Post-Menopausal Bleeding: Role of Imaging.

Post-menopausal bleeding (PMB) accounts for 5% of gynecologic office visits and is the presenting symptom in 90% of women with endometrial cancer, which requires prompt evaluation. The most common etiology of PMB is vaginal or endometrial atrophy and endometrial polyps, while endometrial hyperplasia and carcinoma account for less than 10% of PMB. Transvaginal ultrasonography measurement of an endometrial thickness (EMT) less than or equal to 4 mm has a 99% negative predictive value for endometrial carcinoma. Endometrial sampling is required if EMT >4 mm or persistent bleeding occurs. Further evaluation can be accomplished with saline infusion sonography, magnetic resonance imaging, and hysteroscopy.

Abnormal Uterine Bleeding in Reproductive Age Women: Role of Imaging in the Diagnosis and Management.

Abnormal uterine bleeding (AUB) is defined by the International Federation of Gynecology and Obstetrics as bleeding from the uterine corpus that is abnormal in regularity, volume, frequency, or duration and occurs in the absence of pregnancy. AUB is a common condition that affects about a third of women in their lifetime. Abnormal bleeding in duration, quantity, or timing consists of 2 categories, predictable cyclical heavy menstrual bleeding (HMB) and irregular non-cyclical intermenstrual bleeding (IMB). The most common causes of HMB include fibroids and adenomyosis and IMB is commonly caused by ovulatory dysfunction such as in polycystic ovaries, endometrial polyp, or an IUD. A pelvic ultrasound is the initial and often only imaging modality needed in the imaging evaluation of abnormal uterine bleeding and can accurately identify the common causes of abnormal uterine bleeding in the reproductive age group.

Morbidly Adherent Placenta: Ultrasound Assessment and Supplemental Role of Magnetic Resonance Imaging.

Morbidly adherent placenta or placenta accreta is being increasingly encountered in obstetrical practice mainly owing to the increasing rates of cesarean delivery. This condition is associated with increased maternal morbidity and mortality resulting from postpartum hemorrhage. When unsuspected, outcomes can be catastrophic to the pregnant woman. Timely diagnosis during the antenatal period, on the contrary, allows for optimal planning of a multidisciplinary management approach and delivery at a tertiary care institution. A higher index of suspicion in those at greatest risk such as in women with placenta previa and with history of some prior cesarean deliveries should lead to diligent antenatal evaluation for possible placenta accreta. Management of invasive placenta implantation often involves cesarean delivery hysterectomies; uterus-sparing alternatives to manage this condition can be an option in selected cases. Ultrasound imaging remains the modality of choice for the diagnosis. This review article discusses the ultrasound image findings in placenta accreta, its limitations and pitfalls, and the supplemental role of magnetic resonance imaging in the imaging evaluation of placenta accreta.

Adnexal Masses: Role of Supplemental Imaging With Magnetic Resonance Imaging.

Sonography is the primary and often the only imaging modality used for evaluation of an adnexal mass. Grayscale sonography with color and spectral Doppler imaging is able to accurately characterize most of the adnexal masses. Supplemental imaging with computed tomography and magnetic resonance imaging (MRI) is useful in selected cases. Computed tomography is preferred for evaluation of bowel-related pathology masquerading as an adnexal mass and for staging of gynecologic cancers. Owing to its superior contrast resolution and multiplanar imaging capability, MRI is helpful in characterizing an indeterminate adnexal mass, as well as determining the organ of origin of an adnexal mass. MRI thereby allows planning of appropriate surgical or nonsurgical management of neoplastic and nonneoplastic conditions affecting the adnexa. Imaging evaluation of adnexal masses and the supplemental role of MRI in the management of adnexal masses are discussed.

Magnetic resonance imaging and breast ultrasonography as an adjunct to mammographic screening in high-risk patients.

Screening mammography remains the standard of care for breast cancer screening of the general population and is likely to remain so in the foreseeable future. We discuss the current role of breast ultrasound and magnetic resonance imaging (MRI) in screening for breast cancer in the high-risk population. Breast ultrasound finds small cancers not seen on mammography particularly in women with dense breasts. Breast MRI has sensitivity significantly higher than that of mammography, breast ultrasound, or a combination of mammography and breast ultrasound.

Screening and diagnosis of breast cancer in low-resource countries: what is state of the art?

