MRI-guided needle localization: technique

Magnetic resonance imaging (MRI) is being used increasingly in breast cancer diagnosis. Such indications include the search for a breast primary in women with metastatic carcinoma in the axillary lymph nodes, improving surgical planning in women with a biopsy-proven breast cancer, and in screening very high-risk women. If a suspicious lesion is found by MRI, localization with either directed additional mammographic or sonographic views or with MRI-guided needle localization or biopsy is necessary. We describe the use of a biopsy device with embedded internal fiducial markers. The coordinates for needle placement are calculated by distances between the fiducial markers and the lesion. The technique is simple to master and is aided by the use of a practice phantom.

Dissociable effects of the 5-HT(2) antagonist mianserin on associative learning and performance in the rabbit

Serotonin 5-HT(2) antagonists that significantly retard the acquisition of classically conditioned responses (CRs) also impair the performance of the unconditioned response (UR). Effects on the UR appear to be due to an inverse agonist action at the 5-HT(2) receptor. These findings raised the possibility that the learning deficits were either secondary to a performance deficit and/or that the retardation of learning was not due to actions at the serotonin 5-HT(2) receptor. In this study, we examined the effects of the 5-HT(2)-receptor antagonists, namely mianserin and D-2-bromolysergic acid diethylamide hydrogen tartrate (BOL), on CR acquisition. We also determined whether the retarded acquisition of CRs produced by mianserin (a) was due to an action at the 5-HT(2) receptor and (b) was secondary to a performance deficit. Effects of drugs on CR acquisition, maintenance, and retention were determined during trace-conditioning of the rabbit's nictitating membrane (NM) response. BOL (0.058 to 5.8 micromol/kg) had no effect on CR acquisition, whereas mianserin (0.1 to 10 micromol/kg) produced a significant and dose-dependent retardation of CR acquisition. The retarded CR acquisition produced by mianserin (10 micromol/kg) was due to its actions at the 5-HT(2) receptor, because this effect was completely blocked by a dose of BOL (5.8 micromol/kg) that had no effect when given alone. Neither maintenance nor retention of learning was affected by mianserin treatment during acquisition. We conclude that mianserin acts as an inverse agonist at the serotonin 5-HT(2) receptor to produce both a retardation of CR acquisition and an impairment of the UR. However, the learning and performance effects of mianserin are separable.

Competition induces adaptive shifts in caste ratios of a polyembryonic wasp

An important transition in insect life-history evolution was the shift from a solitary existence to living in groups comprising specialized castes. Caste-forming species produce some individuals that reproduce and others with worker functions that have few or no offspring. Morphologically specialized castes are well known in eusocial species like ants and termites, but castes have also evolved in less-studied groups like thrips, aphids and polyembryonic wasps. Because selection acts at both the individual and the colony level, ratios of investment in different castes are predicted to vary with environmental factors like competition and resources. However, experimental evidence for adaptive shifts in caste ratios is limited owing to the experimental difficulty of manipulating factors thought to influence caste ratios, and because some species produce behaviourally flexible castes that switch tasks in response to colony needs. Unlike other caste-forming species, the broods of polyembryonic wasps develop clonally, so that increased production of one caste probably results in decreased production of the other. Here we show that the polyembryonic wasp Copidosoma floridanum alters caste ratios in response to interspecific competition. Our results reveal a distinct trade-off by C. floridanum between reproduction and defence, and show experimentally that caste ratios shift in an adaptive manner.

Association of infiltrating lobular carcinoma with positive surgical margins after breast-conservation therapy

OBJECTIVE

To determine whether infiltrating lobular carcinoma (ILC) is associated with high positive-margin rates for single-stage lumpectomy procedures, and to define clinical, mammographic, or histologic characteristics of ILC that might influence the positive-margin rate, thereby affecting treatment decisions.

SUMMARY BACKGROUND DATA

Infiltrating lobular cancer represents approximately 10% of all invasive breast carcinomas and is often poorly defined on gross examination.

