Microbreweries and celebrating the holidays

Holiday Season is well upon us again, and the hospital has closed down for the holiday break. We return to work on Wednesday (Boxing Day).



Celebrating "Christmas cheer" in a micrbrewery here, means drinking the seasonal beers, and last night we went to the Gordon Biersch microbrewery on the Embarcadero. As part of the welcome you are offered a taster of small glasses of several beers, including the seasonal beer, which had both a subtle taste of fruit, along with quite a kick at the end (8% wbv alcohol)

The beers are placed on the informative sheet of paper, shown above, which allows you to choose the beer of choice for the evening.

Happy Holidays everyone

RSNA Breast Imaging - Ultrasound

1. US screening of women with personal history of breast cancer: Cancer detection in the contralateral breast (Korea) - US can detect mammographically occult cancers - increased from 4 to 9 cancers in 1314 women
2. Breast Ca staging using cortical thickness of axillary lymph nodes at ultrasound (Boston, MA) - Maximum cortical thickness of >3mm (compared with Nottingham Criteria of 2mm) is a simple and accurate sonographic criterion (US + FNAC/core gave sensitivity of 91%, specificity of 100%, PPV 100%, NPV 72%)
3. 3D US for the identification and diagnosis of breast cancer (Peoria, IL) - SomoVu 3D reconstruction enabled visualization of mammo occult and MR occult lesions
4. US screening of mastectomy site for detection of non-palpable recurrent cancer (Korea) - some recurrences visible when non-palpable
5. Reproducibility of tool for breast ultrasound assessment and reporting (San Diego, CA)
6. Adjunct diagnostic value of US in patients with suspected ductal breast disease (Rome, Italy) - Important role in the diagnosis of benign focal masses and duct ectasia. Can replace galactography
7. Elasticity imaging of the breast: results of a multi-center trial (Korea) - high sensitivity in characterizing malignant breast lesions. Variability in specificity between centers requires standardization of the technique
8. US Elastography of breast lesions associated with suspicious microcalcifications detected at mammography (Korea) - Malignant calcifications have less strain (HARDER) than benign calcifications
9. Inter and Intra-observer agreement in interpretation of US elastography (Korea) - Interobserver agreement was moderate to substantial and intraobserver agreement was substantial to perfect for the visual assessment of strain images

RSNA Breast Imaging - Computer Aided Detection

1. CAD of malignant and benign clustered microcalcifications in temporal pairs of mammograms and it's effect on Radiologists characterization performance (Ann Arbor, MI) - increased diagnostic accuracy when using interval change analysis
2. CAD review of false -ve FFDM exams on priors (Korea) - CAD correctly identified 34 0f 46 (73%) of retrospectively visible lesions and 14 of 14 (100%) of actionable lesions
3. Critical analysis of studies measuring the effectiveness of CAD in screening (Chicago, IL) - while each individual study is small, the aggregate of studies indicate that performance is comparable to double reading by radiologists
4. An inductive CAD system using genetic algorithms for detection of calcification on mammograms (Orinda, CA) - CAD teaching itself and learning from it's mistakes
5. US CAD into clinical practice: and observational study (Chicago, IL) - cautious optimism using CADx
6. Independent US CAD BI RADS assessment of breast lesions (Philadelphia, PA) - Initial study showed significant improvement in the hands of trained users
7. MRI detected suspicious findings: comparison of kinetic feature measurement using CAD in benign and malignant lesions (Seattle, WA) - ONLY delayed kinetics categorized by the most suspicious type of enhancement were significantly different between B/M. In keeping with MRI BI RADS recommendation of reporting the most suspicious kinetic curve. Any washout enhancement was assoc with malignancy in nearly 50%, entirely persistent with 13.3%
8. Application of CAD in MRM: do we really need whole lesion time curve distribution analysis? (Jena, Germany) - Higher diagnostic accuracy for curve distribution data after application of a statistical regression model compared to semi-automatic detected 'most suspect curve' type

