L. Pescarini

Digital breast tomosynthesis versus digital mammography: a clinical performance study

ObjectiveTo compare the clinical performance of digital breast tomosynthesis (DBT) with that of full-field digital mammography (FFDM) in a diagnostic population.MethodsThe study enrolled 200 consenting women who had at least one breast lesion discovered by mammography and/or ultrasound classified as doubtful or suspicious or probably malignant. They underwent tomosynthesis in one view [mediolateral oblique (MLO)] of both breasts at a dose comparable to that of standard screen-film mammography in two views [craniocaudal (CC) and MLO]. Images were rated by six breast radiologists using the BIRADS score. Ratings were compared with the truth established according to the standard of care and a multiple-reader multiple-case (MRMC) receiver-operating characteristic (ROC) analysis was performed. Clinical performance of DBT compared with that of FFDM was evaluated in terms of the difference between areas under ROC curves (AUCs) for BIRADS scores.ResultsOverall clinical performance with DBT and FFDM for malignant versus all other cases was not significantly different (AUCs 0.851 vs 0.836, p = 0.645). The lower limit of the 95% CI or the difference between DBT and FFDM AUCs was −4.9%.ConclusionClinical performance of tomosynthesis in one view at the same total dose as standard screen-film mammography is not inferior to digital mammography in two views.

Combination of one-view digital breast tomosynthesis with one-view digital mammography versus standard two-view digital mammography: per lesion analysis

AbstractObjectiveTo evaluate the clinical value of combining one-view mammography (cranio-caudal, CC) with the complementary view tomosynthesis (mediolateral-oblique, MLO) in comparison to standard two-view mammography (MX) in terms of both lesion detection and characterization.MethodsA free-response receiver operating characteristic (FROC) experiment was conducted independently by six breast radiologists, obtaining data from 463 breasts of 250 patients. Differences in mean lesion detection fraction (LDF) and mean lesion characterization fraction (LCF) were analysed by analysis of variance (ANOVA) to compare clinical performance of the combination of techniques to standard two-view digital mammography.ResultsThe 463 cases (breasts) reviewed included 258 with one to three lesions each, and 205 with no lesions. The 258 cases with lesions included 77 cancers in 68 breasts and 271 benign lesions to give a total of 348 proven lesions. The combination, DBT(MLO)+MX(CC), was superior to MX (CC+MLO) in both lesion detection (LDF) and lesion characterization (LCF) overall and for benign lesions. DBT(MLO)+MX(CC) was non-inferior to two-view MX for malignant lesions.ConclusionsThis study shows that readers’ capabilities in detecting and characterizing breast lesions are improved by combining single-view digital breast tomosynthesis and single-view mammography compared to two-view digital mammography.Key Points• Digital breast tomosynthesis is becoming adopted as an adjunct to mammography (MX) • DBT(MLO)+MX(CC)is superior to MX(CC+MLO)in lesion detection (overall and benign lesions) • DBT(MLO)+MX(CC)is non-inferior to MX(CC+MLO)in cancer detection • DBT(MLO)+MX(CC)is superior to MX(CC+MLO)in lesion characterization (overall and benign lesions) • DBT(MLO)+MX(CC)is non-inferior to MX(CC+MLO)in characterization of malignant lesions

Systematic approach to human error in radiology.

We propose a systematic approach to human errors in radiology. We consider perceptual, cognitive and system errors. Practical aspects with psychological and clinical involvement are discussed with tree diagrams.

Juxtaglomerular Cell Tumor of the Kidney

A juxtaglomerular cell tumor (JGCT) was found in a 40 year old woman. For 5 years she had mild hypertension, responding to classical anti-hypertensive treatment, then she became severely hypertensive. Two renal angiographies and a CT scan were reported as normal. A second CT scan and third selective renal angiography were diagnostic, associated with lateralization of renin in renal vein measurement. Light, electron microscopy and immunohistochemistry of the resected tumor confirmed the diagnosis of renin-secreting juxtaglomerular cell tumor of the kidney.

Cytological and histological structures identification with the technique IBIL in elemental microanalysis

Abstract Ion beam induced luminescence (IBIL) is applied to the inspection of histological and cytological specimens, dried and placed in vacuum. It is shown to offer a way for a precise aiming of a proton microbeam on the sample for a subsequent traditional microanalysis. We used the nuclear microprobe of the Laboratori Nazionali di Legnaro and its IBIL facility to identify biostructures stained with some usual fluorescent dyes, capable of discriminating tissues and cells of different nature or different parts of a cell. To this purpose we produced low dose IBIL maps of the region of interest, employing a high sensitivity light detector. We describe the experimental set-up, propose a peculiar support for specimens, specify the properties of few widespread used staining procedures and evaluate their IBIL emission.

