Needle aspiration biopsy of palpable breast masses

One hundred fifteen patients underwent needle aspiration biopsy of palpable breast masses prior to open biopsy. Aspirates were obtained by surgical residents, prepared by a cytotechnologist present at the procedure, and evaluated by a single pathologist. Cytologic findings were interpreted as positive or highly suspicious for malignancy, normal or benign, or insufficient. All patients underwent open biopsy. Patients with positive or highly suspicious cytologic findings who preferred partial mastectomy and radiotherapy were offered a segmental mastectomy. No patient was offered total mastectomy based on cytologic findings alone. There were two false-positive and two false-negative results, for a 92 percent sensitivity and 97 percent specificity. The value of needle aspiration biopsy lies in its ability to identify patients at high risk for malignancy. Total mastectomy cannot be recommended based on cytologic findings alone. The setting of a surgical residency program does not adversely affect the reliability of the technique.     

Mammography after needle aspiration of palpable breast masses

Hematoma resulting from attempted aspiration of a palpable breast mass can cause incorrect mammographic interpretation by rendering irregular and indistinct the otherwise smooth and sharply defined margins characteristic of a benign lesion. In this study of recently aspirated breast masses, we found 17 benign lesions that demonstrated poorly defined, irregular margins on mammograms that suggested malignancy. All these false-positive interpretations occurred when aspiration preceded mammography by less than 2 weeks (17 of 47, 36 percent); no such diagnostic error occurred in the 31 cases when mammography was delayed for 2 weeks or more after aspiration. An appreciation of the frequency and natural history of postaspiration hematoma formation should either encourage physicians to request mammography before carrying out invasive procedures, or alternatively, to defer mammography until 2 weeks after aspiration, since mammography then should more clearly portray the benign characteristics of truly benign masses, thereby possibly obviating biopsy.     

Diagnosis of palpable breast masses: ultrasound-guided large core biopsy in a multidisciplinary setting

Cytologic diagnosis of palpable breast masses is an accepted method for diagnosis. However, the high nondiagnostic rate causes repeat biopsy, unnecessary delays, and increased costs. Our purpose is to evaluate the use of ultrasound (US)-guided large-core needle biopsy as part of the minimally invasive multidisciplinary diagnosis of palpable breast masses. We studied 502 consecutive patients with 510 palpable solid breast masses seen and evaluated by a multidisciplinary team. Patients had US-guided core biopsy. Clinical-imaging-pathologic correlation (CIPC) was done in all cases. Core biopsy was deemed conclusive if CIPC was congruent and was used to guide definitive management. The median age of our patients was 39 years. Median tumor size was 2.2 cm. Of these cases, 463 (91%) had a conclusive diagnosis on CIPC. Core needle findings on 47 masses were nondefinitive to guide therapy (fibroepithelial lesion, atypical ductal hyperplasia, intraductal papilloma, CIPC). Three cancers were detected in this group on excisional biopsy. In conclusion, US-guided large-core needle biopsy is a sensitive method for diagnosis of palpable breast masses. Multidisciplinary correlation of clinical findings, imaging, and pathology is essential for success. This approach improves use of operating room resources and maximizes patient participation in the decision-making process.     

Fine-needle aspiration of clinically suspicious palpable breast masses with histopathologic correlation

