Scoring System to Stratify Malignancy Risks for Mammographic Microcalcifications Based on Breast Imaging Reporting and Data System 5th Edition Descriptors

OBJECTIVE: To develop a scoring system stratifying the malignancy risk of mammographic microcalcifications using the 5th edition of the Breast Imaging Reporting and Data System (BI-RADS).MATERIALS AND METHODS: One hundred ninety-four lesions with microcalcifications for which surgical excision was performed were independently reviewed by two radiologists according to the 5th edition of BI-RADS. Each category's positive predictive value (PPV) was calculated and a scoring system was developed using multivariate logistic regression. The scores for benign and malignant lesions or BI-RADS categories were compared using an independent t test or by ANOVA. The area under the receiver operating characteristic curve (AUROC) was assessed to determine the discriminatory ability of the scoring system. Our scoring system was validated using an external dataset.RESULTS: After excision, 69 lesions were malignant (36%). The PPV of BI-RADS descriptors and categories for calcification showed significant differences. Using the developed scoring system, mean scores for benign and malignant lesions or BI-RADS categories were significantly different (p < 0.001). The AUROC of our scoring system was 0.874 (95% confidence interval, 0.840–0.909) and the PPV of each BI-RADS category determined by the scoring system was as follows: category 3 (0%), 4A (6.8%), 4B (19.0%), 4C (68.2%), and 5 (100%). The validation set showed an AUROC of 0.905 and PPVs of 0%, 8.3%, 11.9%, 68.3%, and 94.7% for categories 3, 4A, 4B, 4C, and 5, respectively.CONCLUSION: A scoring system based on BI-RADS morphology and distribution descriptors could be used to stratify the malignancy risk of mammographic microcalcifications.

Identification of Preoperative Magnetic Resonance Imaging Features Associated with Positive Resection Margins in Breast Cancer: A Retrospective Study

OBJECTIVE: To determine which preoperative breast magnetic resonance imaging (MRI) findings and clinicopathologic features are associated with positive resection margins at the time of breast-conserving surgery (BCS) in patients with breast cancer. MATERIALS AND METHODS: We reviewed preoperative breast MRI and clinicopathologic features of 120 patients (mean age, 53.3 years; age range, 27–79 years) with breast cancer who had undergone BCS in 2015. Tumor size on MRI, multifocality, patterns of enhancing lesions (mass without non-mass enhancement [NME] vs. NME with or without mass), mass characteristics (shape, margin, internal enhancement characteristics), NME (distribution, internal enhancement patterns), and breast parenchymal enhancement (BPE; weak, strong) were analyzed. We also evaluated age, tumor size, histology, lymphovascular invasion, T stage, N stage, and hormonal receptors. Univariate and multivariate logistic regression analyses were used to determine the correlation between clinicopathological features, MRI findings, and positive resection margins. RESULTS: In univariate analysis, tumor size on MRI, multifocality, NME with or without mass, and segmental distribution of NME were correlated with positive resection margins. Among the clinicopathological factors, tumor size of the invasive breast cancer and in situ components were significantly correlated with a positive resection margin. Multivariate analysis revealed that NME with or without mass was an independent predictor of positive resection margins (odds ratio [OR] = 7.00; p < 0.001). Strong BPE was a weak predictor of positive resection margins (OR = 2.59; p = 0.076). CONCLUSION: Non-mass enhancement with or without mass is significantly associated with a positive resection margin in patients with breast cancer. In patients with NME, segmental distribution was significantly correlated with positive resection margins.

