Role of vacuum assisted excision in minimising overtreatment of ductal atypias

PURPOSE

B3 lesions are indeterminate lesions of uncertain malignant potential. They include lesions with and without epithelial atypia. Those with atypia include atypical intraductal epithelial proliferation (AIDEP)/atypical ductal hyperplasia (ADH) and flat epithelial atypia (FEA). They are traditionally managed with surgery. Vacuum assisted excision (VAE) allows larger samples to be obtained using a vacuum assisted biopsy (VAB) device, which equates to a surgical biopsy. We propose that VAE and mammographic surveillance is a safe alternative to surgery in managing the ductal atypias; (AIDEP/ADH and FEA).

METHOD

Retrospective analysis of prospectively collected data on B3 lesions (April 2009 - March 2016) from consecutive breast screening patients diagnosed with AIDEP/ADH or FEA on initial diagnostic core biopsy. Mammographic abnormality, breast density, size, management pathway and upgrade to cancer and types of cancer were also collected during the treatment pathway and 5 year surveillance period (April 2009 - April 2019).

RESULTS

273 cases of ductal atypia were identified. 187/273 (68.5 %) cases were managed with VAE only as no upgrade to malignancy and then 5 year mammographic surveillance. 34/273 (12.5 %) cases had a VAE diagnosing malignancy. 24/273 (8.8 %) cases had a VAE and then a surgical biopsy due to radiological or pathological concern, 8/24 upgraded to malignancy. 22/273 (8%) cases had a surgical diagnostic biopsy, 9/22 (41 %) cases were upgraded to malignancy. In total 51/273 (19 %) cases were diagnosed with cancer on the new pathway (13 invasive (all ER positive and Her2 negative) and 38 non-invasive, (34 ductal carcinoma in situ (DCIS) and 4 cases of lobular carcinoma in situ (LCIS)). While 17/273 (6.2 %) cases developed malignancy (12 invasive (all HER2 negative) and 4 DCIS and 1 LCIS) during the 5 year surveillance period.

CONCLUSIONS

VAE is a safe alternative to surgery in managing ductal atypias. 187/273 (68.5 %) women avoided surgery. While 34/51 cancers (66.7 %) were diagnosed preoperatively using VAE, allowing the women to have a single therapeutic procedure.

Neural Correlates of Schizophrenia Negative Symptoms: Distinct Subtypes Impact Dissociable Brain Circuits

BACKGROUND

The negative symptoms of schizophrenia include deficits in emotional expression and motivation. These deficits are stable over the course of illness and respond poorly to current medications. Previous studies have focused on negative symptoms as a single category; however, individual symptoms might be related to separate neurological disturbances. We analyzed data from the Functional Biomedical Informatics Research Network dataset to explore the relationship between individual negative symptoms and functional brain activity during an auditory oddball task.

METHODS

Functional magnetic resonance imaging was conducted on 89 schizophrenia patients and 106 healthy controls during a two-tone auditory oddball task. Blood oxygenation level-dependent (BOLD) signal during the target tone was correlated with severity of five negative symptom domains from the Scale for the Assessment of Negative Symptoms.

RESULTS

The severity of alogia, avolition/apathy and anhedonia/asociality was negatively correlated with BOLD activity in distinct sets of brain regions associated with processing of the target tone, including basal ganglia, thalamus, insular cortex, prefrontal cortex, posterior cingulate and parietal cortex.

CONCLUSIONS

Individual symptoms were related to different patterns of functional activation during the oddball task, suggesting that individual symptoms might arise from distinct neural mechanisms. This work has potential to inform interventions that target these symptom-related neural disruptions.

Female adolescents with severe substance and conduct problems have substantially less brain gray matter volume

Objective

Structural neuroimaging studies have demonstrated lower regional gray matter volume in adolescents with severe substance and conduct problems. These research studies, including ours, have generally focused on male-only or mixed-sex samples of adolescents with conduct and/or substance problems. Here we compare gray matter volume between female adolescents with severe substance and conduct problems and female healthy controls of similar ages. Hypotheses: Female adolescents with severe substance and conduct problems will show significantly less gray matter volume in frontal regions critical to inhibition (i.e. dorsolateral prefrontal cortex and ventrolateral prefrontal cortex), conflict processing (i.e., anterior cingulate), valuation of expected outcomes (i.e., medial orbitofrontal cortex) and the dopamine reward system (i.e. striatum).

