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Breast MRI provides high sensitivity but modest positive predictive value for identifying breast cancers, with approximately 75% of MRI-guided biopsies returning benign pathologies. Fibrocystic change (FCC) is a descriptive term used colloquially by many radiologists (and falling out of favor with many pathologists) to refer to several benign entities encountered in the breast. Many of the benign entities believed to comprise FCC can show enhancement on MRI. Recognizing the pathologic correlates of these enhancing lesions should help guide management after such a result on MRI-guided biopsy. Premenopausal women may present with clinical symptoms attributed to FCC, including pain, nipple discharge, breast lumps, or discrete masses. Benign entities associated with FCC include proliferative lesions such as usual ductal hyperplasia and sclerosing adenosis, and nonproliferative lesions including cysts, apocrine metaplasia, and stromal fibrosis. Fibrocystic change can be diffuse or focal. Diffuse FCC usually presents as non-mass enhancement (NME), often with persistent kinetics. Focal FCC can present as an irregular mass or focus with variable enhancement patterns including washout kinetics. Following a benign concordant MRI-guided biopsy result of one or more of the above entities, follow-up with MRI in 12 months is reasonable. Accurate radiologic–pathologic correlation can be achieved when careful review of histologic findings is carried out in the context of MRI features.

Two heterogeneous populations with widely varying needs are being increasingly encountered in breast care facilities: blind or low vision patients and deaf or hard of hearing patients. The Americans with Disabilities Act and the Rehabilitation Act mandate that all governments, businesses, and not-for-profit organizations provide effective communication to those facing hearing, vision, or speech communication disabilities and that the provided communication is equally effective as that provided to those lacking communication disabilities. It is vitally important that breast center providers understand the requirements put forth by these acts in the provision of patient care, which includes interactions with the patient as well as their family members and partner. Breast center providers must identify each patient’s individual needs and preferred method of communication. Options to assist in communication for the deaf or hard of hearing include the use of text conversations, preprinted or accessible video health care education material, and dedicated American Sign Language or video interpreters. Attention to breast imaging facility design, access to large print or braille documents, and the use of qualified readers can aid in improving access and communication for the blind or low-vision individual. All members of the breast health team, from scheduling staff to front office personnel, technologists, and breast imaging radiologists, should understand how to respectfully communicate with and identify the needs of patients facing these challenges.

Rationale and Objectives To evaluate interview techniques currently used in the selection of diagnostic radiology resident candidates and to identify factors influencing the use of alternative interview techniques. Materials and Methods An anonymous 25 question e-mail survey was provided to 319 active members of the Association of Program Directors in Radiology. The survey included questions on residency demographics, organization of resident applicant interviews, types of interview techniques utilized, scoring and ranking of applicants, and facets of the interview/application felt most important to the selection process. Statistical analysis was performed to identify factors associated with the use of alternative interview techniques. Results 93.7% of responding programs use traditional interview techniques, with 92% using unblinded, unstructured interviews, 8% blinded, unstructured interviews. Structured interview questions were incorporated in 22%. Few programs used alternative techniques like the multiple mini-interview. None of the programs used written prompts during the interview, 3% used casual visual cognitive testing, 10% used panel interview techniques, and none used formal personality testing. For ranking candidates in the match, the most important facets considered were USMLE Step scores, performance on the interview, clinical course grades, and letters of reference. Factors associated with use of alternative techniques were domains associated with program size and number of faculty. Conclusion The majority of radiology training programs still rely upon the traditional unblinded interview technique. There is an opportunity for training programs to examine alternative techniques that reduce bias and may provide better insight into other aspects of the candidate that may not be as readily highlighted with the traditional, unblinded interview.

Competency-based medical education (CBME) is a method of educating and assessing trainees that focuses on outcomes, rather than process. In this review, we inform radiologists involved in breast imaging training on the tenets of CBME and its relationship to the milestones, feedback and assessment. We also describe multiple methods for assessment specific to the breast imaging curriculum, and techniques for improving feedback to trainees in breast imaging.

The purpose of this study was to quantify the amount of scatter radiation received at the skin surface overlying the thyroid gland, salivary gland, lens of the eye, sternum, and uterus during a routine screening digital mammographic examination measured in a representative patient population.The subjects were 207 women without symptoms with varied body mass indexes who underwent annual screening mammography while wearing six optically stimulated luminescence dosimeters placed at the bridge of the nose, right submandibular gland, right and left thyroid lobes, mid sternum, and 2 cm caudal to the umbilicus to assess scatter radiation dose to the skin.The average scatter radiation doses at the skin surface during digital screening mammography in the representative population of women were as follows: overlying the right lobe of the thyroid, 0.24 mGy; left lobe of the thyroid, 0.25 mGy; salivary gland, 0.2 mGy; bridge of the nose, 0.025 mGy; sternum, 0.87 mGy; and umbilicus, 0.011 mGy. The scatter radiation doses at the umbilicus and the bridge of the nose were too low to measure with statistical confidence. Scatter radiation dose increased with increasing body mass index and increasing breast compression thickness.Scatter radiation dose at the skin overlying organs of interest is a small fraction of the entrance skin dose to the breast. The low levels of scatter radiation measured do not support delaying clinically indicated mammography during early pregnancy.

Musculoskeletal injuries have been and remain a significant issue for sonographers. Despite its importance, the topic of musculoskeletal injury in sonographers has received little attention in the radiology literature. Our goal is to bring this extremely important issue to the forefront, with the hope of initiating conversations and actions leading to improved workplace practices for sonographers.

Professionalism is part of the milestone program instituted by the Accreditation Council for Graduate Medical Education and the American Board of Radiology. A unique feature of ultrasound professionalism is the relationship between the radiologist and the sonographer. Because this relationship is important for sonographic quality and ultimately patient outcome, residents should be trained to achieve an optimal professional relationship with sonographers. This article describes milestones for ultrasound professionalism and suggests methods of implementation.

