Role of pre-surgical breast MRI in the management of invasive breast carcinoma.

The purpose of the study was to assess the role of preoperative breast magnetic resonance imaging (MRI) as a complementary tool to routine imaging methods in the management of women affected by invasive breast carcinoma. Mammograms, sonograms and biopsy results of 121 breasts in 118 women affected by invasive breast carcinoma, who underwent pre-surgical breast MR, were re-examined to identify patients theoretically eligible for conservative surgery instead of radical mastectomy. Surgery effectively performed was evaluated to identify cases for which MRI determined a change in management. The gold standard was the final pathology. Breast MRI determined an overall change in management in 22 out of 121 breasts (18.2%), and in two out of 87 breasts (25.3%) in patients eligible for conservative surgery. In the evaluation of single breasts, MRI resulted in true-positive in 22 out of 29 breasts (75.9%), false-positive in 7 out of 29 breasts (24.1%), leading to over-treatment in women whose treatment was changed from conservative surgery to radical mastectomy. MRI sensitivity in the detection of additional foci not seen on conventional imaging was 57.4%, overall sensitivity 87.4%, sensitivity for invasive cancers 93.1%, while for ductal carcinoma in situ it was 58.8%. In conclusion, breast MRI determines a significant change in the management of patients affected by invasive breast carcinoma, particularly in patients eligible for conservative surgery after standard breast examination.

Deep retroperitoneal pelvic endometriosis: MR imaging appearance with laparoscopic correlation.

Deep pelvic endometriosis is defined as subperitoneal infiltration of endometrial implants in the uterosacral ligaments, rectum, rectovaginal septum, vagina, or bladder. It is responsible for severe pelvic pain. Accurate preoperative assessment of disease extension is required for planning complete surgical excision, but such assessment is difficult with physical examination. Various sonographic approaches (transvaginal, transrectal, endoscopic transrectal) have been used for this purpose but do not allow panoramic evaluation. Furthermore, exploratory laparoscopy has limitations in demonstrating deep endometriotic lesions hidden by adhesions or located in the subperitoneal space. Despite some limitations, magnetic resonance (MR) imaging is able to directly demonstrate deep pelvic endometriosis. The MR imaging features depend on the type of lesions: infiltrating small implants, solid deep lesions mainly located in the posterior cul-de-sac and involving the uterosacral ligaments and torus uterinus, or visceral endometriosis involving the bladder and rectal wall. Solid deep lesions have low to intermediate signal intensity with punctate regions of high signal intensity on T1-weighted images, show uniform low signal intensity on T2-weighted images, and can demonstrate enhancement on contrast-enhanced images. MR imaging is a useful adjunct to physical examination and transvaginal or transrectal sonography in evaluation of patients with deep infiltrating endometriosis.

Final results and exploitation plans for MammoGrid.

The MammoGrid project has delivered the first deployed instance of a healthgrid for clinical mammography that spans national boundaries. During the last year, the final MammoGrid prototype has undergone a series of rigorous tests undertaken by radiologists in the UK and Italy and this paper draws conclusions from those tests for the benefit of the Healthgrid community. In addition, lessons learned during the lifetime of the project are detailed and recommendations drawn for future health applications using grids. Following the completion of the project, plans have been put in place for the commercialisation of the MammoGrid system and this is also reported in this article. Particular emphasis is placed on the issues surrounding the transition from collaborative research project to a marketable product. This paper concludes by highlighting some of the potential areas of future development and research.

Contrast-enhanced breast MRI in patients with suspicious microcalcifications on mammography: results of a multicenter trial.

