Percutaneous imaging-guided core breast biopsy: 5 years' experience in a community hospital

OBJECTIVE

This study reports the results of a percutaneous imaging-guided core breast biopsy program in a community hospital.

MATERIALS AND METHODS

We reviewed the prospectively collected results of our imaging-guided core biopsy program during its first 5 years (1994-1998). A total of 1333 lesions (94% of which were Breast Imaging Reporting and Data System (BI-RADS) assessment category 4) were sampled in 1183 patients. Patients with BI-RADS assessment category 5 lesions were referred to surgeons. Stereotactic guidance was used for the core biopsy of 506 lesions, and sonography was used to guide the predominantly 16-gauge needle core biopsy of 827 solid masses.

RESULTS

One hundred forty-seven cancers were diagnosed in 1333 biopsies, resulting in a positive yield of 11%. Of 1020 patients with benign, concordant core biopsy results, 981 (96%) had at least one follow-up imaging examination within 36 months of the biopsy. Nineteen (2%) of these 1020 patients had a suspicious change at follow-up; 18 of these patients underwent surgical excision with benign findings. No cancers were found at imaging follow-up or by tumor registry linkage. All malignant core biopsy results were confirmed as malignant at surgical excision (positive predictive value 100%). Twenty-two patients with atypical ductal hyperplasia at core biopsy had subsequent surgery, and 12 (55%) of them were found to have cancer at surgery.

CONCLUSION

An imaging-guided core biopsy program, developed and implemented by a small group of radiologists in a community hospital, can achieve successful results and provide an important service to patients and a cost-effective alternative to surgical biopsy. Our program emphasized sonographic guidance and achieved high follow-up compliance.

Mammographic changes after hormone replacement therapy in patients who have undergone breast irradiation

OBJECTIVE

We examined three patients who began hormone replacement therapy after lumpectomy and breast irradiation. In these women increased tissue density appeared on mammography only or disproportionately in the nonirradiated breast. To our knowledge, this observation has not been reported.

CONCLUSION

Breast irradiation may induce tissue changes that prevent or diminish the proliferative response that can be induced in breast tissue by postmenopausal hormone replacement therapy. Because this treatment is now recommended for some women after breast conservation therapy, mammographers may recognize this finding with increasing frequency.

Toward implementation: managed care and delivery systems

The Oxford Health Plans Foundation seeks to create an environment that fosters innovation and encourages new solutions to old problems. That philosophy drives all of the initiatives discussed in this paper. Oxford is optimistic and enthusiastic regarding the potential of many of these collaborative relationships and believes that they can dramatically improve the health status of inner-city populations.

Wegener's granulomatosis presenting with erosive arthritis

We describe a patient with Wegener's granulomatosis who presented with erosive arthritis. The patient's multisystem disease responded to cyclophosphamide treatment, and the erosions healed. Our findings suggest that Wegener's granulomatosis should be added to the differential diagnosis of diseases associated with erosive arthritis.

Progressive systemic sclerosis and Graves' disease. Report of three cases

Progressive systemic sclerosis (PSS) is associated with a broad spectrum of autoimmune thyroid diseases. While an association between PSS and hypothyroidism is well established, a relationship between PSS and hyperthyroidism is less well defined. We treated three patients with PSS whose course was complicated by Graves' disease. Because hyperthyroidism can simulate many of the symptoms of PSS progression and treatment of hyperthyroidism can lead to resolution of clinical deterioration in such patients, it is important to recognize the simultaneous occurrence of these diseases.

Acromegalic arthropathy: a reversible rheumatic disease

Acromegalic arthropathy may be the initial manifestation of growth hormone over-production. The presence of an underlying endocrinopathy may go unrecognized for a long period of time because of the predominance of articular signs and symptoms. We describe 2 cases of acromegaly presenting with rheumatologic manifestations, the first resembling seronegative rheumatoid arthritis, the second, post traumatic low back syndrome. Unlike previous reports, both our cases showed resolution of musculoskeletal symptoms after pituitary surgery.

Rheumatoid rigor: gold induced myokymia. A report and review of the literature

Myokymia is a spontaneous movement disorder characterized by slow, undulating, persistent movement of the involved muscles. It is an unusual manifestation of gold neurotoxicity, rarely reported in the rheumatologic literature. We report a case of gold induced myokymia associated with gold-induced dermatitis and nephropathy.

