Radiomic analysis of HTR-DCE MR sequences improves diagnostic performance compared to BI-RADS analysis of breast MR lesions.

PURPOSE: To assess the diagnostic performance of radiomic analysis using high temporal resolution (HTR)-dynamic contrast enhancement (DCE) MR sequences compared to BI-RADS analysis to distinguish benign from malignant breast lesions. MATERIALS AND METHODS: We retrospectively analyzed data from consecutive women who underwent breast MRI including HTR-DCE MR sequencing for abnormal enhancing lesions and who had subsequent pathological analysis at our tertiary center. Semi-quantitative enhancement parameters and textural features were extracted. Temporal change across each phase of textural features in HTR-DCE MR sequences was calculated and called "kinetic textural parameters." Statistical analysis by LASSO logistic regression and cross validation was performed to build a model. The diagnostic performance of the radiomic model was compared to the results of BI-RADS MR score analysis. RESULTS: We included 117 women with a mean age of 54 years (28-88). Of the 174 lesions analyzed, 75 were benign and 99 malignant. Seven semi-quantitative enhancement parameters and 57 textural features were extracted. Regression analysis selected 15 significant variables in a radiomic model (called "malignant probability score") which displayed an AUC = 0.876 (sensitivity = 0.98, specificity = 0.52, accuracy = 0.78). The performance of the malignant probability score to distinguish benign from malignant breast lesions (AUC = 0.876, 95%CI 0.825-0.925) was significantly better than that of BI-RADS analysis (AUC = 0.831, 95%CI 0.769-0.892). The radiomic model significantly reduced false positives (42%) with the same number of missed cancers (n = 2). CONCLUSION: A radiomic model including kinetic textural features extracted from an HTR-DCE MR sequence improves diagnostic performance over BI-RADS analysis. KEY POINTS: • Radiomic analysis using HTR-DCE is of better diagnostic performance (AUC = 0.876) than conventional breast MRI reading with BI-RADS (AUC = 0.831) (p < 0.001). • A radiomic malignant probability score under 19.5% gives a negative predictive value of 100% while a malignant probability score over 81% gives a positive predictive value of 100%. • Kinetic textural features extracted from HTR-DCE-MRI have a major role to play in distinguishing benign from malignant breast lesions.

Magnetic resonance imaging classification of deep pelvic endometriosis: description and impact on surgical management.

STUDY QUESTION: Is an MRI classification of deep pelvic endometriosis (DE) able to correctly predict the risk of DE surgery. SUMMARY ANSWER: A new radiological classification, that we have called the deep pelvic endometriosis index (dPEI) classification, is accurate and reproducible to assess the extension of the disease in central and lateral compartments and well correlated with operating time, hospital stay duration and the risk of voiding dysfunction. WHAT IS KNOWN ALREADY: Few imaging classifications are currently available to predict the extent of DE to help preoperative assessment of surgical outcomes and provide the patient with objective information about the risk of surgical complications. STUDY DESIGN, SIZE, DURATION: Retrospective monocentric observational study was conducted between 01 January 2017 and 31 December 2018 and included 150 women (mean age = 34.5 years, 20-52 years) with DE on MRI and who subsequently underwent surgery. PARTICIPANTS/MATERIALS, SETTING, METHODS: Two radiologists independently graded the disease according to MRI-based Enzian classification (A (rectovaginal septum and vagina locations), B (uterosacral locations) and C (rectosigmoid locations)) and a new radiological classification, that we have called the dPEI, that grades the severity of DE as: mild, moderate or severe DE. MRI findings and classification were correlated with surgical and pathological results. MAIN RESULTS AND THE ROLE OF CHANCE: MRI-based and surgical Enzian classifications were concordant for A lesions in 78.7% (118/150), for B lesions in 34.7% (52/150) and for C lesions in 82.7% (124/150). Operating time and hospital stays were longer in Group A2 (rectovaginal septum and vagina, 1-3 cm) compared to A0, B2 (uterosacral, 1-3 cm) compared to B0, C3 (rectosigmoid >3 cm) compared to C2 (rectosigmoid 1-3 cm) or C0 (P < 0.001), in severe compared to moderate DE patients, and in moderate compared to mild extensive patients (P < 0.01). Patients with vaginal or rectosigmoid involvement were respectively six and three times more likely to experience high-grade complications according to Clavien-Dindo classification than patients without vaginal or rectosigmoid disease (P < 0.001). Postoperative voiding dysfunction was correlated with A lesions (odds ratio (OR) = 6.82, 95% CI 2.34-20.5), moderate or severe DE (OR = 4.15, 95% CI 1.26-17.9), the presence of at least unilateral lateral pelvic involvement (OR = 3.6, 95% CI 1.14-11.2, P = 0.03) and C lesions (OR = 2.6, 95% CI 1.03-6.8, P < 0.01). LIMITATIONS, REASONS FOR CAUTION: The study was conducted in an expert center and needs to be validated in a multicenter study. There is a limited number of patients with lateral pelvic endometriosis beyond the parietal fascia, probably due to the low prevalence of this disease presentation. WIDER IMPLICATIONS OF THE FINDINGS: MRI imaging can be used to accurately predict postoperative complications for women with DE. This may help the clinician to preoperatively inform a patient about the risks of surgery. Larger clinical studies are required to validate these results. STUDY FUNDING/COMPETING INTEREST(S): No external funding was used for this study. I.T.N.: Remunerated lecture GE, Hologic, Guerbet, Canon; Advisory board: Siemens - These relationships are on the topic of breast imaging, not related to the topic of this paper. Other coauthors have no conflict of interest to declare. TRIAL REGISTRATION NUMBER: Not applicable.

