Objectives: To determine the feasibility of implementing Ovarian-Adnexal Reporting & Data System (O-RADS) ultrasound (US) for reporting of adnexal masses at our institution, with a specific goal of increasing the use of O-RADS from a baseline of <5% to at least 75% over a 16-month period. Methods: A prospective interrupted time series quality improvement study was undertaken over a 16-month period. Plan, do, study, act cycles included: (1) Engagement of interested parties, (2) Targeted educational sessions, (3) Development of reporting templates, (4) Weekly audit-feedback. Inter-reader variability assessment was performed on 70% of O-RADS risk-category 2 to 5. The primary outcome was the reporting of an O-RADS risk category. Results: A total of 635 female pelvic US were performed at our centre between July 2022 and April 2023. An O-RADS risk category was provided on the final radiology report by the radiologist for 489/635 (77%) US. From November 2022 to April 2023, the weekly rate of O-RADS risk category reporting reached 88%. The O-RADS score was concordant between readers for 83/103 (81%) of US reports with kappa score of 0.69 corresponding to good agreement. Conclusions: The reporting of O-RADS risk category increased from <5% to 88% over a 16-month period with a high level of agreement among readers in assigning O-RADS risk category. Implementation of a standardizing reporting ultrasound system at a tertiary cancer centre is feasible with rapid learning and uptake curves.

ObjectiveTo assess the impact of the introduction of universal transvaginal cervical screening and certification on the quality of cervical length ultrasound images.MethodsThe present study included a retrospective cohort of singleton pregnancies that underwent transvaginal cervical length measurement at the anatomical scan (180/7 and 236/7 weeks) before (period A, 2015-2017) and after (period B, 2017-2019) the introduction of universal transvaginal cervical length screening. Independent observers blindly evaluated the images obtained for cervical length using a qualitative scoring method based on five criteria, according to the Fetal Medicine Foundation.ResultsIn all, 6013 patients met the inclusion criteria, 3333 in period A and 2680 in period B. Maternal characteristics and risk factors for preterm birth were similar between the two periods. The acceptance of transvaginal cervical length measurement in period B was 95.5% in the overall cohort and 100% in the subgroup of high-risk patients. The quality score was significantly higher in period B than in period A. Among the image quality criteria, the anterior/posterior ratio, the correct magnification of the images, and the calipers' placement contributed significantly to the improved quality score in period B. Most of the sonographers performed better in period B, irrespective of the years of experience, but certificate holders obtained higher scores than non-certified sonographers, particularly those in mid-career. The identification of short cervix was significantly higher in period B than in period A.ConclusionThe implementation of universal transvaginal cervical length screening and the certification process are associated with improved quality of cervical length images, even among expert sonographers and in the presence of anatomical pitfalls. The impact of the introduction of universal transvaginal cervical screening and certification on the quality of cervical length ultrasound images in both low- and high-risk populations.

Gestational trophoblastic diseases (GTD) encompass a spectrum of rare pre-malignant and malignant entities originating from trophoblastic tissue. This updated review will highlight important radiological features, pathology and classification, and provide insight into the clinical management of these uncommon disorders. There is a wide geographic variation with the incidence of hydatidiform mole varying between 0.57 and 2 per 1000 pregnancies. The use of ultrasound (US) in the management of early pregnancy symptoms and complications has positively impacted the earlier detection of these diseases and resulted in diminished morbidity. Additional imaging modalities are reserved for problem solving or assessment of pulmonary manifestations of molar pregnancy. Having an awareness of their pleomorphic sonographic presentation and additional pathology that can mimic GTD is critical to avoiding pitfalls. Histologic and molecular analysis further aids in differential diagnosis. Gestational trophoblastic neoplasia (GTN) is inclusive of all malignant GTDs, and arises after 20% of molar pregnancies but can also be seen with non-molar gestations. Biochemical monitoring with human chorionic gonadotrophin is imperative for ongoing monitoring and surveillance and allows early detection of this entity. Doppler US is used for confirmation of diagnosis with magnetic resonance imaging (MRI) reserved for problem solving or assessment of myometrial invasion. This is of heightened relevance in patients undergoing surgical management. Cross sectional imaging is reserved for patients in the setting of GTN for the purposes of staging, prognostication and in the setting of recurrent disease. This may require a combination of computed tomography, MRI and positron emission tomography. Doppler US can provide insight into chemotherapeutic response/predict resistance in patients with GTN. As our understanding of these disorders evolves, there has been maturation in management options with a shift from traditional chemotherapy to innovative immunotherapy, particularly in the setting of resistant or high-risk disease.

