Stereotactic Needle Research Articles

Long-Term Follow-up of 25 Cases of Biopsy-Proven Radiation Necrosis or Post-Radiation Treatment Effect Treated With Magnetic Resonance-Guided Laser Interstitial Thermal Therapy.

Magnetic resonance-guided laser-induced thermal therapy (MRgLITT) is a minimally invasive surgical treatment for progressive neoplasms and post-radiation treatment effect (PRTE). To evaluate the radiographic response and efficacy of MRgLITT for biopsy-confirmed PRTE and the quality-of-life outcomes of patients following MRgLITT. We conducted a single-center retrospective study of radiographic responses and clinical outcomes of 25 patients with previously treated primary or secondary brain neoplasms (World Health Organization grades 4 [n = 8], 3 [n = 5], 2 [n = 5]) and metastatic brain tumors (n = 7). MRgLITT was applied directly following stereotactic needle biopsy confirming PRTE without any evidence of tumor presence. Mean overall survival times (months) for grades 4 and 3 and for metastatic brain tumors were 39.2 (standard error [SE], 7.6; 95% confidence interval [CI], 24.3-54.1), 29.1 (SE, 7.7; 95% CI, 14.0-44.2), and 55.9 (SE, 10.0; 95% CI, 36.3-75.4), respectively. Mean progression-free survival times after MRgLITT were 9.1 (SE, 3.6; 95% CI, 2.1-16.1), 8.5 (SE, 2.4; 95% CI, 3.9-13.2), and 11.4 (SE, 3.9; 95% CI, 3.8-19.0), respectively. Mean survival times after MRgLITT were 13.1 (SE, 2.3; 95% CI, 8.5-17.6), 12.2 (SE, 4.0; 95% CI, 4.4-20.0), and 19.2 (SE, 5.3; 95% CI, 8.9-29.6), respectively. The SF-36 indicated significant overall effects on mental health (P = .029) and vitality (P = .005). MRgLITT may be a viable option for patients with symptomatic advancing PRTE and is less invasive than open craniotomy. Although our results suggest a positive effect for MRgLITT on PRTE, prospective randomized trials with larger numbers of patients are needed to validate the study results. cRBV, relative cerebral blood volumeHIF1a, hypoxia-inducible factor 1aIMRT, intensity-modulated radiation therapyKPS, Karnofsky Performance StatusLITT, laser-induced thermal therapyMBT, metastatic brain tumorMRgLITT, magnetic resonance-guided laser-induced thermal therapyPRTE, post-radiation treatment effectSRS, stereotactic radiosurgeryVEGF, vascular endothelial growth factorWBXRT, whole brain radiation therapy.

C-arm cone-beam computed tomography with stereotactic needle guidance for percutaneous adrenal biopsy: initial experience.

Background Metastasis to the adrenal glands is frequent in patients with various cancers and adrenal gland biopsy is routinely performed using ultrasound or computed tomographic (CT) guidance. However, this method is technically challenging, especially in the case of small masses. Purpose To determine whether the new real-time stereotactic needle guidance technique C-arm cone-beam CT (CBCT) allows safe and accurate biopsy of adrenal gland masses, especially those in hard-to-reach anatomical locations. Material and Methods CBCT guidance was used to perform 60 stereotactic biopsy procedures of lesions that were inaccessible with ultrasound or CT guidance. The needle path was carefully planned and calculated on the CBCT virtual navigation guidance system, which acquired 3D CT-like cross-sectional images. The adrenal biopsy procedures were performed with fluoroscopic feedback. Technical success rate, sensitivity, specificity, accuracy, and complications were investigated. Results The technical success rate of adrenal biopsy under CBCT virtual navigation was 100%, with a mean total procedure time of 14.6 ± 3.6 min. Of the 60 lesions, 46 were malignant, 11 were benign, and three were non-diagnostic. The three non-diagnostic lesions proved to be malignant. Thus, the sensitivity, specificity, and accuracy were 93.8%, 100%, and 95.0%, respectively. Minor bleeding occurred in two (3.3%) cases. Conclusion CBCT guidance allows safe and accurate biopsy of adrenal gland masses and may be especially useful for hard-to-reach anatomical locations.

