Unilateral axillary adenopathy following COVID-19 vaccination: a multimodality pictorial illustration and review of current guidelines.

We present a multimodality pictorial review of axillary lymphadenopathy in patients recently vaccinated against COVID-19. As the mass vaccination programme continues to be rolled out worldwide in an effort to combat the pandemic, it is important that radiologists consider recent COVID-19 vaccination in the differential diagnosis of unilateral axillary lymphadenopathy and are aware of typical appearances across all imaging methods. We review current guidelines on the management of unilateral axillary lymphadenopathy in the context of recent COVID-19 vaccination.

The impact of digital mammography on screening a young cohort of women for breast cancer in an urban specialist breast unit.

OBJECTIVE: To compare the diagnostic performance of full-field digital mammography (FFDM) with screen-film mammography (SFM) in a corporate screening programme including younger women. METHODS: Data were available on 14,946 screening episodes, 5010 FFDM and 9936 SFM. Formal analysis was by logistic regression, adjusting for age and calendar year. FFDM is compared with SFM with reference to cancer detection rates, cancers presenting as clustering microcalcifications, recall rates and PPV of recall. RESULTS: Overall detection rates were 6.4 cancers per thousand screens for FFDM and 2.8 per thousand for SFM (p < 0.001). In women aged 50+ cancer detection was significantly higher for FFDM at 8.6 per thousand vs. 4.0 per thousand, (p = 0.002). In women <50, cancer detection was also significantly higher for FFDM at 4.3 per thousand vs. 1.4 per thousand, (p = 0.02). Cancers detected as clustering microcalcifications increased from 0.4 per thousand with SFM to 2.0 per thousand with FFDM. Rates of assessment recall were higher for FFDM (7.3% vs. 5.0%, p < 0.001). FFDM provided a higher PPV for assessment recall, (32 cancers/364 recalls, 8.8%) than SFM, (28 cancers/493 recalls, 5.7%). CONCLUSIONS: Cancer detection rates were significantly higher for FFDM than for SFM, especially for women <50, and cancers detected as clustering microcalcifications.

The mRNA expression of SETD2 in human breast cancer: correlation with clinico-pathological parameters.

BACKGROUND: SET domain containing protein 2 (SETD2) is a histone methyltransferase that is involved in transcriptional elongation. There is evidence that SETD2 interacts with p53 and selectively regulates its downstream genes. Therefore, it could be implicated in the process of carcinogenesis. Furthermore, this gene is located on the short arm of chromosome 3p and we previously demonstrated that the 3p21.31 region of chromosome 3 was associated with permanent growth arrest of breast cancer cells. This region includes closely related genes namely: MYL3, CCDC12, KIF9, KLHL18 and SETD2. Based on the biological function of these genes, SETD2 is the most likely gene to play a tumour suppressor role and explain our previous findings. Our objective was to determine, using quantitative PCR, whether the mRNA expression levels of SETD2 were consistent with a tumour suppressive function in breast cancer. This is the first study in the literature to examine the direct relationship between SETD2 and breast cancer. METHODS: A total of 153 samples were analysed. The levels of transcription of SETD2 were determined using quantitative PCR and normalized against (CK19). Transcript levels within breast cancer specimens were compared to normal background tissues and analyzed against conventional pathological parameters and clinical outcome over a 10 year follow-up period. RESULTS: The levels of SETD2 mRNA were significantly lower in malignant samples (p = 0.0345) and decreased with increasing tumour stage. SETD2 expression levels were significantly lower in samples from patients who developed metastasis, local recurrence, or died of breast cancer when compared to those who were disease free for > 10 years (p = 0.041). CONCLUSION: This study demonstrates a compelling trend for SETD2 transcription levels to be lower in cancerous tissues and in patients who developed progressive disease. These findings are consistent with a possible tumour suppressor function of this gene in breast cancer.

Oncological safety and patient satisfaction with skin-sparing mastectomy and immediate breast reconstruction.

