Detection Of Axillary Lymph Nodes Research Articles

Phase II study of uPAR-PET/CT for staging of primary breast cancer in comparison with ultrasound and fine needle biopsies

Accurate initial staging of patients with breast cancer is essential for planning optimal treatment strategies. However, currently, no imaging modality is able to detect lymph node metastases preoperatively with sufficient reliability; therefore, the N status depends on the sentinel node procedure for ~ 70% of patients. In a prospective clinical trial of breast cancer patients, we compared head-to-head uPAR-PET/CT with current standard-of-care, ultrasound (US) and fine needle biopsy (FNB) as staging methods. Forty-nine patients (48 women and 1 man) with biopsy-proven early breast cancer underwent uPAR-PET/CT prior to surgery. All image data were analyzed by two separate teams, each consisting of a highly experienced certified specialist in nuclear medicine and a highly experienced certified specialist in radiology for visualization of primary tumor lesions and detection of lymph node and distant metastases. Histopathological assessment and verification of malignancy in the excised tissues (primary tumors and lymph nodes) were considered standard-of-truth. On a per patient basis, uPAR PET/CT demonstrated a sensitivity of 94% [CI: 83–99%] for detecting the primary tumor (both teams). For the detection of axillary lymph nodes the pooled sensitivity of uPAR PET/CT was 33.3% [CI: 16.5–54.0%], specificity 87.0% [CI: 66.4–97.2%] and accuracy 58.0% [CI: 43.2–71.8%]. In comparison, the standard-of-care preoperative clinical staging algorithm with US and FNB had a sensitivity of 41% [CI: 22–61%] and specificity of 100% [CI: 85–100%] for axillary lymph node metastases. We conclude that the results do not support the use of uPAR PET/CT for staging in breast cancer patients. However, the finding that 94% of primary tumors were uPAR-PET positive may be encouraging for pursuing uPAR theranostics in localized disease. Additionally, other potential applications, such as using uPAR-PET as a prognostic imaging biomarker of tumor aggressiveness, remain to be investigated.

Experimental Assessment of Axillary Lymph Node Microwave Tomography Using Anthropomorphic Phantoms

We assess the application of microwave tomography (MWT) for the detection of axillary lymph nodes (ALNs) in breast cancer patients. We numerically study the effects of limiting angular view in axillary MWT, as probes can only be placed on a limited arc around the axillary region. We also numerically study the possibility of increasing the amount of retrievable information by acquiring data in two consecutive steps, with a single antenna set in two different angular positions. We finally experimentally test axillary MWT on anthropomorphic phantoms with different levels of anatomical fidelity, and different ALN positions. Our MWT system (0.8–2.5 GHz) employs six monopole antennas placed on a single transverse plane, facing the axillary region. The reconstruction algorithm implements the distorted Born iterative method, combined with the two-step iterative shrinkage/thresholding for the inversion (DBIM-TwIST). Our numerical results i) highlight the challenges associated with the limited angular view, and ii) show that performing two-step angular measurements enhances imaging results, suggesting that rotating the antenna set between consecutive measurements is an effective means to increase the retrievable information in ALN MWT. Our experimental results show that our MWT system can detect an ALN in different positions. To the best of our knowledge this is the first paper to assess ALN MWT in a realistic 3-D experimental scenario.

Efficient Axillary Lymph Node Detection Via Two-stage Spatial-information-fusion-based CNN

Background and objective: Preoperative imaging diagnosis of axillary lymph node (ALN) metastasis is particularly important for breast cancer patients. This paper focuses on developing non-invasive and automatic schemes for accurate localization and classification (metastasis prediction) of ALN via contrast-enhanced computed tomography (CECT) image and deep learning models. Methods: Based on a two-stage strategy, a novel detection neural network is proposed, where the convolutional block attention module is utilized to extract spacial information and the bottleneck feature fusion module is designed for feature fusion in different scales. Results: Owing to the two embedded modules, the proposed convolutional neural network (CNN) model outperforms Faster R-CNN, YOLOv3, and EfficientDet in the sense that the achieved mAP is 0.454, higher than 0.247, 0.335, and 0.329, respectively. In particular, considering the function of classification only, the proposed model reaches the best performance on most indices (accuracy of 0.968, positive predictive value of 0.972, negative predictive value of 0.966, specificity of 0.983), compared with the methods that have been frequently adopted to predict ALN. In addition, the proposed CNN model has the function of locating ALN, which is lacking in existing models. Conclusions: In this paper, a supervised deep learning method is proposed to detect ALN in CECT images. The positive effect of new added modules are verified, and the benefits of spatial information in ALN detection are confirmed. Further, the two subtasks called localization and classification are evaluated separately, where the proposed model achieves the best performance on most indices. The source code mentioned in this article will be released later.

