Patient expectations and costs of immediate reporting of screening mammography: talk isn't cheap.

OBJECTIVE: Our purpose was to determine whether patients prefer immediate or delayed results of screening mammography and to determine the cost of immediate reporting at our institution. MATERIALS AND METHODS: A survey was anonymously and randomly distributed to 129 women who were 35-70 years old during a visit to their primary care physician, asking the women's preference for receiving mammography results by one of two systems: by letter with a return visit for any additional tests; or by speaking at once with the radiologist, with the option of additional tests being performed during the same visit. Patients' willingness to pay for the latter service was also determined. A cost identification model was constructed using commercially available software. We considered the impact on radiologists' and technologists' time and the need for additional equipment and space, and we analyzed the effect on the cost of immediate reporting. RESULTS: One hundred twenty (93%) surveys were completed. Eighty women (67%) preferred immediate reporting, and 62 (78%) of these 80 patients would wait 30-60 min. The additional cost of immediate reporting is $28.22 per patient. Only 11% of patients were willing to pay this additional cost. When new equipment and space were not required, the cost would increase by $4.38. This cost was most influenced by the time required to give patients normal results. CONCLUSION: Most surveyed patients preferred speaking with a radiologist immediately but were unwilling to pay additional fees. Radiologists, hospital administrators, and health care planners must be aware of the costs of immediate reporting and must factor these costs into any change in hospital or national policy.

Technical factors influencing sonographic visualization of fetal echogenic intracardiac foci.

PURPOSE: A fetal echogenic intracardiac focus (EIF) is most commonly a normal variant in a normal fetus, but owing to reports of an increased risk of aneuploidy with EIFs, the finding causes concern when noted on routine obstetric sonograms. This study was undertaken to determine which factors influence the sonographic visualization of fetal EIFs. METHODS: In part 1 of the study, records from 1,920 fetal sonographic examinations were reviewed for fetal age, indication for sonography, and abnormal findings. For all cases with EIFs recorded and 645 randomly selected cases with no record of EIFs, sonograms were reviewed for heart position at the time of the 4-chamber view, technologist performing the examination, fetal position, heart visibility, transducer frequency, machine type, amount of amniotic fluid, and presence/absence of an EIF. In part 2 of the study, machine settings were evaluated with respect to visualization of EIFs. RESULTS: In part 1 of the study, only the technologist performing the examination and the fetal position were associated with visualization of EIFs. In part 2 of the study, we found that the standard obstetric mode settings are better for visualization of EIFs than are the fetal echocardiographic mode settings. CONCLUSIONS: We conclude that technical factors influence visualization of EIFs.

Sonographic appearance of early complete molar pregnancies.

Since our anecdotal experience indicates that the classically described "snowstorm" appearance on ultrasonography of early molar pregnancies is often not present and that theca-lutein cysts are also rare, we examined the ultrasonographic appearance of early complete molar pregnancies. We reviewed the ultrasonographic reports and clinical data of 21 cases of histologically diagnosed complete molar pregnancies with a mean gestational age at sonography of 10.5 weeks (range, 4 to 18 weeks). The diagnosis of molar pregnancy was made on ultrasonography in 12 (57%) cases, was second in the differential diagnosis of one (4.8%) case, and was not considered in eight (38%) cases. No theca-lutein cysts were identified. Five of five (100%) molar pregnancies of 13 weeks or over were diagnosed prospectively, while only eight of 16 (50%) earlier pregnancies were correctly diagnosed prospectively. In a retrospective review of the available images of 16 patients, only nine of 16 (56%) images demonstrated the classic appearance, and no theca-lutein cysts were seen. We conclude that the classic appearance of complete moles on ultrasonography is seen in less than two thirds of cases and even less commonly in the first trimester. The prevalence of theca-lutein cysts is very low.

Diagnostic accuracy with US: remote radiologists' versus on-site radiologists' interpretations.

