High dose rate brachytherapy for prostate cancer: A prospective toxicity evaluation of a one day schedule including two 13.5 Gy fractions

Publication date: Available online 3 April 2018
Source:Radiotherapy and Oncology
Author(s): Gorka Nagore, Jose Luis Lopez Guerra, Evita Krumina, Mark Lagos, Beatriz Ovalles, Antonio Miró, Lourdes Beltran, Emilia Gómez, Juan Manuel Praena-Fernandez, Eleonor Rivin del Campo, Ignacio Azinovic, Alfonso Gomez-Iturriaga
Background and purposeHigh dose-rate (HDR) brachytherapy (BT) provides a highly conformal method of dose delivery to the prostate. The purpose of this study is to prospectively determine the toxicity of the treatment protocol of 13.5 Gy × 2 fractions.Materials and methodsFrom 2010 through 2017, 119 patients with low (71%) or intermediate-risk prostate cancer were prospectively treated in a single institute with HDR-BT at 13.5 Gy × 2 fractions within one day. Median follow-up time was 4.4 years.ResultsActuarial rates of no biochemical evidence of disease, overall survival and metastasis-free survival for all patients were 96%,98% and 98%, respectively. The cumulative incidence of acute grade 2 and 3 genitourinary (GU) toxicity was 9% and 2%, respectively. The corresponding incidences of late GU toxicity were 18% and 1%. No grade ≥4 of either type of toxicity was detected. Multivariate analysis showed that having higher international prostate symptom score (IPSS; P = 0.041) or higher V200 (P = 0.013) was associated with a higher risk of experiencing any grade of acute GU toxicity. In addition, patients having a higher IPSS (P = 0.019) or a higher V150 (P = 0.033) were associated with a higher grade >1 acute GU toxicity.ConclusionsThe findings of this study show that HDR-BT 13.5 Gy × 2 as monotherapy was safe and effective for prostate cancer patients with low-intermediate risk.



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ENLIGHT: European network for Light ion hadron therapy

Publication date: Available online 3 April 2018
Source:Radiotherapy and Oncology
Author(s): Manjit Dosanjh, Ugo Amaldi, Ramona Mayer, Richard Poetter
The European Network for Light Ion Hadron Therapy (ENLIGHT) was established in 2002 following various European particle therapy network initiatives during the 1980s and 1990s (e.g. EORTC task group, EULIMA/PIMMS accelerator design). ENLIGHT started its work on major topics related to hadron therapy (HT), such as patient selection, clinical trials, technology, radiobiology, imaging and health economics. It was initiated through CERN and ESTRO and dealt with various disciplines such as (medical) physics and engineering, radiation biology and radiation oncology. ENLIGHT was funded until 2005 through the EC FP5 programme. A regular annual meeting structure was started in 2002 and continues until today bringing together the various disciplines and projects and institutions in the field of HT at different European places for regular exchange of information on best practices and research and development. Starting in 2006 ENLIGHT coordination was continued through CERN in collaboration with ESTRO and other partners involved in HT. Major projects within the EC FP7 programme (2008–2014) were launched for R&D and transnational access (ULICE, ENVISION) and education and training networks (Marie Curie ITNs: PARTNER, ENTERVISION). These projects were instrumental for the strengthening of the field of hadron therapy.With the start of 4 European carbon ion and proton centres and the upcoming numerous European proton therapy centres, the future scope of ENLIGHT will focus on strengthening current and developing European particle therapy research, multidisciplinary education and training and general R&D in technology and biology with annual meetings and a continuously strong CERN support. Collaboration with the European Particle Therapy Network (EPTN) and other similar networks will be pursued.



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PROGRAD – An observational study of the prognosis of inpatients evaluated for palliative radiotherapy

Publication date: Available online 3 April 2018
Source:Radiotherapy and Oncology
Author(s): Andre Tsin Chih Chen, Geovanne Pedro Mauro, Flavia Gabrielli, Cristiane de Lacerda Gonçalves Chaves, Igor Castro, Karina Moutinho Vasconcelos, Milena Reis, Thalita Saraiva, Heloisa Andrade de Carvalho
Background and purposeLow-and-middle-income countries have resource constraints and waiting lists for radiotherapy (RT). In this context, we sought to determine the survival of inpatients evaluated for palliative RT in a large referral cancer center in Brazil.Material and methodsFrom November 2014 through December 2015, we enrolled 333 inpatients with palliative RT evaluation requests in this prospective observational study. We applied Palliative Prognostic Index (PPI) and Survival Prediction Score using Number of Risk Factors (NRF). Primary endpoint was overall survival. Secondary endpoints were survival by PPI and NRF. (ClinicalTrials.gov number, NCT02312791).ResultsMedian survival (MS) for the entire cohort was 73 days. PPI ≤2 had MS of 120 days; PPI 2.5–4 had MS of 55 days (HR 1.84; 95% CI, 1.07–3.16); PPI >4 had MS of 39 days (HR 3.45; 95% CI, 2.07–5.74) (p < .0001). NRF 0–1 had MS of 129 days; NRF 2 had MS of 73 days (HR 1.74; 95% CI 0.89–3.38); NRF 3 had MS of 40 days (HR 2.95; 95% CI, 1.50–5.78) (p < .0001).ConclusionInpatients with palliative RT requests seem to have an overall poor survival. PPI and NRF can define subgroups with different prognosis. This could help hospitals and healthcare systems to standardize criteria for prioritization and contribute for fairness.



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Copyright

Publication date: May 2018
Source:Radiologic Clinics of North America, Volume 56, Issue 3





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Contributors

Publication date: May 2018
Source:Radiologic Clinics of North America, Volume 56, Issue 3





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Contents

Publication date: May 2018
Source:Radiologic Clinics of North America, Volume 56, Issue 3





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CME Accreditation Page

Publication date: May 2018
Source:Radiologic Clinics of North America, Volume 56, Issue 3





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Forthcoming Issues

Publication date: May 2018
Source:Radiologic Clinics of North America, Volume 56, Issue 3





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Imaging of Lung Cancer: Update on Staging and Therapy

Publication date: May 2018
Source:Radiologic Clinics of North America, Volume 56, Issue 3
Author(s): Jeremy J. Erasmus, Mylene T. Truong




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Imaging of Lung Cancer: Update on Screening, Staging, and Therapy

Publication date: May 2018
Source:Radiologic Clinics of North America, Volume 56, Issue 3
Author(s): Jeremy J. Erasmus, Mylene T. Truong




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Pulmonary Nodule Management in Lung Cancer Screening

Publication date: May 2018
Source:Radiologic Clinics of North America, Volume 56, Issue 3
Author(s): Myrna C.B. Godoy, Erika G.L.C. Odisio, Mylene T. Truong, Patricia M. de Groot, Girish S. Shroff, Jeremy J. Erasmus

Teaser

The number of screening-detected lung nodules is expected to increase as low-dose computed tomography screening is implemented nationally. Standardized guidelines for image acquisition, interpretation, and screen-detected nodule workup are essential to ensure a high standard of medical care and that lung cancer screening is implemented safely and cost effectively. In this article, we review the current guidelines for pulmonary nodule management in the lung cancer screening setting.