Role of magnetic resonance imaging in detection of metastatic axillary lymph nodes in breast cancer patients

Background: Magnetic resonance imaging has been evolved as a very important tool in diagnosing the axillary lymph nodes pre-operatively. In recent studies, in women with various risk profiles, the sensitivity ranges between 81% and 100%, which is approximately twice as high as the sensitivity of mammography. Methods: This prospective study was performed at PGIMS, Haryana from December 2018 to March 2020. Total 30 patients (n=30) were included in the study. All the patients presenting with clinically palpable breast lump, underwent triple assessment test. All the patient underwent modified radical mastectomy and the final histopathological report of the specimen was then compared with the preoperative clinical and MRI assessment of the metastatic axillary lymph nodes. Results: This study aimed at detection of axillary lymph node metastasis in breast malignancies by breast MRI. The sensitivity of this MRI came to be about 80.00%, specificity of about 80%, positive predictive value of about 95.24%, negative predictive value of about 44.44% and accuracy of about 80.0% with 95% confidence interval.Conclusions: Magnetic resonance imaging is a very important investigation in detection of breast malignancies, their depth, muscles and skin involvement as well as axillary lymph node detection. Axillary lymph nodes can although be detected by clinical examination, but problem lies in their sensitivity and specificity as axillary lymph nodes of small size cannot be detected by clinical examination.

Dynamic contrast-enhanced MRI radiomics nomogram for predicting axillary lymph node metastasis in breast cancer

PurposeThe goal of this study is to develop and validate a radiomics nomogram integrating the radiomics features from DCE-MRI and clinical factors for the preoperative diagnosis of axillary lymph node (ALN) metastasis in breast cancer patients.ProceduresA total of 432 patients with breast cancer were enrolled in this retrospective study and divided into a training cohort (n = 296) and a validation cohort (n = 136). Radiomics features were extracted from the second phase of dynamic contrast enhanced (DCE) MRI images. The least absolute shrinkage and selection operator (LASSO) regression method was used to screen optimal features and construct a radiomics signature in the training cohort. Multivariable logistic regression analysis was used to establish a radiomics nomogram model based on the radiomics signature and clinical factors. The predictive performance of the nomogram was quantified with respect to discrimination and calibration, which was further evaluated in the independent validation cohort.ResultsFourteen ALN metastasis-related features were selected to construct the radiomics signature, with an area under the curve (AUC) of 0.847 and 0.805 in the training and validation cohorts, respectively. The nomogram was established by incorporating the histological grade, multifocality, MRI report lymph node status and radiomics signature and showed good calibration and excellent performance for ALN detection (AUC of 0.907 and 0.874 in the training and validation cohorts, respectively). The decision curve, which demonstrated the radiomics nomogram, displayed promising clinical utility.ConclusionsThe radiomics nomogram can be used as a noninvasive and reliable tool to assist clinicians in accurately predicting ALN metastasis in breast cancer preoperatively.

Lymph Node Metastases Detection Using Gd2O3@PCD as Novel Multifunctional Contrast Imaging Agent in Metabolic Magnetic Resonance Molecular Imaging.

