Dense breasts: a review of reporting legislation and available supplemental screening options.

OBJECTIVE: The objectives of this article are to discuss the Mammography Quality Standards Act (MQSA) and what it means for patients, define breast density and explain how it is measured, review the new state-based legislation regarding the reporting of dense breast tissue directly to patients and the possibility of an adjunct screening examination, describe possible supplemental screening options and the advantages and disadvantages of each, and outline the current shortcomings and unanswered questions regarding new legislation. CONCLUSION: Breast density is now established as an independent risk factor for developing breast cancer irrespective of other known risk factors. Women with breast density in the upper quartile have an associated four to five times greater risk of developing breast cancer relative to women with breast density in the lower quartile. Many states have enacted or proposed legislation requiring mammographers to report to patients directly if they have dense breast tissue and recommend discussing the possibility of a supplemental screening examination with their physicians. However, there is currently no consensus as to whether a supplemental screening examination should be pursued or which modality to use. Possible supplemental screening modalities include ultrasound, MRI, digital breast tomosynthesis, and molecular breast imaging. The U.S. Food and Drug Administration recently approved an automated breast ultrasound system for screening whole-breast ultrasound in patients with dense breasts. However, many questions are still unanswered including the impact on morbidity and mortality, cost-effectiveness, and insurance coverage.

Vascular stent fracture and migration to pulmonary artery during arteriovenous shunt thrombectomy.

PURPOSE: Endovascular stent fracture and migration is an extremely rare complication of arteriovenous shunt thrombectomy. TECHNIQUE: We report a case of endovascular stent fracture following repeat arteriovenous graft thrombectomy, which was complicated by migration of a 26 millimeter stent fragment to the left main pulmonary artery. Attempts at percutaneous transvenous retrieval were unsuccessful, and an open thoracotomy to extract the stent fragment was performed. CONCLUSIONS: Although there is no consensus for the management of endovascular stents that have migrated to the pulmonary arteries, stent retrieval may be necessary in cases where arterial flow is compromised or heavy clot burden is a concern. Moreover, steps toward prevention of stent fracture and migration should be considered in order to preclude such occurrences--avoidance of puncturing the stent for hemodialysis access, discontinuation of use of the Arrow-Trerotola device through or near stents, and consideration of short segment angioplasty for regional intrastent stenosis rather than typical long segment venous angioplasty.

Toward the establishment of optimal computed tomographic parameters for the assessment of lumbar spinal fusion.

BACKGROUND CONTEXT: The accurate detection of the extent of bony fusion after attempted lumbar arthrodesis is important given that subsequent efforts-such as decisions regarding need for continued external bracing, use of enhancing modalities (electrical stimulation and pulsed ultrasound), recommended activity levels, return to employment, early surgical intervention, and others-may be needed to reduce the risk of late failure, especially in light of the fact that late revisions for failed fusions often result in poor outcomes and significant costs. Thin-cut computed tomography (CT) has emerged as the study of choice for this purpose. PURPOSE: To delineate the optimal CT parameters for determining fusion versus pseudarthosis after attempted lumbar fusion. STUDY DESIGN: Blinded CT assessment with cadaveric specimen as a gold standard. METHODS: A human cadaveric spine specimen with a T10 to S1 thoracolumbar posterolateral fusion augmented by instrumentation and anterior lumbar interbody fusions was used as a gold standard. Two experienced spine surgeons and one musculoskeletal radiologist-all blinded to the pathology results-assessed a series of CT scans of the specimen, each CT using one of six predefined sets of parameters. RESULTS: Predictive values and sensitivity generally improved with decreasing slice thickness and slice spacing, but only modestly. All sets of parameters had higher negative predictive value (NPV) than positive predictive value (PPV). Computed tomographic parameters of 0.9-mm thick sections with 50% overlap showed the highest PPV and NPV, where NPV was 90, but PPV was only 59. CONCLUSIONS: In this study, using the best widely available CT technologies and the ideal gold standard, thin-cut CT remained less than ideal for the assessment of lumbar arthrodesis/pseudarthrosis. Tuning slice thickness and slice spacing down generally improves detail, but marginally. We have successfully defined "optimal" as "best available," but "optimal" as "nearly perfect" awaits further technological advances.