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Cystic lesions of the breast are an everyday encounter in the symptomatic breast clinic. While the vast majority of cystic lesions are benign, it is important to be aware of the imaging manifestations that indicate a sinister pathology and the pitfalls of biopsy in a complex cystic lesion which make the diagnosis challenging. We present a case of cystic Grade 3 breast cancer and highlight the imaging characteristics and clinical-radiological concordance that achieved the correct diagnosis.

It is well reported that patients who have undergone breast augmentation and subsequently develop breast cancer can successfully undergo breast-conserving therapy with preservation of their implants. However, there is a paucity of literature on the radiological investigations and surgical techniques in postmastectomy implant-reconstructed patients who develop recurrences to enable preservation of their implant-based reconstruction whilst effectively treating the local recurrence. The wide adoption of acellular dermal matrix use in prosthetic breast reconstruction in recent years has made radiological evaluation of such patients challenging. Herein presented is a case of a 37-year-old woman where wide local excision of a local recurrence abutting a peri-implant capsule following previous mastectomy and implant-acellular dermal matrix (ADM) reconstruction was performed with successful preservation of reconstruction volume (and shape) using an ADM patch to repair the capsular defect whilst retaining the implant in situ. Radiological investigation facilitated and guided the surgical planning and oncological clearance.

Sebaceous carcinoma is a rare, malignant tumor of the sebaceous glands. This is a case report of a 75-year-old man who presented with a right lower axillary mass which initially was considered to be a benign sebaceous cyst from sonography. The lesion rapidly changed in clinical and sonographic appearances and on histology was a sebaceous carcinoma. This unusual tumor accounts for less than 1% of all cutaneous malignant tumors, and the chest wall is a rare extraocular site with only nine cases described in the literature. Immunohistochemistry was negative for MSH2 and MSH6, and positive for MLH1 and PMS2, raising the possibility of Lynch or Muir-Torre Syndrome which is a known association with this rare tumor.

Purpose of Review Automated breast ultrasound (ABUS) is a three-dimensional imaging technique, used as a supplemental screening tool in women with dense breasts. This review considers the technical aspects, pitfalls, and the use of ABUS in screening and clinical practice, together with new developments and future perspectives. Recent Findings ABUS has been approved in the USA and Europe as a screening tool for asymptomatic women with dense breasts in addition to mammography. Supplemental US screening has high sensitivity for cancer detection, especially early-stage invasive cancers, and reduces the frequency of interval cancers. ABUS has similar diagnostic performance to handheld ultrasound (HHUS) and is designed to overcome the drawbacks of operator dependence and poor reproducibility. Concerns with ABUS, like HHUS, include relatively high recall rates and lengthy reading time when compared to mammography. ABUS is a new technique with unique features; therefore, adequate training is required to improve detection and reduce false positives. Computer-aided detection may reduce reading times and improve cancer detection. Other potential applications of ABUS include local staging, treatment response evaluation, breast density assessment, and integration of radiomics. Summary ABUS provides an efficient, reproducible, and comprehensive supplemental imaging technique in breast screening. Developments with computer-aided detection may improve the sensitivity and specificity as well as radiologist confidence and reduce reading times, making this modality acceptable in large volume screening centers.

Primary hyperparathyroidism (PHPT) is characterized by hypercalcemia driven by excess parathyroid hormone (PTH) secretion. PHPT is a common endocrine condition with a prevalence of 1 to 7 cases per 1000 adults. PHPT typically presents in the fifth or sixth decade and shows significant female preponderance. Solitary hyperfunctioning parathyroid adenomas account for 85% to 90% of PHPT cases. The remaining 10% to 15% include cases of multiglandular disease (multiple adenomas or hyperplasia) and, rarely, parathyroid carcinoma (1%). Ectopic parathyroid adenomas may arise due to abnormal embryological migration of the parathyroid glands and can be difficult to localize preoperatively, making surgical cure challenging on the first attempt. The potential existence of multiglandular disease should be considered in all patients in whom preoperative localization fails to identify a target adenoma or following unsuccessful parathyroidectomy. Risk factors for multiglandular disease include underlying genetic syndromes (eg, MEN1/2A), lithium therapy, or previous radiotherapy. In addition to multifocal disease, the possibility of an ectopic parathyroid gland should also be considered in patients requiring repeat parathyroid surgery. In this article, we use illustrative clinical vignettes to discuss the approach to a patient with primary hyperparathyroidism (PHPT) and a suspected ectopic parathyroid adenoma.

