Breast or chest? A diagnostic conundrum.
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Breast Neoplasms↗
Biomedical subjects
D M King
Publications and source records attributed to D M King.
Evaluation of the response to treatment of solid tumours - a consensus statement of the International Cancer Imaging Society.
New guidelines to evaluate the response to treatment in solid tumors using imaging techniques have major limitations and important implications for radiological workload. This consensus statement from the International Cancer Imaging Society (ICIS) reviews the RECIST criteria and addresses several challenges regarding tumour measurement. Recommendations are made regarding tumour measurement and other issues are raised. The growing need to introduce a multimodality approach to monitoring response is recognized. ICIS welcomes a dialogue with the authors of RECIST to address issues raised in this review.
Clinical Trials as Topic↗
Measurement of tumour size in case selection for breast cancer therapy by clinical assessment and ultrasound.
AIMS: Clinical assessment of tumour size is often used to choose between mastectomy and primary medical therapy. Clinical and imaging modalities may have varying levels of accuracy across the range of tumour sizes. The aim of this study was to compare the accuracy of clinical measurement and ultrasound in discriminating palpable tumours up to 3 cm vs those greater than 3 cm. METHODS: A prospective analysis of 111 consecutive patients with palpable breast cancer was performed. All women had clinical measurement by caliper and ultrasound assessment prior to any needle biopsy. Clinical measurement and ultrasound assessment of size were compared to pathological tumour size of the surgical specimen. RESULTS: Both clinical and ultrasound measurement underestimate the size of larger tumours. The overall accuracy of clinical assessment and ultrasound examination in correctly identifying a 30 mm cut off was 70.3 and 77.5%, respectively. Ultrasound was significantly more accurate at determining the size of tumours <30 mm (p=0.007) but there was no significant difference between both modalities in assessing tumours greater than 30 mm. CONCLUSIONS: Ultrasound assessment of breast cancer size is more accurate than clinical assessment for tumours less than 30 mm. As clinical examination is as accurate on ultrasound for tumours greater than 30 mm, clinical assessment of tumour size alone is adequate to select patients for primary medical therapy or mastectomy.
Adult↗
A retrospective study comparing the individual modalities of triple assessment in the pre-operative diagnosis of invasive lobular breast carcinoma.
AIMS: Early invasive lobular breast carcinoma (ILC) is associated with few symptoms and signs. The individual sensitivity of clinical examination, mammography, ultrasonography, cytology and core biopsy have each been reported to be of limited value. The aim of this study was to evaluate the accuracy of triple assessment in the pre-operative detection of patients identified to have ILC from their surgical pathology. METHODS: Pure ILC was defined as tumours containing at least 90% lobular features. The triple assessment of 273 patients diagnosed primarily at our institution were reviewed. RESULTS: 87.5% of women were symptomatic and 12.5% were screen detected. The mean patient age was 59 (range 30-81) years and the median tumour size was 26 (range 5-110) mm. The main mammographic abnormalities were a spiculated lesion (33.3%), an ill-defined mass (33.3%) or architectural distortion (23.5%). The sensitivities for detecting ILC of each modality were: clinical examination (76.6%), mammography (79.8%), ultrasound examination (93.9%), fine-needle aspiration cytology (FNAC) (60.5%) and core biopsy (90.8%). Combining the three modalities of clinical examination, imaging and cyto/pathology increased the pre-operative detection rate of ILC. CONCLUSION: Triple assessment is useful in the diagnosis of ILC. As the features of ILC may be subtle, a high index of suspicion is required to facilitate early diagnosis.
Adult↗
In vivo mutant frequency of thioguanine-resistant T-cells in the peripheral blood and lymph nodes of melanoma patients.
