Richard Hyer

Major Finding: Traumatic intracranial hemorrhage was seen in 6.2% of all trauma admissions in 1999–2000 and in 12.3% in 2007-2008, while the use of strong antiplatelet agents increased fivefold.

Data Source: Review of the hospital records for 526 patients admitted with intracranial hemorrhage.

Disclosures: Dr. Siracuse reported no relevant financial interests. The study was sponsored by Beth Israel Deaconess Medical Center, and the principal investigator was Dr. Carl J. Hauser.

CHICAGO — Increasing rates of traumatic intracranial hemorrhage in elderly patients appeared to be related to the use of antiplatelet agents in a retrospective study.

The rise in traumatic intracranial hemorrhage (TICH) occurred without significant increases in diagnosis of atrial fibrillation or in use of warfarin (Coumadin), and overall mortality did not change, Dr. Jeffrey J. Siracuse said at the annual meeting of the Central Surgical Association.

“Patients with atrial fibrillation are at high risk for stroke and may also be at high risk for bleeding complications,” said Dr. Siracuse of Beth Israel Deaconess Medical Center, Boston. These patients often are treated with anticoagulants based on their estimated risk of thromboembolism, and are likely to be taking antiplatelet agents.

The review of the hospital's trauma registry database of 5,371 patients examined records for all 526 admitted with intracranial hemorrhage during 1999–2000 (139 patients) and 2007–2008 (387 patients). Intracranial hemorrhages were considered traumatic if they were secondary to an identified external injury.

The principal cause of trauma in both groups was a simple fall from the standing position. In the 1999–2000 group, 6.2% of all trauma admissions were TICH patients; this doubled to 12.3% in the 2007–2008 group.

The study found little increase in warfarin use in either group. But the use of “strong antiplatelet agents, specifically clopidogrel and Aggrenox, increased fivefold between the two periods,” Dr. Siracuse said. In the earlier period, 27% of TICH patients were on aspirin, but by the later period, 48% were on aspirin.

Overall, the mortality of patients with TICH was unchanged between the two periods (12.4% vs. 12.2%), and there was no difference in the mean number of hospital- and ICU-free days.

“We did not see a large increase, as we thought we would, in atrial fibrillation or in Coumadin use in our TICH population. This could perhaps reflect [the fact] that Massachusetts has the highest patient/physician primary care patient ratio in the country,” Dr. Siracuse said. This suggests that medical conditions were identified early and treated aggressively.

The vast majority of patients were injured by simple falls from standing, he said, and many patients on anticoagulation because of high risk for thromboembolism were also at high risk for falls. Increasing rates of TICH appeared to be associated with the use of strong antiplatelet agents rather than with increased warfarin use, he concluded.

Major Finding: Traumatic intracranial hemorrhage was seen in 6.2% of all trauma admissions in 1999–2000 and in 12.3% in 2007-2008, while the use of strong antiplatelet agents increased fivefold.

Data Source: Review of the hospital records for 526 patients admitted with intracranial hemorrhage.

Disclosures: Dr. Siracuse reported no relevant financial interests. The study was sponsored by Beth Israel Deaconess Medical Center, and the principal investigator was Dr. Carl J. Hauser.

CHICAGO — Increasing rates of traumatic intracranial hemorrhage in elderly patients appeared to be related to the use of antiplatelet agents in a retrospective study.

The rise in traumatic intracranial hemorrhage (TICH) occurred without significant increases in diagnosis of atrial fibrillation or in use of warfarin (Coumadin), and overall mortality did not change, Dr. Jeffrey J. Siracuse said at the annual meeting of the Central Surgical Association.

“Patients with atrial fibrillation are at high risk for stroke and may also be at high risk for bleeding complications,” said Dr. Siracuse of Beth Israel Deaconess Medical Center, Boston. These patients often are treated with anticoagulants based on their estimated risk of thromboembolism, and are likely to be taking antiplatelet agents.

The review of the hospital's trauma registry database of 5,371 patients examined records for all 526 admitted with intracranial hemorrhage during 1999–2000 (139 patients) and 2007–2008 (387 patients). Intracranial hemorrhages were considered traumatic if they were secondary to an identified external injury.

The principal cause of trauma in both groups was a simple fall from the standing position. In the 1999–2000 group, 6.2% of all trauma admissions were TICH patients; this doubled to 12.3% in the 2007–2008 group.

The study found little increase in warfarin use in either group. But the use of “strong antiplatelet agents, specifically clopidogrel and Aggrenox, increased fivefold between the two periods,” Dr. Siracuse said. In the earlier period, 27% of TICH patients were on aspirin, but by the later period, 48% were on aspirin.

Overall, the mortality of patients with TICH was unchanged between the two periods (12.4% vs. 12.2%), and there was no difference in the mean number of hospital- and ICU-free days.

“We did not see a large increase, as we thought we would, in atrial fibrillation or in Coumadin use in our TICH population. This could perhaps reflect [the fact] that Massachusetts has the highest patient/physician primary care patient ratio in the country,” Dr. Siracuse said. This suggests that medical conditions were identified early and treated aggressively.

The vast majority of patients were injured by simple falls from standing, he said, and many patients on anticoagulation because of high risk for thromboembolism were also at high risk for falls. Increasing rates of TICH appeared to be associated with the use of strong antiplatelet agents rather than with increased warfarin use, he concluded.

Major Finding: Traumatic intracranial hemorrhage was seen in 6.2% of all trauma admissions in 1999–2000 and in 12.3% in 2007-2008, while the use of strong antiplatelet agents increased fivefold.

Data Source: Review of the hospital records for 526 patients admitted with intracranial hemorrhage.

Disclosures: Dr. Siracuse reported no relevant financial interests. The study was sponsored by Beth Israel Deaconess Medical Center, and the principal investigator was Dr. Carl J. Hauser.

CHICAGO — Increasing rates of traumatic intracranial hemorrhage in elderly patients appeared to be related to the use of antiplatelet agents in a retrospective study.

The rise in traumatic intracranial hemorrhage (TICH) occurred without significant increases in diagnosis of atrial fibrillation or in use of warfarin (Coumadin), and overall mortality did not change, Dr. Jeffrey J. Siracuse said at the annual meeting of the Central Surgical Association.

“Patients with atrial fibrillation are at high risk for stroke and may also be at high risk for bleeding complications,” said Dr. Siracuse of Beth Israel Deaconess Medical Center, Boston. These patients often are treated with anticoagulants based on their estimated risk of thromboembolism, and are likely to be taking antiplatelet agents.

The review of the hospital's trauma registry database of 5,371 patients examined records for all 526 admitted with intracranial hemorrhage during 1999–2000 (139 patients) and 2007–2008 (387 patients). Intracranial hemorrhages were considered traumatic if they were secondary to an identified external injury.

The principal cause of trauma in both groups was a simple fall from the standing position. In the 1999–2000 group, 6.2% of all trauma admissions were TICH patients; this doubled to 12.3% in the 2007–2008 group.

The study found little increase in warfarin use in either group. But the use of “strong antiplatelet agents, specifically clopidogrel and Aggrenox, increased fivefold between the two periods,” Dr. Siracuse said. In the earlier period, 27% of TICH patients were on aspirin, but by the later period, 48% were on aspirin.

Overall, the mortality of patients with TICH was unchanged between the two periods (12.4% vs. 12.2%), and there was no difference in the mean number of hospital- and ICU-free days.

“We did not see a large increase, as we thought we would, in atrial fibrillation or in Coumadin use in our TICH population. This could perhaps reflect [the fact] that Massachusetts has the highest patient/physician primary care patient ratio in the country,” Dr. Siracuse said. This suggests that medical conditions were identified early and treated aggressively.

The vast majority of patients were injured by simple falls from standing, he said, and many patients on anticoagulation because of high risk for thromboembolism were also at high risk for falls. Increasing rates of TICH appeared to be associated with the use of strong antiplatelet agents rather than with increased warfarin use, he concluded.

CHICAGO - A chest x-ray after the surgical treatment of melanoma, as suggested in the National Comprehensive Cancer Networks guidelines, does not detect recurrence at levels sufficient to justify its use, according to an analysis from the Sunbelt Melanoma Trial.

In the review of more than 1,200 patients who had yearly chest x-rays following surgical treatment for melanoma, fewer than 0.1% of the x-rays showed pulmonary metastases that were amenable to resection, Dr. Russell E. Brown said at the annual meeting of the Central Surgical Association.

This finding has implications for patients' exposure to radiation, and, according to one member of the audience, for health care costs as well. "I think in 2010, with health care reform, we all need to look very carefully at what these follow-up criteria are and what we're using resources for," said Dr. Thomas Howard, professor of surgery at Indiana University, Indianapolis. "These are powerful data, and they really speak to the inadvisability of having a chest x-ray for everyone."

The National Comprehensive Cancer Networks Medical Practice Guidelines in Oncology (v.2.2009) describes the "option" of a chest x-ray - as well as a CBC and a lactate dehydrogenase (LDH) measurement - every 6-12 months in patients with melanoma stage IB-IV and no evidence of disease.

However, physicians do not necessarily view such guidelines as optional, said Dr. Brown of the University of Louisville (Ky.). "Recommendations such as these lead physicians to feel obligated to use the chest x-ray during follow-up," he noted.

The Sunbelt Melanoma Trial was a prospective, randomized trial of 3,619 patients (aged 18-70 years) at 79 centers in the United States and Canada. The trial evaluated the role of completion lymph node dissection or high-dose interferon alpha-2b in patients with melanoma that was staged by sentinel lymph node biopsy. All patients were clinically node negative, with primary tumors at least 1 mm thick. Those who had positive nodes in sentinel lymph node biopsy underwent completion lymphadenectomy. All patients also had yearly follow-up chest x-rays.

This analysis from the University of Louisville studied a subset of 1,235 patients whose follow-up comprised both a chest x-ray and other exams, including blood tests and evaluation of disease state and recurrence pattern. Within the subset, 1,025 patients (83%) had no recurrence, and 210 (17%) had recurrence. Sites of recurrence were locoregional in 108 patients (51%), distant in 74 (35%), and in the lung only in 28 (13%).

The subset of 1,235 patients had 4,218 chest x-rays, of which 38 (0.9%) were true positives and 3,593 (85.2%) were true negatives.

"An overwhelming 3,593 true negatives," said Dr. Brown. Of the 38 positives, 35 had widely disseminated metastases.

Only 3 (0.07%) of the 4,218 chest x-rays showed pulmonary metastases that were amenable to resection, said Dr. Brown. He invited the audience to extrapolate, pointing out that 1,406 chest x-rays were required to find a single resectable pulmonary metastasis. "Or conversely, 412 patients that you screen yearly for 74 months," he said.

Dr. Brown noted that the ideal screening test is noninvasive, low cost, and widely available, and has high sensitivity and specificity. It also must have potential for therapeutic benefit. A chest x-ray has "terrible" sensitivity and little therapeutic potential, he said.

Discussant Dr. Margo Shoup of Loyola University Medical Center in Maywood, Ill., asked Dr. Brown whether these findings have altered his practice in Louisville.

"Practice in multidisciplinary settings varies widely," said Dr. Brown. "Among our surgeons, we do not routinely perform chest x-ray imaging, LDH, or really anything other than physical exams. We rely heavily on patient education, and we see our patients about every 6 months for the first 1-5 years," he said. "Our medical colleagues use PET and CT liberally, without proven benefit, especially with the lack of effective systemic therapies."

Dr. Brown disclosed that the Sunbelt Melanoma Trial was supported by a grant from Schering Oncology/Biotech.

CHICAGO - A chest x-ray after the surgical treatment of melanoma, as suggested in the National Comprehensive Cancer Networks guidelines, does not detect recurrence at levels sufficient to justify its use, according to an analysis from the Sunbelt Melanoma Trial.

