Addressing Imaging Pitfalls to Reduce Cardiovascular Disease Misdiagnosis in Patients With Breast Cancer Following Reconstruction

Oren, Ohad; Blankstein, Ron; Bhatt, Deepak L.

doi:10.1001/jamacardio.2021.4564

“…To the Editor In the LCZ696 in Hospitalized Advanced Heart Failure (LIFE) trial, the authors reported no benefit of sacubitril/ valsartan over valsartan on the primary end points or decrease in plasma N-terminal pro-brain natriuretic peptide (NT-proBNP). 1 Data from Prospective Comparison of ARNI With an ACE-Inhibitor to Determine Impact on Global Mortality and Morbidity in Heart Failure (PARADIGM-HF) already hinted this result, as the primary end point was not met in patients with New York Heart Association heart failure class III or IV, although the extent of the error bar suggested the lack of benefit only affected the most severe patients. 2 Besides the low recruitment and lack of statistical power, brain natriuretic peptide (BNP)-mediated neprilysin inhibition could also account for those results.…”

Section: Could Neprilysin Be Already Inhibited By Bnp In the Life Trial?mentioning

confidence: 99%

“…In Reply We thank Manisty et al for the opportunity to further reinforce the strengths and potential pitfalls of contemporary cardiovascular imaging in women who have been diagnosed with breast cancer and who underwent breast reconstruction. 1 CMR provides essential data regarding the presence and extent of a host of cardiovascular processes, including cancer therapeutic-mediated cardiotoxic effects, image artifacts have been described in women with breast implants. Saline breast implants may result in oscillations in longitudinal magnetization and ghost artifacts in segmented inversion-recovery magnetic resonance imaging (MRI) that may potentially overlay cardiac structures.…”

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confidence: 99%

“…To the Editor We welcome the Viewpoint from Oren et al highlighting the importance of ensuring high-quality cardiovascular (CV) imaging for patients living with (or survivors of) breast cancer with breast implants. Patients commonly require functional CV imaging to establish CV safety during or after receiving cancer treatment for screening for cancer treatment–related cardiac dysfunction (CTRCD) in line with available guidelines and consensus statements .…”

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confidence: 99%

See 1 more Smart Citation

No Diagnostic Concerns With Cardiovascular Magnetic Resonance Imaging in Patients With Breast Cancer and Breast Implants

Manisty

¹

,

Barac

²

,

Lenihan³

2022

JAMA Cardiol

1

0

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To the Editor We welcome the Viewpoint from Oren et al 1 highlighting the importance of ensuring high-quality cardiovascular (CV) imaging for patients living with (or survivors of) breast cancer with breast implants. Patients commonly require functional CV imaging to establish CV safety during or after receiving cancer treatment for screening for cancer treatment-related cardiac dysfunction (CTRCD) in line with available guidelines and consensus statements. 2 Echocardiography has long been known to be challenging in patients with breast implants, 3 and inaccurate imaging risks not only late detection of potentially life-threatening cardiotoxic effects but also inappropriate withholding of cancer treatments. Alternative imaging modalities are therefore commonly required to ensure accurate diagnosis and appropriate clinical decisionmaking. Investigation and monitoring of incident CV toxic effects also requires optimal CV noninvasive imaging, and the spectrum of disease demands a multimodality approach, with false-positive results reported in this patient group with both electrocardiography 4 and nuclear (single-photon emission computed tomography) imaging. 5 The authors state that the diagnostic performance of cardiovascular magnetic resonance imaging (CMR) may be impaired by the presence of breast prostheses. They propose that formal evaluation of the sensitivity and specificity of CMR in patients with breast cancer and implants is required, notably for investigation of immune checkpoint inhibitor-related myocarditis.We strongly refute that suggestion. There is no evidence to suggest that the presence of a breast implant should impact tissue characterization-either for late gadolinium enhancement fibrosis imaging or for parametric mapping for measurement of T1, T2, or T2*. The constituent components of the implants (silicone, saline) are nonferromagnetic and have no impact on relaxometry. Many thousands of patients globally have undergone CMR with breast implants, and there are no published or anecdotal reports of artifacts.The only area where care should be taken with patients with breast cancer undergoing CMR is for patients with some tissue expanders with MAGNA-SITE injection ports, which are labelled as MR-Unsafe. Tissue expanders are temporary devices used prior to breast implantation following mastectomy. All breast implants are labelled as MR-Safe and many new tissue expanders are labelled MR-Conditional.Options for quality diagnostic CV imaging in patients with breast cancer with implants may be limited, and for these specific patients, the impact of not evaluating for CTRCD or other cardiotoxic effects is high. Suggesting that either CMR or computed tomography be inaccurate is not only incorrect but also potentially harmful to patients. On behalf of the cardiooncology community and patients, we would strongly advocate that this Viewpoint article be amended to correct this statement.

