Breast cancer-specific mortality after invasive local recurrence in patients with ductal carcinoma-in-situ of the breast

BACKGROUND: Previous studies on the efficacy of primary treatments for ductal carcinoma-in-situ (DCIS) have focused on local recurrence rates. Our objective was to detail the outcomes of local invasive recurrence, distant recurrence, and breast cancer mortality in patients previously treated for DCIS. METHODS: Clinical, pathologic, and outcome data were collected prospectively for 1236 patients with pure DCIS accrued from 1972 through 2005. RESULTS: There were 150 recurrences (87 DCIS and 63 invasive). Invasive local recurrence after mastectomy was rare (0.5% of patients) and after breast preservation was more frequent (12.0% of patients). The 12-year probabilities of breast cancer-specific mortality after mastectomy and after breast preservation were 0.8% and 1.0%, respectively. The 12-year breast cancer-specific mortality and distant disease probability for the 63 patients with invasive recurrences were 12% and 15%, respectively. CONCLUSIONS: Regardless of initial treatment, most patients with invasive local recurrence after treatment for DCIS can be treated and cured.     

Interobserver reproducibility in the diagnosis of ductal proliferative breast lesions using standardized criteria.

Although the categorization of proliferative breast lesions provides valuable information regarding subsequent risk of breast cancer, the ability of pathologists to classify such lesions in a reproducible fashion has not been adequately evaluated. To assess further interobserver reproducibility in the categorization of proliferative breast lesions, six pathologists each reviewed 24 proliferative ductal lesions and classified them as either usual hyperplasia (H), atypical hyperplasia (AH), or carcinoma in situ (CIS). Before evaluation of the study slides, all the participants were instructed to use the diagnostic criteria of Page and co-workers and were provided with both a written summary of these criteria and a set of teaching slides with representative examples of each type of lesion. Complete agreement among all six pathologists was seen in 14 cases (58%); five or more agreed in 17 cases (71%); and four or more arrived at the same diagnosis in 22 cases (92%). No pathologist consistently rendered more "benign" or "malignant" diagnoses than any other. After assigning numerical values for each diagnostic category (H = 1, AH = 2, CIS = 3), the scores for the group of 24 cases did not differ significantly by pathologist (p = 0.68; average score range, 1.7-2.0). Our results indicate that with the use of standardized criteria, interobserver concordance in the diagnosis of proliferative ductal breast lesions can be obtained in the majority of cases.     

The reliability and reproducibility of the Neer classification system - Digital radiography (PACS) improves agreement

Introduction

We investigated if the introduction of digital radiography, with its software permitting enhancement of plain radiographs, improved inter- and intra-observer agreement in the Neer classification.

Methods

Five observers participated in classifying 50 randomly selected radiographs with a confirmed proximal humeral fracture. The observers included a junior registrar, an upper-limb fellow, a lower-limb orthopaedic consultant and two orthopaedic shoulder consultants. Agreement was quantified via kappa values.

Results

In general, good (0.61-0.80) results were obtained using kappa value for inter-observer reliability throughout all grades. On further analysis, however, discrepancies persist in the classification between Neer type 1/2 and Neer type 5 categories. The latter was not restricted to more inexperienced surgeons. Intra-observer agreement (>0.81) was excellent throughout all grades.

Conclusion

The introduction of digital radiography aids the improvement of Neer classification of proximal humeral fractures across all grades. With superior agreement in displacement and fracture patterns, improved communication and discussion of these injuries and similar treatment plans can be expected. This may help negate one aspect of the variability in outcome of proximal humeral shaft fractures. More complex fracture configurations continue to have difficulty in interpretation and may require further imaging analysis to conclude definitively.     

Urinary incontinence self-report questions: reproducibility and agreement with bladder diary

Introduction and hypothesis  

This study aims to measure self-report urinary incontinence questions’ reproducibility and agreement with bladder diary.     