HomeRadioGraphicsVol. 43, No. 3 PreviousNext UltrasoundRadioGraphics FundamentalsO-RADS US Risk Stratification and Management System: Case-based Learning Approach for Daily PracticeKalesha Hack, Lori Strachowski, Rochelle F. Andreotti, Hournaz Ghandehari, Priyanka Jha, Christopher Lim, Chirag Patel, Phyllis Glanc Kalesha Hack, Lori Strachowski, Rochelle F. Andreotti, Hournaz Ghandehari, Priyanka Jha, Christopher Lim, Chirag Patel, Phyllis Glanc Author AffiliationsFrom the Department of Medical Imaging, University of Toronto, Sunnybrook Health Sciences Centre, MG160, 2075 Bayview Ave, Toronto, ON, Canada M4N 3M5 (K.H., H.G., C.L., C.P., P.G.); Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, Calif (L.S., P.J.); and Department of Radiology, Vanderbilt University, Nashville, Tenn (R.F.A.).Address correspondence to P.G. (email: [email protected]).Kalesha HackLori StrachowskiRochelle F. AndreottiHournaz GhandehariPriyanka JhaChristopher LimChirag PatelPhyllis Glanc Published Online:Feb 23 2023https://doi.org/10.1148/rg.220079MoreSectionsFull textPDF ToolsImage ViewerAdd to favoritesCiteTrack CitationsPermissionsReprints ShareShare onFacebookTwitterLinked In AbstractUnderstanding the O-RADS US lexicon and how to apply it accurately can improve care in daily practice by decreasing unnecessary follow-up and surgery and promoting rapid referral to a gynecologic oncologist.Suggested ReadingsAndreotti RF, Timmerman D, Benacerraf BR, et al. Ovarian-Adnexal Reporting Lexicon for Ultrasound: A White Paper of the ACR Ovarian-Adnexal Reporting and Data System Committee. J Am Coll Radiol 2018;15(10):1415–1429 [Published correction appears in J Am Coll Radiol 2019;16(3):403–406.]. Crossref, Medline, Google ScholarAndreotti RF, Timmerman D, Strachowski LM, et al. O-RADS US risk stratification and management system: a consensus guideline from the ACR Ovarian-Adnexal Reporting and Data System Committee. Radiology 2020;294(1):168–185. Link, Google ScholarBasha MAA, Metwally MI, Gamil SA, et al. Comparison of O-RADS, GI-RADS, and IOTA simple rules regarding malignancy rate, validity, and reliability for diagnosis of adnexal masses. Eur Radiol 2021;31(2):674–684. Crossref, Medline, Google ScholarCao L, Wei M, Liu Y, et al. Validation of American College of Radiology Ovarian-Adnexal Reporting and Data System Ultrasound (O-RADS US): Analysis on 1054 adnexal masses. Gynecol Oncol 2021;162(1):107–112. Crossref, Medline, Google ScholarGiede KC, Kieser K, Dodge J, Rosen B. Who should operate on patients with ovarian cancer? An evidence-based review. Gynecol Oncol 2005;99(2):447–461. Crossref, Medline, Google ScholarGlanc P, Benacerraf B, Bourne T, et al. First international consensus report on adnexal masses: management recommendations. J Ultrasound Med 2017;36(5):849–863. Crossref, Medline, Google ScholarHack K, Gandhi N, Kahn D, Glanc P. OC03.05: External validation O-RADS ultrasound risk stratification and management system. Ultrasound Obstet Gynecol 2021;58(S1):8–9. Crossref, Google ScholarHack