L. Perbeck

Sensitivity and specificity of MR mammography with histopathological correlation in 250 breasts.

Purpose: The aim of our prospective study was to determine the diagnostic accuracy of MR mammography (MRM) in detecting malignant disease. Material and Methods: In 231 consecutive patients scheduled for surgery because of mammographic or palpable lesions suspected of malignancy, the breasts were examined with T1-weighted transversal images using a 3-D fast low angle shot (FLASH) sequence. One pre- and 2 post-contrast images were obtained. Histological examination of the surgical specimens showed carcinoma in 155 breasts, of which 138 were invasive and 17 in situ. Results: MRM detected 144 of the 155 malignancies and was false-negative in 11 cases. Eight of these MRM-missed tumours were invasive and 3 were in situ cancers. Benign lesions were found at microscopy in 95 breasts, of which MRM correctly diagnosed 69. The cellular composition of the 26 false-positive lesions (myxomatous stromal change, high vascularity, and epithelial or apocrine hyperplasia) might explain the false positivity. The sensitivity and specificity of MRM were 93% and 73%, respectively. Conclusion: MRM should be interpreted with caution, and supplemented with e.g. mammography and ultrasonography.

Diagnostic Accuracy of Mammography and Contrast-Enhanced MR Imaging in 238 Histologically Verified Breast Lesions

Purpose: To determine the sensitivity and specificity of X-ray mammography and of MR imaging in 238 consecutively operated breasts, and to correlate the findings to histopathological diagnosis. Material and Methods: Over 15 months, 220 patients scheduled for breast surgery were examined consecutively, before surgery, by means of both mammography and MR imaging. of the 220 patients, 18 underwent bilateral breast surgery. The entire breast was examined by means of T1-weighted transversal images using a 3D fast low-angle shot (FLASH) sequence. One pre— and 2 post-contrast scans were performed. Each breast was examined by means of mammography and 3 views were applied as routine. All palpable and mammographically suspect lesions were examined on additional images as microfocus magnification or spot compression. The two methods were evaluated independently of each other. Results: In total, 145 malignant and 93 benign lesions were found at histopathological examination. The sensitivity of mammography was 89% and MR imaging 92%. The specificity was 72% in both methods. When the results of the 2 methods were combined, a sensitivity of 99% and a specificity of 55% was achieved. Conclusion: Mammography and MR imaging seemed to complement each other to produce a high sensitivity. Unfortunately it is impossible at present to supplement mammography with MR imaging in each patient as a routine owing to the current technical and financial limitations.

Contrast-Enhanced MR Imaging of the Breast in Patients with Breast Implants After Cancer Surgery

The purpose of the study was to determine the value of contrast-enhanced MR imaging in the assessment of local recurrence in breast cancer patients who underwent mastectomy and breast reconstruction with an implant. Eighty-three patients have been evaluated by semidynamic contrast-enhanced MR imaging. The T1-weighted FLASH 3-D sequence was repeated twice postcontrast for evaluation of the entire breast bilaterally. The findings were compared to physical examination, mammography and histopathology. Recurrence verified by histopathology occurred in 14 of 83 patients (17%). Contrast-enhanced MR imaging was superior to palpation and mammography in revealing recurrences, especially when these were located close to the chest wall. MR was also more sensitive in detecting multiple foci of cancers. Our study revealed that MR imaging was influenced by size, type and composition of the tumor, as illustrated by the false-negative results. Therefore, the use of all 3 investigation methods is necessary for detecting recurrence at an early stage during the postoperative follow-up.

Lymph Drainage Studied by Lymphoscintigraphy in the Arms after Sentinel Node Biopsy Compared with Axillary Lymph Node Dissection Following Conservative Breast Cancer Surgery

Purpose: To investigate lymphatic drainage as measured by lymphoscintigraphy in the arms of patients undergoing either sentinel lymph node biopsy (SNB) or axillary lymph node dissection (ALND). Material and Methods: From January 2001 to December 2002, 30 patients with unilateral invasive breast carcinoma underwent breast-conserving surgery with SNB and 30 patients with ALND. All patients received radiotherapy to the breast. Lymphoscintigraphy was performed, and skin circulation, skin temperature, and arm volume were measured 2–3 years after radiotherapy. Results: None of the 30 patients who underwent SNB showed any clinical manifestation of lymphedema. Of the 30 patients undergoing ALND, six (20%) had clinical lymphedema, with an arm volume that was >10% larger on the operated than on the non-operated side (P<0.01). Scintigraphically, visual analysis revealed lymphatic dysfunction in three patients, manifested as forearm dermal back flow. Two of these patients also had an increased arm volume. Quantitative analysis showed no differences between the groups, apart from a smaller amount of isotope in the axilla in the ALND group. There was no difference in skin circulation or skin temperature. Conclusion: Our study shows that lymph drainage in the operated arm compared with the non-operated arm was less affected by SNB than by ALND, and that morbidity associated with SNB was lower than with ALND. However, the results do not confirm our hypothesis that lymphoscintigraphy can reveal differences in lymph circulation that are not evident clinically in the form of manifest lymphedema. The most sensitive clinical method of assessing lymph drainage seems to be measurement of arm volume.

