Inter-reader agreement of breast magnetic resonance imaging and contrast-enhanced mammography in breast cancer diagnosis: a multi-reader retrospective study.

OBJECTIVE: Breast magnetic resonance imaging (MRI) and contrast-enhanced mammography (CEM) are nowadays used in breast imaging but studies about their inter-reader agreement are lacking. Therefore, we compared the inter-reader agreement of CEM and MRI in breast cancer diagnosis in the same patients. METHODS: Breast MRI and CEM exams performed in a single center (09/2020-09/2021) for an IRB-approved study were retrospectively and independently evaluated by four radiologists of two different centers with different levels of experience who were blinded to the clinical and other imaging data. The reference standard was the histological diagnosis or at least 1-year negative imaging follow-up. Inter-reader agreement was examined using Cohen's and Fleiss' kappa (κ) statistics and compared with the Wald test. RESULTS: Of the 750 patients, 395 met inclusion criteria (44.5 ± 14 years old), with 752 breasts available for CEM and MRI. Overall agreement was moderate (κ = 0.60) for MRI and substantial (κ = 0.74) for CEM. For expert readers, the agreement was substantial (κ = 0.77) for MRI and almost perfect (κ = 0.82) for CEM; for non-expert readers was fair (κ = 0.39); and for MRI and moderate (κ = 0.57) for CEM. Pairwise agreement between expert readers and non-expert readers was moderate (κ = 0.50) for breast MRI and substantial (κ = 0.74) for CEM and it showed a statistically superior agreement of the expert over the non-expert readers only for MRI (p = 0.011) and not for CEM (p = 0.062). CONCLUSIONS: The agreement of CEM was superior to that of MRI (p = 0.012), including for both expert (p = 0.031) and non-expert readers (p = 0.005).

Contrast-enhanced digital mammography and magnetic resonance imaging: reproducibility compared to pathologic anatomy.

PURPOSE: To compare the reproducibility between contrast-enhanced digital mammography (CEDM) and magnetic resonance imaging (MRI) with the postsurgical pathologic examination. In addition, the applicability of the Breast Imaging-Reporting and Data System (BI-RADS) lexicon of MRI to CEDM was evaluated for mass lesions. METHODS: A total of 62 patients with a histologically proven diagnosis of breast cancer were included in this study, for a total of 67 lesions. Fifty-nine patients underwent both methods. The reproducibility between MRI vs CEDM and the reference standard (postoperative pathology) was assessed by considering the lesion and breast size as pivotal variables. Reproducibility was evaluated by computing the concordance correlation coefficient (CCC). Bland-Altman plots were used to depict the observed pattern of agreement as well as to estimate the associated bias. Furthermore, the pattern of agreement between the investigated methods with regard to the breast lesion characterization (i.e. mass/nonmass; shape; margins; internal enhanced characteristics) was assessed by computing the Cohen kappa and its 95% confidence interval (CI). RESULTS: The reproducibility between MRI and the reference standard and between CEDM and the reference standard showed substantial agreement, with a CCC value of 0.956 (95% CI, 0.931-0.972) and 0.950 (95% CI, 0.920-0.969), respectively. By looking at the Bland-Altman analysis, bias values of 2.344 and 1.875 mm were observed for MRI and CEDM vs reference evaluation, respectively. The agreement between MRI and CEDM is substantial with a CCC value of 0.969 (95% CI, 0.949-0.981). The Bland-Altman analysis showed bias values of -0.469 mm when comparing CEDM vs MRI. Following the Landis and Koch classification criteria, moderate agreement was observed between the two methods in describing BI-RADS descriptors of mass lesions. CONCLUSION: CEDM is able to measure and describe tumor masses comparably to MRI and can be used for surgical planning.

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.

Radiological pattern in ARDS patients: partitioned respiratory mechanics, gas exchange and lung recruitability.

