DWIBS: Can it replace DCE-MRI in detection and characterization of suspicious breast lesions?

Objectives

Unenhanced MR imaging of the breast have recently been introduced. These include STIR, T2-weighted TSE and DWIBS sequences. These sequences could characterize breast lesions, although not yet able to avoid histological characterization.

The clinical value of bilateral breast MR imaging: is it worth performing on patients showing suspicious microcalcifications on mammography?

The purpose of this study was to evaluate the clinical value of bilateral breast magnetic resonance (MR) imaging (MRI) in patients showing suspicious microcalcifications on mammography and negative ultrasound findings. Fifty patients underwent MRI before stereotactic vacuum-assisted breast biopsy (SVAB). MR findings were classified into five types for interpretation, and types 4 and 5 were considered malignant. SVAB revealed 13 carcinomas and 37 benign lesions. Malignant lesions were more frequently found in cases of positive MRI diagnoses than in negative MRI diagnoses (P < 0.001). Mammography had a sensitivity of 100%, a specificity of 24% and an accuracy of 44%, whereas mammography plus MRI had a sensitivity of 85%, a specificity of 100% and an accuracy of 96%. In the evaluation of mammographically detected microcalcifications, bilateral breast MRI is of good diagnostic value and may alter the indications for SVAB.     

Elastography ultrasound and questionable breast lesions: Does it count?

Objective

To check possible additional value of using elastography ultrasound in the specification of questionable breast lesions.

Subjects and methods

Questionable breast lesions on gray scale ultrasound examination had been further evaluated by elastography ultrasound in 97 cases with median age of 42 years. The studied lesions were pathologically proven (58 benign and 39 malignant) using true cut tissue/surgical excision biopsy that was considered the gold standard of reference.

Results

Conventional ultrasound categorization before biopsy included: category 3 (probably benign) in 42.3% (n = 41), category 4a (low suspicion of malignancy) in 13.4% (n = 13), category 4b (intermediate suspicion of malignancy) in 16.5% (n = 16) and category 4c (moderate suspicion of malignancy) in 27.8% (n = 27). We had evaluated elastography ultrasound regarding elastography strain scoring and quantitative strain ratio.Sensitivity, specificity and accuracy were 89.7%, 86.2% and 87.6% for conventional ultrasound, 92.3%, 74.1% and 81.4% for elastogram 5-point scoring method and 87.1%, 89.6% and 88.6% for the calculated strain ratios respectively in the assessment of the examined breast lesions.

Conclusion

Ultrasound elastography, using both qualitative and quantitative methods can improve the performance of conventional B-mode ultrasound and enhance its specificity and accuracy in the diagnosis of questionable (BI-RADS categories 3 and 4) breast lesions.     

Real-time ultrasound elastography: Does it improve B-mode ultrasound characterization of solid breast lesions?

Introduction

Elastography is a non-invasive medical imaging technique that detects tumors based on their stiffness (elasticity). Strain images display the relative stiffness of lesions compared with the stiffness of surrounding tissue as cancerous tumors tend to be many times stiffer than the normal tissue, which “gives” under compression. An image in which different degrees of stiffness show as different shades of light and dark is called an elastogram.

Purpose

To prospectively evaluate the sensitivity and specificity of the real-time sonoelastography as compared with B-mode US for distinguishing between benign and malignant solid breast masses. The density of the glandular breast tissue was taken in consideration in addition to the Breast Imaging Reporting and Data System (BI-RADS) categories of the lesions, with biopsy results as the reference standard.

Methods

A total of 216 candidate solid lesions (123 benign and 93 malignant) in 188 patients were examined with 2-dimensional ultrasonography, elastosonography and mammography (for 147 patients). The lesions were classified according to the density of the glandular breast tissue into low density group (D1) and a high density group (D2) and were categorized with the BIRADS score. Elastographic images were assigned an elasticity score of 1 to 5 (1–3, benign; 4 and 5, malignant) according to the Multi-Center Team of Study and the strain ratios of the lesions were measured. Concordance between the imaging findings and histopathologic results was documented. Statistical analysis was performed and sensitivity, specificity and positive and negative predictive values for both elastography and conventional sonography were calculated.

