Strategies for Creating Multidisciplinary Community Care Teams to Address Barriers to Providing Family Based Treatment of Eating Disorders.

Eating disorders, especially anorexia nervosa, are complex and devastating illnesses. Although eating disorders have a high mortality rate and are relatively common, there are many barriers for those seeking treatment. Provider training and education, weight bias among health care providers, geographical and language barriers, and a lack of options because of insurance restrictions prevent many families from receiving appropriate care, especially in smaller or rural communities. In those areas, providers are left to piece together treatment using a small number of other providers from different disciplines who have a willingness to work with this population. Outpatient family based treatment is an evidenced-based treatment of anorexia nervosa and relies on a multidisciplinary approach to care. Community-based care teams can be an effective way to treat those with eating disorders seeking family based treatment. There are several strategies for building collaborative teams that can provide comprehensive and accessible care to those with few options. [Pediatr Ann. 2024;53(1):e22-e27.].

Qualitative Versus Quantitative Mammographic Breast Density Assessment: Applications for the US and Abroad.

Mammographic breast density (MBD) has been proven to be an important risk factor for breast cancer and an important determinant of mammographic screening performance. The measurement of density has changed dramatically since its inception. Initial qualitative measurement methods have been found to have limited consistency between readers, and in regards to breast cancer risk. Following the introduction of full-field digital mammography, more sophisticated measurement methodology is now possible. Automated computer-based density measurements can provide consistent, reproducible, and objective results. In this review paper, we describe various methods currently available to assess MBD, and provide a discussion on the clinical utility of such methods for breast cancer screening.

New York State Breast Density Mandate: Follow-up Data With Screening Sonography.

OBJECTIVES: To evaluate the impact on breast cancer detection from screening breast sonography performed in women with mammographically dense breasts. METHODS: This study used a retrospective chart review. Data collected included total number of screening mammograms, total number of dense breast screening sonograms, total number of procedures performed, biopsy results, and demographic data. Data were obtained from January 1, 2013, through August 31, 2015. During this period, there were a total of 195,982 screening mammographic examinations performed at our facility. Of these, 83,234 patients (42.5%) were informed that their breast tissue was heterogeneously dense or extremely dense. We specifically reviewed cases to identify those with findings on sonography only. The positive predictive value, biopsy rate, and cancer detection rate were determined. RESULTS: During the study period, 5434 screening sonographic examinations were performed in 4898 women with heterogeneously dense or extremely dense breasts. Most (95.7%) of the sonographic examinations resulted in an American College of Radiology Breast Imaging Reporting and Data System (BI-RADS) category 1 or 2 designation. A total of 101 lesions were given a BI-RADS 3 designation; 134 suspicious findings were given a BI-RADS 4 or 5 designation; and 100 of these were seen on sonography only, all of which underwent tissue sampling, resulting in the diagnosis of 18 malignancies; all were invasive. In evaluating screening sonographic findings, we found a positive predictive value of 18.0%, with an overall biopsy rate of 2.0% and a cancer detection rate of 3.3 per 1000. CONCLUSIONS: The results of our continued evaluation of our screening sonography program confirm that screening breast sonography in women with dense breast tissue can detect otherwise occult malignancy, with a low biopsy rate.

Initial Experience with a Cone-beam Breast Computed Tomography-guided Biopsy System.

OBJECTIVE: To evaluate our initial experience with a cone-beam breast computed tomography (BCT)-guided breast biopsy system for lesion retrieval in phantom studies for use with a cone-beam BCT imaging system. MATERIALS AND METHODS: Under the Institutional Review Board approval, a phantom biopsy study was performed using a dedicated BCT-guided biopsy system. Fifteen biopsies were performed on each of the small, medium, and large anthropomorphic breast phantoms with both BCT and stereotactic guidance for comparison. Each set of the 45 phantoms contained masses and calcification clusters of varying sizes. Data included mass/calcium retrieval rate and dose and length of procedure time for phantom studies. RESULTS: Phantom mass and calcium retrieval rate were 100% for BCT and stereotactic biopsy. BCT dose for small and medium breast phantoms was found to be equivalent to or less than the corresponding stereotactic approach. Stereotactic-guided biopsy dose was 34.2 and 62.5 mGy for small and medium breast phantoms, respectively. BCT-guided biopsy dose was 15.4 and 30.0 mGy for small and medium breast phantoms, respectively. Both computed tomography biopsy and stereotactic biopsy study time ranged from 10 to 20 min. CONCLUSION: Initial experience with a BCT-guided biopsy system has shown to be comparable to stereotactic biopsy in phantom studies with equivalent or decreased dose.

