Factors associated with ever use of mammography in a limited resource setting. A mixed methods study.

OBJECTIVE: To evaluate facilitators and barriers influencing mammography screening participation among women. DESIGN: Mixed methods study. SETTING: Three hospital catchment areas in Hidalgo, Mexico. PARTICIPANTS: Four hundred and fifty-five women aged 40-69 years. INTERVENTION: Three hundred and eighty women completed a survey about knowledge, beliefs and perceptions about breast cancer screening, and 75 women participated in semi-structured, in-person interviews. Survey data were analyzed using logistic regression; semi-structured interviews were transcribed and analyzed using elements of the grounded theory method. MAIN OUTCOME MEASURE: Women were categorized as never having had mammography or having had at least one mammogram in the past. RESULTS: From survey data, having had a Pap in the past year was associated with ever having had breast screening (odds ratio = 2.15; 95% confidence interval 1.30-3.54). Compared with never-screened women, ever-screened women had better knowledge of Mexican recommendations for the frequency of mammography screening (49.5% vs 31.7% P < 0.001). A higher percentage of never-screened women perceived that a mammography was a painful procedure (44.5% vs 33.8%; P < 0.001) and feared receiving bad news (38.4% vs 22.2%; P < 0.001) compared with ever-screened women. Women who participated in semi-structured, in-person interviews expressed a lack of knowledge about Mexican standard mammographic screening recommendations for age for starting mammography and its recommended frequency. Women insured under the 'Opportunities' health insurance program said that they are referred to receive Pap tests and mammography. CONCLUSIONS: Local strategies to reduce mammogram-related pain and fear of bad news should work in tandem with national programs to increase access to screening.

Cancer care for Ukrainian refugees: Strategic impact assessments in the early days of the conflict.

BACKGROUND: The invasion of Ukraine by Russia in February 2022 has resulted in destruction of healthcare infrastructure and triggered the largest wave of internally displaced populations and refugees since World War Two. Conflicts in transitioned countries such as Ukraine create new non-communicable disease (NCD) challenges, especially for cancer care for refugees and humanitarian assistance in host countries. In the early days, rapid attempts were made to model possible impacts. METHODS: By evaluating open source intelligence used in the first three months of the conflict through snowball search methods, we aimed to address: (i) burden of cancer in Ukrainian population, specifically considering translating to the refugees population, and its cancer care capacity; ii) baseline capacity/strengths of cancer systems in initial host countries. Moreover, using a baseline scenario based on crude cancer incidence in Ukraine, and considering data from UNHCR, we estimated how cancer cases would be distributed across host countries. Finally, a surveillance assessment instrument was created, intersecting health system's capacity and influx of internally displaced populations and refugees. FINDINGS AND CONCLUSIONS: The total new cancer patients per month in pre-conflict Ukraine was estimated as 13,106, of which < 1 % are paediatric cases. The estimated cancer cases in the refugee population (combining prevalent and incident), assuming 7.5 million refugees by July 2022 and a female:male ratio of 9:1, was 33,121 individuals (Poland: 19284; Hungary: 3484; Moldova: 2651; Slovakia: 2421; Romania: 5281). According to our assessments, Poland is the only neighbouring country classified as green/yellow for cancer capacity, i.e. sufficient ablility to absorb additional burden into national health system; Slovakia we graded as yellow, Hungary and Romania as yellow/red and Moldova as red.

Mitochondrial proliferation and paradoxical membrane depolarization during terminal differentiation and apoptosis in a human colon carcinoma cell line.

Herbimycin A, a tyrosine kinase inhibitor, induces cellular differentiation and delayed apoptosis in Colo-205 cells, a poorly differentiated human colon carcinoma cell line. Cell cycle analysis in conjunction with end labeling of DNA fragments revealed that G2 arrest preceded apoptotic cell death. Ultrastructural examination of herbimycin-treated cells demonstrated morphologic features of epithelial differentiation, including formation of a microvillar apical membrane and lateral desmosome adhesions. A marked accumulation of mitochondria was also observed. Fluorometric analysis using the mitochondrial probes nonyl-acridine orange and JC-1 confirmed a progressive increase in mitochondrial mass. However these cells also demonstrated a progressive decline in unit mitochondrial transmembrane potential (DeltaPsim) as determined by the DeltaPsim-sensitive fluorescent probes rhodamine 123 and JC-1 analyzed for red fluorescence. In concert with these mitochondrial changes, Colo-205 cells treated with herbimycin A produced increased levels of reactive oxygen species as evidenced by oxidation of both dichlorodihydrofluorescein diacetate and dihydroethidium. Cell-free assays for apoptosis using rat-liver nuclei and extracts of Colo-205 cells at 24 h showed that apoptotic activity of Colo-205 lysates requires the early action of mitochondria. Morphological and functional mitochondrial changes were observed at early time points, preceding cleavage of poly (ADP-ribose) polymerase. These results suggest that apoptosis in differentiated Colo-205 cells involves unrestrained mitochondrial proliferation and progressive membrane dysfunction, a novel mechanism in apoptosis.

