What is the yield of breast MRI in the assessment of palpable breast findings?

AIM: To examine the contribution of magnetic resonance imaging (MRI) to characterise palpable breast masses after conventional imaging was found to be non-contributory. MATERIALS AND METHODS: The breast MRI database was reviewed for studies performed between January 2010 and December 2015 for the clinical indication of palpable breast finding with negative standard imaging. Medical files were reviewed for demographic data, clinical information, radiology, and pathology reports. Benign versus malignant outcomes were determined at histopathology or a minimum of 12 month follow-up. RESULTS: Investigation of palpable breast finding was the clinical indication for 167 of 7,782 (2%) examinations. Thirty-two (19%) women in the study had positive MRI findings. Most (20, 63%) findings corresponded to the palpable area, resulting in three carcinomas being diagnosed. Only one carcinoma required MRI-guided biopsy for diagnosis. Eighteen women with negative MRI underwent ultrasound-guided biopsy from the palpable area, which resulted in a diagnosis of one carcinoma. One carcinoma was incidentally detected in another location. Within the present population, the sensitivity for detecting malignancy was 80%, specificity 78%, negative predictive value 99%, and positive predictive value 13%. CONCLUSIONS: Although cancer was found in four cases in the palpable area, the biopsy was directed using MRI in only one case. A new palpable finding with non-contributory standard imaging should prompt a needle-guided biopsy and not further evaluation using MRI.

Does change in microcalcifications with neoadjuvant treatment correlate with pathological tumour response?

AIM: To determine whether change in microcalcification density and extent after neoadjuvant treatment (NAT) can predict tumour response. MATERIALS AND METHODS: This single-institution, retrospective study included all women with breast cancer who underwent NAT between 1 January 2008 and 31 December 2014, and fulfilled the following criteria: mammography before NAT with pathological microcalcifications, mammography performed after NAT, and tumour resection at Tel-Aviv Sourasky Medical Center. Correlation was made between mammography features and clinicopathological information. RESULTS: Fifty-four patients met the inclusion criteria. Post-NAT, the number of calcifications remained stable in 30 (55.5%) patients, decreased in 23 (42.6%) patients, and increased in one (1.9%) patient. Patients with a decreased number of malignant calcifications post-NAT had higher rates of pathological complete response compared to patients with no change (59% versus 20%, p=0.009). Patients with triple negative and human epidermal growth factor receptor 2 (HER2) receptor subtypes had higher rates of decreased number of calcifications post-NAT (50% versus 35%) and pathological complete response (57% versus 11%, p=0.007) compared to patients with luminal receptor subtype. In addition, patients who received a combination of chemotherapy and biological treatment had more cases of decreased number of calcifications compared to patients who received chemotherapy alone (56% versus 39%). No significant correlation was observed between calcification change post-NAT and calcification morphology or distribution pattern. CONCLUSIONS: Patients with breast carcinoma and decreased number of pathological calcifications post-NAT had higher rates of pathological complete response compared to patients with no change in calcifications; however, a substantial number of patients with complete pathological response had no change in microcalcification distribution with treatment, questioning the need to completely excise all calcifications post-NAT.

Pathogenesis and current management of gastrooesophageal-reflux-related asthma.

In the past decade the use of proton pump inhibitors on the one hand, and an aggressive surgical approach on the other hand have revolutionised the treatment of gastro-oesophageal reflux disease (GORD). Many studies have suggested that the successful management of GORD results in improvement of the symptoms of asthma which coexist in many of these patients. In this paper we review the pathogenesis and the medical and surgical treatment of GOR-related asthma. Both anti-reflux operations and anti-acid medications improve GORD and GOR-related asthma. Although anti-reflux surgery is superior to H2 blockers, there are not sufficient data to evaluate proton pump inhibitors compared with operation in controlling the symptoms of asthma.

Laparoscopy: searching for the proper insufflation gas.

BACKGROUND: Although many aspects of laparoscopic surgery have been determined, the question of which insufflation gas is the best arises repeatedly. The aim of this study was to review the findings on the major gases used today in order to provide information and guidelines for the laparoscopic surgeon. METHODS: We reviewed the literature for clinical and laboratory studies on the currently used laparoscopic insufflation gases: carbon dioxide (CO(2)), nitrous oxide (N(2)O), helium (He), air, nitrogen (N(2)), and argon (Ar). The following parameters were evaluated: acid-base changes, hemodynamic and respiratory sequelae, hepatic and renal blood flow changes, increase in intracranial pressure, outcome of venous emboli, and port-site tumor growth. RESULTS: The major advantage of CO(2) is its rapid dissolution in the event of venous emboli. Hemodynamic and acid-base changes with CO(2) insufflation usually are mild and clinically negligible for most patients. Although N(2)O is advantageous for procedures requiring local/regional anesthesia, it does not suppress combustion. Findings show that Ar may have unwanted hemodynamic effects, especially on hepatic blood flow. There are almost no hemodynamic or acid-base sequelae with the use of He, air, and N(2), but they dissolve slowly and carry a potential risk of lethal venous emboli. CONCLUSIONS: Clearly, CO(2) maintains its role as the primary insufflation gas in laparoscopy, but N(2)O has a role in some cases of depressed pulmonary function or in local/regional anesthesia cases. Other gases have no significant advantage over CO(2) or N(2)O and should be used only in protocol studies. The relation of port-site metastasis to a specific type of gas requires further research.

Relative contributions of hyaluronic acid capsule and M protein to virulence in a mucoid strain of the group A Streptococcus.

The antiphagocytic effect of M protein has been considered a critical element in virulence of the group A streptococcus. The hyaluronic acid capsule also appears to play an important role: studies of an acapsular mutant derived from the mucoid or highly encapsulated M protein type 18 group A streptococcal strain 282 indicated that loss of capsule expression was associated with decreased resistance to phagocytic killing and with reduced virulence in mice. To study directly the relative contributions to virulence of M protein and the hyaluronic acid capsule in strain 282, we inactivated the gene encoding the M protein (emm18) both in wild-type strain 282 and in its acapsular mutant, strain TX72. Inactivation of emm18 was accomplished by integrational plasmid mutagenesis, using the temperature-sensitive shuttle vector pJRS233 harboring a 5' DNA segment of emm18. As reported previously, wild-type strain 282 was resistant to phagocytic killing in vitro, both in whole human blood and in 10% serum. The capsule mutant TX72 was highly susceptible to phagocytic killing in 10% serum and moderately sensitive in whole blood. The M protein mutant 282KZ was highly susceptible to phagocytic killing in blood but only moderately sensitive in 10% serum. The double mutant TX74 was sensitive to killing in both conditions. In a mouse infection model, the 50% lethal dose was increased by 60- and 80-fold for the capsule and double mutants, respectively, compared with that of strain 282, but only by 6-fold for the M protein mutant. Integration of the strain 282 capsule genes into the chromosome of a nonmucoid M1 strain resulted in high-level capsule production and rendered the transformed strain resistant to phagocytic killing in 10% serum. These results provide further evidence that the hyaluronic acid capsule confers resistance to phagocytosis and enhances group A streptococcal virulence. The results suggest also that assessment of in vitro resistance to phagocytosis in 10% serum rather than in whole blood may be a more accurate reflection of virulence in vivo of group A streptococci.