OBJECTIVE. The purpose of this project was to achieve sustained improvement in mammographic breast positioning in our department. MATERIALS AND METHODS. Between June 2013 and December 2016, we conducted a team-based performance improvement initiative with the goal of improving mammographic positioning. The team of technologists and radiologists established quantitative measures of positioning performance based on American College of Radiology (ACR) criteria, audited at least 35 mammograms per week for positioning quality, displayed performance in dashboards, provided technologists with positioning training, developed a supportive environment fostering technologist and radiologist communication surrounding mammographic positioning, and employed a mammography positioning coach to develop, improve, and maintain technologist positioning performance. Statistical significance in changes in the percentage of mammograms passing the ACR criteria were evaluated using a two-proportion z test. RESULTS. A baseline mammogram audit performed in June 2013 showed that 67% (82/122) met ACR passing criteria for positioning. Performance improved to 80% (588/739; p < 0.01) after positioning training and technologist and radiologist agreement on positioning criteria. With individual technologist feedback, positioning further improved, with 91% of mammograms passing ACR criteria (p < 0.01). Seven months later, performance temporarily decreased to 80% but improved to 89% with implementation of a positioning coach. The overall mean performance of 91% has been sustained for 23 months. The program cost approximately $30,000 to develop, $42,000 to launch, and $25,000 per year to maintain. Almost all costs were related to personnel time. CONCLUSION. Dedicated performance improvement methods may achieve significant and sustained improvement in mammographic breast positioning, which may better enable facilities to pass the recently instated Enhancing Quality Using the Inspection Program portion of a practice's annual Mammography Quality Standards Act inspections.

Azygous Vein Aneurysm (AVAs) is an uncommon cause of mediastinal mass. They are typically asymptomatic and do not commonly require treatment. They may mimic mediastinal adenopathy on chest radiographs. We present a case of AVAs found during evaluation of chest pain in a patient who was also found to have pulmonary thromboembolism. The mass was worked up with cross-sectional imaging techniques using both Computerized Tomography (CT) and Magnetic Resonance Imaging (MRI) and ultimately Positron Emission Tomography (PET). Due to recurrent symptomatology, the aneurysm was coiled.

Breast cancer is the second most common cancer in women in the United States after skin cancer. Mammography remains the mainstay of cancer screening, but breast MRI has a role in screening of women at high risk of breast cancer (e.g., BRCA mutation). In women who are identified with breast cancer at diagnostic mammography and subsequent breast biopsy, breast MRI also has a role in the evaluation of the extent of disease. Typically, abnormal findings on breast MRI can be grouped into two categories—mass enhancement and non-mass enhancement (NME). Most breast imagers are comfortable with assessing radiologic-pathologic correlation in the setting of biopsy of a mass on breast MRI, but non-mass enhancement can create more uncertainty as to whether cancer is present because hormonally influenced breast tissue can appear as non-mass enhancement on breast MRI. After studying this CME activity, the diagnostic radiologist will be able to discuss the appearance of non-mass enhancement on breast MRI, principles of MRI-guided breast biopsy of non-mass enhancement, common diagnoses accounting for non-mass enhancement, and approaches to assessing radiologic-pathologic concordance of non-mass enhancement with MRI-guided breast biopsy.

United States Armed Forces radiologists deployed to Afghanistan and Iraq in modern military conflicts may encounter pediatric patients as a casualty of war or when providing humanitarian assistance to the indigenous population. Pediatric patients account for 4–7% of admissions at U.S. military hospitals during the Iraq and Afghanistan conflicts. It is pertinent for radiologists in the humanitarian care team to be familiar with imaging pediatric trauma patients, the pathology endemic to the local population, and delayed presentations of congenital and developmental disorders to adequately care for these patients. The radiological manifestations of various pediatric disorders seen in the setting of the Iraq and Afghanistan conflicts will be explored.

