Peter Britton

How reliable is modern breast imaging in differentiating benign from malignant breast lesions in the symptomatic population

AIM To assess the ability of mammography and ultrasound individually and in combination to predict whether a breast abnormality is benign or malignant in patients with symptomatic breast disease. MATERIALS AND METHODS Patients included were those in whom histological confirmation of the abnormality following surgical excision was available. Mammographic and ultrasound appearances were prospectively classified using a four-point scale (1 = no significant lesion, 2 = benign lesion, 3 = possibly malignant, 4 = probably malignant). RESULTS Histological confirmation following surgical excision was available in 559 patients, of which 303 were benign and 256 were malignant. The imaging classification was correlated with histology in these 559 lesions. In predicting final histology, the sensitivity and specificity of mammography alone were 78.9 and 82.7%, respectively, of ultrasound alone were 88.9 and 77.9%, respectively, and of mammography and ultrasound in combination were 94.2 and 67.9%, respectively. Only one patient had both a mammogram and ultrasound reported as normal (category 1 for both tests) in whom subsequent histology revealed a carcinoma (0.4% of all carcinomas). CONCLUSION We found that the extensive use of ultrasound increases the cancer detection rate in this selected population by 14%.

Changing to core biopsy in an NHS breast screening unit.

We recently changed from using fine needle aspiration cytology to using core biopsy exclusively in the assessment of screen detected abnormalities. Two hundred and two biopsies (1% of women screened) were performed. Surgical histological confirmation was obtained in 111 patients (101 malignant and 10 benign). The remaining patients were either returned to standard 3-yearly screening or early repeat screening after 1 year. Analysis of the results was performed in accordance with the standards specified in the National Health Service Breast Screening Programme (NHSBSP) Publication Number 22. Absolute sensitivity was 89.3%, complete sensitivity was 93.2%, specificity (including patients undergoing both surgical excision and follow-up) was 88.7%. The predictive value of a positive (malignant) core biopsy result was 100%. The false negative rate was 3.9%. Twelve (5.9%) biopsies were classified inadequate for diagnosis. Core biopsy is a safe and accurate way of assessing screen detected abnormalities and can be used as a substitute for fine needle aspiration cytology with results that exceed the National Health Service Breast Screening Programme target standards, even in the learning phase.

Interdisciplinary consensus on the uses and technique of MR-guided vacuum-assisted breast biopsy (VAB): Results of a European consensus meeting

PURPOSE Quality assurance of MR-guided vacuum-assisted breast biopsy (VAB). METHOD A consensus was achieved based on the existing literature and experience of an interdisciplinary group comprising European specialists in breast imaging and VAB. RESULTS Full imaging work-up must be completed according to existing standards before an indication for MR-guided VAB is established. The procedure should be reserved for lesions demonstrable by MRI alone. Acquisition of >24 cores (11-Gauge) should be routinely attempted, with the intention of sufficiently removing small lesions for accurate diagnosis. Following biopsy the patient should be re-imaged to demonstrate the biopsy site and its proximity to the lesion and hence the likely accuracy of the sampling. All patients should be discussed in a regular interdisciplinary conference and a documented consensus reached regarding patient management. Regular audit and review of all MR-guided VAB results and subsequent follow-up are recommended. CONCLUSION This consensus includes protocols for the indication, performance parameters, interdisciplinary interpretation therapeutic recommendation, documentation and follow-up of MR-guided VAB. It does not replace official recommendations for percutaneous biopsy.

Liver transplantation for hepatic arteriovenous malformation in hereditary haemorrhagic telangiectasia

Symptomatic hepatic involvement is a rare complication of hereditary hemorrhagic telangiectasia and most commonly consists of fibrosis or cirrhosis. We describe a 33-year-old woman in whom multiple hepatic arteriovenous malformations led to high output cardiac failure and liver failure due to biliary necrosis with refractory biliary sepsis, requiring orthotopic liver transplantation. Hepatic arteriovenous malformations were the first manifestation of the disease and a similar asymptomatic hepatic tumour was subsequently detected in her 60-year-old father who also had the classical cutaneous stigmata of the syndrome. Unrecognised genetic factors may determine the clinical spectrum of hereditary haemorrhagic telangiectasia including the hepatic manifestations.

Doppler ultrasound of the hepatic veins: Normal appearances

Doppler ultrasound of the hepatic veins gives a pulsatile velocity profile which mirrors the cardiac cycle. We describe the physiological basis for the complex waveform and suggest a venous pulsatility index (VPI) which can be used to quantify it. We have studied normal volunteers under differing conditions to establish a normal range of VPI. This provides a baseline against which abnormal patterns of hepatic vein Doppler can be judged.

Duplex doppler ultrasound for the detection of vascular occlusion following liver transplantation in children

Sixty-three children and adolescent patients who received 78 consecutive orthotopic liver transplants and had serial duplex ultrasound monitoring were retrospectively reviewed for episodes of occlusion of the hepatic artery or portal vein. There were 13 documented episodes of complete occlusion of the main hepatic artery or a major branch, of which nine were diagnosed by the absence of flow during duplex ultrasound examination. Four occlusions were not detected, two affected hepatic artery branches, one an accessory hepatic artery, and one the main hepatic artery. The overall sensitivity of the method was 69% and specificity 100%. Six portal vein occlusions were documented in five patients and all six were successfully diagnosed on ultrasound examination, giving a sensitivity and specificity of 100%. Three of the patients had simultaneous occlusions of both vessels. In the early post-operative period duplex Doppler ultrasound examination has proved an effective non-invasive method for the detection of vascular occlusion, but is not yet sensitive enough to replace angiography fully for the detection of hepatic artery occlusion, particularly when this occurs distal to the main hepatic artery.

