MR-guided vacuum-assisted breast biopsy of MRI-only lesions: a single center experience

Purpose

The purpose of this study was to compare three different biopsy devices on false-negative and underestimation rates in MR-guided, vacuum-assisted breast biopsy (VABB) of MRI-only lesions.

Methods

This retrospective, single-center study was IRB-approved. Informed consent was waived. 467 consecutive patients underwent 487 MR-guided VABB using three different 8-10-gauge-VABB devices (Atec-9-gauge,A; Mammotome-8-gauge,M; Vacora-10-gauge,V). VABB data (lesion-type, size, biopsy device, histopathology) were compared to final diagnosis (surgery, n?=?210 and follow-up, n?=?277). Chi-square, and Kruskal–Wallis tests were applied. P values?<?0.05 were considered significant.

Results

Final diagnosis was malignant in 104 (21.4 %), high risk in 64 (13.1 %) and benign in 319 (65.5 %) cases. Eleven of 328 (3.4 %) benign-rated lesions were false-negative (1/95, 1.1 %, A; 2/73, 2.7 %, M; 8/160 5.0 % V; P?=?0.095). Eleven high-risk (11/77, 14.3 %) lesions proved to be malignant (3/26, 11.5 % A; 4/12, 33.3 % M; 4/39, 10.3 % V; P?=?0.228). Five of 34 (14.7 %) DCIS were upgraded to invasive cancer (2/15, 13.3 %, A; 1/6, 16.6 % M; 2/13, 15.3 %, V; P?=?0.977). Lesion size (P?=?0.05) and type (mass vs. non-mass, P?=?0.107) did not differ significantly.

Conclusion

MR-guided VABB is an accurate method for diagnosis of MRI-only lesions. No significant differences on false-negative and underestimation rates were observed between three different biopsy devices.

Key Points

? MR-guided VABB is an accurate procedure for the diagnosis of MRI-only lesions. ? Similar false-negative and underestimation rates allow all three different MR-guided VABB devices for clinical application. ? High-risk lesions should undergo surgery due to a substantial underestimation rate. ? Agreement between MR-guided VABB and final diagnosis (benign/malignant) was 95.5% (465/487).

     

Influence of Calcium on Choline Measurements by 1H MR Spectroscopy of Thigh Muscles

Objective

To study the effects of calcium on the choline peak measurements with 1H MR spectroscopy.

Material and methods

The thigh muscles of two cadaveric specimens were prospectively evaluated on a 3 T MR unit before and after the injection of calcium carbonate (up to 0.4322 g). The choline peaks of 147 spectra from 10 different anatomic locations were quantitatively evaluated. The influence of the calcium concentration and its disposition with respect to the main magnetic field were considered. B₀ phase maps were used to evaluate field inhomogeneities.

Results

The presence of calcium led to a 43 % underestimation of the choline peak and the choline concentration (p?=?0.0002 and 0.0036). The mean choline concentrations before and after CaCO3 injection were 3.53?±?1.72 mmol/l and 1.58?±?0.63 mmol/l. The influence of calcium carbonate on the choline peak estimations was proportional to the calcium concentration. There was a significant position-dependent difference in the estimation of the choline peak amplitude (p?<?0.0154). Calcium injection led to a measurable increase in field inhomogeneities.

Conclusion

There was a significant underestimation of the choline peak amplitude and concentration in the presence of calcium, which might cause misinterpretations of MR spectra.

Key Points

? The presence of calcium led to significant underestimation of choline measurements. ? The influence of calcium is dependent on its concentration and distribution. ? Quantitative MR spectroscopy of calcified tumours should be interpreted with caution.     

Core needle biopsy can minimise the non-diagnostic results and need for diagnostic surgery in patients with calcified thyroid nodules

Purpose

To evaluate the role of core needle biopsy (CNB) for calcified thyroid nodules.

Methods

Between October 2008 and July 2011, 264 patients underwent ultrasound-guided CNB for 272 calcified thyroid nodules at our institution. We retrospectively evaluated the incidence of technical failure, non-diagnostic readings, and the diagnostic performance of CNB, and analysed the relationship between the types of calcification and the CNB results. Finally, the incidence of diagnostic surgery was calculated.

