Detection with MR imaging of residual tumor in the breast soon after surgery.

OBJECTIVE: Difficulties in the preoperative assessment of tumor size and extent result in a positive pathologic margin in up to 70% of patients undergoing breast conservation surgery. Although positive margins usually require reexcision, the location and extent of surgery required are often difficult to establish by current imaging techniques. We investigated the accuracy of three-dimensional rotating delivery of excitation off resonance (3D RODEO) MR imaging of the breast in revealing the presence and extent of residual tumor within the breast soon after surgery. MATERIALS AND METHODS: Nineteen patients who had undergone lumpectomy or excisional biopsy were evaluated with contrast-enhanced 3D RODEO MR imaging of the breast within 10 months after surgery. The MR imaging results were correlated with serial-sectioned mastectomy or partial mastectomy specimens from 18 patients and with a clinical and mammographic follow-up examination in one patient. RESULTS: We found that 3D RODEO MR imaging accurately revealed the presence or absence and the location and extent of recurrent tumor in 15 of the 18 patients who had pathologic confirmation. Of the three MR imaging-pathology mismatches, two had irregular or nodular enhancement that corresponded to microabscesses. The third mismatch showed multicentric disease on MR imaging but only single-quadrant lobular carcinoma at pathologic examination. Our 19th patient showed no evidence of recurrent tumor on MR imaging or at 2-year follow-up clinical and mammographic examinations. CONCLUSION: MR imaging with 3D RODEO technique correctly revealed the presence or absence, the location, and the extent of recurrent tumor in 84% of patients who had recently undergone breast surgery.

Three-dimensional RODEO breast MR imaging of lesions containing ductal carcinoma in situ.

PURPOSE: To assess whether rotating delivery of excitation off resonance (RODEO) breast magnetic resonance (MR) imaging can help detect ductal carcinoma in situ (DCIS) lesions, determine tumor extent, and differentiate pure DCIS from DCIS with an invasive component. MATERIALS AND METHODS: Twenty-two patients with DCIS lesions were evaluated with three-dimensional RODEO MR imaging. Nineteen patients had available mammograms for review. RESULTS: MR imaging enabled detection of all 22 cases of DCIS, DCIS with microinvasion, or invasive ductal carcinoma with extensive intraductal component. A clumped enhancement pattern was seen on MR images in all cases of pure DCIS. Spiculated enhancement was seen in four of six (67%) patients who had DCIS with microinvasion and in nine of 11 (82%) who had invasive ductal carcinoma with extensive intraductal component. RODEO MR imaging enabled accurate determination of tumor extent in 21 of 22 (95%) patients. Mammography depicted 18 of 19 DCIS lesions. No mammographic feature helped differentiate pure DCIS from DCIS with microinvasion. Mammography enabled accurate determination of tumor extent in 14 of 19 (74%) patients. CONCLUSION: Three-dimensional RODEO MR imaging can be an adjunct to mammography because of its ability to enable better determination of tumor extent and differentiation of pure DCIS from DCIS with an invasive component.

Stroke before 55 years of age at Karolinska Hospital 1973-77. A study of 399 well-defined cases. Risk indicators and etiological considerations.

The etiological characteristics of cerebrovascular disease (CVD) before the age of 55 are reviewed in 399 patients admitted to the Department of Neurology, Karolinska Hospital, Stockholm, from 1973-77. The material was well-defined with regard to subtypes of stroke as well as to the diseased population. The control material consists of 829 males and females of corresponding age randomly selected from the Stockholm population. In the ischemic group, 61% had angiographic evidence of atherosclerosis and, compared to controls, in most patient groups a significant (P less than 0.05-0.001) association with hypertension, diabetes, heart disease and smoking was found as well as for female patients under age 40 the use of oral contraceptives (P less than 0.001). In the hemorrhagic group, angiography demonstrated aneurysms in 76% of the patients with subarachnoidal bleeding but also atherosclerotic lesions in about 12% of the whole group. This would imply that atherosclerosis is an important precursor also for hemorrhagic lesions, further supported by a significant (P less than 0.01-0.001) association of hypertension, diabetes and smoking with this group.

PIP: This study investigated the etiologic characteristics of cerebrovascular disease (CVD) before the age of 55 years in 399 patients admitted to Karolinska Hospital, Stockholm, in 1973-77. 829 age-matched controls were randomly selected. Cases were further classified by subtype of CVD: subarachnoid, intracerebral, ischemic, and unclassified lesions. A family history of cerebrovascular incidents, heart disease, other vascular diseases, diabetes, and hypertension was reported in 10-30% of the cases. Among male cases with ischemic lesions before age 40, a history of treated diabetes, heart disease, and smoking was reported significantly more often than by controls. Among comparable female cases, a history of treated hypertension and oral contraceptive (OC) use at the onset of the disease was found significantly more often than in controls. In terms of ischemic lesions after the age of 40, a history of treated hypertension and smoking was significantly more frequent in male and female cases than in corresponding controls; treated diabetes and heart disease were reported more often in male cases only. No differences between cases and controls were found in the use of OCs. 61% of cases in the ischemic group had angiographic evidence of atherosclerosis. In the hemorrhagic group, angiography demonstrated aneyrysms in 76% of patients with subarachnoid bleeding but also atherosclerotic lesions in 12% of the whole group, implying that atherosclerosis is an important precursor for hemorrhagic lesions as well. The results from this study seem to support an association between OC use and circulatory complications; however, since mortality rates from circulatory disease are declining in countries where OC use is widespread, conclusions about a casual relationship may be unwarranted.

