Tubular carcinoma of the breast: sensitivity of diagnostic techniques and correlation with histopathology.

OBJECTIVE: Our objective was to assess our experience in diagnosing pure tubular carcinoma of the breast and to correlate the radiologic and histopathologic features. MATERIALS AND METHODS: A retrospective review of 932 consecutive cases of proven breast cancer diagnosed between 1990 and 1997 revealed 78 cases (8.4%) of tubular carcinoma in 69 patients. Clinical, imaging, cytologic, and histologic findings were analyzed. RESULTS: Mammography revealed tubular carcinoma in 68 (87%) of the 78 cases. Sonography showed tubular carcinoma in all 38 cases in which it was used; nine of these lesions were mammographically occult. These nine lesions were slightly, but not significantly (p < .05), smaller than the 29 lesions that had also been detected on mammography. Large core needle biopsy was performed in 22 patients (sensitivity, 91%). At biopsy, diagnoses were malignant (n = 16 [73%]), suspicious (n = 4 [18%]), atypia (n = 1 [4.5%]), and benign (n = 1 [4.5%]). Fine-needle aspiration biopsy was used to evaluate 36 cases of tubular carcinoma (sensitivity, 50%); cytologic diagnoses were malignant (n = 15 [42%]), suspicious (n = 3 [8%]), atypia (n = 10 [28%]), and benign (n = 8 [22%]). Only 15 (19%) of the 78 tubular carcinomas were palpable. Other tumors were detected within the excised tissue in 47 of the patients (68%); of these other types of lesions, ductal carcinoma in situ was found most often. CONCLUSION: Most cases of tubular carcinoma can be revealed by mammography; for mammographically occult tubular carcinoma, sonography can be performed. The rate of accuracy for determining the presence of tubular carcinoma is higher with large core needle biopsy than with fine-needle aspiration biopsy. Finally, when tubular carcinoma is diagnosed, other histologic types of carcinoma often occur in the same breast.

The driving advisement system: a computer-augmented quasi-simulation of the cognitive prerequisites for resumption of driving after brain injury.

No other activity so starkly pits the needs of the individual recovering from brain injury against the protection of society than does operating a motor vehicle. Cognitive abilities (e.g., response to complex processing demands, impulse control, ability to sustain performance, mental flexibility, and judgment), while evident only indirectly, are essential to performance, yet few are well sampled in currently used assessment procedures, which, instead, emphasize visuo-motor coordination and reaction time. In response to this need, a computerized quasi-simulation, the Driving Advisement System (DAS), was developed and is introduced here. The DAS incorporates a set of computer-based tasks for use by professionals charged with rendering advice concerning cognitive abilities necessary for driving safely. Normative data on DAS measures were obtained from a group of over 60 safe drivers free of significant neurological impairment. Preliminary validation findings are summarized. A sample DAS-generated report for a brain-injury survivor, who sought to resume driving, is used to illustrate the graphic norm-referenced presentation of an individual's performance together with self-appraisal ratings.

Cognitive rehabilitation: a neuropsychological speciality comes of age.

In its first decade cognitive rehabilitation has emerged from infancy with the energy and much of the turmoil of youth. It has become an established speciality in brain-injury rehabilitation and has inspired many neuropsychologists to broaden their expertise beyond diagnosis and address their efforts to intervention. Restoration, although controversial, is an important and valid goal at the outset of cognitive rehabilitation, whereas the substitution of other means of goal achievement and environmental redesign are significant components of a comprehensive neuro-rehabilitative treatment programme. Efficacy is being demonstrated in many ways, ranging from increased patterns of use to controlled empirical studies. Few continue to raise the naive issue of whether there is any scientific basis for this neuropsychological speciality; instead, questions have become more focused on understanding the process of change to best serve human needs. In the next decade the refinement of current approaches can be anticipated, as well as the breaking of new ground. Neuropsychologists specializing in cognitive rehabilitation are likely to be turning their attention to underserved populations, such as those emerging from protracted coma, individuals suffering from 'progressive' neurological conditions, and persons whose brains were injured early in development. Scientific (theoretical, methodological and empirical) developments in cognitive psychology will help to delve more precisely into the underlying basic processes, including the sensory substrate. We will be challenged to address specific applications, such as advising people with known or suspected cognitive deficits who wish to drive.

Stereotaxic localization for fine-needle aspiration breast biopsy. Initial experience with 300 patients.