Using Volumetric Breast Density to Quantify the Potential Masking Risk of Mammographic Density.

OBJECTIVE: The purposes of this study were to compare BI-RADS density categories with quantitative volumetric breast density (VBD) for the reporting of mammographic sensitivity and to identify which patient factors are most predictive of a diagnosis of interval cancer of the breast versus screen-detected cancer. MATERIALS AND METHODS: This retrospective study included screen-detected cancers (n = 652) and interval cancers (n = 119) identified between January 2009 and December 2012. Multivariate logistic regression analysis was used to determine which patient factors are predictive of a diagnosis of interval cancer. Sensitivity (screen-detected cancer / [screen-detected cancer + interval cancer]) was determined with the BI-RADS 4th edition density categories and an automated equivalent density grade obtained with a proprietary tool. Sensitivity changes within automated density grade categories were investigated by use of quantitative thresholds at the midpoints of each category. RESULTS: In univariate analysis, age, menopausal status, and breast density were associated with a diagnosis of interval cancer. Of these risk factors, breast density was the only independent factor whether it was assessed by visual BI-RADS category (odds ratio, 3.54; 95% CI, 1.55-8.10), automated density grade (odds ratio, 4.68; 95% CI, 2.26-9.67), or VBD (odds ratio, 4.51; 95% CI, 1.92-10.61). Sensitivity decreased consistently across increasing automated density grade categories from fatty to extremely dense (95%, 89%, 83%, 65%) and less so for visual BI-RADS (82%, 90%, 84%, 66%). Further dichotomization with VBD cutoffs showed a striking linear relation between VBD and sensitivity (R2 = 0.959). CONCLUSION: In this study, breast density was the only risk factor significantly associated with a diagnosis of interval cancer versus screen-detected cancer. Quantitative VBD captures the potential masking risk of breast density more precisely than does the widely used visual BI-RADS density classification system.

Concentrations of Polychlorinated Biphenyls and Organochlorine Pesticides in Umbilical Cord Blood Serum of Newborns in Kingston, Jamaica.

To date much of the biomonitoring related to exposure to polychlorinated biphenyls (PCBs) and organochlorine (OC) pesticides is from middle to high income countries, including the U.S., Canada and Europe, but such data are lacking for the majority of low to middle income countries. Using data from 64 pregnant mothers who were enrolled in 2011, we aimed to assess the concentrations of the aforementioned toxins in umbilical cord blood serum of 67 Jamaican newborns. For 97 of the 100 PCB congeners and 16 of the 17 OC pesticides, all (100%) concentrations were below their respective limits of detection (LOD). Mean (standard deviation (SD)) lipid-adjusted concentrations in cord blood serum for congeners PCB-153, PCB-180, PCB-206 and total PCB were 14.25 (3.21), 7.16 (1.71), 7.30 (1.74) and 28.15 (6.03) ng/g-lipid, respectively. The means (SD) for the 4,4'-dichlorodiphenyldichloroethylene (DDE)-hexane fraction and total-DDE were 61.61 (70.78) and 61.60 (70.76) ng/g-lipid, respectively. Compared to the U.S. and Canada, the concentrations of these toxins were lower in cord-blood serum of Jamaican newborns. We discuss that these differences could be partly due to differences in dietary patterns in these countries. Despite limitations in our dataset, our results provide information on the investigated toxins in cord blood serum that could serve as a reference for Jamaican newborns.

