MRI-guided needle localization of suspicious breast lesions: results of a freehand technique.

Magnetic resonance imaging (MRI) can detect clinically and mammographically occult breast lesions. In this study we report the results of MRI-guided needle localization of suspicious breast lesions by using a freehand technique. Preoperative MRI-guided single-needle localization was performed in 220 patients with 304 MRI-only breast lesions at our hospital between January 1997 and July 2004. Procedures were performed in an open 0.5-T Signa-SP imager allowing real-time monitoring, with patient in prone position, by using a dedicated breast coil. MRI-compatible hookwires were placed in a noncompressed breast by using a freehand technique. MRI findings were correlated with pathology and follow-up. MRI-guided needle localization was performed for a single lesion in 150 patients, for two lesions in 56 patients, and for three lesions in 14 patients. Histopathologic analysis of these 304 lesions showed 104 (34%) malignant lesions, 51 (17%) high-risk lesions, and 149 (49%) benign lesions. The overall lesion size ranged from 2.0-65.0 mm (mean 11.2 mm). No direct complications occurred. Follow-up MRI in 54 patients showed that two (3.7%) lesions were missed by surgical biopsy. MRI-guided freehand needle localization is accurate and allows localization of lesions anterior in the breast, the axillary region, and near the chest wall.

Use of automated microscopy for the detection of disseminated tumor cells in bone marrow samples.

The use of automated microscopy has reached the maturity necessary for its routine use in the clinical pathology laboratory. In the following study we compared the performance of an automated microscope system (MDS) with manual method for the detection and analysis of disseminated tumor cells present in bone marrow preparations from breast carcinoma patients. The MDS System detected rare disseminated tumor cells among bone marrow mononuclear cells with higher sensitivity than standard manual microscopy. Automated microscopy also proved to be a method of high reproducibility and precision, the advantage of which was clearly illustrated by problems of variability in manual screening. Accumulated results from two pathologists who had screened 120 clinical slides from breast cancer patients both by manual microscopy and by use of the MDS System revealed only two (3.8%) missed by the automatic procedure, whereas as many as 20 out of 52 positive samples (38%) were missed by manual screening.

Freehand iMRI-guided large-gauge core needle biopsy: a new minimally invasive technique for diagnosis of enhancing breast lesions.

The lack of reliable methods for minimally invasive biopsy of suspicious enhancing breast lesions has hindered the utilization of contrast-enhanced magnetic resonance imaging (MRI) for the detection and diagnosis of breast cancer. In this study, a freehand method was developed for large-gauge core needle biopsy (LCNB) guided by intraprocedural MRI (iMRI). Twenty-seven lesions in nineteen patients were biopsied using iMRI-guided LCNB without significant complications. Diagnostic tissue was obtained in all cases. Nineteen of the 27 lesions were subsequently surgically excised. Histopathologic analysis confirmed that iMRI-guided LCNB correctly distinguished benign lesions from malignancy in 18 of the 19 lesions. The histology revealed by core biopsy was partially discrepant with surgical biopsy in 2 of the other 19 lesions. Freehand iMRI-guided LCNB of enhancing breast lesions is promising. Larger studies are needed to determine the smallest lesion that can be sampled reliably and to precisely measure the accuracy of iMRI-guided LCNB as a minimally invasive tool to diagnose suspicious lesions found by breast MRI. J. Magn. Reson. Imaging 2001;13:896-902.

Milk of calcium in the breast: appearance on prone stereotactic imaging.

Microcalcifications discovered by mammography require careful analysis, occasionally leading to core biopsy to exclude associated breast cancer. We report unrecognized milk of calcium layering on small field of view prone digital stereotactic images. We illustrate important features on prone digital images attributed to milk of calcium which can exclude breast neoplasm, suggest this diagnosis, and prevent unnecessary biopsy.

New bilateral microcalcifications at mammography in a postlactational woman: case report.

A 33-year-old woman with a strong family history of breast cancer who was referred for mammography 5 weeks after completing lactation was found to have new diffuse bilateral microcalcifications in the breast ducts. Contrast material-enhanced magnetic resonance imaging of the breast showed bilateral patchy areas of abnormal enhancement. Large-core needle biopsy showed diffuse calcifications within expanded benign ducts in a background of lactational change, without evidence of malignancy. To the authors' knowledge, these calcifications have not been previously reported and are possibly related to milk stasis or apoptosis associated with lactation.