Breast cancer is the most common type of cancer in women worldwide; there has been a significant increase in the incidence of breast cancer in low-resource countries, with a disproportionately greater mortality rate compared to high-resource countries attributed to a lack of public awareness of the disease, absence of organized screening programs, and lack of accessible and effective treatment options. Mammography is not a cost-effective or a feasible option for screening and early detection of breast cancer in low-resource countries. A triple test assessment approach of screening clinical breast examination, diagnostic breast ultrasound, and ultrasound-guided fine-needle aspiration cytology may be a feasible option for the early detection of breast cancer.

Early detection of breast, cervical, ovarian and endometrial cancers in low resource countries: an integrated approach.

The incidence of breast and gynecological cancers continues to increase in low and middle resource countries [LRC'S and MRC's] with a disproportionately higher mortality rate compared to that in high resource countries. This has been attributed to factors such as an increased life span due to better control of communicable diseases and improved nutrition, as well as lifestyle and reproductive changes. A lack of public awareness and understanding of these cancers, absence of an organized screening program and a lack of accessible and effective treatment options, is responsible for the higher mortality rate. A practical approach of a combined program of integrating a well woman examination with screening for breast and cervical cancer and diagnostic evaluation for Ovarian and Endometrial cancer in symptomatic women is proposed in this article which can serve as a model to be studied for efficacy in low resource countries.

Abdominal computed tomography during pregnancy: a review of indications and fetal radiation exposure issues.

This article reviews the radiation risks to the developing fetus when exposed in utero to diagnostic radiological procedures. The discussion focuses primarily on abdominal computed tomography as this is the examination that delivers the highest radiation dose to the fetus among the diagnostic radiological procedures performed during pregnancy. The review describes the common indications for abdominal computed tomography, the biological risks to the developing fetus, radiation dose, and dose modulation techniques as well as the need for establishing a pregnancy policy to guide performance of radiological investigations in pregnancy.

Abdominal computed tomography during pregnancy for suspected appendicitis: a 5-year experience at a maternity hospital.

The objective of this article is to evaluate the role of computed tomography (CT) in a pregnant patient with right lower quadrant pain in whom there was a clinical suspicion of acute appendicitis. During a 5-year period the clinical records of all pregnant women who underwent imaging examination for clinically suspected appendicitis were reviewed. The imaging findings were correlated with patient management and final outcome. Thirty-nine pregnant patients were referred for imaging, of which 35 underwent initial evaluation with sonography, 23 of these women underwent a computed tomographic examination, and an additional 4 patients were directly imaged with CT without earlier sonographic assessment. Surgery confirmed appendicitis in all 5 patients who were operated on on the basis of findings of appendicitis on a CT scan. Two patients underwent surgery based on an alternate diagnosis suggested preoperatively (tubal torsion = 1, ovarian torsion = 1). All patients with negative findings at CT had an uneventful clinical course. In those patients who were evaluated only with ultrasound, a diagnosis of appendicitis was missed in 5 patients. The sensitivity of CT in the diagnosis of appendicitis in our study group was 100%, compared with a sensitivity of 46.1% for ultrasound. CT provides an accurate diagnosis in patients suspected to have acute appendicitis and is of value in avoiding false negative exploratory laparatomy with its consequent risk of maternal and fetal mortality and morbidity. Although sonography is the preferred initial imaging modality as its lack of ionizing radiation, CT is more accurate in providing a timely diagnosis and its use is justified to reduce maternal mortality and mortality in patients with appendicitis.

Screening for breast cancer with mammography: current status and an overview.

This article reviews the current status of Mammographic screening in early detection of Breast cancer. A brief introduction on the global breast cancer burden is followed by an overview of the data proving the benefits of screening mammography in those countries where screening programs are in place. The screening recommendations, the benchmarks of a successful mammographic screening program and an overview of the guidelines that have been implemented for ensuring quality assurance in the USA and Europe are presented. The pertinent aspects of mammographic interpretation and the role of non mammographic screening methods are also discussed.

Presurgical localization of breast abnormalities: an overview and analysis of 202 cases.

The purpose of this study was to analyze cases undergoing imaging guided localization prior to surgical excisional biopsy of abnormalities in the breast and to describe the methodology utilized to perform such presurgical localization procedures. Presurgical localization of non palpable breast abnormalities is a simple, safe and effective procedure; it is now used more selectively for this indication due to availability of minimally invasive percutaneous biopsy procedures that can be performed under ultrasound or stereotactic guidance.