INTRODUCTION: The management of early breast cancer with skin-sparing mastectomy (SSM) and immediate breast reconstruction (IBR) is not based on evidence from randomised controlled trials. The purpose of this study is to evaluate the oncological safety, post-operative morbidity and patients' satisfaction with SSM and IBR using the latissimus dorsi (LD) myocutaneous flap and/or breast prosthesis. METHODS: Eighty-three consecutive women underwent 93 SSMs with IBR (10 bilateral), using the LD flap plus implant (n=55) or implant alone (n=38), indications included early breast cancer and prophylaxis due to BRCA-1 gene mutation. Nipple reconstruction was performed in 38 patients, using the trefoil local flap technique, nipple sharing or Monocryl mesh. Twenty-three underwent contra-lateral surgery in order to optimise symmetry, including 15 augmentations and eight mastopexy/reduction mammoplasties. Patient satisfaction with the outcome of surgery was assessed on a linear visual analogue scale ranging from 0 (not satisfied) to 10 (most satisfied). RESULTS: There was no local recurrence (LR) after a median follow-up of 34 months (range=3-79 months). Overall survival was 98.8%, three patients developed distant disease and one patient died of metastatic breast cancer. No case of partial or total LD flap loss was observed. Morbidities included infection, requiring implant removal in two patients and one patient developed marginal ischaemia of the skin envelope. Significant capsule formation, requiring capsulotomy, was observed in 87% of patients who had either PMR or prior RT compared with 13% for those who did not have RT. Sixty-one (73.5%) of 83 patients completed the questionnaire with a median and mean satisfaction scores of 10.0 and 9.3, respectively (range=6-10). CONCLUSION: SSM with IBR is associated with low morbidity, high levels of patient satisfaction and is oncologically adequate for T(is), T1 and T2 tumours without extensive skin involvement.

Evidence of a tumour suppressive function of E2F1 gene in human breast cancer.

BACKGROUND: The E2F family of transcription factors are key regulators of genes involved in cell cycle progression, cell fate determination, DNA damage repair and apoptosis. E2F1 is unique in that it contributes both to the control of cellular proliferation and cellular death. Furthermore, unlike other E2Fs, E2F1 responds to various cellular stresses. This study aimed to examine the level of mRNA expression of E2F1 gene in normal and malignant breast tissue and correlate the level of expression to tumour stage. MATERIALS AND METHODS: One hundred and twenty-seven breast cancer tissue and 33 normal tissues were analyzed. Levels of transcription of E2F1 were determined using real-time quantitative PCR, normalized against CK19. Levels of expression were analyzed against TNM stage, nodal involvement, tumour grade and distant metastasis. RESULTS: The levels of E2F1 mRNA were lower in malignant tissues. They declined further with increasing TNM stage. This became statistically significant when TNM stages 3 and 4 were compared to TNM stages 1 and 2 disease (TNM1 vs. TNM3 p = 0.032; TNM1 vs. TNM4 p = 0.032; TNM2 vs. TNM3 p = .019; TNM2 vs. TNM4 p = 0.021). The levels of E2F1 also fell with increasing tumour grade, when comparing grade 2 and 3 with grade 1, however, the differences were not statistically significant. CONCLUSION: These results are highly suggestive of the role of E2F1 as a tumour suppressive gene in human breast cancer.

The potential clinical applications of insulin-like growth factor-1 ligand in human breast cancer.

Insulin-like growth factor-1 (IGF-1) has become recognized as a growth factor with pro-mitogenic and antiapoptotic effects on a variety of human cells. This article reviews the potential role of IGF-1 ligand in the clinical management of breast cancer patients. Many studies have shown that IGF-1 acts synergistically with oestrogen to stimulate breast cancer cells. Case-control studies have also demonstrated that premenopausal women with high levels of serum IGF-1 have an increased risk of developing breast cancer later in life. Serum IGF-1 levels can therefore be used as a potential biomarker for predicting breast cancer risk. Furthermore, there is evidence that serum IGF-1 levels can serve as a response biomarker in chemoprevention drug trials. The role of IGF-1 expression in breast cancer tissue as a prognostic marker is not clearly established. Identifying the IGF-1 gene polymorphism can potentially be used in predicting breast cancer risk.

Evidence for a tumour suppressive function of IGF1-binding proteins in human breast cancer.