The purpose of this study was to compare hematoma formation after breast core needle biopsy performed on patients undergoing and those not undergoing concurrent antithrombotic therapy.A prospective assessment of core needle biopsies (stereotactic, ultrasound guided, or MRI guided) performed on patients enrolled between September 2011 and July 2012 formed the basis of this study. Postprocedure mediolateral and craniocaudal mammograms were evaluated for the presence and size of hematomas. Patients were clinically evaluated for complications 24-48 hours after the procedure through telephone call or face-to-face consultation. Needle size, type of biopsy, and presence of hematoma and documented complications were correlated with use of antithrombotic agents (including aspirin, warfarin, clopidogrel, and daily nonsteroidal antiinflammatory medications).No clinically significant hematomas or bleeding complications were found. Eighty-nine of 617 (14.4%) non-clinically significant hematomas were detected on postprocedure mammograms. The probability of development of a non-clinically significant hematoma was 21.6% for patients taking antithrombotics and 13.0% for those not taking antithrombotics. Concurrent antithrombotic therapy and larger needle gauge were significant factors contributing to the probability of hematoma formation. The volume of the hematoma was not related to needle gauge or presence of antithrombotic therapy.No clinically significant hematomas were found. Because there are potential life-threatening risks to stopping antithrombotic therapy before breast biopsy, withholding antithrombotic therapy for core needle breast biopsy is not recommended because the incidence of non-clinically significant hematoma is low.

The National Lung Screening Trial (NLST) is a randomized multicenter study comparing low-dose helical computed tomography (CT) with chest radiography in the screening of older current and former heavy smokers for early detection of lung cancer, which is the leading cause of cancer-related death in the United States. Five-year survival rates approach 70% with surgical resection of stage IA disease; however, more than 75% of individuals have incurable locally advanced or metastatic disease, the latter having a 5-year survival of less than 5%. It is plausible that treatment should be more effective and the likelihood of death decreased if asymptomatic lung cancer is detected through screening early enough in its preclinical phase. For these reasons, there is intense interest and intuitive appeal in lung cancer screening with low-dose CT. The use of survival as the determinant of screening effectiveness is, however, confounded by the well-described biases of lead time, length, and overdiagnosis. Despite previous attempts, no test has been shown to reduce lung cancer mortality, an endpoint that circumvents screening biases and provides a definitive measure of benefit when assessed in a randomized controlled trial that enables comparison of mortality rates between screened individuals and a control group that does not undergo the screening intervention of interest. The NLST is such a trial. The rationale for and design of the NLST are presented.

The purpose of this study was to characterize the type and frequency of diagnostic evaluations after screening mammography and to summarize their association with the likelihood of biopsy and subsequent breast cancer diagnosis.The data source was 584,470 women with no previous breast cancer from six states in the Breast Cancer Surveillance Consortium. In this observational study, we linked data from 1,207,631 routine screening mammograms performed between January 1, 1996, and December 31, 2002, to data on additional imaging, interventional procedures, and biopsy outcome (benign or malignant). Additional examinations were categorized into diagnostic mammography, sonography, or both. Events were further subdivided by whether they were performed on the same day as the screening examination and whether patients reported breast symptoms. Logistic regression analysis was used to examine the association between additional evaluation performed and the likelihood of biopsy and the likelihood of subsequent breast cancer diagnosis after adjustment for patient and screening mammographic characteristics.Most (92%) of the screening examinations did not include additional imaging. The probability of biopsy ranged from 0.4% for examinations with no follow-up to 20.1% for those with diagnostic mammography and sonography on the same day as screening among women without symptoms and from 2.1% for those with no follow-up to 18.9% for those with diagnostic mammography and sonography on a day different from screening among women with symptoms. Thirty percent of women without symptoms who underwent biopsy had cancer, whereas 27.1% of women with symptoms who underwent biopsy had cancer. Women who underwent biopsy after screening mammography with diagnostic mammography and sonography on the same day had the highest probability of breast cancer (37.6% among women without symptoms, 36.4% among women with symptoms), whereas those who underwent only sonography performed at a later date had the lowest probability of breast cancer (11.9% among women without symptoms, 17.1% among women with symptoms).Women who undergo screening mammography followed by diagnostic mammography and sonography have a high probability of undergoing biopsy and having the biopsy result of breast cancer when follow-up imaging is performed on the same day as screening mammography whether or not breast symptoms are present. Biopsy performed after sonography in the absence of diagnostic mammography had a low yield of breast cancer.

Context The objective of this paper is to report the prevalence and correlates of both prescription and non-prescription hormone use. Design/setting/sample Cross-sectional baseline study from a prospective cohort of 30,448 women receiving mammography in New Hampshire. Main outcome measures Odds of prescription hormone and non-prescription hormone use. Results 29,851 women were included; 62% reported some use of prescription hormone therapy, with current long-term prescription hormone therapy users representing the largest group (25%). Among ever-users, estrogen only was the most commonly used preparation (71% versus 30% for estrogen and progestin combined). Both single agent estrogen and estrogen and progestin combined regimens were taken primarily for treatment of menopausal symptoms or disease prevention. Correlates for prescription hormone use included a family history of breast cancer (associated with decreased use—OR 0.88; 95% CI: 0.84, 0.93), and family history of heart disease (associated with increased use—OR 1.11; 95% CI: 1.06, 1.17). Ten percent of women reported ever use of phytoestrogens (over-the-counter hormones). Family history of breast cancer was a correlate of over-the-counter hormone use (OR 1.10; 95% CI: 1.01, 1.19). Conclusion Management of menopausal symptoms and disease prevention were the main reasons for using prescription hormones, and health histories were important correlates of both prescription and over-the-counter hormone exposures. As evidence changes regarding risks and benefits of hormone exposure, primary care physicians should help women reassess their use of hormonal agents.

