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Rationale and Objectives: To evaluate two- and three-dimensional (2D and 3D) image quality of sub-milliSievert (mSv) computed tomography (CT) colonography utilizing a third-generation dual source CT scanner featuring a tin filter.Methods: We retrospectively evaluated 26 consecutive patients who underwent third-generation dual source CT colonography, nine with the standard-dose clinical-scan protocol (SDP) and 17 with a low-dose protocol (LDP) featuring a tin filter. Radiation dose was evaluated by volume computed tomography dose index (CTDIvol), dose length product (DLP), effective dose (E), and size-specific dose estimate. Objective image quality was evaluated utilizing signal-to-noise ratio (SNR) derived from standardized placed regions of interest on the transverse 2D images and the ratio of SNR/CTDIvol (normalized SNR). Two radiologists in consensus assessed subjective image quality of the virtual 3D images.Results: There were no significant differences in subjective image quality (P = .661). All examinations were rated "excellent" or "good" for diagnostic confidence. The mean total for DLP/E was 143.4 ± 29.8 mGy/3.00 ± 0.40 mSv in the SDP and therefore significantly higher than in the LDP with 36.9 ± 8.7 mGy/0.75 ± 0.16 mSv (P < .001). The SNR was 8.9 ± 2.1 in the SDP and 4.9 ± 0.8 in the LDP.Conclusions: Third-generation dual source CT featuring a tin filter enables consistent sub-mSv colonography without substantially impairing image quality. [ABSTRACT FROM AUTHOR]

Rationale and Objectives: This study aimed to evaluate the diagnostic performance of using a reformatted single-in-plane image reformation of the rib cage for the detection of rib fractures in computed tomography (CT) examinations, employing different levels of radiological experience.Materials and Methods: We retrospectively evaluated 10 consecutive patients with and 10 patients without rib fractures, whose CT scans were reformatted to a single-in-plane image reformation of the rib cage. Eight readers (two radiologists, two residents in radiology, and four interns) independently evaluated the images for the presence of rib fractures using a reformatted single-in-plane image and a multi-planar image reformation. The time limit was 30 seconds for each read. A consensus of two radiologist readings was considered as the reference standard. Diagnostic performance (sensitivity, specificity, positive predictive value [PPV], and negative predictive value [NPV]) was assessed and evaluated per rib and per location (anterior, lateral, posterior). To determine the time limit, we prospectively analyzed the average time it took radiologists to assess the rib cage, in a bone window setting, in 50 routine CT examinations. McNemar test was used to compare the diagnostic performances.Results: Single image reformation was successful in all 20 patients. The sensitivity, specificity, PPV, and NPV for the detection of rib fractures using the conventional multi-planar read were 77.5%, 99.2%, 89.9%, and 98.0% for radiologists; 46.3%, 99.7%, 92.5%, and 95.3% for residents; and 29.4%, 99.4%, 82.5%, and 93.9% for interns, respectively. Sensitivity, PPV, and NPV increased across all three groups of experience, using the reformatted single-in-plane image of the rib cage (radiologists: 85.0%, 98.6%, and 98.7%; residents: 80.0%, 92.8%, and 98.2%; interns: 66.9%, 89.9%, and 97.1%), whereas specificity did not change significantly (99.9%, 99.4%, and 99.3%). The diagnostic performance of the interns and residents was significantly better when evaluating the single-in-plane image reformations (P < .01). The diagnostic performance of the radiologists was better when evaluating the single-in-plane image reformations; however, there was no significant difference (statistical power: 0.32).Conclusions: The diagnostic performance for the detection of rib fractures, using CT images that have been reformatted to a single-in-plane image, improves for readers from different educational levels when the evaluation time is restricted to 30 seconds or less. [ABSTRACT FROM AUTHOR]

Rationale and Objectives: To evaluate a computer-aided diagnosis (CADx) system for the characterization of liver lesions in computed tomography (CT) scans. The stand-alone predictive performance of the CADx system was assessed and compared to that of three radiologists who were provided with the same amount of image information to which the CADx system had access. Materials and Methods: The CADx system operates as an image search engine exploiting texture analysis of liver lesion image data for the lesion in question and lesions from a database. A region of interest drawn around an indeterminate liver lesion is used as input query. The CADx system retrieves lesions of similar histology (benign/malignant), density (hypodense/hyperdense), or type (cyst/hemangioma/metastasis). The system's performance was evaluated with leave-one-patient-out receiver operating characteristic area under the curve on 685 CT scans from 372 patients that contained 2325 liver lesions (193 <1 cm³). Sensitivity, specificity, and positive and negative predictive values were evaluated separately for subcentimeter lesions. Results were compared to those of three radiologists who rated 83 liver lesions (20 hemangiomas, 20 metastases, 20 cysts, 20 hepatocellular carcinomas, and 3 focal nodular hyperplasias) displaying only the liver. Results: The CADx system's leave-one-patient-out receiver operating characteristic area under the curve was 97.1% for density, 91.4% for histology, and 95.5% for lesion type. For subcentimeter lesions, input of additional semantic information improved the system's performance. The CADx system has been proved to significantly outperform radiologists in discriminating lesion histology and type, provided the radiologists have no access to information other than the image. The radiologists were most reliable in diagnosing hemangioma given the limited image data. Conclusions: The CADx system under study discriminated reliably between various liver lesions, even outperforming radiologists when accessing the same image information and demonstrated promising performance in classifying subcentimeter lesions in particular. [Copyright &y& Elsevier]