UNLABELLED: The role of the insulin like growth factor (IGF) system in various human malignancies has been well established. The aim of this study was to determine the levels of mRNA expression of insulin-like growth factor-binding protein (IGFBP)-1, -3 and -7 genes in benign and malignant breast tissue and explore their relationship with various prognostic parameters. MATERIALS AND METHODS: Breast cancer tissue (n=127) and normal background tissue (n-33) were prospectively collected and analysed for levels of IGFBP-1, -3 and -7 mRNA using real-time Q-PCR. mRNA levels were then analysed against tumour grade, nodal status, Nottingham prognostic index (NPI)/TNM stage and tumour type. RESULTS: For IGFBP-1 and -3, mRNA expression was higher in normal tissue. This was significant for IGFBP-1 when comparing NPI 3 with NPI 1 (p=0.050) and the normal group (p=0.040). With respect to TNM analysis, there was less IGFBP-1 mRNA when comparing TNM 3 with normal (p=0.017), TNM 1 (p=0.047) and TNM 2 (p=0.019) tumours. This was also found when comparing TNM 4 samples with normal tissue (p=0.017), TNM 1 (p=0.046) and TNM 2 (p=0.019). For IGFBP-3 mRNA, there was less mRNA when comparing TNM 3 with TNM 1 (p= 0.017) and TNM 2 (p=0.050), and also less mRNA expression when comparing TNM 4 with TNM 1 (p=0.030). For IGFBP-7 mRNA, both TNM 1 (p=0.0077) and TNM 2 (p=0.015) had significantly more expression than TNM 3 samples. CONCLUSION: This study supports the role of IGFBP-1, -3 and -7 as potential tumour suppressor genes in human breast cancer.

HTERT mRNA expression correlates with matrix metalloproteinase-1 and vascular endothelial growth factor expression in human breast cancer: a correlative study using RT-PCR.

BACKGROUND: Telomerase activity has been significantly associated with nodal metastasis and cellular proliferation in human breast cancer, indicating that its degree of expression has some form of vital control over the invasive nature of the malignancy concerned. Of the telomerase subunits, the reverse transcriptase (hTERT) is the main determinant of enzyme activity. Vascular endothelial growth factors (VEGF)-C and (VEGF)-D, matrix metalloprotease type 1 (MMP-1) and protease-activated receptors (PARs) have all been linked to promotion of tumour invasiveness and metastatic dissemination. This study aims to examine the association between hTERT transcription and that of VEGF-D, VEGF-C, MMP-1, PAR1a and PAR1b through a correlative analysis of the mRNA transcripts of these genes in human breast cancer. MATERIALS AND METHODS: Breast cancer tissues (n = 116) and normal tissues (n-31) were collected immediately after surgery and stored at -80 degrees C until use. The level of hTERT transcripts from the prepared DNA from the above samples was determined using real time-quantitative PCR based on the Amplifluor technology. The levels of the transcript were generated from a standard that was simultaneously amplified with the samples. Normalisation against cytokeratin 19 (CK19) and glyceraldehyde-3-phosphate dehydrogenase (GAPDH) was also carried out. RESULTS: There was a positive correlation between hTERT mRNA expression (after CK19 normalisation) with both VEGF-D and MMP-1 in human breast cancer. PAR1 was seen to correlate with hTERT (after GAPDH normalisation) with a highly significant correlation with PAR1a alone. However there was no correlation between hTERT transcription and VEGF-C or with PAR1b alone. CONCLUSION: Our findings suggest that hTERT is a potential up-regulator of MMP-1, PAR1 and VEGF-D expression and this may explain its apparent control over the invasiveness and metastasis of the malignancy concerned.

Neurogenic Unilateral Leg Edema.

This case report describes neurogenic unilateral leg edema that was a consequence of chronic regional pain syndrome induced by an S1 radiculopathy.

hTERT mRNA expression is associated with a poor clinical outcome in human breast cancer.

