Gravitational Reflux Does Not Correlate with Clinical Status of Venous Stasis

Objective:

To quantify venous reflux by a standard duplex ultrasound technique and correlate the data obtained with clinical grades of severity of venous disease.

Design:

A prospective study in a single group of patients with venous insufficiency.

Setting:

Private practice in secondary and tertiary care.

Patients:

133 inpatients undergoing investigation for venous disease. Patients with known venous obstruction, arterio-venous malformations or lymphoedema were excluded from the study.

Main outcome measures:

Duplex ultrasound scanning was performed to measure the cross-sectional area, severity and duration of venous reflux following calf compression using a standardized technique.

Results:

Clinical classification assigned to each limb correlated with the presence of venous reflux, but not the quantity, velocity or duration of reflux in the veins studied. Presence of reflux and diameter of the vein studied correlated ( p<0.001) in all the veins except the popliteal vein ( p > 0.03).

Conclusion:

Quantification of venous reflux obtained by cuff deflation does not correlate with clinical severity of venous stasis, but does detect reflux accurately. This allowed greater saphenous sparing in nine limbs in 41 patients but proved the need for saphenous removal in seven limbs not previously suspected clinically of requiring this procedure.

Abstract P6-10-04: Factors determining underutilization of core biopsy prior to breast surgery

BACKGROUND:

The American College of Surgeons National Accreditation Program for Breast Centers, Standard 2.9, requires a palpation-guided or image-guided needle biopsy as the initial diagnostic approach for breast cancer rather than an open biopsy. In replacing excisional biopsies, this minimally invasive technique demonstrates accuracy and precision in determining tumor characteristics and allows for more optimal breast cancer care. Recent studies have suggested that needle biopsy is underused in the United States. In a recently published analysis of U.S. Medicare data from 2003-2007, needle biopsy was used in 68.4% of all patients with breast cancer surgery. In this single-institution study, we analyzed the utilization of image-guided preoperative breast biopsies and which patient and system related factors contributed to the underutilization of image-guided breast biopsies and clinical outcomes.

MATERIALS AND METHODS:

In this retrospective study, we analyzed all breast cancer cases diagnosed over a four year period at Mount Sinai Medical Center (MSMC) from January 1, 2009 to December 31, 2013 (n=485). We performed a detailed chart review of the surgical cases that did not meet breast biopsy standards to identify contributing patient and surgeon level factors. Descriptive statistics and univariate analysis were used to characterize breast biopsy patterns and outcomes as well as delineate the associations between patient and surgical covariates with needle biopsy receipt.

RESULTS:

Needle biopsy was used in 86% (n=419) of all breast cancer surgeries. The median age for the cohort of patients without needle biopsy was 68.0 years (range 35-94). There was no significant variation in utilization of needle biopsy by race or surgeon. The proportion of patients without needle biopsy decreased significantly over time from 2009-2013. The most common reason for the lack of preoperative breast biopsy was the surgeon's preference to proceed with surgery because of very suspicious imaging studies (including mammograms and MRI) (n=9). There were an additional nine cases where the biopsy was attempted but was non-diagnostic. The most common patient-related factors for lack of needle biopsy were advanced age, use of anticoagulation and noncompliance due to a psychiatric diagnosis and patient discomfort. Other factors identified include lack of surgeon consultation before biopsy, biopsy of axillary lymph nodes as a means of diagnosis and patient's inpatient status.

CONCLUSIONS:

In this single institution, the rate of needle biopsy for breast cancer diagnosis was above national benchmarks. The most common reason for lack of a preoperative breast biopsy was the surgeon's preference to proceed with surgery because of very suspicious imaging studies. Patients with advanced age, psychiatric history, and inpatient workup were also more likely to lack a preoperative breast biopsy.

Citation Format: Fan T, Paramo J, Mesko T, Poppiti R, Ruiz A, Rodriguez E. Factors determining underutilization of core biopsy prior to breast surgery. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P6-10-04.