Systemic sclerosis and pregnancy complicated by obstructive uropathy

A patient with progressive systemic sclerosis whose twin pregnancy was complicated by obstructive uropathy due, in part, to a noncompliant abdominal wall is reported. The effects of progressive systemic sclerosis on pregnancy and those of pregnancy on progressive systemic sclerosis are reviewed and discussed.

Computed tomography of posterior lumbar apophyseal ring fractures

Lumbar apophyseal fracture is an uncommon injury that occurs during adolescence. We described two cases in young adults with back pain. The radiographic findings were distinctive. In both cases CT demonstrated characteristic bony fragments displaced posteriorly into the spinal canal and a corresponding defect in the posteroinferior aspect of the vertebral body rim. Recognition of this entity is important in evaluating back pain in both adolescents and adults.

Type II collagen-induced arthritis. A morphologic and biochemical study of articular cartilage

Articular cartilage was obtained from type II collagen-induced arthritic rat joints. Transmission electron microscopy showed a gradual degeneration of chondrocytes, disorganization of the collagenous extracellular matrix, and formation of microscars. Biochemical analyses indicated that type II collagen was the only collagen present and that it was normal in regard to hydroxylation of lysine and glycosylation of hydroxylysine. Analyses of the proteoglycan in the extracellular matrix revealed a 50% loss of chondroitin sulfate and keratan sulfate.

Gas-liquid chromatographic analysis of synovial fluid: volatile short-chain fatty acids in septic arthritis

Volatile short-chain fatty acids (SCFA) in synovial fluid from 80 patients were quantified by gas-liquid chromatography (GLC). Characteristic patterns of volatile SCFA could not be associated with septic, nonseptic inflammatory, or noninflammatory groups. Mean concentrations of pentanoic and hexanoic acids were similar in all groups studied. In the septic arthritis group 3 of 4 patients with acetic acid and of 3 of 3 with 3-methyl butanoic acid had culture-proved staphylococcal infections. In patients with synovial fluid findings consistent with septic arthritis, including markedly raised leucocyte count, decreased glucose level, or detectable succinic acid, the detection of acetic and 3-methyl butanoic acids by GLC analysis may increase the suspicion that Staphylococcus aureus is the cause of the septic arthritis.

Pythiaceous fungi associated with the decomposition of Nymphoides peltata

Selective isolation procedures were carried out on decaying leaves of Nymphoides peltata (Gmel.) O. Kuntze in order to study the pythiaceous fungi (Peronosporales) associated with the decomposition processes. In addition to Pythium marsipium Drechsler and P. pleroticum T. Ito, a number of Pythium species were isolated with filamentous non-swollen sporangia. Under special culture conditions (in water under a day/night rhythm) sexual reproductive structures of P. diclinum Tokunaga and P. apleroticum Tokunaga were also obtained. However, several isolates designated as Pythium 'F', remained sterile. Within this group three types could be distinguished according to their temperature-growth relationships. As the species recorded have been found very rarely and only one was represented in the CBS collection, detailed descriptions with short discussions are presented.

Gas-liquid chromatographic analysis of synovial fluid. Succinic acid and lactic acid as markers for septic arthritis

Nonvolatile short-chain fatty acids from 80 synovial fluids were quantified by gas-liquid chromatography. Succinic acid was detectable in all 23 septic synovial fluids infected with either gram-positive or gram-negative organisms and in only 5 of 57 nonseptic synovial fluids. Lactic acid was present in all of the effusions but was correlated with septic arthritis only when present in concentrations greater than 250 mg%. Neither short-chain fatty acid was more sensitive than high white blood cell counts (greater than 50,000 mm3) or depressed glucose concentration (less than 40 mg/dl) in diagnosing septic arthritis before antibiotic therapy; however, the detection of succinic acid was helpful in identifying patients with septic arthritis who had been given antibiotic treatment before arthrocentesis. Thus, gas-liquid chromatography, a rapid and sensitive method for the detection of short-chain fatty acids, may complement the currently available methods used to diagnose septic arthritis.

