Incorporating dose-volume histogram parameters of swallowing organs at risk in a videofluoroscopy-based predictive model of radiation-induced dysphagia after head and neck cancer intensity-modulated radiation therapy.

PURPOSE: To develop a videofluoroscopy-based predictive model of radiation-induced dysphagia (RID) by incorporating DVH parameters of swallowing organs at risk (SWOARs) in a machine learning analysis. METHODS: Videofluoroscopy (VF) was performed to assess the penetration-aspiration score (P/A) at baseline and at 6 and 12 months after RT. An RID predictive model was developed using dose to nine SWOARs and P/A-VF data at 6 and 12 months after treatment. A total of 72 dosimetric features for each patient were extracted from DVH and analyzed with linear support vector machine classification (SVC), logistic regression classification (LRC), and random forest classification (RFC). RESULTS: 38 patients were evaluable. The relevance of SWOARs DVH features emerged both at 6 months (AUC 0.82 with SVC; 0.80 with LRC; and 0.83 with RFC) and at 12 months (AUC 0.85 with SVC; 0.82 with LRC; and 0.94 with RFC). The SWOARs and the corresponding features with the highest relevance at 6 months resulted as the base of tongue (V65 and Dmean), the superior (Dmean) and medium constrictor muscle (V45, V55; V65; Dmp; Dmean; Dmax and Dmin), and the parotid glands (Dmean and Dmp). On the contrary, the features with the highest relevance at 12 months were the medium (V55; Dmin and Dmean) and inferior constrictor muscles (V55, V65 Dmin and Dmax), the glottis (V55 and Dmax), the cricopharyngeal muscle (Dmax), and the cervical esophagus (Dmax). CONCLUSION: We trained and cross-validated an RID predictive model with high discriminative ability at both 6 and 12 months after RT. We expect to improve the predictive power of this model by enlarging the number of training datasets.

Yttrium-90 Radioembolization for Hepatocellular Carcinoma with Portal Vein Invasion: Validation of the Milan Prognostic Score.

The aim of the present study was to retrospectively analyze clinical outcomes of patients with hepatocellular carcinoma (HCC) and portal vein tumor thrombosis (PVTT) treated with yttrium-90 radioembolization stratified by Milan PVTT score according to PVTT extension, tumor burden, and bilirubin levels. Seventy patients were included and classified into good (n = 15; 21.4%), intermediate (n = 33; 47.1%), and dismal (n = 22; 31.4%) prognostic groups. Median overall survival durations were 24.6 mo, 13 mo (hazard ratio = 3.2; 95% confidence interval [CI], 1.2-9.7; P = .016), and 5.9 mo (hazard ratio = 4.1; 95% CI, 1.4-13.4; P = .0096), respectively. The Milan score represents an easy tool to select patients with HCC with PVTT who may benefit from radioembolization.

Role of Transhepatic Arterial Radioembolization in Metastatic Colorectal Cancer.

The liver represents the most frequent location of metastatic disease in colorectal cancer (CRC). In oligometastatic disease, while surgery remains the mainstay of treatment, loco-regional therapies allow to locally control tumor progression and prolong survival. There is consensus in the use of transhepatic arterial radioembolization (TARE) in metastatic CRC chemorefractory patients, with liver-only or liver-dominant disease. Beyond this indication, TARE may be considered in other clinical scenarios, such as in the second-line combined with chemotherapy, as a bridge in between different lines of systemic therapies, and as ablative technique under specific circumstances. This paper outlines the current evidence for TARE in mCRC and presents possible future indications and directions.

Yttrium-90 transarterial radioembolization for liver metastases from medullary thyroid cancer.

