Confirmation of the posterior gastric artery using multi-detector row computed tomography

Background The blood supply of the stomach is well characterized. Although the posterior gastric artery (PGA) is the second most important artery supplying the upper third of the stomach, the main features and clinical importance of the PGA have not been established. The aim of this study was to use multi-detector row computed tomography (MD-CT) to investigate the features of the PGA with respect to its incidence, location and size, and to correlate the findings with clinical practice. Methods In August 2004, 50 preoperative patients (33 men and 17 women) were evaluated prospectively by MD-CT. Informed consent for the present study was accepted at Kochi Medical School. The length of the PGA, from the root of the splenic artery, and the internal diameter of the PGA were examined. Correlations between body mass index (BMI) and the observed features of the PGA were investigated. Results The PGA was recognized in all patients. In 49 (98%) patients, the PGA branched from the splenic artery. In 1 (2%) patient, the PGA originated from the root of the celiac trunk. The PGA was discernible for a length of 4.2–14.3 cm (mean, 9.1 cm) from the root of the splenic artery, and the internal diameter of the PGA was 0.5–2.1 mm (mean, 1.0 mm). BMI did not correlate with PGA length or internal diameter. Conclusion Our current study suggested that the anatomical and clinical features of the PGA can be shown by clinical methods, and that these features are useful in planning surgical treatment.     

Multidetector row computed tomography for diagnosing intraductal extension of breast carcinoma

OBJECTIVES: Several reports supported the association of higher ipsilateral breast tumor recurrence rates with positive or intermediate margins compared with negative pathologic margins. Precise evaluation of intraductal component and adequate surgical margin are important factors affecting the tumor recurrence after breast conserving surgery. Numerous studies have reported the utility of magnetic resonance imaging for diagnosing developing intraductal extension of breast cancer, but few have investigated multidetector-row computed tomography (MD-CT). The present study evaluated the clinical utility of MD-CT for detecting intraductal extension of breast carcinoma, and analyzed clinical parameters affecting the detection of intraductal extension under MD-CT. METHODS: Subjects comprised 44 patients grouped into three categories according to degree of intraductal extension of the main tumor under MD-CT (Intraductal spread grade 1 approximately 3: IDS 1 approximately 3). Tumors were also categorized histopathologically (p-IDS 0 approximately 3), and CT-pathological correlations were examined retrospectively. Clinical parameters were evaluated to determine the affect on detection of intraductal components. RESULTS: MD-CT detected 44 breast lesions (100%). Sensitivity for detection of intraductal component was 81.2%, specificity was 67.8%, and accuracy was 72.7%. Regarding extent of intraductal components, significant correlations were found between histopathological and MD-CT findings. A strong correlation was found in postmenopausal women between T2 tumor and high histological grade. CONCLUSIONS: MD-CT findings of intraductal extension from breast carcinoma correlate with histological degree of intraductal extension, and MD-CT may be useful for preoperative assessment of breast-conserving surgery, particularly for postmenopausal women with histological high nuclear grade and T2 tumor.     

Mode of detection and secular time for ductal carcinoma in situ

In this article, the published literature on the role of screening mammography in the detection of ductal carcinoma in situ (DCIS) is reviewed. This includes what is known about the detection of DCIS in different demographic groups. Finally the author describes her views on how the field might be advanced.     

乳腺导管原位癌与导管原位癌伴微浸润的临床比较

目的 分析乳腺导管原位癌(DCIS)及原位癌伴微浸润(DCIS-MI)患者治疗模式变化、临床特征、治疗结果及预后因素。方法 回顾性分析中国医学科学院肿瘤医院1999-2013年收治的866例女性患者资料。DCIS患者631例,DCIS-MI患者235例。用Kaplan-Meier法计算局控(LC)、无瘤生存(DFS)、总生存(OS)率,并Logrank检验和单因素预后分析。结果 DCIS及DCIS-MI两组之间OS、LC及DFS相近(P>0.05)。单因素分析显示Her-2阳性为OS及DFS影响因素,保乳未放疗患者LC和DFS劣于全乳切除术患者。结论 导管原位癌和导管原位癌伴微浸润总体生存结果类似,Her-2阳性为OS及DFS预后不良因素,保乳未放疗患者的LC和DFS劣于全乳切除术。     

