Abnormal Nodes Research Articles

Altered functional hubs and connectivity in type 2 diabetes mellitus with and without mild cognitive impairment.

Cognitive impairment in type 2 diabetes mellitus (T2DM) is associated with functional and structural abnormalities of brain networks, especially the damage to hub nodes in networks. This study explored the abnormal hub nodes of brain functional networks in patients with T2DM under different cognitive states. Sixty-five patients with T2DM and 34 healthy controls (HCs) underwent neuropsychological assessment. Then, degree centrality (DC) analysis and seed-based functional connectivity (FC) analysis were performed to identify the abnormal hub nodes and the FC patterns of these hubs in T2DM patients with mild cognitive impairment (MCI) (DMCI group, N = 31) and without MCI (DMCN group, N = 34). Correlation analyzes examined the relationship between abnormal DC and FC and clinical/cognitive variables. Compared with HCs, both T2DM groups showed decreased DC values in the visual cortex, and the T2DM patients with MCI (DMCI) showed more extensive alterations in the right parahippocampal gyrus (PHG), bilateral posterior cingulate cortex (PCC), and left superior frontal gyrus (SFG) regions than T2DM patients with normal cognitive function. Seed-based FC analysis of PHG and PCC nodes showed that functional disconnection mainly occurred in visual and memory connectivity in patients with DMCI. Multiple abnormal DC values correlated with neuropsychological tests in patients with T2DM. In conclusion, this study found that the DMCI group displayed more extensive alterations in hub nodes and FC in vision and memory-related brain regions, suggesting that visual-related regions dysfunctions and disconnection may be involved in the neuropathology of visuospatial function impairment in patients with DMCI.

Network Information Data Security Transmission Method Based on the DES Algorithm

In view of the current network information data security transmission method in the process of data transmission, the abnormal data detection performance is poor and the attack rate is high in the process of data transmission. This paper proposes a network information data security transmission method based on the DES algorithm. The 3DES algorithm is used to complete the data encryption process, and the RSA encryption algorithm is used to encrypt the key to get the final data transmission object. The network model is constructed. The LOF algorithm is used to eliminate the abnormal data nodes, and the reliable network nodes are used to complete the data transmission. The experimental results show that this method can effectively reduce the missing rate of abnormal data, further improve the data resistance to attack, and promote the development of network data transmission technology.

Decomposition-Based Bayesian Network Structure Learning Algorithm for Abnormity Diagnosis Model for Coal Mill Process

In the structure learning of the large-scale Bayesian network (BN) model for the coal mill process, taking the view of the problem that the decomposition-based method cannot guarantee the sufficient learning of abnormal state node neighborhood in the diagnosis model, this paper proposes a new BN structure learning method based on decomposition. Firstly, a sketch is constructed based on an improved Markov blanket discovery algorithm and edge thickening and thinning. Second, the node centrality of k-path is used to search the important nodes, and the subgraph decomposition is realized by extracting these important nodes and their neighborhoods from the sketch. Then, through the targeted design of subgraph de-duplication, subgraph learning, and subgraph reorganization methods, the learning of large-scale BN is realized. This method is applied to public data sets, and its advantages and disadvantages are analyzed by comparing them with other methods. The advantage of the BN structure learning method of the abnormal condition diagnosis model is further verified by applying the method to the coal mill process, which is consistent with the original design intention.

Localizing Positive Axillary Lymph Nodes in Breast Cancer Patients Post Neoadjuvant Therapy

