Use of axillary ultrasound to guide breast cancer management in the genomic assay era.

INTRODUCTION: Chemotherapy is conventionally offered to non-stage IV breast cancer patients with metastatic nodes. However, the RxPONDER trial showed that chemotherapy can be omitted in selected patients with 1-3 metastatic nodes if the 21-gene assay recurrence score is ≤25. We aimed to investigate if axillary ultrasound can identify this group of patients with limited nodal burden so that they can undergo upfront surgery followed by gene assay testing, to potentially avoid chemotherapy. METHODS: T1-3, node positive, hormone receptor-positive and HER2-negative breast cancer patients ≥50 years old with axillary lymph node dissection (ALND) were reviewed from 2 centres. Patients with neoadjuvant chemotherapy and bilateral cancers were excluded. Number of ultrasound-detected abnormal axillary nodes, demographic and histological parameters were correlated with the number of metastatic nodes found on ALND. RESULTS: 138 patients were included, 59 (42.8%) and 79 (57.2%) patients had 1-3 and >3 metastatic nodes on ALND respectively. On logistic regression and ROC analysis, the number of ultrasound-detected abnormal nodes was significant (p < 0.001) for predicting limited nodal burden (ROC AUC = 0.7135). Probabilities of <4 metastatic nodes with ultrasound cut-offs of 5, 6 and 8 abnormal nodes were 0.057, 0.026 and 0.005 respectively, with 100% specificity. CONCLUSION: A cut-off of ≤5 ultrasound-detected abnormal nodes can distinguish between patients with limited versus high nodal burden, with high specificity. Hence, incorporating the number of abnormal ultrasound-detected nodes into clinical practice may prove useful in guiding between upfront surgery and gene assay testing or neoadjuvant chemotherapy in this group of patients.

Complications of Caesarean delivery part 2: Non-pregnant and pregnancy-related complications.

Introduction: With the rise in Caesarean deliveries, complications related to the procedure are increasingly encountered. Sonography has an indispensable role in the assessment of these complications and is often the first-line investigation of choice.Topic description: Part 2 of this pictorial review summarises the non-pregnant and pregnancy-related complications of Caesarean deliveries. Discussion: Non-pregnant complications include Caesarean scar defects, scar endometriosis and malpositioned intrauterine devices. Complications related to future gestations include scar ectopic pregnancy, abnormal placentation and intrapartum uterine dehiscence or rupture. Key sonographic features of these conditions are illustrated. Pitfalls, mimics, limitations and indications for cross-sectional imaging are discussed. Conclusion: Sound knowledge of the sonographic features of common non-pregnant and pregnancy-related complications of Caesarean delivery will facilitate accurate diagnosis, timely management and improved patient outcomes.

Complications of Caesarean delivery part 1: Early complications.

Introduction: With the rise in Caesarean deliveries, complications related to the procedure are increasingly encountered. Sonography has an indispensable role in the assessment of these complications and is often the first-line investigation of choice.Topic Description: Part 1 of this pictorial review summarises the early complications unique to and associated with Caesarean deliveries. Discussion: Acute haemorrhagic complications include retained products of conception, subfascial and bladder flap haematomas and, rarely, postpartum uterine dehiscence or rupture and iatrogenic vascular complications. Infective complications include puerperal and wound infections. Key sonographic features of these conditions are illustrated. Pitfalls, mimics, limitations and indications for cross-sectional imaging are discussed. Conclusion: Sound knowledge of the sonographic features of common early complications of Caesarean delivery will facilitate accurate diagnosis, timely management and improved patient outcomes.

Temporal Evolution of Intramural Esophageal Dissection with 3D Reconstruction and Cinematic Virtual Fly-Through.

Intramural esophageal dissection is an uncommon condition, involving the separation of the esophageal mucosa from the muscular layers. To our knowledge, the temporal evolution of intramural esophageal dissection on computed tomography has not been previously demonstrated. We present a case of a 51-year-old male who first presented to the emergency department with fever, odynophagia, and dysphagia. He was treated for acute tonsillitis and discharged, but presented again after 10 days with worsening symptoms. A series of radiographs and computed tomography studies, with 3D reconstruction and cinematic virtual fly-through, in these 2 admissions depicts the temporal evolution of intramural hematoma to subsequent intramural esophageal dissection. Recognizing its appearance on imaging is invaluable in distinguishing it from other important differential diagnoses. A complete description of the case, relevant radiologic imaging, and review of the relevant literature are provided.

Clinics in diagnostic imaging (186). Atrial septal defect with pulmonary arterial hypertension.

We report a case of a 61-year-old woman with a large atrial septal defect (ASD) that was detected incidentally on chest radiography and computed tomography when she presented with sepsis. Echocardiography confirmed a large secundum ASD with left-to-right shunt flow, right heart dilatation and severe pulmonary hypertension. The patient had a poor clinical outcome despite intensive care and eventually passed away. Haemodynamically significant ASDs have a known association with increased morbidity and mortality, and their early detection and closure cannot be understated. This article aimed to highlight the imaging features of ASD, with special emphasis on the routine chest radiograph. The pathophysiology and clinical manifestations of ASD are also briefly discussed.

Metastatic breast cancer to the rectum: A case report with emphasis on MRI features.

RATIONALE: Less than 1% of breast carcinomas metastasize to the gastrointestinal tract. The diagnosis is frequently not recognized especially when the history of breast carcinoma is remote. PATIENT CONCERNS: A 61-year-old female with a remote history of breast carcinoma presented with a 3-month history of change in bowel habits. Colonoscopy showed a circumferential rectal mass with initial impression of primary rectal cancer. MRI of the rectum showed findings that are atypical for primary rectal cancer. DIAGNOSES: Deep biopsy of the rectal mass confirmed lobular breast carcinoma metastasis to the rectum. INTERVENTION AND OUTCOMES: The patient was treated with radiotherapy and hormonal therapy. She is symptomatically well 2 years after presentation and remains on hormonal therapy. LESSONS: Lobular breast cancer which metastasizes to the rectum can mimic primary rectal cancer clinically. The unique MRI features described in our case when present with a concordant history of lobular breast carcinoma should alert the radiologist to the possibility of this diagnosis which has important treatment implications.