Epidemiology of acute cerebrovascular disease before the age of 55 in the Stockholm County 1973-77: I. Incidence and mortality rates.

The incidence and mortality rates of cerebrovascular disease (CVD) before age 55 were estimated for the Stockholm county between 1973 and 1977 using community based diagnosis and death statistics registers. Annual validation procedures concluded that less than 5% of hospitalized patients may have escaped registration. During the study period a diagnosis of CVD (initial stroke or TIA) was reported in 2,103 individuals, giving annual average crude incidence rates for stroke and TIA of 34 and 4 respectively per 100,000 inhabitants under age 55. Hemorrhagic lesions were reported in 45.4% of the cases, ischemic lesions in 33.1% and unclassified lesions in 21.5%. For all diagnostic categories a strong correlation to age is found, and for most categories the male:female ratio is high. The mortality rates are high for hemorrhagic lesions and low for ischemic and unclassified lesions. Incidence rates are higher than in Uppsala and Gothenburg, Sweden, but lower than in North Karelia, Finland. Mortality rates are similar to those reported by most other investigators.

Computed tomography and CSF spectrophotometry. Diagnosis and prognosis in 300 patients with cerebrovascular disease.

Computed tomography (CT) has been reported to show normal findings in 13-52% of patients with cerebrovascular diseases. Among factors deciding the diagnostic accuracy are the size and location of the lesion, the time elapsed from onset to examination, the use of contrast enhancement and the type of CT scanner used. To further elucidate these aspects, we designed the present study including 300 consecutive patients, all investigated by CT with a 160 x 160 matrix and cerebrospinal fluid spectrophotometry (CSF-SPE). CT indicated a specific diagnosis in 52.7%. In the majority of the remaining cases, additional subclassification was possible by CSF-SPE, emphasizing the complementary information obtained by combined examinations. CT was also found to be a useful tool for reliable prognostic prediction, irrespective of the initial clinical course.

Positron emission tomography with 68Ga-EDTA compared with transmission computed tomography in the evaluation of brain infarcts.

The diagnostic value of positron emission tomography (PET) was evaluated in 41 examinations of 40 patients. 68Ga-EDTA was used as a positron source. The findings were correlated with those of conventional of CT scanning. A clearly pathologic accumulation of 68Ga-EDTA was detected in 29 of 41 PET scans. The precontrast CT scans were negative in 11 and non-conclusive in one patient. CT after administration of contrast medium was performed in 29 patients. Of these, 21 had a clearly pathologic PET scan and 14 had visible contrast enhancement on CT examination. The injury of the blood-brain barrier thus was better demonstrated with PET than with CT. The topologic diagnosis was, however, better demonstrated at CT. It seems that CT and PET are supplementary examinations and that PET is superior to CT in the detection of injury of or absence of the blood-brain barrier.

Isoelectric focusing of cerebrospinal fluid proteins in ischemic cerebrovascular disease.

The cerebrospinal fluid (CSF) protein patterns, in ischemic cerebrovascular disease (ICD), of varying extension were studied by isoelectric focusing (IEF) in 100 patients at different intervals after the onset of symptoms. The diagnoses were based on conventional clinical examinations and CSF spectrophotometry in all cases. Computed tomography was performed on 52 cases. One or more CSF protein aberrations were noted in 94 patients. Some of these findings were most common with small lesions including TIA. Other aberrations were most frequent with the more extensive infarctions. A regional increase in the gammaglobulin range was found in six cases. The findings were most frequent in the first days after the stroke except for barrier damage which reached a maximum during the second week. The IEF findings of CSF seem to be of diagnostic value. Taken together with the clinical signs and CT findings, they could conceivably give prognostic information.

Dyslipoproteinemia in patients with ischemic cerebro-vascular disease: a study of stroke before the age of 55.

