Enlarging Left Mandibular Mass • Xray of the Week A 30 year old female presented with rapidly increasing left mandibular swelling over the last 3 months. What is the diagnosis? Figure.1 (A) Plain radiograph of the mandible showing typical soap-bubble lesion on the left side. (B) CT 3D reconstruction shows multiple osteolytic lesions. Figure 2. (A) Plain radiograph of the mandible showing typical soap-bubble lesion on the left side. There is breach of the cortex (yellow arrow). (B) CT 3D reconstruction shows multiple osteolytic lesions. There is breach of the cortex (green arrows). Figure 3. Coronal contrast enhanced CT scan demonstrates intramandibular, expansile lytic lesion with breach of the cortex at multiple sites (yellow arrows). MRI STIR coronal image shows hyperintense, multiloculated, lesion in left side of the mandible (green arrows). Discussion An expansile radiolucent lesion with no calcified matrix in plain x-rays of the jaw suggests many diagnoses, such as odontogenic cysts, nonodontogenic cysts, cystic neoplasms, and inflammatory granulomas. Among them, odontogenic keratocysts, which contain keratinaceous material, and ameloblastomas, which are benign cystic neoplasms have high recurrence rates. Ameloblastoma arises from the enamel-forming cells of the odontogenic epithelium. The tumor most commonly occurs in the posterior mandible, typically in the third molar region. On radiography, the mixed cystic and solid type of ameloblastoma appears as an expansile, radiolucent, multilocular mass, with internal septations that form a honeycomb or soap bubble appearance on all modalities, which is a classic finding. References: 1. Minami M, Kaneda T, Ozawa K et-al. Cystic lesions of the maxillomandibular region: MR imaging distinction of odontogenic keratocysts and ameloblastomas from other cysts. AJR Am J Roentgenol. 1996;166 (4): 943-9. 2. Minami M, Kaneda T, Yamamoto H et-al. Ameloblastoma in the maxillomandibular region: MR imaging. Radiology. 1992;184 (2): 389-393. 3. Dunfee BL, Sakai O, Pistey R et-al. Radiologic and pathologic characteristics of benign and malignant lesions of the mandible. Radiographics. 26 (6): 1751-1768. 4. Dunn JL, Olan WJ, Bank WO, et-al. Giant ameloblastoma: radiologic diagnosis and treatment. Radiographics. 1997;17 (2): 531-536. 5. Plunk MR, Oda D, Parnell SE, et-al. Focal Benign Disorders of the Pediatric Mandible With Radiologic-Histopathologic Correlation: Mandibular Development and Lucent Lesions. American Journal of Roentgenology. 2017;208: 180-192.5. G. Balachandran, MBBS, MD Dept. of Radiology, Sri Manakula Vinayakar Medical College and Hospital, Pondicherry, India Dr. Balachandran is a Professor of Radiology at Sri Manakula Vinayagar Medical College and Hospital (SMVMCH). He earned his MBBS degree at the Government Stanley Medical College in Madras India in 1975, followed by DMRD at the Government Madras Medical College in Madras India in 1984, MD (RD) at Jimper Pondicherry in 1988, and DNB(RD) at MHFW, GO in New Delhi in 1991. Dr. Balachandran is a life member of the Indian Radiological and Imaging Association (IRIA) and the Indian College of Radiology (ICR).

