[Systematic second opinion review of outside imaging in breast cancer diagnosis: An added value]. / Relecture systématique des bilans radiologiques extérieurs de diagnostic du cancer du sein : une valeur ajoutée.

INTRODUCTION: The systematic second opinion review in cancer centers after breast cancer detection is currently under development. The purposes were the evaluation of review's consequences, in particularly of the axillary staging and the evolution of the delays. METHODS: A retrospective study was conducted on patients who consulted a clinician at Cancer Center of Lorraine in Nancy from January 1st, 2016 to December 31th, 2016. We analyzed from their medical charts: the outside exams, the initial therapeutic plan, the second opinion review, the additional exams, the multidisciplinary consultation conclusions, the first treatment, the multidisciplinary consultation after surgery. RESULTS: In all, 251 patients were analyzed. Second opinion review discrepancies were seen in 72.5%. As a result, 43.4% of all patients had new breast-axillary biopsies. New malignancies lesions were identified in 19.9% of patients. Modifications in therapeutic plan were recommended in 19.9% of patients (including patients with and without new malignancies lesions diagnosed). Before a second opinion review, 9.8% of axillary ultrasound lead to a positive fine-needle biopsy. The additional exams identified 9.6% additional lesions. After a positive sentinel lymph node excision biopsy, the multidisciplinary consultation recommended a revision surgery of axillary lymph node dissection for 27% of patients with axillary ultrasound performed in our cancer center, and for 70% of patients without ultrasound (P=0.023). DISCUSSION: The systematic second opinion at cancer center allows the detection of new malignancies lesions and significant modifications in the therapeutic plan. A systematic evaluation of axillary ultrasound in cancer center could be considered.

Self-compression Technique vs Standard Compression in Mammography: A Randomized Clinical Trial.

Importance: Many women dread undergoing mammography, and some may not attend or reattend breast cancer screening because of the discomfort or pain induced by breast compression. Objective: To evaluate the noninferiority of the self-compression mammography technique for reducing breast thickness compared with standard compression. Design, Setting, and Participants: This prospective, parallel-group, noninferiority randomized clinical trial was conducted from May 7, 2013, to October 26, 2015, at 6 cancer care centers in France. Participants were women aged 50 to 75 years, without a history of recent breast surgical procedure or treatment, and who could perform self-compression. Analyses were performed on intention-to-treat basis from January 27, 2017, to March 30, 2018. Interventions: Patients were randomized 1:1 to the self-compression group or the standard compression group. Main Outcomes and Measures: Primary end point was breast thickness expressed as the mean of 4 views: right and left craniocaudal and right and left mediolateral oblique. The predefined noninferiority margin was a difference of 3 mm, with a 1-sided 95% CI. Secondary end points included compression force, image quality, requirement for additional views, pain, and patient satisfaction and radiographer assessment questionnaires. Results: Among the 549 women randomized, 548 (97.3%) completed the trial. Of these, 275 (48.8%) (mean [SD] age, 61.35 [6.34] years) were randomized to the self-compression arm and 273 (48.5%) (mean [SD] age, 60.84 [6.41] years) to the standard compression arm. The difference in the mean thickness between the 2 arms was lower than the noninferiority margin, with an upper 1-sided 95% CI less than 3 mm (-0.17; 95% CI,-∞ to 1.89 mm; P < .05). Compression force was higher in the self-compression group compared with the standard compression arm for the 4 mammographic views. Pain was statistically significantly lower in the self-compression group (n = 274) compared with the standard compression group (n = 269) (median [interquartile range (IQR)] score, 2 [1-5] vs 3 [1-5]; P = .009). No difference was reported in the image quality scores of the 2 groups or in the number of additional views performed (median [IQR] extra views, 2 [2-2] vs 2 [2-3] extra views; P = .64), whatever the indication, including insufficient image quality (29 [16.8%] vs 27 [15.0%] insufficient quality views; P = .65). No adverse effects or pain were reported by the participants after the self-compression mammography. Conclusions and Relevance: Self-compression does not appear to be inferior to standard compression mammography in achieving minimal breast thickness without increasing pain or compromising image quality; this technique may be an effective option for women who want to be involved in their breast examination. Trial Registration: ClinicalTrials.gov identifier: NCT02866591.

Cyberknife® stereotactic radiation therapy for stage I lung cancer and pulmonary metastases: evaluation of local control at 24 months.

