Nonpalpable breast cancer: percutaneous diagnosis with 11- and 8-gauge stereotactic vacuum-assisted biopsy devices.

PURPOSE: To compare the accuracy of diagnosis of invasive breast cancer with 11- and 8-gauge stereotactic vacuum-assisted biopsy (SVAB) devices and to correlate lesion diameter and accuracy of breast cancer diagnosis at SVAB. MATERIALS AND METHODS: During a 22-month period, 489 SVAB procedures were performed with an 11-gauge probe and 305 with an 8-gauge probe. SVAB and surgical pathologic results of 104 breast carcinomas were reviewed and correlated with lesion size, number of specimens obtained, and type of SVAB probe used. RESULTS: Four of 38 ductal carcinoma in situ (DCIS) lesions diagnosed with 11-gauge SVAB demonstrated invasion at surgery, whereas one of 23 DCIS lesions diagnosed with 8-gauge SVAB demonstrated invasion at surgery (P =.6). A mean of 12 specimens per lesion were obtained in each group. In lesions 30 mm or larger, the underestimation rate for DCIS was 43% (three of seven) with 11-gauge SVAB and 17% (one of six) with 8-gauge SVAB (P =.6). Overall, the rate of underestimation for DCIS was significantly higher in lesions 30 mm or larger (four of 13) than in smaller lesions (one of 48, P =.006). CONCLUSION: This study demonstrated no difference in breast cancer diagnosis with the 8- and 11-gauge SVAB systems, but the accuracy of breast cancer diagnosis was greater in lesions smaller than 30 mm than in larger lesions.

Reliability of histologic diagnosis of breast cancer with stereotactic vacuum-assisted biopsy.

The purpose of this study was to determine the accuracy of 11-gauge stereotactic vacuum-assisted breast biopsy (SVAB) for the diagnosis of breast cancer. Percutaneous biopsies of 426 suspicious breast lesions in 365 patients using 11-gauge SVAB were performed between September 1996 and June 1998. Of these biopsies 59 (13.8%) resulted in a diagnosis of breast carcinoma and 56 (95%) were surgically excised. These 56 lesions constitute the basis of this study. Pathology of SVAB and surgically excised tissue of the 56 carcinomas as well as imaging findings were correlated. At percutaneous biopsy 34 (61%) lesions demonstrated ductal carcinoma in situ (DCIS) and 22 (39%) invasive carcinomas. Surgical excision demonstrated the presence of an invasive cancer in three lesions percutaneously diagnosed as DCIS (9%; confidence interval 2-24%). No residual carcinoma was surgically demonstrated in seven (12.5%) lesions. Sensitivity of 11-gauge SVAB for the diagnosis of invasion in breast cancer was 88 per cent. Using SVAB the diagnosis of invasive carcinoma is reliable. However, a percutaneous finding of DCIS does not exclude the presence of invasion in 9 per cent of cases as confirmed by subsequent surgery. Using SVAB 12.5% of carcinomas are completely excised.

Focal fibrosis of the breast: imaging characteristics and histopathologic correlation.

PURPOSE: To characterize mammographic and ultrasonographic (US) features of focal fibrosis of the breast (FFB), to compare the radiologic and histopathologic findings, to investigate the incidence of FFB, and to determine if histopathologic diagnosis of FFB is an acceptable diagnosis for specific mammographic and US findings. MATERIALS AND METHODS: Retrospective review of findings from 1,268 surgical excisional and 796 percutaneous breast biopsies (290 US-guided, 370 stereotactically guided, and 136 vacuum-assisted stereotactically-guided) revealed 44 (2.1%) diagnoses of FFB. Mammographic and US features were correlated with histopathologic types. RESULTS: Thirty-seven (84%) of the 44 lesions diagnosed as FFB were visualized on mammograms and appeared as six (14%) circumscribed masses, two (5%) lobulated masses, one (2%) microlobulated mass, 11 (25%) obscured masses, two (5%) architectural distortions, and 15 (34%) asymmetric densities. Seven palpable lesions were not visualized on mammograms. Thirty-three of the 44 lesions were evaluated at US; 25 (76%) of 33 were visible. Twenty (80%) of 25 were well-defined hypoechoic masses; three (12%), ill-defined masses; and two (8%), marked shadowing without visible mass. At histopathologic examination, 17 (39%) of the 44 lesions were characterized as mass-like fibrosis; 14 (32%), as nodular fibrosis; 12 (27%), as haphazard fibrosis; and one (2%), as septal fibrosis. Histopathologic type and specific imaging findings did not correlate statistically. CONCLUSION: FFB is a histopathologic entity that has a wide spectrum of imaging findings. It is an acceptable histopathologic result of percutaneous breast biopsy, provided that careful radiologic-histopathologic clinical correlation is performed.

Atypical ductal hyperplasia: histologic underestimation of carcinoma in tissue harvested from impalpable breast lesions using 11-gauge stereotactically guided directional vacuum-assisted biopsy.

