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American Institute of Ultrasound in Medicine <strong>Proceedings</strong> J Ultrasound Med 32(suppl):S1–S134, 20131518801 Ultrasound-Guided Fine-Needle Aspiration Biopsy ofThyroid Nodules Performed by Family Practitioners in aHealth Clinic SettingMaría Mata Castrillo, 1 * Jose Ignacio Jaen Diaz, 1 BlancaCordero Garcia, 1 Eugenio Cerezo Lopez, 2 Francisco Lopezde Castro, 1 Paolo Ciardo 1 1 Buenavista Health Care Center,Toledo, Spain; 2 Ultrasound Explorations, Madrid, SpainObjectives—Evaluate the impact of family practitioner interventionson the development of nodular thyroid pathology: techniques diagnosis,fine-needle aspiration biopsy (FNAB), and surgical follow-up.Methods—Two family practitioners at a health clinic in Toledo,Spain, which is charged with overseeing the health of 16,800 individuals,performed all thyroid ultrasonography requested by the health centerphysicians for their patients. These evaluations were previously performedin a reference hospital. All explorations were analyzed in writing, and thereports included a recommendation regarding patient follow-up and treatment.According to recommendations from the international literature, andfollowing informed consent, FNAB was performed on those nodules thatwere suitable for the procedure. Previously, the decision to perform theFNAB, its execution, and the treatment course were all left in the handsof the reference hospital.Results—A total of 392 ultrasonographic explorations wereperformed between July 2011 and July 2012. Of these, 336 (85.7%) ofthe subjects were female (mean age, 46.4 years), and 56 (14,3%) weremale (mean age, 45.2 years). The reasons for performing the explorationsincluded the following: clinical suspicion of thyroid pathology (goiter,nodules), 37.5%; suspicion of thyroid pathology based on clinical analyses,15.9%; follow-up of known nodular pathology, 34.4%; and follow-upof other known thyroid problems (thyroiditis, postsurgical thyroids),12.2%. Seventy-five FNAB procedures were performed, 9 (12%) of whichyielded insufficient material for diagnosis. Four cases of cancer were detected,all of them of a papillary nature. There were no complications duringthe conduct of these procedures.Conclusions—Ultrasound-guided thyroid FNAB is a simpleand uncomplicated procedure that can be performed with a high degree ofsuccess by family practitioners in community health centers as part of thecomprehensive management of nodular thyroid pathology. In our study,this approach was time efficient for patients and provided a mechanism forrapid intervention in a rather frequent pathology. Future studies will be requiredto evaluate the overall cost-effectiveness of this approach.1522432 Small Retained Foreign Bodies: What Is the Limit of DetectionUsing Current Emergency Ultrasound Equipment?Daniel Jafari, 1 Kenneth Cody, 2 Nova Panebianco, 1 FrancesShofer, 1 Bon Ku, 3 Arthur Au, 3 Anthony Dean 1 *1 EmergencyMedicine, University of Pennsylvania, Philadelphia, PennsylvaniaUSA; 2 Emergency Medicine, Kaiser Oakland MedicalCenter, Oakland, California USA; 3 Emergency Medicine,Thomas Jefferson University, Philadelphia, Pennsylvania USAObjectives—Previous studies of small foreign bodies (FBs)have shown a wide range of accuracies of FB detection using animal models,with high accuracy rates for FBs >10 mm and variable accuracy ratesfor 4- to 5-mm FBs. This study aimed to determine the lower limit of sonographicdetection of FB using current emergency ultrasound equipment ina soft tissue model.Methods—FBs made of metal, glass, wood, and plastic (3 ofeach), 1 × 1 × 3 mm in size, were placed at a depth of 0.5 to 2.0 cm in 12pork feet. Eight feet were punctured without FB placement. Pork feet weresubmerged during this process to minimize air in tissue. Seven emergencydepartment (ED) sonologists with >2 years of experience were blinded tothe overall number, type, and depth of FBs but not to size. FB sites werescanned by each sonologist using either a hockey stick or traditional lineararray transducer in a randomized preassigned order. Sonologist confidencein the diagnosis was reported using a visual analog scale for eachsite. Sensitivity, specificity, and positive and negative predictive values(PPV and NPV) with 95% confidence intervals (CIs) were calculated. Todetermine if sonologist confidence differed by the perceived presence orabsence of a foreign body, a paired t test was used.Results—A total of 140 ultrasound scans were performed,which reported sensitivity, specificity, PPV, and NPV as 50% (95% CI,39%–61%), 50% (37%–61%), 60% (48%–72%), and 40% (28%–52%),respectively. There was little agreement among the sonologists (only 2sites with 100% agreement). Sensitivity ranged from 25% to 75%, specificity37% to 62%, PPV 42% to 75%, and NPV 25% to 57% for each sonologist.Sonologists were more confident reporting a positive result (81%vs 51%; P < .0001), irrespective of the actual presence of FBs. The differencebetween detection rates of 4 types of FB did not reach statisticalsignificance.Conclusions—Current emergency ultrasound equipment usedby ED sonologists is unreliable in detection of 3-mm FBs in a human extremitysoft