Search

The purpose of this study was to evaluate imaging-guided vacuum-assisted mammotome biopsy as a minimally invasive method of obtaining a satisfactory diagnosis and eliminating the bothersome symptoms in patients presenting with nipple discharge.Forty-nine women who presented with nipple discharge and who had final pathologic diagnoses of papillary lesions were retrospectively identified. Fifty-six lesions were biopsied in this group. The examinations included mammography, ductography, sonography, and, if possible, percutaneous biopsy. All lesions were centrally located and most were superficial. Of this study group, four patients with five lesions proceeded to sonographically guided automated core biopsy, and 38 patients with 44 intraductal lesions identified by sonography advanced to sonographically guided biopsy with an 11-gauge mammotome probe. One patient underwent stereotactic 11-gauge mammotome biopsy. Patients not advancing to sonographically guided biopsy were those with masses either in the nipple or nipple-areolar complex (five patients), one patient with no identifiable lesion at sonography, and one directly referred for open surgical biopsy.In all biopsied patients, satisfactory tissue for diagnosis was obtained. In patients biopsied with the mammotome probe, follow-up at a mean time of 13 months revealed resolution of the presenting problematic discharge in 97.2% of patients. Complications were mild and infrequent. Only one of 50 percutaneously biopsied lesions was not benign and required subsequent surgery.Papilloma excision with percutaneous biopsy allows safe and accurate tissue analysis and a high probability of terminating the symptomatic nipple discharge.

To determine whether sonography could help accurately distinguish benign solid breast nodules from indeterminate or malignant nodules and whether this distinction could be definite enough to obviate biopsy.Seven hundred fifty sonographically solid breast nodules were prospectively classified as benign, indeterminate, or malignant. Benign nodules had no malignant characteristics and had either intense homogeneous hyperechogenicity or a thin echogenic pseudocapsule with an ellipsoid shape or fewer than four gentle lobulations. Sonographic classifications were compared with biopsy results. The sensitivity, specificity, and negative and positive predictive values of the classifications were calculated.Benign histologic features were found in 625 (83%) lesions; malignant histologic features, in 125 (17%). Of benign lesions, 424 had been prospectively classified as benign. Two lesions classified as benign were found to be malignant at biopsy. Thus, the classification scheme had a negative predictive value of 99.5%. Of 125 malignant lesions, 123 were correctly classified as indeterminate or malignant (98.4% sensitivity).Sonography can be used to accurately classify some solid lesions as benign, allowing imaging follow-up rather than biopsy.

To evaluate the efficacy of ultrasound (US)-guided automated large-core percutaneous needle breast biopsy, biopsy of 181 ultrasonographically suspicious breast lesions was performed by using a long-throw biopsy gun and 14-gauge needles with continuous US guidance. A "freehand" technique with either 5.0- or 7.5-MHz linear-array transducers was used. Needle core diagnoses were compared with surgical diagnoses in the 49 lesions subsequently surgically excised. The remaining 132 cases were followed for 12-36 months. Agreement between needle-core and surgical diagnoses in the 49 lesions was 100%. This group included 34 cancers (28 infiltrating ductal, two mucinous, one mixed infiltrating ductal and lobular, and one each of intraductal, infiltrating lobular, and tubular carcinoma). To date, no cancers have been found in the other 132 cases. The procedure time averaged 20 minutes, and no complications occurred. With an accuracy approaching that of excisional biopsy, US-guided needle core biopsy provides an alternative to surgery.

Segmental renal artery branches within the renal sinus were prospectively evaluated with color Doppler imaging and pulsed-Doppler spectral analysis in 56 patients before angiography. Waveforms were evaluated for the tardus and parvus abnormalities of prolonged acceleration time, diminished acceleration index, and loss of the normal early systolic compliance peak/reflective-wave complex (ESP). Findings obtained with these parameters were compared with the subsequent findings on angiograms to ascertain their efficacy in detection of hemodynamically significant (greater than or equal to 60%) renal arterial stenosis (RAS), which was present in 32 kidneys in 26 patients. Simple pattern-recognition analysis of ESP proved to be the best of the three parameters. Loss of ESP enabled identification of RAS with 95% sensitivity, 97% specificity, a 92% positive predictive value, a 98% negative predictive value, a 96% overall accuracy. On the basis of the high technical success rate, high sensitivity and specificity, and short examination time, waveform analysis for detection of tardus-parvus abnormalities, especially loss of ESP, of the segmental artery is recommended as an alternative to direct examination of the main renal arteries for evaluation of RAS.