Methods

We conducted whole-brain voxel-based morphometric comparison of structural MR images of 22 patients (14-18 years) with severe substance and conduct problems and 21 controls of similar age using statistical parametric mapping (SPM) and voxel-based morphometric (VBM8) toolbox. We tested group differences in regional gray matter volume with analyses of covariance, adjusting for age and IQ at p<0.05, corrected for multiple comparisons at whole-brain cluster-level threshold.

Results

Female adolescents with severe substance and conduct problems compared to controls showed significantly less gray matter volume in right dorsolateral prefrontal cortex, left ventrolateral prefrontal cortex, medial orbitofrontal cortex, anterior cingulate, bilateral somatosensory cortex, left supramarginal gyrus, and bilateral angular gyrus. Considering the entire brain, patients had 9.5% less overall gray matter volume compared to controls.

Conclusions

Female adolescents with severe substance and conduct problems in comparison to similarly aged female healthy controls showed substantially lower gray matter volume in brain regions involved in inhibition, conflict processing, valuation of outcomes, decision-making, reward, risk-taking, and rule-breaking antisocial behavior.

Abstract P2-02-01: Did established clinical practice regarding MRI bias the COMICE trial?

Introduction: The negative COMICE study and reports of inappropriate mastectomies worldwide have served to discredit the use of preoperative MRI for the purpose of aiding conservative breast surgery. We postulate that established clinical practice regarding MRI at the time of the COMICE trial lead to bias in case selection, with more complicated cases being preselected out prior to randomisation. We reviewed the local practice at the time of COMICE.

Methods and materials: Retrospective analysis of all cases of Breast MRI performed to assess disease extent pre-operatively during recruitment to COMICE (December 2001 - January 2007) was undertaken. Size on mammogram/ultrasound, MRI and histology was documented. As pre-PAC's era, the information was obtained from imaging and pathology reports. Where reports did not include distance between lesions in multifocal/multicentric disease, the sum of the lesions was used (taken as immediately adjacent) so as not to overestimate the size. All cases were reviewed blinded to COMICE status. Cases with mammogram/ultrasound size &gt;/ = 40mm were excluded as these were deemed unsuitable for conservative surgery.

Results: A total of 318 breast MRI examinations were performed in this interval to assess disease extent pre-operatively of which, 81 were excluded appropriately, for inadequate information (n = 47), size on conventional imaging &gt;/ = 40mm (n = 18), receiving neo-adjuvant treatment (n = 6), non cancer diagnosis (n = 7) and non invasive disease (n = 3). 242 cancers from 237 patients were included comprising 77COMICE and 160NON-COMICE patients. Statistical difference was noted in the types of surgery between the groups, p&lt;0.001. Re-excision rates were similar: COMICE = 11.7% and NON-COMICE = 8%. Mastectomy rates were however different, 15.6% of the COMICE group and 42% of the NON-COMICE group.

There was a significant difference in histological size between the 2 groups, mean size in NON-COMICE cases 32mm versus 26mm in the COMICE group (p = 0.009). There was a significant difference in the tumour types between the 2 groups (p&lt;0.001). Notably 37% of cases in the NON-COMICE group were of lobular type compared to 13% of the COMICE group.

Conclusion: Data from this well established MRI unit has demonstrated clinical bias in the COMICE trial with more complicated cases, which benefited from MRI, being pre-selected out prior to randomisation which understated the value of MRI. MRI in appropriately selected patients in conjunction with modern oncoplastic surgical techniques will increase the opportunities for conservative surgery rather than increase mastectomy rates. An aggressive biopsy policy for MRI detected lesions is required to avoid inappropriate mastectomies.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P2-02-01.

The NHS breast screening programme

This article reviews the NHS breast screening programme and outlines some of the issues it currently faces.