BACKGROUND: The ARDS is characterized by different degrees of impairment in oxygenation and distribution of the lung disease. Two radiological patterns have been described: a focal and a diffuse one. These two patterns could present significant differences both in gas exchange and in the response to a recruitment maneuver. At the present time, it is not known if the focal and the diffuse pattern could be characterized by a difference in the lung and chest wall mechanical characteristics. Our aims were to investigate, at two levels of PEEP, if focal vs. diffuse ARDS patterns could be characterized by different lung CT characteristics, partitioned respiratory mechanics and lung recruitability. METHODS: CT patterns were analyzed by two radiologists and were classified as focal or diffuse. The changes from 5 to 15 cmH2O in blood gas analysis and partitioned respiratory mechanics were analyzed. Lung CT scan was performed at 5 and 45 cmH2O of PEEP to evaluate lung recruitability. RESULTS: One-hundred and ten patients showed a diffuse pattern, while 58 showed a focal pattern. At 5 cmH2O of PEEP, the driving pressure and the elastance, both the respiratory system and of the lung, were significantly higher in the diffuse pattern compared to the focal (14 [11-16] vs 11 [9-15 cmH2O; 28 [23-34] vs 21 [17-27] cmH2O/L; 22 [17-28] vs 14 [12-19] cmH2O/L). By increasing PEEP, the driving pressure and the respiratory system elastance significantly decreased in diffuse pattern, while they increased or did not change in the focal pattern (Δ15-5: - 1 [- 2 to 1] vs 0 [- 1 to 2]; - 1 [- 4 to 2] vs 1 [- 2 to 5]). At 5 cmH2O of PEEP, the diffuse pattern had a lower lung gas (743 [537-984] vs 1222 [918-1974] mL) and higher lung weight (1618 [1388-2001] vs 1222 [1059-1394] g) compared to focal pattern. The lung recruitability was significantly higher in diffuse compared to focal pattern 21% [13-29] vs 11% [6-16]. Considering the median of lung recruitability of the whole population (16.1%), the recruiters were 65% and 22% in the diffuse and focal pattern, respectively. CONCLUSIONS: An early identification of lung morphology can be useful to choose the ventilatory setting. A diffuse pattern has a better response to the increase of PEEP and to the recruitment maneuver.

Interventional Radiology ex-machina: impact of Artificial Intelligence on practice.

Artificial intelligence (AI) is a branch of Informatics that uses algorithms to tirelessly process data, understand its meaning and provide the desired outcome, continuously redefining its logic. AI was mainly introduced via artificial neural networks, developed in the early 1950s, and with its evolution into "computational learning models." Machine Learning analyzes and extracts features in larger data after exposure to examples; Deep Learning uses neural networks in order to extract meaningful patterns from imaging data, even deciphering that which would otherwise be beyond human perception. Thus, AI has the potential to revolutionize the healthcare systems and clinical practice of doctors all over the world. This is especially true for radiologists, who are integral to diagnostic medicine, helping to customize treatments and triage resources with maximum effectiveness. Related in spirit to Artificial intelligence are Augmented Reality, mixed reality, or Virtual Reality, which are able to enhance accuracy of minimally invasive treatments in image guided therapies by Interventional Radiologists. The potential applications of AI in IR go beyond computer vision and diagnosis, to include screening and modeling of patient selection, predictive tools for treatment planning and navigation, and training tools. Although no new technology is widely embraced, AI may provide opportunities to enhance radiology service and improve patient care, if studied, validated, and applied appropriately.

Bleeding of Perivascular Spaces in Midbrain of a Young Patient With Head Trauma.

Perivascular spaces (PVSs) surrounding the walls of arteries, arterioles, and venules are a common finding in brain imaging. Even if they do not directly communicate with subarachnoid spaces, there are some cases in which subarachnoid hemorrhage (SAH) and intracerebral hematomas extend to the PVSs by leakage of the leptomeninges. In this report, we present a case of enlargement and bleeding of PVSs in the midbrain of a young woman with head trauma, without evident SAH or intracerebral hematomas.

