Stereotactic 14G core biopsy of non-palpable breast cancer: what is the relationship between the number of core samples taken and the sensitivity for detection of malignancy?

AIM: Percutaneous 14-gauge core biopsy (CB) guided by digital stereotactic mammography is now an established technique in the investigation of women with non-palpable suspicious mammographic lesions. Diagnostic sensitivity of CB is affected both by the nature of the mammographic abnormality and by the number of core samples taken. METHODS AND RESULTS: A retrospective review of 500 women who have undergone CB in our institution showed that in 235 cases, invasive or non-invasive carcinoma was found on final surgical histology. Correlation between CB result and surgical histology revealed a significant increase in sensitivity for the diagnosis of malignancy if a larger number of cores were taken (84.3% for two cores and 90.2% for five cores vs. 97.9% for six or more cores). This trend was maintained when patients were subdivided according to mammographic abnormality, either soft tissue mass or microcalcifications. The effect on diagnostic sensitivity of increasing the number of tissue cores obtained was most pronounced in patients with microcalcifications graded as low or moderately suspicious for malignancy (70.1% for two cores and 79.1% for five cores vs 94.0% for six or more cores). The presence of an invasive component in a malignant lesion was correctly diagnosed using CB in 79.2% overall if at least six cores were taken. If the mammographic lesion was a soft tissue mass, this figure rose to 95.7%, but was only 35.7% if the visible lesion was composed of microcalcifications alone. CONCLUSION: Our series confirms the reliability of stereotactic CB in the diagnosis of breast carcinoma. Diagnostic sensitivity is improved by increasing the number of cores taken (to six or more), particularly in women with mammographic microcalcifications of an equivocal nature.

Acute inflammation of the breast--the role of breast ultrasound in diagnosis and management.

Twenty female patients aged between 24 and 69 years were referred for breast ultrasound (US) examination between June 1989 and June 1990, with clinical suspicion of a breast abscess. Six were currently lactating. Initial US examination confirmed the presence of an abscess collection in nine out of 20 patients. Seven of these subsequently had surgical incision and drainage. Two settled on medical treatment. No abscess was detected on initial US examination in the remaining 11 patients who were treated conservatively with oral antibiotics. One patient, who had markedly dilated ducts on her initial US examination, remained symptomatic. Follow-up US demonstrated a small fluid collection, which within 7 days developed into a large multiloculated abscess requiring surgical drainage. We feel that US is very useful in accurately demonstrating the presence or absence of an abscess collection in the acutely inflamed breast.

Evaluation of magnification and paddle compression techniques in the assessment of mammographic screening detected abnormalities.

Between February 1988 and December 1989, 8.6% of all women who presented to the South East London Breast Screening Centre for mammography were recalled for assessment. Magnification or paddle compression techniques were used in the assessment of 39% of these patients. The aim of the study was to evaluate the improvement in mammographic specificity provided by these 'special views'. Three hundred and thirty cases were reviewed. The basic mammograms were assessed both alone and together with the special views, and the mammographic findings were scored according to the index of suspicion for malignancy. Special views were felt to be helpful when they led to an increase in mammographic specificity. It was found that special views increased mammographic specificity in 50.8% of cases. Sixteen 'equivocal' diagnoses became 'normal' or 'benign' and 15 of these patients avoided surgical biopsy. Twelve 'equivocal' diagnoses became 'malignant', which helped surgical planning, and in all 12 cases, histology confirmed the diagnosis of malignancy. It is felt that 'special views' are necessary for the complete mammographic assessment of many screen-detected abnormalities.

Interventional radiology of the biliary tract. Intraductal radiation.

One palliative method of treating patients with a high duct cholangiocarcinoma is the use of 192Ir wire. This is placed through the tumor, which has been previously intubated, and delivers a high local dose of radiation. The mean survival time in 30 patients treated with intraductal radiation was 16.8 months, an improvement compared to surgical bypass or endoscopic and radiologic drainage procedures.

Biliary complications following orthotopic liver transplantation.

The gall-bladder conduit anastomosis (choledocho-cholecysto-choledochostomy) has been the most frequently used technique for the biliary tract anastomosis in the Cambridge/King's College Hospital joint liver transplantation programme since 1976. Cholangiograms and interventional biliary procedures performed over a 3 year period were reviewed retrospectively. Seventy-six of 148 patients managed post-operatively at King's College Hospital were studied (79 transplants). Cholangiograms were abnormal in 63 (80%) transplants with biliary strictures; inspissated bile formation, bile leak and T-tube malposition occurring in 50, 23, 14 and three transplants respectively. Anastomotic strictures occurred most frequently, predominantly at the proximal anastomosis, and the presence of inspissated bile and the T-tube in relation to these contributed towards subsequent biliary obstruction. Non-anastomotic strictures in the donor biliary tract were associated with a high position of the T-tube tip at or above the liver hilum. Saline irrigation of the bile ducts for inspissated bile or its removal via the endoscope were effective measures in the management of biliary obstruction but percutaneous balloon dilatation and endoscopic stent insertion for biliary strictures were found to have a limited role.

The expansion of interventional radiology. Report of a survey conducted by the Royal College of Radiologists.

The Interventional Radiology Group of the Royal College of Radiologists sent a questionnaire to major hospitals in the United Kingdom in 1982 and 1987 in order to assess the impact of the introduction and growth of interventional procedures on patient management over the 5-year period and to consider the implications of these data for the future staffing and equipment requirements of radiology departments. In the 194 hospitals correctly completing the most recent survey, a total of 30,794 interventional procedures were performed in a 12 month period, representing an overall increase of 116% since the previous survey of 1982.