BACKGROUND: Telomerase is a ribonucleoprotein enzyme that synthesises telomeres after cell division and maintains chromosomal length and stability thus leading to cellular immortalisation. hTERT (human telomerase reverse transcriptase) gene is the rate-limiting determinant of telomerase reactivation. The present study aims to quantitatively measure the expression of hTERT mRNA in human breast cancer, examine the association between hTERT and the clinicopathological characteristics of the cancer specimens including the Nottingham Prognostic Index (NPI) and to explore the relationship between hTERT expression and clinical outcome. MATERIALS AND METHODS: RNA was extracted from 116 breast carcinomas and 31 matched adjacent non-cancerous tissue (ANCT). hTERT mRNA expression was estimated by reverse transcriptase-PCR (RT-PCR) and Taqman methodology. RESULTS: hTERT mRNA was present in all of the cancerous specimens (mean=0.1701, median=0.0205) and most ANCT specimens with levels being 2.6 times higher in the cancerous tissue than in ANCT (mean=0.156 vs. 0.68, p=0.18). The mean mRNA levels increased with NPI scores (0.0816 for NPI 1, 0.1186 for NPI 2 and 0.68 for NPI 3), however this failed to reach statistical significance (P-values= 0.33 for NPI 1 vs. 2, 0.27for NPI2 vs. 3 and 0.24 for NPI 1 vs. 3). hTERT levels also increased with increasing tumour's grade (mean= 0.0459 for grade 1, 0.111for grade 2, and 0.27 for grade 3) but this trend did not reach a statistical significance. Low levels of hTERT were associated with mucinous carcinoma compared with ductal (p=0.023) and lobular (p=0.021) types. hTERT mRNA levels were higher in patients who had recurrent disease or died from breast cancer compared with those who remained alive without disease after a median follow up of 6 years (p=0.0026). CONCLUSION: High hTERT mRNA levels are associated with a poor clinical outcome in human breast cancer and should be included as a prognostic marker in future validation studies.

The role of STS and OATP-B mRNA expression in predicting the clinical outcome in human breast cancer.

BACKGROUND: Steroid sulfatase (STS) is the enzyme responsible for hydrolysing biologically inactive estrogen sulfates to active estrogens. Therefore it plays a significant role in supporting the growth of hormone-dependent tumours of the breast, endometrium and prostate. OATP-B is a member of a family of membrane transporter proteins that regulates the uptake of steroid sulfates through cell membranes. Our objective was to determine, using quantitative PCRA whether the mRNA expression levels from these genes were positively correlated with clinical outcome in human breast cancer. This is the first study in the literature to examine the relationship between STS and OATP-B in human breast cancer and to investigate the potential prognostic value of OATP-B. MATERIALS AND METHODS: A total of 153 samples (120 tumour tissues and 33 normal breast tissues) were analysed. The levels of transcription of STS and OATP-B were determined using real-time quantitative PCR and normalized against cytokeratin 19. The levels of expression were analysed against tumour's stage, grade, nodal status, local relapse, distant metastasis, ERalpha, ERbeta and HER1-4 receptor status and survival over a 10 year follow up period. RESULTS: The levels of STS mRNA were significantly higher in malignant samples (p=0.031) and in node positive disease (p=0.0222). STS mRNA expression increased with increasing tumour grade but this did not reach statistical significance. A significant increase was also noted in levels correlating with tumour stage when stages TNM1 and TNM2, TNM2 and TNM3, and TNM3 and TNM4 (p=0.00001, 0.0017 and 0.02, respectively) were compared. Furthermore, STS expression levels positively correlated with progression of disease, as levels were significantly higher in samples from patients who developed metastasis, local recurrence, or died of breast cancer when compared to those who were disease free for >10 years (p=0.0036). No significant correlation was found between the levels of STS expression and ERalpha/ERbeta/ status. The levels positively correlated with HER1 and HER3 receptors. The levels of mRNA expression of OATP-B were higher in malignant tissue compared to normal tissue; this, however, did not reach statistical significance (p=0.4045). Levels were also higher in node positive disease (p=0.0672). Expression levels increased with increasing tumour grade and this became statistically significant when comparing grade 1 to 2, and grade 2 to 3 (p=0.0271 and 0.0289, respectively). An increase in levels correlating with TNM tumour staging was also observed; this, however, did not reach statistical significance. There was no significant correlation between OATP-B expression levels and clinical progression of breast cancer. No correlation was found between STS and OATP-B expression levels. CONCLUSION: This study demonstrates a compelling trend for STS transcription levels to be higher in cancer tissues and in patients who developed progressive disease. OATP-B expression levels correlated with the grade and stage of the disease, but not with the clinical outcome. These results suggest that STS mRNA has a significant potential as an important predictor of clinical outcome in patients with breast cancer.

