Ξένες δημοσιεύσεις

Women with a high familial breast cancer risk have an increased likelihood of developing breast cancer and a subsequent increased risk of developing contralateral malignancy. Therefore, additional surveillance has been recommended to reduce risks.

Screening for High-Familial-Risk Women

21. The performance of 3D ABUS versus HHUS in the visualization and BI-RADS characterization of breast lesions in a large cohort of 1.886 women.

Athina Vourtsis & Aspasia Kachulis

The study aimed to evaluate automated breast ultrasound (ABUS) compared to hand-held traditional ultrasound (HHUS) in the visualisation and BIRADS characterisation of breast lesions.

3D ABUS performance vs. HHUS in the visualization and BI-RADS characterization of breast lesions

20. Using 3D ABUS to achieve improved breast care outcomes. Breast imaging expert panel

Dr. Athina Vourtsis, MD, PhD, Radiologist
How is screening handled in countries that do not have a national regulated Breast Cancer Screening program?
How did you decide to offer 3D ABUS for women with dense breasts? What are the clinical advantages of using 3D ABUS?
How does the 3D ABUS coronal view help solve the problem of architectural distortions?
What are the workflow advantages of using 3D ABUS compared to HHUS?
How do you educate your patients about breast density and supplemental ABUS screening? What should patients know?
What do you see as the next steps to set a standard of care for screening women with dense breasts?

Using 3D ABUS to achieve improved breast care outcomes

19. Breast Imaging and Health Care in Greece

A. Vourtsi
Did you know that the incidence of breast cancer is Greece in lower than in Northern Europe and the United States? Dr. Athina Vourtsis writes about screening and breast health awareness in her article “Breast Imaging and Health Care in Greece“. The article is also reprinted in Greek. http://www.pageturnpro.com/Society-of-Breast-Imaging/78574-SBI-17-07-SBI-2017-Issue-2-DigiNews-ePub_FINAL/default.html#page/10

18. Breast cancer as a major health issue and the role of mammography in early diagnosis

A. Vourtsi – Hellenic Breast Imaging Society
This position paper on screening for breast cancer (BC) has been proposed by the Executive Board and the Scientific Committee of the European Society of Breast Imaging (EUSOBI) and approved by 30 national breast radiology bodies/sections. The aim is to give a clear message in favour of screening mammography to national/local governments, policy makers, referring physicians and the general population. Among the 30 national breast radiology bodies who signed a Memorandum of Understanding with the European Society of Breast Imaging and co-authored this paper, the Hellenic Breast Imaging Society.
“Breast cancer as a major health issue and the role of mammography in early diagnosis“.

17. The effect of low dose hormone therapy on mammographic breast density

George E. Christodoulakos, Irene V. Lambrinoudaki, Athina D. Vourtsi, Sofia Vlachou, Maria Creatsa, Konstantinos P.C. Panoulis, Dimitrios Botsis
Maturitus 54 (2006)78-85
Objectives: To evaluate the effect of two standard and one low dose continuous hormone therapy regimens on mammography.
Methods: One hundred and thirty-two non-hysterectomized pοstmenopausal women were randomly allocated either to conjugated equine estrogens 0.625mg plus medroxyprogesterone acetate 5mg (CEE/MPA, n=38) 17β-estradiol 2mg plus norethisterone acetate 1mg (E2/NETA,n=44) or 17β-estradiol 1mg plus norethisterone acetate 0.5mg (low E2/NETA, N=50). Treatment was continuous and the study period lasted 12 months. Main outcome measures were the changes according to Wolfe classification between baseline and 12-month mammograms.
Results: Five (13.2% women in the CEE/MPA group showed an increase in breast density. Fourteen (31.8%) women on E2/NETA and 6 (12.2%) on low E2/NETA treatment revealed an increase in breast density. No women exhibited an involution of fibroglandular tissue.
Conclusion: Different hormone therapy regimens have a variable impact on breast density probably depending on the steroid used. Low dose hormone therapy associates with significantly lesser increase in breast density.

16. Male Breast Hemangioma

A. Vourtsi, S. Zervoudis, A. Pafiti, S. Athanasiadis
Accepted for publication in The Breast Journal 12(3) May June 2006
Abstract: Hemangioma is a very rare breast tumor and their association in a male breast is, in fact extremely rare. A case of breast hemangioma in a 77-year-old male patient is presented with description of the mammographic and pathologic findings.

Index Terms: Hemangioma – Male Breast – Mammography

Hemangioma of the male breast is an extremely rare benign vascular tumor and information regarding its mammographic appearance is not available. Only one case of hemangioma in a male breast is reported in the literature, in which only the pathologic findings are described [1]. The present paper describes the mammographic and pathologic findings of a male breast hemangioma.

15. The effect of low dose hormone therapy on mammographic breast density

G.E. Christodoulakos, I.V. Lambrinoudaki, A. Vourtsi, S. Vlachos, M. Kreatsa, K. Panoulis, D. Botsis
Accepted for publication in Maturitas (09/2005)
Objectives: To evaluate the effect of two standard and one low dose continuous hormone therapy regimens on mammography.

Methods: 132 non-hysterectomized postmenopausal women were randomly allocated either to conjugated equine estrogens 0.625mg plus medroxyprogesterone acetate 5mg (CEE/MPA, n=38 ), 17β-estradiol 2mg plus norethisterone acetate 1mg (E2/NETA, n=44) or 17β-estradiol 1mg plus norethisterone acetate 0,5mg (low E2/NETA , n=50). Treatment was continuous and the study period lasted 12 months. Main outcome measures were the changes according to Wolfe classification between baseline and 12-month-mammograms.

Results: 5 (13.2%) women in the CEE/MPA group showed an increase in breast density. 14 (31.8%) women on E2/NETA and 6 (12.2%) on low E2/NETA treatment revealed an increase in breast density. No woman exhibited an involution of fibroglandular tissue.

Conclusions: Different hormone therapy regimens have a variable impact on breast density probably depending on the steroid used. Low dose hormone therapy associates with significantly lesser increase in breast density.

