Indication For Surgical Excision Research Articles

Management of nipple adenomas during pregnancy: a case report

BackgroundNipple adenoma is a very uncommon, benign neoplasm that involves the nipple. A palpable mass of the nipple associated with nipple discharge and erosion or ulceration is the common clinical presentation. Generally, complete surgical excision of the nipple is the main treatment, alternative therapeutic methods such as Mohs micrographic surgery, nipple splitting enucleation, and cryotherapy can be considered. Disorders of the breast in young women are generally benign. Even if the management during pregnancy is usually conservative and surgical excision is reserved for very strong malignancy suspicion, benign lesions can cause the impossibility to breastfeed after giving birth when involving the nipple.Case presentationWe present the case of a 28-year-old female, who was referred to the Breast Unit of the University Hospital of Modena (Italy) in May 2020 with a 12-months history of enlargement of the left nipple with associated erythema, serohemorrhagic discharge, and pain in the left nipple region. The diagnostic assessment came out in favor of a nipple adenoma. After surgical treatment was recommended, the patient got pregnant. Taking into account the major risks of surgery during pregnancy, a multidisciplinary discussion was conducted, to consider whether to proceed with surgery or postpone it after pregnancy. Because of the volume and the position of the adenoma, the indication for surgical excision was confirmed, to allow regular lactation and breastfeeding immediately after giving birth and to avoid potential obstructive complications. Surgical excision of nipple adenoma without complete resection of the nipple was performed after her first trimester of pregnancy under local anesthesia. A histopathological examination confirmed the diagnosis. No recurrence occurred after 12 months. The patient gave birth, had no deficit in lactation, and successfully breastfed.ConclusionsTherefore, we consider that nipple adenoma enucleation might be a safe treatment even during pregnancy. Moreover, conservative local treatment of nipple adenomas can preserve the nipple aesthetically and functionally, thus allowing regular lactation and breastfeeding in young women.

Anatomical and Surgical Considerations for Ileocolic Endometriosis

We aim to review the incidence, location, and management of bowel endometriosis and demonstrate relevant surgical principles while emphasizing anatomic considerations for minimally invasive resection of ileocolic lesions. This video briefly reviews the background of bowel endometriosis and indications for surgical excision. We present a case of a patient diagnosed with symptomatic terminal ileum endometriosis and review the preoperative imaging. We demonstrate the steps of a medial-to-lateral surgical approach for ileocolic resection and highlight the relevant surgical anatomy. Institutional review board approval was not required. This procedure was performed at a large academic institution with a multidisciplinary team of minimally invasive gynecologic and colorectal surgeons. The case presented is a 44-year-old female with a known history of stage IV endometriosis. She presented with acute abdominal pain and was found to have a small bowel obstruction from a 3-centimeter lesion thought to be an endometrioma. She failed conservative management and was thoroughly counseled about the need for surgical intervention. Pelvic magnetic resonance imaging was performed for preoperative planning. Laparoscopic ileocolic resection is performed using a medial-to-lateral approach for excision of a symptomatic 3-centimeter ileocecal endometrioma. The following techniques are highlighted: (1) Evaluation of the entire small bowel starting at the ligament of Treitz (2) Entry into the retroperitoneum below the ileum with cranial and caudal dissection (3) Mobilization of the ascending colon to the level of the falciform ligament (4) Extension of the umbilical incision to perform an extracorporeal ileocecal resection and anastomosis CONCLUSION: The bowel is the most common extragenital site for endometriosis to occur, with the highest rate of lesions located in the rectosigmoid colon [1]. Lesions can be either superficial or deeply infiltrative and can lead to a range of symptoms. A serious sequela of bowel endometriosis includes bowel obstruction requiring surgical intervention.

