Ultrasound-guided 8-Gauge vacuum-assisted excision for selected B3 breast lesions: a preliminary experience

PURPOSE

Nowadays, surgical excision is no longer justified for all B3 lesions and a minimally-invasive therapeutic treatment has been encouraged. The aim of this study was to evaluate the feasibility and the therapeutic efficacy of ultrasound-guided vacuum-assisted excision (US-VAE) for the treatment of selected breast lesions of uncertain malignant potential (B3).

MATERIAL AND METHODS

From July 2018 to December 2019, 11/48 breast lesions classified as B3 after ultrasound-guided core needle biopsy were treated with US-VAE in our Institution. Inclusion criteria were: B3 nodules ultrasonographically detectable for which VAE is recommended by international guidelines², size ranging between 5 and 25 mm, circumscribed margins, and lesion position at least 5 mm from the skin and the nipple. A radiological follow-up to evaluate the completeness of excision, the presence of post-procedural hematoma or of residual disease/recurrence was performed after 10 and 30 days and 6 and 12 months. 12-month ultrasound was considered the gold standard. All patients were asked to complete a satisfaction survey and a full assessment of the costs of US-VAE was performed.

RESULTS

Complete excision was achieved in 81.8% of US-VAE. No lesions were upgraded to carcinoma and no patients had to undergo surgery. No complications occurred during or after US-VAE. All patients were satisfied with the procedure and the cosmetic result (100%). US-VAE cost approximately 422 Euros per procedure.

CONCLUSION

US-VAE has proven to be an optimal tool for the therapeutic excision of selected B3 lesions, with high success rate, good patient compliance and considerable money savings compared to surgery. This technique has the potential to reduce unnecessary surgery and healthcare costs.

Gadoteridol-enhanced MRI of the breast: can contrast agent injection rate impact background parenchymal enhancement?

BACKGROUND

Normal background parenchymal enhancement (BPE) is a dynamic parameter affected by multiple factors.

PURPOSE

To determine whether contrast agent injection rate affects the degree of BPE in women undergoing breast magnetic resonance imaging (MRI).

MATERIAL AND METHODS

A total of 85 patients included in our prospective study randomly received 0.1 mmol/kg gadoteridol at a rate of 3 mL/s (group A; n = 46) or 2 mL/s (group B; n = 39). Breast MRI was performed at 3T using a standard protocol including postcontrast axial 3D GRE T1-weighted sequences. Two expert breast radiologists, blinded to clinical and radiological information, independently quantified BPE on early postcontrast subtracted images, assigning a score of 1-4. Mean comparison and regression analysis were performed to assess the influence of injection rate on BPE.

RESULTS

Groups were homogeneous in terms of age and final BI-RADS score. The mean BPE score was significantly lower among patients in group A (mean of two readers: 1.36 vs. 1.90; P < 0.01) with 70%-72% of patients assigned a BPE score of 1, compared with 36%-38% of patients in group B. Lower BPE scores were noted with the higher flow rate in subgroup analyses of both pre- and postmenopausal women, although the effect was more evident in premenopausal women. Regression analysis confirmed that the likelihood of a BPE 1 score was significantly increased with a higher flow rate (P < 0.01). The inter-reader agreement was excellent (0.83).

CONCLUSION

A higher contrast agent injection flow rate (3 mL/s) during breast MRI significantly reduces the degree of BPE, potentially allowing improved diagnostic accuracy by reducing false-positive and false-negative findings.

Nipple discharge: The state of the art

Over 80% of females experience nipple discharge during their life. Differently from lactational (milk production) and physiological (white, green, or yellow), which are usually bilateral and involving multiple ducts, pathologic nipple discharge (PND) is a spontaneous commonly single-duct and unilateral, clear, serous, or bloody secretion. Mostly caused by intraductal papilloma(s) or ductal ectasia, in 5-33% of cases is due to an underlying malignancy. After clinical history and physical examination, mammography is the first step after 39, but its sensitivity is low (7-26%). Ultrasound shows higher sensitivity (63-100%). Nipple discharge cytology is limited by a false negative rate over 50%. Galactography is an invasive technique that may cause discomfort and pain; it can be performed only when the duct discharge is demonstrated at the time of the study, with incomplete/failed examination rate up to 15% and a difficult differentiation between malignant and benign lesions. Ductoscopy, performed under local anesthesia in outpatients, provides a direct visualization of intraductal lesions, allowing for directed excision and facilitating a targeted surgery. Its sensitivity reaches 94%; however, it is available in only few centers and most clinicians are unfamiliar with its use. PND has recently emerged as a new indication for contrast-enhanced breast MRI, showing sensitivity superior to galactography, with an overall sensitivity up to 96%, also allowing tailored surgery. Surgery no longer can be considered the standard approach to PND. We propose a state-of-the art flowchart for the management of nipple discharge, including ductoscopy and breast MRI as best options.

