Controlled introduction of the sentinel node biopsy in breast cancer in a multi-centre setting: the role of a coordinator for quality control.

AIMS: It is proposed that sentinel node biopsy should replace axillary lymph-node dissection. We analysed the role of a coordinator in the introduction of the sentinel node biopsy in breast cancer in a multi-centre setting to assure standardization and quality control. METHODS: We included 232 operable breast cancer patients. Part of the procedure was an ultrasound examination of the axilla with fine needle aspiration cytology. The sentinel node was identified with 99m-Technetium and Patent Blue. RESULTS: The results of the procedure, sensitivity and false negativity, were the same for the three participating hospitals. We think this is mostly due to the coordinator who supplied information about the technique, pitfalls and results to all teams. CONCLUSIONS: Our experience regarding the organization aspects of introducing the sentinel node procedure in a multi-centre setting now serves as a model in organizing its application in a much wider number of hospitals.

Lymphedema and lymphocysts following lymphadenectomy may be prevented by omentoplasty: A pilot study.

OBJECTIVES: Pelvic lymph node dissection as part of the staging surgery for cervical carcinoma interrupts the afferent lymphatics, so the lymph drains retroperitoneally. New surgical techniques designed to leave the peritoneum open after the retroperitoneal dissection, in particular the application of a pedicled omentoplasty along the dissection route, have been advocated to prevent the formation of lymphocysts and lymphedema. We investigated the possible benefit of pedicled omentoplasty in preventing lymphocysts and lymphedema following pelvic lymph node dissection. METHODS: In this pilot study with historical controls we compared the formation of lymphocysts and lymphedema following two different surgical techniques for pelvic node dissection: group I (historical controls), in which the dorsal peritoneum was left open, and group II, in which the dorsal peritoneum was left open with application of a pedicled omentoplasty. In these two groups of gynecologic patients, we compared the lymph flow patterns and the occurrence of lymphedema following systemic pelvic lymphadenectomy. The two groups were of comparable clinical status and consisted of 12 (group I) and 10 (group II) patients. Lymphocysts, if any, were detected by CT scan, the lymph flow patterns were visualized by dynamic lymphscintography, and lymphedema was visualized by physical examination and magnetic resonance imaging of the groin and the upper leg. RESULTS: In both groups a distinct intraperitoneal absorption of the lymph fluid was observed. Pedicled omentoplasty seemed to facilitate the absorption or transport of lymph fluid, resulting in less lymphedema in the upper leg. CONCLUSION: It appeared that leaving the dorsal peritoneum open to give the lymph stream the opportunity to pour into the abdominal cavity is important in preventing lymphocysts and lymphedema. The dynamic lymphscintigraphy described in this paper showed that the intraabdominal lymph flow is absorbed by the peritoneum and even more quickly by the pedicled omentum.

CT-guided bone biopsy in a cancer center: experience with a new apple corer-shaped device.

In this article we report our experience with CT-guided bone biopsy (CTGBB) using a new nondisposable bone biopsy device with in a uniform protocol for all lesions and compare our results with data from bone biopsies obtained with other techniques. With this biopsy device, the specimen is collected in a 20 x 2 mm chamber of an apple corer-shaped needle. In 46 consecutive cancer patients that were candidates for bone biopsy, 50 CTGBB procedures were performed and analyzed. Lesions with cortical defects and/or surrounding soft tissue infiltration were excluded. There were no complications. Of 50 CTGBB procedures, 90% were diagnostic. Four of the five inconclusive biopsies were repeated: All were conclusive, one malignant. Of 19 with CT-indistinguishable lesions (detected on MRI or isotope studies), 35% were malignant. Thirty-eight percent of the lesions were not accompanied by pain. The procedure was less painful than injection of the local anesthetic prior to biopsy in 90% of the cases. With the new device, CTGBB procedures can be carried out safely. Biopsy with the described technique has a high diagnostic output, better results than those of biopsy with reported uniform techniques, and equal results to the best results of combined techniques. If a lesion is not distinguishable on CT and/or not accompanied by pain, malignancy is not ruled out. CTGBB in the described technique is less or equally time consuming, less painful, and cheaper than reported for other bone biopsy procedures.

The value of ultrasound with ultrasound-guided fine-needle aspiration biopsy compared to computed tomography in the detection of regional metastases in the clinically negative neck.