Results

The incidence of technical failure was 1.1 % (3/275) and that of non-diagnostic results was 0.7 % (2/272). The diagnostic accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of CNB were 94.7 %, 89.5 %, 100 %, 100 %, and 90.2 %, respectively. There were no significant differences according to the calcification subtype for either the non-diagnostic results or the incidence of technical failure (P?>?0.99 and P?>?0.99). CNB could prevent diagnostic surgery for 92.9 % (13/14) of the patients who showed more than two non-diagnostic results in previous FNA.

Conclusions

CNB can minimise the non-diagnostic results as well as diagnostic surgery in patients with calcified thyroid nodules. Therefore, CNB may be used as a first-line diagnostic tool for calcified thyroid nodules rather than FNA.

Key points

? CNB results show the low incidence of technical failure (1.1 %, 3/275). ? CNB results show the low non-diagnostic rate (0.7 %, 2/272). ? There were no significant differences according to the calcification subtype. ? CNB can prevent unnecessary diagnostic surgery in 92.9 % (13/14).     

Role of preoperative MR imaging in the evaluation of patients with persistent or recurrent gynaecological malignancies before pelvic exenteration

Purpose

To determine the diagnostic performance of MRI in assessing local tumour extent and evaluate associations between MRI features and survival in patients undergoing MRI before pelvic exenteration for persistent or recurrent gynaecological cancers.

Methods and materials

The study included 50 patients with persistent or recurrent gynaecological malignancies who underwent pelvic exenteration between January 1999 and December 2011 and had MRI at most 90 days before surgery. Two radiologists independently assessed invasion of adjacent organs (on a 5-point scale). Diagnostic accuracy, inter-reader agreement, and associations between organ invasion on MRI and patient survival were evaluated.

Results

Areas under receiver operating characteristic curves (AUCs) for invasion of the bladder, rectum and pelvic sidewall were 0.96, 0.90 and 0.98 for reader 1 and 0.95, 0.88 and 0.90 for reader 2. Corresponding sensitivities/specificities were 87.0 %/92.6 %, 81.3 %/97.0 % and 87.5 %/97.2 % for reader 1, and 87.0 %/100.0 %, 75.0 %/97.0 % and 75.0 %/94.4 % for reader 2. Inter-reader agreement was excellent for organ invasion (κ?=?0.81–0.85). Pelvic sidewall invasion on MRI was associated with overall and recurrence-free survival (P?=?0.01–0.04 for the two readers).

Conclusion

Preoperative MRI is accurate in predicting organ invasion. It may guide surgical planning and serve as a predictive biomarker in patients undergoing pelvic exenteration for gynaecological malignancies.

Key Points

? MRI can accurately assess bladder and rectal wall invasion before major surgery. ? MRI identifies patients requiring extended pelvic exenteration by detecting sidewall invasion. ? Inter-reader agreement for detecting organ invasion and tumor size is excellent. ? Pelvic sidewall invasion on MRI is associated with shorter overall and recurrence-free survival.     

Diverticular disease severity score based on CT colonography

Objective

We propose a diverticular disease severity score (DDSS) based on CT colonography (CTC) findings.

Methods

Seventy-nine patients (62?±?14.5 years) underwent CTC after recovering from an episode of acute diverticulitis. Two independent readers classified each case using a four-point scale (DDSS), based on maximum sigmoid colon wall thickness (MSCWT) and minimum lumen diameter at CTC: 1?=?MSCWT <3 mm, lumen diameter ≥15 mm; 2?=?MSCWT 3–8 mm, lumen diameter ≥5 mm; 3?=?MSCWT ≥8 mm, lumen diameter ≥5 mm; 4?=?MSCWT ≥8 mm, lumen diameter <5 mm. Intra- and interobserver reproducibility was evaluated. Of 79 patients, 32 (40 %) underwent surgery after CTC; MSCWT was directly measured on the pathological specimen.

