Ultrasound guided excisional biopsy of non-palpable breast lesions: technique and preliminary results

OBJECTIVE: To develop a simple and accurate technique of incisional biopsy under ultrasonographic guidance to aid the histological diagnosis of non-palpable lesions of the breast DESIGN: Open prospective study. SETTING: Teaching hospital, Italy. SUBJECTS: 35 patients who presented to this hospital with 42 non-palpable lesions diagnosed by echography or mammography during 18 month period 1995-1996. INTERVENTIONS: Creation of a pocket in the breast in which the transducer of the ultrasound scanner was inserted to guide the surgeon while an excision biopsy was taken. MAIN OUTCOME MEASURES: Histological diagnosis, and quality of scar. RESULTS: Mean (SD) diameter of the lesions was 11.6 (3.15) mm on the ultrasound scan, that of the biopsy specimens was 18.1 (5.82) mm, and that of the histological specimens 9.7 (3.52) mm. 29 lesions showed fibrocystic mastopathy with apocrine metaplasia, 10 fibroadenomas, 2 invasive ductal carcinoma, and 1 atypical duct hyperplasia. There were no unsightly scars. CONCLUSIONS: We have developed a simple and accurate technique for incisional biopsy under ultrasound control.     

Magnetic resonance guided localization and biopsy of suspicious breast lesions

Nausea, vomiting, and abdominal pain are common symptoms that suggest many diagnoses. The patient's symptoms may be related to an anatomical defect such as a peptic ulcer or a mechanical small bowel obstruction. However, no anatomical abnormality may be identified despite radiological, endoscopic, or laboratory studies. The cause of the patient's symptoms may have significant impact on the patient's quality of life (nonulcer dyspepsia) and life span (intestinal pseudo-obstruction). Abnormal antroduodenal motility may be the underlying cause of the patient's symptoms. Normally, coordinated phasic contractions in the stomach and small intestine maintain digestion and absorption of food. A prolonged set of phasic contractions (phase 3 of the migrating complex) begins in the stomach and propagates down the small intestine to excrete nondigestible foods, bacteria, and dead cells. Any disturbance in the normal motility pattern can lead to maldigestion and symptoms of upper intestinal dysfunction. Objective tests of motility disturbances in the stomach and small intestine include measurement of gastric emptying, intestinal transit, contractions of the stomach and duodenum, and electrogastrography. Abnormal antroduodenal motility may be secondary to an abnormality in the smooth muscle (myopathy) or the nerves in controlling smooth muscle contractions (neuropathy). Antroduodenal motility measurements may help identify a partial small bowel obstruction, the cause of small intestinal overgrowth, and the cause of chronic abdominal visceral pain. Motility studies may suggest useful drugs for correcting the underlying pathophysiology and relieving symptoms.     

Likelihood of malignant disease for various categories of mammographically detected, nonpalpable breast lesions

To determine the likelihood of malignant disease for mammographically detected, nonpalpable breast lesions, we defined 11 morphologic categories and retrospectively reviewed the mammograms in 859 cases in which biopsy was performed after a wire localization procedure at our institution during 1989 and 1990. Within each category, the total number of lesions and the percentage of cases with a surgical pathologic diagnosis of malignant involvement were as follows: benign calcification, 25 (0% malignant); indeterminate calcification, 200 (22%); malignant calcification, 39 (92%); smooth mass, 84 (1%); irregular mass, 337 (40%); architectural distortion, 45 (47%); asymmetric breast tissue, 37 (3%, or 1 case of asymmetrically prominent ducts); smooth mass with calcification, 3 (0%); irregular mass with calcification, 68 (66%); architectural distortion with calcification, 14 (57%); and asymmetric breast tissue with calcification, 7 (29%). The overall rate of malignant involvement for the 859 cases was 34%. If follow-up examinations rather than biopsies had been done for the lesions categorized as benign calcification, smooth mass, smooth mass with calcification, and asymmetric breast tissue (excluding asymmetrically prominent ducts), the overall positive predictive value would have increased from 34 to 41%, and 148 biopsies would have been deferred (17% of all biopsies). If morphologic criteria are applied to the evaluation of mammographically detected, nonpalpable lesions, the rate of malignant disease at biopsy may reach 40%. This rate correlates with that in recent large series.     

