Reduced Time to Breast Cancer Diagnosis with Coordination of Radiological and Clinical Care

Introduction Diagnostic delays for breast problems is a current concern in British Columbia and diagnostic pathways for breast cancer are currently under review. Breast centres have been introduced in Europe and reported to facilitate diagnosis and treatment. Guidelines for breast centers are outlined by the European Society for Mastology (EUSOMA). A Rapid Access Breast Clinic (RABC) was developed at our hospital applying the concept of triple evaluation for all patients and navigation between clinicians and radiologists. We hypothesize that the Rapid Access Breast Clinic will decrease wait times to diagnosis and minimize duplication of services compared to usual care. Methods A retrospective review was undertaken looking at diagnostic wait times and the number of diagnostic centres involved for consecutive patients seen by breast surgeons with diagnostic workups performed either in the traditional system (TS) or the RABC. Only patients presenting with a new breast problem were included in the study. Results Patients seen at the RABC had a decreased time to surgical consultation (33 vs 86 days, p<0.0001) for both malignant (36 vs 59 days, p=0.0007) and benign diagnoses (31 vs 95 days, p<0.0001). Furthermore, 13% of the patients referred to the surgeon in the TS without a diagnosis were eventually diagnosed with a malignancy and waited a mean of 84 days for initial surgical assessment. Of the patients seen at the RABC, 5% required investigation at more than one institution compared to 39% patients seen in the TS (p<0.0001). Cancer patients had a shorter time from presentation to surgery in the RABC (64 vs 92 days, p=0.009). Conclusion The establishment of the RABC has significantly reduced the time to surgical consultation, time to breast cancer surgery, and duplication of investigations for patients with benign and malignant breast complaints. It is feasible to introduce a EUSOMA-based breast clinic in the Canadian Health Care System and improvements in diagnostic wait times are seen. We recommend the expansion of coordinated care to other sites.

Phosphorylated caveolin-1 regulates Rho/ROCK-dependent focal adhesion dynamics and tumor cell migration and invasion

Rho/ROCK signaling and caveolin-1 (Cav1) are implicated in tumor cell migration and metastasis; however, the underlying molecular mechanisms remain poorly defined. Cav1 was found here to be an independent predictor of decreased survival in breast and rectal cancer and significantly associated with the presence of distant metastasis for colon cancer patients. Rho/ROCK signaling promotes tumor cell migration by regulating focal adhesion (FA) dynamics through tyrosine (Y14) phosphorylation of Cav1. Phosphorylated Cav1 is localized to protrusive domains of tumor cells and Cav1 tyrosine phosphorylation is dependent on Src kinase and Rho/ROCK signaling. Increased levels of phosphorylated Cav1 were associated with elevated GTP-RhoA levels in metastatic tumor cells of various tissue origins. Stable expression and knockdown studies of Cav1 in tumor cells showed that phosphorylated Cav1 expression stimulates Rho activation, stabilizes FAK association with FAs, and promotes cell migration and invasion in a ROCK-dependent and Src-dependent manner. Tyrosine-phosphorylated Cav1, therefore, functions as an effector of Rho/ROCK signaling in the regulation of FA turnover and, thereby, tumor cell migration and invasion. These studies define a feedback loop between Rho/ROCK, Src, and phosphorylated Cav1 in tumor cell protrusions, identifying a novel function for Cav1 in tumor metastasis that may contribute to the poor prognosis of some Cav1-expressing tumors.

Use of intravenous hydrocortisone in Henoch-Schonlein purpura

Henoch-Schonlein purpura should be considered in children with severe abdominal pain that is unresponsive to conventional treatment when no apparent cause is found on investigation. Such children may respond dramatically to a trial of intravenous corticosteroid and, hence, may avoid unnecessary investigations and laparotomy.

Ectopic thyroid: residual function after withdrawal of treatment in infancy and later childhood

Plasma thyroxine (T4) and thyrotrophin (TSH) were estimated in 34 children identified by neonatal hypothyroid screening and subsequently found to have ectopic thyroid tissue on isotope scan. Before treatment plasma T4 ranged from 8-143 nmol/l and TSH from 39-1,230 mU/l. After one week off treatment during their second year, repeat T4 in 26 of these cases showed a significant correlation with the pre-treatment values (r = 0.57). However, only 3 of the 5 children with pre-treatment T4 levels over 100 nmol/l at diagnosis had normal T4 values when retested. Similarly, when 10 children with pre-treatment T4 values over 65 nmol/l were retested off treatment at the ages of 5.8-8.2 years, only 4 had plasma T4 levels in the normal range. These results illustrate the wide range of thyroid function which can occur in children with ectopic thyroid tissue and indicate that some continue to have near-normal thyroid function for considerable periods. However, pre-treatment T4 results do not allow accurate identification of these latter cases.

Hypothalamic defects in two adult patients with septo-optic dysplasia

Two adult patients with unilateral hypoplastic optic nerves, absent septa pellucida and hypopituitarism are described. Patient 1, aged 20, presented with diabetes insipidus due to partial vasopressin deficiency. Patients 2, aged 29, presented with focal epilepsy. Both had short stature. They showed absent growth hormone (GH) response to insulin-hypoglycaemia or glucagon, but responded to 100 micrograms growth hormone releasing factor (GRF-44) with a rise in circulating GH, suggesting a hypothalamic defect in GH release though a co-existing pituitary defect cannot be excluded. Other hypothalamic-pituitary functions were normal. These two patients probably represent the milder form of the clinical spectrum of septo-optic dysplasia which, with the extensive use of CT brain scans, will be increasingly encountered by physicians attending adult patients.

Galactolipid Synthesis in Vicia faba Leaves: II. Formation and Desaturation of Long Chain Fatty Acids in Phosphatidylcholine, Phosphatidylglycerol, and the Galactolipids

The labeling kinetics of the fatty acids of phosphatidylcholine (PC), phosphatidylglycerol (PG), monogalactosyldiglyceride (MGDG), and digalactosyldiglyceride (DGDG) were examined after (14)CO(2) feeding and incubation of leaf discs of Vicia faba over 72 hours in continuous light. The results indicate a rapid accumulation and turnover of radioactivity into PC and PG fatty acids (oleic acid in PC and oleic and palmitic acids in PG). Radioactivity accumulates in MGDG and DGDG fatty acids much more slowly and continuously over 72 hours. Most of this activity is found in linoleic and linolenic acids; very little activity is found in the more saturated fatty acids. Little or no desaturation occurs in situ in conjunction with the galactolipids. The results suggest that PC and PG may act as "carriers" for MGDG and DGDG fatty acid synthesis. Analyses of the labeling patterns of the molecular species of MGDG after (14)CO(2) and (14)C-acetate feeding confirm that MGDG is formed by galactosylation of a preformed diglyceride containing predominantly unsaturated fatty acids.