To asses inter- and intra-observer variability for breast density and BIRADS assessment categories in mammographic reporting.

OBJECTIVE: To evaluate the inter- and intra-observer variability among radiologists in the characterisation of mammograms according to Breast Imaging Reporting and Data System assessment and breast density categories. METHODS: The descriptive cross-sectional study was conducted at Aga Khan University Hospital, Karachi, from January 2014 to June 2014. Using non-probability purposive sampling, all mammograms in the study were interpreted by three radiologists on the basis of Breast Imaging Reporting and Data System categories and by assessing the breast density composition. The inter-observer variability was recorded by comparing the difference in the interpretation and categorisation of each case. Intra-observer variability was noted by comparing the differences in the two sets of results from reading the same mammogram three months apart. RESULTS: A total of 254 mammograms were reviewed and the mean age of patients was 55.2±11.6 years. In the first round of diagnostic imaging, there was moderate agreement among all three possible pairs of observers regarding breast density (k= 0.50-0.41), but for Breast Imaging Reporting and Data System categories the agreement was less (k=0.27-0.13). After 3 months, variability of observer 1 showed substantial agreement (k=0.65).Variability between observer 2 and observer 3 showed moderate agreement (k=0.13).In terms of categories, intra-observer differences were variable: observer 1 (?=0.61; observer 2(?=0.17); observer 3 (k=0.45). CONCLUSIONS: Despite standardised guidelines for reporting density and assessment categories, observer variability continues to exist.

Diagnostic Accuracy of Transvaginal Ultrasound in Adenomyosis Taking MRI as a Gold Standard.

OBJECTIVE: To evaluate the accuracy of transvaginal ultrasound in the diagnosis of adenomyosis using MRI as the gold standard, and to characterise the most commonly seen and accurate ultrasonographic features and their combination. STUDY DESIGN: Cross-sectional, descriptive study. Place and Duration of the Study: Department of Radiology, The Aga Khan University Hospital, Karachi, from January 2018 to July 2021. METHODOLOGY: Transvaginal ultrasound examination was performed on patients (n = 208) who presented with symptoms related to menstrual cycles and pelvic abnormalities. Additionally, patients who sought infertility evaluation were also included in the study. The findings from the ultrasound examinations were assessed and tabulated alongside the results of the MRI scans. All examinations were conducted by senior radiologists / sonographers. The sensitivity, specificity, positive and negative predictive values (PPV and NPV, respectively) of ultrasound features were calculated individually and in combination, taking MRI as the gold standard. To enhance the accuracy of ultrasound findings, various variables were combined, and their sensitivities and specificities were calculated. RESULTS: Overall, transvaginal ultrasound had a high specificity of 96.15% (95% CI: 85.67 - 99.33), a relatively low sensitivity of 74.36% (95% CI: 66.63 - 80.85), PPV of 98.31 (95% CI: 93.40 - 99.70) and NPV of 55.56 (95% CI: 44.73 - 65.90). The most sensitive dual variable used was a bulky uterus combined with altered myometrial echotexture, with a sensitivity of 72.97% (95% CI: 64.95 - 79.78) and specificity of 95.83% (95% CI: 84.57-99.27). The best combined triple variable was a bulky uterus with altered echotexture and streaky myometrium, with a sensitivity of 71.85% (95% CI: 63.35 - 79.10) and a specificity of 95.46% (95% CI: 83.30 - 99.21). CONCLUSION: Transvaginal ultrasound features can identify adenomyosis characteristics in most of the patients. This could reduce the number of pelvic MRIs performed for the detection of adenomyosis. KEY WORDS: Adenomyosis, Diagnosis, Magnetic resonance imaging, Bulky uterus, Altered myometrial, Echotexture, Ultrasound.

Percutaneous cholecystostomy (PC) in the management of acute cholecystitis in high risk patients.

OBJECTIVE: To determine the role of ultrasound-guided percutaneous cholecystostomy (PC) regarding complications and outcome in the management of acute cholecystitis in patients high risk for surgery and anaesthesia and not responding to conservative management. STUDY DESIGN: Observational case series. PLACE AND DURATION OF STUDY: The study was carried out at The Aga Khan University Hospital, Karachi, from January 2003 to December 2007. METHODOLOGY: The study included patients admitted with acute cholecystitis considered unfit for immediate surgery but not responding to conservative management. Percutaneous cholecystostomy was conducted under ultrasound guidance. The studied variables included patients' demographics, co-morbid, ultrasound findings of biliary tree, indication for percutaneous cholecystostomy, its route, complication during or after procedure, patient's clinical outcome (upto 48 hours) and 30 days follow-up. Those with incomplete medical record and follow-up were excluded. Data were analyzed and results compiled using SPSS 16.0 version. Mean and standard deviation for quantitative variable like age was derived. Proportions were computed for complications and patient's clinical outcome. RESULTS: Forty one patients with complete medical record were studied including 15 (37%) males and 26 (63%) females. Mean age was 65 +/-13.5 years. Indications for PC included calculus cholecystitis in 25, acalculous cholecystitis in 10, empyema in 04 and gallbladder perforation in 02 patients. No complication was seen during or after procedure in 31 (75%) patients. Complications occurred in 10 (25%) patients including vagal reaction, pain during procedure, tube blockage, catheter dislodgement and bile leakage. Favourable clinical response (improvement in clinical symptoms) was noted in 34 (83%) patients. Seven (17%) patients did not show any improvement in clinical condition after the procedure. On 30 days follow-up, 9 patients had undergone cholecystectomy, 5 (12%) patients expired due to underlying clinical conditions and the rest were settled without requiring an immediate cholecystectomy. There was no direct procedure-related mortality. CONCLUSION: Imaging guided PC is a safe and effective procedure for immediate management of non-resolving acute cholecystitis in patients high risk for surgery and anaesthesia and not responding to conservative management.

