Intraoperative ultrasound guidance in breast-conserving surgery shows superiority in oncological outcome, long-term cosmetic and patient-reported outcomes: Final outcomes of a randomized controlled trial (COBALT).

BACKGROUND: The multicenter randomized controlled COBALT trial demonstrated that ultrasound-guided breast-conserving surgery (USS) results in a significant reduction of margin involvement (3.1% vs. 13%) and excision volumes compared to palpation-guided surgery (PGS). The aim of the present study was to determine long term oncological and patient-reported outcomes including quality of life (QoL), together with their progress over time. METHODS: 134 patients with T1-T2 breast cancer were randomized to USS (N = 65) or PGS (N = 69). Cosmetic outcomes were assessed with the Breast Cancer Conservative Treatment cosmetic results (BCCT.core) software, panel-evaluation and patient self-evaluation on a 4-point Likert-scale. QoL was measured using the EORTC QLQ-C30/-BR23 questionnaire. RESULTS: No locoregional recurrences were reported after mean follow-up of 41 months. Seven patients (5%) developed distant metastatic disease (USS 6.3%, PGS 4.4%, p = 0.466), of whom six died of disease (95.5% overall survival). USS achieved better cosmetic outcomes compared to PGS, with poor outcomes of 11% and 21% respectively, a result mainly attributable to mastectomies due to involved margins following PGS. There was no difference after 1 and 3 years in cosmetic outcome. Dissatisfied patients included those with larger excision volumes, additional local therapies and worse QoL. Patients with poor/fair cosmetic outcomes scored significantly lower on aspects of QoL, including breast-symptoms, body image and sexual enjoyment. CONCLUSION: By significantly reducing positive margin status and lowering resection volumes, USS improves the rate of good cosmetic outcomes and increases patient-satisfaction. Considering the large impact of cosmetic outcome on QoL, USS has great potential to improve QoL following breast-conserving therapy.

Early MR features of hypoxic-ischemic brain injury in neonates with periventricular densities on sonograms.

BACKGROUND AND PURPOSE: In the early 1980s, diagnosing periventricular leukomalacia (PVL) in neonates by using cranial sonography was possible for the first time. Our purpose was to investigate the possibility of diagnosing PVL in the acute stage by using MR imaging. We evaluated early MR features of hypoxic-ischemic brain injury in neonates with periventricular densities (flares) on cranial sonograms to determine the added value of MR imaging over sonography alone for early diagnosis of brain damage. METHODS: In a prospective study, infants who showed flares and/or cysts on sonograms underwent MR imaging during the (sub)acute stage. RESULTS: Fifty infants were classified according to the highest sonographic grade up to the day of MR imaging: 23 infants had sonographic grade 1 (flares < 1 week), 15 had sonographic grade 2 (flares > or = 1 week), four had sonographic grade 3 (small localized cysts), and eight had sonographic grade 4 (extensive periventricular cysts); none had sonographic grade 5 (multicystic leukomalacia) on the day of MR imaging. Overall, the additional information provided by MR imaging (over sonography alone) consisted of the depiction of hemorrhagic lesions in 64% of the infants. Extent and severity of the hemorrhages varied from isolated punctate lesions to extensive hemorrhages throughout the white matter; the latter were followed by cystic degeneration at autopsy in two infants. In nine of the 12 infants with cystic PVL, MR images showed more numerous or more extensive cysts. In addition, in two infants, MR images showed cysts not present on sonograms. In 32% of the infants, MR imaging provided no additional information; in these children, all but one had flares on sonograms whereas MR images showed no abnormalities or a zone of mild periventricular signal change. CONCLUSION: MR imaging can depict the precise site and extent of hypoxic-ischemic brain injury at an earlier stage and allows a wider differentiation of lesions as compared with sonography alone. Hemorrhagic PVL is considered to be rare, but was present in 64% of our study population.

Accuracy of ultrasonography and magnetic resonance imaging in detecting failure of breast implants filled with silicone gel.

We prospectively studied the accuracy of magnetic resonance imaging (MRI) and ultrasonography (US) for preoperative detection of rupture in 35 single-lumen implants filled with silicone gel in 18 patients. The positive predictive value of US for rupture of an implant was 70% and the negative predictive value 64%. Sensitivity and specificity were 44% and 87%, respectively. Accuracy, defined as the total true positive and true negative values divided by the total number of implants studied was 66%. The positive predictive value of MRI was 100% and the negative predictive value 90%. The corresponding sensitivity and specificity were 88% and 100% and the accuracy 94%. MRI offers significantly better diagnostic sensitivity (p = 0.02) and accuracy (p = 0.004), and should be regarded as the "gold standard" in the evaluation of rupture of breast implants filled with silicone gel. When MRI is not readily available, US is an acceptable alternative.

Ultrasound-guided lumpectomy of nonpalpable breast cancers: A feasibility study looking at the accuracy of obtained margins.

