Wire-guided excision of non-palpable breast cancer: determinants and correlations between radiologic and histologic margins and residual disease in re-excisions.

In cases of wire-guided excision of non-palpable breast cancer (WGE), data concerning the determinants and correlations between radiologic and histologic margins and residual cancer in re-excisions are sparse. A total of 21 variables in 66 WGE followed by 49 re-excisions were prospectively analyzed. In multivariate analysis, only large mammographic lesions were clearly related to positive margins in specimen radiography (P<0.05). Multifocality (P<0.001), large pathologic size (P<0.05) and superficial excision (P<0.05) were related to positive histologic margins and multifocality (P=0.001) to residual disease in re-excisions. The sensitivity, specificity and positive predictive values of specimen radiography for predicting histologic margins were 33%, 79% and 53%, and those for predicting residual disease 30%, 80% and 38%, respectively. The ability of histologic margins to predict residual disease was 91%, 58% and 38%, respectively. In WGE, large mammographic lesions carry a significant risk for radiologically incomplete excision, while pathologically large and multifocal tumors may be histologically incompletely excised, especially if the excision does not extend down to the pectoral fascia. The excision sites of multifocal tumors should be re-excised because of the considerable risk of residual disease. The radiologic and histologic margins of the specimen may be misleading.

Cosmetic results after wire-guided biopsy of benign breast lesions.

BACKGROUND: There are surprisingly few reports about the cosmetic results of wire-guided biopsy of benign breast lesions as opposed to breast-conserving surgery and irradiation of early breast cancer (BCT). STUDY DESIGN: Twenty potential perioperative risk factors for adverse cosmetic results after wire-guided breast biopsy were prospectively evaluated in 101 patients undergoing the first single biopsy after suspicion of a malignant lesion that subsequently proved to be benign. The overall cosmetic result was evaluated by using 6 specific cosmetic indices individually scored 6 months after the breast biopsy. RESULTS: The overall cosmesis was excellent, good, fair, or poor in 48.5%, 26.7%, 12.9%, and 11.9% of cases, respectively. The corresponding figures according to appraisal by the patients were 22.8%, 58.4%, 17.8%, and 1.0%, respectively. Unsatisfactory (fair or poor) overall cosmetic results were related to excisions extending down to the fascia (p = 0.001) and postoperative complications (p = 0.018) in multivariate analysis. Notably, specimen volume had no significant impact on overall cosmesis, as opposed to cosmesis after BCT. CONCLUSIONS: Cosmetic outcomes after wire-guided biopsy of benign breast lesions were excellent or good in at least 75% of cases. Excisions extending down to the pectoralis fascia and complications were associated with poor aesthetic outcomes.

Mammographic and ultrasonographic findings in bilateral breast cancer: a comparative study.

To compare the results of mammographic and US examinations in unilateral and bilateral breast cancers in routine clinical work, the files of all patients with 825 preoperative mammograms and 525 preoperative US examinations operated on for primary breast cancer in the Oulu University Hospital from 1983 through 1993 were retrospectively reviewed. The only statistically significant difference noted in the mammographic findings was the false-negative rates in unilateral, bilateral and metachronous second breast cancers (6.8, 16.3 and 23.3 %, respectively). The differences were mainly due to the lower sensitivity of mammography in the detection of palpable bilateral breast cancers. The false-negative rate of US was also significantly higher in bilateral breast cancers (23 %) than in unilateral cancers (11 %), and significantly higher for nonpalpable than palpable cancers in both the bilateral and the unilateral groups. The mammographic failure rates and the difference between these two groups were most pronounced during the early study period, which underscores the importance of experience and dedicated imaging technique. The smaller tumour size at the time of diagnosis and probably the loss of the opposite breast for comparison have contributed to the higher false-negative rates in bilateral breast cancer.

Preoperative methylene blue staining of galactographically suspicious breast lesions.

Microdochectomy is the standard treatment of galactographically suspicious breast lesions. Precise preoperative marking of the suspicious duct and intraductal lesions facilitates selective minimal-volume microdochectomy. Methylene blue dye staining fulfills this criterion. A retrospective review of our experience of preoperative methylene blue staining in 30 patients with unilateral spontaneous nonlactiferous single duct nipple discharge operated on during 1986-1995 in the Oulu University Hospital for galactographically suspicious breast lesions. Galactography was successful in 29 out of 30 (93.3%) cases. Preoperative methylene blue staining was attempted in all cases on the day of surgery and it was successful in 22 (73.3%) cases making subsequent selective minimal-volume microdochectomy easy to perform. The failure of methylene blue staining led to quadrantectomy in 4 cases and smaller breast resections in the remaining 4 cases. Preoperative methylene blue dye staining crucially facilitates selective minimal-volume microdochectomy. An interval between primary galactography and later methylene blue staining leads to failures in approximately one quarter of the cases. A higher success rate would necessitate scheduling the microdochectomy on the same day as the primary galactography (and the subsequent methylene blue staining in suspicious cases).

