Ahuva Grubstein

Siliconomas mimicking cancer.

INTRODUCTION Silicone breast implants are widely used for breast augmentation and breast reconstruction following mastectomy. Implant rupture has specific radiological signs. With the advent use of new imaging technique such as positron emission tomography (PET) computed tomography (CT) and magnetic resonance imaging (MRI) of the breast, these signs may simulate malignancy. PATIENTS AND METHODS We retrospectively reviewed four cases of patients with silicon breast implants who arrive to the mammography clinic for further evaluation of a suspected malignant process demonstrated on either PET CT or breast MRI. RESULTS Two cases were of PET CT performed for routine oncology follow-up of breast cancer. On both, the PET CT demonstrated multiple-spread benign silicone granulomas manifesting as multiple masses having an increase fluorodeoxyglucose (FDG) uptake. One case of a new mass was demonstrated as a suspicious mass on the dynamic sequences on MRI of the breast. Ultrasound-guided biopsy demonstrated benign tissue response to silicone. One case demonstrated bilateral ruptured breast implants on breast MRI, as well as bilateral axillary and mediastinal lymphadenopathy. Eventually, the patient underwent bronchoscopy for pulmonary workup of dry cough, revealing sarcoidosis. CONCLUSION Silicone granulomas can manifest as masses with suspicious morphology and enhancement dynamics on breast MRI or with increased FDG uptake on PET CT. The presence of silicone implants and awareness of the possibility of a rupture and formation of silicone granulomas may help in facilitating a correct diagnosis.

Invasive Lobular Carcinoma of the Breast: Appearance on Digital Breast Tomosynthesis

Background: The aim of this study was to characterize the signs of invasive lobular carcinoma of the breast on digital breast tomosynthesis (DBT) imaging. Patients and Methods: The study group included 23 women with pathologically proven invasive lobular carcinoma of the breast for whom both digital mammography (DM) and DBT images were available. The images were read jointly by 2 experienced breast radiologists. Findings were recorded according to the descriptors in the Breast Imaging and Reporting Data System lexicon and correlated with the detailed pathology results. Results: In 21 of the 23 patients, the combination of DM and DBT yielded pathologic findings (91%). Architectural distortions or spiculations were demonstrated in 87% of cases. The addition of DBT to DM improved lesion detection by more clearly depicting both the lesion margins and architectural distortions. Only 2 lesions were occult by both DM and DBT, including 1 lesion in a peripheral location that was not incorporated in the standard mediolateral oblique and craniocaudal views. Conclusion: DBT improves the detection of invasive lobular carcinoma lesions by more clearly depicting architectural distortions and spiculations.

Effectiveness and safety of nivolumab in advanced non-small cell lung cancer: the real-life data

OBJECTIVES Nivolumab has recently received regulatory approval as a 2nd-line treatment of non-small cell lung cancer (NSCLC). The data regarding its effectiveness and safety in real life setting is lacking. MATERIALS AND METHODS 260 consecutive patients with advanced NSCLC treated with nivolumab at five Israeli cancer centers between January 2015 and March 2016 were evaluated for overall survival (OS) and toxicity. OS was analyzed by the Cox proportional-hazards regression model. Overall response rate (ORR) and progression-free survival (PFS) were assessed in 49 patients using RECIST, v.1.1. RESULTS Median age was 67y (41-99); males 68%; smokers 76%; ECOG PS ≥2 46%; non-squamous/squamous/other/NR 70%/23%/6%/1%; brain metastases 21%; liver metastases 21%; treatment line: 1st/2nd/3rd+-line/NR 6%/64%/26%/4%. With median survival follow-up of 18.5 months (range, 12.0-26.9), 155 (60%) patients died; median OS comprised 5.9 months (95% CI 4.7-7.4). In univariate and multivariate analysis, the only variable which significantly correlated with OS was ECOG PS. Median OS of patients with ECOG PS 0/1 and ECOG PS ≥2 comprised 9.5 months (95% CI, 6.7-NR) and 3.5 months (95% CI, 2.6-4.5), respectively. For 49 patients evaluable for response (median follow-up of 8.4 months (range, 2-16.8), ORR was 35%, median PFS was 2.8 months (95% CI, 1.8-7.7), incidence of pseudo-progression was 9%. The nivolumab safety profile was in accordance with the literature data, except for febrile neutropenia and pericarditis (observed in 1 case each). CONCLUSION In real life setting, the effectiveness of nivolumab is reasonable yet less prominent than it has been demonstrated in clinical trials. ECOG PS ≥2 is associated with poor prognosis.

Radiological Evaluation of Artificial Stone Silicosis Outbreak: Emphasizing Findings in Lung Transplant Recipients.

