Invasive lobular carcinoma of the breast; clinicopathologic profile and response to neoadjuvant chemotherapy over a 15-year period

INTRODUCTION

Invasive lobular carcinoma (ILC) accounts for 5-15% of invasive breast cancers. Typical ILC is oestrogen receptor (ER) positive and human epidermal growth factor receptor 2 (HER2) negative. Atypical biomarker profiles (ER- and HER2+, ER+ and HER2+ or triple negative) appear to differ from typical ILCs. This study compared subtypes of ILC in terms of clinical and pathological parameters, and response to neoadjuvant chemotherapy (NACT) according to biomarker profile.

METHODS

All patients with ILC treated in a single centre from January 2005 to December 2020 were identified from a prospectively maintained database. Clinicopathologic and outcome data was collected and analysed according to tumour biomarker profile.

RESULTS

A total of 582 patients with ILC were treated. Typical ILC was observed in 89.2% (n = 519) and atypical in 10.8% (n = 63). Atypical ILCs were of a higher grade (35% grade 3 vs 9.6% grade 3, p < 0.001). A larger proportion of atypical ILC received NACT (31.7% vs 6.9% p < 0.001). Atypical ILCs showed a greater response to NACT (mean RCB (Residual Cancer Burden Score) 2.46 vs mean RCB 3.41, p = 0.0365), and higher pathological complete response rates (15% vs 0% p = 0.017). Despite this, overall 5-year disease-free survival (DFS) was higher in patients with typical ILC (91% vs 83%, p = 0.001).

CONCLUSIONS

Atypical ILCs have distinct characteristics. They are more frequently of a higher grade and demonstrate a superior response to NACT. Despite the latter, atypical ILCs have a worse 5-year DFS which should be taken into consideration in terms of prognostication and may assist patient selection for NACT.

"What Works" to Support LGBTQ+ Young People's Mental Health: An Intersectional Youth Rights Approach

Despite overwhelming international evidence of elevated rates of poor mental health in LGBTQ+ youth compared to their cis-heterosexual peers, we know relatively little about effective mental health services for this population group. This study aims to produce the first early intervention model of "what works" to support LGBTQ+ youth with emerging mental health problems. Utilizing a mixed method case study, we collected data across 12 UK mental health service case study sites that involved: (a) interviews with young people, parents, and mental health practitioners (n = 93); (b) documentary analysis; (c) nonparticipant observation. The data analysis strategy was theoretical using the "explanation-building" analytical technique. Our analysis suggests an intersectional youth rights approach with 13 principles that must be enacted to provide good mental health services as advocated by the United Nations Convention on the Rights of the Child and World Health Organization. This approach should address the multiple forms of marginalization and stigmatization that LGBTQ+ youth may experience, enable informed independent decision-making, and uphold the right to freedom of safe self-expression. A rights-based approach to mental health services for LGBTQ+ young people is not prominent. This needs to change if we are to tackle this mental health inequality and improve the mental well-being of LGBTQ+ youth worldwide.

Reducing LGBTQ+ adolescent mental health inequalities: a realist review of school-based interventions

BACKGROUND

LGBTQ+ young people have elevated rates of poor mental health in comparison to their cisgender heterosexual peers. School environment is a key risk factor and consistently associated with negative mental health outcomes for LGBTQ+ adolescents.

AIMS

To examine how, why, for whom and in what context school-based interventions prevent or reduce mental health problems in LGBTQ+ adolescents.

METHODS

A realist review methodology was utilised and focused on all types of school-based interventions and study designs. A Youth Advisory Group were part of the research team. Multiple search strategies were used to locate relevant evidence. Studies were subject to inclusion criteria and quality appraisal, and included studies were synthesised to produce a programme theory. Seventeen studies were included in the review.

RESULTS

Eight intervention components were necessary to address LGBTQ+ pupils mental health: affirmative visual displays; external signposting to LGBTQ+ support; stand-alone input; school-based LGBTQ support groups; curriculum-based delivery; staff training; inclusion policies; trusted adult. Few school-based interventions for this population group were identified.

CONCLUSIONS

The programme theory indicates that "to work" school-based interventions must have a "whole-school" approach that addresses specifically the dominant cis-heteronormative school environment and hence the marginalisation, silence, and victimisation that LGBTQ+ pupils can experience.

A National Survey of Hereditary Angioedema and Acquired C1 Inhibitor Deficiency in the United Kingdom

BACKGROUND

Detailed demographic data on people with hereditary angioedema (HAE) and acquired C1 inhibitor deficiency in the United Kingdom are relatively limited. Better demographic data would be beneficial in planning service provision, identifying areas of improvement, and improving care.

OBJECTIVE

To obtain more accurate data on the demographics of HAE and acquired C1 inhibitor deficiency in the United Kingdom, including treatment modalities and services available to patients.

METHODS

A survey was distributed to all centers in the United Kingdom that look after patients with HAE and acquired C1 inhibitor deficiency to collect these data.

RESULTS

The survey identified 1152 patients with HAE-1/2 (58% female and 92% type 1), 22 patients with HAE with normal C1 inhibitor, and 91 patients with acquired C1 inhibitor deficiency. Data were provided by 37 centers across the United Kingdom. This gives a minimum prevalence of 1:59,000 for HAE-1/2 and 1:734,000 for acquired C1 inhibitor deficiency in the United Kingdom. A total of 45% of patients with HAE were on long-term prophylaxis (LTP) with the most used medication being danazol (55% of all patients on LTP). Eighty-two percent of patients with HAE had a home supply of acute treatment with C1 inhibitor or icatibant. A total of 45% of patients had a supply of icatibant and 56% had a supply of C1 inhibitor at home.

CONCLUSIONS

Data obtained from the survey provide useful information about the demographics and treatment modalities used in HAE and acquired C1 inhibitor deficiency in the United Kingdom. These data are useful for planning service provision and improving services for these patients.

Development of cancer surveillance guidelines in ataxia telangiectasia: A Delphi-based consensus survey of international experts

BACKGROUND/OBJECTIVES

Ataxia telangiectasia (A-T) is a multiorgan disorder with increased vulnerability to cancer. Despite this increased cancer risk, there are no widely accepted guidelines for cancer surveillance in people affected by A-T. We aimed to understand the current international practice regarding cancer surveillance in A-T and agreed-upon approaches to develop cancer surveillance in A-T.

DESIGN/METHODS

We used a consensus development method, the e-Delphi technique, comprising three rounds. Round 1 consisted of a Delphi questionnaire and a survey that collected the details of respondents' professional background, experience, and current practice of cancer surveillance in A-T. Rounds 2 and 3 were designed based on previous rounds and modified according to the comments made by the panellists. The pre-specified consensus threshold was ≥75% agreement.