Axillary lymph node detection is crucial to staging and prognosis of the lymph node metastatic spread in breast cancer. Currently, lymphoscintigraphy and blue dye, as the conventional methods to localize sentinel lymph nodes (SLNs), are invasive and can only be performed during surgery. This study has had a novel hybrid gadolinium oxide nanoparticle coating with Cyclodextrin-based polyester as a high-relaxivity T1 magnetic resonance molecular imaging (MRMI) contrast agent (CA). Twelve female BALB/c mice were randomly divided into three groups of four mice; each group was injected with 4T1 cells to obtain metastasis lymph nodes and diagnosed by using the 3D T1W (VIBE) MRI (Siemens 3T, Prisma). The synthesized Gd2O3@PCD nanoparticles with a suitable particle size range of 20–40 nm have had much higher longitudinal relaxivity (r1) for Gd2O3@PCD and Gd-DOTA (Dotarem) with the values of 3.98 mM−1·s−1 ± 0.003 and 2.71 mM−1·s−1 ± 0.005, respectively. Identical MR images in coronal views were subsequently obtained to create time-intensity curves of the right axillary lymph nodes and to measure the contrast ratio (CR). The peak CR and qualitative assessment of axillary lymph nodes at five-time points were evaluated. After subcutaneous injection, the contrast ratio of axillary lymph node and tumor in mice exhibited CR peak of Gd2O3@PCD and Dotarem with the values of 2.21 ± 0.06 and 0.40 ± 0.004 for lymph node and 2.54 ± 0.04 and 1.21 ± 0.007 for the tumor, respectively. Furthermore, the lumbar-aortic lymph node is weakly visible in the original coronal image. In conclusion, the use of Gd2O3@PCD nanoparticles as novel MRMI CAs enables high resolution for the detection of lymph node metastasis in mice with the potential capability for breast cancer diagnostic imaging.

Correlation of clinical examination and ultrasonogram with histopathology in predicting the metastatic axillary lymph nodes in breast cancer

Background: Examination of breast and axilla is an integral part of triple assessment of patient with suspected carcinoma breast. A retrospective study was conducted to compare the axillary lymph nodes in carcinoma breast based on clinical, ultrasonogram (USG) and post-operative histopathology (HPR). Methods: One hundred patients with early breast cancer were included in the study. Clinical examination of axilla, followed by USG examination of all patients was done preoperatively. This was compared with the post-operative HPR of axillary lymph nodes (gold standard). The validity of the findings was evaluated by using sensitivity and specificity. Results: There is a strong positive correlation for the detection of total number of lymph nodes (r=0.935) between USG and HPR which is statistically significant (p <0.05). The correlation between clinical detection and HPR detection of axillary lymph nodes was weak (r= 0.278). Accuracy of the USG findings was good (81%) compared to the HPR findings and this was statistically significant (p <0.05). The USG morphologic lymph node features with the greatest correlation with malignancy were loss of central fatty hilum (r= 0.953) and cortical thickness (r= 0.914). In HPR and USG, the number of positive lymph nodes was high in stage II. Conclusions: The sensitivity for detecting malignancy by USG is only average. USG is more likely to detect an abnormal node if there is morphologic features of increased cortical thickening and loss of central fatty hilum. A multidisciplinary effort is needed to reduce unnecessary axillary dissections.

Simultaneous whole-body 18F-FDG PET-MRI in primary staging of breast cancer: A pilot study

PurposeAccurate initial staging in breast carcinoma is important for treatment planning and for establishing the likely prognosis. The purpose of this study was to assess the utility of whole body simultaneous 18F-FDG PET-MRI in initial staging of breast carcinoma. Methods36 patients with histologically confirmed invasive ductal carcinoma underwent simultaneous whole body 18F-FDG PET-MRI on integrated 3T PET-MR scanner (Siemens Biograph mMR) for primary staging. Primary lesion, nodes and metastases were evaluated on PET, MRI and PET-MRI for lesion count and diagnostic confidence (DC). Kappa co relation analysis was done to assess agreement between the satellite, nodal and metastatic lesions detected by PET and MRI. Histopathology, clinical/imaging follow-up served as the reference standard. Results36 patients with 37 histopathologically proven index breast cancer were retrospectively studied. Of 36 patients, 25 patients underwent surgery and 11 patients received systemic therapy. All index cancers were seen on PET and MR. Fused PET-MRI showed highest diagnostic confidence score of 5 as compared to PET (median 4; range 3–5) and MRI (median 4; range 4–5) alone. 2/36 (5.5%) patients were detected to have unsuspected contralateral synchronous cancer. 47 satellite lesions were detected on DCE MRI of which 23 were FDG avid with multifocality and multicentricity in 21 (58%) patients. Kappa co relation analysis revealed fair agreement for satellite lesion detection by the two modalities (κ=0.303; P=0.003).The study showed a sensitivity of 60% and 93.3% on PET and MRI respectively for detection of axillary lymph nodes with a specificity of 91% for both and a false negative rate of 6.7% on MRI and 40% on PET. Kappa co relation analysis between PET and MRI for all the lymph nodes detected revealed fair agreement by the two modalities (κ=0.337; P=0.000). Combined PET-MRI increased diagnostic confidence for nodal involvement (median DC 5, range 4–5; P<0.05).Distant metastases were found in 8/36 (22%) patients at the time of diagnosis with a total of 91 metastatic lesions on PET (DC≥4) and 105 on MRI (DC≥4), the difference being statistically significant (P=0.001) while Kappa co relation analysis showed significant agreement between the two modalities (κ=0.667; P=0.000). Overall PET-MRI led to a change in management in 12 (33.3%) patients. ConclusionIn this pilot study, simultaneous 18F-FDG PET-MR, has been found to be useful in whole-body initial staging of breast cancer patients.