Amyloidosis is a heterogeneous group of disorders of protein folding and shape with associated deposition of protein fragments in body tissues. Amyloidosis has an incidence of about 1 in 100,000 patients annually in the United States. Most patients are women, diagnosed between 50 and 70 years of age. Certain chronic diseases such as rheumatoid arthritis and multiple myeloma often coexist with amyloidosis, whereas other predisposing factors may be familial (genetic) or acquired, as in patients with chronic renal failure on long-duration hemodialysis. As a consequence of protein fragment deposition, organ dysfunction and failure may ensue. Throughout this process, imaging examinations may offer clues that point to a diagnosis of amyloidosis. With this CME activity, the radiologist will be able to recognize some of the potential imaging findings that may be associated with amyloidosis, thus leading to a higher level of suspicion when a patient presents with organ dysfunction because of amyloidosis.

Normal breast anatomy can be seen on a variety of imaging modalities. Knowledge of normal breast anatomy on imaging examinations is important for an interventionalist, primarily to avoid mistaking normal anatomy for a pathologic disorder, so as not to harm a patient with an unnecessary intervention. Knowledge of breast anatomy is also critical in planning safe breast interventions and unwanted procedural complications. The key anatomical structures in the breast include skin, fat, fascial layers, Cooper ligaments, fibroglandular tissue, lymphatics, and neurovascular structures, all positioned over the chest wall. In men, the breast parenchyma is usually only composed of fat, with absence of fibroglandular tissue. In women, fibroglandular tissue volumes vary with age, with many women having a predominance of fat within the breasts after menopause. Embryologically, the breast develops under genetic and hormonal influence from skin precursor cells during the fourth through twelfth weeks of gestation, and the resulting breast bud continues to lengthen and branch throughout the remainder of gestation, forming a complex network of radially arranged breast ducts that connect the nipple with the mammary lobules. The key arterial blood supply to the breast arises from the internal thoracic artery, but additional arterial blood supply is seen from intercostal and lateral thoracic arteries. The venous anatomy and lymphatic drainage of the breast generally parallels the arterial anatomy, with presence of variation in communicating channels between deep and superficial venous and lymphatic channels. Tools that assess breast vascular structures (eg, contrast-enhanced breast magnetic resonance imaging) and lymphatic structures (nuclear medicine lymphoscintigraphy) are routinely used to assess extent of breast disease and help guide breast interventions.

Male breast disease includes a variety of benign and malignant conditions, many of which are hormonally influenced. Gynecomastia and skin lesions account for the majority of conditions in symptomatic men with a palpable abnormality, and these conditions should be accurately recognized. Imaging patterns of gynecomastia include nodular, dendritic, and diffuse patterns. Histopathologically, the nodular and dendritic patterns correlate with the florid and quiescent (fibrotic) phases of gynecomastia, respectively. The diffuse pattern may have features of both phases and is associated with exposure to exogenous estrogen. Benign-appearing palpable masses in male patients should be approached cautiously, given the overlapping morphologic features of benign and malignant tumors. In addition to gynecomastia, other benign male breast tumors include lipoma, pseudoangiomatous stromal hyperplasia, granular cell tumor, fibromatosis, myofibroblastoma, schwannoma, and hemangioma. Male breast cancer accounts for 1% of all breast carcinomas. Invasive ductal carcinoma accounts for the majority of cases in adult males and typically appears as a subareolar mass without calcifications that is eccentric to the nipple. Other epithelial and mesenchymal tumors that may occur, albeit not as commonly as in women, include papillary carcinoma, invasive lobular carcinoma, adenoid cystic carcinoma, liposarcoma, dermatofibrosarcoma, pleomorphic hyalinizing angiectatic tumor, basal cell carcinoma of the nipple, hematopoietic malignancies, and secondary tumors. Knowledge of the natural history, clinical characteristics, and imaging features of tumors that occur in the male breast will help narrow the radiologic differential diagnosis and optimize treatment.