The aim of this study was to assess the feasibility of rapid sodium MRI (23Na-MRI) for the imaging of peritoneal cancer deposits in high grade serous ovarian cancer (HGSOC) and to evaluate the relationship of 23Na-MRI with tumour cellularity. 23Na-MRI was performed at 3 T on twelve HGSOC patients using a 3D-cones acquisition technique. Tumour biopsies specimens were collected after imaging and cellularity was measured from histology. Total 23Na-MRI scan time for each patient was approximately 11 min. At an isotropic resolution of 5.6 mm, signal-to-noise ratios (SNRs) of 82.2 ± 15.3 and 15.1 ± 7.1 (mean ± standard deviation) were achieved for imaging of tumour tissue sodium concentration (TSC) and intracellular weighted sodium concentration (IWS) respectively. Tumour TSC and IWS concentrations were: 56.8 ± 19.1 mM and 30.8 ± 9.2 mM respectively and skeletal muscle TSC and IWS concentrations were 33.2 ± 16.3 mM and 20.5 ± 9.9 mM respectively. There were significant sodium concentration differences between cancer and skeletal muscle, Wilcoxon signed-rank test, P

Introduction Women with mammographically dense breasts have an increased risk of breast cancer. Dense breasts can limit detection of small breast lesions due to overlapping fibroglandular tissue. BRAID is a randomised, multi-centre UK study assessing the impact of supplementary imaging, including abbreviated breast MRI (ABB-MRI), in detection of breast cancer in women aged 50-70 years with dense breasts. ABB-MRI is a shorter protocol breast MRI, allowing much faster acquisition times. The aim of this study is to review the feasibility of introducing ABB-MRI into the NHS setting as a part of a research trial. Protocol ABB-MRI is performed on a 1.5 tesla MRI scanner. Sequences obtained include a 2 mm axial T2 weighted sequence, a dual echo (Dixon water/fat separation) 3D DCE acquisition consisting of one pre- and two post-contrast images with generation of post-contrast subtracted images and post-processed MIP images. Scheduling ABB-MRIs are performed on a dedicated breast MRI list. Participants arrive 30 minutes prior to appointment time with pre-filled safety questionnaire. ABB-MRIs are scheduled for a 20-minute appointment slot, allowing 10 women to be scanned in a 3-hour session. Specific roles are allocated to staff members. Improving Efficiency of ABB-MRI in the UK Challenges encountered are similar to those encountered with FDP: IV cannulation, BMI and claustrophobia. Dedicated MR sessions with standard contrast doses and prefilled safety questionnaires help improve efficiency of sessions and allow examination times under 15 minutes.

Radiology continues to play an essential role in the management of benign gynaecological conditions. Multiple imaging modalities are utilised to investigate benign conditions: ultrasound; computed tomography and magnetic resonance imaging. Each modality has a different role in diagnosis, treatment selection and follow-up. This review discusses the different imaging modalities and their recommended roles in the imaging benign gynaecological conditions. The imaging findings of common benign female pelvic pathology are discussed and illustrated.

Diffusion weighted imaging (DWI) has become an essential part of the gynaecological magnetic resonance imaging (MRI) protocol. DWI is used as an adjunct to conventional MRI sequences and has been shown to improve reporting accuracy in the imaging of gynaecological malignancy. In this review, we discuss the role of DWI in the diagnosis, staging, and assessment of treatment response of endometrial, cervical, and ovarian cancer. We also review the role of DWI in the assessment of the sonographically indeterminate ovarian lesion. Further, we highlight potential pitfalls that can beset the accurate interpretation of DWI in patients with gynaecological malignancy.

