The first BGICC consensus and recommendations for breast cancer awareness, early detection and risk reduction in low- and middle-income countries and the MENA region

In low-middle income countries (LMICs) and the Middle East and North Africa (MENA) region, there is an unmet need to establish and improve breast cancer (BC) awareness, early diagnosis and risk reduction programs. During the 12th Breast, Gynecological & Immuno-oncology International Cancer Conference - Egypt 2020, 26 experts from 7 countries worldwide voted to establish the first consensus for BC awareness, early detection and risk reduction in LMICs/MENA region. The panel advised that there is an extreme necessity for a well-developed BC data registries and prospective clinical studies that address alternative modalities/modified BC screening programs in areas of limited resources. The most important recommendations of the panel were: (a) BC awareness campaigns should be promoted to public and all adult age groups; (b) early detection programs should combine geographically distributed mammographic facilities with clinical breast examination (CBE); (c) breast awareness should be encouraged; and (d) intensive surveillance and chemoprevention strategies should be fostered for high-risk women. The panel defined some areas for future clinical research, which included the role of CBE and breast self-examination as an alternative to radiological screening in areas of limited resources, the interval and methodology of BC surveillance in women with increased risk of BC and the use of low dose tamoxifen in BC risk reduction. In LMICs/MENA region, BC awareness and early detection campaigns should take into consideration the specific disease criteria and the socioeconomic status of the target population. The statements with no consensus reached should serve as potential catalyst for future clinical research.

Papillary lesions of the breast: To excise or observe?

Papillary lesions of the breast range from benign to atypical to malignant. Although papillomas without frank cancer are benign, their management remains controversial. When a core needle biopsy of a lesion yields a diagnosis of intraductal papilloma with atypia, excision is generally recommended to rule out a concurrent malignant neoplasm. For intraductal papillomas without atypia, however, recommendations for excision versus observation are variable. The aims of this study are to evaluate the rate of concurrent malignancies for intraductal papilloma diagnosed on core needle biopsy and to assess the long-term risk of developing cancer after the diagnosis of a papillary lesion. This single institution retrospective study analyzed 259 patients that were diagnosed with intraductal papilloma (IDP) by core needle biopsy from 1995 to 2010. Patients were grouped by initial diagnosis into three groups (papilloma without atypia, papilloma with atypia, and papilloma with atypical duct hyperplasia or atypical lobular hyperplasia (ADH/ALH) and followed up for long-term outcomes. After a core needle biopsy showing IDP with atypia or IDP + ADH/ALH, surgical excision yielded a diagnosis of concomitant invasive or ductal in situ cancer in greater that 30% of cases. For intraductal papilloma without atypia, the likelihood of cancer was much lower. Moreover, even with excision, the finding of intraductal papilloma with atypia carries a significant risk of developing cancer long-term, and such patients should be followed carefully and perhaps should be considered for chemoprevention.

Abstract P5-08-37: Intraductal papillomas: Risk of cancer, immediate and delayed

Introduction

The management of Intraductal papillomas (IP) of the breast diagnosed on core needle biopsy (CNBx) is still controversial. For IP with atypia, excision is generally recommended. For IP w/o atypia, data for excision vs. observation are variable. A clearer understanding of the risk of the presence of invasive or in situ malignancy (IDC or DCIS) coincident with IP, as well as the long-term risk for cancer would be helpful in managing these patients. The aim of this study is to evaluate the rate of malignancy on immediate excision or with prolonged follow-up. We hypothesized that IP w/o atypia do not require excision, as the risk of malignancy is low. Conversely, we hypothesized that IP w/ atypia should be excised because of a significant rate of concomitant malignancy. We also evaluated the long-term risk of malignancy in either breast with excision or observation of women with IP.

Methods

266 women who underwent a CNbx between 1995 and 2010 were identified from surgical pathology and breast imaging records. Four groups were defined based on the CNBx diagnosis (IP w/o atypia, IP with atypia, IP + ADH/ALH and Papillomatosis) and were also separated on the basis of immediate excision versus observation. For the 15-year period, it was generally the policy to excise IP lesions with atypia or ADH/ALH. Management of IP w/o atypia was more variable, but in the most recent 5 years, patients with IP w/o atypia were usually observed. For those who underwent immediate excision, the proportions with IDC or DCIS were calculated and compared using Fisher's exact test. Kaplan Meier curves were determined for each group's estimated time to cancer diagnosis, and significance was evaluated by the log-rank test.