METHODS

A group of 47 patients with biopsy-proven ILC undergoing breast-conservation therapy (BCT) at the University of Virginia Health Sciences Center between 1975 and 1999 was compared with a group of 150 patients with infiltrating ductal cancer undergoing BCT during the same time period. The pathology of the lumpectomy specimen was reviewed for each patient to confirm surgical margin status. Office and surgical notes as well as mammography reports were examined to determine whether the lesions were deemed palpable before and during surgery. Patients were stratified according to age, family history, tumor size, tumor location, and histologic features of the tumor.

RESULTS

The incidence of positive margins was greater in the ILC group compared with the infiltrating ductal cancer group. Patient age, family history, and preoperative palpability of the tumor did not correlate with surgical margin status. Of the mammographic features identified, including spiculated mass, calcifications, architectural distortion, and other densities, only architectural distortion predicted positive surgical margin status. Tumor grade, tumor size, lymph node status, and receptor status were not predictive of surgical margin status.

CONCLUSIONS

For patients with ILC, BCT is feasible, but these patients are at high risk of tumor-positive resection margins (51% incidence) after the initial resection. Only the mammographic finding of architectural distortion was identified as a preoperative marker reliably identifying a subgroup of ILC patients at especially high risk for a positive surgical margin. For all patients with ILC considering BCT, careful counseling about the potential need for a second procedure to treat the positive margin should be included in the treatment discussion.

Associative learning is enhanced by selective neuronal nitric oxide synthase inhibitors and retarded by a nitric oxide donor in the rabbit

RATIONALE

Previous studies had reported that the nitric oxide (NO) donor, sodium nitroprusside (SNP), retarded and the non-specific NO synthase (NOS) inhibitor, Nomega-nitro-L-arginine methyl ester (L-NAME), enhanced acquisition of classically conditioned responses (CRs). These effects of IV SNP and IP L-NAME on CR acquisition occurred in the absence of any effect on non-associative processes or performance variables and at a time when there were no alterations in blood pressure or heart rate.

OBJECTIVES

In this study, we examined whether the changes in associative learning produced by L-NAME and SNP were due to their central effects on NO content of brain. To this end, we examined the effects of the selective neuronal NOS inhibitors 7-nitroindazole (7-NI) and AR-R 17477 and the effects of central (ICV) administration of the NO donor SNP on learning.

METHODS

Effects of drugs on CR acquisition were determined during classical conditioning of the rabbit's nictitating membrane (NM) response. Explicitly unpaired presentations of conditioned stimuli (CSs) and unconditioned stimuli (USs) were employed to measure non-associative levels of responding and unconditioned response (UR) topography.

RESULTS

The SC injection of 7-NI and AR-R 17477 significantly enhanced associative learning while ICV administration of SNP significantly retarded learning.

CONCLUSION

Production of NO within the brain by neuronal NOS normally acts to retard associative learning presumably by decreasing excitability within neuronal circuits involved in the acquisition of the classically conditioned NM reflex.

Apparent ipsilateral decrease in breast size at mammography: a sign of infiltrating lobular carcinoma

PURPOSE

To assess if infiltrating lobular carcinoma (ILC) is associated with an ipsilateral mammographic decrease in breast size.

MATERIALS AND METHODS

Mammographic change in size was evaluated by measuring the distance from the nipple to the pectoralis major muscle on the mediolateral oblique view of the diagnostic mammogram and on a preceding mammogram in 30 patients with ILC. Clinical, mammographic, and histopathologic findings were retrospectively reviewed.

RESULTS

Five patients (17%) had an ipsilateral decrease in mammographic size. No patients noticed a physical decrease in breast size. Patients with an ipsilateral decrease in mammographic size most commonly had breast thickening at examination (four of five patients [80%], P < .001) and either a focal asymmetry density (three of five patients [60%]) or architectural distortion (one of five patients [20%]) at mammography; those patients with no change in size most commonly had a palpable mass (six of 25 patients [24%]) or normal findings (19 of 25 patients [76%]) and a mass (13 of 25 patients [52%]) at mammography. The mean tumor size was 66 mm for those with an ipsilateral size decrease and 16 mm for those with no size decrease (P < .001). At histologic analysis, tumors associated with an ipsilateral decrease in mammographic size had more diffuse involvement of the breast, and discrete masses were not seen.

CONCLUSION

An apparent decrease in mammographic size may help identify cases of ILC, especially when associated with thickening at clinical examination and focal asymmetric density at mammography.