Metachronous cecal and sigmoid volvulus.

BACKGROUND AND AIMS: Metachronous cecal and sigmoid volvulus is very rare. MATERIAL AND METHODS: A case report. RESULTS AND CONCLUSION: Two different volvuli necessitated three operations. Cecal volvulus was treated by caecostomy and sigmoid volvulus by detorsion three years later. Sigmoid volvulus recurred after simple operative detorsion, but the patient recovered without complications after a mesocolosplasty. We recommend operative treatment when recurrent colonic volvulus is suspected, and resection is preferable in medically fit patients.

Determinants of positive histologic margins and residual tumor after lumpectomy for early breast cancer: a prospective study with special reference to touch preparation cytology.

BACKGROUND AND OBJECTIVES: Removal of the entire tumor by breast-conserving surgery is important, but the determinants of adequate excision have not been established. METHODS: A prospective study of 55 consecutive lumpectomies for early breast cancer was performed to study the correlation between touch preparation cytology and histologic margins and the determinants of positive histologic margins and residual disease after the initial excision. RESULTS: The correlation between touch preparation cytology and histologic margins was poor: sensitivity and specificity were 37.5% and 85.1%, respectively. The histologic margins were positive in 8 cases (14.5%) and were related to the presence of intraductal carcinoma and to the large pathologic size of the index tumor. Re-excision specimen of the tumor bed (34 of 55 cases) contained residual cancer in seven cases (20.6%). Multifocal and nonpalpable index tumors predicted residual cancer. Residual disease was found in 37.5% of the cases (3 of 8) with positive and in 15.4% of the cases (4 of 26) with negative histologic margins. CONCLUSIONS: Touch preparation cytology cannot be recommended as a method of assessing lumpectomy margins for early breast cancer. Histologic margins are misleading in predicting residual cancer in re-excision specimens. To minimize the risk of residual cancer, wide excision or mastectomy should be considered in the management of multifocal and nonpalpable tumors.

Nonpalpable breast lesions: pathologic correlation of ultrasonographically guided fine-needle aspiration biopsy.

To evaluate the usefulness of ultrasonographically guided fine-needle aspiration biopsy in routine clinical use, we evaluated retrospectively all of the 781 nonpalpable breast lesions operated on in the Oulu University Hospital during the period 1986 to 1993. There were 86 patients with 90 nonpalpable breast lesions, of which samples were taken by ultrasonographically guided fine-needle aspiration biopsy. Open wire-guided surgical biopsy was obtained in all cases for a histologic diagnosis. Two false-negative results and one insufficient cytologic sample occurred in the 26 malignancies and one false-positive result and two insufficient cytologic samples were found in the 73 benign breast lesions, giving sensitivity, specificity, positive predictive value, negative predictive value, and overall diagnostic accuracy values of 84%, 93%, 94%, 95%, and 90%, respectively. The calculations include the insufficient samples. We conclude that ultrasonographically guided fine-needle aspiration biopsy is a method comparable to mammographic and stereotactic fine-needle aspiration biopsy methods.

Ultrasonographically guided wire localization of nonpalpable breast lesions.

The results of 102 preoperative ultrasonographically guided wire localizations of nonpalpable breast lesions were reviewed. Ultrasonography was used because of nonvisualization during mammography (16 cases), a difficult location of the lesion (3 cases), vasovagal syncope during mammographic guidance (two cases), or the radiologist's preference (81 cases). All localizations were successful. Removal was confirmed by specimen mammography or ultrasonography or both in 85 cases and by macroscopic examination in 10 cases. In seven cases specimen radiography was not performed. One syncope and one wire insertion into the pectoralis fascia occurred. Ultrasonographically guided wire localization is accurate and well tolerated in aiding surgical biopsy of breast lesions.

Breast cancer recurrence after mastectomy: diagnosis with mammography and US.