Ruptured abdominal aortic aneurysm commonly presents as acute abdominal or lower back pain and hemodynamic instability. We discuss the case of a 90-year-old patient who presented to the emergency unit with a 3-day history of left testicular pain. Ultrasound scan demonstrated and a computed tomography scan confirmed a 6 cm in diameter ruptured abdominal aortic aneurysm with enlargement and hematoma of the left psoas muscle causmg the symptoms. This atypical presentation highlights the need for clinical vigilance and emergency physician-performed ultrasound scan in the older patients with seemingly benign testicular symptoms. [ABSTRACT FROM AUTHOR]

Opportunistic screening using existing CT images may be a new strategy to identify subjects at increased risk for osteoporotic fracture. Low bone mineral density (BMD) is a key parameter but routine clinical CT scans do not include a calibration phantom to calculate BMD from the measured CT values. An alternative is internal or phantomless calibration, which is based on the CT values of air and of internal tissues of the subject such as blood, muscle or adipose tissue. However, the composition and as a consequence the CT values of these so-called internal calibration materials vary among subjects, which introduces additional BMD accuracy errors compared to phantom based calibration. The objective of this study was to quantify these accuracy errors and to identify optimum combinations of internal calibration materials (IM) for BMD assessments in opportunistic screening. Based on the base material decomposition theory we demonstrate how BMD can be derived from the CT values of the internal calibration materials. 121 CT datasets of the lumbar spine form postmenopausal women were used to determine the population variance of blood assessed in the aorta or the inferior vena cava, skeletal muscle of the erector spinae or psoas, subcutaneous adipose tissue (SAT) and air. The corresponding standard deviations were used for error propagation to determine phantomless calibration related BMD accuracy errors. Using a CT value of 150 HU, a typical value of trabecular bone, simulated BMD accuracy errors for most IM combinations containing air as one of the two base materials were below 5% or 6 mg/cm 3 . The lowest errors were determined for the combination of blood and air (<2 mg/cm 3 ). The combination of blood and skeletal muscle resulted in higher errors (>10.5% or >12 mg/cm 3 ) and is not recommended. Due to possible age-related differences in tissue composition, the selection of IMs is suggested to be adapted according to the measured subject. In younger subjects without significant aortic calcifications, air and blood of the aorta may be the best combination whereas in elderly subjects, air and SAT (error of 4%) may be preferable. The use of skeletal muscle as one of the two IMs is discouraged, in particular in elderly subjects because of varying fatty infiltration. A practical implementation of the internal calibration with different IM pairs confirmed the theoretical results. In summary, compared to a phantom based calibration the phantomless approach used for opportunistic screening creates additional BMD accuracy errors of 2% or more, dependent on the used internal reference tissues. The impact on fracture prediction still must be evaluated., (Copyright © 2022 Elsevier Inc. All rights reserved.)

To evaluate the reader's diagnostic performance against the ground truth with and without the help of a novel content-based image retrieval system (CBIR) that retrieves images with similar CT patterns from a database of 79 different interstitial lung diseases. We evaluated three novice readers' and three resident physicians' (with at least three years of experience) diagnostic performance evaluating 50 different CTs featuring 10 different patterns (e.g., honeycombing, tree-in bud, ground glass, bronchiectasis, etc.) and 24 different diseases (sarcoidosis, UIP, NSIP, Aspergillosis, COVID-19 pneumonia etc.). The participants read the cases first without assistance (and without feedback regarding correctness), and with a 2-month interval in a random order with the assistance of the novel CBIR. To invoke the CBIR, a ROI is placed into the pathologic pattern by the reader and the system retrieves diseases with similar patterns. To further narrow the differential diagnosis, the readers can consult an integrated textbook and have the possibility of selecting high-level semantic features representing clinical information (chronic, infectious, smoking status, etc.). We analyzed readers' accuracy without and with CBIR assistance and further tested the hypothesis that the CBIR would help to improve diagnostic performance utilizing Wilcoxon signed rank test. The novice readers demonstrated an unassisted accuracy of 18/28/44%, and an assisted accuracy of 84/82/90%, respectively. The resident physicians demonstrated an unassisted accuracy of 56/56/70%, and an assisted accuracy of 94/90/96%, respectively. For each reader, as well as overall, Sign test demonstrated statistically significant ( p < 0.01) difference between the unassisted and the assisted reads. For students and physicians, Chi²-test and Mann-Whitney-U test demonstrated statistically significant ( p < 0.01) difference for unassisted reads and statistically insignificant ( p > 0.01) difference for assisted reads. The evaluated CBIR relying on pattern analysis and featuring the option to filter the results of the CBIR by predominant characteristics of the diseases via selecting high-level semantic features helped to drastically improve novices' and resident physicians' accuracy in diagnosing interstitial lung diseases in CT.