The So-Called “Debate” Over Breast Cancer Screening is Not a True Debate Originally published February 15, 2017 in MEI News on www.mammographyed.com Republished with permission of the authors. Above: Mammogram of invasive ductal carcinoma of the right breast in a 42 year old. Instead, it is an unequal confrontation between the scientists who have access to the individual patient-based data and also have the expertise needed to evaluate the data, and those who have strong prejudices against the early detection of breast cancer, but who must resort to “estimates”, “approximations” and “assumptions” to support their beliefs, having no access to individual patient data and lacking the expertise needed to interpret peer reviewed, published results. The impact of the early detection of breast cancer upon death from this disease has been studied since the 1960s. Few medical procedures have been tested so thoroughly and subjected to such intense scrutiny as the prospective early detection trials and the widespread, ongoing service screening programs. detection trials and the widespread, ongoing service screening programs. These studies have proved without question that the early detection and treatment of breast cancer at an early stage have significantly decreased the rate of advanced cancers and, as a result, have significantly decreased the rate of death from breast cancer. Despite all this vigorous scientific evidence the following statement in January 2017 from the Nordic Cochrane Center that “breast cancer has a biology that doesn’t lend itself to screening” can be compared to the belief that the Earth is flat. There still appears to exist a small coterie of individuals who share the ideology that women should wait for their breast cancer become symptomatic, advanced. When will the Nordic Cochrane Center issue a formal apology to the relatives of those deceased Danish breast cancer victims who, as a result of the Center’s long-running anti-screening campaign, did not obtain access to early detection and whose breast cancers were detected at too late a stage to be curable? Why does vehement opposition to screening come from Denmark, which has one of the highest breast cancer death rates in Europe? We agree with Professor Stephen W. Duffy who has summarized the situation as follows: “The term "controversy" hardly seems to apply to mammography screening. What ought to be regarded as controversial is the regular opportunity provided by scientific journals and mass media for a group of pseudo-skeptics to repeat over and over again the same flawed science and logic to question the value of screening”.​ László Tabár, MD, FACR (Hon) the Professor Emeritus of Radiology Uppsala University, Faculty of Medicine, Sweden and the Medical Director Emeritus of the Department of Mammography, Falun Central Hospital, Sweden. Through his company, Mammography Education, Inc, he has also been the course director and principal lecturer at more than 300 mammography courses on 6 continents. His pioneering research has laid the foundation for early detection through modern mammographic screening. Dr. Tabár is the recipient of numerous awards including the Gold Medal from the Society of Breast Imaging, American Cancer Society's Distinguished Service Award, and the first Alexander Margulis Award for Scientific Excellence from the Radiological Society of North America (RSNA). All Posts by László Tabár, MD All Breast Imaging Posts

"I look forward to the meeting and traveling back to Israel – it has been nearly 15 years since I was there." - Donald Resnick, MD, FACR Global Radiology CME is thrilled to have Donald Resnick join us in Jerusalem for Imaging in Israel - 2017. Donald L. Resnick, MD, Professor of Radiology and Chief of Osteoradiology at the University of California, San Diego (UCSD), has devoted more than 30 years to musculoskeletal radiology education. Dr Resnick has written over 1100 scientific and educational articles (more than 100 published in Radiology), 72 book chapters, and 16 books on musculoskeletal radiology. Dr Resnick is a renowned lecturer, having given over 50 named lectures throughout the world including the Wilhelm Conrad Roentgen Honorary Lecture at the European Congress of Radiology and the Ho Hung Chiu Medical Education Foundation Lecture in Hong Kong. His list of dozens of awards and honors includes the American Roentgen Ray Gold Medal, Diagnostic Imaging Magazine’s 20 Most Influential People in Radiology, Medical Imaging Industry’s Top 10 Radiologists, twice-awarded AuntMinnie.com Most Effective Radiology Educator, and an Honorary Doctorate from the University of Zurich.Dr Resnick is a member of 9 radiology societies, and is a past president of the International Skeletal Society. In addition, he is an Honorary Fellow of 6 radiology societies in Europe and Asia. He serves on a multitude of departmental, hospital/medical school, and national committees. He has served on editorial boards and as a manuscript reviewer for 18 leading journals including AJR, Radiology, and RadioGraphics. More than 150 clinical fellows and 400 international research fellows, from over 20 countries throughout the world, have received one-on-one training through his fellowship programs. Amazingly, 70% of these fellows pursued academic careers after their training. More than 1000 visitors have come to his base of operations, formerly known as “The Bone Pit”, and now aptly dubbed "The Bone Palace." I had the honor of gifting Dr. Resnick some #PinkSocks at RSNA 2106.

