Recurrent disease after breast preserving therapy (BPT) and radiation therapy for breast cancer--diagnostic yield of palpation, mammography and ultrasonography.

PURPOSE: According to the S-3 guidelines for the diagnosis and treatment of breast cancer, only palpation and mammography are mandatory follow-up examinations. Ultrasonography is only mentioned as an optional technique. Aiming to elucidate the diagnostic yield for detecting recurrent disease after breast-preserving therapy (BPT) and radiation treatment, we analysed the sensitivity of palpation, mammography, ultrasonography, and combinations of these methods. MATERIALS AND METHODS: Over a period of 12 years, 27 suspicious lesions in patients status post BPT and radiation therapy were biopsied (histologic results: 16 benign lesions: 59.3 %, 11 malignant lesions: 40.7 %). Prior to biopsy, the benign or malignant character of each lesion was predicted by palpation, mammography and ultrasonography (BIRADS). Sensitivity, specifity, positive predictive value (ppv), negative predictive value (npv), and efficiency were calculated from a contingency table. RESULTS: For lesions status post BPT and radiation treatment, palpation had a sensitivity of 72.7 % and was 25 % specific. For mammography, the respective values were 36.4 % and 87.5 %, and for ultrasonography 90.9 % and 68.8 %. Palpation and mammography combined were 81.8 % sensitive and had a specificity of 6.2 %. The computed sensitivity for the 3 methods applied together was 100 %. Adding ultrasonography to palpation and mammography therefore increases sensitivity by 18.2 %. CONCLUSION: For diagnosing recurrent disease in patients status post BPT and radiation therapy, ultrasonography is superior to palpation and/or mammography and should become an obligatory follow-up tool. The role of mammographic follow-up appears overrated and the role of ultrasonographic assessment underrated. The S-3 guidelines will need to be changed accordingly.

Ultrasound and mammography guided wire marking of non-palpable breast lesions: analysis of 741 cases.

PURPOSE: Aim of the study were to evaluate the success of ultrasound and mammography guided wire marking of non-palpable breast lesions and the results of specimen mammography/ultrasonography, completeness of resection, and number of secondary resections (during the initial surgical session and as a separate intervention) were analysed. MATERIALS AND METHODS: Between May 1994 and December 2004, 668 women with 741 non-palpable breast lesions underwent surgery at the Greifswald University Department of Gynaecology and Obstetrics. Ultrasound directed wire marking was used in 418, mammography directed marking in 284 cases. In 39 lesions, both techniques were combined. RESULTS: Out of all lesions approached with ultrasound directed wire marking, 88 (21.1 %) were malignant. Among lesions marked during mammography, 52 (19.3 %) were malignant. Specimen ultrasonography indicated that 90.9 % of lesions were resected completely. Specimen mammography demonstrated complete resection in 89.1 %. On histological examination, 19.5 % of the malignant lesions marked with sonographic guiding and 36.5 % of the malignant lesions marked with mammographic guiding did not have clear margins. Secondary resections (during the first procedure) for incomplete specimens were needed in 10 patients in whom sonographic localisation had been used, and in 25 patients in whom mammographic localisation had been employed. A second surgical session for secondary resection was required in 5.5 % of lesions marked with ultrasound and in 12.3 % of lesions marked with mammography guidance. CONCLUSION: Sonography directed wire localisation appears to be superior to the respective mammographic method. Ultrasound guided wire marking should be considered the preferred method for all mammographic lesions with an ultrasonographic equivalent and no micro-calcifications.

[Teleradiology and mammography screening: evaluation of a network with dedicated workstations for reporting]. / Teleradiologie im Mammographie-Screening: Evaluation eines Testnetzes mit dedizierten Befundungsstationen.