Results

When surgical excision was performed for IP w/ atypia or IP + ADH/ALH on CNBx, cancer was found in 32% and 38.5% respectively. Of the 109 excisions for IP w/o atypia, cancer was found in 8.3%, significantly different from IP w/ atypia (p=0.004) and IP + ADH/ALH (p=0.007). For patients without atypia or ADH/ALH at the time of biopsy and no cancer on excision, the probability of remaining cancer-free was not significantly different for patients who had immediate surgical excision versus those that were observed (93.8% and 91.5% cancer-free at 10 years, p= 0.773). For patients with atypia or ADH/ALH at the time of biopsy but no cancer on excision, the probability of remaining cancer-free in both breasts was 85.9% at 10 years, and did not differ between patients who were excised or observed (p= 0.518). However, those w/atypia or ADH/ALH were significantly less likely to remain cancer-free than those w/o atypia (85.9% versus 92.8% at 10 years, respectively, p=0.008).

Conclusions

After a CNBx showing IP w/ atypia or IP + ADH/ALH, surgical excision is clearly justified, based on a 30-40% risk of concomitant invasive or in situ cancer. For IP w/o atypia, the likelihood of cancer is much lower. Moreover, even with excision, the finding of IP with atypia carries a significant risk of developing cancer long-term, and such patients should be followed carefully and perhaps should be considered for chemoprevention.

Citation Format: Khan S, Diaz A, Archer KJ, Lehman RR, Mullins TC, Cardenosa G, Bear HD. Intraductal papillomas: Risk of cancer, immediate and delayed. [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 P5-08-37.

Comparing the performance of mammographic enhancement algorithms: a preference study

OBJECTIVE

The objective of this study was to compare the performance of four image enhancement algorithms on secondarily digitized (i.e., digitized from film) mammograms containing masses and microcalcifications of known pathology in a clinical soft-copy display setting.

MATERIALS AND METHODS

Four different image processing algorithms (adaptive unsharp masking, contrast-limited adaptive histogram equalization, adaptive neighborhood contrast enhancement, and wavelet-based enhancement) were applied to one image of secondarily digitized mammograms of forty cases (10 each of benign and malignant masses and 10 each of benign and malignant microcalcifications). The four enhanced images and the one unenhanced image were displayed randomly across three high-resolution monitors. Four expert mammographers ranked the unenhanced and the four enhanced images from 1 (best) to 5 (worst).

RESULTS

For microcalcifications, the adaptive neighborhood contrast enhancement algorithm was the most preferred in 49% of the interpretations, the wavelet-based enhancement in 28%, and the unenhanced image in 13%. For masses, the unenhanced image was the most preferred in 58% of cases, followed by the unsharp masking algorithm (28%).

CONCLUSION

Appropriate image enhancement improves the visibility of microcalcifications. Among the different algorithms, the adaptive neighborhood contrast enhancement algorithm was preferred most often. For masses, no significant improvement was observed with any of these image processing approaches compared with the unenhanced image. Different image processing approaches may need to be used, depending on the type of lesion. This study has implications for the practice of digital mammography.

Clinical evaluation of wavelet-compressed digitized screen-film mammography

RATIONALE AND OBJECTIVES

The authors compared diagnostic accuracy and callback rates with conventional screen-film mammograms and wavelet-compressed digitized images.

MATERIALS AND METHODS

Sixty sets of mammograms (four views per case) were digitized at a spatial resolution of 100 microm. The images were wavelet compressed to a mean compression ratio of 8:1 and reviewed by three mammographers. Five regions were evaluated in each breast. Suspicion of malignancy was graded on a scale of 0% to 100%, and receiver operating characteristic (ROC) analysis was performed. Callback rates were calculated by using the American College of Radiology's Breast Imaging Reporting and Data System lexicon scale.