乳腺导管原位癌与导管原位癌伴微浸润的临床比较

目的 分析乳腺导管原位癌(DCIS)及原位癌伴微浸润(DCIS-MI)患者治疗模式变化、临床特征、治疗结果及预后因素。方法 回顾性分析中国医学科学院肿瘤医院1999-2013年收治的866例女性患者资料。DCIS患者631例,DCIS-MI患者235例。用Kaplan-Meier法计算局控(LC)、无瘤生存(DFS)、总生存(OS)率,并Logrank检验和单因素预后分析。结果 DCIS及DCIS-MI两组之间OS、LC及DFS相近(P>0.05)。单因素分析显示Her-2阳性为OS及DFS影响因素,保乳未放疗患者LC和DFS劣于全乳切除术患者。结论 导管原位癌和导管原位癌伴微浸润总体生存结果类似,Her-2阳性为OS及DFS预后不良因素,保乳未放疗患者的LC和DFS劣于全乳切除术。     

Multidetector row helical computed tomography for invasive ductal carcinoma of the breast: correlation between radiological findings and the corresponding biological characteristics of patients

The aim of this study is to evaluate the correlation between multidetector row helical computed tomography (MDCT) findings and the histopathological characteristics of patients with invasive ductal carcinoma. We retrospectively reviewed MDCT findings and the corresponding histopathological features of 442 women with invasive ductal carcinoma. We received informed consent from the patients and the protocol was approved by the Ethics Committee at Tohoku University. The median age was 53 years (26-89 years). We examined the MDCT findings based on mass shape classified into well, moderate, poorly and scattered demarcated shapes, the enhancement pattern classified into homogenous, heterogeneous, rim and poor, and mass density classified into high, intermediate or low. We subsequently compared these radiological findings with the histological characteristics and clinical outcome. Poorly demarcated types were higher in ER+/HER2- (P = 0.008), while the well-demarcated type was higher in ER-/HER2- and ER-/HER2+ (P < 0.001 and P = 0.010). Rim pattern was higher in ER-/HER2- (P < 0.001). Intermediate or low density was higher in ER-/HER2- (P < 0.001, respectively). Further analysis based on histological grade, mitotic counts and lymphovascular invasion demonstrated that the well-demarcated shape was higher in grade 2 and 3 (P = 0.006 and P < 0.001, respectively), and rim pattern was observed in grade 3 (P < 0.001). Regarding mitotic counts, poorly and scattered demarcated shapes were observed in score 1 (P = 0.008 and P = 0.014), while well-demarcated shape and rim enhancement were observed in score 3 (P < 0.001, respectively). Lymphovascular invasion correlated with a moderate demarcated shape (P = 0.029). Regarding recurrence rates, there were statistically significant differences between well and moderate, poorly or scattered demarcated shapes (P = 0.007, 0.028 and 0.035, respectively). These proposed MDCT diagnostic criteria based on biological characteristics contribute to more accurately predicting the biological behavior of breast cancer patients.     

Accuracy of mammography in predicting histological extent of ductal carcinoma in situ (DCIS)

Accuracy of mammography in predicting pathological extent of ductal carcinoma in situ (DCIS). BACKGROUND AND AIMS: Mammographic extent is the main determinant for offering wide local excision (WLE) for DCIS. It is recognized that this is not always accurate. Patients who prove to have larger lesions than predicted require further surgery. The aim of this study was to define the degree of variance between mammographic (MMG) and pathological (path) measurements of DCIS and to analyse the factors predicting a significant discrepancy. METHODS: The pathological and mammographic data for 174 cases of DCIS were reviewed. RESULTS: The mammographic size was bigger than the histological size in 97 (55.7%) and there was >10mm difference in 18 (10.3%) cases. The histological size was bigger than the mammographic size in 69 (39.7%) cases and >10mm difference was found in 30 (17.2%) cases. There was a significant relationship between larger MMG size, MMG size measured in two dimensions (MMG bi-dimensional product) and MMG-path size discrepancy (p<0.01). In addition, the larger the size discrepancy, the greater the chance of requiring more than one therapeutic procedure (p<0.01). There was no significant correlation between age, histological grade, mammographic density and shortest distance from nipple with degree of mammographic-pathological size discrepancy.     

