Real-time reading in mammography breast screening.

PURPOSE: This study was undertaken to assess the role of real-time reading in the mammography screening programme carried out at the Hospital of Marzana, Verona, Italy. MATERIALS AND METHODS: During the 5-year period 1999-2004, 54,472 women attended the screening programme (32,291 first calls: unadjusted uptake 41.4%, adjusted uptake 50.3%; 21,551 2- year routine recalls: unadjusted uptake 86.4%, adjusted uptake 89.9%). Further diagnostic investigations [(FDI), imaging and cytohistological] were performed immediately after real-time reading of the screening mammograms (FDI rate among first calls 10.9%; FDI rate among 2-year recalls 5.4%). Overall, cytohistological FDI were requested in 27% of imaging FDI, with a clear prevalence of cytological [fine-needle aspiration cytology (FNAC) 87%] over histological procedures [core needle biopsy (CNB) 11%; vacuum aspiration biopsy (VAB) 2%]. RESULTS: Imaging FDI proved to be conclusive in 73%. Cytohistological FDI led to the use of surgical biopsy (SB) in 39.5% (ratio between benign and malignant SB: 0.19/first calls, 0.14/2-year recalls). There were a total of 427 screen-detected breast cancers (BC), with a very good breast cancer detection rate (BCDR/first calls 9.7 per thousand; BCDR/2-year recalls 5.1 per thousand). In the 427 screen-detected BC, the incidence of pTis, pT1a,b cancers was 59.6% (diagnostic anticipation); the incidence of pN0 cancers was 61.2%; the incidence of conservative surgical procedures was 78.6%. In interval cancers, the false negative rate was 8.3% only, whereas the proportional incidence was very low indeed (14% first year; 38% second year). CONCLUSIONS: The high sensitivity exhibited by the Marzana mammography screening programme suggests that the value of real-time reading should be validated by other programmes adopting a similar approach.

[The assessment of the impact of a double reading by expert readers in a mass mammographic study]. / Valutazione dell'impatto della doppia lettura da parte di lettori esperti in un'indagine mammografica di massa.

PURPOSE: To evaluate the role of double reading of screening mammograms by expert radiologists. MATERIAL AND METHODS: We analyzed the results of independent readings of a proficiency test of screening mammography (140 cases, 32 cancers) performed by four expert radiologists. Double reading was simulated by matching the four original readings in 6 possible combinations. The impact of double reading over single reading was evaluated in terms of increased sensitivity and increased recall rate. RESULTS: Of 32 carcinomas 22, 6, or 4 were identified by 4, 3, or 2 readers, respectively. Of 108 cases negative for cancer a recall for further investigations was suggested by 4, 3, 2, 1 or no reader(s) in 3, 3, 9, 14, or 79 cases, respectively. Inter-reader diagnostic repeatability was good (k = 0.65). Single readers achieved an average sensitivity of 89% (range 87.5-90.6%) and an average recall rate of 12.2% (range 7.4-16.6%). Simulated double reading achieved an average increase in sensitivity of 8.8% (range 6.2-10.95%) and an average increase of recall rate of 6.2% (range 3.8-8.3%). CONCLUSIONS: Even though the relative increase of recall rate is relevant (+53.2%), the corresponding gain in sensitivity justifies the use of double reading, which was confirmed to be worthwhile also when expert radiologists are involved. This study confirms the opportunity of adopting double reading as a routine procedure in mammographic screening.

Intraductal papillary mucinous tumor of the pancreas: a pictorial essay.

Intraductal papillary mucinous tumor (IPMT) of the pancreas was identified and classified only recently. IPMT has a primarily intraductal, papillomatous growth pattern, which is associated with excessive mucin secretion and results in progressive ductal dilatation or cyst formation. The tumor occurs in four forms: segmental or diffuse involvement of the main pancreatic duct and macrocystic or microcystic involvement of a branch duct. In the past, many IPMTs may have been misdiagnosed as chronic pancreatitis because of their generally benign behavior. The correct diagnosis, once achieved only with endoscopic retrograde cholangiopancreatography (ERCP), can now be made with noninvasive imaging modalities, particularly computed tomography (CT) and magnetic resonance (MR) imaging. ERCP remains the imaging modality of choice for diagnosis of IPMT. With ERCP, the communication between the cystically dilated ductal segment or branch duct and the main pancreatic duct is easily demonstrated. However, reflux of contrast material due to an excess of mucin or an enlarged papillary orifice hinders filling of the ductal tree. Filling defects due to mucin globs or mural nodules are also important clues to the diagnosis. Bulging of the papilla into the duodenal lumen is virtually pathognomonic of IPMT and is well demonstrated with CT or MR imaging.

