Journal highlights
The following are highlights from the current issues of RSNA’s peer-reviewed journals.
TOCEM Trial Analysis on Women with a Personal History of Breast Cancer
Early detection of interval breast cancers in women with prior breast cancer history is crucial for better outcomes. Routine mammography may miss these cancers, prompting the need for additional screening with US or MRI.
Contrast-enhanced mammography (CEM) is a lower-cost alternative to MRI that appears to be better tolerated and is preferred by approximately 70% of women who have undergone both examinations.
In an article published in Radiology, Wendie A. Berg, MD, PhD, University of Pittsburgh School of Medicine, and colleagues conducted an interim analysis of the Tomosynthesis or Contrast-Enhanced Mammography (TOCEM) prospective clinical trial. TOCEM includes three rounds of annual screening with both digital breast tomosynthesis (DBT) and CEM. The study focused on the addition of CEM to DBT compared with DBT alone and evaluated its impact on false-positive findings.
From October 2019 to December 2022, the authors assessed the effects of adding CEM to DBT on incremental cancer detection rate, cancer type and node status, recall rate and other performance characteristics. In women with a personal history of breast cancer, adding CEM to DBT increased the number of second malignancy detections by 7.1 per 1,000 screenings in year one and 3.8 per 1,000 in years two and three, with corresponding increases in the number of recalls by 6.6% and 5.0%, respectively.
“Adding CEM to DBT substantially improved the detection of early breast cancer in women with a personal history of breast cancer, and this benefit appears to persist each year,” the authors conclude.
Read the complete study, “Addition of Contrast-enhanced Mammography to Tomosynthesis for Breast Cancer Detection in Women with a Personal History of Breast Cancer: Prospective TOCEM Trial Interim Analysis.” Follow the Radiology editor on X @RadiologyEditor.
Images in a 67-year-old woman with triple receptor–negative invasive ductal carcinoma (IDC) seen only at contrast-enhanced mammography (CEM) at year 2. (A) Left craniocaudal (CC) (left) and mediolateral oblique (MLO) (right) low-energy images show scattered fibroglandular density and postsurgical scarring, with clips in the lower inner quadrant at the site of lumpectomy for a 2.1-cm grade 3 IDC, estrogen receptor– and progesterone receptor–positive and human epidermal growth factor receptor 2 (HER2) (ERBB2 gene)–negative lesion 11 years prior. Scattered benign-appearing calcifications are noted. The participant also completed radiation therapy and adjuvant chemotherapy and was treated with tamoxifen for 7 years and then with an aromatase inhibitor for 3 years, with last use 1 year prior to study entry. (B) Recombined CC (left) and MLO (right) CEM images obtained in year 2 show moderately conspicuous enhancement of an oval mass in the upper outer left breast (arrows), which was new from the prior CEM examination (not shown). This lesion was assessed as Breast Imaging Reporting and Data System (BI-RADS) 4B, moderately suspicious, by observer 1 and as BI-RADS 3, probably benign, but recommended for additional evaluation, by observer 2. At the time, CEM-guided biopsy was not available, so the participant underwent MRI and MRI-guided biopsy. (C) Axial maximum intensity projection from T1-weighted fat-suppressed MRI (left) shows moderately intense enhancement of the same mass (arrow), with plateau and washout kinetics (arrow) on axial post-contrast fat-suppressed T1-weighted image with kinetic overlay (right). MRI-guided biopsy and excision revealed a 0.5-cm grade 3 IDC, triple receptor–negative lesion (Ki-67 proliferation index of 55%). Three sentinel nodes were negative for metastasis.
https://doi.org/10.1148/radiol.231991 © RSNA 2024
Diagnosis of Cesarean Scar Ectopic Pregnancy
Cesarean section rates globally have increased, reaching 50% in some countries. The risk of abnormal implantation from prior cesarean scars poses severe complications, including maternal and fetal mortality and fertility loss.
Subsequent cesarean scar ectopic pregnancies (CSEPs) are on the rise, particularly in recent decades. Underdiagnosis and underreporting make the true incidence unclear, leading to high maternal morbidity and mortality rates.
In an article published in RadioGraphics, Anne Kennedy, MBBCh, BAO, and Paula Woodward, MD, University of Utah, Salt Lake City, and colleagues review the signs of CSEP at imaging, some pitfalls that may lead to delayed or missed diagnosis, and the resulting consequences.