In the review of more than 1,200 patients who had yearly chest x-rays following surgical treatment for melanoma, fewer than 0.1% of the x-rays showed pulmonary metastases that were amenable to resection, Dr. Russell E. Brown said at the annual meeting of the Central Surgical Association.

This finding has implications for patients' exposure to radiation, and, according to one member of the audience, for health care costs as well. "I think in 2010, with health care reform, we all need to look very carefully at what these follow-up criteria are and what we're using resources for," said Dr. Thomas Howard, professor of surgery at Indiana University, Indianapolis. "These are powerful data, and they really speak to the inadvisability of having a chest x-ray for everyone."

The National Comprehensive Cancer Networks Medical Practice Guidelines in Oncology (v.2.2009) describes the "option" of a chest x-ray - as well as a CBC and a lactate dehydrogenase (LDH) measurement - every 6-12 months in patients with melanoma stage IB-IV and no evidence of disease.

However, physicians do not necessarily view such guidelines as optional, said Dr. Brown of the University of Louisville (Ky.). "Recommendations such as these lead physicians to feel obligated to use the chest x-ray during follow-up," he noted.

The Sunbelt Melanoma Trial was a prospective, randomized trial of 3,619 patients (aged 18-70 years) at 79 centers in the United States and Canada. The trial evaluated the role of completion lymph node dissection or high-dose interferon alpha-2b in patients with melanoma that was staged by sentinel lymph node biopsy. All patients were clinically node negative, with primary tumors at least 1 mm thick. Those who had positive nodes in sentinel lymph node biopsy underwent completion lymphadenectomy. All patients also had yearly follow-up chest x-rays.

This analysis from the University of Louisville studied a subset of 1,235 patients whose follow-up comprised both a chest x-ray and other exams, including blood tests and evaluation of disease state and recurrence pattern. Within the subset, 1,025 patients (83%) had no recurrence, and 210 (17%) had recurrence. Sites of recurrence were locoregional in 108 patients (51%), distant in 74 (35%), and in the lung only in 28 (13%).

The subset of 1,235 patients had 4,218 chest x-rays, of which 38 (0.9%) were true positives and 3,593 (85.2%) were true negatives.

"An overwhelming 3,593 true negatives," said Dr. Brown. Of the 38 positives, 35 had widely disseminated metastases.

Only 3 (0.07%) of the 4,218 chest x-rays showed pulmonary metastases that were amenable to resection, said Dr. Brown. He invited the audience to extrapolate, pointing out that 1,406 chest x-rays were required to find a single resectable pulmonary metastasis. "Or conversely, 412 patients that you screen yearly for 74 months," he said.

Dr. Brown noted that the ideal screening test is noninvasive, low cost, and widely available, and has high sensitivity and specificity. It also must have potential for therapeutic benefit. A chest x-ray has "terrible" sensitivity and little therapeutic potential, he said.

Discussant Dr. Margo Shoup of Loyola University Medical Center in Maywood, Ill., asked Dr. Brown whether these findings have altered his practice in Louisville.

"Practice in multidisciplinary settings varies widely," said Dr. Brown. "Among our surgeons, we do not routinely perform chest x-ray imaging, LDH, or really anything other than physical exams. We rely heavily on patient education, and we see our patients about every 6 months for the first 1-5 years," he said. "Our medical colleagues use PET and CT liberally, without proven benefit, especially with the lack of effective systemic therapies."

Dr. Brown disclosed that the Sunbelt Melanoma Trial was supported by a grant from Schering Oncology/Biotech.

CHICAGO - A chest x-ray after the surgical treatment of melanoma, as suggested in the National Comprehensive Cancer Networks guidelines, does not detect recurrence at levels sufficient to justify its use, according to an analysis from the Sunbelt Melanoma Trial.

In the review of more than 1,200 patients who had yearly chest x-rays following surgical treatment for melanoma, fewer than 0.1% of the x-rays showed pulmonary metastases that were amenable to resection, Dr. Russell E. Brown said at the annual meeting of the Central Surgical Association.

This finding has implications for patients' exposure to radiation, and, according to one member of the audience, for health care costs as well. "I think in 2010, with health care reform, we all need to look very carefully at what these follow-up criteria are and what we're using resources for," said Dr. Thomas Howard, professor of surgery at Indiana University, Indianapolis. "These are powerful data, and they really speak to the inadvisability of having a chest x-ray for everyone."

The National Comprehensive Cancer Networks Medical Practice Guidelines in Oncology (v.2.2009) describes the "option" of a chest x-ray - as well as a CBC and a lactate dehydrogenase (LDH) measurement - every 6-12 months in patients with melanoma stage IB-IV and no evidence of disease.

However, physicians do not necessarily view such guidelines as optional, said Dr. Brown of the University of Louisville (Ky.). "Recommendations such as these lead physicians to feel obligated to use the chest x-ray during follow-up," he noted.

The Sunbelt Melanoma Trial was a prospective, randomized trial of 3,619 patients (aged 18-70 years) at 79 centers in the United States and Canada. The trial evaluated the role of completion lymph node dissection or high-dose interferon alpha-2b in patients with melanoma that was staged by sentinel lymph node biopsy. All patients were clinically node negative, with primary tumors at least 1 mm thick. Those who had positive nodes in sentinel lymph node biopsy underwent completion lymphadenectomy. All patients also had yearly follow-up chest x-rays.

This analysis from the University of Louisville studied a subset of 1,235 patients whose follow-up comprised both a chest x-ray and other exams, including blood tests and evaluation of disease state and recurrence pattern. Within the subset, 1,025 patients (83%) had no recurrence, and 210 (17%) had recurrence. Sites of recurrence were locoregional in 108 patients (51%), distant in 74 (35%), and in the lung only in 28 (13%).

The subset of 1,235 patients had 4,218 chest x-rays, of which 38 (0.9%) were true positives and 3,593 (85.2%) were true negatives.

"An overwhelming 3,593 true negatives," said Dr. Brown. Of the 38 positives, 35 had widely disseminated metastases.

Only 3 (0.07%) of the 4,218 chest x-rays showed pulmonary metastases that were amenable to resection, said Dr. Brown. He invited the audience to extrapolate, pointing out that 1,406 chest x-rays were required to find a single resectable pulmonary metastasis. "Or conversely, 412 patients that you screen yearly for 74 months," he said.

Dr. Brown noted that the ideal screening test is noninvasive, low cost, and widely available, and has high sensitivity and specificity. It also must have potential for therapeutic benefit. A chest x-ray has "terrible" sensitivity and little therapeutic potential, he said.

Discussant Dr. Margo Shoup of Loyola University Medical Center in Maywood, Ill., asked Dr. Brown whether these findings have altered his practice in Louisville.

"Practice in multidisciplinary settings varies widely," said Dr. Brown. "Among our surgeons, we do not routinely perform chest x-ray imaging, LDH, or really anything other than physical exams. We rely heavily on patient education, and we see our patients about every 6 months for the first 1-5 years," he said. "Our medical colleagues use PET and CT liberally, without proven benefit, especially with the lack of effective systemic therapies."

Dr. Brown disclosed that the Sunbelt Melanoma Trial was supported by a grant from Schering Oncology/Biotech.

Major Finding: Targeted ultrasound has 100% sensitivity in evaluating women 30–39 years of age presenting with focal breast signs or symptoms.

Data Source: Two retrospective studies of data involving more than 1,000 breast lesions each.

Disclosures: Both studies were funded by the University of Washington. Dr. Lehman disclosed work as an instructor with General Electric Co. Dr. Portillo said he had nothing to disclose.

CHICAGO — Women younger than 40 years with focal breast signs or symptoms should be evaluated by targeted ultrasound, and probably not mammography or biopsy, according to findings from two studies of more than 1,800 patients treated at one medical center.

“This is particularly timely with the recent [U.S. Preventive Services Task Force] recommendations that women not perform [breast self-exam],” said Dr. Constance Lehman of the University of Washington in Seattle.

“One of the USPSTF's concerns was that women will go through unnecessary harms and procedures. We think imaging can better guide us in reducing harms that can be associated with a [breast self-exam].”

The studies' findings could have broad implications for practice patterns and cost. Reducing biopsies and surgical excision of lumps would lessen trauma and cost, while limiting mammography would reduce cost and unnecessary radiation.

Dr. Lehman described the two studies in a press briefing at the annual meeting of the Radiological Society of North America. Both were retrospective studies of data from the University of Washington.

In the first, investigators reviewed all breast exams performed on women under age 30 from Feb. 1, 2002, to Aug. 30, 2006, and found 1,091 lesions in 830 patients. Three malignancies were found, and all were identified as suspicious by ultrasound. No malignancy was found in any patient with a negative, benign, or probably benign ultrasound.

The rate of biopsy was high, and the yield was low. For example, a third (46/140, 33%) of patients with a Breast Imaging Reporting and Data System (BIRADS) 3 lesion (probably benign) underwent tissue sampling, and none of these lesions was found to be malignant.

The authors concluded that mammography was not indicated in this setting, and that close surveillance might be a preferred alternative to tissue sampling.

The second study, which included women aged 30–39 years, also found ultrasound to have 100% sensitivity. In this study, investigators reviewed 1,327 lesions in 1,032 patients, finding that 98% (1,301/1,327) were benign and 2% (26/1,327) were malignant.

Ultrasound and mammography had been used to evaluate 91% (1,207/1,327) of cases, yet all cancers at the site of clinical concern were detected by ultrasound and none by mammography alone.

In a solitary case (1/1,327, 0.08%), mammography resulted in detection of a malignancy in an asymptomatic area.

The authors concluded that ultrasound has 100% sensitivity in evaluating women 30–39 years of age presenting with focal signs or symptoms.

“The added value of mammography in this setting is less apparent,” Dr. Lehman said. “It did help one woman who had an area of cancer identified in another region of the breast, but in all other women, there was no added value of the mammogram.”

In answer to a question from the audience, Dr. Lehman said that ultrasound is recommended as a diagnostic tool and not as a screening tool.

“We strongly recommend women have screening mammography annually, at age 40 and older, and if they are shown to be at high risk, that they add MRI to that. We don't recommend ultrasound as a screening tool,” she said, because the specificity of ultrasound is low.

At the scientific session, Dr. Michael Portillo, one of Dr. Lehman's coauthors, was asked whether his institution had changed its practice in the wake of this study. “At this point we're still following the [American College of Radiology guidelines], but we are currently considering changing our practice,” said Dr. Portillo, who worked on the project while a fellow at the University of Washington.

Coauthors (from left) Dr. Constance Lehman, Dr. Michael Portillo, and Dr. Vilert Loving “don't recommend ultrasound” as a screen.

Source Richard Hyer/Elsevier Global Medical News

Major Finding: Targeted ultrasound has 100% sensitivity in evaluating women 30–39 years of age presenting with focal breast signs or symptoms.

Data Source: Two retrospective studies of data involving more than 1,000 breast lesions each.

Disclosures: Both studies were funded by the University of Washington. Dr. Lehman disclosed work as an instructor with General Electric Co. Dr. Portillo said he had nothing to disclose.

CHICAGO — Women younger than 40 years with focal breast signs or symptoms should be evaluated by targeted ultrasound, and probably not mammography or biopsy, according to findings from two studies of more than 1,800 patients treated at one medical center.

“This is particularly timely with the recent [U.S. Preventive Services Task Force] recommendations that women not perform [breast self-exam],” said Dr. Constance Lehman of the University of Washington in Seattle.

“One of the USPSTF's concerns was that women will go through unnecessary harms and procedures. We think imaging can better guide us in reducing harms that can be associated with a [breast self-exam].”

The studies' findings could have broad implications for practice patterns and cost. Reducing biopsies and surgical excision of lumps would lessen trauma and cost, while limiting mammography would reduce cost and unnecessary radiation.

Dr. Lehman described the two studies in a press briefing at the annual meeting of the Radiological Society of North America. Both were retrospective studies of data from the University of Washington.