Aqueductal stenosis: a possible late sequela of central nervous system inflammation in systemic lupus

We have described a patient with a history of central nervous system lupus who had obstructive hydrocephalus secondary to stenosis of the aqueduct of Sylvius. The course of this patient's neurologic disease suggest that the obstruction was caused by a post-inflammatory lesion of CNS lupus. This report illustrates the importance of a complete neurologic evaluation of a patient with SLE who has CNS dysfunction.

Reiter's syndrome: a male and female disease

A diagnosis of Reiter's syndrome was made in 12 males and 13 females based on an asymmetrical oligoarthritis with lower extremity predominance and at least 1 characteristic extraarticular manifestation. The pattern of disease was similar in both sexes; females had more extensive upper extremity joint involvement and ocular inflammation; males had more nonbacterial urethritis. Eighty-two % of males and 62% of females were HLA-B27 positive. We suggest that Reiter's syndrome has not been diagnosed in more females in the past because of an historical bias, a reliance on the complete classical triad, and confusion with seronegative rheumatoid arthritis.

Renal vein thrombosis: occurrence in membranous glomerulonephropathy and lupus nephritis

Renal vein thrombosis developed in 11 of 280 patients having either biopsy-proved membranous glomerulonephropathy or systemic lupus erythematosus with nephritis. All 11 also were found to have nephrotic syndrome. In nine, nephrotic syndrome developed before renal vein thrombosis; the diagnoses of nephrotic syndrome and renal vein thrombosis were made simultaneously in the other two. Ten of the 11 patients also had pulmonary emboli at or near the time of renal vein thrombosis.

Hepatocellular carcinoma: clinical and angiographic findings and predictability for surgical resection

Demographic, clinical, and angiographic data were reviewed for 63 consecutive patients with hepatocellular carcinoma. Angiography remains the critical examination in determining extent of disease and potential surgical cure. Angiographic findings were correlated with surgical or autopsy findings for 26 of the patients. The absence of venous invasion and lack of involvement of at least one hepatic segment favor resectability. Selective hepatic injections and oblique views accurately answered these questions in more than 80% of our patients. Pitfalls to angiographic accuracy include vascular invasion by very small tumor masses, hypovascular or diffuse hepatocellular carcinomas, metastatic disease, and involvement of the left lobe.

Diminished radiopacity of contrast material: a urographic sign of ureteral calculus

Eleven patients with unilateral ureteral calculus had excretory urography which showed the radiopacity of excreted contrast material to be diminished on the side of the calculus. This finding was of diagnostic importance in nine patients who demonstrated little or no dilatation of the urinary tract proximal to the calculus. Other forms of unilateral renal disease, such as acute pyelonephritis, can produce the same urographic finding.

Bleeding simulated by the distal internal pudendal artery stain

A capillary and venous phase blush in the region of the distal branches of the internal pudendal artery that simulates bleeding can sometimes be seen on arteriograms of male patients who are not bleeding. We describe five such cases. Correct identification of this pooling of contrast material is important to avoid unnecessary treatment by transcatheter embolization or by infusion of vasoactive drugs.

Neoplastic pseudoaneurysm of the superior mesenteric artery

The authors describe a case of pseudoaneurysm of the superior mesenteric artery caused by arterial invasion by a liposarcoma. Neoplastic pseudoaneurysms are rare; most are due to sarcomas and usually involve veins.

Mechanisms of hemopoietic and immunological dysfunction induced by lymphocytic choriomeningitis virus

Sublethal irradiation (500 R) of C3H mice is followed by a gradual replacement of radiosensitive cells in their spleens by surviving stem cells originating in bone marrow. This compensatory hemopoiesis was quantitated by counting the numbers of stem cell-derived colonies appearing on spleen surfaces, as well as those which grew in vitro after marrow cells, suspended in soft agar, were overlaid onto syngenic mouse embryo fibroblast feeder layers. Compensatory colony formation, both in vivo and in vitro, was severely depressed when mice were infected with lymphocytic choriomeningitis virus (LCMV) 1 day before irradiation, although the induction of virus-specific cytotoxic T cells in their spleens was unimpaired. Without irradiation, mice, acutely infected with LCMV, showed a dramatic reduction in the numbers of specific antibody-forming cells generated in their spleens after priming with sheep erythrocytes during week 1 post-infection, yet the ability of their marrow cells to form colonies in vitro remained normal. Therefore, the basis of immunodepression is distinct from that of defective hemopoiesis since the latter is apparent only when LCMV infection is accompanied by irradiation. However, as discussed, both phenomena may be related to alterations induced within the splenic environment by LCMV.

