Is mammography of value in women with disseminated cancer of unknown origin?

Mammography is often requested to try to identify occult primary breast carcinoma in women with metastatic cancer of unknown primary site. This study aimed to investigate whether mammography is of use in these patients in identifying the breast as the origin of the metastatic disease. Thirty-one women with a working diagnosis of metastatic cancer underwent mammography in an attempt to determine the primary site. None of these women had a palpable breast mass. The site of presentation, pathological type of tumour, site of origin, and benefit of mammography and mammography-provoked biopsy were clarified for each patient. The patients were also followed up to determine survival. The commonest sites of presentation were lung (45%), lymph nodes (19%) and abdomen (16%). The primary sites of these cancers were identified with confidence in 27 patients (87%). The commonest known primary tumour sites were lung (45%), breast (16%) and ovary (16%). Abnormal mammograms were detected in four patients (13%), but three of these did not have breast cancer. In one, the site of origin remained indeterminate, as either breast or lung. Five (16%) had a confident diagnosis of breast carcinoma; all of these women had normal mammograms. We conclude that mammography in women presenting with metastatic disease from an unknown primary site is unhelpful and is not recommended. Furthermore, we could not demonstrate its value in women presenting with axillary lymphadenopathy.

Ductal carcinoma in situ of the human breast: clinico-pathological aspects

The apparent increase of incidence of DCIS is related to the development of mammographic screening programs and requires an effort of diagnostic, classification and treatment revision. The same natural history of the DCIS is still poorly known, and the phases of its evolution are supposed essentially on epidemiologic and statistics bases. The efforts for a classification are aimed to the search of a prognostic meaning: nuclear grading and possible invasive evolution; association of nuclear grading and necrosis. Both are correlated with local recurrence and free interval. The finding of micro-calcifications is the basis of the instrumental mammographic diagnosis; the possible isolated and unique finding encourages choices of conservative surgery. But as the less large lesions are as a rule of higher grade than those more extended, there are the treatment can be puzzling. As a consequence in fact the former are exposed to wider resections than the last ones. The DCIS is also characterized in its post-surgical evolution from the borders of the excision, from the pathologic classification, from the nuclear degree and from the dimensions of the lesion. In the more favourable conditions the surgical excision represents an adequate treatment. The radiotherapy finds his role in the more elevated degrees and in the case of incomplete excision, also if only presumptive. The alternative is the reoperation and the mastectomy.

Pulmonary tuberculosis: radiological features in west Africans coinfected with HIV

A retrospective study was performed to document and compare the radiological appearances of newly diagnosed pulmonary tuberculosis (PTB) in groups of West African patients with (n = 86) and without (n = 106) human immunodeficiency virus (HIV) coinfection. Analysis of chest radiographs showed that the HIV-positive group had less consolidation (mean 3.1 zones vs 3.7 zones; p < 0.05), less apical involvement (64.0% vs 85.5%; p < 0.001), less bronchopulmonary spread (27.9% vs 58.5%; p < 0.001), less volume loss (53.5% vs 76.4%; p < 0.001) and less pleural thickening (46.5% vs 61.3%; p < 0.05) compared with the HIV-negative group. However, HIV-positive patients more commonly had pleural effusions (17.4% vs 6.6%; p < 0.05) and lymphadenopathy (9.3% vs 1.9%; p < 0.05). Previous studies on this subject from sub-Saharan Africa have focused either on selected patient groups likely to have more advanced immunosuppression or on smear-positive cases only, or where there has been only limited radiological documentation. This study suggests that the highly significant differences that exist may not be as frequent as previously shown. The lower frequencies of bronchopulmonary pattern of consolidation and pleural thickening in HIV-positive subjects have not previously been documented. The possible reasons for the altered radiographic appearance of PTB in HIV positive subjects are discussed.

