Radiologic recommendation for breast biopsy on screening mammography reports.

Radiologic reports on screening mammography findings often obligate breast biopsy. Ready recommendation for biopsy of nonpalpable lesions imaged by x ray is a conservative radiologic policy but is unsettling for patients and creates an imperative bind for surgeons. Like the decision to send the patient with right lower quadrant abdominal pain home rather than to the operating room, the diagnosis that requires clinical confidence and precision is nonappendicitis. Noncancer of the breast is a similar diagnosis that can usually be made on clinical and mammographic findings rather than passing such patients through to invasive diagnosis. A series of 84 patients was referred for needle localization of nonpalpable mammographically detected lesions called suspicious on screening examination. Of these 84 patients, new radiographic reports reinterpreting the findings without biopsy were written on the original mammogram in 15 patients. This is a cancellation rate of 21 per cent. In 69 patients needle localization was carried out with the finding of cancer in 28 per cent, compared with the national average of 15 per cent. This higher than average yield caused concern whether any unbiopsied cancers had been followed, and a review of these patients was undertaken. In the log of patients referred for needle localization, the prereading by the mammographer performing the needle localization was recorded in advance of biopsy confirmation, and specificity proved to be 94 per cent and sensitivity 96 per cent. Of the cancers that were detected, 39 per cent were proven in patients older than 50 years.(ABSTRACT TRUNCATED AT 250 WORDS)

Extracolonic manifestations of the familial adenomatous polyposis syndromes.

The classic prototypes of the gastrointestinal polyposis syndromes are familial polyposis coli and Gardner syndrome. Extracolonic manifestations have been described in both diseases, and the distinction between them has become less clear. In fact, some authorities have suggested that familial polyposis coli and Gardner syndrome may represent a spectrum of the same disease. In both conditions, extracolonic expressions are the rule rather than the exception, and familiarity with them is essential for accurate diagnosis and correct patient management. In this pictorial essay, we discuss familial polyposis coli and Gardner syndrome together under the heading familial adenomatous polyposis syndromes. The colonic characteristics of these syndromes will be reviewed briefly, followed by examples of the most common extracolonic manifestations.

Application of clinical indicators in the emergency department.

Clinical indicators were developed and used to assess the quality of patient care resulting from the system of shared responsibility between emergency department (ED) and radiology department faculty physicians for interpretation of ED roentgenograms. The first indicator--all discrepancies in roentgenogram interpretation between ED and radiology department faculty--measured an overall discrepancy rate of 3.3% (776 films). Three hundred fifty-two apparent discrepancies were not related to the accuracy with which ED faculty interpreted films, resulting in a revised overall discrepancy rate of 1.8%. The second indicator--undesirable patient care outcomes as a result of delayed accurate radiological diagnosis--measured an occurrence rate of 0 after clinical reevaluation of more than 99% of patients within 24 hours of initial ED evaluation. Aspects of the development and use of clinical indicators are discussed in relationship to the broader monitoring and evaluating process necessary for the continuous improvement of patient care.

Physician assessments of practice patterns in emergency department radiograph interpretation.

Emergency and radiology department directors at 517 acute-care US teaching hospitals were sent identical questionnaires surveying practice patterns of ED plain film radiograph interpretation. Fifty-seven percent of ED directors and 51% of radiology department (RD) directors responded. Both groups reported that the most common practice pattern (60%) was alternating responsibility for immediate interpretation between emergency physicians and radiologists during a 168-hour week. Remaining hospitals were nearly equally divided between systems in which radiologists always provided immediate interpretation and those in which the emergency physicians always provided the initial interpretation. In all systems in which emergency physicians provided some immediate radiograph interpretation, radiologists provided subsequent review. Institutions varied as to the level of training of the physician in both the ED and RD who provided immediate radiograph interpretation; at least 30% of the institutions responding were reported to have either emergency physicians or radiologists of resident level providing immediate interpretation at least part of the 24-hour day. Interpretation discrepancy rates between emergency physicians and radiologists were estimated to be 4% to 6%. The large amount of variation among hospitals in ED radiograph interpretation systems suggests that these systems were not designed with quality of care concerns as their primary criterion. As a consequence, objective patient outcome and process measures need to be developed and measured to ensure that a particular internal system for ED radiograph interpretation is providing an acceptably high standard of patient care.

