Assessment of whole-body MRI including diffusion-weighted sequences in the initial staging of breast cancer patients at high risk of metastases in comparison with PET-CT: a prospective cohort study.

OBJECTIVE: The aim of this study was to assess the diffusion-weighted whole-body-MRI (WBMRI) in the initial staging of breast cancer at high risk of metastases in comparison with positron emission tomography (PET)-CT. METHODS: Forty-five women were prospectively enrolled. The inclusion criteria were female gender, age >18, invasive breast cancer, an initial PET-CT, and a performance status of 0-2. The exclusion criteria were contraindication to WB-MRI and breast cancer recurrence. The primary outcome was the concordance of WB-MRI and PET-CT in the diagnosis of distant metastases, whereas secondary outcomes included their concordance for the primary tumor and regional lymph nodes (LN), as well as the agreement of WB-MRI interpretation between two radiologists. RESULTS: The mean age was 51.2 years with a median size of the primary tumor of 30 mm. Concordance between the two modalities was almost perfect for metastases staging, all sites included (k = 0.862), with excellent interobserver agreement. The accuracy of WB-MRI for detecting regional LN, distant LN, lung, liver, or bone metastases ranged from 91 to 96%. In 2 patients, WB-MRI detected bone metastases that were overlooked by PET-CT. WB-MRI showed a substantial agreement with PET-CT for staging the primary tumor, regional LN status, and stage (k = 0.766, k = 0.756, and k = 0.785, respectively) with a high interobserver agreement. CONCLUSION: WB-MRI including DWI could be a reliable and reproducible examination in the initial staging of breast cancer patients at high risk of metastases, especially for bone metastases and therefore could be used as a surrogate to PET-CT. CLINICAL RELEVANCE STATEMENT: Whole-body-MRI including DWI is a promising technique for detecting metastases in the initial staging of breast cancer at high risk of metastases. KEY POINTS: Whole-body-MRI (WB-MRI) was effective for detecting metastases in the initial staging of 45 breast cancer patients at high risk of metastases in comparison with PET-CT. Concordance between WB-MRI and PET-CT was almost perfect for metastases staging, all sites included, with excellent interobserver agreement. The accuracy of WB-MRI for detecting bone metastases was 92%.

Assessment of diffusion-weighted MRI in predicting response to neoadjuvant chemotherapy in breast cancer patients.

To compare region of interest (ROI)-apparent diffusion coefficient (ADC) on diffusion-weighted imaging (DWI) measurements and Ki-67 proliferation index before and after neoadjuvant chemotherapy (NACT) for breast cancer. 55 women were enrolled in this prospective single-center study, with a final population of 47 women (49 cases of invasive breast cancer). ROI-ADC measurements were obtained on MRI before and after NACT and were compared to histological findings, including the Ki-67 index in the whole study population and in subgroups of "pathologic complete response" (pCR) and non-pCR. Nineteen percent of women experienced pCR. There was a significant inverse correlation between Ki-67 index and ROI-ADC before NACT (r = - 0.443, p = 0.001) and after NACT (r = - 0.614, p < 0.001). The mean Ki-67 index decreased from 45.8% before NACT to 18.0% after NACT (p < 0.001), whereas the mean ROI-ADC increased from 0.883 × 10-3 mm2/s before NACT to 1.533 × 10-3 mm2/s after NACT (p < 0.001). The model for the prediction of Ki67 index variations included patient age, hormonal receptor status, human epidermal growth factor receptor 2 status, Scarff-Bloom-Richardson grade 2, and ROI-ADC variations (p = 0.006). After NACT, a significant increase in breast cancer ROI-ADC on diffusion-weighted imaging was observed and a significant decrease in the Ki-67 index was predicted. Clinical trial registration number: clinicaltrial.gov NCT02798484, date: 14/06/2016.

Prenatal Diagnosis of a Liver Mass by Tru-Cut® Biopsy.

A 32-year-old woman, gravida 2 para 1 at 33 weeks' gestation, was referred for a third opinion regarding a large fetal liver mass. The couple sought approval for a termination of pregnancy, following a differential diagnosis of hepatoblastoma. A specialized ultrasound and fetal magnetic resonance imaging were repeated in our unit and the results were consistent with a presumed diagnosis of hemangioma. A Tru-Cut® (Merit Medical, Utah, USA) liver biopsy was performed confirming a benign hemangioma and the couple opted to continue with the pregnancy.

