Breast Arterial Calcifications on Mammography: Awareness and Reporting Preferences Amongst Referring Physicians in Canada.

Purpose: Breast arterial calcifications (BAC) on mammography have been correlated with increased cardiovascular risk. The Canadian Society of Breast Imaging released a position statement on BAC reporting in January 2023. This study evaluates the awareness of the clinical significance of BAC and reporting preferences of referring physicians in Canada. Methods: A 15-question survey was distributed to Canadian physicians who may review mammography results via regional and subspecialty associations and on social media following local institutional ethical approval. Responses were collected over 10 weeks from February to April 2023. Results: Seventy-two complete responses were obtained. We are unable to determine the response rate, given the means of distribution. Only 17% (12/72) of responding physicians were previously aware of the association between BAC and increased cardiovascular risk, and 51% (37/72) preferred the inclusion of BAC in the mammography report. Fifty-six percent (40/72) indicated that BAC reporting would prompt further investigation, and 63% (45/72) would inform patients that their mammogram showed evidence of BAC. Sixty-nine percent (50/72) would find grading of BAC beneficial and 71% (51/72) agreed that there is a need for national guidelines. Conclusion: Less than a quarter of responding Canadian referring physicians were previously aware of the association between BAC and cardiovascular risk, although half of respondents indicated a preference for BAC reporting on mammography. Most participating physicians would inform their patients of the presence of BAC and consider further cardiovascular risk management. There was consensus that a national BAC grading system and clinical management guidelines would be beneficial.

Authorship gender among articles about artificial intelligence in breast imaging.

RATIONALE AND OBJECTIVES: The purpose of this study is to investigate the variance of women authors, specifically first and senior authorship among peer-reviewed artificial intelligence-related articles with a specific focus in breast imaging. MATERIALS AND METHODS: A strategic search was conducted in July 2022 according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to capture all existing and publicly available peer-reviewed articles intersecting AI and breast imaging. Primary outcomes were first and senior authors' gender, which were assigned with the aid of an emailed self-declaration survey. Secondary outcomes included country of article, journal impact factor, and year of publication. Comparisons were made using logistic regression models and analysis of variances. RESULTS: 115 studies were included in the analysis. Women authors represented 35.7% (41/115) and 37.4% (43/115) of first and senior authors, respectively. Logistic regression modelling showed a significant increase in women senior authors over time but no changes in women first authors. Impact factor was not associated with female authorship and certain countries had women authorship reach over 50%. CONCLUSION: This study demonstrates that there is a significant authorship gender gap in artificial intelligence breast imaging research. An increasing temporal trend of senior authors in breast imaging AI-related research is a promising prognosis for more women voices in this field. Further study needs to be done to understand the reasons behind this gap and any potential implications.

Breast Cancer Screening in the Intermediate-Risk Population: Falling Through the Cracks?

Breast cancer screening guidelines vary for women at intermediate risk (15%-20% lifetime risk) for developing breast cancer across jurisdictions. Currently available risk assessment models have differing strengths and weaknesses, creating difficulty and ambiguity in selecting the most appropriate model to utilize. Clarifying which model to utilize in individual circumstances may help determine the best screening guidelines to use for each individual.

Addressing Misinformation About the Canadian Breast Screening Guidelines.

Screening mammography has been shown to reduce breast cancer mortality by 41% in screened women ages 40-69 years. There is misinformation about breast screening and the Canadian breast screening guidelines. This can decrease confidence in screening mammography and can lead to suboptimal recommendations. We review some of this misinformation to help radiologists and referring physicians navigate the varied international and provincial guidelines. We address the ages to start and stop breast screening. We explore how these recommendations may vary for specific populations such as patients who are at increased risk, transgender patients and minorities. We identify who would benefit from supplemental screening and review the available supplemental screening modalities including ultrasound, MRI, contrast-enhanced mammography and others. We describe emerging technologies including the potential use of artificial intelligence for breast screening. We provide background on why screening policies vary across the country between provinces and territories. This review is intended to help radiologists and referring physicians understand and navigate the varied international and provincial recommendations and guidelines and make the best recommendations for their patients.

