Sahar Mahmoud Mansour

Breast imaging in the young: the role of magnetic resonance imaging in breast cancer screening, diagnosis and follow-up

Diagnosis of breast cancer in young individuals (younger than 40 years old) poses a real challenge to breast radiologists because their breast tissue is often denser than the breast tissue of older women. Magnetic Resonance Imaging (MRI) may be particularly helpful in such situations. The American Cancer Society (ACS) recommended breast MRI screening as an adjunct to mammography for: BRCA mutation carriers and their first-degree relatives; women with a lifetime breast cancer risk ≥20% to 25%; women with a history of chest radiation between ages of 10 and 30 years; and women with predisposing genetic syndromes. Currently, breast MRI demonstrates a high sensitivity in the range of 93-100%. As many benign lesions also show enhancement or other atypical features on MRI, the primary weakness of contrast enhanced MRI remains in its low specificity, reported to be in the range of 37-97%. Breast MRI is helpful in demonstrating the true tumor size initially, as well as identifying residual tumor following the completion of neo-adjuvant therapy. In general, sensitivities ranging from 61% to 86% for detecting residual disease have been reported. The absence of enhancement virtually excludes a recurrence and the presence of enhancement is very specific for tumor even in the radiated breast. MRI is also the preferred modality for assessment of the breast after re- constructive surgery. The role of Magnetic Resonance Imaging (MRI) in breast diagnosis will continue to evolve as technology improves and clinical experience with new techniques expands.

Elastography ultrasound and questionable breast lesions: Does it count?

OBJECTIVE To check possible additional value of using elastography ultrasound in the specification of questionable breast lesions. SUBJECTS AND METHODS Questionable breast lesions on gray scale ultrasound examination had been further evaluated by elastography ultrasound in 97 cases with median age of 42 years. The studied lesions were pathologically proven (58 benign and 39 malignant) using true cut tissue/surgical excision biopsy that was considered the gold standard of reference. RESULTS Conventional ultrasound categorization before biopsy included: category 3 (probably benign) in 42.3% (n=41), category 4a (low suspicion of malignancy) in 13.4% (n=13), category 4b (intermediate suspicion of malignancy) in 16.5% (n=16) and category 4c (moderate suspicion of malignancy) in 27.8% (n=27). We had evaluated elastography ultrasound regarding elastography strain scoring and quantitative strain ratio. Sensitivity, specificity and accuracy were 89.7%, 86.2% and 87.6% for conventional ultrasound, 92.3%, 74.1% and 81.4% for elastogram 5-point scoring method and 87.1%, 89.6% and 88.6% for the calculated strain ratios respectively in the assessment of the examined breast lesions. CONCLUSION Ultrasound elastography, using both qualitative and quantitative methods can improve the performance of conventional B-mode ultrasound and enhance its specificity and accuracy in the diagnosis of questionable (BI-RADS categories 3 and 4) breast lesions.

Does MRI add to ultrasound in the assessment of disorders of sex development

OBJECTIVE The objective of the study was to evaluate the need of magnetic resonance imaging and using different approaches (transabdominal, endoluminal and transperineal) in the proper assessment of disorders of sex development regarding gonadal detection and gender differentiation. SUBJECTS AND METHODS Twenty five patients with abnormalities of sex disorders were included. They were classified into two groups according to the time of clinical presentation: Group 1 (early onset) included eight cases. Their age ranged from one month to 12 years (mean age=3.0). They presented with overt genital ambiguity of clitoral hypertrophy in a phenotypic female, non palpable testes or micropenis in a phenotypic male. Group 2 (late onset) included 17 cases. Their age ranged from 16 to 33 years (mean age 18.1). This group presented by distressing puberty symptoms of primary amenorrhea in a female phenotype or undescended testis and behaving as a male. Cases were subjected to Ultrasound and MR imaging examinations. Imaging results were correlated results of chromosomal and hormonal assays as well as laparoscopy findings. RESULTS The study included: 10/25 cases (40%) of female pseudo-hermaphroditism, 13/25 cases (52%) of male pseudo-hermaphroditism, one case (4%) of true hermaphroditism and one case (4%) of pure gonadal dysgenesis. The accuracy of multi approach ultrasound was 89.8% compared to 85.7% in MR imaging. CONCLUSION Ultrasound should be considered the initial screening modality in the assessment of developmental sex disorders. MRI examination could be reserved for gonad identification when ultrasound examination fails to do so and for corrective surgery guidance.

