[Diagnostic image (238). A girl with abdominal pain after a play-fight].
A 15-year-old girl presenting with abdominal pain after a play-fight was diagnosed with a duodenal rupture, which was surgically repaired.
Abdominal Injuries↗
Biomedical subjects
R M Pijnappel
Publications and source records attributed to R M Pijnappel.
Diagnostic accuracy for different strategies of image-guided breast intervention in cases of nonpalpable breast lesions.
To find out whether ultrasound-guided fine-needle aspiration (FNA) and ultrasound and stereotactic-guided large core needle biopsy (LCNB) are reliable alternatives to needle-localised open breast biopsy (NLBB) in daily practice, we performed a retrospective study and evaluated the validity of these methods. In all, 718 women with 749 nonpalpable breast lesions from three Dutch Hospitals were included, and the validity of the various methods for diagnosis was assessed. This was carried out according to a method described by Burbank and Parker for evaluating the quality of an image-guided breast intervention. We compared our results with the outcome of the COBRA study. Overall, all diagnostic strategies (NLBB, FNA, LCNB ultrasound and stereotactic guided) show comparable agreement rates. However, the miss rates differ: 2% for NLBB, 3% for COBRA (LCNB in study setting), 5% for FNA and 8-12% for LCNB in practice. Fine-needle aspiration was nonconclusive in 29%, and shows an overestimation for DCIS in 9%. The DCIS underestimate rate in NLBB was 8%. For the assessment of lesions consisting of microcalcifications only and to exclude malignancy in all other lesions, a 14-gauge needle should be used. Ultrasound-guided intervention can be performed in a large percentage of nonpalpable lesions. Lesions consisting only of microcalcifications on mammography need special attention.
Adult↗
Cost-effectiveness of stereotactic large-core needle biopsy for nonpalpable breast lesions compared to open-breast biopsy.
This paper demonstrates that the introduction of large-core needle biopsy (LCNB) replacing needle-localised breast biopsy (NLBB) for nonpalpable (screen-detected) breast lesions could result in substantial cost savings at the expense of a possible slight increase in breast cancer mortality. The cost-effectiveness of LCNB and NLBB was estimated using a microsimulation model. The sensitivity of LCNB (0.97) and resource use and costs of LCNB and NLBB were derived from a multicentre consecutive cohort study among 973 women who consented in getting LCNB and NLBB, if LCNB was negative. Sensitivity analyses were performed. Replacing NLBB with LCNB would result in approximately six more breast cancer deaths per year (in a target population of 2.1 million women), or in 1000 extra life-years lost from breast cancer (effect over 100 years). The total costs of management of breast cancer (3% discounted) are estimated at pound 4676 million with NLBB; introducing LCNB would save pound 13 million. The incremental cost-effectiveness ratio of continued NLBB vs LCNB would be pound 12 482 per additional life-year gained (3% discounted); incremental costs range from pound -21 687 (low threshold for breast biopsy) to pound 74 378 (high sensitivity of LCNB).
Aged↗
Ductal carcinoma in situ presenting as microcalcifications: the effect of stereotactic large-core needle biopsy on surgical therapy.
The aim of this investigation was to study the efficacy of surgical therapy in patients with non-palpable ductal carcinoma in situ (DCIS) presenting as microcalcifications diagnosed by means of stereotactic large-core needle biopsy (SCNB). This is a retrospective study with a historical control group within a 12-year period. Two groups of consecutive patients diagnosed with DCIS (1991-2002) by means of needle-localised open breast biopsy (NLBB, n=49) and SCNB (n=51) were studied. Both groups were comparable for clinical, radiological and pathological characteristics. The therapeutic interval (time from presentation to definitive of therapy) was 62-days in the SCNB group versus 32-days in the NLBB group (p<0.001). In the SCNB group fewer surgical procedures were required for completion of surgical therapy (p=0.006) and after local excision the surgical margins were more often tumour free (p=0.002). It is postulated that the need for fewer surgical procedures and the greater frequency of tumour-free margins after local excision may be attributable to SCNB.
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Reproducibility of mammographic classifications for non-palpable suspect lesions with microcalcifications.
