Screening chest wall ultrasound in the mastectomy patient.

BACKGROUND: While there are clear guidelines regarding chest wall ultrasound in the symptomatic patient, there is conflicting evidence regarding the use of ultrasound in the screening of women post-mastectomy. OBJECTIVE: To assess the utility of screening chest wall ultrasound after mastectomy and to assess features of detected malignancies. METHODS: This IRB approved, retrospective study evaluates screening US examinations of the chest wall after mastectomy. Asymptomatic women presenting for screening chest wall ultrasound from January 2016 through May 2017 were included. Cases of known active malignancy were excluded. All patients had at least one year of clinical or imaging follow-up. 43 exams (8.5 %) were performed with a history of contralateral malignancy, 465 exams (91.3 %) were performed with a history of ipsilateral malignancy, and one exam (0.2 %) was performed in a patient with bilateral prophylactic mastectomy. RESULTS: During the 17-month period, there were 509 screening US in 389 mastectomy patients. 504 (99.0 %) exams were negative/benign. Five exams (1.0 %) were considered suspicious, with recommendation for biopsy, which was performed. Out of 509 exams, 3 (0.6 %) yielded benign results, while 2 (0.39 %) revealed recurrent malignancy, with a 95 % confidence interval (exact binomial) of 0.05 % to 1.41 % for screening ultrasound. Both patients who recurred had previously recurred, and both had initial cancer of lobular histology. CONCLUSION: Of 509 chest wall screening US exams performed in mastectomy, 2 malignancies were detected, and each patient had history of invasive lobular carcinoma and at least one prior recurrence prior to this study, suggesting benefit of screening ultrasound in these populations.

Suspicious Ultrasound-Occult Non-Calcified Mammographic Masses, Asymmetries, and Architectural Distortions Are Moderate Probability for Malignancy.

Suspicious non-calcified mammographic findings have not been evaluated with modern mammographic technique, and the purpose of this work is to compare the likelihood of malignancy for those findings. To do this, 5018 consecutive mammographically guided biopsies performed during 2016-2019 at a large metropolitan, community-based hospital system were retrospectively reviewed. In total, 4396 were excluded for targeting calcifications, insufficient follow-up, or missing data. Thirty-seven of 126 masses (29.4%) were malignant, 44 of 194 asymmetries (22.7%) were malignant, and 77 of 302 architectural distortions (AD, 25.5%) were malignant. The combined likelihood of malignancy was 25.4%. Older age was associated with a higher likelihood of malignancy for each imaging finding type (all p ≤ 0.006), and a possible ultrasound correlation was associated with a higher likelihood of malignancy when all findings were considered together (p = 0.012). Two-view asymmetries were more frequently malignant than one-view asymmetries (p = 0.03). There were two false-negative biopsies (98.7% sensitivity and 100% specificity). In conclusion, the 25.4% likelihood of malignancy confirms the recommendation for biopsy of suspicious, ultrasound-occult, mammographic findings. Mammographically guided biopsies were highly sensitive and specific in this study. Older patient age and a possible ultrasound correlation should raise concern given the increased likelihood of malignancy in those scenarios.

Diagnostic ultrasound of the chest wall in the symptomatic patient after mastectomy.

