Hormonal Symptoms Research Articles

P4-19-03: Physical and Psychological Sequelae of Breast Cancer in Men.

Abstract Introduction: Little is known about the physical and emotional health of men with breast cancer. Information is also lacking regarding whether their informational and supportive care needs are being met regarding fertility and genetic concerns. Methods: In an online pilot study recruiting participants through three websites focused on male breast cancer, www.outoftheshadowofpink.com, www.malebreastcancer.org, and www.malebreastcancer.ca, we surveyed men with breast cancer about their attitudes, symptoms, experiences, and health perceptions. We measured anxiety and depression using the Hospitalized Anxiety and Depression Scale (HADS), health-related quality of life (QOL) using Functional Assessment of Cancer Therapy-Breast (FACT-B), and hormonal and sexual symptoms using the Expanded Prostate Cancer Index Composite (EPIC) Hormonal and Sexual Scales. We assessed select toxicities from therapy and history of genetic and fertility counseling. Results: Forty-two men responded to this online survey at least in part. Conclusions: Men with breast cancer experience substantial symptoms in follow-up. Sexual functioning, in particular, may be impaired (in men without cancer, mean EPIC Sexual Score is 61.4 with SD 23.6). Hormonal symptoms are also prevalent (in men without cancer, mean EPIC Hormonal Score is 91.7 with SD 9.7). We plan to use data from this pilot study to inform a larger study and develop targeted interventions to improve sexual functioning and reduce symptoms in male breast cancer survivors. Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P4-19-03.

Malignant Pheochromocytoma Presenting as Incapacitating Bony Pain

Among adrenal incidentalomas, pheochromocytomas are rare. Malignant pheochromocytoma is even less common, and it typically presents with classic hormonal symptoms, such as palpitations, labile blood pressures, and headaches. Bony metastasis usually occurs late in disease, but we report an unusual case of incapacitating bony pain as the initial presentation of malignant pheochromocytoma. Our patient is a 70-year-old woman with neurofibromatosis type 1 and a history of primary hyperparathyroidism, who tested negative for the ret mutation. She came to medical attention with chest pain and palpitations and was incidentally found to have an adrenal mass. Serum and urine testing was consistent with pheochromocytoma. Her blood pressure was easily controlled as she awaited elective adrenalectomy; however, she quickly developed severe, diffuse bony pain. She represented with hypercalcemia, spontaneous fractures, and incapacitating pain that required such high doses of pain medications that she had to be intubated. Further imaging and bone marrow biopsy confirmed metastatic neuroendocrine tumor. She received one round of chemotherapy with no change in her bony pain, which was her primary complaint. Unfortunately, her treatment options were limited by the heavy sedation required for comfort, and in the end, it was her bony pain rather than hormonal symptoms that made her disease untreatable.

Evaluation of the efficacy and the safety of lanreotide autogel 120 mg on tumor growth stabilization in patients with progressive neuroendocrine tumors (NETs) who are not eligible to surgery or chemotherapy.

