Additional Imaging Evaluation Research Articles

Anatomic Variations in the Circle of Willis and Headache: A Case Report Study

Introduction: Anatomic variation in the circle of Willis (CoW) is a common finding among the population. Headache has been reported as one of the symptoms of these variations. Case Presentation: Recent studies suggest a possible association between neurovascular accidents and these variations. In this case, a 50-year-old male presenting with headache underwent imaging evaluation, revealing anatomic variations in CoW. Conclusions: Headaches with or without neurological symptoms or a history of migraine and transient ischemic attack (TIA) may suggest the diagnosis of CoW disease and variations, and additional imaging evaluation is recommended in these cases.

Out-of-Pocket Costs of Diagnostic Breast Imaging Services After Screening Mammography Among Commercially Insured Women From 2010 to 2017

This cross-sectional study evaluates the out-of-pocket costs of diagnostic breast imaging services incurred by commercially insured women who underwent additional imaging evaluation and procedures after screening mammography.

Karzinoide der Lunge und im Abdomen

Pulmonary carcinoids and carcinoids of the small intestine (jejunum and ileum) are often asymptomatic and can affect various parts of the body, which makes diagnosis difficult. Contrast-enhanced computed tomography (CE-CT) is commonly used for primary diagnostics. In case of concomitant pulmonary consolidation (e.g., atelectasis or pneumonia), tumor lesions can be obscured. In addition, differentiation between atypical (AC) and typical carcinoids (TC) is not possible using CT. Small tumors of the small intestine are easily overlooked (sensitivity: 50-85%, specificity: 25-97%, based on the literature). Additional functional imaging evaluation using hybrid imaging techniques can be applied, e.g., positron emission tomography/computed tomography (PET/CT). Depending on the histological characteristics of the tumor, PET/CT scans can be performed with different tracers. Since most carcinoids (e.g., TC) express somatostatin receptors (SSR), 68 gallium-radiolabeled PET tracers (e.g. 68 Ga-DOTA-TOC) are commonly used (sensitivity: 88-93%, specificity: 88-95%, based on the literature). Poorly differentiated carcinoids (e.g., AC) demonstrate lower SSR expression; thus, use of 18F‑FDG (sensitivity: 37-72%, based on the literature) is indicated. In principle, these methods enable anoninvasive prognostic differentiation based on SSR expression and 18F‑FDG uptake. However, the diagnosis must always be histologically confirmed. Hybrid imaging with CE-CT and PET is useful to detect pulmonary carcinoids and carcinoids of the small intestine, respectively, and can be utilized for primary diagnostics and restaging.

Significance of the absent vertebral artery T2 flow void on cervical spine MRI in atraumatic patients without acute neurological symptoms.

Loss of the T2 vertebral artery flow void can be an ominous sign in patients with trauma. However, the significance of an absent vertebral artery flow void is less clear when discovered incidentally in patients without trauma or acute neurological symptoms. The purpose of this study was to review retrospectively the results of additional imaging and clinical evaluation in atraumatic patients without acute neurological symptoms found to have an incidentally discovered absent vertebral artery flow void on magnetic resonance imaging. An imaging database was reviewed for absent vertebral artery flow voids in atraumatic cervical spine magnetic resonance images. Imaging and long-term clinical follow-up were recorded. Fifty-four patients were included in the study. All patients had clinical follow-up and 22 patients (40% of cases) had vascular imaging follow-up. Nine patients had a hypoplastic but patent vertebral artery on follow-up vascular imaging, and no further action was taken. Ten patients had evidence of stenosis or occlusion of the vertebral artery on follow-up imaging, none with acute neurological symptoms or new symptoms/subsequent change in management during follow-up. Three additional patients had vertebral artery dissections on follow-up imaging, but all of them had acute neurological symptoms at the time of imaging and acute infarcts on current or subsequent magnetic resonance imaging. The other 32 patients had clinical follow-up and remained asymptomatic throughout the study period, without change in management. In the absence of trauma or acute neurological symptoms an absent vertebral artery flow void has a low likelihood of altering patient management.