Thanks for asking: Adolescent attitudes and preferences regarding the use of chaperones during physical examinations.

BACKGROUND: There is no uniformity as to how and when chaperones should be used for general and intimate (genitalia and/or breasts) physical examinations of adolescents. OBJECTIVE: To explore adolescents' attitudes and preferences regarding the use of medical chaperones during physical examinations. METHODS: The present analysis was a cross-sectional descriptive study performed as part of a quality improvement project in the Adolescent Medicine Clinics at The Hospital for Sick Children (Toronto, Ontario) between January 1 and April 30, 2011. Adolescents 13 to 18 years of age completed an anonymous 10-item, self-administered questionnaire regarding their thoughts on chaperones during physical examinations. Demographic and descriptive data were collected. RESULTS: A total of 127 adolescents participated in the present study. The mean (± SD) age was 16.3±1.5 years and the majority (93.7%) were female. More than one-half (61%) of female adolescents had previous experience with an intimate examination; however, a chaperone was present only 36% of the time. Seventy percent of female adolescents wanted the choice of a chaperone for a general examination compared with 61% for an intimate examination. Among female adolescents with past chaperone experience, 78% wanted the choice of a chaperone for subsequent intimate examinations, compared with 55% among those with no previous chaperone experience. Only 21% believed they would ask for a chaperone if one were not offered. CONCLUSIONS: Although there was variation in adolescents' attitudes and preferences regarding the use of chaperones, many females indicated a desire to discuss the option of a chaperone for all types of examinations.

HISTORIQUE: Il n'y a pas d'uniformité quant à la manière et au moment de faire appel à un chaperon lors des examens généraux et intimes (organes génitaux ou seins) des adolescents. OBJECTIF: Explorer les attitudes et les préférences des adolescents à l'égard du recours à des chaperons médicaux pendant l'examen physique. MÉTHODOLOGIE: La présente analyse descriptive transversale fait partie d'un projet d'amélioration de la qualité aux cliniques de médecine des adolescents du Hospital for Sick Children de Toronto, en Ontario, entre le janvier et le 30 avril 2011. Des adolescents de 13 à 18 ans ont rempli eux-mêmes un questionnaire anonyme de dix questions sur leurs perceptions à l'égard de la présence d'un chaperon pendant les examens physiques. Les données démographiques et descriptives ont été colligées. RÉSULTATS: Au total, 127 adolescents ont participé à la présente étude. Ils avaient un âge moyen (± ÉT) de 16,3±1,5 ans, et la majorité (93,7 %) étaient des filles. Plus de la moitié (61 %) des adolescents avaient déjà subi un examen physique, mais un chaperon était présent dans seulement 36 % des cas. Pourtant, 70 % des adolescentes auraient voulu se faire proposer la présence d'un chaperon lors de l'examen général, par rapport à 61 % lors d'un examen intime. Chez les adolescentes qui avaient déjà été accompagnées d'un chaperon, 78 % voulaient qu'on leur propose la présence d'un chaperon lors des prochains examens physiques, par rapport à 55 % de celles qui n'avaient jamais été accompagnées d'un chaperon. Seulement 21 % pensaient demander la présence d'un chaperon si on ne la leur proposait pas. CONCLUSIONS: Même si les adolescents avaient des attitudes et des préférences variées à l'égard de la présence d'un chaperon, de nombreuses filles ont exprimé le souhait qu'on leur propose la présence d'un chaperon lors de tous les types d'examens.

Personal History of Premenopausal Breast Cancer as a Risk Factor for Referral to Screening Breast MRI.

