R. James Brenner

Breast Cancer Screening With Imaging: Recommendations From the Society of Breast Imaging and the ACR on the Use of Mammography, Breast MRI, Breast Ultrasound, and Other Technologies for the Detection of Clinically Occult Breast Cancer

Screening for breast cancer with mammography has been shown to decrease mortality from breast cancer, and mammography is the mainstay of screening for clinically occult disease. Mammography, however, has well-recognized limitations, and recently, other imaging including ultrasound and magnetic resonance imaging have been used as adjunctive screening tools, mainly for women who may be at increased risk for the development of breast cancer. The Society of Breast Imaging and the Breast Imaging Commission of the ACR are issuing these recommendations to provide guidance to patients and clinicians on the use of imaging to screen for breast cancer. Wherever possible, the recommendations are based on available evidence. Where evidence is lacking, the recommendations are based on consensus opinions of the fellows and executive committee of the Society of Breast Imaging and the members of the Breast Imaging Commission of the ACR.

Impact of Micrometastases in the Sentinel Node of Patients With Invasive Breast Cancer

PURPOSE Lymph node metastases are the most significant prognostic indicator for patients with breast cancer. Sentinel node biopsy (SNB) has led to an increase in the detection of micrometastases in the sentinel node (SN). This prospective study was designed to determine the survival impact of micrometastases in SNs of patients with invasive breast cancer. This study is based on the new sixth edition of the American Joint Committee on Cancer (AJCC) staging criteria. PATIENTS AND METHODS Between January 1, 1992 and April 30, 1999, 790 patients entered this prospective study at the John Wayne Cancer Institute. The SN was examined first by hematoxylin and eosin (HE), and if the SN was negative with HE, then immunohistochemical staining was performed. The patients were then divided into four groups based on AJCC nodal staging: pN0(i-), no evidence of tumor (n = 486); pN0(i+), tumor deposit < or = 0.2 mm (n = 84); pN1mi, tumor deposit more than 0.2 mm but < or = 2 mm (n = 54), and pN1, tumor deposit more than 2 mm (n = 166). Disease-free survival (DFS) and overall survival (OS) were estimated using the Kaplan-Meier method. The log-rank test was used to determine differences in DFS and OS of patients from different groups. RESULTS At a median follow-up of 72.5 months, the size of SN metastases was a significant predictor of DFS and OS. CONCLUSION Patients with micrometastatic tumor deposits, pN0(i+) or pN1mi, do not seem to have a worse 8-year DFS or OS compared with SN-negative patients. As expected, there was a significant decrease in 8-year DFS and OS in patients with pN1 disease in the SN.

National trends and practices in breast MRI.

OBJECTIVE The objective of our study was to report on the current practices of radiologists involved in the performance and interpretation of breast MRI in the United States. MATERIALS AND METHODS We invited the 1,696 active physician members of the Society of Breast Imaging to participate in a survey addressing whether and how they performed and interpreted breast MRI. Respondents were asked to select one member of their practice to complete the survey. A total of 754 surveys were completed. Every respondent did not reply to every question. RESULTS Contrast-enhanced breast MRI was offered at 557 of 754 (73.8%) practices. Of these, 346 of 553 (62.6%) performed at least five breast MRI examinations per week, and only 56 of 553 (10.1%) performed > 20 per week. Radiologists qualified under the Mammography Quality Standards Act supervised the performance of and interpreted breast MRI in the majority of facilities. Of 552 respondents, breast MRI was interpreted as soft copy with computer-aided detection (CAD) in 280 practices (50.7%), as soft copy without CAD in 261 (47.3%), and as hard copy in 11 (2.0%). Of 551 respondents, 256 (46.5%) never and 207 (37.6%) rarely interpreted breast MRI without correlating mammography or sonography findings. The majority of respondents never (269/561, 48.0%) or rarely (165/561, 29.4%) interpreted breast MRI performed at an outside facility. Screening breast MRI was offered at 359 of 561 (64.0%) practices. Of the practices performing contrast-enhanced examinations, 173 of 557 (31.1%) did not perform MRI-guided interventional procedures. CONCLUSION Contrast-enhanced breast MRI is now widely used in the United States. The information gained from this survey should provide reasonable approaches for the development of professional practice guidelines.

