Harper, Laura

PURPOSE Contrast-enhanced mammography (CEM) and magnetic resonance imaging (MRI) have shown similar diagnostic performance in detection of breast cancer. Limited CEM data are available for high-risk breast cancer screening. The purpose of the study was to prospectively investigate the efficacy of supplemental screening CEM in elevated risk patients. MATERIALS AND METHODS A prospective, single-institution, institutional review board–approved observational study was conducted in asymptomatic elevated risk women age 35 years or older who had a negative conventional two-dimensional digital breast tomosynthesis screening mammography (MG) and no additional supplemental screening within the prior 12 months. RESULTS Four hundred sixty women were enrolled from February 2019 to April 2021. The median age was 56.8 (range, 35.0-79.2) years; 408 of 460 (88.7%) were mammographically dense. Biopsy revealed benign changes in 22 women (22/37, 59%), high-risk lesions in four women (4/37, 11%), and breast cancer in 11 women (11/37, 30%). Fourteen cancers (10 invasive, tumor size range 4-15 mm, median 9 mm) were diagnosed in 11 women. The overall supplemental cancer detection rate was 23.9 per 1,000 patients, 95% CI (12.0 to 42.4). All cancers were grade 1 or 2, ER+ ERBB2–, and node negative. CEM imaging screening offered high specificity (0.875 [95% CI, 0.844 to 0.906]), high NPV (0.998 [95% CI, 0.993 to 1.000), moderate PPV1 (0.164 [95% CI, 0.076 to 0.253), moderate PPV3 (0.275 [95% CI, 0.137 to 0.413]), and high sensitivity (0.917 [95% CI, 0.760 to 1.000]). At least 1 year of imaging follow-up was available on all patients, and one interval cancer was detected on breast MRI 4 months after negative screening CEM. CONCLUSION A pilot trial demonstrates a supplemental cancer detection rate of 23.9 per 1,000 in women at an elevated risk for breast cancer. Larger, multi-institutional, multiyear CEM trials in patients at elevated risk are needed for validation.

Abstract Buffered lidocaine is a local anesthetic option during percutaneous needle-directed procedures in the breast. At our institution, sodium bicarbonate (the buffer) is dispensed in volumes that frequently lead to medical waste and shortages. In this study, we describe how moving the buffering of lidocaine from the procedure room to our clinical hospital pharmacy results in a reduction in costs and improves satisfaction across the breast radiology department. While cost savings are difficult to tease out in practices that opt for bundled payments, we were able to access pricing and supply data and coordinate with our pharmacy to change our practice. Making these changes saves our practice $26 000 a year and allows us to continue to offer buffered lidocaine even during sodium bicarbonate shortages. This manuscript describes how these changes came about and their economic impact.

Abstract Introduction Primary testicular lymphoma (PTL) and testicular involvement of systemic lymphoma (secondary testicular lymphoma, STL) are uncommon. Most testicular lymphomas are aggressive B-cell lymphomas and portend a high risk of extranodal relapse, including CNS relapse. As such, when testicular lymphoma is identified, the management strategy is often changed to include CNS prophylaxis. It is, therefore, essential to evaluate testicular involvement in diagnosis and staging. F-18 fluorodeoxyglucose positron emission tomography/computed tomography (FDG PET/CT) is a standard imaging modality to stage aggressive lymphoma. Physiologic testicular FDG activity can be challenging to distinguish from involvement by lymphoma given a wide range of normal. An imaging threshold for testicular PET uptake would be clinically relevant and would help guide management. We compare testicular FDG avidity in testicular lymphoma with physiologic testicular FDG avidity. Methods Records of patients (pts) diagnosed with PTL or STL from 2002-2018 enrolled in the University of Iowa/Mayo Clinic Lymphoma SPORE Molecular Epidemiology Resource were reviewed, yielding 36 pts with testicular lymphoma. Physiologic testicular avidity by FDG PET/CT was determined from analysis of 70 randomly selected patients who received FDG PET/CT from 2013-2018 prior to treatment for non-lymphoma indications including pulmonary nodule, lung carcinoma, head & neck squamous cell carcinoma, gastrointestinal carcinomas, and metastatic melanoma, without known hematologic malignancy, testicular pathology, or history of testicular infection/surgery by medical chart review. Imaging parameters compared in this analysis were SUVmax and SUVmean. All FDG PET/CT exams were reviewed centrally by a nuclear medicine radiologist and a radiology resident. Results Of the 36 pts with testicular lymphoma, 19 had an orchiectomy prior to FDG PET/CT and 7 pts did not have a staging FDG PET/CT scan. Of the 10 pts with intact testes at the time of staging FDG PET/CT, 1 pt with low-grade lymphoma was excluded. 9 pts with aggressive lymphomas were included in this analysis: 7 pts with diffuse large B cell lymphoma (DLBCL), and 1 pt each with Burkitt lymphoma and peripheral T-cell lymphoma, not otherwise specified. Testicular lymphoma was diagnosed by orchiectomy in 3 pts, and by percutaneous biopsy in 3 pts. 3 pts did not have tissue sampling of testes or scrotal contents, but had an overtly FDG-avid testicle highly suggestive of lymphomatous involvement. These 3 pts had biopsy-proven lymphoma in parotid, bone marrow, and stomach, respectively, with mean testicular SUVmax 6.8 among the 3 pts. The median age in this analysis cohort was 62 years (range 35-88). Of the 7 analyzed DLBCL pts, 6 were non-germinal center B-cell, and 1 was germinal center B-cell. The 70 control pts had a median age of 55 years (range 18-90). In known testicular lymphoma cases and control pts, SUVmax and SUVmean were assessed from the most FDG-avid testicle. Median SUVmax for the testicular lymphoma cases was 13.3 (range 5.5-29.9), compared to a median of 3.8 (range 2.1-5.5) for controls (Wilcoxon p <0.0001). Median SUVmean for testicular lymphoma was 9.2 (range 3.3-18.6), compared to a median of 3.1 (range 1.8-4.8) for controls (Wilcoxon p <0.0001) (Figure). Based on this dataset, an SUVmax cutoff of 5.0 has a sensitivity of 100% (95% CI 66.3-100) and a specificity of 98.6% (98% CI 92.3-99.9) for the detection of testicular involvement by an aggressive lymphoma. Conclusions FDG PET/CT shows significantly greater FDG avidity for testicular aggressive lymphomas as compared with physiologic testicular FDG uptake in this single institution study with centralized radiology review of cases and controls. Testicular FDG avidity greater than an SUVmax 5.0 in staging aggressive lymphoma is highly suggestive for testicular involvement, warranting follow-up clinical exam and ultrasound, at a minimum. In addition, testicles with SUVmax <5.0 in a patient with known lymphoma but no symptoms or signs of testicular involvement should be considered negative for the purposes of staging and treatment planning. A pragmatic limitation of this study is that most patients with testicular involvement of lymphoma underwent orchiectomy prior to FDG PET/CT scan, which decreased our sample size. Larger, pooled studies would be helpful to validate these clinically relevant findings. Figure. Figure. Disclosures Witzig: Celgene: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding. Cerhan:Celgene: Research Funding; Jannsen: Other: Scientific Advisory Board; Nanostring: Research Funding.