Katrina N. Glazebrook

Identification of Intraarticular and Periarticular Uric Acid Crystals with Dual-Energy CT: Initial Evaluation

PURPOSE To estimate the accuracy, sensitivity, specificity, and interobserver agreement of dual-energy computed tomography (CT) in detection of uric acid crystals in joints or periarticular structures in patients with arthralgia and patients suspected of having gout, with joint aspiration results as reference standard. MATERIALS AND METHODS With institutional review board approval, patient consent, and HIPAA compliance, 94 patients (age range, 29-89 years) underwent dual-source, dual-energy (80 and 140 kVp) CT of a painful joint. A material decomposition algorithm was used to identify uric acid. Two blinded musculoskeletal radiologists evaluated the dual-energy CT images and classified the examination findings as positive or negative for the presence of uric acid crystals. Reference standard was the result of joint aspiration. RESULTS Forty-three of 94 patients (46%) underwent attempted joint aspiration within 1 month of dual-energy CT. Aspiration was successful in 31 of 43 patients (72%). In 12 of 31 patients (39%), uric acid crystals were identified at joint aspiration; in 19 patients, they were not. Readers 1 and 2 had no false-negative findings for uric acid at dual-energy CT. Sensitivity was 100% (12 of 12; 95% confidence interval (CI): 74%, 100%) for both readers. Specificity was 89% (17 of 19; 95% CI: 67%, 99% ) for reader 1 and 79% (15 of 19; 95% CI: 54%, 94%) for reader 2, with near-perfect agreement between the readers (κ = 0.87; range, 0.70-1.00) in the 31 patients who underwent aspiration. CONCLUSION Initial retrospective assessment suggests that dual-energy CT is a sensitive, noninvasive, and reproducible method for identifying uric acid deposits in joints and periarticular soft tissues in patients suspected of having gout.

Dual-energy CT for the diagnosis of gout: an accuracy and diagnostic yield study

Objectives To assess the accuracy of dual-energy CT (DECT) for diagnosing gout, and to explore whether it can have any impact on clinical decision making beyond the established diagnostic approach using polarising microscopy of synovial fluid (diagnostic yield). Methods Diagnostic single-centre study of 40 patients with active gout, and 41 individuals with other types of joint disease. Sensitivity and specificity of DECT for diagnosing gout was calculated against a combined reference standard (polarising and electron microscopy of synovial fluid). To explore the diagnostic yield of DECT scanning, a third cohort was assembled consisting of patients with inflammatory arthritis and risk factors for gout who had negative synovial fluid polarising microscopy results. Among these patients, the proportion of subjects with DECT findings indicating a diagnosis of gout was assessed. Results The sensitivity and specificity of DECT for diagnosing gout was 0.90 (95% CI 0.76 to 0.97) and 0.83 (95% CI 0.68 to 0.93), respectively. All false negative patients were observed among patients with acute, recent-onset gout. All false positive patients had advanced knee osteoarthritis. DECT in the diagnostic yield cohort revealed evidence of uric acid deposition in 14 out of 30 patients (46.7%). Conclusions DECT provides good diagnostic accuracy for detection of monosodium urate (MSU) deposits in patients with gout. However, sensitivity is lower in patients with recent-onset disease. DECT has a significant impact on clinical decision making when gout is suspected, but polarising microscopy of synovial fluid fails to demonstrate the presence of MSU crystals.

Prophylactic and therapeutic mastectomy in BRCA mutation carriers: can the nipple be preserved?

BackgroundUse of nipple-sparing mastectomy (NSM) is increasing. We sought to look at the role of NSM in BRCA mutation carriers.MethodsTissue from women with a BRCA1 or BRCA2 mutation who underwent mastectomy between March 1987 and June 2009 at a single institution was reviewed. The entire nipple–areolar complex (NAC) was excised and histologically evaluated. The presence of terminal duct lobular units (TDLUs) and premalignant or malignant lesions in the NAC was noted.ResultsSixty-two NACs from 33 women (25 BRCA1, 8 BRCA2) were studied. TDLUs were present in 15 (24%) NAC specimens. No evidence of atypical hyperplasia, carcinoma in situ, or invasive carcinoma was found in any of the 33 prophylactic mastectomy specimens. Among the 29 breasts with cancer and available tissue, 2 (7%) had malignant findings and 1 (3%) had atypia in the NAC. One woman who underwent bilateral mastectomy for bilateral invasive carcinoma had one nipple with tumor within lymphatics, and her contralateral nipple had atypical lobular hyperplasia. A second woman had ductal carcinoma in situ involving a single major lactiferous duct.ConclusionsThe probability of nipple involvement by premalignant or malignant lesions in the NAC of BRCA mutation carriers is low at time of prophylactic mastectomy, but higher (10%) in women undergoing therapeutic mastectomy. NSM may be appropriate and oncologically safe for selected women with BRCA mutations. However, 24% of NACs contained TDLUs, with only 8% found in the nipple papilla; the significance of this for long-term risk is unknown.

