Incremental Role of Mammography in the Evaluation of Gynecomastia in Men Who Have Undergone Chest CT.

OBJECTIVE: The purpose of this study was to determine whether additional breast imaging is clinically valuable in the evaluation of patients with gynecomastia incidentally observed on CT of the chest. MATERIALS AND METHODS: In a retrospective analysis, 62 men were identified who had a mammographic diagnosis of gynecomastia and had also undergone CT within 8 months (median, 2 months). We compared the imaging findings of both modalities and correlated them with the clinical outcome. RESULTS: Gynecomastia was statistically significantly larger on mammograms than on CT images; however, there was a high level of concordance in morphologic features and distribution of gynecomastia between mammography and CT. In only one case was gynecomastia evident on mammographic but not CT images, owing to cachexia. Two of the 62 men had ductal carcinoma, which was obscured by gynecomastia. Both of these patients had symptoms suggesting malignancy. CONCLUSION: The appearance of gynecomastia on CT scans and mammograms was highly correlated. Mammography performed within 8 months of CT is unlikely to reveal cancer unless there is a suspicious clinical finding or a breast mass eccentric to the nipple. Men with clinical symptoms of gynecomastia do not need additional imaging with mammography to confirm the diagnosis if they have undergone recent cross-sectional imaging.

Risk of malignancy when microscopic radial scars and microscopic papillomas are found at percutaneous biopsy.

OBJECTIVE: The objective of our study was to assess the incidence of associated malignancy when microscopic radial scars and microscopic intraductal papillomas are encountered at percutaneous biopsy for lesions that otherwise reveal benign histopathology. MATERIALS AND METHODS: A search of the pathology database for the period from December 14, 2006, through December 21, 2009, identified patients with a microscopic radial scar, a microscopic intraductal papilloma, or both at percutaneous biopsy. Patients whose percutaneous biopsy was performed for a lesion that revealed carcinoma or a high-risk pathology result were excluded to avoid confounding bias, as were patients who had only imaging follow-up. Only patients who underwent surgery solely for the study lesion were included. The lesion type that prompted core biopsy, biopsy guidance and device, sample number, and surgical outcomes were recorded. The incidences of benign, high-risk, and malignant pathology findings from surgery were calculated. RESULTS: The search revealed 35 patients (18 microscopic radial scars, 17 microscopic papillomas) who underwent surgery solely for the study lesion. Stereotactic guidance was used for 15 (43%); ultrasound, for 12 (34%); and MRI, for eight (23%). At surgery, 12 patients (34%) had high-risk histopathology results and 23 (66%) had benign results. No study lesions were upgraded to malignancy. CONCLUSION: Our study found no evidence of associated malignancy at surgical excision when microscopic radial scars and microscopic intraductal papillomas were encountered at percutaneous biopsy in patients who otherwise had benign histopathology results; thus, routine imaging follow-up may be performed.

MRI Features of Free Liquid Silicone in the Transgender Female Breast.

OBJECTIVE: To define MRI features of free liquid silicone injection (FLSI) of the breast in transgender women considering surgical management. METHODS: This study was IRB-approved. MRI images from transgender women with FLSI imaged between 2009 and 2019 were reviewed. Presence and location of fibrotic masses (FMs) in the breast(s) and pectoralis muscle and patterns of granulomas were correlated with clinicopathologic findings. Background enhancement was quantified. Comparisons were performed using two-tailed Fisher exact and Student's t test. RESULTS: Of 21 transgender women with FLSI (mean age 46.8 years), 13/21 (61.9%) had a dominant FM measuring over 4 cm; these were limited to breast and pectoralis in 6/21 (28.6%), breast in 9/21 (42.9%), and pectoralis only in 2/21 (9.5%). Four of 21 patients (19.0%) had no FMs, and 4/21 (19.0%) had masses under 4 cm. Mean size of the dominant FM was 7.4 cm (range 4-12 cm). FMs were enhancing in 5/13 (38.5%) and contained T2 high signal granulomas in 8/13 (61.5%). While 18/21 (85.8%) of cases showed mild to moderate overall background enhancement, the majority 7/13 (61.5%) of dominant FM were non-enhancing. About half of cases (11/21, 52.4%) had diffuse foci, and half (10/21, 47.6%) had diffuse foci and masses throughout the breast and pectoralis muscle. These foci and masses displayed T2 high signal in 13/21 (61.9%). There were no occult carcinomas observed. CONCLUSION: MRI performed on symptomatic FLSI patients considering surgical treatment is helpful in assessing the extent of silicone infiltration and fibrotic reaction of the breast and pectoralis muscle.

