Nomogram for selecting thyroid nodules for ultrasound-guided fine-needle aspiration biopsy based on a quantification of risk of malignancy.

BACKGROUND: Our aim through this study was to develop a statistical tool to quantify risk of malignancy in thyroid nodules based on clinical, biochemical, and ultrasound features, which could be used to select which nodules require ultrasound-guided fine-needle aspiration. METHODS: Clinical records, biochemical profiles, pathology reports, and ultrasound images were reviewed. Multivariate logistic regression was used to rank variables in their ability to predict malignancy. RESULTS: In all, 190 nodules were reviewed. The final diagnoses were papillary carcinoma in 105 patients (66%), other carcinoma in 8 patients (5%), and benign thyroid pathology in 45 patients (29%). After exclusions, 182 nodules remained for analysis on a per nodule basis. The 8 variables with highest predictive value were: age; thyroid-stimulating hormone; and ultrasound size, shape, echo texture, calcification, margin, and vascularity. The nomogram had a concordance index of 75%. CONCLUSION: We produced a nomogram able to accurately predict the need to perform ultrasound-guided fine-needle aspiration on a thyroid nodule based on biochemical, clinical, and ultrasound features.

Evaluation of renal masses with contrast-enhanced ultrasound: initial experience.

OBJECTIVE: Nearly 25% of solid renal tumors are indolent cancer or benign and can be managed conservatively in selected patients. This prospective study was performed to determine whether preoperative IV microbubble contrast-enhanced ultrasound can be used to differentiate indolent and benign renal tumors from more aggressive clear cell carcinoma. SUBJECTS AND METHODS: Thirty-four patients with renal tumors underwent preoperative gray-scale, color, power Doppler, and octafluoropropane microbubble IV contrast-enhanced ultrasound. Three blinded radiologists reading in consensus compared rate of contrast wash-in, grade and pattern of enhancement, and contrast washout compared with adjacent parenchyma. Contrast ultrasound findings were compared with surgical histopathologic findings for all patients. RESULTS: The 34 patients had 23 clear cell carcinomas, three type 1 papillary carcinomas, one chromophobe carcinoma, one clear rare multilocular low-grade malignant tumor, two unclassified lesions, three oncocytomas, and one benign angiomyolipoma. The combination of heterogeneous lesion echotexture and delayed lesion washout had 85% positive predictive value, 43% negative predictive value, 48% sensitivity, and 82% specificity for predicting whether a lesion was conventional clear cell carcinoma or another tumor. Diminished lesion enhancement grade had 75% positive predictive value, 81% negative predictive value, 55% sensitivity, and 91% specificity for non-clear cell histologic features, either benign or low-grade malignant. Combining delayed washout with quantitative lesion peak intensity of at least 20% of kidney peak intensity had 91% positive predictive value, 40% negative predictive value, 63% sensitivity, and 80% specificity in the prediction of clear cell histologic features. CONCLUSION: Ultrasound features of gray-scale heterogeneity, lesion washout, grade of contrast enhancement, and quantitative measure of peak intensity may be useful for differentiating clear cell carcinoma and non-clear cell renal tumors.

Ultrasonographically detected small thyroid bed nodules identified after total thyroidectomy for differentiated thyroid cancer seldom show clinically significant structural progression.

BACKGROUND: High-resolution ultrasound (US) is the primary tool used to identify locoregional recurrences in differentiated thyroid cancer. Although small thyroid bed (TB) nodules are a commonly reported sonographic finding, their natural history, regardless of whether they are benign or malignant, has not been well characterized. This study was designed to determine the likelihood, magnitude, and rate of growth of small TB nodules identified on routine surveillance neck US after thyroidectomy for differentiated thyroid cancer as well as to identify ultrasonographic and clinical predictors of growth. METHODS: This retrospective review identified 191 patients with at least one TB nodule (≤ 11 mm) on the first postoperative US performed at a comprehensive cancer center. Change in size of each TB nodule was determined using serial US studies over time. Clinicopathologic and sonographic characteristics were analyzed as possible predictors for growth of the TB nodules. RESULTS: Over a median clinical follow-up of 5 years, 9% (17/191) of patients had increase in size of at least one TB nodule. Median size of the TB nodules was 5 mm (range: 2-11 mm). Suspicious US features were seen in 63% (121/191) of patients with TB nodules identified on initial US and in 31% (21/67) of those with TB nodules detected on subsequent follow-up US. The rate of growth was 1.3 mm/year in those nodules showing an increase in size and thus demonstrated a significant increase in size only after several years of follow-up. The negative predictive values associated with the absence of any suspicious US features (0.97), the absence of abnormal cervical lymph nodes (0.94), and the lack of a rising serum thyroglobulin (0.93) provided clinically useful information regarding the likelihood that nodules would not increase in size. CONCLUSION: Most TB nodules do not show clinically significant growth over several years of follow-up. Thus, TB nodules can be followed up with cautious observation and serial ultrasonography using an approach similar to that recommended by the American Thyroid Association thyroid cancer guidelines for the management of small abnormal cervical lymph nodes.

