Cost-effectiveness of MR imaging and core-needle biopsy in the preoperative work-up of suspicious breast lesions.

PURPOSE: To assess the clinical and economic consequences of the use of preoperative breast magnetic resonance (MR) imaging and core-needle biopsy (CNB) to avert excisional biopsy (EXB). MATERIALS AND METHODS: A decision-analytic Markov model was constructed to compare MR imaging, CNB, and EXB without preoperative testing in a woman with a suspicious breast lesion. Stage-specific cancer prevalence, tumor recurrence, progression rates, and MR imaging and CNB sensitivity and specificity were obtained from the literature. Cost estimates were obtained from the literature and from the Medicare fee schedule. RESULTS: EXB without preoperative testing was associated with the greatest quality-adjusted life expectancy, followed by MR imaging and CNB; life expectancies were 17.409, 17.405, and 17.398 years, respectively. EXB resulted in the greatest lifetime treatment cost ($31,438), followed by MR imaging ($29,072) and CNB ($28,573). Results were robust over a wide range of cancer prevalence, stage distribution, tumor progression rates, and procedure and treatment costs. Incremental cost-effectiveness ratios showed that preoperative testing was cost-effective, but the choice between MR imaging and CNB was highly dependent on the accuracy of each test and to patient preferences. CONCLUSION: Preoperative testing of most suspicious breast lesions was cost-effective. More precise estimates of MR imaging and CNB test performance characteristics are needed. Until those are available, patient preferences should inform individual decisions regarding preoperative testing.

Accuracy of MR imaging in the work-up of suspicious breast lesions: a diagnostic meta-analysis.

RATIONALE AND OBJECTIVES: The authors performed a systematic, critical review of the literature on magnetic resonance (MR) imaging for primary breast cancer detection in patients with suspicious breast lesions, analyzed MR test performance in the articles meeting study criteria, and used this information to examine the cost-effectiveness of preoperative MR imaging. MATERIALS AND METHODS: A structured, predefined MEDLINE search was conducted to identify potentially relevant, peer-reviewed, English-language references from January 1996 through August 1997 on the diagnostic accuracy of breast MR imaging. This information was supplemented by manually searching bibliographies of the retrieved articles for additional potentially relevant references. All studies were independently abstracted by two reviewers using a prospectively designed worksheet. Abstraction results were analyzed with the summary receiver operating characteristic (ROC) method. RESULTS: Of 41 identified studies, 16 met the inclusion criteria. These studies reported sensitivities ranging from 63% to 100% and specificities ranging from 21% to 100%. Maximum joint sensitivity and specificity of the summary ROC curve was 89% (95% confidence interval [CI]: 82%, 93%). At a sensitivity of 95%, specificity was 67%. When test performance values were applied to a previous cost-effectiveness analysis, the cost-effectiveness of preoperative MR imaging relative to that of excisional biopsy was confirmed, but its cost-effectiveness relative to that of needle core biopsy varied widely. CONCLUSION: For MR imaging to be a cost-effective alternative to excisional biopsy for diagnosis of suspicious breast lesions, its diagnostic test performance must be equal to or better than the best results in recently published studies.

Total proctocolectomy and ileoanal pouch: the role of contrast studies for evaluating postoperative leaks.

BACKGROUND: To assess the role of contrast enemas for the evaluation of leaks in symptomatic and asymptomatic patients after the first stage of restorative proctocolectomy. METHODS: We reviewed the findings of 59 contrast enemas in 40 patients who underwent total proctocolectomy with creation of an ileoanal pouch and a proximal diverting ileostomy. Thirty-seven patients initially underwent routine contrast studies of the ileoanal pouch, and three underwent contrast studies because of suspected fistulas or obstruction. Medical records were also reviewed to determine the clinical presentation and course of these patients. RESULTS: Of 37 patients who underwent routine postoperative contrast enemas, 33 (89%) had normal studies, three (8%) had clinically silent leaks (including two blind-ending tracks from the ileoanal anastomosis and one from the pouch), and one (3%) had pouchitis. In all three patients with unsuspected leaks, ileostomy closure was delayed. In two other patients with abdominal pain and fever, contrast enemas revealed leaks from the ileoanal pouch and distal ileum, respectively. The remaining patient had a contrast enema because of abdominal pain and distention; this patient had a distal ileal obstruction due to adhesions. CONCLUSIONS: Routine postoperative contrast studies revealed clinically silent leaks from the ileal J pouch or ileoanal anastomosis in three of 37 patients (8%) after the first stage of restorative proctocolectomy. Our findings suggest that routine contrast enema can detect clinically silent leaks after this surgery.