Imaging of breast cancer-beyond the basics.

Imaging of breast cancer is the backbone of breast cancer screening, diagnosis, preoperative/treatment assessment and follow-up. The main modalities are mammography, ultrasound and magnetic resonance imaging, each with its own advantages and disadvantages. New emerging technologies have also enabled each modality to improve on their weaknesses. Imaging-guided biopsies have allowed for accurate diagnosis of breast cancer, with low complication rates. The purpose of this article is to review the common modalities for breast cancer imaging in current practice with emphasis on the strengths and potential weaknesses, discuss the selection of the best imaging modality for the specific clinical question or patient population, and explore new technologies / future directions of breast cancer imaging.

A retrospective study evaluating outcomes of surgical excision versus radiologic follow-up of benign breast papillomas without atypia.

BACKGROUND: There is uncertainty whether benign breast papillomas without atypia (BP) can be followed by imaging or require surgical resection. METHODS: A single-center, retrospective cohort study of patients diagnosed with BP (2011-2021) to determine the upgrade rate on surgery, and factors associated with surgical intervention and upgrade. RESULTS: 139 BPs were included. 27(19.4%) had upfront surgery; 112(80.6%) had imaging follow-up. The upfront surgery group had higher rates of pre-excision nipple inversion (n = 2(8.3%)vs.n = 0(0%),p = 0.003). In the imaging group, the median follow-up was 3.8years, and 9 had subsequent resection. Upgrade rate was 5.8%(8/139). Of all BPs undergoing surgery (n = 36), patients ≥60years (75.0%vs.25.0%,p = 0.049) or with family history of breast cancer (87.5%vs.48.1%,p = 0.048) were more likely to have upgrade. CONCLUSIONS: Despite a low number of events, this study supports radiologic follow-up of BP except in patients ≥60 years or with family history of breast cancer, adding to the growing body of evidence supporting watchful waiting of BPs.

North American survey and systematic review on caudal Septoplasty.

BACKGROUND: Surgical correction of caudal septal deviation is a technically challenging step of functional rhinoplasty. Multiple surgical techniques have been described in the literature but comparing the efficacy of each in relieving obstruction presents a challenge. Outcome measures are necessary to adequately compare techniques. This study aims to describe the current caudal septoplasty techniques of Otolaryngologists and Facial plastic and reconstructive surgeons (FPRS), as well as their use of outcome measures, and to compare these practices with surgical trends described in the literature. METHODS: An online survey was sent to three Otolaryngology and FPRS associations in Canada and the United States. A systematic review was conducted on SCOPUS and PubMed to classify the caudal septoplasty techniques described in the literature and the outcome measurement tools used. RESULTS: Our survey identified that caudal septoplasty is more commonly performed by surgeons with an FPRS training background. The most common techniques were the swinging door technique (69.5%), extracorporeal septoplasy (46.7%), cartilage scoring (45.3%), and splinting with bone (25.4%). Despite using a vast array of surgical techniques, North American physicians rarely rely on standardized outcome assessment tools. Patient reported outcome measures (PROMs) are used almost twice as frequently in the literature as they are by surgeons in their clinical practice. CONCLUSION: We recommend that future studies of caudal septoplasty include an assessment of both form and function using a validated PROM such as the Standardized Cosmesis and Health Nasal Outcomes Survey.

Value of Shear Wave Elastography for the Differentiation of Benign and Malignant Microcalcifications of the Breast.

OBJECTIVE. The objective of our study was to evaluate whether shear wave elastography (SWE) can differentiate benign from malignant microcalcifications of the breast when detected on ultrasound (US). SUBJECTS AND METHODS. Between February 9, and June 23, 2016, 74 patients with mammographically detected suspicious microcalcifications underwent breast US. When microcalcifications were identified on US, stiffness was assessed using SWE. Biopsy was subsequently performed under US guidance using a 10-gauge vacuum-assisted needle. Qualitative and quantitative elastography results were compared between benign and malignant calcifications as well as between pure ductal carcinoma in situ and lesions with invasive components using the Mann-Whitney U test. ROC curves were created to assess the performance of SWE in detecting malignancy and invasive components. RESULTS. Twenty-nine groups of microcalcifications in 29 patients were identified on US. At pathology, 16 groups were benign and 13 were malignant. Stiffness of malignant calcifications was significantly higher than that of the benign ones (p = 0.0004). The AUC, sensitivity, specificity, negative predictive value, positive predictive value, and accuracy of SWE for the diagnosis of malignancy were 0.89, 69%, 100%, 80%, 100%, and 86%, respectively, and for detection of an invasive component were 0.93, 75%, 100%, 75%, 100%, and 85%. CONCLUSION. SWE has the potential to differentiate benign from malignant micro-calcifications of the breast when detected on US with high specificity.

