Motivations for completing pulmonary rehabilitation - A qualitative analysis.

Background: Previous studies have focused on demographic factors that might predict non-completion of pulmonary rehabilitation (PR). We aimed to identify key modifiable factors that promote completion of PR. Methods: A mixed methods survey was offered to participants completing a discharge assessment following PR. Descriptive statistics and inductive thematic analysis were used to analyse the survey responses, with investigator triangulation. Results: 62 of 187 (33%) patients attending a PR discharge assessment between November 2022 and April 2023 returned the anonymised survey. Desire to improve health and wellbeing was the main reason for both initially committing to a course and for continuing with PR past transient thoughts of leaving. The positive impact of staff was the second most common reason. The enjoyment of the PR programme, being held accountable to attend classes, and the importance of other group members were other key themes identified. Conclusions: In conclusion, our findings suggest PR services need to implement strategies which ensure regular promotion and reinforcement of the health benefits of PR as well as implementation of PR modalities which best monopolise on the positive impact skilled staff have on motivating patients to complete PR.

Radiation doses and fractionation schedules in non-low-risk ductal carcinoma in situ in the breast (BIG 3-07/TROG 07.01): a randomised, factorial, multicentre, open-label, phase 3 study.

BACKGROUND: Whole breast irradiation (WBI) after conservative surgery for ductal carcinoma in situ (DCIS) reduces local recurrence. We investigated whether a tumour bed boost after WBI improved outcomes, and examined radiation dose fractionation sensitivity for non-low-risk DCIS. METHODS: The study was an international, randomised, unmasked, phase 3 trial involving 136 participating centres of six clinical trials organisations in 11 countries (Australia, New Zealand, Singapore, Canada, the Netherlands, Belgium, France, Switzerland, Italy, Ireland, and the UK). Eligible patients were women aged 18 years or older with unilateral, histologically proven, non-low-risk DCIS treated by breast-conserving surgery with at least 1 mm of clear radial resection margins. They were assigned to one of four groups (1:1:1:1) of no tumour bed boost versus boost after conventional versus hypofractionated WBI, or randomly assigned to one of two groups (1:1) of no boost versus boost after each centre prespecified conventional or hypofractionated WBI. The conventional WBI used was 50 Gy in 25 fractions, and hypofractionated WBI was 42·5 Gy in 16 fractions. A boost dose of 16 Gy in eight fractions, if allocated, was delivered after WBI. Patients and clinicians were not masked to treatment allocation. The primary endpoint was time to local recurrence. This trial is registered with ClinicalTrials.gov (NCT00470236). FINDINGS: Between June 25, 2007, and June 30, 2014, 1608 patients were randomly assigned to have no boost (805 patients) or boost (803 patients). Conventional WBI was given to 831 patients, and hypofractionated WBI was given to 777 patients. Median follow-up was 6·6 years. The 5-year free-from-local-recurrence rates were 92·7% (95% CI 90·6-94·4%) in the no-boost group and 97·1% (95·6-98·1%) in the boost group (hazard ratio 0·47; 0·31-0·72; p<0·001). The boost group had higher rates of grade 2 or higher breast pain (10% [8-12%] vs 14% [12-17%], p=0·003) and induration (6% [5-8%] vs 14% [11-16%], p<0·001). INTERPRETATION: In patients with resected non-low-risk DCIS, a tumour bed boost after WBI reduced local recurrence with an increase in grade 2 or greater toxicity. The results provide the first randomised trial data to support the use of boost radiation after postoperative WBI in these patients to improve local control. The international scale of the study supports the generalisability of the results. FUNDING: National Health and Medical Research Council of Australia, Susan G Komen for the Cure, Breast Cancer Now, OncoSuisse, Dutch Cancer Society, Canadian Cancer Trials Group.

Implementation of Abbreviated Breast MRI for Screening: AJR Expert Panel Narrative Review.