Sonographic Features of Onychopapilloma: A Single Center Retrospective Observational Study

(1) Background: Onychopapilloma is a benign tumor of the nail bed and distal matrix. which usually manifests as monodactylous longitudinal eryhtronychia associated with subungual hyperkeratosis. The impossibility to rule out a malignant neoplasm is an indication for surgical excision and histological examination. Our aim is to report and describe the ultrasonographic features of onychopapilloma. (2) Methods: we conducted a retrospective analysis of patients with a histological diagnosis of onychopapilloma who underwent ultrasonographic examination in our Dermatology Unit from January 2019 to December 2021. (3) Results: Six patients were enrolled. Erythronychia, melanonychia, and splinter hemorrhages were the main dermoscopical findings. Ultrasonography detected nail bed dishomogeneity in three patients (50%) and a distal hyperechoic mass (5 patients, 83.3%). Color Doppler imaging did not show vascular flow in any of the cases. (4) Conclusions: the detection of a subungual distal non-vascularized hyperechoic mass by US, together with classical onychopapilloma clinical features, supports the diagnosis, especially in those patients who were unable to perform excisional biopsy.

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Anatomical and Surgical Considerations for Ileocolic Endometriosis

<h3>Study Objective</h3> We aim to review the incidence, location, and management of bowel endometriosis, as well as demonstrate anatomical considerations for surgical resection of ileocolic lesions. <h3>Design</h3> This video briefly reviews the background of bowel endometriosis and indications for surgical excision. We present a case of a patient diagnosed with a symptomatic ileocolic endometriosis lesion and review the preoperative imaging. We demonstrate the steps of a medial-to-lateral surgical approach for ileocolic resection and highlight the relevant surgical anatomy. <h3>Setting</h3> This procedure was performed at a large academic institution with a multidisciplinary team of minimally invasive gynecologists and colorectal surgeons. <h3>Patients or Participants</h3> The case presented is a 44-year-old female with a known history of stage IV endometriosis. She presented with acute abdominal pain, nausea and vomiting associated with her menses, and was found to have a small bowel obstruction from a 3cm lesion thought to be an endometrioma. She failed conservative management and was thoroughly counseled about the need for surgical intervention. Pelvic MRI was performed for preoperative planning. <h3>Interventions</h3> Laparoscopic ileocolic resection is performed utilizing a medial-to-lateral approach for excision of a symptomatic 3cm ileocecal endometrioma. <h3>Measurements and Main Results</h3> Successful excision of the endometrioma with a side-to-side ileocolic anastomosis was performed with resolution of the patient's symptoms. <h3>Conclusion</h3> The bowel is the most common extragenital site for endometriosis to occur, with the highest rate of lesions located in the rectosigmoid colon. Lesions can be either superficial or deeply infiltrative and can lead to a range of symptoms. A serious sequela of bowel endometriosis includes bowel obstruction requiring surgical intervention. We present a case of a 44-year-old female with acute bowel obstruction from a 3cm ileocecal endometrioma and demonstrate a medial-to-lateral surgical technique for ileocolic resection while emphasizing the relevant anatomical structures.

Comparison of Outcomes for Classic-Type Lobular Carcinoma In Situ Managed with Surgical Excision After Core Biopsy Versus Observation.

Studies report low upgrade rates following excision for classic-type lobular carcinoma in situ (LCIS) with radiologic-pathologic concordance. Thus, in the absence of other high-risk lesions, observation has become standard. We report long-term outcomes of excision versus observation following a core biopsy diagnosis of classic-type LCIS. Women with LCIS treated from 2013-2020 and managed with excision or observation were identified from a prospective database. Women with cancer upgrade at excision or history of cancer were excluded. We compared rates and characteristics of subsequent breast cancers by clinical management strategy. Of 312 women, 170 (54%) underwent excision and 142 (46%) were managed with observation. Among the excision group, 36 of 170 (21%) had radiologic-pathologic concordant LCIS without other high-risk lesions, mass, or symptoms (concordant LCIS excision group). Overall, at 3.1 years median follow-up, 11 (6.5%) women managed with excision and 11 (7.7%) women managed with observation developed cancer. Cancer development was not associated with management choice (overall excision cohort vs. observation group [p = 0.8]) and did not differ between the concordant LCIS excision and observation groups (p > 0.9). The 5-year cancer development rate was 8.9% (95% confidence interval [CI]: 2.3-31.6%) in the concordant LCIS excision group and 10.3% (95% CI 5.5-18.6%) in the observation group. No difference in breast cancer rates existed among women with a core-biopsy diagnosis of classic-type LCIS managed with excision or observation. These data support management of LCIS as a risk factor, with consideration of chemoprophylaxis, rather than as an indication for surgical excision.