Ductal lavage for detection of cellular atypia in women at high risk for breast cancer.

BACKGROUND: Breast cancer originates in breast epithelium and is associated with progressive molecular and morphologic changes. Women with atypical breast ductal epithelial cells have an increased relative risk of breast cancer. In this study, ductal lavage, a new procedure for collecting ductal cells with a microcatheter, was compared with nipple aspiration with regard to safety, tolerability, and the ability to detect abnormal breast epithelial cells. METHODS: Women at high risk for breast cancer who had nonsuspicious mammograms and clinical breast examinations underwent nipple aspiration followed by lavage of fluid-yielding ducts. All statistical tests were two-sided. RESULTS: The 507 women enrolled included 291 (57%) with a history of breast cancer and 199 (39%) with a 5-year Gail risk for breast cancer of 1.7% or more. Nipple aspirate fluid (NAF) samples were evaluated cytologically for 417 women, and ductal lavage samples were evaluated for 383 women. Adequate samples for diagnosis were collected from 111 (27%) and 299 (78%) women, respectively. A median of 13,500 epithelial cells per duct (range, 43-492,000 cells) was collected by ductal lavage compared with a median of 120 epithelial cells per breast (range, 10-74,300) collected by nipple aspiration. For ductal lavage, 92 (24%) subjects had abnormal cells that were mildly (17%) or markedly (6%) atypical or malignant (<1%). For NAF, corresponding percentages were 6%, 3%, and fewer than 1%. Ductal lavage detected abnormal intraductal breast cells 3.2 times more often than nipple aspiration (79 versus 25 breasts; McNemar's test, P<.001). No serious procedure-related adverse events were reported. CONCLUSIONS: Large numbers of ductal cells can be collected by ductal lavage to detect atypical cellular changes within the breast. Ductal lavage is a safe and well-tolerated procedure and is a more sensitive method of detecting cellular atypia than nipple aspiration.

Oncoplastic breast conserving surgery: a renaissance of anatomically-based surgical technique.

Using oncoplastic surgical techniques for breast preservation, breast surgeons can achieve widened surgical margins at the same time that the shape and appearance of the breast is preserved and sometimes rejuvenated. Oncoplastic surgical resection is designed to follow the cancer's contour, which generally follows the segmental anatomy of the breast, which has been well understood since the mid 19th century because of pioneering anatomic studies performed by Sir Astley Paston Cooper. The quadrantectomy, developed by Veronesi and colleagues in the 1970's, follows these same anatomic principles of wide segmental resection. The more surgically narrow lumpectomy as popularized in the U.S. uses a smaller, scoop-like non-anatomic resection of cancer. With negative surgical margins, the lumpectomy is equivalent to the quadrantectomy in achieving the goals of breast conservation as measured by local recurrence and survival. However, the lumpectomy is less versatile for resection of larger cancers, and can be more prone to creating suboptimal cosmetic defects. Cancers with large in situ components can be particularly problematic for resection with the standard lumpectomy, when they extend both centrally toward the nipple and peripherally to distal terminal ductulo-lobular units, which typically occur in a pie-shaped segmental distribution. Ductal segments, each of which ultimately drains to a single major lactiferous sinus at the nipple, vary in size and depth in the breast. Breast surgeons should carefully evaluate the cancer distribution and extent in the breast before operation. A combination of imaging methods (mammography with magnification views, ultrasonography, magnetic resonance imaging [MRI], or all) may yield the best estimates of overall tumor extent. Multiple bracketing wires afford the greater help to complete surgical excision. Those tumors with segmental spreading are best excised by oncoplastic resections according to their distribution.