Keywords: low dose hormone therapy, mammography, breast density

14. Mammographic changes associated with raloxifene and tibolone therapy in postmenopausal women: a prospective study

George E. Christodoulakos, MD, Irene V. Lambrinoudaki, MD, Athina D. Vourtsi, MD, Konstantinos P.C. Panoulidis, MD, Dimitrios A. Kelekis, MD, George C. Creatsas, MD, FACS
Menopause: The Journal of The North American Menopause Society Vol 9,
No 2, pp. 110-116, 2002
Objective: The prolonged use of estrogen therapy is associated with a slightly increased risk of breast cancer. Alternative therapies that are effective in the prevention of menopause, having associated morbidities but no unwanted effects, are of primary interest in the pharmacologic research. The aim of this study was to evaluate the effect of two alternatives to estrogenes drugs, the selective estrogen receptor modulator raloxifene and the tissue-specific tibolone, on the mammographic appearance of the breast.

Design: The study group comprised 131 postmenopausal women aged 41 to 67 years. The women were at least 2 years postmenopausal, free of climacteric symptoms, and at the time of entry to the study had not had therapy for at least 9 months. Women with risk factors for osteoporosis or cardiovascular disease were allocated either to tibolone(n=56) or raloxifene (n=48) therapy. Women with no risk factors and women who either did not qualify for or denied treatment (n=27) served as controls. The study duration was 12 months. Women received a baseline mammogram before commencing therapy and a repeat mammogram at the end of the study period. Mammogram findings were classified according to the modified Wolfe criteria by two expert radiologists.

Results: No difference was identified between groups with respect to baseline characteristics associated with breast cancer risk. Similarly, no difference was detected between groups concerning the modified Wolfe classification of baseline mammographic findings. In the tibolone group, 10.7% of the women showed an increase in breast density in the 12-month reevaluation. The respective figure in the raloxifene group was 6.3%, whereas no woman in the control group showed an increase in breast density. Differences in the increase in breast density between groups did not, however, reach statistical significance. Accordingly, 10.7% of women in the tibolone group and 18.8% of women in the raloxifene group exhibited involutionary changes in the repeat mammogram, whereas 25.9% of women in the control group revealed a decrease in breast density in the 12-month examination. The percentages were not significantly different between groups.

Conclusions: Breast density as shown by mammography was stable in a majority of patients and changed in a minority of cases for both tibolone and raloxifene. In most patients, these drugs are not likely to interfere with mammogram interpretation. Larger long-term studies are needed to confirm the impact of prolonged tibolone or raloxifene administration no mammography.

Keywords: Mammographic density – Estrogen therapy – Tibolone – Raloxifene

13. The effect of various regimens of hormone replacement therapy on mammographic breast density

George E. Christodoulakos, Irene V. Lambrinoudaki, Konstantinos P.C. Panoulis,
Athina D. Vourtsi, L. Vlachos, E. Georgiou, George C. Creatsas
Maturitus 45 (2003) 109-118
Objectives: To evaluate the effect of three distinct hormone replacement therapy regimens on mammography.

Methods: 121 postmenopausal women who had never received or were past users of hormone replacement therapy were studied prospectively. Women with an intact uterus were randomly allocated either to conjugated equine estrogens 0.625 mg plus medroxyprogesterone acetate 5 mg (CEE/MPA, n=34) or to 17β-estradiol 2 mg plus norethisterone acetate 1 mg (E2/NETA, n=35). Hysterectomized women received CEE 0.625 mf (CEE, n=25). Women who either declined or did not qualify for treatment served as controls (n=27). Treatment was continuous and the study period lasted 12 months. Main outcome measures were the changes according to Wolfe classification between baseline and 12-month-mammograms.

Results: No increase in breast density was identified in any of the women in the control group. Two women (8%) in the CEE group showed an increase in breast density. Four women (11.8%) in the CEE/MPA and 11 women (31.4%) in the E2/NETA group revealed an increase in breast density. No woman in the therapy groups showed an involution of fibroglandular tissue while seven women (25.9%) in the control group exhibited involution of breast parenchyma.

Conclusions: Our study suggests that hormone replacement therapy may suspend breast involution but does not increase breast density in the majority of patients. In the minority of patients who show a density increase, the magnitude of this increase varies according to the regimen employed.

Keywords: Hormone replacement therapy; Mammography; Breast density

12. Breast pain and mammographic density increase as a consequence of raloxifene therapy

G.E. Christodoulakos, I.V. Lambrinoudaki, A.D. Vourtsi, K.P. Panoulis, G.C. Creatsas
Journal of Endocrinological Investigation 25:564-566, 2002
A 55-yr-old post-menopausal woman with osteopenia and no history of breast disease is presented. She was placed on raloxifene HCI 60 mg and soon after developed severe breast pain. The follow-up mammogram, performed prematurely at 6 months, showed a marked increase in breast density. Therapy was accordingly stopped and mastodynia subsided. The patient’s mammogram regressed to pre-treatment status after 6 months off-therapy.

11. CT appearance of solitary and multiple cystic and cavitary lung lesions

Α. Vourtsi, A. Gouliamos, L. Moulopoulos, X. Papacharalampous, A. Chatziioannou,
D. Kehagias, N. Lamki
European Radiology 2001;11:612-622
Cystic and cavitary lung lesions constitute a spectrum of pulmonary diseases diagnosed in both children and adults. We have reviewed the computed tomographic (CT) findings of the most common cystic and cavitary lesions and we have defined useful morphologic criteria that will help radiologists to distinguish benign from malignant cavitary lesions. However, in many cases the considerable overlap in morphologic features of benign and malignant cavities, renders transthoracic needle biopsy necessary to establish the correct diagnosis.

10. False negative mammogram

A. Vourtsi, F. Petrogiannis, X. Papacharalampous, A. Gouliamos, L. Vlachos
Where we Stand with Breast Cancer,
1999 Edited by Niki J. Agnantis, D.D. Tsiftsis
Although mammography is a valuable tool for the detection of breast cancer at an early or preclinical stage, something which results in the decrease of breast cancer deaths, still, a false negative mammogram remains a matter of deep concern.The factors which may affect a false negative mammography are the following: a benign o probably benign appearance, lesions visualized on only one of the two standard views, a location where visualization is difficult, mammographically occult breast lesions and interpretation error. A better understanding of these factors would enable a decreased percentage of the sequellae from a false negative mammographic study. This study investigates representatives cases of a false negative mammography and explains the significant traits which will help obviate a false negative mammographic reading. Mammographer can reduce the number of false negative mammographic readings by updating equipment, technical quality, and interpretation skills. However, it should be kept in mind that, in the presence of suspicious clinical findings, mammography is not a substitute for biopsy.