English

BACKGROUND Most of the thyroid swellings are non-neoplastic and with normal thyroid hormone. So, it doesn't require any surgical excision, even though the thyroid swelling is an indication for surgical excision. The present study was done to evaluate the accuracy of fine needle aspiration cytology (FNAC) for the thyroid swellings and correlate it with the histopathological findings. METHODS This is a prospective study. A total of 47 cases were studied. Fine needle aspiration cytology was done, slides were made and studied. Histopathological examination of the corresponding 47 cases was also done and correlated with FNAC findings. Sensitivity, specificity and accuracy were calculated. RESULTS Age of the patients varied from 20 - 69 yrs. Most of them were in the age group of 30 - 39 years and 50 - 59 years. The ratio of male to female was 1:4.9. Swelling of the neck was the most common presentation in most of the patients. On FNAC 33 (70.2 %) cases were diagnosed as colloid nodular goitre, 04 (8.5 %) as autoimmune thyroiditis, 08 (17.0 %) as follicular neoplasm, 01 (2.1 %) as suspicious of malignancy, 01 (2.1 %) as papillary carcinoma. On histopathological examination 25 (53.2 %) cases were diagnosed as colloid nodular goitre, 01 (2.1 %) as fibrous thyroiditis, 01 (2.1 %) as Graves’ disease, 07 (14.9 %) as Hashimoto’s’ thyroiditis, 06 (12.8 %) as follicular adenoma, 01 (2.1 %) as follicular carcinoma, 04 (8.5 %) as papillary carcinoma and 02 (4.2 %) as NIFTP (noninvasive follicular thyroid neoplasm with papillary like nuclear features). The overall sensitivity was 69.2 %, specificity was 97.0 % and accuracy was 89.3 %. CONCLUSIONS FNAC is a minimally invasive, highly accurate and cost-effective procedure. FNAC helps the clinician to diagnose malignant lesions with confidence. It has high rates of specificity and accuracy but comparatively has less sensitivity. However, it is very important for the management of patients with thyroid swelling. KEYWORDS Fine Needle Aspiration, Prospective Study, Sensitivity, Specificity, Thyroid Swelling

Pseudo scapula alata: a case report of a scapular osteochondroma

&lt;p class="abstract"&gt;An osteochondroma is a type of cartilaginous tumour, that frequently affects long bones. In the scapula, although rare, this benign tumour is the most frequently encountered. The symptoms at this location are usually related to the mass effect that it can produce. Surgery is recommended when symptoms of compression, pain or an increase in size are noticed. The authors present a case of a 11 year-old-boy with an osteochondroma on the ventral surface of the scapula, that cause a pseudo winging of this bone and pain, with indication for surgical excision. Pseudo scapula alata should be differentiated from the true one, which is a dynamic dyskinesia. In the presence of this static deformity the surgeon must keep in mind other diagnosis as a scapular osteochondroma or other mass effect lesions. This benign tumour does not frequently suffer malignant transformation. Surgery can lead to a complete resolution of the symptoms, and if done properly decrease to almost zero the rate of recurrence. The diagnosis of the tumour in this location can be delayed due to its atypical location and presentation. With this case report the authors expect to raise awareness of the unusual manifestations of osteochondroma, especially in the paediatric setting.&lt;/p&gt;&lt;p class="abstract"&gt; &lt;/p&gt;

A study on evaluation of solitary nodular thyroid lesions by FNAC and its histopathological correlation