Insulin-like growth factor 1 (IGF-1) and its receptor mRNA levels in breast cancer and adjacent non-neoplastic tissue.

UNLABELLED: Previous studies investigating the insulin-like growth factor 1 receptor (IGF-1R) expression in breast cancer tissue and adjacent non-neoplastic breast tissue (ANCT) have produced conflicting results. The IGF-1 and IGF-1R expression in pairs of breast cancer tissue and ANCT were investigated using RT-PCR and immunohistochemistry. The results of both methods were compared. MATERIALS AND METHODS: IGF-1 and IGF-1R mRNA from 31 specimen pairs were estimated using RT-PCR. Immunohistochemistry for IGF-1R was carried out on 20 specimen pairs and the strength of staining was scored. RESULTS: The mean relative IGF-1 mRNA level was lower in the cancerous tissue (mean 0.450 +/- 0.206) than in the ANCT (mean 0.632 +/- 0.384) (paired t-test, p = 0.001). There was no measurable difference in relative IGF-1R mRNA levels in the cancerous tissue (mean 0.146 +/- 0.08) and the ANCT (mean 0.14608 +/- 0.108) (paired t-test, p = 0.807). Using immunohistochemistry, there was no statistical difference (paired t-test, p = 0.910) in IGF-1R staining scores between cancer (mean 1.93) and ANCT (mean 1.90). The comparison between the two methodologies showed no correlation (Pearson's Correlation Coefficient = -0.393). DISCUSSION: It can be concluded that IGF-1 expression is lower in cancerous tissue, thus supporting a paracrine relationship between cancerous tissue and ANCT, which may be useful in the prevention, diagnosis and treatment of breast cancer. There was no difference in the expression of the IGF-1 receptor in both types of tissue, as proven by RT-PCR and immunohistochemistty. Conflicting results in previous studies may be due to the different methods used to measure IGF-1R expression.

Breast cancer risk in flight attendants: an update.

Although further research is required, epidemiological evidence indicates that breast cancer risk is increased by 40% among flight attendants. Female flight attendants and women who fly frequently should be informed of this potential increase in risk and be encouraged to participate in appropriate breast cancer screening programs.

Screening mammography in women aged 40-49: is it time to change?

There is little doubt that significant benefits can accrue from carrying out screening mammography of women aged 40-49 in the setting of a highly quality assured service delivery. This will best be achieved using digital mammography to maximise detection rates and trained and high volume reading expert radiologists to apply economic cushions of optimising specificity as well as sensitivity in addition to utilising modern and accurate assessment and tissue sampling techniques that have evolved.

Oncological considerations of skin-sparing mastectomy.

AIM: To review evidence concerning the oncological safety of performing skin-sparing mastectomy (SSM) for invasive breast cancer and ductal carcinoma in situ (DCIS). Furthermore, the evidence concerning RT in relation to SSM and the possibility of nipple preservation was considered. METHODS: Literature review facilitated by Medline and PubMed databases. FINDINGS: Despite the lack of randomised controlled trials, SSM has become an accepted procedure in women undergoing mastectomy and immediate reconstruction for early breast cancer. Compared to non-skin-sparing mastectomy (NSSM), SSM seems to be oncologically safe in patients undergoing mastectomy for invasive tumours smaller than 5 cm, multicentric tumours, DCIS or risk-reduction. However, the technique should be avoided in patients with inflammatory breast cancer or in those with extensive tumour involvement of the skin in view of the high risk of local recurrence. SSM with nipple areola complex (NAC) preservation appears to be oncologically safe, provided the tumour is not close to the nipple and a frozen section protocol for the retro-areolar tissue is followed. Although radiotherapy (RT) does not represent a contraindication to SSM, the latter should be used with caution if postoperative RT is likely, since it detracts from the final cosmetic outcome.

Does mammary ductoscopy have a role in clinical practice?