Additional value of F-18 FDG PET/CT for initial staging in breast cancer with clinically negative axillary nodes

The aim of this study was to evaluate the clinical impact of the preoperative ¹⁸F-FDG PET/CT in the initial workup of breast cancer with clinically negative axillary nodes. Whether the status of the clinical axillary nodal involvement can be considered a parameter for making a decision to omit the preoperative ¹⁸F-FDG PET/CT in the situation reported herein was also determined. A total of 178 patients who had newly diagnosed breast cancer and for whom the conventional diagnostic modalities showed no sign of axillary node metastasis were retrospectively enrolled in this study. All the patients underwent preoperative ¹⁸F-FDG PET/CT. The images and histologic results that were obtained were analyzed. ¹⁸F-FDG PET/CT detected primary lesions in 156 of the 178 patients, with an overall sensitivity of 87.6 %, and false negative results were obtained for 22 patients (12.4 %). The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of ¹⁸F-FDG PET/CT in the detection of axillary nodes were 20.8, 86.9, 37.0, 74.8, and 69.1 %, respectively. Extra-axillary node metastasis was identified in two patients (1.1 %) who had internal mammary nodes. There was no distant metastasis, but coexisting primary tumor was detected in five patients (2.8 %). In total, the therapeutic plan was changed based on ¹⁸F-FDG PET/CT in seven (3.9 %) of the 178 patients, but considering only the cases confined to breast cancer, the change occurred in only two patients (1.1 %). ¹⁸F-FDG PET/CT almost did not affect the initial staging and treatment plan in breast cancer with clinically negative axillary node. If the axillary node is clinically negative in the preoperative workup of breast cancer, then ¹⁸F-FDG PET/CT can be omitted.

Diagnostic accuracy of dual-time-point 18F-FDG PET/CT for the detection of axillary lymph node metastases in breast cancer patients