The California Breast Density Information Group: A Collaborative Response to the Issues of Breast Density, Breast Cancer Risk, and Breast Density Notification Legislation

In anticipation of breast density notification legislation in the state of California, which would require notification of women with heterogeneously and extremely dense breast tissue, a working group of breast imagers and breast cancer risk specialists was formed to provide a common response framework. The California Breast Density Information Group identified key elements and implications of the law, researching scientific evidence needed to develop a robust response. In particular, issues of risk associated with dense breast tissue, masking of cancers by dense tissue on mammograms, and the efficacy, benefits, and harms of supplementary screening tests were studied and consensus reached. National guidelines and peer-reviewed published literature were used to recommend that women with dense breast tissue at screening mammography follow supplemental screening guidelines based on breast cancer risk assessment. The goal of developing educational materials for referring clinicians and patients was reached with the construction of an easily accessible Web site that contains information about breast density, breast cancer risk assessment, and supplementary imaging. This multi-institutional, multidisciplinary approach may be useful for organizations to frame responses as similar legislation is passed across the United States. Online supplemental material is available for this article.

Surveillance mammography and stereotactic core breast biopsy for probably benign lesions: a cost comparison analysis.

RATIONALE AND OBJECTIVES The authors compared the economic effect of stereotactic core needle biopsy (CNB) with that of short-term unilateral surveillance mammography in the management of probably benign breast lesions detected during routine screening mammography. METHODS Published data with regard to the cost of stereotactic CNB and unilateral mammography were applied to 3,184 patients who underwent surveillance mammography; including 161 patients who underwent biopsy. Costs of immediate tissue diagnosis were compared with costs of surveillance with use of ratios of published reimbursement scales to minimize geographic variations. Sensitivity analyses were applied to this ratio. RESULTS The cost of managing probably benign breast lesions with surveillance mammography was

FALSE-NEGATIVE MAMMOGRAMS: Medical, Legal, and Risk Management Implications

3,307,575 less than if all lesions had been managed with CNB. The ratio of the cost of CNB to the cost of surveillance mammography was 8:1. This ratio is more sensitive to the frequency of use of CNB than to reimbursement schedules. CONCLUSION With similar false-negative rates, CNB is more costly than surveillance and has a negative effect in the management of probably benign breast lesions, unless interval change during surveillance prompts tissue diagnosis.

Benefit of Semiannual Ipsilateral Mammographic Surveillance Following Breast Conservation Therapy

From a strictly biologic perspective, delay in diagnosis of breast cancer is axiomatic. The number of cell divisions that must occur before detection is possible by either clinical or mammographic methods means that a finite time has occurred in which the outcome for any given case may have already been determined. That early detection and diagnosis of breast cancer lead to improved survival may be intuitive, but clinical trials have been necessary to validate the concept. Delay in diagnosis is unavoidable but the period of delay may be lessened in many cases, prompting earlier intervention and impacting outcomes. Mammography is an important vehicle for such earlier intervention and the issue of the false-negative mammogram is of concern to the radiology community, the lay community, and the courts. Mammographic interpretation has not yet approached a sufficiently standardized benchmark. Detection and diagnosis are dependent on a series of factors that need to be integrated to achieve the dual goals of timely intervention for bonafide purposes and reduction of unnecessary procedures and interventions. Some of the reasons for delay in diagnosis are unavoidable, beginning with the absence of clinical or imaging features of malignancy and extending to limitations of sufficiently specific features to prompt intervention. On the other hand, other reasons are avoidable and attention to many of these causes should lessen the incidence of such delay. Regardless of the reason, those women who feel that their breast cancer should have been diagnosed at an earlier time may consider subjecting their mammographic studies to independent reviews. At such a point, the precise reasons for delay may be better analyzed, all in an attempt to provide an adequate reconciliation of what has come to be known as the false-negative mammogram.

