Intraoperative sonographic localization of breast masses: success with specimen sonography and surgical bed sonography to confirm excision.

OBJECTIVE: To assess the use of intraoperative sonography for localization of breast masses at excisional biopsy, with specimen and surgical bed sonography to confirm excision. METHODS: A computer search of the 5-year period from January 1993 through January 1998 revealed 138 consecutive women referred for sonographically guided excisional biopsy of 148 masses; 35 masses were excluded because they had no postoperative mammograms. One hundred thirteen masses constituted the study group. Specimen sonography (n = 60) or surgical bed sonography (n = 53) was performed as the initial evaluation to confirm excision, but ultimately, surgical bed sonography may have been necessary after specimen sonography, and specimen sonography may have been necessary after surgical bed sonography. The miss rates determined by postoperative imaging were calculated for each group and compared with those of mammographically guided needle localization series from the literature. RESULTS: Follow-up physical examination and mammography showed no residual mass in the region of surgery in any patient. However, follow-up sonography had 1 miss in the initial specimen sonogram group (1 [1.7%] of 60) and 1 miss in the initial surgical bed group (1 [1.9%] of 53). As shown by the Fisher exact test, there was no significant difference between the miss rates of the 2 initial methods of confirming lesion excision or between the miss rates of these initial methods, both groups combined, and 6 mammographic localization series from the literature. CONCLUSION: Intraoperative breast sonography, using specimen sonography and scanning the surgical bed, has miss rates comparable with those of mammographic needle localization. Follow-up sonography must be performed if there is any doubt of complete excision.

Sonographically guided renal mass biopsy: indications and efficacy.

PURPOSE: To review the clinical indications, pathologic results, and success rate of all our sonographically guided solid renal mass biopsies over a 5-year period. METHODS: Between 1993 and 1998, 44 consecutive patients underwent sonographically guided percutaneous biopsy of a solid renal mass. Indications included prior history of nonrenal malignancy, metastatic disease of unknown primary origin, previous contralateral nephrectomy for a renal cell neoplasm, a renal transplant mass, suspected renal lymphoma, history of tuberous sclerosis, and poor surgical candidacy. Aspiration biopsies were initially performed with 22- to 18-gauge spinal needles. If the initial cytologic evaluation findings were nondiagnostic, core biopsies were then performed with 20- to 18-gauge core biopsy guns. Dictated sonographic reports of the biopsies were reviewed to determine the following: indication for biopsy, location and size of the renal mass, needle gauge and type, number of needle passes, and complications. Final cytologic and surgical pathologic records were reviewed. RESULTS: Thirty-six (82%) of the 44 biopsy specimens were diagnostic. Aspirated smears were diagnostic in 24 (67%) of these cases, with the diagnosis made on the basis of cell block alone in an additional 2 (6%). A definitive diagnosis came from core biopsy alone in 10 cases (28%). The 18-gauge core needle yielded diagnostic results more reliably than the 20-gauge core needle, and a significant correlation was seen between core biopsy needle size and the rate of diagnostic core samples (P = .017). Pathologic diagnoses included renal cell carcinoma (n = 18), lymphoma (n = 4), oncocytic neoplasm (n = 4), transitional cell carcinoma (n = 2), angiomyolipoma (n = 1), papillary cortical neoplasm (n = 1), and metastatic carcinoma (n = 6). Complications were seen in 4 (9%) of 44 cases; all were treated conservatively. CONCLUSIONS: For specific clinical indications, sonographically guided fine-needle aspiration and core biopsy of a solid renal mass can be performed safely. In many cases, a definitive diagnosis can be made on the basis of fine-needle aspiration alone. However, diagnosis may ultimately require core biopsy, for which 18-gauge core needles would be more reliably diagnostic than 20-gauge needles.

Clinical impact of sonographically guided biopsy of salivary gland masses and surrounding lymph nodes.

