Diagnostic accuracy of pelvic MRI for determination of the cervical involvement in endometrial cancer

Objective: To determine the diagnostic accuracy of pelvic MRI for assessment of the cervical involvement in endometrial cancer. Study Design: Cross-sectional analytical study. Place and Duration of Study: Radiology Department of the Aga Khan University Hospital, Karachi from January 2014 to December 2015

Methodology: Patients with biopsy-proven endometrial cancer were included, who had both their MRI and histopathological diagnosis performed at our institution. Those patients treated with chemo/radiotherapy or had incomplete medical records, were excluded. The extent of cervical involvement by endometrial carcinoma was seen on T2WI images, and findings were correlated after surgery taking histopathology as the gold standard. The sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy were calculated

Results: The mean age of the 56 patients was 60.87 +/-8.80 years [range 37-84 years]. The most common clinical indication was post-menopausal bleeding [n=37, 66.1%]. The most common histological subtype was endometrioid adenocarcinoma [n=50, 89.3%]. The sensitivity, specificity, diagnostic accuracy, positive and negative predictive values of MRI in the detection of cervical invasion were 92.85%, 88.09%, 89.28%, 72.22% and 97.36%, respectively

Conclusion: MRI is a highly sensitive and specific imaging modality for detection of cervical invasion in endometrial carcinoma

Imaging guided breast interventions

Breast imaging is a developing field, with new and upcoming innovations, decreasing the morbidity and mortality related to breast pathologies with main emphasis on breast cancer. Breast imaging has an essential role in the detection and management of breast disease. It includes a multimodality approach, i.e. mammography, ultrasound, magnetic resonance imaging, nuclear medicine techniques and interventional procedures, done for the diagnosis and definitive management of breast abnormalities. The range of methods to perform biopsy of a suspicious breast lesion found on imaging has also increased markedly from the 1990s with hi-technological progress in surgical as well as percutaneous breast biopsy methods. The image guided percutaneous breast biopsy procedures cause minimal breast scarring, save time, and relieve the patient of the anxiety of going to the operation theatre. The aim of this review was to describe and discuss the different image guided breast biopsy techniques presently employed along with the indications, contraindication, merits and demerits of each method

Diagnostic accuracy of diffusion weighted magnetic resonance imaging in the detection of myometrial invasion in endometrial carcinoma

Objective: To determine the diagnostic accuracy of Diffusion-Weighted Magnetic Resonance Imaging [DWMRI] in the detection of myometrial invasion in endometrial cancer taking histopathology as gold standard

Study Design: Cross-sectional validation study

Place and Duration of Study: Department of Radiology, The Aga Khan University Hospital, Karachi, from January to December 2012

Methodology: DWMRI [b-value = 50,400 and 800 s/mm[2]] was performed in 85 patients of biopsy-proven endometrial carcinoma before hysterectomy using body and spine coil at 1.5 Tesla. DWI was evaluated for presence of myometrial invasion by tumor with histopathology as gold standard. Sensitivity, specificity, the negative predictive value and positive predictive value and accuracy of DWI were assessed against the gold standard

Results: On DWI, superficial myometrial invasion was found in 42 patients and deep myometrial invasion in 43. On histopathology, superficial myometrial invasion was found in 53 patients and deep myometrial invasion in 32. Hence sensitivity, specificity, positive predictive value, negative predictive value and accuracy for the assessment of myometrial invasion by endometrial tumor on DW images was 90%, 73%, 67%, 92% and 80%, respectively. Diagnostic accuracy of diffusion-weighted magnetic resonance imaging in detection of myometrial invasion in endometrial cancer was 80%

Conclusion: DWI is highly accurate in assessing myometrial invasion and can be used as an adjunct to routine MRI for pre-operative evaluation of myometrial invasion of endometrial cancer

Targeted ultrasound of an indeterminate breast lesion on mammography: when does it influence management?

To determine the change over mammographic diagnosis, BI-RADS category and management following targeted ultrasound of an indeterminate lesion seen on mammography and associated factors, if any. Descriptive, analytical study. Radiology Department, The Aga Khan University Hospital and Clifton Medical Services, Karachi, from April 2010 to May 2011. Patients referred for targeted breast ultrasound following X-ray mammography were selected regardless of age. Targeted Ultrasound [TUS] was defined as a limited ultrasound of a specific lesion or breast part as indicated by the referring source. Comparison was made between the post mammography and post TUS lesion characterization, diagnosis and BI-RADS category [0-5] which was taken as a measure of management change. Those were evaluated to determine significance of age, marital status, parity, breast parenchymal pattern [dense, fatty, heterogeneous], referring source for the TUS [radiology resident, radiologist or surgeon], lesion characteristics [density, echogenecity, shape, location, margins, size, depth-to-width ratio, enhancement or shadowing], presenting symptoms or signs and reason for TUS. A p-value of 0.05 or less was taken as significant. There were a total of 342 patients with mean age of 49.7 +/- 13.5 years. It assigned a definite category in 232 patients with an indefinite category [0] on mammography requiring further investigation. It decreased the suspicion for malignancy in 180 [77.58%] by assigning a low BI-RADS category and increased the suspicion in 52 [22.41%]. The factors significantly associated with this changes included clinical indication being diagnostic [p < 0.001], lesion characteristics on imaging [p < 0.001], heterogenous breast parenchymal pattern [p < 0.001] and presence of known risk factors [p=0.049]. TUS served as a problem solving tool in the evaluation and management of an indeterminate breast lesion in a high number of patients, particularly when there was a lump as indication for imaging in the presence of risk factors in a patient with otherwise heterogeneously dense breast parenchyma