Implementation of evidence-based guidelines for thyroid nodule biopsy: a model for establishment of practice standards.

OBJECTIVE: Multiple studies have defined criteria for the selection of thyroid nodules for biopsy. No set of criteria is sufficiently sensitive and specific. The aim of this study is to develop a method for assessing consistency of practice in an ultrasound group and to determine whether a 5-point malignancy rating scale can be used to select patients for biopsy. MATERIALS AND METHODS: One hundred one nodules (50 benign and 51 malignant) were selected from a thyroid biopsy database. Seven radiologists were educated on evidence-based criteria used to select nodules for biopsy. Using this information, readers graded the likelihood of malignancy using a 5-point malignancy rating scale, where 1 equals the lowest probability of malignancy and 5 equals the highest probability of malignancy, on the basis of overall impression of sonographic findings. Interobserver agreement on biopsy recommendation, reader sensitivity, specificity, and accuracy were determined. RESULTS: The sensitivity and specificity of biopsy recommendation were 96.1% and 52%, respectively. The misclassification rate was 25.7%, and accuracy was 74.3%. Interobserver agreement on biopsy recommendation was fair to substantial (κ, 0.38-0.69). The proportion of agreement was excellent for malignant nodules (0.88-1.0). The risk of malignancy increased with increasing malignancy rating: 4.3% of nodules with a malignancy rating of 1 were malignant versus 93.4% of those assigned a rating of 5. CONCLUSION: Our study illustrates a method to evaluate the standard of practice for thyroid nodule assessment among radiologists within an ultrasound group. Application of a 5-point malignancy rating scale to select nodules for biopsy is feasible and shows good diagnostic accuracy.

Nomogram for predicting malignancy in thyroid nodules using clinical, biochemical, ultrasonographic, and cytologic features.

BACKGROUND: Thyroid nodules often discovered incidentally and present a management problem particularly when investigations suggest atypical or suspicious cells. Prediction of the risk of malignancy within such a thyroid nodule is based on clinical, biochemical, ultrasonographic, and cytologic features. Our aim was to create a nomogram to predict accurately the chance of malignancy within a thyroid nodule. METHODS: All patients with thyroid nodules who underwent ultrasonographic-guided fine needle aspiration and operative resection at our institution during 2007-2008 were identified. Clinical records, biochemical profiles, pathology reports, ultrasonographic images, and cytology slides were reviewed. A multivariate logistic regression was used to quantify the value of the variables in estimating the risk of malignancy. RESULTS: The records of 158 patients with 190 nodules were reviewed. Eighteen nodules were excluded. The 8 variables with the greatest predictive value selected for the nomogram were biochemical (thyroid-stimulating hormone), ultrasonography (shape, echo texture, and vascularity), and cytology (nuclear grooves, pseudoinclusions, cellularity, and presence of colloid). The nomogram had an excellent predictive accuracy with a concordance index of 91%. CONCLUSION: We produced a nomogram that can quantify accurately the risk of malignancy in a thyroid nodule based on biochemical, ultrasonographic, and cytologic features.

Polypoid lesions of the gallbladder: diagnosis and followup.