Background: Solitary nodular enlargement of thyroid is one of the common indications for surgical excision. Since most of the nodules are benign, symptomless, normal thyroid hormone profile, they do not require excision. This study was done to evaluate the utility of FNAC as a rapid diagnostic method in various thyroid lesions and guide the clinician for further treatment.&#x0D; Objective: This main objective of the study to evaluate the cyto-histopathological findings, and the accuracy of fine needle aspiration cytology (FNAC) procedure in solitary nodular thyroid lesions.&#x0D; Materials and Methods: This prospective study comprises total 160 cases with thyroid lesions referred to cytopathology laboratory and gland morphology studied by ultrasonography (USG). Based on ultrasonography report Fine Needle Aspiration were done manually or guided and aspirated material fixed on fixative and stained to examine.&#x0D; Results: Age incidence varied from 10-80 yrs. The commonest age group affected was 21-40 yrs. The ratio of male to female was 1:2.2. The duration of symptoms ranged from 10 days to 15 years. Maximum number of cases presented with midline swelling of the neck. On cytology 52 (32.5%) cases were diagnosed as colloid goiter, 46 (28.75%) as colloid goiter with cystic change, 16(10%) as thyroiditis - among them 6(3.75%) as granulomatous thyroiditis, 8(5%) as lymphocytic thyroiditis, 2(1.25%) as dequervain thyroiditis, 10 (6.25%) as follicular neoplasm, 2(1.25%) as hurthle cell adenoma, 5(3.3%) as papillary carcinoma, 2 (1.25%) as medullary carcinoma, 1(0.33%) anaplastic carcinoma and 1(0.33%) NHL as suspicious smear. Histopathological examination was possible in 60 cases. The overall sensitivity was 90.2%, specificity was 98.2% and accuracy was 97.1%.&#x0D; Conclusion: FNAC is a rapid, efficient, cost-effective, relatively painless procedure and produces a early result with a high diagnostic accuracy. It has high rates of sensitivity and specificity to diagnose the solitary thyroid lesions and thereby it is an important diagnostic tool and further management of patients with thyroid lesions.&#x0D; Bangladesh Journal of Medical Science Vol.18(4) 2019 p.789-795

Mammotome biopsy in diagnosing and treatment of intraductal papilloma of the breast

Intraductal papilloma is a benign breast tumor which needs histopathological verification because of the risk of cancer coincidence. To assess the value of the mammography-guided and ultrasound-guided vacuum-assisted core biopsy in the diagnosis and treatment of intraductal papillomas of breast and to answer the question if mammotome biopsy allows to avoid surgery in these patients. In the period 2000-2011, a total of 2246 vacuum-assisted core biopsies were performed, of which 1495 were ultrasound-guided and 751 were mammography-guided (stereotaxic). In 76/2246 patients (3.4%), aged 19-88 years (mean age was 51,5) histopathological examination confirmed intraductal papilloma. Atypical lesions were accompanying intraductal papilloma in 16/76 cases (21%). Open surgical biopsy performed in these group revealed invasive cancer in 3 women. In all 60 cases (79%) with benign papilloma in biopsy specimens, further clinical observation did not show recurrence or malignant transformation of lesions. Vacuum-assisted core biopsy is a minimally invasive and efficient method used for diagnosing intraductal papilloma of the breast. If histopathological examination confirms a benign character of the lesion, surgery may be avoided but regular follow-up is recommended. However, in all cases histopathological diagnosis of papilloma with atypical hyperplasia, should always be indication for surgical excision.

