Haresh Devalia

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.

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.

Predictive factors for invasive cancer in surgical specimens following an initial diagnosis of ductal carcinoma in situ after stereotactic vacuum-assisted breast biopsy in microcalcification-only lesions

PURPOSE The aim of this study was to determine the incidence of invasive breast carcinoma in patients with preoperative diagnosis of ductal carcinoma in situ (DCIS) by stereotactic vacuum-assisted biopsy (SVAB) performed for microcalcification-only lesions, and to identify the predictive factors of invasion. METHODS From 2000 to 2010, the records of 353 DCIS patients presenting with microcalcification-only lesions who underwent SVAB were retrospectively reviewed. The mammographic size of microcalcification cluster, presence of microinvasion within the cores, the total number of calcium specks, and the number of calcium specks within the retrieved core biopsy specimen were recorded. Patients were grouped as those with or without invasion in the final pathologic report, and variables were compared between the two groups. RESULTS The median age was 58 years (range, 34-88 years). At histopathologic examination of the surgical specimen, 63 of 353 patients (17.8%) were found to have an invasive component, although SVAB cores had only shown DCIS preoperatively. The rate of underestimation was significantly higher in patients with microcalcification covering an area of 40 mm or more, in the presence of microinvasion at biopsy, and in cases where less than 40% of the calcium specks were removed from the lesion. CONCLUSION Invasion might be underestimated in DCIS cases diagnosed with SVAB performed for microcalcification-only lesions, especially when the mammographic size of calcification is equal to or more than 40 mm or if microinvasion is found within the biopsy specimen and less than 40% of the calcifications are removed. At least 40% of microcalcification specks should be removed from the lesion to decrease the rate of underestimation with SVAB.

Breast microcalcification: diagnostic value of calcified and non-calcified cores on specimen radiographs.

To determine if the specimen without calcification, as depicted on specimen radiography, made any contribution to the final histopathological diagnosis in comparison to the specimen with calcification. The records of 1312 stereotactic vacuum‐assisted biopsies for breast microcalcifications between February 2000 and December 2010 were reviewed retrospectively. Following specimen x‐ray the biopsy tissues with and without microcalcifications were sent in two separate pots (pot 1 and pot 2 respectively). The number of cores in each pot and the number of calcium specks within the cores were recorded. In 1135 of the 1312 (86%) cases the histopathological findings were similar for pot 1 and pot 2. In 165 cases (13%) the diagnosis was made solely on pot 1 while cores in pot 2 did not reveal any additional pathology. In 12 biopsies (1%) the significant pathology was only present in the specimen without any calcification. For “microcalcification only” breast lesions the specimen containing calcium will yield a correct diagnosis in 99% of cases. Cores containing no calcification rarely contribute to the diagnosis on their own, but in 87% of cases an accurate diagnosis would still have been made even if the targeted calcification had been missed.