Johannes Uhlig

The role of cone-beam breast-CT for breast cancer detection relative to breast density

ObjectivesTo evaluate the impact of breast density on the diagnostic accuracy of non-contrast cone-beam breast computed tomography (CBBCT) in comparison to mammography for the detection of breast masses.MethodsA retrospective study was conducted from August 2015 to July 2016. Fifty-nine patients (65 breasts, 112 lesions) with BI-RADS, 5th edition 4 or 5 assessment in mammography and/or ultrasound of the breast received an additional non-contrast CBBCT. Independent double blind reading by two radiologists was performed for mammography and CBBCT imaging. Sensitivity, specificity and AUC were compared between the modalities.ResultsBreast lesions were histologically examined in 85 of 112 lesions (76%). The overall sensitivity for CBBCT (reader 1: 91%, reader 2: 88%) was higher than in mammography (both: 68%, p<0.001), and also for the high-density group (p<0.05). The specificity and AUC was higher for mammography in comparison to CBBCT (p<0.05 and p<0.001). The interobserver agreement (ICC) between the readers was 90% (95% CI: 86-93%) for mammography and 87% (95% CI: 82-91%) for CBBCT.ConclusionsCompared with two-view mammography, non-contrast CBBCT has higher sensitivity, lower specificity, and lower AUC for breast mass detection in both high and low density breasts.Key Points• Overall sensitivity for non-contrast CBBCT ranged between 88%-91%.• Sensitivity was higher for CBBCT than mammography in both density types (p<0.001).• Specificity was higher for mammography than CBBCT in both density types (p<0.05).• AUC was larger for mammography than CBBCT in both density types (p<0.001).

Contrast-enhanced cone-beam breast-CT (CBBCT): clinical performance compared to mammography and MRI

ObjectivesTo evaluate the diagnostic accuracy of contrast-enhanced (CE) cone-beam breast computed tomography (CBBCT) in dense breast tissue and compare it to non-contrast (NC) CBBCT, mammography (MG) and magnetic resonance imaging (MRI).MethodsThis prospective institutional review board-approved study included 41 women (52 breasts) with American College of Radiology (ACR) density types c or d and Breast Imaging Reporting and Data System (BI-RADS) 4 or 5 assessments in MG or ultrasound (US). Imaging modalities were independently evaluated by two blinded readers.ResultsA total of 100 lesions (51 malignant, 6 high-risk, and 43 benign) were identified. For readers 1/2, respectively, and p values comparing CE-CBBCT to other modalities: diagnostic accuracy (AUC) for CE-CBBCT was 0.83/0.77, for MRI 0.88/0.89 (p = 0.2272/0.002), for NC-CBBCT 0.73/0.66 (p = 0.038/ 0.0186) and for MG 0.69/0.64 (p = 0.081/0.0207). CE-CBBCT sensitivity (0.88/0.78) was 37-39% higher in comparison to MG (0.49/0.41, p < 0.001 both) but inferior to MRI (0.98/0.96, p = 0.0253/0.0027). CE-CBBCT specificity (0.71/0.71) was numerically higher compared to MRI (0.61/0.69, p = 0.0956/0.7389).ConclusionsCBBCT diagnostic performance varied with the respective reader and experience. CE-CBBCT improved AUC and sensitivity in comparison to MG and NC-CBBCT, and was comparable to MRI in dense breast tissue. In tendency, specificity was higher for CE-CBBCT than MRI.Key Points• CE-CBBCT diagnostic accuracy (AUC) was comparable to MRI in dense breasts.• CE-CBBCT improved sensitivity and AUC in comparison to MG and NC-CBBCT.• CE-CBBCT has inferior sensitivity but higher specificity than MRI.• CE-CBBCT is a potential imaging alternative for patients with MRI contraindications.

Contrast-enhanced cone-beam breast-CT: Analysis of optimal acquisition time for discrimination of breast lesion malignancy