Radiofrequency ablation of breast cancer: first report of an emerging technology.

HYPOTHESIS: Radiofrequency (RF) energy applied to breast cancers will result in cancer cell death. DESIGN: Prospective nonrandomized interventional trial. SETTING: A university hospital tertiary care center. PATIENTS: Five women with locally advanced invasive breast cancer, aged 38 to 66 years, who were undergoing surgical resection of their tumor. One patient underwent preoperative chemotherapy and radiation therapy, 3 patients received preoperative chemotherapy, and 1 had no preoperative therapy. All patients completed the study. INTERVENTIONS: While patients were under general anesthesia and just before surgical resection, a 15-gauge insulated multiple-needle electrode was inserted into the tumor under sonographic guidance. Radiofrequency energy was applied at a low power by a preset protocol for a period of up to 30 minutes. Only a portion of the tumor was treated to evaluate the zone of RF ablation and the margin between ablated and nonablated tissue. Immediately after RF ablation, the tumor was surgically resected (4 mastectomies, 1 lumpectomy). Pathologic analysis included hematoxylin-eosin staining and enzyme histochemical analysis of cell viability with nicotinamide adenine dinucleotide-diaphorase (NADH-diaphorase) staining of snap-frozen tissue to assess immediate cell death. MAIN OUTCOME MEASURE: Cancer cell death as visualized on hematoxylin-eosin-stained paraffin section and NADH-diaphorase cell viability stains. RESULTS: There was evidence of cell death in all patients. Hematoxylin-eosin staining showed complete cell death in 2 patients. In 3 patients there was a heterogeneous pattern of necrotic and normal-appearing cells within the ablated tissue. The ablated zone extended around the RF electrode for a diameter of 0.8 to 1.8 cm. NADH-diaphorase cell viability stains of the ablated tissue showed complete cell death in 4 patients. The fifth patient had a single focus of viable cells (<1 mm) partially lining a cyst. There were no perioperative complications related to RF ablation. CONCLUSIONS: Intraoperative RF ablation results in invasive breast cancer cell death. Based on this initial report of the use of RF ablation in breast cancer, this technique merits further investigation as a percutaneous minimally invasive modality for the local treatment of breast cancer.

Stereotactic, automated, large-core needle biopsy of nonpalpable breast lesions: false-negative and histologic underestimation rates after long-term follow-up.

PURPOSE: To determine the rate and causes of false-negative findings and histologic underestimates at stereotactic biopsy of nonpalpable breast lesions. MATERIALS AND METHODS: Stereotactic, 14-gauge, automated, large-core needle biopsy (LCNB) was performed in 483 consecutive nonpalpable breast lesions. Excision was advised for the 143 carcinomas, 25 atypical ductal hyperplasia (ADH) lesions, and five radial scars. Mammographic follow-up was advised for the benign lesions without a repeat biopsy. RESULTS: Of the 310 benign lesions, 259 underwent mammographic follow-up at 6-85 months (median, 55 months) without repeat biopsy, 48 underwent repeat biopsy and three were lost to follow-up. On the basis of the histologic diagnosis of carcinoma at surgical biopsy, diagnosis with LCNB was not correct (i.e., disease was underestimated at histologic examination) in 14 (58%) of 24 ADH lesions and two (40%) of five radial scars. Two (1.2%) of 161 lesions with a final diagnosis of carcinoma were benign at LCNB but malignant at repeat biopsy (i.e., false-negative findings at LCNB). Repeat biopsy was prompted by mammographic progression at 6 and 18 months after LCNB. CONCLUSION: The false-negative rate with LCNB was 1.2% in this study and 4.0% in the literature. The presence of carcinoma in ADH and radial scar lesions was often underestimated.

Percutaneous removal of benign mammographic lesions: comparison of automated large-core and directional vacuum-assisted stereotactic biopsy techniques.

