Rebekah Moan

 has stirred up debate once again about whether breast MRI leads to more mastectomies. The author said yes it does while others insist it does not.

Routine use of breast MRI in managing of patients with early-stage breast cancer may be unwarranted; there is no evidence to support a clear benefit in that setting, according to Malcolm Kell, a consultant surgeon and senior lecturer at Eccles Breast Screening Unit at University College Dublin in Ireland.

Kell references a meta-analysis published in 2008 in the 

 that concluded MR staging identifies additional disease in nearly one in five women previously diagnosed with breast cancer. It also suggests that women may undergo more extensive surgeries than originally planned because of false-positive MR findings.

 from a more recent study, the Comparative Effectiveness of Magnetic Resonance Imaging in Breast Cancer (COMICE) trial, also found the rate of mastectomy was higher in the MRI group versus those who did not undergo MRI (7% vs. 1%). COMICE was a multicenter randomized controlled trial conducted in the U.K. to assess the impact of MR mammography in patients with breast cancer who were thought to be amenable to breast-conserving treatment after standard triple assessment.

“MR mammography identifies occult disease in the breast that may not be visible on other imaging modalities, and this may lead to inappropriate treatment decisions,” Kell said.

Clear and consistent evidence from a large number of studies indicate preoperative MRI is directly associated with a change from planned breast conservation to more radical surgery, according to Dr. Nehmat Houssami, coauthor of the 

 study and an associate professor at the University of Sydney in Australia.

Houssami agrees with the editorial and said routine use of preoperative MRI in women newly diagnosed with breast cancer does not improve clinical outcomes and appears to be causing unnecessary mastectomy in women who would have received breast-conserving surgery otherwise.

“The results of COMICE are very important and represent evidence from a randomized controlled trial, hence removing the effect of confounding and bias,” she said. “It would be fair to say that MRI advocates/experts have been critical of the COMICE trial. In my opinion this seems to be a case of shooting the messenger.”

The COMICE study is the only randomized controlled trial to examine reoperation rates in women planning to have breast-conservation surgery and has demonstrated that preoperative MRI does not have a significant effect in reducing reexcision surgery, she said.

“We must be careful not to keep referring to small, nonrandomized studies to counter the evidence provided from a large randomized, controlled trial such as COMICE,” she said.

Not everyone agrees with Kell’s position.

Many studies reveal breast MRI can detect additional lesions when performed in patients just diagnosed with cancer. This will inevitably lead to additional surgery, such as wider lumpectomy or mastectomy, but that doesn’t mean MRI is to blame, according to Dr. Stamatia Destounis, an attending radiologist at Elizabeth Wende Breast Care in Rochester, New York.

“We have found more of our patients choosing mastectomies. However, I believe that is based on patients discussing all options with their surgeons, having genetic testing that is positive, or having several family members with history of cancer,” she said. “I don’t think MRI alone has caused women to choose mastectomy over lumpectomy.”

Plus, additional cancer may be found in the other breast, she said. There is no way of knowing whether the tumor that remains undiagnosed without breast MRI is the one that will affect the patient’s survival.

“MRI should be performed in women with newly diagnosed breast cancer, especially if they are premenopausal, have dense breast tissue that may make the mammogram difficult to interpret, and/or strong family history,” Destounis said. “We make more of a difference when we find the small breast tumors, which are easier to treat and cure.”

Articles

An editorial published in BMJ has stirred up debate once again about whether breast MRI leads to more mastectomies. The author said yes it does while others insist it does not.

Breast MRI's role in mastectomies remains open

Transvaginal ultrasound demonstrates good sensitivity and specificity for detecting endometrial cancer, 

a study from the University College, London.

 finds. But that doesn’t mean it’s suited for use in the general population just yet. The researchers found transvaginal ultrasound is better for high-risk groups prone to endometrial cancer, and especially in the management of postmenopausal women undergoing pelvic scans for reasons other than vaginal bleeding. 

  Endometrial cancer is the most common gynecological cancer in Europe, and has an increasing incidence in postmenopausal women in many northern and western European countries. In the U.K., overall incidence of endometrial cancer jumped from 13.5 per 100,000 in 1993 to 17.9 per 100,000 in 2005. The increase in obesity and the fall in fertility rates, two risk factors for endometrial cancer, suggest the incidence of endometrial cancer will continue to rise in postmenopausal women and will become a substantial public health problem worldwide, the authors said. 

  For asymptomatic women, there is currently no screening test to detect early stage endometrial cancer. For symptomatic women, transvaginal ultrasound (TVS) and endometrial sampling are used to assess the endometrium. Thicker endometria are associated with endometrial cancer. 

  Ian Jacobs, from the Gynecological Oncology department at 

, and colleagues conducted a nested case-control study of postmenopausal women who underwent TVS in the Collaborative Trial of Ovarian Cancer Screening, which included 37,038 women. 

  Using an endometrial thickness cutoff of 5.15mm, TVS has an 80.5% sensitivity and an 86.2% specificity. Using this threshold, if the entire population was screened, one case of endometrial cancer would be detected for every 47.7 women screened (Lancet doi:10.1016/S1470-2045(10)70268-0 ).

