Ultrasound-guided fine needle aspiration biopsy in the diagnosis of breast cancer recurrence after mastectomy

PURPOSE: To define the accuracy and clinical impact of fine needle aspiration biopsy (FNAB) in diagnosing recurrent breast cancer after mastectomy. MATERIAL AND METHODS: The results of ultrasonography (US) and US-guided FNAB of 175 lesions located at the mastectomy site or in the ipsilateral axilla were reviewed. The final diagnosis was recurrent cancer in 77 cases and benign lesion in 98 cases, as verified by histological examination (n = 77) or follow-up (n = 98). RESULTS: FNAB yielded a representative aspirate in 92.6% of cases. The sensitivity, specificity and overall accuracy of FNAB cytology were 96.1%, 89.8% and 92.6% respectively. US and FNAB cytology were complementary methods in recurrent cancer diagnosis. The cytologic examination increased the specificity of US. The only recurrent tumor which appeared benign both sonographically and cytologically was removed because of a suspicious finding at palpation. FNAB cytologic diagnosis was found to have a clinical impact in 92.2% of the recurrent cases. CONCLUSION: US-guided FNAB provided an accurate adjunct to clinical examination and mammography for diagnosing and excluding breast cancer recurrence after mastectomy.     

Significance of nondiagnostic fine-needle aspiration of the thyroid

BACKGROUND: Fine-needle aspiration biopsy (FNAB) has been shown to be rapid and cost effective in the evaluation of thyroid nodules. The significance of nondiagnostic (unsatisfactory) FNAB is uncertain, however. METHODS: We reviewed 345 consecutive thyroid FNABs and identified 59 patients with initially unsatisfactory specimens. These patients had follow-up to determine whether their thyroid nodules proved to be malignant. RESULTS: Three patients (5.1%) were found to have organ-confined papillary carcinoma of the thyroid, the largest tumor mass measuring 1.2 cm. Six patients (10.2%) had benign adenomas. CONCLUSIONS: In most cases of initially nondiagnostic FNAB of a thyroid nodule, neoplasia is not found subsequently. A minority of cases may still harbor malignancy. None of our patients in whom repeated FNA was either nondiagnostic or suggestive of benign disease were ultimately found to have a malignancy.     

Primary cryptococcal infection of the larynx in a patient with AIDS: a case report

From January of 1990 to December of 1992, 6,954 consecutive cytologic breast fine-needle aspiration biopsies (FNAB) were performed at the Laboratory of Pathology of Sant'Anna Hospital in Turin. Of these cases 62% were solid nodes, 35% were cystic nodes, and 2.7% were nonpalpable breast lesions (stereotaxic or ultrasound guided FNAB). We verified 4,110 cases: 913 cases underwent surgery and 3,197 were evaluated clinically, and/or cytologically, and/or with mammography at least 1 yr after the first diagnosis, or checked with the database of the Tumor Registry of Turin. In our series the FNAB sensitivity was 94.6%, specificity was 99.9%, accuracy was 98.8%, inadequate samples were 6.4%, false-negative rate was 1.4%, and false-positive rate was 0.3%. Our results indicate that the use of cell block improves sensitivity (from 85.2 to 94.6%) and strongly reduces false-negative results (from 3.9 to 1.4%). We conclude that FNAB is a discriminant procedure to the surgical biopsy in cases with clinical, ultrasound, or mammographic low or intermediate suspect, contributing to allow a high malignant/benign surgical biopsy rate and to reduce the need for frozen section diagnosis and medical costs.     