IntroductionMultiple trials demonstrated the feasibility of sentinel lymph node biopsy (SLNB) after neoadjuvant chemotherapy. Those trials reported > 10% false-negative rate; however, a subset analysis of the Z1071 trial demonstrated that removing the clipped positive lymph node (LN) during SLNB reduces the false-negative rate to 6.8% post neoadjuvant chemotherapy. This study examines the factors that might contribute to the ability to identify the clipped nodes post neoadjuvant therapy (NAT). Materials and methodsBreast cancer patients with biopsy-proven metastatic axillary LN who underwent NAT, converted to N0, had preoperative localization, and then SLNB between 2018 and 2020 at a single institution were identified. A retrospective chart review was performed. Demographic and preoperative variables were compared between localization and nonlocalization groups. ResultsEighty patients who met inclusion criteria were included. A total of 39 patients were localized after NAT completion (49%). Only half of the patients with ultrasound-detectable marker clips were able to be localized. Minimal LN abnormality was seen in imaging after NAT completion in 39 patients and is significantly associated with localization; 26 (67%) were localized (Odds Ratio 4.31, P = 0.002, 95% Confidence Interval 1.69-10.98). ConclusionsOur study suggests that radiologically abnormal LNs on preoperative imaging after NAT completion are more likely to be localized. Nodes that ultimately normalize by imaging criteria remain a significant challenge to localize, and thus localization before starting NAT is suggested. A better technology is needed for LN localization after prolonged NAT for best accuracy and avoids repeated procedures.

Impaired macroglial development and axonal conductivity contributes to the neuropathology of DYRK1A-related intellectual disability syndrome

The correct development and activity of neurons and glial cells is necessary to establish proper brain connectivity. DYRK1A encodes a protein kinase involved in the neuropathology associated with Down syndrome that influences neurogenesis and the morphological differentiation of neurons. DYRK1A loss-of-function mutations in heterozygosity cause a well-recognizable syndrome of intellectual disability and autism spectrum disorder. In this study, we analysed the developmental trajectories of macroglial cells and the properties of the corpus callosum, the major white matter tract of the brain, in Dyrk1a+/− mice, a mouse model that recapitulates the main neurological features of DYRK1A syndrome. We found that Dyrk1a+/− haploinsufficient mutants present an increase in astrogliogenesis in the neocortex and a delay in the production of cortical oligodendrocyte progenitor cells and their progression along the oligodendroglial lineage. There were fewer myelinated axons in the corpus callosum of Dyrk1a+/− mice, axons that are thinner and with abnormal nodes of Ranvier. Moreover, action potential propagation along myelinated and unmyelinated callosal axons was slower in Dyrk1a+/− mutants. All these alterations are likely to affect neuronal circuit development and alter network synchronicity, influencing higher brain functions. These alterations highlight the relevance of glial cell abnormalities in neurodevelopmental disorders.

Multi-parameter ultrasonography-based predictive model for breast cancer diagnosis.

To develop, validate, and evaluate a predictive model for breast cancer diagnosis using conventional ultrasonography (US), shear wave elastography (SWE), and contrast-enhanced US (CEUS). This retrospective study included 674 patients with 674 breast lesions. The data, a main and an independent datasets, were divided into three cohorts. Cohort 1 (80% of the main dataset; n = 448) was analyzed by logistic regression analysis to identify risk factors and establish the predictive model. The area under the receiver operating characteristic curve (AUC) was analyzed in Cohort 2 (20% of the main dataset; n = 119) to validate and in Cohort 3 (the independent dataset; n = 107) to evaluate the predictive model. Multivariable regression analysis revealed nine independent breast cancer risk factors, including age > 40 years; ill-defined margin, heterogeneity, rich blood flow, and abnormal axillary lymph nodes on US; enhanced area enlargement, contrast agent retention, and irregular shape on CEUS; mean SWE higher than the cutoff value (P < 0.05 for all). The diagnostic performance of the model was good, with AUC values of 0.847, 0.857, and 0.774 for Cohorts 1, 2, and 3, respectively. The model increased the diagnostic specificity (from 31% to 81.3% and 7.3% to 73.1% in cohorts 2 and 3, respectively) without a significant loss in sensitivity (from 100.0% to 90.1% and 100.0% to 81.8% in cohorts 2 and 3, respectively). The multi-parameter US-based model showed good performance in breast cancer diagnosis, improving specificity without a significant loss in sensitivity. Using the model could reduce unnecessary biopsies and guide clinical diagnosis and treatment.