e14660 Background: Somatostatin analogs (SSTAs) are the treatment of choice for hormonal symptoms associated with NETs. Clinical studies have suggested stabilization or, in rare cases, partial response in the tumour mass. In a population of documented progressive NETs no data of antitumoral activity of SSTAs analogs given as sole treatment has been presented. We undertook a phase II trial (NCT0032646) to evaluate the efficacy of lanreotide Autogel 120mg on tumour growth stabilisation in patients with documented progressive NETs. Methods: Thirty patients from 17 Spanish hospitals with advanced and/or metastatic well-differentiated NETs progressive within the last 6 months were treated with lanreotide Autogel 120 mg every 28 days until progression. Treatment with SSTA during the previous 6 months was an exclusion criterion. No patients received chemotherapy (CT) or interferon (IFN) during the 4 weeks before study inclusion. Radiologic evaluation was performed every 3 cycles. Primary endpoint was progression-free survival (PFS) per central blind review. Clinical baseline characteristics were: Age median: 63y (40-78), M/F (50%/50%), Median time since diagnosis 5.5y (0.2-22.2), ECOG 0/1/2: 63%/30%/7% Foregut/Midgut/Unknown: 47%/40%/13%; Ki index: median 2.0 (1-20); Functioning/Non Funct. (63%/37%); Previous treatment: CT/ IFN/SSTAs (33%/23%/20%) Results: Median PFS (95% CI) was 12.9 months (7.9-16.5) both in ITT and PP populations. Best tumour responses were: 4%PR/89%SD/7% PD. Ki 67 index was the most likely prognostic factor for PFS (HR 1.17; p= 0.017). Discontinuation of treatment because of adverse events (AE) occurred in one patient. Only one severe related AE was detected (aerophagia). No impairment in EORTC QLQ-C30 for the whole group was detected during treatment. Conclusions: In this study, the sole treatment with lanreotide Autogel 120 mg in progressive NET patients provides a median PFS > 12 months with a very low toxicity. This apparent tumoral control effect should be confirmed in a phase III ongoing trial (Clarinet, NCT00842348). Acknowledgment: Study sponsored by IPSEN.

Transarterial Chemoembolization and Selective Internal Radiation for the Treatment of Patients with Metastatic Neuroendocrine Tumors: A Comparison of Efficacy and Cost

Hepatic arterial therapy (HAT) has been proven to be effective at palliation of hormonal symptoms of metastatic neuroendocrine tumors (NETs), as well as a means of cytoreduction. Recently, the newer modalities of yttrium-90 and drug-eluting beads with doxorubicin (DEBDOX) have been reported to be effective in the treatment of metastatic NETs. The aim of this study was to compare the safety, efficacy, and cost of selective internal radiation with DEB therapy. An institutional review board-approved, multicenter, multinational prospective treatment registry to investigate the safety and efficacy of yttrium-90 and doxorubicin microspheres was reviewed. In all, 43 patients underwent a combined 69 HAT treatments, with 15 patients receiving 23 yttrium-90 treatments and 28 patients receiving 46 DEBDOX treatments. The extent of disease-based on the number of lesions, bilobar distribution, patient performance status, and size of largest lesion-was similar in both the yttrium-90 and DEBDOX groups. After a median follow-up of 12 months, response rates were similar with the two treatments, but then there was a significantly lower response rate in the yttrium-90 group at 12 months than in the DEBDOX group. In an evaluation of cost for the two treatments, the median cost for yttrium-90 was $25,243 and the median cost for DEBDOX was $13,400. HAT is a safe and effective therapy in patients with unresectable NETs to the liver. The size of the lesions, total lesion volume, and expense of therapy need to be considered when choosing which HAT method is optimal.

Complete and sustained remission of neuroendocrine tumor-associated liver metastases during somatostatin analogue treatment

Somatostatin analogues represent a major treatment modality in the therapy of neuroendocrine tumors. Their efficacy is well documented in the inhibition of hormone secretion; however, novel data seem to underline their effectiveness in tumor regression, as well. In this report authors present a case of type 1 neuroendocrine tumors of the stomach associated with liver metastases. Somatostatin analogue treatment resulted in a complete regression of the primary tumor and the metastases within two years. This case draws attention on the importance of somatostatin analogue treatment not only in the control of hormonal symptoms but also in the inhibition of tumor growth. Orv. Hetil., 2011, 152, 407–410.

