Novel Prognostic Staging System for Patients With De Novo Metastatic Breast Cancer

PURPOSE

Given the heterogeneity and improvement in outcomes for metastatic breast cancer (MBC), we developed a staging system that refines prognostic estimates for patients with metastatic cancer at the time of initial diagnosis, de novo MBC (dnMBC), on the basis of survival outcomes and disease-related variables.

METHODS

Patients with dnMBC (2010-2016) were selected from the National Cancer Database (NCDB). Recursive partitioning analysis (RPA) was used to group patients with similar overall survival (OS) on the basis of clinical T category, grade, estrogen receptor (ER), progesterone receptor, human epidermal growth factor receptor 2, histology, organ system site of metastases (bone-only, brain-only, visceral), and number of organ systems involved. Three-year OS rates were used to assign a final stage: IVA: >70%, IVB: 50%-70%, IVC: 25 to <50%, and IVD: <25%. Bootstrapping was applied with 1,000 iterations, and final stage assignments were made based on the most commonly occurring assignment. Unadjusted OS was estimated. Validation analyses were conducted using SEER and NCDB.

RESULTS

At a median follow-up of 52.9 months, the median OS of the original cohort (N = 42,467) was 35.4 months (95% CI, 34.8 to 35.9). RPA stratified patients into 53 groups with 3-year OS rates ranging from 73.5% to 5.7%; these groups were amalgamated into four stage groups: 3-year OS, A = 73.2%, B = 61.9%, C = 40.1%, and D = 17% (log-rank P < .001). After bootstrapping, the survival outcomes for the four stages remained significantly different (log-rank P < .001). This staging system was then validated using SEER data (N = 20,469) and a separate cohort from the NCDB (N = 7,645) (both log-rank P < .001).

CONCLUSION

Our findings regarding the heterogeneity in outcomes for patients with dnMBC could guide future revisions of the current American Joint Committee on Cancer staging guidelines for patients with newly diagnosed stage IV disease. Our findings should be independently confirmed.

Scintillation light detection in the 6-m drift-length ProtoDUNE Dual Phase liquid argon TPC

DUNE is a dual-site experiment for long-baseline neutrino oscillation studies, neutrino astrophysics and nucleon decay searches. ProtoDUNE Dual Phase (DP) is a 6  ×  6  ×  6 m 3 liquid argon time-projection-chamber (LArTPC) that recorded cosmic-muon data at the CERN Neutrino Platform in 2019-2020 as a prototype of the DUNE Far Detector. Charged particles propagating through the LArTPC produce ionization and scintillation light. The scintillation light signal in these detectors can provide the trigger for non-beam events. In addition, it adds precise timing capabilities and improves the calorimetry measurements. In ProtoDUNE-DP, scintillation and electroluminescence light produced by cosmic muons in the LArTPC is collected by photomultiplier tubes placed up to 7 m away from the ionizing track. In this paper, the ProtoDUNE-DP photon detection system performance is evaluated with a particular focus on the different wavelength shifters, such as PEN and TPB, and the use of Xe-doped LAr, considering its future use in giant LArTPCs. The scintillation light production and propagation processes are analyzed and a comparison of simulation to data is performed, improving understanding of the liquid argon properties.

Abstract OT1-09-01: A randomized study comparing surgical excision versus eadjuvant adiotherapy followed by delayed surgical excision of uctal carcinoma n itu (

Lumpectomy and breast radiotherapy (RT) achieve good longterm control of disease in patients diagnosed with ductal carcinoma in situ (DCIS). In the combined analysis of NSABP B-17/B-24 DCIS trials, these treatments were shown to reduce invasive ipsilateral breast tumor recurrences by 52% compared to lumpectomy alone. RT has been consistently used as an adjuvant to surgery and therefore, little is known of its activity on intact/untreated DCIS. Elucidating the effectiveness of radiation therapy may help optimize the treatment of DCIS and avoid over-treatment.Trial Design The objective of the ongoing phase 2 pilot trial is to evaluate the ablative and treatment effects of neoadjuvant RT (neoRT) on DCIS. Patients diagnosed with DCIS on core needle biopsy are randomized to upfront lumpectomy (Arm 1) followed by partial breast irradiation (PBI) or neoRT PBI followed by delayed surgical excision (Arm 2). Arm 1 serves as a reference group for pathological-radiological correlations as well as to ascertain the rate of upstaging to invasive cancer. The neoRT regimen consists of 6 Gy daily x 5 (consecutive or non-consecutive days) to the intact tumor with a 0.5 cm margin. Surgical excision is delayed 12-16 weeks, allowing for the ablative effects of neoRT to occur. Specific Aims •To determine if neoRT can completely ablate 30% of DCIS cases•To determine if DCIS subtypes exhibit differential sensitivity to neoRT•To evaluate microscopic treatment effects; wound complication rates; post-RT breast imaging changes; and invasive carcinoma rate.Eligibility Women 18 years of age or older diagnosed with DCIS by core needle biopsy and intending to receive breast conserving surgery are eligible. Tumors must be ≤4 cm, discovered as mammographic microcalcifications and/or MRI non-mass enhancement measuring with evidence of residual imaging abnormality after diagnostic needle biopsy. Statistics A total of 50 patients will be recruited. Upstaging to invasive cancer is anticipated to be approximately 10%. With 25 subjects in each arm, we will have 80% power to detect a 30% or higher improvement in the DCIS complete response rate following neoadjuvant PBI. Accrual 10 (open 2019) Contact wapnir@stanford.edu. Wapnir IL, Dignam JJ, Fisher B, et al. Long-term outcomes of invasive ipsilateral breast tumor recurrences after lumpectomy in NSABP B-17 and B-24 randomized clinical trials for DCIS. J Natl Cancer Inst. 2011;103(6):478-488. doi:10.1093/jnci/djr027.McCormick B, Winter K, Hudis C, et al. RTOG 9804: a prospective randomized trial for good-risk ductal carcinoma in situ comparing radiotherapy with observation. J Clin Oncol. 2015;33(7):709-715. doi:10.1200/JCO.2014.57.9029.