The authors emphasize the importance of differentiating CSEPs from low implantation of a normal pregnancy, cervical ectopic pregnancy and evolving pregnancy loss. Early recognition of CSEPs allows for prompt and safe treatment that is usually surgical and can reduce health care costs and hospital stays and preserve fertility. Early diagnosis and treatment of CSEP can also avert the need for a hysterectomy, lessening psychological impacts.
“The most important thing that radiologists can do to avoid delayed or missed diagnosis of CSEP is to routinely check for a history of cesarean section. If there are findings of concern for CSEP, prompt referral for further evaluation and treatment is mandatory. Treatment early in the first trimester is safe and effective and allows preservation of fertility in women who desire future pregnancy. Management of CSEP is determined on an individual basis in all cases,” the authors conclude.
Read the complete article, “Cesarean Scar Ectopic Pregnancy: A Do-Not-Miss Diagnosis.” This article is also available for CME at RSNA.org/Learning-Center. Follow the RadioGraphics editor on X @RadG_Editor.
Missed diagnosis of CSEP. Gravid hysterectomy was required to control severe abdominal pain and recurrent episodes of vaginal bleeding. (A) Sagittal transabdominal US image in the panoramic mode shows the entire uterus. This patient had been scanned three times because of pain and bleeding and was reassured that it was a live intrauterine pregnancy. At review, all prior images were obtained with a small field of view and were focused on the GS (triangle). Therefore, the low sac location was not appreciated. Note the empty endometrial cavity (arrow) and how the fundus is excluded when a small field of view is used. (B) Sagittal transabdominal US image at 9 weeks gestation (the second scan) shows how the uterus was measured. The measurements include the external contours of the CSEP and part of the cervix. The incompletely imaged empty uterus is visible to the left of the measured structures but was not appreciated. All the other images were targeted to the measurement of the embryo and documentation of the rate of cardiac activity. This was an unplanned pregnancy, and the patient had no desire for ongoing fertility and thus chose gravid hysterectomy at 14 weeks rather than continuing the pregnancy with a high risk of uterine rupture and PAS.
Identifying Features of Pulmonary Edema Using AI
In patients with congestive heart failure, pulmonary edema is a leading cause of hospitalization. Imaging is critical for assessing the severity of this condition and determining the optimal treatment and monitoring plan.
In an article published in Radiology Advances, Viacheslav V. Danilov, PhD, Pompeu Fabra University, Barcelona, Spain, and colleagues sought to develop a deep learning method for identifying radiographic features associated with pulmonary edema.
For this retrospective study, the researchers used a dataset of chest radiograph images from 741 patients suspected of pulmonary edema. An experienced radiologist annotated various features of edema including cephalization, Kerley lines, pleural effusion, bat wings and infiltrate features of edema. The methodology involved two stages: lung segmentation using an ensemble of three object detection networks, and edema feature localization which evaluated eight object detection networks, assessing their performance with average precision (AP) and mean AP.
Effusion, infiltrate, and bat wing features were best detected by the Side-Aware Boundary Localization (SABL) network with corresponding APs of 0.599, 0.395, and 0.926, respectively. Furthermore, SABL achieved the highest overall mean AP of 0.568. The Cascade Region Proposal Network attained the highest AP of 0.417 for Kerley lines and the Probabilistic Anchor Assignment network achieved the highest AP of 0.533 for cephalization.
“The proposed methodology, with the application of SABL, Cascade Region Proposal Network, and Probabilistic Anchor Assignment detection networks, is accurate and efficient in localizing and identifying pulmonary edema features and is, therefore, a promising diagnostic candidate for interpretable severity assessment of pulmonary edema,” the authors conclude.
Read the complete study, “Explainable AI to identify radiographic features of pulmonary edema.”
Enhancing Academic Collaboration: Follow the RSNA Journals on Social Media
The RSNA journals’ social media following is growing. Following and interacting with other authors on these channels enhances the visibility and awareness of your research. Engaging with peers through comments, retweets or discussions can lead to beneficial collaborations and networking opportunities, opening doors for joint research projects.
Additionally, these interactions often provide immediate feedback and diverse perspectives, which can be invaluable for refining ongoing research.
Stay updated with current trends and emerging topics in radiology by following the journals on social media. You can find the journal editors on X:
• Radiology – @RadiologyEditor
• RadioGraphics – @RadG_Editor
• Radiology: Cardiothoracic Imaging – @RadiologyCTI
• Radiology: Artificial Intelligence – @Radiology_AI
• Radiology: Imaging Cancer – @RadIC_Editor