Prevalence and Predictors of Inappropriate Antithrombotic Prescription in Patients Presenting With Traumatic Brain Injury

BACKGROUND AND OBJECTIVES

A growing proportion of the US population is on antithrombotic therapy (AT), most significantly within the older subpopulation. Decision to use AT is a balance between the intended benefits and known bleeding risk, especially after traumatic brain injury (TBI). Preinjury inappropriate AT offers no benefit for the patient and also increases the risk of intracranial hemorrhage and worse outcome in the setting of TBI. Our objective was to examine the prevalence and predictors of inappropriate AT among patients presenting with TBI to a Level-1 Trauma Center.

METHODS

A retrospective chart review was performed on all patients with TBI and preinjury AT who presented to our institution between January 2016 and September 2020. Demographic and clinical data were collected. Appropriateness of AT was determined through established clinical guidelines. Clinical predictors were determined by logistic regression.

RESULTS

Of 141 included patients, 41.8% were female (n = 59) and the average age (mean ± SD) was 80.6 ± 9.9. The prescribed antithrombotic agents included aspirin (25.5%, n = 36), clopidogrel (22.7%, n = 32), warfarin (46.8%, n = 66), dabigatran (2.1%, n = 3), rivaroxaban (Janssen) (10.6%, n = 15), and apixaban (Bristol-Myers Squibb Co.) (18.4%, n = 26). The indications for AT were atrial fibrillation (66.7%, n = 94), venous thromboembolism (13.4%, n = 19), cardiac stent (8.5%, n = 12), and myocardial infarction/residual coronary disease (11.3%, n = 16). Inappropriate antithrombotic therapy use varied significantly by antithrombotic indication ( P < .001) with the highest rates seen with venous thromboembolism. Predictive factors also include age ( P = .005) with higher rates younger than 65 years and older than 85 years and female sex ( P = .049). Race and antithrombotic agent were not significant predictors.

CONCLUSION

Overall, 1 in 10 patients presenting with TBI were found to be on inappropriate AT. Our study is the first to describe this problem and warrants investigation into possible workflow interventions to prevent post-TBI continuation of inappropriate AT.

Cytomegalovirus durably primes neutrophil oxidative burst

Cytomegalovirus (CMV) is a ubiquitous herpes virus that infects most humans, thereafter persisting lifelong in tissues of the host. It is a known pathogen in immunosuppressed patients, but its impact on immunocompetent hosts remains less understood. Recent data have shown that CMV leaves a significant and long-lasting imprint in host immunity that may confer some protection against subsequent bacterial infection. Such innate immune activation may come at a cost, however, with potential to cause immunopathology. Neutrophils are central to many models of immunopathology, and while acute CMV infection is known to influence neutrophil biology, the impact of chronic CMV infection on neutrophil function remains unreported. Using our murine model of CMV infection and latency, we show that chronic CMV causes persistent enhancement of neutrophil oxidative burst well after resolution of acute infection. Moreover, this in vivo priming of marrow neutrophils is associated with enhanced formyl peptide receptor expression, and ultimately constitutive c-Jun N-terminal kinase phosphorylation and enhanced CD14 expression in/on circulating neutrophils. Finally, we show that neutrophil priming is dependent on viral load, suggesting that naturally infected human hosts will show variability in CMV-related neutrophil priming. Altogether, these findings represent a previously unrecognized and potentially important impact of chronic CMV infection on neutrophil responsiveness in immunocompetent hosts.