Results

Intra- and interobserver reproducibility of DDSS were almost perfect (k?=?0.90–0.84). DDSS significantly correlated with the probability of surgery (P?=?0.001). After surgery, histopathology revealed acute/chronic diverticular inflammation only in 29 cases, and superimposed sigmoid cancer (n?=?2) or Crohn’s disease (n?=?1) in 3 patients with a DDSS of 4. MSCWT at histopathology correlated with DDSS (P?=?0.008).

Conclusion

DDSS is highly reproducible and correlates with pathological MSCWT. Nearly 1 in 3 patients with a DDSS of 4 had significant superimposed histopathology. CTC with DDSS can provide colorectal surgeons with valuable information.

Key Points

? A diverticular disease severity score (DDSS) based on CT colonography is proposed. ? This DDSS is based on sigmoid colon wall thickness and lumen diameter. ? High scores may be associated with relevant coexisting lesions. ? A CTC-based DDSS may influence therapeutic decision-making.     

Placement of retrievable self-expandable metallic stents with barbs into patients with obstructive prostate cancer

Objectives

To evaluate the technical feasibility and clinical effectiveness of retrievable self-expandable metallic stents with barbs in patients with obstructive prostate cancer.

Methods

Retrievable self-expandable metallic stents with eight barbs each were inserted into eight consecutive patients with obstructive prostate cancer. Patient ages ranged from 55 to 76 years (mean, 69 years). All eight patients had previously received hormone therapy, and three had undergone palliative transurethral prostatectomy. Stents were removed using a 21-F stent removal set if they caused complications.

Results

Stent placement was technically successful and well tolerated in all patients. One had severe incontinence, which improved spontaneously, and two had gross haematuria, which disappeared spontaneously within 4 days. Peak urine flow rates and post-void residual urine volumes 1 month after stent placement were 5.6–10.2 ml/s (mean, 8.3 ml/s), and 5–45 ml (mean, 27 ml), respectively. During a mean follow-up of 192 days (range, 39–632 days), one patient required stent removal after 232 days because of stone formation within the stent. No further intervention was required because the mass improved after stent removal.

Conclusions

These preliminary results suggest that retrievable stents with eight barbs are both feasible to place and effective in patients with obstructive prostate cancer.

Key Points

? Retrievable metallic urethral stents can help patients with obstructive prostate cancer. ? Retrievable self-expandable stents with eight barbs are both feasible and effective. ? These stents apparently overcome the problem of stent migration. ? Removal of these stents was safe without surgery under local anaesthesia.     

Thyroid nodules with initially non-diagnostic,fine-needle aspiration results: comparison of core-needle biopsy and repeated fine-needle aspiration

Objective

To evaluate the role of core-needle biopsy (CNB) by comparing the results of CNB and repeated fine-needle aspiration (FNA) for thyroid nodules with initially non-diagnostic FNA results.

Methods

From October 2008 to December 2011, 360 nodules – 180 consecutive repeated FNAs and 180 consecutive CNBs –– from 360 patients (83 men, 277 women; mean age, 54.4 years) with initially non-diagnostic FNA results were analyzed retrospectively. The incidence of non-diagnostic results, inconclusive results, diagnostic surgery, and diagnostic performance of repeated FNA and CNB were assessed, and factors affecting second non-diagnostic results were evaluated.

Results

CNB achieved a significantly lower non-diagnostic and inconclusive rate than repeated FNA (1.1 % versus 40.0 %, P?P?P?=?0.047). Multivariate logistic regression analysis showed that repeated FNA was the most important factor for second non-diagnostic results (OR?=?56.06, P?P?=?0.003).

Conclusions

CNB is more useful than repeated FNA for reducing the number of non-diagnostic and inconclusive results and for preventing unnecessary diagnostic surgery for thyroid nodules with initially non-diagnostic FNA results.

Key Points

? Core-needle biopsy achieved a lower number of non-diagnostic and inconclusive results. ? Core-needle biopsy achieved better diagnostic performance. ? Use of core-needle biopsy could prevent unnecessary diagnostic surgery. ? Repeated fine-needle aspiration was significantly associated with a second non-diagnosis.     

