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OBJECTIVE. The objective of this article is to assess radiologist concordance in characterizing thyroid nodules using the American College of Radiology Thyroid Imaging Reporting and Data System (TI-RADS), focusing on the effect of radiologist experience on reader concordance. MATERIALS AND METHODS. Three experienced and three less experienced radiologists assessed 150 thyroid nodules using the TI-RADS lexicon. Percent concordance was determined for various endpoints. RESULTS. Interreader concordance for the five TI-RADS categories was 87.2% for shape, 81.2% for composition, 76.1% for echogenicity, 72.9% for margins, and 69.8% for echogenic foci. Concordance for individual features was 96.3% for rim calcifications, 90.8% for macrocalcifications, 90.1% for spongiform, 83.5% for comet tail artifact, and 77.7% for punctate echogenic foci. Concordance for the TI-RADS level and recommendation for fine-needle aspiration (FNA) were 50.4% and 78.9%, respectively. Concordance was significantly (p 0.05) for the remaining categories and features. CONCLUSION. A range of TI-RADS categories, features, and recommendations for FNA had generally moderate interreader agreement among six radiologists. Our results show that concordance for numerous characteristics was significantly higher for the less experienced versus the more experienced readers. These results suggest that less experienced readers relied more on the explicit TI-RADS criteria, whereas the experienced radiologists partially relied on their accumulated experience when forming impressions. However, the overall TI-RADS level and recommendation for FNA were unaffected, supporting the robustness of the TI-RADS lexicon and its continued use in practice.

The Ovarian-Adnexal Reporting and Data System (O-RADS) US risk stratification and management system is designed to provide consistent interpretations, to decrease or eliminate ambiguity in US reports resulting in a higher probability of accuracy in assigning risk of malignancy to ovarian and other adnexal masses, and to provide a management recommendation for each risk category. It was developed by an international multidisciplinary committee sponsored by the American College of Radiology and applies the standardized reporting tool for US based on the 2018 published lexicon of the O-RADS US working group. For risk stratification, the O-RADS US system recommends six categories (O-RADS 0-5), incorporating the range of normal to high risk of malignancy. This unique system represents a collaboration between the pattern-based approach commonly used in North America and the widely used, European-based, algorithmic-style International Ovarian Tumor Analysis (IOTA) Assessment of Different Neoplasias in the Adnexa model system, a risk prediction model that has undergone successful prospective and external validation. The pattern approach relies on a subgroup of the most predictive descriptors in the lexicon based on a retrospective review of evidence prospectively obtained in the IOTA phase 1-3 prospective studies and other supporting studies that assist in differentiating management schemes in a variety of almost certainly benign lesions. With O-RADS US working group consensus, guidelines for management in the different risk categories are proposed. Both systems have been stratified to reach the same risk categories and management strategies regardless of which is initially used. At this time, O-RADS US is the only lexicon and classification system that encompasses all risk categories with their associated management schemes.

Objective: Surgery for leiomyomas is common; yet, no reliable test can help distinguish a benign leiomyoma and malignant leiomyosarcoma (LMS). Materials and Methods: This retrospective observationa...

Introduction Our institution implemented a preoperative protocol to identify high-risk cases for which power morcellation should be avoided. Material and methods In this retrospective cohort study, an institutional protocol requiring preoperative Magnetic Resonance Imaging with diffusion-weighted imaging and serum Lactate Dehydrogenase levels was implemented. Chart review was performed including all women who underwent intra-abdominal surgery for symptomatic fibroids from 4/23/2013 to 4/23/2015. Results A total of 1,085 women were included, 479 before and 606 after implementation of the Magnetic Resonance Imaging / Lactate Dehydrogenase protocol. The pre-protocol group had more post-menopausal women (4% vs. 2%, p = 0.022) and women using tamoxifen (2% vs. 0%, p = 0.022) than those in the post-protocol group, but baseline patient characteristics were otherwise similar between groups. Incidence of malignant pathological diagnoses did not change significantly over the time period in relation to protocol implementation. The rate of open surgery for both hysterectomy and myomectomy remained the same in the year preceding and the year following initiation of the protocol (open hysterectomy rate was 19% vs. 16% in pre- and post-protocol groups, respectively, P = 0.463, and open myomectomy rate was 10% vs. 9% rates in pre- and post-protocol groups, respectively, P = 0.776). There was a significant decrease in the use of power morcellation (66% in pre- and 50% in post-protocol cohorts, p Conclusions Rates of MIS procedures were decreased for women with abnormal preoperative Magnetic Resonance Imaging results. False positive results appear to be one of the main drivers for the use of an open surgical route.

Imaging is used to detect and characterize adnexal masses and to stage ovarian cancer both before and after initial treatment, although the role for imaging in screening for ovarian cancer has not been established. CT and MRI have been used to determine the resectability of tumors, the candidacy of patients for effective cytoreductive surgery, the need for postoperative chemotherapy if debulking is suboptimal, and the need for referral to a gynecologic oncologist. Radiographic studies such as contrast enema and urography have been replaced by CT and other cross-sectional imaging for staging ovarian cancer. Contrast-enhanced CT is the procedure of choice for preoperative staging of ovarian cancer. MRI without and with contrast may be useful after equivocal CT, but is usually not the best initial procedure for ovarian cancer staging. Fluorine-18-2-fluoro-2-deoxy-D-glucose–PET/CT may not be needed preoperatively, but its use is appropriate for detecting and defining post-treatment recurrence. Ultrasound is useful for evaluating adnexal disease, but has limited utility for staging ovarian cancer. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

Women of reproductive age with pelvic pain, vaginal bleeding, and a positive pregnancy test often require evaluation with pelvic ultrasound. In these situations, the primary role of pelvic ultrasound is to differentiate an ectopic pregnancy from either a normal or abnormal intrauterine pregnancy. While an accurately performed and interpreted pelvic ultrasound results in rapid diagnosis and management, numerous diagnostic pitfalls can lead to negative outcomes. Therefore, familiarity with the appropriate laboratory tests, sonographic technique, and imaging features of ectopic pregnancy is essential for all radiologists. We present a review of ectopic pregnancy cases from our institution with attention to common pitfalls and troubleshooting tips for physicians who perform and interpret pelvic ultrasounds. We also present recently published literature to aid in the management of first trimester pregnancy.