Incidental Breast Lesions on Chest CT: Clinical Significance and Differential Features Requiring Referral

PURPOSE@#To evaluate the CT features of incidental breast lesions on chest CT and to suggest useful criteria for referral to a specialized breast unit.@*MATERIALS AND METHODS@#Between May 2009 and April 2014, enhanced chest CT examination reports containing the key word ‘breast’ were reviewed retrospectively. Patients who had incidental breast lesion and were referred to a specialized breast unit and then underwent pathological confirmation or follow-up over a 1-year period were included. Finally, 86 patients (all female, mean age, 48.9 ± 12.6 years) were enrolled. Two radiologists evaluated lesion characteristics, including size, shape, margins, and enhancement. The correlations between the CT features and pathologies were evaluated, and the diagnostic accuracy of CT features in various combinations was assessed.@*RESULTS@#Among the CT features, irregular shape, non-circumscribed margin, and high contrast enhancement were different between malignant and benign lesions (p < 0.05). The combination of non-circumscribed margin and high contrast enhancement had the highest accuracy (97.7%).@*CONCLUSION@#Reliable CT features for incidental malignant breast masses are irregular shape, non-circumscribed margin, and high contrast enhancement. The combination of non-circumscribed margin and high contrast enhancement could help distinguish incidental malignant breast lesions and indicate referral to a specialized breast unit.

Shear-wave elastography in breast ultrasonography: the state of the art

Shear-wave elastography (SWE) is a recently developed ultrasound technique that can visualize and measure tissue elasticity. In breast ultrasonography, SWE has been shown to be useful for differentiating benign breast lesions from malignant breast lesions, and it has been suggested that SWE enhances the diagnostic performance of ultrasonography, potentially improving the specificity of conventional ultrasonography using the Breast Imaging Reporting and Data System criteria. More recently, not only has SWE been proven useful for the diagnosis of breast cancer, but has also been shown to provide valuable information that can be used as a preoperative predictor of the prognosis or response to chemotherapy.

Thyroid nodules with nondiagnostic results on repeat fine-needle aspiration biopsy: which nodules should be considered for repeat biopsy or surgery rather than follow-up?

PURPOSE: The goal of this study was to assess the clinicopathologic and ultrasonographic features of thyroid nodules with nondiagnostic results on repeat ultrasonography (US)-guided fineneedle aspiration biopsy (FNAB) according to size and the number of suspicious findings and to determine the proper management of nodules with consecutive nondiagnostic results. METHODS: This retrospective study included 297 nodules with nondiagnostic results on repeat FNAB that were evaluated by US over the course of at least 12 months of follow-up, a follow-up biopsy, or an operation. We compared clinical and US variables between benign and malignant nodules in thyroid nodules with repeat nondiagnostic results. RESULTS: The comparison of benign and malignant nodules with repeat nondiagnostic results revealed that age, marked hypoechogenicity, irregular or microlobulated margins, microcalcifications, and nonparallel shape were significantly associated with malignancy. Multivariate logistic regression analysis in malignant nodules revealed that microcalcifications and irregular or microlobulated margins were independently associated with malignancy. Among them, only irregular or microlobulated margins were independently significant as a predictor of malignancy in repeatedly nondiagnostic nodules measuring >10 mm. Using receiver operating characteristic analysis, the best cutoff value for the "number of suspicious findings" between benign and malignant nodules was three in nodules of all sizes, three in nodules measuring ≤10 mm, and two in nodules measuring >10 mm. CONCLUSION: Irregular or microlobulated margins may be the most frequent US features in repeatedly nondiagnostic nodules >10 mm. The presence of "two or more suspicious findings" can be used as the cutoff for distinguishing benign and malignant nodules.

Comparison of hormonal receptor and HER2 status between ultrasound-guided 14-gauge core needle biopsy and surgery in breast cancer patients