BACKGROUND: Polypoid lesions of the gallbladder (PLG) are commonly seen on ultrasonography (US), but optimal management of this problem is ill-defined. The aims of this study were to assess the natural history and the histologic characteristics of US-detected PLG. STUDY DESIGN: Patients with PLG detected by abdominal US were identified retrospectively. Patients with infiltrative masses suspicious for gallbladder cancer were not included. Histologic findings were analyzed in patients who underwent cholecystectomy, and change in polyp size was determined in patients who underwent serial US imaging. RESULTS: From 1996 through 2007, 417 patients with PLG detected on US were identified. Two hundred twenty-nine patients (55%) were women, and median age was 59 years (range 20 to 94 years). Two hundred sixty-five patients (64%) were found to have PLG on US during the workup of other unrelated disease; 94 patients (23%) had abdominal symptoms. Ninety-four percent of patients had PLG< or =10 mm, and 7% had PLG>10 mm; 59% of patients had a single polyp and 12% had gallstones. Among 143 patients who had repeat US followup, growth was observed in only 8 patients (6%). Cholecystectomy (n=80) revealed that most patients had either pseudopolyps (58%) or no polyp (32%). Neoplastic polyps (adenoma) were found in 10% of patients. In situ cancer was seen in one patient with a 14-mm lesion. CONCLUSIONS: Small PLG (< or =10 mm in diameter) detected by US are infrequently associated with symptoms and can be safely observed. The risk of invasive cancer is very low, and was not seen in any patient in this study.

Imaging of late complications from mantle field radiation in lymphoma patients.

Hodgkin lymphoma is one of the most curable cancers because of its sensitivity to both radiation and several chemotherapy agents. Radical radiotherapy alone provided curative therapy for patients who had Hodgkin lymphoma as early as six decades ago. Yet, the radiation field included normal organs, such as breast tissue, thyroid, and coronary arteries, which were at risk for long-term complications. Dedicated imaging approaches have been developed to evaluate late radiation effects on these structures.

A Phase II study of SU5416 in patients with advanced or recurrent head and neck cancers.

BACKGROUND: SU5416 (semaxanib) is a synthetic small molecule inhibitor of the tyrosine kinase domain of vascular endothelial growth factor receptor 2 (VEGFR2). This Phase II study was conducted to determine the safety and efficacy of SU5416 in patients with recurrent or metastatic head and neck cancers. PATIENTS AND METHODS: This was an open label, single arm, Phase 2 study for patients who had received no more than 2 cytotoxic regimens. Thirty-five patients received intravenous SU5416 (145 mg/m(2)) twice per week by intravenous catheter. Radiologic imaging for response assessment was planned at the conclusion of each 8 week cycle. Serum VEGF levels and power Doppler ultrasound tumor imaging were explored as potential surrogate markers for SU5416 activity. RESULTS: Thirty-two patients had received prior radiotherapy, including 18 patients who received prior concurrent chemoradiotherapy. Twelve patients had received prior chemotherapy in the recurrent disease setting. Thirty-one patients were evaluable for response. There was one partial response and one minor response. The median number of 8-week cycles received was 1 (range 1-4). Median overall survival was 6.25 months. The most common > or = grade 3 toxicity was headache (31%). There was one fatal carotid artery hemorrhage. Fatigue, nausea, and vomiting were common grade 1-2 adverse events. Power Doppler ultrasound demonstrated decreased tumor vascularity in 5 of 7 patients. CONCLUSIONS: Treatment with SU5416 in patients with head and neck cancers is feasible, but objective responses are rare. Studies evaluating more potent anti-angiogenic agents in this disease are of interest.

Predicting the histology of renal masses using preoperative Doppler ultrasonography.

PURPOSE: Traditional imaging techniques cannot differentiate among benign, indolent and malignant renal neoplasms. Since conventional clear cell carcinomas are highly vascular, we used preoperative color and/or power Doppler ultrasonography to evaluate the association between vascular flow in a renal mass and surgical pathology. MATERIALS AND METHODS: Nephrectomies performed at our institution between January 2001 and December 2004 were retrospectively evaluated. Any detection of flow in the renal mass on color Doppler ultrasonography was defined as vascular flow. A prospective validation study was then performed from January 2005 to October 2005 and a nomogram was constructed to predict clear cell histology. RESULTS: Of 299 renal lesions in the retrospective cohort 210 (70%) had evidence of vascular flow, including 156 of 169 conventional clear cell carcinomas (92%) (p <0.0001). On logistic regression analysis vascular flow was associated with conventional clear cell histology (OR 16.9, 95% CI 8.7-32.8; p <0.0001). This finding was validated prospectively in 97 patients. Vascular flow was detected in 54 of 65 renal masses (83%) with conventional clear cell histology (p <0.0001), which was associated with an OR of 10.8 (95% CI 4.0-29.0; p <0.0001). A nomogram incorporating vascular flow along with clinical variables (clinical size, patient sex and age) to predict conventional clear cell histology was constructed on the retrospective cohort and validated on the prospective data set (concordance index 0.82 and 0.76, respectively). CONCLUSIONS: Vascular flow detected by color Doppler ultrasonography is strongly associated with conventional clear cell histology. A nomogram incorporating vascular flow on color Doppler ultrasonography and clinical parameters may aid in the preoperative characterization of renal lesions.

