[Consensus Meeting of Course Directors in Breast Imaging, 7 May 2011, in Frankfurt am Main--topic: MRI of the breast]. / Konsensustreffen der Kursleiter in der Mammadiagnostik am 7.5.2011 in Frankfurt am Main--Magnet-Resonanz-Tomografie der Mamma.

PURPOSE: The general gap in the BIRADS lexicon between lesion description and categorization leads to very different recommendations in clinical breast radiology. This is particularly true for breast MRI. The third consensus meeting of course directors in breast imaging aimed at an increase in standardization of breast MRI. MATERIALS AND METHODS: Between 166 and 344 participants in the audience (A) and 9 and 13 expert panel participants (P) took part in an electronic wireless voting system. The audience consisted of 98% radiologists and 2% gynecologists (A: n=295; P: n=12: radiologists 92%/gynecologists 8%). Of all participants, 62% had more than 10 years of experience in breast imaging and only 9% had less than 3 years of experience (P: 100%>10 years of experience). The day before 44, clinically relevant, though unresolved questions were formulated by the expert panel. For the evaluation a distinction was made between answers with a great majority (>75%), simple majority (50-<75%) and no majority (<50%) as well as answers from the expert panel and answers from the audience. RESULTS: Of 44 questions, all but two were answered with simple or great majority. CONCLUSION: Technique, reporting and clinical use are becoming more and more accurately defined in MRI of the breast and MR-guided interventions. The third consensus meeting of this kind gained numerous answers and thus enables recommendations for didactic as well as clinical routine work.

[Consensus Meeting of Course Directors in Breast Imaging, 9 May 2009, in Frankfurt am Main - Topic: Masses]. / Konsensustreffen der Kursleiter in der Mammadiagnostik am 9.5.2009 in Frankfurt am Main - Thema: Herdbefunde.

Fourteen directors of breast imaging courses met on behalf of the German Society of Radiology to discuss the actual standards of the diagnosis of masses. Open questions on the fields of mammography, breast ultrasound and breast MRI were elucidated by a presentation of one of the 14 panel members, followed by an electronic anonymous voting. Beside of the panel members, more than 300 participants of the consensus meeting contributed their opinions by electronic voting. Answers with definite majorities (> 75 %), answers with narrow majorities and those with missing majorities were discriminated from each other. The opinions of the plenum were compared to the majorities of the podium and showed only a few critical differences. Due to unequivocal majorities seven answers to important questions concerning the diagnosis of masses can lead to a further standardization of breast cancer diagnosis.

Comparison of full-field digital mammography and film-screen mammography: image quality and lesion detection.

The objective of this study is to compare image quality and lesion detection for full field digital mammography (FFDM) and film-screen mammography (FSM). In 200 women we performed digital mammography of one breast and film-screen mammography of the other breast. Imaging parameters were set automatically. Image quality, visualization of calcifications and masses were rated by three readers independently. Mean glandular dose was calculated for both systems. We found no significant difference in mean glandular dose. Image quality was rated by reader A/B/C as excellent for FFDM in 153/155/167 cases and for FSM in 139/116/114 cases (p<0.03/0.001/0.001). Microcalcifications were detected by FFDM in 103/89/98 and by FSM in 76/76/76 cases (p<0.01/0.06/0.01). Detection of masses did not differ significantly. FFDM provided significantly better visibility of skin and nipple-areola region (p<0.01). FFDM demonstrated improved image quality compared with film-screen mammography. Microcalcification detection was also significantly better with the digital mammography system for two of the three readers.

Microcalcifications of the breast: how does radiologic classification correlate with histology?