BACKGROUND: CyberKnife® stereotactic radiotherapy allows for minimally invasive treatment with satisfactory results in patients with inoperable primary or metastatic lung cancer. The objective of this study was to identify factors influencing the probability of local control. METHODS: Ninety-five patients (100 lung tumors) treated between January and December 2013 at our department by SBRT (stereotactic body radiation therapy) using CyberKnife® were included in the study. There were 71 stage T1 or T2 primary tumors and 29 secondary tumors. The tracking methods were as follow: fiducial markers with Synchrony® in 50 cases (gold seeds in 35, coils in 15 cases), spine with 4D-CT and Xsight® Spine in 43 cases, and direct viewing by Xsight® Lung in 7 cases. The methods were allocated according to the characteristics of each target. RESULTS: With a median follow-up of 24 months, the probability of local control at 24 months was 88%. The probability of local control differed according to the size of the target (92% for tumors ≤35 mm and 54% for tumors >35 mm: P=0.013) and according to the distance of the fiducial markers in relation to the target (95% when <50 mm and 69% when ≥50 mm: P=0.011). CONCLUSIONS: The best results were obtained with small lesions. With Synchrony®, the distance of the target relative to the fiducial markers should be less than 50 mm. Gold seeds are recommended, although coils may be used instead of gold seeds. The number of fiducial markers did not have a significant impact on the probability of local control. With an appropriate tracking method, stereotactic radiotherapy is an efficient treatment for stage I lung cancer and lung oligometastases.

Impact of an abbreviated protocol for breast MRI in diagnostic accuracy.

PURPOSE: We aimed to compare the diagnostic accuracy and interpretation time of an abbreviated protocol relative to the complete protocol of breast magnetic resonance imaging (MRI) with the use of breast imaging reporting and data system (BI-RADS). Between-reader and between-protocol variability for BI-RADS classification and influence of reader expertise on diagnostic accuracies were also evaluated. METHODS: We conducted a retrospective reader study in 90 women who underwent breast MRI: 30 benign examinations (graded as American College of Radiology [ACR] 1 or 2), 30 examinations graded as ACR 3 and 30 examinations requiring a histologic proof (graded as ACR 4 or 5). Two radiologists independently reviewed the protocols. The reference standard was 24 months of imaging follow-up (66.6%, n=60), percutaneous biopsy at the 12th month imaging follow-up (5.5%, n=5), and breast surgery (27.9%, n=25). Analysis was done on a per-breast basis. There were 26 cancers in 168 breasts (15.1%) RESULTS: Interpretation time was higher for the complete protocol (mean difference: 84 s, 95% CI [67;101] for senior and 83 s, 95% CI [70;95] for junior reader; P < 0.001). The reliability of BI-RADS classification between both protocols was very good with intraclass correlation coefficient of 0.89 for junior reader and 0.98 for senior reader; the inter-reader reliability was 0.94 and 0.90 for the complete and abbreviated protocols, respectively. For senior reader, the abbreviated and complete protocols yielded 95.1% and 94.4% specificity and 100% sensitivity. CONCLUSION: Our data provide corroborating evidence that abbreviated protocols decrease interpretation time without compromising sensitivity or specificity. There was a high level of concordance between the abbreviated and complete protocols and between the two readers.

Abbreviated breast magnetic resonance protocol: Value of high-resolution temporal dynamic sequence to improve lesion characterization.

PURPOSE: To evaluate the added value of ULTRAFAST-MR sequence to an abbreviated FAST protocol in comparison with FULL protocol to distinguish benign from malignant lesions in a population of women, regardless of breast MR imaging indication. MATERIALS AND METHODS: From March 10th to September 22th, 2014, we retrospectively included a total of 70 consecutive patients with 106 histologically proven lesions (58 malignant and 48 benign) who underwent breast MR imaging for preoperative breast staging (n=38), high-risk screening (n=7), problem solving (n=18), and nipple discharge (n=4) with 12 time resolved imaging of contrast kinetics (TRICKS) acquisitions during contrast inflow interleaved in a regular high-resolution dynamic MRI protocol (FULL protocol). Two readers scored MR exams as either positive or negative and described significant lesions according to Bi-RADS lexicon with a TRICKS images (ULTRAFAST), an abbreviated protocol (FAST) and all images (FULL protocol). Sensitivity, specificity, positive and negative predictive values, and accuracy were calculated for each protocol and compared with McNemar's test. RESULTS: For all readers, the combined FAST-ULTRAFAST protocol significantly improved the reading with a specificity of 83.3% and 70.8% in comparison with FAST protocol or FULL protocol, respectively, without change in sensitivity. By adding ULTRAFAST protocol to FAST protocol, readers 1 and 2 were able to correctly change the diagnosis in 22.9% (11/48) and 10.4% (5/48) of benign lesions, without missing any malignancy, respectively. Both interpretation and image acquisition times for combined FAST-ULTRAFAST protocol and FAST protocol were shorter compared to FULL protocol (p<0.001). CONCLUSION: Compared to FULL protocol, adding ULTRAFAST to FAST protocol improves specificity, mainly in correctly reclassifying benign masses and reducing interpretation and acquisition time, without decreasing sensitivity.