A prospective comparative study to evaluate the displacement of four commercially available breast biopsy markers

Radiopaque markers are commonly deployed following breast biopsies to indicate the location of the targeted lesion. A frequently encountered complication is the displacement of these markers. This study compared the degree of displacement among four newer generation markers after stereotactic core needle biopsy. 80 consecutive biopsies were performed at three breast centre sites. The markers included: HydroMARK(®) (Mammotome, Cincinnati, OH), MammoMARK™ (Mammotome, Cincinnati, OH), MammoStar™ (Mammotome, Cincinnati, OH) and SecurMark(®) (Hologic, Bedford, MA). Each marker was composed of a radiopaque core with a unique polymeric encasing component. Post-procedure mammograms were obtained and the degree of marker displacement was measured. MammoMARK™ exhibited the greatest mean net displacement, followed by HydroMARK(®), SecurMark(®) and MammoStar™ (13.9, 7.7, 5.8 and 4.7 mm, respectively), although these differences did not reach statistical significance (p = 0.398). 73% of the markers did not displace at all. However, in the 19 of 22 markers in which displacement occurred, the distance from the biopsy cavity was >10 mm. No statistically significant contributing factors to predict displacement were found. Newer generation biopsy markers perform comparably with one another. However, clinically significant and unpredictable marker displacement persists. Compared with multiple similar studies of older generation bare metallic markers, the overall displacement rate of newer generation markers seems to be lower, possibly owing to the use of polymeric embedding agents that self-expand within the biopsy cavity. This article compares the post-procedure displacement of breast biopsy markers, which have not been evaluated or discussed in detail since markers with polymeric embedding agents gained widespread use.

NS-15NEUROSURGICAL MANAGEMENT OF TECTAL GLIOMAS

NS-15. NEUROSURGICAL MANAGEMENT OF TECTAL GLIOMAS Andrea Carai1, Antonio Marrazzo2, Vito Andrea dell’Anna2, Alessandro De Benedictis1, Raffaella Messina1, Franco Randi1, Giovanna Stefania Colafati3, Antonella Cacchione2, Evelina Miele2, Angela Mastronuzzi2, and Carlo Efisio Marras1; Department of Neurosciences and Neurorehabilitation, Neurosurgery Unit, Bambino Gesu Children’s Hospital, Rome, Italy; Department of Hematology and Oncology, Bambino Gesu Children’s Hospital, Rome, Italy; Department of Imaging, Neuroradiology Unit, Rome, Italy Tectal gliomas are a rare entity mostly showing an indolent clinical course. However, in some cases progression of disease prompts medical treatment. We report a series of 12 consecutive patients diagnosed with tectal glioma at the Bambino Gesu Children’s Hospital from 2012 to 2016. Diagnosis was made according to typical radiological features. Mean follow-up was 43 months (4 to 75 months). Symptoms at onset were macrocrania and full fontanelle in congenital cases and headache, vomiting, ataxia, postural instability, short term memory and attention difficulties in older children, suggesting a strong role of hydrocephalus. Mean age at diagnosis was 8 years and girls were three times more frequent than boys. Hydrocephalus was present at the timeof the diagnosis virtually inall cases (10/11). In three caseshydrocephalus was congenital but diagnosis of tectal glioma was made 8 years later in one case, due to limited access to MRI imaging at the time of hydrocephalus treatment. Hydrocephalus was treated by endoscopic ventriculostomy in all patients presenting after 2008. We had a major complication in one girl, suffering acute intracranial hypertension with severe outcome 20 months after diagnosis presumably from unexpected ventriculostomy closure. After that, we propose routine positioning of a Rickham ventricular access device in all children with hydrocephalus secondary to tectal gliomas. Three children showed progression of their tectal lesion or gaze disturbances prompting stereotactic needle biopsy to obtain histological diagnosis and start oncological treatment. Surgical resection was never indicated, as large esophytic lesions were not observed in our series. Neuro-Oncology 18:iii127–iii134, 2016. doi:10.1093/neuonc/now078.15 #The Author(s) 2016. Published by Oxford University Press on behalf of the Society for Neuro-Oncology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