Abbreviated breast MRI (AB-MRI) is being rapidly adopted to harness the high sensitivity of screening MRI while addressing issues related to access, cost, and workflow. The successful implementation of an AB-MRI program requires collaboration across administrative, operational, financial, technical, and clinical providers. Institutions must be thoughtful in defining patient eligibility for AB-MRI and providing recommendations for screening intervals, as existing practices are heterogeneous. Similarly, there is no universally accepted AB-MRI protocol, though guiding principles should harmonize abbreviated and full protocols while being mindful of scan duration and amount of time patients spend on the MRI table. The interpretation of AB-MRI will be a new experience for many radiologists and may require a phased rollout and a careful audit of performance metrics over time to ensure benchmark metrics are achieved. AB-MRI finances, which are driven by patient self-payment, will require buy-in from hospital administration with the recognition that downstream revenues will be needed to support initial costs. Finally, successful startup of an AB-MRI program requires active engagement with the larger community of patients and referring providers. As AB-MRI becomes more widely accepted and available, best practices and community standards will continue to evolve to ensure high-quality patient care.

Patient Characteristics Associated With Patient-Reported Deterrents to Adjunct Breast Cancer Screening of Patients With Dense Breasts.

BACKGROUND. The success of adjunct breast cancer screening of women with dense breasts can be enhanced by identifying and addressing patient concerns regarding adjunct screening modalities. OBJECTIVE. The purpose of this study was to identify patient characteristics associated with patient-reported concerns about adjunct breast cancer screening to facilitate the development of a more effective screening model for women with dense breasts. METHODS. Patients with dense breasts completed surveys between March 2017 and February 2018 regarding factors that might deter them from adjunct screening and about which of three hypothetical screening examinations they might prefer. Additional patient data were extracted from medical records, and socioeconomic data were imputed from federal census data. Logistic regression analyses were conducted to identify associations between patient characteristics and patient attitudes toward adjunct screening. RESULTS. Surveys were completed by 508 women (median age, 59.0 years) with dense breasts. Lower confidence in the sensitivity of mammography of dense breasts was independently associated with lesser concern about adjunct screening examination time (1 divided by adjusted odds ratio [1/AOR], 0.55 [95% CI, 0.34-0.89]), additional imaging that could result (1/AOR, 0.51 [95% CI, 0.31-0.85]), and greater preference for a more sensitive hypothetical screening examination (1/AOR, 1.85 [95% CI, 1.20-2.86]). Concern about examination cost, the most commonly cited deterrent to adjunct screening (66.9%), was independently associated with younger age (1/AOR, 1.45 [95% CI, 1.01-2.08]) but not with imputed socioeconomic variables or other tested variables. Younger age was also associated with lesser concern about pain (1/AOR, 0.69 [95% CI, 0.48-0.99]), additional imaging that could result (1/AOR, 0.48 [95% CI, 0.31-0.76]), and IV contrast administration (1/AOR, 0.56 [95% CI, 0.37-0.83]). CONCLUSION. Younger age and lower confidence in the sensitivity of mammography among women with dense breasts are independently associated with lesser patient concern about common deterrents to adjunct breast cancer screening. Younger age is independently associated with greater concern about the cost of undergoing adjunct breast cancer screening. CLINICAL IMPACT. Concerns about adjunct screening may be reduced by educating patients about the lower sensitivity of mammography of dense breasts and by finding ways to address or mitigate the financial and daily-life impact of adjunct screening, especially for younger patients.

Comparison of Abbreviated Breast MRI vs Digital Breast Tomosynthesis for Breast Cancer Detection Among Women With Dense Breasts Undergoing Screening.

