Diagnosis of mast cell activation syndrome: a global "consensus-2"

The concept that disease rooted principally in chronic aberrant constitutive and reactive activation of mast cells (MCs), without the gross MC neoplasia in mastocytosis, first emerged in the 1980s, but only in the last decade has recognition of "mast cell activation syndrome" (MCAS) grown significantly. Two principal proposals for diagnostic criteria have emerged. One, originally published in 2012, is labeled by its authors as a "consensus" (re-termed here as "consensus-1"). Another sizable contingent of investigators and practitioners favor a different approach (originally published in 2011, newly termed here as "consensus-2"), resembling "consensus-1" in some respects but differing in others, leading to substantial differences between these proposals in the numbers of patients qualifying for diagnosis (and thus treatment). Overdiagnosis by "consensus-2" criteria has potential to be problematic, but underdiagnosis by "consensus-1" criteria seems the far larger problem given (1) increasing appreciation that MCAS is prevalent (up to 17% of the general population), and (2) most MCAS patients, regardless of illness duration prior to diagnosis, can eventually identify treatment yielding sustained improvement. We analyze these proposals (and others) and suggest that, until careful research provides more definitive answers, diagnosis by either proposal is valid, reasonable, and helpful.

Systematic review of the impact of breast-conserving surgery on cancer outcomes of multiple ipsilateral breast cancers

Background

The clinical effectiveness of treating ipsilateral multifocal (MF) and multicentric (MC) breast cancers using breast‐conserving surgery (BCS) compared with the standard of mastectomy is uncertain. Inconsistencies relate to definitions, incidence, staging and intertumoral heterogeneity. The primary aim of this systematic review was to compare clinical outcomes after BCS versus mastectomy for MF and MC cancers, collectively defined as multiple ipsilateral breast cancers (MIBC).

Methods

Comprehensive electronic searches were undertaken to identify complete papers published in English between May 1988 and July 2015, primarily comparing clinical outcomes of BCS and mastectomy for MIBC. All study designs were included, and studies were appraised critically using the Newcastle–Ottawa Scale. The characteristics and results of identified studies were summarized.

Results

Twenty‐four retrospective studies were included in the review: 17 comparative studies and seven case series. They included 3537 women with MIBC undergoing BCS; breast cancers were defined as MF in 2677 women, MC in 292, and reported as MIBC in 568. Six studies evaluated MIBC treated by BCS or mastectomy, with locoregional recurrence (LRR) rates of 2–23 per cent after BCS at median follow‐up of 59·5 (i.q.r. 56–81) months. BCS and mastectomy showed apparently equivalent rates of LRR (risk ratio 0·94, 95 per cent c.i. 0·65 to 1·36). Thirteen studies compared BCS in women with MIBC versus those with unifocal cancers, reporting LRR rates of 2–40 per cent after BCS at a median follow‐up of 64 (i.q.r. 57–73) months. One high‐quality study reported 10‐year actuarial LRR rates of 5·5 per cent for BCS in 300 women versus 6·5 per cent for mastectomy among 887 women.

Conclusion

The available studies were mainly of moderate quality, historical and underpowered, with limited follow‐up and biased case selection favouring BCS rather than mastectomy for low‐risk patients. The evidence was inconclusive, weakening support for the St Gallen consensus and supporting a future randomized trial.

Abstract P4-15-02: Impact of radiotherapy and endocrine therapy on further events: Final multivariate analysis of a prospective, national cohort study of screen detected ductal carcinoma in situ (DCIS) of the breast

Key words: DCIS, radiotherapy, endocrine therapy, survival, surgical margins

Background:

The benefits and risks of breast screening remain controversial, with particular concern that ductal carcinoma in situ (DCIS) may be over-diagnosed and over-treated. There is little prospective data on treatment or outcomes for screen detected DCIS.

Methods:

A prospective cohort of non-invasive lesions diagnosed through the United Kingdom National Health Service Breast Screening Programme (NHSBSP) (1 April 2003 to 31 March 2012) was linked to national databases and case note review to analyse patterns of care, recurrence and mortality.

Results:

Screen-detected DCIS in 9938 women was analysed, 33% (9938/30041) of women with a final diagnosis of non-invasive breast neoplasia diagnosed through the NHSBSP over the same time.

The patients (mean age was 60 years: range 46-87 years) were treated by breast conservation surgery (BCS; 7007; 70.5%) or mastectomy (2931). At 64 months median follow up, 697 (6.8%) had further DCIS or invasive breast cancer after BCS (7.8%) or mastectomy (4.5%) (p<0.001) and 228 women (2.3%) developed contralateral malignancy.

Breast radiotherapy (RT) after BCS (4363/7007; 62%) was associated with a 3.1% absolute reduction in any ipsilateral DCIS or invasive cancer (No RT: 7.2% vs RT: 4.1% (p<0.001) and a 1.9% absolute reduction for ipsilateral invasive breast recurrence (No RT: 3.8% vs RT: 1.9% (p<0.001), independent of excision margin width or size of DCIS. Women who did not receive RT after BCS had more ipsilateral events (p=0.008) when the radial excision margin was <2mm. RT was rarely used after mastectomy for DCIS (33 women). Adjuvant endocrine therapy (prescribed for 1208/9938; 12.2%) was associated with a reduction in any ipsilateral recurrence, independent of whether women did (HR 0.57: 95% CI 0.41 - 0.80) or did not (HR 0.68: 95% CI 0.51 - 0.91) receive RT after BCS.

Among 321 (3.2%) women who died, 46 deaths (0.5%; 14.3% of all deaths) were attributed to invasive breast cancer. Death from breast cancer was uncommon and outnumbered 5:1 by death due to other causes. RT after BCS was associated with a non-significant 0.2% absolute reduction in breast cancer mortality. However, women who developed invasive breast cancer had a worse survival than those with further DCIS (p<0.001).

Conclusions:

Recurrent DCIS or invasive cancer is uncommon following screen detected DCIS treated by surgery and adjuvant therapy. Both RT and endocrine therapy following surgery were associated with a significant reduction in further DCIS and invasive disease, but not breast cancer mortality, within 5 years of diagnosis. This study quantifies the benefits of radiotherapy and endocrine therapy to inform decision making in the management of screen detected DCIS.

