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Gastrointestinal Imaging |
1 From the Department of Radiology, Memorial Sloan-Kettering Cancer Center, 1275 York Ave, New York, NY 10021 (D.M.P., H.I.K., S.A.P.); and Weill Medical College of Cornell University, New York, NY (D.M.P.). From the 2004 RSNA Annual Meeting. Received June 22, 2004; revision requested August 19; revision received November 5; accepted November 22. Address correspondence to D.M.P. (e-mail: panicekd@mskcc.org).
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMATERIALS AND METHODS RESULTSDISCUSSIONREFERENCES |
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MATERIALS AND METHODS: Approval for this retrospective study was obtained from the institutional review board, which waived the requirement for informed consent. For each woman who received a diagnosis of breast cancer between 1998 and 2002, the authors reviewed the report of the first contrast material–enhanced CT examination that included assessment of the liver. For women with no definite liver metastasis and at least one hepatic lesion considered TSTC, reports of follow-up imaging examinations were reviewed for a change in lesion size; medical records and images were reviewed if there was a change in lesion size. The 95% confidence intervals (CIs) were calculated for best- and worst-case analyses of cases in which different assumptions were used to classify a lesion as benign.
RESULTS: Of 7692 women, 1012 (13.2%) underwent contrast-enhanced CT including liver assessment. The mean age of the 1012 women was 54.6 years (range, 20.7–89.1 years). The median time from diagnosis of breast cancer to initial CT examination was 14.1 weeks (range, –3.7 to 296 weeks). The presence of at least one hepatic lesion deemed TSTC was reported in 277 of 941 women (29.4%) in whom no definite hepatic metastasis was reported. Subsequent imaging examinations were performed in 191 of the 277 women (69.0%) (median time from initial CT to last follow-up imaging examination, 54 weeks; range, 0.3–302 weeks). Those examinations revealed the lesions were unchanged in 175 (91.6%) women, no longer visible in eight (4.2%), and larger in six (3.1%). In two women (1.0%), change could not be determined. The enlarging hepatic lesions deemed TSTC represented metastatic breast cancer (three patients), metastatic pancreatic cancer (one patient), or cysts (one patient); in one patient, the etiology was not known. Results of best- and worst-case analyses showed that the lesions were benign in 96.9% (95% CI: 93%, 99%) and 92.7% (95% CI: 88%, 96%) of women, respectively.
CONCLUSION: In 92.7%–96.9% of women with breast cancer and hepatic lesions deemed TSTC but no definite liver metastases at initial CT, the lesions represented a benign finding.
© RSNA, 2005
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODS RESULTSDISCUSSIONREFERENCES |
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Hepatic lesions 1.5 cm in diameter or smaller are frequently difficult to characterize at CT and are often reported as being "too small to characterize" (TSTC) by the interpreting radiologist. With the use of multi–detector row helical CT and its attendant thinner collimation, increasingly smaller hepatic lesions can be detected, and, thus, a larger number of small lesions can be identified in patients. The clinical importance of these lesions often remains unknown until biopsy or other imaging examinations are performed for further characterization or until follow-up imaging is performed months later. Results of prior studies (6,7) have shown that most of these lesions are benign, even in patients known to have malignancy; nevertheless, it can be difficult to assume that a small hepatic lesion is benign in an individual patient at presentation. Given that breast cancer is one of the most common cancers, the number of women with hepatic lesions deemed TSTC is of substantial magnitude, and it would be useful to have some guidance in the management of those lesions. Thus, the purpose of our study was to retrospectively evaluate the prevalence and clinical importance of hepatic lesions considered TSTC at initial CT in women with breast cancer.
