Background enhancement in contrast-enhanced spectral mammography (CESM): are there qualitative and quantitative differences between imaging systems?

OBJECTIVE: To evaluate the impact of the digital mammography imaging system on overall background enhancement on recombined contrast-enhanced spectral mammography (CESM) images, the overall background enhancement of two different mammography systems was compared. METHODS: In a retrospective single-center study, CESM images of n = 129 female patients who underwent CESM between 2016 and 2019 were analyzed independently by two radiologists. Two mammography machines of different manufacturers were compared qualitatively using a Likert-scale from 1 (minimal) to 4 (marked overall background enhancement) and quantitatively by placing a region of interest and measuring the intensity enhancement. Lesion conspicuity was analyzed using a Likert-scale from 1 (lesion not reliably distinguishable) to 5 (excellent lesion conspicuity). A multivariate regression was performed to test for potential biases on the quantitative results. RESULTS: Significant differences in qualitative background enhancement measurements between machines A and B were observed for both readers (p = 0.003 and p < 0.001). The quantitative evaluation showed significant differences in background enhancement with an average difference of 75.69 (99%-CI [74.37, 77.02]; p < 0.001). Lesion conspicuity was better for machine A for the first and second reader respectively (p = 0.009 and p < 0.001). The factor machine was the only influencing factor (p < 0.001). The factors contrast agent, breast density, age, and menstrual cycle could be excluded as potential biases. CONCLUSION: Mammography machines seem to significantly influence overall background enhancement qualitatively and quantitatively; thus, an impact on diagnostic accuracy appears possible. KEY POINTS: • Overall background enhancement on CESM differs between different vendors qualitatively and quantitatively. • Our retrospective single-center study showed consistent results of the qualitative and quantitative data analysis of overall background enhancement. • Lesion conspicuity is higher in cases of lower background enhancement on CESM.

Reassessment of Surgical Procedures for Complex Obstructive Genital Malformations: A Case Series on Different Surgical Approaches.

The objective of this case series was to describe different uterus-preserving surgical approaches and outcomes in patients with complex obstructive Müllerian duct malformation caused by cervical and/or vaginal anomalies. A retrospective analysis was performed including patients undergoing uterovaginal anastomosis (n = 6) or presenting for follow-up (n = 2) at the Department for Gynecology at the University of Tuebingen between 2017 and 2022. Uterovaginal anastomosis was performed with a one-step combined vaginal and laparoscopic approach (method A), a two-step/primary open abdominal approach with primary vaginal reconstruction followed by abdominal uterovaginal anastomosis after vaginal epithelization (method B) or an attempted one-step approach followed by secondary open abdominal uterovaginal anastomosis due to reobstruction (method A/B). Patients presented at a mean age of 15 years. Two patients were treated by method A, four by method B and two by method A/B. Functional anastomosis was established in seven of eight patients, with normal vaginal length in all patients. Concerning uterovaginal anastomosis, the primary open abdominal approach with or without previous vaginal reconstruction seems to have a higher success rate with fewer procedures and should be implemented as standard surgical therapy for complex obstructive genital malformations including the cervix.

Breast tomosynthesis for the clarification of mammographic BI-RADS 3 lesions can decrease follow-up examinations and enables immediate cancer diagnosis.