PURPOSE: To assess the correlation between the pre-biopsy classification of microcalcifications and the underlying histology. MATERIAL AND METHODS: Using the morphology and distribution patterns according to the Breast Imaging-Reporting and Data System (BI-RADS) lexicon, the microcalcifications of 199 lesions in 163 consecutive patients scheduled to undergo 11 G vacuum core biopsy were classified within the BI-RADS categories. The correlation between BI-RADS assessment categories 3, 4, and 5 and the final histological results was statistically evaluated with the chi2 test. The diagnostic indices were calculated. RESULTS: The prospectively classified BI-RADS 3/4/5 findings revealed a malignant histology in 5.9%/17.6%/90.9% of all lesions, respectively. The relationship between BIRADS categories 3, 4, and 5 and histology was statistically highly significant (P<0.0001). The sensitivity, specificity, positive and negative predictive values were 95.7%/21.2%,/37.8%/94.3%, respectively. CONCLUSION: The BI-RADS lexicon describes microcalcifications of the breast and provides diagnostic categories that lead to standardized biopsy recommendations. Nevertheless, how to link description to classification of microcalcifications is still a difficult diagnostic task. The evaluation of microcalcifications as proposed in this article may help to set standards in the clinical routine and in the comparability of scientific data.

[Clinical value of mammography, ultrasound and MR imaging during the first year after breast conserving therapy of breast cancer]. / Klinischer Stellenwert bildgebender Verfahren im ersten Jahr nach brusterhaltender Therapie des Mammakarzinoms.

PURPOSE: To compare the accuracy of lesion detection and characterization and to determine the agreement of observers, methods and timing of mammography (MX), ultrasound (US) and MR imaging (MRI) during the first year after breast conserving therapy. MATERIALS AND METHODS: The study included 20 patients diagnosed with breast cancer of stages equal or inferior to T2 N1bi M0 after breast conserving therapy and subsequent radiotherapy. Patients with any history of breast diseases in the affected or contralateral breast were excluded. Patients were examined before and at 3, 6 and 12 months after adjuvant radiotherapy with MX, US and dynamic MR mammography. Additional US and MRI were performed 3 months after radiotherapy. All 220 examinations were retrospectively read in a randomized order by two independent readers, blinded for the results of the other examinations. The outcome after 2.5 years of follow-up was used as gold standard. Histological examination was available in one case. Lesion detection and specificity were assessed including kappa values for different reliabilities between observers, timing and methods. The kappa values were used to characterize the degree of agreement as follows: > 0.8 very good; 0.6 - 0.8 good; 0.4 - 0.6 fair; 0.2 - 0.4 minimal; and < 0.2 negligible. RESULTS: Based on the interpretation of all available findings (clinical examination, MX, US, MRT and histology in one case), 20 patients observed for a mean period of 2.5 years had no evidence of intramammary recurrence. Therefore the sensitivity of the various methods could not be assessed. The reading of certainly no lesion was given by MRI in 43 %, by MX in 30 % and by US in 5 % of all examinations (p < 0.05). True negative findings were observed by MRI in 94.4 %, by MX in 90.4 % and by US in 82.5 %. Reliability between observers, timing and imaging methods was 0.496, 0.411, and 0.215 for lesion detection and 0.303, 0.282, and 0.030 for lesion characterization. CONCLUSION: Within the first year after breast conserving therapy, MRI was the most confident method for the exclusion of lesions and presented the highest true negative rate. The assessment of dignity of a particular lesion was difficult by all imaging methods, reflected by the weak agreement between observers, methods and timing. The difference between times of readings were marginal in the first year after therapy. Agreement between the different diagnostics methods was minimal to negligible.

Takayasu's arteritis secondary to myelodysplasia as a predictor of poor outcome: two case reports.

We present two patients with myelodysplasia in association with Takayasu's arteritis (TA). In both patients intensive immunosuppressive treatment could not control the vascular inflammation. Subsequently both patients developed myelodysplasia, rapidly progressing to secondary acute myelogenous leukaemia. One patient had a peripheral blood stem cell transplant from a compatible sibling donor, but died of refractory leukaemia 5 months later. The other patient died of fungal sepsis. These are the first two patients reported to have TA associated with myelodysplasia/secondary leukaemia.

