Magnetic Localization of Breast Lesions: A Large-Scale European Evaluation in a National Cancer Institute

INTRODUCTION

For decades the standard for preoperative breast lesions' localization has been wire localization. In recent years the options for nonwired localization have significantly expanded and include radioactive seeds, radar reflectors, radiofrequency identification tags and magnetic seeds. The aim of our study is to evaluate on a large scale the performance of preoperative magnetic seed localization of nonpalpable breast lesions.

MATERIAL AND METHODS

We prospectively collected data on all patients undergoing image-guided magnetic seed localization from September 2019 to December 2022. We analyzed imaging findings, histological results, and type of surgery. The primary outcome was the successful localization rate. Secondary outcomes were the successful placement rate, the ease of percutaneous positioning, the procedural complications, and the reintervention rate.

RESULTS

A total of 1123 magnetic seeds were placed in 1084 patients by 4 radiologists under ultrasound (1053) or stereotactic (70) guidance. All seeds were detectable transcutaneously in all breasts sizes and at all depths by 7 surgeons with a success rate of 100%. A total of 97.5% seeds were correctly placed into the target lesions (only 2.5% were dislocated). All radiologists have shown good compliance during the procedure, and there were no complications or safety issues. The reoperation rate was 5.1%.

CONCLUSIONS

Image-guided localization with magnetic seeds is an easy, safe, reliable, and effective method for localizing nonpalpable breast lesions. Both radiologists and surgeons agreed that the technology was intuitive to use and that it can be widely applied in preoperative localization in breast units.

Bridging the treatment gap in India: Online training of psychologists in basic mental health services

Introduction

The National Mental Health Survey of India 2015-16 (Gururaj et al., 2016) indicated a large treatment gap of 70-92% for mental disorders and a paucity of mental health specialists in the country. In order to address this treatment gap and develop human resources, the National Institute of Mental Health and Neuro Sciences (NIMHANS), Bengaluru, India, with impetus from the Ministry of Health and Family Welfare, Govt. of India, launched the online course of Diploma in Community Mental Health for Psychologists.

Objectives

The course was designed with the objective of training individuals with a Master’s Degree in Psychology, in providing first-level psychological care in the community.

Methods

The course is a 3-month online programme comprising of approximately 25 hours of self-paced e-learning and 11 hours of live real-time interactive discussion via video conference. The course comprises of 6 modules, with an assessment at the completion of each module. Pre- and Post-Assessment is conducted to evaluate competencies achieved.

Results

On successful completion of the course, trainees are expected to have achieved competencies to: Screen for and identify mental health problems in adults and children, and understand factors influencing them; Understand management options; Conduct interview-based functional developmental assessment for intellectual deficits; Conduct first-level brief psychosocial interventions; Make appropriate referrals to Mental Health Professionals and other health professionals.

Conclusions

This digitally-driven online course is a viable option for development of human resources on a large scale, in a resource-scarce (i.e. of mental health specialists) country such as India.

Disclosure

No significant relationships.

Correlation between Radiotherapy and Suture Fistulas following Colo-anal Anastomosis for Carcinoma of the Rectum Evaluation of 152 Consecutive Patients

Introduction

The aim of this study was to evaluate the prevalence of suture fistulas and their possible correlation with adjuvant therapy in patients who underwent colo-anal anastomosis and J pouch reconstruction with a protective colostomy. The reliability of the radiological screening and monitoring program was also verified.

Methods

One hundred and fifty-two consecutive patients were evaluated radiologically with water-soluble radio-opaque contrast enema before surgery for closure of the protective colostomy. Fifty-seven patients were treated with surgery alone (group A) and 95 patients received adjuvant treatment (group B).

Results

A total of 54 fistulas were seen: 17 in group A (28.9% of patients in group A) and 37 in group B (38.9% of patients in group B). Six fistulas involved the rectovaginal septum. All fistulas were managed medically. The time to resolution was 30 days in 76.4% of patients in group A and about 50 days in 82% of patients in group B. Rectovaginal fistulas always took much longer to heal in both groups and failed to heal in two of the four cases in group B.

Conclusions

Two factors appear to contribute to the high prevalence of fistulas in this series: extension of radiological screening to all operated patients and adjuvant radiotherapy. However, the postoperative course was not compromised by radiotherapy in that these fistulas resolved with medical treatment alone, although healing took longer. The incidence of rectovaginal fistulas was substantially the same in the two groups, but two of the four occurring in group B did not heal. Postoperative monitoring with water-soluble contrast enema appears to be the diagnostic procedure of choice because it is well tolerated, non-invasive and a reliable aid in planning surgical bowel recanalization since no false negative cases were detected clinically after closure of the colostomy.

