Volumetric quantification of the effect of aging and hormone replacement therapy on breast composition from digital mammograms.

OBJECTIVE: To assess the physiological changes in breast composition with aging using volumetric breast composition measurement from digital mammograms and to assess the effect of hormone replacement therapy (HRT). METHODS: A total of 764 consecutive mammograms of 208 non-HRT using women and 508 mammograms of 134 HRT-using women were analyzed using a volumetric breast composition assessment software (Quantra™, Hologic Inc.). Fibroglandular tissue volume (FTV), breast volume (BV), and percent density (PD) were measured. For statistical analysis, women were divided into a premenopausal (<46 years), a perimenopausal (46-55 years), and a postmenopausal (>55 years) age group. More detailed graphical analysis was performed using smaller age brackets. Women using HRT were compared to age-matched controls not using HRT. RESULTS: Women in the postmenopausal age group had a significantly lower FTV and PD and a significantly higher BV than women in the premenopausal age group (FTV: 77 vs. 120 cm(3), respectively; PD: 16% vs. 28%, respectively; BV 478 vs. 406 cm(3), respectively; p<0.01 for all). Median FTV was nearly stable in consecutive mammograms in the premenopausal and postmenopausal age groups, but declined at a rate of 3.9% per year in the perimenopausal period. Median PD was constant in the premenopausal and postmenopausal age groups and declined at a rate of 0.57% per year in the perimenopausal age group. BV continuously increased with age. Women using HRT throughout the study had a 5% higher PD than women not using HRT (22% vs. 17%, respectively; p<0.001). CONCLUSIONS: Accurate knowledge of normal changes in breast composition are of particular interest nowadays due to the importance of breast density for breast cancer risk evaluation. FTV and PD change significantly during the perimenopausal period but remain relatively constant before and thereafter. Median total breast volume consistently increases with age and further contributes to changes in breast density. HRT use is associated with a significantly higher PD.

Impact of magnification views on the characterization of microcalcifications in digital mammography.

PURPOSE: To evaluate the additional benefit of true geometric (air-gap) magnification views for the characterization of microcalcifications in digital mammography. MATERIALS AND METHODS: After ethical approval, we retrospectively reviewed patient records to identify 100 patients with suspicious microcalcifications (35 malignant, 65 benign) who had a standard digital mammography and an additional digital magnification view in the same projection within three months. All images were obtained using an amorphous silicon-based full-field digital system (Senographe 2000 D, GE Healthcare, Chalfont St. Giles, UK). Images were independently analyzed by six board-certified radiologists. The probability of malignancy was estimated using first standard contact mammography alone (MG) and then mammography in combination with the magnification view (MG+MAG) using a modified Breast Imaging Reporting and Data System (BI-RADS) classification system and a percentage scale. Results were compared using receiver operating characteristic (ROC) analysis. In addition, readers assessed the subjective visibility of the calcifications. RESULTS: For all six readers combined, the area under the curve (AUC) was 0.664 ±â€Š0.052 for MG and 0.813 ±â€Š0.042 for MG + MAG, resulting in a statistically significant improvement of 0.148 ±â€Š0.120. Each reader had a higher AUC for MG + MAG than MG, with the improvement being statistically significant in four of the six readers. In 76.34 % of the cases, MG + MAG resulted in better visibility of calcifications compared with mammography alone. In 33 % slightly more and in 39 % significantly more calcifications were found. CONCLUSION: Even in digital mammography with the option of using electronic magnification (zoom) at the viewing workstation, true geometric (air-gap) magnification views remain important for the visibility and correct classification of microcalcifications and for the assessment of their extent.

Contrast-enhanced spectral mammography versus MRI: Initial results in the detection of breast cancer and assessment of tumour size.