Percutaneous cervical coblation as therapeutic technique in the treatment of algo-dysfunctional pain of discal herniation.

OBJECTIVE: To confirm the validity of coblation nucleoplasty in reduction of cervical discogenic nature. STUDY DESIGN: In a monocentric prospective clinical observational study recruiting 20 patients, treated with percutaneous coblation for cervical discogenic pain in 16 months in our hospital, we have clinically evaluated 18 patients. The pain was scored with the Visual Analogic Scale (VAS) in a pre-procedural questionary, 3/4 monthly follow-up from treatment and, finally, in a long-term follow-up 2 years after procedure. RESULTS: The mean pre-procedural VAS score was 7.9 ± 1.6 (95%-Confidence Interval 7.198-8.634), while the mean post-procedural score after 3-4 months has been 2.5 ± 3.1 (95%-Confidence Interval 1.089-3.965) and 2.5 ± 2.5 (95%-Confidence Interval 1.367-3.687) after 2 years. Among 18 patients, in the shortly post-treatment follow-up, nine had a complete pain relief, four had a > 50% VAS reduction, two hada < 50% VAS reduction, three did not have any variation of VAS; after 2 years, six patients had a total pain resolution, eight had a > 50% VAS reduction, two hada < 50% VAS reduction, two did not have any benefit. No peri- and post-procedural complication has been observed. CONCLUSIONS: In a spite of a little sample, our results showed coblation as a valid therapeutic option to reduce cervical discogenic pain in medicine-refractory patients, as an alternative or a previous choice before a more invasive surgical treatment.

Automated breast ultrasound compared to hand-held ultrasound in surveillance after breast-conserving surgery.

PURPOSE: To investigate the agreement between automated breast ultrasound (ABUS) and hand-held ultrasound (HHUS) in surveillance of women with a history of breast cancer in terms of recurrences or new ipsilateral or contralateral breast cancer. METHODS: The institutional review board approved this retrospective study and informed consent was waived. From April to June 2016, women with dense breasts undergoing annual surveillance with mammography and HHUS after breast-conserving surgery were offered supplemental ABUS (Invenia). HHUS was performed by a breast radiologist and ABUS by a trained technician. Images were reviewed by 2 breast radiologists. A per-patient BI-RADS category was independently assigned in all cases and categories were dichotomized into negative (1, 2, 3) and positive (4, 5). Cohen κ, McNemar, and Wilcoxon statistics were used. Final pathology was used as reference standard for malignant lesions. RESULTS: A total of 154 women (mean age 62±11 years) were enrolled. Time from surgery was a mean of 8±6 years. Cancer prevalence was 4/154 (2.6%). Interreader agreement for ABUS was 1. Intermethod interreader agreement for HHUS and ABUS was substantial for BI-RADS categories (κ = 0.785) and for dichotomic assessment (κ = 0.794). There was no difference in dichotomic assignment between 2 readers (p = 0.5) but a significant difference in assigning BI-RADS categories (p < 0.05). CONCLUSIONS: A substantial agreement resulted between HHUS and ABUS in surveillance of women with a previous history of breast cancer. In particular, ABUS recognized all cancers detected by HHUS and could play a role in first-level surveillance of women at intermediate risk.

Image-guided percutaneous mechanical disc decompression for herniated discs: a technical note.

Interventional radiology plays a key role in the treatment of symptomatic herniations of intervertebral discs. Through image-guided techniques, it is possible to use minimally invasive procedures with a percutaneous approach that are usually proposed before classic surgery. Thanks to imaging guidance, it is possible to significantly increase accuracy and decrease complication rates. The pivotal principle of these mini-invasive techniques is to remove a small amount of volume of the nucleus of the intervertebral disc which results in a significant reduction in intradiscal pressure; allowing for a consequent reduction in compression of the nervous structures that generate spinal pain. However, it must be considered that this type of treatment is only addressed to contained disc herniations previously diagnosed with a suitable neuroimaging examination. There are different types of treatment using a variety of chemical, thermal or mechanical processes that result in partial removal of the nucleus pulposus. The purpose of this technical note is to illustrate mechanical disc decompression treatment via a percutaneous approach using the DISKOM device (DISKOM percutaneous discectomy probe, Biopsybell, Mirandola, Italy). Indications, complications and various methods of use are described in relation to the different levels of the spine to be treated.