RESULTS

The mean diagnostic accuracy with compressed and conventional images was 0.832 and 0.860, respectively. The upper 95% confidence bound for the difference in ROC areas was 0.061. The mean false-positive rate at a fixed sensitivity of 0.90 was 0.041 for compressed images and 0.059 for conventional images. The mean callback rates for normal, benign, and malignant regions were 0.023, 0.305, and 0.677, respectively, for compressed images and 0.036, 0.447, and 0.750, respectively, for conventional images. The upper 95% confidence bound for the (absolute) differences in callback rates was 0.012 for normal regions, 0.163 for benign regions, and 0.138 for malignant regions.

CONCLUSION

Diagnostic accuracies were equivalent for both compressed and conventional images. The mean false-positive rate at fixed sensitivity was much better with the compressed images. However, the callback rates for malignant lesions were lower when the compressed images were used.

How new technology is changing mammography and breast cancer management

Breast-imaging technology has improved in ways that allow one not only to detect breast cancer earlier, but also to distinguish benign from malignant lesions better. These capabilities are influencing the approach to breast cancer. We review current trends and issues for the non-radiologist.

Film-screen versus digitized mammography: assessment of clinical equivalence

OBJECTIVE

The purpose of this study was to determine whether diagnostic accuracy and callback rates using digitized film images are equivalent to those using film-screen mammograms.

MATERIALS AND METHODS

Sixty sets of mammograms (four views per case) were digitized at a spatial resolution of 100 microm. The images were reviewed by seven mammographers. Five regions were evaluated in each breast. Each region was scored on a scale of 0 100% for suspicion of malignancy, and a receiver operating characteristic analysis was performed. Callback rates were calculated using a published lexicon scale.

RESULTS

The observers' mean diagnostic accuracies using films and digitized images were 0.872 and 0.848, respectively. The upper 95% confidence boundary on the difference in accuracy was 0.066. The mean callback rate for normal, benign, and malignant areas using films versus digitized images was 0.048 versus 0.055, 0.498 versus 0.441, and 0.786 versus 0.737, respectively. The upper 95% confidence boundary for the absolute difference in callback rates was 0.037, 0.026, and 0.130 for normal, benign, and malignant areas, respectively.

CONCLUSION

The diagnostic accuracies of the digitized images and films were similar; however, an increase in callback rates of 0.037 (i.e., upper 95% confidence boundary) for normal results and a reduction in the callback rates of 0.130 for malignant lesions is important. The use of digitized film images, at a spatial resolution of 100 microm, may compromise patient treatment in clinical practice.

Mammographic halo sign revisited

PURPOSE

To determine whether increased silver halide deposition accounts for some curvilinear areas of hyperlucency (halo signs) that surround breast masses on screen-film mammograms.

MATERIALS AND METHODS

Breast images obtained in 43 women (aged 30-67 years; mean, 48.6 years) that showed a halo sign were selected from the authors' teaching files. Optical magnification (x8.0-12.5) of the masses with halos was used to establish the pattern of silver halide deposition in the film emulsion.

RESULTS

True radiolucent halos, differentiated from Mach bands by means of the increased silver halide deposition in the film emulsion, were identified in 44 masses in 36 women. Partial true radiolucent halos were identified in 32 (73%) of 44 masses. Thirty-eight (86%) of the 44 masses were cysts; three (7%), fibroadenomas; two (4%), infiltrating ductal carcinomas; and one (2%), axillary lymph node metastasis. True radiolucent halos were more common in growing benign and malignant lesions.

CONCLUSION

A halo is not always a perceptual illusion.

Percutaneous large-core breast biopsy: a multi-institutional study

PURPOSE

To assess the reliability and reproducibility of automated large-core breast biopsy.

MATERIALS AND METHODS

A consortium of 20 institutions reported, in a standardized fashion, their core breast biopsy data. All biopsies were performed with "long-throw" (2.3-cm) automated core biopsy devices fitted with 14-gauge needles. Needle guidance was accomplished by means of either a dedicated, stereotaxic device, in which the patient lies in the prone position, or high-frequency electronically focused ultrasound equipment.

RESULTS

The data in 6,152 lesions were gathered. Clinical or surgical follow-up was available in 3,765 lesions; 1,363 of these lesions were subsequently surgically excised, and the core histologic study showed cancer in 910 lesions, mammary intraepithelial neoplasia in 173 lesions, and benign disease in 280 lesions. In these 280 lesions, there were 15 false-negative core biopsies.

