Breast Shadows Research Articles

Prone Chest Radiographs: Distinguishing Features and Identification of Support Devices.

PurposeProne position is known to improve acute lung injury, and chest radiographs are often necessary to monitor disease and confirm support device placement. However, there is a paucity of literature regarding radiographs obtained in this position. We evaluated prone radiographs for distinguishing features and ability to identify support devices.MethodsPairs of prone and supine radiographs obtained during the COVID-19 pandemic were assessed retrospectively. IRB approval and waiver of informed consent were obtained. Radiographs were assessed for imaging adequacy, distinguishing features, and support device identification (endotracheal tube, enteric tube, or central line). Radiographs were reviewed by ≥ 2 cardiothoracic radiologists.ResultsRadiographs from 81 patients (63yo ± 13, 30% women) were reviewed. Prone and supine radiographs were comparable for imaging the lung bases (81% vs. 90%, p = 0.35) and apices (93% vs. 94%, p = 1); prone radiographs more frequently had significant rotation (36% vs. 19%, p = 0.021). To identify prone technique, scapula tip located beyond the rib border was 89% sensitive (95%CI 80–95%) and 85% specific (76–92%), and a fundal stomach bubble was 44% sensitive (33–56%) and 90% specific (81–96%). For women, displaced breast shadow was 46% sensitive (26–67%) and 92% specific (73–99%). Prone and supine radiographs each identified > 99% of support devices. Prone exams trended toward increased rate of malpositioned device (12% vs. 6%, p = 0.07).ConclusionScapula position reliably distinguishes prone from supine position; fundal stomach bubble or displaced breast shadow is specific for prone position. Prone radiographs reliably identify line and tube position, which is particularly important as prone patients appear at increased risk for malpositioned devices.

Role of Computerized Tomography in Evaluation of Coronary Bypass Grafts—Special Reference to Women

AbstractComputerized tomography-coronary angiography (CT-CAG) is gaining popularity as an alternative to conventional CAG to evaluate grafts in a post-coronary artery bypass graft (post-CABG) patient, since it is a noninvasive procedure and is less influenced by cardiac motion. The primary challenge is to image a rapidly beating heart. With introduction of 64-slice scanner, the coronary imaging became a possibility with acceptable accuracy. In recent years, with the development of 128,256 and 320 multislice CT scanners, further enhancement in the temporal and spatial resolution is achieved due to lesser influence of the respiratory and cardiac motion, enhancing the accuracy of the lesion assessment in the grafts and the native vessels. Achieving low heart rate and artifact-free image acquisition, proper reconstruction, and image interpretation are challenges to the radiologists and the technicians involved in coronary imaging. Women pose special subset because of smaller sized coronary vessels, interference due to breast shadows, low-referrals, and gender-specific reluctance to accept the procedure itself. Cardiologists and radiologists caring for these patients must be familiar with the pros and cons of CT-CAG and gender-specific challenges.

A scatter correction method for contrast-enhanced dual-energy digital breast tomosynthesis

Contrast-enhanced dual energy digital breast tomosynthesis (CE-DE-DBT) is designed to image iodinated masses while suppressing breast anatomical background. Scatter is a problem, especially for high energy acquisition, in that it causes severe cupping artifact and iodine quantitation errors. We propose a patient specific scatter correction (SC) algorithm for CE-DE-DBT. The empirical algorithm works by interpolating scatter data outside the breast shadow into an estimate within the breast shadow. The interpolated estimate is further improved by operations that use an easily obtainable (from phantoms) table of scatter-to-primary-ratios (SPR)—a single SPR value for each breast thickness and acquisition angle. We validated our SC algorithm for two breast emulating phantoms by comparing SPR from our SC algorithm to that measured using a beam-passing pinhole array plate. The error in our SC computed SPR, averaged over acquisition angle and image location, was about 5%, with slightly worse errors for thicker phantoms. The SC projection data, reconstructed using OS-SART, showed a large degree of decupping. We also observed that SC removed the dependence of iodine quantitation on phantom thickness. We applied the SC algorithm to a CE-DE-mammographic patient image with a biopsy confirmed tumor at the breast periphery. In the image without SC, the contrast enhanced tumor was masked by the cupping artifact. With our SC, the tumor was easily visible. An interpolation-based SC was proposed by (Siewerdsen et al Med. Phys. 33 187–97) for cone-beam CT (CBCT), but our algorithm and application differ in several respects. Other relevant SC techniques include Monte-Carlo and convolution-based methods for CBCT, storage of a precomputed library of scatter maps for DBT, and patient acquisition with a beam-passing pinhole array for breast CT. Our SC algorithm can be accomplished in clinically acceptable times, requires no additional imaging hardware or extra patient dose and is easily transportable between sites.