OBJECTIVE: The purpose of our study was to evaluate how often histologically benign lesions were completely removed as shown by the initial mammogram after biopsy. We compared three percutaneous biopsy techniques. MATERIALS AND METHODS: Retrospective review was performed on 1206 consecutive impalpable breast lesions having percutaneous stereotactic biopsies done on a prone biopsy table using 14-gauge automated large-core needles (n = 721); 14-gauge directional vacuum-assisted probes (n = 192); and 11-gauge directional vacuum-assisted probes (n = 293). Lesions that were histologically benign and that did not have subsequent surgical excision had mammographic follow-up. The 667 initial mammograms after biopsy (advised to be done at 6 or 12 months and accomplished at 1-53 months [median, 7 months] after biopsy) were reviewed to see if the lesions were no longer apparent. RESULTS: The lesion was absent in 9% (40/422) of lesions for which 14-gauge large-core biopsy was used, 22% (21/95) of lesions for which 14-gauge vacuum-assisted biopsy was used, and 64% (96/150) of lesions for which 11-gauge vacuum-assisted biopsy was used (p < .0001). No mammographic pseudolesions were created by the biopsy. No clinically significant complications occurred. CONCLUSION: The lesion was more often completely removed with directional vacuum-assisted biopsy than with automated large-core biopsy and more often completely removed with 11-gauge probes than with 14-gauge probes.

Ultrasound-guided fine-needle aspiration biopsy of thyroid masses.

The purpose of this study was to determine the impact of ultrasound-guided fine-needle aspiration biopsy (USFNA) in the cytological diagnosis of nodular thyroid disease. It remains unclear exactly what role USFNA should play in the cytological diagnosis of nodular thyroid disease. All patients who underwent fine-needle aspiration (FNA) for nodular thyroid disease at Stanford University Medical Center from 1991 to 1996 were included in the study. Histopathologic diagnoses were compared to cytological diagnoses for those patients who underwent surgery. FNA was performed on a total of 497 thyroid nodules. Palpation-guided FNA (pFNA) was performed on 370 nodules, and USFNA was done on 127. The USFNAs were performed for the following reasons: 95 (75%) for nonpalpable or difficult-to-palpate nodules; 14 (11%) for previously failed FNA; and 18 (14%) for incidentally detected nodules. FNA had an unsuccessful biopsy rate of 16% and a sensitivity and specificity of 89% and 69%, respectively. USFNA had an unsuccessful biopsy rate of 7% and a sensitivity and specificity of 100% and 100%, respectively. The cancer yield at surgery for pFNA was 40%, and the cancer yield at surgery for USFNA was 59%. The complementary use of USFNA with pFNA improves the diagnostic approach to nodular thyroid disease. The use of USFNA has increased the cancer yield at surgery and the sensitivity of thyroid biopsy at our institution.

Primary squamous cell carcinoma of the breast.

Primary squamous cell carcinoma of the breast is a rare cancer. Published reports of prognosis are variable, and most studies are case reports of one or a few patients. We report an additional case of squamous cell carcinoma of the breast occurring in a 53-year-old black woman. In reviewing the reported cases of this tumor over the past 20 years, we compared features of this cancer with those of the more common breast adenocarcinoma with squamous metaplasia. When squamous cell carcinoma of the breast is encountered, a skin primary lesion and metastasis from a distant site should be excluded. Prognosis is determined largely by stage and does not differ significantly from the prognosis in breast adenocarcinoma with squamous metaplasia.

The importance of the lumpectomy surgical margin status in long-term results of breast conservation.

BACKGROUND: The impact of the surgical margin status on long-term local control rates for breast cancer in women treated with lumpectomy and radiation therapy is unclear. METHODS: The records of 289 women with 303 invasive breast cancers who were treated with lumpectomy and radiation therapy from 1972 to 1992 were reviewed. The surgical margin was classified as positive (transecting the inked margin), close (less than or equal to 2 mm from the margin), negative, or indeterminate, based on the initial biopsy findings and reexcision specimens, as appropriate. Various clinical and pathologic factors were analyzed as potential prognostic factors for local recurrence in addition to the margin status, including T classification, N classification, age, histologic features, and use of adjuvant therapy. The mean follow-up was 6.25 years. RESULTS: The actuarial probability of freedom from local recurrence for the entire group of patients at 5 and 10 years was 94% and 87%, respectively. The actuarial probability of local control at 10 years was 98% for those patients with negative surgical margins versus 82% for all others (P = 0.007). The local control rate at 10 years was 97% for patients who underwent reexcision and 84% for those who did not. Reexcision appears to convey a local control benefit for those patients with close, indeterminate, or positive initial margins, when negative final margins are attained (P = 0.0001). Final margin status was the most significant determinant of local recurrence rates in univariate analysis. By multivariate analysis, the final margin status and use of adjuvant chemotherapy were significant prognostic factors. CONCLUSIONS: The attainment of negative surgical margins, initially or at the time of reexcision, is the most significant predictor of local control after breast-conserving treatment with lumpectomy and radiation therapy.