Fibroadenomatoid hyperplasia: a cause of suspicious microcalcification on mammographic screening

OBJECTIVE

Fibroadenomatoid hyperplasia is a well-described but rare benign breast lesion with composite features of fibroadenoma and fibrocystic change. Because fibroadenomatoid hyperplasia has not to our knowledge been reported as a cause of suspicious microcalcifications and because several pathology reports of biopsies of mammographically detected microcalcification at our institution included fibroadenomatoid hyperplasia, we undertook this study to describe the features of mammographically detected microcalcification seen in patients with fibroadenomatoid hyperplasia.

MATERIALS AND METHODS

Two breast pathologists reviewed the records of 54 mammographically detected lesions that were compatible with a diagnosis of fibroadenomatoid hyperplasia and that provoked subsequent core biopsy or surgical excision of microcalcifications. Eleven cases (20%) fulfilled the diagnostic criteria for fibroadenomatoid hyperplasia. The sites of all calcifications found at histology were documented, and the mammographic features were described.

RESULTS

Eleven cases of fibroadenomatoid hyperplasia were identified in nine core biopsy samples and two surgical specimens. Calcification was present in all 11 pathologic specimens. Calcification was stromal in nine, subepithelial in two, and epithelial in none. The mammographic features of fibroadenomatoid hyperplasia in all 11 cases were granular microcalcifications that varied in shape, size, and density and had no associated mass; of these calcifications, 91% were in a localized, irregularly shaped cluster. Rod-shaped calcifications were also seen in 64% of cases.

CONCLUSION

Fibroadenomatoid hyperplasia is a cause of suspicious, granular, clustered microcalcifications on screening mammography. Fibroadenomatoid hyperplasia can be confirmed using 14-gauge core biopsy in most cases.

Effects of systemic heparinization on the thrombogenicity of hydrophilic and nonhydrophilic catheters in a swine model

We assessed the effect of systemic heparinization on the in-vivo thrombogenicity of various micro- and guiding catheters in a swine model. Microcatheters were placed through 6-F guiding catheters into the common carotid arteries of swine for 30-min (short-term) and 90-min (medium-term) periods, with and without systemic heparinization. At the end of the placement period the microcatheters were retracted through the guiding catheters and fixed for scanning electron microscopy (SEM). Guiding catheters were harvested after 5 h placement, with and without systemic heparinization, by retraction through 8-F sheaths and fixed for SEM. The surfaces of both hydrophilic and nonhydrophilic microcatheters all demonstrated more accumulation of debris during placement without than with systemic heparinization. The difference was primarily in the amount of fibrillary material on the catheter surface. The guiding catheters also demonstrated increased debris accumulation without systemic heparinization. This suggests that, even when using relatively nonthrombogenic catheters, systemic heparinization is indicated during cerebral angiography.

In vivo evaluation of a new type I collagen hemostatic plug for high-risk, large-core biopsies

PURPOSE

To evaluate in a swine model the hemostatic properties of a new, expansile type I collagen plug for use in high-risk renal biopsies.

MATERIALS AND METHODS

Highly purified bovine type I collagen was formed into porous cylindrical plugs and compressed radially to fit into a 5-F delivery system. On hydration these collagen plugs demonstrated radial expansion with approximately 1,600% volumetric expansion ratio. Direct exposure of both kidneys was performed in a 25-kg swine, and a bolus of 3,000 U of heparin was administered to create a coagulopathic state. A 14-gauge Temno coaxial biopsy gun was utilized in performing nine pairs of renal biopsies. The first biopsy of each biopsy pair represented the control biopsy (without collagen plug placement), whereas the second biopsy of each pair represented the plugged biopsy. The presence and duration of hemorrhage from each biopsy site was monitored visually.