In the first, investigators reviewed all breast exams performed on women under age 30 from Feb. 1, 2002, to Aug. 30, 2006, and found 1,091 lesions in 830 patients. Three malignancies were found, and all were identified as suspicious by ultrasound. No malignancy was found in any patient with a negative, benign, or probably benign ultrasound.

The rate of biopsy was high, and the yield was low. For example, a third (46/140, 33%) of patients with a Breast Imaging Reporting and Data System (BIRADS) 3 lesion (probably benign) underwent tissue sampling, and none of these lesions was found to be malignant.

The authors concluded that mammography was not indicated in this setting, and that close surveillance might be a preferred alternative to tissue sampling.

The second study, which included women aged 30–39 years, also found ultrasound to have 100% sensitivity. In this study, investigators reviewed 1,327 lesions in 1,032 patients, finding that 98% (1,301/1,327) were benign and 2% (26/1,327) were malignant.

Ultrasound and mammography had been used to evaluate 91% (1,207/1,327) of cases, yet all cancers at the site of clinical concern were detected by ultrasound and none by mammography alone.

In a solitary case (1/1,327, 0.08%), mammography resulted in detection of a malignancy in an asymptomatic area.

The authors concluded that ultrasound has 100% sensitivity in evaluating women 30–39 years of age presenting with focal signs or symptoms.

“The added value of mammography in this setting is less apparent,” Dr. Lehman said. “It did help one woman who had an area of cancer identified in another region of the breast, but in all other women, there was no added value of the mammogram.”

In answer to a question from the audience, Dr. Lehman said that ultrasound is recommended as a diagnostic tool and not as a screening tool.

“We strongly recommend women have screening mammography annually, at age 40 and older, and if they are shown to be at high risk, that they add MRI to that. We don't recommend ultrasound as a screening tool,” she said, because the specificity of ultrasound is low.

At the scientific session, Dr. Michael Portillo, one of Dr. Lehman's coauthors, was asked whether his institution had changed its practice in the wake of this study. “At this point we're still following the [American College of Radiology guidelines], but we are currently considering changing our practice,” said Dr. Portillo, who worked on the project while a fellow at the University of Washington.

Coauthors (from left) Dr. Constance Lehman, Dr. Michael Portillo, and Dr. Vilert Loving “don't recommend ultrasound” as a screen.

Source Richard Hyer/Elsevier Global Medical News

Major Finding: Targeted ultrasound has 100% sensitivity in evaluating women 30–39 years of age presenting with focal breast signs or symptoms.

Data Source: Two retrospective studies of data involving more than 1,000 breast lesions each.

Disclosures: Both studies were funded by the University of Washington. Dr. Lehman disclosed work as an instructor with General Electric Co. Dr. Portillo said he had nothing to disclose.

CHICAGO — Women younger than 40 years with focal breast signs or symptoms should be evaluated by targeted ultrasound, and probably not mammography or biopsy, according to findings from two studies of more than 1,800 patients treated at one medical center.

“This is particularly timely with the recent [U.S. Preventive Services Task Force] recommendations that women not perform [breast self-exam],” said Dr. Constance Lehman of the University of Washington in Seattle.

“One of the USPSTF's concerns was that women will go through unnecessary harms and procedures. We think imaging can better guide us in reducing harms that can be associated with a [breast self-exam].”

The studies' findings could have broad implications for practice patterns and cost. Reducing biopsies and surgical excision of lumps would lessen trauma and cost, while limiting mammography would reduce cost and unnecessary radiation.

Dr. Lehman described the two studies in a press briefing at the annual meeting of the Radiological Society of North America. Both were retrospective studies of data from the University of Washington.

In the first, investigators reviewed all breast exams performed on women under age 30 from Feb. 1, 2002, to Aug. 30, 2006, and found 1,091 lesions in 830 patients. Three malignancies were found, and all were identified as suspicious by ultrasound. No malignancy was found in any patient with a negative, benign, or probably benign ultrasound.

The rate of biopsy was high, and the yield was low. For example, a third (46/140, 33%) of patients with a Breast Imaging Reporting and Data System (BIRADS) 3 lesion (probably benign) underwent tissue sampling, and none of these lesions was found to be malignant.

The authors concluded that mammography was not indicated in this setting, and that close surveillance might be a preferred alternative to tissue sampling.

The second study, which included women aged 30–39 years, also found ultrasound to have 100% sensitivity. In this study, investigators reviewed 1,327 lesions in 1,032 patients, finding that 98% (1,301/1,327) were benign and 2% (26/1,327) were malignant.

Ultrasound and mammography had been used to evaluate 91% (1,207/1,327) of cases, yet all cancers at the site of clinical concern were detected by ultrasound and none by mammography alone.

In a solitary case (1/1,327, 0.08%), mammography resulted in detection of a malignancy in an asymptomatic area.

The authors concluded that ultrasound has 100% sensitivity in evaluating women 30–39 years of age presenting with focal signs or symptoms.

“The added value of mammography in this setting is less apparent,” Dr. Lehman said. “It did help one woman who had an area of cancer identified in another region of the breast, but in all other women, there was no added value of the mammogram.”

In answer to a question from the audience, Dr. Lehman said that ultrasound is recommended as a diagnostic tool and not as a screening tool.

“We strongly recommend women have screening mammography annually, at age 40 and older, and if they are shown to be at high risk, that they add MRI to that. We don't recommend ultrasound as a screening tool,” she said, because the specificity of ultrasound is low.

At the scientific session, Dr. Michael Portillo, one of Dr. Lehman's coauthors, was asked whether his institution had changed its practice in the wake of this study. “At this point we're still following the [American College of Radiology guidelines], but we are currently considering changing our practice,” said Dr. Portillo, who worked on the project while a fellow at the University of Washington.

Coauthors (from left) Dr. Constance Lehman, Dr. Michael Portillo, and Dr. Vilert Loving “don't recommend ultrasound” as a screen.

Source Richard Hyer/Elsevier Global Medical News

CHICAGO — The Framingham Heart Study risk algorithm fails to identify a significant number of individuals at high risk of coronary heart disease, and its accuracy could be improved significantly by integrating coronary calcium scoring, according to a new study from the Netherlands.

“Coronary calcium scoring, detected by computed tomography, is a promising way to improve cardiovascular risk prediction. Population-based studies have shown that the calcium score is a strong predictor of coronary events,” said Rozemarijn Vliegenthart Proença, Ph.D., of University Medical Center Groningen (the Netherlands).

This 7-year-long study of 2,038 patients, conducted at the medical center, is supported by outcomes data demonstrating that nearly two-thirds of patients who would be classified as intermediate risk should actually be reclassified as having either high or low risk. Dr. Vliegenthart Proença presented the data here at the annual meeting of the Radiological Society of North America.

The study questioned whether adding the calcium score to known cardiovascular risk factors would actually improve risk classification in the population.

The imaging analysis was embedded into the population-based Rotterdam Study, and 2,038 individuals aged 55–85 years were invited to participate.

“We assessed as clinical outcome coronary heart disease comprising nonfatal myocardial infarction, [coronary heart disease] mortality, coronary artery bypass grafting, and percutaneous coronary interventions,” Dr. Vliegenthart Proença said. Coronary calcification was measured by electron beam tomography, and Agatson's method was used to calculate calcium scores.

Investigators created two prediction models: one with variables of the Framingham risk score, fitted to this patient population, and the other including the calcium score. Risk estimates for coronary events were extrapolated to 10 years, the common time horizon for predicting cardiovascular risk.

“Then we calculated reclassification percentages to assess what the actual effect is of adding the calcium score to risk factors. Finally we compared the predicted risk, in the different categories, to the actually observed risk,” Dr. Vliegenthart Proença said.

Patients had a mean age of 70 years, and 1,171 (57%) were women. During the course of the study, 84 men and 45 women had a coronary event.

An elevated calcium score corresponded to significantly increased risk of events. Men with a calcium score over 400 had a sevenfold increased risk, compared with men who had a calcium score of 0–10. “When we adjusted for cardiovascular risk factors, these relative risks did not materially change,” Dr. Vliegenthart Proença said.

The strong association between the amount of coronary calcification and the risk of coronary heart disease was evident in the women's cohort as well.

When the calcium score was included with the Framingham risk score, almost 30% migrated to different risk categories. Reclassification was most prominent in the intermediate Framingham risk category, where nearly two-thirds of men and women were reclassified as either lower or higher risk.

According to Dr. Vliegenthart Proença, this was one of the study's strengths.

“Reclassification was based on the actual events. The observed risk in the different categories were calculated on the basis of our risk model, our prediction model, and on the basis of the actual events occurring in the different risk categories.”

An audience member questioned whether the Netherlands has used this data to change treatment recommendations.

“Actually, that is work in progress. At this moment there is no screening for coronary calcium in the Dutch population,” Dr. Vliegenthart Proença explained.

Session moderator Dr. Frank John Rybicki III of Harvard Medical School, Boston, agreed.

“This was an important study because it used actual patient outcomes with a follow-up of almost 7 years to then reclassify risk, integrating calcium score into the traditional methods of risk, which is the Framingham model. And it showed with outcomes that there is a positive influence integrating calcium with those more traditional risk factors. It pretty specifically shows that integration of the calcium score has a very high chance of being beneficial in determining one's overall risk.”

In a separate presentation, Dr. Vliegenthart Proença argued for noninvasive cardiac imaging of asymptomatic patients with peripheral arterial disease. A randomized, controlled trial of 231 such patients at her institution found that one in five were indicated for coronary revascularization.

Dr. Rybicki did not find this surprising. “A fifth of patients with peripheral arterial disease are also going to have significant coronary disease. We expect that. The main finding that 20% of those patients actually have severe coronary disease is interesting and important to demonstrate, but not particularly surprising.”

The studies were sponsored by University Medical Center Groningen.

Dr. Vliegenthart Proença reported having no potential inancial conflicts of interest.

Including the calcium score moved 30% of patients to different risk categories.

Source DR. VLIEGENTHART PROENÇA

CHICAGO — The Framingham Heart Study risk algorithm fails to identify a significant number of individuals at high risk of coronary heart disease, and its accuracy could be improved significantly by integrating coronary calcium scoring, according to a new study from the Netherlands.

“Coronary calcium scoring, detected by computed tomography, is a promising way to improve cardiovascular risk prediction. Population-based studies have shown that the calcium score is a strong predictor of coronary events,” said Rozemarijn Vliegenthart Proença, Ph.D., of University Medical Center Groningen (the Netherlands).

This 7-year-long study of 2,038 patients, conducted at the medical center, is supported by outcomes data demonstrating that nearly two-thirds of patients who would be classified as intermediate risk should actually be reclassified as having either high or low risk. Dr. Vliegenthart Proença presented the data here at the annual meeting of the Radiological Society of North America.

The study questioned whether adding the calcium score to known cardiovascular risk factors would actually improve risk classification in the population.

The imaging analysis was embedded into the population-based Rotterdam Study, and 2,038 individuals aged 55–85 years were invited to participate.

“We assessed as clinical outcome coronary heart disease comprising nonfatal myocardial infarction, [coronary heart disease] mortality, coronary artery bypass grafting, and percutaneous coronary interventions,” Dr. Vliegenthart Proença said. Coronary calcification was measured by electron beam tomography, and Agatson's method was used to calculate calcium scores.

Investigators created two prediction models: one with variables of the Framingham risk score, fitted to this patient population, and the other including the calcium score. Risk estimates for coronary events were extrapolated to 10 years, the common time horizon for predicting cardiovascular risk.

“Then we calculated reclassification percentages to assess what the actual effect is of adding the calcium score to risk factors. Finally we compared the predicted risk, in the different categories, to the actually observed risk,” Dr. Vliegenthart Proença said.