Abstract P3-15-06: No Correlation between Endocrine Symptoms and Musculoskeletal Symptoms in Women Receiving Adjuvant Aromatase Inhibitor Therapy

Abstract Background: The etiology of Aromatase Inhibitor (AI) associated musculoskeletal symptoms remains unclear. It has been proposed that musculoskeletal side effects are related to the estrogen depletion achieved on AI therapy. Estrogen depletion with AI therapy is known to result in endocrine side effects. The 18-item Functional Assessment of Cancer Therapy Breast Cancer-Endocrine Subscale (FACTB-ES) is a reliable and well validated quality of life questionnaire shown to be sensitive to changes in endocrine symptoms in breast cancer patients. The objective of this study was to determine whether among women with breast cancer treated with adjuvant AI therapy, self reported musculoskeletal side effects correlate with increased hormonal side effects as measured by the FACTB-ES. Methods: In this 6 month, single center, prospective cohort study, post-menopausal women with hormone-sensitive, non-metastatic breast cancer prescribed AIs by their treating oncologist were evaluated by a rheumatologist at baseline (before starting the AI) and at 6 months. Women who reported new or worsening musculoskeletal symptoms since starting the AI were classified as symptomatic. The FACTB-ES was administered at each visit. Changes in scores between baseline and 6 months were compared between the symptomatic and asymptomatic groups Results: Thirty-five subjects completed the 6 month follow up period. Nineteen (54%) were symptomatic and n=2 (5.7%) discontinued the AI due to these musculoskeletal symptoms. Mean time to onset of symptoms was 6 weeks (range 2 to 18 weeks). Baseline characteristics including age, ethnicity and body mass index did not differ between the groups. There was no significant difference in hormonal symptoms between groups. Both groups had equivalent worsening of their endocrine symptoms as seen by the reduction in their FACTB-score. The mean change in FACTB-ES score was -2.52 (range: -31.00, 23.00) in the symptomatic women versus -2.06 (range: -19.00, 22.21) in the asymptomatic women (Wilcoxon rank sum p=0.95). Conclusions: These data suggest that endocrine symptoms as measured by the FACTB-ES do not correlate with the development of musculoskeletal pain in women treated with adjuvant AI therapy for breast cancer. Though larger studies are necessary to confirm these results, the musculoskeletal symptoms associated with AI use may not be estrogen-dependent. Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P3-15-06.

Study of dyadic communication in couples managing prostate cancer: a longitudinal perspective.

Cancer patients and partners often report inadequate communication about illness-related issues, although it is essential for mutual support and informal caregiving. This study examined the patterns of change in dyadic communication between patients with prostate cancer and their partners, and also determined if certain factors affected their communication over time. Using multilevel modeling, this study analyzed longitudinal data obtained from a randomized clinical trial with prostate cancer patients and their partners, to examine their communication over time. Patients and partners (N=134 pairs) from the usual-care control group independently completed baseline demographic assessment and measures of social support, uncertainty, symptom distress, and dyadic communication at baseline, and 4-, 8-, and 12-month follow-ups. The results indicated that (1) patients and partners reported similar levels of open communication at the time of diagnosis. Communication reported by patients and partners decreased over time in a similar trend, regardless of phase of illness; (2) phase of illness affected couples' open communication at diagnosis but not patterns of change over time; and (3) couples' perceived communication increased as they reported more social support, less uncertainty, and fewer hormonal symptoms in patients. Couples' demographic factors and general symptoms, and patients' prostate cancer-specific symptoms did not affect their levels of open communication. Perceived open communication between prostate cancer patients and partners over time is affected by certain baseline and time-varying psychosocial and cancer-related factors. The results provide empirical evidence that may guide the development of strategies to facilitate couples' interaction and mutual support during survivorship.