Objectives: Liver metastases occur in 45% of patients with advanced metastatic medullary thyroid cancer (MTC). Transarterial radioembolization (TARE) has been proposed to treat liver metastases (LM), especially in neuroendocrine tumors. The aim of this study was to investigate the biochemical (calcitonin and carcino-embryonic antigen) and objective response of liver metastases from MTC to TARE. Methods: TARE is an internal radiotherapy in which microspheres loaded with ß-emitting yttrium-90 (90Y) are delivered into the hepatic arteries that supply blood to LM. Eight patients with progressive multiple LM underwent TARE and were followed prospectively. They were clinically, biochemically and radiologically evaluated at 1, 4, 12 and 18 months after TARE. Results: Two patients were excluded from the analysis due to severe liver injury and death due to extrahepatic disease progression, respectively. One month after TARE, a statistically significant (P = 0.02) reduction of calcitonin was observed in all patients and remained clinically relevant during follow-up; reduction of CEA, although not significant, was found in all patients. Significant reduction of liver tumor mass was observed 1, 4 and 12 months after TARE (P = 0.007, P = 0.004, P = 0.002, respectively). After 1 month, three of six patients showed partial response (PR) and three of six stable disease (SD) according to RECIST 1.1, while five of six patients had a PR and one of six a SD according to mRECIST. The clinical response remained relevant 18 months after TARE. Excluding one patient, all others showed only a slight and transient increase in liver enzymes. Conclusions: TARE is effective in LM treatment of MTC. The absence of severe complications and the good tolerability make TARE a valid therapeutic strategy when liver LM are multiple and progressive.

Toward an effective use of laser-driven very high energy electrons for radiotherapy: Feasibility assessment of multi-field and intensity modulation irradiation schemes.

Radiotherapy with very high energy electrons has been investigated for a couple of decades as an effective approach to improve dose distribution compared to conventional photon-based radiotherapy, with the recent intriguing potential of high dose-rate irradiation. Its practical application to treatment has been hindered by the lack of hospital-scale accelerators. High-gradient laser-plasma accelerators (LPA) have been proposed as a possible platform, but no experiments so far have explored the feasibility of a clinical use of this concept. We show the results of an experimental study aimed at assessing dose deposition for deep seated tumours using advanced irradiation schemes with an existing LPA source. Measurements show control of localized dose deposition and modulation, suitable to target a volume at depths in the range from 5 to 10 cm with mm resolution. The dose delivered to the target was up to 1.6 Gy, delivered with few hundreds of shots, limited by secondary components of the LPA accelerator. Measurements suggest that therapeutic doses within localized volumes can already be obtained with existing LPA technology, calling for dedicated pre-clinical studies.

No evidence of chromosome damage in children and adolescents with differentiated thyroid carcinoma after receiving 131I radiometabolic therapy, as evaluated by micronucleus assay and microarray analysis.

PURPOSE: As (131)I therapy, used to achieve ablation of thyroid gland remnant, can cause chromosome damage in cultured peripheral lymphocytes especially, we investigated whether administration of radioiodine may induce early genome damage in peripheral T lymphocytes of adolescents with differentiated thyroid carcinoma (DTC). METHODS: We studied 11 patients, aged 14.8 +/- 3.1 years, who assumed (131)I (range: 1.11-4.44 GBq) to ablate thyroid remnant. A blood sample for micronucleus assay and for evaluating expression of some genes involved in the DNA repair or the apoptosis pathways was obtained from each patient 1 h before (T(0)) and 24 (T(1)) and 48 h (T(2)) post-radioiodine administration. RESULTS: Compared to T(0), we did not find any difference in the number of micronucleated cells at both T(1) and T(2) in any subject. Nine out of 11 patients had altered expression levels in a majority of the DNA repair and apoptosis genes at T(1), which decreased at T(2). CONCLUSIONS: We demonstrated for the first time that peripheral cells of DTC children and adolescents who received (131)I at a mean dosage of 3.50 +/- 0.37 GBq did not show chromosome damage within 48 h from the end of radiometabolic therapy. This may be due to a prompt activation of the cell machinery that maintains the integrity of the genome to prevent harmful double-strand breaks from progressing to chromosome mutations, either by repairing the lesions or by eliminating the most seriously damaged cells via apoptosis.

Induction of chromatid-type aberrations in peripheral lymphocytes of hospital workers exposed to very low doses of radiation.

Radiological personnel represent workers exposed to low cumulative doses of radiation. As their surveillance is generally based on physical dosimetry, there is little or inconclusive information on biological effects due to radiation exposure at these doses. We aimed to explore the extent of chromosomal damage in circulating lymphocytes of hospital workers (technicians, nurses and physicians) chronically exposed to a very low level of radiation using conventional and molecular cytogenetic analyses (chromosome painting with chromosomes #2, #3 and #10 as probe cocktail). Compared with controls, exposed workers displayed a significant increase in the frequency of aberrant lymphocytes (1.26+/-0.11/100 cells versus 1.63+/-0.17/100 cells). In particular, exposed technicians showed significantly higher mean values than nurses or physicians (3.68+/-1.17/100 cells versus 1.36+/-0.18/100 cells and 1.36+/-0.09/100 cells, respectively). Interestingly, we found that the chromosomal damage was prevalently expressed as chromatid-type aberrations. Chromosome painting indicated that the frequency of chromosome rearrangements (CR; translocations and dicentrics pooled together) was approximately comparable between radiological workers and the control group. Moreover, we did not detect any significant difference due to radiation exposure when CR rates were considered separately for each of the three chromosomes in the probe cocktail.