Carcinosarcoma of the spleen. An extragenital malignant mixed müllerian tumor?

A 55-year-old woman with painful splenomegaly underwent surgical exploration and resection of the spleen. Pathologic examination revealed a neoplasm of the spleen exhibiting malignant stromal and epithelial components with müllerian features. In the absence of a recognized neoplasm elsewhere, the carcinosarcoma most likely arose as a primary splenic tumor and may represent an extrauterine malignant mixed müllerian tumor arising in the spleen.

Marginating neutrophils are reversibly adherent to normal lung endothelium.

Neutrophils have been implicated in the pathogenesis of several inflammatory lung disorders including asthma, emphysema, and adult respiratory distress syndrome. The precursors of these destructive cells are thought to be marginating neutrophils that, although intravascular, remain intimately associated with endothelium, resisting the shearing forces of flowing blood. The purposes of this study were (1) to examine a method for quantitating marginating lung neutrophils, (2) to assess the adherence of marginating neutrophils to normal lung endothelium, and (3) to determine the reversibility of neutrophil-endothelial cell adherence. Rats were anesthetized and ventilated, and their lungs were exposed through a median sternotomy. The left lung was tied off with blood in situ and the right lung was perfused intraarterially with colloid for 2 minutes. In separate experiments, both left and right lungs were perfused intraarterially with colloid for 25 minutes. Myeloperoxidase, a neutrophil granule enzyme, was related to lung neutrophils. Dithionite-sensitive optical density (DSOD) was related to lung hemoglobin. Marginating lung neutrophils were quantitated by measuring the peroxidase activity of normal blood-perfused lung (myeloperoxidase assay) and subtracting from it the fraction of activity corresponding to the lung blood content (DSOD). The marginating neutrophil pool was identified by 2.1 units myeloperoxidase (5 x 10(6) neutrophils) per gm wet lung. Although the marginating pool was depleted by 54% during 2 minutes of lung colloid perfusion, lung erythrocytes (DSOD) were decreased by a significantly greater 93% (p less than 0.05). Lungs perfused with colloid for 25 minutes had negligible remaining myeloperoxidase activity. We conclude that (1) marginating lung neutrophils can be quantitated with the myeloperoxidase and DSOD assays, (2) marginating neutrophils are relatively adherent to normal lung endothelium compared with intravascular erythrocytes, and (3) the adherence of marginating neutrophils is fully reversible.

Reversible lung neutrophil accumulation can cause lung injury by elastase-mediated mechanisms.

Neutrophils have been implicated in multiple models of end-organ injury. The purposes of this study were to determine whether (1) a sublethal septic insult promotes lung neutrophil accumulation, (2) this pulmonary neutrophil accumulation is reversible, (3) these accumulated neutrophils can be activated to injure lung, and (4) this pulmonary neutrophil accumulation obligates lung injury. Rats were administered low-dose endotoxin, 500 micrograms/kg, intraperitoneally, and at 6 or 12 hours, lungs were harvested and assayed for myeloperoxidase, a marker of neutrophil accumulation, and iodine 125-labeled albumin uptake, a marker of lung injury. A second set of rats were administered low-dose endotoxin and at 6 or 12 hours were given a neutrophil activator formyl-norleucyl-leucyl-phenylalanine (FNLP) 250 micrograms/kg, intravenously. At 8 or 14 hours, lungs were harvested and assayed for 125I-labeled albumin uptake. A third set of rats were administered low-dose endotoxin, and at 5 1/2 hours 30 minutes before FNLP administration, they were given a neutrophil elastase inhibitor, methyoxysuccinyl-L-alanine-L-alanine-L-proline-L-valine-chlorometh yl ketone, 2.5 mg/kg, intraperitoneally. At 6 hours rats were given FNLP, and at 8 hours lungs were harvested and assayed for 125I-labeled albumin uptake. The following results were obtained: (1) low-dose endotoxin caused a transient increase (p less than 0.05) in lung neutrophil accumulation at 6 hours, which was resolved by 12 hours; (2) lung 125I-labeled albumin uptake was unchanged both 6 and 12 hours after isolated low-dose endotoxin administration; (3) neutrophil activation increased (p less than 0.05) lung 125I-labeled albumin uptake when imposed 6 but not 12 hours after low-dose endotoxin administration; and (4) elastase inhibition decreased (p less than 0.05) the lung 125I-labeled albumin uptake promoted by endotoxin and FNLP. We conclude that sublethal endotoxemia causes a reversible lung neutrophil accumulation and that this lung neutrophil accumulation does not obligate lung injury; but activation of these accumulated neutrophils can promote lung injury, and this neutrophil-associated lung injury is mediated in part by neutrophil elastase.

