Accelerated partial breast irradiation using 3D conformal radiotherapy: toxicity and cosmetic outcome.

PURPOSE: The aim of this paper is to analyze the incidence of acute and late toxicity and cosmetic outcome in breast cancer patients submitted to breast conserving surgery and three-dimensional conformal radiotherapy (3D-CRT) to deliver accelerated partial breast irradiation (APBI). METHODS AND MATERIALS: 84 patients were treated with 3D-CRT for APBI. This technique was assessed in patients with low risk stage I breast cancer enrolled from September 2005 to July 2011. The prescribed dose was 34/38.5 Gy delivered in 10 fractions twice daily over 5 consecutive days. Four to five no-coplanar 6 MV beams were used. In all CT scans Gross Tumor Volume (GTV) was defined around the surgical clips. A 1.5 cm margin was added by defining a Clinical Target Volume (CTV). A margin of 1 cm was added to CTV to define the planning target volume (PTV). The dose-volume constraints were followed in accordance with the NSABP/RTOG protocol. Late toxicity was evaluated according to the RTOG grading schema. The cosmetic assessment was performed using the Harvard scale. RESULTS: Median patient age was 66 years (range 51-87). Median follow-up was 36.5 months (range 13-83). The overall incidence of acute skin toxicities was 46.4% for grade 1 and 1% for grade 2. The incidence of late toxicity was 16.7% for grade 1, 2.4% for grade 2 and 3.6% for grade 3. No grade 4 toxicity was observed. The most pronounced grade 2 late toxicity was telangiectasia, developed in three patients. Cosmetics results were excellent for 52%, good for 42%, fair for 5% and poor for 1% of the patients. There was no statistical correlation between toxicity rates and prescribed doses (p = 0.33) or irradiated volume (p = 0.45). CONCLUSIONS: APBI using 3D-CRT is technically feasible with very low acute and late toxicity. Long-term results are needed to assess its efficacy in reducing the incidence of breast relapse.

Radiography of the surgical specimen in early stage breast lesions: diagnostic reliability in the analysis of the resection margins.

PURPOSE: The purpose of this study was to evaluate the diagnostic reliability of specimen radiography in the assessment of the status of resection margins in early stage breast lesions. MATERIALS AND METHODS: The study involved 123 consecutive patients who underwent breast-conserving surgery for early stage breast lesions. Specimen radiography in the two orthogonal views and with direct magnification was obtained in all cases to assess presence or absence of the lesion, position of the lesion within the surgical specimen and direction in which to extend the excision in cases of lesions located close to the margin. Diagnostic reliability was evaluated for only 102 patients with malignant lesions. RESULTS: Comparison between the radiological and histological diagnoses before immediate reexcision had 66% sensitivity, 86% specificity, 74% positive predictive value and 81% negative predictive value. Definitive histological assessment of margin status, including status after reexcision, was infiltrated margins in 23 patients (23%) and clear margins in 79 patients (77%). Definitive histological assessment in 12/19 patients (63.15%) with intraoperative reexcision, confirmed margin infiltration of the first specimen. Twenty patients (20%) underwent a second surgical procedure. CONCLUSIONS: Specimen radiography was reliable in identifying clear margins (74% positive predictive value) and reduced the rate of reintervention from 31% to 20%. Better results will be provided by digital mammographic equipment.

[Neurolytic block of the celiac plexus and splanchnic nerves with computed tomography. The experience in 150 cases and an optimization of the technic]. / Il blocco neurolitico del plesso celiaco e dei nervi splancnici con Tomografia Computerizzata. Esperienza su 150 casi e ottimizzazione della tecnica.