"Early detection of breast cancer saves lives, one of the great accomplishments of cancer research during the past forty years." - László Tabár​, MD, FACR (Hon) We are honored to have László Tabár one of the world's foremost breast imaging authorities join us at Imaging in Israel in June, 2017. Dr. László Tabár is a visionary physician, researcher, and educator who has contributed significantly in the worldwide fight against breast cancer. In a career spanning over 40 years, he has worked tirelessly to reduce or eliminate suffering and death from the disease. Through his company, Mammography Education, Inc, he has also been the course director and principal lecturer of more than 300 mammography courses on 6 continents. As a clinician, he has applied his expertise to the interpretation of well over one million mammograms. His pioneering research has laid the foundation for early detection through modern mammographic screening. A consummate educator, Dr. Tabár is responsible for the mentoring of tens of thousands of breast imagers, surgeons and pathologists worldwide. His influence is felt on every continent and there can be no doubt that his work as researcher and educator has saved the lives of hundreds of thousands of women. Dr. Tabár is the recipient of numerous awards including the Terry Fox Award from the British Columbia Medical Association for contributions to cancer research, the Gold Medal from the Society of Breast Imaging, American Cancer Society's Distinguished Service Award, the IMPACT Award for Lifetime Achievement in the Fight Against Breast Cancer by the National Consortium of Breast Care Centers, the Pathfinder Award by the American Society of Breast Disease, and the first Alexander Margulis Award for Scientific Excellence from the Radiological Society of North America (RSNA) in 2012. Click here to see Dr. Tabár's interesting cases on the Global Radiology CME blog

"My passion is to favorably change the standard of care in a short amount of time through innovation." - Neil Rofsky, MD Neil Rofsky noted body imager from Texas will be joining the Global Radiology CME team in Jerusalem. Dr Rofsky is at the forefront of Body MRI research and will be teaming up with other radiology luminaries including László Tabár and Donald Resnick to deliver state of the art education to the attendees of Imaging in Israel - 2017. Neil Rofsky, M.D., is Professor and Chair of UT Southwestern’s Department of Radiology and the Effie and Wofford Cain Distinguished Chair in Diagnostic Imaging. Dr. Rofsky also serves as Co-Director of Translational Research for the Advanced Imaging Research Center (AIRC), a collaboration of UT Southwestern and the University of Texas at Dallas. As Chair of Radiology, he also leads efforts to rapidly bring the benefits of new technologies, including some developed at the AIRC, into clinical practice. A native of New York, Dr. Rofsky received his bachelor’s degree in biochemistry from the University of Maryland and his medical degree from New York Medical College. He then completed an internship in internal medicine at Middlesex University Hospital; a fellowship in nuclear medicine at the University of Utah Medical Center; a residency in radiology at the New York University Medical Center; and fellowships in abdominal imaging and magnetic resonance imaging at New York University Medical Center, where he was mentored by Morton Bosniak, Alec Megibow, and Jeffrey Weinreb. Before joining the faculty of UT Southwestern, Dr. Rofsky served as Chief of MRI at Beth Israel Deaconess Medical Center, Boston, and as Professor of Radiology at Harvard Medical School. Dr. Rofsky concentrates his research on translating innovations in magnetic resonance imaging (MRI) and spectroscopy into clinical practice. His current studies emphasize developing MRI techniques to improve detection and evaluation of prostate cancer and to better guide treatment. In his research, Dr. Rofsky seeks to apply MRI techniques such as arterial spin labeling (ASL) to measure blood flow in prostate and renal cell carcinomas. Since blood flow can reflect the viability of a tumor, these measurements can offer valuable insights into the potential aggressiveness of tumors and the effectiveness of treatments. Dr. Rofsky and his collaborators have also pioneered the use of rapid contrast-agent-enhanced three-dimensional diagnostic imaging of the abdomen. Such rapid imaging is important because it enables clinicians to obtain high-resolution 3-D images during the brief time that a patient can hold a single breath, reducing the artifacts from respiratory and other motions. Dr. Rofsky serves as an active member of the Board of Trustees of the Society of Computed Body Tomography and Magnetic Resonance (SCBTMR) and recently finished serving on the Board of Trustees of the International Society for Magnetic Resonance in Medicine (ISMRM). He has authored more than 150 peer-reviewed publications, several textbooks, and presents regularly at such medical societies as the Radiological Society of North America, the ISMRM and the SCBTMR. Just recently he delivered a plenary lecture to the ISMRM entitled, The Evolution of the MR Biomarker. Trained as a classical musician, Dr. Rofsky is an oboist who appreciates the art and science of shaping the instrument’s reeds, which give it its unique sound. He also enjoys playing guitar, including numerous acoustic and electric instruments, and is the proud owner of a Steinway Model A Grand Piano built in 1884.