Refined use of scintigraphy in the evaluation of nodular thyroid disease

BACKGROUND: Scintigraphy has been advocated in patients with a thyroid nodule when fine needle aspiration biopsy (FNAB) is not definitive. The purpose of this study was to determine the incidence of hyperfunctioning nodules in patients without a definitive FNAB, the correlation of serum thyrotropin (TSH) levels with the functional status of a nodule, and whether a sensitive TSH assay can be used in lieu of scintigraphy. METHODS: From 1990 to 1996, patients with a thyroid nodule were evaluated with FNAB and serum TSH measurement. Iodine-123 scintigraphy was reserved for patients without a definitive FNAB and was correlated with TSH levels. RESULTS: Of 356 patients with a thyroid nodule, 102 did not have a definitive FNAB. A hyperfunctioning nodule was diagnosed in 14 of the 102 patients. A low TSH level was detected in 12 (86%) of 14 patients with a hyperfunctioning nodule (mean = 0.04 +/- 0.38 microIU/mL) and only 20 (23%) of 88 patients with a hypofunctioning nodule (mean = 0.87 +/- 4.11 microIU/mL) (P < .05). Only 2 of 70 (2.8%) patients with a normal or increased TSH level had a hyperfunctioning nodule. CONCLUSIONS: A 14% incidence of hyperfunctioning nodules in patients without a definitive FNAB warrants the use of scintigraphy but only when serum TSH levels are low, thus avoiding unnecessary scans in 91% of patients with a thyroid nodule.     

Role of ultrasound-guided fine-needle aspiration biopsy in evaluation of nonpalpable thyroid nodules

To determine the role of ultrasound-guided fine-needle aspiration biopsy (US-FNAB) in the evaluation of incidentally diagnosed nonpalpable thyroid nodules (NP-TN), we compared the diagnostic yield of US-FNAB in NP-TN larger than 10 mm in diameter, with palpation-guided (P-FNAB) in palpable thyroid nodules (P-TN) in the same hospital setting. Of 108 consecutive patients with NP-TN (female/male: 97/11, age: 55.2 +/- 14.3, mean +/- SD), malignancy was identified in 8 patients (7 with thyroid papillary carcinoma, 4 of which had extrathyroidal spread, and 1 patient had metastasis of pulmonary adenocarcinoma). Male gender was associated with higher prevalence of malignancy (p = 0.09) while calcification and/or cystic degeneration of the nodule did not predict the cytological findings. Malignancy was identified in 16 of 151 consecutive patients with P-TN (female/male: 139/12, age: 44.1 +/- 9.5, mean +/- SD) indicating a similar rate of malignancy in both NP-TN and P-TN. In the P-TN group thyroid cancer was more common in males (p = 0.007), and the US properties of the nodule did not predict its cytological diagnosis. In conclusion, because similar rates of cancer are detected by FNAB in both NP-TN and P-TN, an FNAB is recommended for NP-TN larger than 10 mm.     

Adenoid cystic carcinoma of the breast: mammographic appearance and pathologic correlation

OBJECTIVE: The objective of our study was to describe the mammographic features of adenoid cystic carcinoma of the breast and to correlate mammography findings with histopathologic findings. CONCLUSION: Adenoid cystic carcinoma is a rare type of breast neoplasm that usually appears as a slowly enlarging nodule. In spite of its low incidence, recognition is important because early detection ensures good prognosis. On mammography, these tumors often appear as moderately circumscribed, lobulated nodules that are similar to other types of benign and malignant tumors. Therefore, cytologic and histologic evaluations are needed for accurate diagnosis.     

Diagnostic role of mammography and clinical examination in the framework of a screening program for breast carcinoma in Brescia

Screening by mammography is at present the only way to obtain good results in terms of diagnosis of breast cancer at an early stage. In this paper we present the results of first and second rounds of a mammographic and clinical screening programme carried out in the health district of Brescia. At the first round out of 129 cancers detected, mammography was diagnostic in 124 cases; in 82 cases, the examination also allowed the identification of a suspicious nodule, while in 42 cases non palpable neoplasm was diagnosed with mammography alone. In the remaining 5 cases mammography was negative and only clinical examination led to the discovery of breast neoplasms. In the second round, in the 125 cancers detected, mammography was diagnostic in 124 cases; clinical examination allowed the identification of 59 of these tumours, while in 65 cases non palpable tumours were found with mammography alone. Only in one case mammography was negative and clinical examination led to the identification of the tumour.     