Epidemiology of ductal carcinoma in situ

Ductal carcinoma in situ (DCIS) is a relatively common diagnosis among women undergoing screening mammography. The greatest increases in DCIS incidence have been in non-comedo subtypes of DCIS that are not associated with subsequent invasive cancer. After a 500% increase in DCIS from 1983 to 2003, the incidence of DCIS declined in women aged 50 years and older, whereas the incidence in women younger than age 50 continues to increase. Having undergone mammography is one of the strongest and most prevalent risk factors associated with a diagnosis of DCIS. Other risk factors for DCIS are similar to that for invasive cancer including increasing age, family history of breast cancer, high mammographic breast density, and postmenopausal hormone therapy use. Treatment for DCIS is relatively aggressive with the use of both surgery and radiation therapy and most recently adjuvant hormonal therapy. Breast cancer mortality is low and similar with all types of treatment. New information regarding incidence of DCIS and subtypes of DCIS according to frequency of mammography and risk factors could lead to insights into the biology of DCIS.     

Tamoxifen in ductal carcinoma in situ

The widespread adoption of screening mammography has resulted in an increased incidence of ductal carcinoma in situ (DCIS), which now accounts for 20% to 30% of new breast cancer diagnoses. Despite treatment with combined lumpectomy and radiation therapy, up to 15% of women will experience an ipsilateral breast recurrence, with 50% of these recurrences containing invasive disease. There is also a 6% incidence of contralateral breast cancers in women treated for DCIS. The recognition that adjuvant tamoxifen reduces local, regional, and distant disease in women diagnosed with invasive breast cancer led to the National Surgical Adjuvant Breast and Bowel Project (NSABP) B-24 study, which randomized more than 1,800 women undergoing breast-sparing surgery and radiation for DCIS to adjuvant tamoxifen versus placebo for 5 years. At 7 years of follow-up, there was a statistically significant 27% reduction in the annual incidence rate of all breast cancer-related events for those women receiving tamoxifen, including a 48% reduction in invasive breast cancer. The benefit attributable to tamoxifen was confined to those tumors that were estrogen receptor (ER)-positive. However, adverse events, including endometrial cancer, thromboembolic events, and cataracts, are more common in older women. Tamoxifen should be considered as an adjunct to treatment for women undergoing breast-conserving surgery for ER-positive DCIS.     

乳腺导管增生及原位癌的形态学定量分析

目的对比分析乳腺导管增生及导管原位癌的形态学定量参数。方法细胞涂片经常规巴氏染色,组织学切片经HE染色; 带有数码摄像机的彩色病理图像采集系统及半自动图像定量分析系统; 定量指标包括：细胞核直径、周长、面积、圆形度及核质比例; 结果乳腺导管增生及导管原位癌所分析的各项参数均有差异,具有统计学意义（P〈0.001,P〈0.05）; 乳腺导管增生及导管原位癌各组内部,细胞涂片和组织切片对比所分析的各项参数均无差异。结论细胞核直径、周长、面积、核质比及圆形度可作为形态学特征性定量参数,区分乳腺导管增生及导管原位癌。     

Radiotherapy for ductal carcinoma in situ

AimsThe introduction of breast screening mammography has led to an increase in the diagnosis of ductal carcinoma in situ (DCIS). Mastectomy gives high rates of local control. However, most cases are suitable for local excision. The aim of this article is to review the role of radiotherapy in the treatment of DCIS after breast conserving surgery.Material and methodsA review of the literature relating to radiotherapy and DCISResultsThe published trials show that adjuvant radiotherapy after breast conserving surgery halves the ipsilateral recurrence rates of DCIS and invasive cancer. No subgroups have been reliably identified that do not benefit from adjuvant radiotherapy. Risk factors for recurrence are discussed.DiscussionAll patients with DCIS have potential benefit to gain from adjuvant radiotherapy. However, radiotherapy also has adverse effects and represents over-treatment from many women. Support should be given to current trials which are assessing endocrine treatment of DCIS, and whether radiotherapy can reasonably be omitted in lower risk disease.     