Mammography screening can involve subsequent work-up to determine a final screening outcome. Understanding the likelihood of different events that follow initial screening is important if women and their health care providers are to be accurately informed about the screening process.We conducted an analysis of additional work-up following screening mammography to characterize use of supplemental imaging and recommendations for biopsy and/or surgical consultation and the factors associated with their use. We included all events following screening mammography performed between 1/1/1998 and 12/31/1999 on a population-based sample of 37,632 New Hampshire women. We calculated adjusted odds ratios (OR) and 95% confidence intervals (CI) for supplemental imaging and recommended biopsy and/or surgical consultation as function of age, menopausal status and HRT use, breast density, and family history of breast cancer.Ninety-one percent of women (n = 34,445) did not require supplemental imaging. Among those who did (n = 3187), 84% had additional views, 9% ultrasound, and 7% received both. Supplemental imaging was affected by age (OR 0.84; 95% CI = 0.76-0.94 for 50-59; OR = 0.66; 95% CI = 0.58-0.75 foror = 60 versus50), menopausal status, and HRT use (OR = 1.33; 95% CI = 1.21-1.47 for peri- or post-menopausal HRT users; OR = 1.14; 95% CI = 1.01-1.29 for premenopausal versus peri- or post-menopausal non-HRT users), breast density (OR = 1.43; 95% CI = 1.33-1.55 for dense versus fatty breasts) and family history (OR = 1.15; 95% CI = 1.06-1.25 for any versus none). In women with supplemental imaging, age (OR = 1.80; 95% CI = 1.11-2.90 foror = 60, relative to50) and imaging type (OR = 3.23; 95% CI = 2.38-4.38 for ultrasound with or without additional views versus additional views only) were significantly associated with biopsy and/or surgical consultation recommendation. In those with no supplemental imaging, breast density was associated with recommended biopsy and/or surgical consultation (OR = 1.53; 95% CI = 1.13-2.07 for dense versus fatty breasts).Breast density and HRT use are both independent predictors of use of supplemental imaging in women. With advancing age (age 60 and older), women were less likely to require follow-up imaging but more likely to receive a recommendation for biopsy and/or surgical consultation. This information should be used to inform women about the likelihood of services received as part of the screening work-up.

First-trimester sonography is an essential tool in the assessment of the viability of the early pregnancy. Familiarity with prognostic indicators, such as abnormalities of the gestational sac, yolk sac, and embryonic heart rate, allow the sonologist to appropriately caution patients or allay fears i

Background The correlation between facial and/or head pain in patients clinically suspected of having sinusitis and actual localized findings on sinus computed tomographic (CT) imaging are poorly understood. Objective To prospectively evaluate the relationship of paranasal sinus pain symptoms with CT imaging. Methods Two hundred consecutive patients referred by otolaryngologists and internists for CT of the paranasal sinuses participated by completing a questionnaire immediately before undergoing CT. Three radiologists blinded to the patients' responses scored the degree of air/fluid level, mucosal thickening, bony reaction, and mucus retention cysts using a graded scale of severity (0 to 3 points). The osteomeatal complexes and nasolacrimal ducts were also evaluated for patency. Bivariate analysis was performed to evaluate the relationship between patients' localized symptoms and CT findings in the respective sinus. Results One hundred sixty-three patients (82%) reported having some form of facial pain or headache. The right temple/forehead was the most frequently reported region of maximal pain. On CT imaging the maxillary sinus was the most frequently involved sinus. Bivariate analysis failed to show any relationship between patient symptoms and findings on CT. Patients with a normal CT reported a mean 5.88 sites of facial or head pain versus 5.45 sites for patients with an abnormal CT. Conclusions Patient-based responses of sinonasal pain symptoms fail to correlate with findings in the respective sinuses. CT should therefore be reserved for delineating the anatomy and degree of sinus disease before surgical intervention.

OBJECTIVE Five image reconstruction techniques have been used with CT angiography: axial (cross-sectional), maximum intensity projection (MIP), curved multiplanar reconstruction (MPR), shaded-surface display, and volume rendering. This study used a phantom to compare the accuracy of these techniques for measuring stenosis. SUBJECTS AND METHODS A 19-vessel phantom containing various grades of concentric stenoses (0-100%) and three lengths (5, 7.5, and 10 mm) of stenoses was used for this study. Scans were obtained with a slice thickness of 2.0 mm, slice interval of 1.0 mm, pitch of 1.0, 120 kVp, 200 mA, and with the vessels oriented parallel to the z-axis and opacified with nonionic contrast material. CT angiography images were produced using five optimized techniques: axial, MIP, MPR, shaded-surface display, and volume rendering; and measurements were made with an electronic cursor in the normal lumen and mid stenosis by five separate investigators who were unaware of vessel and stenosis diameters. Each of the techniques was first optimized according to the radiology literature and our own preliminary testing. RESULTS For vessels greater than 4 mm in diameter, axial, MIP, MPR, shaded-surface display, and volume-rendering CT angiography techniques all had a measurement error of less than 2.5%. However, axial, MIP, MPR, and shaded-surface display techniques were less accurate in estimating smaller (

Rationale and Objectives The authors performed this study to determine the optimum threshold for performing computed tomographic (CT) angiography with shaded surface display (SSD). Materials and Methods A dedicated phantom was developed with an 8-mm luminal diameter. Each of 19 vessels had stenoses ranging from 0% to 93.8%. Five blinded, experienced reviewers separately measured each vessel by using SSD with display thresholds of 50, 100, 150, and 200 HU. Results For vessel diameters of 2 mm and larger, the best threshold value was 100 HU. This yielded measurements within 2% of the actual diameter and produced no false occlusions. For vessels 1 mm in diameter, the best threshold remained 100 HU, but this threshold was significantly less accurate than the standard ( P = .0001) and produced two false occlusions in 15 vessels. For vessels 0.5 mm in diameter, the best threshold was 50 HU, although this still produced measurements significantly less accurate than the gold standard ( P = .036) and one false occlusion in 15 vessels. Conclusion CT angiography with SSD and an optimized threshold value is a useful technique in vessels 1 mm and larger.

The authors evaluated the relative importance of the following scanning parameters at computed tomographic bronchoscopy in an anesthetized adult sheep's thorax: section thickness (2, 4, 8 mm), pitch (1.0, 1.5, 2.0), milliampere setting (100, 175, 250 mA), and overlap of reconstructed sections (0%, 25%, 50%, 75%). Five blinded readers ranked the images twice in comparison with photographs of the mounted specimen. Differences in image quality were significant (P < .001) with section thickness of 2 mm and a pitch of 1.0. The milliampere setting had only a minor effect on image quality, and a 50% overlap of reconstructed sections was best.