Variability of Breast Density Assessment and the Need for Additional Imaging: A Comparison between Computed Mammography and Digital Mammography.

OBJECTIVE: To determine the variability of breast density assessment and the need for additional imaging using computed radiography (CR) mammography versus digital radiography (DR) mammography. STUDY DESIGN: Cohort study. PLACE AND DURATION OF STUDY: Department of Radiology, The Aga Khan University Hospital, Karachi from March to June 2018. METHODOLOGY: Patients who underwent screening CR mammography, followed by DR mammography a year later, were selected. Only disease-free individuals were included in the study. Evaluation of breast density was done subjectively, using the breast imaging reporting and data system (BI-RADS) by two independent experienced radiologists. Statistical analysis was performed using the Wilcox Signed Rank-sum test to compare both modalities. Fisher Exact method was used to compare the need for ultrasound imaging.   Results: A total of 295 patients were included in the study. The mean age of the patients was 52.76 ± 0.64 years. There was a significant difference in the change of breast density when comparing both modalities (Z= -11.839, p <0.001). A statistically significant reduction in the need for further breast ultrasound was observed after DR mammography than with CR mammography (p <0.001).  Conclusion: Use of DR mammography, especially in patients with dense breast parenchyma, is a better screening tool overall. It translates to better feasibility for the radiologist and is more economical for the patient. DR mammography decreases unnecessary imaging and leads to better visualisation, thus providing a more accurate categorisation of breast density. Key Word: Computed radiography mammography, Breast density, Screening, Breast cancer, Digital mammography, Ultrasound.

Malignant phyllodes tumour as an intracystic growth with osteosarcomatous differentiation.

Phyllodes tumour is an uncommon fibro epithelial tumour of breast that often presents clinically as a rapidly enlarging lump. On mammography it appears as a soft tissue density well circumscribed mass. Ultrasound shows it to be a solid hypoechoic mass with small cystic spaces. A case of malignant phyllodes tumour with an atypical appearance of intracystic tumour on sonography is reported with pertinent imaging features and histopathological diagnostic criteria. The tumour had undergone osteosarcomatous differentiation.

Diagnostic Performance of Breast MRI in the Evaluation of Contralateral Breast in Patients with Diagnosed Breast Cancer.

AIMS: The purpose of our study was to evaluate the diagnostic performance of breast magnetic resonance imaging (MRI) in the evaluation of contralateral breast in patients with diagnosed breast cancer. A secondary objective was to determine accuracy of breast MRI in diagnosing multi-focal and multicentric lesions in the ipsilateral breast. MATERIALS AND METHODS: Using a non-probability convenience sampling technique, patients with histopathologically diagnosed breast cancer with MRI of breast performed to exclude additional lesions were included. MRI findings were correlated with histopathology. In addition, follow-up imaging with mammography and ultrasound was also assessed for establishing stability of negative findings and for the detected of benign lesions. RESULTS: Out of 157 MRI breast conducted during the period of 2008 to 2013, 49 were performed for patients with diagnosed breast cancer. The sample comprised of all females with mean age 50.7 ± 11.0 years. The patient follow-up imaging was available for a period of 2-5 years. The sensitivity, specificity, and positive and negative predictive values of MRI in the detection of multifocal/multicenteric lesions was 85.7%, 88.8%, 60% and 96.6% respectively and for the detection of lesions in the contralateral breast were 100%, 97%, 83.3% and 100% respectively. CONCLUSIONS: Our study highlights the diagnostic performance and the added value of MRI in the detection of multifocal /multicenteric and contralateral malignant lesions. In patients with diagnosed breast cancer having dense breast parenchyma and with infiltrating lobular carcinoma as the index lesion MRI is particularly useful with excellent negative predictive value in the exclusion of additional malignant foci in the ipsilateral and contralateral breasts.

Learning from errors in radiology to improve patient safety.

OBJECTIVE: To determine the views and practices of trainees and consultant radiologists about error reporting. STUDY DESIGN: Cross-sectional survey. PLACE AND DURATION OF STUDY: Radiology trainees and consultant radiologists in four tertiary care hospitals in Karachi approached in the second quarter of 2011. METHODOLOGY: Participants were enquired as to their grade, sub-specialty interest, whether they kept a record/log of their errors (defined as a mistake that has management implications for the patient), number of errors they made in the last 12 months and the predominant type of error. They were also asked about the details of their department error meetings. All duly completed questionnaires were included in the study while the ones with incomplete information were excluded. RESULTS: A total of 100 radiologists participated in the survey. Of them, 34 were consultants and 66 were trainees. They had a wide range of sub-specialty interest like CT, Ultrasound, etc. Out of the 100 responders, 49 kept a personal record/log of their errors. In response to the recall of approximate errors they made in the last 12 months, 73 (73%) of participants recorded a varied response with 1 - 5 errors mentioned by majority i.e. 47 (64.5%). Most of the radiologists (97%) claimed receiving information about their errors through multiple sources like morbidity/mortality meetings, patients' follow-up, through colleagues and consultants. Perceptual error 66 (66%) were the predominant error type reported. Regular occurrence of error meetings and attending three or more error meetings in the last 12 months was reported by 35% participants. Majority among these described the atmosphere of these error meetings as informative and comfortable (n = 22, 62.8%). CONCLUSION: It is of utmost importance to develop a culture of learning from mistakes by conducting error meetings and improving the process of recording and addressing errors to enhance patient safety.