Public Release: 

Pathologists often disagree on breast biopsy results when diagnosing DCIS

American College of Physicians

1. Pathologists often disagree on breast biopsy results when diagnosing DCIS

Abstract: http://www.annals.org/article.aspx?doi=10.7326/M15-0964

Editorial: http://www.annals.org/article.aspx?doi=10.7326/M16-0526

URL goes live when the embargo lifts

A study applying B-Path (Breast Pathology) Study results to patient populations found that pathologists disagree with one another about 8 percent of the time when diagnosing a single breast biopsy slide. Discordance was more likely in cases of DCIS or atypia, with a tendency toward overdiagnosing disease. The findings are published in Annals of Internal Medicine.

Results of the B-Path Study, an evaluation of diagnostic agreement among pathologists interpreting breast biopsy specimens, raised concerns about the accuracy of breast cancer diagnoses in general clinical practice. However, the study was not intended to reflect population impact. To provide a more clinically relevant assessment of accuracy than previously reported, researchers analyzed the B-Path Study data using U.S. population-adjusted estimates. The researchers estimated the probability that a pathologist's interpretation of a single breast biopsy slide would be confirmed by a consensus-based reference standard derived from three expert breast pathologists interpreting the same slide. For example, if a single slide from a woman's biopsy was interpreted as DCIS, how likely is it that her slide would get the same diagnosis from a panel of three expert pathologists?

The researchers found that pathologists were likely to agree on invasive breast cancer diagnoses, but agreement was substantially lower for interpretations of DCIS and atypia. For example, 1 in 5 women with an initial diagnosis of DCIS would have her biopsy specimen interpreted as atypia or benign by the reference consensus panel and half of the women with atypia would have their diagnosis downgraded to benign without atypia.

According to the authors, noninvasive but potentially high-risk breast lesions represent a gray area in medicine; there is not always a "right" or "wrong" diagnosis. They suggest that women with borderline findings may benefit from revised guidelines for clinical treatment and management.

Note: For an embargoed PDF, please contact Cara Graeff. To interview the lead author, Dr. Joann Elmore, please contact Brian Donohue at bdonohue@uw.edu or 206-543-7856.

2. Evidence suggests that PCSK9 antibodies may help to manage acute coronary syndrome

Abstract: http://www.annals.org/article.aspx?doi=10.7326/M15-2994

Editorial: http://www.annals.org/article.aspx?doi=10.7326/M16-0422

URL goes live when the embargo lifts

A review of published evidence suggests that proprotein convertase subtilisin/Kexin type 9 (PCSK9) could be used to help patients manage acute coronary syndrome (ACS). A summary of the evidence is published in Annals of Internal Medicine.

ACS is often treated with antiplatelet and anticoagulation therapies and early revascularization, as well as intensive statin therapy. However, the condition remains associated with a high rate of adverse events attributable to the culprit plaque responsible for the index event and the residual ischemic risk from nonculprit coronary plaques that are more vulnerable and prone to rupture during ACS. PCSK9 are a new lipid lowering therapy that bind PCSK9 and prevent degradation of low-density lipoprotein. This is important because acute coronary events induce a dynamic increase of PCSK9 levels that may play a role in plaque vulnerability of both culprit and nonculprit coronary vessels.

Researchers reviewed published evidence to describe the influence of PCSK9 antibodies on plaque composition and instability, as well as the therapy characteristics that could potentially be beneficial in treating early ACS. The evidence showed that treatment with PCSK9 antibodies could benefit patients with ACS through reduction of low-density lipoprotein cholesterol levels and through early plaque stabilization via anti-inflammatory and antithrombotic mechanisms. The authors recommend trials of PCSK9 to evaluate clinical outcomes in ACS patients.

Note: For an embargoed PDF, please contact Cara Graeff. The lead author, Dr. Eliano Navarese, can be reached directly at elianonavarese@gmail.com or through Gail Walters at Gail.Walters@inova.org or 703-772-7084.

Also in this issue:

Antimicrobial Access in the 21st Century: Delays and Critical Shortages

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Ideas and Opinions

http://www.annals.org/article.aspx?doi=10.7326/M15-3076

Acquired Syphilis With Anemia and Leukoerythroblastic Reaction: A Case Report

Kalyan C. Mantripragada, MD, MPH; Sophia Fircanis Rizk, MD; John L. Reagan, MD; Mark LeGolvan, MD Observation

http://www.annals.org/article.aspx?doi=10.7326/L15-0527

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