Assessing longitudinal quality of life in prostate cancer patients and their spouses: a multilevel modeling approach

This study aimed at examining the relationship between quality of life (QOL) in prostate cancer (PCa) patients and partners and how baseline demographics, cancer-related factors, and time-varying psychosocial and symptom covariates affect their QOL over time. Guided by a modified Stress-Coping Model, this study used multilevel modeling to analyze longitudinal data from a randomized clinical trial that tested a family-based intervention to improve QOL in couples managing PCa. Patients and partners from the usual-care control group (N = 134 dyads) independently completed the measurements at baseline, and at 4-, 8-, and 12-month follow-ups. Correlations of QOL between patients and partners over time were small to moderate. Patients' lower education level, partners' older age, higher family income, and localized cancer at baseline were associated with better QOL in couples. Over time, couples' QOL improved as their social support and cancer-related dyadic communication increased and as couples' uncertainty, general symptoms, and patients' prostate cancer-related sexual and hormonal symptoms decreased. Evidence indicates that couples' QOL during cancer survivorship is affected by multiple contextual factors (e.g., baseline demographics and time-varying psychosocial factors and symptoms). Intervention research is needed to explore comprehensive strategies to improve couples' QOL during the continuum of PCa survivorship.

The relative analysis of clinical endocrine features and pathological types of pituitary microadenomas

To study the relationship between the clinical presentation, endocrinal findings and pathological types in patients with pituitary microadenomas, so as to improve the accuracy of clinical diagnosis and choose the best therapy strategy before the operation. From January 2007 to June 2009, the clinical data of 94 patients who were surgically removed pituitary microadenomas were obtained, including the clinical presentation, endocrinal findings and pathological diagnosis. The analysis was accomplished with Chi-square test. Hormonal symptoms were found in 86 patients (91.5%), it occurred more frequently in immunopositive patients (85/92, 92.4%) than in immunonegative patients (1/2, 50.0%) (P < 0.05). The coincidence of hormonal symptoms and immunohistochemistry diagnosis was 71.7%; 88.9% patients had the symptoms of amenorrhea, galactorrhea and sexual function diseases in prolactin (PRL) positive group and 28.1% patients had the symptoms of gigantism or acromegaly in growth hormone (GH) positive group. The coincidence of endocrinal findings and immunohistochemistry diagnosis was 69.0%; 87.7% patients had high level of blood PRL in PRL positive group and 21.9% patients had high level of blood GH in GH positive group. There is an obvious relationship between the clinical presentation, endocrinal findings and pathological diagnosis in patients with pituitary microadenomas, which may contribute to the clinical diagnosis and treatment of pituitary secreting microadenomas.

The role of comorbidity in delineating the etiopatomechanism of disease: the co-occurrence of migraine with aura and restless leg syndrome

Background The etiology and patomachanism of migraine is not yet fully understood. This may be related to the fact that the eitopathology of disorders comorbid with migraine (depression, restless leg syndrome) is also not fully known. The common well-known syndromes of migraine attack include nausea, vomiting, drowsiness, and its comorbidity with restless leg syndrome (RLS) and related neurogenetic and neurochemical research in the past years led to the proposal of the pathogenetic role of the dopaminergic system in the development of migraine. RLS affects about 10-15% of USA population and shows a 17% comorbidity with migraine. RLS is a sensomotor disorder showing a circadian pattern which worsens in a quiet awake state (especially around falling asleep). Often a permanent sleep-wake disorder develops with mental and affective disturbances. The origin of RLS is idiopathic in 30-40% of cases but it can also be familiar. In the background of secunder RLS there is often iron deficiency periferal neuropahty, uraemia, rheumatoid arthiritis, diabetes, etc is present. Pregnancy and hormonal symptoms may also enhance the symptoms. The treatment is complex: pharmacological and non-pharmacological therapy. We would like to present the case of a 57 year old woman who suffers from migraine with visual aura since her young adulthood and from restless leg syndrome since the age of 48, together with relevant literature data. She sought medical and psychological help for her sleep-wake disturbances, affective symptoms and deterioriating quality of life present in the last few years. Author details Department of Clinical Psychology, Faculty of Medicine, Semmelweis University, Budapest, Hungary. Department of Clinical and Theoretical Mental Health, Faculty of Medicine, Semmelweis University, Budapest, Hungary. Department of Pharmacology and Pharmacotherapy, Faculty of Medicine, Semmelweis University, Budapest, Hungary.