Can strain elastography improve the characterization of breast lesions identified during second-look MRI-directed sonographic examination?

PURPOSE: To evaluate strain elastography as a complementary tool for characterization of lesions identified during second-look MRI-directed sonographic examination. METHODS: We reviewed 83 breast lesions evaluated with MRI, secondlook ultrasound (US) and strain elastography in 75 consecutive patients (median age, 56 years). US-guided biopsies were performed in all cases. RESULTS: After histopathological examination, 44 lesions were benign, 38 were malignant and 1 was high-risk. At MRI, the mean size of the lesions was 12 mm. Forty lesions (48.2%) appeared as masses, 30 (36.1%) as "non-masses" and 13 (15.7%) as "foci." At second-look US examination, 56 (67.5%) appeared as masses (mean size, 7 mm) and 27 (32.5%) as non-masses (mean size, 14 mm). At strain elastography, among the 39 malignant/high risk lesions, 5 (12.8%) had a score of 4 or 5, whereas 16 (41%) had a score of 1 and 2 (false negative). Among the 44 benign lesions, 36 (82%) had a score of 1 or 2, whereas none had a score of 5. Sensitivity and specificity of strain elastography in the diagnosis of breast cancer were 58% and 81%, respectively. CONCLUSION: The addition of strain elastography offers no benefit in the characterization of lesions identified on second-look US after breast MRI.(E1, 3).

Retroareolar Carcinomas in Breast Ultrasound: Pearls and Pitfalls.

Breast Ultrasound (US) is an important tool for both screening and diagnostic examinations. Although breast US has benefitted from significant recent technical improvements, its use for the retroareolar region is known to be more challenging than for other locations. The retroareolar location was defined by Giess et al. in 1998 as the region where any lesion is situated at less than two cm from the nipple and/or involves the nipple-areolar complex on mammogram. Understanding of the complex anatomy and physiology of the nipple-areolar region is important to avoid misinterpretation and misdiagnosis. The ability for the breast imager to manage difficulties related to the retroareolar area is paramount by adjusting settings (compounding, frequency, Doppler) and utilizing specific manoeuvers. Cases illustrating difficulties encountered in diagnosis of retroareolar carcinomas are presented.

Cervical spine motion during tracheal intubation with manual in-line stabilization: direct laryngoscopy versus GlideScope videolaryngoscopy.

BACKGROUND: The optimal tracheal intubation technique for patients with potential cervical (C) spine injury remains controversial. Using continuous cinefluoroscopy, we conducted a prospective study comparing C-spine movement during intubation using direct laryngoscopy (DL) or GlideScope videolaryngoscopy (GVL), with uninterrupted manual in-line stabilization of the head by an assistant. METHODS: Twenty patients without C-spine pathology were studied. After induction of general anesthesia with neuromuscular blockade, both DL and GVL were performed on every patient in random order. Cinefluoroscopic images of C-spine movement during GVL and DL were acquired and divided into four stages: a baseline image before airway manipulation, glottic visualization, insertion of the endotracheal tube into the glottis, and tracheal intubation. Peak segmental motion from the occiput to C5 was measured offline for each patient and each stage, averages were calculated, and movements induced by each instrument were compared using a two-way ANOVA. Also studied were the proportion of patients with occiput-C1 rotation exceeding 10, 15, or 20 degrees, and the quality of glottic visualization. RESULTS: No significant difference was found between DL and GVL regarding average segmental spine movement at any level (P values between 0.22 and 0.70). During both techniques, motion was mainly an extension concentrated in the rostral C-spine and occurred predominantly during glottic visualization. The proportion of patients with occiput-C1 extension of more than 10, 15, or 20 degrees was not significantly different. Glottic visualization was significantly better with GVL compared with DL. CONCLUSION: During intubation under general anesthesia with neuromuscular blockade and manual in-line stabilization, the use of GVL produced better glottic visualization, but did not significantly decrease movement of the nonpathologic C-spine when compared with DL.