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BACKGROUND:Uterine leiomyomas (fibroid tumors) cause considerable symptoms in 30-50% of women and are the leading cause of hysterectomy in the United States. Women with uterine fibroid tumors often seek uterine-preserving treatments, but comparative effectiveness trials are lacking. OBJECTIVE:The purpose of this study was to report treatment effectiveness and ovarian function after uterine artery embolization vs magnetic resonance imaging-guided focused ultrasound surgery from the Fibroid Interventions: Reducing Symptoms Today and Tomorrow study. STUDY DESIGN:The Fibroid Interventions: Reducing Symptoms Today and Tomorrow study, which is a randomized controlled trial of uterine artery embolization vs magnetic resonance imaging-guided focused ultrasound surgery, enrolled premenopausal women with symptomatic uterine fibroid tumors; women who declined randomization were enrolled in a parallel observational cohort. A comprehensive cohort design was used for outcomes analysis. Our target enrollment was 220 women, of which we achieved 41% (n=91) in the randomized and parallel arms of the trial. Primary outcome was reintervention for uterine fibroid tumors within 36 months. Secondary outcomes were change in serum anti-Müllerian hormone levels and standardized measures of fibroid symptoms, quality of life, pain, and sexual function. RESULTS:From 2010-2014, 83 women (mean age, 44.4 years) were treated in the comprehensive cohort design (43 for magnetic resonance imaging-guided focused ultrasound surgery [27 randomized]; 40 for uterine artery embolization [22 randomized]); baseline clinical and uterine characteristics were similar between treatment arms, except for higher fibroid load in the uterine artery embolization arm. The risk of reintervention was higher with magnetic resonance imaging-guided focused ultrasound surgery than uterine artery embolization (hazard ratio, 2.81; 95% confidence interval, 1.01-7.79). Uterine artery embolization showed a significantly greater absolute decrease in anti-Müllerian hormone levels at 24 months compared with magnetic resonance imaging-guided focused ultrasound surgery. Quality of life and pain scores improved in both arms but to a greater extent in the uterine artery embolization arm. Higher pretreatment anti-Müllerian hormone level and younger age at treatment increased the overall risk of reintervention. CONCLUSION:Our study demonstrates a lower reintervention rate and greater improvement in symptoms after uterine artery embolization, although some of the effectiveness may come through impairment of ovarian reserve. Both pretreatment anti-Müllerian hormone level and age are associated with risk of reintervention. CLINICAL TRIAL REGISTRATION NUMBER:NCT00995878, clinicaltrials.gov.

BackgroundUterine fibroids are a common problem for reproductive-aged women, yet little comparative effectiveness research is available to guide treatment choice. Uterine artery embolization and magnetic resonance imaging-guided focused ultrasound surgery are minimally invasive therapies approved by the US Food and Drug Administration for treating symptomatic uterine fibroids. The Fibroid Interventions: Reducing Symptoms Today and Tomorrow study is the first randomized controlled trial to compare these 2 fibroid treatments.ObjectiveThe objective of the study was to summarize treatment parameters and compare recovery trajectory and adverse events in the first 6 weeks after treatment.Study designPremenopausal women with symptomatic uterine fibroids seen at 3 US academic medical centers were enrolled in the randomized controlled trial (n = 57). Women meeting identical criteria who declined randomization but agreed to study participation were enrolled in a nonrandomized parallel cohort (n = 34). The 2 treatment groups were analyzed by using a comprehensive cohort design. All women undergoing focused ultrasound and uterine artery embolization received the same postprocedure prescriptions, instructions, and symptom diaries for comparison of recovery in the first 6 weeks. Return to work and normal activities, medication use, symptoms, and adverse events were captured with postprocedure diaries. Data were analyzed using the Wilcoxon rank sum test or χ2 test. Multivariable regression was used to adjust for baseline pain levels and fibroid load when comparing opioid medication, adverse events, and recovery time between treatment groups because these factors varied at baseline between groups and could affect outcomes. Adverse events were also collected.ResultsOf 83 women in the comprehensive cohort design who underwent treatment, 75 completed postprocedure diaries. Focused ultrasound surgery was a longer procedure than embolization (mean [SD], 405 [146] vs 139 [44] min; P

BackgroundUterine fibroids are an important source of morbidity for reproductive-aged women. Despite an increasing number of alternatives, hysterectomies account for about 75% of all fibroid interventional treatments. Evidence is lacking to help women and their health care providers decide among alternatives to hysterectomy. Fibroid Interventions: Reducing Symptoms Today and Tomorrow (NCT00995878, clinicaltrials.gov) is a randomized controlled trial to compare the safety, efficacy, and economics of 2 minimally invasive alternatives to hysterectomy: uterine artery embolization and magnetic resonance imaging-guided focused ultrasound surgery. Although randomized trials provide the highest level of evidence, they have been difficult to conduct in the United States for interventional fibroid treatments. Thus, contemporaneously recruiting women declining randomization may have value as an alternative strategy for comparative effectiveness research.ObjectiveWe sought to compare baseline characteristics of randomized participants with nonrandomized participants meeting the same enrollment criteria and to determine whether combining the 2 cohorts in a comprehensive cohort design would be useful for analysis.Study designPremenopausal women with symptomatic uterine fibroids seeking interventional therapy at 3 US academic medical centers were randomized (1:1) in 2 strata based on calculated uterine volume (

