The Influence of Radiology Image Consultation in the Surgical Management of Breast Cancer Patients

Imaging-Based Disease Assessment and Management Recommendations: Impact of Multidisciplinary Sarcoma Tumor Board

Multidisciplinary tumor boards (MTBs) facilitate decision-making among subspecialists in the care of oncology patients, but the mechanisms by which they enhance outcomes remain incompletely understood. Our aim was to measure the agreement between sarcoma MTBs and radiology reports' disease assessment and management recommendations. This single-center IRB-approved retrospective study evaluated cases presented at a weekly sarcoma MTB from 1 August 2020 to 31 July 2021. Cases without clinical notes, imaging studies, or radiology reports were excluded. The data collected included the patient's clinical status at the time of the MTB, the treatment response assessment by the MTB and radiologists (stable disease; partial response; complete response; progressive disease/recurrence), and the recommendations of the radiology reports and of the MTB. The agreement between the initial radiologist review and MTB on disease assessment and recommendations was analyzed using kappa statistics. In total, 283 cases met the inclusion criteria. Radiology reports provided recommendations in 34.3% of cases, which were adhered to by the ordering providers in 73.2% of cases. The agreement between MTBs and radiology reports was moderate in disease assessment (86.2% agreement; κ = 0.78; p < 0.0001) and negligible in recommendations (36% agreement; κ = 0.18; p < 0.0001). Radiologists were more likely to assign progressive disease/recurrence than MTBs (54.4% vs. 44.4%; p < 0.001) and to recommend short-term imaging follow-up more commonly than MTBs (46.4% vs. 21.7%; p < 0.001). At a tertiary care center, radiologists' isolated interpretations of imaging findings and management recommendations frequently differ from the MTB's consensus, reflecting the value of multidisciplinary discussions incorporating the patient's clinical status and the available treatment options into the final radiographic assessment.

Body oncologic imaging subspecialty training a curriculum based on the experience in a tertiary cancer center

PURPOSE

To describe the structure of a dedicated body oncologic imaging fellowship program. To summarize the numbers and types of cross-sectional imaging examinations reported by fellows.

METHODS

The curriculum, training methods, and assessment measures utilized in the program were reviewed and described. An educational retrospective analysis was conducted. Data on the number of examinations interpreted by fellows, breakdown of modalities, and examinations by disease management team (DMT) were collected.

RESULTS

A total of 38 fellows completed the fellowship program during the study period. The median number of examinations reported per fellow was 2296 [interquartile range: 2148 - 2534], encompassing all oncology-relevant imaging modalities: CT 721 [646-786], MRI 1158 [1016-1309], ultrasound 256 [209-320] and PET/CT 176 [130-202]. The breakdown of examinations by DMT revealed variations in imaging patterns, with MRIs most frequently interpreted for genitourinary, musculoskeletal, and hepatobiliary cancers, and CTs most commonly for general staging or assessment of nonspecific symptoms.

CONCLUSION

This descriptive analysis may serve as a foundation for the development of similar fellowship programs and the advancement of body oncologic imaging. The volume and diversity of examinations reported by fellows highlights the comprehensive nature of body oncologic imaging.

Can Pre-biopsy Second-Look Breast Ultrasound Affect Clinical Management? Experience From a Single Tertiary Hospital

Objectives

Interpretation discrepancy is a major disadvantage of breast imaging. This study aimed to determine the clinical benefit of the pre-biopsy second-look breast ultrasound (US).

Methods

Patients with suspicious breast masses referred to our tertiary hospital for US-guided breast biopsy were retrospectively reviewed between August 2017 and November 2019. Here, second-look assessments were performed by experienced specialized breast radiologists via performing a bilateral breast US scan plus reviewing former imaging studies, and results were compared with the initial assessment. Interpretation changes in terms of biopsy recommendation and surgical management (i.e., lumpectomy to mastectomy) were analyzed.

Results

A total of 537 patients were enrolled in this study. Interpretation discrepancies occurred in 109 patients (20%; 95% CI, 17%–24%). Among them, there were 84 patients (16%; 95% CI, 13%–19%) whose masses were re-classified as BI-RADS 3 by the second-look US and underwent 2-year follow-up, showing 82 benign, 1 malignant, and 1 high-risk lesions. On the other hand, 16 patients (3%; 95% CI, 2%–5%) undertook biopsy at an additional site, identifying 10 new malignant lesions, 3 high-risk lesions, and 3 benign lesions, resulting in surgical management changes in 12 patients. In addition, nine (2%; 95% CI, 1%–3%) patients received discrepant disease ranges, which also altered surgical management. Overall, 21 patients (4%; 95% CI, 3%–6%) got their surgical management altered by the second-look US.