The diagnostic accuracy of FDG-PET/CT for the detection of axillary lymph node metastases in breast cancer patients acquired 60 min after FDG administration is reported to be only moderate, especially due to low sensitivity. To test whether a delayed scan 90 min after FDG administration could enhance the diagnostic accuracy of FDG-PET/CT for the detection of axillary lymph node metastases. Thirty-eight women suffering from primary breast cancer (mean age 52 years; range 25-78 years; standard deviation 14 years) underwent a pre-therapeutic dual-time-point FDG-PET/CT scan. The maximum standardized uptake value (SUVmax) of axillary lymph nodes was measured at two different time points (time point T1: 60 min after FDG injection, time point T2: 90 min after FDG injection). SUVmax of axillary lymph nodes at T1 and T2 were assessed for statistical significance using a paired Wilcoxon-Test (P < 0.05). At T1 a qualitative analysis of the FDG-PET/CT scan was performed to define physiologic and metastatic lymph nodes. At T2 an increase of the SUVmax of at least 3.75% over time was rated as indicating malignancy. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and the accuracy of FDG-PET/CT for the detection of axillary lymph node metastases was calculated at time points T1 and T2. Statistically significant differences were determined using Fisher's exact test (P < 0.05). Histopathology served as the standard of reference. A compartment based analysis was done. Axillary lymph nodes had a mean SUVmax of 1.6 (range 0.6-10.8; SD 1.9) at T1 and a mean SUVmax of 1.8 (range 0.5-17.9; SD 3.5) at T2. This difference was statistically significant (P = 0.047). The sensitivity, specificity, PPV, NPV, and accuracy of FDG-PET/CT for the detection of axillary lymph node metastases was 81%, 100%, 100%, 88%, and 92% at T1, and 88%, 50%, 56%, 85%, and 66% at T2, respectively. This difference was not statistically significant (P = 0.27). There is a slight increase of the FDG accumulation of axillary lymph nodes between 60 and 90 min after FDG administration. This increase did not translate into a statistical significant enhancement of the diagnostic accuracy of FDG-PET/CT for the detection of axillary lymph nodes. Especially due to false-positive results a delayed FDG-PET/CT scan 90 min after FDG administration is not able to enhance the diagnostic accuracy for the detection of lymph node metastases.

Diagnostic performance of one‐step nucleic acid amplification for intraoperative sentinel node metastasis detection in breast cancer patients

The purpose of this prospective multicenter study was to assess one-step nucleic acid amplification (OSNA) for intraoperative sentinel lymph node (SLN) metastasis detection in breast cancer patients, using final histology as the reference standard. OSNA results were also compared to intraoperative histology SLN evaluation and to standard clinicopathological risk markers. For this study, fresh SLNs were cut in four blocks, and alternate blocks were used for OSNA and histology. CK19 mRNA copy number was categorized as strongly positive, positive or negative. Positive histology was defined as presence of macrometastasis or micrometastasis. When discrepancies occurred, the entire SLNs were subjected to histological studies and the node lysates to additional molecular studies. Five hundred three SLN samples from 233 patients were studied. Mean time to evaluate two SLNs was 40 min. Sensitivity per patient was 91.4% (95% CI, 76.9-98.2%), specificity 93.3% (95% CI, 88.6-96.6%), positive likelihood ratio 13.7 and negative likelihood ratio 0.1. Sensitivity was 63.6% for frozen sections and 47.1% for touch imprint cytology. Both methods were 100% specific. Positive histology and positive OSNA were significantly associated with highest clinical stage, N1 status and vascular invasion; and OSNA results correlated with HER2/neu status and benefited patients with negative histology. These findings show that OSNA assay can allow detection of SLN metastasis in breast cancer patients intraoperatively with a good sensitivity, thus minimizing the need for second surgeries for axillary lymph node detection.

Evaluation of axillary lymph nodes by diffusion‐weighted MRI using ultrasmall superparamagnetic iron oxide in patients with breast cancer: Initial clinical experience

To investigate the diagnostic performance and clinical feasibility of diffusion-weighted magnetic resonance imaging (MRI) using ultrasmall superparamagnetic iron oxide (USPIO) in the evaluation of axillary lymph nodes (ALNs) in patients with breast cancer. Sixteen patients with known breast cancer underwent 1.5 T MRI. Axial diffusion-weighted images (DWIs) and conventional T1- and T2*-weighted images (CIs) were acquired before and 24-36 hours after intravenous administration of USPIO. Detection of ALNs was evaluated on DWIs in comparison with CIs. The apparent diffusion coefficient values (ADCvs) of the nonmetastatic and metastatic nodes in precontrast DWIs were determined. The diagnostic performance of DWI using USPIO was compared with that of CIs using USPIO with pathological correlation. Out of a total of 286 ALNs, 216/286 (76%) nodes were detected on DWIs and 238/286 (83%) on CIs. The differences in the ADCvs between metastatic and nonmetastatic nodes were not significant (P = 0.06). Sensitivity of CIs and DWIs using USPIO were respectively 70% and 83%, specificity 98% and 98%, and overall accuracy 93% and 95%. Although the detection on DWIs of ALNs in patients with breast cancer was inferior compared to CIs, the sensitivity and accuracy of DWIs using USPIO were superior in the diagnosis of ALNs metastasis.