US-guided high-intensity focused ultrasound as a promising non-invasive method for treatment of primary hyperparathyroidism

Objectives

To investigate the long-term efficacy and safety of ultrasound (US)-guided high-intensity focused ultrasound (HIFU) treatment in patients with primary hyperparathyroidism (PHPT).

Methods

In our prospective study, 13 of 72 screened patients with PHPT were eligible for HIFU treatment, which was performed in one or two sessions. Parathyroid adenoma size and function were evaluated at baseline, 1, 3, 6, 9, and 12 months after the final HIFU session.

Results

In 11 females and 2 males, mean age 55.2?±?12.41 years, the mean applied energy was 15.2?±?7.7 kJ. Parathyroid size and parathyroid hormone decreased significantly one month after HIFU therapy (p?p?p?p?Conclusions HIFU is a promising non-invasive technique for PHPT treatment, which could serve as therapeutic alternative for selected patients.

Key Points

? US-guided HIFU is a new non-invasive ablative technique for parathyroid adenomas. ? The method is efficient and ensures good disease control in most patients. ? HIFU is a good alternative for patients not meeting surgery criteria. ? Treatment is well-tolerated with only transient side effects.     

A comparison of open and arthroscopic surgery for treatment of diffuse pigmented villonodular synovitis of the knee

Purpose

To compare the outcomes of diffuse pigmented villonodular synovitis (PVNS) of the knee treated with routine anteroposterior open surgery or modified multi-directional arthroscopy.

Methods

Medical records of patients with diffuse PVNS who underwent surgery between 2002 and 2010 were reviewed. Patients were followed up at 3, 6, 12, 24, and 36 months. Operative time, blood loss, length of hospital stay, recurrence rate, and International Knee Documentation Committee (IKDC) scores and Lysholm knee scores at 1- and 3-year postoperatively were compared between the open surgery and arthroscopy groups.

Results

A total of 41 patients with diffuse PVNS were included (20 in open surgery group and 21 in multi-directional arthroscopy group). There was no significant difference in the baseline characteristics between the two groups. Operation time, postoperative bleeding, and length of hospital stay were all significantly lower in the arthroscopy group than in the open surgery group (all, P < 0.05). There were four recurrences in the open surgery group and one in arthroscopy group. All five recurrences received a second surgery without any subsequent recurrences. At both 1- and 3-year postoperatively, IKDC and Lysholm scores were significantly greater in the arthroscopy group than the open surgery group (all P < 0.001).

Conclusions

The multi-directional arthroscopic technique was associated with significantly shorter operation time and hospital stay, less blood loss, and better postoperative IKDC and Lysholm scores than open surgery.

Level of evidence

Retrospective study with controls, Level III.     

Preoperative computed tomography of the chest in lung cancer patients: the predictive value of calcified lymph nodes for the perioperative outcomes of video-assisted thoracoscopic surgery lobectomy

Objectives

To determine the predictive value of identifying calcified lymph nodes (LNs) for the perioperative outcomes of video-assisted thoracoscopic surgery (VATS).

Methods

Fifty-six consecutive patients who underwent VATS lobectomy for lung cancer were included. We evaluated the number and location of calcified LNs on computed tomography (CT). We investigated clinical parameters, including percentage forced expiratory volume in 1 s (FEV₁%), surgery duration, chest tube indwelling duration, and length of hospital stay. We performed linear regression analysis and multiple comparisons of perioperative outcomes.

Results

Mean number of calcified LNs per patient was 0.9 (range, 0–6), mostly located in the hilar-interlobar zone (43.8 %). For surgery duration (mean, 5.0 h), FEV₁% and emphysema severity were independent predictors (P?=?0.010 and 0.003, respectively). The number of calcified LNs was an independent predictor for chest tube indwelling duration (P?=?0.030) and length of hospital stay (P?=?0.046). Mean duration of chest tube indwelling and hospital stay was 8.8 days and 12.7 days in no calcified LN group; 9.2 and 13.2 in 1 calcified LN group; 12.8 and 19.7 in ≥2 calcified LNs group, respectively.