BACKGROUND: Lack of standardized imaging recommendations among mastectomy patients has led to variability in how recurrences are detected. OBJECTIVE: To describe the findings and assess the diagnostic efficacy of ultrasound in the evaluation of symptomatic post-mastectomy patients. MATERIALS AND METHODS: This single institution, retrospective study included 749 consecutive diagnostic chest wall ultrasound examinations performed in mastectomy patients, from January 2016 to June 2017. Chest wall ultrasound evaluated the mastectomy bed with or without reconstruction. Electronic health records were queried for the primary breast cancer histology prior to mastectomy, clinical symptoms prompting the diagnostic ultrasound, ultrasound findings, subsequent cytology and pathology, and follow-up data. Excluded were patients with a known recurrence, asymptomatic patients, and those with <2 years of clinical or imaging follow-up. Descriptive and comparative statistical analyses were performed. RESULTS: Among the 749 ultrasounds performed, 58 malignancies were identified for a 7.7% (58/749) malignancy rate, with a median tumor size of 20 mm. Patients diagnosed with a malignancy most often presented with a palpable abnormality (79.3%, 46/58) or skin changes (13.8%, 8/58) and rarely with pain (1.7%, 1/58). Patients who underwent a biopsy yielding a benign result most often presented with a palpable abnormality (41.5%, 287/691), pain (25.6%,177/691), or postoperative swelling/suspected fluid collection (17.8%, 123/691). Diagnostic ultrasound yielded a 91.4% sensitivity (95% CI 81.0, 97.1), 96.1% specificity (95% CI 94.4, 97.4), 66.3% PPV3 (95% CI 57.4, 74.1), and 99.3% negative predictive value (95% CI 98.3, 99.7) for cancer detection. There were 5 false negative ultrasound cases after a skin punch biopsy was performed due to clinically suspicious skin changes. CONCLUSIONS: Chest wall ultrasound has a high sensitivity and negative predictive value for detection of breast cancer recurrence in symptomatic patients after mastectomy. Skin changes remain an important clinical manifestation of a cancer recurrence.

Pseudoangiomatous Stromal Hyperplasia: Radiologic-Pathologic Correlation.

Pseudoangiomatous stromal hyperplasia (PASH) is a benign mesenchymal proliferative lesion of the breast. PASH is postulated to be hormonally induced and predominantly occurs in premenopausal women and postmenopausal women on menopausal hormone therapy. Clinical presentation varies from screen-detected lesions to palpable masses. Imaging findings of PASH are nonspecific. The most common mammographic findings are an oval or round circumscribed non-calcified mass or developing asymmetry. On US, PASH is often seen as an oval hypoechoic mass that may be circumscribed and can have an echogenic rim, or, when manifest as mammographic asymmetry, US may show a corresponding non-mass focal area of echogenic tissue. Limited studies have investigated the MRI appearance, with PASH most often manifesting as non-mass enhancement, or, less often, as an oval or irregular mass with persistent kinetics. Histopathologically, PASH can be mistaken for a fibroadenoma or phyllodes tumor and has features overlapping low-grade angiosarcoma. Assessment of radiologic-pathologic concordance is particularly important as PASH is often an incidental finding, adjacent to the targeted lesion at histopathology. Surgical excision or repeat core-needle biopsy is necessary for discordant suspicious cases. After a benign, concordant diagnosis of PASH, the patient may resume routine screening.

Dense Sampling Approaches for Psychiatry Research: Combining Scanners and Smartphones.

Together, data from brain scanners and smartphones have sufficient coverage of biology, psychology, and environment to articulate between-person differences in the interplay within and across biological, psychological, and environmental systems thought to underlie psychopathology. An important next step is to develop frameworks that combine these two modalities in ways that leverage their coverage across layers of human experience to have maximum impact on our understanding and treatment of psychopathology. We review literature published in the last 3 years highlighting how scanners and smartphones have been combined to date, outline and discuss the strengths and weaknesses of existing approaches, and sketch a network science framework heretofore underrepresented in work combining scanners and smartphones that can push forward our understanding of health and disease.

Nipple Discharge Imaging Evaluation with Mammography, Ultrasound, Galactography, and MRI.

RATIONALE AND OBJECTIVE: To determine the diagnostic yield of various imaging tests used to evaluate nipple discharge. MATERIALS AND METHODS: A single institution, IRB-approved, retrospective study was performed of 320 consecutive patients presenting with nipple discharge. Imaging and pathology were reviewed to determine the yield for malignancy, atypical high-risk lesions (HRLs), and intraductal papillomas (IDPs). RESULTS: Of the 320 patients, pathology or follow up confirmed 40 breast malignancies (40/320, 12.5%),14 atypical HRLs (14/320, 4.4%), 71 IDPs (71/320, 22.2%), 48 other benign pathologies (48/320,15.0%), and 147 unknown but benign cases (147/320, 45.9%). Physiologic discharge characteristics were observed in a minority of malignant cases: nonspontaneous (4/40, 10.0%); neither bloody nor clear (4/40, 10.0%); bilateral (3/40, 7.5%). Malignancy was associated with older age (p < 0.001) and bloody discharge (odds ratio 6.5, p < 0.0001). The combination of digital mammography and ultrasound had a 93% sensitivity and a 98% NPV, while contrast enhanced MRI (CE-MRI) had a 100% sensitivity and a 100% NPV for malignancy. Only three galactography examinations were performed among the malignant cohort, with minimal contribution (1 of 3) to the diagnostic evaluation. In this case, galactography findings helped determine imaging-pathology discordance, prompting a recommendation for surgical excision and subsequently a malignant diagnosis. CONCLUSION: The combination of mammography and ultrasonography detected 93% of breast malignancies associated with nipple discharge and had a 98% NPV for malignancy. The value of CE-MRI is its ability to detect the remaining malignancies, not detected on mammography or ultrasound, and its ability to obviate the need for surgical duct excision.

