Biomedical subjects
Publications and source records attributed to G Cardenosa.
A defective molybdenum filter in a dedicated mammographic unit was found to have a detrimental effect on image quality. The authors present a simple method for testing of molybdenum filters and suggest that it be incorporated into the acceptance testing routine for new mammographic units and that it be used in annual quality control checks.
Of 335 women who underwent lumpectomy and radiation therapy for breast cancer, 42 subsequently developed calcifications. Particles typical of calcified suture material were identified in 21 of the 42 women (50%). No obvious calcified suture material was found in approximately 1,140 women of 38,000 (3%) who had undergone mammography after they had previously undergone breast biopsy for a benign lesion and thus had not undergone radiation therapy. Calcified suture material rarely develops in the nonirradiated breast, but it is common after radiation therapy and should not be confused with recurrent breast cancer. These calcifications are likely the result of delayed resorption of catgut sutures, which provide a matrix on which calcium can precipitate in a suitable local environment.
The discovery of clinically occult breast cancer creates an exciting opportunity to alter the natural history of one of the major killers of women in our society. The skills required for this endeavor depend on high-quality images that provide the mammographer with sufficient information to construct three-dimensional perceptions recognizable as departures from normal architecture. Altering the natural course of breast cancer depends on early detection. Early detection of breast cancer depends on high-quality imaging techniques. Paramount among the imaging techniques for breast cancer detection is mammographic positioning. Optimal mammographic positioning is achieved by understanding the capabilities of available dedicated mammographic equipment and applying this understanding to take full advantage of natural breast mobility in overcoming various anatomic limitations. Compression of breast tissue, essential for proper parenchymal imaging, is achieved by moving one surface of the breast toward the other. The concept of moving the mobile surface of the breast toward the more fixed and immobile surface has been stressed as an important principle in optimizing the amount of tissue that can be imaged on standard mammographic views. Visualizing the fine details of a lesion or the margins of an area of clinical or perceived radiographic concern may be crucial to determining the need for biopsy. Visualization of such details is best achieved by projecting the suspected lesion into interface with adjacent radiolucent fat through separation of overlapping parenchyma by using spot compression or by tangential imaging against subcutaneous fat. Unique problems require creative, tailored solutions. Such tailoring is made less difficult by understanding and using equipment capability with breast anatomy and mobility. The very small, very large, or very dense breast can be imaged properly with modified techniques. Likewise, the augmented breast, mastectomy site, or axilla can be imaged with specialized techniques. Artistic application of these mammographic positioning principles will be rewarded with high-quality images, fewer missed breast cancers, and more lives saved.
Paraffin block radiography has been shown to be useful in helping identify lesions in biopsy specimens of breast tissue. Use of an orthogonal view enables determination of the approximate depth of a lesion within a paraffin block. This simple technique further guarantees histologic evaluation of the area of radiographic concern.
All recommendations for immediate additional studies and biopsies following routine mammography during a 6-month period were reviewed retrospectively to establish compliance rates and determine the time intervals for completion of the recommendations. During this period, 5,693 mammograms were obtained. Additional mammographic studies and biopsies were recommended for 364 (6.4%) and 180 (3.2%) of all patients, respectively. The compliance rates were 99.7% (n = 363) for additional studies and 98.9% (n = 178) for biopsies. Additional studies and biopsies were completed within 30 days of the recommendations in 98.4% (n = 358) and 91.7% (n = 165) of the patients, respectively. Compliance with recommendations for additional studies within relatively short periods can be maximized by having the mammographic facility schedule examinations directly with the patients. Compliance with biopsy recommendations can be optimized by directly contacting the referring physician. Follow-up written reports should specifically state that a biopsy is recommended and that this has been discussed directly with the referring physician.
