Predictors of outcomes in managing breast abscesses-A large retrospective single-center analysis.

We have retrospectively examined a wide range of clinical characteristics, sonographic features, microbiology, and antibiotic regimens in patients with breast abscesses to seek predictive features related to outcome. Because consensus for optimal treatment of breast abscesses has moved toward minimally invasive management using single or repeated needle aspiration (ASP) coupled with adjuvant antibiotics, we assessed whether any factors correlate with the need for repeat procedures by analyzing the number of ASPs and/or surgical incision and drainage (I&D) per abscess. We examined 127 abscesses in 114 patients from a single urban public hospital, and among clinical characteristics, we found that only smoking history (P = .021) and the presence of nipple rings (P = .005) were associated with greater likelihood of necessitating repeat for abscess resolution procedures. Neither diabetes, lactational status, and HIV nor ultrasound features imaging of an abscess including size >3 cm, multiloculation, rind thickness, or central vs peripheral location were correlated with the need for a repeat procedure. Likewise, no specific micro-organisms predicted a greater likelihood of requiring repeat procedures, and no specific initial antibiotic regimen (gram-positive and/or gram-negative or multiresistance coverage) impacted clinical outcomes. Our data indicate that no specific imaging abscess characteristics, type of micro-organism, or initial choice of antibiotics affect outcomes, and therefore, these features should not preclude attempts at conventional therapy by repeated aspiration and antibiotic treatment. While a smoking history and presence of a nipple ring may increase the risk of a prolonged course, the decision to change antibiotics or repeat aspiration should rely instead on clinical evaluation and judgment by experienced physicians.

Can Breast Compression Be Reduced in Digital Mammography and Breast Tomosynthesis?

OBJECTIVE: The objective of this study was to investigate the impact of decreasing breast compression during digital mammography and breast tomosynthesis (DBT) on perceived pain and image quality. MATERIALS AND METHODS: In this two-part study, two groups of women with prior mammograms were recruited. In part 1, subjects were positioned for craniocaudal (CC) and mediolateral oblique (MLO) views, and four levels of compression force were applied to evaluate changes in breast thickness, perceived pain, and relative tissue coverage. No imaging was performed. In part 2, two MLO DBT images of one breast of each patient were acquired at standard and reduced compression. Blurring artifacts and tissue coverage were judged by three breast imaging radiologists, and compression force, breast thickness, relative tissue coverage, and perceived pain were recorded. RESULTS: Only the first reduction in force was feasible because further reduction resulted in inadequate breast immobilization. Mean force reductions of 48% and 47% for the CC and MLO views, respectively, resulted in a significantly reduced perceived pain level, whereas the thickness of the compressed breast increased by 0.02 cm (CC view) and 0.09 (MLO view, part 1 of the study) and 0.38 cm (MLO view, part 2 of the study), respectively, with no change in tissue coverage or increase in motion blurring. CONCLUSION: Mammography and DBT acquisitions may be possible using half of the compression force used currently, with a significant and substantial reduction in perceived pain with no clinically significant change in breast thickness and tissue coverage.

Preoperative MRI Evaluation of Axillary Lymph Nodes in Invasive Ductal Carcinoma: Comparison of Luminal A Versus Luminal B Subtypes in a Paradigm Using Ki-67 and Receptor Status.

OBJECTIVE: The purpose of this study is to assess whether luminal A versus luminal B molecular subtypes of breast cancer affect the diagnostic utility of preoperative MRI evaluation of the axilla. MATERIALS AND METHODS: This study identified 125 patients who underwent preoperative breast MRI evaluation of tumors classifiable as luminal A or luminal B molecular subtypes between January 2012 and August 2014. The subtypes were classified on the basis of immunohistochemical staining surrogates combining receptor status and the Ki-67 proliferation index. Statistical analysis was performed using chi-square analysis and one-way ANOVA. When a statistically significant difference was found, follow-up analysis involving pairwise comparison using the Bonferroni correction was performed. Multivariate logistic regression analysis was also used to determine whether the molecular subtype was independently predictive of lymph node involvement. RESULTS: A total of 80 patients had tumors classifiable as the luminal A molecular subtype, whereas 45 patients had tumors classifiable as the luminal B subtype. Pathologically proven axillary lymph node (ALN) disease occurred statistically significantly more frequently in luminal B tumors (18/45 [40.0%]) than in luminal A tumors (11/80 [13.8%]; p < 0.01). In addition, pathologically proven ALN disease was 4.3 times more likely to occur in luminal B tumors after controlling for patient age, tumor size, and tumor grade (p < 0.01). We found no difference in the negative predictive value of the MRI assessment of the axilla when luminal A tumors were compared with luminal B tumors. The positive predictive value of MRI evaluation of ALNs is statistically significantly higher for luminal B tumors than for luminal A tumors (76.2% vs 28.0%, respectively; p = 0.004). CONCLUSION: With the use of molecular subtype classification including the Ki-67 proliferation index, suspicious nodes detected in luminal B tumors by MRI are likely to have positive findings and warrant preoperative tissue sampling. Conversely, in view of the high false-positive rate of suspicious nodes detected in luminal A tumors by MRI, proceeding straight to sentinel lymph node biopsy for all cases, except for those with highly suspicious findings, is suggested. These results should, however, be validated in a larger prospective study.