Objective To evaluate the safety and tolerability of MRI-guided focused ultrasound (MRgFUS) for the treatment of facet joint–mediated pain in human subjects for whom conventional treatment had failed. Secondarily, to evaluate effectiveness of the procedure. Methods Consecutive patients who underwent MRgFUS at our institution were retrospectively identified. Chart review was performed to obtain relevant clinical and technical data. All patients had chronic low back pain and positive comparative medial branch blocks. Results Twenty-six MRgFUS treatments in 20 patients were included. Mean sonication energy was 1436.6 Joules. The procedure was technically successful in all patients. Of the treated patients, 29.6% experienced short-term worsening of low back pain immediately after the procedure, all by 1–4 points on a 0–10 scale. One patient (3.8%) reported temporary worsening of preexisting radicular symptoms after the procedure. Of 21 treatments with clinical follow-up of at least 3 months available, 12 (57.1%) had >3 months' pain relief, 2 (10%) had <3 months' benefit, 6 (30%) reported no benefit, and 1 (5%) patient was lost to follow-up. In patients who reported at least some benefit with prior conventional radiofrequency ablation, 8/10 (80%) benefited from the MRgFUS procedure. Conclusion The present study demonstrates that MRgFUS ablation of the lumbar facet joints is a safe and tolerable procedure in human subjects and could provide another option for patients for whom radiofrequency ablation had failed. More than half of all patients received significant durable pain relief, which jumped to 80% for patients who had experienced at least some benefit from prior radiofrequency ablations. [ABSTRACT FROM AUTHOR]

There are very few true breast emergencies. While infrequent, women do present to emergency departments or urgent care centres with breast‐related concerns. In this case‐based review, both common and uncommon urgent and emergent breast lesions are presented, emphasising ultrasound characteristics and imaging optimisation to improve accurate diagnosis and appropriate recommendations. [ABSTRACT FROM AUTHOR]

Background: Women with uterine fibroids often seek uterine-preserving treatments, rather than hysterectomy. Imaging-defined endpoints following nonsurgical treatments for fibroids are limited. Materials and Methods: Fibroid Interventions: Reducing Symptoms Today and Tomorrow (FIRSTT), a randomized controlled trial of uterine artery embolization (UAE) versus magnetic resonance imaging-guided focused ultrasound surgery (MRgFUS), enrolled premenopausal women with symptomatic uterine fibroids. In this subanalysis, we report imaging results up to 36 months after UAE or MRgFUS. Magnetic resonance imaging (MRI) was performed at baseline for all women and during the 36 months after treatment if they did not meet other study endpoints. The main outcome of this subanalysis was fibroid volume reduction (defined both in terms of total fibroid load and volume of the largest fibroid), uterine volume reduction, and nonperfused volume. Results: During 2010–2014, 25 of the 37 women who were randomized and treated at Mayo Clinic had a 24-month follow-up MRI (11 UAE; 14 MRgFUS); among these women, 15 (7 UAE and 8 MRgFUS) had a 36-month follow-up MRI. Average age for the cohort was 44.1 (standard deviation, SD = 4.4) years. Nine patients had a second fibroid procedure by 36 months (seven in the MRgFUS arm and two in UAE arm). Median total fibroid load reduction was ∼50% in both treatment arms at both 24- and 36-month follow-up. Volume of the largest fibroid decreased more in the MRgFUS arm, whereas uterine volume decreased more in the UAE arm (neither reached statistical significance). At 24 months, median nonperfused volume was higher in the UAE arm (92%) than the MRgFUS arm (10%). Conclusions: Similar fibroid volume reduction was seen for the MRgFUS and UAE treatments in this comparative effectiveness study. Nonperfused volume 24 months after the procedure was higher in the UAE arm than in the MRgFUS arm. Clinical Trial Registration Number: NCT00995878, clinicaltrials.gov [ABSTRACT FROM AUTHOR]

Objective: To present the rationale, design, and methodology of the Fibroid Interventions: Reducing Symptoms Today and Tomorrow (FIRSTT) study.Design: Randomized clinical trial.Setting: Two academic medical centers.Patient(s): Premenopausal women with symptomatic uterine fibroids.Intervention(s): Participants are randomized to two U.S. Food and Drug Administration-approved minimally invasive treatments for uterine leiomyomas: uterine artery embolization and magnetic resonance-guided focused ultrasound.Main Outcome Measure(s): The primary endpoint is defined as the need for an additional intervention for fibroid symptoms following treatment. Secondary outcomes consist of group differences in symptom alleviation, recovery trajectory, health-related quality of life, impairment of ovarian reserve, treatment complications, and the economic impact of these issues.Result(s): The trial is currently in the phase of active recruitment.Conclusion(s): This randomized clinical trial will provide important evidence-based information for patients and health care providers regarding optimal minimally invasive treatment approach for women with symptomatic uterine leiomyomas.Clinical Trial Registration: NCT00995878. [ABSTRACT FROM AUTHOR]