Conclusion

Pre-biopsy second-look assessment of breast US can reduce unnecessary biopsies in 16% of patients and alter surgical management in 4% of patients, suggesting it is a practical and valuable method for patient care improvement.

Variations and Challenges to Performing Outside Study Interpretations in Breast Imaging: A National Survey of the Society of Breast Imaging Membership

OBJECTIVE

Second-opinion interpretations of outside facility breast imaging provide value-added care but are operationally challenging for breast radiologists. Our objective was to survey members of the Society of Breast Imaging (SBI) to assess practice patterns and perceived barriers to performing outside study interpretations (OSIs).

METHODS

An anonymous survey was developed by the Patient Care and Delivery Committee of the SBI and distributed via e-mail to SBI radiologist members. Survey questions included practice demographics and OSI volumes, billing practices, clinical scenarios, and imaging modalities, logistics, and barriers. Responses were aggregated and comparisons were made by univariate analysis using likelihood ratio tests, t-tests, and Spearman's rank correlation tests as appropriate. Ordinal or nominal logistic modeling and linear regression modeling was also performed.

RESULTS

There were 371 responses (response rate of 13%). Most respondents practice at an affiliated specialty breast care center (306/371, 83%) and said their practice performed OSIs (256/371, 69%). Academic practices reported the highest OSI volumes (median 75 per month) and were most likely to indicate increases in OSI volumes over time (100/144, 69%). The most common indication for OSI was second opinion for a biopsy recommendation (245/256, 96%). Most practices provide a final BI-RADS assessment (183/261, 70%). The most cited barrier to performing OSIs was physician time constraints (252/369, 68%).

CONCLUSION

Breast imaging OSI practice patterns are variable among SBI members with notable differences by practice setting and multiple barriers identified. More unified guidelines and recommendations may be needed for radiologists to better perform this valuable task.

Value of Second-Opinion Interpretation of Outside-Facility Breast Imaging Studies to a Radiology Department and Cancer Center

PURPOSE

The aim of this study was to estimate the physician work effort for formal written breast radiology second-opinion reports of imaging performed at outside facilities, to compare this effort with a per-report credit system, and to estimate the downstream value of subsequent services provided by the radiology department and institution at a National Comprehensive Cancer Network-designated comprehensive cancer center.

METHODS

A retrospective review was conducted of consecutive reports for "outside film review" from July 1, 2015, to June 30, 2018. The number and types of breast imaging studies reinterpreted for each individual patient request were tabulated for requests for a 3-month sample from each year. Physician effort was estimated on the basis of the primary interpretation CMS fee schedule for work relative value units (wRVUs) for the study-specific Current Procedural Terminology (CPT) code and study type. This effort was compared with the interpreting radiologist credit of 0.44 wRVUs per report. Subsequent imaging and evaluation and management encounters generated by these second-opinion patient requests were tracked through June 30, 2019.

RESULTS

For the 3-year period reviewed, 2,513 unique patient requests were identified, averaging 837 per fiscal year. For January to March of 2016, 2017, and 2018, 645 unique patient reports were identified. For these reports, 2,216 studies were reinterpreted, with an estimated physician effort of 2,660 wRVUs compared with 284 wRVUs on the basis of per-report credit. The range of annualized wRVUs for all outside studies interpreted and credited per specific CPT code was 3,135 to 3,804 (mean, 3,547). However, the institutional relative value unit credit received for fiscal years 2015, 2016, and 2017, on the basis of the number of patient requests, was only 385, 375, and 345 wRVUs, respectively.

CONCLUSIONS

This study demonstrates the substantial work effort necessary to provide formal second-opinion interpretations for breast imaging studies at a National Comprehensive Cancer Network cancer center. The authors believe that these data support billing for the study-specific CPT code and crediting the radiologist with the full wRVUs for each study reinterpreted.

Repeat Breast Ultrasound Demonstrates Utility with Added Cancer Detection in Patients following Breast Imaging Second Opinion Recommendations

Purpose

Second opinion consultation for patients with suspicious findings on breast imaging and patients with known breast cancer is not uncommon. We sought to determine the frequency of second opinion breast and axillary ultrasound imaging review and the subsequent impact on clinical management.

Materials and Methods

An IRB-approved retrospective chart review was conducted on 400 consecutive patients with second opinion radiology interpretations performed by subspecialized breast radiologists at a designated cancer center, including mammogram and ultrasound review. The outside institution imaging reports were compared with second opinion reports to categorize ultrasound review discrepancies which were defined as any BI-RADS category change. The discrepancy frequency, relevant alterations in patient management, and added cancer detection were measured.