Ultrasound is the most commonly used imaging technique for the evaluation of ovarian and other adnexal lesions. The interpretation of sonographic findings is variable because of inconsistency in descriptor terminology used among reporting clinicians. The use of vague terms that are inconsistently applied can lead to significant differences in interpretation and subsequent management strategies. A committee was formed under the direction of the ACR initially to create a standardized lexicon for ovarian lesions with the goal of improving the quality and communication of imaging reports between ultrasound examiners and referring clinicians. The ultimate objective will be to apply the lexicon to a risk stratification classification for consistent follow-up and management in clinical practice. This white paper describes the consensus process in the creation of a standardized lexicon for ovarian and adnexal lesions and the resultant lexicon.

Many disorders of the liver, gallbladder, and biliary tree may cause right upper quadrant pain and clinical diagnosis may be challenging. Imaging plays a key role in establishing a prompt diagnosis and guiding appropriate management. Although ultrasonography is the initial imaging modality of choice for most hepatobiliary disorders, radionuclide imaging, computed tomography (CT), and MR imaging also play important roles. Acute cholecystitis may be associated with many complications that have characteristic imaging features. MR cholangiopancreatography achieves high accuracy in diagnosis of choledocholithiasis and allows for noninvasive imaging when ultrasonography and CT are indeterminate.

To evaluate the utility of conventional MRI and diffusion-weighted imaging (DWI) in differentiating benign from malignant endometrial lesions.52 patients with an abnormal endometrium on MRI and subsequent pathologic evaluation (35 benign, 17 malignant) were included. Two radiologists (R1, R2) independently evaluated endometrial abnormalities for characteristics on conventional MRI and DWI. Findings were assessed using unpaired t-tests, Fisher's exact test, and multi-variate logistic regression.Findings with significantly higher frequency in malignant abnormalities were: presence of irregularly marginated endometrial lesion (R1: 71% vs. 34%, R2: 94% vs. 26%), irregular endo-myometrial interface on T2WI (R1: 77% vs. 26%, R2: 94% vs. 29%), irregular endo-myometrial interface on post-contrast T1WI (R1: 82% vs. 23%, R2: 88% vs. 20%), increased signal on high b-value DWI (R1: 82% vs. 20%, R2: 94% vs. 20%), decreased ADC (R1: 88 vs. 40%, R2: 94% vs. 20%) (all p0.001, both readers). Endometrial thickness, presence of any focal endometrial lesion regardless of contour, diameter of endometrial lesion, endometrial heterogeneity on T2WI, decreased T2 signal, and increased endometrial enhancement, failed to show significant differences between groups (all p≥0.159, both readers). At multivariate analysis, for R1, irregular endo-myometrial interface on post-contrast T1WI and increased DWI signal were significant independent predictors of malignancy (AUC=0.89); for R2, only increased DWI signal was a significant independent predictor of malignancy (AUC=0.87).Abnormal signal on DWI and irregularity of either the endo-myometrial interface or focal endometrial lesion were the most helpful MRI features in differentiating benign from malignant endometrial abnormalities.

The utility of MR imaging in evaluating abdominal and pelvic pain in the pregnant patient is discussed. Details regarding the indications, technical aspects, and imaging findings of various common abdominal and pelvic abnormalities in pregnancy are reviewed.

Background.Since its introduction in 1996, uterine fibroid embolization (UFE) has become standard medical practice in the management of symptomatic uterine fibroids. An extremely rare complication, pyomyoma, has been reported only 5 times previously in the literature following UFE.Case.A 37-year-old woman underwent UFE for symptomatic leiomyomas of the uterus. Signs and symptoms of uterine infection ensued, beginning at 6 days following the procedure. Recurrent fevers and increasing leukocytosis despite the intravenous administration of appropriate antibiotics eventually necessitated surgical intervention on postprocedure day #18.Conclusion.An extremely rare complication of UFE is herein presented, pyomyoma, with a review of other reported cases. Commonalities are sought among these few reported cases with the hope of increasing diagnostic acumen in the detection of this disease.

It is well recognized that preterm birth is the leading cause of perinatal mortality and morbidity. There is a significant association between cervix length and preterm birth risk. Most authorities consider a cervical length3 cm as the lower limit of normal. A cervical length3 cm has a high negative predictive value for delivery less than 34 weeks. A cervical length of15 mm is moderately predictive (∼ 70%) of preterm birth within 48 hours. Cervical length is normally distributed and should remain relatively constant until the third trimester. Transabdominal US is the least reliable method of cervical length assessment. The most reliable method of documenting cervical length is transvaginal ultrasound (TVUS). Transperineal US is an alternative for imaging if TVUS is contraindicated, such as with premature rupture of membranes. However, the resolution is decreased compared to TVUS. Short cervix length is the single most important predictive finding for premature delivery. This observation should prompt consultation for high risk obstetrical care and consideration of other management options such as cerclage or activity restriction.The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed biennially by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging.

