Imrana Masroor

Frequency and Outcome of Carotid Atheromatous Disease in Patients With Stroke in Pakistan

Background and Purpose— Limited data exist on the frequency and outcome of carotid artery disease in Pakistan. Such information would help guide the usefulness of screening for the condition in this low-middle income health care setting. Methods— A prospective, descriptive study was conducted among 3 large teaching hospitals in Karachi, Pakistan. Patients referred for carotid Doppler ultrasound examination were included if they had experienced a stroke or TIA within the previous month. The severity and morphology of carotid disease were characterized by trained technicians using standardized criteria. Demographic and risk factor data were collected at baseline, and the outcome of patients was assessed at least 6 months later. Results— A total of 672 patients underwent bilateral carotid Doppler ultrasound (1344 carotid examinations). The findings revealed 0% to 50% stenosis in 526 (78%), 51% to 69% stenosis in 57 (8%), 70% to 99% stenosis in 82 (12%), and total occlusion in 7 patients (1%). Potentially surgically correctable disease, defined as 70% to 99% carotid artery stenosis, was present in only 79 (12%) patients, of whom 47 (60%) were ipsilateral symptomatic, 15 (20%) asymptomatic, and 17 (20%) had status unknown. Outcome information at ≥6 months follow-up was available for 36 of the 47 (76%) surgically correctable and only 4 of these patients (12%) had undergone surgical or radiological intervention (carotid endarterectomy in 3 patients and carotid stenting in 1 patient). Conclusion— The frequency of carotid artery disease of at least moderate severity is very low in patients with recent stroke or TIA and there is low utilization of high-cost, carotid intervention procedures in Pakistan. These data raise questions regarding the applicability and cost-effectiveness of routine carotid ultrasound screening in our country and similar population in Asia. The local socio-economic and clinical data do not support routine carotid Doppler ultrasound in every patient with stroke and TIA in Pakistan. Studies are warranted to determine predictors of significant carotid artery stenosis in stroke/TIA patients of our country to develop reliable stroke guidelines appropriate for local population.

Role of Ultrasound in Characterization of Ovarian Masses

BACKGROUND Ovarian cancer is the second most common malignancy in Pakistani women, accounting for 4% of all cancers in the female population. The aim of this study was to determine sensitivity, specificity, positive and negative predictive values and 95% confidence intervals for ultrasound in characterization of ovarian masses in patients presenting at public and private tertiary care hospitals in Karachi, Pakistan. MATERIALS AND METHODS We adopted a cross-sectional analytical study design to retrospectively collect data from January 2009-11 from medical records of two tertiary care hospitals. Using a non-probability purposive sampling technique, we recruited a sample of 86 women aged between 15 and 85 years fulfilling inclusion criteria with histopathologically proven ovarian masses presenting for an ultrasound examination in our radiology departments. RESULTS Our retrospective data depicted sensitivity and specificity of ultrasound to be 90.7%, 95%CI (0.77, 0.97) and 91.4%, 95%CI (0.76, 0.98) respectively. Positive predictive value was 93%, 95%CI (0.79, 0.98) and negative predictive value was 89%, 95%CI (0.73, 0.96). A total of 78 ovarian masses were detected, out of which 42 were malignant and 36 were benign. CONCLUSIONS Results of our study further reinforce the conclusion that ultrasound should be used as an initial modality of choice in the workup of every woman suspected of having an ovarian mass. It not only results in decreasing the mortality but also avoids unnecessary surgical interventions.

Evaluation of Common Risk Factors for Breast Carcinoma in Females: a Hospital Based Study in Karachi, Pakistan.

BACKGROUND Breast malignancies are one of the leading causes of deaths in females worldwide. There are a number of risk factors associated with breast cancer but in Karachi Pakistan there are insufficient data available. MATERIALS AND METHODS A case control study was conducted on females in age group between 30-80 years. This study was accomplished by retrospective data collection in Aga Khan University Hospital Karachi, Pakistan. A total of 108 females with primary malignancy of breast were included along with 108 matched controls. Relationship of various factors with disease was studied using logistic regression to calculate odds ratios with 95 % confidence intervals. RESULTS A total of 14 variables were analyzed and based on and 7 were found to be risk factors: old age, family history of breast cancer, family history of other carcinomas, personal history of breast carcinoma, early age of menarche, older age of mother at first delivery and lower number of children. Five factors, parity, breast feeding, history of oral contraceptive pills intake, past history of oophorectomy and hysterectomy showed protective associations. One variable, use of hormonal replacement therapy, showed a controversial link and one other, marital status, was not significant in this study. CONCLUSIONS It is concluded that most of the well-known risk factors for breast cancer are also associated with the disease in the female population of Karachi, Pakistan. High risk patients should be the focus with the help of this study so that screening can be more effective for early diagnosis before clinically evident breast malignancy.

