Francesco Sardanelli

Magnetic resonance imaging of the breast: Recommendations from the EUSOMA working group

The use of breast magnetic resonance imaging (MRI) is rapidly increasing. EUSOMA organised a workshop in Milan on 20-21st October 2008 to evaluate the evidence currently available on clinical value and indications for breast MRI. Twenty-three experts from the disciplines involved in breast disease management - including epidemiologists, geneticists, oncologists, radiologists, radiation oncologists, and surgeons - discussed the evidence for the use of this technology in plenary and focused sessions. This paper presents the consensus reached by this working group. General recommendations, technical requirements, methodology, and interpretation were firstly considered. For the following ten indications, an overview of the evidence, a list of recommendations, and a number of research issues were defined: staging before treatment planning; screening of high-risk women; evaluation of response to neoadjuvant chemotherapy; patients with breast augmentation or reconstruction; occult primary breast cancer; breast cancer recurrence; nipple discharge; characterisation of equivocal findings at conventional imaging; inflammatory breast cancer; and male breast. The working group strongly suggests that all breast cancer specialists cooperate for an optimal clinical use of this emerging technology and for future research, focusing on patient outcome as primary end-point.

Multicenter surveillance of women at high genetic breast cancer risk using mammography, ultrasonography, and contrast-enhanced magnetic resonance imaging (the high breast cancer risk italian 1 study): final results.

Objectives:To prospectively compare clinical breast examination, mammography, ultrasonography, and contrast-enhanced magnetic resonance imaging (MRI) in a multicenter surveillance of high-risk women. Materials and Methods:We enrolled asymptomatic women aged ≥25: BRCA mutation carriers; first-degree relatives of BRCA mutation carriers, and women with strong family history of breast/ovarian cancer, including those with previous personal breast cancer. Results:A total of 18 centers enrolled 501 women and performed 1592 rounds (3.2 rounds/woman). Forty-nine screen-detected and 3 interval cancers were diagnosed: 44 invasive, 8 ductal carcinoma in situ; only 4 pT2 stage; 32 G3 grade. Of 39 patients explored for nodal status, 28 (72%) were negative. Incidence per year-woman resulted 3.3% overall, 2.1% <50, and 5.4% ≥50 years (P < 0.001), 4.3% in women with previous personal breast cancer and 2.5% in those without (P = 0.045). MRI was more sensitive (91%) than clinical breast examination (18%), mammography (50%), ultrasonography (52%), or mammography plus ultrasonography (63%) (P < 0.001). Specificity ranged 96% to 99%, positive predictive value 53% to 71%, positive likelihood ratio 24 to 52 (P not significant). MRI showed significantly better negative predictive value (99.6) and negative likelihood ratio (0.09) than those of the other modalities. At receiver operating characteristic analysis, the area under the curve of MRI (0.97) was significantly higher than that of mammography (0.83) or ultrasonography (0.82) and not significantly increased when MRI was combined with mammography and/or ultrasonography. Of 52 cancers, 16 (31%) were diagnosed only by MRI, 8 of 21 (38%) in women <50, and 8 of 31 (26%) in women ≥50 years of age. Conclusion:MRI largely outperformed mammography, ultrasonography, and their combination for screening high-risk women below and over 50.

Autologous hematopoietic stem cell transplantation suppresses Gd-enhanced MRI activity in MS.

Background: Autologous hematopoietic stem cell transplantation (ASCT) has been recently utilized with encouraging results in patients with poorly controlled MS. Objective: To determine in severe cases of MS the effect of ASCT on gadolinium (Gd)-enhanced MRI and to obtain information on clinical course and safety. Methods: In a cooperative study, 10 patients with rapidly evolving secondary progressive MS were transplanted, after BEAM conditioning regimen (carmustine, etoposide, cytosine-arabinoside, and melphalan), with unmanipulated autologous peripheral blood SC mobilized with high-dose cyclophosphamide (CY; 4 g/m2) and granulocyte-colony-stimulating factor. Triple-dose Gd-enhanced scans were performed monthly for a pretreatment period of 3 months and compared with serial monthly Gd-enhanced MRI for the following 6 months and then once every 3 months. Results: The median follow-up is now 15 months (range 4 to 30 months). The number of Gd-enhancing lesions decreased immediately after mobilization with CY and finally dropped to zero in all cases after the conditioning regimen. The number of new T2-weighted positive lesions paralleled data obtained for Gd-enhanced MRI. Clinically, patients improved slightly or remained stable. Conclusion: These results demonstrate that the therapeutic sequence CY–BEAM–ASCT has the capacity to completely suppress MR-enhancing activity, an effect that is sustained with time. The final impact of this procedure on disease course remains to be established.