Tumor response assessment by MRI following stereotactic body radiation therapy for hepatocellular carcinoma.

BACKGROUND: To evaluate the MRI features of a tumor response, local control, and predictive factors of local control after stereotactic body radiation therapy (SBRT) for hepatocellular carcinoma (HCC). METHODS: Thirty-five consecutive patients with 48 HCCs who were treated by SBRT were included in this retrospective study. All patients provided written informed consent to be treated by SBRT, and prior to inclusion they authorized use of the treatment data for further studies. The assessment was made using MRI, with determination of local and hepatic responses according to Response Evaluation Criteria in Solid Tumors (RECIST) and modified RECIST (mRECIST) criteria during a two-year follow-up. RESULTS: The local response rate according to mRECIST was higher than with RECIST. A tumor diameter less than 20 mm at baseline was an independent predictive factor for RECIST and mRECIST responses, as was diffusion-weighted signal for RECIST. During follow-up, a tumor diameter of <20 mm (p = 0.034) and absence of a high intensity on T2-weighted (p = 0.006) and diffusion-weighted images (p = 0.039) were associated with a better response according to RECIST. Post-treatment changes include peritumoral ring-like enhanced changes with high intensity on T2-weighted images. CONCLUSIONS: SBRT is a promising technique for the treatment of inoperable HCC. Post-treatment changes on MRI images can resemble tumor progression and as such must be adequately distinguished. The regression of tumorous enhancement is variable over time, although diffusion-weighted and T2-weighted intensities are predictive factors for tumor RECIST responses on subsequent MRIs. They hence provide a way to reliably predict treatment responses.

Comparison of the histopathological results of the radioguided percutaneous microbiopsies and the operative specimens of soft tissue tumors of limbs, trunk and retroperitoneum.

INTRODUCTION: Suspicious lesions of sarcoma require preoperative biopsies. If surgical biopsies remain the gold standard, radioguided percutaneous microbiopsies are gaining an increasing importance. The purpose of this study was to compare histopathological results of percutaneous biopsies of soft tissues, trunk and retroperitoneal tumors with the histopathological results of operative specimens. METHODS: This is a retrospective study including 84 patients treated in our institution. The concordance between the results of the microbiopsy and the operative specimen for the benign-malignant differentiation and the histological type was evaluated. The microbiopsy accuracy was calculated. The sensitivity and the specificity of the microbiopsies compared to the operative specimen were also evaluated for the benign-malignant differentiation. RESULTS: The concordance was 0.92 [0.79-1] for the benign-malignant differentiation, 0.97 [0.92-1] for the histological type. The accuracy of microbiopsies was therefore 96% (sensibility=97.0%; specificity=94.1%) for the benign-malignant detection and 97.8% for the histological type. CONCLUSION: Percutaneous microbiopsies play an important part in the diagnosis of soft tissue tumors of the limbs, trunk and retroperitoneum, in particular as a replacement to more invasive surgical biopsies. This study evidences the increasing importance of the collaboration between radiologist, surgeon and pathologist in the diagnosis of sarcoma.

Age Estimation in Living Adults using 3D Volume Rendered CT Images of the Sternal Plastron and Lower Chest.

Age estimation is commonly of interest in a judicial context. In adults, it is less documented than in children. The aim of this study was to evaluate age estimation in adults using CT images of the sternal plastron with volume rendering technique (VRT). The evaluation criteria are derived from known methods used for age estimation and are applicable in living or dead subjects. The VRT images of 456 patients were analyzed. Two radiologists performed age estimation independently from an anterior view of the plastron. Interobserver agreement and correlation coefficients between each reader's classification and real age were calculated. The interobserver agreement was 0.86, and the correlation coefficients between readers classifications and real age classes were 0.60 and 0.65. Spearman correlation coefficients were, respectively, 0.89, 0.67, and 0.71. Analysis of the plastron using VRT allows age estimation in vivo quickly and with results similar than methods such as Iscan, Suchey-Brooks, and radiographs used to estimate the age of death.

Investigation of ectopic recurrent skull base and cervical chordomas: The Institut Curie's proton therapy center experience.

