An audit of mammographic screen detected lesions of uncertain malignant potential (B3) diagnosed on initial image guided needle biopsy: how has our practice changed over 10 years?

AIM: To review all cases of B3 lesion diagnosed at initial image-guided needle biopsy over two 5-year cohorts to identify upgrade rates to malignancy and the effect of changing guidance on the management of such lesions. MATERIALS AND METHODS: Data was collected retrospectively. Mammographic features, biopsy type and management were recorded for each lesion. Upgrade rates for each B3 histological category were quantified. Statistical analysis was performed using SPSS. RESULTS: There were 224 cases in 2005-2010 and 240 cases in 2010-2015. Mammographically 211 lesions were microcalcifications, 182 masses, 65 distortions and six asymmetric densities with no difference in the mammographic features in the two cohorts. Two hundred and eight 14 G core biopsies and 256 initial vacuum-assisted biopsies were performed. There was a statistically significant reduction in benign surgical biopsies and an increase in second-line vacuum biopsy/excision in the latter cohort, with no significant change in the upgrade rate. There was an overall 6% upgrade to invasive malignancy and 13% upgrade to ductal carcinoma in situ (DCIS). The upgrade rates for the following histological categories were atypical intraductal epithelial proliferation (AIDEP) 33.2% (21/63); classical (not pleomorphic) in situ lobular neoplasia (ISLN) 18.2% (6/33); flat epithelial hyperplasia (FEA) 21.7% (20/92); papilloma with atypia 53.8% (7/13), without atypia 12.1% (8/66); and radial scar/complex sclerosing lesion with atypia 16.7% (2/12), and without atypia 7.9% (6/76). CONCLUSION: Upgrade rates remain high for some histological categories even with first-line use of vacuum biopsy. Management of borderline lesions should be considered carefully in a multidisciplinary meeting. In many cases, the need for diagnostic surgical excision has been replaced by image-guided vacuum sampling.

Can digital breast tomosynthesis accurately predict whether circumscribed masses are benign or malignant in a screening population?

AIM: To evaluate whether digital breast tomosynthesis (DBT) can predict if circumscribed masses are benign or malignant by assessing margin sharpness. MATERIALS AND METHODS: Circumscribed masses were evaluated on co-registered two-dimensional digital mammography (2DDM) and DBT. Lesions were categorised as follows: category 1=visible sharp border 0-25% of the total margin; category 2 = 26-50% category 3= 51-75%, and category 4=76-100%. Changes in category between 2DDM and DBT were analysed; if the category was lower on DBT the change was negative, if higher the change was positive. RESULTS: Of 759 lesions, 121 masses classified as circumscribed on DBT were included; 25 were malignant and 96 benign. Of the benign lesions, 8/96 were within category 3 or 4 on 2DDM compared with 48/96 benign lesions within category 3 or 4 on DBT (Fisher's exact test p<0.000527). Forty-eight of 51 (94.1%) lesions categorised as 3 or 4 on DBT were benign and 65/67 (97.01%) of the positive category change group were benign. Lesions in category 1 on DBT had 45.4% chance of being malignant (20/44) compared with 22.72% (20/88) on 2DDM (chi-squared test p<0.001). Sixty-five of 67 (97.01%) lesions in the positive category change group were benign and 23/54 (42.6%) lesions with either no or negative category change were malignant. CONCLUSION: The present study demonstrates 97% accuracy in predicting circumscribed lesions as benign when using positive category change and 94% accuracy when >50% of the margin is sharply defined on DBT.

Evolving imaging techniques for staging axillary lymph nodes in breast cancer.

The presence and extent of axillary nodal metastases at the time of breast cancer diagnosis is a critical factor in disease prognosis and plays a central role in deciding the best treatment for patients. Accurate assessment of the axilla is therefore an essential component in staging breast cancer. Over the years, axillary staging has evolved from surgical axillary lymph node dissection (ALND), with its numerous associated long-term complications, to the much less-radical surgical sentinel lymph node excision biopsy (SLNB), the current reference standard. In parallel, radiological staging of the axilla has become increasingly more useful as our knowledge and techniques have improved. Preoperative axillary ultrasound is used widely to stage patients with breast cancer, providing an evaluation of node morphology and allowing targeted biopsy of abnormal nodes. This is important in helping stratify which patients should proceed directly to ALND and which should undergo SLNB first. Grey-scale ultrasound on its own is not perfect and can over- and underestimate axillary disease. Newer ultrasound techniques such as elastography may help to improve diagnostic confidence when visually assessing axillary nodes; for example, in more accurately assessing the extent of axillary disease burden or in differentiating benign reactive nodes from malignant nodes in equivocal cases. The use of intradermal "microbubbles" has shown great promise in being able to locate and biopsy the sentinel lymph node under ultrasound guidance, and raises the possibility that in the future such techniques may obviate the need for surgical SLNB in select patient populations.

Microflow imaging: New Doppler technology to detect low-grade inflammation in patients with arthritis.

AIM: To assess the efficacy of microvascular imaging in detecting low-grade inflammation in arthritis compared with Power Doppler ultrasound (PDUS). METHOD AND MATERIALS: Patients presenting for ultrasound with arthralgia were assessed with grey-scale, PDUS and Superb Microvascular Imaging (SMI). Videoclips were stored for analysis at a later date. Three musculoskeletal radiologists scored grey-scale changes, signal on PDUS and/or SMI within these joints. If a signal was detected on both PDUS and SMI, the readers graded the conspicuity of vascular signal from the two Doppler techniques using a visual analogue scale. RESULTS: Eighty-three patients were recruited with 134 small joints assessed. Eighty-nine of these demonstrated vascular flow with both PD and SMI, whilst in five no flow was detected. In 40 joints, vascularity was detected with SMI but not with PDUS (p = 0.007). Out of the 89 joints with vascularity on both SMI and PDUS, 23 were rated as being equal; while SMI scored moderately or markedly better in 45 cases (p <0.001). CONCLUSION: SMI is a new Doppler technique that increases conspicuity of Doppler vascularity in symptomatic joints when compared to PDUS. This allows detection of low grade inflammation not visualised with Power Doppler in patients with arthritis. KEY POINTS: • SMI detects vascularity with improved resolution and sensitivity compared to Power Doppler. • SMI can detect low-grade inflammation not seen with Power Doppler. • Earlier detection of active inflammation could have significant impact on treatment paradigms.

