Best Practice Guidelines for Breast Imaging, Breast Imaging Society, India: Part—2

Breast imaging is a prerequisite for providing high quality breast health care. Choosing the appropriate investigation is central to diagnosing breast disease in patients who present to health professionals for treatment. These patients present to doctors of different subspecialties as well as to general practitioners in our country. It is important, therefore, to provide uniform guidance to doctors in different healthcare setups of our country, urban and rural, government and private, for optimal management of breast diseases. These guidelines framed by the task group set up by the Breast Imaging Society, India, have been formulated focusing primarily on the Indian patients and health care infrastructures. They aim to provide a framework for the referring doctors and practicing radiologists to enable them to choose the appropriate investigation for patients with breast symptoms and signs. The aim has been to keep this framework simple and practical so that it can guide not only subspecialists in breast care but also help doctors who do not routinely deal with breast diseases, so that breast cancer is not missed. Overall, the aim of this document is to provide a holistic approach to standardize breast care imaging services in India. Part 2 of these guidelines focuses on the best practice principles for breast interventions and provides algorithms for the investigation of specific common breast symptoms and signs. Ultrasound is the preferred imaging modality for image-guided breast interventions due to real-time needle visualization, easy availability, patient comfort and absence of radiation. Stereotactic mammography guided procedures are performed if the lesion is visualized on mammography but not visualized on ultrasound. 14-gauge automated core biopsy device is preferred for breast biopsies although vacuum assisted biopsy devices are useful for biopsy of certain abnormalities as well as for imaging guided excision of some pathologies. MRI guided biopsy is reserved for suspicious lesions seen only on MRI. Algorithms for investigation of patients presenting with mastalgia, breast lumps, suspicious nipple discharge, infections and inflammation of the breast have been provided. For early breast cancers routine use of investigations to detect occult distant metastasis is not advised. Metastatic work up for advanced breast cancer is required for selection of appropriate treatment options.

Best Practice Guidelines for Breast Imaging, Breast Imaging Society, India: Part—1

Breast imaging is one of the prerequisites for providing high quality breast health care. Choosing the appropriate investigation is central to diagnosing breast disease in women and men who present to health professionals for treatment. Patients with breast disease present to doctors of different subspecialties as well as general practitioners in our country. It is important therefore to provide uniform guidance to doctors in different health care setups of our country, urban and rural, government and private, for breast diseases to be diagnosed and treated optimally. These guidelines framed by the task group set up by the Breast Imaging Society, India have been formulated focusing primarily on the Indian patients and health care infrastructures. These guidelines aim to provide a framework for the referring doctors and practicing radiologists, to enable them to choose the appropriate investigation for patients with breast symptoms and signs. The aim has been to keep this framework simple and practical so that it can guide not only subspecialists in breast care but also help doctors who do not routinely deal with breast diseases, so that breast cancer is not missed. Overall, the aim of this document is to provide a holistic approach to standardize breast care imaging services in India. Part 1 of these guidelines focuses on the best practice principles for mammography, breast ultrasound and breast magnetic resonance imaging. In the absence of a population-based screening program in India, the guidelines to be followed for those women who wish to be screened by mammography have been provided. The key points of these guidelines include the recommendations that mammography is the modality of choice for breast screening and investigation of symptomatic women aged over forty years. Screening is advised annually from the age of forty. Ultrasound is the investigation of choice for pregnant and lactating women and women less than thirty years of age. For women between thirty to thirty-nine years of age, ultrasound can be used initially followed by mammography in presence of clinical or sonographic suspicion of breast cancer. All women diagnosed with breast cancer should have ultrasound and mammography. Breast MRI is useful for assessment of disease extent, problem solving, evaluation of response to neo-adjuvant chemotherapy, identifying occult breast primary and evaluation of augmented breasts.

Hepatic and Cardiac Iron-load in Children on Long-term Chelation with Deferiprone for Thalassemia Major

Objective: To evaluate the efficacy of prolonged deferiprone monotherapy in patients with ?-thalassemia major. Methods: This cross-sectional study included 40 patients (age range 9 to38 years) with thalassemia major receiving deferiprone for ?5 years. Serum ferritin, andmyocardial iron concentration (MIC) and liver iron concentration (LIC) assessed by T2*MRIwere recorded. Results: The patients were receiving deferiprone for a mean (SD) duration of12.1 (4.7) years. The median (IQR) dose of deferiprone was 85 (74.3, 95) mg/kg/day. TheMIC was normal or had a mild, moderate or severe elevation in 29 (72.5%), 3 (7.5%), 3(7.5%), and 5 (12.5%) patients. The LIC was normal or had a mild, moderate or severeelevation in 2 (5%), 4 (10%), 11 (27.5%) and 23 (57.5%) patients. Conclusions: The majorityof patients receiving deferiprone had a moderate/severe hepatic but normal cardiac iron load.Prolonged deferiprone monotherapy was suboptimal for hepatic iron load in the majority.

