Assessing breast arterial calcification in mammograms and its implications for atherosclerotic cardiovascular disease risk.

PURPOSE: Breast arterial calcifications (BAC) are incidentally observed on mammograms, yet their implications remain unclear. We investigated lifestyle, reproductive, and cardiovascular determinants of BAC in women undergoing mammography screening. Further, we investigated the relationship between BAC, coronary arterial calcifications (CAC) and estimated 10-year atherosclerotic cardiovascular (ASCVD) risk. METHODS: In this cross-sectional study, we obtained reproductive history and CVD risk factors from 215 women aged 18 or older who underwent mammography and cardiac computed tomographic angiography (CCTA) within a 2-year period between 2007 and 2017 at hospital. BAC was categorized as binary (present/absent) and semi-quantitatively (mild, moderate, severe). CAC was determined using the Agatston method and recorded as binary (present/absent). Adjusted odds ratios (ORs) and 95 % confidence intervals (CIs) were calculated, accounting for age as a confounding factor. ASCVD risk over a 10-year period was calculated using the Pooled Cohort Risk Equations. RESULTS: Older age, systolic and diastolic blood pressures, higher parity, and younger age at first birth (≤28 years) were significantly associated with greater odds of BAC. Women with both BAC and CAC had the highest estimated 10-year risk of ASCVD (13.30 %). Those with only BAC (8.80 %), only CAC (5.80 %), and no BAC or CAC (4.40 %) had lower estimated 10-year risks of ASCVD. No association was detected between presence of BAC and CAC. CONCLUSIONS: These findings support the hypothesis that BAC on a screening mammogram may help to identify women at potentially increased risk of future cardiovascular disease without additional cost and radiation exposure.

Bleeding Events After Image-Guided Breast Biopsies: Comparison of Patients Temporarily Discontinuing Versus Maintaining Antithrombotic Therapy During Biopsy.

BACKGROUND. Antithrombic (AT) therapy is commonly temporarily discontinued before breast core needle biopsy (CNB), introducing risks of thrombotic events and diagnostic delay. OBJECTIVE. The purpose of this article was to compare the frequency of postbiopsy bleeding events among patients without AT use, patients temporarily discontinuing AT therapy, and patients maintaining AT therapy during breast CNB. METHODS. This retrospective study included 5302 patients (median age, 52 years) who underwent image-guided breast or axillary CNB between January 1, 2014, and December 31, 2019. From January 1, 2014, to December 31, 2016, patients temporarily discontinued all AT therapy for 5 days before CNB; from January 1, 2017, to December 31, 2019, patients maintained AT therapy during CNB. Immediate postbiopsy mammograms were reviewed for imaging-apparent hematoma. Patients were called 24-48 hours after biopsy and asked regarding palpable hematoma and breast bruise. The EMR was reviewed for clinically significant postbiopsy hematoma (i.e., hematoma requiring drainage, primary care or emergency department visit for persistent symptoms, or hospital admission). Bleeding events were compared among groups, including Firth bias-reduced multivariable logistic regression analysis. RESULTS. During CNB, 4665 patients were not receiving AT therapy, 423 temporarily discontinued AT therapy, and 214 maintained AT therapy. Imaging-apparent hematoma occurred in 3% of patients without AT use, 6% of patients discontinuing AT therapy, and 7% of patients maintaining AT therapy (p = .60 [discontinuing vs maintaining]). Palpable hematoma occurred in 2% of patients without AT use, 4% of patients maintaining AT therapy, and 4% of patients discontinuing AT therapy (p = .92 [discontinuing vs maintaining]). Breast bruise occurred in 2% of patients without AT use, 1% of patients discontinuing AT therapy, and 6% of patients maintaining AT therapy (p < .001 [discontinuing vs maintaining]). In multivariable analysis adjusting for age, biopsy imaging modality, needle gauge, number of biopsy samples, and pathologic result, discontinued AT therapy (using maintained AT therapy as reference) was not a significant independent predictor of imaging-apparent hematoma (p = .23) or palpable hematoma (p = .91) but independently predicted decreased risk of bruise (OR = 0.11, p < .001). No patient developed clinically significant postbiopsy hematoma. CONCLUSION. Frequencies of imaging-apparent and palpable hematoma were not significantly different between patients temporarily discontinuing versus maintaining AT therapy. CLINICAL IMPACT. The findings support the safety of continuing AT therapy during CNB. Patients who maintain AT therapy should be counseled regarding risk of bruise.

Axillary Lymphadenopathy After a COVID-19 Vaccine Booster Dose: Time to Resolution on Ultrasound Follow-Up and Associated Factors.