BACKGROUND: The purpose of this study was to compare the diagnostic accuracy of fine-needle aspiration (FNA) of clinically suspicious palpable breast masses in women younger and older than 40 years of age.METHODS: All women who had FNA biopsy with subsequent tissue biopsy were included. The cytologic diagnoses were classified into three groups: malignant, suspicious, or benign. Histopathologic correlation was based on either a needle core biopsy, an excisional biopsy, or a mastectomy specimen. RESULTS: A total of 1,158 fine-needle aspirations performed between 1982 and 2000, on women being evaluated for a clinically palpable breast mass were included in the study. The patients were divided into two groups: group I consisted of 231 patients aged 40 years and younger, and group II consisted of 927 patients aged 41 years and older. In group I there were 117 (51%) malignant FNA diagnoses, and only 1 (1%) false-positive case, subsequently diagnosed on histopathologic material as an atypical papillomatosis. There were 20 (9%) cases diagnosed as suspicious on FNA. On histopathology 10 were malignant, and 10 were benign. Of the 91 (39%) cases interpreted as benign, only 1 (1%) was a false negative. In group II, which comprised 927 patients, there were 693 (74%) malignant FNA diagnoses, and 3 (less than 1%) false-positive cases, which on follow-up histopathologic examination revealed 2 atypical ductal hyperplasias and 1 atypical papilloma. There were 90 (10%) cases diagnosed as suspicious on FNA. On histopathology, 68 were malignant and 22 were benign. Of the 131 (14%) lesions interpreted as benign, there were 18 false-negative cases (14%), which included 17 infiltrating carcinomas and 1 ductal carcinoma in-situ. Twelve (1%) of the cases were inadequate for the study. CONCLUSIONS: The sensitivity, specificity, and positive predictive values were remarkably high and comparable in both groups: group I had 99% sensitivity, 99% positive predictive value, 99% specificity, and 99% negative predictive value; and group II had 98% sensitivity, 97% specificity, 99% positive predictive value, and 86% negative predictive value. The overall rate of false-positive (less than 1%) and false-negative cases (9%) is comparable with published literature. Suspicious cases should be further evaluated, as our study revealed more than 50% to be malignant. The incidence of malignancy in patients presenting with a clinically palpable breast mass with follow-up biopsy was 51% in patients aged 40 years and younger and 74% in patients aged 41 years and older. Fine-needle aspiration is an excellent diagnostic tool in assessing clinically palpable breast masses.     

A new score for the evaluation of palpable breast masses in women under age 40

BACKGROUND: The purpose of this study was to develop a rapid and accurate diagnostic test for palpable breast masses in women under age 40. METHODS: Masses were evaluated utilitzing a modified triple test score (MTTS), which assigned scores of 1 point for benign, 2 points for suspicious, or 3 points for malignant findings from physical examination, ultrasonography, and fine needle aspiration. The MTTS was the sum of the three scores and was correlated with biopsy or follow-up. RESULTS: Among 113 masses, 100 scored 3 points, 8 scored 4 points; all were benign. Three scored 5 points; 1 was malignant. Two scored >or=6 points: both were malignant. CONCLUSIONS: The MTTS has 100% diagnostic accuracy when other than 5 points. Masses scoring or=6 points may proceed to definitive therapy. Masses scoring 5 points (3%) require biopsy. This approach avoids open biopsy in the majority of cases, while capturing all malignancies.     

Usefulness of the triple test score for palpable breast masses; discussion 1012-3

HYPOTHESIS: The triple test score (TTS) is useful and accurate for evaluating palpable breast masses. DESIGN: Diagnostic test study. SETTING: University hospital multidisciplinary breast clinic. PATIENTS: Four hundred seventy-nine women with 484 palpable breast lesions evaluated by TTS from 1991 through July 2000. MAIN OUTCOME MEASURES: Physical examination, mammography, and fine-needle aspiration were each assigned a score of 1, 2, or 3 for benign, suspicious, or malignant results; the TTS is the sum of these scores. The TTS has a minimum score of 3 (concordant benign) and a maximum score of 9 (concordant malignant). The TTS was correlated with subsequent histopathologic analysis or follow-up. INTERVENTIONS: The TTS was prospectively calculated for each mass. Lesions with a TTS greater than or equal to 5 were excised for histologic confirmation, whereas lesions with scores less than or equal to 4 were either excised (n = 60) or followed clinically (n = 255). RESULTS: All lesions with TTS less than or equal to 4 were benign on clinical follow-up, including 8 for which the fine-needle aspiration was the suspicious component. Of the 60 biopsied lesions, 51 were normal breast tissue, 4 showed fibrocystic change, 1 was a papilloma, and 4 were atypical hyperplasia. All lesions with a TTS greater than or equal to 6 (n = 130) were confirmed to be malignant on biopsy. Thus, a TTS less than or equal to 4 has a specificity of 100% and a TTS greater than or equal to 6 has a sensitivity of 100%. Of the 39 lesions (8%) with scores of 5, 19 (49%) were malignant, and 20 (51%) were benign. CONCLUSIONS: The TTS reliably guides evaluation and treatment of palpable breast masses. Masses scoring 3 or 4 are always benign. Masses with scores greater than or equal to 6 are malignant and should be treated accordingly. Confirmatory biopsy is required only for the 8% of the masses that receive a TTS of 5.     

