Comparison of Complications in Patients with Ductal Cholangiocarcinoma (CCC) and Patients with Colorectal Liver Metastases (CRLMs) After Portal Vein Embolization (PVE): A Matched Cohort Study.

PURPOSE: To compare complications in patients with cholangiocarcinoma (CCC) and patients with colorectal liver metastases (CRLMs) after portal vein embolization (PVE) and to identify possible predictive factors. MATERIAL AND METHODS: Retrospective analysis of consecutive patients, who underwent PVE between July 2011 and March 2020. The study groups were matched for sex and age. Multivariable analysis was performed for the endpoints of complications categorized according for their respective effect on surgical treatment: "Minor" complications had no effect on subsequent surgical treatment, while "intermediate" and "severe" complications delayed or prevented surgery. RESULTS: A total of 160 patients with either CCC (n = 80) or CRLMs (n = 80) were included: 34/160 experienced complications: 27 (CCC: 21; CRLMs: 6) "minor", 4 (CCC: 3; CRLMs: 1) "intermediate", and 3 (CCC: 2; CRLMs: 1) "severe" complications respectively (p = .01). Patients with CCC received a biliary drainage 5 days on average before PVE. Baseline bilirubin levels were 1.1 mg/dl in CCC patients and 0.55 mg/dl in CRLMs patients (p < .01). Postinterventional infections were more common in CCC patients. The preintervention future liver remnant volume (odds ratio (OR) 0.93; 95% confidence interval (CI) 0.88-0.99; p = .02), body mass index (OR 1.19; 95% CI 1.04-1.36; p = .01), age (OR 0,91; 95% CI 0.84-0.99; p = .01), chemotherapy before PVE (OR 0.03; 95% CI 0.01-0.23; p < .01) and severe liver steatosis (OR 29.52; 95% CI 1.87-467,13; p = .02) were the only significant predictive factors for the occurrence of (minor) complications. CONCLUSION: PVE can be performed in CCC patients with prior biliary drainage, with similar procedural safety as in patients with CRLMs.

Contrast-enhanced breast imaging: Current status and future challenges.

BACKGROUND: Contrast-enhanced breast MRI and recently also contrast-enhanced mammography (CEM) are available for breast imaging. The aim of the current overview is to explore existing evidence and ongoing challenges of contrast-enhanced breast imaging. METHODS: This narrative provides an introduction to the contrast-enhanced breast imaging modalities breast MRI and CEM. Underlying principle, techniques and BI-RADS reporting of both techniques are described and compared, and the following indications and ongoing challenges are discussed: problem-solving, high-risk screening, supplemental screening in women with extremely dense breast tissue, breast implants, neoadjuvant systemic therapy (NST) response monitoring, MRI-guided and CEM- guided biopsy. RESULTS: Technique and reporting for breast MRI are standardised, for the newer CEM standardisation is in progress. Similarly, compared to other modalities, breast MRI is well established as superior for problem-solving, screening women at high risk, screening women with extremely dense breast tissue or with implants; and for monitoring response to NST. Furthermore, MRI-guided biopsy is a reliable technique with low long-term false negative rates. For CEM, data is as yet either absent or limited, but existing results in these settings are promising. CONCLUSION: Contrast-enhanced breast imaging achieves highest diagnostic performance and should be considered essential. Of the two contrast-enhanced modalities, evidence of breast MRI superiority is ample, and preliminary results on CEM are promising, yet CEM warrants further study.

Correlation Between Sarcopenia and Growth Rate of the Future Liver Remnant After Portal Vein Embolization in Patients with Colorectal Liver Metastases.

