Decision quality and regret with treatment decisions in women with breast cancer: Pre-operative breast MRI and breast density.

PURPOSE: We evaluated self-report of decision quality and regret with breast cancer surgical treatment by pre-operative breast MRI use in women recently diagnosed with breast cancer. METHODS: We conducted a survey with 957 women aged 18 + with stage 0-III breast cancer identified in the Breast Cancer Surveillance Consortium. Participants self-reported receipt of pre-operative breast MRI. Primary outcomes were process measures in the Breast Cancer Surgery Decision Quality Instrument (BCS-DQI) (continuous outcome) and Decision Regret Scale (dichotomized outcome as any/none). Generalized estimating equations with linear and logit link were used to estimate adjusted associations between breast MRI and primary outcomes. All analyses were also stratified by breast density. RESULTS: Survey participation rate was 27.9% (957/3430). Study population was primarily > 60 years, White, college educated, and diagnosed with early-stage breast cancer. Pre-operative breast MRI was reported in 46% of women. A higher proportion of women who were younger age (< 50 years), commercially insured, and self-detected their breast cancer reported pre-operative breast MRI use. In adjusted analysis, pre-operative breast MRI use compared with no use was associated with a small but statistically significantly higher decision quality scores (69.5 vs 64.7, p-value = 0.043). Decision regret did not significantly differ in women who reported pre-operative breast MRI use compared with no use (54.2% v. 48.7%, respectively, p-value = 0.11). Study results did not vary when stratified by breast density for either primary outcome. CONCLUSIONS AND RELEVANCE: Breast MRI use in the diagnostic work-up of breast cancer does not negatively alter women's perceptions of surgical treatment decisions in early survivorship. CLINICAL TRIALS REGISTRATION NUMBER: NCT03029286.

The "Sweet Spot" Revisited: Optimal Recall Rates for Cancer Detection With 2D and 3D Digital Screening Mammography in the Metro Chicago Breast Cancer Registry.

OBJECTIVE. One central question pertaining to mammography quality relates to discerning the optimal recall rate to maximize cancer detection while minimizing unnecessary downstream diagnostic imaging and breast biopsies. We examined the trade-offs for higher recall rates in terms of biopsy recommendations and cancer detection in a single large health care organization. MATERIALS AND METHODS. We included 2D analog, 2D digital, and 3D digital (tomosynthesis) screening mammography examinations among women 40-79 years old performed between January 1, 2005, and December 31, 2017, with cancer follow-up through 2018. There were 36, 67, and 38 radiologists who read at least 1000 2D analog examinations, 2D digital examinations, and 3D tomosynthesis examinations, respectively, who were included in these analyses. Using logistic regression with marginal standardization, we estimated radiologist-specific mean recall (abnormal interpretations/1000 mammograms), biopsy recommendation, cancer detection (screening-detected in situ and invasive cancers/1000 mammograms), and minimally invasive cancer detection rates while adjusting for differences in patient characteristics. RESULTS. Among 1,060,655 screening mammograms, the mean recall rate was 10.7%, the cancer detection rate was 4.0/1000 mammograms, and the biopsy recommendation rate was 1.60%. Recall rates between 7% and 9% appeared to maximize cancer detection while minimizing unnecessary biopsies. CONCLUSION. The results of this investigation are in contrast to those of a recent study suggesting appropriateness of higher recall rates. The "sweet spot" for optimal cancer detection appears to be in the recall rate range of 7-9% for both 2D digital mammography and 3D tomosynthesis. Too many women are being called back for diagnostic imaging, and new benchmarks could be set to reduce this burden.

Population-Based Assessment of the Association Between Magnetic Resonance Imaging Background Parenchymal Enhancement and Future Primary Breast Cancer Risk.

