Stereotactic breast biopsy: a study of first core samples.

Stereotactic core needle biopsy (SCNB) is a sensitive and specific indicator of breast pathology. Commonly the first biopsy core is taken from the center of the lesion in question. Multiple cores are then taken from points peripheral to the central core. The sensitivity and specificity of the central core to diagnose breast disease is unclear. We compared the pathology of the central core biopsy with that of the remaining cores in a prospective study to determine the sensitivity and specificity of the central core to diagnose breast disease. All patients undergoing SCNB for breast lesions in a single surgical office during a 7-month period were eligible for inclusion. One hundred thirty-three patients with first cores from 145 biopsy sites were included. The histologic diagnosis from 117 (81%) of the first cores from these 145 biopsy sites were representative of their respective samples as a whole. Seventy-seven (53%) of the first cores were in complete agreement with the final histologic diagnosis whereas 40 (28%) had minor differences with the histologic diagnosis that had little or no clinical significance. Twenty-eight (19%) central core samples did not agree with the final pathologic diagnosis. Seven of these 28 patients each had a final diagnosis of cancer missed by the central core biopsy. The first core sample had a sensitivity for cancer detection of 79 per cent and specificity 100 per cent. SCNB remains a sensitive and specific identifier of breast pathology. When mammographic evidence of calcifications was the primary indication for SCNB (n = 75) calcification was present in the central core in 51 (68%). In these 51 patients the central core biopsy was in agreement with the final histologic diagnosis in 46 (90%) specimens. Histologic review of the first core sample alone lends no increased benefits and in fact misrepresents the pathology present in a significant number of patients. When analyzed as an independent predictor of breast pathology the first core is a more sensitive indicator than subsequent individual cores, but the most accurate predictor of pathology is examination of the entire group of core samples. This study confirms the need for acquisition of multiple cores from each lesion in question.

Stereotactic and ultrasound core needle breast biopsy performed by surgeons.

BACKGROUND: The authors evaluated outcomes and treatment costs of stereotactic core needle biopsy (SCNB) and ultrasound core needle biopsy (UCNB), and needle localization biopsy (NLB) in managing patients with mammographic abnormalities presenting to the surgeon. METHODS: Data for all patients with mammographic lesions who underwent SCNB or UCNB since their introduction at this institution were prospectively collected over 17 months. Mean inclusive costs of the three procedures were accumulated and compared. RESULTS: Stereotactic core needle biopsy was performed for 342 lesions in 319 women, for a malignancy rate of 19%; UCNB was performed for 157 lesions in 144 patients, yielding a malignancy rate of 17%. With a mean follow-up of 13.5 months, 1 patient with in situ carcinoma was diagnosed late. Absolute cost savings for the period studied was $721,963. CONCLUSIONS: Minimally invasive breast biopsy procedures can safely and reliably be performed by surgeons in clinical practice with increased patient convenience and decreased costs.

Bringing core biopsy into a surgical practice.

Minimally invasive diagnostic techniques in evaluating patients with breast disease have been increasingly utilized and accepted by physicians and patients over recent years. The incorporation of stereotactic core needle biopsy and ultrasound-guided core needle biopsy into the office practice of evaluating patients with breast disease by our surgical faculty has been met favorably. These procedures are readily learned by surgeons. The judicious use of these procedures is evidenced by the malignancy rate of core biopsies of 16 per cent, identical to the historical rate for needle localization assisted excisional biopsy at our institution. Core breast biopsy expedites definitive diagnosis and optimizes patient convenience. Reimbursement is highly variable, and active physician participation in negotiating with payors to insure that costs are met is essential.

Postoperative pulmonary complications and morbidity after abdominal aneurysmectomy: a comparison of postoperative epidural versus parenteral opioid analgesia.