RESULTS

Thirty-five expert panellists from 13 countries completed the study. The survey indicated that the current practice of cancer surveillance varies widely between experts and centres'. Consensus was reached that evidence-based guidelines are needed for cancer surveillance in people with A-T, with separate recommendations for adults and children. Statements relating to the tests that should be included, the age for starting and stopping cancer surveillance and the optimal surveillance interval were also agreed upon, although in some areas, the consensus was that further research is needed.

CONCLUSION

The international expert consensus statement confirms the need for evidence-based cancer surveillance guidelines in A-T, highlights key features that the guidelines should include, and identifies areas of uncertainty in the expert community. This elucidates current knowledge gaps and will inform the design of future clinical trials.

Respiratory Outcomes at 5-Year Follow-Up in Children with Mannose-Binding Lectin Deficiency: A Retrospective Cohort Study

OBJECTIVE

Mannose-binding lectin deficiency may predispose children to having increased infection susceptibility. However, there is no conclusive evidence that mannose-binding lectin deficiency is associated with adverse respiratory consequences in children. We aimed to evaluate the effects of mannose-binding lectin deficiency (defined as a level of less than 0.6 mg/L) on clinical, radiological, and microbiological characteristics in children presenting with troublesome respiratory symptoms, as compared to those who are mannosebinding lectin-sufficient.

MATERIAL AND METHODS

We conducted a retrospective cohort study to investigate the association between mannose-binding lectin deficiency and respiratory outcomes in children over a period of 10 years in a large teaching hospital. Children presenting with frequent or persistent respiratory symptoms such as a chronic wet cough lasting more than 4 weeks, recurrent lower respiratory tract infections (≥4 infections in a year), or severe respiratory tract infections requiring admission to intensive care or to high dependency unit were included in the study.

RESULTS

The study showed no significant difference in clinical outcomes with mannose-binding lectin deficiency and sufficiency. Thirty-two percent of children with mannose-binding lectin deficiency and 30% of those with mannose-binding lectin sufficiency had positive respiratory microbiology. Twenty-three percent of children with mannose-binding lectin deficiency and 24% of those with mannose-binding lectin sufficiency had radiological changes on plain radiographs; also the prevalence of bronchiectasis was similar in both groups. The rates of admission to pediatric intensive care unit were comparable in the 2 groups.

CONCLUSIONS

Children with mannose-binding lectin deficiency and sufficiency showed similar clinical, radiological, and microbiological characteristics. Our study suggests that there are no childhood adverse respiratory consequences with mannose-binding lectin deficiency.

Understanding How School-Based Interventions Can Tackle LGBTQ+ Youth Mental Health Inequality: A Realist Approach

Globally, research indicates that LGBTQ+ young people have elevated rates of poor mental health in comparison with their cisgender heterosexual peers. The school environment is a major risk factor and is consistently associated with negative mental health outcomes for LGBTQ+ young people. The aim of this UK study was to develop a programme theory that explained how, why, for whom, and in what context school-based interventions prevent or reduce mental health problems in LGBTQ+ young people, through participation with key stakeholders. Online realist interviews were conducted in the UK with (1) LGBTQ+ young people aged between 13-18 years attending secondary schools (N = 10); (2) intervention practitioners (N = 9); and (3) school staff (N = 3). A realist retroductive data analysis strategy was employed to identify causal pathways across different interventions that improved mental health outcomes. The programme theory we produced explains how school-based interventions that directly tackle dominant cisgender and heterosexual norms can improve LGBTQ+ pupils' mental health. We found that context factors such as a 'whole-school approach' and 'collaborative leadership' were crucial to the delivery of successful interventions. Our theory posits three causal pathways that might improve mental health: (1) interventions that promote LGBTQ+ visibility and facilitate usualising, school belonging, and recognition; (2) interventions for talking and support that develop safety and coping; and (3) interventions that address institutional school culture (staff training and inclusion polices) that foster school belonging, empowerment, recognition, and safety. Our theoretical model suggests that providing a school environment that affirms and usualises LGBTQ+ identities and promotes school safety and belonging can improve mental health outcomes for LGBTQ+ pupils.

Outcomes following SARS-CoV-2 infection in patients with primary and secondary immunodeficiency in the UK

In March 2020, the United Kingdom Primary Immunodeficiency Network (UKPIN) established a registry of cases to collate the outcomes of individuals with PID and SID following SARS-CoV-2 infection and treatment. A total of 310 cases of SARS-CoV-2 infection in individuals with PID or SID have now been reported in the UK. The overall mortality within the cohort was 17.7% (n = 55/310). Individuals with CVID demonstrated an infection fatality rate (IFR) of 18.3% (n = 17/93), individuals with PID receiving IgRT had an IFR of 16.3% (n = 26/159) and individuals with SID, an IFR of 27.2% (n = 25/92). Individuals with PID and SID had higher inpatient mortality and died at a younger age than the general population. Increasing age, low pre-SARS-CoV-2 infection lymphocyte count and the presence of common co-morbidities increased the risk of mortality in PID. Access to specific COVID-19 treatments in this cohort was limited: only 22.9% (n = 33/144) of patients admitted to the hospital received dexamethasone, remdesivir, an anti-SARS-CoV-2 antibody-based therapeutic (e.g. REGN-COV2 or convalescent plasma) or tocilizumab as a monotherapy or in combination. Dexamethasone, remdesivir, and anti-SARS-CoV-2 antibody-based therapeutics appeared efficacious in PID and SID. Compared to the general population, individuals with PID or SID are at high risk of mortality following SARS-CoV-2 infection. Increasing age, low baseline lymphocyte count, and the presence of co-morbidities are additional risk factors for poor outcome in this cohort.

A case of wild-type rubella-associated cutaneous granuloma in ataxia telangiectasia

Granulomatous skin disease is known to be associated with various primary immunodeficiencies, including ataxia telangiectasia (AT). Recent reports of persistence of live vaccine strain rubella within such cutaneous granulomas have raised concern regarding the safety of vaccination. Here we report a case of cutaneous granuloma in association with AT, demonstrating wild type, rather than vaccine strain rubella. This supports the persistence of rubella as a causative mechanism, but suggests it is not vaccine strain-specific, and thus may impact the decision of those considering not vaccinating this subset of children.