BREAST CYTOPATHOLOGY

During the last several years, the discipline of cytopathology has played a major role in responding to the changing trends in breast health care. Pathologists have been engaged not only in interpreting but also in performing minimally invasive procedures such as FNAB, CNB, and ductal lavage. These procedures have proved efficient in the diagnoses of malignant breast disease and are reliable in providing prognostic/predictive information.Fine needle aspiration biopsy is a time challenged, convenient, cost effective and rapid procedure, which is designed to remove the anxiety of a patient with a benign breast disease. With the availability of the bedside interpretation, the diagnosis of malignancy can accelerate plans for an optimal therapy. Core needle biopsy is more time consuming, more invasive and more expensive. It also shares similar limitations with FNAB. Sampling errors associated with inherent heterogeneity of breast lesions are serious concerns. In CNB, the rate of discovering carcinoma in situ in the follow up surgical excision of a lesion previously diagnosed as atypical ductal hyperplasia is significant. In addition, it is not unusual to discover invasive lesions in lumpectomy or mastectomy specimens diagnosed as in situ lesions by CNB.Despite the credibility of breast FNAB and CNB, the choice of the procedure will ultimately depend on local practice considerations and the availability of an experienced pathologist interested in breast cytopathology. The National Cancer Institute guidelines recommending appropriate FNAB sampling technique, training requirements, uniform criteria for specimens adequacy and radiologic pathologic correlation may assist in further acceptance of FNAB as a preferred diagnostic procedure particularly in palpable breast lesions.Aside from FNAB, breast cytomorphology has become an integral part of practice of breast pathology. The use of imprint cytology for assessment of metastatic disease in sentinel lymph node biopsy is now a common practice. Lymphatic mapping with sentinel lymph node biopsy allows a detailed pathologic examination of the nodes most likely to contain metastatic tumor. This procedure is designed for accurately staging and detection of macromutations. Intraoperative detection of micrometastasis will lead to a complete axillary lymph node detection in one surgical setting. Imprint cytology has shown superiority to frozen section and is the recommended procedure by the College of American Pathologists and the panelist of the ‘‘Philadelphia Consensus Meeting for Sentinel Node Biopsy.’’ Imprint cytology has also been effectively utilized for assessment of breast lumpectomy margins as a complement to frozen section.In addition, recent focus on early breast cancer detection and prevention has opened a new way to use minimally invasive procedures, such as FNAB, nipple fluid aspiration and ductal lavage for identification of high risk individuals. Chemopreventive studies have already confirmed the value of cytomorphology as a risk predictor. Recognition of cytomorphology of high risk proliferative breast disease and premalignant lesions is an intriguing concept to identify patients who may benefit from various risk reduction modalities. Coupled with molecular biologic testing and the new innovative imaging and surgical procedure such as ductoscopy, soon there will be an exciting opportunity for breast cytopathology to become an integral part of breast cancer research and preventions.

Klinische Wertigkeit der FDG PET in der Diagnostik gynäkologischer Tumoren: Empfehlungen der dritten Deutschen Interdisziplinären Konsensuskonferenz, „Onko-PET III“

