Differentiating benign from malignant solid breast masses: value of shear wave elastography according to lesion stiffness combined with greyscale ultrasound according to BI-RADS classification

Background:

The aim of this study was to assess the performance of shear wave elastography combined with BI-RADS classification of greyscale ultrasound images for benign/malignant differentiation in a large group of patients.

Methods:

One hundred and seventy-five consecutive patients with solid breast masses on routine ultrasonography undergoing percutaneous biopsy had the greyscale findings classified according to the American College of Radiology BI-RADS. The mean elasticity values from four shear wave images were obtained.

Results:

For mean elasticity vs greyscale BI-RADS, the performance results against histology were sensitivity: 95% vs 95%, specificity: 77% vs 69%, Positive Predictive Value (PPV): 88% vs 84%, Negative Predictive Value (NPV): 90% vs 91%, and accuracy: 89% vs 86% (all P>0.05). The results for the combination (positive result from either modality counted as malignant) were sensitivity 100%, specificity 61%, PPV 82%, NPV 100%, and accuracy 86%. The combination of BI-RADS greyscale and shear wave elastography yielded superior sensitivity to BI-RADS alone (P=0.03) or shear wave alone (P=0.03). The NPV was superior in combination compared with either alone (BI-RADS P=0.01 and shear wave P=0.02).

Conclusion:

Together, BI-RADS assessment of greyscale ultrasound images and shear wave ultrasound elastography are extremely sensitive for detection of malignancy.

Vaccination of sheep with a live incomplete strain (S48) of Toxoplasma gondii and their immunity to challenge when pregnant

Sixty-four ewes were vaccinated with tachyzoites of an incomplete strain (S48) of Toxoplasma gondii grown either in the peritoneal cavity of mice (group 1) or vero cell culture (group 2) and 30 ewes (group 3) were not vaccinated. All the ewes were mated 77 days later and challenged orally with 2000 sporulated oocysts at 89 to 90 days of gestation. Ten additional unvaccinated (group 4) and 10 vaccinated (group 5) control ewes were not challenged. The unvaccinated ewes developed a characteristic febrile response to challenge while in the vaccinated ewes the fever commenced earlier but was less severe and of shorter duration. After challenge, the antibody titres against T gondii rose rapidly to high values in the vaccinated ewes while the ewes in group 3 responded more slowly. Only eight of the 45 fetuses/lambs (17.8 per cent) from group 3 were viable compared with 72.3 per cent of those in group 1 and 80.8 per cent of those in group 2. Gestation in the unvaccinated challenged ewes was shortened and the mean birthweight of their single, viable offspring was significantly lower than the weight of single lambs from the vaccinated (groups 1 and 2) and control ewes (groups 4 and 5). Examination of precolostral sera showed that almost two-thirds of the lambs from the vaccinated ewes were infected in utero. The 20 control ewes appeared clinically normal at all times and lambed normally. The two vaccine preparations were equally effective.

Measurement of the Positive Muon Anomalous Magnetic Moment to 0.46 ppm

We present the first results of the Fermilab National Accelerator Laboratory (FNAL) Muon g-2 Experiment for the positive muon magnetic anomaly a_{μ}≡(g_{μ}-2)/2. The anomaly is determined from the precision measurements of two angular frequencies. Intensity variation of high-energy positrons from muon decays directly encodes the difference frequency ω_{a} between the spin-precession and cyclotron frequencies for polarized muons in a magnetic storage ring. The storage ring magnetic field is measured using nuclear magnetic resonance probes calibrated in terms of the equivalent proton spin precession frequency ω[over ˜]_{p}^{'} in a spherical water sample at 34.7 °C. The ratio ω_{a}/ω[over ˜]_{p}^{'}, together with known fundamental constants, determines a_{μ}(FNAL)=116 592 040(54)×10^{-11} (0.46 ppm). The result is 3.3 standard deviations greater than the standard model prediction and is in excellent agreement with the previous Brookhaven National Laboratory (BNL) E821 measurement. After combination with previous measurements of both μ^{+} and μ^{-}, the new experimental average of a_{μ}(Exp)=116 592 061(41)×10^{-11} (0.35 ppm) increases the tension between experiment and theory to 4.2 standard deviations.

