Screening for breast cancer in 2018-what should we be doing today?

Although screening mammography has delivered many benefits since its introduction in Canada in 1988, questions about perceived harms warrant an up-to-date review. To help oncologists and physicians provide optimal patient recommendations, the literature was reviewed to find the latest guidelines for screening mammography, including benefits and perceived harms of overdiagnosis, false positives, false negatives, and technologic advances. For women 40-74 years of age who actually participate in screening every 1-2 years, breast cancer mortality is reduced by 40%. With appropriate corrections, overdiagnosis accounts for 10% or fewer breast cancers. False positives occur in about 10% of screened women, 80% of which are resolved with additional imaging, and 10%, with breast biopsy. An important limitation of screening is the false negatives (15%-20%). The technologic advances of digital breast tomosynthesis, breast ultrasonography, and magnetic resonance imaging counter the false negatives of screening mammography, particularly in women with dense breast tissue.

Solitary fibrous tumour of pleura: CT differentiation of benign and malignant types.

AIM: To analyse and compare the computed tomography (CT) features of benign and malignant types of histopathologically proven cases of solitary fibrous tumours of pleura (SFTP). MATERIALS AND METHODS: Retrospective analysis of preoperative CT images of 28 cases of histopathologically proven and classified SFTP from three participating institutions was performed. Patient demographics and lesion characteristics including size, borders, presence of a pedicle, extension into the fissure, attenuation, enhancement, pleural effusion, and calcifications were recorded and correlated with the final histopathological diagnosis. Type and results of preoperative biopsy were also recorded. Follow-up imaging and the clinical charts were reviewed to identify recurrence. RESULTS: Out of 28 cases (15 women and 13 men), 18 were proven to be benign and 10 were malignant. The mean age of patients was 58.1±15.9 and 66.5±11.8 years (p=0.1564) for benign and malignant tumours, respectively. The median (interquartile range) diameter was 6.05 (3.2-10.9) cm for benign and 15.7 (7.1-17.5) cm for malignant type tumours (p=0.0291). Tumours had lobulate borders in 28% (5/18) of benign cases and in 80% (8/10) of malignant cases (p=0.0163). Extension into adjacent fissure was seen in 22% (4/18) of benign lesions and 40% (4/10) of malignant lesions (p=0.40). A pedicle was present in 17% (3/18) of benign and 10% (1/10) of malignant lesions (p=1). Heterogeneous attenuation was present in 61% (11/18) of benign and 90% (9/10) of malignant lesions (p=0.19). Calcification was present in 17% (3/18) of benign tumours and in 70% (7/10) of malignant tumours (p=0.0113). Pleural effusion was present in 6% (1/18) of benign and 40% (4/10) of malignant lesions (p=0.04). Only 1/13 preoperative fine-needle aspirates yielded diagnosis of SFTP. Preoperative diagnosis of SFTP was made in all cases (11/11) with core biopsies. At follow-up (1-10 years, mean 3 years), local recurrence occurred in 3/6 (50%) patients with malignant SFTP and in none of the 10 patients with benign SFTP. CONCLUSION: No definite imaging feature to differentiate benign from malignant SFTP was found. Large size, lobulate borders, presence of calcification, and ipsilateral pleural effusion were the only CT features predictive of malignancy. In suspected cases, core biopsies should be performed rather than fine-needle aspiration.

Underestimation of malignancy in biopsy-proven cases of stromal fibrosis.

OBJECTIVE: To determine the rate of underestimation of malignancy in patients with biopsy-proven stromal fibrosis. METHODS: Following institutional review board approval, we retrospectively reviewed the charts of patients with biopsy-proven stromal fibrosis who underwent percutaneous breast biopsy in the 5-year period between 1 January 2005 and 31 December 2009. The medical records and the histopathology in patients who underwent repeat biopsy and/or surgical excision at the site of stromal fibrosis within 2 years were reviewed. Interval stability for up to 2 years was documented in patients who did not undergo additional biopsy or surgical excision. An upgrade was defined as any patient with biopsy-proven stromal fibrosis or fibroadenoma with evidence of malignancy at the site of biopsy within 2 years. RESULTS: 365 cases of stromal fibrosis were identified, of which 25 (7%) were upgraded to in situ or invasive malignancy on repeat biopsy or surgical excision. 7 were upgraded to ductal carcinoma in situ and 18 were upgraded to invasive cancer. Of the upgraded cases, 8 out of 24 (32%) were considered concordant with a benign diagnosis. The false-negative rate, that is, cases of stromal fibrosis concordant with benignity, but with subsequent upgrade, comprised 2% of all cases. CONCLUSION: In biopsy-proven cases of stromal fibrosis, there is a 7% upgrade to malignancy. We recommend that all instances of stromal fibrosis with radiology-pathology discordance undergo repeat biopsy or surgical excision. Cases that demonstrate radiology-pathology concordance can be safely categorized as a Breast Imaging Reporting and Data System 3 (BI-RADS® 3) lesion with a 6-month follow-up, owing to a false-negative rate for missed cancer of 2%. ADVANCES IN KNOWLEDGE: We now recommend that concordant cases of stromal fibrosis be categorized as BI-RADS 3 with a short-term follow-up, as this results in a missed cancer rate of 2%.

