Architectural distortion on digital breast tomosynthesis mammograms in symptomatic breast clinics: What are the result outcomes?

OBJECTIVES: In April 2020, standard two-dimensional Full-field Digital Mammograms (FFDM) were replaced with Digital Breast Tomosynthesis (DBT) and synthesised 2D views for symptomatic breast clinics. This study aimed to evaluate the positive predictive value for malignancy in DBT-detected Architectural Distortion (AD). METHODS: All mammogram reports with the word 'distortion' were assessed between April 2020 and October 2022. There were 458 mammograms with the word 'distortion'. After excluding mammograms with no distortion (n = 128), post-surgical distortion (n = 173), distortion with mass (n = 33), and unchanged distortion (n = 14), there were 111 patients with pure distortion. Correlation with histopathology was obtained where possible. All patients were followed for a minimum of two years. RESULTS: Forty-two out of 111 patients (37.84%) with AD had a normal ultrasound(US) and were discharged. Fifty-five (49.5%) patients had sonographic correlation corresponding to the distortion, leading to US-guided biopsy. Thirteen (23.6%) had Tomosynthesis-guided biopsy, and one had a skin biopsy. The positive predictive value (PPV) for malignancy was 42.34%. Malignancy diagnoses were higher with US-guided biopsies than Tomosynthesis-guided biopsies, 78.1% and 30%, respectively. CONCLUSION: With a total malignancy rate of 42.34%, DBT-detected Architectural Distortion has a high enough PPV for malignancy to justify selective tissue sampling if a sonographic correlate is present or with suspicious mammograms. The chances of malignancy are higher when a sonographic correlate corresponding to AD is present. ADVANCES IN KNOWLEDGE: Architectural Distortion on DBT/SM views in Symptomatic Breast clinic patients justifies selective sampling.

Diagnostic accuracy of magnetic resonance imaging to evaluate axillary lymph node status in breast cancer patients receiving neoadjuvant chemotherapy.

OBJECTIVES: Axillary lymph node status is an important prognostic factor for breast cancer patients. This study aimed to assess the accuracy of MRI in assessing the axillary nodal status in breast cancer patients receiving neo-adjuvant chemotherapy (NACT). METHODS: Data were retrospectively collected for 88 patients between 2011 and 2016 from the hospital records. All patients had baseline MRI, followed by the end of neoadjuvant chemotherapy MRI. Patient demographics, cancer type, grade, stage, receptor status, and the number of positive lymph nodes identified on the baseline and preoperative MRI were recorded. The imaging results were compared to post-operative histopathological lymph node findings. The median patient age of the patients was 54 years (32-77 years). RESULTS: There were 67 (76.1%) patients with histologically proven positive axillary lymph nodes on baseline MRI. The overall conversion from abnormal to normal axillary nodes following chemotherapy (ypN0) was 38.8% (26 patients out of 67). The sensitivity and specificity of MRI for predicting axillary status was 68.85 and 85.71%, respectively, with an overall MRI diagnostic accuracy of 73.07%. CONCLUSION: MRI has low sensitivity and diagnostic accuracy in predicting axillary nodal status in breast cancer patients receiving neoadjuvant chemotherapy. Given the low NPV of MRI of the axilla, a negative MRI does not obviate the need for definitive axillary surgery. ADVANCES IN KNOWLEDGE: In its current state, MRI cannot obviate the need for axillary surgery in patients receiving NACT. Long: short axis ratio (L: S) of the axillary lymph node is not a good predictor of axillary metastases.

The symptomatic breast services in a university hospital: pandemic peak compared to the pre-pandemic year and future implications.

BACKGROUND: COVID-19 infection led to a substantial overhaul of the symptomatic breast services within the UK. AIM: The purpose of this study was to evaluate the pattern of primary care referrals to the symptomatic one-stop clinic during the pandemic. This study also provides a snapshot of the workings of symptomatic breast services and the scope for improvements. METHODS: The data points were collected for 1 month during the peak of the pandemic (April 2020) and compared to corresponding data points for the same month in the previous year (April 2019). This was compared to the monthly data from Wales Cancer Network (WCN) data source. A hundred patients from each month over 2 years were evaluated to get a snapshot into the working of the breast clinic. RESULTS: A total of 516 patients were referred from primary care or General Practitioners (GPs), and were seen in the Hospital 'one-stop breast clinic' in April 2019. This number dropped to 330 patients during the peak of the pandemic in April 2020. Ninety percent of referrals from the GP were urgent suspected cancers or urgent referrals. This trend of referrals did not change over 2 years. There was a 5% and 7% cancer diagnosis rate in 2020 and 2019, respectively. CONCLUSIONS: Most patients were referred from GP as 'urgent' or 'urgent suspected cancer'. The cancer diagnosis rate reduced from 7 to 5% during the pandemic peak but the number of 'worried well' patients did not reduce. The total number of referrals reduced, which is predictive of increased demand in the future. The authors have suggested ways to meet this demand.

