Alice Rim

Preoperative Breast Magnetic Resonance Imaging in Early Breast Cancer : Implications for Partial Breast Irradiation

Accelerated partial breast irradiation (APBI) of patients with early breast cancer is being investigated on a multi‐institutional protocol National Surgical Adjuvant Breast and Bowel Project (NSABP) B‐39/RTOG 0413. Breast magnetic resonance imaging (MRI) is more sensitive than mammography (MG) and may aid in selection of patients appropriate for PBI.

A prospective review of the decline of excisional breast biopsy

BACKGROUND Although excisional breast biopsy has long been considered the standard for breast cancer diagnosis, core biopsies are now used more frequently. Whether core biopsy can eventually replace excisional biopsy remains unknown. The purpose of this study was to evaluate the relationship between diagnostic excisional and core biopsies relative to surgical treatment procedures. METHODS We analyzed our data collected prospectively from 1995 through 2000, which included inpatient and outpatient surgical data, office visits, and radiology biopsy data including stereotactic, mammotome, and ultrasound core biopsies. The Cochran-Armitage trend test was used to assess the shift in diagnostic technique. RESULTS From 1995 through 2000 there were 2,631 core biopsies performed, 2,685 excisional biopsies, 2,881 surgical procedures for breast cancer, and 51,109 office visits. Although the percentage of core biopsies relative to excisional biopsies increased from 31% to 68% (P <0.001), the percentage of biopsies relative to the number of office visits remained stable at 10% to 11%. The percentage of breast cancer procedures relative to office visits also remained stable at 5% to 6%. CONCLUSIONS Our data indicate that core biopsies are being performed more often than excisional biopsies. Nevertheless, one in three biopsies done at our institution is excisional.

Does ultrasound core breast biopsy predict histologic finding on excisional biopsy

BACKGROUND The purpose of this study was to determine whether ultrasound-guided core breast biopsy accurately predicts the histologic finding of a subsequent excisional procedure. METHODS Data were collected prospectively from 1997 to 2001 for 832 ultrasound-guided core breast biopsies (USB) that were followed by excisional breast procedure (EP) within 1 year at our institution. The principal histologic finding obtained at USB and EP was identified for each procedure and the degree of agreement was assessed. RESULTS The USB histology predicted EP histology in 90% (n = 746) of the procedures. The USB histology was more significant than EP histology in 3% (n = 22) of procedures; USB histology underdetermined EP histology in 7% (n = 64) of procedures. Overall, our results indicate moderate agreement between the principal histology identified at USB relative to that identified at EP. CONCLUSIONS Ultrasound-guided core breast biopsy is an effective diagnostic method, but sampling limitations do exist.

Does core needle breast biopsy accurately reflect breast pathology

BACKGROUND Core needle breast biopsy (CB) has replaced excisional biopsy as the initial diagnostic biopsy procedure for many suspicious breast lesions; however, CB remains a sampling procedure. The purpose of this study was to determine the degree of agreement between histology obtained at CB and that obtained at a subsequent excisional procedure (EP). We hypothesized a high degree of agreement. METHODS Data were collected prospectively for 3035 CBs performed by breast radiologists using either ultrasound or stereotactic guidance between January 1995 and July 2002, 1410 (46%) of which had a subsequent EP within 1 year. Histologic categories were defined as invasive breast cancer, duct carcinoma in-situ, atypia/lobular carcinoma in-situ, and benign. The principal histology (PH) from CB and EP was identified and compared. RESULTS Overall, there was moderate agreement (kappa=0.669) between CB and EP histology. Complete agreement occurred in 1168 (83%) procedures. For the remaining 242, the PH was identified only at CB for 78 (5%) procedures, and only after EP for 164 (12%) procedures. CONCLUSIONS Although the majority (83%) of CB and EP demonstrated exact histologic agreement, CB was diagnostic for 1246 (88%) procedures.

The importance of preoperative breast MRI for patients newly diagnosed with breast cancer

Abstract:  The use of preoperative breast magnetic resonance imaging (bMRI) for patients newly diagnosed with breast cancer has been criticized for increasing the number of therapeutic mastectomies performed, as well as increasing the cost of treatment. The purpose of this report is to examine one surgeon’s practice and to describe the MRI findings for patients with breast cancer to determine if those findings changed the therapeutic options for those patients in. Data were collected prospectively between August 2003 and January 2006 for patients newly diagnosed with breast cancer. Diagnoses were made by core biopsy or fine‐needle aspiration; all lesions were intact at the time of MRI. Twenty‐five percent of patients were found to have previously occult, but suspicious lesions on MRI that required additional diagnostic evaluation, including ultrasound, core biopsy, excisional biopsy, or any combination; for approximately half of these patients a separate cancer was confirmed. For most of these patients, the new lesion was ipsilateral and multicentric, and most required mastectomy. For the remaining 75% of patients, MRI confirmed the index lesion was the only area of concern, and appropriate surgical treatment was completed. Preoperative bMRI for patients newly diagnosed with breast cancer identified previously occult and separate tumors in 13% of patients, resulting in surgical treatment change for many.

Guidelines for using breast magnetic resonance imaging to evaluate implant integrity.

The purpose of this report was to review our experience with using breast magnetic resonance imaging to evaluate breast implant integrity and to offer a decision tree to assist physicians in managing these patients. Data were available for 81 patients with 146 implants placed either unilaterally or bilaterally for either cosmesis or breast reconstruction. The chief complaint for a majority of patients (n = 24) was breast pain. Thirty-two patients were found to have 44 ruptured implants, the majority of whom were found to have either contracture (n = 7) or negative findings (n = 7) on physician examination. The likelihood of rupture increased with number of years in place. When a patient presents for a possible implant rupture, the initial concern is to rule out malignancy, but because clinical and radiologic findings are often convoluted and complicated, a decision tree is helpful.