Patients had a mean age of 70 years, and 1,171 (57%) were women. During the course of the study, 84 men and 45 women had a coronary event.

An elevated calcium score corresponded to significantly increased risk of events. Men with a calcium score over 400 had a sevenfold increased risk, compared with men who had a calcium score of 0–10. “When we adjusted for cardiovascular risk factors, these relative risks did not materially change,” Dr. Vliegenthart Proença said.

The strong association between the amount of coronary calcification and the risk of coronary heart disease was evident in the women's cohort as well.

When the calcium score was included with the Framingham risk score, almost 30% migrated to different risk categories. Reclassification was most prominent in the intermediate Framingham risk category, where nearly two-thirds of men and women were reclassified as either lower or higher risk.

According to Dr. Vliegenthart Proença, this was one of the study's strengths.

“Reclassification was based on the actual events. The observed risk in the different categories were calculated on the basis of our risk model, our prediction model, and on the basis of the actual events occurring in the different risk categories.”

An audience member questioned whether the Netherlands has used this data to change treatment recommendations.

“Actually, that is work in progress. At this moment there is no screening for coronary calcium in the Dutch population,” Dr. Vliegenthart Proença explained.

Session moderator Dr. Frank John Rybicki III of Harvard Medical School, Boston, agreed.

“This was an important study because it used actual patient outcomes with a follow-up of almost 7 years to then reclassify risk, integrating calcium score into the traditional methods of risk, which is the Framingham model. And it showed with outcomes that there is a positive influence integrating calcium with those more traditional risk factors. It pretty specifically shows that integration of the calcium score has a very high chance of being beneficial in determining one's overall risk.”

In a separate presentation, Dr. Vliegenthart Proença argued for noninvasive cardiac imaging of asymptomatic patients with peripheral arterial disease. A randomized, controlled trial of 231 such patients at her institution found that one in five were indicated for coronary revascularization.

Dr. Rybicki did not find this surprising. “A fifth of patients with peripheral arterial disease are also going to have significant coronary disease. We expect that. The main finding that 20% of those patients actually have severe coronary disease is interesting and important to demonstrate, but not particularly surprising.”

The studies were sponsored by University Medical Center Groningen.

Dr. Vliegenthart Proença reported having no potential inancial conflicts of interest.

Including the calcium score moved 30% of patients to different risk categories.

Source DR. VLIEGENTHART PROENÇA

CHICAGO — The Framingham Heart Study risk algorithm fails to identify a significant number of individuals at high risk of coronary heart disease, and its accuracy could be improved significantly by integrating coronary calcium scoring, according to a new study from the Netherlands.

“Coronary calcium scoring, detected by computed tomography, is a promising way to improve cardiovascular risk prediction. Population-based studies have shown that the calcium score is a strong predictor of coronary events,” said Rozemarijn Vliegenthart Proença, Ph.D., of University Medical Center Groningen (the Netherlands).

This 7-year-long study of 2,038 patients, conducted at the medical center, is supported by outcomes data demonstrating that nearly two-thirds of patients who would be classified as intermediate risk should actually be reclassified as having either high or low risk. Dr. Vliegenthart Proença presented the data here at the annual meeting of the Radiological Society of North America.

The study questioned whether adding the calcium score to known cardiovascular risk factors would actually improve risk classification in the population.

The imaging analysis was embedded into the population-based Rotterdam Study, and 2,038 individuals aged 55–85 years were invited to participate.

“We assessed as clinical outcome coronary heart disease comprising nonfatal myocardial infarction, [coronary heart disease] mortality, coronary artery bypass grafting, and percutaneous coronary interventions,” Dr. Vliegenthart Proença said. Coronary calcification was measured by electron beam tomography, and Agatson's method was used to calculate calcium scores.

Investigators created two prediction models: one with variables of the Framingham risk score, fitted to this patient population, and the other including the calcium score. Risk estimates for coronary events were extrapolated to 10 years, the common time horizon for predicting cardiovascular risk.

“Then we calculated reclassification percentages to assess what the actual effect is of adding the calcium score to risk factors. Finally we compared the predicted risk, in the different categories, to the actually observed risk,” Dr. Vliegenthart Proença said.

Patients had a mean age of 70 years, and 1,171 (57%) were women. During the course of the study, 84 men and 45 women had a coronary event.

An elevated calcium score corresponded to significantly increased risk of events. Men with a calcium score over 400 had a sevenfold increased risk, compared with men who had a calcium score of 0–10. “When we adjusted for cardiovascular risk factors, these relative risks did not materially change,” Dr. Vliegenthart Proença said.

The strong association between the amount of coronary calcification and the risk of coronary heart disease was evident in the women's cohort as well.

When the calcium score was included with the Framingham risk score, almost 30% migrated to different risk categories. Reclassification was most prominent in the intermediate Framingham risk category, where nearly two-thirds of men and women were reclassified as either lower or higher risk.

According to Dr. Vliegenthart Proença, this was one of the study's strengths.

“Reclassification was based on the actual events. The observed risk in the different categories were calculated on the basis of our risk model, our prediction model, and on the basis of the actual events occurring in the different risk categories.”

An audience member questioned whether the Netherlands has used this data to change treatment recommendations.

“Actually, that is work in progress. At this moment there is no screening for coronary calcium in the Dutch population,” Dr. Vliegenthart Proença explained.

Session moderator Dr. Frank John Rybicki III of Harvard Medical School, Boston, agreed.

“This was an important study because it used actual patient outcomes with a follow-up of almost 7 years to then reclassify risk, integrating calcium score into the traditional methods of risk, which is the Framingham model. And it showed with outcomes that there is a positive influence integrating calcium with those more traditional risk factors. It pretty specifically shows that integration of the calcium score has a very high chance of being beneficial in determining one's overall risk.”

In a separate presentation, Dr. Vliegenthart Proença argued for noninvasive cardiac imaging of asymptomatic patients with peripheral arterial disease. A randomized, controlled trial of 231 such patients at her institution found that one in five were indicated for coronary revascularization.

Dr. Rybicki did not find this surprising. “A fifth of patients with peripheral arterial disease are also going to have significant coronary disease. We expect that. The main finding that 20% of those patients actually have severe coronary disease is interesting and important to demonstrate, but not particularly surprising.”

The studies were sponsored by University Medical Center Groningen.

Dr. Vliegenthart Proença reported having no potential inancial conflicts of interest.

Including the calcium score moved 30% of patients to different risk categories.

Source DR. VLIEGENTHART PROENÇA

CHICAGO — Women younger than 40 years with focal breast signs or symptoms should be evaluated by targeted ultrasound, and probably not mammography or biopsy, according to findings from two studies of more than 1,800 patients treated at one medical center.

“This is particularly timely with the recent [U.S. Preventive Services Task Force] recommendations that women not perform self–breast exam,” said Dr. Constance Lehman of the University of Washington in Seattle.

“One of the USPSTF's concerns was that women will go through unnecessary harms and procedures. We think imaging can better guide us in reducing harms that can be associated with a self–breast exam.”

The studies' findings could have broad implications for practice patterns and cost. Reducing biopsies and surgical excision of lumps would lessen trauma and cost, while limiting mammography would reduce cost and unnecessary radiation.

Dr. Lehman described the two studies in a press briefing at the annual meeting of the Radiological Society of North America. Both were retrospective reviews of data from the University of Washington.

In the first analysis, investigators reviewed all breast exams performed on women under age 30 from Feb. 1, 2002, to Aug. 30, 2006, and found 1,091 lesions in 830 patients. Three malignancies were found, and all were identified as suspicious by ultrasound. No malignancy was found in any patient with a negative, benign, or probably benign ultrasound.

The rate of biopsy was high, and the yield was low. For example, a third (46/140, 33%) of patients with a Breast Imaging–Reporting and Data System (BI-RADS) 3 lesion (probably benign) underwent tissue sampling, and none of these lesions was found to be malignant.

The authors concluded that mammography was not indicated in this setting, and that close surveillance might be a preferred alternative to tissue sampling.

The second study, which included women aged 30–39 years, also found ultrasound to have 100% sensitivity. In this study, investigators reviewed 1,327 lesions in 1,032 patients, finding that 98% (1,301/1,327) were benign and 2% (26/1,327) were malignant. Ultrasound and mammography had been used to evaluate 91% (1,207/1,327) of cases, yet all cancers at the site of clinical concern were detected by ultrasound and none by mammography alone.

In a solitary case (1/1,327, 0.08%), mammography resulted in detection of a malignancy in an asymptomatic area.

The authors concluded that ultrasound has 100% sensitivity in evaluating women 30–39 years of age presenting with focal signs or symptoms.

“The added value of mammography in this setting is less apparent,” Dr. Lehman said. “It did help one woman who had an area of cancer identified in another region of the breast, but in all other women, there was no added value.”

In answer to a question from the audience, Dr. Lehman said that ultrasound is recommended as a diagnostic tool and not as a screening tool.

“We strongly recommend women have screening mammography annually, age 40 and older, and if they are shown to be at high risk, that they add MRI to that. We don't recommend ultrasound as a screening tool,” she said, because the specificity of ultrasound is low.

At the scientific session, Dr. Michael Portillo, one of Dr. Lehman's coauthors, was asked whether his institution had changed its practice in the wake of this study. “At this point we're still following the [American College of Radiology guidelines], but we are currently considering changing our practice,” said Dr. Portillo, who worked on the project while a fellow at the University of Washington.

Disclosures: Both studies were funded by the University of Washington. Dr. Lehman disclosed work as an instructor with General Electric Co. Dr. Portillo had nothing to disclose.

Coauthors (from left) Dr. Constance Lehman, Dr. Michael Portillo, and Dr. Vilert Loving “don't recommend ultrasound” as a screen.

Source Richard Hyer/Elsevier Global Medical News

CHICAGO — Women younger than 40 years with focal breast signs or symptoms should be evaluated by targeted ultrasound, and probably not mammography or biopsy, according to findings from two studies of more than 1,800 patients treated at one medical center.

“This is particularly timely with the recent [U.S. Preventive Services Task Force] recommendations that women not perform self–breast exam,” said Dr. Constance Lehman of the University of Washington in Seattle.

“One of the USPSTF's concerns was that women will go through unnecessary harms and procedures. We think imaging can better guide us in reducing harms that can be associated with a self–breast exam.”

The studies' findings could have broad implications for practice patterns and cost. Reducing biopsies and surgical excision of lumps would lessen trauma and cost, while limiting mammography would reduce cost and unnecessary radiation.

Dr. Lehman described the two studies in a press briefing at the annual meeting of the Radiological Society of North America. Both were retrospective reviews of data from the University of Washington.

In the first analysis, investigators reviewed all breast exams performed on women under age 30 from Feb. 1, 2002, to Aug. 30, 2006, and found 1,091 lesions in 830 patients. Three malignancies were found, and all were identified as suspicious by ultrasound. No malignancy was found in any patient with a negative, benign, or probably benign ultrasound.

The rate of biopsy was high, and the yield was low. For example, a third (46/140, 33%) of patients with a Breast Imaging–Reporting and Data System (BI-RADS) 3 lesion (probably benign) underwent tissue sampling, and none of these lesions was found to be malignant.

The authors concluded that mammography was not indicated in this setting, and that close surveillance might be a preferred alternative to tissue sampling.

The second study, which included women aged 30–39 years, also found ultrasound to have 100% sensitivity. In this study, investigators reviewed 1,327 lesions in 1,032 patients, finding that 98% (1,301/1,327) were benign and 2% (26/1,327) were malignant. Ultrasound and mammography had been used to evaluate 91% (1,207/1,327) of cases, yet all cancers at the site of clinical concern were detected by ultrasound and none by mammography alone.

In a solitary case (1/1,327, 0.08%), mammography resulted in detection of a malignancy in an asymptomatic area.

The authors concluded that ultrasound has 100% sensitivity in evaluating women 30–39 years of age presenting with focal signs or symptoms.