Is there a Specific Magnetic Resonance Phenotype Characteristic of Hereditary Breast Cancer?

Aims and background

The aim of the study was to investigate the growth rate of inherited breast cancer, to analyze its T2 signal intensity besides kinetic and morphologic aspects, and to verify whether there is any correlation between magnetic resonance imaging phenotype and BRCA status.

Methods

Between June 2000 and September 2009, we enrolled 227 women at high genetic risk for breast cancer in a surveillance program, within a multicenter project of the Istituto Superiore di Sanità (Rome).

Results

Thirty-four cancers were detected among 31 subjects. One patient refused magnetic resonance imaging because of claustrophobia. Compared with sporadic disease, hereditary cancer showed some differences, in terms of biologic attitude and semeiotic patterns. These differences were mainly registered for magnetic resonance imaging, where the most frequent radiological variant was represented by the very high T2 signal intensity (73%). Moreover, the size of 8 of the neoplasms showed a significant increase in less than one year, 5 of them in less than 6 months. Six lesions were in BRCA1 patients and the remaining in BRCA2. Furthermore, cancers with a high growth rate also demonstrated a significant increment in T2 signal intensity.

Conclusions

Our results confirmed the high growth rate within BRCA-related breast cancers, especially for BRCA1 mutation carriers. In our experience, we found a specific imaging phenotype, represented by the high T2 signal intensity of hereditary breast cancer. To our knowledge, this is the first report that points out this new semeiotic parameter, which is usually typical of benign lesions. Considering the correlation between high growth rate and high T2 signal intensity, the former seems to be related to the absence of induction of a desmoplastic reaction that could somehow restrict cancer growth.

Performance and role of the breast lesion excision system (BLES) in small clusters of suspicious microcalcifications

PURPOSE

To assess the diagnostic performance of the BLES as a biopsy tool in patients with ≤ 1 cm clusters of BIRADS 4 microcalcifications, in order to possibly avoid surgical excision in selected patients.

MATERIALS

This is a retrospective study of 105 patients undergone to stereotactic breast biopsy with the BLES. It excises a single specimen containing the whole mammographic target, allowing better histological assessment due to preserved architecture.

RESULTS

Our case series consists of 41 carcinomas (39%) and 64 benign lesions (61%). Cancer involved the specimen margins in 20/41 cases (48.8%) or was close to them (≤ 1 mm) in 14 cases (34.1%); margins were disease-free in only 7 DCIS (17.1%). At subsequent excision of 39/41 malignant cases, underestimation occurred for 5/32 DCIS (15.6%), residual disease was found in 15/39 cancers (38.5%) and no cancer in 19/39 cases (48.7%). For DCIS cases, no residual disease occurred for 66.7% G1-G2 cases and for 35.3% G3 cases (P=0.1556) as well as in 83.3%, 40.0% and 43.8% cases respectively for negative, close and positive BLES margins (P=0.2576).

CONCLUSIONS

The BLES is a good option for removal of small clusters of breast microcalcifications, giving better histological interpretation, lower underestimation rates and possibly reducing the need of subsequent surgical excision in selected patients.

Occurrence of breast cancer after chest wall irradiation for pediatric cancer, as detected by a multimodal screening program

PURPOSE

To assess the occurrence of breast cancer (BC) after exposure to ionizing radiation for pediatric cancer, by means of a multimodal screening program.

PATIENTS AND METHODS

We identified 86 patients who had received chest wall radiation therapy for pediatric cancer. Clinical breast examination (CBE), ultrasound (US), and mammography (MX) were performed yearly. Magnetic resonance imaging (MRI) was added as of October 2007. We calculated the risk of developing BC by radiation therapy dose, patient age, and menarche before or after primary treatment.

RESULTS

Eleven women developed a BC from July 2002-February 2010. The sensitivity of the screening methods was 36% for CBE, 73% for MX, 55% for US, and 100% for MRI; the specificity was 91%, 99%, 95%, and 80% for CBE, MX, US, and MRI, respectively. The annual BC detection rate was 2.9%. The median age at BC diagnosis was 33 years. Although age had no influence, menarche before as opposed to after radiation therapy correlated significantly with BC (P=.027): the annual BC detection rate in the former subgroup was 5.3%.

CONCLUSIONS

Mammography proved more sensitive and specific in our cohort of young women than CBE or US. Magnetic resonance imaging proved 100% sensitive (but this preliminary finding needs to be confirmed). Our cohort of patients carries a 10-fold BC risk at an age more than 20 years younger than in the general population.

