The potential use of ultra-low radiation dose images in digital mammography--a clinical proof-of-concept study in craniocaudal views.

OBJECTIVE: To estimate the potential of low-dose images in digital mammography by analysing the effect of substantial dose reduction in craniocaudal (CC) views on clinical performance. METHODS: At routine mammography, additional CC views were obtained with about 10% of the standard dose. Five radiologists retrospectively read the standard [mediolateral oblique (MLO) + CC] and combination low-dose mammograms (standard MLO + low-dose CC). If present, lesion type, conspicuity and suggested work-up were recorded. Final diagnoses were made by histology or follow up. A t-test or χ(2) test was used to compare results. RESULTS: 421 cases were included, presenting 5 malignancies, 66 benign lesions and multiple non-specific radiologic features. Using MLO with low-dose CC, all lesions were detected by at least one reader, but altogether less often than with standard mammography (sensitivity, 73.9% vs 81.5%). Missed lesions concerned all types. Lesions detected with both protocols were described similarly (p = 0.084) with comparable work-up recommendations (p = 0.658). CONCLUSION: Mammography with ultra-low-dose CC images particularly influences detection. While sensitivity decreased, specificity was unaffected. In this proof-of-concept study a lower limit was to be determined that is not intended nor applicable for clinical practice. This should facilitate further research in optimization of a low-dose approach, which has potential in a relatively young and largely asymptomatic population. ADVANCES IN KNOWLEDGE: Tungsten/silver-acquired mammography images might facilitate substantial dose reduction. Ultra-low-dose CC images reduce sensitivity, but not specificity. Low-dose images have potential in a largely young and asymptomatic population; a baseline is set for further research in optimization of a low-dose approach.

Wire localization of non-palpable breast lesions: out of date?

AIMS: With the increasing use of screening mammography, more and more non-palpable lesions are found. As less invasive techniques like core needle biopsy are introduced, we evaluated our experience with the well-known standard procedure of surgical excision after wire localization. METHODS: We retrospectively evaluated the results of 479 wire localizations for non-palpable breast lesions between 1992 and 1999 in 465 patients. Feasibility and reliability of the procedure and the incidence of complications are reported. RESULTS: The mean age of these patients was 57 years (range 22-81 years). The mammographic finding with the highest rate of malignancy was density combined with architectural distortion (72%). The removal of the lesion was radiologically confirmed in 93%; if the lesion appeared to be not removed, after 3 months mammography was repeated, in 14 patients a second localization procedure was done and in 10 patients still a malignancy was found. In 79%, the excision after initial fine-wire localization was irradical. Twenty-five patients developed a haematoma and five patients had a wound infection. The overall malignancy rate was 50%. With a mean follow-up of 18 months in 11 patients with a diagnosis of benign disease after an adequate procedure, still a malignancy was found at the original excision site. CONCLUSION: In selected cases, especially as a part of the therapeutic procedure in breast-conserving therapy, there will remain a place for wire localization and excision biopsy. However, we have to reconsider its place as a diagnostic procedure as the results of less invasive procedures are promising.

Palliative embolization in gynaecological patients.

Palliative embolization in patients with gynaecological malignancies is indicated, if other methods of treatment like irradiation, surgery and chemotherapy are impossible or contra-indicated. The experience in 9 patients is reported, with embolization of one renal artery because of metastasis in the kidney and in eight patients the hypogastric arteries uni- or bilaterally by means of Gelfoam and/or Gianturco coils because of inoperable bleeding malignancies.

A rare developmental variant of the atlas.

Congenital anomalies of the arch of the atlas in the sense of clefts are uncommon. As such anomalies may be mistaken for fractures, radiologists should be aware of them. A case of aplasia of the right part of the posterior arch producing wide, asymmetric medial cleft of the atlas is presented. The patient also had hypoplastic left part of the arch with the lateral cleft formed by a secondary ossification centre in the posterior tubercle. This combination of anomalies has not formerly been presented in literature.

Castleman's disease or giant lymph node hyperplasia.