Rotator Cuff Calcific Tendonitis: Short-term and 10-year Outcomes after Two-Needle US-guided Percutaneous Treatment— Nonrandomized Controlled Trial

PURPOSE To compare short- and long-term outcomes of patients with rotator cuff calcific tendonitis who did and did not undergo ultrasonographically (US)-guided percutaneous treatment. MATERIALS AND METHODS Institutional review board approval and informed patient consent were obtained. Of patients referred for US-guided treatment of rotator cuff calcific tendonitis, 219 (86 men, 133 women; mean age, 40.3 years +/- 10.9 [standard deviation]) were treated; 68 (31 men, 37 women; mean age, 40.2 years +/- 11.3) patients refused treatment and served as control subjects. After local anesthesia was induced, two 16-gauge needles were inserted into the calcific deposit. Saline solution was injected through one needle, and the dissolved calcium was extracted through the other needle. Shoulder joint function was assessed by using Constant scores, and pain was assessed by using visual analogue scale (VAS) scores. Mann-Whitney U and chi(2) tests were performed. RESULTS At baseline, no significant difference in age or sex distribution, Constant score, or VAS score was detected between treated and nontreated (control) patients. Compared with control subjects, treated patients reported a significant decrease in symptoms at 1 month (mean Constant score, 73.2 +/- 6.2 vs 57.5 +/- 3.9; mean VAS score, 4.8 +/- 0.6 vs 9.1 +/- 0.5), 3 months (mean Constant score, 90.2 +/- 2.6 vs 62.6 +/- 7.2; mean VAS score, 3.3 +/- 0.4 vs 7.3 +/- 1.8), and 1 year (mean Constant score, 91.7 +/- 3.1 vs 78.4 +/- 9.5; mean VAS score, 2.7 +/- 0.5 vs 4.5 +/- 0.9) (P < .001). Symptom scores were not significantly different between the groups at 5 years (mean Constant score, 90.9 +/- 3.6 vs 90.5 +/- 4.8; mean VAS score, 2.6 +/- 0.5 vs 2.8 +/- 0.7) (P >or= .795) and 10 years (mean Constant score, 91.8 +/- 5.0 vs 91.3 +/- 9.6; mean VAS score, 2.5 +/- 0.6 vs 2.7 +/- 0.6) (P >or= .413). CONCLUSION US-guided percutaneous treatment facilitated prompt shoulder function recovery and pain relief. Treated patients had better outcomes than did nontreated patients at 1 year. However, 5 and 10 years after the procedure, the nontreated group reported outcomes similar to those of the treated group.

Early prediction of pathologic response to neoadjuvant therapy in breast cancer: Systematic review of the accuracy of MRI

Magnetic resonance imaging (MRI) has been proposed to have a role in predicting final pathologic response when undertaken early during neoadjuvant chemotherapy (NAC) in breast cancer. This paper examines the evidence for MRIs accuracy in early response prediction. A systematic literature search (to February 2011) was performed to identify studies reporting the accuracy of MRI during NAC in predicting pathologic response, including searches of MEDLINE, PREMEDLINE, EMBASE, and Cochrane databases. 13 studies were eligible (total 605 subjects, range 16-188). Dynamic contrast-enhanced (DCE) MRI was typically performed after 1-2 cycles of anthracycline-based or anthracycline/taxane-based NAC, and compared to a pre-NAC baseline scan. MRI parameters measured included changes in uni- or bidimensional tumour size, three-dimensional volume, quantitative dynamic contrast measurements (volume transfer constant [Ktrans], exchange rate constant [k(ep)], early contrast uptake [ECU]), and descriptive patterns of tumour reduction. Thresholds for identifying response varied across studies. Definitions of response included pathologic complete response (pCR), near-pCR, and residual tumour with evidence of NAC effect (range of response 0-58%). Heterogeneity across MRI parameters and the outcome definition precluded statistical meta-analysis. Based on descriptive presentation of the data, sensitivity/specificity pairs for prediction of pathologic response were highest in studies measuring reductions in Ktrans (near-pCR), ECU (pCR, but not near-pCR) and tumour volume (pCR or near-pCR), at high thresholds (typically >50%); lower sensitivity/specificity pairs were evident in studies measuring reductions in uni- or bidimensional tumour size. However, limitations in study methodology and data reporting preclude definitive conclusions. Methods proposed to address these limitations include: statistical comparison between MRI parameters, and MRI vs other tests (particularly ultrasound and clinical examination); standardising MRI thresholds and pCR definitions; and reporting changes in NAC based on test results. Further studies adopting these methods are warranted.