乳腺导管原位癌和乳腺导管原位癌伴微浸润的分子分型差异性研究

背景与目的：乳腺导管原位癌伴微浸润（ductal carcinoma in situ with microinvasion,DCISMI）是乳腺导管原位癌（ductal carcinoma in situ,DCIS）发展到浸润性乳腺癌（invasive breast cancer,IDC）的中间阶段,该研究旨在分析乳腺DCIS和DCIS-MI这两类早期乳腺癌不同临床病理学特征和各个分子分型间的差异。方法：本回顾性研究纳入了317例DCIS患者,其中227例（71.6%）为纯DCIS患者,90例（28.4%）为DCIS-MI患者。所有患者根据其DCIS成分而非微浸润成分的免疫组织化学检查结果分成腔面A型［雌激素受体（estrogen receptor,ER）和（或）孕激素受体（progesterone receptor,PR）阳性,人类表皮生长因子受体2（human epidermal growth factor receptor 2,HER-2）阴性］、腔面B型［ER和（或）PR阳性,HER-2阳性］、HER-2过表达型（ER和PR阴性,HER-2阳性）和基底样型（ER和PR阴性,HER-2阴性）。结果：DCIS-MI患者的肿瘤大小倾向更大（P=0.059）,病理核分级显著更高（P=0.002）。和DCIS患者相比,乳腺DCIS-MI患者中腔面A型比例较低而基底样型比例较高（P=0.001）。结论：乳腺DCIS和DCIS-MI间分子分型分布不同,临床病理特征迥异,提示DCIS-MI是DCIS发展的新阶段,有了“质”的改变,本结论有待后续更大样本量的研究进行验证。     

Pure ductal carcinoma in situ and in situ component of ductal invasive carcinoma of the breast. A preliminary morphometric study

Nuclear pleomorphism is a fundamental feature in evaluating the aggressiveness of ductal carcinoma in situ (DCIS) of the breast. In this study, pure DCIS and the in situ component (IS-comp) of invasive duct carcinoma (IDC) are compared in order to verify if these are two different entities or the same process observed at different times during its evolution. Five cases of pure DCIS and nine of IDC with extensive in situ component were selected. They were moderately and poorly differentiated. 30 nuclei for each DCIS, and 30 nuclei for both the in situ and invasive component of each IDC were studied; thus, a total of 720 nuclei were submitted to the SAM (Shape Analytical Morphometry) analysis, which enables a numerical expression not only of dimensions (area, perimeter, diameter) but also of nuclear contour irregularities and nuclear shape distortions. Univariate statistical comparisons were carried out between the nuclei of: (1) DCIS and in situ component of invasive duct carcinoma, (2) DCIS and the invasive component of infiltrating carcinoma and (3) between the in situ and invasive component of infiltrating carcinoma. Multivariate analysis was utilized to compare nuclei of DCIS with the in situ component of IDC. The in situ features of each tumor were also evaluated with the mitotic index (MI). Nuclei of pure DCIS resulted significantly larger (p < 0.001) and with a more regular shape (p < 0.001) than those of the in situ component of IDC. No differences were observed between the nuclei of the in situ and the invasive component of infiltrating carcinomas. Multivariate statistical analysis discriminated 77% of nuclei of in situ proliferation when both G2 and G3 tumors were considered, and 80% when only G3 tumors were considered. In conclusions morphological differences exist between pure DCIS and the in situ component of IDC, which may be an expression of their biological behavior; moreover, these morphological differences seem to have a better discriminating power within the same histological grade.     

Genomic differences between pure ductal carcinoma in situ and synchronous ductal carcinoma in situ with invasive breast cancer

Although ductal carcinoma in situ (DCIS) precedes invasive ductal carcinoma (IDC), the related genomic alterations remain unknown. To identify the genomic landscape of DCIS and better understand the mechanisms behind progression to IDC, we performed whole-exome sequencing and copy number profiling for six cases of pure DCIS and five pairs of synchronous DCIS and IDC. Pure DCIS harbored well-known mutations (e.g., TP53, PIK3CA and AKT1), copy number alterations (CNAs) and chromothripses, but had significantly fewer driver genes and co-occurrence of mutation/CNAs than synchronous DCIS-IDC. We found neither recurrent nor significantly mutated genes with synchronous DCIS-IDC compared to pure DCIS, indicating that there may not be a single determinant for pure DCIS progression to IDC. Of note, synchronous DCIS genomes were closer to IDC than pure DCIS. Among the clinicopathologic parameters, progesterone receptor (PR)-negative status was associated with increased mutations, CNAs, co-occurrence of mutations/CNAs and driver mutations. Our results indicate that although pure DCIS has already acquired some drivers, more changes are needed to progress to IDC. In addition, IDC-associated DCIS is more aggressive than pure DCIS at genomic level and should really be considered IDC. Finally, the data suggest that PR-negativity could be used to predict aggressive breast cancer genotypes.     