OBJECTIVE: The objective of our study was to test dynamic MRI in evaluating mammographically detected suspicious microcalcifications. MATERIALS AND METHODS: One hundred twelve patients with mammographically detected microcalcifications with BI-RADS category 5 (n = 78) or 4 (n = 34) lesions were studied at 17 centers a using 3D gradient-echo dynamic coronal technique (< or = 3 mm thickness) and 0.1 mmol/kg of gadoteridol. A pathologic sample was obtained in all cases. Agreement between the major diameter measured on mammography, MRI, or both and the major diameter measured at pathologic examination was calculated in 62 cases. RESULTS: Of the 112 lesions, pathologic examination revealed 37 benign lesions, 33 ductal carcinoma in situ (DCIS), and 42 invasive carcinomas. The specificity of MRI for benign lesions was 68%. Considering the subgroups of calcifications alone and calcifications associated with masses, the specificity values became 79% and 33%, respectively. The sensitivity of MRI for DCIS was 79%. Analysis of the two subgroups showed sensitivity values of 68% for calcifications alone and of 1% for calcifications associated with masses. The sensitivity for invasive carcinomas was 93%. Analysis of the two subgroups showed sensitivity values to be 92% for calcifications alone and 94% for calcifications associated with masses. Considering the overall results, the sensitivity of MRI was 87%; specificity, 68%; positive predictive value, 84%; negative predictive value, 71%; and accuracy, 80%. Considering the subgroups of calcifications alone and calcifications associated with masses, the sensitivity values became 80% and 97%; the positive predictive values, 86% and 82%; the negative predictive values, 71% and 75% (95% confidence interval [CI], 0.19-0.99); and the accuracy values, 80% and 82% (95% CI, 0.66-0.92), respectively. An odds ratio (OR) of 13.54 (95% CI, 5.20-35.28) showed a raised risk of malignant breast tumor in subjects with positive MR examination of mammographically detected suspicious clusters of microcalcifications. The statistical analysis on each subgroup showed an OR of 15.07 (95% CI, 4.73-48.08) for calcifications alone and an OR of 14.00 (95% CI, 1.23-158.84) for calcifications associated with masses. Any significant improvement in the predictive ability of dynamic MRI depending on the extent of calcifications on mammography was not proved. Considering the 62 cases of proved malignancy with measured maximal diameter at pathologic examination, both mammography and MR examination seem to overestimate tumor extent. CONCLUSION: The not-perfect sensitivity of MRI (87%), when applying our interpretation criteria and imaging sequences, is a crucial point that prevents us from clinical use of MRI in the diagnosis of mammographically detected microcalcifications.

Polyp size at CT colonography after electronic subtraction cleansing in an anthropomorphic colon phantom.

PURPOSE: To evaluate the effect of various bowel contrast material concentrations and subtraction software on size measurements of well-defined polyp lesions in a colon phantom at CT colonography. MATERIALS AND METHODS: Repeated scanning and a precise reference standard required the use of a colon phantom in which 21 polyps were randomly distributed. Two readers who had each reviewed computed tomographic (CT) colonographic images from more than 100 cases evaluated polyp size on images obtained when the phantom was partially filled with varying concentrations of contrast material, scanned by using CT colonography, and subjected to electronic subtraction cleansing. The single largest dimension was recorded for each reader for a randomized series of polyps. These measurements were compared with a reference standard that was based on a combination of the manufacturer's polyp size specifications and the subsequent verification of these sizes by an independent consensus panel. Six weeks after initial observations, readers evaluated images of the phantom scanned without the presence of contrast material. Polyp size estimations for the two readers for each series were compared with the reference standard to obtain a mean absolute measurement error for each reader for each series. Data for each reader were compared by using a nonparametric Kruskal-Wallis analysis of variance test. A pair-wise comparison of the experimental and control series was then performed by using the Dunn post hoc test. RESULTS: Contrast material dilutions resulting in an average attenuation of less than 500 HU resulted in complete subtraction and the absence of streak artifacts. There was no statistically significant difference between the average measurement error for contrast attenuations between 300 and 500 HU when compared with that of control. Streak artifact was noticeable for the highest dilution (mean, 840 HU). No statistically significant differences were observed for series in which cleansing software was used in the absence of bowel contrast material. CONCLUSION: The combination of electronic cleansing and bowel contrast enhancement in the range of 300-500 HU results in no substantial change in readers' estimations of polyp size at CT colonography.

Deployment of a grid-based medical imaging application.

