Frequency and characteristics of additionally detected ipsilateral breast lesions following recall at screening mammography

PurposeTo determine the frequency and outcome of additionally detected ipsilateral breast abnormalities following recall at screening mammography.Methods and materialsWe included a consecutive series of 130,338 screening mammograms obtained between January 1, 2014 and January 1, 2016. During 2-year follow-up, clinical data were collected of all recalls. Women with a bilateral recall (115) and women recalled for multiple lesions in one breast (165) were excluded from the analyses. Screening outcome parameters were determined for recalled women with or without evaluation of additional ipsilateral breast abnormalities following recall.ResultsA total of 3995 women were recalled (recall rate, 3.1%). In 258 (6.4%) of these women, another lesion was detected in the ipsilateral breast than the one for which she had been recalled. Biopsy was more frequently performed of additionally detected ipsilateral lesions than of recalled lesions (55.8% (144/258)) versus 39.7% (1375/3457), (p < 0.001)). The proportion of malignancy in recalled lesions and additionally detected lesions was comparable (21.5% (743/3457) versus 19.0% (49/258), p = 0.34). Of all 144 biopsies of additionally detected ipsilateral lesions, 9 revealed a synchronous tumour in addition to a malignant recalled lesion, and 33 biopsies revealed multicentric or multifocal tumours. In 5 women, the recalled lesion turned out to be benign, whereas the additional lesion in a different quadrant was malignant at biopsy. A total of 97 biopsies showed benign findings.ConclusionA substantial proportion of women are analyzed for additional ipsilateral breast lesions following recall. These lesions are more frequently biopsied than recalled lesions, but have a comparable probability of being malignant. The majority of additionally detected cancerous lesions are part of multifocal or multicentric malignancies.     

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.     

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.     

Correlation between MRI and biopsies under second look ultrasound

The term “second look” lesions in MRI refers to lesions detected by MRI that were not initially seen on mammography or ultrasound. The objectives of our study were to analyse the displacement of targets between MRI and ultrasound; to define discriminating BIRADS morphological criteria to predict benign or malignant character and better establish the indications of second look ultrasound and biopsy; and to analyse the agreement between ultrasound and MRI in terms of morphological criteria. A retrospective and monocentric review was performed of the records of consecutive patients with breast abnormalities (mass or non-mass) initially detected by MRI that were not initially seen on mammography or ultrasound. All patients with abnormalities found during the performance of second look ultrasound and biopsied were included in the study. All lesions were documented using the BIRADS lexicon for MRI and ultrasound. Of 100 included patients, 108 lesions were detected by MRI, found via second look ultrasound and biopsied between January 2008 and 2010. All of the included patients were followed-up for a variable period, from 2 to 5 years. Eighty-two upon 108 biopsied lesions (76%) were benign and 26/108 lesions (24%) were malignant. This study confirmed the switch from procubitus to decubitus essentially displaces the tumour in the antero-posterior direction. It showed that the risk factors were not reliable criteria for establishing an indication for second look ultrasound. This study also showed that circumscribed contours and a progressive enhancement curve (type I) for masses on MRI had the strongest negative predictive value of greater than 0.85. In ultrasound, the round or oval shape, circumscribed contours and the parallel orientation to the skin favoured benignity with a NPV of greater than 0.85. For masses, the study showed that the agreement in interpretation of the benign versus suspicious morphological criteria between the MRI and the ultrasound was very weak for the shape (Kappa = 0.09) and weak for the contours (Kappa = 0.23). Finally, the MRI overestimated the size of the targets compared to ultrasound (Student t-test, p = 0.0001). The performance of second look ultrasound has to be performed after the detection of an abdnormality on MRI even for lesion classified BIRADS 3. The biopsy indications must be wide with insertion of a clip and a control MRI. Only this control allows to stop the investigation if the biopsied lesion is benign.     

