[Neurofibroma in Children hand - Case Report and Literature Review]

Neurofibromas rarely occur before the age of 7 in children. They are a rarity on the hand, especially if they are accompanied by sensory disturbances and impairment of the gripping function. We report on a 9-year-old girl with symptomatic neurofibroma of the third and fourth ray of the right palm.

Memory and PTPIP51--a new protein in hippocampus and cerebellum

Previously the expression of Protein Tyrosine Phosphatase Interacting Protein 51 (PTPIP51) in mouse brain was reported. Here, we investigated PTPIP51 mRNA and protein in two of the brain regions namely the hippocampus and the cerebellum of mouse brains. On a cellular level both the protein and the mRNA were related to the pyramidal cells of the hippocampal formation, the granular cells of the dentate gyrus and the cells of the adjacent strata. In the cerebellum PTPIP51 was traced in Purkinje cells, the cells of the molecular layer and the granular layer. On a subcellular level only partial co-localization was seen for the endoplasmic reticulum, but not with mitochondria. In addition the interactome of PTPIP51 was analysed. In hippocampal cells a strong interaction with PTP1B and vesicle-associated membrane protein-associated protein B (VAPB) was detected. A somewhat differing interaction profile was found in the cerebellum, where high interaction levels were found for 14-3-3, diacylglycerol kinase α (DGKα), NFκB and PTP1B. These interaction partners represent specific signalling pathways linked to building memory. PTPIP51 can be associated with nerve growth factor signalling, dendritic and axonal growth, synaptogenesis, and all processes needed for memory formation. Moreover, in HT-22 mouse hippocampal cells PTPIP51 expression was induced by administrating the fibroblast growth factor 1 (FGF-1), which is known to take part in learning/memory processes. Knocking down p38-MAPK also led to an up-regulation of PTPIP51 probably resembling a compensative mechanism. Thus, a possible connection to the processing of memories can be anticipated. Differences in the interaction profile in both regions may be attributed to the actual/local differences in memory formation.

PTPIP51: a new interaction partner of the insulin receptor and PKA in adipose tissue

AIMS

Our previous experiments revealed an association of PTPIP51 (protein tyrosine phosphatase interacting protein 51) with the insulin signalling pathway through PTP1B and 14-3-3beta. We aimed to clarify the role of PTPIP51 in adipocyte metabolism.

METHODS

Four groups of ten C57Bl/6 mice each were used. Two groups were fed a standard diet; two groups were fed a high-fat diet. Two groups (one high-fat diet and one standard diet) were submitted to endurance training, while the remaining two groups served as untrained control groups. After ten weeks, we measured glucose tolerance of the mice. Adipose tissue samples were analyzed by immunofluorescence and Duolink proximity ligation assay to quantify interactions of PTPIP51 with either insulin receptor (IR) or PKA.

RESULTS

PTPIP51 and the IR and PTPIP51 and PKA, respectively, were colocalized in all groups. Standard diet animals that were submitted to endurance training showed low PTPIP51-IR and PTPIP51-PKA interactions. The interaction levels of both the IR and PKA differed between the feeding and training groups.

CONCLUSION

PTPIP51 might serve as a linking protein in adipocyte metabolism by connecting the IR-triggered lipogenesis with the PKA-dependent lipolysis. PTPIP51 interacts with both proteins, therefore being a potential gateway for the cooperation of both pathways.

PTPIP51, a positive modulator of the MAPK/Erk pathway, is upregulated in glioblastoma and interacts with 14-3-3β and PTP1B in situ