Long-term follow-up results for ultrasound-guided vacuum-assisted removal of benign palpable breast mass

Background

This study was conducted to evaluate the long-term follow-up results from ultrasound-guided vacuum-assisted removal (US-VAR) of palpable benign breast mass and to identify patient characteristics that are correlated with recurrence or residual lesions.

Methods

US-VAR was performed on 95 benign, palpable breast masses that underwent subsequent intervention or at least a 2-year follow-up. During the follow-up period, we reviewed the lesion and patient's characteristics, and then determined whether the presence of recurrence or residual lesions was associated with any of the characteristics.

Results

Six lesions (6.3%) underwent subsequent intervention due to the recurrence of palpability. The remaining 89 lesions underwent imaging follow-up (range, 24 to 60 months; mean, 35 months). Among these lesions, 32.6% (31 of 95 masses) showed sonographically visible, nonpalpable residual lesions. The remaining 61.1% (58 masses) showed no evidence of residual lesion. The initial size of the lesion at VAR was the only characteristic correlated with recurrence (P = .017; odds ratio, 1.238).

Conclusion

Our long-term follow-up results show that US-VAR may be a useful alternative to surgical excision in the management of palpable breast masses.     

Tactile imaging of breast masses: first clinical report

HYPOTHESIS: Tactile imaging can accurately document the palpable extent of breast masses. DESIGN: Prospective nonrandomized interventional trial, comparing mass size estimates from preoperative physical examination, ultrasound, and tactile imaging with postoperative measurements of the resected masses. SETTING: A community ambulatory surgical center and a university hospital tertiary care center. PATIENTS: Twenty-three women undergoing surgical excision of breast masses. All subjects had a single, palpable, dominant mass, 0.5 to 3 cm in diameter. INTERVENTION: Prior to surgery, the size of each mass was estimated from tactile imaging using an array of pressure sensors that is stroked over the mass. Size was also estimated by ultrasound and physical examination. Immediately following resection of the mass, it was bisected, and the palpable extent was measured with a caliper. MAIN OUTCOME MEASURE: Maximum mass diameter estimates from ultrasound, physical examination, and tactile imaging, compared with the resected measurement. RESULTS: Tactile imaging estimates were repeatable (7.5% mean SD for multiple estimates of the same mass) and show good agreement with the resected measurements. Mean absolute error was 13%, and linear regression with zero intercept had a slope of 0.94, r(2) = 0.51. Physical examination and ultrasound estimates had respective mean absolute errors of 46% and 34%, regression slopes of 1.27 and 0.89, and r(2) = 0.28 and 0.37. CONCLUSIONS: Tactile imaging can provide accurate and reproducible estimates of the size of breast masses. This capability can enhance cancer surveillance for patients with benign masses (eg, due to scarring or fibrocystic changes) because previous work suggests that reliable detection of a difference in mass size by physical examination requires a 40% change in diameter. In contrast, this study suggests tactile imaging requires only a 15% change (95% confidence interval).     

A systematic review of decision aids for patients making a decision about treatment for early breast cancer

Several complex treatment decisions may be offered to women with early stage breast cancer, about a range of treatments from different modalities including surgery, radiotherapy, and endocrine and chemotherapy. Decision aids can facilitate shared decision-making and improve decision-related outcomes. We aimed to systematically identify, describe and appraise the literature on treatment decision aids for women with early breast cancer, synthesise the data and identify breast cancer decisions that lack a decision aid.A prospectively developed search strategy was applied to MEDLINE, the Cochrane databases, EMBASE, PsycINFO, Web of Science and abstract databases from major conferences. Data were extracted into a pre-piloted form. Quality and risk of bias were measured using Qualsyst criteria. Results were synthesised into narrative format.Thirty-three eligible articles were identified, evaluating 23 individual treatment decision aids, comprising 13 randomised controlled trial reports, seven non-randomised comparative studies, eight single-arm pre-post studies and five cross-sectional studies. The decisions addressed by these decision aids were: breast conserving surgery versus mastectomy (+/− reconstruction); use of chemotherapy and/or endocrine therapy; radiotherapy; and fertility preservation. Outcome measures were heterogeneous, precluding meta-analysis. Decisional conflict decreased, and knowledge and satisfaction increased, without any change in anxiety or depression, in most studies. No studies were identified that evaluated decision aids for neoadjuvant systemic therapy, or contralateral prophylactic mastectomy.Decision aids are available and improved decision-related outcomes for many breast cancer treatment decisions including surgery, radiotherapy, and endocrine and chemotherapy. Decision aids for neoadjuvant systemic therapy and contralateral prophylactic mastectomy could not be found, and may be warranted.     