The objective of this study was to evaluate the utility of a low mA 1.5 pitch helical versus conventional high mA conventional technique in abdominal computed tomography (CT). Twenty-five patients who had both a conventional high mA (>300) and a 1.5 pitch low mA (80–125) helical CT within 3 months were selected for inclusion in the study. Patients were excluded who had a significant change in pathology between the two studies. The other parameters (injection rate, contrast type and volume, and filming window/level) were constant. The studies were randomized and blinded to five separate experienced readers who graded the studies by a variety of normal anatomical structures and pathological criteria. Overview questions also assessed noise, resolution, contrast, and overall quality. The abdominal wall/retroperitoneum and hiatal hernias were statistically better visualized on the conventional high mA studies. However, for all other normal anatomical and pathological sites, there was equivalent or better visualization on the helical versus the conventional CT examinations. The resolution of the helical studies was graded statistically better than the high mA conventional CT scans as was the amount of noise present on the images. While there was some advantage for conventional high mA CT with respect to contrast enhancement and low contrast sensitivity, these differences were not statistically significant. It appears from the data of this study that a low mA technique in evaluating the abdomen may be a useful option in performing routine abdominal CT. The radiation dose savings to the patient is significant and there appears to be little degradation of image quality using a low mA 1.5 helical versus mA conventional CT technique.

The purpose of this article is to show radiologists how to readily recognize nonpuerperal subareolar abscess and its complications in order to help reduce the time to definitive therapy and improve patient care. To achieve this purpose, the various theories of pathogenesis and the associated histopathologic features are reviewed; the typical clinical characteristics are detailed in contrast to those seen in lactational abscess and inflammatory breast cancer; the common imaging findings are described with emphasis on the sonographic features; correlative pathologic findings are presented to reinforce the imaging findings as they pertain to disease origins; and the various treatment options are reviewed.Nonpuerperal subareolar mastitis and abscess is a benign breast entity often associated with prolonged morbidity. Through better understanding of the underlying disease process the imaging, physical, and clinical findings of this rare process can be more readily recognized and treatment options expedited, improving patient care.

The authors performed a comprehensive prospective clinical trial comparing 1.0-, 1.5-, and 2.0-pitch abdominal helical computed tomography (CT) in the evaluation of normal and pathologic structures/lesions.Seventy-five consecutive patients were randomized by computer into one of three equal groups: helical CT pitch 1.0, 1.5, and 2.0. The imaging parameters and contrast enhancement of all 75 patients were kept constant. The 75 studies were masked, placed into a randomized order, and evaluated by five separate experienced radiologists who rated visualization of 25 normal structures and up to five pathologic findings per patient using a scale of 1 (not seen) to 5 (very well seen/very sharp margins).There were no statistical differences in 1.0- and 1.5-pitch abdominal CT scans when assessing the display of normal and pathologic lesions. In addition, helical pitch 1.0 and 1.5 studies were equivalent for both normal and pathologic structures/lesions, whereas equivalency was not demonstrated for helical pitch 2.0 studies. Overall study assessment questions again found equivalency between helical 1.0- and 1.5-pitch studies.Abdominal CT performed with pitches of 1.0 and 1.5 are equivalent. Because of its advantages, we advocate the routine use of an extended pitch (1.5) in routine abdominal CT. Further studies are required to evaluate the usefulness of the helical 2.0-pitch technique.

Purpose Our goal was to perform a detailed comparison of the relative performances of helical CT (pitches 1.0, 1.5, and 2.0) and conventional (overlapped and nonoverlapped) CT in detailed 3D and MPR musculoskeletal imaging. Method A specially designed bone fragment phantom was imaged with multiple slice thicknesses using conventional (overlapped and nonoverlapped) and helical (varying pitch and slice index) CT. Studies were randomized, blinded, and graded using predetermined criteria by 10 radiologists. Statistical analysis included an assessment of raw image scores, a separate testing using duplicate copies of the conventional images as gold standards, and a multivariate model based upon the results of both scoring systems. Results When assessing raw scores of the images, conventional scans were consistently scored more favorably than helical studies. Decreasing the slice index improved conventional CT studies and helical studies with a pitch of 1.0, but showed no effect on helical studies with a pitch of > 1.0. When using the conventional studies as gold standards, the helical studies were consistently graded as poorer than conventional overlapped and nonoverlapped studies. Conclusion For detailed musculoskeletal 3D and MPR work, helical CT may not adequately compare with conventional CT and offers no discernible advantage, particularly for pitches of > 1.0.

The purpose of this study was to evaluate the variability between radiologists interpreting thoracic and abdominal/pelvic CT scans in selecting specific sites of metastatic tumor for measurement (indicator lesions) and to assess interobserver and intraobserver variability in tumor measurement.Three separate experienced radiologists were asked to review 24 combined thoracic and abdominal CT scans in patients with metastatic tumor. Each radiologist was asked to identify the indicator lesions representative of each patient's tumor bulk. In the second phase of the study, 105 specific foci on 26 combined thoracic and abdominal CT studies (including the original 24) were reviewed twice by the same three radiologists. Up to eight foci were randomly identified per patient, and each observer was asked to determine the slice with the maximum diameter for each tumor focus and to measure it in three dimensions (maximum diameter, its perpendicular, and length).A total of 132 tumor sites were present on the CT studies in phase I, all of which were chosen by at least one observer as an indicator lesion. Of the 116 of these that were separate and nonoverlapped, 57 (49%) were measured by only one observer, whereas 32 (28%) and 27 (23%) were measured by two or all three observers, respectively. Observers were more inclined to pick round or defined/well-defined lesions rather than irregular, oval, or poorly defined ones, although this tendency was not statistically significant. The second phase of the study showed considerable interobserver variability (15%) in CT tumor measurement, which was worse for poorly defined and irregular lesions. Intraobserver variability in measuring individual foci was less (6%).Radiologists interpreting thoracic and/or abdominal/pelvic CT scans for metastatic cancer should measure and report a significant number of each patient's tumor sites, especially larger ones in different anatomic areas. When interpreting a follow-up CT scan of a patient with metastatic cancer, the interpreting radiologist should remeasure the indicator lesions on the previous and on the follow-up CT scans, especially when the results will change the patient's treatment response category.