An IDS based on modified chaos Elman’s neural network approaches for securing mobile ad hoc networks against DDoS attack

A mobile ad hoc network (MANETs) is a collection of moving nodes that combine into a network with no predefined infrastructure. There are many types of attacks that could target MANETS, one among them is Distributed Denial of service attacks (DDoS). DDoS is defined as attacking routing functions and taking down the entire operation of the mobile ad hoc network. The two primary victims of DDoS attacks are the functions of routing and battery capacity. The DDoS attack can cause routing table overflow which in turn can potentially cause the infected node floods. The routing overflow is followed by creating a fake route packet to consume the available resources of the participating active nodes. This cause disrupts the normal functioning of legitimate routes. In recent years, different approaches are implemented to improve the security level of MANET. In this work, the Cuckoo Search Algorithm-based Modified Elman’s Neural Network (CSA - MENN) approaches have been proposed to overcome DDoS attacks. The CSA - MENN approaches consists of three-part which are Cuckoo search algorithm clustering area to enhance the route from source to destination, chaos theory module is used to detect the abnormal nodes, then the Modified Elman Neural Network (MENN) is employed to prevent a malicious node from sending data to the destination by determining node that consumed more resources. Packets could be lost or the victim could reset the path between the attacker and itself. CICIDS dataset has been used to test and evaluate the performance of the proposed approach based on the criteria of accuracy, packet loss, and jitter. The data set, CICIDS 2017, used in this article divides the data into 7 groups: 5 for training, 1 for validation, and 1 for generalization. In summary, approximately 71.4 percent of data is used for training and 28.6 percent for validation and generalization.

Redefining the clinical axillary lymph node staging using SPECT/CT in early breast cancer during SLNB

BackgroundSPECT/CT imaging can provide information on axillary nodal morphology, number, and status of axillary levels, along with information on primary tumor morphology, mediastinum, and lungs that assesses nodal status beyond localization. The current study aims to evaluate the feasibility of SLNB with SPECT/CT for reporting nodal information in terms of morphology, number, and axillary levels that assess nodal staging. Ninety consecutive patients with early breast cancer were included. Thirty-seven MBq (1 mCi) of Tc99m nanocolloid was used. SPECT/CT followed PS. Nodal morphology, number, and axillary levels of sentinel and non-SLNs were reported along with their localization through a gamma probe.ResultsThe mean population age was 54.5 ± 3 years. PS visualized 152 SLNs in 79 patients (success rate of 88%), and SPECT/CT showed 178 SLNs in 84 patients (93% success rate). SPECT/CT showed 90% of SLNs localized at axillary levels I & II, with 10% at the rest of the nodal areas. Out of total surgically excised, 103/706 nodes were tumor positive, and 603/706 nodes were histopathologically tumor-free. Out of 178 hot nodules, 40 showed morphologically abnormal nodes, including a few with more than one abnormal feature. The average scores in the characterization of nodal morphology for the two observers were 2.4 ± 0.71 and 2.53 ± 0.52, respectively, with a substantial agreement (k = 0.76).ConclusionsHybrid imaging with SPECT/CT defines axillary lymph nodes' level and morphological features. This additional information directs the surgeon to nodes not seen by planar imaging during SLNB and can help redefine the clinical axillary lymph node staging.