Appraisal of early evaluation of blunt chest trauma: development of a standardized scoring system for initial clinical decision making

BACKGROUND: Current techniques for assessment of chest trauma rely on clinical diagnoses or scoring systems. However, there is no generally accepted standard for early judgement of the severity of these injuries, especially in regards to related complications. This drawback may have a significant impact on the management of skeletal injuries, which are frequently associated with chest trauma. However, no convincing conclusions can be determined until standardization of the degrees of chest trauma is achieved. We investigated the role of early clinical and radiologic assessment techniques on outcome in patients with blunt multiple trauma and thoracic injuries and developed a new scoring system for early evaluation of chest trauma. METHODS: A retrospective investigation was performed on the basis of 4,571 blunt polytrauma (Injury Severity Score [ISS] > or = 18) patients admitted to our unit. Inclusion criteria were treatment of thoracic injury that required intensive care therapy, initial Glasgow Coma Scale score greater than 8 points, and no local or systemic infection. Patients with thoracic trauma and multiple associated injuries (ISS > or = 18) were included. In all patients, the association between various parameters of the thoracic injuries and subsequent mortality and morbidity was investigated. RESULTS: A total of 1,495 patients fulfilled the inclusion criteria. Patients' medical records and chest radiographs were reevaluated between May 1, 1998, and June 1, 1999. The association between rib fractures and chest-related death was low (> three ribs unilateral, mortality 17.3%, odds ratio 1.01) unless bilateral involvement was present (> three ribs bilateral, mortality 40.9%, odds ratio 3.43). Injuries to the lung parenchyma, as determined by plain radiography, were associated with chest-related death, especially if the injuries were bilateral or associated with hemopneumothorax (lung contusion unilateral, mortality 25.2%, odds ratio 1.82; lung contusion bilateral + hemopneumothorax, mortality 53.3%, odds ratio 5.1). When plain anteroposterior chest radiographs were used, the diagnostic rate of rib fractures (< or = three ribs) increased slightly, from 77.1% to 97.3% during the first 24 hours of admission. In contrast, pulmonary contusions were often not diagnosed until 24 hours after admission (47.3% at admission, 92.4% at 24 h, p = 0.002). A new composite scoring system (thoracic trauma severity score) was developed that combines several variables: injuries to the chest wall, intrathoracic lesions, injuries involving the pleura, admission PaO2/FIO2 ratio, and patient age. The receiver operating characteristic curve demonstrated an adequate discrimination, as demonstrated by a value of 0.924 for the development set and 0.916 for the validation set. The score was also superior to the ISS (0.881) or the thorax Abbreviated Injury Score (0.693). CONCLUSION: Radiographically determined injuries to the lung parenchyma have a closer association with adverse outcome than chest-wall injuries but are often not diagnosed until 24 hours after injury. Therefore, clinical decision making, such as about the choice of surgery for long bone fractures, may be flawed if this information is used alone. A new thoracic trauma severity score may serve as an additional tool to improve the accuracy of the prediction of thoracic trauma-related complications.     

Magnetic resonance-guided percutaneous cryosurgery of breast carcinoma: technique and early clinical results.

PURPOSE: This phase I study was designed to demonstrate the feasibility, safety, efficacy and predictability of percutaneous cryosurgery, guided under magnetic resonance (MR) imaging, in the treatment of invasive breast carcinoma. PATIENTS AND METHODS: Under the guidance of near-real-time T1-weighted FSE images of a 0.5-T open-configuration MR system, percutaneous cryosurgery was performed in 25 patients with operable invasive breast carcinoma, 4 weeks prior to their scheduled mastectomy. Predictive assessments by interventional radiologists using 4 breast-imaging techniques (mammography, sonography, scintigraphy and MR) were correlated with postmastectomy results of histopathology and assessed for predictability. Local and systemic morbidity were also evaluated during the month of follow-up preceding mastectomy. RESULTS: Percutaneous cryosurgery resulted in no serious complications, either local or systemic. All tumoural tissues included in the cryogenic "iceball" were destroyed, with no viable histologic residues. Ablation was total in 13 of the 25 tumours treated. Combining periprocedural MR images with postprocedure scintimammographic findings enabled a 96% rate for predicting the cryosurgical results. CONCLUSIONS: MR-guided cryosurgery of breast carcinoma is feasible, safe and efficient, with predictable results. Major drawbacks are that the cryolesion (a palpable iceball) persists for a month or more after the procedure, undermining the reliability of the physical examination; and that breast imaging (mammography, ultrasound and MR) presents the same difficulty of interpretation as the physical exam even 1 month after the procedure. More studies are required to refine this treatment method.     