PURPOSE: Evaluation of a system that supports a workflow for breast cancer screening by mammography. The time of installation, system reliability and workstation operation were evaluated. MATERIALS AND METHODS: The evaluated system (Image Diagnost, Munich, Germany) contains 2 diagnostic mammography workstations, a centralized server, and 2 Dicom shuttles for exchanging images via a physically existing network structure. Temporary archiving is possible. A mask designed for the needs of mammography screening facilitates assignment of BIRADS categories. The system automatically compares the categories assigned by a first and second reviewer and decides whether a consensus conference should be held. In the event that a conference is needed, the reviews are transmitted to the mammography expert responsible for the screening program and the consensus conference. Images are transferred via ISDN, Germany's National Research and Education Network (in the following DFN) and a central server between 2 sites which are approx. 100 km apart. We evaluated the duration of installation, the reliability of the system, and the usability of the workstation. Since we used curative mammography for evaluating the system, the patient age was noted for comparison. RESULTS: The system was installed in five days. Once installed, the system functioned without any major breakdowns. Mammography units of 2 manufacturers were able to be connected to the system without difficulty. Mammographies of 151 patients were exchanged between the sites and evaluated by 2 radiologists. 57 % of the patients were in the screening age (50-69 years). 9 exams were classified BIRADS 4a, 2 were 4b and 3 were BIRADS 5. The evaluations were technically perfect in 146/151 cases; hanging protocols had to be altered manually in 6 cases; the window/level had to be manually adjusted in 26/151 cases. Magnification was sufficient in all cases. The system exchanges examinations extremely quickly; up to 100 mammography exams may be evaluated in 1 hr. CONCLUSION: The system supports the workflow given by the German Mammography Screening program both locally and in a network.

Radial scar/complex sclerosing lesion of the breast--value of ultrasound.

PURPOSE: Although benign, radial scar/complex sclerosing adenosis is a lesion which histopathologically resembles tubular carcinoma. On physical examination, it is difficult to distinguish radial scar from a malignant tumour. Mammography cannot differentiate radial scar from malignancy. This clinical study aims to delineate the role of preoperative ultrasonography with emphasis on the question whether ultrasonography could lower the number of false-positive readings and therefore the number of open biopsies required. MATERIALS AND METHODS: In this examination, we present the clinical, mammographic, ultrasonographic, and histopathological features of 6 cases of radial scars. RESULTS: Although most authors describe radial scars as non-palpable, 2 of 6 lesions were indeed palpable. On mammograms, radial scars have a spiculated appearance, a feature observed in all of our cases. Numerous ultrasonographic characteristics are listed in the literature, but ultrasonography is not reported to have clear-cut advantages. CONCLUSION: Although this study did not elucidate any unique ultrasonographic features to characterise these lesions, the analysis of all ultrasonographic results made us recognise a set of "nearly specific ultrasonographic features" of radial scars. Current B-mode imaging does not appear to lead to the desirable reduction of the rate of unnecessary open biopsies.

Non-palpable breast lesions in asymptomatic women: diagnostic value of initial ultrasonography and comparison with mammography.

AIM: This prospective double-blind study was designed to assess (i) if primary breast screening by ultrasonography is capable of detecting breast cancer independent of tissue density and (ii) if the rate of unnecessary biopsies remains acceptable when diagnostics are based on ultrasonography. PATIENTS AND METHODS: Bilateral breast ultrasonography was performed in 448 asymptomatic women as the initial diagnostic method. Sonograms were interpreted using a set of standardized diagnostic criteria. Subsequently, mammograms were obtained. The radiologists reading the mammograms were blinded to the sonographic results. RESULTS: Overall, 3 non-palpable breast cancers were detected by ultrasound and mammography. All 3 ultrasonographically detected breast cancers were smaller than 1 cm (0.7, 0.7, 0.6 cm). All 3 carcinomas were correctly detected by both methods. For ultrasonography, the false positive rate was 1.1% (n=5) and for mammography 0.6% (n=3). When both methods were combined, the rate of unnecessary open biopsies was 1.6% (n=7). The ratio of benign to malignant lesions was 3.7/1. CONCLUSION: Without prior mammography, primary high-resolution breast ultrasonography is capable of detecting non-palpable breast carcinomas in asymptomatic women at an early stage. The rate of unnecessary open biopsies is low and the ratio of benign to malignant biopsies acceptable.

Parenchymal leiomyoma of the breast--clinical, sonographic, mammographic and histological features.