Glioblastoma multiforme (GBM) is the most common and most malignant primary brain tumour. Protein tyrosine phosphatase interacting protein 51 (PTPIP51) is an interaction partner of 14-3-3β, which correlates with the grade of malignancy in gliomas. In this study PTPIP51 and its interacting partners 14-3-3β, PTP1B, c-Src, Raf-1 as well as EGFR were investigated in human glioblastoma. Twenty glioblastoma samples were analyzed on transcriptional and translational level by immunohistochemistry, in situ hybridization and RT-PCR. To compare PTPIP51 expression in gliomas of different malignancies, quantitative RT-PCR for grade II astrocytoma and GBM samples was employed. Additionally, we analyzed the correlation between PTPIP51 and 14-3-3β transcription, and checked for in situ interaction between PTPIP51 and 14-3-3β and PTP1B, respectively. PTPIP51 and 14-3-3β mRNA showed a tumour grade dependent upregulation in gliomas. Glioblastoma cells displayed a strong immunoreaction of PTPIP51, which co-localized with 14-3-3β and PTP1B. The duolink proximity ligation assay corroborated a direct in situ interaction of PTPIP51 with both proteins, known to interact with PTPIP51 in vitro. The in vitro interacting partners Raf-1 and c-Src showed a partial co-localization. Besides, immune cells located in capillaries or infiltrating the tumour tissue and endothelial cells of pseudoglomerular vessels revealed a high PTPIP51 expression. The upregulation of PTPIP51 and its connection with the EGFR/MAPK pathway by 14-3-3β via Raf-1 and by PTP1B via c-Src, argue for a functional role of PTPIP51 in the pathogenesis of human glioblastoma.

PTPIP51 interaction with PTP1B and 14-3-3β in adipose tissue of insulin-resistant mice

OBJECTIVE

We investigated the expression of protein tyrosine phosphatase-interacting protein 51 (PTPIP51) and its interaction with protein tyrosine phosphatase 1B (PTP1B) and 14-3-3β in mice exhibiting insulin resistance and obesity.

DESIGN

A total of 20 mice were included in the study. Eight control animals were fed a normal standard diet, six animals were fed a high-fat diet and six animals were submitted to a treadmill training parallel to the feeding of a high-fat diet. After 10 weeks, a glucose tolerance test was performed and abdominal adipose tissue samples of the animals were collected.

RESULTS

PTPIP51 protein was identified in the adipocytes of all samples. PTPIP51 interacted with PTP1B and with 14-3-3β protein. Compared with untrained mice fed a standard diet, the interaction of PTPIP51 with PTP1B was reduced in high-fat diet-fed animals. The highest interaction of PTPIP51 with 14-3-3β was seen in trained animals on high-fat diet, whereas untrained animals on high-fat diet displayed lowest values.

CONCLUSION

PTPIP51 is expressed in adipose tissue of humans, rats and mice. Obesity with enhanced insulin resistance resulted in a reduction of PTPIP51 levels in adipocytes and influenced the interactions with PTP1B and 14-3-3β. The interaction of PTPIP51 with PTP1B suggests a regulatory function of PTPIP51 in insulin receptor signal transduction. The interaction of PTPIP51 with 14-3-3β, especially in trained individuals, hints to an involvement of PTPIP51 in the downstream regulation of insulin action.

[Delirium in the intensive care unit]

In recent years delirium in the intensive care unit (ICU) has internationally become a matter of rising concern for intensive care physicians. Due to the design of highly sophisticated ventilators the practice of deep sedation is nowadays mostly obsolete. To assess a ventilated ICU patient for delirium easy to handle bedside tests have been developed which permit a psychiatric scoring. The significance of ICU delirium is equivalent to organ failure and has been proven to be an independent prognostic factor for mortality and length of ICU and hospital stay. The pathophysiology and risk factors of ICU delirium are still insufficiently understood in detail. A certain constellation of pre-existing patient-related conditions, the current diagnosis and surgical procedure and administered medication entail a higher risk for the occurrence of ICU delirium. A favored hypothesis is that an imbalance of the neurotransmitters acetylcholine and dopamine serotonin results in an unpredictable neurotransmission. Currently, the administration of neuroleptics, enforced physiotherapy, re-orientation measures and appropriate pain treatment are the basis of the therapeutic approach.

Expression profile of PTPIP51 in mouse brain

This study demonstrates the expression of the novel protein protein tyrosine phophatase-interacting protein 51 (PTPIP51) in mammalian brain tissue. Serial sections of the whole adult mouse brain were analyzed for PTPIP51 protein and mRNA by immunohistochemistry, immunoblotting, RT-PCR, and in situ hybridization. Recent investigations by Yu et al. (2008) describe PTPIP51 as being capable of activating Raf-1, thereby modulating the MAPK pathway. The role of Raf-1, as well as of 14-3-3, in neurological disorders is well established. PTPIP51 expression was confined to neurons in the following structures: the piriform cortex and their connections to the anterior commissure, nucleus accumbens, paraventricular and supraoptical nuclei, neurohypophysis, superior colliculus, genu of facialis nerve, spinal trigeminal tract, inferior cerebellar peduncle, and cerebellum. In the cerebellum, a subpopulation of Purkinje cells and their dendrites was strongly PTPIP51 positive. Moreover, PTPIP51 was found to be colocalized with vasopressin and its transport protein neurophysin II in the neuroendocrine nuclei and their connections to the neurohypophysis. The data presented here suggest a role of PTPIP51 in neuronal homeostasis, axonal growth, and transport.