“The added value of mammography in this setting is less apparent,” Dr. Lehman said. “It did help one woman who had an area of cancer identified in another region of the breast, but in all other women, there was no added value.”

In answer to a question from the audience, Dr. Lehman said that ultrasound is recommended as a diagnostic tool and not as a screening tool.

“We strongly recommend women have screening mammography annually, age 40 and older, and if they are shown to be at high risk, that they add MRI to that. We don't recommend ultrasound as a screening tool,” she said, because the specificity of ultrasound is low.

At the scientific session, Dr. Michael Portillo, one of Dr. Lehman's coauthors, was asked whether his institution had changed its practice in the wake of this study. “At this point we're still following the [American College of Radiology guidelines], but we are currently considering changing our practice,” said Dr. Portillo, who worked on the project while a fellow at the University of Washington.

Disclosures: Both studies were funded by the University of Washington. Dr. Lehman disclosed work as an instructor with General Electric Co. Dr. Portillo had nothing to disclose.

Coauthors (from left) Dr. Constance Lehman, Dr. Michael Portillo, and Dr. Vilert Loving “don't recommend ultrasound” as a screen.

Source Richard Hyer/Elsevier Global Medical News

CHICAGO — Women younger than 40 years with focal breast signs or symptoms should be evaluated by targeted ultrasound, and probably not mammography or biopsy, according to findings from two studies of more than 1,800 patients treated at one medical center.

“This is particularly timely with the recent [U.S. Preventive Services Task Force] recommendations that women not perform self–breast exam,” said Dr. Constance Lehman of the University of Washington in Seattle.

“One of the USPSTF's concerns was that women will go through unnecessary harms and procedures. We think imaging can better guide us in reducing harms that can be associated with a self–breast exam.”

The studies' findings could have broad implications for practice patterns and cost. Reducing biopsies and surgical excision of lumps would lessen trauma and cost, while limiting mammography would reduce cost and unnecessary radiation.

Dr. Lehman described the two studies in a press briefing at the annual meeting of the Radiological Society of North America. Both were retrospective reviews of data from the University of Washington.

In the first analysis, investigators reviewed all breast exams performed on women under age 30 from Feb. 1, 2002, to Aug. 30, 2006, and found 1,091 lesions in 830 patients. Three malignancies were found, and all were identified as suspicious by ultrasound. No malignancy was found in any patient with a negative, benign, or probably benign ultrasound.

The rate of biopsy was high, and the yield was low. For example, a third (46/140, 33%) of patients with a Breast Imaging–Reporting and Data System (BI-RADS) 3 lesion (probably benign) underwent tissue sampling, and none of these lesions was found to be malignant.

The authors concluded that mammography was not indicated in this setting, and that close surveillance might be a preferred alternative to tissue sampling.

The second study, which included women aged 30–39 years, also found ultrasound to have 100% sensitivity. In this study, investigators reviewed 1,327 lesions in 1,032 patients, finding that 98% (1,301/1,327) were benign and 2% (26/1,327) were malignant. Ultrasound and mammography had been used to evaluate 91% (1,207/1,327) of cases, yet all cancers at the site of clinical concern were detected by ultrasound and none by mammography alone.

In a solitary case (1/1,327, 0.08%), mammography resulted in detection of a malignancy in an asymptomatic area.

The authors concluded that ultrasound has 100% sensitivity in evaluating women 30–39 years of age presenting with focal signs or symptoms.

“The added value of mammography in this setting is less apparent,” Dr. Lehman said. “It did help one woman who had an area of cancer identified in another region of the breast, but in all other women, there was no added value.”

In answer to a question from the audience, Dr. Lehman said that ultrasound is recommended as a diagnostic tool and not as a screening tool.

“We strongly recommend women have screening mammography annually, age 40 and older, and if they are shown to be at high risk, that they add MRI to that. We don't recommend ultrasound as a screening tool,” she said, because the specificity of ultrasound is low.

At the scientific session, Dr. Michael Portillo, one of Dr. Lehman's coauthors, was asked whether his institution had changed its practice in the wake of this study. “At this point we're still following the [American College of Radiology guidelines], but we are currently considering changing our practice,” said Dr. Portillo, who worked on the project while a fellow at the University of Washington.

Disclosures: Both studies were funded by the University of Washington. Dr. Lehman disclosed work as an instructor with General Electric Co. Dr. Portillo had nothing to disclose.

Coauthors (from left) Dr. Constance Lehman, Dr. Michael Portillo, and Dr. Vilert Loving “don't recommend ultrasound” as a screen.

Source Richard Hyer/Elsevier Global Medical News

CHICAGO — Percutaneous disc decompression may resolve back pain and weakness caused by a herniated spinal disc, according to a study that compared the minimally invasive procedure with conservative therapy.

However, audience members who heard the study presented at the annual scientific meeting of the Radiological Society of North America said that several important weaknesses of the trial make it difficult to draw any conclusions about the long-term results of the intervention.

In patients who had herniation of an intervertebral disc, Dr. Dimitrios Filippiadis and his associates at Attikon University Hospital in Athens followed two groups of patients from January 2005 to January 2008 after they had received either conservative therapy (conservative treatment with analgesics, anti-inflammatory drugs, muscle relaxants, and physiotherapy for 6 weeks) or fluoroscopically guided percutaneous disc decompression.

Each group comprised 17 men and 14 women with a mean age of 36 years and a history of unsuccessful or incomplete medical treatment with conservative therapy. Each patient underwent magnetic resonance imaging to verify the disc herniation.

During the procedure, “a needle is inserted into the disc and 2–5 g of tissue are removed, diminishing pressure,” study co-author Dr. Alexios Kelekis said at a press conference during the meeting.

The intervention is not without risk, he pointed out. Potential complications include discitis, epidural abscess, reflex sympathetic dystrophy, nerve root injury, and injury to retroperitoneal structures.

Patients measured their pain with a 0–10 visual analog scale. Members of the conservative therapy group started at a mean of 6.87, and their pain declined to 0.9 within one month. The average pain score returned to about 4 by 12 and 24 months.

The percutaneous intervention group started with pain at a mean of 7.40, which declined to 2.96 at the end of one month. By 12 months, this group's pain was at 1.67, and at 24 months, 1.61.

“Initial effect was noted at 3 weeks, and sustained effect at 12 and 24 months. Only five patients—16%—had less than 4 points of pain relief,” said Dr. Kelekis, who is also with Attikon University Hospital.

When audience members asked for more detail about the method of disc decompression, Dr. Filippiadis said that “patients in this study were treated with different instruments available. We believe that all these procedures have similar results. It doesn't matter if you use ablation, laser, ozone, or alcohol gel. All of these procedures accelerate what nature would do in about 4–5 years.”

Dr. Nathalie Bureau, one of the session moderators, expressed concerns about the study.

“It's difficult to take out any conclusion [about the study]. There was a lot of bias in patient selection and methods, and the study didn't treat a very homogenous group of patients. The results were very good, but with those selection criteria, it's hard to derive any conclusions,” said Dr. Bureau of the University of Montreal. “The method wasn't very sound; there was no randomized controlled trial.”

Dr. Bureau also questioned the aggressive intervention. “Are we really proving that we're doing better than conservative treatment? Degenerative disc disease may be accelerated by [surgical intervention].

“It's an interesting study, but there are a lot of questions about the method, so I'm not sure the conclusions are very sound.”

Dr. Kelekis is a teaching consultant for ArthroCare Corp. and for DePuy Spine Inc., a Johnson & Johnson company. The other investigators had no relevant conflicts of interest to disclose.

The study was sponsored by the University of Athens.

The average pain score after 24 months was about 4 for conservative therapy and 1.61 for disc decompression.

Source DR. KELEKIS

This MRI shows a patient's spine prior to undergoing treatment for a herniated disc.

In this image, the spine is seen 1 year after the percutaneous disc decompression.

Source Images courtesy Radiological Society of North America

CHICAGO — Percutaneous disc decompression may resolve back pain and weakness caused by a herniated spinal disc, according to a study that compared the minimally invasive procedure with conservative therapy.

However, audience members who heard the study presented at the annual scientific meeting of the Radiological Society of North America said that several important weaknesses of the trial make it difficult to draw any conclusions about the long-term results of the intervention.

In patients who had herniation of an intervertebral disc, Dr. Dimitrios Filippiadis and his associates at Attikon University Hospital in Athens followed two groups of patients from January 2005 to January 2008 after they had received either conservative therapy (conservative treatment with analgesics, anti-inflammatory drugs, muscle relaxants, and physiotherapy for 6 weeks) or fluoroscopically guided percutaneous disc decompression.

Each group comprised 17 men and 14 women with a mean age of 36 years and a history of unsuccessful or incomplete medical treatment with conservative therapy. Each patient underwent magnetic resonance imaging to verify the disc herniation.

During the procedure, “a needle is inserted into the disc and 2–5 g of tissue are removed, diminishing pressure,” study co-author Dr. Alexios Kelekis said at a press conference during the meeting.

The intervention is not without risk, he pointed out. Potential complications include discitis, epidural abscess, reflex sympathetic dystrophy, nerve root injury, and injury to retroperitoneal structures.

Patients measured their pain with a 0–10 visual analog scale. Members of the conservative therapy group started at a mean of 6.87, and their pain declined to 0.9 within one month. The average pain score returned to about 4 by 12 and 24 months.

The percutaneous intervention group started with pain at a mean of 7.40, which declined to 2.96 at the end of one month. By 12 months, this group's pain was at 1.67, and at 24 months, 1.61.

“Initial effect was noted at 3 weeks, and sustained effect at 12 and 24 months. Only five patients—16%—had less than 4 points of pain relief,” said Dr. Kelekis, who is also with Attikon University Hospital.

When audience members asked for more detail about the method of disc decompression, Dr. Filippiadis said that “patients in this study were treated with different instruments available. We believe that all these procedures have similar results. It doesn't matter if you use ablation, laser, ozone, or alcohol gel. All of these procedures accelerate what nature would do in about 4–5 years.”

Dr. Nathalie Bureau, one of the session moderators, expressed concerns about the study.

“It's difficult to take out any conclusion [about the study]. There was a lot of bias in patient selection and methods, and the study didn't treat a very homogenous group of patients. The results were very good, but with those selection criteria, it's hard to derive any conclusions,” said Dr. Bureau of the University of Montreal. “The method wasn't very sound; there was no randomized controlled trial.”

Dr. Bureau also questioned the aggressive intervention. “Are we really proving that we're doing better than conservative treatment? Degenerative disc disease may be accelerated by [surgical intervention].

“It's an interesting study, but there are a lot of questions about the method, so I'm not sure the conclusions are very sound.”

Dr. Kelekis is a teaching consultant for ArthroCare Corp. and for DePuy Spine Inc., a Johnson & Johnson company. The other investigators had no relevant conflicts of interest to disclose.

The study was sponsored by the University of Athens.

The average pain score after 24 months was about 4 for conservative therapy and 1.61 for disc decompression.

Source DR. KELEKIS

This MRI shows a patient's spine prior to undergoing treatment for a herniated disc.

In this image, the spine is seen 1 year after the percutaneous disc decompression.

Source Images courtesy Radiological Society of North America

CHICAGO — Percutaneous disc decompression may resolve back pain and weakness caused by a herniated spinal disc, according to a study that compared the minimally invasive procedure with conservative therapy.

However, audience members who heard the study presented at the annual scientific meeting of the Radiological Society of North America said that several important weaknesses of the trial make it difficult to draw any conclusions about the long-term results of the intervention.

In patients who had herniation of an intervertebral disc, Dr. Dimitrios Filippiadis and his associates at Attikon University Hospital in Athens followed two groups of patients from January 2005 to January 2008 after they had received either conservative therapy (conservative treatment with analgesics, anti-inflammatory drugs, muscle relaxants, and physiotherapy for 6 weeks) or fluoroscopically guided percutaneous disc decompression.

