A. Bucci

Multifocal, multicentric and contralateral breast cancers: breast MR imaging in the preoperative evaluation of patients with newly diagnosed breast cancer

PurposeThis study was done to verify the usefulness of preoperative breast magnetic resonance (MR) imaging in patients with newly diagnosed breast cancer.Materials and methodsA retrospective analysis of 291 patients with invasive breast cancer newly diagnosed with conventional breast imaging (mammography and ultrasound) was performed. All patients underwent MR imaging prior to surgery. The MR imaging detection rate of additional malignant cancers occult to mammography and ultrasound was calculated. Data were analysed with Fisher’s exact test (p<0.05) according to the following parameters: histopathological features of the index tumour (histological type and size) and mammographic density [according to the Breast Imaging Reporting and Data System (BI-RADS) classification from 1 fatty to 4 dense). The gold standard was the histological examination on the surgical specimen.ResultsMR imaging identified 40 mammographically and sonographically occult malignant lesions other than the index cancer in 27/291 patients (9%). These additional cancers were located in the same quadrant as the index cancer in 13 women (4%), in a different quadrant in 12 (4%) and in the contralateral breast in the remaining two (1%). The cancer detection rate in the subgroup of index cancers with lobular histological type was 25%, significantly higher (p=0.03) than the detection rate of 11% recorded in the subgroup of ductal cancers. The cancer detection rate in the subgroup of index cancers >2 cm was 27%, significantly higher (p=0.001) than the rate of 8% found in the subgroup of index cancers <2 cm. Mammographic density was not correlated (p=0.48) with MR detection of additional cancer, with 14% of additional malignancies being detected in both dense and fatty breasts.ConclusionsIn patients with newly diagnosed invasive breast cancer, preoperative MR imaging is useful for detecting additional synchronous malignancies that are not detected on conventional breast imaging. The cancer detection rate is 9%. The use of preoperative MR imaging as an adjunct to conventional breast imaging in women with an infiltrating lobular index cancer and an index cancer >2 cm is especially beneficial.RiassuntoObiettivoVerificare l’utilità dell’esecuzione della risonanza magnetica (RM) mammaria preoperatoria in pazienti con carcinoma invasivo della mammella.Materiali e metodiSono state analizzate retrospettivamente 291 pazienti con carcinoma invasivo della mammella sottoposte a mammografia, ecografia e RM prima di intervento chirurgico. È stato calcolato il tasso diagnostico aggiuntivo di lesioni maligne sincrone rispetto al tumore principale identificate dalla sola RM, occulte alla mammografia e all’ecografia. I dati sono stati analizzati con il test esatto di Fisher (p<0,05) secondo i seguenti parametri: caratteri istologici della lesione principale (istotipo tumorale e dimensione), densità mammografica (classificazione Breast Imaging Reporting and Data System [BI-RADS] in categorie da 1=adiposa a 4=densa). Il gold standard è stato l’esame istologico del pezzo operatorio.RisultatiL’indagine RM ha diagnosticato 40 lesioni maligne sincrone in 27/291 Pazienti (tasso diagnostico: 9%). Le lesioni maligne identificate dalla RM erano nello stesso quadrante rispetto alla lesione principale in 13 pazienti (4%), interessavano un altro quadrante in 12 pazienti (4%) e la mammella controlaterale nei rimanenti 2 pazienti (1%). Una correlazione significativa positiva (p=0,03) è emersa tra il tasso di identificazione RM di lesione maligna e istotipo lobulare del carcinoma principale (lesioni maligne sincrone sono state rilevate nel 25% dei tumori lobulari vs 11% dei tumori duttali). Una correlazione significativa (p=0,001) è stata osservata tra identificazione RM di lesione maligne e dimensione della lesione principale superiore a 2 cm (lesioni maligne sincrone sono state diagnosticate dalla RM nel 27% dei tumori superiori a 2 cm vs 8% dei tumori inferiori a 2 cm). L’aspetto radiologico della densità mammaria non è risultato correlato (p=0,48) con l’incidenza di malignità, in quanto lesioni maligne sincrone sono state trovate nel 14% dei casi sia con seno denso che adiposo.ConclusioniIn pazienti con neoplasia mammaria infiltrante, l’indagine RM preoperatoria è utile nella ricerca di lesioni occulte e identifica foci multipli sincroni alla lesione principale nel 9% delle Pazienti. Il tasso diagnostico è superiore quando la neoplasia principale ha istotipo lobulare e dimensioni >2 cm.

MR-guided vacuum-assisted breast biopsy in the management of incidental enhancing lesions detected by breast MR imaging.

