Contrast-enhanced mammography for the assessment of screening recalls: a two-centre study.

OBJECTIVES: To evaluate the potential of contrast-enhanced mammography (CEM) for reducing the biopsy rate of screening recalls. METHODS: Recalled women were prospectively enrolled to undergo CEM alongside standard assessment (SA) through additional views, tomosynthesis, and/or ultrasound. Exclusion criteria were symptoms, implants, allergy to contrast agents, renal failure, and pregnancy. SA and CEM were independently evaluated by one of six radiologists, who recommended biopsy or 2-year follow-up. Biopsy rates according to SA or recombined CEM (rCEM) were compared with the McNemar's test. Diagnostic performance was calculated considering lesions with available final histopathology. RESULTS: Between January 2019 and July 2021, 220 women were enrolled, 207 of them (median age 56.6 years) with 225 suspicious findings analysed. Three of 207 patients (1.4%) developed mild self-limiting adverse reactions to iodinated contrast agent. Overall, 135/225 findings were referred for biopsy, 90/225 by both SA and rCEM, 41/225 by SA alone and 4/225 by rCEM alone (2/4 being one DCIS and one invasive carcinoma). The rCEM biopsy rate (94/225, 41.8%, 95% CI 35.5-48.3%) was 16.4% lower (p < 0.001) than the SA biopsy rate (131/225, 58.2%, 95% CI 51.7-64.5%). Considering the 124/135 biopsies with final histopathology (44 benign, 80 malignant), rCEM showed a 93.8% sensitivity (95% CI 86.2-97.3%) and a 65.9% specificity (95% CI 51.1-78.1%), all 5 false negatives being ductal carcinoma in situ detectable as suspicious calcifications on low-energy images. CONCLUSIONS: Compared to SA, the rCEM-based work-up would have avoided biopsy for 37/225 (16.4%) suspicious findings. Including low-energy images in interpretation provided optimal overall CEM sensitivity. KEY POINTS: • The work-up of suspicious findings detected at mammographic breast cancer screening still leads to a high rate of unnecessary biopsies, involving between 2 and 6% of screened women. • In 207 recalled women with 225 suspicious findings, recombined images of contrast-enhanced mammography (CEM) showed a 93.8% sensitivity and a 65.9% specificity, all 5 false negatives being ductal carcinoma in situ detectable on low-energy images as suspicious calcifications. • CEM could represent an easily available one-stop shop option for the morphofunctional assessment of screening recalls, potentially reducing the biopsy rate by 16.4%.

Guiding vacuum-assisted biopsy in prone position: digital breast tomosynthesis vs stereotactic.

PURPOSE: To compare the performance of prone digital breast tomosynthesis (DBT)-vacuum-assisted biopsy (VAB) with prone stereotactic-guided VAB (sVAB), focusing on time of procedure, number of expositions, average glandular dose, and complications. METHODS: The institutional review board approved this retrospective study and informed consent was waived. From July 2015 to January 2017, 306 patients with 306 suspicious mammographic findings (BI-RADS ⩾4) underwent mammography-guided biopsy, prone sVAB, or prone DBT-VAB. Student t test, chi-square, and multivariate regression statistics were used. RESULTS: During the study period, 155 prone sVAB procedures in 155 patients (mean age, 56 years; age range, 39-84 years) and 151 DBT-VABs in 151 patients (mean age, 57 years; age range, 33-84 years) were performed. Mean procedure time was shorter with DBT-VAB versus sVAB (14.5 versus 17.4 minutes, respectively; p < 0.001), and fewer images were acquired with DBT-VAB versus sVAB (8 vs 11, respectively; p < 0.001); the average glandular dose was significantly lower in DBT-VAB versus sVAB (11.8 mGy versus 18 mGy, respectively; p < 0.001). There were no differences in the distribution of histologic results (p = 0.74) or breast density (p = 0.09) between the two groups. No major complications were observed in either group. CONCLUSION: Performance of prone DBT-VAB was superior to prone sVAB because it allowed a faster procedure with fewer radiologic expositions and lower radiation dose.

