How reliable is modern breast imaging in differentiating benign from malignant breast lesions in the symptomatic population?

AIM: To assess the ability of mammography and ultrasound individually and in combination to predict whether a breast abnormality is benign or malignant in patients with symptomatic breast disease. MATERIALS AND METHODS: Patients included were those in whom histological confirmation of the abnormality following surgical excision was available. Mammographic and ultrasound appearances were prospectively classified using a four-point scale (1 = no significant lesion, 2 = benign lesion, 3 = possibly malignant, 4 = probably malignant). RESULTS: Histological confirmation following surgical excision was available in 559 patients, of which 303 were benign and 256 were malignant. The imaging classification was correlated with histology in these 559 lesions. In predicting final histology, the sensitivity and specificity of mammography alone were 78.9 and 82.7%, respectively, of ultrasound alone were 88.9 and 77.9%, respectively, and of mammography and ultrasound in combination were 94.2 and 67.9%, respectively. Only one patient had both a mammogram and ultrasound reported as normal (category 1 for both tests) in whom subsequent histology revealed a carcinoma (0.4% of all carcinomas). CONCLUSION: We found that the extensive use of ultrasound increases the cancer detection rate in this selected population by 14%.     

Ultrasound elastography: How can it help in differentiating breast lesions?

Introduction

Elastography is considered a non-invasive imaging modality which determines the tumors according to their stiffness. Strain images representing the stiffness of the lesions compared to that of the surrounding normal tissue.

Indeterminate breast lesions: Can contrast enhanced digital mammography change our decisions?

Objective

To assess the efficiency of dual energy contrast enhanced mammography in the assessment of the indeterminate breast lesions (BIRADS 3 and BIRADS 4).

Pre-operative staging of invasive breast cancer with MR mammography and/or PET: boon or bunk?

This study compared pre-operative staging with MR mammography (MRM) and positron emission tomography (PET) in patients with clinically suspected breast cancer according to the Breast Imaging Reporting and Data System, category 5. A total of 43 patients with breast cancer were examined. MRM included both T(2) weighted turbo spin echo sequences and T(1) weighted gradient echo sequences (three-dimensional fast low angle shot) before and after application of gadolinium-DPTA. All patients then underwent examination with a modern full-ring PET scanner following injection of fluorodeoxyglucose. We evaluated the efficacy of these methods in the diagnosis of primary tumour, contralateral carcinomas, bifocal, trifocal or multifocal disease, as well as non-invasive cancer portions and tumour size. Determination of patients' N-status was only attempted using PET. All findings were validated by histological examination. MRM was slightly superior to PET in several areas, such as in the respective methods' sensitivity and specificity. Sensitivities for MRM and PET were: 100% vs 93.0% in diagnosis of the primary tumour; 100% vs 100% in diagnosis of contralateral carcinomas; and 95.2% vs 92.5% in diagnosis of bifocal, trifocal or multifocal disease. Specificities for MRM and PET were: 100% vs 97.5% in diagnosis of contralateral carcinomas; and 96.8% vs 90.3% in diagnosis of bifocal, trifocal or multifocal disease. Non-invasive cancer portions and tumour sizes were equally well determined with both methods. The sensitivity of PET for detection of lymph node involvement was 80% and specificity 95%. MRM and PET were superior to conventional methods in nearly all areas studied; the findings of one or both of the methods impacted positively on patients' surgical treatment in 12.5-15% of cases. Pre-operative MRM and/or PET can have a positive influence on surgical treatment planning. Therefore, it appears useful to perform pre-operative staging with MRM or PET in these patients.     

Size-specific dose estimates: Localizer or transverse abdominal computed tomography images?