Contrast-Enhanced Breast MRI in Patients with Suspicious Microcalcifications on Mammography: Results of a Multicenter Trial

OBJECTIVE The objective of our study was to test dynamic MRI in evaluating mammographically detected suspicious microcalcifications. MATERIALS AND METHODS One hundred twelve patients with mammographically detected microcalcifications with BI-RADS category 5 (n = 78) or 4 (n = 34) lesions were studied at 17 centers a using 3D gradient-echo dynamic coronal technique (< or = 3 mm thickness) and 0.1 mmol/kg of gadoteridol. A pathologic sample was obtained in all cases. Agreement between the major diameter measured on mammography, MRI, or both and the major diameter measured at pathologic examination was calculated in 62 cases. RESULTS Of the 112 lesions, pathologic examination revealed 37 benign lesions, 33 ductal carcinoma in situ (DCIS), and 42 invasive carcinomas. The specificity of MRI for benign lesions was 68%. Considering the subgroups of calcifications alone and calcifications associated with masses, the specificity values became 79% and 33%, respectively. The sensitivity of MRI for DCIS was 79%. Analysis of the two subgroups showed sensitivity values of 68% for calcifications alone and of 1% for calcifications associated with masses. The sensitivity for invasive carcinomas was 93%. Analysis of the two subgroups showed sensitivity values to be 92% for calcifications alone and 94% for calcifications associated with masses. Considering the overall results, the sensitivity of MRI was 87%; specificity, 68%; positive predictive value, 84%; negative predictive value, 71%; and accuracy, 80%. Considering the subgroups of calcifications alone and calcifications associated with masses, the sensitivity values became 80% and 97%; the positive predictive values, 86% and 82%; the negative predictive values, 71% and 75% (95% confidence interval [CI], 0.19-0.99); and the accuracy values, 80% and 82% (95% CI, 0.66-0.92), respectively. An odds ratio (OR) of 13.54 (95% CI, 5.20-35.28) showed a raised risk of malignant breast tumor in subjects with positive MR examination of mammographically detected suspicious clusters of microcalcifications. The statistical analysis on each subgroup showed an OR of 15.07 (95% CI, 4.73-48.08) for calcifications alone and an OR of 14.00 (95% CI, 1.23-158.84) for calcifications associated with masses. Any significant improvement in the predictive ability of dynamic MRI depending on the extent of calcifications on mammography was not proved. Considering the 62 cases of proved malignancy with measured maximal diameter at pathologic examination, both mammography and MR examination seem to overestimate tumor extent. CONCLUSION The not-perfect sensitivity of MRI (87%), when applying our interpretation criteria and imaging sequences, is a crucial point that prevents us from clinical use of MRI in the diagnosis of mammographically detected microcalcifications.

In Vivo Evaluation of the Chemical Composition of Urinary Stones Using Dual-Energy CT

OBJECTIVE The purpose of this article is to evaluate in vivo the chemical composition of urinary stones using dual-source and dual-energy CT, with crystallography as the reference standard. MATERIALS AND METHODS Forty patients (mean [± SD] age, 49 ± 17 years) with known or suspected nephrolithiasis underwent unenhanced abdominal CT for urinary tract evaluation using a dual-energy technique (tube voltages, 140 and 80 kVp). For each stone 5 mm or larger in diameter, we evaluated the site, diameter, CT density, surface (smooth vs rough), and stone composition. Patients were treated with extracorporeal shock wave lithotripsy (n = 34), percutaneous nephrolithotomy (n = 4), or therapeutic ureterorenoscopy (n = 2). Collected stones underwent crystallography, and the agreement with the results of dual-energy CT was calculated with the Cohen kappa coefficient. The correlation among stone composition, diameter, and CT density was estimated using the Kruskal-Wallis test. RESULTS Thirty-one patients had a single stone and nine had multiple stones, for a total of 49 stones. Forty-five stones were in the kidneys, and four were in the ureters; 23 had a smooth surface and 26 had a rough surface. The mean stone diameter was 12 ± 6 mm; mean CT density was 783 ± 274 HU. According to crystallography, stone composition was as follows: 33 were calcium oxalate, seven were cystine, four were uric acid, and five were of mixed composition. Dual-energy CT failed to identify four stones with mixed composition, resulting in substantial agreement between dual-energy CT and crystallography (Cohen κ = 0.684). Stone composition was not correlated with either stone diameter (p = 0.920) or stone CT density (p = 0.185). CONCLUSION CT showed excellent accuracy in classifying urinary stone chemical composition, except for uric acid-hydroxyapatite mixed stones.