While contrast enhanced magnetic resonance imaging (MRI) is generally considered the modality of choice for staging malignant breast disease and PET/CT is considered the modality of choice for staging distant spread, ultrasound (US) can also be used to assess the local extent of malignant breast disease in many patients. Most patients will undergo breast sonography prior to breast MRI or PET/CT. Thus, US offers us our first chance to determine the local extent of disease in many cases. US is good enough at 'staging' that in any patient with a solid nodule characterized as BIRADS 4 or BIRADS 5 we routinely perform whole breast US and assess the axillary lymph nodes during the initial sonogram or immediately prior to performing US-guided biopsy of the index lesion. US staging involves determining the maximum diameter of the index lesion, assessing for multifocal and multicentric disease, and looking for the presence of extensive intraductal components (EIC). Regional lymph nodes can also be assessed sonographically at the same time that the suspicious index solid nodule and ipsilateral breast are evaluated. US-detected secondary and tertiary lesions can, and should, be 'mapped out' with US-guided biopsies. Accurate US staging leads to the appropriate type of extirpative surgery, minimizes the number of surgeries necessary to rid the patient of disease, and can minimize the risk of local recurrence. In fact, 'local recurrence' is almost always residual unresected disease that was not recognized preoperatively or intraoperatively by the surgeon. It can also obviate staging MRI and sentinel node procedures in some cases. We then place nine individual suspicious findings into three categories: 'hard', 'soft', and 'mixed' suspicious findings. 'Hard' findings suggest the presence of invasion, and include angular margins, spiculation, and acoustic shadowing. 'Soft' findings suggest the presence of ductal carcinoma in situ (DCIS) components, and include duct extension, branch pattern, calcifications, and most cases of microlobulation. It is important to include soft findings in the sonographic algorithm because they improve the sensitivity for pure DCIS, but also because they help us to better assess the true extent of lesions that contain both invasive and intraductal components. Most invasive ductal carcinomas contain DCIS components, which frequently lie in the periphery and contribute to the surface characteristics and shape of the lesion. 'Mixed' findings are not specific and can be seen with either invasive or DCIS components of the lesion, and include taller-than-wide (antiparallel) shape, hypoechogenicity, and a minority of microlobulations. The most basic prognostic feature of a malignant lesion is its maximum diameter. There are two different maximum diameters – the prognostic diameter used in determining the TNM stage and the surgical diameter necessary to completely remove the lesion. The prognostic diameter is the maximum diameter of the invasive component of the tumor, and is represented sonographically by the largest part of the lesion than manifests hard sonographic findings. The resection diameter includes both invasive and DCIS components of the tumor and is represented sonographically by the greatest length of combined hard and soft findings in the lesion. Multifocal invasive carcinoma usually represents separate foci of invasion in a single malignant lesion that are connected by DCIS components of the lesion. By scanning parallel to the long axis of the mammary ducts in the region of a suspicious breast nodule, we are frequently able to show 'bridges' of DCIS connecting the foci of invasion. EIC increase the likelihood of local recurrence in patients who undergo breast-conserving therapy. Prominent 'soft' findings suggest the presence of EIC. Certain suspicious sonographic features correlate with the histologic grade of the lesion or with the nuclear grade of the DCIS components of invasive ductal carcinomas. The presence of enhanced through-transmission deep to a suspicious solid nodule more than doubles risks that the lesion is high grade. Shadowing favors the lesion being low or intermediate grade. The thicker the ill-defined echogenic halo relative to the size of the hypoechoic central nidus, the more likely the lesion is to be low grade. Circumscribed malignant nodules that are surrounded by a thin echogenic capsule are more likely to be high-grade invasive ductal carcinomas or special-type tumors such as colloid or medullary. Large microlobulations and branch pattern suggest a high-grade lesion, intermediate-sized microlobulations and branch pattern suggest an intermediate-grade lesion, and very small microlobulations suggest the presence of a low-grade lesion. Once we have completely evaluated the breast to look for multifocal and multicentric disease and EIC, we proceed to evaluate the axillary lymph nodes. If abnormal lymph nodes are found, we perform US-guided biopsy of the lymph node. If the biopsy is positive for metastatic disease, the sentinel lymph node procedure becomes unnecessary and the patient proceeds straight to axillary dissection. If the biopsy is negative for metastatic disease, the patient undergoes the sentinel node procedure as originally planned. There is a distinct advantage to this pattern of sonographic evaluation. The sentinel node procedure is not perfect. False negative sentinel node procedures occur in a small percentage of patients. In such cases, the cause of failure is 'tumor damming'. Metastases to the sentinel node block the normal lymphatic drainage through the sentinel node, causing it to go through collaterals to a higher node that may still be histologically negative. Sentinel nodes that are so grossly filled with tumor that they alter the normal lymphatic drainage pattern are easily identified as being abnormal by sonography and can easily be targeted for US-guided biopsy.