PSAT278 A Curious Case of Thyroglossal Duct Cancer

Abstract Introduction Thyroglossal duct (TGD) cyst is a common congenital anomaly. Thyroid cancer rarely occurs in TGD cysts, affecting less than 1% of cysts. Here we present a case of TGD cancer presenting as a central neck mass. Case Presentation 60 y.o female presented to her primary care physician with a neck mass without any compressive symptoms. She had no history of head/neck radiation exposure and no family history of thyroid cancer. She was noted to have a non-tender central neck mass with palpable cervical lymphadenopathy. Neck ultrasound revealed a 5.7 cm multilobulated cystic and solid mass anterior to the thyroid gland. CT scan of the neck revealed a lobulated mixed solid cystic mass at the level of the thyroid cartilage projecting anteriorly, with an abnormal right submandibular lymph node measuring 2.2×1.0 cm. She was evaluated by ENT and underwent resection of the neck mass and the hyoid bone (Sistrunk's procedure). Level 1b lymph node was also removed. Operative findings were concerning for a malignant process. This was confirmed on pathology with findings of TGD papillary thyroid cancer (PTC) and level 1b lymph node demonstrating metastatic PTC with cystic features. She was then referred to endocrine. Thyroid ultrasound revealed multiple bilateral intermediate suspicion nodules. Left inferior thyroid nodule was noted to have high suspicion sonographic features with abnormal right sided level 2 and 3 lymph nodes. She was referred for total thyroidectomy, pathology revealed multifocal PTC with lymph node involvement with extra nodal extension and metastasis to the left sternohyiod muscle, pT2, pN1b, AJCC stage 2. 6-week post-surgical labs revealed TSH of 1.69 mIU/L (ref range 0.40-4.50), thyroglobulin level of 0.8 ng/ml (ref range athyrotic &amp;lt;0.1), with undetectable thyroglobulin antibodies &amp;lt;1 IU/ml (ref range &amp;lt; or = 1 IU/mL). She underwent RAI with 104.6 mci. I-131 Metastatic survey revealed increased uptake in the thyroid bed, otherwise no increased activity elsewhere. Stimulated TSH and Thyroglobulin levels were done but not collected appropriately and therefore not mentioned here. Repeat labs 12 weeks after RAI revealed a TSH of 2.86 mIU/L, Thyroglobulin level of 0.2 ng/ml, and undetectable Thyroglobulin antibody. Conclusion There are no standardized guidelines for management of TGD cancer given the rarity of this condition. FNAB (Fine need aspiration biopsy) may be associated with high false negatives due to inadequate sampling, given the cystic nature of these lesions. In majority of these cases definitive diagnosis of cancer is made after excision of the TGD cyst. Some experts favor a conservative approach via Sistrunk's procedure and pursuing total thyroidectomy if there is high suspicion of thyroid gland involvement as well. Whereas other authors have suggested a more aggressive approach with total thyroidectomy even without evidence of concomitant involvement of the thyroid gland. Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

Completion thyroidectomy and lateral neck dissection revealed adhesions in the lateral neck compartment after gasless transaxillary endoscopic thyroidectomy: a case report

Endoscopic thyroidectomy is effective and safe surgical option for thyroid surgery while providing satisfactory cosmetic results. Gasless transaxillary endoscopic approaches have been reported to achieve endoscopic thyroidectomy in our center. We present a patient who previously underwent gasless transaxillary endoscopic lobectomy with ipsilateral central neck dissection who underwent open completion thyroidectomy and lateral neck dissection (LND) (reoperation) in our center. The ultrasound test before the first treatment did not reveal abnormal lymph nodes in the central and lateral neck compartments. Further evaluation of the neck lymph nodes was not performed. Meanwhile, this patient did not participate in the originally planned follow-up at the 3- and 6-month visits. At the one-year visit, imaging tests revealed enlarged and suspicious malignant lymph nodes in levels III and IV of the lateral neck compartments. We believed that reoperation was performed for persistent, rather than truly recurrent disease for this patient. During the second surgery, we found that the surface of internal jugular vein (IJV) was significantly adhered to the surrounding fibroadipose tissue and the omohyoid muscle was adhered to the IJV. After carefully dissected the IJV, the dissection of the lateral neck compartment had been performed successfully. Exposure of the lateral neck compartment in the gasless transaxillary procedure, especially exposure of the IJV, causes adhesions of the lateral neck compartment and brings difficulties for possible future LND. Gasless transaxillary endoscopic thyroid surgery should be performed in strictly selected patients with adequate preoperative assessment. The IJV should be carefully dissected to avoid IJV injury, and the lateral neck compartment could be dissected successfully during reoperation.