Ovarian cancer.

Imaging has become an essential part of the clinical management of patients with ovarian cancer, contributing to tumor detection, characterization, staging, treatment planning, and follow-up. Imaging findings incorporated into the clinical impression assist in creating a treatment plan specific for an individual patient. Advances in cross-sectional imaging and nuclear medicine (PET) have yielded new insights into the evaluation of tumor prognostic factors. A multimodality approach can satisfy the complex imaging needs of a patient with ovarian cancer; however, the success of such an approach always depends on available resources and on the skills of the physicians involved.

Imaging of uterine cancer.

Although surgical staging is the primary method of assessing prognostic factors in endometrial cancer, cross-sectional imaging may help in treatment planning by providing information about factors such as the depth of myometrial invasion, cervical involvement, and nodal status. The pretreatment evaluation of cervical cancer traditionally has consisted of clinical evaluation, laboratory tests, and conventional radiographic studies, but more advanced imaging methods allow additional insights into the morphologic and metabolic features of cervical cancer. This article reviews the applications of modern imaging modalities in the assessment of endometrial cancer and cervical cancer and their impact on treatment planning and posttreatment follow-up.

Proximal deep vein thrombosis after hip replacement for oncologic indications.

BACKGROUND: Patients with cancer who undergo surgery about the hip are at increased risk for the development of deep vein thrombosis. We implemented a program of chemical and mechanical prophylaxis to prevent this problem. This study was performed to assess the effectiveness of that program. METHODS: Eighty-seven consecutive patients with an active malignant tumor who underwent hip replacement surgery at our institution over a two-year period were included in the study. All patients were treated with intermittent pneumatic compression devices. Seventy-eight patients received anticoagulants, and nine did not. Postoperative surveillance for proximal deep vein thrombosis was routinely performed on all patients with duplex Doppler ultrasonography. RESULTS: Four patients had proximal deep vein thrombosis, and one patient, who did not receive anticoagulation, had a nonfatal pulmonary embolism. The use of prophylactic low-molecular-weight heparin (dalteparin) was associated with a 4% rate of proximal deep vein thrombosis (three of seventy-eight patients). Proximal deep vein thrombosis developed in three of eight patients with pelvic disease, one of nineteen patients with femoral disease, and zero of sixty patients with hip disease (p < 0.00001). The prevalence of proximal deep vein thrombosis was significantly higher (p < 0.02) following replacements in patients with sarcoma (three of twenty-one) than it was after replacements in patients with carcinoma (zero of fifty-seven) or hematologic malignant disease (one of nine). On multivariate analysis, only the location of the disease (the pelvis, femur, or hip) was found to be independently significant for an association with deep vein thrombosis. A wound complication developed in four of twenty-one patients with sarcoma and no patient with carcinoma or hematologic malignant disease (p < 0.001). The pathologic type was the only factor studied that was independently significant for an association with wound complications on multivariate analysis. CONCLUSIONS: The rate of proximal deep vein thrombosis in patients who had undergone hip replacement for oncologic indications was low when the use of an intermittent pneumatic compression device was supplemented with prophylaxis with low-molecular-weight heparin.

A practical approach to analyzing focal lesions in the liver.

Ultrasound evaluation of patients with hepatic masses should extend beyond basic lesion detection to characterization and clinical management. A systematic approach for hepatic lesion evaluation using ultrasound makes it possible to triage patients and, in many cases, leads to definitive diagnosis that may eliminate the need for additional imaging.

Ovarian carcinoma screening in women at intermediate risk: impact on quality of life and need for invasive follow-up.