Results

The second opinion imaging review resulted in discrepant findings in 108/400 patients (27%). Patients with heterogeneously or extremely dense breasts had higher discrepancy frequency (36% discrepancy, 68/187) than those with almost entirely fatty or scattered fibroglandular breast tissue (19% discrepancy, 40/213) with P = 0.0001. Discrepancies resulted in the following changes in impression/recommendations: 70 repeat ultrasounds for better characterization of a breast lesion, 11 repeat ultrasounds of a negative region, 20 repeat ultrasounds for benign axillary lymph nodes, 5 downgrades from probably benign to benign, and 2 upgrades from benign to suspicious. Repeat ultrasounds of the axilla in 19 patients resulted in 13 biopsy recommendations, and 4 were metastatic (PPV3 31%). In the breast, repeat ultrasounds in 81 patients resulted in 14 upgrades to suspicious. Of these, 5 yielded malignancy. In addition, one patient was upgraded from benign to suspicious based on the outside image, with pathology revealing malignancy (breast PPV3 40%). Breast lesion BI-RADS category downgrades in 27 patients resulted in 10 avoided biopsies. Ultimately, second opinion ultrasound review resulted in altered management in 12% of patients (47/400). This included discovery of additional breast malignancies in 6 patients, metastatic lymph nodes in 4 patients, excisional biopsy for atypia in 1 patient, 4 patients proceeding to mastectomy, 10 patients who avoided biopsies, and 22 patients who avoided follow-up of benign findings.

Conclusions

In this study, subspecialized second opinion ultrasound review had an impact on preventing unnecessary procedures and follow-up exams in 8% of patients while detecting additional cancer in 2.5%.

Application of a second opinion ultrasound in Breast Imaging Reporting and Data System 4A cases: can immediate biopsy be avoided?

Objective

The probability of malignancy in women who are diagnosed with a Breast Imaging Reporting and Data System (BI-RADS) 4A score is low. Application of a second opinion ultrasound (SOUS), which is low in cost and minimally invasive, may lower the biopsy rate for patients who fall into this category. This study aimed to apply SOUS to patients with a BI-RADS score of 4A and predict the pathological results of a biopsy.

Methods

One hundred seventy-eight patients were analyzed. Univariate and multivariate analyses were performed to screen for predictive factors that are associated with malignancy. Categorical alteration of downgraded, unchanged, or upgraded was made after SOUS results. Changes in category were compared with biopsies to determine their predictive value of benignancy or malignancy.

Results

Independent factors associated with malignancy were age (>50 years), tumor size (≥20 mm), margin (not circumscribed), orientation (not parallel), and peripheral location, and an upgraded categorical alteration from SOUS. Downgraded categorical alterations were associated with benignancy.

Conclusions

In BI-RADS 4A cases, a biopsy is recommended when independent factors are associated with malignancy. A downgraded result from an SOUS examination is a protective factor, supporting the likelihood of benignancy in these patients.

Effect of an Artificial Intelligence Clinical Decision Support System on Treatment Decisions for Complex Breast Cancer

PURPOSE

To examine the impact of a clinical decision support system (CDSS) on breast cancer treatment decisions and adherence to National Comprehensive Cancer Center (NCCN) guidelines.

PATIENTS AND METHODS

A cross-sectional observational study was conducted involving 1,977 patients at high risk for recurrent or metastatic breast cancer from the Chinese Society of Clinical Oncology. Ten oncologists provided blinded treatment recommendations for an average of 198 patients before and after viewing therapeutic options offered by the CDSS. Univariable and bivariable analyses of treatment changes were performed, and multivariable logistic regressions were estimated to examine the effects of physician experience (years), patient age, and receptor subtype/TNM stage.

RESULTS

Treatment decisions changed in 105 (5%) of 1,977 patients and were concentrated in those with hormone receptor (HR)-positive disease or stage IV disease in the first-line therapy setting (73% and 58%, respectively). Logistic regressions showed that decision changes were more likely in those with HR-positive cancer (odds ratio [OR], 1.58; P < .05) and less likely in those with stage IIA (OR, 0.29; P < .05) or IIIA cancer (OR, 0.08; P < .01). Reasons cited for changes included consideration of the CDSS therapeutic options (63% of patients), patient factors highlighted by the tool (23%), and the decision logic of the tool (13%). Patient age and oncologist experience were not associated with decision changes. Adherence to NCCN treatment guidelines increased slightly after using the CDSS (0.5%; P = .003).