OBJECTIVES: To compare mammography (MG), contrast-enhanced spectral mammography (CESM), and magnetic resonance imaging (MRI) in the detection and size estimation of histologically proven breast cancers using postoperative histology as the gold standard. METHODS: After ethical approval, 80 women with newly diagnosed breast cancer underwent MG, CESM, and MRI examinations. CESM was reviewed by an independent experienced radiologist, and the maximum dimension of suspicious lesions was measured. For MG and MRI, routine clinical reports of breast specialists, with judgment based on the BI-RADS lexicon, were used. Results of each imaging technique were correlated to define the index cancer. Fifty-nine cases could be compared to postoperative histology for size estimation. RESULTS: Breast cancer was visible in 66/80 MG, 80/80 CESM, and 77/79 MRI examinations. Average lesion largest dimension was 27.31 mm (SD 22.18) in MG, 31.62 mm (SD 24.41) in CESM, and 27.72 mm (SD 21.51) in MRI versus 32.51 mm (SD 29.03) in postoperative histology. No significant difference was found between lesion size measurement on MRI and CESM compared with histopathology. CONCLUSION: Our initial results show a better sensitivity of CESM and MRI in breast cancer detection than MG and a good correlation with postoperative histology in size assessment. KEY POINTS: • Contrast-enhanced spectral mammography (CESM) is slowly being introduced into clinical practice. • Access to breast MRI is limited by availability and lack of reimbursement. • Initial results show a better sensitivity of CESM and MRI than conventional mammography. • CESM showed a good correlation with postoperative histology in size assessment. • Contrast-enhanced spectral mammography offers promise, seemingly providing information comparable to MRI.

Volumetric breast density assessment: reproducibility in serial examinations and comparison with visual assessment.

BACKGROUND AND PURPOSE: Mammographic breast density is the strongest known marker of breast cancer risk. Visual breast density assessment is subject to significant intra- and inter-rater variability. The aim of the present study was to test the reproducibility of automatic breast density assessment and to compare the results to the visual assessment. PATIENTS AND METHODS: Serial mammograms of 141 patients were retrospectively reviewed. Breast density was assessed both visually using a BI-RADS four-category breast density scale and with a software tool for volumetric breast density measurement. RESULTS: The intra- and inter-rater reproducibility as well as inter-examination reproducibility were assessed for both techniques by calculating the intraclass correlation coefficient (ICC). The inter-examination reproducibility of the volumetric measurement of breast percent density was 0.91 (ICC; 95 % CI 0.87 - 0.93). There was no difference in the strength of the correlation between patients with a large vs. small difference in compression force. The intra- and inter-rater reproducibility ranged from 0.81 - 0.84 and 0.71 - 0.77, respectively. The inter-examination reproducibility of visual assessment was 0.75 - 0.81. The agreement of visual assessment with volumetric measurement was similar to the agreement among readers. CONCLUSION: Our results indicate that volumetric breast density measurement provides higher reproducibility in serial examinations than visual assessment and may thus be preferable in the longitudinal assessment of breast density and in the measurement of breast density for risk stratification.

MRI of the breast as part of the assessment in population-based mammography screening.

PURPOSE: To evaluate the indications and impact of MRI of the breast as an assessment modality in population-based mammography screening. MATERIALS AND METHODS: 135 consecutive contrast-enhanced MRI exams of the breast, which were performed between April 2007 and October 2012 as part of the assessment at one mammography screening unit before issuance of a final management recommendation (e. g. definitely benign or malignant), were retrospectively reviewed. Overall, the cases with an MRI exam of the breast during assessment represent less than 2 % of all assessment cases at this screening unit. All MRI exams were performed as part of the routine clinical care on a 1.5 T or 3 T whole-body magnet using a standard dynamic breast MRI protocol. RESULTS: In the 135 study patients, a total of 30 malignancies in 28 patients were found, including two bilateral cancers. One patient was diagnosed with a non-Hodgkin lymphoma, and of the remaining 29 malignant lesions, 3 (10 %) were in-situ cancers (DCIS) and 26 (90 %) were invasive breast cancers including 3 multifocal or multicentric cancers. All 26 detected invasive cancers were lymph-node negative and 25/29 (86 %) of the detected breast cancer were early stage cancers (stage 0 or 1). 53 of the 135 MRI exams (39.3 %) were suspicious for malignancy (BIRADS 4 or 5) with no cancer missed by MRI. The sensitivity, specificity, positive predictive value, and negative predictive value of the MRI on a per patient basis were 100 %, 77 %, 0.53, and 1, respectively. CONCLUSION: MRI is a useful problem-solving tool in mammography screening assessment with a high sensitivity and an acceptable positive predictive value.