[Radiologic-histopathologic correlation of microcalcifications from 11g vacuum biopsy: analysis of 3196 core biopsies]. / Radiologisch-histopathologische Korrelation von Mikrokalzifikationen in 11-G-Vakuumbiopsaten - eine Analyse von insgesamt 3196 Proben.

PURPOSE: To perform a statistical evaluation of microcalcifications (MC) from suspicious breast lesions detected by radiography and histopathology. MATERIALS AND METHODS: Histological and radiological detection of calcifications were compared from 116 biopsies in 96 women. Lesions with identical description of calcifications detected in histopathology and radiography were considered concordant, patients with obvious discrepancies discordant. If histological and radiological groups of calcifications were identical in number but differed in location, the case was considered pseudo-concordant. RESULTS: Histopathology classified 24 of 116 lesions as malignant and 92 as benign. A total of 3196 core biopsies were examined, 851 of these contained groups of calcifications or single calcifications. Both modalities detected 579 calcifications, with 169 exclusively detected by radiography and 103 exclusively by histopathology. In 35 cases (30 %) radiologic and pathologic results were concordant, in 6 cases pseudo-concordant (4 %) and in 75 cases (65 %) discordant. The case-based Kappa coefficient was - 0.09 (- 0.24 to 0.07). The 122 calcifications not detected by histopathology were few or single calcifications at the edge of the core that were probably lost during processing, 18 were possible artefacts. Six cores contained calcium oxalate, 3 contained milk of calcium. In 6 cases malignant disease was found after the first examination, hence the cores were not searched thoroughly for the missing calcifications. In the remaining 14 cases, no calcifications were found despite complete processing of the tissue. In 49 of 103 cases of radiologically undetected microcalcifications, the retrospect analysis showed dense tissue areas that probably contained the calcification. The remaining 54 cases contained calcifications, which were too small to be detected radiologically. SUMMARY: Discordant results from pathological and radiological examinations of biopsies can mainly be explained by calcifications at the edge of the specimen lost during processing, which are therefore not detected in histopathology, and calcifications too small to be visualized radiologically.

Extensive peritoneal and omental lymphomatosis with raised CA 125 mimicking carcinomatosis: CT and intraoperative findings.

Diffuse peritoneal and omental seeding are well-known forms of dissemination of metastatic carcinoma. A wide variety of primary neoplasms may cause peritoneal and omental carcinomatosis, most commonly carcinomas of the ovary, gastrointestinal tract and breast. Extensive involvement of the peritoneal cavity with lymphoma is, however, rare. The association of peritoneal lymphoma with a raised CA 125, a tumour marker which is commonly raised in ovarian carcinoma, is a highly challenging clinical situation, which to our knowledge has not been published before in the medical literature. Not being aware of the possibility of this unusual combination of clinical, laboratory and imaging findings can lead to an erroneous diagnosis, as in our case.

[Stereotactic vacuum-assisted breast biopsy--success, histologic accuracy, patient acceptance and optimizing the BI-RADSTM-correlated indication]. / Stereotaktische Vakuumbiopsie mammographisch detektierter Läsionen - Erfolg, histologische Sicherheit, Patientenakzeptanz und BI-RADS trade mark -korrelierte Indikationsoptimierung.

