Repeated surgeries in invasive lobular breast cancer with preoperative MRI: Role of additional carcinoma in situ and background parenchymal enhancement.

OBJECTIVES: Analysing the influence of additional carcinoma in situ (CIS) and background parenchymal enhancement (BPE) in preoperative MRI on repeated surgeries in patients with invasive lobular carcinoma (ILC) of the breast. METHODS: Retrospective analysis of 106 patients (mean age 58.6±9.9years) with 108 ILC. Preoperative tumour size as assessed by MRI, mammography and sonography was recorded and compared to histopathology. In contrast-enhanced MRI, the degree of BPE was categorised by two readers. The influence of additionally detected CIS and BPE on the rate of repeated surgeries was analysed. RESULTS: Additional CIS was present in 45.4% of the cases (49/108). The degree of BPE was minimal or mild in 80% of the cases and moderate or marked in 20% of the cases. In 17 cases (15.7%) at least one repeated surgery was performed. In n=15 of these cases, repeated surgery was performed after BCT (n=9 re-excisions, n=6 conversions to mastectomy), in n=2 cases after initial mastectomy. The initial surgical procedure (p=0.008) and additional CIS (p=0.046) significantly influenced the rate of repeated surgeries, while tumour size, patient age and BPE did not (p=ns). CONCLUSIONS: Additional CIS was associated with a higher rate of repeated surgeries, whereas BPE had no influence.

MR imaging-guided vacuum-assisted breast biopsy: reduction of false-negative biopsies by short-term control MRI 24-48 h after biopsy.

AIM: To evaluate whether another contrast-enhanced (CE) magnetic resonance imaging (MRI) examination 24-48 h after MRI-guided vacuum-assisted breast biopsy (MRI-VAB) can reduce the rate of false-negative cases. MATERIALS AND METHODS: The study included 252 patients who underwent MRI-VAB for the clarification of 299 lesions. The success of MRI-VAB was assessed at interventional MRI and another CE MRI 24-48 h after the intervention. In cases of successful MRI-VAB (complete or partial lesion removal) and benign histological results, follow-up breast MRI was performed. In cases of unsuccessful biopsy (unchanged lesion), tissue sampling was repeated. False-negative cases were calculated to assess the diagnostic value of MRI follow-up within 2 days after intervention. RESULTS: Ninety-eight malignant (32.8%) and 201 (67.2%) benign lesions were diagnosed using MRI-VAB. At immediate unenhanced control MRI, all lesions were assessed as successfully biopsied. In 18 benign cases (6%), CE MRI after 24-48 h showed an unsuccessful intervention. Further tissue sampling revealed another 13 cancers in these patients. This results in a false-negative rate of 11.7%. Follow-up MRI of the benign lesions presented no further malignancy. CONCLUSIONS: MRI-VAB with immediate unenhanced control offers a success rate of 94%. The rate of false-negative biopsies (11.7%) could be reduced to zero by using short-term follow-up MRI. Therefore, a further CE breast MRI 24-48 h after benign MRI-VAB to eliminate missed cancers is recommended.

Management of breast lesions detectable only on MRI.

UNLABELLED: Breast MR imaging has become established as the most sensitive imaging method for diagnosing breast cancer. As a result of the increasing examination volume and improved image quality, the number of breast lesions detected only on MRI and requiring further clarification has risen in recent years. According to the S3-guideline "Diagnosis, Therapy, and Follow-Up of Breast Cancer" as revised in July 2012, institutions performing breast MRI should provide the option of an MRI-guided intervention for clarification. This review describes the indications, methods and results of MRI-guided interventions for the clarification of breast lesions only visible on MRI. Recent guidelines and study results are also addressed and alternative methods and pitfalls are presented. KEY POINTS: ▶ Up to 57 % of lesions originally visible only on MRI can be sonographically correlated and biopsied. ▶ MRI-guided intervention is necessary for the clarification of BI-RADS® 4 and 5 lesions detectable only on MRI ▶ MRI-guided vacuum-assisted breast biopsy should be preferentially used ▶ MRI-guided localization and surgical excision should be used if MRI-guided vacuum-assisted biopsy is not possible ▶ If BI-RADS® 4 and 5 findings visible only on MRI are not detectable on interventional MRI, a follow-up MRI should be performed within six months.