RATIONALE AND OBJECTIVES: The purpose of this study was to examine whether patients with premenopausal breast cancer history only can benefit from screening breast magnetic resonance imaging (MRI) by comparing them to patients with both a personal and a family history of breast cancer. MATERIALS AND METHODS: With Institutional Review Board approval and waiver of informed consent, a retrospective review was conducted to determine patients previously diagnosed with premenopausal breast cancer undergoing screening MRI. From December 2003 to October 31, 2014, a total of 4436 screening MRI examinations were performed; 381 examinations were performed in 131 patients with a personal history (PH) of premenopausal breast cancer. This cohort was evaluated further and revealed 146 examinations in 52 patients with PH only, and 235 examinations in 79 patients with personal history and family history (PHFH). Fisher's exact test was used to compare the distribution between the groups. RESULTS: Total number of MRI examinations performed per patient ranged from 1 to 10, with an average of 2.9 in the PHFH group and 2.8 in the PH only group. Patient age at time of original diagnosis was significantly different between the groups (P = 0.0391). There were 74 (19.4%) suspicious MRI findings: 27 in the PH only group and 47 in the PHFH group. Fifty-two had needle biopsy tissue sampling performed; three additional lesions were sampled at excision. Malignancy was detected in 27.3%: 53.3% in the PHFH group and 46.7% in the PH only group (P = 0.7963). There was no significant difference when the pathology between the PH only group and the PHFH group was compared (P = 0.5692). Of those diagnosed with cancer, average time between diagnoses was 6.9 years for the PHFH group and 7.1 for the PH only group (range 2-16). CONCLUSIONS: Patients with a PH only are at a similar risk level as those with additional family history for the development of a subsequent breast cancer and therefore benefit from screening breast MRI, as a similar rate of cancer detection was found in both groups.

Implementation of a risk assessment program in a breast-imaging community practice.

BACKGROUND: To review the initial results of the implementation of a risk assessment program in our outpatient community-based breast-imaging practice. METHODS: From May 1, 2011 through November 4, 2013 a total of 96,389 patients presented to our facility. Each patient was required to complete a health history form. 24,850 (25.7 %) were flagged through our radiology information system (RIS) as potentially being at increased risk for breast cancer per responses on the health history form. Patient flagging was based on a system we developed. Letters were generated informing flagged patients and her physician that the patient could be a candidate for further breast cancer risk assessment. Genetic testing performed was primarily for BRCA1/BRCA2; testing for other mutations was offered based on personal and family history of the patient. RESULTS: 1,088 genetic counseling appointments occurred during the time frame from the 24,850 patients flagged, leading to 887 genetic tests performed. Forty-three mutations were detected: 21 BRCA1, 19 BRCA2, 1 MLH1, 1 MSH6 and 1 CHEK2. There were 717 negative tests, 20 variants of unknown significance; the remaining cases were cancelled. 464 high-risk MRIs were performed after the patient was referred from the program, from which 52 biopsies were performed due to a finding on MRI revealing 14 malignancies. CONCLUSIONS: In our experience after implementation of a risk assessment program, 24,850 potential at-risk patients have been flagged, revealing 40 BRCA 1 or 2 mutations. Screening with breast MRI provided to at-risk patients revealed 14 cancers diagnosed that may have otherwise been undetected.

Initial experience with the New York State breast density inform law at a community-based breast center.

OBJECTIVES: The purpose of this study was to review our initial experience with the New York State breast density inform law (New York public health law, S2404-C) at our outpatient breast center. We sought to review the findings in patients returning for screening breast sonography after a screening mammogram revealed heterogeneously dense or extremely dense breast tissue. METHODS: From January 1, 2013, through May 31, 2014, 102,841 patients who underwent screening mammography were seen at our institution. Of these, 35,153 were determined to have heterogeneously dense breast tissue, and 11,864 were determined to have extremely dense breast tissue. Due to the New York State breast density inform law, these 47,017 patients were notified of their breast density, with 935 patients (2%) returning for 971 screening breast sonographic examinations. RESULTS: Heterogeneously dense breast tissue was noted in 66% of the patients (619), and extremely dense breast tissue was noted in 34% (316). Thirty-one percent of the patients (290) reported no additional risk factors; 68% (635) presented with 1 or more additional risk factors; and 1% (10) were adopted, and the risk status could not be assessed. Twenty-five procedures (2.6%) were performed after screening breast sonography, resulting in 22 benign findings, 1 atypical finding, and 2 malignancies. The overall positive predictive value was 8% (2 of 25), and the overall cancer detection rate was 2.1 per 1000 (2 of 935). CONCLUSIONS: Handheld screening breast sonography performed in women with dense breast tissue can aid in the detection of otherwise occult breast cancer, as we found 2 cancers in the study population, with an overall positive predictive value of 8%. The addition of screening sonography in this cohort did lead to an increase in minimally invasive procedures in 2.6%.