Importance: Improved screening methods for women with dense breasts are needed because of their increased risk of breast cancer and of failed early diagnosis by screening mammography. Objective: To compare the screening performance of abbreviated breast magnetic resonance imaging (MRI) and digital breast tomosynthesis (DBT) in women with dense breasts. Design, Setting, and Participants: Cross-sectional study with longitudinal follow-up at 48 academic, community hospital, and private practice sites in the United States and Germany, conducted between December 2016 and November 2017 among average-risk women aged 40 to 75 years with heterogeneously dense or extremely dense breasts undergoing routine screening. Follow-up ascertainment of cancer diagnoses was complete through September 12, 2019. Exposures: All women underwent screening by both DBT and abbreviated breast MRI, performed in randomized order and read independently to avoid interpretation bias. Main Outcomes and Measures: The primary end point was the invasive cancer detection rate. Secondary outcomes included sensitivity, specificity, additional imaging recommendation rate, and positive predictive value (PPV) of biopsy, using invasive cancer and ductal carcinoma in situ (DCIS) to define a positive reference standard. All outcomes are reported at the participant level. Pathology of core or surgical biopsy was the reference standard for cancer detection rate and PPV; interval cancers reported until the next annual screen were included in the reference standard for sensitivity and specificity. Results: Among 1516 enrolled women, 1444 (median age, 54 [range, 40-75] years) completed both examinations and were included in the analysis. The reference standard was positive for invasive cancer with or without DCIS in 17 women and for DCIS alone in another 6. No interval cancers were observed during follow-up. Abbreviated breast MRI detected all 17 women with invasive cancer and 5 of 6 women with DCIS. Digital breast tomosynthesis detected 7 of 17 women with invasive cancer and 2 of 6 women with DCIS. The invasive cancer detection rate was 11.8 (95% CI, 7.4-18.8) per 1000 women for abbreviated breast MRI vs 4.8 (95% CI, 2.4-10.0) per 1000 women for DBT, a difference of 7 (95% CI, 2.2-11.6) per 1000 women (exact McNemar P = .002). For detection of invasive cancer and DCIS, sensitivity was 95.7% (95% CI, 79.0%-99.2%) with abbreviated breast MRI vs 39.1% (95% CI, 22.2%-59.2%) with DBT (P = .001) and specificity was 86.7% (95% CI, 84.8%-88.4%) vs 97.4% (95% CI, 96.5%-98.1%), respectively (P < .001). The additional imaging recommendation rate was 7.5% (95% CI, 6.2%-9.0%) with abbreviated breast MRI vs 10.1% (95% CI, 8.7%-11.8%) with DBT (P = .02) and the PPV was 19.6% (95% CI, 13.2%-28.2%) vs 31.0% (95% CI, 17.0%-49.7%), respectively (P = .15). Conclusions and Relevance: Among women with dense breasts undergoing screening, abbreviated breast MRI, compared with DBT, was associated with a significantly higher rate of invasive breast cancer detection. Further research is needed to better understand the relationship between screening methods and clinical outcome. Trial Registration: ClinicalTrials.gov Identifier: NCT02933489.

Investigating the feasibility of stratified breast cancer screening using a masking risk predictor.

BACKGROUND: Women with dense breasts face a double risk for breast cancer; they are at a higher risk for development of breast cancer than those with less dense breasts, and there is a greater chance that mammography will miss detection of a cancer in dense breasts due to the masking effect of surrounding fibroglandular tissue. These women may be candidates for supplemental screening. In this study, a masking risk model that was previously developed is tested on a cohort of cancer-free women to assess potential efficiency of stratification. METHODS: Three masking risk models based on (1) BI-RADS density, (2) volumetric breast density (VBD), and (3) a combination of VBD and detectability were applied to stratify the mammograms of 1897 cancer-free women. The fraction of cancer-free women whose mammograms were deemed by the algorithm to be masked and who would be considered for supplemental imaging was computed as was the corresponding fraction in a screened population of interval (masked) cancers that would be potentially detected by supplemental imaging. RESULTS: Of the models tested, the combined VBD/detectability model offered the highest efficiency for stratification to supplemental imaging. It predicted that 725 supplemental screens would be performed per interval cancer potentially detected, at an operating point that allowed detection of 64% of the interval cancers. In comparison, stratification based on the upper two BI-RADS density categories required 1117 supplemental screenings per interval cancer detected to capture 64% of interval cancers. CONCLUSION: The combined VBD/detectability models perform better than BI-RADS and offer a continuum of operating points, suggesting that this model may be effective in guiding a stratified screening environment.

