Non mass-like enhancement categories detected by breast MRI and histological findings

OBJECTIVE

To correlate the different non masslike enhancement categories detected by Magnetic Resonance Imaging (MRI) and the corresponding histological findings.

PATIENTS AND METHODS

Two experienced radiologists reviewed the MRI examinations of 94 patients presenting non mass-like enhancements who had performed histological evaluation. According to the BI-RADS (Breast Imaging Reporting and Data System) lexicon, non masslike enhancements were classified as focal, linear, segmental, regional, ductal and diffuse enhancements. We focused on segmental, regional and ductal patterns.

RESULTS

Among the 94 patients, 52.1% showed a regional pattern, 27.7% a segmental pattern and 20.2% a ductal pattern of enhancement. Of the 49 patients showing a regional pattern, the histological diagnosis was ductal invasive carcinoma (DIC) in 28 cases, ductal carcinoma in situ (DCIS) in 4 cases, lobular invasive carcinoma (LIC) in 3 cases and a benign disease in 9 cases. Of the 26 patients showing a segmental pattern, the histological outcome was DIC in 10 cases, DCIS in 7 cases and a benign disease in 5 cases. Among the 19 patients showing a ductal pattern, the result was DIC in 4 cases, DCIS in 4 cases and a benign disease in 7 cases. In most cases DIC presented as a regional pattern, while DCIS showed a segmental pattern in 26.9%, a ductal pattern in 21.1% and a regional pattern in 8.2% of cases.

CONCLUSIONS

Our findings about ductal and segmental enhancements agree with the literature. We found a high rate of DIC presenting as a regional enhancement, instead; thus, we recommend a more detailed diagnosis, especially when an homogeneous/heterogeneous and clumped internal enhancement pattern is present.

Neuroendocrine lung cancer presenting as a breast lump

We report the case of a 54-year-old woman presenting to our attention for a palpable breast lump. The mammographic examination showed multiple round/oval areas of increased opacity spread on both breasts. The ultrasonographic examination showed multiple hypo-anechoic nodularities without retro-tumor acoustic shadowing. The mammo/ultrasonographic findings were worthy of histological analysis, thus we performed a ultrasound (US)-guided core-biopsy, obtaining a histological diagnosis of neuroendocrine carcinoma, probably originating from the lungs. The subsequent whole body CT scan, performed to search the primary neoplasm, put in evidence a neoplasm in the left lung, involving the pulmonary hilum, and infiltrating the bronchial branches. Moreover, there were multiple secondary lesions involving adrenal glands, brain and bowel. A review of the literature confirmed that breast lumps may be the first manifestation of a metastatic disease.

An incidental finding of breast cancer after breast injury

We report of a 52-year-old woman presenting with a breast palpable mass after a trauma due to accidental fall. The patient came to our attention to perform an ultrasonographic examination because of the persistence of the mass after the trauma. The exam showed an hypo-anechoic oval formation with blurred margins and no vascularization at Power Doppler, located to the union of the upper quadrants of the right breast. The patient also performed mammographic examination, which showed an unknown oval radiopaque area. The findings were consistent with post-traumatic hematoma, even in relation to the anamnestic data, therefore we recommended anti-inflammatory therapy and a new check in fifteen days. The next ultrasonographic examination showed the persistence of the mass, slightly reduced in size, so we tried to achieve a more detailed diagnosis by performing MRI; however, the diagnostic doubt still remained, so we decided to perform a US-guided core-biopsy: the histological diagnosis was infiltrating ductal carcinoma of the breast. A review of the literature confirmed that breast lesions often are incidental findings after a breast trauma.

Skin thickening as unique pathologic sign of an inflammatory breast cancer: a case report and review of the literature

We report the case of a 42-year-old woman with inflammatory cancer of the right breast treated with neoadjuvant chemotherapy, surgery, additional chemotherapy, and consolidative radiotherapy (RT), that has metastatized to the chest wall and presented a resumption of disease on the contralateral breast. Magnetic Resonance (MR), performed after the second phase's fourth round of additional chemotherapy, showed a modest reduction of scar metastases on the right and a contralateral anomalous skin thickening with high signal intensity in T2 weighted images (WI) with multiple mass-like enhancements located in a wide area of the central region at the union of higher quadrants. These findings were suggestive for resumption of contralateral disease; the biopsy confirmed an inflammatory breast cancer (IBC) infiltrating lobular type with high mitotic rate. A retrospective evaluation of the previous MR exam, performed 5 months before, was conducted: on the left side only a modest skin thickening was found as an early sign. A careful review of the literature has confirmed that skin thickening, increased density and clinical signs of inflammation are the most common findings in inflammatory cancer. We report the case of a patient affected by IBC whose unique early sign of resumption on the contralateral breast was skin thickening.