T-cell activation by malignant melanoma would be anticipated to stimulate T-cell proliferation, which in turn has been associated with increasing the likelihood of somatic gene mutation. The purpose of this study was to test the hypothesis that in vivo hypoxanthine guanine phosphoribosyltransferase (hprt) mutant frequencies (MFs) are increased in peripheral blood T-cells from melanoma patients compared to normal controls. Assays were made of 48 peripheral blood samples from melanoma patients with stage 3 (13 patients) and stage 4 (35 patients) disease, 38 normal controls, and of nine tumor bearing lymph nodes. The mean hprt log(10)(MF) in patient peripheral blood was -4.77 (geometric mean hprt MF=17.0x10(-6)) compared to a mean hprt log(10)(MF) of -4.87 (geometric mean hprt MF=13.5x10(-6)) in controls. Although modest, this difference is statistically significant both by t-test (P=0.049) and after adjustment for covariates of age, gender, and cigarette smoking by regression analysis (P=0.001). Among the melanoma patients, the mean log(10)(MF) for the 17 patients who had received potentially genotoxic therapies was not significantly different from the mean log(10)(MF) for the 31 patients not receiving such therapies. The hprt MFs in the nine tumor bearing nodes were compared with MFs in peripheral blood from the same patients and revealed a non-significant (P=0.07) trend for increasing MFs in blood. Furthermore, analyses of T-cell receptor gene rearrangement patterns revealed hprt mutants originating from the same in vivo clone in both peripheral blood and a tumor-bearing node. The finding of elevated hprt MFs not entirely explained by genotoxic therapies in patients compared to controls can be explained either by hypermutability or in vivo T-cell activation. The similar MFs in peripheral blood and tumor bearing lymph nodes, as well as the finding of mutant representatives of the same in vivo T-cell clone in both locations, support monitoring peripheral blood to detect events in the nodes. If in vivo proliferation accounts for the current findings, the hprt deficient (hprt-) mutant fraction in blood may be enriched for T-cells that mediate the host immune response against malignant melanoma. Further studies will characterize the functional reactivity of hprt mutant isolates against melanoma-related antigens.
Adult↗
Concentration-dependent, temperature-dependent non-Newtonian viscosity of lung surfactant dispersions.
The bulk shear viscosities of aqueous dispersions of lavaged calf lung surfactant (LS) and its chloroform:methanol extract (CLSE) were measured as a function of concentration, shear rate and temperature. At 10-mg phospholipid per milliliter, dispersions of LS and vortexed CLSE in 0.15 M NaCl (saline) had low viscosities near 1 cp over a range of shear rates from 225 to 1125 s(-1). Lung surfactant viscosity increased with phospholipid concentration and became strongly non-Newtonian with higher values at low shear rates. At 37 degrees C and 40 mg/ml, LS and vortexed CLSE in saline had viscosities of 38 and 34 cp (77 s(-1)) and 12 and 7 cp (770 s(-1)), respectively. Viscosity values for LS and CLSE were dependent on temperature and, at fixed shear, were lower at 23 degrees C than at 37 or 10 degrees C. Hysteresis was also present in viscosity measurements depending on whether shear rate was successively increased or decreased during study. Addition of 5 mM Ca(2+) at 37 degrees C markedly reduced CLSE viscosity at all shear rates and decreased LS viscosity at low shear rates. Dispersion by sonication rather than vortexing increased the viscosity of CLSE at fixed shear, while synthetic phospholipids dispersed by either method had low, relatively Newtonian viscosities. The complex viscous behavior of dispersions of LS and CLSE in saline results from their heterogeneous aggregated microstructure of phospholipids and apoproteins. Viscosity is influenced not only by the aggregate surface area under shear, but also by phospholipid-apoprotein interactions and aggregate structure/deformability. Similar complexities likely affect the viscosities of biologically-derived exogenous surfactant preparations administered to patients in clinical surfactant therapy.
1,2-Dipalmitoylphosphatidylcholine↗
The use of ultrasound by breast surgeons in outpatients: an accurate extension of clinical diagnosis.
AIMS: To assess the accuracy of breast ultrasound scan (USS) performed by a surgeon in outpatients and to evaluate the additional contribution of USS to clinical diagnosis. METHODS: A prospective study of 302 patients with symptomatic breast disease (322 lumps) was performed. Group 1 consisted of 213 clinic USS of lumps surgically removed for appropriate clinical indications. In Group 2, a USS was performed on 231 lumps by both the surgeon and radiologists as part of triple assessment. Each clinic USS was compared to the surgical pathology (Group 1) or USS performed by the radiologist (Group 2). RESULTS: In Group 1 (n=213), 89 lumps were proven benign and 124 malignant on histology. Ultrasound scans performed by the surgeon compared to histology had a sensitivity of 98.3% and specificity of 91.7%. An abnormal clinic USS heightened the index of suspicion in 22/213 (10.3%) of cases felt clinically to be benign but subsequently confirmed malignant on histology. Fifty-seven lumps felt to be indeterminate clinically were correctly identified on USS by surgeon as benign (n=56) or malignant (n=1). In Group 2 (n=231), there was complete concordance of USS scans by surgeon and radiologists in 197 (96%) and complete discordance in eight (3.9%) patients. Of the discordant scans, the surgeon correctly identified 7/8 diagnoses on histology. A USS examination by the radiologists provided a correct diagnosis of 6/14 scans scored by the clinician as indeterminate. CONCLUSION: USS performed in outpatients by a breast surgeon is accurate and a useful adjunct to clinical assessment. This enables rapid diagnosis in one-stop breast clinics, selecting difficult diagnostic procedures for USS by radiologists at the same visit.
