Anmol Malhotra

Metastases to the breast revisited: radiological-histopathological correlation.

Metastases to the breast from extramammary tumours are infrequent. The main challenge in diagnosis is differentiating them from primary breast cancer. Radiologically this can be difficult as there are no specific imaging characteristics for metastases to the breast. Cytopathological evaluation, as well as full radiological assessment, is vital to avoid unnecessary surgery. Sources of primary tumours include a wide variety of cancers. In this pictorial review we illustrate a number of the commonest sources of primary tumours including lymphoma, lung, ovarian and cervical carcinoma, intestinal carcinoid and rare cases of Ewings sarcoma and malignant pigmented melanocytic schwannoma (low-grade malignant melanoma).

Imaging of primary central nervous system lymphoma

Primary central nervous system lymphoma (PCNSL) comprises 5% of all primary brain tumours. PCNSL demonstrates a variety of well-documented imaging findings, which can vary depending on immune status and histological type. Imaging features of PCNSL may overlap with other tumours and infection making definitive diagnosis challenging. In addition, several rare variants of PCNSL have been described, each with their own imaging characteristics. Advanced imaging techniques including 2-[(18)F]-fluoro-2-deoxy-d-glucose ((18)FDG) and (11)Cxa0positron-emission tomography (PET), (201)Tl single-photon emission computed tomography (SPECT), (1)H-magnetic resonance spectroscopy (MRS), and MR perfusion, have been used to aid differentiation of PCNSL from other tumours. Ultimately, no imaging method can definitively diagnose PCNSL, and histology is required.

Complications of Continuous Ambulatory Peritoneal Dialysis

Continuous ambulatory peritoneal dialysis (CAPD) is used to treat end-stage renal failure in an increasing number of patients. CAPD has an advantage over hemodialysis in that it allows patients greater freedom to perform daily activities; it also provides other clinical benefits. However, the long-term effectiveness of CAPD is limited by complications, which have various causes. Complications with an infectious cause include bacterial peritonitis, tuberculous peritonitis, and infections of the catheter exit site and tunnel. Noninfectious complications include catheter dysfunction, dialysate leakage, hernias, and sclerosing encapsulating peritonitis. Many imaging modalities-radiography, ultrasonography, peritoneal scintigraphy, computed tomography (CT), and magnetic resonance (MR) imaging-are useful for characterizing these complications. CT peritoneography and MR peritoneography are techniques specifically suited to this purpose. Imaging plays a critical role in ensuring that complications are detected early and managed appropriately.

18F-FDG PET and biomarkers for tumour angiogenesis in early breast cancer

PurposeTumour angiogenesis is an independent and strong prognostic factor in early breast carcinoma. We performed this study to investigate the ability of 18F-FDG to detect angiogenesis in early breast carcinoma using PET/CT.MethodsTwenty consecutive patients with early (T1-T2) breast carcinoma were recruited prospectively for 18F-FDG PET/CT. The PET/CT data were used to calculate whole tumour maximum standardized uptake value (SUVmax) and mean standardized uptake value (SUVmean). All patients underwent subsequent surgery without prior chemotherapy or radiotherapy. The excised tumour underwent immunohistochemistry for vascular endothelial growth factor (VEGF), CD105 and glucose transporter protein 1 (GLUT1).ResultsThe SUVmax showed the following correlation with tumour histology: CD105: ru2009=u20090.60, pu2009=u20090.005; GLUT1: ru2009=u20090.21, pu2009=u20090.373; VEGF: ru2009=u2009−0.16, pu2009=u20090.496. The SUVmean showed the following correlation with tumour histology: CD105: ru2009=u20090.65, pu2009=u20090.002; GLUT1: ru2009=u20090.34, pu2009=u20090.144; VEGF: ru2009=u2009−0.18, pu2009=u20090.443Conclusion18F-FDG uptake is highly significantly associated with angiogenesis as measured by the immunohistochemistry with CD105 for new vessel formation. Given that tumour angiogenesis is an important prognostic indicator and a predictor of treatment response, 18F-FDG PET may have a role in the management of primary breast cancer patients even in early-stage disease.