PURPOSE: To evaluate the concordance of estrogen receptor, progesterone receptor, and human epidermal growth factor receptor 2 (HER2) statuses between ultrasound (US)-guided 14-gauge core needle biopsy (CNB) and surgery and to analyze whether the clinicopathological and imaging features including those from mammography and ultrasonography can predict the concordance in breast cancer patients. METHODS: The concordance of receptor status between CNB and surgery was assessed for 55 breast cancers in 55 women who underwent CNB before treatment. The clinicopathological and imaging features and the concordance rates were compared between the non-neoadjuvant chemotherapy (non-NAC) group and the NAC group according to the initial treatment. The concordance rates were analyzed according to the clinicopathological and imaging features, by using the chi-square or Fisher exact test and McNemar test for the categorical and the independent t-test for continuous variables. RESULTS: Among 55 women, 22 women (40%) were part of the non-NAC group and 33 women (60%) were part of the NAC group. The concordance rates were 0.86-1.00 in the non-NAC group and 0.76-0.88 in the NAC group. In all three receptors, the difference in the concordance rate between the two groups was not significant. In the NAC group, the absence of axillary lymph node metastasis (1.00, P=0.02) and visibility of cancer on mammography (0.93, P=0.04) showed the higher concordance of the HER2 status. CONCLUSION: Concordance of the receptor status between surgery and US-guided 14-gauge CNB was feasible in breast cancer patients. The absence of axillary lymph node metastasis after NAC and the visibility of cancer on mammography prior to NAC may be helpful for predicting the concordance of HER2 in breast cancer patients.

Thyroid nodules with Bethesda System IV Cytology: Can Ultrasonography Differentiate Malignancy from Benign?

PURPOSE: The purpose of this study is to identify clinical and imaging parameters that can be used in differentiation of benign versus malignancy of preoperative FNA diagnosis of Bethesda system IV nodules. MATERIALS AND METHODS: We analyzed clinical, ultrasonographic, and CT findings of 28 thyroid nodules with Bethesda system IV cytology on FNA, which were proven as follicular or Hurthle cell neoplasms on surgical pathology. RESULTS: No statistically significant differences according to age, sex, and ultrasonographic parameters, including echogenicity, margin, calcification, shape, cystic component, and degree of vascularity and enhancement on CT were observed between benign and malignant follicular neoplasms. Only the lesion size was significantly different (p<0.05). CONCLUSION: The size of follicular neoplasm is predictive of malignancy. If a thyroid nodule with the Bethesda IV cytology is larger than 24.5 mm, there will be a greater probability of malignancy.

Evaluation of the Cause of Internal Jugular Vein Obstruction on Head and Neck Contrast Enhanced 3D MR Angiography Using Contrast Enhanced Computed Tomography

PURPOSE: To evaluate the cause of internal jugular vein (IJV) obstruction on contrast enhanced 3D MR angiography (CE-MRA) using contrast enhanced computed tomography (CE-CT). MATERIALS AND METHODS: A total number of 30 patients were enrolled, who underwent both head and neck CE-MRA and CE-CT from 2005 to 2008. We defined obstruction group which had IJV obstruction and control group which had no IJV obstruction on CE-MRA. The following parameters were measured from axial images of CE-CT: 1) diameter of IJV; 2) distance between the styloid process and ipsilateral lateral mass of the atlas; 3) maximum area of lateral mass of the atlas. Each parameter was compared between obstruction group and control group. RESULTS: The diameter of IJV and distance between the styloid process and lateral mass of the atlas at IJV obstruction side in obstruction group were 1.6 +/- 1.0 mm and 4.1 +/- 2.1 mm respectively, which resulted in statistical significance (p<0.01). The maximum area of lateral mass of the atlas at IJV obstruction side in obstruction group was 103.4 +/- 25.3 mm2 which is significantly larger than in control group (p<0.05). CONCLUSION: We found that the cause of IJV obstruction on CE-MRA could be narrow space between the styloid process and the lateral mass of the atlas, which was related with asymmetric larger area of lateral mass of atlas.