Philippe Grenier, MD Chairman of the Department of Diagnostic Radiology at the Hôpital Pitié-Salpêtrière - Paris, France | Past President of The Fleischner Society, Past President of The European Society of Thoracic Imaging, and General Secretary of the Société Française de Radiologie Dr. Grenier will be speaking at Imaging in Israel - 2017 on: The radiological approach to indeterminate pulmonary nodules Smoking-related interstitial lung diseases CT phenotyping of COPD Philippe Grenier, a native of Paris, France, received his medical degree from the school of medicine at the University of Paris in 1972. He then completed a residency in diagnostic radiology at the Assistance Publique – Hôpitaux de Paris and a fellowship in the Department of Radiology of the Hôpital Beaujon, Faculté de Médecine Xavier Bichat. Upon completion of his fellowship in 1982, Dr. Grenier remained at Faculté de Médecine Xavier Bichat as an associate professor of radiology. From there, he went on to the Faculté de Médecine de Bobigny as professor of radiology in 1988. The following year he accepted his present position as professor of radiology with the Faculté de Médecine Pitié-Salpêtrière, Université Pierre et Marie Curie, where he served as vice-president of the university from 1998 to 2001. Since 1989, he has been chairman of the Department of Diagnostic Radiology at the Hôpital Pitié-Salpêtrière in Paris. A pioneer in the diagnosis of chronic airway disease and chronic diffuse infiltrative lung disease using high-resolution CT, Dr. Grenier is currently contributing to the evaluation of chest disease with multislice CT. A respected expert in chest imaging and respiratory disease, Dr. Grenier is author or coauthor of 175 peer-reviewed articles, 57 books or book chapters. He has contributed to more than 400 scientific presentations and exhibits at national and international congresses. He is currently a member of the editorial boards for European Radiology, Journal of Thoracic Imaging and Academic Radiology. In addition Dr. Grenier reviews for several national and international scientific journals on medical imaging and respiratory diseases, amongst them European Respiratory Journal, Investigative Radiology, Journal de Radiologie, New England Journal of Medicine, Thorax, and Radiology, for which he received an 'Editor’s recognition award for reviewing with distinction in 2004. Dr. Grenier has obtained 18 grants for research and several awards for scientific exhibitions and outstanding scientific research from international societies including the Radiological Society of North America and the European Congress of Radiology (2002, 2004, 2005). He has given invited lectures at more than one hundred international scientific meetings. Dr. Grenier is an honorary member of the Swedish Society of Medical Radiology, the Japan Radiological Society, the Radiological Society of North America, the Société Canadienne Française de Radiologie, the Austrian Society of Radiology, the Italian Society of Radiology, and he is also Honorary Fellow of the Royal College of Radiologists. Furthermore, he is a founding member of the Société d'Imagerie Thoracique and the European Society of Thoracic Imaging. Dr. Grenier has been actively involved in the organisation of the European Congress of Radiology since 1991. He was president of ECR 2002 and the chairman of the ECR Executive Committee in 2003. He has served as chairman of the EAR Committee for Subspecialties (1998-1999) and the EAR Education Committee (2002-2005). In 2003 Dr. Grenier was president of the prestigious Fleischner Society, a group in which he was elected a member more than 15 years ago. He has been President of the European Society of Thoracic Imaging, and has been General Secretary of the Société Française de Radiologie. In recognition of his exceptional achievements in radiology, particularly in Thoracic Imaging, Dr. Philippe Grenier was awarded the 2007 Gold Medal of the European Congress of Radiology and the European Association of Radiology.

You can add hyperlinks to reports that a referring physician can click on in the report module in PACS or Vue Motion. It will open the image that was marked. You can also add key images directly to the report so the referring physician can see the image in question. Thanks to Renaissance Imaging Medical Associates IT department for the images below. Here is how to do it: You can also Auto bookmark every measurement so they are available to you on your right click during reporting. Go to Graphics and click on the A with a Star. Now all measurements are bookmarked. You will still need to place them in your report and you won't be able to right click and create bookmark---since it already set to do so. Related posts: How To Add Critical Results Reporting to Your Carestream Reports Kevin Rice, MD is the president of Global Radiology CME Dr. Rice serves as the Chair of the Radiology Department of Valley Presbyterian Hospital in Los Angeles, California and is the Chief Compliance Officer of Renaissance Imaging Medical Associates. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015 Dr. Rice launched Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. Follow Dr. Rice on Twitter @KevinRiceMD All posts by Kevin M. Rice, MD