The radiological spectrum of pulmonary lymphoproliferative disease.

Pulmonary lymphoproliferative disorders (LPD) are characterised by abnormal proliferation of indigenous cell lines or infiltration of lung parenchyma by lymphoid cells. They encompass a wide spectrum of focal or diffuse abnormalities, which may be classified as reactive or neoplastic on the basis of cellular morphology and clonality. The spectrum of reactive disorders results primarily from antigenic stimulation of bronchial mucosa-associated lymphoid tissue (MALT) and comprises three main entities: follicular bronchiolitis, lymphoid interstitial pneumonia and (more rarely) nodular lymphoid hyperplasia. Primary parenchymal neoplasms are most commonly extranodal marginal zone lymphomas of MALT origin (MALT lymphomas), followed by diffuse large B-cell lymphomas (DLBCLs) and lymphomatoid granulomatosis (LYG). Secondary lymphomatous parenchymal neoplasms (both Hodgkin and non-Hodgkin lymphomas) are far more prevalent than primary neoplasms. Acquired immune deficiency syndrome (AIDS)-related lymphoma (ARL) and post-transplantation lymphoproliferative disorder (PTLD) may also primarily affect the lung parenchyma. Modern advances in treatments for AIDS and transplant medicine are associated with an increase in the incidence of LPD and have heightened the need to understand the range of imaging appearance of these diseases. The multidetector CT (MDCT) findings of LPD are heterogeneous, thereby reflecting the wide spectrum of clinical manifestations of these entities. Understanding the spectrum of LPD and the various imaging manifestations is crucial because the radiologist is often the first one to suggest the diagnosis and has a pivotal role in differentiating these diseases. The current concepts of LPD are discussed together with a demonstration of the breadth of MDCT patterns within this disease spectrum.

Systemic arterial air embolism after percutaneous lung biopsy.

Systemic arterial air embolism is a rarely encountered but much feared complication of percutaneous lung biopsy. We present a comprehensive review of iatrogenic air embolism post-lung biopsy, a complication that is often suboptimally managed. This review was inspired by our own institutional experience and we use this to demonstrate that excellent outcomes from this complication can be seen with prompt treatment using hyperbaric oxygen chamber therapy, after initial patient stabilization has been achieved. Pathophysiology, clinical features, and risk factors are reviewed and misconceptions regards venous versus arterial air embolism are examined. An algorithm is provided for radiologists to ensure suspected patients are appropriately managed with more favourable outcomes.

Breast MRI in the evaluation of locally recurrent or new breast cancer in the postoperative patient: correlation of morphology and enhancement features with the BI-RADS category.

BACKGROUND: While breast magnetic resonance imaging (MRI) is a highly sensitive test for detecting breast carcinoma, its specificity is lower, and several methods have been described on how to optimize specificity. PURPOSE: To compare the specificity and sensitivity of the BI-RADS category with the Fischer score in breast MRI for diagnosing cancer in women previously treated for breast cancer. MATERIAL AND METHODS: Women referred for evaluation of possible local recurrence or new breast cancer underwent breast MRI examination. Morphologic and kinetic enhancement characteristics were evaluated. BI-RADS category and Fischer score were assigned for each enhancing lesion and compared using a chi-square test. Sensitivity, specificity,and positive predictive values for 27 morphologic and enhancement characteristics were calculated. Pathologic diagnosis was obtained in all patients with enhancing lesions who had ultrasound or mammographic correlation. In those without correlate, 6-, 12-, and 24-month follow-up breast MRIs were obtained. Interobserver kappa correlation was determined for each variable studied. RESULTS: 34 benign and 32 malignant lesions were identified in 26 of 30 patients. BIRADS category yielded a specificity of 77.1% and a sensitivity of 81.8%. Fischer score had a lower specificity and sensitivity (62.9% and 72.7%, respectively) (P<0.0001). Of the 27 variables studied, >100% enhancement was more sensitive than BI-RADS for malignant lesions. Specificity was highest for rim enhancement (97.1%), but sensitivity was low (24.2%). Interobserver kappa correlation was good for all 27 characteristics(k=0.84), and highest for BI-RADS assessment (k=0.91). CONCLUSION: BI-RADS category in breast MRI had the highest combination of specificity and sensitivity, and the highest interobserver correlation. Fischer score and other morphologic and enhancement features lack sensitivity or specificity and do not have high positive predictive values when analyzed as single independent variables.

In situ central pulmonary artery thrombosis in primary pulmonary hypertension.

A rare case of extensive in situ central pulmonary artery thrombosis in primary pulmonary hypertension (PPH) is presented. The differentiation from chronic thromboembolic pulmonary arterial hypertension (CTEPH) is of paramount importance because of different therapeutic strategies. In this case, the presence of mural thrombus in the central pulmonary arteries on computed tomography made the distinction difficult. However, the possibility of in situ thrombosis was suggested on the basis of absence of other findings of CTEPH (abrupt narrowing/truncation of segmental arteries, variation in size of segmental vessels, arterial webs, mosaic attenuation, pulmonary infarcts, and dilated bronchial arteries), and this was confirmed on final pathology.