Results

Elastography showed less sensitivity but higher specificity than conventional sonography in the differentiation of benign from malignant solid lesions: B-mode sonography had sensitivity of 85.1%, specificity of 93.9%, a positive predictive value of 92.5% and a negative predictive value of 87.8%, compared with the sensitivity of 80.1%, specificity of 97.1%, a positive predictive value of 96.8% and a negative predictive value of 82.1% for elastography. Elastography was superior to B-mode US in diagnosing solid lesions in the low density group (D1) (96.6% vs. 92.4% specificity) and less in the dense glandular tissue (97.8% vs. 95.9% specificity).

Conclusions

Real-time sonoelastography is an useful technique for the characterization of benign and malignant solid lesions as it increases the diagnostic specificity comparable to B-mode ultrasound, particularly in both ACR 1 and 2, thus reducing the false-positive rate.     

Chest ultrasound in the assessment of patients in ICU: How can it help?

Background: Different imaging techniques can be used for assessment of chest problems in ICU patients, however ultrasound is a good diagnostic tool giving more information and at the same time without exposure to radiation and without risk of critical patient transfer.Aim of the work: The aim of this work was to study the role of thoracic ultrasound in assessment of ICU patients.Materials and methods: The study was carried out on 30 patients admitted to the ICU.B and M modes chest ultrasound was done for all patients using EsaoteMyLab?Alpha with eHD Technology.Results: The study included 19 males and 11 females with mean age of 42.6 ± 21.4 years. In this study ultrasound was able to diagnose Pneumothorax: 3 cases (10%). Pleural effusion: 20 cases (66.6%). Alveolar interstitial syndrome: 7 cases (23.3%). Lung consolidation: 20 cases (66.6%). Pulmonary infarcts: 1 case (3.3%). Neoplastic disease: 1 case (3.3%). Chest wall pathology: 1 case (3.3%).Conclusion: Ultrasound examination of the chest is a non- invasive, and promising bed side tool for examination of ICU patients.     

Musculoskeletal ultrasound and MRI: which do I choose?

In the diagnosis of musculoskeletal disorders, there are several applications where both ultrasound and magnetic resonance imaging (MRI) may be considered viable alternatives. Because there are advantages and disadvantages to each imaging method, often it is unclear which should be considered for a specific indication. This article reviews this topic in the following manner. First, musculoskeletal applications where there are significant advantages for the use of ultrasound are discussed, which includes evaluation of soft tissue foreign bodies, peripheral nerves, pathologies that require dynamic imaging for diagnosis, and soft tissues adjacent to metal hardware. This is followed by a discussion of indications where both ultrasound and MRI may be considered, such as evaluation of a focal tendon abnormality, focal ligament abnormality, soft tissue fluid collection, and confirmation of a probable benign cyst, such as Baker's cyst and wrist ganglion. Musculoskeletal ultrasound should be viewed as an imaging method that complements MRI rather than one that competes with MRI in the evaluation of musculoskeletal abnormalities, as it can offer important information.     

Predictive model for contrast-enhanced ultrasound of the breast: Is it feasible in malignant risk assessment of breast imaging reporting and data system 4 lesions?

AIM: To build and evaluate predictive models for contrast-enhanced ultrasound (CEUS) of the breast to distinguish between benign and malignant lesions. METHODS: A total of 235 breast imaging reporting and data system (BI-RADS) 4 solid breast lesions were imaged via CEUS before core needle biopsy or surgical resection. CEUS results were analyzed on 10 enhancing patterns to evaluate diagnostic performance of three benign and three malignant CEUS models, with pathological results used as the gold standard. A logistic regression model was developed basing on the CEUS results, and then evaluated with receiver operating curve (ROC). RESULTS: Except in cases of enhanced homogeneity, the rest of the 9 enhancement appearances were statistically significant (P < 0.05). These 9 enhancement patterns were selected in the final step of the logistic regression analysis, with diagnostic sensitivity and specificity of 84.4% and 82.7%, respectively, and the area under the ROC curve of 0.911. Diagnostic sensitivity, specificity, and accuracy of the malignant vs benign CEUS models were 84.38%, 87.77%, 86.38% and 86.46%, 81.29% and 83.40%, respectively. CONCLUSION: The breast CEUS models can predict risk of malignant breast lesions more accurately, decrease false-positive biopsy, and provide accurate BI-RADS classification.     

Interval growth of probably benign breast lesions on follow-up ultrasound: how can these be managed?

Objectives  

To investigate the malignancy rate in probably benign lesions with interval growth on follow-up ultrasound (US) and the cut-off values for predicting malignancy.     

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.

Colour flow Doppler ultrasound of the carotid bifurcation: can it replace routine angiography before carotid endarterectomy?