tissue model. Future studies may further delineate accuracyrates among different sizes and materials of FBs.1522516 Four Consecutive Recurrent Cesarean Scar Pregnancies ina Single PatientSimi Gupta, 1 * Christina Cordeiro, 2 Grace Pineda, 1 ShermanRubin, 3 Ilan Timor 1 1 Obstetrics and Gynecology, New YorkUniversity, New York, New York USA; 2 Weill Cornell MedicalCollege, New York, New York USA; 3 Sherman Rubin, JacksonHeights, New York USAObjectives—With the increase in conservative management ofcesarean scar pregnancies (CSP), there has been a growing interest in fertilityoutcomes for these patients. This is the first known report of 4 recurrentCSPs.Methods—This is a case report on a patient who was referredto a single institution with 4 recurrent CSPs. Data on evaluation, treatment,and follow-up of each of the pregnancies were collected.Results—The patient had a pertinent obstetric history of 2 cesareansections, the first for breech presentation and the second an electiverepeat cesarean section. The patient’s first CSP was diagnosed 7 years laterwith an ultrasound finding of a pregnancy in the prior cesarean sectionscar at 7 6/7 weeks of gestation with positive fetal cardiac activity. Thispregnancy was initially treated with transcervical intra-amniotic injectionof methotrexate with complete resolution. Nine months later, the patientpresented with her second CSP at 6 0/7 weeks of gestation with positivefetal cardiac activity and was treated similarly with transcervical injectionof methotrexate with complete resolution. The patient’s third recurrencewas 9 months later when she presented at 5 4/7 weeks of gestation withpositive fetal cardiac activity and again was treated with transcervical injectionof methotrexate with complete resolution. Finally, the patient’sfourth recurrence occurred 8 months later. She was diagnosed at 6 1/7weeks of gestation with positive fetal cardiac activity and again was treatedwith transcervical injection of methotrexate. The patient is currently receivingfollow-up for this CSP.Conclusions—This is the first case report of 4 recurrent CSPsin single patient. Each of this patient’s CSPs was treated conservativelywith local methotrexate. In reviewing the literature, there have been 6cases of recurrent CSPs, with 1 report of 3 CSPs in the same patient. Thosecases were reportedly treated with methotrexate or surgery with or withoutresection of the scar. This information is important to help counsel patientswho desire future fertility after a CSP.S89
American Institute of Ultrasound in Medicine <strong>Proceedings</strong> J Ultrasound Med 32(suppl):S1–S134, 20131522877 Many Faces of Uterine Adenomyosis: Ultrasound andMagnetic Resonance ImagingVijayanadh Ojili Radiology, University of Texas HealthScience Center, San Antonio, Texas USAObjectives—To describe the sonographic findings in differenttypes of uterine adenomyosis and correlate these with magnetic resonanceimaging (MRI) findings where available.Methods—A brief review of different types of uterine adenomyosis(diffuse adenomyosis, focal adenomyosis/adenomyoma, and cysticadenomyosis) will be presented. The sonographic findings will bedescribed and correlated with MRI findings. The potential role of newerultrasound techniques (3D sonography and elastosonography) and pertinentmanagement issues will be briefly discussed.Results—Not applicable as this is a pictorial review.Conclusions—Uterine adenomyosis is often misdiagnosed oris not easily recognized, although it is responsible for disabling symptomssuch as menorrhagia, dysmenorrhea, and infertility. Therefore, it is importantfor the radiologist to accurately diagnose this condition in a timelyfashion. Although MRI is the imaging modality of choice for comprehensiveevaluation, ultrasound is often the initial imaging test performedin the diagnostic workup of these patients and will provide a diagnosis inmost cases.1527190 Determining the Accuracy of Ultrasound in IdentifyingAxillary Lymph Node Metastasis in Breast Cancer PatientsMadelene Lewis,* Abid Irshad, Susan Ackerman Radiology,Medical University of South Carolina, Charleston, SouthCarolina USAObjectives—Axillary lymph node staging is the most importantprognostic indicator of outcome in breast cancer patients. A positivepercutaneous biopsy eliminates the need for sentinel lymph node (SLN)biopsy, saving patients discomfort, time, and money. The purpose of thisstudy was to evaluate our ability to predict axillary nodal involvementusing ultrasound (US) in patients with invasive breast cancer.Methods—After Institutional Review Board approval, a retrospectivereview was performed of 116 patients diagnosed with invasivebreast cancer between January 2010 and June 2011. Sonographic evaluationof the axilla was performed as part of our standard protocol for patientsundergoing biopsy of a breast mass at our institution. Lymph nodeswere considered positive by US if any of the following criteria were present:cortical thickness ≥3 mm, eccentric cortical thickening, cortical lobulation,loss of fatty hilum, or nonhilar blood flow. US findings werecorrelated with pathology results from fine-needle aspiration (FNA), coreneedle biopsy (CNB), SLN, and/or