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MATERIALS AND METHODS |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODS RESULTSDISCUSSIONREFERENCES |
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The tumor registry at Memorial Sloan-Kettering Cancer Center, a dedicated tertiary cancer center, was searched electronically by personnel of the clinical information center to identify all women with breast cancer diagnosed between 1998 and 2002 who also underwent contrast material–enhanced CT, including examination of the liver, after the initial diagnosis of breast cancer. CT examinations performed within a month before the initial pathologic diagnosis of breast cancer were also included because such examinations are sometimes ordered and performed before breast biopsy when the mammographic appearance is highly suggestive of breast cancer. A member of the radiology department’s information technology group then excluded from this study those CT examinations that were performed outside our institution owing to inconsistent availability of the official reports for those examinations.
The initial and follow-up CT examinations were performed at our institution with various scanners (GE Medical Systems, Milwaukee, Wis) between 1998 and 2004, with our standard protocols tailored to each particular scanner. Before October 2000, some images were obtained with a conventional nonhelical scanner; most scans, however, were obtained with a helical scanner with one to 16 detector rows. Standard collimation was 10 mm for the nonhelical scanner, 7 mm for single–detector row scanners, 3.75 mm for four–detector row scanners, 2.5 mm for eight–detector row scanners, and 1.25 mm for 16–detector row scanners. The pitch used on helical scanners varied during the study period and with different scanners but ranged from 0.75 to 1.5. The standard section thickness for image viewing was 10 mm for nonhelical scanners, 7 mm for single–detector row scanners, and 7.5 mm for four-, eight-, and 16–detector row scanners. A dynamic power injection of 150 mL of nonionic intravenous contrast material was given at 2.5 mL/sec (or slower if mandated by suboptimal venous access). Time delay to scanning varied with the type of scanner used but was determined on the basis of the typical time to portal venous phase imaging; automated bolus tracking to initiate scanning was not employed. All scans were sent to our enterprise-wide PACS (picture archiving and communication system) for interpretation on PACS workstations.
Data Collection
A member of the radiology department’s information technology group determined the number of initial CT examinations that were performed with the nonhelical scanner by determining which had been performed before the scanner’s replacement date.
The electronic medical records were searched by personnel of the clinical information center for patient age, date of breast cancer diagnosis, type of breast cancer (as determined with pathologic examination), and stage at diagnosis. A research assistant in the radiology department calculated the mean patient age at diagnosis, as well as the median time from the diagnosis to the initial CT examination and from the initial CT examination to the last available follow-up imaging examination.
The indication for performing each initial CT, as stated in the radiology report, was recorded by one of two body imaging fellows (H.I.K., S.A.P.). Each CT report was categorized by one of those fellows as mentioning no liver metastasis, at least one liver metastasis, or findings indeterminate for liver metastasis. The report of each CT examination categorized as mentioning either no liver metastasis or findings indeterminate for liver metastasis was then classified according to the presence and number of small hepatic lesions considered TSTC. A hepatic lesion deemed TSTC is typically 1.5 cm in diameter or smaller (6–8) or is determined by the interpreting radiologist at our institution to be too small to allow accurate characterization on the available images. Although the majority of hepatic lesions deemed TSTC are hypoattenuating relative to surrounding liver parenchyma at CT, no distinction was made in this study between hypo- and hyperattenuating lesions. For each patient whose initial CT report mentioned at least one hepatic lesion deemed TSTC but no definite liver metastasis, the official reports of subsequent CT, MR imaging, and US examinations were reviewed by one of two body imaging fellows (H.I.K., S.A.P.). Specifically, if the report of the last available follow-up imaging examination stated that the initial hepatic lesion(s) was unchanged in size, the report of at least one additional intervening follow-up imaging examination (if performed) was reviewed to assess for intervening change. If the report of the last available follow-up imaging examination indicated that the initial hepatic lesion(s) had changed in size or was no longer visible, the reports of all available intervening imaging examinations were reviewed.
