Ovarian tumors in children and adolescents: A series of 41 cases

ObjectivePictorial review with a detailed semiological analysis of ovarian tumors in children and adolescents to provide a relevant diagnostic approach.Patients and methodsRetrospective study (2001–2011) of 41 patients under the age of 15 who underwent surgery for an ovarian mass with a definite pathological diagnosis.ResultsSixty-two percent of the lesions were benign, 33% were malignant and 5% were borderline. Germ cell tumors were most frequent (77.5%), followed by sex cord stromal tumors (12.5%) and epithelial tumors (7.5%). Malignant tumors were more frequent in children between 0 and 2 years old. On imaging, calcifications and fat were specific for germ cell tumors; the presence of a mural nodule was predictive of a mature teratoma (P < 0.001). Predictive factors for malignancy were clinical, including abdominal distension (P < 0.01) or a palpable mass (P = 0.05), biological, including increased hCG and/or AFP levels (P < 0.001) and radiological, including tumors larger than 12 cm (P < 0.05), tumoral hypervascularity (P < 0.01) and voluminous ascites (P < 0.01).ConclusionThis semiological analysis confirms the role of imaging in diagnosing the etiology of ovarian lesions in children and adolescents and emphasizes the importance identifying tumoral hypervascularity, which, in addition to classic criteria, is highly predictive of malignancy.     

MRI vacuum-assisted breast biopsies

The indications, technique, results and limitations of MRI vacuum-assisted breast biopsies are discussed from a review of the literature. This was initially a home-grown technique and its development was slowed down by several factors. As a result of major technical advances, it has become a reliable and very consistent procedure with a low rate of underestimation. It is now an undisputed technique when suspicious MRI enhancement is seen with no corresponding mammography or ultrasound features.     

Transarterial chemoembolisation for breast cancer with liver metastasis: A systematic review

BackgroundThere is limited data on the impact of transarterial chemoembolisation (TACE) on survival in patients of breast cancer with liver metastasis (BCLM).MethodsA systematic review was conducted to assess TACE effect on BCLM patients. A search for clinical studies published since 1/1/2000 to 1/1/2017 was performed. Survival data from all studies were extracted to evaluate the efficacy of TACE, including overall survival, disease free survival and response rate. Toxic side effects data were also extracted to assess the safety of TACE.ResultsA total of 10 studies with 519 BCLM patients were identified. 78.0% patients were treated with TACE, 9.9% were treated with TACE plus systematic chemotherapy and 12.1% were treated with systematic chemotherapy alone. Pooled median overall survival of patients who received TACE ranged from 7.3 to 47.0 months, median disease free survival ranged from 2.9 to 17.0 months and response rates ranged from 7.0 to 73.5%. Pooled Grade 3 and 4 side effects (blood toxicities, liver toxicity and post-embolization syndrome) ranged from 0.0 to 17.4%.ConclusionsTACE is one of an effective treatment for BCLM and whether a specific patient is appropriate to receive TACE depends on a multiple disciplinary team discussion.     

Clinical abnormalities of the nipple-areola complex: The role of imaging

Clinical examination of the nipple is part of normal breast screening procedures. Abnormal processes of benign or malignant nature may be reflected by erythema, erosion, swelling or acquired inversion. In patients presenting with a persistent unilateral nipple lesion, it is advisable to collect a sample to exclude Paget's disease of the nipple, a rare form of ductal carcinoma in situ (DCIS). Imaging should be performed to detect breast cancer, which is found in more than 80% of cases, and determine its possible multifocal nature. Breast MRI is indicated if breast-conserving surgery is planned. The main differential diagnoses are erosive adenomatosis and eczema of the nipple. Acquired inverted nipple is generally of inflammatory origin. It is usually diagnosed by conventional breast examination but breast MRI can be helpful when in doubt about possible underlying neoplasia.     

Urinary endometriosis: MR Imaging appearance with surgical and histological correlations

ObjectivesThe goals of the study were to describe the MR imaging features of endometriosis of the urinary tract and identify those that suggest intrinsic involvement of ureteric wall.Materials and methodsThirty-five women with proven urinary tract endometriosis and who had preoperative MR imaging between 2001 and 2011 were included retrospectively. MR images were intrepreted by one junior and one senior radiologists. To characterize the intrinsic parietal involvement, the ureteric circumference involved by the lesion of endometriosis was noted.ResultsThirty-eight ureteric and 13 bladder lesions were analyzed. They were found in association in nine women. Ureteric lesions were bilateral in seven women. Of the 38 ureteric lesions, 27 were extrinsic and 11 intrinsic at histopathological analysis. Sixteen women with extrinsic lesions and 10 with intrinsic ones were correctly identified on MR imaging. When the ureter was included less than 360° in the lesion, extrinsic involvement was confirmed in 80% of cases.ConclusionMR imaging appears to be more sensitive (91%vs 82%) but less specific (59% vs 67%) than surgery for the diagnosis of intrinsic form of ureteric location.     

