Clinical performance metrics of 3D digital breast tomosynthesis compared with 2D digital mammography for breast cancer screening in community practice.

OBJECTIVE: The objective of our study was to assess the clinical performance of combined 2D-3D digital breast tomosynthesis (DBT), referred to as "3D DBT," compared with 2D digital mammography (DM) alone for screening mammography in a community-based radiology practice. MATERIALS AND METHODS: Performance outcomes measures were assessed for 14 radiologists who interpreted more than 500 screening mammography 3D DBT studies after the initiation of tomosynthesis. Outcomes from screening mammography during the study period between August 9, 2011, and November 30, 2012, using 3D DBT (n = 23,149 patients) versus 2D DM (n = 54,684 patients) were compared. RESULTS: For patients screened with 3D DBT, the relative change in recall rate was 16.1% lower than for patients screened with 2D DM (p > 0.0001). The overall cancer detection rate (CDR), expressed as number of cancers per 1000 patients screened, was 28.6% greater (p = 0.035) for 3D DBT (6.3/1000) compared with 2D DM (4.9/1000). The CDR for invasive cancers with 3D DBT (4.6/1000) was 43.8% higher (p = 0.0056) than with 2D DM (3.2/1000). The positive predictive value for recalls from screening (PPV1) was 53.3% greater (p = 0.0003) for 3D DBT (4.6%) compared with 2D DM (3.0%). No significant difference in the positive predictive value for biopsy (PPV3) was found for 3D DBT versus 2D DM (22.8% and 23.8%, respectively) (p = 0.696). CONCLUSION: In community-based radiology practice, mammography screening with 3D DBT yielded lower recall rates, an increased CDR for cancer overall, and an increased CDR for invasive cancer compared with 2D DM. The PPV1 was significantly greater in the group screened using 3D DBT.

Underestimation of atypical ductal hyperplasia at MRI-guided 9-gauge vacuum-assisted breast biopsy.

OBJECTIVE: The purposes of this study were to determine the frequency of diagnosis of atypical ductal hyperplasia (ADH) at MRI-guided 9-gauge vacuum-assisted breast biopsy and to assess the rate of underestimation of ADH at subsequent surgical excision. MATERIALS AND METHODS: We conducted a retrospective review of medical records of 237 lesions consecutively detected with MRI and then subjected to MRI-guided 9-gauge vacuum-assisted breast biopsy during a 33-month period. Underestimated ADH was defined as a lesion yielding ADH at vacuum-assisted biopsy and cancer at surgery. Scientific tables were used to calculate 95% CI. RESULTS: Histologic analysis of MRI-guided vacuum-assisted breast biopsy specimens yielded ADH without cancer in 15 (6%) of 237 lesions. Among 15 patients in whom vacuum-assisted breast biopsy yielded ADH, the median age was 52 years (range, 46-68 years). The median number of specimens obtained was nine (range, 8-18 lesions). Median MRI lesion diameter was 1.3 cm (range, 0.7-7.0 cm). Among 15 MRI lesions, 10 (67%) were nonmasslike enhancement and five (33%) were masses. Surgical excision was performed on 13 lesions. Surgical histologic findings were malignancy in five (38%) of the cases, all ductal carcinoma in situ; high-risk lesion in six (46%) of the cases, including ADH without other high-risk lesions (n = 2), ADH and lobular carcinoma in situ (LCIS) (n = 1), ADH, LCIS, and papilloma (n =1), ADH and papilloma (n = 1), and LCIS (n = 1); and benign in two (15%) of the cases. These data indicated an ADH underestimation rate of 38% (95% CI, 14-68%). CONCLUSION: ADH without cancer was encountered in 6% of MRI-guided 9-gauge vacuum-assisted breast biopsies. ADH at MRI-guided vacuum-assisted breast biopsy is an indication for surgical excision because of the high (38%) frequency of underestimation of these lesions.

Hepatocellular carcinoma in the cirrhotic liver: gadolinium-enhanced 3D T1-weighted MR imaging as a stand-alone sequence for diagnosis.

PURPOSE: To retrospectively assess the usefulness of contrast material-enhanced T1-weighted magnetic resonance (MR) imaging alone and with T2-weighted MR imaging in the diagnosis of hepatocellular carcinoma (HCC). MATERIALS AND METHODS: A waiver of informed consent and institutional review board approval for this retrospective study were granted. The study was HIPAA compliant. Twenty-eight men (mean age, 49 years; range, 23-70 years) and 10 women (mean age, 53 years; range, 42-72 years) with cirrhosis underwent T2-weighted and contrast-enhanced T1-weighted MR imaging at 1.5 T within 90 days of liver transplantation. Three readers reviewed the T1-weighted images alone and then the T2-weighted and T1-weighted images together. Lesion detection, characterization, and reader confidence levels were recorded. RESULTS: At liver explantation, 57 lesions were present in 18 patients: 19 HCCs, 33 dysplastic nodules, and five cysts. Contrast-enhanced T1-weighted imaging depicted 13 of 19 HCCs with an overall sensitivity of 68.4% (13 of 19) and specificity of 65.7% (23 of 35). The sensitivity and specificity for detection of dysplastic nodules (sensitivity, 9%; specificity, 68.4%) and HCCs (sensitivity, 68.4%; specificity, 65.7%) were nearly identical for T1-weighted images read alone or read with T2-weighted images. The only difference was the specificity for T1-weighted images read alone (65.7%) and read with T2-weighted images (62.9%). The addition of T2-weighted images altered the diagnosis in one of 90 (1.1%) cases and provided an increase in diagnostic confidence in four of 258 (1.6%) cases for independent readers and three of 90 (3.3%) cases at consensus reading. CONCLUSION: Contrast-enhanced T1-weighted imaging can be used as a stand-alone sequence for the diagnosis of HCC in patients with cirrhosis prior to liver transplantation.