A giant hemorragic adrenal pseudocyst: contrast-enhanced examination (CEUS) and computed tomography (CT) features

INTRODUCTION

Adrenal pseudocysts are rare cystic masses that arise from the adrenal gland and which are usually non-functional and asymptomatic. We report a rare case of a giant hemorrhagic adrenal pseudocyst presenting with abdominal pain and we discussed the radiological features.

PRESENTATION OF CASE

A 75 year old man was admitted with acute abdominal pain post mild-trauma. Computed tomography (CT) of abdomen revealed a hemorrhagic mass measuring 18 cm located in the right suprarenal region, displacing the right kidney and liver. He subsequently underwent to contrast enhancement ultrasound (CEUS), which showed features suggestive for hemorrhagic adrenal pseudocyst. A complete endocrine working didn't show any hormonal hypersecretion. The patient underwent laparotomy and right adrenal mass was excised. Histological examination revealed giant hemorrhagic adrenal pseudocyst. The abdominal pain resolved after surgery.

CONCLUSIONS

to the best our knowledge, this is the first case studied with CEUS reported in the literature.

Ultrasound evaluation of liver fibrosis: preliminary experience with acoustic structure quantification (ASQ) software

PURPOSE

The aim of our study was to assess the diagnostic accuracy of acoustic structure quantification (ASQ) ultrasound software in estimating the degree of hepatic fibrosis compared to Fibroscan and liver biopsy.

MATERIALS AND METHODS

Seventy-seven patients with chronic viral hepatitis B and C underwent standard ultrasound examination, ASQ, Fibroscan and liver biopsy. ASQ analysis was conducted by placing a single region of interest (ROI) on each image captured, and calculating mode, average and standard deviation. The sonographic technique was developed through a preliminary evaluation of 20 healthy volunteers.

RESULTS

The area under the receiver operating characteristic (AUROC) curve for the diagnosis of cirrhosis (F≥4) with ASQ was 0.77, whereas for the diagnosis of any degree of fibrosis (F≥1) it was 0.71. The AUROC for the diagnosis of cirrhosis (F≥4) with Fibroscan was 0.98, while for the diagnosis of any degree of fibrosis (F≥1) it was 0.94. The difference between the AUROC was statistically significant (p<0.05).

CONCLUSIONS

ASQ is a promising new ultrasound software programme which offers encouraging results in the diagnosis of both liver cirrhosis (F=4) and fibrosis (F≥1). However, to date it has not attained the same level of diagnostic performance as Fibroscan.

Adrenomedullin immunoreactivity tissue distribution in parathyroids of the patients with primary hyperparathyroidism

Adrenomedullin (ADM) is a new potent vasorelaxant peptide identified originally in extracts of pheochromocytoma, and is widely distributed within the tissue. Although histopathological studies have demonstrated the presence of ADM-immunoreactivity (ir-ADM) in some human neuroendocrine tumors (such as insulinoma, pituitary adenoma, and gastrointestinal neuroendocrine tumors), data on the presence of ADM in normal and pathological parathyroid gland are not available. Plasma AM concentrations were recently reported to be elevated in patients with PHP (primary hyperparathyroidism). The aim of our study was to determine tissue distribution of ir-AM in 34 patients with PHP (27 female and 7 male, mean age 50 +/- 6 years) undergoing surgery. Six normal parathyroid samples incidentally found during thyroidectomy for neoplastic diseases and ten sections of human rectus abdominis muscle tissue were used as controls (C). Adenomatous parathyroids were found in 22 PHP and hyperplastic parathyroids in twelve PHP patients. Four hyperplastic parathyroids were found in three PHP patients and three parathyroids in 10 PHP patients. Eight parathyroids revealed a prevalent diffuse growth pattern and four showed a prevalent nodular growth pattern. Immunohistochemical ADM expression was seen in seven of twelve (58.3 %) hyperplastic parathyroids and in fourteen of twenty-two (66.6 %) adenomatous glands. Parathyroid chief cells showed strong cytoplasmatic staining, whereas oncocytic cells showed a faintly aspecific cytoplasmatic staining. Normal parathyroids were negative for ir-ADM. In conclusion, we found the presence of ADM in parathyroid chief cells of PHP patients using immunohistochemistry in our study.