乳腔镜腋窝淋巴结清扫术的初期应用分析

目的：探讨乳腔镜腋窝淋巴结清扫术的疗效,并与传统腋窝淋巴结清扫术的早期结果进行对比。方法：选取2012年1月至2013年4月收治的54例临床Ⅰ、Ⅱ期乳腺癌患者,其中腔镜组12例,传统手术组42例,对比分析两组患者临床资料及手术指标。结果：两组手术均顺利完成。两组患者创面引流液量、引流时间、术后住院时间、淋巴水肿、创面积液及清除淋巴结数量差异无统计学意义（P〉0．05）,腔镜组在术后患侧上肢疼痛、麻木及肩部活动受限率方面优于传统手术组（P〈0．05）,尽管腔镜组手术时间稍长于传统手术组（P=0．001）,但腔镜组术中出血量明显少于传统手术组（P=0．004）。结论：掌握精细的腔镜操作技术,熟悉腋窝结构,术中细致解剖,手术流程正确,早期开展乳腔镜腋窝淋巴结清扫术是可行的,显著改善了腋窝淋巴结清扫手术的预后,达到了生理微创与心理微创的双重目的,与传统手术相比优势明显。     

Incidence of invasive versus non-invasive carcinoma in comparing palpable and non-palpable solid breast lesions

A retrospective study was done of all patients with a suspicious mammographic breast lesion surgically biopsied in our institution within the last 5 years. Incidence of invasive versus non-invasive carcinoma and stage at presentation (according to TNM classification system) of palpable and non-palpable lesions were compared. We found a significant difference of non-invasive carcinoma in non-palpable and palpable cancers: 42.2% versus 4.3% (p < 0.001). Patients with a non-palpable invasive carcinoma presenting at stage I (i.e. pT1 with no axillary metastasis) rated significantly higher compared to those with palpable lesions 51.8% versus 9.4% (p < 0.001). The true positive biopsy rate is 30%. As low as 10% has been considered reasonable. We have a total of 56% carcinomas detected on all biopsies: 30% for non-palpable lesions and 66.8% for palpable lesions. A more aggressive approach towards screening and biopsy of breast lesions might increase early detection of carcinoma and so improve survival.     

Combined fine-needle aspiration,physical examination and mammography in the diagnosis of palpable breast masses: their relation to outcome for women with primary breast cancer

Objective

To examine the combined and individual predictive values of fine-needle aspiration (FNA), physical examination (PE) of the breast and mammography (the “triple test”) in diagnosing breast cancer in relation to the results of open surgical biopsy.

Design

A study of the records of patients who received both FNA and open surgical biopsy for the same palpable breast lump. The results of diagnostic assessment and open surgical biopsy were categorized as positive or negative. Concordance (percentage of tests found to be correct at biopsy), sensitivity, specificity (percentage of patients without breast cancer for whom the diagnostic test was negative) and positive predictive value (percentage of patients with a positive test found to have breast cancer) were determined for the triple test for each diagnostic modality. In addition, prognostic variables (tumour size, node positivity, estrogen and progesterone receptor status) and outcomes were assessed in patients with a diagnosis of breast cancer.

Setting

A university-affiliated general hospital with a special focus on women’s health.

Patients

Of 290 patients who had both FNA and open surgical biopsy, 191 underwent all three diagnostic procedures.

Main Outcome Measures

The diagnostic accuracy of FNA, PE and mammography to permit preoperative definitive therapy or to allow observation without mandating open surgical biopsy.

