Combined image guidance excision of non-palpable breast lesions

When mammogramography detects a non-palpable lesion the surgeons may be called upon to establish a diagnosis. Various techniques are currently employed. We describe a technique, which can be used both for diagnostic and for therapeutic procedures. The technique essentially involves localising the tip of a guide-wire, placed under mammographic guidance, with ultrasound scanning. This minimises many of the problems encountered with wire guided excision. We conducted a prospective non-randomised study using our combined image guidance technique (CIG) for patients undergoing diagnostic (n = 24) and therapeutic biopsy (n = 13). We found that significantly smaller diagnostic biopsy weights were achievable using CIG, compared to non-CIG techniques. Reduced biopsy weights are recommended by current guidelines.     

Importance of early diagnosis in the improvement of prognosis in breast carcinoma: non-palpable lesions. Preliminary results

There are still marked differences in the current indications for breast screening proposed by the various international school of oncology. Epidemiological data to the effect that breast screening in asymptomatic women aged over 50 reduces the death rate due to breast cancer now appears to be widely accepted, but an analogous finding for women aged between 40-49 has not yet been confirmed. Following a brief analysis of the most important breast screening programmes carried out to date, the Authors report the preliminary results regarding the identification and biopsy of non-palpable breast lesions during the course of a screening programme in 1986 by the Dept. of Cancer Surgery. Of a total of 1128 breast scans in asymptomatic patients aged between 40 and 73, 24 suspect (1.9%) non-palpable lesions were found of which 5 (20.8%) proved to be carcinomas.     

Intact乳腺活检系统经皮整块切除非扪及性乳腺病灶的初步研究

目的 研究Intact乳腺活检系统对非扪及性乳腺病灶整块切除活检的有效性和安全性.方法 经医院伦理委员会批准及患者知情同意后,36例非扪及的性质不确定的乳腺病灶患者,用Intact乳腺活检系统行乳腺病灶完整切除活检,并行病理学检查,并观察其切缘.观察患者术中和术后的疼痛评分以及并发症发生情况.结果 36例患者共62个病灶均完整切除,病灶平均大小9.8 mm（2～ 13 mm）.其中46个病灶诊断为乳腺纤维腺瘤,2个病灶为乳腺导管内乳头状瘤,12个病灶为乳腺纤维腺病,1个病灶为良性分叶状肿瘤,1个病灶为浸润性导管癌.所有患者术中、术后疼痛均耐受.1例患者发生术后血肿,保守治疗后治愈,无皮肤灼伤等并发症.结论 Intact乳腺活检系统对于性质不确定的乳腺小病灶是一种安全有效的新的活检方法,并可获得完整的病灶切缘.     

Radioguided excision of non-palpable breast lesions with simultaneous sentinel lymph node biopsy

As a result of mammographic screening nonpalpable breast lesions are found with increasing frequency. The surgical management of these lesions presents two main problems: (1) How to localize the lesion pre- and intraoperatively; (2) What should be the extension of the axillary dissection for malignant lesions. This study is aimed to evaluate the technical feasibility of radioguided excision of nonpalpable breast lesions and the possibility of performing simultaneous sentinel lymph node biopsy for malignant lesions. Radioguided breast excisions have been performed in our Department since November 2000. The basis of this method is that radioisotope labelled colloid is injected into the lesion under stereo tactic or sonographic guidance. A gamma-probe is used intraoperatively to locate the lesion and guide its excision. Dual agent guided technique is used for sentinel lymph node biopsy. Radioguided breast excision was performed on 85 patients (93 lesion) till February 2002. The localization and excision were successful in 84 patients (92 lesions) (99%). Multifocal lesions were successfully localized and excised in 7 patients. There were 61 parenchyma lesions (66%) and 31 microcalcifications (34%). Localization was performed under sonographic guidance in 44 patients (52%) and under stereotactic guidance in 40 patients (48%). There were 25 benign (27%) and 67 malignant (73%) lesions. Second surgical procedure (mastectomy) was needed in 4 patients (6.5%) because of histologically incomplete excision. Sentinel lymph node biopsy was performed in 50 patients. The biopsy was successful in 45 patients (90%). The sentinel lymph node was histologically positive in 2 patients (4.4%). Radioguided localization with the intraoperative use of a gamma-probe is an easy, rapid and highly accurate technique for removing nonpalpable breast lesions and allows simultaneous sentinel lymph node biopsy for malignant lesions.     