BACKGROUND. Because administration of booster doses of COVID-19 vaccines is ongoing, radiologists are continuing to encounter COVID-19 vaccine-related axillary lymphadenopathy on imaging. OBJECTIVE. The purposes of this study were to assess time to resolution of COVID-19 vaccine-related axillary lymphadenopathy identified on breast ultrasound after administration of a booster dose and to assess factors potentially associated with time to resolution. METHODS. This retrospective single-institution study included 54 patients (mean age, 57 years) with unilateral axillary lymphadenopathy ipsilateral to the site of injection of a booster dose of messenger RNA COVID-19 vaccine visualized on ultrasound (whether an initial breast imaging examination or follow-up to prior screening or diagnostic breast imaging) performed between September 1, 2021, and December 31, 2022, and who underwent follow-up ultrasound examinations until resolution of lymphadenopathy. Patient information was extracted from the EMR. Univariable and multivariable linear regression analyses were used to identify predictors of time to resolution. Time to resolution was compared with that in a previously described sample of 64 patients from the study institution that was used to evaluate time to resolution of axillary lymphadenopathy after the initial vaccination series. RESULTS. Six of the 54 patients had a history of breast cancer, and two had symptoms related to axillary lymphadenopathy (axillary pain in both patients). Among the 54 initial ultrasound examinations showing lymphadenopathy, 33 were screening examinations and 21 were diagnostic examinations. Lymphadenopathy had resolved a mean of 102 ± 56 (SD) days after administration of the booster dose and 84 ± 49 days after the initial ultrasound showing lymphadenopathy. Age, vaccine booster type (Moderna vs Pfizer-BioNTech), and history of breast cancer were not significantly associated with time to resolution in univariable or multivariable analyses (all p > .05). Time to resolution after administration of a booster dose was significantly shorter than time to resolution after administration of the first dose in the initial series (mean, 129 ± 37 days) (p = .01). CONCLUSION. Axillary lymphadenopathy after administration of a COVID-19 vaccine booster dose has a mean time to resolution of 102 days, shorter than the time to resolution after the initial vaccination series. CLINICAL IMPACT. The time to resolution after administration of a booster dose supports the current recommendation for a follow-up interval of at least 12 weeks when vaccine-related lymphadenopathy is suspected.

Transient ipsilateral breast edema following COVID-19 vaccination.

While ipsilateral lymphadenopathy following COVID-19 vaccination is a relatively common finding on mammography and breast ultrasound transient ipsilateral breast edema is rare with only a few published case reports. Radiologists should be aware of this potential imaging appearance of the breast and axilla following COVID-19 vaccination given the imaging features of edema such as trabecular thickening, skin thickening, and increased echogenicity can overlap with benign and malignant breast conditions such as mastitis and inflammatory breast cancer. We describe a case of transient ipsilateral breast edema after COVID-19 vaccination followed by a discussion summarizing the current understanding and management of transient ipsilateral breast edema following COVID-19 vaccination.

Time for Resolution of COVID-19 Vaccine-Related Axillary Lymphadenopathy and Associated Factors.

BACKGROUND. The variable clinical course of subclinical lymphadenopathy detected on breast imaging after COVID-19 vaccination creates management challenges and has led to evolving practice recommendations. OBJECTIVE. The purpose of this study was to assess the duration of axillary lymphadenopathy ipsilateral to COVID-19 vaccination detected by breast imaging and to assess factors associated with the time until resolution. METHODS. This retrospective single-center study included 111 patients (mean age, 52 ± 12 years) with unilateral axillary lymphadenopathy ipsilateral to mRNA COVID-19 vaccine administration performed within the prior 8 weeks that was detected on breast ultrasound performed between January 1, 2021, and October 1, 2021, and who underwent follow-up ultrasound examinations at 4- to 12-week intervals until resolution of the lymphadenopathy. Patient information was extracted from medical records. Cortical thickness of the largest axillary lymph node on ultrasound was retrospectively measured and was considered enlarged when greater than 3 mm. Multivariable linear regression analysis was used to identify independent predictors of time until resolution. RESULTS. The mean cortical thickness at the initial ultrasound examination was 4.7 ± 1.2 mm. The lymphadenopathy resolved a mean of 97 ± 44 days after the initial ultrasound examination, 127 ± 43 days after the first vaccine dose, and 2.4 ± 0.6 follow-up ultrasound examinations. A significant independent predictor of shorter time to resolution was Pfizer-BioNTech (rather than Moderna) vaccination (ß = -18.0 [95% CI, -34.3 to -1.7]; p = .03]. Significant independent predictors of longer time to resolution were receipt of the second dose after the initial ultrasound examination (ß = 19.2 [95% CI, 3.1-35.2]; p = .02) and greater cortical thickness at the initial ultrasound examination (ß = 8.0 [95% CI, 1.5-14.5]; p = .02). Patient age, history of breast cancer, and axillary symptoms were not significantly associated with time to resolution (all p > .05). CONCLUSION. Axillary lymphadenopathy detected with breast ultrasound after COVID-19 mRNA vaccination lasts longer than reported in initial vaccine clinical trials. CLINICAL IMPACT. The prolonged time to resolution supports not delaying screening mammography because of recent COVID-19 vaccination. It also supports the professional society recommendation of a follow-up interval of at least 12 weeks when vaccine-related lymphadenopathy is suspected.

Ink on the move: tattoo pigment resembling axillary lymph node calcifications.

High-density foci within axillary lymph nodes are associated with a number of potential diagnoses. In this case series, we present four tattooed patients who had mammographic findings that demonstrated high-density material in axillary lymph nodes, indicative of tattoo pigment migration. The aim of presenting these cases is to highlight the importance of recognizing such pigment migration in order to help breast radiologists form an appropriate differential diagnosis that might include this entity.

