Improving B mode ultrasound evaluation of breast lesions with real-time ultrasound elastography--a clinical approach

Ultrasound elastography using the extended combined auto-correlation method of tissue elasticity allows for real-time strain image visualisation using a free-hand probe with concurrent conventional B mode imaging. Four hundred and fifteen consecutive women with 550 breast lesions confirmed on B mode ultrasound were assessed with elastography using the elasticity score. There were 119 malignant and 431 benign lesions. The elastography sensitivity was 78.0%, specificity was 98.5% and overall accuracy was 93.8%. The median score for malignancy was 5 and that for benign lesions was 2. There was good correlation with B mode BIRADS category. 98.6% of lesions with an elasticity score of 2 or below (95%CI=96.8-99.4) were benign. BIRADS 3 lesions with an elasticity score of 2 or below may be re-classified as BIRADS 2 lesions. We found that 15.3% of BIRADS 2 and 3 lesions with an elasticity score of 3 were malignant. Real-time ultrasound elastography is user-friendly with a high accuracy rate, thereby improving B mode ultrasound assessment.     

The effectiveness of digital infrared thermographic imaging in patients with shoulder impingement syndrome

We prospectively evaluated 100 patients with unilateral impingement syndrome, before they underwent an arthroscopic subacromial decompression, to detect the relationship between clinical and operative findings and digital infrared thermographic imaging (DITI) findings in patients with shoulder impingement syndrome. The DITI system was used to measure the temperature of each patient's upper body, and the relative temperature values between involved and the uninvolved sides were used for analysis. A control group of 30 subjects without impingement syndrome was also evaluated. In DITI findings, 73% of patients had abnormal thermal changes in more than 1 of the 4 regions of interest: 51% displayed hypothermia, and 22% had hyperthermia. In the hypothermic group, limitation of shoulder motion was more prominent than in the hyperthermic and normal groups (P < .05). Other clinical findings did not correlate with the DITI findings, however. DITI can be used to reflect shoulder stiffness objectively in impingement syndrome, especially in those cases with a hypothermic thermal pattern.     

A single-institution study of 117 pregnancy-associated breast cancers (PABC): Presentation,imaging, clinicopathological data and outcome

BackgroundThis retrospective single-institution study was designed to describe the main clinical, radiological and histological features, as well as the outcome of pregnancy-associated breast cancer (PABC), with a special emphasis on imaging and diagnostic difficulties.Material and methodsWe reviewed all breast cancers diagnosed during pregnancy or during the 12 months following delivery at our institution, between 1993 and 2009. Out of a total of 16,555 new cases of breast cancer observed during this period, 117 PABC (0.7%) were diagnosed.ResultsMean age at diagnosis was 33.7 years. Most cancers (81.2%) were diagnosed after delivery. Intermediate or high family risk was frequent (27.5%). The most common mode of presentation was a palpable mass (89.7%). Mean time to diagnosis was 5.8 months. Sensitivity for mammography was 80.9% and for ultrasound 77%. Most prognostic factors were unfavourable: frequent lymph node involvement (51.8%), high-grade tumours, hormone receptor negativity (45.9%) and HER2 positivity (38.7%). Treatments generally included surgery (61.7% mastectomies), radiotherapy (96%) and chemotherapy (79.6%). Overall 5-year survival was 81.8%.ConclusionPABC is an uncommon but aggressive form of breast cancer and must be considered in the presence of any breast abnormality during pregnancy or the months following delivery. Mammography and ultrasound should both be performed at the slightest clinical suspicion. Radiologists must be aware that masses may lack typical malignant ultrasound characteristics. Biopsies should be largely performed.     