Computed tomography follow-up of acute portal vein thrombosis

PurposeTo assess the evolution of acute portal vein thrombosis by computed tomography (CT).Patients and methodsRetrospective single-centre study (2005–2011) including 23 patients who had an initial CT scan and a CT scan during the first year. The analysis compared the last CT scan available with that of the initial CT scan. Neoplastic thrombosis, extrinsic compressions and cavernomas were excluded. All patients received anticoagulant treatment.ResultsThe causes included: cirrhoses (n = 6), blood disorders (n = 4), locoregional inflammations and infections (n = 8), abdominal surgery (n = 1). The thrombosis was idiopathic in 4 cases. After a mean follow-up of 7.7 months, 7 patients (30%) benefited from a restitutio ad integrum of the portal system, a stable or partially regressive thrombosis was noted in 12 patients (52%) and an aggravation of the thrombosis was noted in 4 patients (18%). In the sub-group of portal vein thrombosis, repermeabilisation was noted in 37.5% of the patients (6/16) and 6 cavernomas developed.ConclusionCT monitoring helps follow the evolution of an acute portal vein thrombosis and demonstrates complete repermeabilisation of the portal vein in 30% of the patients.     

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.     

Is OSNA better than imprint cytology for intraoperative diagnosis of cancer involvement of axillary sentinel node in breast cancer?

ObjectiveThe study aim was to establish Sensitivity, Specificity, Positive Predictive Value, Negative Predictive Value (NPV), and Accuracy Values of both imprint cytology (IC) and the OSNA assay for intraoperative assessment of axillary sentinel node (SN) cancer involvement in breast cancer. Specifically, we wished to find out if true positive and false negative results of IC were associated to axillary lymphadenectomy (ALND). Also, we addressed a comparative cost analysis between techniques.Methods244 patients treated for breast cancer in the Breast Unit of Hospital Germans Trias i Pujol from 2011 to 2015 were prospectively included. A transversal, consecutive design was applied to assess IC compared to the reference test (OSNA). Inclusion criteria were: T1 and T2 tumors with negative nodes, both clinically and on ultrasound.ResultsSensitivity of IC for macrometastases was 70%. The NPV of IC for macrometastases was 95,75%. Accuracy of IC was 96,12%. In the comparative cost analysis, the release time of results for OSNA doubled that of IC and was associated with an increased cost of € 370.ConclusionsIC has been stated as a good technique for intraoperative cancer involvement SN with high sensitivity and NPV compared to the OSNA assay. It allows keeping the whole node tissue and thus the possibility of improved histopathological evaluation, which can be useful for adjuvant, and offers the advantage of being less time consuming. Cost analysis shows a higher cost for OSNA, which may exceed the benefit of sorting out false negatives from IC.     

Renal papillary carcinoma: CT and MRI features

PurposeTo describe the CT and MRI appearances of papillary renal cell carcinoma.Materials and methodsRetrospective study of 102 papillary carcinomas in 79 patients, 81 tumors examined by CT and 56 by MRI. Tumor size, homogeneity and contrast enhancement were recorded.ResultsThe most common presentation of papillary renal cell carcinoma was a small homogeneous hypovascular tumor both on CT and MRI. Eighty-nine percent of lesions were hypointense on T2 weighted images compared to the renal parenchyma. Seventeen percent of the lesions did not significantly enhance with contrast on CT. All of the lesions examined on MRI had a significant enhancement percentage. Calcifications were rare and only seen in 7% of cases (CT). The second most common presentation was a bulky necrotic tumor. In addition, atypical types of disease were found which were difficult to diagnose, including infiltrating tumors and tumors with a fatty component.ConclusionA homogeneous hypovascular renal tumor which is hypointense on T2 weighted images should suggest a diagnosis of papillary carcinoma. Some papillary carcinomas do not enhance significantly on CT. MRI is then required to diagnose the renal tumor.     