Percutaneous Transhepatic Biliary Drainage in the Management of Postsurgical Biliary Leaks in Patients with Nondilated Intrahepatic Bile Ducts

PURPOSE

To assess the feasibility of percutaneous transhepatic biliary drainage (PTBD) for the treatment of postsurgical biliary leaks in patients with nondilated intrahepatic bile ducts, its efficacy in restoring the integrity of bile ducts, and technical procedures to reduce morbidity.

METHODS

Seventeen patients out of 936 undergoing PTBD over a 20-year period had a noncholestatic liver and were retrospectively reviewed. All patients underwent surgery for cancer and suffered a postsurgical biliary leak of 345 ml/day on average; 71% were in poor condition and required permanent nutritional support. An endoscopic approach failed or was excluded due to inaccessibility of the bile ducts.

RESULTS

Established biliary leaks and site of origin were diagnosed an average of 21 days (range 1-90 days) after surgery. In all cases percutaneous access to the biliary tree was achieved. An external (preleakage) drain was applied in 7 cases, 9 patients had an external-internal fistula bridging catheter, and 1 patient had a percutaneous hepatogastrostomy. Fistulas healed in an average of 31 days (range 3-118 days ) in 15 of 17 patients (88%) following PTBD. No major complications occurred after drainage. Post-PTBD cholangitis was observed in 6 of 17 patients (35%) and was related to biliary sludge formation occurring mostly when drainage lasted >30 days and was of the external-internal type. Median patient survival was 17.7 months and in all cases the repaired biliary leaks remained healed.

CONCLUSIONS

PTBD is a feasible, effective, and safe procedure for the treatment of postsurgical biliary leaks. It is therefore a reliable alternative to surgical repair, which entails longer hospitalization and higher costs.

The role of interventional radiology in biliary complications after orthotopic liver transplantation: a single-center experience

This study evaluated interventional radiological experience in the management of biliary complications of OLT at the National Cancer Institute of Milan. Seventeen patients who had undergone orthotopic liver transplantation in various hospital were referred to our unit with biliary complications. Group I consisted of 8 patients with anastomotic biliary fistula who came to our attention a short time after transplantation. Group II consisted of 9 patients with anastomotic strictures who came to our attention in a longer period. Two different interventional radiological approaches were used: (a) percutaneous transhepatic biliary drainage (PTBD) in the presence of fistulas in patients of group I; and (b) percutaneous transhepatic biliary drainage combined with dilatation of the strictures with a balloon catheter in patients of group II. On the whole resolution of the biliary complications was achieved in 13 of the 17 cases treated (76.5%), 5 of 8 in group I and 8 of 9 in group II. No secondary stenosis after PTBD were observed in group I, whereas two patients of group II needed a second dilatation. Percutaneous biliary drainage is indicated as a valid treatment in the management of biliary complications, either to allow closure of the fistula either to perform balloon dilatation of stenosis.

Long-term results of balloon dilation of benign bile duct strictures

PURPOSE

To evaluate the results of percutaneous balloon dilation of benign bile duct strictures in a series of patients with a long follow-up period.

MATERIAL AND METHODS

56 patients with benign bile duct strictures underwent balloon catheter dilation. These patients had strictures of various origins: postsurgical, postlocal not surgical treatments, associated with gallstones, due to primary sclerosing cholangitis and to Mirizzi's syndrome. In 41 cases the diagnosis was made on the basis of radiological findings and history and in 15 cases on the basis of transluminal biopsy.

RESULTS

In 87.5% of cases the treatment was immediately successful. There were no early recurrences, but 7 (21%) recurrences were seen over 1 year after treatment; of these, 57% underwent another balloon dilation procedure with a positive long-term outcome.

CONCLUSION

The long-term success rate obtained in 72% of this series confirms that percutaneous bile duct dilation is a valid alternative to surgery without being burdened by complications; the procedure is also a valid alternative to the approach using endoscopic stents.

Long-term results of balloon dilation of benign bile duct strictures

PURPOSE

To evaluate the results of percutaneous balloon dilation of benign bile duct strictures in a series of patients with a long follow-up period.

MATERIAL AND METHODS

56 patients with benign bile duct strictures underwent balloon catheter dilation. These patients had strictures of various origins: postsurgical, postlocal not surgical treatments, associated with gallstones, due to primary sclerosing cholangitis and to Mirizzi's syndrome. In 41 cases the diagnosis was made on the basis of radiological findings and history and in 15 cases on the basis of transluminal biopsy.

RESULTS

In 87.5% of cases the treatment was immediately successful. There were no early recurrences, but 7 (21%) recurrences were seen over 1 year after treatment; of these, 57% underwent another balloon dilation procedure with a positive long-term outcome.