OBJECTIVE: This review was undertaken to determine the reliability of the histologic diagnosis of atypical ductal hyperplasia (ADH) made from tissue obtained by 11-gauge stereotactically guided directional vacuum-assisted biopsy of impalpable breast lesions. MATERIALS AND METHODS: Four hundred twenty-two 11-gauge stereotactically guided vacuum-assisted breast biopsies were performed at our institution between November 5, 1996, and June 30, 1998. Biopsies were performed with the patient prone on a dedicated stereotactic biopsy table. A directional vacuum-assisted biopsy device was used. Eight to 24 cores (mean, 13.4) were harvested from each lesion. Radiography of core specimens was performed in cases in which the target lesion contained microcalcifications. Twenty (4.7%) of the 422 biopsies yielded a histopathologic diagnosis of ADH. Surgical excision of 16 of the 20 lesions was subsequently performed. We compared the histopathologic results of the core extracted and the corresponding surgically excised tissue. RESULTS: Of the 16 surgically excised lesions, four (25.0%) retained the diagnosis of ADH. Four (25%) were upgraded to carcinoma: Two (12.5%) were ductal carcinoma in situ without comedonecrosis, one (6.3%) was invasive carcinoma, and one (6.3%) was tubular carcinoma. Of the remaining eight surgically excised lesions, six (37.5%) were interpreted as benign fibrocystic changes with ductal hyperplasia without atypia, and two (12.5%) were interpreted as lobular carcinoma in situ. CONCLUSION: Because ADH was underdiagnosed in 25% of the lesions, we recommend that surgical excision be performed whenever ADH is found in tissue obtained from 11-gauge directional vacuum-assisted breast biopsy.

Lessons from mammographic-histopathologic correlation of large-core needle breast biopsy.

A thorough understanding of the limitations of sampling and histopathologic issues affecting lesion management is critical to successful large-core (14-gauge) needle breast biopsy. The most common problems are differentiating usual hyperplasia, atypical hyperplasia, and carcinoma in situ; satisfactory sampling of microcalcifications, often present in adjacent benign and malignant processes; differentiating phyllodes tumor from cellular fibroadenoma; and assessing the extent of an in situ component in mixed invasive and in situ carcinoma. Equally important is understanding what constitutes an acceptable histopathologic result given the mammographic appearance of the lesion. Mammographers and pathologists need experience in identifying benign processes that can manifest as discrete masses at mammography and core biopsy: focal fibrosis, apocrine metaplasia, sclerosing adenosis, and fat necrosis. When present as discrete histopathologic processes at core biopsy, such diagnoses should be accepted. Nonspecific diagnoses such as "benign breast tissue" should be avoided by pathologists when a discrete process is evident; absence of a discrete finding to explain the mammographic appearance should prompt repeat core or excisional biopsy.

Template-guided breast US.

The authors modified a standard breast compression plate to allow ultrasound (US) scanning to be performed in the longitudinal and transverse directions with the breast positioned craniocaudally or laterally in a mammographic unit. The technique allows quick mammographic-US correlation of lesions, characterization of lesions as cystic, solid, or indeterminate, and the ability (with coordinates marked on the plate) to proceed directly with aspiration of sonographically indeterminate lesions.

Hormonal replacement therapy: mammographic manifestations.

Anecdotal observation of mammographic changes in patients receiving hormonal replacement therapy prompted a retrospective review of a screening population of 1,500 consecutive patients. Thirty patients were identified who underwent mammography both before or after therapy and during therapy. The duration of hormonal replacement therapy ranged from 1 to 72 months (mean, 22.2 months). An increase in fibroglandular tissue was seen on the mammograms of five of the 30 patients (17%) receiving therapy. The mammograms from the remaining 25 patients (83%) showed no change. A proportion of women receiving hormonal replacement therapy will show increased tissue density at mammography. Awareness of this response should temper concern and, in the absence of suggestive anatomic changes, allow for serial, vigilant monitoring of these patients.

Bacterial renal infection: role of CT.

The imaging studies done on 62 patients hospitalized for acute renal infections were retrospectively reviewed. Thirty-six (58%) had one or more abscesses, 17 (27%) had focal or diffuse acute bacterial nephritis, five (8%) had pyonephrosis, and four (6%) had pyelonephritis. All had prolonged fever (greater than or equal to 72 hours) and leukocytosis. Among 25 patients examined with both ultrasound (US) and computed tomography (CT), US failed to depict three of five (60%) cases of acute bacterial nephritis and seven of 15 (47%) intrarenal and extrarenal abscesses. One renal abscess was misdiagnosed as a tumor at CT. US is not an adequate screening test for detecting lesions that may require invasive therapy. CT is more sensitive for the detection of acute renal inflammatory disease and for defining the extent of disease for planning of radiologic or surgical intervention.

Equivocal mammographic findings: evaluation with spot compression.

Seventy-five spot compression views of equivocally suspicious lesions detected at routine mammographic examination of 72 women were reviewed in this retrospective study. Sixty-five of the 75 lesions appeared less suspicious on spot compression views, two did not change, and eight appeared more suspicious. Biopsy findings confirmed that the eight more suspicious lesions were cancer. The adjunctive use of spot compression helped characterize equivocal findings seen on routine mammographic views and improved the accuracy of mammographic interpretation.