At RSNA 2015 and recently on Twitter, there has been an abundance of dialogue about radiologists getting "out of the darkness, and into the light" by notable Twitter enthusiasts and health care leaders such as @CancerGeek (Andy DeLaO), @nxtstop1 (Bernadette Keefe MD), @Jim_Rawson_MD and @KristaKotrla. Watch this video to see our own Dr. Rice talking with one of his his patients about his condition. Nicholas presented to the hospital with jaundice and weight loss; and Dr. Rice did a CT guided biopsy that determined the diagnosis of pancreatic cancer. Nicholas and his family were devastated, but Dr. Rice later performed a novel procedure that gave Nicholas what he describes as a "second chance". Listen to Nicholas's incredible story and see how Dr. Rice is one of the #HumansofRadiology. Related articles: Figure 1 Features Dr. Kevin Rice Dr. Kevin Rice: Semifinalist for 2016 AuntMinnie.com's Most Effective Radiology Educator All posts by Kevin Rice, MD

We are pleased to announce Global Radiology CME's Kevin Rice, MD was featured as a Figure 1 on 1 Fellow on April 29, 2016. Dr. Kevin Rice, a radiologist at Renaissance Imaging Medical Associates and Chair of Radiology at Valley Presbyterian Hospital in Los Angeles, California is one of only 5 radiologists from around the world to be a participant in the Q&A format on the Figure 1 platform. Dr. Rice's posts on Figure 1 have had several hundreds of thousands of views. Dr. Rice "loves posting cases on Fig. 1, as there are so many participants from all over the world. The varied background of everyone also allows for a multitude of perspectives in the discussions." Here are some of Dr. Rice's answers questions on topics as broad as artificial intelligence, how to explain radiology to patients, and advice to a new resident in interventional radiology. "I think artificial intelligence and machine learning are in their infancy, and will propel radiology (and medicine in general) forward in the future in ways we can not yet imagine." "I always explain things in layperson's terms. There is no sense using jargon that patients do not understand. If I am doing an interventional procedure, I often draw a diagram or show the patient a sample implantable device such as an IVC filter, or Port-a-Cath." "1. Always stay focused on your patients and treat them the same way you would want to be treated. 2. Learn as much as you can while in training - you are only in the formal training program for a short time. 3. Never stop learning - technology and our understanding of disease is constantly and rapidly evolving. " With more than 1 million top healthcare professionals on the app and over 1 billion page views, Figure 1 is described as the Instagram for doctors and healthcare professionals. First launched in 2013, the app allows users to share images of their toughest medical cases with other specialists around the world. Beyond seeking diagnoses from other medical professionals, the app is also being used to share interesting cases as a way to spread knowledge of new procedures, techniques or technology. Dr. Rice serves as the Chair of the Radiology Department of Valley Presbyterian Hospital in Los Angeles, California and is a radiologist with Renaissance Imaging Medical Associates. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA and writing the popular Xray of the Week for radiology social media. In 2015 Dr. Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" award for the Most Effective Radiology Educator. Dr. Rice is on Twitter, posting what matters to radiologists @KevinRiceMD All posts by Kevin Rice, MD Related articles: Dr. Kevin Rice: Semifinalist for 2016 AuntMinnie.com's Most Effective Radiology Educator Kevin Rice, MD - One of the #HumansOfRadiology

Right Breast Mass in 24F • Xray of the Week 2017 • Week #6 This 24 year old woman presented with a self-detected hard mass in the upper inner quadrant of her right breast. Her paternal grandmother had breast cancer at age 34 and died of the disease at age 54. Clinical breast examination confirmed the presence of a freely mobile hard tumor with irregular borders. No skin changes or discharge were present. The axillary lymph nodes were normal by palpation. What unusual type of breast mass could this be in this young lady? Figure 1. Bilateral mammogram shows a high density mass with indistinct margins in the right breast centrally. The metal BB marker indicates it is palpable. The left breast is normal. Figure 2. Left image: MLO mammogram shows a high density mass with indistinct margins in the right breast centrally. The metal BB marker indicates it is palpable. Right image: Magnification mammogram shows the mass with indistinct margins and associated grouped fine pleomorphic microcalcifications and possible spiculation. Figure 3: Ultrasound images show a hypoechoic right breast nodule with distended ducts, some of which having cystic dilatation. Figure 4: A,B. Axial MRI with contrast images show bilateral considerable background contrast enhancement. Left breast: normal MRI finding. Right breast: 4 cm deep to the nipple at 2:00, there is a 2.2 x 1.8 cm triangle shaped heterogeneous non-mass enhancement, suspicious for in situ or/and small invasive cancer focus. C,D. Sagittal MRI with contrast. No pathologic lymph nodes are seen in the axilla. MRI images courtesy of