"The Two Sides of the Same Coin"-Medical Cannabis, Cannabinoids and Immunity: Pros and Cons Explained.

Cannabis, as a natural medicinal remedy, has long been used for palliative treatment to alleviate the side effects caused by diseases. Cannabis-based products isolated from plant extracts exhibit potent immunoregulatory properties, reducing chronic inflammatory processes and providing much needed pain relief. They are a proven effective solution for treatment-based side effects, easing the resulting symptoms of the disease. However, we discuss the fact that cannabis use may promote the progression of a range of malignancies, interfere with anti-cancer immunotherapy, or increase susceptibility to viral infections and transmission. Most cannabis preparations or isolated active components cause an overall potent immunosuppressive impact among users, posing a considerable hazard to patients with suppressed or compromised immune systems. In this review, current knowledge and perceptions of cannabis or cannabinoids and their impact on various immune-system components will be discussed as the "two sides of the same coin" or "double-edged sword", referring to something that can have both favorable and unfavorable consequences. We propose that much is still unknown about adverse reactions to its use, and its integration with medical treatment should be conducted cautiously with consideration of the individual patient, effector cells, microenvironment, and the immune system.

Is there any added value to substitute the 2D digital MLO projection for a MLO tomosynthesis projection and its synthetic view when a 2D standard digital mammography is used in a one-stop-shop immediate reading mammography screening?

OBJECTIVES: Breast cancer screening consists of batch interpretation of two-view (cranio-caudal CC- and medio-lateral oblique MLO) digital mammography (DM) per breast. The DM-MLO view was substituted by an MLO-digital breast tomosynthesis (DBT) and its synthetic (2D-synthetic mammography (SM)-MLO) view. The performance of this hybrid protocol was evaluated in a one-stop-shop screening visit, providing immediate reading and additional work up. METHODS: Retrospective, observational review, comparing the cancer detection rate (CDR), breast US rates, and biopsy rates in 13,048 women screened with DM from June 2015 to November 2016 and 8639 women screened with SM-DBT/DM from January 2017 to July 2018. Chi-square tests or Fisher's exact tests were used to compare proportions between the two screening imaging methods. RESULTS: SM + DBT/DM significantly increased the overall CDR (10.8‰) versus DM (7.5‰) (p = 0.0120) with more invasive lobular carcinoma (14% versus 4%) (p = 0.0357) detected and overall more invasive cancers among women with breast density type B (p = 0.0411) and those aged between 60 and 70 (p = 0.0306). This was achieved at the expense of additional sonographic examinations performed (33.5% in DBT group versus 26.7% in DM group) (p < 0.0001), more BI-RADS category III assigned (1.8% in SM-DBT/DM group versus 1.5% in DM group) (p = 0.0443) and more biopsy rates (3.0 % in SM-DBT/DM group versus 1.7% in DM group) (p < 0.0001). CONCLUSIONS: Hybrid mammographic protocol replacing 2D-MLO by DBT-MLO and SM-MLO views in a one-stop-shop screening visit improved CDR, at the expense of more sonographic examinations, biopsies, and BI-RADS III lesions. Breast US alone detected 9.2% of all breast cancers in this cohort. KEY POINTS: • Hybrid protocol including MLO (DBT + SM) with 2D DM CC may improve CDR compared to standard 4 views 2D DM in a screening program providing immediate interpretation. • Adding screening breast US, when perceived necessary, in the same visit of a screening mammography, increases cancer detection rate of 9.2%. • Based on our results, hybrid protocol including DBT + SM in MLO plane and DM in CC plane could be safely implemented as a transition towards DBT and SM alone, without any compromise in the cancer detection ability. Our results may vary according to the properties of machines from different vendors.

Medical Cannabis in Oncology: a Valuable Unappreciated Remedy or an Undesirable Risk?

OPINION STATEMENT: The use of the cannabis plant by cancer patients has been rising significantly in the past few years worldwide, primarily driven by public demand. There is an obvious need for more reliable scientific data, pharmacology information, a better understanding of its mode of action, and available clinical evidence supporting its robust use. Physicians must complete a thorough medical assessment, screening for potential drugs, or treatment contraindications before allowing its consumption. In light of the growing popularity of cannabis usage, it is highly essential that, in the near future, the medical community will be able to provide practical recommendations and explicit guidelines, including doses, and that cannabinoid concentrations in the used products are defined regarding its prescription before any medical procedure involving its usage is authorized. Here, we review and describe the favorable outcomes demonstrating the benefits of cannabis as an adjunctive treatment to conventional medicines for chemotherapy-induced nausea, vomiting, and cancer-related pain (primarily refractory chronic or neuropathic pain). Although not yet substantial enough, the treatment of anorexia, insomnia, depression, and anxiety is also seemingly favorable. To date, reports regarding its anti-neoplastic effects or its potent immunosuppressive properties influencing response to immunotherapy are still very conflicting and controversial. Thus, with the current state of evidence, cannabis use is not advisable as initial treatment, as an adjunct or an advanced line of care. In the coming years, we expect that preclinical data and animal models will shift to the clinical arena, and more patients will be recruited for clinical trials, and their reports will advance the field. Thus, physicians should prescribe cannabis only if careful clarification and consideration is provided together with a follow-up response evaluation.