A Report from a Workshop of the International Stem Cell Banking Initiative, Held in Collaboration of Global Alliance for iPSC Therapies and the Harvard Stem Cell Institute, Boston, 2017

This report summarizes the recent activity of the International Stem Cell Banking Initiative held at Harvard Stem Cell Institute, Boston, MA, USA, on June 18, 2017. In this meeting, we aimed to find consensus on ongoing issues of quality control (QC), safety, and efficacy of human pluripotent stem cell banks and their derivative cell therapy products for the global harmonization. In particular, assays for the QC testing such as pluripotency assays test and general QC testing criteria were intensively discussed. Moreover, the recent activities of global stem cell banking centers and the regulatory bodies were briefly summarized to provide an overview on global developments and issues. stem cells2019;37:1130–1135

Abstract P2-09-17: Evaluation of the oncomine comprehensive assay for the identification of actionable mutations for therapeutic stratification from the TEAM pathology cohort

Large-scale sequencing initiatives have revealed a wealth of common and novel variants as well as copy-number aberrations, across different malignancies. This growing list of variants/aberrations can sometimes be matched to specific therapeutics. Such “actionable mutations/changes” hold promise for personalized treatment in the future, with treatments tailored to molecular abnormalities. Presently, women with hormone positive early breast cancer continue to experience improved survival on adjuvant anti-hormone therapy, but a significant number of women continue to progress. Therefore, there is a need to identify those women for whom current therapies are insufficient and to identify alternative therapeutic interventions. We explored the used of genetic profiling using a comprehensive solid tumor next generation sequencing (NGS) assay (the Oncomine Comprehensive Assay, OCA) to characterize early invasive breast cancer. The OCA is based on the Ion Torrent™ NGS platform and Ion AmpliSeq™ library preparation technology, coupled to the Oncomine™ Knowledgebase, for target selection, variant calling, and data annotations. The OCA includes 87 genes for hotspot mutation detection, 48 genes for full length sequencing and 43 genes for focal copy number assessment. The OCA provides a standardized informatics workflow and quality control (QC) parameters to process samples in a translational clinical research setting. To explore the application of the OCA to early invasive breast cancers, we performed a retrospective pilot study in a subset of cases from the TEAM trial. From the TEAM pathology samples, 420 were chosen in a case-control fashion, 413 samples were analyzed, 388 samples passed standard QC metrics, and 254 samples (65%) were found to contain 368 variants with Oncomine Knowledgebase annotations. Briefly, variants of PIK3CA were most frequent at 42.7% (157/368), followed by TP53 at 27.2% (100/368), PTEN at 5.7% (21/368), BRCA2 at 3.8% (14/368), SF3B1 (12/368), AKT1 (11/368) and PTCH1 (11/368) at 3.3%, 3.0%, 3.0%; respectively. Other variants were detected in ATM, ERBB2, RB1, FGFR2, NF1, CDKN2A, PIK3R1 and others. Amongst the 43 genes assessed for copy-number, 23 showed copy-number changes across 132 samples totalling 167 CNVs. 256 samples showed no copy-number alterations in any of the genes on the panel. ERBB2 was most frequently altered at 28.1% (47/167), followed by FGFR1 at 23.4% (39/167), CCND1 at 15.0% (25/167) and MDM2 at 10.2% (17/167). Copy-number losses were identified in TP53, RB1, PTEN, BRCA2 at 0.6% each; as well as CDKN2A at 1.8% (3/167). Analytical validation of a subset of gene variants and copy-number changes will be presented in addition to the evidence of potential future application of the Oncomine Comprehensive Assay to precision oncology goals.

Citation Format: Bayani J, Crozier C, Quintayo MA, Amemiya Y, Zhang X, Larivière M, Sadis S, Smith JM, Hasenburg A, Kieback D, Markopoulos C, Dirix L, Yaffe M, Seth A, Feilotter H, Rea D, Bartlett JMS. Evaluation of the oncomine comprehensive assay for the identification of actionable mutations for therapeutic stratification from the TEAM pathology cohort [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 P2-09-17.

Highlight: A new way to block the development of asthma from dust mites

Targeting a transcription factor, generally considered to be "nondruggable," may help to prevent asthma from developing.

Abstract P6-09-30: Factors influencing survival among patients with HER2-positive metastatic breast cancer treated with Trastuzumab

Background: We have limited capability to predict survival among patients treated for metastatic HER2+ breast cancer. Individual patient survival varies and further research is warranted to identify significant prognostic and predictive factors influencing overall survival (OS).