PURPOSE: To compare the diagnostic accuracy of radiologists interpreting static ultrasonographic (US) images electronically transmitted to an academic medical center (remote radiologists) with that of radiologists performing "hands-on" US at a community-based outpatient site (on-site radiologists). MATERIALS AND METHODS: During 8 months, 80 patients underwent pelvic US at a community-based outpatient site. Images were electronically transmitted to a remote medical center as they were acquired at the community site and were printed on a laser printer identical to the one used at the outpatient site. The reference standard for correct diagnosis was based on histopathologic findings (n = 13), additional imaging results (n = 34), or review by a second independent observer (n = 33). Both an on-site and a remote radiologist interpreted the images, and their interpretations were rated as agree, both correct; agree, both incorrect; or disagree. Cases of disagreement were rated as major or minor. RESULTS: On-site and remote radiologists agreed in 69 of 80 patients (86%), and both radiologists were correct in all of these cases. There were 10 minor discrepancies and one major discrepancy. The diagnostic accuracies of the one-site and remote radiologists were 92% and 94%, respectively. CONCLUSION: High levels of diagnostic accuracy can be achieved by radiologists interpreting static US images. Strict protocols and excellent communication between the radiologist and sonographer are necessary to avoid diagnostic errors.

Placenta accreta: evaluation with color Doppler US, power Doppler US, and MR imaging.

PURPOSE: To determine the value of transabdominal ultrasound (US), transvaginal US, color Doppler US, power Doppler US, and magnetic resonance (MR) imaging in the diagnosis of placenta accreta. MATERIALS AND METHODS: Nineteen patients in the third trimester of pregnancy who were at risk for placenta accreta underwent color Doppler and power Doppler US; 18 patients also underwent MR imaging. Images were interpreted prospectively for signs of accreta by two reviewers. The reviewers' confidence in their diagnosis was graded on a five-point scale. RESULTS: Outcomes at delivery were as follows: normal placenta (n = 11), hysterectomy owing to uncontrollable bleeding (n = 1), and placenta accreta (n = 7). Five cases of lower-uterine-segment placenta accreta were diagnosed with a high level of confidence with vaginal and power Doppler US. In one patient with a posterior placenta who had previously undergone myomectomy, MR imaging enabled the diagnosis of placenta accreta, which was not well depicted at US. CONCLUSION: In patients with a history of uterine scars, vaginal US with power Doppler US performed well in the evaluation of lower-uterine-segment placenta accreta. MR imaging depicts posterior placenta accreta.

Dynamic echo-planar imaging of the breast: experience in diagnosing breast carcinoma and correlation with tumor angiogenesis.

PURPOSE: To correlate quantitative echo-planar magnetic resonance (MR) imaging measures of gadopentetate dimeglumine tumor uptake with histologic diagnoses and microvessel density (MVD) and to compare dynamic echo-planar imaging of breast lesions with conventional dynamic MR imaging techniques. MATERIALS AND METHODS: The study group comprised 63 patients (aged 13-70 years) with 71 breast lesions who underwent conventional and echo-planar MR imaging. The T1 values, change in gadopentetate dimeglumine concentration, and extraction-flow products were calculated with the echo-planar imaging data and were correlated with histologic findings and MVD estimates. Extraction-flow product data normalized to pectoral muscle gadopentetate dimeglumine concentration in invasive cancers was also correlated with MVD. RESULTS: On average, cancer T1 values were shorter than benign values, but there was substantial overlap between the two groups. Cancers had higher extraction-flow products than benign lesions (P < .001). Sensitivity, specificity, positive predictive value, and negative predictive value were 83%, 79%, 67%, and 90%, respectively. Receiver operating characteristic analysis showed improved performance with extraction-flow products than with percentages of signal intensity change. Among the invasive cancers, there was no significant correlation between extraction-flow product and MVD. CONCLUSION: The T1 value remains important in more precise quantitative estimation of gadopentetate dimeglumine uptake in breast tumors, which helps improve the specificity of dynamic imaging. Tumor MVD affects the contrast medium enhancement of breast lesions, but other factors contribute.

