Faculty Bibliography

Appropriate imaging evaluation of nipple discharge depends the nature of the discharge. Imaging is not indicated for women with physiologic nipple discharge. For evaluation of pathologic nipple discharge, multiple breast imaging modalities are rated for evidence-based appropriateness under various scenarios. For women age 40 or older, mammography or digital breast tomosynthesis (DBT) should be the initial examination. Ultrasound is usually added as a complementary examination, with some exceptions. For women age 30 to 39, either mammogram or ultrasound may be used as the initial examination on the basis of institutional preference. For women age 30 or younger, ultrasound should be the initial examination, with mammography/DBT added when ultrasound shows suspicious findings or if the patient is predisposed to developing breast cancer. For men age 25 or older, mammography/DBT should be performed initially, with ultrasound added as indicated, given the high incidence of breast cancer in men with pathologic nipple discharge. Although MRI and ductography are not usually appropriate as initial examinations, each may be useful when the initial standard imaging evaluation is negative. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

OBJECTIVE: The purpose of this study was to determine the rate, characteristics, and outcomes of discordant MRI-guided vacuum-assisted biopsy (VAB) in women with suspected breast cancer. MATERIALS AND METHODS: This retrospective study reviewed 1314 MRI-guided VABs performed in 1211 women between 2007 and 2013 and yielded 25 discordant results in 24 women. MRI characteristics; BI-RADS assessments; whether the lesion was missed, partially sampled, or excised at biopsy; and biopsy and surgical pathology results were reviewed. Statistical analyses were performed using Fisher exact and Mann-Whitney U tests. RESULTS: Among 1314 lesions that underwent MRI-guided VAB, 25 results were discordant (1.9%; 95% CI, 1.2-2.8%), and nine lesions with discordant results (36.0%, 95% CI, 18.5-56.9%) were malignant at surgical excision (three invasive ductal carcinoma and six ductal carcinoma in situ). There was no significant association between malignancy and lesion type, size, enhancement pattern, BI-RADS assessment, or clinical indication. Forty-four percent (11/25) of discordant lesions were missed, 48.0% (12/25) were partially sampled, and 8.0% (2/25) appeared to have been excised. Of the nine malignant lesions, 44.4% (4/9) discordant malignant lesions were missed, 44.4% (4/9) were partially sampled, and 11.1% (1/9) appeared to have been excised. Lesion sizes and types were similar in the missed and partially excised groups. CONCLUSION: The potential for false-negative results at MRI-guided VAB underscores the importance of radiologic-histologic correlation and imaging review after biopsy. Rebiopsy or excision in discordant cases is therefore recommended.

Purpose To demonstrate the feasibility of the use of a rapid, noninvasive, in vivo imaging method to measure fatty acid fractions of breast adipose tissue during diagnostic breast magnetic resonance (MR) examinations and to investigate associations between fatty acid fractions in breast adipose tissue and breast cancer status by using this method. Materials and Methods The institutional review board approved this retrospective HIPAA-compliant study and informed consent was waived. Between July 2013 and September 2014, multiple-echo three-dimensional gradient-echo data were acquired for 89 women. Spectra were generated and used to estimate fractions of monounsaturated fatty acid (MUFA), polyunsaturated fatty acid (PUFA), and saturated fatty acid (SFA) in the breast adipose tissue. Analysis of covariance and exact Mann-Whitney tests were used to compare groups and the Spearman rank correlation coefficient was used to characterize the association of each imaging measure with each attribute. Results For postmenopausal women, MUFA was lower (0.38 +/- 0.06 vs 0.46 +/- 0.10; P < .05) and SFA was higher (0.31 +/- 0.07 vs 0.19 +/- 0.11; P < .05) for women with invasive ductal carcinoma than for those with benign tissue. No correlation was found between body mass index (BMI) and fatty acid fractions in breast adipose tissue. In women with benign tissue, postmenopausal women had a higher PUFA (0.35 +/- 0.06 vs 0.27 +/- 0.05; P < .01) and lower SFA (0.19 +/- 0.11 vs 0.30 +/- 0.12; P < .05) than premenopausal women. Conclusion There is a possible link between the presence of invasive ductal carcinoma and fatty acid fractions in breast adipose tissue for postmenopausal women in whom BMI values are not correlated with the fatty acid fractions. (c) RSNA, 2016 Online supplemental material is available for this article.

RATIONALE AND OBJECTIVES: To investigate whether quantitative kinetic analysis of lesions and background parenchyma in breast magnetic resonance imaging can elucidate differences between BRCA carriers and sporadic controls with high risk for breast cancer. MATERIALS AND METHODS: Fifty-nine BRCA and 59 control cases (49 benign, 10 malignant) were examined in this study. Principal component analysis was applied for quantitative analysis of dynamic signal in background parenchyma (B) and lesion (L) in terms of initial enhancement ratio (IER) and delayed enhancement ratio (DER). RESULTS: Control B-IER, B-DER, L-IER, and L-DER were higher than BRCA cases in all women and in women with benign lesions; statistically significant differences in B-IER and B-DER (all women: P = 0.02 and P = 0.02, respectively; benign only: P = 0.005 and P = 0.005, respectively). In the control cohort, B-IER and B-DER were higher in the premenopausal women than in the postmenopausal women (P = 0.013 and 0.003, respectively), but not in the BRCA cohort; this led to significant differences in B-IER and B-DER between the control and the BRCA groups in the premenopausal women (P = 0.01 and 0.01, respectively) but not in the postmenopausal women. CONCLUSION: Results suggest possible differences in the vascular properties of background parenchyma between BRCA carriers and noncarriers and its association with menopausal status.

