Coordinated interplay between palmitoylation, phosphorylation and SUMOylation regulates kainate receptor surface expression

Kainate receptors (KARs) are key regulators of neuronal excitability and synaptic transmission. KAR surface expression is tightly controlled in part by post-translational modifications (PTMs) of the GluK2 subunit. We have shown previously that agonist activation of GluK2-containing KARs leads to phosphorylation of GluK2 at S868, which promotes subsequent SUMOylation at K886 and receptor endocytosis. Furthermore, GluK2 has been shown to be palmitoylated. However, how the interplay between palmitoylation, phosphorylation and SUMOylation orchestrate KAR trafficking remains unclear. Here, we used a library of site-specific GluK2 mutants to investigate the interrelationship between GluK2 PTMs, and their impact on KAR surface expression. We show that GluK2 is basally palmitoylated and that this is decreased by kainate (KA) stimulation. Moreover, a non-palmitoylatable GluK2 mutant (C858/C871A) shows enhanced S868 phosphorylation and K886 SUMOylation under basal conditions and is insensitive to KA-induced internalisation. These results indicate that GluK2 palmitoylation contributes to stabilising KAR surface expression and that dynamic depalmitoylation promotes downstream phosphorylation and SUMOylation to mediate activity-dependent KAR endocytosis.

Multifocal MRI-Directed Simultaneous Integrated Boost (SIB) in the Treatment of Prostate Cancer with Stereotactic Body Radiation Therapy (SBRT)

PURPOSE/OBJECTIVE(S)

Conventionally fractionated MRI-directed radiation boosts in the treatment of prostate cancer have been shown to improve oncologic outcomes in the FLAME trial. Moreover, recent data has demonstrated local recurrences following SBRT predominately occur at the site of the dominant intraprostatic lesion. Modern protocols including HYPO-Flame have demonstrated early safety profiles of a 5-fraction intraprostatic SBRT boost. This study aims to determine if multifocal SIB treatment is associated with additional acute toxicity relative to unifocal boosts.

MATERIALS/METHODS

In this single-center retrospective analysis, we identified all patients who underwent SBRT with a SIB using a robotic radiosurgical platform. Fiducial markers and hydrogel rectal spacers were placed prior to simulation. All patients underwent treatment planning MRI with documented PI-RADS 3-5 lesions targeted for SIB delineation. Patients were treated to a prescription dose of 3500 to 3625 cGy in 5 fractions, or 1800 to 2100 cGy in 3 fractions in concert with pelvic nodal irradiation. The SIB prescription dose ranged from 4000 to 4200 cGy and 2100 to 2300 cGy for the 5- and 3-fraction regimens, respectively. Acute toxicity was defined as that occurring within 60 days of treatment completion using the CTCAE v. 5.0.

RESULTS

A total of 35 patients with a median age of 70 underwent SBRT SIB from 5/2022 to 1/2023 with the following risk distribution: low (3%), intermediate (66%), high (28%), and regional (3%). Most patients received rectal spacers (77%) and neoadjuvant ADT (71%) prior to treatment. The majority of patients underwent 5-fraction SBRT (74%) with the remainder receiving SBRT as a boost. Approximately half (51%) of the cohort was treated with a multifocal SIB to multiple PI-RADS lesions. Mean SIB dose was 4105 and 2377 cGy in 5- and 3-fractions, respectively. With a median follow up of 33 days, we identified no grade 3+ acute toxicities. Crude rate of grade 2 GU and GI toxicity was 51% and 6%, respectively, on par with prior unifocal publications. There was no difference in median SIB volume between uni- and multifocal boosts (1.47 vs. 1.72 cc, p = 0.57), nor was SIB volume associated with an increased risk of grade 2 GU toxicity (p = 0.28). Dominant lesion location was not associated with increased grade 2 GU toxicity (p = 0.29). No grade 2 GI toxicities occurred in the multifocal group. Finally, univariate analysis did not identify multifocal boost as a risk of grade 2 GU toxicity (35%) relative to unifocal (67%) boost (p = 0.09).

CONCLUSION

In the first analysis of its kind in the literature, we demonstrate that multifocal MRI-directed intraprostatic SBRT SIB yields no acute high-grade toxicity and is not associated with a higher risk of low-grade GU and GI toxicity relative to unifocal boost. Longer follow is necessary to determine risk of late toxicity and oncologic efficacy.

Histology of Convergent Probing Appendages in Mormyridae

Mormyridae is an early diverging family of Teleostean fishes that produce an electric field for navigation and communication using an electric organ. This clade has a diverse array of soft-tissue rostral appendages, such as the chin-swelling, the Schnauzenorgan, and the tubesnout combined with a Schnauzenorgan, that have evolved multiple times. Here we assess if macroscopically convergent, soft-tissue rostral appendages are also histologically convergent. Further, we investigate how the histology of these appendages can inform their function. We sampled independent gains of the chin-swelling and Schnauzenorgan to understand similarities and differences in their anatomies. We show that macroscopically convergent rostral appendages are also convergent at a histological level, and different types of rostral appendages share a similar anatomy; that said, minor differences likely relate to their specific functions. Based on a comparison of the skeletal muscle distribution and the differing attachment shapes of each appendage to the dentary, we conclude that the Schnauzenorgan is capable of a wider range of movements than the chin swelling. Furthermore, the anatomy suggests that these soft-tissue rostral appendages likely function as electrosensory foveas (i.e., an appendage that focuses a sensory system). Lastly, these histological data support the hypothesis that the chin swelling may be a precursor to the Schnauzenorgan.

SNX27-Retromer directly binds ESCPE-1 to transfer cargo proteins during endosomal recycling

Coat complexes coordinate cargo recognition through cargo adaptors with biogenesis of transport carriers during integral membrane protein trafficking. Here, we combine biochemical, structural, and cellular analyses to establish the mechanistic basis through which SNX27-Retromer, a major endosomal cargo adaptor, couples to the membrane remodeling endosomal SNX-BAR sorting complex for promoting exit 1 (ESCPE-1). In showing that the SNX27 FERM (4.1/ezrin/radixin/moesin) domain directly binds acidic-Asp-Leu-Phe (aDLF) motifs in the SNX1/SNX2 subunits of ESCPE-1, we propose a handover model where SNX27-Retromer captured cargo proteins are transferred into ESCPE-1 transport carriers to promote endosome-to-plasma membrane recycling. By revealing that assembly of the SNX27:Retromer:ESCPE-1 coat evolved in a stepwise manner during early metazoan evolution, likely reflecting the increasing complexity of endosome-to-plasma membrane recycling from the ancestral opisthokont to modern animals, we provide further evidence of the functional diversification of yeast pentameric Retromer in the recycling of hundreds of integral membrane proteins in metazoans.

Sorting nexin-27 regulates AMPA receptor trafficking through the synaptic adhesion protein LRFN2

The endosome-associated cargo adaptor sorting nexin-27 (SNX27) is linked to various neuropathologies through sorting of integral proteins to the synaptic surface, most notably AMPA receptors. To provide a broader view of SNX27-associated pathologies, we performed proteomics in rat primary neurons to identify SNX27-dependent cargoes, and identified proteins linked to excitotoxicity, epilepsy, intellectual disabilities, and working memory deficits. Focusing on the synaptic adhesion molecule LRFN2, we established that SNX27 binds to LRFN2 and regulates its endosomal sorting. Furthermore, LRFN2 associates with AMPA receptors and knockdown of LRFN2 results in decreased surface AMPA receptor expression, reduced synaptic activity, and attenuated hippocampal long-term potentiation. Overall, our study provides an additional mechanism by which SNX27 can control AMPA receptor-mediated synaptic transmission and plasticity indirectly through the sorting of LRFN2 and offers molecular insight into the perturbed function of SNX27 and LRFN2 in a range of neurological conditions.

