Evaluating the preoperative breast cancer characteristics affecting the accuracy of axillary ultrasound staging

We evaluate the preoperative breast cancer (BC) characteristics that affect the diagnostic accuracy of axillary ultrasound (US) and determine the reliability of US in the different subgroups of BC patients. Axillary US assessments in women with invasive BC diagnosed between 2009 and 2016 in a single institution were retrospectively reviewed. The diagnostic accuracy of axillary US was obtained using surgical nodal histology as the gold standard. Preoperative breast tumor sonographic and histological factors affecting axillary US diagnostic accuracy were examined. Of the 605 newly diagnosed invasive BC cases reviewed, 251 (41.5%) had nodal metastases. Axillary US sensitivity was 75.7%, specificity 92.9%, positive predictive value 88.4%, negative predictive value 84.4%, and false‐negative rate 24.3%. Lower US sensitivity was seen with invasive lobular cancer (ILC) (P = .043), grade I/II, (P = .021), unifocal (P = .039), and smaller tumors (P < .001). US specificity was lower in grade III (P < .001), estrogen receptor (ER)‐negative (P < .001), progesterone receptor (PR)‐negative (P = .004), HER2‐positive (P = .015), triple‐negative (P = .001), and larger breast tumors (P < .001). US has moderate sensitivity and good specificity in detecting metastatic axillary lymph nodes. Based on preoperative cancer characteristics, US was less sensitive for nodal metastases from ILC, unifocal, lower grade, and smaller breast tumors. It was also less specific in grade III, ER‐negative, PR‐negative, HER2‐positive, triple‐negative, and larger breast tumors. Caution is suggested in interpreting the US axillary findings of patients with these preoperative tumor features.     

Impact of Cardiac Comorbidity on Early Outcomes after Pancreatic Resection

Background

In patients undergoing pancreatic resection (PR), identification of subgroups at increased risk for postoperative complications can allow focused interventions that may improve outcomes.

Study Design

Patients undergoing PR from 2005–2010 were selected from the American College of Surgeons National Surgical Quality Improvement Program database and categorized as having any history of cardiac disease (angina, congestive heart failure (CHF), myocardial infarction (MI), cardiac stent, or bypass) or as having acute cardiac disease (symptoms of CHF or angina within 30 days or MI within 6 months). These variables were utilized to examine the relationship between cardiac disease and outcomes after PR.

Results

The rate of serious complications and perioperative mortality in patients with any history of cardiac disease vs. those without was 34 vs. 24 % (p?<?0.001) and 4.5 vs. 2.0 % (p?<?0.001), respectively, and in patients with acute cardiac disease compared to patients without was 37 vs. 25 % (p?<?0.001) and 8.6 vs. 2.2 % (p?<?0.001), respectively. In multivariate analysis, the two cardiac disease variables remained associated with mortality.

Conclusions

In patients undergoing PR, cardiac disease is a significant risk factor for adverse outcomes. These observations are critical for meaningful informed consent in patients considering pancreatectomy.     

Feasibility and accuracy of coronary imaging in elderly patients using the 64-row multi-detector computed tomography: a correlation study with conventional coronary angiography

Background Elderly patients generally have higher occurrence of coronary calcification, increased heart rate and difficulty with prolonged breath-holding. The aim of our study was to investigate the feasibility and accuracy of using 64-row multi-detector computed tomography (MDCT) in the assessment of coronary artery stenoses in elderly patients. Methods One hundred and fifty two patients with suspected or known coronary artery disease were divided into 4 groups according to their age (Group A: 40-49 years, n=34; Group B: 50-59 years, n=57; Group C: 60-69 years, n=48; Group D: 70 years and above; n=13). Coronary CT angiography (CTA) using a 64-row MDCT was performed and the findings were compared with that of conventional coronary angiography (CCA). Using axial images, multi-planar reconstructions (MPR) and maximum intensity projections (MIP), coronary segments of lumen diameter = 1.5mm were analyzed for the presence of significant stenosis (= 50% ). Results Percentages of poor image quality from coronary CTA preventing reliable correlations with CCA were 21%, 14%, 19% and 62% in Groups A to D respectively. Patients in Group D had significantly higher calcium scores compared with the other groups (P<0.001). In patients where CTA images were of acceptable quality, percentages of accurate correlations with CCA were 89.8%, 93.4%, 86.6% and 78.0% for Groups A to D respectively. There were no significant difference in serum creatinine, heart rate and contrast volume between the 4 groups. Conclusions The 64-row MDCT coronary angiography was less accurate and feasible for patients aged 70 years or above due to heavy coronary calcification and inability to perform a satisfactory breath-hold. However, a high diagnostic accuracy with the MDCT is possible in patients aged less than 70 years.(J Geriatric Cardiol 2006;3(1):9-14)     