Transpleural abdominal systemic artery-pulmonary artery anastomosis in patients with chronic pulmonary infection

Systemic-pulmonary artery anastomoses commonly occur in lung diseases characterized by inflammation and decreased pulmonary artery perfusion. Three cases are reported in which anastomotic branches arose within the abdomen and crossed the pleural space. Arteriography differentiated acquired abdominal systemic artery supply from that seen in sequestration. In each case an inferior phrenic artery was involved, and a tangle of anastomotic branches was present at the pleural surface. Intensive medical therapy prior to lobectomy may be indicated in such patients.

Value of ultrasonography in the detection of retroperitoneal inflammatory masses

The ultrasonographic and radiologic findings for 7 patients with retroperitoneal inflammatory processes are presented. Ultrasonographic findings were critical to the diagnosis in 6 of the 7 patients and allowed for rapid evaluation and the institution of successful therapy. The relative sensitivity and specificity of ultrasonography is compared with conventional radiologic modalities. The application of diagnostic ultrasound to the problem of retroperitoneal inflammation is advocated.

Lymphocytic choriomeningitis virus-induced immunosuppression: a virus-induced macrophage defect

Primary immunizing infections with LCM virus result in a transient depression of the in vitro proliferative responses of splenic lymphocytes to mitogens specifically reactive with T cells or B cells. This depression of lymphocyte function is the result of a virus-induced defect in an adherent, phagocytic cell population required for in vitro lymphocyte activation. Depressed responses persist for about 1 week after virus clearance and can be corrected by the addition of normal PEM or 2-ME to infected spleen cell cultures. Although the precise nature of this defect remains unclear, it is postulated that it is due to a productive infection of macrophages and their precursors that renders them dysfunctional. Secondary LCM virus infections do not result in depressed in vitro responses to mitogens, presumably because of rapid virus clearance and limited numbers of infected cells. Primary infections of immunologically immature mice, mice rendered functionally athymic, or mice treated with nonspecific immunosuppressive agents result in LCM virus persistence. Shortly after infection, these animals show a similar depression of immunologic reactivity that returns to normal as the virus carrier state becomes established. Despite virus persistence, few PEM from established LCM virus carrier mice contain viral antigens and these cells function normally. Thus, LCM virus-induced immunosuppression appears to reflect a subtle cytopathic effect of LCM virus replication that is not mediated by the virus-specific cell-mediated immune mechanisms responsible for acute LCM virus disease.

Cell-mediated immune response to herpes simplex virus: type-specific lymphoproliferative responses in lymph nodes draining the site of primary infection

Cell-mediated immune responses to type 1 and type 2 HSV were studied in rabbits using an in vitro lymphocyte transformation assay. The footpad route of inoculation was used to allow us to study the specificity and degree of localization of the responses. Rabbits inoculated in the hind footpads with infectious HSV-I or HSV-II mount type-specific lymphocyte transformation responses that are localized to draining lymphoid organs. Type-specificity requires careful control of all in vitro culture conditions and reflects the extensive cross-reactivity demonstrated by serologic techniques. While lymphocyte transformation responses can be detected with immune SL and PBL, presumably the result of early escape of antigen into the systemic circulation, responses by draining LNL are significantly greater in magnitude. Distant LNL have not been shown to respond. It is postulated that the augmented local immune response to HSV plays a significant role in controlling recurrent HSV infections.

The role of emergency excretory urography in evaluation of blunt, abdominal trauma

In our hospital, patients seen for blunt, abdominal trauma have an "emergency" urogram. The results of our review of 209 such patients with complete urographic evaluations indicate that (1) the clinical examination, urinalysis, and plain abdominal roentgenogram do not reliably allow one to predict which patients would show urographic abnormalities and (2) the clinical management of these patients is rarely altered by the knowledge of the results of the urogram.