Fetal MRI of the cardiovascular system: role of steady-state free precession sequences for the evaluation of normal and pathological appearances

PURPOSE

This study aimed to evaluate the feasibility of fetal magnetic resonance imaging (MRI) with steady-state free precession (SSFP) sequences to visualise the normal and pathological appearances of the cardiovascular system.

MATERIALS AND METHODS

This is a prospective observational study of 83 pregnant women who underwent fetal cardiac MRI: 43 patients (cases) had echocardiographic suspicion of congenital heart disease; 40 patients (controls) did not. Fetal cardiac MRI consisted of a static phase with multiplanar SSFP sequences and a dynamic phase with real-time SSFP sequences. Two radiologists evaluated the diagnostic quality of the SSFP images in both the controls and cases, the MRI morphological and functional features in the controls and the MRI signs of congenital heart disease in the cases.

RESULTS

In both groups, SSFP sequences produced goodquality MR images and good visualisation of morphological features. Functional data appeared to be unavailable due to the current small temporal resolution and the technical impossibility of fetal cardiac triggering. MRI detected direct signs of congenital heart disease in 21 fetuses, indirect signs in six and both signs in 15.

CONCLUSIONS

SSFP sequences are effective in demonstrating the morphological features of the cardiovascular system, whereas dynamic SSFP cine-MRI sequences may provide adjunctive albeit suboptimal functional information.

[Seroma in residual fibrous capsule after breast implant explantation: a case report]

The Authors present a singular case of seroma which developed in residual fibrous capsule after explantation of breast prostheses without replacement. Mammographic and sonographic findings of the seroma make difficult the diagnosis: mammograms revealed a radiopaque, well-circumscribed mass anterior to the pectoralis major muscle in the region of the prior sub-glandular implant, that was initially misinterpreted as breast implant radiographic feature. It is particularly important review and carefully correlate mammographic and sonographic findings with patient's surgical history for a correct diagnosis.

Diagnostic utility of combined ultrasonography and mammography in the evaluation of women with mammographically dense breasts

PURPOSE

To assess the diagnostic utility and additional cost of combined breast ultrasonography and mammography in the evaluation of asymptomatic women with mammographically dense breasts.

MATERIALS AND METHODS

Of 5108 asymptomatic women, who underwent mammography, 1754 had dense breasts (BI-RADS 3 or 4) and negative mammographic outcome. They were divided in 4 subgroups according to their age (<40 yrs; 40-49 yrs; 50-59 yrs; >59 yrs). Breast ultrasonography was performed immediately after mammography. Lesions detected at ultrasonography were examined cytologically/histologically. Mammograms from women, who were diagnosed carcinoma at ultrasonography, were reviewed by an external radiologist. Costs per diagnosed carcinoma and per examined woman were calculated on the basis of current regional charges.

RESULTS

Mammographies (5108) were performed, 67 cancers were detected (cancer detection rate 13.1‰): mammography identified 55 carcinomas and ultrasonography performed in women with dense breasts identified 12 cancers (17.9% of all cancers detected, overall cancer detection rate 6.8‰). Ultrasonography identified a benign condition in 1567 out of 1754 women (89.3%) (in 925 absence of focal lesions; 438 simple cysts; 56 ductal ectasia; 148 benign solid lesions); 97 complex cysts, 52 lesions that could not be differentiated as liquid or solid lesions, and 38 solid lesions suspicious for malignancy in the remaining 187 out of 1754 patients (10.7%). Cytology/histology confirmed carcinoma in 12 women (overall biopsy rate 26.2‰, benign biopsy rate 19.4‰). The additional costs were: € 6,123.45 per detected cancer, € 41.89 per examined woman.

CONCLUSION

Breast ultrasonography immediately after mammography in women with dense breasts is useful to avoid diagnostic delays and inconvenient medico-legal implications even though this procedure involves increased costs.

Adjunctive diagnostic value of ultrasonography evaluation in patients with suspected ductal breast disease

PURPOSE

The purpose of this study was to evaluate the adjunctive diagnostic value of breast ultrasonography (US) in the study of benign ductal breast disease.

MATERIALS AND METHODS

Fifty-two patients underwent US examinations for bloody nipple discharge, palpable retroareolar masses, retroareolar opacities or ductal pattern on mammography. US enabled visualisation of mammary-duct ectasia (simple or pseudocystic, retroareolar and/or peripheral) and focal masses (endoluminal or periductal, with ill-defined or regular margins). All patients with nipple discharge underwent cytological evaluation. After the US examination, all focal masses with ill-defined margins underwent fine-needle aspiration biopsy (FNAB), if necessary. The benign alterations were followed up.