To evaluate patients' radiation exposure undergoing CT-guided joint injection in preparation of MR-arthrography. We developed a novel ultra-low-dose protocol utilizing tin-filtration, performed it in 60 patients and compared the radiation exposure (DLP) and success rate to conventional protocol (26 cases) and low-dose protocol (37 cases). We evaluated 123 patients' radiation exposure undergoing CT-guided joint injection from 16 January-21 March. A total of 55 patients received CT-guided joint injections with various other examination protocols and were excluded from further investigation. In total, 56 patients received shoulder injection and 67 received hip injection with consecutive MR arthrography. The ultra-low-dose protocol was performed in 60 patients, the low-dose protocol in 37 patients and the conventional protocol in 26 patients. We compared the dose of the interventional scans for each protocol (DLP) and then evaluated success rate with MR-arthrography images as gold standard of intraarticular or extracapsular contrast injection. There were significant differences when comparing the DLP of the ultra-low-dose protocol (DLP 1.1 ± 0.39; p < 0.01) to the low dose protocol (DLP 5.3 ± 3.24; p < 0.01) as well as against the conventional protocol (DLP 22.9 ± 8.66; p < 0.01). The ultra-low-dose protocol exposed the patients to an average effective dose of 0.016 millisievert and resulted in a successful joint injection in all 60 patients. The low dose protocol as well as the conventional protocol were also successful in all patients. The presented ultra-low-dose CT-guided joint injection protocol for the preparation of MR-arthrography demonstrated to reduce patients' radiation dose in a way that it was less than the equivalent of the natural radiation exposure in Germany over 3 days-and thereby, negligible to the patient.

This study aimed to evaluate the radiation exposure to the radiologist and the procedure time of prospectively matched CT interventions implementing three different workflows-the radiologist-(I) leaving the CT room during scanning; (II) wearing a lead apron and staying in the CT room; (III) staying in the CT room in a prototype radiation protection cabin without lead apron while utilizing a wireless remote control and a tablet. We prospectively evaluated the radiologist's radiation exposure utilizing an electronic personal dosimeter, the intervention time, and success in CT interventions matched to the three different workflows. We compared the interventional success, the patient's dose of the interventional scans in each workflow (total mAs and total DLP), the radiologist's personal dose (in µSV), and interventional time. To perform workflow III, a prototype of a radiation protection cabin, with 3 mm lead equivalent walls and a foot switch to operate the doors, was built in the CT examination room. Radiation exposure during the maximum tube output at 120 kV was measured by the local admission officials inside the cabin at the same level as in the technician's control room (below 0.5 μSv/h and 1 mSv/y). Further, to utilize the full potential of this novel workflow, a sterile packed remote control (to move the CT table and to trigger the radiation) and a sterile packed tablet anchored on the CT table (to plan and navigate during the CT intervention) were operated by the radiologist. There were 18 interventions performed in workflow I, 16 in workflow II, and 27 in workflow III. There were no significant differences in the intervention time (workflow I: 23 min ± 12, workflow II: 20 min ± 8, and workflow III: 21 min ± 10, p = 0.71) and the patient's dose (total DLP, p = 0.14). However, the personal dosimeter registered 0.17 ± 0.22 µSv for workflow II, while I and III both documented 0 µSv, displaying significant difference ( p < 0.001). All workflows were performed completely and successfully in all cases. The new workflow has the potential to reduce interventional CT radiologists' radiation dose to zero while relieving them from working in a lead apron all day.