The Change in Ocular Higher-Order Aberrations After Pterygium Excision With Conjunctival Autograft

To investigate the effects of pterygium excision with conjunctival autograft plus corneal polishing on ocular higher-order aberrations (HOAs) and to monitor the changes throughout the first postoperative year. A total of 18 eyes of 16 patients with primary pterygium who had an indication for surgical excision were included in the study. All patients underwent a detailed ophthalmologic examination preoperatively and at the third and twelfth postoperative months. Pterygium excision with conjunctival autograft plus corneal polishing was performed by the same surgeon (K.G.). Corneal topography and ocular HOAs were measured by NIDEK optical path difference scanning system ARK-10000 refractive power/corneal analyzer. Root mean square values of total aberrations and total HOAs were found to be significantly decreased both at 3 and 12 months after an uneventful pterygium surgery. Although solely root mean square values of coma and trefoil revealed a statistically significant reduction in the third postoperative month (P=0.043 and P=0.018, respectively), after 1 year, all parameters (total coma: P<0.001; total trefoil: P=0.004; total quatrefoil: P=0.010; and total high astigmatism: P=0.016) except for total spherical aberration (P=0.236) were found to be lower when compared with the preoperative values. Uneventful pterygium excision with conjunctival autograft plus corneal polishing can significantly reduce most of the pterygium-induced HOAs. Moreover, the reduced postoperative aberrations continue to change beyond the early postoperative period even into the 1-year postoperative period. Therefore, any refractive procedures should be postponed at least 1 year after the pterygium surgery until corneal stability occurs.

Vacuum-Assisted Core Biopsy in Diagnosis and Treatment of Intraductal Papillomas

BackgroundThe aim of this study was to assess the value of mammographically-guided and ultrasonographically-guided vacuum-assisted core biopsy (VACB) in the diagnosis and treatment of intraductal papillomas of breast and to answer the question of whether biopsy with the Mammotome (Mammotome; Cincinnati, OH) allows the avoidance of surgery in these patients. Patients and MethodsIn the period 2000 to 2010, a total of 1896 vacuum-assisted core biopsies were performed, of which 1183 were ultrasonographically guided and 713 were mammographically guided (stereotaxic). ResultsIn 62 patients (3.2%) histopathologic examination confirmed intraductal papilloma, and in 12 patients (19.4%) atypical lesions were also found. Open surgical biopsy specimens revealed invasive cancer in 2 women these 12 women (false-negative rate, 16.7%; negative predictive value, 83.3%). Biopsy specimens from the remaining 50 patients (80.6%) revealed papilloma without atypia, and further clinical observation and imaging examinations did not show recurrence or malignant transformation of lesions. Hematoma developed in 3 (4.8%) patients as a complication of biopsy; surgical intervention was not required in any of the patients. ConclusionVACB is a minimally invasive and efficient method for diagnosing intraductal papilloma of the breast. If histopathologic examination confirms a benign lesion and corresponds to the clinical presentation, surgery may be avoided. However in all cases, histopathologic diagnosis of papilloma with atypical hyperplasia or a suspected malignant lesion in imaging examinations, despite negative biopsy results, should always be an indication for surgical excision.

Hiperplasia ductal atípica de mama: correlación de la biopsia percutánea y los resultados de la biopsia quirúrgica

ObjetiveThe purpose was to evaluate the prevalence of carcinoma found at surgical biopsy of llesions identified as atypical ductal hyperplasia by percutaneous breast biopsy. MethodsWe performed a retrospective study of all asymptomatic patients with a result of atypical ductal hyperplasia on percutaneous breast biopsy and who underwent surgical excision from January 2002 to December 2010. ResultsSixty-eight patients were found to have atypical ductal hyperplasia at percutaneous breast biopsy and were evaluated with surgical biopsy. Seventeen patients (25%) had carcinoma at surgical excision, 10 had ductal carcinoma in situ, and 7 patients had invasive carcinoma. The mammographic characteristics associated with malignancy were analyzed. ConclusionsA finding of atypical ductal hyperplasia at percutaneous breast biopsy frequently corresponds to cancer and is therefore an indication for surgical excision.

