Ali Sever

Preoperative Sentinel Node Identification With Ultrasound Using Microbubbles in Patients With Breast Cancer

OBJECTIVE Sentinel lymph node (SLN) biopsy is the standard procedure for axillary staging in early breast cancer. Lymphatic imaging after peritumoral microbubble injection has been described in animal models. The aim of this study was to identify and localize SLNs preoperatively by contrast-enhanced sonography after intradermal injection of microbubbles in patients with breast cancer. SUBJECTS AND METHODS Eighty consecutive consenting patients with primary breast cancer were recruited. Patients received a periareolar intradermal injection of microbubble contrast agent. Breast lymphatics were visualized by sonography and followed to the axilla to identify SLNs. A guidewire was deployed to localize the SLN. The next day, patients underwent standard tumor excision and SLN biopsy. RESULTS In 71 (89%) of the 80 patients, SLNs were identified and guidewires were inserted. In these patients, operative findings using conventional radioisotope and blue dye techniques confirmed that the wired nodes were SLNs. Fourteen patients were found to have metastases in SLNs. In these patients, the SLNs were identified correctly and were localized with guidewires before surgery. CONCLUSION SLNs may be identified and localized before surgery using contrast-enhanced sonography after injection of microbubbles.

Preoperative needle biopsy of sentinel lymph nodes using intradermal microbubbles and contrast-enhanced ultrasound in patients with breast cancer.

OBJECTIVE The purpose of this study was to assess whether sentinel lymph nodes (SLNs) that undergo targeted needle biopsy after identification by contrast-enhanced ultrasound (CEUS) using intradermally injected microbubbles results in more node-positive breast cancer patients being diagnosed preoperatively. Furthermore, we sought to determine whether the addition of CEUS to gray-scale sonography of the axilla reduces the number of patients having axillary lymph node (ALN) dissection as a second procedure. SUBJECTS AND METHODS Intradermal microbubble injection was performed in 136 breast cancer patients who had no abnormal ALNs on routine gray-scale axillary sonography. When an enhancing ALN was visualized, percutaneous sonography-guided fine-needle aspiration cytology or core needle biopsy was performed. Depending on the biopsy results, patients underwent SLN biopsy or ALN dissection. If the putative SLN biopsy was positive or a biopsy tract was seen in the excised SLN, the procedure was defined as successful. RESULTS SLNs were identified and biopsied in 126 of the 136 cases (93%). Seventeen patients had positive sonography-guided biopsy results (13%) and were treated with immediate ALN dissection. In seven patients, the biopsied node was the only positive node. The remaining 109 patients underwent SLN biopsy. In nine cases (8%), a positive lymph node was identified. Four of these false-negative cases had only micrometastases. CONCLUSION SLNs can be identified and biopsied using CEUS to increase the accuracy of preoperative axillary staging. If the needle biopsy result is negative, conventional SLN biopsy is indicated.

Axillary ultrasound assessment in primary breast cancer: an audit of 653 cases.

Abstract:  Axillary lymph node status is an important factor in determining the prognosis and treatment in patients with invasive breast cancer. The introduction of the sentinel lymph node biopsy technique in the axilla has significantly reduced the number of patients requiring an axillary clearance procedure. However, a proportion of patients will be found to have axillary metastases after a sentinel node biopsy and will then require a second axillary surgical procedure. A retrospective audit of 653 consecutive patients presenting with invasive breast cancer showed a preoperative diagnosis rate of axillary disease of 23% using axillary ultrasound and fine‐needle aspiration (FNA) together. We performed 232 axillary FNAs to diagnose 150 positive axillae. This avoided the need for a second operation in 150 women. The negative predictive value for axillary metastases using this technique was 79%. Overall accuracy was 84%.

Dynamic Visualization of Lymphatic Channels and Sentinel Lymph Nodes Using Intradermal Microbubbles and Contrast-Enhanced Ultrasound in a Swine Model and Patients With Breast Cancer