Citation Format: Thompson AM, Clements K, Cheung S, Pinder SE, Lawrence G, Sawyer E, Kearins O, Ball GR, Tomlinson I, Hanby AM, Thomas J, Maxwell AJ, Wallis MG, Dodwell DJ. Impact of radiotherapy and endocrine therapy on further events: Final multivariate analysis of a prospective, national cohort study of screen detected ductal carcinoma in situ (DCIS) of the breast [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P4-15-02.

Abstract P4-15-04: A longitudinal cohort study to identify risk factors for the development of invasive cancer in unresected DCIS

Background: The variable natural history of ductal carcinoma in situ (DCIS) remains poorly understood. Randomized trials of active surveillance versus guideline concordant care are currently underway: the Comparison of Operative to Monitoring and Endocrine Therapy (COMET) trial in the US, LOw Risk dcIS (LORIS) trial in the UK and Low Risk Dcis (LORD) in Europe. Given this context, we examined the outcomes of a contemporary group of women with DCIS who did not undergo initial surgical resection.

Methods: A longitudinal cohort of women diagnosed with DCIS on needle biopsy who did not undergo initial surgical excision for ≥1 year were identified through the Cancer Registry with case note and death certificate review for subsequent outcomes.

Results: Eighty-nine eligible women with DCIS alone diagnosed on needle biopsy (most with 14-gauge core needle biopsy) between 1998 and 2010 were identified. The mean age at diagnosis was 72 years (range 44-94 years) with mean follow-up (diagnosis to death, invasive disease or last review) of 62 months (range 12-180 months). Twenty-nine women (33%) developed histologically proven invasive breast cancer, 28 at the site of the initial DCIS biopsy, after a mean interval of 54 months (range 12-144 months): 14/29 (48%) women originally had high grade DCIS, 10/31 (32%) intermediate grade and 3/17 (18%) low grade DCIS (initial grade not known in 12). Time to detect a diagnosis of invasive breast cancer was associated with initial grade of DCIS (p=0.0016, log-rank test): after mean intervals of 41 months (high grade), 69 months (intermediate grade) and 78 months (low grade) respectively. Younger age was associated with development of invasive disease (p<0.003, Mann-Whitney U-Test). High grade (grade 3) invasive breast cancer exclusively occurred in women with a prior diagnosis of high grade DCIS. Invasion was more frequent in lesions with calcification as the predominant feature than those without (23/50 v. 5/25; p<0.05, Fisher exact test). Forty-four women were prescribed endocrine therapy, use of which was associated with a lower rate of invasive breast cancer (p<0.05). Ultimately 18 women underwent surgery, 17 for invasive cancer. The mean interval from DCIS diagnosis to death was 76 months for those who developed invasive cancer; 48/89 women died, 12 had a certified cause of death as breast cancer.

Conclusion: High grade DCIS, mammographic microcalcification and lack of endocrine therapy were associated with progression to invasion. The findings suggest surgical excision of high grade DCIS should continue but provides support that women with DCIS features which include low grade should be considered for the COMET, LORIS or LORD active surveillance trials.

Citation Format: Maxwell AJ, Clements K, Hilton B, Dodwell DJ, Evans A, Olive K, Pinder SE, Thomas J, Matthew WG, Thompson AM. A longitudinal cohort study to identify risk factors for the development of invasive cancer in unresected DCIS [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P4-15-04.

Abstract P2-01-21: Preoperative axillary ultrasound guided needle sampling in breast cancer: Comparing the sensitivity of fine needle aspiration cytology and core needle biopsy

Background: Preoperative axillary ultrasound (US) combined with selective US-guided needle sampling (UNS) can be used to identify lymph node metastases. This can inform decisions about neoadjuvant chemotherapy and allow a patient to proceed immediately to axillary lymph node dissection (ALND) thus avoiding an extra sentinel node biopsy (SNB) procedure. We acknowledge the landmark ACOSOG Z0011 trial showing a subgroup of patients (T1-2) undergoing breast conserving surgery and whole-breast radiotherapy in which ALND can safely be omitted if they have minimal nodal disease burden. For these patients the utility of UNS may be limited if the surgeon has modified their practice according to the trial. For patients not fitting the Z0011 trial criteria, preoperative UNS remains important.

Previous studies comparing the sensitivity of axillary US-guided fine needle aspiration cytology (FNA) and core needle biopsy (CNB) have been small and a meta-analysis has not shown a difference in sensitivity1. Our aim was to directly compare the sensitivity of the two techniques.

Method: Patients with macrometastatic nodal involvement that were treated at a tertiary referral centre between January 2013 and December 2014 were retrospectively identified from pathology records. Preoperative UNS had been performed by one of eight Consultant Radiologists with the sampling method being according to each individual radiologist's preference. The result of the first UNS performed on each patient was compared to post-operative histopathology results. Patients who had undergone previous axillary surgery or any part of their investigations/treatment at another unit were excluded.

Results: A total of 101 CNBs and 181 FNAs were performed in 282 patients. There were 78 true positive CNBs and 96 true positive FNAs. US-guided CNB was therefore more sensitive than US-guided FNA (77.2% vs. 53.0%, p=<0.001). Two non-diagnostic CNBs and eight non-diagnostic FNAs were performed. Five patients in the CNB group were correctly identified preoperatively as having isolated tumour cells (ITCs) or micrometastatic disease only in their axillary lymph nodes and were therefore triaged to SNB rather than ALND. A single haematoma requiring non-operative management was recorded in the CNB group.

Conclusion: US-guided CNB of the axilla is more sensitive than US-guided FNA and is a safe technique in experienced hands. We also highlight the additional potential benefit (whilst accepting the possibility of sampling error) of CNB over FNA in assisting the multidisciplinary planning of axillary surgery in patients who are found to have ITCs or micrometastatic disease only during their preoperative axillary staging.

References: Houssami N, Ciatto S, Turner RM, et al. Preoperative ultrasound-guided needle biopsy of axillary nodes in invasive breast cancer: meta-analysis of its accuracy and utility in staging the axilla. Ann Surg 2011;254:243-251.

Citation Format: Topps AR, Barr SP, Pritchard S, Maxwell AJ. Preoperative axillary ultrasound guided needle sampling in breast cancer: Comparing the sensitivity of fine needle aspiration cytology and core needle biopsy [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P2-01-21.