Abstract: Purpose: To assess 12-month outcomes and safety of clinical magnetic resonance (MR)–guided focused ultrasound (US) treatments of uterine leiomyomas. Materials and Methods: Between March 2005 and December 2009, 150 women with symptomatic uterine leiomyomas were clinically treated with MR-guided focused US at a single institution; 130 patients completed treatment and agreed to have their data used for research purposes. Patients were followed through retrospective review of medical records and phone interviews conducted at 3-, 6-, and 12-month intervals after treatment to assess additional procedures and symptom relief. Outcome measures and treatment complications were analyzed for possible correlations with the appearance of the tumors on T2-weighted imaging. Results: The cumulative incidence of additional tumor-related treatments 12 months after MR-guided focused US was 7.4% by the Kaplan–Meier method. At 3-, 6-, and 12-month follow-up, 86% (90 of 105), 93% (92 of 99), and 88% (78 of 89) of patients reported relief of symptoms, respectively. No statistically significant correlation between tumor appearance on T2-weighted imaging and 12-month outcome was found. Treatment-related complications were observed in 17 patients (13.1%): 16 patients had minor complications and one had a major complication (deep vein thrombosis). All complications were resolved within the 12-month follow-up period. Conclusions: MR-guided focused US is a noninvasive treatment option that can be used to effectively and safely treat uterine leiomyomas and delivers significant and lasting symptom relief for at least 12 months. The incidence of additional treatment during this time period is comparable with those in previous reports of uterine artery embolization. [Copyright &y& Elsevier]

Objective: To describe magnetic resonance-guided focused ultrasound surgery (FUS) as a treatment for a case of leiomyoma-associated infertility. Design: Case report from a randomized clinical trial. Setting: Academic medical center. Patient(s): A 37-year-old woman with known leiomyomas and a history of 18 months of home-inseminations from a known donor. Intervention(s): Magnetic resonance-guided FUS treatment of uterine fibroids, where the dominant fibroid distorted the uterine cavity. Main Outcome Measure(s): Pregnancy. Result(s): A viable intrauterine pregnancy, with a full-term vaginal delivery, was conceived after a single clomiphene citrate and intrauterine insemination cycle. Conclusion(s): The role of FUS for enhancement of fertility in women with nonhysteroscopically resectable uterine fibroids distorting the uterine cavity should be investigated further. [ABSTRACT FROM AUTHOR]

Breast ultrasound utilizes various scanning techniques to acquire optimal images for diagnostic evaluation. During interventional procedures, such as ultrasound-guided biopsies or preoperative localizations, knowledgeable and purposeful scanning adjustments are critical for successfully identifying the targeted mass or biopsy marker or clip. While most ultrasound scanning parameters are similar across different vendors, detailed descriptions specifically addressing the scanning parameters-often referred to as "knobology"- for breast ultrasound is at best limited in the literature. This review highlights ten key operator-controlled adjustments (including transducer selection, beam focusing, power, depth, gain and time gain compensation, harmonic imaging, spatial compounding, dynamic range, beam steering, and color Doppler) that significantly influence image quality in breast ultrasound. Each adjustment is accompanied by an "In practice" section providing examples and practical tips on implementation. The last topic discusses color Doppler which is generally used in breast ultrasound for evaluating the vascularity of a finding. Color Doppler, or more specifically, color Doppler twinkling, can be leveraged as a technique to detect certain breast biopsy markers that are challenging to detect by conventional B-mode ultrasound. While the cause of color Doppler twinkling is still under active investigation, twinkling is a clinically well-known, compelling ultrasound feature typically described with kidney stones. A step-by-step guide on how to use color Doppler twinkling to detect these markers is provided., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tbcr.amegroups.org/article/view/10.21037/tbcr-24-30/coif). C.U.L. serves as an unpaid editorial board member of Translational Breast Cancer Research from October 2023 to September 2025. C.U.L. and M.W.U. are co-PIs on a National Institute of Biomedical Imaging and Bioengineering (NIBIB) grant (R01 EB033008) to the Mayo Clinic and on an internal Mayo Clinic Discovery Translation Program award. Patents are pending for non-metallic ultrasound detectable markers as well as Doppler ultrasound twinkling technologies. G.K.H. was supported by NIBIB grant (R01 EB033008) to the Mayo Clinic and by an internal Mayo Clinic Discovery Translation Program award. The other authors have no other conflicts of interest to declare., (2024 AME Publishing Company. All rights reserved.)

Objective: Arterial stiffening serves as an early indicator for a variety of cardiovascular diseases. Arterial Dispersion Ultrasound Vibrometry (ADUV) is a method that leverages acoustic radiation force to stimulate arterial wall motion, assess wave propagation characteristics, and subsequently calculate the arterial shear modulus. Previously, we introduced an inversion technique based on a guided cylindrical wave model, which proved effective in rubber tube phantom experiments. In this study, we broaden the scope of our investigation from phantom experiments to in vivo examination of common carotid arteries in human subjects, identify the challenges, and provide solutions, leading to a systematic protocol for ADUV application and robust estimation of the elastic modulus of common carotid arteries., Methods: We achieve this by analyzing ADUV data from 59 subjects categorized as (a) confirmed atherosclerotic cardiovascular disease (n = 27), (b) with cardiovascular risk factors (n = 20), and (c) healthy (n = 12). A crucial aspect of this work is the development of metrics to differentiate high-quality ADUV data from unusable data., Results and Conclusions: With the proposed metrics, in our cohort, we observed 82% of diameter data and 78% of motion data as usable data. Future work will involve applying this protocol to a larger cohort with subsequent statistical analysis to assess and validate the resulting biomarkers., Competing Interests: Conflict of interest The authors declare no competing interests., (Copyright © 2024 World Federation for Ultrasound in Medicine & Biology. Published by Elsevier Inc. All rights reserved.)