Effects of prenatal cocaine exposure on amphetamine-induced dopamine release in the caudate nucleus of the adult rabbit

Acute amphetamine (AMPH) challenge has been used to probe the neurochemical and behavioral integrity of dopaminergic neurons under various conditions including prenatal cocaine exposure. In this study, we employed in vivo microdialysis to examine the effects of prenatal cocaine exposure on AMPH-induced dopamine (DA) release in the caudate nucleus of the awake adult rabbit. Pregnant rabbits were given intravenous injections of either saline or cocaine (4 mg/kg) twice a day from gestational day 8 (G8) through G29. Microdialysis was performed in adult saline and cocaine progeny at approximately postnatal day 70 (P70). There were no significant differences between cocaine and saline progeny in their basal concentrations of DA or its metabolites, 3,4-dihydroxyphenylacetic acid (DOPAC) and homovanillic acid (HVA). AMPH (5 mg/kg, i.v.) significantly increased extracellular DA in the caudate of both groups. However, AMPH-induced DA release was 2 to 3-fold greater in cocaine progeny than in the saline controls. Although, DOPAC decreased in both groups following AMPH injection, there was no significant group effect. In addition, there were no significant changes in concentrations of HVA. AMPH is known to release DA by a mechanism of exchange diffusion via the presynaptic DA transporter (DAT). Therefore, we examined the binding of [(3)H]WIN 35,428 to membrane fractions prepared from fresh caudate tissue to determine whether prenatal exposure to cocaine had altered the density (B(max)) or affinity (K(d)) of the DAT. While the B(max) for [(3)H]WIN 35,428 binding increased 3-fold between P3 and P120, there were no significant differences between saline and cocaine progeny at any age examined. The K(d) for [(3)H]WIN 35,428 binding did not change with postnatal age and did not differ between cocaine and saline progeny. These findings suggest that prenatal exposure to cocaine produces a long-term increase in the size of the presynaptic, AMPH releasable, cytoplasmic pool of DA.

Use and cost of breast imaging for postmenopausal women undergoing hormone replacement therapy

OBJECTIVE

The purpose of this study was to evaluate the use and associated costs of breast imaging studies for postmenopausal women undergoing hormone replacement therapy (HRT).

MATERIALS AND METHODS

Clinical findings, mammographic findings, and imaging studies performed on 1133 postmenopausal women during a 5-month period in 1996 were retrospectively reviewed. Cost was estimated using Medicare reimbursement rates.

RESULTS

Of the 1133 women, 699 (62%) underwent HRT. The number of women with breast complaints was similar for those undergoing (n = 62, 9%) and not undergoing (n = 26, 6%) HRT. Benign findings were more common for women undergoing HRT (n = 186, 27%) than for women not undergoing HRT (n = 92, 21%) (p = .04). Masses were noted in 133 of the women undergoing HRT (19%), compared with 42 women not undergoing HRT (10%) (p < .000). Specifically, cysts were seen in 46 women undergoing HRT (7%), compared with five women not undergoing HRT (1%) (p < .0001). Diagnostic mammograms and sonograms were more commonly obtained in women undergoing HRT (33 and 13 per 100 women, respectively) than in women not undergoing HRT (24 and seven per 100, respectively) (p = .014 and .0007, respectively). The overall cost of breast imaging was $89 for each woman undergoing HRT and $87 for each woman not undergoing HRT.

CONCLUSION

Benign mammographic findings, primarily cysts, in women undergoing HRT result in an increased use of diagnostic mammography and sonography. The minimal increase in cost should not be a significant factor in the decision to use HRT.

Effect of 5-HT2 receptor antagonists on a cranial nerve reflex in the rabbit: evidence for inverse agonism