Observer variability in interpretation of mammograms is a well-known problem, especially for microcalcifications. The classification of the mammographic findings depends upon this interpretation. We performed an intraobserver study to evaluate a breast imaging reporting and data system (BI-RADS) based method for description and classification of non-palpable lesions with microcalcifications. A set of 100 non-palpable mammographic lesions mainly consisting of microcalcifications was described and classified on two occasions, by two radiologists at an interval of 6 months. The intraobserver variability was evaluated with kappa statistics. The overall agreement for the classification was moderate (kappa 0.54). The lowest kappa values were observed for the categories "probably benign (BI-RADS 3, kappa 0.59)" and "suspicious abnormality (BI-RADS 4, kappa 0.44)". The clinical management (follow-up or biopsy) of non-palpable lesions consisting of microcalcifications depending upon radiological classification in the groups BI-RADS 3 (follow-up) and BI-RADS 4 (biopsy) is therefore debatable.
Biopsy, Needle↗
Interobserver variability between general and expert pathologists during the histopathological assessment of large-core needle and open biopsies of non-palpable breast lesions.
The purpose of this study was to assess whether general pathologists are able to make as accurate and reproducible a diagnosis on large-core needle biopsies as on open breast biopsy specimens. A total of 688 patients underwent a stereotactic large-core (14G) needle biopsy and subsequent surgical excision of 718 non-palpable breast lesions. Forty-two pathologists from 10 departments of pathology (generalists) made a diagnosis on both the needle and open biopsy specimens. Afterwards, three pathologists and two radiologists with extensive experience in breast pathology (experts) diagnosed all of the biopsy specimens. The general pathologists made a similar histological diagnosis as the experts in 632 (88%) of the needle biopsies and 649 (90%) of the open biopsy specimens. Accordingly, the interobserver agreement for the diagnosis of large-core needle biopsies between the general and experts pathologists was excellent (kappa 0.83) and not significantly different from the interobserver agreement for the diagnosis of open breast biopsies (kappa 0.86). However, many inconsistencies were observed in the category of borderline lesions: only 24% of the large-core needle biopsies and 43% of the open biopsies with an expert diagnosis of 'borderline' were diagnosed similarly by the general pathologists. Additionally, the risk of benign/malignant inconsistencies between general pathologists and experts was approximately 1 in 55 for both needle and open biopsies.
Adult↗
Diagnostic strategies in non-palpable breast lesions.
The number of non-palpable breast lesions is growing. Needle-localised breast biopsy (NLBB) is the gold standard for evaluating these lesions. Cost-saving techniques and less invasive alternatives such as core-needle biopsy (LCNB) and fine-needle aspiration (FNA) have emerged. The aim of this study was to find out if the lesions of patients who were sent directly for surgery to undergo a NLBB differed from lesions of patients who were send for a non-operative procedure. Furthermore, if a benign result was obtained, we assessed the total and kind of subsequent diagnostic procedures that were undertaken. A retrospective study on 718 women with 749 non-palpable breast lesions was performed. In 58% of women with non-palpable breast lesion, a non-surgical procedure was chosen. Lesions sent directly for surgery were more frequently not visible on ultrasound (62%) and mainly consisted of microcalcifications only (56%). In 45%, this primary surgical approach could have been avoided. If the non-operative procedure showed a non-malignant result, 41% of these women received an additional surgical diagnostic procedure. These figures obtained from routine daily practice show the importance of protocols in order to standardise diagnostic procedures and prevent unnecessary surgery.
Adult↗
Stereotactic large core needle biopsy for all nonpalpable breast lesions?