Intensive breast screening in BRCA2 mutation carriers is associated with reduced breast cancer specific and all cause mortality

Background

The addition of annual MRI screening to mammography has heightened optimism that intensive screening along with improved treatments may substantially improve life expectancy of women at high risk of breast cancer. However, survival data from BRCA2 mutation carriers undergoing intensive combined breast screening are scarce.

Methods

We have collated the results of screening with either annual mammography or mammography with MRI in female BRCA2 mutation carriers in Manchester and Oslo and use a Manchester control group of BRCA2 mutation carriers who had their first breast cancer diagnosed without intensive screening.

Results

Eighty-seven BRCA2 mutation carriers had undergone combined (n = 34) or mammography (n = 53) screening compared to 274 without such intensive screening. Ten year breast cancer specific survival was 100 % in the combined group (95 % CI 82.5–100 %) and 85.5 % (95 % CI 72.6–98.4 %) in the mammography group compared to 74.6 % (95 % CI 66.6–82.6 %) in the control group. Better survival was driven by lymph node status (negative in 67 % of screened vs 39 % of unscreened women; p < 0.001) and a significantly greater proportion of intensively screened women had invasive breast cancers <2 cm at diagnosis (74.6 % vs 50.4 %; p = 0.002).

Conclusion

Intensive combined breast cancer screening with annual MRI and mammography appears to improve survival from breast cancer in BRCA2 mutation carriers. Data from larger groups are required to confirm the effectiveness of combined screening in BRCA2 carriers.

A randomised pilot study comparing 13 G vacuum-assisted biopsy and conventional 14 G core needle biopsy of axillary lymph nodes in women with breast cancer

AIM

To compare the acceptability, safety, and feasibility of vacuum-assisted biopsy (VAB) and core needle biopsy (CNB) of axillary lymph nodes in women with breast cancer.

MATERIALS AND METHODS

This parallel, non-blinded, randomised study was approved by the National Research Ethics Service. Following written informed consent, women with abnormal appearing axillary lymph nodes and radiologically malignant breast masses were randomised 1:1 to lymph node sampling under local anaesthetic with either 14 G CNB or 13 G VAB in a single UK centre. Primary outcomes were study uptake rate and patient willingness to undergo a repeat procedure if necessary. Procedure duration, immediate and post-procedure pain scores, diagnostic yield, complications, and surgical histopathology were recorded.

RESULTS

Ninety-five women were approached; 81 (85.3%) consented and were randomised. Forty underwent CNB; 40 underwent VAB; one was excluded. Median age was 57 years. The median procedure time was 2 minutes for both techniques. The median number of samples obtained was three for CNB and four for VAB. Median pain scores for the procedure and first 3 days were 1/10 and 1/10 for CNB and 1/10 and 2/10 for VAB (p=0.11 and 0.04). More women were prepared to undergo repeat CNB compared to VAB, but the difference was not significant (38/39 versus 33/39; p=0.11). Two patients developed a haematoma after VAB. One CNB and six VABs failed to yield adequate tissue (p=0.11), but the sensitivity was similar at 79% and 78%.

CONCLUSION

Study uptake was high. Acceptability of the two procedures was similar, but VAB was associated with more post-procedure pain. The sensitivity appears to be similar.

Prolonged neuropsychiatric effects following management of chloroquine intoxication with psychotropic polypharmacy

Susceptibility to quinoline antimalarial intoxication may reflect individual genetic and drug-induced variation in neuropharmacokinetics. In this report, we describe a case of chloroquine intoxication that appeared to be prolonged by subsequent use of multiple psychotropic medications. This case highlights important new considerations for the management of quinoline antimalarial intoxication.

Rosai-Dorfman disease of the breast

A 56-year-old female was recalled for assessment following screening mammography that demonstrated a new 9-mm indeterminate density in the left breast. Clinical breast examination was normal. Ultrasound confirmed a 9-mm predominantly well-defined hypoechoic breast mass. Core biopsy demonstrated large histiocytes with emperipolesis and positive staining for S100, which is consistent with Rosai-Dorfman disease (RDD). Multidisciplinary team discussion concluded case concordance. The patient was discharged back to the screening programme. RDD is a rare, benign condition that may mimic breast cancer. This case demonstrates that identification of RDD on core needle biopsy may help avoid unnecessary surgery.

Efficacy and safety of antifungal additives in Optisol-GS corneal storage medium

IMPORTANCE

Optisol-GS, the most common corneal storage medium in the United States, contains antibacterial but no antifungal supplementation. Most postkeratoplasty endophthalmitis and keratitis cases are now of a fungal origin.

OBJECTIVE

To assess the efficacy and safety of voriconazole and amphotericin B in reducing Candida species contamination of Optisol-GS under normal storage conditions.

DESIGN, SETTING, AND PARTICIPANTS

In vitro laboratory study using 15 pairs of research-grade donor corneas and 20-mL vials of Optisol-GS.

INTERVENTIONS

Twenty vials of Optisol-GS were supplemented with either voriconazole at 1×, 10×, 25×, or 50× minimum inhibitory concentration (MIC) or amphotericin B at 0.25×, 0.5×, 1×, or 10× MIC. Known concentrations of Candida albicans and Candida glabrata were each added to a set of vials. Safety studies were performed by separating 15 pairs of donor corneas into unsupplemented Optisol-GS or Optisol-GS plus an antifungal.

MAIN OUTCOMES AND MEASURES

Efficacy outcomes were viable fungal colony counts determined from samples taken on days 2, 7, and 14 immediately after removal from refrigeration and after warming to room temperature for 2 hours. Safety outcomes included percentage of intact epithelium and endothelial cell density on days 0, 7, and 14, as well as percentage of nonviable endothelial cells by vital dye staining on day 14.

RESULTS

Growth of C albicans and C glabrata was observed in all voriconazole-supplemented vials. In contrast, there was no growth of either organism in amphotericin B-supplemented vials, except at 0.25× and 0.5× MIC on day 2, when viable counts of C glabrata were reduced by 99% and 96%, respectively. Compared with paired controls, with the exception of Optisol-GS plus amphotericin B at 10× MIC, donor corneas in supplemented Optisol-GS appeared to have no difference in endothelial cell density reduction, percentage of intact epithelium, or percentage of nonviable endothelial cells.