Screening mammography: effect of national guidelines on current physician practice.

PURPOSE: To evaluate the effect of national breast cancer screening guidelines on current physician attitudes toward and practice of screening mammography. MATERIALS AND METHODS: Questionnaire responses from 278 physicians were analyzed. The questionnaire had four sections: general information on physician practice and experience, current use of breast cancer screening, perceptions of screening mammography, and physician awareness of and response to the controversy in breast cancer screening. RESULTS: In women aged 40-49 years, 144 (52%) of 278 physicians performed annual clinical breast examination and screening mammography every 2 years; 57 (21%) favored annual mammography and clinical breast examination. In women aged 50 years and older, 232 (83%) physicians screened patients annually with clinical breast examination and mammography. Two hundred seventeen (78%) physicians were aware of the recommended changes in screening guidelines; 54 (19%) were not aware of the changes. Of those aware of the changes, 56 (26%) changed to the new guidelines, 150 (69%) did not change, and six (3%) modified their practice somewhat. CONCLUSION: Physician practice as regards screening mammography is influenced by national guidelines.

Patients' opinion of mammography screening services: immediate results versus delayed results due to interpretation by two observers.

OBJECTIVE: The purpose of this study was to evaluate by random questionnaire mailings the preferences of women who have undergone mammography in our region regarding communication of mammography screening results. MATERIALS AND METHODS: Questionnaires were mailed to 400 randomly selected women who were more than 35 years old and who had been treated at our institution for medical or surgical reasons. Questions regarding use of mammography screening at our institution versus services at other locations were included. The questionnaire described two possible mammography services; either a double reading service that would provide delayed reports (DRDR) with the benefit of extra cancers detected, and a service that provides immediate reports given directly to the patient by an on-site radiologist. The presentation of the services was reversed in half the questionnaires to avoid bias. Patients' choices were collected, as were demographic data. The choice of one system over the other was evaluated using the one-sample lest for binomial probability. The chi-square test was used to determine if the order of questions on the survey or the site of patients' screening mammography affected responses. RESULTS: The response rate was 42% (n = 168). Of these, one response informed us of the death of a patient. Of the remaining 167 respondents, 75% (n = 126) preferred the DRDR system, 13% (n = 22) preferred the system providing immediate results (p < .0001), and the other 19 respondents did not select a preference. Of the 167 respondents, 156 answered the question regarding previous screening mammography experience. Of the 105 patients who had undergone screening mammography at our institution, 78% (n = 82) preferred the DRDR system. Of the 51 patients who had undergone mammography elsewhere or who had never undergone mammography, 75% (n = 38) preferred the DRDR system. We found that ordering of presentation of the systems in the questionnaire had no effect on responses. Likewise, whether a respondent had undergone mammography at our institution had no effect on responses (p = 1.0). CONCLUSION: A statistically significant number of women who responded to our questionnaire preferred the DRDR system of reporting screening mammographic results. Educational material about double reading that we included with each patient's questionnaire could account for these results. If the use of a second interpreter is feasible and is done for batch interpretation of screening mammograms, then education of patients about this process may increase acceptance of a delayed mammographic report.

Should women with implants or a history of treatment for breast cancer be excluded from mammography screening programs?

