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A recent study was conducted to evaluate the diagnostic characteristics of sonographic surveillance for detection of metachronous contralateral breast cancer in patients with a history of breast cancer surgery, in order to determine whether sonography in addition to mammography might be justified in terms of time and cost.

The results, published in AJR, indicate that while annual screening sonography in addition to mammography may be useful for the discovery of metachronous contralateral cancers, the time and cost involved may not be justified.

The Study
Over a 1-year retrospective period, patients who had undergone surgery for biopsy-proven breast malignancy were identified. Those who had sonographic evaluation in addition to mammographic evaluation were included in the study. Patients had undergone bilateral whole breast sonography in addition to mammography every 6 months for the first 2 years and then annually thereafter. Exclusion criteria included a history of bilateral breast cancer surgery.

Methodology
1256 Asian women (mean age, 50 years) were included in the study. Over the follow-up period, the contralateral breast was classified as a BI-RADS 1 or 2 93.6% of the time. A BI-RADS 3 category was assigned to 3.8%, category 4 to 2.3%, and category 5 to 0.3%.

One radiologist reviewed the reports of the imaging studies and documented the BI-RADS category. The images were not reread.

Those classified as BI-RADS 1 or 2 were considered negative. BI-RADS categorization of 3, 4, or 5 were only included if they were referring to the breast contralateral to the surgical breast.

In other words, the originally reported BI-RADS was re-categorized to assess only the contralateral breast. The final diagnosis of each patient was determined based on tissue diagnosis at a follow-up time of ≥1 year.
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Results
Overall, 46 biopsies were performed. When tissue diagnosis was compared with BI-RADS category, the positive-predictive value (PPV) was 41.0%.

One cancer was missed, resulting in a false-negative rate of 0.06%.Of patients who continued sonographic adjuvant surveillance for >2 years, a 0.4% false-negative rate was revealed.

Two cases of biopsy-proven contralateral metachronous breast cancer were found on sonography and not detected on mammography.

Annual screening sonography may be useful for the discovery of metachronous contralateral cancers.

Reviewer’s Comments
The authors do not comment extensively on the finding that only 2 cancers discovered on sonography were also mammographically occult. For the remaining cases of metachronous cancer, the mammogram was judged to be positive as well.

Although a significant tool for those 2 cases, does it truly justify the time and cost of performing sonographic surveillance in addition to mammographic surveillance in a patient with otherwise no complaints?

On the other hand, those with a history of breast cancer, or any symptoms, might certainly consider having both sonography and mammography to rule out any chance of a false negative.

Author: Basil Hubbi, MD
Reference:
Kim MJ, Kim E-K, et al. Sonographic Surveillance for the Detection of Contralateral Metachronous Breast Cancer in an Asian Population. AJR; 2009; 192 (January): 221-228.

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In patients undergoing virtual endoscopy to screen for colorectal cancer and polyps, the colon is gently distended with either room air or carbon dioxide via an insufflation tube immediately before and during the examination.

Once distended, a scout radiograph is taken to verify that the distention is adequate.

Often, the radiograph shows that the sigmoid colon is not distended as much as needed. If the patient can tolerate some more pressure inside the colon, then more air or carbon dioxide may be pumped into the colon.

Scanning
In our practice, we currently use a 16-slice scanner. Depending on the patient’s height, roughly 290 contiguous scans (1.25 mm) can be done through the abdomen in about 12 seconds (a single breathhold) in an average-sized patient.

First, the patient is scanned in the supine position. Then we flip the patient over and repeat the scan with the patient in the prone position.

The advantage of thin-slice scanning is that we get better spatial resolution on the resultant 3-dimensional or multiplanar reformations.

This provides better definition of folds, better definition of polyps sitting next to a fold, and better isotropic data (decrease volume averaging).

The scan should be performed in a single breathhold or else registration will be an issue and some parts of the colon may be missed.

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Radiation Dose
With virtual colonoscopy, CT tube currents are operated at low levels (I use about 80 mAs), which is much lower than a conventional CT scanner. With that low dose, the results will have grainy images and thin slices.

Although detecting extracolonic abnormalities is not the primary purpose of virtual colonoscopy, grainy images make it harder to detect these abnormalities. However, grainy images really do not affect the screening examination.

I scan most patients at 70 mAs to 100 mAs. I am considering lowering these dosages much further. A recent study suggests going as low as 2.5 mAs.

With these parameters, the radiation dose is similar to that of a double-contrast barium enema, even doing supine and prone examinations, essentially 2 examinations.

With use of tagging, we may not need the second set of examinations, and may be able to do only 1 examination in either the supine or prone position.

Although we still need to perform 2 examinations, our goal is to some day reduce the radiation dose by half.

Conclusion
Virtual colonoscopy performed with thin-slice scanning helps maximize the spatial resolution on the resultant 3-dimensional or multiplanar reformations, and provides better definition of the folds and the polyps sitting next to the folds.

Author: Richard S. Breiman, MD

Excerpted from his paper: Low-Dose Multi-Slice Scans Improve Resolution and Decrease Radiation Exposure for Virtual Colonoscopy.

Dr. Breiman practices Diagnostic Radiology in Oakland and San Francisco, California.

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