Value of diffusion-weighted MRI in predicting early response to neoadjuvant chemotherapy of breast cancer: comparison between ROI-ADC and whole-lesion-ADC measurements.

OBJECTIVE: The aim of the study was to assess DWI with ROI-ADC and WL-ADC measurements in early response after NAC in breast cancer. METHODS: Between January 2016 and December 2019, 55 women were enrolled in this prospective single-center study. MRI was performed at three time points for each patient: before treatment (MRI 1: DW and DCE MRI), after one cycle of NAC (MRI 2: noncontrast DW MRI), and after completion of NAC before surgery (MRI 3: DW and DCE MRI). ROI-ADC and WL-ADC measurements were obtained on MRI and were compared to histology findings and to the RCB class. Patients were categorized as having pCR or non-pCR. RESULTS: Among 48 patients, 9 experienced pCR. An increase of ROI-ADC between MRI 1 and 2 of more than 47.5% had a sensitivity of 88.9% and a specificity of 63.4% in predicting pCR, whereas WL-ADC did not predict pCR. An increase of ROI-ADC between MRI 1 and 2 of more than 47.5% had a sensitivity of 83.3% and a specificity of 64.9% in predicting radiologic complete response. An increase of WL-ADC between MRI 1 and 2 of more than 25.5% had a sensitivity of 83.3% and a specificity of 75.5% in predicting radiologic complete response. CONCLUSION: After one cycle of NAC, a significant increase in breast tumor ROI-ADC at DWI predicted complete pathologic and radiologic responses. KEY POINTS: • An increase of WL-ADC between MRI 1 and 2 of more than 25.5% had a sensitivity of 83.3% and a specificity of 75.5% in predicting radiologic complete response. • An increase of ROI-ADC between MRI 1 and 2 of more than 47.5% had a sensitivity of 88.9% and a specificity of 63.4% in predicting pCR, and a sensitivity of 83.3% and a specificity of 64.9% in predicting radiologic complete response. • A significant increase in breast tumor ROI-ADC at DWI predicted complete pathologic and radiologic responses.

Added Value of Quantitative Analysis of Diffusion-Weighted Imaging in Ovarian-Adnexal Reporting and Data System Magnetic Resonance Imaging.

BACKGROUND: The ovarian-adnexal reporting and data system-magnetic resonance imaging (O-RADS-MRI) score decreases the incidence of indeterminate adnexal masses from 18% to 31% with ultrasound till 10.8% to 12.5% with MRI. Further improvement of this score may be useful to improve patients' management. PURPOSE: To evaluate the added value of quantitative diffusion-weighted imaging (DWI) in the diagnosis of adnexal masses classified according to the O-RADS-MRI score. STUDY TYPE: Prospective cohort study with retrospective DWI analysis. POPULATION: Among 402 recruited patients, surgery was done only in 163 women (median-age: 51 years) with 201 indeterminate adnexal masses, which were included in the final analysis. FIELD STRENGTH/SEQUENCE: Standardized MRI (1.5 and 3-T) including diffusion and dynamic contrast-enhanced sequences (diffusion-weighted single-shot spin-echo echo-planar imaging) were used. ASSESSMENT: Two radiologists classified the adnexal masses according to O-RADS-MRI and they were blinded to the pathology report. Two methods of quantitative analysis were applied using region-of-interest apparent-diffusion-coefficient (ROI-ADC) and whole-lesion ADC-histogram (WL-ADC). STATISTICAL TESTS: Fisher's exact and Mann-Whitney-U tests were used to compare variables among malignant and benign lesions. Receiver-operating-characteristic (ROC) curves were constructed to examine the sensitivity/specificity of each parameter. ROI-ADC and WL-ADC of lesions with O-RADS-MRI score-4 were plotted to identify thresholds of malignant lesions. The improvement of the O-RADS-MRI score after adding these thresholds was assessed by two ROC-curves. A P < 0.05 was considered to be statistically significant. RESULTS: Fifty-eight of the 201 lesions (28.9%) were malignant. The ROI-ADC and the WL-ADC means of malignant lesions were significantly lower than those of benign lesions. Forty-two lesions (20.9%) had an O-RADS-MRI score-4. In this subgroup, 76% of lesions with ROI-ADC < 1.7 × 10-3  mm2 /sec and WL-ADC < 2.6 × 10-3  mm2 /sec were malignant, whereas only 11.8% with ROI-ADC ≥ 1.7 × 10-3  mm2 /sec or a WL-ADC ≥ 2.6 × 10-3  mm2 /sec were malignant. The overall performance of the O-RADS-MRI score combined with these thresholds was improved. DATA CONCLUSION: Integrating ADC-thresholds in O-RADS-MRI score-4 may discriminate low-to-intermediate and intermediate-to-high malignancy risk groups. LEVEL OF EVIDENCE: 2 TECHNICAL EFFICACY STAGE: 2.