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Tumor Staging of Lung Cancer

Publication date: May 2018
Source:Radiologic Clinics of North America, Volume 56, Issue 3
Author(s): Constantine A. Raptis, Caroline L. Robb, Sanjeev Bhalla

Teaser

Several important modifications have been proposed for the tumor (T) descriptor for lung cancers. New size cutoffs have been determined and there are new T descriptors for adenocarcinoma in situ, minimally invasive adenocarcinoma, and part-solid adenocarcinomas with a solid component > 0.5 cm to 3 cm (T1a, T1b, T1c). There are also recommendations for multifocal adenocarcinoma, which are classified by the lesion with the highest level T descriptor, and the number of lesions is indicated. Knowledge of these changes is important in the appropriate clinical staging of patients with lung cancer.


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Staging Lung Cancer

Publication date: May 2018
Source:Radiologic Clinics of North America, Volume 56, Issue 3
Author(s): Ahmed H. El-Sherief, Charles T. Lau, Brett W. Carter, Carol C. Wu

Teaser

This article reviews regional lymph node assessment in lung cancer. In the absence of a distant metastasis, the absence or location of lung cancer spread to a regional mediastinal lymph node affects treatment options and prognosis. Regional lymph node maps have been created to standardize assessment of the N descriptor. The International Association for the Study of Lung Cancer lymph node map is used for the standardization of N descriptor assessment. CT, PET/CT with fluorodeoxyglucose, endobronchial ultrasound–guided and/or esophageal ultrasound–guided biopsy, and mediastinoscopy are common modalities used to determine the N descriptor.


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Dilemmas in Lung Cancer Staging

Publication date: May 2018
Source:Radiologic Clinics of North America, Volume 56, Issue 3
Author(s): Ioannis Vlahos

Teaser

The advent of the 8th edition of the lung cancer staging system reflects a further meticulous evidence-based advance in the stratification of the survival of patients with lung cancer. Although addressing many limitations of earlier staging systems, several limitations in staging remain. This article reviews from a radiological perspective the limitations of the current staging system, highlighting the process of TNM restructuring, the residual issues with regards to the assignment of T, N, M descriptors, and their associated stage groupings and how these dilemmas impact guidance of multidisciplinary teams taking care of patients with lung cancer.


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Update of MR Imaging for Evaluation of Lung Cancer

Publication date: May 2018
Source:Radiologic Clinics of North America, Volume 56, Issue 3
Author(s): Mario Ciliberto, Yuji Kishida, Shinichiro Seki, Takeshi Yoshikawa, Yoshiharu Ohno

Teaser

Since MR imaging was introduced for the assessment of thoracic and lung diseases, various limitations have hindered its widespread adoption in clinical practice. Since 2000, various techniques have been developed that have demonstrated the usefulness of MR imaging for lung cancer evaluation, and it is now reimbursed by health insurance companies in many countries. This article reviews recent advances in lung MR imaging, focusing on its use for lung cancer evaluation, especially with regard to pulmonary nodule detection, pulmonary nodule and mass assessment, lung cancer staging and detection of recurrence, postoperative lung function prediction, and therapeutic response evaluation and prediction.


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Lung Cancer

Publication date: May 2018
Source:Radiologic Clinics of North America, Volume 56, Issue 3
Author(s): Marcelo F. Benveniste, James Welsh, Chitra Viswanathan, Girish S. Shroff, Sonia L. Betancourt Cuellar, Brett W. Carter, Edith M. Marom

Teaser

In this review, we discuss the different radiation delivery techniques available to treat non–small cell lung cancer, typical radiologic manifestations of conventional radiotherapy, and different patterns of lung injury and temporal evolution of the newer radiotherapy techniques. More sophisticated techniques include intensity-modulated radiotherapy, stereotactic body radiotherapy, proton therapy, and respiration-correlated computed tomography or 4-dimensional computed tomography for radiotherapy planning. Knowledge of the radiation treatment plan and technique, the completion date of radiotherapy, and the temporal evolution of radiation-induced lung injury is important to identify expected manifestations of radiation-induced lung injury and differentiate them from tumor recurrence or infection.


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Targeted Therapy and Immunotherapy in the Treatment of Non–Small Cell Lung Cancer

Publication date: May 2018
Source:Radiologic Clinics of North America, Volume 56, Issue 3
Author(s): Girish S. Shroff, Patricia M. de Groot, Vassiliki A. Papadimitrakopoulou, Mylene T. Truong, Brett W. Carter

Teaser

The treatment strategy in advanced non–small cell lung cancer (NSCLC) has evolved from empirical chemotherapy to a personalized approach based on histology and molecular markers of primary tumors. Targeted therapies are directed at the products of oncogenic driver mutations. Immunotherapy facilitates the recognition of cancer as foreign by the host immune system, stimulates the immune system, and alleviates the inhibition that allows the growth and spread of cancer cells. The authors describes the role of targeted therapy and immunotherapy in the treatment of NSCLC, patterns of disease present on imaging studies, and immune-related adverse events encountered with immunotherapy.


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High dose rate brachytherapy for prostate cancer: A prospective toxicity evaluation of a one day schedule including two 13.5 Gy fractions

High dose-rate (HDR) brachytherapy (BT) provides a highly conformal method of dose delivery to the prostate. The purpose of this study is to prospectively determine the toxicity of the treatment protocol of 13.5 Gy × 2 fractions.

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PROGRAD – An observational study of the prognosis of inpatients evaluated for palliative radiotherapy

Low-and-middle-income countries have resource constraints and waiting lists for radiotherapy (RT). In this context, we sought to determine the survival of inpatients evaluated for palliative RT in a large referral cancer center in Brazil.