Cost analysis of sentinel lymph node biopsy as an alternative to elective lymph node dissection in patients with malignant melanoma

In the current era of managed care and cost containment, physicians and administrators are placed in the predicament of increasing quality of care while decreasing costs. The purpose of this article is to offer a cost analysis, while also demonstrating what patients, providers, payers, employers, and industry may stand to gain from establishing sentinel lymph node biopsy as a standard care in certain groups of patients.

Lymphatic mapping for melanomas of the upper extremity

Over a period of 4 years, 127 consecutive patients with upper extremity melanomas were identified from a prospectively accrued database. A protocol consisting of preoperative lymphoscintigraphy and intraoperative lymphatic mapping and with a vital blue dye and radiocolloid was used; the protocol had a 98% success rate of identifying the sentinel lymph node (SLN). Preoperative lymphoscintigraphy identified unpredictable cutaneous lymphatic flow in 15 (12%) of the patients. These discordant areas would not have been included in classic regional node dissection and possible sites of metastatic disease would not have been identified. Metastatic disease was identified within the SLNs in 12 (9%) of the patients. Of the 12 patients with a positive SLN, 2 (17%) were found on complete node dissection to have metastatic disease in higher nodes in the regional basin. The SLN was the only site of disease in 10 of these 12 patients with documented metastases in the regional basin. Patients with a negative SLN biopsy can be spared the morbidity and expense of a complete lymph node dissection.

Cutaneous lymphatic drainage in patients with grossly involved nodal basins

BACKGROUND

The development of lymphatic mapping techniques has facilitated the identification of the sentinel lymph node (SLN), the first node in the regional basin into which cutaneous lymphatics flow from a particular skin area. Previous studies have shown that SLN histology reflects the histology of the entire basin, because melanoma metastases progress in an orderly fashion, involving the SLN before higher nodes in the basin become involved with metastatic disease. It is uncertain whether these orderly cutaneous lymphatic flow patterns are maintained in grossly involved basins. Lymphatic mapping was performed in a population of melanoma patients with clinically palpable lymphadenopathy to address this question. We aimed to determine whether the presence of gross nodal disease in the basin alters lymphatic flow into that basin so that lymphatic mapping techniques are not applicable, and, in patients referred with a grossly involved basin, whether preoperative lymphoscintigraphy should be performed to identify other regional basins at risk for metastases.

METHODS

Eight patients presented with grossly palpable disease in the regional basin and underwent preoperative lymphoscintigraphy. All patients with palpable disease and all basins indicated by lymphoscintigraphy to be at risk were dissected. Three patients presented with clinically palpable nodes at the time of diagnosis, and five developed nodal disease on clinical follow-up after undergoing initial wide local excision only. A total of 10 basins in the eight patients were dissected. Of these, eight of the basins had grossly palpable regional nodal disease, and the other two basins were identified by preoperative lymphoscintigraphy as being at risk for metastases. The SLN was identified with intraoperative mapping, harvested, and submitted to pathology. Complete therapeutic lymph node dissections were performed following the SLN harvest in the basins with grossly palpable disease. SLN biopsy alone was performed in the two basins that did not have clinically palpable adenopathy but showed cutaneous lymphatic flow from the scintigram.

RESULTS

Sixteen SLNs were harvested from these eight basins with grossly palpable disease, and 14 (87.5%) contained tumor. In each case, one of the SLNs was the grossly palpable node, and in six of the basins (75%) it was the only site of melanoma metastases. An additional 190 higher level, non-SLNs were removed, 32 (16.8%) of which contained microscopic foci of metastatic melanoma (P = .015). The null hypothesis that melanoma nodal metastasis is a random event is rejected. Two patients with trunk melanoma primary sites were identified to have other basins at risk for metastatic disease on lymphoscintigraphy. SLN biopsies were performed in these two patients, and one had microscopic nodal disease in the SLN.