Breast MRI: Is Faster Better?

OBJECTIVE. Fast breast MRI protocols have the same sensitivity as conventional protocols, but their specificity is variable and can be inadequate. An ultrafast sequence provides early enhancement of lesion characteristics that optimize the characterization of the fast protocol, increasing positive predictive values without increasing time. CONCLUSION. These new abbreviated protocols could constitute a viable screening tool both for women at high risk of breast cancer and for those at intermediate risk with high breast density.

Laterally Extended Endopelvic Resection of Recurrent Epithelioid Trophoblastic Tumor by Laparoscopy.

We report the resection of a recurrent epithelioid trophoblastic tumor by laparoscopic laterally extended endopelvic resection (LEER). The LEER technique was developed to resect en bloc multiple visceral compartments involving the lateral pelvic wall with negative margins for local control of advanced and recurrent malignancies. Described by Höckel, this procedure is usually performed by a midline laparotomy. Our patient had undergone prior laparotomic surgery including hysterectomy, partial bladder resection, and a right ureteral reimplantation for an epithelioid trophoblastic tumor without adjuvant treatment. She presented a recurrent tumor infiltrating the bladder, the ureter, and the right pelvic wall as well as the internal and external iliac vessels. A vascular surgeon first performed a femorofemoral bypass by bilateral groin incisions with a subcutaneous tunnel. The surgery was then exclusively performed by laparoscopy using the LEER technique including resection of both external and internal iliac vessels and the pelvic wall through the lateral pelvic muscles and iterative bladder resection associated with a ureteral reimplantation using the psoas hitch bladder technique. The patient experienced Clavien-Dindo classification grade II postoperative complications. Histology showed a margin-free resection (R0).

Abbreviated breast MRI combining FAST protocol and high temporal resolution (HTR) dynamic contrast enhanced (DCE) sequence.

PURPOSE: We evaluated the diagnostic value of a high temporal resolution (HTR) dynamic contrast enhanced (DCE) sequence added to a FAST protocol. MATERIALS AND METHODS: 120 women (mean age = 55 years (28-88)) who underwent breast MRI between July 2016 and March 2017 and in whom a biopsy was performed (i.e., gold standard) (n = 179: 69 benign, 7 borderline and 103 malignant lesions) were retrospectively and consecutively included. Two readers classified lesions according to the Breast Imaging-Reporting and Data System (BI-RADS) by reading: a FAST protocol (T1W, T2W, T1W-fat saturated 2 min after injection) and then a FULL standard protocol. Independently they determined if lesions were visible and when (Time To Enhancement (TTE)) on the HTR-DCE sequence. An Abbreviated protocol was then built using data from the HTR-DCE sequence added to the FAST protocol. RESULTS: All lesions were visible with the FAST protocol. 171/179 (95.5%) lesions were detected by reading theHTR-DCE sequence. There were a higher number of cancers rated BI-RADS 3 (PPV of malignancy of 27.6% (8/29) in FAST versus 18.7% (3/16) FULL protocol). An early enhancement on the HTR-DCE sequence (TTE < 31 s) was associated with malignancy with an OR 5.6 (CI 95%: 3.3-20.4) (p < 0.0001). Adding a TTE < 31 s to FAST analysis (AUROC = 0.826) significantly improved lesion characterization with a diagnostic gain of 10.6% (19/179) lesions correctly reclassified (p = 0.0034) compared to FAST protocol; with shorter acquisition time (7 min 48 s versus 13 min 54 s). CONCLUSION: Adding an HTR-DCE sequence to a FAST protocol increases diagnostic performance reaching that of the FULL protocol while reducing acquisition time.

Hyperechoic breast images: all that glitters is not gold!

Hyperechogenicity is a sign classically reported to be in favour of a benign lesion and can be observed in many types of benign breast lesions such as hamartoma, lipoma, angiolipoma, haemangioma, haematoma, fat necrosis, fibrosis and galactocele, among others. However, some rare malignant breast lesions can also present a hyperechoic appearance. Most of these hyperechoic malignant lesions present other characteristics that are more typically suggestive of malignancy such as posterior shadowing, a more vertical axis or irregular margins that help to guide the diagnosis. Post magnetic resonance imaging, second-look ultrasound may visualise hyperechoic malignant lesions that would not have been identified at first sight and radiologists must know how to recognise these lesions. TEACHING POINTS: • Some rare malignant breast lesions can present a hyperechoic appearance. • Malignant lesions present other characteristics that are suggestive of malignancy. • An echogenic mass with fat density on mammography does not require biopsy.