PURPOSE: To evaluate comparative associations of breast magnetic resonance imaging (MRI) background parenchymal enhancement (BPE) and mammographic breast density with subsequent breast cancer risk. PATIENTS AND METHODS: We examined women undergoing breast MRI in the Breast Cancer Surveillance Consortium from 2005 to 2015 (with one exam in 2000) using qualitative BPE assessments of minimal, mild, moderate, or marked. Breast density was assessed on mammography performed within 5 years of MRI. Among women diagnosed with breast cancer, the first BPE assessment was included if it was more than 3 months before their first diagnosis. Breast cancer risk associated with BPE was estimated using Cox proportional hazards regression. RESULTS: Among 4,247 women, 176 developed breast cancer (invasive, n = 129; ductal carcinoma in situ,n = 47) over a median follow-up time of 2.8 years. More women with cancer had mild, moderate, or marked BPE than women without cancer (80% v 66%, respectively). Compared with minimal BPE, increasing BPE levels were associated with significantly increased cancer risk (mild: hazard ratio [HR], 1.80; 95% CI, 1.12 to 2.87; moderate: HR, 2.42; 95% CI, 1.51 to 3.86; and marked: HR, 3.41; 95% CI, 2.05 to 5.66). Compared with women with minimal BPE and almost entirely fatty or scattered fibroglandular breast density, women with mild, moderate, or marked BPE demonstrated elevated cancer risk if they had almost entirely fatty or scattered fibroglandular breast density (HR, 2.30; 95% CI, 1.19 to 4.46) or heterogeneous or extremely dense breasts (HR, 2.61; 95% CI, 1.44 to 4.72), with no significant interaction (P = .82). Combined mild, moderate, and marked BPE demonstrated significantly increased risk of invasive cancer (HR, 2.73; 95% CI, 1.66 to 4.49) but not ductal carcinoma in situ (HR, 1.48; 95% CI, 0.72 to 3.05). CONCLUSION: BPE is associated with future invasive breast cancer risk independent of breast density. BPE should be considered for risk prediction models for women undergoing breast MRI.

Comparison of Resource Utilization and Clinical Outcomes Following Screening with Digital Breast Tomosynthesis Versus Digital Mammography: Findings From a Learning Health System.

RATIONALE AND OBJECTIVES: To compare outcomes associated with breast cancer screening with digital mammography (DM) alone versus in combination with digital breast tomosynthesis (DBT) in a large representative cohort. MATERIALS AND METHODS: A total of 325,729 screening mammograms from 247,431 women were analyzed, across two healthcare systems, from June 2015 to September 2017. Patient level demographic, calculated risk levels, and clinical outcomes were extracted from radiology information system and electronic medical records. Multivariable regression modeling adjusting for institution, age, breast density, and first exam was conducted to compare patient characteristics, recall rates, time to biopsy and final diagnosis, clinical outcomes, and diagnostic performance. Participating institutions and the Coordinating Center received Institutional Review Board approval for a waiver of consent to collect and link data and perform analysis. RESULTS: A total of 194,437 (59.7%) screens were DBT versus 131,292 (40.3%) with DM. Women with dense breasts and higher calculated risk were more likely to be screened with DBT. Recall rates were lower for DBT overall (8.83% DBT vs 10.98% DM, adjusted odds ratio, 95% confidence interval = 0.85, 0.83-0.87) and across all age groups, races, and breast densities, and at facilities that used predominantly DBT (8.05%) versus predominantly DM (11.22%), or a combination (10.73%). The most common diagnostic pathway after recall was mammography and ultrasound. Women recalled from DBT were more likely to proceed directly to ultrasound. The median time to biopsy (18 vs 22 days) and final diagnosis (10 vs 13 days) was shorter for DBT. The adjusted cancer rate, cancer detection rate, and specificity were higher for DBT. CONCLUSION: DBT demonstrated a more efficient screening pathway and improved quality measures with lower recall rates in all patient types, reduced diagnostic mammography and shorter time to biopsy and final diagnosis.

Pterygoid Plate Fractures: Not Limited to Le Fort Fractures.

Pterygoid plate fractures are often described in the setting of Le Fort fractures. The goal of this study was to define other craniofacial fracture patterns causing injury to the pterygoid plates. A retrospective review of computed tomography (CT) scans obtained on craniofacial trauma patients over a 5-year period revealed 209 patients with pterygoid plate fractures. Pterygoid plate fractures in 78 patients (37.3%) were unrelated to Le Fort fractures. Common causes included sphenotemporal buttress fractures in 26 patients (33.3%), temporal bone fractures in 18 patients (23.1%), zygomaticomaxillary complex fractures in 17 patients (21.8%), and displaced mandible fractures in 14 patients (17.9%). These findings indicate that approximately one third of pterygoid plate fractures do not result from Le Fort pattern injuries and that the craniofacial surgeon should have a broad differential for causes of pterygoid plate fractures when reviewing trauma imaging.

Extensive sinovenous thrombosis and hemorrhagic infarction during therapy for T-cell acute lymphoblastic leukemia.

