Breast reconstruction and revision surgery for implant-associated breast deformities using porcine acellular dermal matrix: a multicenter study of 156 cases.

BACKGROUND: Acellular dermal matrix is increasingly used as caudolateral coverage for breast implants in immediate breast reconstruction after skin-sparing mastectomy or in the correction of implant-associated breast deformities. Matrices of human, bovine, and porcine origin are available. The purpose of this retrospective multicenter study was to report experiences with porcine acellular dermal matrices, as only limited data can be found in the literature. METHODS: In the hospital databases of five institutions, 127 patients were identified who underwent breast reconstructions in 156 breasts using an acellular porcine dermal matrix. Medical records were reviewed. Patients were divided into three groups: immediate expander-implant or direct to implant reconstructions (n = 98), delayed expander-implant reconstructions (n = 14), and revision surgery for implant-associated breast deformities (n = 44). RESULTS: With a mean follow-up of 19.6 months, total major complication rate was 7.1 %: implant loss (3.2 %), skin flap necrosis (2.6 %), delayed skin healing (2.6 %), hematoma (1.9 %), seroma (1.3 %), infection (0.6 %), and capsular contracture (0.6 %). Total minor complication rate was 22.9 %, with seroma being the most frequent complication (19.2 %). In the group of immediate breast reconstructions, 20.4 % of the breasts had received radiotherapy in the past. These patients exhibited a significantly higher rate of seroma than patients without prior radiotherapy (35.0 vs. 14.9 %, p = 0.031). CONCLUSIONS: Complication rates using porcine acellular dermal matrix in breast reconstruction are comparable to complication rates reported in studies using human acellular dermal matrices. Thus, porcine acellular dermal matrices can safely be applied in breast reconstructive surgery.

[Sonoelastography usage among German DEGUM-certified breast ultrasound specialists]. / Einsatz der Sonoelastografie in der Mammadiagnostik: Analyse unter DEGUM-zertifizierten Untersuchern.

PURPOSE: Sonoelastography of the breast is an emerging technology with evident data in the literature suggesting diagnostic advantages. Our study investigates the current usage of sonoelastography among German DEGUM-certified breast ultrasound specialists. MATERIALS AND METHODS: We used a standardized questionnaire with 18 items. In 2012, the survey was sent to all members of the breast ultrasound section of the DEGUM (n = 654). RESULTS: The group of survey participants (n = 208) performs 193 025 breast ultrasound examinations and examines 20 110 breast cancers per year. 21.2 % of the participants in the survey use sonoelastography, mainly for diagnostic purposes in BI-RADS®-US 3 and 4 lesions, less often for other categories or under study conditions. The most commonly applied criteria for the evaluation of the elastogram are the Tsukuba Elasticity Score (43.2 %), the fat-lesion ratio (29.5 %) and the determination of tissue stiffness with shear wave elastography expressed in kilopascal (25.0 %). The majority of non-users of elastography (58.6 %) would like to have the option of using sonoelastography in the future. CONCLUSION: Sonoelastography is a feasible and helpful method in the evaluation of breast lesions. A significant number of German ultrasound specialists already apply this technology today. We expect a growing number of sonographers to perform sonoelastography in the near future, provided that they have the necessary ultrasound system and that they are trained in the method. Evidence from the literature and the recommendations of the medical societies support this development.

The biology of malignant breast tumors has an impact on the presentation in ultrasound: an analysis of 315 cases.

BACKGROUND: The aim of this study was to evaluate the relation of some ultrasound morphological parameters to biological characteristics in breast carcinoma. METHODS: Ultrasound data from 315 breast masses were collected. We analyzed the ultrasound features of the tumors according to the ACR BI-RADS®-US classification system stratified by hormone receptor status, HER2 status, histology grade, tumor type (ductal versus lobular), triple-negativity, breast density, tumor size, lymph node involvement and patient's age. RESULTS: We found a variety of ultrasound features that varied between the groups. Invasive lobular tumors were more likely to have an angulated margin (39% versus 22%, p = 0.040) and less likely to show posterior acoustic enhancement (3% versus 16%, p = 0.023) compared to invasive ductal carcinoma. G3 tumors were linked to a higher chance of posterior acoustic enhancement and less shadowing and the margin of G3 tumors was more often described as lobulated or microlobulated compared to G1/G2 tumors (67% versus 46%, p = 0.001). Tumors with an over-expression of HER2 exhibited a higher rate of architectural distortions in the surrounding tissue, but there were no differences regarding the other features. Hormone receptor negative tumors were more likely to exhibit a lobulated or microlobulated margin (67% versus 50%, p = 0.037) and less likely to have an echogenic halo (39% versus 64%, p = 0.001). Furthermore, the posterior acoustic feature was more often described as enhancement (33% versus 13%, p = 0.001) and less often as shadowing (20% versus 47%, p < 0.001) compared to hormone receptor positive tumors. CONCLUSION: Depending on their biological and clinical profile, breast cancers are more or less likely to exhibit the typical criteria for malignancy in ultrasound. Moreover, certain types of breast cancer tend to possess criteria that are usually associated with benign masses. False-negative diagnosis may result in serious consequences for the patient. For the sonographer it is essential to be well aware of potential variations in the ultrasound morphology of breast tumors, as described in this paper.