Preoperative axillary imaging with percutaneous lymph node biopsy is valuable in the contemporary management of patients with breast cancer

BACKGROUND ACOSOG Z11 and other studies showing little benefit to axillary dissection (ALND) for early-stage breast cancers with limited nodal disease have led to questioning the value of preoperative axillary imaging ± ultrasound-guided needle biopsy (USNB). Data are lacking on the value of this approach in identifying cases that fall outside Z11 guidelines. METHODS We studied 988 consecutive patients with invasive breast cancers who underwent operation including axillary surgery in 2010-2011. RESULTS Preoperative axillary ultrasonography (AUS) was performed in 92% and breast/axillary magnetic resonance imaging (MRI) in 51%; 82 (33.5%) of 245 patients with suspicious lymph nodes (LN) were USNB-positive. Regarding nodal status, AUS, MRI, and USNB had negative and positive predictive values of 78%, 76%, 70% and 54%, 58%, 100%, respectively. AUS/MRI visualization of one versus multiple abnormal LNs visualized predicted >2LN+ on final pathology (13.5%/15.1% % vs 30.8%/32.6%, P < .009). Among USNB-LN+ T1/T2 patients, 51.6% had 1-2 LN+ while 60% with multiple and 31% with one AUS-abnormal LN(s) had > 2LN+, P = .001. CONCLUSION In our contemporary series, preoperative AUS±USNB streamlined surgical care for 29% of node-positive patients. Two-thirds of T1/T2 USNB-LN+ patients with multiple AUS-suspicious LNs had >2LN+, suggesting they should undergo ALND without SLNB. AUS±USNB helps identify node-positive breast cancer patients who fall outside Z11 guidelines.

Advanced Imaging in Gout

OBJECTIVE The purpose of this article is to describe the role of advanced imaging using ultrasound, CT, and MRI in the assessment and diagnosis of gout. CONCLUSION Dual-energy CT can quantitatively identify monosodium urate crystal deposits with high sensitivity and specificity within joints, tendons, and periarticular soft tissues. There are several characteristic ultrasound imaging findings, which include visualization of echogenic monosodium urate crystal deposition, tophus, and adjacent erosions. MRI is sensitive in showing soft-tissue and osseous abnormalities of gout, although the imaging findings are not specific. Gout commonly involves specific joints and anatomic structures, and knowledge of these sites and imaging appearances are clues to the correct diagnosis.

Adenoid Cystic Carcinoma of the Breast

OBJECTIVE The purpose of our study was to describe the imaging findings in adenoid cystic carcinoma (ACC) of the breast, with pathologic and clinical correlation. MATERIALS AND METHODS We retrospectively searched our surgical database from January 1994 through December 2008 for cases of pathologically proven ACC of the breast. Of approximately 15,000 breast biopsies, 11,250 were malignant. Eleven cases of ACC (0.1% of all malignancies), all with imaging available for review, were included in the study. RESULTS Mammographically (n = 10), tumors appeared as developing asymmetric densities or irregular masses. Sonographically (n = 9), they appeared as irregular, heterogeneous, or hypoechoic masses with minimal vascularity on color Doppler imaging. MRI (n = 5)--because of better soft-tissue contrast and dedicated, multiplanar breast sequences--helped show the extent of the tumor, particularly if dense breast tissue obscured the mass on CT. Two cases with subtle sonographic findings were better delineated on MRI because of tumor enhancement. The solid variant showed increased signal intensity on T2-weighted imaging. ACC showed variable enhancement kinetics ranging from persistent enhancement to washout kinetics in the larger lesions. On molecular breast imaging (n = 1), the tumors showed avid uptake of radiotracer but did not always show activity on PET (n = 1). CT (n = 2) showed areas of rapid, nodular enhancement. CONCLUSION Recognition of ACC is important to avoid delay in diagnosis because this tumor has a good prognosis with rare metastases to axillary lymph nodes. Axillary nodal sampling by fine-needle aspiration or core biopsy is rarely indicated.