Idiopathic gigantomastia in a patient on polypharmacy.

Gigantomastia is an uncommon benign condition characterized by massive breast enlargement. It is most often due to hormonal imbalance secondary to puberty or pregnancy, or induced by a pharmacological agent but can also be idiopathic. Herein, we report a rare case of idiopathic gigantomastia in a 46-year-old female on antiepileptic multiple-drug therapy who underwent total bilateral mastectomy to relieve associated pain.

Impact of Long-term, High-fat, and High-cholesterol Diet on Murine Vertebrae Bones.

As the percentage of overweight individuals in the population rises, diseases associated with excess weight resulting from poor nutrition are becoming more and more widespread. So far, the influence of weight or nutrition on bone health has shown conflicting results. In the literature, the existing studies disagree about the effect of diet on bones. Therefore, this study investigated the impact of a long-term, high-fat, and high-cholesterol diet on the spine in a mouse model. Wild-type mice were randomly separated into two groups; one group received a high-fat and high-cholesterol diet, and a control group was fed with a regular diet since birth for a duration of 8 months. The first to fifth thoracic vertebrae were extracted and investigated using histology and micro-CT. Samples were analyzed regarding different parameters: percentage of bone structure compared to the whole vertebra and the amount and thickness of the trabeculae. Both methods of the analysis showed similar results. Diet did not have a significant impact on the bone density of the vertebrae. The micro-CT examination showed that the average bone percentage of the examined vertebra was 6% (p = 0.2330) higher in the control group compared to the diet group. The same tendency was demonstrated in histology even though with a smaller difference of only 5%. The results of both methods were comparable and showed trends for the influence of different diets but not significant impacts. In summary, this study showed that a high-fat and high-cholesterol diet has a slightly negative impact on bone density. In order to further analyze the effects of different diets on bone composition, structure, and density, additional long-term studies should be carried out, and more parameters such as movement and genetic factors should be analyzed. Furthermore, other parameters such as exercise and genetic factors that could have a secondary influence on obesity should be investigated.

Breast MRI Does Not Help Differentiating Radial Scar With and Without Associated Atypia or Malignancy.

PURPOSE: To review breast magnetic resonance imaging (MRI) features of radial scar (RS) with and without associated atypia/malignancy. METHODS: Twenty-eight (mean age 56.8) patients diagnosed with 30 biopsy-proven RS (n = 25, ultrasound-guided 14-gauge, n = 5, stereotactically guided 9-gauge) subsequently underwent breast MRI followed by surgery. Magnetic resonance imaging protocol included axial T1, axial fat sat T2, and postgadolinium in axial and sagittal planes. Two radiologists reviewed the mammographic and MRI findings in consensus according to the Breast Imaging Reporting and Data System lexicon. RESULTS: Of the 30 RSs excised surgically, 14 (14/30, 47.7%) were not associated with atypia/malignancy while atypia/malignancy was found in 16 (16/30, 53.3%) RSs. Three (3/30, 10%) RS lesions did not enhance on dynamic MR. Mean lesion size on MRI was 1.4 cm (range, 0.5-5 cm). Seventeen (17/30, 56.7%) lesions presented as nonmass enhancement and 9 (9/30, 30%) as masses. Nonmass lesions showed focal distribution (13/17, 76.5%) and heterogeneous enhancement (15/17, 88.2%). Masses showed irregular shape and margins (6/9, 67%) and heterogeneous enhancement (8/9, 89%). Multivariate analysis did not show any significant difference in MRI presentation between RS only and RS associated with atypia/malignancy. CONCLUSION: Breast MRI does not help differentiate between RS with or without associated atypia/malignancy.

Case 285: Primary Breast Lymphoma.

History A 25-year-old woman was referred to our breast clinic for assessment of a palpable mass in her left breast that developed quickly in 2 weeks. She denied any associated fever, chills, redness, or pain. She had no relevant medical or surgical history; no evidence of recent pregnancy, abortion, or breastfeeding; and no family history of breast cancer. Clinical examination enabled confirmation of a firm mass occupying the retroareolar region and the outer quadrant of the left breast with no skin retraction, edema, or erythema. There was no evidence of enlarged axillary lymph nodes. US of the left breast, bilateral breast MRI, and fluorine 18 (18F) fluorodeoxyglucose (FDG) PET/CT were performed.