Sliding scale versus tight glycemic control in the noncritically ill at a community hospital.

BACKGROUND: Development of hyperglycemia during hospitalization is an area of concern in patients with and without diabetes mellitus. Tight glycemic control has been debated for critically ill and noncritically ill patients with hyperglycemia. Although many studies have been performed in the critically ill, adequate data are not available in the noncritically ill population. OBJECTIVE: To compare traditional sliding scale (SS) with a tight glycemic control (TC) algorithm. The primary endpoint was the percentage of total blood glucose measurements in the target range of 80-150 mg/dL. The secondary endpoint evaluated was safety, defined as percentage of all blood glucose measurements that were 0-60 mg/dL. METHODS: A 1-year, retrospective analysis from June 1, 2007, to May 31, 2008, was performed evaluating all inpatients with hyperglycemia within the first 48 hours of admission to the Medical Center of Plano, Plano, TX. A cohort of patients managed with SS (n =121) was compared with those treated with TC (n = 210). Patients on SS insulin received a traditional SS regimen with regular insulin or insulin aspart based on physician preference. RESULTS: Demographics and comorbidities were similar between the 2 groups; however, the TC cohort was younger (64.8 + or - 14.1 vs 70.8 + or - 13.7 y; p < 0.001). There were more persons with type 2 diabetes mellitus in the TC cohort (81.9%) versus the SS cohort (60.3%; p < 0.001). In the TC cohort, 42.9% of blood glucose measurements were in the target range of 80-150 mg/dL compared with 30.6% of the measurements in the SS cohort (p < 0.001). Regarding safety, 2% of blood glucose measurements of the TC cohort were in the range of 0-60 mg/dL versus 0.3% of the SS cohort (p < 0.001). No clinical sequelae of hypoglycemia were observed. Patients achieved more blood glucose measurements in the target range when treated with TC versus SS insulin, without regard to prior history of diabetes. CONCLUSIONS: Patients treated with TC experienced more blood glucose measurements in the target range as compared with patients treated with SS with relatively low hypoglycemia rates.

BI-RADS 3: Current and Future Use of Probably Benign.

PURPOSE OF REVIEW: Probably benign (BI-RADS 3) causes confusion for interpreting physicians and referring physicians and can induce significant patient anxiety. The best uses and evidence for using this assessment category in mammography, breast ultrasound, and breast MRI will be reviewed; the reader will have a better understanding of how and when to use BI-RADS 3. RECENT FINDINGS: Interobserver variability in the use of BI-RADS 3 has been documented. The 5th edition of the BI-RADS atlas details the appropriate use of BI-RADS 3 for diagnostic mammography, ultrasound, and MRI, and discourages its use in screening mammography. Data mining, elastography, and diffusion weighted MRI have been evaluated to maximize the accuracy of BI-RADS 3. SUMMARY: BI-RADS 3 is an evolving assessment category. When used properly, it reduces the number of benign biopsies while allowing the breast imager to maintain a high sensitivity for the detection of early stage breast cancer.

Breast Imaging Reporting and Data System category 3 for magnetic resonance imaging.