[Digital radiography of the thorax with selenium detector. Clinical results and optimization potential of the technique]. / Radiografia digitale del torace con detettore al selenio. Risultati clinici e possibilità di ottimizzazione della tecnica.

INTRODUCTION: We compared the image quality of the chest radiograph obtained with a digital selenium detector and with a conventional system and investigated the possible improvements in the digital technique resulting from kilovoltage (kV) lowering, antiscattering grid addition and image format reduction. MATERIAL AND METHODS: 150 subjects in the first series were submitted to posteroanterior chest radiography with both the selenium and the conventional systems. Image quality was compared by giving a score to the depiction of anatominal and pathologic findings. Thirty-two and 31 subjects from two other series were submitted to two digital chest radiographs each: the former at high (150) and low (90) kV, and the latter at 150 kV with the antiscattering grid and at 90 kV without the grid. Comparisons were made by choosing the better of the two images of each subjects. A score was given to the depiction quality of several difficult-to-detect findings in full-size and small-size format digital images obtained in another series of 27 subjects. RESULTS: As for anatomical detailing, digital selenium images were of much better quality than conventional images: the mean scores given by 3 observers to digital images (5.32; 5.55; 6.68) are higher than those given to the corresponding conventional images (4.49; 5.02; 5.81) and the difference is statistically significant (p < 0.001 in all cases). The advantage of digital over conventional images is also significant with reference to diagnostic confidence in the identification of pathologic findings (p < 0.001; p < 0.005; p < 0.01), but to a lessere extent (mean scores: 3.98; 4.22; 3.60 for the digital system, versus 3.43; 3.69; 3.38 for the conventional system). The digital images acquired at lower kV (90 kV) were much more frequently chosen by the two observes (87.5% and 96.8% of cases) than the images acquired at 150 kV; the entry dose at lower energies (91 muGy using an anthropomorphic phantom) is not significantly higher than the dose given at 150 kV (85 muGy). No significant difference was found in the two observers' choice between the digital images taken at 90 kV without antiscattering grid and those taken at 150 kV with the grid, the former being preferred in 38.7% and 58% of cases. The level of diagnostic confidence in the detailing of difficult-to-detect findings was slightly higher in full-size digital images (mean scores: 5.33 and 6.77) than in small-size ones (4.88 and 5.96). DISCUSSION AND CONCLUSIONS: Digital selenium images always exibit better quality than conventional images: the difference is very marked relative to anatomical detailing and not so striking, though still significant, in showing pathologic findings. Digital selenium image quality can be improved relative to the manufacturer's guidelines (150 kV exposure with no grid), by lowering the kV and adding the antiscattering grid, without increasing patient exposure too much. Digital image format reduction allows cost containment without affecting diagnostic reliability.

Cystic dystrophy of the duodenal wall: radiologic findings.

PURPOSE: To determine the radiologic characteristics of cystic dystrophy of the duodenal wall. MATERIALS AND METHODS: Ten patients with cystic dystrophy of the duodenal wall and chronic pancreatitis underwent ultrasonography (US) (n = 10), computed tomography (CT) (n = 10), endoscopic US (n = 5), and endoscopic retrograde cholangiopancreatography (ERCP) (n = 9). Cystic dystrophy of the duodenal wall was classified as either cystic or solid. The imaging findings were retrospectively analyzed and compared with findings at pancreatoduodenectomy (n = 10). RESULTS: The more frequent cystic type (n = 7) of cystic dystrophy of the duodenal wall was characterized by the presence of easily recognizable cystic lesions (diameter, more than 1 cm), located within the thickened wall of the second portion of the duodenum. The solid type (n = 3) of cystic dystrophy of the duodenal wall demonstrated fibrous thickening of the duodenal wall within which small cysts (diameter, less than 1 cm) were present. The intraduodenal cysts were usually elongated or bilobate with a thick wall. The thickening of the duodenal wall appeared as a solid layer between the duodenal lumen and the pancreas, hypoechoic at US, isoattenuating at unenhanced CT, and hypoattenuating in the early phase (after initiation of infusion of contrast material) and isoattenuating in the late phase (after completion of infusion) at contrast material-enhanced CT. Findings at retrospective analysis of CT and endoscopic US images were characteristic. CONCLUSION: Imaging modalities, notably CT and endoscopic US, helped establish the diagnosis of cystic dystrophy of the duodenal wall.