CONCLUSIONS AND RELEVANCE

The addition of amphotericin B to Optisol-GS may significantly improve activity against contamination with Candida species, the primary cause of fungal infection after corneal transplantation. This study found significant endothelial toxic effects at the maximal concentration of amphotericin B.

Benign papilloma diagnosed on image-guided 14 G core biopsy of the breast: effect of lesion type on likelihood of malignancy at excision

AIM

To ascertain the negative predictive value (NPV) for atypia and malignancy of 14 G core biopsy of papillomas and to determine whether lesion type influences the likelihood of malignancy at lesion excision.

MATERIALS AND METHODS

Ninety-six lesions with a 14 G core biopsy diagnosis of benign papilloma without atypia in 95 women were included. The imaging features (mass or microcalcification), biopsy mode, and number of core samples taken were documented. All patients subsequently underwent lesion excision with either extensive vacuum-assisted biopsy (VAB; 72 lesions) or surgery (24 lesions). Mammographic follow-up of at least 2 years was available for 32 lesions that were benign at VAB.

RESULTS

Atypia or malignancy was found more commonly in association with microcalcification (six of 29 lesions: 21%; median number of nine 14 G cores) than a mass (five of 67 lesions: 7%; median number of three 14 G cores), although the difference does not reach statistical significance (p = 0.088). The NPV of a 14 G core biopsy diagnosis of papilloma for atypia or malignancy is 89% (85/96). Disease underestimation may be more common in microcalcification lesions despite the greater number of cores obtained.

CONCLUSION

Excision (using VAB or surgically) of all papillomas diagnosed as benign on 14 G needle core biopsy is recommended. Surgery may be more appropriate than VAB for some microcalcification lesions unless they are small and can be confidently removed in their entirety using VAB.

Hypercholesterolemia impairs exercise capacity in mice

We previously reported an attenuation of both exercise hyperemia and measures of aerobic capacity in hypercholesterolemic mice. In this study, we expanded upon the previous findings by examining the temporal and quantitative relationship of hypercholesterolemia to aerobic and anaerobic capacity and by exploring several potential mechanisms of dysfunction. Eight-week-old wild type (n = 123) and apoE knockout (n = 79) C57BL/6J mice were divided into groups with distinct cholesterol levels by feeding with regular or high-fat diets. At various ages, the mice underwent treadmill ergospirometry. To explore mechanisms, aortic ring vasodilator function and nitrate (NO(x)) activity, urinary excretion of NO(x), running muscle microvascular density and citrate synthase activity, as well as myocardial mass and histologic evidence of ischemia were measured. At 8 weeks of age, all mice had similar measures of exercise capacity. All indices of aerobic exercise capacity progressively declined at 12 and 20 weeks of age in the hypercholesterolemic mice as cholesterol levels increased while indices of anaerobic capacity remained unaffected. Across the four cholesterol groups, the degree of aerobic dysfunction was related to serum cholesterol levels; a relationship that was maintained after correcting for confounding factors. Associated with the deterioration in exercise capacity was a decline in measures of nitric oxide-mediated vascular function while there was no evidence of aberrations in functional or oxidative capacities or in other components of transport capacity. In conclusion, aerobic exercise dysfunction is observed in murine models of genetic and diet-induced hypercholesterolemia and is associated with a reduction in vascular nitric oxide production.

Follow-up for screen-detected ductal carcinoma in situ: results of a survey of UK centres participating in the Sloane project

AIMS

To investigate the variations in follow-up practice for screen-detected ductal carcinoma in situ (DCIS) in the UK.

METHODS

A questionnaire enquiring about follow-up practice and the perceived value of clinical follow-up after surgery for screen-detected DCIS was sent to the 74 UK screening centres participating in the Sloane Project.

RESULTS

Responses were received from 66 hospitals serving 54 screening centres. These demonstrate wide variations in practice. Clinical follow-up duration ranges from 1 year to indefinite, with the frequency of visits from three-monthly to annually. Formal mammographic follow-up duration ranges from none to indefinite. Mammographic frequency ranges from 1 to 2 years. Follow-up varies according to factors such as size and grade of disease and margin status in 23 units and according to whether adjuvant therapy is given in 23. Seven hospitals perform mammography of reconstructed breasts. Thirty-one centres consider clinical follow-up of DCIS to be of value or limited value whereas 28 consider it to be of little or no value.

CONCLUSIONS

There is no consensus with regard to the duration and frequency of follow-up for screen-detected DCIS, the contribution of predictive and treatment factors, the use of mammography of the reconstructed breast or the perceived value of clinical follow-up. Published guidelines show no consensus. Multidisciplinary teams involved in the care of women with screen-detected non-invasive cancer should contribute to audits such as the Sloane Project in order to determine the most effective and efficient ways to treat and follow up these patients.

NOS inhibition accelerates atherogenesis: reversal by exercise

In this study, we assessed the effects of chronic exercise training (12 wk) on atherosclerotic lesion formation in hypercholesterolemic apolipoprotein E-deficient mice (n = 31). At the age of 9 wk, mice were assigned to the following groups: sedentary (Sed; n = 9); exercise (Ex; n = 12); sedentary and oral NG-nitro-L-arginine (L-NNA, Sed-NA; n = 4), or exercise and oral L-NNA (Ex-NA; n = 6). Chronic exercise training was performed on a treadmill for 12 wk (6 times/wk and twice for 1 h/day) at a final speed of 22 m/min, and an 8 degrees grade. L-NNA was discontinued 5 days before final treadmill testing. The farthest distance run to exhaustion was observed in Ex-NA mice (Sed: 306 +/- 32 m; Ex: 640 +/- 87; Sed-NA: 451 +/- 109 m; Ex-NA: 820 +/- 49 m; all P < 0.05). Lesion formation was assessed in the proximal ascending aorta by dissection microscopy after oil red O staining. The aortas of Sed-NA mice manifested a threefold increase in lesion formation compared with the other groups. This L-NNA-induced lesion formation was reduced by chronic exercise training (Sed, 786 +/- 144; Ex, 780 +/- 206; Sed-NA, 2,147 +/- 522; Ex-NA, 851 +/- 253; Sed-NA vs. all other groups: P < 0.001). In conclusion, treatment with oral L-NNA (an nitric oxide synthase antagonist) leads to accelerated atherogenesis in genetically determined hypercholesterolemic mice. This adverse effect can be overcome by chronic exercise training.

