Publications by authors named "Mehmet Halit Yilmaz"

37 Publications

Second Look Ultrasonography-Guided Breast Biopsy with Magnetic Resonance Imaging Confirmation by Intralesional Contrast Injection.

Eur J Breast Health 2021 Jan 24;17(1):1-9. Epub 2020 Dec 24.

Clinic of Radiology, Memorial Hospital, İstanbul, Turkey.

Objective: This study aimed to introduce an alternative pre-biopsy confirmation technique that combines sonography-guided intra-lesional contrast injections and single non-enhanced magnetic resonance imaging (MRI) pulse sequence in order to identify sonographic correlates of incidentally detected breast MRI lesions which were occult on primary ultrasonography (USG) and mammography examination.

Materials And Methods: From May 2014 through May 2015, a total of 37 incidental breast lesions of 37 patients, which were detected by breast MRI, were evaluated with targeted second look ultrasound (SLUS). The suspected lesion on USG was marked with a gadolinium-based contrast agent under USG guidance. After a single non-enhanced T1 weighted control MR sequence, positively correlated lesions with initial MRI were sampled by USG guided core biopsy.

Results: Of the 37 lesions evaluated, 32 (86%) lesions showed a correlation between MRI and SLUS findings. On SLUS core biopsy, there were eight (25%) malignant and 11 (34.4%) high-risk lesions among these 32 cases with correlated MRI findings; while the remaining 13 (40.6%) cases had benign histopathology. Eleven (34.4%) of the SLUS-discovered lesions were focus, 11 (34.4%) were non-mass enhancements, and the remaining 10 (31.2%) were mass lesions. Of the five lesions (13.5%) that showed no correlations on MRI and SLUS examinations, four were non-mass enhancements and one was focus.

Conclusion: SLUS represents a method for identifying MRI-detected lesions and provides a bridge to ultrasound-guided biopsy for histopathological diagnosis. There is a need for confirmation of biopsies to avoid false negative results. We describe a cheap, safe, and easy-to-apply USG-guided pre-biopsy lesions marking method in order to ensure definite correlation.
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http://dx.doi.org/10.5152/ejbh.2020.5663DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8006787PMC
January 2021

In Vivo Evaluation of the Biomechanical Properties of Optic Nerve and Peripapillary Structures by Ultrasonic Shear Wave Elastography in Glaucoma.

Iran J Radiol 2016 Apr 31;13(2):e36849. Epub 2016 Mar 31.

Department of Radiology, Istanbul University Cerrahpasa Medical Faculty, Istanbul, Turkey.

Background: Primary open-angle glaucoma is a multifactorial serious disease characterized by progressive retinal ganglion cell death and loss of visual field.

Objectives: The purposes of this study were to investigate shear wave elastography (SWE) use in the evaluation of the optic nerve (ON) and peripapillary structures, and to compare the findings between glaucomatous and control eyes.

Patients And Methods: A case-controlled study, including 21 patients with primary open-angle glaucoma and 21 age-matched control subjects, was carried out. All of the participants had comprehensive ophthalmological exams that included corneal biomechanical measurements with ocular response analyzer. In vivo evaluation of the biomechanical properties of the ON and peripapillary structures were performed with SWE in all participants. The Kolmogorov-Smirnov test was used to analyze the normal distribution of data. Differences of parameters in ophthalmologic data and stiffness values of patients with and without glaucoma were evaluated using the Mann-Whitney U test.

Results: There were no statistically significant differences between the glaucoma and control groups in terms of age (P > 0.05) and gender (P > 0.05). Corneal hysteresis was lower in the glaucoma group (P < 0.05). Corneal compensated intraocular pressure and Goldmann correlated intraocular pressure were higher in the glaucoma group (P < 0.0001 for both). The mean stiffness of the ON and peripapillary structures were significantly higher in glaucoma patients for each measured region (P < 0.05).

Conclusion: The study evaluated the biomechanical properties of the ON and peripapillary structures in vivo with SWE in glaucoma. We observed stiffer ON and peripapillary tissue in glaucomatous eyes, indicating that SWE claims new perspectives in the evaluation of ON and peripapillary structures in glaucoma disease.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5039735PMC
http://dx.doi.org/10.5812/iranjradiol.36849DOI Listing
April 2016

Sentinel lymph node biopsy under fluorescent indocyanin green guidance: Initial experience.

Ulus Cerrahi Derg 2016 18;32(1):50-3. Epub 2015 Aug 18.

Department of General Surgery, Breast Diseases Service, İstanbul University, Cerrahpaşa Medical Faculty İstanbul, Turkey.

Objective: Sentinel lymph node biopsy can be applied by using either blue dye or radionuclide method or both in breast cancer. Fluorescent imaging with indocyanine green is a new defined method. This study evaluates the applicability of sentinel lymph node biopsy via fluorescent indocyanine green.

Material And Methods: IC-VIEW (Pulsion Medical Systems AG, Munich, Germany) infrared visualization system was used for imaging. Two mL of indocyanine green was injected to visualize sentinel lymph nodes. After injection, subcutaneous lymphatics were traced and sentinel lymph nodes were found with simultaneous imaging. Sentinel lymph nodes were excised under fluorescent light guidance, and excised lymph nodes were examined histopathologically. Patients with sentinel lymph node metastases underwent axillary dissection.

Results: Four patients with sentinel lymph node biopsy due to breast cancer were included in the study. Sentinel lymph nodes were visualized with indocyanine green in all patients. The median number of excised sentinel lymph node was 2 (2-3). Two patients with lymph node metastasis underwent axillary dissection. No metastasis was detected in lymph nodes other than the sentinel nodes in patients with axillary dissection. There was no complication during and after the operation related to the method.

Conclusion: According to our limited experience, sentinel lymph node biopsy under fluorescent indocyanine green guidance, which has an advantage of simultaneous visualization, is technically feasible.
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http://dx.doi.org/10.5152/UCD.2015.2832DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4771427PMC
March 2016

Magnetic Resonance Imaging Guided Vacuum Assisted and Core Needle Biopsies.