Hepatic haemangioma: a critical review of diagnosis and management.

Twenty-four adults (10 male; age 27-65 years, median 43.5) with hepatic haemangioma are reviewed. Fifteen had right hypochondrial pain (lesions 8 cm or more in diameter in nine). Six lesions were found incidentally, at ultrasound examination or elective cholecystectomy. Diagnosis, from ultrasonic and angiographic appearances, was confirmed in 12 by percutaneous biopsy without complication. Eleven patients were followed untreated for up to 60 months (median 24 months): lesion size (median 2.5 cm) did not change and all remained well. Surgical resection succeeded in two of three patients; the third and eight other patients (seven with symptoms) with lesions 3 to 30 cm in diameter were selected for Gelfoam embolization. Transient minor side effects preceded improvement in most, but two patients (with lesions of 20 cm or greater in diameter) developed multiple liver abscesses: recovery was protracted. Embolization failed in three; two remain well, untreated, to 24 and 51 months. Two patients had hepatic artery ligation, one with radiotherapy. Further imaging at from eight to 60 months (median 24) showed little change in lesion size or vascularity with any non-resectional technique. Expectant management of small asymptomatic haemangiomas appears appropriate. Embolization may reduce pain but the risk of abscess formation is high for large tumours, and reduction in size or vascularity of lesions is unlikely whatever their initial diameter.

Radiological investigation of liver trauma.

Difficult diagnostic problems may occur both acutely and in the long term in patients who have suffered severe upper abdominal trauma. Radiological investigation accurately demonstrates the presence and extent of liver damage. This article discusses the indications for both diagnostic and therapeutic radiological techniques and their roles in patient management.

Use of arterial devascularization and cytotoxic drugs in 30 patients with the carcinoid syndrome.

Thirty patients with symptoms of the carcinoid syndrome and other symptoms not controlled by pharmacological agents were analysed with respect to the value of various treatment measures used. Tumour devascularization was carried out in 11 patients, either by surgical ligation of the main hepatic artery (6) or by percutaneous arterial embolization (5). The latter was shown to be the safer technique, both with respect to initial morbidity/mortality and other side effects. Control of flushing and diarrhoea was achieved in 80% and the technique was also repeated on one occasion with success when symptoms recurred. The use of cytotoxic drugs alone, including 5-fluorouracil, cyclophosphamide and Adriamycin produced symptomatic relief in only 4 of the 22 patients treated. They should only be considered if devascularization by arterial embolization proves impossible or cannot be repeated when symptoms recur.

Intratumor gas--an ultrasound sign of tumour necrosis.

The ultrasound appearances of primary liver tumour in three patients are described. Changes in these appearances following devascularisation of the tumour by transcatheter embolisation are demonstrated. A possible mechanism for the change in appearances is suggested and is discussed in the light of plain radiographic and computerised tomographic findings.

Oral-contraceptive-associated liver tumours: occurrence of malignancy and difficulties in diagnosis.

Seven of ten women with oral-contraceptive-associated liver tumours were found to have hepatocellular carcinoma. The diagnosis was often delayed, although hepatomegaly was always present on examination, and liver-function tests and erythrocyte sedimentation-rates were abnormal in most cases. Other investigations, including routine technetium liver scans and biopsy, were sometimes misleading. There were important differences in alpha-fetoprotein concentration, vascularity on angiography, and survival between liver tumours in pill users and non-users.

PIP: A physician's personal series of 10 women treated from 1970-1979 for oral contraceptive-associated liver tumors is presented. Of the 10 women treated, 7 had hepatocellular carcinoma and 3 had benign adenomas. Symptomatology is described. Problems with diagnosis of liver dysfunctions included misleading biopsies and liver scans. The erythrocyte sedimentation rate was raised in all but 1 woman, and it was above 70 mm/h in 7. Changes in liver function tests were consistent with an intrahepatic tumor, with a striking increase in alkaline phosphatase in 9 (1170 IU/ml), and with only a slight rise in serum aspartate transaminase (mean 55 IU/ml). None of the patients had alpha fetoprotein levels above the upper limit of normal, and all patients were negative for hepatitis B surface antigen and antibody and anticore antibody. The carcinoma characteristics were similar in 7 patients (irregular trabecular arrangement with basophilic and dysplastic cells with nuclear pleomorphism and increased mitotic figures). When these oral contraceptive users were compared with 7 women diagnosed with hepatocellular tumors who had never used oral contraceptives, several striking differences were found. None of the poll users with carcinoma had raised alpha fetoproteins, whereas 4/7 nonpill users did. By arteriography, tumors in nonusers were much less vascular and less well defined. Survival rates also differed, with a 50% survival time of 1-8 years in nonusers compared with 4-8 years in pill users. The striking feature of this series is the delay in reaching a diagnosis in most of the 10 cases treated.

Treatment of bleeding oesophageal varices by infusion of vasopressin into the superior mesenteric artery.

Seventeen patients bleeding from oesophageal varices were treated by continuous infusion of vasopressin through a catheter inserted percutaneously and positioned in the superior mesenteric artery and in two other patients catheterization proved technically impossible. Bleeding was completely controlled on only four out of 18 occasions in the 17 patients treated. In seven patients, bleeding was controlled for two or more days but then recurred although the infusion was continued with an increased dose of vasopressin. There was a high incidence of complications, including bleeding from the site of catheter insertion in the groin and septicaemias. Sengstaken balloon tamponade and oesophageal transection had to be used to control bleeding in some patients but only six out of 17 survived to leave hospital.