Finding positive meaning in memories of negative events adaptively updates memory.

Finding positive meaning in past negative memories is associated with enhanced mental health. Yet it remains unclear whether it leads to updates in the memory representation itself. Since memory can be labile after retrieval, this leaves the potential for modification whenever its reactivated. Across four experiments, we show that positively reinterpreting negative memories adaptively updates them, leading to the re-emergence of positivity at future retrieval. Focusing on the positive aspects after negative recall leads to enhanced positive emotion and changes in memory content during recollection one week later, remaining even after two months. Consistent with a reactivation-induced reconsolidation account, memory updating occurs only after a reminder and twenty four hours, but not a one hour delay. Multi-session fMRI showed adaptive updates are reflected in greater hippocampal and ventral striatal pattern dissimilarity across retrievals. This research highlights the mechanisms by which updating of maladaptive memories occurs through a positive emotion-focused strategy.

The social value of positive autobiographical memory retrieval.

Positive memory retrieval generates pleasant feelings that can counteract negative affective states and improve mood. However, not all positive memories are created equal. Our most treasured memories are likely experiences we shared with other people (e.g., birthday party) rather than something we did alone (e.g., receiving good grades). Here, we explored whether the social context within a positive memory enhanced its subjective value and contributed to an individual's well-being. In Study 1, participants were asked how much they would be willing to pay to reexperience positive memories that occurred with socially close others (high-social), with acquaintances (low-social) or alone (nonsocial). When controlling for the memory's positivity, participants were still willing to pay 1.5 times as much for high-social than for low-social or nonsocial memories. Likewise, participants chose to reminisce about high-social memories more frequently than less social ones of equal positive feeling. In Study 2, recalling memories rich in social context recruited regions previously implicated in mentalizing and reward (e.g., caudate), which further correlated with greater ability to savor positive emotions in daily life. Finally, we examined the benefit of social context by asking participants to recall positive memories that varied in social context after acute stress exposure. In Study 3, recalling memories that included higher social context led to a greater dampening of the physiological stress response (i.e., cortisol). Taken together, these findings suggest that social context inherent in a positive memory enhances its value, providing a possible mechanism by which positive reminiscence aids stress coping and enhances well-being. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Imaging of Intracystic Papillary Carcinoma.

OBJECTIVE: To describe the clinical, imaging, and histopathologic findings of intracystic papillary carcinoma (IPC) of the breast. MATERIALS AND METHODS: Following institutional review board approval, a database at a single institution was searched to identify cases of patients who received a diagnosis of IPC from 1999-2013 and who had undergone preoperative imaging with mammography, sonography, or MRI. The clinical, mammographic, sonographic, and MRI features of IPC were compared and analyzed using the BI-RADS mammography, ultrasound, and MRI lexicons. RESULTS: The study sample included 40 patients, 36 females and 4 males. The most common clinical presentation was a palpable mass. Mammographic data was assessed in 31 patients. A tumor was mammographically occult in one patient. The predominant features were oval shape of 17 tumors (57%), obscured margins of 12 (40%), and high density of 20 (67%). Ultrasound data of 37 patients revealed 20 oval masses, 13 irregular masses, and 4 round masses. Fourteen complex solid and cystic masses were identified. One patient underwent MRI that showed a complex, enhancing mass with washout kinetics. Ultrasound guided biopsy was performed on 33 of the 37 masses. Core needle biopsy and fine needle aspiration (FNA) biopsy were most commonly performed on the solid components of the complex solid and cystic masses. IPC was diagnosed by stereotactic biopsy in 1 patient with a suspicious mass on mammography with no correlate on sonography and 6 patients had surgical excision without imaging-guided biopsy. Pathology showed in situ IPC in 31/40 tumors and 11 were solid and cystic complex masses on ultrasound. Pathology revealed invasive IPC in 9 tumors and five had an irregular mass on ultrasound. CONCLUSION: Our study reveals no specific imaging features to differentiate in situ vs invasive IPC. The most common ultrasound feature in biopsy proven IPC was an oval mass, however, we identified that a complex solid and cystic mass is more often associated with the diagnosis of in situ IPC and an irregular mass is more often associated with the diagnosis of invasive IPC. Future studies with larger cohorts are needed to further define the clinical and imaging features of this rare malignancy.

