Joe T. Davis

Ultrasound-Guided Fine-Needle Aspiration of Clinically Negative Lymph Nodes Versus Sentinel Node Mapping in Patients at High Risk for Axillary Metastasis

BackgroundSonographically directed fine-needle aspiration is a less invasive and less costly alternative to sentinel node (SN) mapping in breast cancer patients at high risk for metastatic disease but with clinically negative axillae.MethodsRadiographic, cytological, and histological diagnostic data on breast primary tumors from 114 consecutive SN candidates were prospectively assessed for clinicopathologic variables associated with an increased incidence of axillary metastases. Patients in whom these variables were identified underwent sonographic examination of their axillae followed by fine-needle aspiration when abnormal nodes were detected. SN mapping was performed in patients with normal axillary sonogram results or negative cytological results. Patients with positive cytological results proceeded to complete axillary dissection. Final axillary histological outcomes from patients not meeting the high-risk criteria were recorded. Additionally, a cost analysis was performed in which the costs of ultrasonography and ultrasound-guided fine-needle aspiration of the axilla were compared with those of SN mapping.ResultsAccording to our selection criteria, a third of the patients with clinically negative axillae (37 of 114; 32%) were considered at high risk for axillary metastases. Fifty-nine percent of these patients (22 of 37) had metastatic disease on final histological analysis. Forty percent (15 of 37) of high-risk patients were spared SN mapping, with a reduction in health care costs of 20% in this patient population. Eighty-seven percent of patients not meeting high-risk criteria were SN negative.ConclusionsThis study suggests that in patients at increased risk for axillary metastases, the use of sonographic evaluation of the axilla in combination with fine-needle aspiration is not only clinically justified, but also cost-effective.

Sentinel node micrometastasis in breast carcinoma may not be an indication for complete axillary dissection.

The decision whether to proceed with complete axillary node dissection based on sentinel node status is clear for patients with negative or macrometastatic disease. However, the course of action based on sentinel node micrometastasis remains controversial. We reviewed 358 cases from 6/1999 to 7/2003. All sentinel nodes were evaluated at three levels by frozen section, touch preparation, and scrape preparation. Micrometastasis was defined as tumor deposits between 0.2 and 2 mm. Size, grade, and lymphvascular invasion of the primary tumor, as well as number, status, size of metastatic disease, and presence of extranodal capsular extension of sentinel and nonsentinel nodes were recorded. Of the 358 cases, 89 had positive sentinel nodes, 29 of which represented micrometastases. Only one (3%) of the 29 cases contained a nonsentinel node with macrometastasis. In 60 of the 89 cases sentinel nodes contained macrometastases. Of these, 38 cases (63%) had metastatic tumor in nonsentinel nodes. Intraoperative consult was performed in 53 of the 89 cases with positive sentinel nodes. Only 1 of the 19 (5%) intraoperative consult cases with micrometastatic sentinel nodes had positive nonsentinel nodes, while 21 of 34 (62%) of macrometastatic sentinel nodes at intraoperative consult had tumor in nonsentinel nodes. No single variable studied discriminated between micro- vs macrometastatic disease. At intraoperative consult, macrometastatic disease was present in all three diagnostic preparations, while diagnostic material in micrometastatic sentinel nodes was usually present in only one modality. This analysis suggests that the risk of finding tumor in nonsentinel nodes differs significantly between cases with micro (3%)- vs macro (63%)-metastatic disease in sentinel nodes. This holds true for cases assessed by intraoperative consult. Considering the known morbidity of complete axillary dissection, assessments of risk vs benefit of undertaking this procedure should be performed on a case-by-case basis in patients with sentinel node micrometastases.

The Critical Role of Axillary Ultrasound and Aspiration Biopsy in the Management of Breast Cancer Patients with Clinically Negative Axilla

BackgroundSonographic evaluation of the axilla can predict node status in a significant proportion of clinically node-negative patients. This review focuses on the value of ultrasound followed by ultrasound-guided cytology in assessing the need for sentinel node mapping and conservative versus complete axillary dissections.DesignBreast primaries from 168 sentinel node candidates were prospectively assessed for clinicopathologic variables associated with increased incidence of axillary metastases. Patients were classified accordingly, and those at a higher risk underwent ultrasound of their axillae, followed by aspiration biopsy if needed. Sentinel node mapping was performed in all low-risk patients, and in high-risk patients with normal axillary ultrasounds or negative cytology. Final axillary status was compared in terms of nodal stage, number of positive nodes, and size of metastasis.Results112 patients were at high risk for nodal disease (67%), with a statistically significant lower probability for remaining node-negative and a statistical significantly higher risk for having more than one positive node. All patients with more than three positive nodes were detected by ultrasound-guided cytology. High-risk patients with final positive axillae missed by ultrasound or ultrasound guided cytology had tumor deposits measuring ≤5 mm.ConclusionExtent of axillary dissections can be decided based on the risk for axillary metastases: sentinel node mapping for low-risk patients; less-aggressive axillary dissections for high-risk patients with negative ultrasound and/or negative cytology; and a standard dissection for high-risk patients with positive cytology.