Crude open biopsy rates for benign screen detected lesions no longer reflect breast screening quality--time to change the standard

OBJECTIVES

To investigate the changing nature of the benign screen detected breast abnormalities removed at open biopsy over a seven year period and to compare this with the improving cancer detection rate and non-operative diagnosis rate.

SETTING

The Bolton, Bury, and Rochdale Breast Screening Programme.

METHODS

The histopathology reports of the benign lesions removed from patients undergoing open biopsy for screen detected abnormalities between 1 April 1994 and 31 March 2001 were reviewed and the lesions classified on the B1 to B5 scale. Cancer detection rates and non-operative cancer diagnosis rates were ascertained from the breast screening computer system.

RESULTS

148 benign surgical biopsies were performed in the seven year period. There was a moderate increase in the overall benign biopsy rate over the period (from 1.26 open biopsies per 1000 women screened for the three years 1994-97 to 1.63 open biopsies per 1000 women screened for the three years 1998-2001). The biopsy rate for B2 (benign) lesions decreased slightly over the study period but the biopsy rate for B3 lesions (that is, of uncertain malignant potential) more than doubled. The majority (84%) of the B3 lesions were radial scars. There was a steady improvement in the cancer detection rate and the non-operative cancer diagnosis rate over the period, similar to that seen nationally.

CONCLUSIONS

Improvements in screening technique and detection ability result in an increase in the number of subtle radiologically indeterminate or suspicious lesions detected. Many of these are radial scars, which require excision. Crude benign open biopsy rates for screening programmes are no longer meaningful, and should now be refined with separate rates for B2 lesions and B3 lesions. High quality programmes can expect to have low B2 open biopsy rates and high B3 open biopsy rates. It is inappropriate to have an upper limit for the B3 open biopsy rate.

Mechanisms of dysfunction of the nitric oxide pathway in vascular diseases

Vascular nitric oxide (NO) is involved in many physiologic and pathophysiologic processes throughout the body. Many vascular diseases have a reduction in the activity of endothelium-derived NO as an important component involved in the initiation and/or progression of the disease. It is now known that there are multiple mechanisms for this reduction in NO activity with one or more mechanisms operating depending on the specific condition or stage of a disease. In other instances, the therapy for certain diseases is responsible for the reduction in NO activity and contributes to the acceleration of vascular disease. This review details the known mechanisms of dysfunction of the NO pathway leading to vascular diseases, which provides the rationale for why certain therapies can improve while other therapies adversely affect vascular health.

Randomized trial of a medical food for the dietary management of chronic, stable angina

OBJECTIVES

We determined the electrocardiographic, vascular and clinical effects of a medical food bar enriched with L-arginine and a combination of other nutrients known to enhance endothelium-derived nitric oxide (NO) in patients with stable angina.

BACKGROUND

Enhancement of vascular NO by supplementation with L-arginine and other nutrients has been shown to have clinical benefits in patients with angina secondary to atherosclerotic coronary artery disease (CAD). However, the amounts and combinations of these nutrients required to achieve a clinical effect make traditional delivery by capsules and pills less suitable than alternative delivery methods such as a specially formulated nutrition bar.

METHODS

Thirty-six stable outpatients with CAD and class II or III angina participated in a randomized, double-blind, placebo-controlled, crossover trial with two treatment periods each of two weeks' duration (two active bars or two placebo bars per day). Flow-mediated brachial artery dilation was measured by ultrasound. Electrocardiographic measures of ischemia, exercise capacity and angina onset time were measured by treadmill exercise testing and by Holter monitor during routine daily activities. Quality of life was assessed by SF-36 and Seattle Angina Questionnaires and by diary.

RESULTS

The medical food improved flow-mediated vasodilation (from 5.5 +/- 4.5 to 8.0 +/- 4.9, p = 0.004), treadmill exercise time (by 20% over placebo, p = 0.05) and quality-of-life scores (SF-36 summary score; 68 +/- 13 vs. 63 +/- 21 after placebo, p = 0.04, Seattle Angina Questionnaire summary score; 67 +/- 10 vs. 62 +/- 18, p = 0.04) without affecting electrocardiographic manifestations of ischemia or angina onset time.

CONCLUSIONS

These findings reveal that this arginine-rich medical food, when used as an adjunct to traditional therapy, improves vascular function, exercise capacity and aspects of quality of life in patients with stable angina.

Uric acid is closely linked to vascular nitric oxide activity. Evidence for mechanism of association with cardiovascular disease

OBJECTIVES

The study was undertaken to determine whether the mechanism of association of elevated serum uric acid level (SUA) with cardiovascular disease (CVD) is secondary to a common link with vascular nitric oxide (NO) activity.

BACKGROUND

Epidemiologic studies demonstrate an association of elevated SUA with CVD. The mechanism of this association is unknown, but both may be linked via an impairment in vascular NO activity. To examine this, we determined the relationship of SUA to vascular NO activity and to CVD risk. We then determined the effect of enhancing vascular NO activity on SUA.

METHODS

In part 1, individuals with various degrees of CVD (n = 458) were surveyed and underwent measurement of flow-mediated brachial artery vasodilation (FMV), a measure of vascular NO activity. In part 2, we performed an analysis of data pooled from six separate clinical trials of a medical food designed to enhance vascular NO activity in individuals with CVD (n = 217 subjects representing 253 treatment periods) to determine the effect on SUA.

RESULTS

In part 1, of all risk factors tested, SUA was second only to age in correlation with FMV, accounting for 7% (p < 0.0001) of the variability in FMV. Both SUA and FMV were related to the degree of disease risk (p < 0.0001 and p = 0.00025 by analysis of variance, respectively). By multivariate analysis, SUA did not continue to contribute significantly to the determination of FMV. In part 2, enhancement of FMV (5.8 +/- 4 to 8.6 +/- 5, p < 0.0001) was associated with a decrease in SUA (5.5 +/- 1.5 to 5.0 +/- 1.5, p < 0.0001). There was no placebo effect on FMV or SUA.