Abstract P6-02-11: When needles are needed

Abstract Background Women with positive screening mammograms but negative at assessment (false-positive) are referred back to routine screening assuming that they have an average risk of breast cancer. However in a long-term follow-up of women with false-positive screening mammography we found that these women had in fact an excess risk of breast cancer later in life; RR=1.67(von Euler-Chelpin et al, JNCI 2012). This finding has later been supported by Castells et al.(Cancer Epidemiol, 2013). Furthermore, we studied the breast cancer cases in false-positive women and found that 26% of the cases were misclassified and were in fact true positives. However, even correction for misclassification, the false-positive women in our study remained at an excess breast cancer risk. At the same time, it was clear that, in the later periods of our study, when more modern techniques were used, the rate of misclassification decreased (von Euler-Chelpin et al, Cancer Epidemiol., 2014). Over time there have been changes both in the imaging and biopsy techniques. We used data from an organised screening programme in Denmark. Since its start in 1991, needle biopsies have been performed on all palpable solid lesions and on all uncertain, suspicious or malignant findings. In the very beginning fine needle aspiration cytology (FNAC) was used, later to be replaced by needle core biopsies in the majority of cases. Since 2002, suspicious micro-calcifications and impalpable mammographic findings not found by ultrasound have been examined using stereotactic needle core biopsy and later with vacuum-assisted breast biopsy as a replacement for surgical biopsy. To have a needle breast biopsy taken is a psychological burden on the woman. To minimize the harms and maximize the benefits is at the core of developing medical care. We therefore mapped the use of needle biopsies over time in a long-standing, organised screening programme. Method: We used data from the population-based screening mammography program in Copenhagen, Denmark. The programme has a database including personal records on demographic data, date of invitation, data of screening, and test results,1998-2013. Data from the Mammography Register were linked to the Danish Pathology Register (for biopsy procedures). Results: A total of 208 500 screens were included in the study. The rate of recall for assessment ranged between 1.7-3.2% of screened women with a mean of 2.4. The false-positive rate ranged between 1.0-2.5% with a mean of 1.6%. In 1998, 56% of all recalled women had a biopsy taken, which by 2013 had risen to 74% (using two-year smoothing). In proportion of all screens, the biopsy rate was 1.9% in 1998/99 which then fell to 0.7% in 2005/06 and the rose again 2.0% in 2012/13. In 1998, 59% of the biopsies were fine-needle aspiration cytology (FNAC) which by 2013 was only used in 11% of the cases, and replaced by core biopsies, ultrasound or stereotactic guided. Conclusion While the recall rate, as well as the false-positive rate, has been fairly stable during the study period the use of needle core biopsies has had a u-shaped development and has intensified in the later years. Citation Format: von Euler-Chelpin M, Vejborg I, Lænkholm A-V, Guleria S, Peterkin A, Lynge E. When needles are needed. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P6-02-11.

Diagnostic underestimation of atypical ductal hyperplasia and ductal carcinoma in situ at percutaneous core needle and vacuum-assisted biopsies of the breast in a Brazilian reference institution.

ObjectiveTo determine the rates of diagnostic underestimation at stereotactic percutaneous core needle biopsies (CNB) and vacuum-assisted biopsies (VABB) of nonpalpable breast lesions, with histopathological results of atypical ductal hyperplasia (ADH) or ductal carcinoma in situ (DCIS) subsequently submitted to surgical excision. As a secondary objective, the frequency of ADH and DCIS was determined for the cases submitted to biopsy.Materials and MethodsRetrospective review of 40 cases with diagnosis of ADH or DCIS on the basis of biopsies performed between February 2011 and July 2013, subsequently submitted to surgery, whose histopathological reports were available in the internal information system. Biopsy results were compared with those observed at surgery and the underestimation rate was calculated by means of specific mathematical equations.ResultsThe underestimation rate at CNB was 50% for ADH and 28.57% for DCIS, and at VABB it was 25% for ADH and 14.28% for DCIS. ADH represented 10.25% of all cases undergoing biopsy, whereas DCIS accounted for 23.91%.ConclusionThe diagnostic underestimation rate at CNB is two times the rate at VABB. Certainty that the target has been achieved is not the sole determining factor for a reliable diagnosis. Removal of more than 50% of the target lesion should further reduce the risk of underestimation.