Anti-myeloperoxidase antibody positivity in patients without primary systemic vasculitis.

OBJECTIVES: We aimed to elucidate the frequency and associations of MPO-ANCA positivity in patients without ANCA-associated vasculitis (AAV), in a large urban, multi-ethnic teaching hospital. METHODS: Retrospective review of 200 patients identified as MPO-ANCA positive over a five-year period at Royal Free Hospital, London, UK. RESULTS: The incidence of anti-MPO positivity in patients without AAV was 39.5%. Gastrointestinal tract disorders, infections and other connective tissue disorders made up the majority of diagnoses, and there was a higher incidence of other concomitant autoantibodies compared to the group with known AAV. Renal disease was common in non-vasculitic patients with anti-MPO antibody positivity (occurring in 48%), the majority of whom went on to renal biopsy to exclude vasculitic involvement. CONCLUSIONS: The high incidence of MPO-ANCA positivity in patients with non-vasculitic conditions highlights the need for careful clinical correlation and confirmatory tissue diagnosis.

Evaluation of Pediatric Cardiac ICU Advanced Practice Provider Education and Practice Variation.

OBJECTIVES: The education, training, and scope of practice of cardiac ICU advanced practice providers is highly variable. A survey was administered to cardiac ICU advanced practice providers to examine specific variations in orientation format, competency assessment during and at the end of orientation, and scope of clinical practice to determine gaps in resources and need for standardization. DESIGN: This study was a cross-sectional descriptive study utilizing survey responses. SETTING: Pediatric cardiac ICUs in the United States. SUBJECTS: The survey was delivered to a convenience sample of advanced practice providers currently practicing in pediatric cardiac ICUs. INTERVENTIONS: A list of pediatric cardiothoracic surgery programs was generated from the Society of Thoracic Surgery database. A self-administered, electronic survey was delivered via email to advanced practice providers at those institutions. Descriptive data were compared using a chi-square test or Fisher exact test depending on the normalcy of data. Continuous data were compared using a Student t test or Mann-Whitney U test. MEASUREMENTS AND MAIN RESULTS: Eighty-three of 157 advanced practice providers responded (53% response rate, representing 36 institutions [35% of institutions]). Sixty-five percent of respondents started as new graduates. Ninety-three to one-hundred percent obtain a history and physical, order/interpret laboratory, develop management plans, order/titrate medications, and respiratory support. Ability to perform invasive procedures was highly variable but more likely for those in a dedicated cardiac ICU. Seventy-seven percent were oriented by another advanced practice provider, with a duration of orientation less than 4 months (66%). Fifty percent of advanced practice providers had no guidelines in place to guide learning/competency during orientation. Sixty-seven percent were not evaluated in any way on their knowledge or skills during or at the end of orientation. Orientation was rated as poor/fair by the majority of respondents for electrophysiology (58%) and echocardiography (69%). Seventy-one percent rated orientation as moderately effective or less. Respondents stated they would benefit from more structured didactic education with clear objectives, standardized management guidelines, and more simulation/procedural practice. Eighty-five percent were very/extremely supportive of a standardized cardiac ICU advanced practice provider curriculum. CONCLUSIONS: Orientation for cardiac ICU advanced practice providers is highly variable, content depends on the institution/preceptor, and competency is not objectively defined or measured. A cardiac ICU advanced practice provider curriculum is needed to standardize education and promote the highest level of advanced practice provider practice.

The impact of bariatric surgery on qualitative and quantitative breast density.