CONCLUSION

The data show that percutaneous large-core breast biopsy is a reproducible and reliable alternative to surgical biopsy.

Ductography of the breast: technique and findings

The evaluation of spontaneous nipple discharge is controversial. Many surgeons advocate major subareolar duct excision for postmenopausal patients or solitary duct excision for premenopausal women with this symptom, without preoperative diagnostic imaging. There is no dispute that as a symptom, nipple discharge can be eliminated by severing the major subareolar ducts. However, this decision requires generous assumptions on the part of the surgeons: first, that the abnormal duct can be identified correctly; second, that the segmental area or areas of the breast drained by the duct can be predicted accurately; and third, that the amount of tissue that needs to be excised to ensure inclusion of the lesion or lesions can be defined. Ductography can show the course of abnormal ducts, as well as the variability in location and extent of intraductal lesions. Preoperative mapping of the abnormal duct can expedite surgery, facilitate accurate minimal-volume breast biopsies, and alert the surgeon to the existence of an extensive ductal lesion or multiple lesions. In patients with fibrocystic changes or duct ectasia on ductography, surgery might be averted altogether. In an effort to demonstrate the usefulness of ductography and encourage its increased use, we review the technique and illustrate normal and abnormal findings.

Mucinous (colloid) breast cancer: clinical and mammographic findings in 10 patients

OBJECTIVE

The purpose of this study was to review the clinical and mammographic findings in patients with mucinous (colloid) breast cancer.

MATERIALS AND METHODS

We retrospectively reviewed the pathology reports of 444 women with breast cancers diagnosed between May 1988 and October 1993 after mammographic evaluation. Of these, 10 women 31-88 years old (mean, 67 years) had pure mucinous adenocarcinoma of the breast. We reviewed the clinical and mammographic findings in these 10 patients.

RESULTS

Three patients (30%) had palpable masses. Mammographic abnormalities were detected on screening studies in the seven patients (70%) who were asymptomatic. The mammographic findings included poorly defined, lobulated, solitary masses in seven patients, poorly defined, clustered masses in two patients, and a well-circumscribed mass in one patient. No tumors had calcifications as the primary finding, and only one tumor had a few scattered, round, calcifications associated with clustered masses. Two patients had areas of noncomedo ductal carcinoma in situ without calcifications adjacent to the invasive mucinous adenocarcinoma. The tumors were 7-35 mm in diameter. No metastases were found in the axillary lymph nodes in the eight patients in whom biopsies of these nodes were done.

CONCLUSION

The most common and distinctive mammographic feature of mucinous breast carcinoma is a poorly defined, lobulated mass. The absence of axillary nodal metastases, even in patients with large palpable tumors, supports the notion that biologically, mucinous carcinomas are slower growing, less aggressive tumors than infiltrating ductal carcinomas not otherwise specified.

Assessing adequacy of mammographic image quality

High-quality mammographic images enhance the radiologist's ability to interpret mammograms with high sensitivity for detecting abnormalities and high specificity for classifying lesions suspicious for malignancy. In addition to proper exposure, contrast, resolution, compression, and positioning, high-quality mammographic images must be accompanied by pertinent history and available comparison images. To avoid negating the benefits of technically ideal images, mammograms must be viewed under optimal viewing conditions. Constant attention to quality control, with every image evaluated for adherence to strict technical standards, is essential for maintaining image quality.

Cystic neoplasms of the pancreas: evaluation with endoscopic retrograde pancreatography

Images from endoscopic retrograde pancreatography performed in 38 patients with cystic pancreatic neoplasms were reviewed to determine whether they might allow differentiation of malignant from benign lesions. Twenty-three patients had histologically proved benign lesions; 15 had frankly malignant lesions. Images were classified into four groups on the basis of the appearance of the pancreatic duct: (a) normal, (b) showing narrowing or draping; (c) showing communication with a cystic space, and (d) showing obstruction. Of the 23 patients with benign lesions, eight had normal studies, 11 had studies showing narrowing or draping, three had studies showing communication, and one had a study showing obstruction. Of the 15 patients with malignant lesions, one had a normal study, three had studies showing narrowing or draping, two had studies showing communication, and nine had studies showing obstruction. Overall, there was a significant difference in the rates of pancreatographic findings for benign and malignant tumors (P = .001). Although no finding proved to be an absolute indicator of benign or malignant disease, obstruction occurred with 60% of malignant tumors and was seen with only one benign lesion (4%).

