Biomedical subjects
Publications and source records attributed to S G Orel.
This article examines technical and clinical issues related to MR guided biopsy of the breast. Designed features of breast biopsy instrumentation are discussed. Procedures for performing breast biopsies as well as clinical indications are also explored.
Ipsilateral breast tumor recurrence occurs in approximately 10% to 15% of patients undergoing conservative surgery and definitive radiation therapy. Mammography alone detects one third of breast recurrences. Most recurrences are invasive, few demonstrate simultaneous distant metastasis, and approximately 40% have axillary lymph node involvement. Mastectomy is the standard salvage procedure. Axillary lymph node dissection may help guide adjuvant treatment as well as reduce the risk of a subsequent regional recurrence. The decision of whether to use adjuvant therapy should be based on tumor size, lymph node status, receptor status, DNA index, S-phase fraction, and disease-free interval. Ipsilateral recurrence may be an independent prognostic factor for distant metastasis.
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In selected patients with early-stage breast cancer, conservative surgery and radiation represent an alternative equal to mastectomy in terms of local recurrence, distant metastasis, survival, and long-term complications. Patients with early-stage breast cancer who are candidates for conservative surgery and radiation include those whose primary tumor is less than 4 to 5 cm in size without evidence of gross multicentricity or diffuse microcalcifications. Patients with an extensive intraductal component may be appropriate candidates provided that margins of resection are negative. Young age is not a contraindication to the conservative treatment. A preexisting history of collagen vascular disease or prior mantle irradiation for Hodgkin's or non-Hodgkin's lymphoma represents a contraindication to conservative surgery and radiation because of the potential for severe complications. An additional contraindication is the pregnant woman in whom delivery cannot be accomplished before the initiation of radiation. Mammography is essential in the pretreatment evaluation and posttreatment follow-up of the conservatively treated patient. The goal of the pretreatment mammogram is to assess the extent of disease in the ipsilateral breast as well as to evaluate the contralateral breast. In patients who present with microcalcifications, a postbiopsy mammogram before radiation is essential to document complete removal of all malignant-appearing microcalcifications. Mammography is an essential part of the follow-up program in order to detect a recurrence in the treated breast as well as a cancer in the contralateral breast cancer. The optimal interval for follow-up mammography has not been determined, although programs employing mammography on a yearly basis after treatment have been associated with the detection of early recurrences and excellent survival after salvage mastectomy for these recurrences.
The prognostic implications of detection mode in local recurrence after lumpectomy and radiation therapy were assessed. Seventy-two women treated with lumpectomy and irradiation for American Joint Committee on Cancer stages I and II invasive breast cancer developed recurrent cancer in the ipsilateral breast, had physical examination and mammography performed at the time of recurrence, and underwent salvage mastectomy. There was a statistically significant association between detection with mammography alone and lower T stage (P = .05), and there was a nonstatistically significant trend toward noninvasive histologic findings. No significant association was noted between detection method and site of recurrent current cancer in the breast, interval to recurrence, or patient age. There were nonstatistically significant trends toward improved relapse-free survival and overall survival for patients with recurrences detected solely with mammography. that postirradiation surveillance mammography is important for the early detection of recurrent cancer. While the trend did not reach statistical significance, detection with mammography alone had a clinically apparent impact on relapse-free and overall survival.
Between 1977 and 1989, 102 of 1,145 patients treated with lumpectomy and radiation as an alternative to mastectomy required subsequent biopsy for suspected ipsilateral recurrence. The authors reviewed the mammograms of 58 of those patients for whom at least two sets of mammograms were available, including one set obtained within 3 months of the subsequent repeated biopsy. Of 38 biopsy-proved recurrences, 13 (34%) were detected with mammography alone, 17 (45%) with palpation alone, and eight (21%) with both mammography and palpation. While standard mammographic criteria for biopsy were followed, distortions and calcifications inherent to posttreatment appearances necessitated judicious modifications. As anticipated, sensitivities and positive predictive values showed more impairment within the lumpectomy quadrant. In addition, all cases of purely in situ cancer were detected solely with mammography. Mammography plays an important complementary role to physical examination in posttreatment follow-up. On the basis of these findings, a follow-up algorithm for the ongoing evaluation of these patients was developed.