The effect of accompanying in situ ductal carcinoma on accuracy of measuring malignant breast tumor size using B-mode ultrasonography and real-time sonoelastography.

Objectives. Clinical estimation of malignant breast tumor size is critical for preoperative planning and is crucial for following up the tumor's response to the therapy in case she receives a neoadjuvant chemotharapy. Ductal carcinoma in situ (DCIS) accompanies about 25.4% of detected invasive breast cancers. The aim of this study was to examine the effect of the presence of DCIS on the accuracy of the ultrasonographic measuring malignant breast tumor size using B-mode and real time elastography. Materials and Methods. We recruited histologically confirmed breast cancer patients in a prospective observational study. Results. We recruited 50 breast cancer patients with a median age of 57.5 years. DCIS was confirmed to accompany 42% (n = 21) of the cases. Tumor size estimation using B-mode sonography (P < 0.001) as well as using real time elastography (P < 0.001). was statistically significant correlated to the actual tumor size. Presence of DCIS in 42% of our recruited patients affected the tumor size estimation using both methods thus losing the correlation between both estimations (P = 0.794). Conclusion. This study shows that the presence of DCIS significantly affects the accuracy of measuring the sizes of malignant breast tumors when using either B-mode ultrasonography or real time elastography.

[Diagnostic value of strain ratio measurement in the differentiation of malignant and benign breast lesions]. / Diagnostische Aussagekraft der Strain-Ratio-Messung zur Unterscheidung zwischen malignen und benignen Brusttumoren.

PURPOSE: The aim of this study was to evaluate the strain ratio measurement of breast lesions, to calculate the diagnostic value and to provide practically oriented recommendations concerning execution. MATERIALS AND METHODS: 117 breast lesions in 98 patients were included in the study. All lesions were examined by B-mode ultrasound and elastography using strain ratio measurement. The preinterventional findings of the different methods were compared to the final histopathological results. The sensitivity, specificity, positive and negative predictive value and the diagnostic accuracy were calculated for each method. RESULTS: There was a significant difference between the strain ratio of malignant (mean 6.50; sd 3.03; 95 %-CI 5.68 - 7.33) and benign (mean 1.79; sd 3.83; 95 %-CI 0.92 - 2.75) lesions. The strain ratio showed a sensitivity of 92.6 % (95 %-CI 82.1 - 97.9) and a specificity of 95.2 % (95 %-CI 86.7 - 99.0). The positive and negative predictive values were 94.3 % and 93.7 %. B-mode ultrasound achieved a sensitivity of 94.4 % (95 %-CI 84.6 - 98.8) and a specificity of 87.3 % (95 %-CI 76.5 - 94.3). The positive and negative predictive values were 86.4 % and 94.8 %. CONCLUSION: Strain ratio measurement of breast lesions is a standardized fast method for analyzing the stiffness inside the examined areas. Used as an additional tool to B-mode ultrasound, it helps to increase the specificity of the examination.

Multicenter study of ultrasound real-time tissue elastography in 779 cases for the assessment of breast lesions: improved diagnostic performance by combining the BI-RADS®-US classification system with sonoelastography.

PURPOSE: Hitachi real-time tissue elastography (HI-RTE) is an ultrasound technique that facilitates the estimation of tissue elasticity. Our study evaluates whether sonoelastography improves the differentiation of benign and malignant breast lesions. MATERIALS AND METHODS: In a multicenter approach sonoelastography of focal breast lesions was carried out in 779 patients with subsequent histological confirmation. We present data from 3 study centers (Berlin, Bielefeld, Homburg/Saar) focusing on the sensitivity (SE), specificity (SP) and the positive (PPV) and negative predictive value (NPV) of sonoelastography. In addition we performed an analysis of the diagnostic performance, expressed by the pretest and posttest probability of disease (POD), in BI-RADS®-US 3 or 4 lesions as these categories can imply both malignant and benign lesions and a more precise prediction would be a preferable aim. RESULTS: Sonoelastography demonstrated an improved SP (89.5 %) and an excellent PPV (86.8 %) compared to B-mode ultrasound (76.1 % and 77.2 %). Especially in dense breasts ACR III-IV, the SP was even higher (92.8 %). In BI-RADS-US 3 lesions, a suspicious elastogram significantly modified the POD from 8.3 % to a posttest POD of 45.5 %. In BI-RADS-US 4 lesions, we found a pretest POD of 56.6 %. The posttest POD changed significantly to 24.2 % with a normal elastogram and to 81.5 % with a suspicious elastogram. CONCLUSION: Our data demonstrates that the complementary use of sonoelastography definitely improves the performance in breast diagnostics. Finally we present a protocol of how sonoelastography can be integrated into our daily practice.