J Breast Health 2016 Jan 1;12(1):25-30. Epub 2016 Jan 1.

Department of Radiology, İstanbul University Faculty of Medicine, İstanbul, Turkey.

Objective: The purpose of this study to present the results of Magnetic resonance imaging (MRI) guided cutting needle biopsy procedures of suspicious breast lesions that can be solely detected on Magnetic resonance (MR) examination.

Materials And Methods: The study included 48 patients with 48 lesions which were solely be observed in breast MRI, indistinguishable in ultrasonography and mammography, for MR guided vacuum-assisted cutting needle biopsy and 42 patients with 42 lesions for MR guided cutting needle biopsy for the lesions of the same nature. MR imaging was performed using a 1.5-Tesla MRI device. Acquired MR images were determined and biopsy protocol was performed using computer-aided diagnosis system on the workstation. Vacuum biopsies were performed using 10 G or 12 G automatic biopsy systems, cutting needle biopsy procedures were performed using fully automated 12 G biopsy needle.

Results: All biopsy procedures were finalized successfully without major complications. The lesions were 54 mass (60%), 28 were non-mass contrast enhancement (31%) and 8 were foci (9%) in the MR examination. Histopathological evaluation revealed 18 malignant (invasive, in-situ ductal carcinoma and lobular carcinoma), 66 benign (apocrine metaplasia, fibrosis, fibroadenomatoid lesion, sclerosing adenosis, fibrocystic disease and mild-to-severe epithelial proliferation) and 6 high-risk (atypical ductal hyperplasia, intraductal papilloma, radial scar) lesions.

Conclusion: Magnetic resonance guided vacuum and cutting needle biopsy methods are successful methods fort he evaluation of solely MRI detected suspicious breast lesions. There are several advantages relative to each other in both methods.
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http://dx.doi.org/10.5152/tjbh.2015.2769DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5351431PMC
January 2016

Ex Vivo Assessment of Sentinel Lymph Nodes in Breast Cancer Using Shear Wave Elastography.

J Ultrasound Med 2016 Feb 29;35(2):271-7. Epub 2015 Dec 29.

Departments of Radiology (F.K., S.G.K., A.S.D., M.E.E., F.K., M.H.Y.), General Surgery (M.V., F.A.), and Pathology (T.O.), Istanbul University Cerrahpasa Medical Faculty, Istanbul, Turkey.

Objectives: Axillary lymph node status is one of the important prognostic factors in early-stage breast cancer. Despite the combined use of sonography, fine-needle aspiration, and sentinel lymph node (SLN) dissection, there is a gap between the potential effectiveness of those techniques and current success to determine the axillary lymph node status. The main aim of this study was to evaluate the baseline accuracy of shear wave elastography for differentiation of benign versus malignant SLNs in an ex vivo artifact-free environment.

Methods: Thirty patients with breast cancer scheduled for SLN dissection were enrolled prospectively after informed consent and Institutional Review Board approval were obtained. After dissection, lymph nodes were embedded in ultrasound gel and examined with grayscale sonography and shear wave elastography. Findings were compared to histopathologic results.

Results: A total of 64 SLNs obtained from the 30 patients were evaluated. Twelve of them (18.8%) were metastatic, and 52 (81.2%) were benign. The mean cortical thickness (benign versus metastatic, 1.6 versus 4.4 mm), short-axis length (4.63 versus 7.50 mm), cortical stiffness (10.7 versus 25.5 kPa), and hilar stiffness (7.5 versus 11.3 kPa) were statistically higher in metastatic lymph nodes (P ≤ .02). Area under the receiver operator characteristic curve values for these variables were 0.814, 0.768, 0.786, and 0.759, respectively. Cortical thickness was found to have the highest diagnostic performance, followed by cortical stiffness.

Conclusions: Shear wave elastography can be used with grayscale sonography for evaluation of cases to decide on needle biopsy sampling. However, it cannot be used as a replacement for fine-needle aspiration or SLN dissection.
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http://dx.doi.org/10.7863/ultra.15.03039DOI Listing
February 2016

Bilateral idiopathic granulomatous mastitis.

Asian J Surg 2016 Jan 2;39(1):12-20. Epub 2015 May 2.

Department of General Surgery, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey. Electronic address:

Objectives: Idiopathic granulomatous mastitis (IGM) is a benign rare inflammatory pseudotumor. Bilateral involvement of IGM has been reported in a few cases. To our knowledge, this study is the largest series of bilateral cases to date. The goals of this study were to present clinical features of bilateral IGM and to evaluate the results of treatments.

Materials And Methods: We performed a retrospective review of the idiopathic granulomatous mastitis database from 2010 to 2013. Ten female patients who met required histologic and clinical criteria of IGM in both breasts were included in study. Demographic data, clinical findings, medication history, and radiologic findings are presented.

Results: The mean age at onset of the disease was 38.4 ± 8.3 years (range: 29-52 years). Nine patients had no recurrence during a mean follow-up period of 21 months (range: 11-26 months). Additionally, the median time to second breast involvement was 15.6 months.

Conclusion: Bilateral IGMs have a higher rate of more relapse and greater resistance to medical therapies than do unilateral IGMs. Surgical management should be avoided unless all medical treatment options have been exhausted. Nevertheless, expectant management seems a rational option for the treatment of bilateral IGM.
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http://dx.doi.org/10.1016/j.asjsur.2015.02.003DOI Listing
January 2016

Shear wave elastography of placenta: in vivo quantitation of placental elasticity in preeclampsia.

Diagn Interv Radiol 2015 May-Jun;21(3):202-7

Department of Radiology, Istanbul University Cerrahpasa School of Medicine, Istanbul, Turkey.

Purpose: We aimed to evaluate the utility of shear wave elastography (SWE) for assessing the placenta in preeclampsia disease.