PURPOSE: To investigate whether sarcopenia and myosteatosis correlate with the degree of hypertrophy (DH) and kinetic growth rate (KiGR) of the future liver remnant (FLR) in patients with colorectal liver metastases undergoing portal vein embolization (PVE) in preparation for right hepatectomy. MATERIALS AND METHODS: Forty-two patients were included. Total liver volume and FLR volume were measured before and 2-4 weeks after PVE. KiGR of the FLR was calculated. Sarcopenia was assessed using the total psoas muscle volume (PMV), the psoas muscle cross-sectional area (PMCS) and the total skeletal muscle index (L3SMI) at the level of 3rd lumbar vertebra. Degree of myosteatosis was assessed by mean muscle attenuation at L3 (L3MA). Correlations between muscle indices and DH and KiGR were assessed using simple linear regression analyses. RESULTS: Mean DH was 8.9 ± 5.7%, and mean KiGR was 3.6 ± 2.3. Mean PMV was 55.56 ± 14.19 cm3/m3, mean PMCS was 8.76 ± 2.3 cm2/m2, mean L3SMI was 45.6 ± 9.89 cm2/m2, and mean L3MA was 27.9 ± 18.6 HU. There was a strong positive correlation between PMV and DH (R = 0.503, p = 0.001) and PMV and KiGR (R = 0.545, p < 0.001). Furthermore, there was a moderate correlation between PMCS and KiGR (R = 0.389, p = 0.014). L3SMI and L3MA were neither associated with DH (p = 0.390 and p = 0.768, respectively) nor with KiGR (p = 0.188 and p = 0.929, respectively). CONCLUSION: We identified a positive correlation between PMV and PMCS, as markers for sarcopenia, and the KiGR of the FLR after PVE. PMV and PMCS might therefore aid to identify patients who are poor candidates for FLR augmentation using PVE alone.

Short-Term Oral Sorafenib for Therapy of Intratumoral Shunts of Hepatocellular Carcinoma to Enable Intraarterial Treatment.

INTRODUCTION: Significant intratumoral shunts between tumor-supplying arteries and portal or liver veins are a contraindication for transarterial therapy of HCC because interventional treatment of these shunts is frequently insufficient. Sorafenib has anti-angiogenic effects and is indicated for palliative treatment of patients with HCC. Here, we report our experience with the use of sorafenib for the closure of intratumoral shunts in patients scheduled for transarterial therapy of HCC. MATERIALS AND METHODS: Three patients with HCC, aged 65, 82 and 79 years, exhibited a significant intratumoral shunting from tumor artery to portal (n = 1) or liver veins (n = 2). In all cases, intratumoral shunting had already been suspected based on pre-interventional CT angiography, and DSA confirmed the shunt. Oral sorafenib (800 mg/day) was administered for at least four weeks, only and specifically to occlude the shunt. Hereafter, patients were re-evaluated by CT and DSA. RESULTS: All patients tolerated the full prescribed dose for at least 4 weeks. In one case, therapy was prolonged with an adapted dose (400 mg/day) due to sorafenib-related hand-foot syndrome. After sorafenib treatment, CT and DSA confirmed a complete closure of intratumoral shunts for all patients. No tumor progression was observed. All three patients hereafter underwent successful transarterial treatment by TACE (n = 2) or TARE (n = 1) without complications. Progression-free survival according to mRECIST was 501, 397 and 599 days, respectively. CONCLUSION: Even short-term oral sorafenib seems to effectively close intratumoral shunts in patients with HCC and thus might enable transarterial treatment of these patients.

Toward Transpulmonary Chemoembolization with Degradable Starch Microspheres: Systematic Analysis of Local and Systemic Effects in a Porcine Model.

PURPOSE: To investigate local and systemic effects of transpulmonary chemoembolization (TPCE) with degradable starch microspheres (DSM) and doxorubicin. The long-term goal is to establish DSM-TPCE as a treatment option for pulmonary malignancies. MATERIALS AND METHODS: Nine pigs underwent TPCE of either the right or left lower lobe pulmonary artery (LLPA) and bland embolization (TPE) of the contralateral LLPA. Before the procedures, macroaggregated albumin (MAA) particles were injected into both LLPAs, to exclude systemic shunting. Pulmonary arterial pressure, heart rate and oxygenation were recorded immediately before and at 1, 3, 5 and 10 min after treatment. To investigate possible nontarget embolization, animals underwent cerebral MRI (cMRI). We killed the animals after a contrast-enhanced chest computed tomography (CT) and performed a pathologic examination at 12 h (3), 24 h (3) and 72 h (3) after treatment. RESULTS: All experiments were technically successful. Mean injected DSM dose until stasis was similar in TPCE and TPE (4.3 ± 1.4 vs. 4.0 ± 1.4 mL). Pulmonary arterial pressure increased significantly 3 min after treatment (TPE: 17 ± 5 vs. 27 ± 7 mmHg; TPCE: 22 ± 6 vs. 36 ± 8 mmHg). No significant changes in heart rate or peripheral oxygenation levels occurred. We observed no evidence of structural lung damage or permanent perfusion disruption on CT. MAA test injection and cMRI revealed no shunting or nontarget embolization. The pathologic assessment revealed nonspecific local inflammation of the lung parenchyma. CONCLUSION: In this large-animal model, TPCE and TPE appear feasible and safe. We observed a mild increase in pulmonary arterial pressure. Nontarget embolization did not occur. TPCE, as well as TPE, did not cause structural damage to the normal lung parenchyma.