RESULTS

The biopsy sites without collagen plug showed immediate hemorrhage in nine of nine cases (100%), and in two of nine cases (22%) pulsatile bleeding was noted. With the use of the collagen plug, seven of nine (78%) sites showed immediate hemorrhage, but in no case was pulsatile bleeding noted. Mean bleeding duration was 156 seconds for the control biopsies versus 73 seconds for the biopsy sites plugged with collagen (P = .03, Mann-Whitney rank sum test). Bleeding duration was less than 1 minute in only one of nine (11%) control biopsies compared to six of nine (67%) collagen plug biopsies.

CONCLUSIONS

A recently developed, expansile collagen hemostatic plug significantly decreases the duration of hemorrhage at renal biopsy sites in an anticoagulated swine model.

The accuracy of breast ultrasound in the evaluation of clinically benign discrete, symptomatic breast lumps

INTRODUCTION

Recent reports have suggested that breast ultrasound (US) is of value in distinguishing malignant from benign processes. The aim of this study was to establish the accuracy of US in detecting invasive malignancy in clinically benign, discrete, symptomatic breast lumps.

METHODS

The US appearances of 205 clinically benign breast masses were documented prospectively and prior to mammography by one radiologist (AJE). The US appearances were then correlated with the fine needle aspiration (FNA), core biopsy and surgical findings and compared with the mammographic findings.

RESULTS

The US findings were normal 72 (35%), simple cyst 63 (31%), solid benign 51 (25%), solid indeterminate 15 (7%) and solid malignant four (2%). Ultrasound characterized 13 (93%) of the 14 patients found to have invasive carcinoma as indeterminate or malignant. No patients with normal or simple cyst US findings had invasive malignancy. Ultrasound had significantly better accuracy (97% vs 87%, P < 0.02) sensitivity (93% vs 57%, P < 0.05) and negative predictive value (99% vs 92%, P < 0.002) than mammography in the detection of invasive carcinoma when indeterminate and malignant imaging findings were taken as positive.

CONCLUSION

US is a useful adjunct to FNA/core biopsy in confirming the nature of symptomatic, clinically benign breast masses and is superior to mammography in this clinical setting.

Screening women aged less than 50 years with a family history of breast cancer

Family history is an important breast cancer risk factor and is a common reason for referral to specialist breast clinics for consideration of breast screening. The aims of this study were to determine cancer detection rates and prognostic features of breast cancers identified in women aged less than 50 years at increased risk of breast cancer who attend a Family History Breast Screening Clinic (FHC). Between January 1988 and December 1995, 1371 asymptomatic women aged less than 50 years underwent annual clinical breast examination and biennial mammography due to a family history of breast cancer. A total of 29 cancers (23 invasive and 6 in situ) were detected or presented as interval cancer during a mean follow-up of 22 months (range 0-96 months). This gave a relative risk for invasive breast cancer in this high-risk group of 5 when compared with an age-matched female population in the U.K. The cancer screening detection rates were similar to those of women aged 50 years or over undergoing population screening in the NHS Breast Screening Programme (NHSBSP)--FHC prevalent screen 8 per 1000 screening visits versus NHSBSP 6.5 per 1000, FHC incident screen 3.3 per 1000 screening visits versus NHSBSP 3.8 per 1000. A higher proportion of in situ cancers were detected in the FHC screened group compared with cancers identified in symptomatic patients from an age-matched risk group (21% versus 4%). No differences were demonstrated for invasive tumour size, grade or lymph node stage between symptomatic and screened women. The early results of this study suggests that young women at risk of breast cancer due to a family history may benefit from regular breast screening due to the early detection of in situ lesions.

Endogenous insulin and insulin sensitivity. An important determinant of skeletal muscle blood flow in chronic heart failure?

AIM

Patients with heart failure have a reduced sensitivity to insulin's actions on glucose metabolism and a compensatory increase in endogenous plasma insulin levels. As insulin has a selective vasodilatory action in skeletal muscle, we have studied the association between insulin sensitivity and central and regional haemodynamics in patients with heart failure.