导丝定位切除活检诊断不能触及的乳腺癌

目的 评价导丝定位切除活检诊断不能触及的乳腺癌的准确性和有效性.方法 对324例355个钼靶发现的临床不能触及的乳腺病灶进行金属丝定位切除活检.结果 355个活检标本中,107例是乳腺癌,其中54例为导管内癌,53例为浸润性癌.217例为良性,其中纤维囊性增生症99例,其余为纤维腺瘤、导管内乳头状瘤、纤维囊性增生症伴钙化、导管不典型增生、脂肪坏死等.在355次导丝定位中,352次导丝位于病灶周围2cm范围内,未发生严重手术并发症.结论 导丝定位切除活检是一种简单、准确的诊断不能触及的乳腺癌的方法.     

Intra-operative specimen analysis using faxitron microradiography for excision of mammographically suspicious, non-palpable breast lesions

Recent advances in digital imaging have made Faxitron microradiography an attractive alternative to intra-operative conventional specimen radiography (CSR) for the excision of wire-localized breast lesions. Faxitron specimen analysis time, usefulness of digital image manipulation and re-excision rates were evaluated in comparison to CSR in 299 consecutive wire-localized excisions for mammographically suspicious non-palpable breast lesions (172 procedures with Faxitron, 127 with CSR) in a non-randomized study. The corresponding mean operation times were 34.7 vs. 42.7 min and the respective re-excision rates were 19.8% vs. 31.5% (no significant difference on chi analysis P < 0.1). Faxitron digital image manipulation led to cavity biopsies in 50% (60/121) of the cancer excisions. In 19 of these (16%), histological excision margins were converted from incomplete to complete. The shorter Faxitron mean operating time enables an additional wire-localized operation per theatre list. Digital imaging guides the surgeon for additional cavity biopsies, resulting in re-excision rates as good as CSR.     

Incidence of invasive versus non-invasive carcinoma in comparing palpable and non-palpable solid breast lesions

A retrospective study was done of all patients with a suspicious mammographic breast lesion surgically biopsied in our institution within the last 5 years. Incidence of invasive versus non-invasive carcinoma and stage at presentation (according to TNM classification system) of palpable and non-palpable lesions were compared. We found a significant difference of non-invasive carcinoma in non-palpable and palpable cancers: 42.2% versus 4.3% (p < 0.001). Patients with a non-palpable invasive carcinoma presenting at stage I (i.e. pT1 with no axillary metastasis) rated significantly higher compared to those with palpable lesions 51.8% versus 9.4% (p < 0.001). The true positive biopsy rate is 30%. As low as 10% has been considered reasonable. We have a total of 56% carcinomas detected on all biopsies: 30% for non-palpable lesions and 66.8% for palpable lesions. A more aggressive approach towards screening and biopsy of breast lesions might increase early detection of carcinoma and so improve survival.     

Fine-wire localization and biopsy of non-palpable breast lesions

We have undertaken fine-wire localization and biopsy of 130 impalpable breast lesions identified by mammography and considered suspicious of malignancy. Histologically 22 of these lesions were invasive carcinomas and 24 were in situ carcinomas (35 per cent malignant). Twenty-nine per cent of the lesions were identified during the screening of asymptomatic women. In the remainder, the presenting symptoms bore no relation to the eventual histological diagnosis. Clusters of microcalcification were more often malignant than were abnormal soft-tissue masses. Malignancy in the absence of microcalcification was almost always invasive.     

Increase of newly--detected in situ cancers in non-palpable breast lesions

Great importance in detecting cancer in the phase of in situ lays in the fact that the epithelial layer is deprived of blood and lymph vessels, so metastases may develop only when basal membrane has been broken. This paper includes 46 operated women in whom it preoperatively had been verified suspect non-palpable lesion. The preoperative diagnostics included use of high- resolution mammography, aimed mammography, palpatory examination, as well as fine-needle aspiration (FNA), biopsy and cytologic analysis of the sample. The methodology of this work implies the use of stereotaxic marking, specimen mammography and ex-tempore pathohistology analysis. Out of 46 investigated patients in clinical stage T0N0M0, in whom there were no signs of malignant disease, and according to suspect lesion of initial screening mammography, malignant lesions of breast tissue were diagnosed in 19 patients (41%) intraoperatively. Three of these lesions (15,8%) were histopathologically verified as in situ. Comparing our results with data of the Institute of oncology and radiology of Serbia hospital registry (IORS) for the year 2001, from 1173 patients registered with malignant lesions, only 16 ones (1,4%) had in situ cancer, operated on the basis of the suspect mammography of clinical stage T0N0M0. Statistically significant difference was found related to the number of detected cancers in this early phase of the breast malignant disease. This limits surgical intervention to tumorectomy, with preservation of the remaining breast tissue, what brings to healing, justifying in that way, screening examinations and routine application of the most contemporary diagnostic procedures.     