非肿块型乳腺导管癌数字化乳腺X线摄影表现形式与病理类型的相关性分析

目的探讨非肿块型乳腺导管癌数字化乳腺X线摄影(DR)表现形式与病理类型的相关性。方法回顾性分析经手术、病理证实的非肿块型乳腺导管癌195例,其中导管内癌36例(1组),导管内癌伴微浸润25例(2组),浸润性导管癌58例(3组),浸润性导管癌伴导管内癌76例(4组),对DR表现形式及病灶长径进行对比和统计学处理。结果 DR表现形式与病理类型关系在总体上差异有统计学意义(P0.05),x~2分割检验显示导管内癌与浸润性导管癌组及浸润性导管癌伴导管内癌组差异均有统计学意义(P0.008),后两组之间差异有统计学意义(P0.008),病灶长径与病理类型关系在总体上差异有统计学意义(P0.05),x~2分割显示导管内癌与浸润性导管癌伴导管内癌组差异有统计学意义(P0.008),浸润性导管癌与浸润性导管癌伴导管内癌组差异有统计学意义(P0.008),其他组之间差异无统计学意义(P0.008)。结论导管内癌DR表现形式主要是单纯钙化;以片影伴钙化为表现的,病理类型多是浸润性导管癌伴导管内癌;病灶长径50 mm,浸润性导管癌伴导管内癌的可能性大。     

The clinical significance of cytokeratin-positive cells in lymph nodes at the time of mastectomy from patients with ductal carcinoma-in-situ

Background We determined the presence or absence of and clinical significance of cytokeratin-positive cells in the lymph nodes of patients who had had mastectomies for ductal carcinoma-in-situ. Methods Two pathologists independently assessed the axillary lymph nodes found. All patients had either a core or open biopsy performed before the time of mastectomy. The lymph nodes were assessed with hematoxylin and eosin stain and immunohistochemistry for cytokeratin marker AE1/AE3. The slides were assessed for the presence or absence of epithelial cells. As a control, axillary lymph nodes found in prophylactic mastectomies were assessed. None of these had had a previous biopsy performed. Results Lymph nodes from all patients demonstrated no obvious epithelial cells on hematoxylin and eosin stain. Peripheral sinuses of lymph nodes from six patients (23%) who had mastectomies for ductal carcinoma-in-situ contained a few cytokeratin-positive cells on immunohistochemistry. The lymph nodes of the control group demonstrated no cytokeratin-positive cells. The mean follow-up of patients was 5 years, and all patients were alive without recurrence at the time of the study. Conclusions Epithelial cells may be present in the lymph nodes draining a site of recent breast biopsy in the absence of invasive carcinoma, indicating that these are an artifact of recent surgery and not of micrometastatic disease.     

Pathological classification of ductal carcinoma in situ of the breast correlates with surgical treatment and may be predicted by mammography

In order to assess the correlation of pathological and radiological features of ductal carcinoma in situ (DCIS) of the breast and their association with surgical outcome, a consecutive series of 150 patients was retrospectively examined. Pathological slides from all patients were divided into three categories according to the pathological EPWG (European Pathologist Working Group) and DIN (Ductal Intraepithelial Neoplasia) classifications, which showed very good inter-correlation (r=0.99) (whole series). Mammographic images from 46 of these cases were blindly classified into five categories according to the level of radiological suspicion (R), morphology of calcifications (Ca) and preoperative results of needle biopsy (C/B) (limited series). No significant differences in the distribution of clinical and pathological variables were detected among whole and limited series. The lesions were grouped into two (low versus high) pathological (PRG), radiological (RRG and CaRG) and needle biopsy (C/BRG) risk groups. PRG was associated with both RRG (p=0.002) and CaRG (p=0000), but not with C/BRG. Correlations with surgical outcome were also explored, with lesions of high PRG being more likely to undergo re-excision for inadequate first wide local excision [odds ratio (OR)=2.1], mastectomy (OR=2.6) and nodal staging procedures (OR=3.8) in the whole series. Conversely, no significant correlation was found between PRG, RRG, CaRG and C/BRG with surgical outcome in the limited series. We suggest that pathological features of DCIS are associated with surgical outcome and may be predicted by mammography.     

Neer分型的可靠性研究

目的 通过比较检查者Neer分型的组间一致性与组内可重复性评价其可信度和可重复性,以及经验对Neer分型的影响.方法 选取2010年1月至2010年12月收治的40例肱骨近端骨折患者的影像学资料(术前肩关节正位、侧位、改良腋位X线片,以及肩关节横断位CT平扫或三维重建),分2次(至少间隔3个月)呈递给12名检查者,以同样的流程进行16分法Neer分型,使用Kappa检验评估组间可信度和组内可重复性.同时比较接受过肩关节外科专科培训的检查者(专业组,6人)与未接受过肩关节外科专科培训的检查者(对照组,6人)的分型一致性,并重组数据后评估简化分型的可靠性.结果 2次测试Neer分型组间可信度分别为0.534和0.473,组内可重复性为0.669.专业组分型可靠性显著高于对照组,差异有统计学意义(P＜0.05).所有数据在新的6分法(简化分型)基础上重组后的组间可信度为0.581和0.502,组内可重复性为0.680,组间可信度有提升,但一致性仍维持在一般水平.所有12名检查者分型一致的病例占总病例数的17.5％(第1次测试)和15.0％(第2次测试).结论 本研究对Neer分型评估取得了一般的组间可信度和良好的组内可重复性,并显示专业水平是分型可靠性的重要影响因素,肩关节外科专业培训对提高组间可信度和组内可重复性至关重要;简化Neer分型对提升可靠性并无明显帮助.     