OBJECTIVEnTo investigate the optimal acquisition time of contrast-enhanced cone-beam breast-CT (CBBCT) for best discrimination of breast lesion malignancy and whether contrast enhancement can aid in classification of tumor histology.nnnMATERIAL AND METHODSnThe study included patients with BI-RADS 4 or 5 lesions identified on mammography and/or ultrasound. All patients were examined by non-contrast (NC-CBBCT) and contrast-enhanced CBBCT (CE-CBBCT) at 2 and 3min after contrast media (CM) injection. Lesion enhancement of suspicious breast lesions was evaluated in corresponding CBBCT slices.nnnRESULTSnA total of 31 patients with 57 breast lesions, 30 malignant and 27 benign, were included. Malignant breast lesions demonstrated higher contrast enhancement than benign breast lesions at both 2min and 3min CE-CBBCT (2min: 48.17 vs. 0.3 HU, p<0.001; 3min: 57.38 vs. 15.43 HU, p<0.001). Enhancement differences between malignant and benign breast lesions were largest at 2min CE-CBBCT. Ductal carcinoma in situ (DCIS) showed highest mean contrast enhancement among malignant breast lesions (100.93 HU at 3min CE-CBBCT, p=0.0314) compared to invasive carcinoma of no special type with DCIS component (55.82 HU at 3min CE-CBBCT) and invasive ductal carcinoma (52.31 HU at 3min CE-CBBCT).nnnCONCLUSIONSnThe contrast enhancement on CE-CBBCT best discriminates between malignant and benign breast lesions at 2min after CM injection. The enhancement has the potential to differentiate histopathological subtypes, with highest enhancement among malignant lesions seen for DCIS.

Contrast Enhancement on Cone-Beam Breast-CT for Discrimination of Breast Cancer Immunohistochemical Subtypes

PURPOSE: To evaluate whether contrast enhancement on cone-beam breast-CT (CBBCT) could aid in discrimination of breast cancer subtypes and receptor status. METHODS: This study included female patients age >40 years with malignant breast lesions identified on contrast-enhanced CBBCT. Contrast enhancement of malignant breast lesions was standardized to breast fat tissue contrast enhancement. All breast lesions were approved via image-guided biopsy or surgery. Immunohistochemical staining was conducted for expression of estrogen (ER), progesterone (PR), human epidermal growth factor receptor-2 (HER2) and Ki-67 index. Contrast enhancement of breast lesions was correlated with immunohistochemical breast cancer subtypes (Luminal A, Luminal B, HER2 positive, triple negative), receptor status and Ki-67 expression. RESULTS: Highest contrast enhancement was seen for Luminal A lesions (93.6 HU) compared to Luminal B lesions (47.6 HU, P = .002), HER2 positive lesions (83.5 HU, P = .359) and triple negative lesions (45.3 HU, P = .005). Contrast enhancement of HER2 positive lesions was higher than Luminal B lesions (P = .044) and triple negative lesions (P = .039). No significant difference was evident between Luminal B and triple negative lesions (P = .439). Lesions with high Ki-67 index showed lower contrast enhancement than those with low Ki-67 index (P = .0043). ER, PR and HER2 positive lesions demonstrated higher contrast enhancement than their receptor negative counterparts, although differences did not reach statistical significance (P = .1714; P = .3603; P = .2166). CONCLUSIONS: Contrast enhancement of malignant breast lesions on CBBCT correlates with immunohistochemical subtype and proliferative potential. Thereby, CBBCT might aid in selecting individualized treatment strategies for breast cancer patients based on pre-operative imaging.

Radiological imaging characteristics of intramammary hematological malignancies: results from a german multicenter study

To assess radiological procedures and imaging characteristics in patients with intramammary hematological malignancies (IHM). Radiological imaging studies of histopathological proven IHM cases from ten German University affiliated breast imaging centers from 1997–2012 were retrospectively evaluated. Imaging modalities included ultrasound (US), mammography and magnetic resonance imaging (MRI). Two radiologists blinded to the histopathological diagnoses independently assessed all imaging studies. Imaging studies of 101 patients with 204 intramammary lesions were included. Most patients were women (95%) with a median age of 64 years. IHM were classified as Non Hodgkin lymphoma (77.2%), plasmacytoma (11.9%), leukemia (9.9%), and Hodgkin lymphoma (1%). The mean lesion size was 15.8u2009±u200910.1 mm. Most IHM presented in mammography as lesions with comparable density to the surrounding tissue, and a round or irregular shape with indistinct margins. On US, most lesions were of irregular shape with complex echo pattern and indistinct margins. MRI shows lesions with irregular or spiculated margins and miscellaneous enhancement patterns. Using US or MRI, IHM were more frequently classified as BI-RADS 4 or 5 than using mammography (96.2% and 89.3% versus 75.3%). IHM can present with miscellaneous radiological patterns. Sensitivity for detection of IHM lesions was higher in US and MRI than in mammography.