Flat Epithelial Atypia of the Breast on Core Needle Biopsy: An Indication for Surgical Excision

Flat epithelial atypia (FEA) is an increasingly diagnosed breast lesion yet there remains a paucity of data regarding these findings and their clinical significance. By determining the pathologic concordance rate, we sought to evaluate the indications for surgical intervention for FEAs diagnosed on core needle biopsy (CNB). Using a retrospective review of an international pathology referral center database, we included all breast CNB specimens with FEA as the most advanced diagnosis that underwent surgical excision. Patient demographics, caliber of biopsy needle, and pathology results were then analyzed. Between 2000 and 2009, 463 FEAs were diagnosed among 15,000 specimens referred for expert opinion. Twenty-four lesions (5%) met inclusion criteria. Sampling ranged from 8- to 18-guage needles. Two lesions (8.4%) were upgraded after surgical excision; one patient was found to have infiltrating ductal carcinoma and another with tubular carcinoma. Twelve patients who were diagnosed with FEA did not undergo surgical excision but had no immediate evidence of malignancy. Based on the 8.4% upgrade rate, FEA diagnosed on CNB requires follow-up surgical excision. Regardless of CNB caliber, the risk of sampling error precludes nonoperative management and FEA should be considered an at-risk lesion until more studies and pooled analysis prove otherwise.

Cohort study of patients with adrenal lesions discovered incidentally

This prospective cohort study investigated the incidence, clinical features and natural history of incidentally discovered adrenal mass lesions (adrenal incidentaloma, AI) in an unselected population undergoing radiological examination. During an 18-month period, all patients with AI were reported prospectively from all 19 radiology departments in western Sweden. Inclusion criteria were: incidentally discovered adrenal enlargement or mass lesion in patients without extra-adrenal malignancy on detection. Clinical and biochemical evaluation was performed on inclusion and after 24 months. Computed tomography (CT) of the adrenals was scheduled at 4, 12 and 24 months. Magnetic resonance imaging was performed for lesions larger than 20 mm. The indications for surgical excision were: hormone activity, lesion diameter more than 30 mm, lesion growth or other radiological features suspicious of malignancy. Of 534 patients assessed for eligibility, 226 (mean age 67 years, 62·4 per cent women; mean lesion diameter 23·9 mm, 22·6 per cent bilateral) fulfilled the inclusion criteria. Mean follow-up was 19·0 months. After baseline evaluation, 14 patients had surgery owing to primary hyperaldosteronism (3), catecholamine-producing tumour (1), tumour size (6), size and indication of subclinical hypercortisolism (3) and metastasis (1). No hypersecreting lesions were confirmed during follow-up; one patient underwent adrenalectomy for a suspected phaeochromocytoma (adrenocortical adenoma at histopathology). No primary adrenal malignancy was found. In this prospective cohort study 6·6 per cent of patients with an AI had surgery and benign hormone-producing tumours were verified in 3·1 per cent. Repeat CT and hormone evaluation after 2 years did not increase the sensitivity for diagnosis of malignant or hormone-producing tumours.

Extent and Histologic Pattern of Atypical Ductal Hyperplasia Present on Core Needle Biopsy Specimens of the Breast Can Predict Ductal Carcinoma In Situ in Subsequent Excision

Atypical ductal hyperplasia (ADH) diagnosed by core needle biopsy (CNB) is regarded as an indication for surgical excision. We investigated whether histologic subtype and extent of ADH in a series of 123 CNB specimens can predict the presence of carcinoma on surgical excision. We found that ADH present in more than 2 foci in CNB specimens was a strong predictor of ductal carcinoma in situ (DCIS) on excision (>2 foci, 16/41 vs 6/82 for 1 or 2 foci; P < .0001). The micropapillary subtype of ADH also predicted the presence of DCIS (P = .0006). Our study suggests that micropapillary histologic subtype and extent of ADH in CNB specimens can be applied to predict the presence of DCIS on surgical excision. By using the combination of the extent of ADH in CNB specimens (1 or 2 foci), the presence of microcalcifications within the lesion, and the lack of residual mammographic calcifications after CNB, we identified a low-risk group of patients (n = 25), none of whom had carcinoma on surgical excision. Patients with ADH restricted to fewer than 3 foci may not need surgical excision, especially when the mammographic abnormality is completely removed by CNB.

