Tommaso Perretta

Small Breast Cancers: In Vivo Percutaneous US-guided Radiofrequency Ablation with Dedicated Cool-Tip Radiofrequency System

PURPOSE To evaluate in vivo the efficacy of a newly developed breast radiofrequency (RF) ablation system in human small invasive breast carcinomas in terms of induction of complete tumor necrosis, reproducibility of ablation lesion size and shape, and cosmetic outcome. MATERIALS AND METHODS This study had institutional review board approval, and written informed consent was obtained. Thirty-four postmenopausal women (mean age, 53 years +/- 5 [standard deviation]; range, 49-62 years) with small (< or = 2 cm) biopsy-proved invasive ductal breast carcinomas were enrolled. RF energy was delivered through a 25-mm 15-gauge monopolar cool-tip needle electrode by using the temperature-controlled mode. Patients were divided into three groups according to their breast pattern as assessed at mammography. The volumetric size and geometry of the coagulation zone, together with ablation time, were determined. Histopathologic data were compared with postprocedural 3.0-T contrast material-enhanced magnetic resonance (MR) images. Cosmesis after RF ablation was assessed. Four weeks after RF ablation, patients underwent definitive surgery. RESULTS All ablation procedures were performed successfully. For 97% of the procedures, nicotinamide adenine dinucleotide in its reduced form-diaphorase staining showed no evidence of viable cells. The mean induced ablation volume, as assessed with histologic analysis, was 12.50 cm(3) +/- 0.8. Tumor ablation volume on the postablation MR images showed good correlation with results of histopathologic analysis (r = 0.823, P < .005). No differences were observed in terms of duration of the procedure or ablation volume with respect to the glandular pattern of the breast (P > .05 for both). The general shape of the induced necrosis was close to a sphere in all cases. Cosmesis was excellent in 28 patients. CONCLUSION A dedicated breast cool-tip RF ablation system can induce complete tumor necrosis and reproducible ablation volumes independently of breast glandular pattern, providing excellent cosmesis. Postablation MR images are a reliable tool in predicting histologic findings.

MR imaging-guided 10-gauge vacuum-assisted breast biopsy: histological characterisation

PurposeThe aim of this study was to evaluate a handheld vacuum-assisted device for magnetic resonance imaging (MRI)-guided breast biopsy.Materials and methodsIn 47 patients, a total of 47 suspicious breast lesions (mean maximum diameter 9 mm) seen with MRI (no suspicious changes on breast ultrasound or mammography) were sampled using a 10-gauge vacuum-assisted breast biopsy (VAB) device under MRI guidance. Histology of biopsy specimens was compared with final histology after surgery or with follow-up in benign lesions.ResultsTechnical success was achieved in all biopsies. Histological results from VAB revealed malignancy in 15 lesions (32%), atypical ductal hyperplasia in four lesions (8%) and benign findings in 28 lesions (60%). One of four lesions with atypical ductal hyperplasia was upgraded to ductal carcinoma in situ after surgery. One of seven lesions showing ductal carcinoma was upgraded to invasive carcinoma after surgery. Two lesions diagnosed as infiltrating carcinoma by VAB were not validated at excisional biopsy due to complete removal of the lesion during the procedure. During the follow-up (mean 18 months) of histologically benign lesions, we observed no cases of breast cancer development. Because of morphological changes on follow-up MRI scans, two lesions underwent surgical excision, which confirmed their benign nature. Besides minor complications (massive bleeding, n=1) requiring no further therapeutic intervention, no complications occurred.ConclusionsMRI-guided biopsy of breast lesions using a handheld vacuum-assisted device is a safe and effective method for the workup of suspicious lesions seen on breast MRI alone.RiassuntoObiettivoValutare l’accuratezza diagnostica dei prelievi con sistema portatile ad aspirazione retroazionata (VAB) 10 gauge sotto-guida RM nella caratterizzazione delle lesioni mammarie visibili unicamente alla RM.Materiali e metodi47 lesioni (diametro massimo 9 mm) visibili unicamente all’esame RM, sono state caratterizzate usando un sistema portatile ad aspirazione retroazionata (VAB) con ago da 10 Gauge, sotto guida RM. L’istologia delle biopsie VAB è stata confrontata con l’istologia definitiva dopo l’escissione chirurgica o con i reperti di follow-up.RisultatiIl successo tecnico è stato ottenuto in tutti i casi. I risultati istologici della biopsia VAB hanno mostrato 15 lesioni maligne (32%), 4 lesioni classificabili come iperplasia duttale atipica (ADH) (8%), e 28 lesioni come benigne (60%). Alla istologia definitiva una delle quattro lesioni classificate come ADH è stata riclassificata come carcinoma duttale in situ (DCIS), mentre una delle lesioni classificate come DCIS è stata riclassificata come carcinoma invasivo. Due lesioni diagnosticate al VAB come carcinoma infiltrante non sono state riscontrate alla istologia definitiva, probabilmente a causa della totale rimozione durante la procedura VAB. Il follow-up delle lesioni benigne ha confermato la benignità delle lesioni. Due lesioni benigne che all’Imaging RM hanno mostrato una modificazione della morfologia, sono andate incontro ad intervento chirurgico che ha confermato la benignità della lesione. Ad eccezione di un massivo sanguinamento in 1 caso, non si sono osservate complicanze.ConclusioniI prelievi VAB sotto-guida RM sono una mammetodica sicura ed efficace per la caratterizzazione delle lesioni mammarie visibili unicamente all’RM.

