Diagnosis of diffuse idiopathic skeletal hyperostosis with chest computed tomography: inter-observer agreement.

OBJECTIVE: To evaluate and improve the interobserver agreement for the CT-based diagnosis of diffuse idiopathic skeletal hyperostosis (DISH). METHODS: Six hundred participants of the CT arm of a lung cancer screening trial were randomly divided into two groups. The first 300 CTs were scored by five observers for the presence of DISH based on the original Resnick criteria for radiographs. After analysis of the data a consensus meeting was organised and the criteria were slightly modified regarding the definition of 'contiguous', the definition of 'flowing ossifications' and the viewing plane and window level. Subsequently, the second set of 300 CTs was scored by the same observers. κ ≥ 0.61 was considered good agreement. RESULTS: The 600 male participants were on average 63.5 (SD 5.3) years old and had smoked on average 38.0 pack-years. In the first round κ values ranged from 0.32 to 0.74 and 7 out of 10 values were below 0.61. After the consensus meeting the interobserver agreement ranged from 0.51 to 0.86 and 3 out of 10 values were below 0.61. The agreement improved significantly. CONCLUSIONS: This is the first study that reports interobserver agreement for the diagnosis of DISH on chest CT, showing mostly good agreement for modified Resnick criteria. KEY POINTS: • DISH is diagnosed on fluoroscopic and radiographic examinations using Resnick criteria • Evaluation of DISH on chest CT was modestly reproducible with the Resnick criteria • A consensus meeting and Resnick criteria modification improved inter-rater reliability for DISH • Reproducible CT criteria for DISH aids research into this poorly understood entity.

Performance analysis of a dedicated breast MR-HIFU system for tumor ablation in breast cancer patients.

MR-guided HIFU ablation is a promising technique for the non-invasive treatment of breast cancer. A phase I study was performed to assess the safety and treatment accuracy and precision of MR-HIFU ablation in breast cancer patients (n=10) using a newly developed MR-HIFU platform dedicated to applications in the breast. In this paper a technical analysis of the performance of the dedicated breast MR-HIFU system during breast tumors ablation is described. The main points of investigation were the spatial targeting accuracy and precision of the system and the performance of real-time respiration-corrected MR thermometry.The mean targeting accuracy was in the range of 2.4-2.6 mm, whereas the mean targeting precision was in the range of 1.5-1.8 mm. To correct for respiration-induced magnetic field fluctuations during MR temperature mapping a look-up-table (LUT)-based correction method was used. An optimized procedural sedation protocol in combination with the LUT-based correction method allowed for precise MR thermometry during the ablation procedure (temperature standard deviation <3 °C). No unwanted heating in the near field (i.e. skin) nor in the far field (pectoral muscle) was detected.The newly developed dedicated breast MR-HIFU system allows for safe, accurate and precise ablation of breast tumors.

3-T breast magnetic resonance imaging in patients with suspicious microcalcifications on mammography.

OBJECTIVE: To investigate the diagnostic value of 3-Tesla (T) breast MRI in patients presenting with microcalcifications on mammography. METHODS: Between January 2006 and May 2009, 123 patients with mammographically detected BI-RADS 3­5 microcalcifications underwent 3-T breast MRI before undergoing breast biopsy. All MRIs of the histopathologically confirmed index lesions were reviewed by two breast radiologists. The detection rate of invasive carcinoma and ductal carcinoma in situ (DCIS) was evaluated, as well as the added diagnostic value of MRI over mammography and breast ultrasound. RESULTS: At pathology, 40/123 (33%) lesions proved malignant; 28 (70%) DCIS and 12 (30%) invasive carcinoma. Both observers detected all invasive malignancies at MRI, as well as 79% (observer 1) and 86% (observer 2) of in situ lesions. MRI in addition to conventional imaging led to a significant increase in area under the receiver operating characteristic (ROC) curve from 0.67 (95% CI 0.56­0.79) to 0.79 (95% CI 0.70­0.88, observer 1) and to 0.80 (95% CI 0.71­0.89, observer 2), respectively. CONCLUSIONS: 3-T breast MRI was shown to add significant value to conventional imaging in patients presenting with suspicious microcalcifications on mammography. KEY POINTS: • 3-T MRI is increasingly used for breast imaging in clinical practice. • On 3-T breast MRI up to 86% of DCIS lesions are detected. • 3-T MRI increases the diagnostic value in patients with mammographically detected microcalcifications.