Detection of T. gondii in tissues of sheep and cattle following oral infection

It has been reported in the literature that cattle are more resistant to toxoplasmosis than sheep. Congenital disease due to T. gondii infection is rarely reported in cattle whereas the parasite is a major cause of abortion and neonatal mortality in sheep. It is believed that sheep remain chronically infected for life. Undercooked meat from infected sheep is an important source of infection for man. In contrast cattle are thought to harbour fewer parasite tissue cysts which may not persist for the lifetime of the host. Therefore, cattle are believed to pose less of a risk for human infection. In this study we examined the presence of T. gondii within a range of tissues in sheep and cattle at 6 weeks and 6 months following oral infection with 10(3) or 10(5) sporulated oocysts of T. gondii. The presence of parasite was determined by bioassay in mice and using polymerase chain reaction (PCR). The results from this study show that T. gondii was more frequently and consistently detected in sheep, in particular within brain and heart tissues, whereas parasites were not detected in the samples of tissues taken from cattle. T. gondii was more frequently detected in sheep given the higher dose of T. gondii. Examination of tissues at either 6 weeks or 6 months after infection did not appear to affect the distribution of T. gondii. The polymerase chain reaction has more specificity and sensitivity when detecting the presence of T. gondii in large animals than histological detection.

Deletion of the CD4 silencer element supports a stochastic mechanism of thymocyte lineage commitment

The mechanism of T cell lineage commitment remains controversial; to examine it we deleted the CD4-silencer element in the germ line of a mouse using a combination of gene targeting and Cre/LoxP-mediated recombination. We found that these mice were unable to extinguish CD4 expression either in immature thymocytes or mature CD8+ cytotoxic T cells (CTLs), which resulted in the development of major histocompatibility complex class II-restricted double-positive CTLs in the periphery. This finding strongly supports a stochastic over an instructive mechanism of coreceptor down-regulation.

Obstetric epidurals and chronic adhesive arachnoiditis

It has been suggested that obstetric epidurals lead to chronic adhesive arachnoiditis (CAA). CAA is a nebulous disease entity with much confusion over its symptomatology. This review outlines the pathological, clinical, and radiological features of the disease. The proposed diagnostic criteria for CAA are: back pain that increases on exertion, with or without leg pain; neurological abnormality on examination; and characteristic MRI findings. Using these criteria, there is evidence to show that epidural or subarachnoid placement of some contrast media, preservatives and possibly vasoconstrictors, may lead to CAA. No evidence was found that the preservative-free, low concentration bupivacaine with opioid mixtures or plain bupivacaine currently used in labour lead to CAA.

Use of ketamine in prolonged entrapment

This paper discusses the advantages of ketamine analgesia in the management of trapped patients after serious incidents. Four case histories and a review of the literature lead us to the conclusion that ketamine is the drug of choice in these situations.

What are the characteristics of breast cancers misclassified as benign by quantitative ultrasound shear wave elastography?

OBJECTIVES

Shear wave elastography (SWE) is a promising adjunct to greyscale ultrasound in differentiating benign from malignant breast masses. The purpose of this study was to characterise breast cancers which are not stiff on quantitative SWE, to elucidate potential sources of error in clinical application of SWE to evaluation of breast masses.

METHODS

Three hundred and two consecutive patients examined by SWE who underwent immediate surgery for breast cancer were included. Characteristics of 280 lesions with suspicious SWE values (mean stiffness >50 kPa) were compared with 22 lesions with benign SWE values (<50 kPa). Statistical significance of the differences was assessed using non-parametric goodness-of-fit tests.

RESULTS

Pure ductal carcinoma in situ (DCIS) masses were more often soft on SWE than masses representing invasive breast cancer. Invasive cancers that were soft were more frequently: histological grade 1, tubular subtype, ≤10 mm invasive size and detected at screening mammography. No significant differences were found with respect to the presence of invasive lobular cancer, vascular invasion, hormone and HER-2 receptor status. Lymph node positivity was less common in soft cancers.

CONCLUSION

Malignant breast masses classified as benign by quantitative SWE tend to have better prognostic features than those correctly classified as malignant.

KEY POINTS

• Over 90 % of cancers assessable with ultrasound have a mean stiffness >50 kPa. • 'Soft' invasive cancers are frequently small (≤10 mm), low grade and screen-detected. • Pure DCIS masses are more often soft than invasive cancers (>40 %). • Large symptomatic masses are better evaluated with SWE than small clinically occult lesions. • When assessing small lesions, 'softness' should not raise the threshold for biopsy.