Concentration of lead, mercury, cadmium, aluminum, arsenic and manganese in umbilical cord blood of Jamaican newborns.

The objective of this study was to characterize the concentrations of lead, mercury, cadmium, aluminum, and manganese in umbilical cord blood of Jamaican newborns and to explore the possible association between concentrations of these elements and certain birth outcomes. Based on data from 100 pregnant mothers and their 100 newborns who were enrolled from Jamaica in 2011, the arithmetic mean (standard deviation) concentrations of cord blood lead, mercury, aluminum, and manganese were 0.8 (1.3 µg/dL), 4.4 (2.4 µg/L), 10.9 (9.2 µg/L), and 43.7 (17.7 µg/L), respectively. In univariable General Linear Models, the geometric mean cord blood aluminum concentration was higher for children whose mothers had completed their education up to high school compared to those whose mothers had any education beyond high school (12.2 µg/L vs. 6.4 µg/L; p < 0.01). After controlling for maternal education level and socio-economic status (through ownership of a family car), the cord blood lead concentration was significantly associated with head circumference (adjusted p < 0.01). Our results not only provide levels of arsenic and the aforementioned metals in cord blood that could serve as a reference for the Jamaican population, but also replicate previously reported significant associations between cord blood lead concentrations and head circumference at birth in other populations.

Screening for dense breasts: digital breast tomosynthesis.

OBJECTIVE. Digital breast tomosynthesis (DBT) is a recent imaging technology that was developed to address the limitations of conventional 2D mammography. The limitations of standard mammography are well known and include reduced sensitivity in dense breasts. Clinical research studies of DBT and the implementation of DBT have revealed that DBT has potential benefits for evaluating patients with dense breasts. This article will discuss the benefits and limitations of DBT as a screening alternative for women with dense breasts. CONCLUSION. Studies to date have revealed that the use of DBT reduces recall rates and increases cancer detection rates. This has been demonstrated with the use of DBT for both screening and diagnostic purposes, as well as with imaging dense breasts. DBT has the ability to reduce breast tissue overlap, thus potentially revealing lesions that would otherwise have been missed. The limitations of DBT include longer interpretation times, higher costs, and increased radiation dose. These limitations present challenges that radiologists must consider before DBT implementation.

Importance of presurgical breast MRI in patients 60 years of age and older.

OBJECTIVE: To demonstrate the importance of presurgical bilateral breast Magnetic Resonance Imaging (MRI) in women 60 years of age and older. MATERIALS AND METHODS: Institutional review board approval was obtained with waiver of informed consent for this retrospective review. From December 2003 to December 2011, all patients 60 years and older who had presurgical bilateral breast MRI were reviewed, revealing 1268 presurgical MRI examinations; 310 had a new lesion identified by MRI. Cases were excluded due to incomplete or missing data, resulting in 243 patients with 272 findings eligible for analysis. Data recorded included patient demographics, core biopsy method and pathology, type of surgery, and surgical pathology results. RESULTS: Of 1268 exams performed in this population, 272 (21.5%) patients with suspicious MRI findings underwent needle biopsy. Malignancy was found in 114 (42%), benign findings in 127 (47%), and atypia in 31 (11%). Of the malignancies, 83 were in the ipsilateral breast and 31 in the contralateral breast to the original diagnosis. Of the ipsilateral findings, 47 were in the same quadrant as the primary diagnosis, 28 in a different quadrant, and 8 were metastatic lymph nodes. Of the 31 atypical findings, 14 were contralateral to the primary diagnosis and 17 were ipsilateral. Two hundred and thirty-three patients underwent surgical excision; 111 changed their surgical management as a lesion was seen on MRI and was diagnosed as cancer on needle biopsy. CONCLUSIONS: Among the patients aged 60 years and above who had presurgical bilateral breast MRI, we found additional cancers in 9.0% (n = 114/1268) and atypia in 2.4% (n = 31/1268). A change in management as a result of the MRI-detected lesion occurred in 8.8% (n = 111/1268). These results demonstrate that performing presurgical bilateral breast MRI is of value in women 60 years of age and above.

