Breast MRI artefacts: evaluation and solutions in 630 consecutive patients.

AIM: To evaluate the problems that may arise in breast magnetic resonance imaging (MRI) related to the presence of artefacts and pitfalls, in order to improve its accuracy, sensitivity, and specificity. MATERIALS AND METHODS: Six hundred and thirty breast MRI examinations performed using a 1.5 T magnet were analysed retrospectively. Each type of artefact that may have affected the correct interpretation of the acquired images was considered and analysed. In particular, the presence of technical artefacts, which are related to patient-dependent factors or to the examination itself, and non-technical artefacts, which are the result of inadequate and incorrect image interpretation occurring in absence of technical issues, were examined. In every case of suspicious findings, doubtful lesions were subjected to histological characterization for appropriate therapeutic planning. In the remainder of cases, patients underwent follow-up for at least 18 months. RESULTS: Artefacts were found in 33% of all examinations, among those 48.6% were caused by movement, 33.6% were due to non-homogeneous or failed fat saturation, 8.7% to incorrect positioning of the patient, 7.2% to metallic artefacts, 1.4% to aliasing, and 0.5% were "zebra artefacts". When the artefact was identified in a sequence, the sequence was performed a second time after corrective measures. No artefacts affected diagnostic interpretation of the obtained images. CONCLUSION: The present study provides a specific and precise review of the most frequent artefacts with a discussion of possible and practical solutions. A highly qualified team is required to perform accurate diagnostic tests and to limit or remove the possibility of misinterpretation.

Cost-effectiveness of two breast biopsy procedures: surgical biopsy versus vacuum-assisted biopsy.

PURPOSE: The aim of this study was to compare the cost-effectiveness of two breast biopsy procedures: surgical biopsy and vacuum-assisted biopsy (VAB). MATERIALS AND METHODS: Between November 2008 and September 2009, 200 patients with suspicious breast lesions underwent biopsy procedures at our radiology department: 100 underwent VAB and 100 underwent surgical biopsy. 66 lesions were sampled under sonographic guidance, 109 under mammographic guidance and 25 under magnetic resonance guidance. RESULTS: All procedures were successfully completed. No significant differences in diagnostic efficacy were found between the biopsy procedures. Surgical biopsy has a higher unit cost compared with VAB. CONCLUSIONS: Our analysis emphasises the benefits of VAB compared with surgical biopsy in terms of both cost-effectiveness, and less invasiveness from a psychological and aesthetic point of view.

Value of the correct diagnostic pathway through conventional imaging (mammography and ultrasound) in evaluating breast disease.

PURPOSE: This study evaluated the role of the correct diagnostic pathway through conventional imaging in evaluating breast disease. MATERIALS AND METHODS: Six hundred patients aged between 35 and 75 years were enrolled in the study. All patients underwent detailed history and clinical examination, ultrasound (US) and mammography. US scans were repeated after mammography. All suspicious lesions were studied by cytological and histological characterisation and magnetic resonance (MR) imaging. RESULTS: The first US scan showed 147 solid lesions, 67 lesions characterised by posterior acoustic shadowing and 193 areas of heterogeneous echostructure. The second US scan, performed after mammography, confirmed 123/147 solid nodular lesions, 53/67 lesions characterised by posterior acoustic shadowing and 183/193 areas of heterogeneous echostructure; it also showed 13 nodular lesions not seen on the first scan and two cases of nodular lesions with irregular calcifications. CONCLUSIONS: Our experience suggests that US not performed in conjunction with mammography gives rise to incorrect diagnostic interpretations (either false positive or false negative results). The detection rate of the US scan performed after mammography increases from 4.16% to 5.5%.

Pathological classification of DCIS and planning of therapeutic management.

BACKGROUND: Ductal intraepitelial neoplasia (DIN) represents a spectrum of disease that may progress from usual hyperplasia to ductal carcinoma in situ (DCIS) grade 3. The aim of the study was to asses the correlation between the DIN classification and the surgical treatment including sentinel lymph node biopsy (SLNB). PATIENTS AND METHODS: In this retrospective study, 229 patients with DIN had undergone conservative or radical surgical treatment and SLNB in cases of DIN1C-DIN3. RESULTS: Breast conservative surgery was the definitive treatment in 80% of the cases. The H&E evaluation of excised sentinel nodes was negative for metastatic disease; nevertheless the immunohistochemical (IHC) evaluation revealed the presence of metastatic cells in 6 patients (3.7%). CONCLUSION: In cases of DIN lesions SLNB is not indicated. The only reason SLNB should be considered is when there is an evidence of invasive foci at definitive histology or when radical mastectomy is proposed.

Rectus sheath haematoma: are there prognostic risk factors of haemodynamic instability motivating an early operative treatment?

