Biopsy method: a major predictor of adherence after benign breast biopsy?

OBJECTIVE: Adopting a longitudinal approach to assess women after breast biopsy with a benign result, this study aimed to comparatively evaluate the effect of the biopsy method on compliance with clinical recommendations for follow-up. MATERIALS AND METHODS: For this study, 410 patients who underwent biopsy of a breast lesion were included: fine-needle aspiration biopsy, n = 95 patients; core biopsy, n = 84; local excision under local anesthesia, n = 72; vacuum-assisted breast biopsy, n = 100; and hookwire localization, n = 59. Information about patient age, place of residence, whether complications occurred, and type of lesion was collected. RESULTS: Compliance was higher among women who had undergone vacuum-assisted breast biopsy than those who had undergone one of the other biopsy methods. The superiority (carryover effect) of vacuum-assisted breast biopsy persisted for 18 months after the biopsy procedure. Patient compliance for all of the other biopsy methods followed an M pattern, with the peaks corresponding to the follow-up mammography sessions. In patients who had undergone vacuum-assisted breast biopsy, a gradual decrease in compliance over time was observed. Older women were more compliant than younger women with follow-up recommendations regardless of biopsy method. A subanalysis of the vacuum-assisted breast biopsy group indicated that complications are associated with better compliance. CONCLUSION: Women more often adhere to clinical recommendations for follow-up sessions comprising mammography. Patient age and whether biopsy complications occurred also seem to modify compliance. Further studies should assess whether superior compliance after vacuum-assisted breast biopsy persists in other settings, such as with stereotactic or ultrasound guidance, different numbers of cores, and procedures of various durations.

Increased incidence of papillary thyroid cancer detection among thyroidectomies in Greece between 1991 and 2006.

OBJECTIVE: To examine existing evidence, trends and possible factors that may have affected the incidence of papillary thyroid cancer (PTC) among patients undergoing thyroidectomies in an iodine-sufficient population of Greece. STUDY DESIGN: All histology records from the patients who had undergone thyroid surgery at the Department of Surgery Laiko Hospital, Athens, Greece from January 1991 to December 2006 were retrospectively analyzed. Records were placed in a database which included patients' demographics, history, and medical condition, clinical and surgical parameters. PATIENTS AND METHODS: One thousand four hundred and twenty-six patients (265 males and 1161 females) had undergone thyroidectomy during the above period of time. All surgeons favoured total thyroidectomy with resection of pro- and paratracheal lymph nodes. Thyroid tumors were classified according to the WHO classification system and were staged according to the TNM staging system. RESULTS: In 278 patients, PTC was histologically diagnosed. From 1999 onwards, thyroid surgery shifted towards total thyroidectomy, while statistically significantly increased incidence of PTC and papillary microcarcinoma detection and decreased incidence of PTC greater than 10 mm detection in the whole population were noticed. Moreover, from 1999 onwards, smaller size of primary tumors, higher incidence of T1 tumors, lower incidence of T4 tumors, lower incidence of metastatically infiltrated peritracheal lymph nodes, higher incidence of stage I tumors and lower incidence of stage IV tumors were documented. Finally, a higher incidence of PTC in males, females and the whole population aged 51-70 years compared to the other age groups since 2003 was noticed. CONCLUSION: The increased incidence of PTC clearly correlated to the increased incidence of papillary microcarcinoma detection, reflecting the proportion for total thyroidectomy as well as changes in the diagnostic approach boosted by more careful pathological examination, rather than the effect of environmental factors such as the Chernobyl accident. Whether the Chernobyl accident has any predisposing effect on the increased incidence of PTC remains to be proven.

Efficacy of protected renal artery primary stenting in the solitary functioning kidney.

BACKGROUND: Significant renal artery stenosis (RAS) in a solitary functioning kidney (SFK) represents one of the most acceptable indications for renal revascularization. Percutaneous transluminal renal artery stenting (PTRAS) is increasingly being used as a first line treatment for renal revascularization, associated with renal function improvement or stabilization in the majority of the patients with solitary kidneys, but also with deterioration in up to 38% of the cases. Atheroembolism during PTRAS has been postulated as a potential cause for this acute renal function worsening. The aim of this study was to report on the feasibility, safety, and early outcomes of PTRAS in a series of patients with SFK using distal embolic protection (DEP). METHODS: All PTRAS procedures in SFKs performed under DEP between June 2002 and September 2007 were reviewed. Renal function, blood pressure, and the number of anti-hypertensive medications were assessed pre- and post-intervention. Renal function improvement and deterioration were defined as a 20% increase and decrease in serum creatinine, respectively, compared with preoperative values. Primary and primary assisted patency rates were also calculated. Statistical differences between values before and after intervention were determined by the Student t test and statistical significance was taken at P < .05. RESULTS: Protected PTRAS was performed in 14 patients with a SFK (9 men, 6 women, mean age 65.6 +/- 6.8 years). All patients were hypertensive and had varying degrees of azotemia. Mean pre-intervention stenosis degree was 86.8% +/- 7.8%. Immediate technical success was obtained in 100% of the patients. Renal function was cured (7.1%), improved (50%), or stabilized (42.9%) in all 14 (100%) patients after the procedure and no deterioration was noticed in any patient at 6-month follow-up. Pre- and postintervention serum creatinine levels were 3.01 +/- 1.15 mg/dL and 2.16 +/- 0.68 mg/dL, respectively, (P = .02). Hypertension was improved in 6 (42.9%) patients and stabilized in the remaining 8 (57.1%). Primary patency was 100% and 90% at 1 and 3 years, respectively, while primary assisted patency remained 100% for the whole follow-up period (mean, 31.8 +/- 19.4 months). CONCLUSION: These findings suggest that in patients with a SFK, protected PTRAS represents a safe and effective treatment for halting the progression of renal dysfunction to renal loss and warrants further investigation.