Prior studies on contrast-enhanced ultrasound (CEUS) lymphography for preoperative mapping before lymphaticovenous anastomosis surgery in patients with extremity lymphedema have been limited to using only Lumason and Sonazoid as microbubble contrast agents. The purpose of this study was to determine the feasibility of using two other Food & Drug Administration-approved microbubble agents, Optison and Definity, for imaging lymphatic vessels in the upper extremities. Nine female adults with unilateral upper extremity lymphedema anticipating lymphaticovenous anastomosis surgery underwent CEUS lymphography of the unaffected upper extremity randomized to either Lumason, Definity, or Optison. Lymphatic vessels were visualized in all but one case when undilated Definity was used. In the eight upper extremities where lymphatic vessels were visualized, an average of eight intradermal injections of microbubbles were performed in the extremity. Lymphatic vessels could be identified in 57% (36 of 63) of the injections. The effective dilution for each of the microbubble agents is provided. This was the first successful demonstration of lymphatic vessel visualization using either Definity or Optison. Broadening the range of available microbubble agents for CEUS lymphography could improve accessibility to the procedure and provide potentially safer alternatives., Competing Interests: The authors have no financial interest to declare in relation to the content of this article. This work was funded by the Radiological Society of North America (RSNA) Research & Education Foundation., (Copyright © 2024 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

Lymphaticovenous anastomosis (LVA) surgery is an effective surgery for the treatment of lymphedema in the extremities. Indocyanine green lymphography is the reference standard for visualizing lymphatics for LVA surgery, but it has several limitations; most notably, superficial dermal congestion can mask deeper lymphatic vessels. To overcome the limitations, we add contrast-enhanced ultrasound (CEUS) lymphography. We have previously reported that CEUS lymphography can identify lymphatic vessels for LVA surgery that indocyanine green lymphography does not. Here, we describe how we perform CEUS lymphography, including workflow, technique, and documentation. Before informed consent, the patient must be screened for possible adverse reactions to microbubbles. The procedure involves multiple intradermal injections of the microbubble agent at various sites along the extremity. After each injection, imaging for microbubble uptake by lymphatic vessels is performed using an ultrasound scanner with contrast-specific software. We use sulfur hexafluoride lipid-type A microspheres (Lumason/SonoVue; Bracco Suisse SA), but we are investigating the performance of other Food & Drug Administration-approved microbubble agents for CEUS lymphography. Having a systematic approach to marking the skin can mitigate the hindrance of marking over ultrasound coupling gel. Another benefit of CEUS lymphography is the rapid identification of neighboring veins compatible in size and location for anastomosis. We hold regular scheduled multidisciplinary meetings for coordination of care, discussion of outcomes, quality assurance, and ongoing innovation., Competing Interests: The authors have no financial interest to declare in relation to the content of this article., (Copyright © 2023 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

Breast biopsy markers play an essential role in the surgical management of patients with clinically node-positive breast cancer. Marking a pathology-proven lymph node ensures accurate imaging assessment of response to neoadjuvant systemic therapy and decreased false-negative rates in sentinel lymph node biopsy. There is a clinically unmet need to make breast biopsy markers, particularly in the axilla, more sonographically visible or identifiable for preoperative localization purposes. Previously described color Doppler US twinkling artifact of some breast biopsy markers in in vitro gel phantoms and in ex vivo cadaveric breasts suggests that twinkling of such markers can be leveraged for improved in vivo detection. In this retrospective case series of eight female patients (mean age, 58.6 years ± 12.3 [SD]), conventional B-mode US imaging failed to identify the biopsy marker associated with a surgical target in the breast or in an axillary lymph node. However, in each patient, the marker was successfully identified with the help of color Doppler US twinkling. Keywords: Breast, Ultrasound, Color Doppler US, Lymphatic, Artifacts, Biopsy Marker Published under a CC BY 4.0 license.

