Magnetic resonance imaging-guided core needle biopsy and needle localized excision of occult breast lesions.

BACKGROUND: Breast magnetic resonance imaging (MRI) has been reported to be twice as sensitive and three times more specific in detecting breast cancer. We report a series of MRI-guided stereotactic breast biopsies (SCNBB) and needle localized breast biopsies (NLBB) to evaluate MRI as a localization tool. METHODS: Forty-one breast lesions were identified in 39 patients who subsequently had SCNBB or NLBB. Suspicious areas of enhancement were stereotactically biopsied with 16-G core biopsy needles or localized with 22-G wires for excision under laser guidance. RESULTS: Forty-one breast lesions were identified from 1,292 breast MRIs. SCNBB identified three malignancies and two areas of atypia. Two additional cancers were found after NLBB. In patients having NLBB alone, five cancers and two areas of atypia were identified. CONCLUSIONS: In this initial series, breast MRI-guided SCNBB and NLBB were valuable tools in the management of patients with suspicious abnormalities seen only on MRI.

Racial differences in breast cancer survival: the effect of residual disease.

BACKGROUND: A survival difference has been seen in numerous studies between African-American (AA) and Caucasian (C) women with breast cancer. The purpose of this study was to elucidate the differences in patient characteristics and outcomes between AA and C women with breast cancer in our population. METHODS: We performed a retrospective analysis of 1345 women with newly diagnosed breast cancer who were entered into our tumor registry from October 1980 to December 1998. RESULTS: The association between race and stage at presentation was significant, as was the difference in the overall median survival between C and AA women. The data revealed no significant differences in survival between C and AA women presenting with Stage I or II disease. However, the differences between the median survival times for AA and C women presenting with Stage III and IV disease were both highly significant. A significantly lower percentage of AA women became "disease free" after initial therapy as compared with C women (P < 0.001). Interestingly, when data were stratified by stage, only in Stage III and IV were there significant differences between the races for becoming disease free. CONCLUSIONS: AA women tend to present at a later stage and have poorer survival from later-stage disease as compared with C women. The poorer survival appears to be related to the decreased ability to achieve disease-free status in AA women with advanced disease. The underlying causes of this difference in treatment outcome need further evaluation.

Intraoperative ultrasound and other techniques to achieve negative margins.

Over the past few decades new procedures and technologies have been introduced into clinical practice for the evaluation and management of breast disease. Ultrasound is rapidly becoming a valued tool in the armamentarium of the breast surgeon. The use of ultrasound by radiologists and breast surgeons to evaluate nonpalpalable detected breast lesions has increased dramatically. With its easy portability and improvements in the technology, the use of ultrasound has now expanded into the operating room. In this work we review the value of intraoperative ultrasound and other techniques in obtaining and assessing margin status.

Effect of 7,12-dimethylbenz[a]anthracene (DMBA) on gut glutathione metabolism.

BACKGROUND: One mechanism of the mammary carcinogenesis of 7,12-dimethylbenz[a]anthracene (DMBA) is thought to be the generation of reactive oxygen species known to play an important role in initiation and progression. We hypothesized that DMBA would disrupt gut glutathione (GSH) metabolism and this disruption would correlate with mammary cell carcinogenesis. METHODS: Sixty-four Sprague-Dawley rats were randomized to the DMBA versus control groups. At age 50 days, rats were gavaged with a one-time dose of 20 mg DMBA or sesame oil. Rats from each group were sacrificed at 1 week (n = 16), 2 weeks (n = 16), 4 weeks (n = 16), and 11 weeks (n = 16). Tumor appearance, arterial and gut GSH concentration, and gut GSH extraction were measured over time. RESULTS: Gut GSH extraction (normally negative; production) was significantly depressed over the time points, even showing uptake (positive extraction) at Weeks 1 and 2. Tumors developed in all animals in the DMBA group by Week 11. CONCLUSIONS: A one-time oral administration of DMBA has a significant and prolonged depressive effect on gut GSH production that has not previously been described. These data support the hypothesis that the carcinogenic effect of DMBA is mediated, at least in part, by oxidative damage and that the disruption of gut GSH metabolism may play a greater role in carcinogenesis than previously realized.

Hematoma-directed ultrasound-guided breast biopsy.