The purpose of this article is to compare 3D T2-weighted sampling perfection with application-optimized contrast with different flip-angle evolutions (SPACE) with three-plane 2D turbo-spin echo (TSE) sequences for female pelvic imaging at 3 T.Twenty women were imaged with 2D TSE and 3D SPACE sequences. Three radiologists independently assessed image quality, diagnostic quality, and artifacts; measured normal anatomic structures; evaluated pathologic abnormalities; and recorded interpretation time. Readers subsequently performed a side-by-side comparison, and their preferences were graded according to overall interpretation, sharpness of lesion edges, motion and other artifacts, uterine and cervical zonal anatomy distinction, identification of adnexal pathologic abnormalities, and distinction between fat and fluid. Quantitative comparison of relative signal intensity and relative tissue contrast was performed.The mean acquisition time of 3D SPACE was significantly shorter than that of 2D TSE (6 minutes 35 seconds vs 8 minutes 50 seconds; p0.005). Intrareader agreement between interpretations of 2D and 3D sequences was excellent. There were no significant differences among readers in detecting artifacts, normal structures, and pathologic abnormalities or in determining endometrial thickness, image quality, or interpretation time (p0.05). Except for distinctions between fat and fluid, the average reader score indicated a slight preference for the 3D sequence. Three-dimensional multiplanar reconstructions were helpful but not considered essential. Relative agreement between readers was moderate (r ≥ 0.4) to strong (r ≥ 0.7). The relative signal intensity was higher for fat and bladder fluid on the 3D sequence than on the 2D sequence (p = 0.014 and p = 0.018, respectively). Relative tissue contrast was higher for the 3D sequence (p0.05), with no significant difference in bladder or fat contrast (p = 0.31) but a trend toward more superior contrast on the 2D sequence.At 3 T, 3D SPACE has similar image quality and diagnostic quality with shorter scan time when compared with 2D TSE but with reduced contrast between fat and fluid.

To determine the added value of reimaging the female pelvis with ultrasound (US) immediately following multidetector CT (MDCT) in the emergent setting. CT and US exams of 70 patients who underwent MDCT for evaluation of abdominal/pelvic pain followed by pelvic ultrasound within 48 h were retrospectively reviewed by three readers. Initially, only the CT images were reviewed followed by evaluation of CT images in conjunction with US images. Diagnostic confidence was recorded for each reading and an exact Wilcoxon signed rank test was performed to compare the two. Changes in diagnosis based on combined CT and US readings versus CT readings alone were identified. Confidence intervals (95%) were derived for the percentage of times US reimaging can be expected to lead to a change in diagnosis relative to the diagnosis based on CT interpretation alone. Ultrasound changed the diagnosis for the ovaries/adnexa 8.1% of the time (three reader average); the majority being cases of a suspected CT abnormality found to be normal on US. Ultrasound changed the diagnosis for the uterus 11.9% of the time (three reader average); the majority related to the endometrial canal. The 95% confidence intervals for the ovaries/adnexa and uterus were 5-12.5% and 8-17%, respectively. Ten cases of a normal CT were followed by a normal US with 100% agreement across all three readers. Experienced readers correctly diagnosed ruptured ovarian cysts and tubo-ovarian abscesses (TOA) based on CT alone with 100% agreement. US reimaging after MDCT of the abdomen and pelvis is not helpful: (1) following a normal CT of the pelvic organs or (2) when CT findings are diagnostic and/or characteristic of certain entities such as ruptured cysts and TOA. Reimaging with ultrasound is warranted for (1) less-experienced readers to improve diagnostic confidence or when CT findings are not definitive, (2) further evaluation of suspected endometrial abnormalities. A distinction should be made between the need for immediate vs. follow-up imaging with US after CT.

Although computed tomography (CT) is generally not the first-line imaging test of choice for the evaluation of female pelvic disorders, it is often the initial diagnostic examination performed in the emergency setting in patients who present with abdominal pain and nonspecific clinical symptoms. Multidetector CT coupled with reconstruction software permits isotropic voxel acquisition that can be used to generate two-dimensional multiplanar reformatted (MPR) images for evaluation of the female pelvis with no additional radiation exposure. Multidetector CT with MPR allows improved visualization of the normal anatomy and anatomic variants as well as greater diagnostic accuracy in the evaluation of the female pelvis. Although ultrasonography and magnetic resonance imaging remain the primary imaging modalities for the assessment of most female pelvic disorders, more accurate diagnosis of these disorders at multidetector CT may obviate additional imaging tests and allow more appropriate management.

Ovarian stromal hyperplasia and ovarian hyperthecosis are non-neoplastic conditions of the ovary associated with clinical manifestations of hyperandrogenism from ovarian production of male hormones. In this article, we present the first published cases of the magnetic resonance imaging appearance of these conditions, which may mimic that of ovarian neoplasm. In contrast to bilateral ovarian vein sampling, magnetic resonance imaging may provide a noninvasive means of suggesting a diagnosis of ovarian stromal hyperplasia/ovarian hyperthecosis when a hormone-secreting ovarian neoplasm is suspected clinically and thereby may assist in identifying patients who may be effectively treated nonsurgically with gonadotrophin-releasing hormone therapy.

The purpose of this study was to evaluate morphologic features predictive of benign thyroid nodules.From a registry of the records of 1,232 fine-needle aspiration biopsies performed jointly by the cytology and radiology departments at a single institution between 2005 and 2007, the cases of 650 patients were identified for whom both a pathology report and ultrasound images were available. From the alphabetized list generated, the first 500 nodules were reviewed. We analyzed the accuracy of individual sonographic features and of 10 discrete recognizable morphologic patterns in the prediction of benign histologic findings.We found that grouping of thyroid nodules into reproducible patterns of morphology, or pattern recognition, rather than analysis of individual sonographic features, was extremely accurate in the identification of benign nodules. Four specific patterns were identified: spongiform configuration, cyst with colloid clot, giraffe pattern, and diffuse hyperechogenicity, which had a 100% specificity for benignity. In our series, identification of nodules with one of these four patterns could have obviated more than 60% of thyroid biopsies.Recognition of specific morphologic patterns is an accurate method of identifying benign thyroid nodules that do not require cytologic evaluation. Use of this approach may substantially decrease the number of unnecessary biopsy procedures.