Pancreatic lymphangioma

Lymphangioma develops as a consequence of lymphatic malformation and blockage of lymphatic flow. Pancreatic lymphangioma is a rare benign tumour which can grow reasonably large prior to manifestation of symptoms. On imaging, it appears as a complex multiseptated cystic mass. However, this appearance is not diagnostic and overlaps with cystic pancreatic neoplasm. We present a case of pancreatic lymphangioma incidentally discovered in an elderly lady who was managed conservatively since surgery could not be performed as the patient was high risk for surgery. Imaging findings along with follow-up of the case and review of literature is presented

Learning from errors in radiology to improve patient safety

To determine the views and practices of trainees and consultant radiologists about error reporting. Cross-sectional survey. Radiology trainees and consultant radiologists in four tertiary care hospitals in Karachi approached in the second quarter of 2011. Participants were enquired as to their grade, sub-specialty interest, whether they kept a recod/log of their errors [defined as a mistake that has management implications for the patient], number of errors they made in the last 12 months and the predominant type of error. They were also asked about the details of their department error meeting. All duty completed questionnaires were included in the study while the ones with incomplete information were excluded. A total of 100 radiologists participated in the survey. Of them 34 were consultants and 66 were trainees. They had a wide range of sub-specialty interest like CT, Ultrasound, etc. Out of the 100 responders, 49 kept a personal record/log of their errors. In response to the recall of approximate errors they made in the last 12 months. 73 [73%] of participants recorded a varied response with 1 - 5 errors mentioned by majority i.e. 47 [64.5%]. Most of the radiologists [97%] claimed receiving information about their errors through multiple sources like morbidity/mortality meetings, patients' follow-up, through colleagues and consultants. Perceptual error 66 [66%] were the predominant error type reported. Regular occurrence of error meetings and attending three or more error meetings in the last 12 months was reported by 35% participants. Majority among these described the atmosphere of these error meetings as informative and comfortable [n = 22, 62.8%]. It is of outmost importance to develop a culture of learning from mistakes by conducting error meetings and improving the process of recording and addressing errors to enhance patient safety

Migration of health workers: a challenge for health care system

The migration of health workers has resulted in a growing apprehension universally because of its impact on health system of the developing countries. Although the choice to migrate is basically a personal one, however, the overall social and economic circumstances have important impact on the decision to migrate. The "push and pull" factors for migration are disparity in working conditions, pay, lack of promotion opportunities, poor living conditions, desire to gain experience, professional development, family background and family wealth. A strategic approach by the government and other agencies is mandatory for regulating the flow of health workers between countries. A range of policies and interventions are needed to deal with the broader health system issue and problems of health workers that influence their recruitment, retention, deployment and progress

Goldston syndrome

Goldston syndrome is a rare entity describing the association of polycystic kidneys and Dandy Walker malformation with or without hepatic fibrosis. A 28 years old pregnant woman came to radiology department for the first antenatal scan. Ultrasound showed a single fetus corresponding to 27 week of gestation. The fetal brain revealed deficient vermis with a posterior fossa cyst communicating with the 4th ventricle suggestive of Dandy-Walker malformation [DWM]. The kidneys were enlarged, and echogenic containing small cysts with associated amniotic fluid index of 5 cm suggestive of Oligohydramnios. A diagnosis of Goldston syndrome was suggested. These findings were confirmed on post natal head and renal ultrasound