Pediatric breast masses are relatively rare and most are benign. Most are either secondary to normal developmental changes or neoplastic processes with a relatively benign behavior. To fully understand pediatric breast disease, it is important to have a firm comprehension of normal development and of the various tumors that can arise. Physical examination and targeted history (including family history) are key to appropriate patient management. When indicated, ultrasound is the imaging modality of choice. The purpose of this article is to review the benign breast conditions that arise as part of the spectrum of normal breast development, as well as the usually benign but neoplastic process that may develop within an otherwise normal breast. Rare primary carcinomas and metastatic lesions to the pediatric breast will also be addressed. The associated imaging findings will be reviewed, as well as treatment strategies for clinical management of the pediatric patient with signs or symptoms of breast disease.The majority of breast abnormalities in the pediatric patient are benign, but malignancies do occur. Careful attention to patient presentation, history, and clinical findings will help guide appropriate imaging and therapeutic decisions.

Hysterectomy, one of the most commonly performed surgical procedures, leads to characteristic changes in the appearance of the pelvis on imaging studies. Women who have had a hysterectomy are often at risk for several complications, both benign and malignant, that are frequently evaluated with cross-sectional imaging. This pictorial essay explores the appearance of the normal pelvis after hysterectomy as well as the many complications that can occur, stressing the appropriate utilization of such studies and correlation with clinical history to aid in patient management.

This in vitro study was designed to assess the z-axis resolving capabilities of reconstructed helical CT scans obtained with various imaging parameters versus those of conventional CT scans and the effect of decreasing slice index on the z-axis resolution of helical CT.A z-axis line-pair phantom was imaged using conventional nonoverlapped CT scans, conventional CT scans that overlapped by 50%, and helical CT scans with pitches of 1.0 and 1.5. All helical images were reconstructed at comparable slice indexes (image indexes of 2.0, 1.0, and 0.5 mm for pitch = 1.0, and image indexes of 3.0, 1.5, and 0.75 mm for pitch = 1.5). Midline coronal and sagittal reconstructed images were obtained to allow standardized visualization of line pairs. The reconstructed images were reviewed separately by 10 radiologists.The overall z-axis resolution of reconstructed helical CT scans equaled or exceeded that of nonoverlapped conventional CT scans in all cases and equaled that of 50% overlapped conventional CT scans in 75% of cases. The 1.0-pitch helical sequences showed improved z-axis resolution with decreasing slice index. No statistically significant improvement in z-axis resolution could be determined by the observers for 1.5-pitch sequences with decreasing slice index.The use of helical CT with a pitch of 1.0 or 1.5 and an increased slice index can improve the z-axis resolution of reconstructed images when compared with nonoverlapped conventional CT and frequently equals the resolution of 50% overlapped conventional CT. This improvement in z-axis resolution should improve the appearance of reconstructed images (as used in CT angiography and three-dimensional imaging) by reducing partial volume artifacts while affording faster scanning at a reduced skin-surface radiation dose.

Exencephaly is a rare congenital anomaly, thought to be a precursor of anencephaly. Like anencephaly, this abnormality is characterized by absence of the cranial vault above the orbits. However, unlike anencephaly, discrete, sometimes disorganized, brain tissue can be identified above the cranial defect. In this article, the authors report a case of exencephaly diagnosed prenatally during transvaginal ultrasound examination, with anatomic and pathologic correlation.

PURPOSE We sought to determine how breast cancers that occur within 1 year after a normal mammogram are discovered. METHODS Using population-based mammography registry data from 2000–2002, we identified 143 women with interval breast cancers and 481 women with screen-detected breast cancers. We surveyed women’s primary care clinicians to assess how the interval breast cancers were found and factors associated with their discovery. RESULTS Women with interval cancers were twice as likely to have a personal history of breast cancer (30.1%) as women with screen-detected cancers (13.6%). Among women with interval cancers, one half of the invasive tumors (49.5%) were discovered when women initiated a health care visit because of a breast concern, and 16.8% were discovered when a clinician found an area of concern while conducting a routine clinical breast examination. Having a lump and both a personal and a family history of breast cancer was the most common reason why women initiated a health care visit (44%) (P

Congenital mesoblastic nephroma is the most common neonatal renal tumor. Although the mass may be large and is usually associated with polyhydramnios, these tumors rarely recur and rarely metastasize. Presented is a case, with clinical-pathologic correlation, of a pregnant female with size-greater-than-dates secondary to polyhydramnios associated with a congenital mesoblastic nephroma. This diagnosis should be considered in any fetus with polyhydramnios and a large flank/abdominal mass.

A method of power injection of contrast material pushed with injectable saline solution during thoracic computed tomography (CT) was evaluated in 75 patients to help decrease the amount of contrast material necessary. Patients received 50-125 mL of 60% nonionic contrast material alone or pushed with 50 mL of saline. A volume of 75 mL of contrast material pushed with saline provided enhancement of the thoracic vasculature equal to that provided by a 125-mL volume of contrast material administered alone (P < .001) and caused significantly less beam-hardening artifact (P < .01).

Epignatic teratoma with intracerebral extension is a very rare entity, and the prognosis is always grim, with death occurring within the first month of life. Generally, the pregnancy is complicated by a rapid onset of polyhydramnions, which prompts prenatal ultrasound examination. The size of the teratoma interferes with normal fetal swallowing of amniotic fluid, which causes the onset of polyhydramnios. Prenatal ultrasound helps with the assessment of oropharangeal involvement, which can optimize care plans in the postnatal period.