Impact of Oncotype DX on Treatment Decisions in ER‐Positive,Node‐Negative Breast Cancer with Histologic Correlation

Oncotype DX, a gene‐expression profiling assay, provides stratification of patients with estrogen‐receptor positive, lymph‐node‐negative early breast cancer into risk groups based on recurrence score, which are associated with distant recurrence and response to chemotherapy. This study aims to determine whether Oncotype DX influences clinicians' treatment decisions, and whether assay results correlate with histologic assessment. Fifty patients with estrogen‐receptor positive, node‐negative early breast cancer analyzed by Oncotype DX and operated on by two breast surgeons were included. To assess effect on treatment decisions, clinical vignettes were created by retrospective chart review. Physicians were then presented with the clinical vignettes and instructed to make a treatment decisions (i.e., hormone therapy alone versus hormone therapy combined with chemotherapy) both before and after knowledge of the recurrence score. To assess correlation with histologic assessment, a prospective, blinded review of tumor slides was performed by two pathologists. Based on this review, tumors were placed into low, intermediate and high risk groups for comparison with Oncotype DX assay results. Treatment decisions were changed based on Oncotype DX results in 36 and 18% of cases by breast surgeons and medical oncologists, respectively. All tumors categorized as high risk by Oncotype DX were categorized as high risk based on histologic assessment, and 96% of cases categorized as low risk by recurrence score were categorized as low or intermediate risk by histologic assessment. Oncotype DX significantly influences management of estrogen‐receptor positive, lymph‐node‐negative early breast cancer. Further studies are needed to assess association of histologic categorization to assay results.     

Sonobreast: predicting individualized probabilities of malignancy in solid breast masses with echographic expression

To create an individualized predictive tool for the risk of malignancy in solid breast masses, based on echographic and clinical characteristics. Research Ethics Committee approval and informed consent were obtained. This multi-center study included 1,403 solid breast masses prospectively. Each ultrasound feature was analyzed and compared with the definitive diagnosis. The ultrasound results, women's ages and family histories of breast cancer were included in a multivariate logistic regression model. Among the 1,403 lesions included in the study, 1,390 (99.1%) had a conclusive diagnosis: 343 malignant tumors (24.7%), and 1,047 benign masses (75.3%). The odds ratio (and confidence interval) for breast malignancy for each variable included in the model, as calculated by multivariate analysis, were as follows: irregular shape/noncircumscribed margins, 16.02 (7.75-33.09); heterogeneous echo texture, 4.50 (2.42-8.23); vertical orientation (not parallel to the skin), 2.23 (1.04-4.75); anterior echogenic rim, 2.62 (1.09-6.31); posterior shadowing, 2.38 (1.23-4.62); age more than 40 years, 2.19 (1.26-3.81); positive first-degree family history (mother, sister or daughter), 7.50 (2.65-21.18). There was no advantage in including the presence of internal vascularity, presence of thickened Cooper's ligaments or size of the mass, in the model. The predictive tool was named SONOBREAST and it is freely available for medical purposes on the internet site: http://www.sonobreast.com. The probability of malignancy in breast masses can be specified based on their ultrasound features, the woman's age and the family history of breast cancer.     

Utility of screening tools for the prediction of low bone mass in African American men

Introduction Osteoporosis remains under-diagnosed, particularly in African American men, despite the availability of reliable diagnostic tests. In women, several screening tools, including heel ultrasound and clinical assessment tools, reliably predict low bone mass, however the usefulness of these screening tools in African American men is unknown. The aim of this study was to determine the utility of screening tools, namely heel ultrasound, the osteoporosis self-assessment tool (OST), weight-based criterion (WBC) and body mass index (BMI), in screening for low bone mass in African American men. Materials and methods African American men 35 years of age and older were invited to participate. The OST risk index is a score based on age and weight [(weight in kilograms – age in years) × 0.2]. Bone mineral density (BMD) of the heel was measured by heel ultrasound, and BMD of both the lumbar spine and hip were determined by dual energy X-ray absorptometry (DXA). One hundred and twenty-eight men fulfilled the inclusion criteria for our study. Results The population prevalence of osteopenia and osteoporosis were 39% and 7%, respectively. Using a heel ultrasound T-score cut-off value of −1 or less, we predicted low bone mass (T-score of −2 or less at the hip) with a sensitivity of 83%, a specificity of 71% and an area under the curve (AUC) of 0.80. Using an OST cut-off value of 4, we predicted low bone mass with a sensitivity of 83%, a specificity of 57% and an AUC of 0.83. The OST risk index ranged from 18.1 to −6.1, based on which we categorized risk as: low, 5 or greater; moderate, 0–4; high, −1 or less. Of the men with a high-risk OST score, 87% had either osteopenia or osteoporosis based on World Health Organization (WHO) criteria. Using the WBC alone with a cut-off value of 85 kg, we predicted low bone mass with a sensitivity of 74%, a specificity of 50% and an AUC of 0.70. A BMI cut-off value of 30 or greater yielded a sensitivity of 83%, a specificity of 43% and an AUC of 0.70 for the diagnosis of low bone mass. Discussion The prevalence of osteopenia and osteoporosis were unexpectedly high in outpatient African American male veterans, who are considered to be at low risk for low bone mass. Heel ultrasound was able to predict low bone mass with sufficiently high sensitivity and specificity for use as a screening tool. Surprisingly, WBC and BMI proved ineffective in predicting low bone mass with adequate sensitivity and specificity. The OST, a clinical formula based on weight and age, appeared to be an easy and reliable screening tool for identifying men at high risk for low bone mass.     