Androgen Stimulates Growth of Mouse Preantral Follicles In Vitro: Interaction With Follicle-Stimulating Hormone and With Growth Factors of the TGFβ Superfamily

Androgens are essential for the normal function of mature antral follicles but also have a role in the early stages of follicle development. Polycystic ovary syndrome (PCOS), the most common cause of anovulatory infertility, is characterized by androgen excess and aberrant follicle development that includes accelerated early follicle growth. We have examined the effects of testosterone and dihydrotestosterone (DHT) on development of isolated mouse preantral follicles in culture with the specific aim of investigating interaction with follicle-stimulating hormone (FSH), the steroidogenic pathway, and growth factors of the TGFβ superfamily that are known to have a role in early follicle development. Both testosterone and DHT stimulated follicle growth and augmented FSH-induced growth and increased the incidence of antrum formation among the granulosa cell layers of these preantral follicles after 72 hours in culture. Effects of both androgens were reversed by the androgen receptor antagonist flutamide. FSH receptor expression was increased in response to both testosterone and DHT, as was that of Star, whereas Cyp11a1 was down-regulated. The key androgen-induced changes in the TGFβ signaling pathway were down-regulation of Amh, Bmp15, and their receptors. Inhibition of Alk6 (Bmpr1b), a putative partner for Amhr2 and Bmpr2, by dorsomorphin resulted in augmentation of androgen-stimulated growth and modification of androgen-induced gene expression. Our findings point to varied effects of androgen on preantral follicle growth and function, including interaction with FSH-activated growth and steroidogenesis, and, importantly, implicate the intrafollicular TGFβ system as a key mediator of androgen action. These findings provide insight into abnormal early follicle development in PCOS.

Identification of nitroso compounds from biotransformation of 2,4-dinitrotoluene

The intermediates of microbial transformation of 2,4-dinitrotoluene by a mixed bacterial culture derived from activated sludge were identified as 2-amino-4-nitrotoluene, 4-amino-2-nitrotoluene, 2-nitroso-4-nitrotoluene, and 4-nitroso-2-nitrotoluene. The biotransformation of 2,4-dinitrotoluene occurred only under anaerobic conditions with an exogenous carbon source. The two nitroso compounds were unstable and could be observed only at the early stage of 2,4-dinitrotoluene anaerobic biotransformation.

Information, support, and communication needs of women with a family history of breast cancer

In this article, the role of information, support, and communication in promoting adaptation to the risk of breast cancer is reported. These variables emerged from an in-depth study of women at risk for breast cancer because of breast cancer in one or more of their primary (first degree) relatives. Fifty-five women with mothers, sisters, mother and sister, or mother and another primary relative were interviewed using in-depth semi-structured, tape-recorded interviews. After transcription, data were analyzed using qualitative analysis procedures. A three-phase process of adaptation to the risk of breast cancer was uncovered, which was subsequently validated with two study participants. Information, support, and communication emerged as important factors in facilitating the adjustment of women throughout the three phases of the process: as women "lived" the breast cancer experience of their relative; as they developed a perception of their personal risk for breast cancer; and finally as they put the risk of breast cancer "in its place." Despite the importance of information and support, most women had difficulty meeting these needs. Also, communication patterns both within the family and with health professionals were generally not helpful for these women. Issues related to the ill relative as "manager" of cancer-related information, the "ownership style" of the woman at risk, and the accessibility and availability of resources influenced women's adaptation to feelings of risk. Women's needs for information, support, and communication and facilitating factors are described in detail, and recommendations for clinical practice and research offered.

Influence of region of interest size and ultrasound lesion size on the performance of 2D shear wave elastography (SWE) in solid breast masses

AIM

To evaluate the influence of the region of interest (ROI) size and lesion diameter on the diagnostic performance of 2D shear wave elastography (SWE) of solid breast lesions.

MATERIALS AND METHODS

A study group of 206 consecutive patients (age range 21-92 years) with 210 solid breast lesions (70 benign, 140 malignant) who underwent core biopsy or surgical excision was evaluated. Lesions were divided into small (diameter <15 mm, n=112) and large lesions (diameter ≥15 mm, n=98). An ROI with a diameter of 1, 2, and 3 mm was positioned over the stiffest part of the lesion. The maximum elasticity (Emax), mean elasticity (Emean) and standard deviation (SD) for each ROI size were compared to the pathological outcome. Statistical analysis was undertaken using the chi-square test and receiver operating characteristic (ROC) analysis.