Citation Format: Irene Wapnir, Carol Marquez, Kimberly Stone, Kimberly Allison, Wendy DeMartini, Catherine Salem, Jacqueline Tsai, Robert West, Alex McMillan, Melinda Telli, Kathleen Horst. A randomized study comparing surgical excision versus NeOadjuvant Radiotherapy followed by delayed surgical excision of Ductal carcinoma In Situ (NORDIS) [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr OT1-09-01.

Molecular analysis of TCGA breast cancer histologic types

Breast cancer is classified into multiple distinct histologic types, and many of the rarer types have limited characterization. Here, we extend The Cancer Genome Atlas Breast Cancer (TCGA-BRCA) dataset with additional histologic type annotations, in a total of 1063 breast cancers. We analyze this extended dataset to define transcriptomic and genomic profiles of six rare special histologic types: cribriform, micropapillary, mucinous, papillary, metaplastic, and invasive carcinoma with medullary pattern. We show the broader applicability of our constructed special histologic type gene signatures in the TCGA Pan-Cancer Atlas dataset with a predictive model that detects mucinous histologic type across cancers of other organ systems. Using a normal mammary cell differentiation score analysis, we order histologic types into a continuum from stem cell-like to luminal progenitor-like to mature luminal-like. Finally, we classify TCGA-BRCA into 12 consensus groups based on integrated genomic and histological features. We present a rich openly accessible resource of histologic and genomic characterization of TCGA-BRCA to enable studies of the range of breast cancers.

Integrated genomic characterization of ERBB2/HER2 alterations in invasive breast carcinoma: a focus on unusual FISH groups

In patients with invasive breast cancer, fluorescence in situ hybridization (FISH) testing for HER2 typically demonstrates the clear presence or lack of ERBB2 (HER2) amplification (i.e., groups 1 or 5). However, a small subset of patients can present with unusual HER2 FISH patterns (groups 2-4), resulting in diagnostic confusion. To provide clarity, the 2018 CAP/ASCO HER2 testing guideline recommends additional testing using HER2 immunohistochemistry (IHC) for determining the final HER2 status. Despite this effort, the genomic correlates of unusual HER2 FISH groups remain poorly understood. Here, we used droplet digital PCR (ddPCR) and targeted next-generation sequencing (NGS) to characterize the genomic features of both usual and unusual HER2 FISH groups. In this study, 51 clinical samples were selected to represent FISH groups 1-5. Furthermore, group 1 was subdivided into two groups, with groups 1A and 1B corresponding to cases with HER2 signals/cell ≥6.0 and 4-6, respectively. Overall, our findings revealed a wide range of copy number alterations in HER2 across the different FISH groups. As expected, groups 1A and 5 showed the clear presence and lack of HER2 copy number gain, respectively, as measured by ddPCR and NGS. In contrast, group 1B and other uncommon FISH groups (groups 2-4) were characterized by a broader range of HER2 copy levels with only a few select cases showing high-level gain. Notably, these cases with increased HER2 copy levels also showed HER2 overexpression by IHC, thus highlighting the correlation between HER2 copy number and HER2 protein expression. Given the concordance between the genomic and protein results, our findings suggest that HER2 IHC may inform HER2 copy number status in patients with unusual FISH patterns. Hence, our results support the current recommendation for using IHC to resolve HER2 status in FISH groups 2-4.

Abstract OT3-09-04: A randomized phase II study comparing surgical excision versus NeOadjuvant Radiotherapy followed by delayed surgical excision of Ductal carcinoma In Situ (NORDIS)

A randomized phase II study comparing surgical excision versus NeOadjuvant Radiotherapy followed by delayed surgical excision of Ductal carcinoma In Situ (NORDIS)

Breast radiotherapy (RT) for DCIS has been studied only in the adjuvant setting, following lumpectomy surgery. Adjuvant RT reduced invasive recurrences by 52% in the combined analysis of the two largest DCIS trials NSABP B-17/B-24, and reduced recurrences even for low or intermediate grade DCIS in the RTOG 9804 trial (recurrence 0.9% with RT versus 6.7% without RT). The mechanism of action is hypothesized to be elimination of occult disease and/or inhibition of neoplastic transformation in normal breast tissue.