EBUS-TBNA in Extrathoracic Malignancies: Diagnostic and Prognostic Implications.

In patients with extrathoracic malignancies (EM) the role of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) for the assessment of abnormal mediastinal lymph nodes (MLN) is controversial. The aim of this study was to assess the diagnostic yield and prognostic significance of EBUS-TBNA in these patients. Retrospective analysis of patients with EM and abnormal MLN detected by Computed Tomography (CT) and/or Positron Emission Tomography (PET). A total of 161 patients with EM and abnormal MLN were included (93 males, 58%). The most common EM was melanoma (19%) and gastrointestinal cancer (17%). Assessed lymph nodes were mediastinal in 70% of cases and hilar in 30%. The most frequently sampled lymph nodes were subcarinal (45%) and lower right paratracheal (21%). Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of EBUS-TBNA for the diagnosis of malignancy were 88%, 100%, 100% and 87%, respectively. These values were similar regardless the type of EM except for head and neck tumors where the NPV was particularly low (67%). The diagnosis of neoplastic involvement by EBUS-TBNA implied a worse prognosis in terms of overall survival (p < 0.02)and cancer-specific survival (p < 0.001). In patients with EM and abnormal MLN, EBUS-TBNA has a high diagnostic yield. However, the NPV decrease in patients with head and neck tumors. Neoplastic MLN detected by EBUS-TBNA has prognostic implications in these patients.

Hybrid of WOA-ABC and proposed CNN for intrusion detection system in wireless sensor networks

Wireless sensor networks (i.e., WSNs) are self-configured and infrastructure-less wireless networks that monitor environmental or physical factors, such as sound, temperature, vibration, motion, pressure, or pollutants, and collaborate with the base station for analysis of their data. A sink, also known as a base station, serves as a link between customers and the network. However, WSNs have various challenges such as high energy consumption, high bandwidth demand, quality of service, compression techniques, data processing, and intrusion. To avoid intrusion, an intrusion detection system is the best solution. It investigates the network by gathering enough information from each node and detecting abnormal sensor node behavior. The intrusion detection system is primarily divided into two steps: feature extraction/selection and classification. In this work, we introduced a new intrusion detection system based on a deep learning network. For feature selection, a proposed hybrid WOA-ABC algorithm is used, and a proposed CNN architecture is used for classification. In WSN there are various attacks available mainly DoS attack, Sybil attack, black hole attack, wormhole attack, etc. In this paper, the NSLKDD dataset is used for intrusion detection. In the NSLKDD dataset, numerous attacks available but those attacks come under 4 types of attacks. There are Dos, UR2, R2L, and probe. So, in this work mainly we concentrate to classify these 4 types of attacks. Compared to the existing method our proposed architecture gives the best performance result in terms of execution time, detection rate, accuracy, and false alarm rate. When compared to existing approaches, our proposed mechanism minimizes execution time by 76.54 %.

Sternal lymphadenopathy in dogs with malignancy in different localizations: A CT retrospective study of 60 cases.