Probable causes of recurrence in patients with chordoma and chondrosarcoma of the base of skull and cervical spine

PURPOSE

141 patients with chordoma and chondrosarcoma of the base of skull and cervical spine were treated with proton and photon irradiation between 1980 and 1989. The local disease was controlled in 111 of these patients. This study reviews the 26 patients who have had their disease recur, and who have evaluable diagnostic studies to examine for probable causes of recurrence.

METHODS AND MATERIALS

The histologies of the recurrent tumors were 21 non-chondroid chordomas, two chondroid chordomas, and three chondrosarcomas. The prescribed doses ranged from 67 Cobalt-Gray-Equivalent (CGE) to 72 CGE (average of 69 CGE). Doses to small regions of the tumor were deliberately reduced where they abutted certain normal tissues (brain stem, spinal cord, optic chiasm, and optic nerves) in order to keep these structures at acceptance dose levels. The first study, CT or MR scan, on which there was evidence of increase in tumor was carefully evaluated and that volume transferred to the CT scan on which the treatment plan had been developed. The 3D dose distribution in the region of recurrence was carefully analyzed and a judgement made as to the most probable cause of recurrence.

RESULTS

Approximately one quarter (6 of 26) of the cases failed in the prescribed dose region. More than half (15 of 26) failed in regions where tumor dose was limited by normal tissue constraints. Approximately 10% of the patients recurred in the surgical pathway and 10% were judged to be marginal misses.

CONCLUSIONS

Overall, 75% of the patients failed in regions receiving less than the prescribed dose. All tumors which failed in the high dose region had volume greater than 75 cc. Patients with cervical spine disease had a higher rate of recurrence (10 or 26) and larger tumors (average volume of 102 cc) than those with base of skull disease (16 of 115) with an average volume of 63 cc.

Calcified suture material in the breast after radiation therapy

Of 335 women who underwent lumpectomy and radiation therapy for breast cancer, 42 subsequently developed calcifications. Particles typical of calcified suture material were identified in 21 of the 42 women (50%). No obvious calcified suture material was found in approximately 1,140 women of 38,000 (3%) who had undergone mammography after they had previously undergone breast biopsy for a benign lesion and thus had not undergone radiation therapy. Calcified suture material rarely develops in the nonirradiated breast, but it is common after radiation therapy and should not be confused with recurrent breast cancer. These calcifications are likely the result of delayed resorption of catgut sutures, which provide a matrix on which calcium can precipitate in a suitable local environment.

Effects of a defective filter on magnification image quality in mammography

A defective molybdenum filter in a dedicated mammographic unit was found to have a detrimental effect on image quality. The authors present a simple method for testing of molybdenum filters and suggest that it be incorporated into the acceptance testing routine for new mammographic units and that it be used in annual quality control checks.

The art of mammographic positioning

The discovery of clinically occult breast cancer creates an exciting opportunity to alter the natural history of one of the major killers of women in our society. The skills required for this endeavor depend on high-quality images that provide the mammographer with sufficient information to construct three-dimensional perceptions recognizable as departures from normal architecture. Altering the natural course of breast cancer depends on early detection. Early detection of breast cancer depends on high-quality imaging techniques. Paramount among the imaging techniques for breast cancer detection is mammographic positioning. Optimal mammographic positioning is achieved by understanding the capabilities of available dedicated mammographic equipment and applying this understanding to take full advantage of natural breast mobility in overcoming various anatomic limitations. Compression of breast tissue, essential for proper parenchymal imaging, is achieved by moving one surface of the breast toward the other. The concept of moving the mobile surface of the breast toward the more fixed and immobile surface has been stressed as an important principle in optimizing the amount of tissue that can be imaged on standard mammographic views. Visualizing the fine details of a lesion or the margins of an area of clinical or perceived radiographic concern may be crucial to determining the need for biopsy. Visualization of such details is best achieved by projecting the suspected lesion into interface with adjacent radiolucent fat through separation of overlapping parenchyma by using spot compression or by tangential imaging against subcutaneous fat. Unique problems require creative, tailored solutions. Such tailoring is made less difficult by understanding and using equipment capability with breast anatomy and mobility. The very small, very large, or very dense breast can be imaged properly with modified techniques. Likewise, the augmented breast, mastectomy site, or axilla can be imaged with specialized techniques. Artistic application of these mammographic positioning principles will be rewarded with high-quality images, fewer missed breast cancers, and more lives saved.

