Faculty Bibliography

OBJECTIVE. The purposes of this study were to determine the frequency of underestimation of high-risk lesions at MRI-guided 9-gauge vacuum-assisted breast biopsy and to determine the imaging and demographic characteristics predictive of lesion upgrade after surgery. MATERIALS AND METHODS. We retrospectively reviewed consecutively detected lesions that were found only at MRI and biopsied under MRI guidance from May 2007 to April 2012. Imaging indications, imaging features, and histologic findings were reviewed. The Fisher exact test was used to assess the association between characteristics and lesion upgrade. Patients lost to follow-up or who underwent mastectomy were excluded, making the final study cohort 140 women with 151 high-risk lesions, 147 of which were excised. RESULTS. A database search yielded the records of 1145 lesions in 1003 women. Biopsy yielded 252 (22.0%) malignant tumors, 184 (16.1%) high-risk lesions, and 709 (61.9%) benign lesions. Thirty of the 147 (20.4%) excised high-risk lesions were upgraded to malignancy. The upgrade rate was highest for atypical ductal hyperplasia, lobular carcinoma in situ, and radial scar. No imaging features were predictive of upgrade. However, there was a significantly higher risk that a high-risk lesion would be upgraded to malignancy if the current MRI-detected high-risk lesion was in the same breast as a malignant tumor previously identified in the remote history, a recently diagnosed malignant tumor, or a high-risk lesion previously identified in the remote history (p = 0.0001). The upgrade rate was significantly higher for women with a personal cancer history than for other indications combined (p = 0.0114). CONCLUSION. The rate of underestimation of malignancy in our series was 20%. No specific imaging features were seen in upgraded cases. Surgical excision is recommended for high-risk lesions found at MRI biopsy and may be particularly warranted for women with a personal history of breast cancer.

The incidence of ductal carcinoma in situ (DCIS) has increased over the past few decades and now accounts for over 20% of newly diagnosed cases of breast cancer. Although the detection of DCIS has increased with the advent of widespread mammography screening, it is essential to have a more accurate assessment of the extent of DCIS for successful breast conservation therapy. Recent studies evaluating the detection of DCIS with magnetic resonance (MR) imaging have used high spatial resolution techniques and have increasingly been performed to screen a high-risk population as well as to evaluate the extent of disease. This work has shown that MR imaging is the most sensitive modality currently available for identifying DCIS and is more accurate than mammography in evaluating the extent of DCIS. MR imaging is particularly sensitive for identifying high-grade and intermediate-grade DCIS. DCIS may have variable morphologic features on MR images, with non-mass enhancement morphology being the most common manifestation. Less commonly, DCIS may also manifest as a mass on MR images, in which case it is most likely to be irregular. The kinetics of DCIS are also variable, with fast uptake and a plateau curve reported as the most common kinetic pattern. Additional MR imaging tools such as diffusion-weighted imaging and quantitative kinetic analysis combined with the benefit of high field strength, such as 3 T, may increase the sensitivity and specificity of breast MR imaging in the detection of DCIS. (c) RSNA, 2013.

Breast magnetic resonance (MR) imaging is increasingly performed for a variety of indications, most commonly with the goal of detecting breast cancer. Percutaneous biopsy (usually under MR guidance or ultrasound if there is a correlating finding) is commonly used to evaluate suspicious imaging findings detected on MR imaging with the goal of identifying malignancy. It is important to be familiar with the characteristics and management of high-risk lesions detected or biopsied under MR guidance. This review focuses on the appearance of a variety of breast lesions detected on MR imaging that require excision with focus on pathologic correlation.

PURPOSE: To evaluate feasibility of using magnetization transfer ratio (MTR) in conjunction with dynamic contrast-enhanced MRI (DCE-MRI) for differentiation of benign and malignant breast lesions at 3 Tesla. MATERIALS AND METHODS: This prospective study was IRB and HIPAA compliant. DCE-MRI scans followed by MT imaging were performed on 41 patients. Regions of interest (ROIs) were drawn on co-registered MTR and DCE postcontrast images for breast structures, including benign lesions (BL) and malignant lesions (ML). Initial enhancement ratio (IER) and delayed enhancement ratio (DER) were calculated, as were normalized MTR, DER, and IER (NMTR, NDER, NIER) values. Diagnostic accuracy analysis was performed. RESULTS: Mean MTR in ML was lower than in BL (P < 0.05); mean DER and mean IER in ML were significantly higher than in BL (P < 0.01, P < 0.001). NMTR, NDER, and NIER were significantly lower in ML versus BL (P < 0.007, P < 0.001, P < 0.001). IER had highest diagnostic accuracy (77.6%), sensitivity (86.2%), and area under the ROC curve (.879). MTR specificity was 100%. Logistic regression modeling with NMTR and NIER yielded best results for BL versus ML (sensitivity 93.1%, specificity 80%, AUC 0.884, accuracy 83.7%). CONCLUSION: Isolated quantitative DCE analysis may increase specificity of breast MR for differentiating BL and ML. DCE-MRI with NMTR may produce a robust means of evaluating breast lesions. J. Magn. Reson. Imaging 2013;37:138-145. (c) 2012 Wiley Periodicals, Inc.