  Using an endometrial thickness cutoff of 10 mm or greater, TVS has a 54.1% sensitivity and a 97.2% specificity. 

  When the analysis was restricted to the 96 asymptomatic women who developed endometrial cancer, or atypical endometrial hyperplasia, during the follow-up period, an endometrial thickness cutoff of 5 mm achieved a sensitivity of 77.1% and specificity of 85.8%. In the high-risk population, an endometrial thickness cutoff 6.75 mm achieved sensitivity of 84.3% and specificity of 89.9%. 

  “Although the role of population screening for endometrial cancer remains uncertain, the findings are of immediate value in the management of increased endometrial thickness in postmenopausal women undergoing pelvic scans for reasons other than vaginal bleeding,” the researchers said. 

  A study like this lets physicians use TVS to triage the incidental findings in asymptomatic patients as opposed to using it as a pure screening mechanism, said Dr. Michael Blumenfeld, an associate professor in the ob/gyn department at 

 and the clinical director of the center for women’s health. 

  “To be a screening test TVS has to affect and improve survival,” he said. “There is no evidence from a prospective study that it’s going to change the long-term outcome.” 

  There’s a concern if physicians performed TVS on every single patient, including those at low risk, more harm than good would be done due to unnecessary procedures, he said. 

  For radiologists, the study will provide more information on what they find, he said. In all likelihood, TVS will end up being a part of the pelvic exam, Blumenfeld said. 

  “If a doctor scans for reasons such as an ovarian mass, and then finds an endometrial thickness, he or she needs to know how to triage the patient,” he said. “This study helps with that.” 

  This study forms the basis for further research, Jacobs said. In particular, issues of early detection, morbidity, acceptability, and health economics of intervening on the basis of endometrial thickness will need to be the subject of future studies.

Transvaginal ultrasound demonstrates good sensitivity and specificity for detecting endometrial cancer, a study from the University College, London. finds. But that doesn’t mean it’s suited for use in the general population just yet. The researchers found transvaginal ultrasound is better for high-risk groups prone to endometrial cancer, and especially in the management of postmenopausal women undergoing pelvic scans for reasons other than vaginal bleeding.

Large cohort supports ultrasound for endometrial cancer scans

Radiologists have mixed feelings about the new merger between Virtual Radiologic and NightHawk. Opinions range from pleased because the new entity could be a potential partner to worry it will take away radiology jobs.

Privately held Virtual Radiologic announced Sept. 27 it will acquire NightHawk, a publicly traded national teleradiology practice, which makes Virtual Radiologic the largest radiology practice in the country.

The combined entity will have 325 radiologists serving nearly 2700 healthcare facilities across all 50 states and reading approximately six million studies annually. Additionally, more than 75% of the affiliated radiologists will be fellowship-trained subspecialists. The merger is set to be completed in the first quarter of 2011.

Virtual Radiologic’s move is an incredibly smart one because they not only bought out their largest competitor, they bought the name NightHawk, according to Dr. Lawrence Muroff, president and CEO of Imaging Consultants in Tampa, FL, and a longtime follower of radiology business.

In recent years “NightHawk” has become synonymous with “teleradiology,” so much so that when people refer to “nighthawking,” often they’re not referring to the company.

“If you were a manufacturer of tissues and you had the opportunity to buy Kleenex, which is synonymous in people’s minds with tissue, wouldn’t you do it?,” he said. “I think it was a very smart move and one I would have made in Virtual Radiologic’s position.”

Repercussions of the move remain to be seen, but most likely not much will change in the day-to-day radiology world, said Dr. Howard Forman, a professor of diagnostic radiology and epidemiology and director of the M.D./MBA program at Yale University.

“It’s a consolidation in an industry that is still having a hard time proving where it adds value. Certainly [in terms of] economies of scale, they potentially have more to offer than they do as stand-alone entities,” he said. “But neither entity can prove it specifically adds value as opposed to just acting as a broker for radiology services.”

Whether the combined firms will have a competitive advantage is another question, he added.

“They are an enormous entity in terms of the teleradiology space, but they compete with thousands of other practices,” he said.

Other radiologists share Forman’s point of view.

“There is still a great deal of competition in this space, so I don’t see this merger as particularly harmful to the market or consumers,” Dr. Allen Elster, radiology chair at Wake Forest University Baptist Medical Center in Winston-Salem, NC. “I don’t fear this; it is simply reality.”

This merger may not mean nearly as much as people imagine it will, said Dr. Mark Klein, a radiologist at Washington Radiology Associates in the District of Columbia.

“First of all, many hospitals and clinicians are happy with their imaging situations,” he said. “They need interventionalists and mammographers onsite, and if the local radiologists are doing a good job, providing high-quality interpretations and timely service, there is little incentive right now for these institutions to change.”

Dissatisfied hospitals would eventually have made a change anyway; this is just another option, he said. Rob Kill, president and CEO of Virtual Radiologic, said the merger is no cause for alarm among the radiology community.

