Maria Bernathova

Triple-Modality Screening Trial for Familial Breast Cancer Underlines the Importance of Magnetic Resonance Imaging and Questions the Role of Mammography and Ultrasound Regardless of Patient Mutation Status, Age, and Breast Density

PURPOSE To evaluate the breast cancer screening efficacy of mammography, ultrasound, and magnetic resonance imaging (MRI) in a high-risk population and in various population subgroups. PATIENTS AND METHODS In a single-center, prospective, nonrandomized comparison study, BRCA mutation carriers and women with a high familial risk (> 20% lifetime risk) for breast cancer were offered screening with mammography, ultrasound, and MRI every 12 months. Diagnostic performance was compared between individual modalities and their combinations. Further comparisons were based on subpopulations dichotomized by screening rounds, mutation status, age, and breast density. RESULTS There were 559 women with 1,365 complete imaging rounds included in this study. The sensitivity of MRI (90.0%) was significantly higher (P < .001) than that of mammography (37.5%) and ultrasound (37.5%). Of 40 cancers, 18 (45.0%) were detected by MRI alone. Two cancers were found by mammography alone (a ductal carcinoma in situ [DCIS] with microinvasion and a DCIS with < 10-mm invasive areas). This did not lead to a significant increase of sensitivity compared with using MRI alone (P = .15). No cancers were detected by ultrasound alone. Similarly, of 14 DCISs, all were detected by MRI, whereas mammography and ultrasound each detected five DCISs (35.7%). Age, mutation status, and breast density had no influence on the sensitivity of MRI and did not affect the superiority of MRI over mammography and ultrasound. CONCLUSION MRI allows early detection of familial breast cancer regardless of patient age, breast density, or risk status. The added value of mammography is limited, and there is no added value of ultrasound in women undergoing MRI for screening.

Ultrasound of the lateral femoral cutaneous nerve: normal findings in a cadaver and in volunteers.

Objective: To assess the feasibility of ultrasound (US) in visualizing the lateral femoral cutaneous nerve (LFCN) in a cadaver and 8 volunteers. Methods: Ultrasound and US-guided dye injection was performed in 1 cadaver to show the feasibility of detecting the LFCN. We then performed US in 8 volunteers to assess position of the nerve in respect to the anterior iliac spine. We subsequently performed US-guided anesthetic block of the LFCN on both sides with 0.3 mL local anesthetic. Success rate, time to maximum peak blockade, and duration of blockade were noted. Results: Ultrasound allowed visualization of the LFCN in the cadaveric specimen on both sides and in all but 1 volunteer. Ultrasound-guided block of the LFCN was successful in all but 1 volunteer. The mean distance of LFCN from the anterior iliac spine was 2.9 cm on the right side and 2.8 cm on the left side. The mean duration of the block was 4.4 hours. Conclusion: Ultrasound enables visualization of the LFCN in a cadaver and in volunteers. Ultrasound-guided injection successfully blocked the LFCN.

Sonographic diagnosis of plantar vein thrombosis: report of 3 cases.

The purpose of this series is to describe sonographic findings in 3 patients with plantar vein thrombosis.

Diffusion-weighted MRI of breast lesions: a prospective clinical investigation of the quantitative imaging biomarker characteristics of reproducibility, repeatability, and diagnostic accuracy.

Diffusion‐weighted MRI (DWI) provides insights into tissue microstructure by visualization and quantification of water diffusivity.

A simple classification system (the Tree flowchart) for breast MRI can reduce the number of unnecessary biopsies in MRI-only lesions

AbstractObjectivesTo assess whether using the Tree flowchart obviates unnecessary magnetic resonance imaging (MRI)-guided biopsies in breast lesions only visible on MRI.MethodsThis retrospective IRB-approved study evaluated consecutive suspicious (BI-RADS 4) breast lesions only visible on MRI that were referred to our institution for MRI-guided biopsy. All lesions were evaluated according to the Tree flowchart for breast MRI by experienced readers. The Tree flowchart is a decision rule that assigns levels of suspicion to specific combinations of diagnostic criteria. Receiver operating characteristic (ROC) curve analysis was used to evaluate diagnostic accuracy. To assess reproducibility by kappa statistics, a second reader rated a subset of 82 patients.ResultsThere were 454 patients with 469 histopathologically verified lesions included (98 malignant, 371 benign lesions). The area under the curve (AUC) of the Tree flowchart was 0.873 (95% CI: 0.839–0.901). The inter-reader agreement was almost perfect (kappa: 0.944; 95% CI 0.889–0.998). ROC analysis revealed exclusively benign lesions if the Tree node was ≤2, potentially avoiding unnecessary biopsies in 103 cases (27.8%).ConclusionsUsing the Tree flowchart in breast lesions only visible on MRI, more than 25% of biopsies could be avoided without missing any breast cancer.Key Points• The Treeflowchart may obviate >25% of unnecessary MRI-guided breast biopsies.• This decrease in MRI-guided biopsies does not cause any false-negative cases. • The Treeflowchart predicts 30.6% of malignancies with >98% specificity. • The Tree’shigh specificity aids in decision-making after benign biopsy results.