Acute inactivation of retromer and ESCPE-1 leads to time-resolved defects in endosomal cargo sorting

Human retromer, a heterotrimer of VPS26 (VPS26A or VPS26B), VPS35 and VPS29, orchestrates the endosomal retrieval of internalised cargo and promotes their cell surface recycling, a prototypical cargo being the glucose transporter GLUT1 (also known as SLC2A1). The role of retromer in the retrograde sorting of the cation-independent mannose 6-phosphate receptor (CI-MPR, also known as IGF2R) from endosomes back to the trans-Golgi network remains controversial. Here, by applying knocksideways technology, we develop a method for acute retromer inactivation. While retromer knocksideways in HeLa and H4 human neuroglioma cells resulted in time-resolved defects in cell surface sorting of GLUT1, we failed to observe a quantifiable defect in CI-MPR sorting. In contrast, knocksideways of the ESCPE-1 complex – a key regulator of retrograde CI-MPR sorting – revealed time-resolved defects in CI-MPR sorting. Together, these data are consistent with a comparatively limited role for retromer in ESCPE-1-mediated CI-MPR retrograde sorting, and establish a methodology for acute retromer and ESCPE-1 inactivation that will aid the time-resolved dissection of their functional roles in endosomal cargo sorting.

Summary: Retromer, a master controller of endosomal cargo sorting, is deregulated in neurodegenerative disease. Here, we develop and apply a retromer knocksideways methodology to quantify endosomal cargo sorting upon acute perturbation.

Protein Interactors and Trafficking Pathways That Regulate the Cannabinoid Type 1 Receptor (CB1R)

The endocannabinoid system (ECS) acts as a negative feedback mechanism to suppress synaptic transmission and plays a major role in a diverse range of brain functions including, for example, the regulation of mood, energy balance, and learning and memory. The function and dysfunction of the ECS are strongly implicated in multiple psychiatric, neurological, and neurodegenerative diseases. Cannabinoid type 1 receptor (CB1R) is the most abundant G protein-coupled receptor (GPCR) expressed in the brain and, as for any synaptic receptor, CB1R needs to be in the right place at the right time to respond appropriately to changing synaptic circumstances. While CB1R is found intracellularly throughout neurons, its surface expression is highly polarized to the axonal membrane, consistent with its functional expression at presynaptic sites. Surprisingly, despite the importance of CB1R, the interacting proteins and molecular mechanisms that regulate the highly polarized distribution and function of CB1R remain relatively poorly understood. Here we set out what is currently known about the trafficking pathways and protein interactions that underpin the surface expression and axonal polarity of CB1R, and highlight key questions that still need to be addressed.

The C-terminal helix 9 motif in rat cannabinoid receptor type 1 regulates axonal trafficking and surface expression

Cannabinoid type one receptor (CB1R) is only stably surface expressed in axons, where it downregulates neurotransmitter release. How this tightly regulated axonal surface polarity is established and maintained is unclear. To address this question, we used time-resolved imaging to determine the trafficking of CB1R from biosynthesis to mature polarised localisation in cultured rat hippocampal neurons. We show that the secretory pathway delivery of CB1R is axonally biased and that surface expressed CB1R is more stable in axons than in dendrites. This dual mechanism is mediated by the CB1R C-terminus and involves the Helix 9 (H9) domain. Removal of the H9 domain increases secretory pathway delivery to dendrites and decreases surface stability. Furthermore, CB1R^ΔH9 is more sensitive to agonist-induced internalisation and less efficient at downstream signalling than CB1R^WT. Together, these results shed new light on how polarity of CB1R is mediated and indicate that the C-terminal H9 domain plays key roles in this process.

The brain contains around 100 billion neurons that are in constant communication with one another. Each consists of a cell body, plus two components specialized for exchanging information. These are the axon, which delivers information, and the dendrites, which receive it. This exchange takes place at contact points between neurons called synapses. To send a message, a neuron releases chemicals called neurotransmitters from its axon terminals into the synapse. The neurotransmitters cross the synapse and bind to receptor proteins on the dendrites of another neuron. In doing so, they pass on the message.

Cannabinoid type 1 receptors (CB1Rs) help control the flow of information at synapses. They do this by binding neurotransmitters called endocannabinoids, which are unusual among neurotransmitters. Rather than sending messages from axons to dendrites, endocannabinoids send them in the opposite direction. Thus, it is dendrites that release endocannabinoids, which then bind to CB1Rs in axon terminals. This backwards, or 'retrograde', signalling dampens the release of other neurotransmitters. This slows down brain activity, and gives rise to the 'mellow' sensation that recreational cannabis users often describe.

Like most other proteins, CB1Rs are built inside the cell body. So, how do these receptors end up in the axon terminals where they are needed? Are they initially sent to both axons and dendrites, with the CB1Rs that travel to dendrites being rerouted back to axons? Or do the receptors travel directly to the axon itself? Fletcher-Jones et al. tracked newly made CB1Rs in rat neurons growing in a dish. The results revealed that the receptors go directly to the axon, before moving on to the axon terminals. A specific region of the CB1R protein is crucial for sending the receptors to the axon, and for ensuring that they do not get diverted to the dendrite surface. This region stabilizes CB1Rs at the axon surface, and helps to make the receptors available to bind endocannabinoids.

CB1Rs also respond to medical marijuana, a topic that continues to generate interest as well as controversy. Activating CB1Rs could help treat a wide range of diseases, such as chronic pain, epilepsy and multiple sclerosis. Future studies should build on our understanding of CB1Rs to explore and optimize new therapeutic approaches.

ADAR2-mediated Q/R editing of GluK2 regulates kainate receptor upscaling in response to suppression of synaptic activity

Kainate receptors (KARs) regulate neuronal excitability and network function. Most KARs contain the subunit GluK2 (also known as GRIK2), and the properties of these receptors are determined in part by ADAR2 (also known as ADARB1)-mediated mRNA editing of GluK2, which changes a genomically encoded glutamine residue into an arginine residue (Q/R editing). Suppression of synaptic activity reduces ADAR2-dependent Q/R editing of GluK2 with a consequential increase in GluK2-containing KAR surface expression. However, the mechanism underlying this reduction in GluK2 editing has not been addressed. Here, we show that induction of KAR upscaling, a phenomenon in which surface expression of receptors is increased in response to a chronic decrease in synaptic activity, results in proteasomal degradation of ADAR2, which reduces GluK2 Q/R editing. Because KARs incorporating unedited GluK2(Q) assemble and exit the ER more efficiently, this leads to an upscaling of KAR surface expression. Consistent with this, we demonstrate that partial ADAR2 knockdown phenocopies and occludes KAR upscaling. Moreover, we show that although the AMPA receptor (AMPAR) subunit GluA2 (also known as GRIA2) also undergoes ADAR2-dependent Q/R editing, this process does not mediate AMPAR upscaling. These data demonstrate that activity-dependent regulation of ADAR2 proteostasis and GluK2 Q/R editing are key determinants of KAR, but not AMPAR, trafficking and upscaling.This article has an associated First Person interview with the first author of the paper.