Atosiban vs ritodrine used prophylactically with cerclage in ICSI pregnancies to prevent pre-term birth in women identified as being at high risk on the basis of transvaginal ultrasound scan

Our objective was to compare the effectiveness and safety of atosiban and ritodrine, in pregnancies obtained by intracytoplasmic sperm injection (ICSI) undergoing cervical cerclage. Data from a prospective study were compared with those from a retrospective study. Sixteen ICSI pregnant women, 20-24 weeks' gestation and maternal age >18 years, received atosiban (bolus dose 6.75 mg i.v., followed by 300 microg/min i.v. for 3 h and 100 microg/min i.v. for 45 h). Cervical cerclage was performed 3 h after starting atosiban. The control group (group B) of 16 ICSI pregnant women were matched and received ritodrine hydrochloride (100-350 microg/min) for 48 h. Cervical cerclage was performed after 24 h. Pre-term rupture of membranes occurred within 48 h of cervical cerclage in one woman receiving atosiban and in four women receiving ritodrine. There was no significant difference in terms of pregnancies not delivered at 48 h (short-term tocolysis) and at 7 days (long-term tocolysis). However, there was a significantly higher incidence of maternal tachycardia with ritodrine compared with atosiban (p < 0.001). The mean gestational age at delivery was significantly higher for atosiban compared with ritodrine (36 vs 33 weeks; p < 0.001). The neonatal outcome was poorer for ritodrine than atosiban, as there were very low birth weight infants (p = 0.008), resulting in lower Apgar scores (p = 0.005) and there were more neonates requiring a long stay in the neonatal intensive care unit (p = 0.005). We conclude that atosiban is associated with a significantly lower incidence of maternal tachycardia and improved neonatal outcome compared with ritodrine.

Intraoperative sentinel lymph node mapping in patients with colon cancer

BACKGROUND

The sentinel lymph node (SLN) mapping technique has been used in breast cancer and melanoma, and was recently described for colon cancer.

METHODS

Thirty-five patients with colon cancer underwent intraoperative SLN mapping. One milliliter of 1% isosulfan blue was injected subserosally around the tumor. The first nodal area that was highlighted with blue was identified as the SLN. All lymph nodes underwent examination with hematoxylin and eosin (H&E) stain. SLNs underwent additional sectioning and were stained with CAM 5.2.

RESULTS

Lymphatic mapping adequately identified the SLN in 25 patients (71%). In the 15 cases where the SLNs were negative for metastases, all other non-SLNs were also negative (0% false negative rate). The SLN was the only site of metastases in 6 (17%) of 35 patients. CAM 5.2 staining provided the only evidence of micrometastases in 4 (11%) of 35 patients.

CONCLUSIONS

Intraoperative SLN mapping is a feasible technique with a reasonable SLN identification rate (71%). The absence of metastases in the SLNs accurately predicts the status of the non-SLNs. Tumors in 11% of patients were upstaged by the demonstration of micrometastatic involvement, and these patients may benefit from further adjuvant chemotherapy.

Recurrent umbilical cord torsion leading to fetal death in 3 subsequent pregnancies: a case report and review of the literature

During a span of 3.5 years, a 30-year-old, gravida 9, para 3 woman experienced 3 pregnancies complicated by umbilical cord torsion and constriction. In each case, the complication resulted in acute vascular compromise and intrauterine fetal demise. Gross examination disclosed cord constriction and torsion at the fetal end of the cord in each instance. Histologic sections from the cord torsion sites demonstrated fibrosis and deficiencies in Wharton's jelly in each case. Cytogenetic studies prepared using fetal villous tissue demonstrated normal karyotypes in fetal cells from the first 2 pregnancies (46,XX and 46,XY, respectively). The karyotype from the third pregnancy showed a 46,XX,del(X)(q24) mutation in 3 of 15 cultured cells, while 12 of 15 cells possessed a normal 46,XX karyotype. This cytogenetic abnormality was not believed to represent the cause of fetal demise in this case. To our knowledge, this is the first report of umbilical cord torsion in 3 pregnancies within one family. The familial clustering observed in this report suggests that a genetic predisposition for umbilical cord torsion may exist in some cases.