BACKGROUND: Obesity and breast density are associated with breast cancer in postmenopausal women. Bariatric surgery effectively treats morbid obesity, with sustainable weight loss and reductions in cancer incidence. We evaluated changes in qualitative and quantitative density; hypothesizing breast density would increase following bariatric surgery. METHODS: Women undergoing bariatric surgery from 1990 to 2015 were identified, excluding patients without a mammogram performed both before and after surgery. Changes in body mass index (BMI), time between mammograms and surgery, and American College of Radiology Breast Imaging Reporting and Data System (BI-RADS) scores were assessed. VolparaDensity™ automated software calculated volumetric breast density (VBD), fibroglandular volume (FGV), and total breast volume for the 82 women with digital data available. Differences between pre- and postsurgery values were assessed. RESULTS: One hundred eighty women were included. Median age at surgery was 50.0 years, with 8.8 months between presurgery mammogram and surgery and 62.3 months between surgery and postsurgery mammogram. Median BMI significantly decreased over the study period (46.0 vs 35.4 kg/m2 ; P < 0.001). No change in BI-RADS scores was seen between the pre- and postsurgery mammograms. Eighty-two women had VolparaDensity™ data available. While VBD increased in these patients, FGV and total breast volume both decreased following bariatric surgery. CONCLUSIONS: Increased VBD, decreased FGV, and decreased total breast volume were seen following bariatric surgery-induced weight loss. There was no difference in qualitative breast density, highlighting the discrepancy between BI-RADS and VolparaDensity™ measurements. Further investigation will be required to determine how differential changes in components of breast density may affect breast cancer risk.

Outcome of Architectural Distortion Detected Only at Breast Tomosynthesis versus 2D Mammography.

Purpose To compare the outcome of architectural distortion (AD) without associated mass only on digital breast tomosynthesis (DBT) with AD seen at two-dimensional (2D) mammography and to evaluate if the incidence of malignancy is influenced by the presence of a correlate at ultrasonography (US). Materials and Methods This retrospective study had institutional review board approval and was HIPAA compliant. All consecutive cases in which patients with AD were ultimately assigned Breast Imaging Reporting and Data System (BI-RADS) 4 or 5 categories from 2009 to 2016 were reviewed by three readers for visibility (2D vs DBT). The level of suspicion was assigned using a Likert scale. Pathologic results were compared between 2D-detected and DBT-detected AD. Frequencies were compared by using the McNemar and Pearson χ2 exact tests. Results One hundred eighty-one AD lesions were included; 122 (67.4%) were 2D visible while 59 (32.6%) were DBT detected. Forty-two women (with 43 lesions) underwent 2D mammography prior to initiation of DBT. In 117 women with 121 AD lesions who underwent 2D mammography plus DBT, 59 lesions (48.8%) were detected only with DBT. The malignancy rate based on final pathology was significantly higher for 2D-detected AD (53 [43.4%] of 122) compared with DBT (six [10.2%] of 59) (P < .001). A US correlate was more frequent with 2D-detected AD (103 [84.4%] of 122) than DBT (33 [55.9%] of 59) (P < .001). Malignancy rate was not different for DBT-detected AD with (four [12.1%] of 33; 95% confidence interval [CI]: 3.4%, 28.2%]) or without (two [7.7%] of 26; 95% CI: 0.9%, 25.1%]) a US correlate. NPV based on radiologists' level of suspicion was high (91.8%-98.0%) but not sufficient enough to forgo biopsy. Conclusion DBT-detected suspicious AD has a lower malignancy outcome compared with 2D mammography-detected suspicious AD, although still high enough to warrant biopsy. © RSNA, 2018 Online supplemental material is available for this article.

Do women with dense breasts have higher radiation dose during screening mammography?