To evaluate the diagnostic performance and reader agreement of a novel MRI image fusion method enabling the reconstruction of oblique images for the assessment of the tibiofibular syndesmosis. We evaluated 40 magnetic resonance imaging examinations of patients with ankle sprains (16 with ruptures and 24 without) for the presence of anteroinferior tibiofibular ligament rupture. For all patients, we performed a fusion of standard two-dimensional transversal and coronal 3 mm PDw TSE images into an oblique-fusion reconstruction (OFR) and compared these against conventionally scanned oblique sequence for the evaluation of the tibiofibular syndesmosis. To evaluate diagnostic performance, two expert readers independently read the OFR images twice. We analyzed sensitivity, specificity, negative and positive predictive values, accuracy, and agreement. Reader 1 misinterpreted one OFR as a false negative, demonstrating a sensitivity of 0.94 and specificity of 1.00, reader 2 demonstrated perfect accuracy. Intrareader agreement was almost perfect for reader 1 (α = 0.95) and was perfect for reader 2 (α = 1.00). Additionally, interreader agreement between all fusion sequence reads was almost perfect (α = 0.97). The proposed OFR enables reliable detection of anteroinferior tibiofibular ligament rupture with excellent inter- and intrareader agreement, making conventional scanning of oblique images redundant and supplies a method to retroactively create oblique images, e.g., from external examinations.

Purpose  Projects involving collaborations between different institutions require data security via selective de-identification of words or phrases. A semi-automated de-identification tool was developed and evaluated on different types of medical reports natively and after adapting the algorithm to the text structure. Materials and Methods  A semi-automated de-identification tool was developed and evaluated for its sensitivity and specificity in detecting sensitive content in written reports. Data from 4671 pathology reports (4105 + 566 in two different formats), 2804 medical reports, 1008 operation reports, and 6223 radiology reports of 1167 patients suffering from breast cancer were de-identified. The content was itemized into four categories: direct identifiers (name, address), indirect identifiers (date of birth/operation, medical ID, etc.), medical terms, and filler words. The software was tested natively (without training) in order to establish a baseline. The reports were manually edited and the model re-trained for the next test set. After manually editing 25, 50, 100, 250, 500 and if applicable 1000 reports of each type re-training was applied. Results  In the native test, 61.3 % of direct and 80.8 % of the indirect identifiers were detected. The performance (P) increased to 91.4 % (P25), 96.7 % (P50), 99.5 % (P100), 99.6 % (P250), 99.7 % (P500) and 100 % (P1000) for direct identifiers and to 93.2 % (P25), 97.9 % (P50), 97.2 % (P100), 98.9 % (P250), 99.0 % (P500) and 99.3 % (P1000) for indirect identifiers. Without training, 5.3 % of medical terms were falsely flagged as critical data. The performance increased, after training, to 4.0 % (P25), 3.6 % (P50), 4.0 % (P100), 3.7 % (P250), 4.3 % (P500), and 3.1 % (P1000). Roughly 0.1 % of filler words were falsely flagged. Conclusion  Training of the developed de-identification tool continuously improved its performance. Training with roughly 100 edited reports enables reliable detection and labeling of sensitive data in different types of medical reports. Key Points:   · Collaborations between different institutions require de-identification of patients' data. · Software-based de-identification of content-sensitive reports grows in importance as a result of 'Big data'. · A de-identification software was developed and tested natively and after training. · The proposed de-identification software worked quite reliably, following training with roughly 100 edited reports. · A final check of the texts by an authorized person remains necessary. Citation Format · Seuss H, Dankerl P, Ihle M et al. Semi-automated De-identification of German Content Sensitive Reports for Big Data Analytics. Fortschr Röntgenstr 2017; 189: 661 - 671., Competing Interests: Conflict of interest: Compliance with ethical standards This retrospective study was conducted in accordance with the guidelines of the Declaration of Helsinki and approved by the Ethics Committee of the University Hospital Erlangen. The use of written informed consent was waived by the ethics committee. Conflict of interest Matthias Ihle and Andrea Grandjean are employees of the Averbis GmbH, Freiburg, Germany. They provided the software within the context of the Smart Data Program in the KDI project of the Federal Ministry for Economic Affairs and Energy, Germany (01MT14 001E). They did not participate in the design, conduction and evaluation of the study. Therefore, the authors declare that no competing interests exist. Funding This research has been supported by the Smart Data Program in the KDI project of the Federal Ministry for Economic Affairs and Energy, Germany (01MT14 001E)., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: Reports on long-term (≥10 years) effects of cancer vaccines are missing. Therefore, in 2002, we initiated a phase I/II trial in cutaneous melanoma patients to further explore the immunogenicity of our DC vaccine and to establish its long-term toxicity and clinical benefit after a planned 10-year followup., Methods: Monocyte-derived DCs matured by TNFα, IL-1β, IL-6, and PGE2 and then loaded with 4 HLA class I and 6 class II-restricted tumor peptides were injected intradermally in high doses over 2 years. We performed serial immunomonitoring in all 53 evaluable patients., Results: Vaccine-specific immune responses including high-affinity, IFNγ-producing CD4+ and lytic polyfunctional CD8+ T cells were de novo induced or boosted in most patients. Exposure of mature DCs to trimeric soluble CD40 ligand, unexpectedly, did not further enhance such immune responses, while keyhole limpet hemocyanin (KLH) pulsing to provide unspecific CD4+ help promoted CD8+ T cell responses - notably, their longevity. An unexpected 19% of nonresectable metastatic melanoma patients are still alive after 11 years, a survival rate similar to that observed in ipilimumab-treated patients and achieved without any major (>grade 2) toxicity. Survival correlated significantly with the development of intense vaccine injection site reactions, and with blood eosinophilia after the first series of vaccinations, suggesting that prolonged survival was a consequence of DC vaccination., Conclusions: Long-term survival in advanced melanoma patients undergoing DC vaccination is similar to ipilimumab-treated patients and occurs upon induction of tumor-specific T cells, blood eosinophilia, and strong vaccine injection site reactions occurring after the initial vaccinations., Trial Registration: ClinicalTrials.gov NCT00053391., Funding: European Community, Sixth Framework Programme (Cancerimmunotherapy LSHC-CT-2006-518234; DC-THERA LSHB-CT-2004-512074), and German Research Foundation (CRC 643, C1, Z2).