CONCLUSIONS

These data support the fact that cutaneous lymphatic drainage patterns are maintained in patients with grossly involved basins, thus buttressing the idea that the SLN is the node most likely to develop metastatic disease. Gross disease in the basin does not significantly alter cutaneous lymphatic flow into the regional basin, as the sentinel lymph node identified under these circumstances is the same as with the grossly involved node. Preoperative lymphoscintigraphy in patients who present with grossly involved nodes in one basin may identify other regional basins with micrometastatic disease and deserves further study in this setting.

The progression of melanoma nodal metastasis is dependent on tumor thickness of the primary lesion

BACKGROUND

Recent results of several clinical trials using the technique of intraoperative lymphatic mapping and sentinel lymph node (SLN) biopsy confirm the validity of the concept of there being an order to the progression of melanoma nodal metastases. This report reviews the H. Lee Moffitt Cancer Center experience with this procedure, one of the largest series described to date. These data demonstrate that the involvement of the SLNs, as well as higher-echelon nodes, is directly proportional to the melanoma tumor thickness, as measured by the method of Breslow.

METHODS

The investigators at the H. Lee Moffitt Cancer Center retrospectively reviewed their experience using lymphatic mapping and SLN biopsies in the treatment of malignant melanoma. All eligible patients with primary malignant melanomas underwent preoperative and intraoperative mapping of the lymphatic drainage of their primary sites, along with SLN biopsies. All patients with positive SLNs underwent complete regional basin nodal dissection. For 20 consecutive patients with one positive SLN, all of the nodes from the complete lymphadenectomy were serially sectioned and examined by S-100 immunohistochemical analysis, to detect additional metastatic disease.

RESULTS

Six hundred ninety-three patients consented to undergo lymphatic mapping and SLN biopsy. The SLNs were successfully identified and collected for 688 patients, yielding a 99% success rate. One hundred patients (14.52%) showed evidence of nodal metastasis. The rates of SLN involvement for primary tumors with thicknesses of <0.76 mm, 0.76-1.0 mm, 1.0-1.5 mm, 1.5-4.0 mm, and >4.0 mm were 0%, 5.3%, 8%, 19%, and 29%, respectively. Eighty-one patients underwent complete lymph node dissection after observation of a positive SLN, and only six patients with positive SLNs demonstrated metastatic disease beyond the SLN (7.4%). The tumor thicknesses for these six patients ranged from 2.8 to 6.0 mm. No patient with a tumor thickness of <2.8 mm was found to have evidence of metastatic disease beyond the SLN in complete lymph node dissection. All 20 patients with a positive SLN for whom all of the regional nodes were serially sectioned and examined by S-100 immunohistochemical analysis failed to show additional positive nodes.

CONCLUSIONS

These results suggest that regional lymph node involvement may be dependent on the thickness of the primary tumor. As the primary tumor thickness increases, so does the likelihood of involvement of SLNs and higher regional nodes in the basin beyond the positive SLNs.

Lymphatic mapping and selective lymphadenectomy as an alternative to elective lymph node dissection in patients with malignant melanoma

This article reviews the use of selective lymphadenectomy, otherwise known as sentinel lymph node biopsy, as a clinical alternative in patients with malignant melanoma. This represents a compromise between the two traditional treatment modalities, elective lymph node dissection or observation of the regional nodal basin followed by therapeutic lymph node dissection once disease becomes clinically apparent.

Efficacy of hyperthermic isolated limb perfusion for extremity-confined recurrent melanoma

BACKGROUND

Recurrent melanoma of the extremity has been treated by local excision, systemic chemotherapy, amputation, or a combination of these approaches. Hyperthermic isolated limb perfusion (HILP) provides a method of limb preservation through isolation, allowing the administration of chemotherapy in higher doses than is possible through systemic treatment.

METHODS

An experimental group of 59 HILP patients with melanoma recurrences of the extremity was studied prospectively. A control group of 248 melanoma patients with similar recurrences was excluded from HILP because their recurrences were in non-extremity locations. The experimental group underwent HILP and excision; the control group had excision only. The experimental procedure consisted of vascular isolation of the affected extremity and a 1-hour perfusion with melphalan. Temperatures were maintained at 40 degrees C in the perfusion circuit.

RESULTS

The HILP patients had a lower rate of locoregional recurrence (P=.028) and demonstrated increased survival (P=.026) compared to the control group. In multivariate regression analysis, which included age, ulceration and thickness of the primary, and the treatment variable of perfusion, age (P=.02) and perfusion for the treatment of recurrence (P=.006) were significant predictors of survival.