PURPOSE: To evaluate success, histologic accuracy, patient acceptance and BI-RADS TM-correlated malignancy rate of stereotactic vacuum-assisted breast biopsies in order to optimize the indication. MATERIALS AND METHODS: In 132 patients with mammographically detected breast lesions 166 stereotactic vacuum- assisted 11 gauge core biopsies were performed. All lesions were classified according to the BI-RADS TM categories of the ACR. Removal of the lesion was radiographically assessed as complete, representative or not representative. Patient acceptance was evaluated. RESULTS: Of the 166 lesions, 54 (32.5 %) lesions were judged completely removed, 110 (66.3 %) representatively removed and 2 (1.2 %) not representatively removed. Malignancy was found in 38 (22.9 %) lesions. The rate of malignancy increased from 6.3 % (2/32) for BI-RADS TM category 3 to 16.7 % (19/114) for BI-RADS TM category 4 and increased further to 85 % (17/20) for BI-RADS TM category 5 (p < 0.001). The histology of a sufficient vacuum-assisted biopsy was underestimated in 6 (15 %) of the 40 lesions that were subsequently excised surgically. Most patients (98.5 %; 130/132) stated they would undergo a vacuum-assisted biopsy again. CONCLUSION: Vacuum-assisted breast biopsy is accurate, has a justifiable rate of histologic underestimation and is well accepted by patients. Patients with BI-RADS TM category 4 microcalcification benefit the most. Lesions of BI-RADS TM category 3 and BI-RADS TM category 5 should be biopsied only under special circumstances (family risk of breast cancer; assessment of lesions extension).

Large-core needle biopsy for diagnosis and treatment of breast lesions.

PURPOSE: Large-core needle biopsy (LCNB) has become a more widely used technique in the evaluation of breast lesions. This study was undertaken to access the accuracy of percutaneous LCNB on breast lesions and the impact on further proceeding. METHODS: A retrospective review of imaging-guided LCNB of 159 breast lesions was done. 143 LCNB were taken with ultrasound guided automated spring gun biopsy and 16 stereotactic-guided with vacuum-assisted biopsy device. Histology and morphobiological parameters were compared with subsequent material from surgery. RESULTS: In 113 core biopsies (71%), an infiltrating breast cancer was diagnosed, 5 biopsies (3%) yielded in-situ/atypical lesions and a benign lesion was shown in 38 cases (24%). In 3 cases, insufficient/necrotic material was obtained. 108 patients underwent subsequent surgery. In 100/108 cases (93%), histology on LCNB and surgery was identical. LCNB was false negative in 5 core biopsies (5%). Immunhistochemical stains of hormone receptors, bcl-2, c-erbB-2, p53 and MIB-1 was comparable on LCNB and on surgical material. Based on the results of LCNB, 17/113 patients (15%) with infiltrating carcinoma were primarily treated with hormones or with neoadjuvant therapy. 32/38 patients (84%) with benign lesions were followed up by imaging control. CONCLUSIONS: In patients with benign lesions on imaging, open biopsies can be avoided by LCNB. In patients with biopsy proven carcinoma, therapy planning is improved. The addition of morphobiological parameters allows early individual treatment.

[Quantitative assessment of therapy related effects after breast conserving therapy with dynamic MRI of the breast]. / Quantitative Erfassung von Gewebsveränderungen der Mamma nach brusterhaltender Therapie mit der dynamischen MR-Mammographie *

PURPOSE: To quantify therapy related effects after breast conservation therapy (BCT) with dynamic MRI of the breast. METHODS: Twenty patients (median age 51 years) with breast conserving tumor excision were included. Contrast enhanced dynamic MRI was performed before and 3, 6 and 12 months after adjuvant radiation therapy (RT) with a total dose of 50.0 to 50.4 Gy. The following sequences were applied: axial fat-suppressed T(2)-weighted; coronal contrast enhanced 3D spoiled gradient-echo (first measurement prior to the administration of 0.16 mmol/kg Gd-DTPA, six repetitive measurements); sagittal T(1)-weighted Flash3D. Enhancement data were obtained using a computer software with automated segmentation of regions of interest (ROIs). After defining ROIs for skin, parenchyma and pectoral muscle of each breast the early enhancement after the first post contrast measurement (E(1)) and the slope of enhancement between the second and last postcontrast measurement (SE(2-L)) were calculated. The edema was quantified by assessing the signal intensities (SI) in the T(2)-weighted images. The thickness of the skin was measured in the sagittal T(1)-weighted images. RESULTS: Three months after RT statistically significant increases between 51 and 179 % of the SI and E(1) quotients were detected for all tissues compared to the examinations prior to RT. Six months after RT the skin still presented a by 102 % significantly higher E(1) quotient, and a by 140 % significantly increased SI quotient. No significant differences for SI and E(1) quotients could be observed 12 months after RT compared to the examinations prior to RT. A significant increase of the SE(2-L) difference for the skin from 0.0225 to 0.0691 and 0.0665 was found 3 and 6 months after RT, respectively. No significant differences between the initial MR examination and the follow-up examinations 3, 6 and 12 months could be detected for the SE(2-L) differences of the parenchyma. CONCLUSION: Early therapy related effects after BCT can be exactly quantified with dynamic MRI using an automated ROI-segmentation and whole breast analysis software. Both edema formation and early enhancement show peaks 3 months after RT, and after 12 months there is no statistically significant difference compared with baseline.