A Decade of Change: An Institutional Experience with Breast Surgery in 1995 and 2005

With the adoption of routine screening mammography, breast cancers are being diagnosed at earlier stages, with DCIS now accouting for 22.5% of all newly diagnosed breast cancers. This has been attributed to both increased breast cancer awareness and improvements in breast imaging techniques. How have these changes, including the increased use of image-guided sampling techniques, influenced the clinical practice of breast surgery? The institutional pathology database was queried for all breast surgeries, including breast reconstruction, performed in 1995 and 2005. Cosmetic procedures were excluded. The results were analysed utilizing the Chi-square test. Surgical indications changed during 10-year study period, with an increase in preoperatively diagnosed cancers undergoing definitive surgical management. ADH, and to a lesser extent, ALH, became indications for surgical excision. Fewer surgical biopsies were performed for indeterminate abnormalities on breast imaging, due to the introduction of stereotactic large core biopsy. While the rate of benign breast biopsies remained constant, there was a higher percentage of precancerous and DCIS cases in 2005. The overall rate of mastectomy decreased from 36.8% in 1995 to 14.5% in 2005. With the increase in sentinel node procedures, the rate of ALND dropped from 18.3% to 13.7%. Accompanying the increased recognition of early-stage cancers, the rate of positive ALND also decreased, from 43.3% to 25.0%. While the rate of benign breast biopsies has remained constant over a recent 10-year period, fewer diagnostic surgical image-guided biopsies were performed in 2005. A greater percentage of patients with breast cancer or preinvasive disease have these diagnoses determined before surgery. More preinvasive and Stage 0 cancers are undergoing surgical management. Earlier stage invasive cancers are being detected, reflected by the lower incidence of axillary nodal metastases.

Underestimation of Atypical Ductal Hyperplasia at MRI-Guided 9-Gauge Vacuum-Assisted Breast Biopsy

The purposes of this study were to determine the frequency of diagnosis of atypical ductal hyperplasia (ADH) at MRI-guided 9-gauge vacuum-assisted breast biopsy and to assess the rate of underestimation of ADH at subsequent surgical excision. We conducted a retrospective review of medical records of 237 lesions consecutively detected with MRI and then subjected to MRI-guided 9-gauge vacuum-assisted breast biopsy during a 33-month period. Underestimated ADH was defined as a lesion yielding ADH at vacuum-assisted biopsy and cancer at surgery. Scientific tables were used to calculate 95% CI. Histologic analysis of MRI-guided vacuum-assisted breast biopsy specimens yielded ADH without cancer in 15 (6%) of 237 lesions. Among 15 patients in whom vacuum-assisted breast biopsy yielded ADH, the median age was 52 years (range, 46-68 years). The median number of specimens obtained was nine (range, 8-18 lesions). Median MRI lesion diameter was 1.3 cm (range, 0.7-7.0 cm). Among 15 MRI lesions, 10 (67%) were nonmasslike enhancement and five (33%) were masses. Surgical excision was performed on 13 lesions. Surgical histologic findings were malignancy in five (38%) of the cases, all ductal carcinoma in situ; high-risk lesion in six (46%) of the cases, including ADH without other high-risk lesions (n = 2), ADH and lobular carcinoma in situ (LCIS) (n = 1), ADH, LCIS, and papilloma (n =1), ADH and papilloma (n = 1), and LCIS (n = 1); and benign in two (15%) of the cases. These data indicated an ADH underestimation rate of 38% (95% CI, 14-68%). ADH without cancer was encountered in 6% of MRI-guided 9-gauge vacuum-assisted breast biopsies. ADH at MRI-guided vacuum-assisted breast biopsy is an indication for surgical excision because of the high (38%) frequency of underestimation of these lesions.

