Alan H. Freeman

How reliable is modern breast imaging in differentiating benign from malignant breast lesions in the symptomatic population

AIM To assess the ability of mammography and ultrasound individually and in combination to predict whether a breast abnormality is benign or malignant in patients with symptomatic breast disease. MATERIALS AND METHODS Patients included were those in whom histological confirmation of the abnormality following surgical excision was available. Mammographic and ultrasound appearances were prospectively classified using a four-point scale (1 = no significant lesion, 2 = benign lesion, 3 = possibly malignant, 4 = probably malignant). RESULTS Histological confirmation following surgical excision was available in 559 patients, of which 303 were benign and 256 were malignant. The imaging classification was correlated with histology in these 559 lesions. In predicting final histology, the sensitivity and specificity of mammography alone were 78.9 and 82.7%, respectively, of ultrasound alone were 88.9 and 77.9%, respectively, and of mammography and ultrasound in combination were 94.2 and 67.9%, respectively. Only one patient had both a mammogram and ultrasound reported as normal (category 1 for both tests) in whom subsequent histology revealed a carcinoma (0.4% of all carcinomas). CONCLUSION We found that the extensive use of ultrasound increases the cancer detection rate in this selected population by 14%.

Changing to core biopsy in an NHS breast screening unit.

We recently changed from using fine needle aspiration cytology to using core biopsy exclusively in the assessment of screen detected abnormalities. Two hundred and two biopsies (1% of women screened) were performed. Surgical histological confirmation was obtained in 111 patients (101 malignant and 10 benign). The remaining patients were either returned to standard 3-yearly screening or early repeat screening after 1 year. Analysis of the results was performed in accordance with the standards specified in the National Health Service Breast Screening Programme (NHSBSP) Publication Number 22. Absolute sensitivity was 89.3%, complete sensitivity was 93.2%, specificity (including patients undergoing both surgical excision and follow-up) was 88.7%. The predictive value of a positive (malignant) core biopsy result was 100%. The false negative rate was 3.9%. Twelve (5.9%) biopsies were classified inadequate for diagnosis. Core biopsy is a safe and accurate way of assessing screen detected abnormalities and can be used as a substitute for fine needle aspiration cytology with results that exceed the National Health Service Breast Screening Programme target standards, even in the learning phase.

Barium enema or computed tomography for the frail elderly patient

In order to determine whether abdominopelvic computed tomography (CT) offers an alternative to barium enema (BE) for the investigation of the large bowel in frail elderly patients, we have assessed and compared the results of both tests performed in each patient. Thirty-seven patients aged 71 to 88 (mean 80) with a history or clinical findings suggestive of large bowel disease were studied. The seven colonic neoplasms in this group were demonstrated by both techniques (apart from one patient who did not undergo BE as CT had shown an obstructing lesion). CT showed useful additional data in four patients (e.g. abdominal wall involvement) and demonstrated numerous extracolonic lesions (e.g. ovarian carcinoma). However, CT did raise the possibility of a large bowel neoplasm in four patients where none was shown by BE and missed one case of Crohns disease. CT was the preferred test amongst the 25 patients where the acceptability of the two techniques could be compared. Only in 16 patients were the BE studies adjudged to be of good quality. CT should be the initial investigation of the large bowel in frail elderly patients requiring inpatient bowel preparation; the more unpleasant BE could be reserved for those cases where CT is equivocal or severe symptoms are unexplained.

A prospective randomised study comparing enteroclysis with small bowel follow-through examinations in 244 patients

Abstract. The purpose of this study was to determine whether small bowel enema or barium follow-through is the most appropriate examination for the routine investigation of patients without documented small bowel disease referred from outpatient sources in our hospital. Two hundred and forty-four patients were prospectively randomised to either small bowel enema (SBE) or barium follow-through (FT). Radiation doses and room times were recorded for the first 95 patients and abnormal results were documented for all. One hundred and twelve FTs and 75 SBEs were performed. The incidence of abnormal results was low overall and comparable in the two groups. There were significantly more abnormalities in the FT group which required further investigations for confirmation. Of those assigned to SBE, 19% were converted to FT due to patient refusal and technical failure. Radiation doses were similar in the two groups, but the time spent occupying the fluoroscopy room was significantly shorter for FT. In our department FT is as effective as SBE in detecting small bowel abnormalities de novo. The radiation dose is similar, but more FTs can be performed per list. Follow-through is also less invasive than SBE and therefore we use this technique as the first line of investigation in this group of patients.