Evaluation of the Cause of Internal Jugular Vein Obstruction on Head and Neck Contrast Enhanced 3D MR Angiography Using Contrast Enhanced Computed Tomography

PURPOSE: To evaluate the cause of internal jugular vein (IJV) obstruction on contrast enhanced 3D MR angiography (CE-MRA) using contrast enhanced computed tomography (CE-CT). MATERIALS AND METHODS: A total number of 30 patients were enrolled, who underwent both head and neck CE-MRA and CE-CT from 2005 to 2008. We defined obstruction group which had IJV obstruction and control group which had no IJV obstruction on CE-MRA. The following parameters were measured from axial images of CE-CT: 1) diameter of IJV; 2) distance between the styloid process and ipsilateral lateral mass of the atlas; 3) maximum area of lateral mass of the atlas. Each parameter was compared between obstruction group and control group. RESULTS: The diameter of IJV and distance between the styloid process and lateral mass of the atlas at IJV obstruction side in obstruction group were 1.6 +/- 1.0 mm and 4.1 +/- 2.1 mm respectively, which resulted in statistical significance (p<0.01). The maximum area of lateral mass of the atlas at IJV obstruction side in obstruction group was 103.4 +/- 25.3 mm2 which is significantly larger than in control group (p<0.05). CONCLUSION: We found that the cause of IJV obstruction on CE-MRA could be narrow space between the styloid process and the lateral mass of the atlas, which was related with asymmetric larger area of lateral mass of atlas.

3D Whole-Heart Coronary MR Angiography at 1.5T in Healthy Volunteers: Comparison between Unenhanced SSFP and Gd-Enhanced FLASH Sequences

OBJECTIVE: To validate the optimal cardiac phase and appropriate acquisition window for three-dimensional (3D) whole-heart coronary magnetic resonance angiography (MRA) with a steady-state free precession (SSFP) sequence, and to compare image quality between SSFP and Gd-enhanced fast low-angle shot (FLASH) MR techniques at 1.5 Tesla (T). MATERIALS AND METHODS: Thirty healthy volunteers (M:F = 25:5; mean age, 35 years; range, 24-54 years) underwent a coronary MRA at 1.5T. 3D whole-heart coronary MRA with an SSFP was performed at three different times: 1) at end-systole with a narrow (120-msec) acquisition window (ESN), 2) mid-diastole with narrow acquisition (MDN); and 3) mid-diastole with wide (170-msec) acquisition (MDW). All volunteers underwent a contrast enhanced coronary MRA after undergoing an unenhanced 3D true fast imaging with steady-state precession (FISP) MRA three times. A contrast enhanced coronary MRA with FLASH was performed during MDN. Visibility of the coronary artery and image quality were evaluated for 11 segments, as suggested by the American Heart Association. Image quality was scored by a five-point scale (1 = not visible to 5 = excellent). The signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) were evaluated at the proximal coronary arteries. RESULTS: The SSFP sequence rendered higher visibility coronary segments, higher image quality, as well as higher SNR and CNR than the Gd-enhanced FLASH technique at 1.5T (p < 0.05). The visibility of coronary segments, image quality, SNR and CNR in the ESN, MDN and MDW with SSFP sequence did not differ significantly. CONCLUSION: An SSFP sequence provides an excellent method for the 3D whole-heart coronary MRA at 1.5T. Contrast enhanced coronary MRA using the FLASH sequence does not help improve the visibility of coronary segments, image quality, SNR or CNR on the 3D whole-heart coronary MRA.

Evaluation of Reperfused Myocardial Infarction by Low-Dose Multidetector Computed Tomography Using Prospective Electrocardiography (ECG)-Triggering: Comparison with Magnetic Resonance Imaging

