Georgia Giannakopoulou

Breast ductal endoscopy: how many procedures qualify?

BackgroundBreast ductal endoscopy is a relatively new diagnostic method with ever growing importance in the work-up of patients with bloody nipple discharge. The ability to perform ductal endoscopy is very important and useful for breast fellows. Learning curve in breast ductal endoscopy remains a terra incognita, since no systematic studies have addressed this topic. The purpose of this study is to determine the point (number of procedures during training) beyond which ductal endoscopy is successfully performed.FindingsTen breast fellows received training in our Breast Unit. For the training process, an ex vivo model was adopted. Fellows were trained on 20 surgical specimens derived from modified radical mastectomy for breast cancer. The target of the education program was to acquire proficiency in performing ductoscopy. The achievement of four consecutively successful ductal endoscopies was determined as the point beyond which proficiency had been achieved. The number of procedures needed for the achievement of proficiency as defined above ranged between 9 and 17 procedures. The median value was 13 procedures; i.e. 50% of trainees had achieved proficiency at the 13th procedure or earlier.ConclusionThese pilot findings point to approximately 13 procedures as a point beyond which ductal endoscopy is successfully performed; studies on a larger number of fellows are nevertheless needed. Further research, focusing on the learning curves of different training models of ductal endoscopy, seems desirable.

Downgrading BIRADS 3 to BIRADS 2 category using a computer-aided microcalcification analysis and risk assessment system for early breast cancer

This paper explores the potential of a computer-aided diagnosis system to discriminate the real benign microcalcifications among a specific subset of 109 patients with BIRADS 3 mammograms who had undergone biopsy, thus making it possible to downgrade them to BIRADS 2 category. The system detected and quantified critical features of microcalcifications and classified them on a risk percentage scale for malignancy. The system successfully detected all cancers. Nevertheless, it suggested biopsy for 11/15 atypical lesions. Finally, the system characterized as definitely benign (BIRADS 2) 29/88 benign lesions, previously assigned to BIRADS 3, and thus achieved a reduction of 33% in unnecessary biopsies.

Biopsy Method: A Major Predictor of Adherence After Benign Breast Biopsy?

OBJECTIVE Adopting a longitudinal approach to assess women after breast biopsy with a benign result, this study aimed to comparatively evaluate the effect of the biopsy method on compliance with clinical recommendations for follow-up. MATERIALS AND METHODS For this study, 410 patients who underwent biopsy of a breast lesion were included: fine-needle aspiration biopsy, n = 95 patients; core biopsy, n = 84; local excision under local anesthesia, n = 72; vacuum-assisted breast biopsy, n = 100; and hookwire localization, n = 59. Information about patient age, place of residence, whether complications occurred, and type of lesion was collected. RESULTS Compliance was higher among women who had undergone vacuum-assisted breast biopsy than those who had undergone one of the other biopsy methods. The superiority (carryover effect) of vacuum-assisted breast biopsy persisted for 18 months after the biopsy procedure. Patient compliance for all of the other biopsy methods followed an M pattern, with the peaks corresponding to the follow-up mammography sessions. In patients who had undergone vacuum-assisted breast biopsy, a gradual decrease in compliance over time was observed. Older women were more compliant than younger women with follow-up recommendations regardless of biopsy method. A subanalysis of the vacuum-assisted breast biopsy group indicated that complications are associated with better compliance. CONCLUSION Women more often adhere to clinical recommendations for follow-up sessions comprising mammography. Patient age and whether biopsy complications occurred also seem to modify compliance. Further studies should assess whether superior compliance after vacuum-assisted breast biopsy persists in other settings, such as with stereotactic or ultrasound guidance, different numbers of cores, and procedures of various durations.

