Can digital breast tomosynthesis accurately predict whether circumscribed masses are benign or malignant in a screening population?

AIM: To evaluate whether digital breast tomosynthesis (DBT) can predict if circumscribed masses are benign or malignant by assessing margin sharpness. MATERIALS AND METHODS: Circumscribed masses were evaluated on co-registered two-dimensional digital mammography (2DDM) and DBT. Lesions were categorised as follows: category 1=visible sharp border 0-25% of the total margin; category 2 = 26-50% category 3= 51-75%, and category 4=76-100%. Changes in category between 2DDM and DBT were analysed; if the category was lower on DBT the change was negative, if higher the change was positive. RESULTS: Of 759 lesions, 121 masses classified as circumscribed on DBT were included; 25 were malignant and 96 benign. Of the benign lesions, 8/96 were within category 3 or 4 on 2DDM compared with 48/96 benign lesions within category 3 or 4 on DBT (Fisher's exact test p<0.000527). Forty-eight of 51 (94.1%) lesions categorised as 3 or 4 on DBT were benign and 65/67 (97.01%) of the positive category change group were benign. Lesions in category 1 on DBT had 45.4% chance of being malignant (20/44) compared with 22.72% (20/88) on 2DDM (chi-squared test p<0.001). Sixty-five of 67 (97.01%) lesions in the positive category change group were benign and 23/54 (42.6%) lesions with either no or negative category change were malignant. CONCLUSION: The present study demonstrates 97% accuracy in predicting circumscribed lesions as benign when using positive category change and 94% accuracy when >50% of the margin is sharply defined on DBT.

An audit of mammographic screen detected lesions of uncertain malignant potential (B3) diagnosed on initial image guided needle biopsy: how has our practice changed over 10 years?

AIM: To review all cases of B3 lesion diagnosed at initial image-guided needle biopsy over two 5-year cohorts to identify upgrade rates to malignancy and the effect of changing guidance on the management of such lesions. MATERIALS AND METHODS: Data was collected retrospectively. Mammographic features, biopsy type and management were recorded for each lesion. Upgrade rates for each B3 histological category were quantified. Statistical analysis was performed using SPSS. RESULTS: There were 224 cases in 2005-2010 and 240 cases in 2010-2015. Mammographically 211 lesions were microcalcifications, 182 masses, 65 distortions and six asymmetric densities with no difference in the mammographic features in the two cohorts. Two hundred and eight 14 G core biopsies and 256 initial vacuum-assisted biopsies were performed. There was a statistically significant reduction in benign surgical biopsies and an increase in second-line vacuum biopsy/excision in the latter cohort, with no significant change in the upgrade rate. There was an overall 6% upgrade to invasive malignancy and 13% upgrade to ductal carcinoma in situ (DCIS). The upgrade rates for the following histological categories were atypical intraductal epithelial proliferation (AIDEP) 33.2% (21/63); classical (not pleomorphic) in situ lobular neoplasia (ISLN) 18.2% (6/33); flat epithelial hyperplasia (FEA) 21.7% (20/92); papilloma with atypia 53.8% (7/13), without atypia 12.1% (8/66); and radial scar/complex sclerosing lesion with atypia 16.7% (2/12), and without atypia 7.9% (6/76). CONCLUSION: Upgrade rates remain high for some histological categories even with first-line use of vacuum biopsy. Management of borderline lesions should be considered carefully in a multidisciplinary meeting. In many cases, the need for diagnostic surgical excision has been replaced by image-guided vacuum sampling.

The accuracy of digital breast tomosynthesis compared with coned compression magnification mammography in the assessment of abnormalities found on mammography.