Although fine-needle aspiration biopsy of salivary gland masses has been reported in the otolaryngology literature, the use of sonography to guide the biopsy of nonpalpable masses and masses seen on other cross-sectional imaging studies has not been described. Our goal was to evaluate sonographically guided biopsy of masses and lymph nodes related to the salivary glands. We analyzed the records of 18 patients who had undergone fine-needle aspiration biopsy of a salivary gland mass or lymph node with a 25-, 22-, or 20-gauge needle. A definitive cytologic diagnosis was made for 13 of the 18 patients (72%); cytology was suggestive but not definitive in three patients (17%) and insufficient in two (11%). Definitive diagnoses were made in three cases of reactive lymph node, in two cases each of lymph node metastasis and Warthin's tumor, and in one case each of pleomorphic adenoma, adenoid-cystic carcinoma, schwannoma-neurofibroma, parotid metastasis, parotid lymphoma, and Sjögren's-related lymphoid-epithelial lesion. Sonographically guided biopsy allows for confident needle placement in masses seen on computed tomography and magnetic resonance imaging. Sonography can usually distinguish a perisalivary lymph node from true intrasalivary masses, and it can help the surgeon avoid the pitfall of a nondiagnostic aspiration of the cystic component of masses. We conclude that sonographically guided biopsy of salivary gland masses can provide a tissue diagnosis that can have a direct impact on clinical decision making.

Laparoscopic liver sonography: preliminary experience in liver metastases compared with CT portography.

This study evaluated the ability of laparoscopic ultrasonography to detect, localize, and characterize focal liver masses. Laparoscopic ultrasonography and CT portography of the liver were performed in 13 patients with known or suspected malignancy. Laparoscopic ultrasonography directly influenced surgical management in four (31%) cases; three by detection of small focal masses and one by exclusion of masses suspected on CT portography. Laparoscopic ultrasonography provided guidance for biopsy or added important anatomic information in three cases. Laparoscopic ultrasonography was complementary to CT portography but added no additional information in three cases, and it failed to provide any information in two cases. Laparoscopic ultrasonography was falsely negative in one case. In this preliminary series, laparoscopic ultrasonography assisted surgeons in critical decision-making by either providing important new information, clarifying questionable areas, or complementing CT portography.

Ultrasonographic features of gastrointestinal duplications.

The variable sonographic appearance of duplication cysts is presented. Eighteen sonograms from 14 patients, aged 1 day to 8 years, were reviewed over an 8 year period. Water and other aqueous contrast agents were used in six patients as part of the sonographic evaluation. All lesions were confirmed by surgery. All but two patients were symptomatic. Twenty-four cysts were detected, ranging in size from 1.7 to 15.5 cm. The duplication cysts revealed a spectrum of sonographic findings (cystic to solid appearing masses). The mass characteristics, including the "muscular rim sign," and internal debris or hemorrhage, were demonstrated. Multiple unsuspected cysts (3 of 14 or 20%) and complications such as perforation were readily seen with ultrasonography. Serial sonograms demonstrated the changing morphology of two cysts. Other unsuspected intra-abdominal and pelvic pathologic conditions, including pyloric stenosis and ovarian cysts, were identified. Identification of the muscular rim sign is the most reliable indication of a duplication cyst. Multiple masses as well as possible accompanying anomalies in the abdomen and pelvis are readily evaluated with sonography. Lesions are easily followed with serial studies if there is no surgical intervention.

Randomized controlled trial in alcohol relapse prevention: role of atenolol, alcohol craving, and treatment adherence.