Explaining effective mental health support for LGBTQ+ youth: A meta-narrative review

This meta-narrative review on mental health early intervention support for LGBTQ+ ​youth aimed to develop a theoretical framework to explain effective mental health support. Using the RAMESES standards for meta-narrative reviews, we identified studies from database searches and citation-tracking. Data extraction and synthesis was conducted through conceptual coding in Atlas.ti. in two stages: 1) conceptual mapping of the meta-narratives; 2) comparing the key concepts across the meta-narratives to produce a theoretical framework. In total, 2951 titles and abstracts were screened and 200 full papers reviewed. 88 studies were included in the final review. Stage 1 synthesis identified three meta-narratives - psychological, psycho-social, and social/youth work. Stage 2 synthesis resulted in a non-pathological theoretical framework for mental health support that acknowledged the intersectional aspects of LGBTQ+ ​youth lives, and placed youth at the centre of their own mental health care. The study of LGBTQ+ ​youth mental health has largely occurred independently across a range of disciplines such as psychology, sociology, public health, social work and youth studies. The interdisciplinary theoretical framework produced indicates that effective early intervention mental health support for LGBTQ+ ​youth must prioritise addressing normative environments that marginalises youth, LGBTQ+ ​identities and mental health problems.

•

Despite elevated rates of poor mental health, LGBTQ ​+ ​youth underutilize mental health services and often experience inadequate support.

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There is a limited evidence-base examining LGBTQ ​+ ​youth early intervention mental health support needs.

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Early intervention services for LGBTQ ​+ ​youth mental health must de-pathologize emotional distress, difficult thoughts and behaviours.

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Early intervention support must address normative environments that marginalises youth, intersectional LGBTQ ​+ ​identities and mental health.

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Mental health support ​providers must understand individual lives, connect with LGBTQ+ youth, facilitate their autonomy and encourage agency.

Simple Measurement of IgA Predicts Immunity and Mortality in Ataxia-Telangiectasia

Patients with ataxia-telangiectasia (A-T) suffer from progressive cerebellar ataxia, immunodeficiency, respiratory failure, and cancer susceptibility. From a clinical point of view, A-T patients with IgA deficiency show more symptoms and may have a poorer prognosis. In this study, we analyzed mortality and immunity data of 659 A-T patients with regard to IgA deficiency collected from the European Society for Immunodeficiencies (ESID) registry and from 66 patients with classical A-T who attended at the Frankfurt Goethe-University between 2012 and 2018. We studied peripheral B- and T-cell subsets and T-cell repertoire of the Frankfurt cohort and survival rates of all A-T patients in the ESID registry. Patients with A-T have significant alterations in their lymphocyte phenotypes. All subsets (CD3, CD4, CD8, CD19, CD4/CD45RA, and CD8/CD45RA) were significantly diminished compared to standard values. Patients with IgA deficiency (n = 35) had significantly lower lymphocyte counts compared to A-T patients without IgA deficiency (n = 31) due to a further decrease of naïve CD4 T-cells, central memory CD4 cells, and regulatory T-cells. Although both patient groups showed affected TCR-ß repertoires compared to controls, no differences could be detected between patients with and without IgA deficiency. Overall survival of patients with IgA deficiency was significantly diminished. For the first time, our data show that patients with IgA deficiency have significantly lower lymphocyte counts and subsets, which are accompanied with reduced survival, compared to A-T patients without IgA deficiency. IgA, a simple surrogate marker, is indicating the poorest prognosis for classical A-T patients. Both non-interventional clinical trials were registered at clinicaltrials.gov 2012 (Susceptibility to infections in ataxia-telangiectasia; NCT02345135) and 2017 (Susceptibility to Infections, tumor risk and liver disease in patients with ataxia-telangiectasia; NCT03357978)

The role of percutaneous CT-guided biopsy of an adrenal lesion in patients with known or suspected lung cancer

PURPOSE

To determine the sensitivity, specificity, and complication rate of percutaneous adrenal biopsy in patients with known or suspected lung cancer.

METHODS

This study was approved by the Institutional Review Board at our institution as a retrospective analysis; therefore, the need for informed consent was waived. All percutaneous adrenal biopsies performed between April 1993 and May 2019 were reviewed. 357 of 582 biopsies were performed on 343 patients with known or suspected lung cancer (M:F 164:179; mean age 66 years). The biopsy results were classified into malignant, benign, or non-diagnostic. The final diagnosis was established by pathology (biopsy and/or surgical resection) or imaging follow-up on CT for at least 12 months following the biopsy. Patients with less than 12 months follow-up were excluded (n = 44). Complications were recorded.

RESULTS

The final diagnosis was metastatic lung cancer in 235 cases (77.8%), metastasis from an extrapulmonary primary in 2 cases (0.7%), pheochromocytoma in 2 cases (0.7%), and benign lesions in 63 cases (20.9%). Percutaneous adrenal gland biopsy had a sensitivity of 97% and specificity of 100% for lung cancer metastases. The non-diagnostic rate was 0.6%. Larger lesions were more likely to be malignant (p = 0.0000) and to be correctly classified as a lung metastasis (p = 0.025). The incidence of minor complications was 1.1%. There were no major complications.

CONCLUSION

Over 20% of adrenal lesions in patients with known or suspected lung cancer were not related to lung cancer. Percutaneous adrenal gland biopsy is a safe procedure, with high sensitivity and specificity for lung cancer metastases.

Psychological Correlates of Self-Harm within Gay, Lesbian and Bisexual UK University Students

This study explores the association between lesbian, gay or bisexual (LGB) status and self-harm in UK higher education students. There is currently limited data on this association, and the role psychological variables have in potentially explaining this link, in UK students. We examine whether LGB status is associated with self-harm (both non-suicidal self-injury [NSSI] and suicide attempts [SA]), and whether 4 psychological variables (depression, anxiety, belongingness, self-esteem) mediate this association. A cross-sectional survey was used. UK university students (n = 707) completed an online survey including measures of self-harm, affective symptoms, belongingness, and self-esteem. Latent Variable Modelling (LVM) was used to test our hypotheses. LGB status remained associated with an elevated risk of NSSI and SA even after accounting for mediating factors. Self-esteem and (in the case of SA but not NSSI) thwarted belongingness, did, however, explain some of this association and were correlated with self-harm risk. The findings suggest that psychological factors may account for the association between LGB status and self-harm and, as such, prevention and intervention efforts directed at these psychological mediators may help to reduce self-harm risk in this population.

The social determinants of lesbian, gay, bisexual and transgender youth suicidality in England: a mixed methods study

Background

Lesbian, gay, bisexual and transgender (LGBT) youth have a higher risk of suicidality and self-harm than heterosexual youth populations but little is known about the underlying mechanisms. We aimed to investigate the social determinants of this mental health inequality.