BACKGROUND: Women with family histories suggestive of an increased risk of ovarian carcinoma who have not had a deleterious BRCA1 or BRCA2 mutation identified are commonly suggested to consider ovarian carcinoma screening with transvaginal ultrasound and/or assessment of CA 125 levels. Limited information is available regarding the impact of this approach on either quality of life (QOL) or need for invasive follow-up in this group of women. METHODS: From November 1999 to October 2002, 184 women at intermediate risk of ovarian carcinoma were enrolled in a prospective study. Participants were screened with twice yearly transvaginal ultrasound and CA 125 assessments. Impact on QOL was measured using the Mental Component Summary (MCS) score of the Medical Outcomes Studies Short Form-36. Need for invasive follow-up was determined by questionnaire and medical record review. RESULTS: In the current study, 135 participants underwent > or = 1 follow-up assessment. During a mean of 19.8 months of follow-up, 12.9% of ultrasounds and 3.8% of CA 125 assessments were abnormal. The authors reported that 38.5% of participants had > or = 1 abnormal ovarian screen that required a short interval follow-up. Because of either abnormal bleeding or ultrasound abnormalities, 24% of participants underwent > or = 1 endometrial sampling. Controlling for a history of breast carcinoma and menopausal status, abnormal ovarian screening results were associated with a decrease in MCS score (P = 0.034), whereas the need for endometrial sampling was not (P = 0.87). CONCLUSIONS: Ovarian carcinoma screening in women at intermediate risk was associated with a substantial rate of abnormal screen results, endometrial sampling, and in women with abnormal ovarian screening findings, a decrease in MCS scores. These findings may have important implications for women considering ovarian carcinoma screening and for the design of future ovarian carcinoma screening trials.

Pilot study prospectively evaluating the use of the measurement of preoperative sonographic endometrial thickness in postmenopausal patients with endometrial cancer.

OBJECTIVE: The value of sonographic evaluation of the endometrial thickness as a screening or a prognostic tool for endometrial cancer remains controversial. The objective of this study was to prospectively evaluate the endometrial thickness in women with known endometrial cancer to assess the predictive value of this modality and its preoperative use in this disease. DESIGN: In a prospective, nonrandomized trial, 29 patients with pathologically confirmed endometrial cancer had preoperative transvaginal ultrasound and endometrial thickness evaluated. Body mass index (BMI) and endometrial thickness were recorded and correlated with surgical and pathologic information. RESULTS: The median age at diagnosis of endometrial cancer was 61.6 years (range, 48-87 years). Tumor grade was as follows: grade 1, 23; grade 2, 3; and grade 3, 3. All patients had an endometrial stripe of 5.0 mm or more. The median preoperative sonographic endometrial stripe was 12.0 mm (range, 5.0-32.0 mm). After surgery, 25 patients (86%) were diagnosed with International Federation of Gynecology and Obstetrics (FIGO) stage I disease (IA, 8; IB, 14; IC, 3), 2 (7%) with stage II disease, and 2 (7%) with stage III disease. Median BMI was 33 (range, 20-56). The patients' BMIs were found to be directly associated with endometrial thickness (rank correlation = 0.39; P = 0.03). Stage was only marginally associated with endometrial thickness (correlation 0.23; P = 0.07). Sonographic endometrial thickness was not associated with depth of myometrial invasion. No correlation was found between endometrial thickness and patient age or tumor grade. CONCLUSIONS: Although patients with endometrial cancer and a high BMI are likely to have a thickened endometrial stripe, endometrial thickness does not correlate with tumor grade or stage. The use of preoperative transvaginal ultrasound in diagnosed endometrial cancer appears limited.

Sonohysterography compared with endometrial biopsy for evaluation of the endometrium in tamoxifen-treated women.

OBJECTIVE: This study was performed to compare endometrial biopsy and sonohysterography for evaluation of the endometrium in tamoxifen-treated women. METHODS: Medical records were retrospectively reviewed to identify 51 consecutive tamoxifen-treated women who had sonohysterography and correlative endometrial biopsy for evaluation of postmenopausal bleeding or thickened endometrium of greater than 8 mm. Endometrial biopsy and sonohysterographic results were compared in all women, and for 27 (53%) women who had hysteroscopy with dilation and curettage, endometrial biopsy and sonohysterographic findings also were compared with surgical pathologic findings. RESULTS: Thirty-two (63%) of 51 sonohysterograms revealed endometrial polyps; 4 (8%) showed endometrium of greater than 5 mm; 14 (27%) showed endometrium of less than 5 mm; and 1 (2%) was inadequate. Endometrial biopsy findings were benign endometrium in 42 (82%), polyps in 4 (8%), and insufficient samples in 5 (10%). Among the adequate sonohysterograms, 64% (32 of 50) resulted in a diagnosis of polyps (95% confidence interval, 49%-77%) whereas the corresponding proportion for endometrial biopsy was 9% (4 of 46; 95% confidence interval, 2%-21%). For the group with hysteroscopy, 24 (92%) of 26 polyps were confirmed histopathologically; 1 polyp had complex hyperplasia. Polyps were present in 23 (89%) of 26 women with benign endometrium or insufficient samples by endometrial biopsy, and only 1 confirmed polyp was identified by endometrial biopsy. The sensitivity of sonohysterography for diagnosis of endometrial polyps (100%) was significantly higher than for endometrial biopsy (4%; P < .01). CONCLUSIONS: In tamoxifen-treated women, sonohysterography provides a significant improvement in sensitivity for diagnosis of endometrial polyps compared with endometrial biopsy.