Sternal lymph nodes (SLNs) drain a multitude of regions in dogs, including the pectoral and shoulder region, the thoracic wall and mammary glands, the mediastinum, thymus, diaphragm, and the ventral abdominal wall and peritoneal cavity. Neoplastic conditions of these regions can lead to sternal lymphadenopathy. The aim of this study was to assess the most frequent localizations of the primary neoplasia and the most frequent tumor types in dogs with sternal lymphadenopathy. Computed tomographic (CT) characteristics of SLNs in dogs with confirmed neoplasia were also described. For this single-center retrospective descriptive study, dogs with sternal lymphadenopathy and cytological or histological diagnosis of neoplasia were included. Sixty dogs fulfilled the inclusion criteria: 30 (50%) with thoracic neoplasia, 19 (32%) with abdominal neoplasia, 6 (10%) with neoplasia of the front limbs and 5 (8%) with generalized neoplasia. Based on the cytological/histological diagnosis of the primary neoplasia, 31/60 (52%) dogs presented with a sarcoma, 15/60 (25%) with carcinoma, and 14/60 (23%) with round cell tumor. The presence of heterogeneous contrast enhancement was more frequent in dogs with sarcoma, while the concomitant presence of other abnormal lymph nodes was more frequent in dogs with round cell neoplasia. Tumors of different types and in different location can result in sternal lymphadenopathy in dogs. The most frequent in this study were thoracic and abdominal neoplasia, followed by neoplasia of the shoulder region. Sarcoma was the most common tumor type detected in this study, and the main CT characteristic of the SLNs in case of sarcoma was heterogeneous contrast enhancement.

Successful localization of abnormal parathyroid tissue with ultrasound-guided methylene blue dye injection before surgery for metastatic or recurrent thyroid cancers and parathyroid adenomas

ObjectivesA surgery to be performed on a previously operated neck includes difficulties such as increased risk of complications and prolonged operation time. The aim of the present study is to analyze the benefit of pre-anesthetic ultrasound-guided injection of methylene blue into parathyroid adenomas and abnormal lymph nodes to simplify their safe and satisfactory extraction. MethodsWe analyzed the case series records of 14 patients who were operated for reoperative neck surgery due to recurrent thyroid cancer (8 patients) and parathyroid adenoma (6 patients) and in the technique; 0.2 ml of a 1:5 dilution of 1 % methylene blue solution was injected directly onto the target during real-time ultrasound guidance before the operating room. ResultsIn adenomas, ultrasound-guided methylene blue injection was successfully applied in all cases, an average of 33.1 min before entering the operating room (range = 28–38 min). There were no complications related to dye injection. For patients with recurrent thyroid tumors, preoperative ultrasound-guided methylene blue injection was successfully applied in all patients, on average 27.5 min before entering the operating room (range = 20–35 min). No complications occurred due to dye injection. The blue stained lesion was easily identified during surgery. ConclusionsWe analyzed the feasibility of the injection process, the certainty of defining pathological lymph nodes, and the complications of the procedure. Preoperative administration of methylene blue preserved its intraoperative efficacy and maintained the easy the detection of reoperative or primary pathologies. The present study suggest that methylene blue dye injection is a safe, sufficient, and quietly effective method for identifying recurrent tumors and parathyroid adenomas in scarred reoperative neck surgeries. Our cases had comparatively short operative times and lower complication rates.

Radio-isotope occult lesion localization (ROLL) techniques to identify the clipped node for targeted axillary dissection (TAD) in breast cancer.

Breast cancer patients having neoadjuvant systemic therapy (NAST) who have a positive (clipped) lymph node (CN) at presentation must have that CN removed to assess pathologic response at later surgery. Multiple techniques for localizing the CN have been described. We describe a novel ROLL-based approach. Consecutive patients between 2018 and 2021, having NAST with biopsy proven positive lymph node(s), had a clip placed into the most abnormal node(s). At later surgery sentinel node and occult lesion localization (SNOLL) was performed with peritumoral radio-isotope (99m Tc-Nanoscan) injected under ultrasound guidance. Planar and single photon emission computed tomography (SPECT-CT) images were used to identify sentinel nodes (SN) and the CN. If the CN was not a SN, then additional 99m Tc-Nanoscan was injected directly into the CN using ultrasound (ROLL). TAD was performed using a gamma probe and intra-operative specimen radiographs to confirm excision of the CN. Thirty-eight patients underwent TAD. 20/38 CNs were SNs on SPECT-CT. 17/38 CN were localized separately. 1/38 CN was not a SN and could not be identified on ultrasound. The remaining 37/38 (97.4%) of the CNs were removed intra-operatively. Pathological complete response in the axilla was identified in 18/38 cases. The CN was the only positive node in 10/20 cases. In 18/20 cases the CN contained the largest tumour deposit. Combining SNOLL and ROLL techniques to identify the SNs and, if separate, the CN for TAD is very reliable and logistically robust, especially for units already performing peritumoral lymphoscintigraphy.