Hyperplastic ductal and lobular lesions and carcinomas in situ of the breast: reproducibility of current diagnostic criteria among community- and academic-based pathologists

Due to the increased efforts of early detection and biopsy of breast lesions, the number of cases with hyperplastic and in situ lesions seen in most pathology laboratories has increased significantly. Pathologists are faced with a greater number of biopsies and a wider spectrum of lobular and ductal lesions including papillary lesions. A set of 31 randomly selected glass slides of ductal, lobular and papillary lesions (benign, borderline, and carcinomas in situ) was circulated among five community- and five academic-based pathologists (median 9 years of experience). The pathologists filled out a standard form for each case which included lesion type (ductal, lobular, or papillary) and diagnostic category (ductal, lobular, or papillary; hyperplasia or carcinoma). We compare the participants' diagnoses, their histologic criteria, and the reproducibility of the diagnoses. Kappa statistics were calculated to measure the levels of agreement among community and academic pathologists, overall for all the pathologists, and within a subgroup of eight participants reporting the use of the same diagnostic criteria (Page's). All pathologists agreed with the diagnosis of cancer in 10 cases (33%), kappa overall 0.347 (fair); with the diagnostic category of lesions in 8 cases (27%), kappa overall 0.537 (moderate); and with the lesion type in 16 cases (53%), kappa overall 0.789 (substantial). Community pathologists were more likely to interpret ductal and papillary lesions as hyperplasias than carcinomas in situ. In contrast, academic pathologists interpreted more cases as carcinomas than hyperplasias (60 versus 45). There was little to no improvement in the level of agreement observed when we considered the subgroup of pathologists using the same standardized criteria. This study demonstrates that the overall agreement in the diagnosis of carcinoma in situ of the breast remains low between pathologists using or not using standardized diagnostic criteria. Papillary and ductal lesions pose a significant problem between observers in characterizing them as benign or malignant. Current diagnostic criteria need to be modified, reemphasized, or replaced, either through the literature or with additional training to decrease interobserver variability.     

乳腺导管原位癌及导管原位癌伴微浸润的诊断与治疗

导管原位癌（ductal carcinoma in situ，DCIS）的概念首先在1960年被提出，随后的一些研究证实了DCIS多起源于乳腺终末导管小叶单位（terminal duct／lobular unit，TDLU），并且可以进一步发展为浸润性癌。在20世纪70年代之前，其治疗策略与浸润性癌基本一致。随着乳腺钼靶X线摄片技术问世，DCIS的发病率逐年上升，对其生物学特性及治疗手段的探索也成为乳腺肿瘤研究领域的热点。目前，虽然NCCN乳腺癌临床实践指南（2007版）对其诊断与治疗已有相关规定，     

GATA脊柱结核分型的可信度与可重复性研究

目的:对GATA脊柱结核分型的可信度及可重复性进行分析,为临床应用提供参考。方法:让4名脊柱外科医师以GATA脊柱结核分型为标准独立对100例脊柱结核患者进行两次分型(间隔1个月),通过计算两两医师之间及同一医师前后两次分型对最后分型、各指标判断相同的平均百分比,确定分型一致性,应用Kap-pa值和Spearman系数判定其可信度和可重复性,当Kappa值>0.5时有中度或中度以上的一致性,Spearman相关系数值>0.40时有中度或中度以上正性相关。结果:4名医师对各指标(椎体塌陷、椎旁脓肿、脊柱稳定性、脊柱后凸畸形、矢状面指数、椎间盘破坏)及最后分型判断相同的平均百分比分别为61.92%、91.83%、63.33%、60.08%、78.25%、82.00%、52.33%;可信度的Kappa值分别为0.430、0.519、0.317、0.380、0.536、0.531、0.343;Spearman相关系数分别为0.392、0.526、0.392、0.503、0.569、0.582、0.576。同一医师前后两次对各指标(椎体塌陷、椎旁脓肿、脊柱稳定性、脊柱后凸畸形、矢状面指数、椎间盘破坏)及最后分型判断相同的平均百分比分别为72.75%、91.00%、85.25%、70.75%、88.75%、81.75%、73.00%;可重复性的Kappa值分别为0.574、0.453、0.627、0.523、0.724、0.584、0.591;Spearman相关系数分别为0.748、0.473、0.632、0.660、0.730、0.613、0.762。结论:GATA脊柱结核分型具有较高的可重复性,但可信度较差。     

