Do Eligibility Criteria for Ductal Carcinoma In Situ (DCIS) Active Surveillance Trials Identify Patients at Low Risk for Upgrade to Invasive Carcinoma?

BACKGROUND: Clinical trials are currently ongoing to determine the safety and efficacy of active surveillance (AS) versus usual care (surgical and radiation treatment) for women with ductal carcinoma in situ (DCIS). This study aimed to determine upgrade rates of DCIS at needle biopsy to invasive carcinoma at surgery among women who meet the eligibility criteria for AS trials. METHODS: A retrospective review was performed of consecutive women at an academic medical center with a diagnosis of DCIS at needle biopsy from 2007 to 2016. Medical records were reviewed for mode of presentation, imaging findings, biopsy pathology results, and surgical outcomes. Each patient with DCIS was evaluated for AS trial eligibility based on published criteria for the COMET, LORD, and LORIS trials. RESULTS: During a 10-year period, DCIS was diagnosed in 858 women (mean age 58 years; range 28-89 years). Of the 858 women, 498 (58%) were eligible for the COMET trial, 101 (11.8%) for the LORD trial, and 343 (40%) for the LORIS trial. The rates of upgrade to invasive carcinoma were 12% (60/498) for the COMET trial, 5% (5/101) for the LORD trial, and 11.1% (38/343) for the LORIS trial. The invasive carcinomas ranged from 0.2 to 20 mm, and all were node-negative. CONCLUSIONS: Women who meet the eligibility criteria for DCIS AS trials remain at risk for occult invasive carcinoma at presentation, with upgrade rates ranging from 5 to 12%. These findings suggest that more precise criteria are needed to ensure that women with invasive carcinoma are excluded from AS trials.

Digital 2D versus Tomosynthesis Screening Mammography among Women Aged 65 and Older in the United States.

Background Although breast cancer incidence and mortality rates increase with advancing age, there are limited data on the benefits and risks of screening mammography in older women and on the performance of two-dimensional digital mammography (DM) and digital breast tomosynthesis (DBT) in older women. Purpose To compare performance metrics of DM and DBT among women aged 65 years and older. Materials and Methods For this retrospective study, consecutive screening mammograms in patients aged 65 years and older from March 2008 to February 2011 (DM group) and from January 2013 to December 2015 (DBT group) were reviewed. Cancer detection rate, abnormal interpretation rate, positive predictive values, sensitivity, and specificity were calculated. Multivariable logistic regression models were fit to compare performance metrics in the DM versus DBT groups. Results The DM group had 15 019 women (mean age ± standard deviation, 72.7 years ± 6.3), and the DBT group had 20 646 women (mean age, 72.1 years ± 5.9). After adjusting for multiple variables, there was no difference in cancer detection rate between the DM and DBT groups (6.9 vs 8.2 per 1000 examinations; adjusted odds ratio [AOR], 1.13; P = .23). Compared with the DM group, the DBT group had a lower abnormal interpretation rate (5.7% vs 5.8%; AOR, 0.88; P < .001), higher positive predictive value 1 (14.5% vs 11.9%; AOR, 1.26; P = .03), and higher specificity (95.1% vs 94.8%; AOR, 1.18; P < .001). The DBT group had a higher proportion of invasive cancers relative to in situ cancers (81.1% vs 74.4%; P = .06) and fewer node-positive cancers (10.2% vs 16.6%; P = .054) than did the DM group. Conclusion In women aged 65 years and older, integration of digital breast tomosynthesis led to improved performance metrics, with a lower abnormal interpretation rate, higher positive predictive value 1, and higher specificity. © RSNA, 2019 See also the editorial by Philpotts and Durand in this issue.

Canceled MRI-guided Breast Biopsies Due to Nonvisualization: Follow-up and Outcomes.

RATIONALE AND OBJECTIVE: The objective of this study was to evaluate breast lesion outcomes in patients after canceled MRI-guided breast biopsy due to lesion nonvisualization. MATERIALS AND METHODS: Electronic medical records (January 2007-December 2014) were searched for patients with canceled magnetic resonance imaging (MRI)-guided breast biopsies due to lesion nonvisualization. A total of 1403 MRI-detected lesions were scheduled for MRI-guided biopsy and 89 were canceled because of nonvisualization. Imaging studies and medical records were reviewed for patient demographics, lesion characteristics, and subsequent malignancy. Patients without adequate MRI follow-up imaging were excluded. Statistical analysis was employed to determine if patient demographics or lesion characteristics were predictive of lesion resolution or lesion biopsy after subsequent follow-up. RESULTS: Eighty-nine (6.3% [89/1403]; 95% confidence interval, 5.2%-7.7%) biopsies in 89 women were canceled because of nonvisualization. Follow-up MRIs greater than 5.5 months were available for 60.7% (54/89) of women. In 74.1% (40/54) of these patients, the lesions completely resolved on follow-up. In 25.9% (14/54) of the patients, the lesion persisted on follow-up; 42.9% (6/14) of these patients underwent biopsy. One case (1.9% [1/54]) yielded ductal carcinoma in situ with microinvasion at the 6-month follow-up. No patient demographics or lesion features were associated with lesion resolution or lesion biopsy. CONCLUSIONS: The majority of canceled MRI-guided biopsy lesions resolved on later follow-up; however, because of the small possibility of a missed malignancy, follow-up MRI imaging at 6 months is recommended.