Since it is widely recognized that a radial scar of the breast can mimic scirrhous carcinoma at mammography, criteria to differentiate the two lesions continue to be suggested. Mammographic features that have been described as occurring with radial scars include a radiolucent central core; elongated, radiating spicules; and absence of calcifications. Recent studies have documented the unreliability of the first two parameters; calcifications, however, have been reported to be unusual in mammograms of radial scar lesions. From recent case material, the authors present four cases of biopsy-proved radial scars associated with mammographically visible microcalcifications. The mammographic findings, with pathologic correlation, are reported to emphasize the occurrence of microcalcifications within radial scars. When a stellate lesion is seen at mammography in the absence of a surgical scar, biopsy should be performed promptly, since no reliable mammographic features exist to distinguish radial scars from scirrhous carcinomas.
Meticulous correlation of mammographic and pathologic findings is essential to improve detection and understanding of the many processes that affect the breast. A review of recent radiologic papers dealing with several breast cancer variants as well as two benign lesions, the radial scar and the breast hamartoma, is presented. Important papers from the pathologic, oncologic, and radiologic literature are reviewed. These papers described the evolving concepts of proliferative breast disease as risk markers, as well as insights into prognostic differences among the histologic subtypes of ductal carcinoma in situ.
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Gastrointestinal contrast studies and CT performed on 43 patients with known Crohn disease with acute symptoms were retrospectively reviewed to assess the ability of each study to define the location and extent of disease. In 39 of 43 (91%) patients the contrast studies and CT agreed on the location of active disease. However, in 15 of 43 (35%) patients, contrast studies demonstrated additional areas of mucosal disease remote from the major area of activity that were not suggested by CT. In addition to demonstrating more extensive mucosal disease, contrast studies proved superior in demonstrating enteroenteric fistulae, sinus tracts, strictures, postsurgical anatomy, and relation of recurrence to anastomosis. Computed tomography proved superior in demonstrating mesenteric inflammation, abscesses, enterovesical and enterocutaneous fistulae, fistula to iliopsoas muscle and to sacrum. We conclude that in the patient with suspected abscess, enterovesical or enterocutaneous fistula, CT is the study of choice. In other clinical circumstances both CT and contrast studies should be performed since they are complementary.
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An interpretation model for evaluating magnetic resonance (MR) images of the breast was constructed that allowed differentiation of benign from malignant palpable or mammographically visible abnormalities. Architectural features define each node of the model. Investigation was subsequently made of the histologic findings in individuals within each node and of the frequency with which each histologic finding manifested as a particular architectural feature to determine whether nodal location and specific histologic findings are mutually predictive. The strongest associations were found between fibrocystic change and smooth masses, fibroadenoma and lobulated masses with nonenhancing internal septations, invasive ductal carcinoma (with or without ductal carcinoma in situ [DCIS]) and enhancing irregular or spiculated masses, invasive tubular carcinoma or radial scar and spiculated masses, medullary or colloid carcinoma and enhancing lobulated masses, invasive lobular carcinoma and the absence of a focal mass, DCIS and ductal enhancement, and DCIS (with or without invasive ductal carcinoma) and regional enhancement. Nodal location and histologic findings proved to be mutually predictive within the model; that is, the nodal location of MR imaging features within the model can be used to predict histologic findings and vice versa.
Palpable breast masses arising in pediatric and adolescent patients are uncommon. A careful physical examination should be performed first, followed by an ultrasonographic evaluation when a suspect mass is present. In this study population, palpable findings were all due to benign causes, which is concordant with the literature. Benign causes included gynecomastia, cyst, fibroadenoma, lymph node, galactocele, duct ectasia, and infection. Though extremely rare, breast malignancies do occur in the pediatric and adolescent population.
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