Radiology in Public Focus

Press releases have been sent to the medical news media for the following articles appearing in the March issue of Radiology (RSNA.org/radiologyjnl):

Papillary Lesions of the Breast on Percutaneous Core Needle Biopsy

Papillary lesions of the breast diagnosed as benign on core needle biopsy should be surgically excised, a group of New York researchers has concluded.

Cecilia L. Mercado, M.D., of NYU Medical Center, and colleagues conducted a retrospective study of 43 biopsies performed on 42 patients with benign papillary lesions on core needle biopsy. The authors found there was a substantial rate of upgrade to papilloma with adjacent foci of atypical ductal hyperplasia (ADH) or papillary ductal carcinoma in situ (DCIS).

Following the 43 biopsies, 36 lesions were surgically excised and seven were subjected to long-term imaging follow-up. Dr. Mercado and colleagues found that 21 percent of all patients, whether the lesions were excised or followed with imaging, were later upgraded to either ADH or DCIS. Of those patients whose lesions were excised, 25.7 percent were upgraded to ADH or DCIS.

The authors note that while a variety of papillary lesions of the breast are occasionally encountered with the widespread use of core needle biopsy, past studies have shown a lack of agreement on how to manage benign papillomas diagnosed with the procedure. Some lesions are followed by imaging, while others are surgically excised.

“Given the considerable upgrade to either ADH or DCIS (25.7 percent) found for all patients with excised benign papillary lesions in our study, we are recommending excision of all benign papillary lesions of the breast diagnosed by core needle biopsy,” the authors wrote.

Additional long-term studies are needed to assess whether or not radiologic follow-up can be an acceptable alternative to excision,” the authors continued. “However, at this time, our data concludes that benign papillary lesions of the breast are best managed with surgical excision.”

The study is limited as symptomatic patients with nipple discharge or palpable masses were not included, possibly underestimating the risk of upgrades, the authors noted.

Atypical papilloma with adjacent ADH. (a) Mediolateral oblique view of right breast in 50-year-old woman shows 1-cm cluster of heterogeneous microcalcifications. Histologic examination of specimens from core-needle biopsy (not shown) revealed intraductal papilloma with branching fronds. No atypia was identified. (b) Mediolateral oblique view of right breast of same woman obtained 37 months after core-needle biopsy shows interval increase in microcalcifications at biopsy site. Histologic examination of specimens from excisional biopsy (not shown) revealed atypical intraductal papilloma with solid areas of epithelial cells and adjacent ducts that displayed ADH.

(Radiology 2006;238: 801-808)
© RSNA, 2006. All rights reserved. Printed with permission.

MR Imaging of Acute Appendicitis in Pregnancy

MR imaging is an excellent modality for excluding acute appendicitis in pregnant women who present with acute abdominal pain and in whom the normal appendix is not visualized at ultrasonography, according to a study from Beth Israel Deaconess Medical Center and Harvard Medical School in Boston.

Ivan Pedrosa, M.D., of the Department of Radiology at Beth Israel Deaconess Medical Center, and colleagues retrospectively reviewed MR images from 51 consecutive pregnant patients clinically suspected of having acute appendicitis. Four patients had appendicitis, including two cases missed by ultrasound.

The team notes that ultrasonography, because of its availability and lack of ionizing radiation, is the imaging modality of choice in pregnant patients who present with right lower quadrant pain. However, it does have limitations. CT is often the modality of choice in the evaluation of acute appendicitis in patients who are not pregnant but, with an estimated radiation dose as high as 30 mGy (3 rad) to the uterus with use of conventional protocols, there is a need for a noninvasive imaging technique that avoids ionizing radiation in pregnant patients.

“Our finding that MR imaging has a negative predictive value of 100 percent supports the idea that it can be safely used to exclude the diagnosis of appendicitis in pregnant patients,” the researchers note. “MR imaging during pregnancy has no known deleterious effects to the fetus, and its use in patients who need additional imaging in pregnancy has been advocated by the safety committee of the Society of Magnetic Resonance Imaging.”

The researchers go on to state that, on the basis of the low prevalence of acute appendicitis during pregnancy, MR imaging has the potential to eliminate unnecessary radiation from CT in a large number of patients by providing direct visualization of the normal appendix.

“Furthermore, MR imaging can offer an alternative diagnosis in a substantial number of pregnant women with right-sided abdominal pain,” Dr. Pedrosa and colleagues add.

Among the limitations of the study, the researchers note, is the small number of patients in the study diagnosed with acute appendicitis. They also note that the initial interpretations of the MR images were performed by the attending radiologist who covered the service and was aware of the ultrasonography results in most cases; therefore, the sensitivity of MR imaging could be falsely elevated on the basis of the nonblinded nature of those interpretations.

MR images in a 32-year-old woman (gestational age, 8 weeks) with normal appendix.
(a) Transverse T2-weighted half-Fourier single-shot fast SE image (1076/60, 4-mm-thick sections, 192 ´ 256 matrix, 130°--155° flip angle, 62-kHz bandwidth, 35-cm FOV) shows a thin tubular structure (arrow) in the right lower quadrant. (b) Transverse time-of-flight gradient-echo image (repetition time, 30 msec; minimum full echo time; 45° flip angle; 3-mm-thick sections; 1-mm gap; 256 ´ 128 matrix; 31-kHz bandwidth; 35-cm FOV) shows blooming effect in this tubular structure (arrow) due to the presence of oral contrast material, air, or both in the lumen. This finding helps confirm that this structure represents the appendix. Blood vessels(arrowhead) demonstrate high signal intensity owing to the time-of-flight effect. Blooming effect is also noted in the rest of the bowel, which is opacified with oral contrast material.

Media Coverage of RSNA 2005

Preliminary data indicate that RSNA 2005 annual meeting news reached an estimated two billion people worldwide. More than 4,000 print, broadcast and online media carried stories from the event, including CNN’s Anderson Cooper 360 and Housecall with Dr. Sanjay Gupta, as well as the Los Angeles Times, Chicago Tribune, Seattle Post-Intelligencer and Boston Herald. Stories also appeared New Scientist and Time Magazine.

In addition, press releases originating from Radiology content recently were featured in the Ladies Home Journal (a 2004 study on full-body CT) and on networks such as WNBC-TV and WMAQ-TV (a 2004 alert outlining the dangers of swallowing multiple magnets, especially for children).