and/or surgery in 15 of 16 cases. Both coronal and transverse planes were useful in assessing the location and direction of tracts and abscesses. Both contrast-enhanced T1W FSE and fat-suppressed T2W FSE images were useful in assessing the activity of lesions and the course of tracts. Conclusion: MRI showed accurate correlation with surgical findings and aided in preoperative management and planning for surgery.

Evaluating diabetic foot infection with magnetic resonance imaging: Kuwait experience.

Objective: The aim of this study was to evaluate the capability of magnetic resonance imaging (MRI) to depict and characterize the changes seen in diabetic foot infections. Subjects and Methods: MRI studies of 29 diabetic patients with suspected foot infection were evaluated. Sagittal and transverse T1-weighted images before and after intravenous gadolinium, and transverse fat-suppressed T2-weighted images were performed on the affected regions. The MRI findings were compared to subsequent clinical and/or histopathological findings. Results: The MRI findings were: osteomyelitis in 14 patients, abscess in 5, cellulitis in 26, tenosynovitis in 4 and neuropathic joint in 8. Three cases were normal. Pathological confirmations were obtained in 19 patients. MRI and histological diagnosis were in concordance in 79% of osteomyelitis cases, 100% of neuropathy cases and 100% of cellulitis cases. The sensitivity and specificity of MRI in diagnosing osteomyelitis were 100 and 63%, respectively. The positive predictive and negative predictive values, and the accuracy were 79, 100 and 84%, respectively. MRI helped surgical planning for limb salvage procedures in 6 of the osteomyelitis cases and in a cellulitis case. Conclusion: The results indicate that MRI is a sensitive and accurate imaging modality for the evaluation of foot infections in diabetic patients and for planning proper treatment.

Contrast Media Extravasation: Manual versus Power Injector

Objective: To compare the incidence and complications of extravasation of low-osmolar nonionic contrast media, injected manually and by the automatic power injector (API). Subjects and Methods: Three thousand five hundred and sixty patients underwent contrast-enhanced abdominal and thoracic computerized tomography scan in the Department of Clinical Radiology, Al-Amiri Hospital, Kuwait, between June 1998 and De cember 2002. These patients were prospectively analyzed for contrast media extravasation, its relation to injection rate, cannula insertion and gauge and its complications. 920 patients were administered low-osmolar nonionic contrast media (Ultravist 300, Omni Paque 240 or 300) intravenously by manual injection and 2,640 patients by automatic power injector. Results: Of the 3,560 patients contrast media extravasation occurred in 11 (0.3%). The symptoms were observed in 9 patients (0.3%) in the API group and 2 patients (0.2%) in the manual injection group, respectively. None of the patients had any soft tissue injury. Conclusion: The incidence of contrast media extravasation is not significantly increased by the use of the API. Low-osmolar nonionic contrast media extravasation resulting from the use of API does not cause any morbidity.

Inter- and intraobserver variation between radiologists in the detection of abnormal parenchymal lung changes on high-resolution computed tomography.

Background and Objectives : Radiological and histological evaluations are affected by subjective interpretation. This study determined the level of inter- and intraobserver variation among radiologists for detection of abnormal parenchymal lung changes on high resolution computed tomography (HRCT). Methods : HRCT images of 65 patients known to have systemic lupus erythematosus (with clinical pulmonary involvement) were retrospectively reviewed by four nonthoracic radiologists (two with expertise in magnetic resonance [MR] and two general radiologists). Each radiologist read the scans twice, with an interval between readings of at least 6 months. The interobserver variation among the first and second readings of the four radiologists and the intraobserver variation of each radiologist′s two readings were assessed by the kappa statistic. Results : There was good agreement between the first and second readings of each radiologist. There was moderate agreement between the two readings of one MR radiologist (kappa=0.482); the other three radiologists had kappa values that were good to excellent (0.716, 0.691, and 0.829). There was a clinically acceptable level of interobserver variability between all radiologists. The agreement was fair to moderate between the MR radiologist and the other observers (kappa range: 0.362-0.519) and moderate to good between the other three radiologists (0.508-0.730). Conclusion : The interpretation of imaging findings of abnormal parenchymal lung changes on HRCT is reproducible and the agreement between general radiologists is clinically acceptable. There is reduced agreement when the radiologist is not involved on a regular basis with thoracic imaging. Difficult or indeterminate cases may benefit from review by a chest radiologist.

Accuracy of the Fischer scoring system and the Breast Imaging Reporting and Data System in identification of malignant breast lesions.

Background and Objectives :Fischer developed a scoring system in 1999 that made identifying malignant lesions much easier for inexperienced radiologists. Our study was performed to assess whether this scoring system would help beginners to accurately diagnose breast lesions on magnetic resonance (MR) imaging and to assess the correlation between the magnetic resonance mammography Breast Imaging Reporting and Data System (MRM BI-RADS) grade and the final diagnosis. Patients and Methods :The lesion morphology and contrast kinetics of 63 masses in 41 patients were evaluated on MRI and accorded a MRM BI-RADS final assessment category using the Fischer scoring system. The accuracy was evaluated after the final diagnosis was obtained by tissue sampling and follow-up imaging. Results: There were 25 malignant and 30 benign lesions. Eight lesions were seen by MRI only and we could not verify their pathology since we did not have MR-guided biopsy facilities at the time of the study. On MR mammography, the proven carcinomatous lesions were characterized as BI-RADS category V in 16 (64%), category IV in 7 (28%), and category III in 2 (8%) lesions. Benign lesions were graded as category V in 3 (10%), category IV in 6 (20%), and category III in 3 (10%), category II in 10 (33%) and category I in 8 (27%) lesions. The MRM BI-RADS category accurately predicted malignancy in 92% and a benign pathology in 70% of the lesions. The overlap between the MRM features of chronic inflammatory lesions and carcinomas resulted in a lower accuracy in diagnosing benign as compared to malignant lesions. Conclusion: The MRM BI-RADS lexicon using the Fischer scoring system is useful and has a high predictive value, especially for malignant breast lesions, and is easy to apply. Overlapping features between benign inflammatory and malignant lesions might yield a reduced accuracy in inflammatory pathologies.