Use of perfusional CBCT imaging for intraprocedural evaluation of endovascular treatment in patients with diabetic foot: a concept paper.

Diabetes mellitus (DM) is one of the most common metabolic diseases worldwide; its global burden has increased rapidly over the past decade, enough to be considered a public health emergency in many countries. Diabetic foot disease and, particularly diabetic foot ulceration, is the major complication of DM: through a skin damage of the foot, with a loss of epithelial tissue, it can deepen to muscles and bones and lead to the amputation of the lower limbs. Peripheral arterial disease (PAD) in patients with diabetes, manifests like a diffuse macroangiopathic multi-segmental involvement of the lower limb vessels, also connected to a damage of collateral circulation; it may also display characteristic microaneurysms and tortuosity in distal arteries. As validation method, Bold-MRI is used. The diabetic foot should be handled with a multidisciplinary team approach, as its management requires systemic and localized treatments, pain control, monitoring of cardiovascular risk factors and other comorbidities. CBCT is an emerging medical imaging technique with the original feature of divergent radiation, forming a cone, in contrast with the spiral slicing of conventional CT, and has become increasingly important in treatment planning and diagnosis: from small anatomical areas, such as implantology, to the world of interventional radiology, with a wide range of applications: as guidance for biopsies or ablation treatments. The aim of this project is to evaluate the usefulness of perfusion CBCT imaging, obtained during endovascular revascularization, for intraprocedural evaluation of endovascular treatment in patients with diabetic foot.

Interventional radiology management of high flow priapism: review of the literature.

INTRODUCTION: High-flow priapism is a persistent partial penile tumescence, related to high flow arterial blood into the corpora. In the treatment of high flow priapism, super-selective embolization is considered treatment of choice when conservative treatment fails as reported in the "EAU Guidelines on Priapism", but there are only few series reporting the outcome, the efficacy of different embolic materials and these studies are uncontrolled and relatively small. OBJECTIVES: The aim of this study is to review the literature to outline the state of the art of this interventional treatment and to analyse the outcome of the different embolic agents. METHODS: Through Medline database we searched all the English-language published articles related to priapism. Keywords were chosen according to MeSH terms. We selected case-series from 1990 to 2020 including at least five cases of high-flow priapism.The variables extracted from the selected articles were: number of patients, mean age, diagnostic imaging modality, mono or bilateral involvement of the arteries, embolization material, technical success, clinical success, complications, recurrence rate and type of reintervention, mean follow up, onset of erectile dysfunction. RESULTS: We analyzed 11 papers.A total of 117 patients, mean age of 30 years, were studied during a period of 8 to 72 months. Technical success average was 99%, varying from 93 to 100%. Clinical success average was 88%, varying from 56 to 100%. After two or more treatments, resolution of priapism was obtained in all patients. No major adverse events registered. Recurrence rate of 21%(25/117) was observed, and only 4 pts underwent surgery. A total of 17 pts (15%) developed erectile dysfunction (ED). CONCLUSION: Our data suggested comparable outcomes using different types of materials.In line with the last evidences we suggest that the choice of the embolic material should be selected basing on the expertise of the operator, the characteristic of the fistula and characteristic of the patients.

Prostatic artery embolization in patients with benign prostatic hyperplasia: perfusion cone-beam CT to evaluate planning and treatment response.

