Contrast-Enhanced Mammography: A Systematic Guide to Interpretation and Reporting.

OBJECTIVE: The purpose of this article is to discuss the essential steps involved in performing, interpreting, managing, and reporting findings on contrast-enhanced mammography for successful implementation into clinical practice. CONCLUSION: To successfully implement contrast-enhanced mammography into clinical practice, an understanding about the acquisition of images, image interpretation, and reporting of the spectrum of negative, benign, and malignant findings is essential.

Osteonecrosis in children after therapy for malignancy.

OBJECTIVE: Osteonecrosis in the growing population of childhood cancer survivors results from disease and treatment. Imagers must be knowledgeable about patient groups at risk for its development, patterns of involvement and potential implications. This review will focus on implications of this potentially life-altering toxicity. CONCLUSION: Childhood cancer survivors are at increased risk for developing osteonecrosis. Because osteonecrosis is often asymptomatic until late in the process, imaging is critical for its detection and characterization when interventions may be most effective to ameliorate its progression.

Femoral resurfacing in young patients with hematologic cancer and osteonecrosis.

UNLABELLED: Resurfacing hemiarthroplasties were performed to treat advanced osteonecrosis of 20 femoral heads in 14 patients (median age, 19.8 years; range, 15.1-27.4 years), treated for hematologic cancer in childhood or adolescence. Seven hips in five patients were revised to total hip arthroplasties (THA) because of pain; three of these showed radiographic loosening of the femoral head resurfacing component. The median time from resurfacing to revision was 2.4 years (range, 0.9-4.8 years). Marginal Cox-regression analysis, adjusting for correlations owing to bilateral involvement, showed positive association of revision-free survival of the prosthesis with patient's age; time from resurfacing to the end of anticancer therapy, end of glucocorticosteroid therapy; percentage of joint space at the last radiograph; and size of the lesion has a negative association with revision-free survival. Because of this study's exploratory nature, p values were not adjusted for the number of statistical comparisons. Among 14 patients, the probability of not requiring resurfacing prosthesis revision was 66% (SE, +/-15%; 95% CI, 44%-100%) at 3 years. Osteonecrosis of the femoral head in young patients treated for hematologic cancer in childhood or adolescence poses a serious challenge to the orthopaedic surgeon. The data of this preliminary study suggest that in selected patients resurfacing hemiarthroplasty may delay the need for THA for 3-7 years. LEVEL OF EVIDENCE: Level II, prognostic study. See the Guidelines for Authors for a complete description of levels of evidence.

Femoral head osteonecrosis in pediatric and young adult patients with leukemia or lymphoma.

PURPOSE: Osteonecrosis of the capital femoral epiphysis is a significant late toxicity of treatment for childhood leukemia and lymphoma. We determined clinical and imaging risk factors predicting clinical joint outcomes of femoral head osteonecrosis in pediatric patients with leukemia or lymphoma. PATIENTS AND METHODS: We reviewed retrospectively medical records and magnetic resonance imaging scans of 80 patients with osteonecrosis of the capital femoral epiphysis. Logistic regression was used to examine relationships between risk factors and outcomes of joint surface collapse and arthroplasty. We used Kaplan-Meier survival curves to display the time to joint surface collapse and arthroplasty based on selected predictors. RESULTS: Median time between primary diagnosis and diagnosis of osteonecrosis of the hip was 1.7 years (range, 0.1 to 17.5 years). Twenty-three patients (29%) underwent arthroplasty in 36 hips at a mean of 1.3 years (range, 0.5 to 8.6 years) after diagnosis of osteonecrosis. Median age at time of first arthroplasty was 20.1 years (range, 15.1 to 35.4 years). Joint outcome of osteonecrosis was predicted solely by lesion size at diagnosis of osteonecrosis. The worst prognosis was associated with lesions occupying more than 30% of the femoral head volume; 80% of hips with these lesions collapsed within 2 years of diagnosis and 50% required arthroplasty. CONCLUSION: Lesion size of osteonecrosis is the best predictor of clinical joint outcome of hip osteonecrosis in survivors of pediatric hematologic malignancy. Lesions occupying more than 30% of the femoral head have high likelihood of joint deterioration necessitating arthroplasty at a young age.

QCT versus DXA in 320 survivors of childhood cancer: association of BMD with fracture history.