Pre-operative assessment of living renal transplant donors with state-of-the-art imaging modalities: computed tomography angiography versus magnetic resonance angiography in 118 patients.

PURPOSE: To compare current technology multislice computed tomography angiography (CTA) with magnetic resonance angiography (MRA) in the pre-operative evaluation of vascular anatomy of living renal transplant donors. METHODS AND MATERIALS: Two hundred and thirty-six kidneys were included in the CTA and MRA analysis. Renal vasculature was evaluated independently by two readers in each modality with a delay of 4 weeks between reading sessions. Surgical correlation on the operated side was available in all patients. The reference standard was defined by surgical correlation and consensus reading of both modalities. RESULTS: Detection rate of CTA for arteries was 99.1 and 95.0 % for reader 1 and reader 2, respectively. Detection rate of MRA for arteries was 95.0/94.3 %. Most of the undetected arteries were ≤ 1 mm diameter (reader 1: 2 of 3 in CTA and 9 of 16 in MRA; reader 2: 11 of 16 in CTA, and 8 of 18 in MRA). Detection rates for arteries ≥ 2 mm for reader 1/reader 2 were 99.7/98.7 % in CTA and 99.1/97.8 % in MRA, respectively. Detection rates for veins were 99.6/97.4 % in CTA and 97.8/96.9 % in MRA, respectively. Both readers misdiagnosed between 0 and 1 non-present arteries and between 2 and 3 non-present veins in both modalities. CONCLUSIONS: Modern multislice CT and MRI scanners allow highly accurate evaluation of the vascular anatomy, especially for vessels of ≥ 2 mm diameter. CTA may provide slightly better depiction of very small arteries; however, this may be reader-dependent. Additional factors affecting the choice of imaging modality should include local availability, cost, and the desire to avoid ionizing radiation in healthy transplant donors.

Intraoperative specimen radiography in patients with nonpalpable malignant breast lesions.

PURPOSE: Specimen mammography of nonpalpable wire-localized breast lesions is the standard in breast-conserving surgery. The aim of this study was to evaluate the reliability of intraoperative 2-view specimen mammography in different cancer types. MATERIALS AND METHODS: After ethics approval, 3 readers retrospectively evaluated margins on 266 2-view specimen radiographs. They determined the closest margin and the orientation. The results were correlated with the histopathology (intra-class correlation coefficient [ICC] and contingency coefficient [CC]) and compared (Wilcoxon test). RESULTS: Invasive ductal carcinoma (IDC) with ductal carcinoma in situ (DCIS) was present in 115 (43 %), IDC in 75 (28 %), invasive lobular carcinoma (ILC) in 57 (22 %) and rare cancers (CA) in 19 specimens (7 %). The sensitivity/specificity and positive/negative predictive value (P/NPV) of specimen mammography were 0.50/0.86 and 0.86/0.50 for CA, 0.42/0.68 and 0.48/0.63 for IDC, 0.36/0.81 and 0.69/0.51 for ILC, and 0.22/0.78 and 0.68/0.32 for IDC+DCIS. Readers correctly identified the orientation of the closest margin in at least one view in an average of 149 specimens (56 %). CCs were between 0.680 (IDC) and 0.912 (CA), suggesting a moderate correlation between radiographic and histological orientation. The correlations were worse for the radiographic and histological distances, with ICC ranging from 0.238 (ILC) to 0.475 (CA). The Wilcoxon test revealed overestimation of the radiographic margins compared to the histological ones for DCIS. CONCLUSION: Our results suggest that specimen radiography has relatively good overall specificity and good PPV, while the sensitivity and NPV are low for DCIS. A negative result on specimen radiography does not rule out histologically involved margins.