Favourable outcome of combined medical surgical treatment of cerebral aspergillosis of pulmonary origin

Introduction: Cerebral aspergillosis is a highly fatal infection. Its origin is most likely blood-borne from the lungs and most patients are immunosuppressed. Mortality is over 90 % and the treatment chosen is key for survival. Case presentation: We report a 32-year-old female with a history of acute myeloid leukaemia (M3) who was admitted to the hospital due to a nodular infiltrate in the right superior lobe. A lung computed tomography (CT) scan displayed a right upper lobe cavitated nodule. A brain CT scan showed a right hemisphere deep abscess. Pulmonary aspergillosis was diagnosed after bronchoalveolar lavage. Three weeks later, while on antifungal treatment with voriconazole and liposomal amphotericin B, she suffered left motor focal deficits, and brain abscess puncture and aspiration by neuronavigation were performed for diagnosis and decompression. A PCR assay was positive for Aspergillus fumigatus. One week later, she developed an intraventricular brain haemorrhage requiring external ventricular drainage and intrathecal fibrinolysis with recombinant tissue plasminogen activator. She eventually achieved a good neurological outcome. A control brain CT showed an important reduction in mass size. Conclusion: Antifungal treatment is the mainstay for brain abscess treatment, and its combination with stereotactic needle aspiration is a better option compared with open surgery, particularly in abscesses located in deep motor areas.

PTCT-02STEREOTACTIC LASER INTERSTITIAL ABLATION THERAPY FOR PEDIATRIC LOW-GRADE GLIAL NEOPLASMS

INTRODUCTION: Slowly growing deeply situated brain tumors in children pose a unique management dilemma. Considerations of watchful waiting, resection, chemotherapy and radiation therapy must be weighed carefully. With concerns over neurosurgical resection morbidity, the typical long-term ineffectiveness of chemotherapy and the feared sequelae of radiation therapy, our institution has chosen to manage select tumors using laser interstitial ablation via the stereotactic Visualase® system. METHODS: Five patients, ages 7, 8, 12, 15, 16 years had clinicoradiographic histories of slowly enlarging deep brain lesions characteristic of low-grade glial tumors. Locations included deep thalamus (2), cerebellar vermis (1), parieto-occiptal region (1) and a SEGA near a foramen of Monro (1). Options for management were discussed with each family, and laser ablation was decided upon. RESULTS: The patients were taken to the intraoperative MRI operating room for stereotactic needle biopsy and laser interstitial ablation during the same operation. Frozen section tissue analysis in all cases showed a low-grade glial tumor. Each patient underwent standard post-operative scanning, all showing evidence of lesional/peri-lesional signal change, a sign suggestive of desired zonal ablation injury to the tumor. Four patients had no evidence of post-procedure complications and were discharged several days post-procedure. One patient (cerebellar vermis) had significant post-ablation procedure ataxia and had evidence of incomplete ablation by virtue of tumor progression 16 months later, requiring a second ablation. None had evidence of concerning hemorrhage. All tumors were finalized as being low-grade glial (pilocytic) tumors. CONCLUSIONS: Stereotactic laser ablation therapy should be considered as an option in the management of select patients with deeply-situated glial tumors, in order to avoid potential serious neurosurgical morbidity via resection, or the dangers of irradiation. Continued long-term patient follow up will be needed in order to determine whether ablation therapy was successful. Further reporting on this technique by other investigators is suggested.