Combination of a clinical risk assessment score and rapid whole blood D-dimer testing in the diagnosis of deep vein thrombosis in symptomatic patients.

PURPOSE: The clinical diagnosis of deep vein thrombosis (DVT) is unreliable in more than 50% of cases, and, in recent years, plasma D-dimer assays have been used to predict the presence of DVT with high sensitivity and negative predictive values. This study investigated the use of a rapid whole blood test that could be performed and interpreted by the bedside in addition to a clinically derived risk assessment score (RAS) to determine whether a practical and cost-effective clinical model could be developed for the diagnosis and exclusion of DVT in symptomatic patients. METHODS: Two hundred consecutive patients who were referred to the vascular laboratory with clinically suspected DVT underwent the following procedures: (1) clinical assessment and stratification into low, moderate, or high risk for DVT on the basis of an RAS related to history, symptoms, and physical examination findings; (2) rapid (5-minute) whole blood D-dimer testing with a semi-qualitative agglutination technique on a fingerprick blood sample; and (3) color flow duplex ultrasound scanning with standard criteria for the diagnosis of proximal and calf DVT. RESULTS: Forty-six patients (23%) had acute DVT on duplex ultrasound scanning. Of these cases, 28 (61%) had proximal DVT and 18 (39%) were confined to the calf. A total of 88 patients were classified as low risk, 67 were classified as moderate, and 45 were classified as high risk on the basis of the RAS method. Of the patients who were classified at low risk, 4.5% (4/88) had DVT, as compared with 17.9% (12/67) in the moderate clinical risk group and 66.7% (30/45) in the high risk group. Isolated calf DVT was found in 30% (9/30), 50% (6/12), and 75% (3/4) of the high, moderate, and low risk groups, respectively. The sensitivity (8.7%, 26.1%, 65.2%), specificity (45.5%, 64.3%, 90.3%), positive predictive value (4.5%, 17.9%, 66.7%), and overall accuracy rate (37%, 55.5%, 84.5%) of the low, moderate, and high risk groups, respectively, in the diagnosis of DVT increased significantly with increasing risk score stratification. The sensitivity, specificity, positive and negative predictive value, and overall accuracy of the rapid D-dimer test for all DVT were 91.3%, 81.9%, 60%, 96.9%, and 84%, respectively, with a 100% sensitivity and negative predictive value for proximal DVT. A combination of the RAS and D-dimer identified a low risk group with a negative D-dimer as having less than a 1% likelihood of DVT and a high risk group with positive D-dimer as having a likelihood of more than 90%. CONCLUSION: A combination of clinical assessment and rapid D-dimer testing provides an effective means of excluding proximal DVT in symptomatic patients. The application of a clinical diagnostic model on the basis of these parameters has the potential for saving a large proportion of unnecessary duplex scans with the associated time and costs.     