Optoacoustic imaging with ultrasound (OPUS) can assess in-vivo perfusion/oxygenation through surrogate measures of oxy, deoxy and total hemoglobin content in tissues. The primary aim of our study was to evaluate the ability of OPUS to detect physiological changes in the breast during the menstrual cycle and to determine qualitative/quantitative metrics of normal parenchymal tissue in pre-/post-menopausal women. The secondary aim was to assess the technique's repeatability. We performed a prospective ethically approved study in volunteers using OPUS (700, 800 and 850 nm wavelengths) in the proliferative/follicular and secretory phase of the menstrual cycle. Regions of interest (ROIs) were drawn on the most superficial region of fibroglandular tissue and same-day intra-observer repeatability was assessed. We used t-tests to interrogate differences in the OPUS measurements due to hormonal changes and interclass correlation coefficients/Bland-Altman plots to evaluate the repeatability of mean ROI signal intensities. 22 pre-menopausal and 8 post-menopausal volunteers were recruited. 21 participants underwent repeatability examinations. OPUS intensity values were significantly higher (p 0.0001) at all excitation wavelengths in the secretory compared to the proliferative/follicular phase. Post-menopausal volunteers showed similar optoacoustic values to the proliferative/follicular phase of pre-menopausal volunteers. The repeatability of the technique was comparable to other handheld ultrasound modalities. OPUS detects changes in perfusion/vascularity related to the menstrual cycle and menopausal status of breast parenchyma.ZIEL: Optoakustische Bildgebung mittels Ultraschall (OPUS) erlaubt die in-vivo Beurteilung von Perfusion/Oxygenierung mittels Surrogatmessungen von Oxy-, Deoxy- und totalem Hämoglobingehalt im Gewebe. Das vorrangige Ziel dieser Studie war es zu evaluieren, ob physiologische Veränderungen im Brustparenchym während des Menstruationszyklus nachweisbar sind und qualitative sowie quantitative Merkmale normalen Brustparenchyms in prä- und postmenopausalen Probandinnen zu bestimmen. Als weiteres Ziel wurde die Reproduzierbarkeit dieser Technik evaluiert. Die vorliegende prospektive Studie zur Evaluierung von OPUS (700, 800 und 850 nm Wellenlänge) an freiwilligen Probandinnen während der proliferativen/follikulären und sekretorischen Zyklusphasen wurde von der lokalen Ethikkommission positive beurteilt. Regions of interest (ROIs) wurden im oberflächlichsten fibroglandulären Gewebe gezeichnet und die Intraobserver-Reproduzierbarkeit wurde am selben Untersuchungstag beurteilt. Um Unterschiede zwischen OPUS-Messungen in Abhängigkeit von Zyklusphasen zu beurteilen, wurden t-Tests verwendet. Interklassen-Korrelationskoeffizienten/Bland-Altman Plots wurden verwendet um die Reproduzierbarkeit der mittleren ROI Signalintensität zu untersuchen. 22 prämenopausale und 8 postmenopausale Probandinnen wurden rekrutiert. 21 Probandinnen unterzogen sich Reproduzierbarkeitstests. Unabhängig von der Exzitationswellenlänge waren OPUS Intensitätswerte während der sekretorischen Phase signifikant höher (p 0,0001) als während der proliferativen/follikulären Phase. Die Messwerte in postmenopausalen Probandinnen glichen denen prämenopausaler Probandinnen während der proliferativen/follikulären Phase. Die Reproduzierbarkeit dieser Technik glich der anderer Ultraschallhandgeräte. OPUS detektiert Veränderungen der Perfusion/Vaskularisation des Brustparenchyms in Abhängigkeit von Menstruationszyklus und Menopausenstatus.