Treatment with drugs able to reduce iodine efflux significantly increases the intracellular retention time in thyroid cancer cells stably transfected with sodium iodide symporter complementary deoxyribonucleic acid.

CONTEXT: One of the major limits of gene therapy with sodium iodide symporter (NIS), which enables cells to be subjected to radioiodine therapy, is that NIS-transfected cells rapidly release the intracellular iodine. METHODS: We transfected human anaplastic (FRO) and medullary (TT) thyroid cancer-derived cell lines that were unable to take up iodine with human NIS cDNA. The possibility of increasing the iodine retention time by treating the transfected clones with myricetin, lithium, 17-(allylamino)-17-demethoxygeldanamycin (17-AAG), and 4,4'-diisothiocyanatostilbene-2,2'-disulfonic acid (DIDS) was explored. RESULTS: We obtained 19 FRO and 16 TT clones stably transfected with NIS. Twelve of 19 FRO and nine of 16 TT clones expressed the full-length NIS mRNA; 11 of 12 FRO and four of nine TT clones were able to take up radioiodine and correctly expressed NIS protein on the plasma membrane. Kinetic analysis of iodide uptake in the two clones (FRO-19 and TT-2) with the highest uptaking activity revealed that the plateau was reached after 30 min by FRO-19 and after 60 min by TT-2. The t(1/2) of the iodide efflux was 9 min in FRO-19 and 20 min in TT-2. The treatment of the two cell lines with four different drugs revealed that DIDS and 17-AAG, but not myricetin and lithium, significantly increased the intracellular iodide retention time in FRO-19, but not in TT-2. CONCLUSIONS: We showed that 17-AAG and DIDS prolong the retention time of (131)I in NIS-transfected thyroid tumoral cells, thus reinforcing the hope of using this approach for future clinical application, especially in patients with thyroid carcinoma who are no longer responsive to conventional therapy.

Analysis of chromosome damage in circulating lymphocytes of radiological workers affected by thyroid nodules.

The aim of our study was to assess whether or not thyroid nodularity in combination with occupational exposure to low levels of ionising radiation would be correlated with chromosome damage in peripheral lymphocytes. Conventional chromosome-aberration analysis was performed on a group of 92 hospital workers with or without thyroid nodules. On the basis of measurements of their exposure levels, the workers were classified into a low (mean total level=0.03 mSv), medium (mean total level=1.04 mSv) or high (mean total level=8.60 mSv) exposure category. Our results indicate that among workers with thyroid nodules, the high-exposed workers showed significantly higher levels of both total (2.35+/-0.34 per 100 cells) and chromosome-type aberrations (1.46+/-0.20 per 100 cells) than medium-exposed (0.98+/-0.42 and 0.68+/-0.25 per 100 cells, respectively) or low-exposed workers (1.11+/-0.29 and 0.58+/-0.17 per 100 cells, respectively). Workers without thyroid nodules had comparable frequencies of chromosome aberrations among the three exposure categories. To our knowledge, this is the first study revealing a slight, but significant increase of chromosome damage in peripheral lymphocytes from hospital workers who developed thyroid nodules under conditions of occupational exposure to radiation well below the threshold limit for the workplace. The existence of a possible association between chromosome aberrations and development of thyroid nodularity will be discussed.

Characterization of a low-cost PIN photodiode for dosimetry in diagnostic radiology.