Beef Cow Numbers, Crop Acreage, and Crop Policy

Land use shifts between cropland and pasture affect the demand for beef cow inventories because economically viable cow-calf enterprises are pasture-based. Econometric analysis indicates an inverse relationship of −36.6 thousand head of beef cows per million acre change in harvested cropland. Curtailment of the expansion phase of the current cattle cycle and subsequent declines in cow numbers is in part attributable to large acreages converted from pasture to cropland in the early 1980s. Conversely, crop policies which encouraged reconversion to pasture would stimulate rebuilding beef cow numbers and increase beef supply.

Pediatric whole-body MRI: A review of current imaging techniques and clinical applications.

There are many congenital, neoplastic, inflammatory, and infectious processes in the pediatric patient for which whole‐body imaging may be of benefit diagnostically and prognostically. With recent improvements in magnetic resonance imaging (MRI) hardware and software and resultant dramatically reduced scan times, imaging of the whole body with MRI has become a much more practicable technique in children. Whole‐body MRI can provide a high level of soft tissue and skeletal detail while avoiding the exposure to ionizing radiation inherent to computed tomography and nuclear medicine imaging techniques. This article reviews the more common current whole‐body MRI techniques in children and the primary pathologies for which this imaging modality may be most useful to the radiologists and referring clinicians. J. MAGN. RESON. IMAGING 2016;44:783–793.

JOURNAL CLUB: Can Coronal STIR Be Used as Screening for Acute Nontraumatic Hip Pain in Children?

OBJECTIVE The objective of this study is to evaluate whether coronal STIR MRI can be used as a screening test for nontraumatic acute hip pain in children. MATERIALS AND METHODS From 2008 to 2012, we identified all patients younger than 18 years at our tertiary care facility who underwent pelvic MRI including coronal STIR for the following indications: acute hip pain, limping, or refusal to bear weight. Patients with a history of trauma were excluded. Each MR image was independently reviewed by four radiologists who were blinded to the clinical outcome. After first reviewing the coronal STIR images only, they then reviewed the full MRI studies in a random order different from that used for review of the coronal STIR images. The sensitivity and specificity of STIR-only images in identifying the presence of abnormality and specific diagnoses were calculated, with the full MRI study considered as the reference standard. Kappa values were calculated for STIR-only and full MRI studies. RESULTS A total of 127 patients (67 female patients and 60 male patients; median age, 9 years; range, 5 months to 17 years) were identified. The most common abnormalities (calculated as the mean of frequency values noted by four readers) were hip effusion (52%; range, 46-58%), osteomyelitis (42%; range, 29-48%), and myositis (32%; range, 20-40%). For the detection of any abnormality, STIR-only images had a mean sensitivity of 95% and a mean specificity of 67%. For approximately one-third of STIR-only studies with true-positive results, additional abnormalities were found on full MRI studies. CONCLUSION Coronal STIR imaging of the pelvis has high sensitivity (95%) in the detection of abnormalities associated with acute nontraumatic hip pain in children, but it often misses additional abnormalities.

Variability in billing practices for whole-body magnetic resonance imaging: reply to Degnan et al.

Dear Editors, We would like to thank Degnan and colleagues [1] for their insightful comments regarding our recent article on utilization and procedural practices in pediatric whole-body MRI. As was stated in our article and expanded upon by Degnan and colleagues, billing practices are variable for pediatric wholebody MRI [2]. The lack of dedicated Current Procedural Terminology (CPT) codes for whole-body MRI permits this variability, exacerbates billing challenges, and may ultimately lead to patient care challenges. As an imaging community, we should work toward a cohesive definition of what encompasses a whole-body MRI examination in the pediatric patient population. Our article revealed the amount of variability that exists in what body parts are included in an exam that is labeled as a wholebody MRI [1]. An initial task in creating a whole-body MRI procedure-specific code is to define what parts of the body must be imaged to constitute a “whole-body” MRI. While standardization of coverage is necessary, formulating a requisite standardized set of sequences for pediatric whole-body MRI is impractical because of the need to account for patient-, providerand institution-specific variables. Rather, guidelines for best practices (including sequence selection and plane of imaging) could be delivered via an entity such as the American College of Radiology Appropriateness Criteria. Such appropriateness criteria could provide valuable guidance and further definition. Whole-body MRI is a valuable imaging tool in pediatric patients that must continue to be further defined. Ultimately, determining the constituent body parts, establishing guidelines for best practices, and creating procedure-specific billing codes will all help improve pediatric whole-body MRI.

Children with Cough and Fever: Up-to-date Imaging Evaluation and Management

Cough and fever in infants and children are frequent but nonspecific symptoms. Several usual differential diagnoses are under consideration and imaging is often necessary to help arrive at an accurate diagnosis and ensure proper management. A broad spectrum of underlying disorders may be present. Radiologists must remain cognizant of the potential for immune dysfunction and underlying structural abnormalities. A clear understanding of up-to-date imaging evaluation recommendations and characteristic imaging features can assist radiologists and clinicians in arriving at the most accurate diagnosis in a timely manner and help ensure proper management and necessary follow-up imaging assessment.

Gastrointestinal Tract Perforation in the Newborn and Child: Imaging Assessment

Gastrointestinal tract perforation can arise from various underlying etiologies ranging from congenital causes to ingested foreign bodies in the pediatric patient population. Imaging assessment in patients with suspected gastrointestinal tract perforation plays a central role in making the diagnosis and follow-up evaluation. This article reviews the more common etiologies of gastrointestinal tract perforation in pediatric patients, their imaging manifestations, and strategies for imaging assessment to assist the radiologist in arriving at a timely and accurate diagnosis.