Objective. Sentinel lymph node (SLN) identification using intradermal micro‐bubbles and contrast‐enhanced ultrasound (CEUS) has been recently reported in swine models and patients with breast cancer. The objective of this study was to investigate the dynamics of intradermally administered microbubbles as they travel to draining SLNs in pigs. We also performed a detailed study of the passage of microbubbles through breast lymphatic channels in a small group of patients with breast cancer. Methods. Nine anesthetized healthy pigs were used for the study, and 5 female patients with primary breast cancer were recruited. Pigs received intradermal injections of a microbubble contrast agent in several territories to access lymphatic drainage to regional lymph nodes. Patients had periareolar intradermal injection of the microbubble contrast agent. Ultrasound examination was performed in the real‐time contrast pulse sequencing mode with a commercial scanner. Results. Sentinel lymph nodes were identified rapidly (<1 minute) and consistently in pigs. Intradermal microbubble injection and CEUS were found to have perfect concordance with the Evans blue dye method in locating swine SLNs. In all 5 patients with breast cancer, the microbubble contrast agent entered breast lymphatic channels and traveled to draining ipsilateral axillary SLNs within 3 minutes. Conclusions. Intradermally injected microbubbles traverse readily though lymphatic channels in pigs and human breast tissue. The ability to rapidly identify SLNs in the diagnostic period would enable targeted biopsy and may facilitate preoperative axillary staging in patients with early breast cancer.

Diagnostic value of susceptibility-weighted imaging of abdominal wall endometriomas during the cyclic menstrual changes: a preliminary study.

OBJECTIVE The purpose of this study is to investigate the value of susceptibility-weighted imaging (SWI) for the evaluation of cyclic morphological and hemorrhagic changes in abdominal wall endometriomas (AWE). MATERIALS AND METHODS Fourteen patients with a total of 17 lesions who were admitted with complaints of abdominal wall mass and cyclic pain were evaluated by MRI. Patients were scanned during the first three days of the menstrual cycle and during the mid-cycle phase (day 13-15). In addition to conventional images SWI was performed. The signal changes within the lesions on SWI were compared and graded on both studies. RESULTS There was no significant difference in the size of the lesions in the early days of the menstruation compared to the mid-menstrual period. The SWI taken on mid-cycle phase showed that the center was hyperintense and the peripheral zone was hypointense in all lesions. A signal void related to increased blood and the shrinkage of complete disappearance of hyperintensity in the venter of the lesion was seen 15 (88%) of the 17 cases on the SWI series performed during the menstrual phase scan. CONCLUSION SWI is a sensitive technique and has the capability to show hemorrhage and deposition of hemosiderin within the lesions. For patients suspected with AWE, valuable diagnostic findings may be obtained if the MRI examination including SWI is performed during the early and mid phase menstrual cycle.

Percutaneous removal of sentinel lymph nodes in a swine model using a breast lesion excision system and contrast-enhanced ultrasound

AbstractObjectivesTo investigate the feasibility of percutaneous removal of the entire sentinel lymph node (SLN) in an animal model using a breast lesion excision system after identifying these nodes using contrast-enhanced ultrasound (CEUS) and intradermal microbubbles.MethodsAnimal studies approval was obtained. SLNs were identified using CEUS and intradermal injection of microbubbles in two young pigs. Microbubbles were mixed with blue dye and injected around the mammary papillae to access lymphatic drainage to the superficial inguinal lymph nodes. When enhancing nodes were identified, the breast lesion excision system (BLES) was used to remove these nodes percutaneously. Both animals then underwent surgical lymph node dissection. Histopathological examination of all the samples was performed.ResultsRemoval of the entire SLN was successful in three groins in the pigs. All three nodes were stained with blue dye. No other stained nodes were observed in the node dissection specimens. The nodal architecture of removed lymph nodes was well preserved on microscopy. There were no signs of excess trauma within the biopsy bed.ConclusionThe results obtained from the swine model demonstrated that it is feasible to remove the entire SLN percutaneously under the guidance of CEUS and microbubbles.Key Points• Intradermal injection of microbubbles and CEUS can identify sentinel lymph nodes • Ultrasound could then guide percutaneous removal of intact and complete SLNs • We have shown this was feasible in pigs but not yet in humans • This technique may eventually have the potential to reduce futile SLN biopsies.

How Long Will I Be Blue? Prolonged Skin Staining Following Sentinel Lymph Node Biopsy Using Intradermal Patent Blue Dye

Background: Blue dye used for sentinel lymph node biopsy (SLNB) in breast cancer patients may cause prolonged skin discoloration at the site of injection. The aim of this study was to assess the duration of such skin discoloration. Patients and Methods: 236 consecutive patients who had undergone breast conserving surgery and SLNB for breast cancer were reviewed prospectively from January 2007 to December 2009. Results: Of the 236 patients, 2 had undergone bilateral surgery, and 41 had been examined in consecutive yearly reviews. Blue discoloration remained visible at the injection site after 12, 24, and > 36 months in 36.5, 23.6, and 8.6% of the patients, respectively. Conclusion: The use of patent blue for identification of the sentinel lymph node in patients undergoing breast cancer surgery may result in prolonged discoloration of the skin at the injection site.

Factors that impact the upgrading of atypical ductal hyperplasia.