Pseudoangiomatous Stromal Hyperplasia: Imaging Findings With Pathologic and Clinical Correlation

OBJECTIVE The purpose of this article is to describe the imaging characteristics of pseudoangiomatous stromal hyperplasia, where the primary histologic component was pseudoangiomatous stromal hyperplasia. CONCLUSION The tumoral form of pseudoangiomatous stromal hyperplasia is rare. The most common mammographic and sonographic finding is a circumscribed mass. Its appearance on MRI is nonspecific, but it may present as clumped nonmasslike persistent enhancement on contrast-enhanced imaging. Biopsy guided by MRI may be necessary to confirm the diagnosis.

Diagnosis and Management of Benign, Atypical, and Indeterminate Breast Lesions Detected on Core Needle Biopsy

Imaging abnormalities detected by mammographic screening often lead to diagnostic evaluations, with suspicious abnormalities subjected to image-guided core needle biopsy (CNB) to exclude malignancy. Most CNBs reveal benign pathological alterations, termed benign breast disease (BBD). Adoption of CNB presents challenges with pathologic classification of breast abnormalities and management of patients with benign or atypical histological findings. Patient management and counseling after CNB diagnosis of BBD depends on postbiopsy determination of radiologic-pathologic concordancy. Communication between radiologists and pathologists is crucial in patient management. Management is dependent on the histological type of BBD. Patients with concordant pathologic imaging results can be reassured of benign biopsy findings and advised about the future risk of developing breast cancer. Surgical consultation is advised for patients with discordant findings, symptomatic patients, and high-risk lesions. This review highlights benign breast lesions that are encountered on CNB and summarizes management strategies. For this review, we conducted a search of PubMed, with no date limitations, and used the following search terms (or a combination of terms): atypical ductal hyperplasia, atypical hyperplasia, atypical lobular hyperplasia, benign breast disease, cellular fibroepithelial lesions, columnar cell lesions, complex sclerosing lesion, core needle biopsy, fibroadenomas, flat epithelial atypia, lobular carcinoma in situ, lobular neoplasia, mucocele-like lesions, phyllodes tumor, pseudoangiomatous stromal hyperplasia, radial scar, and vascular lesions. The selection of references included in this review was based on study relevance and quality. We used additional articles culled from the bibliographies of retrieved articles to examine the published evidence for risk factors of BBD.

Carcinoma of the breast mimicking an areolar dermal lesion

This report describes the sonographic features of 2 patients with invasive carcinoma of the breast that sonographically mimicked benign epithelial cysts of the areola.

Idiopathic granulomatous mastitis: imaging update and review

AbstractObjectivesThe purpose of this study was to review the imaging features of idiopathic granulomatous mastitis (IGM) with clinical and pathology correlation.MethodsWith institutional review board (IRB) approval, a retrospective search of the surgical pathology database from January 2000 to July 2015 was performed. Clinical, imaging and histology findings were reviewed. Cases of granulomatous mastitis without a known source, diagnosed with percutaneous or surgical biopsy, were included in our analysis.ResultsSeventeen cases of IGM were identified with imaging available for review. The majority of patients presented with a palpable abnormality, whereas a minority were asymptomatic with an abnormal screening mammogram. At imaging, IGM most often demonstrated a focal asymmetry at mammography, a hypoechoic mass with irregular or angular margins at ultrasound, and robust enhancement with mixed progressive and plateau kinetics at magnetic resonance imaging (MRI). Axillary lymph nodes were reactive in appearance at ultrasound. Molecular breast imaging performed in one case showed mild focal asymmetric radiotracer uptake.ConclusionIGM is a rapidly progressive rare inflammatory condition of the breast resulting in non-necrotizing granuloma formation. Imaging features mimic breast carcinoma and diagnosis can be difficult. Radiologists’ awareness of this condition is essential to prevent delayed or unnecessary treatment.Teaching points• Idiopathic granulomatous mastitis is rapidly progressive inflammatory condition. • Imaging features may mimic breast carcinoma or infection. • Ultrasound shows irregular hypoechoic masses with increased vascularity and sinus tracts. • MRI shows irregular, enhancing masses or non-mass enhancement with microabscesses. • MRI is useful for assessment of breast involvement and response to treatment.