In Vivo Proton MR Spectroscopy of the Breast Using the Total Choline Peak Integral as a Marker of Malignancy

OBJECTIVE The purpose of our study was to use the total choline-containing compound (tCho) peak integral as a marker of malignancy in breast MR spectroscopy (MRS). SUBJECTS AND METHODS Forty-eight single-voxel water- and fat-suppressed 1.5-T MRS measurements were performed in 42 patients, obtaining both absolute tCho peak integral and tCho peak integral normalized for the volume of interest (VOI). Our reference standard was histology for lesions with BI-RADS category 4 and 5 and histology or at least a 2-year follow-up for findings with BI-RADS 2 and 3 and normal glands. Receiver operating characteristic (ROC) analysis, Mann-Whitney U test, and Spearmans rank correlation were used. RESULTS Three of 48 measurements (6%) failed. Of the remaining 45 spectra, 18 nonmalignant tissues showed no tCho peak, eight nonmalignant tissues showed a tCho peak integral from 0.99 to 9.03 arbitrary units (AU), and 19 malignant lesions showed a tCho peak integral from 1.26 to 19.80 AU. The diameter of nonmalignant tissues was 16.9 +/- 7.4 mm; that of malignant lesions was 15.3 +/- 6.9 mm (p = 0.308). At ROC analysis, the optimal threshold was 1.90 AU for absolute tCho peak, with 0.895 (17/19) sensitivity, 0.923 (24/26) specificity, and an AUC (area under the curve) of 0.917 (95% CI, 0.822-1.000); the optimal threshold was 0.85 AU/mL for the normalized tCho peak integral with 0.842 (16/19) sensitivity, 0.885 (23/26) specificity, and an AUC of 0.941 (0.879-1.000) (p = 0.470). A negative correlation (p = 0.011) was found between the VOI and the normalized tCho peak integral of malignant tissues. CONCLUSION Breast MRS using tCho peak integral reaches a high level of diagnostic performance.

Relation of Echocardiographic Epicardial Fat Thickness and Myocardial Fat

Epicardial and myocardial fats increase with degree of visceral adiposity and possibly contribute to obesity-associated cardiac changes. Echocardiographic epicardial fat thickness is a new and independent marker of visceral adiposity. The aim of this study was to test whether echocardiographic epicardial fat is related to myocardial fat. Twenty consecutive Caucasian men (body mass index 30.5 +/- 2 kg/m(2), 42 +/- 7 years of age) underwent transthoracic echocardiography for epicardial fat thickness, morphologic and diastolic parameter measurements, hydrogen-1 magnetic resonance spectroscopy for myocardial fat quantification, and magnetic resonance imaging for epicardial fat volume estimation. Hydrogen-1 magnetic resonance spectroscopic myocardial fat content, magnetic resonance imaging of epicardial fat volume, and echocardiographic epicardial fat thickness range varied from 0.5% to 31%, 4.5 to 43 ml, and 3 to 15 mm, respectively. Myocardial fat content showed a statistically significant correlation with echocardiographic epicardial fat thickness (r = 0.79, p <0.01), waist circumference (r = 0.64, p <0.01), low-density lipoprotein cholesterol (r = 0.54, p <0.01), plasma adiponectin levels (r = -0.49, p <0.01), and isovolumic relaxation time (r = 0.59, p <0.01). However, multivariate linear regression analysis showed epicardial fat thickness as the most significant independent correlate of myocardial fat (p <0.001). Although this study is purely correlative and no causative conclusions can be drawn, it can be postulated that increased echocardiographic epicardial fat accumulation could reflect myocardial fat in subjects with a wide range of adiposity.

Breast MRI: EUSOBI recommendations for women's information.

AbstractThis paper summarizes information about breast MRI to be provided to women and referring physicians. After listing contraindications, procedure details are described, stressing the need for correct scheduling and not moving during the examination. The structured report including BI-RADS® categories and further actions after a breast MRI examination are discussed. Breast MRI is a very sensitive modality, significantly improving screening in high-risk women. It also has a role in clinical diagnosis, problem solving, and staging, impacting on patient management. However, it is not a perfect test, and occasionally breast cancers can be missed. Therefore, clinical and other imaging findings (from mammography/ultrasound) should also be considered. Conversely, MRI may detect lesions not visible on other imaging modalities turning out to be benign (false positives). These risks should be discussed with women before a breast MRI is requested/performed. Because breast MRI drawbacks depend upon the indication for the examination, basic information for the most important breast MRI indications is presented. Seventeen notes and five frequently asked questions formulated for use as direct communication to women are provided. The text was reviewed by Europa Donna–The European Breast Cancer Coalition to ensure that it can be easily understood by women undergoing MRI.Key Points• Information on breast MRI concerns advantages/disadvantages and preparation to the examination • Claustrophobia, implantable devices, allergic predisposition, and renal function should be checked • Before menopause, scheduling on day 7–14 of the cycle is preferred • During the examination, it is highly important that the patient keeps still • Availability of prior examinations improves accuracy of breast MRI interpretation