BACKGROUND. Targeted axillary lymph node dissection after neoadjuvant systemic therapy (NST) for breast cancer depends on identifying marked metastatic lymph nodes. However, ultrasound visualization of biopsy markers is challenging. OBJECTIVE. The purpose of our study was to identify biopsy markers that show actionable twinkling in cadaveric breast and to assess the association of actionable twinkling with markers' surface roughness. METHODS. Commercial breast biopsy markers were evaluated for twinkling artifact in various experimental conditions relating to scanning medium (solid gel phantom, ultrasound coupling gel, cadaveric breast), transducer (ML6-15, 9L, C1-6), and embedding material (present vs absent). Markers were assigned twinkling scores from 0 (confident in no twinkling) to 4 (confident in exuberant twinkling); a score of 3 or greater represented actionable twinkling (sufficient confidence to rely solely on twinkling for target localization). Markers were hierarchically advanced to evaluation with increasingly complex media if showing at least minimal twinkling for a given medium. A 3D coherence optical profiler measured marker surface roughness. Mixed-effects proportional odds regression models assessed associations between twinkling scores and transducer and embedding material; Wilcoxon rank sum test evaluated associations between actionable twinkling and surface roughness. RESULTS. Thirty-five markers (21 with embedding material) were evaluated. Ten markers without embedding material advanced to evaluation in cadaveric breast. Higher twinkling scores were associated with presence of embedding material (odds ratio [OR] = 5.05 in solid gel phantom, 9.84 in coupling gel) and transducer (using the C1-6 transducer as reference; 9L transducer: OR = 0.36, 0.83, and 0.04 in solid gel phantom, ultrasound coupling gel, and cadaveric breast; ML6-15 transducer: OR = 0.07, 0.18, and 0.00 respectively; post hoc p between 9L and ML6-15: p < .001, p = .02, and p = .04). In cadaveric breast, three markers (Cork, Professional Q, MRI [Flex]) exhibited actionable twinkling for two or more transducers; surface roughness was significantly higher for markers with than without actionable twinkling for C1-6 (median values: 0.97 vs 0.35, p = .02) and 9L (1.75 vs 0.36; p = .002) transducers. CONCLUSION. Certain breast biopsy markers exhibited actionable twinkling in cadaveric breast. Twinkling was observed with greater confidence for the C1-6 and 9L transducers than the ML6-15 transducer. Actionable twinkling was associated with higher marker surface roughness. CLINICAL IMPACT. Use of twinkling for marker detection could impact preoperative or intraoperative localization after NST.

Purpose To evaluate the short-term safety of a nonmetallic twinkle marker and compare its conspicuity at color Doppler US with that of standard breast biopsy clips and radioactive seeds by using B-mode US in axillary lymph nodes. Materials and Methods This prospective study (November 2020-July 2021) of participants with node-positive breast cancer who completed chemotherapy involved placing a twinkle marker at the time of preoperative radioactive seed localization. A five-point scoring system (1 = easiest, 5 = most difficult) was used to rate the ease of identifying the clip, seed, and twinkle marker on postlocalization sonograms, mammograms, specimen radiographs, and gross pathologic specimens. Descriptive statistics were used. Results Eight women (mean age, 57 years ± 16 [SD]) were enrolled. The median scores for US conspicuity of each device were 3.9 (range, 3.7-5.0) for the radioactive seed, 2.4 (range, 1.0-5.0) for the clip, and 2.0 (range, 1.0-4.3) for the twinkle marker. In six of eight participants, the twinkle marker was the most identifiable at US. The seeds, clips, and twinkle markers were scored "very easy" to identify on seven of eight postlocalization mammograms. The surgeon retrieved all eight twinkle markers 1-3 days after localization. In all 16 interpretations, the seeds, clips, and twinkle markers were rated as very easy to identify on specimen radiographs. The clip was the most difficult device to identify at pathologic examination in all participants, and the twinkle marker was the easiest to identify in seven of eight participants. Conclusion This pilot study demonstrates that the safety and ease of US detection of a twinkling tissue marker may be comparable to a biopsy clip. Keywords: Ultrasonography, US-Doppler, Breast, Localization, Surgery Clinical trial registration no. NCT04674852 © RSNA, 2022.

Background Lymphaticovenous anastomosis (LVA) surgery is an effective surgical treatment of secondary lymphedema in the extremities, but indocyanine green (ICG) fluorescent lymphography, the reference standard for imaging target lymphatic vessels, has several limitations. More effective methods are needed for preoperative planning. Purpose To evaluate whether contrast-enhanced US (CEUS) can be used to identify target lymphatic vessels for LVA surgery in patients with secondary upper extremity lymphedema and compare the results with those from ICG fluorescent lymphography. Materials and Methods In this single-center retrospective review, CEUS with intradermal injection of microbubbles was performed in patients before LVA surgery in the upper extremities between October 2019 and September 2021. All patients had secondary upper extremity lymphedema from breast cancer treatment. Technical success rate was defined as lymphatic vessels identified with use of CEUS that led to successful LVAs. Descriptive statistics were used. Results All 11 patients were women (mean age, 56 years ± 8 [SD]). The median number of microbubble injection sites was 11 (range, 8-14). CEUS helped identify lymphatic vessels in all 11 women, including in six women in whom ICG fluorescent lymphography could not be performed or failed to help identify any targets. Thirty-five explorations (median, three per patient; range, two to four) were performed, and 24 LVAs (median, three per patient; range, zero to four) were created. Of the anastomoses, 33% (eight of 24) were mapped with use of both CEUS and ICG fluorescent lymphography, 58% (14 of 24) with CEUS only, and 8% (two of 24) with ICG fluorescent lymphography only. Among the 33 explorations on targets mapped with CEUS, an anastomosis could be made at 22 sites, for a technical success rate of 67%. Seven women had at least one additional LVA created from the use of CEUS. Conclusion Contrast-enhanced US is a promising tool for identifying lymphatic vessels in the upper extremities, especially when indocyanine green fluorescent lymphography fails to depict targets or cannot be used. Published under a CC BY 4.0 license.

