Nodal positivity in patients with clinically and radiologically node-negative breast cancer treated with neoadjuvant chemotherapy: multicentre collaborative study

BACKGROUND

The necessity of performing a sentinel lymph node biopsy in patients with clinically and radiologically node-negative breast cancer after neoadjuvant chemotherapy has been questioned. The aim of this study was to determine the rate of nodal positivity in these patients and to identify clinicopathological features associated with lymph node metastasis after neoadjuvant chemotherapy (ypN+).

METHODS

A retrospective multicentre study was performed. Patients with cT1-3 cN0 breast cancer who underwent sentinel lymph node biopsy after neoadjuvant chemotherapy between 2016 and 2021 were included. Negative nodal status was defined as the absence of palpable lymph nodes, and the absence of suspicious nodes on axillary ultrasonography, or the absence of tumour cells on axillary nodal fine needle aspiration or core biopsy.

RESULTS

A total of 371 patients were analysed. Overall, 47 patients (12.7%) had a positive sentinel lymph node biopsy. Nodal positivity was identified in 22 patients (29.0%) with hormone receptor+/human epidermal growth factor receptor 2- tumours, 12 patients (13.8%) with hormone receptor+/human epidermal growth factor receptor 2+ tumours, 3 patients (5.6%) with hormone receptor-/human epidermal growth factor receptor 2+ tumours, and 10 patients (6.5%) with triple-negative breast cancer. Multivariable logistic regression analysis showed that multicentric disease was associated with a higher likelihood of ypN+ (OR 2.66, 95% c.i. 1.18 to 6.01; P = 0.018), whilst a radiological complete response in the breast was associated with a reduced likelihood of ypN+ (OR 0.10, 95% c.i. 0.02 to 0.42; P = 0.002), regardless of molecular subtype. Only 3% of patients who had a radiological complete response in the breast were ypN+. The majority of patients (85%) with a positive sentinel node proceeded to axillary lymph node dissection and 93% had N1 disease.

CONCLUSION

The rate of sentinel lymph node positivity in patients who achieve a radiological complete response in the breast is exceptionally low for all molecular subtypes.

Circulating fibrocyte percentage and neutrophil-lymphocyte ratio are accurate biomarkers of uncomplicated and complicated appendicitis: a prospective cohort study

BACKGROUND

There is increasing evidence that uncomplicated appendicitis (UA) may be treated nonoperatively in cases of UA. This study aimed to evaluate and compare the diagnostic accuracy of circulating fibrocyte percentage (CFP), white blood cell count, C-reactive protein, and neutrophil-lymphocyte ratio (NLR) in diagnosing uncomplicated and complicated appendicitis.

MATERIALS AND METHODS

Eighty consecutive adult patients presenting with suspected appendicitis were recruited in a cohort-based prospective study between June 2015 and February 2016 at University Hospital Limerick in Ireland. Peripheral venous samples were obtained at the presentation. Clinical, biochemical, radiological, and histopathological parameters were recorded. The CFP was determined by dual-staining for CD45 and collagen-I using flow cytometry analysis and correlated with histopathological diagnoses.

RESULTS

Of the 46 patients who underwent appendicectomy, 34 (73.9%) had histologically proven acute appendicitis. A comparison of the diagnostic accuracy of biomarkers demonstrated the CFP had the highest diagnostic accuracy for UA (area under the curve=0.83, sensitivity=72.7%, specificity=83.3%, P=0.002). The NLR had the highest diagnostic accuracy in relation to complicated appendicitis (area under the curve=0.84, sensitivity=75.5%, specificity=83.3%, P=0.005).

CONCLUSIONS

CFP and NLR are accurate biomarkers of UA and complicated appendicitis.

The use of computed tomography in the management of injury in tertiary emergency departments in Western Australia: Evidence of overtesting?

BACKGROUND

This study investigated trends in computed tomography (CT) utilization across different triage categories of injury presentations to tertiary emergency departments (EDs) and associations with diagnostic yield measured by injury severity, hospitalization and length of stay (LOS), and mortality.

METHODS

A total of 411,155 injury-related ED presentations extracted from linked records from Western Australia from 2004 to 2015 were included in the retrospective study. The use of CT scanning and diagnostic yield measured by rate of diagnosis with severe injury, hospitalizations and LOS, and mortality were captured annually for injury-related ED presentations. Multivariable regression models were used to calculate the annual adjusted rate of CT scanning for injury presentations and hospitalizations across triage categories, diagnosis with severe injury, LOS, and mortality. The significance of changes observed was compared among patients with CT imaging relative to those without CT.