INTRODUCTION: CT-guided celiac plexus and splanchnic nerve neurolytic blocks are procedures for pain relief in patients with upper abdominal malignancies. In the last 20 years, the technique has been modified by the introduction of CT guidance providing improved precision and safety. We report our personal experience and provide suggestions for technique optimization. MATERIALS AND METHODS: In 1991-1998 we performed 150 celiac plexus and/or splanchnic nerve neurolytic blocks with ethyl alcohol in 144 cancer patients; the procedure was repeated in 6 patients. In 69% of cases the patient had a pancreatic lesion. We prefer an anterior approach with very thin needles (22 Gauge). The sites of alcohol injection (celiac plexus, splanchnic nerves or both) are chosen after evaluation of anatomy by preliminary CT scans, or during the procedure, depending on alcohol (mixed with a contrast agent) spread. RESULTS: The mean duration of the procedure ranged 50 min (1991) to 22 min (1998). 48 hours after the block we obtained major pain relief in 79% of cases. After 15 days, 21% of patients had no pain (drugs: none), 29% had mild pain (therapy: non-steroid anti-inflammatory drugs), 32% had marked pain (therapy: non-steroid anti-inflammatory drugs and, occasionally, opioids), 18% had severe pain (only opioid therapy). Pain relief was more frequent in splanchnic nerve blocks. DISCUSSION: Our experience confirms that neurolytic celiac plexus and/or splanchnic nerve block is a good choice in the treatment of upper abdominal cancer pain. We would also like to add that: 1) celiac plexus block with CT guidance (with the needle tip positioned anterior to aorta) and splanchnic nerve block (with the needle tip positioned posterior to diaphragmatic crura) are no longer two separated techniques, but they can be chosen and combined according to patients needs. 2) All procedures can be performed with anterior approach, in supine position, with a single thin needle, allowing to reach the target without any complication, even after puncturing stomach, liver, bowel, pancreas or aorta. 3) With CT guidance, even splanchnic nerve neurolysis is a low-risk technique, which should be adopted in all cases of insufficient alcohol spread in the celiac plexus. 4) When the operators are skilled and experienced enough, the time required for the block can be significantly decreased to nearly the time required for US-guided or fluoroscopic-guided procedures.

[Ultrasonography contrast media Levovist and power Doppler in the study of the breast. Methodology, vascular morphology and automatic enhancement quantification with wash-in and wash-out curves]. / Il mezzo di contrasto ecografico Levovist e il power Doppler nella senologia. Metodologia, morfologia vascolare e quantificazione automatica dell'accentuazione vascolare con curve di wash-in e wash-out.

PURPOSE: To define the technique for contrast-enhanced power Doppler US studies of breast lesions and to identify possible clinical applications. MATERIAL AND METHODS: We studied 51 breast lesions detected at mammography and confirmed at cytology and/or surgical biopsy; 15 were benign lesions and 36 carcinomas, namely 14 T1ab, 29 T1c and 8 T2. We found 14 masses with regular margins, 28 with irregular margins, 1 asymmetric density, 2 architectural distortions and 6 clustered calcifications. US studies were performed with an AU5 Harmonic unit (Esaote Biomedica, Genoa, Italy) equipped with a software for online image storage, analysis and automatic quantification of US signal intensity changes after contrast agent injection, namely wash-in and wash-out contrast enhancement curves. The echocontrast agent Levovist (Schering AG, Berlin, Germany), 4.0 g preparation, was administered by i.v. injection (cubital vein) in two times at a concentration of 400 mg/mL. The first 4 mL of Levovist suspension were injected as a bolus at approximately .5 mL/s to evaluate lesion vascularization and choose the best scanning plane for wash-in and wash-out quantification. The remaining 6 mL of Levovist suspension were injected at approximately 1.0 mL/s and dedicated to wash-in and wash-out recording. RESULTS: The region of interest could not be identified in 2 of 6 calcifications. After Levovist administration, signal enhancement was seen in 36 lesions. Nonsignificant curves were obtained in 7 fibroadenomas, 1 fibrocystic mastopathy and 5 carcinomas. Pathology diagnosed an in situ component around the lesion core (true positives) in 12 carcinomas with perilesional vessels and also 3 more carcinomas with perilesional foci in situ missed at contrast-enhanced US (false negatives). The wash-in/wash-out curves of 30 carcinomas differed from those of the 6 fibroadenomas, in that the former had faster wash-in and an earlier enhancement peak, as well as longer enhancement than the latter. Moreover, fibroadenoma curves are regularly increasing, with moderate variations. As for wash-out, carcinomas exhibited three main patterns, namely a monophasic, a polyphasic and a plateau pattern. DISCUSSION: The pattern of enhancement curves in fibroadenomas is related to straight and regular vessels, while arteriovenous shunts in carcinomas cause early signal intensity peaks. Wash-out is longer in carcinomas than in fibroadenomas because the former present anarchic and tortuous vessels with slow flows. CONCLUSIONS: Levovist enhanced US is a complementary test to study known breast lesions which permits the differential diagnosis of carcinomas and fibroadenomas. Our results justify a larger clinical trial to assess the role of this technique for diagnosis, prognosis and staging purposes.