BACKGROUND: Stereotactic large-core needle biopsy (SLCNB) is a minimally invasive method for histological diagnosis of nonpalpable breast disease. We studied differences in cancer prevalence between a group of women referred through the national screening program and a non-screening group, and assessed whether the validity of SLCNB differed between these groups. METHODS: A group of non-selective, consecutive patients presenting with a nonpalpable mammographic lesion, who participated in a recently conducted multicenter study regarding the accuracy of SLCNB in The Netherlands, were the basis for this study. Prevalence of carcinoma, predictive value of a benign diagnosis, sensitivity, and specificity rate of SLCNB were compared between the two groups. RESULTS: Of the 1029 lesions in 972 patients included, 858 were evaluable. In 850/858 lesions (99.1%) the reason for referral was clear. The prevalence of cancer in the screening group (n = 511 lesions) was 64.0% (95%CI 59.8-68.2), versus 49.6% in the non-screening group (n = 339) (95%CI 44.2-54.9). Respective predictive values of a benign diagnosis on SLCNB were 97.0 versus 94.8% (non-significant). The sensitivity rates of SLCNB were 98.5% (screening; 95%CI 96.5-99.5) versus 95.2% (non-screening; 95%CI 90.8-97.9). Specificity rates were 97.8 (95%CI 94.5-99.4) and 99.4% (95%CI 96.8-100), respectively. CONCLUSION: Despite a significant difference in the prevalence of carcinoma, the accuracy of SLCNB did not show a statistically significant difference between both patient groups. Therefore, SLCNB appears accurate in diagnosing nonpalpable breast lesions both in screening and non-screening patient groups.
Aged↗
[Diagnostics in clinically occult, radiologically suspect breast lesions more often surgery than needle diagnostics with image monitoring].
OBJECTIVE: To inventory the diagnostic methods used in patients with clinically occult, radiologically suspect breast lesions. DESIGN: Enquiry. METHOD: The departments of radiology of all Dutch hospitals were sent a list in January 2000 containing questions concerning the number of thread localizations in 1999 and the use of cytological or histological needle diagnostics with image monitoring prior to surgical intervention in clinically occult, radiologically suspect breast lesions. Of the 120 questionnaires mailed, 74 (62%) were completed and returned by clinics throughout the country. RESULTS: Fifty-one of the 74 hospitals (69%) had prior to operation carried out histological or cytological examinations and in these 51 hospitals this was done in 1743 of the 2857 lesions (61%): fine-needle aspiration cytology was performed in 1046 (/1743 = 60%; /4140 lesions in all 74 hospitals = 25%) and/or histological needle biopsy in 784 (45%; /4140 = 19%). CONCLUSION: In less than half of all non-palpable breast abnormalities non-surgical methods of diagnosis are used, histological needle biopsy less often than fine needle aspiration cytology.
Biopsy↗
Cost comparison between stereotactic large-core-needle biopsy versus surgical excision biopsy in The Netherlands.
Yearly, approximately 7200 Dutch women with non-palpable breast lesions are referred for a diagnostic surgical excision biopsy. Recently, less invasive alternatives such as stereotactic large-core-needle biopsy have emerged. The aim of this study was to compare the costs of surgical excision biopsy and large-core-needle biopsy. As stereotactic equipment is expensive, the costs of large-core-needle biopsy depend on the extent of centralisation of this facility. Therefore, we assessed the extent of economies of scale in four different scenarios of (de)centralisation. We collected cost data in five Dutch hospitals. The cost of surgical excision biopsy amounted to 1184 Euros. In cases where large-core-needle biopsy would be employed decentralised in all 114 hospitals in The Netherlands, the average costs were estimated to be 1186 Euros compared with 572 Euros in a centralised scenario with involvement of 10 hospitals. Therefore, centralisation of stereotactic equipment for core-needle biopsies would be advisable from an economic perspective.
Biopsy↗
Risk factors for cancellation of stereotactic large core needle biopsy on a prone biopsy table.