QIM19-123: Addressing Opportunities for Improving Care Cadence by Driving Interdepartmental Collaboration

Background: Southern Ohio Medical Center (SOMC) is a community hospital in Portsmouth, Ohio. Review of data pertaining to breast care delivery demonstrated opportunities for improvement. Analysis of the cadence of care processes across departments demonstrated delays in care and outmigration potential. One quality study demonstrated 10% of patients did NOT select SOMC for surgical intervention post biopsy. Method: SOMC reached out to industry for solutions and suggestions to better coordinate care and address barriers within the breast program. A team of clinical, process excellence specialists from Leica Biosystems conducted telephonic interviews and on-site assessments relative to internal processes and methods for care delivery. The SOMC Breast Health Leadership Team (BHLT) in concert with the Leica Biosystems Process Excellence Team identified the following barriers and opportunities: Barriers were (1) Lack of timely data to drive breast care coordination and prioritization; (2) Inefficiencies in patient scheduling; (3) Lack of common goal deployment across departments; and (4) Limitations of resources. Opportunities were to (1) Improve coordination, (2) improve quality and safety of care provided, (3) increase market share, and (4) increase patient loyalty. Results: The SOMC BHLT purposefully initiated interdepartmental communications and emphasized the importance of interdepartmental task interdependence. Data reviewed and collected during the on-site observational analysis provided baselines for opportunities for improvement in care delivery and pointed out where delays and risks for patient safety existed. Patients requiring additional imaging evaluation and/or comparison to prior mammograms (BI-RADS 0) experienced improvement when changes were implemented relative to scheduling; days from screening to diagnostic mammogram in 2017 was 21.8 days versus 6.5 days in 2018. Patients with BI-RADS 4 or 5 experienced improved timelines from diagnostic mammogram to biopsy, 4.5 days in 2017 to 2.5 days in 2018. Finally, 34% of patients received their biopsy within 24 hours in the fourth quarter in 2017 while 76% of the patients received a biopsy within 24 hours in the most recent quarter (July–September 2018). Conclusion: Working together, industry can provide expertise and guidance not always available in community hospital settings to help: identify barriers and opportunities, drive interdepartmental care optimization, reduce opportunity for outmigration, mitigate risks, and strive to improve quality.

Abstract P1-02-01: Improvement of breast cancer screening access and quality in an underserved population through system interventions

Abstract Background: Differences in access to and quality of screening and treatment are proposed to contribute to racial disparities in breast cancer outcomes. Interventions designed to improve mammography access and quality encompass strategies at the individual patient, healthcare provider, and system levels. In 2016, an urban safety net healthcare system based in Chicago implemented several changes in response to collected data showing variations in quality at institutions performing mammography. These changes included the installation of digital machines at one of four sites, centralizing reading of images from all four sites to a single site with radiologists specialized in mammography and increasing care coordination including enhanced patient outreach efforts. We examined the impact of these systems-based interventions on the access to and quality of mammography services. Methods: Data was obtained on 15,918 screening mammograms performed across four mammography centers within the Cook County Health & Hospitals System from the six months prior to and one year after implementation of changes. Manual chart abstraction was performed for each study that was assessed as BIRADS 0 (Breast Imaging and Reporting Data System), meaning an incomplete study requiring additional imaging evaluation, or mammograms that appeared suspicious or highly suspicious and categorized as BIRADS 4 or 5. Screening mammogram volume at each site was recorded and compared. Quality of screening mammograms was assessed using eleven metrics reflecting radiologist performance and efficiency of facility care processes. These metrics included the rate of recall, cancer detection rate, proportion of cancers that were early stage or minimal in size, proportion of women with timely follow-up imaging and biopsy, and rates of loss to follow-up. Results: The volume of screening mammograms completed at each of the four sites increased from the six months prior to intervention to the six months after (range of 61-322% increase). At one-year post intervention, there were smaller, but sustained increases in volume (range of 12-70% increase). Improvements were seen in at least one quality metric at each site in the post-intervention period (range 1-8). The proportion of women with timely follow-up after abnormal mammogram also improved across all four sites: from 38% getting follow-up imaging within 30 days pre-intervention to 68% after, and from 62% to 75% of women with biopsy completion within 60 days. Rate of cancer detection improved at two of the sites with the lowest pre-intervention values, from 1.7 to 3.1 and 2.8 to 5.7 per 1,000 mammograms (quality benchmark: 3-10/1,000 screening tests). Conclusion: Improvements in access to and quality of screening mammography demonstrate the value of implementing system level changes in enhancing breast cancer care and may translate to better outcomes for all women. Citation Format: Manst DJ, Gil D, Marcus EA, Mullarkey P, Ganschow PS. Improvement of breast cancer screening access and quality in an underserved population through system interventions [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P1-02-01.