Review of complex breast cysts: implications for cancer detection and clinical practice

The use of ultrasound in breast diagnosis has resulted in the increasing identification of incidental benign-appearing lesions, of which complex (or atypical) breast cysts are frequently reported. Complex breast cysts were estimated to be reported in approximately 5% of breast ultrasound examinations. A systematic review of the literature on sonographically detected complex breast cysts was carried out. The quality of primary studies and extracted data on cancer detection was assessed. Very few studies have examined complex breast cysts and quantified the associated cancer detection rate. In most of these studies, subjects have been selected on the basis of progress to intervention, which would overestimate the likelihood of malignancy. The only study to examine complex cysts from all consecutive ultrasounds reported one case of non-invasive cancer from 308 lesions--0.3% (95% confidence interval, 0.01-1.84). Ultrasound features associated with a higher risk of the lesion being a cancer are: thickened walls, thick internal septations, a mix of cystic and solid components, and an imaging classification of indeterminate. Using the information from the present review, complex breast cysts were categorized on the basis of associated risk of malignancy, and an approach to the management of these lesions to assist clinical decision-making was suggested. Provided adequate information is given to the patient, complex breast cysts with a very low risk of malignancy do not always require image-guided biopsy.     

The Connecticut Experiments Second Year: Ultrasound in the Screening of Women with Dense Breasts

To determine if the addition of screening breast ultrasound in women with mammographically normal but dense breasts improves breast cancer detection. The study utilized a retrospective chart review. Data collected included: (a) total number of screening mammograms; (b) total number of dense breast screening ultrasounds; (c) screening ultrasound Breast Imaging Reporting Data System (BI‐RADS) code results; (d) biopsy results; and (e) demographic data on women with malignant biopsies. Data were obtained from sites throughout Connecticut from November 1, 2010 to October 31, 2011. Data from 5 Connecticut radiology practices covering 10 sites were collected. Sites conducted a total of 57,417 screening mammograms and 10,282 dense breast screening ultrasounds. Of the screening ultrasounds, 87% (8,972/10,282) were BI‐RADS 1 or 2, 9% (875/10,282) were BI‐RADS 3, 4% (435/10,282) were BI‐RADS 4 or 5, and 39 were found to have a cancer or high‐risk lesion on biopsy. This correlates to 3.8 cancers or high‐risk lesions per 1,000 women screened. If high‐risk lesions are excluded, there are 24 cases of biopsy proven malignancy corresponding to 2.3 cancers per 1,000 women screened. In this study, screening breast ultrasound in women with mammographically normal but dense breasts demonstrated a positive predictive value of 9% (39/435) and specificity of 96% (8,972/9,368). Based on the data collected from sites throughout Connecticut, screening breast ultrasound in women with dense breast parenchyma detects mammographically occult malignancy and high‐risk lesions. The results are especially significant given recent studies suggesting that breast density is an independent risk factor for breast cancer and that mammography is less effective in detecting cancer in dense breasts. The improved specificity and sensitivity between the 1st and 2nd years’ suggests there is a learning curve that may continue to improve the results.     

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??Value analysis of different clinical and imaging features in the diagnosis of benign and malignant nipple discharge HUANG Jia-hui??CHEN Xiao-song, WU Jia-yi, et al. Comprehensive Breast Health Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
Corresponding author: SHEN Kun-wei, E-mail: kwshen@medmail.com.cn
Abstract Objective To analyze the value of different clinical and imaging features in the diagnosis of benign and malignant nipple discharge. Methods The clinical data of 233 patients treated with surgery for nipple discharge from January 2011 to February 2016 in Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine were analyzed retrospectively. A total of 233 cases without palpable mass were enrolled in the analysis. Thirty-three patients (14.2%) were diagnosed as breast cancer, and the other 200 patients (85.8%) were diagnosed as benign disease. The sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV) of mammogram, ultrasound, MRI and their combination in predicting malignant disease were calculated. Results Patients with bloody nipple discharge (P=0.008), with suspicious calcification on mammography (P<0.001)??with segmental enhancement (P=0.003) or with washout-pattern kinetic curve (P=0.023) on MRI had higher risk of breast cancer. The sensitivity of mammography in diagnosing breast cancer was 57.6%, significantly lower than that of ultrasound (87.9%,P=0.012) and MRI (93.9%??P=0.001). The sensitivity of mammography combined with ultrasound or with MRI was 90.9% and 100% respectively, significantly higher than that of mammography alone (P=0.004, P<0.001) .Conclusion Bloody nipple discharge, with suspicious calcification on mammography, with segmental or with washout-pattern kinetic curve on MRI are risk factors for predicting breast cancer in patients with nipple discharge without palpable disease. The sensitivity of breast cancer can be elevated with ultrasound or MRI comparing with mammography alone.     