On the basis of this review, each hepatic lesion deemed TSTC was categorized as showing no change, a decrease in size, or an increase in size. Indeterminate change was noted if the follow-up examination demonstrated at least one new hepatic lesion that obscured the initial lesion but that did not clearly arise from growth of the original TSTC lesion. For lesions that increased in size, one of two body imaging fellows (H.I.K., S.A.P.) and an attending radiologist (D.M.P.) determined the initial and subsequent sizes by reviewing the images. Results of any subsequent pathologic analysis of these lesions or the presence of other types of primary cancers were also recorded. Medical records were reviewed by one of two body imaging fellows (H.I.K., S.A.P.) and by an attending radiologist (D.M.P.) for patients in whom lesions decreased in size or resolved to determine whether the patient had received chemotherapy in the interval and to determine the treating physician’s clinical assessment of the lesion(s).
The location of any extrahepatic metastasis was determined by one of two body imaging fellows (H.I.K., S.A.P.) from the clinical records in all patients with hepatic lesions deemed TSTC but no definite liver metastasis reported at initial CT. Such metastases were classified as nodal (axillary vs nonaxillary) or extrahepatic nonnodal (bone, lung, pleura, chest wall, other).
Data Analysis
Best- and worst-case scenario analyses were performed by one author (D.M.P.) because of the lack of a reference standard for some of the lesions that grew slightly, were no longer visible at follow-up imaging, or could not be assessed at follow-up imaging due to interval appearance of multiple hepatic metastases.
For the best-case analysis, a hepatic lesion deemed TSTC was assumed to be benign if it (a) was unchanged in size at follow-up imaging, (b) was not visible at follow-up imaging but was considered benign on the basis of the clinical context by the treating physicians, (c) was shown to represent a benign lesion or no lesion at MR imaging, (d) enlarged slightly but remained of indeterminate etiology at follow-up, or (e) was indeterminate for change in size owing to the development of metastases that obscured the region of the original lesion.
For the worst-case analysis, a hepatic lesion deemed TSTC was assumed to be benign only if it was unchanged in size at follow-up imaging or was shown to represent a benign lesion or no lesion at MR imaging.
Statistical Analysis
A 95% confidence interval (CI) was calculated by a faculty statistician for the best- and worst-case analyses to help extrapolate the results from this study sample to the general population of women with breast cancer.
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RESULTS |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODS RESULTSDISCUSSIONREFERENCES |
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Liver Lesions
Of the 1012 women with breast cancer who underwent CT including liver examination, 885 (87.5%) had no liver metastasis reported at initial CT, 71 (7.0%) had at least one liver metastasis, and 56 (5.5%) had CT findings reported as indeterminate for liver metastasis (Fig 1). Of the 941 women with no liver metastasis or findings indeterminate for liver metastasis, 664 (70.6%) had no hepatic lesions deemed TSTC, 137 (14.6%) had one lesion deemed TSTC, and 140 (14.9%) had more than one lesion deemed TSTC.
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Enlarging Lesions
In one of the six women with enlarging lesions, the initial CT examination showed one lesion measuring 6 x 5 mm; follow-up CT performed 9 months later revealed interval enlargement of this lesion to 15 x 15 mm and the appearance of new hepatic lesions compatible with metastases. CT-guided fine-needle aspiration of one of the hepatic lesions revealed metastasis from the patient’s known pancreatic cancer.
In a second patient, the initial CT examination showed one lesion measuring 6 x 3 mm; follow-up CT performed 6 weeks later revealed interval enlargement of this lesion to 16 x 13 mm and the appearance of multiple new liver lesions of variable size (Fig 2); all were presumed to represent progression of metastatic breast cancer. Two other patients each had two lesions deemed TSTC at initial CT; one of the lesions in one patient and both lesions in the other patient were enlarged at follow-up CT and showed typical features of metastasis.
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In a fifth patient, one of the hepatic lesions deemed TSTC at initial CT showed, in retrospect, a definite target sign appearance, which is a finding compatible with a metastasis. The patient also had pulmonary and pleural metastases at that time, for which she received chemotherapy.
