Adverse childhood experiences and co-occurring psychological distress and substance abuse among juvenile offenders: the role of protective factors.

OBJECTIVE: The purpose of this study was to estimate associations between cumulative exposure to adverse childhood experiences (ACEs), protective factors, and co-occurrence among male and female juvenile offenders. STUDY DESIGN: Cross-sectional study. METHODS: Validated measures of ACEs, internal resilience, external youth assets, psychological distress, and substance abuse were collected from 429 youths involved in the juvenile justice system in Nevada. A three-level outcome variable was created using the psychological distress and substance use measures: no problems, one problem, or co-occurring problems. Hierarchical multinomial logistic regression models were used to determine the independent, direct, and moderating impact of the protective factors on ACEs and the outcome. RESULTS: Internal resilience, family communication, school connectedness, peer role models, and non-parental adult role models were associated with lower odds of co-occurrence compared to having no problems (adjusted odds ratios [AORs] ranged from 0.11 to 0.33). When ACEs were added to the model, internal resilience and all assets except for one (non-parental adult role models) continued to offer protection against co-occurrence. Internal resilience was the only protective factor that significantly moderated the association between ACEs and co-occurrence (AOR, 0.24; 95% CI, 0.06, 0.99). CONCLUSION: Most protective factors decreased co-occurring mental health and substance abuse problems in the presence of ACE exposure and internal resilience moderated the relationship between ACEs and co-occurrence. Juvenile justice systems should use positive youth development approaches to help prevent co-occurrence among youths.

Stereotactic core-needle breast biopsy: a multi-institutional prospective trial.

PURPOSE: To assess the accuracy of stereotactic core-needle biopsy (CNB) of nonpalpable breast lesions within the context of clinically important parameters of anticipated tissue-sampling error and concordance with mammographic findings. MATERIALS AND METHODS: CNB was performed in 1,003 patients, with results validated at surgery or clinical and mammographic follow-up. Mammographic findings were scored according to the American College of Radiology Breast Imaging Reporting and Data System with a similar correlative scale for histopathologic samples obtained at either CNB or surgery. Agreement of CNB findings with surgical findings or evidence of no change during clinical and mammographic follow-up (median, 24 months) for benign lesions was used to determine results. Three forms of diagnostic discrimination measures (strict, working [strict conditioned by tissue sampling error], applied [working conditioned by concordance of imaging and CNB findings) were used to evaluate the correlation of CNB, surgical, and follow-up results. RESULTS: Strict, working, and applied sensitivities were 91% +/- 1.9; 92% +/- 1.8, and 98% +/- 0.9, respectively; strict, working, and applied specificities were 100%, 98% +/- 0.8, and 73% +/- 0.9; strict, working, and applied accuracies were 97%, 96%, and 79%. CONCLUSION: Percutaneous stereotactic CNB is an accurate method to establish a histopathologic diagnosis of nonpalpable breast lesions. Accuracy increases when additional surgery is performed for lesions with anticipated sampling error or when CNB findings are discordant with mammographic findings. An understanding of the interrelationship among these parameters is necessary to properly assess results.

Stereotactic breast biopsy of nonpalpable lesions: determinants of ductal carcinoma in situ underestimation rates.

PURPOSE: To measure the effect of biopsy device, probe size, mammographic lesion type, lesion size, and number of samples obtained per lesion on the ductal carcinoma in situ (DCIS) underestimation rate. MATERIALS AND METHODS: Nonpalpable breast lesions at 16 institutions received a histologic diagnosis of DCIS after 14-gauge automated large-core biopsy in 373 lesions and after 14- or 11-gauge directional vacuum-assisted biopsy in 953 lesions. The presence of histopathologic invasive carcinoma was noted at subsequent surgical biopsy. RESULTS: By performing the chi(2) test, independent significant DCIS underestimation rates by biopsy device were 20.4% (76 of 373) of lesions diagnosed at large-core biopsy and 11.2% (107 of 953) of lesions diagnosed at vacuum-assisted biopsy (P <.001); by lesion type, 24.3% (35 of 144) of masses and 12.5% (148 of 1,182) of microcalcifications (P <.001); and by number of specimens per lesion, 17.5% (88 of 502) with 10 or fewer specimens and 11.5% (92 of 799) with greater than 10 (P <.02). DCIS underestimations increased with lesion size. CONCLUSION: DCIS underestimations were 1.9 times more frequent with masses than with calcifications, 1.8 times more frequent with large-core biopsy than with vacuum-assisted biopsy, and 1.5 times more frequent with 10 or fewer specimens per lesion than with more than 10 specimens per lesion.