PurposeThe objective of this study was to determine the clinical value and accuracy of magnetic resonance (MR)-guided vacuum-assisted breast biopsy (VAB).Materials and methodsWe retrospectively analysed 106 incidental breast lesions detected on MR imaging in 98 patients. Patients with nonpalpable suspicious lesions that were only MR visible were referred for MR-VAB performed with a 10-gauge needle. All patients with a VAB diagnosis of infiltrating carcinoma, carcinoma in situ or atypical epithelial hyperplasia were referred for surgery. Histopathology of the surgical specimen was considered the reference standard.ResultsMR-guided VAB was attempted in 29/106 lesions (27%); in 2/29 patients, the procedure could not be performed owing to failure to visualise the lesion. Lesions with clearly malignant features and borderline lesions (atypical ductal hyperplasias) were identified in 12 cases (44%) and benign entities in 15 (56%). Seven of 12 (58%) malignant lesions were <10 mm. Among the 27 successful MR-VAB procedures, VAB yielded one false-negative diagnosis (4%) and underestimation (4%). MR-guided VAB sensitivity and specificity were 92% and 100%, respectively, with a positive predictive value of 100% and a negative predictive value of 93%.ConclusionsThe results of this study indicate that MR-guided VAB offers good accuracy in characterising nonpalpable breast lesions visible on MR imaging alone. Small lesion size (<1 cm) did not prove to be a limitation for the success of the procedure.RiassuntoObiettivoScopo del nostro lavoro è stato valutare l’incidenza e l’accuratezza del sistema di ago-biopsia mammaria sotto guida di risonanza magnetica (RM) con dispositivo aspirante sotto vuoto (VAB).Materiali e metodiSono stati analizzati retrospettivamente 98 pazienti portatori di 106 lesioni identificate incidentalmente all’esame RM. Sono state avviate al VAB, con l’utilizzo di un ago da 10 gauge, le pazienti con alterazioni sospette alla RM, non riconoscibili con ecografia né mammografia, non palpabili, in cui la tipizzazione non poteva essere ottenuta con metodiche alternative. Tutte le pazienti con diagnosi VAB di carcinoma infiltrante, di carcinoma in situ e di iperplasia epiteliale con atipie cellulari sono state indirizzate all’intervento. Il gold standard è stato l’esame istopatologico proveniente dall’escissione chirurgica.RisultatiLe lesioni avviate a prelievo microistologico sotto-guida RM sono state 29/106 (27%). In 2/29 casi non è stato possibile procedere al prelievo per la mancata visualizzazione della lesione. Il riscontro di patologia francamente maligna o di lesioni border-line si è verificato in 12 casi (44%), nei restanti 15 casi (56%) si è rilevata patologia benigna. Sette/12 (58%) lesioni maligne avevano diametro inferiore o uguale a 10 mm. Uno/27 casi (4%) è risultato falso negativo al VAB; 1/27 casi (4%) è stato sottostimato dal VAB. Complessivamente, il prelievo VAB sotto guida RM ha mostrato valori di sensibilità e specificità rispettivamente del 92% e 100% con valore predittivo positivo del 100% e valore predittivo negativo del 93%.ConclusioniIl prelievo con VAB è metodica affidabile nella tipizzazione di lesioni mammarie non palpabili, solo RM visibili. Le dimensioni della lesione inferiori a 1 cm non sono un limite per la metodica.

ARFI: from basic principles to clinical applications in diffuse chronic disease—a review

The many factors influencing the shear wave velocity (SWV) measured with Acoustic Radiation Force Impulse (ARFI) are examined in order to define the most correct examination technique. In particular, attention is given to the information achieved by experimental models, such as phantoms and animal studies. This review targets the clinical applications of ARFI in the evaluation of chronic diffuse disease, especially of liver and kidneys. The contribution of ARFI to the clinical workout of these patients and some possible perspectives are described.Teaching Points• Stiffness significantly varies among normal and abnormal biological tissues.• In clinical applications physical, geometrical, anatomical and physiological factors influence the SWV.• Elastographic techniques can quantify fibrosis, which is directly related to stiffness.• ARFI can be useful in chronic diffuse disease of liver and kidney.