RSNA Breast Imaging - Mammography

1. Assessment of microcalcifications with large core biopsy (VAB) in a screening population (Weisbaden, Germany) - biopsy of all clusters of microcalcification lead to an improvement in their benign/malignant ratio through increased detection of DCIS
2. Coronary Artery Calcification on mammograms ? correlates with coronary artery disease? (Staten Island, NY) - No correlate with C.A.Disease, but with age only
3. Mammo features post Mammosite therapy (Norfolk, VA) - 7x more likely to get seromas and 3.3x to get fat necrosis compared with whole breast irradiation
4. Single dilated duct at Mammography - outcomes (San Francisco, CA) - Rare finding with a greater than 2% chance of malignancy. Should be called a BIRADS 4A rather than a 3 assessment
5. Breast density evaluations from mammograms and central tomosynthesis projections (Philadelphia, PA) - Correlation better with tomosynthesis
6. LCD vs CRT displays for digital mammography calcs and masses (Korea) - Comparable performance, but LCDs better than CRT for microcalcifications - non significant

RSNA Breast Interventional Papers 2

More interventional papers given on Wednesday morning -

1. Is surgical excision of core biopsy proven benign papillomas necessary? (Durham, NC) - close imaging FU is all they do in their practice.
2. Underestimation of papillary lesions by core: correlation with surgical excision ( Scottsville, NY) - 6% underestimate by core. 91% of lesions were identified as atypical
3. Follow-up rather than excision for papillary lesions with VAB (Philadelphia, PA) - 11g VAB can be safely followed rather than having surgical excision
4. How many calcs for diagnosis in VAB for non-mass calcifications? (Korea) - 6 or more cores should be obtained
5. Impact of 10g Vacora and 9G Suros ATEC biopsy for MRI guided biopsy (Bonn, Germany) - Lesions sampled at VAB reduced the chances of localisation biopsy
6. 8G vs 11G needle diagnostic accuracy for stereo cores (Boston, MA) - improvement of over 90% by using 8G for calcs
7. False -ve rate for 14G core biopsy (Korea) - accurate method for diagnosing cancer
8. Clip displacement following VAB, comparison of conventional and gel markers(Vienna, Austria) - SenoRX clips cw Micromark clips. Displacement of up to 20mm with conventional clips. Conventional clips should no longer be used.
9. Diagnostic accuracy of 14G core biopsy for Phyllodes tumours (Korea) - tendency to UNDERSAMPLE.

RSNA Mixed Papers

1. Comparison of Mammo, US and MRI in evaluation of DCIS extent (Korea) - MRI better correlate with pathology
2. Correlation between Mammo and US findings of node -ve IDC (Korea) - HER2 +ve correlated with segmental microcalcs with a mass on US
3. Performance of electrical impedance device to detect cancer in women (Charleston) - HEDA breast scan has a better diagnostic accuracy for breast cancer detection than mammography in women under 50 yrs and small breasts, but no difference with normal sized breasts.

RSNA DIGITAL MAMMOGRAPHY Papers

1. Adding tomosynthesis to FFDM reduces callbacks by 43%, regardless of breast density (Boston)
2. Comparison of Tomosynthesis and FFDM in an OP symptomatic setting (Amsterdam) - No differences found between the 2 techniques in their population
3. Tomosynthesis vs conventional: comparison of breast mass detection and characterisation (Ann Arbor) - More masses detected by tomosynthesis. Better margin assessment but same malignancy rating
4. Comparison of FDDM and SFM within a population based UK screening programme (Barts, London) - Similar recall rates, cancer detection and PPV. FFDM detects larger invasive tumours in the 50-60 age group
5. Digital monitor zooming vs magnificaton FFDM ( Korea) - Better quality of image and increased confidence of diagnosis of radiologists when using magnification rather than simple magnification
6. Improved diagnostic accuracy with contrast enhanced FFDM (Berlin)
7. Technical recall rates FFDM vs SFM (Houston) - digital significantly LOWER TR rate regardless of whether there were prior mammograms available

RSNA Breast Interventional Papers

1. Axillary US in SLNB (Korea) - including US localisation to prevent technical failure of SLNB or false -ve when tumour filed with malignancy
2. Radiofrequency ablation of breast cancer and assessment of ablation zone (Glasgow) - Safe and effective in achieving cell death with CE US to assess immediate response
3. Cryoablation vs radiofrequency ablation of small breast cancer: measurement with 3T MRI imaging ( Rome) - US guided ablation feasible and reliable. CE MRI ideal method to quantify procedure efficacy
4. US mammotome excision of low risk benign lesions (Korea) - can replace surgical excision for low risk benign lesions
5. US mammotome excision of benign intraduct mass for treatment of nipple discharge (Korea)
6. US mammotome excision of benign papillary masses (Korea) - to preclude surgical biopsy

RSNA HIGH RISK SCREENING SESSION

Wendy Berg presented 2 papers with the early results of the ACRIN 6666 trial
When added to mammography in the high risk setting, the diagnostic sensitivity of screening increases. The second paper showed the serious downside with a large proportion of false positive screens with additional unnecessary biopsies.