“The professional services market for radiology is $20 billion. Combined, Virtual Radiologic and NightHawk have slightly more than 1%, which is not a lot of concentration,” he said. “It’s a big market out there, so yes, obviously we’re a big player, but it’s a drop in the bucket of the overall market.”

Others are not so keen to believe the merger is nonthreatening. Dr. Stamatia Destounis, a radiologist at Elizabeth Wende Breast Care in Rochester, NY, said the merger could hurt radiologists.

“These huge acquisitions will take jobs from local radiologists, create issues for referring doctors, possibly create delays for the care of patients, and cause the local radiologists to review/reread these studies when the consulting doctors come to ask for advice or help with the original reads,” she said.

The merger could also harm the local community by taking money from local radiologists, and cause hardship for them if their volume and reimbursement decrease, she said.

While the new company may be a competitor for local radiologists, it’s also likely Virtual Radiologic/ NightHawk will act as a potential partner, according to Muroff.

“I think this company will be very capable of taking over hospital contracts. But it will also be capable of providing subspecialty expertise and night assistance for existing practices,” he said. “It could partner, it could compete. My guess is it will do both.”

Kill emphasized competing with local groups is not the company’s not. “In all cases, we want to partner as an invited guest to help them at their practice,” he said. “We’re not looking to compete with local radiology practices.”

Don’t panic and don’t sell into a falling market, is Klein’s advice to radiologists. Get better at everything: improve quality of interpretations, minimize radiation dose, optimize the level of service and timeliness of reports, and provide metrics, he said.

“If you can provide top-level care with proven safeguards and documentation of best practices, I would predict ongoing success, no matter how big Virtual Radiologic or other teleradiology groups grow,” he said.

The Virtual Radiologic and NightHawk merger has some experts worrying about jobs, referral issues, a delays in care. 

Radiologists mixed on Virtual Radiologic/NightHawk merger

A new study using functional MRI shows the right and left hemispheres of the brain don’t communicate well in patients with an autistic condition. The study is yet another in a series that suggests autism may be a disorder of connectivity. Such information could ultimately aid in the development of earlier, more effective treatments by distinguishing types of autism and allowing physicians to get to the root of the disease.

University of Utah medical researchers used fMRI to identify regions where the left and right hemispheres of the brains of autistic patients do not properly communicate with one another.

Those regions are in “hot spots” associated with functions such as motor skills, attention, facial recognition, and social functioning-all areas in which abnormal behavior is often noted in autistic patients. Scans of people without the disorder did not show the same deficits (Cerebral Cortex doi:10.1093/cercor/bhq190).

“One of the biggest problems with autism is that until recently we really didn’t understand the mechanism of the disease in the brain,” said Dr. Jeffrey Anderson, lead author of the study and a neuroradiologist at the university. “It’s hard to design treatment strategies, drugs, or other therapies if you don’t understand exactly what is wrong.”

The current study starts to show exactly what is wrong. In their investigation of 53 high-functioning male subjects with autism and 39 typically developing male subjects, the researchers found decreased interhemispheric correlations between homologous voxels in some regions of the brain in the autism sample.

The investigators constructed spatial maps of correlation between homologous voxels in each hemisphere and found significantly reduced interhemispheric correlation specific to regions relating to autistic behavior. Those areas include the: sensorimotor cortex, anterior insula, fusiform gyrus, superior temporal gyrus, and superior parietal lobe.

“Once we have hard, reproducible differences in the brain, there is so much more we can do,” said Anderson, who is also an assistant professor of radiology at the university. “We can trace these connectivity disturbances back and test what is wrong with the cells of the brain or the wiring that causes them.”

The researchers can also use the differences in connectivity to identify genes that may be abnormal.

“Ultimately we can work out the whole disease mechanism by tracing backward from known ‘hard’ abnormalities,” he said. “We have a handhold to grab onto and work with.”

If fMRI is combined with other tests, such as differences in the diffusion of water, or differences in size of brain regions, a composite test can be created to effectively classify individual patients.

“Many investigators are actively working on this right now,” Anderson said.

An autism expert from the University of California, San Francisco (UCSF) said Anderson’s research adds support to the importance of connectivity in the etiology of autism.

“We are still a long way from a diagnostic test-this research will need to be replicated-but they had a good sized sample and multiple sites were involved,” said Dr. Robert Hendren, vice chair of the psychiatry department and director of child and adolescent psychiatry at UCSF.

This study moves researchers closer to defining subtypes that may help them identify useful treatment targets, he said.

If investigators are able to diagnose autism early, it can aid treatment for the patient.

“The most effective treatments for autism right now involve adaptation strategies that are most effective if begun early,” Anderson said. “Delaying diagnosis until after a child begins school, for example, can limit options for treatment that may help a child better prepare for school, social interactions, and managing their environment at home.”

A new study using functional MRI shows the right and left hemispheres of the brain don’t communicate well in patients with an autistic condition.

Rebekah Moan

Articles

Breast MRI's role in mastectomies remains open

Large cohort supports ultrasound for endometrial cancer scans

Radiologists mixed on Virtual Radiologic/NightHawk merger

FMRI shows connections missing in autistic brains