Hypovascular hepatic nodules at gadoxetic acid-enhanced MRI: whole-lesion hepatobiliary phase histogram metrics for prediction of progression to arterial-enhancing hepatocellular carcinoma.

PURPOSE: To explore whole-lesion histogram analysis of the hepatobiliary phase (HBP) defect in indeterminate hypovascular liver lesions for predicting progression to arterial-enhancing hepatocellular carcinoma (HCC). METHODS: Twenty patients undergoing gadoxetic acid-enhanced MRI for HCC screening with 12° and 25° flip angle (FA) HBP acquisitions demonstrating an indeterminate lesion showing HBP hypointensity but no arterial enhancement were included. Volumes-of-interest were placed on HBP defects, from which histogram metrics were obtained. Associations between these metrics and progression to arterial-enhancing HCC on follow-up imaging were investigated. Lesions were also assessed for the presence of a signal abnormality on conventional sequences. RESULTS: 40% of lesions progressed to arterial-enhancing HCC; 60% were stable at ≥6 months follow-up. Neither T2-hyperintensity increased diffusion signal nor portal/equilibrium phase washout was different between progressing and nonprogressing lesions (p = 1.0). Among direct signal intensity-based measures (overall mean; mean of bottom 10th, 10-25th, and 25-50th percentiles), area-under-the-curve (AUC) for prediction of progression to arterial-enhancing HCC was consistently higher at 25° (range 0.619-0.657) than at 12° (range 0.512-0.548). However, at both FAs, the four measures with highest AUC were measures related to lesion texture and heterogeneity [standard deviation (SD), coefficient of variation (CV), skewness, and entropy], having AUC of 0.655-0.750 at 12° and 0.686-0.800 at 25. The metric with highest AUC at 12° was SD (AUC = 0.750) and at 25° was CV (AUC = 0.800). CONCLUSION: Whole-lesion histogram HBP measures of indeterminate hypovascular liver lesions may help predict progression to arterial-enhancing HCC by reflecting greater lesion heterogeneity, particularly at higher FA. Larger studies are therefore warranted.

Most Common Publication Types in Radiology Journals:: What is the Level of Evidence?

RATIONALE AND OBJECTIVES: This study aimed to assess the most common publication types in radiology journals, as well as temporal trends and association with citation frequency. MATERIALS AND METHODS: PubMed was searched to extract all published articles having the following "Publication Type" indices: "validation studies," "meta-analysis," "clinical trial," "comparative study," "evaluation study," "guideline," "multicenter study," "randomized study," "review," "editorial," "case report," and "technical report." The percentage of articles within each category published within clinical radiology journals was computed. Normalized percentages for each category were also computed on an annual basis. Citation counts within a 2-year window following publication were obtained using Web of Science. Overall trends were assessed. RESULTS: Publication types with the highest fraction in radiology journals were technical reports, evaluation studies, and case reports (4.8% to 5.8%). Publication types with the lowest fraction in radiology journals were randomized trials, multicenter studies, and meta-analyses (0.8% to 1.5%). Case reports showed a significant decrease since 1999, with accelerating decline since 2007 (P = 0.002). Publication types with highest citation counts were meta-analyses, guidelines, and multicenter studies (8.1 ± 10.7 to 12.9 ± 5.1). Publication types with lowest citation counts were case reports, editorials, and technical reports (1.4 ± 2.4 to 2.9 ± 4.3). The representation in radiology journals and citation frequency of the publication types showed weak inverse correlation (r = -0.372). CONCLUSIONS: Radiology journals have historically had relatively greater representation of less frequently cited publication types. Various strategies, including methodological training, multidisciplinary collaboration, national support networks, as well as encouragement of higher level of evidence by funding agencies and radiology journals themselves, are warranted to improve the impact of radiological research.

Frequency of carcinoma at secondary imaging-guided percutaneous breast biopsy performed after a high-risk pathologic result at primary biopsy.