This study examined the role of the serotonin 5-HT2 receptor in motor function by examining the effect of antagonists on the motor performance of a cranial nerve reflex, the nictitating membrane (NM) reflex of the rabbit. The NM reflex was elicited by varying intensities of a tactile stimulus and the magnitudes of the elicited responses were measured at each intensity. Dose-response curves were obtained for the effects of several 5-HT2 receptor antagonists on response magnitude. d-Bro-molysergic acid diethylamide (BOL), LY-53,857 and ketanserin had no significant effect on the magnitude of the NM reflex, indicating that they are neutral antagonists. However, the 5-HT2 receptor antagonists ritanserin, MDL-11,939 and mianserin produced a significant reduction in response magnitude with no significant effects on response frequency, suggesting that they were acting as inverse agonists at the 5-HT2 receptor. The reduction in reflex magnitude produced by mianserin (10 micromol/kg) was fully blocked by BOL (5.8 micromol/kg), supporting the conclusion that mianserin was producing a reduction in reflex magnitude through an effect at the 5-HT2 receptor. The occurrence of inverse agonism suggests the possible existence of constitutive activity in vivo. We conclude that the 5-HT2 receptor (either 2A or 2C) plays an important role in motor function, perhaps by providing a tonic influence on motor systems.

Acute inactivation of the inferior olive blocks associative learning

Can acute inactivation of the inferior olive block associative learning? We anaesthetized the inferior olive with lidocaine while rabbits simultaneously: (i) performed conditioned nictitating membrane responses to a flashing light to which they had already been trained; and (ii) underwent their first experience with classical conditioning of the same response to a tone. Inactivation of the inferior olive immediately and reversibly abolished the performance of conditioned responses and prevented learning during rabbits' initial conditioning with a tone-conditioned stimulus. When olivary function was restored, rabbits showed no signs of having learned under olivary anaesthesia. The experiment demonstrates that an acute disruption in olivary function can block learning, in addition to severely degrading motor control. The results are interpreted to indicate the importance of the inferior olive in optimizing learning, perhaps through a general role in regulating temporal processing.

Percutaneous breast biopsy for nonpalpable lesions

Increasingly, biopsies for suspected breast abnormalities are conducted by percutaneous needle extraction of core samples rather than by standard surgical excision or fine-needle aspiration (FNA) of cellular material. Core-needle biopsies are highly accurate and have many advantages over surgical excisions, including reduction of the morbidity and cost of breast disease diagnosis. Limitations include differentiating atypical ductal hyperplasia from ductal carcinoma in situ. Equipment and technique for stereotactic and ultrasound-guided core breast biopsy are discussed. Appropriate indications for core-needle biopsy, excisional biopsy after needle localization, and FNA are provided. Appropriate management after core-needle biopsy includes the establishment of concordance of histologic results with the level of suspicion of the mammographic findings to prevent false-negative core biopsies. A recommendation for return to regular mammographic screening, short-interval (6-month) mammographic follow-up, or repeat core or surgical appearance depends on this correlation.

US-guided core needle biopsy of the breast: technique and pitfalls

When core needle biopsy of the breast is performed with ultrasound (US) guidance, the curvature of the breast is used to advantage. The breast is entered from the periphery; this approach allows one to avoid chest wall injury and improves needle visualization. Bringing the needle to the lesion by using a sweeping motion while keeping the transducer position relatively fixed will expedite the biopsy. Standard techniques are modified for evaluation of difficult lesions. Mobile lesions can be fixed with the palm of the operator's hand. Deep lesions can be lifted away from the chest wall with the tip of the needle. For lesions in large breasts, a steeper angle of approach may be necessary but can be matched with the transducer to improve needle visualization. Careful correlation with the mammogram will ensure that the corresponding sonographic abnormality is sampled. Although complications are uncommon, hematoma or infection may occur after the procedure. With practice, application of standard and modified techniques can result in efficient and accurate US-guided core needle biopsy of the breast.

Prenatal cocaine exposure: long-term deficits in learning and motor performance

We have developed a rabbit model of in utero exposure to intravenous injections of cocaine given twice daily to dams from gestational days 8-29. At the doses employed (4 mg/kg, injected twice daily), no differences were found in the body weight gain of dams, time to delivery, litter size, and body weight or other physical characteristics of the offspring. However, cocaine-exposed pups displayed an abnormal structural and neurochemical development of the anterior cingulate cortex which persisted into adulthood. In agreement with the known functions of the anterior cingulate cortex, we found that adult, sexually mature rabbits, exposed to cocaine prenatally, demonstrate impairments in motor function, alterations in associative learning and severe impairments in discrimination learning. Moreover, the alterations in discrimination learning were interpreted to be due to deficits in attentional processes. Specifically, cocaine progeny preferentially attend to more salient stimuli even when these are not relevant to the task. Consequently they have difficulty in attending to less salient but relevant stimuli when more salient but irrelevant stimuli occur in the same context. We concluded that the learning deficits are a reflection of the morphologic and neurochemical abnormalities of the anterior cingulate cortex. Alterations in dopamine function of the caudate nucleus may also contribute to the deficits in motor performance.