Sonographically occult screen detected breast masses: a retrospective analysis of cases undergoing biopsy.

OBJECTIVE: The purpose of this study was to evaluate nonpalpable breast masses identified on mammograms that are sonographically occult. METHODS: The pathology data base at the Woman's Place for Breast Care of the Woman's Hospital of Texas was searched to identify patients who had undergone biopsy for a nonpalpable breast mass identified on mammograms in which a mass was not visible at sonography. RESULTS: There were 32 of 231 such nonpalpable masses that were sonographically occult. Twenty-eight of the masses were histologically benign; four were malignant. CONCLUSION: A small percentage of mammographically visible nonpalpable breast masses are sonographically occult; a majority of these masses are benign. However, biopsy of such masses should be considered and the decision to biopsy based on mammographic features and interval change.

Sonographic evaluation of isolated abnormal axillary lymph nodes identified on mammograms.

OBJECTIVE: To evaluate the role of sonography in evaluation of abnormal axillary lymph nodes identified in patients with otherwise negative or benign findings on mammography. METHODS: For 3 years 2 months, we retrospectively reviewed 30 consecutive cases that had undergone sonographic evaluation for abnormal axillary lymph nodes identified in patients whose mammograms had an American College of Radiology Breast Imaging Reporting and Data System final assessment of 1 or 2. Mammographic and sonographic features of the lymph nodes were analyzed and correlated with the histologic diagnosis in patients undergoing biopsy. Patients who did not undergo biopsy had clinical or imaging follow-up. RESULTS: Twenty of the 30 patients studied had an abnormal sonographic appearance. Biopsy was recommended in 17 of the 20 patients on the basis of an abnormal sonographic appearance. In the remaining 3 patients, there was an underlying cause for lymphadenopathy, and these patients underwent clinical and sonographic follow-up. Eighteen patients underwent biopsy, including 1 patient with normal findings on sonography. Ten of these patients had malignant histologic findings: 6 were metastatic adenocarcinoma; 1, poorly differentiated sarcoma, and 3, lymphoma. The remaining 8 patients had benign histologic findings. The nonbiopsy group had clinical and or imaging follow-up (mean, 17.6 months; range, 6-25 months). The sensitivity (true-positive/true-positive + false-negative) of sonography for assessment of suspected abnormal lymph nodes in the patients studied was 100% (10 of 10); specificity (true-negative/true-negative + false-positive), 50% (10 of 20); positive predictive value (true-positive/true-positive + false-positive) for malignancy based on the presence of 2 or more abnormal sonographic features, 50% (10 of 20); and negative predictive value, 100%. CONCLUSIONS: Sonography is useful in further characterization of isolated abnormal axillary lymph nodes identified on mammography. Sonographic evaluation helps improve the specificity of imaging evaluation in assessment of these lymph nodes.

Prospective evaluation of the value of combined mammographic and sonographic assessment in patients with palpable abnormalities of the breast.

OBJECTIVE: To evaluate the role of combined mammographic and sonographic imaging in patients with palpable abnormalities of the breast. METHODS: Four hundred eleven consecutive cases of palpable abnormalities of the breast underwent combined mammographic and sonographic evaluation. Patients who did not undergo biopsy had imaging and clinical follow-up; the mean follow-up period was 28.9 months (range, 24-33 months). RESULTS: One hundred sixty-five (40.1%) of 411 palpable abnormalities had a benign assessment; 97 (58.7%) of the 165 benign lesions were visible on both mammography and sonography; 66 (40%) of 165 benign lesions were mammographically occult and identified at sonographic evaluation. In 60 (14.6%) of the 411 cases, imaging evaluation resulted in a suspicious assessment; 49 (81.7%) of the 60 lesions categorized as suspicious underwent biopsy; 14 (28.5%) of 49 lesions were histologically proved to be carcinoma. Nineteen (31.6%) of the 60 lesions categorized as suspicious were mammographically occult and identified only on sonography; 14 (73.7%) of these 19 lesions underwent biopsy; 12 (63.1%) of 19 were benign, and 2 (10.5%) were malignant. One hundred eighty-six (45.2%) of the 411 palpable abnormalities had negative imaging assessment findings; 12 patients with negative imaging findings underwent biopsy, and all had benign findings. The sensitivity (14 of 14) and negative predictive value (186 of 186) for a combined mammographic and sonographic assessment were 100%; the specificity was 80.1% (186 of 232). CONCLUSIONS: Cancer was diagnosed in 14 (3.4%) of 411 women who underwent combined imaging for palpable abnormalities of the breast. Combined mammographic and sonographic assessment was shown to be very helpful in identifying benign as well as malignant lesions causing palpable abnormalities of the breast.