Previous studies suggest that beta-adrenergic blockers reduce craving levels during acute alcohol withdrawal. We conducted a new study to assess whether the daily use of atenolol by the abstinent alcoholic could maintain a blunted craving for alcohol and result in a decreased rate of relapse for alcohol abuse. The study was designed as a randomized, controlled, double-blind clinical trial. Among all 100 patients (50 atenolol, 50 placebo), only 15 stayed in the trial and remained fully abstinent for 1 year (7 atenolol, 8 placebo). Of the remaining 85 patients, 30 withdrew early while still abstinent (17 atenolol, 13 placebo). In the 57 high-risk patients who reported craving for alcohol at baseline, the treatment failure rates were 90% for patients receiving placebo, and was reduced to 65% in those who received atenolol (risk reduction = 28%, 95% confidence interval, -3% to 49%). The data from this trial also support the observation that poorer levels of treatment adherence are strongly associated with adverse outcomes for alcoholics during follow-up. This relationship was present both for patients who received atenolol and for those who received placebo.

The impact of gender on clinical characteristics and outcome in alcohol withdrawal.

Few studies have compared the social and clinical features of alcoholism for women and men, and none has focused on patients entering treatment for withdrawal. We investigated the role of gender by analyzing the data for 179 patients (34 women, 145 men) who underwent outpatient withdrawal. Our analysis focused on two questions: 1) How do women and men compare in terms of baseline social and clinical features? and 2) Do women and men have similar treatment outcomes in alcohol withdrawal? Baseline sociodemographic features revealed that women were more likely to be poor (90% vs. 71%, p = .03) but less likely to be uninsured (32% vs. 51%, p = .05), homeless (6% vs. 20%, p = .05), or have legal problems (29% vs. 54%, p = .02). Surprisingly, women and men reported a similar mean daily alcohol intake (240 g vs. 243 g). Women reported a shorter duration of alcohol abuse prior to entering treatment (16.1 y vs. 19.1 y). Although women experienced a higher treatment failure rate (53% vs. 43%), this difference is not significant. Our analysis highlights gender similarities and differences among patients entering treatment for withdrawal. We conclude that women and men have similar treatment outcomes in the management of alcohol withdrawal.

Social and clinical features as predictors of outcome in outpatient alcohol withdrawal.

OBJECTIVE: To identify patient features--both social and clinical--that may be associated with treatment failure in outpatient alcohol withdrawal. DESIGN: A prospective observational cohort study of patients who underwent outpatient management of the alcohol withdrawal syndrome. SETTING: Community hospital-based outpatient alcohol treatment program. PATIENTS: The 179 patients who were eligible for and participated in a clinical trial of drug therapy for outpatient management of the alcohol withdrawal syndrome. MAIN RESULTS: Treatment failure occurred for 45% (80/179) of the patients. Failure rating did not vary according to diverse sociodemographic features such as age, level of education, income, medical insurance status, and marital status. Persons who were homeless did as well as those who were not. In contrast, two clinical features of withdrawal were associated with significantly higher rates of treatment failure: craving and withdrawal symptom severity. High cravers had a treatment failure rate of 56% (22/39), compared with 36% (41/115) for those with lower scores (p less than 0.03). Among those with moderate-to-high withdrawal symptom severity, 49% (74/151) represented treatment failures, compared with 22% (6/27) of those in the low-symptom group (p less than 0.01). CONCLUSIONS: While these data do not confirm that socially disadvantaged persons are at increased risk for withdrawal treatment failure, two clinical features--craving and withdrawal symptom severity--may help identify high-risk patients.

Sonographic appearance of the torcular Herophili.

The sonograms of 12 infants aged 2 days to 7 months were evaluated to determine if the torcular Herophili could be demonstrated routinely on cranial sonography. Sonography, which was performed for a variety of indications (prematurity, seizures, hydrocephalus, sepsis, congenital anomalies, and subarachnoid hemorrhage) demonstrated the torcular Herophili in all cases. It appeared as a variable-sized, anechoic, and triangular or elongated structure inferior to the occipital lobes, posterior to the cerebellum, and just inside the cranial vault. Correlation with computed tomographic scans was available in four patients. A detailed description of the normal anatomy of the torcular Herophili is provided. Knowledge of the variable sonographic appearance of the torcular Herophili is important to distinguish it from a pathologic entity.