The MammoGrid project has deployed its Service-Oriented Architecture (SOA)-based Grid application in a real environment comprising actual participating hospitals. The resultant setup is currently being exploited to conduct rigorous in-house tests in the first phase before handing over the setup to the actual clinicians to get their feedback. This paper elaborates the deployment details and the experiences acquired during this phase of the project. Finally the strategy regarding migration to an upcoming middleware from EGEE project will be described. This paper concludes by highlighting some of the potential areas of future work.

Locally advanced breast cancer: comparison of mammography, sonography and MR imaging in evaluation of residual disease in women receiving neoadjuvant chemotherapy.

The accuracy of mammography, sonography and magnetic resonance imaging (MRI) in identifying residual disease after neoadjuvant chemotherapy is evaluated and imaging findings are correlated with pathologic findings. Fifteen patients enrolled in an experimental protocol of preoperative neoadjuvant chemotherapy underwent clinical examination, mammography, sonography and dynamic MRI, performed in this order, before and respectively after 2 and 4 cycles of neoadjuvant chemotherapy. Four radiologists, two for mammography, one for sonography and one for MR, examined the images, blinded to the results of the other examinations. All patients underwent radical or conservative surgery, and imaging findings were compared with pathologic findings. MRI identified 2/15 (13.3.%) clinically complete response (CR), 9/15 (60%) partial response (PR), 3/15 (20%) stable disease (SD) and 1/15 (6.7%) progressive disease. Mammography identified 1/15 (6.7%) clinically CR, 8/15 (53.3%) PR and 4/15 (27%) SD, and was not able to evaluate the disease in 2/15 (13%) cases. Sonography presented the same results as MRI. Therefore, MRI and sonography compared to mammography correctly identified residual disease in 100 vs. 86%. MRI resulted in two false-negative results because of the presence of microfoci of in situ ductal carcinoma (DCIS) and invasive lobular carcinoma (LCI). MRI was superior to mammography in cases of multifocal or multicentric disease (83 vs. 33%). Sonography performed after MRI improves the accuracy in evaluation of uncertain foci of multifocal disease seen on MR images with an increase of diagnostic accuracy from 73 to 84.5%. MRI assesses response to neoadjuvant chemotherapy better than traditional methods of physical examination and mammography.

Doppler evaluation of arterial complications of adult orthotopic liver transplantation.

PURPOSE: The aim of this study was to analyze the role of the resistance index (RI), systolic acceleration time (SAT), and spectral waveform's morphologic characteristics in the sonographic evaluation of the hepatic artery for early detection of stenosis or thrombosis after orthotopic liver transplantation. METHODS: Arterial Doppler sonograms of 174 transplanted livers in 150 patients were analyzed for presence or absence of blood flow, RI, SAT, and peak systolic velocity. A qualitative evaluation of the spectral waveform morphologic characteristics was also made. In patients who had had abnormal findings on sonography, we compared those results with results obtained on multislice helical CT or angiography. RESULTS: At least 1 of the Doppler criteria for hepatic artery stenosis or thrombosis was identified in 25 of the transplants. The findings on multislice helical CT, angiography, or both confirmed the diagnosis of stenosis or thrombosis in 20 of the 25 cases: in 9 of 10 cases of absent hepatic arterial blood flow, 5 of 9 with an RI lower than 0.5, 6 of 7 cases with an SAT longer than 0.08 second, 10 of 11 cases of changes to a tardus-parvus-like spectral waveform, and in the 1 case of a peak systolic velocity greater than 2 m/second. CONCLUSIONS: The most accurate indicator of hepatic arterial stenosis or thrombosis was a change in the spectral waveform to a tardus-parvus pattern, with 91% sensitivity and 99.1% specificity. Among the other parameters, an increase of the SAT value (> 0.08 second), when associated with the morphologic modification of the systolic peak, is a more reliable parameter than the RI for early detection of artery stenosis, especially when the type of anastomosis is unknown.

Pseudomesotheliomatous angiosarcoma of the chest wall and pleura.