Recent advances in cross-sectional imaging have led to an increasingly important role for radiology in the management of gynaecological conditions. Multiple imaging modalities are utilized to investigate the female pelvis including: ultrasound; computed tomography; magnetic resonance imaging; and positron emission tomography/computed tomography. Each modality has a different role in screening, diagnosis, staging, treatment selection and follow-up. This review will discuss the various imaging techniques and recommended roles for each modality and how these modalities are best employed in the imaging of the female pelvis. The imaging findings of common female pelvic pathology are discussed and illustrated.

Key content • Congenital uterine abnormalities are a diverse and complex group of conditions which can cause anxiety and psychological distress because of infertility or issues with sexual identity. • Magnetic resonance imaging (MRI) is the most accurate technique for the study of the anatomy of the female pelvis and the method of choice for evaluation of congenital uterine anomalies. • MRI allows detailed anatomical mapping which is paramount in understanding patient management and for the planning of any surgical procedure aimed at re-establishing normal anatomy and/or fertility in these challenging cases. Learning objectives • To learn about the optimal MRI techniques for assessing congenital uterine anomalies. • To recognise the specific MRI characteristics of a wide range of congenital uterine anomalies, including mullerian duct abnormalities, vaginal septa, hermaphroditism and complete androgen insensitivity syndrome. Ethical issues • Should surgery be performed on infants with ambiguous genitalia? • What are people's attitudes generally about intersexuality? • Can non-disclosure to a patient of their intersex condition be justified?

To compare the image quality of water-only images generated from a dual-echo Dixon technique with that of standard fast spin-echo T1-weighted chemical shift fat-suppressed images obtained in patients evaluated for pelvic pain with a 1.5-T magnetic resonance (MR) system.The ethics board granted approval for this retrospective study; patient consent was not required. Twenty-five women underwent both standard axial T1-weighted fast spin-echo chemical shift fat-suppressed imaging and dual-echo Dixon imaging of the pelvis. Two readers independently scored the acquisitions for image quality, fat suppression quality, and artifact. On the basis of signal intensity measurements, the uniformity of fat suppression, the contrast between fat-suppressed and non-fat-suppressed tissue, and the contrast between pathologic lesions and suppressed fat were calculated. Values obtained with the T1-weighted fat-suppressed and dual-echo Dixon techniques were compared by using the Wilcoxon signed rank test.The images generated with the dual-echo Dixon technique were of higher quality, had better fat suppression, and had less artifact (qualitative scores: 4.4, 4.6, and 4.0, respectively) compared with the standard T1-weighted fat-suppressed images (qualitative scores: 3.4, 3.3, and 3.6, respectively; P.01). Contrast between fat-suppressed and non-fat-suppressed tissue (contrast ratio: 0.86 for dual-echo Dixon technique vs 0.42 for T1-weighted fat-suppressed technique, P.001) and between pathologic lesions and suppressed fat (contrast ratio: 0.88 for dual-echo Dixon technique vs 0.57 for T1-weighted fat-suppressed technique, P =.012) was significantly improved with the dual-echo Dixon technique. Twelve pathologic lesions were identified with dual-echo Dixon imaging versus eight that were identified with T1-weighted fat-suppressed imaging.Compared with standard T1-weighted fat-suppressed imaging, dual-echo Dixon imaging facilitates improved image quality of fat-suppressed images of the pelvis, enabling better delineation of pathologic lesions.

Aims The aim of this paper is to guide the radiologist to the most likely location of the sentinel lymph node (SLN). Materials and methods Patients with invasive breast cancer underwent axillary ultrasound examination. The position and morphological appearances of the lymph nodes were noted and core biopsy (CB) was performed of the largest or most suspicious node. Those patients whose biopsy revealed no evidence of malignancy proceeded to a surgical sentinel lymph node (SLN) biopsy (SLNB) looking for histopathological evidence of previous CB. Results Of 121 patients who underwent axillary ultrasound and CB no malignancy was identified in 73, all of whom subsequently underwent SLNB. Histological evidence of CB in the SLN was identified in 47 (64%) patients. The position of all the lymph nodes identified on ultrasound and the 47 patients whose SLNs were identified were drawn on composite diagrams of the axilla. Of the 36 nodes identified as sentinel whose position relative to other nodes could be determined, 29 (81%) represented the lowest node identified in the axilla, four (11%) were the second lowest, and three (8%) were the third lowest node. None of the four patients whose CB was from the fourth lowest node had the CB site identified at subsequent SLNB. Conclusion Ultrasound of the axilla should be carried out in a systematic fashion focusing on level I nodes paying particular attention to the lowest one or two lymph nodes.