Radial scars of the breast: sonographic findings.

The purpose of this study was to identify the sonographic features of radial scars of the breast and to determine whether sonography has a role in imaging of radial scars suspected on mammography. Over a period of 4 years and 6 months, patients with a pathologic diagnosis of a radial scar and who had undergone mammographic and sonographic evaluation before biopsy were identified. During the period studied, there were 17 patients with a histopathologic diagnosis of a radial scar who had undergone sonographic and mammographic evaluation before biopsy. A radial scar was sonographically visible in eight of the 17 patients. In three of these patients, the lesion was more apparent on the sonogram than on the mammogram, and in one patient the radial scar was identified only on sonographic evaluation. It was concluded that radial scars of the breast may be sonographically visible; hence, additional sonographic evaluation may be helpful in those patients in whom mammographic findings are subtle or apparent on only one mammographic view to aid in the localization of the lesion before biopsy.

Sonographic evaluation of focal asymmetric density of the breast.

The purpose of this study was to examine the role of sonography in the evaluation of a focal asymmetric density of the breast in patients who subsequently underwent biopsy for this finding. During a 30-month period, the clinical, sonographic, and pathologic findings were retrospectively reviewed in 36 women who underwent biopsy for a focal asymmetric density of the breast after mammographic and sonographic workup. Sonographic evaluation of a focal asymmetric density of the breast in 36 women demonstrated a solid mass in 15, a suspected complicated cyst in two, echogenic tissue in nine women, and no focal sonographic change in 10. Excisional biopsy of the focal asymmetric density revealed infiltrating ductal cancer in seven patients (19.4%: 7/36). Two of these seven patients with breast cancer had no focal abnormality at sonographic examination. Twenty-nine patients had benign pathologic findings. In this retrospective study, the negative predictive value of sonography for breast cancer in a patient with a focal asymmetric density undergoing biopsy was found to be 89.4% (17/19). Sonographic evaluation of a focal asymmetric density is helpful, particularly to identify an underlying mass. When sonography demonstrates echogenic tissue corresponding to the focal asymmetric density, a benign process is likely; however, absence of a corresponding focal finding does not exclude malignancy. Therefore, although the negative predictive value of sonography for breast cancer in a patient with a focal asymmetric density is high, biopsy is still indicated for this mammographic finding when it is new, enlarging, or palpable, even in the absence of a suspicious sonographic finding.

Sonographic findings in focal fibrocystic changes of the breast.

The purpose of this study was to identify the spectrum of sonographic appearances in histologically proven focal fibrocystic changes (FC) of the breast to enhance understanding of imaging findings in this commonly encountered benign condition of the breast. During a 28-month period, the pathology database at two breast centers was searched to identify all patients with a pathologic diagnosis of focal FC resulting from biopsy of a focal mammographic, sonographic, or palpable abnormality and who had undergone sonographic evaluation before biopsy. The authors included lesions with a pathologic diagnosis of FC with or without a specific histologic subtype, such as stromal fibrosis, sclerosing adenosis, and apocrine metaplasia. In 58 patients, there were 60 lesions with a pathologic diagnosis of focal FC. Sonographically, focal FC appeared as solid mass in 28 cases (46.6%) and as cysts in eight (13.3%). In nine cases (15%), heterogeneously echogenic tissue was seen, and in the remaining 15 (25%) cases, there was no sonographically visible focal change. Thirteen of the 28 (46.4%) masses were classified as sonographically indeterminate. One mass was classified as probably malignant, and 14 masses were sonographically benign. A significant number of focal FC appear as solid masses. The sonographic features are not specific enough to differentiate between those that have a dominant component of focal fibrosis, sclerosing adenosis, or apocrine metaplasia from FC without a specific histologic subtype. Many of these solid masses may appear indeterminate, based on published criteria. An understanding of the imaging findings also helps to avoid repeat biopsy for discordant histologic and imaging findings.