The objective of this study was to assess the diagnostic accuracy of colour flow Doppler ultrasound (CFD) and its potential to replace digital subtraction angiography (DSA) before carotid endarterectomy (CEA). All patients undergoing CFD of the carotid bifurcation in our department over a period of 1-1/2 years for whom both CFD and DSA results were available were included in the study. We evaluated the feasibility of CFD, its diagnostic accuracy and its potential to diagnose clinically significant stenosis (50%, 70% and 90% NASCET type diameter stenosis) compared with DSA. 225 carotid bifurcations in 116 patients met the criteria for evaluation (biplane arterial DSA without superimposition). Data analysis yielded the following diagnostic performance of CFD: sensitivity for a 50% stenosis 91.4% (95% confidence interval (CI) 83.3--96.2%), specificity 93.2% (95% CI 87.1--96.8%) and accuracy 92.4% (95% CI 88.4--95.4%); sensitivity for a 70% stenosis 89.2% (95% CI 81.9--94.1%), specificity 96.2% (95% CI 90.5--98.6%) and accuracy 92.4% (95% CI 88.4--95.4%). In 9 of 116 cases, carotid angiography was used to evaluate inconclusive CFD results. DSA disclosed relevant information not suspected by CFD in only 1 of the 116 cases. Thus, 91% (106/116) of the angiographies could have been dispensed with without loss of information. One major stroke occurred during diagnostic DSA. We conclude that DSA of the carotid arteries is unnecessary when CFD is unequivocal. The diagnostic gain of DSA must be counterweighted against its potential risks.     

“I can see clearly now.” fundamentals of breast ultrasound optimization

Unlike other modalities in breast imaging, breast ultrasound is very operator dependent. Proper characterization and management of breast lesions depends on the knowledge and skill of the radiologist performing the exam. Breast ultrasound optimization continues to evolve as the technology of ultrasound machines improves. The American College of Graduate Medical Education (ACGME) program requirements for graduate medical education in diagnostic radiology recently updated requirements to include competency in ultrasound physics, knobology, and image generation. As trainees are held to high ultrasound optimization standards, practicing radiologists who perform breast ultrasound exams must keep up to date on current breast ultrasound optimization techniques to avoid mischaracterizing and mismanaging breast ultrasound findings. In this paper, ultrasound optimization techniques, including patient positioning, transducer frequency, transducer contact and pressure, depth, gain, focus, tissue harmonic imaging, spatial compounding, dynamic range, speed of sound imaging, Doppler evaluation, and elastography will be described. Multiple ultrasound case examples will be used to illustrate application of these skills. After reading this paper, the reader will be able to apply these techniques to their own breast ultrasound practice, improving characterization and management of breast lesions in their patients.     

Comparison between different imaging techniques in the evaluation of malignant breast lesions: can 3D ultrasound be useful?

Purpose

This study was done to assess the feasibility of three-dimensional ultrasonography (3D-US) for volume calculation of solid breast lesions.

Materials and methods

The volumes of 36 malignant lesions were measured using conventional 2D-US, 3D-US and magnetic resonance imaging (MRI) and compared with that obtained with histology (standard of reference). With 2D Ultrasouns, volume was estimated by measuring three diameters and calculating volume with the mathematical formula for spheres. With 3D-US, stored images were retrieved and boundaries of masses were manually outlined; volume calculation was performed with VOCAL software. For MRI, volume measurements were obtained with special software for 3D reconstructions, after each lesion had been manually outlined. Histology measured the three main diameters and the volume was estimated using the mathematical formula for spheres. Interclass correlation coefficient (ICC) and Bland–Altman plots were used to assess agreement between the volumes measured.

Results

ICC indicated that a good level of concordance was identified between 3D-US and histology (0.79). According to the Bland–Altman analysis, limits of agreement of mean differences of the volumes measured with the three imaging modalities were comparable with histology: ?2÷1.5 cm³ for 3D-US; ?2.3÷1.3 cm³ for 2D-US and ?2.2÷1.6 cm³ for MRI.

Conclusions

3D-US is a reliable method for the volumetric assessment of breast lesions. 3D-US is able to provide valuable information for the preoperative evaluation of lesions.     

Neural control of motor output: can training change it?

Henneman's size principle of motor unit recruitment and rate coding reduces fatigue, minimizes error in transfer of information from the nervous system, and produces smooth force output. Plasticity present at various sites of the motor system may change endurance, force, speed, or precision with training, but not the recruitment order.