Imaging findings in renal hydatid disease

The aim of this work is to describe the image findings of renal hydatid disease, especially on MR. Four cases of echinococcal involvement of the kidney were retrospectively reviewed. All patients had intravenous urography (IVU) and US performed. Computed tomography examination was available in three patients and MR in two cases. Intravenous urography demonstrated communication of the cyst to the collecting system in one case. Ultrasound revealed multicystic appearance in three cases and unilocular in one case. Computed tomography demonstrated unilocular thick-walled or multilocular cysts with well-defined walls, calcified in one case. In multilocular cysts the CT densities of the fluid of daughter cysts was significantly lower than the fluid of mother cysts. This typical appearance was present in three of our cases. The presence of a hypointense rim and a multicystic appearance were distinctive in MR imaging. The combined findings of these different imaging modalities aid greatly in establishing the correct diagnosis. Magnetic resonance imaging is of value in determining the presence of a characteristic rim and enables the evaluation of anatomical relationships.     

MR lesion detection in a breast cancer population

Implementation of MR imaging of the breast as an extension of the existing imaging modalities in the diagnosis of breast cancer was evaluated in a university cancer center, MR imaging of the breast was performed in 54 patients, in whom the MR results were compared with the triple test (the combination of clinical examination, mammographic evaluation, and cytology) and the final histological diagnosis. MR imaging of the breast depicted 30 of the 33 malignancies (sensitivity, 91%). In two of the malignancies, the carcinoma was clinically and mammographically occult. For the three patients with a false-negative MRI diagnosis, the conventional mammography showed suspicions clustered microcalcifications as a sign of in situ carcinoma. For seven patients, MR imaging of the breast incorrectly suggested the presence of a malignant lesion (specificity, 67%). To improve MR specificity, we perform MR-guided ultrasonographic fine-needle aspiration biopsy (FNAB). Although MR imaging of the breast is a highly sensitive examination, conventional x-ray mammography remains the most efficient imaging modality in the diagnosis of breast cancer. In our patient population, MR imaging of the breast had additional value for women with mammographically dense breast tissue and especially for patients with clinical evidence of breast carcinoma that could not be detected with conventional diagnostic methods.     

The accuracy of breast ultrasound in the evaluation of clinically benign discrete, symptomatic breast lumps

INTRODUCTION: Recent reports have suggested that breast ultrasound (US) is of value in distinguishing malignant from benign processes. The aim of this study was to establish the accuracy of US in detecting invasive malignancy in clinically benign, discrete, symptomatic breast lumps. METHODS: The US appearances of 205 clinically benign breast masses were documented prospectively and prior to mammography by one radiologist (AJE). The US appearances were then correlated with the fine needle aspiration (FNA), core biopsy and surgical findings and compared with the mammographic findings. RESULTS: The US findings were normal 72 (35%), simple cyst 63 (31%), solid benign 51 (25%), solid indeterminate 15 (7%) and solid malignant four (2%). Ultrasound characterized 13 (93%) of the 14 patients found to have invasive carcinoma as indeterminate or malignant. No patients with normal or simple cyst US findings had invasive malignancy. Ultrasound had significantly better accuracy (97% vs 87%, P < 0.02) sensitivity (93% vs 57%, P < 0.05) and negative predictive value (99% vs 92%, P < 0.002) than mammography in the detection of invasive carcinoma when indeterminate and malignant imaging findings were taken as positive. CONCLUSION: US is a useful adjunct to FNA/core biopsy in confirming the nature of symptomatic, clinically benign breast masses and is superior to mammography in this clinical setting.     

Transition from cold to hot thyroid nodules

We report three cases of autonomously functioning thyroid nodules (AFTNs) that appeared hypofunctioning at radioactive iodine (131I) thyroid scan carried out at initial observation. Since at that time thyroid hormones and thyrotropin (TSH) were also normal, they were initially classified as "cold" nodules and treated with levothyroxine (LT4). The correct diagnosis of AFTN was made years later when a thyroid scintigraphy was repeated. In two of these patients, re-evaluation of the nodule was done because of the development of LT4 intolerance. A possible explanation is that these AFTNs had undergone hemorrhagic/cystic degeneration when they were first studied, but in subsequent years, proliferation of residual AFTN tissue caused the recurrence of a typical functioning nodule.     