Objective: Implant-based breast reconstruction after mastectomy remains the most common reconstructive modality worldwide. Infection is a frequent complication that negatively affects the reconstructive outcome and increases health-care costs. The aim of this study is to evaluate the accuracy of ultrasonography in identifying fluid collections in patients with breast implant infection., Methods: After receiving institutional review board approval, a retrospective chart review was performed on patients who presented with breast implant infection after breast reconstruction, during the period 2009-2017. To estimate the sensitivity and specificity of ultrasound (US) in detecting fluid collections, only patients with US evaluation and surgery during the same admission were included., Results: In total, 64 patients with 64 infected implants met the inclusion criteria. Infected devices included 44 (69%) tissue expanders, and 20 (31%) implants, of which 40 (62%) were placed in the subpectoral and 24 (38%) prepectoral positions. Periprosthetic fluid was identified by US preoperatively in 45 (70%) of the patients, and a fluid collection was found in 61 (95%) of the patients during surgery. Sensitivity and specificity of US were 74% and 100%, respectively. Inaccurate US results were more likely in patients with silicone implants than patients with saline expander implants., Conclusion: Caution should be exercised in interpreting negative US findings in patients with silicone implants in the setting of infection. Other imaging modalities should be explored if US results are negative in cases with high clinical suspicion., (© Society of Breast Imaging 2019. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objective: The objective of our study was to characterize the temporal and clinical manifestation of major bleeding events after biopsy to guide clinicians in the institution of appropriate surveillance., Materials and Methods: We performed a retrospective review of percutaneous image-guided biopsies performed between September 1, 2005, and May 31, 2012, including 18,947 biopsy events. According to routine protocol, follow-up telephone calls were made to patients 24 hours after biopsy, and chart review was performed 3 months after biopsy. Bleeding complications were defined using the Common Terminology Criteria for Adverse Events (CTCAE, version 4.0) established by the National Cancer Institute. In patients with a grade 3 or greater bleeding complication, a retrospective chart review was performed to characterize the details of the complication including the timing of the complication and the primary clinical presentation of the event., Results: Grade 3 hemorrhage was associated with 64 of 18,947 (0.3%) procedures, and there were three deaths associated with the biopsy event (0.02% or ≈ 2/10,000). Hemorrhage was most commonly associated with biopsy of a native kidney (17/1407, 1.2%). Twenty patients (31%) presented with a bleeding complication within 1 hour of biopsy. Twenty-seven patients (42%) presented within 2 hours of biopsy. Fifty-two patients (81%) presented within 24 hours, and the remaining 12 patients (19%) presented more than 24 hours after biopsy. Pain was the most common presentation of patients with bleeding complications, occurring in 39 (61%) patients., Conclusion: The incidence of major bleeding after percutaneous biopsies is very low, but delayed complications occur more frequently than anticipated. Pain is the most common clinical presentation of major bleeding complications.

Background: Magnetic resonance-guided focused ultrasound (MRgFUS) is a relatively new minimally invasive treatment, approved by the US Food and Drug Administration in 2004 for treatments of symptomatic uterine leiomyomas (fibroids). The purpose of this work is to present retrospective cohort analysis of women that underwent commercial MRgFUS treatment between 2005 and 2009 at a single center, to identify baseline patient characteristics that predict successful MRgFUS fibroid treatment. Identifying these clinical predictors of MRgFUS would be helpful to clinicians choosing the optimal patient for this treatment modality., Methods: One hundred thirty women with symptomatic uterine leiomyomas who underwent MRgFUS were followed up with a mean length of follow up of 17.4 ± 10.3 months. The main outcome measure of the follow-up was to identify patients who required additional fibroid treatment due to continued fibroid symptoms. Additionally, patient medical history and radiological findings obtained prior to MRgFUS were reviewed, and statistical analysis was performed to identify factors associated with reduced risk of having additional fibroid treatment., Results: Twenty-nine patients (22.3%) underwent additional fibroid treatment due to continued or recurrent fibroid symptoms during the follow up. Cumulative incidence of additional fibroid treatment was 9.7%, 29.3%, and 44.7% at 1, 2, and 3 years following MRgFUS, respectively. In multivariable Cox proportional hazard regression analyses, older age (hazard ratio (HR) 0.54 per 5-year increase in age, 95% confidence interval 0.39 to 0.76, p < 0.001), greater number of fibroids (HR 0.19 for more than three vs. one fibroid, 95% CI 0.05 to 0.67, p = 0.033), and greater fibroid volume (HR 0.70 per doubling in volume, 95% CI 0.51 to 0.96, p = 0.025) were significantly associated with less risk of having additional fibroid treatment., Conclusions: Older age at treatment and having multiple fibroids with larger volume are associated with a lower risk of additional intervention following MRgFUS treatment for uterine fibroids.