The use of Speckle Reduction Imaging (SRI) Ultrasound in the characterization of carotid artery plaques.

BACKGROUND AND PURPOSE: Speckle Reduction Imaging is a new algorithm that improves the image quality of B-mode scanning by reducing the reverberation artifacts. In the present study the value of this method for the characterization of atherosclerotic plaques in the internal carotid artery was investigated. METHODS: Two hundred and twenty two patients (161 men, 61 women; mean age 73 years) referred for carotid ultrasound evaluation were included in the study. Patients with plaques of the internal carotid artery as identified by conventional B-mode scanning were investigated also with the addition of Speckle Reduction Imaging (SRI) with the use of a 4-11-MHz wide band linear transducer. Plaque morphology was rated according to a standardized protocol by two independent observers. RESULTS: For the determination of plaque echogenicity, the reproducibility of SRI (kappa=0.83) was higher than that of conventional B-mode ultrasound (kappa=0.68). The interobserver agreement for plaque surface characterization was also higher for SRI (kappa=0.8) than for conventional B-mode (kappa=0.61). At the evaluation of the image quality through a semiquantitative analysis, SRI was rated superior in the plaque texture resolution, plaque borders determination, vessel wall demarcation and fibrous cap depiction. In addition, the level of "speckle" was reduced with the use of SRI. CONCLUSIONS: SRI is a technique that shows good general agreement with high-resolution B-mode and can be used for the characterization of atherosclerotic plaques in the carotid artery. Furthermore, because this advanced technique allows reduction of ultrasound artifacts, it improves the image quality allowing more precise visualization of plaque morphological details.

Endovascular repair of late abdominal aortic aneurysm rupture owing to mixed-type endoleak following endovascular abdominal aortic aneurysm repair.

We report the successful endovascular repair of a ruptured abdominal aortic aneurysm (AAA) in a multimorbid patient 8 months after endovascular abdominal aortic aneurysm repair (EVAR). A 74-year-old man with a history of EVAR 8 months earlier presented with hypotension, severe back pain, and tenderness on abdominal palpation. A contrast-enhanced computed tomographic scan showed a large retroperitoneal hematoma and confirmed the diagnosis of secondary abdominal aortic rupture. Because the patient had severe comorbidities, the endovascular method was chosen for further management. Two stent grafts were placed appropriately to eliminate a type 1a and a type 3 endoleak owing to modular separation of the left iliac graft limb from the main body stent graft. An additional self-expanding stent was deployed in the solitary right renal artery to open its origin, which was partially overlapped by the proximal cuff. The patient was discharged on the tenth postoperative day and is alive and well 1 year postoperatively. This case indicates that endovascular repair is feasible not only in cases of primarily ruptured AAAs but also in secondarily ruptured AAAs after failure of EVAR.

Emergency stenting of a ruptured infected anastomotic femoral pseudoaneurysm.

A 74-year-old man presented with a ruptured infected anastomotic femoral pseudoaneurysm. Due to severe medical comorbidities he was considered unsuitable for conventional surgical management and underwent an emergency endovascular repair with a balloon-expandable covered stent. The pseudoaneurysm was excluded successfully and the patient had an uneventful postoperative recovery with long-term suppressive antimicrobials. He remained well for 10 months after the procedure with no signs of recurrent local or systemic infection and finally died from an acute myocardial infarction. To our knowledge, emergency endovascular treatment of a free ruptured bleeding femoral artery pseudoaneurysm has not been documented before in the English literature. This case illustrates that endovascular therapy may be a safe and efficient alternative in the emergent management of ruptured infected anastomotic femoral artery pseudoaneurysms when traditional open surgery is contraindicated.

Endovascular repair of a type III thoracoabdominal aortic aneurysm in a patient with occlusion of visceral arteries.

The successful endovascular repair of a type III thoracoabdominal aortic aneurysm (TAAA) with the use of a tube endograft is reported. A 56-year-old male with a 6.4-cm type III TAAA, a 4.2-cm infrarenal abdominal aortic aneurysm, and chronic renal insufficiency presented with flank pain, nausea, acute anuria, and serum creatinine of 6.1 mg/dl. Acute occlusion of the left solitary renal artery was diagnosed and emergent recanalization with percutaneous transluminal angioplasty and stenting was performed successfully, with reversal of the serum creatinine level at 1.6 mg/dl. Further imaging studies for TAAA management revealed ostial occlusion of both the celiac artery (CA) and the superior mesenteric artery (SMA) but a hypertrophic inferior mesenteric artery (IMA) providing retrograde flow to the aforementioned vessels. This rare anatomic serendipity allowed us to repair the TAAA simply by using a two-component tube endograft without fenestrations (Zenith; William Cook, Bjaeverskov, Denmark) that covered the entire length of the aneurysm, including the CA and SMA origins, since a natural arterial bypass from the IMA to the CA and SMA already existed, affording protection from gastrointestinal ischemic complications. The patient had a fast and uneventful recovery and is currently doing well 6 months after the procedure. To our knowledge, this is the first report in the English literature of successful endovascular repair of a TAAA involving visceral arteries with the simple use of a tube endograft.