Dynamic contrast-enhanced and ultra-high-resolution breast MRI at 7.0 Tesla.

OBJECTIVE: To assess the feasibility of 7-T contrast-enhanced breast MRI in patients with suspicious masses. METHODS: Twenty patients with 23 suspicious breast masses on conventional imaging (mean size 13 mm, range 5-27 mm) were examined at 7 T. The MRI protocol included a dynamic series with injection of 0.1 mmol/kg gadobutrol (seven consecutive 3D T1-weighted gradient echo sequences, resolution 1 × 1 × 2 mm(3), temporal resolution 63 s) and ultra-high-resolution imaging (T1-weighted 3D gradient echo sequence, resolution 0.45 × 0.57 × 0.45 mm(3)). Two observers (R1 and R2) independently judged the examinations on image quality and classified lesions according to BI-RADS. The added value of ultra-high-resolution imaging was assessed. RESULTS: The image quality was deemed excellent in 1 and 0, good in 10 and 12, sufficient in 8 and 8, and insufficient in 1 and 0 for R1 and R2 respectively. Twenty of the 23 lesions were identified at 7-T MRI by both observers. All histopathologically proven malignant lesions (n = 19) were identified and classified as BI-RADS-MRI 4 or 5. Ultra-high-resolution imaging increased reader confidence in 88 % (R1) and 59 % (R2) of acquisitions. CONCLUSION: The study shows the feasibility of dynamic contrast-enhanced 7-T breast MRI, where all malignant mass lesions were identified by two observers. KEY POINTS: • Magnetic resonance imaging is important in the evaluation of breast cancer. • Recently, 7-T MRI has become available. • The 7-T dynamic contrast-enhanced breast MRI is feasible in patients. • The 7-T breast examinations are amenable to evaluation according to BI-RADS.

Interprocedural comparison of changes in natural flow velocity patterns in the internal carotid artery following CAS or CEA.

BACKGROUND AND PURPOSE: Different flow velocities have been reported after carotid angioplasty with stenting (CAS) than after carotid endarterectomy (CEA). We compared blood flow velocities following CAS and CEA in the International Carotid Stenting Study (ICSS; ISRCTN25337470). MATERIALS AND METHODS: In total, 254 patients (70% male; 129 CAS and 125 CEA) were included. Mean peak systolic velocities (PSVICA) were assessed at baseline, 30 days, 1 and 2 years. Following both treatments, restenosis ≥ 50% was defined as PSVmean >125 cm s(-1). RESULTS: CAS and CEA resulted in a similar reduction in PSVICA 1 month after treatment. Post-intervention analysis for each treatment separately revealed that PSVICA following CAS increased significantly during follow-up (30 days to 2 years; 22.4 cm s(-1); 95% confidence interval (CI), 14.3 to 30.5). On the contrary, PSVICA following CEA remained relatively stable during follow-up (4.7 cm s(-1); 95% CI, -6.5 to 15.9). When we analysed the increase in PSVICA between both treatments after 2 years of follow-up, no significant interprocedural difference was observed. The internal carotid artery/common carotid artery (ICA/CCA) PSV ratio increased after CAS but not after CEA: 1.2 vs. 1.1 (0.04, 95% CI; -0.16 to 0.25) at 30 days; 1.5 vs. 1.1 (0.39, 95% CI; 0.13 to 0.65) at 1 year; and 1.5 vs. 1.1 (0.36; 95% CI, 0.08 to 0.63) at 2 years. The rate of apparent ipsilateral ICA restenosis >50% was higher following CAS (hazard ratio 2.35; 95% CI, 1.35 to 4.09). CONCLUSION: Two years after carotid revascularisation, no significant interprocedural difference was observed in the increase of PSVICA between CAS and CEA. However, the ICA/CCA ratio increased more following CAS resulting in an apparent higher rate of restenosis following CAS.