The Role of Blood Tumor Marker Measurement (Using a Biochemical Index Score and C-Erbb2) in Directing Chemotherapy in Metastatic Breast Cancer

The role of blood tumor markers in monitoring response in advanced breast cancer is established in endocrine therapy and standard chemotherapy. This study examines marker levels in patients receiving new chemotherapy regimens. Thirty patients were recruited into two multicenter trials in which docetaxel-based regimens were used in 15 patients. The other 15 received doxorubicin-based regimens. Biochemical response calculated from a score using CA15.3, CEA and ESR was compared with UICC response. Marker changes at 2, 4 and 5 months correlated with UICC response at 3, 41/2 and 6 months, respectively (p < 0.03). Eleven patients achieved both clinical/radiological and biochemical response at the end of treatment; markers had not yet returned to below cutoffs in seven, suggesting a possible advantage to continue chemotherapy. No patient showed a biochemical response whilst judged clinically/radiologically progressive. Nineteen patients had progressed either clinically/radiologically or biochemically at six months; of these, eight showed progression assessed earlier by markers so that a median of four cycles of chemotherapy could have been saved. Measurements of serum c-erbB2 showed a correlation with tissue c-erbB2 staining in the primary tumor (p < 0.003). Among the patients with positive tissue staining, sequential changes in serum c-erbB2 completely paralleled initial response.

Distinguishing globally-driven changes from regional- and local-scale impacts: The case for long-term and broad-scale studies of recovery from pollution

Marine ecosystems are subject to anthropogenic change at global, regional and local scales. Global drivers interact with regional- and local-scale impacts of both a chronic and acute nature. Natural fluctuations and those driven by climate change need to be understood to diagnose local- and regional-scale impacts, and to inform assessments of recovery. Three case studies are used to illustrate the need for long-term studies: (i) separation of the influence of fishing pressure from climate change on bottom fish in the English Channel; (ii) recovery of rocky shore assemblages from the Torrey Canyon oil spill in the southwest of England; (iii) interaction of climate change and chronic Tributyltin pollution affecting recovery of rocky shore populations following the Torrey Canyon oil spill. We emphasize that "baselines" or "reference states" are better viewed as envelopes that are dependent on the time window of observation. Recommendations are made for adaptive management in a rapidly changing world.

Assembly, Secretory Pathway Trafficking, and Surface Delivery of Kainate Receptors Is Regulated by Neuronal Activity

Ionotropic glutamate receptor (iGluR) trafficking and function underpin excitatory synaptic transmission and plasticity and shape neuronal networks. It is well established that the transcription, translation, and endocytosis/recycling of iGluRs are all regulated by neuronal activity, but much less is known about the activity dependence of iGluR transport through the secretory pathway. Here, we use the kainate receptor subunit GluK2 as a model iGluR cargo to show that the assembly, early secretory pathway trafficking, and surface delivery of iGluRs are all controlled by neuronal activity. We show that the delivery of de novo kainate receptors is differentially regulated by modulation of GluK2 Q/R editing, PKC phosphorylation, and PDZ ligand interactions. These findings reveal that, in addition to short-term regulation of iGluRs by recycling/endocytosis and long-term modulation by altered transcription/translation, the trafficking of iGluRs through the secretory pathway is under tight activity-dependent control to determine the numbers and properties of surface-expressed iGluRs.

Abstract P4-02-07: Preoperative assessment of breast cancer survival using ultrasound diameter and shear wave elastography

This abstract was not presented at the symposium.

Abstract PD3-04: Which measure of the interim changes in breast tumoral volume at breast MRI in response to neoadjuvant chemotherapy best predicts final pathological response?

BACKGROUND: Interim changes in breast tumour volume at magnetic resonance imaging (MRI) can predict ultimate response to neoadjuvant chemotherapy (NAC), but there is little data on the best measure of volumetric change.

PURPOSE: To assess whether changes in measurements of semi-automated enhancing tumour volume (ETV) or fully automated functional tumour volume (FTV) between baseline and interim contrast-enhanced MRI are equivalent in predicting ultimate pathological response to neoadjuvant chemotherapy (NAC) for primary breast cancer, assessed using the residual cancer burden (RCB) score.

MATERIALS & METHODS: 78 patients undergoing treatment with NAC for primary breast cancer underwent contrast-enhanced MRI on a 1.5T or 3.0T MRI scanner using a dedicated bilateral breast coil before and after two or three cycles of NAC. Image analysis was performed using either semi-automated, user-defined thresholding (ITK-Snap; ETV) or fully-automated (Siemens SyngoVia BreVis; FTV) approaches. For ETV, the two-minute post-contrast subtracted volumes were analysed, with enhancing pixels thresholded to define tumour volume. FTV was measured using a manufacturer default setting of 50% enhancement threshold, relative to pre-contrast signal intensity, to define tumour volume. ETV intra-observer reproducibility was assessed by repeat analysis one month after initial analysis and a second observer also repeated the measure. Coefficient of reproducibility (CoR) and intraclass correlation coefficents (ICC) were calculated for intra- and inter-observer repeatability.

ETV and FTV percentage reduction between baseline and interim examinations was compared with final pathological response, as assessed using the residual cancer burden (RCB) score on resected cancer specimens.

Correlation of the two volumetric measures was performed using a Pearson Intra-class Correlation Coefficient (ICC) and pair-wise comparisons of ETV and FTV changes between RCB groups carried out using a Mann-Whitney U test. All statistical assessment was performed using SPSS, v21, with p&lt;0.05 considered significant.

RESULTS: There was significant correlation between ETV and FTV (ICC= 0.744, p&lt;0.05). Intra and inter observer reproducibility for ETV was excellent, with ICC 0.940 and 0.861 respectively and corresponding CoRs of 11.6% and 14.8%.

Average percentage reductions in ETV for each pathological response category were: pCR 96.4% (n=12), RCB-I 66.6% (n=10), RCB-II 62.9% (n=39) and RCB-III 27.3% (n=17). Corresponding values for FTV were 88.8%, 70.6%, 54.6% and 20.8%.

Significant differences in percentage ETV changes were found for pCR vs. RCB-I (p&lt;0.008), II (p&lt;0.001) & III (p&lt;0.001) and RCB-II vs. RCB-III (p&lt;0.001). For FTV, significant differences were measured only for pCR vs. RCB-II & III (p&lt;0.001).

CONCLUSION: changes in the semi-automated ETV measuement between baseline and interim MRI may provide more useful predictive information on final pathological response to NAC than FTV, as the changes are better able to discriminate between pCR and minimal residual disease (RCB-I). The ability to confidently predict pCR versus all other residual disease categories could facilitate planning of enhanced approaches to surgical management.

Citation Format: Thompson AM, Vinnicombe SJ, Waugh SA, Purdie CA, Evans AJ, Brunton T, Fuller-Pace FV. Which measure of the interim changes in breast tumoral volume at breast MRI in response to neoadjuvant chemotherapy best predicts final pathological response? [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr PD3-04.