Efficacy of subcutaneous and topical local anaesthesia for pain relief after resection of malignant breast tumours

OBJECTIVE Infiltration and topical application of local anaesthetics close to the surgical wound may be used to prevent postoperative pain. We evaluated the efficacy of these treatments after breast surgery for cancer. DESIGN Double-blind randomised trial with two treatment groups and one control group. SETTING University hospital, Sweden. INTERVENTIONS Patients were allocated to treatment with bupivacaine infiltration (n = 29), topical application of lignocaine/prilocaine (n = 31), or no local treatment (n = 30). MAIN OUTCOME MEASURES Difference and time related patterns in pain scores measured on a visual analogue scale (VAS), and morphine consumption. RESULTS. None of the local anaesthetics significantly reduced the VAS score or morphine consumption. However, fewer patients in the anaesthetic groups had high VAS scores than controls, the 75 centile for the mean score after operation being 2.7, 2.0 and 2.1 for the controls, infiltration, and topical anaesthetic groups, respectively. The controls had higher scores from 6 hours postoperatively onwards. The corresponding median morphine consumption was 24.5, 18.5, and 16.2 mg. CONCLUSIONS. Local anaesthesia slightly reduced the overall pain scores and the morphine consumption, but was of potential clinical value only in the patients who had the highest pain scores.

Fluid retention in Bioplasty Misti Gold II breast prostheses with development of capsular contracture.

We compared the incidence of capsular contracture in an implant (Bioplasty Misti® Gold II) which has a textured surface and is filled with polyvinyl-pirrolidone (PVP)-hydrogel, with that in saline-filled implants with textured surfaces when the implants are placed subcutaneously during immediate reconstruction after subcutaneous mastectomy. In 41 patients, mean age 55 years (range 30-81), with breast cancer that was not suitable for breast conservation, 20 patients had 22 Misti Gold II prostheses inserted (two patients bilaterally) and 21 patients had saline-filled prostheses (one patient bilaterally). The development of capsular contracture was assessed using Bakers classification and applanation tonometry. Fourteen patients with Misti Gold II implants were classified one year postoperatively as Baker 2 and 3 compared with five with saline-filled implants (pWe compared the incidence of capsular contracture in an implant (Bioplasty Misti Gold II) which has a textured surface and is filled with polyvinyl-pirrolidone (PVP)-hydrogel, with that in saline-filled implants with textured surfaces when the implants are placed subcutaneously during immediate reconstruction after subcutaneous mastectomy. In 41 patients, mean age 55 years (range 30-81), with breast cancer that was not suitable for breast conservation, 20 patients had 22 Misti Gold II prostheses inserted (two patients bilaterally) and 21 patients had saline-filled prostheses (one patient bilaterally). The development of capsular contracture was assessed using Bakers classification and applanation tonometry. Fourteen patients with Misti Gold II implants were classified one year postoperatively as Baker 2 and 3 compared with five with saline-filled implants (p = 0.01). On applanation tonometry 16 of the Misti Gold II group had an operative:postoperative ratio of < or = 0.75, compared with 50% in the saline-filled group (p = 0.096). In the 12 Misti Gold II prostheses that were removed because of capsular contracture between 13-40 months postoperatively, the volume in the prostheses had increased by 48%. The poor results obtained with the Misti Gold II prosthesis can be explained by the volume that they gained after implantation as a result of osmosis.

Evaluation of planar scintimammography with 99mTc-MIBI in the detection of axillary lymph node metastases of breast carcinoma.