The Role of Sonoelastography in the Evaluation of Testes With Varicocele

OBJECTIVE To evaluate the role of elastosonography in the evaluation of testicular elasticity as a predictive sign of testicular damage in patients with varicocele. MATERIALS AND METHODS Between December 2010 and December 2014, we evaluated patients with varicocele by sonoelastography (SE) of the testes. We created 3 groups: group A included patients with untreated varicocele; group B, patients treated with the same technique; and group C, healthy age-matched patients without varicocele. All patients underwent SE for the evaluation of testicular stiffness and results were graded from 1 to 3 following the color scale grading. RESULTS During the study period, 36 boys (9-16 years old) with untreated varicocele, 47 treated patients, and 24 age-matched healthy subjects underwent control visit for varicocele and SE. All right testes of all groups were scored as 1, whereas testes with varicocele were stiffer than normal; all hypotrophies were scored as 3, whereas not all testes that were scored 3 were associated with testicular hypotrophy. There was a significant and statistical recovery rate of the testicular volume and the sonoelastographic score after surgery. CONCLUSION Testes with varicocele are significantly stiffer than normal ones. All testes with testicular hypotrophy had grade 3 sonoelastographic scores, but not all patients with a grade 3 score have testicular hypotrophy or continuous spermatic vein reflux. Our results show that sonoelasography can play a significant role in the evaluation of testicular elasticity as a predictive sign of testicular damage.

Renal shear wave velocity and estimated glomerular filtration rate in children with chronic kidney disease

A shear wave velocity (SWV) value obtained by the acoustic radiation force impulse technique depends on tissue elasticity. We investigated the relationship between SWV values and the estimated glomerular filtration rate (eGFR) in children with chronic kidney disease. A total of 29 patients were enrolled in the study. There were 18 primary and 11 secondary cases of vesicoureteral reflux. eGFR was calculated using Schwartzs formulas (2012). Partial eGFR for each kidney was assessed by multiplying the eGFR by the percentage of renal function measured by means of renal (99m)Tc-dimercaptosuccinic acid scintigraphy. All ultrasound tests were done by a single qualified technician using a convex probe (frequency 4 MHz) on an S-2000 system. The mean SWV values of the two kidneys were significantly and negatively correlated with eGFR calculated with both univariate (cystatin C [Cys C] and multivariate (creatinine, Cys C, and nitrogen) equations. Of all the formulae, the strongest correlation was obtained with eGFR (Cys C). SWV of the renal cortex correlates with the eGFR of patients affected by malformative uropathies. Nevertheless, this technique needs standardization and validation.

Acustic radiation force impulse (ARFI) evaluation of small (< 4 cm) renal masses-preliminary results

Purpose: The justification and optimisation of medical imaging employing ionizing radiation have been intensely discussed in recent years, particularly for computed tomography (CT). A key point in this discussion is the estimation of patient dose, which commonly employs radiation output metrics developed for quality assurance and no patient specific information. Such patient dose estimates are of limited value, and more refined methods needs to be promoted and provided to the community. Methods and Materials: AAPM Task Group 246 was formed in 2013, and in a joint venture with EFOMP charged with summarizing present methodology and DICOM information available for estimating patient dose with computed tomography.Results: The Joint Report of AAPM Task Group 246 and EFOMP is a comprehensive resource for the clinical medical physicist. The possibilities of patient specific dosimetry from the Computed Tomography Dose Index (CTDIvol), to the Size-Specific Dose Estimates (SSDE) and advanced Monte Carlo methods are discussed together with available DICOM information, as well as practical examples on how patient dose estimates can be achieved. The report also summarizes important factors contributing to the uncertainty in patient dose estimates and gives examples of achievable confidence intervals.Conclusion: The SSDE and Monte Carlo methods can together with detailed scanner, examination and patient specific DICOM information offer refined estimates of patient dose for justification and optimisation of CT examinations. Given the present robustness of available methods AAPM Task Group 246 and EFOMP recommend that all reports of patient dose should be accompanied by estimates of the associated uncertainty.

Renal elasticity quantification by acoustic radiation force impulse in children born preterm: preliminary results

An emerging hypothesis from the recent literature describes how specific adverse factors related to growth retardation and low birth weight might influence renal development during fetal life and the insurgence of relevant pathologies in adulthood. Preterm births and related perinatal events can affect the mechanical proprieties of kidneys in childhood. We retrieved the laboratory medical records of 3 children born preterm, all in good condition, and investigated the elastic properties of their kidneys using the acoustic radiation force impulse (ARFI) technique. Shear wave velocity (SWV) obtained by the ARFI technique depends on the elasticity of a parenchymatous tissue. Medical records of case patient 1 showed a shorter right kidney (5th percentile), a greater protein/creatinine ratio and higher α1-microglobulin in the urine spot if compared with controls. Patients 2 and 3 had unremarkable laboratory results. Moreover, compared with the same results of healthy full-term normal children obtained from a previous study of ours, we observed higher SWV values (m/s) for the left kidney in patients 1 and 3; patient 2 had lower SWV values in both kidneys. The altered SWV values, measured in these children born preterm, may be correlated with a possible underlying renal pathology (for instance, disruption of the renal histology). Altered SWV values are generally observed also in 2 out of 3 children with a history of normal laboratory markers of renal function. Further studies are needed on larger cohorts of patients.