Effects of serotonin 5-HT(2A/2C) antagonists on associative learning in the rabbit

The 5-HT(2A/2C) receptor antagonist, ritanserin, was reported to retard the acquisition of conditioned responses (CRs) during classical conditioning of the rabbit's nictitating membrane (NM) response. The present study compared the effects of ritanserin on acquisition of CRs to a tone conditioned stimulus (CS) with that of the 5-HT(2A/2C) receptor antagonist, LY-53,857 and the 5-HT2A selective antagonist, MDL-11,939. All three drugs were injected at equimolar doses of 0.067, 0.67 and 6.7 micromol/kg, SC, 1 h before behavioral testing. Ritanserin and MDL-11,939 retarded CR acquisition to a tone CS, while LY-53,857 had no effect. Control experiments demonstrated that ritanserin (1 micromol/kg), MDL-11,939 (1 micromol/kg) and LY-53,857 (2 micromol/kg) had no effect on baseline responding or non-associative responding to the CS. However, both ritanserin and MDL-11,939 impaired the performance of the unconditioned NM reflex, as measured by a decrease in UR amplitudes on US alone trials, while LY-53,857 had no effect. In previously trained animals, ritanserin robustly impaired the performance of CRs, as measured by a reduced ability of the CS to elicit CRs, while the effects of LY-53,857 and MDL-11,939 were marginal. The retardation of associative learning produced by ritanserin and MDL-11,939 may have been due, at least in part, to their impairment of the NM reflex arc. Since MDL-11,939 is a highly selective 5-HT2A antagonist, the retardation of learning and impairment of UR amplitudes produced by MDL-11,939 and ritanserin may have been due to blockade of the 5-HT2A receptor. The ability of ritanserin and MDL-11,939 to produce effects on learning and performance that were opposite to that of 5-HT(2A/2C) agonists suggests that they may be acting as inverse agonists at that receptor. These results stress the importance of the serotonergic system for optimal associative learning and motor function.

Survey of breast cancer patients concerning their knowledge and expectations of adjuvant therapy

PURPOSE

A survey of breast cancer survivors in the United States was conducted to define what they had been told about their prognosis and the value of adjuvant therapy, what they estimated their prognosis to be with and without adjuvant therapy, and what level of improvement they would have found minimally worthwhile.

MATERIALS AND METHODS

Survey questionnaires were mailed to individual members and member organizations of the National Alliance of Breast Cancer Organizations (NABCO). Questionnaires were returned anonymously in prepaid mailers. Five hundred sixty-two women responded. Of these, the 318 women who received adjuvant chemotherapy were included in this analysis.

RESULTS

Only 39% of the women recalled receiving quantitative estimates of their prognosis, and only 31% of women received a quantitative estimate both with and without adjuvant therapy. Sixty-eight percent of the women were able to provide a quantitative estimate for their outcome at 5 years both with and without adjuvant therapy. From these estimates, we calculated that the median estimated proportional risk reduction for recurrence that women thought they had achieved was 79%. Women were asked what degree of absolute benefit they would have found acceptable. The median acceptable extension of life expectancy was 3 to 6 months, and acceptable reduction in recurrence risk was 0.5% to 1.0%. However, there was considerable variation, with 27% of women not accepting less than 1 year and 26% not accepting a less than 5% reduction in recurrence risk.

CONCLUSION

In general, American women in the surveyed population (1) do not recall being provided quantitative estimates of outcome during the process of making decisions about adjuvant therapy, (2) overestimate the value of their therapy, and (3) often will accept remarkably low degrees of net benefit. Overall, these observations can be used to support the argument that improvements in doctor/patient communication may be important to truly informed decision-making, and that flexibility for individual patients' preferences should not be superseded by rigid treatment guidelines.