Male inflammatory breast cancer.

A case of a 48-year-old male with an inflammatory breast cancer is used to illustrate this uncommon malignancy. The physical examination of thickening and erythema made the clinical diagnosis. Mammographic findings of increased density in the right breast with coarsened stroma and an underlying mass confirmed the clinical findings. The sonographic evaluation revealed a 2-cm ill-defined hypoechoic mass. The pathologic examination of the mastectomy specimen showed an infiltrating duct cell carcinoma with lobular features. Male breast cancer afflicts 1500 men each year. Clinically it must be differentiated from gynecomastia, a much more common and benign condition.

Rate of insufficient samples for fine-needle aspiration for nonpalpable breast lesions in a multicenter clinical trial: The Radiologic Diagnostic Oncology Group 5 Study. The RDOG5 investigators.

BACKGROUND: Radiologic Diagnostic Oncology Group 5 is a multicenter clinical trial designed to evaluate fine-needle aspiration (FNA) of nonpalpable breast lesions performed by multiple operators using the same protocol. METHODS: Four hundred and nineteen women with mammographically detected nonpalpable breast lesions were enrolled on the trial at 18 institutions. Group A institutions randomized women to stereotactically guided FNA (SFNA) followed by stereotactically guided core needle biopsy (SCNB), or SCNB only. Group B institutions randomized women to SFNA and SCNB, SCNB, or ultrasonographically guided FNA followed by ultrasonographically guided core needle biopsy (USCNB), or USCNB only. A total of 377 women were eligible for analysis. RESULTS: FNA yielded 128 insufficient samples for the 377 patients (33.95%; 95% confidence interval, 29.2-38.7%). The rate of insufficient samples varied by type of lesion with calcified lesions associated with a significantly higher rate of insufficient sampling than masses (P < 0.001). The radiologist's level of suspicion of the lesion was not a statistically significant predictor of insufficient samples for mass lesions, but was a predictor for calcified lesions. For the 336 lesions for which histologic information was available, insufficient samples occurred in significantly more benign than malignant lesions. CONCLUSIONS: The high rate of insufficient samples for FNA of nonpalpable breast lesions in this multicenter trial makes its use impractical in this setting. Because of this factor, the study was terminated early.

Atypical ductal hyperplasia diagnosed at stereotactic breast biopsy: improved reliability with 14-gauge, directional, vacuum-assisted biopsy.

PURPOSE: To compare histologic findings of atypical ductal hyperplasia (ADH) at 14-gauge, directional, vacuum-assisted breast biopsy (hereafter, vacuum-assisted biopsy) and at 14-gauge, automated, large-core breast biopsy (hereafter, large-core biopsy) with findings at histologic examination after surgical biopsy. MATERIALS AND METHODS: Nonpalpable breast lesions were diagnosed as ADH at histologic examination after vacuum-assisted biopsy in 88 lesions in seven institutions and after large-core biopsy in 55 previously reported lesions. Histologic findings at subsequent surgical biopsy were compared for the presence of carcinoma. RESULTS: On the basis of histologic findings of carcinoma at surgical biopsy, the diagnosis of ADH was not correct in 26 (48%) of 54 lesions sampled at large-core biopsy and in 13 (18%) of 74 lesions sampled at vacuum-assisted biopsy (Fisher exact test, P < .0004). More tissue specimens were obtained at vacuum-assisted biopsy (mean, 15.8 specimens) than at large-core biopsy (mean, 9.7 specimens). Individual specimens were twice as large at vacuum-assisted biopsy (mean, 34 mg) as at large-core biopsy (mean, 17 mg) (previously reported). CONCLUSION: ADH was diagnosed 2.7 times more reliably at vacuum-assisted biopsy than at large-core biopsy (with no increase in complications) with most of the improvement as a result of acquisition of more than 10 specimens per lesion, but carcinoma was sufficiently underestimated with both methods to necessitate surgical biopsy.