Radiology of nonpalpable breast lesions

The authors reviewed 619 consecutive cases of breast nonpalpable lesions detected with mammography in which wire-directed open biopsy or stereotaxic biopsy was performed from 1984 to 1993. The ratio of benign to malignant biopsy findings was 4:1 for the whole series. The positive predictive value (PPV) of different radiologic pattern was determined. Biopsy is advised in the presence of patterns such as strongly suspect microcalcifications (granular or branching morphologic features), stellate masses, parenchimal distortion, opacities with undefined borders and asymmetric density, which yielded higher PPVs (26%, 93%, 92%, 35%, 42% and 19% respectively). However, follow-up with mammography is advised in probably benign lesions (opacity with regular borders and clusters of round or oval particles of calcifications), which yielded lower PPVs (1.5% and 3%). By decreasing the number of biopsies of probably benign lesions and thereby substantially reducing costs, this approach may help to widespread use of mammographic screening.     

New instrumentation allows for removal of nonpalpable breast lesions

Breast cancer is the second leading cause of cancer deaths in women. Approximately 90% of breast cancer is curable if it is diagnosed and treated early. Increasingly, women are participating in mammographic screenings, which result in earlier detection of nonpalpable lesions. In the past, surgical removal was not an option for small lesions, and frequent mammographic monitoring was required until patients' lesions were large enough for needle core biopsies or needle localization for open surgical biopsies. Technology now has combined stereotactic imaging with a minimally invasive biopsy system for removal of these nonpalpable lesions. This capability for accurate early diagnosis and intervention is essential in improving patients' survival rates.     

Localization of nonpalpable breast lesions detected by xeromammography

A technique for localizing nonpalpable lesions of the breast using methylene blue dye is described. This technique is recommended for its accuracy, patient acceptance, and reduction in size of the biopsy specimen.     

Diagnostic framework of nonpalpable lesions of the breast

Mammography is the most sensitive test for non-palpable lesions, but its specificity is quite limited. When a decision for biopsy is based only on the mammographic appearance the benign/malignant biopsy ratio (B/M) is around 3:1. The B/M varies according to the radiological pattern being favourable for stellate opacities, high for regular opacities, and intermediate for distortions and microcalcifications. Aspiration cytology of non-palpable lesions, either sonographically or stereotaxically guided, is highly accurate. When the decision for surgical biopsy is taken also on the basis of cytology, B/M may be reduced by up to 0.5:1. As false negatives are expected for cytology, lesions which are strongly suspicious at mammography must be biopsied anyway. Sonography guided aspiration is possible in about a half of mammographically detected non-palpable lesions, particularly for opacities, whereas distortions and microcalcification are seldom visualized at sonography. Cytology should be routinely performed in the presence of questionable non-palpable lesions.     

Single plane fluoroscopic guided biopsy of thoracic lesions

Single plane fluoroscopic guided biopsy was performed successfully in 61 of 70 patients with thoracic lesions using inexpensive spinal needles. Lesions smaller than 2 cm and those located within 2 cm distance from vascular structures were not biopsied using this technique. Post-biopsy pneumothorax developed in 15 of the 46 biopsies of the intrapulmonary lesions. Five patients required a chest tube placement for symptomatic pneumothoraces. There were no fatalities. It is suggested that in a selected group of patients single plane fluoroscopic guided biopsy is a safe and fast method for diagnosis of a thoracic lesion.     

Endoscopic laser excisional biopsy for selected glottic carcinomas

From January 1988 to December 1990, 44 previously untreated patients with squamous cell carcinomas (SCCs) of the true vocal cord (33 T1a, 11 Tis) underwent carbon dioxide laser excision. The mean follow-up was 28 months (range, 12 to 44 months). Endoscopic excisional biopsy was the primary treatment in 38 of the 44 patients, whereas postoperative radiotherapy was added in 6 cases in which the pathology report showed positive margins. Recurrent vocal cord SCC developed in 8 (18%) of the cases, with an average interval of 17.8 months. Re-treatment consisted of a second laser excision in 4 cases, radiotherapy in 1, hemilaryngectomy in 1, and total laryngectomy in 2. The definitive cure rate with endoscopic excisional biopsy for the patients originally treated with laser excision alone was 94.7% (36/38). Endoscopic laser treatment for selected glottic SCC proves to be an excellent alternative to radiotherapy or open neck surgery.     

