MammoGrid--a prototype distributed mammographic database for Europe.

This paper describes the prototype for a Europe-wide distributed database of mammograms entitled MammoGrid, which was developed as part of an EU-funded project. The MammoGrid database appears to the user to be a single database, but the mammograms that comprise it are in fact retained and curated in the centres that generated them. Linked to each image is a potentially large and expandable set of patient information, known as metadata. Transmission of mammograms and metadata is secure, and a data acquisition system has been developed to upload and download mammograms from the distributed database, and then annotate them, rewriting the annotations to the database. The user can be anywhere in the world, but access rights can be applied. The paper aims to raise awareness among radiologists of the potential of emerging "grid" technology ("the second-generation Internet").

A comparison of some anthropometric parameters between an Italian and a UK population: "proof of principle" of a European project using MammoGrid.

AIM: To demonstrate the use of grid technology to produce a database of mammograms and supporting patient data, specifically using breast density as a biomarker of risk for breast cancer, for epidemiological purposes. METHOD: The cohort comprised 1737 women from the UK and Italy, aged 28-87 years, mean 54.7 years, who underwent mammography after giving consent to the use of their data in the project. Information regarding height, weight, and exposure data (mAs and kV) was recorded. The computer program Generate-SMF was applied to all films in the database to measure breast volume, dense breast volume, and thereby percentage density. Visual readings of density using a six-category classification system were also available for 596 women. RESULTS: The UK and Italian participants were similar in height, but the UK women were significantly heavier with a slightly higher body mass index (BMI), despite being younger. Both absolute and percentage breast density were significantly higher in the Udine cohort. Images from the medio-lateral projection (MLO) give a significantly lower percentage density than cranio-caudal (CC) images (p<0.0001). Total breast volume is negatively associated with percentage density, as are BMI and age (p<0.0001 for all), although 80% of the variability in percentage density remains unexplained. CONCLUSION: The study offers proof of principle that confederated databases generated using Grid technology provide a useful and adaptable environment for large quantities of image, numerical, and qualitative data suitable for epidemiological research using the example of mammographic density as a biomarker of risk for breast cancer.

CAD systems for mammography: a real opportunity? A review of the literature.

The introduction of systems for automated reading in mammography has been proposed to improve the sensitivity [computer-aided detection (CADe) systems] and, more recently, the specificity [computer-aided diagnosis (CADi) systems] of the test. Only CADe systems have been approved by the U.S. Food and Drug Administration (FDA) and are used in current practice. These systems are still under discussion. Several studies have demonstrated that they are beneficial to inexperienced readers and that, through comparison with the computer, radiologists are led to improve their performance. However, there is still considerable variation among different studies in the level of benefit deriving from CAD. Therefore the role of these systems in clinical practice is still debated, and their real contribution to the overall management of the diagnostic process is not yet clear.

Sonographic criteria for differentiation of benign and malignant solid breast lesions: size is of value.

PURPOSE: The purpose of this study was to evaluate whether lesion size may influence the value of sonographic findings in the differential diagnosis between benign or malignant breast lesions. MATERIALS AND METHODS: Sonographic features of 256 histologically confirmed (148 benign, 108 malignant) breast lesions were retrospectively and independently reviewed by three radiologists unaware of mammographic findings and pathology results. Each lesion was assessed for several sonographic features and assigned a level of suspicion. Logistic modelling defined the predictive value of each sonographic feature per se and in relation to lesion size. The k statistic (k) evaluated interobserver agreement in lesion classification. The accuracy of breast sonography in characterising solid lesions was also evaluated. RESULTS: Analysis of the sonographic features predictive of malignant disease, taken as a whole, showed that only irregular margins and marked hypoechogenicity maintain their predictive value independent of lesion size. When lesion size is considered, the other features remain significant only for lesions larger than 7 mm. Interobserver agreement for sonographic suspicion, when calculated not taking into account lesion size, was good or excellent whereas it was reduced for lesions smaller than 7 mm. Accuracy of breast sonography improved when evaluating lesions larger than 7 mm. CONCLUSIONS: Lesion size influences the value of sonographic findings in distinguishing benign from malignant lesions. The usually adopted criteria in sonography have a significantly lower accuracy in characterisation of small lesions.

Multidetector CT with double arterial phase and high-iodine-concentration contrast agent in the detection of hepatocellular carcinoma.