OBJECTIVE: Our objective was to determine whether it is scientifically justified to require that women with implants or a history of treatment for breast cancer be screened in a diagnostic mammography setting and that they be excluded from mammography screening programs. MATERIALS AND METHODS: The recall rates for women with breast implants or a history of treatment for breast cancer who were screened in a dedicated mammography screening program were compared with those of other women in the screening program. The computerized records for the breast screening program of the Department of Radiology at our institution for January 1, 1990, through December 31, 1995, were reviewed. The recall rates for women who had breast implants and those for women with a history of treatment for breast cancer were compared with the recall rates for the other women who underwent screening. Each recall rate included women who were called back for additional evaluation in addition to those for whom a biopsy was recommended on the basis of the screening study. RESULTS: Of 45,134 screening examinations done during the review period, 43,454 (96%) were for women who had no history of breast cancer or of breast implants; 590 (1%) were for women who had undergone mastectomy; 991 (2%) were for women who had been treated with lumpectomy and irradiation for breast cancer; and 99 (0.2%) were for women with breast implants. Among the 43,454 examinations of women with no history of breast cancer or implants, 3081 examinations (7%) led to interpretations that produced requests for the patient to return for additional evaluation. Thirty-six women who had been treated for breast cancer by mastectomy were recalled (6%). Seventy-five women who had undergone lumpectomy and irradiation for breast cancer were recalled (8%). Five women with breast implants were recalled (5%). Statistically, these rates were not significantly different. CONCLUSION: We find no scientific reason to exclude women who have been treated for breast cancer or who have breast implants from dedicated screening programs.

Silicone gel-filled breast implants in women: findings at H-1 MR spectroscopy.

PURPOSE: To evaluate, at hydrogen-1 magnetic resonance (MR) spectroscopy, the effect of implantation time, implant status, and implant removal on the amount of silicone in the liver in women with silicone gel-filled breast prostheses. MATERIALS AND METHODS: The study population included 55 women (39 patients with silicone gel-filled prostheses and seven from whom implants had been removed, and nine control subjects [eight with no implant and one with saline-filled implants]). Stimulated-echo acquisition mode, or STEAM, H-1 MR spectroscopy was performed to determine the concentration of silicone in the liver. Implant status at the time of spectroscopy was diagnosed at MR imaging. RESULTS: Twenty of 39 (51%) women with implants had ruptured prostheses. Resonances associated with the presence of silicone and partially hydrolyzed silicone (0.3 to -0.8 ppm with respect to water at 4.7 ppm) and other resonances that are not yet assigned (-2 to -5 ppm) were detected in 27 (69%) of the 39 women (17 with ruptured implants). Relative signal intensities of the silicone species detected in the liver in these women were found to vary substantially and were not correlated with the status of the implants (P > .70). Silicone resonances were not detected in the livers in the nine control subjects. After implant removal, no resonances between 0.3 and -0.8 ppm were observed in six of seven women, but silicone-related peaks were still detectable in the region of -2 to -5 ppm. CONCLUSION: Proton MR spectra obtained in the liver of women with silicone gel-filled breast implants helped measure silicone exposure.

Positive predictive value of breast biopsy performed as a result of mammography: there is no abrupt change at age 50 years.

PURPOSE: To determine if the positive predictive value (PPV) of a biopsy initiated because of an abnormal mammogram changes abruptly at age 50 years. MATERIALS AND METHODS: The PPV and its variation with age was analyzed for 4,778 women who underwent biopsy for a clinically occult abnormality detected at mammography. The relationship of the results to the patient's age was analyzed with age represented as a continuous and two-categorized (< 50, > 50) measure. The latter measure represented an abrupt change, which distinguished those aged 49 years and younger from those aged 50 years and over. With this measure, the patients in each of the two age groups were statistically indistinguishable. RESULTS: The results were consistent with a steady increase in PPV and the yield of cancers with age, and there was no abrupt change at age 50 years. The modeled PPV for all cancers for these 4,778 patients was approximately 12% for women aged 40 years and increased to 46% by age 79 years. CONCLUSION: The PPV did not change abruptly at any age for women aged 40-79 years but increased steadily, which reflects the prior probability of breast cancer at each age. Inappropriate grouping of data can lead to misinterpretation of results. Screening guidelines should not be predicated on the false assumption that this variable changes at age 50 years.

Physicians' opinions on the delivery of mammographic screening services: immediate interpretation versus double reading.