Stereotactic Needle Biopsy: Sharpening the Tip

Stereotactic Needle Biopsy: Sharpening the Tip

III. Current concepts in primary central nervous lymphoma.

III. Current concepts in primary central nervous lymphoma.

Complications Following Stereotactic Needle Biopsy of Intracranial Tumors

Data from single-institution studies suggest that perioperative complication rates after stereotactic needle brain biopsies range from 6% to 12%, with permanent morbidity and mortality ranging from 3.1% to 6.4% and 0% to 1.7%, respectively. However, no population-level data are available. We conducted a population-based analysis to study complications after needle brain biopsy. We analyzed patients recorded in the Nationwide Inpatient Sample who underwent stereotactic needle brain biopsy for neoplastic lesions between 2006 and 2012. A multivariate logistic model was used to identify factors associated with complications. We identified 7514 patients who underwent biopsy for various intracranial pathologies, including primary malignant neoplasm (52.3%), unspecified neoplasm (17.9%), metastasis (9.7%), meningioma (1.5%), radiation necrosis (0.8%), lymphoma (0.5%), and pineal region neoplasm (0.3%). Intracranial hemorrhage was the most frequent complication (5.8%). Other complications, including operative infection (0.1%) and wound breakdown (0.2%), were rare. Multivariate logistic regression analysis revealed that hemorrhage is associated with older age (reference <40 years; 40-59 years, odds ratio [OR] 2.26, 95% confidence interval [CI] 1.51-3.38; ≥60 years, OR 1.90, 95% CI 1.22-2.97), hydrocephalus (OR 3.02, 95% CI 2.20-4.14), and cerebral edema (OR 2.16, 95% CI 1.72-2.72). Hemorrhage is less likely when taking a biopsy from a primary malignant neoplasm (OR 0.73, 95% CI 0.59-0.90). Overall inpatient mortality after biopsy was 2.8%. Patients with intracranial hemorrhage were significantly more likely than patients without hemorrhage to die in the hospital (12.8% vs. 2.2%, P < 0.001) or be discharged to a rehabilitation/nursing facility (45.2% vs. 23.1%, P < 0.001). Intracranial hemorrhage is the most frequent complication associated with needle brain biopsy and is associated with inpatient mortality and hospital disposition. Other complications are rare.

Mucocele-like lesions in the breast diagnosed with percutaneous biopsy: is surgical excision necessary?

The purpose of this study was to determine the frequencies of atypia and cancer at excisional biopsy of lesions with a diagnosis of mucocele-like lesion (MLL) at percutaneous breast biopsy. Retrospective review of 9286 lesions subjected to percutaneous imaging-guided biopsy identified MLLs in 35 (0.38%) patients. Medical records, imaging studies, and histologic results were reviewed. Of the 35 patients with core biopsy findings of MLL, 27 underwent stereotactic core needle biopsy (19 with microcalcifications, five with calcifications with an associated mass, and three with only a mass), and eight underwent ultrasound-guided core needle biopsy (four with a solid mass, three with a complex cystic mass). At core biopsy, 12 of 35 (34%) MLLs were associated with atypia (10 cases of atypical ductal hyperplasia, two of flat epithelial atypia), and 23 of 35 (66%) were benign MLL only. All 12 MLLs associated with atypia and 12 of 23 benign MLLs were surgically excised. Eleven patients did not undergo surgery, five of whom were lost to follow-up. One of the 12 (3% of the 35) MLLs associated with atypia was upgraded to DCIS. None were upgraded to invasive cancer. None of the benign MLLs were upgraded to malignancy, and findings at excision of four of the 23 (17%) benign MLLs led to a change in diagnosis to a high-risk lesion (three atypical ductal hyperplasia, one atypical lobular hyperplasia). MLL is a rare diagnosis but is encountered in large-volume breast practices. The findings are nonspecific with a range of imaging appearances. No imaging test is reliable for differentiating MLL from other suspicious lesions or lesions with associated atypia. Surgery is clearly warranted for MLL associated with atypia at core needle biopsy because it may be upgraded to malignancy upon excision. However, if the presence of atypia at excision of benign MLL will change clinical management, then benign MLL at core needle biopsy warrants surgical excision in some cases. In patients whose treatment will not change if atypia is found at excision, close surveillance with short-interval follow-up is a reasonable alternative.

Does 8-guage stereotactic core needle biopsy improve the accuracy over 11-gauge devices? Evaluation of pure DCIS on stereotactic biopsy and the rate of upstaging.

97 Background: Ductal carcinoma in situ (DCIS) accounts for 25% of newly diagnosed breast cancers. Core needle biopsy (CNB) has replaced open surgical biopsy for mammographic calcifications. We compare our experience with 8-gauge vs. 11-gauge vacuum assisted core needle biopsy in pure DCIS. We hypothesize that the diagnosis of DCIS with use of an 8-gauge vacuum-assisted core needle will lead to a lower rate of upstaging to invasive cancer at definitive surgical excision compared to 11-gauge vacuum-assisted core needle biopsy. Methods: A retrospective study was performed evaluating all patients who underwent a stereotactic core needle biopsy at our institution for DCIS during 2008-2012.We then compared the upstaging rates between patients biopsied using 8 or 11-gauge biopsy devices. Results: A total of 580 patients underwent STCNB during 2008-2012 at our institution, there were 461 patients excluded as they did not meet inclusion criteria and 119 patients were included. The most common mammographic finding was calcifications in 104/119 (87.4%) and a mammographic mass in 15/119 (12.60%). Biopsy with the 11 gauge needle was utilized in 60 patients and 59 patients with 8-G needle. Factors associated with upstaging were using a smaller 11 gauge needle and a mass on imaging, higher grade and more than four cores obtained on biopsy. There was an upstaging rate of 17/60 (28%) in patients who underwent stereotactic biopsy using a11-gauge needle versus upstaging rate of 7/59 (11.8%) in patients who underwent stereotactic biopsy using 8 gauge needle. We obtained a statistically significant p-value of 0.025. Conclusions: This is one of the few studies comparing upstaging rates from pure DCIS on STCNB using 8 and 11-gauge stereotactic vacuum assisted needles. Our results show that there is a statistically significant decrease in upstaging of pure DCIS to invasive malignancy at excision using the larger 8-gauge needle devices. The clinical implication is that SLNB need not be performed secondary to the low upstaging rate. We recommend that all stereotactic core needle biopsies be performed using the 8-gauge needle devices, and that SLNB generally be omitted for DCIS.