Magnetic resonance-guided high-intensity focused ultrasound (MR-HIFU) ablation of liver tumours.

Recent decades have seen a paradigm shift in the treatment of liver tumours from invasive surgical procedures to minimally invasive image-guided ablation techniques. Magnetic resonance-guided high-intensity focused ultrasound (MR-HIFU) is a novel, completely non-invasive ablation technique that has the potential to change the field of liver tumour ablation. The image guidance, using MR imaging and MR temperature mapping, provides excellent planning images and real-time temperature information during the ablation procedure. However, before clinical implementation of MR-HIFU for liver tumour ablation is feasible, several organ-specific challenges have to be addressed. In this review we discuss the MR-HIFU ablation technique, the liver-specific challenges for MR-HIFU tumour ablation, and the proposed solutions for clinical translation.

Radiation exposure and mortality risk from CT and PET imaging of patients with malignant lymphoma.

OBJECTIVE: To quantify radiation exposure and mortality risk from computed tomography (CT) and positron emission tomography (PET) imaging with (18)F-fluorodeoxyglucose ((18)F-FDG) in patients with malignant lymphoma (Hodgkin's disease [HD] or non-Hodgkin's lymphoma [NHL]). METHODS: First, organ doses were assessed for a typical diagnostic work-up in children with HD and adults with NHL. Subsequently, life tables were constructed for assessment of radiation risks, also taking into account the disease-related mortality. RESULTS: In children with HD, cumulative effective dose from medical imaging ranged from 66 mSv (newborn) to 113 mSv (15 years old). In adults with NHL the cumulative effective dose from medical imaging was 97 mSv. Average fractions of radiation-induced deaths for children with HD [without correction for disease-related mortality in brackets] were 0.4% [0.6%] for boys and 0.7% [1.1%] for girls, and for adults with NHL 0.07% [0.28%] for men and 0.09% [0.37%] for women. CONCLUSION: Taking into account the disease-related reduction in life expectancy of patients with malignant lymphoma results in a higher overall mortality but substantial lower incidence of radiation induced deaths. The modest radiation risk that results from imaging with CT and (18)F-FDG PET can be considered as justified, but imaging should be performed with care, especially in children.

Volumetric feedback ablation of uterine fibroids using magnetic resonance-guided high intensity focused ultrasound therapy.

OBJECTIVE: The purpose of this prospective multicenter study was to assess the safety and technical feasibility of volumetric Magnetic Resonance-guided High Intensity Focused Ultrasound (MR-HIFU) ablation for treatment of patients with symptomatic uterine fibroids. METHODS: Thirty-three patients with 36 fibroids were treated with volumetric MR-HIFU ablation. Treatment capability and technical feasibility were assessed by comparison of the Non-Perfused Volumes (NPVs) with MR thermal dose predicted treatment volumes. Safety was determined by evaluation of complications or adverse events and unintended lesions. Secondary endpoints were pain and discomfort scores, recovery time and length of hospital stay. RESULTS: The mean NPV calculated as a percentage of the total fibroid volume was 21.7%. Correlation between the predicted treatment volumes and NPVs was found to be very strong, with a correlation coefficient r of 0.87. All patients tolerated the treatment well and were treated on an outpatient basis. No serious adverse events were reported and recovery time to normal activities was 2.3 ± 1.8 days. CONCLUSION: This prospective multicenter study proved that volumetric MR-HIFU is safe and technically feasible for the treatment of symptomatic uterine fibroids. KEY POINTS: • Magnetic-resonance-guided high intensity focused ultrasound allows non-invasive treatment of uterine fibroids. • Volumetric feedback ablation is a novel technology that allows larger treatment volumes • MR-guided ultrasound ablation of uterine fibroids appears safe using volumetric feedback.

Prevalence and clinical consequences of carotid artery residual defects following endarterectomy: a prospective CT angiography evaluation study.