Ultrasonographic assessment of liver fibrosis with computer-assisted analysis of liver surface irregularities

PurposeThe goal of this study was to evaluate the diagnostic accuracy of a software program that automatically analyzes the liver surface to diagnose significant fibrosis, by comparing it to the subjective analysis of a radiologist and to transient elastography (Fibroscan^®).Patients and methodsOne hundred fourteen patients with chronic liver disease were included in the study. They underwent liver biopsy, FibroScan^® and ultrasonographic examination of the liver surface. The liver surface was analyzed by a software program that gave a score of surface irregularities. This evaluation was compared to subjective analysis by a radiologist expert in liver imaging and by two general radiologists.ResultsFifty percent of the patients had significant fibrosis according to the METAVIR score. The AUROC for the diagnosis of significant fibrosis by the software program was 0.80 (95%CI: 0.71–0.87), which was equivalent (P = 0.86) to that of FibroScan^® (0.81; 95%CI: 0.71–0.89). Results of the subjective analysis by the expert radiologist were poorer than those of the software analysis (P = 0.02) (AUROC = 0.66; 95%CI: 0.56–0.75). Interobserver agreement among radiologists was poor (0.25 < kappa < 0.37).ConclusionComputer-assisted liver surface analysis was better than subjective analysis, and similar to that of the FibroScan^®. This method could be useful for the diagnosis of significant fibrosis in patients with chronic hepatitis and complementary to the other non-invasive diagnostic tests.     

The association between pain catastrophising and kinesiophobia with pain and function in people with plantar heel pain

BackgroundPsychological variables, including catastrophic thoughts and kinesiophobia, are common in people with chronic musculoskeletal pain and are associated with pain and function. However, the role of each factor has not been evaluated in people with plantar heel pain (plantar fasciitis).MethodsThirty-six participants diagnosed with plantar heel pain were recruited. Main outcome measures included the Pain Catastrophising Scale, Tampa Scale of Kinesiophobia, the Foot Health Status Questionnaire and a Visual Analogue Scale. Hierarchical regression models were developed to evaluate the association between each psychological variable with variations in foot pain, first step pain and foot function.ResultsIn a full model with age, sex and BMI, kinesiophobia contributed to 21% of the variability in foot function and was a significant predictor in this model (Beta = −0.49, P = 0.006). In a separate model, catastrophising explained 39% of the variability in foot function and was a significant predictor in this model (Beta = −0.65, P < 0.001). Finally, pain catastrophising accounted for 18% of the variability in first step pain and was a significant predictor in a model that also included age, sex and BMI (Beta = 0.44, P = 0.008).ConclusionsAfter controlling for age, sex and BMI, kinesiophobia and catastrophising were significantly associated with foot function, while catastrophising was associated with first step pain in people with plantar heel pain. In addition to addressing biological factors in the management of plantar heel pain, clinicians should consider the potential role of pain catastrophising and kinesiophobia in this population.     

Imaging of the cavernous sinus lesions

This educational paper reviews the normal anatomy of the cavernous sinus (CS) and the imaging findings of common and uncommon lesions of this region. CS lesions may arise from different components of the CS or from adjacent structures and spaces. They can be classified as tumoral, inflammatory/infectious, vascular and congenital. Tumoral lesions include benign (meningiomas, pituitary adenomas, schwannomas) and malignant neoplasms (chondrosarcomas, chordomas, nasopharyngeal carcinomas, leukemia, metastases). Inflammatory/infectious conditions comprise: Tolosa Hunt, abscess, Lemierre syndrome and thrombophlebitis. Vascular lesions include: hemangiomas, carotido-cavernous fistula, aneurysms, arteriovenous malformations. Congenital conditions include the epidermoid cyst, dermoid cyst and fatty deposits. Although imaging features of non-vascular CS diseases are most often non-specific, careful analysis of the adjacent structures suggests the correct diagnosis. In vascular pathology, characteristic MR imaging findings are observed.     

Risk of herpes/herpes zoster during anti-tumor necrosis factor therapy in patients with rheumatoid arthritis. Systematic review and meta-analysis