Altered fronto-limbic activity in children and adolescents with familial high risk for schizophrenia

Early symptoms of schizophrenia tend to emerge during adolescence, hich is a critical period for development of executive and emotional processing. While individuals with familial high risk (FHR) for schizophrenia may show cognitive and emotional changes, the neural mechanisms underlying the development of these changes remain unclear. The goal of this study was to identify functional differences in fronto-striato-limbic regions in children with FHR. Functional magnetic resonance imaging (MRI) data were collected from 21 children with a first-degree family member with schizophrenia and 21 controls without FHR. Participants performed an emotional oddball task requiring both selective attention and suppression of task-irrelevant emotional information. During selective attention, the group with FHR showed enhanced activation in the inferior frontal gyrus and caudate, with decreases in middle frontal gyrus and insular activation. The FHR group also showed greater age-related recruitment of anterior cingulate, temporal and occipital cortical areas during selective attention. During emotional processing, the FHR group showed decreased anterior cingulate activation, with decreased age-related recruitment of inferior frontal, parietal and occipital areas. The results suggest that FHR for schizophrenia may be associated with abnormal hyperactivation and hypoactivation of the neural circuitry engaged during executive and emotional processing and with age-related changes in neural recruitment during adolescence.

CT staging for breast cancer patients with poor prognostic tumours

The aim of this study was to assess the value of computed tomography (CT) staging of the chest, abdomen and pelvis in patients with poor prognostic tumours and no symptoms of metastatic disease in those who have undergone primary surgical management for the treatment of breast cancer. Patients who had primary operable invasive breast cancer treated by surgery over a 2-year period were retrospectively identified. Pathological data from the surgical resection were used to calculate the Nottingham Prognostic Index. Patients with no symptoms of distant metastases who underwent CT staging of the chest, abdomen and pelvis as a result of being placed in the poor prognostic group were identified. The presence and sites of metastatic disease or any indeterminate finding were documented. Additional investigations generated as a result of the staging CT and the outcome were also recorded. Sixty-seven patients (80%) in the poor prognostic group underwent a staging CT. Forty-seven patients (70%) had no signs of metastatic disease on the staging CT. Two patients (3%) were diagnosed with metastatic disease, on the basis of the initial CT scan. Eighteen patients (27%) had an indeterminate finding requiring further investigation, generating 21 additional imaging tests - following this only one additional patient was diagnosed with metastatic disease. Seventeen patients with an initially indeterminate finding did not have metastatic disease, giving a false-positive rate of 25%. In total, three patients (4%) had a final diagnosis of metastatic disease. The routine use of CT staging in patients with no symptoms of distant metastases with primary operable breast cancer even when in a poor prognostic group is of limited value, with a low pick-up rate of metastatic disease and considerable risk of false-positive findings.

Does the insertion of a gel-based marker at stereotactic breast biopsy allow subsequent wire localizations to be carried out under ultrasound guidance?

AIM

To investigate whether the insertion of a gel-based marker at the time of stereotactic breast biopsy allows subsequent preoperative localization to be performed under ultrasound guidance.

MATERIALS AND METHODS

One hundred consecutive women who underwent either a 10 G stereotactic vacuum-assisted breast biopsy or 14 G stereotactic core biopsy with marker placement, followed by wire localization and surgical excision were identified. All had mammographic abnormalities not initially visible with ultrasound. The method of preoperative localization was recorded and its success judged with reference to the wire position on the post-procedure films relative to the mammographic abnormality and the marker. Histopathology data were reviewed to ensure the lesion had been adequately excised.

RESULTS

Eighty-three women (83%) had a successful ultrasound-guided wire localization. Successful ultrasound-guided localization was more likely after stereotactic vacuum biopsy (86%) compared to stereotactic core biopsy (68%), although this did not quite reach statistical significance (p=0.06).

CONCLUSION

The routine placement of a gel-based marker after stereotactic breast biopsy facilitates preoperative ultrasound-guided localization.