Low-Grade Adenosquamous Carcinoma of the Breast Developing Around a Localization Wire Fragment.

We present the case of a 67-year-old white woman with a history of benign biopsy results in the previous 10 years before she developed low-grade adenosquamous carcinoma around a residual localization wire fragment. A possible theory of carcinogenesis may be related to reparative epithelium in a healing biopsy site that underwent squamous metaplasia; alternately, there may have been carcinogenesis related to long-term metal exposure at the wire placement site. In vitro and in vivo studies have demonstrated a link between carcinogenesis and long-term exposure to various metals. This case report raises important questions regarding carcinogenesis in the setting of long-term metal exposure and the reparative response of the body at the site of injury or biopsy.

Granulomatous mastitis: changing clinical and imaging features with image-guided biopsy correlation.

OBJECTIVES: To review clinical presentation, revisit patient demographics and imaging findings in granulomatous mastitis and determine the optimal biopsy method for diagnosis. METHODS: A retrospective study was performed to review the clinical presentation, imaging findings and biopsy methods in patients with granulomatous mastitis. Twenty-seven patients with pathology-proven granulomatous mastitis were included. RESULTS: The average age at presentation was 38.0 years (range, 21-73 years). Seven patients were between 48 and 73 years old. Twenty-four patients presented with symptoms and three patients were asymptomatic. Nineteen patients were imaged with mammography demonstrating mammographically occult lesions as the predominant finding. Twenty-six patients were imaged with ultrasound and the most common finding was a mass lesion. Pathological diagnosis was made by image-guided biopsy in 44 % of patients. The imaging features of granulomatous mastitis on mammography are infrequently described. CONCLUSIONS: Our study demonstrates that granulomatous mastitis can occur in postmenopausal or asymptomatic patients, although previously reported exclusively in young women with palpable findings. Presentation on mammography as calcifications requiring mammographically guided vacuum-assisted biopsy has not been previously described. The diagnosis of granulomatous mastitis can easily be made by image-guided biopsy and surgical excision should be reserved for definitive treatment. KEY POINTS: • Characterizes radiographic appearance of granulomatous mastitis in postmenopausal or asymptomatic patients. • Granulomatous mastitis can present exclusively as calcifications on mammography. • The diagnosis of granulomatous mastitis is made by image-guided biopsy techniques.

Repeat intradetrusor injections of onabotulinum toxin a for refractory idiopathic overactive bladder patients: a single-center experience.

OBJECTIVES: : The objective of the study was to evaluate the safety and efficacy of repeat intradetrusor onabotulinum toxin A injection in patients with idiopathic overactive bladder refractory to anticholinergic medications. Furthermore, 2 doses, 100 and 150 U, were compared. METHODS: : We prospectively enrolled 60 patients in our investigator-initiated, single-center randomized trial. Thirty patients were randomized to each dosage arm. Total study duration was 3 years. Patients were eligible to receive 6 onabotulinum toxin A injections. Subjects completed a 3-day voiding diary and Urogenital Distress Inventory 6 (UDI-6) questionnaire and graded their quality of life on a visual analog scale (VAS) before study enrollment and at week 6 after every injection. The outcome was based on the amount of improvement noted on the UDI-6 and VAS scores at 6 weeks post every injection as compared with study enrollment. RESULTS: : There were 9 men and 51 women. The mean UDI-6 and VAS scores improved significantly (P = 0.0001) at week 6 after initial onabotulinum toxin A injection, and no change was seen when comparing repeat injections; 20% and 10% of the patients randomized to 150 and 100 U required performing clean intermittent catheterization, respectively. The mean UDI-6 scores after repeat onabotulinum toxin A injections did not differ significantly between 100 and 150 U. CONCLUSIONS: : Repeat injections of onabotulinum toxin A are capable of significantly improving UDI-6 scores and quality of life in refractory patients with idiopathic overactive bladder. There was no evidence of decreased efficacy after repeat injections. Lower clean intermittent catheterization rates were noted in patients randomized to 100 U as compared with 150 U. Both doses, 100 and 150 U, were equally efficacious.