Trial Design To understand the ablative effects of RT on pure DCIS, we are conducting a prospective randomized trial comparing histopathological findings of surgical excision (Arm 1) to neoadjuvant partial breast irradiation (neoRT) followed by delayed surgical excision (Arm 2) for patients with core needle biopsy proven DCIS. Arm 1 will provide a reference group for upstaging to invasive cancer, molecular markers and pathological-radiological correlations. Arm 2 participants will receive 6 Gy daily x 5 to the intact tumor with a 0.5 cm margin of normal tissue. Surgical excision will be delayed 12-16 weeks to allow for the radioablative effects to occur and radiation-induced inflammation to subside.

Specific Aims To determine if neoRT can completely ablate at least 30% of pure DCISTo determine if DCIS subtypes exhibit differential sensitivity to neoRTTo determine the radiation-induced treatment effects; wound complication rates; radiological

Eligibility Women 18 years of age or older with DCIS diagnosed on vacuum assisted core needle biopsy who intend to receive breast conserving surgery are eligible, excluding those with a prior history of ipsilateral breast cancer. The imaging abnormality must be mammographic microcalcifications and/or MRI non-mass enhancement measuring &lt;3 cm and not completely removed by core needle biopsy.

Statistics A total of 50 patients will be recruited. Upstaging to invasive cancer is anticipated to be approximately 10% in the reference group. With 25 subjects in each arm, we will have 80% power to detect a 30% or higher improvement in the DCIS complete response rate following neoRT.

Accrual Opened to accrual June 1, 2019

Contact wapnir@stanford.edu

Wapnir IL, Dignam JJ, Fisher B, et al. Long-term outcomes of invasive ipsilateral breast tumor recurrences after lumpectomy in NSABP B-17 and B-24 randomized clinical trials for DCIS. J Natl Cancer Inst. 2011;103(6):478-488. doi:10.1093/jnci/djr027.

McCormick B, Winter K, Hudis C, et al. RTOG 9804: a prospective randomized trial for good-risk ductal carcinoma in situ comparing radiotherapy with observation. J Clin Oncol. 2015;33(7):709-715. doi:10.1200/JCO.2014.57.9029.

Citation Format: Irene Wapnir, Wendy DeMartini, Kimberly Allison, Kimberly Stone, Frederick Dirbas, Carol Marquez, Debra Ikeda, Sunita Pal, Jacqueline Tsai, Rachel Yang, Robert West, Alex McMillan, Melinda Telli, Kathleen Horst. A randomized phase II study comparing surgical excision versus NeOadjuvant Radiotherapy followed by delayed surgical excision of Ductal carcinoma In Situ (NORDIS) [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr OT3-09-04.

Randomised controlled trial of internet-delivered cognitive behaviour therapy for clinical depression and/or anxiety in cancer survivors (iCanADAPT Early)

PURPOSE

To evaluate internet-delivered cognitive behavioural therapy (iCBT) on clinical depression and/or anxiety, distress, fear of cancer recurrence, and quality of life in cancer survivors.

METHODS

Random assignation of 114 participants to iCBT or treatment-as-usual (TAU). The clinician-supervised iCBT program (iCanADAPT Early) consisted of eight lessons over 16 weeks. Self-report questionnaires occurred at baseline, midpoint, and posttreatment for both groups with 3-month follow-up for iCBT participants. A mixed modelling approach to compare groups occurred.

RESULTS

iCBT was superior to TAU on all outcome measures at posttreatment. Compared with TAU, the iCBT group showed a significant decrease over time in anxiety and depression symptoms (primary outcome, Hospital Anxiety and Depression Scale, Hedges g = 1.51). Additionally the iCBT group had significantly lower general distress (Kessler-10, g = 1.56), fear of cancer recurrence (Fear of Cancer Recurrence Inventory, g = 0.39), and significantly higher quality of life (Functional Assessment of Cancer Therapy-General, g = 0.74) at posttreatment compared with the TAU group. High adherence and satisfaction were found for iCBT with low clinician time.

CONCLUSION

Clinician-supervised iCBT has significant benefits for cancer survivors with clinical depression and anxiety disorders.

Hip joint moments during walking in people with hip osteoarthritis: a systematic review and meta-analysis

OBJECTIVE

This systematic review and meta-analysis investigated surrogate measures of hip joint loading during walking in people with hip osteoarthritis (OA).

METHODS

Five databases were searched up to January 14^th, 2018. Studies that measured hip joint moments in the frontal or sagittal plane during walking in people with hip OA and used either a healthy control group or the unaffected leg to compare hip joint moments were included. Standardised mean differences (SMD) in sagittal and frontal plane moments were pooled as appropriate, using a random effect approach. Methodological quality was assessed using the Downs and Black checklist.