A commercial silicon PIN-photodiode was tested and characterized as ionizing radiation detector for radiological applications. A current-to-voltage amplification stage was designed and realized in order to acquire the photodiode signal in current mode. The system was tested with clinical beams routinely used for radiography and mammography. A Monte Carlo simulation of the detector was performed with the MCNPX code in order to model and fully understand, in particular, the impact of the sensor casing on the low energy response of the device. A reproducible output linearity was found over the dose range 0.03-4.5 mGy of great clinical relevance. The system sensitivity was found to be stable at 0.2 V s Gy(-1) for effective X-ray energies between 17 and 40 keV. The batch-to-batch reproducibility of the diodes was also experimentally investigated for two different batches of 14 diodes each. An inter-comparison with dosimeters routinely used in medical physics (i.e. Barracuda MPD RTI) showed a linear correlation between PIN-photodiode readout and absorbed dose measured with Barracuda, in the range of doses received by mammography and radiology patients.

Treatment with lithium prevents serum thyroid hormone increase after thionamide withdrawal and radioiodine therapy in patients with Graves' disease.

Serum thyroid hormone concentrations increase after radioiodine (RAI) therapy for Graves' disease. This phenomenon has been ascribed to either antithyroid drug withdrawal before RAI therapy or release of preformed thyroid hormones into the bloodstream from the RAI-damaged thyroid. Lithium blocks the release of iodine and thyroid hormones from the thyroid, thus enhancing the effectiveness of RAI therapy. Changes in serum-free thyroxine (FT4) and triiodothyronine (FT3) levels after methimazole (MMI) discontinuation and RAI therapy were evaluated in a prospective, randomized, control study of 36 patients with Graves' disease. After a 3- to 4-month course of MMI, patients were assigned to one of three groups: G1 (RAI alone); G2 (RAI plus lithium for 6 d starting on the day of RAI therapy); or G3 (RAI plus lithium for 19 d starting on the day of MMI withdrawal). G1-G2 patients had an increase in serum FT4 and FT3 levels from 13.5 +/- 6.5 to 19.8 +/- 9.2 pmol/liter and 5.0 +/- 2.0 to 8.0 +/- 4.8 pmol/liter, respectively (P < 0.0001), 2-5 d after MMI withdrawal, but G3 patients showed no changes. In the 30 d after RAI therapy, mean serum FT4 values increased in G1 patients (P = 0.02), peaking at 3-7 d (P < 0.05) but not in G2 and G3 patients. Serum FT3 levels decreased in G1, G2, and G3 (P = 0.03, P = 0.001, P = 0.02, respectively). Hyperthyroidism was cured in 8 of 12 G1 patients, 11 of 12 G2 patients, and 11 of 12 G3 patients (P = 0.31). Control of hyperthyroidism was prompter in G2 (P = 0.08) and G3 (P < 0.05) than in G1 patients. Patients in the three groups received a similar dose of RAI, but the committed radiation to the thyroid was higher in G3 (563 +/- 174 Gray) and G2 (588 +/- 347 Gray) than in G1 (429 +/- 204 Gray) (P < 0.03). In conclusion, the results of the present study demonstrate that: 1) MMI withdrawal is associated with a slight rise in serum thyroid hormone levels; 2) a further increase occurs after RAI therapy; 3) changes in serum thyroid hormone concentrations are prevented by lithium; and 4) the increased effectiveness of RAI therapy in lithium-treated patients is related to the increased RAI retention in the thyroid gland. Accordingly, a short course of lithium therapy can be considered a useful adjunct to RAI therapy to obtain a prompter control of thyrotoxicosis and avoid its transient exacerbation because of MMI withdrawal and RAI administration.

Risks Related To Fluoroscopy Radiation Associated With Electrophysiology Procedures.

The benefits of cardiac imaging are immense, and modern cardiac electrophysiology (EP) requires the extensive and versatile use of a variety of cardiac imaging and radiology-based techniques. In the cardiac electrophysiology lab, doses can range around a reference effective dose (ED) of 15 milliSievert corresponding to 750 chest x-rays for a cardiac radiofrequency ablation, ranging from less than 2 to > 60 mSv. The reference dose for a regular pacemaker or ICD implant is 4 mSv (range 1.4-17) and for a CRT implant is 22 mSv (range 2.2-95). Doses on the order of magnitude of 10-100 milliSievert (mSv) correspond to a low (albeit definite, not negligible) additional lifetime risk of fatal and non-fatal cancer from between 1 in 1000 (10 mSv) to 1 in 100 (100 mSv). The increasing use and complexity of cardiac electrophysiology techniques have not been matched by increasing awareness and knowledge by prescribers and practitioners. The protection of doctors is just as important as protection of patients. Most experienced (and most exposed) interventional cardiologists and electrophysiologists have an exposure per annum of around 5 mSv, two to three times higher than diagnostic radiologists, with a typical cumulative lifetime attributable risk on the order of magnitude of 1 cancer (fatal and non-fatal) per 100 exposed subjects. Operator dose per procedure correlates somewhat with the patient dose, but may be typically 1000 times lower depending upon the shielding employed (one unit of incidence scatter dose for the operator when 1000 units of incident dose are given to the patient). However, adequate radiation protection training and diligent protection can reduce this radiation exposure by 90%. The priority given to radioprotection in every cardiology department is an effective strategy for primary prevention of cancer, a strong indicator of the quality of the cardiology division, and the most effective shielding for enhancing the safety of patients, doctors, and staff.