The clinical presentation, pathologic characteristics, and mammographic/ductographic (also known as galactographic) findings were reviewed in 77 patients with histologically proved benign papillary neoplasms of the breast. Patients were classified as having either solitary or multiple papillomas. Patients with multiple papillomas were further subclassified as having either central or peripheral papillomas. Fifty-one patients (66%) had solitary papillomas. Thirty-seven of these patients were symptomatic; 36 had spontaneous nipple discharge, and one had a palpable mass. Ductography was positive in 32 of the 35 patients who underwent the procedure. In the 14 asymptomatic patients, subareolar (n = 10) and peripheral (n = 4) mammographic abnormalities prompted biopsy. Fourteen patients (18%) had multiple peripheral papillomas, and one patient also had bilateral central solitary papillomas. Eleven of these patients were asymptomatic, while two presented with palpable abnormalities and one with spontaneous bilateral discharge. Mammographic findings included microcalcifications (n = 5) and clustering nodules (n = 2). Associated atypical ductal hyperplasia was found in six (43%) of the 14 patients with multiple peripheral papillomas. Some of these patients also had lobular carcinoma in situ and radical scars. Twelve patients had multiple central papillomas; all presented with spontaneous nipple discharge and had positive ductograms.
Five patients with sarcomas of the spermatic cord were imaged with sonography and/or computed tomography (CT). The former modality is most helpful in demonstrating the extratesticular origin of the mass and evaluating its scrotal extension for local staging. CT is necessary for pelvic staging and searching for distant metastasis. The fat in liposarcomas was easily identified by CT, although it was not echogenic on sonography. Sonography should be the primary imaging modality for scrotal or inguinal masses. If a neoplasm is found, CT should be used for staging, prior to definitive surgical treatment.
Within a 12-year period we treated 67 patients (49 women, 18 men; mean age, 61 years) with cystic neoplasms of the pancreas, including 18 serous cystic adenomas, 15 benign mucinous cystic neoplasms, 27 mucinous cystadenocarcinomas, 3 papillary cystic tumors, 2 cystic islet cell tumors, and 2 cases of mucinous ductal ectasia. Mean tumor size was 6 cm (2 to 16 cm). In 39% the patients had no symptoms, and in 37% the lesions had been misdiagnosed as a pseudocyst. Computed tomography was useful for detection, for distinguishing the microcystic subgroup of serous cystadenoma, and for showing rim calcification (all 7 cases were malignant) but was not reliable for distinguishing neoplasm from pseudocyst, serous from mucinous tumors, or benign from malignant. Arteriography showed hypervascularity in 4 of 10 serous adenomas, 3 of 11 mucinous carcinomas, and 1 of 1 papillary cystic tumors. Endoscopic pancreatography showed no communication with the cyst cavity in 37 of 37 cases of cystic neoplasms but opacified the ectatic ducts in 2 of 2 cases of mucinous ductal ectasia. Stenosis or obstruction of the pancreatic duct indicated cancer. The tumor was resected by distal pancreatectomy in 25 patients, by proximal resection in 29, and by total pancreatectomy in one, with no operative deaths. Forty-four per cent of the tumors were malignant. In 10 cases the tumor was unresectable because of local extension or distant metastases, and those patients died at a mean of 4 months. Seventy-five per cent of those resected for cure are alive without evident recurrence. Because the epithelial lining of the tumor was partially (5% to 98%) absent in 40% to 72% of cases of the major tumor types, and the mucinous component comprised only about 65% of mucinous cystadenoma lining, misdiagnoses on frozen and even permanent sections were made. Mitoses and histologic solid growth correlated with malignancy. Neuroendocrine elements were seen in 87% of benign and 47% of malignant mucinous tumors. It is recommended that the terms macrocystic and microcystic be abandoned in favor of the histologic designations serous and mucinous. Incomplete examination of the cyst wall can be misleading, however. It is suggested that mucinous ductal ectasia be recognized separately from cystic tumors and that all of these lesions be resected, with the possible exception of asymptomatic confirmed serous cystadenomas.
