Clip migration in stereotactic biopsy

BACKGROUND: Needle localization breast biopsy (NLBB) is the standard for removal of breast lesions after vacuum assisted core biopsy (VACB). Disadvantages include a miss rate of 0% to 22%, a positive margin rate of approximately 50%, and vasovagal reactions (approximately 20%). We hypothesized that clip migration after VACB is clinically significant and may contribute to the positive margin rates seen after NLBB. METHODS: We performed a retrospective review of postbiopsy films in patients who had undergone VACB with stereotactic clip placement for abnormal mammograms. We measured the distance between the clip and the biopsy site in standard two view mammograms. The location of the biopsy air pocket was confirmed using the prebiopsy calcification site. The Pythagorean Theorem was used to calculate the distance the clip moved within the breast. Pathology reports on NLBB or intraoperative hematoma-directed ultrasound-guided breast biopsy (HUG, which localizes by US the VACB site) were reviewed to assess margin status. RESULTS: In all, 165 postbiopsy mammograms on patients who had VACB with clip placement were reviewed. In 93 evaluable cases, the mean distance the clip moved was 13.5 mm +/- 1.6 mm, SEM (95% CI = 10.3 mm to 16.7 mm). Range of migration was 0 to 78.3 mm. The median was 9.5 mm. In 21.5% of patients the clip was more than 20 mm from the targeted site. Migration of the clip did not change with the age of the patient, the size of the breast or location within the breast. In the subgroup of patients with cancer, margin positivity (including those with close margins) after NLBB was 60% versus 0% in the HUG group. CONCLUSIONS: Significant clip migration after VACB may contribute to the high positive margin status of standard NLBBs. Surgeons cannot rely on needle localization of the clip alone and must be cognizant of potential clip migration. HUG as an alternative biopsy technique after VACB eliminates operator dependency on clip location and may have superior results in margin status.     

Correlation of magnetic resonance imaging and pathologic size of infiltrating lobular carcinoma of the breast

BACKGROUND: Determining the extent of infiltrating lobular carcinoma (ILCA) in the breast is difficult. This study was designed to determine if the size of ILCA on magnetic resonance imaging (MRI) correlated with final pathology. METHODS: Retrospective study of patients between 1998 and 2004, who were evaluated for extent of ILCA prior to definitive treatment, was conducted. Demographic data and radiology and pathology results were obtained. Spearman correlation coefficient was used. RESULTS: Twenty-nine patients (median age 62 years) had MRI of breast. Fourteen patients (48%) had contralateral MRIs; 13 (45%) normal; 1 (8%) prompted core biopsy; 6 of 13 patients underwent contralateral mastectomies, which were benign. The distribution of tumor size was: T1 = 15 (52%); T2 = 7 (24%); T3 = 5 (17%); T4 = 2 (7%). Spearman correlation coefficient between tumor size on ultrasound and MRI with pathology was .19 (P = .5) and .88 (P < .001), respectively. CONCLUSION: MRI provided superior correlation between tumor size and pathology.     

Inherited disorders of the IL-12-IFN-γ axis in patients with disseminated BCG infection

Disseminated BCG infection is a rare complication of vaccination that occurs in patients with impaired immunity. In recent years, a series of inherited disorders of the IL-12-IFN- axis have been described that predispose affected individuals to disseminated disease caused by BCG, environmental Mycobacteria, and non-typhoidal Salmonella. The routine immunological work-up of these patients is normal and the diagnosis requires specific investigation of the IL-12-IFN- circuit. We report here the first two such patients originating from and living in Iran. The first child is two years old and suffers from complete IFN- receptor 2 deficiency and disseminated BCG infection. He is currently in clinical remission thanks to prolonged multiple antibiotic therapy. The other, a 28-year-old adult, suffers from IL-12p40 deficiency and presented with disseminated BCG infection followed by recurrent episodes of systemic salmonellosis. He is now doing well. A third patient of Iranian descent, living in North America, was reported elsewhere to suffer from IL-12R1 deficiency. These three patients thus indicate that various inherited defects of the IL-12-IFN- circuit can be found in Iranian people. In conclusion we recommend to consider the disorders of the IL-12-IFN- circuit in all patients with severe BCG infection, disseminated environmental mycobacterial disease, or systemic non-typhoidal salmonellosis, regardless of their ethnic origin and country of residence.     

Regulation of phosphate acquisition in<Emphasis Type="Italic"> Saccharomyces cerevisiae</Emphasis>

Membrane transport systems active in cellular inorganic phosphate (P(i)) acquisition play a key role in maintaining cellular P(i) homeostasis, independent of whether the cell is a unicellular microorganism or is contained in the tissue of a higher eukaryotic organism. Since unicellular eukaryotes such as yeast interact directly with the nutritious environment, regulation of P(i) transport is maintained solely by transduction of nutrient signals across the plasma membrane. The individual yeast cell thus recognizes nutrients that can act as both signals and sustenance. The present review provides an overview of P(i) acquisition via the plasma membrane P(i) transporters of Saccharomyces cerevisiae and the regulation of internal P(i) stores under the prevailing P(i) status.     