The effect of Ginkgo biloba extract on genotoxic damage in patients with differentiated thyroid carcinoma receiving thyroid remnant ablation with iodine-131.

BACKGROUND: Radioiodine ((131)I) therapy is usually performed in patients with differentiated thyroid cancer (DTC). Although (131)I is generally considered safe, genotoxic damage has been demonstrated both in vivo and in vitro. The aim of the current study was to evaluate the effect of Ginkgo biloba extract (GBE) on the time-course of appearance, after (131)I therapy for DTC, of plasma factors with chromosome-damaging properties (so-called "clastogenic" factors [CFs]) and of micronuclei (MN) in lymphocytes. METHODS: Twenty-three patients (median age 42 years, range 18-73) with DTC receiving (131)I activity (3.7 GBq) for thyroid remnant ablation were randomly assigned to receive GBE (120 mg/day for one month; n=10) or placebo (n=13) in a double-blind manner. Blood samples were taken at various intervals (from baseline to 90 days) after (131)I therapy. The frequency of MN in blood lymphocytes was determined, and CFs were assayed in plasma by a method that used MN increase in lymphocytes from an healthy donor as the endpoint of the assay. RESULTS: MN in blood lymphocytes increased significantly after (131)I treatment in the placebo group, peaking at the 7th day (p=0.002) and slowly declining thereafter. In contrast, in similarly treated patients who were also treated with GBE both before and after (131)I treatment, a significant increase of blood lymphocyte MN level was not observed. In addition, only the placebo group showed a significant, progressive increase in CFs activity. This peaked at the 14th day (p=0.003 vs. baseline) and was still noted for the last plasma sample. The differences in the change in lymphocyte MN and CFs activity between the placebo and GBE-treated groups were significant (p<0.01 and p<0.05, respectively). Thyroid function tests, including serum thyroglobulin (Tg) and anti-Tg antibody levels, were never significantly different. CONCLUSIONS: GBE may protect from possible oxidative and genotoxic damage associated with (131)I treatment in patients requiring (131)I therapy for thyroid cancer, without affecting the clinical outcome. Further studies with larger cohorts of patients are needed to confirm this report and verify the beneficial effect of GBE in patients requiring (131)I therapy, particularly for those in whom repeated treatments and high activities of (131)I are required.

Radioimmunotherapy with radretumab in patients with relapsed hematologic malignancies.

UNLABELLED: We present here a systematic analysis of lymphoma and MM patients recruited into 2 clinical trials or treated with radretumab according to compassionate use, describing the biodistribution, dosimetry, safety, and clinical activity of radretumab. METHODS: Uptake in lymphoma lesions, safety, and clinical activity of radretumab radioimmunotherapy (R-RIT) were evaluated in 18 relapsed lymphoma or multiple myeloma patients. RESULTS: In 14 of 18 patients, selective tumor uptake was found; 11 of 15 lymphoma patients, including 9 of 11 with Hodgkin lymphoma (HL), were eligible for R-RIT (a priori criteria-based target-to-bone marrow ratio > 10:1 for EudraCT no. 2005-000545 or > 4:1 for EudraCT no. 2007-007241-12 at dosimetric imaging). Two HL and 1 diffuse large B cell lymphoma patient achieved complete response; 1 HL patient had partial response. Both multiple myeloma patients receiving R-RIT experienced stabilization of disease. Therefore, the overall objective response rate was 40%. Uncomplicated grade 3-4 thrombocytopenia or leukocytopenia was observed in 5 R-RIT patients, lasting 4-129 d. CONCLUSION: R-RIT showed a favorable benefit and risk profile in advanced relapsed lymphoma patients and induced complete response in 2 heavily pretreated, relapsed HL patients and in 1 diffuse large B cell lymphoma patient. These results warrant further exploration of R-RIT in larger phase II clinical trials.