RESULTS

In 38/52 cases, US diagnosed mammary-duct ectasia and in 30/52 cases, the presence of focal masses (mean size 7 mm). In the nine women who underwent biopsy, histopathological evaluation diagnosed five solitary papillomas, one solitary papilloma with a focal area of ductal carcinoma in situ (DCIS), two multiple papillomas of the nipple and one papillomatosis.

CONCLUSIONS

High-frequency US plays an important role in the detection of benign ductal disease both for the diagnosis and classification of focal masses and mammary-duct ectasia. US can be used as a complementary imaging method to galactography or as a valuable alternative when galactography is not available.

Evaluation of normal brain development by prenatal MR imaging

PURPOSE

The aim of this study was to describe the normal pattern of development and maturation of the foetal brain with respect to gestational age as assessed with magnetic resonance imaging (MRI) and to provide an overview of the possibilities of the technique.

MATERIALS AND METHODS

Foetal cerebral MRI was performed on 56 pregnant women between 19 and 37 weeks of gestation. Half-Fourier single-shot turbo spin-echo (HASTE), true fast imaging with steady precession (FISP), T1-weighted fast low angle shot (FLASH) two-dimensional (2D) and diffusion-weighted (DW) sequences with apparent diffusion coefficient (ADC) were obtained. Biometric parameters and developmental areas of the cerebral cortex were correlated to gestational age by using the Spearman rank correlation test.

RESULT

We found a negative correlation between the germinal matrix/biparietal diameter ratio and gestational age and a positive correlation between the germinal and cortical matrix when expressed as external intraocular diameter ratio (R=0.452, p=0.02). The cortical mantle was correlated with biometric parameters, such as the biparietal diameter and the frontooccipital diameter, and with gestational age. The interhemispheric fissure, the parietooccipital fissure and the sylvian fissure were detectable by the 22nd week. In the grey matter, the mean ADC values varied from 1.76 x 10(-3) mm(2)/s (at week 19) to 0.89 x 10(-3) mm(2)/s (at week 37), whereas in the white matter, the values varied from 2.03 x 10(-3) mm(2)/s (at week 19) to 1.25 x 10(-3) mm(2)/s (at week 37).

CONCLUSIONS

MRI provides a reliable valuation of brain maturation during pregnancy.

Benign and malignant breast lesions: efficacy of real time contrast-enhanced ultrasound vs. magnetic resonance imaging

PURPOSE

To assess the efficacy of low mechanical index (MI) real time grey scale contrast-enhanced US (CEUS) in the differentiation of breast lesions in comparison to Magnetic Resonance Imaging (MRI).

MATERIALS AND METHODS

50 lesions previously detected at mammography or conventional US were evaluated by means of CEUS and MRI. Contrast-enhanced examinations were performed with a dedicated equipment (Esatune, Esaote, Genoa, Italy), before and after injection of 4.8 ml of Sonovue (Bracco, Milan, Italy). MRI was conducted with a 1.5 T equipment (Siemens Vision Plus, Erlangen, Germany) with bilateral dedicated superficial coil, on T2w STIR and 3D Flash T1w before and 1, 2, 3, 4, 5 minutes after the administration of contrast agent (Gd-DTPA, 1.5 ml/kg). Wash-in and wash-out curves were assessed for both procedures. A specific sonographic quantification software (Qontrast, Bracco, Milan, Italy), based on pixel by pixel signal intensity over time, was used to obtain contrast-enhanced sonographic perfusion maps for each lesion. Mc Nemar test was then calculated.

RESULTS

24 invasive ductal carcinomas, 18 fibroadenomas, 4 fibro-cystic dysplasias, 1 mucinous carcinoma, 1 invasive ducto-lobular carcinoma, 1 intraductal florid papillomatosis and 1 phylloides tumour were diagnosed. Contrast-enhanced sonographic patterns correlated well with those provided by MRI. Sensitivity, specificity, and accuracy of US were: 69.2 %, 66.7 %, and 68 %, respectively. According to the different contrast enhancement patterns and the resulting perfusion maps, all the malignant lesions and 9 out of 12 benign lesions were correctly diagnosed, thus resulting in 87.5 % of specificity and 100 % of sensitivity. Regarding the specificity, there is no difference between US and CEUS with McNemar (p = 0.18). Regarding sensitivity, the difference between contrast-enhanced US and US is significant as calculated with McNemar test (p = 0.013). The three lesions which were incorrectly classified as malignant were two hypervascularised fibroadenomas in young women and a phylloides tumour.

CONCLUSION

CEUS seems to be a reliable method to differentiate breast lesions, since it provides typical enhancement patterns. Contrast sonographic perfusion curves correlate well with MRI wash in--wash out curves.