Methods: We identified HER2+ metastatic breast cancer patients receiving trastuzumab (T) at the Sunnybrook Odette Cancer Centre (SOCC) from 1999-2013 through a Cancer Care Ontario Registry (n=256) and selected patients with pathology also available at SOCC (n=154). A retrospective chart review was completed documenting clinical, pathologic, laboratory and survival outcomes. OS was defined as date of 1st T therapy to death. The Kaplan-Meier method was used to estimate time-to-event outcomes. Cox proportional hazards regression models and log-rank tests were used to identify prognostic factors for overall survival (OS). Logarithmic transformations were performed for statistical purposes. Multivariable models were constructed including known prognostic factors: 1) number of visceral metastatic sites and 2) CNS metastasis. After adjusting for these two factors, stepwise selection was used to create an optimal model for additional factors. Analyses were two-sided and statistical significance was defined at the p=0.05 level.

Results: Cohort characteristics: mean age was 55 (SD: 13 years), ≥2 sites of visceral metastasis: 45%, CNS metastasis: 7%, ER positive: 53%. Median OS for the cohort was 24 months (95% CI: 21-33). Clinical factors recorded at metastatic presentation such as the presence of a visceral metastasis, having multiple sites of visceral metastasis and CNS metastasis were prognostic for overall survival in univariate models (p&lt;0.05). ER/PR status was not of significance (p&gt;0.05). Laboratory measures such as the neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte ratio (PLR) and alkaline phosphatase (ALP) were of significance in univariate models (p=&lt;0.05). The multivariable model identified older age (HR=1.18 / decade, 95% CI=1.02-1.37, p=0.030), higher PLR (HR=1.75 / log-unit, 95% CI=1.25-2.46, p=0.001), increased ALP (HR=1.87 / log-unit, 95% CI=1.41-2.49, p&lt;0.001) and ER positivity (HR=0.63, 95% CI=0.42-0.96, p=0.032), as significant prognostic factors in addition to the presence of CNS metastasis (HR=3.19, 95% CI=1.59-6.38, p=0.001) and two or more metastatic sites (HR=2.10, 95% CI=1.19-3.70, p=0.010).

Conclusion: Our results have identified a number of prognostic factors influencing survival among patient with HER2+ breast cancer treated with T. Age, ALP, PLR and ER status were identified as significant prognostic factors after adjusting for presence of CNS metastasis and number of metastatic sites. Further study of PLR as a prognostic and predictive factor is warranted.

Citation Format: Blanchette PS, Desautels DN, Pond G, Bartlett JMS, Nofech-Mozes S, Yaffe M, Pritchard KI. Factors influencing survival among patients with HER2-positive metastatic breast cancer treated with Trastuzumab [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 P6-09-30.

Abstract P1-05-27: Evaluation of the Oncomine focus and comprehensive assays for therapeutic stratification in early hormone receptor positive breast cancers