9. Liver invasion by recurrent granulosa cell tumour of the ovary: MR imaging findings

D. Kehagias, A. Vourtsi, L. Moulopoulos, E. Karvouni, L. Vlachos
European Journal of Obstetrics & Genecology
and Reproductive Biology 2000;89:63-67
Granulosa cell tumour of the ovary is a rare neoplasm of low malignant potential, late recurrences, local spread and high survival rates. We report the MR imaging appearance of invasion of the liver parenchyma by recurrent granulosa cell tumour of the ovary 15 years after initial diagnosis.

8. Rare cystic lesions of the abdomen and the pelvis: Imaging findings with pathologic correlation

D. Kehagias, E. Panourgias, A.C. Pafiti, L. Moulopoulou, A. Vourtsi, A. Gouliamos,
S. Trakadas, L. Vlachos
Hepato-Gastrenterology (In Press)
Cystic masses of the abdomen and the pelvis, originating from the mesentery, peritoneum and retroperitoneum are categorized into: a) congenital malformations, such as lymphangioma, enteric duplication cyst, enteric cyst, mesothelial cyst, lymphangioleiomyomatosis, cystic teratoma and retrorectal cyst hamartoma, b) inflammatory precesses, such as peritoneal echinococcus infection, c) benign tumours such as cystic mesothelioma and mucinous cystadenoma, d) malignant tumours such as peritoneal leimyosarcomatosis, malignant cystic fibrous histiocytoma, pseudomyxoma peritonei, peripheral primary neuroectodermal tumors, liposarcoma and cystic metastases and finally, e) other entities such as intramural bowel haemorrhage, appendiceal mucocele and nonpancreatic pseudocyst. In this article we present the imaging findings of these cystic appearing lesions correlated with the pathologic features. Although the radiologic findings are in many cases informative, in the majority of cases imaging findings are non-specific. Definite diagnosis of cystic masses of the abdomen and pelvis is often difficult and requires histologic confirmation.

7. Bone Lesions with Soft-Tissue Mass: Magnetic Resonance Imaging Diagnosis of Lymphomatous Involvement of the Bone Marrow Versus Multiple Myeloma and Bone Metastases

L. Moulopoulos, M.A. Dimopoulos, A. Vourtsi, S. Gouliamos, L. Vlachos
Leukemia and Lymphoma 1999;34:179-184
Bone metastases from solid primary tumours, as well as multiple myeloma and secondary lymphoma may all present with bone lesions and associated soft-tissue masses on magnetic resonance images of the spine. In bone metastases and myeloma, the cortex of the affected bone is usually destroyed and a bulging contour is observed at the site of extraosseous spread. In cases of lymphomatous involvement of the bone marrow, however, we have observed that spread to the extraosseous soft-tissues occurs without alternation of the shape or contour of the affected bone. In order to assess whether this pattern of spread is indeed suggestive or even diagnostic of lymphoma of the bone marrow, we reviewed spinal bone marrow MR images of 66 patients, with bone metastases from solid primary tumours (33 patients), multiple myeloma (20 patients) and stage IV lymphoma with bone marrow involvement (13 patients), who had bone lesions and contiguous soft-tissue masses. If tumour was present of either side of the bony cortex but the contour of the affected bone was preserved, a “wrap-around” sing was diagnosed. A “wrap-around” sign was found in 12 of the 13 patients with lymphoma but in none of the patients with metastases or myeloma. On MR images of the bone marrow, the demonstration of tumours spread beyond the bony cortex without disruption of the outline of the diseased bone may favour the diagnosis of lymphoma more than that of metastases or multiple myeloma.

6. Hepatic epithelioid hemangioendothelioma: MR imaging findings

D. Kehagias, L. Moulopoulos, A. Antoniou, V. Psichogios, A. Vourtsi, L. Vlachos
Hepato-Gastroenterology 2000;47(36):1711-3

5. Endovaginal color Doppler sonographic evaluation of ectopic pregnancy in women after in Vitro fertilization and embryo transfer

A. Vourtsi, A. Antoniou, T. Stefanopoulos, E. Kapetanakis, L. Vlachos
European Radiology, 1999;9:1208-1213
The aim of this study was to evaluate the value of endovaginal color Doppler ultrasonography in the early diagnosis of ectopic pregnancy in women after in vitro fertilization and embryo transfer, and to correlate the sonographic findings with β-hCG serum levels. Thirty-five patients had proven ectopic pregnancies and 4 other patients had heterotopic pregnancies. The diagnosis was disclosed correctly in all cases by endovaginal color Doppler US by identifying an adnexal mass with placental flow and a nongravid uterus called a “cold uterus”. An intrauterine sac with “double ring sign” was found in all normal intrauterine pregnancies when the hCG levels exceeded 1000 IU/Ibut in none of the patients with ectopic pregnancy (EP). These findings suggest the efficacy of the discriminatory hCG serum level of 1000 IU/I in the investigation of EP. In conclusion, this studydescribes the diagnostic importance of transvaginal color Doppler US in correlation with hCG serum levels in the early detection of EP avoiding life threatening complications and improving patient outcome.

4. Comparison of CT, MRI and CT during arterial portography in the detection of malignant hepatic lesions

D. Kehagias, A. Metafa, A. Hatjiioannou, D. Mourikis, A. Vourtsi, A. Prahalias,
V. Smyrniotis, A. Gouliamos, L. Vlachos
Hepato-Gastroenterology 2000,47(35):1399-1403
A prospective study was performed to compare the sensitivities of CT, MRI and CT during arterial portography (CTAP) in the detection of focal malignant hepatic lesions. Twenty-eight (28) patients with primary and secondary hepatic malignant tumours were evaluated. All of these patients underwent hepatic resection and a lesion –to- lesion imaging pathological analysis was performed. The overall sensitivities were 53% for CT, 66% for MRI sequences and 88% for CTAP. For lesions smaller than 1 cm the sensitivities were 6% for CT, 17% for MRI and 72% for CTAP. The combination of CTAP and MRI yielded an overall detection rate of 93%. The difference between the sensitivity of CTAP and that of the other two imaging techniques was statistically significant (p<0.04) according to the McNemar test. CTAP demonstrated four false-positive lesions, two of which were correctly characterized by MRI and one by CT. In six patients (21.4%) the surgical plan was modified after CTAP. We concluded that, CTAP has the highest sensitivity and should be part of the preoperative examination. In some instances, the addition of MR imaging must be considered complementary in the preoperative diagnostic algorithm.