Preventive Services Utilization Among Cancer Survivors Compared to Cancer-free Controls

RESEARCH ARTICLE Preventive Services Utilization Among Cancer Survivors Compared to Cancer-free Controls Annemarie Uhlig, Johannes Uhlig, Arne Strauss, Lutz Trojan, Joachim Lotz and Ali Seif Amir Hosseini Department of Urology, University Medical Center, University of Göttingen, Göttingen, Germany Department of Interventional and Diagnostic Radiology, University Medical Center, University of Göttingen, Göttingen, Germany Division of Interventional Radiology, Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT, United States of America German CT for Cardiovascular Research, Partnersite Goettingen, Goettingen, Germany

Temporal changes within mechanical dyssynchrony and rotational mechanics in Takotsubo syndrome: A cardiovascular magnetic resonance imaging study

Background The pathophysiological significance of dyssynchrony and rotation in Takotsubo syndrome (TTS) is unknown. We aimed to define the influence of cardiovascular magnetic resonance feature tracking (CMR-FT) dyssynchrony and rotational mechanics in acute and during clinical course of TTS. Methods This multicenter study included 152 TTS patients undergoing CMR (mean 3u202fdays after symptom onset). Apical, midventricular and basal short axis views were analysed in a core-laboratory. Systolic torsion, diastolic recoil and dyssynchrony expressed as circumferential and radial uniformity ratio estimates (CURE and RURE: 0 to 1; 1u202f=u202fperfect synchrony) were compared to a matched control group (nu202f=u202f21). Follow-up CMR (nu202f=u202f20 patients; mean 62u202fdays, SD 7.2) and general follow-up (nu202f=u202f136; mean 3.3u202fyears, SD 2.4) were performed. Results CURE was initially reduced compared to controls (pu202f=u202f0.001) and recovered at follow-up (pu202f<u202f0.001) as opposed to RURE (pu202f=u202f0.116 and pu202f=u202f0.179). CURE and RURE discriminated between ballooning patterns (pu202f=u202f0.001 and pu202f=u202f0.045). Recoil was generally impaired during the acute phase (pu202f=u202f0.015), torsion only in highly dyssynchronous patients (pu202f=u202f0.024). Diabetes (pu202f=u202f0.007), physical triggers (pu202f=u202f0.013) and malignancies (pu202f=u202f0.001) predicted mortality. The latter showed a distinct association with impaired torsion (pu202f=u202f0.042) and dyssynchrony (pu202f=u202f0.047). Physical triggers and malignancies were related to biventricular impairment (pu202f=u202f0.004 and pu202f=u202f0.026), showing higher dyssynchrony (pu202f<u202f0.01), greater reduction of left ventricular function (pu202f<u202f0.001) and a strong trend towards increased mortality (pu202f=u202f0.074). Conclusion Transient circumferential dyssynchrony and impaired rotational mechanics are distinct features of TTS with different severities according to the pattern of ballooning. Patients with malignancies and precipitating physical triggers frequently show biventricular affection, greater dyssynchrony and high mortality risk.

Diagnostic accuracy of cone-beam breast computed tomography: a systematic review and diagnostic meta-analysis

PurposeTo review the published evidence on cone-beam breast computed tomography (CBBCT) and summarize its diagnostic accuracy for breast lesion assessment.Materials and MethodsA systematic literature search was conducted using the EMBASE, MEDLINE and CENTRAL libraries. Studies were included if reporting sensitivity and specificity for discrimination of benign and malignant breast lesions via breast CT. Sensitivity and specificity were jointly modeled using a bivariate approach calculating summary areas under the receiver-operating characteristics curve (AUC). All analyses were separately performed for non-contrast and contrast-enhanced CBBCT (NC-CBBCT, CE-CBBCT).ResultsA total of 362 studies were screened, of which 6 with 559 patients were included. All studies were conducted between 2015 and 2018 and evaluated female participants. Four of six studies included dense and very dense breasts with a high proportion of microcalcifications. For NC-CBBCT, pooled sensitivity was 0.789 (95% CI: 0.66–0.89) and pooled specificity was 0.697 (95% CI: 0.471–0.851), both showing considerable significant between-study heterogeneity (I2 = 89.4%, I2 = 94.7%, both p < 0.001). Partial AUC for NC-CBBCT was 0.817. For CE-CBBCT, pooled sensitivity was 0.899 (95% CI: 0.785–0.956) and pooled specificity was 0.788 (95% CI: 0.709–0.85), both exhibiting non-significant moderate between-study heterogeneity (I2 = 57.3%, p = 0.0527; I2 = 53.1%, p = 0.0738). Partial AUC for CE-CBBCT was 0.869.ConclusionThe evidence available for CBBCT tends to show superior diagnostic performance for CE-CBBCT over NC-CBBCT regarding sensitivity, specificity and partial AUC. Diagnostic accuracy of CE-CBBCT was numerically comparable to that of breast MRI with meta-analyses reporting sensitivity of 0.9 and specificity of 0.72.Key Points• CE-CBBCT rather than NC-CBBCT should be used for assessment of breast lesions for its higher diagnostic accuracy.• CE-CBBCT diagnostic performance was comparable to published results on breast MRI, thus qualifying CE-CBBCT as a potential imaging alternative for patients with MRI contraindications.