Serum lipoproteins were determined 8-12 weeks after the onset of ischemic cerebro-vascular disease (ICD) in 61 patients, 38 males and 23 females, before the age of 55. The results were compared with those of a matched control material. The diagnosis was based on clinical findings, CSF spectrophotometry, computer tomography, and angiography. Hyperlipoproteinemia was no common finding in these young and middle-aged patients with ICD. The normal mean total serum cholesterol concentration was the result of a slight increase in VLDL cholesterol and a concomitant HDL cholesterol reduction. In men, the HDL cholesterol concentration was lower than expected for any VLDL-TG concentration. The mean value of the HDL cholesterol concentration in the patients was 18% lower than in the control group. On agarose electrophoresis the lipoprotein variants "late prebeta", "sinking prebeta" and "rapid beta" lipoproteins could be demonstrated in the same frequency as in controls. There was no significant correlation between the degree of atherosclerosis, estimated by angiography, and any serum lipoprotein fraction. Several recent studies have stressed the importance of a low HDL concentration as an independent risk factor for atherosclerosis. The decreased HDL cholesterol levels found in the present material require further attention to the possible beneficial role of HDL in ICD.

Spectrophotometry of the CSF (CSF-SPE) and computer tomography (CT) in traumatic head injuries.

Combined examinations with quantitative CSF spectrophotometry (CSF-SPE) and computer tomography (CT) were performed on 53 patients with traumatic head injuries. In cerebral concussion the results were mainly normal in both examinations. In cerebral contusion bleeding patterns were found by CSF-SPE in all subjects, with a special bleeding pattern (S2 pattern) occurring in 86%. CT showed findings described as typical for contusion in 8 of 14 examined patients, the remaining CT scans showing questionable or normal signs. In extra- and intracerebral haematomas, all patients had bleeding patterns on the CSF-SPE. A special bleeding component (H factor) was found in about 72%. The H component was not observed during the first 3 to 4 days after the trauma. All but one patient examined later than the 4th day had an H component with or without an S-pattern. CT demonstrated a haematoma in 14 of 18 verified haematoma patients, while 4 subjects with subdural haematoma (e.g. one third of this group) had questionable CT findings. The combined examinations with CT and CSF-SPE, being complementary to each other, are of great value in the different diagnosis of traumatic head injuries.

Pathogenetic profile of TIA before 55. A three-year investigation.

Fifty-seven cases admitted to the Karolinska Hospital 1973-1976 with the diagnosis transient cerebral ischemia were reviewed. Seventeen cases were excluded as not fulfilling the strict TIA definition. An analysis of the records and the supplementary questionnaire of the remaining cases showed considerable sex differences in the stroke-prone profile. In the male group arteriosclerosis in the extracranial cerebral arteries was demonstrated in 90% of these examined by angiography. In the female group factors recognized as interfering with the coagulation system were obvious in more than 70% and two women had fibromuscular dysplasia. These differences may have therapeutic and prognostic implications. In the total material only 35% had hypertension. Diabetes was not present in any of the patients. Of the men 46.6% had abnormal blood lipids against 15.4% of the women. Seventy-five percent of the patients with verified arteriosclerosis were regular smokers. At a mean follow-up time of 18.7 months only one patient, in the untreated group, developed completed stroke.

Normal serum-cholesterol but low H.D.L.-cholesterol concentration in young patients with ischaemic cerebrovascular disease.

Serum-lipoproteins were determined in male and female patients aged under 55 who had survived an attack of ischaemic cerebrovascular disease (I.C.D.). The results were compared with findings in healthy controls. Total serum triglyceride and cholesterol concentrations were not increased. However, in the very-low-density lipoprotein fraction increased cholesterol concentrations were found, and the mean value of high-density-lipoprotein (H.D.L.) cholesterol in I.C.D. patients was 18% lower than in controls. Since a low H.D.L.-cholesterol concentration has been suggested as an independent strong risk factor, it is possible that the susceptibility of I.C.D. patients to atherosclerosis is the result of a low H.D.L. rather than hyperlipoproteinaemia.

Computer tomography of the brain and spectrophotometry of the CSF in cerebral concussion and contusion.

Computer tomography (CT) and spectrophotometry of CSF were performed in 30 patients with the clinical diagnosis of cerebral concussion or contusion. The patients with concussion all had normal CT-findings. Spectrophotometry of CSF was sometimes positive for cerebral contusion with normal CT-findings, but the two methods were complementary so that the extent of the lesion was determined by CT and spectrophotometry of CSF indicated the cause.

Diagnostic significance of CSF spectrophotometry and computer tomography in cerebrovascular disease. A comparative study in 231 cases.

Two hundred and thirty-one patients with cerebrovascular disease were examined by spectrophotometry of the cerebrospinal fluid (CSF) and by computer tomography. Many were followed by repeated examinations. Specific diagnoses --- bleeding as opposed to non-hemorrhagic or hemorrhagic infactions --- were indicated in 97% by spectrophotometry and in 65% by CT scan in 201 of the 231 cases (excluding 25 patients with transient ischemic attacks and five patients with cerebral tumors with cerebrovascular onset). Comparison between the two methods revealed agreement in most cases, with disagreement in only a few. The specific diagnosis was generally established on only one examination by both methods: repeated examinations were necessary in only a few cases. The results indicated that a combination of the two complementary methods established the diagnosis in almost all cerebrovascular disorders. This was particularly evident if the examinations were performed 24 hours to 21 days after onset of disease.