3. Male breast myofibroblastoma and MR imaging finding. Report of a case

A. Vourtsi, D. Kehagias, A. Antoniou, A. Moulopoulos, E. Deligeorgi, L. Vlachos
Journal of Computer Assisted Tomography 1999 ;414-416
Myofibroblastoma of the breast is a rare benign tumor seen predominantly in men in the sixth to seventh decades of life. We present a case of breast myofibroblastoma in a man and describe the mammographic, sonographic and MR findings. To our knowledge, this is the only case of myofibroblastoma of the breast shown by MRI.

2. Langerhans cell histiocytosis with involvement of the pons. Case report

A. Vourtsi, A. Papadopoulos, L. Moulopoulos, J. Xenellis, L. Vlachos
Neuroradiology 1998 ;40 :161-163
Central nervous system involvement is uncommon in Langerhans cell histiocytosis. The suprasellar region is more frequently affected. There have been few reports of involvement of the brain parenchyma shown on CT or MRI. We present a case of involvement of the pons, showing marked contrast enhancement on MRI.

1. Abnormal enhancement in a case of a relapsing polychondritis

A. Vourtsi, A. Papadopoulos, J. Xenellis, S. Golfinopoulos, L. Vlachos
Annals of Otology, Rhinology & Laryngology 1998 ;107 ;81-82
Relapsing polychondritis is a rare disease of unknown cause, first described in 1923 by Jaksch-Wartenhorst. It is characterized by an inflammatory reaction primarily involving the cartilage of the nose, ears, joints and upper respiratory tract and occasionally abnormalities of the cardiovascular system. Fifty percent of the patients present sensorineural hearing loss, which is usually reversible with steroid therapy. We describe a case of a middle-aged woman with relapsing polychondritis and vestibulocochlear manifestations. Although enhancement of the membranous labyrinth has been described in several pathologic conditions of the inner ear, this is the first reported case of this finding in relapsing polychondritis, to our knowledge.

INTERNATIONAL CONFERENCES – MEETINGS

22. Cost analysis of Computer-Aided Diagnosis in Medical Imaging. Medical Physics Vol. 35, Νumber 6, June 2008. Proceedings of the 1st Educational Means for Biomedical Technology and Medical Physics post-graduate. Farsaris M, Skopelitis M, Vourtsi A, and Kallergi M.
Purpose: To design implement, and evaluate a computer aided diagnosis (CADx) algorithm for the benign/malignant differentiation of breast calcifications clusters that uses features defined from both breast views recorded with other screen/film (SF) or full field digital mamography (FFDM). Methods: Two sets of data were tested in this work. An SF set of 101 pairs of images consisting of CC and MLO views of the same calcification cluster and an FFDM set of 50 pairs. Regions of interest, 512×512 pixels in size were selected on each view and centered on the calcification cluster of interest. Eight different experiments were conducted with the SFM set and one experiment is in progress with the FFDM data. The SFM experiments involved different methods of feature estimation from the two views, different sets of features, as well as a single-view based classification for comparison purposes. Results: On the single-view run the classifier achieved an AZ=0.889 with 88% sensitivity and 77% specificity at an operating point of 0.4; 12 features were selected as the most important. On the two-view dataset, the classifier trained only with the CC views achieved the highest AZ=0.968 and a sensitivity=98%; 9 features were the most important in the case. When the average value of features from the two views was used, classification achieved an AZ=0.958 with a sensitivity and specificity of 98% and 80 respectively. Combinations of features from the two views surpassed the average value classifier yielding an AZ=0.976 with 96% sensitivity and 82% specificity. Conclusions: The combination of two-view information is instrumental in enhancing CADx performance but faces several challenges particularly in setting criteria of the optimum selection of features from the two views. Our method was transferred from film to digital without major modifications. FFDM results will be reported in the meeting.

21. The effect of estrogen, continuous combined hormone replacement therapy and tibolone on mammography

Irene Lambrinoudaki, G. Christodoulakos, C. Panoulis, S. Dendrinos, A. Vourtsi,
C. Papadias, G. Creatsas
2nd Department of Obstetrics and Gynecology, University of Athens, Aretaeion Hospital, Dionysos, Athens, Greece Maturitus,
44 Suppl. 2, S83-S166, 2003
Objectives: To evaluate the effect of estrogen, continuous combined hormone replacement therapy and tibolone on mammography. Methods: 153 postmenopausal women who had never received or were past users of hormone replacement therapy were studied prospectively. Women with an intact uterus were randomly allocated either to conjugated equine estrogens 0.625mg plus medroxyprogesterone acetate 5mg (CEE/MPA, n=34) or to 12β-estradiol 2mg plus norethisterone acetate 1mg (E2/NETA, n=35) or tibolone 2.5mg (n=32). Hysterectomized women received CEE 6.025mg (CEE, n=25). Women who either declined or did not qualify for treatment served as controls (n=27). Treatment was continuous and the study period lasted 12 months. Main outcome measures were the changes according to Wolfe classification between baseline and1 12-month mammograms. No increase in breast density was identified in any of the women in the control group. Two women (8%) in the CEE group showed an increase in breast density. Four women (11.8%) in the CEE/MPA and 11 women (31.4%) in the E2/NETA group revealed an increase in breast density. One woman in the tibolone group showed an increase in breast density (3.1%). Four women in the tibolone group (12.5%) and seven women in the control group (25.9%) exhibited involution of breast parenchyma. Concluding, our study suggests that hormone replacement therapy may suspend breast involution but does not increase breast density in the majority of patients. In the minority of patients who show a density increase, the magnitude of this increase varies according to the regimen employed. Tibolone, ot the other hand does not increase breast density and in some cases may promote involution of breast parenchyma.

