Determination of recall rates for assessment in high-risk women undergoing annual surveillance breast MRI

Detection of incidental adrenal nodules on computed tomography by radiographers

INTRODUCTION

This research investigated whether radiographers' age, qualifications, shift rotations and years of post-qualification experience as a radiographer affect the detection rate of incidental adrenal nodules, also known as adrenal incidentalomas in Malta. Additionally, local statistics of adrenal incidentaloma findings were evaluated.

METHODS

This research consisted of two phases and employed a non-experimental, cross-sectional quantitative approach. Phase 1 comprised of a self-designed data collection sheet to retrospectively determine the occurrence of recalled computed tomography (CT) examinations resulting from an adrenal incidentaloma finding during a six-month period between July 2020 and December 2020. In phase 2, a self-designed questionnaire with anonymised CT scan images (n = 30) displayed on ViewDex (Viewer for Digital Evaluation of X-ray images) was prospectively completed by CT radiographers (n = 23) to identify adrenal incidentalomas on the images.

RESULTS

In phase 1, adrenal incidentalomas were present in 1.4% of contrast-enhanced CT (CECT) examinations (n = 12139), out of which, 79.8% were not acknowledged by the radiographers on the initial scans and patients had to be recalled for a dedicated adrenal CT scan. In phase 2, a statistically significant (p < 0.05) relationship was determined between the radiographers' qualifications, shift rotations and years of post-qualification experience as a radiographer, with their detection rate of adrenal incidentalomas.

CONCLUSION

Findings suggest that radiographers' qualifications, shift rotations and years of post-qualification experience were found to be statistically significant factors affecting their detection rate of adrenal incidentalomas. These could have contributed to one of the reasons for recalling patients, which in turn results in an added burden to both the patient and the Radiology Department.

IMPLICATIONS FOR PRACTICE

Detection of adrenal incidentalomas by radiographers has a direct impact on clinical practice. If identified during the initial CT examination and a further delay scan is performed, this will benefit patients by reducing the risks of additional radiation and potential risks from contrast media administration; prompt diagnosis and treatment. While the Radiology Department benefits in terms of cost effectiveness, work load and appointment scheduling.

"High-Risk Breast Cancer Screening in BRCA1/2 Carriers Leads to Early Detection and Improved Survival After a Breast Cancer Diagnosis"

BACKGROUND

Germline BRCA1/2 pathogenic variant (PV) carriers have high lifetime risk of developing breast cancer and therefore subjected to intense lifetime screening. However, solid data on the effectiveness of high-risk screening of the BRCA1/2 carrier population is limited.

PATIENTS AND METHODS

Retrospectively, we analyzed 346 women diagnosed with breast tumors. Patients were divided according to the timing of BRCA1/2 PVrecognition, before (BRCA-preDx awareness, N = 62) or after (BRCA-postDx awareness group, N = 284) cancer diagnosis.

RESULTS

Median follow-up times were 131.42 and 93.77 months in the BRCA-preDx awareness and BRCA-postDx awareness groups, respectively. In the BRCA-preDx awareness group, 78.7% of the patients had invasive tumors and 21.3% were diagnosed with pure ductal carcinoma in situ. In contrast, in the BRCA-postDx awareness group over 93% of women were diagnosed with invasive cancer and only 6.4% had in situ disease. The mode of tumor detection differed significantly between the groups: 71.9% in the BRCA-postDx awareness group and 26.2% in the BRCA-preDx awareness group were diagnosed after personally palpating a lump. Tumor size and nodal involvement were significantly more favorable in the BRCA-preDx awareness group. T stage was significantly lower in the BRCA-preDx awareness group: 54.84% at T1 and 20.96% at Tis. In the BRCA-postDx awareness group, only 37.54% were at T1 and 6.49% at Tis. The N stage was also significantly lower in the BRCA-preDx awareness group: 71% had no lymph node metastases, compared with 56.1% in the BRCA-postDx awareness group. Additionally, therapeutic procedures varied between the groups: BRCA-preDx awareness group patients underwent more breast conserving surgeries. Axillary lymph node dissection was done in 38% of women in the BRCA-postDx awareness group and in only 8.7% of the BRCA-preDx awareness group patients. Interestingly, improved survival was found among patients who underwent high-risk screening (hazard ratio=0.34).