Correlation Between Breast Arterial Calcifications and Higher Cardiovascular Risk: Awareness and Attitudes Amongst Canadian Radiologists Who Report Mammography.

Background: Breast arterial calcification (BAC) on mammography correlates with increased cardiovascular risk. Reporting BAC is not standard practice. Our study evaluates the awareness of Canadian radiologists who report mammography of the clinical significance of BAC and their attitudes towards reporting BAC compared to their European and American counterparts. Methods: Following local institutional ethics approval, a 25 question survey (SurveyMonkey) was disseminated to Canadian radiologists via provincial and national society email lists. Responses were collected over 5 weeks (April-June 2022). Results: One hundred and eighty-six complete responses were collected. Sixty percent (112/186) were aware of the association between BAC and cardiovascular risk and 16% (29/186) document its presence in mammogram reports. Thirty five percent (65/186) occasionally document BAC if severe or in a young patient. Four percent (7/186) had local departmental guidelines on BAC reporting and 82% (153/186) agreed there is a need for national BAC reporting guidelines. Fewer Canadian radiologists were aware of the association between BAC and cardiovascular risk compared to European radiologists (60% vs 81%), report the presence of BAC compared to both European (15% vs 62%) and American (15% vs 35%) radiologists, and inform the patient of the presence of BAC compared to European radiologists (1% vs 46%). Conclusion: Canadian radiologists who report mammography were less aware of the association between BAC and cardiovascular risk than their European and American counterparts and were less likely to document the presence of BAC. Given the correlation of BAC with increased cardiovascular event risk, there is increased need for awareness as well as national BAC reporting guidelines.

Gender Disparity in Surgical Device Patents: A Five-year Trend From Canada and the United States.

INTRODUCTION: Despite an increasing number of women pursuing careers in science, engineering, and medicine, gender disparities in patents persist. This study sought to analyze trends in inventor's gender for surgical device patents filed and granted in Canada and the United States from 2015 to 2019. METHODS: This study analyzed patents filed and granted by the Canadian Intellectual Property Office (CIPO) in the category of "Diagnosis; Surgery; Identification" and the United States Patent and Trademark Office (USPTO) in the category of "Surgery" from 2015 to 2019. The gender of the patent applicants was determined using a gender algorithm that predicts gender based on first names. Gender matches with names having a probability of less than 95% were excluded. RESULTS: We identified 14,312 inventors on patents filed and 12,737 inventors on patents granted by the CIPO for "Diagnosis; Surgery; Identification". In the USPTO category of "Surgery," we identified 75,890 inventors on patents filed and 44,842 inventors on patents granted. Female inventors accounted for 7%-10% of inventors from 2015 to 2019 for both patents filed and granted. The proportion of female inventors on patents granted was significantly lower than for patents filed for four of the 5 y analyzed for both the USPTO and CIPO. CONCLUSIONS: Female representation in surgical device patenting has stagnated, between 7 and 10%, from 2015 to 2019 in Canada and the United States. This underrepresentation of female inventors in surgical device patenting represents sizable gender disparity.

Unsuspected Pregnancies in Hysterosalpingography: Implementation and Review of a Multi-Institutional Pre-Procedural Pregnancy Screening Protocol.

