Reef sharks: recent advances in ecological understanding to inform conservation.

Sharks are increasingly being recognized as important members of coral-reef communities, but their overall conservation status remains uncertain. Nine of the 29 reef-shark species are designated as data deficient in the IUCN Red List, and three-fourths of reef sharks had unknown population trends at the time of their assessment. Fortunately, reef-shark research is on the rise. This new body of research demonstrates reef sharks' high site restriction, fidelity and residency on coral reefs, their broad trophic roles connecting reef communities and their high population genetic structure, all information that should be useful for their management and conservation. Importantly, recent studies on the abundance and population trends of the three classic carcharhinid reef sharks (grey reef shark Carcharhinus amblyrhynchos, blacktip reef shark Carcharhinus melanopterus and whitetip reef shark Triaenodon obesus) may contribute to reassessments identifying them as more vulnerable than currently realized. Because over half of the research effort has focused on only these three reef sharks and the nurse shark Ginglymostoma cirratum in only a few locales, there remain large taxonomic and geographic gaps in reef-shark knowledge. As such, a large portion of reef-shark biodiversity remains uncharacterized despite needs for targeted research identified in their red list assessments. A research agenda for the future should integrate abundance, life history, trophic ecology, genetics, habitat use and movement studies, and expand the breadth of such research to understudied species and localities, in order to better understand the conservation requirements of these species and to motivate effective conservation solutions.

Diagnostic accuracy of 99mTc-sestamibi breast imaging: multicenter trial results.

UNLABELLED: Although mammography is well established as a first-line tool for breast cancer screening and detection, efforts to develop complementary procedures continue. Observation of 99mTc-sestamibi tumor uptake provided the impetus for its evaluation as an adjunctive technique. This trial's objectives were to determine in a multicenter trial the diagnostic accuracy of 99mTc-sestamibi in women with suspected breast cancer and to investigate factors influencing diagnostic accuracy. METHODS: Our multicenter trial enrolled 673 women (387 with nonpalpable abnormalities; 286 with palpable abnormalities) scheduled for excisional biopsy or mastectomy. Blinded and unblinded interpretations of scintigraphic images were compared with core laboratory established histopathologic diagnoses to define the diagnostic accuracy of 99mTc-sestamibi breast imaging. RESULTS: Blinded readers' diagnostic accuracy was 78%-81%. Inter-reader agreement was excellent, ranging from 95% to 100% (kappa = 0.82-0.99). Overall institutional sensitivity and specificity for 99mTc-sestamibi breast imaging were 75.4% and 82.7%, respectively. In this population with a 40.1% disease prevalence, the positive predictive value was 74.5% and the negative predictive value was 83.4%. The negative predictive value was 94% in patients with a 40% or lower mammographic likelihood of breast cancer. Sensitivity was higher for palpable abnormalities; specificity was higher for nonpalpable abnormalities. Sensitivity was decreased for tumors <1 cm in largest dimension but appeared not to be affected by patient's age. CONCLUSION: As an adjunct to current procedures, 99mTc-sestamibi breast imaging may contribute to patient management decisions in selected populations, including women with dense breasts, mammographically indeterminate lesions >1 cm, and palpable abnormalities.

Use of Doppler ultrasound in the evaluation of breast carcinoma.

Ultrasound is an imaging modality commonly used to evaluate breast lesions in hopes to distinguish benign from malignant solid masses. Angiogenesis, defined as the emergence of new vessels to further the growth of tumor, has stimulated interest in the potential uses of Doppler ultrasound in patients with breast cancer. This article describes different forms of Doppler ultrasound, including color Doppler (CD), power Doppler (PD), and spectral Doppler (SD), as well as 3-dimensional (3D) ultrasound and ultrasound contrast media. We review the role of Doppler ultrasound in distinguishing benign from malignant solid breast masses. We also discuss the role of ultrasound in predicting tumor grade, histology, node status, and lymphatic vascular invasion, and in monitoring breast cancer treatment.

Accuracy of touch imprint cytology of image-directed breast core needle biopsies.