Usefulness of hook wire localization biopsy under imaging guidance for nonpalpable breast lesions detected radiologically

Background The purpose of this study was to evaluate the usefulness of hook wire localization biopsy under imaging guidance for nonpalpable breast lesions detected radiologically. Methods This was a descriptive study conducted at the Department of Radiology, Aga Khan University Hospital, Karachi. All patients undergoing needle localization biopsy of a nonpalpable breast lesion under mammographic or ultrasound guidance between January 2009 to December 2010 were included in the study. Patients with incomplete medical records were excluded. All patients’ mammograms or ultrasound were categorized using BI-RADS® assessment categories. The percentages of benign and malignant lesions were determined by pathological examination of surgically removed specimens. A correlation was sought between preoperative imaging assessment and the final diagnosis. The complications associated with the procedure were also recorded. Results A total of 151 biopsies were carried out, of which 80 were performed under mammographic guidance and 71 were performed under ultrasound guidance. The mean age of the patients was 51.89 years. The overall malignancy rate was 25.16%. Of 93 cases reported radiologically as malignant, 60 turned out to be malignant, and of the 58 cases reported as benign on imaging, three proved to be malignant on histopathology. The sensitivity of imaging findings was 95% and the specificity was 62%. The malignancy rate was 5% for benign lesions and 64% for malignant lesions, respectively. There were no complications related to wire localization, and only two patients had minor complications following surgical excision, giving a complication rate of 1.32%. Conclusion Hook wire localization biopsy is a safe and effective procedure for definitive diagnosis of suspicious lesions on imaging, and is more helpful if the imaging findings are suspicious.

Evaluation of chronic liver disease: does ultrasound scoring criteria help?

Noninvasive approaches for assessment of liver histology include routine laboratory tests and radiological evaluation. The purpose of our study was to determine the utility of a simplified scoring system based on routinely evaluated ultrasound features for the evaluation of chronic liver disease and correlate it with the histological findings. For this cross-sectional analytical study the data was collected prospectively by nonprobability purposive sampling technique. The ultrasound variables/parameters and their assigned scoring system that was a modified version adopted from published literature were evaluated. Sensitivity, specificity, positive and negative predictive values of the liver morphological score and combined score of liver morphology and sizes was determined using stage and grade as reference standard. Our results show a high sensitivity and PPV of liver morphological sonographic evaluation for the staging and grading of CLD respectively thus supporting it as a screening diagnostic strategy. Of the three liver morphology variables, specificity of liver surface evaluation was highest for the stage of fibrosis and grade of inflammation. The simplified ultrasound scoring system evaluated in our study is clinically relevant and reproducible for differentiating patients with CLD with mild or no fibrosis from moderate to severe fibrosis.

Ovarian Masses: Is Multi-detector Computed Tomography a Reliable Imaging Modality?

BACKGROUND Ovarian cancer continues to pose a major challenge to physicians and radiologists. It is the third most common gynecologic malignancy and estimated to be fifth leading cancer cause of death in women, constituting 23% of all gynecological malignancies. Multi-detector computed tomography (MDCT) appears to offer an excellent modality in diagnosing ovarian cancer based on combination of its availability, meticulous technique, efficacy and familiarity of radiologists and physicians. The aim of this study was to compute sensitivity, specificity, positive and negative predictive values and diagnostic accuracy of 64- slice MDCT in classifying ovarian masses; 95% confidence intervals were reported. MATERIALS AND METHODS We prospectively designed a cross-sectional analytical study to collect data from July 2010 to August 2011 from a tertiary care hospital in Karachi, Pakistan. A sample of 105 women aged between 15-80 years referred for 64-MDCT of abdomen and pelvis with clinical suspicion of malignant ovarian cancer, irrespective of stage of disease, were enrolled by non- probability purposive sampling. All patients who were already known cases of histologically proven ovarian carcinoma and having some contraindication to radiation or iodinated contrast media were excluded. RESULTS Our prospective study reports sensitivity, specificity; positive and negative predictive values with 95%CI and accuracy were computed. Kappa was calculated to report agreement among the two radiologists. For reader A, MDCT was found to have 92% (0.83, 0.97) sensitivity and 86.7% (0.68, 0.96) specificity, while PPV and NPV were 94.5% (0.86, 0.98) and 86.7% (0.63, 0.92), respectively. Accuracy reported by reader A was 90.5%. For reader B, sensitivity, specificity, PPV and NPV were 94.6% (0.86, 0.98) 90% (0.72, 0.97) 96% (0.88, 0.99) and 87.1% (0.69, 0.95) respectively. Accuracy computed by reader B was 93.3%. Excellent agreement was found between the two radiologists with a significant kappa value of 0.887. CONCLUSION Based on our study results, we conclude MDCT is a reliable imaging modality in diagnosis of ovarian masses accurately with insignificant interobserver variability.