CONCLUSIONS

HILP improves prognosis by sterilizing the treated extremity, controlling locoregional disease, and perhaps preventing metastasis, thus having a positive impact on overall survival.

Results of complete lymph node dissection in 83 melanoma patients with positive sentinel nodes

BACKGROUND

The technique of sentinel lymph node (SLN) biopsy for melanoma provides accurate staging information because the histology of the SLN reflects the histology of the entire basin, particularly when the SLN is negative.

METHODS

We combined two mapping techniques, one using vital blue dye and the other using radiolymphoscintigraphy with a hand-held gamma Neoprobe, to identify the SLN in 600 consecutive patients with stage I-II melanoma. The SLNs were examined using conventional histopathology and immunohistochemistry for S-100.

RESULTS

Eighty-three (13.9%) patients had micrometastatic disease in the SLNs. Thirty percent of patients with primary melanomas greater than 4.0 mm in thickness had positive SLNs, followed by 48 of 267 (18%) of patients with tumors between 1.5 mm and 4 mm, and 12 of 169 (7%) of those with lesions between 1.0 mm and 1.5 mm. No patient with a tumor less than 0.76 mm in thickness had a positive SLN. Sixty-four of the 83 SLN-positive patients consented to undergo complete lymph node dissection (CLND), and five of 64 (7.8%) of the CLNDs were positive. All patients with positive CLNDs had tumor thicknesses greater than 3.0 mm.

CONCLUSIONS

The rate of SLN-positive patients increases with increasing thickness of the melanoma. SLN-positive patients with primary lesions less than 1.5 mm in thickness may have disease confined to the SLN, thus rendering higher-level nodes free of disease, and may not require a CLND.

Lymphatic Mapping for Melanoma: Long-term Results of Regional Nodal Sampling With Radioguided Surgery

BACKGROUND: Lymphatic mapping and sentinel lymph node (SLN) biopsy are new techniques used in the surgical treatment of patients with malignant melanoma. These procedures have the potential to change the surgical treatment of the disease to provide a more rational approach to adjuvant therapy. METHODS: A prospective database of melanoma patients undergoing lymphatic mapping and SLN biopsy was reviewed to identify prognostic factors for overall and disease-free survival in this patient population. RESULTS: Five-year overall and disease-free survival was 92.3% and 79.0%, with a median follow-up of 17 months. The number of histologically positive SLNs was the most powerful predictor of overall and disease-free survival. Patients with no histologically positive SLNs had a five-year overall and disease-free survival of 97.9% and 93.3%, respectively. Tumor ulceration and Clark level greater than or equal to III were the significant prognostic factors for survival. CONCLUSIONS: The use of lymphatic mapping and SLN biopsy effectively stages patients with primary cutaneous melanoma. Additionally, the presence of histologically positive SLNs is the most powerful indicator of overall and disease-free survival for these patients.

Redefining cutaneous lymphatic flow: the necessity of preoperative lymphoscintigraphy in the management of malignant melanoma

OBJECTIVE

The purpose of this study is to emphasize the instrumental role of preoperative lymphoscintigraphy in the surgical treatment of patients with malignant melanoma.

SUMMARY BACKGROUND DATA

The efficacy of lymphoscintigraphy is reflected in its ability to reveal cutaneous lymphatic drainage to regional nodal basins that are at risk for melanoma metastases but not necessarily discernable to be at risk through standard historical anatomical guidelines or clinical experience. This preoperative lymphatic mapping technique has contributed greatly to the accuracy and efficiency of staging procedures including sentinel node biopsy and elective lymph node dissection.

PATIENTS AND METHODS

After informed consent, a selected series of four patients with primary melanomas located in watershed areas of the body (left neck, right mid-abdomen, right scapula, left back) and two patients with extremity melanomas (right distal forearm and left ankle) underwent pre-operative lymphoscintigraphy to identify all basins for metastases.

RESULTS

In all of the cases, lymphatic drainage occurred in an unusual and unexpected basin that could not have been predicted clinically and in three of the cases the resected basins contained positive sentinel nodes. If not for the preoperative lymphoscintigraphy, these nodal basins would not have been resected and metastatic disease would have been left behind. In addition, the staging of the melanoma patient would have been inaccurate.