PURPOSE: The purpose of this study was to determine whether the double arterial phase with multidetector computed tomography MDCT and high-iodine-concentration contrast material (CM) improves identification of hepatocellular carcinoma (HCC). MATERIALS AND METHODS: Fifty patients with 111 HCC foci (61 confirmed histologically, 46 confirmed by percutaneous interventional procedures, four confirmed by CT follow-up of at least 6 months) underwent MDCT with a double arterial phase and a portal venous phase after administration of contrast material with a high iodine concentration (400 mgI/ml, 2 ml/kg, 5 ml/s). Two radiologists independently evaluated the images in three distinct reading sessions (early arterial phase (EAP), late arterial phase (LAP) and double arterial phase) to determine presence, number and degree of suspicion of HCC. The sensitivity and the positive predictive value (PPV) were calculated for every reading session. The following statistical evaluations were used: k statistic and McNemar's test. RESULTS: Mean sensitivity and PPV in the detection of HCC were, respectively, 83.8% and 93.5% for EAP, 90.5% and 94.8% for LAP, and 94.1% and 95.1% for the double arterial phase. Sensitivity of the double arterial phase was statistically higher when compared with EAP alone but showed no statistically significant difference when compared with LAP. The k values ndicated moderate-to-excellent interobserver agreement in all reading sessions. CONCLUSIONS: Sensitivity and PPV increase progressively when passing from EAP to LAP to double-arterial-phase images obtained with contrast material with a high iodine concentration. However, the difference in sensitivity between LAP and the double arterial phase was not statistically significant.

Resolving clinicians' queries across a Grid's infrastructure.

OBJECTIVES: The past decade has witnessed order of magnitude increases in computing power, data storage capacity and network speed, giving birth to applications which may handle large data volumes of increased complexity, distributed over the internet. METHODS: Medical image analysis is one of the areas for which this unique opportunity likely brings revolutionary advances both for the scientist's research study and the clinician's everyday work. Grids [1] computing promises to resolve many of the difficulties in facilitating medical image analysis to allow radiologists to collaborate without having to co-locate. RESULTS: The EU-funded MammoGrid project [2] aims to investigate the feasibility of developing a Grid-enabled European database of mammograms and provide an information infrastructure which federates multiple mammogram databases. This will enable clinicians to develop new common, collaborative and co-operative approaches to the analysis of mammographic data. CONCLUSION: This paper focuses on one of the key requirements for large-scale distributed mammogram analysis: resolving queries across a grid-connected federation of images.

Staging of pelvic endometriosis based on MRI findings versus laparoscopic classification according to the American Fertility Society.

BACKGROUND: Preoperative staging of pelvic endometriosis helps the gynecologist plan therapy and offers a prognosis to patients. We compared a staging system of pelvic endometriosis based on magnetic resonance imaging (MRI) findings with the American Fertility Society (AFS) laparoscopic classification. METHODS: Forty-four consecutive females with clinically suspected endometriosis underwent MRI examination to demonstrate the presence of endometriomas and pelvic implants. Laparoscopy was performed within 2 weeks. An MRI score was developed to classify endometriosis into four classes comparable to those of AFS laparoscopic staging. Concordance between MRI and laparoscopic classification was evaluated with kappa statistics. RESULTS: Laparoscopy confirmed 60 of 61 endometriomas detected by MRI. Implants were discovered in 20 of 44 patients with MRI and in 23 of 44 with laparoscopy. MRI detected 50 endometrial implants of 65 detected by laparoscopy (76.9%). With regard to endometriosis staging, we obtained a concordance between MRI and AFS classification in 42 of 44 patients (kappa = 0.913). CONCLUSION: Although MRI has limitations such as suboptimal depiction of small implants and adhesions, this technique is very useful to guide laparoscopy. Moreover, the optimal concordance (95%) between our proposed MRI staging and the AFS laparoscopic classification demonstrated a new advantage of MRI in preoperative staging of endometriosis.

[Papillary lesions of the breast: diagnostic imaging and contribution of percutaneous needle biopsy with 14G needle]. / Lesioni papillari della mammella: diagnosi per immagini ed apporto dell'agobiopsia percutanea con ago da 14 gauge.

