Suzan Menasce Goldman

Impact of breast MRI on surgical treatment, axillary approach, and systemic therapy for breast cancer.

Abstract:  The purpose of this study is to determine how often breast magnetic resonance imaging (MRI) brings additional information that influences management of patients with breast cancer concerning surgical treatment, axillary lymph node approach, and systemic therapy. From July 2004 to July 2005, 99 patients recently diagnosed with breast cancer in clinical stages 0, I, and II were prospectively evaluated about their therapeutic plans, at first based on usual protocol (physical examination, mammography and ultrasound) and next going through bilateral breast MR. Examinations were carried out at 1.5 T on five sequences of FSPGR 3D for 90 seconds (four post‐gadolinium diethylenetriaminepenta acetic acid 0.16 mM/Kg). Parameters analyzed on MRI were extension of primary lesion; detection of multifocality, multicentricity, or contra lateral lesion; muscular or skin involvement; and presence of lymph node involvement. Pathologic confirmation of additional lesions was achieved by core or excisional biopsy. MRI made 69 additional findings in 53 patients. Fifty‐one findings were true‐positives (51/69 = 73.9%) including 16 larger single lesions; 18 cases of multifocality; 7 cases of multicentricity; 3 cases of contra lateral lesion; 5 cases of lymph node involvement (one of them involved medial thoracic chain); 1 with muscular involvement; 1 with skin involvement. MRI has changed previous management plans in 44.4% of 99 patients. We observed increase in mastectomies (26.8%) on axillary lymph node dissection (25%) and changes on systemic therapy (20.2%), all because of additional MRI true‐positive findings. Breast MRI alters significantly the rate of mastectomy, the approach of axillary chain for staging, and the use of systemic therapy because of its accuracy in evaluating breast cancer local extent.

Analysis by MRI of residual tumor after radiofrequency ablation for early stage breast cancer.

OBJECTIVE The objective of our study was to evaluate the effectiveness of MRI in the detection of possible residual lesions after radiofrequency ablation (RFA) in the treatment of breast cancer. SUBJECTS AND METHODS We prospectively evaluated 14 patients who had undergone ultrasound-guided core biopsies diagnostic of invasive ductal carcinoma (IDC; range of diameters, 1.0-3.0 cm) and then ultrasound-guided percutaneous RFA with sentinel node biopsy as the primary treatment. Breast MRI was performed 1 week before RFA to evaluate tumor extension and again 3 weeks after RFA to verify the presence of possible residual lesions. Conventional surgical resection of the tumors was performed 1 week after RFA. The MRI findings were compared with histopathologic analyses to confirm the presence or absence of residual tumor. RESULTS There was no residual enhancement in seven lesions on the postablation breast MRI scans. These findings were confirmed by negative histopathologic findings in the surgical specimens. The MRI scans of five patients showed small areas of irregular enhancement that corresponded to residual lesions. In the two remaining patients, we observed enhancement of almost the entire lesion, indicating that RFA had failed. CONCLUSION Breast MRI is effective in detecting residual lesions after RFA in patients with IDC.

Cystic phaeochromocytoma is a distinctive subgroup with special clinical, imaging and histological features that might mislead the diagnosis.

To report and analyse cases of cyctic phaeochromocytoma at our institution and in previous publications, as adrenal cystic masses are usually associated with nonfunctional lesions, but they can be phaeochromocytoma.

New Trends in Diffusion-Weighted Magnetic Resonance Imaging as a Tool in Differentiation of Serous Cystadenoma and Mucinous Cystic Tumor: A Prospective Study

Background/Aims: Pancreatic cystic lesions are increasingly being recognized. Magnetic resonance imaging (MRI) is the method that brings the greatest amount of information about the morphologic features of pancreatic cystic lesions. To establish if diffusion-weighted MRI (DW-MRI) can be used as a tool to differentiate mucinous from nonmucinous lesions. Methods: Fifty-six patients with pancreatic cystic lesions (benign, n = 46; malignant, n = 10) were prospectively evaluated with DW-MRI in order to differentiate mucinous from nonmucinous lesions. Final diagnosis was obtained by follow-up (n = 31), surgery (n = 16) or endoscopic ultrasound-guided fine needle aspiration (n = 9). Serous cystadenoma was identified in 32 (57%) patients. Results: The threshold value established for the differentiation of mucinous from nonmucinous lesions was 2,230.06 s/mm2 for ADC of 700. DWI-MRI behavior between mucinous and nonmucinous groups revealed sensitivity, specificity, positive predictive value, negative predictive value and accuracy to be 80, 98, 92, 93 and 93%, respectively (p < 0.01, power of sample = 1.0). In the comparison of the diffusion behavior between mucinous (n = 13) and serous (n = 32) lesions, the sensitivity, specificity, positive predictive value, negative predictive value and accuracy were 100, 97, 92, 100 and 98%, respectively (p < 0.01, power of sample = 1.0). The results of endoscopic ultrasound-guided fine needle aspiration were similar to those of DW-MRI. Conclusions: DW-MRI can be included as part of the array of tools to differentiate mucinous from nonmucinous lesions and can help in the management of pancreatic cystic lesions.