Diagnostic performance of a Near-Infrared Breast Imaging system as adjunct to mammography versus X-ray mammography alone.

OBJECTIVES: Radiologist reader performance for breast cancer detection using mammography plus Near-Infrared Breast Imaging (NIBI) was compared with mammography alone. METHODS: Two hundred seventy-six consecutive patients with suspected breast lesions underwent both mammography and NIBI. Four blinded radiologists independently first reviewed the mammograms alone. Readers subsequently reviewed the mammograms in combination with NIBI. The diagnostic benefit of NIBI as an adjunct to mammography was determined by performing receiver operating characteristics (ROC) analyses for each reader based on BI-RADS categories (Breast Imaging Reporting and Data System) and LOS (level of suspicion) scores. Additionally, a multireader-multicase (ROC) analysis of variance (ANOVA) was carried out. RESULTS: For the LOS-based analysis, the combination of mammography and NIBI resulted in a slightly larger area under the curve (AUC) for all four readers. The analysis based on BI-RADS categories also demonstrated a slight increase in AUC for three readers for the combination of mammography and NIBI compared with mammography alone. For the fourth reader, AUC was smaller for the combination compared with mammography alone. Neither for the separate ROC-analyses nor for the ANOVA, significant differences between the two methods were obtained. CONCLUSIONS: The combination of mammography and NIBI did not perform significantly better than mammography alone. KEY POINTS: The intrinsic contrast provided by optical breast imaging may be inadequate We found slightly (but nonsignificant) higher accuracy for optical imaging and mammography compared with mammography alone. Contrast agents might be necessary to improve the performance of optical breast imaging.

Diffuse idiopathic skeletal hyperostosis (DISH): relation to vertebral fractures and bone density.

UNLABELLED: Radiographs and spinal bone mineral density (BMD) were evaluated from 342 elderly men regarding possible effects of diffuse idiopathic skeletal hyperostosis (DISH) on vertebral fractures and densitometry measurements. Prevalent vertebral fractures were more frequent among men with DISH compared to men with no DISH even after fracture prevalence was adjusted for BMD. Paravertebral calcifications should be considered in patients with DISH when interpreting BMD measurements because both dual X-ray absorptiometry (DXA) and quantitative CT (QCT) densitometry may not be reliable. INTRODUCTION: The purpose of this study is to evaluate the prevalence of DISH in older men and its association with vertebral fractures and with BMD determined by DXA and QCT. METHODS: Lateral radiographs of the spine were analyzed in a sample of 342 men aged ≥ 65 years participating in the MrOS Study concerning the presence and grade of DISH and vertebral fractures. Lumbar BMD was measured by both DXA (areal, grams per square centimeter) and QCT (volumetric, grams per cubic centimeter). The association between DISH, BMD, and presence of fractures was studied using χ ( 2 ) and t tests. RESULTS: DISH was present in 52% (178/342) of the men. Men with DISH were older (mean, 75.1 vs 73.3, p < 0.05) and more likely to have prevalent fractures (28% vs 20%, p < p = 0.09). BMD assessed with DXA (1.08 vs 1.00 g/cm(2), p ≤ 0.0001), but not with QCT (0.11 vs 0.11 g/cm3, p = 0.65), was significantly higher in men with DISH compared to men without DISH. Significantly lower BMD of men with both DISH and fractures compared to men with DISH but without fractures was only detected by QCT (-25%, 0.09 vs 0.12, p < 0.05). Both DXA BMD and QCT BMD were significantly higher in severe lumbar DISH (+22% and +31%, p < 0.0001), respectively. CONCLUSION: DISH was associated with a higher prevalence of vertebral fractures in elderly men. Lumbar ossifications related to DISH should be considered when interpreting BMD measurements to predict their fracture risk.