Case 285.

History A 25-year-old woman was referred to our breast clinic for assessment of a palpable mass in her left breast that developed quickly in 2 weeks. She denied any associated fever, chills, redness, or pain. She had no relevant medical or surgical history; no evidence of recent pregnancy, abortion, or breastfeeding; and no family history of breast cancer. Clinical examination enabled confirmation of a firm mass occupying the retroareolar region and the outer quadrant of the left breast with no skin retraction, edema, or erythema. There was no evidence of enlarged axillary lymph nodes. US of the left breast (Fig 1), bilateral breast MRI (Fig 2), and fluorine 18 fluorodeoxyglucose PET/CT (Fig 3) were performed.

Use of Intraoperative Radioguidance in Recurrent Merkel Carcinoma.

Merkel cell carcinoma is a rapidly progressive nonmelanoma skin cancer with a high risk of recurrence. When recurrence occurs, it is associated with poor prognosis and there is a lack of guidelines for the management of such cases. This article describes a challenging case in which the innovative use of iodine-125 radioactive seeds permitted us to precisely identify and resect two nonpalpable recurrent nodules. The safety and accuracy of the surgical procedure were compromised by the presence of scar tissue following two past resections and two courses of radiotherapy. Radioactive seed localization is a well-known procedure in breast cancer, demonstrating potential for an extended application in other cancer types and in complex clinical situations.

Venous malformation of the pectoral muscle depicted on mammogram.

Venous malformation of the pectoral muscle diagnosed on a mammogram of a 41-year-old patient presenting with clinical suspicion of a gynecomastia.

Added Value of Quantitative Ultrasound and Machine Learning in BI-RADS 4-5 Assessment of Solid Breast Lesions.

The purpose of this study was to evaluate various combinations of 13 features based on shear wave elasticity (SWE), statistical and spectral backscatter properties of tissues, along with the Breast Imaging Reporting and Data System (BI-RADS), for classification of solid breast lesions at ultrasonography by means of random forests. One hundred and three women with 103 suspicious solid breast lesions (BI-RADS categories 4-5) were enrolled. Before biopsy, additional SWE images and a cine sequence of ultrasound images were obtained. The contours of lesions were delineated, and parametric maps of the homodyned-K distribution were computed on three regions: intra-tumoral, supra-tumoral and infra-tumoral zones. Maximum elasticity and total attenuation coefficient were also extracted. Random forests yielded receiver operating characteristic (ROC) curves for various combinations of features. Adding BI-RADS category improved the classification performance of other features. The best result was an area under the ROC curve of 0.97, with 75.9% specificity at 98% sensitivity.

Imaging features of pure and mixed forms of mucinous breast carcinoma with histopathological correlation.

METHODS:: A cross-sectional study identified cases of mucinous breast carcinoma from pathology records (2004-2012). Two radiologists classified imaging features by consensus and two pathologists classified cases into pure or mixed subtypes. Bi-variable analyses were performed using relevant statistical tests. RESULTS:: We identified 80 lesions in 77 female patients (median age 65 years, range 29-88): 58 lesions on mammograhy, 72 on ultrasound, and 25 on MRI. Statistically significant findings (p < 0.05) are as follows. On mammography, tumour margins tended to be indistinct (12, 48%) and spiculated (11, 44%) for pure and mixed lesions, respectively. Pure mucinous masses were less microcalcified (23, 77%) and mixed masses equally so. On ultrasound, pure tumours tended towards an irregular or oval shape (44, 42%) with mixed tumours having an irregular shape (78%). More pure tumours (53%) had posterior acoustic enhancement than mixed lesions (33%), and all pure tumours lacked posterior acoustic shadowing. Pure lesions had a heterogeneous echo pattern more than mixed tumours (78% vs 39%). On MRI, pure tumours tended towards a persistent kinetic curve (42%) whereas mixed tumours predominantly had a washout pattern (75%). Most pure tumours were T2 hyperintense (83%) whereas mixed lesions were T2 isointense or hyperintense (61%, 23%), respectively. CONCLUSION:: An analysis of imaging features can help to infer underlying histology of pure and mixed forms of mucinous breast carcinoma. ADVANCES IN KNOWLEDGE:: Pure mucinous carcinomas present less suspicious imaging features than mixed mucinous carcinomas and could be mistaken for non malignant lesions. An imaging analysis of mucinous breast carcinoma can help infer their underlying histology.