To review the authors' experience with patients who presented with breast lumps and had normal mammograms and normal sonograms.The findings from 600 lumps in 486 women with no focal ultrasonographic (US) mass or mammographic finding in the area of clinical concern were retrospectively studied. Evaluated parameters included the individual reporting the lump, qualitative descriptors for the physical finding, mammographic density, US characteristics in the area of concern, whether there was a change in imaging and/or physical examination results, and whether there were diagnostic biopsy findings at follow-up. The study group included 540 lumps in 435 women who had a minimum mammographic and clinical follow-up of 2 years, as well as 60 additional lumps in 51 patients who underwent biopsy.No patient in the nonbiopsy group developed carcinoma at the initial site of concern during a mean mammographic and clinical follow-up period of 43 months, and all biopsy specimens were benign (negative predictive value, 100%).Results of this retrospective study suggest that breast biopsy may be avoided in women with palpable abnormalities when both US and mammography depict normal tissue at the lump site.

The 1999 US-Japan Workshop on High Heat Flux Components and Plasma Surface Interactions in Next Step Fusion Devices was held at the St. Francis Hotel in Santa Fe, New Mexico, on November 1-4, 1999. There were 42 presentations as well as discussion on technical issues and planning for future collaborations. The participants included 22 researchers from Japan and the United States as well as seven researchers from Europe and Russia. There have been important changes in the programs in both the US and Japan in the areas of plasma surface interactions and plasma facing components. The US has moved away from a strong focus on the ITER Project and has introduced new programs on use of liquid surfaces for plasma facing components, and operation of NSTX has begun. In Japan, the Large Helical Device began operation. This is the first large world-class confinement device operating in a magnetic configuration different than a tokamak. In selecting the presentations for this workshop, the organizers sought a balance between research in laboratory facilities or confinement devices related to plasma surface interactions and experimental research in the development of plasma facing components. In discussions about the workshop itself, the participants affirmed their preference for a setting where ''work-in-progress'' could be informally presented and discussed.

Posttraumatic syringomyelia as a cause of progressive neurologic deterioration has been well described. More recently, the noncystic posttraumatic tethered cord has been associated with identical progressive neurologic deterioration. A retrospective analysis of patients treated surgically with spinal cord untethering and/or cyst shunting to arrest a progressive myelopathy from a posttraumatic tethered and/or cystic cord was performed. Emphasis was on outcome using the American Spinal Injury Association (ASIA) sensory and motor scoring systems. During an 18-month period from May 1993 to December 1994, 70 patients with spinal cord injury were operated upon for tethered and/or cystic spinal cords because of a progressive myelopathy and deteriorating ASIA sensory/motor scores. Fifty-nine patients had follow-up data 1 year postoperatively. At the 1 year follow-up, there was small improvement in light touch sensory scores (0.67 points), pinprick scores (1.3 points), and motor scores (0.41 points) demonstrating that the progression of the myelopathic process was arrested. Thirty-four of these 59 patients had no previous surgery to their spinal cords. At 1 year follow-up, light touch scores improved on average 2.38 points, pinprick scores 3.88 points (p < 0.05), and motor scores 1.47 points, suggesting better outcome with first-time surgery. Of this latter group, 64.3% regained a lost function, 62.5% saw improvement in spasticity, 55.6% had substantial improvement in neurogenic pain, and 95.8% felt that surgery prevented further neurologic deterioration.

With the ability to perform good diagnostic mammography, breast ultrasound, ductography, cyst aspiration, abscess drainage, and stereotactic or ultrasound-guided percutaneous biopsy, the modern breast radiologist should play the central role in breast diagnosis. The definitive diagnoses afforded by percutaneous breast biopsy that obviate surgery entirely in benign lesions and streamline the therapeutic surgery for malignant lesions now can be obtained routinely. The future holds even more exciting challenges for the radiologist as percutaneous lumpectomy becomes a reality. Thus the breast radiologist, armed with the technology and techniques of the twenty-first century, truly stands on the threshold of a new era.