OBJECTIVE AND SUMMARY BACKGROUND DATA: The standard technique for removal of nonpalpable breast lesions is needle localization breast biopsy. Because traumatic hematomas can often be seen with ultrasound, the authors hypothesized that iatrogenically induced hematomas could be used to guide the excision of nonpalpable lesions using ultrasound. METHODS: Twenty patients with nonpalpable breast lesions detected by magnetic resonance imaging only were enrolled in this single-institution trial, approved by the institutional review board. A hematoma consisting of 2 to 5 mL of the patient's own blood was injected into the breast to target the nonpalpable lesion. Intraoperative ultrasound of the hematoma was used to direct the excisional biopsy. RESULTS: The average age of women was 53.8 +/- 10 years. Ninety-five percent of lesions detected by magnetic resonance imaging were localized by hematoma injection. All the hematomas used to recognize targeted lesions were identified at surgery by ultrasound and removed without complication. Eight (40%) of the lesions were malignant, with an average tumor size of 12 +/- 6 mm (range 4-25). The remaining 12 lesions (60%) comprised papillomas, sclerosing adenosis, radial scar, fibroadenoma, and areas of atypical ductal hyperplasia. CONCLUSION: The results of this pilot study show the effectiveness of hematoma-directed ultrasound-guided breast biopsy for nonpalpable lesions seen by magnetic resonance imaging. This new procedure is potentially more comfortable for the patient because no wire or needle is left in the breast. It is technically faster and easier because ultrasound is used to visualize directly the location of the hematoma at surgery and to confirm lesion removal in the operating room by specimen ultrasound. The hematoma can be placed several days before biopsy, easing scheduling, and without fear of the migration that may occur with needle localization. This method may have ready application to mammographically detected lesions.

Intraoperative localization after stereotactic breast biopsy without a needle.

BACKGROUND: Needle localization breast biopsy (NLBB) is the standard for the removal of breast lesions after vacuum-assisted breast biopsy (VABB). Disadvantages include a miss rate of 0% to 22%, risk of vasovagal reactions, and scheduling difficulties. We hypothesized that the hematoma resulting from VABB could be used to localize the VABB site with intraoperative ultrasonography (US) for excision. METHODS: Twenty patients had VABB followed by intraoperative US-guided excision. RESULTS: The previous VABB site in 19 patients was successfully visualized with intraoperative US and excised at surgery. One patient had successful removal of the targeted area under US guidance, but failed to show removal of the clip on initial specimen mammogram. CONCLUSION: This study demonstrates the effectiveness of US in identifying hematomas after VABB for excision. This technique, which can be performed weeks after VABB, improves patient comfort and allows easier scheduling.

Human papillomavirus DNA is present in a subset of unselected breast cancers.

OBJECTIVE: The major molecular events in the genesis of most breast cancers are unknown. However, human papillomaviruses (HPV) have been reported to be found in a significant portion of breast cancers of women with concomitant cervical intraepithelial neoplasia III. To investigate a potential HPV-breast cancer link, we carried out a small survey to identify HPV in unselected, general breast cancer tissues. STUDY DESIGN/METHODS: Deoxyribonucleic acid (DNA) was isolated from 17 breast cancer tissues (and one cervical swab) taken from our local, randomly selected patient population. Two different previously characterized broad-spectrum primer sets (targeting the E6/E7 or L1 regions) were used to amplify HPV DNA, and another primer set was used to amplify the ColE1/pBR322 origin of replication by polymerase chain reaction amplification. The polymerase chain reaction product DNA was analyzed by dot blot hybridization with HPV-16, -18, -31, or pRB322 DNA probes. Total cellular DNA was also analyzed by one- and two-dimensional Southern blot analysis. Finally, the E6/E7 polymerase chain reaction products were cloned, sequenced, and compared to previously cloned HPV types. RESULTS: Polymerase chain reaction/dot blot analysis by both the HPV E6-E7 and L1 primer sets identified the same 6 out of 17 (35%) breast cancers as being HPV positive. ColE1/pBR322 origin targeted polymerase chain reaction/dot blot analysis failed to identify plasmid contamination. One- and two-dimensional Southern blot analysis showed that the breast cancers specimens contained significant levels of HPV DNA and that the viral DNA was largely episomal. The sequences of the HPV clones demonstrated that HPV-16, -18, and possibly type 11 were present within the breast cancer specimens. Furthermore, the HPV sequences cloned from the cervical swab and breast cancer of the same patient were found to be identical. CONCLUSIONS: These data suggest that HPV may be associated with a significant subset of breast cancers, and further suggest that additional studies are warranted.