New strategies in platelet inhibition in noncoronary interventions.

Thrombembolic complications frequently occur during and after endovascular procedures because of associated arterial injury and thrombotic characteristics of implanted devices such as stents. New strategies in platelet aggregation inhibition are now available blocking the final and common pathway of platelet aggregation, the glycoprotein IIb/IIIa receptor. This treatment modality seems to be more effective for prophylaxis and prevention of thrombembolic complications than standard antiplatelet therapy. Most of the data provided for glycoprotein IIb/IIIa receptor blockade are derived from studies of coronary interventions. This report reviews the pharmacodynamic differences of classic and new drugs for platelet inhibition and the basic considerations for antiplatelet therapy in noncoronary interventions.

[Clinical experience with large-core needle biopsies of the breast and evaluation of histopathology]. / Klinische Erfahrungen mit perkutanen Biopsien der Brust und deren histologische Beurteilung.

OBJECTIVE: Interventional techniques allow a microinvasive diagnostic of breast lesions. We examined the reliability of large core needle biopsies for histologic diagnosis on breast lesions. MATERIAL AND METHODS: 143 ultrasound guided automated spring gun biopsies and 16 stereotactic guided vacuum-assisted device biopsies were analyzed. Indications included confirmation of malign or benign lesions and diagnosis of suspicious lesions. RESULTS: In 113 biopsies (71%) an invasive breast carcinoma was diagnosed, in 5 biopsies (3%) in situ/atypical lesions were seen and 38 cases (24%) showed benign lesions. Based on the bioptic results, 108 patients underwent subsequent surgery. An identical histology was seen in 100/108 patients (93%), 5 biopsies were false negative (5%) and 3 specimens yielded necrotic/insufficient material. The immunohistochemical results of percutaneous biopsies and surgical specimens were comparable. 17 out of 113 patients (15%) with biopsy proven carcinoma were treated with neoadjuvant therapy. 32/38 patients with benign lesions were follow-up clinically. CONCLUSION: Ultrasound- or stereotactic guided percutaneous biopsies are methods to confirm histological diagnosis. Based on the biopsy results the, number of surgical excisions can be reduced and treatment of biopsy proven carcinoma can be improved by individual presurgical planing.

International investigation of breast MRI: results of a multicentre study (11 sites) concerning diagnostic parameters for contrast-enhanced MRI based on 519 histopathologically correlated lesions.

A multicentre study was undertaken to provide fundamentals for improved standardization and optimized interpretation guidelines of dynamic contrast-enhanced MRI. Only patients scheduled for biopsy of a clinical or imaging abnormality were included. They underwent standardized dynamic MRI on Siemens 1.0 (163 valid lesions > or = 5 mm) or 1.5 T (395 valid lesions > or = 5 mm) using 3D fast low-angle shot (FLASH; 87 s) before and five times after standardized bolus of 0.2 mmol Gd-DTPA/kg. One-Tesla and 1.5 T data were analysed separately using a discriminant analysis. Only histologically correlated lesions entered the statistical evaluation. Histopathology and imaging were correlated in retrospect and in open. The best results were achieved by combining up to five wash-in or wash-out parameters. Different weighting of false-negative vs false-positive calls allowed formulation of a statistically based interpretation scheme yielding optimized rules for the highest possible sensitivity (specificity 30%), for moderate (50%) or high (64-71%) specificity. The sensitivities obtained at the above specificity levels were better at 1.0 T (98, 97, or 96%) than at 1.5 T (96, 93, 86%). Using a widely available standardized MR technique definition of statistically founded interpretation rules is possible. Choice of an optimum interpretation rule may vary with the clinical question. Prospective testing remains necessary. Differences of 1.0 and 1.5 T are not statistically significant but may be due to pulse sequences.