High risk breast lesions identified on MRI-guided vacuum-assisted needle biopsy: outcome of surgical excision and imaging follow-up.

OBJECTIVE:: To determine whether breast MRI-guided vacuum-assisted biopsy (MRI-VAB) high-risk lesion histology influences surgical or long-term imaging follow-up outcomes. METHODS:: Patients with imaging-concordant high-risk findings on 9-gauge breast MRI-VAB between January 2007 and July 2012 who had surgical histopathology or 2 year imaging follow-up were retrospectively reviewed. RESULTS:: 90 patients with 99 lesions were included. Lesions were atypical ductal hyperplasia (ADH) (n = 21), lobular neoplasia [n = 36; atypical lobular hyperplasia (ALH) (n = 22), lobular carcinoma in situ (LCIS) (n = 6), and ALH plus LCIS (n = 8)], and other high-risk lesion (n = 42; papillary lesions, radial scar, flat epithelial atypia, atypia unspecified). Of 53 excised lesions, 6 (11%) were upgraded to invasive cancer or ductal carcinoma in situ (DCIS). 4 of 21 (19%) ADH lesions were upgraded to DCIS. 2 of 36 (6%) lobular neoplasia lesions, both combined ALH and LCIS, were upgraded to DCIS, and invasive lobular carcinoma, respectively. The remaining 46 lesions were managed conservatively with imaging follow-up: 17 (37%) had mammography only, while 29 (63%) had mammography and MRI follow-up. There was no evidence of breast cancer development at the site of MRI-VAB in the cases with only imaging follow-up. CONCLUSION:: We conclude that the upgrade rate for high-risk lesions at MRI-VAB at surgical excision is low. Surgical excision is warranted for ADH and combined ALH-LCIS lesions. For other lesions, a multidisciplinary approach to decide on personalized management may be appropriate. ADVANCES IN KNOWLEDGE:: Surgical excision is warranted for ADH lesions and combined ALH-LCIS lesions identified at breast MRI-VAB. A multidisciplinary approach to patient management of other high-risk lesions may be appropriate.

Positive autobiographical memory retrieval reduces temporal discounting.

People generally prefer rewards sooner rather than later. This phenomenon, temporal discounting, underlies many societal problems, including addiction and obesity. One way to reduce temporal discounting is to imagine positive future experiences. Since there is overlap in the neural circuitry associated with imagining future experiences and remembering past events, here we investigate whether recalling positive memories can also promote more patient choice. We found that participants were more patient after retrieving positive autobiographical memories, but not when they recalled negative memories. Moreover, individuals were more impulsive after imagining novel positive scenes that were not related to their memories, showing that positive imagery alone does not drive this effect. Activity in the striatum and temporo parietal junction during memory retrieval predicted more patient choice, suggesting that to the extent that memory recall is rewarding and involves perspective-taking, it influences decision-making. Furthermore, representational similarity in the ventromedial prefrontal cortex between memory recall and decision phases correlated with the behavioral effect across participants. Thus, we have identified a novel manipulation for reducing temporal discounting-remembering the positive past-and have begun to characterize the psychological and neural mechanisms behind it.

Reminiscing about positive memories buffers acute stress responses.