Angiosarcoma is a rare soft tissue sarcoma that usually occurs in deep soft tissues, breast, spleen, liver, and bone. Primary thoracic parietal localization of angiosarcoma is rare and prognosis is poor. In this report, we present the CT and PET features of a patient with pseudomesotheliomatous angiosarcoma of the chest wall and pleura, which, to the best of our knowledge, have not previously been described.

Staging of pelvic endometriosis using magnetic resonance imaging compared with the laparoscopic classification of the American Fertility Society: a prospective study.

PURPOSE: To introduce a staging of pelvic endometriosis based on Magnetic Resonance Imaging (MRI) features, compared with the American Fertility Society (AFS) laparoscopic classification. MATERIALS AND METHODS: Thirty-five consecutive females with clinically suspected endometriosis underwent MRI examination using TSE T1, T2W, and SE FAT-SAT T1W sequences, to demonstrate the presence of endometriomas and pelvic implants. Laparoscopy was performed within two weeks (mean 8 days) of the examination. A radiologist experienced in pelvic pathology evaluated the presence of endometriomas and implants and calculated a score to classify endometriosis in four classes, comparable with those of AFS laparoscopic staging. The MRI score was based on size, edges, wall thickness, septations, signal intensity on T2-weighted images of endometriomas and presence of pelvic implants. The concordance between MRI and laparoscopic classification was evaluated using k-statistics. RESULTS: Laparoscopy confirmed 47/48 endometriomas, ranging in size from 10 to 62 mm, detected by MRI, with only one false positive due to an hemorrhagic corpus luteum. Nevertheless, 2 intra-ovarian endometriomas were detected by laparoscopy only thanks MRI guidance. Implants were discovered in 17/30 patients with MRI, laparoscopically in 18/30. MRI detected 46 endometrial implants out of 57 detected by laparoscopy (80.7%): 17/46 implants were directly confirmed by laparoscopy, 29/46 were indirectly confirmed by the presence of adhesions. As regards staging, there was agreement between the MRI and AFS classification in 33/35 patients with only two case of discordance (K= 0,892). CONCLUSIONS: Although MRI has limitations such as suboptimal depiction of small implants and adhesions, this technique is very useful for guiding laparoscopy. Moreover, the high level of agreement (96.6%) between the MRI staging proposed in this paper and laparoscopic classification demonstrates a further advantage of the use of MRI in the preoperative staging of endometriosis.

Comparing Levovist-enhanced pulse inversion harmonic imaging and ferumoxides-enhanced MR imaging of hepatic metastases.

OBJECTIVE: The aim of this study was to compare the sensitivity of pulse inversion harmonic digital sonography, unenhanced transabdominal sonography, and ferumoxides-enhanced MR imaging in the depiction of liver metastases. In addition, pulse inversion harmonic digital sonography was performed at different scanning times after Levovist injection to define the best phase for depiction. SUBJECTS AND METHODS: Twenty-six consecutive patients with findings of extrahepatic primary malignancies and liver metastases suspected on transabdominal sonography were examined with both pulse inversion harmonic imaging and ferumoxides-enhanced MR imaging within a 7-day period. Pulse inversion harmonic imaging was performed before and at 20, 100, and 180 sec after a bolus injection of Levovist. MR imaging was performed before and after ferumoxides administration, using breath-hold gradient-recalled echo T1-weighted and turbo spin-echo short tau inversion recovery T2-weighted sequences. Two radiologists independently evaluated image quality, and the number, location, and diameter of lesions scanned using both techniques. Intraoperative sonography or at least 8-month follow-up confirmed the lesions depicted. Analyses included Wilcoxon's signed rank test and Interclass correlation test. RESULTS: Levovist-enhanced pulse inversion harmonic imaging revealed 104 metastases on the first scan after contrast injection, 126 on the second scan, and 118 on the third, compared with 66 on the unenhanced scan. Pulse inversion harmonic digital sonography depicted 90% of lesions shown on ferumoxides-enhanced MR imaging (140 metastases) (p = 0.001). CONCLUSION: Levovist-enhanced pulse inversion harmonic digital sonography is a sensitive technique for depiction of liver metastases. Pulse inversion harmonic digital sonography may have a potential role in imaging patients with possible metastatic involvement of the liver. Further studies are needed to define its place in the workup of these patients. At present, ferumoxides-enhanced MR imaging, being more sensitive, must be performed in all patients in whom pulse inversion harmonic digital sonography is not conclusive or when after pulse inversion harmonic digital sonography, patients remain eligible for surgery.