Objective: The objective of our study was to determine the incidence of infectious complications of common ultrasound-guided procedures including fine-needle aspiration (FNA), drain placement, biopsy, pseudoaneurysm thrombin injection, thoracentesis, and paracentesis., Subjects and Methods: The infection prevention and control (IPAC) committee at the Mayo Clinic, Rochester, MN, conducts surveillance of selected infections including radiology procedures. When a positive culture, hospital admission, or operating room visit for infection is identified, the patient's electronic records are thoroughly reviewed by an infection control practitioner looking for information about prior interventions. Similarly, the department of radiology prospectively follows all patients who have undergone ultrasound-guided hepatic, renal, and pancreatic biopsies for complications 24 hours, 3 months, and 12 months after biopsy. We reviewed 2 years of these data to determine the incidence of infections after common ultrasound-guided procedures., Results: We performed 13,534 ultrasound-guided procedures from January 2006 to December 2007. There were 11 likely and three possible procedure-related infections for an overall incidence of 0.1% (14/13,534). The infections consisted of five abscesses, four bloodstream infections, four cases of peritonitis, and one urinary tract infection. The highest incidence of infections occurred after ultrasound-guided biopsy (0.2%, 10/5,487), with biopsy of a hepatic transplant having the highest incidence (1.0%, 2/192). No infections occurred after thoracentesis and FNA despite the large number of procedures performed (2,489 and 2,340, respectively). Nearly all patients improved on antibiotics. One patient died 5 days after paracentesis; however, death was likely due to multiorgan failure in the setting of fulminant liver failure with hepatorenal syndrome., Conclusion: The incidence of a serious infectious complication after ultrasoundguided intervention is low. Radiologists can use these data to provide more accurate information to patients when asking for consent before procedures and to reassure their patients.

Objective: The objective of our study was to report the incidence of bleeding after imaging-guided percutaneous core biopsy at a single center using a standardized technique., Materials and Methods: We performed a retrospective review of percutaneous core biopsies performed at our institution from January 2002 through February 2008. Data were collected at the time of biopsy, and clinical information was obtained 24 hours and 3 months after the biopsy. The specific information that was collected included the results of coagulation studies, aspirin use, the organ biopsied, the size of the biopsy needle, and the number of needle passes. Bleeding complications were defined using the Common Terminology Criteria for Adverse Events (CTCAE, version 3.0) established by the National Cancer Institute., Results: Among the 15,181 percutaneous core biopsies performed during the study period, 70 hemorrhages (0.5%) that were CTCAE grade 3 or greater were identified within 3 months of biopsy. The incidence of bleeding in patients taking aspirin within 10 days before biopsy was 0.6% (18/3,195), which was not statistically different compared with the incidence of bleeding in those not taking aspirin (52/11,986, 0.4%; p = 0.34). The incidence of bleeding after liver biopsy was 0.5%; kidney biopsy, 0.7%; lung biopsy, 0.2%; pancreas biopsy, 1.0%; and other biopsy, 0.2%. There were significant associations between major bleeding and serum platelet count and international normalized ratio (p < 0.001), although the association between major bleeding and the size of the biopsy needle was not significant (p = 0.97)., Conclusion: The overall incidence of major bleeding after imaging-guided percutaneous core needle biopsy is low. Recent aspirin therapy does not appear to significantly increase the risk of such bleeding complications.

Objective: The purpose of this study was to determine the frequency and characteristics of adverse effects of low-osmolar iodinated and gadolinium contrast agents in a single-center experience with a large number of cases., Materials and Methods: A retrospective review of all intravascular doses of low-osmolar iodinated and gadolinium contrast materials administered from 2002 through 2006 was conducted. Adverse effects were identified through the use of radiologist and nurse event recording. Adverse effects were examined for type and severity of reaction, treatment required, and outcome., Results: A total of 456,930 contrast doses (298,491 low-osmolar iodinated, 158,439 gadolinium) were administered over the study period. A total of 522 cases of adverse effects (0.11% of total) were identified (458 low-osmolar iodinated, 64 gadolinium). The most common adverse effects were hives (274, 52.5%) and nausea (92, 17.6%). Of all adverse effects, 79 of low-osmolar iodinated and 15 of gadolinium contrast material necessitated treatment. Most treatments were performed in the radiology department alone. Only 16 cases of adverse effects necessitated transfer for further observation or treatment. Epinephrine was used to manage an adverse effect in nine instances. Thirty-two of the adverse effects of low-osmolar iodinated contrast material (6.9%) occurred in patients with a history of allergy who received premedication. Only two of these premedication reactions necessitated transfer to the emergency department. The one death in the study period occurred after administration of low-osmolar iodinated contrast material. The patient had no symptoms during the contrast administration or imaging but died suddenly within 30 minutes of receiving the dose., Conclusion: Both iodinated and gadolinium contrast agents are associated with a very low rate of adverse effects. Most adverse effects are mild and can be managed in the radiology department. Transfer for additional treatment or observation is rarely needed.