Transarterial Liver-Directed Therapies of Neuroendocrine Hepatic Metastases

Neuroendocrine tumors (NETs) comprise a diverse group of slowly growing tumors with an indolent course, characterized by the capacity to synthesize and secrete polypeptide products that are hormonally active. Presence of liver metastases results in significant debilitating hormonal symptoms, and is associated with poor prognosis. Systemic chemotherapy has limited success in the management of patients with NET hepatic metastases. Although somatostatin analogs are effective in controlling symptoms in many of these patients, the disease can become refractory to treatment. For these reasons, interventional radiologic techniques for liver-directed therapy have become an important treatment option in patients with metastatic NETs. Transcatheter arterial procedures such as transarterial embolization (TAE), transarterial chemoembolization (TACE), and selective internal radiation therapy (SIRT) have been shown to reduce hormone levels, palliate symptoms, and reduce the tumor burden in many patients with unresectable and symptomatic NET hepatic metastases. This article summarizes the most recent information on arterial-based liver-directed therapies in the treatment of metastatic NETs.

New Medical Strategies for Midgut Carcinoids

Patients with well-differentiated neuroendocrine tumours of the gastrointestinal tract often present with metastases and hormonal symptoms. These patients can be palliated by interventional tumour reduction and medical treatment with somatostatin analogues; no effective chemotherapy is available. Radionuclide therapy via somatostatin receptors is one new therapeutic alternative. The recognition that neuroendocrine tumours express specific receptors for growth factors and chemokines, which are of importance for tumour growth, vascularization, and spread, may open the way for new therapeutic approaches. The signalling pathways in carcinoid tumours are incompletely explored. This review summarizes potential new treatment strategies from clinical and experimental studies, e.g. inhibition of angiogenesis, targeting of growth factors or their receptors by tyrosine kinase inhibitors, interference with specific cellular pathways (mTOR, PI3K, RAS/RAF, Notch), and also inhibition of the proteasome and histone deacetylation. Combining targeted therapy with chemotherapy, or using drugs to sensitize for radionuclide therapy, may enhance the treatment outcome.

Oncocytic adrenocortical carcinoma

Only 17 cases of oncocytic adrenocortical carcinoma have been reported in the English literature. Here, we report an incidental case of oncocytic adrenocortical carcinoma. The patient was a 69-year-old man with the chief complaint of abdominal pain. Abdominal computed tomography revealed a left adrenal tumor. No hormonal symptoms were observed. The excised tumor was whitish, encapsulated, and 75 x 60 x 45 mm in size. Large polygonal tumor cells were arranged in a generally diffuse architecture and exhibited abundant eosinophilic granular cytoplasm. Nuclear atypia with atypical mitotic figures and capsular and sinusoidal invasions were observed. The tumor cells were immunopositive for vimentin, neuron-specific enolase, and synaptophysin but not for alpha-inhibin, melan A, or p53. Diffuse and strong immunopositivity with an antimitochondrial antibody proved that this tumor was truly oncocytic. Upon review of previous cases of oncocytic adrenocortical tumors, we reconsidered the diagnostic findings of the potential for malignancy.

Survival gains needed to justify the side effects of treatment for localized prostate cancer