Neuroendocrine tumors: role of interventional radiology in therapy.

The management of neuroendocrine tumors (NETs) is complex. Although NETs can affect a variety of organ systems, hepatic metastatic disease in particular lends itself to a wide range of interventional treatment options. Prior detailed radiologic assessment and careful patient selection are required. Curative surgery should always be considered but is rarely possible. Embolization, radionuclide therapy, or ablative techniques may then be undertaken. Transcatheter arterial embolization (TAE) may be used alone or in combination with transcatheter arterial chemoembolization (TACE). NET type and extent of hepatic involvement are factors that can help predict the success of either TAE or TACE. Embolization techniques can also be useful in patients with nonhepatic NETs. Radionuclide therapy is emerging as a valuable adjunct and is dependent on positive somatostatin receptor status. Therapeutic radiopeptides may be delivered arterially. Ablative techniques have been shown to play a role in the palliation of symptoms and principally involve radiofrequency ablation. Hepatic cryotherapy and percutaneous ethanol injection have also been used. A multidisciplinary approach to treatment and follow-up is important. Imaging should involve dual-phase multidetector computed tomography and contrast material-enhanced magnetic resonance imaging. The role of the interventional radiologist will continue to expand as imaging techniques become more refined.

CT-guided deep inferior epigastric perforator (DIEP) flap localization — Better for the patient, the surgeon, and the hospital

AIMSnTo define the clinical benefits to the patient of preoperative imaging planning for deep inferior epigastric perforator (DIEP) flap reconstruction.nnnMATERIALS AND METHODSnSince 2009 computed tomography angiography (CTA) has been provided for the preoperative planning of DIEP flap breast reconstruction in the largest plastic surgery unit in southeast England. In a retrospective, cohort-control study the outcomes of 100 consecutive patients who underwent preoperative CTA planning were compared with a closely-matched control group who underwent ultrasound planning only. The cohorts were evaluated for operative duration, mean operative blood loss and transfusion requirement, morbidity and flap or donor-site complications.nnnRESULTSnThere were statistically significant improvements in mean operative duration (p < 0.05), intra-operative blood loss (p < 0.05), shorter mean inpatient stay (p < 0.05) for the CTA planning versus the ultrasound planning of DIEP flap reconstruction.nnnCONCLUSIONnStatistically significant benefits were demonstrated in key aspects of the surgical procedure following CTA-guided planning. The implications of these benefits are profound in terms of pure healthcare cost benefits.

Mechanical Thrombectomy of Occluded Hemodialysis Native Fistulas and Grafts Using a Hydrodynamic Thrombectomy Catheter: Preliminary Experience

The purpose of this study was to evaluate the efficacy and safety of a new hydrodynamic percutaneous thrombectomy catheter in the treatment of thrombosed hemodialysis fistulas and grafts. Twenty-two patients (median age: 47 years; range: 31–79 years) underwent mechanical thrombectomy for thrombosed hemodialysis fistulas or polytetrafluoroethylene (PTFE) grafts. In all cases, an Oasis hydrodynamic catheter was used. Five patients had native fistulas and 17 had PTFE grafts. Six patients required repeat procedures. All patients with native fistulas and 15 of the 17 with PTFE grafts also underwent angioplasty of the venous limb following the thrombectomy. Major outcome measures included technical success, clinical success, primary and secondary patency, and complication rates. Twenty-eight procedures were performed in total. The technical success rate was 100% and 90% and clinical success was 86% and 76% for native fistulas and grafts, respectively. The primary patency at 6 months was 50% and 59% for fistulas and grafts, respectively, and the secondary patency at 6 months was 75% and 70% for fistulas and grafts, respectively. Two patients died of unrelated causes during the follow-up period. The Oasis catheter is an effective mechanical device for the percutaneous treatment of thrombosed hemodialysis access. Our initial success rate showed that the technique is safe in the treatment of both native fistulas and grafts.