Adult↗
Role of chest radiography after the insertion of a subclavian vein catheter for ambulatory chemotherapy.
OBJECTIVE: To determine the need for routine chest radiography after the insertion of a catheter via the subclavian vein for ambulatory chemotherapy. METHODS: The case notes of all patients who had undergone catheter insertion between 1994 and 1998 were reviewed retrospectively. RESULTS: Of 3844 cases, there were 52 (1.4%) complications detected on chest radiographs after catheter insertion, 46 of which were pneumothoraces; 15 of the 46 patients had a clinical risk factor at insertion (technical difficulty or symptoms), and 14 had a risk factor after insertion (respiratory symptoms and signs). For 22 (47.8%) pneumothoraces, there was no clinical risk factor identified; 3 of these patients required intercostal drain insertion. Other complications (n = 6) included catheter malposition and kinking, and chest radiography made an important contribution to management in at least 1 of these cases. CONCLUSION: In approximately 0.1% of cases of catheter insertion in the subclavian vein, chest radiography detected a clinically occult complication significant enough to require intervention.
Adult↗
Benign metastasizing leiomyoma with intracaval leiomyomatosis.
We present an unusual case of benign metastasizing leiomyoma in association with intracaval leiomyomatosis. To our knowledge, this is the first reported case of metastasizing leiomyoma with coexistent intravenous leiomyomatosis (IVL). Magnetic resonance imaging is useful for the diagnosis of pelvic and caval IVL.
Adult↗
Diagnosis and management of male breast enlargement in patients with HIV/AIDS.
There have been several recent reports describing gynecomastia in HIV-1-seropositive patients treated with HAART. However, the etiology of gynecomastia in this setting is far from clear. In this article, we describe the main issues in diagnosis and treatment of gynecomastia and stress the importance of differentiating between "true" gynecomastia and "lipomastia" (pseudogynecomastia), characterized by subcutaneous fat deposition. The importance of switching antiretroviral drugs is also discussed. In addition, newer medical therapies are highlighted.
Gynecomastia↗
Behavioral management instruction of anxious clients in the dental hygiene curricula.
PURPOSE: This study sought to determine the type and amount of instruction on behavioral management of anxious clients in dental hygiene curricula, the instructional differences between associate and baccalaureate programs, and the opinions of educators regarding behavioral management. METHODS: A 19-item questionnaire was mailed to the directors of 210 dental hygiene programs who were asked to furnish information pertaining to behavioral instruction in their curricula and to express their opinions by use of a Likert scale. Data were analyzed using descriptive statistics and the chi-square and Z hypothesis tests. RESULTS: Two mailings resulted in an overall response rate of 81%, with 170 questionnaires returned. Results revealed that 86% of programs surveyed taught behavioral management of anxious clients to their students. Types of strategies taught and percentage of programs teaching them were: information provision (96%), distraction (51%), modeling (51%), relaxation (62%), and hypnosis (7%). No significant relationships were found between associate and baccalaureate degree programs relating to the type of behavioral instruction; however, baccalaureate degree programs devoted significantly more curricular hours to this instruction. In general, the sample of dental hygiene educators held positive opinions regarding the use of behavioral management, with only 28% having had formal education in this area. CONCLUSION: Results suggest that comprehensive instruction on behavioral management of client anxiety is not provided to students in all dental hygiene programs, even though dental hygiene educators consider this modality effective during oral health care.
Behavior Therapy↗
Isolated bone metastasis from an endometroid ovarian carcinoma.
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Bone Neoplasms↗
Right atrial metastatic melanoma detected by dynamic contrast enhanced spiral CT.
The use of and transoesophageal echocardiography has been well described in the diagnosis of intracardiac metastases. We present a case of a right atrial mass in a patient with metastatic melanoma which was unexpectedly detected by dynamic enhanced spiral CT. The diagnosis was subsequently confirmed by MRI. It is likely that the increasingly widespread use of spiral CT will result in a greater detection rate of intracardiac tumours.
Adult↗
Ultrasound diagnosis of metastatic melanoma of the gallbladder.