BackgroundTNF blockers have demonstrated efficacy in inflammatory rheumatic diseases (IRDs). The drugs are associated with a moderate but definite risk of bacterial infection, but risk of viral infection is not clearly known.ObjectiveTo assess the risk of herpes zoster (HZ) reactivation in patients with rheumatoid arthritis (RA) receiving TNF blockers as compared with DMARDs.MethodsA systematic search of literature up to March 2013 was performed, in MEDLINE, EMBASE, the Cochrane library and abstracts from the ACR and EULAR congresses from 2008 to 2011. Studies were included if they reported the incidence of HZ, respectively, in patients receiving anti-TNF and conventional DMARDs.ResultsThe literature search identified 3446 articles and 88 congress abstracts; a manual search retrieved seven articles. Finally, 26 articles and nine abstracts were included; six articles and one abstract were of meta-analyses estimating the relative risk of HZ in patients with RA with a total follow-up of 163,077 patient-years. From the meta-analyses of data for seven registries, the pooled risk ratio for HZ with TNF blockers was 1.61 [95%CI 1.16–2.23] (P = 0.004). Proportions of severe HZ ranged from 4.9% to 20.9% with TNF-blockers and from 2.0% to 5.5% with conventional DMARDs, in the different registries.ConclusionsThis meta-analysis revealed a significantly increased risk of HZ, up to 61%, in patients with IRD receiving TNF blockers. These data raise the issue of systematic prophylactic treatment with known history of HZ or vaccination without this history.     

Standardization of selection criteria for percutaneous image-guided cryoablation of recurrent soft-tissue sarcomas

PurposePercutaneous image-guided cryoablation has not been validated for local management of recurrence of soft tissue sarcoma (STS) of the trunk or limbs. This study aims to identify selection criteria for cryoablation in order to standardize indications of this treatment.Patients and methodsBetween 2000 and 2010, 46 patients (57 tumors) presenting local recurrences of STS of the trunk or limbs and treated following standards of care were selected from our institutional database. Eligibility for cryoablation was assessed by two radiologists according to predefined criteria: maximal diameter size of the tumor ≤ 10 cm, distance to skin >5 mm, distance to neurovascular structures 3 mm at least, absence of articular involvement and planned cryoablation covering the entire lesion volume. Characteristics and outcomes were compared.ResultsThere was nearly perfect agreement for all criteria (k coefficient ranging from 0.83 to 0.98) between both readers. A subgroup of 13 patients was identified as eligible for cryoablation. Locations to the trunk, pelvic girdle or shoulder were significantly more present in the cryoablation group (P = 0.002). In this group, tumors were mainly located deeply (P = 0.002) with great axes ≤ 5 cm (P = 0.044). High local tumor aggressiveness (P = 0.016) and differentiated myxoid liposarcoma or myxofibrosarcoma (P = 0.007) were more frequent in the eligible group.ConclusionBased on these criteria, two groups of patients with local relapse of STS can be identified. These results may improve the standardization of selection of patients who could be candidates for cryoablation.     

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.     

High anti-CCP antibody titres predict good response to rituximab in patients with active rheumatoid arthritis

ObjectivePrevious studies reported that anti-CCP antibody positivity predicts good response to rituximab (RTX) in rheumatoid arthritis (RA). A quantitative approach to such possibility could be a good way to detect the subset of patients most likely to respond. We investigated whether serum anti-CCP antibody titres could predict response to RTX in RA patients.MethodsWe retrospectively investigated RA patients who received RTX. The primary criterion was decrease in DAS28 > 1.2 at 6 months (M6). Secondary efficacy criteria included a good response and remission according to EULAR. Predictors of response were investigated by multivariate logistic regression analysis.ResultsWe included 114 RA patients (81.6% female, median age 53.5 [IQR 45.7–61.2] years, median disease duration 8.5 [4.0–16.0] years). Anti-CCP antibodies were present in 93 patients (81.6%), with median anti-CCP antibody titres 583 [195–1509] U/mL. In all, 44 patients (38.6%) showed decreased DAS28 > 1.2 at M6. On univariate analysis, high anti-CCP titres were associated with response rather than non-response to RTX (median 1122 [355–1755] vs. 386 [149–800] U/mL, P = 0.0191) at M6. On multivariate regression analysis, with a cut-off of 1000 U/mL, anti-CCP antibody titres ≥ 1000 was associated with a decrease in DAS28 > 1.2 (OR 5.10 [1.97–13.2], P = 0.0002); a EULAR good response (4.26 [1.52–11.95], P = 0.0059); and a trend for EULAR remission (2.52 [0.78–8.12], P = 0.1207).ConclusionHigh anti-CCP antibody titres predict response to RTX in RA. This factor, easily assessed in clinical practice, can help with personalized medicine and selecting the best candidates for RTX treatment.     