PURPOSE: Owing to the increasing average age of first-time mothers, as well as advances in assistive reproductive technology, the number of hysterosalpingography (HSG) requests has continued to rise. This increases the likelihood of patients presenting with unsuspected early pregnancies prior to HSG. Currently, there is no standard of practice for the pre-procedural screening of pregnancy prior to HSG, with most institutions using patient-reported pregnancy status and unreliable menstrual cycle dating methods. We implemented a multi-institutional pre-procedural pregnancy screening protocol in order to determine the rate of unsuspected pregnancies prior to HSG and improve the quality and safety of these procedures. METHODS: Following multi-institutional and multidisciplinary input, a consensus protocol was formulated and implemented across 9 institutions in the Lower Mainland of British Columbia, Canada. Subsequent tracking of pregnancy testing was then performed over a period of 3 years. RESULTS: Pre-implementation review of protocols demonstrated large disparities between institutions. A total of 6333 HSG examinations were scheduled in the review period following implementation. Of these, 10 patients were found to have positive pregnancy tests (0.16%), despite self-reporting that they were not pregnant or had recent menstrual bleeding. DISCUSSION: Hysterosalpingography is contraindicated in pregnancy, yet we identified 10 unsuspected pregnancies in patients who would have otherwise undergone HSG examinations with existing guidelines. While there remains insufficient data on the deleterious effects of performing HSG on an unsuspected pregnancy, the potential physical, economical, and psychosocial consequences of performing an HSG during pregnancy are sufficient to merit consideration of relatively inexpensive routine pregnancy screening prior to HSG.

Multidisciplinary Development of Mobile Radiography Guidelines Reduced the Number of Inappropriate Mobile Exams in Patients Receiving Chest Radiographs in British Columbia.

AIM: To decrease the number of mobile chest radiograph requests for inpatients in British Columbia who are medically able to tolerate transport to the main department by introducing and implementing request criteria. METHOD: Concerns regarding inappropriate mobile exam requests in patients receiving chest radiography were surveyed at 28 medical imaging sites. In response, a multidisciplinary team composed a set of mobile radiography request guidelines incorporating feedback from all sites. These were successfully implemented along with in-person education to 21 sites. The number of adult annual mobile chest radiographs was tracked from 2014 to 2018, and informal feedback was obtained from participating sites. RESULTS: The percentage of mobile chest radiographs of all chest radiographs performed between 2014 and 2018 decreased by 3.2%, while the total number of all chest radiographs performed during this time, including both departmental and mobile, increased by 1.9%. Sites reported positive engagement with the initiative and expressed need for ongoing education to optimize its effect. CONCLUSION: Implementation of request guidelines with in-person education helped to reduce inappropriate mobile exams in patients receiving chest radiographs in British Columbia between 2014 and 2018. These guidelines promote patient safety through reduced radiation exposure, empower radiographers to mitigate inappropriate requests, and help to optimize use of limited hospital resources by reducing inappropriate mobile exams where routine departmental exams are more suitable.

Predictors of long-term outcome in patients with well-differentiated gastroenteropancreatic neuroendocrine tumors after peptide receptor radionuclide therapy with 177Lu-octreotate.

UNLABELLED: Outcome analyses for patients with gastroenteropancreatic neuroendocrine tumors (GEP NET) after peptide receptor radionuclide therapy (PRRT) are still limited, especially with regard to the impact of the Ki-67 index. Using a single-center analysis, we aimed to establish predictors of survival. METHODS: We retrospectively analyzed a consecutive cohort of 74 patients who had metastatic GEP NET and underwent PRRT with (177)Lu-octreotate (mean activity of 7.9 GBq per cycle, aimed at 4 treatment cycles at standard intervals of 3 mo). Patients (33 with pancreatic NET and 41 with nonpancreatic GEP NET) had unresectable metastatic disease graded as G1 or G2 (G1/G2) and documented morphologic or clinical progression within less than 12 mo or uncontrolled disease under somatostatin analog treatment. Responses were evaluated according to modified Southwest Oncology Group criteria. Potential predictors of survival were analyzed with the Kaplan-Meier curve method (log-rank test) and multivariate analysis (P < 0.05). RESULTS: The response rates were 36.5% partial response, 17.6% minor response, 35.1% stable disease, and 10.8% progressive disease for the entire cohort; 54.5% partial response, 18.2% minor response, 18.2% stable disease, and 9.1% progressive disease for pancreatic NET; and 22.0% partial response, 17.1% minor response, 48.8% stable disease, and 12.2% progressive disease for nonpancreatic GEP NET. The median progression-free survival and overall survival were 26 mo (95% confidence interval, 18.3-33.7) and 55 mo (95% confidence interval, 48.8-61.2), respectively. Besides the Ki-67 index, a Karnofsky performance score of less than or equal to 70%, a hepatic tumor burden of greater than or equal to 25%, and a baseline plasma level of neuron-specific enolase of greater than 15 ng/mL independently predicted shorter overall survival (hazard ratio, 2.1-3.1). Patients with a Ki-67 index of greater than 10% still had median progression-free survival and overall survival of 19 and 34 mo, respectively. CONCLUSION: The results of this study demonstrated the favorable response and long-term outcome of patients with G1/G2 GEP NET after PRRT. Independent predictors of survival were the Ki-67 index, the patient's performance status (Karnofsky performance scale score), the tumor burden, and the baseline neuron-specific enolase level. Even patients with a Ki-67 index of greater than 10% seemed to benefit from PRRT, with a good response and a notable long-term outcome. We present the first evidence, to our knowledge, that even in patients with metastatic disease the distinction between G1 and G2-in particular, between G1 (Ki-67 index of 1%-2%) and low-range G2 (Ki-67 index of 3%-10%)-provides prognostic stratification.

