MRI as a complementary tool for the assessment of suspicious mammographic calcifications: Does it have a role?

INTRODUCTION: Mammography remains the standard imaging modality for the identification and characterization of breast calcifications. However, its low specificity results in high biopsy rates in cases of suspicious calcifications. OBJECTIVES: To evaluate the diagnostic performance of MRI as an additional tool in the assessment of suspicious mammographic calcifications and to identify the enhancement patterns most related to malignancy. METHODS: An observational, prospective, cross-sectional, bi-centre study was conducted including consecutive patients with suspicious calcification groups on mammography (BI-RADS® 4 and 5). Anatomopathological results obtained from biopsies were considered the reference standard, and the patients were followed up for at least two years. MRI examinations were interpreted by two radiologists in consensus. The chi-square test was used to evaluate the correlation between MRI features and histological results. The overall diagnostic performance of MRI for malignancy was calculated. RESULTS: 162 female patients were included (mean age, 53 years; range 34-82 years), with 163 mammographic lesions, of which 77 (47.2%) were benign, 64 (39.3%) malignant, and 22 (13.5%) precursor lesions on histopathology. Malignant lesions demonstrated a significantly higher presence of enhancement (56/64; 87.5%) than benign lesions (17/77; 22.1%) (p < 0.001). Non-mass enhancement (NME) was the morphology most related to malignant lesions (38/56; 67.9%). The accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of MRI for malignancy were 81.5%, 87.5%, 77.8%, 71.8%, and 90.5%, respectively. CONCLUSION: MRI performed as an adjunct tool allows to increase imaging specificity for malignancy in suspicious calcifications, which may contribute to reduce the need for biopsy.

Computed tomography angiography in patients with active gastrointestinal bleeding / Angiotomografia abdominal no paciente com sangramento gastrintestinal ativo

Abstract Gastrointestinal bleeding represents a common medical emergency, with considerable morbidity and mortality rates, and a prompt diagnosis is essential for a better prognosis. In such a context, endoscopy is the main diagnostic tool; however, in cases where the gastrointestinal hemorrhage is massive, the exact bleeding site might go undetected. In addition, a trained professional is not always present to perform the procedure. In an emergency setting, optical colonoscopy presents limitations connected with the absence of bowel preparation, so most of the small bowel cannot be assessed. Scintigraphy cannot accurately demonstrate the anatomic location of the bleeding and is not available at emergency settings. The use of capsule endoscopy is inappropriate in the acute setting, particularly in the emergency department at night, and is a highly expensive method. Digital angiography, despite its high sensitivity, is invasive, presents catheterization-related risks, in addition to its low availability at emergency settings. On the other hand, computed tomography angiography is fast, widely available and minimally invasive, emerging as a promising method in the diagnostic algorithm of these patients, being capable of determining the location and cause of bleeding with high accuracy. Based on a critical literature review and on their own experience, the authors propose a computed tomography angiography protocol to assess the patient with gastrointestinal bleeding.

Resumo O sangramento gastrintestinal representa uma emergência médica comum, com taxas consideráveis de morbimortalidade, sendo essencial um rápido diagnóstico para se obter um prognóstico favorável. A endoscopia digestiva alta é o principal método diagnóstico, porém, em casos de sangramento maciço, o exato local de sangramento pode não ser detectável. Além disso, nem sempre está disponível um profissional treinado para a sua execução. A colonoscopia óptica na urgência tem suas limitações ligadas à ausência do preparo intestinal adequado e não permite avaliar a maior parte do intestino delgado. A cintilografia não determina a localização precisa do sangramento e não é disponível na emergência. O uso da cápsula endoscópica é inapropriado no cenário emergencial e tem custo elevado. A angiografia digital, apesar de altamente sensível, é um método invasivo, tem riscos associados ao cateterismo, além de baixa disponibilidade emergencial. Por outro lado, pela sua rapidez, ampla disponibilidade e baixa invasividade, a angiotomografia desponta como opção promissora no algoritmo diagnóstico desses pacientes, sendo capaz de determinar o local e a causa do sangramento com alta acurácia, bem como orientar o seu tratamento. Com base em revisão crítica da literatura e na nossa própria experiência, propomos um protocolo de exame de angiotomografia para o paciente com hemorragia digestiva.

Computed tomography angiography in patients with active gastrointestinal bleeding.

Gastrointestinal bleeding represents a common medical emergency, with considerable morbidity and mortality rates, and a prompt diagnosis is essential for a better prognosis. In such a context, endoscopy is the main diagnostic tool; however, in cases where the gastrointestinal hemorrhage is massive, the exact bleeding site might go undetected. In addition, a trained professional is not always present to perform the procedure. In an emergency setting, optical colonoscopy presents limitations connected with the absence of bowel preparation, so most of the small bowel cannot be assessed. Scintigraphy cannot accurately demonstrate the anatomic location of the bleeding and is not available at emergency settings. The use of capsule endoscopy is inappropriate in the acute setting, particularly in the emergency department at night, and is a highly expensive method. Digital angiography, despite its high sensitivity, is invasive, presents catheterization-related risks, in addition to its low availability at emergency settings. On the other hand, computed tomography angiography is fast, widely available and minimally invasive, emerging as a promising method in the diagnostic algorithm of these patients, being capable of determining the location and cause of bleeding with high accuracy. Based on a critical literature review and on their own experience, the authors propose a computed tomography angiography protocol to assess the patient with gastrointestinal bleeding.

O sangramento gastrintestinal representa uma emergência médica comum, com taxas consideráveis de morbimortalidade, sendo essencial um rápido diagnóstico para se obter um prognóstico favorável. A endoscopia digestiva alta é o principal método diagnóstico, porém, em casos de sangramento maciço, o exato local de sangramento pode não ser detectável. Além disso, nem sempre está disponível um profissional treinado para a sua execução. A colonoscopia óptica na urgência tem suas limitações ligadas à ausência do preparo intestinal adequado e não permite avaliar a maior parte do intestino delgado. A cintilografia não determina a localização precisa do sangramento e não é disponível na emergência. O uso da cápsula endoscópica é inapropriado no cenário emergencial e tem custo elevado. A angiografia digital, apesar de altamente sensível, é um método invasivo, tem riscos associados ao cateterismo, além de baixa disponibilidade emergencial. Por outro lado, pela sua rapidez, ampla disponibilidade e baixa invasividade, a angiotomografia desponta como opção promissora no algoritmo diagnóstico desses pacientes, sendo capaz de determinar o local e a causa do sangramento com alta acurácia, bem como orientar o seu tratamento. Com base em revisão crítica da literatura e na nossa própria experiência, propomos um protocolo de exame de angiotomografia para o paciente com hemorragia digestiva.