CONCLUSION

If the sentinel node biopsy of elective lymph node dissection (ELND) were based on clinical predictions only, nodes equally at risk for metastatic disease would not have been resected and in some cases, nodal basins not at risk for metastases would have been resected unnecessarily. Without lymphoscintigraphy, the validity and efficacy of the ELND or the sentinel node biopsy for nodal staging is greatly compromised. These six case studies illustrate the difficulty of predicating lymphatic drainage from primary sites located on the head and neck, truck and even the extremities and demonstrate the indispensability of preoperative lymphoscintigraphy in the management of malignant melanoma.

The clinical relevance of sentinel lymph nodes identified with radiolymphoscintigraphy

BACKGROUND

The purpose of this case report is to illustrate the utility of radio-guided mapping of sentinel lymph nodes (SLN's) as demonstrated by the technique's successful identification of nodes containing metastatic disease that would have been left behind if only the visual-oriented vital blue dye mapping technique had been used.

METHOD

The patient underwent preoperative lymphoscintigraphy and intra-operative lymphatic mapping using vital blue dye and radiolymphoscintigraphy using the Neoprobe (handheld gamma probe). Nodes which were blue and/or "hot" (i.e., radioactive counts were three times the background count) were considered SLN's.

RESULTS

Four SLN's were harvested, all of which were "hot" but only one of which was both "hot" and blue. Pathology revealed that the two SLN's positive for metastatic disease were not blue.

CONCLUSION

While the blue dye lymphatic mapping technique provides the surgeon with a visual road map in the identification of SLN's, the Neoprobe increases the success rate of localization when compared to vital blue dye mapping due to the reliable migration of radiocolloid to the SLN's in the regional basin. Radiolymphoscintigraphy also increases the accuracy and efficiency of the SLN harvest by providing a directed dissection to the level of the nodes in the basin. The Neoprobe increases the yield of SLN's, some of which are clinically relevant since they contain metastatic disease.

Multiple primary melanomas: implications for screening and follow-up programs for melanoma

BACKGROUND

Once individuals are diagnosed with malignant melanoma, they are at an increased risk of developing another melanoma when compared with the normal population.

METHODS

To determine the impact of an intensive follow-up protocol on the stage of disease at diagnosis of subsequent primary melanomas, a retrospective query was performed of an electronic medical record database of 2,600 consecutively registered melanoma patients.

RESULTS

Sixty-seven patients (2.6%) had another melanoma diagnosed at the time of presentation to the clinic or within 2 months (synchronous) and another 44 patients (1.7%) developed a second primary melanoma during the follow-up period (metachronous). For the 44 patients diagnosed with metachronous lesions, the Breslow mean tumor thickness for the first invasive melanoma was 2.27 mm compared with 0.90 mm for the second melanoma. The first melanomas diagnosed are thicker by an average of 3.8 mm (p = 0.008). The mean Clark level for the initial melanoma was greater than the mean level for subsequently diagnosed melanomas (p = 0.002). Twenty-three percent of the initial melanomas were ulcerated, whereas only one of the second primary lesions showed this adverse prognostic factor (p = 0.002).

CONCLUSIONS

Once individuals are diagnosed with melanoma, they are in a high-risk population for having other primary site melanomas diagnosed and should be placed in an intensive follow-up protocol consisting of a complete skin examination.

Medical-legal pitfalls for the breast surgeon: incomplete mammographic localization of suspicious lesions and the correlation between palpable and mammographic abnormalities

In approximately 5 per cent of mammographically detected lesions, the mammographic abnormality is present in only one view, either craniocaudal or mediolateral. In such a scenario, the physician has been left with the option of closely following the lesion, hoping it will eventually become apparent in two views, or guessing the approximate location of the lesion for subsequent open biopsy. However, with today's advances in technology, CT scan and its production of a three-dimensional image can compensate for mammography's two-dimensional limitation. With diminished need for identification on two mammographic views, localization in these instances falls more within the realm of possibility. This paper highlights Moffitt Cancer Center's experience with CT-directed breast biopsy as an alternative to close follow-up or blind-biopsy. In addition, because palpable breast abnormalities may not be the same as mammographic abnormalities, the report details the accuracy of CT-directed biopsy in allowing the surgeon to perform precise open biopsy, thus avoiding medical-legal exposure.