Serous cystadenoma of the pancreas: report of 30 cases with emphasis on the imaging findings.

PURPOSE: Our goal was to evaluate retrospectively 30 cases of serous cystadenoma (SCA) to determine its main imaging features as well as to discuss the differential diagnosis problems versus the other cystic lesions of the pancreas. METHOD: Thirty SCAs were analyzed; they were all benign lesions, proven at surgery. Twenty-three tumors were evaluated with US, 26 with CT, and 5 with MRI. RESULTS: Three different morphostructural patterns were identified: microlacunar (n = 19), mixed (n = 6), and macrolacunar (n = 5). The diagnosis of SCA, possible in either the microlacunar or the mixed patterns, was achieved in 74% of cases with US (17/23) and in 61.5% with CT (16/26). Among the 19 patients evaluated with both modalities, the joint information allowed a correct diagnosis in 16 cases (84%). The five macrolacunar tumors were undistinguishable from other cystic masses of the pancreas. CONCLUSION: The diagnosis of SCA can be considered certain in the microlacunar, likely in the mixed, and not possible in the macrolacunar type.

Focal malignant hepatic lesions: MR imaging enhanced with gadolinium benzyloxypropionictetra-acetate (BOPTA)--preliminary results of phase II clinical application.

PURPOSE: To investigate enhancement with gadolinium benzyloxypropionictetraacetate (BOPTA) at magnetic resonance (MR) imaging to detect focal malignant hepatic lesions. MATERIALS AND METHODS: A phase II trial was performed in 34 patients. Gd-BOPTA-enhanced spin-echo (SE) and gradient-recalled-echo (GRE) T1-weighted MR imaging were performed at 40 and 90 minutes after intravenous injection of 0.05 and 0.10 mmol/kg Gd-BOPTA. RESULTS: The percentage of enhancement in liver parenchyma was significantly (P<.05) increased on GRE T1-weighted compared with SE T1-weighted images at 40 and 90 minutes after injection of the higher dose and compared with SE and GRE T1-weighted images obtained with the lower dose. The contrast-to-noise ratio of metastases was significantly increased on GRE T1-weighted images (0.10 mmol/kg) at 90 minutes compared with precontrast images. Significantly more small primary metastases were detected on GRE T1-weighted images (0.10 mmol/kg) at 90 minutes compared with precontrast SE T1-weighted images. CONCLUSION: Gd-BOPTA is a safe hepatobiliary contrast agent that helps detection of small metastases.

Papillary cystic neoplasm of the pancreas: radiological findings.

We report a series of 10 papillary cystic neoplasms of the pancreas evaluated in our institution. The lesions are analyzed in retrospect to define the existence of eventual specific imaging patterns as well as to point out the existing problems of differential diagnosis versus other pancreatic tumors.

Intraductal mucin-producing tumors of the pancreas: imaging findings.

PURPOSE: To evaluate the radiologic characteristics of intraductal mucin-producing tumors of the pancreas. MATERIALS AND METHODS: Sixteen patients with intraductal tumors underwent ultrasound (US); (n = 15), computed tomography (CT); (n = 16), endoscopic retrograde cholangiopancreatography (ERCP); (n = 12), and intraoperative pancreatography (n = 2). Findings were compared with those from surgery (n = 14) or biopsy (n = 2). RESULTS: Lesions were classified as either main duct type or branch duct type tumors. Main duct tumors were characterized at US and CT by either diffuse or segmental dilatation of the Wirsung duct. Pancreatography showed ductal dilatation and filling defects caused by mucin deposits. At US and CT, branch duct tumors, which were mainly located at the uncinate process, were seen as fluid-filled masses with central septa and the pancreatic duct was dilated. ERCP showed partial or complete opacification of the lesion. In four patients, endoscopy showed protrusion of the papilla into the duodenal lumen and mucin leaking from its dilated orifice. CONCLUSION: Imaging modalities, especially US and ERCP, enable early diagnosis of mucin-producing pancreatic tumors.