20. The effect of various forms of hormone replacement therapy on the mammographic appearance of the breast

G. Christodoulakos, I. Lambrinoudaki, A. Vourtsi, C. Panoulis, L. Vlachos, G. Creatsas
2nd Department of Obstetrics and Gynekology, University of Athens, Aretaeion Hospital, Athens, Greece Amsterdam Menopause Symposium 2001
OBJECTIVE: to evaluate the effect of various regimens of hormones replacement therapy on the mammographic appearance of the breast in postmenopausal women over one year of therapy in comparison to mammograms of women receiving no therapy.
MATERIAL AND METHODS: The study group consisted of 121 postmenopausal women aged 38 to 66 years. Women were at least 2 years postmenopausal and either had never received HRT or were off-HRT for at least 9 months. Ninety-four women with climacteric complaints or risk factors for cardiovascular disease or osteoporosis received HRT. The remaining 27 women who either declined or did not qualify for HRT served as controls. In the HRT group, women with an intact uterus were randomly allocated either to conjugated equine estrogens 0.625mg plus medroxyprogesterone acetate (CEE/MPA) or to 17β-estradiol 2mg plus norethisterone acetate 1mg (17βE2/NETA). Hysterectomized women received CEE 0.625mg only. The study period was 12 months. Women were subjected to mammography at baseline and at the end of the study period. Mammographic evaluation was performed according to the modified Wolfe criteria by two expert radiologists who were blinded with respect to the study groups.
RESULTS: The study groups did not differ between each other with respect to baseline demographic parameters and baseline mammographic classification. No increase in breast density was identified in any woman in the control group. On the contrary, 2 women (8%) in the CEE group showed an increase in breast density over 12 months of therapy. Accordingly, 4 women (11.8%) in the CEE/MPA and 11 women (31.4%) in the 17βE2/NETA group revealed an increase in breast density at the end of the study period. No woman in the HRT groups showed an involution of fibrogladural tissue while 7 women (25.9%) in the control group exhibited involution of breast lesions.

19. Paraffinomas of the breast: Mammographic, ultrasonographic and MR apperances with histopathological correlation

D. Vourtsi*, A.D. Kelekis**, M. Kousaris***, L. Moulopoulos***, K. Kyriakou*
*Breast Department of Hygeia Diagnostic & Therapeutic Center
**B Laboratory of Radiology, University of Athens, Evgenideio Hospital
***Department of Radiology, Aretaeion Hospital, University of Athens
HSBCR 5TH International Congress November 2001, Athens Greece
Purpose: The purpose of the study is to evaluate the mammographic, ultrasonographic and MR appearances of breast paraffinoma, a late complication of breast augmentation, by direct injection of liquid paraffin wax into the breast.
Methods: Five women ranged in age from 34-42 years old with a history of paraffin oil injection for breast augmentation underwent Mammography, Sonography and MR imaging. A Sigma 1.5 – T clinical whole body image was used with a dedicated breast coil (General Electric Medical Systems). Results: On mammography paraffinomas appear as dense streaky opacities causing bizarre architectural distortion while of sonography, marked acoustic shadowing associated with dense fibrosis is noted. On T1-Weighted and T2-Weighted sequences paraffinomas appear with low signal intensity. On contrast enhanced T1-Weighted Fat suppressed sequences, paraffinomas appear markedly hypointense to fibroglandular tissue. Histology demonstrated hyalinized and densely sclerotic fibrous tissue with cystic spaces of various sizes.
Conclusion: Although useful for the diagnosis of paraffinomas, neither Mammography nor Sonography can be used to evaluate the surrounding breast tissue. We found that breast paraffinomas have characteristic MR appearance that correlates well histopathologic findings. In addition, MR imaging appears to be the best imaging technique for demonstrating the extend of paraffinomas and for detection of breast carcinoma in the surrounding breast tissue.

18. Doppler Perfusion Index in Benign and Malignant Liver Tumors

K. Kyriakopoulou, MD, Athens, Greece A. Vourtsi, MD, A.G. Antoniou, MD, E. Iliopoulou, MD, S. Lahanis, MD, S.J. Trakadas, MD
RSNA 2000, 86th Scientific Assembly Chicago, Illinois, USA
PURPOSE: To evaluate the Doppler Perfusion Index (DPI) of the liver in detecting benign and malignant hepatic lesions. METHOD AND MATERIALS: Sixty-eight patients (age 30-77y) after a 12 hours fasting period, had a liver Doppler sonogram. The common hepatic artery (HA) and the portal vein (PV) flow volume was recorded and the DPI of the liver was calculated as the ratio {HA flow volume}/{HA+PV FLOW VOLUME}. All patients had either an upper abdominal dual-phase spiral CT scan or a MRI scan of the liver. Forty-eight patients found to have benign tumors (26 solitary hemangiomas, 1 hypoechoic hemangioma, 1 hepatic abscess, 2 hepatic adenonas, 2 multiple hemangiomas, 10 cavernous hemangiomas, 1 hydatic cyst, 5 focal nodular hyperplasias) and 20 patients malignant tumors, (1 cholangiocarcinoma, 1 hepatoma, 18 metastases-7 ca breast, 1 ca esophageal, 1 carcinoid ca, 3 unknown primary, 2 lung ca, 4 colorectal carcinoma).
RESULTS: There was a significant increase, in the cross-sectional area and the blood velocity in the hepatic artery in the patients with overt hepatic metastases. Both the cross-sectional area and the time averaged mean velocity of the portal vein was
reduced in the group with confirmed hepatic involvement. The portal venous blood flow was also significantly reduced in the group with metastases. None of the above parameters correlated with age. In all cases with benign liver lesions the DPI value range was 0.10-0.16 in the males and 0.10-0.18 in the females with the exception of the hydatid cyst. In this case the DPI was 0.28. In the malignant liver lesions the DPI value range was 0.53-0.63 in the males and 0.52-0.62 in the females. The DPI measurements were independent of the size, the number and the location of the liver lesions. Spiral CT, MRI or Real Time Ultrasonograms were diagnostic for the hemangiomas, the primary and the metastatic tumors. In seven (7) cases biopsy was performed to establish the diagnosis of the FNH and multiple adenomas. CONCLUSIONS: Doppler Perfusion Index measurements may be used in the differential diagnosis of hepatic lesions as an adjunct to Real Time and Color Doppler ultrasound.