OBJECTIVES: It is still unclear whether residual defects seen after carotid endarterectomy (CEA) have clinical consequences. We investigated prevalence of residual defects in the carotid artery and their possible impact on clinical and Duplex ultrasound (DUS) follow-up. MATERIALS AND METHODS: Sixty-five patients who had undergone CEA were prospectively examined with 1-3 month postoperative computed tomographic angiography (CTA), clinical and DUS follow-up. Defects in common (CCA), external (ECA) and internal carotid artery (ICA) were scored as clamp marks, intimal step or flap, mural thrombus, kink, microdehiscence suture or residual stenosis. RESULTS: Fifty-eight patients (89.2%) had residual defects in CCA, ECA or ICA (143 defects). Intimal steps (n = 39) and residual stenosis (n = 17) were most noted defects. Only residual defects in ECA were significantly associated with significant higher PSV values both at short-term and long-term follow-up (1990 vs. 1400 mm s(-1) at 1 year and 2000 vs. 1230 mm s(-1) at 2 years, P-values 0.031 and 0.016). CONCLUSION: Carotid artery residual defects on CTA after CEA are very common, simple fingerprints of the operative procedure, have no clear consequence. When CTA is performed clinically after CEA, knowledge of high prevalence and type of defects detected on CTA may be of importance for radiologists and clinicians.

Preoperative MRI and surgical management in patients with nonpalpable breast cancer: the MONET - randomised controlled trial.

BACKGROUND: We evaluated whether performing contrast-enhanced breast MRI in addition to mammography and/or ultrasound in patients with nonpalpable suspicious breast lesions improves breast cancer management. METHODS: The MONET - study (MR mammography of nonpalpable breast tumours) is a randomised controlled trial in patients with a nonpalpable BIRADS 3-5 lesion. Patients were randomly assigned to receive routine medical care, including mammography, ultrasound and lesion sampling by large core needle biopsy or additional MRI preceding biopsy. Patients with cancer were referred for surgery. Primary end-point was the rate of additional surgical procedures (re-excisions and conversion to mastectomy) in patients with a nonpalpable breast cancer. FINDINGS: Four hundred and eighteen patients were randomised, 207 patients were allocated to MRI, and 211 patients to the control group. In the MRI group 74 patients had 83 malignant lesions, compared to 75 patients with 80 malignant lesions in the control group. The primary breast conserving surgery (BCS) rate was similar in both groups; 68% in the MRI group versus 66% in the control group. The number of re-excisions performed because of positive resection margins after primary BCS was increased in the MRI group; 18/53 (34%) patients in the MRI group versus 6/50 (12%) in the control group (p=0.008). The number of conversions to mastectomy did not differ significantly between groups. Overall, the rate of an additional surgical intervention (BCS and mastectomy combined) after initial breast conserving surgery was 24/53 (45%) in the MRI group versus 14/50 (28%) in the control group (p=0.069). INTERPRETATION: Addition of MRI to routine clinical care in patients with nonpalpable breast cancer was paradoxically associated with an increased re-excision rate. Breast MRI should not be used routinely for preoperative work-up of patients with nonpalpable breast cancer.

Characterization of ex vivo healthy human axillary lymph nodes with high resolution 7 Tesla MRI.

OBJECTIVE: To characterize ex vivo healthy human axillary lymph nodes on 7 Tesla MRI and to correlate the findings with pathological analysis as a first step towards non-invasive staging of breast cancer patients in the future. METHODS: Four axillary lymph node dissection (ALND) specimens from 2 autopsy patients, who had no cancer, were examined on a clinical 7 Tesla MRI system. For morphological analysis a 3D T1-weighted fat-suppressed fast-field-echo [isotropic resolution 180 µm] was acquired. For quantitative analyses 2D T1-, 3D T2-, T2*- and diffusion-weighted images were acquired. The ALNDs were mapped and stained for precise correlation of MRI to pathology. Nodes were sliced in 3 µm sections, Haematoxylin & Eosin stained, and examined by an experienced pathologist. RESULTS: MRI detected all 45 nodes and 6 additional nodes that were not detected at pathological analysis. B-cell follicles, efferent- and afferent lymph vessels and blood vessels were identified. Mean T1, T2, T2*, ADC values (± standard deviation) were 944 ± 113 ms, 32 ± 2 ms, 16 ± 2 ms, 0.39 ± 0.09·10⁻³ mm²/s, respectively. CONCLUSIONS: 7 Tesla MRI of ex vivo human axillary lymph nodes correlated well with pathology. MRI detected all nodes present in the specimens and allowed visualization of fine structural detail. Pathology-correlated quantitative MRI data are presented.