The role of hepatic vein Doppler in diagnosing acute rejection following paediatric liver transplantation.

Serial Doppler ultrasound examinations of the hepatic veins were performed on 50 consecutive paediatric liver transplants. Damping of the normally pulsatile signal was observed in 23 of the 32 biopsy-proven episodes of rejection. In 10 episodes, the reduction in hepatic vein pulsatility preceded clinical and biochemical evidence of rejection by up to 36 h. Seven cases had damped signals throughout the post-operative period which precluded assessment by this method. In two patients the hepatic vein signals remained pulsatile despite rejection, one patient having unsuspected tricuspid regurgitation, and the other a stenotic IVC anastomosis. In the 35 liver transplants with normal pulsatility, hepatic vein Doppler proved to be a valuable indicator of acute rejection during the first 2 weeks following transplantation (sensitivity 92%, specificity 100%, positive predictive value 100% and negative predictive value 83%).

Duplex Doppler measurements of the portal vein in portal hypertension

In order to assess the validity of quantitative duplex Doppler measurements of portal vein flow, 10 patients with proven diffuse liver disease and portal hypertension were examined serially by two independent observers over a 3 month period. Multiple measurements of the portal vein were made using a consistent technique in an attempt to minimize observer errors. One patient proved unsuitable for ultrasound examination. In the remaining nine patients the intra-observer portal vein measurements for one observer (19 paired examinations) correlated significantly for flow velocity (r = 0.80, P < 0.001) and derived bulk flow (r = 0.54, P < 0.02) but not for cross-sectional area (r = 0.27, P > 0.05). The intra-observer measurements for the second observer (11 paired examinations) were significantly correlated for cross-sectional area (r = 0.64, P < 0.05) and derived bulk flow (r = 0.61, P < 0.05) but not for flow velocity (r = 0.5, P > 0.05). The inter-observer measurements (28 paired examinations) of the portal vein were all highly significantly correlated for cross-sectional area (r = 0.63, P < 0.001), flow velocity (r = 0.79, P < 0.001) and derived bulk flow (r = 0.73, P < 0.001). These results suggest that this quantitative Doppler technique may be valid for the serial study of portal vein flow in selected groups of patients with diffuse liver disease and portal hypertension.

Ultrasound of the axilla: where to look for the sentinel lymph node

AIMS The aim of this paper is to guide the radiologist to the most likely location of the sentinel lymph node (SLN). MATERIALS AND METHODS Patients with invasive breast cancer underwent axillary ultrasound examination. The position and morphological appearances of the lymph nodes were noted and core biopsy (CB) was performed of the largest or most suspicious node. Those patients whose biopsy revealed no evidence of malignancy proceeded to a surgical sentinel lymph node (SLN) biopsy (SLNB) looking for histopathological evidence of previous CB. RESULTS Of 121 patients who underwent axillary ultrasound and CB no malignancy was identified in 73, all of whom subsequently underwent SLNB. Histological evidence of CB in the SLN was identified in 47 (64%) patients. The position of all the lymph nodes identified on ultrasound and the 47 patients whose SLNs were identified were drawn on composite diagrams of the axilla. Of the 36 nodes identified as sentinel whose position relative to other nodes could be determined, 29 (81%) represented the lowest node identified in the axilla, four (11%) were the second lowest, and three (8%) were the third lowest node. None of the four patients whose CB was from the fourth lowest node had the CB site identified at subsequent SLNB. CONCLUSION Ultrasound of the axilla should be carried out in a systematic fashion focusing on level I nodes paying particular attention to the lowest one or two lymph nodes.

A comparison of MR and duplex doppler ultrasound for vascular assessment prior to orthotopic liver transplantation

A prospective blinded comparison of duplex Doppler ultrasound (DDU) and a magnetic resonance angiography (MRA) 2-D time-of-flight technique was performed to assess the hepatic vasculature in 23 adult patients referred for orthotopic liver transplantation. Both techniques confirmed patency of the inferior vena cava in all patients, demonstrated a complete portal vein occlusion in one patient, and accurately defined the vascular and organ anatomy in a patient with situs inversus. The results were confirmed at surgery in 18 of the patients who have subsequently undergone liver transplantation. In one patient a partial portal vein thrombosis was found at surgery which was not detected by either imaging technique. MRA was more sensitive overall in detecting porto-systemic collaterals (31 locations in 17 patients) compared with ultrasound (24 locations in 17 patients), although ultrasound detected more patients with recanalized para-umbilical veins (DDU: 10 patients; MRA: 8 patients). These results indicate that a simple MRA technique can equal duplex Doppler ultrasound for the non-invasive assessment of patency of the hepatic vasculature and should be considered when DDU examination is equivocal or technically inadequate. MRA may provide additional information on the presence and size of porto-systemic collaterals which may be of value in monitoring portal hypertension.