CONCLUSION

Use of an artificial intelligence-based CDSS had a significant impact on treatment decisions and NCCN guideline adherence in HR-positive breast cancers. Although cases of stage IV disease in the first-line therapy setting were also more likely to be changed, the effect was not statistically significant (P = .22). Additional research on decision impact, patient-physician communication, learning, and clinical outcomes is needed to establish the overall value of the technology.

Impact of Second Opinions in Breast Cancer Diagnostics and Treatment: A Retrospective Analysis

BACKGROUND

Breast cancer care is becoming increasingly complex, and patients with breast cancer are increasingly aware of the different treatment options, resulting in requests for second opinions (SOs). The current study investigates the impact of breast cancer SOs on final diagnosis and treatment in the Netherlands Cancer Institute (NCI) using a newly designed Breast Cancer Second Opinion (BCSO) classification system.

METHODS

Patients who visited the NCI for an SO between October 2015 and September 2016 were included. Demographics, diagnostics, and treatment proposals were compared between first and SO. Discrepancy was categorized using our BCSO classification system, categorizing SOs into (1) noncomparable, (2) identical, and (3) minor or (4) major discrepancy.

RESULTS

The majority of SOs (n = 591) were patient initiated (90.7%). A total of 121 patients underwent treatment prior to their SO, leaving 470 patients for assessment of discrepancies according to our BCSO classification system. More than 45% of these SOs resulted in at least one discrepancy, with comparable rates for physician- and patient-initiated SOs (42.5% vs. 45.6%, p = 0.708). Significantly more discrepancies were observed in patients with additional imaging (51.3% vs. 37.2%, p = 0.002) and biopsies (53.7% vs. 40.3%, p = 0.005). Almost 60% of all discrepancies were categorized as major (neoadjuvant systemic treatment instead of primary surgery, breast-conserving surgery instead of mastectomy, and proposing postmastectomy immediate breast reconstruction).

CONCLUSIONS

Our findings show substantial differences in diagnostic and treatment options in breast cancer patients visiting the Netherlands Cancer Institute for an SO, thereby emphasizing more consensus for the indications of these treatment modalities.

[Systematic second opinion review of outside imaging in breast cancer diagnosis: An added value]

INTRODUCTION

The systematic second opinion review in cancer centers after breast cancer detection is currently under development. The purposes were the evaluation of review's consequences, in particularly of the axillary staging and the evolution of the delays.

METHODS

A retrospective study was conducted on patients who consulted a clinician at Cancer Center of Lorraine in Nancy from January 1st, 2016 to December 31th, 2016. We analyzed from their medical charts: the outside exams, the initial therapeutic plan, the second opinion review, the additional exams, the multidisciplinary consultation conclusions, the first treatment, the multidisciplinary consultation after surgery.

RESULTS

In all, 251 patients were analyzed. Second opinion review discrepancies were seen in 72.5%. As a result, 43.4% of all patients had new breast-axillary biopsies. New malignancies lesions were identified in 19.9% of patients. Modifications in therapeutic plan were recommended in 19.9% of patients (including patients with and without new malignancies lesions diagnosed). Before a second opinion review, 9.8% of axillary ultrasound lead to a positive fine-needle biopsy. The additional exams identified 9.6% additional lesions. After a positive sentinel lymph node excision biopsy, the multidisciplinary consultation recommended a revision surgery of axillary lymph node dissection for 27% of patients with axillary ultrasound performed in our cancer center, and for 70% of patients without ultrasound (P=0.023).

DISCUSSION

The systematic second opinion at cancer center allows the detection of new malignancies lesions and significant modifications in the therapeutic plan. A systematic evaluation of axillary ultrasound in cancer center could be considered.

Specialized Second Opinion Review of Breast MRI Impacts Management and Increases Cancer Detection

OBJECTIVE

The aim of our study is to determine MRI review discrepancy frequency and the subsequent impact on patient management for patients pursuing breast imaging second opinions.

METHODS

A retrospective chart review was conducted on 1,000 consecutive patients with second opinion radiology interpretations performed by subspecialty-trained breast radiologists at a dedicated cancer center July 1 through December 31, 2016. Of these, 205 included review of outside breast MRI. Outside imaging reports were compared with second opinion reports to categorize breast MRI review discrepancies. These included relevant BI-RADS category changes or identification of additional extent of disease >4 cm. The discrepancy frequency, relevant alterations in patient management, and incremental cancer detection were measured. Statistical analyses were performed using Fisher's exact test.