[Positive predictive value of radiologic features in mammography and contribution of assessment procedures]. / Valore predittivo positivo dei segni radiologici in mammografia e apporto degli esami di approfondimento.

PURPOSE: To investigate the positive predictive value for cancer of abnormal mammographic findings and the role of assessment procedures. MATERIALS AND METHODS: We reviewed a series of 962 patients recalled and examined in the 1st Breast Screening Center of Turin, out of 18; 996 women aged 50-59 screened for the first time from 1991 to 1995, within a population-based mammography program. The diagnostic assessment procedures included one or more of the following: physical examination, additional mammographic views (detail or magnification), ultrasonography, and ultrasonography/X-ray-guided fine needle aspiration cytology. Surgical biopsies detected 152 cancers. RESULTS: The positive predictive value for screening mammography with abnormal findings steadily grew from 10.9% in 1991-92 to 15.6% in 1993, topping 21.1% in 1994 and 20.1% in 1995. The highest positive predictive value for cancers was observed among cases referred for opacities with irregular margins (88.2%) and isolated calcifications (23.8%). The benign/malignant biopsy ratio was .54 in 1991-92, .31 in 1993, .27 in 1994 and .25 in 1995. The accuracy of assessment procedures was different for each abnormal radiologic sign: the accuracy of cytology was high for opacities, intermediate for calcifications, low for architectural distortions; ultrasonography and physical examination had low sensitivity among cases referred for calcifications or opacities with regular margins. The positive predictive value of surgical indications was high for opacities, intermediate for calcifications, low for architectural distortions. The role of assessment procedures in excluding surgery was different for each abnormal radiologic sign. DISCUSSION AND CONCLUSIONS: The results of this study confirm the accuracy of mammography in the early detection of breast cancer and the different role of assessment procedures in the various abnormal mammographic findings. The improvement in positive predictive value for screening recalls from about 10% (close to recommended European standards) up to about 20% (well above European standards) demonstrates the importance of the "learning curve" within the screening team. Most of this improvement could be referred to refined diagnostic criteria for calcifications, as shown by an increase in positive predictive value for calcifications from 13.7% in 1991-92 to 40.5% in 1995.

[Breast carcinoma diagnosed in mammographic screening incidentally. Research on the radiologic signs in prior mammograms]. / Il carcinoma mammario diagnosticato nello screening mammografico nei passaggi di incidenza. Ricerca dei segni radiologici sulle mammografie precedenti.