Application of boundary detection information in breast tomosynthesis reconstruction.

Digital tomosynthesis mammography (DTM) is one of the most promising techniques that can potentially improve early detection of breast cancers. DTM can provide three-dimensional (3D) structural information by reconstructing the whole imaged volume from a sequence of projection-view (PV) mammograms that are acquired at a small number of projection angles over a limited angular range. Our previous study showed that simultaneous algebraic reconstruction technique (SART) can produce satisfactory tomosynthesized image quality compared to maximum likelihood-type algorithms. To improve the efficiency of DTM reconstruction and address the problem of boundary artifacts, we have developed methods to incorporate both two-dimensional (2D) and 3D breast boundary information within the SART reconstruction algorithm in this study. A second generation GE prototype tomosynthesis mammography system with a stationary digital detector was used for PV image acquisition from 21 angles in 3 degrees increments over a +/- 30 degrees angular range. The 2D breast boundary curves on all PV images were obtained by automated segmentation and were used to restrict the SART reconstruction to be performed only within the breast volume. The computation time of SART reconstruction was reduced by 76.3% and 69.9% for cranio-caudal and mediolateral oblique views, respectively, for the chosen example. In addition, a 3D conical trimming method was developed in which the 2D breast boundary curves from all PVs were back projected to generate the 3D breast surface. This 3D surface was then used to eliminate the multiple breast shadows outside the breast volume due to reconstruction by setting these voxels to a constant background value. Our study demonstrates that, by using the 2D and 3D breast boundary information, all breast boundary and most detector boundary artifacts can be effectively removed on all tomosynthesized slices.

Effect of prone position and attenuation correction on test characteristics of myocardial perfusion imaging in female patients with breast shadow artifacts

Background: Anterior wall defects due to breast decrease specificity of myocardial perfusion imaging (MPI) in female patients (pts.). We compared prone position uncorrected (PRN), supine uncorrected (NO AC), and attenuation corrected (AC) MPI for perfusion scores, sensitivity, specificity, and diagnostic accuracy in women. Methods: 68 female pts. (70±12 yrs) with (+) or without (-) left anterior descending (LAD) coronary artery stenosis ≥ 70% underwent rest TL-201/stress Tc-99m sestamibi MPI as follows: NO AC + simultaneous AC. 45/68 pts. also had PRN. All pts. had: breast shadow on the raw data; anterior, anteroseptal, or apical defects in the LAD distribution as per AHA/ASNC position statement; no anterior wall infarct; diagnostic angiography within 30 days of MPI. Summed stress perfusion scores were based on a 5-point/17-segment model, and % myocardium in the LAD territory perfusion defects (% LV) was calculated from the scores. Friedman rank test was used for %LV, and McNemar's test for statistical significance (p<0.05) between tests' results. Results: See Table %LV ALL % LV LAD(−) %LV LAD(+) Sensitivity Sensitivity Accuracy PRN (n = 45) 4% 3% (n = 33) 6% (n = 12) 50% 94% 82% NO AC (n = 68) 6% 4% (n = 46) 9% (n = 22) 86% 61% 68% AC (n = 68) 8% 5% (n = 46) 12% (n = 22) 83% 79% 80% p 0.0001 0.005 0.007 ns 0.001 PRN and AC vs. NO AC 0.02 PRN and AC vs. NO AC Conclusion: %LV was lowest with PRN, and highest with AC MPI. Compared with NO AC, AC and PRN MPI had increased specificity and accuracy but a trend to a lower sensitivity was observed for PRN.