[Radiological examination of the Lap-Band for the treatment of severe obesity]

The aim of this study is to determine the role of radiographic assessment in patient who underwent an adjustable laparoscopic (or laparotomic) banding for the treatment of morbid obesity, and to evaluate the different type of postoperative complications. Forty-three consecutive patients with morbid obesity were examined before and after surgical treatment with positioning of Lap-Band. In all patients radiological examination permitted to evaluate the bend position, the dimensions of the gastric pouch and of the stoma. In such cases it was possible to modify the stoma dimensions under fluoroscopy. 74.4% of patients obtained satisfactory weight loss without complications. In 16.2% of patients the treatment was unsatisfactory and the radiological examination demonstrated the presence and the type of complications. In 9.3% of patients the radiological exam was negative for complications but they didn't obtain satisfactory weight loss. Radiographic assessments are crucial in the management of weight loss and detection of postoperative complications in this surgical treatment.

Heterotaxia: radiological and surgical observations in a case of polysplenic syndrome

We describe a case of asymptomatic polysplenic syndrome as suggested by ultrasonography, gastrointestinal series, computed tomography, magnetic resonance imaging scans and arteriography, and confirmed at surgery. Spleen malformation is frequently associated with heterotaxia and other malformations of the thoracic and abdominal organs, but no pathognomonic features can be detected in relation to this condition. In our patient, imaging studies revealed the presence of a polylobulated spleen in an atypical position below the liver, associated with malpositioning of the gastric fundus and gastro-oesophageal junction with interruption of the inferior vena cava, but no congenital heart disease. In conclusion, polysplenic syndrome is a rare clinical condition, occasionally found in asymptomatic adults. Radiological detection could be mistaken for mediastinal or abdominal pathological masses, and only a thorough study performed with several different radiological methods can determine the precise anatomy of the structures involved so as to be able to plan surgery where necessary.

[Evaluation of the efficacy of image-guided drainage in the treatment of abdominal fluid collections]

In this paper the Authors report their experience in the diagnosis and management of abdominal fluid collections either primary or secondary to surgery. Sixty-eight patients with abdominal fluid collections were considered: in 28 cases an imaging guided percutaneous drainage was performed, while in 40 cases patients were treated with medical or surgical therapy. The Authors describe the different techniques, the approaches and the types of catheter used on the basis of the localization of the collections. The results show the efficacy of drainage procedures in 89% of the patients treated, without any major complication. Some considerations comparing patients treated with percutaneous drainage and patients who underwent different therapy as well as a review of the international literature are also reported. In conclusion the Authors affirm that percutaneous imaging guided drainage is the treatment of choice for abdominal fluid collections anatomically accessible, for the high effectiveness, good tolerability, low cost and minimal incidence of major complications.

Conservative surgical treatment for a giant thoracoabdominal benign teratoma

The authors describe an adult patient with a giant, cystic teratoma (33 x 22 x 18 cm) involving the posterior mediastinum and retroperitoneum. A conservative surgical approach consisting of a partial endocystectomy plus injections of tetracycline into the residual cavity, was performed. Two months after surgery, a CT scan showed a 6 x 5 x 3 cm residual cyst. The authors believe that the excision of the inner surface of the cystic lesion and the intracystic administration of tetracycline, may successfully prevent the accumulation of fluid which is the main cause of the progressive enlargement of such benign cystic teratomas.

[Role of ultrasonography in the study of patients with acute pancreatitis]

The aim of the present study is to establish the role of ultrasound examination (US) in the diagnosis of acute pancreatitis and its ability in differentiating mild or edematous acute pancreatitis (EAP) from severe or necrotizing acute pancreatitis (NAP) in order to indicate further diagnostic procedures and appropriate therapy. Forty patients with clinical suspect of acute pancreatitis were examined with US. All of them were followed-up clinically and with laboratory tests. Nineteen patients underwent a CT examination with contrast media and one without. In 28 cases US diagnosed acute pancreatitis in agreement with clinical and laboratory data. US identified 19 patients with EAP and 9 with NAP. CT, performed in 20 cases on the basis of clinical and US findings, confirmed US diagnosis in 19 cases while in 1 patient CT identified a NAP instead of the EAP suggested by US. According to our results, US is an easy-to-perform and accurate method for the diagnosis of acute pancreatitis and effective in differentiating EAP from NAP; it is also useful in suggesting further diagnostic procedures such as contrast-enhanced CT required in patients with NAP to assess the extension of peripancreatic fluid-collections and possible complications.