BACKGROUND: Cervical and skull base chordomas may relapse locally, marginally, or in ectopic sites (ie, surgical pathway, lymph nodes, prevertebral space, subdural space, or distant organs). METHODS: Among 371 patients treated between 1995 and 2010, we matched the initial dosimetry with the 3D imaging of recurrence and selected the patients with isolated ectopic recurrence. RESULTS: During our follow-up, we identified 13 patients who developed ectopic relapses (n = 18) in the form of lung metastasis (n = 2), axial dissemination (n = 6), nodal recurrence (n = 2), subcutaneous metastasis (n = 3), and/or seeding along the surgical pathway (n = 5). Despite treatment of these 13 patients with radiation, surgical interventions, and/or chemotherapy, we could only salvage 5 patients with recurrence in surgical pathway, whereas the remaining 8 patients succumbed to a poor prognosis. CONCLUSION: Our study emphasizes an urgent need for prediction and early diagnosis of ectopic relapses in patients with cervical and skull base chordoma to improve accuracy of their aggressive treatments. © 2015 Wiley Periodicals, Inc. Head Neck 38: E1238-E1246, 2016.

Teaching medical anatomy: what is the role of imaging today?

PURPOSE: Medical anatomy instruction has been an important issue of debate for many years and imaging anatomy has become an increasingly important component in the field, the role of which has not yet been clearly defined. The aim of the paper was to assess the current deployment of medical imaging in the teaching of anatomy by means of a review of the literature. MATERIALS: A systematic search was performed using the electronic database PubMed, ScienceDirect and various publisher databases, with combinations of the relevant MeSH terms. A manual research was added. RESULTS: In most academic curricula, imaging anatomy has been integrated as a part of anatomical education, taught using a very wide variety of strategies. Considerable variation in the time allocation, content and delivery of medical imaging in teaching human anatomy was identified. Given this considerable variation, an objective assessment remains quite difficult. DISCUSSION: In most publications, students' perceptions regarding anatomical courses including imaging anatomy were investigated by means of questionnaires and, regardless of the method of teaching, it was globally concluded that imaging anatomy enhanced the quality and efficiency of instruction in human anatomy. More objective evaluation based on an increase in students' performance on course examinations or on specific tests performed before and after teaching sessions showed positive results in numerous cases, while mixed results were also indicated by other studies. CONCLUSION: A relative standardization could be useful in improving the teaching of imaging anatomy, to facilitate its assessment and reinforce its effectiveness.

Stereotactic body radiation therapy as an ablative treatment for inoperable hepatocellular carcinoma.

PURPOSE: To describe efficacy and safety of stereotactic body radiation therapy (SBRT) for the treatment of inoperable hepatocellular carcinoma. METHODS: The records of 77 consecutive patients treated with SBRT for 97 liver-confined HCC were reviewed. A total dose of 45Gy in 3 fractions was prescribed to the 80% isodose line. Local control (LC), overall survival (OS), progression-free survival (PFS) and toxicity were studied. RESULTS: The median follow-up was 12months. The median tumor diameter was 2.4cm. The LC rate was 99% at 1 and 2years. The 1 and 2-year OS were 81.8% and 56.6% respectively. The median time to progression was 9months (0-38). The rate of hepatic toxicity was 7.7% [1.6-13.7], 14.9% [5.7-23.2] and 23.1% [9.9-34.3] at 6months, 1year and 2years respectively. In multivariate analysis, female gender (HR 7.87 [3.14-19.69]), a BCLC B-C stage (HR 3.71 [1.41-9.76]), a sum of all lesion diameters ⩾2cm (HR 7.48 [2.09-26.83]) and a previous treatment (HR 0.10 [0.01-0.79]) were independent prognostic factors of overall survival. CONCLUSION: SBRT allows high local control for inoperable hepatocellular carcinomas. It should be considered when an ablative treatment is indicated in Child A patients.

Recent advances in medical imaging: anatomical and clinical applications.

The aim of this paper was to present an overview of the most important recent advances in medical imaging and their potential clinical and anatomical applications. Dramatic changes have been particularly observed in the field of computed tomography (CT) and magnetic resonance imaging (MRI). Computed tomography (CT) has been completely overturned by the successive development of helical acquisition, multidetector and large area-detector acquisition. Visualising brain function has become a new challenge for MRI, which is called functional MRI, currently based principally on blood oxygenation level-dependent sequences, which could be completed or replaced by other techniques such as diffusion MRI (DWI). Based on molecular diffusion due to the thermal energy of free water, DWI offers a spectrum of anatomical and clinical applications, ranging from brain ischemia to visualisation of large fibrous structures of the human body such as the anatomical bundles of white matter with diffusion tensor imaging and tractography. In the field of X-ray projection imaging, a new low-dose device called EOS has been developed through new highly sensitive detectors of X-rays, allowing for acquiring frontal and lateral images simultaneously. Other improvements have been briefly mentioned. Technical principles have been considered in order to understand what is most useful in clinical practice as well as in the field of anatomical applications. Nuclear medicine has not been included.