Benign papillary neoplasms of the breast: mammographic findings

The clinical presentation, pathologic characteristics, and mammographic/ductographic (also known as galactographic) findings were reviewed in 77 patients with histologically proved benign papillary neoplasms of the breast. Patients were classified as having either solitary or multiple papillomas. Patients with multiple papillomas were further subclassified as having either central or peripheral papillomas. Fifty-one patients (66%) had solitary papillomas. Thirty-seven of these patients were symptomatic; 36 had spontaneous nipple discharge, and one had a palpable mass. Ductography was positive in 32 of the 35 patients who underwent the procedure. In the 14 asymptomatic patients, subareolar (n = 10) and peripheral (n = 4) mammographic abnormalities prompted biopsy. Fourteen patients (18%) had multiple peripheral papillomas, and one patient also had bilateral central solitary papillomas. Eleven of these patients were asymptomatic, while two presented with palpable abnormalities and one with spontaneous bilateral discharge. Mammographic findings included microcalcifications (n = 5) and clustering nodules (n = 2). Associated atypical ductal hyperplasia was found in six (43%) of the 14 patients with multiple peripheral papillomas. Some of these patients also had lobular carcinoma in situ and radical scars. Twelve patients had multiple central papillomas; all presented with spontaneous nipple discharge and had positive ductograms.

Rate of compliance with recommendations for additional mammographic views and biopsies

All recommendations for immediate additional studies and biopsies following routine mammography during a 6-month period were reviewed retrospectively to establish compliance rates and determine the time intervals for completion of the recommendations. During this period, 5,693 mammograms were obtained. Additional mammographic studies and biopsies were recommended for 364 (6.4%) and 180 (3.2%) of all patients, respectively. The compliance rates were 99.7% (n = 363) for additional studies and 98.9% (n = 178) for biopsies. Additional studies and biopsies were completed within 30 days of the recommendations in 98.4% (n = 358) and 91.7% (n = 165) of the patients, respectively. Compliance with recommendations for additional studies within relatively short periods can be maximized by having the mammographic facility schedule examinations directly with the patients. Compliance with biopsy recommendations can be optimized by directly contacting the referring physician. Follow-up written reports should specifically state that a biopsy is recommended and that this has been discussed directly with the referring physician.

Paraffin block radiography following breast biopsies: use of orthogonal views

Paraffin block radiography has been shown to be useful in helping identify lesions in biopsy specimens of breast tissue. Use of an orthogonal view enables determination of the approximate depth of a lesion within a paraffin block. This simple technique further guarantees histologic evaluation of the area of radiographic concern.

Spermatic cord sarcomas: sonographic and CT features

Five patients with sarcomas of the spermatic cord were imaged with sonography and/or computed tomography (CT). The former modality is most helpful in demonstrating the extratesticular origin of the mass and evaluating its scrotal extension for local staging. CT is necessary for pelvic staging and searching for distant metastasis. The fat in liposarcomas was easily identified by CT, although it was not echogenic on sonography. Sonography should be the primary imaging modality for scrotal or inguinal masses. If a neoplasm is found, CT should be used for staging, prior to definitive surgical treatment.