PURPOSE: Head and neck oncologists have not reached consensus regarding the role of contemporary imaging techniques in the evaluation of the clinically negative neck in patients with head and neck squamous cell carcinoma (HNSCC). The purpose of the present study was to compare the accuracy of ultrasound with guided fine-needle aspiration biopsy (UGFNAB) and computed tomography (CT) in detecting lymph node metastasis in the clinically negative neck. METHODS AND MATERIALS: Sixty-four neck sides of patients with HNSCC were examined preoperatively by ultrasound/UGFNAB and CT at one of five participating tertiary care medical centers. The findings were correlated with the results of histopathologic examination of the neck specimen. RESULTS: Ultrasound with guided fine-needle aspiration biopsy was characterized by a sensitivity of 48%, specificity of 100%, and overall accuracy of 79%. Three cases had nondiagnostic aspirations using UGFNAB and were excluded. CT demonstrated a sensitivity of 54%, specificity of 92%, and overall accuracy of 77%. UGFNAB detected two additional metastases not visualized on CT, whereas CT detected no metastases not seen on UGFNAB. The results of UGFNAB were similar between the participating centers. CONCLUSIONS: Approximately one half of the clinically occult nodal metastases in our patient group were identified by both CT and UGFNAB. Overall, UGFNAB and CT demonstrated comparable accuracy. The sensitivity of CT was slightly better than UGFNAB, but the latter remained characterized by a superior specificity. The results of CT and UGFNAB did not appear to be supplementary. The choice of imaging modality for staging of the clinically negative neck depends on tumor site, T-stage, and experience and preference of the head and neck oncologist. If CT is required for staging of the primary tumor, additional staging of the neck by UGFNAB does not provide significant additional value.

Regional metastasis in head and neck squamous cell carcinoma: revised value of US with US-guided FNAB.

PURPOSE: To verify the acclaimed accuracy of ultrasound (US) combined with US-guided fine-needle aspiration biopsy (FNAB) in the detection of lymph node metastasis in the neck and to evaluate the interobserver variability. MATERIALS AND METHODS: In a prospective, multicenter study of 185 patients with head and neck squamous cell carcinoma, US (n=238 neck sides) with US-guided FNAB (n=178 neck sides) was used for evaluation of the lymph node status of the neck. Findings were correlated with those of histopathologic examination in 238 neck sides. RESULTS: US with US-guided FNAB had a sensitivity of 77% and a specificity of 100%. Nineteen of 178 aspirations were nondiagnostic. There were no significant differences between the four participating hospitals or the individual sonologists (P>.05). CONCLUSION: Sensitivity of US with US-guided FNAB was slightly lower compared with previous reports. Specificity was similar to previous reports. Interobserver variability appeared to be low. The validity of US with US-guided FNAB is high and warrants widespread use of the procedure for evaluation of the neck.

Biopsy of nonpalpable cervical lymph nodes: selection criteria for ultrasound-guided biopsy in patients with head and neck squamous cell carcinoma.

This article is designed to find an appropriate policy to select nonpalpable cervical lymph nodes in head and neck squamous cell carcinoma patients for ultrasound-guided aspiration biopsy (USB). According to the literature, generally used selection criteria are width of nodes > 10 mm, length-to-width ratio > 2 and absent echo-rich hilum. In 562 nonpalpable nodes of 355 patients (mean age 60 y, range 20-92 y) with head and neck squamous cell carcinoma, a USB procedure was carried out. Nodes were classified according to dimensions and to echo pattern. Representative cytology was obtained in 489 nodes; 112 were classified as malignant. Of the 412 nodes with a width < or = 10 mm, 79 were malignant. Width is the strongest predictor for malignancy and, if corrected for width, the length-to-width ratio is of no influence. Of the 142 nodes with an echo-poor centre, or an inhomogeneous pattern, 46% were malignant, compared to 13% of 342 nodes with an echo-rich centre. It is concluded that selection of lymph nodes of the neck of patients with squamous cell carcinoma of the head and neck should be based on width and echo pattern. We advise subjecting nodes with an echo-rich centre or homogeneous pattern and a width > or = 4 mm to USB, and also subjecting nodes with an echo-poor centre or inhomogeneous pattern with a width > or = 3 mm to USB.