Incidental ovarian cysts are frequently detected on imaging. Despite published follow-up consensus statements, there remains variability in radiologist follow-up recommendations and clinician practice patterns. The aim of this study was to evaluate if collaborative ovarian cyst management recommendations and a radiologist decision support tool can improve adherence to follow-up recommendations.Gynecologic oncologists and abdominal radiologists convened to develop collaborative institutional recommendations for the management of incidental, asymptomatic simple ovarian cysts detected on ultrasound, CT, and MRI. The recommendations were developed by modifying the published consensus recommendations developed by the Society of Radiologists in Ultrasound on the basis of local practice patterns and the experience of the group members. A less formal process involved the circulation of the published consensus recommendations, followed by suggestions for revisions and subsequent consensus, in similar fashion to the ACR Incidental Findings Committee II. The recommendations were developed by building on the published work of experienced groups to provide the authors' medical community with a set of recommendations that could be endorsed by both the Department of Gynecology and the Department of Radiology to provide supportive guidance to the clinicians who manage incidental ovarian cysts. The recommendations were integrated into a radiologist decision support tool accessible from the dictation software. Nine months after tool launch, institutional review board approval was obtained, and radiology reports mentioning ovarian cysts in the prior 34 months were retrospectively reviewed. For cysts detected on ultrasound, adherence rates to Society of Radiologists in Ultrasound recommendations were calculated for examinations before tool launch and compared with adherence rates to the collaborative institutional recommendations after tool launch. Additionally, electronic medical records were reviewed to determine the follow-up chosen by the clinician.For cysts detected on ultrasound, radiologist adherence to recommendations improved from 50% (98 of 197) to 80% (111 of 139) (P.05). Overmanagement decreased from 34% (67 of 197) to 10% (14 of 139) (P.05). A recommendation was considered "overmanaged" if the radiologist recommended follow-up when it was not indicated or if the recommended follow-up time was at a shorter interval than indicated. Clinician adherence to radiologist recommendations showed statistically nonsignificant improvement from 49% (36 of 73) to 57% (27 of 47) (P = .5034).Management recommendations developed through collaboration with clinicians may help standardize follow-up of ovarian cysts and reduce overutilization.

Three-Tesla whole body imaging is rapidly becoming part of routine clinical practice. Although it is generally thought that pelvic imaging at 3.0 T will be beneficial because of increased signal to noise and greater spectral separation, adjustments in protocol and sequence parameters are necessary to optimize image quality. The question remains as to whether 3.0-T imaging will offer further benefits beyond 1.5 T in terms of lesion characterization and functional imaging. This article aims to address safety concerns and to illustrate the potential benefits and technical challenges of imaging the female pelvis at 3.0 T. Imaging protocols and sequence parameters for routine gynecologic indications are suggested, and potential clinical applications at 3.0 T are discussed such as magnetic resonance spectroscopy, perfusion, diffusion weighted imaging, and the use of alternate contrast agents.

The objective of this study was to determine the sensitivity and specificity of sonography as an aid in detecting hepatocellular carcinomas and dysplastic nodules using explantation correlation in patients with cirrhosis and no known hepatocellular carcinomas.The sonography reports of 200 patients with cirrhosis who underwent sonography and then underwent liver transplantation within 90 days were retrospectively reviewed for focal solid liver lesions. All focal solid masses detected on sonography were considered possible hepatocellular carcinomas. The sonographic findings were compared with thin-section explanted liver pathologic results.Twenty-seven patients (13.5%) had hepatocellular carcinoma at explantation, including four patients with diffuse, multifocal tumors. Eight of the 39 lesions were detected on sonography for a patient sensitivity of 29.6% and a lesion sensitivity of 20.5%. Sonography revealed three (75%) of four hepatocellular carcinomas larger than 5 cm in diameter, one (50%) of two hepatocellular carcinomas with diameters of 3.1-5.0 cm, one (20%) of five hepatocellular carcinomas with diameters of 2.1-3.0 cm, three (13.6%) of 22 hepatocellular carcinomas with diameters of 1-2 cm, and no lesions with diameters smaller than 1 cm. Forty-two patients (21%) had a total of 126 dysplastic nodules including two patients with innumerable lesions. Sonography depicted only two dysplastic nodules, for a patient sensitivity of 4.8% and a lesion sensitivity of 1.6%. The overall specificity of sonography for either hepatocellular carcinomas or dysplastic nodules was 96%.Sonography has low sensitivity but high specificity in revealing hepatocellular carcinomas and dysplastic nodules in patients with a cirrhotic liver requiring liver transplantation. In these patients, sonography should not be the sole imaging modality used for lesion detection before transplantation.

Although ultrasound (US) is the primary imaging modality of choice in the radiologic evaluation of the female patient with acute pelvic pain, the role of computed tomography (CT) in the evaluation of abdominal and pelvic pain continues to expand. CT may be performed if a gynecologic disorder is not initially suspected, if US findings are equivocal, or if the abnormality extends beyond the field of view achievable with the endovaginal probe and further characterization of pelvic disease is required. Many gynecologic disorders that cause acute pelvic pain (eg, uterine disorders, ovarian disorders, endometriosis, pelvic inflammatory disease, postoperative or postpartum complications) demonstrate characteristic CT findings. Familiarity with these CT appearances is important: It will allow the radiologist to guide appropriate treatment of affected patients and may eliminate the need for further imaging evaluation.

Using receiver-operating characteristic (ROC) methodology, the ability to diagnose acute appendicitis with computed tomography (CT) images displayed at varying levels of lossy compression was evaluated. Nine sequential images over the ileocecal region were obtained from 53 consecutive patients with right lower quadrant pain who were clinically suspected to have acute appendicitis. Thirty were proven surgically to have acute appendicitis, alternative diagnoses confirmed in 23. The image sets were subjected to a lossy wavelet-based compression algorithm "Embedded Predictive Wavelet Image Coder" (EPWIC). Compression levels were: none, 8:1, 16:1, and 24:1, resulting in 4 sets of images per patient. Image sets were randomized and evaluated separately by 4 body radiologists on a 1,024 × 768-pixel SVGA color PC monitor in 512 × 512 format. The readers were aware of the clinical suspicion of appendicitis but were unaware of the positive fraction of cases. Individual and combined reader ROC and c2 analyses of sensitivity, specificity, and accuracy were determined. For all readers, sensitivity decreases at 16:1 and 24:1 levels (P