- Introduction: The purpose of the 3rd Consensus Conference - PET in Oncology III was the evaluation of the present position - of FDG PET in oncology on the basis of international publications. - This study presents the data for gynecological tumors. Methods: A systematic literature research was performed in all common medical literature databases between 1997 and 2000. - All hits were manually checked and abstracts, case reports, tech- nically oriented papers and reviews were excluded from analysis. t The papers were selected using standardized quality assessment according to evidence-based medicine criteria. The selected papers were reviewed by an interdisciplinary panel of experts from oncology, radiology, radiation oncology, and nuclear medicine r and the clinical use was judged according to the following grading scheme (groups): 1a, established clinical use; 1b, clinical use r probable; 2, useful in individual cases; 3, not yet assessable owing to missing or incomplete data; 4, clinical use rare (either as inferred theoretical considerations or as demonstrated by published studies). Results: Breast cancer: Between 1997 and 2000, 21 studies with 924 patients were evaluable. The sensitivity and specificity of FDG PET for the diagnosis of breast cancer were 68%-100% and 83%-100%, respectively. Detection of primary breast cancer was classified in group 2 because of the possibility of a false-negative diagnosis especially in the case of small breast cancer and the ease of obtaining a histological diagnosis. The sensitivity of FDG PET for detection of axillary lymph node metastases was 84 - 100% with a specificity of 66% in one study and 85 - 100% in the others. Sensitivity was influenced by the number of involved lymph nodes and the tumor size of the primary lesions. Therefore, detection of axillary lymph node metastases was classified in group 1 b in patients with primary lesions > 2cm. First results indicate a high sensitivity of using FDG PET for detection of distant metastases and an early therapy monitoring. These indications were classified in group 3 because of the low number of studies. Other gynecological tumors: For the other gynecological tumors, data are as yet insufficient to enable a reliable assessment of clinical efficiency of FDG PET. Only the diagnosis of recurrence in Patients with ovarian cancer was classified in group 2. Outlook: According to the opinion of experts, the detection of axillary lymph nodes and distant metastases and therapy monitoring in breast cancer patients as well as the diagnosis of recurence in ovarian cancer are potentially useful clinical indications for FDG PET. Therefore, prospective studies with large patient groups are essential to further evaluate the benefit of FDG PET in these indications.

Lymph node revealing solution: a new method for detection of minute axillary lymph nodes in breast cancer specimens.

The staging and prognosis of patients with breast cancer is related to the presence or absence of axillary lymph node involvement. However, in some cases no lymph nodes or too small a number of lymph nodes are revealed by the traditional method of palpating and sectioning the axillary fat. In the present study we demonstrate the usefulness of the lymph node revealing solution (LNRS) in breast cancer. Specimens from 13 patients, in whom <10 lymph nodes were identified in the axilla by the traditional method, were included in the study. After excising the lymph nodes by the traditional method, axillary tissue was immersed in LNRS for 6-12 hours. Additional lymph nodes, which stood out as white chalky nodules, were excised and processed as usual. The LNRS increased the mean number of nodes per case from 6.0+/-2.5 found by the traditional method to 12.54+/-4.61 nodes per case (p < 0.01). The size of the nodes identified by the LNRS was significantly smaller (p < 0.01) than those detected by the traditional method. The LNRS changed the lymph node stage of the disease in four of the studied cases (30%). LNRS seems to be the technique of choice for detection of axillary lymph nodes in cases where the number of detected lymph nodes by the traditional method is too small for accurate staging.

High-frequency ultrasound (10–13 MHz) in inflammatory diseases of the breast

The role of high frequency ultrasound (10–13 MHz) in inflammatory disease of the breast is described. Forty-six patients with inflammatory breast problems were examined using both 10–13 and 7.5 MHz ultrasound; 39 patients also had mammography, 15 ultrasound-guided biopsy and 1 ductography. The diagnosis of inflammatory disease was confirmed by clinical and imaging follow-up only in 31, by cytology in 13 and at open surgical biopsy in 2. Diffuse mastitis imaged with 10–13 MHz ultrasound showed the following features: lymphatic involvement with (4 patients) or without (13 patients) a complex mass, ductal involvement with (1 patient) or without (4 patients) a complex mass, and ductal involvement associated with a complex mass and lymphangiectasia (1 patient). Focal mastitis imaged at 10–13 MHz demonstrated the following features: a complex predominantly solid mass (11 patients), a focal lesion with a predominantly fluid content (9 patients) and circumscribed ductal involvement with (1 patient) or without (2 patients) lymphangiectasia. Ultrasound imaging at 7.5 MHz failed to demonstrate lymphatic involvement in 15 of 19 patients and ductal involvement in all the patients. No difference was observed in the detection of axillary nodes at 7.5 MHz and 13 MHz. Ultrasound imaging at 7.5 MHz failed to identify focal solid lesions with a diameter of more than 10 mm in 2 of 6 patients. Ultrasound imaging at 7.5 MHz identified the nature of a solid mass in only 4 of 14 patients. We conclude that high frequency ultrasound (10–13 MHz) is effective, and more useful than conventional ultrasound at 7.5 MHz, in differentiating infection from lymphatic obstruction in patients with breast inflammation.