Large-scale sequencing initiatives have revealed a wealth of common and novel variants as well as copy-number aberrations, across different solid tumours and hematological malignancies. The growing list of variants/aberrations can sometimes be matched to specific therapeutics. Such “actionable mutations/changes” hold promise for personalized treatment, as treatments could be tailored to molecular abnormalities, rather than disease site. In breast cancer, women with hormone positive early breast cancer continue to experience improved survival on adjuvant anti-hormone therapy, but even today, a significant number of women continue to progress. Therefore there is not only a need to identify those women for whom current therapies are insufficient, but to identify alternative therapeutic interventions. The ThermoFisher Scientific Oncomine™ Focus and Oncomine™ Comprehensive Assays (OFA and OCA) are based on the Ion Torrent™ next-generation sequencing platform and Ion AmpliSeq™ library preparation technology, coupled to the Oncomine™ Knowledgebase, for target selection, variant calling, and data annotations. Both panels interrogate the most referenced oncology biomarker variants that are matched to curated published evidence from clinical trials supporting the matching of driver genetic variants with relevant potential clinical therapeutic options. The ability to identify SNVs, CNVs and fusion events in a single assay provides an unprecedented approach to maximizing the molecular information to be derived from a single tumour sample. To explore the value of the Oncomine™ assays in early invasive breast cancers, we have performed a pilot study to assess the reproducibility and accuracy of the OFA and OCA from nucleic acids extracted from formalin-fixed paraffin embedded tissues. In addition to the sequencing and copy-number data generated by these assays, we will compare these results to copy-number information generated using the Oncoscan® (Affymetrix)copy-number assay as well as information derived by Multiplex Ligation-dependent Probe Amplification-based panels (MRC-Holland) and Fluorescent in situ Hybridization (FISH). Our preliminary analyses of 35 invasive breast cancers by Oncoscan® identified the frequent whole chromosomal gains of 2, 3, 5, 7, 18, 19 and 20; gains of 1q, 7p, 8q, 11p, 16p, 17q; losses at 1p, 8p, 11q, 13, 16q, 17p and chromosome 18. High level amplifications were also identified for breast cancer related genes such as ERBB2, CCND1, MYC, FGFR1; in addition to the frequent losses of TP53, RB1, CDKN2A. Copy-number changes were confirmed by locus-specific FISH and MLPA. Data generated from the OFA and OCA from these same samples will be compared to the other platform findings and provide a snapshot of the mutational landscape of early breast cancers across these pan-cancer panels. Having established the robustness and accuracy of the assays, the applicability of the OCA in the context of improved stratification for breast cancers for prognostic and predictive tests will be discussed.

Citation Format: Bayani J, Crozier C, Zhang NX, Amemiya Y, Quintayo MA, Yan FJ, Dion D, Mccormack S, Yaffe M, Seth A, Feilotter H, Bartlett JMS. Evaluation of the Oncomine focus and comprehensive assays for therapeutic stratification in early hormone receptor positive breast cancers [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 P1-05-27.

Three-dimensional ultrasound-based spectroscopic imaging for detection of prostate cancer in men

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Background: The objective of this translational research was to investigate the use of real-time novel three-dimension, quantitative ultrasound-based spectroscopic imaging of the prostate as a means of cancer detection.

Methods: Ten patients with T2-3 prostate cancer underwent a 6-9 MHz trans-rectal ultrasound scan of the prostate prior to radical prostatectomy. Equally spaced axial ultrasound images (0.5 cm separation) corresponding elasticity and spectroscopy data were collected in each patient. Colour-coded spectroscopic parametric maps of 0-Mhz intercept (0-Mhz), mid-band fit (MBF) and slope of line of best fit (slope) were generated indicating where the disease in the prostate gland is hypothetically located. Quantitative data (% volume of cancer over the prostate gland) were compared to whole-mount radical prostatectomy histopathology maps to determine the sensitivity and accuracy in parametrically delineating prostate cancer.

Results: Representative data indicate spectral changes were associated with the presence of co-incident disease as located on correlative histopathology whole mount sections. Of the 10 patients enrolled, 7 have been analyzed and presented here. The mean % difference between 0-MHz and MBF, with H&E, was 14% (SD 38%) and 21% (SD 24%), respectively. Gross areas of disease were readily visualized in ultrasound parametric maps and corresponded to a maximum 10dB decrease in 0-MHz or MBF. Parametric maps generated from the spectral slope offered no discrimination of disease.

Conclusions: Initial results suggest that there is good correlation between spectroscopic maps with disease on whole-mount specimens. This method may ultimately permit ultrasound-guided targeted biopsies to improve detection rates and non-invasive assessment of disease for radiotherapy planning.

No significant financial relationships to disclose.

3rd US-EU workshop: systems level understanding of DNA damage responses

The 3rd US-EU Workshop on systems level understanding of DNA damage responses was held from March 30 to April 1, 2009 in Egmond aan Zee, The Netherlands. Objectives of the workshop were (1) to assess the current science of the DDR, in particular network level responses to chemotherapeutic and environmentally induced DNA damage; and (2) to establish the basis for a reciprocal scientific exchange program between the EU and US in the relevant areas of DDR research. Here, we report the highlights of the meeting program and conclude that this third meeting in 2009 refined the role of DDR networks in human disease.