Planar Bone Scan Versus Computerized Tomography in Staging Locally Advanced Breast Cancer in Asymptomatic Patients: Does Bone Scan Change Patient Management Over Computerized Tomography?

AIM: The Royal College of Radiologists guidelines from 2013 recommend that contrast-enhanced computerized tomography of chest, abdomen and pelvis (CT TAP) for breast cancer patients with suspected metastasis could obviate the need for bone scan in asymptomatic patients. The purpose of this study was to perform a head-to-head comparison of bone scan and CT scan in locally advanced breast cancer patients. The aim of this study was to evaluate the utility of planar bone scan in changing the stage or management of locally advanced breast cancer patients. METHODS: Between June 2006 and January 2016, 156 breast cancer patients had staging investigations (either CT and bone scans, bone scans only, or CT only). All images and reports on picture archiving and communication system were evaluated retrospectively. RESULTS: One hundred five of 156 patients had both CT TAP and bone scan within 10 days of each other. Of the total of 105 patients, 33 (31.4%) had concordant normal results on CT TAP and bone scan. There were 18/105 (17.1%) patients with extraosseous metastasis on CT with negative or inconclusive bone scan. Bone scans diagnosed peripheral osseous metastasis in 5/105 (4.7%), which were either skull or extremity metastasis outside CT TAP field of view. All of these 5 patients had other metastatic lesions within axial skeleton or soft tissues on CT and led to no change in patient management. CONCLUSIONS: Our findings suggest routine use of bone scan in asymptomatic patients with locally advanced breast cancer did not change patient management.

Can Nomograms Predict Preoperative Axillary Lymph Node Metastasis in Patients With Breast Cancer to Guide Second Look Ultrasonography?

OBJECTIVES: The low sensitivity of ultrasonography (US) for diagnosing axillary lymph node metastasis in patients with breast cancer has led to the development of multiple tools in an attempt to increase preoperative sensitivity, including second-look US. We compared axillary lymph node metastasis predictor scores with postsurgical findings, using the Memorial Sloan Kettering Cancer Center (MSKCC; New York, NY) and Evidencio (www.evidencio.com) nomograms: 2 freely available online predictor tools. METHODS: We retrospectively evaluated 450 patients with breast cancer and analyzed data from 194 patients. Sonograms were evaluated to measure lymph node cortical thickness, transverse diameter, and hilum status. Patients were divided into 3 groups: namely 0, 1, and 2 based on the number of postoperative positive nodes (0, 1 and ≥2, respectively). One-way analysis of variance was used to analyze the differences in mean scores across the 3 nodal groups for both nomograms. P < .05 was considered statistically significant. RESULTS: There were significant differences in mean scores across the 3 nodal groups when using MSKCC (P < .001) as well as Evidencio (P < .001). However, there was an overlap of scores across the 3 groups; thus, mutually exclusive values were not obtained. A strong positive correlation was found between MSKCC and Evidencio (P < 0.001). Tumor size and the presence of lymphovascular invasion were significantly associated with axillary nodal disease (P < .001; P = .003, respectively). CONCLUSIONS: The use of nomograms to predict axillary nodal involvement in patients with breast cancer can guide discussions, but in their present state, these scores cannot guide clinical decisions or direct second-look US of axilla.

Measurement of change in estimated glomerular filtration rate in patients with renal insufficiency after contrast-enhanced computed tomography: a case-control study.

AIM: To test the safety of intravenous contrast in patients with renal insufficiency undergoing computed tomography compared with a concurrent group of patients who received no contrast. MATERIALS AND METHODS: Between October 2006 and February 2007, 106 consecutive patients with renal insufficiency who underwent intravenous contrast computed tomography were retrospectively reviewed. A separate group of 52 patients with renal insufficiency who did not receive intravenous contrast was also reviewed and acted as control group. Baseline and repeat creatinine (in micromole per liter) and estimated glomerular filtration rate (eGFR) levels were obtained for all patients using the modification of diet in renal disease equation within 3.5 days. Mann-Whitney U test was used to determine any statistically significant changes in creatinine and eGFR values. Subgroup analysis involving only patients with eGFR values of less than 60 was also performed. RESULTS: The mean creatinine before and after contrast was 135.45 and 151.37, respectively (P = 0.724). The mean eGFR before and after contrast was 44.33 and 43.41, respectively (P = 0.824). Subgroup analysis of 63 patients involving patients with eGFR of less than 60 revealed precontrast and postcontrast creatinine mean to be 136.21 and 158.40, respectively (P = 0.248). Estimated GFR mean values in the same group before and after contrast were 43.71 and 40.70, respectively (P = 0.250). Control group showed precontrast and postcontrast eGFR (and creatinine) mean values to be 40 (162.04) and 38 (168.52), respectively (P = 0.641). CONCLUSIONS: Estimated GFR (and creatinine) values in patients with renal insufficiency did not show a statistically significant increase after a mean of 3.5 days of receiving intravenous contrast and therefore supports a conservative outpatient-based management approach.