The Advanced Breast Biopsy Instrumentation (ABBI), a system for stereotactic excision of mammographically suspect nonpalpable findings in the breast

Advanced Breast Biopsy Instrumentation (ABBI) allows radiologically guided stereotactic excision of non-palpable radiodense lesions with high accuracy. Tissue cylinders of 5, 10, 15 or 20 mm diameter and of variable lengths can be removed very accurately under local anaesthesia and on an outpatient basis. Thirty-six patients with suspicious clusters of microcalcifications (n = 29) and with round lesions (n = 7) of the breast were qualified for ABBI. We were able to perform the excisional biopsy in a total of 34 patients. The breast of one woman was too small to safely fit into the system and in another woman the lesion could not be visualized by the system. In 2/34 cases (6%), the excision was imprecise due to slight dislocation of the breast parenchyma by the advancing cylinder knife. In one case (3%), ABBI missed the target within a dense mastopathic breast. In all cases the excisions were well tolerated. No wound complications occurred and the cosmetic result was excellent. Histology revealed 28 benign (82%) and 6 malignant (18%) lesions. Among the 27 small microcalcifications there were 3 invasive carcinomas, 3 ductal carcinomas in situ (DCIS), 1 lobular hyperplasia, 14 mastopathies, 1 fibroadenoma, 1 duct papilloma and 4 calcifications in scars. Four of the 7 round-shaped lesions were found to be fibroadenomas, 1 lobular hyperplasia, and 2 mastopathies. With the ABBI system, non-palpable breast lesions can be precisely localized and excised.     

Percutaneous blind needle biopsy versus combined laparoscopic excisional and guided needle biopsy in the diagnosis of liver disorders in pediatric patients

A special interest, both in scientific publications and in the mass media, is recently emerged about the use of hormone replacement therapy (HRT) in post-menopausal women. Beside, in fact, the specific indication for the relief of menopausal symptoms, hypotheses are debated about a possible role of HRT in the reduction of risk of osteoporosis and cardiovascular diseases, and in the increased risk of breast cancer. This situation emphasizes the need for assessing the benefit/risk profile for HRT in order to ensure that strategies of proven clinical effectiveness, based on large randomized clinical trials, will be adopted in the population.     

Percutaneous large-core biopsy of papillary breast lesions

Neisseria meningitidis, Haemophilus influenzae, and Streptococcus pneumoniae possess the ability to cleave human IgA1 antibodies, and all successfully colonize and occasionally invade the human upper respiratory tract. N. meningitidis invades the bloodstream after a period of nasopharyngeal colonization. We directly compared levels of IgA1 protease activity in strains (n=52) derived from the cerebrospinal fluid or blood of patients with meningococcal disease with strains of N. meningitidis obtained from asymptomatic carriers (n=25). IgA1 protease activity was determined by a sensitive semiquantitative ELISA assay. Levels of IgA1 protease activity were significantly higher (P<0.0001) in strains associated with invasive meningococcal disease (98% with detectable activity, mean = 580 mU) than with those obtained from asymptomatic carriers (76% with detectable activity, mean = 280 mU). Despite marked variation in enzyme activity, almost all strains (96%) possessed the gene for IgA1 protease. Given the panmictic population structure of the bacterial isolates investigated, these data, obtained from two groups infected with N. meningitidis, but with markedly different clinical outcomes, provide the first quantitative evidence that IgA1 protease activity is a virulence determinant that contributes to the pathogenic phenotype, and suggest IgA1 protease as a potential target for prophylaxis.     

An update on core needle biopsy for radiologically detected breast lesions

BACKGROUND: Traditionally, radiologically detected lesions of the breast have been evaluated by open surgical biopsy with wire localization. Recently, core needle biopsy has been introduced as an alternative to open surgical biopsy. The authors evaluated their own results with long term follow-up after core needle biopsy and reviewed the experience of other physicians with this new technique. METHODS: Four hundred thirty-one core needle biopsies performed at UCLA were analyzed. The outcome of these cases was determined by either surgery or long term follow-up. Statistical analysis was performed to determine the accuracy of the method. RESULTS: Definitive outcome was obtained in 96% of the core needle biopsy cases, with a median follow-up time of 18 months (range, 6-38 months). The authors achieved a sensitivity of 99% and a specificity of 100%. The false-negative rate was 1.7%. There were no complications in this series. CONCLUSIONS: Core needle biopsy is a highly accurate and safe method for the diagnosis of radiologically detected lesions of the breast.     