Chest radiographs made easy.

Chest radiographs made easy.

Do false positive thallium-201 scans lead to unnecessary catheterization? outcome of patients with perfusion defects on quantitative planar thallium-201 scintigraphy

Objectives. We postulated that artifactually abnormal thallium-201 scans are well identified at the time of initial clinical interpretation by experienced readers and do not lead to unnecessary coronary angiography.Background. Exercise thallium-201 scintigraphy employing quantitative imaging techniques has yielded sensitivity and specificity values of 80% to 90%. There are image artifacts, such as breast shadows, and variants of normal that, if not correctly identified, can lead to a high false positive rate for detection of coronary artery disease.Methods. Data from 338 consecutive patients with one or more focal thallium-201 defects on quantitative planar Images were reviewed. All patients had undergone symptom-limited exercise scintigraphy and were classified as having either artifactual or nonartifactual thallium-201 defects after review of clinical reports.Results. Of the 265 patients with defects judged to be nonartifactual on clinical readings, 167 underwent coronary angiography, which demonstrated significant coronary artery disease (≥50% stenosis) in 161 (96%) and normal findings in 6. Four of the latter six had documented prior myocardial infarction. The remaining 73 patients (85% female) had thallium-201 defects deemed to be artifactual on clinical readings, chiefly as a result of breast (66%) and diaphragmatic (8%) attenuation or variants of normal (26%). Only 4 (5%) of the 73 patients underwent subsequent coronary angiography; none had coronary artery disease. One had aortic stenosis and two had variant angina. Follow-up (mean 20 ± 2 months) of the 69 patients in this group who did not undergo coronary angiography revealed no deaths and one nonfatal non-Q wave myocardial infarction.Conclusions. Artifactual defects on quantitative planar thallium-201 scintigraphy are well recognized by experienced interpreters and do not result in a high false positive rate leading to unnecessary cardiac catheferization. The incidence of coronary artery disease is high in patients with thallium-201 defects judged to be nonartifactual, and many patients with perfusion defects and angiographically normal coronary arteries have organic heart disease.

Chest radiograph appearances after head and neck flap reconstructive surgery.

The chest radiographs of 17 patients who had undergone pectoralis major myocutaneous flap (PMMF) reconstruction for head and neck cancers were reviewed. Surgical procedure correlated well with radiographic findings, which consisted of the following signs: abnormal axillary and supraclavicular folds, replacement of normal vertical neck fold by an oblique fold, soft tissue mass and loss of facial plane at base of the neck. Unilateral radiolucent hemithorax was present in 41% of cases. In females, loss of breast shadow simulating the post-mastectomy appearance was present.

Dust exposure and pneumoconiosis in a South African pottery. 2. Pneumoconiosis and factors influencing reading of radiological opacities.

A cross sectional radiological survey of workers exposed to pottery dust during the manufacture of wall tiles and bathroom fittings was conducted in a South African factory. Roughly one third of workers with 15 or more years of service in high dust sections of the factory had pneumoconiosis. Previously undiagnosed advanced cases, including two with progressive massive fibrosis, were working in dusty occupations. A firm diagnosis of potters' pneumoconiosis was made in 11 of the 358 workers radiographed; all had served more than 10 years suggesting that radiography of workers with more than 10 years service would be a successful case finding strategy in South Africa. A combination of rounded and irregular opacities was the most common radiological finding in the workers with pneumoconiosis (55%). Three readers reported on the chest radiographs, and all found an association between small radiological opacities, which were usually irregular or a combination of irregular and rounded, and exposure to pottery dust. The occurrence of irregular radiological opacities in workers exposed to pottery dust deserves further study. The least experienced reader significantly associated age with small opacities when duration of service (years) was used to measure exposure to dust. Sex was not an important predictor of radiological changes consistent with pneumoconiosis. Breast shadows were not an important cause of false positive readings and participating women did not develop pneumoconiosis after less exposure than men.