Methods

A two-stage sequential mixed method study was conducted. Firstly, 29 semi-structured interviews with LGBT youth (aged 13–25 years old) were completed. Data was analysed thematically. Stage 2 involved a self-completed questionnaire employing an online community-based sampling strategy (n = 789). Logistic regression analysis was performed to predict suicidality.

Results

Five social determinants explained suicidal risk: (i) homophobia, biphobia or transphobia; (ii) sexual and gender norms; (iii) managing sexual and gender identities across multiple life domains; (iv) being unable to talk; (v) other life crises. Youth who were transgender (OR = 1.50, P < 0.022), disabled (OR = 2.23, P < 0.000), had self-harmed (OR = 7.45, P < 0.000), were affected by abuse (OR = 2.14, P < 0.000), and affected by not talking about their emotions (OR = 2.43, P < 0.044) were most likely to have planned or attempted suicide.

Conclusions

Public health universal interventions that tackle bullying and discrimination in schools, and selected interventions that provide specific LGBT youth mental health support could reduce LGBT mental health inequalities in youth suicidality.

Conducting sexualities research: an outline of emergent issues and case studies from ten Wellcome-funded projects

This letter seeks to synthesise methodological challenges encountered in a cohort of Wellcome Trust-funded research projects focusing on sexualities and health. The ten Wellcome Trust projects span a diversity of gender and sexual orientations and identities, settings; institutional and non-institutional contexts, lifecourse stages, and explore a range of health-related interventions.  As researchers, we originate from a breadth of disciplinary traditions, use a variety of research methods and data sources. Despite this breadth, four common themes are found across the projects: (i) inclusivity, representations and representativeness, (ii) lumping together of diverse groups, (iii) institutions and closed settings (iv) ethical and governance barriers.

Family trouble: Heteronormativity, emotion work and queer youth mental health

Conflict with the family about sexual orientation and gender diversity is a key risk factor associated with poor mental health in youth populations. Findings presented here derive from a UK study that employed an interdisciplinary critical mental health approach that de-pathologised emotional distress and conceptualised families as social and affective units that are created through everyday practices. Our aim was to explore how family relationships foster, maintain or harm the mental health and well-being of LGBTQ+ youth. Data were generated through exploratory visual, creative and digital qualitative methods in two phases. Phase 1 involved digital/paper emotion maps and interviews with LGBTQ+ youth aged 16 to 25 (n = 12) and family member/mentor interviews (n = 7). Phase 2 employed diary methods and follow-up interviews (n = 9). The data analytic strategy involved three stages: individual case analysis, cross-sectional thematic analysis and meta-interpretation. We found that family relationships impacted queer youth mental health in complex ways that were related to the establishment of their autonomous queer selves, the desire to remain belonging to their family and the need to maintain a secure environment. The emotion work involved in navigating identity, belonging and security was made difficult because of family heteronormativity, youth autonomy and family expectations, and had a stark impact on queer youth mental health and well-being. Improving the mental health of LGBTQ+ youth requires a much deeper understanding of the emotionality of family relationships and the difficulties negotiating these as a young person.

Bi-allelic Loss-of-Function CACNA1B Mutations in Progressive Epilepsy-Dyskinesia

The occurrence of non-epileptic hyperkinetic movements in the context of developmental epileptic encephalopathies is an increasingly recognized phenomenon. Identification of causative mutations provides an important insight into common pathogenic mechanisms that cause both seizures and abnormal motor control. We report bi-allelic loss-of-function CACNA1B variants in six children from three unrelated families whose affected members present with a complex and progressive neurological syndrome. All affected individuals presented with epileptic encephalopathy, severe neurodevelopmental delay (often with regression), and a hyperkinetic movement disorder. Additional neurological features included postnatal microcephaly and hypotonia. Five children died in childhood or adolescence (mean age of death: 9 years), mainly as a result of secondary respiratory complications. CACNA1B encodes the pore-forming subunit of the pre-synaptic neuronal voltage-gated calcium channel Ca_v2.2/N-type, crucial for SNARE-mediated neurotransmission, particularly in the early postnatal period. Bi-allelic loss-of-function variants in CACNA1B are predicted to cause disruption of Ca²⁺ influx, leading to impaired synaptic neurotransmission. The resultant effect on neuronal function is likely to be important in the development of involuntary movements and epilepsy. Overall, our findings provide further evidence for the key role of Ca_v2.2 in normal human neurodevelopment.

Acquisition of Verb Meaning From Syntactic Distribution in Preschoolers With Autism Spectrum Disorder

Purpose

Our goal was to investigate whether preschool children with autism spectrum disorder (ASD) can begin to learn new word meanings by attending to the linguistic contexts in which they occur, even in the absence of visual or social context. We focused on verbs because of their importance for subsequent language development.

Method

Thirty-two children with ASD, ages 2;1-4;5 (years;months), participated in a verb-learning task. In a between-subjects design, they were randomly assigned to hear novel verbs in either transitive or intransitive syntactic frames while watching an unrelated silent animation or playing quietly with a toy. In an eye-tracking test, they viewed two video scenes, one depicting a causative event (e.g., boy spinning girl) and the other depicting synchronous events (e.g., boy and girl waving). They were prompted to find the referents of the novel verbs, and their eye gaze was measured.

Results

Like typically developing children in prior work, children with ASD who had heard the verbs in transitive syntactic frames preferred to look to the causative scene as compared to children who had heard intransitive frames.

Conclusions

This finding replicates and extends prior work on verb learning in children with ASD by demonstrating that they can attend to a novel verb's syntactic distribution absent relevant visual or social context, and they can use this information to assign the novel verb an appropriate meaning. We discuss points for future research, including examining individual differences that may impact success and contrasting social and nonsocial word-learning tasks directly.

Phenotype, penetrance, and treatment of 133 cytotoxic T-lymphocyte antigen 4-insufficient subjects

BACKGROUND

Cytotoxic T-lymphocyte antigen 4 (CTLA-4) is a negative immune regulator. Heterozygous CTLA4 germline mutations can cause a complex immune dysregulation syndrome in human subjects.

OBJECTIVE

We sought to characterize the penetrance, clinical features, and best treatment options in 133 CTLA4 mutation carriers.

METHODS

Genetics, clinical features, laboratory values, and outcomes of treatment options were assessed in a worldwide cohort of CTLA4 mutation carriers.