Background The limited sensitivity of mammography in case of a high breast density often produces unclear or false-positive findings, so-called BI-RADS 3 lesions, which have to be followed up to prove benignity. Digital breast tomosynthesis (DBT) was developed to reduce such summation effects. Purpose To evaluate the influence of an additional DBT on the management of mammographic BI-RADS 3 findings and whether DBT can decrease the time to definitive diagnosis or not. Material and Methods We analyzed 87 patients with a mammographic non-calcified BI-RADS 3 lesion who underwent an additional DBT of the affected breast. A follow-up two-dimensional (2D) examination or a histological result of the lesion had to be available. The images were analyzed especially for the BI-RADS category and incremental diagnostic accuracy. Moreover, the inter-reader reliability and the radiation dose were evaluated. Results The BI-RADS category has been changed by the addition of DBT: 57.1% were assessed as BI-RADS 1 or 2, 4.6% as BI-RADS 4, and only 38.3% remained as BI-RADS 3. The intraclass correlation coefficient for the three readers showed a good agreement for inter-reader reliability. No false-negative examination was found in the follow-ups. Nine lesions were biopsied (seven benign, two malignant). Both malignant lesions were suspicious in the DBT (BI-RADS 4). A significant higher glandular dose was necessary for the DBT. Conclusion DBT has the potential to reduce the recall-rate of BI-RADS 3 lesions and to find and diagnose malignant lesions earlier than 2D mammography alone.

BI-RADS® 3 lesions at contrast-enhanced breast MRI: is an initial short-interval follow-up necessary?

BACKGROUND: Magnetic resonance imaging (MRI) BI-RADS® 3 lesions should have a very high probability of being benign. To prove benignity most institutions do follow-up MRI. PURPOSE: To evaluate the necessity of initial short-interval follow-up after 6 months as it is suggested for mammographic BI-RADS®3 lesions. MATERIAL AND METHODS: We analyzed 163 consecutive MRI-BI-RADS® 3 lesions on follow-up MRI: 75 masses (46%), 67 foci (41.1%), and 21 (12.9%) non-mass-like enhancing lesions (NMLE). RESULTS: During MRI follow-up (mean time, 563 days) 20% of the lesions disappeared, 23% decreased, 52% did not change, and 4.9% showed increase. All increasing lesions were biopsied (5 benign, 2 ductal carcinoma in situ, 1 invasive carcinoma). The rate of malignancy was 1.8%. All malignant lesions (1 mass, 1 focus, 1 NMLE) showed increase at initial follow-up after a mean interval of 190 days. CONCLUSION: In this study the malignancy rate of MRI-BI-RADS® 3 lesions corresponded to mammographic BI-RADS® 3 lesions. Initial short-interval MRI should be suggested to identify malignant MRI-BI-RADS® 3 lesions.

Aftercare in patients with Cushing's disease and acromegaly: is there room for improvement?

PURPOSE: Evaluation of aftercare, medical therapy and remission rate for Cushing's disease (CD) and acromegaly (AC). METHODS: Fifty-eight CD and 83 AC patients operated on over 10 years were carefully evaluated. The patients received a disease-related questionnaire and were invited for a follow-up at the outpatient clinic of the Department of Neurosurgery. Thirty-three CD and 52 AC patients returned the questionnaire; 25 CD and 37 AC patients participated personally. CD patients underwent a dexamethasone suppression test, and IGF-1 levels were assessed in AC patients. Data on postoperative therapy were assessed. RESULTS: 84.8% of those with CD and 75.0% of those with AC had been followed by endocrinologists; 9.1% of CD and 1.9% of AC patients had been under no aftercare; 96% of CD patients were in remission. A recurrence occurred in four patients, two were newly detected by our study. IGF-1 was postoperatively normalized in 25 of 37 AC patients (67.6%). Twenty patients remained in remission, five relapsed. One patient received medical therapy upon recurrence and presented normal IGF-1; four patients with relapse had not been treated yet. Ten of 12 patients with elevated early postoperative IGF-1 received medical therapy that was commenced within 6 months in nine cases. The mean duration of medical therapy was 36 months (range 2-92). IGF-1 was still elevated at the last follow-up in eight of these ten patients, all of them receiving monotherapy. In four patients, the dose had been increased once. CONCLUSIONS: The postoperative transfer back to the endocrinologist after operative treatment is achieved well in both groups. In uncured AC, medical therapy is initiated early, but options of therapy offer room for improvement. Therapy of recurrence is delayed in both pathologies.