K, Glanc P. The Abnormal Ovary: Evolving Concepts in Diagnosis and Management. Obstet Gynecol Clin North Am 2019;46(4):607–624. Crossref, Medline, Google ScholarLevine D, Patel MD, Suh-Burgmann EJ, et al. Simple adnexal cysts: SRU consensus conference update on follow-up and reporting. Radiology 2019;293(2):359–371. Link, Google ScholarPi Y, Wilson MP, Katlariwala P, et al. Diagnostic accuracy and inter-observer reliability of the O-RADS scoring system among staff radiologists in a North American academic clinical setting. Abdom Radiol (NY) 2021;46(10):4967–4973. Crossref, Medline, Google ScholarSadowski, EA, et al. O-RADS MRI Risk Stratification System: Guide for Assessing Adnexal Lesions from the ACR O-RADS Committee. Radiology 2022;303:35–47. Link, Google ScholarStrachowski LM, Jha P, Chawla TP, et al. O-RADS for Ultrasound: A User's Guide, From the AJR Special Series on Radiology Reporting and Data Systems. AJR Am J Roentgenol 2021;216(5):1150–1165. Crossref, Medline, Google ScholarTimmerman D. Lack of standardization in gynecological ultrasonography. Ultrasound Obstet Gynecol 2000;16(5):395–398. Crossref, Medline, Google ScholarArticle HistoryReceived: Apr 8 2022Revision requested: May 16 2022Revision received: June 3 2022Accepted: June 8 2022Published online: Feb 23 2023 FiguresReferencesRelatedDetailsAccompanying This ArticleO-RADS US Risk Stratification and Management System: Case-based Learning Approach for Daily PracticeFeb 23 2023Default Digital Object SeriesRecommended Articles O-RADS US Risk Stratification and Management System: A Consensus Guideline from the ACR Ovarian-Adnexal Reporting and Data System CommitteeRadiology2019Volume: 294Issue: 1pp. 168-185Physiologic Ovarian Cysts versus Other Ovarian and Adnexal Pathologic Changes in the Preadolescent and Adolescent Population: US and Surgical Follow-upRadiology2019Volume: 292Issue: 1pp. 172-178Ovarian Cancer Detection in Average-Risk Women: Classic- versus Nonclassic-appearing Adnexal Lesions at USRadiology2022Volume: 303Issue: 3pp. 603-610Benign-appearing Incidental Adnexal Cysts at US, CT, and MRI: Putting the ACR, O-RADS, and SRU Guidelines All TogetherRadioGraphics2022Volume: 42Issue: 2pp. 609-624MRI of Borderline Epithelial Ovarian Tumors: Pathologic Correlation and Diagnostic ChallengesRadioGraphics2022Volume: 42Issue: 7pp. 2095-2111See More RSNA Education Exhibits O-RADS: Case Based LearningDigital Posters2021Update on Ovarian Neoplasm: What Radiologists Need to Know on Clinical, Laboratory, and an Algorithmic Imaging Approach to Benign versus Malignant Neoplasms Digital Posters2019Multifaceted Pancreatic Serous Cystadenoma and Its Differential Diagnosis at MRIDigital Posters2019 RSNA Case Collection Endometrioma RSNA Case Collection2022Pancreatic serous cystadenoma RSNA Case Collection2021Intraductal Papillary Mucinous Neoplasm RSNA Case Collection2020 Vol. 43, No. 3 Slide PresentationAbbreviations Abbreviations: O-RADS Ovarian-Adnexal Reporting and Data System Metrics Altmetric Score PDF download