To retrospectively compare standard and BLADE T2-weighted imaging (T2WI) sequences of the prostate in terms of image quality and tumor assessment. 49 prostate cancer patients (64 ± 6 years) who underwent 3 T phased-array coil MRI before prostatectomy were included. T2WI was acquired using standard rectilinear and BLADE techniques. Two readers (R1, R2) independently localized the dominant lesion using T2WI alone and using multi-parametric imaging; recorded presence of extraprostatic extension (EPE) in each lobe; and scored lesion conspicuity and absence of motion artifact (1–5 scale; 5 = highest quality). A third reader, unblinded to pathology, placed ROIs to record tumor-to-peripheral-zone contrast. Standard and BLADE T2WI were compared using paired Wilcoxon tests. BLADE showed a trend toward improved motion artifact for R1 (3.4 ± 1.3 vs. 2.9 ± 1.5; p = 0.054) but not R2 (4.0 ± 1.0 vs. 3.9 ± 1.1; p = 0.880). Dominant lesions showed significantly lower conspicuity using BLADE for R1 (2.8 ± 2.0 vs. 3.2 ± 2.0; p = 0.011) but not R2 (2.3 ± 1.6 vs. 2.4 ± 1.7; p = 0.353), and significantly lower tumor-to-peripheral-zone contrast using BLADE (0.35 ± 0.13 vs. 0.42 ± 0.15; p ≤ 0.001). R1 and R2 correctly localized four and three fewer dominant tumors, respectively, using BLADE than standard T2WI, although both correctly localized a similar fraction of dominant tumors using multi-parametric sequences. While R1 detected EPE in 10 of 11 patients using both sequences, R2 detected EPE in 3 more patients using BLADE. BLADE may help reduce motion artifact of prostate T2WI and assist EPE detection, although at expense of reduced image contrast. In practice, BLADE may be useful in patients in whom initial T2WI is degraded by motion.

Aim To evaluate the performance of multidetector computed tomography (MDCT) in the measurement of endometrial thickness and assessment for endometrial disease. Materials and methods Seventy-nine MDCT examinations, including sagittal reformats from isotropic data, were retrospectively evaluated for the presence of endometrial abnormality, endometrial thickness, and recommendation for transvaginal ultrasound (TVUS) after CT. The endometrial thickness was measured on sagittal images using two different methods, between the inner-to-inner hypoattenuating stripe, and when visible, between the outer-to-outer hyperattenuating stripe. TVUS performed within 48 h of CT in premenopausal and 1 month in postmenopausal patients served as reference standard. Interobserver agreement for endometrial thickness and abnormalities was assessed using concordance correlation (CC) and kappa statistics. Results Interobserver agreement for endometrial thickness on sagittal CT images was excellent (CC 0.98), and highly accurate using the inner-to-inner measurement. For determination of abnormal thickening, the positive predictive value and negative predictive value were 67–100% and 99.5–100%. For detection of any endometrial abnormality, the positive predictive value and negative predictive value were 79–90% and 84–95%, respectively. False-negative missed abnormalities included small volume hydrometra, a polyp, and endometrial distortion by a fibroid. Conclusion At MDCT, sagittal reformatted images provide reliable endometrial measurement using the inner-to-inner hypoattenuating stripe and are accurately categorized as normal or abnormal thickness using the same numerical criteria as at sonography.

The purpose of this study was to determine whether the addition of gadolinium-enhanced imaging to heavily T2-weighted MR imaging of the liver is valuable in differentiating hemangiomas from metastases. The T2 relaxation time was also included in our analysis.Fifty-one patients with 52 proven liver lesions (24 hemangiomas and 28 metastases) larger than 1 cm underwent MR imaging at 1.5 T with T2-weighted spin-echo (TR/TE, 3000/80, 160) and gadolinium chelate-enhanced dynamic T1-weighted gradient-recalled echo (80/2.6, 80) pulse sequences. Images were reviewed by observers who were unaware of the patients' clinical history; first, only T2-weighted images were reviewed and then T2-weighted plus dynamic images were reviewed together. The T2 relaxation times were calculated for each lesion. Diagnostic accuracy by each method was compared using receiver operating characteristic analysis.Mean T2 relaxation times were 76 +/- 26 msec for metastases and 133 +/- 25 msec for hemangiomas. The addition of dynamic scanning to the T2-weighted sequence made a statistically significant difference for only one observer (p = 0.03). However, it did not make a statistically significant contribution for either observer when compared with the T2 relaxation time. Although addition of the dynamic images resulted in correct diagnosis of six lesions, three lesions were misdiagnosed after having been correctly characterized on the T2-weighted images alone.When optimized T2-weighted images are obtained and the T2 relaxation time is calculated, routine use of gadolinium enhancement for differentiation of hemangiomas from metastases is unnecessary although dynamic scanning is valuable in selected cases.

Imaging is used to detect and characterize adnexal masses and to stage ovarian cancer both before and after initial treatment, although the role for imaging in screening for ovarian cancer has not been established. CT and MRI have been used to determine the resectability of tumors, the candidacy of patients for effective cytoreductive surgery, the need for postoperative chemotherapy if debulking is suboptimal, and the need for referral to a gynecologic oncologist. Radiographic studies such as contrast enema and urography have been replaced by CT and other cross-sectional imaging for staging ovarian cancer. Contrast-enhanced CT is the procedure of choice for preoperative staging of ovarian cancer. MRI without and with contrast may be useful after equivocal CT, but is usually not the best initial procedure for ovarian cancer staging. Fluorine-18-2-fluoro-2-deoxy-D-glucose-PET/CT may not be needed preoperatively, but its use is appropriate for detecting and defining post-treatment recurrence. Ultrasound is useful for evaluating adnexal disease, but has limited utility for staging ovarian cancer. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