The diagnosis of non-palpable lesions in laparoscopic surgery of the colon

The identification of small neoplasms or areas presenting lesions associated with previous endoscopic polypectomy is one of the major problems in laparoscopic colonic resection. The aim of our study was to evaluate the effectiveness of tattooing with Indian ink to identify the area of the colon that is the site of the lesion in order to be able to perform colonic resections with oncologically correct margins. Eighty-four patients were observed with polypoid lesions or diagnosed as presenting lesions associated with endoscopic polypectomy for which colonic resection had been recommended. Marking was performed during preoperative colonoscopy by injecting 1 ml of Indian ink solution with a sclerotherapy needle into each of the four quadrants of the colon wall. This method, which is simple to execute, invariably allowed easy identification of the site of the neoplasm and laparoscopic colon resection with correct oncological margins. In the 84 cases, we recorded only one complication (1.1%) due to a paucisymptomatic microperforation discovered during the operation. The identification of small colon lesions can be performed easily using Indian ink. It is a simple, quick method which, if performed properly, always allows the site of the lesion to be identified and is associated with a negligible rate of complications.     

超声引导对乳腺隐匿性病灶亚甲蓝多点定位的临床研究

目的 探讨应用超声引导亚甲蓝多点标记,切除触诊阴性乳腺肿物的价值.方法 对66例乳腺隐匿性病灶患者,术前1h在超声引导下,用亚甲蓝对肿物及肿物四周行多点定位注射,然后通过手术准确地切除肿物.术后1个月时,超声复查有无残留或误切.结果 66例患者的78个肿物,均准确切除,无残留和误切.结论 超声引导亚甲蓝多点定位切除乳腺隐匿性病灶,定位准确,操作简单,便于普及和推广.     

直肠癌局部切除术的外科疗效与预后分析

目的 分析局部切除术治疗直肠癌的疗效及影响复发和预后的因素.方法 回顾性分析采用局部切除术治疗的46例中低位直肠癌患者临床资料,并对其预后影响因素进行单因素及多因素分析.结果 46例患者中经肛门局部切除38例,经骶尾部切除8例;术后并发症发生率为10.9%,围手术期病死率为0;局部复发率为17.4%,Tis、T1及T2期病变的局部复发率分别为0,12.0%,33.3%.肿瘤大体类型、肿瘤直径和分化程度与术后局部复发相关.总体5年生存率为83.3%,Tis、T1、T2期5年生存率分别为100%、90.9%、66.7%.单因素分析显示,肿瘤大小、分化程度、术后放化疗、脉管癌栓和局部复发是影响预后的因素.多因素分析显示,局部复发是影响预后的主要因素.结论 早期（Tis、T1期）高中分化癌,病灶直径≤3 cm,无脉管浸润的隆起型直肠癌,局部切除术是有效的治疗方法.T2期及以上的肿瘤应首选根治性手术,不能耐受根治术者或拒行腹壁人工肛门者,可考虑姑息性局部切除术后加行辅助放、化疗.     

SiteSelect: minimally invasive excision of breast lesions

The goal of screening mammograms is to provide early detection of breast cancer. As mammography technology improves, the ability to detect smaller and smaller suspicious lesions is increased. However, as mammography cannot always differentiate between malignant and benign lesions, biopsies are often needed. With the decreasing size of lesions seen on mammography, the size of the biopsy specimen needed for diagnosis also decreases. Thus, a smaller amount of normal breast tissue needs to be removed during a biopsy. For a majority of the small lesions, excision with a small margin of normal breast tissue is sufficient for diagnosis. The SiteSelect procedure utilizes stereotactic guidance to excise completely a tumor that is noted on a mammogram. The procedure can be performed under local anesthesia through a minimal incision (usually 1.5 cm). The SiteSelect™ biopsy procedure completely excises small tumors noted on the mammogram with minimal trauma to the breast tissue and with excellent cosmetic results. It is well tolerated by patients. For tumors requiring only local excision, such as atypical ductal hyperplasia or lobular carcinoma in situ, the SiteSelect procedure may be the only diagnostic procedure required.     