This proof of concept is to evaluate the utility of perfusion cone-beam computed tomography (CT) in patients undergoing prostatic artery (PA) embolization (PAE) for benign prostatic hyperplasia (BPH) with moderate or severe-grade lower urinary tract symptoms (LUTS). PAE is a novel minimally invasive therapy and is both safe and effective procedure with low risks and high technical successes, making this procedure as the best alternative to surgery. A lot of technical changes would compromise clinical outcomes after procedure, including a variable prostate vascular anatomy, thin PA, and extensive atherosclerotic disease. The purpose of our study is to exploit the advantages of Perfusion Cone Beam Computed Tomography (CBCT) that could impact treatment and help interventional radiologists for treatment planning, diagnosis and for assessing the technical feasibility during PAE, mitigating the risk of nontarget embolization and suggesting clinical outcomes. Qualitative and quantitative clinical pre- and post-treatment values will be compared, to reach the best possible results.

In-bore MRI targeted biopsy.

Clinical suspicion of Prostate Cancer (PCa) is largely based on increased prostate specific antigen (PSA) level and/or abnormal digital rectal examination (DRE) and/or positive imaging and, up today, biopsy is mandatory to confirm the diagnosis. The old model consisted of Standard Biopsy (SBx), that is random sampling of the prostate gland under ultrasound guidance (TRUS), in subjects with clinical suspicion of PCa. This involves the risk of not diagnosing a high percentage of tumors (up to 30%) and of an incorrect risk stratification. Multiparametric Magnetic Resonance Imaging (mpMRI) has transformed the diagnostic pathway of PCa, not only as an imaging method for detecting suspicious lesions, but also as an intraprocedural guidance for Target Biopsy (MRI-TBx), thus bridging the diagnostic gap. Several single and multicenter randomized trials, such as PROMIS, MRI first, PRECISION and that reported by Van der Leest et al. have confirmed the superiority of the "MRI pathway", consisting of mpMRI and MRI-TBx of suspicious lesions, over the "standard pathway" of SBx in all patients with elevated PSA and/or positive DRE. MRI-TBx appears to be advantageous in reducing the overall number of biopsies performed, as well as in reducing the diagnosis of clinically insignificant disease while maintaining or improving the diagnosis of clinically significant PCa (cs-PCa). Moreover, it shows a reduction in the diagnosis of ins-PCa, and therefore, of overdiagnosis, when using MRI-TBx without sacrificing performance in the diagnosis of cs-PCa.

Cooled radiofrequency ablation technology for painful bone tumors.

Bone metastases are a common cause of cancer-related debilitating pain, especially when -localized in the vertebral column and not responsive to standard treatment. In such cases, various treatment options are available; among these is Radiofrequency, whose role has been rapidly growing over the past few years. In this study, we used the innovative Osteocool RF Ablation System (Medtronic) on a patient with a painful bone metastasis localized in the 5th lumbar vertebra, with encouraging results. The radiofrequency ablation of bone metastases with palliative aim represents an excellent treatment option, as it is a minimally invasive and safe procedure, and can be repeated multiple times.

Contrast-enhanced mammography in the evaluation of breast calcifications: preliminary experience.

AIM: To evaluate the presence of contrast enhancement at the site of calcifications on contrast-enhanced mammography (CEM) and histopathologic results at vacuum-assisted biopsy (VAB), and to examine the association with lesion size and immunohistochemical characteristics, in order to assess disease aggressiveness in malignant lesions. METHODS: A total of 34 patients with 36 clusters of suspicious calcifications (BI-RADS 4) were investigated with CEM before the scheduled VAB. We evaluated the presence or absence of enhancement, histologic diagnosis, and, in case of malignant lesions, their size and the expression of Ki-67. RESULTS: In our case series, 15/36 (41.7%) lesions were malignant. In 7 cases, contrast enhancement was found at the site of calcifications. Data about size of lesions and immunohistochemical characterization were not available for all malignant cases. In 5 cases with CEM enhancement, all lesions were >5 mm and overexpressing Ki-67 (>20%); in 6 cases with no contrast enhancement, the lesions were <5 mm and with low Ki-67 values (<20%). CONCLUSION: Our preliminary study provides indications on the ability of CEM to recognize neoplasms larger than 5 mm, with high proliferative index (Ki-67 >20%), and frequently human epidermal growth factor receptor 2-positive. Our preliminary results suggest that CEM could detect aggressive malignancies. This could be the starting point for planning further studies with larger numbers of cases, in an attempt to reduce overdiagnosis and consequent overtreatment.