Pre- and postmenopausal high-risk women undergoing screening for ovarian cancer: anxiety, risk perceptions, and quality of life.

OBJECTIVE: Recommendations for women at high risk of ovarian cancer include prophylactic salpingo-oophorectomy (PSO) or screening with transvaginal ultrasonography (TVUS) and CA125 levels. The best strategy for improving survival and maintaining quality of life in high-risk women is not known. Premenopausal women may be more reluctant than postmenopausal women to undergo PSO. However, the risk of false-positive screening results may be more likely in premenopausal women, posing potential psychological risk for those enrolled in high-risk ovarian cancer surveillance programs. We sought to determine whether anxiety, depression, perception of ovarian cancer risk, and false-positive test frequency differed between high-risk premenopausal and postmenopausal women initiating ovarian cancer screening. METHODS: High-risk women aged > or = 30 years enrolling in a TVUS plus CA125 ovarian cancer screening study completed standard QOL (SF-36), cancer-specific anxiety (IES), depression (CES-D), and ovarian cancer risk perception measures. CA125 > 35 and TVUS showing solid or complex cystic ovarian masses were considered abnormal. Abnormal tests were repeated after 4-6 weeks. Persistently abnormal tests prompted a search for malignancy. Tests that normalized on repeat were considered false positive. RESULTS: One hundred forty-seven high-risk women, median age 46 (range, 30-78), 78 premenopausal and 69 postmenopausal, had > or = 1 TVUS/CA125/outcome assessment. Premenopausal women were more likely than postmenopausal women to consider themselves at higher risk of ovarian cancer compared with women their age (P < 0.001) and compared with women with similar family histories (P < 0.001). Mean personal perception of lifetime risk of ovarian cancer among premenopausal women was 37% (range, 0-90%) versus 26% (range, 0-60%) among postmenopausal women (P = 0.02). While general QOL and depression scores were similar, 38% of premenopausal women reported high anxiety versus 27% of postmenopausal women (P = 0.03). Thirty percent of women required repeat CA125 or TVUS after first screening; 10.8% of premenopausal women versus 4.6% of postmenopausal women required repeat CA125; and 23.3% of premenopausal and 20.6% of postmenopausal women required repeat TVUS. One postmenopausal woman with persistently rising CA125 >100 had negative mammography, colonoscopy, and dilation and curettage/bilateral salpingo-oophorectomy. All other abnormal tests normalized on repeat. Two premenopausal women withdrew due to anxiety following false-positive CA125 results. Five women (2 premenopausal, 3 postmenopausal) with normal TVUS/CA125 screening tests elected PSO, with benign findings. CONCLUSION: Premenopausal women perceive their ovarian cancer risk to be higher, report greater ovarian cancer risk-related anxiety, and are more likely to have false-positive screening results than postmenopausal women. Few high-risk women elect PSO in the short term. Knowledge of the frequency of false-positive screening results and psychosocial outcomes is important for high-risk women choosing strategies for managing ovarian cancer risk.

The use of MRI in the diagnosis and management of a bulky cervical carcinoma.