Dose reduction with iterative reconstruction: Optimization of CT protocols in clinical practice

ObjectivesTo create an adaptable and global approach for optimizing MDCT protocols by evaluating the influence of acquisition parameters and Iterative Reconstruction (IR) on dose reduction and image quality.Materials and methodsMDCT acquisitions were performed on quality image phantom by varying kVp, mAs, and pitch for the same collimation. The raw data were reconstructed by FBP and Sinogram Affirmed Iterative Reconstruction (SAFIRE) with different reconstruction kernel and thickness. A total of 4032 combinations of parameters were obtained. Indices of quality image (image noise, NCT, CNR, SNR, NPS and MTF) were analyzed. We developed a software in order to facilitate the optimization between dose reduction and image quality. Its outcomes were verified on an adult anthropomorphic phantom.ResultsDose reduction resulted in the increase of image noise and the decrease of SNR and CNR. The use of IR improved these indices for the same dose without affecting NCT and MTF. The image validation was performed by the anthropomorphic phantom. The software proposed combinations of parameters to reduce doses while keeping indices of the image quality adequate. We observed a CTDIvol reduction between −44% and −83% as compared to the French diagnostic reference levels (DRL) for different anatomical localization.ConclusionThe software developed in this study may help radiologists in selecting adequate combinations of parameters that allows to obtain an appropriate image with dose reduction.     

Smoking and FGFR2 rs2981582 variant independently modulate male breast cancer survival: A population-based study in Tuscany,Italy

AimMale breast cancer (MBC) is a rare disease and recommendations for its clinical management are often extrapolated from those for female breast cancer, even if breast cancer (BC) has different characteristics in the two sexes. The purpose of this study was to assess the influence of several individual characteristics including clinico-pathological, lifestyle and genetic factors on overall survival (OS) of a relatively large and well characterized population-based series of 166 MBCs enrolled in Tuscany.MethodsWe genotyped MBC cases at BRCA1/2 genes and at 9 candidate BC susceptibility SNPs. Kaplan-Meier method and multivariate Cox regression, adjusted for several individual characteristics were used. To reduce a possible selection bias related to the interval between diagnosis and enrolment of MBC cases into the study, we used the date of blood donation as the date of the start of observation for survival analysis.ResultsOnly smoking habits had a significant effect on OS at 10 years (for current smokers, HR: 3.34; 95% CI 1.45–7.68; p = 0.004), while lymph node status fell short of reaching statistical significance (for pN positive, HR: 2.07; 95% CI 0.93–4.55; p = 0.07). In the same multivariate analysis we found a significantly higher OS in cases with FGFR2 rs2981582 variant in the dominant transmission model (HR: 0.29; 95% CI: 0.13–0.62; p = 0.028). A sensitivity analysis with left truncation showed similar results.ConclusionsOur results may contribute to shed light on factors influencing MBC survival suggesting an important role for cigarette smoking and FGFR2 rs2981582 variant, and provide clues for better patient management.     

Radioembolization with yttrium-90 microspheres work up: Practical approach and literature review

Radioembolization (RE) is a selective internal radiotherapy technique in which yttrium-90 blended microspheres are infused through the hepatic arteries. It is based on the fact that primary and secondary hepatic tumors are vascularized mostly by arterial blood flow whereas healthy hepatocytes obtain their blood supply mostly from the portal network. This enables high radiation doses to be delivered, sparing the surrounding non-malignant liver parenchyma. Most of the complications are caused by unexpected particles passing into the gastrointestinal tract through branches originating from the main hepatic arterial supply. Knowledge of this hepatic arterial network and of its variations and the technical considerations this raises are required in preparation for treatment. This work describes the specific anatomical features and techniques for this anatomy through recent literature illustrated by cases from our own experience.     