In a sixth patient, the only available follow-up CT examination was performed without intravenous contrast material, and this limited the evaluation of the liver. In a seventh patient, the lesion deemed TSTC at the initial CT examination could not be identified in retrospect. The lesion deemed TSTC in an eighth patient was reported as a possible artifact, and no liver lesion was seen at MR imaging performed 1 week later.
Analysis of Best- and Worst-Case Scenarios
For the best-case analysis, hepatic lesions deemed TSTC in the 191 women who underwent follow-up imaging were assumed to be benign because they were unchanged in size at follow-up imaging (175 women), were shown to represent cysts (one woman with enlarging lesions) or no lesion (one woman) at subsequent MR imaging, were not visible at follow-up imaging but considered benign on the basis of the clinical context by the treating physicians (three women), were likely artifactual at initial CT (one woman), were likely not visible due to lack of intravenous contrast material at follow-up CT (one woman), enlarged slightly but remained of indeterminate etiology at follow-up imaging (one woman), or were indeterminate for change in size due to the development of hepatic metastases that obscured the region of the original lesion (two women). In this best-case analysis, the hepatic lesions in 185 of the 191 women (96.9%; 95% CI: 93%, 99%) would be considered benign.
For the worst-case analysis, hepatic lesions deemed TSTC in the 191 women who underwent follow-up imaging were assumed to be benign because they were unchanged in size at follow-up imaging (175 women) or were shown to represent cysts (one woman with enlarging lesions) or no lesion (one woman) at subsequent MR imaging. In this worst-case analysis, the hepatic lesions in 177 of the 191 women (92.7%; 95% CI: 88%, 96%) would be considered benign.
Extrahepatic Metastases
Of the 277 women who had at least one hepatic lesion deemed TSTC but no definite liver metastasis reported at initial CT, 146 had extrahepatic metastases. Lymph node metastasis was found at presentation in 130 of the 277 women (46.9%). The nodal metastases were in axillary lymph nodes in 122 of the 130 women (93.8%) and in nonaxillary (predominantly mediastinal and supraclavicular) lymph nodes in eight (6.2%). Extrahepatic nonnodal metastases reported at presentation were located in bone (n = 18), lung (n = 9), pleura (n = 5), chest wall (n = 2), and other (n = 2) sites; metastases involved more than one site in several women.
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODS RESULTSDISCUSSIONREFERENCES |
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Jones et al (6) reported that 82% of 1454 outpatients in their study were referred for abdominal CT because of known extrahepatic malignant disease (from a wide range of primary tumors) or previous hepatic metastasis. Fifty-one percent of the patients known to have cancer had small (15 mm or smaller in diameter) hepatic lesions at CT that were benign, and 26% had malignant small lesions. In a study of 2978 patients with various types of cancers, Schwartz et al (7) found small hepatic lesions in 12.7% of patients; these lesions were benign (according to stability at follow-up CT) in 80.2% of patients and metastatic in 11.6%. In 92.7%–96.9% of the women without gross liver metastasis at presentation in our study, the hepatic lesions deemed TSTC at initial CT represented a benign finding; these worst- and best-case estimates were needed owing to the lack of a reference standard for some of the lesions, such as those that were not visible at follow-up imaging.
The percentage of hepatic lesions deemed TSTC that were benign was higher in our study than in other studies, probably because of the different criteria used for selecting patients and lesions; our study was restricted to women with breast cancer and to hepatic lesions deemed TSTC that were discovered only at initial presentation in women without definite liver metastasis. Given the relatively high prevalence of hepatic lesions deemed TSTC in patients with breast cancer and the relatively low reported prevalence of liver metastasis in such patients at initial presentation (1–3), it is not surprising that most hepatic lesions deemed TSTC are found to be benign.