Comparative Effectiveness of Frame-Based, Frameless, and Intraoperative Magnetic Resonance Imaging–Guided Brain Biopsy Techniques

To compare the diagnostic yield and safety profiles of intraoperative magnetic resonance imaging (MRI)-guided needle brain biopsy with 2 traditional brain biopsy methods: frame-based and frameless stereotactic brain biopsy. A retrospective analysis was performed of 288 consecutive needle brain biopsies in 277 patients undergoing stereotactic brain biopsy with any of the 3 biopsy methods at Brigham and Women's Hospital from 2000-2008. Variables including age, sex, history of radiation and previous surgery, pathology results, complications, and postoperative length of hospital stay were analyzed. Over the course of 8 years, 288 brain biopsies were performed. Of these, 253 (87.8%) biopsies yielded positive diagnostic tissue. Young age (<40 years old) and history of brain radiation or surgery were significant negative predictors for a positive biopsy diagnostic yield. Excluding patients with prior radiation or surgeries, no significant difference in diagnostic yield was detected among the 3 groups, with frame-based biopsies yielding 96.9%, frameless biopsies yielding 91.8%, and intraoperative MRI-guided needle biopsies yielding 89.9% positive diagnostic yield. Serious adverse events occurred 19 biopsies (6.6%). Intraoperative MRI-guided brain biopsies were associated with less serious adverse events and the shortest postoperative hospital stay. Frame-based, frameless stereotactic, and intraoperative MRI-guided brain needle biopsy techniques have comparable diagnostic yield for patients with no prior treatments (either radiation or surgery). Intraoperative MRI-guided brain biopsy is associated with fewer serious adverse events and shorter hospital stay.

SU‐E‐I‐88: Mammography Imaging: Does Positioning Matter?

Purpose:In mammography, compression is imperative for quality images and glandular radiation exposure dose. The thickness of the compressed breast directly determines mammography acquisition parameters. The compressed thickness varies due to variation in technologist practice, even for the same patient imaged at different time. This study is to investigate potential effect of the variation in breast positioning on radiation dose and image quality.Methods:Radiation dose at different thicknesses was measured with a BR‐12 breast phantom for both conventional craniocaudal view and tomosynthesis in a Hologic Tomosynthesis mammography system. The CIRS stereotactic needle biopsy training phantom embedded dense masses and microcalcification in various sizes were imaged for image quality evaluation. Radiologists evaluated images. Clinical mammograms from the same patient but acquired at different time were retrospectively retrieved to evaluate potential effects of variation in positioning.Results:Acquisition parameters (kVp and mAs) increase with the increased phantom thickness. Radiation exposure increases following an exponential trend. The stereotactic phantom images showed loss of spatial and contrast resolution with inappropriate positioning. The compressed pressure may not be a good indicator for appropriate positioning. The inclusion of different amount of pectoralis muscle may lead to the same compressed pressure but different compressed thickness. The initial retrospective study of 3 patients showed that there were potential large variations in positioning the same patient at different examination time, resulting in large variations in patient radiation dose and image quality.Conclusion:Variations in patient positioning potentially influence patient radiation dose and image quality. The technologist has the critical responsibility to position patient to provide quality images in spite of different breast and body types. To reduce intra and inter practice variations in positioning patient, a training program among each breast imaging center may be a need.