Andreas Adam, MD Figure 5: Ultrasound images show biopsy of the mass. Histology was hyperplastic breast change, most probably Juvenile Papillomatosis (Swiss Cheese Disease) of the Breast. No signs of malignancy. Due to the suspicious appearance on mammography and MRI, ultrasound biopsy was performed [Fig.5] followed by excision of the mass. Pathology was juvenile papillomatosis (Swiss cheese disease) of the breast. Figure 6: Specimen radiograph of excisional biopsy with associated large section histology. There is no invasive component. Histology images are courtesy of Tibor Tot, MD PhD - Associate Professor, Department of Pathology and Clinical Cytology, Central Hospital Falun, Falun, Sweden. Figure 7: A. Histology demonstrated a 25 x 20 mm mass with the appearance of Swiss cheese disease (Juvenile papillomatosis). B. Multiple benign cysts within the stroma. C. Multiple benign papillomas with florid epithelial hyperplasia. A central papilloma with sclerotic stroma gives the impression of a stellate mass; however, there is no histologic evidence of malignancy. D. Actual Swiss cheese. Histology images are courtesy of Tibor Tot, MD PhD - Associate Professor, Department of Pathology and Clinical Cytology, Central Hospital Falun, Falun, Sweden Discussion Juvenile papillomatosis is a rare benign proliferative breast process which occurs in women with a mean age of 19-23 and is rare over age 40 [1-6]. On histology the lesion demonstrates papillary epithelial hyperplasia within the small ducts and lobules [1-9]. Numerous cysts and dilated ducts are present, separated by areas of dense stroma, which results in the characteristic “Swiss cheese” appearance [9] [Figs. 6-7]. Juvenile papillomatosis occasionally may be associated with severe atypia or focal epithelial necrosis, features which are considered pre-malignant in older women [9]. Clinically, juvenile papillomatosis has benign findings with a firm, mobile well-circumscribed mass in a young patient. As in this case, mammography may demonstrate a spiculated mass with microcalcifications [Figs. 1-2]. Ultrasound typically shows a heterogeneous mass with small cystic regions, which correspond to the small cysts seen histologically [8-10] [Figs. 3,5]. According to a case report, MRI demonstrated a lobulated mass which was low in signal intensity on T1-weighted images and showed marked contrast enhancement. In the dynamic sequence the lesion showed a benign enhancement profile. Multiple small internal cysts were best shown on the T2 weighted images [3] [Fig. 4]. As with the patient in this case, juvenile papillomatosis is a marker for familial breast cancer. Moreover, patients diagnosed with the disease are at higher risk for breast cancer, especially if there is bilateral or recurrent juvenile papillomatosis or there is a family history of breast cancer [8]. Treatment is wide surgical excision [Figs. 8-10]. In cases such as this, the radiologist plays a very important role in the workup and diagnosis. During the evaluation of this 24 year old patient, Dr. Tabár emphasized that although there was a suspicious enhancement pattern on MRI, the ultrasound demonstrated very benign features with small cysts and dilated ducts and no malignant features whatsoever. Since juvenile papillomatosis represents actively proliferating hyperplastic breast epithelial tissue, it is not surprising to find that it enhances on MRI. A malignant breast tumor would not have cystic changes and proliferating ducts within the tumor on ultrasound. There are 2 types of hyperplastic breast change that would have this ultrasound appearance- radial scar which is usually not palpable, and juvenile papillomatosis (Swiss cheese disease) which is palpable in most cases. Other breast imaging cases on Global Radiology CME: Invasive Ductal Carcinoma of the Breast in 27 Year Old Phyllodes Tumor Medullary Breast Cancer Breast Hemangioma Radial Scars and Invasive Breast Cancer References: 1. Kaneda HJ, Mack J, Kasales CJ, et al. Pediatric and Adolescent Breast Masses: A Review of Pathophysiology, Imaging, Diagnosis, and Treatment. American Journal of Roentgenology. 2013;200: W204-W212. 2 Batori M, Gallinaro LS, D'urso A et-al. Papillomatosis and breast cancer: a case report and a review of the literature. Eur Rev Med Pharmacol Sci. 4 (4): 99-103. 3. Mussurakis S, Carleton PJ, Turnbull LW. Case report: MR imaging of juvenile papillomatosis of the breast. Br J Radiol. 1996;69 (825): 867-70. 4. Chung EM, Cube R, Hall GJ et-al. From the archives of the AFIP: breast masses in children and adolescents: radiologic-pathologic correlation. Radiographics. 29 (3): 907-31. 5. Sabate JM, Clotet M, Torrubia S et-al. Radiologic evaluation of breast disorders related to pregnancy and lactation. Radiographics. 2007;27 Suppl 1 : S101-24. 6. Kersschot EA, Hermans ME, Pauwels C et-al. Juvenile papillomatosis of the breast: sonographic appearance. Radiology. 1988;169 (3): 631-3. 7. Rosen PP, Cantrell B, Mullen DL et-al. Juvenile papillomatosis (Swiss cheese disease) of the breast. Am. J. Surg. Pathol. 1980;4 (1): 3-12. 8. Rosen PP, Holmes G, Lesser ML et-al. Juvenile papillomatosis and breast carcinoma. Cancer. 1985;55 (6): 1345-52. 9. Rosen PP, Kimmel M. Juvenile papillomatosis of the breast. A follow-up study of 41 patients having biopsies before 1979. Am. J. Clin. Pathol. 