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.     

Outcomes and utilization of postmastectomy radiotherapy for T3N0 breast cancers

BackgroundThe role of postmastectomy radiotherapy (PMRT) for women with pT3N0M0 breast cancer is controversial. We sought to determine the benefit of PMRT in this cohort using the National Cancer Database (NCDB).MethodsWe analyzed women with pT3N0M0 breast cancer who received mastectomy with or without PMRT between 2004 and 2012. We excluded men, women ≤18 years, neoadjuvant or unknown radiation or chemotherapy status, unknown estrogen or progesterone receptor status, unknown surgical margin status, histology other than invasive ductal or lobular carcinoma, and if death occurred <3 months after diagnosis. A total of 4291 patients was included for analysis. Chi-squared analysis was used to compare patient characteristics. Univariate (UVA) and multivariate (MVA) Cox proportional hazards modeling was used to identify factors associated with survival. Propensity score matching was performed to address confounding variables. Survival analysis was performed using Kaplan-Meier and shared frailty models.ResultsOf the 4291 women analyzed, 2030 (47%) received PMRT. On MVA, PMRT (HR 0.72, p < 0.001), chemotherapy (HR 0.51, p < 0.001), and hormone therapy (HR 0.63, p < 0.001) were associated with improved overall survival (OS). After propensity score matching, a matched cohort of 2800 women was analyzed. At 5 years, OS was 83.7% and 79.8% with and without PMRT, respectively (p < 0.001). This difference in OS benefit increased with time. At 10 years, OS was 67.4% and 59.2% with and without PMRT, respectively.ConclusionsPMRT was associated with improved OS in women with pT3N0M0 breast cancer, which strongly suggests PMRT may provide a survival advantage and should be considered.     

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.     

Tumor necrosis after preventive embolization of large renal angiomyolipomas

ObjectivesThe purpose of this study was to retrospectively evaluate tumor necrosis following preventive embolization in patients with renal angiomyolipoma (RAML) at high risk of bleeding.Patients and methodsArterial embolization was performed in 24 patients (22 women, 2 men; mean age, 43 ± 13 years) with a total of 30 RAMLs (mean volume, 137 cm³ ± 163) between 1996 and 2012. Two sub-groups of patients were identified and further compared based on the presence or not of necrosis following arterial embolization.ResultsThe technical and clinical success rates of arterial embolization of RAMLs were 97% and 87%, respectively. The mean initial volume of RAMLs differed between the two sub-groups with 331 cm³ in the group with tumor necrosis and 88 cm³ in the group without tumor necrosis (P = 0.0047). High-fat content RAMLs were predominantly observed in the necrosis group and the mean volume reduction observed for high-fat RAMLs was 65% whereas it was 36% for low-fat content RAMLs. The six patients who developed RAML necrosis had arterial embolization using microspheres (one patient with microspheres alone and five with a combination of microspheres and metallic coils). All necrotic RAMLs displayed arterial dysplasia.ConclusionThe risk of tumor necrosis is higher for larger RAMLs. The role of distal arterial embolization with microspheres in tumor necrosis in RAML is suggested by the results of our study but could not be definitely demonstrated statistically due to the limited sample size.     

Diagnostic performance of contrast-enhanced spectral mammography: Systematic review and meta-analysis

PurposeTo estimate sensitivity and specificity of CESM for breast cancer diagnosis.MethodsSystematic review and meta-analysis of the accuracy of CESM in finding breast cancer in highly selected women. We estimated summary receiver operating characteristic curves, sensitivity and specificity according to quality criteria with QUADAS-2.ResultsSix hundred four studies were retrieved, 8 of these reporting on 920 patients with 994 lesions, were eligible for inclusion. Estimated sensitivity from all studies was: 0.98 (95% CI: 0.96–1.00). Specificity was estimated from six studies reporting raw data: 0.58 (95% CI: 0.38–0.77). The majority of studies were scored as at high risk of bias due to the very selected populations.ConclusionCESM has a high sensitivity but very low specificity. The source studies were based on highly selected case series and prone to selection bias. High-quality studies are required to assess the accuracy of CESM in unselected cases.