Covid-19 and blood groups: ABO antibody levels may also matter.

BACKGROUND: Susceptibility to Covid-19 has been found to be associated with the ABO blood group, with O type individuals being at a lower risk. However, the underlying mechanism has not been elucidated. Here, we aimed to test the hypothesis that Covid-19 patients might have lower levels of ABO antibodies than non-infected individuals as they could offer some degree of protection. METHODS: After showing that the viral spike protein harbors the ABO glycan epitopes when produced by cells expressing the relevant glycosyltransferases, like upper respiratory tract epithelial cells, we enrolled 290 patients with Covid-19 and 276 asymptomatic controls to compare their levels of natural ABO blood group antibodies. RESULTS: We found significantly lower IgM anti-A + anti-B agglutination scores in blood group O patients (76.93 vs 88.29, P-value = 0.034) and lower levels of anti-B (24.93 vs 30.40, P-value = 0.028) and anti-A antibodies (28.56 vs 36.50, P-value = 0.048) in blood group A and blood group B patients, respectively, compared to controls. CONCLUSION: In this study, we showed that ABO antibody levels are significantly lower in Covid-19 patients compared to controls. These findings could indicate that patients with low levels of ABO antibodies are at higher risk of being infected.

Fetal postmortem imaging: an overview of current techniques and future perspectives.

Fetal death because of miscarriage, unexpected intrauterine fetal demise, or termination of pregnancy is a traumatic event for any family. Despite advances in prenatal imaging and genetic diagnosis, conventional autopsy remains the gold standard because it can provide additional information not available during fetal life in up to 40% of cases and this by itself may change the recurrence risk and hence future counseling for parents. However, conventional autopsy is negatively affected by procedures involving long reporting times because the fetal brain is prone to the effect of autolysis, which may result in suboptimal examinations, particularly of the central nervous system. More importantly, fewer than 50%-60% of parents consent to invasive autopsy, mainly owing to the concerns about body disfigurement. Consequently, this has led to the development of noninvasive perinatal virtual autopsy using imaging techniques. Because a significant component of conventional autopsy involves the anatomic examination of organs, imaging techniques such as magnetic resonance imaging, ultrasound, and computed tomography are possible alternatives. With a parental acceptance rate of nearly 100%, imaging techniques as part of postmortem examination have become widely used in recent years in some countries. Postmortem magnetic resonance imaging using 1.5-Tesla magnets is the most studied technique and offers an overall diagnostic accuracy of 77%-94%. It is probably the best choice as a virtual autopsy technique for fetuses >20 weeks' gestation. However, for fetuses <20 weeks' gestation, its performance is poor. The use of higher magnetic resonance imaging magnetic fields such as 3-Tesla may slightly improve performance. Of note, in cases of fetal maceration, magnetic resonance imaging may offer diagnoses in a proportion of brain lesions wherein conventional autopsy fails. Postmortem ultrasound examination using a high-frequency probe offers overall sensitivity and specificity of 67%-77% and 74%-90%, respectively, with the advantage of easy access and affordability. The main difference between postmortem ultrasound and magnetic resonance imaging relates to their respective abilities to obtain images of sufficient quality for a confident diagnosis. The nondiagnostic rate using postmortem ultrasound ranges from 17% to 30%, depending on the organ examined, whereas the nondiagnostic rate using postmortem magnetic resonance imaging in most situations is far less than 10%. For fetuses ≤20 weeks' gestation, microfocus computed tomography achieves close to 100% agreement with autopsy and is likely to be the technique of the future in this subgroup. The lack of histology has always been listed as 1 limitation of all postmortem imaging techniques. Image-guided needle tissue biopsy coupled with any postmortem imaging can overcome this limitation. In addition to describing the diagnostic accuracy and limitations of each imaging technology, we propose a novel, stepwise diagnostic approach and describe the possible application of these techniques in clinical practice as an alternative or an adjunct or for triage to select cases that would specifically benefit from invasive examination, with the aim of reducing parental distress and pathologist workload. The widespread use of postmortem fetal imaging is inevitable, meaning that hurdles such as specialized training and dedicated financing must be overcome to improve access to these newer, well-validated techniques.