The efficacy of stereotaxic aspiration biopsy was evaluated in 300 consecutive patients with nonpalpable mammographic lesions. Sixty-eight patients (23%) had suspicious or malignant aspirates; all cases were proved malignant by subsequent examination of operative specimens. Two hundred sixteen patients (72%) had benign aspirates. Of these, 65 were confirmed by operation and 151 had subsequent mammography at 6- and 12-month intervals with no demonstrable mammographic change. In 10 instances (3%), the aspirates were atypical, and in six (2%), nondiagnostic. Biopsy specimens were obtained in all 16 instances, and eight were malignant. The sensitivity of stereotaxic breast aspiration for the diagnosis of cancer was 96%, and the specificity was 100%. Our experience confirms the efficacy of stereotaxic aspiration for the initial evaluation of mammographically detected, nonpalpable lesions.

Response system analysis: what the neuropsychologist can contribute to the rehabilitation of individuals emerging from coma.

The process of coma emergence is defined and important issues are identified. Rehabilitative goals for persons emerging from coma are best served by a focus on their response capabilities, rather than sensory stimulation. A method called "response system analysis" is described to guide assessment and treatment of response capabilities.

Rehabilitative optometric services for survivors of acquired brain injury.

In a retrospective study of clinical management practices, we assessed the impact of offering rehabilitative optometric services to a group of severely head-injured residents of a long-term rehabilitation facility. Each testable patient admitted (n = 55) was screened for visual function, and more than half were identified as having visual problems in need of treatment. A few were sent to local practitioners, but most (n = 26) were referred to a rehabilitative optometrist (with a specialty in low vision). For all but two patients, optometric treatment recommendations were implemented. All of those who received treatment benefited; indeed, in most cases the impact on participation in the overall rehabilitation program was significant. For the severely brain-injured, the study emphasized the need for (1) careful screening of visual-sensory function, (2) referral for rehabilitative optometric evaluation and treatment, (3) taking the necessary time for evaluations, and (4) the value of having a cognitive rehabilitation therapist assist the rehabilitative optometrist.

Visual imperception in brain-injured adults: multifaceted measures.

Visual imperception denotes the disorders of perceptual functioning commonly associated with unilateral brain injury. Typically the same half of the visual fields of both eyes are affected on the side opposite to that of the brain injury. The disorder may have a sensory or an attentional basis or both, moreover, the patient is often not aware of the problem. The condition interferes with daily activities including reading and navigating abilities, and it increases the likelihood that a person will have accidents. Thus, it becomes an obstacle to rehabilitation. Two comprehensive tests for visual imperception, Search-A-Word (SAW) and Speeded Reading of Word Lists (SRWL), were administered to a large sample of brain-injured and nonbrain-injured adult rehabilitation patients. Measures included: search times for left- and right-side targets, words missed at either margin, completion rates, errors on displaced words, and within-span errors. Right hemisphere brain injury was reliably associated with errors on the left side; left hemisphere brain injury was associated with overall poor performance. A factor analysis of performance measures revealed three major independent factors: (1) left spatial hemi-imperception, (2) lateral scanning dysfunction, and (3) left foveal hemi-imperception. These findings support a neurosensory-based view of imperception, especially in brain-injured persons. Finally, differential assessment of these problems is essential for comprehensive rehabilitation.

Helping brain-injured people to contend with hidden cognitive deficits.

In brain injury, cognitive processes are often impaired. These impairments may be hidden, complicating rehabilitation. We discuss clinical issues in cognitive rehabilitation with particular emphasis on its implications for daily living. For illustration we present two cases of persons with severe, but isolated disorders of memory and visual perception, respectively.

Training the short- and long-term verbal recall of a postencephalitic amnesic.

After encephalitis, a professor showed gross deficits in remembering new information. Both short- and long-term recall, as measured by free recall of word lists, were affected. Memory-training tasks directed at each of these two components were introduced according to a multiple-baseline experimental design. Each recall component increased only when corresponding training began.

The order of recall and the recall of order.

Adelphi University, Garden City, Long Island, New York 11530 Four experiments are described. The first three lend support to the assertion that retrieval from short-term storage (STS) is improved, possibly to a maximum, if items are recalled in their originally presented order. In the fourth experiment a modified recall condition was introduced in which written position of recall reflected order information. Although the subject was not constrained to recall the items in order under this modified recall condition, both item and order retention increased in comparison to both free and serial recall conditions. Within the theoretical framework adopted, the results indicate that retrieval from STS is improved by recalling in order; while long-term storage (LTS) is reduced by the constraint to recall in order. However, LTS is increased by the retention of order information when recalling in order is not required.