Subspecialized radiology review at multidisciplinary pancreas conference: impact on patient management.

At our tertiary medical center, multidisciplinary subspecialists meet twice a week during a CME-accredited conference to discuss oncologic and non-oncologic patients with pancreatic diseases at which time a subspecialized abdominal staff radiologist reinterprets the patient's relevant imaging studies. This study assesses the changes in patient management due to imaging reinterpretation during multidisciplinary pancreas conference (MPC). In this retrospective, IRB-approved, HIPAA-compliant study, imaging studies of all patients discussed at MPC between July 1 and December 31, 2015 were assessed for technical adequacy, and original reports analyzed for congruency with reinterpretation. Management measures included change in diagnosis, clinical stage, treatment, or workup. Additional data were obtained on referring services affected and their resultant change in practice. Changes in surgical resectability, surgical approach, or delayed operative dates were noted for surgeons. Changes in chemotherapeutic or radiation oncology regimens as well as decisions for additional imaging, laboratory workup, or histologic evaluation were also recorded. A total of 252 patients were included (54.4% males, 45.6% females, mean age 63.71years). Relevant imaging consisted of 142 abdominal CT scans, 112 abdominal MRI scans, 1 abdominal ultrasound, and 1 nuclear medicine octreotide study of which 69.4% were performed in-house. Image quality was deemed appropriate in 95.2%. Cases presented included solid pancreatic malignancies (n = 140; 55.6%), cystic pancreatic lesions (n = 41; 16.3%), acute and chronic inflammatory conditions (n = 52; 20.6%), and miscellaneous entities (n = 10; 4.0%); 9 (3.6%) cases were normal. Image reinterpretation was congruent with original reports in 56.7%, with minor, moderate, and major discrepancies occurring in 9.5, 26.2%, and 7.5% of cases, respectively. Incongruent reinterpretation was predominantly due to perceptional errors (false-negative reports due to missed findings) and interpretative errors (false-positive results due to over-reporting or misclassification of diagnoses). Services most commonly affected included surgical oncology, radiology, and gastroenterology at 16.7%, 13.1%, and 12.7% of cases, respectively. Management changes included a change in diagnosis in 8.7%, change in clinical stage in 8.7%, change in treatment in 17.9%, and further workup needed in 19.0% of patients, respectively. No change in management occurred in the remaining 61.5% of cases. Subspecialized abdominal radiologist reinterpretation in the context of more comprehensive patient information heavily impacts the multidisciplinary management of patients with pancreatic disorders. Further efforts are needed to solidify the abdominal radiologist's role in the multidisciplinary clinical setting.

The Median Nerve at the Carpal Tunnel … and Elsewhere

The median nerve (MN) may be affected by various peripheral neuropathies, each of which may be categorized according to its cause, as either an extrinsic (due to an entrapment or a nerve compression) or an intrinsic (including neurogenic tumors) neuropathy. Entrapment neuropathies are characterized by alterations of the nerve function that are caused by mechanical or dynamic compression. It occurs because of anatomic constraints at specific locations including sites where the nerve courses through fibro-osseous or fibromuscular tunnels or penetrates a muscle. For the diagnosis of peripheral neuropathies, physicians traditionally relied primarily on clinical findings and electrodiagnostic testing with electromyography. However, if further doubt exists, clinicians may ask for an additional imaging evaluation.