Aim To retrospectively evaluate the prevalence of pelvic organ prolapse as an incidental finding on dynamic magnetic resonance imaging (MRI) using two different references lines. Materials and methods Sixty women with symptoms unrelated to pelvic floor dysfunction who underwent MRI including a dynamic sagittal true fast imaging with steady-state free precession (TrueFISP) sequence during straining were identified. Two radiologists in consensus used the pubococcygeal line (PCL) and mid-pubic line (MPL) to diagnose and grade prolapse in all three pelvic compartments. Results Cystocele was absent, mild, moderate, and severe in 88% (53/60), 7% (4/60), 5% (3/60), and 0% (0/60) of patients, respectively, using PCL, versus 78% (47/60), 13% (8/60), 5% (3/60), and 3% (2/60) of patients, respectively, using MPL. Vaginal prolapse was absent, mild, moderate, and severe in 95% (57/60), 5% (3/60), 0% (0/60), and 0% (0/60) of patients, respectively, using PCL, versus 80% (48/60), 17% (10/60), 3% (2/60), and 0% (0/60) of patients, respectively, using MPL. Rectal descent was absent, mild, moderate, and severe in 63% (38/60), 10% (6/60), 23% (14/60), and 3% (2/60) of patients, respectively, using PCL, versus 43% (26/60), 27% (16/60), 27% (16/60), and 3% (2/60) of patients, respectively, using MPL. No enterocele, peritoneocele, or muscular defect was identified. Two percent (1/60) of patients had mild rectocele, 8% (5/60) had abnormal vesico-urethral angle, and 25% (15/60) had abnormal levator plate angle. Conclusion In asymptomatic women, dynamic MRI identified the greatest degrees of prolapse in the posterior compartment. The MPL consistently yielded greater frequency of prolapse than the PCL. Findings of pelvic organ prolapse may be observed in asymptomatic patients and are of uncertain significance, requiring correlation with clinical and physical examination findings.

Multiple gestations are high-risk compared with singleton pregnancies. Prematurity and intrauterine growth restrictions are the major sources of morbidity and mortality common to all twin gestations. Monochorionic twins are at a higher risk for twin-twin transfusion, fetal growth restriction, congenital anomalies, vasa previa, velamentous insertion of the umbilical cord and fetal death. Therefore, determination of multiple gestation, amnionicity and chorionicity in the first trimester is important. Follow up examinations to evaluate fetal well-being include assessment of fetal growth and amniotic fluid volume, umbilical artery Doppler, nonstress test and biophysical profile. To date, there is a paucity of literature regarding imaging schedules for follow-up. At the very least, antepartum testing in multiple gestations is recommended in all situations in which surveillance would ordinarily be performed in a singleton pregnancy. The ACR Appropriateness Criteria® are evidence-based guidelines for specific clinical conditions that are reviewed biennially by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging.

Premenopausal women who present with acute pelvic pain frequently pose a diagnostic dilemma, exhibiting nonspecific signs and symptoms, the most common being nausea, vomiting, and leukocytosis. Diagnostic considerations encompass multiple organ systems, including obstetric, gynecologic, urologic, gastrointestinal, and vascular etiologies. The selection of imaging modality is determined by the clinically suspected differential diagnosis. Thus, a careful evaluation of such a patient should be performed and diagnostic considerations narrowed before a modality is chosen. Transvaginal and transabdominal pelvic sonography is the modality of choice when an obstetric or gynecologic abnormality is suspected, and computed tomography is more useful when gastrointestinal or genitourinary pathology is more likely. Magnetic resonance imaging, when available in the acute setting, is favored over computed tomography for assessing pregnant patients for nongynecologic etiologies because of the lack of ionizing radiation. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every two years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

Computed tomography (CT) is not generally advocated as the first-line imaging examination for disorders of the female pelvis. However, multidetector CT is often the modality of choice for evaluating nongynecologic pelvic abnormalities, particularly in emergent settings, in which all the pelvic organs are invariably assessed. Incidental findings of uterine and cervical contrast enhancement in such settings may easily be mistaken for abnormalities, given the broad spectrum of anatomic variants and enhancement patterns that may be seen in the normal uterus and cervix. The authors' review of CT and magnetic resonance (MR) imaging enhancement patterns, augmented by case examples from their clinical radiology practice, provides a solid foundation for understanding the spectrum of normal uterine and cervical appearances and avoiding potential pitfalls in the diagnosis of benign cervical lesions, adenomyosis, infection, malignancy, and postpartum effects. This information should help radiologists more confidently differentiate between normal and abnormal CT findings and, when CT findings are not definitive, offer appropriate recommendations for follow-up ultrasonography or MR imaging.

Purpose To determine if pretreatment apparent diffusion coefficient (ADC) of leiomyomas could predict volumetric response (VR) following uterine artery embolization (UAE). Materials and Methods We retrospectively studied 11 women who underwent pelvic MRI before and >120 days following UAE. MRI included conventional and diffusion weighted imaging sequences. Percentage change in leiomyoma volume was determined by multiplanar T2-weighted imaging. A Pearson correlation coefficient was calculated between leiomyoma VR following UAE and the following pre-embolization parameters: initial volume, relative enhancement, relative T2 signal intensity (SI) and ADC. Receiver operating characteristic (ROC) curve analysis was used to determine the sensitivity and specificity of ADC for predicting volumetric response. Results Twenty-eight leiomyomas were included with a mean interval from UAE to follow-up MRI of 207 days. The preprocedural volume of the leiomyomas ranged from 18 to 182 cm3 (median 47 cm3). and ADC ranged from 0.37 to 1.71 mm2/s (mean 0.80 mm2/s). All leiomyomas were 100% necrotic following UAE. Leiomyoma VR following UAE was 48% ± 3.5%. with significant correlation between VR and ADC (r = 0.41; P = 0.017) but no correlation with initial leiomyoma volume, relative T2 SI, or relative enhancement. Using a threshold of 0.875 × 10−3 mm2/s, ADC could predict > 50% VR with sensitivity and specificity of 70% and 83%, respectively. Conclusion Pre-UAE ADC of leiomyomas correlated significantly with percent VR following UAE. In contrast, no correlation was seen between VR post-UAE and conventional imaging findings. This suggests that VR following UAE depends on leiomyoma histology reflected in DWI rather than features revealed by conventional MRI. J. Magn. Reson. Imaging 2011;33:641–646. © 2011 Wiley-Liss, Inc.