Evaluation of malignant breast lesions in the diagnostic setting with cone beam breast computed tomography (Breast CT): feasibility study.

To investigate the feasibility of noncontrast and contrast-enhanced cone beam breast Computed Tomography (CT) in demonstrating malignant breast lesions in the diagnostic setting. This Institutional Review Board approved, Health Information Portability and Accountability Act compliant, prospective study enrolled BI-RADS four and five patients from 2008 to 2010. Eighty-seven subjects had noncontrast breast CT, 42 had contrast-enhanced breast CT (CE-breast CT) with 70 pathologically confirmed cancer diagnoses. All 70 comprise the study cohort for noncontrast breast CT, and 23 who had CE-breast CT comprise the cohort for CE-breast CT. All had diagnostic work-up. Patient age, breast density, lesion size and characteristics, biopsy method, and core pathology were recorded. A Fisher's exact test was used to detect a difference in detectability. For agreement in size measurement between the imaging modalities, a paired t-test was employed. Reported p-values were based on 2-sided tests. Two one-sided tests were calculated to determine equivalence within ±0.3 cm at a 90% significance level. Noncontrast breast CT identified 67 of 70 malignant lesions, detected by diagnostic work-up. CE-breast CT identified 23 of 23 index malignant lesions and in addition, found three malignant lesions in three cases not previously detected. Noncontrast breast CT demonstrated the index lesion in 67 of 70 cases and CE-breast CT demonstrated the index lesion in all 23 cases. An additional three new malignant lesions not seen with conventional diagnostic work-up were detected. In this preliminary study, breast CT with or without contrast was shown to be accurate at identifying malignant breast lesions in the diagnostic setting.

Initial experience with combination digital breast tomosynthesis plus full field digital mammography or full field digital mammography alone in the screening environment.

OBJECTIVES: Initial review of patients undergoing screening mammography imaged with a combination of digital breast tomosynthesis (DBT) plus full field digital mammography (FFDM) compared with FFDM alone. MATERIALS AND METHODS: From June 2011 to December 2011, all patients presenting for routine screening mammography were offered a combination DBT plus FFDM exam. Under institutional review board approval, we reviewed 524 patients who opted for combination DBT plus FFDM and selected a sample group of 524 FFDM screening exams from the same time period for a comparative analysis. The χ(2) (Chi-square) test was used to compare recall rates, breast density, personal history of breast cancer, and family history of breast cancer between the two groups. RESULTS: Recall rate for FFDM, 11.45%, was significantly higher (P < 0001) than in the combination DBT plus FFDM group (4.20%). The biopsy rate in the FFDM group was 2.29% (12/524), with a cancer detection rate of 0.38% (2/524, or 3.8 per 1000) and positive predictive value (PPV) of 16.7% (2/12). The biopsy rate for the DBT plus FFDM group was 1.14% (n = 6/524), with a cancer detection rate 0.57% (n = 3/524, or 5.7 per 1000) and PPV of 50.0% (n = 3/6). Personal history of breast cancer in the FFDM group was significantly lower (P < 0.0001) than in the combination DBT plus FFDM group; 2.5% and 5.7%, respectively. A significant difference in family history of breast cancer (P < 0.0001) was found, with a higher rate in the combination DBT plus FFDM group (36.0% vs. 53.8%). There was a significant difference between the combination DBT plus FFDM group and FFDM alone group, when comparing breast density (P < 0.0147, 61.64% vs. 54.20% dense breasts, respectively) with a higher rate of dense breasts in the DBT plus FFDM group. In follow-up, one cancer was detected within one year of normal screening mammogram in the combination DBT plus FFDM group. CONCLUSION: Our initial experience found the recall rate in the combination DBT plus FFDM group was significantly lower than in the FFDM alone group, despite the fact that the combination DBT plus FFDM group had additional risk factors.