320-slice CT neuroimaging: initial clinical experience and image quality evaluation.

The aim of this study was to report initial clinical experience with a 320-slice CT scanner and to perform an image quality evaluation. 26 patients with presumptive cerebrovascular pathology underwent 320-slice CT. Single-rotation CT of the head, incremental CT angiography (three-dimensional (3D) CTA) as well as four-dimensional whole-brain CTA (4D CTA) and whole-brain CT perfusion (CTP) were performed and the resulting images were assessed for quality and compared with those obtained with 64-slice CT protocols. 320-slice CT neuroimaging could be performed in all cases. The image quality of 320-slice CT of the head and 3D CTA was inferior to that of the 64-slice protocols. The image quality of 4D 320-slice CTA was rated as inferior to both 320- and 64-slice 3D CTA. 4D CTA-CTP imaging added information with pivotal clinical implications. 320-slice CT neuroimaging is feasible technique that permits whole-brain 4D imaging and has the potential to identify pathologies with altered haemodynamics. However, image quality is a limitation of this technique at present.

Presentation, treatment and outcome in patients with ampullary tumours.

BACKGROUND: Ampullary tumours are relatively rare, and few large single-centre reports provide information on their treatment and outcome. The aim of this study was to analyse outcome and determine predictors of survival for patients with ampullary tumours treated in a specialist centre. METHODS: Over an 11-year period, 561 patients were treated for periampullary tumours, 88 of whom had a histologically proven ampullary neoplasm. Prospectively gathered data were analysed to assess predictors of survival. RESULTS: The overall resection rate was 92 per cent; there were no postoperative deaths. Median survival was 45.8 months for patients with resectable tumours and 8.0 months for those with irresectable disease (P < 0.001). On univariate analysis, age less than 70 years (P = 0.015) and a bilirubin level of 75 micromol/l or less (P = 0.012) favoured long-term survival. Among 70 patients who underwent cancer resection, factors associated with significantly worse long-term survival on univariate analysis included poorly differentiated tumour (P < 0.001), positive nodes (P < 0.001), perineural invasion (P = 0.001) and invasion of the pancreas (P = 0.018). Multivariate analysis identified positive nodes and bilirubin concentration as independent predictors of survival. CONCLUSION: An aggressive surgical approach to ampullary tumours is justified by the low proportion of benign lesions, the absence of postoperative mortality and improved long-term survival.

Prognostic factors in the palliation of pancreatic cancer.

AIM: Few patients with pancreatic cancer are eligible for resection. In the remainder, estimation of prognosis is important to optimise various aspects of care, including palliation of biliary obstruction and trial of chemotherapy. The aim is to evaluate the prognostic significance of clinical and laboratory variables in patients with unresectable pancreatic cancer. METHODS: Information was gathered retrospectively for 325 patients with unresectable pancreatic cancer who underwent palliative interventions, including surgical bypass, endoscopic or percutaneous stenting or who received supportive care only. RESULTS: Histological proof was obtained in 182 patients (56%). Median survival was 5.7 months. Absence of therapeutic intervention, leukocytosis (WCC> or =11 x 10(9)/l), gamma glutamyl transferase (gamma GT)>165U/L, prothrombin time ratio > or =1.1, and C-reactive protein (CRP) > or = 5mg/dL were associated with shorter survival on univariate analysis. Only absence of therapeutic intervention, leukocytosis, and gamma GT>165 U/L reached significance on multivariate analysis. In the 51 patients in whom serum CRP was available, CRP was the only significant predictor of survival on multivariate analysis. CONCLUSIONS: Leukocytosis, elevated gamma GT and raised CRP predict shorter survival and may help to guide the choice of palliative intervention for patients with unresectable pancreatic cancer.