[MRI investigations in patients with problems due to metal-on-metal implants]. / Magnetresonanztomographische Untersuchungen bei Problemen mit Metall-auf-Metall-Implantaten.

Until recently, metal-on-metal (MoM) hip implants were commonly used for joint replacement and resurfacings. Their use has rapidly declined following reports of Frühversagen and soft tissue disease caused by the release of metal debris from the prosthesis. Detection of these soft tissue lesions has proven difficult using conventional imaging techniques and blood metal ion tests. Current guidelines recommend the use of imaging modalities including metal artefact reduction sequence (MARS) magnetic resonance imaging (MRI), computed tomography and ultrasound but provide little indication which is best. MARS significantly reduces the susceptibility artefact induced by the presence of metal objects, thereby producing diagnostic quality images that can be shared with other physicians and compared over time. The clinical interpretation of MRI findings of solid pseudotumours and severe muscle atrophy is straightforward: revision is usually recommended. However, the most common MRI findings are of a cystic pseudotumour and minor muscle wasting. In these cases decision-making is difficult and we currently use multi-disciplinary and multi-colleague based meetings to make decisions regarding patient management. This article presents a comparison of imaging modalities and an update on the interpretation of MARS MRI for the investigation of patients with MoM hip implants.The English full-text version of this article is available at Springer Link (under "Supplemental").

Can contrast-enhanced sonography distinguish benign from malignant breast masses?

BACKGROUND: We investigated whether microvascular enhancement on contrast-enhanced sonographic (CEUS) imaging can aid in distinguishing between benign and malignant lesions and correlated these findings with histopathological findings. METHOD: Fifteen patients with a palpable breast mass were recruited. Following informed consent, 4.8 mL of the microbubble contrast agent SonoVue was injected intravenously. Digital video clips of lesion enhancement were obtained and reviewed by a consultant radiologist who scored each lesion on the following characteristics: homogeneous versus heterogeneous enhancement, the presence or absence of focal defects, well- versus ill-defined margins and vascular morphology score (VMS). RESULT: Histologically there were 7 malignant and 8 benign lesions. The calculated sensitivity for CEUS in the diagnosis of malignancy was 100%, with a 37.5% specificity. There was no statistically significant difference in overall mean VMS between the malignant and benign lesions. CONCLUSION: The results of our study have not shown any additional benefit in the use of CEUS over conventional triple assessment. The positive trend seen in the higher mean VMS for the malignant tumors needs further investigation with a larger cohort of patients.

Carcinoma of the breast wire localisation post nuclear medicine sentinel lymph node imaging. Are radiologists receiving a significant dose?

OBJECTIVE: To assess the radiation dose received by the radiologist when performing wire localisation for axillary radio-isotope sentinel node imaging-guided biopsy in patients with impalpable breast cancers treated with breast-preserving excision. When wire placement follows radio-isotope sentinel node imaging (RSNI) the radiologist is exposed to a radiation risk that has never been previously assessed. METHODS: Radiation doses to radiologists performing ultrasound-guided localisation following nuclear medicine sentinel node imaging were measured for procedures on the day of surgery (20 MBq) and also on the day before surgery (40 MBq). These measurements were compared with theoretically calculated doses. RESULTS: Twelve patients showed comparable results between measurements and estimated doses. The mean measured dose was 1.8 muSv (estimated 1.8 muSv) for same-day and 4.8 muSv (estimated 3.4 muSv) for next-day surgery cases. At worst, radiologists who perform 36 wire localisations per year immediately following RSNI receive a radiation dose of 0.17 mSv. CONCLUSIONS: This study highlights the need to inform radiologists of the relative risk when performing pre-surgical localisation after RSNI. This risk should be justified locally in accordance with the total dose received by the localising radiologist. Particular consideration should be given to pregnant staff and the possibility of performing wire localisations before radio-isotope injection.

Colorectal breast metastases presenting with atypical imaging features.

Breast metastases from non-breast primaries are rare in female patients and exceedingly rare in male patients, with only a handful of cases described. Lymphoma, metastatic melanoma and bronchial carcinoma are the primary sites for the majority of breast metastases. Breast metastases from colorectal carcinoma have been described previously in only a small number of cases in the literature. Here, we report a further two patients with biopsy-proven colorectal carcinoma metastases to both breasts, who demonstrate contrasting unusual and atypical imaging features that have not been reported previously. In one case, the imaging appearances mimic a multifocal primary breast carcinoma. Metastatic disease in the breast is a marker for disseminated metastatic spread, with a correspondingly poor prognosis. Therefore, we review the imaging features that differentiate metastatic breast disease from multifocal breast primaries, which are important to recognize because the management options for these patients differ greatly.

Acute appendicitis presenting with a testicular mass: ultrasound appearances.

Acute appendicitis presenting with scrotal symptoms is a rare event, occurring when a patent processus vaginalis persists. We present a case where ultrasound demonstrated an inflamed appendix and a scrotal abscess, allowing the correct surgical management in a difficult clinical situation. In a child presenting with scrotal signs and vague lower abdominal symptoms, an ultrasound assessment of the right iliac fossa should always be performed.