Follow-up recommendations for benign breast biopsies

Histologically proven benign breast disease increases a woman's relative risk for subsequent cancer development. Yet follow-up guidelines for mammogram and clinical breast examination after a benign breast biopsy are lacking. Our objective was to determine if increased surveillance is indicated following a benign breast biopsy. Following institutional review board approval, a retrospective database review was conducted of prospectively gathered patients who had a benign breast biopsy (core or excisional) for an abnormality detected on mammogram, ultrasound, or clinical breast examination. Follow-up, for all subjects, was a clinical breast examination and mammogram or ultrasound at 6 months, 1 year, and 2 years after benign breast biopsy by a breast surgeon. End points were the need for additional biopsies or cancer detection. Statistical analysis was performed using chi-squared analysis. From January 2000 to July 2003, 156 patients age 18-86 years had a benign breast biopsy. During the 2 year follow-up, 20 patients (13%) required a subsequent biopsy. No significant difference was observed in mean age, race, menarche, menopause, parity, age at first live birth, use of oral contraceptives, history of prior biopsy, or the pathology of the initial lesion between those who needed a subsequent biopsy and those who did not. Seven excisional biopsies were performed (one at 6 months, four at 1 year, and two at 2 years follow-up) for growth of the benign breast biopsy lesion, and pathology remained concordant with the original diagnosis. Thirteen biopsies were done for new findings on mammogram or ultrasound. Three of these (1.9%) yielded a cancer diagnosis (one at 6 months, one at 1 year, and one at 2 years follow-up). No new lesions were identified on follow-up by clinical breast examination alone. Increased surveillance following a benign breast biopsy is necessary because of the increased need for subsequent biopsy or risk of cancer development. This should include imaging (mammography or ultrasound) and a clinical breast examination 6 months, 1 year, and 2 years after a benign breast biopsy.     

Ultrasound mammography in the management of breast cancer

In this centre, ultrasound mammography has been shown to be more accurate in elucidating the nature of palpable breast lesions than X-ray mammography. A prospective study was devised to determine whether this accuracy could be translated into improved management of patients with breast carcinoma. A total of 223 patients with palpable breast masses were assessed by clinical examination, imaging (X-ray and ultrasound mammography) and aspiration cytology. Each was scored on a five-point scale and treatment was planned according to the total score. According to the protocol, an adequate total score would permit definitive surgery avoiding frozen section. By using sonography rather than radiology, the number of correct diagnoses could be improved by 25 per cent. This was because the greater sensitivity of ultrasound (92.8 per cent) compared to X-ray mammography (82.5 per cent) was reflected in a higher total score, which was sufficient to allow definitive surgical treatment without prior histological confirmation of diagnosis.     

Screening Magnetic Resonance Imaging Recommendations and Outcomes in Patients at High Risk for Breast Cancer

The purpose of this study was to determine magnetic resonance imaging (MRI) screening recommendations and the subsequent outcomes in women with increased risk for breast cancer evaluated by oncology subspecialists at an academic center. Patients evaluated between 1/1/2007 and 3/1/2011 under diagnosis codes for family history of breast or ovarian cancer, genetic syndromes, lobular carcinoma in situ or atypical hyperplasia were included. Patients with a history of breast cancer were excluded. Retrospective review of prospectively acquired demographics, lifetime risk of breast cancer, and screening recommendations were obtained from the medical record. Retrospective review of the results of prospectively interpreted breast imaging examinations and image‐guided biopsies were analyzed. 282 women were included. The majority of patients were premenopausal with a median age of 43. Most (69%) were referred due to a family history of breast or ovarian cancers. MRI was recommended for 84% of patients based on a documented lifetime risk >20%. Most women referred for MRI screening (88%) were compliant with this recommendation. A total of 299 breast MRI examinations were performed in 146 patients. Biopsy was performed for 32 (11%) exams and 10 cancers were detected for a positive predictive value (PPV) of 31% (based on biopsy performed) and an overall per exam cancer yield of 3.3%. Three cancers were detected in patients who did not undergo screening MRI. The 13 cancers were Stage 0–II; all patients were without evidence of disease with a median follow‐up of 22 months. In a cohort of women seen by breast subspecialty providers, screening breast MRI was recommended according to guidelines, and used primarily in premenopausal women with a family history or genetic predisposition to breast cancer. Adherence to MRI screening recommendations was high and cancer yield from breast MRI was similar to that in clinical trials.     