OBJECTIVE: Mammographic services are delivered in many ways. Emphasis has been placed on providing women with immediate reports of their screening mammograms. We believe that double reading of mammograms is more important than an immediate report. We sought to determine physicians' attitudes toward this issue and if education affects their opinions. MATERIALS AND METHODS: Questionnaires were mailed to 1000 physicians in Massachusetts who were randomly selected from 16,000 members of the state medical society. The questionnaire had four sections, of which two were pertinent to this subject. The first section collected general information on the physician's practice and experience. The second section described two common delivery systems for mammographic screening services and asked physicians to choose the delivery system that would most benefit their patients. RESULTS: Of the 1000 physicians, 294 returned the questionnaire, giving a response rate of 29%. Of these, 16 physicians returned blank surveys, leaving 278 for analysis. Two hundred forty-nine (90%) valued off-site, delayed interpretation of mammographic screening for their patients over on-site reading by a single radiologist if an off-site, delayed reading made double reading possible. CONCLUSION: An off-site, double-reading delivery system for mammographic screening services is preferred by many physicians for their patients once they are educated as to the benefits of double reading.

Computed tomography-guided needle localization of nonpalpable breast lesions: review of 24 cases.

RATIONALE AND OBJECTIVES: We examined the role of computed tomography (CT) in breast imaging, especially in guiding needle localization procedures. METHODS: We reviewed our institution's breast imaging database, from 1978 to 1994, for procedures in which CT scanning was used. Twenty-four CT-guided needle localizations were identified. Medical records, mammograms, CT scans, and pathology reports were reviewed for all patients. RESULTS: Twenty-four needle localizations were performed on 22 female patients. The average size of the lesions localized was 12 mm. The most common reason for CT scanning was the inability to image a suspicious density by conventional mammography on two orthogonal views. Nine malignant and 15 benign lesions were localized under CT guidance. One patient developed a postoperative hematoma. No other complications occurred. CONCLUSION: CT-guided breast localization is a reliable technique that may be used to define selected breast lesions that are difficult to triangulate or localize by conventional two-view mammography.

The sternalis muscle: an unusual normal finding seen on mammography.

OBJECTIVE: We studied the appearance of the sternalis muscle on mammography and on CT and MR imaging. To our knowledge, this is the first description of this normal anatomic variant. An approach is provided that permits differentiation of the sternalis from significant pathology. SUBJECTS AND METHODS: Between January 1992 and December 1994, four women of an estimated 32,000 who had mammograms at the Massachusetts General Hospital had an unusual, irregular structure visible medially on the craniocaudal projection that posed a diagnostic dilemma. The records and imaging studies of these women and two others from the Deaconess Hospital breast imaging program were reviewed to determine the etiology of the findings seen by mammography and to establish a diagnostic approach. RESULTS: Surgery in one patient and cross-sectional imaging in the other five established that the structure was the sternalis muscle. Although it may be bilateral, the sternalis muscle was visible only unilaterally on the mammograms of these six women. The appearance of the muscle ranged from an irregularly rounded density at the sternal edge of the film to flame-shaped and almost completely surrounded by fat. CT and MR imaging are diagnostic when they show the longitudinal extent of the muscle, which lies anterior to the medial margin of the pectoralis major muscle. CONCLUSION: The sternalis muscle is an unusual variant of the chest wall musculature. It may be visible as a rounded or irregular density on the craniocaudal mammogram along the sternal edge of the film. With improved mammographic positioning it will be seen more frequently. The muscle has a variety of appearances that should be familiar to the radiologist to avoid confusion with a malignant lesion. The etiology can be confirmed and cancer excluded by CT or MR imaging.

Benign and malignant breast lesions: differentiation with echo-planar MR imaging.

PURPOSE: To quantify dynamic enhancement of breast lesions with echo-planar and conventional magnetic resonance (MR) imaging, to correlate these data with histologic findings and vessel density, and to evaluate MATERIALS AND METHODS: Twenty female patients with 22 breast lesions underwent conventional and MR echo-planar imaging T1 values, change in gadopentetate dimeglumine concentration, and extraction-flow products were calculated with echo-planar imaging data and were correlated with histologic findings and microvessel density. RESULTS: T1 values of cancers were not statistically significantly shorter. Cancers had more rapid uptake and higher extraction-flow products (P < .02). Sensitivity was 86% and specificity was 93% for diagnosis of malignancy. Microvessel density was higher for malignant lesions (P < .02) with an overall positive (not statistically significant) correlation between extraction-flow product and microvessel density. CONCLUSION: Echo-planar imaging appears promising for quantification of breast lesion enhancement. Microvessel data indicate that tumor angiogenesis affects enhancement.