OBJECTIVE: To evaluate the accuracy of touch imprint (TI) cytology of image-directed core needle biopsy (CNB) specimens of nonpalpable breast lesions. STUDY DESIGN: Fifty-two consecutive CNBs from 44 patients were performed under mammographic or ultrasound guidance. Air- dried TIs of CNBs were stained with Diff-Quik. TI cellularity was considered adequate if six or more ductal cell groups were identified. CNBs and TIs were interpreted in a blinded fashion. RESULTS: TI cellularity was adequate in 37/52 (71%) cases, including 17/20 carcinomas and 20/32 benign lesions. Among 17 carcinomas, TIs were positive in 12, suspicious in 4 and atypical in 1. One case of lactational change was suspicious on TI, and 5/8 fibroadenomas were atypical. No benign lesions were called "carcinoma" on cytology. When lesions categorized as "carcinoma" or "suspicious" were considered positive and those classified as "atypical" or "benign" were scored as negative, TI sensitivity and specificity were 94% and 95%, respectively. When the "atypical" cases were grouped with the positive cases, TI sensitivity was 100%, with 75% specificity. CONCLUSION: With satisfactory cellularity, TIs of CNBs are highly accurate. When immediate evaluation of CNB specimens is important, TIs can potentially decrease the number of biopsy passes required and provide preliminary diagnoses.

Solid breast lesions: evaluation with power Doppler US.

PURPOSE: To evaluate power Doppler ultrasound (US) in detection of vascularity of solid breast lesions and to correlate patterns of vascular distribution with histopathologic findings. MATERIALS AND METHODS: Eighty-six solid breast masses, which were subsequently sampled for biopsy, were studied with gray-scale and power Doppler US. Patterns of vascular distribution were assigned before biopsy. RESULTS: There were 25 cancers, 38 fibroadenomas, and 23 other benign lesions. Seventeen (68%) cancers had penetrating vessels, four had peripheral vessels, and four had no vessels. Power Doppler US depicted no vessels in 21 fibroadenomas, peripheral vessels in 15, and penetrating vessels in two. Other benign lesions included 11 with no detectable vessels, nine with peripheral vessels, two with central vessels, and one with penetrating vessels. By using penetrating vessels to indicate malignancy, sensitivity for power Doppler US was 68%, specificity was 95%, positive predictive value was 85%, and negative predictive value was 88%. Two cancers were found to be malignant with power Doppler US only. CONCLUSION: The pattern of distribution and morphology of blood vessels in solid breast masses seen at power Doppler US is a potentially important feature to be considered along with other sonographic criteria to predict the likelihood of malignancy.

Angiosarcoma of the breast with report of unusual site of first metastasis.

Angiosarcoma of the breast accounts for less than 1% of all primary breast lesions. It occurs at all ages, but more frequently in younger women than does primary breast carcinoma. It often has a rapidly progressive clinical course and, as in one of the reported cases, can present with unusual sites of metastases even after a long disease-free interval.

Intramammary arterial calcifications associated with diabetes.

Arterial calcification was seen on the mammograms of 37 of 319 patients. Twenty-eight patients were known diabetics, while 7 had an abnormal fasting blood sugar level or glucosuria but were not being treated for diabetes. Eighteen (51%) of the 35 diabetic and borderline diabetic patients had breast arterial calcification, compared to only 19 (6.7%) of the 284 nondiabetics (p greater than 0.01). These findings suggest that arterial calcification on mammograms may be a sign of co-existing diabetes.

Diffuse osteosclerosis with lymphocytic lymphoma. A case report.

A unique case of diffuse osteosclerosis of the hemopoietic skeleton in a patient with lymphocytic lymphoma is described. Biopsy findings excluded a concurrent myeloproliferative disorder.

Optical spectroscopy (INVOS) is unreliable in detecting breast cancer.

Recently a new nonionizing, nonimaging technique for evaluating risk of breast cancer, in vivo optical spectroscopy (INVOS), became available. The procedure evaluates the biochemical composition of the breast with spectrophotometry to provide a risk number related to the development of breast cancer. INVOS was evaluated in a prospective study of 180 women who were referred to our institution for needle localization and excisional biopsy of 181 breast lesions. All women had mammography and INVOS before surgical biopsy. The INVOS risk numbers and mammographic findings were compared with the pathologic diagnoses. Of 39 breast cancers, 19 (49%) had high-risk INVOS numbers, as did 52% of women with benign disease. INVOS had a sensitivity of 95%, specificity of 4%, and a positive predictive value of 21% for the detection of breast cancer. Mammography predicted malignancy with a sensitivity of 97%, specificity of 48%, and a positive predictive value of 34%. Receiver-operating-characteristic (ROC) curve analysis also was performed. The ROC area for mammography was 0.85 compared with 0.43 for INVOS, indicating a significantly greater (p less than .0000001) ability for mammography to detect breast cancer. We conclude that because INVOS cannot accurately predict the presence of breast cancer, it is unlikely that INVOS can be used to predict which patients are at risk for the development of breast cancer.