Hydrogel versus Bare Platinum Coils in Patients with Large or Recurrent Aneurysms Prone to Recurrence after Endovascular Treatment: A Randomized Controlled Trial

BACKGROUND AND PURPOSE

Some patients are at high risk of aneurysm recurrence after endovascular treatment: patients with large aneurysms (Patients Prone to Recurrence After Endovascular Treatment PRET-1) or with aneurysms that have previously recurred after coiling (PRET-2). We aimed to establish whether the use of hydrogel coils improved efficacy outcomes compared with bare platinum coils.

MATERIALS AND METHODS

PRET was an investigator-led, pragmatic, multicenter, parallel, randomized (1:1) trial. Randomized allocation was performed separately for patients in PRET-1 and PRET-2, by using a Web-based platform ensuring concealed allocation. The primary outcome was a composite of a residual/recurrent aneurysm, adjudicated by a blinded core laboratory, or retreatment, intracranial bleeding, or mass effect during the 18-month follow-up. Secondary outcomes included adverse events, mortality, and morbidity (mRS > 2). The hypothesis was that hydrogel would decrease the primary outcome from 50% to 30% at 18 months, necessitating 125 patients per group (500 for PRET-1 and PRET-2).

RESULTS

The trial was stopped once 250 patients in PRET-1 and 197 in PRET-2 had been recruited because of slow accrual. A poor primary outcome occurred in 44.4% (95% CI, 35.5%-53.2%) of those in PRET-1 allocated to platinum compared with 52.5% (95% CI, 43.4%-61.6%) of patients allocated to hydrogel (OR, 1.387; 95% CI, 0.838-2.295; P = .20) and in 49.0% (95% CI, 38.8%-59.1%) in PRET-2 allocated to platinum compared with 42.1% (95% CI, 32.0%-52.2%) allocated to hydrogel (OR, 0.959; 95% CI, 0.428-1.342; P = .34). Adverse events and morbidity were similar. There were 3.6% deaths (1.4% platinum, 5.9% hydrogel; P = .011).

CONCLUSIONS

Coiling of large and recurrent aneurysms is safe but often poorly effective according to angiographic results. Hydrogel coiling was not shown to be better than platinum.

SUMOylation of Syntaxin1A regulates presynaptic endocytosis

Neurotransmitter release from the presynaptic terminal is under very precise spatial and temporal control. Following neurotransmitter release, synaptic vesicles are recycled by endocytosis and refilled with neurotransmitter. During the exocytosis event leading to release, SNARE proteins provide most of the mechanical force for membrane fusion. Here, we show one of these proteins, Syntaxin1A, is SUMOylated near its C-terminal transmembrane domain in an activity-dependent manner. Preventing SUMOylation of Syntaxin1A reduces its interaction with other SNARE proteins and disrupts the balance of synaptic vesicle endo/exocytosis, resulting in an increase in endocytosis. These results indicate that SUMOylation regulates the emerging role of Syntaxin1A in vesicle endocytosis, which in turn, modulates neurotransmitter release and synaptic function.

Vision outcomes and major complications after endovascular coil embolization of ophthalmic segment aneurysms

BACKGROUND AND PURPOSE

As aneurysms arising from the ophthalmic segment of the internal carotid artery increase in size, they can compress the optic nerve, prompting patients to present with visual disturbances. The purpose of this article is to describe the clinical and angiographic results with an emphasis on visual outcomes following the endovascular treatment of ophthalmic segment ICA aneurysms.

MATERIALS AND METHODS

The records of 1254 patients who presented for endovascular treatment of a cerebral aneurysm were retrospectively reviewed to identify 65 consecutive patients who underwent coil embolization of an ophthalmic segment ICA aneurysm. The clinical records, treatment reports, and imaging were reviewed with a focus on visual outcomes.

RESULTS

Twenty-two of the 65 patients (34%) who presented for treatment of an ophthalmic aneurysm reported a visual disturbance at presentation. Fifteen of the 22 patients (68%) experienced an improvement in their symptoms after treatment. Overall, patients with visual symptoms were significantly more likely to benefit from treatment than to have a decline in vision (P = .03). The overall morbidity was 4%, and mortality was 0%. The retreatment rate was high at 30%, though this was disproportionately weighted by an 86% retreatment rate in patients with ruptured aneurysms.

CONCLUSIONS

Patients with visual symptoms attributable to ophthalmic segment ICA aneurysms undergoing endovascular coil embolization were statistically more likely to experience an improvement in their vision than to have worsening or unchanged vision. Coiling was associated with a low morbidity rate, though an elevated retreatment rate.

Patients prone to recurrence after endovascular treatment: periprocedural results of the PRET randomized trial on large and recurrent aneurysms

BACKGROUND AND PURPOSE

Some patients with large or recurrent aneurysms may be at increased risk of recurrence postcoiling. The Patients Prone to Recurrence after Endovascular Treatment (PRET) trial was designed to assess whether hydrogel coils were superior to platinum coils in these high-risk patients. This article reports periprocedural safety and operator-assessed angiographic results from the PRET trial.

MATERIALS AND METHODS

PRET was a pragmatic, multicenter, randomized controlled trial. Patients had ≥10-mm aneurysms (PRET-1) or a major recurrence after coiling of an aneurysm of any size (PRET-2). Patients were randomly allocated to hydrogel or control arms (any platinum coil) by using concealed allocation with minimization. Assist devices could be used as clinically required. Aneurysms could be unruptured or recently ruptured. Analyses were on an intent-to-treat basis.

RESULTS

Four hundred forty-seven patients were recruited (250 PRET-1; 197 PRET-2). Aneurysms were recently ruptured in 29% of PRET-1 and 4% of PRET-2 patients. Aneurysms were ≥10 mm in all PRET-1 and in 50% of PRET-2 patients. They were wide-neck (≥4 mm) in 70% and in the posterior circulation in 24% of patients. Stents were used in 28% of patients (35% in PRET-2). Coiling was successful in 98%. Adverse events occurred in 28 patients with hydrogel and 23 with platinum coils. Mortality (n=2, unrelated to treatment) and morbidity (defined as mRS>2 at 1 month) occurred in 25 patients (5.6%; 12 hydrogel, 13 platinum), related to treatment in 10 (4 hydrogel; 6 platinum) (or 2.3% of 444 treated patients). No difference was seen between hydrogel and platinum for any of the indices used to assess safety up to at least 30 days after treatment. At 1 month, 95% of patients were home with a good outcome (mRS≤2 or unchanged). Operator-assessed angiographic outcomes were satisfactory (complete occlusion or residual neck) in 339 of 447 or 76.4% of patients, with no significant difference between groups.

CONCLUSIONS

Endovascular treatment of large and recurrent aneurysms can be performed safely with platinum or hydrogel coils.

Preoperative embolization of intracranial meningiomas: efficacy, technical considerations, and complications

BACKGROUND AND PURPOSE

Preoperative embolization for intracranial meningiomas offers potential advantages for safer and more effective surgery. However, this treatment strategy has not been examined in a large comparative series. The purpose of this study was to review our experience using preoperative embolization to understand the efficacy, technical considerations and complications of this technique.

MATERIALS AND METHODS

We performed a retrospective review of patients undergoing intracranial meningioma resection at our institution (March 2001 to December 2012). Comparisons were made between embolized and nonembolized patients, including patient and tumor characteristics, embolization method, operative blood loss, complications, and extent of resection. Logistic regression analyses were used to identify factors predictive of operative blood loss and extent of resection.