Arzoxifene for prevention of fractures and invasive breast cancer in postmenopausal women

Arzoxifene is a selective estrogen receptor modulator (SERM) that has been shown to be more potent in preclinical testing than currently available agents. Its effects on clinical outcomes are not known. In a randomized, blinded trial, women aged 60 to 85 years with osteoporosis, defined as a femoral neck or lumbar spine bone mineral density T‐score of ?2.5 or less or a vertebral fracture, and women with low bone mass, defined as a bone density T‐score of ?1.0 or less and above ?2.5, were assigned to arzoxifene 20 mg or placebo daily. The primary endpoints were new vertebral fracture in those with osteoporosis and invasive breast cancer in the overall population. After 3 years, the cumulative incidence of vertebral fractures in patients with osteoporosis was 2.3% lower in the arzoxifene group than in the placebo group, a 41% relative risk reduction [95% confidence interval (CI) 0.45–0.77, p < .001]. In the overall population, the cumulative incidence of invasive breast cancer over 4 years was reduced by 1.3%, with a 56% relative reduction in risk (hazard ratio = 0.44, 95% CI 0.26–0.76, p < .001); there was no significant decrease in nonvertebral fracture risk. Arzoxifene increased the cumulative incidence of venous thromboembolic events by 0.7%, with a 2.3‐fold relative increase (95% CI 1.5–3.7). Like other SERMs, arzoxifene decreased vertebral fractures and invasive breast cancer while the risk of venous thromboembolic events increased. © 2011 American Society for Bone and Mineral Research.     

Bilateral synchronous breast cancer: mode of detection and comparison of histologic features between the 2 breasts

BACKGROUND: Bilateral synchronous breast cancer is uncommon (accounting for 1.0%-2.6% of all patients with breast cancer), and most physicians do not accumulate a large personal experience of patients with this disease. We reviewed our experience with patients with bilateral synchronous breast cancer, focusing on the mode of detection and histologic features in the 2 breasts. METHODS: The charts of patients who were treated at this institution for bilateral synchronous breast cancer during the 15-year period of 1984 through 1999 were reviewed. Information regarding age, mode of detection, histopathologic features, treatment, and overall survival were analyzed. RESULTS: During the study period, 51 patients (all women) were treated at our institution for bilateral synchronous breast cancer. This comprised 2.1% of all patients (n = 2382 patients) treated for breast cancer during the same period of time. The first cancer was detected by palpation in 81% and by mammography in 14%. The corresponding figures for the contralateral cancer were 24% and 54%, respectively. The histologic type of cancer was identical in the 2 breasts in 29 patients (57%) and was different between the 2 breasts in 22 patients (43%). The overall 10-year survival rate was 63%. CONCLUSIONS: Bilateral synchronous breast cancer is often detected by mammography and is frequently of the same histologic type as the index cancer. A better awareness of the risk for this disease may help detect bilateral breast cancer earlier.     

The significance of at-risk factors in ultrasound surveillance of developmental dysplasia of the hip. A ten-year prospective study

Of the 34,723 infants born between 1 June 1992 and 31 May 2002, the hips of 2578 with clinical instability or at-risk factors for developmental dysplasia of the hip were imaged by ultrasound. Instability of the hip was present in 77 patients, of whom only 24 (31.2%) had an associated risk factor. From the 'at-risk' groups, the overall risk of type-III dysplasia, instability and irreducibility was 1:15 when family history, 1:27 when breech delivery and 1:33 when foot deformity were considered as risk factors. Of those hips which were ultrasonographically stable, 88 had type-III dysplasia. A national programme of selective ultrasound screening of at-risk factors for the diagnosis of hip dislocation or instability alone cannot be recommended because of its low predictive value (1:88). However, the incidence of type-III dysplasia and hip dislocation or dislocatability in the groups with clinical instability, family history, breech position and possibly postural foot deformity as risk factors could justify a programme of selective ultrasound imaging.     