Hemodynamic effects of transurethral alprostadil measured by color duplex ultrasonography in men with erectile dysfunction

PURPOSE

We evaluated the hemodynamic effects of transurethral alprostadil in 21 patients with erectile dysfunction using color duplex ultrasonography.

MATERIALS AND METHODS

Penile arterial diameter, peak flow velocity and end diastolic velocity were compared following intraurethral administration of 500 microg. alprostadil and intracavernosal injection of 10 microg. alprostadil.

RESULTS

A dose of 500 microg. transurethral alprostadil resulted in significant increases in corporeal blood flow comparable to those achieved with intracavernosal injection of 10 microg. alprostadil as measured by duplex ultrasonography in men with erectile dysfunction. Transurethral alprostadil resulted in statistically significant increases in arterial diameter and peak flow velocity comparable to those achieved with intracavernosal injection. End diastolic velocities were higher after transurethral alprostadil than intracavernosal injections. Color ultrasonography following transurethral alprostadil showed arterial and venous hyperemia of the corpus spongiosum and corpora cavernosa. Furthermore, color ultrasonography revealed communicating vessels between the corpus spongiosum and corpora cavernosa following administration of transurethral alprostadil.

CONCLUSIONS

The visualization of communicating vessels between the corpus spongiosum and corpora cavernosa after transurethral alprostadil suggests local mechanisms of drug transfer from one to the other. In addition to potential clinical benefits, transurethral alprostadil may be useful to visualize the vascular anatomy of the penis and to test for patient responsiveness to local vasoactive agents.

Upper extremity blood flow in collegiate and high school baseball pitchers A preliminary report

The arterial and venous volume blood flow in the dominant and nondominant upper extremities of five male pitchers, ages 16 to 21, was measured using color flow duplex ultrasound. Blood-flow measurements were obtained at baseline, after warm-up, and after each sequence of 20 pitches until 100 pitches were thrown. Blood flow was additionally determined 1 hour after the last pitch. The velocity of each pitch was recorded with a speed gun. Anthropomorphic measurements of the upper extremity were obtained at baseline and immediately after Pitch 100 using a standard measuring tape. The highest average arterial volume flow in the pitching arm occurred after 40 pitches, reaching a peak of 549 ml/min (56% increase from baseline). Thereafter, the average arterial blood flow steadily declined, reaching an average of 402 ml/min after the 100th pitch (14% increase from baseline). In contrast, the arterial blood flow in the nonpitching arm increased only slightly from baseline, reaching a maximal volume flow of 448 ml/min immediately after the warm-up period (10% increase from baseline). The volume flow then persistently fell to a level 30% below baseline after the 100th pitch. Although this small pilot study does not demonstrate causation between a decline in pitching performance and arterial blood flow, it suggests arterial flow in the dominant extremity falls as the pitch count increases.

Limited B-mode venous imaging versus complete color-flow duplex venous scanning for detection of proximal deep venous thrombosis

PURPOSE

The purpose of this study was to compare the accuracy of a limited B-mode compression technique (BMCT) with a complete color-flow duplex venous examination (CDVE) for the detection of proximal deep vein thrombosis (DVT).

METHODS

We prospectively studied 72 patients (20 men and 52 women) for DVT. Two technologists blinded to each other performed either BMCT or CDVE independently. The BMCT is an abbreviated technique compressing two sites per limb. One site was the saphenofemoral junction including the superficial femoral and deep femoral vein confluence; the other was the saphenopopliteal junction including tibial vein confluence. Total limbs studied were 144. CDVE was considered the gold standard for purposes of sensitivity, specificity, and accuracy.

RESULTS

The technical failure rate of BMCT was three of 144. In all technically satisfactory examinations, the BMCT result was positive in 15 of 14 limbs, and the CDVE result was positive in 13. Sensitivity of BMCT was 100%, specificity was 98%, and overall accuracy was 99%. There were two false-positive results with BMCT; both were cases of popliteal veins deep to the artery leading to difficulty in compression. The BMCT was able to detect chronic thrombus, floating thrombus, and small thrombus behind femoral vein valve cusps.