A case of the rare condition giant lymph node hyperplasia is presented, where CT showed a mass with the same density as muscle while at angiography the vascular pattern appeared benign. Castleman's disease is benign and surgical excision is curative.

Influence of negative ultrasound findings on the management of in- and outpatients with suspected deep-vein thrombosis.

Real-time ultrasonography (US) was used as a single non-invasive method in the management of 174 patients (56 inpatients and 118 outpatients) with suspected deep-vein thrombosis (DVT). Therapeutic decisions were based on the results of ultrasonography alone. If the US examination was abnormal anticoagulant treatment was started. If the initial US examination was normal, no treatment was given and the patient underwent repeated testing and physical examination after 1 day, 7 days and 3 months. In the outpatient group, 1.3% of the ultrasonographic negative patients developed thromboembolic complications (95% confidence limits, 0.03-7.21%). None of the initial ultrasonographic negative patients developed proximal DVT after 1 day and 7 days. In the inpatient group, 10% of the ultrasonographic negative patients developed thromboembolic complications (95% confidence limits, 1.2-31.7%). In 18% of the ultrasonographic negative patients an alternative, unexpected diagnosis was obtained by ultrasound. The most frequent alternative diagnosis was a popliteal cyst. The results indicate that US alone appears to be a safe diagnostic method in the management of outpatients with suspected DVT. In the inpatient group further research is required for definite recommendations regarding a safe ultrasound follow-up schedule.

Radiological visualization of the portal venous system. A historical review.

A summary of several techniques for visualization of the portal venous system, developed in the last four decades, is given. The various methods are divided into direct and indirect techniques. Indirect arterial portography is the method of choice in patients with cirrhosis of the liver, being the most physiologic technique, visualizing the total portal venous system including arterial supply and having a low complication risk.

Arterial hypertension treated by angioplasty (Dotter). A serious complication.

Typical renovascular hypertension in a middle-aged woman was treated by percutaneous transluminal angioplasty. The initial result was good, but cerebral complications developed within 2 weeks. Examination of the major neck vessels before undertaking treatment leading to a permanent reduction in the blood pressure, is recommended.

Multiple epiphyseal dysplasia complicated by severe osteochondritis dissecans of the knee. Incidence in two families.

Two families are described which appear to contain examples of multiple epiphyseal dysplasia. In both families a striking incidence of severe osteochondritis of the knees was encountered. It is suggested that this was caused by the fragmented and maldeveloped epiphyses characteristic of epiphyseal dysplasia.

Restenosis of the renal artery after percutaneous transluminal renal angioplasty: an inevitable outcome?

We performed follow-up studies in 26 patients four to 36 months after percutaneous transluminal renal angioplasty. Restenosis was found in 47 per cent of the patients who had an atherosclerotic type of stenosis and in 14 per cent of the patients with fibromuscular dysplasia. We could not detect any significant differences between the atherosclerotic patients who did develop restenosis and those who did not. In fact, the presence of generalised atherosclerosis, the severity of the stenosis and the initial success of the dilatation were similar in the two groups. It thus cannot be predicted which patients will develop restenosis.

Restenosis prevalence and long-term effects on renal function after percutaneous transluminal renal angioplasty.

We studied the frequency of restenosis and the effects of percutaneous transluminal renal angioplasty (PTRA) on blood pressure (BP) and particularly on renal function in all patients in whom successful dilatation was performed. Restenosis was found in 42% of the patients with an atherosclerotic renal artery stenosis and in 22% of the patients with fibromuscular dysplasia. BP improvement was seen in 70-80% of the patients with unilateral stenosis or with successful bilateral dilatation (group I) whereas only seldom was an effect on BP observed in patients with more complicated disease, such as those with an occlusion of the contralateral artery (group II). Remarkably, however, both in group I and in group II, in about half of the patients an improvement in renal function was found, even 2-3 years after the procedure. Our results thus indicate that PTRA can be useful in preservation or even improvement of renal function, even if no effect on blood pressure can be expected.