Each group comprised 17 men and 14 women with a mean age of 36 years and a history of unsuccessful or incomplete medical treatment with conservative therapy. Each patient underwent magnetic resonance imaging to verify the disc herniation.

During the procedure, “a needle is inserted into the disc and 2–5 g of tissue are removed, diminishing pressure,” study co-author Dr. Alexios Kelekis said at a press conference during the meeting.

The intervention is not without risk, he pointed out. Potential complications include discitis, epidural abscess, reflex sympathetic dystrophy, nerve root injury, and injury to retroperitoneal structures.

Patients measured their pain with a 0–10 visual analog scale. Members of the conservative therapy group started at a mean of 6.87, and their pain declined to 0.9 within one month. The average pain score returned to about 4 by 12 and 24 months.

The percutaneous intervention group started with pain at a mean of 7.40, which declined to 2.96 at the end of one month. By 12 months, this group's pain was at 1.67, and at 24 months, 1.61.

“Initial effect was noted at 3 weeks, and sustained effect at 12 and 24 months. Only five patients—16%—had less than 4 points of pain relief,” said Dr. Kelekis, who is also with Attikon University Hospital.

When audience members asked for more detail about the method of disc decompression, Dr. Filippiadis said that “patients in this study were treated with different instruments available. We believe that all these procedures have similar results. It doesn't matter if you use ablation, laser, ozone, or alcohol gel. All of these procedures accelerate what nature would do in about 4–5 years.”

Dr. Nathalie Bureau, one of the session moderators, expressed concerns about the study.

“It's difficult to take out any conclusion [about the study]. There was a lot of bias in patient selection and methods, and the study didn't treat a very homogenous group of patients. The results were very good, but with those selection criteria, it's hard to derive any conclusions,” said Dr. Bureau of the University of Montreal. “The method wasn't very sound; there was no randomized controlled trial.”

Dr. Bureau also questioned the aggressive intervention. “Are we really proving that we're doing better than conservative treatment? Degenerative disc disease may be accelerated by [surgical intervention].

“It's an interesting study, but there are a lot of questions about the method, so I'm not sure the conclusions are very sound.”

Dr. Kelekis is a teaching consultant for ArthroCare Corp. and for DePuy Spine Inc., a Johnson & Johnson company. The other investigators had no relevant conflicts of interest to disclose.

The study was sponsored by the University of Athens.

The average pain score after 24 months was about 4 for conservative therapy and 1.61 for disc decompression.

Source DR. KELEKIS

This MRI shows a patient's spine prior to undergoing treatment for a herniated disc.

In this image, the spine is seen 1 year after the percutaneous disc decompression.

Source Images courtesy Radiological Society of North America

CHICAGO — The Framingham Heart Study risk algorithm fails to identify a significant number of individuals at high risk of coronary heart disease, and its accuracy could be improved significantly by integrating coronary calcium scoring, according to a new study from the Netherlands.

“Coronary calcium scoring, detected by CT, is a promising way to improve cardiovascular risk prediction. Population-based studies have shown that the calcium score is a strong predictor of coronary events,” said Rozemarijn Vliegenthart Proença, Ph.D., of University Medical Center Groningen (the Netherlands).

This 7-year-long study of 2,038 patients, conducted at the medical center, is supported by outcomes data demonstrating that nearly two-thirds of patients who would be classified as intermediate risk should actually be reclassified as either high or low risk. The data were reported at the annual meeting of the Radiological Society of North America.

The study questioned whether adding the calcium score to known cardiovascular risk factors would improve risk classification in the population. It was embedded into the population-based Rotterdam Study, and 2,038 individuals aged 55–85 years were invited to participate.

“We assessed as clinical outcome coronary heart disease comprising nonfatal myocardial infarction, [coronary heart disease] mortality, coronary artery bypass grafting, and percutaneous coronary interventions,” Dr. Vliegenthart Proença said.

Investigators created two prediction models: one with variables of the Framingham risk score, fitted to this patient population, and the other including the calcium score. Risk estimates for coronary events were extrapolated to 10 years, the common time horizon for predicting cardiovascular risk.

“Then we calculated reclassification percentages to assess what the actual effect is of adding the calcium score to risk factors. Finally we compared the predicted risk, in the different categories, to the actually observed risk,” Dr. Vliegenthart Proença said.

Patients had a mean age of 70 years, and 1,171 (57%) were women. During the course of the study, 84 men and 45 women had a coronary event.

An elevated calcium score corresponded to significantly increased risk of events. Men with a calcium score over 400 had a sevenfold increased risk, compared with men who had a calcium score of 0–10. “When we adjusted for cardiovascular risk factors, these relative risks did not materially change,” Dr. Vliegenthart Proença said.

The strong association between the amount of coronary calcification and the risk of coronary heart disease was evident in the women's cohort as well.

When the calcium score was included with the Framingham risk score, almost 30% migrated to different risk categories. Reclassification was most prominent in the intermediate Framingham risk category, where nearly two-thirds of men and women were reclassified as either lower or higher risk.

According to Dr. Vliegenthart Proença, this was one of the study's strengths. “Reclassification was based on the actual events. The observed risk in the different categories were calculated on the basis of our risk model, our prediction model, and on the basis of the actual events occurring in the different risk categories.”

A member of the audience questioned whether the Netherlands has used this data to change treatment recommendations.

“Actually, that's work in progress. At this moment there is no screening for coronary calcium in the Dutch population,” Dr. Vliegenthart Proença said.

Session moderator Dr. Frank John Rybicki III of Harvard Medical School, Boston, agreed.

“This was an important study because it used actual patient outcomes with a follow-up of almost 7 years to then reclassify risk, integrating calcium score into the traditional methods of risk, which is the Framingham model. And it showed with outcomes that there is a positive influence integrating calcium with those more traditional risk factors. It pretty specifically shows that integration of the calcium score has a very high chance of being beneficial in determining one's overall risk,” he said.

In a separate presentation, Dr. Vliegenthart Proença argued for noninvasive cardiac imaging of asymptomatic patients with peripheral arterial disease. A randomized, controlled trial of 231 such patients at her institution found that one in five were indicated for coronary revascularization.

Dr. Rybicki did not find this surprising. “A fifth of patients with peripheral arterial disease are also going to have significant coronary disease. We expect that.”

The studies were sponsored by University Medical Center Groningen.

Dr. Vliegenthart Proença had nothing to disclose.

Studies have shown that the calcium score is a strong predictor of coronary events.

Source DR. VLIEGENTHART PROENÇA

CHICAGO — The Framingham Heart Study risk algorithm fails to identify a significant number of individuals at high risk of coronary heart disease, and its accuracy could be improved significantly by integrating coronary calcium scoring, according to a new study from the Netherlands.

“Coronary calcium scoring, detected by CT, is a promising way to improve cardiovascular risk prediction. Population-based studies have shown that the calcium score is a strong predictor of coronary events,” said Rozemarijn Vliegenthart Proença, Ph.D., of University Medical Center Groningen (the Netherlands).

This 7-year-long study of 2,038 patients, conducted at the medical center, is supported by outcomes data demonstrating that nearly two-thirds of patients who would be classified as intermediate risk should actually be reclassified as either high or low risk. The data were reported at the annual meeting of the Radiological Society of North America.

The study questioned whether adding the calcium score to known cardiovascular risk factors would improve risk classification in the population. It was embedded into the population-based Rotterdam Study, and 2,038 individuals aged 55–85 years were invited to participate.

“We assessed as clinical outcome coronary heart disease comprising nonfatal myocardial infarction, [coronary heart disease] mortality, coronary artery bypass grafting, and percutaneous coronary interventions,” Dr. Vliegenthart Proença said.

Investigators created two prediction models: one with variables of the Framingham risk score, fitted to this patient population, and the other including the calcium score. Risk estimates for coronary events were extrapolated to 10 years, the common time horizon for predicting cardiovascular risk.

“Then we calculated reclassification percentages to assess what the actual effect is of adding the calcium score to risk factors. Finally we compared the predicted risk, in the different categories, to the actually observed risk,” Dr. Vliegenthart Proença said.

Patients had a mean age of 70 years, and 1,171 (57%) were women. During the course of the study, 84 men and 45 women had a coronary event.

An elevated calcium score corresponded to significantly increased risk of events. Men with a calcium score over 400 had a sevenfold increased risk, compared with men who had a calcium score of 0–10. “When we adjusted for cardiovascular risk factors, these relative risks did not materially change,” Dr. Vliegenthart Proença said.

The strong association between the amount of coronary calcification and the risk of coronary heart disease was evident in the women's cohort as well.

When the calcium score was included with the Framingham risk score, almost 30% migrated to different risk categories. Reclassification was most prominent in the intermediate Framingham risk category, where nearly two-thirds of men and women were reclassified as either lower or higher risk.

According to Dr. Vliegenthart Proença, this was one of the study's strengths. “Reclassification was based on the actual events. The observed risk in the different categories were calculated on the basis of our risk model, our prediction model, and on the basis of the actual events occurring in the different risk categories.”

A member of the audience questioned whether the Netherlands has used this data to change treatment recommendations.

“Actually, that's work in progress. At this moment there is no screening for coronary calcium in the Dutch population,” Dr. Vliegenthart Proença said.

Session moderator Dr. Frank John Rybicki III of Harvard Medical School, Boston, agreed.

“This was an important study because it used actual patient outcomes with a follow-up of almost 7 years to then reclassify risk, integrating calcium score into the traditional methods of risk, which is the Framingham model. And it showed with outcomes that there is a positive influence integrating calcium with those more traditional risk factors. It pretty specifically shows that integration of the calcium score has a very high chance of being beneficial in determining one's overall risk,” he said.

In a separate presentation, Dr. Vliegenthart Proença argued for noninvasive cardiac imaging of asymptomatic patients with peripheral arterial disease. A randomized, controlled trial of 231 such patients at her institution found that one in five were indicated for coronary revascularization.

Dr. Rybicki did not find this surprising. “A fifth of patients with peripheral arterial disease are also going to have significant coronary disease. We expect that.”

The studies were sponsored by University Medical Center Groningen.

Dr. Vliegenthart Proença had nothing to disclose.

Studies have shown that the calcium score is a strong predictor of coronary events.

Source DR. VLIEGENTHART PROENÇA

CHICAGO — The Framingham Heart Study risk algorithm fails to identify a significant number of individuals at high risk of coronary heart disease, and its accuracy could be improved significantly by integrating coronary calcium scoring, according to a new study from the Netherlands.

“Coronary calcium scoring, detected by CT, is a promising way to improve cardiovascular risk prediction. Population-based studies have shown that the calcium score is a strong predictor of coronary events,” said Rozemarijn Vliegenthart Proença, Ph.D., of University Medical Center Groningen (the Netherlands).

This 7-year-long study of 2,038 patients, conducted at the medical center, is supported by outcomes data demonstrating that nearly two-thirds of patients who would be classified as intermediate risk should actually be reclassified as either high or low risk. The data were reported at the annual meeting of the Radiological Society of North America.

The study questioned whether adding the calcium score to known cardiovascular risk factors would improve risk classification in the population. It was embedded into the population-based Rotterdam Study, and 2,038 individuals aged 55–85 years were invited to participate.

“We assessed as clinical outcome coronary heart disease comprising nonfatal myocardial infarction, [coronary heart disease] mortality, coronary artery bypass grafting, and percutaneous coronary interventions,” Dr. Vliegenthart Proença said.

Investigators created two prediction models: one with variables of the Framingham risk score, fitted to this patient population, and the other including the calcium score. Risk estimates for coronary events were extrapolated to 10 years, the common time horizon for predicting cardiovascular risk.

“Then we calculated reclassification percentages to assess what the actual effect is of adding the calcium score to risk factors. Finally we compared the predicted risk, in the different categories, to the actually observed risk,” Dr. Vliegenthart Proença said.