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ENLIGHT: European network for Light ion hadron therapy

The European Network for Light Ion Hadron Therapy (ENLIGHT) was established in 2002 following various European particle therapy network initiatives during the 1980s and 1990s (e.g. EORTC task group, EULIMA/PIMMS accelerator design). ENLIGHT started its work on major topics related to hadron therapy (HT), such as patient selection, clinical trials, technology, radiobiology, imaging and health economics. It was initiated through CERN and ESTRO and dealt with various disciplines such as (medical) physics and engineering, radiation biology and radiation oncology.

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Speculation on the naming of Moyamoya disease – Letter to the Editor

Publication date: Available online 3 April 2018
Source:Journal of Neuroradiology
Author(s): Mari Mori, Naoko Kurokawa, Gordon Worley




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Brain CT Perfusion Improves Intracranial Vessel Occlusion Detection on CT Angiography

Publication date: Available online 3 April 2018
Source:Journal of Neuroradiology
Author(s): Marinus J. Becks, Rashindra Manniesing, Jeroen Vister, Sjoert A.H. Pegge, Stefan C.A. Steens, Ewoud J. van Dijk, Mathias Prokop, Frederick J.A. Meijer
Background and PurposeTo evaluate whether brain CT perfusion (CTP) aids in the detection of intracranial vessel occlusion on CT angiography (CTA) in acute ischemic stroke.Materials and methodsMedical-ethical committee of our hospital was obtained and informed consent was waived. Patients suspected of acute ischemic stroke who underwent non-contrast CT(NCCT), CTA and whole-brain CTP in our center in the year 2015 were included. Three observers with different levels of experience evaluated the imaging data of 110 patients for the presence or absence of intracranial arterial vessel occlusion with two strategies. In the first strategy, only NCCT and CTA were available. In the second strategy, CTP maps were provided in addition to NCCT and CTA. Receiver-operating-characteristic (ROC) analysis was used for the evaluation of diagnostic accuracy.ResultsOverall, a brain perfusion deficit was scored present in 87-89% of the patients with an intracranial vessel occlusion, more frequently observed in the anterior than in the posterior circulation. Performance of intracranial vessel occlusion detection on CTA was significantly improved with the availability of CTP maps as compared to the first strategy (p=0.023), due to improved detection of distal and posterior circulation vessel occlusions (p-values of 0.032 and 0.003 respectively). No added value of CTP was found for intracranial proximal vessel occlusion detection, with already high accuracy based on NCCT and CTA alone.ConclusionThe performance of intracranial vessel occlusion detection on CTA was improved with the availability of brain CT perfusion maps due to the improved detection of distal and posterior circulation vessel occlusions.



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Experimental Evaluation of the NeVaTM Thrombectomy Device a Novel Stent Retriever Conceived to Improve Efficacy of Organized Clot Removal

Publication date: Available online 3 April 2018
Source:Journal of Neuroradiology
Author(s): Paolo Machi, Arthur J. Ulm, Gianmarco Bernava, Olivier Brina, Karl Olof Lovblad, Franck Jourdan
Background And PurposeStent retrievers are recognized as the most effective devices for intracranial thrombectomy. Although highly effective, such devices fail in clot removal when the brain vessel occlusion is due to organized, firm clots. The mechanism of failure is that during the retrieval, devices remain compressed by the organized clot and slide between it and the vessel wall without any removal effect. The aim of the current study is to present the preclinical evaluation of the Neva™ device, a novel stent retriever designed to improve the incorporation and removal of organized thrombi.Materials And MethodsPreclinical evaluation of the Neva™ device was divided in three main chapters: efficacy analysis, mechanical analysis and safety analysis. Efficacy and mechanical analysis aimed to investigate the behavior during the retrieval of the Neva™ device and its interaction with experimental organized clots. Safety analysis was conducted on animals in order to investigate the effect of the Neva™ device on real arteries after simulated thrombectomy maneuvers.ResultsNeva™ device showed a high rate of "optimal clot integration" and "effective clot removal" which was related to constant cohesion to the vessel wall during retrievals. Safety analysis showed as the most frequent finding the disruption of the intima of the tested vessels with, in some cases, minimal disruption of the internal elastic lamina.ConclusionsThe Neva™ device has demonstrated safety and efficacy in a pre-clinical study. Such encouraging, preliminary results have to be compared with those of clinical trials.



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Blunt Injury of the Bowel and Mesentery

Abstract

Purpose of Review

Although not common, blunt bowel and mesenteric trauma requires prompt identification and intervention to avoid significant morbidity and mortality.

Recent Findings

Developments in MDCT technology especially with 64 and higher slice MDCT have improved image quality for better detection and depiction of bowel and mesenteric injury. Recent reports indicate that administration of oral contrast does not increase diagnostic accuracy, allowing for more rapid door to scan time. Dual-source CT (DS-CT) ability to generate iodine maps and virtual noncontrast images has the potential to increase conspicuity of bowel perfusion abnormalities, better distinguish hypo-perfused from nonperfused bowel, and reveal bowel wall hematoma obscured by mural enhancement.

Summary

This article will review the current state-of-the-art approach in using direct and indirect MDCT signs of bowel injury in an attempt to differentiate surgical from nonsurgical lesions, and discuss imaging protocols used at our institution for follow-up imaging in nonsurgical lesions. We will also demonstrate the potential utility of DS-CT in blunt bowel injury.

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State-of-the-Art Imaging in Human Chordoma of the Skull Base

Abstract

Purpose of Review

Chordoma are rare tumours of the axial skeleton which occur most often at the base of the skull and in the sacrum. Although chordoma are generally slow-growing lesions, the recurrence rate is high and the location makes it often difficult to treat. Both computed tomography (CT) and magnetic resonance imaging (MRI) are crucial in the initial diagnosis, treatment planning and post-treatment follow-up.

Recent Findings

Basic MRI and CT characteristics of chordoma were described in the late 1980s and early 1990s. Since then, imaging techniques have evolved with increased resolution and new molecular imaging tools are rapidly evolving. New imaging tools have been developed not only to study anatomy, but also physiologic changes and characterization of tissue and assessment of tumour biology. Recent studies show the uptake of multiple PET tracers in chordoma, which may become an important aspect in the diagnosis, follow-up and personalized therapy.

Summary

This review gives an overview of skull base chordoma histopathology, classic imaging characteristics, radiomics and state-of-the-art imaging techniques that are now emerging in diagnosis, treatment planning and disease monitoring of skull base chordoma.