Mixed form, diffusely scattered calcifications in breast cancer with apocrine features

Diffusely scattered calcifications visible with mammography are almost always benign. Certain patterns, however, should arouse concern. For example, extensive comedocarcinoma is associated with large areas of mammographically visible calcium deposition. The authors identified 10 women in whom calcifications were visible throughout large volumes of breast tissue at mammography. The calcifications did not resemble those typical of extensive comedocarcinoma, yet they were associated with extensive breast cancer. Their mammographic pattern was characterized by a strikingly wild, chaotic appearance with profuse deposition of calcium. As in many cancers, the particles were heterogeneous, but unlike in most carcinomas, many deposits had a typically benign morphology. Histologic examination showed that even these typically benign calcifications were associated with malignant cells. The authors believe that the apocrine features displayed by many of the cancer cells in these 10 patients may explain the unusual profusion of calcium deposits.

Cystic tumors of the pancreas. New clinical, radiologic, and pathologic observations in 67 patients

Within a 12-year period we treated 67 patients (49 women, 18 men; mean age, 61 years) with cystic neoplasms of the pancreas, including 18 serous cystic adenomas, 15 benign mucinous cystic neoplasms, 27 mucinous cystadenocarcinomas, 3 papillary cystic tumors, 2 cystic islet cell tumors, and 2 cases of mucinous ductal ectasia. Mean tumor size was 6 cm (2 to 16 cm). In 39% the patients had no symptoms, and in 37% the lesions had been misdiagnosed as a pseudocyst. Computed tomography was useful for detection, for distinguishing the microcystic subgroup of serous cystadenoma, and for showing rim calcification (all 7 cases were malignant) but was not reliable for distinguishing neoplasm from pseudocyst, serous from mucinous tumors, or benign from malignant. Arteriography showed hypervascularity in 4 of 10 serous adenomas, 3 of 11 mucinous carcinomas, and 1 of 1 papillary cystic tumors. Endoscopic pancreatography showed no communication with the cyst cavity in 37 of 37 cases of cystic neoplasms but opacified the ectatic ducts in 2 of 2 cases of mucinous ductal ectasia. Stenosis or obstruction of the pancreatic duct indicated cancer. The tumor was resected by distal pancreatectomy in 25 patients, by proximal resection in 29, and by total pancreatectomy in one, with no operative deaths. Forty-four per cent of the tumors were malignant. In 10 cases the tumor was unresectable because of local extension or distant metastases, and those patients died at a mean of 4 months. Seventy-five per cent of those resected for cure are alive without evident recurrence. Because the epithelial lining of the tumor was partially (5% to 98%) absent in 40% to 72% of cases of the major tumor types, and the mucinous component comprised only about 65% of mucinous cystadenoma lining, misdiagnoses on frozen and even permanent sections were made. Mitoses and histologic solid growth correlated with malignancy. Neuroendocrine elements were seen in 87% of benign and 47% of malignant mucinous tumors. It is recommended that the terms macrocystic and microcystic be abandoned in favor of the histologic designations serous and mucinous. Incomplete examination of the cyst wall can be misleading, however. It is suggested that mucinous ductal ectasia be recognized separately from cystic tumors and that all of these lesions be resected, with the possible exception of asymptomatic confirmed serous cystadenomas.

Ankylosing spondylitis

Associated with the presence of HLA-B27 antigen, this inflammatory disorder of unknown etiology predominantly affects young adult men. Most patients present with low back pain and stiffness. Radiographs may show erosions, sclerosis and ankylosis in the pelvis and in the discovertebral, apophyseal, costovertebral and atlantoaxial joints. Hips and shoulders are the peripheral joints most commonly affected. Although most of the axial and appendicular skeleton may be involved, bilateral and symmetric sacroiliac involvement is the hallmark of ankylosing spondylitis.

Radiographic features of gout

Hyperuricemia is the hallmark of gout. Deposition of monosodium urate crystals in the joints and periarticular soft tissues can lead to arthritic changes. Radiographic features include periarticular soft tissue swelling, "punched-out" bony erosions and joint space narrowing. Although gout has a predilection for the first metatarsophalangeal joint, it may also affect the feet, hands, wrists, elbows and knees.