PURPOSE: To determine how many cancers screen-detected at subsequent rounds were already visible on previous screening mammograms, and to study their radiological features. MATERIALS AND METHODS: The previous screening mammograms of 100 women who had cancers screen-detected at subsequent rounds (group A), and the negative screening mammograms of 200 women (group B) who had a further negative screening test two years later, were mixed for a new reading. The two groups were similar for age and year of examination. These films were blindly reviewed by 5 radiologists. Then, mammograms were reviewed retrospectively, with knowledge of subsequent diagnostic results. Finally the A group findings were classified as: 1) true negative: no radiological signs; 2) minimal sign: a nonspecific abnormality is retrospectively visible at the site of subsequent cancer; 3) false negative: "she should have been recalled"; 4) misdiagnosis at assessment: the woman had been recalled, but the cancer was missed after the assessment procedures. RESULTS: 60% of cases were true negatives, 29% were minimal signs, 9% were false negative and 2% were misdiagnosed at assessment. The most common radiological sign found among false negative cases was an architectural distortion: opacities and calcifications were more frequent among minimal signs. Only 10 of 40 cancers retrospectively visible on previous mammograms had reached stage II at diagnosis. At blinded review, the radiologists found false abnormalities in a considerable number of healthy women (average: 29%). DISCUSSION AND CONCLUSIONS: Our study shows that mammography sensitivity can be improved. Cancer radiological signs may go undetected due to difficult interpretation (opacities, calcifications) or perception (architectural distortions). The use of a low threshold of suspicion (as in a reading test) in real screening might permit to detect more cancers (most of them, however, would not reach advanced stages at subsequent rounds), but might also lead to many unnecessary assessments and, probably, to some benign biopsies in healthy women. In conclusion, an attempt at improving mammography sensitivity by lowering the threshold of suspicion can not be directly recommended due to the considerable negative effects related to a loss in specificity. A reading test similar to the one presented in our study would be a useful training procedure for radiologists who are involved in a screening program.

[Indications for tubal recanalisation in diagnostic and interventional hysterosalpingography]. / Indicazioni alla disostruzione tubarica nell'isterosalpingografia diagnostico-interventistica.

Three hundred and seventy-seven hysterosalpingographies performed in 1992 in the Radiology Department of the S. Anna Hospital, Turin, Italy, were reviewed to assess the role and the real incidence of indications to catheterization and to selective salpingography. Proximal tube obstruction treatable by means of extemporary mono-bilateral catheterization was found in 18.3% of cases, but only in 7.4% was catheterization really indicated. In 67.2% of patients repeated contrast medium injections, at high pressure, with the catheter end in front of the internal ostium of the Fallopian tube, allowed recanalization--which made catheterization unnecessary. Catheterization was performed in 18 cases where double injection had failed and was successful in 15 patients (83.3%). Even though selective interventional salpingography is valuable, its use in rarely necessary, especially if conventional hysterosalpingography is performed at the correct injection pressure. Therefore, we conclude that the interventional kit for proximal tube recanalization must always be available, but its use in routine exams is unnecessary.

[Diagnostic imaging in non-palpable breast lesions. Targeted++ ultrasonography versus direct radiologic magnification]. / Approfondimenti diagnostici nelle lesioni mammarie non palpabili. Ecotomografia mirata versus ingrandimento radiologico diretto.

The main target of mammography in asymptomatic women is the early diagnosis, or rather the identification, of non-palpable breast cancers. Doubtful or suspicious findings on conventional mammograms with no clinical evidence call for radiologic or other complementary imaging techniques to assess the exact lesion nature. Direct magnification and US are targeted techniques to employ as additional investigations after conventional mammography. Fifty consecutive patients were referred to our department of radiology for the preoperative localization of non-palpable breast lesions previously identified on conventional mammograms. The diagnostic or complementary roles of direct magnification and of US were thus investigated. US was always repeated during the preoperative localization; a 10-MHz immersion sectorial probe was used. Magnification was performed if absent or poor in conventional mammograms. The contribution of each technique to conventional mammography was graded as valuable (A), medium (B), or null (C). The lesions were grouped according to their structure: microcalcifications (a), nodules (b), scars (c), and complex lesions (a+b, a+c, b+c, ecc.). Six cases are included in our series which had been diagnosed as questionable or suspicious on previous mammograms. In our department, they were diagnosed as benign. Two of them were operated on because biopsy was required by the gynecologist and the other underwent stereotaxic FNB: negative cytology was considered the final diagnosis. Forty-six histologic and 4 cytologic examinations diagnosed 25 malignant and 25 benign lesions. Direct magnification was of great value in all cases, whereas US was useless in microcalcifications and useful in nodular or complex lesions, especially those with a nodular component. However, the incidence of US false-negatives was high, even in very suspicious cases on mammography, which suggests that US negativity cannot be considered an adequate sign to rule malignancy out.