Eline E. Deurloo

Ultrasonography‐guided fine‐needle aspiration cytology before sentinel node biopsy in patients with penile carcinoma

To assess the accuracy of ultrasonography (US)‐guided fine‐needle aspiration cytology (FNAC) for detecting occult lymph node metastases in patients with squamous cell carcinoma of the penis.

Radio-guided surgery improves outcome of therapeutic excision in non-palpable invasive breast cancer.

Intratumoral injection of a radiocolloid for lymphatic mapping enables the therapeutic excision of clinically occult breast cancer with the aid of a gamma-ray detection probe. The aim of this study was to determine the success rate of radio-guided tumour excision in addition to a guide wire and to identify factors predicting clear margins. Sixty-five consecutive patients underwent radio-guided tumour excision after intratumoral injection of 99mTc-nanocolloid guided by ultrasound or stereotaxis. A localization wire was inserted after scintigraphy had been performed (group 1). The results were compared with retrospective data from 67 consecutive patients who underwent therapeutic wire-directed excision alone (group 2). Factors predicting clear margins (≥1 mm) were determined in a logistic regression model. Adequate margins were obtained in 83% of group 1 and in 64% of group 2 (P=0.014). The invasive component was incompletely excised in two patients in group 1 and in 14 patients in group 2. Further surgery was performed in four patients in group 1 and in 14 patients in group 2. Factors predictive of clear margins were decreasing pathological tumour diameter (P=0.035), increasing weight of the specimen (P=0.046), absence of microcalcifications (P=0.004) and absence of carcinoma in situ component (P=0.024). Radio-guided excision was an independent predictor of complete excision of the invasive component (P=0.012). The application of radio-guided surgery combined with wire localization seems to improve the outcome of therapeutic excision of non-palpable invasive breast cancer compared with wire-directed excision alone.

MRI of the breast in patients with DCIS to exclude the presence of invasive disease

AbstractObjectivesCore biopsy underestimates invasion in more than 20% of patients with preoperatively diagnosed ductal carcinoma in situ (DCIS) without evidence of invasion (pure DCIS). The aim of the current study was to evaluate the efficacy of preoperative magnetic resonance imaging (MRI) to discriminate between patients with DCIS who are at high risk of invasive breast cancer and patients at low risk.MethodsOne hundred and twenty-five patients, preoperatively diagnosed with pure DCIS (128 lesions; 3 bilateral) by core-needle biopsy, were prospectively included. Clinical, mammographic, histological (core biopsy) and MRI features were assessed. All patients underwent breast surgery. Analyses were performed to identify features associated with presence of invasion.ResultsEighteen lesions (14.1%) showed invasion on final histology. Seventy-three lesions (57%) showed suspicious enhancement on MRI with a type 1 (n = 12, 16.4%), type 2 (n = 19, 26.0%) or type 3 curve, respectively (n = 42, 57.5%). At multivariate analysis, the most predictive features for excluding presence of invasive disease were absence of enhancement or a type 1 curve on MRI (negative predictive value 98.5%; AZ 0.80, P = 0.00006).ConclusionContrast medium uptake kinetics at MRI provide high negative predictive value to exclude presence of invasion and may be useful in primary surgical planning in patients with a preoperative diagnosis of pure DCIS.Key Points• It is important to determine invasion in breast DCIS. • MRI contrast medium uptake kinetics can help exclude the presence of invasion.• However, the positive predictive value for the presence of invasion is limited.• MRI features were more accurate at predicting invasion than mammographic features alone.