Synchronous and metachronous transitional cell carcinoma of the urinary tract: prevalence, incidence, and radiographic detection.

Six hundred forty-five cases of transitional cell carcinoma (TCC) of the bladder, ureter, and/or kidney were reviewed retrospectively to determine the frequency of synchronous and metachronous lesions elsewhere in the urinary tract. Among 597 patients with TCC of the bladder, 23 (3.9%) developed an upper-tract lesion, after an average delay of 61 months. Metachronous upper-tract tumors developed in 13% of 38 patients with primary ureteral TCC and in 11% of 63 with renal TCC, after average delays of 28 and 22 months, respectively. Synchronous TCC was found in 2.3% of patients with bladder TCC, 39% of those with ureteral TCC, and 24% of those with renal TCC. Seventeen percent of the subsequent upper-tract lesions would have been demonstrated by intravenous or retrograde urography performed 1 year after the initial onset of primary bladder cancer, and 61% would have been demonstrated by studies performed within 2 years. Therefore, the authors recommend annual radiologic evaluation of the upper urinary tract for 2 years after initial diagnosis and treatment of an upper-tract or bladder TCC.

Dermal breast calcifications: localization with template-guided placement of skin marker.

Reliable localization of skin calcifications in the breast was achieved with a true tangential view obtained after superimposition of a radiopaque skin marker. The marker was placed with the aid of a localization template. This method expedited such localizations and obviated the need for repeat radiographs to achieve accurate positioning of the marker.

Candida of the bladder wall: computerized tomography demonstration.

We describe a patient with a history of vulvar cancer, aplastic anemia and diabetes who was found to have a bladder wall lesion on a computerized tomography scan, which was compatible with malignancy. Pathological examination of the biopsy specimen revealed the lesion to be Candida. The differential diagnosis of filling defects in the bladder as seen on computerized tomography is discussed.

Renal vein thrombosis in patients with nephrotic syndrome: CT diagnosis.

A retrospective evaluation of the computed tomography (CT) findings in 50 patients with the nephrotic syndrome was undertaken. In four patients with clinical manifestations of acute renal vein thrombosis (RVT) on initial examination, the diagnosis was confirmed by CT findings. Three patients had left RVT, one had right RVT, and all four had thrombus in the inferior vena cava (IVC) at the level of the renal veins. Of the remaining 46, otherwise asymptomatic patients, one had bilateral RVT, two had left RVT, and five had isolated IVC thrombus. The abnormalities noted on CT scans were widened renal vein(s) containing thrombus, thrombus in the IVC, renal enlargement, thickened Gerota fascia and formation of pericapsular venous collaterals, and an abnormal renal parenchymal enhancement pattern consisting of prolonged corticomedullary discrimination, delayed and/or persistent paraenchymal opacification, and delayed or absent pyelocalyceal visualization.

CT in the diagnosis of enterovesical fistulae.

Enterovesical fistulae are difficult to demonstrate by conventional radiographic methods. Computed tomography (CT), a sensitive, noninvasive method of documenting the presence of such fistulae, is unique in its ability to outline the extravesical component of the primary disease process. Twenty enterovesical fistulae identified by CT were caused by diverticulitis (nine), carcinoma of the rectosigmoid (two), Crohn disease (three), gynecologic tumors (two), bladder cancer (one), cecal carcinoma (one), prostatic neoplasia (one), and appendiceal abscess (one). The CT findings included intravesical air (90%), passage of orally or rectally administered contrast medium into the bladder (20%), focal bladder-wall thickening (90%), thickening of adjacent bowel wall (85%), and an extraluminal mass that often contained air (75%). The fistulae secondary to diverticulitis, rectosigmoid neoplasms, carcinoma of the bladder, and uterine tumors involved the left and/or posterior aspects of the bladder. Those form Crohn disease of the terminal ileum or cecal and appendiceal lesions implicated the right lateral or anterior aspects of the bladder. CT proved to be an important new method in the diagnosis of enterovesical fistulae.

Excretory urography and computed tomography in the initial evaluation of patients with cervical cancer: are both examinations necessary?

One hundred ten patients with carcinoma of the cervix were studied to determine if both excretory urography and computed tomography are needed for routine evaluation. Computed tomography gave more information in 25 patients and the excretory urogram was more informative in 10 patients. Thirty-five hydroureters were detected by computed tomography, whereas excretory urography identified 21. The hydroureter in its entirety was seen more often using computed tomography, and the site of obstruction was identified in 29 of 35 cases. The superiority of computed tomography was particularly evident in patients with stage IIB or more advanced lesions. In stage I-IIA lesions, both techniques yielded the same information about the urinary tract. It was concluded that routine use of both examinations is not indicated. Excretory urography is currently sufficient in evaluation of stage I or IIA lesions, while computed tomography obviates excretory urography in patients with advanced cervical cancer (IIB-IVB).