1990;93 (5): 599-603. 10. Al sarakbi W, Worku D, Escobar PF et-al. Breast papillomas: current management with a focus on a new diagnostic and therapeutic modality. Int Semin Surg Oncol. 2006;3 : 1 László Tabár, MD, FACR (Hon) the Professor Emeritus of Radiology Uppsala University, Faculty of Medicine, Sweden and the Medical Director Emeritus of the Department of Mammography, Falun Central Hospital, Sweden. Through his company, Mammography Education, Inc, he has also been the course director and principal lecturer at more than 300 mammography courses on 6 continents. His pioneering research has laid the foundation for early detection through modern mammographic screening. Dr. Tabár is the recipient of numerous awards including the Gold Medal from the Society of Breast Imaging, American Cancer Society's Distinguished Service Award, and the first Alexander Margulis Award for Scientific Excellence from the Radiological Society of North America (RSNA). Dr. Tabár will be sharing his vast knowledge of breast imaging at Imaging in Israel - 2017. Kevin M. Rice, MD is the President of Global Radiology CME Dr. Rice serves as the Chair of the Radiology Department of Valley Presbyterian Hospital in Los Angeles, California and is a radiologist with Renaissance Imaging Medical Associates. Dr. Rice has made several media appearances and as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015 Dr. Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" award for the Most Effective Radiology Educator. Follow Dr. Rice on Twitter @KevinRiceMD All Posts by Kevin M. Rice, MD All Posts by László Tabár, MD All Breast Imaging Posts

Abdominal Pain and Distension • Xray of the Week 2016 • Week #51 An 83 year old female with multiple comorbidities presented to the Emergency Department with abdominal pain, distention, and altered mental status. What is the diagnosis? Figure 1. Sagittal (A) and axial (B) contrast enhanced CT. Figure 2. Sagittal (A) and axial (B) contrast enhanced CT of mesentero-axial gastric volvulus. Massively dilated stomach, herniating into the thoracic cavity via the gastroesophageal hiatus. The stomach descends into the abdominal cavity before herniating back intrathoracically and the duodenum finally descends intraabdominally with the remainder of the GI tract. Green arrow: GE junction Blue arrow: antrum. Discussion: Gastric volvulus is an uncommon cause of abdominal pain and may be a surgical emergency which requires prompt communication with the clinical team and treatment (1,2). The Borchardt triad of intractable retching, sudden epigastric abdominal pain and inability to pass a nasogastric tube (3) is classically described, but patients may also present with more chronic symptoms. Unlike the sigmoid colon and cecum, the stomach is an uncommon site for volvulus. There are two types of volvulus, organo-axial and mesentero-axial, which are differentiated based on the axis of rotation. Organo-axial volvulus represents an 180◦ twist along the cardiapyloric/long axis of the stomach with the greater curvature often displaced superior to the lesser curvature. This type is more common, representing approximately 2/3 of cases (1) of gastric volvulus, and commonly associated with hiatal hernias and traumatic events such as diaphragmatic rupture (4). With less than 180◦ of rotation, patients are usually asymptomatic and this should be termed organo-axial positioning of the stomach rather than volvulus. Although this may predispose to future volvulus, it is unclear if these patients require treatment. Mesentero-axial volvulus is a twist along the short axis of the stomach, along the mesenteric attachment (2). As seen in this case, the antrum presents above the gastroesophageal junction (Figs. 1 and 2). Although less common in the adult population (3), this tends to present with a more acute symptomatology. Due to the higher association with strangulation of the gastric blood supply, this is a surgical emergency. If diagnosed early, treatment may only require surgical repair. However, late diagnosis may result in gastric necrosis, necessitating a gastrectomy (1,3). References: 1. Peterson CM, Anderson JS, Hara AK, Carenza JW, Menias CO. Volvulus of the gastrointestinal tract: appearances at multimodality imaging. RadioGraphics 2009;29(5):1281–1293. 2. Menuck L. Plain film findings of gastric volvulus herniating into the chest. AJR Am J Roentgenol. 1976;126 (6): 1169-74. 3. Guniganti P, Bradenham CH, Raptis C et-al. CT of Gastric Emergencies. Radiographics. 2015;35 (7): 1909-2 4. Lee NK, Kim S, Jeon TY, Kim HS, Kim DH, Seo HI et al. Complications of congenital and developmental abnormalities of the gastrointestinal tract in adolescents and adults: evaluation with multimodality imaging. Radiographics 2010: 30(6):1489–1507