Papillary cystic neoplasm of the pancreas: radiological findings.

We report a series of 10 papillary cystic neoplasms of the pancreas evaluated in our institution. The lesions are analyzed in retrospect to define the existence of eventual specific imaging patterns as well as to point out the existing problems of differential diagnosis versus other pancreatic tumors.

[Invasive pulmonary aspergillosis: possibility of radiologic diagnosis]. / L'aspergillosi polmonare invasiva: possibilità di diagnosi radiologica.

The incidence of invasive pulmonary aspergillosis is increasing in the patients with malignant hematologic diseases; this occurs in the phase of granulocytopenia induced by chemotherapy. In these cases an early diagnosis is mandatory to start a prompt antimycotic treatment. The authors reviewed the personal series of 56 patients with malignant hematologic diseases who, in the phase of granulocytopenia, developed a pulmonary lesion: 32/56 with invasive pulmonary aspergillosis; 8/56 with Candida and 16/56 with bacterial infection. All patients underwent several conventional radiologic controls: 9 cases with invasive pulmonary aspergillosis were also studied with Computed Tomography (CT). After a short pathologic introduction, the conventional radiologic and CT patterns of invasive pulmonary aspergillosis are analyzed, both at onset and over its evolutive phase. The most significant feature for an early conventional radiologic diagnosis is the nodular pattern--single or multiple--; this allowed a correct diagnosis, at onset, of 20/32 (62%) invasive pulmonary aspergillosis cases. CT provided a further diagnostic contribution by showing a peri-nodular halo. Of interest was also the CT demonstration of high-density pleural thickening adjacent to the mycotic lesion, probably due to fungal involvement of the sub-pleural space. The routine chest roentgenogram is the modality of choice; CT may be useful in questionable cases.

Contribution of CT to characterization of focal nodular hyperplasia of the liver.

Our personal series of 20 cases of focal nodular hyperplasia (FNH) of the liver is presented. All lesions were studied with computed tomography (CT), 16 of which with surgical control. Retrospective evaluation of the CT features of the identified FNH, along with those of five hepatocellular adenomas (HCA) and 30 hepatocellular carcinomas (HCC), allowed the definition of specific patterns leading to a correct characterization of FNH in 78% of cases. This greatly reduced the diagnostic errors, with the sole exception of patients with fatty liver in whom nuclear medicine may eventually provide a correct characterization. Fine-needle biopsy is thus only necessary in the dubious cases. A precise diagnostic workup of FNH is necessary, since it may avoid the surgical intervention.

Case report 686. Stress fracture at distal end of femur simulating "periosteal desmoid".

A 13-year-old female presented after repeated trauma with pain of the distal end of the thigh. The findings on plain films, bone scan, and CT were indeterminate. MRI accurately demonstrated a fracture line with bone marrow edema, suggesting the diagnosis of stress fracture. MRI patterns of stress fracture were considered and the importance of establishing the correct diagnosis was emphasized.

Multiplanar study of the mediastinum with electronically reconstructed computed tomography images.

Refinements of computer software permit electronic reconstructions of CT sagittal, parasagittal, and coronal planes, which have markedly improved our understanding of the relations among mediastinal structures, most of which present a vertical course, as well as between focal lesions and adjoining structures.

[Role and limits of diagnostic imaging in the staging of lung cancer]. / Ruolo e limiti dell'imaging diagnostico nella stadiazione del cancro del polmone.