The authors reviewed mammograms and/or ultrasound (US) scans of 76 lesions (67 patients) suspected of being recurrent breast cancer. All patients had previously undergone mastectomy. Sixty-one cases were malignant disease and 15 were benign. Mammography and US were complementary to clinical examination in evaluating palpable lesions at the mastectomy site. Both imaging methods revealed nonpalpable recurrences. The sensitivity of US was 91%, whereas the sensitivities of clinical examination and mammography were 79% and 45%, respectively. US was the best imaging method for evaluating tumors in the chest wall far from the scar and in the axilla, as these could not be visualized on mammograms. Most recurrent cancers were seen as circumscribed masses at mammography and as hypoechoic lesions at US. Hyperechoic recurrences could not be differentiated from benign lesions. The value of early detection of recurrences with imaging methods remains to be seen.

Wire localized biopsy of breast lesions: a review of 425 cases found in screening or clinical mammography.

A total of 425 wire localized biopsies for non-palpable breast lesions found by screening (n = 169) or clinical (n = 256) mammography between 1986-1990 are reviewed with reference to the biopsy success rate with different localization techniques, the positive predictive value of the mammographic findings and the staging and treatment of carcinomas in the clinical and screening groups. Specimen radiographs were available for review in 371 cases and confirmed the removal of the lesion in 90.6%, were indeterminate in 4.8% and were negative in 4.6%. Some 95% of the failures occurred in mammography-guided localizations using the Kopans hookwire. In later years this wire was replaced with th Homer retractable needle/wire system, with a 99% success rate. The Kopans wire was found to be accurate in ultrasound (US)-guided procedures, which were tolerated very well with no complications, as compared with a 10.2% rate of vasovagal reactions in mammography-guided procedures. The success rate of the localizations performed under general anaesthesia was 93.7%, as compared with 80.2% of the localizations performed under local anaesthesia. A more clearcut improvement of the success rate (from 66.7% in 1986-1987 to 99% in 1990) was seen over the years with growing experience and the development of teamwork between radiologists, surgeons and pathologists. The histological diagnosis was malignant in 27% of cases. The positive predictive value for malignancy improved from 21% to 32% from 1986 to 1990, due mainly to an increase in the screening group. A total of 71% of the carcinomas found were of stage 0 (TisN0M0) or I (TIN0M0) indicating a good prognosis.(ABSTRACT TRUNCATED AT 250 WORDS)

Radiography of the male breast in gynecomastia.

In order to investigate the role of imaging methods in the evaluation of the male breast we reviewed the mammograms and ultrasonograms (US) performed in 40 men with breast enlargement or pain. The patients, whose breasts were examined by either mammography (n = 7) or US (n = 1) or both (n = 32), ranged in age from 14 to 83 years. The final diagnoses were gynecomastia in 35 patients, lipomas in one, abscess or sequelae to abscess in 2, and normal in 2. In gynecomastia the subareolar density was of varying shape and size or showed a diffuse pattern of heterogeneous density occupying the whole breast on mammography, and a retromammillar hypoechoic focus, a diffuse heterogenous area, or a combination of these was observed at US. Eleven breasts and one axillary lymph node were examined by US-guided fine-needle aspiration biopsy (FNAB), which was diagnostic in all cases. Mammography is recommended for the evaluation of the male breast if the differential diagnosis between gynecomastia and fatty enlargement is not clinically evident, and in all cases of unilateral breast symptoms. US is a complementary method to mammography and is also useful to provide guidance for FNAB.

Abdominal operations for intraabdominal metastases from extraabdominal primary tumors.

Forty consecutive patients with an extraabdominal primary tumor, later treated surgically for intraabdominal problems, were investigated. The most common causes of abdominal operations were intestinal obstruction (N = 17), intraabdominal tumor mass (N = 8), and intraabdominal hemorrhage (N = 5). The overall postoperative mortality was 25%, morbidity 48%, median survival 3 months, and cumulative 5 year survival 3%. The mortality after emergency procedures, 67%, was significantly higher (P less than 0.01) than after elective operations, 18%. Conditions requiring enterostomy (N = 14) were associated with a mortality of 36%, whereas the figures in resected (N = 13) and bypassed (N = 7) patients were 14% and 17%, respectively. Wound infection (N = 5) and pulmonary infection (N = 5) were the most common complications, and pulmonary infection was fatal in three of the five cases. Of the patients, 22 (55%) were discharged from hospital to their home; ten (25%) of them had postoperatively a 3 month relief of cancer symptoms and four (10%) a 6 month relief. Nine patients (25%) have survived for over 1 year and one (3%) for over 5 years. It is concluded that abdominal procedures seldom prevent further cancer growth within these patients and that symptoms are relieved only in one in every four patients. According to strict criteria, these operations are useful and can add to patient comfort.