The 'twinkle' artifact - A novel method of clip identification to facilitate targeted axillary surgery following neoadjuvant chemotherapy in breast cancer patients.

OBJECTIVES: A targeted surgical approach which accurately determines axillary status after neoadjuvant chemotherapy (NAC) may allow appropriate de-escalation of surgical treatment. It is postulated that the combined use of a particular marker clip, ULTRACOR®TWIRL™ (Bard, Inc.), and specific ultrasound settings for its identification, may overcome the challenges of pre-operative localisation with size diminution of nodes following NAC. Hence, this feasibility study was performed. METHODS: Three patients with locally advanced breast cancer (LABC), who had the Twirl marker clip placed in biopsy-proven metastatic axillary lymph nodes and completed treatment were included in this preliminary study. Preoperative sonographic identification of the clip and associated node was done on the day of surgery, confirmed by eliciting the 'twinkle' artifact, followed by hookwire localisation and resection. The 'twinkle' artifact was demonstrated within each specimen after resection. RESULTS: All three patients who completed treatment for LABC had successful identification and resection of clipped node aided by the 'twinkle artifact'. CONCLUSION: The 'twinkle' artifact is a novel and useful aid in identifying the Twirl™ clip marking a lymph node in the post-NAC setting, with the potential to be used intraoperatively.

Integrating anatomy, radiology, pathology, and surgery: An alternative approach in resecting multifocal and multicentric breast carcinoma.

The sick lobe hypothesis provides the basis for a lobar approach in radiology, pathology, and surgical treatment of breast cancer. This approach aims to remove the tumor together with the surrounding field of genetic aberrations. Detailed preoperative lobar imaging that properly maps the disease and assesses its extent guides the parenchymal resection. Integration of our knowledge of breast anatomy and pathology with the results of preoperative radiological mapping is critical in assessing the eligibility of patients with multifocal and/or multicentric breast cancer for breast conservation treatment. Through an appropriately selected incision, a multisegment resection of the diseased lobe(s) is performed, which leaves the residual parenchyma in a formation that allows dovetailing of one part into the other, like the way pieces of a jigsaw puzzle fit together. Detailed pathologic analysis of the surgical specimen provides valuable feedback to the radiologist, establishes the completeness of surgical intervention, and generates predictive information for therapeutic decisions. Our approach is a step in continuous search for ideal tailored therapy to avoid under or over-treatment of breast cancer patients.

Small masses on breast MR: is biopsy necessary?

RATIONALE AND OBJECTIVES: To evaluate outcome of magnetic resonance (MR)-detected biopsied breast lesions ≤5 mm by correlating imaging characteristics with pathology. METHODS AND MATERIALS: Institutional review board-approved retrospective review of 565 lesions biopsied with MR guidance between March 2004 and February 2009 found 68 lesions ≤5 mm in 61 patients. Lesions evaluated were those prospectively recommended for biopsy based on clinical setting, suspicious lesion morphology, and kinetics. Two study radiologists, blinded to final pathology, reviewed MR exams recording patient age, exam indication (staging, surveillance, diagnostic, or follow-up), mass location, size, morphology, T2-weighted signal, and kinetics. Chart review provided final pathology. RESULTS: Of 68 masses ≤5 mm, 14 (20.6%) were malignant. Of 32 <5 mm, 32 (28.1%) were malignant. Of 14 malignancies, 7 (50%) were in patients with recently diagnosed breast cancer, 6 in the same breast, of which 4 (66.7%) were in same quadrant. Higher likelihood of malignancy based on proximity to known cancer was statistically significant (P = .01). No significant difference in proportion of malignancies was found based on age, T2-weighted signal, morphology, or kinetics. CONCLUSION: For MR-detected biopsied masses, the positive predictive value for malignancy of those ≤5 mm was 20.6%. The highest prevalence of cancers was in the same quadrant as a newly diagnosed breast cancer. The decision to biopsy small masses should be based on carefully assessed MR features, and in the context of exam indication, not solely on size.

Using real-time tissue elastography for breast lesion evaluation: our initial experience.

OBJECTIVE: The purpose of this study was to prospectively assess the performance of real-time tissue elastography (RTE) in the evaluation of breast masses and correlate RTE and American College of Radiology Breast Imaging Reporting and Data System (BI-RADS) assessments with pathologic findings. METHODS: Informed consent was obtained from all patients for this Health Insurance Portability and Accountability Act-compliant, Institutional Review Board-approved study. Patients with sonographically visible breast lesions for which a biopsy was recommended were considered potential study participants. Between October 2006 and February 2008, 186 consecutive women with 200 lesions were enrolled. Twelve lesions in 11 patients were excluded, resulting in a study population of 188 lesions in 175 women. After routine B-mode sonographic examination, RTE was performed using a manual free-hand compression technique. Study lesions were assigned elasticity scores (ES) based on the system proposed by Itoh et al (Radiology 2006; 239:341-350), where 1 is normal and 5 represents abnormal strain. The lesion size on RTE and B-mode imaging was compared. Results were correlated with BI-RADS assessment and pathologic findings. RESULTS: Pathologic examination revealed 61 of 188 malignancies (32.4%) and 127 of 188 benign lesions (67.6%). Of the malignant lesions, 84% had ES of 5 and 4, whereas 76% of benign lesions had ES of 1 and 2. The sensitivity of RTE was 92.7%, and specificity was 85.8%, with 4 false-negative and 16 false-positive results. Of the biopsy-proven benign BI-RADS 4A lesions, 63 of 76 (82.9%) had ES of 1 and 2, consistent with normal tissue. CONCLUSIONS: Real-time tissue elastography may provide additional characterization of breast lesions, improving specificity, particularly for low-suspicion lesions.

Multimodality imaging of hepato-biliary disorders in pregnancy: a pictorial essay.

Hepato-biliary disorders are rare complications of pregnancy, but they may be severe, with high fetal and maternal morbidity and mortality. Imaging is, therefore, essential in the rapid diagnosis of some of these conditions so that appropriate, life-saving treatment can be administered. This pictorial essay illustrates the multimodality imaging features of pregnancy-induced hepato-biliary disorders, such as acute fatty liver of pregnancy, preeclamsia and eclampsia, and HELLP syndrome, as well as those conditions which occur in pregnancy but are not unique to it, such as viral hepatitis, Budd-Chiari syndrome, focal hepatic lesions, biliary sludge, cholecystolithiasis, and choledocholithiasis.