CONCLUSIONS

High-risk screening might facilitate downstaging of detected breast tumor among BRCA1/2 carrier population.

The Effect of Prior Comparison MRI on Interpretive Performance of Screening Breast MRI

OBJECTIVE

To evaluate the effect of prior comparison MRI on interpretive performance of screening breast MRI.

METHODS

After institutional review board approval, all screening breast MRI examinations performed from January 2011 through December 2014 were retrospectively reviewed. Screening performance metrics were estimated and compared for exams with and without a prior comparison MRI, using logistic regression models to adjust for age and screening indication (BRCA mutation or thoracic radiation versus breast cancer history versus high-risk lesion history versus breast cancer family history).

RESULTS

Most exams, 4509 (87%), had a prior comparison MRI (incidence round), while 661 (13%) did not (prevalence round). Abnormal interpretation rate (6% vs 20%, P < 0.01), biopsy rate (3% vs 9%, P < 0.01), and false-positive biopsy recommendation rate per 1000 exams (21 vs 71, P < 0.01) were significantly lower in the incidence rounds compared to the prevalence rounds, while specificity was significantly higher (95% vs 81%, P < 0.01). There was no difference in cancer detection rate (CDR) per 1000 exams (12 vs 20, P = 0.1), positive predictive value of biopsies performed (PPV3) (35% vs 23%, P = 0.1), or sensitivity (86% vs 76%, P = 0.4).

CONCLUSION

Presence of a prior comparison significantly improves incidence round screening breast MRI examination performance compared with prevalence round screening. Consideration should be given to updating the BI-RADS breast MRI screening benchmarks and auditing prevalence and incidence round examinations separately.

Intensive Surveillance with Biannual Dynamic Contrast-Enhanced Magnetic Resonance Imaging Downstages Breast Cancer in BRCA1 Mutation Carriers

PURPOSE

To establish a cohort of high-risk women undergoing intensive surveillance for breast cancer.Experimental Design: We performed dynamic contrast-enhanced MRI every 6 months in conjunction with annual mammography (MG). Eligible participants had a cumulative lifetime breast cancer risk ≥20% and/or tested positive for a pathogenic mutation in a known breast cancer susceptibility gene.

RESULTS

Between 2004 and 2016, we prospectively enrolled 295 women, including 157 mutation carriers (75 BRCA1, 61 BRCA2); participants' mean age at entry was 43.3 years. Seventeen cancers were later diagnosed: 4 ductal carcinoma in situ (DCIS) and 13 early-stage invasive breast cancers. Fifteen cancers occurred in mutation carriers (11 BRCA1, 3 BRCA2, 1 CDH1). Median size of the invasive cancers was 0.61 cm. No patients had lymph node metastasis at time of diagnosis, and no interval invasive cancers occurred. The sensitivity of biannual MRI alone was 88.2% and annual MG plus biannual MRI was 94.1%. The cancer detection rate of biannual MRI alone was 0.7% per 100 screening episodes, which is similar to the cancer detection rate of 0.7% per 100 screening episodes for annual MG plus biannual MRI. The number of recalls and biopsies needed to detect one cancer by biannual MRI were 2.8 and 1.7 in BRCA1 carriers, 12.0 and 8.0 in BRCA2 carriers, and 11.7 and 5.0 in non-BRCA1/2 carriers, respectively.

CONCLUSIONS

Biannual MRI performed well for early detection of invasive breast cancer in genomically stratified high-risk women. No benefit was associated with annual MG screening plus biannual MRI screening.See related commentary by Kuhl and Schrading, p. 1693.