17. Vergleich bildgebender Verfahren bei Milzveranderungen

Deutsche Rontgengesellschaft Wiesbaden, Germany 2000
Ιατρικά Ανάλεκτα, Θεραπευτηρίου Υγεία Τεύχος 21,
Ιουλίος-Σεπτεμβριος 2003

16. Wertigkeit bildgebender Verfahren (US, MRT) bei Schulterge lenkerkrankungen klinische und operative korrelation.

Papacharalampous, X. Maris, J. Beck, A. Mundiger, A. Vourtsi, Papageorgiou A,
Vlahos L, Langer M.
RSNA 2000, 86th Scientific Assembly Chicago, Illinois, USA

15. Mammographic appearance of uncommon breast lesions

A. Vourtsi, G. Panagi, A. Gouliamos, F. Petrogiannis, D. Kehagias, L. Vlachos
European Congress of Radiology Vienna, Austria March 2000
The purpose of this exhibit is to present the radiologic findings of unusual conditions of the breast. We retrospectively assessed the radiologic findings in 15 patients diagnosed with uncommon breast lesions examined during January 1998 and August 1999. Patients were examined with mammography in conventional projections (n=15) and US (n=4). In 11 patients fine-needle aspiration biopsy (FNAB) was performed and surgery followed. Diagnosis included primary non-Hodgkin lymphoma (n=1), phyllodes tumors (n=4, tubular carcinoma (n=2), xanthomatous nodule (n=1), lipophagic granuloma (n=1), intraductal papilloma (n=1), radial scar (n=2), hamartoma (n=2), silicone granulomas (n=1) and reconstructed breast with a rectus abdominis musculocutaneous flap (TRAM) (n=1). In conclusion radiological awareness of unusual lesion characteristics allows the mammographer to set the grounds for the diagnosis with higher confidence.

14. Uncommon causes of sensorineural hearing loss: MRI appearance

A. Papadopoulos, A. Vourtsi, V. Maniatis, C. Sumara, S. Kavadias, K. Strigaris, L. Vlachos
XXV Congress and 9th Advanced Course of Neuroradiology
Vienna, Austria 1999
Idiopathic cases with no imaging findings of acoustic neuroma constitute the vast majority among patients with sensorineural hearing loss (SNHL). Demonstration of uncommon lesions responsible for SNHL is the purpose of this study. Over a period of 36 months, 146 patients with SNHL were examined. Axial SE T2-W images of the brain and axial and coronal pre- and post-Gd SE T1-W images of the petrous bonewere obtained. Complete audiologic and electronystagmographic studies were available. Patients with acoustic neuromas and meningeomas of the CPA were excluded form the study. MRI findings responsible for SNHL were visualized in ten patients: Two cases with secondary deposits in the IAC, one cochlear schwannoma, one case of pontine Langerhans cell histiocytosis, one case of autoimmune labyrinthitis one patient with relapsing polychondritis, one case of a large vestibular aqueduct syndrome, two cases of active otospongiosis, one case with Paget disease, and one with fibrous dysplasia. In conclusion, uncommon lesions of the petrous bone, membranous labyrinth and retrocochlear acoustic pathway may cause SNHL. MRI can suggest the correct diagnosis, and familiarity of the radiologist with the appearance of these conditions is mandatory.

13. Νεώτερες απεικονιστικές μέθοδοι στην διαγνωστική προσέγγιση παθήσεων του μαστού

A. Vourtsi, F. Petrogiannis, X. Papacharalampous, A. Gouliamos, L. Vlachos
Hellenic Society for Breast Cancer Research, Crete, Greece 1999
The purpose of this study is to review the mammographic appearance of various causes of a false negative mammography. A series of 16 false negative mammograms were retrospectively analyzed. The factors affecting the false negative mammography are classified into 1) benign or probably benign appearance, 2) lesions visualized on only one of the two standard views, 3) location where visualization was difficult, 4) mammographically occult breast lesions and 5) interpretation error. This exhibit illustrates representative cases of a false negative mammography and explains the significant traits that help obviate a false negative mammographic reading. In conclusion any indirect signs of malignancy scrupulously observed together with the optimization of radiographic technique and clinical findings are imperative in order to reduce the rate of a false-negative mammographic study.

12. The Role of Transvaginal Sonohysterography in the Assessment of the Uterine Cavity in Patients with Fertility Problems
του μαστού

A. Vourtsi, T. Stefanopoulos, A. Antoniou, D. Kehagias, E. Kapetanakis, L. Vlachos
European Congress of Radiology; Vienna, Austria 1999
The purpose of this study was to evaluate the role of transvaginal sonohysterograhy in the assessment of uterine abnormalities in infertility patients. Transvaginal sonohysterography was performed in 43 patients (aged 32-47 years) in whom conventional transvaginal sonography suggested intrauterine abnormalities either by endometrial thickening or abnormal morphology. In all cases the examination was performed by placing a small catheter into the endometrial canal and injection of 5-10cc of saline solution under sonographic visualization. Transvaginal sonohysterography depicted endometrial polyps (n=10), intracavitary fibroids (n=13), endometrial thickening (n=8), carcinoma (n=1) and normal cavities (n=11).
All patients underwent diagnostic hysteroscopy and in 1 case hysterectomy was performed. All findings diagnosed with tranvaginal sonohysterography corresponded to the results observed with hysteroscopy and hysterectomy. No complications occurred. In conclusion transvaginal sonohysterography using saline solution injected is a low-cost, easy and very sensitive procedure in the assessment of the uterine cavity, and we believe it should be the primary examination in evaluating patients with fertility problems.

11. Can MRI Suggests the Diagnosis in Lesions of the Temporal Bone?

A. Papadopoulos, A. Vourtsi, M. Douskou, E. Georgiadis, V. Vantali, C. Drossos
European Congress of Radiology; Vienna, Austria 1999
MRI has evolved as the imaging modality of choice in the evaluation of patients with sensorineural hearing loss. Uncommon lesions of the temporal bone may be demonstrated, with which the radiologists are not familiar yet. The purpose of this exhibit is to demonstrate the MR findings in some of these conditions. Two hundred and fifty MR examinations of the petrous bones were performed during the last two years. The imaging protocol consisted of axial SE PD/T2-W images of the brain and axial and coronal SE T1-W pre- and post-Gd and thin slice FSE T2-W images of the petrous bone. CT is available in most patients presented here. Lesions of the external and middle ear, membranous labyrinth and internal acoustic canal without involvement of the surrounding bony structures were excluded from the study. Presented are two cases of active otospongiosis, one of fibrous dysplasia, one with Paget disease, one chondrosarcoma, two cholesterol granuloma, one glomus jugulare tumor and two retention cysts. MRI may demonstrate specific findings in pathological conditions with involvement of the temporal bone. Familiarity of the radiologist with the radiologist with the imaging characteristics of these lesions will facilitate the correct diagnosis and obviate a further CT examination.