Effect of intravenous pulse dexamethasone versus daily oral prednisolone on bone mineral density in dermatology patients: Is it a site-specific response?

Background: The use of glucocorticoids in various forms of administration is complicated by their systemic side effects. Although intravenous pulse therapy is considered to have lesser systemic side effects, there are few studies in literature comparing the effects of intravenous pulse glucocorticoids versus oral daily glucocorticoids on bone mineral density. Aim: To compare the effects of intravenous pulse glucocorticoids and oral daily glucocorticoids on bone mineral density with the aim of finding any site-specific osteopenic side effect. Methods: The study was conducted by the department of dermatology of Postgraduate Institute of Medical Education and Research, Chandigarh, India. The study comprised of two groups of patients. Group A consisted of 28 patients with pemphigus vulgaris who received intravenous pulses of dexamethasone at 4 weekly intervals. Group B consisted of 21 patients with airborne contact dermatitis who received oral daily prednisolone therapy. All the patients had a dual X-ray absorptiometry scan at baseline, and at 3 and 6 months of follow-up. The results were analyzed as changes in bone mineral density. Results: There was loss of bone mineral density at lumbar spine and the head of radius in both the groups. At the lumbar spine, Group B showed more reduction in bone mineral density at 3 months whereas in Group A it was more at the head of radius. In patients on oral steroids, the lumbar spine was significantly more affected than the head of radius at both 3 and 6 months of follow-up. However, in patients on intravenous pulse steroids, both the sites were equally affected at 3 and 6 months. Limitations: In our study, we used different glucocorticoids in the two groups: prednisolone in the oral daily group and dexamethasone in the intravenous pulse steroids group. A similar reduction in bone mineral density in both the groups may have been due to a longer half-life or more bone-directed side effects of dexamethasone as compared to prednisolone. Conclusion: Dermatologists need to be aware of the detrimental effects of high-dose intravenous pulsed glucocorticoids on bone mineral density and assessment of this parameter should be done before the initiation of therapy and also at regular intervals thereafter. During follow up, either the lumbar spine or the head of radius can be used to assess the osteopenic effect of intravenous pulse steroids, whereas the lumbar spine is a better site for this evaluation in patients on oral steroids.

Weight homeostasis & its modulators in hyperthyroidism before & after treatment with carbimazole.

Background & objectives: Hyperthyroidism is associated with increased food intake, energy expenditure and altered body composition. This study was aimed to evaluate the role of adipocytokines in weight homeostasis in patients with hyperthyroidism. Methods: Patients (n=27, 11men) with hyperthyroidism (20 Graves’ disease, 7 toxic multinodular goiter) with mean age of 31.3±4.2 yr and 28 healthy age and body mass index (BMI) matched controls were studied. They underwent assessment of lean body mass (LBM) and total body fat (TBF) by dual energy X-ray absorptiometer (DXA) and blood sample was taken in the fasting state for measurement of leptin, adiponectin, ghrelin, insulin, glucose and lipids. Patients were re-evaluated after 3 months of treatment as by that time all of them achieved euthyroid state with carbimazole therapy. Results: The LBM was higher (P<0.001) in healthy controls as compared to hyperthyroid patients even after adjustment for body weight (BW), whereas total body fat was comparable between the two groups. Serum leptin levels were higher in patients with hyperthyroidism than controls (22.3±3.7 and 4.1±0.34 ng/ml, P<0.001), whereas adiponectin levels were comparable. Plasma acylated ghrelin was higher in patients than in controls (209.8±13.3 vs 106.2±8.2 pg/ml, P<0.05). Achievement of euthyroidism was associated with significant weight gain (P<0.001) and significant increase in lean body mass (P<0.001). The total body fat also increased but insignificantly from 18.4±1.8 to 19.9±1.8 kg. There was significant decrease (P<0.05) in serum leptin and acylated ghrelin but adiponectin levels remained unaltered after treatment. Serum leptin positively correlated with TBF and this correlation persisted even after adjustment for BW, BMI, gender and age (r=0.62, P=0.001). However, serum leptin and acylated ghrelin did not correlate with the presence or absence of hyperphagia. Interpretation & conclusion: Patients with hyperthyroidism predominantly had decreased lean body mass which increased after achievement of euthyroidism with carbimazole. The hyperphagia and the alterations in weight homeostasis associated with hyperthyroidism were independent of circulating leptin and ghrelin levels.