Computed tomography demonstration of systemic arterial supply to lung without sequestration.

We present two cases of systemic arterial supply to lung without sequestration diagnosed confidently based on imaging findings on computed tomography scan, thereby obviating the need for invasive diagnostic procedures.

Oropharyngeal airway diameter during sedation in children with and without developmental delay.

STUDY OBJECTIVE: To determine whether children with developmental delay would have closer apposition of upper airway tissues during sedation, perhaps because of poor coordination of upper airway musculature. DESIGN: Case-control and retrospective chart review. SETTING: Tertiary-care pediatric teaching hospital. PATIENTS: 40 children 3 to 6 years of age, with and without a diagnosis of developmental delay. MEASUREMENTS: Subjects received only pentobarbital sedation by a protocol. Magnetic resonance imaging (MRI) scans of the head were reviewed, and transverse airway diameters at the soft palate and tongue were determined from midline sagittal images. MAIN RESULTS: Age, weight, sedative dose, MRI window level, and window width were not different between patients with and without developmental delay. We found the airway diameter at the level of the soft palate was decreased 40% in children with developmental delay compared with those children without delay, 3 mm (1.4, 5.5 interquartile range) versus 5 mm (3, 8); p = 0.035, power 76%. CONCLUSIONS: The anteroposterior oropharyngeal airway diameter was smaller in children with developmental delay than in those without developmental delay, in static MRI images. It is possible that children with developmental delay are at higher risk for airway obstruction during sedation.

Systemic sclerosis: using high-resolution CT to detect lung disease in children.

OBJECTIVE: The purpose of this study was to determine the prevalence of interstitial lung disease and the severity of disease in children with systemic sclerosis using high-resolution CT (HRCT). SUBJECTS AND METHODS: Eleven children (mean age, 11 years) with scleroderma underwent HRCT, chest radiography, and pulmonary function testing. Eight of these 11 patients also underwent follow-up HRCT. HRCT studies were assessed by two observers for ground-glass attenuation, honeycombing, and other abnormalities. Profusion scores for ground-glass attenuation and honeycombing were determined by multiplying severity of disease by the percentage of lung involvement. RESULTS: Chest radiographs predicted interstitial lung disease in only two patients, whereas HRCT showed interstitial lung disease in eight patients (p = .05). On HRCT, ground-glass attenuation was found in eight patients (73%), honeycombing in five patients (45%), linear opacities in six patients (55%), and subpleural micronodules in seven patients (64%). By the end of the study, 10 patients (91%) had evidence of interstitial lung disease on HRCT. Overall, profusion scores for these 10 patients showed four patients with mild, one with moderate, and five with severe disease. Also, HRCT revealed worsening disease in three of eight patients. We found no correlation between duration of scleroderma and severity of interstitial lung disease (p > .02). Seven patients with evidence of lung disease on HRCT had abnormal results on pulmonary function tests; patients with the highest scores for ground-glass attenuation had the most abnormal results on pulmonary function tests (p < .01). CONCLUSION: HRCT shows significant pulmonary disease in children with systemic sclerosis, revealing abnormalities in 91% of our patients. Pulmonary disease should be suspected in children with scleroderma, even if the chest radiograph has normal findings.

High-resolution CT of pediatric lung disease: imaging findings.

The HRCT findings of diseases of the pulmonary parenchyma and airways in children are often similar to those seen in adults. However, some conditions, particularly IPF, pulmonary fibrosis associated with scleroderma, and Langerhans histiocytosis, may have different presentations and a more rapid progression in children than in adults. HRCT may be helpful for assessing patients with suspected diseases of the pulmonary parenchyma or airways, particularly when radiographic findings are normal or nonspecific.

T1 lung cancer: prevalence of mediastinal nodal metastases and diagnostic accuracy of CT.

To determine the prevalence of mediastinal lymph node metastases in T1 non-small cell lung cancer and assess the sensitivity and specificity of computed tomography (CT) in detection of such metastases, the CT scans and surgical findings in 104 patients with T1 lesions were reviewed. Nodes longer than 10 mm on the short or long axis were considered abnormal. All patients underwent thorough mediastinal lymph node dissection at mediastinoscopy or thoracotomy. A total of 362 lymph nodes were sampled. Nodal metastases were present in 22 patients (21%). The sensitivity of CT for metastases to individual nodal stations was 41% for nodes measured on the short axis and 55% for those measured on the long axis. The specificity was 93% and 86%, respectively. When the adjacent nodal stations were included in the analysis, the sensitivity of CT was 59% for nodes measured on the short axis and 77% for those measured on the long axis; the specificity was 91% and 73%, respectively. T1 lung cancer has a higher prevalence of lymph node metastasis than previously reported, and CT is recommended in the preoperative staging of this disease.