Abnormally enlarged visceral arteries in the abdomen and pelvis must be recognized radiologically because early treatment can improve the quality of life and prevent life-threatening complications. These lesions, typically classified as aneurysms and pseudoaneurysms, are being detected more frequently with increased utilization of imaging and have various causes (eg, atherosclerosis, trauma, infection) and complications that may be identified radiologically. Ultrasonography, computed tomography, and magnetic resonance imaging often enable detection of visceral vascular lesions, but angiography is important for further diagnosis and treatment. Endovascular treatment is often the first-line therapy. Endovascular intervention or open surgical repair is necessary for all visceral pseudoaneurysms and is likely indicated for visceral aneurysms 2 cm or more in diameter. Endovascular exclusion of flow can be achieved with coils, stents, and injectable liquids. Techniques include embolization ("sandwich" or "sac-packing" technique), exclusion of flow with luminal stents, and stent-assisted coil embolization. Management often depends on the location and technical feasibility of endovascular repair. Embolization is usually preferred for aneurysms or pseudoaneurysms within solid organs, and the sandwich technique is often used when collateral flow is present. Covered stent placement may be preferred to preserve the parent artery when main visceral vessels are being treated. It is usually tailored to lesion location, and a cure can often be effected while preserving end-organ arterial flow. Posttreatment follow-up is usually based on treatment location, modality accuracy, and potential consequences of treatment failure. Follow-up imaging may help identify vessel recanalization, unintended thrombosis of an artery or end organ, or sequelae of nontarget embolization. Retreatment is usually warranted if the clinical risks for which embolization was performed are still present.

JERSEY SL, JESINGER RA, PALKA P. Brain magnetic resonance imaging anomalies in U-2 pilots with neurological decompression sickness. Aviat Space Environ Med 2013; 84:3-11. Introduction: This was a retrospective observational study of imaging used to evaluate and treat 13 U-2 pilots with neurological decompression sickness (DCS). Magnetic resonance imaging (MRI) and computed tomography (CT) provided data for screening, diagnosis, and determinations of fitness to fly after recovery. While small series and case reports described the role of imaging in diving DCS, none addressed radiology's role in aviation DCS. Methods: We performed a literature review of altitude DCS radiology studies. We then reviewed radiology images at our institution on U-2 pilots with neurological DCS between January 2002 and August 2010. We retrospectively analyzed MRI data for white matter hyper-intensities (WMHs), defined as hyperintense lesions >= 3 mm on T2 and FLAIR. All studies occurred after hyperbaric oxygen (HBO) treatment. Results: There were 17 pilots who reported 20 neurological DCS incidents. Of these 17 pilots, 13 underwent imaging. Two (15%) demonstrated acute subcortical lesions on MRI, seven (54%) had asymptomatic WMHs, and six (46%) were normal. The clinical significance of the lesions is unknown. Consistent with diving DCS, imaging played no role in acute diagnosis. However, imaging was vital for determining fitness for return to flying. Additionally, CT identified a potentially predisposing sinus condition in one pilot which may enable return to flying after treatment. Conclusions: Modern imaging has unique findings for altitude DCS patients. The high incidence of WMHs in this series is a matter of ongoing research to determine potential clinical consequences. Emerging techniques such as functional MRI may play important roles in future aeromedical decisions.

Cocaine is the second most abused illicit drug in the United States with 2.4 million users in 2006 (Cannabis is the leading offender). Cocaine is also the most common recreational drug resulting in emergency department visits. According to the Drug Abuse Warning Network, a public health surveillance system, there were 2.1 million drug-abuse-related emergency department visits in the United States in 2008, and more than 400,000 of these visits directly involved cocaine use. Based on the 2010 National Survey on Drug Use and Health report, the 18- to 25-year-old population accounted for nearly 45% of illicit drug use during 2010, with those aged 26 to 34 years accounting for an additional 30%. These statistics are important because cocaine use can result in acute and chronic pathology involving almost every body organ system and often more than a single organ system at a time. Commonly involved organ systems include the central nervous, cardiovascular, pulmonary, gastrointestinal, and musculoskeletal. The most dramatic complication of cocaine use is sudden death, which can occur after a single-use episode. After completing this CME activity, the radiologist will be able to recognize the emergency department presentations that may be associated with cocaine use, thus leading to a higher level of suspicion of cocaine abuse when a young, relatively healthy patient presents to the emergency department.

