CT directed diagnostic and therapeutic pericardiocentesis: 8-year experience at a single institution.

UNLABELLED: A retrospective review of the 8-year experience at a single institution performing more than 300 CT directed pericardiocenteses was performed. The technique, results, and complications were determined. Comparative data from the literature relating to cardiology and thoracic surgery are reviewed. A CPT code data base search was performed to identify all imaging directed pericardiocenteses at a 550 bed regional medical center between 1993 and 2001. Medical records, imaging studies, and reports as well as pertinent laboratory, chemistry and hematology values were reviewed. Demographics, results, fluid analyses, techniques, systems used and complications were recorded. RESULTS: Three hundred and nineteen pericardiocenteses using CT localization were attempted on 261 patients. One hundred and forty-two men were included and mean age was 61 years (range 6 months to 89 years). Mean volume aspirated was 418 cc (range 0-1,875 cc). The major complication rate was 0.3%; the minor complication rate was 6.9%. Technical success was achieved in 98.4% procedures. Emergent pericardiocentesis was performed on anticoagulated patients without significant bleeding. Seventy-nine percent of patients with echocardiographic evidence of tamponade had symptomatic improvement. Patients with marked shortness of breath without other evidence of tamponade benefited symptomatically in 78%. Pericardiocenteses with CT localization is relatively safe and many patients achieve symptomatic relief.

Routine chest roentgenography is unnecessary in the work-up of stage I and II breast cancer.

PURPOSE: Clinical practice guidelines of many professional societies call for routine staging chest x-rays (SCXR) for all patients with invasive cancer. Given the estimated 157,000 patients annually for whom this recommendation pertains, this screening examination represents a considerable health care expenditure. If it were shown that SCXR rarely changed the management of low-risk subsets of this population, it might be possible to selectively omit this practice from the care of these patients with substantial resultant cost savings. PATIENTS AND METHODS: All patients with clinical stage I and II breast cancer presenting to the Baystate Medical Center from 1989 through 1997 were identified through the Tumor Registry. Their hospital records were reviewed for clinical presentation and documentation of SCXR. RESULTS: One thousand four hundred ninety-four patients were identified with clinical stage I and II disease. SCXR were available for review on 1,003 patients. Only one asymptomatic patient was upstaged to stage IV based on a SCXR. Two patients with primary lung tumors were also identified. These data demonstrate an asymptomatic pulmonary metastasis detection rate of 0. 099% (95% confidence interval, 0.0% to 0.6%). The total charges of SCXR for this group approached $180,000. CONCLUSION: These data demonstrate the low diagnostic yield and high cost of routine SCXR in the management of asymptomatic patients with clinical stage I and stage II breast cancer. Because other studies have shown that SCXR changes neither quality of life nor overall survival, SCXR should be limited to symptomatic patients in whom metastatic disease is suspected.

Touch-preparation cytologic examination of breast core biopsy specimens: accuracy in predicting benign or malignant core histologic results.

RATIONALE AND OBJECTIVES: The purpose of this study was to determine the accuracy of touch-preparation cytologic examination of breast core biopsy specimens in predicting benign or malignant core histologic results. MATERIALS AND METHODS: One hundred two core biopsies were performed on 88 women with stereotactic or ultrasonographic (US) guidance. Slides were prepared by smearing one core sample on each slide, spraying the slides with fixative, and staining them with the Papanicolaou technique. Slides were blindly reviewed by a cytopathologist. Cytologic results were categorized as positive for malignancy, not diagnostic for malignancy, or insufficient for diagnosis. Results were correlated with histologic results from all specimens obtained during the core biopsy. RESULTS: Imaging depicted the lesions sampled for biopsy as masses (n = 70), clustered calcifications (n = 29), focal asymmetries (n = 2), or architectural distortion (n = 1). Touch-preparation slides of 87 (85%) lesions contained sufficient material for diagnosis. Cytologic results correctly identified 12 of 16 (three of five intraductal and nine of 11 invasive) malignancies in 10 of 13 masses and two of three clusters of calcifications. Two false-positive results occurred, both with fibroadenomas. Overall, touch-preparation studies produced 69 true-negative and four false-negative results. Excluding slides with insufficient material, the sensitivity, specificity, and accuracy of touch-preparation results were 75%, 97%, and 93%, respectively. Including insufficient samples, accuracy was 79%. CONCLUSION: Although touch-preparation cytologic examination of breast core biopsy specimens is fairly accurate in prediction of benign or malignant core histologic results, its correlation with histologic results is not sufficient to justify routine use in immediate counseling and treatment planning.

Intrapancreatic ciliated enteric duplication cyst presenting with biliary obstruction.

A 46-yr-old man presenting with biliary obstruction from an intrapancreatic tumor underwent pancreaticoduodenectomy. The pathology report showed the tumor to be an enteric duplication cyst. Diagnostic imaging features and operative management are discussed.