PURPOSE: To evaluate the potential of prospective electrocardiography (ECG)-gated 64-slice multidetector computed tomography (MDCT) for evaluation of myocardial enhancement, infarct size, and stent patency after percutaneous coronary intervention (PCI) with stenting in patients with myocardial infarction. MATERIALS AND METHODS: Seventeen patients who were admitted with acute myocardial infarction were examined with prospective ECG-gated 64-slice cardiac MDCT and magnetic resonance (MR) imaging after reperfusion using PCI with stenting. Cardiac MDCT was performed with two different phases: arterial and delayed phases. We evaluated the stent patency on the arterial phase, and nonviable myocardium on the delayed phase of computed tomography (CT) image, and they were compared with the results from the delayed MR images. RESULTS: Total mean radiation dose was 7.7 +/- 0.5 mSv on the two phases of CT images. All patients except one showed good patency of the stent at the culprit lesion on the arterial phase CT images. All patients had hyperenhanced area on the delayed phase CT images, which correlated well with those on the delayed phase MR images, with a mean difference of 1.6% (20 +/- 10% vs. 22 +/- 10%, r = 0.935, p = 0.10). Delayed MR images had a better contrast-to-noise ratio (CNR) than delayed CT images (27.1 +/- 17.8% vs. 4.3 +/- 2.1%, p < 0.001). CONCLUSION: Prospective ECG-gated 64-slice MDCT provides the potential to evaluate myocardial viability on delayed phase as well as for stent patency on arterial phase with an acceptable radiation dose after PCI with stenting in patients with myocardial infarction.

Evaluation of Left Atrial Volumes Using Multidetector Computed Tomography: Comparison with Echocardiography

OBJECTIVE: To prospectively assess the relationship between the two different measurement methods for the evaluation of left atrial (LA) volume using cardiac multidetector computed tomography (MDCT) and to compare the results between cardiac MDCT and echocardiography. MATERIALS AND METHODS: Thirty-five patients (20 men, 15 women; mean age, 60 years) underwent cardiac MDCT angiography for coronary artery disease. The LA volumes were measured using two different methods: the two dimensional (2D) length-based (LB) method measured along the three-orthogonal planes of the LA and the 3D volumetric threshold-based (VTB) method measured according to the threshold 3D segmentation of the LA. The results obtained by cardiac MDCT were compared with those obtained by echocardiography. RESULTS: The LA end-systolic and end-diastolic volumes (LAESV and LAEDV) measured by the 2D-LB method correlated well with those measured by the 3D-VTB method using cardiac MDCT (r = 0.763, r = 0.786, p = 0.001). However, there was a significant difference in the LAESVs between the two measurement methods using cardiac MDCT (p < 0.05). The LAESV measured by cardiac MDCT correlated well with measurements by echocardiography (r = 0.864, p = 0.001), however with a significant difference (p < 0.01) in their volumes. The cardiac MDCT overestimated the LAESV by 22% compared to measurements by echocardiography. CONCLUSION: A significant correlation was found between the two different measurement methods for evaluating LA volumes by cardiac MDCT. Further, cardiac MDCT correlates well with echocardiography in evaluating the LA volume. However, there are significant differences in the LAESV between the two measurement methods using cardiac MDCT and between cardiac MDCT and echocardiography.

Percutaneous Stenting of the Superior Mesenteric Artery for the Treatment of Chronic Mesenteric Ischemia

PURPOSE: We wanted to evaluate the effectiveness of stent placement on the superior mesenteric artery as a treatment for chronic mesenteric ischemia. MATERIALS AND METHODS: Seven patients (mean age: 55 years, age range: 43-66 years) with chronic mesenteric ischemia were enrolled between March 2000 and September 2003. All the patients underwent pre-procedure contrast enhanced computerized tomography to evaluate for occlusion or stenosis of the mesenteric arteries and they then underwent an angiographic procedure. A balloon-expandable metal stent was placed in the superior mesenteric artery, and this was combined with balloon angioplasty and thrombolysis. We evaluated the angiographic and procedural success after the procedures. RESULTS: Angiographic and procedural success was obtained in 100% of the patients and the clinical symptoms improved in 100% of the patients. The patency at 6-months and 1-year was 85% and 71%, respectively. The mean follow-up period was 12 months (range: 1-25 months). During the follow-up period, ischemic symptoms recurred in 2 patients, and restenosis in a stent was confirmed with angiography; one patient was successfully treated by stent placement in the celiac artery and the other patient died due to extensive mesenteric thrombosis. CONCLUSION: For the treatment of chronic mesenteric ischemia, percutaneuos stent placement on the superior mesenteric artery showed a favorable result and it was an effective alternative to surgery for the high-risk patients.