Comparison of the relative incidence of impalpable invasive breast carcinoma and ductal carcinoma in situ in cancers detected in patients older and younger than 50 years of age.

PURPOSE: To compare the relative incidence of impalpable ductal carcinoma in situ (DCIS) and invasive breast carcinoma detected mammographically in women younger than 50 years of age and those aged 50 years and older. MATERIALS AND METHODS: Needle-wire localization and surgical biopsy were performed in 4,428 impalpable lesions in 3,734 patients. A total of 1,179 breast cancers were found. Histologic findings were reviewed retrospectively, and lesions were classified as invasive cancer or DCIS. The patients were categorized into two groups: those aged 50 years and older and those younger than 50 years of age. RESULTS: A total of 294 cancers were found in women younger than 50 years of age. Of these cancers, 137 (46.6%) were DCIS and 157 (53.4%) were invasive. In women aged 50 years and older, 885 cancers were found. Of these, 325 (36.7%) DCIS and 558 (63.1%) invasive cancers were found. CONCLUSION: For mammographically detected breast carcinomas, there is a higher relative incidence (46.6% vs 36.6%) of DCIS in the younger age group, which may lend further support for aggressive screening of women younger than 50 years of age.

Stereotactic core-needle biopsy of the breast: a report of the Joint Task Force of the American College of Radiology, American College of Surgeons, and College of American Pathologists.

A national task force consisting of members from the American College of Radiology, the American College of Surgeons, and the College of American Pathologists examined the issues surrounding stereotactic core-needle biopsy for occult breast lesions. Their report includes indications and contraindications, informed consent, specimen handling, and management of indeterminate, atypical, or discordant lesions.

MR imaging in the management before surgery of lobular carcinoma of the breast: correlation with pathology.

OBJECTIVE: Our objective was to investigate the use of MR imaging in preoperative staging and characterization of lobular carcinoma. MATERIALS AND METHODS: MR imaging studies and mammographic studies in 20 patients with infiltrating lobular carcinoma were evaluated and correlated with pathology findings on serially sectioned tissue. The MR images and mammograms were reviewed retrospectively by three independent examiners unaware of the clinical, imaging, and pathology findings. RESULTS: The extent of disease found pathologically correlated with that predicted by MR imaging studies in 85% of patients, compared with a 32% correlation (p < .0001) with mammographic studies. Interobserver agreement on lesion morphology and extent of disease was higher for MR imaging (91% and 100%, respectively) than for mammography (64% and 91%, respectively). The retrospective MR readings did not differ from the prospective reports. No false-positive lymphadenopathy was interpreted on MR imaging. Lymph nodes having metastatic lobular carcinoma on the pathology examination were missed on MR imaging in four patients. CONCLUSION: MR imaging is significantly more accurate than mammography in determining the extent of disease and characterizing the morphology of infiltrating lobular carcinoma. MR imaging may play a role in preoperative planning, especially when breast conservation is being considered.

Three-dimensional RODEO breast MR imaging of lesions containing ductal carcinoma in situ.

PURPOSE: To assess whether rotating delivery of excitation off resonance (RODEO) breast magnetic resonance (MR) imaging can help detect ductal carcinoma in situ (DCIS) lesions, determine tumor extent, and differentiate pure DCIS from DCIS with an invasive component. MATERIALS AND METHODS: Twenty-two patients with DCIS lesions were evaluated with three-dimensional RODEO MR imaging. Nineteen patients had available mammograms for review. RESULTS: MR imaging enabled detection of all 22 cases of DCIS, DCIS with microinvasion, or invasive ductal carcinoma with extensive intraductal component. A clumped enhancement pattern was seen on MR images in all cases of pure DCIS. Spiculated enhancement was seen in four of six (67%) patients who had DCIS with microinvasion and in nine of 11 (82%) who had invasive ductal carcinoma with extensive intraductal component. RODEO MR imaging enabled accurate determination of tumor extent in 21 of 22 (95%) patients. Mammography depicted 18 of 19 DCIS lesions. No mammographic feature helped differentiate pure DCIS from DCIS with microinvasion. Mammography enabled accurate determination of tumor extent in 14 of 19 (74%) patients. CONCLUSION: Three-dimensional RODEO MR imaging can be an adjunct to mammography because of its ability to enable better determination of tumor extent and differentiation of pure DCIS from DCIS with an invasive component.