新型冠状病毒肺炎疫情期间乳腺外科运行情况分析

背景与目的:尽管目前国内新型冠状病毒肺炎(COVID-19)疫情得到了有效的控制,但国外病例仍在持续增加,防控形势依然严峻。本研究以陆军军医大学第一附属医院乳腺外科为例,分析总结新型冠状病毒肺炎疫情期间综合性三甲医院乳腺外科运行情况,为疫情期间及后疫情时期安全、高效地开展乳腺外科工作提供有效参考和经验做法。方法:选取自2020年1月31日—2020年2月20日COVID-19流行期间陆军军医大学第一附属医院乳腺甲状腺外科收治的37例乳腺癌患者,对其临床特征、防护手段及治疗效果等病例资料进行回顾性分析。对患者的入院和术前准备、术中防护、术后康复等关键环节,以及医护人员自我防护及心理疏导进行方法总结。对专科治疗及疫情防控的效果进行随访研究。分析在后疫情时期如何提升对潜在传染病风险的认知,结合乳腺外科的诊治特点,从手术指征把握、气溶胶管理和诊室防护等多方面加强疫情防控和职业防护工作。结果:37例乳腺癌患者经排除COVID-19风险后均接受手术治疗,平均手术时间为(152.23±46.19)min,平均术中出血量为(85.23±23.47)mL,无术中输血病例。在37例乳腺癌患者中,有19例患者接受术前6～8周期新辅助治疗,其中7例术后证实为病理学完全缓解。术后2例出现持续发热,经过隔离、监测体温及对症支持治疗后恢复正常,新型冠状病毒核酸检测排除COVID-19感染可能。经跟踪随访,患者及陪护人员均无发热、咳嗽、乏力等COVID-19疑似表现,相关医护人员同样未出现疑似病例,总体防控效果较好。结论:在COVID-19疫情流行期间,在科学防控、竭力避免医患双方感染COVID-19的前提下,可结合当地疫情情况全力为乳腺癌患者提供有效治疗。应继续遵从"科学决策、人文服务"的精神,严格遵循上级下发的各类防控指南和管理规范,并依据实际完成乳腺癌患者的院前排查、术前准备、术中防护、术后康复等必要环节。严格在患者入院前及围手术期各环节遵循疫情防护规范、协调好疫情防控与专科诊治的关系,有利于最大限度地确保乳腺外科手术安全地完成,守护患者及医务人员的健康。     

Mammotome微创旋切术切除乳腺肿块1081例分析

目的探讨超声引导下Mammotome微创旋切术治疗乳腺肿块的方法和效果。方法回顾性分析1081例、1913处乳腺肿块经超声引导下Mammotome微创旋切术治疗后的疗效和随访效果。结果对1081例患者、1913处肿块行Mammotome微创旋切切除术,每处病灶平均用时4分钟,平均旋切组织15次。1063例、1894处（99.01%）为乳腺良性病变,18例、19处（0.99%）为乳腺癌。共发生术中、术后并发症39处。结论Mammotome微创旋切系统是目前临床治疗乳腺良性肿块和诊断早期乳腺癌的有效方法之一。     

Excisional biopsy with wire localisation of non-palpable breast lesions: indications and limitations

Preoperative localisation of non-palpable breast lesions is necessary for excisional biopsies. This can be achieved with methods such as anchor wire, charcoal marking, or radio-guided localisation. The aim of the present study was to evaluate retrospectively our experience with the wire localisation technique. One hundred and eighty-two patients with non-palpable breast lesions (diameter: 0.4-1.5 cm) were operated on under local anaesthesia. Intraoperative X-rays were performed in all cases. No serious perioperative complications occurred. Three patients (2 with postoperative haematomas and 1 with wound infection) underwent conservative therapy. The lesions were benign in 67/182 patients (37%), ductal and/or lobular invasive cancer in 42 (23%), carcinoma in situ in 23 patients (12.5%) and ADH-ALH in 50 patients (27.5%). Our experience confirms that wire localisation biopsies constitute an excellent method for the excision of non-palpable breast lesions. This technique is characterised by high reliability (100% total excisions) and assures a prognostic evaluation of high-risk lesions such as ductal an/or lobular atypical hyperplasia.     

Residual tumour after biopsy for non-palpable ductal carcinoma in situ of the breast

In a group of 40 patients with non-palpable ductal carcinoma in situ (DCIS) of the breast, 41 breast specimens were available for studying residual tumour after biopsy. In one group of ten patients seen before 1977, simple histological examination revealed a 9 per cent incidence of residual tumour. However, after thorough examination residual foci of DCIS were found in 77 per cent of a subsequent group of 30 patients. This means that the majority of patients would have had to undergo reoperation if a breast-saving procedure had been performed. This fact must be taken into account when planning treatment of patients with non-palpable DCIS.     

Precursor lesions of breast carcinoma

Precursors of invasive breast cancer are discussed. Evidence is presented to suggest that both carcinomas of tubular and tubuloductal (tubular variant) type originate in radial scars.