Long-term outcome and toxicity after dose-intensified treatment with 131I-MIBG for advanced metastatic carcinoid tumors.

UNLABELLED: Reported experience with systemic (131)I-metaiodobenzylguanidine ((131)I-MIBG) therapy of neuroendocrine tumors comprises different dosing schemes. The aim of this study was to assess the long-term outcome and toxicity of treatment with 11.1 GBq (300 mCi) of (131)I-MIBG per cycle. METHODS: We performed a retrospective review of 31 patients with advanced metastatic neuroendocrine tumors (20 with carcinoid tumors and 11 with other tumors) treated with (131)I-MIBG. Treatment outcome was analyzed for patients with carcinoid tumors (the most common tumors in this study), and toxicity was analyzed for the entire patient cohort (n = 31). Treatment comprised 11.1 GBq (300 mCi) per course and minimum intervals of 3 mo. The radiographic response was classified according to modified Response Evaluation Criteria in Solid Tumors. Toxicity was determined according to Common Terminology Criteria for Adverse Events (version 3.0) for all laboratory data at regular follow-up visits and during outpatient care, including complete blood counts and hepatic and renal function tests. Survival analysis was performed with the Kaplan-Meier curve method (log rank test; P < 0.05). RESULTS: The radiographic responses in patients with carcinoid tumors comprised a minor response in 2 patients (10%), stable disease in 16 patients (80%; median time to progression, 34 mo), and progressive disease in 2 patients (10%). The symptomatic responses in patients with functioning carcinoid tumors comprised complete resolution in 3 of the 11 evaluable symptomatic patients (27%), partial resolution in 6 patients (55%), and no significant change in 11 patients. The median overall survival in patients with carcinoid tumors was 47 mo (95% confidence interval, 32-62), and the median progression-free survival was 34 mo (95% confidence interval, 13-55). Relevant treatment toxicities were confined to transient myelosuppression of grade 3 or 4 in 15.3% (leukopenia) and 7.6% (thrombocytopenia) of applied cycles and a suspected late adverse event (3% of patients), myelodysplastic syndrome, after a cumulative administered activity of 66.6 GBq. The most frequent nonhematologic side effect was mild nausea (grade 1 or 2), which was observed in 28% of administered cycles. No hepatic or renal toxicities were noted. CONCLUSION: Dose-intensified treatment with (131)I-MIBG at a fixed dose of 11.1 GBq (300 mCi) per cycle is safe and offers effective palliation of symptoms and disease stabilization in patients with advanced carcinoid tumors. The favorable survival and limited toxicity suggest that high cycle activities are suitable and that this modality may be used for targeted carcinoid treatment--either as an alternative or as an adjunct to other existing therapeutic options.

Does the pretherapeutic tumor SUV in 68Ga DOTATOC PET predict the absorbed dose of 177Lu octreotate?