Recalling happy memories elicits positive feelings and enhances one's wellbeing, suggesting a potential adaptive function in using this strategy for coping with stress. In two studies, we explored whether recalling autobiographical memories that have a positive content - i.e., remembering the good times - can dampen the hypothalamic-pituitary-adrenal (HPA) axis stress response. Participants underwent an acute stressor or control task followed by autobiographical memory recollection (of only positive or neutral valence). Across both studies, recalling positive, but not neutral, memories resulted in a dampened cortisol rise and reduced negative affect. Further, individuals with greater self-reported resiliency showed enhanced mood, despite stress exposure. During positive reminiscence, we observed engagement of corticostriatal circuits previously implicated in reward-processing and emotion regulation, and stronger connectivity between ventrolateral and dorsolateral prefrontal cortex as a function of positivity. These findings highlight the restorative and protective function of self-generated positive emotions via memory recall in the face of stress.

Toward a cumulative science of functional integration: A meta-analysis of psychophysiological interactions.

Much of the work in cognitive neuroscience is shifting from a focus on single brain regions to a focus on the connectivity between multiple brain regions. These inter-regional connectivity patterns contribute to a wide range of behaviors and are studied with models of functional integration. The rapid expansion of the literature on functional integration offers an opportunity to scrutinize the consistency and specificity of one of the most popular approaches for quantifying connectivity: psychophysiological interaction (PPI) analysis. We performed coordinate-based meta-analyses on 284 PPI studies, which allowed us to test (a) whether those studies consistently converge on similar target regions and (b) whether the identified target regions are specific to the chosen seed region and psychological context. Our analyses revealed two key results. First, we found that different types of PPI studies-e.g., those using seeds such as amygdala and dorsolateral prefrontal cortex (DLPFC) and contexts such as emotion and cognitive control, respectively-each consistently converge on similar target regions, thus supporting the reliability of PPI as a tool for studying functional integration. Second, we also found target regions that were specific to the chosen seed region and psychological context, indicating distinct patterns of brain connectivity. For example, the DLPFC seed reliably contributed to a posterior cingulate cortex target during cognitive control but contributed to an amygdala target in other contexts. Our results point to the robustness of PPI while highlighting common and distinct patterns of functional integration, potentially advancing models of brain connectivity. Hum Brain Mapp 37:2904-2917, 2016. © 2016 Wiley Periodicals, Inc.

Cognitive reserve modulates ERPs associated with verbal working memory in healthy younger and older adults.

Although many epidemiological studies suggest the beneficial effects of higher cognitive reserve (CR) in reducing age-related cognitive decline and dementia risk, the neural basis of CR is poorly understood. To our knowledge, the present study represents the first electrophysiological investigation of the relationship between CR and neural reserve (i.e., neural efficiency and capacity). Specifically, we examined whether CR modulates event-related potentials associated with performance on a verbal recognition memory task with 3 set sizes (1, 4, or 7 letters) in healthy younger and older adults. Neural data showed that as task difficulty increased, the amplitude of the parietal P3b component during the probe phase decreased and its latency increased. Notably, the degree of these neural changes was negatively correlated with CR in both age groups, such that individuals with higher CR showed smaller changes in P3b amplitude and less slowing in P3b latency (i.e., smaller changes in the speed of neural processing) with increasing task difficulty, suggesting greater neural efficiency. These CR-related differences in neural efficiency may underlie reserve against neuropathology and age-related burden.

Savoring the past: positive memories evoke value representations in the striatum.

Reminders of happy memories can bring back pleasant feelings tied to the original experience, suggesting an intrinsic value in reminiscing about the positive past. However, the neural circuitry underlying the rewarding aspects of autobiographical memory is poorly understood. Using fMRI, we observed enhanced activity during the recall of positive relative to neutral autobiographical memories in corticostriatal circuits that also responded to monetary reward. Enhanced activity in the striatum and medial prefrontal cortex was associated with increases in positive emotion during recall, and striatal engagement further correlated with individual measures of resiliency. Striatal response to the recall of positive memories was greater in individuals whose mood improved after the task. Notably, participants were willing to sacrifice a more tangible reward, money, in order to reminisce about positive past experiences. Our findings suggest that recalling positive autobiographical memories is intrinsically valuable, which may be adaptive for regulating positive emotion and promoting better well-being.