Use of breast core biopsy in the United States: results of a national survey.

OBJECTIVE: We analyzed the results of a national survey to determine the current use and practice of breast core biopsy. MATERIALS AND METHODS: A survey was mailed to 1700 members of the Society of Breast Imaging who reside in the United States. The questions included frequency of biopsy, specialty of responsible physician, type of guidance used, physician credentialing, method and duration of follow-up, referral patterns, scheduling practices, and types of lesions biopsied. Opinions about the future usefulness of breast core biopsy were solicited. RESULTS: We received 458 responses (27% response rate) from 48 states and the District of Columbia. Eighty-one percent of the respondents indicated that breast core biopsy is performed at their practice or institution: among these, 85% are performed solely by radiologists. Of those performing the procedure, 61% do not have special credentials. Seventy-one percent use both stereotaxic and sonographic guidance. For follow-up after the procedure, patients are tracked manually and by computer in near-equal proportions. The median period of patient follow-up is 12 months: 11% of the respondents track indefinitely. Surgeons and primary care physicians most commonly refer patients for core biopsy. The procedure is most often performed after notification of the referring physician (76%), and 80% of the respondents schedule core biopsy without prior surgical consultation. Masses and calcifications categorized as probably benign to highly suspicious are included as indications for core biopsy. Forty percent of the respondents offer core biopsy on the same visit as when an abnormality is found. Eighty percent of the respondents believe the procedure will increase in use 48% believe that core biopsy will replace most surgical biopsies for nonpalpable lesions. CONCLUSIONS: Breast core biopsy is widely used in the United States for sampling a broad spectrum of imaging abnormalities. Both sonographic and stereotaxic guidance are commonly used. Credentialing requirements, practice patterns, and follow-up after the core biopsy procedure vary considerably among different sites.

Diagnosis of renal cell carcinoma: value of fine-needle aspiration cytology in patients with metastases or contraindications to nephrectomy.

OBJECTIVE: A retrospective study of imaging-directed percutaneous fine-needle aspiration cytology of focal renal lesions was performed. The objectives were to determine the efficacy and safety of renal aspiration biopsy in establishing the diagnosis of renal cell carcinoma and avoiding nephrectomy in patients with a renal mass and disseminated metastases or with a renal mass and relative contraindications to nephrectomy. MATERIALS AND METHODS: Between September 1987 and September 1991, 55 consecutive patients had 57 imaging-directed renal aspiration biopsies at our institution. We examined the medical records, pathology reports, imaging studies, and follow-up information of the 23 patients who had the procedure because of disseminated metastases (10 patients) or relative contraindications to nephrectomy (13 patients). Preliminary diagnoses were based on the cytopathology, and final diagnoses were based on the surgical pathology (six patients) or clinical course over more than 6 months (17 patients). RESULTS: Cytopathologic findings were true-positive in 12 patients, true-negative in eight, false-negative in three, and false-positive in none. The sensitivity was 80%, the specificity was 100%, and the accuracy was 87%. Of the 10 patients with a renal mass and disseminated metastases, aspiration cytology failed to show malignancy in only one. None of these patients had surgery, and all died within 1 year. Of the 13 patients with relative contraindications to surgery, seven were treated without surgery. The cytologic diagnosis was renal cell carcinoma in two of the seven, and these two patients have since died. Cytopathology was negative for renal cell carcinoma in five of the seven, and subsequent imaging studies in these patients have shown no renal mass enlargement or metastases 2-3 years after biopsy (three patients) or the patients have died of severe heart disease (two patients). Nephrectomy was performed in the remaining six patients, and no evidence of disease had been found 2-4 years after removal of two oncocytomas and four renal cell carcinomas. There were no significant complications. CONCLUSION: Percutaneous renal aspiration biopsy cytology is accurate, safe, and useful in establishing the diagnosis of renal cell carcinoma in patients with disseminated metastases or relative contraindications to surgery.

Practices and attitudes about cathode-ray tube-based and film-based image interpretation.

A questionnaire was mailed to 708 practicing radiologists and 348 members of the Society for Computer applications in Radiology (SCAR) in order to evaluate current practices and attitudes regarding the perceived advantages or disadvantages of film- and CRT-based image interpretation. A total of 27% of the 1,056 questionnaires (137 practicing radiologists; 145 SCAR members were returned. Ninety percent of practicing radiologists used film at least 75% of the time. Advantages of film-based reading listed by more than 75% of the respondents included: film reading is faster, and facilitates viewing multiple images. Advantages of CRT-based reading included: access to the entire dynamic range and potential imaging processing. Desirable attributes of existing displays included: adjustable grey scale, magnification, ability to view multiple images, allow quick review, and viewing by several individuals. Valued potential advances included: multiple higher resolution monitors, image processing and multimodality display. Practicing radiologists and computer applications society members had similar attitudes. Film-based reading is still nearly universal, but radiologists are interested in CRT-based reading if such devices have the proper features and become more available.