RESULTS

We identified 133 subjects from 54 unrelated families carrying 45 different heterozygous CTLA4 mutations, including 28 previously undescribed mutations. Ninety mutation carriers were considered affected, suggesting a clinical penetrance of at least 67%; median age of onset was 11 years, and the mortality rate within affected mutation carriers was 16% (n = 15). Main clinical manifestations included hypogammaglobulinemia (84%), lymphoproliferation (73%), autoimmune cytopenia (62%), and respiratory (68%), gastrointestinal (59%), or neurological features (29%). Eight affected mutation carriers had lymphoma, and 3 had gastric cancer. An EBV association was found in 6 patients with malignancies. CTLA4 mutations were associated with lymphopenia and decreased T-, B-, and natural killer (NK) cell counts. Successful targeted therapies included application of CTLA-4 fusion proteins, mechanistic target of rapamycin inhibitors, and hematopoietic stem cell transplantation. EBV reactivation occurred in 2 affected mutation carriers after immunosuppression.

CONCLUSIONS

Affected mutation carriers with CTLA-4 insufficiency can present in any medical specialty. Family members should be counseled because disease manifestation can occur as late as 50 years of age. EBV- and cytomegalovirus-associated complications must be closely monitored. Treatment interventions should be coordinated in clinical trials.

Comprehensive Cancer-Predisposition Gene Testing in an Adult Multiple Primary Tumor Series Shows a Broad Range of Deleterious Variants and Atypical Tumor Phenotypes

Multiple primary tumors (MPTs) affect a substantial proportion of cancer survivors and can result from various causes, including inherited predisposition. Currently, germline genetic testing of MPT-affected individuals for variants in cancer-predisposition genes (CPGs) is mostly targeted by tumor type. We ascertained pre-assessed MPT individuals (with at least two primary tumors by age 60 years or at least three by 70 years) from genetics centers and performed whole-genome sequencing (WGS) on 460 individuals from 440 families. Despite previous negative genetic assessment and molecular investigations, pathogenic variants in moderate- and high-risk CPGs were detected in 67/440 (15.2%) probands. WGS detected variants that would not be (or were not) detected by targeted resequencing strategies, including low-frequency structural variants (6/440 [1.4%] probands). In most individuals with a germline variant assessed as pathogenic or likely pathogenic (P/LP), at least one of their tumor types was characteristic of variants in the relevant CPG. However, in 29 probands (42.2% of those with a P/LP variant), the tumor phenotype appeared discordant. The frequency of individuals with truncating or splice-site CPG variants and at least one discordant tumor type was significantly higher than in a control population (χ2 = 43.642; p ≤ 0.0001). 2/67 (3%) probands with P/LP variants had evidence of multiple inherited neoplasia allele syndrome (MINAS) with deleterious variants in two CPGs. Together with variant detection rates from a previous series of similarly ascertained MPT-affected individuals, the present results suggest that first-line comprehensive CPG analysis in an MPT cohort referred to clinical genetics services would detect a deleterious variant in about a third of individuals.

CA 15–3: A Prognostic Marker in Breast Cancer

CA 15–3 (also known as MUC1) is the most widely used serum marker in breast cancer. MUC1 is a large transmembrane glycoprotein which is frequently overexpressed and aberrantly glycosylated in cancer. Physiologically, MUC1 appears to play a role in cell adhesion and the high levels present in cancer may be causally involved in metastasis. At present the main uses of CA 15–3 are in preclinically detecting recurrent breast cancer and monitoring the treatment of patients with advanced breast cancer. In a prospective study of 368 patients we show that patients with high preoperative levels of CA 15–3 (>30.4 U/mL) had a worse outcome than patients with low levels of the marker. In multivariate analysis CA 15–3 as a prognostic marker was independent of both tumor size and nodal status. Furthermore, in multivariate analysis the prognostic impact of CA 15–3 was stronger than that of tumor size and at least as strong as nodal status. CA 15–3 may thus be the first independent prognostic serum marker in breast cancer.

Detection of Estrogen Receptor-Beta mRNA in Breast Cancer Using RT-PCR

The estrogen receptor (ER) is the most useful marker currently available for breast cancer, being used both to predict response to therapy and assess prognosis. Recently, a new form of the ER, known as ER-beta, was identified. In this preliminary study we show that ER-beta mRNA was expressed less frequently in breast cancers than ER-alpha. ER-alpha but not ER-beta levels correlated with ER protein as determined by ELISA. We conclude that ER-beta is expressed in approximately 50% of breast cancers but it does not appear to be detected by a widely available ELISA.

Bronchiectasis and deteriorating lung function in agammaglobulinaemia despite immunoglobulin replacement therapy

Immunoglobulin replacement therapy enhances survival and reduces infection risk in patients with agammaglobulinaemia. We hypothesized that despite regular immunoglobulin therapy, some patients will experience ongoing respiratory infections and develop progressive bronchiectasis with deteriorating lung function. One hundred and thirty-nine (70%) of 199 patients aged 1-80 years from nine cities in the United Kingdom with agammaglobulinaemia currently listed on the UK Primary Immune Deficiency (UKPID) registry were recruited into this retrospective case study and their clinical and laboratory features analysed; 94% were male, 78% of whom had Bruton tyrosine kinase (BTK) gene mutations. All patients were on immunoglobulin replacement therapy and 52% had commenced therapy by the time they were 2 years old. Sixty per cent were also taking prophylactic oral antibiotics; 56% of patients had radiological evidence of bronchiectasis, which developed between the ages of 7 and 45 years. Multivariate analysis showed that three factors were associated significantly with bronchiectasis: reaching 18 years old [relative risk (RR) = 14·2, 95% confidence interval (CI) = 2·7-74·6], history of pneumonia (RR = 3·9, 95% CI = 1·1-13·8) and intravenous immunoglobulin (IVIG) rather than subcutaneous immunoglobulin (SCIG) = (RR = 3·5, 95% CI = 1·2-10·1), while starting immunoglobulin replacement after reaching 2 years of age, gender and recent serum IgG concentration were not associated significantly. Independent of age, patients with bronchiectasis had significantly poorer lung function [predicted forced expiratory volume in 1 s 74% (50-91)] than those without this complication [92% (84-101)] (P < 0·001). We conclude that despite immunoglobulin replacement therapy, many patients with agammaglobulinaemia can develop chronic lung disease and progressive impairment of lung function.