© Author(s) (or their employer(s)) 2022. Reuse permitted under CC BYNC. No commercial reuse. See rights and permissions. Published by BMJ. INTRODUCTION Thyroid nodules are extremely common ; however, most nodules are benign, and even malignant nodules typically follow an indolent course. 4 With the advancement in ultrasonography and diagnostic techniques, thyroid nodules are biopsied more frequently, and the incidence of thyroid cancer has markedly increased. However, mortality from thyroid cancer has remained relatively stable, suggesting an increasing trend towards overinvestigation. The American College of Radiology published the Thyroid Imaging Reporting and Data System (TIRADS) in 2017 that aimed to reduce unnecessary investigations of thyroid nodules based on findings on ultrasounds. Several studies have shown that, when compared with other risk stratification systems, the TIRADS guidelines led to a reduction in unnecessary fineneedle aspiration (FNA) biopsies while ensuring most malignant nodules were either biopsied or monitored. The purpose of this study was to implement TIRADS guidelines in a tertiary care radiology department with the aim to reduce unnecessary FNAs.

Background The Ovarian-Adnexal Reporting and Data System (O-RADS) US risk stratification and management system (O-RADS US) was designed to improve risk assessment and management of ovarian and adnexal lesions. Validation studies including both surgical and nonsurgical treatment as the reference standard remain lacking. Purpose To externally validate O-RADS US in women who underwent either surgical or nonsurgical treatment and to determine if incorporating acoustic shadowing as a benign finding improves diagnostic performance. Materials and Methods This retrospective study included consecutive women who underwent pelvic US between August 2015 and April 2017 at a tertiary referral oncology center. Two independent readers blinded to clinical and histologic outcome assigned an O-RADS risk category and an International Ovarian Tumor Analysis (IOTA) Assessment of Different NEoplasias in the adneXa (ADNEX) model risk of malignancy score to assessable lesions. Reference standards were surgical histopathology or 2-year imaging follow-up. Receiver operating characteristic (ROC) curve analysis was used to evaluate performance of the O-RADS US, ADNEX, and modified O-RADS models incorporating acoustic shadowing. Results In total, 227 women (mean age, 52 years ± 16 [SD]) with 262 ovarian or adnexal lesions were evaluated. Of these lesions, 187 (71%) were benign and 75 (29%) were malignant. The proportion of malignancy was 0% (0 of 100) for O-RADS 2, 3% (one of 32) for O-RADS 3, 35% (22 of 63) for O-RADS 4, and 78% (52 of 67) for O-RADS 5. The area under the ROC curve (AUC) for O-RADS and ADNEX was 0.91 (95% CI: 0.88, 0.94) and 0.95 (95% CI: 0.92, 0.97; P = .01), respectively. The addition of acoustic shadowing as a benign finding improved O-RADS AUC to 0.94 (95% CI: 0.91, 0.96; P = .01). Use of O-RADS 4 as a threshold yielded a sensitivity of 99% (74 of 75; 95% CI: 96, 100) and a specificity of 70% (131 of 187; 95% CI: 64, 77). Conclusion In a tertiary referral oncology center, the Ovarian-Adnexal Reporting and Data System US risk stratification and management system enabled accurate distinction of benign from malignant ovarian and adnexal lesions. Adding acoustic shadowing as a benign finding improved its diagnostic performance. © RSNA, 2022 See also the editorial by Levine in this issue.

Introduction: The goal of this study was to compare the performance characteristics of the American College of Radiology Thyroid Imaging Reporting and Data System (ACR-TIRADS) and the American Thyroid Association (ATA) systems in identifying malignant thyroid nodules. Methods: In a retrospective chart review, ultrasound images of all thyroid nodules biopsied in 2014- 2015 at a Canadian academic centre were reviewed by two radiologists. The ultrasound characteristics of thyroid nodules were compared with cytologic or pathologic results to determine the positive predictive value (PPV), negative predictive value (NPV), sensitivity and specificity for TIRADS and ATA in predicting cancer risk. Clinical course of nodules not requiring follow up or intervention according to ACR-TIRADS was described. Vascularity was added to ACR-TIRADS to determine whether sensitivity of TIRADS improves. Results: A total of 417 thyroid nodules were reviewed, 82% were benign (Bethesda II). The sensitivity, specificity, PPV, and NPV were 97%, 11%, 9%, 98%, and 70%, 29%, 18%, and 81% for ATA and TIRADS, respectively. Of the 10 nodules that did not need ultrasound follow up based on TIRADS criteria, 2 were malignant, the rest were FLUS. If vascularity was added to TIRADS (TIRADS-Vasc), the number of malignant cases missed could have been reduced by 43% (from 7 to 4 cases). Conclusions: TIRADS is more specific but less sensitive than ATA, and misses a small number of malignant nodules. Clinicians need to use their judgement to decide which nodules require biopsy as some malignant cases will be missed using TIRADS alone.