Cardiac-synchronized gadolinium-enhanced MR angiography: preliminary experience for the evaluation of the thoracic aorta.

Gadolinium (Gd)-enhanced three-dimensional breath-hold magnetic resonance cardiac-synchronized angiography was performed in 13 patients suspected or known to have thoracic aortic disease. High-quality angiograms of the ascending/descending thoracic aorta and coronary arteries were obtained with this method. MR angiograms were compared with Gd-enhanced angiograms obtained without cardiac synchronization. Synchronized imaging showed significantly better aortic valve leaflet and proximal coronary artery depiction. Synchronization reduced motion artifacts, allowing better visualization of the aortic root and proximal coronary arteries.

Importance of small (< or = 20-mm) enhancing lesions seen only during the hepatic arterial phase at MR imaging of the cirrhotic liver: evaluation and comparison with whole explanted liver.

PURPOSE: To retrospectively assess the importance and imaging appearance of small (< or = 20 mm in diameter) hepatic arterial phase-enhancing (HAPE) lesions that are occult during portal and/or equilibrium phases and at unenhanced T1- and T2-weighted magnetic resonance (MR) imaging and to determine the gross pathologic diagnosis with whole-liver explant comparison. MATERIALS AND METHODS: This retrospective study was approved by the institutional review board and compliant with HIPPA. Forty-six patients with cirrhosis who underwent MR imaging and transplantation within 90 days were evaluated with breath-hold T2-weighted and volumetric three-dimensional gadolinium-enhanced gradient-echo MR imaging in the hepatic arterial, portal venous, and equilibrium phases at 1.5 T. Three readers, who were blinded to the pathologic results, retrospectively reviewed the MR images in consensus for small HAPE nodules that were occult at T2-weighted and portal and/or equilibrium phase MR imaging. Only patients with nodules that enhanced during the arterial phase were included in the final study group, which included 16 patients (12 men and four women) aged 18-66 years (median age, 51.5 years). Explanted livers were serially sliced into 5-8-mm-thick sections to evaluate dysplastic nodules and hepatocellular carcinomas (HCCs). The Fisher exact test was performed to determine whether there was a relationship between HCC and the presence of a neoplastic HAPE-only lesion. The Mann-Whitney test was used to determine if patients with at least one neoplastic HAPE-only lesion had a larger number of non-HAPE-only lesions. RESULTS: The 16 patients had 45 HAPE-only lesions; three (7%) of which were neoplastic, including one overt HCC, one HCC arising in a dysplastic nodule, and one dysplastic nodule. None of the remaining 42 HAPE-only lesions (93%) had correlative pathologic findings. All three neoplastic lesions seen only during the arterial phase were found in eight patients with concomitant HCC, who also had an additional 13 pathologically proved nonneoplastic HAPE-only lesions. In eight patients without HCC, none of the HAPE-only lesions were neoplastic. A concomitant non-HAPE-only neoplastic lesion was not a significant (P = .2) predictor for the presence of at least one neoplastic HAPE-only lesion. There was a preliminary but insignificant (P = .13) indication that the number of non-HAPE-only lesions tends to be higher in patients with neoplastic HAPE-only lesions. CONCLUSION: The majority (93%) of HAPE-only lesions that are occult at T2-weighted and portal and/or equilibrium phase MR imaging are nonneoplastic, even in patients with pathologically proved HCC.

Parallel magnetic resonance imaging using coils with localized sensitivities.

The purpose of this study was to present clinical examples and illustrate the inefficiencies of a conventional reconstruction using a commercially available phased array coil with localized sensitivities. Five patients were imaged at 1.5 T using a cardiac-synchronized gadolinium-enhanced acquisition and a commercially available four-element phased array coil. Four unique sets of images were reconstructed from the acquired k-space data: (a) sum-of-squares image using four elements of the coil; localized sum-of-squares images from the (b) anterior coils and (c) posterior coils and a (c) local reconstruction. Images were analyzed for artifacts and usable field-of-view. Conventional image reconstruction produced images with fold-over artifacts in all cases spanning a portion of the image (mean 90 mm; range 36-126 mm). The local reconstruction removed fold-over artifacts and resulted in an effective increase in the field-of-view (mean 50%; range 20-70%). Commercially available phased array coils do not always have overlapping sensitivities. Fold-over artifacts can be removed using an alternate reconstruction method. When assessing the advantages of parallel imaging techniques, gains achieved using techniques such as SENSE and SMASH should be gauged against the acquisition time of the localized method rather than the conventional sum-of-squares method.

The value of single-shot black-blood MR imaging for mapping of the coronary arteries: a comparison of four different orientations during breath-holding and free breathing.

The value of ECG-gated single-shot black-blood MR imaging for rapid visualization of the origin and course of the coronary arteries was investigated. The study population included 28 patients with known or suspected cardiac disease. ECG-gated single-shot black-blood MR acquisitions were acquired in the transverse, coronal, sagittal and LAO orientations, during free breathing and breath-holding. The origin of the left coronary artery was most frequently visualized in the coronal and LAO orientations and the origin of the right coronary artery was most frequently visualized in the LAO orientation. Overall, no significant difference was found for the visualization of the coronary artery segments and the overall image quality among acquisitions during breath-holding and free breathing. ECG-gated single-shot black-blood MR imaging (HASTE) appears to be a time-efficient and robust method for mapping of the entire coronary artery tree, without the need for breath-holding. The LAO orientation provides the most consistent visualization of the origins and major coronary artery segments.