Anterior rectocele: assessment with radiographic defecography, dynamic magnetic resonance imaging, and physical examination.

PURPOSE: The aim of this study was to devise a measuring method for an anterior rectocele on standardized defecographies and magnetic resonance images (MRI) to quantify anterior rectocele and to test whether this could substantiate clinical decision making for operative treatment for anterior rectocele. METHODS: Quantitative analysis by the measuring method as proposed was compared with qualitative scores on defecographies and MRI from the same patients. Thirty-eight patients with symptoms compatible with an anterior rectocele were subjected to physical examination in the left decubitis position and supine position and to defecography. Findings on defecography were compared with findings on physical examination. Thirteen patients were examined before and after surgical correction of the anterior rectocele for a total of 51 qualitative and quantitative examinations. The group of operated patients was analyzed for treatment results. Nineteen controls were included. RESULTS: Sixty-six radiographs of 33 defecographies were qualified in three grading classes and quantified with the proposed method by two observers. The mean measured value of the anterior rectocele in the three subjective grading classes is significantly different (P < 0.001). Anterior rectoceles qualified as severe had a measured value of 20 mm or more in 96 percent of the radiographs. Lower gradings were never > 20 mm. On MRI severe anterior rectoceles were not scored and measured values did not correlate with qualitative scores. When findings on physical examination were compared with defecographic measurement, the coefficient of correlation (r) between the radiologic assessment and clinical examination in the left decubitis position is r = 0.87, for the examination in the supine position, r = 0.77. All 15 cases scored as severe anterior rectocele in the left decubitis position had a measured anterior rectocele of > or = 20 mm. In the 13 cases that received surgery, there was a significant reduction of the anterior rectocele (P < 0.001) and clinical improvement. Patients with small or moderate anterior rectocele on physical examination with a size > or = 20 mm on defecography were cured by surgical correction. None of the controls had an anterior rectocele on physical examination or an anterior rectocele > or = 20 mm on defecography. CONCLUSIONS: An anterior rectocele with a size of 20 mm or more corresponds with a qualitative score of "severe" on radiographic defecography. Physical examination for anterior rectocele in the left decubitis position corresponds best with quantitative radiographic assessment and anterior rectocele with a size > or = 20 mm on defecography is pathologic. Patients with complaints compatible with anterior rectocele can be assessed in objective and quantitative terms by radiography and can be successfully surgically treated, even if at physical examination the anterior rectocele is not classified as large, provided that dynamic defecography shows an anterior rectocele of > or = 20 mm. The potential of dynamic MRI with regard to anterior rectoceles presently seems absent.

Renal masses: value of duplex Doppler ultrasound in the differential diagnosis.

In a prospective study, 84 nonanechoic renal masses were examined with duplex Doppler ultrasound with a 3.5 mHz. transducer. This study included malignant lesions in 49 cases (30 renal carcinomas, 9 metastases, 8 lymphomas and 2 sarcomas) and benign lesions in 35 (18 complicated cysts, 6 inflammatory processes, 5 columns of Bertin, 3 angiomyolipomas and 3 hematomas). We analyzed whether duplex Doppler ultrasound can have a role in the differential diagnoses of these solid renal masses. Renal carcinomas demonstrated Doppler shifts of 2.5 kHz. or more in 23 cases (77%). These masses had significantly higher Doppler shifts than all of the other malignant masses (p < 0.001). Among the benign lesions the Doppler shifts were less than 2.5 kHz. in 33 cases (84%). The 2 masses with a Doppler shift of more than 2.5 kHz. in this group were inflammatory lesions. Detection of a Doppler shift of 2.5 or greater in a renal mass supports suspicion of a renal cell carcinoma, although an inflammatory process may also produce such a high Doppler shift. Doppler shifts of less than 2.5 kHz. in solid renal masses support the diagnoses of a benign lesion and a malignant lesion other than renal cell carcinoma.

Solid breast neoplasms: differential diagnosis with pulsed Doppler ultrasound.