CONCLUSIONS

These results suggest that the association of elevated SUA with CVD may be a consequence of an impairment of vascular NO activity. This may be owing to an ability of NO to modulate uric acid production through its influence on xanthine oxidase activity.

A study of breast cancers detected in the incident round of the UK NHS Breast Screening Programme: the importance of early detection and treatment of ductal carcinoma in situ

One hundred and seventy eight cancers detected on incident round screening in the UK National Health Service Breast Screening Programme were reviewed. Critical review of the immediately preceding screening films (from 3 years previously) found abnormalities at the site of the subsequently detected cancer in 93 cases (52%). Forty-eight of these (27% of the total) had microcalcification as the sole abnormality. All of these 48 women had invasive ductal carcinoma and/or ductal carcinoma in situ (DCIS) (including four cases in which DCIS was associated with another type of primary invasive breast cancer). The finding of microcalcification on the previous mammograms at the site of a subsequently detected cancer was a strong predictor for the presence of DCIS (with or without associated invasive disease) (P<0.0001). Of the women with invasive ductal carcinoma, those with microcalcification on previous films were significantly more likely to have intermediate or high grade (grade 2 or 3) tumours than those women without microcalcification on previous films (P=0.0015). Previous films were also read blind by two independent experienced breast radiologists. Cancers were correctly identified by one or both readers in 39 cases. However, 35 of the remaining 139 cases showed microcalcification which was not detected or considered significant by the readers. If only these 139 'true negative' screens are analysed, similar associations are seen between microcalcification on previous films and subsequent finding of DCIS (P=0.03) and between microcalcification on previous films and high grade invasive ductal carcinomas (P=0.015). These findings provide support for the hypothesis that microcalcification seen on previous screening films at the site of a subsequently detected invasive ductal carcinoma represents ductal carcinoma in situ. In this series, 19 of 82 women (23%) with invasive ductal carcinoma in the 'true negative' screen group had microcalcification suggestive of DCIS on mammograms taken, on average, 3 years previously. Significant microcalcification is often overlooked using current detection criteria. Early detection and treatment of DCIS is essential in order to prevent the development of aggressive invasive disease. Revision of the NHSBSP targets for DCIS detection is recommended.

Pediatric Primary Pulmonary Hypertension

Primary pulmonary hypertension is a disease for which there is no single best therapy. Rather, it is a process that progresses inexorably to disability and death, for which there are a variety of palliative therapies, all with significant side effects, and none curative. Nevertheless, it is clear that the available therapies improve the quality of life and prolong life; failure to offer therapy for patients with this disease in the current era is indefensible. As primary pulmonary hypertension progresses, one must chose from among the available therapies the regimen that provides the most benefit for the patient with the least associated morbidity. Organ replacement is appropriate only after all other available therapies have been exhausted. The recommended hierarchy of therapy is 1) anticongestive therapy, anticoagulation, and supplemental oxygen, 2) calcium channel blockade, 3) continuous intravenous prostacyclin, 4) beta-receptor agonists for cardiac support, and 5) lung transplantation. Newer therapies, described in this review, soon will be incorporated into this hierarchy.

Primary and metastatic lobular carcinoma of the breast

Invasive lobular carcinoma of the breast is the second most common type of primary breast cancer, accounting for 8-14% of cases, but is often difficult to diagnose early. It typically shows a diffuse pattern of infiltration within the breast, resulting in a variety of often subtle radiological appearances. A similar infiltrative pattern is seen in its metastatic form, with involvement of the gastrointestinal tract, peritoneum, retroperitoneum, bone marrow, meninges and uterus occurring more frequently than with the more common infiltrating ductal carcinoma of the breast. This pictorial essay illustrates the spectrum of radiological appearances which may be encountered with both primary and secondary lobular carcinoma.

L-arginine enhances aerobic exercise capacity in association with augmented nitric oxide production

We tested whether supplementation with L-arginine can augment aerobic capacity, particularly in conditions where endothelium-derived nitric oxide (EDNO) activity is reduced. Eight-week-old wild-type (E(+)) and apolipoprotein E-deficient mice (E(-)) were divided into six groups; two groups (LE(+) and LE(-)) were given L-arginine (6% in drinking water), two were given D-arginine (DE(+) and DE(-)), and two control groups (NE(+) and NE(-)) received no arginine supplementation. At 12-16 wk of age, the mice were treadmill tested, and urine was collected after exercise for determination of EDNO production. NE(-) mice demonstrated a reduced aerobic capacity compared with NE(+) controls [maximal oxygen uptake (VO(2 max)) of NE(-) = 110 +/- 2 (SE) vs. NE(+) = 122 +/- 3 ml O(2). min(-1). kg(-1), P < 0.001]. This decline in aerobic capacity was associated with a diminished postexercise urinary nitrate excretion. Mice given L-arginine demonstrated an increase in postexercise urinary nitrate excretion and aerobic capacity in both groups (VO(2 max) of LE(-) = 120 +/- 1 ml O(2). min(-1). kg(-1), P < 0.05 vs. NE(-); VO(2 max) of LE(+) = 133 +/- 4 ml O(2). min(-1). kg(-1), P < 0.01 vs. NE(+)). Mice administered D-arginine demonstrated an intermediate increase in aerobic capacity in both groups. We conclude that administration of L-arginine restores exercise-induced EDNO synthesis and normalizes aerobic capacity in hypercholesterolemic mice. In normal mice, L-arginine enhances exercise-induced EDNO synthesis and aerobic capacity.

Relocation of a static breast screening unit: a study of factors affecting attendance

OBJECTIVE

To assess the effect of relocation of an urban static breast screening unit on the attendance rates (uptake) in different parts of the catchment area.

SETTING

The Bolton Breast Screening Programme.

METHODS

The attendance rates for screening for patients in each of the seven Bolton postcode districts were obtained from the breast screening computer system for the 29 months prior to and 38 months following the relocation of the screening unit.

RESULTS

The overall attendance rate for screening in Bolton fell by 1%. The fall was most marked in BL1 (2.0%), the location of the original screening unit. BL4, the district housing the new unit, showed an increase in attendance of 1.1%. The other districts showed a similar trend with smaller reductions in attendances from districts that were closer to the screening unit than before, and vice versa. The direct distance between the centre of the women's home postcode district and the screening unit had a significant effect on the attendance rate (p = 0.045). For each kilometre further from the screening unit, the attendance decreased by approximately 2%. However, there was a 6.4% difference between the highest and lowest district attendance rates, the highest rates being in the less deprived areas.