Mucormycosis attributed mortality: A seven-year review of surgical and medical management

IntroductionHistorically, mucormycosis infections have been associated with high mortality. The purpose of this study was to determine the incidence, associated mortality, and management strategies of mucormycosis in a major burn center.MethodsA retrospective review was performed via obtaining all patients with mucormycosis admitted from January 2003 to November 2009 at our adult burn center was performed obtaining demographic data relevant to fungal burn wound infection or colonization.ResultsThe incidence of mucormycosis at our facility was 4.9 per 1000 admissions; specifically, 11 military casualties and one civilian were diagnosed with mucormycosis. The median percentage Total Body Surface Area (TBSA) burned, 11 patients, or open wound, one patient, was 60 (IQR, 54.1–80.0), and the incidence of documented inhalation injury was 66.7% (8 of 12). Ten patients had surgical amputations. A median of eight days (IQR, 3.5–74.5) elapsed from diagnosis of mucormycosis until death in the 11 patients who expired. The overall mortality was 92%; however, autopsy attributed mucormycosis mortality was 54.5% (6 of 11) with all six patients having invasive mucormycosis.ConclusionAggressive surgical intervention should be undertaken for invasive mucormycosis; additionally, implementation of standardized protocols for patients with large soft tissue injuries may mitigate mucormycosis superimposition.     

Radiography of scoliosis: Comparative dose levels and image quality between a dynamic flat-panel detector and a slot-scanning device (EOS system)

PurposeTo compare radiation dose and image quality between a slot-scanning system (SSS) and a dynamic flat-panel detector (DFD) in assessing scoliosis in children.MethodsAn experimental study was first performed with a phantom to assess the quality of each device. The clinical part included a prospective observational dosimetric and qualitative comparative study with acquisition of whole-spine X-ray: SSS (31 children), DFD (26 children). Institutional review board approval and informed consent were obtained. Dosimetric statistical analysis was performed from dose area product (DAP) and entrance skin dose measured by thermo-luminescent dosimeters localized in the cervical, thoracic and sacral areas. Assessment of the diagnostic quality (phantom and clinical) was realized by independent evaluation by 3 observers, using statistical analysis of quality score and inter-observer reproducibility.ResultsDAP was equivalent with the 2 systems. Entrance skin dose was significantly higher with DFD in thoracic and pelvic regions (P < 0.05). Image quality scores of the SSS were significantly better than DFD for a majority of criteria, in both phantom and clinical evaluations.ConclusionFor scoliosis evaluation, the SSS, compared to the DFD system, offers enhanced image quality while reducing the entrance skin dose in the most radiosensitive areas.     

Biological therapies in breast cancer: Common toxicities and management strategies

In recent years, a number of new molecules – commonly known as biological therapies – have been approved or are in late stages of regulatory evaluation for the treatment of advanced breast cancer. These innovative compounds have improved treatment efficacy and have probably contributed to the increase in survival length observed in some breast cancer subtypes. However, these agents are not deprived of toxicity, which can impair quality of life and may occasionally be life-threatening. In this article, we reviewed the most common toxicities associated with these drugs and provided a number of practical recommendations on their optimal clinical management.     

An evaluation of resource utilisation of single stage porcine acellular dermal matrix assisted breast reconstruction: A comparative study

ObjectivesTo evaluate resource utilization of single stage porcine acellular dermal matrix (ADM) assisted breast reconstruction compared with tissue expander (TE), latissimus dorsi flap and implant (LD/I) and latissimus dorsi flap and TE (LD/TE) reconstructive techniques.Materials and methodsClinical data was collected for length of stay, operative time, additional hospitalisations and operative procedures, and outpatient appointments for 101 patients undergoing unilateral implant based breast reconstruction. Resources utilised by ADM (Strattice Reconstructive Tissue Matrix™) patients were analysed and compared to the resource usage of traditional techniques.Results25 patients undergoing single stage ADM (ADM/I) were compared with 27 having TE, 32 having LD/I and 17 having LD/TE reconstructions. Follow up was 24 months. Compared to TE, ADM/I had similar length of stay and operative time, lower rate and number of additional procedures, fewer, shorter re-admissions (p < 0.05) and fewer appointments (p < 0.05). Compared to LD/TE, ADM/I had shorter length of stay and operative time (p < 0.05), lower rate and number of additional procedures, fewer, shorter re-admissions (p < 0.05) and fewer appointments (p < 0.05). Compared to LD/I, ADM/I had shorter length of stay (p < 0.05) and operative time (p < 0.05), fewer appointments, similar rate and number of additional procedures but required more and longer re-admissions.ConclusionIn our experience, unilateral single stage ADM/I was associated with fewer resources utilised in comparison with two staged TE and LD/TE reconstructions in both complication-free and complicated settings over a 24-month period, despite requiring aesthetic revision in 60.9% of patients. Compared to LD/I, resource utilisation was commensurate in complication-free and complicated settings.     