OBJECTIVE: The purpose of this study was to determine the frequency of carcinoma identified with secondary presurgical imaging-guided percutaneous biopsy for patients with high-risk pathologic findings at primary percutaneous biopsy. MATERIALS AND METHODS: A retrospective computerized search of our breast imaging database from January 1, 2005, to October 1, 2010, was conducted to identify the cases of patients with high-risk pathologic findings at primary biopsy who underwent at least one secondary biopsy within 9 months and underwent surgical excision. Lesion type, location, biopsy guidance, device, number of samples, and histopathologic findings were recorded. The pathologic findings at surgical excision were compared with the percutaneous biopsy results. RESULTS: One hundred twenty-three patients underwent 158 secondary biopsies. On average, 1.3 additional biopsies were performed per patient. Among the 158 secondary biopsies, 105 (66.4%) had benign, 48 (30.4%) had high-risk, and five (3.2%) had malignant histopathologic findings. No malignant tumors were identified at secondary percutaneous biopsies in cases in which the same lesion type was biopsied in the same quadrant. Use of secondary percutaneous biopsy led to detection of nine malignant tumors in 7.3% of patients-with percutaneous biopsy in four (3.2%) patients and at surgical excision in five (4.1%) patients. CONCLUSION: After initial imaging-guided percutaneous biopsy reveals high-risk pathologic findings, identification of additional high-risk lesions at secondary percutaneous biopsy is common, and detection of malignancy is relatively infrequent. However, because the secondarily identified high-risk lesions are sometimes upstaged to cancer at surgical excision, additional imaging-directed biopsy has potential benefit for patients with known highrisk lesions and multiple synchronous findings.

(99m)Tc MIBI SPECT findings in parathyromatosis--a rare entity causing recurrent hyperparathyroidism.

Parathyromatosis is a rare clinical condition resulting in recurrent hyperparathyroidism that often poses challenges in its diagnosis and complete surgical cure. We report the (99m)Tc MIBI SPECT findings in a patient with recurrent hyperparathyroidism requiring multiple parathyroid explorations. MIBI SPECT helped localize the areas of these "recurrent parathyroid lesions" that were often found outside of the expected locations within the neck.

Left ventricular myocardium metastasis in a patient with primary renal cell carcinoma detected by 18F-FDG PET/CT.

Cardiac metastases from renal cell carcinoma are rare but should be recognized when present. We report PET/CT findings in a patient with headache and diplopia and cerebral metastasis from an unknown primary of clear cell adenocarcinoma origin. PET/CT revealed uptake with a left renal cell carcinoma, and revealed multiple metastatic lesions, including an FDG-avid metastasis within the left ventricular myocardium.

Concise review: Stem cells in the corneal stroma.

The cornea is a tough transparent tissue admitting and focusing light in the eye. More than 90% of the cornea is stroma, a highly organized, transparent connective tissue maintained by keratocytes, quiescent mesenchymal cells of neural crest origin. A small population of cells in the mammalian stroma displays properties of mesenchymal stem cells, including clonal growth, multipotent differentiation, and expression of an array of stem cell-specific markers. Unlike keratocytes, the corneal stromal stem cells (CSSCs) undergo extensive expansion in vitro without loss of the ability to adopt a keratocyte phenotype. Several lines of evidence suggest CSSCs to be of neural crest lineage and not from bone marrow. CSSCs are localized in the anterior peripheral (limbal) stroma near to stem cells of the corneal epithelium. CSSCs may function to support potency of the epithelial stem cells in their unique limbal niche. On the other hand, little information is available documenting a role for CSSCs in vivo in stromal wound healing or regeneration. In vitro CSSCs reproduce the highly organized connective tissue of the stroma, demonstrating a potential use of these cells in tissue bioengineering. Direct introduction of CSSCs into the corneal stroma generated transparent tissue in a mouse model of corneal opacity. Human CSSCs injected into mice corneas did not elicit immune rejection over an extended period of time. The CSSCs therefore appear offer an opportunity to develop cell- and tissue-based therapies for irreversible corneal blindness, conditions affecting more than 10 million individuals worldwide.

Mammographic appearance of recurrent breast cancer after breast conservation therapy.

RATIONALE AND OBJECTIVES: To compare the mammographic appearance of recurrent breast cancer to the primary tumor in patients treated with breast conservation therapy. MATERIALS AND METHODS: The charts of women with American Joint Committee on Cancer Stage I or II breast cancer who underwent breast conservation therapy between 1977 and 2001 at our institution were reviewed. A total of 132 patients were diagnosed with local recurrence. RESULTS: The mammographic appearance of the local recurrence often varied from the appearance of the original breast cancer. This was especially true for women who had mammographically occult primary breast cancer. In these women, the recurrence was detected mammographically 76.9% of the time. CONCLUSIONS: Given the variable appearance of the local recurrence after breast conservation therapy, any suspicious finding needs to be carefully evaluated regardless of the mammographic appearance of the original tumor.