axillary lymph node dissection(ALND).Results—A total of 116 patients (all females) were diagnosedwith invasive breast cancer. Mean age was 58.6 ± 11.9 (SD) years (range,33–84 years) and included 69 white, 42 black, and 4 females from otherraces. Axillary US was performed in all 116 patients. Sonographically, 41patients had positive axillary lymph nodes, and 39 (95.1%) of these 41were sampled by FNA, CNB, SLN, or ALND. Metastatic disease waspositive in 28 (72%) of 39 patients. Of the 75 patients with negative axillaryUS, 68 patients had final pathology. Of these, 51 (75%) remainednegative on SLN or ALND, while 17 (25%) of 68 had metastatic nodes.The sensitivity, specificity, positive predictive value, and negative predictivevalue of US for predicting axillary metastasis were 72% (95% confidenceinterval [CI], 55%–84%), 75% (95% CI, 63%–84%), 62% (95%CI, 47%–76%), and 82% (95% CI, 70%–90%). The overall accuracy ofUS was 74%.Conclusions—Preoperative US evaluation of the axilla inbreast cancer patients is effective for determining metastatic nodes. However,an SLN biopsy is still required in patients with negative preoperativeUS.1527866 Equivalence of 2- and 3-Dimensional Ultrasound inthe Evaluation of First-Trimester Nuchal Translucency byMaternal-Fetal Medicine FellowsSteffen Brown,* Michael Wolfe, Lesley de la Torre, MatthewBrennan, Rebecca Hall Obstetrics and Gynecology, Universityof New Mexico, Albuquerque, New Mexico USAObjectives—Conflicting data exist that 3D ultrasound producesequivalent images to 2D for nuchal translucency (NT) assessment. Weaimed to prospectively evaluate the equivalence of 2D and 3D techniquesfor obtaining the NT measurement as performed by maternal-fetal medicinefellows.Methods—Prospectively enrolled subjects had first-trimesterscreening performed per protocol at our institution by a fellow in maternal-fetalmedicine under the supervision of an NT-certified sonologist.This included transabdominal imaging first, followed by endovaginal imagingif necessary to obtain the proper image. A 3D image using the sameapproach was then obtained and manipulated for measurement of the NT.The 2D and 3D measurements were then compared using a Fisher exacttest and Bland-Altman plot, including root mean squared (RMS) to quantifypaired differences.Results—A total of 43 women were enrolled in the study.Acceptable transabdominal NT measurements were obtained in 34 of the43 subjects (79%), and the remaining 9 (21%) required endovaginal assessmentto complete the exam. The differences in the NT measurementsusing 2D vs 3D nuchal translucency values were normally distributed bythe Shapiro-Wilk test (P = .97). The 2D and 3D values averaged 1.40 ±0.43 and 1.46 ± 0.49 mm, respectively. The 3D image did not significantlyovermeasure or undermeasure the NT (P = .69). 2D and 3D modalitiescorrelated within 3.7 mm (RMS) of one another. 3D imaging required anaverage of 105 seconds more than 2D to complete (P < .001), though totaltime for 3D averaged around 3 minutes (197 ± 179 seconds).Conclusions—2D and 3D NT measurements correlate closely.Performance and manipulation of a 3D volume sweep during NT assessmentmay provide an adjunct or confirmatory image.1528363 Comparative Effectiveness of Fetal Magnetic ResonanceImaging for Improvement of Diagnostic AccuracyChristina Herrera,* Amber Samuel, Sherelle Laifer-Narin,Lynn Simpson, Russell Miller Obstetrics and Gynecology,Columbia University Medical Center, New York, New York USAObjectives—Fetal magnetic resonance imaging (MRI) is performedas an adjunct to routine ultrasound with the intent of improving diagnosticaccuracy, yet data are limited to substantiate benefit to this costlyimaging modality. This study analyzed the billed cost of fetal MRI relativeto diagnostic information gained for patients with antenatal diagnosesof a fetal anomaly and known postnatal outcomes.Methods—This was a retrospective review of all fetal MRIsperformed between 2003 and 2011 at a tertiary care center. Potential caseswere identified if MRI was performed following sonographic concern fora fetal anomaly. Inclusion required documented neonatal outcomes orpostmortem assessments. Test performance characteristics were calculated,from which the number needed to secure an additional accurate diagnosisby MRI was determined. Applying the cost per MRI at the studycenter to this estimate, the cost per additional accurate diagnosis was calculated.Results—A total of 799 MRIs were performed, of which 406had documented neonatal or pathologic outcomes. One hundred thirtyonepostnatal diagnoses were secured, of which MRI identified 51 (12.6%)that ultrasound failed to correctly characterize. When the most common diagnosisgroups were considered, meningomyelocele had the lowest costper additional correct diagnosis by MRI and ventriculomegaly the highest(Table 1). The cost per additional accurate diagnosis for cases of congenitaldiaphragmatic hernia, omphalocele, vein of Galen malformation,S90
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Small-Animal Preclinical High-Frequ
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2013 AIUM Award WinnersJoseph H. Ho
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