Chest x-ray severity score in COVID-19 patients on emergency department admission: a two-centre study.

BACKGROUND: Integration of imaging and clinical parameters could improve the stratification of COVID-19 patients on emergency department (ED) admission. We aimed to assess the extent of COVID-19 pulmonary abnormalities on chest x-ray (CXR) using a semiquantitative severity score, correlating it with clinical data and testing its interobserver agreement. METHODS: From February 22 to April 8, 2020, 926 consecutive patients referring to ED of two institutions in Northern Italy for suspected SARS-CoV-2 infection were reviewed. Patients with reverse transcriptase-polymerase chain reaction positive for SARS-CoV-2 and CXR images on ED admission were included (295 patients, median age 69 years, 199 males). Five readers independently and blindly reviewed all CXRs, rating pulmonary parenchymal involvement using a 0-3 semiquantitative score in 1-point increments on 6 lung zones (range 0-18). Interobserver agreement was assessed with weighted Cohen's κ, correlations between median CXR score and clinical data with Spearman's ρ, and the Mann-Whitney U test. RESULTS: Median score showed negative correlation with SpO2 (ρ = -0.242, p < 0.001), positive correlation with white cell count (ρ = 0.277, p < 0.001), lactate dehydrogenase (ρ = 0.308, p < 0.001), and C-reactive protein (ρ = 0.367, p < 0.001), being significantly higher in subsequently dead patients (p = 0.003). Considering overall scores, readers' pairings yielded moderate (κ = 0.449, p < 0.001) to almost perfect interobserver agreement (κ = 0.872, p < 0.001), with better interobserver agreement between readers of centre 2 (up to κ = 0.872, p < 0.001) than centre 1 (κ = 0.764, p < 0.001). CONCLUSIONS: Proposed CXR pulmonary severity score in COVID-19 showed moderate to almost perfect interobserver agreement and significant but weak correlations with clinical parameters, potentially furthering CXR integration in patients' stratification.

Chest x-ray in the COVID-19 pandemic: Radiologists' real-world reader performance.

PURPOSE: To report real-world diagnostic performance of chest x-ray (CXR) readings during the COVID-19 pandemic. METHODS: In this retrospective observational study we enrolled all patients presenting to the emergency department of a Milan-based university hospital from February 24th to April 8th 2020 who underwent nasopharyngeal swab for reverse transcriptase-polymerase chain reaction (RT-PCR) and anteroposterior bedside CXR within 12 h. A composite reference standard combining RT-PCR results with phone-call-based anamnesis was obtained. Radiologists were grouped by CXR reading experience (Group-1, >10 years; Group-2, <10 years), diagnostic performance indexes were calculated for each radiologist and for the two groups. RESULTS: Group-1 read 435 CXRs (77.0 % disease prevalence): sensitivity was 89.0 %, specificity 66.0 %, accuracy 83.7 %. Group-2 read 100 CXRs (73.0 % prevalence): sensitivity was 89.0 %, specificity 40.7 %, accuracy 76.0 %. During the first half of the outbreak (195 CXRs, 66.7 % disease prevalence), overall sensitivity was 80.8 %, specificity 67.7 %, accuracy 76.4 %, Group-1 sensitivity being similar to Group-2 (80.6 % versus 81.5 %, respectively) but higher specificity (74.0 % versus 46.7 %) and accuracy (78.4 % versus 69.0 %). During the second half (340 CXRs, 81.8 % prevalence), overall sensitivity increased to 92.8 %, specificity dropped to 53.2 %, accuracy increased to 85.6 %, this pattern mirrored in both groups, with decreased specificity (Group-1, 58.0 %; Group-2, 33.3 %) but increased sensitivity (92.7 % and 93.5 %) and accuracy (86.5 % and 81.0 %, respectively). CONCLUSIONS: Real-world CXR diagnostic performance during the COVID-19 pandemic showed overall high sensitivity with higher specificity for more experienced radiologists. The increase in accuracy over time strengthens CXR role as a first line examination in suspected COVID-19 patients.