Methods: A total of 50 pregnant women in the second or third trimester (23 preeclampsia patients and 27 healthy control subjects) were enrolled in the study. Obstetrical grayscale and Doppler ultrasonography, SWE findings of placenta, and prenatal/postnatal clinical data were analyzed and the best SWE cutoff value which represents the diagnosis of preeclampsia was determined. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and diagnostic accuracy of preeclampsia were calculated based on SWE measurements.

Results: Mean stiffness values were much higher in preeclamptic placentas in all regions and layers than in normal controls. The most significant difference was observed in the central placental area facing the fetus where the umbilical cord inserts, with a median of 21 kPa (range, 3-71 kPa) for preeclampsia and 4 kPa (range, 1.5-14 kPa) for the control group (P < 0.01). The SWE data showed a moderate correlation with the uterine artery resistivity and pulsatility indices. The cutoff value maximizing the accuracy of diagnosis was 7.35 kPa (area under curve, 0.895; 95% confidence interval, 0.791-0.998); sensitivity, specificity, PPV, NPV, and accuracy were 90%, 86%, 82%, 92%, and 88%, respectively.

Conclusion: Stiffness of the placenta is significantly higher in patients with preeclampsia. SWE appears to be an assistive diagnostic technique for placenta evaluation in preeclampsia.
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http://dx.doi.org/10.5152/dir.2014.14338DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4463268PMC
February 2016

Changes in the elasticity of fibroadenoma during the menstrual cycle determined by real-time sonoelastography.

Eur J Radiol 2015 Jun 16;84(6):1044-8. Epub 2015 Mar 16.

Istanbul University Cerrahpasa Medical Faculty, Department of Radiology, Turkey.

Objective: Shear-wave elastography (SWE) presents quantitative data that thought to represent intrinsic features of the target tissue. Factors affecting the metabolism of the breast parenchyma as well as age, menstrual cycle, hormone levels, pregnancy and lactation, pre-compression artifact during the examination could affect these elastic intrinsic features. Aim of our study is to determine variation of fibroadenoma elasticity during the menstrual cycle (MC) by means of real-time shear-wave elastography (SWE) and identify the optimal time for SWE evaluation.

Methods: Thirty volunteers (aged 20-40 years) who had biopsy-proven fibroadenoma greater than 1cm in diameter, with regular menstrual cycle and without contraceptive medication underwent SWE (ShearWave on Aixplorer, France) once weekly during MC. Statistical data were processed by using the software Statistical Package for the Social Sciences (SPSS) 19.0. A repeated measures analysis of variance was used for each lesion where the repeated factor was the elastographic measurements (premenstrual, menstrual and postmenstrual). Pillai's trace test was used. Pairwise correlation was calculated using Bonferroni correction. Values of p<0.05 were considered statistically significant.

Results: The mean elasticity value of fibroadenomas in mid-cycle was 28.49 ± 12.92 kPa, with the highest value obtained in the third week corresponding to the premenstrual stage (32.98 ± 13.35 kPa) and the lowest value obtained in the first week corresponding to the postmenstrual stage (25.39 ± 10.21 kPa). Differences between the elasticity values of fibroadenomas in premenstrual and postmenstrual periods were statistically significant (p<0.001). There were no significant differences in lesion size between the different phases of the menstrual cycle (p>0.05).

Conclusion: In this study, we found that there is significant difference between the elasticity values of fibroadenomas on premenstrual and postmenstrual period. We propose that one week after menstruation would be appropriate time to perform breast SWE.
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http://dx.doi.org/10.1016/j.ejrad.2015.03.006DOI Listing
June 2015

Ductal Carcinoma In Situ Detected by Shear Wave Elastography within a Fibroadenoma.

J Breast Cancer 2014 Jun 27;17(2):180-3. Epub 2014 Jun 27.

Department of Radiology, Istanbul University Cerrahpasa Medical Faculty, Istanbul, Turkey.

Fibroadenoma is the most common breast tumor in women. Malignant transformation occurs rarely within fibroadenoma at older ages. Clinicians, radiologists, and pathologists need to be aware of malignant transformation within fibroadenomas. Radiologic studies play an important role in the diagnosis of fibroadenoma; however, radiologic findings are often nonspecific for malignancy and may appear completely benign. We detected an occult ductal carcinoma in situ that originated inside a fibroadenoma by using shear wave elastography. We report shear wave elastography findings of ductal carcinoma in situ within fibroadenoma and discuss the diagnostic role of this modality.
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http://dx.doi.org/10.4048/jbc.2014.17.2.180DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4090322PMC
June 2014

Use of shear wave elastography to differentiate benign and malignant breast lesions.

Diagn Interv Radiol 2014 May-Jun;20(3):239-44

From the Departments of Radiology İstanbul University Cerrahpaşa School of Medicine, İstanbul, Turkey.

Purpose: We aimed to determine the correlations between the elasticity values of solid breast masses and histopathological findings to define cutoff elasticity values differentiating malignant from benign lesions.

Materials And Methods: A total of 115 solid breast lesions of 109 consecutive patients were evaluated prospectively using shear wave elastography (SWE). Two orthogonal elastographic images of each lesion were obtained. Minimum, mean, and maximum elasticity values were calculated in regions of interest placed over the stiffest areas on the two images; we also calculated mass/fat elasticity ratios. Correlation of elastographic measurements with histopathological results were studied.

Results: Eighty-three benign and thirty-two malignant lesions were histopathologically diagnosed. The minimum, mean, and maximum elasticity values, and the mass/fat elasticity ratios of malignant lesions, were significantly higher than those of benign lesions. The cutoff value was 45.7 kPa for mean elasticity (sensitivity, 96%; specificity, 95%), 54.3 kPa for maximum elasticity (sensitivity, 95%; specificity, 94%), 37.1 kPa for minimum elasticity (sensitivity, 96%; specificity, 95%), and 4.6 for the mass/fat elasticity ratio (sensitivity, 97%; specificity, 95%).

Conclusion: SWE yields additional valuable quantitative data to ultrasonographic examination on solid breast lesions. SWE may serve as a complementary tool for diagnosis of breast lesions. Long-term clinical studies are required to accurately select lesions requiring biopsy.
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http://dx.doi.org/10.5152/dir.2014.13306DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4463348PMC
July 2015

A case of an idiopathic massive osteolysis with skip lesions.