Objectives Evaluate known breast cancer risk factors in relation to breast density. Methods We examined factors in relation to breast density in 144,018 New Hampshire (NH) women with at least one mammogram recorded in a statewide mammography registry. Mammographic breast density was measured by radiologists using the BI-RADS classification; risk factors of interest were obtained from patient intake forms and questionnaires. Results Initial analyses showed a strong inverse influence of age and body mass index (BMI) on breast density. In addition, women with late age at menarche, late age at first birth, premenopausal women, and those currently using hormone therapy (HT) tended to have higher breast density, while those with greater parity tended to have less dense breasts. Analyses stratified on age and BMI suggested interactions, which were formally assessed in a multivariable model. The impact of current HT use, relative to nonuse, differed across age groups, with an inverse association in younger women, and a positive association in older women (p < 0.0001 for the interaction). The positive effects of age at menarche and age at first birth, and the inverse influence of parity were less apparent in women with low BMI than in those with high BMI (p = 0.04, p < 0.0001 and p = 0.01, respectively, for the interactions). We also noted stronger positive effects for age at first birth in postmenopausal women (p = 0.004 for the interaction). The multivariable model indicated a slight positive influence of family history of breast cancer. Conclusions The influence of age at menarche and reproductive factors on breast density is less evident in women with high BMI. Density is reduced in young women using HT, but increased in HT users of age 50 or more.

This study was designed to evaluate the utility of the routine use of high spatial frequency algorithms and higher order helical interpolators for imaging lung parenchyma during routine thoracic CT.We evaluated 50 consecutive patients undergoing clinically indicated thoracic CT using the same imaging parameters and scanner. The helical volume was reconstructed three separate times using standard and higher order (180 degrees linear with double-sided lobes) interpolators and standard and high spatial frequency (bone) algorithms. The images were photographed and given to five separate readers who were kept unaware of the interpolator and algorithm and who were asked to evaluate simultaneously each patient's three sets of images for best, in-between, and worst images of the lung interstitium, pathology, and normal anatomy.All five readers rated the standard interpolator and algorithm images as the worst (p.01). All five readers consistently rated the double-sided lobe interpolator and bone algorithm images as the best (p.01).A second reconstruction of routine thoracic helical CT data using higher order helical interpolators and a bone algorithm significantly improves interstitial detail of lung parenchyma and overall visualization of normal anatomy and pathologic processes.

Meckel diverticulum is the most frequent congenital malformation of the gastrointestinal tract, occurring in approximately 2% of the population. Diagnosis of Meckel diverticulum in the pediatric population is made most often by a nuclear medicine scan and also by fluoroscopy, plain-film radiography, computed tomography, and magnetic resonance imaging. We present a case of Meckel diverticulum evident in utero on a prenatal sonographic examination performed at 33 weeks' gestational age. There were no prenatal complications, and postnatal surgery confirmed Meckel diverticulum. In view of the rarity of Meckel diverticulum, we hope this information will aid radiologists involved in fetal sonography to help determine the differential diagnosis of anechoic intra-abdominal masses in the fetus.

Zebrafish have become a widely used model organism in developmental biology research. In order to initiate an experimental foundation for aging studies, we have determined some basic gerontological parameters for populations of outbred zebrafish, and the golden sparse strain. Outbred zebrafish manifested a mean life span of about 42 months, with the longest living individual surviving for 66 months. The golden sparse populations had a mean life span of 36 months and a maximum longevity of 58 months. Skeletal length at death increased with age, suggestive of indeterminate growth. A common age-related phenotype was spinal curvature. Radiographic analysis excluded bony changes as the cause of the spinal curvature, suggesting muscle abnormalities as a primary mechanism. These data and a growing abundance of related biological resources suggest that the zebrafish may be a compelling model organism for studies on aging.

The purpose of our study was to assess the current experience of radiology residents and fellows in obstetric sonography.Written surveys were sent to the directors of 206 accredited radiology residency programs and 85 fellowship programs in the United States. The surveys encompassed obstetric sonographic experience during routine working hours and after hours, the level of supervision, the types of scanning performed, and the extent of formal lectures available during training. Additional questions concerned the relative knowledge of laboratory accreditation processes and training of faculty covering obstetric sonography.Sixty (29%) of 206 accredited radiology residency programs and 24 (28%) of 85 fellowship programs returned surveys. The experience among residency programs was similar, providing fewer than 4 weeks per year of obstetric sonography, usually within their own department of radiology. Residents were more likely to be sent to outside departments for second or third trimester sonography experience. A decrease in scanning assistance was reported for examinations performed after hours, more so for second or third trimester studies. Lecture topics revealed similar deficiencies for residency and fellowship programs.Greater emphasis on the performance of prenatal sonographic examinations may be warranted during formal sonography rotations. Current levels of experience in obstetric sonography may not be providing sufficient experience to allow residents to appropriately manage call cases or for practicing radiologists to provide such services after their training is completed.

We performed a comparative assessment of CT and sonographic techniques used to assess appendicitis.One hundred patients with clinically suspected acute appendicitis were examined with sonography, unenhanced focused appendiceal CT, complete abdominopelvic CT using IV contrast material, focused appendiceal CT with colonic contrast material, and repeated sonography with colonic contrast material. Each sonogram was videotaped for subsequent interpretation by three radiologists and two sonographers. The mean sensitivity, specificity, positive and negative predictive values, inter- and intraobserver variability, and diagnostic confidence scores of all observers were used for comparative performance assessments. The three CT examinations were filmed and interpreted separately by four radiologists. Patient discomfort was assessed on a 10-point scale for each radiologic study. Diagnoses were confirmed by pathologic evaluation of resected appendixes or clinical follow-up for a minimum of 3 months after presentation.Twenty-four of the 100 patients had positive findings for acute appendicitis. Both sonographic techniques had high specificity (85-89%) and comparable accuracy (73-75%) but low sensitivity (33-35%) and inter- and intraobserver variability (kappa = 0.15-0.20 and 0.39-0.42, respectively). Unenhanced focused appendiceal CT, abdominopelvic CT, and focused appendiceal CT with colonic contrast material all significantly outperformed sonography (p0.0001), with sensitivities of 78%, 72%, and 80%; specificities of 86%, 91%, and 87%; and accuracies of 84%, 87%, and 85%, respectively. Abdominopelvic CT gave the greatest confidence in cases with negative findings (p = 0.001), and focused appendiceal CT with colonic contrast material gave the greatest confidence for cases with positive findings (p = 0.02). In terms of inter- and intraobserver variability, focused appendiceal CT with colonic contrast material yielded the highest, and unenhanced focused appendiceal CT the lowest, agreement (interobserver kappa = 0.45 vs. 0.36 and intraobserver kappa = 0.85 vs. 0.76, respectively) (p0.05). Colonic contrast material was unsuccessfully advanced into the cecum in 18% of patients and leaked in another 24%. Patient discomfort was greatest with focused appendiceal CT using colonic contrast material and least with unenhanced focused appendiceal CT (p0.05).A standard abdominopelvic CT scan is recommended as the initial examination for appendicitis in adult patients. However, focused appendiceal CT with colonic contrast material material should be used as a problem-solving technique in difficult cases.