Clinical application of Acoustic Radiation Force Impulse Imaging with Virtual Touch IQ in breast ultrasound: diagnostic performance and reproducibility of a new technique

Background Virtual Touch IQ (VTIQ) is a novel technique of quantitative sonoelastography that applies acoustic radiation force impulse (ARFI). Purpose To evaluate breast ARFI imaging with VTIQ in the clinical setting, with regard to reproducibility and diagnostic performance, and to specify cutoff limits for the differentiation of benign and malignant lesions. Material and Methods This retrospective study included 83 patients with 85 breast lesions (51 benign, 34 malignant) who received ARFI imaging with VTIQ. Two independent ARFI measurements of each lesion were performed and shear wave velocities (SWV) of the lesion and the adjacent tissues were measured. A lesion-to-fat velocity ratio (L/F Ratio) was calculated for each lesion. Diagnostic performance of SWV measurements and L/F Ratios was evaluated with receiver operating curve (ROC) analysis. The intraclass correlation coefficient and Bland–Altman plots were used to evaluate measurement reproducibility. Results All measurements showed equal diagnostic performance, as measured by the area under the ROC curve (0.853 for SWV, 0.882 for the L/F Ratio). At a cutoff value of 3.23 m/s, sensitivity and specificity were 82.4% and 80.4%, respectively. An L/F Ratio cutoff value of 2.23 revealed a sensitivity and specificity of 89.7% and 76.5%. The reproducibility of the SWV measurements was moderate (limits of agreement, 40.3–44.4%) and higher than that of the L/F Ratios (54.5–60.2%). Conclusion ARFI imaging with VTIQ is a novel, moderately reproducible, quantitative elastography technique, which provides useful information for the differentiation of benign and malignant breast lesions in the clinical setting.

Superficial desmoid tumors: MRI and ultrasound imaging characteristics

OBJECTIVES To describe the imaging characteristics of superficial desmoid tumors using magnetic resonance imaging (MRI) and high-resolution sonography (HRUS). METHODS We retrospectively examined 18 patients (12 females and 6 males) with histologically proven superficial desmoids. Fourteen patients received MRI examinations, while 12 patients were examined with HRUS. The lesions were assessed with regard to location, muscular fascia involvement, and spread into the subcutaneous fatty tissue septa, adjacent muscle, and bone. In addition, size, shape, signal intensity/echogenicity relative to muscle, amount of collagen components, Doppler vascularity on HRUS and the degree of contrast enhancement in MRI were evaluated. RESULTS Altogether there were 20 subcutaneous lesions: six involved the chest wall and the breasts, five the hip, four each the shoulder and the flank, and one the abdominal wall. All but three lesions showed a stellar-type configuration with multiple irregular sun-burst-like extensions along the fascial planes and septa of the subcutaneous fat tissue. The extensions spread away from the main tumor focus, and in nine lesions, these extensions reached the cutis. The remaining three lesions had a spindle shape and also presented extensions along the fascial planes. Another imaging feature in all lesions was the presence of variable amounts of collagen components, with typical low signal on MRI and/or fibrillar hyperechoic appearance in HRUS. CONCLUSION The distinctive imaging features of collagen components associated with sun-burst-like extensions in our sample of superficial desmoids are valuable diagnostic clues in the challenging non-invasive differential diagnosis of these tumors.

Virtual Touch IQ elastography reduces unnecessary breast biopsies by applying quantitative “rule-in” and “rule-out” threshold values

Our purpose was to evaluate Virtual Touch IQ (VTIQ) elastography and identify quantitative “rule-in” and “rule-out” thresholds for the probability of malignancy, which can help avoid unnecessary breast biopsies. 189 patients with 196 sonographically evident lesions were included in this retrospective, IRB-approved study. Quantitative VTIQ images of each lesion measuring the respective maximum Shear Wave Velocity (SWV) were obtained. Paired and unpaired, non-parametric statistics were applied for comparisons as appropriate. ROC-curve analysis was used to analyse the diagnostic performance of VTIQ and to specify “rule-in” and “rule-out” thresholds for the probability of malignancy. The standard of reference was either histopathology or follow-up stability for >24 months. 84 lesions were malignant and 112 benign. Median SWV of benign lesions was significantly lower than that of malignant lesions (p < 0.001). The application of a “rule-out” threshold of 1.9 m/s lead to a sensitivity of >98% with a concomitant significant (p = 0.032) reduction in false positive cases of almost 15%, whereas a “rule-in” threshold of 6.5 m/s suggested a probability of malignancy of >95%. In conclusion, VTIQ elastography accurately differentiates malignant from benign breast lesions. The application of quantitative “rule-in” and “rule-out” thresholds is feasible and allows reduction of unnecessary benign breast biopsies by almost 15%.