腰椎退变性滑脱临床与影像学分型的可信度与可重复性分析

【摘要】 目的：探讨腰椎退变性滑脱临床与影像学（CARDS）分型的可信度与可重复性,分析其临床应用价值。方法：以CARDS分型为标准,由5位研究者对2010年1月~2013年12月在我院就诊的49例退变性腰椎滑脱患者进行独立分型,1个月后再次独立分型。收集结果,分别行不同观察者间可信度和同一观察者内可重复性分析,计算Kappa值与Spearman相关系数。结果：共计490例次分型中,包括A型74例次（15%）,B型167例次（34%）,C型187例次（38%）和D型62例次（13%）。5位研究者在第1次测试中对椎间隙高度、后凸畸形、滑脱距离及最终分型判断一致的百分比分别为77.6%~93.9%（89.6%）、69.4%~91.8%（86.6%）、67.3%~81.6%（77.5%）和65.3%~81.6%（74.1%）;可信度Kappa值分别为、0.764、0.719、0.596和0.641;Spearman相关系数分别为0.564、0.612、0.576和0.589。同一研究者前后两次测试中对椎间隙高度、后凸畸形、滑脱距离及最终分型判断一致的百分比分别为85.7%~98.0%（94.7%）、89.8%~95.9%（92.1%）、77.6%~91.8%（87.5%）和75.5%~87.8%（82.4%）;其可重复性Kappa值分别为0.857、0.842、0.779和0.804;Spearman相关系数分别为0.714、0.702、0.689和0.645。结论：CARDS分型应用于退变性腰椎滑脱患者具有较高的可信度与极佳的可重复性,值得临床推广应用。     

Unified classification of open fractures: Based on Gustilo and OTA classification schemes

BackgroundThe Orthopaedic Trauma Association (OTA) classification scheme for open fractures has improved precision, validity and reliability over the modified Gustilo classification system. However, it needs to be modified into a simple and practical classification system to gain widespread acceptance and application.Material and methodsWe devised a new “unified” classification of open fractures based on the Gustilo and OTA classification systems. The new classification was tested for interobserver reliability on five different fractures classified by 15 surgeons each using the Krippendorff’s alpha. Preference of surgeons for the Gustilo, OTA and unified classifications was assessed.ResultsThe new classification showed excellent interobserver reliability (α = 0.93). A significantly higher number of surgeons expressed preference for the new over the Gustilo and OTA classifications for routine clinical use.ConclusionThe new “unified” classification of open fractures has good validity, reliability and acceptability, and has the potential to replace all other existing classification systems.     

Radiographic signs of union of scaphoid fractures. An analysis of inter-observer agreement and reproducibility

Inter-observer agreement and reproducibility of opinion were assessed for the radiographic diagnosis of union of scaphoid fractures on films taken 12 weeks after injury. Weighted kappa statistics were used to compare the opinions of eight senior observers reviewing 20 sets of good quality radiographs on two occasions separated by two months. There was poor agreement on whether trabeculae crossed the fracture line, whether there was sclerosis at or near the fracture and on whether the proximal part of the scaphoid was avascular. As a consequence, agreement on union also was poor; it appears that radiographs taken 12 weeks after a scaphoid fracture do not provide reliable and reproducible evidence of healing.     

Cancer of the male breast with atypical ductal hyperplasia and contralateral gynecomastia

A case of right mammary invasive ductal carcinoma in young man with atypical ductal hyperplasia and gynecomastia of the second breast is described. The review of the existing literature stress the rarity of this observation. Nevertheless, in all cases of male mammary carcinoma the accurate examination must always include the contralateral breast to search the possible precancerous lesions or etiologic factors.     

