Transthoracic decompression of emphysematous bulla: a novel experience

Emphysematous bullae are closed air containing spaces in lung parenchyma that may severely compromise lung function in patients of chronic obstructive pulmonary disease (COPD). We describe a simple and minimally invasive procedure to decompress a large emphysematous bullae in a patient with advanced COPD and high surgical risk. Transthoracic decompression of the bulla was accomplished under short-acting anaesthesia and muscle relaxation resulting in significant symptomatic, radiological and functional improvement.

Abstract P6-01-06: Identification of Molecular Subtypes of DCIS and Invasive Breast Cancer Using Computerized Image Analysis for Data Integration

Background: Breast cancer is a heterogeneous disease with different putative therapeutic targets based upon the particular subtype. The particular subtype can have profound implications for therapy, as in the case of basal-like carcinomas which tend to be more aggressive with less therapeutic options. Although many studies have examined the transition from Ductal Carcinoma in-situ (DCIS) to Invasive Breast Cancer (IBC), the mechanisms involving the transformation are poorly understood. DCIS cases that are more likely to progress to IBC can be treated more aggressively. This study used image analysis to examine the association between predictive molecular biomarkers between pure DCIS, DCIS associated with IBC and IBC.

Methods: With approval by the Institutional Review Board, we evaluated tissue microarrays comprising 453 tissue cores from 149 patients. Five immunohistochemical biomarkers were utilized: estrogen (ER), progesterone (PR), human epidermal growth factor receptor 2 (HER2), epidermal growth factor receptor (EGFR), and cytokeratin 5/6 (CK-5/6). We then employed the Automated Cellular Image Analysis (ACIS) to score the biomarker status. We compared regional scoring (rated 0, 1, 2, or 3) between an experienced pathologist's subjective assessment and an automated score derived from ACIS. An image library was generated and integrated to our Translational Data Mart (TraM: http://tram.uchicago. edu). Statistical analyses included a comparison of histological grade, race, age, tumor size, and lymph node status associated with the prevalence of subtypes between pure DCIS tumors and those that advanced to IBCs. Results: The concordance between ACIS-based and pathologist-based scoring was moderate (kappa = 0.38). There was more variability in the pathologist's scoring with a standard deviation of 1.14 as compared to 0.85 for ACIS. Subtypes associated with IBC were also present in DCIS. In the pure DCIS cases, there was a higher proportion of the luminal A subtype (74.1%, n = 54) as compared to DCIS adjacent to IBC (54.2%, n=24) or pure IBC cases (57.4%, n = 115) (p=0.05). In contrast, there was more basal-like subtypes in DCIS juxtaposed with IBC (20.8%) and IBC (27.8%) than in pure DCIS tumors (9.3%).

Discussion: Molecular subtype analysis of DCIS could be useful in predicting DCIS with high risk of progressing to invasive cancer. The resemblance between subtypes bolsters the hypothesis that IBCs and DCIS originate from the same precursor lesion. Although the automated scoring featured by ACIS would be useful in expediting readings, it must be validated by a pathologist's assessment.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P6-01-06.

Barriers to accessing care in patients with chronic hepatitis C: the impact of depression

BACKGROUND

Patients with hepatitis C viral (HCV) may perceive barriers to accessing speciality care for HCV, and these barriers may be related to depressive symptoms.

AIM

To evaluate the relationship between barriers to care, demographics, and depressive symptoms.

METHODS

A cross-sectional analysis of 126 patients referred for HCV at two speciality HCV clinics. Barriers to care, depressive symptoms and sociodemographics were measured using standardized instruments. A retrospective chart review was conducted to collect clinical outcome data.

RESULTS

Depressive symptoms were reported in 26%. Common barriers included lack of personal financial resources; lack of HCV knowledge in the community; lack of professionals competent in HCV care; stigmatization of HCV; and long distances to clinics offering care. After we controlled for sociodemographics, depression accounted for an additional 7-18% of variability in all barriers (all p values <0.01). Lower depression, marital and employment status were associated with subsequent receipt of HCV treatment in 38% (45/120) of patients; perceived barriers were not.

CONCLUSIONS

Depression is independently associated with perceived barriers to care. Higher depressive scores, but not perceived barriers, were associated with nontreatment. Healthcare providers who diagnose HCV need to be cognizant of numerous perceived barriers to accessing HCV care, and the impact that depression may have on these perceptions and receipt of treatment.

Lipid Resonance on In Vivo Proton MR Spectroscopy: Value of other Metabolites in Differential Diagnosis