Comparison of breast cancers diagnosed in screening patients in their 40s with and without family history of breast cancer in a community outpatient facility.

OBJECTIVE: The purpose of this study was to compare invasive breast cancer in patients in their 40s with and without a family history of breast cancer as well as the lymph node meta-static rate and mastectomy rate. MATERIALS AND METHODS: From 2000 to 2011, a total of 793,827 examinations were performed; 221,541 (28%) were women between 40 and 49 years old. A total of 6965 cancers were found in 6511 patients. Specifically, 1207 cancers (17.3%) were detected in 1162 patients in their 40s. Patients presenting for diagnostic evaluation and those with a personal history of breast cancer were excluded, leaving 388 cancers available for study; 238 (61%) cancers were in patients with no family history of breast cancer, and 150 (39%) were in patients with a family history of breast cancer. Pearson chi-square, Fisher exact, and Student t tests were used for between-group comparisons for qualitative data. A two-sided p value was reported for all tests. RESULTS: The difference in lesions detected by imaging was not statistically significant (p = 0.17); 65% (154/238) had invasive and 35% (84/238) noninvasive disease in the no family history of breast cancer group and 65% (98/150) and 35% (52/150), respectively, in the family history of breast cancer group (p = 0.90). The mastectomy rate was not statistically significantly different (p = 0.14). Fifteen percent (35/238) of the no family history of breast cancer patients and 12% (18/150) of the family history of breast cancer patients had positive lymph nodes (p = 0.45). CONCLUSION: In patients in their 40s with or without a family history of breast cancer, no differences were detected in the proportion of invasive versus noninvasive cancers diagnosed, lymph node metastases, or mastectomy rates. Screening mammography should be performed in this age group regardless of family history.

Underestimation of papillary breast lesions by core biopsy: correlation to surgical excision.

BACKGROUND: The purpose of this study was to evaluate papillary lesions of the breast diagnosed at needle core biopsy and the outcomes of follow-up imaging and surgical findings. METHODS: Retrospective review of 13,806 needle core biopsies performed from 2004 to 2010 revealed 352 patients with 368 papillary lesions; 137 of these lesions underwent surgical excision and 215 had a minimum of 2 year imaging follow-up. Outcomes of imaging follow-up and underestimation of carcinoma by comparison to surgical excision, as applicable, were determined. Patient demographics, clinical presentation, BI-RADS(®) breast density, palpability, biopsy methods, number of specimens, and pathology were recorded. A two-tailed Fisher exact test was used to assess associations between biopsy techniques and the results of surgical excision as well as the association between palpability and the results of surgical excision. SAS(®) V 9.1.3 was used to perform the calculations. RESULTS: One hundred and thirty-seven lesions proceeded to surgical excision. A total of 28 lesions were underestimated; 21 of these were underestimated carcinomas. When comparing biopsy devices in the underestimated group, 64 % were biopsied with directional vacuum-assisted devices and 36 % with automated large core devices (p < 0.0706). In total 18 % of the palpable lesions were underestimated, whereas 17 % of the nonpalpable lesions were underestimated (p < 0.6560); this was not a significant difference. CONCLUSIONS: Overall, carcinoma was underestimated at needle biopsy in 6 % (21/368) of papillary lesions diagnosed when compared to surgical excision. In cases that underwent excision, 34 % (47/137) revealed carcinoma; 45 % (21/47) of these were underestimated carcinomas. Lesion palpability and biopsy method did not affect underestimation in this study population.

Recurrent contralateral hearing loss after 2 craniotomies for vestibular schwannoma: etiologic implications.