Acute promyelocytic leukaemia with t(11;17)(q23;q12-21) and a good initial response to prolonged ATRA and combination chemotherapy

Acute myeloid leukaemia (AML) of FAB subtype M3 is associated with t(15;17)(q22;q21) and a relatively good prognosis when treated with all- trans retinoic acid (ATRA) and combination chemotherapy. Rarely, alternative balanced translocations have been described in this subtype of AML. The translocation t(11;17)(q23;q21) leading to a PLZF/RARα rearrangement has been described in a very small number of cases and has been associated with a poor response to ATRA and an adverse prognosis. We describe a case of AML FAB type M3 with this translocation who entered morphological and cytogenetic complete remission after concurrent prolonged ATRA and one course of induction chemotherapy and remains in morphological and molecular remission at 10 months after presentation. This diagnosis therefore may not always be associated with a poor initial response to treatment.     

The effects of recombinant-DNA-derived interferons on the growth of myeloid progenitor cells

Interferons (IFNs) have been shown to have significant effects on hematopoietic cell growth. Previous studies defining these effects have utilized mouse and human alpha-, beta-, and gamma-IFN isolated from supernatants of stimulated cells. Despite purification, the possible presence of other lymphokines and soluble factors remains a concern. In this study, the effects of gene-cloned alpha- and gamma-IFN on colony- forming units of granulocyte/macrophage (CFU-GM) progenitors cultured from the peripheral blood of normal volunteers were examined. In addition, blast cell colonies from one patient with acute myelogenous leukemia (AML) were studied. The growth of normal CFU-GM and AML blast cell colonies was inhibited in a dose-dependent manner by gamma- and alpha-IFN. gamma-IFN was ten to 100 times more potent than alpha-IFN in that this species of IFN reduced colony formation by greater than 50% at concentrations of less than 15 antiviral U/mL. The effects of gamma- IFN were neutralized by a monoclonal antibody specific for gamma-IFN. These in vitro studies indicate that human gamma-IFN may be an important modulator of myelopoiesis. Although these data indicate a possible efficacy of gamma-IFN in the treatment of AML, the in vitro results should be considered for their in vivo significance.     

Comparison of the Framingham Risk Score,SCORE and WHO/ISH cardiovascular risk prediction models in an Asian population

Background

Cardiovascular risk-prediction models are used in clinical practice to identify and treat high-risk populations, and to communicate risk effectively. We assessed the validity and utility of four cardiovascular risk-prediction models in an Asian population of a middle-income country.

Methods

Data from a national population-based survey of 14,863 participants aged 40 to 65 years, with a follow-up duration of 73,277 person-years was used. The Framingham Risk Score (FRS), SCORE (Systematic COronary Risk Evaluation)-high and -low cardiovascular-risk regions and the World Health Organization/International Society of Hypertension (WHO/ISH) models were assessed. The outcome of interest was 5-year cardiovascular mortality. Discrimination was assessed for all models and calibration for the SCORE models.

Results

Cardiovascular risk factors were highly prevalent; smoking 20%, obesity 32%, hypertension 55%, diabetes mellitus 18% and hypercholesterolemia 34%. The FRS and SCORE models showed good agreement in risk stratification. The FRS, SCORE-high and -low models showed good discrimination for cardiovascular mortality, areas under the ROC curve (AUC) were 0.768, 0.774 and 0.775 respectively. The WHO/ISH model showed poor discrimination, AUC = 0.613. Calibration of the SCORE-high model was graphically and statistically acceptable for men (χ² goodness-of-fit, p = 0.097). The SCORE-low model was statistically acceptable for men (χ² goodness-of-fit, p = 0.067). Both SCORE-models underestimated risk in women (p < 0.001).

Conclusions

The FRS and SCORE-high models, but not the WHO/ISH model can be used to identify high cardiovascular risk in the Malaysian population. The SCORE-high model predicts risk accurately in men but underestimated it in women.