RESULTS

While the number of ED presentations with injury increased by 65% from 2004 to 2015, the use of CT scanning in these presentations increased by 176%. The largest increase in CT use was among ED presentations triaged as semi-/nonurgent (+256%). Injury presentations with CT, compared to those without, had a higher rate of diagnosis with moderate/severe injury and hospitalization but no difference in LOS and mortality. The probability/rate observed in the outcomes of interest had a greater decrease over time in those with CT scanning compared with those without CT scanning across triage categories.

CONCLUSIONS

The reduction in diagnostic yield in terms of injury severity and hospitalization found in our study might indicate a shift toward overtesting using CT in ED for injury or a higher use of CT to assist in the management of injuries. This helps health care policymakers consider whether the current increase in CT use meets the desired levels of quality and efficient care.

How have advances in CT dosimetry software impacted estimates of CT radiation dose and cancer incidence? A comparison of CT dosimetry software: Implications for past and future research

Objective

Organ radiation dose from a CT scan, calculated by CT dosimetry software, can be combined with cancer risk data to estimate cancer incidence resulting from CT exposure. We aim to determine to what extent the use of improved anatomical representation of the adult human body “phantom” in CT dosimetry software impacts estimates of radiation dose and cancer incidence, to inform comparison of past and future research.

Methods

We collected 20 adult cases for each of three CT protocols (abdomen/pelvis, chest and head) from each of five public hospitals (random sample) (January-April inclusive 2010) and three private clinics (self-report). Organ equivalent and effective dose were calculated using both ImPACT (mathematical phantom) and NCICT (voxelised phantom) software. Bland-Altman plots demonstrate agreement and Passing-Bablok regression reports systematic, proportional or random differences between results. We modelled the estimated lifetime attributable risk of cancer from a single exposure for each protocol, using age-sex specific risk-coefficients from the Biologic Effects of Ionizing Radiation VII report.

Results

For the majority of organs used in epidemiological studies of cancer incidence, the NCICT software (voxelised) provided higher dose estimates. Across the lifespan NCICT resulted in cancer estimates 2.9%-6.6% and 14.8%-16.3% higher in males and females (abdomen/pelvis) and 7.6%-19.7% and 12.9%-26.5% higher in males and females respectively (chest protocol). For the head protocol overall cancer estimates were lower for NCICT, but with greatest disparity, >30% at times.

Conclusion

When the results of previous studies estimating CT dose and cancer incidence are compared to more recent, or future, studies the dosimetry software must be considered. Any change in radiation dose or cancer risk may be attributable to the software and phantom used, rather than—or in addition to—changes in scanning practice. Studies using dosimetry software to estimate radiation dose should describe software comprehensively to facilitate comparison with past and future research.

Revisiting consent for health information databanks

This paper argues that specific individual informed consent and other forms of consent predicated on a right to autonomy may not in all circumstances be appropriate for the establishment and use of large data sets of health information. We suggest that there are inherent failings in such an approach, shortcomings that we analyse below. We argue that individuals share an obligation to contribute their data, as doing so is cost-free (however cost is construed) and benefits accrue to the population as a whole. Large health data sets can be considered public goods – goods that are non-rival in consumption (they are not depleted in being used, so others are not prevented from using them) and in some cases non-exclusive in use (e.g. when large datasets of non-identifiable information are publicly-accessible without cost, such as some Australian Bureau of Statistics data) – and contributing to these goods may be an obligation, the meeting of which allows citizens to invest in knowledge infrastructure. The approach argued for here is a variation of a communitarian ethic in which people have an obligation to contribute their data but have no correlative right to expect or receive an individual benefit.

The increase in cancer prevalence and hospital burden in Western Australia, 1992-2011

PURPOSE

To describe cancer prevalence and hospital service utilization by prevalent cancer patients in Western Australia from 1992 to 2011.

METHODS

This study was a population-based cohort study using the Western Australia (WA) Cancer Registry (1982 to 2011) as the source of incident cancer cases. These data were linked to mortality (1982 to 2011) and hospital morbidity (1998 to 2011) records via the WA Data Linkage System to ascertain complete and limited-duration prevalence and cancer-related hospitalizations over time. Prevalence rates were calculated using estimated residential population data from the Australian Bureau of Statistics.

RESULTS

In 2011, one in every 27 people living in WA had been diagnosed with cancer at some time in their lifetime, and one in 68 had been diagnosed within the previous five years. Between 1992 and 2011, complete cancer prevalence in Western Australia increased by a magnitude of 2.5-fold. Forty-five and 44% of the increase in complete cancer prevalence in males and females between 1992 and 2011 can be attributed to prostate and breast cancer, respectively. The absolute number of cancer-related bed days increased 81 and 74% in males and females, respectively, diagnosed within one year, between 1998 and 2011.

CONCLUSIONS

The prevalence of cancer and the burden it places on hospitals continues to rise, demanding ongoing efforts to prevent cancer through modifiable risk factors and better, more efficient use of health resources. Steps should to be taken to understand and address overdiagnosis and overtreatment.