Recovery pattern of hypothalamo-pituitary-testicular axis in patients with macroprolactinomas after treatment with cabergoline.

Background & objectives: Hyperprolactinaemia affects testicular functions by influencing hypothalamo-pituitary-testicular (HPT) axis at various levels. Available literature on the level of defect, time course of improvement of gonadal functions and its relation with decline in prolactin levels is scanty. We carried out this study to evaluate the HPT axis in patients with macroprolactinomas, before and six months after cabergoline therapy. Methods: Fifteen men with macroprolactinomas underwent gonadotropin and testosterone response to their respective stimuli before and after six months of cabergoline therapy. Results: Serum prolactin levels decreased after six months of therapy. Pretreatment, mean lutenizing and follicle stimulating hormones (LH and FSH) levels were 2.0 ± 0.4 and 1.4 ± 0.2 IU/l, respectively. However, LH and FSH responses to GnRH were preserved in majority of the patients and LH peaked to 12.1 ± 2.3 IU/l (P<0.01), while FSH to 2.9 ± 0.4 IU/l suggesting the influence of hyperprolactinaemia at the level of hypothalamus with preserved gonadotrope reserve. After cabergoline therapy, there was an increase in basal as well as stimulated LH and FSH levels, though these were not statistically significant when compared to respective pretherapy levels. Basal testosterone (T) levels significantly improved after therapy, but peak T response to hCG was similar at both pre- and post treatment. A significant correlation was observed between peak LH and peak T at baseline (r=0.53, P<0.01) and it further strengthened after therapy (r=0.70, P<0.01). After cabergoline therapy, there was significant improvement in seminal volume, sperm count and motility and sperm count correlated with peak FSH response (r=0.53, P<0.05). Interpretation & conclusions: Hyperprolactinaemia affects testicular functions probably by influencing at the level of hypothalamus resulting in subnormal basal secretion of gonadotropins required for optimal testicular functions.

Fibrous dysplasia & McCune-Albright syndrome: An experience from a tertiary care centre in north India.

Background & objectives Fibrous dysplasia (FD) is a rare metabolic bone disease and information available from India is limited to only anecdotal case reports. We describe the clinical profile and therapeutic outcome of 25 patients with FD observed over a period of 14 yr in a tertiary care centre from north India. Methods In this retrospective study patients (n = 25) with diagnosis of fibrous dysplasia based on either classical radiological features and/or histological evidence on bone biopsy, were analyzed. Associated endocrinopathies if any, were evaluated. The diagnosis of McCune Albright syndrome (MAS) was considered when fibrous dysplasia was accompanied by either café-au-lait macules and/or endocrinopathies. The clinical presentation, biochemical parameters and imaging were analysed. Seven patients received bisphosphonate therapy. The final outcome and side effects were noted. Results Age of the patients ranged from 7 to 48 yr (mean ± SD, 24.2 ± 11.4 yr) with a lag time between onset of symptoms and presentation ranging from 1 to 20 yr (mean ± SD, 6.6 ± 6.2 yr). The mean duration of follow up was 3.5 ± 2.1 yr. Eighteen (72%) patients had polyostotic disease while the remaining had monostotic FD. Eight patients had endocrinopathies: five had acromegaly, one each had gonadotropin independent precocious puberty (GIPP), hyperthyroidism and hypophosphatemic rickets. One child with GIPP later developed hyperthyroidism. McCune Albright syndrome was observed in 10 (40%) patients. A majority of the patients underwent various minor or major surgical procedures and seven patients received bisphosphonates for recurrent pathological fractures. Bone pain was reduced in all bisphosphonate treated patients with a decrease in subsequent fractures. Interpretation & conclusions This series of FD patients from north India shows the varying presentations of this rare disease. Medical treatment with bisphosphonates appears to be potentially rewarding.

Imaging in adult patients with acute febrile encephalopathy: What is better computerized tomography or magnetic resonance imaging.