Hematocolpos in double vagina associated with uterus didelphus: US and MR findings

The malformative syndrome of double vagina in association with uterus didelphus and kidney agenesis is a rare condition, often asymptomatic: if this condition is accompanied by imperforated obstructed hemivagina, the clinical manifestations depend on the presence of hematocolpos. MRI plays an important role for diagnosis because it allows to characterize the nature of the lesion and to evaluate the anatomical details of the uterine malformation. The authors describe this complex genital malformation and discuss the main US and MRI features.

[Diagnostic problems and results of laparoscopic cholecystectomy in chronic acalculous cholecystitis]

We report on our experience with laparoscopic cholecystectomy in 15 patients, 12 females and 3 males (mean age: 44 years), with chronic acalculous cholecystitis. These patients presented with recurrent episodes of biliary colic together with a dysmorphic or dysfunctioning gallbladder as confirmed by ultrasound and/or cholescintiscan with 99m-Tc HIDA performed in fasting conditions and after meals. First of all, we considered the possible presence of concomitant digestive disease (peptic ulcer disease, recurrent pancreatitis, irritable bowel syndrome, chronic hepatitis) potentially responsible for the pain. Ultrasound investigations revealed a pathological gallbladder in 10 patients. Cholecystectomy was curative in 8/10. Cholescintiscan revealed a pathological gallbladder in 8 patients and cholecystectomy was curative in only 5 of these. No postoperative deaths or significant complications occurred. The mean duration of the operation (35 vs 48 min) and hospital stay (2.1 vs 2.8 days) were reduced in comparison to 346 cholecystectomies performed for gallstones. After 6-36 months' follow-up, resolution of symptoms was successful in 10/15 cases (66.6%); in 3 cases, only dyspepsia was reduced, whilst in the other 2 cases, who also presented concomitant irritable bowel syndrome and gastroduodenitis, there was no improvement in pain. In all but the latter two cases (86.6%), histological examination revealed chronic gallbladder inflammation. In conclusion, laparoscopic cholecystectomy was curative (66.6%) or led to an improvement in symptoms (20%) in patients with chronic acalculous cholcystitis. Cholescintiscans were not always diagnostic for the disease, whereas ultrasound findings were more useful as an indication for surgery.

[A statistical evaluation of the variability in the measurements of the resistive index in kidney transplantation]

INTRODUCTION

Doppler ultrasound (US) is a valuable tool to measure blood flow in the transplanted kidney, but its operator-dependence can greatly affect repeatability and reproducibility of measurements. Aim of this work was to evaluate intraobserver and interobserver variability in measuring the resistive index (RI) in renal transplants.

PATIENTS AND METHODS

Ten renal transplant recipients were randomly selected among those undergoing follow-up and examined by two operators (FG and LB) with 3.5 MHz and 10 MHz scanheads to assess the variability of RI measurements. Each observer obtained two measurements of the RI with each scanhead within a 10-15 minutes' period. In all, 80 measurements were made, 4 per patient per observer. The statistical analysis included two-tailed Student's t-test for paired data and calculation of repeatability/reproducibility coefficients.

RESULTS

Student's t-test analysis demonstrated a statistically significant difference (p = 0.037) between the means of the first and second measurements by FG with the 3.5 MHz scanhead and the first and the second measurements by LB with the same scanhead. Differences between the other means were not statistically significant. Intraobserver variability ranged 0.03 units (or 2.07%) and 0.07 units (or 4.24%), while interobserver variability was 0.04 units with both 3.5 and 10 MHz scanheads, or 3.61 and 3.73%, respectively.

CONCLUSIONS

Doppler US of renal transplants has statistically quantifiable operator-dependent variability: the possible evidence of statistically significant differences can be minimized by having the same operator make the measurements. However, RI variations ranging 0.02 to 0.04 units should not be considered significant.

99mTc MIBI scintimammography with a high resolution single tube gamma camera: preliminary study

99mTc MIBI scintimammography is a sensitive and specific diagnostic technique for breast cancer detection when cancers more than 1 cm sized are considered. However the sensitivity falls in the case of submillimetric lesions. We developed a new Small Field of View, High Resolution Detector, able to image the breast in similar conditions of x-ray mammography: it allows the performance of Single Photon Emission Mammography (SPEM) studies. Seven patients with suspicion of malignant lesions were comparatively submitted to a Prone Scintimammography (PSM) by Anger camera and to a cranio-caudal view SPEM. The final diagnosis was reached by histopathology. Four malignant lesions were identified by SPEM but not by PSM, which that failed to image two submillimetric cancers. Both the cameras gave normal findings for benign lesions, confirming the high sensitivity of this technique. The results allow us to consider the SPEM camera as promising to improve scintimammographic sensitivity, even when small-sized tumors are examined.