The Value of Fine Needle Aspiration Biopsy in the Pre-Operative Assessment of the Axilla in Breast Cancer Patients

This paper reviews the role of fine needle aspiration biopsy (FNAB) in assessing the axilla prior to definitive surgery or neoadjuvant therapy in breast cancer patients. The radiological criteria for biopsy are discussed and pathological techniques and pitfalls illustrated. The sensitivity and specificity of the technique and the clinical utility are addressed, with particular reference to the current controversies in the management of the axilla in the light of the American College of Surgeons Oncology Group Z0011 trial results. The low morbidity procedure of FNAB is recommended when the radiological and clinical features suggest a high yield from the abnormal axillary nodes, with consideration of core biopsy if an expected positive result is not obtained or the circumstances require tissue for ancillary studies. In conclusion, FNAB of the axilla is a highly sensitive procedure which can offer further valuable information to assist in clinical decision making. The technique is of particular value in the setting of a large primary tumour size and multiple enlarged nodes. A summary flow chart is provided to facilitate pre-operative management of the axilla and to encourage a universal approach.

CYSTIC ADENOMATOID MALFORMATION OF THE LUNG IN AN ADULT: A CASE REPORT

CYSTIC ADENOMATOID MALFORMATION OF THE LUNG IN AN ADULT: A CASE REPORT

S2204 A Rare Case of Medullary Carcinoma of the Colon With Lymphatic Metastasis

Introduction: Medullary carcinoma of the colon (MAC) is a rare cancer encompassing only .03% of all colorectal carcinomas. We present a rare case of MAC occurring in an older adult with a strong tobacco use history. Case Description/Methods: A 76-year-old female with PMHx of tobacco use disorder, COPD, and known pulmonary nodules presented to the ED for surveillance of her pulmonary nodules. A review of systems was positive for chronic shortness of breath and cough. A CT scan of the chest revealed enlarging lung nodules and mediastinal adenopathy. A PET scan revealed a hypermetabolic 2.5 x 2.5 cm soft mass in the distal ascending colon and hypermetabolic lymph nodes in the right upper quadrant (Figure). Colonoscopy revealed an infiltrative 2 cm mass at the hepatic flexure, and pathology revealed an invasive, poorly differentiated adenocarcinoma with normal expression of MSH2 and MSH6 and absence of MLH1 and PMS2. These findings were consistent with medullary carcinoma of the colon. Endoscopic ultrasound with biopsy of peripancreatic and porta-hepatis lymph nodes favored metastatic medullary carcinoma. The patient underwent a right hemicolectomy and follows closely outpatient. Discussion: MAC is a rare cancer associated with a high level of microsatellite instability and deficient mismatch repair proteins. It is a non-gland forming cancer composed of large polygonal eosinophilic cells growing in solid sheets and infiltrated with small lymphocytes. The majority of reported cases revealed a lack of MLH-1 and PMS2, just as our patient did. They instead express markers that are not commonly associated with colorectal cancers, such as calretinin, CK7, SATB2, and CDH17. MACs were previously difficult to differentiate from poorly differentiated adenocarcinomas due to their unique tumor marker expression and histopathology. The current standard for diagnosis of MAC therefore requires distinct microscopic morphology and molecular staining patterns. There are no current treatment guidelines due to the rarity of MACs, although MACs do have a favorable prognosis when compared to other adenocarcinomas and surgical resection and FOLFOX chemotherapy have been used successfully in some studies. Although MACs have been sporadically reported in case reports, further studies are required to determine guidelines for both diagnosis and treatment of this rare disease.Figure 1.: Endoscopic Visualization with Final Needle Aspiration of Abnormal Lymph Node.