Korean J Radiol 2013 Nov-Dec;14(6):946-50. Epub 2013 Nov 5.

Department of Radiology, Arnavutkoy State Hospital, Instanbul 34275, Turkey.

A patient with a 2-year history of pain in the left arm, and decreased strengths unrelieved by non-steroidal anti-inflammatory therapy, was being referred for repeating radiography. The radiologic examinations have demonstrated a unique pattern of non-contiguous osteolysis in the left elbow, proximal and distal radius, ulna, wrist, carpal bones, proximal and distal metacarpals and phalanges. Multi-site biopsies were being performed and confirmed the diagnosis of massive osteolysis. To our knowledge, this is the first case in which multifocal, non-contiguous osteolysis with skip lesions without associated nephropathy and without a hereditary pattern is being described in one extremity.
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http://dx.doi.org/10.3348/kjr.2013.14.6.946DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3835643PMC
July 2014

The management and the diagnosis of fever of unknown origin.

Expert Rev Anti Infect Ther 2013 Aug;11(8):805-15

Infectious Diseases Department, Cerrahpasa Medical School, Istanbul University, Istanbul, Turkey.

Prolonged fever presents a challenge for the patient and the physician. Fever with a temperature higher than 38.3°C on several occasions that lasts for at least 3 weeks and lacks a clear diagnosis after 1 week of study in the hospital is called a fever of unknown origin (FUO). More than 200 diseases can cause FUO, and the information gathered from history taking, physical examination, laboratory and imaging studies should be evaluated with care. History taking and physical examination may provide some localizing signs and symptoms pointing toward a diagnosis. Infection, cancers, noninfectious inflammatory diseases and some miscellaneous diseases are the main etiologies, and some patients remain undiagnosed despite investigations. Tuberculosis, lymphoma and adult-onset Still's disease are the main diseases. Fluorodeoxyglucose PET is a promising imaging modality in FUO. Establishing a uniform algorithm for FUO management is difficult. Every patient should be carefully evaluated individually considering the previous FUO management experience.
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http://dx.doi.org/10.1586/14787210.2013.814436DOI Listing
August 2013

Spontaneous intracranial hypotension syndrome may mimic aseptic meningitis.

Scand J Infect Dis 2012 Jul 11;44(7):481-8. Epub 2012 Mar 11.

Department of Infectious Diseases and Clinical Microbiology, Cerrahpasa Medical School, Istanbul University, Istanbul, Turkey.

Background: Spontaneous intracranial hypotension (SIH) is recognized with increasing frequency. A throbbing headache occurring or worsening in the upright position and improving after lying down, a so-called 'orthostatic headache', low cerebrospinal fluid (CSF) pressure, and diffuse pachymeningeal enhancement on brain magnetic resonance imaging (MRI) are the major features of the classic syndrome. These patients, who are admitted with fever, headache, and CSF findings revealing lymphocytic pleocytosis, elevated protein concentration, normal glucose levels, and negative culture results, are prone to be misdiagnosed with aseptic meningitis. The aims of this single-centre retrospective study were to determine the epidemiological, clinical, laboratory, and radiological features of patients initially evaluated as having aseptic meningitis but subsequently diagnosed with SIH, and to touch upon the key points of the differential diagnosis in daily infectious diseases practice.

Methods: Patients referred to Cerrahpasa Medical School with a presumed diagnosis of aseptic meningitis or viral meningitis between 1 January 2006 and 1 January 2011 were reviewed. Epidemiological, clinical, laboratory, radiological, and follow-up data obtained from the hospital database were processed. Patients confirmed to have SIH syndrome were included for evaluation.

Results: Eleven cases of SIH syndrome were diagnosed during the study period (8 male and 3 female, median age 30 y, range 21-44 y). All had headache, hearing changes, and nausea. Vomiting (10/11) and posterior neck pain (9/11) were also frequent. Seven had fever and 5 had a stiff neck. Four cases had lymphocytic pleocytosis, 4 cases had elevated CSF protein concentrations (> 1.5 times the upper limit of normal), and 2 cases had slightly lower CSF glucose levels. Polymerase chain reaction (PCR) analyses of the CSF for Mycobacterium tuberculosis complex, herpes simplex viruses 1 and 2, and enteroviruses were negative in all cases. MRI of the 11 cases revealed signs of spontaneous CSF leaks with diffuse pachymeningeal gadolinium enhancement (11/11), sagging of the brain (9/11), enlargement of the pituitary (6/11), engorgement of the venous structures (5/11), and subdural fluid collections (2/11). CSF leaks were demonstrated by intrathecal magnetic resonance or computed tomography myelography at different levels along the thoracic spine (7/11), cervico-thoracic junction (2/11), and thoraco-lumbar junction (2/11). Autologous blood injection into the spinal epidural space ('blood patch') was performed for treatment. Strict bed rest followed, and all patients recovered fully within a week; no recurrence or complication was observed during the follow-up periods, which ranged from 6 months to 5 y.

Conclusions: Findings of fever, headache, and meningeal irritation are generally accepted as the clinical features of meningitis. When CSF findings are not characteristically compatible with bacterial meningitis and particularly when the headache is orthostatic in nature, SIH should also be included in the differential diagnosis. MRI findings are characteristic and clearly contribute to the differential diagnosis between viral meningitis and SIH.
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http://dx.doi.org/10.3109/00365548.2012.664776DOI Listing
July 2012

Vertebral osteomyelitis: eight years' experience of 100 cases.

Rheumatol Int 2012 Nov 18;32(11):3591-7. Epub 2011 Nov 18.

Cerrahpasa Medical Faculty, Department of Infectious Diseases and Clinical Microbiology, Istanbul University, Kocamustafa Paşa, 34098 Istanbul, Turkey.