The Breast Imaging Reporting and Data System (BI-RADS) category 3 signifies a probably benign finding and should be reserved for those findings that have a less than 2% risk of malignancy. There are limited data defining the use of this category in magnetic resonance imaging (MRI) and the imaging features of probably benign lesions are not well defined. Most recent studies have shown that the frequency of use of BI-RADS 3 is comparable with that reported in mammography and ultrasound and that the rate of malignancy is within the targeted range. Several findings, once assessed as BI-RADS 3, are now known to represent benign entities, such as variations of background parenchymal enhancement and intramammary lymph nodes. A subset of masses, foci, and nonmass enhancement can appropriately be assigned BI-RADS 3 on baseline MRI. The BI-RADS 3 is most appropriately used for round, dot-like foci, which are unique and separate from background parenchymal enhancement and for oval masses with circumscribed margins and homogeneous enhancement, such as those typically seen in incidental fibroadenomas. The BI-RADS 3 may also be appropriate for a focal or regional distribution of nonmass enhancement without suspicious features.

Digital breast tomosynthesis of gynecomastia and associated findings-a pictorial review.

Men referred for breast imaging most frequently present with a unilateral palpated breast lump or breast enlargement. In the vast majority of these cases, the cause is benign and the most common etiology is gynecomastia. This pictorial review illustrates the appearance by full field digital mammography and digital breast tomosynthesis of gynecomastia as well as additional findings in the male breast including sternalis muscle and hypertrophied pectoralis muscle, lipoma, intramammary lymph node, fat necrosis, breast cancer, and atypical ductal hyperplasia.

Crystal structure and mutational analysis of heparan sulfate 3-O-sulfotransferase isoform 1.

Heparan sulfate interacts with antithrombin, a protease inhibitor, to regulate blood coagulation. Heparan sulfate 3-O-sulfotransferase isoform 1 performs the crucial last step modification in the biosynthesis of anticoagulant heparan sulfate. This enzyme transfers the sulfuryl group (SO(3)) from 3'-phosphoadenosine 5'-phosphosulfate to the 3-OH position of a glucosamine residue to form the 3-O-sulfo glucosamine, a structural motif critical for binding of heparan sulfate to antithrombin. In this study, we report the crystal structure of 3-O-sulfotransferase isoform 1 at 2.5-A resolution in a binary complex with 3'-phosphoadenosine 5'-phosphate. This structure reveals residues critical for 3'-phosphoadenosine 5'-phosphosulfate binding and suggests residues required for the binding of heparan sulfate. In addition, site-directed mutagenesis analyses suggest that residues Arg-67, Lys-68, Arg-72, Glu-90, His-92, Asp-95, Lys-123, and Arg-276 are essential for enzymatic activity. Among these essential amino acid residues, we find that residues Arg-67, Arg-72, His-92, and Asp-95 are conserved in heparan sulfate 3-O-sulfotransferases but not in heparan N-deacetylase/N-sulfotransferase, suggesting a role for these residues in conferring substrate specificity. Results from this study provide information essential for understanding the biosynthesis of anticoagulant heparan sulfate and the general mechanism of action of heparan sulfate sulfotransferases.

Crystal structure of human cholesterol sulfotransferase (SULT2B1b) in the presence of pregnenolone and 3'-phosphoadenosine 5'-phosphate. Rationale for specificity differences between prototypical SULT2A1 and the SULT2BG1 isoforms.

The gene for human hydroxysteroid sulfotransferase (SULT2B1) encodes two peptides, SULT2B1a and SULT2B1b, that differ only at their amino termini. SULT2B1b has a predilection for cholesterol but is also capable of sulfonating pregnenolone, whereas SULT2B1a preferentially sulfonates pregnenolone and only minimally sulfonates cholesterol. We have determined the crystal structure of SULT2B1a and SULT2B1b bound to the substrate donor product 3'-phosphoadenosine 5'-phosphate at 2.9 and 2.4 A, respectively, as well as SULT2B1b in the presence of the acceptor substrate pregnenolone at 2.3 A. These structures reveal a different catalytic binding orientation for the substrate from a previously determined structure of hydroxysteroid sulfotransferase (SULT2A1) binding dehydroepiandrosterone. In addition, the amino-terminal helix comprising residues Asp19 to Lys26, which determines the specificity difference between the SULT2B1 isoforms, becomes ordered upon pregnenolone binding, covering the substrate binding pocket.