[Preoperative diagnosis of thyroid nodule. Ultrasonography-guided fine-needle aspiration]

Nodular thyroid pathology weighs heavily for 4-5% of the general population, being the most common among the endocrinopathies. Because of this these diagnostic methods have gained more and more importance as FNA able to select already in the pre-operation phase the malignant nodules from the benign ones and to decide on the most suitable surgical intervention. In the period of time between January 1989 and June 1992 in the Institute of the III Surgical Clinic in Rome there have been performed 403 FNA. From the whole total we have extrapolated 221 patients. In this study we stressed how the FNA method has a sensibility of 80%, a specificity of 93% and afterwards an accurate diagnosis of 92%. Besides we have verified that sonography and radionuclide scanning have a truth worthiness respectively of 64% and 52%. The FNA in our opinion allows us to have in the pre-operation phase a much more accurate diagnosis as regards that obtained with only sonography and radionuclide scanning therefore the latter methods must be considered complementary to FNA.

[Role of diagnostic imaging in primary and secondary hyperparathyroidism]

The authors take in consideration the sensitivity of imaging methods in localization of adenomas and hyperplastic glands in primary and secondary hyperparathyroidism. Advantages and limits of Ultrasound, Computed Tomography, Magnetic Resonance Imaging and Dual Isotope Subtraction Scintigraphy are considered, specifying the correct technique of execution and the indications for each examination. The sensitivity of these imaging methods is fairly good, but inferior in comparison to surgical exploration of the neck; it has been seen that this value improves sensibly when a two-study combination is considered as a single test. After a wide review of the literature and considering their experience, the authors stress the opportunity of a routinary preoperative use of diagnostic imaging, both in primary intervention and in case of reintervention. According to the authors US and MRI are the best imaging modalities: US are of simple execution, non-invasive and have a high sensitivity in the localization of adenomas in the typical location; MRI is a multiplanar technique, has a high contrast resolution and a very good capability of exploring the neck and mediastinum, allowing the localization of ectopic adenomas.

[The preoperative staging of rectal cancer with endorectal echography]

The authors stress the value of the routine use of endorectal US for the preoperative staging of rectal cancer. This method accurately demonstrates the exact level of the lesion, the degree of circumferential invasion, the depth of local involvement and the extent of eventual spread beyond the rectal wall, the invasion of the surrounding structures and the presence of enlarged perirectal lymph nodes. A hundred and forty-one patients with rectal carcinoma located 3-16 cm from the ano-cutaneous line were examined with endorectal US preoperatively; a comparison was made between US findings and pathological data, so that a correlation could be made between US (uT) and histologic (pT) findings. A radial probe and a 7-MHz transducer were employed. Our results show US accuracy to be 93.6% with only 4 cases of understaging and 5 of overstaging. A hundred and twenty-nine patients who had undergone major surgery were also studied to evaluate US accuracy in lymph node detection: in 110 cases the actual lymph node status was correctly demonstrated; US diagnostic accuracy was 85.3% with 16 false positives and 3 false negatives. The correct evaluation of the actual local tumor spread, as demonstrated by endoluminal US, allows the choice of the correct treatment, together with a personalized therapeutic schedule, to reduce the incidence of local recurrences and to save, whenever possible, sphincter functionality.

[Ultrasonography and the kidney: a screening method?]

The Authors retrospectively analyzed 733 hepatic U.S. involving non symptomatic urologic patients. The study detected 23 renal cysts, 3 lithiasis (with associated hydronephrosis in two) and 3 kidney neoplasms. It is concluded that U.S. represents a reliable and useful screening method for renal carcinoma, therefore it should be routinely adopted.

[Use of ultrasound-guided needle aspiration in the diagnosis and treatment of breast cysts]

The authors evaluated the advantages obtained utilizing FNAB with ultrasound in the needle aspiration of breast cysts. Echography can guide the aspiration up to its end in an effective and localized way. Cytologic examination of the cystic fluid confirmed the benign nature of the cyst. The association of needle aspiration and guided echography was related to a low number of relapses (19.8%). Among these relapses some risk factors have been found as well as a correlation between cystic fluid cytologic examination and relapses incidence has been determined.

[Benign cystic neoplasm of the pancreas: considerations on 2 surgically treated cases]

Two cases of pancreatic cystoadenoma are reported. The value of ultrasound as the first choice imaging technique approach is stressed.