Congenital Absence of the Mammary Gland

Tc-99m pertechnetate is known for its uptake and excretion by the mammary gland. Generally, lactating women are not advised to have any radioisotopic studies. If it is necessary to have one, it is recommended that they do not breast-feed their children for at least 24 hours. Congenital absence of the mammary gland is a rare condition. This case was accidently discovered. Nuclear medicine physicians should be aware of the value of clinical examination of patients, and that not every absent or asymmetric breast shadow is due to surgical resection.

The Complete Border Sign Of Breast Augmentation

To the Editor.— Breast augmentation with silicone implants may be diagnosed on posterior-anterior (PA) roentgenograms of the chest by observing that the breast shadow is sharply defined in its entire circumference—the complete border sign. On a PA roentgenogram of the chest, the normal female breast is an excellent example of the incomplete border sign. 1 The inferior margin of the breast is sharply defined while the superior portion blends imperceptibly with the chest wall and lacks a definitive border (Fig 1). Silicone implants have a slightly greater density than normal breast tissue. Women who have a silicone breast augmentation usually have enough added density in the superior portion of the breast to form a distinct superior margin on PA roentgenograms of the chest. When this occurs, the breast shadow is seen with a complete border both inferiorly and superiorly—the complete border sign (Fig 2).

The Elimination of Confusing Breast Shadows in Chest Radiography

SUMMARY The use of the supine position in chest radiography is advocated as an additional technique to eliminate confusing breast shadows and its advantages discussed.

Roentgen changes following radical neck dissection.

We propose to describe and demonstrate the changes in the postero-anterior roentgenograms of the chest resulting from a relatively common surgical procedure, the radical neck dissection described by Crile. This problem first presented itself when we noted in one of our cases (Case 1) a calcific excrescence on the clavicle, the significance of which was not understood until we learned that the patient had been subjected to a radical neck dissection. We concluded that the calcific projection represented a spur consequent to surgical trauma to the clavicular periosteum. Subsequently we collected and analyzed all available cases of neck dissection performed in this hospital and observed other roentgenographic stigmata referable to the operation. It is well known that many surgical procedures are associated with characteristic roentgenographic manifestations and can thus be recognized by the radiologist with a high index of assurance, even in the absence of a clear history. Radical mastectomy provides the outstanding example of an operation which produces changes recognizable for what they are even in the absence of a history. Knowledge of previous surgery is often one of the important building blocks essential for correct interpretation of a roentgen study. Every roentgenologist is aware of the orientation of his thought processes following directly upon observation of the absence of the breast shadow. In the same way, he may recognize the presence of a radical neck dissection by the roentgen findings, even without prior knowledge of the procedure. The value of roentgenographic recognition of a previous surgical procedure may be threefold: (a) It may provide the radiologist, and even the clinician, with information which is not otherwise available to them, (b) Pursuant to the above, it will direct the radiologist's attention toward pathology of the type that may reasonably follow as a complication of the surgery or the underlying disease process. (c) It may assist the radiologist to avoid the pitfall of interpreting the changes resulting from surgery as a spontaneous pathologic process or an anatomic abnormality. Certainly, in most instances, this last consideration would be dominant. The Surgical Procedure The radical neck dissection done in the cases reported here conforms essentially to the procedure described by Crile. The accompanying diagram (Fig. 1) illustrates the appearance of the completed dissection prior to skin closure. The side operated upon presents salient anatomical features, important from a radiographic standpoint, as follows: 1. General soft-tissue deficiency. 2. Absence of the sternomastoid muscle. 3. Interruption of the eleventh cranial nerve, innervating the trapezius muscle. The nerve is frequently excised, although occasionally left intact.