AIM: To compare the diagnostic accuracy of the digital breast tomosynthesis (DBT) with coned compression magnification mammography (CCMM). MATERIALS AND METHODS: The study design included two reading sessions completed by seven experienced radiologists. In the first session, all readers read bilateral standard two-view mammograms and a CCMM view of the lesion before giving a combined score for assessment. In the second session, readers read bilateral standard two-view mammograms plus one-view DBT. The two reading sessions of the experiment were separated by at least 2 weeks to reduce the chance of reader memory of the images read in the previous session from influencing the performance in the subsequent session. RESULTS: Three hundred and fifty-four lesions were assessed and receiver-operative characteristic (ROC) analysis was used to evaluate the difference between the two modes. For standard two-view mammography plus CCMM, the area under the curve (AUC) was 0.87 [95% confidence interval (CI): 0.83-0.91] and for standard two-view mammography plus DBT the AUC was 0.93 (95% CI: 0.91-0.95). The difference between the AUCs was 0.06 with p-value of 0.0014. CONCLUSION: Two-view mammography with one-view DBT showed significantly improved accuracy compared to two-view mammography and CCMM in the assessment of mammographic abnormalities. These results show that DBT can be used effectively in the further evaluation of mammographic abnormalities found at screening and in symptomatic diagnostic practice.

Serum prealbumin, retinol-binding protein, transferrin, and albumin levels in patients with large bowel cancer.

In a study of the levels of serum prealbumin (PALB), retinol-binding protein (RBP), transferrin (TF), and albumin (ALB) in patients with large bowel cancer, critical values were established as (g/liter): PALB, 0.15; RBP, 40 X 10(-3); TF, 2.0; and ALB, 30. Values consistently below these were taken as a sign of malnutrition. The proteins in this system were interrelated and tended to show a similar pattern of change. Metastatic colon cancer caused a relatively small decline of ALB compared to the mean in tumor-free patients. PALB was the most sensitive indicator of nutrition, and its levels and rates of change had a prognostic significance. A rapid fall of PALB often occurred 2--3 months prior to the patients's death; this preterminal phase in ambulant patients was frequently heralded by a progressive rise in the level of C-reactive protein in the absence of any obvious infection.

Injury to the ureter during laparoscopic tubal sterilization.

As the use of laparoscopy and laparoscopic tubal sterilization has increased, a number of serious complications have been reported. A case is described in which the ureter was damaged during laparoscopic sterilization. The majority of serious complications associated with laparoscopic sterilization have been burn injuries resulting from the use of cautery instruments. Thermal injuries are likely to occur when the operator is inexperienced, and when cautery instruments of the high-energy type are used. Meticulous technique is required in the performance of laparoscopic sterilization and low-energy "cold cautery" units should be used in this procedure.

Hepatic Histological Changes in Ulcerative Colitis.

Operative liver biopsy was performed on 58 consecutive patients coming to radical excisional surgery for ulcerative colitis. The histological changes seen in the liver were: increased cellularity of the portal tracts (83 per cent); fatty infiltration (83 per cent); areas of focal necrosis (47 per cent); and early cirrhosis (2 per cent). Severe liver damage was shown to he associated with severe active colitis, and with a poor subsequent post-operative prognosis. The mechanisms responsible for liver damage in patients with colitis are discussed.

Visceral and parietal suture in abdominal surgery.

The effect of various modifications in suture technic on the healing of intestinal and other alimentary anastomoses is reviewed in the light mainly of controlled clinical comparisons by the author and other workers. (a) In small bowel anastomoses and in colonic and colorectal anastomoses in which both participating stumps have a peritoneal coat an inverting technic of suture has been found to be much more secure than an everting technic, but no significant difference has been demonstrated between the classic two-layer inverting technic and a one-layer inverting technic. However, for low anterior resections in which the distal stump is devoid of a peritoneal coat, the one-layer end-on slightly inverting technic has been shown to be followed by significantly fewer anastomotic dehiscences than the two-layer technic. (b) No controlled clinical studies are available regarding anastomoses in the upper gastrointestinal tract, but for anastomoses between the stomach and the intestine, the weight of surgical experience seems to be heavily in favor of a two-layer technic, whereas for esophago-gastric, -jejunal, or -colonic anastomoses there is one body of authoritative opinion in favor of a one-layer inverting technic. (2) The method of determining the relative merits of some of the many different ways of closing parietal abdominal wounds, by means of controlled clinical trails, is discussed. By one such trial, continuous layer suture with chromic catgut has been shown to be significantly inferior to catgut layer suture combined with tension, sutures or to figure-of-eight (Tom Jones) sutures of wire, as judged by the incidence of wound dehiscence or of subsequent incisional herniation. Reference is made to other trials in progress for evaluation of Prolene, Dexon, and other suture materials and comparison of median and paramedian incisions.