Introduction The placement of intramammary marker clips has proven to be helpful for tumor localization in patients undergoing neoadjuvant chemotherapy and breast-conserving surgery. The purpose of our study was to investigate the feasibility of using a clip marker system for breast cancer localization and its influence on the imaging assessment of treatment responses after neoadjuvant chemotherapy. Patients and Methods Between March and June 2015, a total of 25 patients (n = 25), with a suspicion of invasive breast cancer with diameters of at least 2 cm (cT2), underwent preoperative sonographically guided core needle biopsy using a single-use breast biopsy system (HistoCore™) and intramammary clip marking using a directly adapted clip system based on the established O-Twist Marker™, before their scheduled preoperative neoadjuvant chemotherapy. Localization of the intramammary marker clip was controlled by sonography and digital breast tomosynthesis. Results Sonography detected no dislocation of intrammammary marker clips in 20 of 25 patients (80 %), while digital breast tomosynthesis showed accurate placement without dislocation in 24 patients (96 %) (p < 0.05). There was no evidence of significant clip migration during preoperative follow-up imaging after neoadjuvant chemotherapy. No complication related to the clip marking was noted and there was no difficulty in evaluating the treatment response to neoadjuvant chemotherapy. Among the breast-conserving surgeries performed, no cases were identified in which intraoperative loss of the marker clip had occurred. Conclusion Our study underscores the importance of intramammary marking clip systems before neoadjuvant chemotherapy. Placement of marker clips is advised to facilitate accurate tumor bed localization. With regard to digital breast tomosynthesis, its development continues to improve the quality of diagnostics and the therapy of breast cancer particularly for small breast cancer tumors or in neoadjuvant chemotherapy setting.

Background: Proprioceptive neuromuscular stimulating insoles are increasingly applied in treating functional complaints, chronic pain, foot disorders and so on., Objectives: To evaluate rasterstereography as a tool in objectifying postural changes resulting from neuromuscular afferent stimulation and proprioceptive neuromuscular stimulating insoles and to compare the respective effects on posture., Study Design: This is a prospective experimental study., Methods: A total of 27 healthy volunteers were consecutively exposed to six different varying intense neuromuscular afferent stimulating test conditions at three different times. One test condition featured proprioceptive neuromuscular stimulating insoles. In each test condition, a sequence of 12 rasterstereographic recordings of back shape was documented. Changes between six different test conditions and over time for 14 posture characterising parameters were investigated, for example, trunk inclination, pelvic torsion, lateral deviation of the spine's amplitude or sagittal spinal curve., Results: Standard deviation of our rasterstereographic measurements (±2.67 mm) was better than in most comparable reference values. Different neuromuscular stimuli were found to provoke significant changes to various posture parameters, including trunk inclination, pelvic torsion and so on ( each p < 0.001, F-tests). Proprioceptive neuromuscular stimulating insoles induced significant changes for parameter lateral deviation of the spine's amplitude (p = 0.03)., Conclusion: Neuromuscular afferent stimulation and proprioceptive neuromuscular stimulating insoles induce postural changes, which can be detected reliably by rasterstereography., Clinical Relevance: We demonstrated that rasterstereography - a radiation-free imaging modality - enables visualisation and documentation of subtle postural changes induced by varying intense neuromuscular afferent stimulation and the application of proprioceptive neuromuscular stimulating insoles., (© The International Society for Prosthetics and Orthotics 2014.)

