Predicting Nipple–Areolar Involvement Using Preoperative Breast MRI and Primary Tumor Characteristics

Background

Preoperative assessment of the nipple–areolar complex (NAC) is invaluable when considering nipple-sparing mastectomy. Our hypothesis is that breast magnetic resonance imaging (MRI) may predict involvement of the NAC with tumor.

Methods

Clinical, histopathologic, and imaging data were compiled for patients who underwent preoperative breast MRI followed by mastectomy or nipple-sparing mastectomy for malignancy between 2006 and 2009. Blinded rereview of all MRI studies was performed by a breast MRI imager and compared to initial MRI findings. Multivariate analysis identified variables predicting NAC involvement with tumor.

Results

Of 77 breasts, 18 (23 %) had tumor involving or within 1 cm of the NAC. The sensitivity of detecting histopathologically confirmed NAC involvement was 61 % with history and/or physical examination, and 56 % with MRI. Univariate analysis identified the following variables as significant for NAC involvement: large tumors near the nipple on preoperative MRI, node-positive disease, invasive lobular carcinoma, advanced histopathologic T stage, and neoadjuvant chemotherapy. On multivariate analysis, only tumor size >2 cm and distance from tumor edge to the NAC <2 cm on MRI maintained significance. Pearson correlation coefficient for MRI size compared to histopathologic size was 0.53 (P < 0.0001).

Conclusions

MRI is not superior to thorough clinical evaluation for predicting tumor in or near the NAC. However, MRI-measured tumor size and distance from the NAC are correlated with increased risk of NAC involvement. The combination of preoperative history and physical examination, tumor characteristics, and breast MRI can aid the surgeon in predicting a tumor-involved nipple more than any single modality alone.     

Short-Term Outcomes after Combined Colon and Liver Resection for Synchronous Colon Cancer Liver Metastases: A Population Study

Introduction

The timing of surgical resection for stage IV colon cancer with liver metastasis and the safety of simultaneous colon and liver resection remains controversial. The purpose of our study was to evaluate short-term outcomes after combined colon and liver resection (CCLR) versus colon resection (CR) or liver resection alone (LR) using a population database.

Methods

The National Inpatient Sample was used to select patients who had surgery for colon cancer from 2002 to 2006. We evaluated for in-hospital morbidity, mortality, and prolonged length of stay (PLOS). Our analysis was done using design-weighted unadjusted analysis and logistic regression.

Results

We identified 361,096 patients during our study period (CCLR 3,625; CR 322,286; LR 35,185). CCLR was not associated with an increased risk of complications (odds ratio (OR) 1.12; 95 % confidence interval (CI) 0.94–1.33; P = 0.21) or PLOS (OR 1.19; 95 % CI 0.99–1.4; P = 0.06) compared with CR. In-hospital mortality occurred in 3.5 % of patients who underwent CCLR and was not significantly associated with mortality compared with CR alone (OR 1.17; 95 % CI 0.79–1.74; P = 0.43). Liver lobectomy with CR was associated with a PLOS and a trend toward increased morbidity and mortality. Significant predictors of complications, mortality, and PLOS included: age >70 years, male gender, nonprivate health insurance, and Elixhauser score >1.

Conclusions

CCLR with limited liver resection can be performed with similar morbidity and mortality to colectomy alone. For patients who require hepatic lobectomy, however, strong consideration should be given to a staged approach.     

Advanced Imaging Modalities in Early Stage Breast Cancer: Preoperative Use in the United States Medicare Population

Background

Guidelines for breast cancer staging exist, but adherence remains unknown. This study evaluates patterns of imaging in early stage breast cancer usually reserved for advanced disease.

Methods

Surveillance Epidemiology, and End Results data linked to Medicare claims from 1992–2005 were reviewed for stage I/II breast cancer patients. Claims were searched for preoperative performance of computed tomography (CT), positron emission tomography (PET), bone scans, and brain magnetic resonance imaging (MRI) (“advanced imaging”).