The development and evaluation of a clinical test of surgical resident proficiency.

The two purposes of this study were to develop a clinical test of surgical resident proficiency and to compare this clinical test with currently applied methods of resident evaluation. Appendicitis is a common surgical disease, and its accurate diagnosis depends largely on clinical acumen. Ten third-year surgical residents prospectively evaluated 107 patients admitted because of suspected appendicitis. After taking a history, performing a physical examination, and reviewing laboratory data, these residents were asked to state, as a percentage, the likelihood that each patient had appendicitis. Sixty-three patients had appendicitis documented by pathologic inspection after appendectomy. Forty-four patients did not have appendicitis, as was determined by operation (17) or by in-house observation and resolution of abdominal pain (27). These outcomes were used to calculate a diagnostic ability score (DAS) for each resident. Residents were evaluated by standard methods including in-service examinations and monthly evaluations by the attending staff. Residents were also evaluated by nonstandard, but potentially useful, neuropsychologic and psychologic tests, including the trail making test, the Ravens progressive matrices test, the paced auditory serial addition test (PASAT), the grooved pegboard test of manual dexterity, and the profile of mood states (POMS) psychologic questionnaire. Cumulative scores were calculated and compared by multiple regression with coefficient variance analysis. The correlation (R2) of DAS with standard evaluation techniques was as follows: In-service (0.055), faculty (0.508), trails (-0.293), Ravens (0.028), PASAT (0.251), dexterity (0.432), POMS (0.381). We found that (1) the DAS is a discriminating clinical test; (2) the DAS correlates with subjective faculty evaluation; and (3) the DAS does not correlate with in-service examination scores. We conclude that faculty evaluation remains the best currently applied test of surgical resident clinical proficiency as measured by the DAS.

Pretreatment with a nontoxic derivative of endotoxin induces functional protection against cardiac ischemia/reperfusion injury.

We hypothesized that low-dose pretreatment of an intact animal with a nontoxic derivative of endotoxin, monophosphoryl lipid A (MPL), would induce protection against cardiac ischemia/reperfusion (I/R) injury. The purposes of this study were to investigate whether MPL pretreatment would induce functional protection against cardiac I/R injury, to delineate the temporal induction of protection, and to examine antioxidant enzyme induction as a mechanism of protection. Rats were administered a 5 mg/kg dose of MPL at 2 hours and 24 hours before a 25-minute, global, 37 degrees C ischemic insult followed by reperfusion (modified Langendorff). At 40 minutes of reperfusion, ventricular function was assessed (ventricular balloon; developed pressure, rate of contraction, rate of relaxation). Hearts from rats pretreated with MPL 24 hours before isolation exhibited preservation of ventricular function (p less than 0.05). After I/R, hearts from rats pretreated with MPL 24 hours before isolation had increased (p less than 0.05) catalase activity compared to saline pretreated controls and rats pretreated with MPL 2 hours before isolation. We conclude that (1) pretreatment with MPL induces functional protection against cardiac I/R injury, (2) protection (not evident at 2 hours) is maximal at 24 hours, suggesting enzyme induction, and (3) increased catalase activity correlates with the functional protection.

Hypovolemic shock promotes neutrophil sequestration in lungs by a xanthine oxidase-related mechanism.

Our results suggest that xanthine oxidase (XO) contributes to lung neutrophil sequestration in hypovolemic shock. Catheterized rats subjected to shock by phlebotomy (approximately 30% blood loss) had decreased mean arterial blood pressures (P less than 0.05) and increased (P less than 0.05) lung myeloperoxidase (MPO) activities (indicative of lung neutrophil accumulation) compared with sham-treated normotensive rats. In contrast, rats depleted of lung and plasma XO activity by tungsten diet before phlebotomy had decreased (P less than 0.05) lung MPO activities compared with phlebotomized rats fed regular diets.

Xanthine oxidase is increased and contributes to paraquat-induced acute lung injury.