Supplemental Breast Cancer Screening With Molecular Breast Imaging for Women With Dense Breast Tissue

PURPOSE To compare cancer recurrence outcomes on the basis of compliant semiannual versus noncompliant annual ipsilateral mammographic surveillance following breast conservation therapy (BCT). MATERIALS AND METHODS A HIPAA-compliant retrospective review was performed of post-BCT examinations from 1997 through 2008 by using a deidentified database. The Committee on Human Research did not require institutional review board approval for this study, which was considered quality assurance. Groups were classified according to compliance with institutional post-BCT protocol, which recommends semiannual mammographic examinations of the ipsilateral breast for 5 years. A compliant semiannual examination was defined as an examination with an interval of 0-9 months, although no examination had intervals less than 3 months. A noncompliant annual examination was defined as an examination with an interval of 9-18 months. Cancer recurrence outcomes were compared on the basis of the last examination interval leading to diagnosis. RESULTS Initially, a total of 10 750 post-BCT examinations among 2329 asymptomatic patients were identified. Excluding initial mammographic follow-up, there were 8234 examinations. Of these, 7169 examinations were semiannual with 94 recurrences detected and 1065 examinations were annual with 15 recurrences detected. There were no differences in demographic risk factors or biopsy rates. Recurrences identified at semiannual intervals were significantly less advanced than those identified at annual intervals (stage I vs stage II, P = .04; stage 0 + stage I vs stage II, P = .03). Nonsignificant findings associated with semiannual versus annual intervals included smaller tumor size (mean, 11.7 vs 15.3 mm; P = .15) and node negativity (98% vs 91%, P = .28). CONCLUSION Results suggest that a semiannual interval is preferable for ipsilateral mammographic surveillance, allowing detection of a significantly higher proportion of cancer recurrences at an earlier stage than noncompliant annual surveillance.

Iodine absorption from the gastrointestinal tract during hypaque-enema examination.

OBJECTIVE Molecular breast imaging was implemented in routine clinical practice at a large community-based breast imaging center. The aim of this study was to retrospectively assess the clinical performance of molecular breast imaging as a supplementary screening tool for women with dense breast tissue. MATERIALS AND METHODS Women with dense breasts and negative mammography results who subsequently underwent screening with 300 MBq (8 mCi) (99m)Tc-sestamibi molecular breast imaging were retrospectively analyzed. Outcome measures included cancer detection rate, recall rate, biopsy rate, and positive predictive values (PPVs). RESULTS Molecular breast imaging screening of 1696 women in this study resulted in the detection of 13 mammographically occult malignancies, of which 11 were invasive, one was node positive, and one had unknown node positivity. The lesion size ranged from 0.6 to 2.4 cm, with a mean of 1.1 cm. The incremental cancer detection rate was 7.7‰ (95% CI, 4.5-13.1‰), the recall rate was 8.4% (95% CI, 7.2-9.8%), and the biopsy rate was 3.7% (95% CI, 2.9%-4.7%). The PPV for recall (PPV 1) was 9.1% (95% CI, 5.4-15.0%), and the PPV for biopsy (PPV 3) was 19.4% (95% CI, 11.4-30.9%). CONCLUSION When incorporated into a community-based clinical practice environment, molecular breast imaging yielded a high incremental cancer detection rate of 7.7‰ at an acceptable radiation dose. These results show the utility of molecular breast imaging as a supplementary screening tool to mammography for women with dense breasts.

Timeliness of Follow-up after Abnormal Screening Mammogram: Variability of Facilities

Iodinated contrast agents administered intravenously or intra-arterially may cause serious reactions in hypersensitive patients. Oral administration of Hypaque (diatrizoate sodium) results in minimal absorption of iodine, but the amount of iodine absorbed with Hypaque-enema studies is unreported. Hypaque-enema examinations were performed in 20 normal, nonsensitive patients and increased serum iodine levels ten to 200 times base-line values, peaking after approximately one hour in patients who had measurements obtained for four hours. Therefore, before Hypague-enema studies, patients must be carefully questioned about their tolerance of iodinated contrast agents, and preparations should be made for possible serious hypersensitivity reactions.