Recurrence of Kawasaki disease in an adult patient with cholecystitis

We report recurrence of Kawasaki disease in a 20-year-old man eighteen years after the primary episode. Athough sixty-nine cases have been reported among adults in the literature, this represents only the second case of Kawasaki disease recurring in an adult patient after childhood presentation. Our patient presented with the characteristic mucocutaneous features, fever, arthralgia, epigastric pain and cholecystitis. His presentation was complicated by arthralgias and abnormal liver function tests, which are more common in the adult patient. The diagnosis was made based on clinical findings after the exclusion of other causes of persistent febrile illness. He was successfully treated with high dose aspirin and intravenous immunoglobulin therapy. Despite a second presentation of Kawasaki disease our patient did not have any demonstrable coronary arterial involvement. Although typically a self-limiting disease, cardiac complications can cause significant morbidity and mortality in those not treated with aspirin and IVIG. This report serves to highlight that late recurrence of Kawasaki disease may develop in adults many decades after the initial presentation. A twenty-year-old male, presented to the Emergency department with a one-week history of general malaise. He complained of sore throat, 5-day history of fever (39 degree celsius), epigastric discomfort, rash, nausea, vomiting, generalised arthralgia and myalgia. He was jaundiced with dark urine and pale stools. He had been commenced on oral penicillin three times a day for possible streptococcal infection after the rash had occurred. Past medical history was notable for a previous episode of Kawasaki disease (KD) at 2 years of age, after which there were no adverse sequelae, a history of asthma and non-alcoholic fatty liver disease.

The prevalence of antiphospholipid antibody syndrome among systemic lupus erythematosus patients

Systemic lupus erythematosus (SLE) is an autoimmune disease characterised by excess autoantibody production. It typically affects women of childbearing age. Antiphospholipid antibody syndrome (APLAs) is associated with serious co-morbidity to mother and child characterized by recurrent vascular thrombosis and/or pregnancy associated morbidity. We reviewed SLE patients attending a specialist connective tissue disease clinic both to assess the occurrence of APLAs and its clinical presentations and to audit the effectiveness of screening for APL antibodies in a specialist clinic. 204 patients attended the newly established connective tissue disease outpatient clinic over a twenty-seven month period; 42 (34 female, 8 male) with a diagnosis of SLE. Ten patients (24%), eight female and 2 male with a median age of 38.5 years (range 20 to 64 years) fulfilled the ACR criteria for secondary APLAs (Table 2). The commonest clinical presentation was pulmonary embolus (five patients). Overall 37 patients (88%) with SLE were screened for APLAs during the study period: 94% of females and 62.5% of males were screened (for anticardiolipin antibodies, lupus anticoagulant or both), 27% had evidence of APLAs, 24% had positive antibodies but were asymptomatic. There is a significant occurrence of APLAs among SLE patients. Given the important clinical implications of this disorder including substantial risk of fetal loss and patient morbidity or mortality, routine screening of all SLE patients for APL antibodies is recommended.

Association between paclitaxel and necrotic pancreatitis

To our knowledge this is the first reported case of paclitaxel associated necrotic pancreatitis requiring a pancreatic necrostomy. This was a near fatal complication associated with paclitaxel with a high resulting morbidity. Although this is a rare association physicians should be wary of the potential to develop severe pancreatitis in patients receiving this therapeautic agent. Monitoring of serum amylase during therapy is therefore warranted.

Sibling adjustment to pediatric traumatic brain injury: a case-controlled pilot study

OBJECTIVE

To assess depressive symptoms, self-concept, and behavior in non-affected siblings of children with severe pediatric traumatic brain injury (TBI).

DESIGN

Cross-sectional study with case controls.

SETTING

Children's hospital tertiary care center.

PARTICIPANTS

Twelve siblings of children consecutively admitted to an inpatient rehabilitation unit after a severe TBI. Case controls were randomly selected from the sibling's classmates.

MAIN OUTCOME MEASURES

The Child Behavior Checklist (CBCL), the Teacher's Report Form of the CBCL (TRF-CBCL), the Self-Perception Profile for Children and the Children's Depression Inventory (CDI).

RESULTS

No statistical differences were found in depressive symptoms, self-concept, or behavior between the siblings and their classmates 3 to 18 months after injury. Poorer functional outcomes in the child with a TBI were found to correlate significantly with lower self-concept and more symptoms of depression in the siblings.

CONCLUSIONS

Further research is needed to evaluate the potential impact on sibling adjustment after pediatric TBI.