Radiation dose during screening mammography is a concern among women. The purpose of this study was to evaluate the relative contribution of breast density to the radiation dose from screening mammography. This IRB approved retrospective study involved collecting patient age, weight, height, compressed breast thickness, and average glandular dose for each exposure for 434 sequential patients undergoing screening mammography at our institution. Automated volumetric density software was used to quantify breast density. The relationship of predictors was evaluated by univariate and multivariate analysis. Median patient age was 58 years and median body mass index (BMI) was 26.8. Median volumetric breast density was 5.8% (range 1.7-30.5%). Median compressed breast thickness was 63.4 mm (range 24.5-111.5 mm). Univariate analysis showed positive associations between radiation dose and both breast thickness and BMI, an inverse association with age, and no association with density. Multivariate regression analysis demonstrated a significant association between dose and age (P=.021), laterality (P<.001), BMI (P=.038), density (P<.001), and breast thickness (P<.001). Decomposition of the multivariate regression model coefficient of determination showed that breast thickness was the primary determinant of dose, accounting for 76% of the 58% of the dose variability, followed by density (8%), laterality (4%), age (<1%), and BMI (<1%). Compressed breast thickness had the greatest effect on average glandular dose. Breast density has a minor impact, while BMI and age have minimal impact on dose.

Comparison Between Digital and Synthetic 2D Mammograms in Breast Density Interpretation.

OBJECTIVE: The purpose of this study was to compare assessments of breast density on synthetic 2D images as compared with digital 2D mammograms. MATERIALS AND METHODS: This retrospective study included consecutive women undergoing screening with digital 2D mammography and tomosynthesis during May 2015 with a negative or benign outcome. In separate reading sessions, three radiologists with 5-25 years of clinical experience and 1 year of experience with synthetic 2D mammography read digital 2D and synthetic 2D images and assigned breast density categories according to the 5th edition of BI-RADS. Inter- and intrareader agreement was assessed for each BI-RADS density assessment and combined dense and nondense categories using percent agreement and Cohen kappa coefficient for consensus and all reads. RESULTS: A total of 309 patients met study inclusion criteria. Agreement between consensus BI-RADS density categories assigned for digital and synthetic 2D mammography was 80.3% (95% CI, 75.4-84.5%) with κ = 0.73 (95% CI, 0.66-0.79). For combined dense and nondense categories, agreement reached 91.9% (95% CI, 88.2-94.7%). For consensus readings, similar numbers of patients were shifted between nondense and dense categories (11 and 14, respectively) with the synthetic 2D compared with digital 2D mammography. Interreader differences were apparent; assignment to dense categories was greater with digital 2D mammography for reader 1 (odds ratio [OR], 1.26; p = 0.002), the same for reader 2 (OR, 0.91; p = 0.262), and greater with synthetic 2D mammography for reader 3 (OR, 0.86; p = 0.033). CONCLUSION: Overall, synthetic 2D mammography is comparable with digital 2D mammography in assessment of breast density, though there is some variability by reader. Practices can readily adopt synthetic 2D mammography without concern that it will affect density assessment and subsequent recommendations for supplemental screening.

Does Mammographic Density have an Impact on the Margin Re-excision Rate After Breast-Conserving Surgery?

BACKGROUND: Limited and conflicting data exist on an association between mammographic density (MD) and re-excision rates after breast-conserving surgery (BCS). Additionally, the correlation of MD with resection of unnecessary margins during initial BCS is unknown. METHODS: All women with a diagnosis of breast cancer from 2003 to 2012 and enrolled in a larger study on MD were evaluated. Operative and pathology reports were reviewed to determine margin resection and involvement. Mammographic density was determined both by breast imaging-reporting and data system (BI-RADS) classification and by an automated software program (Volpara Solutions). Additional margins were deemed unnecessary if the lumpectomy specimen margin was free of invasive tumor [≥2 mm for ductal carcinoma in situ (DCIS)] or if further re-excision was needed. RESULTS: Of 655 patients, 398 (60.8%) had BCS, whereas 226 (34.5%) underwent initial mastectomy. The women with denser breasts (BI-RADS 3 or 4) underwent initial mastectomy more frequently than the women with less dense breasts (40.0 vs. 30.5%, respectively; p = 0.0118). Of the patients with BCS, 166 (41.7%) required separate re-excision. Additional margins were taken during BCS in 192 (48.2%) patients, with 151 (78.6%) proving to be unnecessary. In the bivariable analysis, the patients with denser breasts according to BI-RADS classification and volumetric density showed a trend toward requiring more frequent re-excision, but this association was not seen in the multivariable analysis. The rate of unnecessary margins did not differ by breast density. In the multivariate analysis, the re-excision rates increased with DCIS (p < 0.0003) and decreased with resection of additional margins (p = 0.0043). CONCLUSIONS: Mammographic density is not associated with an increased need for re-excision or resection of unnecessary margins at initial BCS.