Although metastatic disease is the greatest clinical concern when at least one hepatic lesion deemed TSTC is demonstrated at CT, those lesions also could be due to various other entities, such as cysts, biliary hamartomas, and hemangiomas. Hepatic cysts and hemangiomas are well-known, common benign entities that often can be readily characterized at imaging when they are of sufficient size and show typical imaging features. Biliary hamartomas are less well known to many radiologists but are common, benign malformations that consist of focal, disorderly collections of bile ducts. The bile ducts within these collections can be of variable size and subcapsular or parenchymal in location. Biliary hamartomas are more often multiple than single at imaging and typically are less than 5 mm in diameter. In a study of patients with various primary malignancies, all biliary hamartomas had lower attenuation than the surrounding normal liver parenchyma at contrast-enhanced CT (9). The spectrum of radiologic manifestations of biliary hamartomas in that study included one or two circumscribed lesions measuring 5–10 mm; multiple lesions measuring approximately 5 mm each; innumerable tiny, nearly uniform 2–5-mm lesions; and innumerable lesions measuring 2–15 mm. Biliary hamartoma is one benign etiology of liver lesions deemed TSTC that can mimic liver metastasis and should be considered in the differential diagnosis of such lesions.
Robinson et al (10), in a recent study of small hepatic lesions in patients known to have or suspected of having malignant disease, used CT to assess various lesion features, including size, shape, margin sharpness, homogeneity, and attenuation. These authors found that most isolated small liver lesions were benign, even in patients known to have or suspected of having cancer; with use of a model derived by using multiple logistic regression analysis, lesions smaller than 5 mm and showing a sharp margin were found to have only a 6% probability of being malignant.
Note that our study was designed to assess only those liver lesions that the interpreting radiologist deemed TSTC at initial CT; other small hepatic lesions that the radiologist could characterize would not have been included in this study. Subjective features of a lesion, such as margin sharpness, internal homogeneity, and relative attenuation, can influence the assessment of a specific lesion. Given that a lesion can be difficult to characterize accurately unless section thickness is less than half the lesion diameter, we believe that lesions up to 1.5 cm in diameter can be TSTC owing to partial volume effects with 7.5-mm-thick sections. Despite this relatively lenient size criterion for deeming a hepatic lesion to be TSTC, nearly all such lesions in our study turned out to be benign. The judgment as to whether a small hepatic lesion can be characterized is necessarily subjective.
In addition to immediate biopsy, several imaging options exist for the evaluation of hepatic lesions deemed TSTC at initial CT. Eberhardt et al (11) found that targeted liver US can help improve the detection and characterization of hepatic TSTC lesions when such lesions are specifically sought and larger than 0.5 cm. In that study, the authors assessed the utility of US evaluation of small hepatic lesions found at CT in patients with cancer and found that 66% of lesions were seen at US when they were specifically being sought and the specific CT finding was being referred to; only 32% of lesions were found when the CT finding was not specifically referenced. Forty-eight percent of the indeterminate lesions could be identified at US, and 93% of the US-detected small hepatic lesions could be further characterized as cysts, solid or metastatic lesions, or hemangiomas. The diagnosis made at US was confirmed in 93% of the lesions at follow-up hepatic US.
Similarly, MR imaging can help definitively characterize many small hepatic lesions as cysts or hemangiomas (12), particularly if heavily T2-weighted sequences (such as single shot or turbo fast spin echo) and gadolinium-based contrast material are used. Positron emission tomography is of limited value for characterizing lesions smaller than 1–1.5 cm (13,14). Even when a hepatic lesion deemed TSTC cannot be confidently characterized at imaging, interval follow-up CT, MR imaging, or US can be useful for assessing a change in lesion size; for all practical purposes, those small hepatic lesions that remain stable over time are assumed by treating physicians to be benign. Obviously, any new hepatic lesion that appears at follow-up imaging must be assumed to represent a metastasis until proved otherwise.