A total of 474 histologically proved Lung Cancers (LC) were evaluated by Conventional Radiology (CR) and Computed Tomography (CT) in order to assess the role of these two diagnostic modalities in the staging of LC. In 196/474 LC it was possible also to refer, for the evaluation of the diagnostic reliability, to the surgical control. The CR features of LC both at stage III (13% of the global series) and at stage I-peripheral T1 (16% of the global series) presented very high positive and negative predictive values (90% and 95%, retrospectively); in these cases it was considered useless to perform CT. The CT grading showed a high negative predictive value in excluding stage III caused respectively by grade T3 (91.5%) and grade N2 (93.5%). As to the staging, the CT assessment of the stage I and II showed a high predictive value (91.5%). On the other hand, the CT assessment of stage III presented an unsatisfactory predictive value (71%), due to the low predictive value in grade T3 (71.5%), poor in grade N2 (57.5%). The increase of the value threshold mediastinal adenopathies from 1 to 2 cm, leads to a great improvement of this predictive value (92%). The CT reliability was matched with the two different surgical "philosophies" (non aggressive or aggressive); surgery was excluded or performed according to the presence of omo-lateral mediastinal adenopathy. A correct advice to perform surgery was achieved in 33.5% (non aggressive "philosophy") and 43.8% (aggressive "philosophy") of cases; surgery was correctly excluded respectively in 49.6% and 45.9%. The resort to mediastinoscopy was advised in 7.8% and 1.3% of the cases respectively. In both "philosophies" the error of under-staging was lower (2.5%), than that of over-staging (6.6%).

[Role of digital intravenous angiography in the study of reversible cerebral ischemia]. / Le rôle de l'angiographie numérique par voie intra-veineuse dans l'étude de l'ischémie cérébrale régressive.

The brachiocephalic, carotid, vertebral and intra-cranial vessels of 497 patients presenting reversible ischemic attacks (R.I.A.) were evaluated with venous digital subtraction angiography (V.D.S.A.). Alterations of the vascular wall were observed in 289/497 (58.2%) patients, of whom 60% presented multiple locations (539 lesions): obstruction (12%), stenosis greater than 50% (29%), stenosis less than 50% (49.8%), kinking (9%), aneurysm (0.2%). An ulcerating arteriosclerotic plaque was observed in 24.6% of the stenoses less than 50% and in 48% of the stenoses greater than 50%. The incidence of vascular lesions was higher (p less than 0.01) in patients with multiple R.I.A. (66.6%) than in those with one isolated R.I.A. (55.6%). Among the patients (207/497) studied also with cerebral computed tomography (C.T.) no relationship could be defined between the extra-cranial vascular lesions demonstrated by V.D.S.A. and the cerebral alterations shown by C.T. Among the patients (64/497) studied also with high frequency ultrasonography (U.S.), the lesion shown by V.D.S.A. could be also demonstrated by U.S. in 84.8% of cases. The personal flow-chart in the study of R.I.A. is described emphasizing the primary role played by V.D.S.A. as well as the complementary role of the other techniques, both non invasive (U.S., C.T.) and invasive (conventional or digital subtraction angiography).

Venous digital subtraction angiography in the evaluation of renovascular hypertension.

The study of renovascular hypertension (R.V.H.) presently requires multiple non invasive examinations in order to select between patients with R.V.H. or other kind of hypertension, before resorting to angiography. The use of venous digital subtraction angiography (V.D.S.A.) may change this diagnostic flow-chart. For this purpose, 100 patients with clinical and laboratory data suspect of R.V.H. underwent V.D.S.A. Compared to angiography, V.D.S.A. showed a 100% sensitivity and 93% specificity. Since the sensitivity and specificity of the non invasive techniques vs. V.D.S.A. in the same series was always lower, V.D.S.A. may be proposed as the first examination in the study of R.V.H. The arterial route for D.S.A. is generally not required for diagnostic purposes.

C. T. criteria of the differential diagnosis in primary retroperitoneal masses.

This personal series of 44 primary retroperitoneal masses (P.R.P.M.) studied by C. T. is analyzed. The reliability of C. T. in the identification (44/44), characterization (43/44) and origin evaluation (41/44) of P.R.P.M. has been absolutely satisfactory. In particular, those criteria of C. T. diagnosis which may be utilized in the evaluation of the origin of upper abdominal masses are thoroughly described. The evaluation of the involvement (non invasive; invasive) of adjacent viscera has been achieved in 22/38 P.R.P.M. verified at operation. The evaluation of tumour resectability has been less reliable due to the high incidence of under-diagnosis (60% in our personal experience). C. T. may be used in addition as an aid to different diagnostic techniques (percutaneous guided needle biopsy) or to therapy (drainage of retroperitoneal abscesses). C. T. is absolutely necessary in the follow-up of P.R.P.M. after surgery, radiotherapy or chemotherapy.