The role of pre-operative B mode ultrasound in the evaluation of the axillary lymph node metastases in the initial staging of breast carcinoma

The lymph node status of a breast cancer is one of the main prognostic criterias. This status is very important to determine the therapeutic approach. Physical examination alone is not sufficient to assess axillary metastases. Mammographic examination can give us an idea about breast cancer and axillary involvement. Ultrasonographic evaluation can improve the sensitivity of clinical and mammographic examination in assessing axillary lymph node status. 42 patients operated on for breast cancer between January 2000-January 2003 were included in this prospective study. In the study, we used axillary B mode ultrasound to evaluate the axillary lymph nodes. There are several sonographic features to categorize them. Axillary B mode ultrasound was performed to evaluate the axillary lymph nodes for metastatic involvement. In the evaluation of lymph nodes, the sonographic criteria were centric echogenity, thickening of cortex, length/width ratio (L/W) and the diameter of lymph nodes. Hyperechogenic hilus was accepted as a benign finding. The thickening of the cortex less than 50% of the thickening of the centric echogenic hilus was also accepted as a benign finding. L/W ratio below 2 and parameters above 2 cm were accepted as malignant findings. 168 lymph nodes in 42 patients were evaluated pre-operatively with axillary B mode ultrasound. As a result, these lymph nodes were defined as benign in 19 patients (45.2%) and malignant in 23 patients (54.8%). Axillary lymph node status was found as benign in 18 patients (42.9%) and malignant in 24 patients (57.1%) pathologically . Comparative results of ultrasound and axillary lymph node status can be seen on Table III. As a result, the sensitivity of axillary B mode ultrasound to show the metastases was found as 79.1%, specificity was 77.7%, positive predictive value 82.6% and negative predictive value 73.6%. We think some better results may be obtained in the future and these developments may affect the surgeon's decisions concerning axillary dissection for breast cancer operations.     

Preoperative predictors of survival after resection of small hepatocellular carcinomas

OBJECTIVE: To determine preoperative predictors of survival that can guide the choice of treatment for patients with small hepatocellular cancers (HCCs). SUMMARY BACKGROUND DATA: The treatment of patients with small (相似文献   

Intraoperative breast problem--focused sonography a valuable tool in the training of surgical residents

INTRODUCTION: In surgical residency education, "hands-on" learning is important in the operating room. Mastering the interpretation of preoperative data is a must for intraoperative decisions. Because preoperative evaluations of breast masses by ultrasound are performed and interpreted in the Department of Radiology, our study aimed to assess and improve surgical residents' ability to perform ultrasound and to interpret their results before performing breast mass biopsies. METHODS: Between January 2000 and May 2007, 128 female patients found to have palpable breast masses were scheduled for biopsy. An on-table ultrasound was performed by a surgical resident under the supervision of an attending surgeon. The resident was unaware of the result reported by the Department of Radiology. The parameters used to evaluate on-table ultrasound were the echogenicity, diameter (transverse vs vertical), and margins (regular vs irregular) of patients' lesions. Based on these criteria, residents classified lesions as benign, malignant, or indeterminate. The results were compared with the preoperative ultrasound evaluations provided by the Department of Radiology and pathology reports. RESULTS: Eliminating the 10 indeterminate lesions on ultrasound, the residents found that 87 lesions were benign and 31 lesions were malignant. The residents' assessment of the breast lumps had a sensitivity of 90.32% and a specificity of 96.55%, with a positive predictive value of 90.32% and a negative predictive value of 96.55%. CONCLUSIONS: The residents' overall accuracy of 94.91% approximates that of the radiologists in differentiating between benign and malignant lesions. The study allowed us to assess the knowledge and skills of residents who responded as required by Accreditation Council for Graduate Medical Education core competencies.