Reliability of automated breast density measurements.

PURPOSE: To estimate the reliability of a reference standard two-dimensional area-based method and three automated volumetric breast density measurements by using repeated measures. MATERIALS AND METHODS: Thirty women undergoing screening mammography consented to undergo a repeated left craniocaudal examination performed by a second technologist in this prospective institutional review board-approved HIPAA-compliant study. Breast density was measured by using an area-based method (Cumulus ABD) and three automated volumetric methods (CumulusV [University of Toronto], Volpara [version 1.4.5; Volpara Solutions, Wellington, New Zealand), and Quantra [version 2.0; Hologic, Danbury, Conn]). Discrepancy between the first and second breast density measurements (Δ1-2) was obtained for each algorithm by subtracting the second measurement from the first. The Δ1-2 values of each algorithm were then analyzed with a random-effects model to derive Bland-Altman-type limits of measurement agreement. RESULTS: Variability was higher for Cumulus ABD and CumulusV than for Volpara or Quantra. The within-breast density measurement standard deviations were 3.32% (95% confidence interval [CI]: 2.65, 4.44), 3.59% (95% CI: 2.86, 4.48), 0.99% (95% CI: 0.79, 1.33), and 1.64% (95% CI: 1.31, 1.39) for Cumulus ABD, CumulusV, Volpara, and Quantra, respectively. Although the mean discrepancy between repeat breast density measurements was not significantly different from zero for any of the algorithms, larger absolute breast density discrepancy (Δ1-2) values were associated with larger breast density values for Cumulus ABD and CumulusV but not for Volpara and Quantra. CONCLUSION: Variability in a repeated measurement of breast density is lowest for Volpara and Quantra; these algorithms may be more suited to incorporation into a risk model.

Digital Breast Tomosynthesis in the Diagnostic Setting: Indications and Clinical Applications.

Digital breast tomosynthesis (DBT) is an emerging technology used in diagnostic breast imaging to evaluate potential abnormalities. In DBT, the compressed breast tissue is imaged in a quasi-three-dimensional manner by performing a series of low-dose radiographic exposures and using the resultant projection image dataset to reconstruct cross-sectional in-plane images in standard mammographic views. Improved visualization of breast detail at diagnostic DBT allows improved characterization of findings, including normal structures and breast cancer. This technology reduces the summation of overlapping breast tissue, which can mimic breast cancer, and provides improved detail of noncalcified mammographic findings seen in breast cancer. It also assists in lesion localization and determining mammographic extent of disease in women with known or suspected breast cancer. The authors review the potential uses, benefits, and limitations of DBT in the diagnostic setting and discuss how radiologists can best use DBT to characterize lesions, localize potential abnormalities, and evaluate the extent of known or suspected breast cancer. The authors' experience shows that DBT can be implemented effectively in the diagnostic workflow to evaluate and localize potential lesions more efficiently. DBT may potentially replace conventional supplemental mammography at diagnostic workup and obviate ultrasonography in select cases.

3D-MR Ductography and Contrast-Enhanced MR Mammography in Patients with Suspicious Nipple Discharge; a Feasibility Study.

