We describe 18 nonimmunocompromised patients with chronic pulmonary aspergillosis. Duration of the disease ranged from several months to >12 years. All 18 patients had prior pulmonary disease. Weight loss, chronic cough (often with hemoptysis and shortness of breath), fatigue, and chest pain were the most common symptoms. All 18 patients had cavities, usually multiple and in 1 or both upper lobes of the lung, that expanded over time, with or without intraluminal fungal balls. All had detectable Aspergillus precipitins and inflammatory markers. Elevated levels of total immunoglobulin E were seen in 78% of patients and of Aspergillus-specific immunoglobulin E in 64%. Directed lung biopsies showed chronic inflammation, necrosis, or granulomas without hyphal invasion. Antifungal therapy with itraconazole resulted in 71% of patients improved or stabilized, with relapse common. Interferon-gamma treatment was useful in 3 patients. In azole nonresponders, modest responses to intravenous amphotericin B (80%) followed by itraconazole were seen. Surgery removed disease but postoperative pleural aspergillosis was inevitable. Indicators of good long-term medical outcomes were mild symptoms, thin-walled quiescent cavities, residual pleural fibrosis, and normal inflammatory markers.

Background In principle, risk-stratification as a routine part of the NHS Breast Screening Programme (NHSBSP) should produce a better balance of benefits and harms. The main benefit is the offer of NICE-approved more frequent screening and/ or chemoprevention for women who are at increased risk, but are unaware of this. We have developed BC-Predict, to be offered to women when invited to NHSBSP which collects information on risk factors (self-reported information on family history and hormone-related factors via questionnaire; mammographic density; and in a sub-sample, Single Nucleotide Polymorphisms). BC-Predict produces risk feedback letters, inviting women at high risk (≥8% 10-year) or moderate risk (≥5 to < 8% 10-year) to have discussion of prevention and early detection options at Family History, Risk and Prevention Clinics. Despite the promise of systems such as BC-Predict, there are still too many uncertainties for a fully-powered definitive trial to be appropriate or ethical. The present research aims to identify these key uncertainties regarding the feasibility of integrating BC-Predict into the NHSBSP. Key objectives of the present research are to quantify important potential benefits and harms, and identify key drivers of the relative cost-effectiveness of embedding BC-Predict into NHSBSP. Methods A non-randomised fully counterbalanced study design will be used, to include approximately equal numbers of women offered NHSBSP (n = 18,700) and BC-Predict (n = 18,700) from selected screening sites (n = 7). In the initial 8-month time period, women eligible for NHSBSP will be offered BC-Predict in four screening sites. Three screening sites will offer women usual NHSBSP. In the following 8-months the study sites offering usual NHSBSP switch to BC-Predict and vice versa. Key potential benefits including uptake of risk consultations, chemoprevention and additional screening will be obtained for both groups. Key potential harms such as increased anxiety will be obtained via self-report questionnaires, with embedded qualitative process analysis. A decision-analytic model-based cost-effectiveness analysis will identify the key uncertainties underpinning the relative cost-effectiveness of embedding BC-Predict into NHSBSP. Discussion We will assess the feasibility of integrating BC-Predict into the NHSBSP, and identify the main uncertainties for a definitive evaluation of the clinical and cost-effectiveness of BC-Predict. Trial registration Retrospectively registered with clinicaltrials.gov (NCT04359420).

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This case reports on secondary extramedullary multiple myeloma within both breasts in the absence of axillary nodal involvement and discusses the difficulty in interpretation with clinical recommendations and learning outcomes. Differentiating plasmacytic lesions in the breast is often difficult as clinical and radiological appearances are known to mimic benignity and high-grade primary breast cancer. Extramedullary presentation can determine progression of the disease and can necessitate cross-sectional imaging. Therefore definitive diagnosis is essential as the clinical management of the patient may be altered.

Background Risk stratification as a routine part of the NHS Breast Screening Programme (NHSBSP) could provide a better balance of benefits and harms. We developed BC-Predict, to offer women when invited to the NHSBSP, which collects standard risk factor information; mammographic density; and in a sub-sample, a Polygenic Risk Score (PRS). Methods Risk prediction was estimated primarily from self-reported questionnaires and mammographic density using the Tyrer–Cuzick risk model. Women eligible for NHSBSP were recruited. BC-Predict produced risk feedback letters, inviting women at high risk (≥8% 10-year) or moderate risk (≥5–<8% 10-year) to have appointments to discuss prevention and additional screening. Results Overall uptake of BC-Predict in screening attendees was 16.9% with 2472 consenting to the study; 76.8% of those received risk feedback within the 8-week timeframe. Recruitment was 63.2% with an onsite recruiter and paper questionnaire compared to <10% with BC-Predict only ( P < 0.0001). Risk appointment attendance was highest for those at high risk (40.6%); 77.5% of those opted for preventive medication. Discussion We have shown that a real-time offer of breast cancer risk information (including both mammographic density and PRS) is feasible and can be delivered in reasonable time, although uptake requires personal contact. Preventive medication uptake in women newly identified at high risk is high and could improve the cost-effectiveness of risk stratification. Trial registration Retrospectively registered with clinicaltrials.gov (NCT04359420).

proved so has the quality of US images. Therefore, the role of ultrasound has expanded beyond characterizing solid from cystic masses, but now also has a role in distinguishing between malignant and benign breast lumps such as fibroadenomas. Many studies have shown that FNA or core biopsy are not required to confirm the diagnosis of fibroadenomas in young women [1,2] providing strict criteria are used; no known risk factors for breast malignancy; mass not rapidly enlarging; smooth discrete mobile mass on clinical examination, or lesion impalpable; well-defined homogeneously isoechoic or mildly hypoechoic solid mass; less than 3 cm in greatest dimension; ovoid shape, aligned parallel to the skin surface; smooth or gently lobulated contour (two or three lobulations only; no microlobulation); thin echogenic pseudocapsule; no calcification; no acoustic shadowing [1][2][3]. We propose that the age can be increased to 35 years providing the above strict criteria are used, and there is no clinical suspicion of a malignant lesion. The purpose of this study was to review the need to biopsy fibroadenomas in the 25 to 35-year age group. MethodsRecords of women presenting to East Lancashire NHS Trust Breast Unit between 2013 and 2015 were obtained. Only patients between 25 and 35 years at the age of presentation, with clinical benign (P2-benign) breast lump and an USS diagnosis of fibroadenoma (U2-benign) were included in the study. All ultrasounds were performed by Breast Radiologists or Advanced Mammography Practitioners using an Aplio 500 ultrasound system (Toshiba), linear-array transducer with frequency range of 7 to 18 MHz Corresponding Fine Needle Aspiration (FNA) cytology was noted and if there were Abstract Introduction: Best practice guidelines suggest that patients < 25 years with ultrasound diagnosis of fibroadenoma, biopsy can be avoided if certain radiological criteria are satisfied. There is a cohort of patients < 35 years with ultrasound features suggestive of fibroadenoma who are being exposed to unnecessary biopsies. The aim of this study is to determine how many patients with ultrasound features of fibroadenoma have had normal histology and therefore could potentially avoid a biopsy.

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