MO‐A‐BRD‐01: An Investigation of the Dynamic Response of a Novel Acousto‐Optic Liquid Crystal Detector for Full‐Field Transmission Ultrasound Breast Imaging

Purpose:To characterize the dynamic response of a novel acousto‐optic (AO) liquid crystal detector for high‐resolution transmission ultrasound breast imaging. Transient and steady‐state lesion contrast were investigated to identify optimal transducer settings for our prototype imaging system consistent with the FDA limits of 1 W/cm2 and 50 J/cm2 on the incident acoustic intensity and the transmitted acoustic energy flux density.Methods:We have developed a full‐field transmission ultrasound breast imaging system that uses monochromatic plane‐wave illumination to acquire projection images of the compressed breast. The acoustic intensity transmitted through the breast is converted into a visual image by a proprietary liquid crystal detector operating on the basis of the AO effect. The dynamic response of the AO detector in the absence of an imaged breast was recorded by a CCD camera as a function of the acoustic field intensity and the detector exposure time. Additionally, a stereotactic needle biopsy breast phantom was used to investigate the change in opaque lesion contrast with increasing exposure time for a range of incident acoustic field intensities.Results:Using transducer voltages between 0.3 V and 0.8 V and exposure times of 3 minutes, a unique one‐to‐one mapping of incident acoustic intensity to steady‐state optical brightness in the AO detector was observed. A transfer curve mapping acoustic intensity to steady‐state optical brightness shows a high‐contrast region analogous to the linear portion of the Hurter‐Driffield curves of radiography. Using transducer voltages between 1 V and 1.75 V and exposure times of 90 s, the lesion contrast study demonstrated increasing lesion contrast with increasing breast exposure time and acoustic field intensity. Lesion‐to‐background contrast on the order of 0.80 was observed.Conclusion:Maximal lesion contrast in our prototype system can be obtained using the highest acoustic field intensity and the longest breast exposure time allowable under FDA standards.Department of Defense (DOD) Breast Cancer Research Program IDEA Award W81XWH‐11‐1‐0332; National Institutes of Health (NIH) Grant T32 EB002103‐21 from the National Institute of Biomedical Imaging and Bioengineering (NIBIB)

Use of intraoperative fluorescein sodium fluorescence to improve the accuracy of tissue diagnosis during stereotactic needle biopsy of high-grade gliomas

Stereotactic needle biopsy is valuable for tissue diagnosis of suspected high-grade gliomas, but limited by a sampling error that can lead to inappropriate grading of the tumor or failure to provide diagnosis. Increasing the number of biopsy attempts can increase morbidity. The authors designed a protocol to increase safety and efficiency of the procedure. Six consecutive patients with suspected high-grade gliomas who were not candidates for cytoreductive surgery underwent fluorescein-guided stereotactic needle biopsy. All received an injection of 3 mg/kg fluorescein sodium during anesthesia induction. Samples were obtained and observed under a microscope-integrated fluorescent module. If the initial specimens were fluorescent, the procedure was complete if the pathologist confirmed diagnostic tissue. Additional specimens were obtained only at the pathologist's request. An independent neuropathologist later analyzed and graded samples for diagnostic value, tumor, and necrosis. This information was correlated to the degree of intraoperative fluorescent signal in biopsy samples. During six biopsy procedures, 26 specimens were obtained: 15 (58 %) fluorescent and 11 (42 %) nonfluorescent. All fluorescent specimens contained diagnostic tissue appropriate for tumor grading. Of 11 nonfluorescent specimens, four (36 %) did not contain tumor, three (27 %) contained minor hypercellularity or gliosis, and four (36 %) contained tumor with a high proportion of necrosis. All six tumors were diagnosed as glioblastoma multiforme. The sensitivity and specificity for fluorescein fluorescence was 79 % and 100 %, respectively. Fluorescein fluorescence may improve diagnostic accuracy and expedite stereotactic biopsy procedures.