LAPAROSCOPIC PANCREATIC RESECTION. FROM ENUCLEATION TO PANCREATODUODENECTOMY. 11-YEAR EXPERIENCE

CONTEXT Our experience with laparoscopic pancreatic resection began in 2001. During initial experience, laparoscopy was reserved for selected cases. With increasing experience more complex laparoscopic procedures such as central pancreatectomy and pancreatoduodenectomies were performed. OBJECTIVES The aim of this paper is to review our personal experience with laparoscopic pancreatic resection over 11-year period. METHODS All patients who underwent laparoscopic pancreatic resection from 2001 through 2012 were reviewed. Preoperative data included age, gender, and indication for surgery. Intraoperative variables included operative time, bleeding, blood transfusion. Diagnosis, tumor size, margin status were determined from final pathology reports. RESULTS Since 2001, 96 patients underwent laparoscopic pancreatectomy. Median age was 55 years old. 60 patients were female and 36 male. Of these, 88 (91.6%) were performed totally laparoscopic; 4 (4.2%) needed hand-assistance, 1 robotic assistance. Three patients were converted. Four patients needed blood transfusion. Operative time varied according type of operation. Mortality was nil but morbidity was high, mainly due to pancreatic fistula (28.1%). Sixty-one patients underwent distal pancreatectomy, 18 underwent pancreatic enucleation, 7 pylorus-preserving pancreatoduodenectomies, 5 uncinate process resection, 3 central and 2 total pancreatectomies. CONCLUSIONS Laparoscopic resection of the pancreas is a reality. Pancreas sparing techniques, such as enucleation, resection of uncinate process and central pancreatectomy, should be used to avoid exocrine and/or endocrine insufficiency that could be detrimental to the patients quality of life. Laparoscopic pancreatoduodenectomy is a safe operation but should be performed in specialized centers by highly skilled laparoscopic surgeons.

Prevalence of incidental pancreatic cysts on 3 tesla magnetic resonance.

Objectives To ascertain the prevalence of pancreatic cysts detected incidentally on 3-Tesla magnetic resonance imaging (MRI) of the abdomen and correlate this prevalence with patient age and gender; assess the number, location, and size of these lesions, as well as features suspicious for malignancy; and determine the prevalence of incidentally detected dilatation of the main pancreatic duct (MPD). Methods Retrospective analysis of 2,678 reports of patients who underwent abdominal MRI between January 2012 and June 2013. Patients with a known history of pancreatic conditions or surgery were excluded, and the remaining 2,583 reports were examined for the presence of pancreatic cysts, which was then correlated with patient age and gender. We also assessed whether cysts were solitary or multiple, as well as their location within the pancreatic parenchyma, size, and features suspicious for malignancy. Finally, we calculated the prevalence of incidental MPD dilatation, defined as MPD diameter ≥ 2.5 mm. Results Pancreatic cysts were detected incidentally in 9.3% of patients (239/2,583). The prevalence of pancreatic cysts increased significantly with age (p<0.0001). There were no significant differences in prevalence between men and women (p=0.588). Most cysts were multiple (57.3%), distributed diffusely throughout the pancreas (41.8%), and 5 mm or larger (81.6%). In 12.1% of cases, cysts exhibited features suspicious for malignancy. Overall, 2.7% of subjects exhibited incidental MPD dilatation. Conclusions In this sample, the prevalence of pancreatic cysts detected incidentally on 3T MRI of the abdomen was 9.3%. Prevalence increased with age and was not associated with gender. The majority of cysts were multiple, diffusely distributed through the pancreatic parenchyma, and ≥ 5 mm in size; 12.1% were suspicious for malignancy. An estimated 2.7% of subjects had a dilated MPD.