CONCLUSION

These data suggest that BMCT is a rapid, acceptable, alternative technique for detecting proximal DVT. In cases of equivocal or positive findings, the spectral and color-flow Doppler examination should be used to confirm the results.

Angiotensin II increases glucose utilization during acute hyperinsulinemia via a hemodynamic mechanism

To determine whether hemodynamic changes can modulate insulin action in vivo, we administered angiotensin II (AII) to normal men under three separate, euglycemic conditions. First, in the presence of physiological hyperinsulinemia (approximately 115 microU/ml), infusion of AII at rates of 2, 10, and 20 ng/min per kg caused significant elevations of blood pressure, whole-body glucose clearance, and plasma insulin concentrations in an AII dose-dependent manner. Second, in the presence of plasma insulin concentrations that stimulate glucose transport maximally (approximately 5,000 microU/ml), AII infusions increased whole-body glucose clearance without enhancing glucose extraction across the leg. Third, in the presence of basal insulin concentrations (approximately 13 microU/ml), AII infusions had no effect on whole-body glucose turnover or leg glucose extraction. Thus, AII enhanced whole-body glucose utilization without directly stimulating glucose transport in a major skeletal muscle bed. To evaluate a possible hemodynamic mechanism for the effects of AII on glucose utilization, we measured blood flow to two areas that differ in their sensitivity to insulin: the kidneys and the leg. We found that AII redistributed blood flow away from the predominantly insulin-independent tissues of the kidney and toward the insulin-sensitive tissues of the leg during both sham and hyperinsulinemic glucose clamps. The redistribution of flow had no effect on whole-body glucose turnover when leg glucose uptake was unstimulated (sham clamps). However, when leg glucose uptake was activated by insulin, the redistribution of flow caused a net increase in whole-body glucose utilization. Our findings indicate that hemodynamic factors can modulate insulin action in vivo. Furthermore, our results suggest that variable activity of the renin-angiotensin system may contribute to inconsistencies in the association between insulin resistance and hypertension.

Clear cell myoepithelial neoplasm of the breast

Primary clear cell tumors of the breast are rare neoplasms. Traditionally, their differential diagnosis has included lipid-rich, glycogen-rich, and secretory carcinomas of the breast. Although clear cell myoepithelial tumors of the salivary gland and skin have been reported, a primary clear cell myoepithelial carcinoma of the breast has not been previously described. We report a case of clear cell myoepithelial neoplasm of the breast showing an infiltrative histologic growth pattern highly suggestive of carcinoma. Electron microscopy showed evidence of myoepithelial differentiation manifested by cytoplasmic microfilaments with randomly dispersed fusiform densities in conjunction with specialized membrane junctions and remnants of basal membrane. Immunohistologically, the tumor cells were positive for actin, keratin, and S-100 protein. This tumor should be included in the differential diagnosis of the clear cell neoplasms of the breast.

Fine needle aspiration of the lung: a study of 53 consecutive cases

We reviewed our fine needle aspirations of the lung and chest on 53 consecutive patients from January 1979 through June 1982. Almost all of the patients had been studied by sputum and bronchial cytology and many by bronchial or transbronchial biopsy, but none of the patients had a definitive diagnosis. All of the lung aspirates were done in the department of radiology, using a 22 gauge Chiba disposable needle and the Wright-Giemsa stain. Twenty-four cases (45%) were diagnosed as malignant and ten cases (19%) were considered suggestive. Nineteen cases (36%) were read as negative for malignant cells, but in six of these cases (11% of total) we were able to make the diagnosis of an infectious process based on characteristic cytologic findings.

Tunga penetrans in south Florida

We have described a 25-year-old man with infestation of the feet by the burrowing flea Tunga penetrans, acquired in Brazil. We have also presented the microscopic characteristics of the flea and the histologic differential diagnosis.

Malignant mesenchymoma of kidney and inferior vena cava

Herein is reported the first known case of malignant mesenchymoma involving the kidney and secondarily the vena cava in an adult. A thirty-nine-year-old woman succumbed to this malignancy within three months after the diagnosis was established, despite multimodal therapy.