METHODS

Ten patients with stable symptomatic heart failure were studied. We used non-invasive techniques to measure cardiac output, forearm blood flow, superior mesenteric artery blood flow and right renal artery blood flow. Blood samples were assayed for noradrenaline, renin and atrial natriuretic peptide levels. Insulin sensitivity was assessed using the low dose short insulin tolerance test.

RESULTS

There was a significant inverse correlation between forearm blood flow and insulin sensitivity (r = -0.67, P = 0.03), patients with lesser degrees of insulin sensitivity having the greater forearm blood flows. There was no correlation with the other haemodynamic or neurohumoral parameters. Patients with greater insulin resistance tended to have higher circulating endogenous insulin levels, although this relationship did not reach statistical significance (r = -0.53, P = 0.12).

CONCLUSIONS

Insulin sensitivity appears to be an important determinant of skeletal muscle blood flow in heart failure. We speculate that this is secondary to the increased circulating endogenous insulin levels, and suggest that the therapeutic potential of exogenous insulin merits further investigation.

Hemorrhagic complications in embolization of a meningioma: case report and review of the literature

We report a case of hemorrhage in a parasellar meningioma shortly after embolization of the dural cavernous carotid artery branches supplying the tumor. This represents the first report of hemorrhage within a meningioma resulting from embolization with small (50 to 150-microns) polyvinyl alcohol particles, as well as the first reported case of hemorrhage complicating meningioma embolization from internal rather than external carotid artery branch embolization. We also review previously reported cases of postembolization hemorrhage from meningiomas.

Radiological features of papillary carcinoma of the breast

Seventeen patients with papillary carcinoma of the breast were analysed with respect to the radiological findings by three experienced breast radiologists. The most frequent mammographic appearance of papillary tumours was of an ill-defined (70%) and lobulated (60%) mass and at ultrasound as a well-defined (76%), inhomogeneous (62%) and hypoechoic (92%) lesion. Histopathological subtypes of encysted papillary carcinoma, encysted papillary carcinoma with an invasive focus and invasive papillary carcinomas could not be predicted from the radiological features, although invasive tumours tended to be larger at presentation than the other subtypes.

Incidental detection of an aortic valve papillary fibroelastoma by echocardiography in an asymptomatic patient presenting with hypertension

Papillary fibroelastomas are rare, frond-like tumours of uncertain etiology seen on cardiac valves, uncommonly found antemortem. They carry a significant risk of embolization, making their detection and excision during life an important issue. A case of an aortic valve papillary fibroelastoma is described, which was found at echocardiography in a patient being assessed for previously unrecognized, severe hypertension.

Women's satisfaction with medical abortion with RU486

The combination of RU486 (mifepristone) and prostaglandin analogues has been used for medical abortion in several European centres. We surveyed 41 Australian women who successfully used this method of abortion in a World Health Organization-sponsored trial. Overall, the women were satisfied with the method and found the associated pain level acceptable.

Diagnosis and prognosis of primary breast cancer

The diagnosis of breast cancer should be made in the context of a multidisciplinary team: preoperative diagnosis can be made in over 90% of patients with symptomatic and screen-detected cancers. A preoperative diagnosis allows patients the opportunity to come to terms with the diagnosis of breast cancer and to consider their treatment options before progressing to therapeutic surgery. Surgery remains the primary therapeutic treatment for operable breast cancer with radiotherapy and systemic therapies as adjuvant treatments. Surgery in addition provides pathological specimens from which important prognostic information may be obtained. The traditional TNM classification in itself is no longer sufficient although there is still considerable prognostic information to be gained in staging patients. However, markers of tumour biology provide prognostic data independent of TNM staging. Both need to be considered in any overall assessment of patient prognosis.

Thrombogenicity of hydrophilic and nonhydrophilic microcatheters and guiding catheters

PURPOSE

To assess in a swine model the in vivo thrombogenicity of various microcatheters and guiding catheters as a function of catheter material, catheter coating, and duration of implantation.

