Mode of detection matters: Differences in screen-detected versus symptomatic breast cancers.

OBJECTIVE: Although extensive analyses evaluating screening mammography for breast cancer have been published, some utilized databases do not distinguish between modes of detection, which confounds the conclusions made about the impact of screening mammography. METHODS: A retrospective cohort study of women at our institution with pathologically-proven breast cancer from January 2015 to April 2018 was conducted. Subjects were categorized by their mode of diagnosis: screening or non-screening. Patient demographics, tumor characteristics, and treatments were compared between detection methods using Wilcoxon rank-sum test for continuous variables and chi-squared or Fisher's exact test. RESULTS: 1026 breast cancers were analyzed. 80.8% of screen-detected breast cancers were invasive. Compared to symptomatically detected cancers, screen-detected were smaller (median size 8 mm vs. 15 mm, p < 0.001), less invasive (80.8% vs. 94.3), had a lower pathologic grade (29% grade 3 vs. 45.7%, p < 0.001), a lower clinical stage, and less aggressive histology (51.9% low Ki67 vs. 30.5%, and 88.2% HER2 negative vs. 76.6%, p < 0.001). Screen-detected cancers were less likely to have extramammary disease (13.2% positive lymph nodes vs. 34.0% and 0.4% distant metastases vs. 6.9%, p < 0.001). Women with screen-detected cancers were more likely to undergo conservative treatment (74.8% underwent lumpectomy vs. 59.9%, and 80.0% received no chemotherapy vs. 51.3%, p < 0.001). CONCLUSION: In this study, while the vast majority of screen-detected cancers were invasive, they were more likely to be smaller, less aggressive, and a lower pathologic grade and clinical stage. Furthermore, women with screen-detected cancers were less likely to have extramammary disease and more likely to undergo conservative treatment.

Breast cancer in women under age 40: A decade of trend analysis at a single institution.

BACKGROUND: Women should be evaluated for breast cancer risk by age 30 to assess for screening need. Recent trends in breast cancer in this population may further inform recommendations. OBJECTIVE: The aim of this study was to analyze trends over time in the rate of breast cancer, tumor characteristics and treatment in women under age 40. METHODS: Retrospective cohort study of women under age 40 at our institution diagnosed with breast cancer from January 2007 to April 2018 was conducted. Patient demographics, tumor characteristics and treatment outcomes were collected. Descriptive statistics and the Mann-Kendell Trend test were calculated. Two-proportion z-tests were used to compare proportions of stage, pathology and treatment between 2007-2013 and 2014-2018. RESULTS: 197 women under age 40 were treated for a new diagnosis of breast cancer at our institution. A higher proportion of women were diagnosed with invasive carcinoma in 2013-2018 (91%) compared to 2007-2012 (78%), p = 0.008. A higher proportion of women were diagnosed with advanced stage disease (stage III-IV) in 2013-2018 (24%) compared to 2007-2012 (2%), p = 0.001. No statistically significant evidence for an increasing trend of overall rate of breast cancer over the last 11 years (p = 0.419) was observed. CONCLUSIONS: While no statistically significant increase in overall rate of breast cancer was noted, an increase in invasive and later staged breast cancers was observed. CLINICAL IMPACT: Rise in more aggressive cancers in a population that is largely not screened may have implications both on the individual young woman's morbidity as well as on a public health level.

Diffusion tensor imaging and quantitative susceptibility mapping as diagnostic tools for motor neuron disorders.

PURPOSE: Diffusion tensor imaging (DTI) and quantitative susceptibility mapping (QSM) have been proposed as methods to aid in the diagnosis of amyotrophic lateral sclerosis (ALS) and primary lateral sclerosis (PLS), both diseases affecting upper motor neurons. We test the performance of DTI and QSM alone and in combination to distinguish patients with diseases affecting upper motor neurons (ALS/PLS) from patients with other motor symptom-predominant neurologic disorders. METHODS: 3.0 Tesla MRI with DTI and QSM in patients referred to a subspecialty neurology clinic for evaluation of motor symptom-predominant neurologic disorders were retrospectively reviewed. Corticospinal tract fractional anisotropy and maximum motor cortex susceptibility were measured. Subjects were categorized by diagnosis and imaging metrics were compared between groups using Student's t-tests. Receiver operating characteristic curves were generated for imaging metrics alone and in combination. RESULTS: MRI scans for 43 patients with ALS or PLS and 15 patients with motor symptom predominant, non-upper motor neuron disease (mimics) were reviewed. Fractional anisotropy was lower (0.57 vs. 0.60, p < 0.01) and maximum motor cortex magnetic susceptibility higher (64.4 vs. 52.7, p = 0.01) in patients with ALS/PLS compared to mimics. There was no significant difference in area under the curve for these metrics alone (0.73, 0.63; p > 0.05) or in combination (0.75; p > 0.05). CONCLUSION: We found significant differences in DTI and QSM metrics in patients with diseases affecting upper motor neurons (ALS/PLS) compared to mimics, but no significant difference in the performance of these metrics in diagnosing ALS/PLS compared to mimics.

Relationship Between Endothelial Wall Shear Stress and High-Risk Atherosclerotic Plaque Characteristics for Identification of Coronary Lesions That Cause Ischemia: A Direct Comparison With Fractional Flow Reserve.

