John M. Lewin

Contrast Enhanced Spectral Mammography: A Review☆☆☆★

Contrast-enhanced spectral mammography (CESM) provides low-energy 2D mammographic images comparable to standard digital mammography and a post-contrast recombined image to assess tumor neovascularity similar to magnetic resonance imaging (MRI). The utilization of CESM in the United States is currently low but could increase rapidly given many potential indications for clinical use. This article discusses historical background and literature review of indications and diagnostic accuracy of CESM to date. CESM is a growing technique for breast cancer detection and diagnosis that has levels of sensitivity and specificity on par with contrast-enhanced breast MRI. Because of its similar performance and ease of implementation, CESM is being adopted for multiple indications previously reserved for MRI, such as problem-solving, disease extent in newly diagnosed patients, and evaluating the treatment response of neoadjuvant chemotherapy.

Unusual Sonographic Appearance of Melanoma Metastases in the Breast

Metastasis to the breast is a relatively rare occurrence that can arise from virtually any primary malignancy. Melanoma is the most common primary malignancy to metastasize to the breast. 1 On sonography, breast metastases (including melanoma) are usually round or oval hypoechoic masses with circumscribed or indistinct margins. These sonographic characteristics have been described by multiple authors. 2-8 In our review of the literature, we found no report of melanoma metastases to the breast appearing sonographically as hyperechoic masses. We report a unique case that describes this finding.

Small cell carcinoma as the cause for a nondiagnostic V/Q lung scan.

Pulmonary thromboembolism (PTE) is a common cause of morbidity and mortality in an emergency department patient population. The advent of ventilation/perfusion (V/Q) lung scanning and the more recent publication of well- controlled analysis of results, such as the Prospective Investigation of Pulmonary Embolism Diagnosis (PIOPED) data, have provided the clinician with effective diagnostic algorithms to use in suggestive cases. However, there are disorders other than PTE, such as bronchogenic carcinoma, that can cause characteristic abnormalities in V/Q scanning. One such case is described in this report.

Pulmonary arterial hypertension in nonagenarians.

made it difficult for him to follow serial programs on television. He said that his wife accused him of being snappy. His wife reported that his behavior had changed dramatically during the last 6 years. He behaved disgracefully, and he was shunned in the home where they lived; his memory had gone. On examination he was cooperative but a bit slow, and, except for the date, fully orientated in time. Assessment of the mental status showed failures only on memory tasks. Although the available information was strongly suggestive for dementia (DSM-111-R) his wife also mentioned that she had never been happy with him. Aggravation was suspected. Information from the team at the day center based on several months’ observations indicated that he behaved more like a volunteer than a patient in that setting. He was not demented, in their opinion, and he was kind and helpful to others. It became obvious that his personality had not altered but that his wife was tired of him. His diagnosis was then changed from Dementia to a mild Amnestic Syndrome

Initial Experience of Tomosynthesis-Guided Vacuum-Assisted Biopsies of Tomosynthesis-Detected (2D Mammography and Ultrasound Occult) Architectural Distortions

OBJECTIVE As experience and aptitude in digital breast tomosynthesis (DBT) have increased, radiologists are seeing more areas of architectural distortion (AD) on DBT images compared with standard 2D mammograms. The purpose of this study is to report our experience using tomosynthesis-guided vacuum-assisted biopsies (VABs) for ADs that were occult at 2D mammography and ultrasound and to analyze the positive predictive value for malignancy. MATERIALS AND METHODS We performed a retrospective review of 34 DBT-detected ADs that were occult at mammography and ultrasound. RESULTS We found a positive predictive value of 26% (nine malignancies in 34 lesions). Eight of the malignancies were invasive and one was ductal carcinoma in situ. The invasive cancers were grade 1 (4/8; 50%), grade 2 (2/8; 25%), or grade 3 (1/8; 13%); information about one invasive cancer was not available. The mean size of the invasive cancers at pathologic examination was 7.5 mm (range, 6-30 mm). CONCLUSION Tomosynthesis-guided VAB is a feasible method to sample ADs that are occult at 2D mammography and ultrasound. Tomosynthesis-guided VAB is a minimally invasive method that detected a significant number of carcinomas, most of which were grade 1 cancers. Further studies are needed.