PURPOSE: Selection of candidates for peptide receptor radionuclide therapy (PRRT) is increasingly based on receptor positron emission tomography (PET) imaging, including the common tracer 68Ga DOTATOC. However, no studies have yet compared standardized uptake values (SUVs) and absorbed doses in this field. MATERIALS AND METHODS: We retrospectively analyzed a consecutive cohort of 21 patients with 61 evaluable tumor lesions undergoing both pretherapeutic 68Ga DOTATOC-PET/CT (Biograph Duo [Siemens Medical Solutions, Erlangen, Germany]; PET acquisition, 75.3 ± 15.4 minutes postinjection; 117.3 ± 33.9 MBq 68Ga DOTATOC) and PRRT with Lu octreotate (7.47 ± 1.39 GBq; intratherapeutic tumor dosimetry with serial whole-body scans; 1, 2, and 4 days postinjection) at our institution. SUVs were compared with the tumor-absorbed doses per injected activity (D/A0) of the subsequent first treatment cycle. RESULTS: The correlation of SUV and D/A0 was r = 0.72 (SUVmean) and r = 0.71 (SUVmax), both P < 0.001. Pancreatic origin and hepatic localization were associated with higher D/A0, and chromogranin A level and Ki-67 index had no influence on SUV or D/A0. High-SUV lesions (SUVmean >15; SUVmax >25) resulted in high D/A0 (>10 Gy/GBq) in 66.7% to 70.8% and low D/A0 (<5 Gy/GBq) in only 8.3% to 12.5% on subsequent PRRT. The mentioned low D/A0 range, on the other hand, was achieved by all lesions with SUVmean <7 or SUVmax <9. CONCLUSIONS: Somatostatin receptor PET imaging may predict tumor-absorbed doses. The ability to indicate insufficient target irradiation by a low SUV could aid in selection of appropriate candidates for PRRT. However, larger series are needed to confirm and validate these initial findings.

Response and long-term control of bone metastases after peptide receptor radionuclide therapy with (177)Lu-octreotate.

UNLABELLED: Peptide receptor radionuclide therapy (PRRT) is an efficient treatment for gastroenteropancreatic neuroendocrine tumors (GEP NETs), with outstanding overall response rates and survival. However, little is known about the particular efficacy regarding bone metastasis (BM). METHODS: We retrospectively analyzed a consecutive subgroup of 42 patients with BM of GEP NETs treated with PRRT ((177)Lu-octreotate, 4 intended cycles at 3 monthly intervals [10-14 wk]; mean activity per cycle, 8.1 GBq). Availability of restaging and outcome data was required for patient inclusion. Baseline characteristics, including age, tumor origin, performance score, Ki-67 index, tumor load, tumor uptake, plasma chromogranin A, and neuron-specific enolase, were analyzed regarding impact on tumor regression (modified M.D. Anderson criteria) and time to progression. Survival analyses were performed using Kaplan-Meier curves, log-rank test at a significance level of P less than 0.05, and Cox proportional hazards model for uni- and multivariate analyses. RESULTS: Median follow-up was 32 mo. The observed response of BMs consisted of complete remission in 2 (4.8%), partial remission in 14 (33.3%), minor response in 5 (11.9%), stable disease in 16 (38.1%), and progressive disease in 5 (11.9%) patients. Median progression-free survival and overall survival (OS) were 35 mo (26-44, 95% confidence interval) and 51 mo (37-65, 95% confidence interval), respectively. Patients with responding BMs (complete remission, partial remission, or minor response) exhibited a trend toward better OS (median OS not reached after 53 mo) when compared to nonresponding patients (39 mo, P = 0.076). Only Ki-67 index (>10%) and chromogranin A level (>600 ng/mL) contributed to regression analysis. CONCLUSION: BM of GEP NETs is effectively controlled by PRRT, with long progression-free survival and OS. Poor patient condition and multifocality of BMs do not clearly affect treatment efficacy, possibly encouraging the use of PRRT in advanced bone metastatic disease. Larger studies are needed to assess predictors of treatment outcome in these patients.