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Can We Perform CT of the Appendix with Less Than 1 mSv? A De-escalating Dose-simulation Study

Abstract

Objectives

To systematically explore the lowest reasonably achievable radiation dose for appendiceal CT using an iterative reconstruction (IR) in young adults.

Methods

We prospectively included 30 patients who underwent 2.0-mSv CT for suspected appendicitis. From the helical projection data, 1.5-, 1.0- and 0.5-mSv CTs were generated using a low-dose simulation tool and the knowledge-based IR. We performed step-wise non-inferiority tests sequentially comparing 2.0-mSv CT with each of 1.5-, 1.0- and 0.5-mSv CT, with a predetermined non-inferiority margin of 0.06. The primary end point was the pooled area under the receiver-operating-characteristic curve (AUC) for three abdominal and three non-abdominal radiologists.

Results

For the abdominal radiologists, the non-inferiorities of 1.5-, 1.0- and 0.5-mSv CT to 2.0-mSv CT were sequentially accepted [pooled AUC difference: 2.0 vs. 0.5 mSv, 0.017 (95% CI: -0.016, 0.050)]. For the non-abdominal radiologists, the non-inferiorities of 1.5- and 1.0-mSv CT were accepted; however, the non-inferiority of 0.5-mSv CT could not be proved [pooled AUC difference: 2.0 vs. 1.0 mSv, -0.017 (-0.070, 0.035) and 2.0 vs. 0.5 mSv, 0.045 (-0.071, 0.161)].

Conclusion

The 1.0-mSv appendiceal CT was non-inferior to 2.0-mSv CT in terms of diagnostic performance for both abdominal and non-abdominal radiologists; 0.5-mSv appendiceal CT was non-inferior only for abdominal radiologists.

Key points

• For both abdominal and non-abdominal radiologists, 1.0-mSv appendiceal CT could be feasible.

• The 0.5-mSv CT was non-inferior to 2.0-mSv CT only for expert abdominal radiologists.

• Reader experience is an important factor affecting diagnostic impairment by low-dose CT.

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Cervical ultrasonography has no additional value over negative 18 F-FDG PET/CT scans for diagnosing cervical lymph node metastases in patients with oesophageal cancer

Abstract

Objectives

To investigate the additional value of cervical ultrasonography over ¹⁸F-FDG PET/CT for diagnosing cervical lymph node metastases in patients with newly diagnosed oesophageal cancer.

Methods

Between January 2013 and January 2016, 163 patients with newly diagnosed oesophageal cancer underwent both cervical ultrasonography and ¹⁸F-FDG PET/CT at a tertiary referral centre in the Netherlands. Retrospective clinical data analysis was performed to assess the diagnostic value of cervical ultrasonography and ¹⁸F-FDG PET/CT for the detection of cervical lymph node metastases. Fine needle aspiration or clinical follow-up was used as reference standard.

Results

The overall incidence of patients with cervical lymph node metastases was 14%. The sensitivity of ¹⁸F-FDG PET/CT to detect cervical lymph node metastases was 82% (95% CI 59–94%) and specificity was 91% (95% CI 85–95%). The sensitivity and specificity of cervical ultrasonography were 73% (95% CI 50–88%) and 84% (95% CI 77–90%), respectively. In patients with a negative ¹⁸F-FDG PET/CT, 12 of 133 (9%) patients had suspicious nodes on cervical ultrasonography. In all these 12 patients the nodes were confirmed benign.

Conclusions

Cervical ultrasonography has no additional diagnostic value to a negative integrated ¹⁸F-FDG PET/CT for the detection of cervical lymph node metastases in patients with newly diagnosed oesophageal cancer.

Key Points

• Cervical ultrasonography has no value over PET/CT in evaluating cervical node metastases.

• PET/CT provides greater diagnostic confidence compared to cervical ultrasonography.

• Cervical ultrasonography during standard diagnostic work-up may be considered unnecessary.

• Cervical lesions on PET/CT require cytopathological confirmation by FNA.

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Round-the-clock performance of coronary CT angiography for suspected acute coronary syndrome: Results from the BEACON trial

Abstract

Objective

To assess the image quality of coronary CT angiography (CCTA) for suspected acute coronary syndrome (ACS) outside office hours.

Methods

Patients with symptoms suggestive of an ACS underwent CCTA at the emergency department 24 hours, 7 days a week. A total of 118 patients, of whom 89 (75 %) presented during office hours (weekdays between 07:00 and 17:00) and 29 (25 %) outside office hours (weekdays between 17:00 and 07:00, weekends and holidays) underwent CCTA. Image quality was evaluated per coronary segment by two experienced readers and graded on an ordinal scale ranging from 1 to 3.

Results

There were no significant differences in acquisition parameters, beta-blocker administration or heart rate between patients presenting during office hours and outside office hours. The median quality score per patient was 30.5 [interquartile range 26.0–33.5] for patients presenting during office hours in comparison to 27.5 [19.75–32.0] for patients presenting outside office hours (p=0.043). The number of non-evaluable segments was lower for patients presenting during office hours (0 [0–1.0] vs. 1.0 [0–4.0], p=0.009).

Conclusion

Image quality of CCTA outside office hours in the diagnosis of suspected ACS is diminished.

Key Points

• Quality scores were higher for coronary-CTA during office hours.

• There were no differences in acquisition parameters.

• There was a non-significant trend towards higher heart rates outside office hours.

• Coronary-CTA on the ED requires state-of-the-art scanner technology and sufficiently trained staff.

• Coronary-CTA on the ED needs preparation time and optimisation of the procedure.

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The impact of injector-based contrast agent administration in time-resolved MRA

Abstract

Objectives

Time-resolved contrast-enhanced MR angiography (4D-MRA), which allows the simultaneous visualization of the vasculature and blood-flow dynamics, is widely used in clinical routine. In this study, the impact of two different contrast agent injection methods on 4D-MRA was examined in a controlled, standardized setting in an animal model.

Methods

Six anesthetized Goettingen minipigs underwent two identical 4D-MRA examinations at 1.5 T in a single session. The contrast agent (0.1 mmol/kg body weight gadobutrol, followed by 20 ml saline) was injected using either manual injection or an automated injection system. A quantitative comparison of vascular signal enhancement and quantitative renal perfusion analyses were performed.

Results

Analysis of signal enhancement revealed higher peak enhancements and shorter time to peak intervals for the automated injection. Significantly different bolus shapes were found: automated injection resulted in a compact first-pass bolus shape clearly separated from the recirculation while manual injection resulted in a disrupted first-pass bolus with two peaks. In the quantitative perfusion analyses, statistically significant differences in plasma flow values were found between the injection methods.