Percutaneous core biopsy of the breast: effect of operator experience and number of samples on diagnostic accuracy.

OBJECTIVE: The purpose of our study was to assess the degree of operator experience and the number of core biopsy samples required to achieve an accurate histologic diagnosis for each of five common mammographically defined lesions, using percutaneous core breast biopsy performed on a dedicated prone biopsy table. SUBJECTS AND METHODS: A prospective multisite study was performed that involved nine institutions (academic and private) with experienced breast radiologists and the use of dedicated prone biopsy table units with digital assistance and standardized protocol. Asymptomatic women evaluated during a 2-year study period were assigned a mammographic diagnosis reported in a manner prescribed by the American College of Radiology Breast Imaging Reporting and Data System lexicon. Mammographic lesions evaluated included masses, masses with calcifications, clustered calcifications, focal asymmetries, and architectural distortions. Where histologic diagnosis was indicated, core biopsy was performed with five individual samples obtained and sequentially analyzed. Two hundred thirty patients had immediate excisional biopsy, the results of which provided the basis for a statistical analysis to compare the accuracy of each sequential core biopsy sample with surgical results. Statistical analysis was also done to ascertain the accuracy of core biopsy diagnosis as a function of operator experience. RESULTS: Trends toward increasing accuracy were observed by increasing the number of core biopsies for each of five types of mammographically defined lesions, especially for clustered calcifications. Statistically significant increased accuracy was observed when the number of biopsies was increased beyond one (p = .003). Trends toward increased accuracy with more experience were observed for all lesions, especially for calcifications. Of the 230 lesions studied with immediate surgical validation, more than 80% of all lesions except clustered calcifications (75%) were diagnosed on the basis of two core biopsies; accuracy after five biopsies was 98% for masses, 91% for calcifications, 100% for masses with calcification, 100% for focal asymmetries, and 86% for architectural distortions. CONCLUSIONS: Accuracy of diagnosis based on the results of percutaneous core breast biopsy improved with an increase in the number of core biopsy samples obtained for any given lesion seen on mammograms and with increased experience in performing the procedure. Five samples yielded an overall diagnostic accuracy of 97%. Familiarity with expected accuracy from this procedure for different mammographic lesions and following increased experience may assist physicians in planning patient management.

Breast masses. Appropriate evaluation.

Detection and management of a breast mass requires an optimal environment for interpretation, relevant use of clinical information, technically excellent imaging procedures, proper interpretation of the findings, and pertinent recommendations. Masses suspicious for malignancy by only a single modality ideally should undergo some form of biopsy, as the consequences of delayed diagnosis of breast cancer can be devastating. Early invasive breast cancer can be identified and treated if the appropriate evaluation is performed.

Stereotactic breast biopsy as an alternative to open excisional biopsy.

BACKGROUND: Health care cost continues to play a dominant role in our society. Technological advances are expensive, with the possible exception of stereotactic breast biopsy. We must learn other alternatives that give the same diagnostic accuracy at lower cost. The intention of this study was to find other acceptable alternatives to open excisional breast biopsies. METHODS: Patients were referred to Baylor University Medical Center between May 1990 and June 1992 for stereotactic breast biopsy of nonpalpable mammographic abnormalities. Before stereotactic biopsy, lesions were categorized into low or high suspicion for malignancy based on screening mammography. Slides were reviewed by a pathologist and the histological diagnosis was compared with mammographic characterization. Benign histology confirming the low-suspicion mammographic abnormality demonstrated mammographic and histologic correlation. Mammographic follow-up was recommended. RESULTS: Two hundred twenty-five women underwent 250 stereotactic breast biopsies. Malignancy was diagnosed in 47 patients; the remaining 203 lesions were benign on pathological examination and are being followed regularly. Seventy-eight percent of the lesions were characterized as low suspicion for malignancy, and 22% were characterized as high suspicion. The average cost savings per lesion using stereotactic biopsy was $1,629. CONCLUSION: Stereotactic breast biopsy is an acceptable, less expensive alternative to open excisional biopsy for diagnosing nonpalpable mammographic findings.