CONCLUSION

The long-term success rate obtained in 72% of this series confirms that percutaneous bile duct dilation is a valid alternative to surgery without being burdened by complications; the procedure is also a valid alternative to the approach using endoscopic stents.

The influence of tissue culture on corneal immunogenicity

In this study we examined whether immunization with heterotopic corneal graft can be suppressed by usage of cultured corneal tissue. Starting from the hypothesis that the corneal antigenicity might change during long-time storage, we compared, in a mouse model, the immunization obtained with fresh and> stored corneas. Heterotopic (chest wall) mice corneal allografts were exchanged between donors and hosts: (1) mismatched at multiple minor H loci and (2) only H-Y mismatched animals. Median survival time (MST) of primary and secondary skin grafts exchanged between mentioned donors and hosts was recorded. Recipient mice were immunized with either: (a) tail-skin graft, (b) fresh cornea graft or (c) corneal graft stored for three weeks in tissue culture. Three weeks later, recipients were challenged with skin graft placed at the opposite side of the chest wall and MST of these skin grafts was recorded. MST of secondary skin grafts in animals that had been immunized by skin served as a control. In case of multiple minor H disparity, MST of a first-set skin graft was 12 days, as compared to 9 days in case of secondary skin graft (P<0.05). MST of secondary skin graft following immunization by both fresh and stored corneas was 10 days. These data suggest that stored corneas don't loose ability to sensitize the multiple minor H disparate host. It also show that both cultured and fresh corneas, when placed in non-privileged site, have same immunizing capacity as skin (MST of 10 and 9 days, respectively; P>0. 1). When only H-Y disparate animals were used, MST of a first-set skin grafts was 26 days and of secondary skin graft 11 days (P<0.01). In case of H-Y disparity, MST obtained after immunization with fresh and stored corneal tissue (19 and 18 days, respectively) was significantly longer as compared to skin (P<0.05). However, no significant difference in MST of secondary skin grafts between recipients of fresh (19 days) and stored corneal grafts (18 days) was recorded. According to our results, the ability of corneal tissue to immunize both multiple minor H mismatched, as well as only H-Y mismatched host, was not influenced by storage in a tissue culture.

The effect of allogeneic presensitization on Hya-isograft survival

The effect of allogeneic presensitization on Hya isograft survival was reinvestigated in C57BL, C3H and (C57BL x C3H)F1 females. Three weeks after transplantation of H-2 or non-H-2 differing female or male skin grafts, a syngeneic male skin graft (Hya isograft) was transplanted onto female recipients. C57BL and (C57BL x C3H)F1 females pretreated with a female skin graft of any origin rejected the C57BL male isograft as a first-set, while females pretreated with a male skin graft rejected the C57BL male isograft in a second-set manner. The same happened with the C3H male skin graft transplanted onto previously challenged (C57BL x C3H)F1 females. C3H females pretreated with a C3H or CBA female graft rejected the C3H male isograft as a first-set, whereas those pretreated with a C3H or CBA male graft rejected the male C3H isograft in a second-set manner. However, after pretreatment with a BALB/c male skin graft, C3H females were not sensitized to Hya. They rejected the C3H male isograft slightly faster than was expected for the first graft but this accelerated rejection was not specific, since it occurred as well in C3H females pretreated with grafts of BALB/c females. The best explanation for this unsuccessful immunization of C3H females is that an inferior, non-H-2-dependent Hya recognition system is involved in male isograft rejection.

Chimaerism in lymph nodes of F1 into irradiated parental recipient chimaeras rejecting skin allografts from the other parent

Mice of the C57BL strain were irradiated with 800 R over the whole body. The next day they received i.v. a mixture of 50 x 10(6) spleen and bone marrow cells from (C57BL x CBA-T6T6)F1 hybrid mice, and were challenged with CBA-T6T6 skin grafts later on. About 20% of the recipients rejected the CBA-T6T6 skin, whereas the others were completely tolerant for more than 200 days. By using the cytotoxic test, we found that both tolerant and nontolerant recipients were complete chimaeras, i.e., had only (C57BL x CBA-T6T6)F1 cells in their lymph nodes. However, analysis of the same mice by the chromosome marker technique disclosed a proportion of host (C57BL) cells in lymph nodes of both tolerant and nontolerant chimaeras. The percentage of host metaphases in nontolerant chimeras was significantly higher than that in tolerant chimaeras (P less than 0.01). It is possible therefore that the CBA-T6T6 skin grafts were rejected by residual host (C57BL) cells rather than (C57BL x CBA-T6T6)F1 cells reacting against skin-specific transplantation antigen(s) of the parental graft.