Objectives We sought to evaluate our experience with universal transvaginal ultrasound cervical length(TVCL) screening program in a single academic tertiary care institution. Methods We retrospectively assessed singleton pregnancies who underwent anatomy scan between 18.0-23.6 weeks (wks) gestation. Women subdivided into Group1-after introduction of TVCL screening (April, 2017 to March, 2019) and Group2-prior to screening (April, 2015-March, 2017), when TVUS was performed upon physician request, or if the CL was <3cm at abdominal evaluation. Pregnancies at high risk for preterm birth (PTB) or undergoing termination for fetal anomalies or fetal demise were excluded. Demographics, ultrasound findings, and delivery data were collected. The primary outcome was the incidence of a short cervix(TVCL<25mm), secondary outcomes were the rates of composite intervention (progesterone and cerclage) and PTB below 37, 34, and 32 wks. Results A partial analysis was performed in 3824 over a total of 6067 pregnancies. 3281 pregnancies were suitable for analysis: 1878 in Group1 and 1403 in Group2. Maternal age, nulliparity, and gestational age at scan were similar in both groups. TVCL was performed more in Group1 vs Group2 (92.8% vs.18.5%, p<0.005). The incidence of a short CL and composite intervention rate was significantly higher in Group1 compared with Group2, (2.1% vs.0.9%,p<0.005) and (2.7% vs.1.5%,p<0.02), respectively. The rate of PTB below 37,34, and 32 wks was not significantly different between the groups. Conclusions We found significant differences in the incidence of short cervix and intervention rate before and after TVCL universal screening. After completing our database, we aim to understand better the incidence of a short cervix in a larger cohort of low-risk pregnancies and evaluate the screening test's potential efficacy. We sought to evaluate our experience with universal transvaginal ultrasound cervical length(TVCL) screening program in a single academic tertiary care institution. We retrospectively assessed singleton pregnancies who underwent anatomy scan between 18.0-23.6 weeks (wks) gestation. Women subdivided into Group1-after introduction of TVCL screening (April, 2017 to March, 2019) and Group2-prior to screening (April, 2015-March, 2017), when TVUS was performed upon physician request, or if the CL was <3cm at abdominal evaluation. Pregnancies at high risk for preterm birth (PTB) or undergoing termination for fetal anomalies or fetal demise were excluded. Demographics, ultrasound findings, and delivery data were collected. The primary outcome was the incidence of a short cervix(TVCL<25mm), secondary outcomes were the rates of composite intervention (progesterone and cerclage) and PTB below 37, 34, and 32 wks. A partial analysis was performed in 3824 over a total of 6067 pregnancies. 3281 pregnancies were suitable for analysis: 1878 in Group1 and 1403 in Group2. Maternal age, nulliparity, and gestational age at scan were similar in both groups. TVCL was performed more in Group1 vs Group2 (92.8% vs.18.5%, p<0.005). The incidence of a short CL and composite intervention rate was significantly higher in Group1 compared with Group2, (2.1% vs.0.9%,p<0.005) and (2.7% vs.1.5%,p<0.02), respectively. The rate of PTB below 37,34, and 32 wks was not significantly different between the groups. We found significant differences in the incidence of short cervix and intervention rate before and after TVCL universal screening. After completing our database, we aim to understand better the incidence of a short cervix in a larger cohort of low-risk pregnancies and evaluate the screening test's potential efficacy.

To assess the performance of O-RADS Ultrasound Risk Stratification to distinguish benign and malignant adnexal masses. 262 adnexal lesions were included in 227 patients who underwent pelvic transvaginal ultrasound at a single-site tertiary care referral centre between August 2015 and April 2017. Exclusions included O-RADS 1 normal ovary, bilateral oophorectomy, pregnancy, incomplete imaging and high genetic risk for ovarian cancer. Adnexal masses were assessed by two independent readers blinded to clinical and histologic outcome who assigned O-RADS score based on criteria. Additional descriptors and clinical indices for the IOTA ADNEX model were also assessed and used to determine the ADNEX overall risk of malignancy. The reference standard was histopathology or minimum 2-year follow-up imaging. ROC curve analysis was used to assess the performance of the O-RADS model and to compare the O-RADS and ADNEX models. Of the 262 adnexal lesions, 187 (71.3%) were benign and 75 (28.6%) were malignant. All O-RADS 2 category lesions had benign outcome. The frequency of malignant outcome was 3.1% (1/32) for O-RADS 3, 34.9% (22/63) for O-RADS 4 and 77.6% (52/67) for O-RADS 5. AUC for O-RADS was 0.91 (95% CI 0.88-0.94) and 0.95 for the ADNEX model (95% CI 0.92-0.97) with ADNEX showing statistically significant better performance (p < 0.05). Adding acoustic shadowing as an independent variable to the O-RADS model increased the AUC 0.94 (95% CI 0.91-0.96), with no statistically significant difference between the adjusted O-RADS and ADNEX models (p = 0.3). The optimal threshold for distinguishing benign and malignant masses was O-RADS 3 with sensitivity 1 and specificity 0.53 (95% CI 0.46-0.61). Using O-RADS 4 as a cut-off resulted in decrease in sensitivity to 0.99 (95% CI 0.96-1) with increase specificity to 0.70 (95% CI 0.64-0.77). The O-RADS Ultrasound Risk Stratification System can differentiate benign from malignant adnexal masses with high accuracy. The addition of acoustic shadowing to the ORADS model further improves diagnostic performance.