Clinical course of pain in acute osteoporotic vertebral compression fractures.

PURPOSE: The authors prospectively determined the natural course of pain in patients with conservatively treated acute osteoporotic vertebral compression fractures (VCF). In addition, the type of conservative therapy that these patients received was assessed. MATERIALS AND METHODS: Patients older than 50 years, referred for spine radiography for acute back pain, were asked to complete a baseline clinical questionnaire. Patients with an acute VCF were followed up at 6 and 23 months with a questionnaire that included a Visual Analog Score (VAS) and type of pain medication and other conservative treatment. Significant pain relief was defined as a decrease in VAS of 50% or more. RESULTS: Forty-nine patients (mean age, 78 years; range, 51-95) with acute VCF were followed up for almost 2 years. Significant pain relief was noted in 22 of 35 patients (63%) at 6 months and in 25 of 36 (69%) at 23 months. In patients with persisting pain at 23 months (mean VAS 6.4), some decrease in VAS was apparent at 6 months but not in the 6-23 months interval. No predictors for significant pain relief could be identified. Patients with significant pain relief used less pain medication and had less physical therapy. CONCLUSIONS: In most patients with an acute VCF, pain decreases significantly with conservative therapy, predominantly in the first 6 months. However, almost 2 years after an acute VCF, a third of patients still had severe pain necessitating pain medication and physical therapy in the majority. No predictors for transition from acute to chronic pain could be identified.

Diffusion-weighted magnetic resonance imaging of the liver using tracking only navigator echo: feasibility study.

PURPOSE: To introduce and assess the TRacking Only Navigator echo (TRON) technique for diffusion-weighted magnetic resonance imaging (DWI) of the liver. SUBJECTS AND METHODS: A total of 10 volunteers underwent TRON, respiratory triggered (RT), and free breathing (FB) DWI of the liver. Scan times of TRON and RT DWI were measured, and image sharpness in TRON, RT, and FB DWI was assessed and compared using nonparametric tests. Furthermore, 14 patients with liver metastasis who had undergone TRON and RT DWI of the liver were retrospectively assessed. Relative contrast ratios (RCRs) and apparent diffusion coefficients (ADCs) of the largest hepatic metastasis in TRON and RT DWI were measured. RCRs were compared using a parametric test and agreement in ADCs was assessed using the Bland-Altman method. RESULTS: In the volunteers, mean scan times of TRON and RT relative to FB DWI were 110% to 112% and 261% to 290%, respectively. On axial images, there were no significant differences in images sharpness among TRON, RT, and FB DWI, but on coronal images image sharpness in TRON was nearly always significantly better (P < 0.05) than in RT and FB DWI. In the patients, mean RCRs between TRON and RT DWI were not significantly different (P = 0.9091). Mean difference in ADC +/- limits of agreement (in 10 mm/s) between TRON and RT DWI was -0.16 +/- 0.79. CONCLUSION: TRON offers sharp diffusion-weighted images of the liver using an efficient scan time, making it an excellent alternative to RT and FB DWI. The moderate to poor agreement in ADCs of liver metastases between TRON and RT DWI requires further investigation.

Ultrasound-guided laser-induced thermal therapy for small palpable invasive breast carcinomas: a feasibility study.