To evaluate computed tomographic virtual reality with volumetric versus surface rendering.Virtual reality images were reconstructed for 27 normal or pathologic colonic, gastric, or bronchial structures in four ways: the transition zone (a) reconstructed separately from the wall by using volume rendering; (b) with attenuation equal to air; (c) with attenuation equal to wall (soft tissue); (d) with attenuation halfway between air and wall. The four reconstructed images were randomized. Four experienced imagers blinded to the reconstruction graded them from best to worst with predetermined criteria.All readers rated images with the transition zone as a separate structure as overwhelmingly superior (P.001): Nineteen cases had complete concurrence among all readers. The best of the surface-rendering reconstructions had the transition zone attenuation equal to the wall attenuation (P.001). The third best reconstruction had the transition zone attenuation equal to the air attenuation, and the worst had the transition zone attenuation halfway between the air and wall attenuation.Virtual reality is best with volume rendering, with the transition zone (mucosa) between the wall and air reconstructed as a separate structure.

This retrospective study was designed to evaluate individual sonographic parameters that might help differentiate congenital diaphragmatic hernia (CDH) from other noncardiac thoracic masses such as cystic adenomatoid malformation of the lung (CAMI ) and congenital lobar emphysema (CLE) prenatally. Twenty-four cases of CDH, CAML, and CLE detected during prenatal ultrasound and documented postnatally (with surgical, autopsy, or radiological proof) were identified through extensive chart and record review. The hard copy gray-scale images were retrospectively reviewed for imaging characteristics that may differentiate the three entities. Additionally, the prospective diagnosis during prenatal ultrasound was also compared with the postnatal diagnosis. The most reliable indicators in our retrospective review included confident visualization of a diaphragmatic defect (92.3/100.0 PPV/NPV, p ' 0.002) and/or localization of the stomach within the chest as well as the presence of severe cardiac deviation (both 92.3162.5 PPV/NPV, p ' 0.01). Other sonographic indicators (including the presence of cystic areas, side and size of the lesion and the presence of polyhydramnios) offered lower levels of sensitivity and specificity. Prospective diagnosis during real-time assessment was also integral, offering > 80% sensitivity and specificity (p c 0.001). Accurate prenatal diagnosis of CDH is difficult despite the relative frequency of this lesion. The classic triad of a thoracic mass accompanying a displaced heart, absence of a normally positioned fluid-filled stomach and polyhydramnios, although seen with CDH, may not adequately differentiate this entity from other noncardiac fetal thoracic masses. Real-time assessment remains integral to the appropriate diagnosis.

Purpose : This paper reports on the development of a new phantom for spiral CT. The phantom meets the increased demands on phantom z -axis uniformity in order that objects from the CT slice, immediately above and below the CT slice of interest, do not contribute perturbing information to the reconstructed CT slice. Material and methods : The phantom depends on formulation of tissue-like materials that can be cast and produced in both geometric and anthropomorphic shapes with sufficient z -axis length to enable unperturbed CT slices of test objects of interest. These materials are then used to produce a series of test objects of CT image quality including low contrast samples that do not require volume averaging or mixing of solutions, and that can reflect sub-slice thickness test objects and supra-slice thickness test objects. Results : The overall phantom and its individual test objects provides meaningful tests of spiral CT image quality including slice sensitivity, CT number linearity and tests of high and low contrast resolution. Schematic designs and actual CT scans are shown. Conclusion : The new spiral phantom appears to meet the increased demands of spiral CT on phantom design, particularly z -axis length, and requirements for low contrast resolution test objects.

Purpose: Our purpose was to determine the optimal helical thoracic CT scanning protocol. Method: Three adult Suffolk sheep under general anesthesia were repeatedly scanned by a variety of variable thickness helical and conventional plus thin section high resolution (lung gold standard) CT sequences, reconstructed for mediastinal (standard interpolator and algorithm) and lung parenchymal (extrasharp interpolator, bone algorithm) detail. The images were evaluated in a random order by five separate blinded. experienced imagers utilizing a predetermined grading scale. Results: At equivalent slice thicknesses, the mediastinal images showed no statistically significant differences between conventional and helical CT using pitches of 1.0, 1.5, and 2.0. However, the 5-mm-thick sections, regardless of technique, performed better than did either the 2- or the 10-mm-thick section images. For the lung interstitium, there was an obvious and marked advantage to reconstructing the lung images separately from the mediastinal images with edge-enhancing algorithms and interpolators. With l-mm-high mA thin section, high resolution lung CT as the gold standard, 2 mm conventional and helical pitch 1.0, 1.5, and 2.0 images were all graded equivalent. Of the 5 mm images, the helical pitches of 1.0 and 1.5 were graded equivalent to the gold standard. All of the 10 mm lung sections using both conventional and helical CT were graded statistically worse than the gold standard (p < 0.05). Conclusion: The use of helical CT with a 5 mm beam collimation and a pitch of 1.0 or 1.5 reconstructed twice to maximize both the mediastinal and the lung parenchymal detail provides the optimal way to routinely evaluate the chest.