To evaluate the etiology and characteristics of vertebral osteomyelitis cases in our country, patients with vertebral osteomyelitis between January 2000 and December 2007 were included in this study. Clinical and laboratory data of the patients were collected from the medical records retrospectively. Of these 100 patients, 44 had pyogenic, 24 had brucellar, and 32 had tuberculous spondylodiscitis. The age of the patients ranged from 13 to 82 years, with a mean of (SD±) 55 ± 15.6 years. Within the pyogenic group, 10 (22.7%) patients had a spinal surgery history, and in 18 patients of the pyogenic group, an etiological agent was isolated. Ten (56%) of these 18 were methicillin-sensitive Staphylococcus aureus. While all of the patients included in this study suffered from pain, 49 of these had fever. Sixty-nine percent of the patients had lumbar involvement. The etiological distribution may differ according to geographical areas. Although brucella and tuberculosis (TB) are endemic in our country, pyogenic vertebral osteomyelitis was more frequent. The most common involved area in our patients was the lumbar vertebrae. Although thoracic involvement may be more predominant in tuberculous vertebral osteomyelitis, it does not strongly suggest TB. Magnetic resonance imaging may exclude some disorders mimicking vertebral osteomyelitis and may delineate the degree of the involvement. Microbiological and/or histopathological examination of computerized tomography-guided fine-needle aspiration biopsies are the mainstays for the diagnosis. Suspicion and early diagnosis seem critical for preventing sequelae development.
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http://dx.doi.org/10.1007/s00296-011-2233-zDOI Listing
November 2012

Simultaneous excision of ipsilateral nonpalpable multiple breast lesions using radioguided occult lesion localization.

Breast 2011 Jun 2;20(3):241-5. Epub 2011 Feb 2.

Department of General Surgery, Istanbul University Cerrahpasa Medical School, Istanbul, Turkey.

The purpose of this study was to determine the feasibility and effectiveness of ROLL technique for the identification and excision of ipsilateral nonpalpable multiple breast lesions. Between August 2005 and August 2010, eight women, aged 40-61 years, with a radiographic evidence of two separate nonpalpable lesions within the same breast underwent ROLL, as we termed it, double-ROLL. Each lesion was localized with Tc-99m-labeled human serum albumin macroaggregate under ultrasonography or mamography control. A gamma probe was used to guide surgical excisions. There was no radiotracer overlapping or extravasation in any case. Out of the 16 resected specimens, histopathologic examination revealed benign findings in 13 lesions and malignancy in 3. There was no lesion involvement at the surgical margins, and no residuals were detected in any of the benign cases during follow-up. Double-ROLL technique is feasible and safe for the identification and excision of such multiple ipsilateral breast lesions.
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http://dx.doi.org/10.1016/j.breast.2011.01.008DOI Listing
June 2011

Radio-guided lymph node biopsy for the diagnosis of axillary lymphadenopathy.

Nucl Med Commun 2011 Mar;32(3):233-7

Departments of General Surgery, Istanbul University, Turkey.

Ultrasonography-guided needle biopsy techniques have limitations and conventional excisional biopsy may pose challenges in the diagnosis of ultrasonography-demonstrable axillary lymphadenopathy. In this study, we report an alternative technique, radio-guided lymph node biopsy, and describe its technical aspects and diagnostic role. Between January 2006 and December 2009, six patients were included in this study (five women and one man, aged 23-65 years). After a complete clinical evaluation, all the patients were referred to our general surgery clinic for excisional lymph node biopsy from the axilla. The indications of biopsy were either the new onset of an axillary lympadenopathy on post-therapeutic screening or the presence of a persistent axillary lymphadenopathy. In all of the cases, ultrasonography confirmed the clinical suspicion of axillary lymphadenopathy and the radio-guided lymph node biopsy technique was used for the diagnosis. Tc-99m-labelled human serum albumin macroagregate in saline was injected under ultrasonographic guidance for the localization of the lymph nodes. A γ-probe was used to guide the excisions.The lymph nodes that were involved were successfully localized and excised surgically. The postoperative course was uneventful and no complications occurred in all cases. Pathological examination of the excised lymph nodes showed reactive hyperplasia in three patients, tuberculous lymphadenitis in one patient, Hodgkin's lymphoma in another and, non-Hodgkin's lymphoma in one patient. Radio-guided lymph node biopsy has proved to be an accurate and a safe technique for the diagnosis of axillary lymphadenopathies in the indicated subset of patients.
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http://dx.doi.org/10.1097/MNM.0b013e328341215bDOI Listing
March 2011

Pelvic MRI findings of juvenile-onset ankylosing spondylitis.

Clin Rheumatol 2010 Sep 13;29(9):1007-13. Epub 2010 Jun 13.

Cerrahpasa Medical Faculty, Department of Radiology and Pediatrics, Istanbul University, Istanbul, Turkey.

Ankylosing spondylitis (AS) is the most common clinical subgroup of sero-negative spondyloarthropathies. Radiographic and clinical signs of bilateral inflammatory involvement of sacroiliac joints are the gold standard for the diagnosis of juvenile AS. Although radiographic evidence of sacroiliitis is included in the definition, it is not mandatory for the diagnosis of juvenile AS. The aim of this study is to describe pelvic enthesitis-osteitis MRI findings accompanying sacroiliitis in a group of juvenile AS. Eleven patients suffering from low back pain underwent MRI of the pelvis and were enrolled in this retrospective study. The mean duration of symptoms was 12 months. The mean age of the 11 cases in our study was 12.18 years (range, 6-19). There were eight boys and three girls. Anteroposterior radiographs of the pelvis were obtained in all patients. Sacroiliac joint involvement was detected in all of the cases by pelvic MRI. Pathologic signal changes were detected in the pubic symphisis (osteitis pubis) in ten cases, trochanteric bursitis in six cases, coxofemoral joint in five cases, crista iliaca in three cases, and ischion pubis in three cases. There was increased T2 signal intensity in eight of the 11 cases (72.7%) relevant with soft tissue edema/inflammation. This high correlation between sacroiliitis and enthesitis suggests that enthesitis could be an important finding in juvenile AS.
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http://dx.doi.org/10.1007/s10067-010-1514-3DOI Listing
September 2010

Radioguided occult lesion localization (ROLL) for non-palpable breast cancer: a comparison between day-before and same-day protocols.