BACKGROUND: The next step in breast-conserving surgery for small breast carcinomas could be local ablation. In this study, the feasibility of ultrasound-guided laser-induced thermal therapy (LITT) is evaluated. METHODS: Patients with large-core needle biopsy-proven invasive, palpable breast carcinoma (clinically or=2 cm in size (P = .026). CONCLUSIONS: Successful LITT of invasive breast cancer seems to be feasible when confined to small (<2 cm) nonlobular carcinomas without surrounding extensive in-situ component and angioinvasion. However, to implement LITT in a curative setting, improvements in imaging to more reliably preoperatively assess tumor size and monitoring of fiber tip placement and treatment affect are essential.

Surgical outcome of patients with core-biopsy-proven nonpalpable breast carcinoma: a large cohort follow-up study.

BACKGROUND: Breast-conserving surgery (BCS) is the preferred treatment for nonpalpable breast carcinoma. The outcome, however, may be disappointing. In this study surgical outcome in a large cohort of patients diagnosed with nonpalpable breast carcinoma is evaluated. METHODS: In 833 patients with 841 nonpalpable breast carcinomas the number of re-excisions and type of surgical procedures was calculated and summed per patient. Subsequently, the number of conversions to mastectomy and the number of days until complete tumor removal were analyzed. In a subgroup analysis the patients with an in situ carcinoma were compared with the patients with an invasive carcinoma. RESULTS: The initial surgery consisted of BCS for 589 tumors (70%) and of mastectomy for 242 tumors (29%). For ten tumors (1%) the initial surgery was unknown. After BCS, 158/589 tumors (27%) required a re-excision: 116/337 (34%) for the in situ carcinomas and 63/504 (13%) for the invasive carcinomas (p = 0.0001). The number of conversions from BCS to mastectomy was 106/589 (18%): 66/241 (28%) in patients diagnosed with an in situ carcinoma versus 40/348 (11%) in patients with an invasive carcinoma (p = 0.0001). The median number of days until complete tumor removal was 28, being 38 days for the in situ carcinomas and 25 days for the invasive carcinomas (p = 0.0001). CONCLUSIONS: There is room for improvement in the surgical treatment of nonpalpable breast carcinoma, especially the relatively favorable in situ carcinoma, as it requires significantly more excisions, mastectomies, conversions to mastectomy, and days for complete removal.

Comparison of a 1-day and a 2-day protocol for lymphatic mapping and sentinel lymph node biopsy in patients with nonpalpable breast cancer.

PURPOSE: To compare the identification rate of the sentinel node in a 1-day protocol versus a 2-day protocol in patients with a nonpalpable breast carcinoma. METHODS: In the 1-day protocol an average dose of 120 MBq (99m)Tc-nanocolloid was injected intratumorally on the day of surgery, and in the 2-day protocol an average dose of 370 MBq (99m)Tc-nanocolloid was injected intratumorally the day before surgery. Both a gamma ray detection probe and patent blue were used to locate the sentinel node. RESULTS: In 57 of 67 patients (85%) treated in the 1-day protocol and in 51 of 56 patients (91%) treated in the 2-day protocol the sentinel node was detected (p=0.311). Of the patients in the 1-day protocol and the 2-day protocol, respectively, 18 (27%) and 13 (23%) showed metastasis (p=0.975) CONCLUSION: There was no significant difference in the identification rate of the sentinel node between the 1-day protocol and the 2-day protocol in patients diagnosed with a nonpalpable breast carcinoma.

Unrecognised myocardial infarction in subjects at high vascular risk: prevalence and determinants.

OBJECTIVE: To investigate the prevalence and determinants of unrecognised myocardial infarction (UMI). DESIGN, SETTING, PATIENTS: In this cross-sectional study in a tertiary centre, a delayed enhancement cardiac MRI (DE-CMR), which identifies both Q-wave and non-Q wave MIs, was performed in 502 subjects with manifest extracardiac atherosclerotic disease or marked risk factors for atherosclerosis without symptomatic coronary artery disease. MAIN OUTCOME MEASURES: UMI was defined as the presence of delayed enhancement without corresponding clinical history. RESULTS: DE-CMR was of sufficient image quality in 480 (95.6%) subjects. A UMI was present in 45 (9.4%) of all subjects; in 13.1% of men and in 3.7% of women. The risk of UMI increased from 6.0% (95% CI 2.2 to 9.8%) in those with two vascular risk factors up to 26.2% (95% CI 15.2 to 37.3%) in those with four or five risk factors. In a multivariable analysis, the risk of UMI was related to male gender (OR 2.3 (95% CI 1.0 to 5.6)), age (OR 1.04 (95% CI 1.00 to 1.07) per year), ever smoking (OR 3.1 (95% CI 1.0 to 9.1), history of stroke (OR 1.9 (95% CI 0.8 to 4.3)) and history of aneurysm of the abdominal aorta (OR 2.6 (95% CI 1.0 to 6.9)). CONCLUSIONS: In cardiac asymptomatic subjects at high vascular risk, UMI is common. The risk of UMI increases with increasing presence of risk factors.