METHODS

Microcatheters (Tracker 18 and Fastracker 18, Target Therapeutics, Fremont, Calif; Magic 1.8, Balt, Montmorency, France; and Transit, Cordis Endovascular Systems, Miami Lakes, Fla) were placed through 6F guiding catheters (Fasguide, Target Therapeutics, and Envoy, Cordis Endovascular Systems) into the common carotid arteries of swine for 30 minutes (short term), 90 minutes (medium term), and 35 days (long term). Guiding catheters were implanted for 5 hours. At the end of the implantation periods the catheters were retracted and fixed for scanning electron microscopy.

RESULTS

The surface of the Fastracker microcatheter was devoid of debris after both short- and medium-term implantation. The Tracker microcatheter had minimal accumulation of cellular elements whereas the Transit microcatheter showed moderate accumulation of nondeformed red blood cells. Neither the Tracker nor the Transit microcatheter showed evidence of increasing debris accumulation after medium-term implantation as compared with short-term implantation. The Magic microcatheter was coated with gross thrombus after both short- and medium-term implantation. The Fasguide guiding catheter was nearly devoid of debris, while the Envoy guiding catheter had moderate thrombus formation. Long-term implantation of the Fastracker microcatheter was well tolerated whereas that of the Transit catheter resulted in vessel occlusion.

CONCLUSIONS

Hydrophilic microcatheters and guiding catheters are less thrombogenic than their nonhydrophilic counterparts, but not all hydrophilic coatings are equally hypothrombogenic. Degree of thrombogenicity depends on catheter material rather than surface morphology. Medium-term implantation did not yield increasing thrombus formation relative to short-term implantation.

The effect of hormone replacement therapy on recall rate in the National Health Service Breast Screening Programme

PURPOSE

Hormone replacement therapy (HRT) can lead to an increase in the density of breast parenchyma on mammography and to the development of mammographically visible cysts and fibroadenomas. These changes may obscure features indicative of benign processes or mimic those of a carcinoma on screening mammography. This study was designed to assess the effect of HRT usage on the recall rate of women attending for routine breast screening.

METHOD

Details of HRT usage were taken from 5699 consecutive women aged 49-64 attending for breast screening. Mammograms were read without knowledge of HRT usage and recall for assessment details collected.

RESULTS

A significant fall in recall rate was seen between the prevalent and incident screens in women not taking HRT (P < 0.016). This fall was not present in women taking HRT. The recall rate for the incident screen of women on HRT was 37% higher than that for women who did not take HRT; however the positive predive value for cancer of recall was lower at 3.7% compared to 12.9%.

CONCLUSION

These results indicate that the recall rate for incident screening is likely to be higher in women on HRT. This increase in assessment will lead to increased cost and anxiety in the screened population.

The ultrasound appearances of galactocoeles

Galactocoeles are an uncommon cause of breast masses, usually occurring in lactating women. The purpose of this study was to review the ultrasound (US) features of galactocoeles presenting to the Nottingham Breast Unit. Eight women with galactocoeles were scanned during 1994 and 1995. All the scans were abnormal, 50% of lesions were cystic or multicystic, 37% mixed cystic/solid and 13% appeared solid. A fat-fluid level was seen in only one case. Two of the cystic/solid lesions had ill defined solid components, raising the possibility of an intracystic carcinoma. All cases were confirmed by the aspiration of milk and clinical resolution following aspiration.

Accuracy and precision of CT angiography in a model of carotid artery bifurcation stenosis

PURPOSE

To determine optimal acquisition parameters and measurement techniques for CT angiography of the carotid bifurcation.