The objective of this study was to test whether extended 1.5 pitch helical computed tomography (CT) can be used for routine thoracic CT without a significant loss of clinical scan quality. Thirty consecutive patients presenting for contrast thoracic CT were computer randomized into one of three groups: conventional, 1.0 pitch helical, and 1.5 pitch helical. All other variables, including kV, mA, slice thickness and reconstruction interval, and contrast administration, were kept constant. The studies were randomized to five independent, blinded, experienced radiologists who rated visualization 25 normal structures, and up to five pathologic findings per patient. In addition, each reader evaluated the studies' contrast enhancement, low contrast sensitivity, linear resolution, motion artifact, noise, and overall quality. The visualization score for all normal and overall for pathological lesions did not vary between groups. The three groups were not equivalent for several individual pathologic categories. However, these differences were not consistently in favor of one technique over the other two. The overall score for scan quality was not significantly different between the three groups. Extended 1.5 pitch thoracic helical CT provides equivalent quality versus either 1.0 pitch helical or conventional CT. The use of 1.5 pitch helical thoracic CT allows faster scanning, greater patient coverage, and the use of reduced amounts of intravenous contrast.

RATIONALE AND OBJECTIVES The authors evaluate the usefulness of stacked multiplanar reconstructions in routine, thick-section abdominal computed tomography. MATERIALS AND METHODS Twenty-five routine, thick-section contrast abdominal CTs performed with equivalent technique were reformatted by multiplanar reconstructions in sagittal and coronal planes sequentially from side-to-side and front-to-back. The image sets were submitted, first axial images only followed by axial plus multiplanar reconstructions (MPRs), to 5 separate physician readers including 2 radiologists and 3 nonradiologists. These readers graded the visualization of a variety of normal and up to 5 pathologic lesions per patient on a scale of 1 to 5 (5 = best). RESULTS The addition of sagittal and coronal multiplanar reconstructions significantly improved the visualization of all normal anatomic structures (mean axial only, 3.8; mean axial plus MPR, 4.1; P < 0.0001). In addition, most pathologic lesions were statistically better visualized with the addition of multiplanar reconstructions (mean axial images only, 3.9; mean axial plus MPR, 4.1; P < 0.0001). All five readers found improved visualization in nearly every category with the addition of the multiplanar reconstructions. However, in only 7% of cases, did a reviewer find new diagnostic information with the addition of MPR images. CONCLUSIONS Stacked multiplanar reconstructions of routine, thick-section abdominal CT has clinical value in both the display of normal anatomic and pathologic lesions. Further studies, however, are required to confirm these findings before it is commonly used.

Purpose: Conventional CT has been shown to have wide variability in measured CT attenuation, both temporally within the same scanner and between different scanners. Many radiologists have raised the concern that the increased noise and multiple variables associated with helical CT may lead to degradation in resolution, specifically causing errors in CT number values. This study was designed to specifically evaluate the performance of both types of CT scanning in this regard. Method: A Picker PQ2000 helical CT scanner was used to scan a phantom containing multiple tissue-equivalent densities, allowing the measurement of CT attenuation of soft tissue, distilled water, cortical bone, medullary bone, air, and fat with a variety of techniques. A Catphan phantom was imaged with a variety of slice thicknesses (2, 4, and 8 mm), phantom positions (isocenter, y = +20 cm), and pitches (1.0, 1.5, 2.0) using both conventional and helical sequences. The entire image set was repeated with two additional annuli placed around the Catphan phantom to simulate the abdomen and the calvarium. The attenuation measurements of the same imaging parameters for helical versus conventional CT were statistically compared. Results: No statistical differences were found for the CT numbers based on scan type (conventional versus helical) for all sequences and gantry positions tested, including helical CT with pitches >1.0. Greater CT number variability was found with the extremes of tissue density such as with air and especially cortical bone, but were not statistically significant. The addition of the abdominal and calvarial annuli created a greater variation in CT attenuation values, but again were not statistically significant. Conclusion: The measurement of X-ray attenuation does not vary significantly with the use of the helical technique.

PURPOSE Measurements from sequential axial "2D" data in cancer patients are commonly used to assess treatment response or disease progression. This study compares the volume of tumor bulk calculated with 3D reconstructions with that calculated by conventional methods to determine if it might change patient classification. METHOD All medical, gynecologic, and pediatric oncology patients under treatment who were evaluated with serial CT scans between January 1, 1992, and July 31, 1994, for whom the digital data were available were included in this study. For each tumor site, the maximum diameter and its perpendicular were measured and multiplied together to yield an area. The sum of areas of the measured lesions was used as an approximation of overall 2D tumor volume. In addition, the 2D area of each site was multiplied by its height, yielding a 2D volume. Last, the digital data were loaded into a 3D computer system and total 3D tumor volumes determined. All medical and gynecologic oncology patients were treated based upon the 2D area of tumor. The pediatric oncology patients were treated based upon the 2D volume of tumor measured as per standard practice. The members of each treating oncologic service assessed their patients as to how the other two methods would have changed their classification of the patients' response category. RESULTS Four hundred thirty-three CT scans were performed in 139 patients, which included 204 baseline and 294 follow-up CT examinations. Seventy patients had new tumor foci and would have been classified as failure by all three methods of tumor bulk measurement. The 3D volume versus the 2D area method of tumor bulk assessment would have changed response categories in 52 of the 294 follow-up CT examinations (p < 0.0001). Thirty-five patients were recategorized from either "no response" to "failure" (21 patients) or "no response" to "response" (14 patients) categories. If only those follow-up studies without new metastatic foci are considered, the 3D volume versus the 2D area methods of tumor assessment would have changed the treatment response category in 23.2%. The use of the 2D volume method of calculating tumor volume of bulk tended to overestimate the overall tumor size by an average of 244 cm3 (p = 0.001). CONCLUSION The 3D method of tumor volume measurement differs significantly from conventional 2D methods of tumor volume determination. Large prospective studies analyzing the usefulness of 3D tumor volume measurements and assessing possible changes in patient response categories would be required for full utilization of this more accurate method of following disease bulk.