Background: To evaluate screening and diagnostic accuracy for the detection of osteoblastic rib lesions using an advanced post-processing package enabling in-plane rib reading in CT-images., Methods: We retrospectively assessed the CT-data of 60 consecutive prostate cancer patients by applying dedicated software enabling in-plane rib reading. Reading the conventional multiplanar reconstructions was considered to be the reference standard. To simulate clinical practice, the reader was given 10 s to screen for sclerotic rib lesions in each patient applying both approaches. Afterwards, every rib was evaluated individually with both approaches without a time limit. Sensitivities, specificities, positive/negative predictive values and the time needed for detection were calculated depending on the lesion's size (largest diameter < 5 mm, 5-10 mm, > 10 mm)., Results: In 53 of 60 patients, all ribs were properly displayed in plane, in five patients ribs were partially displayed correctly, and in two patients none of the ribs were displayed correctly. During the 10-s screening approach all patients with sclerotic rib lesions were correctly identified reading the in-plane images (including the patients without a correct rib segmentation), whereas 14 of 23 patients were correctly identified reading conventional multiplanar images. Overall screening sensitivity, specificity, and positive/negative predictive values were 100/27.0/46.0/100 %, respectively, for in-plane reading and 60.9/100/100/80.4 %, respectively, for multiplanar reading. Overall diagnostic (no time limit) sensitivity, specificity, and positive/negative predictive values of in-plane reading were 97.8/92.8/74.6/99.5 %, respectively. False positive results predominantly occurred for lesions <5 mm in size., Conclusions: In-plane reading of the ribs allows reliable detection of osteoblastic lesions for screening purposes. The limited specificity results from false positives predominantly occurring for small lesions.

Background: To evaluate prevalence, radiological reporting and clinical management of pathologic vertebral body fractures (VBFs) of unknown origin in cancer patients receiving computed tomography (CT) examinations., Methods: We investigated all CT examinations (over 1 year) of male and female patients with an underlying malignancy and an increased risk of osteoporosis (age 55-79 years) for the presence of VBFs. We evaluated midline sagittal CT-reformations of the spine for prevalence, fracture type, severity and location, the accuracy and style of radiological reporting, subsequent clinical management and documentation in hospital discharge letters., Results: 848 patients were investigated. We found 143 VBFs in 94 (11 %) patients. 6, 49, and 45 % were grade 1, grade 2, and grade 3 fractures, respectively, while 20, 66, and 14 % were wedge, biconcave and crush fractures, respectively. 32 (34 %) radiological reports correctly classified VBFs as fractures, 25 (27 %) reports recognized VBFs, but did not type them, and VBFs were not described in 37 (39 %) reports. In 3 (3 %) patients further clinical work-up of VBFs was performed, while only 8 (9 %) hospital discharge letters contained the information of the presence of pathologic VBFs of unknown origin., Conclusions: VBFs of unknown origin appear frequently in cancer patients, however, clinical management and documentation was found in only few cases. Moreover, especially in cancer patients consistent radiological reporting of VBFs seems important, as aetiology of VBFs could be from osteoporosis, disease progression or oncological therapy, however, reporting is still performed inconsistently.

Background: Early detection of loco-regional breast cancer recurrence improves patients' overall survival, as treatment can be initiated or active treatment can be changed. If a suspicious lymph node is diagnosed during a follow-up exam, surgical excision is often performed. The aim of this study was to evaluate the diagnostic performance of the minor invasive ultrasound-guided fine-needle aspiration cytology (FNAC) in sonomorphologically suspicious lymph nodes in breast cancer follow-up., Methods: Between April 2010 and November 2012, we performed ultrasound-guided FNAC in 38 sonographically suspicious lymph nodes of 37 breast cancer follow-up patients. Cytological specimens were evaluated if the sample material was sufficient for diagnosis and if they contained cancer cells. Patients with negative cytology were followed up clinically and sonographically. To evaluate the diagnostic performance we calculated sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for physical examination, the different sonomorphological malignancy criteria and FNAC., Results: In 36/38 (94.7 %) lymph nodes, the pathologist had enough material to establish a final diagnosis; in 2/38 (5.3 %) lymph nodes, the probe material was non-evaluable during cytology, these 2 were excluded from further statistical evaluation. Cytology revealed malignancy in 21 lymph nodes and showed no evidence for malignancy in 15 lymph nodes. There was no evidence for malignant disease in follow-up exams in the 15 cytologically benign lymph nodes with an average follow-up time of 3 years. The diagnostic performances of physical examination and FNAC were: Sensitivity 52/100 %, specificity 88/100 %, PPV 85/100 %, NPV 60/100 %, respectively., Conclusions: Our preliminary results show that FNAC is a safe and fast diagnostic approach for the evaluation of suspicious lymph nodes in the follow-up of patients with breast cancer and, thus, together with follow-up represents a feasible alternative to surgery.