Subclinical Breast Cancer: Minimally Invasive Approaches. Our Experience with Percutaneous Radiofrequency Ablation vs. Cryotherapy

Background: The aim of this study was to compare the efficacy of radiofrequency ablation vs. cryoablation in the treatment of early breast cancer. Patients and Methods: 80 women (mean age 73 ± 5 years) with early breast cancer were retrospectively evaluated. 40 patients underwent cryoablation and 40 patients underwent radiofrequency ablation, both with sentinel lymph node excision. Tumor volume and histopatological data were compared by means of postprocedural 3.0-T magnetic resonance imaging (MRI). 30-45 days after the percutaneous ablation, all patients underwent surgical resection of the tumor. The mean follow-up was 18 months without any local recurrences. Results: Both techniques allow good correlation with histopathological data. In 75 patients (93.8%) we observed complete necrosis; in 5 cases there was residual disease in the postprocedural MRI and postoperative histological examination. There was a good correlation between MRI volume and histologic samples. Cosmetic results were good in all patients but 2. Conclusion: Both percutaneous radiofrequency ablation and cryotherapy are minimally invasive techniques with a good clinical and cosmetic outcome in selected cases. MRI examination is an ideal method to assess breast neoplasms in terms of quality and quantity as well as residual tumor extent after percutaneous ablation. Cryotherapy is the preferred method because of the analgesic effect of freezing with better patients compliance.

Cost-effectiveness analysis of two vacuum-assisted breast biopsy systems: Mammotome and Vacora

PurposeThis study was undertaken to compare the cost effectiveness of two vacuum-assisted breast biopsy devices, the Mammotome and Vacora systems.Materials and methodsBetween January and June 2006, 238 vacuum-assisted breast biopsies were performed at our radiology department. Five out of 238 lesions were excluded because of inadequate sampling. The Mammotome system was used in 108/233 lesions and the Vacora system in 125/233. Fifty-eight lesions underwent ultrasound-guided breast biopsy, and 50 lesions underwent mammography-guided biopsy with both Mammotome and Vacora devices. Magnetic-resonance-guided biopsy was possible with the Vacora system only (17/125 lesions).ResultsAll procedures were successfully completed. No significant differences were found between the results of the Mammotome and Vacora biopsies in terms of effectiveness: sensitivity was 84.4% and 86.2%, respectively, and specificity 100%. In terms of cost, the Mammotome system has higher costs per procedure compared with the Vacora.ConclusionsOur clinical results confirm the diagnostic accuracy of both the Mammotome and Vacora systems, whereas our cost analysis shows that there is a considerable difference, mostly related to the initial investment.RiassuntoScopoConfrontare costi ed efficacia di due sistemi di biopsia mammaria ad aspirazione forzata: Mammotome e Vacora.Materiali e metodiPresso il nostro Centro, dal gennaio a giugno 2006 sono state sottoposte a caratterizzazione istologica mediante prelievo VAB 238 lesioni mammarie. Di queste 5/238 sono state escluse dalla nostra casistica per numero insufficiente di frustoli prelevati. In 108/233 lesioni è stato utilizzato il sistema Mammotome ed in 125/233 il Vacora. Con entrambi i sistemi sono state sottoposte a prelievo 58 lesioni sotto guida ecografica e 50 sotto guida mammografica. Per la guida RM è stato utilizzato unicamente il sistema Vacora (17/125 lesioni).RisultatiTutte le procedure considerate sono state portate a termine con successo. L’efficacia diagnostica dei due sistemi è risultata sovrapponibile: sensibilità 84,4%–86,2%, specificità 100%. I costi unitari delle singole procedure risultano maggiori per il sistema Mammotome, rispetto al Vacora.ConclusioniI risultati clinici confermano l’accuratezza diagnostica di entrambi i sistemi mentre, ai fini della valutazione economica delle procedure, il fattore determinante è l’investimento iniziale.

Acute left hemothorax as a late complication of an active-fixation pacemaker lead.

Perforation and migration of pacemaker electrodes into the pleural cavity is a rare event. We report the clinical course and surgical treatment of massive acute hemothorax resulting from intercostal artery laceration, caused by a retained active-fixation pacing lead implanted 10 months earlier.

A Phyllodes Tumor in a Child

Phyllodes tumor of the breast is a rare neoplasm, particularly in adolescent girls and young women. It is usually presented as a unilateral palpable mass. We are reporting the case of an 11-year-old adolescent girl who came to our Diagnostical Imaging Department with non-hematic nipple discharge. Ultrasound, mammography, and magnetic resonance imaging were performed. The histological examination showed a phyllodes tumor. The management and the biological behavior of this uncommon tumor are discussed with particular regard to the very unusual clinical presentation in this patient.