Intrahepatic cholangiocarcinoma: radiologic-pathologic correlation.

Seventeen proved cases of intrahepatic cholangiocarcinoma (ICAC) were reviewed to establish a radiologic-pathologic correlation. The most common appearance of ICAC at computed tomography (CT) is that of a single, homogeneous low-attenuation mass. Multiple low-attenuation lesions were present in four cases. Calcification was depicted by CT in three cases. At angiography, ICAC has a variable appearance with avascular, hypovascular, and hypervascular patterns possible. Portal obstruction was seen in only one case. The most common appearance of ICAC at sonography is that of a homogeneously hyperechoic mass, either single or multiple. In only one case was ICAC hypoechoic. Plain abdominal radiography demonstrated calcification in three patients and evidence of Thorotrast (thorium dioxide) deposition in one. Upper gastrointestinal series demonstrated abnormal gastric folds in two cases, corresponding to gastric invasion by ICAC. There were no characteristic radiographic findings, but the following features may be helpful in differentiating ICAC from other primary intrahepatic tumors, particularly typical hepatocellular carcinoma: a homogeneously echogenic or high-attenuation appearance on images that reflects the uniform nature observed at pathologic examination, the presence of calcification, and the uncommon invasion of portal or hepatic veins. Conversely, the presence of satellite lesions may blur the the distinction between ICAC and metastatic liver disease.

Colorectal hemangioma: radiologic findings.

The authors correlated radiographs with the clinical and histologic data of 12 patients with colorectal hemangioma. All patients presented with rectal bleeding, which was chronic in seven. Phleboliths were also visible in seven cases, which correlated with chronic bleeding in five. On barium studies, three masses were soft and three produced rigid narrowing. The atypical features of rigid luminal narrowing, which might mimic a carcinoma, and hypovascularity correlated with chronic bleeding or visible phleboliths, which suggest the correct diagnosis of colorectal hemangioma.

Hemangioma of the liver: heterogeneous appearance on T2-weighted images.

We reviewed the gross photographs of 19 patients with hemangioma of the liver. On cut sections, all 19 tumors were inhomogeneous. In 17 cases (89%) there were areas of predominantly central fibrosis. Lobulations were present in 10 cases (53%). Areas of thrombosis (nine cases), calcification (four cases), and hemorrhage (four cases) were also present. We also reviewed 15 hemangiomas of the liver in 12 patients studied by MR imaging. Gross photographs and MR scans were available in three hemangiomas, thus allowing direct radiologic-pathologic correlation. Twelve (80%) of the hemangiomas were inhomogeneous on T2-weighted images and three (20%) were homogeneous. Other characteristics were sharp margins in all 15 cases (100%), lobulations in 11 cases (73%), peripheral location in 10 cases (67%), and internal septations in four cases (27%). We concluded that (1) hemangiomas of the liver are frequently inhomogeneous on cut sections; (2) heterogeneity in T2 images is commonly seen and should not exclude hemangioma; and (3) other signs, such as sharp margins, lobulated contour, and peripheral location, may be helpful in the MR diagnosis of hemangioma of the liver.

Intussuscepted Meckel diverticulum: radiologic-pathologic correlation.

Nine cases of Meckel diverticulum presenting with intussusception were reviewed and correlated clinically, radiologically and pathologically. The appearance of intussuscepted Meckel diverticulum by small bowel series is not specific. However, by CT, a central fat density surrounded by a thick collar of soft tissue was noted in one case correlating well with the gross pathologic appearance. The pathologic material in all our cases suggests that this CT appearance is characteristic of an inverted Meckel diverticulum.

Mesenteric and omental cysts: histologic classification with imaging correlation.