Invasive micropapillary breast carcinoma: A retrospective study on the clinical imaging features and pathologic findings.

PurposeTo describe the clinical imaging and pathological features of invasive micropapillary breast carcinoma (IMPC), including breast mammography, sonography, magnetic resonance imaging (MRI), and molecular imaging findings.Patients and methodsWe retrospectively reviewed our institution's surgical pathology database and identified 65 patients with pathologically proven IMBC; 63/65 patients had available imaging results. Two radiologists retrospectively reviewed all imaging evaluations according to the Breast Imaging Reporting / Data System (BI-RADS) Lexicon. Clinical and histopathologic features, receptor statuses, and clinical follow-up data were recorded.ResultsSixty-three patients were admitted with palpable abnormalities; one patient's mammogram revealed no abnormality (3.3%, 1/32), whereas 31 had abnormal mammograms (31/32, 96.8%) demonstrating 37 lesions. Twenty-four had irregular, spiculated masses, 12 had microcalcifications, and 19 had architectural distortion. Sonography detected 69 masses (54 patients), characterized by irregular shapes (61/69, 88.4%), hypoechoic structures (50/69, 72.4%), angular or spiculated margins (38/69, 55.1%; 30/69, 43.4%), echogenic halo (8/69, 11.5%), and abnormal vascularity (52/69, 75.3%). MRI detected 68 lesions (52 patients); 59/68 (86.8%) appeared as masses with angular or spiculated margins (32/68, 47.1%; 35/68, 51.4%), 58 exhibited irregular or lobulated shapes (58/68, 89.7%), 29 displayed heterogeneous internal enhancement (29/68, 42.5%), and 64 demonstrated type II or III washout kinetic curves (37/68, 55%; 27/68, 40%). Breast molecular imaging showed mild-to-moderate radiotracer uptake in 15 focal areas among 13 patients. Thirty-two, 38, and 43 patients had abnormal lymph nodes identified mammographically, by breast sonography, and by MRI, respectively. Immunohistochemistry revealed high estrogen receptor (90.5%), high progesterone receptor (71.6%), and low HER-2 (26.4%) positivity.ConclusionIMPC mammography, sonography, and MRI clinical imaging features highly suggest malignancy. Breast molecular imaging also contributed to the diagnosis. IMPC's invasiveness correlated well with regional lymph node metastasis. Radiologists and surgeons should be more attentive to these imaging findings and additional clinical and pathological IMPC features.

The role of pre-operative axillary ultrasound in assessment of axillary tumor burden in breast cancer patients: a systematic review and meta-analysis.

Recent studies have suggested that a significant proportion of patients with axillary nodal metastases diagnosed by pre-operative axillary ultrasound (AUS)-guided needle biopsy were over-treated with axillary lymph node dissection (ALND). The role of routine AUS and needle biopsy in early breast cancer was questioned. This review aims to determine if pre-operative AUS could predict the extent of axillary tumor burden and need of ALND. PubMed and Embase literature databases were searched systematically for abnormal AUS characteristics and axillary nodal burden. Studies were eligible if they correlated the sonographic abnormalities in AUS with the resultant axillary nodal burden in ALND according to the ACOSOG Z0011 criteria. Eleven retrospective studies and one prospective study with 1658 patients were included. Sixty-five percent of patients with one abnormal lymph node in AUS and 56% of those with two had low axillary nodal burden. Using one abnormal lymph node as the cut-off, the pooled sensitivity and specificity in prediction of axillary nodal burden were 66% (95%CI 63-69%) and 73% (95% CI 70-76%), respectively. Across the six studies that evaluated suspicious nodal characteristics, increased nodal cortical thickness may be associated with high axillary nodal burden. More than half of the patients with pre-operative positive AUS and biopsy proven axillary nodal metastases were over-treated by ALND. Quantification of suspicious nodes and extent of cortical morphological changes in AUS may help identify suitable patients for sentinel lymph node biopsy.