Functional imaging of neoadjuvant chemotherapy response in women with locally advanced breast cancer using diffuse optical spectroscopy

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Background: Functional imaging with tomographic near infrared diffuse optical spectroscopy (DOS) can quantitatively measure tissue parameters such as the concentration of deoxy-hemoglobin (Hb), oxy-hemoglobin (HbO2), percent water (%water), and scattering power (SP). The purpose of this study was to evaluate the correlation between DOS functional parameters with pathologic outcomes. Methods: Patients with locally advanced breast cancer undergoing neoadjuvant chemotherapy or chemoradiotherapy were recruited to this study (n=10). Five scans were conducted per patient: a baseline scan taken up to 3 days prior to treatment and at 1 week, 4 weeks, 8 weeks, and after neoadjuvant treatment prior to surgery. Pulsed near-infrared laser light was used to scan the suspended breast at four different wavelengths and data was used for tomographic reconstruction. Volume-of-interest (VOI) weighted tissue Hb, HbO2, %water, and SP corresponding to the tumour was calculated and compared to pathological response as determined from full mount mastectomy specimens. Results: For all 10 patients the tumour-based VOI was significantly different than background tissue for all functional parameters (p<0.001). Five patients had a good pathologic response. Four patients were considered non-responders. One patient initially had a poor clinical response to chemotherapy but after a change in chemotherapy had a good clinical response. Responders and non-responders were significantly different for all of the functional parameters (p<0.05) at the 4 week scan. In the 5 patients with a good response the mean drop in Hb, HbO2, %water, and SP from baseline to the 4 week scan was 70.4% (SD=18.6), 66.5% (SD=24.5), 59.6% (SD=30.9), and 60.7% (SD=29.2), respectively. In contrast, the 4 non- responders had a mean drop of 17.7% (SD=9.8), 18.0% (SD=20.8), 15.4% (SD=11.7), and 12.6% (SD=10.2), for Hb, HbO2, %water and SP, respectively. Conclusions: Functional imaging using tomographic DOS parameters of Hb, HbO2, %water and SP could be used as an early detector of final pathologic tumour response. This could be evaluated in the future to assess response and potentially adjust chemotherapy regimens.

No significant financial relationships to disclose.

The NDR/LATS family kinase Cbk1 directly controls transcriptional asymmetry

Cell fate can be determined by asymmetric segregation of gene expression regulators. In the budding yeast Saccharomyces cerevisiae, the transcription factor Ace2 accumulates specifically in the daughter cell nucleus, where it drives transcription of genes that are not expressed in the mother cell. The NDR/LATS family protein kinase Cbk1 is required for Ace2 segregation and function. Using peptide scanning arrays, we determined Cbk1′s phosphorylation consensus motif, the first such unbiased approach for an enzyme of this family, showing that it is a basophilic kinase with an unusual preference for histidine −5 to the phosphorylation site. We found that Cbk1 phosphorylates such sites in Ace2, and that these modifications are critical for Ace2′s partitioning and function. Using proteins marked with GFP variants, we found that Ace2 moves from isotropic distribution to the daughter cell nuclear localization, well before cytokinesis, and that the nucleus must enter the daughter cell for Ace2 accumulation to occur. We found that Cbk1, unlike Ace2, is restricted to the daughter cell. Using both in vivo and in vitro assays, we found that two critical Cbk1 phosphorylations block Ace2′s interaction with nuclear export machinery, while a third distal modification most likely acts to increase the transcription factor's activity. Our findings show that Cbk1 directly controls Ace2, regulating the transcription factor's activity and interaction with nuclear export machinery through three phosphorylation sites. Furthermore, Cbk1 exhibits a novel specificity that is likely conserved among related kinases from yeast to metazoans. Cbk1 is functionally restricted to the daughter cell, and cannot diffuse from the daughter to the mother. In addition to providing a mechanism for Ace2 segregation, these findings show that an isotropically distributed cell fate determinant can be asymmetrically partitioned in cytoplasmically contiguous cells through spatial segregation of a regulating protein kinase.