Spider Bite on a Male Breast: A Rare Case in the Capital

The Breast Images presented herein belong to a 56year-old surgeon living in the suburbs of Athens, Greece. Early (6 am) in the morning, due for a scheduled surgery, the surgeon searched in his closet and put quickly his everyday suit on. He did not notice, however, that a spider had been hiding in a fold of his shirt. Immediately, after putting the shirt on, the surgeon felt a mildly painful sting on his breast. He smashed the spider, but took care to preserve it. The pain went on increasing, and when the surgeon arrived at the operation room, a skin lesion had already appeared. Later, within the same day, the image of the painful, pruritic skin lesion is shown in Figure 1. The lesion was located on the patient’s right breast and was characterized by central induration surrounded by a zone of erythema. One day later, the same skin lesion appears in Figure 2. Twenty days later, and despite the appropriate treatment, comprising analgesics, antihistamines, antibiotics, and tetanus prophylaxis, the skin lesion was still present (Fig. 3). It should be stressed that the patient developed no systematic symptoms. The spider was identified to be a Loxosceles rufescens. It belongs to the Loxosceles species, whose most known member in USA is the brown recluse spider (Loxosceles reclusa). In general, these spiders are not

Vacuum-assisted breast biopsy in close proximity to the skin: a case report

IntroductionVacuum-assisted breast biopsy is a minimally invasive technique used increasingly for the assessment of mammographically detected, non-palpable breast lesions. The effectiveness of vacuum-assisted breast biopsy has been demonstrated on lesions both with and without microcalcifications. Given that the position of the lesion represents a major factor in stereotactic vacuum-assisted breast biopsy, targeting lesions in close proximity to the skin (superficial lesions) has been described as a problematic issue.Case presentationA 53-year-old woman presented with a newly developed, non-palpable lesion in her left breast. The lesion consisted of widely spread microcalcifications located approximately 5 mm from the skin. The lesion was isoechoic on ultrasound examination. Vacuum-assisted breast biopsy was scheduled (on the Fischers table, using 11-gauge probes, under local anaesthesia). The vacuum-assisted breast biopsy probe was inserted antidiametrically into the breast, the probe reached the lesion and effort was made to excise the microcalcifications. As only a small proportion of the microcalcifications were excised an accurate diagnosis could not be expected. However, with the probe having entered the breast antidiametrically, the probe tip underlying the skin could be palpated. Following the palpation of the tip, the exact point was marked by a pen, the probe was removed and the patient was transferred to the surgery room to have the remaining lesion removed by a spindle-form excision under local anaesthesia. The mammogram of the removed specimen confirmed the total excision of the suspicious microcalcifications.ConclusionIsoechoic superficial lesions can be localized with a hook-wire and open breast biopsy under general or local anaesthesia can be performed. However, vacuum-assisted breast biopsy might offer an alternative solution and serve as an alternative approach to localize the lesion. The clinical significance of the present exploratory effort remains to be assessed in the future.

Cores with microcalcifications in DCIS diagnosis: how many cores make the difference?

Dear Editor, In a recently published issue of Eur Radiol, Poellinger et al. presented interesting data with respect to the specimens containing microcalcifications in patients with DCIS [1]. Their conclusion underlining the importance of cores with microcalcifications in DCIS diagnosis is in line with our previously published results [2]. However, we believe that certain, additional limitations of the study by Poellinger et al. are worth addressing and discussing. In the population of Poellinger et al. the underestimation rate was equal to 8/35 (22.9%); indeed, this may be relevant to the number of cores excised. The authors have excised 12 cores per lesion. However, in our setting, as described in a double blind study, the excision of more cores (extended protocol, up to 96 cores) results in a reduced underestimation rate of DCIS [3]. Interestingly enough, according to our newest results, the underestimation rate following the implementation of the extended protocol is equal to 2/37 (5.4%), i.e., significantly lower than that reported by Poellinger et al. [2/37 vs. 8/35, Pearson’s chi-square (1) = 4.58, p=0.032]. In light of the above, the graphic representations might be worth extending above 12 cores. The plateau presented might be misleading as the probability of diagnosing DCIS [p(DCIS)] equal to 1 does not represent optimal diagnosis; instead, the plateau described corresponds rather to the 27/35 probability (not underestimated cases), leaving further perspectives open for discussion. Additionally, an interesting phenomenon that is also worth mentioning is the role of cores without microcalcifications in the diagnosing evaluation of DCIS. Cox et al. have reported the existence of higher grade DCIS in such cores [4], whereas our setting has permitted the demonstration of an invasive component in the latter. In conclusion, the study by Poellinger et al. provides valuable insight into the role of specimens containing microcalcifications in the histological examination of DCIS; however, further studies adopting comparative design with the inclusion of extended protocols seem desirable.