BACKGROUND: In the treatment of gynecologic cancer, surgical planning depends on the site and extent of disease. The evaluation of the origin of a large pelvic mass with combined pelvic examination and ultrasound is often adequate. However, the following case report illustrates the utility of magnetic resonance imaging (MRI) when sonographic findings are indeterminate and the origin of a pelvic mass is unclear. CASE: A 73-year-old woman presented for her first gynecologic exam in over 40 years. On speculum examination the cervix was not visible. A large, mobile pelvic mass was palpated during physical examination. Pelvic ultrasound revealed a large, cystic pelvic mass thought to be ovarian in origin. Surgery for presumed ovarian carcinoma was planned. Because a vaginal Pap smear revealed squamous-cell carcinoma, MRI was performed for further evaluation. MRI demonstrated a blood distended uterus with a large cervical tumor obstructing the endocervical os. After cervical dilatation under sonographic guidance, evacuation of the hematometrium was performed. Multiple biopsies of the cervix confirmed the diagnosis of a bulky Stage IIA squamous-cell carcinoma of the cervix. The patient was subsequently treated with concomitant chemotherapy and radiation therapy. Follow-up MRI demonstrated an excellent treatment response. Modified radical hysterectomy was performed demonstrating very small residual tumor. CONCLUSIONS: Magnetic resonance imaging, through multiplanar capabilities and high-contrast resolution, is a valuable tool that can assist the clinician in the evaluation, diagnosis, and management of challenging gynecologic malignancies.

Utility of sonography for small hepatic lesions found on computed tomography in patients with cancer.

OBJECTIVE: To assess the performance of sonography in evaluating small indeterminate liver lesions detected on computed tomography in patients with cancer. METHODS: Radiology database review from January 1, 1998, to August 4, 2000, identified 76 patients with 124 indeterminate hepatic lesions smaller than 1.5 cm on computed tomography who had abdominal sonography within 3 months. Sonographic reports and images were reviewed to assess whether lesions were referenced or specifically sought and to verify lesion correspondence, detection, and characterization. The validity of sonographic characterization was determined by histopathologic examination or follow-up imaging (mean time to follow up, 17 months; range, 6.5-38.8 months). RESULTS: Sixty (48%) of 124 indeterminate lesions were evident on sonography. Detection improved when lesions were specifically sought and lesion size was greater than 0.5 cm. Forty (66%) of 61 lesions were detected when the radiologist referenced the preceding computed tomography versus 20 (32%) of 63 lesions when the computed tomographic findings were not referenced (P = .0004). Fifty-one (67%) of 76 lesions measuring 0.6 to 1.5 cm were detected on sonography versus 9 (19%) of 48 lesions measuring 0.1 to 0.5 cm. Lesion size (P < .0001) and body habitus (P = .02) were significant factors influencing lesion detection. Sonography characterized 56 (93%) of 60 detected lesions (33 cysts, 18 solid lesions/metastases, and 5 hemangiomas). Sonographic diagnoses were supported in 42 (93%) of 45 lesions by follow-up imaging (37 of 40) or histopathologic examination (5 of 5). CONCLUSIONS: Sonography may be useful in cancer patients with average body habitus to characterize small (0.6- to 1.5-cm) indeterminate liver lesions detected on computed tomography.

Is there an increased incidence of contralateral testicular cancer in patients with intratesticular microlithiasis?

OBJECTIVE: The objective of this study was to determine if there is an association between intratesticular microlithiasis and contralateral testicular cancer. MATERIALS AND METHODS: Retrospective review of a radiology database revealed 156 men who had undergone testicular sonography and orchiectomy for testicular cancer. Sonographic abnormalities were correlated with medical records and histopathology. Statistical significance was assessed using Fisher's exact test. RESULTS: Twenty-three (15%) of 156 patients with prior orchiectomy for testicular cancer had microlithiasis, and 133 (85%) did not have microlithiasis. Four of 23 patients with microlithiasis had masses, and eight had heterogeneous changes. Sonograms of 133 patients without microlithiasis revealed masses in seven and heterogeneous changes in 15 patients. Five patients with microlithiasis and six without microlithiasis underwent a second orchiectomy. Contralateral testicular cancer was confirmed in five (22%) of 23 patients with microlithiasis versus three (2%) of 133 men without microlithiasis. Microlithiasis was present in five (63%) of eight patients with bilateral testicular cancer, and microlithiasis was highly associated with confirmed bilateral testicular cancer (5/23 vs 3/133, odds ratio [OR] = 12.0, p = 0.002). Among the 34 patients who had either testicular masses or heterogeneous changes, microlithiasis had an OR of 4.5 (p = 0.10). CONCLUSION: In our study, contralateral testicular cancer was significantly associated with intratesticular microlithiasis. Nevertheless, there was not sufficient evidence that intratesticular microlithiasis adds independent diagnostic information for bilateral testicular cancer in the absence of a mass or heterogeneous changes.