Acute Dysphagia in a 25-Year-Old Male

Author(s): Ullo, Michael; Dym, Robert; Ripper, Jill | Abstract: ABSTRACT: History of present illness: A 25-year-old male with a history of asthma presented to the emergency department (ED) with the sensation of food impaction in the mid-thoracic region and inability to swallow that began twenty minutes prior to arrival after eating chicken. Careful history revealed that the patient had several ED visits for similar episodes during his early childhood. Physical examination was benign with stable vitals. He had a clear oropharynx and normal breath sounds bilaterally. On cardiac auscultation, there was a regular rate and rhythm without appreciable murmur. Significant findings: After an unremarkable chest radiograph was obtained, a computed tomography (CT) scan of the chest was obtained due to possible co-ingestion of bones to rule out perforation. The CT scan demonstrated focal distention of the mid-esophagus due to an impacted food bolus (white arrow). An aberrant right subclavian artery (yellow arrow) was located just distal to the impaction site with partial compression of the esophagus (red arrow). Discussion: Arteria lusoria is an aberrant right subclavian artery. It is the most common embryologic abnormality of the aortic arch, occurring in 0.5% to 1.8% of the population.1 In this condition, the right subclavian artery arises directly off of the aorta, distal to the left subclavian artery, as opposed to the normal branching off the right brachiocephalic artery. While the majority of cases are asymptomatic, occasionally the artery will compress adjacent structures including the trachea and esophagus.2 This phenomenon was first described in 1794 by a London physician who remarked on a fatal case of obstructed deglutition.”3 When the aberrant right subclavian artery causes compression and trachea-esophageal symptoms such as dysphagia, it is termed dysphagia lusoria. The patient was diagnosed with dysphagia lusoria and given an intravenous bolus of glucagon with resolution of symptoms in one hour. He was able to tolerate liquids and solids without difficulty upon discharge. Management of dysphagia varies based on presentation and ability to tolerate oral intake. CT imaging may be useful in cases of recurrent food bolus impactions or high clinical suspicion for aerodigestive injury. Patients unable to swallow may require emergent subspecialist evaluation with additional imaging and endoscopic evaluation. Structural abnormalities such as dysphagia lusoria may ultimately require surgical intervention for definitive resolution of symptoms. Topics: Arteria lusoria, dysphagia, aberrant right subclavian artery.

Extraneural findings during peripheral nerve ultrasound: Prevalence and further assessment.

In this study we evaluated the frequency and further assessment of extraneural findings encountered during peripheral nerve ultrasound (US). Our retrospective review identified 278 peripheral nerve US examinations of 229 patients performed between December 2014 and December 2015. Reports were reviewed to assess the number of studies without peripheral nerve abnormalities and the frequency and further assessment of extraneural findings. A total of 107 peripheral nerve US examinations of 90 patients (49 men and 41 women, mean age 55 ± 16 years) did not report peripheral nerve abnormalities. Extraneural findings were observed in 24 of 107 (22.4%) studies. Fifteen of the 278 [5.4% (95% confidence interval 2.7%-8.1%)] studies led to a recommendation for additional imaging or clinical evaluation of an extraneural finding. At least 5.4% (15 of 278) of peripheral nerve US studies led to additional clinical or imaging assessment. Muscle Nerve 57: 65-69, 2018.

Extramammary Findings on Breast MR Examinations: Frequency, Clinical Relevance, and Patient Outcomes.