Exhumation and no end. A comparative analysis]

INTRODUCTION: In the last 25 years, random trials on the advantages of combined surgery and irradiation/chemotherapy of breast cancer demonstrated similar survival rates to those of massive surgery. However, both irradiation and chemotherapy have advanced and now yield good local control of the disease, so that even large breast cancers can be made operable. Breast cancer follow-up is carried out with imaging and clinical examinations to detect early locoregional recurrences, contralateral lesions and distant recurrences: to this purpose, we carried out a comparative study of all imaging modalities. MATERIAL AND METHODS: We retrospectively reviewed the data of 42 breast cancer (T2-T3 N0-N+) patients of the Senology Center of the Catholic University (Rome, Italy) treated with irradiation and/or chemotherapy for tumor debulking to permit conservative surgery. We investigated the sensitivity and the indications of mammography, B-mode and color Doppler US and MRI in measuring the exact tumor size and detecting locoregional metastatic nodes. RESULTS: After 3 years' treatment, our recurrence rate (19%) is a little higher than those in the major international trials (4.2-9% and 5 tears). The recurrence was on the surgical scar in 75% of cases (6/8), while multifocal tumors were found in 25% of cases. US was the most accurate method in measuring tumor size in 90% of cases (18/20), while mammography frequently overstaged the lesion and yielded exact measurements in 65% of cases (13/20). MRI was as accurate as US, but this technique is too expensive and little available in Italy. US accurately diagnosed lymph node recurrences (70% sensitivity), but MR rate was even higher (80%), while mammography and color Doppler US had only 5-10%. As for treatment outcome, an irregular and blurred nodule or multifocal lesions at mammography indicate poor/no response, while a much smaller radial scar than at previous similar follow-ups indicates treatment success. CONCLUSIONS: When correctly integrated, mammographic, US and MR patterns permit exact tumor size measurement and show possible locoregional lymph node involvement in the patients submitted to conservative surgery and irradiation/chemotherapy. In contrast, color Doppler findings remain poorly specific in this disease, with about 55% sensitivity. Therefore, radiologic studies, with clinical and laboratory data, have a major prognostic value in assessing the biological response to combined treatment.     

The use of fine needle aspiration biopsy in the management of thyroid disease

Fine needle aspiration biopsy is now a first line investigation in thyroid disease. The purpose of this study was to evaluate the results of this technique in comparison with routine histopathology. A total of 593 aspirations over a four year period were included. There were 390 (65.7%) solitary nodules, 124 (20.9%) multinodular goiters, 66 (11.1%) diffuse goitres and 13 (2.2%) recurrent post thyroidectomy nodules. Radioisotope scanning in 386 cases showed 325 (84.2%) cold nodules, 54 (14.0%) warm nodules and 7 (1.8%) hot nodules. There were 458 (77.2%) colloid goitres and cysts, 14 cases of thyroiditis (2.2%) and 30 malignancies diagnosed on fine needle aspiration biopsy. In 19 cases (3.2%) a diagnosis of follicular neoplasm and in 29 cases (4.9%) a diagnosis of suspicious aspirate was made. Histological results were available in 176 cases. In 108 cases findings of histology and FNAB were compared with radioisotope scanning. A sensitivity of 92.8% and 42.8%, a specificity of 90.1% and 98.7% and accuracy index of 90.3% and 94.3% was found, when considering suspicious cases alternatively as positives and negatives. Surgery was recommended in all suspicious cases to prevent reduction in sensitivity of the technique. Fine needle aspiration biopsy was found to be a highly effective procedure which can obviate a lot of unnecessary surgery in thyroid lesions.     

Potentialities of ultrasound examination in differential diagnosis of benign nodules and breast cancer

The results of examination of 410 patients with nodular masses of the breast are analysed. Benign tumors were present in 314 (76.6%) of the patients, cancer of the mammary gland--in 96 (23.4%) of the patients. The tumors were classified into 3 types, depending on the intensity of the ultrasound wave behind the tumor. Based on the clinical and morphological analyses it was demonstrated that the presence of the acoustic wave behind the tumor is typical for the invasive cancer of the duct, scirrous carcinoma and lobular cancer. In medullar and mucosous cancer the intensity of the ultrasound wave does not change. In case of intracystic cancer the symptom of "back magnification" is present. The sensitivity of the ultrasound in detection of mammary gland cancer is 88.5%, specificity--96.5%. The analogous parameters of mammography are: 91.0% and 97.8%. In the use of ultrasound control in fine needle aspiration biopsy (FNAB) the sensitivity and specificity of the method increases from 88.5% to 92.7%. If the diagnosis of mammary gland cancer was established with the use of ultrasound and FNAB the additional use of mammography is not obligatory.     