RESULTS

Thirteen studies with 1,141 participants were eligible and suitable for meta-analyses. Overall, people with hip OA had lower sagittal (SMD -0.55 (95% confidence interval (CI) -1.00 to -0.10) and frontal plane moments (SMD -0.63 (95% CI -0.92, -0.34) compared to controls. However, substantial heterogeneity was observed (I² ≤ 89%). Results by disease stage suggest that people with end-stage hip OA have lower sagittal (SMD -0.96; -1.30, -0.61; I² = 69%) and frontal (SMD -1.17; 95% CI -1.71, -0.64; I² = 85%) plane moments compared to controls. People with less severe hip OA than end-stage disease have comparable sagittal (SMD 0.37; 95% CI -0.17, 0.90; I² = 69%) and frontal (SMD -0.24; 95% CI -0.76, 0.27; I² = 51%) plane moments compared to controls.

CONCLUSION

Hip joint loading may be dependent on disease stage. People with end-stage hip OA under-loaded compared to controls, while those who were not awaiting hip joint replacement had comparable hip joint loads to controls.

iCanADAPT Early protocol: randomised controlled trial (RCT) of clinician supervised transdiagnostic internet-delivered cognitive behaviour therapy (iCBT) for depression and/or anxiety in early stage cancer survivors -vs- treatment as usual

BACKGROUND

This RCT with two parallel arms will evaluate the efficacy of an internet-delivered transdiagnostic cognitive behavioural therapy (iCBT) intervention for the treatment of clinical depression and/or anxiety in early stage cancer survivors.

METHODS/DESIGN

Early stage cancer survivors will be recruited via the research arm of a not-for-profit clinical research unit and randomised to an intervention (iCBT) group or a 'treatment as usual' (TAU) control group. The minimum sample size for each group is 45 people (assuming effect size > 0.6, power of 80%, and alpha at .05), but 10% more will be recruited to account for attrition. A solitary or cumulative diagnosis(es) of Major Depressive Episode (current), Generalised Anxiety Disorder, Illness Anxiety Disorder, Panic Disorder, Agoraphobia, and/or Adjustment disorder will be determined using modules from the Anxiety Disorders Interview Schedule for DSM-5. Depression and anxiety levels with be measured via the total score of the Hospital Anxiety and Depression scale (HADS-T), the primary outcome measure. Secondary measures will include the Kessler 10 to measure general distress, the Fear of Cancer Recurrence Inventory (FCRI) to measure the specific fear of cancer recurrence and the Functional Assessment of Cancer Therapy, General Version 4 (FACT-G) for self-report of physical, social, emotional and functional well-being. iCBT participants will complete the measures before lessons 1 and 5, at post-treatment and at 3-month follow-up. The TAU group will complete similar measures at weeks 1, 8 and 16 of the waiting period. Program efficacy will be determined using intent-to-treat mixed models. Maintenance of gains will be assessed at 3-month follow-up. Mediation analyses using PROCESS will be used to examine the association between change in depressive and anxious symptoms over time and changes in FCRI and FACT-G QOL in separate analysis.

DISCUSSION

This is the first RCT looking at iCBT specifically for clinical depression and/or anxiety in a cancer population. Findings will help to direct the role of iCBT in streamlined psycho-social care pathways.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry: ACTRN12616000231448, registered 19th February 2016 ( www.anzctr.org.au ). This trial protocol is in compliance with the Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) guidelines.

Optimized Protocol for Quantitative Multiple Reaction Monitoring-Based Proteomic Analysis of Formalin-Fixed, Paraffin-Embedded Tissues

Despite a clinical, economic, and regulatory imperative to develop companion diagnostics, precious few new biomarkers have been successfully translated into clinical use, due in part to inadequate protein assay technologies to support large-scale testing of hundreds of candidate biomarkers in formalin-fixed paraffin-embedded (FFPE) tissues. Although the feasibility of using targeted, multiple reaction monitoring mass spectrometry (MRM-MS) for quantitative analyses of FFPE tissues has been demonstrated, protocols have not been systematically optimized for robust quantification across a large number of analytes, nor has the performance of peptide immuno-MRM been evaluated. To address this gap, we used a test battery approach coupled to MRM-MS with the addition of stable isotope-labeled standard peptides (targeting 512 analytes) to quantitatively evaluate the performance of three extraction protocols in combination with three trypsin digestion protocols (i.e., nine processes). A process based on RapiGest buffer extraction and urea-based digestion was identified to enable similar quantitation results from FFPE and frozen tissues. Using the optimized protocols for MRM-based analysis of FFPE tissues, median precision was 11.4% (across 249 analytes). There was excellent correlation between measurements made on matched FFPE and frozen tissues, both for direct MRM analysis (R(2) = 0.94) and immuno-MRM (R(2) = 0.89). The optimized process enables highly reproducible, multiplex, standardizable, quantitative MRM in archival tissue specimens.