Breast 2010 Jun 18;19(3):226-30. Epub 2010 Feb 18.

Istanbul University, Cerrahpasa Medical School, Department of General Surgery, Istanbul, Turkey.

Background: Although radioguided occult lesion localization (ROLL) has become a widely accepted technique, the optimal time interval between the radioisotope injection and surgery has not yet been determined.

Aim: To delineate the effects of time from the injection of the radionuclide until surgery on the ROLL success rate in a patient population diagnosed as having non-palpable breast cancer.

Methods: Between December 2004 and May 2009, 75 patients underwent ROLL procedure. The day-before protocol and same-day protocols included 50 and 25 breast cancer patients respectively.

Results: The two study groups were comparable in terms of age, localization technique, radiological findings and the type of surgical procedures (P > 0.05). No statistically significant difference was noticed in the pathological diagnosis, cancer size and the surgical margin clearance between the two groups (P > 0.05).

Conclusions: Same-day injection of the radiotracer was not superior to the day-before injection in ROLL. The day-before protocol can be scheduled for the convenience of both patients and hospital staff.
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http://dx.doi.org/10.1016/j.breast.2010.01.017DOI Listing
June 2010

Excision of axillary lymph node recurrences in breast cancer patients with axillary ROLL (A-ROLL).

J Surg Oncol 2010 Feb;101(2):141-4

Department of General Surgery, Cerrahpasa Medical School, Istanbul University, Istanbul, Turkey.

Background And Objectives: Conventional surgical exploration to find clinically occult axillary lymph node recurrence of breast cancer can be challenging. The aim of this study was to determine the place of our alternative technique, axillary-ROLL (A-ROLL), in previously treated breast cancer patients with nonpalpable axillary lymph node recurrences.

Methods: Between March 2005 and May 2009, included in this retrospective study were four women (age, 42-51 years) without clinical evidence of distant metastasis who had treatment for breast cancer and were subsequently found to have suspicious axillary lymph node(s) detected by control ultrasonography (US) examination during follow-up. A-ROLL was utilized for the identification of lymph nodes. 0.5-1 mCi (99m)Tc-human serum albumin makroaggregate was injected under US guidance. A gamma probe was then used to guide the excision of the lymph nodes.

Results: The involved lymph nodes were successfully localized by A-ROLL technique and removed surgically. Of all four patients, postoperative histopathologic examination revealed nodal cancer metastases in three patients (75%) and lymphoid hyperplasia in one patient. No complications occurred.

Conclusions: A-ROLL technique has proved to be accurate and safe in the identification and excision of clinically occult axillary lymph node recurrence.
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http://dx.doi.org/10.1002/jso.21450DOI Listing
February 2010

Diagnostic value of magnetic resonance imaging and scintigraphy in patients with metastatic breast cancer of the axial skeleton: a comparative study.

Med Oncol 2008 27;25(3):257-63. Epub 2007 Nov 27.

Department of Radiology, Istanbul University, Cerrahpasa Medical Faculty, Istanbul, Turkey.

Purpose: The goal of this study was to compare the sensitivity of MRI and scintigraphy for detecting metastatic bone disease involving the axial skeleton.

Patients And Methods: A total of 59 patients (58 women and 1 man, age range 28-83 years, mean age 53.0 years) with histopathologically proven breast cancer during a 15-month period (between April 2003 and January 2004) were included in the study. All the patients underwent scintigraphy and MRI examinations for staging, follow-up, or evaluation of bone pain.

Results: MR imaging revealed 59 metastases in 59 patients (sensitivity, 95%; specificity, 100%; positive predictive value, 100%). Four lesions detected by MRI were classified as of uncertain origin (grade 2) and 36 lesions were regarded as definitely benign (grade 1). Scintigraphy revealed 44 metastases in 59 patients (sensitivity, 70%; specificity, 94%; positive predictive value, 95%). A total of 29 lesions were considered as of uncertain origin (grade 2), and 26 lesions were regarded as definitely benign (grade 1). About five lesions were graded as grade 2 in scintigraphy, while MRI graded them as degeneration or benign compression (Grade 1). For 11 lesions the same grade was regarded in both MRI and scintigraphy. Two lesions graded as grade 3, and eleven lesions graded as grade 2 in scintigraphy demonstrated no pathological signal intensity in MRI. In total, 18 lesions with no activity in scintigraphy were graded as grade 3 lesions in MRI.

Conclusion: MRI is more sensitive than scintigraphy in the detection of bone metastases. MRI appears to be able to screen patients more effectively than scintigraphy if the spine and pelvis are included because metastases merely outside the axial skeleton are rare.
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http://dx.doi.org/10.1007/s12032-007-9027-xDOI Listing
December 2008

Pain & resistance in patients with adhesive capsulitis during contrast material injection phase of MR arthrography.

Indian J Med Res 2007 Apr;125(4):572-6

Department of Radiology , Cerrahpasa Medical Faculty Istanbul University, Istanbul, Turkey.

Background & Objective: Adhesive capsulitis of the shoulder is a condition of unknown aetiology that results in the development of restricted active and passive glenohumeral motion. It has been reported that magnetic resonance (MR) imaging is useful in diagnosing adhesive capsulitis. We carried out this study to assess how pain and/or resistance during contrast material injection affects the diagnosis of adhesive capsulitis on magnetic resonance (MR) arthrography.

Methods: The study included MR arthrography examinations of 21 patients with a diagnosis of adhesive capsulitis. The control group consisted of 20 patients who presented clinically with rotator cuff tear. The pain (visual analog scale, VAS), resistance to injection and the amount of contrast material that could be injected during injection phase of MR arthrography was assessed and compared between groups.