Forty-one cases of mesenteric and omental cysts are reported. Histologically, several specific types could be distinguished: lymphangioma, 19 cases; nonpancreatic pseudocyst, 11 cases; enteric duplication cyst, six cases; mesothelial cyst, three cases; and enteric cyst, two cases. A lymphangioma is usually a multiloculated cyst located in the mesentery that shows no discernible wall on computed tomography (CT) and may have characteristics of fat on CT and magnetic resonance imaging. Abnormalities in the small bowel mucosa were frequently noted on barium studies. A nonpancreatic pseudocyst is usually a unilocular or multilocular cyst located in either the mesentery or the omentum, with abundant debris sonographically and an enhancing wall on CT. An enteric duplication cyst is a unilocular cyst with an enhancing wall on CT. Mesothelial and enteric cysts are anechoic, thin-walled cysts. Emphasis is placed on the importance of identifying lymphangioma, which is more difficult to manage than the other forms of mesenteric and omental cysts.

Nodular regenerative hyperplasia of the liver: clinical and radiologic observations.

This report describes 21 cases of nodular regenerative hyperplasia (NRH) and its clinical and radiologic features. NRH of the liver is an established pathologic entity that should not be confused with focal nodular hyperplasia, hepatocellular adenoma, or the regenerative nodules associated with cirrhosis. Correct diagnosis will prevent an unnecessary hepatic lobectomy should NRH be mistaken for hepatocellular adenoma. Unlike focal nodular hyperplasia, NRH may bleed, may be associated with portal hypertension in one-half of cases, and is often associated with a systemic disease such as a myelo- or lymphoproliferative disorder. Correct diagnosis is important because the prognosis in patients with NRH and portal hypertension is better than that in patients with portal hypertension due to cirrhosis. Radiologically, multiple nodules, large masses, or an apparently normal liver (containing nodules less than 0.5 cm in diameter) were visible. The nodules may take up technetium sulfur colloid and have variable echogenicity on sonography. They are often hypodense on CT without significant enhancement. The nodules may fill from the periphery on angiography, are vascular, and sometimes contain small hypovascular areas due to hemorrhage. A large nodule may rupture and cause hemoperitoneum. These findings may resemble some features of focal nodular hyperplasia, hepatocellular adenoma, or metastases. NRH is probably underdiagnosed owing to a lack of recognition of the entity and limited sampling of liver tissue by needle biopsy. Scintigraphy, sonography, and CT of the liver should be performed in cases of idiopathic portal hypertension to detect NRH. In cases with compatible findings, multiple needle biopsies or a laparoscopically guided needle biopsy or wedge liver biopsy should be recommended for definitive diagnosis.

Gastrointestinal teratomas: CT and US appearance with pathologic correlation.

Gastrointestinal teratomas are uncommon, benign neoplasms that occur primarily in children. A retrospective review of five cases (two gastric, one pancreatic, one mesenteric, and one in the lesser omentum) is presented with emphasis on the computed tomographic and ultrasonographic appearances. Principal findings are a well-defined mass with separate cystic and solid components of varying proportions, discrete areas with densities similar to that of fat, or coarse, globular calcifications within the solid component. Recognition of these findings may allow the radiologist to make a correct preoperative diagnosis of teratoma.

Tumors of the small intestine with little or no malignant predisposition: a review of the literature and report of 56 cases.

Benign small bowel tumors are rare. If those with malignant potential are excluded, a small group of truly benign lesions remains. Fifty-six cases of these small bowel tumors were analyzed for clinical data, pathologic diagnosis, number, size, location, and radiologic appearance. Lesions included lipoma, myoepithelial hamartoma, Peutz-Jeghers hamartoma, neurogenic tumors (including gangliocytic paraganglioma), Brunner's gland abnormalities, and inflammatory fibroid polyp. Location, number, and radiographic morphology can be helpful in reaching a more specific diagnosis. Age of patient and size of tumor may be helpful in the differential diagnosis; however, sex of the patient and clinical symptoms are not.

Hemangioma of the spleen: radiologic-pathologic correlation in ten cases.

Ten cases of hemangioma of the spleen were reviewed. Plain abdominal radiographs and scintigrams are helpful in specifying the splenic location. Calcification, either central punctate or peripheral curvilinear, can be detected on radiographs or computed tomographic (CT) scans. The spectrum form solid to cystic change observed in the pathologic specimens is reflected in analogous patterns on CT scans and sonograms: predominantly solid mass; mass with cystic spaces. The angiographic findings are nonspecific. It is possible to suggest the diagnosis of hemangioma of the spleen when an asymptomatic patient presents with a discrete splenic mass, particularly if there is evidence of calcification and cystic change within the lesion.