Chromosome translocation frequency after radioiodine thyroid remnant ablation: a comparison between recombinant human thyrotropin stimulation and prolonged levothyroxine withdrawal.

BACKGROUND: Thyroid remnant ablation of differentiated thyroid carcinoma (DTC) patients is traditionally performed after levothyroxine withdrawal. Recombinant human TSH (rhTSH) administration increases serum TSH levels without inducing hypothyroidism. AIM: The aim of the study was to investigate the frequency of chromosome translocations in DTC patients after the first (131)I therapeutic dose and compare the frequency of translocations between DTC patients off levothyroxine and those receiving rhTSH. PATIENTS AND METHODS: A total of 20 DTC patients were randomly assigned to levothyroxine withdrawal [(30 d) group A; n=10, nine women; mean age 48.5+/- 19.2 yr] or rhTSH injections [(0.9 mg im per 2 consecutive days) group B; n=10, eight women; mean age 50.4+/- 18.8 yr] before undergoing (131)I activity (3.7 GBq). The frequency of translocations in peripheral lymphocytes was analyzed by tricolor fluorescence in situ hybridization with whole-chromosome-specific probes for chromosomes 1, 4, and 8. Lymphocytes were stained routinely (about 500 each time). RESULTS: The two groups showed similar baseline translocation frequency. After (131)I administration, the total chromosomal translocation rate was significantly lower in group B than group A (P = 0.02). The frequency of translocations increased significantly in group A only (P = 0.01 vs. baseline). Rearrangement specifically involved chromosomes 4 and 8 (P = 0.02 vs. baseline). CONCLUSIONS: Our preliminary data show that in hypothyroid status (131)I ablation therapy induces a higher translocation rate, especially in chromosomes 4 and 8. This finding, in agreement with previous dosimetric reports, suggests that whereas inducing a low extrathyroid exposure, rhTSH reduces the potential risk of chromosomal aberration associated with blood irradiation.

Transtympanic steroids as a salvage therapy in sudden hearing loss: preliminary results.

PURPOSE: To understand the real efficacy of transtympanic steroid therapy for sudden sensorineural hearing loss (SSHL) in patients in whom traditional therapies have failed. PROCEDURES: A prospective study was designed in order to evaluate hearing improvement in SSHL patients treated with transtympanic therapy. A solution of methyl-prednisolone (MP) and sodium bicarbonate was administered via a transtympanic injection to 8 patients. Hearing level was evaluated before therapy and at days 1, 7 and 30. RESULTS: Hearing improvement was obtained in 75% of the patients. The patients in this category are usually considered untreatable. CONCLUSION: Transtympanic steroid therapy is an efficacious solution for patients affected by SSHL in whom traditional therapies have failed. Further studies will be required to identify the most favourable dosage, route of administration and type of steroid. Transtympanic steroid application is safe, inexpensive, easy to perform and efficacious in cases of SSHL not responsive to traditional therapy.

Differentiation of benign and malignant breast microcalcifications: mammography versus mammography-sonography combination.

PURPOSE: The aim of this study was to determine the diagnostic contribution of high-frequency sonography in the diagnosis of isolated clustered microcalcifications detected by mammography. MATERIAL AND METHODS: 238 women (aged 3198) with isolated clustered microcalcifications were examined by mammography and subsequently by high frequency sonography (13 MHz) at the site of microcalcification. 170 underwent surgery. 94 were affected by cancer and 76 by benign pathology. The other 68 were considered to have benign microcalcifications after three years follow-up. The ROC statistical technique was employed to compare the diagnostic role of mammography alone versus the combination of mammography and sonography. The area under the ROC curves was calculated by the Wilcoxon method, without any hypothesis on the distribution of the statistical data. RESULTS: The microcalcifications were neoplastic in 39.5% of cases. The difference between the areas under the mammography ROC curve (area = 0.807, standard error = 0.03) and the mammography-sonography ROC curve (area = 0.819, standard error = 0.028) was not statistically significant (p > 0.05). CONCLUSIONS: The higher sensitivity of mammography-sonography combination demonstrates that it may be useful to perform sonography following mammography when mammography yields a diagnosis of non malignant pathology.