Conclusions

The results of both qualitative and quantitative 4D-MRA depend on the contrast agent injection method, with automated injection providing more defined bolus shapes and more standardized examination protocols.

Key points

• Automated and manual contrast agent injection result in different bolus shapes in 4D-MRA.

• Manual injection results in an undefined and interrupted bolus with two peaks.

• Automated injection provides more defined bolus shapes.

• Automated injection can lead to more standardized examination protocols.

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Evaluation of an adaptive detector collimation for prospectively ECG-triggered coronary CT angiography with third-generation dual-source CT

Abstract

Objectives

To investigate the impact of an adaptive detector collimation on the dose parameters and accurateness of scan length adaption at prospectively ECG-triggered sequential cardiac CT with a wide-detector third-generation dual-source CT.

Methods

Ideal scan lengths for human hearts were retrospectively derived from 103 triple-rule-out examinations. These measures were entered into the new scanner operated in prospectively ECG-triggered sequential cardiac scan mode with three different detector settings: (1) adaptive collimation, (2) fixed 64 × 0.6-mm collimation, and (3) fixed 96 × 0.6-mm collimation. Differences in effective scan length and deviation from the ideal scan length and dose parameters (CTDIvol, DLP) were documented.

Results

The ideal cardiac scan length could be matched by the adaptive collimation in every case while the mean scanned length was longer by 15.4% with the 64 × 0.6 mm and by 27.2% with the fixed 96 × 0.6-mm collimation. While the DLP was almost identical between the adaptive and the 64 × 0.6-mm collimation (83 vs. 89 mGycm at 120 kV), it was 62.7% higher with the 96 × 0.6-mm collimation (135 mGycm), p < 0.001.

Conclusion

The adaptive detector collimation for prospectively ECG-triggered sequential acquisition allows for adjusting the scan length as accurate as this can only be achieved with a spiral acquisition. This technique allows keeping patient exposure low where patient dose would significantly increase with the traditional step-and-shoot mode.

Key points

• Adaptive detector collimation allows keeping patient exposure low in cardiac CT.

• With novel detectors the desired scan length can be accurately matched.

• Differences in detector settings may cause 62.7% of excessive dose.

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Prognostic importance of peritoneal lesion-to-primary tumour standardized uptake value ratio in advanced serous epithelial ovarian cancer

Abstract

Objectives

Using preoperative PET/CT, we evaluated the prognostic value of preoperative [¹⁸F]FDG uptake ratio between various metastatic lesions and primary tumour in patients with advanced serous epithelial ovarian cancer (EOC).

Methods

We retrospectively reviewed patients with International Federation of Gynecology and Obstetrics (FIGO) stage III, IV serous EOC who underwent preoperative [¹⁸F]FDG PET/CT scans. Clinico-pathological variables and PET/CT parameters such as maximum standardized uptake value of the ovarian cancer (SUV_ovary), pelvic or para-aortic LN (SUV_LN), peritoneal (SUV_perit) and distant extra-peritoneal (SUV_dist) metastatic lesions, and the metastatic lesion-to-ovarian cancer standardized uptake value ratio were assessed.

Results

Clinico-pathological data were retrospectively reviewed for 97 eligible patients. The median progression-free survival (PFS) was 18 months (range, 6–90 months) and 59 (60.8 %) patients experienced recurrence. In multivariate regression analysis, older age (p = 0.035, hazard ratio (HR) 1.032, 95 % CI 1.002–1.062), and high SUV_perit/SUV_ovary (p = 0.046, HR 1.755, 95 % CI 1.011–3.047) were independent risk factors of recurrence. Patient group categorized by SUV_perit/SUV_ovary showed significant difference in PFS (Log-Rank test, p = 0.001).

Conclusions

In patients with advanced serous EOC, preoperative SUV_perit/SUV_ovary measured by [¹⁸F]FDG PET/CT provides significant incremental performance for prediction of recurrence.

Key points

• PET/CT data from advanced serous epithelial ovarian cancer patients were analysed.

• Prognostic value of SUV ratio between metastatic and primary tumour was investigated.

• SUV _perit /SUV _ovary provides incremental performance for prediction of recurrence.

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Accuracy of computed tomography for selecting the revascularization method based on SYNTAX score II

Abstract

Objectives

The application of SYNTAX score II based on coronary CT angiography (CCTA) for selecting further treatment options has not been studied. This study aimed to investigate the diagnostic performance of CCTA combined with SYNTAX score II for selecting the revascularization method compared with invasive coronary angiography (ICA) based on 2014 European Society of Cardiology (ESC)/European Association for Cardio-Thoracic Surgery (EACTS) guidelines.

Methods

From January–May 2011, 160 patients who underwent both CCTA and ICA within 30 interval days were included. The diagnostic performance of CCTA, CCTA plus CT-SYNTAX score I and CT-SYNTAX score II was analysed using ICA counterparts as references.

Results

Overall sensitivity, specificity, positive predictive value, negative predictive value and accuracy of CCTA plus CT-SYNTAX I for selecting coronary artery bypass grafting (CABG) candidates using ICA plus ICA-SYNTAX I as reference, were 70.6 %, 95.8 %, 66.7 %, 96.5 % and 93.1 %, respectively. The diagnostic performance of CCTA plus CT-SYNTAX II showed improvement with values of 83.3 %, 97.3 %, 71.4 %, 98.6 % and 96.3 %, respectively, using ICA plus ICA-SYNTAX II as reference.

Conclusions

CCTA combined with CT-SYNTAX score II is an accurate method for selecting CABG surgery candidates compared with ICA-SYNTAX score II.

Key points

• SYNTAX plus CCTA can be highly specific for selecting the revascularization method.

• SYNTAX II was complemented by including clinical considerations to SYNTAX I.

• CCTA plus CT-SYNTAX II is an accurate method for selecting CABG candidates.

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18 F-fluorodeoxyglucose specimen-positron emission mammography delineates tumour extension in breast-conserving surgery: Preliminary results

Abstract

Objectives

We aimed to determine whether high-resolution specimen-positron emission mammography (PEM) using fluorodeoxyglucose (¹⁸F-FDG) can reveal extension of breast cancer in breast-conserving surgery (BCS), and assess the safety of radiation exposure to medical staff.