Results

In 81 patients all three diagnostic modalities were in agreement for a diagnosis of either benign or malignant disease; the concordance for the triple test was 98.8%, specificity was 100% and sensitivity was 95.5%. Nodal status, tumour size and outcome were similar whether or not the triple test was positive, but, interestingly, when the triple-test results were positive, estrogen (p < 0.05) and progesterone (p < 0.03) receptor values were more likely to be negative.

Conclusions

When all three diagnostic modalities were in agreement for a diagnosis of malignant disease, the combination of FNA, PE and mammography had excellent concordance with the results of open surgical biopsy, and in this situation definitive treatment may be carried out. If all three modalities are in agreement for a diagnosis of benign disease, a period of close observation with repetition of FNA may be safely entertained. Lack of concordance of the three diagnostic modalities mandates biopsy. Triple-test positivity does not predict a worse outcome.     

Negative findings on fine-needle aspiration biopsy of solid breast masses: patient management

A series of 245 fine-needle aspirations of solid breast masses has been reviewed. Seven aspirations were reported as unsatisfactory, 178 revealed benign masses, 7 were indeterminate, and 53 revealed malignancy. Fifty-two of 53 masses diagnosed on aspiration as malignant were confirmed by surgical biopsy (98 percent sensitivity). Open biopsy was carried out on 50 of 178 masses reported as negative on needle biopsy and benign masses were revealed in 46 cases (92 percent specificity). The remaining 128 masses with negative findings were observed and follow-up of 101 patients obtained. Cancer did not develop in any of these patients. Careful physical examination and mammography can predict if a breast mass is malignant or benign in 85 to 90 percent of patients. If fine-needle aspiration biopsy is added and performed by physicians and cytopathologists experienced in the technique, additional information is obtained which allows greater diagnostic accuracy and may eliminate many breast biopsies.     

Ultrasound-guided surgery for palpable breast cancer is cost-saving: Results of a cost-benefit analysis

Ultrasound-guided surgery (USS) has recently been proven to result in a significant reduction of tumour-involved surgical margins, for patients with palpable invasive breast cancer. The objective of this economic evaluation alongside a randomised trial was to evaluate the costs and benefits of USS compared to palpation-guided surgery (PGS). The hospital perspective was used. On the cost side of the analysis, resource use related to baseline treatment was taken into account and on the benefit side, resource use related to additional treatments was included. On the cost side, the difference in costs per patient was €193 (95% CI €153–€233) with higher costs in the USS group. On the benefit side, the difference in costs per patient was ?€349 (95% CI ?€591 to ?€103) with higher costs in the PGS group. This resulted in a cost decrease of ?€154 (95% CI ?€388 to €81) in the USS group compared to the PGS group. Intra-operative use of a US system during BCS reduces the rate of tumour-involved margins and thereby the costs of additional treatments.     

Clinical prediction rule for locomotive syndrome in older adults: A decision tree model

BackgroundNo previous studies have proposed a clinical prediction rule that analyzes the factors related to the severity of locomotive syndrome. This study developed and assessed a clinical prediction rule for the severity of locomotive syndrome in older adults.MethodsA total of 186 patients were assessed using the locomotive syndrome risk test. Classification and regression tree methodologies were used to develop the clinical prediction rule. This study developed three prediction models based on the severity of the locomotive syndrome, of which Model 3 assessed the most severe condition. The following potential predictive factors were measured and entered into each model; single-leg standing time, grip strength, preferred and maximum walking time, and timed up and go test.ResultsThe single-leg standing test (≤59.4 or >59.4 s) was the best single discriminator for Model 1. Among those with a single-leg standing time >59.4 s, the next best predictor was grip strength (≤37.8 or >37.8 kg). In Model 2, the single-leg standing test was also the best single discriminator (≤12.6 or >12.6 s). Among those with a single-leg standing time ≤12.6, the next best predictor was TUG (≤7.9 or >7.9 s). Additionally, among those with a single-leg standing time >12.6, the next best predictor was single-leg standing time (≤55.3 or >55.3 s). In Model 3, predictive value in Model 2 was the best single discriminator (0 or 1). Among those with 1, the next best predictor was maximum walking time (≤3.75 or >3.75 s). The area under the receiver operating characteristic curves of Models 1, 2, and 3 were 0.737, 0.763, and 0.704, respectively.ConclusionsA clinical prediction rule was developed to assess the accuracy of the models. These results can be used to screen older adults for suspected locomotive syndrome.