10. Benign vs. Malignant Cavitary Lung Lesions: Is it possible to be Distinguished by CT?

A. Vourtsi, M. Kousaris, L. Moulopoulos, A. Kalovidouris, A. Gouliamos, L. Vlachos
2nd Mediterranean Congress on Thoracic Diseases, Athens, Greece 1998
The aim of our study was to evaluate the CT characteristics of cavitary lung lesions and to attempt differentiation of benign from malignant lesions. We reviewed retrospectively 35 patients with solitary and multiple lung cavitary lesions. Of those 17 were malignant and 18 benign. Measurements of the thickness of the cavity wall and evaluation of the outer and inner margins were made on CT images. The precence of short tissue mass, intrapulmonary satellite lesions, infiltration of the thoracic wall and enlarged mediastinal lymph nodes were analyzed and compared with the histological findings. From the results of our study we found a higher incidence of a thin cavity wall, smooth inner and outer margin contour and intrapulmonary satellite lesions in benign cavities. A thick wall with irregularities in its border associated with or without a speculated soft tissue mass, infiltration of the thoracic wall and enlarged mediastinal lymph nodes were more frequent in malignant lesions. In conclusion although the radiological findings of cavitary lesions in 80% of cases suggested a benign of malignant etiology the clinical history and histological examinations remains
necessary in establishing the correct diagnosis.

9. The “Wraparound” sign: A Telltale Sign of Lymphoma of the Bone Marrow?

A. Vourtsi, L. Moulopoulos, A. Gouliamos, A. Kalovidouris, L. Vlachos
European Congress of Radiology; Vienna, Austria 1997
Secondary lymphomatous involvement of the spine may manifest as diffuse or focal marrow abnormality on spinal MR images. Extraosseous mass is often present. We have observed that, when paraspinal mass is present on MR images, the vertebral cortex, though enveloped by tumor, maintains its architecture without obvious signs of destruction. The purpose of this presentation is to illustrate this observation. We present 8 patients (7 men, 1 woman, age range 2-80 years) with biopsy proven secondary lymphoma of the marrow and spinal MR images. Five patients had diffuse and 3 had focal MR patterns of marrow involvement. All patients had paraspinal masses. In each patient, extraosseous tumor was “wrapped” around an apparently intact cortex. The “wraparound” MR sign is infrequently observed in patients with bone metastases. We believed that its presence in patients with lymphoma of the bone marrow reflects the permeative nature of lymphoma and that, when present, it should raise the possibility of this disease.

8. The Value of Gd-DTPA Enhanced MR Imaging in Patients with Unilateral Hearing loss

A. Vourtsi, A. Papadopoulos, J. Xenelis, N. Kanelis, K. Papafragou, A. Antoniou, L. Vlachos
European Congress of Radiology; Vienna, Austria 1997
The purpose of this study was to assess the role of Gd-enhanced MRI in patients with unilateral sensorineural hearing loss (SNHL). Sixty-five consecutive patients with an audiologically confirmed unilateral sensorineural hearing loss were included in the study. MR-examinations were performed on a 0.5 T scanner. First the patients underwent axial SE PD T2-W and sagittal SE T1W images of the whole brain in order to exclude retrocochlear lesions. SE T1W axial and coronal images of the petrous bones were obtained before and after administration of Gd-DTPA. The most common finding was multiple high-signal intensity lesions located in the white matter of the brain, found in 8 patients. They were attributed to microvascular leukoencephalopathy in 6 patients and demyelinating disease in 2 patients. In another patient with documented Langerhans cell histiocytosis a mass like lesion was demonstrated in the pontine region. Enhancement of the membranous labyrinthwas observed only on post-Gd images in two patients with a cochlear schwannoma and relapsing polychondritis respectively. We believe that the use of Gd-DTPA increases the capability of MR imaging for detecting lesions along the acoustic pathway especially those located in the membranous labyrinths and IACs and we would suggest that in patients with complex presentation G-d enhanced MR images should always be obtained.

7. Cholesterol Polyps of the Gallbladder Wall Less Than 2cm: Review of 12 years

M. Tzalonikou, A. Antoniou, A. Vourtsi, A. Pafiti, G. Polymeneas, E. Kapsalaki
European Congress of Radiology; Vienna, Austria 1997
The purpose of this study was to review the clinical, ultrasonographic and histopathological features of cholesterol polyps less than 1 cm in 3.500 patients. Seventy thousand patients underwent abdominal ultrasound examination in our institution over a 12-year period. 3.500 patients were found to have polypoid lesions of the gallbladder smaller than 1 cm in diameter. In 60% of the cases more than one lesion was found. In most of the cases (80%) there was no correlation to clinical symptoms and was an incidental finding. In 70% of the cases various types of hyperlipidemia coexisted. 144 patients underwent cholecystectomy. 81 patients were followed at regular time intervals in the group of surgically and histologically proven 144 cases, gallstones coexisted in 70% of the cases, single cholesterol polyp in 80% and multiple in 20%. In this group 40% of the patients developed gallstones at different time intervals (5-8 years). In two cases a true adenoma was found. 81 cases are followed over a period of 12 years and no significant change in the number and diameter of the lesions was found. Simple or multiple cholesterol polyps of less than 1 cm is usually an incidental finding, which is found in hyperlipidemic patients.

6. Ectopic Pregnancy in Women at High Risk: Diagnostic Value of Endovaginal Sonographic Findings Correlated with Human Chorionic Gonadotropin Levels.

T. Stefanopoulos, A. Vourtsi, A. Antoniou, M. Tzalonikou, K. Kapetanakis, A. Papadopoulos, L. Vlachos
European Congress of Radiology; Vienna, Austria 1997
The purpose of this study was to determine the value of endovaginal color and duplex sonography in the early diagnosis of ectopic pregnancy (E.P.) in women at high risk and to correlate the sonographic findings with serum drawn for measurement of human chorionic gonadotropin (hCG) and progesterone levels. During a 2 ½ year period (January 1994 – July 1996) we studied a group of 300 pregnant women after assisted reproduction as early as 3-4 weeks after conception. All patients had serum drawn for measurement of hCG and progesterone levels and studied endovaginally using color duplex sonography. Of the 300 women studied 39 had an ectopic pregnancy. The diagnosis of E.P. was based on real-time findings as well as on the recognitionof placental blood flow on color duplex sonography. Patients with positive scans were referred for laparoscopy. In all patients with EP, hCG values were above 1000mIU/Ml and progesterone levels increases the diagnostic sensitivity to 100% in the early scanning of a population at increased risk for EP.