Clinical considerations in an individual patient help determine the pretest probability that a hepatic lesion deemed TSTC represents a metastasis. In a woman with ductal carcinoma in situ, for example, it is virtually certain that a hepatic lesion deemed TSTC does not represent metastasis from that breast lesion. The decision of imaging follow-up of a hepatic lesion deemed TSTC versus immediate further work-up must be tempered by the particular clinical scenario, including histologic type and initial stage of breast cancer, results of liver function tests, and the presence of symptoms or signs that might be due to hepatic metastasis.
Small liver lesions also often present a diagnostic challenge in patients with types of cancers other than breast cancer. For example, in patients with colorectal cancer, preoperative characterization of liver lesions is essential yet can be difficult as more hepatic lesions deemed TSTC are detected at helical CT. In a study of patients with colorectal cancer and hepatic lesions measuring less than 2 cm (15), mangafodipir trisodium–enhanced MR imaging of the liver and helical CT each had similar rates for depiction of liver lesions; however, mangafodipir trisodium–enhanced MR imaging was superior to CT for allowing radiologists to characterize the lesions as benign versus malignant. Twelve metastatic lesions found at mangafodipir trisodium–enhanced MR imaging were missed at CT; 11 (91.7%) of those lesions were small.
In further research in liver CT, investigators might attempt to define work-up algorithms based on size criteria for small liver lesions, similar to those proposed for lung nodules detected at CT performed to screen for lung cancer. Because most tiny lung nodules discovered at lung cancer screening CT are benign, nodules smaller than 5 mm could be followed up annually to assess for stability rather than assessed at immediate additional work-up (16).
This study had some limitations. Every woman with newly diagnosed breast cancer did not undergo CT at presentation; this protocol reflects the actual clinical practice of scanning only those women deemed to be clinically at risk of having distant metastasis. Less than 10% of the women who underwent CT at initial presentation in our study had liver metastasis; this finding is in keeping with findings from other reports (1–3,6,7). Inclusion of women with stages 0 and I breast cancers (3.3% and 23.5% of women in our study, respectively) likely increased the percentage of hepatic lesions deemed TSTC that were benign in our study. Although it is theoretically possible that a small hepatic metastasis might remain completely stable in size at serial follow-up imaging because the woman was receiving chemotherapy, in our experience such a finding is uncommon on the multiple scans obtained during and after a course of chemotherapy administration; therefore, we believe this theoretical consideration was unlikely to have substantially biased our results.
In addition, not all women with breast cancer and hepatic lesions deemed TSTC in our study underwent follow-up imaging. Nevertheless, most (69%) women with these lesions did undergo imaging follow-up, and there is no particular reason to suspect that the lesions in the women who did not undergo follow-up imaging were more likely to have represented liver metastases; in fact, the opposite would seem more likely because women who develop liver metastases typically become symptomatic, and follow-up imaging of the liver would then be performed.
In this retrospective study, we reviewed the official CT reports, not the actual CT scans, to determine the presence of hepatic lesions deemed TSTC. This study, however, was not designed to assess the ability of CT or the readers to depict, detect, or characterize small liver lesions; instead, it was undertaken to assess the prevalence and importance of hepatic lesions deemed TSTC in a large number of women with breast cancer in an actual clinical practice at a large, dedicated oncology center. In addition, our radiologists routinely report all hepatic lesions deemed TSTC, except those seen with widespread hepatic metastatic disease—particularly at the first CT examination that a patient undergoes at our institution. Because virtually all CT scans at our institution are obtained in patients with cancer, our radiologists are quite focused on, and adept at, detecting liver lesions, even if they are TSTC. As with all imaging findings, interobserver and intraobserver variability will exist in the detection and reporting of these hepatic lesions at CT; this study was not designed to assess that variability.