RESULTS

The ROI size used has a significant impact on the performance of Emean and SD but not on Emax. Youden's indices show a correlation with the ROI size and lesion size: generally, the benign/malignant threshold is lower with increasing ROI size but higher with increasing lesion size.

CONCLUSIONS

No single SWE parameter has superior performance. Lesion size and ROI size influence diagnostic performance.

Trial of a novel experimental Toxoplasma iscom vaccine in pregnant sheep

Fifteen vaccinated ewes (group 1) and 13 unvaccinated ewes (group 2) were each challenged orally with 2000 sporulated Toxoplasma gondii oocysts at 91 (+/- 1) days' gestation. Another four pregnant ewes acted as unvaccinated unchallenged controls. Lamb mortality in group 1 was 36.4% after a mean gestation of 141 days while in group 2 it was 64.7% after a mean gestation of 131.5 days. These differences were not statistically significant. However, substantially more specific antibody was detected in precolostral sera from live lambs from vaccinated ewes than in live lambs from unvaccinated ewes in group 2.

Investigation of the effect of marathon running on leucocyte counts of subjects of different ethnic origins: relevance to the aetiology of ethnic neutropenia

Healthy subjects of African ancestry, including Afro-Caribbeans, have been observed to have lower total white cell counts and neutrophil counts than healthy Caucasian subjects. The cause of this ethnic neutropenia is unclear. We have previously found no evidence that increased margination of neutrophils is responsible. In this study, we have investigated mobilization of neutrophils from the bone marrow granulocyte reserve by endurance exercise. We investigated subjects of different ethnic origins before and after they had competed in a marathon race. Before the race, the neutrophil counts of Africans/Afro-Caribbeans were significantly lower than those of Caucasians (means 2.49 and 3.21 x 109/l respectively; P = 0.043). After the race, the difference was greater, as was the degree of significance (means 10.21 and 12.33 respectively; P = 0.017). The percentage increment was almost identical whereas the absolute increment was considerably less, although of marginal statistical significance (increment 7.72 and 9. 12 x 109/l respectively; P = 0.10). Similar changes were observed in the monocyte count. Before the race, the difference in the means was of marginal statistical significance (0.35 and 0.41 x 109/l respectively; P = 0.105), whereas after the race the difference was greater and was highly significant (means 0.75 and 1.05 x 109/l respectively; P = 0.001). These observations support the results of our earlier study, both of which suggested that ethnic neutropenia is likely to result from a diminished bone marrow reserve rather than being consequent on altered distribution of neutrophils within the blood stream.

Autologous stem-cell transplantation in patients with mantle cell lymphoma beyond 65 years of age: a study from the European Group for Blood and Marrow Transplantation (EBMT)

BACKGROUND

Limited experience is available on the feasibility and efficacy of autologous stem-cell transplantation (ASCT) in patients with mantle cell lymphoma (MCL) beyond 65 years.

DESIGN AND METHODS

We analysed 712 patients with MCL treated with ASCT from 2000 to 2007 and reported to the European Group for Blood and Marrow Transplantation registry. Patients>65 years were compared with patients<65 years for the end points non-relapse mortality (NRM), relapse incidence, progression-free survival (PFS), and overall survival (OS).

RESULTS

Seventy-nine patients were ≥65 years old. Median time from diagnosis to ASCT was longer in the elderly patients (11 versus 9 months, P=0.005); they had more commonly received at least two treatment lines (62.0% versus 47.9%, P=0.02) and were less commonly in first complete remission at ASCT (35.4% versus 51.2%, P=0.002). Median follow-up after ASCT was 19 and 25 months, respectively. NRM was comparable at 3 months (3.8% versus 2.5%) and at 5 years (5.6% versus 5.0%). There were no differences in relapse rate (66% versus 55% at 5 years), PFS (29% versus 40%) and OS (61% versus 67%) between both populations of patients.

CONCLUSION

ASCT beyond 65 years of age is feasible in selected patients with MCL and results in similar disease control and survival as in younger patients.