RESULTS

Discrepant second opinion breast MRI review was seen in 36 of 205 patients (18%). Additional cancer was detected through image-guided biopsy in 3 of these 36 patients and through excision in 2 (5 of 205, 2%). Additionally, five biopsies yielded high-risk pathologic results without upstage on excision. Findings suspicious for additional extent of disease >4 cm were noted in five patients (2%) treated with mastectomies. Finally, five patients had BI-RADS category downgrades. Ultimately, completion of second opinion MRI review recommendations resulted in altered management in 10% of patients (20 of 205). The absence of prior imaging studies for comparison was associated with increased discrepancy frequency (P = .005).

CONCLUSION

Second opinion breast MRI review by subspecialized breast imaging radiologists increases cancer detection and results in clinically relevant changes in patient management.

Clinical Impact of Second Opinion Radiology Consultation for Patients With Breast Cancer

PURPOSE

To assess the incidence and clinical significance of discrepancy in subspecialty interpretation of outside breast imaging examinations for newly diagnosed breast cancer patients presenting to a tertiary cancer center.

MATERIALS AND METHODS

This Institutional Review Board-approved retrospective study included patients presenting from July 2016 to March 2017 to a National Cancer Institute-designated comprehensive cancer center for second opinion after breast cancer diagnosis. Outside and second opinion radiology reports of 252 randomly selected patients were compared by two subspecialty breast radiologists to consensus. A peer review score was assigned, modeled after ACR's RADPEER^TM peer review metric: 1-agree; 2-minor discrepancy (unlikely clinically significant); 3-moderate discrepancy (may be clinically significant); 4-major discrepancy (likely clinically significant). Among cases with clinically significant discrepancies, rates of clinical management change (management alterations including change in follow-up, neoadjuvant therapy use, and surgical management as a direct result of image review), and detection of additional malignancy were assessed through electronic medical record review.

RESULTS

A significant difference in interpretation (scores = 3 or 4) was seen in 41 of 252 cases (16%, 95% confidence interval [CI], 11.7%-20.8%). The difference led to additional workup in 38 of 252 cases (15%, 95% CI 10.6%-19.5%) and change in clinical management in 18 of 252 cases (7.1%, 95% CI 4.0%-10.2%), including 15 of 252 with change in surgical management (6.0%, 95% CI, 3.0%-8.9%). An additional malignancy or larger area of disease was identified in 11 of 252 cases (4.4%, 95% CI, 1.8%-6.9%).

CONCLUSION

Discrepancy between outside and second-opinion breast imaging subspecialists frequently results in additional workup for breast cancer patients, changes in treatment plan, and identification of new malignancies.

Perception of Breast Oncologists and Physician Extenders on Imaging Consultation Service at a Tertiary Cancer Institute

OBJECTIVE

To evaluate the perception and ease of utilization of the imaging consultation service by different types of referring clinicians and physician extenders within the breast oncology disease center at our tertiary cancer institute using a survey-based questionnaire.

METHODS

An institutional review board-exempted survey was created using a freely available online survey software and questionnaire tool. The survey was sent to 83 clinicians associated with the breast oncology disease center at our tertiary cancer center through an institutional e-mail list. The survey included 2 questions about demographics and 8 statements regarding various aspects of the consultation service scored on a 5-point Likert-type scale. "1'' being "agree completely," "3" being "neutral/neither agree nor disagree," and "5" being "disagree completely." The survey was sent online and was answered anonymously. Responses were tallied and analyzed.

RESULTS

A total of 56 responses (67%) were received. The weighted average of each Likert item ranged from 1.07 to 1.58. Highest positive concordance (95%) pertained to the access to the consult radiologist having a positive impact on patient care. The least concordant statement (78%), though still strong (with weighted average of 1.58% and 78% of respondents agreeing or agreeing completely) pertained to the role of direct consultation with radiologist in clinical management. Although there was variability of agreement to all statements (including responders feeling neutral), there was no one that disagreed with any of the Likert items. The mean Likert score for all the statements together was 1.23 (range: 1.07-1.58).

CONCLUSION

Presence of dedicated oncologic imaging consultation service is perceived positively by the breast oncology team at our tertiary cancer center.

The Impact of Patient-Initiated Subspecialty Review on Patient Care

PURPOSE

To determine the effect of subspecialty review of breast imaging on patients without a diagnosis of breast cancer who self-referred for a second opinion.

METHODS

Institutional review board-approved retrospective review was performed of 415 breast imaging studies submitted to our cancer center for second-opinion review by 245 patients in 2014, excluding cases without follow-up or change in original BI-RADS 0 assessment. One hundred forty-seven patients with 176 lesions were included. Original and second-opinion interpretations and recommendations were compared with histopathology or follow-up imaging.