BACKGROUND: Mammary ductoscopy (MD) is a newly developed endoscopic technique that allows direct visualisation of the mammary ductal epithelium using sub-millimetre fiberoptic microendoscopes inserted through the ductal opening onto the nipple surface. These scopes also provide working channels for insufflation, irrigation, ductal lavage, and possible therapeutic intervention. MD can be performed under local anaesthesia in the office setting. The objective of this study is to assess the technical feasibility of mammary ductoscopy, and examine its role in guiding ductal excision surgery and the early diagnosis of malignancy. METHODS: Mammary ductoscopy (MD) was performed using a 1 mm fiberoptic microendoscope (Mastascope TM) in 26 patients (age range: 14-73 years): 13 patients undergoing mastectomy (n = 12) or lumpectomy (n = 1) for ductal carcinoma (including 12 cases of DCIS and one case of infiltrating ductal carcinoma) and 13 patients with pathological nipple discharge (PND) and benign breast imaging and simple discharge cytology. Of the latter group: 10 procedures were performed under local anaesthesia (LA) in the office setting and 3 procedures were carried out under general anaesthesia (GA) to guide duct excision surgery. The ductoscopic appearances in this group were graded between 0 and 5 (D0-D5) according to the degree of suspicion. RESULTS: Intraoperative MD was accomplished in 11 (84.6%) of 13 patients undergoing surgery for DCIS. MD was unsuccessful in 2 cases: one patient (aged 73 years) had sclerosis of the nipple and one patient had preoperative vital blue injection in the subareolar region as part of the sentinel node biopsy thus resulting in inadequate visualisation. Intraductal pathology was visualised in 8 (80%) of the 10 cases undergoing mastectomy but ductoscopic cytology was positive for malignancy in only 2 cases (sensitivity = 16%, specificity = 100%). In the office setting, MD was accomplished in 9 (90%) out of 10 patients with PND and was well tolerated (mean pain score = 3.8 out of 10: range 0-7). Of these 10 patients; MD was inadequate (D0) in one patient due to complete occlusion of lumen by the lesion, showed a papilloma in 3 patients (D3), duct ectasia (D2) in 3 patients, irregular thickening of the lumen suspicious of DCIS (D4) in one patient and non-specific benign findings (D2) in 2 patients. Three women with benign ductoscopy and ductoscopy-assisted cytology were reassured and treated conservatively. The remaining 7 patients had ductoscopy-guided duct excision which revealed DCIS in one, papilloma in 4 and benign breast disease in 2 patients. Adequate cellular yield was obtained in 7 (70%) out of 10 cases (benign cytology). The three patients who had MD under GA during microdochectomy had benign endoscopic appearances and final histology (one papilloma and 2 cases of duct ectasia). CONCLUSION: MD is technically feasible in most patients and has a potential in the early detection of breast cancer. The procedure can be performed safely in the office setting and should be considered in all patients presenting with a single duct PND. MD has the potential to reduce the number of duct excision procedures and minimise the extent of surgical resection. Ductoscopic cytology is not sufficiently sensitive for the diagnosis of malignancy and the development of a biopsy tool that obtains tissue under direct visualisation is required.

Breast papillomas: current management with a focus on a new diagnostic and therapeutic modality.

Breast papilloma is a term that describes an intraductal papillary configuration of the mammary epithelium on macroscopic or microscopic examination. It includes solitary intraductal papillomas, multiple papillomas, papillomatosis, and juvenile papillomatosis (JP).Recent advances in mammary ductoscopy (MD) have raised new possibilities in the diagnosis and treatment of breast papillomas. This technique represents an important diagnostic adjunct in patients with pathological nipple discharge (PND) by allowing direct visualisation and biopsy of intraductal lesions and guiding duct excision surgery. Treatment of breast papillomas often entails surgical duct excision for symptomatic relief and histopathological examination. Recently, more conservative approach has been adapted. MD-assisted microdochectomy should be considered the procedure of choice for a papilloma-related single duct discharge. Furthermore, there is increasing evidence that MD has the potential to reduce the number of duct excision procedures and minimise the extent of surgical resection. Imaging-guided vacuum-assisted core biopsy can be diagnostic and therapeutic for papillomas seen on mammography and/or ultrasound. Patients with multiple papillomas do have an increased risk of developing cancer and should be kept under annual review with regular mammography (preferably digital mammography) if treated conservatively. Magnetic resonance (MR) can be also used in surveillance in view of its high sensitivity. Because the risk is small, long term and affects both breasts, long-term follow-up is more appropriate than prophylactic mastectomy. Patients who prove to have solitary duct papilloma have insufficient increase in the risk of subsequent malignancy to justify routine follow-up.