In this prospective study, duplex Doppler ultrasound was used in 95 consecutive patients with solid breast masses to evaluate the presence of neovascular flow. A positive Doppler signal, i.e., a Doppler shift frequency of more than 1 kHz using a 5 MHz insonating frequency, was found in 34 of 57 patients with a carcinoma, and also in three patients with a benign condition. These results indicate that negative findings with pulsed Doppler ultrasound cannot be used to exclude malignancy. However, a frequency shift of more than 1 kHz indicates a high probability for malignancy. In our study a high frequency shift was not related to tumor size. We also evaluated the correlation between a high frequency shift and axillary nodal metastasis. According to our results there is a very low chance of axillary metastasis when no high frequency shifts are found.

Defecography and anorectal manometry.

In a prospective study anorectal manometry was performed in 160 consecutive patients who were referred for defecography. Leakage of contrast material of standardized viscosity, the anorectal angle (ARA), anal resting pressure (Pr) and squeeze pressure (Ps) were measured and analyzed. This was done to investigate the role of ARA on rectal continence during defecography and to investigate whether relevant findings of manometry can be predicted from findings at defecography as part of the diagnostic work-up in selected patients in order to avoid manometry in these patients. The ARA was of significance in maintaining rectal continence for the contrast medium (P = 0.008). With increasing leakage, Pr and Ps decreased significantly (P less than 0.001). In all fully incontinent patients (n = 36) Ps was distinctly below normal values. Manometry can be avoided in these patients if the level of Pr is not important for therapeutic strategy.

Vascularization of left kidney by single vessel originating from splenic artery.

According to the literature, sole renal arteries always originate from the aorta. In multiple renal arteries, the origin of an accessory renal artery may be expected from the splenic artery on theoretical basis. This origin, however, never is described. A patient is presented with a sole left renal artery, originating from the splenic artery. The diagnosis is made by angiography and confirmed by computed tomography and surgery.

Normal anorectum: dynamic MR imaging anatomy.

In this study, the anatomy of the anorectum in relation to the surrounding structures and the anorectal angle were analyzed with magnetic resonance (MR) imaging at rest, during perineal contraction, and during straining in 10 asymptomatic subjects. The intra- and inter-observer and intra- and interpatient variations in the measurements of the anorectal angle, position of the anorectal junction, and position of the plica of Kohlrausch in the rectum were established at rest, during perineal contraction, and during straining. The values for the anorectal angle and position of the anorectal junction obtained with MR imaging were compared with standard radiography defecography findings. It was shown that MR imaging has the potential for measuring these parameters in a more precise and more patient-friendly way than defecography. Unlike dynamic defecography, MR imaging is able to depict the mobility of the posterior rectal wall. A descent of over 20 mm from rest to straining should be considered pathologic. This finding might play a role in patient selection for operation.

The effect of posterior rectopexy on fecal continence. A prospective study.

Twenty-three patients with rectal prolapse or intussusception were studied to specifically focus on the effect of posterior rectopexy on fecal continence, anal pressure, and rectal capacity. Before operation, five patients were fully continent (A), 10 were continent for solid stools (B) and eight patients were fully incontinent (C). Group A remained fully continent; continence was regained nine times in group B and in group C, three patients regained full continence, two became continent for solid stools, three patients remained incontinent. Other symptoms such as constipation, false urgency, and a feeling of incomplete evacuation were not beneficially influenced by rectopexy. The patients' continence status was correlated to anorectal manometry and rectal capacity measurement. In group B, incremental pressure (P = squeeze - basal P) increased significantly (P less than 0.02) as well as incremental volume (V = maximum tolerated volume - volume of first sensation) (P less than 0.05). We conclude that, by an increase of incremental anal pressure and incremental rectal volume, posterior rectopexy offers an 83 percent chance of regaining full continence, or a major improvement, and a 17 percent chance of stabilization of fecal incontinence.

Kock pouch urinary diversion: follow-up by ultrasound.

In the post-operative follow-up of 24 patients who received a continent Kock pouch for urinary diversion, several complications were encountered, including hydronephrosis, stone formation and valve dysfunction, resulting in reflux and/or urinary incontinence. After comparing findings on ultrasound with those obtained by Koch pouch cystography, intravenous urography, plain abdominal radiography, Kock pouch endoscopy and operation, we consider ultrasound to be an important technique in the follow-up, especially in non-symptomatic patients. All cases of hydronephrosis and pouch calculi were detected by ultrasound and no false positive findings were encountered in either group. A good correlation is demonstrated between nipple length, as measured by ultrasound, and valve dysfunction, clinically important only for the afferent nipple.