Two lines of investigation suggested that xanthine oxidase- (XO) derived O2 metabolites contribute to paraquat- (PQ) induced acute lung injury. First, PQ treatment increased lung XO activity and decreased lung xanthine dehydrogenase activity. Second, lung albumin uptake increased compared with control values in untreated XO-replete but not tungsten-treated XO-depleted lungs in rats treated with PQ.

Liver injury is a reversible neutrophil-mediated event following gut ischemia.

The purposes of this study were to characterize the temporal relationship of distant organ dysfunction after mesenteric ischemia/reperfusion (I/R), and to ascertain if the neutrophil is critical to this process. Normal and neutrophil-depleted rats (vinblastine sulfate, 0.75 mg/kg intravenously) underwent 45 minutes of superior mesenteric artery occlusion and after 0, 6, and 18 hours of reperfusion, blood was sampled and liver and lungs were harvested. Iodine 125 albumin leak was used as a marker for pulmonary and liver injury, and serum acetoacetate/3-hydroxybutyrate (AcAc/3-OHB) was used as an index of hepatic mitochondrial redox state. Gut I/R at 6 hours increased 125I-albumin lung/blood ratio (gut I/R, 0.077 +/- 0.006; control, 0.045 +/- 0.004) and 125I-albumin liver/blood ratio (gut I/R, 0.120 +/- 0.007; control, 0.077 +/- 0.003), while AcAc/3-OHB decreased significantly (gut I/R, 0.420 +/- 0.040; control, 0.880 +/- 0.120). Neutrophil depletion eliminated these changes at 6 hours (blood AcAc/3-OHB, 0.720 +/- 0.100; 125I liver/blood, 0.068 +/- 0.006; 125I lung/blood, 0.046 +/- 0.007). We conclude the following: (1) intestinal I/R produces simultaneous liver and lung injury; (2) injury was present at 6 hours but is reversed at 18 hours; and (3) the I/R-induced liver and lung injuries were neutrophil mediated.

Chest wall neoplasms and their management.

Although uncommon, primary and metastatic neoplasms can occur in the chest wall. For malignant neoplasms, the potential for cure depends on the completeness of resection, histologic type, and tumor stage. Each patient warrants individual evaluation for chest wall resection. Operative selection is based on the potential benefits, operative feasibility, patient health, and anticipated tumor biology. The choice of reconstruction techniques is based on the tumor's location, the size of the remaining defect, and the availability of autogenous graft materials. Skeletal and soft tissue reconstruction can be performed safely in a single stage.

Transrectal ultrasonography and operative selection for early carcinoma of the rectum.

BACKGROUND: Transrectal ultrasonography (TRUS) supplements clinical evaluation of early carcinoma of the rectum in selecting patients for local operative therapy, such as transanal excision (TAE). STUDY DESIGN: This study was done to evaluate the accuracy of ultrasonographic staging of tumor depth (T stage) in patients with suspected early carcinoma of the rectum, to compare ultrasonographic with clinical T-staging accuracies within this patient group, to determine if any specific tumor characteristics (configuration, size, location) predispose toward ultrasonographic T-staging inaccuracy, and to examine the role of TRUS in operative selection for patients with early carcinoma of the rectum. RESULTS: Between April 1990 and December 1992, 62 patients with primary carcinoma of the rectum underwent ultrasonographic staging (uT), whereby three uT4, 27 uT3, 24 uT2 and eight uT1 carcinomas were identified. Of the 32 patients with suspected intramural (uT1 or uT2) disease, 27 underwent prompt operative excision or resection at our institution, allowing comparative histopathologic staging. In this highly selected patient subset, uT1 staging was correct in all instances; uT2 staging was incorrect in 45 percent of instances, with 30 percent having unpredicted transmural penetration. Ultrasonographic and clinical staging accuracies were quantitatively similar, and no tumor characteristics were consistently associated with ultrasonographic imprecision. CONCLUSIONS: Among patients with clinically suspected early carcinoma of the rectum, the decision to perform TAE is supported by ultrasonographic T1 staging. By contrast, the decision to perform TAE cannot be based solely on ultrasonographic T2 staging, because of the possibility for transmural penetration of tumor.

Axillary web syndrome after axillary dissection.