Abstract P4-01-01: A case series of the Milky Way sign: A diagnostic finding of ductal carcinoma in situ (DCIS) and invasive breast carcinoma (IDC) on digital breast tomosynthesis (DBT)

Purpose: we have previously described the "Milky Way Sign", which manifests as microcalcifications overlying noncalcified band-like density, best seen in digital breast tomosynthesis (DBT), in a patient with ductal carcinoma in situ (DCIS). Here, we describe a series of patients with DCIS, IDC, and rarely, Atypical Ductal Hyperplasia (ADH) with this sign.

Materials and Methods: we performed a systemic search of all stereotactic core biopsies for suspicious calcifications performed at our institution from April 15, 2014, when we first implemented DBT with synthesized 2D mammogram, to October 2, 2014, and identified all cases that were diagnosed as DCIS, IDC, or high-risk lesions (such as ADH, atypical lobular hyperplasia (ALH), and intraductal papilloma) on pathology. From 89 biopsied performed in 87 patients, a total of 13 cases of DCIS, IDC, or IDC with DCIS were identified in 12 patients. 17 cases of high-risk lesions were identified in 16 patients, including 10 ADH in 9 patients, 4 ALH, two intraductal papillomas, and one atypical columnar cell change.

Results: Among the 30 cases of suspicious calcifications with a diagnosis of DCIS, IDC, or high-risk lesions, 37% demonstrated the Milky Way Sign (11/30), including 71% of DCIS cases (5/7), 60% of cases of IDC (3/5), 100% of DCIS/IDC (1/1), and 12% of high-risk lesions (2/17). Both high-risk lesions with the Milky Way sign were ADH from the same patient. Among the 11 cases with the Milky Way sign, the breast density at the site of calcifications is either scattered (6/11) or heterogeneously dense (5/11), whereas the density at 1 cm surrounding the calcifications is either fatty (8/11) or scattered (3/11). The breast is less dense surrounding the calcifications in all but one case. The calcifications seen in the Milky Way cases are predominantly fine pleomorphic calcifications except one case of fine linear and linear branching calcifications. The calcifications are grouped (6/11), linear (3/11), or segmental (2/11) in distribution. Five patients also had contrast-enhanced breast MRIs. Among them, three (one each with the diagnosis of DCIS, IDC or DCIS/IDC) had non-mass enhancement on breast MRI that correlated to the Milky Way sign seen on mammogram. The other two patients (one with DCIS and one with IDC) had post biopsy change instead of Non-mass enhancement were seen in the corresponding areas.

Conclusion: The Milky Way sign, in the context of DBT, is a novel diagnostic sign for both DCIS and IDC. It may occasionally be seen in ADH cases as well. Features that often associate with the Milky Way sign include less dense tissue surrounding the calcifications, calcifications that are fine pleomorphic in morphology and grouped or linear in distribution. Preliminary results also suggest that the Milky Way sign may correspond to non-mass enhancement seen on contrast-enhanced breast MRI.

Clinical Relevance Statement: We hope that the Milky Way sign will facilitate detection of both DCIS and IDC in the context of DBT.

Citation Format: Allison K, Xu Y, Liu YI, Miyake KK, Downey JR, Lipson JA, Ikeda DM. A case series of the Milky Way sign: A diagnostic finding of ductal carcinoma in situ (DCIS) and invasive breast carcinoma (IDC) on digital breast tomosynthesis (DBT). [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 P4-01-01.

Review of emergency department wound management in soft tissue trauma - is there a plan?

OBJECTIVE

To assess current acute wound management in English emergency departments.

METHOD

All English emergency departments including minor injury units (n=207) were successfully contacted and a telephone questionnaire was completed. This considered wound treatment policy; management including cleansing, analgesia, dressing selection, suturing, referral patterns, medical photography and antibiotic use.

RESULTS

There was a 100% response. Only 40% of departments had a wound treatment policy. Most had implemented staff training, however the nature and timing of this was variable. Wound cleansing was performed by all departments. Most administered analgesia. Suturing was selectively performed by all departments. There was great diversity regarding dressing selection. The most common reasons for referral to specialist units were the complexity of injury and cosmetically sensitive areas. Photographs were regularly taken in one third of units questioned.

CONCLUSION

This study confirmed an absence of a standard protocol for early soft tissue wound management in the emergency department setting. Key areas that could be improved are dressing simplification, more defined referral criteria and introduction of standardised protocols with structured teaching programmes. We propose a simple approach to management of acute soft tissue wounds that can be applied to most situations.

DECLARATION OF INTEREST

There were no external sources of funding for this study. The authors have no conflicts of interest to declare.