Mammographic size of ductal carcinoma in situ does not predict the presence of an invasive focus

A proportion of women thought to have ductal carcinoma in situ (DCIS) on mammography and a core biopsy showing DCIS only, in fact have an invasive focus on surgical excision. This study aims to identify the percentage of such patients who harbour an invasive focus and to ascertain features which can predict the presence of invasion. 140 patients had a core biopsy diagnosis of DCIS without invasion. All patients had their core biopsy graded and mammography was performed on 128 patients. Mammographic findings were classified by a radiologist blinded to the surgical findings into normal, mass/distortion or microcalcification. The extent of the microcalcifications was measured. The core biopsies were graded into high, intermediate or low grade DCIS groups. The core biopsy and radiological findings were compared to see if they could predict the presence of invasive disease at surgical excision. Of the 140 patients, 61 (44%) had an invasive focus. 8 (47%) of 17 patients with normal mammography had an invasive focus. 4 (36%) of 11 patients with a mammographic mass had evidence of invasion. Of the 100 patients with mammographic microcalcifications 48 (48%) had an invasive focus. In the 10 patients with low grade DCIS on core biopsy, 3 (30%) had an invasive focus. Comparative studies in patients with intermediate and high grade DCIS, were 7 of 18 (39%) and 51 of 112 (46%), respectively. Thus, 44% of women thought to have DCIS only on preoperative investigation had an invasive focus. In contrast to previous expressed opinions, neither mammography or grade were predictive. We have not identified any factor capable of predicting a higher likelihood of an invasive focus.     

乳腺浸润性导管癌与导管内癌的超声造影血流动力学对比研究

目的评价超声造影在浸润性导管癌(infiltrating ductal carcinoma,IDC)和导管内癌(ductal carcinoma in situ,DCIS)中的鉴别诊断价值。方法回顾性分析2009-05-26-2013-08-21江苏大学附属医院普外科及乳腺外科手术切除,并经病理学确诊的43例乳腺IDC和30例DCIS的彩色多普勒血流特征及超声造影血流动力学特征,找出差异有统计学意义的参数,并利用Logistic回归筛选出区别2种类型乳腺癌相关性较高的参数,由此建立Logistic回归方程。结果分析2种癌各项参数在造影前后差值的平均变化值后发现,收缩期峰值血流速度的差值(Δvmax;t=3.383 4,P=0.009)和搏动指数的差值(ΔPI;t=6.745 4,P=0.032)差异有统计学意义。在造影参数中,峰值强度(t=8.246 3,P=0.018)和强度差值(t=9.637 5,P=0.025)差异有统计学意义。Logistic回归分析结果显示,最后进入方程的3个参数肿块强化方式(P=0.011)、Δvmax(P=0.015)和峰值强度(P=0.025)与乳腺IDC有较高相关性。结论超声造影对于乳腺肿瘤的血流动力学分析对于鉴别IDC及DCIS有重要价值。     

Biology and treatment of ductal carcinoma in situ

Ductal carcinoma in situ (DCIS) is responsible for 25% of screen-detected breast cancers. Various prognostic classifications are in use, including the Van Nuys Prognostic Index and the European Organisation for Research and Treatment of Cancer grading system (well, intermediate or poorly differentiated) based on cytonuclear pattern. This has been modified in screening programs to low, intermediate and high grade. In comparison with normal epithelium, DCIS has a tenfold increase in growth and 15-fold increase in apoptosis. Patients with extensive or multifocal DCIS need mastectomy and sentinel node biopsy, together with reconstruction, if requested. Microinvasion associated with DCIS is an indication for sentinel node biopsy. Randomized trials have confirmed the value of breast irradiation after wide excision, in terms of DCIS relapse and progression to invasive disease. Patients with estrogen receptor-positive DCIS benefit from adjuvant tamoxifen after breast-conserving surgery.     