BACKGROUND: Some patients undergoing axillary lymph node dissection (ALND) experience postoperative pain and limited range of motion associated with a palpable web of tissue extending from the axilla into the ipsilateral arm. The purpose of this study is to characterize the previously undescribed axillary web syndrome (AWS). METHODS: To identify patients with AWS, a retrospective review was performed of all invasive breast cancer patients treated by a single surgeon (REM) between 1980 and 1996. Records were also reviewed of 4 more recent patients who developed AWS after undergoing sentinel node lymph node dissection (SLND) without ALND. RESULTS: Among 750 sequentially treated patients, 44 (6%) developed AWS between 1 and 8 weeks after their axillary procedure. The palpable subcutaneous cords extended from the axillary crease down the ipsilateral arm, across the antecubital space, and in severe cases down to the base of the thumb. The web was associated with pain and limited shoulder abduction (< or = 90 degrees in 74% of patients). AWS resolved in all cases within 2 to 3 months. AWS also occurred after SLND. Tissue sampling of webs in 4 patients showed occlusion in lymphatic and venous channels. CONCLUSIONS: AWS is a self-limiting cause of morbidity in the early postoperative period. More limited axillary surgery, with less lymphovenous disruption, might reduce the severity and incidence of this syndrome, although SLND does not eliminate its occurrence.

NCCN Practice Guidelines for Breast Cancer.

The therapeutic options for patients with noninvasive or invasive breast cancer are complex and varied. In many situations, the patient and physician have the responsibility to jointly explore and ultimately select the most appropriate option from among the available alternatives. With rare exception, the evaluation, treatment, and follow-up recommendations contained within these guidelines were based largely on the results of past and present clinical trials. However, there is not a single clinical situation in which the treatment of breast cancer has been optimized with respect to either maximizing cure or minimizing toxicity and disfigurement. Therefore, patient and physician participation in prospective clinical trials allows patients not only to receive state-of-the-art cancer treatment but also to contribute to the improvement of treatment of future patients.

Increased serum catalase activity in rats subjected to thermal skin injury.

We found that rats subjected to thermal skin injury (burn) had increased serum hydrogen peroxide (H2O2) scavenging activity, serum catalase activity, erythrocyte (RBC) fragility, and edematous lung injury (lung leak) when compared to sham-treated rats. Serum H2O2 scavenging activity was inhibited by addition of sodium azide, a catalase inhibitor. Treatment of rats with the oxygen radical scavenger, dimethylthiourea (DMTU), decreased RBC fragility and lung leak but did not alter increased H2O2 scavenging or catalase activity of serum from rats subjected to skin burn. We conclude that increased serum catalase activity is a consequence of thermal skin injury and that increased serum catalase activity may be a mechanism that modulates H2O2-dependent processes following skin burn.

Breast conservation therapy (BCT): surgery as the cornerstone of multi-specialty care.

Surgical care has been the mainstay of breast cancer diagnosis and treatment. As care has evolved, increased collaborative approaches among surgeons, radiologists, radiation oncologists and medical oncologists have improved the quality of breast cancer treatment for the patient. Breast conservation therapy (BCT) exemplifies how multi-specialty care can increase cancer cure rates at the same time that the disfiguring aspects of breast cancer treatment can be minimized. New questions are being raised within clinical forums about how to do better both for the patient and for her oncologic treatment. The following questions represent three current issues in BCT: 1. What general operative approaches in BCT can minimize morbidity and optimize the cosmetic outcome from surgery? 2. What role does radiation therapy play in BCT for invasive and non-invasive breast cancer to supplement surgical intervention? 3. What role can neoadjuvant chemotherapy play in improving BCT rates?

Diagnosis of congenital vascular malformations of the extremities: new perspectives.

Congenital vascular malformation (CVM's) have traditionally been evaluated angiographically. Unfortunately, this approach does not always give definitive information about the various components, particularly microfistulous lesions and venous angiomata, and it provides little physiologic information. Furthermore, it is expensive, invasive, and is not needed to guide therapy in the majority of patients who either do not need or will not benefit from surgery or embolotherapy. We propose a different approach which begins initially with simple noninvasive screening tests, then selectively uses labelled-albumin microspheres to quantify the AV shunt fraction and/or magnetic resonance imaging (MRI) to define the anatomic extent and involvement of adjacent structures. This approach gives sufficient anatomic and physiologic information in the vast majority of cases to allow reasonable prognostication and to guide future therapy. Angiography is then reserved for patients identified as probably having localized lesions or for those with more extensive CVM's whose symptoms ultimately justify therapeutic intervention.