Asymptomatic Complicated Cysts in Postmenopausal Women: Is Tissue Sampling Unnecessarily High?

RATIONALE AND OBJECTIVES: To determine the malignancy rate of complicated cysts in postmenopausal women and to discuss appropriate (Breast Imaging Reporting and Data System assessment and recommendation. MATERIALS AND METHODS: This study was approved by our institutional review board and informed consent was waived. One hundred fourteen postmenopausal patients with 183 complicated cysts as defined by the newest Breast Imaging Reporting and Data System edition were identified retrospectively between January 2013 and December 2015 (to allow for 2 years follow-up period). One hundred eight complicated cysts were assessed as probably benign and 75 as suspicious. Prospective review of all images and pathology was performed and patient's age, breast density, risk factors, use of hormone replacement therapy, and family history of breast cancer were recorded. A total of 30 symptomatic patients and lesions not meeting criteria for complicated cysts were excluded from our cohort. Benignity was determined by aspiration, biopsy, resolution, recategorization to a simple cyst, or adequate follow-up. RESULTS: None of our complicated cysts proved malignant. Fifteen of 108 probably benign complicated cysts were aspirated yielding benign fluid in 10 and 5 were biopsied yielding benign pathology (only 2 with atypical cells). Twenty-nine of 75 complicated cysts categorized as suspicious were aspirated and fluid was discarded in 25 and 4 sent for cytology yielding benign pathology. The other 41 complicated cysts thought to be suspicious were biopsied with benign pathology (only 1 atypical). CONCLUSION: This study supports the use of a probably benign assessment of asymptomatic complicated cysts irrespective of age. The sensitivity for malignancy was 100% in our cohort.

Breast Cancer Tissue Markers, Genomic Profiling, and Other Prognostic Factors: A Primer for Radiologists.

An understanding of prognostic factors in breast cancer is imperative for guiding patient care. Increased tumor size and more advanced nodal status are established independent prognostic factors of poor outcomes and are incorporated into the American Joint Committee on Cancer (AJCC) TNM (primary tumor, regional lymph node, distant metastasis) staging system. However, other factors including imaging findings, histologic evaluation results, and molecular findings can have a direct effect on a patient's prognosis, including risk of recurrence and relative survival. Several microarray panels for gene profiling of tumors are approved by the U.S. Food and Drug Administration and endorsed by the American Society of Clinical Oncology. This article highlights prognostic factors currently in use for individualizing and guiding breast cancer therapy and is divided into four sections. The first section addresses patient considerations, in which modifiable and nonmodifiable prognostic factors including age, race and ethnicity, and lifestyle factors are discussed. The second part is focused on imaging considerations such as multicentric and/or multifocal disease, an extensive intraductal component, and skin or chest wall involvement and their effect on treatment and prognosis. The third section is about histopathologic findings such as the grade and presence of lymphovascular invasion. Last, tumor biomarkers and tumor biology are discussed, namely hormone receptors, proliferative markers, and categorization of tumors into four recognized molecular subtypes including luminal A, luminal B, human epidermal growth factor receptor 2-enriched, and triple-negative tumors. By understanding the clinical effect of these prognostic factors, radiologists, along with a multidisciplinary team, can use these tools to achieve individualized patient care and to improve patient outcomes. ©RSNA, 2018.

Clinical Performance of Synthesized Two-dimensional Mammography Combined with Tomosynthesis in a Large Screening Population.

Purpose To compare the clinical performance of synthesized two-dimensional (s2D) mammography combined with digital breast tomosynthesis (DBT) with that of full-field digital mammography (FFDM) alone and FFDM combined with DBT in a large community-based screening population by analyzing recall rate, positive predictive value, and cancer detection rate. Materials and Methods This was a retrospective study approved by the institutional review board and was HIPAA compliant with waiver of informed consent. A total of 78 810 screening mammograms from October 11, 2011, to June 30, 2016, were retrospectively collected. Of these, 32 076 were FFDM, 30 561 were DBT-FFDM, and 16 173 were DBT-s2D mammograms. Diagnostic performance of FFDM, DBT-FFDM, and DBT-s2D mammography was compared. Statistical significance was determined by using the Pearson χ2 test and was expressed as odds ratios and related confidence intervals determined by means of logistic regression analysis with pairwise comparisons. Results Recall rates were significantly lower with DBT-s2D mammography (4.3%, 687 of 16 173) when compared with DBT-FFDM (5.8%, 1785 of 30 561; odds ratio, 0.72; 95% confidence interval: 0.65, 0.78; P < .0001) and when compared with FFDM alone (8.7%, 2799 of 32 076; odds ratio, 0.46; 95% confidence interval: 0.43, 0.51). The cancer detection rate was similar among FFDM alone (5.3 of 1000 screening examinations), DBT-FFDM (6.4 of 1000 screening examinations), and DBT-s2D mammography (6.1 of 1000 screening examinations) with no significant difference (FFDM vs DBT-FFDM, P = .08; FFDM vs DBT-s2D, P = .27). The percentage of invasive cancers detected was significantly higher with DBT-s2D mammography (76.5%) than with DBT-FFDM (61.3%, P = .01), and positive predictive values with DBT-s2D mammography (40.8%) were significantly higher than those with DBT-FFDM (28.5%, P < .0001). Conclusion Screening with DBT-s2D mammography in a large community-based practice improved recall rate and positive predictive values without loss of cancer detection rate when compared with DBT-FFDM and FFDM alone. © RSNA, 2017.