Executive functions recover earlier than episodic memory after microsurgical transsphenoidal resection of pituitary tumors in adult patients--a longitudinal study.

Pituitary tumors may lead to cognitive dysfunction, and the most prevalent deficits are impaired memory and attention. To investigate whether memory and executive functions improve after surgical treatment we performed a prospective longitudinal study comprising 106 patients with pituitary tumors. Psychometric evaluation was performed with the d2-Letter Cancellation test, the Trail Making test, the Digit Span test and the Intelligence Structure test-Verbal Memory test at three timepoints: preoperatively, and at 3 months and 12 months after surgery. The preoperative and postoperative maximum suprasellar tumor extension and hormone status was assessed in all participants. The main finding was that concentration, working memory, and attentional speed improved significantly within the first 3 months after surgery (p<0.05), while improvement of episodic memory was not observed until 12 months after surgery (p<0.001). In the patients harbouring non-functioning adenomas, prolactinomas or other sellar lesions, the most important factor promoting improvement of neurocognitive function was the removal of the suprasellar tumor extension.

Demographic factors and the presence of comorbidities do not promote early detection of Cushing's disease and acromegaly.

OBJECTIVE: The aim of the study was to analyze the time-to-diagnosis interval in patients with Cushing's disease (CD) and acromegaly (AC), to assess factors that promote early disease detection and to investigate the medical fields diagnosing the pathologies. METHODS: 33 CD and 52 AC patients operated over 10 years received a self-designed disease-related questionnaire. Data about symptoms and their duration prior to diagnosis, education level, age, gender and place of residence (i. e. rural vs. urban, size of the city) were collected. RESULTS: The mean time-to-diagnosis interval was 6.0 years in CD and 5.8 years in AC patients. The vast majority of 67% of all investigated patients was diagnosed after they changed their primary health care provider or during a hospital stay owing to comorbidities caused by their underlying disease. Only 33% of all cases were diagnosed by their primary physician. In both groups neither gender, age, place of residence, education level, typical comorbidities (e. g. hypertension or diabetes) nor distinctive symptoms and bodily changes of the underlying disease (e. g. prognathism, acral enlargement, weight gain, buffalo hump) were significant factors promoting early detection. CONCLUSIONS: Apparently, patient-related factors do not affect the time-to-diagnosis interval, but rather the change of the primary health care provider. Knowledge of the disease among physicians is prerequisite to early detection. Due to the deleterious sequelae of delayed diagnosis, information programmes in the medical community are of paramount importance. Institution of screening programmes should be evaluated.

Predictive factors for neurocognitive function and Quality of Life after surgical treatment for Cushing's disease and acromegaly.

BACKGROUND: Cushing's disease (CD) and acromegaly (AC) are associated with impairment in quality of life (QoL) and neurocognition that can persist after successful treatment. AIM: To investigate the influence of current disease status (remission vs no remission) on neurocognitive function and QoL in treated CD and AC patients and to determine predictive factors (e.g. demographic, clinical, neurosurgical, endocrinological) for post-operative neurocognition and QoL. SUBJECTS AND METHODS: Twenty-four CD and 37 AC patients underwent neuropsychological testing 1 to 10 yr following surgical therapy. Additionally, QoL was assessed. An overnight 2-mg dexamethasone suppression test in CD and IGF-I and GH levels in AC patients were assessed to determine current disease status. The results were compared with 28 sex-, education- and age-matched healthy controls (HC). RESULTS: Impaired QoL was more pronounced than neurocognitive decrease in both pathologies compared to HC. This finding was independent of the current status of disease. In AC, persistent comorbidities were associated with impaired QoL (p<0.05). Older age at operation in AC patients was a significant predictor for adverse effects on psychomotor speed and attentional functions (p<0.05). In CD persistent hypocortisolism, not hypercortisolism, had adverse effects on neurocognition (p<0.01). CONCLUSIONS: The current status of disease plays a subordinate role in postoperative outcome concerning QoL and neurocognition in either pathology. A possible explanation might be the considerably improved endocrinopathy after treatment compared to untreated patients, even if no cure is achieved. The lasting impairments might be explained by irreversible changes that have occurred during the active phase of the disease.