Interview: Breast cancer: the pathologist’s point of view

Kimberly Allison speaks to Alisa Crisp, Commissioning Editor: Kimberly Allison is Associate Professor in Pathology at the Stanford School of Medicine (CA, USA). She trained at the New York Medical College (NY, USA) and the University of Washington Medical Center (WA, USA). She has clinical expertise in breast pathology and her research interests include how standards should be applied to breast cancer diagnostics (such as HER2 testing), the utility of molecular panel-based testing in breast cancer and identifying the most appropriate management of specific pathologic diagnoses. She is also the author of ‘Red Sunshine’, a memoir about her personal experience with breast cancer, a topic that she speaks about to both patient and healthcare audiences.

Follicular hyperplasia -- a rare differential to metastatic malignant melanoma

The assumption in a patient with a history of melanoma is that any subsequent lymphadenopathy is metastatic disease. We present a case where a seemingly obvious case of metastatic malignant melanoma proved to be Reactive Follicular Hyperplasia, illustrating it is important to be aware of all differential diagnoses, even when a cause appears obvious.

Equine anthelmintics: survey of the patterns of use, beliefs and attitudes among horse owners in the UK

An online survey was conducted to establish horse owners' beliefs, attitudes and practices relating to the use of anthelmintic drugs. Out of a total of 574 respondents, 89 per cent described themselves as 'leisure riders', most of whom took part in a variety of activities including eventing, show jumping, dressage, hunter trials, hunting, driving, endurance and showing. Overall, respondents were generally aware and concerned about the issue of anthelmintic resistance. Less than 60 per cent of all respondents were comfortable with their existing anthelmintic programme, and 25 per cent would like to reduce the use of anthelmintics in their horses. Of all the respondents, 47 per cent used livery, and 49 per cent of those reported that the livery imposed a common anthelmintic programme for horses kept on the premises; 45 per cent of these respondents were not entirely happy with the livery yard's programme. Less than 50 per cent of all respondents included 'veterinary surgeon' among their sources of advice on worming.

Management of a complex hind foot war injury with negative pressure wound therapy: a case study

We report the use of Negative Pressure Wound Therapy (NPWT) in a 39 year old patient with a complex open hind foot injury. The patient sustained an open calcaneal fracture with extensive soft tissue damage following the detonation of an explosively formed penetrating round in a confined space. A remarkable recovery was made following surgical debridement, internal fixation of the fracture and use of NPWT over the soft tissue injury. The patient returned to his normal level of function, without complications within a few months.

The classification and principles of management of wounds in trauma

The correct assessment and early management of wounds is vital in achieving a good outcome in both the acute and chronic setting. A robust management plan for the trauma patient depends upon accurate and timely assessment of all injuries and evaluation of key features such as mechanism of injury, pre-hospital findings and intervention, zone of injury, patient characteristics and structures damaged. This article describes the general principles of wound assessment and management, discussing mechanism and zone of injury, debridement techniques, types of irrigation and the use of antibiotic prophylaxis. Particular attention is given to the management of open tibial fractures, fasciotomy wounds, pretibial lacerations and haematomas and bite wounds.

Incidence of endometrial hyperplasia

OBJECTIVE

The objective of the study was to estimate the age-specific incidence of endometrial hyperplasia: simple, complex, and atypical, in order of increasing likelihood of progression to carcinoma.

STUDY DESIGN

Women aged 18-90 years with endometrial pathology specimens (1985-2003) at a large integrated health plan were identified using automated data. Incidence rates were obtained by dividing the number of cases by the estimated number of female health plan enrollees who retained a uterus.

RESULTS

Endometrial hyperplasia peak incidence was: simple, 142 per 100,000 woman-years, complex, 213 per 100,000 woman-years, both in the early 50s; and atypical, 56 per 100,000 woman-years in the early 60s. Age-adjusted incidence decreased over the study period, especially for atypical hyperplasia.

CONCLUSION

Endometrial hyperplasia incidence without and with atypia peaks in the early postmenopausal years and in the early 60s, respectively. Given that some cases of endometrial hyperplasia likely go undiagnosed, the figures provided should be viewed as minimum estimates of the true incidence.

Massive Visceral Pentastomiasis Caused by Porocephalus crotali in a Dog

The testes of a 5-year-old, male, crossbred Schnauzer dog were the indicator organs for detection of massive pentastomiasis. Necropsy revealed numerous additional encysted parasites within the mesenteric lymph nodes, omentum, liver, sub-serosa of the small and large intestines, mesentery, and lungs. The nymphs had a pseudosegmented body, containing large eosinophilic glands and a chitinous cuticle with characteristic pores. Their hook configuration was consistent with that of Porocephalus. A pentastomid-specific 18S rRNA polymerase chain reaction (PCR) was designed and used to amplify template for sequencing. The sequence of the PCR product was 99.7% homologous with the reference sequence for P. crotali. This pentastomid parasite has been reported in North American snakes of genera Crotalus and Agkistrodon. Mammals are intermediate hosts, and snakes are the definitive hosts. Porocephalus crotali has been reported in dogs only once, and molecular methods have not been used previously to identify the species in clinical pentastomiasis.