In vivo proton MR spectroscopy (1H-MRS) can non-invasively provide biochemical information at the same examination as conventional magnetic resonance imaging (MRI). Lipid resonance (0.9–1.5 ppm) is a marker of cell membrane breakdown and tissue necrosis, but its diagnostic significance has not been well described. We retrospectively analyzed spectra to study the different pathological conditions in patients with abnormal lipid resonance. All patients with neurological diseases showing lipid resonance on 1H-MRS (1.5T) in a tertiary hospital over two years were retrospectively analyzed. 1H-MRS was performed using the single voxel PRESS technique (TR/TE=3000/144 ms, eight excitations). Spectra were analysed for the presence of NAA (2.0 ppm), creatine (3.0 ppm), choline (3.2 ppm), acetate (1.92 ppm), succinate (2.4 ppm), cytosolic amino acids (0.9 ppm), lactate (1.3 ppm) and lipid (0.9–1.5 ppm) peaks. Ninety-two spectra from 69 patients (38 males, 31 females; aged 9 to 89 years) were analyzed. The final diagnosis was infective (n = 33), (tuberculoma n = 17, pyogenic abscess n = 8, fungal abscess n = 3, sterile abscess n = 3, tubercular abscess n = 2), neoplastic (n = 21) (glial tumors n = 9, metastasis n = 8, lymphoma n = 4), and other (n = 15) abnormalities (subacute and chronic stroke n = 6, postictal edema n = 4, multiple sclerosis n = 2, Erdhiem Chester disease n ? 2, Rosai Dorfmann disease n = 1). Succinate and acetate were detected only in pyogenic abscesses (2/4 cases), but amino acids were present in both pyogenic (4/8) and fungal (3/3) abscesses. Choline was seen not only in neoplasms (18) but also in tuberculomas (11/17), but was consistently absent in the abscesses. Lactate was present in glioblastoma (7/9), pyogenic (3/8) tubercular (2/2) and fungal (3/3) abscess. Isolated lipid resonance was found in Erdheim Chester disease (2/2) of the orbit, and lipid and choline was seen in Rosai Dorfmann's disease (1/1). Brain lesions containing lipid on 1H-MRS could be differentiated by the presence of succinate and acetate in pyogenic abscess, and amino acids in pyogenic/fungal abscesses. Choline was seen in neoplasms and in tuberculomas, but not in the abscesses. Thus, the presence of a lipid peak, when combined with features on other MR pulse sequences and available clinical data can help arrive at a specific diagnosis. 1H-MRS should not be interpreted in isolation: it should always be correlated with conventional imaging features, and performing 1H-MRS in isolation remains an important pitfall.

Utility of colour Doppler sonography in patients with Graves' disease

OBJECTIVE

Assessment of thyroid blood flow gives valuable information about underlying functional status. Colour Flow Doppler Sonography (CFDS) is a powerful tool which displays tissue blood flow and vascularity. Colour Flow Doppler Sonography of the thyroid gland in different subsets of patients with Graves' disease was studied to define its role in initial diagnosis and management.

METHODS

Eighty consecutive patients with Graves' disease (both treated and untreated) presented to hospital between August 2007 and February 2008. All patients were evaluated with CFDS of the thyroid for size, vascularity and peak systolic velocity (PSV) of the Inferior Thyroid Artery (ITA). Pertechnate scan and thyroidal autoantibody levels were done in selected cases. The patients were divided into Untreated Graves' disease (n = 31), Graves' disease on treatment but hyperthyroid (n = 26) and euthyroid Graves' disease on therapy (n = 23). Mann-Whitney U-test was used for statistical analysis and a p-value of less than 0.05 was considered significant.

RESULTS

Thyroid blood flow, as assessed by PSV of ITA, was significantly higher in untreated Graves' disease than in Graves disease on treatment but hyperthyroid and euthyroid Graves respectively (61.5 +/- 19.5 versus 42.9 +/- 24.7 versus 32.2 +/- 12.9 cm/s, p < 0.05). Parenchymal vascularity of the thyroid gland was higher in hyperthyroid patients than in euthyroid patients irrespective of therapy. In both groups on therapy, the dose of carbimazole correlated with the vascularity of the gland (r = 0.492 versus 0.564, p < 0.05). Colour Flow Doppler Sonography parameters correlated significantly with pertechnate scan results giving comparable sensitivity and specificity.

CONCLUSION

Assessment of thyroid blood flow by CFDS is an effective marker in the initial diagnosis of Graves' disease. Vascularity of the gland can predict long term disease course while on medical therapy.

Virchow-Robin Spaces in Health and Disease

Virchow-Robin spaces are pial-lined, interstitial fluid-filled structures that do not directly communicate with the subarachnoid space, and accompany penetrating arteries and veins. They are common, incidental, “leave me alone” lesions that should not be mistaken for more ominous disease. They are frequently seen in the supratentorial white matter, basal ganglia region, around the anterior commissure, and surrounding penetrating lenticulostriate arteries, thalamus, midbrain, cerebellum, insular cortex, corpus callosum, cingulate gyrus, extreme capsule, along the optical tracts, and in the hippocampus. Most are small, well-defined fluid-filled cysts less than five mm in diameter, and are isointense to CSF on all pulse sequences. They are often mistaken for lacunar infarcts, cystic neoplasms or infectious cysts. We retrospectively analyzed various appearances of VRS as seen on magnetic resonance imaging of brain in 100 cases, in an attempt to provide a better understanding of these lesions and their significance in various physiological and pathological conditions.

Obesity and thyrotropinemia

OBJECTIVE

To study the relation between body mass index (BMI) and TSH in euthyroid and subclinical hypothyroid obese children and compared serum TSH level among obese and overweight children.

METHODS

Fifty consecutive children (aged 2-18 yr) presenting for obesity were studied. All cases with TSH > 10, low T3/T4, organic and syndromic obesity were excluded. Patients were divided into Group 1: Overweight (n=20) (BMI between 85(th) to 95(th) centile) and Group 2: Obesity (n=30) (BMI > 95(th) centile). Fisher's exact test, Mann-Whitney U test and Pearson's correlation were used for statistical analysis. P value < 0.05 was considered significant.

RESULTS

Elevated TSH level (between 4.5-10 mIU/L) with normal T3, T4 was seen in 4/20 overweight and 9/30 of obese children (P=0.5219). The mean TSH was comparable in both the groups (3.22 +/- 3.1 mIU/L vs. 3.63 +/- 2.2 mIU/L, P=0.3491). Overall TSH showed no correlation with BMI (r= 0.0014, P=0.9924).

CONCLUSION

The preliminary data did not show any relation between severity of obesity and TSH level. Further large scale data from population are required to confirm these findings.