We believe that it was important to include in this study the hepatic lesion deemed TSTC in the one patient whose lesion was shown to represent metastasis from pancreatic cancer, even though it decreased the percentage of these lesions that were deemed benign. Our study was designed to determine the clinical importance of hepatic lesions deemed TSTC in women with breast cancer. Breast cancer does not preclude one from having other cancers, and this patient is a reminder of that important fact.
Although the CT scans were not obtained with a standardized technique because the available technology and protocols evolved rapidly during the study period, all were obtained in a single institution; most scans were obtained with multisection helical scanners. This study was not designed to assess the effect of using various types of CT scanner technology on the radiologist’s ability to detect or characterize hepatic lesions deemed TSTC. We used relatively thick sections (7.0–7.5 mm) that were not optimized for characterization of liver lesions; however, this is the range of section thicknesses used in our standard protocols designed to survey the body for metastasis. If thinner sections were used, it is likely that some of the lesions seen would have been characterized as cysts or hemangiomas and that additional, smaller hepatic lesions deemed TSTC would have been discovered. In addition, some of the hepatic lesions that were not visible at follow-up CT might have been detected had thinner sections been used. A recent study of multi–detector row helical CT revealed that image reconstruction at section thicknesses of 5.00, 3.75, and 2.50 mm yielded statistically significant, progressively higher sensitivity in the detection of liver lesions in general; however, a section thickness of less than 5 mm did not improve sensitivity in the detection of liver metastases 1.5 cm or smaller (17). The results of that study cannot be compared directly with our results because we used thicker sections to view our scans.
Although hepatic lesions deemed TSTC are common at initial CT performed in women with breast cancer, in our study these lesions were of benign etiology in 92.7%–96.9% of the women in whom no definite liver metastasis was evident. As increasingly thin sections are obtained at multi–detector row helical CT, a larger number of benign hepatic lesions deemed TSTC will be discovered. On the basis of the results of this study, at our institution we now recommend that interval follow-up imaging, rather than immediate imaging work-up or biopsy, be performed when at least one hepatic lesion deemed TSTC is discovered at CT in a woman with newly diagnosed breast cancer—particularly if the woman has stage 0 breast cancer and does not have other clinical findings suspicious for liver metastasis.
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ACKNOWLEDGMENTS |
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FOOTNOTES |
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Authors stated no financial relationship to disclose.
Author contributions: Guarantors of integrity of entire study, H.I.K., S.A.P., D.M.P.; study concepts, H.I.K., S.A.P., D.M.P.; study design, D.M.P.; literature research, H.I.K., S.A.P.; clinical studies, H.I.K., S.A.P., D.M.P.; data acquisition, H.I.K., S.A.P., D.M.P.; data analysis/interpretation, H.I.K., D.M.P.; statistical analysis, H.I.K., D.M.P.; manuscript preparation and editing, H.I.K., D.M.P.; manuscript definition of intellectual content, D.M.P.; manuscript revision/review and final version approval, H.I.K., S.A.P., D.M.P.
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REFERENCES |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODS RESULTSDISCUSSIONREFERENCES |
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1.5 cm) malignant hepatic neoplasms. AJR Am J Roentgenol 1995; 164:879-884.2 cm) hepatic lesions in colorectal cancer patients: detection and characterization on mangafodipir trisodium-enhanced MRI. AJR Am J Roentgenol 2004; 182:1233-1240.1.5 cm) liver metastases: is thinner collimation better? Radiology 2002; 225:137-142.This article has been cited by other articles:
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  S. A. Patterson, H. I. Khalil, and D. M. Panicek MRI evaluation of small hepatic lesions in women with breast cancer. Am. J. Roentgenol., August 1, 2006; 187(2): 307 - 312. [Abstract] [Full Text] [PDF]
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months later shows that the lesion (arrow) grew—from 8 x 6 mm to 11 x 8 mm. The size of the other lesion (not shown) remained unchanged. No further work-up was undertaken to evaluate the etiology of either lesion; both remain unchanged in size at follow-up imaging performed 23 months later.