5119 Background: Men diagnosed with localized prostate cancer face difficult treatment decisions. Evidence about the relative survival benefit of treatment options is lacking or piecemeal. Side-effects can vary widely with treatment, affecting some fundamental aspects of quality of life (QOL). Little is known about patients’ views of the relative tolerability of these side-effects or the survival gains needed to justify them. Methods: QOL data were collected prospectively 3 years post-diagnosis in a population-based cohort of men treated for localized prostate cancer (n=1642); these data were used to identify common side-effect profiles. A patient preference survey was conducted in a subset (n=357, stratified by treatment); hypothetical treatment alternatives were described in terms of side-effects and survival. Random parameter logit models were estimated. We adapted the concept of compensating variation from welfare economics to derive a parameter function for the value of changes in QOL in terms of survival time; i.e., the survival gains needed to justify persistent side-effects. Bootstrap confidence intervals (CI) were constructed. Results: The table shows the survival gains needed for a range of common treatment profiles, relative to the base case of active surveillance (in which men typically experienced mild loss of libido and mild fatigue). For example, radical prostatectomy often resulted in severe impotence and mild urinary leakage; men required an extra 8.0 months (95% CI 7.4–8.7) of life to make this worthwhile. Generally, urinary dysfunction and bowel symptoms were considered the least tolerable, hormonal symptoms and fatigue came next, and sexual dysfunction was considered relatively benign. This pattern was relatively consistent across treatment groups. Conclusions: These results highlight the need for better evidence about the actual survival benefits of alternative treatments. They also help to target supportive care to optimize patient QOL after treatment for localized prostate cancer. [Table: see text] No significant financial relationships to disclose.

Prolonged survival after hepatic artery embolization in patients with midgut carcinoid syndrome

Hepatic artery embolization (HAE) is a palliative treatment for patients with liver metastases from neuroendocrine tumours. HAE reduces hormonal symptoms, but its impact on survival has been questioned. Biochemical responses and survival in consecutive patients with disseminated liver metastases from midgut carcinoid tumours were studied after HAE. Repeat HAE was performed in selected patients with radiological and biochemical signs of progression. Of 107 patients who had HAE, the median survival from the first procedure was 56 (range 1-204) months. Prolonged survival showed a strong correlation with reduction of urinary 5-hydroxyindoleacetic acid (P = 0.003) and plasma chromogranin A (P = 0.001) levels. The biochemical response to repeat HAE was similar to that for the first procedure (P = 0.002). The complication rate was low (7.5 per cent), as was the mortality rate (1.9 per cent) within 1 month of HAE. HAE is safe, provides good control of hormonal symptoms, and prolongs survival in biochemically responsive patients. It is a valuable palliative option for patients with midgut carcinoid syndrome due to liver metastases and can be repeated in patients with a favourable response to the first procedure.

Tecoma ovárico

Thecomas represent approximately 1–2% of all ovarian tumors. Generally, these tumors are benign and arise from cells in the internal theca and are thus estrogen producing. Thecomas can cause hormonal symptoms, depending on patient's of age. We present the case of a 49-year-old patient with a white-gray tumor, some areas of edema and hemorrhage on the surface, and gelatinous content that was diagnosed as an ovarian thecoma.

Treatment of liver metastases from neuroendocrine tumours in relation to the extent of hepatic disease

Hepatic surgery is presumed to improve survival of patients with liver metastases (LM) from neuroendocrine tumours (NET). This study identified LM-specific variables that could be used as additional selection criteria for aggressive treatment. A novel classification of LM from NET was established based on their localization and presentation. From 1992 to 2006, 119 patients underwent staging and treatment of LM. Three growth types of LM were identified radiologically: single metastasis (type I), isolated metastatic bulk accompanied by smaller deposits (type II) and disseminated metastatic spread (type III). The three groups differed significantly in terms of chronological presentation of LM, hormonal symptoms, Ki-67 index, 5-hydroxyindoleacetic acid and chromogranin A levels, lymph node involvement, presence of bone metastases and treatment options. The 3-, 5- and 10-year disease-specific survival rates for the entire cohort were 76.4, 63.9 and 46.5 per cent respectively. There were significant differences in survival between the three groups: 5- and 10-year rates were both 100 per cent for type I, 84 and 75 per cent respectively for type II, and 51 and 29 per cent for type III. The localization and biological features of LM from NET defines therapeutic management and is predictive of outcome.

Composite Pituitary Adenoma and Craniopharyngioma?