METHODS

Anatomic phantoms were created in which the diameter of the carotid artery stenoses ranged from 15% to 95%. Initially, we compared the accuracy of stenosis determination obtained by using various values of section collimation and table pitch. Subsequently, applying the combination of collimation and pitch that yielded the greatest longitudinal coverage without degradation in accuracy, we compared the accuracy of measurements performed with various display algorithms, including axial, magnified axial, maximum intensity projection (MIP), and shaded surface display (SSD) images. Last, we determined the effect on accuracy of varying both window and level settings. The standard of reference for all measurements was considered to be caliper measurements made of the models at the time of their construction.

RESULTS

CT angiography was highly accurate for determining the percentage of stenosis; the average difference between CT angiographic measurements and the standard of reference was less than 1% for all parameter combinations and measurement techniques. Precision varied among the measurement techniques. Magnified axial images provided more precise measurements than either the MIP or SSD images. Although there was a trend toward improved precision with the use of magnified versus unmagnified axial images and MIP versus SSD images, neither of these comparisons reached statistical significance. Systematic error was produced by changing the level setting from that halfway between the luminal density and vessel wall density. Random error was introduced by using window settings greater than zero.

CONCLUSION

CT angiography was highly accurate and precise for determining percentage of stenosis. The highest precision was attained by using magnified axial images with the level halfway between luminal density and vessel wall density and with the window set to zero.

Hydrophilic coatings diminish adhesion of glue to catheter: an in vitro simulation of NBCA embolization

PURPOSE

To determine whether new hydrophilic microcatheter coatings exhibit characteristics that diminish the chance of permanent endovascular glue adhesion during liquid acrylic embolization.

METHODS

Common hydrophilic and nonhydrophilic microcatheters (both flow-directed and over-the-wire) used in neurointerventional procedures were evaluated in vitro for liquid acrylic (Histoacryl and Avacryl)-to-catheter bond strength, catheter endovascular friction, and catheter stretch (tensile strength). Sufficient test repetitions were acquired to achieve statistical significance.

RESULTS

The bond strength between hydrophilically coated catheters and NBCA was significantly weaker than between nonhydrophilic catheters and NBCA. Hydrophilic catheter coating reduced dynamic endovascular friction by 30% to 35%. All flow-directed catheters exhibited considerably more stretch (less tensile strength) and therefore were more prone to fracture during withdrawal than over-the-wire systems. Histoacryl bonded to both hydrophilic and nonhydrophilic catheters with a significantly greater force than did Avacryl.

CONCLUSION

Hydrophilically coated catheters should be less likely to exhibit permanent endovascular fixation during acrylic embolization because of a weaker catheter-NBCA bond and because of reduced catheter friction (allowing a larger portion of any applied catheter withdrawal force to be transmitted to the catheter tip with less force dissipated along the catheter resulting in stretch). A significant difference in NBCA types (Histoacryl and Avacryl) was discovered: Avacryl developed a significantly weaker bond with all catheter types.

The detection of ductal carcinoma in situ at mammographic screening enables the diagnosis of small, grade 3 invasive tumours

This study was carried out to assess the frequency of ductal carcinoma in situ (DCIS) occurring within and surrounding grade 3 invasive tumours and the effect of its detection on size and nodal stage of invasive carcinomas at mammographic detection. Grade 3 tumours with either no associated DCIS or DCIS only within the invasive component were significantly larger in size than tumours with surrounding DCIS (P < 0.02) and were less likely to be under or equal to 10 mm in size (0% or 13% vs 30% respectively, P < 0.02). Tumours with mammographic calcification were more likely to be less than or equal to 10 mm in size than non-calcific tumours (32% vs 11% respectively, P < 0.05). This was because of the high frequency of tumours less than or equal to 10 mm in size in the linear/branching calcification group. Tumours showing calcification without a mass also appear to be a group with good prognostic features, with a mean size of 13 mm, 33% being 10 mm or less in size and only 17% being node positive. We have found that the presence of surrounding DCIS enables earlier detection of grade 3 invasive carcinomas because of the presence of mammographically visible calcification. Detection of calcification suggestive of DCIS should remain an important part of mammographic screening.