Among patients undergoing stereotactic needle biopsy of the breast on a prone biopsy table, a substantial proportion of planned procedures are terminated prematurely. This study was undertaken to identify risk factors for cancellation of these procedures and to derive a clinical rule for predicting cancellation. Risk factors for cancellation were assessed in a group of 476 consecutive patients with non-palpable lesions planned for large core needle biopsy. 64 (13%) of these planned procedures were cancelled. Multivariate regression analysis was applied to identify independent risk factors for cancellation. Validation took place by applying the logistic rule on a validation set, including 5 cancelled and 35 successful biopsy procedures. Mammograms that were difficult to interpret owing to extremely dense breast tissue, axillary location of the non-palpable lesion, body mass index below 20, less than 15 mm distance from the lesion to the chest wall or the presence of more than one non-palpable lesion were identified as independent risk factors. The logistic rule discriminated patients with successful and cancelled biopsy procedures with a receiver operator characteristic (ROC) area of 0.72. In the validation set, the area under the ROC curve was 0.92. The prediction rule, based on mammographic and clinical findings, discriminated patients with successful and cancelled needle biopsy procedures to a certain extent. The risk of cancellation of the stereotacic biopsy procedure is considerable in cases of very dense breast tissue or the presence of multiple risk factors.
Biopsy, Needle↗
Diagnostic accuracy of needle-localized open breast biopsy for impalpable breast disease.
BACKGROUND: Needle-localized open breast biopsy (NLBB) is considered the gold standard procedure for the diagnosis of impalpable breast disease. In an observational follow-up study the sensitivity and negative predictive value of this procedure was determined in a clinical population with long-term follow-up. METHODS: Some 199 consecutive patients with a benign histological diagnosis on NLBB were followed for the occurrence of breast cancer, using information from the Dutch National Morbid-Anatomical Record Department. Based on a review of mammograms and histological slides, an expert panel decided whether the carcinomas detected during follow-up were newly developed, or were present already at the time of the NLBB. RESULTS: After a median follow-up of 60.5 months, seven carcinomas were detected. At panel review, six appeared to have been missed by NLBB. The sensitivity of NLBB was 99 per cent after 2 years of follow-up, but dropped to 96 per cent after 5 years. Similarly, the negative predictive value dropped from 99 per cent after 2 years to 94 per cent after 5 years of follow-up. CONCLUSION: NLBB is an accurate diagnostic procedure for the evaluation of impalpable breast disease. However, with longer follow-up the accuracy becomes lower than generally reported.
Adult↗
The diagnostic accuracy of core biopsy in palpable and non-palpable breast lesions.
OBJECTIVE: To assess the accuracy of large-core needle biopsy in evaluating palpable and nonpalpable breast lesions. METHODS AND PATIENTS: Stereotaxic and ultrasound (US) guided core biopsies were performed in 103 breast lesions in 97 patients. Subsequently, all patients underwent surgery. All specimens (core biopsy and surgical) underwent radiography for evaluation of microcalcifications. The histopathologic findings of the core biopsies and the surgical specimens were correlated. RESULTS: Core biopsies and surgery findings were concordant in 100% of the 27 palpable lesions and in 89% of the 76 nonpalpable lesions. One case of malignancy, ductal carcinoma in situ (DCIS), was not diagnosed by core biopsy. In 102 (99%) of the 103 breast lesions, a correct choice for additional diagnostic procedure or definitive treatment could have been made upon histopathologic findings of core biopsy. CONCLUSION: Stereotaxic and ultrasound-guided core biopsy are safe, reliable and less traumatic than excisional biopsy. Special attention is necessary when atypical ductal hyperplasia (ADH) or DCIS without invasive carcinoma is found. Radiography of the biopsy specimens for detection of microcalcifications is essential.
Adult↗
[Digital roentgen-guided large-needle biopsy as an alternative to surgical biopsy in patients with nonpalpable mammographic abnormalities].
OBJECTIVE: To compare histopathological findings from stereotaxic needle core biopsies and from excision biopsies performed on patients with impalpable breast lesions suggestive of carcinoma. DESIGN: Prospective and descriptive, with a description of the stereotaxic needle core biopsy procedure. SETTING: Academic Hospital Utrecht, the Netherlands. METHODS: In 36 patients core biopsies were done with 14-gauge biopsy needles, followed by a localisation procedure with surgical biopsy. The pathological features of the core and excision specimens were compared. RESULTS: Results of 35 (97%) core biopsies corresponded to those of excision biopsies. Stereotaxic core biopsy was not possible due to technical problems in 2 cases. CONCLUSION: Stereotaxic core biopsy appears to be an acceptable alternative to excision biopsy.
Adult↗