PURPOSE: To assess agreement on diagnosis of diminished bone mineral density (BMD) and correlation between BMD values obtained by dual-energy X-ray absorptiometry (DXA) and quantitative computed tomography (QCT) in childhood cancer survivors. PATIENTS AND METHODS: We retrospectively reviewed lumbar spine QCT and DXA studies for BMD in patients who underwent both imaging studies within a 24-hr period. We determined correlation between BMD values and agreement on diagnosis of diminished BMD obtained by both modalities. Diminished BMD was defined as two or more SDs below mean for age- and gender-matched reference values. We evaluated the relationship of BMD values determined by each modality to self-reported fracture history in the 160 (50%) patients with available reports. RESULTS: Of 320 patients, 56% (178) were male; 87% (277) were white. Median age was 16.4 (range, 5.1-36.0) years. Median BMD Z-score was -1.43 (range, -5.96 to 3.20) by QCT and -1.30 (range, -5.50 to 2.80) by DXA. Correlation between QCT- and DXA-determined BMD values was significant but low, and agreement on diminished BMD was fair (kappa = 0.32). There was no association between BMD measured by either QCT or DXA and self-reported traumatic fracture history. Male gender was associated with doubling the traumatic fracture risk (P = 0.0499). CONCLUSIONS: Quantitative computed tomography and DXA may give discrepant results when used to assess bone health in childhood cancer survivors, especially in those of non-white race. This inconsistency in indicators of BMD deficiency may complicate clinical decision-making. Consecutive use of a single modality is recommended to provide reliable longitudinal information.

MRI of knee osteonecrosis in children with leukemia and lymphoma: Part 1, observer agreement.

OBJECTIVE: The aim of this study was to determine whether a new MRI-based staging system for osteonecrosis of the knee in pediatric patients could be used with an acceptable level of intra- and interobserver agreement. MATERIALS AND METHODS: We conducted a retrospective analysis of MRI studies of the knee performed in a single institution between April 1994 and July 2003. Knee osteonecrosis was identified in 168 children with a primary diagnosis of hematologic malignancy. This substantial number prompted us to design a staging system for use with pediatric patients. To assess interobserver reliability of two primary observers in using the system, they reviewed and interpreted the same 36 imaging studies of randomly chosen patients. For the assessment of intraobserver reproducibility, each observer rereviewed 16 studies. A senior observer coded potential causes of disagreement between the primary observers. RESULTS: Interobserver agreement was substantial: the kappa value was 0.66 (95% confidence interval [CI], 0.58-0.75) in locations where the observers had to record only the presence or absence of a lesion, and the weighted kappa value was 0.65 (95% CI, 0.59-0.72) in locations where they had to classify the extent of involvement. The presence of marrow edema, punctate foci of altered signal, and mottled marrow changes was associated with a higher level of disagreement between the primary observers. CONCLUSION: Our proposed classification system, developed specifically for use with MRI, was used with substantial intra- and interobserver agreement. We think its use can contribute to a standardized approach to the interpretation of MRI findings in pediatric osteonecrosis of the knee.

MRI of knee osteonecrosis in children with leukemia and lymphoma: Part 2, clinical and imaging patterns.

OBJECTIVE: This aim of this study was to explore the relationship between MRI findings and clinical symptoms of knee osteonecrosis in children and to determine the significance of this relationship. Such information is important for early diagnosis of this frequent complication and for choosing an appropriate treatment strategy. MATERIALS AND METHODS: Osteonecrotic lesion size and location were determined in a retrospective analysis of MR images of the knee obtained in our institution during the past 10 years. Association between MRI findings and clinical symptoms expressed by the knee scores was tested for a subgroup of our patient population who had clinical evaluation of the knees in the orthopedic clinic within 6 weeks of their MRI studies. RESULTS: In 80% of patients, osteonecrosis was bilateral. Lesions were distributed as follows: femur and tibia, 66% of the knees; femur alone, 26%; and tibia alone, 8%. Clinical symptoms of knee osteonecrosis were associated with lesions involving the articular surface of the distal femur, large lesions, and involvement of any part of the tibia. MR images showed milder osteonecrosis in patients who were less than 10 years old at the time of primary diagnosis. CONCLUSION: Osteonecrosis affecting the knees of children treated for leukemia and lymphoma is mostly asymptomatic. Children who are 10 years old or older have signs of more advanced osteonecrosis. Clinical symptoms often lag MRI presentation and may develop late in the course of the disease. Routine MRI evaluation is recommended for timely diagnosis of treatment-induced osteonecrosis.