The abdominal ultrasound examinations of 464 patients with malignant melanoma performed over a 3 year period were reviewed. 23 (5.2%) had soft tissue material attached to the gallbladder wall and projecting into the lumen. Four of these were polyps of less than 1 cm which were thought to be benign, while the remaining 19 had abnormalities likely to be metastatic melanoma. Upper abdominal ultrasound examinations are frequently requested for staging purposes in patients with thick high grade malignant melanoma or clinical suspicion of metastases. Ultrasound clearly identifies the gallbladder and biliary tree in the vast majority of patients and is generally regarded as the imaging modality of choice for suspected gallbladder pathology. As autopsy studies have confirmed the incidence of gallbladder metastases from malignant melanoma to be 15-20%, a careful review of the gallbladder is advocated when abdominal ultrasound examinations are performed on patients with malignant melanoma.
Aged↗
Imaging of small cell carcinoma of the male urogenital tract.
Five cases of small cell carcinoma (three of the prostate and two of the bladder) are described to illustrate the unusual behaviour of these tumours. Cerebral, hepatic and bulky lymph node spread with large volume local disease occurred. The role the radiologist may play in these diseases is discussed.
Adult↗
Computed tomography, diagnosis, staging and follow-up of pure granulosa cell tumour of the ovary.
Granulosa theca cell tumours represent the largest group of hormone-secreting ovarian tumours and comprise approximately 1.5% of all ovarian malignancy. However, the prognosis and behaviour of pure granulosa cell tumours have been particularly difficult to evaluate, because in previous reports they have been grouped with granulosa theca cell tumours. Consequently, their radiological features and the possible contribution of computed tomography (CT) to clinical management has not been evaluated. We report the CT appearances of 15 patients with pure granulosa cell tumours and their clinical outcome. The results suggest the possibility of a positive relationship between histological grade and FIGO stage at presentation. Large tumour volume, extensive lymph node involvement and ascites on CT are adverse prognostic features. However, patients with abdominal masses less than 9 cm in diameter, absent or small volume lymph node disease and peritoneal and liver metastases achieved complete remission, suggesting that CT can assist in identifying those patients likely to respond best to current therapeutic regimens.
Adult↗
The role of percutaneous nephrostomy in malignant urinary tract obstruction.
Percutaneous nephrostomy is a well established technique for rapid relief of ureteric obstruction and improvement of renal function. However, its role in the management of renal failure resulting from advanced abdominopelvic malignancy is controversial and there are no clear guidelines to predict which patients benefit from such intervention both in terms of survival time and quality of life. To establish a protocol for selection of patients with abdominopelvic malignancy most likely to benefit from nephrostomy for renal obstruction, the medical records of 50 consecutive patients undergoing this procedure at the Royal Marsden Hospital were reviewed. The patients were divided into four groups: Group I, renal obstruction caused by a nonmalignant complication as a result of previous surgery or radiotherapy (n = 8); Group II, renal obstruction due to untreated primary malignancy (n = 16); Group III, renal obstruction from relapsed disease with a viable treatment option (n = 8); and Group IV, relapsed disease with no conventional treatment option (n = 18). There was significant benefit from percutaneous nephrostomy in Groups I-III. The overall median survival time of Group IV patients was extremely poor: 38 days (range 6-143 days) with no long-term survivors. The results suggest that strict selection criteria should be applied to patients with a history of abdominopelvic malignancy before proceeding to percutaneous nephrostomy. No worthwhile benefit is obtained if nephrostomy is used as a palliative measure in the absence of definitive treatment.
Female↗
Mammography in the assessment of response to medical treatment of large primary breast cancer.
The sequential mammograms of 48 patients (median age: 54 years, range: 24-84 years) undergoing primary medical treatment for large operable breast cancer at this institution were reviewed, and compared to the findings at clinical assessment. Twenty-six patients underwent endocrine therapy using tamoxifen, and 22 chemotherapy (CMF or MMM). All had more than two mammograms which were reviewed blindly by two independent radiologists. Response to treatment by both evaluation modalities was recorded using WHO definitions (NC, PR, CR, PD). Some 81% of patients achieved an objective clinical response to treatment, whilst 63% showed mammographic response. Overall comparison of clinical examination with mammography showed agreement in 38 patients (79%) and disagreement in 10 (21%). Agreement in type of response but not in its degree was found in 22 cases (46%). The results suggest that in the majority of cases mammography provides a useful adjunct to clinical examination in monitoring response to primary medical treatment for breast cancer. However, radiological factors such as unchanging microcalcification, and the continuing presence of mammographic density contribute to the discrepancy with clinical response in some tumours, and the search for alternative modalities of assessment should continue.
Adult↗