Breast cancer screening: the underuse of mammography.

The early detection of breast cancer is promoted by the American Cancer Society (ACS) and the American College of Radiology (ACR) by encouraging the regular use of three types of screening: breast self-examination (BSE), the clinical breast examination, and mammography. In August 1983, the ACS publicized seven recommendations pertaining to screening, including a revised statement about the routine use of mammography for women between the ages of 40 and 49 years. In response to the ACS statement, the present study assessed compliance with the updated recommendations for all three types of screening. The results show reasonable rates of compliance for the BSE (53%-69%) and clinical examination (70%-78%). In contrast, only 19% of the women between the ages of 35 and 49 and 25% of the women older than 50 reported complying with the recommendation to undergo one baseline screening mammogram. In addition, only 9% of the mammograms were obtained for the early detection of disease, which is the rationale for the recommendation. In fact, it appears that mammography is being performed mainly for the diagnosis of symptomatic women instead of the screening of asymptomatic women. Some implications for health education by physicians and the professional education by physicians and the professional education of physicians in the use of mammography are discussed.

Assessment of pathologic prognostic factors in breast core needle biopsies.

BACKGROUND: Core needle biopsies (CNB) are being used increasingly as the initial diagnostic procedure in women with breast cancer. Many clinicians are interested in obtaining as much prognostic information as possible from these limited specimens. However, the accuracy of assessing pathologic prognostic factors in core biopsy material has not been studied in detail. DESIGN: We studied CNB and subsequent excision specimens from 79 women with invasive breast cancer. Slides from CNB and excision specimens were reviewed in a blinded fashion and each was assessed for histologic type, tumor size, histologic grade, lymphatic vessel invasion (LVI), and the presence of an extensive intraductal component (EIC). RESULTS: Among the 79 cancers, there were 58 invasive ductal carcinomas, six invasive lobular carcinomas, 13 invasive carcinomas with ductal and lobular features and two tubular carcinomas, based on examination of the excision specimens. Histologic type on CNB correlated with that on excision in 64 cases (81%). Although there was a significant correlation between tumor size on CNB and excision specimens (r2 = 0.30, P = 0.01), the pathologic T stage was underestimated on CNB in 79% of cases. Furthermore, T substage was underestimated on CNB in 71% of T1 lesions. There was concordance in histologic grade between CNB and excisions in 75% of cases. Among the 20 discordant cases, the grade was higher in the excision than in the CNB in 13 cases and lower in seven. However, all discrepancies were within one grade. None of the 17 cancers with LVI in the excision specimen showed LVI on the CNB. Among 14 cases with an EIC on the excision specimen, only four (29%) were scored as having an EIC on CNB. CONCLUSION: Histologic type can be accurately determined on CNB in most cases. While there was concordance in histologic grade between CNB and excision in the majority of cases, grade was discordant in a substantial minority (25%). The ability to accurately determine tumor size (pathologic T-stage), LVI, and EIC on CNB is severely limited.

Possible association between benign hepatomas and oral contraceptives.

PIP: 7 case reports of women with benign hepatic adenoma suggest that, since all of the women were taking oral contraceptives (OCs), there may be an association between ingestion of exogenous hormones and development of benign hepatoma of the liver. The cases were rapidly diagnosed by using hepatic arteriography; prompt, precise diagnosis is emphasized because, though the tumors are benign, they may cause serious, if not fatal, hemorrhage if left unchecked. Case 1 was a 26-year-old woman who had taken Enovid for 2 years, who presented with acute abdomen and impending shock. Coliotomy was performed, in which a left-lobe hepatic tumor was found; she underwent left hepatectomy and cholecystectomy and no evidence of recurrence was found 1 year later. Case 2 had been taking Oracon for a unknown time. Case 3, on OCs for 6 years, had a pedunculated mobile tumor removed. Case 4, 25 years old, had been taking Ovral for 6 months before diagnosis and excision of a right lobe liver tumor. Case 5, 5 years on combined OCs, required surgical intervention for a hypervascular mass. Case 6, taking a total of 8 years of OC therapy, was operated on for an hepatic mass which was a white-to-yellow hemorrhagic mass. Case 7, taking Enovid for 7 years, yielded a surgical specimen that was hemorrhagic, partly necrotic, and yellow-tan, about 10 cm in diameter.^ieng

Ultrasonic evaluation of pleural opacities.