Methods

Sixteen patients underwent positron emission tomography, and then BCS with intraoperative frozen section analysis on the same day. Resected specimens with remaining ¹⁸F-FDG accumulation were scanned by high-resolution PEM. At least 1 day after surgery, tumour extension was evaluated by three independent experienced readers and by binarized images from the specimen-PEM data. Intraoperative exposure of medical staff to ¹⁸F-FDG was measured.

Results

Specimen-PEM evaluations of binarized images and the three investigators detected all (100 %, 12/12) invasive lesions and 94.4 % (17/18) of in situ lesions using both methods. The positive predictive value of the accumulated lesions was 74.4 % (29/39) for the binarized images and 82.9 % (29/35) for the three investigators. Analysis of intraoperative frozen sections detected 100 % (2/2) of the margin-positive cases, also detected by both specimen-PEM evaluation methods with no false-positive margin cases. The mean exposure of the medical staff to ¹⁸F was 18 μSv.

Conclusions

Specimen-PEM detected invasive and in situ lesions with high accuracy and allowable radiation exposure.

Key points

• Specimen-PEM detected invasive and in situ lesions with high accuracy.

• Specimen-PEM predicted complete resection with the same accuracy as frozen section analysis.

• Breast-conserving surgery after fluorodeoxyglucose injection was performed with low medical staff exposure.

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Validation of goose liver fat measurement by QCT and CSE-MRI with biochemical extraction and pathology as reference

Abstract

Objectives

This study aimed to validate the accuracy and reliability of quantitative computed tomography (QCT) and chemical shift encoded magnetic resonance imaging (CSE-MRI) to assess hepatic steatosis.

Methods

Twenty-two geese with a wide range of hepatic steatosis were collected. After QCT and CSE-MRI examinations, the liver of each goose was removed and samples were taken from the left lobe, upper and lower half of the right lobe for biochemical measurement and histology. Fat percentages by QCT and proton density fat fraction by MRI (MRI-PDFF) were measured within the sample regions of biochemical measurement and histology. The accuracy of QCT and MR measurements were assessed through Spearman correlation coefficients (r) and Passing and Bablok regression equations using biochemical measurement as the "gold standard".

Results

Both QCT and MRI correlated highly with chemical extraction [r = 0.922 (p < 0.001) and r = 0.949 (p < 0.001) respectively]. Chemically extracted triglyceride was accurately predicted by both QCT liver fat percentages (Y = 0.6 + 0.866 × X) and by MRI-PDFF (Y = -1.8 + 0.773 × X).

Conclusions

QCT and CSE-MRI measurements of goose liver fat were accurate and reliable compared with biochemical measurement.

Key Points

• QCT and CSE-MRI can measure liver fat content accurately and reliably

• Histological grading of hepatic steatosis has larger sampling variability

• QCT and CSE-MRI have potential in the clinical setting

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Transoesophageal echocardiography prior to catheter ablation could be avoided in atrial fibrillation patients with a low risk of stroke and without filling defects in the late-phase MDCT scan: A retrospective analysis of 783 patients

Abstract

Objectives

To test whether multidetector computed tomography (MDCT) could completely replace transoesophageal echocardiography (TEE) to detect left atrial appendage (LAA) thrombi in atrial fibrillation (AF) patients using a large sample size.

Methods

783 patients with AF who underwent MDCT and TEE before catheter ablation were retrospectively included. Demographic data were obtained. Two radiologists blinded to clinical data made the imaging diagnosis.

Results

Most of the patients (96.2 %) had a CHA₂DS₂-VASc score (congestive heart failure, hypertension, age ≥ 75 years old (doubled), diabetes, stroke/transient ischaemic attack/thromboembolism (doubled), vascular disease, age 65–74 years, female sex) ≤ 3. Eight thrombi were identified by TEE, all of which were detected by MDCT; no thrombus was observed with TEE without the observation of filling defects by late-phase MDCT scanning in any of the patients. Using TEE as reference standard, the sensitivity, specificity, positive predictive value and negative predictive value of MDCT for thrombus detection were 100 %, 95.74 % (95 % CI 94.33 %–97.15 %), 19.51 % (95 % CI 16.73 %–22.29 %) and 100 %, respectively.

Conclusions

For AF patients with low risk of stroke, when MDCT images showed no filling defect in the late phase, TEE prior to catheter ablation can be avoided.

Key Points

• MDCT can help detect the presence of LAA thrombus.

• TEE can be avoided when late-phase MDCT shows no filling defect.

• TEE is required in patients whose MDCT images indicate thrombus.

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The efficacy of real-time colour Doppler flow imaging on endoscopic ultrasonography for differential diagnosis between neoplastic and non-neoplastic gallbladder polyps

Abstract

Objectives

We evaluated the usefulness of real-time colour Doppler flow (CDF) endoscopic ultrasonography (EUS) for differentiating neoplastic gallbladder (GB) polyps from non-neoplastic polyps.

Methods

Between August 2014 and December 2016, a total of 233 patients with GB polyps who underwent real-time CDF-EUS were consecutively enrolled in this prospective study. CDF imaging was subjectively categorized for each patient as: strong CDF pattern, weak CDF pattern and no CDF pattern.

Results

Of the 233 patients, 115 underwent surgical resection. Of these, there were 90 cases of non-neoplastic GB polyps and 23 cases of neoplastic GB polyps. In a multivariate analysis, a strong CDF pattern was the most significant predictive factor for neoplastic polyps; sensitivity, specificity, positive predictive value, negative predictive value and accuracy were 52.2 %, 79.4 %, 38.7 %, 86.9 % and 73.9 %, respectively. Solitary polyp and polyp size were associated with an increased risk of neoplasm.

Conclusions

The presence of a strong CDF pattern as well as solitary and larger polyps on EUS may be predictive of neoplastic GB polyps. As real-time CDF-EUS poses no danger to the patient and requires no additional equipment, it is likely to become a supplemental tool for the differential diagnosis of GB polyps.

Key points

• Differential diagnosis between neoplastic polyps and non-neoplastic polyps of GB is limited.

• The use of real-time CDF-EUS was convenient, with high agreement between operators.

• The real-time CDF-EUS is helpful in differential diagnosis of GB polyps.

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Hemispherical photoacoustic imaging of myocardial infarction: in vivo detection and monitoring

Abstract

Objectives

This study aimed to demonstrate the capacity for noninvasive localisation and characterisation of myocardial infarction (MI) in vivo using a hemispherical photoacoustic imaging (PAI) system. MI remains a leading cause of morbidity and mortality worldwide. To enable optimal treatment of patients, timely and accurate diagnosis and longitudinal monitoring is critical.