PURPOSE: To evaluate the presence of suggestive mammographic, US, color-Doppler, RM findings of 33 PLB and to show the accuracy of the large-core biopsy in evaluating these lesions. MATERIAL AND METHODS: A retrospective review of imaging-guided large-core biopsy of 860 consecutive lesions revealed that PLB were diagnosed in 31/33 cases and 3 were suspicious papillary lesions. Surgical correlation was available for all these lesions. Mammography and US were performed in all patients, Color-Doppler in 13/33 and MR in 10/33. RESULTS: Histological findings by percutaneous biopsy demonstrated 26 (79%) benign, 3 (9%) atypical, and 4 (12%) malignant lesions. Histological findings after surgery confirmed the diagnosis for benign and malignant lesions, while of the 3 atypical lesions, 1 was benign and 2 were malignant. One encysted papillary carcinoma in situ at core-biopsy was classified as invasive papillary carcinoma after surgery. PLB were usually found (52%) in subareolar location and the mean size was 17 mm (range 5-60 mm). The most frequent mammographic appearance of benign PLB was of a well-defined (71%), oval (53%) mass. The microcalcifications had variable features; they were isolated in 3/27 (15%) cases and associated with masses in 4/27 (20%). The mammographic finding of papillary carcinoma was of a well-defined (50%) or ill-defined, oval (50%) or lobulated (50%) mass, but never of a spiculated mass. US finding of the benign PLB most commonly showed a well-defined (84%), oval (84%), complex solid/cystic (52%) mass with frequently (60%) posterior enhancement. US finding of papillary carcinoma was of a well-defined (50%) or ill-defined (50%), oval (50%) or lobulated (50%) mass, most commonly solid-inhomogenous-hypoechoic. Color-Doppler showed high blood flow in 8/10 benign PLB and in 2/3 malignant PLB. Contrast-enhanced MR imaging demonstrated usually well-circumscribed, round masses (71%). The intensity/time curve showed marked focal enhancement (peak signal intensity over 70% at the first minute) in both benign and malignant lesions. DISCUSSION: Often the patients with PBL were symptomatic (for presence of nipple discharge or palpable mass). 31/33 papillary lesions identified at the subsequent imaging-guided large-core biopsy and in the 3/33 remaining lesions percutaneous core-biopsy required a subsequent surgical biopsy for the atypical papillary lesions. US proved to have the highest sensitivity, showing the suggestive feature of a frond-like mass within a dilated duct, and color-Doppler demonstrated high blood flow (which should be considered in differential diagnosis of galactocele). Mammographic finding of papillary lesions was often consistent with benign lesions (fibroadenoma, cyst). MR confirmed the high vascularization of these lesions, showing marked enhancement of the solid component. CONCLUSIONS: US, with Color-Doppler, proved to be the most useful examination for the identification and demonstration of the solid component of these lesions, which, observed further diagnostic investigation. As no definite mammographic, sonographic or RM pattern could be identified to differentiate between benign and malignant PLB, core-biopsy was required. Percutaneous biopsy has shown to be reliable in the diagnosis of benign and malignant PLB (without any false negative): infact, any atypical lesions require surgical examination. The framing of benign and malignant PLB with imaging and core-biopsy was useful because the frequent association of benign PLB with concurrent or subsequent breast carcinoma suggests surgical excision and radiological follow-up.

[Unusual radiological findings in combined laryngeal mucocele]. / Aspetti radiologici peculiari in un caso di mucocele laringeo misto.

In laryngeal mucocele, Morgagni's ventricle fills with mucous resulting from proliferation of the innner glandular epithelium and simultaneous closure of the ventricular opening. In making a diagnosis, the physician must first rule out any underlying neoplasm in Morgagni's ventricle which would give rise to a secondary mucocele. The present work reports a clinical case which came under observation because of cough, dysphonia and swelling of the left ventricular band with normal motility of the true vocal cords. CT of the neck, performed with contrast medium and axial scanning, showed a solid neoformation starting from the left laryngeal ventricle; densitometry proved moderately non homogeneous and showed radiological signs of hypervascularization. On the basis of these data the patient underwent direct bioptic laryngoscopy. During the beginning of the endoscopic maneuver, the pressure exerted by the stiff laryngoscope forced out dense, sticky mucous-like material and caused the laryngeal ventricle to collapse. Subsequently, multiple bioptic samples were taken from the walls and floor of the ventricle. The histological and microbiological examination confirmed the diagnosis of laryngeal mucocele. Six months later the laryngoscopic picture was nearly normal. In the years since computerized tomography came into clinical practice, diagnosis of this pathology has become easier and quicker Computerized tomography provides radiological indication of benignness which is certainly valid for laryngocele, a tumefaction containing air and which is therefore clearly differentiated from the radiodensity of the surrounding tissues. Vice versa, the homogeneous mucous content of the laryngeal mucocele can be altered by bacterial proliferation and may not show up on the CT as a uniformly hypodense area. Phlogosis due to the presence of colonies of bacteria can lead to greater blood flow in the ventricular site, thus making it impossible to distinguish the hyperdense boundary surrounding the hypodense mass. This, in turn, creates a blurry, ambiguous area of hyperdensity typical of increased vascularization. The rarity of the lesion, the relative likelihood of a simultaneous neoplasm and the ambiguousness of the clinical diagnostic elements available justify the use of preliminary bioptic microlaryngoscopy before surgically treating laryngeal mucocele.