Conclusions

The presence of calcified LNs on CT can help predict more complicated perioperative course following VATS lobectomy.

Key Points

? Preoperative chest CT can help predict perioperative outcome following video-assisted thoracoscopic surgery. ? Calcified lymph nodes should be assessed on CT to predict perioperative outcome. ? Multiple calcified LNs are associated with longer chest drainage. ? Hospital stay appears longer in patients with more calcified lymph nodes.     

Diffusion-weighted MR imaging for differentiating borderline from malignant epithelial tumours of the ovary: pathological correlation

Objectives

To investigate diffusion-weighted (DW) magnetic resonance (MR) imaging for differentiating borderline from malignant epithelial tumours of the ovary.

Methods

This retrospective study included 60 borderline epithelial ovarian tumours (BEOTs) in 48 patients and 65 malignant epithelial ovarian tumours (MEOTs) in 54 patients. DW imaging as well as conventional MR imaging was performed. Signal intensity on DW imaging was assessed and apparent diffusion coefficient (ADC) value was measured. The results were correlated with histopathology and cell density.

Results

The majority of MEOTs showed high signal intensity on DW imaging, whereas most BEOTs showed low or moderate signal intensity (P?=?0.000). The mean ADC value of the solid components in BEOTs (1.562?±?0.346?×?10^?3 mm²/s) was significantly higher than in MEOTs (0.841?±?0.209?×?10^?3 mm²/s). A threshold value of 1.039?×?10^?3 mm²/s permitted the distinction with a sensitivity of 97.0 %, a specificity of 92.2 % and an accuracy of 96.4 %. There was an inverse correlation between ADC value and cell density (r?=??0.609; P?=?0.0000) which was significantly lower in BEOTs than in MEOTs.

Conclusions

DW imaging is useful for differentiating borderline from malignant epithelial tumours of the ovary.

Key Points

? DW MR imaging is useful for differentiating BEOTs from MEOTs. ? Patients with BEOTs are treated differently from patients with MEOTs. ? Conservative fertility-sparing laparoscopic surgery can be performed in patients with BEOTs. ? BEOTs often affect young women of childbearing age.     

High-risk lesions diagnosed at MRI-guided vacuum-assisted breast biopsy: can underestimation be predicted?

Objectives

To evaluate the frequency of diagnosis of high-risk lesions at MRI-guided vacuum-assisted breast biopsy (MRgVABB) and to determine whether underestimation may be predicted.

Methods

Retrospective review of the medical records of 161 patients who underwent MRgVABB was performed. The underestimation rate was defined as an upgrade of a high-risk lesion at MRgVABB to malignancy at surgery. Clinical data, MRI features of the biopsied lesions, and histological diagnosis of cases with and those without underestimation were compared.

Results

Of 161 MRgVABB, histology revealed 31 (19%) high-risk lesions. Of 26 excised high-risk lesions, 13 (50%) were upgraded to malignancy. The underestimation rates of lobular neoplasia, atypical apocrine metaplasia, atypical ductal hyperplasia, and flat epithelial atypia were 50% (4/8), 100% (5/5), 50% (3/6) and 50% (1/2) respectively. There was no underestimation in the cases of benign papilloma without atypia (0/3), and radial scar (0/2). No statistically significant differences (p?>?0.1) between the cases with and those without underestimation were seen in patient age, indications for breast MRI, size of lesion on MRI, morphological and kinetic features of biopsied lesions.

Conclusions

Imaging and clinical features cannot be used reliably to predict underestimation at MRgVABB. All high-risk lesions diagnosed at MRgVABB require surgical excision.     

Detection of neck recurrence in patients with differentiated thyroid cancer: comparison of ultrasound, contrast-enhanced CT and 18F-FDG PET/CT using surgical pathology as a reference standard: (ultrasound vs. CT vs. 18F-FDG PET/CT in recurrent thyroid cancer)

Objectives

To compare the diagnostic performance of ultrasound, contrast-enhanced computed tomography (CT) and ¹⁸F-FDG positron emission tomography (PET)/CT for detecting recurrent differentiated thyroid cancer in the neck.