Context: Imaging techniques are commonly used by emergency physicians in a febrile comatose patient. Their utility requires judicious use of the available resources. In this study, we have compared the efficacy of cranial imaging techniques in adult patients with acute febrile encephalopathy. Materials and Methods: This prospective observational study enrolled 101 patients presenting to the emergency with fever of less than 15 days duration and altered sensorium. All the patients were subjected to routine investigations, detailed cerebrospinal fluid analysis, computerized tomograms (noncontrast followed by contrast enhanced), and magnetic resonance imaging of the brain. Final diagnosis was reached after considering the clinical, biochemical findings, imaging results, and response to therapy. The positive yield of radiological investigations was compared against the final diagnosis. Results: The patients were divided into three groups. Forty-eight had evidence of meningoencephalitis, 22 patients had pyogenic meningitis, and 20 were combined together in other group. In 12 patients, a definitive diagnosis could not be made. Only 37% patients were detected to have abnormal computerized tomograms and the most common abnormality was diffuse edema, which failed to point to an etiological diagnosis. Magnetic resonance imaging was abnormal in 62.75% cases and was able to suggest an etiological diagnosis in 100% cases of cerebral venous thrombosis, tubercular meningitis, 95% cases of meningoencephalitis, and 45% patients with meningitis. Conclusions: We can conclude that magnetic resonance imaging provides better information than computerized tomography in adult patients with acute febrile encephalopathy.

Inflammatory pseudotumor of the omentum.

Inflammatory pseudotumor is an unusual quasineoplastic lesion, of uncertain natural history and etiopathogenesis, which consists of inflammatory cells and myofibroblastic spindle cells; and is usually found in children and young adults. Clinical manifestations and radiological feature of this rare entity, can be indistinguishable from a malignant sarcomatous or lymphoproliferative disorders. Here, a case of surgically proven inflammatory pseudotumor of the omentum in a child and its review of literature is presented. Conservative surgery is curative in most cases of inflammatory pseudotumors. Awareness of this lesion is essential for clinicians, radiologists and pathologists, as pre-operative recognition may spare the child from unnecessary radical surgery or harmful chemoradiotherapy.

MDCT venography in the evaluation of inferior vena cava in Budd-Chiari syndrome.

Objective To assess the role of multidetector computed tomography (MDCT) venography in the evaluation of the inferior vena cava (IVC) in Budd-Chiari syndrome (BCS), its accuracy as compared to digital subtraction venography (DSV) and the potential of this technique to replace venography for the defi nitive diagnosis of BCS. Methods Twenty-fi ve suspected cases of BCS were prospectively enrolled in this study and underwent both MDCT venography and DSV. Two observers independently evaluated and graded both the axial and reformatted MDCT images for the presence, site, degree and length of IVC narrowing. The collateral pathways and the hepatic veins were also assessed in all cases. The degree of correlation between MDCT venography and DSV was expressed using Spearman’s rank correlation coeffi cient (Rs). Results There was excellent correlation between MDCT venography and DSV in predicting the presence of stenosis and in grading the degree and length of IVC stenosis (Rs=0.58, p<0.05). Four patients had presence of a web within the IVC and the reconstructed MDCT venography images detected the fl ap of the membrane in all of them. In three cases of complete obstruction the cranial extent of the obstruction could be determined on the reconstructed MDCT venography images, while double catheter access through the femoral and jugular routes was needed to determine the same on DSV. MDCT venography was signifi cantly more informative in depicting the presence and site of both intrahepatic and extrahepatic collaterals as compared to DSV. Conclusion MDCT venography, in the present study, accurately provided information of both conventional CT and IVCgraphy, in the evaluation of the IVC in a non-invasive way. It helped overcome the shortcomings of CT in the evaluation of IVC and was better than DSV for the evaluation of collaterals, calcifi cation and complete IVC obstruction. We suggest that CT venography can be used as a frontline investigation for the diagnosis of IVC obstruction and for planning surgery or percutaneous endovascular intervention.

Biphasic multidetector CT of primary hepatic lymphoma in a patient with HIV infection.

Primary hepatic lymphoma (PHL) is a rare condition. It is the most common hepatic neoplasm in patients with acquired immune deficiency syndrome (AIDS). We report a case of PHL in a patient with human immunodeficiency virus (HIV) infection and describe the imaging findings on biphasic multidetector CT (MDCT).