An experience with a LeVeen ascites shunt

A patient with intractable ascites was treated by placement of the LeVeen peritoneovenous shunt. Shunt failure was caused by malpositioning of the venous limb in the inferior vena cava. This was demonstrated by injection of water-soluble contrast material into the venous limb. Revision of the shunt led to diuresis, weight loss, and reduction of ascites. The physiologic process of the LeVeen shunt is reviewed and we suggest placement of a radiopaque marker into the tubing.

Submucosal hemorrhage of the renal collecting system

Two cases of submucosal hemorrhage in the renal pelvis and ureter are presented. The roentgenographic appearance was identical to that of pyeloureteritis cystica but without evidence of urinary tract infection and, in 1 case, the submucosal impression resolved rapidly. When nodular, submucosal filling defects are demonstrated in the renal collecting system in the clinical setting of anticoagulant therapy or trauma, a diagnosis of submucosal hemorrhage should be considered.

Reversal of oliguria and renal cortical ischemia of hemorrhagic shock in the dog with tris (hydroxymethyl) amino methane (THAM). Hemodynamic studies

We investigated the functional and hemodynamic effects on the kidney of tris (hydroxymethyl) amino methane (THAM) infusion during sustained hemorrhagic hypotension in dogs. The large osmotic load introduced into the vascular compartment during hemorrhagic hypotension resulted in a marked reduction in systemic vascular resistance and a return of cardiac output, total renal blood flow, and the renal arteriographic pattern to normal range. The observed diuresis is probably due to an osmotic effect, because the glomerular filtration rate remains significantly depressed. Anatomical assignment of the mathematical components of the xenon washout curve led to an assessment of intrarenal blood flow distribution that was at variance with the arteriographic pattern and the intrarenal distribution of tagged microspheres.

Vascular manifestations of von Recklinghausen's disease

A casual relationship between von Recklinghausen's disease, or neurofibromatosis, and arteriolar abnormalities has been reported in the European literature. A patient was seen who had biopsy-proved neurofibromatosis and renovascular hypertension and retroperitoneal bleeding. An arteriographic study showed multiple small aneurysms throughout the coeliac axis, the superior mesenteric artery and in several small intrarenal vessels. Renal vein renin levels were elevated particularly in the right renal vein, supporting the diagnosis of renovascular hypertension. Both the aneurysms seen in angiographic studies and the retroperitoneal hemorrhage are probably vascular manifestations of von Recklinghausen's disease. Support for this conclusion is enhanced by the absence of clinical, laboratory or histologic data supporting the only tenable differential diagnosis, periarteritis nodosa.

Inhibition of Antigen-Stimulated in Vitro Proliferation of Thymic Dependent Chicken Spleen Cells by Specific Antibody

The ability of passively administered antibody to inhibit active immune responses suggests that antibody may be an important element in normal immunoregulation. This report describes studies of in vitro lymphocyte transformation in which cells from agammaglobulinemia bursectomized-irradiated (Bx-X) and rabbit anti-chicken lymphocyte serum (ALS)-treated chickens were used to study the effects of specific antibody on the in vitro proliferative responses of thymus dependent (T) and bursal dependent (B) lymphocytes. Intact chickens immunized with keyhole limpet hemocyanin (KLH) and Brucella abortus (BA) developed positive in vitro proliferative responses to these antigens and these responses were specifically inhibited when the appropriate antibody was added to the cultures. Low level “natural” or background proliferative responses were observed in unimmunized chickens in response to Brucella, and these responses could not be inhibited by specific anti-Brucella (anti-BA) antibody.

Agammaglobulinemic (Bx-X) chickens immunized with both KLH and Brucella responded in vitro only to KLH. This response was also inhibitable by specific anti-KLH antibody, indicating that proliferative responses of T cells can be suppressed by specific antibody. Because spleen cells from immunized Bx-X birds failed to respond to Brucella, the in vitro proliferative response to this antigen is probably a B lymphocyte dependent process. This was investigated further by using spleens from immune ALS-treated chickens. These cells failed to respond to either antigen in vitro. When these ALS spleen cells were mixed with immune Bx-X spleen cells, the in vitro proliferative response to BA was reconstituted, demonstrating synergy between the two populations of cells. However, since both T and B cells are needed for the proliferative response to BA, we cannot determine which lymphoid cell was inhibited by anti-BA.