Introduction: This study aimed to compare the accuracy of sonography versus digital breast tomosynthesis to locate intramammary marker clips placed under ultrasound guidance. Patients and Methods: Fifty patients with suspicion of breast cancer (lesion diameter less than 2 cm [cT1]) had ultrasound-guided core needle biopsy with placement of a marker clip in the center of the tumor. Intramammary marker clips were subsequently located with both sonography and digital breast tomosynthesis. Results: Sonography detected no dislocation of intrammammary marker clips in 42 of 50 patients (84 %); dislocation was reported in 8 patients (16 %) with a maximum dislocation of 7 mm along the x-, y- or z-axis. Digital breast tomosynthesis showed accurate placement without dislocation of the intramammary marker clip in 48 patients (96 %); 2 patients (4 %) had a maximum clip dislocation of 3 mm along the x-, y- or z-axis (p < 0.05). Conclusion: The use of digital breast tomosynthesis could improve the accuracy when locating intramammary marker clips compared to sonography and could, in future, be used to complement or even completely replace sonography.

Background: To assess the value of a score-based system which allows standardized evaluation of pulmonary edema on bedside chest radiographs (CXRs) under routine clinical conditions., Methods: Seven experienced readers assessed bedside CXRs of ten patients with an extravascular lung water (EVLW)-value of ≤ 8 mL/kg (range: 4-8 mL/kg; indicates no pulmonary edema) and a series of ten patients with an EVLW-value of ≥ 15 mL/kg (range: 15-21 mL/kg; = indicates a pulmonary edema) with and without customized software which would permit a standardized assessment of the various indications of pulmonary edema. The software provides a score that identifies patients with and without pulmonary edema. EVLW-values were measured instantly after bedside CXR imaging using a pulse contour cardiac output (PiCCO) system and served as a reference standard. The patients were non-traumatic and not treated with diuretics or dobutamine during bedside CXR imaging and the PiCCO measurements. Mean sensitivity, specificity, positive and negative predictive value, the percentage of overall agreement and the free-marginal multirater kappa value was calculated for both the standard and the standardized score-based approach. The net reclassification index was calculated for each reader as well as for all readers., Results: Evaluation of bedside CXRs by means of the score-based approach took longer (23 ± 12 seconds versus 7 ± 3 seconds without the use of the software) but improved radiologists' sensitivity (from 57 to 77%), specificity (from 90 to 100%) and the free-marginal multirater kappa value (from 0.34 to 0.68). The positive predictive value was raised from 85 to 100% and the negative predictive value from 68 to 81%. A net reclassification index of 0.3 (all readers) demonstrates an improvement in prediction performance gained by the score-based approach. The percentage of overall agreement was 67% with the standard approach and 84% with the software-based approach., Conclusions: The diagnostic accuracy of bedside CXRs to discriminate patients with elevated EVLW-values from those with a normal value can be improved with the use of a standardized score-based approach. The investigated system is freely available as a web-based application (accessible via: http://www.radiologie.uk-erlangen.de/aerzte-und-zuweiser/edema).

Purpose: The aim of this study was to evaluate the potential of iterative reconstruction (IR) in chest computed tomography (CT) to reduce radiation exposure. The qualitative and quantitative image quality of standard reconstructions with filtered back projection (FBP) and half dose (HD) chest CT data reconstructed with FBP and IR was assessed., Materials and Methods: 52 consecutive patients underwent contrast-enhanced chest CT on a dual-source CT system at 120 kV and automatic exposure control. The tube current was equally split on both tube detector systems. For the HD datasets, only data from one tube detector system was utilized. Thus, FD and HD data was available for each patient with a single scan. Three datasets were reconstructed from the raw data: standard full dose (FD) images applying FBP which served as a reference, HD images applying FBP and IR. Objective image quality analysis was performed by measuring the image noise in tissue and air. The subjective image quality was evaluated by 2 radiologists according to European guidelines. Additional assessment of artifacts, lesion conspicuity and edge sharpness was performed., Results: Image noise did not differ significantly between HD-IR and FD-FBP (p = 0.254) but increased substantially in HD-FBP (p < 0.001). No statistically significant differences were found for the reproduction of anatomical and pathological structures between HD-IR and FD-FBP, subsegmental bronchi and bronchioli. The image quality of HD-FBP was rated inferior because of increased noise., Conclusion: A 50 % dose reduction in contrast-enhanced chest CT is feasible without a loss of diagnostic confidence if IR is used for image data reconstruction. Iterative reconstruction is another powerful tool to reduce radiation exposure and can be combined with other dose-saving techniques., Key Points: • Iterative reconstructions allow for image noise and artifact reduction.• Comparable image data can thus be attained even at 50 % radiation dose.• Diagnostic confidence remains unaffected., (© Georg Thieme Verlag KG Stuttgart · New York.)