Methods

Ischaemia was induced in Balb/c mice by ligation of the left anterior descending artery. The hemispherical PAI system, equipped with 128 ultrasonic transducers spirally distributed on the surface, along with parallel data acquisition, was applied for imaging of the mouse heart.

Results

Our study showed that hemispherical PAI can delineate thoracic vessels and the morphology of the entire heart. Longitudinal PAI images revealed gradual expansion of the infarcted area along with necrosis and fibrosis, which were quantitatively validated by triphenyltetrazolium chloride staining. After MI modelling, the photoacoustic (PA) signal intensity decreased by 399.1 ± 56.3 (p < 0.001), a ~2.5-fold reduction compared to that of healthy cardiac tissue. The calculated size of the enlarged heart, 10.4 ± 6.0 mm² (p < 0.001), represents an increase of ~18% versus that of a healthy heart.

Conclusions

PAI enables MI diagnosis and injury localisation with its capabilities for both deep organ imaging and lesion region differentiation.

Key Points

• Photoacoustic imaging (PAI), combining optical absorption and ultrasonic resolution, can delineate cardiac anatomy.

• PAI can diagnose myocardial infarction lesions with 10 mm imaging depth in vivo.

• Quantified results are in excellent agreement with enzyme and histological examinations.

• PAI can serve as a complementary modality to SPECT and ultrasound imaging.

• This study will encourage further PAI development for clinical use.

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Advanced CT acquisition protocol with a third-generation dual-source CT scanner and iterative reconstruction technique for comprehensive prosthetic heart valve assessment

Abstract

Objectives

Multidetector CT (MDCT) is a valuable tool for functional prosthetic heart valve (PHV) assessment. However, radiation exposure remains a concern. We assessed a novel CT-acquisition protocol for comprehensive PHV evaluation at limited dose.

Methods

Patients with a PHV were scanned using a third-generation dual-source CT scanner (DSCT) and iterative reconstruction technique (IR). Three acquisitions were obtained: a non-enhanced scan; a contrast-enhanced, ECG-triggered, arterial CT angiography (CTA) scan with reconstructions at each 5 % of the R-R interval; and a delayed high-pitch CTA of the entire chest. Image quality was scored on a five-point scale. Radiation dose was obtained from the reported CT dose index (CTDI) and dose length product (DLP).

Results

We analysed 43 CT examinations. Mean image quality score was 4.1±1.4, 4.7±0.5 and 4.2±0.6 for the non-contrast-enhanced, arterial and delayed acquisitions, respectively, with a total mean image quality of 4.3±0.7. Mean image quality for leaflet motion was 3.9±1.4. Mean DLP was 28.2±17.1, 457.3±168.6 and 68.5±47.2 mGy.cm for the non-contrast-enhanced (n=40), arterial (n=43) and delayed acquisition (n=43), respectively. The mean total DLP was 569±208 mGy.cm and mean total radiation dose was 8.3±3.0 mSv (n=43).

Conclusion

Comprehensive assessment of PHVs is possible using DSCT and IR at moderate radiation dose.

Key points

• Prosthetic heart valve dysfunction is a potentially life-threatening condition.

• Dual-source CT can adequately assess valve leaflet motion and anatomy.

• We assessed a comprehensive protocol with three acquisitions for PHV evaluation.

• This protocol is associated with good image quality and limited dose.

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Preoperative multiparametric MRI of the prostate for the prediction of lymph node metastases in prostate cancer patients treated with extended pelvic lymph node dissection

Abstract

Objectives

To assess the role of preoperative multiparametric MRI (mpMRI) of the prostate in the prediction of nodal metastases in patients treated with radical prostatectomy (RP) and extended pelvic lymph node dissection (ePLND).

Methods

We retrospectively analyzed 101 patients who underwent both preoperative mpMRI of the prostate and RP with ePLND at our institution. For each patient, complete preoperative clinical data and tumour characteristics at mpMRI were recorded. Final histopathologic stage was considered the standard of reference. Univariate and multivariate logistic regression analyses were performed.

Results

Nodal metastases were found in 23/101 (22.8%) patients. At univariate analyses, all clinical and radiological parameters were significantly associated to nodal invasion (all p<0.03); tumour volume at MRI (mrV), tumour ADC and tumour T-stage at MRI (mrT) were the most accurate predictors (AUC = 0.93, 0.86 and 0.84, respectively). A multivariate model including PSA levels, primary Gleason grade, mrT and mrV showed high predictive accuracy (AUC = 0.956). Observed prevalence of nodal metastases was very low among tumours with mrT2 stage and mrV<1cc (1.8%).

Conclusion

Preoperative mpMRI of the prostate can predict nodal metastases in prostate cancer patients, potentially allowing a better selection of candidates to ePLND.

Key points

• Multiparametric-MRI of the prostate can predict nodal metastases in prostate cancer

• Tumour volume and stage at MRI are the most accurate predictors

• Prevalence of nodal metastases is low for T2-stage and <1cc tumours

• Preoperative mpMRI may allow a better selection of candidates to lymphadenectomy

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Diagnostic accuracy of low and high tube voltage coronary CT angiography using an X-ray tube potential-tailored contrast medium injection protocol

Abstract

Objectives

To compare the diagnostic accuracy between low-kilovolt peak (kVp) (≤ 100) and high-kVp (> 100) third-generation dual-source coronary CT angiography (CCTA) using a kVp-tailored contrast media injection protocol.

Methods

One hundred twenty patients (mean age = 62.6 years, BMI = 29.0 kg/m²) who underwent catheter angiography and CCTA with automated kVp selection were separated into two cohorts (each n = 60, mean kVp = 84 and 117). Contrast media dose was tailored to the kVp level: 70 = 40 ml, 80 = 50 ml, 90 = 60 ml, 100 = 70 ml, 110 = 80 ml, and 120 = 90 ml. Contrast-to-noise ratio (CNR) was measured. Two observers evaluated image quality and the presence of significant coronary stenosis (> 50% luminal narrowing).

Results

Diagnostic accuracy (sensitivity/specificity) with ≤ 100 vs. > 100 kVp CCTA was comparable: per patient = 93.9/92.6% vs. 90.9/92.6%, per vessel = 91.5/97.8% vs. 94.0/96.8%, and per segment = 90.0/96.7% vs. 90.7/95.2% (all P > 0.64). CNR was similar (P > 0.18) in the low-kVp vs. high-kVp group (12.0 vs. 11.1), as ws subjective image quality (P = 0.38). Contrast media requirements were reduced by 38.1% in the low- vs. high-kVp cohort (53.6 vs. 86.6 ml, P < 0.001) and radiation dose by 59.6% (4.3 vs. 10.6 mSv, P < 0.001).