In situ breast cancer.

The clinical expression of in situ cancer varies widely but is usually occult. Diagnosis can be made by a variety of minimally invasive techniques. Treatment of lobular carcinoma in situ (LCIS) is patient-directed but generally requires only close follow-up. Mastectomy is the gold standard for ductal carcinoma in situ (DCIS) and is associated with low recurrence rates. Breast conservation therapy (BCT) has become an acceptable alternative. This choice of definitive therapy for DCIS depends largely on the ability to obtain negative margins. Any attempt at BCT should be coupled with the caveat of close postoperative long-term follow-up. Patients diagnosed with LCIS or who have a history of DCIS should be given the options for the use of tamoxifen for the reduction of subsequent development of invasive breast cancer. Risk versus benefits should be clearly defined.

Intraoperative ultrasound-guided breast biopsy.

BACKGROUND: Biopsy of nonpalpable lesions has increased during the last decade. Commonly these lesions are excised using preoperative wire localization. We describe a technique of intraoperative ultrasound-guided breast biopsy that allows easier excision and aids in obtaining surgical margins in breast cancer. METHODS: Intraoperative ultrasound was performed on 81 lesions. Ultrasound was used in an attempt to approximate a 1 cm margin on malignant lesions. RESULTS: All attempts to localize lesions with ultrasound in surgery were successful (81 of 81). Ultrasound-guided surgery was accurate in predicting margins in 24 of 25 malignant lesions. No complications resulted. CONCLUSION: Ultrasound proved to be an effective technique for localizing and excising breast lesions. Benefits may include improving patient comfort, avoiding complications of needle localization breast biopsy, and simplifying the scheduling of surgical procedures. Additionally, this procedure may be used to obtain adequate surgical margins and thus reduce the recurrence rate of breast cancer.

Central venous catheter placement in patients with disorders of hemostasis.

BACKGROUND: Patients requiring central venous access frequently have disorders of hemostasis. The aim of this study was to identify factors predictive of bleeding complications after central venous catheterization in this group of patients. METHODS: A retrospective analysis of all central venous catheters placed over a 2-year period (1997 to 1999) at our institution were performed. The age, sex, clinical diagnosis, most recent platelet count, prothrombin international normalized ratio (INR), activated partial thromboplastin time (aPTT), catheter type, the number of passes to complete the procedure, and bleeding complications were retrieved from the medical records. RESULTS: In a 2-year period, 2,010 central venous catheters were placed in 1,825 patients. Three hundred and thirty placements were in patients with disorders of hemostasis. In 88 of the 330 patients, the underlying coagulopathy was not corrected before catheter placement. In these patients, there were 3 bleeding complications requiring placement of a purse string suture at the catheter entry site. In the remaining 242 patients, there was 1 bleeding complication. Of the variables analyzed, only a low platelet count (<50 x 10(9)/L) was significantly associated with bleeding complications. CONCLUSION: Central venous access procedures can be safely performed in patients with underlying disorders of hemostasis. Even patients with low platelet counts have infrequent (3 of 88) bleeding complications, and these problems are easily managed.

Role of breast magnetic resonance imaging in determining breast as a source of unknown metastatic lymphadenopathy.

BACKGROUND: Occult primary breast cancer (OPBC) represents less than 1% of breast cancer. In only a third of cases, mammography identifies a primary tumor. We hypothesized that rotating delivery of excitation off-resonance breast magnetic resonance imaging (MRI) would identify or exclude the breast as a primary site in patients with OPBC. METHODS: In a retrospective review, 10 patients were identified with OPBC in which MRI was performed. Malignant appearing lesions were correlated with histopathologic findings at biopsy or surgery. RESULTS: MRI identified the primary site in 8 of 10 cases as breast (80%), and excluded it in 2 cases. The extent of disease and location was accurately predicted when compared with histopathologic specimen. CONCLUSIONS: As we continue to focus on a cure of early breast cancer, it is imperative that diagnostic images become more sensitive and specific. MRI accurately predicted OPBC in this subset of patients.