Patients undergoing aortic aneurysm repair have a high prevalence of coexisting cardiac and pulmonary disease, and the postoperative recovery is especially delayed by pulmonary complications. A review of all elective abdominal aneurysm repairs over a 29-month period was undertaken to evaluate the effectiveness of postoperative epidural analgesia in decreasing morbidity and mortality, and specifically pulmonary complications. Patients were placed into two groups; Group 1 (34 patients) used an epidural catheter for postoperative pain control, and Group II (31 patients) used standard parenteral opioid analgesia. The two groups were similar in preoperative combined factors including known risk factors for atherosclerotic cardiovascular disease, preexisting cardiac or pulmonary disease, and preexisting renal insufficiency. A statistically significant decrease (P = < 0.05) was found in both cardiac (P = 0.0002) and pulmonary (P = 0.019) complications in comparison, favoring Group I patients. A significant decrease was also seen in the time to liquid intake (P = 0.044), time out of bed to a chair (P = 0.002), length of stay in the Intensive Care Unit (P = 0.024), and overall hospital charges (P = 0.046) in favor of Group I patients. Although no significant difference (P = > 0.05) was seen in decreasing time to ambulation (P = 0.054), average time required on the ventilator (P = 0.053), or hospital days (P = 0.181), all of these did show a trend in favor of epidural catheter utilization. There were no complications or infections related to the use of the epidural catheter during this study period. In conclusion, the use of an epidural catheter for postoperative pain control has been shown to decrease time of intubation, time in the ICU, number of cardiac and pulmonary complications, which should lead to an overall decrease in hospital charges after elective repair of abdominal aortic aneurysms.

Efficacy of screening MR angiography and Doppler ultrasonography in the evaluation of carotid artery stenosis.

Significant progress has been made in the development of noninvasive screening techniques for evaluation of the carotid bifurcation prior to contrast angiography. The role and significance of Magnetic Resonance Angiography (MRA) as an efficient cost effective screening examination for carotid artery stenosis remains to be determined. To that end, 120 carotid vessels, in 60 consecutive patients with carotid artery disease, were studied using MRA, Duplex ultrasonography (U/S), and conventional Digital Subtraction Arteriography (DSA). In a prospective blinded manner, using a standard scoring schematic, each carotid artery was evaluated with regard to degree of stenosis, zone of stenosis, and quality of the screening examination. The efficacy of MRA and U/S for detection of extracranial carotid stenoses was correlated with conventional DSA, which was used as a "standard of reference" for each patient. Screening studies were considered positive if the vessel stenosis was determined to be greater than 40 per cent. As a screening examination, U/S yielded a sensitivity of 88 per cent and a specificity of 81 per cent with 11 false positive and 7 false negative studies. MRA yielded a sensitivity of 84 per cent and a specificity of 81 per cent with 11 false positive and 9 false negative studies. Range of cost of each imaging modality was surveyed from our region as well as ease of access to each modality. MRA and U/S achieved equivalent accuracy as screening examinations and correlated well in sensitivity and specificity when quality of the examination and experience of the examination center was taken into consideration.(ABSTRACT TRUNCATED AT 250 WORDS)

Juxtarenal infrarenal abdominal aortic aneurysm. Special diagnostic and therapeutic considerations.

Juxtarenal infrarenal abdominal aortic aneurysms are defined as those aneurysms that involve the infrarenal abdominal aorta adjacent to or including the lower margin of renal artery origins. The misinterpretation of findings at exploratory operation or special studies may suggest renal artery involvement and result in abandonment of operation and/or referral to distant centers, thus delaying treatment. This report is concerned with 101 patients with a median age of 68 who had such aneurysms, all referred with a diagnosis of renal or visceral arterial involvement either after exploratory operation (32), because of aneurysmal size (12), or due to misinterpretation of special studies (57). Computed tomographic (CT) scans, ultrasounds, and aortograms in the anterio-posterior projection frequently suggested renal artery involvement due to the fact that the upper end of aneurysm frequently lay over the renal artery origins due to infrarenal aortic elongation and buckling of the aorta at the renal artery level. The true nature of the lesion was best demonstrated by aortography performed in the lateral position. The operation producing the best results was one performed through a midline abdominal incision. The aorta is cross-clamped at the diaphragm and the proximal anastomosis is performed from inside the aneurysm at the renal artery level. The graft then is clamped and the other clamp removed to restore flow in the visceral vessels while the distal anastomosis is completed. Early survival occurred in 93% of patients employing the operation, despite the fact that other conditions frequently were present: renal insufficiency in 19, rupture in seven, renal artery occlusive disease in 20, chronic obstructive pulmonary disease in 34, and hypertension in 77.