CT colonography: digital subtraction bowel cleansing with mucosal reconstruction initial observations.

The authors evaluated a computed tomography (CT) colonographic technique with a combination of preexamination orally ingested positive contrast material and postacquisition image processing to subtract out the ingested opacified bowel contents. With this technique, rigorous physical purging of the bowel was not necessary before structural examination of the colon. With images obtained in 20 patients, two readers were able to correctly identify the majority of polyps confirmed at colonoscopy. Their performance for detection of lesions larger than 1 cm was similar to that with conventional CT colonography.

Detection of liver metastases: comparison of gadobenate dimeglumine-enhanced and ferumoxides-enhanced MR imaging examinations.

PURPOSE: To compare gadobenate dimeglumine (Gd-BOPTA)-enhanced magnetic resonance (MR) imaging with ferumoxides-enhanced MR imaging for detection of liver metastases. MATERIALS AND METHODS: Twenty consecutive patients known to have malignancy and suspected of having focal liver lesions at ultrasonography (US) underwent 1.0-T MR imaging with gradient-recalled-echo T1-weighted breath-hold sequences before, immediately after, and 60 minutes after Gd-BOPTA injection. Subsequently, MR imaging was performed with turbo spin-echo short inversion time inversion-recovery T2-weighted sequences before and 60 minutes after ferumoxides administration. All patients subsequently underwent intraoperative US within 15 days, and histopathologic analysis of their resected lesion-containing specimens was performed. Separate qualitative analyses were performed to assess lesion detection with each contrast agent. Quantitative analyses were performed by measuring signal-to-noise and contrast-to-noise ratios (CNRs) on pre- and postcontrast Gd-BOPTA and ferumoxides MR images. Statistical analyses were performed with Wilcoxon signed rank and Monte Carlo tests. RESULTS: Sensitivity of ferumoxides-enhanced MR imaging was superior to that of Gd-BOPTA-enhanced MR imaging for liver metastasis detection (P <.05). Ferumoxides MR images depicted 36 (97%) of 37 metastases detected at intraoperative US, whereas Gd-BOPTA MR images depicted 30 (81%) metastases during delayed phase and 20 (54%) during dynamic phase. All six metastases identified only at ferumoxides-enhanced MR imaging were 5-10 mm in diameter. There was a significant increase in CNR between the lesion and liver before and after ferumoxides administration (from 3.8 to 6.8, P <.001) but not before or after Gd-BOPTA injection (from -4.8 to -5.5, P >.05). CONCLUSION: Ferumoxides-enhanced MR imaging seems to be superior to Gd-BOPTA-enhanced MR imaging for liver metastasis detection.

Advances in imaging for pancreatic disease.

Pancreatic imaging is an essential tool in the early diagnosis and staging of pancreatic disease. This review analyzes the most recent advances in pancreatic imaging. The specific modalities discussed include helical computed tomography (HCT) and multislice CT (MSCT), CT angiography, magnetic resonance imaging (MRI), magnetic resonance cholangiopancreatography (MRCP), and positron emission tomography (PET). At present, MSCT is generally viewed as the most efficient modality for initial detection and staging of pancreatic carcinoma, with an accuracy rate of about 95% to 97% for initial detection and virtually 100% for staging. CT is also the initial imaging modality used in evaluation of acute pancreatitis. However, recently, MRI has been viewed increasingly as a more precise diagnostic tool in this subgroup of patients. MRCP has been accepted as the primary imaging technique in the diagnosis of chronic pancreatitis. PET imaging, on the other hand, has an increasing role in the staging of pancreatic carcinoma, for which it may be the modality of choice in detection of extrapancreatic metastasis.