A Systematic Literature Review of Imaging Definitions for Detection of Bone and Bone Marrow Metastases in Neuroblastoma Patients

Objective: The presence of bone and bone marrow (BM) metastases in neuroblastoma patients are independent adverse prognostic factors, so precise and consistent definitions of both categories on imaging are important. The objectives of this systematic review were to identify all definitions reported for detection of bone and bone marrow metastases on imaging in neuroblastoma to determine diagnostic accuracies of the most frequently used definitions for detection of bone and/or BM metastases on each imaging technique. Methods: We searched MEDLINE/PubMed (1945 to April 2013) and EMBASE/Ovid (1980 to April 2013). Full-text original studies were included if they reported definitions of bone and/or BM metastases on diagnostic imaging of children with suspected metastatic neuroblastoma. As reference standard for bone metastases bone scintigraphy was used and for bone marrow metastases bone marrow biopsies/aspirates. Methodological quality was assessed. Results: Of 403 identified studies (plus one relevant reference), 131 were assessed in full-text and 31 finally included, 23 described BM metastases and 18 bone metastases. No uniform definitions of bone and bone marrow metastases were reported for each imaging method. On MIBG scintigraphy bone metastases were mostly defined as “focal” and BM metastases as “diffuse” and on MRI both definitions were used for BM metastases. The diagnostic accuracy of different diagnostic methods to detect bone (reference test bone scintigraphy) or BM (reference test bone marrow biopsies/ trephines) metastases varied widely. Conclusion: No uniform definitions of bone and bone marrow metastases were reported for each imaging method and concerning the diagnostic accuracy no general conclusions could be drawn.

Neoplasms of the Genitourinary System

Nephroblastoma or Wilms’ tumor (WT) is the most common renal neoplasm in children accounting for 90 % of pediatric renal tumors (Pastore et al. 2006). It is a tumor with a good prognosis and with well-established treatment strategies. Other rare malignant renal tumors, such as clear cell sarcoma and rhabdoid tumor of the kidney, have a poor prognosis despite aggressive treatment. Renal cell carcinoma occurs in older children, while mesoblastic nephroma is the most frequent renal tumor in the neonate. Hematological malignancies, the most frequent neoplasms in children, may also involve the kidney, most often as part of a multi-organ involvement. Renal infections and malformations are much more common in children than renal tumors and may show a pseudotumoral pattern mimicking a renal tumor. In all cases, close collaboration among radiologists, pediatricians, and pathologists is essential so as to avoid diagnostic pitfalls due to atypical presentations.

Acute Abdominal Presentations of Neoplasia and Malignant Hemopathies

Children with an abdominal neoplasm or a malignant hemopathy may present with acute abdominal symptoms at any time during the course of their disease. The symptoms may be the first manifestation of cancer, they can be related to the subsequent therapy and may occur when there is progression or recurrence.

The impact of reconstruction techniques on observer performance for the detection and characterization of small pulmonary nodules in chest CT of children under 13 years

OBJECTIVE To compare three different reconstruction techniques of CT data for the detection of pulmonary nodules in children under 13 years. Secondly to assess the prevalence of perifissural nodular opacities. MATERIALS AND METHODS The study consisted of chest CTs of 31 children (median age 6.9 years, range 2.1-12.7), of whom 17 had known extra-thoracic malignancies. Four observers assessed three techniques for the presence of nodules: axial 5 mm maximum intensity projections (MIPs) used in conjunction with 1 mm slices (mode A), 1 mm slices alone (mode B) and 3 mm slices (mode C). All modes were available in 3D. Per mode sensitivities were determined above a certain threshold of reader agreement. Confidence level and reader agreement for identification of an opacity as nodule served as surrogate for quality of nodule characterization. RESULTS 103 nodules (median size 2.0 mm) were detected. Mode A yielded the highest interreader agreement (κ 0.336) and a superior sensitivity (71%, p = 0.003) compared to mode B and C (κ 0.218, sensitivity 57% and κ 0.247, sensitivity 56%, respectively). Mode B provided the highest confidence level and interreader agreement with respect to nodule identification (mean 4.3/5, κw 0.508). Double reading improved and evened interreader agreement for all modes (κ 0.450), mode A maintained the highest sensitivity (89.1%, p = 0.05-0.08). A median of 1 intrapulmonary lymph node/patient was seen in children with and without malignancy. CONCLUSION MIP improves the detection of pulmonary nodules in chest CTs of children, but overall interreader agreement is only fair. Double reading represents a powerful tool to increase diagnostic reliability in chest CTs of children with a malignancy. Nodule characterization is best with 1 mm slices. Intrapulmonary lymph nodes occur in children with and without malignancy.