. Alexandra (Sasha) Roudenko, MD is originally from Siberia, Russia and grew up in New York City. After graduating magna cum laude from Barnard College - Columbia University as a chemistry major, she was invited to join the prestigious Phi Beta Kappa Society. She then received her MD degree from New York University School of Medicine. Dr. Roudenko is currently a third year radiology resident at Mount Sinai West - St. Luke's and has developed a passion for body imaging. She is particularly interested in body MRI and plans on pursuing the subspecialty throughout her career. In 2016, Dr. Roudenko was awarded a fellowship in the introduction to academic radiology program at ARRS. All posts by Sasha Roudenko, MD Kevin M. Rice, MD is president of Global Radiology CME and serves as the Chair of the Radiology Department of Valley Presbyterian Hospital in Los Angeles, California and is a radiologist with Renaissance Imaging Medical Associates. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. Dr. Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" award for the Most Effective Radiology Educator. Follow Dr. Rice on Twitter @KevinRiceMD All posts by Kevin M. Rice, MD Carol L Hilfer, MD is an assistant professor of Radiology at The Mount Sinai Hospital - Mount Sinai St. Luke's and Mount Sinai West

Chronic Heel Pain in 60F • Xray of the Week 2016 • Week #48 This 60 year old female has chronic heel pain and lateral heel numbness. What is the diagnosis? Figure 1A. Sagittal T1 weighted image demonstrates fatty atrophy of the abductor digiti minimi muscle (yellow arrow) consistent with chronic inferior calcaneal nerve (Baxter’s nerve) denervation. Figure 1B. Sagittal PD fat sat image showing severe plantar fasciosis, extensive partial tear (yellow arrow), spur, and reactive calcaneal osteitis. Figure 2A.. Coronal PD fat sat image showing fatty atrophy of the abductor digiti minimi muscle (yellow arrow) compared to the normal musculature (blue arrow). Figure 2B. Sagittal PD fat sat image showing plantar fasciosis with abnormal high signal in the calcaneal insertion of the plantar fascia (yellow arrow). Figure 2C. Axial T1 weighted image showing fatty atrophy with abnormal high signal in the abductor digiti minimi muscle (yellow arrow). Although often not recognized, Baxter neuropathy may be the elusive cause of heel pain in up to 20% of cases. The inferior calcaneal nerve which is known as Baxter nerve is almost always the first branch of the lateral plantar nerve and it provides motor innervation to the abductor digiti minimi, lateral half of the quadratus plantae, and flexor digitorum brevis muscles. The nerve provides sensation to the calcaneal periosteum, long plantar ligament, and adjacent vessels. Baxter neuropathy may be due to entrapment as the nerve passes between the deep fascia of the abductor hallucis muscle and the medial plantar margin of the quadratus plantae muscle. In this case more distal entrapment has occurred, due to plantar fascitis and a calcaneal spur as the nerve passes along the anterior aspect of the medial calcaneal tuberosity. Imaging with MR in the acute and subacute phases demonstrates edema of the abductor digiti minimi muscle with high signal on T2 weighted or STIR images. Chronic denervation leads to irreversible muscle atrophy with muscle belly volume loss and fatty replacement manifested as high signal on T1 weighted images. [Fig.1,2] Like most neuropathies, initial treatment is conservative with non-steroidal anti inflammatory drugs, padding and offloading of the entrapment site, steroid injection therapy, and physical therapy. Surgery with medial band plantar fascial release and inferior calcaneal nerve release may be necessary in refractory cases. References: 1. Donovan A et al. MR Imaging of Entrapment Neuropathies of the Lower Extremity Part 2. The Knee, Leg, Ankle, and Foot Radiographics 2010;30:1001-1019 2. Recht MP, Grooff P, Ilaslan H et-al. Selective atrophy of the abductor digiti quinti: an MRI study. AJR Am J Roentgenol. 2007;189 (3): W123-7. 3. Chundru U, Liebeskind A, Seidelmann F et-al. Plantar fasciitis and calcaneal spur formation are associated with abductor digiti minimi atrophy on MRI of the foot. Skeletal Radiol. 2008;37 (6): 505-10. 4. Dirim B, Resnick D, Ozenler NK. Bilateral Baxter's neuropathy secondary to plantar fasciitis. Med. Sci. Monit. 2010;16 (4): CS50-53. 5. Toye L. Baxter’s Nerve (First Branch of the Lateral Plantar Nerve) Impingement. http://radsource.us/baxters-nerve Accessed Nov 25,2016 6. Baxter DE. Release of the nerve to the abductor digiti minimi. In: Kitaoka HB, ed. Master techniques in orthopaedic surgery of the foot and ankle. Philadelphia, PA: Lippincott Williams and Wilkins; 2002: 359. Phillip Tirman, MD is the Medical Director of Musculoskeletal Imaging at the Renaissance Imaging Center in Westlake Village, California. A nationally recognized expert in the applications of MRI for evaluating MSK and spine disorders, Dr. Tirman is the co-author of three textbooks, including Shoulder Magnetic Resonance Imaging and Diagnostic Imaging: Orthopedics. He is also the author or co-author on over sixty original scientific articles published in the radiology and orthopedic literature. All posts by Phillip Tirman, MD Kevin M. Rice, MD is the President of Global Radiology CME Dr. Rice serves as the Chair of the Radiology Department of Valley Presbyterian Hospital in Los Angeles, California and is a radiologist with Renaissance Imaging Medical Associates. Dr. Rice has made several media appearances and as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015 Dr. Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" award for the Most Effective Radiology Educator. Follow Dr. Rice on Twitter @KevinRiceMD All Posts by Kevin M. Rice, MD