Patients had a mean age of 70 years, and 1,171 (57%) were women. During the course of the study, 84 men and 45 women had a coronary event.

An elevated calcium score corresponded to significantly increased risk of events. Men with a calcium score over 400 had a sevenfold increased risk, compared with men who had a calcium score of 0–10. “When we adjusted for cardiovascular risk factors, these relative risks did not materially change,” Dr. Vliegenthart Proença said.

The strong association between the amount of coronary calcification and the risk of coronary heart disease was evident in the women's cohort as well.

When the calcium score was included with the Framingham risk score, almost 30% migrated to different risk categories. Reclassification was most prominent in the intermediate Framingham risk category, where nearly two-thirds of men and women were reclassified as either lower or higher risk.

According to Dr. Vliegenthart Proença, this was one of the study's strengths. “Reclassification was based on the actual events. The observed risk in the different categories were calculated on the basis of our risk model, our prediction model, and on the basis of the actual events occurring in the different risk categories.”

A member of the audience questioned whether the Netherlands has used this data to change treatment recommendations.

“Actually, that's work in progress. At this moment there is no screening for coronary calcium in the Dutch population,” Dr. Vliegenthart Proença said.

Session moderator Dr. Frank John Rybicki III of Harvard Medical School, Boston, agreed.

“This was an important study because it used actual patient outcomes with a follow-up of almost 7 years to then reclassify risk, integrating calcium score into the traditional methods of risk, which is the Framingham model. And it showed with outcomes that there is a positive influence integrating calcium with those more traditional risk factors. It pretty specifically shows that integration of the calcium score has a very high chance of being beneficial in determining one's overall risk,” he said.

In a separate presentation, Dr. Vliegenthart Proença argued for noninvasive cardiac imaging of asymptomatic patients with peripheral arterial disease. A randomized, controlled trial of 231 such patients at her institution found that one in five were indicated for coronary revascularization.

Dr. Rybicki did not find this surprising. “A fifth of patients with peripheral arterial disease are also going to have significant coronary disease. We expect that.”

The studies were sponsored by University Medical Center Groningen.

Dr. Vliegenthart Proença had nothing to disclose.

Studies have shown that the calcium score is a strong predictor of coronary events.

Source DR. VLIEGENTHART PROENÇA

CHICAGO — The Framingham Heart Study risk algorithm fails to identify a significant number of individuals at high risk of coronary heart disease, and its accuracy could be improved significantly by integrating coronary calcium scoring, according to a new study from the Netherlands.

“Coronary calcium scoring, detected by CT, is a promising way to improve cardiovascular risk prediction. Population-based studies have shown that the calcium score is a strong predictor of coronary events,” said Rozemarijn Vliegenthart Proena, Ph.D., of University Medical Center Groningen (the Netherlands).

This 7-year-long study of 2,038 patients, conducted at the medical center, is supported by outcomes data demonstrating that nearly two-thirds of patients who would be classified as intermediate risk should actually be reclassified as either high or low risk.

The study questioned whether adding the calcium score to known cardiovascular risk factors would improve risk classification in the population. It was embedded into the population-based Rotterdam Study, and 2,038 individuals aged 55–85 years were invited to participate.

“We assessed as clinical outcome coronary heart disease comprising nonfatal myocardial infarction, [coronary heart disease] mortality, coronary artery bypass grafting, and percutaneous coronary interventions,” Dr. Vliegenthart Proença said at the annual meeting of the Radiological Society of North America.

Investigators created two prediction models: one with variables of the Framingham risk score, fitted to this patient population, and the other including the calcium score. Risk estimates for coronary events were extrapolated to 10 years, the common time horizon for predicting cardiovascular risk. “Then we calculated reclassification percentages to assess what the actual effect is of adding the calcium score to risk factors. Finally we compared the predicted risk, in the different categories, to the actually observed risk,” Dr. Vliegenthart Proença said.

Patients had a mean age of 70 years, and 1,171 (57%) were women. During the course of the study, 84 men and 45 women had a coronary event.

An elevated calcium score corresponded to significantly increased risk of events. Men with a calcium score over 400 had a sevenfold increased risk, compared with men who had a calcium score of 0–10. “When we adjusted for cardiovascular risk factors, these relative risks did not materially change,” Dr. Vliegenthart Proença said.

The strong association between the amount of coronary calcification and the risk of coronary heart disease was evident in the women's cohort as well.

When the calcium score was included with the Framingham risk score, almost 30% migrated to different risk categories. Reclassification was most prominent in the intermediate Framingham risk category, where nearly two-thirds of men and women were reclassified as either lower or higher risk.

According to Dr. Vliegenthart Proença, this was one of the study's strengths. “Reclassification was based on the actual events. The observed risk in the different categories were calculated on the basis of our risk model, our prediction model, and on the basis of the actual events occurring in the different risk categories.”

An audience member questioned whether the Netherlands has used this data to change treatment recommendations. “Actually, that's work in progress. At this moment there is no screening for coronary calcium in the Dutch population,” Dr. Vliegenthart Proença said.

Session moderator Dr. Frank John Rybicki III of Harvard Medical School, Boston, agreed. This study “pretty specifically shows that integration of the calcium score has a very high chance of being beneficial in determining one's overall risk.”

The study was sponsored by University Medical Center Groningen. Dr. Vliegenthart Proença had nothing to disclose.

My Take

Data May Not Fit Younger Patients

The Framingham risk score, which is based on observations of thousands of patients over decades, is particularly useful in determining primary prevention interventions for middle-aged patients.

This study is provocative but it appears to include an older group of individuals who would be at higher risk for cardiac events based on their age alone.

It may be premature to extrapolate the findings of this study to younger patients.

Dr. Golden

CHICAGO — The Framingham Heart Study risk algorithm fails to identify a significant number of individuals at high risk of coronary heart disease, and its accuracy could be improved significantly by integrating coronary calcium scoring, according to a new study from the Netherlands.

“Coronary calcium scoring, detected by CT, is a promising way to improve cardiovascular risk prediction. Population-based studies have shown that the calcium score is a strong predictor of coronary events,” said Rozemarijn Vliegenthart Proena, Ph.D., of University Medical Center Groningen (the Netherlands).

This 7-year-long study of 2,038 patients, conducted at the medical center, is supported by outcomes data demonstrating that nearly two-thirds of patients who would be classified as intermediate risk should actually be reclassified as either high or low risk.

The study questioned whether adding the calcium score to known cardiovascular risk factors would improve risk classification in the population. It was embedded into the population-based Rotterdam Study, and 2,038 individuals aged 55–85 years were invited to participate.

“We assessed as clinical outcome coronary heart disease comprising nonfatal myocardial infarction, [coronary heart disease] mortality, coronary artery bypass grafting, and percutaneous coronary interventions,” Dr. Vliegenthart Proença said at the annual meeting of the Radiological Society of North America.

Investigators created two prediction models: one with variables of the Framingham risk score, fitted to this patient population, and the other including the calcium score. Risk estimates for coronary events were extrapolated to 10 years, the common time horizon for predicting cardiovascular risk. “Then we calculated reclassification percentages to assess what the actual effect is of adding the calcium score to risk factors. Finally we compared the predicted risk, in the different categories, to the actually observed risk,” Dr. Vliegenthart Proença said.

Patients had a mean age of 70 years, and 1,171 (57%) were women. During the course of the study, 84 men and 45 women had a coronary event.

An elevated calcium score corresponded to significantly increased risk of events. Men with a calcium score over 400 had a sevenfold increased risk, compared with men who had a calcium score of 0–10. “When we adjusted for cardiovascular risk factors, these relative risks did not materially change,” Dr. Vliegenthart Proença said.

The strong association between the amount of coronary calcification and the risk of coronary heart disease was evident in the women's cohort as well.

When the calcium score was included with the Framingham risk score, almost 30% migrated to different risk categories. Reclassification was most prominent in the intermediate Framingham risk category, where nearly two-thirds of men and women were reclassified as either lower or higher risk.

According to Dr. Vliegenthart Proença, this was one of the study's strengths. “Reclassification was based on the actual events. The observed risk in the different categories were calculated on the basis of our risk model, our prediction model, and on the basis of the actual events occurring in the different risk categories.”

An audience member questioned whether the Netherlands has used this data to change treatment recommendations. “Actually, that's work in progress. At this moment there is no screening for coronary calcium in the Dutch population,” Dr. Vliegenthart Proença said.

Session moderator Dr. Frank John Rybicki III of Harvard Medical School, Boston, agreed. This study “pretty specifically shows that integration of the calcium score has a very high chance of being beneficial in determining one's overall risk.”

The study was sponsored by University Medical Center Groningen. Dr. Vliegenthart Proença had nothing to disclose.

My Take

Data May Not Fit Younger Patients

The Framingham risk score, which is based on observations of thousands of patients over decades, is particularly useful in determining primary prevention interventions for middle-aged patients.

This study is provocative but it appears to include an older group of individuals who would be at higher risk for cardiac events based on their age alone.

It may be premature to extrapolate the findings of this study to younger patients.

Dr. Golden

CHICAGO — The Framingham Heart Study risk algorithm fails to identify a significant number of individuals at high risk of coronary heart disease, and its accuracy could be improved significantly by integrating coronary calcium scoring, according to a new study from the Netherlands.

“Coronary calcium scoring, detected by CT, is a promising way to improve cardiovascular risk prediction. Population-based studies have shown that the calcium score is a strong predictor of coronary events,” said Rozemarijn Vliegenthart Proena, Ph.D., of University Medical Center Groningen (the Netherlands).

This 7-year-long study of 2,038 patients, conducted at the medical center, is supported by outcomes data demonstrating that nearly two-thirds of patients who would be classified as intermediate risk should actually be reclassified as either high or low risk.

The study questioned whether adding the calcium score to known cardiovascular risk factors would improve risk classification in the population. It was embedded into the population-based Rotterdam Study, and 2,038 individuals aged 55–85 years were invited to participate.

“We assessed as clinical outcome coronary heart disease comprising nonfatal myocardial infarction, [coronary heart disease] mortality, coronary artery bypass grafting, and percutaneous coronary interventions,” Dr. Vliegenthart Proença said at the annual meeting of the Radiological Society of North America.

Investigators created two prediction models: one with variables of the Framingham risk score, fitted to this patient population, and the other including the calcium score. Risk estimates for coronary events were extrapolated to 10 years, the common time horizon for predicting cardiovascular risk. “Then we calculated reclassification percentages to assess what the actual effect is of adding the calcium score to risk factors. Finally we compared the predicted risk, in the different categories, to the actually observed risk,” Dr. Vliegenthart Proença said.

Patients had a mean age of 70 years, and 1,171 (57%) were women. During the course of the study, 84 men and 45 women had a coronary event.

An elevated calcium score corresponded to significantly increased risk of events. Men with a calcium score over 400 had a sevenfold increased risk, compared with men who had a calcium score of 0–10. “When we adjusted for cardiovascular risk factors, these relative risks did not materially change,” Dr. Vliegenthart Proença said.

The strong association between the amount of coronary calcification and the risk of coronary heart disease was evident in the women's cohort as well.

When the calcium score was included with the Framingham risk score, almost 30% migrated to different risk categories. Reclassification was most prominent in the intermediate Framingham risk category, where nearly two-thirds of men and women were reclassified as either lower or higher risk.

According to Dr. Vliegenthart Proença, this was one of the study's strengths. “Reclassification was based on the actual events. The observed risk in the different categories were calculated on the basis of our risk model, our prediction model, and on the basis of the actual events occurring in the different risk categories.”

An audience member questioned whether the Netherlands has used this data to change treatment recommendations. “Actually, that's work in progress. At this moment there is no screening for coronary calcium in the Dutch population,” Dr. Vliegenthart Proença said.