Mental Health Staff Perceptions and Practice Regarding Self-Harm, Suicidality and Help-Seeking in LGBTQ Youth: Findings from a Cross-Sectional Survey in the UK

Young people who identify as lesbian, gay, bisexual, transgender or queer (LGBTQ) experience higher levels of suicidality compared to heterosexual or cisgender peers, and face significant barriers accessing mental health services including prejudice from staff. In a cross-sectional survey, mental health staff who reported receiving LGBT awareness training were significantly more likely to report in relation to working with LGBT youth that they routinely discussed issues of sexuality and gender (χ²=8.782, df=2, p < 0.05); to feel that their organisation supported them to work with this group (χ²=14.401, df=2, p < 0.001); and report that they had access to adequate skills training that supported their work with suicidality and self-harm with this group (χ²=21.911, df=2, p <0.001). There is a need to enhance the mental health workforce in LGBTQ awareness, and these findings indicate that awareness training could impact positively on practice.

Surviving in Dangerous Places: Lesbian Identity Performances in the Workplace, Social Class and Psychological Health

This article examines the ways in which the psychological health of women may be influenced by workplace sexual identity performances and social class positioning. It draws on UK research through in-depth interviews with 24 women who self-defined as mainly lesbian and/or gay. The article demonstrates that, for the women in the study, sexual identity performances at work involved negotiating employment settings that render heterosexuality compulsory and thus lesbian/gay performances a risk. As a result, the women engaged in risk-assessment strategies that were psychologically demanding. The women's narratives also suggest that the psychological effects of managing an ‘othered’ sexual identity in work was mediated by social class. The working-class women were more likely to be employed in settings where heterosexuality was heavily regulated and their ‘practices of survival’ were potentially more detrimental to their psychological health.

Transition from Reconstruction toward Thin Film on the (110) Surface of Strontium Titanate

The surfaces of metal oxides often are reconstructed with a geometry and composition that is considerably different from a simple termination of the bulk. Such structures can also be viewed as ultrathin films, epitaxed on a substrate. Here, the reconstructions of the SrTiO3 (110) surface are studied combining scanning tunneling microscopy (STM), transmission electron diffraction, and X-ray absorption spectroscopy (XAS), and analyzed with density functional theory calculations. Whereas SrTiO3 (110) invariably terminates with an overlayer of titania, with increasing density its structure switches from n × 1 to 2 × n. At the same time the coordination of the Ti atoms changes from a network of corner-sharing tetrahedra to a double layer of edge-shared octahedra with bridging units of octahedrally coordinated strontium. This transition from the n × 1 to 2 × n reconstructions is a transition from a pseudomorphically stabilized tetrahedral network toward an octahedral titania thin film with stress-relief from octahedral strontia units at the surface.

Abstract P4-14-15: Pre-treatment stromal tumour-infiltrating lymphocytes (S-TILs) are correlated with complete response (CR) to chemotherapy (Chemo) plus trastuzumab (T) in HER2-positive (H+) metastatic breast cancer (MBC)

Background. We have previously reported that ChemoT produces durable (&gt;5 years) CR in a minority of pts with H+MBC, prompting a search for predictive markers. Extensive lymphocytic infiltration of cancers is correlated with high levels of immune gene signatures. International consensus guidelines on TILs define "lymphocyte-predominant BC" at a threshold of S-TILs of 50-60% versus tumour cells. High levels of S-TILs has been correlated with improved outcome in HER2+ early stage BC pts treated with ChemoT. We investigated the degree of S-TIL infiltration in metastatic biopsies from pts with HER2+MBC prior to ChemoT, and attempted to determine whether S-TILs predicted CR in HER2+MBC.

Methods. We searched a database of all pts with HER2+ MBC treated at our institution with anti-HER2 therapy over 15yrs to identify pts who achieved CR according to RECIST 1.0 criteria, which lasted for at least 6 months. We matched them with an equal number of pts from the database who were treated during the same period, but who had progressive (POD) or stable disease (SD) as best response to T. Pts must have at least one pre-treatment tumour sample available for S-TILs assessment, and adequate clinical and follow-up information. S-TILs (mononuclear cells including lymphocytes and plasma cells) contained within the boundaries of invasive tumour were identified on a representative haematoxylin and eosin stained slide and scored as a percentage of the stromal area alone, according to the International TILs Working Group 2014 methodology [Salgado R, 2015]. S-TILs were assessed specifically for this study by a senior pathologist who scored the samples and who was blinded to pts response and clinical details.

Results. Out of 246 MBC pts registered in the HER2+ database we identified 31 CR pts with at least one available pre-treatment metastatic sample. A cohort of 31 matching POD-SD pts was randomly obtained from the same database. In 8 cases (7 CR / 1 POD-SD) S-TILs could not be assessed due to inadequate material, or for other technical reasons. The final study sample is 54 pts (24 CR / 30 POD-SD). Pts characteristics are as follows: median age (range): CR 55 (29-78) / POD-SD 56 (26-89), hormone receptor (HR) pos: CR 12 (50%) / POD-SD 18 (60%), De Novo MBC at diagnosis: CR 13 (54%) / POD-SD 8 (27%) [p&lt;0.05]. All pts received chemotherapy with T (+ lapatinib in 3 pts as part of a clinical trial), and continued on T until POD. Pre-treatment S-TILs &gt;50% were statistically significantly more frequent in CR (50% of pts) than POD/SD (20%) [chi-square p=0.02]. No statistically significant difference in the HR status was observed between the two groups (CR vs POD-SD) or between the high and low S-TILs pts.

Conclusions. S-TILs &gt;50% in the pre-treatment tumour biopsy of HER2+MBC were significantly correlated with subsequent CR to ChemoT, supporting the hypothesis that the immunological effects of T may play a role in determining response. Speculatively, S-TILs might identify pts with a higher likelihood of benefit from T. Further study of the potential role of S-TILs as predictors of T benefit are required.

Citation Format: Gullo G, Quinn C, Zacchia A, Fennelly D, Defrein A, Ballot J, Zanoni D, Walshe J, Maltese M, McDermott E, Crown J. Pre-treatment stromal tumour-infiltrating lymphocytes (S-TILs) are correlated with complete response (CR) to chemotherapy (Chemo) plus trastuzumab (T) in HER2-positive (H+) metastatic breast cancer (MBC). [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 P4-14-15.

Abstract P1-07-09: Retrospective cohort study of patients (pts) diagnosed with breast cancer (BC) &lt;40 yrs: 2000 to 2015⟨

Background

Young women (&lt;40 yrs) with breast cancer (YWBC) account for 7-12% of BC diagnoses. BC is the leading cause of cancer death in this group (G). Age-specific data on outcome and appropriate treatment (Rx) are lacking. YWBC appear to have more biologically aggressive subtypes and a higher risk of relapse and death. We studied the clinico-pathological (ClinPath) characteristics in YWBC, examining how outcomes/Rx have evolved.