To evaluate the frequency of extramammary findings on breast magnetic resonance (MR) images, recommendations for further imaging evaluation of each finding, and the subsequent effect on patient outcomes and health care expenditures. Institutional review board approval was acquired for this HIPAA-compliant study. Informed consent was waived. Review of the institutional database identified 2324 breast MR examinations performed in women from January 1, 2010, to December 31, 2010. Breast MR imaging reports were reviewed for extramammary findings. Extramammary findings were categorized by using the computed tomography (CT) colonography reporting and data system (C-RADS). The electronic medical record was reviewed for each patient with a C-RADS category E3 and E4 finding to assess clinical relevance and pathologic outcome. If an E3 or E4 finding was previously described and evaluated, the finding was downgraded and assigned a final C-RADS E2 category. The cost of additional imaging was estimated by using the Medicare physician fee schedule. Statistical significance was assessed by using χ(2) statistics. A P value less than .05 indicated statistical significance, and 95% exact confidence intervals (CIs) were constructed. Extramammary findings were identified in 391 of 2324 breast MR examinations (16.8%), which included 105 patients (4.5%) with E3 or E4 findings. Of the 2324 patients, 86 patients (3.7% [95% CI: 3.0%, 4.5%]) were recommended to undergo further imaging. After undergoing evaluation for additional imaging, a clinically important finding was found in nine patients (0.4% [95% CI: 0.2%, 0.7%]). Most frequently, hepatic lesions were the indication for additional imaging. Abdominal MR examinations accounted for 55% of costs related to additional imaging. Averaged across the entire cohort, further imaging evaluation and follow-up of incidental findings contributed an additional $16 to each breast MR imaging performed. Additional imaging evaluation for E3 and E4 extramammary findings at breast MR imaging can identify clinically important disease without substantially increasing cost. .

Recall rate of screening ultrasound with automated breast volumetric scanning (ABVS) in women with dense breasts: a first quarter experience

PurposeThe aim of this study was to determine the recall rate of screening ultrasound with automated breast volumetric scanning (ABVS) in women with dense breasts (BI-RADS density classification 3 or 4 on mammogram). Materials and MethodsIn this retrospective cohort study, at the end of the “first quarter” (August–October 2013) of use, our practice database was searched for all ABVS examinations performed and specifically, the positive examinations (defined as abnormal/BI-RADS 0) for which patients were recalled for additional imaging evaluation with handheld ultrasound (HHUS); the latter group was reviewed with respect to final BI-RADS and pathology if relevant. ResultsDuring the 3-month study time period, 558 ABVS studies were performed: 453 (81%) were initially BI-RADS 1 or 2 and 105 (19%) were BI-RADS 0-incomplete and recalled, corresponding with an overall recall rate of 19%; specifically, the recall rate trended down from 24.7% in August to 12.6% in October. To date, 98 of the 105 recalled women have returned for HHUS, with the resultant final BI-RADS as follows: 25/98=25% BI-RADS 1, 46/98=47% BI-RADS 2, 13/98=13% BI-RADS 3, 14/98=15% BI-RADS 4, and 0/98=0% BI-RADS 5. All biopsies performed to date of the ABVS-detected BI-RADS 4 lesions have yielded benign results, with the most common pathology being fibroadenoma. ConclusionThe recall rate of screening ABVS in women with dense breasts at our institution was under 20% overall during its first quarter of use, and trended down from nearly 25% in the first month to under 13% in the third. The clinical implication is that ABVS does have a learning curve, but that is a potentially feasible way to meet the increasing demands for screening ultrasound in women with dense breasts.