Triplet pregnancy is the most common type of high-order multiple gestation, most often occurring after infertility therapy1. Although the number of transferred embryos is generally limited, splitting of one embryo into two may result in multiple pregnancy which is further complicated by monochorionic placentation2,3. Chorioamnionicity has a significant impact on fetal risk and neonatal outcome in twins and even more so in triplets3,4. Ultrasound is the key diagnostic tool to determine chorioamnionicity in multiple pregnancy. Although no specific guidelines are available for high-order multiple pregnancies4, it is common practice to determine chorioamnionicity by counting the number of placentae and amniotic sacs and assessing the thickness of the dividing membranes as early as possible in pregnancy, using high-resolution transvaginal ultrasonography5. In 1996, Sepulveda et al. identified for the first time, in 28 triplet pregnancies, a specific ultrasound landmark called the ‘upsilon zone’, which is the junction of the three interfetal membranes, and demonstrated that it is a useful tool for predicting chorioamnionicity in triplet pregnancies, particularly in the first trimester6. We aimed to investigate if the upsilon zone is easily identifiable at any gestational age and to determine its accuracy in establishing chorionicity and amnionicity in triplets using placental histology as reference. We included retrospectively all triplet pregnancies that underwent ultrasound assessment (using a GE Voluson E8 or E10 (GE Healthcare, Zipf, Austria) or Philips IU22 (Philips Healthcare, Andover, MA, USA) ultrasound system) in our tertiary center between 2013 and 2018. All scans and videoclips from 8 + 0 to 36 + 6 weeks’ gestation were reviewed independently by two observers who were blinded to the final ultrasound report and histopathology results. For each scan, each observer was requested to identify the upsilon zone, defined as the intersection of the three amniotic sacs, and to determine the chorioamnionicity based on the appearance and thickness of the three interfetal membranes at their intersection site (Figure 1). Chorioamnionicity was confirmed by the placental pathology report which was obtained in all pregnancies delivered in our institution. A total of 55 triplet pregnancies were analyzed (Figure S1). Table 1 shows their baseline characteristics. The upsilon zone was identified in 608/638 (95.3%) scans, with an interobserver agreement of 100%. Based on the upsilon zone, 67.3% (37/55) of pregnancies were classified as trichorionic triamniotic, 25.5% (14/55) as dichorionic triamniotic and 1.8% (1/55) as monochorionic triamniotic. In 5.5% (3/55) of pregnancies, the upsilon zone could not be identified, hence, they were classified as dichorionic diamniotic.

To validate the upsilon sign as a pathognomonic landmark for chorionicity/amnionicity in triplet gestations at any gestational age. All triplet pregnancies with serial ultrasound from 8+5 and 36+0 weeks were retrospectively collected from 2013–2018. Two independent blinded observers reviewed all scans aiming to identify the upsilon sign. Amniochorionicity were determined for each scan and compared with the final pathological report generated postpartum. 55 pregnancies were included and 638 ultrasound scans analysed. Conception was spontaneous in 29.1% (16/55) while 20% (11/55) and 50.9% (28/55) resulted after intrauterine insemination or in vitro fertilisation. Median gestational age at the first scan was 14+2 weeks. 67.2% (37/55) were trichorionic triamniotic (TCTA), 25.4% (14/55) dichorionic triamniotic (DCTA), 1.8% (1/55) monochorionic triamniotic (MCTA) and 5.4% (3/55) dichorionic diamniotic (DCDA). After excluding spontaneous/requested reduction (22/55) or termination (3/55) and the three DCDA, a total of 30 triplet pregnancies (30/55 54.5%) with a total number of 616 scans were analysed. The upsilon sign was identified in 98.3% of the scans (606/616). Mean gestational age at birth was 33.5 ± 3.5 weeks. In 82.6% (43/52) of the cases placental histology was available and the prenatal chorionicity/amnionicity was accurate on all the cases. There was 100% intraobserver agreement. The upsilon sign is a valid pathognomonic ultrasound landmark of chorionicity and amnionicity in triplets during the entire duration of pregnancy. Supporting information can be found in the online version of this abstract Supporting Information Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