Forty-one patients with substantial pleural opacities on chest films were examined by A-mode and B-mode ultrasound. Ultrasonic examination provides an accurate means of differentiating pleural fluid from other conditions which produce such opacities and is superior to the chest films as a means of localizing fluid. With the gain setting used in this series, fluid collections less than 1 cm thick were missed and were probably obscured by reverberation from the ribs. M-mode scanning provides a simple and accurate means of localizing the diaphragm in nearly all patients, almost completely eliminating difficulties caused by subdiaphragmatic placement of the thoracocentesis needle.

Mid-sagittal dimensions of cervical vertebral bodies.

A series of lateral radiographs of the cervical spinal column was evaluated in order to determine vertebral body dimensions. The sample included males (N=30) and females (N=31) 18 to 24 years old, comprising three stature percentile ranges (1-20; 40-60; 80-99) of the U.S. adult population. A two-dimensional analysis of vertebral body height (average distance between superior-inferior surgaces), depth (average distance between anteriorposterior surfaces), and area (average height X average depth) revealed minimal effects due to stature. In all subjects, average depth exceeded average height for vertebral bodies C3 through C7. Upon combining stature groups, both sexes revealed maximum average values for these dimensions at the seventh cervical vertebral body. Minimum average height occurred at C5 whereas minimum average depth was found at C3. Significant correlation (alpha greater than 0.05) was found for males between ponderal index and height and depth of the C7 vertebra. Male head weight correlated significantly with C3, C4, C5 and C6 vertebral body height and with C3, C5 and C6 vertebral body depth. For females, C7 height and C6 depth correlated significantly with ponderal index and head weight respectively. Probable biomechanical relationships of specific cervical vertebral bodies are noted

High resolution CT mammography of surgical biopsy specimens.

PURPOSE: Our goal was to assess the performance of high resolution CT on breast biopsy specimens before considering the reevaluation of refined CT techniques in patients with breast abnormalities. METHOD: High resolution CT was done in 44 surgical biopsy specimens following conventional X-ray specimen mammography. The specimens comprised 38 palpable and nonpalpable soft tissue abnormalities with mean size of 19 mm and 6 specimens with clustered microcalcifications only. There were 21 carcinomas, 10 fibroadenomas, and 13 other benign conditions. Evaluation of CT and conventional images was done separately, and a feature-grading list was used to compare the two modalities. RESULTS: In fatty specimens, grading of morphologic features of masses and the confidence to detect a soft tissue abnormality were equal with both techniques. CT significantly improved the confidence to detect a mass in 17 specimens with dense tissue: On a scale of 0-10, the mean score for detection was 3.8 with radiography and 5.8 with CT (p<0.008). For clustered microcalcifications, X-ray was superior to CT. The mean CT attenuation of 18 malignant masses (82 HU) was significantly lower than the mean attenuation of 10 fibroadenomas (131 HU; p = 0.003). CT scans of the American College of Radiology test phantom met the requirements for X-ray accreditation. CONCLUSION: For soft tissue abnormalities, CT specimen mammography performed equally as or better than specimen radiography. These in vitro results suggest potential advantages for increased sensitivity and specificity with CT and justify further investigations.

Patient expectations and costs of immediate reporting of screening mammography: talk isn't cheap.

OBJECTIVE: Our purpose was to determine whether patients prefer immediate or delayed results of screening mammography and to determine the cost of immediate reporting at our institution. MATERIALS AND METHODS: A survey was anonymously and randomly distributed to 129 women who were 35-70 years old during a visit to their primary care physician, asking the women's preference for receiving mammography results by one of two systems: by letter with a return visit for any additional tests; or by speaking at once with the radiologist, with the option of additional tests being performed during the same visit. Patients' willingness to pay for the latter service was also determined. A cost identification model was constructed using commercially available software. We considered the impact on radiologists' and technologists' time and the need for additional equipment and space, and we analyzed the effect on the cost of immediate reporting. RESULTS: One hundred twenty (93%) surveys were completed. Eighty women (67%) preferred immediate reporting, and 62 (78%) of these 80 patients would wait 30-60 min. The additional cost of immediate reporting is $28.22 per patient. Only 11% of patients were willing to pay this additional cost. When new equipment and space were not required, the cost would increase by $4.38. This cost was most influenced by the time required to give patients normal results. CONCLUSION: Most surveyed patients preferred speaking with a radiologist immediately but were unwilling to pay additional fees. Radiologists, hospital administrators, and health care planners must be aware of the costs of immediate reporting and must factor these costs into any change in hospital or national policy.

Do prognostic marker studies on core needle biopsy specimens of breast carcinoma accurately reflect the marker status of the tumor?