Updated breast MRI lexicon

The American College of Radiology (ACR) BI-RADS Breast Imaging Lexicon was developed over a 5 year period, initially organized in 1999 by a Breast MRI “Lesion Diagnosis Working Group” and later by the ACR. This work resulted in a lexicon (dictionary) of terms to describe breast lesions on contrast-enhanced breast magnetic resonance imaging studies. The first publication was developed when breast MRI was first being used and referencing the little data available to produce the lexicon of terms in describing lesions seen on breast MRI. Even though the ACR Lexicon has proved robust for the most part, since its publication there have been technical advances in breast MRI hardware, coils and pulse sequences, resulting in new information on breast cancer morphology and kinetic behavior. Publication on MRI studies using the new hardware and software resulted in increases in cancer sensitivity and specificity in published literature. As a result, information is now available on technical parameters required to obtain both high spatial and temporal resolution on breast MRI scans that resulted in high sensitivity and specificity. These advances and scientific data were used in developing and updating the new Lexicon. The new breast MRI Lexicon is chaired by Elizabeth A Morris, M.D and is expected to be published in the fall of 2012. The new ACR Lexicon includes a web-based format (hardcopy is also available), recommends mammography/US/MRI correlation, and has evidence based information with hyperlinks to references. The Lexicon also includes sections on Quality Assessment with technical parameters and kinetic/functional considerations that influence MRI images. There is a new section on audit recommendations. The ACR also lists a separate ACR Breast MRI Accreditation Program that accredits breast MRI facilities in the United States with technical, outcome and personnel credentialing criteria. Breast MRI Lexicon recommendations include adding T2weighted non-contrast sequences, and combined reporting of MRI with mammographic and ultrasound findings. Finally, simultaneous bilateral MRI scans are recommended and are considered standard of care. There is a new section on breast implants, with a lexicon describing the implant type, location, and findings commonly seen in intact and ruptured implants. In silicone breast implant studies, imaging terms include normal radial folds, subcapsular line, linguine and keyhole/teardrop. Importantly, there is a new section describing background parenchymal enhancement (BPE) that describes how much of the normal breast parenchyma enhances, which in turn can influence the sensitivity of breast MRI to detect cancer. The BPE can be described as none, minimal, mild, moderate or marked. Terms that previously were used to describe findings seen on breast MRI such as “diffuse stippled enhancement” may actually represent moderate BPE, which is a normal finding. As before, both morphology and kinetic information is considered important. There are no changes to the kinetic terminology. Morphology terms in the lexicon have been added or deleted, adding terms that were commonly used, and deleting those that were not used in the scientific literature. Deleted terms include central and septal enhancement, and enhancing septations. Morphology additions include clustered ring enhancement in contrast-enhanced studies. Morphology terms that have been revised include “non-masslike” to “non-mass” enhancement, and “irregular” mass margins to “uneven” mass margins in masses that have an irregular shape. Last, the Lexicon recommends a final BIRADS assessment including BIRADS codes 0 – Incomplete, Need Additional Imaging Evaluation, 1 – Negative, 2 – Benign, 3 – Probably Benign, 4 – Suspicious, 5 – Highly Suggestive of Malignancy, and 6 – Known Biopsy Proven Malignancy. The ACR Breast MRI Lexicon publication also includes an atlas that illustrates the key findings described in the lexicon. Because the contributors to the atlas were based both in the USA and around the world, there are a wide variety of techniques and pulse sequences that were used to generate the images. Variability in the examples include axial, sagittal, multi-planar reconstructions, fatsuppressed and non-fat-suppressed images chosen as state-of-theart, providing the reader with the rare chance to view MRI studies of specific findings using high-quality, varying techniques.

Ankle-brachial index (ABI) and quiescent-interval single shot (QISS) MRA in peripheral arterial disease (PAD): comparison of diagnostic accuracy and need for additional imaging procedures

Background PAD is a major cause of morbidity and accurate diagnosis is essential for optimal patient management. ABI measurement is the initial diagnostic test of choice however, accuracy is sometimes limited, e.g. in diabetic patients and with vessel calcification. Additional imaging with CTA, MRA, or DSA is often required prior to revascularization. QISS MRA is a rapid, operator-independent non-contrast MRA technique which has been reported to evaluate PAD with accuracy comparable to that of CE-MRA (1). We compared ABI and QISS MRA with respect to the following: (a) what is the accuracy for hemodynamically significant stenoses; (b) was the detected abnormality located in the symptomatic limb; (c) after imaging with QISS MRA is there an expectation for additional imaging evaluation prior to intervention?