Contrast-enhanced spectral mammography: Impact of the qualitative morphology descriptors on the diagnosis of breast lesions

OBJECTIVE To analyze the morphology and enhancement characteristics of breast lesions on contrast-enhanced spectral mammography (CESM) and to assess their impact on the differentiation between benign and malignant lesions. MATERIALS AND METHOD This ethics committee approved study included 168 consecutive patients with 211 breast lesions over 18 months. Lesions classified as non-enhancing and enhancing and then the latter group was subdivided into mass and non-mass. Mass lesions descriptors included: shape, margins, pattern and degree of internal enhancement. Non-mass lesions descriptors included: distribution, pattern and degree of internal enhancement. The impact of each descriptor on diagnosis individually assessed using Chi test and the validity compared in both benign and malignant lesions. The overall performance of CESM were also calculated. RESULTS The study included 102 benign (48.3%) and 109 malignant (51.7%) lesions. Enhancement was encountered in 145/211 (68.7%) lesions. They further classified into enhancing mass (99/145, 68.3%) and non-mass lesions (46/145, 31.7%). Contrast uptake was significantly more frequent in malignant breast lesions (p value ≤ 0.001). Irregular mass lesions with intense and heterogeneous enhancement patterns correlated with a malignant pathology (p value ≤ 0.001). CESM showed an overall sensitivity of 88.99% and specificity of 83.33%. The positive and negative likelihood ratios were 5.34 and 0.13 respectively. CONCLUSION The assessment of the morphology and enhancement characteristics of breast lesions on CESM enhances the performance of digital mammography in the differentiation between benign and malignant breast lesions.

Comparative study between computed tomography guided superior hypogastric plexus block and the classic posterior approach: A prospective randomized study.

Context: The classic posterior approach to superior hypogastric plexus block (SHPB) is sometimes hindered by the iliac crest or a prominent transverse process of L5. The computed tomography (CT) – guided anterior approach might overcome these difficulties. Aims: This prospective, comparative, randomized study was aimed to compare the CT guided anterior approach versus the classic posterior approach. Settings and Design: Controlled randomized study. Materials and Methods: A total of 30 patients with chronic pelvic cancer pain were randomized into either classic or CT groups where classic posterior approach or CT guided anterior approach were done, respectively. Visual analog score, daily analgesic morphine consumed and patient satisfaction were assessed just before the procedure, then, after 24 h, 1 week and monthly for 2 months after the procedure. Duration of the procedure was also recorded. Adverse effects associated with the procedure were closely observed and recorded. Statistical Analysis Used: Students t-test was used for comparison between groups. Results: Visual analog scale and morphine consumption decreased significantly in both groups at the measured times after the block compared with the baseline in the same group with no significant difference between both groups. The procedure was carried out in significantly shorter duration in the CT group than that in the classic group. The mean patient satisfaction scale increased significantly in both groups at the measured times after the block compared with the baseline in the same group. The patients in the CT groups were significantly more satisfied than those in classic group from day one after the procedure until the end of the study. Conclusions: The CT guided approach for SHPB is easier, faster, safer and more effective, with less side-effects than the classic approach.

Impact of three dimensional tomosynthesis on the detection and diagnosis of breast lesions

Subjects and methods The study included 166 mammograms with indeterminate findings selected from 1600 mammograms. They were classified into two groups: group 1 ‘Diagnostic mammograms’ of symptomatic women and group 2 ‘Screening mammograms’. Dense breasts assigned as ACR3 and ACR4 presented 69% (n = 114/166) of the studied cases. FFDM and 3D tomosynthesis examination was done and imaging findings were evaluated before and after the use of 3D tomosynthesis images.

Ovarian cancer screening—ultrasound; impact on ovarian cancer mortality

Although ovarian cancer (OC) is the most lethal of all female malignancies, debate still exists concerning the benefits and harms of the screening programs and their impact on long-term survival and mortality from the disease. The most widely tested screening strategies have focused on transvaginal ultrasound (TVU) and on algorithms that measure serum levels or interval changes of cancer antigen-125 (CA-125) either individually or in combination. Transvaginal ultrasound can identify size and morphology changes of the ovary that may signal a developing malignancy; yet, it is still accused of having a low specificity. There is preliminary evidence that screening can improve survival, but the impact of screening on mortality from OC is still unclear and warrants further validation. In spite of having many published prospective studies, up to-date, none have been able to demonstrate conclusively a reduction in mortality from OC both in the screened general or high-risk population. Data from the US Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Trial has not shown survival or mortality benefits in the general population. Most prospective trials have reported a decrease in stage at detection (with the exception of the PLCO trial), thereby allowing treatment to be initiated when the disease is most curable. Research is in progress to develop new diagnostic tests and novel biomarkers, which when used in combination can increase the accuracy and outcomes of screening. In this review article, we will discuss the debate provoked on OC screening programs and the impact of using ultrasound on the reduction of OC-related mortality.

Surface transperineal ultrasound and vaginal abnormalities: applications and strengths

The role of ultrasound in the assessment of the female pelvis whether using transabdominal/transluminal approach is well established. Little was reported about the use of the superficial transperineal approach that could provide a full assessment of the lower cervix and vagina, which may be overlooked in the standard examinations. The proximity of the probe to the vagina helps not only the detection of organ abnormalities but also proper characterization and differentiation of vaginal masses. . We discuss the diagnostic role of this superficial ultrasound approach in improving the perception and interpretation of the anatomy and different diseases of the vagina.