Psycho-oncological support for breast cancer patients: A brief overview of breast cancer services certification schemes and national health policies in Europe

Psycho-oncology addresses the psychological, social, behavioural, and ethical aspects of cancer. Identification and proper management of the patients' psychosocial needs, as well as the needs of their caregivers and family are essential for a person-centred concept of breast cancer care. The aim of this overview is to describe how psychosocial support in breast cancer is incorporated in cancer-related policy documents, such as national cancer plans and breast cancer care certification schemes.     

Clinical significance of fatty liver disease induced by tamoxifen and toremifene in breast cancer patients

Background and AimThe aim of this study was to identify the effect of selective estrogen receptor modulator (SERM) on non-alcoholic fatty liver disease (NAFLD) in Asian women.MethodsWe retrospectively evaluated fatty liver development and/or serum alanine aminotransferase (ALT) elevation during SERM treatment in 1061 women who were diagnosed and treated with breast cancer in 2005 at Asan Medical Center.Results45 of 618 SERM-treated patients with normal ALT at baseline experienced ALT elevation during SERM treatment. Among the 112 SERM-treated patients who underwent liver imaging test, fatty liver was observed in 47 and both fatty liver and ALT elevation developed in 16 of 102 SERM-treated patients with normal baseline ALT. The cumulative rates of ALT elevation (10.7 vs. 4.3%; P = 0.002), fatty liver (48.5 vs. 20.9%; P < 0.001), and both fatty liver and ALT elevation (17.7 vs. 7.1%; P = 0.02) at 60 months were significantly higher in the SERM group than non-SERM group. By multivariate analysis, SERM treatment increased the risk of ALT elevation (hazard ratio [HR], 2.20; P = 0.01), fatty liver development (HR, 3.59; P < 0.001), and both fatty liver and ALT elevation (HR, 4.98; P = 0.01). After discontinuation of SERM, elevated serum ALT normalized in 39 (92.9%) and there were no instances of liver-related death or progression to liver cirrhosis in patients who experienced fatty liver or ALT elevation.ConclusionsAlthough SERM treatment is significantly associated with NAFLD in Asian women, considering the tolerability and reversibility of NAFLD induced by SERM, it can be continued with liver function monitoring in relevant patients.     

Therapeutic strategies in male breast cancer: Clinical implications of chromosome 17 gene alterations and molecular subtypes

Male breast cancer (MBC) is a rare disease. To date, therapy is mainly based on studies and clinical experiences with breast cancer in women. Only little is known about molecular typing of MBC, particularly with regard to potential biological predictors for adjuvant therapy. In female breast cancer tumors with chromosome 17 centromere (CEP17) duplication, HER2 and/or Topoisomerase II alpha (Topo II-α) gene alterations have been suggested to be associated with poor prognosis and increased sensitivity to anthracycline-containing regimens.In a well characterized cohort of 96 primary invasive MBC, we studied CEP17, HER2 and Topo II-α alterations by fluorescence in-situ hybridization (FISH), and expression of hormone receptors (HR), HER2 and Ki67 by immunohistochemistry to define molecular subtypes. Tumor characteristics and follow-up data were available and correlated with molecular findings.HER2 amplification and Topo II-α amplification/deletion were exceptionally rare in MBC (6.3% and 3.1%, respectively). CEP17 polysomy were found in 9.4% of tumors. HER2, Topo II-α and CEP17 gene alterations were not correlated to patients outcome. 96.9% of our cases were HR positive. Triple negative tumors were found in only 3.1% of the cases. In nodal negative tumors luminal A subtypes were significantly associated with better overall survival.Our results provide evidence for a predominant male breast cancer phenotype, characterized by HR expression and a lack of HER2/Topo II-α alterations and CEP17 duplicates. Therefore, the impact of anthracycline sensitivity linked to HER2/Topo II-α alterations as found in female breast cancer has low clinical significance for this specific male breast cancer phenotype.     

Incidence of isolated local breast cancer recurrence and contralateral breast cancer: A systematic review

An increasing number of women is surviving breast cancer and due to that at risk of developing an isolated ipsilateral breast tumor recurrence (IBTR) or a contralateral breast cancer (CBC). Patients' main concern is cancer recurrence. Patient counseling on breast cancer recurrence is challenging. In order to provide healthcare professionals and patients more guidance, a systematic literature review of the incidence of isolated IBTR and CBC in women diagnosed with early invasive breast cancer was performed. Medline, EMBASE and the Cochrane Library were searched from 2000 until October 2015. Multicenter studies reporting an IBTR or CBC rate in curatively treated adult females diagnosed with invasive breast cancer were included. The initial search yielded 6998 potentially relevant articles. Twenty were eligible for inclusion, representing 25 recurrence incidence rates. Both isolated IBTR and CBC incidence rates steadily increased with the length of follow-up, indicating that IBTR and CBC occur even more than 15 years after diagnosis. The annual incidence rate of isolated IBTR and CBC in women diagnosed with an early invasive breast cancer was 0.6% (range: 0.4–1.1%) and 0.5% (range: 0.2–0.7%), respectively. Analyzed data were lacking information about important risk factors and given treatment with regard to the incidence of recurrence, which hampers the prediction of patient tailored recurrence risks. The presented rates are therefore the best available estimates of isolated IBTR and CBC annual incidence rates based on the current literature. Healthcare professionals could use these rates in their communication with patients diagnosed with early invasive breast cancer.     