BACKGROUND: Wall shear stress (WSS) is an established predictor of coronary atherosclerosis progression. Prior studies have reported that high WSS has been associated with high-risk atherosclerotic plaque characteristics (APCs). WSS and APCs are quantifiable by coronary computed tomography angiography, but the relationship of coronary lesion ischemia-evaluated by fractional flow reserve-to WSS and APCs has not been examined. METHODS AND RESULTS: WSS measures were obtained from 100 evaluable patients who underwent coronary computed tomography angiography and invasive coronary angiography with fractional flow reserve. Patients were categorized according to tertiles of mean WSS values defined as low, intermediate, and high. Coronary ischemia was defined as fractional flow reserve ≤0.80. Stenosis severity was determined by minimal luminal diameter. APCs were defined as positive remodeling, low attenuation plaque, and spotty calcification. The likelihood of having positive remodeling and low-attenuation plaque was greater in the high WSS group compared with the low WSS group after adjusting for minimal luminal diameter (odds ratio for positive remodeling: 2.54, 95% CI 1.12-5.77; odds ratio for low-attenuation plaque: 2.68, 95% CI 1.02-7.06; both P<0.05). No significant relationship was observed between WSS and fractional flow reserve when adjusting for either minimal luminal diameter or APCs. WSS displayed no incremental benefit above stenosis severity and APCs for detecting lesions that caused ischemia (area under the curve for stenosis and APCs: 0.87, 95% CI 0.81-0.93; area under the curve for stenosis, APCs, and WSS: 0.88, 95% CI 0.82-0.93; P=0.30 for difference). CONCLUSIONS: High WSS is associated with APCs independent of stenosis severity. WSS provided no added value beyond stenosis severity and APCs for detecting lesions with significant ischemia.

2D mammography, digital breast tomosynthesis, and ultrasound: which should be used for the different breast densities in breast cancer screening?

PURPOSE: To determine which modalities [2D mammography (2D), digital breast tomosynthesis (DBT), whole breast sonography (WBS)] are optimal for screening depending on breast density. METHODS: Institutional retrospective cohort study of 2013 screening mammograms (16,789), sorted by modalities and density. RESULTS: Cancer detection is increased by adding WBS to 2D (P=.02) for the overall study population. Recall rate was lowest with 2D+DBT (10.2%, P<.001) and highest with 2D+DBT+WBS (23.6%, P<.001) for the overall study population as well. CONCLUSION: Women with dense and nondense breasts benefit from reduced recall rate with the addition of DBT; however, this benefit is negated with the addition of WBS.

Adverse reactions to intravenous contrast media: an unexpected discrepancy between inpatient and outpatient cohorts.

Adverse reaction rates to computed tomography (CT) and magnetic resonance imaging (MRI) contrast agents are well published. However, there is no literature regarding systems-based changes to improve contrast reaction management. As part of ongoing quality improvement monitoring at our institution, contrast reaction events were reviewed. Contrast reactions for CT and MRI were captured at lower rates for the inpatient setting compared to outpatient by an order of a magnitude. The documented inpatient events were more likely to be severe in nature. Given this discrepancy, focus is being placed upon identifying potential barriers to capturing and appropriately managing inpatient contrast reactions.

Massive superior mesenteric venous aneurysm with portal venous thrombosis.

Portal venous aneurysm is a rare and sometimes dangerous vascular pathology, which can result in thrombosis or rupture. We present the computed tomography, magnetic resonance, and sonographic imaging of a 27-year-old man with superior mesenteric venous aneurysm and subsequent thrombosis following acute pancreatitis. This multimodality imaging approach can prove useful in the evaluation of these rare aneurysms.

Quantifying Patient-Physician Communication and Perceptions of Risk During Admissions for Possible Acute Coronary Syndromes.

STUDY OBJECTIVE: Disposition decision for patients with possible acute coronary syndrome in the emergency department (ED) is driven primarily by perception of short-term risks. We sought to evaluate communication between patient and physician about these risks by ascertaining the content of discussions surrounding disposition decision. METHODS: We conducted matched-pair surveys of patients admitted for possible acute coronary syndrome and their physicians in 2 academic, inner-city EDs. After disposition conversation, trained research assistants administered surveys querying perceived and communicated risk estimates and purpose of admission. Primary exclusion criteria were ECG or troponin value diagnostic of acute coronary syndrome. The primary outcome measure was agreement in assessment of the risk of myocardial infarction, defined as the proportion of patient-physician pairs whose risk estimates were within 10% of each other. RESULTS: A total of 425 patient-physician survey pairs were collected. Fifty-three percent of patients were men. Patients reported discussing the likelihood of their symptoms' being due to myocardial infarction in 65% of cases, whereas physicians reported this in 46%. After their discussion, physicians' (n=415) median estimate of short-term risk was 5% (95% confidence interval [CI] 3% to 7%), whereas patients' (n=401) was 8% (95% CI 5% to 11%). Most patients (63%; 95% CI 57% to 67%) reported that this estimate remained the same or increased after their conversation. Risk agreement within 10% occurred in 36% of cases (n=404; 95% CI 32% to 41%). Patients' median estimates of the mortality of myocardial infarction at home versus in the hospital were 80% (n=398; 95% CI 76% to 84%) and 10% (n=390; 95% CI 7% to 13%), respectively, whereas physician estimates were 15% (n=403; 95% CI 12% to 18%) and 10% (n=398; 95% CI 7% to 13%). CONCLUSION: Our survey demonstrates poor communication, with overestimation of both the risks of myocardial infarction and potential benefit of hospital admission. These findings suggest that communication surrounding disposition decisions in chest pain patients may at times be ineffective or misleading.