AIM: To investigate effect of body dimensions obtained from localizer radiograph and transverse abdominal computed tomography (CT) images on Size Specific Dose Estimate.METHODS: This study was approved by Institutional Review Board and was compliant with Health Insurance Portability and Accountability Act. Fifty patients with abdominal CT examinations (58 ± 13 years, Male:Female 28:22) were included in this study. Anterior-posterior (AP) and lateral (Lat) diameters were measured at 5 cm intervals from the CT exam localizer radiograph (simple X-ray image acquired for planning the CT exam before starting the scan) and transverse CT images. Average of measured AP and Lat diameters, as well as maximum, minimum and mid location AP and Lat were measured on both image sets. In addition, off centering of patients from the gantry iso-center was calculated from the localizers. Conversion factors from American Association of Physicists in Medicine (AAPM) report 204 were obtained for AP, Lat, AP + Lat, and effective diameter (√ AP * Lat) to determine size specific dose estimate (SSDE) from the CT dose index volume (CTDI_vol) recorded from the dose reports. Data were analyzed using SPSS v19.RESULTS: Total number of 5376 measurements was done. In some patients entire body circumference was not covered on either projection radiograph or transverse CT images; hence accurate measurement of AP and Lat diameters was not possible in 11% (278/2488) of locations. Forty one patients were off-centered with mean of 1.9 ± 1.8 cm (range: 0.4-7 cm). Conversion factors for attained diameters were not listed on AAPM look-up tables in 3% (80/2488) of measurements. SSDE values were significantly different compared to CTDI_vol, ranging from 32% lower to 74% greater than CTDI_vol.CONCLUSION: There is underestimation and overestimation of dose comparing SSDE values to CTDI_vol. Localizer radiographs are associated with overestimation of patient size and therefore underestimation of SSDE.     

Can contrast enhanced mammography solve the problem of dense breast lesions?

Objective

To assess the diagnostic accuracy of dual-energy contrast-enhanced digital mammography (CEDM) as an adjunct to mammography (MX) vs. MX alone and vs. mammography plus ultrasound (US) in dense breasts.

Materials and methods

60 women with suspected findings on MX and/or US underwent CEDM. A pair of low- and high-energy images was acquired using a modified full-field digital mammography system. Exposures were taken in MLO at 2 min and in CC at 4 min after the injection of 1.5 ml/kg of an iodinated contrast agent. Sensitivity, specificity, and area under the ROC curve were estimated.

Results

The results from pathology identified 16 benign and 44 malignant cases. Areas under the ROC curves were significantly superior for MX + CEDM than it was for MX alone using BI-RADS. Sensitivity was higher for MX + CEDM than it was for MX (97.7% vs. 93.2%) with no loss in specificity. The lesion size was closer to the histological size for CEDM. All 12 histologically proven multifocal lesions were correctly detected by MX + CEDM vs. 6 and 8 lesions by MX and US respectively.

Conclusion

Initial clinical results show that CEDM has better diagnostic accuracy than mammography alone and mammography + ultrasound especially in dense breasts.     

Detecting postsurgical recurrent hepatocellular carcinoma with multiphasic helical computed tomography: intrahepatic metastasis or multicentric occurrence?

OBJECTIVE: The aim of this study was to assess the computed tomography (CT) patterns of postoperative recurrent hepatocellular carcinoma (HCC). METHODS: Of 84 patients with histologically proven HCC by hepatectomies, multiphasic helical CT demonstrated 54 HCC lesions of intrahepatic recurrence in 31 (37%) patients. The initial and final appearances of HCC on hepatic arterial phase images were retrospectively determined by the serial CT scans, which were compared with appearances of primary HCC. RESULTS: The initial appearances of 54 recurrent HCCs were identical to the appearances of primary HCC in 41 (76%) lesions. Serial changes from the initial appearance to the final appearance of recurrent HCC were observed in 10 (42%) of 24 lesions. The 13 discordant lesions and the 10 lesions with altered lesion vascularity in our series implied that at least 43% were of multicentric occurrence. CONCLUSION: More than 40% of postoperative recurrent HCCs show intranodular hemodynamic changes. The incompatibility between CT findings of primary and recurrent HCCs implies that these tumors contain nodules of multicentric occurrence.     

Is contrast material needed after treatment of malignant lymphoma in positron emission tomography/computed tomography?