RESULTS

Preoperatively, 224 patients were referred for embolization, of which 177 received embolization. No complications were seen in 97.1%. There were no significant differences in operative duration, extent of resection, or complications. Estimated blood loss was higher in the embolized group (410 versus 315 mL, P=.0074), but history of embolization was not a predictor of blood loss in multivariate analysis. Independent predictors of blood loss included decreasing degree of tumor embolization (P=.037), skull base location (P=.005), and male sex (P=.034). Embolization was not an independent predictor of gross total resection.

CONCLUSIONS

Preoperative embolization is a safe option for selected meningiomas. In our series, embolization did not alter the operative duration, complications, or degree of resection, but the degree of embolization was an independent predictor of decreased operative blood loss.

What are the characteristics of breast cancers misclassified as benign by quantitative ultrasound shear wave elastography?

OBJECTIVES

Shear wave elastography (SWE) is a promising adjunct to greyscale ultrasound in differentiating benign from malignant breast masses. The purpose of this study was to characterise breast cancers which are not stiff on quantitative SWE, to elucidate potential sources of error in clinical application of SWE to evaluation of breast masses.

METHODS

Three hundred and two consecutive patients examined by SWE who underwent immediate surgery for breast cancer were included. Characteristics of 280 lesions with suspicious SWE values (mean stiffness >50 kPa) were compared with 22 lesions with benign SWE values (<50 kPa). Statistical significance of the differences was assessed using non-parametric goodness-of-fit tests.

RESULTS

Pure ductal carcinoma in situ (DCIS) masses were more often soft on SWE than masses representing invasive breast cancer. Invasive cancers that were soft were more frequently: histological grade 1, tubular subtype, ≤10 mm invasive size and detected at screening mammography. No significant differences were found with respect to the presence of invasive lobular cancer, vascular invasion, hormone and HER-2 receptor status. Lymph node positivity was less common in soft cancers.

CONCLUSION

Malignant breast masses classified as benign by quantitative SWE tend to have better prognostic features than those correctly classified as malignant.

KEY POINTS

• Over 90 % of cancers assessable with ultrasound have a mean stiffness >50 kPa. • 'Soft' invasive cancers are frequently small (≤10 mm), low grade and screen-detected. • Pure DCIS masses are more often soft than invasive cancers (>40 %). • Large symptomatic masses are better evaluated with SWE than small clinically occult lesions. • When assessing small lesions, 'softness' should not raise the threshold for biopsy.

miRNA profiling in metastatic renal cell carcinoma reveals a tumour-suppressor effect for miR-215

Background:

Renal cell carcinoma (RCC) is the most common neoplasm of the adult kidney. Metastatic RCC is difficult to treat. The 5-year survival rate for metastatic RCC is ⩽10%. Recently, microRNAs (miRNAs) have been shown to have a role in cancer metastasis and potential as prognostic biomarkers in cancer.

Method:

We performed a miRNA microarray to identify a miRNA signature characteristic of metastatic compared with primary RCCs. We validated our results by quantitative real-time PCR. We performed experimental and bioinformatic analyses to explore the involvement of miR-215 in RCC progression and metastasis.

Results:

We identified 65 miRNAs that were significantly altered in metastatic compared with primary RCCs. We validated our results by examining the expression of miR-10b, miR-126, miR-196a, miR-204 and miR-215, in two independent cohorts of patients. We showed that overexpression of miR-215 decreased cellular migration and invasion in an RCC cell line model. In addition, through gene expression profiling, we identified direct and indirect targets of miR-215 that can contribute to tumour metastasis.

Conclusion:

Our analysis showed that miRNAs are altered in metastatic RCCs and can contribute to kidney cancer metastasis through different biological processes. Dysregulated miRNAs represent potential prognostic biomarkers and may have therapeutic applications in kidney cancer.

Topographical analysis of telomere length and correlation with genomic instability in whole mount prostatectomies

BACKGROUND

Many critical events in prostatic carcinogenesis appear to relate to the emergence of genomic instability. Characteristic genomic abnormalities such as 8p loss, 8q gain, trisomy 7, and PTEN microdeletions may provide selective advantages to increase neoplastic transformation. Evidence suggests that telomere dysfunction is a plausible mechanism for some of these abnormalities on the basis of the break-fusion-bridge cycle that can lead to manifestations of genomic instability.

METHODS

In this study, we correlate telomere length measured by quantitative FISH in various prostatic histologies with markers of genomic instability and immunohistochemical measures of proliferation and oxidative stress.

RESULTS

We find that telomere shortening is correlated with abnormalities on chromosome 8, but not with trisomy 7 or abnormalities of the PTEN locus. There are associations with C-MYC aberrations in stroma with greater proximity to cancer and a correlation between telomere length in a number of prostatic histologies and the adjacent stroma, suggesting the importance of microenvironmental effects on telomere maintenance in the prostate. This finding was also supported by the finding of the correlation between telomere attrition and the levels of oxidative stress as measured by malondialdehyde staining in HPIN lesions close to cancer.

CONCLUSIONS

Telomere attrition in the prostate gland is associated with particular genomic aberrations that contribute to the genomic instability characteristic of prostatic carcinogenesis. Correlations between various histologies and adjacent stroma telomere length suggest it is also may reveal microenvironmental effects within the prostate gland. Oxidative stress may contribute to telomere attrition in HPIN close to cancer.

Entrainment and Flooding in Vertical Still-Heads

An investigation has been made of the entrainment entering, and collected on, vertical still-heads from a boiling solution. The entrainment entering the still-heads increased gradually with increasing distillation rate until the Reynolds Number of the vapour in the still head reached a value of about 10,000. At this point a much greater rate of increase was noted and was accompanied by a greater rate of collection of the entrainment over all sections of the still-head. The value of 10,000 for the Reynolds Number was verified from the observations of others. The true flooding effect did not occur until much higher distillation rates, when there was a sudden increase in the volume of liquid collected at the top of the still-head and a corresponding decrease in that collected at the bottom. Increasing the length of the still-head from 30 to 60 inches showed an increase in maximum collecting efficiency from approximately 96 to 99 per cent. Decontamination factors compared favourably with those obtained by other workers using more complex packed columns.

Concurrent stenting of multiple cerebrovascular stenotic lesions: technical note

INTRODUCTION

Until recently, the treatment of intracranial atherosclerosis has remained limited. Due to advances in endovascular technology and technique, angioplasty and stenting has become an accepted treatment for medically-refractory intracranial atherosclerosis. Patients with intracranial atherosclerosis frequently have multiple lesions, however, the clinical significance of each individual lesion is not always evident. In these instances the treating physician must decide which lesions should be managed conservatively, and which should be treated.

TECHNIQUE

Emphasizing decision-making, we describe a patient in whom 3 separate atherosclerotic lesions in the same vascular territory underwent endovascular treatment in one treatment session. Each of the lesions was treated with angioplasty and stent placement.

CONCLUSION

This may be a relatively safe and efficacious technique that allows for the treatment of multiple lesions without the risks associated with multiple cerebral angiograms.