Objective The aim of this study was to describe the computed tomography (CT) findings and correlate pulmonary function tests (PFTs) of silicosis patients with emphasis on the findings in lung transplantation (LTX) recipients. Methods We studied the chest CT scans from 82 marble workers exposed to artificial stone dust and who had a diagnosis of silicosis, of whom 13 patients underwent LTX. Silicosis-associated findings were graded and correlated to concomitant PFT. Results A statistically significant inverse relationship was found between chest CT scores and PFT including forced expired volume in the first second (r = −0.54, P < 0.0001), total lung capacity (r = −0.4, P < 0.0001), and diffusion capacity for carbon monoxide single breath % (r = −0.6, P < 0.0001) parameters. Progressive massive fibrosis indicating advanced and complicated silicosis was found in 85% of LTX patients, as compared with 40% in patients with maintained pulmonary function. Ground-glass opacities were seen in some LTX patients with or without signs of progressive massive fibrosis. Two of these patients had silicoproteinosis diagnosed within the resected lung, indicating an acute or accelerated form of silicosis. Conclusions This silicosis current outbreak is important because of the worldwide use of this and similar high-silica-content, artificial stone products, which can cause progressive severe forms of silicosis. Along with standard clinical assessment and PFT, CT parameters are indicative measures of the disease severity.

Once bitten, twice shy

A 46-year-old man of Ethiopian origin was admitted to hospital in 2008 for investigation of cough, increasing dyspnoea and weight loss over several weeks. He was known to be HIV positive. He had a history of several opportunistic infections, including Cryptosporidium diarrhoea, tuberculosis, Mycobacterium avium complex and Pseudomonas pneumonia. He had also been treated in 2005 for visceral leishmaniasis with liposomal amphotericin. His prescribed medication included trimethoprim–suxamethoxazole, clarithromycin, efarinez, lamivudine, zidovudine and folic acid. His compliance with highly active antiretroviral therapy (HAART) was known to be poor. On physical examination he was afebrile. Aside from moderate tachypnoea (24 respirations/min), his vital signs were normal. General examination showed cachexia and marked parotid swelling. The abdomen was non-tender with hepatosplenomegaly. Cardiac/respiratory examination was …

Rare targetable drivers (RTDs) in non-small cell lung cancer (NSCLC): Outcomes with immune check-point inhibitors (ICPi)

OBJECTIVES Efficacy of immune check-point inhibitors (ICPi) in NSCLC with rare targetable drivers (RTDs) is largely unknown. MATERIALS AND METHODS Consecutive patients with NSCLC and RTDs (non-EGFR/ALK, n-82) were selected from the Davidoff Cancer Center database. ORR, PFS, OS with ICPi, OS since advanced disease diagnosis, TMB, MSI, and PD-L1 expression were analyzed; uni- and multivariate PFS and OS analyses were done. OS with ICPi was compared between the RTD cohort and the non-selected NSCLC cohort (n-278). RESULTS Of 50 tumors tested, 32%, 38%, and 30% were associated with ≥50%, 1-49% and <1% PD-L1 expression, respectively. Median TMB (n-48) comprised 4 muts/Mb (0-57); TMB ≥ 10 muts/Mb was seen in 19% of tumors. Both TMB and PD-L1 expression varied across different RTDs. All the 47 tumors were MSI stable. ORR with ICPi (n-44) was 16%, median PFS was 3.2 months (95% CI, 2.6-5.0), median OS was 16.2 months (95% CI, 8.4-NR). No correlation was seen between OS with ICPi and PD-L1 expression (p > 0.4), TMB (p > 0.8), or RTD type (p > 0.3). In the multivariate analysis, ECOG PS (p-0.005), targeted agents exposure (p-0.005), and ICPi exposure (p-0.04) were the only variables which correlated with OS since advanced disease diagnosis. Median OS since advanced disease diagnosis comprised 32 months (95% CI, 19.9-44.9) and 13 months (95% CI, 6.6-15.9) for patients who were and were not exposed to ICPi, respectively (log-rank test-6.3; p-0.01). In the inter-cohort comparison, for patients matched for ECOG PS (0/1), median OS with ICPi comprised 17.5 months (95% CI, 8.1-NR) and 8.6 months (95% CI, 6.7-NR) for RTD and non-selected patients, respectively (log-rank test-2.4, p-0.1). CONCLUSION In NSCLC with RTD, ICPi have favorable efficacy and independent impact on OS. NSCLC with RTD is associated with MSI stable status and variable levels of PD-L1 expression and TMB; their predictive value remains to be determined.

Analysis of false-negative readings of automated breast ultrasound studies

To assess the reasons for false‐negative readings of automated breast ultrasound (ABUS) studies.