We report a young man who presented with atrial fibrillation and was subsequently found to have a markedly elevated serum thyroid stimulating hormone level and a solid, noncalcified intrasellar mass on imaging. The patient was treated with thyroid radioablation and hormone replacement and followed for 7 years, during which time the tumor grew to 4.6 cm. He had no visual disturbances or other hormonal symptoms. At transsphenoidal surgery, a tumor consisting of a pituitary adenoma and adamantinomatous craniopharyngiomalike components was resected. Both components were closely intermingled, but there was no evidence of an intermediate morphologic phenotype. Immunohistochemically, the adenoma was not only positive for beta-thyroid stimulating hormone, alpha subunit, and pituitary transcription factor 1, but also stained for beta-follicle stimulating hormone, steroidogenic factor-1, adrenocorticotropic hormone, and pituitary-restricted transcription factor (Tpit), exhibiting an unusual plurihormonal profile. The craniopharyngiomalike component showed immunoreactivity for steroidogenic factor-1, one of the pituitary transcription factors. This lesion may represent an unusual composite tumor attributable to divergent differentiation of a common precursor. Alternatively, it may be viewed as a pituitary adenoma showing metaplastic change analogous to the development of squamous cell nests of the pars tuberalis from adenohypophyseal endocrine cells.

Recurrent Nested Stromal Epithelial Tumor of the Liver with Extrahepatic Metastasis: Case Report and Review of Literature

Nested stromal epithelial tumor is a recently described primary neoplasm of the liver. This tumor is characterized by well-demarcated nests of spindle and epithelioid cells with occasional calcification and bone formation. An association between these tumors and Cushing syndrome has been described. Herein we report a case of a recurrent nested stromal epithelial tumor of the liver in a 17-year-old female with aggressive clinical behavior and an extrahepatic lymph node metastasis. Also, we provide the first detailed clinical, histologic, immunohistochemical, and cytogenetic comparison of the original and recurrent tumors. Initially, the patient presented with Cushingoid symptoms and epigastric pain, radiating to her back. A computed tomographic (CT) scan revealed a large lesion in the liver. After a partial hepatectomy, the Cushingoid features were resolved. A year later, a CT scan revealed multiple lesions within the liver, and positron emission tomographic/CT imaging showed a hypermetabolic lymph node. The patient underwent a cadaveric liver transplant. Histologically, both the original and recurrent tumors had similar characteristics, with different immunoreactivity, correlating with the absence of systemic hormonal symptoms. Electron microscopy of the original neoplasm revealed an abundance of rough cytoplasmic reticulum and mitochondria. No evidence of endocrine differentiation was found. Cytogenetics of the primary tumor was complex with an abnormal hypotriploid karyotype. Our data indicate that patients with nested stromal epithelial tumor of the liver must be carefully followed with imaging to detect hepatic recurrence and extrahepatic metastases.

Communicating side effect risks in a tamoxifen prophylaxis decision aid: The debiasing influence of pictographs

To experimentally test whether using pictographs (image matrices), incremental risk formats, and varied risk denominators would influence perceptions and comprehension of side effect risks in an online decision aid about prophylactic use of tamoxifen to prevent primary breast cancers. We recruited 631 women with elevated breast cancer risk from two healthcare organizations. Participants saw tailored estimates of the risks of 5 side effects: endometrial cancer, blood clotting, cataracts, hormonal symptoms, and sexual problems. Presentation format was randomly varied in a three factor design: (A) risk information was displayed either in pictographs or numeric text; (B) presentations either reported total risks with and without tamoxifen or highlighted the incremental risk most relevant for decision making; and (C) risk estimates used 100 or 1000 person denominators. Primary outcome measures included risk perceptions and gist knowledge. Incremental risk formats consistently lowered perceived risk of side effects but resulted in low knowledge when displayed by numeric text only. Adding pictographs, however, produced significantly higher comprehension levels. Pictographs make risk statistics easier to interpret, reducing biases associated with incremental risk presentations. Including graphs in risk communications is essential to support an informed treatment decision-making process.