Association of diagnostic work-up with subsequent attendance in a breast cancer screening program for false-positive cases

The objective of this study is to determine whether the likelihood of returning for routine breast cancer screening differed for false-positive cases depending on the diagnostic work-up. Using the original data from a French population-based breast cancer screening program, we compared the attendance rates at the subsequent round of screening for 16,946 and 1,127 participants who received negative (i.e., American College of Radiology, ACR, categories 1-2) and false-positive mammograms, respectively. False-positive mammograms were categorized ACR 0 (i.e., warranting additional imaging evaluation), 3 (i.e., warranting clinical and imaging follow-up), and 4-5 (i.e., warranting biopsy). We estimated the odds ratios of attendance at subsequent screening round using logistic regression, adjusting for age and history of previous mammography. The attendance rates at the subsequent screening round were 80.6% for women who received negative mammograms versus 69.6, 74.3, and 70.1% for women who received false-positive mammograms warranting additional imaging evaluation, clinical and imaging follow-up, or biopsy, respectively. In comparison to women who received negative mammograms, the corresponding adjusted odds ratios of returning for routine screening were 0.6 [95% confidence interval (CI) 0.4-0.8], 0.8 (95% CI 0.6-0.9), and 0.6 (95% CI 0.4-0.8). No significant differences were found in odds ratios of attendance across ACR categories among women who received false-positive mammograms. Similar figures were observed for attending at least one of the two subsequent screening rounds. In conclusion, in comparison to women with normal or benign findings on index mammograms, false-positive cases warranting additional imaging evaluation, clinical and imaging follow-up, or biopsy had uniformly decreased odds of attending subsequent routine screening rounds.

Recommendation for Short-Interval Follow-Up Examinations After a Probably Benign Assessment: Is Clinical Practice Consistent With BI-RADS Guidance?

American College of Radiology BI-RADS guidance suggests that women with a probably benign finding on mammography receive a management recommendation for short-interval follow-up; historically, radiologists in community practice have not consistently linked this assessment with short-interval follow-up. We evaluated predictors of discordance between probably benign assessments and short-interval follow-up recommendations. We linked data on 196 radiologists who completed a survey on demographic and practice patterns to 15,515 diagnostic mammograms they interpreted with probably benign assessments between 2001 and 2006. Patient characteristics were collected at the time of the mammography. Using logistic regression, we examined whether patient and radiologist characteristics were associated with the odds of short-interval follow-up recommendations (relative to a recommendation for normal follow-up, additional imaging evaluation, or biopsy or surgical consultation). Overall, 90.9% of mammograms with probably benign findings were recommended for short-interval follow-up; 4.3% were recommended for normal follow-up, 3.0% for additional imaging, and 1.8% for biopsy or surgical consultation. Women with probably benign findings were less likely to receive a short-interval follow-up recommendation if they had extremely dense breasts versus almost entirely fatty breasts (odds ratio [OR], 0.61; 95% CI, 0.39-0.96) or had a breast lump versus no symptoms (OR, 0.55; 95% CI, 0.38-78). Radiologists were less likely to recommend short-interval follow-up if they had >/= 20 years of experience versus < 10 years of experience (OR, 0.57; 95% CI, 0.36-0.90) but more likely if they practiced primarily at an academic medical center versus other institutions (OR, 2.66; 95% CI, 1.14-6.21). In contrast to older studies, the majority of probably benign assessments are now recommended for short-interval follow-up, but the probability of short-interval follow-up recommendations varies by patient and radiologist characteristics.

Anterior Cruciate Ligament Reconstruction With and Without Computer Navigation: A Clinical and Magnetic Resonance Imaging Evaluation 2 Years After Surgery

The purpose of this study was to evaluate the benefits of computer navigation on tunnel placement during anterior cruciate ligament reconstruction. A prospective, randomized, controlled study comparing computer navigation with manual operation was performed between December 2003 and April 2004. We assigned 20 patients to the computer navigation group and 20 patients to the manual navigation group. Surgery was performed by use of a patellar tendon autograft with press-fit fixation. A lateral radiograph of the knee at maximum extension was used to determine the exact position of the tibial tunnel at 4 days postoperatively. Outcomes were evaluated with International Knee Documentation Committee 2000, Tegner, and Lysholm scoring. There was an additional magnetic resonance imaging (MRI) evaluation of tunnel placement and graft quality at the most recent follow-up, approximately 24 months after surgery. The postoperative radiographs and 2-year postoperative MRI scans showed no differences between groups for tibial or femoral tunnel placement. In both groups the mean tibial tunnel placement was 46% of the maximal diameter of the tibia. There were no significant differences between groups for objective and subjective outcomes scoring. Although some qualitative differences existed between groups with respect to MRI graft appearance at 2 years, this had no correlation with overall results. No significant differences were found between computer-assisted and manually navigated anterior cruciate ligament reconstruction with regard to tunnel placement and clinical results at a mean of 2 years postoperatively. Level I, randomized, single-blinded, controlled trial.