Prone table stereotactic breast biopsy: facilitating biopsy of posterior lesions using the arm-through-the-hole technique

This note reports on incidental observations of the early development of the third-stage larvae of Hysterothylacium aduncum from gadid fishes. Gravid H. aduncum females were collected from Pollachius virens, Pollachius pollachius. Gadus morhua, and Molva molva in Norwegian waters. The eggs were incubated at 20 per thousand salinity and 5 C. Spontaneous hatching of third-stage larvae was observed 10-25 days after egg deposition. These larvae were long lived and could infect Acartia tonsa copepods, the infections being maintained for up to 34 days. The morphology of the third-stage larvae in the copepods and some traits of the life cycle were similar to those reported in previous studies. However, our results disagree with evidence suggesting that H. aduncum eggs rarely hatch, and hatched larvae have lower survival and a poorer ability to infect the first intermediate host than unhatched ones. It is difficult to account for these discrepancies because information on the early development of Hysterothylacium species is incomplete. However, we tentatively suggest that differences in the early development of H. aduncum may indicate the existence of at least 2 different taxonomic entities in the North Atlantic, which is consistent with previous evidence based on morphological traits.     

Core needle biopsy of synchronous ipsilateral breast lesions: impact on treatment

OBJECTIVE: The purpose of this study was to evaluate the role of core biopsy in the diagnosis of multiple synchronous ipsilateral breast lesions and to determine the impact of this information on patients' management. MATERIALS AND METHODS: Of 371 patients who underwent core-needle breast biopsy under stereotaxic (n = 278) or sonographic (n = 93) guidance, 20 (5%) underwent core biopsy of two mammographically separate lesions in the ipsilateral breast on the same date. Fourteen of these 20 patients subsequently underwent surgery. We retrospectively reviewed the medical, radiographic, and histopathologic records in these 14 patients and in 91 patients with single mammographic lesions diagnosed as carcinoma by means of core biopsy during the same period. RESULTS: In 11 patients, core biopsy revealed two sites of carcinoma. Core biopsy findings in these 11 patients were two areas of infiltrating ductal carcinoma (n = 5), one infiltrating ductal carcinoma and one infiltrating lobular carcinoma (n = 2), one infiltrating ductal carcinoma and one ductal carcinoma in situ (n = 1), and two foci of ductal carcinoma in situ (n = 3). All 11 patients with two core biopsy-proven foci of carcinoma underwent mastectomy. Patients were significantly more likely to be treated with mastectomy if core biopsy revealed two rather than one site of carcinoma (100% versus 38%, p < .001). CONCLUSION: Core-needle biopsy is useful in diagnosing multiple synchronous ipsilateral breast lesions. By showing whether carcinoma is present in one or more sites in the breast, core biopsy can provide information of critical importance in making treatment decisions.     

Autofluorescence guided biopsy for the early diagnosis of bladder carcinoma

To assess whether there is increased risk of tuberculous infection in children who traveled to or had a household visitor from a country having a high prevalence of tuberculosis, we conducted a case-control study. Children younger than 6 yr of age who had a tuberculin skin test read at public health clinics in areas of California that have a high prevalence of tuberculosis were enrolled. Of the 953 children who had a skin test read, 72 (7.6%) had a positive reaction. By multiple logistic regression analysis, children who had traveled in the 12 mo before the skin test were 3.9 times more likely to have a positive skin test than were children who had not traveled (95% confidence interval [CI], 1.9 to 7.9). Among children born in the United States, those who had traveled were 4.7 times more likely to have a positive skin test (95% CI, 2.0 to 11.2). Children who had a household visitor from a country having a high prevalence of tuberculosis were 2.4 times more likely to have a positive skin test than were those who did not have a visitor (95% CI, 1.0 to 5.5). These data indicate that travel to a country that has a high prevalence of tuberculosis or having a visitor from such countries increase the risk of tuberculous infection among young children. Physicians and tuberculosis control programs should incorporate questions about travel and visitors into their evaluations, and children with a history of extended travel should have a tuberculin skin test.