Comparison of stereotactic core breast biopsy and open surgical biopsy results at a tertiary care hospital in Pakistan

Background The purpose of this study was to determine the yield of stereotactic core breast biopsy and its cost-saving potential. Methods This observational study was conducted at the Department of Radiology at Aga Khan Hospital in Karachi. All female patients (n = 84) undergoing stereotactic core breast biopsy under mammographic guidance from January 2005 to May 2010 were included. Stereotactic core biopsy was performed on a dedicated mammography unit employing a 14-gauge needle with an automated biopsy device. Ten patients with incomplete medical records were excluded. All breast biopsy results were either compared with surgical findings in cases of malignant histopathological findings or with follow-up needle localization in case of benign core biopsy findings. Results Fifteen of our 74 patients had malignant findings on stereotactic biopsy, confirmed on histopathology of the final surgical mastectomy specimen. The remaining 59 patients had benign results on histopathology; five patients had needle localization of the same area due to either suspicious mammographic findings or clinical suspicion of malignancy. All were proven to be histopathologically benign on open surgical biopsy. Fifty-four patients with benign results had follow-up mammograms, and the follow-up period was 18 months to 5 years. The sensitivity and specificity was 100%. The cost saving per patient was US

Diagnostic Performance of Breast MRI in the Evaluation of Contralateral Breast in Patients with Diagnosed Breast Cancer

253. Conclusion Stereotactic core breast biopsy is a safe and cost-effective method for determining the nature of suspicious mammographic findings.

Diagnostic accuracy of pelvic MRI for determination of the cervical involvement in endometrial cancer.

AIMS The purpose of our study was to evaluate the diagnostic performance of breast magnetic resonance imaging (MRI) in the evaluation of contralateral breast in patients with diagnosed breast cancer. A secondary objective was to determine accuracy of breast MRI in diagnosing multi-focal and multicentric lesions in the ipsilateral breast. MATERIALS AND METHODS Using a non-probability convenience sampling technique, patients with histopathologically diagnosed breast cancer with MRI of breast performed to exclude additional lesions were included. MRI findings were correlated with histopathology. In addition, follow-up imaging with mammography and ultrasound was also assessed for establishing stability of negative findings and for the detected of benign lesions. RESULTS Out of 157 MRI breast conducted during the period of 2008 to 2013, 49 were performed for patients with diagnosed breast cancer. The sample comprised of all females with mean age 50.7 ± 11.0 years. The patient follow-up imaging was available for a period of 2-5 years. The sensitivity, specificity, and positive and negative predictive values of MRI in the detection of multifocal/multicenteric lesions was 85.7%, 88.8%, 60% and 96.6% respectively and for the detection of lesions in the contralateral breast were 100%, 97%, 83.3% and 100% respectively. CONCLUSIONS Our study highlights the diagnostic performance and the added value of MRI in the detection of multifocal /multicenteric and contralateral malignant lesions. In patients with diagnosed breast cancer having dense breast parenchyma and with infiltrating lobular carcinoma as the index lesion MRI is particularly useful with excellent negative predictive value in the exclusion of additional malignant foci in the ipsilateral and contralateral breasts.

Twin Reversed Arterial Perfusion Sequence: Assessing the Role of the Correct Imaging Modality in a Rare Clinical Entity

OBJECTIVE To determine the diagnostic accuracy of pelvic MRI for assessment of the cervical involvement in endometrial cancer. STUDY DESIGN Cross-sectional analytical study. PLACE AND DURATION OF STUDY Radiology Department of the Aga Khan University Hospital, Karachi from January 2014 to December 2015. METHODOLOGY Patients with biopsy-proven endometrial cancer were included, who had both their MRI and histopathological diagnosis performed at our institution. Those patients treated with chemo/radiotherapy or had incomplete medical records, were excluded. The extent of cervical involvement by endometrial carcinoma was seen on T2WI images, and findings were correlated after surgery taking histopathology as the gold standard. The sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy were calculated. RESULTS The mean age of the 56 patients was 60.87 ±8.80 years (range 37-84 years). The most common clinical indication was post-menopausal bleeding (n=37, 66.1%). The most common histological subtype was endometrioid adenocarcinoma (n=50, 89.3%). The sensitivity, specificity, diagnostic accuracy, positive and negative predictive values of MRI in the detection of cervical invasion were 92.85%, 88.09%, 89.28%, 72.22% and 97.36%, respectively. CONCLUSION MRI is a highly sensitive and specific imaging modality for detection of cervical invasion in endometrial carcinoma.