Echocardiographic evaluation of cardiac abnormalities in Duchenne's dystrophy and myotonic muscular dystrophy

Routine echocardiographic examinations were performed on 53 individuals with muscular dystrophy (29 with myotonic muscular dystrophy [MMD] and 24 with Duchenne's dystrophy [DD]). Five of 29 (17%) with MMD and six of 24 (25%) with DD had typical mitral valve prolapse evidenced by echocardiography. All patients with DD and mitral valve prolapse had severe thoracic skeletal deformities, while none with MMD and mitral valve prolapse had such abnormalities. Other echocardiographic parameters analyzed included the fractional shortening of the left ventricle (% delta S), excursions of the left ventricular posterior wall (LVPW) and the ventricular septum, pre-ejection period/left ventricular ejection time ratios (PEP/LVET), and thickness of the LVPW and ventricular septum. Abnormal prolongation of the PEP/LVET ratio and increased thicknesses of the LVPW and ventricular septum were noted in some individuals in the MMD group. Decreased % delta S with diminished excursion and diastolic velocity of the LVPW were noted in some with DD.

TCR beta spectratyping in RA: evidence of clonal expansions in peripheral blood lymphocytes

OBJECTIVE

To compare the TCR beta repertoire of peripheral blood CD8 enriched (CD8+) and depleted (CD8-) T cells in rheumatoid arthritis (RA) patients and controls using CDR3 length analysis (spectratyping).

METHODS

CD8+ and CD8- T cells were separated from 14 RA patients and 12 controls, using magnetic beads coated with anti-CD8 monoclonal antibodies. cDNA was prepared as the template for amplification with 22 V beta-C beta primer pairs. The products were resolved by electrophoresis in an ABI373 sequencer using GENESCAN software. Expansions were identified as dominant CDR3 lengths, where the area underlying the corresponding peak exceeded the sum of the areas of the two adjacent peaks. This method was validated by sequencing 10 samples displaying dominant peaks. The expansion frequencies in RA patients and controls were compared using the chi 2 test statistic.

RESULTS

Dominant peaks were evident in several V beta families. They were more frequent in RA patients in both the CD8+ subset (RA normalised frequency 10.6; control normalised frequency 8.0; p = 0.03) and the CD8- subset (RA normalised frequency 2.9; control normalised frequency 1.5; p = 0.02). Sequencing of 10 samples exhibiting dominant peaks revealed an unequivocal clonal expansion in nine (90%).

CONCLUSIONS

RA patients exhibited a significantly increased frequency of T cell expansions both in the CD8+ and CD8- subsets. This phenomenon may reflect the proliferation of autoreactive cells, a nonspecific expansion of memory T cells in response to pro-inflammatory cytokines or a defect of T cell regulation that predates the onset of RA and may itself predipose to disease.

How can the principles of complexity science be applied to improve the coordination of care for complex pediatric patients?

Clinical and technological advances in medicine have resulted in more patients requiring multidisciplinary care and coordination of services. This is particularly challenging in pediatrics, given the dependency of children. Coordination of care is a key ingredient of quality care; when suboptimal, clinical outcomes and satisfaction can suffer. In this article we view coordination of care through the lens of complexity science in an effort to find new solutions to this healthcare challenge.

Ultrasonic detection of myocardial infarction by amplitude analysis

Myocardial infarctions were produced in dogs by occluding the left anterior descending artery; the dogs were killed at varying times, from 30 minutes to 8 days. Prior to sacrifice, Thioflavin S was injected intravenously. The excised heart was scanned by a B-scanner interfaced with a computer that permitted quantification of signal amplitude. The heart was sectioned, photographed, and studied pathologically. Infarcted myocardium showed high ultrasonic reflectivity with average amplitudes 1.4--2.6 times that of normal muscle. Perfusion-histomorphologic evidence of infarction correlated best in infarcts of 24 hours or less; older infarcts were generally underestimated. Tissue changes, sources of false-positive and false-negative findings, signal processing, and potential clinical utility are discussed.

Outcome in patients hospitalised for psoriatic arthritis

Forty patients hospitalised for treatment of psoriatic arthritis (PsA) were followed for a mean of 8.0 years. At the end of this time none had died and only 8% were in functional class IV. 90% received second-line therapy. There was a high incidence of skin rashes on gold but hydroxychloroquine was well tolerated. Patients with psoriatic arthritis had a better outcome than patients with rheumatoid arthritis treated with the same regime.