Cells can differentiate by segregating molecules that direct expression of specific sets of genes to one of the two cells produced by division. This generally occurs by direct mechanical movement or asymmetric anchoring of these molecules, which act after division to influence gene expression. In this study, we define a different mechanism by which the budding yeast transcription regulator Ace2 is asymmetrically partitioned. We show that Ace2 moves from uniform distribution to strong accumulation in the daughter nucleus while mother and daughter cells are still connected, and that the enzyme Cbk1 directly controls this segregation by attaching phosphate to specific sites on Ace2. We also demonstrate that Cbk1 is restricted to the daughter cell. Using both biochemical and live-cell experiments, we show that the Cbk1-mediated modifications activate Ace2 and block its interaction with nuclear export machinery, trapping it in the daughter cell nucleus. In addition to demonstrating Cbk1′s remarkable biochemical similarity to related enzymes in multicellular organisms, our analysis shows that a uniformly distributed regulator of gene expression can be made asymmetrically active in connected cells through the direct action of a localized modifying enzyme.

A conserved protein kinase, Cbk-1, produces different gene expression programs in cytoplasmically connected cells by directly blocking nuclear export of the transcription factor Ace2.

Developing a methodology for three-dimensional correlation of PET-CT images and whole-mount histopathology in non-small-cell lung cancer

BACKGROUND

Understanding the three-dimensional (3D) volumetric relationship between imaging and functional or histopathologic heterogeneity of tumours is a key concept in the development of image-guided radiotherapy. Our aim was to develop a methodologic framework to enable the reconstruction of resected lung specimens containing non-small-cell lung cancer (NSCLC), to register the result in 3D with diagnostic imaging, and to import the reconstruction into a radiation treatment planning system.

METHODS AND RESULTS

We recruited 12 patients for an investigation of radiology-pathology correlation (RPC) in nsclc. Before resection, imaging by positron emission tomography (PET) or computed tomography (CT) was obtained. Resected specimens were formalin-fixed for 1-24 hours before sectioning at 3-mm to 10-mm intervals. To try to retain the original shape, we embedded the specimens in agar before sectioning. Consecutive sections were laid out for photography and manually adjusted to maintain shape. Following embedding, the tissue blocks underwent whole-mount sectioning (4-mum sections) and staining with hematoxylin and eosin. Large histopathology slides were used to whole-mount entire sections for digitization. The correct sequence was maintained to assist in subsequent reconstruction. Using Photoshop (Adobe Systems Incorporated, San Jose, CA, U.S.A.), contours were placed on the photographic images to represent the external borders of the section and the extent of macroscopic disease. Sections were stacked in sequence and manually oriented in Photoshop. The macroscopic tumour contours were then transferred to MATLAB (The Mathworks, Natick, MA, U.S.A.) and stacked, producing 3D surface renderings of the resected specimen and embedded gross tumour. To evaluate the microscopic extent of disease, customized "tile-based" and commercial confocal panoramic laser scanning (TISSUEscope: Biomedical Photometrics, Waterloo, ON) systems were used to generate digital images of whole-mount histopathology sections. Using the digital whole-mount images and imaging software, we contoured the gross and microscopic extent of disease. Two methods of registering pathology and imaging were used. First, selected pet and ct images were transferred into Photoshop, where they were contoured, stacked, and reconstructed. After importing the pathology and the imaging contours to MATLAB, the contours were reconstructed, manually rotated, and rigidly registered. In the second method, MATLAB tumour renderings were exported to a software platform for manual registration with the original pet and ct images in multiple planes. Data from this software platform were then exported to the Pinnacle radiation treatment planning system in DICOM (Digital Imaging and Communications in Medicine) format.