To determine if transperineal or translabial ultrasound assists in clinical management, surgical decision and planning in patients with midurethral sling complications. This is a retrospective study enrolling consecutive patients who underwent midurethral sling insertion, presented to urology clinic for urologic symptoms, and received translabial ultrasound. The presenting symptoms, including pain, dysuria, dyspareunia, recurrent urinary tract infection, urinary frequency, urinary urgency and nocturia were documented. This descriptive data also includes the postoperative outcome (pain, incontinence), location of erosion in the operative finding. We did chart review to determine whether the findings in ultrasound assisted in surgical decision and planning. 49 patients were included from 2010 to 2018; 27 patients had retropubic procedure, 14 patients had transobturator procedure, 2 patient had both and 6 patients were unable to recall their surgical history. More than half of our patients suffered from pain, recurrent urinary infection, urinary urgency, nocturia and urinary incontinence. 36 patients underwent surgery, 23 erosions were found at urethra (11), bladder (6) and vagina (6). 25 patients were pain-free after the surgery. In chart review, 25 ultrasound studies helped with surgical decision, furthermore 17 ultrasound studies were of assistance in identifying the location of the complication. Translabial ultrasound is helpful in clinical and surgical planning in patients with midurethral mesh related complications. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Ovarian lesions are common and require a consistent approach to diagnosis and management for best patient outcomes. In the past 20 years, there has been an evolution in the approach to abnormal ovarian lesions, with increasing emphasis on reducing surgery for benign disease, standardizing terminology, assessing risk of malignancy through use of evidence-based scoring systems, and triaging suspicious abnormalities to dedicated oncology centers. This article provides an evidence-based review of how these changes in diagnosis and management of ultrasound-detected abnormal ovarian lesions have occurred. Current recommended practices are summarized. The current literature on transvaginal screening for ovarian cancer also is reviewed and summarized.

Background In Canada, breast MRI has traditionally been reserved for evaluation of disease extent in patients with known breast malignancy. More recently, MRI has been emerging as an instrument for breast screening. However, its utilization is limited by increased relative cost and increased reader time. In this study, we evaluate a rapid MRI protocol for breast cancer screening within a breast screening population. Methods A series of 100 MRI studies performed in a high-risk breast cancer population were selected, ensuring a mix of malignant and benign pathology and normal cases. These were presented as full and abbreviated MRI protocols to 3 breast-trained radiologists. Each case was evaluated for Breast Imaging Reporting and Data Systems (BIRADS) category and the presence or absence of cancer. The time taken to complete and interpret each study was also recorded. Results Of the 100 cases, 17 were of histopathology-proven invasive carcinoma, 6 were ductal carcinoma in situ, 33 were benign, and 44 were normal cases. Sensitivity using the rapid protocol was 69.6% (CI: 47.1-86.8) vs 83% (CI: 61.2-95.1) using the full protocol. Specificity using the rapid protocol was 77.9% (CI: 67.0-86.6) vs 83% (CI: 61.2-95.1) using the full protocol. Intra-observer agreement of BIRADS category and cancer detection was very good (0.82-0.93 weighted Kappa and 0.81-0.9 weighted Kappa, respectively). Inter-observer variability of BIRADS category and cancer detection was moderate (0.54-0.59 and 0.53-0.58, respectively). Conclusion Our study suggests that a rapid MRI protocol is comparable in performance to that of a standard MRI protocol. In addition, breast imagers are unlikely to change their BIRADS assessment of a study based on the additional sequences provided by the lengthier study. The use of a rapid MRI protocol can improve accessibility, thus making breast MRI a more utilized tool for breast cancer screening.

To evaluate whether biopsy with vacuum-assisted biopsy (VAB) devices improves histologic underestimation rates of benign papillomas when compared to smaller bore core needle biopsy (CNB) devices. Patients with biopsy-proven benign papillomas with surgical resection or minimum 12 months follow-up were selected. Two breast pathologists reviewed all pathology slides of percutaneous and excisional biopsy specimens. Histologic underestimation rates for lesions biopsied with 10-12 Gauge (G) VAB were compared to those with 14G CNB. A total of 107 benign papillomas in 107 patients from two centers were included. There were 60 patients (mean age 57 years, SD 10.3 years) diagnosed with VAB and 47 patients (mean age 57.6 years, SD 11.3 years) with 14G CNB who underwent surgical excision or imaging follow-up. The upgrade rate to ductal carcinoma in situ or invasive carcinoma was 1.6% (1/60) with VAB and 8.5% (4/47) with 14G. Upgrade to atypia was 3.3% (2/60) after VAB and 10.6% (5/47) with CNB. The total underestimation rates were 5% (3/60) with VAB and 19.1% (9/47) with CNB. The odds of an upgrade to malignancy was 5.5 times higher with a 14G needle than VAB (95% CI: 0.592-50.853, p = 0.17). We observed a lower but not statistically significant upgrade rate to malignancy and atypia with the use of the 10-12 G VAB as compared with 14G CNB. When a papilloma without atypia is diagnosed with vacuum biopsy there is a high likelihood that it is benign; however, if surgical excision is not performed, long-term follow-up is still required.