Impact of Preoperative Three-Dimensional Computed Tomography Cholangiography on Postoperative Resection Margin Status in Patients Operated due to Hilar Cholangiocarcinoma.

INTRODUCTION: The purpose of this study was to analyse the value of 3-dimensional computed tomography cholangiography (3D-ERC) compared to conventional retrograde cholangiography in the preoperative diagnosis of hilar cholangiocarcinoma (HC) with special regard to the resection margin status (R0/R1). PATIENTS AND METHODS: All hepatic resections performed between January 2011 and November 2013 in patients with HC at the Department of General, Visceral and Transplant Surgery of the RWTH Aachen University Hospital were analysed. All patients underwent an ERC and contrast-enhanced multiphase CT scan or a 3D-ERC. RESULTS: The patient collective was divided into two groups (group ERC: n = 17 and group 3D-ERC: n = 16). There were no statistically significant differences between the two groups with regard to patient characteristics or intraoperative data. Curative liver resection with R0 status was reached in 88% of patients in group ERC and 87% of patients in group 3D-ERC (p = 1.00). We could not observe any differences with regard to postoperative complications, hospital stay, and mortality rate between both groups. CONCLUSION: Based on our findings, preoperative imaging with 3D-ERC has no benefit for operative planning and R0 resection status. It cannot replace the exploration by an experienced surgeon in a centre for hepatobiliary surgery.

[Chondral and osteochondral defects : Representation by imaging methods]. / Chondrale und osteochondrale Defekte : Darstellung mittels bildgebender Verfahren.

Morphological imaging of cartilage at high resolution allows the differentiation of chondral and osteochondral lesions. Nowadays, magnetic resonance imaging is the principal diagnostic tool in the assessment of cartilage structure and composition. Conventional radiography, computed tomography, ultrasound or optical coherence tomography are adjunct diagnostic modalities in the assessment of cartilage pathologies. The present article discusses the up-to-date diagnostic practice of cartilage imaging in terms of its scientific basis and current clinical status, requirements, techniques and image interpretation. Innovations in the field such as functional MRI are discussed as well due to their mid- to long-term clinical perspective.

Transarterial Alcohol-Lipiodol Therapy in Patients with Hepatocellular Carcinoma Using Low Alcohol Concentrations.

PURPOSE: To evaluate transarterial alcohol-lipiodol therapy (TAL) with low concentrations of alcohol for the treatment of hepatocellular carcinoma (HCC). MATERIALS AND METHODS: 17 patients (69.3 ±â€Š10.7a, 13 male, 4 female) with previously untreated HCC (tumor diameter: 7.7 ±â€Š5.8 cm), who underwent 20 transarterial alcohol-lipiodol injections, were evaluated retrospectively. 14 patients had HCC with coexistent cirrhosis (Child-A n = 9, Child-B n = 4, Child-C n = 1). 9 patients presented an Okuda stage I, 7 patients an Okuda stage II and 1 patient an Okuda stage III. Infiltration of the portal vein was seen in 3 patients. RESULTS: 15 patients underwent TAL with an alcohol:lipiodol ratio of 1:2, another one with a ratio of 1:3 and yet another one with a ratio of 1:5. The median survival was 23 months, and the 1-year and 2-year survival rates were 62.7 % and 31.4 %, respectively. The median survival of patients with HCC < 7.5 cm (n = 10) was 25 months and significantly (p = 0.009) higher than for patients with HCC ≥ 7.5 cm (n = 7; 3 months). Tumor diameters ≥ 7.5 cm were associated with worse lipiodol-contrasting of HCC. Intrainterventional side effects were only feelings of slight abdominal pressure in 2 of 20 interventions. Postinterventional, mild side effects were observed after 3 interventions (abdominal pain n = 1, thoracic pain n = 1, fever n = 1). Serious complications were not observed, in particular there was no decompensation of liver cirrhosis. CONCLUSION: TAL with low concentrations of alcohol was a safe and effective treatment in our cohort in spite of extensive tumors and impaired liver function. TAL could be a treatment option for patients who cannot receive other therapies (e. g. TACE, RFA) because of their advanced tumor disease, liver cirrhosis or other contraindications. KEY POINTS: • TAL can be performed safely in advanced tumor disease and liver cirrhosis Citation Format: • Mohné F, Meyer C, Kuhl CK et al. Transarterial Alcohol-Lipiodol Therapy in Patients with Hepatocellular Carcinoma Using Low Alcohol Concentrations. Fortschr Röntgenstr 2016; 188: 676 - 683.