CONCLUSIONS

There is no one definitive method for 3D volumetric RPC in nsclc. An innovative approach to the 3D reconstruction of resected nsclc specimens incorporates agar embedding of the specimen and whole-mount digital histopathology. The reconstructions can be rigidly and manually registered to imaging modalities such as ct and pet and exported to a radiation treatment planning system.

Is mammography adequate for screening BRCA mutation carriers with low breast density?

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Background: Several large observational studies have demonstrated that magnetic resonance imaging (MRI) is much more sensitive than M (sensitivity 71–96% vs. 28–43%) for screening women > age 25 at high risk for hereditary breast cancer. However, MRI is much more costly and less specific than M. The extent to which the low sensitivity of M in these studies is due to the greater average breast density of younger women is unknown. Accordingly, we sought to determine the sensitivity of M and MRI according to breast density for the detection of breast cancer in a screening study of BRCA mutation carriers. Methods: Breast density was measured on the screening mammogram of the contralateral breast for all women who developed in-situ or invasive breast cancer on study. Density was measured in 2 ways: qualitatively according to the four categories characterized by the BIRADS system: 1) mostly fatty, 2) scattered fibroglandular tissue, 3) heterogeneously dense, 4) extremely dense; and semi-quantitatively using computer-aided techniques with subsequent classification as: A) ≤10%, B) 11–25%, C) 26%-50%, or D) >50% density. Results: Between 11/97 and 06/05 a total of 39 cases (12 in-situ and 27 invasive) were found in 36 mutation carriers (19 BRCA1 and 17 BRCA2). Mean age of the women with cancer was 48 (range 34 to 64). Average semi-quantitative breast density for BRCA1 mutation carriers was 28% and for BRCA2 was 27%. Sensitivity of M vs. MRI for in-situ cases was 25% vs. 83%, and for invasive cases was 30% vs. 93%. Sensitivities for BRCA1 and BRCA2 mutation carriers were similar. For BIRADS 1 to 4 respectively M detected 1/3 (33%), 5/11 (45%), 4/22 (18%), and 1/3 (33%) of cases; and for density groups A to D respectively detected 2/6 (33%), 7/15 (47%), 1/11 (9%) and, 1/7 (14%). Conclusion: Although there was a trend towards decreasing mammographic sensitivity with increasing density, even among BRCA mutation carriers with low breast density mammography is an inadequate screening tool.

No significant financial relationships to disclose.

Epidemiologic and clinical characteristics of children with newly diagnosed inflammatory bowel disease in Wisconsin: a statewide population-based study

OBJECTIVE

To define epidemiologic and clinical characteristics of newly diagnosed pediatric inflammatory bowel disease (IBD) in a large population-based model.

STUDY DESIGN

All pediatric gastroenterologists providing care for Wisconsin children voluntarily identified all new cases of IBD during a 2-year period. Demographic and clinical data were sent to a central registry prospectively for analysis.

RESULTS

The incidence of IBD in Wisconsin children was 7.05 per 100,000, whereas the incidence for Crohn's disease was 4.56, more than twice the rate of ulcerative colitis (2.14). An equal IBD incidence occurred among all ethnic groups, and children from sparsely and densely populated counties were equally affected. The majority (89%) of new IBD diagnoses were nonfamilial.

CONCLUSIONS

This study provides novel, prospective, and comprehensive information on pediatric IBD incidence within the United States. The surprisingly high incidence of pediatric IBD, the predominance of Crohn's disease over ulcerative colitis, the low frequency of patients with a family history, the equal distribution of IBD among all racial and ethnic groups, and the lack of a modulatory effect of urbanization on IBD incidence collectively suggest that the clinical spectrum of IBD is still evolving and point to environmental factors contributing to the pathogenesis.