Partial nephrectomy versus ablative techniques for small renal masses: a systematic review and network meta-analysis

PurposeTo compare partial nephrectomy (PN), radiofrequency ablation (RFA), cryoablation (CRA) and microwave ablation (MWA) regarding oncologic, perioperative and functional outcomes.Material and methodsThe MEDLINE, EMBASE and COCHRANE libraries were searched for studies comparing PN, RFA, CRA or MWA and reporting on any-cause or cancer-specific mortality, local recurrence, complications or renal function. Network meta-analyses were performed.ResultsForty-seven studies with 24,077 patients were included. Patients receiving RFA, CRA or MWA were older and had more comorbidities compared with PN. All-cause mortality was higher for CRA and RFA compared with PN (incidence rate ratio IRR = 2.58, IRR = 2.58, p < 0.001, respectively). No significant differences in cancer-specific mortality were evident. Local recurrence was higher for CRA, RFA and MWA compared with PN (IRR = 4.13, IRR = 1.79, IRR = 2.52, p < 0.05 respectively). A decline in renal function was less pronounced after RFA versus PN, CRA and MWA (mean difference in GFR MD = 6.49; MD = 5.82; MD = 10.89, p < 0.05 respectively).ConclusionHigher overall survival and local control of PN compared with ablative therapies did not translate into significantly better cancer-specific mortality. Most studies carried a high risk of bias by selecting younger and healthier patients for PN, which may drive superior survival and local control. Physicians should be aware of the lack of high-quality evidence and the potential benefits of ablative techniques for certain patients, including a superior complication profile and renal function preservation.Key Points• Patients selected for ablation of small renal masses are older and have more comorbidities compared with those undergoing partial nephrectomy.• Partial nephrectomy yields lower all-cause mortality, which is probably biased by patient selection and does not translate into prolonged cancer-free survival.• The decline of renal function is smallest after radiofrequency ablation for small renal masses.

Intra- and interobserver variability in the diagnosis of GERD by real-time MRI

The purpose of this study was to assess the reproducibility of functional and anatomical parameters of swallowing events as determined by real-time MRI at 40u202fms temporal resolution (25 frames per second). Twenty-three consecutive patients with gastroesophageal reflux disease (GERD) underwent real-time MRI of the gastroesophageal junction at 3.0u202fT. Real-time MRI was based on highly undersampled radial fast low angle shot (FLASH) acquisitions with iterative image reconstruction by regularized nonlinear inversion (NLINV). MRI movies visualized the esophageal transport of a pineapple juice bolus, its passage through the gastroesophageal junction and functional responses during a Valsalva maneuver. His-angle, sphincter position, sphincter length and sphincter transit time were assessed by two radiologists. Interobserver and intraobserver intraclass correlation coefficients (ICC) were evaluated and Bland-Altman plots were constructed to assess the observer agreement. Interobserver agreement was excellent for sphincter transit time (ICCu202f=u202f0.92), His-angle (ICCu202f=u202f0.93), His-angle during Valsalva maneuver (ICCu202f=u202f0.91) and sphincter-to-diaphragm distance (ICCu202f=u202f0.98). Sphincter length and oesophageal diameter showed good interobserver agreement (ICCu202f=u202f0.62 and ICCu202f=u202f0.70). Intraobserver agreement was good for sphincter length (ICCu202f=u202f0.80) and excellent for sphincter transit time, His-angle and His-angle during Valsalva maneuver, sphincter-to-diaphragm distance, and esophageal diameter (ICCu202f=u202f0.91; ICCu202f=u202f0.97; ICCu202f=u202f0.97; ICCu202f=u202f0.998; ICCu202f=u202f0.93). All functional parameters of the gastroesophageal junction had good to excellent reproducibility. Visual assessment of Bland Altman plots did not reveal any systematic interobserver bias. In conclusion, the visualization of swallowing events by real-time MRI has a high potential for clinical application in gastroesophageal reflux disease.