Pneumatoceles in postpneumonic empyema: an algorithmic approach

Purpose The aim of the study was to determine the natural course and select appropriate therapy for pneumatocele (PC) in children with postpneumonic empyema. Materials and Methods Records of 134 children treated for postpneumonic empyema between October 1997 and June 2003 were reviewed retrospectively, and 58 (43%) of them were found to have PC. Their chest x-rays and computed tomography scans as well as patient profiles were evaluated to assess the size, location, course, and complications. Clinical course, treatment indications, and results were also reviewed. Results The patients were aged from 14 months to 15 years (mean 3.8 years). There were 36 boys and 22 girls. The PC was located on the right hemithorax in 34 patients and on the left in 24. Staphylococcus aureus was the most common isolated infective agent. Of the 58 children, 37 (63.7%) showed complete resolution with improvement of the infection within 2 months. Thirteen PCs had evidences of gradual decrease in size without any indication for invasive approaches, and they resolved completely, with a mean time of 6.1 (ranging from 1-13) months. One tension PC, 3 large PCs (>50% of hemithorax), 1 case with bad tolerance to follow-up, and 2 persistent PCs had no reduction in size on follow-up; a total of 7 patients underwent image-guided catheter drainage procedure, and 5 of them resolved completely. In the last 2 cases, surgical excision was required because of persistent cystic cavity caused by thickened PC wall. One patient whose PC had not been decreasing in size developed findings of severe lung abscess with thickened wall and directly underwent surgery. In none of these patients recurrences or complaints related to PC were noted on their control visits. Conclusion Most of these PCs are simple PC and show spontaneous resolution with improvement of the infection within the first 2 months. However, some decrease gradually by time, and close follow-up should be continued in case of complicated PC. Persistent features of chest infection, more than 50% involvement of hemithorax and severe atelectasis, development of broncopleural fistulae (tension PC), and bad tolerance to follow-up remind complicated PC, and they are indications of image-guided catheter drainage procedure. Its failure occurs in PC with thickened wall that does not collapse, as was in our cases with persistent PC and severe infected PC, and thus, this is an indication for surgical excision.

Imaging–histologic discordance at percutaneous breast biopsy

The purpose of the current study was to determine the frequency of imaging-histologic discordance at percutaneous breast biopsy and to assess the likelihood of carcinoma in these discordant lesions. Percutaneous imaging guided breast biopsy was performed on 1785 consecutive lesions during a 7-year period under stereotactic (n = 1205) or sonographic (n = 580) guidance, using an automated needle (n = 1044) or directional vacuum-assisted probe (n = 741). Lesions were prospectively classified according to the Breast Imaging Reporting and Data System (BI-RADS) as Category 3 (probably benign), Category 4 (suspicious), or Category 5 (highly suggestive of malignancy). Imaging-histologic discordance was considered to have occurred when the percutaneous biopsy histology did not provide a sufficient explanation for the imaging features; in such cases, repeat biopsy was recommended. Medical records, imaging studies, and histologic findings were reviewed. Imaging-histologic discordance was present in 56 of 1785 (3.1%) lesions. The frequency of discordance was significantly higher in our first 2 years of experience with percutaneous biopsy than in later years (18 of 361 = 5.0% vs. 38 of 1424 = 2.7%; P < 0.04) and was significantly higher for lesions that were BI-RADS Category 5 rather than BI-RADS Category 4 (20 of 416 = 4.8% vs. 36 of 1366 = 2. 6%; P < 0.04). The frequency of discordance was significantly lower with the 11-gauge vacuum-assisted probe than other devices for calcifications (7 of 414 = 1.7% vs. 16 of 251 = 6.8%; P = 0.001) but not for masses (6 of 161 = 3.7% vs. 26 of 959 = 2.7%; P = 0.44). Repeat biopsy, performed in 45 discordant lesions revealed carcinoma in 11 (24.4%; 95% confidence intervals, 12.9-39.5%). The frequency of carcinoma was significantly higher among discordant BI-RADS Category 5 than discordant BI-RADS Category 4 lesions (7 of 16 = 43. 8% vs. 4 of 29 = 13.7%; P < 0.04). Imaging-histologic discordance occurred in 3.1% of lesions that had percutaneous breast biopsy. Imaging-histologic discordance was an indication for surgical excision because of the high (24.4%) prevalence of carcinoma in these lesions.