Diffusely scattered calcifications visible with mammography are almost always benign. Certain patterns, however, should arouse concern. For example, extensive comedocarcinoma is associated with large areas of mammographically visible calcium deposition. The authors identified 10 women in whom calcifications were visible throughout large volumes of breast tissue at mammography. The calcifications did not resemble those typical of extensive comedocarcinoma, yet they were associated with extensive breast cancer. Their mammographic pattern was characterized by a strikingly wild, chaotic appearance with profuse deposition of calcium. As in many cancers, the particles were heterogeneous, but unlike in most carcinomas, many deposits had a typically benign morphology. Histologic examination showed that even these typically benign calcifications were associated with malignant cells. The authors believe that the apocrine features displayed by many of the cancer cells in these 10 patients may explain the unusual profusion of calcium deposits.
Associated with the presence of HLA-B27 antigen, this inflammatory disorder of unknown etiology predominantly affects young adult men. Most patients present with low back pain and stiffness. Radiographs may show erosions, sclerosis and ankylosis in the pelvis and in the discovertebral, apophyseal, costovertebral and atlantoaxial joints. Hips and shoulders are the peripheral joints most commonly affected. Although most of the axial and appendicular skeleton may be involved, bilateral and symmetric sacroiliac involvement is the hallmark of ankylosing spondylitis.
Hyperuricemia is the hallmark of gout. Deposition of monosodium urate crystals in the joints and periarticular soft tissues can lead to arthritic changes. Radiographic features include periarticular soft tissue swelling, "punched-out" bony erosions and joint space narrowing. Although gout has a predilection for the first metatarsophalangeal joint, it may also affect the feet, hands, wrists, elbows and knees.
The authors compared low-dose (32% of standard exposure) storage phosphor digital imaging (system resolution: 0.2-mm pixels, 10 bits) with isovoltage 75-kVp conventional radiography (standard exposure) in the detection of subtle simulated gastric abnormalities by using air contrast barium studies. Subtle simulated abnormalities (3-7-mm polyps, 4-15-mm ulcer craters, 4-11-mm-diameter edema, and 11-12-mm linear ulcers) were produced in resected canine stomachs. Receiver operating characteristic analysis of 1,800 observations by six readers indicated that the digital images with and without high-frequency edge enhancement were equivalent to conventional radiographs (mean receiver operating characteristic areas [+/- standard deviation]: 0.76 +/- 0.06, 0.78 +/- 0.04, and 0.77 +/- 0.04, respectively). The accuracy of the diagnosis was equivalent for all three modalities. The following mean accuracies of negative and positive responses, respectively, for unenhanced digital, edge-enhanced digital, and conventional images were determined: 0.71 +/- 0.05 and 0.41 +/- 0.07, 0.71 +/- 0.04 and 0.51 +/- 0.09, and 0.68 +/- 0.04 and 0.43 +/- 0.05. It was concluded that low-dose storage phosphor air-contrast barium studies were equivalent to conventional radiography in the detection of subtle gastric abnormalities.
A new tray has been designed for use during procedures involving needles and other sharp objects. The tray includes a foam adhesive pad, marked into 10 sections, into which the sharp objects can be placed point first. After the procedure, the objects can be safely withdrawn by their handles and then discarded. The tray has been used in more than 250 procedures.
To explore the value of accurate preoperative localization of occult breast lesions, we reviewed 100 consecutive needle-directed breast biopsies performed by the same surgeon over a 1-year period. A spring hookwire device for localization was inserted parallel to the chest wall. Two thirds of biopsies were performed under local anesthesia, and all were performed in an outpatient setting. Sixteen lesions were invasive carcinomas, and eight were ductal carcinomas in situ. In 96 lesions, the localizing wire was placed within 2 mm of the lesion, and in the remaining four it was within 5 mm of the abnormality. The mammographic lesion was excised in the first specimen in 96 cases. One patient required a second biopsy because of failure to excise the lesion in question after three specimens were taken. The only surgical complication was one hematoma, which resolved within 3 months. Median specimen volume for the entire series was 6.0 cm3. Median largest specimen diameter was 2.5 cm. Precise preoperative localization with a spring hookwire to within 2 mm of the mammographic lesion allows the surgeon to excise a median volume of 6 cm3 breast tissue with consistent retrieval of the lesion.
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