Purpose  

Positron emission tomography (PET)/computed tomography (CT) with ¹⁸F-fluorodeoxyglucose is widely used for post-therapeutic surveillance of malignant lymphoma. Debate still exists as to whether intravenous contrast media during the CT stage of a PET/CT scan should be used. The purpose of this study was to investigate the clinical value of contrast agent in PET/CT in patients with lymphoma following treatment.     

Can positron emission mammography help to identify clinically significant breast cancer in women with suspicious calcifications on mammography?

Objective

To evaluate the diagnostic accuracy of positron emission mammography (PEM) for identifying malignant lesions in patients with suspicious microcalcifications detected on mammography.

Methods

A prospective, single-centre study that evaluated 40 patients with suspicious calcifications at mammography and indication for percutaneous or surgical biopsy, with mean age of 56.4 years (range: 28-81 years). Patients who agreed to participate in the study underwent PEM with 18F-fluorodeoxyglucose before the final histological evaluation. PEM findings were compared with mammography and histological findings.

Results

Most calcifications (n?=?34; 85.0 %) were classified as BIRADS 4. On histology, there were 25 (62.5 %) benign and 15 (37.5 %) malignant lesions, including 11 (27.5 %) ductal carcinoma in situ (DCIS) and 4 (10 %) invasive carcinomas. On subjective analysis, PEM was positive in 15 cases (37.5 %) and most of these cases (n?=?14; 93.3 %) were confirmed as malignant on histology. There was one false-positive result, which corresponded to a fibroadenoma, and one false negative, which corresponded to an intermediate-grade DCIS. PEM had a sensitivity of 93.3 %, specificity of 96.0 % and accuracy of 95 %.

Conclusion

PEM was able to identify all invasive carcinomas and high-grade DCIS (nuclear grade 3) in the presented sample, suggesting that this method may be useful for further evaluation of patients with suspected microcalcifications.

Key Points

? Many patients with suspicious microcalcifications at mammography have benign results at biopsy. ? PEM may help to identify invasive carcinomas and high-grade DCIS. ? Management of patients with suspicious calcifications can be improved.

     

Detection of simulated vertical root fractures; which is better multi-detector computed tomography or cone beam computed tomography?

Objectives

Multi-detector computed tomography (MDCT) and cone beam computed tomography (CBCT) were compared regarding their ability to detect vertical root fractures.

Can the “pine-needle sign” on computed tomography be used to differentiate pulmonary arteriovenous malformation from its mimics? Analysis based on dynamic contrast-enhanced chest computed tomography in adults

Objectives/purposeTo determine the diagnostic value of morphological features on computed tomography (CT) in the differentiation of pulmonary arteriovenous malformation (pAVM) and its mimics.Materials and methodsWe retrospectively examined 59 consecutive patients (109 lesions) with initially suspected or occult pAVM who underwent contrast-enhanced chest CT from January 2006 to June 2016. All lesions were divided into two groups based on their diagnosis: AVM (n = 93) and non-AVM (n = 16). The non-AVM group comprised patients with an anomalous unilateral single pulmonary vein and congenital pulmonary venous atresia. Two board-certified radiologists reviewed the CT images and achieved consensus. Paired abnormal vessels were assessed with respect to their configuration, direction and continuity with the hilum, location, angle between them, and dilation ratio.ResultsAll pAVM lesions had parallel, straight-running, paired abnormal vessels; most of the vessels ran through the identical segment. Conversely, in the non-AVM group, paired abnormal vessels did not run in parallel but detoured to the hilum through different segments from each other (i.e., the configuration, direction and continuity with the hilum and the location of the vessels were all significantly different between the two groups). The angle between the paired abnormal vessels was significantly narrower in the AVM group. The dilation ratio was not significantly different between the two groups.ConclusionMorphological features can be useful in the differentiation of pAVM and its mimics without contrast-enhanced CT to directly visualize the connection between the abnormal and normal pulmonary vessels. Pulmonary AVMs characteristically had a narrow angle between the two vessels, appearing like a pair of pine-needle leaves.