The efficacy of endovascular stenting in the treatment of supraclinoid internal carotid artery blister aneurysms using a stent-in-stent technique

BACKGROUND AND PURPOSE

Blister aneurysms of the supraclinoid ICA represent a rare but well-documented cause of subarachnoid hemorrhage. These aneurysms are difficult to detect, and their surgical treatment is challenging, with high morbidity and mortality rates. The reports currently in the literature that describe the surgical and endovascular treatment of these aneurysms offer no clear consensus on the optimal treatment. We describe a staged endovascular treatment entailing stenting using a stent-in-stent technique, as well as planned but delayed embolization as the aneurysm increases in size to allow the introduction of coils.

MATERIALS AND METHODS

We performed a retrospective review of all cerebral angiograms performed at our institution over an 8-month period for evaluation of subarachnoid hemorrhage, identifying 6 ICA blister aneurysms.

RESULTS

All 6 blister aneurysms were located in the supraclinoid ICA. The stent-in-stent technique was used for the initial treatment of all patients. Three patients had no residual or recurrent aneurysm following initial treatment. Three patients required retreatment with coils after continued growth of the aneurysm, identified on follow-up angiography. Five patients had good recovery (average mRS score of 1), and 1 patient had poor neurologic recovery (mRS score of 3) due to a large hemorrhagic infarction.

CONCLUSIONS

Our case series suggests that staged endovascular treatment entailing the use of a stent-in-stent technique, augmented with subsequent coil embolization as necessary for progressive disease, is a viable endovascular option for treating ruptured supraclinoid blister aneurysms, allowing for parent artery preservation.

Utility of CT angiography in the identification and characterization of supraclinoid internal carotid artery blister aneurysms

BACKGROUND AND PURPOSE

Blister aneurysms of the supraclinoid ICA represent a rare but potentially catastrophic cause of SAH, often presenting both diagnostic and therapeutic dilemmas. We explore the utility of CTA in the identification and characterization of ICA blister aneurysms.

MATERIALS AND METHODS

We performed a retrospective review of catheter cerebral angiograms obtained at our institution over a 12-month period for evaluation of SAH, identifying 6 cases of ICA blister aneurysms. All patients underwent CTA and DSA for evaluation of SAH. The reports from the CTA and DSA studies were reviewed to identify aneurysms correctly diagnosed prospectively. Retrospective review of the CTA and DSA images was also performed. Review of the interpretations and images was performed for any follow-up studies.

RESULTS

All 6 patients presented with SAH, diagnosed by head CT. All patients subsequently underwent CTA prior to DSA evaluation. All 6 aneurysms were identified prospectively on initial DSA imaging. Of the 6 blister aneurysms, 4 (67%) were identified prospectively; and 5 (83%), retrospectively on CTA. All 6 patients underwent endovascular treatment with stent placement. Four of the 6 aneurysms underwent follow-up CTA (range, 9-22 days), including the 2 aneurysms that had been unidentifiable preprocedurally. All 4 blister aneurysms were seen postprocedurally by DSA. Three of these 4 (75%) residual aneurysms were detected by CTA (both prospectively and retrospectively).

CONCLUSIONS

In the presence of SAH and otherwise negative findings on CTA, a catheter cerebral angiogram should be performed to absolutely exclude an ICA blister aneurysm.

Follow-up for screen-detected ductal carcinoma in situ: results of a survey of UK centres participating in the Sloane project

AIMS

To investigate the variations in follow-up practice for screen-detected ductal carcinoma in situ (DCIS) in the UK.

METHODS

A questionnaire enquiring about follow-up practice and the perceived value of clinical follow-up after surgery for screen-detected DCIS was sent to the 74 UK screening centres participating in the Sloane Project.

RESULTS

Responses were received from 66 hospitals serving 54 screening centres. These demonstrate wide variations in practice. Clinical follow-up duration ranges from 1 year to indefinite, with the frequency of visits from three-monthly to annually. Formal mammographic follow-up duration ranges from none to indefinite. Mammographic frequency ranges from 1 to 2 years. Follow-up varies according to factors such as size and grade of disease and margin status in 23 units and according to whether adjuvant therapy is given in 23. Seven hospitals perform mammography of reconstructed breasts. Thirty-one centres consider clinical follow-up of DCIS to be of value or limited value whereas 28 consider it to be of little or no value.

CONCLUSIONS

There is no consensus with regard to the duration and frequency of follow-up for screen-detected DCIS, the contribution of predictive and treatment factors, the use of mammography of the reconstructed breast or the perceived value of clinical follow-up. Published guidelines show no consensus. Multidisciplinary teams involved in the care of women with screen-detected non-invasive cancer should contribute to audits such as the Sloane Project in order to determine the most effective and efficient ways to treat and follow up these patients.

Predictive value of needle core biopsy diagnoses of lesions of uncertain malignant potential (B3) in abnormalities detected by mammographic screening

AIMS

Breast needle core biopsy (NCB) is now a commonplace diagnostic procedure in breast cancer screening, providing accurate diagnoses of both benign and malignant lesions. However, NCB may result in the borderline diagnoses of lesion of uncertain malignant potential (B3) or suspicious of malignancy (B4). The aim was to study a large series of B3 cases from population-based screening subjects in order to evaluate positive predictive values (PPVs) for malignancy.

METHODS AND RESULTS

The results of 523 NCBs of women screened over a 7-year period (1999-2006) in the East Midlands region, UK, with a B3 diagnosis who underwent surgical excision, were reviewed and compared with the final excision histology. Five percent of NCBs were reported as B3. The most frequent histological subtypes were atypical intraductal epithelial proliferation (AIDEP) and radial scar/complex sclerosing lesion (RS/CSL). Final excision histology was benign in 417 (80%) and malignant in 106 (20%) subjects (60 ductal carcinoma in situ and 46 invasive carcinoma). Lesion-specific PPVs were as follows: AIDEP 32%; lobular neoplasia (LN) 30%; RS/CSL with AIDEP or LN 24%; RS/CSL without atypia 9%; papillary lesion with AIDEP or LN 36%; and papillary lesion without atypia 4%. Five of the 32 fibroepithelial lesions with cellular stroma were phyllodes tumours (four benign and one borderline). None of the five mucinous lesions on NCB was malignant.

CONCLUSIONS

Our results show that approximately one-fifth of NCB of screen-detected breast lesions classified as B3 are malignant on excision, and the likelihood of malignancy varies substantially between different histological subtypes.

The mammographic correlations of a new immunohistochemical classification of invasive breast cancer

AIM

Recent protein expression profiling of breast cancer has identified specific subtypes with clinical, biological, and therapeutic implications. The aim of this study was to identify the mammographic correlates of these novel molecular classes of invasive breast cancer.

MATERIALS AND METHODS

The mammographic findings of 415 patients with operable breast cancer were correlated with the previously described protein expression classes identified by our group using immunohistochemical (IHC) assessment of a large series of breast cancer cases prepared as tissue microarrays (TMAs). Twenty-five proteins of known relevance in breast cancer were assessed, including hormone receptors, HER-2 status, basal and luminal markers, p53 expression, and E-cadherin.

RESULTS

The mammographic background pattern and proportion of lesions that were mammographically occult were similar in all groups. Groups characterized by luminal and hormone receptor positivity had significantly more spiculate lesions at mammography. Groups characterized by HER-2 overexpression, basal characteristics, and E-cadherin positivity had a significantly higher proportion of ill-defined masses. These findings were independent of histological grade.