Mammographically negative breast cancer at the Strathfield Breast Centre

BACKGROUND: The current diagnostic modalities used to detect breast cancer are mammography, together with clinical examination, ultrasound and fine needle aspiration biopsy (FNAB). The accuracy rates for each modality varies and a combination of the modalities is recommended to detect cancer early. Some authors have suggested that mammography should be used primarily as a screening tool because of the false negative mammography results that have been reported in the past 10 years. The records of patients at the Strathfield Breast Centre were reviewed to determine the accuracy of other modalities. METHODS: The records of 371 breast cancer patients treated at the Strathfield Breast Centre in the 6 years form 1989 to 1994 were reviewed to determine the accuracy of mammography, ultrasound, clinical examination and fine needle aspiration biopsy. Of the 371 women with histopathologically diagnosed breast cancer, 349 had mammography. RESULTS: The accuracy rate of mammography in the present study was 91% with a false negative rate of 9%. It was found that there was no significant delay in treatment of breast cancer in mammogram-negative patients. CONCLUSIONS: Mammographically negative breast cancer was found to be more common in younger women, to be similar in size to mammogram-positive cancer, to occur in all histological types and grades and was usually invasive rather than noninvasive. The rate of lymph node involvement was similar to the mammogram-positive group.     

Mammography changes associated with hormone replacement therapy in post-menopausal patients

Hormone replacement therapy (HRT) in post-menopausal or ovariectomized women reduces mortality due to cardiovascular diseases, lowers morbidity due to osteoporosis and improves vasovagal symptoms. Long-term therapy, however, increase the risk of side-effects. HRT may decrease mammographic sensitivity, markedly increasing glandular density. Enlargement of pre-existing cysts and fibroadenomas has also been reported after HRT. The correlation between HRT and breast cancer is highly controversial. We examined 650 women: 550 of them (84.6%) received HRT (157 estrogens and 393 estrogens-progestins) and 100 (15.4%) refused treatment and were thus considered as a control group. All patients underwent mammography and DEXA before HRT and, during treatment, were followed-up yearly with mammography, often combined with US, and DEXA. Fisher's test was used for data analysis (confidence interval: 95%). The statistical analysis showed a significant difference between the HRT group and the control group only for the lumbar spine. Mammographic changes (Tab. II) were shown in 150 of 550 HRT patients. Increased breast density was the most frequent finding. Benign lesions arising de novo or increasing in size and/or number were observed in 41 of 150 patients (27.3%) in the HRT group, where 3 breast carcinomas were detected, versus 1 breast cancer only in the control group. HRT had a marked positive effect on bone mineral content (BMC) at 2 years' follow-up, but it remains debated if it reduces breast cancer risk. In conclusion, our results indicate that a yearly mammography is mandatory in long-term HRT subjects and US may be also needed in particularly dense breasts.     

Nocturnal variation in human sympathetic baroreflex sensitivity

INTRODUCTION: The differential diagnosis of malignancy in small foci of microcalcifications or in extremely small nodes can be difficult. We carried out a retrospective analysis of integrated mammographic and US results, correlated with histologic data, to assess the limitations of each method and to optimize and benign/malignant ratio. MATERIALS AND METHODS: Our series consisted of 485 nonpalpable breast lesions submitted to histologic examination after vegetable charcoal marking. We gave each lesion an 0-5 score according to the degree of diagnostic doubt/suspicion after mammography and US, which results were correlated with histologic data to assess the carcinoma frequency in the various groups identified. RESULTS: The analysis of mammographic and US images showed that the most frequent mammographic alteration in the lesions submitted to biopsy was an isolated cluster of microcalcifications (40.99%): of these, 36.86% were neoplastic. The nodules submitted to biopsy, which were 29.81% of the total, showed a cancer rate (36.80%) very similar to that of the microcalcifications. The carcinoma rate rose to 37.93% when the microcalcifications were associated with nodes. The highest carcinoma rates, i.e., 52.94% and 66.66%, respectively, were found in parenchymal distortions, either isolated or associated with microcalcifications, which however were only 7.03% and 3.10%, respectively, of the total number of cases. DISCUSSION AND CONCLUSIONS: Our study showed that: 1) a highly suspicious US result must be seriously considered when a negative mammography has poor intrinsic contrast; 2) a highly suspicious US image with a little suspicious good contrast mammography requires further confirmation before surgery is planned; 3) when the mammographic finding is mid-to-highly suspicious, further investigations are needed even if US is negative. To conclude, even though the histologic examination of nonpalpable breast lesions involves performing a biopsy, we believe this is acceptable when performed on an outpatient basis, under local anesthesia and removing a limited amount of tissue only. The benign/malignant ratio ranges 2 to 1.5: if it is further reduced (below 1.5), there will be the risk of missing some early neoplastic lesions.     

