John Downey

Mammography before and after bariatric surgery

BACKGROUND Morbidly obese women are at increased risk for breast cancer, and the majority of surgical weight-loss patients are older than 40 years old. OBJECTIVE The purpose of the present study was to determine the technical and interpretive changes in mammography following bariatric surgery. SETTING Accredited Academic Hospital. METHODS Two breast-imaging radiologists reviewed screening mammograms performed on 10 morbidly obese women undergoing bariatric surgery both pre- and postoperatively. American College of Radiology Breast Imaging Reporting and Data System (ACR BI-RADS) density, imaging quality measurements, compression force, breast thickness, pectoral nipple line (PNL) length, and x-ray beam kilovoltage (kVp) and miliamperes per second (mAs) were recorded. RESULTS The average patient age was 56 years old, with mean age at menarche of 13 years old; 70% of patients were postmenopausal (average age 49 years at menopause) and 50% had a family history of breast cancer. There was a significant reduction in both BMI (-13.2 kg/m2, P<.01) and waist circumference (-32.0 cm, P<.01) following bariatric surgery. There was a significant reduction in breast thickness (-23.8 mm), reduction in PNL length (-1.9 cm), reduction in kVp (-1.2), and reduction in mAs (-16.7) even though there was no compression force change in pre- and postoperative mammograms detected. All breast densities were fatty or scattered though there were more scattered and fewer fatty images after surgery (P = .002). CONCLUSION Morbidly obese women can undergo quality mammograms before and after bariatric surgery; however, weight loss after bariatric surgery leads to only slightly denser mammograms. Furthermore, weight loss reduces mammographic radiation doses.

Abstract P3-01-17: A technique for preoperative axillary lymph node tattooing in patients with breast cancer

Purpose: To describe the ultrasound technique for tattooing axillary lymph nodes (ALNs) after lymph node (LN) biopsy in patients with breast cancer. Background: Preoperative evaluation of metastatic disease within ALNs in patients with newly diagnosed breast cancer has significant prognostic value and is quickly becoming routine, particularly in the neoadjuvant setting. A recent study showed tattooed LNs are visible intraoperatively and on histological evaluation months following the tattooing procedure. These results suggest that LN tattooing can obviate the need for additional localization procedures during axillary staging, such as wire localization. Given the increasing use of preoperative ALN biopsy, a robust technique to insure proper LN tattoo marking is proposed. Methods and Technique: Tattooing was performed under real-time US guidance using a 5-cm long 21-gauge hypodermic needle attached to a 1 mL tuberculin syringe containing 1 mL carbon suspension tattoo ink (SPOT™, GI-supply Inc). Imaging was performed with the patient in a supine oblique position with the patient9s arm over their head. The anatomically anterior and lateral aspects of the node and perinodal fat were marked with ink. The only regions of the LN not targeted for ink tattooing were the hilum and the posterior cortex and perinodal fat. At least 0.5 mL of ink was used. Results: Optimal technique for intraoperative visualization was determined to be tattooing the anatomically anterior and lateral aspects of the LN cortex and the adjacent perinodal fat using at least 0.5mL of ink. Tattooed LNs which had undergone biopsy and tattooing months prior to surgery were visible intraoperatively and on histological evaluation. Factors contributing to less optimal visualization of the tattooed lymph node included: using less than 0.5mL of ink, tattooing only the superficial cortex and not the perinodal fat, and tattooing a portion of the LN that was not visible with the patient in the operative position. Discussion: The most easily accessed portion of the LN during the US procedure may not be the portion of the LN most easily seen intraoperatively. Locating and tattooing the anatomically anterior and lateral aspects of the LN, regardless of the patient position and orientation of the ultrasound probe, is the primary challenge. Doing so will maximize the likelihood that the tattoo ink will be visible by the surgeon when the patient is in a supine position with the arm abducted 90 degrees using an axillary incision. Tattooing using less than 0.5 mL resulted in suboptimal visualization. Using a larger volume of ink may be judged necessary for larger LNs, very fatty axillae, and for deeply seated nodes. Other reports in the medical literature suggest cutaneous tattooing can result in ink within ALNs. In patients with ipsilateral cutaneous tattoos, an alternative method of marking any biopsied LNs should be considered to avoid false positives associated with prior migration of the cutaneous tattoo ink to the LN. Tattooing of ALNs under ultrasound guidance is a straightforward technique which can be performed at the time of initial biopsy and obviates the need for future preoperative wire localization of the LN. Citation Format: Wapnir IL, Downey JR, Lipson JA, Ikeda DM. A technique for preoperative axillary lymph node tattooing in patients with breast cancer. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P3-01-17.

The Milky Way Sign: A New Diagnostic Finding of Ductal Carcinoma in situ on Digital Breast Tomosynthesis.

Bluish skin discoloration, thrombocytopenia, hemorrhage and Kasaback-Merritt syndrome have also been reported. Donnell and Rosen proposed a three-tired histologic grading system. Grade I (well-differentiated) consists of interanastomosing vascular channels dissecting interlobular soft tissue. Endothelial cells are flat in single layer with bland or occasionally hyperchromatic nuclei and rare mitosis. Grade II (moderately differentiated) has cellular foci with small papillary endothelial cell proliferation and/or spindle cell nodules with swirling pattern. Grade III (poorly differentiated) is characterized by solid endothelial or spindle cell proliferation with conspicuous mitoses and necrosis. Histologic grade may vary in different areas of a tumor. Angiosarcomas express factor VIII, CD31, CD34, erythroblast transformation-specific-related gene (ERG) nuclear transcription factor, friend leukemia integration 1 transcription factor (FL1) and occasionally podoplanin (D2-40). These markers may be negative in less differentiated foci. Some angiosarcomas may co-express keratins and less often EMA. HHV8 is negative. Nuclear staining for myelocytomatosis virus proto-oncogene (MYC) and prospero-related homeobox-1 (Prox-1) may be helpful to differentiate these tumors from atypical vascular proliferations. MRI is the most useful imaging method in diagnosis and management plan. Color Doppler highlights hypervascularity. Mammogram findings are nonspecific. Positron emission tomography is used for tumor staging. Complete local excision is the best course of action. Conservative and radical surgeries show similar survival rates. Axillary node dissection is not recommended. Role of adjuvant chemotherapy is unclear and adopted from nonbreast soft tissue sarcomas. The median length of disease-free survival for grade I, II, and III were 15 years, 12 years, and 15 months, respectively. Angiosarcomas of the breast are rare malignancies and potential diagnostic pit falls, detection of which requires high index of suspicion with diligent correlation of clinical, radiologic, and pathologic findings.