Analysis of malpractice claims in mammography: a complex issue.

PurposeThe aim of this study was to analyse malpractice claims in mammography, estimate the specific risk of future claims and assess their impact on radiologists and society.Materials and methodsThe study considered insurance claims filed by radiologists of the Italian Society of Medical Radiology (SIRM) over a 12.5-year period between 1 January 1993 and 30 June 2005. We isolated claims related to presumed diagnostic errors in mammography. We then estimated the number of claims arising from events in the study period that are expected to be filed over the next few years, before the expiry of the prescriptive period of 10 years.ResultsThe total number of claims was 1,088. Of these, 302 were caused by alleged diagnostic errors in cases of cancer; 189 (62%) concerned breast cancers and mammographic technique. Assuming a constant frequency of claims filed by radiologists, we expect a further 637 claims relating to the study period, for a total of 1,725 claims, with 178 claims being related to breast imaging. The predicted rate therefore increases to 10.5 per thousand, equal to a risk of one litigation per radiologist per 10 years of work.ConclusionsThe analysis uncovered a complex problem: although radiologists save many lives through the radiographic diagnosis of breast cancer and consequently contribute to the welfare of society, in practice, they can face real or alleged errors, with serious judicial consequences. Awareness of professional risk in current society may represent a valuable reference for choosing and planning to work in radiology.RiassuntoObiettivoLo scopo dello studio è di analizzare le denunce in mammografia, stimare il rischio specifico di ulteriori denunce nei prossimi anni e valutarne l’impatto sui radiologi e sulla società.Materiali e metodiLo studio riguarda le denunce assicurative dei radiologi iscritti alla SIRM dal 01/01/1993 al 30/06/2005 per un periodo di 12,5 anni. Sono state enucleate le denunce causate da presunti errori diagnostici in mammografia. È stato stimato il numero di nuove denunce, relative al periodo di tempo in esame, che perverranno nei prossimi anni, tenuto conto della prescrizione.RisultatiIl numero totale delle denunce è di 1088. Di queste 302 sono state causate da presunti errori diagnostici in casi di neoplasia; 189 (62%) riguardano i tumori mammari e la tecnica mammografica. Nell’ipotesi che la tendenza a denunciare i radiologi sia costante, si prevede che per il periodo d’osservazione giungano ancora 637 nuovi casi, per un totale complessivo di 1725. Per lo studio radiografico della mammella sono attese altre 178 denunce. Il tasso di previsione sale quindi al 10,5 per mille, vale a dire al rischio di una denuncia per radiologo ogni 10 anni di attività.ConclusioniL’analisi condotta indica la presenza di un problema complesso. Benché il radiologo con la diagnosi mammografica dei tumori della mammella salvi molte vite, contribuendo al bene della società, nella pratica può incorrere in errori veri o presunti, con conseguenze giudiziarie sempre più incombenti. La consapevolezza del rischio professionale nell’attuale contesto sociale può essere un valido riferimento per la scelta e la programmazione dell’attività radiologica.Purpose. The aim of this study was to analyse malpractice claims in mammography, estimate the specific risk of future claims and assess their impact on radiologists and society. Materials and methods. The study considered insurance claims filed by radiologists of the Italian Society of Medical Radiology (SIRM) over a 12.5-year period between 1 January1993 and 30 June 2005. We isolated claims related to presumed diagnostic errors in mammography. We then estimated the number of claims arising from events in the study period that are expected to be filed over the next few years, before the expiry of the prescriptive period of 10 years. Results. The total number of claims was 1,088. Of these, 302 were caused by alleged diagnostic errors in cases of cancer; 189 (62%) concerned breast cancers and mammographic technique. Assuming a constant frequency of claims filed by radiologists, we expect a further 637 claims relating to the study period, for a total of 1,725 claims, with 178 claims being related to breast imaging. The predicted rate therefore increases to 10.5 per thousand, equal to a risk of one litigation per radiologist per 10 years of work. Conclusions. The analysis uncovered a complex problem:

The legal implications of error in radiology

Evaluation of the legal implications of error in radiology and therefore the assessment of criminal and civil liability in the practice of the profession requires an analysis of how the public perception of the right to health has radically changed. This change has initiated a defensive approach to medicine and radiology that tends to be oriented towards precautionary measures, with a proliferation of often unnecessary imaging studies. In radiology, errors of omission or commission are frequent. A critical appraisal of the different types of error in radiology will help practitioners undertake the essential corrective measures. Through analysis of several cases derived from legal or insurance proceedings brought against radiologists, the most common forms of error are described, and their implications for criminal and civil liability are illustrated, although it is emphasised that the existence of an error does not always translate into the presence of malpractice.Evaluation of the legal implications of error in radiology and therefore the assessment of criminal and civil liability in the practice of the profession requires an analysis of how the public perception of the right to health has radically changed. This change has initiated a defensive approach to medicine and radiology that tends to be oriented towards precautionary measures, with a proliferation of often unnecessary imaging studies. In radiology, errors of omission or commission are frequent. A critical appraisal of the different types of error in radiology will help practitioners undertake the essential corrective measures. Through analysis of several cases derived from legal or insurance proceedings brought against radiologists, the most common forms of error are described, and their implications for criminal and civil liability are illustrated, although it is emphasised that the existence of an error does not always translate into the presence of malpractice.RiassuntoLa valutazione della rilevanza medico-legale dell’errore in radiologia e, quindi, della responsabilità penale e civile nell’esercizio della professione impone l’analisi di come radicalmente sia modificata nell’opinione pubblica la percezione del diritto alla tutela della salute e, da questo, siano nate una medicina e, quindi, anche una radiologia sempre più facilmente orientate a principi cautelativi o difensivi, con proliferare di accertamenti e procedure spesso inutili. In radiologia l’errore omissivo o commissivo è frequente. Un’analisi critica delle diverse tipologie di errore più facilmente porta ad assumere gli indispensabili comportamenti correttivi. Tramite casi esemplificativi tratti da procedimenti giudiziari o assicurativi ormai risolti contro radiologi, l’articolo descrive le più comuni forme di errore e ne illustra le ricadute in sede penale e civile, evidenziando comunque che l’errore non sempre configura l’esistenza di una responsabilità ovvero di una colpa, in particolare in ambito penalistico.

Clinical Performance of Digital Breast Tomosynthesis Versus Full-Field Digital Mammography: Preliminary Results

Preliminary results of a clinical study designed to compare clinical performance of digital breast tomosynthesis (DBT) versus standard full-field digital mammography (FFDM) in a diagnostic population are presented and discussed. Paired tomosynthesis and mammography examinations were analyzed by three experienced radiologists. One hundred single-breast cases were analyzed. Findings were rated in terms of lesion conspicuity, classified using the ACR BIRADS scale and compared with the truth. Statistically significant differences were found in lesion conspicuity for all radiologists, showing tomosynthesis superior to mammography. Finding classifications (BIRADS) were evaluated by ROC analysis. The results obtained from tomosynthesis images were consistently superior to FFDM for all readers. The difference was statistically significant for one radiologist. The results demonstrated DBT superiority for conspicuity of findings and showed potential for superior clinical performance.