RESULTS

Ninety-six of 176 (55%) lesions were reported as suspicious in the original interpretation. Second-opinion review was discordant with the original interpretation in 82 of 176 (47%) lesions. Second-opinion review downgraded 24 of 96 (25%) lesions originally reported as suspicious to benign or probably benign, averting biopsy of these lesions. Second-opinion review upgraded 31 of 80 (39%) lesions originally reported as benign or probably benign to suspicious. A total of 87 lesions were biopsied yielding malignancy in 23 (26%) biopsies. Twenty-eight of 87 (32%) biopsies performed were recommended after second-opinion review, with 8 of 28 (29%) of these biopsies yielding cancer. Eight of 23 (35%) cancers detected represented malignancy not initially detected in the original interpretation.

CONCLUSION

Second-opinion review is valuable in patients pursuing a breast imaging specialist's opinion, even before they are diagnosed with breast cancer. Second-opinion review disagreed with the original interpretation for 47% of lesions, averted 25% of originally recommended biopsies, and detected cancer in 29% of additional biopsies recommended. Thirty-five percent of cancers diagnosed after second-opinion review were not initially detected in the original interpretation.

Second opinion interpretation of breast ultrasound images-Is it worth another look?

PURPOSE

To determine if real-time breast ultrasound (RTUR) after second opinion reinterpretation of submitted static ultrasound images at a comprehensive cancer center impacts clinical management, specifically by detecting additional cancer and preventing unnecessary biopsy.

MATERIALS AND METHODS

In this IRB-approved and HIPAA-compliant retrospective study, 209 patients were included who had breast ultrasound studies from outside facilities submitted for second opinion review between January 2013 and May 2014, and who subsequently underwent RTUR at our institution within three months of the outside study. Findings on submitted exams were compared with those on RTUR and disagreements between them were annotated to indicate the presence or absence of suspicious lesions and recommendation for biopsy. Changes in management were defined as any additional biopsies performed or biopsies averted after RTUR and reported as frequencies and percentages using 95% confidence intervals.

RESULTS

Following RTUR, 49 additional biopsies were performed in 43/209 patients (20.6%; 95% CI 15.1-26.1%). Additional cancer was found in 12/49 (24.5%) biopsies in 11/209 patients (5.3%; 95% CI 2.2-8.2%). Forty biopsies in 31/209 (14.8%; CI 10.0-19.7%) patients originally recommended were canceled after RTUR. Overall, a change in management after RTUR was observed in 68/209 patients (32.5%; 95% CI 26.1-38.9%), including patients with either additional biopsies performed or biopsies averted.

CONCLUSION

RTUR was found to be an important tool in the management of patients at our comprehensive cancer center. Although additional false-positive lesions may be detected on RTUR, a great number of patients will benefit from RTUR in finding additional cancers or avoiding unnecessary biopsies.

Specialized Second Opinion Interpretations of Breast Imaging: Impact on Additional Workup and Management

BACKGROUND

Women with breast imaging often seek second opinions at tertiary care centers. Our study measures the frequency of discrepancy between initial and second opinion breast imaging recommendations and evaluates the impact on patient management.

MATERIALS AND METHODS

A retrospective chart review was conducted on 504 consecutive patients with second opinion breast radiology interpretations performed by 6 sub-specialized breast radiologists at a dedicated cancer center from January 1, 2014 through September 1, 2014. Outside imaging reports were compared with second opinion reports to categorize discrepancies. Interpretations were considered discrepant in cases with Breast Imaging Reporting and Data System (BI-RADS) category changes, recommendation for additional imaging, or identification of previously undiagnosed additional extent of disease greater than 5 cm. The frequencies of discrepancy, alterations in surgical management, and incremental cancer detection were measured. Statistical analysis of associated factors was performed with the Fisher exact test, with a P-value < .05 considered significant.

RESULTS

Second opinion evaluation discrepancies were seen in 287 (57%) patients and resulted in percutaneous image-guided biopsies in 92 (18%). Forty-five additional sites of cancer were biopsy-detected in 41 (8%) patients, including 20 breast malignancies and 25 axillary metastases. Another 9 biopsies yielded high-risk pathology. Second opinion interpretations altered surgical management in 66 (13%) patients. Factors associated with increased discrepancy frequency were cancer diagnosis at presentation (P = .004), dense breasts (P = .005), and the absence of prior studies for comparison (P = .007).

CONCLUSION

Although additional imaging and resources are required, second opinion radiology review by subspecialized breast radiologists increases cancer detection and results in clinically relevant changes in patient management.