The potential role of dynamic thermal analysis in breast cancer detection.

BACKGROUND: It is presently well accepted that the breast exhibits a circadian rhythm reflective of its physiology. There is increasing evidence that rhythms associated with malignant cells proliferation are largely non-circadian. Cancer development appears to generate its own thermal signatures and the complexity of these signatures may be a reflection of its degree of development. The limitations of mammography as a screening modality especially in young women with dense breasts necessitated the development of novel and more effective screening strategies with a high sensitivity and specificity. The aim of this prospective study was to evaluate the feasibility of dynamic thermal analysis (DTA) as a potential breast cancer screening tool. METHODS: 173 women undergoing mammography as part of clinical assessment of their breast symptoms were recruited prior to having a biopsy. Thermal data from the breast surface were collected every five minutes for a period of 48 hours using eight thermal sensors placed on each breast surface [First Warning System (FWS), Lifeline Biotechnologies, Florida, USA]. Thermal data were recorded by microprocessors during the test period and analysed using specially developed statistical software. Temperature points from each contra-lateral sensor are plotted against each other to form a thermal motion picture of a lesion's physiological activity. DTA interpretations [positive (abnormal thermal signature) and negative (normal thermal signature)] were compared with mammography and final histology findings. RESULTS: 118 (68%) of participating patients, were found to have breast cancer on final histology. Mammography was diagnostic of malignancy (M5) in 55 (47%), indeterminate (M3, M4) in 54 (46%) and normal/benign (M1, M2) in 9 (8%) patients. DTA data was available on 160 (92.5%) participants. Using our initial algorithm, DTA was interpreted as positive in 113 patients and negative in 47 patients. Abnormal thermal signatures were found in 76 (72%) out of 105 breast cancer patients and 37 of the 55 benign cases. Then we developed a new algorithm using multiple-layer perception and SoftMax output artificial neural networks (ANN) on a subgroup (n = 38) of recorded files. The sensitivity improved to 76% (16/21) and false positives decreased to 26% (7/27) CONCLUSION: DTA of the breast is a feasible, non invasive approach that seems to be sensitive for the detection of breast cancer. However, the test has a limited specificity that can be improved further using ANN. Prospective multi-centre trials are required to validate this promising modality as an adjunct to screening mammography especially in young women with dense breasts.

A novel technique to repair a transverse sacral fracture in a previously fused lumbosacral spondylolisthesis.

BACKGROUND: Transverse fractures of the sacrum are rare, and surgical treatment for these fractures ranges from conservative to challenging. Transverse stress fractures of the sacrum after placement of lumbar-to-sacral instrumentation have been previously described. We report a new technique to repair a transverse Type-2 Roy-Camille fracture with spondylolisthesis of S1 over S2 in a previously fused instrumented high-grade L4-L5, L5-S1 spondylolisthesis. CASE DESCRIPTION: A 64-year-old female who previously had an L4-L5, L5-S1 fusion for spondylolisthesis presented with excruciating lower back pain and radiculopathy for over 6 months. She was found to have an S1-S2 transverse fracture caused by previous implantation of pedicle screws. She underwent repositioning of several failed right lumbar and sacral screws and then had bilateral S1-S2 screws placed directly across the fracture line. The patient had an unremarkable postoperative course. She discontinued most of her pain medications within 6 weeks postoperatively. In the months following surgery, she reported only minimal lower back pain and no radiculopathy with the last appointment 5 years postoperatively. CONCLUSIONS: We describe a novel technique to reduce an iatrogenic transverse type-2 Roy-Camille fracture at S1-S2 in a previously instrumented high-grade L4-L5, L5-S1 spondylolisthesis. The patient's fracture achieved adequate reduction and fusion with symptomatic relief.