Introduction: A newly adapted clip system for intramammary marking during ultrasound-guided core needle biopsy for suspicion of breast cancer is described and evaluated here. Material and Method: Fifty patients with suspicion of breast cancer (cT2) had ultrasound-guided core needle biopsy using a newly adapted clip marker system (HistoCore™ and O-Twist Marker™). Subsequently, ultrasound follow-up and tomosynthesis scans were done to determine the location of the marker clips. Results: No dislocation of the marker clip was detected on ultrasound in 45 of 50 patients (90 %), and 5 patients (10 %) had a maximum dislocation of 5 mm along the x-, y- or z-axis. Tomosynthesis scans demonstrated precise placement without dislocation of the clip markers in 48 patients (96 %); 2 patients (4 %) had a maximum dislocation of 3 mm along the x-, y- or z-axis. Conclusion: The newly developed clip marker system, a combination of a single-use breast biopsy needle and a precise, length-adapted intramammary marker clip, represents a further improvement in oncological therapy. This is of particular importance for patients requiring subsequent neoadjuvant chemotherapy, as in cases with complete tumour remission, there is no target point for preoperative, ultrasound-guided wire marking.

Aim: This prospective clinical study aimed to evaluate whether it would be possible to reduce the rate of re-excisions using CMOS technology, a specimen radiography system (SRS) or digital breast tomosynthesis (DBT) compared to a conventional full field digital mammography (FFDM) system. Material and Method: Between 12/2012 and 2/2013 50 patients were diagnosed with invasive breast cancer (BI-RADS™ 5). After histological verification, all patients underwent breast-conserving therapy with intraoperative imaging using 4 different systems and differing magnifications: 1. Inspiration™ (Siemens, Erlangen, Germany), amorphous selenium, tungsten source, focus 0.1 mm, resolution 85 µm pixel pitch, 8 lp/mm; 2. BioVision™ (Bioptics, Tucson, AZ, USA), CMOS technology, photodiode array, flat panel, tungsten source, focus 0.05, resolution 50 µm pixel pitch, 12 lp/mm; 3. the Trident™ specimen radiography system (SRS) (Hologic, Bedford, MA, USA), amorphous selenium, tungsten source, focus 0.05, resolution 70 µm pixel pitch, 7.1 lp/mm; 4. tomosynthesis (Siemens, Erlangen, Germany), amorphous selenium, tungsten source, focus 0.1 mm, resolution 85 µm pixel pitch, 8 lp/mm, angular range 50 degrees, 25 projections, scan time > 20 s, geometry: uniform scanning, reconstruction: filtered back projection. The 600 radiographs were prospectively shown to 3 radiologists. Results: Of the 50 patients with histologically proven breast cancer (BI-RADS™ 6), 39 patients required no further surgical therapy (re-excision) after breast-conserving surgery. A retrospective analysis (n = 11) showed a significant (p < 0.05) increase of sensitivity with the BioVision™, the Trident™ and tomosynthesis compared to the Inspiration™ at a magnification of 1.0 : 2.0 or 1.0 : 1.0 (tomosynthesis) (2.6, 3.3 or 3.6 %), i.e. re-excision would not have been necessary in 2, 3 or 4 patients, respectively, compared to findings obtained with a standard magnification of 1.0 : 1.0. Conclusion: The sensitivity of the BioVision™, the Trident™ and tomosynthesis was significantly (p < 0.05) higher and the rate of re-excisions was reduced compared to FFDM using a conventional detector at a magnification of 2.0 but without zooming.

Purpose: To introduce automated detection and volumetric segmentation of the spleen in spiral CT scans with the THESEUS-MEDICO software. The consistency between automated volumetry (aV), estimated volume determination (eV) and manual volume segmentation (mV) was evaluated., Materials and Methods: Retrospective evaluation of the CAD system based on methods like "marginal space learning" and "boosting algorithms". 3 consecutive spiral CT scans (thoraco-abdominal; portal-venous contrast agent phase; 1 or 5 mm slice thickness) of 15 consecutive lymphoma patients were included. The eV: 30 cm³ + 0.58 (width × length × thickness of the spleen) and the mV as the reference standard were determined by an experienced radiologist., Results: The aV could be performed in all CT scans within 15.2 (± 2.4) seconds. The average splenic volume measured by aV was 268.21 ± 114.67 cm³ compared to 281.58 ± 130.21 cm³ in mV and 268.93 ± 104.60 cm³ in eV. The correlation coefficient was 0.99 (coefficient of determination (R²) = 0.98) for aV and mV, 0.91 (R² = 0.83) for mV and eV and 0.91 (R² = 0.82) for aV and eV. There was an almost perfect correlation of the changes in splenic volume measured with the new aV and mV (0.92; R² = 0.84), mV and eV (0.95; R² = 0.91) and aV and eV (0.83; R² = 0.69) between two time points., Conclusion: The automated detection and volumetric segmentation software rapidly provides an accurate measurement of the splenic volume in CT scans. Knowledge about splenic volume and its change between two examinations provides valuable clinical information without effort for the radiologist., (© Georg Thieme Verlag KG Stuttgart · New York.)