Measuring physician adherence with gout quality indicators: a role for natural language processing.

OBJECTIVE: To evaluate physician adherence with gout quality indicators (QIs) for medication use and monitoring, and behavioral modification (BM). METHODS: Gout patients were assessed for the QIs as follows: QI 1: initial allopurinol dosage <300 mg/day for patients with chronic kidney disease (CKD); QI 2: uric acid within 6 months of allopurinol start; and QI 3: complete blood count and creatinine phosphokinase within 6 months of colchicine initiation. Natural language processing (NLP) was used to analyze clinical narrative data from electronic medical records (EMRs) of overweight (body mass index ≥28 kg/m(2) ) gout patients for BM counseling on gout-specific dietary restrictions, weight loss, and alcohol consumption (QI 4). Additional data included sociodemographics, comorbidities, and number of rheumatology and primary care visits. QI compliance versus noncompliance was compared using chi-square analyses and independent-groups t-test. RESULTS: In 2,280 gout patients, compliance with QI was as follows: QI 1: 92.1%, QI 2: 44.8%, and QI 3: 7.7%. Patients compliant with QI 2 had more rheumatology visits at 3.5 versus 2.6 visits (P < 0.001), while those compliant with QI 3 had more CKD (P < 0.01). Of 1,576 eligible patients, BM counseling for weight loss occurred in 1,008 patients (64.0%), low purine diet in 390 (24.8%), alcohol abstention in 137 (8.7%), and all 3 elements in 51 patients (3.2%). Regular rheumatology clinic visits correlated with frequent advice on weight loss and gout-specific diet (P < 0.0001). CONCLUSION: Rheumatology clinic attendance was associated with greater QI compliance. NLP proved a valuable tool for measuring BM as documented in the clinical narrative of EMRs.

Associations of hydroxychloroquine use with lipid profiles in rheumatoid arthritis: pharmacologic implications.

OBJECTIVE: To evaluate the association of hydroxychloroquine (HCQ) use with lipid profiles in a Veterans Affairs Rheumatoid Arthritis (VARA) cohort. METHODS: Lipid profiles in HCQ users were compared with HCQ nonusers, adjusting for potential confounders (age, sex, race, disease activity, prednisone, disease-modifying antirheumatic drugs, diabetes mellitus, and statin use). Applying current National Cholesterol Education Program Adult Treatment Panel III (NCEP-ATP III) guidelines for reduction of cardiovascular disease (CVD) events risk, the frequency of target lipid profiles with HCQ status was evaluated. Varied periods of HCQ exposure were compared to ascertain pharmacologic associations with lipid values. CVDs were compared between HCQ users and nonusers. RESULTS: In an elderly, predominantly male VARA cohort, 1,011 patients had lipid profiles; 787 patients (77.8%) were white. Statin use was recorded in 11.6% of patients, diabetes mellitus in 33.5%, and CVD in 31.2%. HCQ users (n = 150) were older, had longer rheumatoid arthritis (RA) disease duration, and had lower disease activity. Optimum lipid profiles, including total cholesterol:high-density lipoprotein (HDL) and HDL:low-density lipoprotein ratios (P ≤ 0.001), were more frequent in HCQ users, with the exception of HDL (P = 0.165), and persisted in multivariate analyses. Similarly, more HCQ users had NCEP-ATP III target levels. Varied periods of HCQ exposure suggested lipid changes to occur early, but lost within a year of drug discontinuation. HCQ users had less prevalent CVD. CONCLUSION: In RA patients, HCQ use of at least 3 months' duration was associated with better lipid profiles irrespective of disease activity or statin use. Given the increased CVD risks in RA and the relative low cost and toxicity of HCQ, continued use, regardless of treatment regimen, should be considered.