Superior vena cava syndrome (SVCS) consists of a constel-lation of symptoms that result from some degree of obstruction of the superior vena cava (SVC). The SVC is formed by the union of the left and right brachiocephalic veins and ends with the continuation into the right atrium of the heart. The SVC's function of returning blood from the upper half of the body, and its location anterior to the trachea at the right margin of the sternum, helps explain the typical signs and symptoms of the superior vena cava syndrome. The patient with superior vena cava syndrome might complain of head-ache, dysphagia, hoarseness, or shortness of breath. Blockage of the SVC can lead to clinical signs such as upper body edema, plethora, jugular vein distension, and appearance of prominent collateral veins.

OBJECTIVE. The solid abdominal viscera are secured in place by various suspensory ligaments. Laxity or incomplete development of these anchoring ligaments can lead to hypermobility and predispose the patient to torsion-related ischemic pathology. The clinical symptoms of solid visceral intraabdominal torsions are nonspecific. A prompt diagnosis is critical to avoid life-threatening consequences of prolonged visceral ischemia. Abdominal torsions are rarely diagnosed clinically, and it is often the responsibility of the radiologist to recognize and make the diagnosis through cross-sectional imaging. This article reviews the imaging spectrum, radiologic-pathologic correlations, and therapeutic implications of solid visceral intraabdominal torsions, including some unusual solid organ and abdominal fat torsions. CONCLUSION. The clinical presentation of solid visceral intraabdominal torsion is nonspecific and radiologists are relied on to make this diagnosis on cross-sectional imaging studies. Recognition of the predisposing factors and imaging spectrum of intraabdominal torsions is essential to help direct timely intervention in these potentially life-threatening entities.

Part I of this 2-part series on genitourinary diverticulosis discussed diverticula of the urinary tract in women and men, and was presented previously in Volume 35, Number 12, 2012. This issue, Part II, will cover diverticula of the female reproductive system.Diverticula of the female reproductive system have a wide spectrum of clinical and imaging presentations. The presenting symptoms and therapeutic options often depend on the anatomic location of the diverticulum. Most diverticular diseases of the female reproductive system are acquired secondary to glandular obstruction, infection, inflammation, or trauma. Recognition of diverticular disease of the female reproductive system on imaging is important because diverticula may contribute to female infertility, menstrual dysfunction, and chronic pelvic pain. After completing this CME activity, the diagnostic radiologist should have an appreciation of the range of diverticular diseases of the female reproductive tract, and their multimodality imaging features, common complications, and current treatment strategies.

OBJECTIVE:The gastrointestinal tract is secured in place by various suspensory ligaments. Laxity or incomplete development of these anchoring ligaments can lead to hypermobility and predispose the patient to torsion-related ischemic pathology. A prompt diagnosis is necessary to avoid life-threatening consequences of prolonged visceral ischemia. Abdominal torsions are rarely diagnosed clinically, and it is often the responsibility of the radiologist to recognize and make the diagnosis through radiography, fluoroscopy, or cross-sectional imaging. This article reviews the imaging spectrum (with radiologic-pathologic correlations) and therapeutic implications of gastrointestinal tract torsions.CONCLUSION:Torsion-related ischemic pathology may involve any portion of the gastrointestinal tract from the stomach to the colon. The clinical presentation of gastrointestinal tract torsion is nonspecific, and radiologists are relied on to make this diagnosis. Recognition of the predisposing factors and imaging spectrum of gastrointestinal tract torsions is essential to help direct timely intervention in these potentially life-threatening entities.