Session moderator Dr. Frank John Rybicki III of Harvard Medical School, Boston, agreed. This study “pretty specifically shows that integration of the calcium score has a very high chance of being beneficial in determining one's overall risk.”

The study was sponsored by University Medical Center Groningen. Dr. Vliegenthart Proença had nothing to disclose.

My Take

Data May Not Fit Younger Patients

The Framingham risk score, which is based on observations of thousands of patients over decades, is particularly useful in determining primary prevention interventions for middle-aged patients.

This study is provocative but it appears to include an older group of individuals who would be at higher risk for cardiac events based on their age alone.

It may be premature to extrapolate the findings of this study to younger patients.

Dr. Golden

CHICAGO — Women younger than 40 years with focal breast signs or symptoms should be evaluated by targeted ultrasound, and probably not mammography or biopsy, according to findings from two studies of more than 1,800 patients treated at one medical center.

“This is particularly timely with the recent [U.S. Preventive Services Task Force] recommendations that women not perform self–breast exam,” said Dr. Constance Lehman of the University of Washington in Seattle.

“One of the USPSTF's concerns was that women will go through unnecessary harms and procedures. We think imaging can better guide us in reducing harms that can be associated with a self–breast exam,” Dr. Lehman said.

The studies' findings could have broad implications for practice patterns and cost. Reducing biopsies and surgical excision of lumps would lessen trauma and cost, while limiting mammography would reduce cost and unnecessary radiation.

Dr. Lehman described the two studies in a press briefing at the annual meeting of the Radiological Society of North America. Both were retrospective reviews of data from the University of Washington.

In the first analysis, investigators reviewed all breast exams performed on women under age 30 from Feb. 1, 2002, to Aug. 30, 2006, and found 1,091 lesions in 830 patients. Three malignancies were found, and all were identified as suspicious by ultrasound. No malignancy was found in any patient with a negative, benign, or probably benign ultrasound.

The rate of biopsy was high, and the yield was low. For example, of the 140 patients with a Breast Imaging–Reporting and Data System (BI-RADS) 3 lesion (probably benign), 46 (33%) underwent tissue sampling, and none of these lesions was found to be malignant.

Mammography was not indicated in this setting, and close surveillance might be a preferred alternative to tissue sampling, the authors concluded.

The second study, which included women aged 30–39 years, also found ultrasound to have 100% sensitivity. In this study, investigators reviewed 1,327 lesions in 1,032 patients, finding that 98% (1,301/1,327) were benign and 2% (26/1,327) were malignant. Ultrasound and mammography had been used to evaluate 91% (1,207/1,327) of cases, yet all cancers at the site of clinical concern were detected by ultrasound and none by mammography alone.

In a solitary case (1/1,327, 0.08%), mammography resulted in detection of a malignancy in an asymptomatic area.

The authors concluded that ultrasound has 100% sensitivity in evaluating women 30–39 years of age presenting with focal signs or symptoms.

“The added value of mammography in this setting is less apparent,” Dr. Lehman said. “It did help one woman who had an area of cancer identified in another region of the breast, but in all other women, there was no added value of the mammogram.”

In answer to a question from the audience, Dr. Lehman said that ultrasound is recommended as a diagnostic tool and not as a screening tool.

“We strongly recommend women have screening mammography annually, age 40 and older, and if they are shown to be at high risk, that they add MRI to that. We don't recommend ultrasound as a screening tool,” she said, because the specificity of ultrasound is low.

At the scientific session, Dr. Michael Portillo, one of Dr. Lehman's coauthors, was asked whether his institution had changed its practice in the wake of this study. “At this point we're still following the [American College of Radiology guidelines], but we are currently considering changing our practice,” said Dr. Portillo, who worked on the project while a fellow at the University of Washington.

Scientific session moderator Dr. Ellen B. Mendelson of Northwestern University in Chicago commented: “For every patient 30 years old or older who we'd biopsy, we'd do mammography first.

“In a patient younger than that … the first imaging exam you'd do for something palpable, or that is symptomatic, would be ultrasound. Then, depending on what you find … we would go to bilateral mammography first, before biopsy,” she said.

Both studies were funded by the University of Washington. Dr. Lehman disclosed work as an instructor with General Electric Co. Dr. Portillo had nothing to disclose.

“We don't recommend ultrasound as a screening tool,” said Dr. Constance Lehman (left), with coauthors Dr. Michael Portillo and Dr. Vilert Loving.

Source Richard Hyer/Elsevier Global Medical News

CHICAGO — Women younger than 40 years with focal breast signs or symptoms should be evaluated by targeted ultrasound, and probably not mammography or biopsy, according to findings from two studies of more than 1,800 patients treated at one medical center.

“This is particularly timely with the recent [U.S. Preventive Services Task Force] recommendations that women not perform self–breast exam,” said Dr. Constance Lehman of the University of Washington in Seattle.

“One of the USPSTF's concerns was that women will go through unnecessary harms and procedures. We think imaging can better guide us in reducing harms that can be associated with a self–breast exam,” Dr. Lehman said.

The studies' findings could have broad implications for practice patterns and cost. Reducing biopsies and surgical excision of lumps would lessen trauma and cost, while limiting mammography would reduce cost and unnecessary radiation.

Dr. Lehman described the two studies in a press briefing at the annual meeting of the Radiological Society of North America. Both were retrospective reviews of data from the University of Washington.

In the first analysis, investigators reviewed all breast exams performed on women under age 30 from Feb. 1, 2002, to Aug. 30, 2006, and found 1,091 lesions in 830 patients. Three malignancies were found, and all were identified as suspicious by ultrasound. No malignancy was found in any patient with a negative, benign, or probably benign ultrasound.

The rate of biopsy was high, and the yield was low. For example, of the 140 patients with a Breast Imaging–Reporting and Data System (BI-RADS) 3 lesion (probably benign), 46 (33%) underwent tissue sampling, and none of these lesions was found to be malignant.

Mammography was not indicated in this setting, and close surveillance might be a preferred alternative to tissue sampling, the authors concluded.

The second study, which included women aged 30–39 years, also found ultrasound to have 100% sensitivity. In this study, investigators reviewed 1,327 lesions in 1,032 patients, finding that 98% (1,301/1,327) were benign and 2% (26/1,327) were malignant. Ultrasound and mammography had been used to evaluate 91% (1,207/1,327) of cases, yet all cancers at the site of clinical concern were detected by ultrasound and none by mammography alone.

In a solitary case (1/1,327, 0.08%), mammography resulted in detection of a malignancy in an asymptomatic area.

The authors concluded that ultrasound has 100% sensitivity in evaluating women 30–39 years of age presenting with focal signs or symptoms.

“The added value of mammography in this setting is less apparent,” Dr. Lehman said. “It did help one woman who had an area of cancer identified in another region of the breast, but in all other women, there was no added value of the mammogram.”

In answer to a question from the audience, Dr. Lehman said that ultrasound is recommended as a diagnostic tool and not as a screening tool.

“We strongly recommend women have screening mammography annually, age 40 and older, and if they are shown to be at high risk, that they add MRI to that. We don't recommend ultrasound as a screening tool,” she said, because the specificity of ultrasound is low.

At the scientific session, Dr. Michael Portillo, one of Dr. Lehman's coauthors, was asked whether his institution had changed its practice in the wake of this study. “At this point we're still following the [American College of Radiology guidelines], but we are currently considering changing our practice,” said Dr. Portillo, who worked on the project while a fellow at the University of Washington.

Scientific session moderator Dr. Ellen B. Mendelson of Northwestern University in Chicago commented: “For every patient 30 years old or older who we'd biopsy, we'd do mammography first.

“In a patient younger than that … the first imaging exam you'd do for something palpable, or that is symptomatic, would be ultrasound. Then, depending on what you find … we would go to bilateral mammography first, before biopsy,” she said.

Both studies were funded by the University of Washington. Dr. Lehman disclosed work as an instructor with General Electric Co. Dr. Portillo had nothing to disclose.

“We don't recommend ultrasound as a screening tool,” said Dr. Constance Lehman (left), with coauthors Dr. Michael Portillo and Dr. Vilert Loving.

Source Richard Hyer/Elsevier Global Medical News

CHICAGO — Women younger than 40 years with focal breast signs or symptoms should be evaluated by targeted ultrasound, and probably not mammography or biopsy, according to findings from two studies of more than 1,800 patients treated at one medical center.

“This is particularly timely with the recent [U.S. Preventive Services Task Force] recommendations that women not perform self–breast exam,” said Dr. Constance Lehman of the University of Washington in Seattle.

“One of the USPSTF's concerns was that women will go through unnecessary harms and procedures. We think imaging can better guide us in reducing harms that can be associated with a self–breast exam,” Dr. Lehman said.

The studies' findings could have broad implications for practice patterns and cost. Reducing biopsies and surgical excision of lumps would lessen trauma and cost, while limiting mammography would reduce cost and unnecessary radiation.

Dr. Lehman described the two studies in a press briefing at the annual meeting of the Radiological Society of North America. Both were retrospective reviews of data from the University of Washington.

In the first analysis, investigators reviewed all breast exams performed on women under age 30 from Feb. 1, 2002, to Aug. 30, 2006, and found 1,091 lesions in 830 patients. Three malignancies were found, and all were identified as suspicious by ultrasound. No malignancy was found in any patient with a negative, benign, or probably benign ultrasound.

The rate of biopsy was high, and the yield was low. For example, of the 140 patients with a Breast Imaging–Reporting and Data System (BI-RADS) 3 lesion (probably benign), 46 (33%) underwent tissue sampling, and none of these lesions was found to be malignant.

Mammography was not indicated in this setting, and close surveillance might be a preferred alternative to tissue sampling, the authors concluded.

The second study, which included women aged 30–39 years, also found ultrasound to have 100% sensitivity. In this study, investigators reviewed 1,327 lesions in 1,032 patients, finding that 98% (1,301/1,327) were benign and 2% (26/1,327) were malignant. Ultrasound and mammography had been used to evaluate 91% (1,207/1,327) of cases, yet all cancers at the site of clinical concern were detected by ultrasound and none by mammography alone.

In a solitary case (1/1,327, 0.08%), mammography resulted in detection of a malignancy in an asymptomatic area.

The authors concluded that ultrasound has 100% sensitivity in evaluating women 30–39 years of age presenting with focal signs or symptoms.

“The added value of mammography in this setting is less apparent,” Dr. Lehman said. “It did help one woman who had an area of cancer identified in another region of the breast, but in all other women, there was no added value of the mammogram.”

In answer to a question from the audience, Dr. Lehman said that ultrasound is recommended as a diagnostic tool and not as a screening tool.

“We strongly recommend women have screening mammography annually, age 40 and older, and if they are shown to be at high risk, that they add MRI to that. We don't recommend ultrasound as a screening tool,” she said, because the specificity of ultrasound is low.

At the scientific session, Dr. Michael Portillo, one of Dr. Lehman's coauthors, was asked whether his institution had changed its practice in the wake of this study. “At this point we're still following the [American College of Radiology guidelines], but we are currently considering changing our practice,” said Dr. Portillo, who worked on the project while a fellow at the University of Washington.

Scientific session moderator Dr. Ellen B. Mendelson of Northwestern University in Chicago commented: “For every patient 30 years old or older who we'd biopsy, we'd do mammography first.

“In a patient younger than that … the first imaging exam you'd do for something palpable, or that is symptomatic, would be ultrasound. Then, depending on what you find … we would go to bilateral mammography first, before biopsy,” she said.

Both studies were funded by the University of Washington. Dr. Lehman disclosed work as an instructor with General Electric Co. Dr. Portillo had nothing to disclose.

“We don't recommend ultrasound as a screening tool,” said Dr. Constance Lehman (left), with coauthors Dr. Michael Portillo and Dr. Vilert Loving.

Source Richard Hyer/Elsevier Global Medical News