Pulmonary thromboembolism in hospitalised COVID-19 patients at moderate to high risk by Wells score: a report from Lombardy, Italy.

OBJECTIVES: To present a single-centre experience on CT pulmonary angiography (CTPA) for the assessment of hospitalised COVID-19 patients with moderate-to-high risk of pulmonary thromboembolism (PTE). METHODS: We analysed consecutive COVID-19 patients (RT-PCR confirmed) undergoing CTPA in March 2020 for PTE clinical suspicion. Clinical data were retrieved. Two experienced radiologists reviewed CTPAs to assess pulmonary parenchyma and vascular findings. RESULTS: Among 34 patients who underwent CTPA, 26 had PTE (76%, 20 males, median age 61 years, interquartile range 54-70), 20/26 (77%) with comorbidities (mainly hypertension, 44%), and 8 (31%) subsequently dying. Eight PTE patients were under thromboprophylaxis with low-molecular-weight heparin, four PTE patients had lower-limbs deep vein thrombosis at ultrasound examination (performed in 33/34 patients). Bilateral PTE characterised 19/26 cases, with main branches involved in 10/26 cases. Twelve patients had a parenchymal involvement >75%, the predominant pneumonia pattern being consolidation in 10/26 patients, ground glass opacities in 9/26, crazy paving in 5/26, and both ground glass opacities and consolidation in 2/26. CONCLUSION: COVID-19 patients are prone to PTE. ADVANCES IN KNOWLEDGE: PTE, potentially attributable to an underlying thrombophilic status, may be more frequent than expected in COVID-19 patients. Extension of prophylaxis and adaptation of diagnostic criteria should be considered.

A computer-aided diagnosis system for the assessment and characterization of low-to-high suspicion thyroid nodules on ultrasound.

AIM OF THE STUDY: To compare the diagnostic performance of a commercially available computer-aided diagnosis (CAD) system for thyroid ultrasound (US) with that of a non-computer-aided radiologist in the characterization of low-to-high suspicion thyroid nodules. METHODS: This retrospective study included a consecutive series of adult patients referred for US-guided fine-needle aspiration biopsy (FNAB) of a thyroid nodule. All patients were eligible for thyroid nodule FNAB according to the current international guidelines. An interventional radiologist experienced in thyroid imaging acquired the US images subsequently used for post-processing, performed FNAB and provided the US features of each nodule. A radiology resident and an endocrinology resident in consensus performed post-processing using the CAD system to assess the same nodule characteristics. The diagnostic performance and agreement of US features between the CAD system and the radiologist were compared. RESULTS: Sixty-two patients (50 F; age 60 ± 12 years) were enrolled: 77.4% (48/62) of thyroid nodules were benign, 22.6% (14/62) were undetermined to malignant and required follow-up or surgery. Interobserver agreement between the CAD system and the radiologist was substantial for orientation (K = 0.69), fair for composition (K = 0.36), echogenicity (K = 0.36), K-TIRADS (K = 0.29), and slight for margins (K = 0.03). The radiologist demonstrated a significantly higher sensitivity than the CAD system (78.6% vs. 21.4%; P = 0.008), while there was no statistical difference in specificity (66.7% vs. 81.3%; P = 0.065). CONCLUSION: This CAD system is less sensitive than an experienced radiologist and showed slight-to-substantial agreement with the radiologist for the characterization of thyroid nodules. Although it is an innovative tool with good potential, additional efforts are needed to improve its diagnostic performance.

Rotator cuff calcific tendinopathy: from diagnosis to treatment.