BACKGROUND: Intraparenchymal leiomyomas of the breast are quite rare. Areolar lesions are distinguished from intraparenchymal leiomyomas, which are less frequent. Clinically, leiomyomas appear as nodules; mammographically, they show up as round lesions. Reports on sonographic criteria are rare, and the criteria are nonspecific. Based on our case of an intraparenchymal leiomyoma, we describe additional sonographic features. The clinical, mammographic and sonographic characteristics of an intraparenchymal leiomyoma of the breast were evaluated. After surgery, the diagnosis was confirmed histologically. RESULTS: The clinical presentation of our patient with deep-seated leiomyoma of the breast included skin dimpling and a reduction in tissue mobility, differing from more commonly reported characteristics. Mammographically, the lesion was dense and only partly demarcated clearly, corresponding to other reports. On breast ultrasonography, the leiomyoma appeared as a hypodense, well demarcated, inhomogeneous lesion with posterior acoustic shadowing. A central tumour vessel was visible on Doppler imaging, and Cooper's ligaments were discontinuous. Acoustic shadowing, the hypodense character, hyperechoic border and the central tumour vessel are therefore additional ultrasonographic characteristics of an intraparenchymal leiomyoma of the breast. This type of lesion is usually described as isodense to hyperdense and homogeneous, possibly containing semicystic components. Previous reports have only described posterior acoustic enhancement, but not acoustic shadowing. CONCLUSION: On breast ultrasonography, an intraparenchymal leiomyoma of the breast can present with posterior acoustic shadowing, hypodense echogenicity, a hyperechoic border and a central tumour vessel. Neither imaging studies nor palpation allow distinction between benign and malignant lesions.

Papillary intracystic carcinoma of the female breast--role of ultrasonography.

We report on a 76-year-old patient with papillary intracystic breast carcinoma. Papillary intracystic carcinomas represent a rare entity. Among all malignant breast tumors, this lesion has an incidence of 0.5-2%. Palpation is not sufficient to distinguish benign from malignant findings. The same applies to mammography, unless the tumor infiltrates the cyst wall. The method of pneumocystography has become obsolete. Sonography is the preferred diagnostic modality to distinguish cystic from solid lesions and to differentiate simple cysts from cysts with intracystic growth. In this respect, Doppler and power Doppler sonography can be instrumental. It is feasible to obtain preoperative ultrasound guided FNAC or core biopsies of the cystic and solid components for cytological or histological verification. Complete excision of the cyst which should include the intracystic growth is considered the treatment of choice.

Juvenile papillomatosis (JP) of the female breast (Swiss Cheese Disease) -- role of breast ultrasonography.

This report summarises the imaging findings of juvenile papillomatosis (JP) in a 16-year-old woman. Sonographically, the lesion was oval, well defined, heterogeneous with multiple small, cystic spaces. Ultrasonography can be helpful in differentiating between JP and similar cystic lesions, fibroadenomas, phyllodes tumours, intracystic papillomas and carcinomas. A core needle biopsy is still needed to confirm the diagnosis. An open biopsy with excision of the lesion is mandatory, mere observation is inadequate because of insufficient knowledge about the direct relationship between JP and subsequent cancer.

Ligation of IgE receptors causes an anaphylactic response and neutrophil infiltration but does not induce eosinophilic inflammation in mice.

BACKGROUND: Eosinophils are selectively recruited into the tissues during chronic allergic inflammation. IgE is considered an initiator of the allergic reaction; however, the roles of IgE in allergic inflammation are not fully understood. OBJECTIVE: We tested the hypothesis that antigen interaction with specific IgE antibody provokes eosinophilic inflammation. METHODS: BALB/c mice were actively sensitized with ragweed extract and passively sensitized with anti-dinitrophenyl (anti-DNP) mouse IgE and challenged intraperitoneally by injecting either ragweed extract or DNP-ovalbumin (OVA). Immediate anaphylactic responses were examined by monitoring vascular permeability and by measuring histamine content in peritoneal lavage fluids. Late-phase allergic responses were examined by total cell counts and cell differentials. RESULTS: Mice sensitized and challenged with ragweed showed immediate anaphylactic responses followed by temporal increases in neutrophils at 3 to 12 hours and sustained increases in eosinophils in their peritoneal cavities after 24 hours. Double-sensitized mice (ie, sensitized actively for ragweed and passively for DNP-OVA) challenged with ragweed showed immediate anaphylactic responses and peritoneal eosinophilia at 48 hours. Double-sensitized mice challenged with DNP-OVA showed comparable immediate anaphylactic responses but no peritoneal eosinophilia. Furthermore, at 8 hours, ragweed-challenged animals recruited both eosinophils and neutrophils, but DNP-OVA-challenged animals recruited only neutrophils. Finally, after active sensitization and challenge with ragweed, mast cell-deficient mice (WBB6F1-W/W(v)) lacked the immediate response but showed comparable eosinophil accumulation as their litter mate controls (WBB6F1-+/+). CONCLUSION: Interaction of antigen with IgE antibody is insufficient to provoke eosinophilic inflammation in mice.