Towards understanding ocular motility: III,IV and VI

The study of the ocular-motor nerves must be exhaustive from their source (nuclei in the brainstem) down to the effector muscles (orbit). Visual disturbances have to be analysed by differentiating between a decrease in visual acuity and ocular-motor disorders. Imaging tests are dominated by MRI, including fine slices and gadolinium injection. A study of the Circle of Willis vessels is often useful, and essential in the case of type III impairment. A further CT scan is essential for analysis of the foramina, base of the skull and orbital walls. Impairment of CN VI requires a CT scan of the apex of petrous. The study of the cavernous sinuses must be in-depth (T2 and T1 after gadolinium and elimination of fats) and always comparative. Impairment of CN III is often complex, difficult to identify precisely (complete or partial, with or without a pupil impairment, associated with other neurological signs) and requires a reasoned study based on anatomical, semiological and pathological knowledge. Other than tumour diseases, it is necessary to consider less well known malformative, ischemic and inflammatory aetiology.     

Accuracy of multi-detector computed tomographic angiography assisted by post-processing software for diagnosis atheromatous renal artery stenosis

PurposeTo compare the diagnostic performance of MDCTA versus renal angiography in the detection of > 50% renal artery stenosis in patients suspected of reno-vascular hypertension.Materials and methodsBetween January 2005 and January 2010, 92 MDCTA and renal arteriographies were retrospectively analysed. Renal angiographies were read by one interventional radiologist. Three blinded independent readers (two senior radiologists and one technician) scored MDCTA images using three different approaches. Reader 1 scored stenosis using only MPR and MIP. Reader 2 (technician) used only proprietary automatic arterial segmentation software. Reader 3 used the cited software, using manual diameter measurements.ResultsA total of 92 patients, (235 renal arteries) were assessed in which 48 significant stenosis were found by arteriography. Sensitivity, specificity, of MDCTA compared to renal arteriography were respectively per patient for reader 1: (88%; 80%); for reader 2: (58%; 80%); for reader 3: (96%; 90%) (P < .02).ConclusionWhen using automated vessel analysis software edited by a radiologist, MDCTA studies had a Sensibility/Specificity of 96%/90% to detect > 50% renal artery stenosis.     

Indication for resuscitative thoracotomy in thoracic injuries—Adherence to the ATLS guidelines. A forensic autopsy based evaluation

BackgroundThe appropriate indications for Resuscitative Thoracotomy (RT) are still debated in the literature and various guidelines have been proposed. This study aimed to evaluate whether Advanced Trauma Life Support (ATLS) guidelines for RT were applied correctly and to evaluate the proportion of deceased patients with potentially reversible thoracic lesions (PRTL).MethodsThe database at the Department of Forensic Medicine at Copenhagen University was queried for autopsy cases with thoracic lesions indicated by the SNOMED autopsy coding system. Patients were included if thoracic lesions were caused by a traumatic event with trauma team activation. Patient cases were blinded for any surgical intervention and evaluated independently by two reviewers for indications or contraindications for RT as determined by the ATLS guidelines. Second, autopsy reports were evaluated for the presence of PRTL.ResultsSixty-seven patients met the inclusion criteria. Two were excluded due to insufficient data. The overall agreement with guidelines was 86% and 77% for blunt and penetrating trauma, respectively. For patients submitted to RT the overall agreement with guidelines was 63% being 45% and 74% for blunt and penetrating trauma, respectively. For patients who did not undergo RT the agreement with guidelines was 100%. In all cases where RT was performed in agreement between guidelines and the clinical decision the autopsy reports showed PRTL in 16 (84%) patients. In cases of non-agreement PRTL were found in 9 (82%) patients.ConclusionsAgreement with ATLS guidelines for RT was 63% for intervention and 100% for non-intervention in deceased patients with thoracic trauma. Agreement was higher for penetrating trauma than for blunt trauma. The adherence to guidelines did not improve the ability to predict autopsy findings of PRTL. Although the study has methodical limitations it represents a novel approach to the evaluation of the clinical use of RT guidelines.