We evaluated contrast-enhanced magnetic resonance (ce-MR) imaging and an indirect MR galactogram (MRG) sequence against conventional galactography (CG) in women with suspicious nipple discharge who underwent histologic diagnosis. This study was Institutional Review Board approved and HIPAA compliant. Women with suspicious nipple discharge recommended for CG were recruited for our study. Patients underwent both a ce-MR as well as MRG (MRG-1 and MRG-2, variations in isotropic spatial resolution) followed by CG within 60 days. The ce-MR and MRG studies were interpreted together by a single radiologist separately from CG. Pathology was used as our gold standard and was obtained via image-guided core needle biopsy or surgery with papilloma, atypia, and malignancy considered positive. Of the 21 patients recruited for the study, 20 patients had known histology results for 26 lesions; 18 patients (90.0%) had successful CG, 20 (100.0%) ce-MRI, 20 (100.0%) MRG-1, and 19 (95.0%) MRG-2. Histology showed 5 cancers (4 women), 15 papillomas (2 with atypia) (11 women), and 6 additional benign lesions (6 women). Five patients (25.0%) had additional lesions detected by ce-MR that influenced surgical management. Sensitivity, specificity, positive (PPV), and negative predicted values (NPV) for CG, ce-MRI, MRG-1 were 65.0, 33.3, 76.5, and 22.2; 95.0, 66.7, 90.5, and 80.8; 55.0, 66.7, 84.6, and 30.8, respectively. ce-MR had the highest sensitivity, PPV, and NPV compared with CG or MRG. Our MRG protocols show promise, but were not as sensitive as ce-MRI for women with suspicious nipple discharge.

Host response to human breast Invasive Ductal Carcinoma (IDC) as observed by changes in the stromal proteome.

Following initial transformation, tumorigenesis, growth, invasion, and metastasis involves a complex interaction between the transformed tissue and the host, particularly in the microenvironment adjacent to the developing tumor. The tumor microenvironment itself is a unique outcome of the host reacting to the tumor and perhaps the tumor reacting to the host and in turn the tumor altering the host's response to give rise to an environment that ultimately promotes tumor progression. The tumor-adjacent stromal, sometimes referred to as "reactive stromal" or the desmoplastic stroma, has received some investigative studies, but it is incomplete, and likely different tumors promote a varied response and hence different reactive stroma. In this study, we have investigated the proteomics of the host response, both in vitro and in vivo, to breast epithelial cancer, in the former using tissue culture and in the latter laser microdissection of stromal tissue both adjacent and distal to breast invasive ductal cancer (IDC). From proteomic analysis of in vitro tissue culture studies, we observed that the stroma produced is related to the invasiveness of the stimulating breast cancer cell lines but different from that observed from the stromal proteome of archival tissue. In vivo we have identified several potential markers of a reactive stroma. Furthermore, we observed that the proteome of tumor-adjacent stroma differs from that of tumor-distal stroma. The proteomic description of human breast IDC stroma may serve to enhance our understanding of the role of stroma in the progression of cancer and may suggest potential mechanisms of therapeutic interdiction.

Clinical experience of a tattoo application device.

Introduction: The use of tattoos for radiation therapy (RT) treatment is common practice. The Comfort Marker 2.0 (CQ Medical, Iowa, USA) has been designed to apply tattoos with a controlled depth injection, potentially resulting in tattoos that fade over time. The aim of this study was to investigate the clinical implementation of the Comfort Marker 2.0 tattoo device including the patient experience and clinical workflow. Methods: Patients undergoing RT treatment for breast cancer were invited to participate in this prospective pilot study. Patients completed a questionnaire after the planning session rating the level of pain experienced during tattoo application. Staff rated ease of use after each patient recording any feedback regarding the device. To evaluate tattoo fading, patients were followed up at 6 and 12 months after treatment to assess if tattoos could be visualised. Results: Between August and December 2021, 50 breast cancer patients were recruited to the study. All patients received at least 3 tattoos. The majority of patients (80%) rated their pain between not hurting or hurting a little. More than 85% of staff indicated the device was easy or very easy to use. The three most common areas staff identified for improvement were: cordless device (39.1%), pen size (20.3%) and consumable rubbish (13.0%). All tattoos remained visible at the final follow up appointment. Conclusion: Clinical implementation of the Comfort Marker tattoo device has been successful. Overall, patients found the process reasonably painless and staff found the device easy to use, providing a consistent result.