Low Compliance in a Health-Conscience Spending Era Likely Helps Obviates the Need for 6 month BI-RADS 3 Breast MRI Follow-up After 1 year

The goal of our IRB‐approved study was to assess if a follow‐up MRI every 6 months for 2 years is the most appropriate short‐interval follow‐up schedule. 203 breast MRI exams were performed from October 2009 to January 2014 as part of a BI‐RADS 3 follow‐up representing 2.6% of all breast MRIs (7,822) performed. We performed a retrospective longitudinal medical records review of compliance; malignancy rate of BI‐RADS 3 exams; and average time and number of breast MRIs necessary prior to definitive disposition. While 77.8% eventually returned, only 45.5% of patients were compliant with follow‐up at or near 6 months (4.5–7.5 months). Of those who eventually returned, it took an average of 1.31 follow‐up MRIs (95% CI: 1.20–1.43 exams) and 10.3 months (95% CI: 9.0–11.7 months) before definitive disposition. 93.5% of initial findings were dispositioned as benign after two follow‐up MRI exams (malignancy rate: 0.98%). Our results lend support to the possibility that the follow‐up interval for BI‐RADS 3 breast MRIs could be lengthened to 12 months if additional follow‐up MRIs are necessary after the first year of 6‐month follow‐up breast MRIs. Foremost, this appears to be a safe follow‐up alternative since benign definitive disposition can usually be made in less than 1 year. Supplemental reasons include persistent low‐patient compliance (as redemonstrated in our study) and the higher cost of breast MRI compared to mammogram/ultrasound follow‐up. Finally, this papers findings further support the suggested MRI follow‐up interval in the newest BI‐RADS atlas.

Breast Biopsies are Minimally Painful, Exceed Patient Expectations, and Do Not Represent a Genuine Lasting Harm for Most Women

To the Editor: Psychological distress associated with breast imaging, whether physical from a false-positive biopsy or mental/emotional while awaiting results, are very commonly cited as potential “harms” of mammography by referring providers (1,2). The two most commonly cited sources of pain in breast imaging are breast-related procedures (mostly needle biopsies) and compression from the mammogram (3). In a minority of patients, the pain and anxiety of a mammogram are reasons to forgo this screening exam completely (4). However, for most patients, pain (3) and anxiety (5) are not disincentive enough to skip participation in screening mammography. Moreover, despite certain media coverage undermining the overall effectiveness of mammograms, intention to screen remains significantly higher in younger women, women in poorer health, and those with a false-positive abnormal screening mammogram (FP ASM) (6). Paradoxical to expectation, a FP ASM typically results in higher subsequent annual mammographic compliance rates than women with normal results (4). Adding to the problematic claim that psychological distress is an unqualified harm of mammography for those who support screening mammmography is the fact that pain and a patient’s perceptions now will drive a large pool of reimbursement. Reimbursement for hospitals and private providers is now partly determined by Healthcare Effectiveness Data and Information Set (HEDIS) scores, which include [inpatient] pain management. HEDIS scores are also partly based on the Consumer Assessment of Healthcare Providers and Systems (CAHPS ) surveys, which among other items, measures a patient’s satisfaction with their care in areas such as how well a patient’s pain is addressed including: perceived measures taken to mitigate pain, communication with medical staff, and courteous/respectful responsiveness of the health care facility’s staff (7). As the Centers for Medicare and Medicaid Services (CMS) move away from the prior fee-for-service model and enter into the current pay-for-performance model based upon HEDIS/CAHPS measurements, 1% of all CMS reimbursements (up to

Magnetic resonance imaging as a diagnostic tool for breast cancer in premenopausal women

1 billion dollars) will be held for later redistribution to “top box” hospitals based on regional and national benchmarks, and is set to double to 2% (~

Trends in breast cancer screening and diagnosis

2 billion dollars) by 2017 (8). Aware of the impact radiology will have on patient satisfaction in conjunction with the drive toward minimally invasive image-guided procedures (to include breast biopsies), hospitals are likely to incentivize radiology departments, both positively and negatively, to “perform” with patient satisfaction and pain reduction foremost in mind to preempt potential CMS reimbursement reductions related to dissatisfaction from pain. Anticipating this ahead of time, breast radiologists in particular (as well as other interventionalists) will need to do all that is possible to increase our understanding of how to lessen a patient’s pain during radiology-guided procedures (and mammograms), decrease procedural anxiety, and engender a sense of compassionate, professional trust with the patient. Yet how can anxiety related specifically to breast imaging be broken down and better understood. First, it can be separated into preprocedural (awaiting the biopsy), procedural, and postprocedural (awaiting the results and dealing with any postprocedural discomfort). The most significant cause of anxiety appears to be preprocedural, or awaiting the core-needle biopsy (CNB) itself. This is supported by the fact that patients experienced the largest decrease in anxiety during the first 24 hours after the procedure even though the pathology results were not yet available Address correspondence and reprint requests to: Andrew Mosier, DO, Department of Radiology, Cleveland Clinic Foundation Imaging Institute, 9500 Euclid Ave A-10, Cleveland, OH 44195, USA, or e-mails: mosier51@hotmail.com and andrew.d.mosier4.mil@mail.mil