Abstract P2-14-03: Development and evaluation of a prediction model based on routine clinicopathological variables for predicting underestimated invasive breast cancer in women with ductal carcinoma in situ at stereotactic large core needle biopsy

Abstract Purpose: To develop a multivariable model for prediction of underestimated invasiveness in women with ductal carcinoma in situ (DCIS) at stereotactic large core needle biopsy (LCNB), that can be used to select patients for sentinel node biopsy (SNB) at primary surgery. Methods: From the literature, we selected potential preoperative predictors of underestimated invasive breast cancer. Data of patients with nonpalpable breast lesions who were diagnosed with DCIS at stereotactic LCNB, drawn from the COBRA (Core Biopsy after RAdiological localization) and COBRA2000 studies, were used to fit the multivariable model and assess its overall performance, discrimination, and calibration. Results: 348 women with LCNB-proven DCIS were available for analysis. In 100 (28.7%) patients invasive carcinoma was found at subsequent surgery. Nine predictors were included in the model. In the multivariable analysis, the predictors with the strongest association were lesion size (OR 1.12 per cm, 95% CI 0.98-1.28), the number of cores retrieved at biopsy (OR per core 0.87, 95% CI 0.75-1.01), presence of lobular cancerization (OR 5.29, 95% CI 1.25-26.77), and microinvasion (OR 3.75, 95% CI 1.42-9.87). The overall performance of the multivariable model was poor with an explained variation of 9% (Nagelkerke's R2), mediocre discrimination with area under the receiver operating characteristic curve of 0.66 (95% confidence interval 0.58-0.73), and fairly good calibration. Conclusion: The evaluation of our multivariable prediction model in a large, clinically representative study population, proves that routine clinical and pathological variables are not suitable to select patients with LCNB-proven DCIS for SNB during primary surgery. Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P2-14-03.

Development and Evaluation of a Prediction Model for Underestimated Invasive Breast Cancer in Women with Ductal Carcinoma In Situ at Stereotactic Large Core Needle Biopsy

BackgroundWe aimed to develop a multivariable model for prediction of underestimated invasiveness in women with ductal carcinoma in situ at stereotactic large core needle biopsy, that can be used to select patients for sentinel node biopsy at primary surgery.MethodsFrom the literature, we selected potential preoperative predictors of underestimated invasive breast cancer. Data of patients with nonpalpable breast lesions who were diagnosed with ductal carcinoma in situ at stereotactic large core needle biopsy, drawn from the prospective COBRA (Core Biopsy after RAdiological localization) and COBRA2000 cohort studies, were used to fit the multivariable model and assess its overall performance, discrimination, and calibration.Results348 women with large core needle biopsy-proven ductal carcinoma in situ were available for analysis. In 100 (28.7%) patients invasive carcinoma was found at subsequent surgery. Nine predictors were included in the model. In the multivariable analysis, the predictors with the strongest association were lesion size (OR 1.12 per cm, 95% CI 0.98-1.28), number of cores retrieved at biopsy (OR per core 0.87, 95% CI 0.75-1.01), presence of lobular cancerization (OR 5.29, 95% CI 1.25-26.77), and microinvasion (OR 3.75, 95% CI 1.42-9.87). The overall performance of the multivariable model was poor with an explained variation of 9% (Nagelkerke’s R 2), mediocre discrimination with area under the receiver operating characteristic curve of 0.66 (95% confidence interval 0.58-0.73), and fairly good calibration.ConclusionThe evaluation of our multivariable prediction model in a large, clinically representative study population proves that routine clinical and pathological variables are not suitable to select patients with large core needle biopsy-proven ductal carcinoma in situ for sentinel node biopsy during primary surgery.

Radiofrequency ablation in gastrointestinal cancer: obstacles and goals

Image-guided percutaneous radiofrequency ablation (RFA) is a viable treatment option for unresectable liver metastasis from gastrointestinal cancer. With optimized technology and sufficient safety margins, RFA reaches oncologic results comparable to surgery. However, use of RFA for resectable liver metastases is controversially discussed. The feasibility and success of RFA depend on the size and location of the liver lesion. Single-needle in-plane techniques have important limitations and may be largely overcome by multineedle approaches using 3D treatment planning and stereotactic needle guidance. The major obstacle for the acceptance of RFA is the current lack of an international standardized definition and documentation of treatment success. In analogy to surgical R0 resection, A0 ablation including a 3D safety margin of at least 5 mm, objectively verified and documented by true fusion of post- with preablation images has to be demanded. Considering the patient’s huge advantage of a minimal invasive local therapy, options for RFA should be discussed in interdisciplinary oncologic boards and communicated to the patient. Randomized controlled studies for getting answers to whether A0 ablation may prove as a true alternative to surgical resection in liver metastasis from gastrointestinal cancer are heavily awaited.