Abdominal wall hernias: A cross-sectional pictorial review

The classification of abdominal wall hernias is often made difficult by confusing eponymous and anatomic nomenclature. In this article, we review the anatomy that defines the various types of hernias. The specific cross-sectional radiologic features required to correctly identify each type are then emphasized. The appropriate clinical context and the merits of the various imaging techniques available for the investigation of abdominal wall hernias are also discussed.

CT of the colon in frail elderly patients

CT is presented as an alternative to barium enema examination for the investigation of the colon in frail elderly patients. Carcinomas can be detected reliably and the investigation is better accepted by patients and staff alike. Furthermore, extracolonic lesions are shown. Obviously small polyps are missed, but such lesions are less relevant in older patients. The CT technique is described, and some of the initial difficulties encountered during the adoption of this policy are discussed.

Minimal-preparation abdomino-pelvic CT in frail and elderly patients: prognostic value of colonic and extracolonic findings

AIM To examine the overall survival of patients who had had been referred for minimal preparation abdomino-pelvic computed tomography (MPCT), and to assess the prognostic value of the colonic and extracolonic findings detected. METHODS AND MATERIALS The survival of a cohort of 1029 elderly and frail patients, with clinical symptoms and signs suspicious for colorectal cancer (CRC), who had undergone MPCT between 1995 and 1998 was investigated. Univariate and multivariate survival analyses were undertaken according to the presence of CRC and extracolonic abnormalities (ECA). RESULTS The median age of the 1029 patients was 79.4 years. The overall median survival following MPCT was 5.4 years; and 6.6 years if no abnormality was detected. On multivariate analysis, age, sex, CRC status, and number of ECAs were significant factors in overall survival. Median survival for those with confirmed CRC [n=91 (prevalence, 8.8%)] was 1.1 years, compared with 5.9 years without CRC (p<0.0001); and 2.4 years for those with one or more ECA [n=245 (prevalence, 23.8%)], compared with 6.1 years without ECA (p<0.0001). Survival was progressively shorter for increasing numbers of ECAs; and shorter for previously unknown non-CRC malignancies (n=24) compared with CRC (p<0.0001). CONCLUSIONS MPCT appears to have prognostic potential in this patient population, with significant reductions in survival if a CRC or ECA is detected. The detection of ECA would appear to have at least as important an impact on the usefulness of the examination as the detection of CRC.

Excavated tumours of the gut.

Excavated tumours of the gut are relatively uncommon. We describe four cases of cavitating tumours which have arisen from non-epithelial elements in the bowel wall. Three of these were characterised by an extensive extraluminal component which resulted in the appearance of a cavitated mass outside the bowel lumen.

Diagnostic implications of digital breast tomosynthesis in symptomatic patients

The purpose of this study was to assess the diagnostic performance/utility of digital breast tomosynthesis (DBT) in symptomatic patients in a multidisciplinary clinical setting.

The Acute Stomach and Duodenum

Perforation of peptic ulcer is the most common cause of pneumoperitoneum. Anterior wall ulcers of the stomach and duodenal bulb usually perforate freely into the intraperitoneal space, whereas posterior wall gastric ulcers perforate into the lesser sac. However, a significant proportion of perforated gastric and duodenal ulcers seal off immediately, and free intraperitoneal air can be detected on plain radiography in only 70% of the patients (Rubesin and Levine 2003). An erect chest radiograph and a supine abdominal radiograph are usually obtained if perforation is suspected. Both are very sensitive, and as little as 1 ml of free air can be detected on the horizontal beam examination, which may be aided by the use of a decubitus abdominal radiograph (Fig. 12.1a,b) (Levine et al. 1991). On the erect chest radiograph, air may be shown under one or other diaphragmatic surfaces but rarely both are outlined by air, hence the “continuous diaphragm” sign (Fig. 12.2). Signs of free intraperitoneal air on a supine abdominal radiograph include the “lucent liver” sign, which is air overlying the liver (Fig. 12.3), the “Doges’ cap” sign due to a triangle of air in Morrison’s pouch (Fig. 12.4), and the “falciform ligament” sign.