[Oligometastasized stage IV colorectal cancer : Surgical resection and local ablative procedures]. / Oligometastasierung beim kolorektalen Karzinom im Stadium IV : Chirurgie und lokal ablative Verfahren.

BACKGROUND: By the intensified combination of systemic, surgical and local ablative therapies a significant improvement in therapy results for metastasized colorectal cancer has been achieved in the last decade. Downstaging with subsequent resection is nowadays a standard for oligometastasized primarily unresectable colorectal cancer. MATERIAL AND METHODS: The value of combining resection and local ablation is unclear; therefore, this article gives an overview of the available literature dealing with the combination of surgery and local ablative methods for oligometastasized stage IV colorectal cancer. RESULTS: The best results were obtained following surgical resection alone. Whereas nowadays cryoablation is of minor importance, the most successful results are achieved following local ablative methods by radiofrequency and microwave ablation. In the future irreversible electroporation will be the most promising local ablative method. A combination of surgical resection and local ablation appears to be rational in patients if an R0 resection can be achieved. CONCLUSION: Surgical resection of colorectal liver metastases is the gold standard for oncological therapy whenever possible. The rational combination of non-curative surgical resection and local ablation should be considered in the context of a multimodal therapeutic strategy, particularly in patients with primarily resectable disease.

Stentgraft Implantation for the Treatment of Postoperative Hepatic Artery Pseudoaneurysm.

PURPOSE: Hepatic artery pseudoaneurysms are a rare but potentially life-threatening complication of major pancreaticobiliary surgery. We evaluated the safety and efficacy of endovascular stentgraft implantation for the management of such vascular lesions. MATERIALS AND METHODS: Between May 2013 and October 2015, ten patients with postoperative hepatic artery pseudoaneurysm, of which eight presented with active hemorrhage, were treated with endovascular stentgraft implantation. All patients had undergone major pancreatic or hepatic surgery before (pylorus-preserving pancreaticoduodenectomy, pancreatectomy, hemihepatectomy, extended hemihepatectomy). The pseudoaneurysms were diagnosed 13-202 days after surgery and were associated with postsurgical complications (e.g., leakage of pancreaticojejunal anastomosis). RESULTS: In 9/10 patients, the pseudoaneurysm was completely excluded via stentgraft implantation. In 1/10 patient, the pseudoaneurysm ruptured during the procedure and was successfully treated by immediate open surgery. In 1/10 patient, a second intervention was performed after 6 days because of rebleeding; this was successfully treated by implantation of a second overlapping stentgraft. Mean follow-up time is 51 days. None of the patients died due to stentgraft- or aneurysm-related complications. Further episodes of hemorrhage were not observed. In one patient, clinically asymptomatic complete occlusion of the stentgraft was discovered at follow-up imaging. CONCLUSION: Stentgraft implantation is a safe and effective technique to treat hepatic artery pseudoaneurysms related to major pancreatic or hepatic surgery, especially in the setting of acute hemorrhage.

Lymphatic Interventions for Treatment of Chylothorax.

PURPOSE: To determine effectiveness of lymphatic interventional procedures for treatment of chylothorax. MATERIAL AND METHODS: Analysis of interventions performed from 2001 to 2014. RESULTS: In 21 patients with therapy resistant chylothorax a lymphatic radiological intervention was attempted, which could be performed in 19 cases: 17 thoracic duct embolizations (15 transabdominal, one transzervical and one retrograde transvenous procedure), 2 percutaneous destructions of lymphatic vessels, one CT-guided injection of ethanol next to a duplicated thoracic duct. Fourteen of seventeen (82.3 %) of the technically successful embolizations lead to clinical cure. This encluded three patients with prior unsuccessful surgical thoracic duct ligation. Also the injection of ethanol was clinically effective. Complications were a bile peritonitis requiring operation, and one clinical deterioration of unknown cause. CONCLUSION: Interventional lymphatic procedures allow for effective treatment in many cases of chylothorax, and should be considered early during treatment. KEY POINTS: • Thoracic duct embolization is an effective treatment method for chylothorax. • If embolization is impossible, percutaneous lymphatic destruction or injection of sclerosants/tissue adhesive next to the thoracic duct may be tried.