Product stewardship in wollastonite production

In July 2002, NYCO Minerals, Inc., discovered a heretofore unknown contaminant in its wollastonite ore. The contaminant was first believed to be tremolite asbestos. Immediate efforts were made to eliminate this material. Additional studies were initiated to fully characterize the contaminant and its distribution in the ore body. Subsequent study by NYCO and their consultants led to the identification of the contaminant as a transition material (TM) intermediate between tremolite and talc. In vitro dissolution rate measurements indicated that the TM dissolved much more rapidly than tremolite asbestos. This article provides background information on wollastonite mineralogy and NYCO's product stewardship program (PSP). At present, NYCO Minerals uses selective mining to control the trace levels of TM in the ore and finished product verified by periodic monitoring of workplace air and finished product.

Maintaining standards of aesthetic practice in trainees subject to NHS restrictions

The Specialist Advisory Committee (SAC) in plastic surgery within the United Kingdom (UK) recommends a modular training programme to include aesthetic surgery. The intercollegiate board examinations test candidates on all aspects of aesthetic practice yet there is no formal, national aesthetic training in the UK. Closure of National Health Service (NHS) private patient facilities has reduced training opportunity [Nicolle FV. Sir Harold Gillies Memorial Lecture; Aesthetic plastic surgery and the future plastic surgeon. Br J Plast Surg 1998;51:419-24.] Calmanisation [Hospital doctors: training for the future. The Report of the Working Group on Specialist Medical Training (The Calman Report). London: HMSO; 1993.], the European Working Time Directive (EWTD) [; Phillips H, Fleet Z, Bowman K. The European Working time Directive-interim report and guidance from The Royal College of Surgeons of England working party chaired by Mr Hugh Phillips; 2003 []; Chesser S, Bowman K, Phillips H. The European Working Time Directive and the training of surgeons. BMJ Careers Focus 2002;s69-7.], and more importantly the implementation of "local" aesthetic guidelines have placed further pressures on training. Reductions of NHS case mix will ultimately lead to a reduction in trainee experience. With increasing regulatory pressure from the Commission for Healthcare Improvement, standards of aesthetic practice can only be maintained by increasing private/independent sector involvement. At present a disparity exists between the demand and provision of aesthetic surgery training in the UK. Aesthetic surgery forms part of the training curriculum for plastic surgery and as such remains a training issue. A review of aesthetic surgery training is needed in the UK through consultation with trainers and trainee representatives.

The management of compound leg injuries in the West Midlands (UK): Are we meeting current guidelines?

The joint British Association of Plastic Surgeons and British Orthopaedic Association (BAPS/BOA) guidelines for the management of patients with open tibia fractures were published in 1991 and 1997 and provided a synopsis of injury epidemiology and best care. We present a retrospective review of 66 patients treated over a 2-year period (January 2001-February 2003) at a regional plastic surgery unit. There were 33 direct admissions and 33 transfers from other hospitals in which the average delay in transfer was 7.8 days (1-28) and in whom 26 (79%) patients had already undergone surgery. Plastic surgeons were involved in 46 (62%) of the 66 patient cohort and 27 (82%) transferred patients. The delay after admission until soft tissue cover was 3.8 days (0-15). Twenty-nine (44%) complications were recorded, 20 (69%) of these were in the transferred group and additional orthopaedic intervention was needed in 11 (42%) of patients who had been operated on in other hospitals. Despite widespread dissemination and teaching of the BAPS/BOA guidelines, complex extremity trauma is often not managed well in our region. There are unacceptable delays in admission, late communication, poor note keeping and follow up. The initial surgery/fixation is often sub-optimal and soft tissue reconstruction has to be considered at the least advantageous time period for the patient, leading to an increased hospital stay and complications.

Consensus on the prehospital approach to burns patient management

Burns patients form a large group of trauma patients cared for by first aiders, ambulance staff, nurses, and doctors before reaching specialist care in hospital. Guidance for these important carers is often poor or confused and this engenders anxiety and detracts from optimal patient care. This paper outlines nine key steps in the initial management of burn patients in the prehospital environment based on current available evidence and a consensus of specialists from all disciplines caring for burns patients. The basis of care should be that simple things should always be performed well.

Assessing the impact of direct-to-consumer advertisements on the AA patient: a multisite survey of patients during the office visit