Radiofrequency Ablation of Functioning Adrenal Adenomas: Preliminary Clinical and Laboratory Findings

PURPOSE To evaluate clinical and laboratory findings in patients undergoing radiofrequency (RF) ablation for functioning adrenal adenomas. MATERIALS AND METHODS Eleven adult patients, nine with Conn syndrome and two with Cushing syndrome, underwent percutaneous computed tomography-guided RF ablation for benign adrenal neoplasms. Systolic, diastolic, and mean blood pressure and the number of classes of antihypertensive drugs used by each patient were analyzed before and 1, 4, and 12 weeks after the procedure. Serum hormone levels were analyzed within 30 days before and 12 weeks after the procedure. RESULTS Of the nine patients with Conn syndrome, eight showed normal serum aldosterone levels after the procedure and one patient had a nodule located very close to the inferior vena cava, resulting in incomplete ablation. The two patients with Cushing syndrome had normal serum and salivary cortisol levels after the procedure. Mean aldosterone concentration at baseline was 63.3 ng/dL ± 28.0 and decreased to 13.3 ng/dL ± 13.5 at 12 weeks postoperatively (P = .008). Systolic, diastolic, and mean blood pressures decreased significantly in the first week after the procedure (P < .001) and remained stable during further follow-up. CONCLUSIONS In patients with Conn syndrome or Cushing syndrome, percutaneous RF ablation of functioning adrenal adenomas may result in normalization of hormone secretion, improvement in blood pressure, and reduced need for antihypertensive drugs.

Is It Safe and Effective to Treat Complex Renal Cysts by the Laparoscopic Approach

BACKGROUND AND PURPOSE Bosniak III and IV renal cysts have low mortality potential, and little is reported regarding the feasibility and safety of managing such tumors by laparoscopy and its comparison with open surgery. We report on the experience with 37 complex renal cysts managed in the era of laparoscopy. PATIENTS AND METHODS A retrospective analysis of a prospective database from all patients with renal tumors who were operated on at our institution was evaluated after Institutional Review Board approval. The database comprises information for demographic, clinical, imaging, preoperative, intraoperative, histologic, and follow-up data. A comparison among all performed approaches was done for demographic, American Society of Anesthesiologists classification, operative time, estimated blood loss, ischemia time, hospital stay, oncologic and survival rate. The cysts removed by laparoscopic partial nephrectomy were compared with the solid tumors removed by the same approach at the same period. RESULTS The database included 407 patients with renal tumors who were operated on from 2000 to 2009 at our institution. In 36 patients of the total cohort, there were 37 complex renal cysts. No patients with preoperative Bosniak type I or II underwent surgery. Of the cysts, 60% were Bosniak IV, and 86% were confirmed as malignant; 40% were Bosniak III, and 44% were confirmed as malignant. Laparoscopic partial nephrectomy was performed in 67.5%. The tumor size and hospital stay were significantly different in the laparoscopic group. No cyst spillage occurred either by laparoscopy or by the open approach, and no tumor recurrence was found in a mean follow-up of 43.7 months with overall survival of 100%. CONCLUSION Laparoscopic surgery for complex cysts is safe, feasible, and effective. Nevertheless, regardless of surgical approach, patients with complex renal cysts have excellent overall survival with short-term follow-up.

Transcatheter arterial embolization for unresectable symptomatic giant hepatic hemangiomas: single-center experience using a lipiodol-ethanol mixture.

Objective The present article is aimed at reporting the author’s experience with transcatheter arterial embolization using a lipiodol-ethanol mixture in three cases of unresectable symptomatic giant hepatic hemangiomas. Materials and Methods The cases of three patients with giant unresectable symptomatic hepatic hemangiomas embolized in the period 2009–2010 were retrospectively reviewed. In all the cases, transarterial embolization was performed with an ethanol-lipiodol mixture. Results Symptoms regression and quality of life improvement were observed in all the cases. No complications were observed and all the patients were discharged within 12 hours after the procedure. Conclusion Transcatheter arterial embolization using ethanol mixed with lipiodol was a safe and effective treatment for symptomatic giant hepatic hemangiomas in this small series of patients.

Imaging procedures in adrenal pathology

Imaging plays a vital role in the evaluation of adrenal pathology. The most widely used modalities are computed tomography and magnetic resonance imaging. Alone or in conjunction with appropriate clinical and biochemical data, imaging can provide specific diagnoses that preclude the need for tissue sampling. This article reviews imaging features of normal and diseased adrenals, from both benign and malignant causes.