In vivo MRI visualization of parastomal mesh in a porcine model.

INTRODUCTION: After two-dimensional plane MRI-visible mesh implants could be successfully visualized in phantom and small animal model, the aim of the underlying study was to explore the feasibility of an MRI visualization of complex three-dimensional mesh geometry in close contact to the intestine. We therefore used a MR-visible three-dimensional intra-peritoneal stoma (IPST) mesh in a porcine model. MATERIALS AND METHODS: Laparoscopic terminal sigmoid colostomy has been done with implantation of a prophylactic MRI-visible IPST mesh in two animals. MRI investigations were done after 1 week, 6 months and in case of clinical impairment. These findings were compared to endoscopy and makroscopical and histological investigation of the preparation. RESULTS: The first animal has to be killed because of an ileus 4 weeks after operation. The second animal has to be killed after 7 weeks because of recurrent obstipation. In all cases MRI investigation could identify the IPST mesh and could clearly separate between mesh and intestine. MRI revealed a big bowl ileus due to a funnel dislocation in the first animal. In the second animal, MR diagnostic explored a functional stenosis because of a too small diameter of the central funnel in combination with sticky feces and distension of the terminal sigmoid before discharging into the funnel. Endoscopy, makroscopical and histological investigation of the preparation supported MRI findings. CONCLUSION: Although complicate clinical course was a diagnostic challenge exploring 3D implants such as IPST, visualization of this new MRI-visible IPST mesh could be proved and turned out as an effective diagnostic possibility. Further studies are necessary to analyze long-time effects such as shrinkage, mesh migration and tissue integration using MRI scanning.

Efficacy of magnetic thermoablation using SPIO in the treatment of osteoid osteoma in a bovine model compared to radiofrequency and microwave ablation.

PURPOSE: To evaluate heating efficacy of superparamagnetic iron oxide nanoparticles (SPIO) for electromagnetic ablation (EMA) of osteoid osteoma (OO) using an ex vivo model compared to radiofrequency ablation (RFA) and microwave ablation (MWA). METHODS: A model for OO using sliced bovine tibia and sliced muscle tissue was developed. A bone cavity filled with either a mixture of SPIO and agarose or pure agarose (control group) was established. EMA was performed using an experimental system, RFA and MWA using clinically approved systems, and the ablation protocols recommended by the vendor. For temperature measurements, fiberoptic temperature probes were inserted inside the cavity, on the outside of the periosteum, and at a 5 mm distance to the periosteum. RESULTS: Maximum temperatures with or without SPIO in the nidus were as follows: EMA: 79.9 ± 2.5/22.3 ± 0.7 °C; RFA: 95.1 ± 1.8/98.6 ± 0.9 °C; MWA: 85.1 ± 10.8/83.4 ± 9.62 °C. In RFA with or without SPIO significantly higher temperatures were achieved in the nidus compared to all other groups (p < 0.05). In MWA significantly higher temperatures were observed in the 5 mm distance to the periosteum compared to EMA and RFA with or without SPIO (p < 0.05). In MWA temperature decrease between nidus and the 5 mm distance to the periosteum was significantly lower than in RFA with or without SPIO (p < 0.0001). In MWA without SPIO temperature decrease was significantly lower than in the EMA group (p < 0.05). CONCLUSION: In the experimental setting, ablation of OO is safe and effective using EMA. It is less invasive than RFA and MWA, and it theoretically allows repeated treatments without repeated punctures. In comparison, the highest temperatures in the nidus are reached using RFA.

Silicon carbide-enhanced microwave ablation in an ex-vivo bovine liver model - effects on heat distribution and ablation volume.