Violence against radiologists. I: prevalence and preventive measures

PurposeViolence in the workplace is a specific risk for healthcare workers. Radiologists, especially when involved in emergency services, share that risk. Very few studies in the literature have researched this topic. This study aimed to evaluate the prevalence of violent behaviour in a large sample of Italian radiologists and analyse the phenomenon and its consequences with a view to proposing preventive measures.Materials and methodsA total of 992 radiologists (61.5% men) taking part in a national radiology congress agreed to respond to a questionnaire on violence that contained the Violent Incident Form by Arnetz for the description of violent incidents in healthcare practice.ResultsSome 6.8% of radiologists in public hospitals experienced physical abuse in the previous 12 months, for the most part from patients or their companions. The prevalence of physical abuse is greatest among younger healthcare individuals with less clinical experience, with no differences between sexes. Among younger radiologists, one in five suffered at least one act of physical abuse in a working year. Nonphysical violence is more widespread and throughout radiologists’ working lives affects 65.2% of them. In this case, almost half of the violent incidents originate from colleagues. A total of 5.5% of respondents stated that they were victims of abuse at the time of the survey. In most cases, the violent incidents remain unreported. The immediate consequences of violence in the workplace are emotions such as anger, disappointment, humiliation, anxiety, fear, distress, a feeling of helplessness and isolation, occasionally a feeling of guilt or of having done wrong and a desire to take revenge, change behaviour or change workplace.ConclusionsThe extent of the problem calls for the adoption of a series of measures aimed at eliminating the causes of the various forms of workplace violence.RiassuntoObiettivoLa violenza sul luogo di lavoro è un rischio specifico per i lavoratori della sanità. I radiologi, soprattutto se impegnati nei servizi di emergenza e pronto soccorso, condividono tale rischio. La letteratura è molto povera di studi sull’argomento. Questo lavoro si propone di valutare la prevalenza dei comportamenti violenti in un campione ragguardevole dei radiologi italiani, di analizzare il fenomeno e le sue conseguenze, per proporre le misure preventive.Materiali e metodiNovecentonovantadue (992) radiologi (61,5% di genere maschile), convenuti per il congresso nazionale della disciplina, hanno accettato di rispondere a un questionario sulla violenza, contenente il Violent Incident Form (VIF) di Arnetz per la descrizione degli eventi violenti nelle attività sanitarie.RisultatiIl 6,8% dei radiologi nelle strutture pubbliche ha subito negli ultimi 12 mesi una aggressione fisica, prevalentemente da parte di pazienti o loro accompagnatori. La prevalenza delle aggressioni è massima nei soggetti più giovani e con minore esperienza clinica e non presenta differenze di sesso. Tra i radiologi giovani, uno su cinque subisce almeno una aggressione fisica in un anno di lavoro. La violenza non fisica è molto più diffusa e riguarda, nel corso della vita lavorativa, il 65,2% dei radiologi. In questo caso, quasi metà delle aggressioni proviene da colleghi. Il 5,5% dei rispondenti ha dichiarato di essere tuttora sottoposto ad abusi al momento dell’indagine. Nella gran parte dei casi, le aggressioni non sono segnalate. Le conseguenze immediate della violenza sono emozioni come rabbia, delusione, umiliazione, ansia, paura, angoscia, sensazione di essere indifeso e isolato, a volte senso di colpa o di avere sbagliato, impulso a vendicarsi, a cambiare modo di agire, a cambiare posto di lavoro.ConclusioniLa rilevanza del fenomeno impone la tempestiva adozione di una serie di misure, mirate ad eliminare i determinanti delle varie forme di violenza sul lavoro.

Correlation between magnetic resonance imaging and histopathological tumor response after neoadjuvant chemotherapy in breast cancer.

AIM To evaluate the accuracy of magnetic resonance imaging in assessing tumor response following neoadjuvant chemotherapy in patients with locally advanced breast cancer. MATERIALS AND METHODS Twenty-six patients entered a phase II study of neoadjuvant chemotherapy, undergoing bilateral breast magnetic resonance imaging before therapy and before surgery. Tumor response was classified using RECIST criteria, using tumor size at magnetic resonance imaging. The latter was then compared to residue found at histopathological examination. RESULTS Magnetic resonance imaging showed 6 (23%) complete responses, 17 (65%) partial responses, 3 (11.5%) disease stabilizations and no disease progressions. Twenty-three tumors (88.5%) were considered responsive and 3 (11.5%) unresponsive. Pathological tumor response was: 6 complete responses (23%), 17 partial responses (65%), 2 stable disease (8%), 1 progression (4%). When results of the preoperative magnetic resonance imaging were compared to pathological tumor response, magnetic resonance imaging overestimated tumor size in 12 cases (46%) and underestimated it in 9 (35%). However, preoperative magnetic resonance imaging failed to detect invasive tumor in 2 false-negative cases (8%), 1 of which was multifocal. Mastectomy was performed in 12 cases: 1 case of disease progression even though the neoplasm appeared smaller at magnetic resonance imaging, 3 cases with stable disease, and 4 cases with T3 or T4 disease. The 9th patient was T2N2 with initial retroareolar disease and negative magnetic resonance imaging after chemotherapy. The 10th patient, affected by lobular cancer, was in partial remission but was T3N1. The 11th patient was 57 years old but was not interested in conservative surgery. The 12th patient requested bilateral prophylactic mastectomy due to her positive family history of breast cancer. CONCLUSIONS Magnetic resonance imaging of the breast allowed conservative surgery in 54% of the patients. This low value is primarily due to overestimation of tumor size, with a negative predictive value of 67% in our population. However, surgeons were able to choose conservative surgery with relative safety in cases of small residual disease.