The occurrence of enteric pathogens and Aeromonas species in organic vegetables

A range of commercially available organic vegetables (n = 86) was examined for the presence of Salmonella, Campylobacter, Escherichia coli, E. coli O 157. Listeria and Aeromonas spp., to provide information on the occurrence of such organisms in organic vegetables in Northern Ireland. The study was not designed to quantify such organisms or to compare occurrence with conventionally farmed vegetables. Standard enrichment techniques were used to isolate and identify enteric pathogens and Aeromonas species. No Salmonella, Campylobacter, E. coli. E. coli O 157, Listeria were found in any of the samples examined. Aeromonas species were isolated from 34% of the total number of organic vegetables examined. Many (64%) of the organic vegetables examined were "ready-to-eat" after minimal processing, i.e., washing. Aeromonas spp. was isolated from 41% of these vegetables. Aeromonas spp. was not recovered from certain vegetable types. The most commonly isolated species of Aeromonas was Aeromonas schubertii with 21.0% of all samples contaminated with this species; 5.8% of samples contained A. hydrophila, 5.8% A. trota, 3.5% A. caviae and 2.3% contained A. veronii biovar veronii. Although Aeromonas species are frequently detected in organic vegetables, the absence of accepted enteric pathogens was encouraging, and does not support the allegation of organic foods being of high risk due to the farming methods used.

The expression of proteinases and haemolysins by Aeromonas hydrophila under modified atmospheres

The study estimated the proteolytic activity (against Hide Powder Azure) and haemolytic activity (against horse erythrocytes) in cell-free filtrates (CFF) from four strains of Aeromonas hydrophila growing under a range of commercially relevant modified atmospheres (2% O2, 78% N2, 20% CO2; 10% O2, 80% N2, 10% CO2; 50% N2, 50% CO2; 100% CO2). The examined strains exhibited significant qualitative and quantitative differences in the extent and times of onset of expression of these enzymes under aerobic and modified atmospheres. No proteolytic or haemolytic activities were detected in any Aer. hydrophila cultures grown at sub-optimal temperatures under modified atmospheres containing high concentrations of CO2 (i.e. 50% CO2 or 100% CO2). Although Aer. hydrophila can grow rapidly in modified atmospheres, the overall spoilage and pathogenic potential is grossly affected. Implications of these findings are discussed.

Osteoporosis: identifying high-risk persons

Osteoporosis is the most common systemic bone disorder causing thousands of injuries and deaths each year. The pathogenesis of osteoporosis is a complex puzzle that contains many interlocking pieces involving both genetic and environmental factors. The prevention of age-related bone loss, which could be gained through health teaching by the nurse, should be optimized. Nurses and other caregivers can make significant contributions toward the initial identification of those persons at risk or who may already have the debilitating disease by using the Osteoporosis Risk Questionnaire.

Visual cerebral lateralization over phases of the menstrual cycle: a preliminary investigation

This study investigated whether visual cerebral asymmetries would change in phase with hormonal variations during the menstrual cycle. Lexical decision and line orientation tasks were administered during follicular, luteal, and menstrual phases of each woman's cycle. These tasks were also administered to a reference group of male subjects. Signal detection analyses indicated an unvarying RVF advantage in word/nonword discriminability (d') throughout the menstrual cycle, but a phase-dependent shift in left hemisphere response criterion (log beta). Gender differences were present for discriminability of line orientation, and female performance on this task varied over the cycle. The results imply that the neural systems subserving some cognitive functions are sensitive to fluctuations in gonadal steroids and suggest a hormonal basis for gender differences in some visual-spatial functions.

Disruption of selective attention in the rat following chronic d-amphetamine administration: relationship to schizophrenic attention disorder

In the blocking paradigm, prior training to one conditioned stimulus (CSA) blocks the ability to attend to a second conditioned stimulus (CSB) when the two form a compound (CSAB) in subsequent training. Blocking is an associative process by which animals learn to ignore CSB because it contains no new information regarding the reinforcing event. Experiment 1 showed that d-amphetamine disrupted rats' ability to ignore the irrelevant CSB: The animals responded equally to both elements of the CSAB compound following five dialy administrations of 4 mg/kg d-amphetamine. In Experiment 2 the disruption of blocking by d-amphetamine was eliminated by concomitant administration of 0.02 mg/kg haloperidol. These results are consistent with previous research showing that d-amphetamine disrupts rats' ability to ignore repeated presentations of a single nonreinforced stimulus in the latent inhibition paradigm. The inability of amphetamine-treated animals to ignore one element of a dual-element compound bears some resemblance to selective attention deficits seen among schizophrenic patients.