The method by which patients receive health information continues to change in this new age of increased information and technology. Long gone are the days of the mystique surrounding the physician's prescribing of a medication to cure their patients ailment. In recent years, this mystique has been replaced with more informed patients that bring their questions and concerns their doctor in anticipation of open dialogue. At the other end of the spectrum are the patients that come to the visit armed with notes, copies of Web pages, information from their home medical reference books and information heard or seen from the latest advertisements directed to the consumer about a medication for a self diagnosed disease. The majority of physicians have welcomed and encouraged patients to take on more responsibility of their health and appreciate the dialogue. This is preferred to the patient who sits motionless and nods his/her head in blind agreement with the proposed plan of action. Physicians have read the data on patient compliance and medical outcomes and understand that an informed patient is an ally and not an enemy. However, is there a difference between an informed patient that asks questions seeking a more active role in their healthcare versus a demanding patient that believes that their knowledge base is equal to the physician, thereby reducing the physician to a vending machine dispensing requested prescriptions with little insight or deviation from the patient's demands? Fundamentally, we know that physicians agree that our profession dictates that we use all of the medical knowledge at our fingertips, our interpersonal skills and judgment in making recommendations to our patients. We refuse to be reduced to a simple dispenser of desired medications with no regard to the patient and their well being and in fact are incensed with the assumption that our profession has been reduced to such mediocrity. However, we prefer the middle ground with our patients, neither the demanding or the complacent are our preference, we want relationship and believe that this will improve the patient's health status. The question is whether the increased information, dialogue, and patient involvement utilizing the information from new sources are a good thing, a bad thing or simply a reality of medicine's entrance into the information age. Must we encourage our patients to take an active role in their healthcare but place boundaries on the venues by which they receive information? How do patients interact with their physician in the office after exposure to an ad for a prescription medication? How do physicians react to the questions and do we encourage the interaction? What is the effect of the pharmaceutical industry marketing directly to our patients? Do we know and how will we ever fully assess the impact? Although these questions have no succinct answer, the physician and the patient dyad must be the guiding barometer.

Morphometric analysis of miniature swine hearts as potential human xenografts

Miniature swine are considered to be potential donors for clinical cardiac transplantation. However, it is unclear how an appropriately sized porcine donor will be selected for a particular human recipient. To address this issue, we performed a morphometric study of the swine heart using transthoracic echocardiography (n = 26) to determine the diameters of the aortic annulus and root, pulmonary artery annulus, and mitral valve annulus. We also obtained direct ex vivo measurements of swine heart weight and linear dimensions (n = 71). Relationships between a swine's height, weight, length, chest circumference and these internal and external cardiac dimensions are described. The strongest correlations were found between a pig's body length and its aortic annulus and root diameters (r-values = 0.97). These relationships are accurately described by univariate linear regression models. By cross-relating our morphometric measurements of aortic annulus diameter in the miniature swine with normative human data, we were able to develop a nomogram, relating swine length and human height, which predicts which miniature swine would donate the best size-matched heart for a particular human recipient.

Comparison of neurochemical effects of the monoamine oxidase inhibitors phenelzine, moclobemide and brofaromine in the rat after short- and long-term administration

BACKGROUND

Chronic administration of several irreversible monoamine oxidase (MAO) inhibitors induces a down-regulation of tryptamine and 5-hydroxytryptamine(2) receptors in rat brain, but there is a paucity of information available on the effects of reversible MAO-A inhibitors on these receptors.

METHODS

Acute and chronic experiments were conducted in rats and the effects of the irreversible monoamine oxidase inhibitor, phenelzine and the reversible MAO type-A inhibitors, moclobemide and brofaromine, on tryptamine and 5-hydroxytryptamine(2) receptors were analysed using radioligand binding techniques. In addition, activities of MAO-A and -B were determined radiochemically and brain and/or urine levels of tryptamine, 5-hydroxytryptamine, 3-methoxy-4-hydroxyphenylglycol (MHPG), beta-phenylethylamine, brofaromine and moclobemide were determined by chromatographic procedures.

RESULTS

After 30 days of administration, moclobemide and brofaromine selectively inhibited brain MAO-A activity and phenelzine inhibited MAO-A and -B to equal extents. All three drugs caused a significant down-regulation of tryptamine receptors, whereas only phenelzine significantly down-regulated 5-hydroxytryptamine(2) receptors. In a comparison of phenelzine and brofaromine, both caused marked elevations of urinary tryptamine and decreases of urinary MHPG levels, while only phenelzine increased beta-phenylethylamine levels. After 14 days of administration, phenelzine, but not moclobemide or brofaromine, significantly increased levels of tryptamine in brain; all three drugs significantly increased 5-HT levels.

LIMITATIONS

24-h urine samples were not collected for moclobemide-treated animals and brain levels of tryptamine were not measured after 30-day administration.

CONCLUSIONS

These studies revealed marked neurochemical differences among phenelzine, moclobemide and brofaromine which could contribute to their actions in the clinical setting.

Reconstruction of a large defect of the ear using a composite graft following a human bite injury

Human bites to the ear are not an uncommon injury as a consequence of brawls or even contact sports like rugby. Untreated, the cosmetic outcome of such injury is unsightly. This case history documents how a patient, who had two-thirds of his external ear bitten off, was treated successfully by replacing the part as a composite graft. The segment replanted was minimally trimmed but inset to allow maximal soft tissue apposition at the skin edges. An episode of postoperative venous congestion was treated with leeches. Patience was exercised rather than early debridement of any struggling tissue. All these factors helped the final result, which was 100% take of the replanted segment. Six months from the time of injury, the grafted segment has maintained its shape without cartilage resorption.