OBJECTIVE. The objective of this article is to illustrate the MDCT appearances of several commonly encountered foreign bodies and devices in the female pelvis.CONCLUSION. The presence of a foreign body or device in the female pelvis can be a potential source of confusion to radiologists, particularly to the inexperienced reader. Familiarity with the normal appearances and locations of these devices on MDCT allows their accurate identification and detection of associated complications.

The majority of women with ovarian cancer have advanced stage disease at the time of diagnosis and a poor 5 year survival rate. Hence, screening has been investigated in the hopes of improving survival by diagnosing ovarian cancer at an earlier stage. Most screening methods thus far have included ultrasound and/or serum tumor markers. However, low prevalence of the disease, high false positive rate of current screening methods, and the probable rapid growth of most ovarian carcinomas from no defined precursor lesion, all contribute to difficulty in screening for ovarian cancer. While screening may be able to detect ovarian cancer at an earlier stage, adequate data is presently lacking on whether screening improves survival. The results of ongoing large clinical trials will be available in a few years and should provide critical information regarding the usefulness of screening. Pending results of those large clinical trials, screening is not currently recommended for women at average risk for ovarian cancer. Screening is most likely to be performed in women with an increased familial risk of ovarian cancer, but patients should be aware that even with this risk factor, there is currently insufficient evidence to know if screening is effective. New screening methods, including new or multiple serum markers and proteomics, are also being investigated.

INTRODUCTION This self-assessment module on the imaging spectrum of endometriosis, with emphasis on less common sites of involvement as well as complications, has an educational component and a self-assessment component. The educational component consists of one required article that the participant should read. The self-assessment component consists of 10 multiple-choice questions with solutions. All of these materials are available on the ARRS Website (www. arrs.org). To claim CME and SAM credit, each participant must enter his or her responses to the questions online.

To compare imaging findings between laproscopic and open partial nephrectomy at 6 months after surgery and to follow the evolution of the findings over time.This HIPAA-compliant retrospective study had institutional review board approval and consent was waived. A surgical database was cross-referenced with an imaging database to identify patients who underwent partial nephrectomy and computed tomographic and/or magnetic resonance imaging within 6 months of surgery. Fifty-eight patients (mean age, 61 years; range, 34-78 years; 21 women, 37 men) underwent 62 partial nephrectomies (laparoscopic, 31; open, 31) to remove 68 masses. Two radiologists in consensus reviewed images obtained between 10 days and 72 months (mean, 28 months) after surgery. Preoperative mass size and location and postoperative kidney orientation, fat stranding, parenchymal defect, collection (including size, location, and appearance), and other complications were recorded. Relative incidence of postoperative imaging findings, demographics, and initial imaging findings of both groups were statistically assessed by using Student t and chi(2) tests corrected for multiple comparisons.Common imaging findings following surgery included kidney displacement (48% [30 of 62]), perinephric fat stranding (93% [63 of 68]), parenchymal defect (74% [50 of 68]), and a non-fat-containing postoperative collection 75%, with significantly more posterior renal displacement (P.01) and a trend toward more persistent fat stranding in the open surgery group. Fifty-one collections were identified in 74% (43 of 58) of patients, with significantly more collections in the laparoscopic (90% [27 of 30] vs 55% [16 of 29]; P.05). The proportion of resolved collections increased over time, with significantly more resolving in the open group within 24 months of surgery (P.05). Development or resolution of a collection was not dependent on age, sex, preoperative lesion size, or location (P.05).Prevalence of findings 2-3 years after partial nephrectomy depends on the surgical approach. After laparoscopic partial nephrectomy, collections are more frequently detected on images and may take longer to resolve than following an open approach.

The purpose of this study was to identify the CT features of mucocele of the appendix coexisting with acute appendicitis and to determine whether this entity can be differentiated from acute appendicitis without mucocele.CT scans of 70 patients (12 with acute appendicitis with mucocele, 29 with acute appendicitis without mucocele, 29 with a normal appendix) were retrospectively interpreted by two readers. The appendix was evaluated for maximal luminal diameter, cystic dilatation, luminal attenuation, appendicolith, mural calcification and enhancement, periappendiceal fat stranding, fluid, and lymphadenopathy. CT findings were compared by use of Mann-Whitney U and Fisher's exact tests. Receiver operating characteristics analysis was performed to assess the diagnostic utility of appendiceal luminal diameter in differentiating acute appendicitis with from that without coexisting mucocele.Cystic dilatation of the appendix and maximal luminal diameter achieved statistical significance (p0.05) for the diagnosis of acute appendicitis with mucocele. Mural calcification achieved statistical significance for one reader (p = 0.0049) and a statistical trend for the other (p0.1). A maximal luminal diameter greater than 1.3 cm had a sensitivity of 71.4%, specificity of 94.6%, and overall diagnostic accuracy of 88.2% for the diagnosis of acute appendicitis with mucocele.Although there is overlap with acute appendicitis without mucocele, CT features suggestive of coexisting mucocele in patients with acute appendicitis include cystic dilatation of the appendix, mural calcification, and a luminal diameter greater than 1.3 cm.

Premenopausal women who present with acute pelvic pain frequently pose a diagnostic dilemma, exhibiting nonspecific signs and symptoms, the most common being nausea, vomiting, and leukocytosis. Diagnostic considerations encompass multiple organ systems, including obstetric, gynecologic, urologic, gastrointestinal, and vascular etiologies. The selection of imaging modality is determined by the clinically suspected differential diagnosis. Thus, a careful evaluation of such a patient should be performed and diagnostic considerations narrowed before a modality is chosen. Transvaginal and transabdominal pelvic sonography is the modality of choice when an obstetric or gynecologic abnormality is suspected, and computed tomography is more useful when gastrointestinal or genitourinary pathology is more likely. Magnetic resonance imaging, when available in the acute setting, is favored over computed tomography for assessing pregnant patients for nongynecologic etiologies because of the lack of ionizing radiation.