Rotator cuff calcific tendinopathy (RCCT) is a very common condition caused by the presence of calcific deposits in the rotator cuff (RC) or in the subacromial-subdeltoid (SASD) bursa when calcification spreads around the tendons. The pathogenetic mechanism of RCCT is still unclear. It seems to be related to cell-mediated disease in which metaplastic transformation of tenocytes into chondrocytes induces calcification inside the tendon of the RC. RCCT is a frequent finding in the RC that may cause significant shoulder pain and disability. It can be easily diagnosed with imaging studies as conventional radiography (CR) or ultrasound (US). Conservative management of RCCT usually involves rest, physical therapy, and oral NSAIDs administration. Imaging-guided treatments are currently considered minimally-invasive, yet effective methods to treat RCCT with about 80% success rate. Surgery remains the most invasive treatment option in chronic cases that fail to improve with other less invasive approaches.

Benign thyroid nodules treatment using percutaneous laser ablation (PLA) and radiofrequency ablation (RFA).

PURPOSE: To evaluate the reduction over time of benign thyroid nodules treated using percutaneous laser ablation (PLA) and radiofrequency ablation (RFA) by the same equipe. MATERIALS AND METHODS: Ninety patients (age 55.6 ± 14.1 years) underwent ablation for benign thyroid nodule causing compression/aesthetic dissatisfaction from 2011. Fifty-nine (age 55.8 ± 14.1 years) underwent RFA and 31 (age 55.2 ± 14.2 years) PLA, ultrasound guided. Technical success, complications, duration of ablation and treatment, energy deployed, volumetric percentage reduction at 1, 6 and 12 months were derived. A regression model for longitudinal measurements was used with random intercept and random slope. Values are expressed as mean ± standard deviation or N (%). RESULTS: Technical success was always obtained. No major complications occurred. Mean ablation time was 30.1 ± 13.8 vs. 13.9 ± 5.9 min (p < .0001) and mean energy deployment was 5422.3 ± 2484.5 J vs. 34 662.7 ± 15 812.3 J in PLA vs. RFA group. Mean volume reduced from 20.3 ± 16.4 ml to 13.17 ± 10.74 ml (42% ± 17% reduction) at 1st month, 8.7 ± 7.4 ml (60% ± 15% reduction) at 6th month and 7.1 ± 7.7 ml (70%% ± 16% reduction) at 12th month, in PLA group, and from 32.7 ± 19.5 ml to 17.2 ± 12.9 ml (51%±15% reduction) at 1st month, 12.8 ± 9.6 ml (64 ± 14% reduction) at 6th month and 9.9 ± 9.2 ml (74% ± 14% reduction) at 12th month in RFA group. No difference in time course of the relative volume reduction between the two techniques was found. CONCLUSIONS: RFA and PLA are similarly feasible, safe and effective in treating benign thyroid nodules when performed by the same equipe. RFA is faster than PLA but require significantly higher energy.

Dual-energy X-ray absorptiometry body composition in patients with secondary osteoporosis.

Due to the tight relationship between bone and soft tissues, there has been an increased interest in body composition assessment in patients with secondary osteoporosis as well as other pathological conditions. Dual-energy X-ray absorptiometry (DXA) is primarily devoted to the evaluation of bone mineral status, but continuous scientific advances of body composition software made DXA a rapid and easily available technique to assess body composition in terms of fat mass and lean mass. As a result, the International Society for Clinical Densitometry (ISCD) recently developed Official Positions regarding the use of this technique for body composition analysis. According to ISCD paper, indications are mainly limited to three conditions: HIV patients treated with antiretroviral agents associated with a risk of lipoatrophy; obese patients undergoing treatment for high weight loss; patients with sarcopenia or muscle weakness. Nevertheless, there are several other interesting clinical applications that were not included in the ISCD position paper, such as body composition assessment in patients undergoing organ transplantation, pulmonary disease as well as all those chronic condition that may lead to malnutrition. In conclusion, DXA body composition offers new diagnostic and research possibilities for a variety of diseases; due to its high reproducibility, DXA has also the potential to monitor body composition changes with pharmacological, nutritional or physic therapeutic interventions. ISCD addressed and recommended a list of clinical condition, but the crescent availability of DXA scans and software improvements may open the use of DXA to other indication in the next future. This article provides an overview of DXA body composition indications in the management of secondary osteoporosis and other clinical indications in adults.