The detection of change in mammographic density

Mammographic density is associated with risk of breast cancer, and factors that change density may also change risk. There has, however, been little research into how change in serial mammograms is best detected. The purpose of the work described here was to examine the effects of different reading conditions on the detection of change in mammographic features. Mammograms were selected from women who had participated in a randomized controlled trial of screening for breast cancer. We selected two age-matched groups of subjects, one had undergone menopause after entry (n = 202) and another who had not (n = 202). Serial mammograms from these subjects were then measured four times using a computer-assisted method under different conditions: (a) films were randomized; (b) subjects were randomized (i.e., pairs of films from individuals were read one after the other), but the order of films was random and unknown to the reader; (c) subjects were randomized, and the order of films was sequential and known to the reader; and (d) subjects were randomized, and the order of films was random and unknown to the reader, but both films in each pair were read simultaneously on separate computer screens. The mean effect of the menopause on change in the mammographic measures of total, dense and nondense areas, percent density, and the associated variances were then compared. With one exception, all of the randomization and viewing methods confirmed a change in all mammographic measures at menopause and produced very similar overall results, suggesting that mammographic density is a robust measure. Compared with randomization of all films, the method in which subjects were randomized and paired films read one after the other in random and unknown order was associated with a slightly smaller mean difference and achieved a substantial reduction in variability, suggesting that it is the most sensitive method of randomization and viewing for the detection of change.

The association of breast mitogens with mammographic densities

Radiologically dense breast tissue (mammographic density) is strongly associated with risk of breast cancer, but the biological basis for this association is unknown. In this study we have examined the association of circulating levels of hormones and growth factors with mammographic density. A total of 382 subjects, 193 premenopausal and 189 postmenopausal, without previous breast cancer or current hormone use, were selected in each of five categories of breast density from mammography units. Risk factor information, anthropometric measures, and blood samples were obtained, and oestradiol, progesterone, sex hormone binding globulin, growth hormone, insulin-like growth factor-I and its principal binding protein, and prolactin measured. Mammograms were digitised and measured using a computer-assisted method. After adjustment for other risk factors, we found in premenopausal women that serum insulin-like growth factor-I levels, and in postmenopausal women, serum levels of prolactin, were both significantly and positively associated with per cent density. Total oestradiol and progesterone levels were unrelated to per cent density in both groups. In postmenopausal women, free oestradiol (negatively), and sex hormone binding globulin (positively), were significantly related to per cent density. These data show an association between blood levels of breast mitogens and mammographic density, and suggest a biological basis for the associated risk of breast cancer.

Gestational breast cancer

OBJECTIVE

To study the problems of breast imaging in gestational breast cancer.

PATIENTS AND METHOD

Retrospective review of the charts of 19 patients with breast cancer detected during pregnancy or lactation or within 1 year of delivery, who were referred to a tertiary centre for adjuvant therapy between 1986 and 1996. For 10 patients who underwent breast imaging, mammograms and breast ultrasonograms or reports were requested from outside facilities.

RESULTS

The patients ranged in age from 23 to 41 years (mean 31 years). All 19 patients presented with palpable tumours; in 7 patients, the tumours were stage T2 or higher; in 11 patients, the tumours were at an advanced stage with positive axillary nodes. In 11 of the patients there was a delay in diagnosis, which ranged from 2 to 16 months. Of the 8 mammograms that could be reviewed, 5 showed infiltrating ductal carcinomas with typical features, which were detected as a mass (in 1 case), a mass with microcalcifications (in 1 case), microcalcifications (in 2 cases) and asymmetry (in 1 case). Three mammograms were negative, including 1 obtained from a patient with extensive comedocarcinoma. Breast ultrasonograms obtained from 4 patients (2 of whom also had mammograms) showed solid hypoechoic masses; in 2 of the ultrasonograms, the masses simulated a benign lesion.

CONCLUSIONS

Although breast cancer during pregnancy and lactation is rare, this study suggests that radiologists should include it in the differential diagnosis of a solid breast mass seen during pregnancy or lactation. Clinicians appear to be reluctant to use breast imaging in these patients; however, this can lead to a delay in diagnosis. Ultrasonography is the modality of choice for initial analysis of such a mass in this age group. Mammography with shielding of the abdomen is recommended if there is suspicion of cancer. Clinical, mammographic and sonographic findings should be integrated for optimum interpretation.