BACKGROUND AND OBJECTIVES: Complete excision of a nonpalpable breast cancer after wire localization is a difficult procedure. Often, adequate margins are not obtained, and a second procedure is then required. Prospectively, we studied the feasibility of ultrasound-guided excisions of nonpalpable breast cancers, with particular attention to the accuracy of the procedure in obtaining adequate margins. METHODS: Prospectively, 19 patients with 20 mammographically detected nonpalpable, highly suspect, breast tumors were entered in this feasibility study. In 15 of these, the diagnosis of invasive malignancy was established preoperatively. All patients underwent ultrasound-guided excision with the intent to obtain adequate margins. We also reviewed our own experience with the excision of nonpalpable breast cancers after wire localization. RESULTS: Of the 20 excisions with ultrasound guidance, there were 19 carcinomas and 1 ductal carcinoma in situ. Of the 19 carcinomas, 17 (89%) were excised with adequate margins. Of the 43 carcinomas that were excised after wire localization, only 17 (40%) had been resected with adequate margins. CONCLUSIONS: Ultrasound-guided excision appears to be a reliable procedure for obtaining adequate margins in the resection of nonpalpable breast cancers. Other advantages of this procedure are increased patient comfort and decrease in operating room time.

Rupture of silicone gel filled testicular prosthesis: causes, diagnostic modalities and treatment of a rare event.

PURPOSE: Rupture of the envelope of silicone gel filled testicular prostheses is rare and alleged to be unlikely without intraoperative needle puncture. We observed that it may be caused by chronic intermittent trauma or a single acute increase of pressure, and report diagnostic and therapeutic modalities. MATERIALS AND METHODS: Four cases treated by us during the last 10 years are presented. One patient had testicular implants for Klinefelter's syndrome, whereas the other 3 had been treated for female-to-male transsexualism. Diagnosis was confirmed by ultrasonography and magnetic resonance imaging. The fibrous capsule surrounding the ruptured prosthesis was left intact to allow en bloc surgical extirpation. Histological evaluation of the resected specimen was performed. RESULTS: Rupture of silicone gel filled testicular implants may be caused by acute or chronic pressure without intraoperative needle puncture. CONCLUSIONS: Magnetic resonance imaging offers superior diagnostic accuracy and should be regarded the gold standard in the evaluation of implant rupture. Ultrasonography is an acceptable alternative. In cases when gross symptoms of scrotal inflammation are lacking replacement of implants is facilitated by the fibrous capsule that forms around any prosthesis. Transcapsular migration of silicone particles was observed even when the fibrous capsule was intact.

Imaging signs and radiologists' jargon of ruptured breast implants.

Silicone gel leakage problems are central to the furor over the complications alleged to be caused by breast implants. Because clinical examination may not reveal confirmatory signs of gel bleed or rupture, radiologists are often requested by plastic surgeons to evaluate the integrity of the implant's envelope. The findings of the various imaging investigations are reported in terms such as "teardrop," "linguini," and "snowstorm." To interpret the radiologist's report correctly, the plastic surgeon should be familiar with these terms and the findings they represent. In this article, we present an explanation of the radiologists' vocabulary in these matters, as well as an indication as to the significance of the various signs.

Silicone breast implant bleed and rupture: clinical diagnosis and predictive value of mammography and ultrasound.

Silicone breast implants have been used since 1962. Reliable methods to detect rupture and silicone gel bleed are needed, even more so because of increasing concern about the possible hazards of silicone. In cases in which clinical examination is not conclusive, additional radiodiagnostic evaluation may be useful in diagnosing intracapsular and extracapsular rupture of mammary prostheses. In the series presented, combined ultrasound and mammography shows a sensitivity for prosthesis rupture of 64% and a specificity of 81%. Silicone gel bleed cannot be detected by means of clinical examination or by combined mammography and ultrasound.

Diagnosis and management of neonatal adrenal haemorrhage.

Three patients with neonatal adrenal haemorrhage (NAH), presenting with various signs and symptoms, are reported. The role of ultrasonography in diagnosis and management of this entity is emphasized. Conservative management is advocated, once the diagnosis is confirmed. Surgery is indicated only for cases of uncontrollable haemorrhage.

Nuclear magnetic resonance imaging of bone marrow in childhood leukaemia.

Bone marrow infarction is known to occur in childhood leukaemia. Although it may be suspected on clinical grounds, radiographic evidence is infrequent. We present three cases in which magnetic resonance imaging demonstrated unexpectedly extensive bone marrow lesions and discuss the evidence that these lesions were due to bone marrow infarction.

Hypertrophic osteoarthropathy in a young child with cytomegalovirus pneumonia and the bare lymphocyte syndrome.

A case of hypertrophic osteoarthropathy is reported in a 3-year-old Turkish girl. She had combined immunodeficiency, later shown to be the bare lymphocyte syndrome, and chronic pneumonia. Lung biopsy showed cytomegalovirus. The child developed painful elbow and knee joints and hypertrophic osteoarthropathy was demonstrated radiologically.

Fibrodysplasia ossificans progressiva: current concepts and the role of CT in acute changes.

Fibrodysplasia ossificans progressiva (FOP) may be treated with diphosphonate in an attempt to control the deposition of calcium phosphate. Amounts of calcium deposition may be assayed by plain radiographs and CT. In a sporadic case of FOP treated for 6 years with a diphosphonate (EHDP) we have analyzed the findings from CT. This modality presents a suitable means of monitoring response to new therapeutic agents, but CT also gives insights into the pathogenesis of the disorder.