Assessing breast cancer risk within the general screening population: developing a breast cancer risk model to identify higher risk women at mammographic screening.

OBJECTIVES: To develop a breast cancer risk model to identify women at mammographic screening who are at higher risk of breast cancer within the general screening population. METHODS: This retrospective nested case-control study used data from a population-based breast screening program (2009-2015). All women aged 40-75 diagnosed with screen-detected or interval breast cancer (n = 1882) were frequency-matched 3:1 on age and screen-year with women without screen-detected breast cancer (n = 5888). Image-derived risk factors from the screening mammogram (percent mammographic density [PMD], breast volume, age) were combined with core biopsy history, first-degree family history, and other clinical risk factors in risk models. Model performance was assessed using the area under the receiver operating characteristic curve (AUC). Classifiers assigning women to low- versus high-risk deciles were derived from risk models. Agreement between classifiers was assessed using a weighted kappa. RESULTS: The AUC was 0.597 for a risk model including only image-derived risk factors. The successive addition of core biopsy and family history significantly improved performance (AUC = 0.660, p < 0.001 and AUC = 0.664, p = 0.04, respectively). Adding the three remaining risk factors did not further improve performance (AUC = 0.665, p = 0.45). There was almost perfect agreement (kappa = 0.97) between risk assessments based on a classifier derived from image-derived risk factors, core biopsy, and family history compared with those derived from a model including all available risk factors. CONCLUSIONS: Women in the general screening population can be risk-stratified at time of screen using a simple model based on age, PMD, breast volume, and biopsy and family history. KEY POINTS: • A breast cancer risk model based on three image-derived risk factors as well as core biopsy and first-degree family history can provide current risk estimates at time of screen. • Risk estimates generated from a combination of image-derived risk factors, core biopsy history, and first-degree family history may be more valid than risk estimates that rely on extensive self-reported risk factors. • A simple breast cancer risk model can avoid extensive clinical risk factor data collection.

Pearls, Pitfalls, and Conditions that Mimic Mesenteric Ischemia at CT.

Acute mesenteric ischemia (AMI) is a life-threatening condition with a high mortality rate. The diagnosis of AMI is challenging because patient symptoms and laboratory test results are often nonspecific. A high degree of clinical and radiologic suspicion is required for accurate and timely diagnosis. CT angiography of the abdomen and pelvis is the first-line imaging test for suspected AMI and should be expedited. A systematic "inside-out" approach to interpreting CT angiographic images, beginning with the bowel lumen and proceeding outward to the bowel wall, mesentery, vasculature, and extraintestinal viscera, provides radiologists with a practical framework to improve detection and synthesis of imaging findings. The subtypes of AMI are arterial and venoocclusive disease, nonocclusive ischemia, and strangulating bowel obstruction; each may demonstrate specific imaging findings. Chronic mesenteric ischemia is more insidious at onset and almost always secondary to atherosclerosis. Potential pitfalls in the diagnosis of AMI include mistaking pneumatosis as a sign that is specific for AMI and not an imaging finding, misinterpretation of adynamic ileus as a benign finding, and pseudopneumatosis. Several enterocolitides can mimic AMI at CT angiography, such as inflammatory bowel disease, infections, angioedema, and radiation-induced enterocolitis. Awareness of pitfalls, conditions that mimic AMI, and potential distinguishing clinical and imaging features can assist radiologists in making an early and accurate diagnosis of AMI. ©RSNA, 2020.

Balloon Pulmonary Angioplasty in Chronic Thromboembolic Pulmonary Hypertension: New Horizons in the Interventional Management of Pulmonary Embolism.

Chronic thromboembolic pulmonary hypertension (CTEPH) is an underdiagnosed potential complication of acute or recurrent pulmonary thromboembolic disease. Multiple studies suggest that up to 5% of patients with acute pulmonary thromboembolic disease go on to develop CTEPH. The prognosis of untreated CTEPH is poor, but advances in medical and surgical treatments over the past few decades have improved patient outcomes. The gold standard and curative treatment for CTEPH is pulmonary endarterectomy; however, some patients are inoperable and others who have undergone pulmonary endarterectomy experience persistent or recurrent pulmonary hypertension despite medical therapy. In recent years, balloon pulmonary angioplasty has emerged as a primary and adjunctive treatment for these CTEPH patients at expert or specialized centers. This review outlines an approach to balloon pulmonary angioplasty for CTEPH, including clinical presentation and evaluation; patient selection and indications; treatment planning; equipment and technique; overcoming technical challenges; recognition and management of complications; postprocedural care and clinical follow-up; and expected outcomes.

Percutaneous sharp recanalization of a membranous IVC occlusion with an occlusion balloon as a needle target.

