Breast Cancer Screening in High-Risk Patients during Pregnancy and Breastfeeding: A Systematic Review of the Literature.

There are currently no clear guidelines for high-risk breast cancer screening during the pregnancy and breastfeeding periods. The objective of this systematic review (SR) was to assess the available evidence pertaining to breast cancer screening recommendations in this population with the aim of supporting future guidelines. We performed a SR of the literature using the electronic databases MEDLINE and Embase. Predetermined inclusion and exclusion criteria were used during the abstract screening and full-text data extraction phases. We retrieved 2,274 abstracts after removal of duplicates, from which 16 studies were included based on predetermined eligibility criteria. Most of the studies found were narrative reviews and expert opinions. Clinical breast exam (CBE) was recommended by 12 studies during pregnancy and by 6 studies in the breastfeeding period. Mammography was recommended in the breastfeeding period by 2 studies. Magnetic resonance imaging was recommended in the breastfeeding period by 2 studies. Ultrasound was considered not appropriate for screening in this population. The information extracted from this SR is based primarily on expert opinion and anecdotal evidence, which explains the lack of standardized guidelines for high-risk breast cancer screening in this population. However, expert opinion may be a surrogate outcome for high-risk breast cancer screening recommendations in this subset of patients, and as such, may justify the clinical management to be tailored accordingly. This SR summarizes the evidence pertaining to high-risk breast cancer screening during pregnancy and breastfeeding, which could serve as a catalyst for future research on the topic.

A Comparative Study of Four Oral Contrast Agents for Small Bowel Distension with Computed Tomography Enterography.

PURPOSE: To assess the efficacy of a variety of oral contrast agents in obtaining small bowel distention for computed tomography (CT) enterography examinations. METHODS: A retrospective study was developed to quantitatively assess small bowel luminal distension during CT enterography by using 4 contrast agents, which included water, Metamucil, polyethylene glycol, and lactulose. A total of 256 patients were enrolled in the study and included 64 individuals for each oral regimen. The widest loop of small bowel in each of 4 quadrants on representative coronal images was separately measured for luminal distension. Overall distension and the greatest number of "useful" quadrants were evaluated. Overall distension was calculated by summing the 4 quadrant values into an overall luminal diameter distention score (cm). A "useful" quadrant was defined as having a measurement of ≥2 cm. Each "useful" quadrant was assigned a score of 1, with values that ranged from 0-4. RESULTS: For overall distension, multivariable liner regression analysis showed that the lactulose group had a significantly higher overall distension value than Metamucil, polyethylene glycol, and water by 0.88, 0.92, and 1.63 cm, respectively, with 95% confidence interval. The categorical multivariable logistic regression analysis showed that the lactulose group had greater odds of having more "useful" quadrants than the Metamucil, polyethylene glycol, and water groups, with odds ratios of 3.51, 2.68, and 9.19, respectively. CONCLUSION: Lactulose achieves better small bowel distension for CT enterography studies than the other 3 agents and, therefore, is the preferred oral regimen at our institution.

Updated ultrasound criteria for polycystic ovary syndrome: reliable thresholds for elevated follicle population and ovarian volume.

STUDY QUESTION: Do the ultrasonographic criteria for polycystic ovaries supported by the 2003 Rotterdam consensus adequately discriminate between the normal and polycystic ovary syndrome (PCOS) condition in light of recent advancements in imaging technology and reliable methods for estimating follicle populations in PCOS? STUDY ANSWER: Using newer ultrasound technology and a reliable grid system approach to count follicles, we concluded that a substantially higher threshold of follicle counts throughout the entire ovary (FNPO)-26 versus 12 follicles-is required to distinguish among women with PCOS and healthy women from the general population. WHAT IS KNOWN ALREADY: The Rotterdam consensus defined the polycystic ovary as having 12 or more follicles, measuring between 2 and 9 mm (FNPO), and/or an ovarian volume (OV) >10 cm(3). Since their initial proposal in 2003, a heightened prevalence of polycystic ovaries has been described in healthy women with regular menstrual cycles, which has questioned the accuracy of these criteria and marginalized the specificity of polycystic ovaries as a diagnostic criterion for PCOS. STUDY DESIGN, SIZE, DURATION: A diagnostic test study was performed using cross-sectional data, collected from 2006 to 2011, from 168 women prospectively evaluated by transvaginal ultrasonography. Receiver operating characteristic (ROC) curve analyses were performed to determine the appropriate diagnostic thresholds for: (i) FNPO, (ii) follicle counts in a single cross section (FNPS) and (iii) OV. The levels of intra- and inter-observer reliability when five observers used the proposed criteria on 100 ultrasound cases were also determined. PARTICIPANTS/MATERIALS, SETTING, METHODS: Ninety-eight women diagnosed with PCOS by the National Institutes of Health criteria as having both oligo-amenorrhea and hyperandrogenism and 70 healthy female volunteers recruited from the general population. Participants were evaluated by transvaginal ultrasonography at the Royal University Hospital within the Department of Obstetrics, Gynecology and Reproductive Sciences, University of Saskatchewan (Saskatoon, SK, Canada) and in the Division of Nutritional Sciences' Human Metabolic Research Unit, Cornell University (Ithaca, NY, USA). MAIN RESULTS: Diagnostic potential for PCOS was highest for FNPO (0.969), followed by FNPS (0.880) and OV (0.873) as judged by the area under the ROC curve. An FNPO threshold of 26 follicles had the best compromise between sensitivity (85%) and specificity (94%) when discriminating between controls and PCOS. Similarly, an FNPS threshold of nine follicles had a 69% sensitivity and 90% specificity, and an OV of 10 cm(3) had a 81% sensitivity and 84% specificity. Levels of intra-observer reliability were 0.81, 0.80 and 0.86 when assessing FNPO, FNPS and OV, respectively. Inter-observer reliability was 0.71, 0.72 and 0.82, respectively. LIMITATIONS, REASONS FOR CAUTION: Thresholds proposed by this study should be limited to use in women aged between 18 and 35 years. WIDER IMPLICATIONS OF THE FINDINGS: Polycystic ovarian morphology has excellent diagnostic potential for detecting PCOS. FNPO have better diagnostic potential and yield greater diagnostic confidence compared with assessments of FNPS or OV. Whenever possible, images throughout the entire ovary should be collected for the ultrasonographic evaluation of PCOS. STUDY FUNDING AND COMPETING INTEREST: This study was funded by Cornell University and fellowship awards from the Saskatchewan Health Research Foundation and Canadian Institutes of Health Research. The authors have no conflict of interests to disclose.

Role of dynamic MRI in surgical decision-making for a postpartum woman with a prolapsed degenerating uterine leiomyoma.

BACKGROUND: Surgical decision-making in the case of postpartum complications affecting fibroids can be difficult. We present a case that illustrates the potential role of MRI in assisting these decisions. CASE: A 28-year-old woman with a known uterine leiomyoma presented on postpartum day 10 with abdominal pain, fever, and foul-smelling vaginal discharge. Her condition improved after antibiotic therapy, but she subsequently returned to hospital with a liquefied fibroid filling the vagina and a solid mass palpable above the dilated cervix. Pelvic ultrasound did not conclusively identify the vascular supply or myometrial involvement of the mass. MRI identified one fundal vascular pedicle and a very thin posterior uterine wall. At abdominal myomectomy, the myometrium was found to be only minimally involved, and the fundal vascular pedicle was easily cross-clamped. CONCLUSION: When available, MRI can be used to clarify the location of vascular pedicles and the extent of myometrial involvement of uterine fibroids, and it can assist in fibroid-related surgical decision-making.