OBJECTIVE: To describe recurrent sudden sensorineural hearing loss after contralateral vestibular schwannoma resection and re-resection. STUDY DESIGN: Clinical capsule report. SETTING: Tertiary academic referral hospital. PATIENT: A patient who underwent 2 craniotomies for vestibular schwannoma. RESULTS: In 2003, a patient experienced contralateral low-frequency sensorineural hearing loss after undergoing translabyrinthine resection of a vestibular schwannoma. This resolved after a course of oral steroids. Seven years later, in 2010, the patient developed tumor recurrence. After retrosigmoid resection, the patient experienced a similar episode of transient, contralateral, low-frequency predominant sensorineural hearing loss. CONCLUSION: The recurrence of contralateral hearing loss after craniotomies years apart suggests that patient specific anatomic risk factors predispose an individual to hearing loss after contralateral cerebellopontine angle surgery. Patients with previous history of contralateral hearing loss should be counseled that they may be at increased risk for recurrent loss in the setting of re-resection.

Clinical experience with elasticity imaging in a community-based breast center.

OBJECTIVES: The aim of this study was to evaluate compression elasticity imaging in combination with standard B-mode imaging for assessment of benign versus malignant breast lesions and correlation with needle biopsy. METHODS: Institutional Review Board approval was obtained, and patients were prospectively enrolled from 2007 to 2011. A total of 221 patients yielding 230 elastograms recommended for biopsy were the basis of this analysis. Information collected included patient demographics, lesion laterality and location, and needle biopsy method and results. The longest dimension of the lesion between B-mode and elasticity imaging was measured, and an elasticity imaging/B mode ratio of 1.0 or greater was considered to represent malignancy; a ratio of less than 1.0 was benign. Statistical analysis included calculation of descriptive statistics and generation of figures. RESULTS: Of the 230 biopsies performed, cancer was revealed in 100 cases (43.5%). One hundred thirty (56.5%) benign findings were observed. Of the 100 malignant lesions, 99 had an elasticity imaging/B-mode ratio greater than or equal to 1.0 (99.0%). Of the 130 benign lesions, 119 had an elasticity imaging/B-mode ratio of less than 1.0 (91.5%). These results indicate 99.0% (99 of 100) sensitivity and 91.5% (119 of 130) specificity. Furthermore, we found a positive predictive value of 90.0% (99 of 110) and a negative predictive value of 99.2% (119 of 120). CONCLUSIONS: In this study, elasticity imaging had high sensitivity for malignant and benign lesions. Elasticity imaging in the clinical setting may prove to be an additional tool that is helpful to the breast clinician for characterization of lesions as benign or malignant. At this time, we are continuing our data collection because additional research is still necessary.

Preliminary clinical experience with digital breast tomosynthesis in the visualization of breast microcalcifications.

OBJECTIVES: To compare the visualization and image quality of microcalcifications imaged with digital breast tomosynthesis (DBT) versus conventional digital mammography. MATERIALS AND METHODS: Patients with microcalcifications detected on full field digital mammography (FFDM) recommended for needle core biopsy were enrolled in the study after obtaining patient's consent and institutional review board approval (n = 177 patients, 179 lesions). All had a bilateral combination DBT exam, after undergoing routine digital mammography, prior to biopsy. The study radiologist reviewed the FFDM and DBT images in a non-blinded comparison and assessed the visibility of the microcalcifications with both methods, including image quality and clarity with which the calcifications were seen. Data recorded included patient demographics, lesion size on FFDM, DBT, and surgical excision (when applicable), biopsy, and surgical pathology, if any. RESULTS: Average lesion size on DBT was 1.5 cm; average lesion size on FFDM was 1.4 cm. The image quality of DBT was assessed as equivalent or superior in 92.2% of cases. In 7.8% of the cases, the FFDM image quality was assessed as equivalent or superior. CONCLUSION: In our review, DBT image quality appears to be comparable to or better than conventional FFDM in terms of demonstrating microcalcifications, as shown in 92.2% of cases.