Conclusions

Automated tube voltage selection with a tailored contrast media injection protocol allows CCTA to be performed at ≤ 100 kVp with substantial dose reductions and equivalent diagnostic accuracy for coronary stenosis detection compared to acquisitions at > 100 kVp.

Key points

• Low-kVp coronary CT angiography (CCTA) enables reduced contrast and radiation dose.

• Diagnostic accuracy is comparable between ≤ 100 and > 100 kVp CCTA.

• Image quality is similar for low- and high-kVp CCTA.

• Low-kVp image acquisition is facilitated by automated tube voltage selection.

• Tailoring contrast injection protocols to the automatically selected kVp-level is feasible.

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Optimisation of sonourethrography: the clamp method

Abstract

Purpose

To describe the clamp method for performing retrograde sonourethrography (RSUG) and contrast-enhanced voiding sonourethrography (CE-VSUG) via the transperineal approach in male adults.

Materials and methods

Prospective study of 113 males (14-86 years) with urethral strictures confirmed by urethrography who received sonourethrography via the clamp method between 2011 and 2015. The characteristic parameters of the quantitative variables were calculated and a comparative analysis of the qualitative variables was conducted using the McNemar test.

Results

RSUG was performed successfully in all the cases (n = 113) and detected 49 cases with anterior urethral strictures; the strictures in the proximal bulbar cone in five of them (10.2%) were not visualised on retrograde urethrography (RUG) (p < 0.05). CE-VSUG was performed successfully in 97 cases and observed posterior urethral strictures in 82; the bladder neck strictures in 6 of them (7.3%) were not observed on voiding cystourethrography (VCUG) (p < 0.05). Retrograde bladder filling was achieved in approximately 6 min.

Conclusion

The clamp method enables RSUG and CE-VSUG to be performed simply, effectively and painlessly by a single operator. It also allows the evaluation of cases with urethromeatal alterations (stricture, hypospadias and meatotomy).

Key Points

• The clamp method enables RSUG to be performed simply and painlessly.

• The clamp method requires only one operator and allows assessing urethromeatal alterations.

• RSUG shows greater capacity for detecting anterior urethral strictures than RUG.

• The clamp method achieves retrograde bladder filling in approximately 6 min.

• CE-VSUG shows greater capacity for detecting strictures than VCUG.

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Chemical shift magnetic resonance imaging for distinguishing minimal-fat renal angiomyolipoma from renal cell carcinoma: a meta-analysis

Abstract

Objectives

To determine the performance of chemical shift signal intensity index (CS-SII) values for distinguishing minimal-fat renal angiomyolipoma (mfAML) from renal cell carcinoma (RCC) and to assess RCC subtype characterisation.

Methods

We identified eligible studies on CS magnetic resonance imaging (CS-MRI) of focal renal lesions via PubMed, Embase, and the Cochrane Library. CS-SII values were extracted by lesion type and evaluated using linear mixed model-based meta-regression. RCC subtypes were analysed. Two-sided p value <0.05 indicated statistical significance. Methodological quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies 2 tool.

Results

Eleven articles involving 850 patients were included. Minimal-fat AML had significantly higher CS-SII value than RCC (p < 0.05); there were no significant differences between mfAML and clear cell RCC (cc-RCC) (p = 0.112). Clear cell RCC had a significantly higher CS-SII value than papillary RCC (p-RCC) (p < 0.001) and chromophobe RCC (ch-RCC) (p = 0.045). The methodological quality was relatively high, and Begg's test data points indicated no obvious publication bias.

Conclusions

The CS-SII value for differentiating mfAML from cc-RCC remains unproven, but is a promising method for differentiating cc-RCC from p-RCC and ch-RCC.

Key Points

• RCC CS-SII values are significantly lower than those of mfAML overall.

• CS-SII values cannot aid differentiation between mfAML and cc-RCC.

• CS-SII values might help characterise RCC subtypes.

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Breast lesions classified as probably benign (BI-RADS 3) on magnetic resonance imaging: a systematic review and meta-analysis

Abstract

Purpose

To investigate prevalence, malignancy rates, imaging features, and follow-up intervals for probably benign (BI-RADS 3) lesions on breast magnetic resonance imaging (MRI).

Methods

A systematic database-review of articles published through 22/06/2016 was performed. Eligible studies reported BI-RADS 3 lesions on breast MRI. Two independent reviewers performed a literature review and data extraction. Data collection included study characteristics, number/type of BI-RADS 3 lesions, final diagnosis (histopathology and/or follow-up). Sources of bias (QUADAS-2) were assessed. Meta-analysis included data-pooling, heterogeneity testing, and meta-regression.

Results

Fifteen studies were included. Prevalence was reported in 11 studies (range: 1.2-24.3%). Malignancy rates ranged between 0.5-10.1% (pooled 61/2814, 1.6%, 95%-CI:0.9-2.3% (random-effects-model), I²=53%, P=0.007). In a subgroup of 11 studies (2183 lesions), highest malignancy rates were observed in non-mass lesions (pooled 25/714, 2.3%, 95%-CI:0.8-3.9%, I²=52%, P=0.021) followed by mass lesions (pooled 15/771, 1.5%, 95%-CI:0.7-2.4%, I²=0%, P=0.929), and foci (pooled 10/698, 1%, 95%-CI:0.3-1.7%, I²=0%, P=0.800). There was non-significant negative association between prevalence and malignancy rates (P=0.077). Malignant lesions were diagnosed at all follow-up time points.

Conclusion

While prevalence of MRI BI-RADS 3 lesions was strongly heterogeneous, pooled malignancy rates met BI-RADS benchmarks (<2%). Malignancy rates varied, exceeding 2% in non-mass lesions. Twenty-four-month surveillance is required to detect all malignant lesions.

Key points

• Probably benign (BI-RADS 3) lesions showed a pooled malignancy-rate of 1.6% (95%-CI:0.9-2.3%).

• Malignancy rates differ and are highest in non-mass lesions (2.3%, 95%-CI:0.8-3.9%).

• The prevalence of BI-RADS 3 lesions on breast MRI ranged from 1.2-24.3%.

• Malignant lesions were diagnosed at follow-up time points up to 24 months.

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