Methods

Twenty patients who had undergone previous surgery for differentiated thyroid cancer (19 papillary carcinomas; 1 medullary carcinoma) and presented with pathologically proven recurrence in the neck were included. All patients had undergone ultrasound, CT and PET/CT in the 2 months before further surgery. In each patient, ultrasound, CT and PET/CT images were retrospectively reviewed to determine the presence of loco-regional recurrence by level-by-level analysis. Imaging results were correlated with the histological evaluation of the neck dissection as a standard of reference.

Results

Recurrences were found at 52 out of 110 cervical nodal levels surgically explored. The sensitivity, specificity and accuracy were 69.2 %, 89.7 % and 80.0 % for ultrasound; 63.5 %, 94.8 % and 80.0 % for CT; and 53.8 %, 79.3 % and 67.3 % for PET/CT, respectively. ROC analysis revealed higher diagnostic performance with ultrasound than with PET/CT for detecting recurrent tumour.

Conclusions

Although no significant difference was found among the three techniques, the sensitivity and specificity of ultrasound and CT were higher than those of PET/CT for the evaluation of cervical recurrence in patients with differentiated thyroid cancer.

Key Points

? Ultrasound, CT and ¹⁸ F-FDG PET/CT can all detect recurrent thyroid cancer. ? Ultrasound and CT have higher sensitivity and specificity. ? Ultrasound, CT and ¹⁸ F-FDG PET/CT frequently demonstrated discordant findings     

A comparison of CT- and MR-based attenuation correction in neurological PET

Purpose

To assess the quantitative accuracy of current MR attenuation correction (AC) methods in neurological PET, in comparison to data derived using CT AC.

Methods

This retrospective study included 25 patients who were referred for a neurological FDG PET examination and were imaged sequentially by PET/CT and simultaneous PET/MR. Differences between activity concentrations derived using Dixon and ultrashort echo time (UTE) MR-based AC and those derived from CT AC were compared using volume of interest and voxel-based approaches. The same comparisons were also made using PET data represented as SUV ratios (SUVr) using grey matter cerebellum as the reference region.

Results

Extensive and statistically significant regional underestimations of activity concentrations were found with both Dixon AC (P?<?0.001) and UTE AC (P?<?0.001) in all brain regions when compared to CT AC. The greatest differences were found in the cortical grey matter (Dixon AC 21.3 %, UTE AC 15.7 %) and cerebellum (Dixon AC 19.8 %, UTE AC 17.3 %). The underestimation using UTE AC was significantly less than with Dixon AC (P?<?0.001) in most regions. Voxel-based comparisons showed that all cortical grey matter and cerebellum uptake was underestimated with Dixon AC compared to CT AC. Using UTE AC the extent and significance of these differences were reduced. Inaccuracies in cerebellar activity concentrations led to a mixture of predominantly cortical underestimation and subcortical overestimation in SUVr PET data for both MR AC methodologies.

Conclusion

MR-based AC results in significant underestimation of activity concentrations throughout the brain, which makes the use of SUVr data difficult. These effects limit the quantitative accuracy of neurological PET/MR.     

Medial retinacular flap advancement and arthroscopic lateral release for symptomatic chronic patellar lateral subluxation with tilting

Purpose

The purpose of this study was to investigate outcomes of surgical treatment in patients with symptomatic chronic patellar lateral subluxation with tilting.

Methods

Thirty-two patients (38 knees) underwent arthroscopic lateral release and mini-open advancement of medial retinacular flap for the treatment of symptomatic chronic patellar lateral subluxation with tilting with a mean follow-up of 52.0 ± 11.4 months. The mean age at surgery was 24.7 ± 8.8 years, and the duration of symptoms was 4.8 ± 4.1 years. The patellofemoral function of the knee was evaluated before surgery and at the clinical follow-up using the Kujala functional score.