Optical imaging of the breast.

This review provides a summary of the current state of optical breast imaging and describes its potential future clinical applications in breast cancer imaging. Optical breast imaging is a novel imaging technique that uses near-infrared light to assess the optical properties of breast tissue. In optical breast imaging, two techniques can be distinguished, i.e. optical imaging without contrast agent, which only makes use of intrinsic tissue contrast, and optical imaging with a contrast agent, which uses exogenous fluorescent probes. In this review the basic concepts of optical breast imaging are described, clinical studies on optical imaging without contrast agent are summarized, an outline of preclinical animal studies on optical breast imaging with contrast agents is provided, and, finally, potential applications of optical breast imaging in clinical practice are addressed. Based on the present literature, diagnostic performance of optical breast imaging without contrast agent is expected to be insufficient for clinical application. Development of contrast agents that target specific molecular changes associated with breast cancer formation is the opportunity for clinical success of optical breast imaging.

Radio guided occult lesion localization (ROLL) for non-palpable invasive breast cancer.

BACKGROUND: Wire guided localization (WGL) for non-palpable breast cancer is technically difficult and patient unfriendly. Radio guided occult lesion localization (ROLL) takes advantage of the possibility to detect the tumor through the nuclear tracer that is injected directly into the tumor for the sentinel node procedure. METHODS: Forty patients with 41 invasive breast carcinomas were treated using ROLL. Patients received a dose of 120 Mbq 99mTc Nanocolloid intra-tumorally on the day of surgery or a dose of 370 Mbq 99mTc Nanocolloïd intra-tumorally the prior day. The sentinel node (SN) was located using patent blue and a gamma ray detection probe that was also employed to guide the tumor excision. RESULTS: In 31 patients (78%) the invasive tumor was adequately excised. In two cases (5%) a re-excision was required due to inadequately excised carcinoma in situ and in three patients (7.5%) both the invasive and the in situ tumor were inadequately excised. In 35 patients (88%) the SN was found and removed. CONCLUSIONS: The ROLL procedure seems to be an alternative to WGL in patients with non-palpable breast carcinoma. To determine the place of ROLL versus WGL in the treatment of non-palpable breast cancer, a randomized clinical trial is needed.

Carotid stenting versus carotid endarterectomy: evidence basis and cost implications.

OBJECTIVE: Carotid Angioplasty combined with Stenting (CAS) is increasingly performed because of its presumed benefits. A study was performed to identify key factors that determine the cost-effectiveness as compared to conventional carotid endarterectomy (CEA). METHODS: The incremental cost-effectiveness of CAS over CEA for different scenarios was estimated using a modeling approach. Treatment costs were based on actual costs of successful procedures whereas costs of complications were taken from the literature. Patient survival was modeled using the endarterectomy patients from the ECST trial. RESULTS: Procedural costs of CAS are higher than those of CEA, mainly as a result of the high material costs. Cost-effectiveness of CAS primarily depends on major stroke rates. One percent increase in the peri-operative major stroke rate causes a cost increase of 1051 euros and a loss of 0.06 quality adjusted life years. CONCLUSIONS: At present CAS is at best non-inferior to CEA in terms of clinical outcome. Cost savings due to shorter admission are offset by the high costs associated with catheter-based interventions. At present CAS should be restricted to controlled settings until clinical trials have shown a substantial clinical benefit.