Minimal-volume excision of nonpalpable breast lesions

To explore the value of accurate preoperative localization of occult breast lesions, we reviewed 100 consecutive needle-directed breast biopsies performed by the same surgeon over a 1-year period. A spring hookwire device for localization was inserted parallel to the chest wall. Two thirds of biopsies were performed under local anesthesia, and all were performed in an outpatient setting. Sixteen lesions were invasive carcinomas, and eight were ductal carcinomas in situ. In 96 lesions, the localizing wire was placed within 2 mm of the lesion, and in the remaining four it was within 5 mm of the abnormality. The mammographic lesion was excised in the first specimen in 96 cases. One patient required a second biopsy because of failure to excise the lesion in question after three specimens were taken. The only surgical complication was one hematoma, which resolved within 3 months. Median specimen volume for the entire series was 6.0 cm3. Median largest specimen diameter was 2.5 cm. Precise preoperative localization with a spring hookwire to within 2 mm of the mammographic lesion allows the surgeon to excise a median volume of 6 cm3 breast tissue with consistent retrieval of the lesion.

New universal precaution aspiration tray

A new tray has been designed for use during procedures involving needles and other sharp objects. The tray includes a foam adhesive pad, marked into 10 sections, into which the sharp objects can be placed point first. After the procedure, the objects can be safely withdrawn by their handles and then discarded. The tray has been used in more than 250 procedures.

Subtle gastric abnormalities in a canine model: detection with low-dose imaging with storage phosphors and its equivalence to conventional radiography

The authors compared low-dose (32% of standard exposure) storage phosphor digital imaging (system resolution: 0.2-mm pixels, 10 bits) with isovoltage 75-kVp conventional radiography (standard exposure) in the detection of subtle simulated gastric abnormalities by using air contrast barium studies. Subtle simulated abnormalities (3-7-mm polyps, 4-15-mm ulcer craters, 4-11-mm-diameter edema, and 11-12-mm linear ulcers) were produced in resected canine stomachs. Receiver operating characteristic analysis of 1,800 observations by six readers indicated that the digital images with and without high-frequency edge enhancement were equivalent to conventional radiographs (mean receiver operating characteristic areas [+/- standard deviation]: 0.76 +/- 0.06, 0.78 +/- 0.04, and 0.77 +/- 0.04, respectively). The accuracy of the diagnosis was equivalent for all three modalities. The following mean accuracies of negative and positive responses, respectively, for unenhanced digital, edge-enhanced digital, and conventional images were determined: 0.71 +/- 0.05 and 0.41 +/- 0.07, 0.71 +/- 0.04 and 0.51 +/- 0.09, and 0.68 +/- 0.04 and 0.43 +/- 0.05. It was concluded that low-dose storage phosphor air-contrast barium studies were equivalent to conventional radiography in the detection of subtle gastric abnormalities.

Cadmium-induced accumulation of metallothionein messenger RNA in rat liver

Multiple injections of nontoxic levels of cadmium to a rat result in much higher level of metallothionein (MT) production in the liver than does the single injection. In order to understand the underlying mechanisms we have quantitated and compared the metallothionein-specific messenger RNA contents in the livers following the two induction regimens. Cell-free translation assays coupled with specific immunoprecipitation of MT revealed that MT-mRNA activity in livers of animals multiply injected with Cd is 7- to 10-fold higher than that in livers 4 h after a single Cd-induction. By oligo(dT)-cellulose chromatography, sucrose density gradient centrifugation, and methylmercuric hydroxide-agarose gel electrophoresis this mRNA has been enriched approximately 100-fold from the total RNA. The size of the mRNA is about 400 nucleotides. Hybridization assays with a complementary DNA probe synthesized against the enriched MT-mRNA showed a 4-fold difference in the level of MT-mRNA between the two induction regimens in agreement with the results obtained by the cell-free translation assays. The possible mechanisms for these observations in consideration of the short lived nature of MT-mRNA are discussed.

Spectral characteristics of human leukocytes and their relevance to automated cell identification. III. Eosinophils, neutrophils and lymphocytes

The spectral characteristics of various normal cell types from human blood were examined in respect to an automated, rapid-flow photometric identification system after staining for peroxidase activity. It was found that a plot of light loss against light scatter gave a separation of eosinophils, neutrophils and lymphocytes comparable in accuracy to visual separations. This staining was not useful for the segregation of monocytes and basophils, for which other stains have proven useful in the sytsem under study. It is concluded that automated, rapid-flow photometric identification of blood cell types can produce differential cell counts with good confidence levels.