Ovarian cancer causes more deaths than any other cancer of the female reproductive system and accounts for 4% of all female cancers. In 2010, an estimated 1 in 71 women in the United States will develop ovarian cancer in their lifetime with an estimated 13,850 deaths (Cancer Facts and Figures 2010). However, death rates for ovarian cancer have been decreasing by 1.4% per year since 2002 which is partly due to accurate staging of ovarian carcinoma which is vital for the appropriate management and counseling of patients. Identifying the volume and locations of tumor is valuable in planning percutaneous tissue biopsy and triaging patients to either primary cytoreductive surgery, or primary platinum-based chemotherapy. This chapter will discuss the classification, risk factors, current imaging modalities, and staging of ovarian cancer to provide a comprehensive overview for the clinical radiologist.

Objectives: To validate the use of “Imagebox”- a web-based image review system for large scale multicentre trials. Patients and Methods: As part of the multicentre trial ‘Prospective study of Outcomes in Sporadic versus Hereditary breast cancer (POSH) study’ mammograms were collected and digitised. Software was created allowing digitised mammograms to be viewed from any location with internet access. Two validation studies were performed. Firstly phantom studies using line-pairs (1–20 lpmm -1 ) to assess spatial resolution and the CDMAM 3.4 phantom were used to assess the visibility of gold discs for contrast detail .Secondly a comparison was made between the scoring of 77 patients’ original diagnostic analogue mammograms from 29 hospitals and the corresponding web images. Films and web images were scored by one experienced breast radiologist according to the BIRADS classification. At least 8 weeks elapsed between scoring images from the same patient. Results: The original analogue spatial resolution was 20 lpmm -1 and web resolution of the same image reduced at 8.9 lpmm -1 . Contrast detail assessment demonstrated analogue and web images with near concordance and the image quality factor, IQF inv for the web was reduced but within the 95% confidence interval of the original mammograms. BIRADS final assessment showed good agreement between the analogue and the identical web images (Kappa 0.82). Conclusion: The overall reduction in spatial resolution did not adversely affect the quality of the diagnostic image on “Imagebox”. This may be due to its functionality, specifically the high magnification zoom which enhances diagnostic interpretation. Imagebox is a promising solution to address the logistical challenges for large breast imaging reviews and has further potential for education and self assessment.

To compare the diagnostic performance of diffusion-weighted (DW) magnetic resonance (MR) imaging with that of dynamic contrast material-enhanced (DCE) MR imaging in evaluating the depth of myometrial invasion and overall stage in patients with endometrial cancer.The institutional review board approved this retrospective study; patient consent was not required. From May 2008 to February 2010, 48 women with endometrial cancer underwent preoperative MR imaging, including T1- and T2-weighted imaging, DW MR imaging (b=0 and 800 sec/mm2) and DCE MR imaging. Two radiologists independently interpreted the depth of myometrial invasion, overall stage, and presence of pitfalls associated with inaccurate assessment of myometrial invasion at T1- and T2-weighted imaging, DW MR imaging, and DCE MR imaging. Myometrial invasion and overall stage were compared by using the McNemar test, and κ statistics were used for reader agreement.For assessing the depth of myometrial invasion, diagnostic accuracy, sensitivity, and specificity, respectively, were as follows: DW MR imaging-reader 1, 90%, 84%, and 100%; reader 2, 85%, 84%, and 88%; DCE MR imaging-reader 1, 71%, 61%, and 88%; reader 2, 79%, 77%, and 82%. The improvement in diagnostic accuracy for reader 1 was significant (P=.035). For myometrial invasion, κ values were 0.75 with DW MR imaging and 0.26 with DCE MR imaging. There was no association between inaccurate assessment of myometrial invasion and standard pitfalls with DW MR imaging. Readers 1 and 2 correctly staged more patients by using DW MR imaging (39 and 38 patients, respectively) than by using DCE MR imaging (29 and 30 patients, respectively) (P.05). For overall stage, κ values were 0.74 with DW MR imaging and 0.22 with DCE MR imaging.DW MR imaging has superior diagnostic accuracy in the assessment of myometrial invasion and significantly higher staging accuracy compared with DCE MR imaging.