CONCLUSION

The mammographic features of breast cancer show significant correlation with molecular classes of invasive breast cancer identified by protein expression IHC analysis. The biological reasons for the findings and implications of these regarding imaging protocols require further study and may provide mechanisms for improvement of detection of these lesions.

Comparing the Accuracy of Digital Subtraction Angiography, CT Angiographyand MR Angiography at Estimating the Volume of Cerebral Aneurysms

SUMMARY

While there are many studies that compare imaging modalities in the detection of cerebralaneurysms there are no existing studies that compare two dimensional digital subtraction angiography (DSA), CT angiography (CTA) and MR angiography (MRA) in calculating the volume of cerebral aneurysms. This study will compare these imaging modalities on seven in vitro models of known volume. Seven silicone models of cerebral aneurysms were chosen representing slight variations in geometric shape and size. The volume of each model was measured by weighing the amount of water required to fill the aneurysm to the parentartery. Contrast enhanced images of the modelswere taken with DSA, CTA and MRA. The images were interpreted by four independent readers and the volumes were calculated. The measured volumes from the water weight analysis were compared to the volumes calculated from the interpreter's measurements. The accuracy of DSA, CTA and MRA were compared using the percent of absolute and true variance from the measured volume. The average percent absolute variance for DSA was 14.3%, CTA was 16.8% and MRA was 18.6%. While these differences were minimal, comparing the percent of true variance demonstrated an average variance of -1.9% for DSA, 16.1% for CTA and -15.9% for MRA. Calculating the volume of cerebral aneurysms, while increasingly important, is difficult and error prone. It is important to understand the limitations and inherent errors before relyingon calculated volumes in clinical decision making. Regardless of imaging modality, one should consider error rates of 14-19% for calculatingvolume while keeping in mind the tendencyfor CTA to overestimate volume, MRA to underestimate volume and DSA to both under and overestimate equally.

Primary cutaneous mucormycosis in a lung transplant recipient: case report and concise review of the literature

Mucormycosis (zygomycosis) is an invasive, opportunistic fungal infection caused by organisms of the class Zygomycetes. Immunocompromised individuals, including both solid organ and hematopoietic stem cell transplant recipients, are preferentially affected. Among solid organ transplant (SOT) recipients, the sinuses, with or without involvement of the orbits and cerebrum, are the most common sites of disease, although the pulmonary allograft appears to be targeted following lung transplantation. Here, we describe the unique case of a lung transplant recipient who developed multifocal cutaneous mucormycosis without involvement of the pulmonary allograft, and review the published literature regarding incidence, treatment, and prognosis of primary cutaneous mucormycosis following SOT.

Peritoneal keratin granulomas complicating endometrial carcinoma: a report of two cases and review of the literature

Squamous differentiation in endometrial adenocarcinoma is common. Rarely, it may be complicated by peritoneal keratin granulomas. Keratin granulomas accompanied by viable adenocarcinoma cells are regarded as conventional metastatic foci. However, the significance of keratin granulomas without accompanying viable adenocarcinoma cells is difficult to ascertain. Only a small number of cases with significant follow up are documented in the literature. We present two cases of peritoneal keratin granulomas, review the literature and discuss the significance of these lesions

Can computerised tomography replace bone scintigraphy in detecting bone metastases from breast cancer? A prospective study

BACKGROUND

The aim of this study was to determine whether bone scans (BS) can be avoided if pelvis was included in CT thorax and abdomen to detect bony metastases from breast cancer.

MATERIALS AND METHODS

Results of 77 pairs of CT (thorax, abdomen, and pelvis) and BS in newly diagnosed patients with metastatic breast cancer (MBC) were compared prospectively for 12 months. Both scans were blindly assessed by experienced radiologists and discussed at multidisciplinary team meetings regarding the diagnosis of bone metastases.

RESULTS

CT detected metastatic bone lesions in 43 (98%) of 44 patients with bone metastases. The remaining patient had a solitary, asymptomatic bony metastasis in shaft of femur. BS was positive in all patients with bone metastases. There were 11 cases of false positive findings on BS.

CONCLUSION

Our findings suggest routine BS of patients presenting with MBC is not required if CT (thorax, abdomen, and pelvis) is performed.

Transorbital puncture for the treatment of cavernous sinus dural arteriovenous fistulas

This report describes a series of patients for whom dural arteriovenous fistulae (DAVFs) of the cavernous sinus were successfully embolized using a percutaneous, transorbital technique to directly cannulate the cavernous sinus. A vascular access needle and catheter are percutaneously advanced along the inferolateral aspect of the orbit to access the cavernous sinus via the superior orbital fissure. Safe and effective embolization is achieved without the need for a surgical cut-down.

NHSBSP type 1 interval cancers: a scientifically valid grouping?

AIM

To assess whether there are differences in the pathological features or survival between the new National Health Service Breast Screening Programme (NHSBSP) interval cancer classification system category of type 1 interval cancers, and the previously used, separate categories of occult, unclassified, and true interval cancers.

MATERIALS AND METHODS

The prognostic pathological features (grade, lymph node stage, size, vascular invasion, oestrogen receptor status, and histological type) and survival of 428 type 1 interval invasive breast cancers were analysed by subgroup (occult, unclassified and true interval).

RESULTS

Occult cancers compared with other type 1 interval cancers were of significantly lower grade [38 of 52 (73%) versus 151 of 340 (44%) grade 1 or 2, p=0.0005], more likely to be smaller size [37 of 51 (73%) versus 158 of 341 (46%) <20mm, p=0.0003] and more frequently of lobular type at histology [14 of 42 (32%) versus 50 of 286 (17%), p=0.03]. There was no significant difference in pathological features of unclassified tumours compared with other type 1 tumours. There was no significant survival difference between different type 1 subgroups (p=0.12).

CONCLUSION

The NHSBSP type 1 interval cancers are a heterogeneous grouping with markedly differing pathological features. However, no significant survival difference is seen between the different type 1 subgroups.

Radiological and pathological findings of interval cancers in a multi-centre, randomized, controlled trial of mammographic screening in women from age 40-41 years

AIM

The aim of this study was to analyse the radiographic findings of the screening mammograms of women with interval cancer who participated in a multi-centre, randomized, controlled trial of mammographic screening in women from age 40-48 years.

MATERIALS AND METHODS

The screening and diagnostic mammograms of 208 women with interval cancers were reviewed. Abnormalities were classified as malignant, subtle and non-specific.

RESULTS

Eighty-seven (42%) of women had true, 66 (32%) occult and 55 (26%) false-negative interval cancers. The features most frequently missed or misinterpreted were granular microcalcification (38%), asymmetric density (27%) and distortion (22%). Thirty-seven percent of abnormal previous screens were classified as malignant, 39% subtle change and 21% as non-specific. Granular calcifications were significantly more common on the diagnostic mammograms of false-negative interval cancers than those of true interval cancers (28 versus 14%, p=0.04). Occult interval cancers were more likely to be <10 mm and <15 mm in invasive pathological size than other interval cancers (p=0.03 and 0.005, respectively). True interval cancers were more likely to be histologically grade 3 than other interval cancers (p=0.04). Women who developed true and false-negative interval cancers had similar background patterns, but women with occult cancers had a higher proportion of dense patterns (p<0.05).