Results

There were 67,874 stage I/II breast cancer patients; 18.8 % (n = 12,740) had preoperative advanced imaging. The proportion of patients having CT scans, PET scans, and brain MRI increased from 5.7 % to 12.4 % (P < 0.0001), 0.8 % to 3.4 % (P < 0.0001) and 0.2 % to 1.1 % (P = 0.008), respectively, from 1992 to 2005. Bone scans declined from 20.1 % to 10.7 % (P < 0.0001). “Breast cancer” (174.x) was the only diagnosis code associated with 62.1 % of PET scans, 37.7 % of bone scans, 24.2 % of CT, and 5.1 % of brain MRI. One or more symptoms or metastatic site was suggested for 19.6 % of bone scans, 13.0 % of CT, 13.0 % of PET, and 6.2 % of brain MRI. Factors associated (P < 0.05) with use of all modalities were urban setting, breast MRI and ultrasound. Breast MRI was the strongest predictor (P < 0.0001) of bone scan (odds ratio [OR] 1.63, 95 % confidence interval [CI] 1.44–1.86), Brain MRI (OR 1.74, 95 % CI 1.15–2.63), CT (OR 2.42, 95 % CI 2.12–2.76), and PET (OR 5.71, 95 % CI 4.52–7.22).

Conclusions

Aside from bone scans, performance of advanced imaging is increasing in early stage Medicare breast cancer patients, with limited rationale provided by coded diagnoses. In light of existing guidelines and increasing scrutiny about health care costs, greater reinforcement of current indications is warranted.     

Locomotor Training and Muscle Function After Incomplete Spinal Cord Injury: Case Series

Abstract

Background/Objective: To determine whether 9 weeks of locomotor training (LT) results in changes in muscle strength and alterations in muscle size and activation after chronic incomplete spinal cord injury (SCI). Study Design: Longitudinal prospective case series.

Methods: Five individuals with chronic incomplete SCI completed 9 weeks of LT. Peak isometric torque, torque developed within the initial 200 milliseconds of contraction (Torque₂₀₀), average rate of torque development (ARTD), and voluntary activation deficits were determined using isokinetic dynamometry for the knee-extensor (KE) and plantar-flexor (PF) muscle groups before and after LT. Maximum muscle crosssectional area (CSA) was measured prior to and after LT.

Results: Locomotor training resulted in improved peak torque production in all participants, with the largest increases in the more-involved PF (43.9% ± 20.0%), followed by the more-involved KE (21.1% ± 12.3%). Even larger improvements were realized in Torque200 and ARTD (indices of explosive torque), after LT. In particular, the largest improvements were realized in the Torque200 measures of the PF muscle group. Improvements in torque production were associated with enhanced voluntary activation in both the KE and ankle PF muscles and an increase in the maximal CSA of the ankle PF muscles.

Conclusion: Nine weeks of LT resulted in positive alterations in the KE and PF muscle groups that included an increase in muscle size, improved voluntary activation, and an improved ability to generate both peak and explosive torque about the knee and ankle joints.     

Keratinizing desquamative squamous metaplasia in the kidney of a patient with complex spinal cord injury

Context: Keratinizing desquamative squamous metaplasia (KDSM) of the upper urinary tract was previously thought, but never proven, to represent a premalignant condition. However, no clear guidelines exist regarding the long-term management and follow up once this rare diagnosis has been made.

Findings: Patients with spinal cord injury often develop a range of risk factors for malignancy of the urinary tract. We present the first reported case of KDSM in the kidney of a 44-year-old man with spinal cord injury whose complex urological history includes previous augmentation cystoplasty, recurrent calculi, infections and indwelling catheters.

Clinical relevance: Recent literature has suggested a move away from the previous mainstay of treatment with radical surgery towards nephron-sparing endoscopic and radiological surveillance. This case highlights the complexity of preserving renal function in a spinal cord injured patient with KDSM of the kidney.