Congenital cytomegalovirus infection: contribution and best timing of prenatal MR imaging.

OBJECTIVE: To predict sensorineural hearing loss (SNHL) and neurological impairment in congenital cytomegalovirus (cCMV) infection using MR imaging and define the best timing in pregnancy for prenatal assessment. METHODS: In 121 patients with confirmed cCMV infection, brain features at MR imaging were respectively graded from 1 to 5: normal; isolated frontal/parieto-occipital hyperintensity; temporal periventricular hyperintensity; temporal/occipital cysts and/or intraventricular septa; migration disorders. Grading was correlated with postnatal SNHL and neurological impairment using regression analysis. In 51 fetuses with MR examinations at 26.9 and 33.0 weeks, the predictive value of SNHL and neurological impairment was compared using ROC curves. RESULTS: Postnatal follow-up showed SNHL in 18 infants and neurological impairment in 10. MR grading was predictive of SNHL and of neurological impairment (P < 0.001). In grade 1 or 2, none had SNHL and 1/74 had neurological impairment. The areas under ROC curves for prediction of postnatal SNHL and of neurological impairment from first and second MR examination were comparable. CONCLUSION: Our data suggest that in cCMV infection, prediction of SNHL and neurological impairment is feasible by fetal MR imaging with a high negative predictive value and can equally be done at 27 or 33 weeks of gestation. KEY POINTS: • In cCMV, isolated periventricular T2-weighted signal hyperintensity has a good postnatal prognosis. • In cCMV, SNHL and neurological impairment can be predicted at 27 or 33 weeks. • In cCMV, fetal MR has a high NPV in predicting SNHL. • In cCMV, fetal MR has a high NPV in predicting neurological impairment.

Prophylactic use of the Arabin cervical pessary in fetuses with severe congenital diaphragmatic hernia treated by fetoscopic endoluminal tracheal occlusion (FETO): preliminary experience.

OBJECTIVE: The aim of this study was to describe whether the prophylactic use of a cervical pessary decreases the rate of premature birth in congenital diaphragmatic hernia (CDH) fetuses treated with fetoscopic tracheal occlusion (FETO). METHODS: The study concerns a consecutive series of cases with CDH and FETO and a group of CDH without FETO. In a subgroup of the FETO group, a prophylactic cervical pessary was inserted the day following the procedure. Gestational age (GA) at birth was the primary outcome. RESULTS: Fifty-nine fetuses with FETO and 47 expectantly managed were included. The last 15 FETO had a cervical pessary inserted. The median GA at delivery in the FETO group with pessary was 35.1 weeks and was not different from that in the FETO group without a pessary (34.3 weeks; p = 0.28) but was below that in the expectantly managed group (38.3 weeks; p < 0.001). CONCLUSION: Early results suggest that prophylactic use of an Arabin cervical pessary does not prolong gestation of CDH fetuses treated with FETO. © 2015 John Wiley & Sons, Ltd.

Parental acceptance of minimally invasive fetal and neonatal autopsy compared with conventional autopsy.

OBJECTIVE: To determine parental acceptance of minimally invasive autopsy (MIA) involving postmortem imaging and organ tissue sampling compared with conventional autopsy and to compare the acceptability of percutaneous versus laparoscopic-guided biopsy. METHODS: Following termination of pregnancy parents were offered the option of traditional autopsy and subsequently interviewed about their acceptance of MIA. The McNemar test for paired samples was used to assess the difference in acceptance of MIA and conventional autopsy. The Wilcoxon signed-rank test for paired samples was used to compare the acceptance score for percutaneous versus laparoscopic-guided biopsy. Logistic regression was selected to study the association of parental acceptance of conventional autopsy and MIA with different variables. RESULTS: Conventional autopsy was accepted by 42 (60.0%) of the 70 parents. Regression analysis showed that non-Muslim faith was the only factor significantly associated with acceptance of conventional autopsy (p = 0.030). Of 28 parents who initially refused conventional autopsy, 13(46.4%) subsequently accepted MIA, increasing acceptance to 78.6% (p < 0.001). Regression analysis showed that none of the factors significantly affected MIA acceptance. Parents expressed no preference between postmortem percutaneous versus laparoscopic-guided biopsy (p = 0.061). CONCLUSION: Post-mortem imaging combined with systematic organ biopsies is highly acceptable among all parents independent of their religion and the method used for organ biopsy.