Effects of LSD, ritanserin, 8-OH-DPAT, and lisuride on classical conditioning in the rabbit

d-Lysergic acid diethylamide (LSD), an agonist at the 5-HT(2A/2C) and 5-HT1A receptors, has previously been demonstrated to enhance associative learning as measured by accelerated acquisition of the rabbit's classically conditioned nictitating membrane (NM) response. The present study examined further the role of these receptors in the action of LSD. LSD (30 nmol/kg, I.V.) significantly enhanced conditioned response (CR) acquisition to both tone and light conditioned stimuli (CSs), while the 5-HT1A receptor agonists 8-hydroxy-2-(dipropylamino)tetralin (8-OH-DPAT; 50 and 200 nmol/kg) and lisuride (0.3-30 nmol/kg) had no effect. Ritanserin (6.7-6700 nmol/kg, S.C.), a selective 5-HT(2A/2C) receptor antagonist, retarded acquisition of CRs to both tone and light CSs in a dose-dependent manner. Ritanserin (6.7-670 nmol/kg, S.C.) also dose dependently antagonized the enhancement of CR conditioning produced by LSD (30 nmol/kg, I.V.) to both tone and light CSs. We conclude that the enhancement of CR acquisition by LSD was due to an action at the 5-HT(2A/2C) receptor. These results suggest that the 5-HT(2A/2C) receptor plays an important role in learning.

Impact of metronidazole therapy on preterm birth in women with bacterial vaginosis flora (Gardnerella vaginalis): a randomised, placebo controlled trial

OBJECTIVE

To ascertain whether metronidazole treatment of women with a heavy growth of Gardnerella vaginalis during mid-pregnancy would reduce the risk of spontaneous preterm birth.

DESIGN

A multicentre, randomised, placebo-controlled trial.

SETTING

Four metropolitan hospitals.

PARTICIPANTS

Eight hundred and seventy-nine singleton women with a heavy growth of G. vaginalis or Gram stain indicative of bacterial vaginosis at 19 weeks of gestation.

INTERVENTIONS

Oral metronidazole (400 mg) or placebo twice daily for two days at 24 weeks of gestation, and at 29 weeks if G. vaginalis found in test-of-cure swab four weeks after treatment.

MAIN OUTCOME MEASURES

Spontaneous preterm birth less than 37 weeks.

RESULTS

Intention-to-treat analysis showed no difference between metronidazole and placebo groups in overall preterm birth (31/429 [7.2%] vs 32/428 [7.5%]) or spontaneous preterm birth (20/429 [4.7%] vs 24/428 [5.6%]). Among the 480 women with bacterial vaginosis treatment had no effect on spontaneous preterm birth (11/242 [4.5%] vs 15/238 [6.3%]). In the subset of 46 women with a previous preterm birth, women in the metronidazole group showed a significant reduction in spontaneous preterm birth (2/22 [9.1%] vs 10/24 [41.7%], OR 0.14, 95% CI 0.01-0.84). A treatment effect was also found in compliant women with a previous preterm birth and bacterial vaginosis (0/14 [0%] vs 6/17 [35.3%], OR 0.0, 95% CI 0.0-0.94).

CONCLUSION

Metronidazole treatment of women with a heavy growth of G. vaginalis or bacterial vaginosis did not reduce the preterm birth rate. Among women with a previous preterm birth, treatment reduced the risk of spontaneous preterm birth. Further studies are required to confirm these findings.

Sonographic features of mammary oil cysts

Mammographic lesions that are pathognomonic for oil cysts require no further evaluation. Oil cysts, however, may first be discovered by ultrasonography. Between 1988 and 1995, we performed sonography of 26 oil cysts in 15 patients. Sonography was used to evaluate a palpable finding when an oil cyst was not initially perceived on the mammogram (47%) or as an initial evaluation of a palpable lump (33%); in addition, oil cysts were identified incidentally in 20% of cases. Retrospective review showed that the sonographic appearance of oil cysts is highly variable; only 8% mimic simple apocrine cysts. Twelve percent mimic an intracystic mass. Most have smooth walls (88%), are hypoechoic (65%), and have neither enhancement or shadowing (50%). The sonographic appearance of oil cysts can be suggestive of a pathologic lesion such as an intracystic carcinoma. Unnecessary biopsy can be avoided using directed mammography.