Background: It has been shown that cam deformities are located at a more anterosuperior location than was previously described. Purpose: To establish, in a large group of asymptomatic participants, the normative range of the alpha angle in the anterosuperior location in both the oblique axial and radial views of magnetic resonance imaging (MRI). Study Design: Cross-sectional study; Level of evidence, 3. Methods: In 197 asymptomatic participants (394 asymptomatic hips) with a mean age of 29.4 years (range, 21.4-50.6 years), T1-weighted MRI scans were studied. The anterosuperior alpha angle measurement was performed by 2 observers using a previously described methodology and also using the radial view. The intraclass correlation coefficient (ICC) was determined for interobserver and intraobserver reliability. Descriptive statistics, the Student t test, correlation studies, and the Bland-Altman technique were used for data analysis. Results: The ICC for interobserver and intraobserver reproducibility was 0.74 (good agreement) and 0.84 (very good agreement), respectively. Anterosuperiorly, the mean (±SD) alpha angles in the oblique axial and radial views were 45.11° ± 8.52° and 50.30° ± 7.91°, respectively (P < .0001). The upper limits of the 95% reference interval for the oblique axial and radial views were 63° and 66°, respectively. In the oblique axial view, the mean (±SD) alpha angle for male participants was 48.3° ± 7.5° compared with 42.6° ± 6.2° for female participants (P < .0001), and in the radial view, it was 53.0° ± 7.1° compared with 48.1° ± 5.6°, respectively (P < .0001). Linear regression analysis demonstrated an insignificant relationship between age and alpha angle, regardless of the imaging plane (r2 = 0.06). Conclusion: We suggest using a higher threshold of 63° (in the oblique axial view) and 66° (in the radial view) at the 1:30 clockface position for the diagnosis of a cam-type deformity. This is significantly higher than 50° to 55° at the 3-o’clock position traditionally used based on the oblique axial view that has been initially described.

PURPOSETo determine whether ureteral segments not filled with contrast material at computed tomographic (CT) urography ever contain tumor detectable only by filling these segments with contrast material.MATERIALS AND METHODSIn this institutional review board-approved, HIPAA-compliant retrospective study, with waiver of informed consent, databases were searched for all patients who underwent heminephroureterectomy or ureteroscopy between January 1, 2001, and December 31, 2009, with available CT urography findings in the 12 months prior to surgery or biopsy and patients who had undergone at least two CT urography procedures with a minimum 5-year follow-up between studies. One of two radiologists blinded to results of pathologic examination recorded location of unfilled segments, time of scan, subsequent filling, and pathologic or 5-year follow-up CT urography results. Tumors were considered missed in an unfilled segment if tumor was found at pathologic examination or follow-up CT urography in the same one-third of the ureter and there were no secondary signs of a mass with other index CT urography sequences. Estimated radiation dose for additional delayed sequences was calculated with a 32-cm phantom.RESULTSIn 59 male and 33 female patients (mean age, 66 years) undergoing heminephroureterectomy, 27 tumors were present in 41 partially nonopacified ureters in 20 patients. Six tumors were present in nonopacified segments (one multifocal, none bilateral); all were identifiable by means of secondary signs present with earlier sequences. Among 182 lesions biopsied at ureteroscopy in 124 male and 53 female patients (mean age, 69 years), 28 tumors were present in nonopacified segments in 25 patients (four multifocal, none bilateral), all with secondary imaging signs detectable without delayed scanning. In 64 male and 29 female patients (mean age, 69 years) who underwent 5-year follow-up CT urography, three new tumors were revealed in three patients; none occurred in the unfilled ureter at index CT urography. Estimated radiation dose from additional sequences was 4.3 mSv per patient.CONCLUSIONTargeted delayed scanning at CT urography yielded no additional ureteral tumors and resulted in additional radiation exposure.