Gynecologic malignancies account for 10%–15% of all malignancies in females. A variety of oncologic options are available depending on organ of origin, histologic diagnosis, and disease grade and stage. Gynecologic malignancies are usually treated with surgery, chemotherapy, or radiation therapy. Posttreatment imaging plays a crucial role in the assessment of treatment response and tumor recurrence. Imaging of the female pelvis following chemotherapy and radiation therapy is particularly challenging due to alteration of the normal anatomy and loss of tissue planes. Expected changes in appearance occur following chemotherapy–radiation therapy, as do complications such as fistulas, proctitis, enteritis, typhlitis, cystitis, and insufficiency fractures. Radiologists should be familiar with both the expected posttreatment imaging findings and the imaging features of common complications to help make the correct interpretation and avoid possible pitfalls. © RSNA, 2010

Ovarian cancer is the sixth most commonly diagnosed cancer in the world, accounting for 4% of all female cancers. An estimated 1 in 71 women in the United States will develop ovarian cancer in their lifetime. Accurate staging of ovarian carcinoma is vital in the appropriate management and counseling of patients. The surgical staging proposed by the International Federation of Obstetrics and Gynaecology is the most universally used, and International Federation of Obstetrics and Gynaecology encourages the use of imaging techniques to assess prognostic factors, such as resectable disease and lymph node status. Identifying the volume and locations of tumor is valuable in planning percutaneous tissue biopsy, triaging patients to either primary cytoreductive surgery, or primary platinum-based chemotherapy. Contrast-enhanced computed tomography is the modality of choice for the staging of ovarian carcinoma, with magnetic resonance imaging being used as a problem-solving tool. In this article we discuss and illustrate the staging of ovarian carcinoma, with emphasis on the current imaging modalities and optimal image acquisition.

To assess the feasibility and first experience of combined (18)F-FDG-PET)/dynamic contrast-enhanced (DCE) CT in evaluating breast cancer.Nine consecutive female patients (mean age 64.2 years, range 52-74 years) with primary breast carcinoma were prospectively recruited for combined (18)F-FDG PET/DCE-CT. Dynamic CT data were used to calculate a range of parameters of tumour vascularity, and tumour (18)F-FDG uptake (standardized uptake value, SUVmax) was used as a metabolic indicator.One tumour did not enhance and was excluded. The mean tumour SUVmax was 7.7 (range 2.4-26.1). The mean values for tumour perfusion, perfusion normalized to cardiac output, standard perfusion value (SPV) and permeability were 41 ml/min per 100 g (19-59 ml/min per 100 g), 0.56%/100 g (0.33-1.09%/100 g), 3.6 (2.5-5.9) and 0.15/min (0.09-0.30/min), respectively. Linear regression analysis showed a positive correlation between tumour SUV and tumour perfusion normalized to cardiac output (r=0.55, p=0.045) and a marginal correlation between tumour SUV and tumour SPV (r=0.19, p=0.065). There were no significant correlations between tumour SUV and tumour perfusion (r=0.29, p=0.401) or permeability (r=0.03, p=0.682).The first data from combined (18)F-FDG-PET/DCE-CT in breast cancer are reported. The technique was successful in eight of nine patients. Breast tumour metabolic and vascular parameters were consistent with previous data from (15)O-H(2)O-PET.