CONCLUSIONS

There is a significant inverse relationship between the distance a woman must travel for screening and her likelihood of attending. However, this has a relatively minor effect on attendance rates compared to that of socioeconomic factors.

Endothelial dysfunction in hypercholesterolemia is reversed by a nutritional product designed to enhance nitric oxide activity

The objective of this study was to investigate the vascular and biochemical effects of a formulated product in the form of a bar enriched with a combination of nutrients known to enhance the synthesis or activity of endothelium-derived nitric oxide (EDNO). Individuals with hypercholesterolemia manifest impaired flow-mediated vasodilation, which is largely due to a reduction in EDNO activity. Oral supplementation with large amounts (6-21 g/day) of L-arginine, the precursor of EDNO, have been shown to improve endothelium-mediated vasodilation in hypercholesterolemia. Such large doses are effective but may be impractical to take in capsule form. Accordingly, we have developed a nutrient bar enriched with L-arginine as well as other ingredients that additively enhance EDNO activity. A pilot study in 41 hypercholesterolemic individuals indicated that the bar was well tolerated, had no adverse effects on serum chemistries or lipid profile, and normalized endothelial vasodilator function. To definitively determine if the nutrient bar normalizes endothelial function, a double-blind, placebo-controlled study was performed. Flow-mediated endothelium-dependent vasodilation was assessed by high-resolution ultrasonography before and after 1 week of bar use (2 bars/day) in an additional group of 43 volunteer subjects (57 +/- 10 years old; 22 men, 21 women) with hypercholesterolemia. Subjects manifested an impaired flow-mediated vasodilation before the intervention. Vasodilator function in the active bar group improved to within a normal range (6.5 +/- 3% before to 10 +/- 5% after, P = 0.02; normal, 12 +/- 3%) and was significantly better (P < 0.01) than in the placebo bar group (7.1 +/- 3% before to 6.7 +/- 4% after). These findings reveal that use of a nutrient bar designed to enhance EDNO activity improves flow-mediated endothelium-dependent vasodilation in hypercholesterolemic individuals.

Nutritional therapy for peripheral arterial disease: a double-blind, placebo-controlled, randomized trial of HeartBar

We investigated the clinical effects of a food bar enriched with L-arginine and a combination of other nutrients known to enhance the activity of endothelium-derived nitric oxide (EDNO) in individuals with claudication from atherosclerotic peripheral arterial disease. The study was a 2-week, double-blind, placebo-controlled trial of subjects randomized to three groups (two active bars, one active and one placebo bar, and two placebo bars per day) followed by an 8-week open-label period. Subjects (n=41) were outpatient volunteers with intermittent claudication. Pain-free and total walking distances were measured by variable-grade, treadmill exercise testing. Quality of life was assessed using the Medical Outcome Survey (SF-36). After 2 weeks of treatment, the pain-free walking distance increased 66% while the total walking distance increased 23% in the group taking two active bars/day. The general and emotional/social functioning components of the SF-36 also improved. These effects were not observed in the one active bar/day and placebo groups. The effects were maintained after 10 weeks and, in addition, an improvement in walking distance was observed in the group taking one active bar. These findings reveal that use of a nutrient bar designed to enhance EDNO activity improves pain-free and total walking distance as well as quality of life in individuals with intermittent claudication.

Breast cancers missed in the prevalent screening round: effect upon the size distribution of incident round detected cancers

OBJECTIVE

To determine the effect of false negative screens (missed cancers) in the prevalent screening round on the relative size distribution of cancers detected at the first incident screen.

SETTING

The Bolton, Bury, and Rochdale breast screening programme.

METHODS

One hundred and three breast cancers detected in the first incident round of screening were analysed. The previous (prevalent round) screening films taken between two and four years earlier were subjected to blinded review and classified as either true negatives (no significant abnormality visible) or false negatives (a suspicious abnormality visible at the site of the subsequently detected cancer). The pathological size, type, and grade (where appropriate) of the cancers were recorded.

RESULTS

Fifty one of the 103 cancers (49%) detected in the first incident round screen measured < 15 mm in diameter. A total of 32 cases were classified as false negatives. Of these, 12 (38%) measured < 15 mm in diameter. If all the false negative cancers had been detected at the prevalent screen, 39 (55%) of the remaining 71 cancers detected in the first incident round screen would have measured < 15 mm. A relative excess of lobular carcinomas was found among the false negatives.

CONCLUSIONS

The findings suggest that although false negative screens in the prevalent round increase the number of cancers available for detection at the first incident round screen, many of these cancers are still < 15 mm in diameter at detection. Cancer detection performance in the prevalent screening round has only a minor influence on the relative proportion of small and large cancers detected at the first incident round screen.

Impaired aerobic capacity in hypercholesterolemic mice: partial reversal by exercise training

The present study assessed whether impaired aerobic capacity previously observed in hypercholesterolemic mice is reversible by exercise training. Seventy-two 8-wk-old female C57BL/6J wild-type (+, n = 42) and apolipoprotein E-deficient (-, n = 30) mice were assigned to the following eight interventions: normal chow, sedentary (E+, n = 17; E-, n = 8) or exercised (E+ex, n = 13; E-ex, n = 7) and high-fat chow, sedentary (E+chol, n = 6; E-chol, n = 8) or exercised (E+chol-ex, n = 6; E-chol-ex, n = 7). Mice were trained on a treadmill 2 x 1 h/day, 6 days/wk, for 4 wk. Cholesterol levels correlated inversely with maximum oxygen uptake (r = -0.35; P < 0. 02), which was blunted in all hypercholesterolemic sedentary groups (all P < 0.05). Maximum oxygen uptake improved in all training groups but failed to match E+ex (all P < 0.05). Vascular reactivity and nitric oxide (NO) synthesis correlated with anaerobic threshold (r = 0.36; P < 0.025) and maximal distance run (r = 0.59; P < 0.007). We conclude that genetically induced hypercholesterolemia impairs aerobic capacity. This adverse impact of hypercholesterolemia on aerobic capacity may be related to its impairment of vascular NO synthesis and/or vascular smooth muscle sensitivity to nitrovasodilators. Aerobic capacity is improved to the same degree by exercise training in normal and genetically hypercholesterolemic mice, although there remains a persistent difference between these groups after training.

