Abstract
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%.
Highlights
Tertiary and dedicated care centers utilize a multidisciplinary approach in the evaluation and treatment of cancer patients
In a recent study of 209 patients with second opinion breast ultrasound review, clinical management was altered in 33%, with additional cancer detected in 5% of patients [10]. e purpose of our study was to determine breast ultrasound review discrepancy frequency and the subsequent utility and impact on patient management in a large cohort of patients pursuing breast imaging second opinion
Second opinion review of outside ultrasound imaging resulted in discrepant findings in 27% of patients, leading to the detection of additional cancer in 10 patients (2.5%) and changes in clinical management in 12%. is adds to the growing body of literature supporting the value of subspecialized imaging interpretation in the management of the patients undergoing workup and management of suspicious breast imaging findings, including cancer
Summary
Tertiary and dedicated care centers utilize a multidisciplinary approach in the evaluation and treatment of cancer patients. Second opinion interpretation of imaging by subspecialized radiologists has been previously shown to improve diagnostic ability and alter patient management [2,3,4,5,6,7,8]. A recent study by Whorms et al, for instance, focused on assessing the incidence and clinical significance of discrepancy in subspecialty interpretation of outside breast e Breast Journal imaging at a tertiary cancer center [9]. In a recent study of 209 patients with second opinion breast ultrasound review, clinical management was altered in 33%, with additional cancer detected in 5% of patients [10]. E purpose of our study was to determine breast ultrasound review discrepancy frequency and the subsequent utility and impact on patient management in a large cohort of patients pursuing breast imaging second opinion In a recent study of 209 patients with second opinion breast ultrasound review, clinical management was altered in 33%, with additional cancer detected in 5% of patients [10]. e purpose of our study was to determine breast ultrasound review discrepancy frequency and the subsequent utility and impact on patient management in a large cohort of patients pursuing breast imaging second opinion
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