The objective of our study was to retrospectively compare the degree of pelvic organ prolapse shown on dynamic true fast imaging with steady-state precession (FISP) versus HASTE sequences in symptomatic patients.Fifty-nine women (mean age, 57 years) with suspected pelvic floor dysfunction underwent MRI using both a sagittal true FISP sequence, acquired continuously during rest alternating with the Valsalva maneuver, and a sagittal HASTE sequence, acquired sequentially at rest and at maximal strain. Data sets were evaluated in random order by two radiologists in consensus using the pubococcygeal line (PCL) as a reference. Measurement of prolapse was based on a numeric grading system indicating severity as follows: no prolapse, 0; mild, 1; moderate, 2; or severe, 3. A comparison between sequences on a per-patient basis was performed using a Wilcoxon's analysis with p0.05 considered significant.Overall, 66.1% (39/59) of patients had more severe prolapse (or= 1 degrees ) based on dynamic true FISP images, with 28.8% (17/59) of the cases of prolapse seen exclusively on true FISP images. Only 20.3% (12/59) of patients had greater degrees of prolapse on HASTE images than on true FISP images, with 10.2% (6/59) of the cases seen exclusively on HASTE images. A statistically significant increase in the severity of cystoceles (p0.01) and urethral hypermobility (p0.01)-with a trend toward more severe urethroceles (p0.07), vaginal prolapse (p0.09), and rectal descent (p0.06)-was shown on true FISP images.Overall, greater degrees of organ prolapse in all three compartments were found with a dynamic true FISP sequence compared with a sequential HASTE sequence. Near real-time continuous imaging with a dynamic true FISP sequence should be included in MR protocols to evaluate pelvic floor dysfunction in addition to dynamic multiplanar HASTE sequences.

Schistosomal spinal cord involvement is a rare complication of infection by Schistosoma mansoni. This work reports the MR imaging findings in a patient with schistosomal myelitis involving the lower spinal cord and conus medullaris. MR imaging showed a focal mass with a slightly nodular surface and which had peripheral enhancement after contrast administration. The MR appearance of this complication of schistosomal infection is important to recognize so that early medical therapy can be started in an attempt to maximize neurologic recovery.

report a case of schizencephaly in a dysgenetic fetal brain diagnosed antenatally by the combined use of 2-dimensional (2D) and 3-dimensional (3D) sonography and magnetic resonance imaging (MRI) and then confirmed by postmortem pathologic examination. Schizencephaly is a rare disorder, resulting in mild to devastating effects on fetal neurodevelopment. The term describes a full-thickness cortical defect from the lateral ventricle to the subarachnoid space lined with pia-ependyma. Schizencephaly can be described as unilateral or bilateral and as closed or open (Figure 1). Unilateral closed cases are occasionally found incidentally on adult head imaging with little or no symptoms, whereas open bilateral cases are generally associated with seizures and very limited cerebral function. ' Its etiology is uncertain but may be an early destructive event before completion of neuronal migration at 16 to 20 weeks 2 or a primary neuronal migrational disorder, sometimes associated with a mutation of the EMX2 (empty spiracles homolog 2) gene. 3,4 .

We sought to determine the incidence of the "small-bowel feces" sign (SBFS) in patients with small-bowel obstruction (SBO) and whether it can be used to accurately locate the point of obstruction.From November 2002 until March 2003, 34 consecutive adult patients with CT findings of small-bowel obstruction were prospectively evaluated. The CT findings used to diagnose small-bowel obstruction were a dilated proximal small bowel and a collapsed distal small bowel and colon. CT scans were evaluated to determine the degree of obstruction (mild, moderate, or high-grade), the presence or absence of the SBFS (defined as particulate-type material in the dilated small bowel), the location of the SBFS in relation to the transition zone, and the cause of the obstruction. Mild obstruction was defined as a slight discrepancy between the caliber of the proximal and that of the distal small bowel; moderate SBO was defined as a discrepancy of 50% or more between the calibers of the proximal and the distal small bowel; and high-grade SBO was considered to be present if the distal small bowel and the colon had collapsed. The cause of the obstruction was determined from surgical findings or a combination of CT findings, follow-up barium studies, and clinical assessment.The SBFS was present in 19 (55.9%) of 34 patients with SBO. The degree of SBO was mild in six, moderate in 11, and high-grade in 17 of the patients. The SBFS was present in one of the six patients (16.6%) with mild, eight (72.7%) of the 11 with moderate, and 10 (58.8%) of the 17 with high-grade SBO. In all patients in whom the SBFS was present, the particulate material could be traced to the point of transition and was most conspicuous in the transition zone. The length of fecallike material ranged from 2 to 25 cm and was longer in moderate and high-grade SBO than in mild SBO. The cause of the SBO was an adhesion in 20 patients, a hernia in four patients, Crohn's disease in four patients, a tumor in three patients, and other miscellaneous causes in three patients.When present on CT, the SBFS can be used to help locate the transition zone in patients with SBO. The sign is present more frequently in patients with moderate and high degrees of SBO.

OBJECTIVE. This study reviews the CT findings of Meckel's diverticulitis in 11 patients and, to our knowledge, represents the largest series of such cases reported to date.CONCLUSION. The inflamed Meckel's diverticulum may be visualized on CT in most patients, appearing as a blind-ending pouch of variable size and mural thickness and containing fluid, air, or particulate material with surrounding mesenteric inflammation. The location of the diverticulum may vary from the right lower quadrant to the mid abdomen, with most cases in this series located near midline. Optimal luminal opacification of the ileocecal bowel with oral contrast material facilitated detection of the diverticulum and also proved invaluable in enabling identification of the normal appendix. The diagnosis is most difficult in the setting of secondary intestinal obstruction.