Results

Thirty-six knees (95 %) showed excellent or good results after surgery. Two knees with grade IV chondromalacia of the patella had fair results with persistent apprehension signs and persistent pain. The Kujala patellofemoral functional scores improved by an average of 20.9 points from a mean value of 71.8 ± 12.1 preoperatively to 92.7 ± 10.7 postoperatively (P < 0.01). Radiographically, there were significant improvements in congruence angle from 23.4° ± 7.9° preoperatively to ?7.2° ± 6.4° postoperatively (P < 0.01) and in the lateral patellofemoral angle from ?8.6° ± 6.8° preoperatively to 6.3° ± 4.2° postoperatively (P < 0.01).

Conclusions

Medial retinacular flap advancement and arthroscopic lateral release offer a promising treatment for symptomatic chronic patellar lateral subluxation and tilt without frank traumatic episode.

Level of evidence

Retrospective study, Level IV.     

Complications and clinical outcome of hepatic artery embolisation in patients with hereditary haemorrhagic telangiectasia

Background

Hepatic artery embolisation (HAE) in patients with hereditary haemorrhagic telangiectasia (HHT) is controversial because of the associated complications and unproven long-term benefit. We present our results in 20 such patients over a time span of 17 years.

Methods

Staged HAE was performed using polyvinyl alcohol (PVA) particles and coils. Complications, clinical symptoms and cardiac output were assessed before and after therapy as well as at the end of follow-up (median 92 months, range 26–208 months).

Results

Two patients died within 30 days following HAE (10 %). Four further deaths resulted from causes unrelated to HAE. Ischaemic cholangitis, cholecystitis and focal hepatic necrosis with biliary sepsis necessitated re-intervention in four patients. In all but one patient, clinical symptoms resolved with mean cardiac output falling from 11.84?±?3.22 l/min pre-treatment to 8.13?±?2.67 l/min at the end of follow-up (P?<?0.001). One patient required liver transplantation for de novo symptoms of portal hypertension 4 years after primary symptoms had been cured by HAE.

Conclusion

The 30-day mortality of HAE in patients with HHT is 10 %. The rate of complications requiring re-intervention is 20 %. Clinical response at long-term follow-up is satisfactory.

Key Points

? Hepatic artery embolisation (HAE) in hereditary haemorrhagic telangiectasia (HHT) provides long-term benefit. ? Mortalities of HAE and liver transplantation in HHT patients are comparable. ? In HHT, complications of HAE are lower than those of liver transplantation. ? Complications of HAE can be further reduced by refinement of technique. ? Complications include ischaemic cholangitis, hepatic necrosis, biliary sepsis and death.     

Perforation rate in CT colonography: a systematic review of the literature and meta-analysis

Purpose

The primary aim was to assess the perforation rate of CTC; the secondary aim was to identify potential clinical/technical predictors of this complication.

Methods

Methods for analysis were based on PRISMA (preferred reporting items for systematic reviews and meta-analyses). From the selected studies, the rate of CTC perforation and patient/technical characteristics potentially associated with this event were extracted. Forest plots showing individual and pooled estimates of the perforation rate were obtained for all analyses. I² was used to evaluate heterogeneity between studies.

Results

Eleven articles out of the 187 initially identified were selected for the analysis (103,399 patients). There were 29,048 (28 %) asymptomatic individuals and 30,773 (30 %) symptomatic patients; this characteristic was not reported in the remaining subjects (42 %). Colon distension was obtained manually in 69,222 (67 %) and using an automated carbon dioxide insufflator in 26,479 (26 %) patients; in the remaining 7 % of patients, this information was missing. Twenty-eight colonic perforations were reported, with the CTC perforation rate estimated to be 0.04 % (95 % CI. 0.00-0.10), 19-fold higher in symptomatic than in screening subjects (OR: 19.2, CI 3.3-108 and P?=?0.001). The surgical rate was 0.008 %. No CTC-related deaths were reported.

Conclusions

The perforation rate in CTC is very low, particularly considering asymptomatic individuals.