Tablets for Image Review and Communication in Daily Routine of Orthopedic Surgeons-An Evaluation Study

Medical images are essential in modern traumatology and orthopedic surgery. Access to images is often cumbersome due to a limited number of workstations. Moreover, due to the tremendous increase of data, the time to review or to communicate images has also become limited. One approach to overcome these problems is to make use of modern mobile devices, like tablet computers, to facilitate image access and associated workflows. Ten orthopedic surgeons were equipped with an Apple iPad mini 2 and specialized viewing software for medical images. The surgeons were able to send images from a workstation onto the tablets or to search for patient images directly. The software enabled the physicians to share images, annotated key slices, and messages instantly with their colleagues. The surgeons carried the tablets within or in the periphery of the hospital. The participants evaluated the software by means of daily questionnaires. Data was collected for a period of 9 months. Nearly 25 images were viewed in total by the surgeons per day. The tablet viewer was used for accessing approximately 30% of these images. On average, the surgeons were asked 1.7 times per day by a colleague for a second opinion. They used the tablets in approximately 29% of these cases. Furthermore, the mean time for accessing images was significantly lower using mobile software compared to conventional methods. Tablet computers can play a vital role for image access and communication in the daily routine of an orthopedic surgeon. Mobile image access is an important aspect for surgeons, especially in larger facilities, to facilitate and accelerate the clinical workflows.

Maximizing Value Through Innovations in Radiologist-Driven Communications in Breast Imaging

OBJECTIVE

The purposes of this article are to provide an overview of current and emerging practices in radiologist communications with both referring physicians and patients across the breast cancer care continuum; to highlight areas in which radiologist-driven communications can improve value in breast cancer screening, diagnosis, and treatment; and describe how the integrative reporting and consultative practices of breast imagers can serve as models of higher-value patient-centered care in other radiology subspecialties.

CONCLUSION

The traditional radiology report will eventually no longer be viewed as the sole consultation by radiologists but instead act as a starting point for more detailed communications between radiologists and both patients and physicians. The value-creating practices of breast imagers can be used as a road map for similar practices across other radiologic specialties, similar to the use of BI-RADS as a road map for structured breast imaging reporting.

High density of CD204-positive macrophages predicts worse clinical prognosis in patients with breast cancer

Recent studies have indicated the clinical significance of tumor‐associated macrophages (TAM) in several malignant tumors including breast cancer. Although recent studies have focused on CD68‐positive or CD163‐positive TAM in breast cancer, no study has investigated the significance of CD204‐positive TAM in breast cancer. We found that CD204 expression on macrophages was evaluated following stimulation with the conditioned medium (CM) of breast cancer cell lines. Paraffin sections of 149 breast cancer samples which were diagnosed as invasive ductal carcinoma were immunohistochemically analyzed for CD68, CD163 and CD204 expression. The results of analyses indicated that a high number of CD204‐positive TAM was associated with worse clinical prognoses, including relapse‐free survival, distant relapse‐free survival and breast cancer‐specific survival; however, neither the numbers of CD68‐positive or CD163‐positive TAM were associated with clinical courses. Of the clinicopathological factors investigated, estrogen receptor, Ki‐67 index, hormone subtype, and histological grade were significantly related to the increased number of CD163‐positive and CD204‐positive TAM. These data indicate the clinical significance of CD204‐positive TAM in breast cancer progression and CD204 is a marker for predicting clinical prognosis in breast cancer.

Second-Opinion Review of Breast Imaging at a Cancer Center: Is It Worthwhile?

OBJECTIVE

Second-opinion review of breast imaging studies can be a time-consuming and labor-intensive process. The purpose of this investigation was to determine whether reinterpretation of studies obtained at institutions outside a cancer center influences clinical management, specifically by revealing additional cancer and preventing unnecessary biopsy.

MATERIALS AND METHODS

A review was conducted of breast imaging studies of 200 patients who underwent ultrasound and MRI at community facilities and had the images submitted for second opinions at a cancer center between January and April 2014. Each case was evaluated for concordance between the original report and the second-opinion interpretation. Second-opinion review resulting in the recommendation and performance of new biopsies was further subdivided into benign, high-risk, and malignant categories based on the histopathologic results obtained at the cancer center.

RESULTS

Second-opinion review of the 200 cases showed a change in interpretation in 55 cases (28%; 95% CI, 21-34%). Overall, 26 recommendations (13%; 95% CI, 9-18%) led to a major change in management. Twenty new biopsies were performed, yielding 10 malignancies (5%; 95% CI, 2-9%) and four high-risk lesions (2%; 95% CI, 1-5%). Surgical management was changed to mastectomy for 6 of 10 patients (60%) with new sites of biopsy-proven malignancy. Eight biopsies were averted (4%; 95% CI, 2-8%) on the basis of benign interpretation of the imaging findings, and no disease was found at 1-year follow-up evaluation.