PURPOSE: Evaluation of the maximum temperatures and ablation volumes in microwave ablation (MWA) after injection of different concentrations of silicon carbide (SiC) particles in an ex-vivo bovine liver model. MATERIALS AND METHODS: 15 ml of different concentrations of SiC particles (20 vol% SiC; 50 vol% SiC) mixed with 2 % gelatin were injected into an ex-vivo bovine liver. As a reference group, 2 % gelatin without SiC was injected. MWA was performed using a clinical MWA system with different generator settings (10 - 45 W/10 minutes). The temperature was measured at a distance of 5 mm and 10 mm from the applicator. Afterwards the liver tissue was sliced along the short and long axis, the ablation zones were measured on the x, y and z-axis and the ablation volume was calculated. All experiments were performed 5 times (total: 40 experiments). RESULTS: The average maximum temperatures measured at a generator setting of 45 W at a distance of 5 mm from the applicator were 103.4 ± 4.6 °C (20 vol% SiC), 103.3 ± 6.5 °C (50 vol% SiC) and 96.0 ± 4.2 °C in the control group (0 vol% SiC). At 45 W, injection of 20 vol% SIC caused a significantly higher maximum temperature than that achieved in the control group (p = 0.016). No significant temperature increase compared to the control group could be measured using 50 vol% SiC. The mean ablation volumes at 45 W and 20 vol% SiC and 50 vol% SiC were significantly larger (172.7 ± 31.5 ml and 171.0 ± 34.7 ml, respectively) than those achieved in the control group (111.2 ± 23.8 ml) (p = 0.027 and p = 0.045). CONCLUSION: In an ex-vivo bovine liver model, the SiC particles demonstrated an enhancing effect of MWA with respect to maximum temperatures and ablation volume. Therefore, SiC is a promising candidate for enhancing MWA in vivo.

MR imaging of the prostate at 3.0T with external phased array coil - preliminary results.

INTRODUCTION: Among all imaging modalities, MRI of the prostate has the highest sensitivity to predict extracapsular tumor spread, seems to have added value for the preoperative treatment planning. It is an adjunct tool in patients with high suspicion of prostate cancer and so far negative TRUS-guided biopsies. Due to the higher intrinsic signal, it is expected that 3.0T enables to image the prostate without endorectal coil. Aim of this study was to evaluate the diagnostic accuracy of phased array coil 3.0T MRI in patients with suspicion of prostate cancer. MATERIAL AND METHODS: A high spatial resolution T2-w 3.0T pulse sequence (0.47 x 0.47 x 3mm voxel size) was performed in 26 patients prior to US-guided biopsy. Qualitative analysis comprised visual signal to noise, tissue contrasts and motion artifacts. MR diagnoses were correlated with histology. Diagnostic indices for the detection of prostate cancer in the peripheral zone were calculated. RESULTS: Histopathologic examination revealed pro?state cancer in 12 and benign prostate disorders in 14 patients. Motion artifacts due to peristalsis were rated moderate. Mean visual signal to noise was high. Contrast between peripheral and central zone of the prostate was excellent. MRI had 4 false negative and 2 false positive diagnoses (sensitivity 66.7 %, specificity 86.7 % diagnostic accuracy 76.9%). CONCLUSION: At 3.0T, diagnostic indices for cancer detection seem to be comparable to data reported about endorectal 1.5T MRI. Thus 3.0 T offers new options for MR imaging of the prostate in selected patients who cannot or are not willing to be examined with the endorectal coil.

[Magnetic resonance imaging in preoperative staging for breast cancer: pros and contras]. / Präoperatives Staging mit der Mamma-MRT: Pro und Kontra.

