Diagnostic performance of axillary ultrasound and standard breast MRI for differentiation between limited and advanced axillary nodal disease in clinically node-positive breast cancer patients.

Preoperative differentiation between limited (pN1; 1-3 axillary metastases) and advanced (pN2-3; ≥4 axillary metastases) nodal disease can provide relevant information regarding surgical planning and guiding adjuvant radiation therapy. The aim was to evaluate the diagnostic performance of preoperative axillary ultrasound (US) and breast MRI for differentiation between pN1 and pN2-3 in clinically node-positive breast cancer. A total of 49 patients were included with axillary metastasis confirmed by US-guided tissue sampling. All had undergone breast MRI between 2008-2014 and subsequent axillary lymph node dissection. Unenhanced T2-weighted MRI exams were reviewed by two radiologists independently. Each lymph node on the MRI exams was scored using a confidence scale (0-4) and compared with histopathology. Diagnostic performance parameters were calculated for differentiation between pN1 and pN2-3. Interobserver agreement was determined using Cohen's kappa coefficient. At final histopathology, 67.3% (33/49) and 32.7% (16/49) of patients were pN1 and pN2-3, respectively. Breast MRI was comparable to US in terms of accuracy (MRI reader 1 vs US, 71.4% vs 69.4%, p = 0.99; MRI reader 2 vs US, 73.5% vs 69.4%, p = 0.77). In the case of 1-3 suspicious lymph nodes, pN2-3 was observed in 30.4% on US (positive predictive value (PPV) 69.6%) and in 22.2-24.3% on MRI (PPV 75.7-77.8%). In the case of ≥4 suspicious lymph nodes, pN1 was observed in 33.3% on US (negative predictive value (NPV) 66.7%) and in 38.5-41.7% on MRI (NPV 58.3-61.5%). Interobserver agreement was considered good (k = 0.73). In clinically node-positive patients, the diagnostic performance of axillary US and breast MRI is comparable and limited for accurate differentiation between pN1 and pN2-3. Therefore, there seems no added clinical value of preoperative breast MRI regarding nodal staging in patients with positive axillary US.

Disappearing adrenal masses.

Adrenal incidentalomas are a common finding due to the increasing use and improved technology of imaging studies. The majority of these enlargements are non-functional and irreversible. Publications on reversible adrenal enlargement are sparse. Our patient, a 66-year-old man, was admitted to the hospital due to abdominal discomfort. He was treated for rectal carcinoma 3 years before, and was now free of disease. Computed tomography (CT) scan showed no abnormalities other than the incidental finding of bilateral adrenal enlargement. Metastasis was suspected. The CEA-level, however, was within normal range and there was no evidence of hormonal overproduction. After 1 month the patient was reviewed. Physical examination and laboratory testing were normal. Surprisingly, the CT-scan showed a decreased size of both adrenals and after 3 months even showed completely normalized adrenals. Reversible adrenal enlargements are rare. Commonly described causes of adrenal enlargement are haematomas, cystic lesions and infections of the adrenal glands. The patient in this case did not show any clinical, laboratory or radiological signs of any of these diagnoses. The current existing differential diagnosis for bilateral adrenal enlargement is not sufficient to explain the findings in our patient.