Results: The patients in adhesive capsulitis group (mean VAS score 66.5+/-25.5) experienced more pain when compared with the control group (mean VAS score 34.9+/-27.7, P<0.001). A statistically significant difference (P<0.001) in terms of the amount of the injected fluid (4.3+/-2.6 ml for adhesive capsulitis group, and 10.9+/-4.1 ml for control group) was seen into the joint cavity. Resistance to injection was significantly more (P<0.001) in patients with adhesive capsulitis when compared to control group.

Interpretation & Conclusion: Experience of pain during injection, a decreased amount of contrast material injected and resistance to injection in patients during injection phase of MR arthrography may suggest adhesive capsulitis.
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April 2007

The role of US and MR imaging in detecting local chest wall tumor recurrence after mastectomy.

Diagn Interv Radiol 2007 Mar;13(1):13-8

Department of Radiology, Istanbul University, Cerrahpaşa School of Medicine, Istanbul, Turkey.

Purpose: To determine the role of clinical examination, ultrasonography (US), and magnetic resonance imaging (MRI) in detecting local tumor recurrence in patients who underwent modified radical mastectomy for breast cancer.

Materials And Methods: The study included 27 patients who were examined between April 1999 and April 2003. US evaluation of the chest wall was performed in all patients. MRI was performed on 10 patients due to suspicious findings in clinical examination, on 3 patients due to US findings, and on 8 patients due to both US and clinical examination findings. Six patients without any suspicious findings underwent MRI for follow-up purposes. The lesions detected with MRI were evaluated according to their morphology, contrast enhancement characteristics and dynamics. The focal lesions that enhanced intensely at the early phase were accepted as suspicious for malignancy.

Results: Of the 10 cases that underwent biopsy secondary to suspicious lesions for malignancy according to MRI findings, 7 were found to have recurrence. In the remaining 3 patients, recurrence diagnosis was made based on the fact that the lesions regressed in response to chemotherapy. In 17 cases, there were no suspicious findings on MRI for local recurrence. In 2 of these cases, biopsies were performed due to suspicious US findings; however, no malignancies were detected. The sensitivity and specificity of clinical examination in detecting local recurrence was 70% and 35.2%, respectively. These values were 90% and 88.2% for US, and 100% and 100% for MRI.

Conclusion: In patients with mastectomy, US and MRI were more successful in detecting local recurrence than clinical examination. Considering the fact that US is cheaper and more readily available than MRI, it should be part of the routine follow-up in order to detect local recurrence early. MRI will be helpful in cases with suspicious US findings by increasing the specificity of the evaluation as well as determining the actual size and spread of any lesions, which is valuable information for the subsequent management and response to the particular treatment.
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March 2007

Female breast radiation exposure during thorax multidetector computed tomography and the effectiveness of bismuth breast shield to reduce breast radiation dose.

J Comput Assist Tomogr 2007 Jan-Feb;31(1):138-42

Department of Radiology, Cerrahpasa Medical Faculty, Istanbul University, Turkey.

Objective: The purpose of our study was to determine the breast radiation dose when performing routine thoracic multidetector computed tomography (MDCT). We also evaluated dose reduction and the effect on image quality of using a bismuth breast shield when performing thoracic MDCT.

Material And Methods: The dose reduction achievable by shielding the adult (18 years or older) female breasts was studied in 50 women who underwent routine thoracic MDCT. All examinations were performed with a 16-MDCT scanner (Sensation Cardiac 16; Siemens Medical Solutions). To compare the shielded/unshielded breast dose, the examination was performed with (right breast) and without (left breast) breast shielding in all patients. With this technique, the superficial breast doses were calculated. To determine the average glandular breast radiation dose, we imaged an anthropomorphic dosimetric phantom into which calibrated dosimeters were placed to measure the dose to breast. The phantom was imaged using the same protocol. Radiation doses to the breasts with and without the breast shielding were measured and compared using the Student t test.

Results: In the qualitative evaluation of the MDCT scans, all were considered to be of diagnostic quality. We did not see any differences in quality between the shielded and unshielded lung. The mean radiation doses to the breasts with the shield and to those without the shield were 8.6 +/- 2.33 versus 14.46 +/- 3.94 mGy, respectively. The breast shield enabled a 40.53% decrease in radiation dose to the breast. The difference between the dose received by the breasts with and that received by the breasts without bismuth shielding was significant, with a P value of less than 0.001.

Conclusions: Bismuth in-plane shielding for routine thoracic MDCT decreased radiation dose to the breast without qualitative changes in image quality. The other radiosensitive superficial organs (eg, testes and thyroid gland) specifically must be protected with shielding.
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http://dx.doi.org/10.1097/01.rct.0000235070.50055.e6DOI Listing
March 2007

Coronary calcium scoring with MDCT: the radiation dose to the breast and the effectiveness of bismuth breast shield.

Eur J Radiol 2007 Jan 7;61(1):139-43. Epub 2006 Sep 7.

Istanbul University, Cerrahpasa Medical Faculty, Department of Radiology, Istanbul, Turkey.

Objective: The purpose of our study was to determine the breast radiation dose during coronary calcium scoring with multidetector computerized tomography (MDCT). We also evaluated the degree of dose reduction by using a bismuth breast shield when performing coronary calcium scoring with MDCT.

Materials And Methods: The dose reduction achievable by shielding the adult (35 years or older) female breasts was studied in 25 women who underwent coronary calcium scoring with MDCT. All examinations were performed with a 16-MDCT scanner. To compare the shielded versus unshielded breast dose, the examinations were performed with (right breast) and without (left breast) breast shielding in all patients. With this technique the superficial breast doses were calculated. To determine the average glandular breast radiation dose, we imaged an anthropomorphic dosimetric phantom into which calibrated dosimeters were placed to measure the dose to the breast. The phantom was imaged using the same protocol. Radiation doses to the breasts with and without the breast shielding were measured and compared using the Student's t-test.

Results: The mean radiation doses with and without the breast shield were 5.71+/-1.1 mGy versus 9.08+/-1.5 mGy, respectively. The breast shield provided a 37.12% decrease in radiation dose to the breast with shielding. The difference between the dose received by the breasts with and without bismuth shielding was significant, with a p-value of less than 0.001.