Liver-to-thoracic volume ratio: use at MR imaging to predict postnatal survival in fetuses with isolated congenital diaphragmatic hernia with or without prenatal tracheal occlusion.

OBJECTIVE: To evaluate the relationship of the liver-to-thoracic volume ratio (LiTR) by MRI with postnatal survival in foetuses with isolated congenital diaphragmatic hernia (CDH). METHODS: In 30 conservatively managed CDH foetuses and in 31 who underwent fetoscopic endoluminal tracheal occlusion (FETO), logistic regression analysis was used to investigate the effect on postnatal survival of the observed-to-expected (O/E) ratio of total foetal lung volume (TFLV), LiTR, gestational age at delivery, CDH side, intrathoracic position of the liver and, for those who underwent FETO, gestational age at FETO and occlusion period. For 19 foetuses undergoing FETO, a post-FETO MRI was available. The proportionate increase in O/E ratio of TFLV at 3-8 weeks after FETO was compared with the pre-FETO value and correlated with pre-FETO LiTR using linear regression analysis. RESULTS: For conservatively managed foetuses, only LiTR provided a significant prediction of postnatal survival. For foetuses undergoing FETO, LiTR and gestational age at delivery provided a significant independent prediction of postnatal survival. There was a significant inverse association between lung response and pre-FETO LiTR. CONCLUSION: In foetuses with CDH with/without FETO treatment, the LiTR is predictive of postnatal survival at discharge. In foetuses treated with FETO, LiTR is predictive of post-FETO lung response. KEY POINTS: • Congenital diaphragmatic hernia is usually managed conservatively before surgery soon after delivery • Fetoscopic endoluminal tracheal occlusion (FETO) has been introduced for severely affected foetuses • In conservatively managed CDH, the liver-to-thoracic volume ratio (LiTR) predicted postnatal survival best. • In severe CDH with prenatal FETO, LiTR also helped predict postnatal survival. • LiTR should be integrated into the prenatal decision-making for foetuses with CDH.

Evidence and patterns in lung response after fetal tracheal occlusion: clinical controlled study.

PURPOSE: To prospectively assess changes in lung volume in fetuses with isolated severe congenital diaphragmatic hernia (CDH) after fetoscopic endoluminal tracheal occlusion (FETO) compared with those in fetuses with CDH of variable severity who were expectantly managed. MATERIALS AND METHODS: Informed consent was obtained for this ethics committee-approved study. Forty fetuses with severe CDH (lung-to-head ratio < 1 and intrathoracic liver) who underwent FETO and 18 fetuses with CDH of variable severity who were expectantly managed were longitudinally followed up by using magnetic resonance (MR) imaging volume measurements. Fetuses born prior to 32 weeks were excluded from the study. For those undergoing FETO, lung volume responsiveness was defined as the proportionate increase in observed-to-expected (O/E) ratio of total fetal lung volume (TFLV) at 2-5 weeks after FETO compared with the pre-FETO value. Changes in lung volume were compared by using the Mann-Whitney U test. Regression analysis was used to investigate the effect of pre-FETO O/E ratio of TFLV, gestational age at FETO and at delivery, lung volume responsiveness, occlusion period, side of CDH, and balloon removal prior to delivery on survival. Correlation between post-FETO lung volume responsiveness and gestational age at FETO was performed by using linear regression analysis. RESULTS: A total of 260 MR imaging examinations were performed. For expectantly managed fetuses, O/E ratio of TFLV remained unchanged during gestation, whereas it significantly increased after FETO. Regression analysis demonstrated that pre-FETO O/E ratio of TFLV and lung volume responsiveness at 3.3 weeks after FETO provided significant independent prediction of postnatal survival. There was a significant negative association between lung volume responsiveness and gestational age at FETO. CONCLUSION: In fetuses with CDH, pre-FETO O/E ratio of TFLV and lung volume at 3.3 weeks after FETO provide independent prediction of postnatal survival. SUPPLEMENTAL MATERIAL: http://radiology.rsnajnls.org/cgi/content/full/2522081955/DC1.