We performed a retrospective study of symptomatic peripheral vascular malformations to determine if MR imaging can be used to distinguish slow-flow venous malformations from high-flow arteriovenous malformations and arteriovenous fistulas. Twenty-seven MR examinations in 25 patients with malformations outside the CNS were reviewed. Sixteen venous malformations, nine arteriovenous malformations, and two arteriovenous fistulas were included. In all cases, the MR findings were correlated with the results of angiography. The distinction between slow-flow venous malformations and high-flow arteriovenous malformations and arteriovenous fistulas was made primarily on T2-weighted MR images, which showed high signal intensity in venous malformations and flow voids in high-flow lesions. In addition to the previously described MR features of venous malformations (serpentine pattern with septations, associated muscle atrophy, and typical T1 and T2 signal intensities), several new MR features were apparent. Venous malformations had a propensity for multifocal involvement (37%), orientation along the long axis of extremities or affected muscles (78%), and adherence to neurovascular distributions (64%). Prominent subcutaneous fat was commonly seen adjacent to the malformation. MR images of arteriovenous malformations and arteriovenous fistulas also commonly showed muscle atrophy and subcutaneous fatty prominence. Our results show that slow-flow venous malformations can be distinguished from high-flow arteriovenous malformations and fistulas on the basis of spin-echo MR signal characteristics. The associated imaging characteristics help in the differential diagnosis in problematic cases.

Absolute ethanol was used to treat 20 patients with symptomatic vascular malformations (SVMs) (ie, venous malformations, arteriovenous malformations, and congenital and posttraumatic arteriovenous fistulas) in whom previous surgery or standard embolotherapy had failed or who were not candidates for surgery. All large complex lesions required multiple embolizations as staged procedures. Immediate thrombosis was achieved in all patients; complications (13% of cases) were generally minor and were treated conservatively. Follow-up studies, performed in 19 of 20 patients, showed persistent occlusion of the SVM in all cases. Ethanol embolization of SVMs, performed according to strict techniques, has proved efficacious in SVM management and is emerging as a definitive form of therapy.

Because of the heterogeneity of breast cancer from nodule to nodule, single findings cannot achieve the sensitivity or the negative predictive value necessary to identify a low-risk group that can be offered the option of follow-up (ACR Breast Imaging Reporting and Data System [BIRADS] 3 group). However, by using multiple findings in a strict algorithm, such a group can be identified. It is also important to keep in mind that breast cancer can be heterogeneous within an individual nodule. Part of the nodule may have circumscribed features that simulate a benign lesion, while another part may be spiculated and obviously malignant. Only by scanning the whole surface and substance of the nodule in two orthogonal planes (radial and anti-radial) can the presence of suspicious findings be excluded, and if there is a mixture of benign and suspicious findings, the benign findings should be ignored. These studies show that sonography is useful in the characterization of solid breast masses. Characterizing solid breast nodules into BIRADS categories defines carcinomas that might have been missed clinically or mammographically. It identifies a BIRADS 3 group that has far less than 2% risk of being malignant and can offer the patient the option of follow-up rather than biopsy. Currently, approximately 80% of patients with BIRADS 3 solid nodules are electing to be followed rather than to undergo biopsy. It improves the accuracy of the diagnosis of malignant breast lesions. Importantly, it also accurately defines a population of benign solid breast lesions that do not require biopsy when strict sonographic criteria of benignity are present. To achieve the desired sensitivity and negative predictive values of 98% or greater the algorithm must be strictly adhered to. When the patient elects to be followed rather than undergo biopsy, follow-up should be performed in 6 months, not 1 year. The malignant lesions at most risk to be mischaracterized as BIRADS 3 are higher grade invasive ductal carcinomas that grow rapidly enough for change to be readily detected at 6 months. Table 1 Current study: characterization of solid breast nodules Table 2 Prospective characterization of 1211 solid nodules into BIRADS categories (all 1211 nodules have undergone biopsy)

A complex duplex carotid evaluation involves high resolution imaging and characterization of the carotid plaque as well as quantitative Doppler spectral analysis to determine the presence and degree of flow restriction. Each of the components of the examination is essential to evaluate the carotid arteries adequately for the presence of disease. Both of these components should be assimilated into a final report that can be used to determine who is at risk for embolic as well as flow restrictive disease. By carefully following the reporting system described in this paper, an accurate and reproducible means of evaluating the carotid arteries can be achieved that permits comparison of studies. In addition, this will allow accurate communications among institutions and help to insure a better understanding of the etiology and pathogenesis of atherosclerotic carotid artery disease.