Silicone-suppressed 3D MRI of the breast using rotating delivery of off-resonance excitation.

OBJECTIVE: A new silicone-suppressed MR technique was developed, and its efficacy in identifying free silicone and differentiating it from other breast tissues was investigated. MATERIALS AND METHODS: Silicone-suppressed MRI was performed using the RODEO (rotating delivery of excitation off-resonance) pulse sequence, which selectively eliminated signal from the narrow range of (CH3)4Si resonance. Ninety breasts in 61 patients were evaluated with both a fat-suppressed 3D MR sequence and a silicone-suppressed 3D MR sequence. RESULTS: Extracapsular free silicone and silicone injections demonstrated a unique appearance compared with normal breast tissue in all cases. Magnetic resonance identified free silicone in 26 breasts, 10 of which were confirmed pathologically or from a history of previous silicone injections. No free silicone was present on MR in 64 breasts; 8 of these were confirmed by biopsy or mastectomy as showing no evidence of free silicone. This technique was useful in evaluation of prosthesis integrity, free silicone, focal palpable or mammographic lesions, and the breast with silicone injections. CONCLUSION: Silicone-suppressed RODEO MRI of the breast can accurately identify free and intracapsular silicone and can distinguish silicone from other tissues. This provides unique information about the breast in a number of specific applications.

The use of prostate specific antigen density to improve the sensitivity of prostate specific antigen in detecting prostate carcinoma.

BACKGROUND: Prostate specific antigen (PSA) is useful as a tumor marker for monitoring patients with prostate cancer after definitive therapy. Limitations have been noted when PSA was used for the early detection of prostate cancer. The use of prostate specific antigen density [PSAD = PSA (ng/ml)/prostate volume (cc)] has been suggested to differentiate benign from malignant prostate disease. METHODS: A retrospective analysis of 559 men who underwent transrectal prostate ultrasound and biopsy for an abnormal PSA value (> 4.0 ng/ml) and/or an abnormal prostate gland by digital rectal examination (DRE) was performed. Prostate specific antigen density evaluation was performed on all men, and its utility for diagnosing prostate cancer was compared with those of PSA and DRE. RESULTS: Two hundred, sixty seven (47%) of the 559 men had positive biopsies for prostate cancer. Sixty-one men had PSA levels of less than 4.0 ng/ml, and 17 (27.8%) of these men had positive biopsies for prostate cancer. No patient with a normal DRE had a positive biopsy regardless of the prostate specific antigen density (PSAD) value. PSAD was not more useful than PSA alone in detecting prostate cancer in this group. Two hundred, seventy-seven men had PSA values between 4.1 and 10.0 ng/ml, and 110 (40.0%) had positive biopsies for prostate cancer. For this group as a whole, the mean PSA values of the positive and negative biopsy groups showed no significant difference. The mean PSAD was significantly different (P < 0.0001) between the positive and negative biopsy groups. Two hundred, twenty-one men had PSA values of greater than 10.0 ng/ml, and 140 (63%) had positive biopsies for prostate cancer. Prostate specific antigen density was no more useful than PSA alone in distinguishing men with positive or negative biopsies for prostate cancer in the entire group. In the subset of patients with a normal DRE, (including no benign prostatic hyperplasia) the mean PSAD appeared useful (P < 0.004) in distinguishing the positive from the negative biopsy groups, whereas the mean PSA was not. CONCLUSION: These results suggest that PSAD is useful in discriminating prostate cancer in men with normal DRE and PSA levels between 4.1 and 10.0 ng/ml.