Sinovenous thrombosis (SVT) is a well-recognized and serious complication in children treated for acute leukemia. This frequently occurs during or immediately upon completion of induction therapy and is commonly attributed to asparaginase therapy.Headache is the first and most common clinical symptom to occur during the early development of SVT. With advancement of the thrombosis, the clinical symptoms can progress to increased sleepiness, focal neurological deficit, seizures, and altered consciousness. We report the case of a 4-year-old girl who presented after several days of headaches and anorexia, which then progressed to seizures, left-sided weakness, and altered consciousness. She was later found to have a widespread and occlusive SVT with right cerebral hemorrhagic infarction. This case is notable for the extensive nature of the cerebral SVT and the child's complete clinical recovery from the neurological event. The report discusses the relation of the thrombosis and leukemia and also emphasizes the importance of early recognition and prompt management, while incorporating a collaborative multidisciplinary approach to prevent long-term consequences.

MRI appearance of the proximal hamstring tendons in patients with and without symptomatic proximal hamstring tendinopathy.

OBJECTIVE: The purpose of our study was to determine if six MRI findings of the proximal hamstrings differ in frequency in hamstrings with and without symptoms of tendinopathy. MATERIALS AND METHODS: We reviewed the MRI examinations of 118 consecutive patients who had undergone pelvis MRI and evaluation by a musculoskeletal clinical specialist. The proximal hamstrings were evaluated at four consecutive axial locations for tendon size, internal T1 and T2 signal, peritendinous T2 signal, and ischial tuberosity edema. Statistical analysis was performed to determine the association of the MRI findings with symptomatic hamstring tendinopathy. RESULTS: Twenty-one patients had a clinical diagnosis of unilateral proximal hamstring tendinopathy. The mean width or anteroposterior size was significantly larger in symptomatic hamstrings at all three proximal levels (p = 0.002-0.040). More than 90% of hamstring tendons had increased internal T1 or T2 signal that was not associated with hamstring symptoms. Both hamstrings with and without symptoms of tendinopathy had peritendinous T2 signal, but this was significantly more common in hamstrings with tendinopathy symptoms at the three most distal levels (p = 0.001-0.041). Ischial tuberosity edema and a feathery appearance of the peritendinous T2 signal distally were significantly more common in symptomatic hamstrings (p = 0.004 and 0.001, respectively). CONCLUSION: Increased T1 and T2 signal is commonly seen within the proximal hamstrings but is not associated with symptoms of hamstring tendinopathy. Increased tendon size, peritendinous T2 signal with a distal feathery appearance, and ischial tuberosity edema are significantly associated with symptomatic hamstring tendinopathy but can be seen in asymptomatic individuals.

Clinical criteria for obtaining maxillofacial computed tomographic scans in trauma patients.

BACKGROUND: Over 150,000 patients present with maxillofacial trauma annually to emergency rooms in the United States. Although maxillofacial computed tomography is a sensitive screening tool for identifying facial fractures, indiscriminate use leads to unnecessary radiation exposure and substantial costs. A decision instrument is needed to ensure computed tomographic evaluation of patients at high risk for facial fracture and limit computed tomography use in low-risk patients. METHODS: A retrospective review was conducted of all patients evaluated at a Level I trauma center over a 3-year period. Inclusion criteria were maxillofacial examination on presentation, maxillofacial computed tomography, and head computed tomography. A total of 525 patients met the enrollment criteria. RESULTS: Injury to the maxillofacial skeleton occurred in 332 patients (63.2 percent). The presence of any of the following five physical examination criteria identified patients at high risk for facial fracture: bony stepoff or instability, periorbital swelling or contusion, Glasgow Coma Scale score less than 14, malocclusion, or tooth absence. These criteria identified all but six of the 332 patients with a facial fracture (sensitivity, 98.2 percent; 95 percent confidence interval, 96.5 to 99.1 percent). The negative predictive value was 87.8 percent (95 percent confidence interval, 76.3 to 94.2 percent). No patient determined by these criteria to be at low risk for a facial fracture required surgical treatment. If these criteria had been applied to the study population, radiographic imaging could have been avoided in 9.3 percent of patients. CONCLUSIONS: A decision instrument based on clinical criteria can ensure appropriate screening of patients at high risk for facial fracture. Application of this instrument may reduce unnecessary maxillofacial imaging.