Detection of pooled secretions above endotracheal-tube cuffs: value of plain radiographs in sheep cadavers and patients.

OBJECTIVE: Mechanical ventilation is thought to increase the risk of nosocomial pneumonia by permitting leakage of bacteria-laden gastro-oropharyngeal secretions into the upper airways. The goal of this study was (a) to validate radiographic signs of pooled secretions above endotracheal-tube cuffs (supracuff liquid) in an animal model and (b) to determine whether suctionable pooled supracuff liquid can be identified on bedside radiographs of intubated patients. MATERIALS AND METHODS: Diagnostic criteria for supracuff liquid were initially validated by three radiologists interpreting 162 randomized radiographs made in an intubated sheep cadaver. The primary criteria included (a) replacement of the normal supracuff lucency with liquid opacity and (b) the formation of a sharp interface between the lucency of the upper edge of the cuff below and the liquid above. Graded infusions of 0, 3, 8, 13, and 23 ml of saline were made in triplicate into the space above the cuff, and radiographs were evaluated for the presence or absence of saline. The validated diagnostic criteria were used by two radiologists to estimate the frequency with which pooled liquid was seen on portable chest radiographs of 47 patients undergoing elective short-term postanesthetic mechanical ventilation. RESULTS: In the sheep-cadaver model, the diagnostic criteria for supracuff liquid allowed successful differentiation between no liquid, a small amount of liquid (3-8 ml), and a large amount of liquid (13-23 ml; c2, p < .0001). In a clinical study, radiographic signs of supracuff liquid were identified in 57% of 47 patients. In a small subset of patients (n = 18), the estimated liquid volume (mean +/- SEM) was calculated to be 7.8 +/- 1.1 ml (range = 2.1-18.4 ml). CONCLUSIONS: Radiography is a sensitive means of identifying small volumes of supracuff liquid above the inflated cuffs of endotracheal tubes. Potentially contaminating liquid pooled above the cuff of an endotracheal tube can be identified in about half of patients undergoing short-term mechanical ventilation. Our results suggest the suction of the supracuff space may be a reasonable prophylactic maneuver against nosocomial pneumonia. A much larger study is suggested to investigate the actual relation between pooled supracuff liquid and the development of nosocomial pneumonia.

Endometrial polyps, hyperplasia, and carcinoma in postmenopausal women: differentiation with endovaginal sonography.

PURPOSE: To characterize endometrial polyps, hyperplasia, and carcinoma with endovaginal ultrasound in postmenopausal women. MATERIALS AND METHODS: Seventy-three postmenopausal women with abnormally thick endometria on endovaginal sonograms were retrospectively identified. The endometrial appearance was characterized as hyperechoic, containing cystic spaces, or heterogeneous. The final study group consisted of 68 women, in whom the pathologic and sonographic findings were correlated. RESULTS: Thirty sonograms showed hyperechoic endometria in women with hyperplasia (n = 8), polyps (n = 4), polyps and hyperplasia (n = 2), or atrophy, proliferative change, mild atypia, or normal endometria (n = 16); 27 sonograms showed cystic spaces in women with polyps (n = 21), carcinoma (n = 1), polyps and hyperplasia (n = 2), or atrophy (n = 3); and 11 sonograms showed heterogeneous endometria in women with endometrial carcinoma (n = 7), atrophy (n = 2), proliferative endometrium (n = 1), or secretory endometrium (n = 1). Cystic spaces were predictive of polyps (P = 1.19 x 10(-10)). CONCLUSION: Endovaginal sonography may be useful for differentiation of endometrial polyps, hyperplasia, and carcinoma.