The acquired midtarsus deformity classification system--interobserver reliability and intraobserver reproducibility

A radiographic classification (Schon's) divides Charcot midtarsus deformities into four types identified by Roman numerals (I to IV), according to the anatomical location of the pathological process,11 and an objective method of severity staging using radiographic criteria is introduced and tested. A beta stage is assigned if one of the following criteria is met: 1. a dislocation is present; 2. the lateral talar-first metatarsal angle is > or = 30 degrees; 3. the lateral calcaneal-fifth metatarsal angle > or = 0; or 4. the AP talar-first metatarsal angle is > or = 35 degrees. An alpha stage can be assigned when all four features are absent. Clinical features useful in assessing and managing these deformities have been associated with the various types and stages. To determine whether the classification system is valid, a study was performed. Two examination booklets and an instructional booklet designed to teach the method were distributed to 75 orthopaedic surgeons at the AOFAS summer meeting to test for intraobserver reproducibility and interobserver reliability. Information about the participants was recorded, and the tests were scored. The highest scores for correct responses were achieved by foot and ankle fellows, followed by orthopaedic residents. Attending orthopaedic surgeons achieved the lowest scores. The most common error was a type I deformity misidentified as a type II. The interobserver reliability for correctly classifying the deformities was 81%, and the intraobserver reproducibility was 97%. We concluded that this classification system, intended to clarify the patterns of acquired midfoot collapse, permits assignment of both anatomic type (I to IV) and degree of severity (alpha-beta) with high reliability and reproducibility. It can therefore be used as a tool for diagnosis, planning treatment, and assessing the prognosis.     

脊柱侧凸胸椎椎弓根形态学分型系统的可信度与可重复性研究

【摘要】 目的：探讨脊柱侧凸胸椎椎弓根形态学分型系统在临床应用中的可信度与可重复性。方法：1998年1月~2009年1月手术治疗脊柱侧凸患者60例,术前均行胸椎CT扫描、椎弓根轴位薄层重建。根据椎弓根松质骨管腔的形态特征将脊柱侧凸胸椎椎弓根分为正常型、狭窄型、峡部硬化型、完全硬化型（包括凹陷硬化和平直硬化两个亚型）和缺如型。应用64排CT多层重建技术,测量、分析60例常见类型脊柱侧凸患者1440个胸椎椎弓根CT轴位扫描结果,由3位不了解本研究目的的脊柱外科高年资住院医师,在同一时间分别对1440个胸椎椎弓根CT轴位扫描结果进行分型。间隔1个月后,再次由这3位住院医师对这1440个椎弓根进行分型。应用Stata 10.0软件,运用多类别多评估者的Kappa分析方法进行统计学分析,评价观察者间的可信度及观察者内的可重复性。结果：3位医师之间首次分型结果相同的百分比分别为88%、84%、92%,可信度的Kappa系数分别为0.7647、0.6590、0.8292;同一医师前后两次分型结果相同的百分比分别为95%、97%、96%,可重复性的Kappa系数分别为0.9227、0.9513、0.9117。结论：脊柱侧凸胸椎椎弓根形态学分型系统具有中、高度的可信度和极好的可重复性。     

Reliability and reproducibility of dens fracture classification with use of plain radiography and reformatted computer-aided tomography

BACKGROUND: The classification system of dens fractures by Anderson and D'Alonzo has been widely used in clinical studies. Of the three types of fractures, Type II and Type III are of particular importance because the distinction between them may affect treatment decisions. The purposes of this study were to assess whether this classification is reliable and reproducible and to determine whether computed tomography can improve its reliability and reproducibility. METHODS: Plain radiographs and spiral computed tomography images of dens fractures in eleven patients were assessed, and the fractures were assigned a classification of Type II or Type III at two readings, separated by six months, by two spine surgeons and three neuroradiologists. Kappa coefficients of agreement between the raters as well as the reproducibility of the classifications made by the individual raters were calculated independently for the fracture classifications based on the plain radiographs and those based on the reformatted computed tomography scans. RESULTS: The kappa coefficient for classifications based on plain radiographs was 0.30 and 0.25 (fair agreement) at the first and second readings, respectively. For classifications based on computed tomography scans, the corresponding kappa coefficients were 0.46 (moderate agreement) and 0.67 (substantial agreement). The kappa coefficients for intrarater reliability among the five raters averaged 0.56 (moderate agreement) when computed tomography scans were used and 0.28 (fair agreement) when plain radiographs were used. CONCLUSIONS: Substantial variation with regard to the classification of dens fractures was found within our group of raters. Greater agreement occurred when reformatted computed tomography scans rather than plain radiographs were used as the basis for classification. When classifying dens fractures according to the system of Anderson and D'Alonzo, one should consider using reformatted computed tomography scans and reaching a consensus with multiple raters.