Conclusion: The high radiation during MDCT greatly exceeds the recommended doses and should not be underestimated. Bismuth in plane shielding for coronary calcium scoring with MDCT decreased the radiation dose to the breast. We recommend routine use of breast shields in female patients undergoing calcium scoring with MDCT.
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http://dx.doi.org/10.1016/j.ejrad.2006.08.012DOI Listing
January 2007

Testicular volume before and after hydrocelectomy in children.

J Ultrasound Med 2006 Sep;25(9):1131-6; quiz 1137-8

Department of Radiology, Cerrahpasa Faculty of Medicine, Istanbul University, 34300 Istanbul, Turkey.

Objective: The purpose of this study was to investigate whether there is an association between communicating congenital hydroceles and testicular volume in children.

Methods: Seventeen children with unilateral communicating congenital hydroceles who underwent hydrocelectomies were included in the study. Testicular volumes were measured before and after hydrocelectomy on both the affected and unaffected sides.

Results: We found statistically significant differences in testicular volumes between the normal sides (mean +/- SD, 0.62 +/- 0.24 mL) and the sides with hydroceles (0.72 +/- 0.26 mL) before surgery (P < .001) and in testicular volumes of the sides with hydroceles before (0.72 +/- 0.26 mL) and after (0.60 +/- 0.19 mL) surgery (P < .001). There was no significant difference in testicular volumes before (0.62 +/- 0.24 mL) and after (0.62 +/- 0.21) surgery on the normal sides (P = .978). The mean decrease in volume of the testes with hydroceles after hydrocelectomy was approximately 15%.

Conclusions: This study shows that there is an association between congenital communicating hydroceles and testicular volume in children. Clinicians should be aware that there is a decrease in testicular volume after hydrocelectomy so they do not misdiagnose this change as postoperative trauma or atrophy.
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http://dx.doi.org/10.7863/jum.2006.25.9.1131DOI Listing
September 2006

Traumatic bilateral vertebral artery dissection at the dural entry point site in a 10-year-old boy.

Pediatr Surg Int 2006 May 17;22(5):468-70. Epub 2006 Feb 17.

Department of Radiology, Cerrahpasa Faculty of Medicine, Istanbul University, 34300 Istanbul, Turkey.

We present a 10-year-old boy who was admitted with headache and neurological symptoms after a trauma in the school yard. Cerebral MRI revealed an extensive ischaemia in the bilateral cerebellar hemispheres, left middle cerebellar peduncle, and right vermis. Digital subtraction angiography demonstrated bilateral vertebral artery dissections at the dural entry point site. This case emphasises the management of patients with traumatic vertebral artery dissection.
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http://dx.doi.org/10.1007/s00383-006-1640-9DOI Listing
May 2006

Mesentery artery embolism and splenic infarction in infective endocarditis.

Intern Med 2005 Mar;44(3):270

Internal Medicine, Istanbul University, Cerrahpasa Medical Faculty, TR-34303 Istsanbul, Turkey.

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http://dx.doi.org/10.2169/internalmedicine.44.270DOI Listing
March 2005

Effect of diffuse fatty infiltration of the liver on hepatic artery resistance index.

J Clin Ultrasound 2005 Mar-Apr;33(3):95-9

Department of Radiology, Istanbul University, Cerrahpasa Medical Faculty, Kocamustafapasa Street, 34300-Istanbul, Turkey.

Purpose: This study was conducted to evaluate the effect of various degrees of diffuse fatty infiltration of the liver on the hepatic artery resistance index.

Methods: One-hundred forty subjects were examined using standard color and spectral Doppler sonography protocols. Fatty infiltration of the liver was identified and graded sonographically. The patients were grouped (n = 35 in each of 4 groups) according to the degree of diffuse fatty infiltration of the liver as follows: normal (group 1), mild (group 2), moderate (group 3), and severe (group 4). The resistance index calculated for each patient was the mean of 3 measurements. Mean resistance index of the hepatic artery was then calculated for each group.

Results: The mean resistance index was 0.81 +/- 0.04 for group 1, 0.79 +/- 0.06 for group 2, 0.75 +/- 0.05 for group 3, and 0.73 +/- 0.05 for group 4. We found a statistically significant (p < 0.05) decrease in resistance index when comparing groups 3 and 4 with groups 1 and 2 separately.

Conclusions: Hepatic artery resistance index decreases as the severity of diffuse fatty infiltration increases.
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http://dx.doi.org/10.1002/jcu.20095DOI Listing
July 2005

Gray scale and power Doppler US in the preoperative evaluation of axillary metastases in breast cancer patients with no palpable lymph nodes.

Eur Radiol 2005 Jun 3;15(6):1215-23. Epub 2005 Feb 3.

Cerrahpasa Medical Faculty, Department of Radiology, Istanbul University, Turkey.

The purpose of this study is to evaluate the accuracy of gray scale and Doppler US findings in the detection of axillary metastases in breast cancer patients with no palpable lymph nodes. One-hundred and ninety-eight lymph nodes detected in 83 women were evaluated. The size and longitudinal/transverse axis ratios of each node were documented. Absence of echogenic hilum, asymmetrical cortical thickening, and presence of peripheral flow were prospectively considered signs of malignancy. Histopathologically, there were 93 malignant and 105 benign nodes. The above criteria and a low longitudinal-transverse axis ratio were statistically significant for malignancy. In lymph nodes smaller than 1 cm, only asymmetric cortical thickening and presence of peripheral flow were significant. The sensitivity, specificity, positive predictive value, negative predictive value and accuracy of US were 86.49, 93.62, 91.43, 89.8 and 90.48%, respectively. In conclusion, US is successful and reliable in the determination of axillary metastatic involvement in nonpalpable and small lymph nodes. Inclusion of axillary US in the preoperative diagnostic evaluation would be complimentary to sentinel node biopsy, and also could eliminate the need for it in patients with positive US results, after confirmation with biopsy.
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http://dx.doi.org/10.1007/s00330-004-2605-9DOI Listing
June 2005
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