Imaging and Histopathologic Features of HIV-related Renal Disease

Despite extraordinary recent advances in the management of human immunodeficiency virus (HIV) infection and acquired immunodeficiency syndrome, patients infected with HIV are still susceptible to a variety of complications that stem either from immunodeficiency or from side effects of antiretroviral regimens. Diagnosis is often challenging, since every organ in the body can be affected by HIV, and the kidneys have been increasingly shown to be involved by a variety of disease processes. Opportunistic infections including those caused by atypical organisms, malignancies such as lymphoma and Kaposi sarcoma, and disease processes specific to HIV infection such as HIV-associated nephropathy have all been shown to affect the kidneys. In this era of highly active antiretroviral therapy (HAART), renal disease arising secondary to antiretroviral medication has been added to the list. Furthermore, the introduction of HAART has increased survival of HIV-infected patients; consequently, the frequency of HIV-associated and incidental renal disease is expected to rise in this population. Because mortality and morbidity rates are affected by the early recognition of renal disease in HIV-infected patients, it is paramount that the radiologist be familiar with the imaging features that can be encountered in such cases.

Defining the Role of PET–CT in Staging Early Breast Cancer

INTRODUCTIONnCurrently, there is a lack of data on the role of combined positron emission tomography-computed tomography (PET-CT) in the staging of early invasive primary breast cancer. We therefore evaluated the role of (18)F-fluorodeoxyglucose ((18)F-FDG)-PET-CT in this patient population.nnnMETHODSnWe prospectively recruited 70 consecutive patients (69 women, one man; mean age, 61.9 ± 8.1 years) with early primary breast cancer for staging with (18)F-FDG-PET-CT. All PET-CT images were interpreted by two readers (independently of each other). A third reader adjudicated any discrepancies. All readers had ≥5 years of specific experience. Ethics board approval and informed consent were obtained.nnnRESULTSnThe mean clinical follow-up was 22.7 ± 12.6 months. The primary tumor was identified with PET-CT in 64 of 70 patients. Of the unidentified lesions, surgical pathology revealed two intraductal carcinomas, one invasive tubular carcinoma, and three invasive lobular carcinomas. Undiagnosed multifocal breast disease was shown in seven of 70 patients. PET-CT identified avid axillary lymph nodes in 19 of 70 patients, compared with 24 of 70 confirmed during surgery. There were four patients who were axillary node positive on PET but had no axillary disease at surgery. Five patients were reported with avid metastases. Two of those patients were treated for metastatic disease (nodal, lung, and liver in one and bone metastases in the other) following further imaging and clinical assessment. In the other three patients, lesions (lung, n = 1; pleural, n = 1; paratrachael node, n = 1) were subsequently diagnosed as benign lesions.nnnCONCLUSIONnIntegrated (18)F-FDG-PET-CT may have a role in staging patients presenting with early breast cancer.

Clinico-pathologic characteristics of patients with hepatic lymphoma diagnosed using image-guided liver biopsy techniques

Abstract Primary hepatic lymphoma is a rare presentation of a common disease. Diagnosis is difficult due to the risks of liver biopsy. We report the clinico-pathologic features of this presentation and specifically the utility of image-guided biopsy as a safe method of diagnosis. We retrospectively studied patients diagnosed with ‘hepatic lymphoma’ at a single center. Twenty-two patients fulfilled the criteria. Median age was 53 years (range 29–87). Nine patients were human immunodeficiency virus (HIV)-positive. The most frequent mode of presentation was with B-symptoms (15/22). All procedures were successful at obtaining diagnostic material with no complications. Six patients had synchronous bone marrow involvement. Nineteen patients received chemotherapy (10 had dose reductions) with an overall response rate of 74%. After a median follow-up of 19 months, 12 patients had died; the median overall survival (OS) was 4 months. Grade 3 or 4 aspartate transaminase (AST) abnormality was associated with very poor outcome. The OS of patients with hepatic lymphoma is poor. However, a response to modern induction therapies may predict a better outcome. The optimal dose adjustment of chemotherapy in this setting is unclear. In patients without readily accessible tissue, an image-guided core biopsy of hepatic lesions is a safe procedure with high diagnostic yield.