PURPOSE: Rectus sheath haematoma (RSH) is an uncommon condition caused by lesion of the superior or inferior epigastric arteries or their branches or by rupture of the rectus muscle. Treatment is usually supportive; however, if haemodynamic compromise develops, intravascular embolisation or surgery may be required. Furthermore, in some cases, bleeding may be so conspicuous that it can determine the patient's death before an adequate treatment is performed. We performed a retrospective study on 78 consecutive patients with the diagnosis of RSH admitted to the General Surgery Unit of our hospital between January 2000 and December 2010 in order to identify possible prognostic risk factors that could affect the operational approach before the onset of haemodynamic instability. METHODS: Demographic characteristics, patient history, laboratory and diagnostic imaging examinations were investigated. The variables considered were: gender, age, anti-coagulation or anti-platelet therapy, trauma, international normalised ratio (INR) and bleeding time in the first 72 h of observation and concomitant diseases. The data were used for statistical analysis. RESULTS: Sixty patients received a conservative treatment, while 18 underwent operative treatment for haemodynamic instability (embolisation in 2 patients and surgery in 16 patients). Three of these 18 patients (17 %) died for consumption coagulopathy after surgery. None of the variables included in the univariate statistical analysis was significant (p = ns). CONCLUSION: Ultrasonography or computed tomography are the most common methods used to establish the diagnosis of RSH, so it is no longer a diagnostic dilemma. Most patients can be treated conservatively and an operative treatment is justified only in case of haemodynamic instability. Our retrospective study could not identify any prognostic risk factor of haemodynamic instability in RSH. We believe that only a close observation of the patients with RSH and "common sense" can prevent a possible fatal outcome.

The role of second-look ultrasound of BIRADS-3 mammary lesions detected by breast MR imaging.

OBJECTIVE: To asses the value of second-look ultrasound (US) for identifying BIRADS 3 (Breast Imaging Reporting Data System) mammary lesions detected by breast Magnetic Resonance imaging (MRI). MATERIALS AND METHODS: From April 2008 to May 2009 330 breast MRI were performed of which 60 patients are classified as BIRADS 3. 84 lesions underwent second-look US and percutaneous vacuum biopsy Vacora system US-guided. STATISTICAL ANALYSIS: lesions were stratified into two groups: visible on US (Group 1) and not visible on US (Group 2). The clinical impact of second-look US was studied in terms of negative predictive value (NPV). RESULTS: The positive predictive value (PPV) of category 3 BIRADS MRI was found to be 89%. Second look-US results detected lesions in 51% of the MRI enhancing lesions. The second look-US showed a NPV of 97%. The NPV of second look-US was significantly greater than the NPV of MRI BIRADS 3 (97% vs 89%, p<0.05). The logistic regression analysis showed a higher number of malignant lesions in group 1 than in group 2 (7vs 2, OR 3.7, p<0.05). CONCLUSIONS: The second-look US permitted the correct management of subcentimetric MRI BIRADS 3 lesions not visible with conventional imaging tecniques.

Cost-effectiveness analysis of two vacuum-assisted breast biopsy systems: Mammotome and Vacora.

PURPOSE: This study was undertaken to compare the cost effectiveness of two vacuum-assisted breast biopsy devices, the Mammotome and Vacora systems. MATERIALS AND METHODS: Between January and June 2006, 238 vacuum-assisted breast biopsies were performed at our radiology department. Five out of 238 lesions were excluded because of inadequate sampling. The Mammotome system was used in 108/233 lesions and the Vacora system in 125/233. Fifty-eight lesions underwent ultrasound-guided breast biopsy, and 50 lesions underwent mammography-guided biopsy with both Mammotome and Vacora devices. Magnetic-resonance-guided biopsy was possible with the Vacora system only (17/125 lesions). RESULTS: All procedures were successfully completed. No significant differences were found between the results of the Mammotome and Vacora biopsies in terms of effectiveness: sensitivity was 84.4% and 86.2%, respectively, and specificity 100%. In terms of cost, the Mammotome system has higher costs per procedure compared with the Vacora. CONCLUSIONS: Our clinical results confirm the diagnostic accuracy of both the Mammotome and Vacora systems, whereas our cost analysis shows that there is a considerable difference, mostly related to the initial investment.

MR imaging-guided 10-gauge vacuum-assisted breast biopsy: histological characterisation.

PURPOSE: The aim of this study was to evaluate a handheld vacuum-assisted device for magnetic resonance imaging (MRI)-guided breast biopsy. MATERIALS AND METHODS: In 47 patients, a total of 47 suspicious breast lesions (mean maximum diameter 9 mm) seen with MRI (no suspicious changes on breast ultrasound or mammography) were sampled using a 10-gauge vacuum-assisted breast biopsy (VAB) device under MRI guidance. Histology of biopsy specimens was compared with final histology after surgery or with follow-up in benign lesions. RESULTS: Technical success was achieved in all biopsies. Histological results from VAB revealed malignancy in 15 lesions (32%), atypical ductal hyperplasia in four lesions (8%) and benign findings in 28 lesions (60%). One of four lesions with atypical ductal hyperplasia was upgraded to ductal carcinoma in situ after surgery. One of seven lesions showing ductal carcinoma was upgraded to invasive carcinoma after surgery. Two lesions diagnosed as infiltrating carcinoma by VAB were not validated at excisional biopsy due to complete removal of the lesion during the procedure. During the follow-up (mean 18 months) of histologically benign lesions, we observed no cases of breast cancer development. Because of morphological changes on follow-up MRI scans, two lesions underwent surgical excision, which confirmed their benign nature. Besides minor complications (massive bleeding, n = 1) requiring no further therapeutic intervention, no complications occurred. CONCLUSIONS: MRI-guided biopsy of breast lesions using a handheld vacuum-assisted device is a safe and effective method for the workup of suspicious lesions seen on breast MRI alone.

Transcatheter embolization of a large symptomatic pelvic arteriovenous malformation with Glubran 2 acrylic glue.

A young patient affected by a pelvic arteriovenous malformation (pAVM) with recurrent episodes of hematuria following exercise, underwent transcatheter embolization using Glubran 2 acrylic glue (GEM, Viareggio, Italy). All branches of the pAVM were successfully occluded. The patient showed prompt resolution of symptoms and persistent occlusion of the pAVM at the 6 month follow-up.