Current use of screening laboratory tests before abdominal interventions: a survey of 603 radiologists.

A survey of 2,153 radiologists was conducted to assess both their current practices of evaluating hemostatic function and their use of blood tests before performing image-guided nonvascular abdominal interventions. Among the 603 (28%) who responded, more radiologists routinely perform prothrombin time (81%) or partial thromboplastin time (78%) tests than platelet counts (59%), and relatively few (7%) obtain bleeding times. The most common practice (51%) is to order all of the first three tests. Use of laboratory tests is quite common (greater than 75%) before biopsy of splenic masses, hemangiomas, or hepatomas and before all catheter insertions. These tests are used less frequently (less than or equal to 70%) before fine-needle procedures, including biopsy and cyst aspiration. Only one-third of the radiologists alter their evaluation in patients who have taken aspirin. Most respondents (64%) believe that there should be written guidelines on how to evaluate patients before interventional procedures. Virtually all (97%) thought such evaluation should be the radiologist's responsibility.

Amniotic fluid volume in large-for-gestational-age fetuses of nondiabetic mothers.

Large-for-gestational-age (LGA) fetuses, especially those whose birth weight is greater than 4000 g, are at elevated risk for obstetrical complications. Prenatal diagnosis of the condition has been limited by the inaccuracy of fetal weight estimation and by low positive predictive values of other sonographic parameters. We studied 412 fetuses, 35 LGA and 377 non-LGA, who were scanned within 1 week of delivery, to determine if assessment of amniotic fluid volume can be used to improve the accuracy of fetal weight estimation for diagnosing or excluding LGA. In our study, the positive and negative predictive values of fetal weight estimation alone were 47% and 95%, respectively. The distribution of amniotic fluid volumes in LGA and non-LGA fetuses differed significantly (P less than .001). Polyhydramnios occurred more frequently in LGA fetuses than non-LGA fetuses (17% vs 8%) but had little effect on the positive predictive value of a fetal weight estimate above the 90th percentile. Oligohydramnios occurred less frequently in LGA than non-LGA fetuses (3% vs 19%) and improved the negative predictive value of fetal weight estimation. In particular, the combination of oligohydramnios and a fetal weight estimate below the 90th percentile virtually excluded the possibility of LGA.

Abdominal radiograph and renal ultrasound versus excretory urography in the evaluation of asymptomatic patients after extracorporeal shock wave lithotripsy.

A prospective study was done to compare the relative efficacy of an abdominal radiograph and renal ultrasound to excretory urography for the evaluation of asymptomatic patients 1 month after extracorporeal shock wave lithotripsy. We evaluated 101 renal units in 84 asymptomatic patients who had undergone extracorporeal shock wave lithotripsy 1 month previously with abdominal radiography, excretory urography and ultrasonography to evaluate the presence of retained stone fragments, dilatation of the collecting system and intrarenal or perirenal fluid collections or masses. The combination of abdominal radiography and ultrasonography identified retained fragments in 62 renal units, while excretory urography identified them in 54. Ultrasonography was less specific in identifying dilatation of part or all of the collecting system; proving falsely positive in 7 renal units and falsely negative in 14 compared to excretory urography. However, the case of obstruction was diagnosed correctly by both modalities. Finally, ultrasound appeared to be more specific and more sensitive in the evaluation of the presence of intrarenal or perirenal abnormalities. We conclude that a combination of abdominal radiography and ultrasonography is as good or better than excretory urography in identifying residual stone fragments and intrarenal or perirenal abnormalities. However, the finding of dilatation of all or part of the collecting system by ultrasonography is nonspecific and probably is better evaluated by excretory urography. We suggest that the routine radiological evaluation of asymptomatic patients 1 month after extracorporeal shock wave lithotripsy could be limited routinely to abdominal radiography and ultrasonography. However, when abnormalities of the collecting system are visualized on these studies excretory urography should be performed.

Peripheral pseudoaneurysms: evaluation with duplex US.

The prospectively generated results of 64 duplex sonographic examinations in 59 patients being evaluated for peripheral pseudoaneurysms over a 2-year period were reviewed. Subsequently, two groups of patients were identified. Group 1 (45 examinations) presented with relatively acute symptoms after arterial puncture, and group 2 (19 examinations) had undergone previous vascular surgical procedures and were usually asymptomatic. Duplex sonography demonstrated high sensitivity (94%) and specificity (97%) for the diagnosis of pseudoaneurysm in group 1. Of the 19 studies in group 2, duplex sonography allowed correct identification of pseudoaneurysms in four studies and exclusion of this entity in six examinations. The duplex sonographic findings in nine studies in this group did not allow differentiation of pseudoaneurysm from true aneurysm or oversize graft anastomosis. Duplex sonography is suggested as a primary radiologic method for evaluating possible pseudoaneurysms after arterial puncture, and it may provide valuable information and a means of postsurgical follow-up of selected patients as well.