Diffusion weighted mr imaging [DWI] and ADC values in endometrial carcinoma

To determine the sensitivity of MR imaging utilizing diffusion weighted imaging [DWI] in detection of endometrial cancer and to compare the Apparent Diffusion Coefficient [ADC] values of malignant and normal endometrium. Cross-sectional analytical study. Radiology Department, Aga Khan University Hospital Karachi, from January 2007 to December 2009. Patients were defined as undergoing MRI for suspected endometrial malignancy, and the controls were female subjects who underwent MRI examination for indications other than endometrial malignancy. Studied variables included the signal characteristics of the endometrium and ADC values. The sensitivity of DWI for the detection of endometrial carcinoma was calculated using histopathology as the gold standard, and the ADC values of the endometrium in patients and controls were recorded. The mean ADC values were compared using two-sided t- test with significance at p < 0.05 at 95% confidence interval. Out of 52 patients, 10 had hyperintense, 40 had hypointense and 2 had isointense endometrium on T2 weighted imaging. On DWI, 42 patients had hyperintense and 10 patients had hypointense endometrium. In comparison, 40 controls had hypointense endometrium on DWI and 12 had hyperintense endometrium. The mean ADC value for abnormal endometrium was 0.730 +/- 0.215 x10-[3] mm[2]/sec and of normal endometrium was 1.265 +/- 0.305 x10[3] mm[2]/sec [p < 0.001]. The sensitivity for detection of endometrial carcinoma on DWI was 77.77%. False positive cases were found to be due to secretory and hyperplastic endometrium. False negative findings were found in a few cases of adenocarcinoma, endometroid carcinoma and clear cell sarcoma. In patients with suspected endometrial carcinoma, MRI examination utilizing DWI was a sensitive tool in detecting endometrial cancers with significantly lower ADC values for carcinoma in general. Physiological and histopathological variants may be responsible for a few false results

Percutaneous cholecystostomy [PC] in the management of acute cholecystitis in high risk patients

To determine the role of ultrasound -guided percutaneous cholecystostomy [PC] regarding complications and outcome in the management of acute cholecystitis in patients high risk for surgery and anaesthesia and not responding to conservative management. Observational case series. The study was carried out at The Aga Khan University Hospital, Karachi, from January 2003 to December 2007. The study included patients admitted with acute cholecystitis considered unfit for immediate surgery but not responding to conservative management. Percutaneous cholecystostomy was conducted under ultrasound guidance. The studied variables included patients' demographics, co-morbid, ultrasound findings of biliary tree, indication for percutaneous cholecystostomy, its route, complication during or after procedure, patient's clinical outcome [upto 48 hours] and 30 days follow-up. Those with incomplete medical record and follow-up were excluded. Data were analyzed and results compiled using SPSS 16.0 version. Mean and standard deviation for quantitative variable like age was derived. Proportions were computed for complications and patient's clinical outcome. Forty one patients with complete medical record were studied including 15 [37%] males and 26 [63%] females. Mean age was 65 +/- 13.5 years. Indications for PC included calculus cholecystitis in 25, acalculous cholecystitis in 10, empyema in 04 and gallbladder perforation in 02 patients. No complication was seen during or after procedure in 31 [75%] patients. Complications occurred in 10 [25%] patients including vagal reaction, pain during procedure, tube blockage, catheter dislodgement and bile leakage. Favourable clinical response [improvement in clinical symptoms] was noted in 34 [83%] patients. Seven [17%] patients did not show any improvement in clinical condition after the procedure. On 30 days follow-up, 9 patients had undergone cholecystectomy, 5 [12%] patients expired due to underlying clinical conditions and the rest were settled without requiring an immediate cholecystectomy. There was no direct procedure-related mortality. Imaging guided PC is a safe and effective procedure for immediate management of non-resolving acute cholecystitis in patients high risk for surgery and anaesthesia and not responding to conservative management

Malignant phyllodes tumour as an intracystic growth with osteosarcomatous differentiation

Phyllodes tumour is an uncommon fibro epithelial tumour of breast that often presents clinically as a rapidly enlarging lump. On mammography it appears as a soft tissue density well circumscribed mass. Ultrasound shows it to be a solid hypoechoic mass with small cystic spaces. A case of malignant phyllodes tumour with an atypical appearance of intracystic tumour on sonography is reported with pertinent imaging features and histopathological diagnostic criteria. The tumour had undergone osteosarcomatous differentiation

Impact of prenatal ultrasound consultation on maternal anxiety

To determine whether ultrasound consultation reduces maternal anxiety and increases feto maternal attachment [the desire to care for the fetus and care for self]. Analytical study. Patients coming for routine obstetric ultrasound at the Department of Radiology, Aga Khan University Hospital Karachi were recruited in the study. The study was carried out over the period of two months from January-February 2007 in which sixty patients were included in the study. Patients were randomly assigned to a standard care group or an ultrasound consultation group [30 patients in each arm]. Both groups were required to fill a questionnaire before and after their ultrasound examination. The ultrasound consultation group in addition received counseling before they went in for the ultrasound regarding fetal development and maternal-fetal interaction. The two groups were then compared for difference of change in feto maternal attachment scores and change in anxiety levels regarding their pregnancies before and after the ultrasound. SPSS software [version 14] was used for compilation of the data and the statistical computations Categorical data was compared using Chi-square test and continuous variables were analyzed with paired t-test. P value <0.05 was considered significant. A positive difference in feto-maternal attachment and reduction in anxiety levels was seen in both the groups but this difference was statistically significant in the ultrasound consultation group only. This study suggests that ultrasound examinations with prior consultation has a positive impact on patients as it strengthens bonding toward the fetus, reduces maternal anxiety and increases maternal investment in health during the pregnancy