Breast Magnetic Resonance Imaging: Initial Experience in Kuwait

Objective: To report our initial experience of breast magnetic resonance imaging (MRI) in Kuwait in order to identify and characterize breast lesions. Subjects and Methods: In 58 patients ranging in age from 25 to 64 years, breast MRI was performed as a problem-solving tool (29); for suspicious local relapse of the treated breast (6); to search for a primary breast cancer in patients with metastatic axillary lymph nodes (5); for local staging of breast cancer (5); breast implants (6); screening in high-risk patients (3), and differentiation between inflammation and inflammatory carcinoma (4). Sagittal fat-saturated T2 and axial T1 images were obtained before, and axial fat-saturated T1 and dynamic sagittal fat-saturated T1-weighted images after contrast enhancement in a 1.5-tesla closed magnet. The diagnostic criteria were based on the morphology and kinetics of the lesion. Findings were validated by tissue sampling or radiological follow-up. Results: Seventy breast lesions (25 malignant, 38 benign and 7 lesions detected by MRI only) were identified in the 58 patients. The sensitivity, specificity, and positive and negative predictive values of MRI in diagnosing malignant breast lesions were 96, 67, 71 and 95%, respectively, while the accuracy was 80%. Conclusion: This initial experience is comparable to other published data. Future plans for improving image spatial resolution and MR-guided procedures have been taken into consideration.

Accuracy of the Fischer scoring system and the Breast Imaging Reporting and Data System in identification of malignant breast lesions

BACKGROUND AND OBJECTIVES Fischer developed a scoring system in 1999 that made identifying malignnant lesions much easier for inexperienced radiologists. Our study was performed to assess whether this scoring system would help beginners to accurately diagnose breast lesions on magnetic resonance (MR) imaging and to assess the correlation between the magnetic resonance mammography Breast Imaging Reporting and Data System (MRM BI-RADS) grade and the final diagnosis. PATIENTS AND METHODS The lesion morphology and contrast kinetics of 63 masses in 41 patients were evaluated on MRI and accorded a MRM BI-RADS final assessment category using the Fischer scoring system. The accuracy was evaluated after the final diagnosis was obtained by tissue sampling and follow-up imaging. RESULTS There were 25 malignant and 30 benign lesions. Eight lesions were seen by MRI only and we could not verify their pathology since we did not have MR-guided biopsy facilities at the time of the study. On MR mammography, the proven carcinomatous lesions were characterized as BI-RADS category V in 16 (64%), category IV in 7 (28%), and category III in 2 (8%) lesions. Benign lesions were graded as category V in 3 (10%), category IV in 6 (20%), and category III in 3 (10%), category II in 10 (33%) and category I in 8 (27%) lesions. The MRM BI-RADS category accurately predicted malignancy in 92% and a benign pathology in 70% of the lesions. The overlap between the MRM features of chronic inflammatory lesions and carcinomas resulted in a lower accuracy in diagnosing benign as compared to malignant lesions. CONCLUSION The MRM BI-RADS lexicon using the Fischer scoring system is useful and has a high predictive value, especially for malignant breast lesions, and is easy to apply. Overlapping features between benign inflammatory and malignant lesions might yield a reduced accuracy in inflammatory pathologies.

Sonographic Diagnosis of Papillary Thyroid Carcinoma

Objective: To assess the value of ultrasonography (US) in reliably differentiating benign from malignant thyroid nodules, and in defining the malignant nature and the histotype of papillary thyroid carcinomas (PTC). Methods: A high-resolution real-time US system with a 7.5-MHz linear probe was used. The sonographic features of 39 histopathologically proven PTC cases were retrospectively reviewed and compared with the US features of 52 benign thyroid nodules (BTN). The US identification of PTC malignancy was based on the simultaneous presence of multiple US features seen exclusively in PTC and not in BTN. Results: Based on the simultaneous presence of exclusive malignant US features seen in PTC but not in BTN, identification of the malignant nature of PTC was certain in 74% of the cases and less certain in 8% of the cases. In a third group, 15% of the cases showed predominantly benign US features, while 1 patient (3%) was operated as a case of multinodular goiter and diagnosed histologically as having occult PTC. No malignant features were seen by US and it was not associated with metastasis. US identification of the histological type of PTC was based on the finding that a thyroid lesion presenting as a predominant cyst with a punctately calcified endoluminal projecting solid mural nodule was an exclusively specific feature of cystic primary PTC. Both, totally cystic and microcalcified predominantly cystic metastatic lymph nodes were also characteristically seen in metastatic PTC. Accordingly, the histotype of PTC was only identified in its cystic form, whether it was primary (13%) or metastatic (31%). Both constituted 44% of the 39 PTC cases. Conclusion: High-resolution real-time ultrasonography was found to be a useful first line diagnostic modality of PTC. It was reliable in differentiating benign from malignant thyroid nodules and in identifying the histotype of PTC in cases with cystic metastasis or where the primary or the metastatic nodule is cystic with microcalcified projecting solid mural nodule. Fine needle aspiration biopsy is to be resorted to, mainly in equivocal cases.