Subareolar sentinel node biopsy for multiple breast cancers

BACKGROUND: Sentinel lymph node biopsy (SLNB) is deemed suitable only for unifocal breast cancers since multiple foci of cancers may drain to different nodes. We hypothesized that subareolar injection (SI) could identify the sentinel lymph nodes (SLN) accurately in patients with multiple cancers (MC) in the breast. METHODS: We prospectively employed SI of lymphazurin or technetium sulfur colloid, or both, for the identification of SLN in patients with MC in the breast. All patients underwent axillary dissection to compute the accuracy of SLNB. RESULTS: Forty patients presented with MC in the same breast between January 1996 and July 2002. Fifty-two percent (21 of 40) of patients had involvement of more than 1 quadrant; 18% (7 of 40) had more than 1 histologic type of cancers. SLNs were successfully identified in 100% of patients. Axillary disease was present in 63% (25 of 40) of patients. Sensitivity of SLNB was 100% and false negative rate was 0%. The SLN was the only node involved in 45% (18 of 40) of patients. CONCLUSIONS: SLNB using the SI technique may be an alternative to complete axillary dissection in patients with multiple breast cancers.     

A Case of Bruton’s Disease with Normal Immunoglobulin G Level

X-linked agamaglobulinemia (XLA) or Bruton’s disease is a genetic disease resulting from a mutation in the Bruton’s tyrosine kinase (Btk) gene. This mutation leads to B cell arrest during differentiation (1). This disease was first described by Ogden Bruton in 1952 (2). Approximately 85% of the affected subjects are male (3). This disorder is inherited as an X-linked recessive trait. Carrier females have no symptoms but have a 50% chance for transmission of the disorder to each of their sons. It is now possible to determine if the fetus of a carrier mother has XLA (4). The prevalence of the disease ranges from 1 in 10,000 to 1 in 50,000 (1). Half of the affected individuals are diagnosed during the first year of life and more than 90% of them are diagnosed up to fifth year (3). Diagnosis of the disease is suggested by lymphoid hypoplasia (minimal or no tonsillar tissue and no palpable lymph node) and total immunoglobulins level less than 100 mg/dl. Isohemagglutinins and antibodies to antigens given during routine immunization are abnormally low in this disorder as well. Flow cytometry is an important test for this diagnosis (5). Patients with XLA are protected for the first few months of life by maternal antibody and therefore do not typically present clinically with infection until after 6 months of age, when the maternally-derived antibody level decreases significantly. After diagnosis, treatment includes replacement of intravenous immunoglobulin (IVIG), which significantly reduces the risk of infection (6). The most common organisms affecting these patients are Haemophilus influenza, Streptococcus pneumonia and Staphylococcus aureus (3). Based on our knowledge, 4 cases of XLA patients with normal IgG levels (above 500 mg/dl) and 5 cases of XLA subjects with near normal IgG levels (400-500 mg/dl) have been reported in the world (7). Here, we report a case of Bruton’s disease as the fifth case with normal serum IgG level.     

Circular- vs. Linear-Stapled Gastrojejunostomy in Laparoscopic Roux-En-Y Gastric Bypass

Background  

Different surgical techniques have been developed for the gastrojejunostomy (GJS) in laparoscopic Roux-en-Y gastric bypass (LRYGBP) with the anastomosis performed in a circular-stapled, linear-stapled, or totally hand-sewn way. No technique seems superior to the other as no consistent data on weight loss or complication rates were described.     

Validity and Reliability Determination of Denver Developmental Screening Test-II in 0-6 Year–Olds in Tehran

Objective

This research was designed to identify the validity and reliability of the Persian version of Denver Developmental Screening Test II (DDST-II) in Iranian children, in order to provide an appropriate developmental screening tool for Iranian child health workers.

Methods

At first a precise translation of test was done by three specialists in English literature and then it was revised by three pediatricians familiar with developmental domains. Then, DDST-II was performed on 221 children ranging from 0 to 6 years, in four Child Health Clinics, in north, south, east and west regions of Tehran city. In order to determine the agreement coefficient, these children were also evaluated by ASQ test. Because ASQ is designed to use for 4–60 month- old children, children who were out of this rang were evaluated by developmental pediatricians. Available sampling was used. Obtained data was analyzed by SPSS software.

Findings

Developmental disorders were observed in 34% of children who were examined by DDST-II, and in 12% of children who were examined by ASQ test. The estimated consistency coefficient between DDST-II and ASQ was 0.21, which is weak, and between DDST-II and the physicians’ examination was 0.44. The content validity of DDST-II was verified by reviewing books and journals, and by specialists’ opinions. All of the questions in DDST-II had appropriate content validity, and there was no need to change them. Test-retest and Inter-rater methods were used in order to determine reliability of the test, by Cronbach''s α and Kauder-Richardson coefficients. Kauder-Richardson coefficient for different developmental domains was between 61% and 74%, which is good. Cronbach''s α coefficient and Kappa measure of agreement for test-retest were 92% and 87% and for Inter-rater 90% and 76%, respectively.

Conclusion

This research showed that Persian version of DDST-II has a good validity and reliability, and can be used as a screening tool for developmental screening of children in Tehran city.