[Can follow-up controls improve the accuracy of MR mammography? A retrospective analysis of MR mammography follow-up studies]. / Können Verlaufskontrollen die diagnostische Sicherheit der MR-Mammographie erhöhen? Eine retrospektive Analyse MR-mammographischer Verlaufsuntersuchungen.

PURPOSE: To assess the change in diagnostic confidence between first and follow-up dynamic MR examination of the breast (MRM). METHODS: The reports of a total of 175 MRM in 77 patients (mean age 50 years; 36-76) with 98 follow-up MRM were analyzed. All examinations were performed as a dynamic study (Gd-DTPA, 0.16 mmol/kg; 6-7 repetitive studies). The change in diagnostic confidence was retrospectively classified as follows: controlled lesion vanished during follow-up (category I); diagnostic confidence increases during follow-up (II), more likely benign (IIa), more suspicious (IIb); no difference in diagnostic confidence (III). Long-term follow-up over an average of four years was obtained for 57 patients with category IIa/III findings. RESULTS: In 98 follow-up examinations, only two lesions vanished (2%). In 77/98 cases a category IIa lesion was diagnosed, in 11 cases a category IIb lesion. In 8 cases (8%) there was no change in diagnostic confidence during follow-up. Lesions in category IIb underwent biopsy in 10/11 cases, in one case long-term follow-up proved a completely regredient inflammatory change. In 8/11 suspicious findings (IIb) a malignant tumor was detected. The mean time interval between first and follow-up MRM was 8 months for I-IIb lesions, and 4 months for category III lesions. In the long-term follow-up two patients with a category IIa lesion developed a carcinoma in a different breast area after four and five years. CONCLUSION: MRM follow up increases the diagnostic confidence if the time interval is adequate (> 4 months). A persistently or increasingly suspicious finding warrants biopsy.

[MR tomographic characterization of suspicious breast lesions with dynamic susceptibility-weighted T2* sequences]. / MR-tomographische Charakterisierung suspekter Mammabefunde mittels suszeptibilitätsgewichteter T2*-Sequenzen.

PURPOSE: To increase specificity of MR-mammography by using dynamic T2* sequences. METHODS: 23 patients with suspicious lesions of the breast underwent conventional dynamic T1-weighted (T1-dynamic) breast MRI and, subsequently, dynamic T2*-weighted (T2*-dynamic) perfusion studies. To assess the T1-dynamic, signal enhancement during the first minute (E1) was calculated. To evaluate the T2*-dynamic, relative signal intensity loss after administration of contrast medium was determined. RESULTS: After administration of contrast medium, 6 of 13 malignant lesions did not show a signal decrease during the T2*-dynamic. Two of them exhibited an atypical signal enhancement in the T1-dynamic, with E1 < 100%. On the other hand, in 5 of 10 benign tumors a relative signal decrease of between 5-17% occurred during the T2*-dynamic. Four benign lesions showed a strong early signal enhancement during the T1-dynamic (E1 > 100%), which is more typical for malignant lesions. DISCUSSION: The use of dynamic T2* sequences, following dynamic T1-weighted breast MRI and administration of contrast medium, does not sufficiently increase diagnostic sensitivity. Thus, this study does not support the potential advantage of susceptibility MR imaging for a further characterization of breast lesions.