Failure in self care and heart failure, thiamine deficiency in geriatric patients

The ultrasonographic findings of 25 lesions in 23 patients with surgically proven ovarian masses were reviewed. There were 10 cystic teratomas, two simple cysts, two follicular cysts, two mucinous cystadenomas, two NHL, one corpus luteum cyst, one hydrosalpinx, one serous cystadenoma, one yolk sac carcinoma, one dysgerminoma, one embryonal carcinoma, and one mixed form (yolk sac carcinoma, choriocarcinoma). All patients were less than 15 years old. We classified all cases into four patterns: cystic, cystic with mural nodule, mixed, and solid. Eight lesions of the cystic pattern included two simple cysts, two follicular, cysts and one corpus luteum cyst. The other lesions were benign, too. Nine lesions with the cystic with mural nodule pattern consisted of eight cystic teratomas and one mucinous cystadenoma. All lesions were benign. The mixed pattern was seen in four lesions, half of which were malignant, i. e., one embryonal carcinoma and one yolk sac carcinoma. Four lesions with the solid pattern were all malignant masses: one dysgerminoma, two NHL and one mixed form. In this classification, the cystic and cystic with mural nodule patterns are benign, while mixed and solid patterns are highly suggestive of malignancy.     

Intrathyroidal lymphoepithelial cyst. A report of two cases not associated with Hashimoto's thyroiditis

Two cases of intrathyroidal lymphoepithelial cyst are described. Both of them were solitary, one being found incidentally in a patient operated on for a multinodular goiter, the other being clinically obvious as a cold nodule. They exhibited features of cysts of branchial cleft origin, i.e. squamous cell lining epithelium and abundant lymphoid tissue with reactive germinal centers. The thyroid gland parenchyma showed a discrete lymphoid infiltration consistent with the diagnosis of focal lymphocytic thyroiditis. In the first case a single epidermoid solid cell nest was found. The histogenesis of intrathyroidal lymphoepithelial cysts remains unclear, but their origin from cystically degenerated ultimobranchial body remnants (solid cell nests) seems to be most probable. This assumption is supported by a similar immunohistochemical profile of solid cell nests and epithelial cells lining the cysts and also by the presence of one solid cell nest in the proximity to the cyst in one of our cases.     

Maternal transposition of the great arteries in pregnancy. A case report

To determine the accuracy of whole-breast compression ultrasonography (US) in scanning palpable and nonpalpable breast lesions, the author correlated the findings of this method with those of mammography for 121 patients, ranging in age from 22 to 71 years, over a 2-year period. The two methods were performed on the same day by the same radiologist, who reviewed the mammograms before conducting US. In total, 120 lesions were found in 90 of the patients. Of these lesions, 35 (29.2%) were found in mammograms but were not observed during whole-breast compression US; 26 of the 35 lesions were isoechoic and the other 9 were less than 5 mm in diameter. Eighty-five lesions were observed with both methods. The author emphasizes the need for compression during breast US as well as mammography. Whole-breast compression US allows a view of the whole breast, which complements the views usually obtained by mammography. This method confirms the isoechoic nature of some breast lesions. Although mammography remains the gold standard for breast screening, the author suggests that whole-breast compression US with the patient in the sitting position be used for further assessment of both palpable and nonpalpable lesions, in addition to lesion-directed US.