Diagnosis and management of ductal carcinoma in situ

Opinion statement Ductal carcinoma in situ (DCIS) is a preinvasive form of breast cancer that has increased in incidence over the past 25 years, primarily as a result of mammographically detected microcalcifications. Inadequately treated DCIS carries a risk for evolving into the malignant phenotype; however, the magnitude and timeline for this risk are poorly defined. Treatment options include lumpectomy with or without breast irradiation and mastectomy. The overall survival rate is 96% to 98% with any of these strategies, but the risk of local recurrence (LR) is highest after lumpectomy alone. Breast irradiation can reduce this risk from levels in excess of 40% to 10% over a 10-year follow-up period. Approximately 50% of all LR from DCIS are invasive lesions. Therefore, the occurrence of a LR after breast-conserving therapy is a potentially greater threat to the patient with DCIS compared to the patient diagnosed with invasive cancer. In patients diagnosed with invasive cancer, the risk of micrometastatic disease is present from the time of initial diagnosis. In patients with DCIS, the expectation is that a potentially 100% cure rate should be achieved with local therapy alone. Although most DCIS cases complicated by LR will be successfully salvaged with prolonged overall survival, it is critically important to take every precaution that will minimize the risk of locally recurrent disease. Therefore, radiation therapy as an adjunct to lumpectomy is essential. A subset of patients with DCIS with low-volume low-grade disease who can be safely treated by lumpectomy alone has not yet been clearly defined. Prospective studies designed to identify this category are ongoing. Inadequate margin control is the most consistent risk factor for LR that has been reported thus far, but there is no universally accepted definition for what constitutes an optimal negative margin distance. Young age at diagnosis, high nuclear grade, and comedonecrosis are other factors that have been implicated as increasing the risk for LR. Tamoxifen can further decrease the rate of new in-breast events on the affected side and in the contralateral breast. Ongoing trials will also define the role of aromatase inhibitors as a risk-reducing strategy.     

乳腺导管原位癌伴微浸润与浸润癌患者的临床特征对比分析

目的:分析乳腺导管原位癌伴微浸润（ductal carcinoma in situ with microinvasion,DCIS-MI）与乳腺浸润性导管癌（invasive ductal carcinoma,IDC）患者的临床特征、治疗方式等。方法:回顾性分析55例乳腺导管原位癌伴微浸润及508例乳腺浸润性导管癌患者的临床资料,包括两组患者的年龄、月经情况、雌激素受体（estrogen receptor,ER）、孕激素受体（progestrone receptor,PR）、人表皮生长因子受体（human epidermal growth factor,HER-2）、肿瘤细胞增殖活性标志物（Ki67）的表达情况、分子分型、治疗方式及预后。结果:DCIS-MI组和IDC组患者在年龄上的差异不具有统计学意义（P＞0.05）,DCIS-MI组在已绝经及淋巴结转移阳性比例均低于IDC组（P＜0.05）;DCIS-MI组Ki67阳性表达率显著低于IDC组（P＜0.05）,ER、PR及HER-2阳性表达率与IDC组比较差异无统计学意义（P＞0.05）。DCIS-MI组Luminal A型比例高于IDC组,而Luminal B(HER-2-)型比例低于IDC组,且差异均具有统计学意义（P＜0.05）。其余分子分型差异不具有统计学意义。DCIS-MI组患者单纯乳房切除术比例（10.9%）显著高于IDC组（0.8%）（P＜0.05）。DCIS-MI患者主要采用的手术方式为乳腺癌改良根治术和全乳切除+腋窝淋巴结清扫,其比例分别为60.0%、16.4%,与IDC组患者采用相同手术方式的比例（67.3%、19.9%）无显著差异。DCIS-MI组化疗比例、放疗比例均低于IDC组（P＜0.05）,而两组患者在内分泌治疗、靶向治疗及中药治疗方面差异不具有统计学意义（P＞0.05）。DCIS-MI组和IDC组患者的5年无病生存（disease-free survival,DFS）率分别为97.0%和81.0%,差异具有统计学意义（Log-rank,χ2=4.962,P=0.026）。结论:与IDC患者相比,DCIS-MI组患者绝经前状态比例高、淋巴结转移阳性率及Ki67阳性率更低,Luminal A型比例更高而Luminal B(HER-2-)型比例更低;DCIS-MI组患者行单纯乳房切除术比例更高,放疗及化疗比例更低,其预后更好。