PURPOSE: To assess dynamic contrast-enhanced (DCE) magnetic resonance imaging (MRI) tracer pharmacokinetic parameters obtained with Generalized Kinetic Model (GKM) and extended Shutter Speed Model (SSM2) in renal tumors stratified by histologic subtypes. MATERIALS AND METHODS: In all, 24 patients with renal tumors were imaged at 1.5 T utilizing DCE-MRI with high temporal resolution (1.2 sec/temporal frame) prior to surgery. Tracer kinetic analysis was performed for the entire tumor using individualized aortic input function. GKM and SSM2 were employed to generate transfer constant (K(trans) ), plasma volume, and interstitial volume. These parameters, and DeltaK(trans) (K(trans) SSM2 - K(trans) GKM) were compared between tumors stratified by histologic subtype. RESULTS: There were 25 renal tumors: 15 clear cell, 4 papillary, 3 chromophobe, and 3 oncocytoma/oncocytic subtype. K(trans) GKM was significantly higher in chromophobe compared to other subtypes (P < 0.01). Using K(trans) GKM > 1.0 min(-1) , chromophobe were diagnosed with 100% sensitivity and 90.9% specificity. K(trans) SSM2 was higher than K(trans) GKM for all renal tumors except for all chromophobe and two clear cell subtype. Using K(trans) GKM > 1.0 min(-1) and Delta K(trans) < 0, chromophobe could be discriminated from other lesions with 100% accuracy. CONCLUSION: K(trans) obtained with GKM and SSM2 analysis can potentially discriminate chromophobe from other renal lesions with high accuracy. J. Magn. Reson. Imaging 2013;. (c) 2013 Wiley Periodicals, Inc.

Purpose:To develop and apply a semiautomatic method of segmenting fibroglandular tissue to quantify magnetic resonance (MR) imaging contrast material-enhancement kinetics of breast background parenchyma (BP) and lesions throughout the phases of the menstrual cycle in women with benign and malignant lesions.Materials and Methods:The institutional review board approved this retrospective HIPAA-compliant study, and informed consent was waived. From December 2008 to August 2011, 58 premenopausal women who had undergone contrast material-enhanced MR imaging and MR imaging-guided biopsy were identified. The longest time from the start of the last known period was 34 days. One lesion per patient (37 benign and 21 malignant) was analyzed. The patient groups were stratified according to the week of the menstrual cycle when MR imaging was performed. A method based on principal component analysis (PCA) was applied for quantitative analysis of signal enhancement in the BP and lesions by using the percentage of slope and percentage of enhancement. Linear regression and the Mann-Whitney U test were used to assess the association between the kinetic parameters and the week of the menstrual cycle.Results:In the women with benign lesions, percentages of slope and enhancement for both BP and lesions during week 2 were significantly (P < .05) lower than those in week 4. Percentage of enhancement in the lesion in week 2 was lower than that in week 3 (P < .05). The MR images of women with malignant lesions showed no significant difference between the weeks for any of the parameters. There was a strong positive correlation between lesion and BP percentage of slope (r = 0.72) and between lesion and BP percentage of enhancement (r = 0.67) in the benign group. There was also a significant (P = .03) difference in lesion percentage of slope between the benign and malignant groups at week 2.Conclusion:The PCA-based method can quantify contrast enhancement kinetics of BP semiautomatically, and kinetics of BP and lesions vary according to the week of the menstrual cycle in benign but not in malignant lesions.(c) RSNA, 2013.

In this case-control study of euthyroid first-cycle IVF patients >/= 38 years old with singleton baby, miscarriage, biochemical pregnancy, and no pregnancy outcomes from 2005-2008, we assayed frozen serum for autoimmune thyroid disease (AITD) and thyroid function at cycle start, trigger, and 4 and 5 weeks' gestation. AITD prevalence in older infertile women was similar across clinical outcomes, and although AITD was associated with a higher baseline TSH, TSH remained within acceptable ranges, suggesting that T(4) supplementation may not affect maternal outcomes in older euthyroid AITD patients through 5 weeks gestation

BACKGROUND To minimize the potential for harmful inheritable conditions, donors are rigorously screened according to standard guidelines, yet such guidelines may not be sufficient to exclude egg donors with certain known inheritable conditions. We compared universal screening of oocyte donors with Tay-Sachs, Fragile X, karyotype and Minnesota Multiphasic Personality Inventory-2 (MMPI-2) versus standard American Society of Reproductive Medicine (ASRM) guidelines that do not include such testing. METHODS In this 12 year retrospective cohort study, results of enhanced universal screening of all anonymous oocyte donor candidates from 1997 to 2008 at a university hospital oocyte donation program were reviewed. Primary outcomes were the frequency of oocyte donor candidates excluded as a result of enhanced universal screening (Tay-Sachs, Fragile X, karyotypic analysis and MMPI-2) versus basic screening according to ASRM guidelines. RESULTS Of 1303 candidates who underwent on-site evaluation, 47% passed the screening process, 23% were lost to follow-up and 31% were excluded. Genetic and psychological factors accounted for the most common reasons for candidate exclusion. Enhanced genetic screening excluded an additional 25 candidates (19% of all genetic exclusions) and enhanced psychological screening excluded an additional 15 candidates (12% of all psychological exclusions). Altogether enhanced screening accounted for 40 candidates (10%) of the total pool of excluded candidates. CONCLUSIONS Although our study is limited by its retrospective nature and center-specific conclusions, we show that enhanced comprehensive screening can exclude a significant number of candidates from an oocyte donor program and should be encouraged to assure optimal short-term and long-term outcomes for pregnancies achieved through oocyte donation