Increased workload/demand for breast MRI as a result of the 2007 American Cancer Society guidelines on screening high risk women, similar to the October 2006 UK NICE guidelines
It was shown that in the USA, current units could theoretically cope with the increased numbers of screening examinations 2-3 per week, without additional investment.

Nick Perry hits the news

Nick managed to cause a few headlines yesterday with the presentation of data from the Princess Grace Hospital, showing that women in the city have denser breasts than outside of London.

Thanks to the RSNA press releases, it hit the BBC

So NOT relevant that this was a selected population with a higher use of hormones then??
Would be interesting to do the same thing with the Bart's population

Breast MRI Papers

Today in the Arie Crown Theater, there were some interesting papers on -

1. Review of false negative cases (small size and masking with enhancing parenchyma - Chicago)
2. Despite the use of pre-op MRI, no increase in Mastectomy conversion rate (San Diego)
3. MR CAD - great for IDC but only 50% for DCIS (Toronto)
4. Small cancers (<5mm)>
5. Kinetics good for mass enhancement BUT NOT non-mass like enhancement (Chicago)
6. Value of MRI in work up of lobular Ca (Nice)
7. MR in occult metastatic malignancy - neg exam means treat axilla only (Milan)
8. MR Galactography - initial experience (Erlangen)

RSNA STARTS TODAY

First day at RSNA today. Some breast MRI papers and the film interpretation session.
Hot topics to follow in later posts

Sentinelle MR Breast Biopsy Table

Interesting day looking at the Sentinelle breast biopsy for MR.
Their Vanguard table is installed in the UCSF breast center MRI facility at Mount Zion.
The software they use to analyze and target lesions to biopsy is called Aegis, and is a very simple system to use.

The table is able to support the patient in a comfortable position with arms down by her side for the scan and biopsy. The table can also be moved out of the MR room to a separate biopsy room, so that the MR can continue being used, compared with other types of biopsy which require the patient to remain in close proximity to the magnet. Looking forward to using and developing biopsy with this table

BACK TO FRONT FILMS AND BIRADS

One of the hardest aspects of reporting in the USA is reading mammograms the opposite way to having the patient facing you. Of the centers I have visited in the USA, some view films the 'right' way around, and some (including UCSF) read back to front!

When reporting in UCSF however, a score is given for breast density followed by a score for each breast in turn, starting with the right, then the left, followed by an overall BIRADS score. The films have been read by the residents, before the 'attending' does a readout - essentially dictating the result. In San Francisco, there is a database started by Ed Sickles, which is what the residents use to enter the data, and a patient report is generated.

I wonder how long it will take to adjust to reporting films in mirror image configuration

My new office

Well, after attending a research meeting and getting my UCSF ID badge from the Police Department, I was awaiting my office to be allocated, but there is a shortage of space. As a result, a quick trip to Sausalito was called for, and a lovely lunch was taken overlooking the bay.

The IT guys are meeting with me Monday to explain the choice of computer for my office - I think I need a quad core Mac Pro with 30 inch display, as I use OSIRIX as a DICOM workstation for mammography.

It's tea Jim, but not as we know it

My first week in San Francisco has been different to what I expected. The flight from Heathrow was delayed arriving due to strong headwinds, but the process through immigration was far easier than previously. The border guard was very pleasant, and took us through the paperwork for the I-94 that we had to complete when entering the country with an H1B visa.

Once we arrived at our rented apartment, and we had settled in, sleep took over. The great thing is that there is a Safeway across the road, so it was easy in the morning to get the essentials needed for breakfast, especially as the store opens at 5AM!!!. (see photo above - shot from the apartment)

I bought some Twinings Tea Bags, expecting them to be similar to home, but the whole taste thing was just so insipid!!! I have had that problem with Lipton's tea before, but never with 'British' teas. Oh well. Now I know why I used to take PG tips from Sainburys or Tescos to our vacation home in Florida. Obviously a job for the next trip home.