Methods

YWBC were identified from pathology databases at 2 tertiary centers. Pts were divided into 2 cohorts: BC diagnoses from 2000-2007 (G1) and 2008-2015 (G2). ClinPath and Rx data were retrieved from clinical, radiology and histology databases. Statistical analysis was performed using SPSS.

Results

We identified 347 pts. Tumor features are shown in Table I. Median age is 36 (23-39). By histology, 90.8% (n=315) had invasive ductal carcinoma, 53.1% (n=181) had Grade III BC and 56.3% (n=171) had lymphovascular invasion. Pregnancy-associated BC occurred in 10.7% (n=34). Mastectomy (MX) was performed in 53% (n=176) and axillary lymph node clearance (ALNC) in 63.8% (n=192 [G1: 84.3% vs. G2: 48.6%, p&lt;0.001]).

Table 1Tumor features Group 1 (n=149)Group 2 (n=198)Total (n=347)p-valueMedian tumor size (mm) 252222.5p=0.115Node positivity 88 (60.3%)100(51.5%)188 (55.3%)p=0.109Median node count 4 (1-44)1 (1-30)2 (1-44)p&lt;0.001StageI  99(29%)  II  148 (43.3%)  III  70 (20.5%)  IV  23(7.3%) Biomarker status*ER+/HER2-76 (53.1%)120 (60.6%)196 (56%)p=0.086 HER2+41 (28.7%)45 (22.8%)86 (27%)p=0.031 Triple negative (TN)26 (18.2%)33 (16.8%)59 (17%)p=0.291* Missing data n=6

Rx characteristics are shown in Table 2. 85 pts received neo-adjuvant therapy (NAT); 48.3% (n=41) ER+/HER2-, 27% (n=23) HER2+ and 24.7% (n=21) TNBC. Pts receiving NAT in G2 trended towards improved pCR rate (G2: 24.6% vs G1: 8.3%, p=0.057). Endocrine Rx alone was received by 9.8% (n=22); 13.6% (n=18) in G2 vs 4.3% (n=4) in G1. OncotypeDx(ODx) was used in 23 pts (14.9%) (median score 17), 1 had a DR (ODx Score = 18).

Table 2Tx characteristics n=347 Chemotherapy Total300(86.4%)  NAT85 (28.3%)Pathological Complete Response (pCR)* pCR (n=16, 19.8%)No pCR (n=65, 80.2%) ER+/HER2-18.8%(n=3)53.9% (n=35) HER2+/ER+18.8%(n=3)13.8% (n=9) HER2+/ER-31.2% (n=5)9.2% (n=6) TNBC31.2%(n=5)23.1%(n=15)Local relapse 1 (6.2%)1(1.5%)Distant relapse (DR) 022(33.8%)*Data incomplete n=4

DR occurred in 50 pts (16%), including 13 (20.3%) HER2+ pts. Of note, 92.3% (n=12) of these were in G1. Relapse rates (RR) in TN and ER+/HER- pts were 19.6% (n=11) and 13.7% (n=26) respectively. There was a higher RR in G1 (34.8% vs 11.4%, p&lt;0.001). Overall survival in pts with stage IV dx was 32 mos in G1 and 48 mos in G2.

Conclusion

In line with existing data, locally advanced dx is more prevalent in YWBC. MX and ALNC rates were high and most received multimodal Rx. The extent of axillary surgery declined. Pts in G2 had lower volume BC at diagnosis suggesting increasing awareness. TN and HER2+ subtypes accounted for a slightly higher proportion of BC cases. Pts with PCR had better outcomes. Only 16% relapsed with metastatic dx. The impact of HER2 Rx is highlighted by reduced RR in HER2+ G2 pts. Outcomes were unchanged in pts with ER+/HER2- and TNBC. These remain a priority for future research.

Citation Format: Greally M, Kielty J, Das G, Malouf C, O'Riordan L, Coleman N, Quinn C, McDermott E, Gullo G, Kelly C, Crown J, Prichard R, Walshe J. Retrospective cohort study of patients (pts) diagnosed with breast cancer (BC) &lt;40 yrs: 2000 to 2015⟨. [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 P1-07-09.

Community as a source of health in three racial/ethnic communities in Oregon: a qualitative study

BACKGROUND

A 2011 report by the Oregon Health Authority and the Department of Human Services documented disparities in its Latino and American Indian populations on multiple individual-level health indicators. However, research is lacking on the social contexts in which Latinos and American Indians in Oregon live and how these environments influence the health of communities as a whole. To help fill this gap, this study sought to contextualize the social environments that influence the health of Latinos and American Indian residents in three Oregon communities.

METHODS

Guided by an ecological framework, we conducted one-time semi-structured qualitative interviews with 26 study participants to identify the prominent health-related issues in the communities and to examine the factors that study participants perceived as enabling or inhibiting healthy lifestyles of community residents. We used a grounded theory approach to perform content and thematic analyses of the data.

RESULTS

Study participants identified preventable chronic conditions, such as diabetes, obesity, and hypertension, as the most pressing health concerns in their communities. Results showed that traditional and cultural activities and strong family and community cohesion were viewed as facilitators of good community health. Poverty, safety concerns, insufficient community resources, and discrimination were perceived as barriers to community health. Three themes emerged from the thematic analyses: social connectedness is integral to health; trauma has an ongoing negative impact on health; and invisibility of residents in the community underlies poor health.

CONCLUSIONS

This study's findings provide insight to the social contexts which operate in the lives of some Latinos and American Indians in Oregon. While participants identified community-level factors as important to health, they focused more on the social connections of individuals to each other and the relationships that residents have with their communities at-large. Our findings may also help to explain how the intra- and inter-personal levels, the community/institutional level, and the macro level/public policy contexts can serve to influence health in these communities. For example, trauma and invisibility are not routinely examined in community health assessment and improvement planning activities; nonetheless, these factors appear to be at play affecting the health of residents.

Subsurface cation vacancy stabilization of the magnetite (001) surface

Iron oxides play an increasingly prominent role in heterogeneous catalysis, hydrogen production, spintronics, and drug delivery. The surface or material interface can be performance-limiting in these applications, so it is vital to determine accurate atomic-scale structures for iron oxides and understand why they form. Using a combination of quantitative low-energy electron diffraction, scanning tunneling microscopy, and density functional theory calculations, we show that an ordered array of subsurface iron vacancies and interstitials underlies the well-known (√2 × √2)R45° reconstruction of Fe3O4(001). This hitherto unobserved stabilization mechanism occurs because the iron oxides prefer to redistribute cations in the lattice in response to oxidizing or reducing environments. Many other metal oxides also achieve stoichiometry variation in this way, so such surface structures are likely commonplace.