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“…On the other hand, the rate of misdiagnosis during clinical treatment is a crucial issue that demands attention. Numerous studies have reported a significant variation in the misdiagnosis rates across different medical fields and diseases, ranging from 2% to 71% [6,7]. Misdiagnosis not only poses serious harm and even fatalities to patients but also contributes to the wastage of medical resources and the occurrence of medical disputes.…”

Section: Introductionmentioning

confidence: 99%

Unleashing the Power of Language Models in Clinical Settings: A Trailblazing Evaluation Unveiling Novel Test Design

Li

¹

,

Min

²

2023

Preprint

2

0

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The realm of clinical medicine stands on the brink of a revolutionary break-through as large language models (LLMs) emerge as formidable allies, propelled by the prowess of deep learning and a wealth of clinical data. Yet, amidst the dis-quieting specter of misdiagnoses haunting the halls of medical treatment, LLMs offer a glimmer of hope, poised to reshape the landscape. However, their mettle and medical acumen, particularly in the crucible of real-world professional sce-narios replete with intricate logical interconnections, remain shrouded in uncer-tainty. To illuminate this uncharted territory, we present an audacious quantitative evaluation method, harnessing the ingenuity of thoracic surgery questions as the litmus test for LLMs' medical prowess. These clinical questions covering various diseases were collected, and a test format consisting of multi-choice questions and case analysis was designed based on the Chinese National Senior Health Professional Technical Qualification Examination. Five LLMs of different scales and sources were utilized to answer these questions, and evaluation and feedback were provided by professional thoracic surgeons. Among these models, GPT-4 demonstrated the highest performance with a score of 48.67 out of 100, achieving accuracies of 0.62, 0.27, and 0.63 in single-choice, multi-choice, and case-analysis questions, respectively. However, further improvement is still necessary to meet the passing threshold of the examination. Additionally, this paper analyz-es the performance, advantages, disadvantages, and risks of LLMs, and proposes suggestions for improvement, providing valuable insights into the capabilities and limitations of LLMs in the specialized medical domain.

show abstract

“…In Reply We thank Manisty et al for the opportunity to further reinforce the strengths and potential pitfalls of contemporary cardiovascular imaging in women who have been diagnosed with breast cancer and who underwent breast reconstruction . Cardiac magnetic resonance imaging (CMR) represents an indispensable tool in the diagnosis of cardiovascular pathologies.…”

mentioning

confidence: 99%

No Diagnostic Concerns With Cardiovascular Magnetic Resonance Imaging in Patients With Breast Cancer and Breast Implants—Reply

Oren

¹

,

Blankstein

²

,

Bhatt

³

2022

Self Cite

View full text Add to dashboard Cite

To the Editor We welcome the Viewpoint from Oren et al 1 highlighting the importance of ensuring high-quality cardiovascular (CV) imaging for patients living with (or survivors of) breast cancer with breast implants. Patients commonly require functional CV imaging to establish CV safety during or after receiving cancer treatment for screening for cancer treatment-related cardiac dysfunction (CTRCD) in line with available guidelines and consensus statements. 2 Echocardiography has long been known to be challenging in patients with breast implants, 3 and inaccurate imaging risks not only late detection of potentially life-threatening cardiotoxic effects but also inappropriate withholding of cancer treatments. Alternative imaging modalities are therefore commonly required to ensure accurate diagnosis and appropriate clinical decisionmaking. Investigation and monitoring of incident CV toxic effects also requires optimal CV noninvasive imaging, and the spectrum of disease demands a multimodality approach, with false-positive results reported in this patient group with both electrocardiography 4 and nuclear (single-photon emission computed tomography) imaging. 5 The authors state that the diagnostic performance of cardiovascular magnetic resonance imaging (CMR) may be impaired by the presence of breast prostheses. They propose that formal evaluation of the sensitivity and specificity of CMR in patients with breast cancer and implants is required, notably for investigation of immune checkpoint inhibitor-related myocarditis.We strongly refute that suggestion. There is no evidence to suggest that the presence of a breast implant should impact tissue characterization-either for late gadolinium enhancement fibrosis imaging or for parametric mapping for measurement of T1, T2, or T2*. The constituent components of the implants (silicone, saline) are nonferromagnetic and have no impact on relaxometry. Many thousands of patients globally have undergone CMR with breast implants, and there are no published or anecdotal reports of artifacts.The only area where care should be taken with patients with breast cancer undergoing CMR is for patients with some tissue expanders with MAGNA-SITE injection ports, which are labelled as MR-Unsafe. Tissue expanders are temporary devices used prior to breast implantation following mastectomy. All breast implants are labelled as MR-Safe and many new tissue expanders are labelled MR-Conditional.Options for quality diagnostic CV imaging in patients with breast cancer with implants may be limited, and for these specific patients, the impact of not evaluating for CTRCD or other cardiotoxic effects is high. Suggesting that either CMR or computed tomography be inaccurate is not only incorrect but also potentially harmful to patients. On behalf of the cardiooncology community and patients, we would strongly advocate that this Viewpoint article be amended to correct this statement.

show abstract

Addressing Imaging Pitfalls to Reduce Cardiovascular Disease Misdiagnosis in Patients With Breast Cancer Following Reconstruction

Cited by 5 publications

References 10 publications

No Diagnostic Concerns With Cardiovascular Magnetic Resonance Imaging in Patients With Breast Cancer and Breast Implants

No Diagnostic Concerns With Cardiovascular Magnetic Resonance Imaging in Patients With Breast Cancer and Breast Implants

Unleashing the Power of Language Models in Clinical Settings: A Trailblazing Evaluation Unveiling Novel Test Design

No Diagnostic Concerns With Cardiovascular Magnetic Resonance Imaging in Patients With Breast Cancer and Breast Implants—Reply

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