In oncologic patients, staging of the disease extent is of paramount importance. Imaging studies are used to decide whether the patient is a surgical candidate; if this is the case, imaging is used for detailed planning of the surgical procedure itself. Even in patients with limited prognosis, the first priority is always to achieve clear margins. Due to the widespread use of screening mammography, breast cancers are among the few cancers that are almost always diagnosed in an operable stage and are operated on with curative intention. It is well established that magnetic resonance imaging (MRI) is far superior to mammography (with and without concomitant ultrasound) for mapping the local extent of breast cancer. Accordingly, there is good reason to suggest that a pre-operative breast MRI should be considered an integral part of breast conserving treatment. Still, it is only rarely used in clinical practice. Arguments against its use are: Its high costs, allegedly high number of false positive findings, lack of MR-guided breast biopsy facilities, lack of evidence from randomized prospective trials and, notably, fear of "overtreatment". This paper discusses the reservations against staging MRI and weighs them against its clinical advantages. The point is made that radiologists as well as breast surgeons should be aware of the possibility of overtreatment, i.e. unnecessary mastectomy for very small, "MRI-only" multicentric cancer foci that would indeed be sufficiently treated by radiation therapy. There is a clear need to adapt the guidelines established for treatment of mammography-diagnosed multicentric breast cancer to account for the additional use of MRI for staging. Until these guidelines are available, the management of additional, "MRI-only" diagnosed small multicentric cancer manifestations must be decided on wisely and with caution. MRI for staging may only be done in institutions that can also offer an MR-guided tissue sampling, preferably by MR-guided vacuum assisted biopsy, to provide pre-operative histological proof of lesions visible by breast MRI alone.

Pre-operative staging of breast cancer with breast MRI: one step forward, two steps back?

In the field of oncologic surgery, an accurate local staging, i.e. the delineation of local disease extent, is considered of key importance to guide treatment decisions in patients with operable cancers, in particular patients who are operated on with curative intention. Imaging studies are used to provide a road map for the surgeon to help him or her obtain clear margins-which, in turn, is considered essential in order to avoid recurrent disease. It is well established that breast MRI is by far superior to mammography, with or without concomitant ultrasound, for the local staging of breast cancer. MRI allows the most accurate delineation of the size and the local extent of cancer, including the depiction of multifocal or multicentric or contralateral disease. MRI offers the highest sensitivity for demonstrating intraductal extensions around invasive cancers. Due to its very high negative predictive value, MRI can be used to confidently exclude the presence of breast cancer, and, thus, avoid unnecessary surgery. For all these reasons, MRI should be considered an integral part of the work up of patients who undergo breast-conserving treatment for breast cancer. And yet, the technique is only slowly adopted in clinical practice. Arguments against the use of breast MRI include costs, frequency of false positive diagnoses, lack of availability of minimally invasive biopsy capabilities, lack of evidence by randomized controlled clinical trials, and, last, fear of overtreatment. In this article, these concerns are explained, discussed and weighted against the advantages of pre-operative breast MRI for breast cancer staging. The point is made that breast MRI is essential for surgical planning, but that indeed unnecessary mastectomy may result if old guidelines are simply copied onto a new situation. Guidelines that require mastectomy for multicentric breast cancer have been established before the advent of MRI. Using the same guidelines to manage MR-detected multicentric cancer foci may be inappropriate because some small MRI detected additional multicentric breast cancer foci will be sufficiently treated by radiation therapy.

[Familial breast cancer: what the radiologist needs to know]. / Familiäre Brustkrebserkrankung: klinische Grundlagen und Früherkennung.

About 10 % of breast cancers are "hereditary", i. e. caused by a pathogenic mutation in one of the "breast and ovarian cancer susceptibility genes" (BRCA). The BRCA genes 1 and 2 identified to date follow an autosomal dominant inheritance pattern. A clustering of breast cancer in a family without a documented mutation and without a recognizable inheritance pattern is usually referred to as "familial cancer". A distinction between hereditary and familial is difficult in the individual case because not all of the genetic mutations that cause breast cancer susceptibility are known and thus amenable to genetic testing. Women who are suspected of or documented as carrying a breast cancer susceptibility gene face a substantially increased lifetime risk of breast (and ovarian) cancer ranging from 60-80 % for breast and up to 40 % for ovarian cancer. In addition, the disease develops at a young age (the personal risk starts increasing at age 25; average age of diagnosis is 40). BRCA-associated breast cancers tend to exhibit histologic and histochemical evidence of aggressive biologic behavior (usually grade 3, receptor negative) with very fast growth rates. In particular BRCA1-associated breast cancer may be indistinguishable from fibroadenomas: they appear as well-defined, roundish, hypoechoic masses with smooth borders, without posterior acoustic shadowing on ultrasound, without associated microcalcifications on mammography, and with strong wash-out phenomenon on breast MRI. This article reviews the different options that exist for the prevention of familial or hereditary breast cancer and the specific difficulties that are associated with the radiological diagnosis of these cancers. Lastly, an overview is given of the current evidence regarding the effectiveness of the different imaging modalities for early diagnosis of familial and hereditary breast cancer.