Key Points

? This is the first meta-analysis on this topic, based on 100,000 patients. ? The CTC-related colorectal perforation rate is 0.04 %, 0.02 % in asymptomatic subjects. ? The CTC-induced surgery rate is 0.008 % (1:12,500). ? The perforation rate in CTC is low, particularly in average-risk, asymptomatic individuals.     

Value of CT angiography for the detection of intracranial vascular lesions in patients with acute severe headache

Objectives

To retrospectively investigate the prevalence and characteristics of intracranial vascular lesions in patients with acute severe headache with the use of CT angiography (CTA).

Methods

We systematically searched for neurologically intact patients with acute severe headache and normal unenhanced head CT. The study group consisted of 512 patients; 251 male; mean age 46.2?±?12.4 years. All patients underwent CTA between 1 day and 2 months after the headache attack. CTA images were interpreted by two experienced neuroradiologists for the presence of vascular lesions.

Results

Thirty-four (6.6 %) of the 512 patients had intracranial vascular lesions on CTA, including 33 aneurysms (2 patients had 2 aneurysms each), 2 moyamoya disease and 1 arterial dissection. No gender- or age-related differences were found. Aneurysms arose most commonly on the internal carotid artery (n?=?12), followed by the anterior communicating artery (n?=?7), and the middle cerebral artery (n?=?7). Maximal diameters ranged from 2.0 to 13.1 mm (mean, 3.9?±?2.6 mm).

Conclusions

CTA is a feasible tool for diagnosing intracranial vascular lesions in patients with acute severe headache. The prevalence of vascular lesions in our series was 6.6 %, which is higher than that predicted in the general population.

Key Points

? Unruptured cerebral aneurysms may be a cause of acute severe headache ? CTA assesses intracranial vascular lesions in patients with acute severe headache ? The prevalence of vascular lesions in our series of patients was 6.6 %     

The combination of FDG PET and dynamic contrast-enhanced MRI improves the prediction of disease-free survival in patients with advanced breast cancer after the first cycle of neoadjuvant chemotherapy

Purpose

The aim of this study was to investigate the potential of FDG PET/CT and MRI in predicting disease-free survival (DFS) after neoadjuvant chemotherapy (NAC) and surgery in patients with advanced breast cancer.

Methods

The analysis included 54 women with advanced breast cancer. All patients received three cycles of NAC, underwent curative surgery, and then received three cycles of additional chemotherapy. Before and after the first cycle of NAC, all patients underwent sequential PET/CT and MRI. All patients were analysed using a diverse range of parameters. including maximal standardized uptake value (SUV), percent change in SUV (ΔSUV), initial slope of the enhancement curve (MRslope), apparent diffusion coefficient (ADC), tumour size, change in MRslope (ΔMRslope), change in ADC (ΔADC), change in tumour size (Δsize) and other clinicopathological parameters]. The relationships between covariates and DFS after surgery were analysed using the Kaplan-Meier method and the multivariate Cox proportional hazards model. Time-dependent receiver operating characteristic curves were used to determine the optimal cut-off values of imaging parameters for DFS.

Results

Of the 54 patients, 13 (24 %) experienced recurrence at a median follow-up of 38 months (range 25 – 45 months). Univariate and multivariate analyses showed that a lesser decline in SUV, a lesser decline in MRslope, a lesser increase in ADC, and ER negativity were significantly associated with a poorer DFS (P?=?0.0006, ΔSUV threshold ?41 %; P?=?0.0016, ΔMRslope threshold ?6 %; P?=?0.011, ΔADC threshold 11 %; and P?=?0.0086, ER status, respectively). Patients with a combination of ΔSUV >?41 % and ΔMRslope >?6 % showed a significantly higher recurrence rate (77.8 %) than the remaining of patients (13.3 %, P?Conclusion Functional parameters of both FDG PET and MRI after the first cycle of NAC are useful for predicting DFS in patients with advanced breast cancer. This approach could lead to an improvement in patient care because ineffective NAC agents could be avoided and more aggressive therapy could be used in high-risk patients.