Unusual Cause of Anterior Tarsal Tunnel Syndrome: Ultrasound Findings

We describe a unique case of a trauma-induced deep peroneal intraneural ganglion emerging from the ankle joint causing anterior tarsal tunnel syndrome that was diagnosed and to our knowledge treated for the first time with the help of ultrasound imaging. A 51-year-old woman presented with swelling and pain in the area of the left anterior shin and dorsum of the foot. The patient had sustained a lateral inversion injury of her left ankle 6 months earlier. After the trauma, a slowly growing swelling appeared around the lateral malleolus. In the following 3 months, she also developed paresthesia at the dorsum of the foot and pain at the anterior shin. She was not able to wear tight shoes or shoes with laces, nor could she tolerate even a slightest touch in the affected region. Clinical examination showed a nontender swelling at the left lateral malleolus, numbness between the first and second toes, and weakness in extending the first toe. Conventional x-ray images of the foot and ankle revealed no bony abnormalities. Magnetic resonance imaging (1.5 Tesla) of the ankle showed only a small cyst emerging behind the fibula from the ankle joint, but no other abnormalities. Thereafter, she underwent an ultrasound investigation to rule out muscle tear, chronic compartment syndrome, or deep venous thrombosis. The ultrasound investigation revealed an anechoic cystic lesion within the deep peroneal nerve measuring 7 mm in transverse diameter and 11 mm in length at the level of the extensor retinaculum. It displaced the nerve fascicles inside the nerve more peripherally and closer to the inner side of the nerve sheath (Figure 1). More distally, the cystic lesion extended laterally over the fibula and connected to a ganglion emerging from the ankle joint (Figure 2). Within this cystic extension was a small tubular structure suggestive of an articular nerve branch. All of this led to the diagnosis of an intraneural ganglion of the deep peroneal nerve. After obtaining the patient’s written informed consent, the patient underwent ultrasound-guided fine-needle aspiration of the deep peroneal nerve ganglion, and 1 mL of viscous fluid was aspirated (Figure 3) that laboratory analysis later confirmed to be synovial fluid. In addition, the nerve sheath of the articular branch was dry-needled to avoid refilling of the nerve sheath ganglion. The patient’s symptoms disappeared within 1 week after the procedure. Moreover, a follow-up ultrasound indicated that the ganglion within the deep peroneal nerve did not recur. However, during the following 3 months, the ganglion more laterally near the joint significantly increased in size, and surgical resection of the ganglion without articular nerve dissection was performed. The patient has remained symptom-free for 1 year now. Anterior tarsal tunnel syndrome is a rare condition characterized by compression of the deep peroneal nerve at the level of the extensor retinaculum. Direct trauma, repetitive mechanical irritation, and compression by ganglia are the most common causes of this type of neuropathy.

MRI-based quantification of residual fibroglandular tissue of the breast after conservative mastectomies

PURPOSE Skin-sparing and nipple-sparing mastectomies (SSM; NSM) remove the breasts fibroglandular tissue (FGT), thereby reducing breast cancer risk. The postoperative presence of residual FGT (RFGT) is associated with remaining cancer risk. This study evaluated the role of MRI in the quantitative assessment of RFGT and its impact on the estimation of the remaining breast cancer risk. METHODS The postoperative MRI scans (following EUSOMA recommendations) of 58 patients who had undergone SSM or NSM between 2003 and 2013, as well as preoperative MRI scans that were available in 25 of these patients, were retrospectively evaluated for the presence and location of RFGT by three radiologists. Two different observers quantitatively assessed the volume and percentage of retromamillary and other RFGT (RFGTrm and RFGTother) were assessed. The Fishers exact test, the Students t-test, and intraclass coherence were used to compare patient groups and to assess reproducibility. RESULTS RFGT was found in 20% of all breasts and significantly more frequently after NSM than SSM (50% vs. 13%, p = .003). RFGTrm and RFGTother were more prevalent after NSM (p < 0.001; p = .127). RFGT ranged from 0.5 to 26% of the preoperative FGT, with higher percentages after NSM than SSM (p = .181). CONCLUSIONS The prevalence and percentage of RFGT found on MRI indicate a considerable remaining postoperative breast cancer risk in some women.