Stereotaxic large-core needle biopsy of 450 nonpalpable breast lesions with surgical correlation in lesions with cancer or atypical hyperplasia.

PURPOSE: To determine whether histologic findings of cancer or atypical hyperplasia at large-core needle biopsy (LCNB) of nonpalpable breast lesions match histologic findings at excision. MATERIALS AND METHODS: Stereotaxic LCNB was performed with an automated prone unit, biopsy gun, and 14-gauge cutting needles in 450 nonpalpable breast lesions. Lesions classified as carcinoma or atypical ductal hyperplasia (ADH) at histologic examination after LCNB were excised. A pathologist retrospectively compared core and excisional histologic findings. RESULTS: Histologic comparison was performed in 116 of 135 carcinomas after LCNB. Histologic findings were concordant in 99 carcinomas. Partial discordance in 17 carcinomas led to an additional surgical procedure in one case. Histologic comparison was performed in 16 of 19 ADHs diagnosed with LCNB. Histologic findings were concordant in five and discordant in 11 ADHs. CONCLUSION: LCNB findings of carcinoma are accurate and allow definitive therapeutic surgery, including mastectomy. LCNB findings of ADH are inaccurate, and excisional biopsy is necessary.

The electrophysiologic and histologic effects of the Argon Beam Coagulator on peripheral nerves.

The electrophysiologic and histologic effects of the Bard Argon Beam Coagulator (ABC) were investigated in the New Zealand White rabbit. Thirty-four rabbits were divided into three groups. Controls underwent simple femoral exploration and closure. The remaining rabbits' femoral nerves were spot coagulated with either the ABC or standard electrosurgical unit (ESU). Stimulus thresholds were recorded before treatment and again prior to sacrifice at 0, 30, 60, or 120 days. Thresholds were significantly elevated for the ABC and ESU compared to controls (P = .0077 and .0351, respectively). Changes in threshold were greater for the ABC than for the ESU, but were not significant. All ABC- and ESU-treated nerves had significant histologic injury when compared to controls (P < .0002). Although the ABC may be clinically safe, significant injury to rabbit femoral nerves occurs when they are exposed to energy emitted by this instrument.

Coaxial transthoracic fine-needle biopsy in patients with a history of malignant lymphoma.

Efficacy and safety of coaxial transthoracic fine-needle biopsy were evaluated in 54 patients with a history of malignant lymphoma and new chest lesions. Twenty-one patients had recurrent lymphoma. Correct diagnosis was made in 17 of the 21 patients (81%) after one biopsy. The sensitivity increased to 95% with repeat needle biopsy in three patients. Immunophenotyping (determining phenotype by means of immunologic examination) was essential for a definitive diagnosis of lymphoma in three patients. Non-lymphomatous malignancies were correctly diagnosed in 14 patients. An infectious organism was identified in 11 of 19 patients (58%) with benign lesions. Pneumothorax occurred in eight patients (15%), necessitating placement of a chest tube in two (4%). Mild hemoptysis was observed in four patients (7%). The authors conclude that coaxial transthoracic fine-needle biopsy in patients with a history of lymphoma is safe and accurate. The use of large cutting needles or surgical biopsy can be restricted to patients with false-negative findings at percutaneous biopsy and to patients in whom histologic transformation of lymphoma is suspected.

Epithelioid hemangioendothelioma: cytomorphology and histological features of a case.

A case of epithelioid hemangioendothelioma involving the left lung, the 10th thoracic vertebra, and paravertebral soft tissues is presented. Preoperative sputum cytology was thought to show adenocarcinoma. Histologic examination demonstrated an intravascular bronchioloalveolar tumor; immunohistochemical staining for factor VIII-related antigen revealed strongly positive tumor cells. The cytomorphology of this rare neoplasm is discussed.