Purpose: the aim of our prospective study was to evaluate the role of planar scintimammography with 99mTc-MIBI in detecting axillary lymph node metastases in women with primary breast carcinoma. Material and Methods: Fifty-eight patients underwent scintimammography prior to axillary lymph node dissection. Ten minutes after injection of 700 MBq 99mTc-MIBI, two prone lateral projections were obtained, followed by a supine anterior projection. Sixty-one axillae (3 bilateral) were operated upon and the status of the lymph nodes verified with histopathology. the scintigraphic result was compared to the histopathologic findings. Results: A sensitivity of 67% and a specificity of 80% of planar scintimammography in detecting axillary lymph node metastases were achieved. Conclusion: Scintimammography with 99mTc-MIBI is not recommended as a routine method for the detection of axillary lymph node metastases in patients with breast carcinoma.

The Circulation in the Nipple-Areola Complex Following Subcutaneous Mastectomy in Breast Cancer

To evaluate the decrease in circulation in the nipple-areola complex after subcutaneous mastectomy and immediate implantation of a submuscular prosthesis, the blood flow was studied by both fluorescein flowmetry and laser Doppler flowmetry in 24 patients with invasive breast cancer. In 14 patients a lazy-S-shaped horizontal lateral incision was used, and 10 underwent a subcutaneous reduction mammaplasty. After subcutaneous mastectomy with a lazy-S incision there was no significant decrease in blood flow in the nipple-areola complex compared with that in the untreated contralateral breast. In the breasts in which reduction mammaplasty had been done, the blood flow was reduced by 74% as measured by fluorescein (p less than 0.01), and 70% by laser Doppler flowmetry (p less than 0.05), compared with the contralateral breast. Five patients had partial or complete epidermal, and one patient had total dermal, necrosis of the complex, but there was no deep necrosis. No fluorescence was seen within the areas in which necrosis later developed in any of these six cases. The laser Doppler signal in the corresponding areas, however, was not reduced. The results show that the circulation in the nipple-areola complex is reduced more after subcutaneous reduction mammaplasty than after subcutaneous mastectomy with a lazy-S incision.

Correlation between Fluorescein Flowmetry and Laser Doppler Flowmetry: A Study in the Intestine (Ileoanal Pouch) in Man

A study was undertaken to compare two new methods of capillary blood flow measurement, namely fluorescein flowmetry (FF) and laser Doppler flowmetry (LDF). The blood flow was measured in a pelvic pouch during its construction and in the completed ileoanal anastomosis in 12 patients. There was a high correlation between the two methods (correlation coefficient, 0.78) (p less than 0.01) when the blood flow was measured in the pelvic pouch. The correlation coefficient between the two methods for the difference between the blood flow in the pelvic pouch at the site of the planned anastomosis when the pouch resided in the abdomen and that in the completed ileoanal anastomosis was r = 0.99 (n = 12, p less than 0.001); the reduction amounted to 25% as measured by FF and 27% as measured by LDF (n = 12, p less than 0.01). All ileoanal anastomoses healed perfectly, the lowest FF and LDF values being 0.004 density units/sec and 0.3 V, respectively. The results indicate that either method can be considered for measuring capillary blood flow.

Skin Circulation in the Nipple After Reduction Mammaplasty with a Bipedicle Vertical Dermal Flap

Necrosis of the nipple after a reduction mammaplasty with transposition of the nipple is a serious complication. A study was undertaken to measure the skin circulation in the nipple before, during and after this operation. In 16 patients undergoing reduction mammaplasty according to the method of McKissock, the skin circulation was measured in both breasts by laser Doppler flowmetry (LDF) and fluorescein flowmetry (FF). LDF showed that the skin circulation increased after de-epithelialization to 245.7 +/- 39.3% of the preoperative blood flow (100%) (mean +/- SEM, p less than 0.01). When 40 ml of 0.25% adrenaline was injected into the incision lines, the corresponding increase in blood flow was 153.4 +/- 15.6% (p less than 0.01). After the medical and lateral glandular resections the blood flow in the nipple of the vertical dermal pedicle was 125.6 +/- 21.2% of the preoperative blood flow and when adrenaline was given the corresponding value was 79.3 +/- 6.5%. After the skin had been sutured, the blood flow was 128.4 +/- 25.9% of the preoperative value and in the breast in which adrenaline was injected it was 177 +/- 96.9%. One to four days postoperatively the blood flow was 123.1 +/- 19.9% of the preoperative value and in the breast that received adrenaline 130 +/- 24%. At FF homogeneous fluorescence was observed in the nipple postoperatively in all patients but one; in this patient avascular necrosis later developed. Our results thus show that the circulation in the nipple after reduction mammaplasty by the McKissock method is adequate.