5. Transthoracic Fine Needle Biopsy of Peripheral Lung Lesions

M. Tzalonikou, A. Vourtsi, M. Kousaris, D. Farsaris, A. Moulopoulos, A. Kalovidouris,
A. Gouliamos, L. Vlachos
7th European International Symposium Organized by the Aristoteles Institute; Thessaloniki, Greece 1997
This is retrospective study of 62 cases with peripheral lung lesions and previous non diagnostic bronchoscopy. Criteria for patient selection included: 1) broad angle to the pleura lung lesions 2) narrow-angle to the pleura lung lesions, 3) subpleural nodules. The lesion was localized under CT-guidance and were punctured by fine needle (19-22G) for aspiration of cellular material. The percentage of positive results for malignancy, primary or secondary was 59.7% (37 out of 62 cases). In the remaining 40.3% benign lesions were diagnosed. Fine needle aspiration (FNA) under CT guidance, is extremely helpful in the diagnosis of peripheral malignant lesions and facilitate the diagnostic work-up.

4. Transthoracic Fine Needle Aspiration Biopsy (TFNAB) of Small Pulmonary Nodules

M. Tzalonikou, A. Vourtsi, M. Kousaris, D. Farsaris, V. Dendropoulou, A. Moulopoulou,
A. Kalovidouris, A. Gouliamos, L.Vlachos
7th European International Symposium Organized by the Aristoteles Institute; Thessaloniki, Greece 1997
The aim of this study is to evaluate the accuracy of TFNAB in patients with small pulmonary nodules and to determine the percentage of malignancy in this group of patients. Patients with solitary or multiple pulmonary nodules less that 3cm in diam were selected. The site of the lesion was localized under Ct-guidance. A 19-22G fine needle was used for aspiration. In 41.66% of the cases malignancy was diagnosed. In 5% the pathologic findings were considered suspicious for malignancy. The percentage of lesions of benign etiology was 23.33%. In the remainder 30% of the cases no definite diagnosis could be obtained from the study of the pathologic specimen. CT-guided biopsies by TFNAB can produce diagnostic accuracy comparable with published results of the method in larger pulmonary lesions.

3. Correlation of Thrombosis Between Superficial Femoral Vein (SFV), Common Femoral Vein (CFV) and Popliteal Veins (Pvs).A Follow-up Study With Duplex Scanning

L. Livieratos, G. Zavras, A. Vourtsi, S. Pantou, C. Haritidis, M. Christoforidis, P. Panousis
International Congress of Phlebology Corfu, Greece 1996
The purpose of this study was to evaluate the incidence of SVG thrombosis in patients with thrombosis in the CFV and popliteal veins. One hundred twenty two limbs in 61 patients were examined by Duplex Ultrasonography including forty-seven limbs with fractures of the femur and tibia. The patients were classified in 3 groups on the basis of the site involved (thrombosis of the common femoral vein, the popliteal vein and of both the common femoral and the popliteal veins). In the initial examination Deep Vein Thrombosis (DVT) was diagnosed in 89 limbs, in the rest 33 limbs thrombosis was not identified. Thirty-seven limbs had common femoral vein thrombosis which also involved the superficial femoral vein. Twenty-five limbs had thrombosis of the popliteal vein. Twenty-seven limbs had common femoral vein thrombosis which also involved the superficial femoral vein. Twenty-five limbs had thrombosis of the popliteal vein. Twenty-seven limbs presented with thrombosis of both the common femoral and the popliteal veins. There is a high incidence of superficial femoral vein thrombosis that accompanies the thrombosis of the common femora and popliteal veins. Thereforethe evaluation of the SFV, should be avoided in patients with trauma or fractures of the lower limb with thrombosis of CFV and PVs.

2. The Value of Color Doppler Flow Sonography in Depicting the Post-operative

L. Livieratos, G. Zavras, A. Vourtsi, G. Theodorakopoulos, B. Andrikopoulos,
A. Psaroudakis, P. Panousis
International Congress of Phlebology Corfu, Greece 1996
A prospective study was conducted with color – flow Doppler sonography to document remnants for the LSV and perforating veins after surgical management of the long saphenous vein. Fifty-nine limbs in 55 consecutive patients with excision of the long saphenous vein were studied. They were all out patients and their major complaint was persistent pain in the medial aspect of the leg extending to the ankle. The following branches of the LSV and perforating veins were identified: Deep branch of the tibia in 8 limbs, anterior branch in the femur in 12 limbs, anterior branch in the tibia in 15 limbs, posterior branch in the tibia in 13 limbs, both the anterior and posterior branches in the tibia in 9 limbs, 3 pairs of incompetent deep perforating veins were found proximal to the knee, 21 pairs of incompetent deep perforator veins were detected in the proximal portion of the tibia and finally venous insufficiency of the superficial system was present in 42 limbs. These data suggest that color-flow Doppler sonography is an efficient and accurate method for depicting post-operative remnants of the LSV and popliteal veins, and should be used in routine base for pre-operative mapping of the long saphenous vein.

1. The value of Gd-Enhanced MRI in the Investigation of Sudden Hearing Loss

A. Papadopoulos, A. Vourtsi, N. Kanelis, L. Vlachos, J. Xenelis,
B. K. Papafragou, G. Adamopoulos
Roentgen Centenary Congress Birmingham, England 1995
Recent reports describe labyrinthine enhancement as a highly specific sign of labyrinthine disease, but the sensitivity of this finding has not been reported. In a prospective study we investigated 59 patients with sudden sensorineural hearing loss to elucidate the role of Gd-enhanced MRI in depicting labyrinthine damage. We studied 59 patients with sudden sensorineural hearing loss of less than 1 month duration. Clinical and laboratory evidence of damage at the cochlear level were present in all patients. MR-examinations were performed on a 0.5T scanner, SE T1 weighted axial and coronal images of the petrous bones were obtained before and after administration of GD-DTPA. Enhancement of the membranous labyrinth was observed in only on e patient with a cochlear schwannoma that extended into the fundus of the internal acoustic canal. In two more patients MRI demonstrated causes of their sudden hearing loss: a case of large vestibular aqueduct syndrome and an acoustic neuroma of the cerebellopontine angle. Although specific, labyrinthine-enhancement seems to be an infrequent sign in cases of labyrinthine disease. However, imaging of the acoustic pathway is necessary in patients with sudden cochlear hearing loss, as audiologic testing may fail in localizing the pathological lesion precisely.