Contrast media in liver sonography: correlation with enhanced dynamic magnetic resonance imaging.

Both color Doppler sonography and magnetic resonance are imaging techniques which do not use ionizing radiations, but despite this common feature there remain many differences between them. Thus, color Doppler sonography is a cost-effective technique using mechanical waves and providing real-time images while magnetic resonance imaging is much more expensive, uses magnetic fields and radiofrequency energy and provides static images. The former method is very sensitive in detecting focal liver lesions > 1 cm, but its specificity in characterization is not as good, not even with the color Doppler technique. The main differences between color Doppler sonography, with and/or without echocontrast agents, and contrast-enhanced (Gadolinium chelates) dynamic magnetic resonance imaging in focal liver lesions can be summarized as follows: (1) magnetic resonance imaging depicts tumor vascularization only after paramagnetic contrast media injection. Enhanced images completely depend upon the contrast agent and cannot be achieved without it. In contrast, color Doppler signal is not modified by the contrast agent, it just becomes stronger. (2) Contrast-enhanced magnetic resonance signal (as well as contrast-enhanced computed tomography signal) provides more pieces of information than color Doppler signal about the flow characteristics of liver nodules--i.e. it shows not only blood flow (hyper-/hypovascular nodule), but also the interstitial spread of the agent and its wash-out. For example, hepatocellular carcinoma and focal nodular hyperplasia have similar perfusion while agent spread and wash-out decrease very quickly in the former and more slowly in the latter, except for the low decrease of the central scar. (3) Color Doppler technology improvements, higher sensitivity to slow flows and better signal/noise ratio reduce the applications of contrast-enhanced sonography in focal liver lesions because the agents modify only sensitivity and not the imaging in slow flow studies. (4) The higher cost of contrast studies is justified only in selected cases, namely treatment follow-up in the lesions with rich pretreatment vascularization. Finally, the higher cost of contrast magnetic resonance studies is justified to increase sensitivity and especially to allow lesion characterization.

Retroperitoneal nodular fasciitis: magnetic resonance imaging (MRI) and pathological features.

A case of pelvic nodular fasciitis, with particular reference to its peculiar radiological and pathological features is described. Only a few cases of pelvic nodular fasciitis are reported in the English literature and at the best of our knowledge, this is the first case of retroperitoneal origin. This report discusses the role of MRI in the characterization of soft tissue masses. No specific MRI findings of nodular fasciitis were identified and MRI doesn't add any contribution to the differential diagnosis between benign and malignant lesions. As a consequence, the histopathological examination is necessary for a definitive diagnosis.

[Vaginal and abdominal hysterectomy: comparison and perspectives. Apropos of 385 consecutive cases]. / Isterectomia vaginale e addominale: confronto e prospettive. A proposito di 385 casi consecutivi.

Hysterectomy is the most common non-pregnancy related surgical procedure. However, given the lack of final guidelines on indications, alternative therapies, surgical approach and outcomes, it is desirable to keep its use under constant monitoring. We reviewed 385 hysterectomies for benign conditions-divided according to surgical approach-performed in the Gynaecological Department of San Daniele del Friuli (Udine-Italy) in 1991-1993, and with one-year follow-up. Traditional approaches, i.e. abdominal (39.2%) and vaginal (60.2%), were used. Colporraphy was performed in 79 cases (33.8% of vaginal hysterectomies); 73.4% of colporraphies were followed by urethral suspension. We reviewed population's patterns, indications and surgical outcomes according to Dicker's suggestions. Vaginal hysterectomy with associated colporraphy concerned a population of patients with average age and parity significantly different from patients who underwent simple vaginal or abdominal hysterectomy. These last two groups, on the other hand, have similar characteristics making them comparable. In abdominal hysterectomy and simple vaginal hysterectomy we reported a complication rate respectively of 21.9% and 7.1%. The advantages of simple vaginal hysterectomy include shorter operating time, reduction in antibiotic drugs usage, earlier hospital discharge and quicker recovery, with obvious cost saving. Our experience therefore supports the view that the balance between abdominal and vaginal hysterectomy could safely be shifted in favour of the last one, the advantages of which could then be made available to a larger number of patients.