Magnetic Resonance Appearance of Bone Marrow Edema Associated With Hydroxyapatite Deposition Disease Without Cortical Erosion

The authors report the magnetic resonance (MR) appearance of bone marrow edema associated with hydroxyapatite deposition disease without cortical erosion. Hydroxyapatite deposition disease may have bone marrow edema on MR imaging without radiographic evidence of cortical erosion, mimicking the appearance of fracture, neoplasm, or infection. Awareness of this association can prevent unnecessary additional imaging evaluation or biopsy.

Evaluation of abnormal mammography results and palpable breast abnormalities.

Because approximately 1 in 10 women with a breast lump or abnormal mammography result will have breast cancer, a series of decisions must be taken by a primary care practitioner to exclude or establish a diagnosis of breast cancer among these women. To determine the most accurate and least invasive means to evaluate an abnormal mammography result and a palpable breast abnormality. MEDLINE search (January 1966 to March 2003) for articles and reviews describing the accuracy of clinical examination, biopsy procedures, and radiographic examination for patients with abnormal mammography results or palpable breast abnormalities. The authors reviewed abstracts and selected articles that provided relevant primary data. Studies were included if 1) mammography, fine-needle aspiration biopsy, or core-needle biopsy was performed before a definitive diagnosis was obtained; 2) the study sample included 100 or more women; and 3) breast cancer status was determined from histopathology review of excisional biopsy specimens, from linkage with a state cancer registry or the Surveillance, Epidemiology, and End Results program, or from clinical follow-up of 95% or more of the study sample. One investigator abstracted results. Methods were evaluated for major potential biases, but methodologic scoring was not performed. Likelihood ratios for first screening mammography were 0.1 for the Breast Imaging Reporting and Data System (BI-RADS) assessment category "negative or benign finding," 1.2 for "probably benign finding," 7 for "need additional imaging evaluation," 125 for "suspicious abnormality," and 2200 for "highly suggestive of malignancy." For fine-needle aspiration biopsy of a palpable lump performed by formally trained physicians, the likelihood ratio was infinity for an assessment of "malignant," 2.6 for "atypical/suspicious," and 0.02 for "benign." When diagnostic mammography was used to evaluate a palpable lump or nonpalpable breast abnormality, the positive likelihood ratios were 5.6 and 9.4, and the negative likelihood ratios were 0.15 and 0.19, respectively. Women whose screening mammography results are interpreted as "suspicious abnormality" or "highly suggestive of malignancy" have a high risk for breast cancer and should undergo core-needle biopsy or needle localization with surgical biopsy. Women whose screening mammography results are interpreted as "need additional imaging evaluation" have a moderate risk for breast cancer and should undergo diagnostic mammography or ultrasonography to decide whether a nonpalpable breast lesion should be biopsied. Women whose screening mammography results are interpreted as "probably benign finding" have a low risk for breast cancer and can undergo follow-up mammography in 6 months. Either fine-needle aspiration biopsy or ultrasonography is recommended as the first diagnostic test of a palpable breast abnormality to distinguish simple cysts from solid masses. Fine-needle aspiration biopsy also allows characterization of a solid mass. Diagnostic mammography does not help determine whether a palpable breast mass should be biopsied and should not affect the decision to perform a biopsy.

Nontraumatic avulsions of the pelvis.

The purpose of this report is to describe the imaging findings of nontraumatic avulsions of the pelvis. A diagnosis of avulsion fracture of the pelvis in an adult without appropriate history of substantial trauma must raise the suspicion of an underlying malignancy. If a patient has not been diagnosed as having a primary neoplasm, additional imaging evaluation is recommended. Also, biopsy may be considered in the proper clinical setting.