Secretory otitis media and mastoid air cell development.

Controversy continues over the factors involved in the development of the mastoid air cell system (MACS). This study examines the effect of persistent secretory otitis media with effusion (SOME) on the development of the MACS. Thirty-one children, aged 4, were drawn from a cohort of cleft palate children in a multi-centre, prospective otological study set up in 1984. The initial presence of SOME was assessed by otoscopy, tympanometry and bilateral myringotomy, performed under the same anaesthetic as surgical repair of the cleft lip or palate. Only one ear in each child was ventilated with a tube and the other, the control ear, was assessed by regular follow-up otoscopy and tympanometry. The persistence of SOME after palate repair in over 70% of the non-ventilated ears in 4 years olds and the presence of a contralateral ventilated middle ear provides the perfect model for assessing the effect of SOME on MACS development. Plain, lateral mastoid X-rays were assessed by planimetry to give a well accepted measurement of mastoid pneumatization. Nine children were excluded from analysis as they did not meet the strict criteria of one persistently ventilated middle ear and one with persistent SOME. 22 children (44 ears) were available for analysis, 9 children were tubed at 3 months and 13 were tubed at 12 to 16 months. In 19 of the 22 ears the mastoid air cell system was larger on the tubed side.(ABSTRACT TRUNCATED AT 250 WORDS)

Bradshaw lecture, 1978. Recent trends in the practice of sphincter-saving excision for rectal cancer.

Current fashions in the use of sphincter-saving resections for carcinoma of the rectum are surveyed, with particular reference to the management of growths of the middle third and to the potential role of recently introduced intestinal stapling devices for construction of the anastomoses.

The use of pedicled transplants of sigmoid or other parts of the intestinal tract for vaginal construction.

The use of transplants from different parts of the intestinal tract for vaginal construction is surveyed and the special value of sigmoid colon for this purpose is demonstrated by the results obtained in 7 patients treated by the author.

Current trends in the treatment of colorectal cancer.

In recent years interest in the management of bowel cancer has focussed mainly on two main considerations:- A The prospect of improving the overall curability by:- The achievement of much earlier presymptomatic diagnosis with the aid of Hemoccult screening of sections of the population at risk; The deployment of more radical techniques of operation, especially in regard to rectal cancer; The supplementation of surgical excision with adjuvant radiotherapy and chemotherapy; The development of a more meticulous regime of follow-up after operation, using CEA monitoring and occasional "second look" operations to deal with recurrence. B The greater use of sphincter-saving types of excision for growths of the middle and lower parts of the rectum. To this end several new techniques of rectal resection have become popular--especially the downward extrusion of low anterior resection with the aid of the circular stapler. In addition, for small very favourable low growths local excision or local destruction by diathermy fulguration or contact irradiation have been employed. The rationale and success of these two forms of endeavour are examined.

What can be done to improve the results in colorectal cancer?

It is seldom even under the best of circumstances that more than half the patients suffering from colorectal cancer are cured by conventional surgical management, and the results are often much worse. Attempts to improve this state of affairs have followed 4 main directions, which are here critically examined: 1. earlier (presymptomatic) diagnosis; 2. more radical surgery; 3. adjuvant radio- and chemotherapy; and 4. more meticulous follow-up using CEA monitoring and occasional "second-look" operations.