Objective: To investigate the frequency, imaging features, and surgical outcome of papillary lesions identified at 3-T MRI. Materials and Methods: This HIPAA-compliant institutional review board-approved retrospective study evaluated papillary lesions detected on MRI and sampled with either MR-guided 9-gauge vacuum assisted biopsy (VAB) or ultrasound-guided biopsy from 2008 to 2010. Lesion description, size, BI-RADS category, percutaneous biopsy results (MR-guided, ultrasound-guided, or stereotactic) and any upgrade at final excision were recorded for each lesion. Results: In total, 23 cases of pathology proven MRI-detected papillary lesions were identified in 22 patients. The indication for the initial MR study was a personal history of breast cancer in 13 (59%), a history of high-risk lesions in 2 patients (9%), a history of family history of breast cancer in 1 patient (5%), and other indications in 6 patients (27%). Nine papillary lesions presented as nonmasslike enhancement (NMLE), 13 presented as masses, and one presented as a focus on MR. Eight lesions had a sonographic correlate and were biopsied under ultrasound guidance; of this group, 6 cases were masses and 2 were NMLE. Those lesions with a correlate had a mean size of 1.7 cm, larger than those lesions without a correlate (mean of 1.3 cm), but the difference in means was not statistically significant. Nine of 23 cases (39%) of papillary lesions were in a retroareolar location. Of the 13 masses, 8 cases had irregular margins (62%). No kinetic features were identified more frequently in papillary lesions. In 7 cases (30%), the initial biopsy found additional high risk lesion(s) in association with the papillary finding. Two (8.7%) papillary lesions with associated high-risk lesions were upgraded to DCIS at surgical excision. One of these was found on ultrasound and the other on MR-guided biopsy. There were no cases of an isolated papillary lesion being upgraded to DCIS or invasive carcinoma. Conclusion: Review of the MR findings demons!

OBJECTIVE: Women at high risk for breast cancer and women with newly diagnosed breast cancer often undergo breast MRI. With the increasing availability of MRI-guided biopsy, high-risk lesions are not infrequently encountered. These high-risk lesions include atypical ductal hyperplasia, lobular carcinoma in situ, atypical lobular hyperplasia, papilloma, radial scar, and flat epithelial cell atypia. The management of these lesions is controversial and is often extended to high-risk lesions detected on mammography and ultrasound, with surgical excision usually recommended. The increasing use of MRI for suspicious lesions necessitates review of the imaging characteristics, frequency, and surgical outcome of high-risk lesions identified at MRI. This article addresses the frequency of high-risk lesions detected on breast MRI according to the current literature and discusses MRI features of high-risk lesions, including morphologic and enhancement kinetic characteristics. The surgical outcome for high-risk lesions identified at MRI-guided biopsy will be discussed. Finally, appropriate management guidelines for high-risk lesions identified on MRI-guided biopsy will be determined. CONCLUSION: To our knowledge, no studies to date show definitive and specific characteristics for high-risk lesions. Underestimation of malignancy on MRI-guided biopsy currently warrants surgical management for all high-risk lesions. There is a need for prospective larger power studies

PURPOSE: The aim of this study was (a) to compare arterial enhancement in simultaneously acquired high- and low-kilovoltage images; and (b) to determine whether low tube-voltage imaging would permit PE evaluation on routine chest CT studies or CTPA studies performed with a low volume of contrast media. MATERIALS AND METHODS: We compared 20 CTPA studies (CTPA group), 20 routine thoracic CT studies (RT group) and 10 CTPA studies performed with reduced volume of contrast media (RC group). HU values were measured in all groups at 80kVp and 140kVp images in multiple pulmonary arterial segments bilaterally. The diagnostic quality of the central and peripheral vascular enhancement and the image noise were evaluated at both energies using a five-point scale. RESULTS: For all patients, the mean CT attenuation values were greater at 80kVp than 140kVp images (p<0.001). At 80kVp, CTPA group attenuation values were greater than RT group (p=0.03) with a similar trend at 140kVp (p=0.08). At both 140kVp and 80kVp, CTPA group attenuation values were greater than RC group (p=0.02 and p=0.03, respectively). Qualitative analysis showed that at 140kVp CTPA studies had better global image quality scores than RT (p=0.003) and RC (p=0.001) groups. However, at 80kVp, there was no significant difference of global image quality between CTPA and the other groups (p=0.4 and p=0.5, respectively). Although measurable image noise was greater at 80kVp than 140kVp (p<0.001), qualitative analysis revealed lower image noise at 80kVp images. CONCLUSION: DECT at 80kVp increases arterial enhancement in both CTPA and routine studies. For routine studies this results in central and peripheral enhancement quality equivalent to that of CTPA studies. Low tube-voltage imaging allows marked contrast volume reduction for CTPA. In selected cases, satisfactory lower radiation dose CT might be achievable using lower kVp imaging alone

Despite the proliferation of journals and the demanding responsibilities of an editorship, there are very few clearly delineated standards for editorial education. The editor of a medical journal has a challenging role. He or she must deal with scientific decisions and appraisals that require skill in both writing and critical review. But the editor also has to cope with other concerns, including ethical issues, opposition within the editorial board, and conflict with disgruntled authors. The editor has also to design the journal's future, and make decisions considering the strategic interest of the journal and the needs of the journal's readers. In this paper, we examine the medical editor's role, review the topic of education for those interested in medical editorial work and discuss the tenets and structure of existing medical editorial training programs.

The advantages of autogenous fistulas over grafts and catheters for vascular access in hemodialysis are well recognized and include lower rates of all-cause mortality and infection and significantly decreased total access costs. However, a substantial number of fistulas will never mature and are eventually abandoned. Percutaneous techniques are increasingly used to salvage fistulas to enable maturation and use. The authors report on a patient with a thrombosed immature brachiocephalic dialysis fistula with an occluded outflow vein, in whom fistula function was salvaged through creation of a percutaneous vein-to-vein anastomosis. This technique adds to the growing armamentarium of interventional therapies for occluded venous outflow in hemodialysis access sites