Asking for help online: Lesbian, gay, bisexual and trans youth, self-harm and articulating the ‘failed’ self

International evidence suggests that young people are less likely to seek help for mental health problems in comparison with adults. This study focused on lesbian, gay, bisexual and trans young people who are a population group with an elevated risk of suicide and self-harm, and little is known about their help-seeking behaviour. Utilising qualitative virtual methods, lesbian, gay, bisexual and trans youth web-based discussions about seeking help for suicidal feelings and self-harming were investigated. Findings from a thematic analysis indicate that these young people wanted assistance but found it difficult to (1) ask for help, (2) articulate emotional distress and (3) ‘tell’ their selves as ‘failed’. This analysis suggests that key to understanding these problems are emotions such as shame which arise from negotiating norms connected to heterosexuality, adolescence and rationality. I argue that these norms act to regulate what emotions it is possible to feel, what emotions it is possible to articulate and what type of young lives that can be told. The future development of health and social care interventions which aim to reduce lesbian, gay, bisexual and trans youth suicide and self-harm need to work with a nuanced understanding of the emotional life of young people if they are to be effective.

Abstract P1-01-01: The value of isosulphan blue dye in addition to isotope scanning in the identification of the sentinel lymph node in breast cancer patients with a positive lymphoscintigraphy: A randomised controlled trial (ISRCTN 98849733)

Introduction

The advent of multimodal and targeted breast cancer treatment has seen a radical shift from aggressive surgical intervention to a more minimalist approach, both within the breast and axilla. Primary among these changes is the utilisation of the sentinel lymph node biopsy (SLNB) to detect disease within the axilla and a move away from an obligatory axillary clearance when the sentinel node is positive. This depends on the accurate identification of the SLN and initial studies describe a higher identification rate and a lower false negative rate with a dual tracer identification technique. This encompasses a combination of a blue / green dye and radio-labelled isotope. The use of blue dye has been, of itself, associated with significant morbidity and therefore many clinicians may opt for single tracer identification.

Aims

The aim of the current study was to determine whether the addition of blue dye to radio-isotope increased the positive SLN detection rate, where the SLN was identified pre-operatively on a lymphoscintigram.

Methods

A prospective randomised controlled trial comparing the combined techniques of isosulphan blue dye and isotope scanning versus isotope scanning alone was performed at a single tertiary referral centre. Ethical approval was obtained prior to commencing the study from the hospital ethics committee. Enrolment commenced in March 2010 and ceased in September 2012. The study design was a randomised open label controlled parallel group trial. The primary outcome measure was the effect of the omission of the blue dye on the identification of SLN if the lymphoscintigram was positive (1 -3 nodes identified).

Results

A total of 673 patients were included in the final analysis with 344 patients receiving the combination (blue dye and radio-isotope) and 329 patients who received radio-isotope scanning alone. The groups were evenly matched both demographically and pathologically. The mean age was 48 years (48.3 versus 47.7 years; P = 0.47), the mean tumour size was 23.1mm (23.2mm versus 23.0mm; p = 0.89) and there was no statistically significant difference in the grade of the tumours between the two groups (p = 0.58). Overall, there was no difference in the number of nodes retrieved between the two groups (563 versus 523; p = 0.30). Similarly, there was no difference in the number of positive lymph nodes that were identified between the two groups (107 versus 98; 23.8% versus 22%; p = 0.65).

Conclusions

The addition of isosulphan blue dye does not aid in the identification of the SLN in patients who have a positive lymphoscintigram when radioisotope colloid is used.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P1-01-01.

Youth on the virtual edge: researching marginalized sexualities and genders online

Research shows clear links between lesbian, gay, bisexual, and transgender (LGBT) youth and deliberate self-harm (DSH), but there is a lack of research investigating the social context of young LGBT people's lives and helping to explain the higher DSH risk. In this article, we report on a small-scale methodological study intended to test the feasibility of online qualitative interviews for investigating young people, sexual and gender identity, and emotional distress. There are many methodological dilemmas arising from researching such sensitive issues with marginalized groups. The study reported here was designed to examine (a) sampling diversity in terms of sexuality, gender identities, and class; and (b) the type of data produced. We found that a virtual methodology was effective in recruiting young LGBT participants who might otherwise not take part in research. Online interviewing successfully produced in-depth, "immediate" data that potentially gave access to insights that might not emerge through face-to face interviews.

Role of mammography in the triple assessment of single-quadrant breast symptoms (Br J Surg 2011; 98: 951–955)

The Editors welcome topical correspondence from readers relating to articles published in the Journal. Responses should be sent electronically via the BJS website (www.bjs.co.uk). All letters will be reviewed and, if approved, appear on the website. A selection of these will be edited and published in the Journal. Letters must be no more than 250 words in length.

The non-display of authentic distress: public-private dualism in young people's discursive construction of self-harm

This article draws from focus groups and interviews investigating how young people talk about self-harm. Some of the research participants had personal experience of self-harm but this was not a prerequisite for their inclusion in the study. Thematic coding was used initially to organise and give an overview of the data, but the data were subsequently analysed using a discourse analytic approach. The article focuses on the young people's constructions of deliberate self-harm such as 'cutting'. Throughout the focus groups and interviews, a dichotomy was set up by the young people between authentic, private self-harm which is rooted in real distress (and warrants a sympathetic response) and public, self-indulgent attempts to seek attention. This dualistic construction is discussed in some detail and located in various socio-cultural contexts. It is argued that the dualism illustrates contemporary ambivalence about mental health and youth.

Focal thyroid incidentalomas identified with whole-body FDG-PET warrant further investigation

Fluorodeoxyglucose (FDG) whole body positron emission computed tomography (PET-CT) detects clinically occult malignancy. The aim of this study was to assess the prevalence and significance of focal thyroid 18F - fluorodeoxyglucose uptake. A retrospective review of all patients who had FDG PET-CT examinations, in a single tertiary referral centre was performed. PET scan findings and the final pathological diagnosis were collated. 2105 scans were reviewed. Focal uptake was identified in 35 (1.66%) patients. Final surgical histology was available on eight patients, which confirmed papillary carcinoma in four (20%) patients and lymphoma and metastatic disease in two patients respectively. This gave an overall malignancy rate in focal thyroid uptake of at least 33%. Thyroid incidentalomas occurred with a frequency of 2.13%, with an associated malignancy rate of at least 33% in focal thyroid uptake. The high malignancy rate associated with focal thyroid uptake mandates further investigation in medically fit patients.