PURPOSE The purpose of this study was to identify the factors that may have an impact on upgrading atypical ductal hyperplasia (ADH) lesions to malignancy. MATERIALS AND METHODS Between February 1999 and December 2010, the records of 150 ADH lesions that had been biopsied were retrospectively reviewed. The biopsy types included 11-gauge stereotactic vacuum-assisted biopsy (SVAB) (n=102) and ultrasonography (US)-guided 14-gauge automated biopsy (n=48). The patients were divided into two groups: those who had cancer in the final pathology and those who did not. Variables associated with underestimation of ADH lesions were compared between the groups. RESULTS The underestimation rates according to the biopsy types were 41.7% (20/48) for the US-guided 14-gauge automated biopsy and 20.6% (21/102) for the 11-gauge SVAB (P = 0.007). The rate of underestimation was significantly higher in lesions greater than 7 mm than it was in smaller lesions, with both US-guided 14-gauge automated biopsy and 11-gauge SVAB (P = 0.024 and P = 0.042, respectively). The rate of underestimation was significantly higher with the 11-gauge SVAB (P = 0.025) in lesions that were suspicious (R4) and highly suggestive of malignancy (R5) than in those that were probably benign (R3). CONCLUSION The underestimation rate in ADH lesions was significantly higher with US-guided 14-gauge automated biopsy compared to the 11-gauge SVAB. The underestimation rate was also significantly higher in lesions greater than 7 mm regardless of the biopsy type, and in lesions biopsied using SVAB that were regarded as suspicious (R4) or highly suggestive of malignancy (R5) on imaging.

Causes of failure in removing calcium in microcalcification-only lesions using 11-gauge stereotactic vacuum-assisted breast biopsy.

PURPOSE The aim of this study was to determine the causes and rate of failure in removing calcification in microcalcification-only lesions using 11-gauge stereotactic vacuum-assisted breast biopsy. MATERIALS AND METHODS In total, 1365 microcalcification-only lesions were included in this study. The breast biopsy database was reviewed retrospectively. The biopsies were divided into two groups based on whether the specimen X-ray showed calcium within the cores. Breast composition, lesion size, calcification distribution, density on mammography, and the number of specimens were compared between the two groups. RESULTS In 11 (0.8%) biopsies, no calcium in the specimen radiography could be identified. Re-biopsy was performed in five cases. The initial biopsy result was unchanged at the second biopsy in three cases containing calcium, while in the other two cases, a benign biopsy result was upgraded to atypical ductal hyperplasia and ductal carcinoma in situ, respectively. In six cases, the biopsy was not repeated despite the absence of calcium in the specimen X-ray. In three of these cases, calcifications were reported histopathologically and deemed to be too small to be identified on specimen X-ray. In two of six patients, sufficient information was found in the cores without microcalcification to indicate the need for surgery. One patient refused re-biopsy. A statistically significant higher failure rate was observed in low-density calcification compared with intermediate or high-density calcification on mammography. CONCLUSION The failure to retrieve microcalcification is uncommon when an 11-gauge vacuum-assisted breast biopsy is used. Low-density calcifications have a higher rate of failure. In cases in which no calcium is observed in specimen radiography, repeated biopsy is recommended.

A rare cause of breast mass that mimics carcinoma: Foreign body reaction to amorphous surgical material.

ZusammenfassungEine durch Fremdkörper ausgelöste granulomatöse Reaktion auf chirurgisches Material ist eine sehr seltene Läsion, kann sich aber in der Brust wie ein Karzinom darstellen. Bisher berichtete chirurgische Fremdmateralien sind Nahtmaterial, Silikon, Paraffin, Streupuder und Karbonpartikel, die zur Lokalisation nicht palpabler Brustläsionen verwendet werden. Unserem Wissen nach ist eine Fremdkörperreaktion auf Gazeschwamm bisher noch nicht berichtet worden. Die vorliegende Arbeit berichtet über eine 58-jährige Frau, die einen wachsenden Tumor hatte, der sich wie ein Mammakarzinom darstellte. Der Tumor war die Folge einer Fremdkörperreaktion auf Gazeschwamm. Zusätzlich wird eine Übersicht über die relevante Literatur gegeben.SummaryA breast mass caused by foreign body type granulomatous reaction to surgical material is a very rare lesion and may mimic carcinoma. Reported foreign materials have included suture materials, silicone, paraffin, gunpowder and carbon particles used for localization of a nonpalpable breast lesions. To our knowledge, a foreign body reaction to gauze sponge has not been reported previously. A 58-year-old woman who had an enlarging mass that mimicked breast carcinoma, due to foreign body reaction to gauze sponge is presented here, and relevant literature is reviewed.