A Morphological and Quantitative Analysis of Lung CT Scan in Patients With Acute Respiratory Distress Syndrome and in Cardiogenic Pulmonary Edema.

BACKGROUND: The acute respiratory distress syndrome (ARDS) and cardiogenic pulmonary edema (CPE) are both characterized by an increase in lung edema that can be measured by computed tomography (CT). The aim of this study was to compare possible differences between patients with ARDS and CPE in the morphologic pattern, the aeration, and the amount and distribution of edema within the lung. METHODS: Lung CT was performed at a mean positive end-expiratory pressure level of 5 cm H2O in both groups. The morphological evaluation was performed by two radiologists, while the quantitative evaluation was performed by a dedicated software. RESULTS: A total of 60 patients with ARDS (20 mild, 20 moderate, 20 severe) and 20 patients with CPE were enrolled. The ground-glass attenuation regions were similarly present among the groups, 8 (40%), 8 (40%), 14 (70%), and 10 (50%), while the airspace consolidations were significantly more present in ARDS. The lung gas volume was significantly lower in severe ARDS compared to CPE (830 [462] vs 1120 [832] mL). Moving from the nondependent to the dependent lung regions, the not inflated lung tissue significantly increased, while the well inflated tissue decreased (ρ = 0.96-1.00, P < .0001). Significant differences were found between ARDS and CPE mostly in dependent regions. In severe ARDS, the estimated edema was significantly higher, compared to CPE (757 [740] vs 532 [637] g). CONCLUSIONS: Both ARDS and CPE are characterized by a similar presence of ground-glass attenuation and different airspace consolidation regions. Acute respiratory distress syndrome has a higher amount of not inflated tissue and lower amount of well inflated tissue. However, the overall regional distribution is similar within the lung.

Clinical and instrumental assessment of herniated discs after nucleoplasty: a preliminary study.

BACKGROUND AND AIM: The therapy for low back pain boasts different approaches; one of these is nucleoplasty. We wanted to assess the effectiveness of nucleoplasty both by clinical response both by MR imaging evaluation, including even extrusions larger than one third of the spinal canal. METHODS: Fifty-seven patients were treated with nucleoplasty in our hospital, 11 of these patients accepted both clinical and MRI evaluation after six months from treatment. The clinical evaluation was performed with Visual Analogue Scale (VAS) of pain, scored before and after the procedure. MRI evaluation consisted of analysing some imaging parameters of disc protrusions before and after the treatment. RESULTS: In 10 out of 11 (91%) patients, VAS was reduced and only 1 out of 11 (9%) had the same pain after procedure. The mean of decrease of VAS score was 64%. In our population 8/11 (72%) patients had a herniation larger than 1/3 of the sagittal diameter of spinal canal and 100% of them had an improvement with a mean VAS reduction value of 75%. With MRI evaluation, the mean percentage of expulsion before and after treatment was respectively 40% and 34%. The expulsion decreased in 7/13 discs, remained equal in 4/13, and increased in 2/13 discs. Among the 9 larger protrusions, 3 didn't change, 6 reduced with a decrease mean value of 13%. Other MRI parameters didn't change significantly. CONCLUSIONS: Our preliminary experience supports the success of coblation on pain relief, aiming to show progressively that this treatment is suitable even in case of great extrusions, which are generally treated only with surgical approach. It's not clear the usefulness of MRI control yet, even if in most of cases we could have found a certain reduction of expulsion degree.