A 50-year-old male with right upper quadrant symptoms and hepatic dysfunction was found to have multiple dilated hepatic veins (HVs) with intrahepatic collateralization and membranous occlusion of the intrahepatic inferior vena cava (IVC) consistent with primary Budd-Chiari syndrome. Venacavograms depicted drainage of the intrahepatic collaterals through a left-sided HV entering the IVC above the level of the occlusion. Sharp recanalization of the membranous IVC occlusion was performed with an occlusion balloon as a needle target under echocardiographic monitoring followed by balloon angioplasty with restoration of IVC patency. Clinical, laboratory, and venographic procedural success has been demonstrated to 9 months with minimal residual stenosis.

Ultrasonographic detection of air in the superior sagittal sinus in a neonate with transposition of the great arteries.

Cerebral venous air embolism is a relatively rare condition that arises from iatrogenic or traumatic introduction of air into the venous system. We describe the ultrasonographic findings in a 1-day-old infant with iatrogenic retrograde cerebral venous air embolism, which to our knowledge, is the earliest case reported in the literature to date. This case highlights the role of cerebral ultrasonography in the detection and surveillance of cerebral venous air embolism in neonates.

Percutaneous transcatheter embolisation of active haemorrhage following radiofrequency ablation of hepatocellular carcinoma.

A 72-year-old woman with hepatitis C virus cirrhosis underwent a surveillance ultrasound examination which identified a new hepatic lesion. A workup triphasic CT examination demonstrated a 3.7 cm lesion at the hepatic dome with arterial enhancement and portal venous washout consistent with hepatocellular carcinoma. She subsequently proceeded for treatment with radiofrequency ablation (RFA). RFA was technically successful, but the patient became hypotensive and tachycardic postprocedure. A CT angiogram demonstrated active arterial intraperitoneal haemorrhage from the RFA site. The patient returned to the interventional suite for catheter angiography which confirmed the presence of active haemorrhage from the hepatic arterial branch supplying segment VIII. The bleeding vessel was selectively catheterised with a microcatheter, and successfully embolised with 250-355 µm polyvinyl alcohol particles.

Iterative Reconstruction for Head CT: Effects on Radiation Dose and Image Quality.

BACKGROUND: Iterative reconstruction has been reported to reduce radiation dose in CT, while preserving and even improving image quality. The purpose of this study was to evaluate the effects of sinogram-affirmed iterative reconstruction (SAFIRE) on radiation dose reduction and image quality for noncontrast adult head CT and to compare SAFIRE with conventional filtered back-projection (FBP) reconstruction. METHODS: Institutional review board approval was obtained for this retrospective analysis of head CT scans reconstructed with SAFIRE and/or FBP for 107 patients. Radiation dose parameters were recorded from scanner-generated CT dose reports. Signal-to-noise and contrast-to-noise ratios (SNR, CNR) were calculated from gray and white matter (GM, WM) attenuation measurements. Image noise, artifacts, GM-WM differentiation, small structure visibility, and sharpness were graded by two readers. Statistical analysis included the independent-samples t test for quantitative data, the related samples Wilcoxon signed-rank test for qualitative data, the coefficient of repeatability for intraobserver variation, and κ statistics for interobserver agreement. RESULTS: Mean effective dose was significantly reduced with SAFIRE from 2.0 to 1.7 mSv (p<0.0001). SAFIRE also significantly improved GM SNR, WM SNR, and GM-WM CNR (p<0.0001). Significant reductions in image noise and posterior fossa artifact as well as improvements in GM-WM differentiation, small structure visibility, and sharpness were noted with SAFIRE (P<0.005). CONCLUSIONS: SAFIRE for noncontrast adult head CT reduces patient radiation dose by 15% for the settings employed at our institution, while significantly improving multiple quantitative and qualitative measures of image quality.

Multidetector computed tomography with triple-bolus contrast medium administration protocol for preoperative anatomical and functional assessment of potential living renal donors.

OBJECTIVE: To evaluate multidetector computed tomography (MDCT) with a triple-bolus contrast administration protocol for preoperative anatomical and functional assessment of living renal donors. METHODS: Fifty-five potential living renal donors underwent MDCT of which 27 proceeded to donor nephrectomy. A triple-bolus contrast administration protocol was used for simultaneous acquisition of arterial, nephrographic, and excretory phases. MDCT images were independently reviewed in random order by two radiologists blinded to surgical anatomy findings. Diagnostic accuracy for anatomical variants was quantified by sensitivity and specificity. Differential renal function (DRF) was derived from MDCT for 54 patients and compared with technetium-99 m dimercaptosuccinic acid renography (Tc-99 m DMSA). RESULTS: All triple-bolus MDCT examinations were technically adequate. Accessory renal arteries and veins were identified at surgery in 33% (n = 9/27) and 22% (n = 6/27) of donor kidneys. The mean difference between MDCT-derived DRF and DMSA was 0.8% (95% CI 0.1-1.6) with 95% limits of agreement of -4.6% (95% CI -3.3 to -5.9) to 6.3% (95% CI 5.0-7.6). MDCT delivered a mean (SD, range) radiation dose of 9.5 (3.6, 3.6-17.3) mSv. CONCLUSION: MDCT with a triple-bolus contrast administration provides accurate anatomical and functional evaluation of living renal donors.