Limb blood flow during exercise is dependent on nitric oxide

BACKGROUND

We have recently reported that hypercholesterolemia reduces aerobic exercise capacity in mice and that this is associated with a reduced endothelium-dependent vasodilator function, endothelium-derived nitric oxide (EDNO) production, and urinary nitrate excretion. These findings led us to test the hypothesis that EDNO production contributes significantly to limb blood flow during exercise and to determine whether loss of EDNO production is responsible for the decline in exercise capacity observed in hypercholesterolemia.

METHODS AND RESULTS

Twelve-week-old wild-type (E+; n=9) and apoE-deficient (E-; n=9) C57BL/6J mice were treadmill-tested to measure indices defining exercise capacity on a metabolic chamber-enclosed treadmill capable of measuring oxygen uptake and carbon dioxide excretion. Urine was collected before and after treadmill exercise for determination of vascular NO production assessed by urinary nitrate excretion. The wild-type mice were then given nitro-L-arginine (E+LNA) in the drinking water (6 mg/dL) for 4 days before undergoing a second treadmill testing and urinary nitrate measurement. An additional set of 12-week-old wild-type mice was divided into 2 groups: 1 receiving regular water (E+; n=8) and 1 administered LNA for 4 days (E+LNA; n=8). These mice, along with an additional set of E mice (n=8), underwent treadmill testing to determine maximal oxygen uptake (VO2max). The mice were then cannulated such that the tip of the tubing was positioned in the ascending aorta. Fluorescent microspheres (20000) were infused into the carotid cannula while the mice were sedentary and again while approaching VO2max. When the mice were euthanized, the running muscles were collected and fluorescence intensity was measured to determine the peak-exercise redistribution of blood flow to the running muscles (expressed as percentage of total cardiac output, %COrm) during both states. Both E+LNA and E- mice demonstrated a markedly reduced postexercise urinary nitrate excretion, aerobic capacity, and %COrm at VO2max compared with E+.

CONCLUSIONS

EDNO contributes significantly to limb blood flow during exercise. Conditions that reduce EDNO production disturb the hyperemic response to exercise, resulting in a reduced exercise capacity.

Cardiovascular effects of L-arginine

Most of the known cardiovascular effects of L-arginine are exerted via its conversion to nitric oxide by nitric oxide synthase. Accumulating evidence indicates that supplemental administration of L-arginine is sufficient to restore endothelium-derived nitric oxide production in many disorders in which endothelium-derived nitric oxide production is altered. L-arginine may enhance nitric oxide production by competing as a substrate with an endogenous antagonist for nitric oxide synthase. In other cases, L-arginine may act by competing with molecular oxygen as a substrate so as to reduce the production of superoxide anion. It is likely that other mechanisms exist by which the nitric oxide synthase pathway can be perturbed. Regardless of the mechanism, a wide array of cardiovascular disorders characterized by endothelial dysfunction are reversible by L-arginine.

Assessing residents' readiness for working in a managed care environment

PURPOSE

A the pilot study to assess the state of residents' training for practice in a managed care environment.

METHOD

In May and June 1996, all 178 residents at the University of Kentucky College of Medicine in six programs were approached to participate in the study. An instrument was created to assess the residents' knowledge of, attitudes toward, and exposure to managed care, as well as their perceptions of their residency experience. Attitudinal items were measured using a five-point Likert scale (1 = strongly agree, 5 = strongly disagree), as were the assessments of experience (1 = excellent, 5 = poor). Bivariate statistics were computed between the number of correct responses to the knowledge questions and both the year of training and reported exposure to managed care. The relationship between exposure and knowledge was analyzed using a two-tailed t-test. A Pearson product-moment correlation was computed between residents' knowledge and year of training.

RESULTS

In all, 140 (79%) residents participated, 76% of whom were men. Seventy-three percent of the residents rated their experiences as fair or poor; the mean rating across all the residents was 3.8 (SD, 0.8). Among those reporting some exposure, attitudes toward the effectiveness of their exposure generally ranged from neutral to negative. Across all the residents, the mean number of correct responses to the five knowledge questions was 3.2 (SD, 1.1). No statistically significant relationship was found between year of training and the number of correct responses. The residents who reported some exposure to managed care had a significantly higher mean number of correct responses than did those with no reported exposure (3.4, SD, 1.1, vs 2.8, SD, 1.3, p = .04).

CONCLUSION

The residents reported limited exposure to managed care and that their training experience did not prepare them for working in managed care; this was confirmed (in a limited way) by the responses to the knowledge questions. As managed care expands in the United States, the systematic incorporation of managed care instruction into training is necessary to appropriately prepare residents for future practice.

Screening for prostate cancer: a comparison of urologists and primary care physicians

Prostate cancer screening has assumed increased importance with increasing mortality from this cancer. Newer diagnostic tests such as measurement of prostate-specific antigen (PSA) have improved detection of early prostate cancer. To determine practice patterns of prostate cancer screening, surveys were sent to 487 urologists (231 responses) and 542 family physicians (205 responses) in the Southeast inquiring about actual screening practices. In screening asymptomatic patients, the digital rectal examination was used by 99% of the urologists and 98% of the family physicians, with the mean age of screening initiation being 45 +/- 7 years for the urologists and 43 +/- 7 years for the family physicians. Serum PSA was used for screening asymptomatic patients by 98% of the urologists and 87% of the family physicians, with 49 +/- 4 years being the mean age of screening initiation for both specialties. Although differences in screening emerged, both physician groups approximated the recommended screening guidelines.

Normal versus pathological aging: knowledge of family practice residents

Family physicians may lack discriminatory ability to differentiate normal aging from disease states. To assess such ability, 53 aging-related indicators or symptoms were presented to 65 physicians in three family practice residency programs. Respondents classified each symptom as normal aging or disease. On average, residents classified 73.4% of symptoms correctly. They were more likely to classify disease states correctly (80.0%) than to classify signs of normal aging correctly (66.8%). Misattribution of normal aging signs as disease may prompt physicians to overmedicate and overtreat patients, resulting in adverse clinical outcomes.