CONCLUSION

Reinterpretation of studies obtained outside a cancer center resulted in a change in interpretation in more than one-fourth of submitted studies. Additional cancer was detected in 5% of patients, and biopsy was averted for 4%. The practice of second-opinion review influences clinical management and adds value to patient care.

Radiology Consultation in the Era of Precision Oncology: A Review of Consultation Models and Services in the Tertiary Setting

The purpose of the article is to describe the various radiology consultation models in the Era of Precision Medicine. Since the inception of our specialty, radiologists have served as consultants to physicians of various disciplines. A variety of radiology consultation services have been described in the literature, including clinical decision support, patient-centric, subspecialty interpretation, and/or some combination of these. In oncology care in particular, case complexity often merits open dialogue with clinical providers. To explore the utility and impact of radiology consultation services in the academic setting, this article will further describe existing consultation models and the circumstances that precipitated their development. The hybrid model successful at our tertiary cancer center is discussed. In addition, the contributions of a consultant radiologist in breast cancer care are reviewed as the archetype of radiology consultation services provided to oncology practitioners.

Avoiding Pitfalls, Maximizing Success at Image-guided Breast Interventions: A Pictorial Review

Imaging and image-guided interventions have become increasingly important in the workup and treatment of breast lesions in the past 2 decades. Radiologists should be aware of potential pitfalls during the workup, the procedure itself, and in the postprocedure follow-up. In this pictorial review, we illustrate challenges related to technique and interpretation related to breast interventions, and suggest ways to maximize success.

Cancer Imaging at the Crossroads of Precision Medicine: Perspective From an Academic Imaging Department in a Comprehensive Cancer Center

The authors propose one possible vision for the transformative role that cancer imaging in an academic setting can play in the current era of personalized and precision medicine by sharing a conceptual model that is based on experience and lessons learned designing a multidisciplinary, integrated clinical and research practice at their institution. The authors' practice and focus are disease-centric rather than imaging-centric. A "wall-less" infrastructure has been developed, with bidirectional integration of preclinical and clinical cancer imaging research platforms, enabling rapid translation of novel cancer drugs from discovery to clinical trial evaluation. The talents and expertise of medical professionals, scientists, and staff members have been coordinated in a horizontal and vertical fashion through the creation of Cancer Imaging Consultation Services and the "Adopt-a-Radiologist" campaign. Subspecialized imaging consultation services at the hub of an outpatient cancer center facilitate patient decision support and management at the point of care. The Adopt-a-Radiologist campaign has led to the creation of a novel generation of imaging clinician-scientists, fostered new collaborations, increased clinical and academic productivity, and improved employee satisfaction. Translational cancer research is supported, with a focus on early in vivo testing of novel cancer drugs, co-clinical trials, and longitudinal tumor imaging metrics through the imaging research core laboratory. Finally, a dedicated cancer imaging fellowship has been developed, promoting the future generation of cancer imaging specialists as multidisciplinary, multitalented professionals who are trained to effectively communicate with clinical colleagues and positively influence patient care.

Variation in Additional Breast Imaging Orders and Impact on Surgical Wait Times at a Comprehensive Cancer Center

BACKGROUND

In the multidisciplinary care model, breast imagers frequently provide second-opinion reviews of imaging studies performed at outside institutions. However, the need for additional imaging and timeliness of obtaining these studies has yet to be established. We sought to evaluate the frequency of additional imaging orders by breast surgeons and to evaluate the impact of this supplementary imaging on timeliness of surgery.

METHODS

We identified 2489 consecutive women with breast cancer who underwent first definitive surgery (FDS) at our comprehensive cancer center between 2011 and 2013. The number of breast-specific imaging studies performed for each patient between initial consultation and FDS was obtained. χ (2) tests were used to quantify the proportion of patients undergoing additional imaging by surgeon. Interval time between initial consultation and additional imaging and/or biopsy was calculated. The delay of additional imaging on time to FDS was assessed by t test.

RESULTS

Of 2489 patients, 615 (24.7 %) had at least one additional breast-specific imaging study performed between initial consultation and FDS, with 222 patients undergoing additional biopsies (8.9 %). The proportion of patients receiving imaging tests by breast surgeon ranged from 15 to 39 % (p < 0.0001). Patients receiving additional imaging had statistically longer wait times to FDS for BCT (21.4-28.5 days, p < 0.0001).

CONCLUSIONS

Substantial variability exists in the utilization of additional breast-specific imaging and in the timeliness of obtaining these tests among breast surgeons. Further research is warranted to assess the sources and impact of this variation on patient care, cost, and outcomes.