Cost-effectiveness of two breast biopsy procedures: surgical biopsy versus vacuum-assisted biopsy

PurposeThe aim of this study was to compare the costeffectiveness of two breast biopsy procedures: surgical biopsy and vacuum-assisted biopsy (VAB).Materials and methodsBetween November 2008 and September 2009, 200 patients with suspicious breast lesions underwent biopsy procedures at our radiology department: 100 underwent VAB and 100 underwent surgical biopsy. 66 lesions were sampled under sonographic guidance, 109 under mammographic guidance and 25 under magnetic resonance guidance.ResultsAll procedures were successfully completed. No significant differences in diagnostic efficacy were found between the biopsy procedures. Surgical biopsy has a higher unit cost compared with VAB.ConclusionsOur analysis emphasises the benefits of VAB compared with surgical biopsy in terms of both costeffectiveness, and less invasiveness from a psychological and aesthetic point of view.RiassuntoObiettivoScopo del presente lavoro è stato confrontare costi ed efficacia di due sistemi di biopsia mammaria: la biopsia chirurgica e quella vuoto-assistita (VAB).Materiali e metodiPresso il nostro centro, da novembre 2008 a settembre 2009, abbiamo selezionato 200 pazienti con lesioni mammarie sospette da sottoporre a caratterizzazione istologica, che è stata effettuata in 100/200 pazienti mediante prelievo VAB e nelle rimanenti 100/200 pazienti mediante biopsia chirurgica. Con entrambe le modalità bioptiche sono state sottoposte a prelievo 66 lesioni individuate sotto guida ecografica, 109 sotto guida mammografica e 25 reperti evidenziati sotto guida RM.RisultatiTutte le procedure considerate sono state portate a termine con successo. L’efficacia diagnostica dei due sistemi è risultata sovrapponibile. I costi unitari delle singole procedure risultano maggiori per la biopsia chirurgica rispetto alla procedura VAB.ConclusioniL’analisi da noi svolta ha evidenziato i vantaggi delle procedure VAB, rispetto alla biopsia chirurgica, sia in termini di costo-efficacia che in termini di minor invasività estetica e psicologica.

Value of the correct diagnostic pathway through conventional imaging (mammography and ultrasound) in evaluating breast disease

PurposeThis study evaluated the role of the correct diagnostic pathway through conventional imaging in evaluating breast disease.Materials and methodsSix hundred patients aged between 35 and 75 years were enrolled in the study. All patients underwent detailed history and clinical examination, ultrasound (US) and mammography. US scans were repeated after mammography. All suspicious lesions were studied by cytological and histological characterisation and magnetic resonance (MR) imaging.ResultsThe first US scan showed 147 solid lesions, 67 lesions characterised by posterior acoustic shadowing and 193 areas of heterogeneous echostructure. The second US scan, performed after mammography, confirmed 123/147 solid nodular lesions, 53/67 lesions characterised by posterior acoustic shadowing and 183/193 areas of heterogeneous echostructure; it also showed 13 nodular lesions not seen on the first scan and two cases of nodular lesions with irregular calcifications.ConclusionsOur experience suggests that US not performed in conjunction with mammography gives rise to incorrect diagnostic interpretations (either false positive or false negative results). The detection rate of the US scan performed after mammography increases from 4.16% to5.5%.RiassuntoObiettivoScopo del nostro lavoro è stato valutare il ruolo del corretto iter diagnostico nell’imaging convenzionale nello studio della patologia mammaria.Materiali e metodiSono state esaminate 600 pazienti (35–75 anni) sottoposte ad anamnesi, esame clinico, ecografia e mammografia. È stata effettuata successivamente una rivalutazione ecografica, alla luce della mammografia. Tutte le pazienti con lesioni sospette hanno proseguito il loro iter diagnostico mediante esame cito-istologico e/o risonanza magnetica.RisultatiLa prima ecografia ha documentato 147 lesioni nodulari solide, 67 casi di sbarramento del fascio ultrasonoro e 193 aree di disomogeneità ecostrutturale. Il secondo esame ecografico, eseguito successivamente alla mammografia, ha confermato 123/147 lesioni nodulari solide, 53/67 casi di sbarramento del fascio ultrasonoro e 183/193 aree di disomogeneità ecostrutturale. Sono state inoltre individuate 13 ulteriori lesioni nodulari non evidenziate alla preliminare ecografia ed in due casi abbiamo riscontrato la presenza di substrato nella sede del reperto mammografico di microcalcificazioni.ConclusioniDal nostro studio è emerso che l’ecografia effettuata senza la possibilità di riscontro mammografico, ha dato luogo ad erronee interpretazioni diagnostiche intese sia come falsi positivi che come falsi negativi e secondo i nostri dati, qualora eseguita successivamente alla mammografia, ha consentito di incrementare il valore della detection rate dell’indagine ecografica da 4,16% a 5,5%.