Core needle biopsies (CNB) are often used for the diagnosis of breast lesions. In some breast cancer patients, e.g., those treated with preoperative chemotherapy, the CNB specimen might be the only pretreatment tissue sample available for studies of prognostic and predictive markers. Our purpose was to evaluate whether marker studies performed on CNB specimens accurately reflect the marker status of the tumor. Immunostaining for five commonly used prognostic and predictive markers was performed on both CNB and subsequent excision specimens from 56 consecutive patients who had a CNB with carcinoma followed by excision of the tumor. None of the patients received radiotherapy or chemotherapy between the CNB and the excision. Paraffin sections of the CNB and excision specimens were immunostained for bcl-2, estrogen receptor (ER), c-erbB-2, and p53. These markers were scored as positive or negative. Microvessel density (MVD) was scored as a continuous variable on sections immunostained for Factor VIII-related antigen by calculating the average number of microvessels in three 224x fields of highest tumor vascularity ("hot spots"). Immunostaining results for bcl-2, ER, c-erbB-2, and p53 on the CNB and the corresponding excision specimens were 100% concordant. Although there was significant correlation between MVD on the CNB specimens and the corresponding excisions (r = 0.507, P = 0.0002), the mean MVD on the CNB and corresponding excision specimens differed by more than 10% in 85.7% of cases, with differences ranging from 4.3 to 233.3%. MVD was higher in the CNB than in the excision specimens in 30 (61.2%) of 49 cases. In conclusion, in all of the cases studied, accurate results for the dichotomously scored markers bcl-2, ER, c-erbB-2, and p53 were obtained on CNB specimens. In contrast, in most cases, MVD, which was scored as a continuous variable, could not be reliably assessed on the CNB specimen.

Local recurrence after conservative surgery and radiation therapy for ductal carcinoma in situ: Possible importance of family history.

PURPOSE: The optimal treatment of ductal carcinoma in situ is controversial. Traditionally, women with this disease have been treated with mastectomy with excellent results, but recently the need for such extensive surgery has been questioned. Long-term data on the use of conservative surgery and radiation therapy for treatment are limited. A retrospective analysis was performed to assess treatment outcome and prognostic factors for patients with ductal carcinoma in situ treated with conservative surgery and radiotherapy. PATIENTS AND METHODS: From 1976 to 1990, 76 women with ductal carcinoma in situ were treated with conservative surgery followed by radiation therapy. The median age at diagnosis was 48 years. Seventeen patients had a positive family history of breast cancer in a first-degree (n=8) or second-degree (n=9) relative. Median follow-up interval was 74 months for the 71 survivors. In 54 patients, the carcinoma was detected by mammography alone; in 13 patients, by mammography and physical examination; and in 4 patients, by physical examination with a normal mammogram; and in 5 patients, by physical examination alone without mammography. Fifty patients had re-excision after initial biopsy. Final margins were positive in 11, close in 11, negative in 34, and unknown in 20. The median volume of excised tissue was 60 cm3. The axilla was surgically staged in 30 patients (39%) and all were negative. The whole breast was irradiated to a dose of 45 to 50 Gy in all patients. Seventy-two patients also received a boost to the primary site. The median total radiation dose to the primary site was 61 Gy (range, 46 to 71). RESULTS: Seven patients had a recurrence in the treated breast at 16, 18, 41, 63, 72, 83, and 104 months after treatment. The 5- and 10-year actuarial rates of local recurrence were 4% and 15%, respectively. Six of seven recurrences occurred in the vicinity of the original lesion. Four local recurrences were invasive, and three were ductal carcinoma in situ. Two patients developed a contralateral invasive carcinoma. The 5- and 10-year cause-specific survival rates were 100% and 96%, respectively. The 10-year actuarial rate of local recurrence was 25% in the group with a total excision volume less than 60 cm3, as compared with 0% in those with 60 cm3 or more excised (P=0.04). In patients with a positive family history, the 10-year actuarial rate of local recurrence was 37%, as compared with 9% in patients with a negative family history (P=0.008). Of the 17 patients with a positive family history, four developed either an ipsilateral or contralateral invasive breast cancer, whereas 1 of the 58 patients without a family history developed a subsequent invasive breast cancer (P=0.008). CONCLUSION: These results suggest that patients with ductal carcinoma in situ treated with conservative surgery and radiotherapy (including a boost to the primary site) appear to benefit from wide, rather than limited, resection. These results also suggest that family history may be an important prognostic factor for progression of disease.