During MR-guided focused ultrasound (MRgFUS) treatments of uterine fibroids using ExAblate(R)2000 (InSightec, Haifa, Israel), individual tissue ablations are performed extracorporeally through the patient's abdomen using an annular array FUS transducer embedded within the MR table. Ultrasound intensities in the near field are below therapeutic levels and, under normal conditions, heating of the patient skin is minimal. However, increased absorption of ultrasound energy within sensitive skin areas or areas with differing acoustic properties, such as scars, may lead to skin burns and therefore these areas must be kept outside the near field of the FUS beam. Depending on their location and size the sensitive areas may either obstruct parts of the fibroid from being treated or prevent the entire MRgFUS treatment altogether. The purpose of this work is to evaluate acoustic reflector materials that can be applied to protect skin and the underlying sensitive areas. Reflection coefficients of cork (0.88) and foam (0.91) based materials were evaluated with a hydrophone. An ExAblate 2000 MRgFUS system was used to simulate clinical treatment with discs of reflector materials placed in a near field underneath a gel phantom. MR thermometry was used to monitor temperature elevations as well as the integrity of the focal spot. The phantom measurements showed acoustic shadow zones behind the reflectors with zone depths changing between 7 and 27 mm, for reflector disc diameters increasing from 10 to 30 mm (40 mm diameter discs completely blocked the FUS beam at the depth evaluated). The effects on thermal lesions due to the presence of the reflectors in the FUS beam were found to diminish with decreasing disc diameter and increasing sonication depth. For a 20 mm diameter disc and beyond 50 mm sonication depth, thermal lesions were minimally affected by the presence of the disc. No heating was observed on the skin side of the foam reflectors, as confirmed by measurements performed with adhesive temperature labels. We present these data and discuss possible applications to clinical MRgFUS treatments.

During MRI-guided focused ultrasound (MRgFUS) treatments of uterine fibroids using ExAblate 2000, tissue ablations are delivered by a FUS transducer while MR imaging is performed with a pelvic receiver coil. The consistency of the pelvic coil performance is crucial for reliable MR temperature measurements as well as detailed anatomic imaging in patients. Test sonications in a gel phantom combined with MR thermometry are used to test the performance of the FUS transducer prior to each treatment. As we show, however, these tests do not adequately evaluate receiver coil performance prior to clinical use. This could become a problem since the posterior part of the coil is frequently moved and can malfunction. The aim of this work is to demonstrate the utility of the signal-to-noise ratio (SNR) as a reliable indicator of pelvic coil performance. Slight modification of the vendor-provided coil support was accomplished to assure reproducible coil positioning. The SNR was measured in a gel phantom using axial acquisitions from the 3D-localizer scan. MR temperature and SNR measurements were obtained using a degraded receiver coil (with posterior element removed) and a known faulty coil, and compared to those obtained with a fully functioning coil. While the MR temperature-based tests were insensitive to change in pelvic coil performance, (degraded, p = 0.24; faulty, p = 0.28), the SNR tests were highly sensitive to coil performance, (degraded, p < 0.001; faulty, p < 0.001). Additional clinical data illustrate the utility of SNR testing of the receiver coil. These tests require minimal (or possibly no) additional scan time and have proven to be effective in our clinical practice.

Uterine fibroids are common smooth muscle tumors, which can result in substantial symptoms affecting the quality of life of women. Whereas patients have several options available for treatment, focused ultrasound ablation is one of the least invasive treatment options outside medical therapy. Magnetic resonance-guided focused ultrasound (MRgFUS) ablation combines therapy delivered by an ultrasound transducer with imaging, guidance for therapy, and thermal feedback provided by magnetic resonance imaging. In 2004, the MRgFUS system ExAblate 2000 (InSightec, Haifa, Israel) was approved by the United States Food and Drug Administration for clinical treatments of uterine fibroids. Since its approval, our institution has performed more than 140 treatments. This paper provides an overview of our site's clinical experience with MRgFUS, including a brief description of the treatment system, pertinent features to review on screening magnetic resonance imaging, how the procedure is performed, and risks and benefits of the treatment. Some potential clinical applications of the technology are also briefly reviewed.

Purpose: To prospectively evaluate the sensitivity and specificity of ultrasonographic (US) strain imaging for distinguishing between benign and malignant solid breast masses, with biopsy results as the reference standard., Materials and Methods: The study was institutional review board approved and HIPAA compliant. Informed consent was obtained from all participating patients. US strain imaging of 403 breast masses was performed. The 50 malignant and 48 benign lesions (in patients aged 19-83 years; mean age, 49 years +/- 17 [standard deviation]) with the highest quality were selected for the reader study. Three observers blinded to the pathologic outcomes first described the B-mode image findings by using US Breast Imaging Reporting and Data System descriptors and derived a probability of malignancy. They then updated the probability by assessing strain images. Receiver operating characteristic (ROC) curves were constructed by using these probabilities. Areas under the ROC curve, sensitivities, and specificities were calculated and compared. Interobserver variability and the correlation between automated and subjective image quality assessment were analyzed., Results: The average area under the ROC curve for all three readers after US strain imaging (0.903) was greater than that after B-mode US alone (0.876, P = .014). With use of a 2% probability of malignancy threshold, strain imaging-as compared with B-mode US alone-had improved average specificity (0.257 vs 0.132, P < .001) and high sensitivity (0.993 vs 0.987, P > .99). Significant interobserver variability was observed (P < .001). The ability to assess strain image quality appeared to correlate with the highest observer performance., Conclusion: US strain imaging can facilitate improved classification of benign and malignant breast masses. However, interobserver variability and image quality influence observer performance.