CONCLUSION

Interval cancers in a young screening population have a high proportion of occult lesions that are small and occur in dense background patterns. The proportion of interval cancers that are false negative is similar that seen in older populations and granular microcalcification is the commonest missed mammographic feature.

Interval breast cancers: prognostic features and survival by subtype and time since screening

OBJECTIVES

To investigate the hypothesis that interval cancers arising soon after the previous screen and true interval cancers are biologically aggressive and have a relatively poor prognosis compared with other interval cancers, and to assess which prognostic features are relevant to interval cancers.

METHODS

Analysis of prognostic pathological features (grade, lymph node stage, size, vascular invasion, oestrogen receptor [ER] status and histological type), radiological features (comedo/non-comedo calcification and spiculation) and survival for 538 invasive interval breast cancer cases by type and time since previous screen.

RESULTS

Late interval cancers were less likely to be lymph node positive (13 versus 43%, P = 0.003). Type 1 interval cancers were more likely to be histological grade 3 than type 2 (minimal signs) and type 3 (false-negative) intervals (52 versus 35%, P = 0.05). Type 3 interval cancers were more likely to have lobular features than other intervals (47 versus 20%, P < 0.0001). There was no significant survival difference by interval cancer type (P = 0.64) or interval year (P = 0.83). At univariate analysis of all interval cancers, tumour size, grade, nodal stage, ER status, vascular invasion and comedo calcification were associated with survival. On multivariate analysis of prognostic features significant at univariate analysis, nodal stage (P value = 0.009), tumour size (P = 0.001), ER status (P < 0.0001) and vascular invasion (P < 0.0001) maintained independent significance.

CONCLUSIONS

Our study shows that true intervals and interval cancers arising quickly after screening do not have a worse prognosis than other interval cancers, and that interval cancers have a unique set of prognostic features.

How relevant is breast cancer screening in the Asia/Pacific region?

Nationwide breast cancer screening with mammography is well-established in many western countries. Many studies have shown its benefit in mortality reduction. However, breast cancer screening in Asia has been slow to implement, as it was perceived that the breast cancer incidence was low and the parenchyma of Asian women was difficult to assess mammographically. With changing disease patterns, breast cancer is now one of the most common cancers amongst women in Asia. Breast cancer screening has become an important and relevant health problem. However, apart from biological differences between western and Asian women, cultural and economic considerations need to be addressed. This paper looks at the various issues pertaining to the feasibility and relevance of population-based screening in the Asia/Pacific region.

Radiological findings of screen-detected cancers in a multi-centre randomized, controlled trial of mammographic screening in women from age 40 to 48 years

AIM

To elucidate the mammographic findings of screen-detected cancers in women screened between 40-48 years, and to establish the frequency and nature of abnormal findings on previous mammograms in women with screen-detected cancers.

METHODS

A radiology review panel consisting of three experienced breast radiologists viewed the screening mammograms in chronological order, confirming that any abnormalities detected corresponded to the cancers detected at later screens. An analysis correlating mammographic features with median invasive size and the proportion measuring less than 10 and 15mm was performed.

RESULTS

Two hundred and thirty-two women had screen-detected invasive cancers with mammograms available for review. The most frequent features seen at diagnosis were spiculate mass, ill-defined mass, granular calcification, deformity and comedo calcification. Thirty-four percent of mammograms showed calcification. The mammographic sign associated with smallest median size was calcification. Calcification was also the mammographic abnormality most frequently associated with cancers <10mm in size. In total there were 147 abnormal previous screens of 87 women. The most commonly missed features were granular microcalcification, deformity and ill-defined mass. Of the missed abnormalities 20% were classified as malignant, 43% as subtle change and 32% as non-specific.

CONCLUSION

Compared with older women, screen-detected cancer in younger women more commonly manifests as calcification and less frequently a spiculate mass. Calcification is the sign most frequently associated with invasive cancers <10mm in size. Calcification and deformity are the signs most frequently seen on the previous mammograms of women with screen-detected cancer.

Accuracy of mammography in predicting histological extent of ductal carcinoma in situ (DCIS)

Accuracy of mammography in predicting pathological extent of ductal carcinoma in situ (DCIS).

BACKGROUND AND AIMS

Mammographic extent is the main determinant for offering wide local excision (WLE) for DCIS. It is recognized that this is not always accurate. Patients who prove to have larger lesions than predicted require further surgery. The aim of this study was to define the degree of variance between mammographic (MMG) and pathological (path) measurements of DCIS and to analyse the factors predicting a significant discrepancy.

METHODS

The pathological and mammographic data for 174 cases of DCIS were reviewed.

RESULTS

The mammographic size was bigger than the histological size in 97 (55.7%) and there was >10mm difference in 18 (10.3%) cases. The histological size was bigger than the mammographic size in 69 (39.7%) cases and >10mm difference was found in 30 (17.2%) cases. There was a significant relationship between larger MMG size, MMG size measured in two dimensions (MMG bi-dimensional product) and MMG-path size discrepancy (p<0.01). In addition, the larger the size discrepancy, the greater the chance of requiring more than one therapeutic procedure (p<0.01). There was no significant correlation between age, histological grade, mammographic density and shortest distance from nipple with degree of mammographic-pathological size discrepancy.

Unusual benign breast lesions

The purpose of this article is to show examples of the radiological (mammography and/or ultrasound) and pathological appearances of unusual benign breast lesions. The conditions covered are granular cell tumours, fibromatosis, nodular fasciitis, myofibroblastomas, haemangiomas, neurofibromas, and leiomyomas. The article includes the first published description of the ultrasound appearance of a myofibroblastoma. Knowledge of these appearances may help confirm or refute radiological-pathological concordance of percutaneous biopsy results during multidisciplinary assessment of these lesions and aid patient management.

The pathological and radiological features of screen-detected breast cancers diagnosed following arbitration of discordant double reading opinions

AIM

To compare the mammographic background pattern, the mammographic and the pathological features of screen-detected cancers diagnosed following arbitration of discordant double reading opinions with screen-detected cancers diagnosed following concordant double reading.

METHODS

Between April 2002 and December 2003, 249 patients were diagnosed with screen-detected malignancies following concordant double reading. In the same period 38 patients were diagnosed with screen-detected malignancies after their mammograms had undergone arbitration prior to recall. Mammograms of both groups of patients were reviewed retrospectively and the mammographic features documented. Histological data for both groups were also compared.

RESULTS

Cancers detected following arbitration were more likely to manifest as parenchymal distortions (44 versus 8%, p<0.001) and less likely to manifest as spiculate masses (19 versus 42%, p=0.014). Arbitration cancers were less likely to be detected in fatty breasts (4 versus 29%, p=0.01). Arbitration cancers were smaller (p=0.045). Lobular cancers were commoner in the arbitration group, although this was of borderline significance (19 versus 8%, p=0.057) There was no significant difference in patient age, tumour grade or lymph node stage between the two groups.

CONCLUSION

Cancers detected following arbitration are smaller and more likely to manifest as a parenchymal distortion compared with cancers detected by both readers. Arbitration cancers have broadly similar prognostic features to cancers detected by concordant double reading. It is estimated that approximately 11% more cancers are detected as a result of double reading with arbitration compared with single reading alone, after taking into consideration second reader bias.