Does IgE bind to and activate eosinophils from patients with allergy?

Human eosinophils have been reported to express both the mRNA and protein for the high affinity IgE receptor (FcepsilonRI); it is speculated that this receptor plays a role in eosinophil mediator release in allergic diseases. However, questions still remain. How much of the FcepsilonRI protein is actually expressed on the cell surface of the eosinophil? If they are present, are these IgE receptors associated with effector functions of eosinophils? To address these issues, we studied blood eosinophils from patients with ragweed hay fever. A high level of low affinity IgG receptor (FcgammaRII, CD32), but no expression of FcepsilonRI, was detectable on the eosinophil surface by standard FACS analysis. However, after in vitro sensitization with biotinylated chimeric IgE (cIgE), cell-bound cIgE was detected by PE-conjugated streptavidin. This cIgE binding was partially inhibited by anti-FcepsilonRI mAb, suggesting that eosinophils do express minimal amounts of FcepsilonRI detectable only by a sensitive method. Indeed, FACS analysis of whole blood showed that eosinophils express approximately 0.5% of the FcepsilonRI that basophils express. When stimulated with human IgE or anti-human IgE, these eosinophils did not exert effector functions; there was neither production of leukotriene C4 or superoxide anion nor any detectable degranulation response. In contrast, eosinophils possessed membrane-bound human IgG and showed functional responses when stimulated with human IgG or anti-human IgG. Thus, IgG and/or cytokines, such as IL-5, appear to be more important for eosinophil activation in allergic diseases than IgE.

Ligation of Fc gamma RII (CD32) pivotally regulates survival of human eosinophils.

The low-affinity IgG Fc receptor, FcgammaRII (CD32), mediates various effector functions of lymphoid and myeloid cells and is the major IgG Fc receptor expressed by human eosinophils. We investigated whether FcgammaRII regulates both cell survival and death of human eosinophils. When cultured in vitro without growth factors, most eosinophils undergo apoptosis within 96 h. Ligation of FcgammaRII by anti-CD32 mAb in solution inhibited eosinophil apoptosis and prolonged survival in the absence of growth factors. Cross-linking of human IgG bound to FcgammaRII by anti-human IgG Ab or of unoccupied FcgammaRII by aggregated human IgG also prolonged eosinophil survival. The enhanced survival with anti-CD32 mAb was inhibited by anti-granulocyte-macrophage-CSF (GM-CSF) mAb, suggesting that autocrine production of GM-CSF by eosinophils mediated survival. In fact, mRNA for GM-CSF was detected in eosinophils cultured with anti-CD32 mAb. In contrast to mAb or ligands in solution, anti-CD32 mAb or human IgG, when immobilized onto tissue culture plates, facilitated eosinophil cell death even in the presence of IL-5. Cell death induced by these immobilized ligands was accompanied by DNA fragmentation and was inhibited when eosinophil beta2 integrin was blocked by anti-CD18 mAb, suggesting that beta2 integrins play a key role in initiating eosinophil apoptosis. Thus, FcgammaRII may pivotally regulate both survival and death of eosinophils, depending on the manner of receptor ligation and beta2 integrin involvement. Moreover, the FcgammaRII could provide a novel mechanism to control the number of eosinophils at inflammation sites in human diseases.

[Gallstone ileus--results and problems of surgical therapy]. / Gallensteinileus--Ergebnisse und Probleme der chirurgischen Therapie.

Reported in this paper are 15 patients with gall-stone ileus, between 1976 and 1986. The authors' results are summarised, with reference being made to problems of diagnosis and therapy. In preoperative ileus diagnosis, attention should be given to calculi outside the gallbladder and bile ducts, and the diagnosis should be secured by aerobilia. Opening of the intestine aboral from the occlusion, removal of calculi, and relief of intestinal distension is considered to be a preferential surgical approach. Synchronised surgical treatment of the bile system cannot be recommended.