Postoperative Imaging Appearance of an Implantable Three-dimensional Bioabsorbable Tissue Marker After Breast Surgery: Initial Experience at a Single Institution.

OBJECTIVE: Three-dimensional bioabsorbable tissue marker (BTM) placement during breast surgery is performed for the purpose of improved surgical cavity delineation for radiotherapy and improved cosmetic outcome. The purpose of this study is to evaluate the postsurgical imaging findings of BTM. METHODS: This Institutional Review Board-approved retrospective review included all patients implanted with BTM at breast surgery from January 2017 to September 2018. Demographics, tumor characteristics, imaging, and histologic findings were evaluated. Medical records were reviewed during a three-year period to evaluate for tumor recurrence. RESULTS: Ninety-seven patients had BTM implanted, of which 76 patients had imaging follow-up of at least 1 year. Of the 76 patients who had mammographic follow-up, 3 (3.9%) developed suspicious microcalcifications requiring biopsy, yielding ductal carcinoma in-situ in 2 patients and benign calcifications in 1 patient. Of 61 patients who had sonographic follow-up, 44 (72.1%) patients had complex fluid collections containing avascular, heterogeneously hyperechoic solid components, which remained stable or decreased in size over time; no recurrent tumors were found in this group. One patient (1.6%) had a vascular solid mass, which yielded recurrent papilloma. Four (6.6%) patients developed irregular hypoechoic masses at the surgical site, one of which corresponded with a developing asymmetry mammographically; biopsy yielded fibromatosis. Tissue sampling of the remaining three cases yielded invasive ductal carcinoma, fat necrosis, and radiation changes, respectively. CONCLUSION: Accurate identification of the expected postoperative imaging appearance of BTM may prevent unnecessary biopsy. Suspicious findings necessitating biopsy are pleomorphic calcifications, developing asymmetry and vascular and irregular hypoechoic masses.

Screening Mammography for Women in Their 40s: The Potential Impact of the American Cancer Society and U.S. Preventive Services Task Force Breast Cancer Screening Recommendations.

OBJECTIVE: The purpose of this study was to review screening mammograms obtained in one practice with the primary endpoint of determining the rate of detection of breast cancer and associated prognostic features in women 40-44 and 45-49 years old. MATERIALS AND METHODS: The retrospective cohort study included women in their 40s with breast cancer detected at screening from June 2014 through May 2016. The focus was on cancer detection rate, pathologic findings, and risk factors. RESULTS: A total of 32,762 screens were performed, and 808 biopsies were recommended. These biopsies yielded 224 breast cancers (cancer detection rate, 6.84 per 1000 screens). Women 40-49 years old had 18.8% of cancers detected; 50-59 years, 21.8%; 60-69 years, 32.6%; and 70-79 years, 21.4%. Among the 40- to 49-year-old women, women 40-44 years old underwent 5481 (16.7%) screens, had 132 biopsies recommended, and had 20 breast cancers detected (cancer detection rate, 3.6/1000). Women 45-49 years old underwent 5319 (16.2%) screens, had 108 biopsies recommended, and had 22 breast cancers detected (cancer detection rate, 4.1/1000). Thus, women 40-44 years old had 8.9% and women 45-49 years old had 9.8% of all screen-detected breast cancers. Of these only a small percentage of women with detected cancers had a first-degree relative with breast cancer (40-44 years, 15%; 45-49 years, 32%) or a BRCA mutation (40-44 years, 5%; 45-49 years, 5%), and over 60% of the cancers were invasive. CONCLUSION: Women 40-49 years old had 18.8% of all screen-detected breast cancers. The two cohorts (40-44 and 45-49 years old) had similar incidences of screen-detected breast cancer (8.9%, 9.8%) and cancer detection rates within performance benchmark standards, supporting a similar recommendation for both cohorts and the American College of Radiology recommendation of annual screening mammography starting at age 40.

Intradermal invasive lobular carcinoma presenting: Not everything in the skin is benign.

In this case report, the history and imaging of two patients with invasive lobular carcinoma (ILC) in the skin are presented, followed by a discussion of both benign and malignant intradermal findings on breast ultrasound. Although the majority of dermal findings are benign, these cases are a reminder that malignancy can manifest within the skin. The purpose of presenting these cases together is to remind breast imagers of the importance of considering malignancy in the differential diagnosis of intradermal lesions on breast ultrasound, especially in special circumstances such as a personal history of breast cancer or associated clinical findings.

Advocating Nonsurgical Management of Patients With Small, Incidental Radial Scars at the Time of Needle Core Biopsy: A Study of 77 Cases.

CONTEXT: Radial scars are benign sclerosing lesions that are routinely excised when diagnosed in a needle core biopsy. Optimal management for patients with incidental and small (≤5 mm) radial scars is uncertain. OBJECTIVE: To assess pathologic upgrade of radial scars diagnosed in needle core biopsy samples and identify a subset of patients who could benefit from conservative management. DESIGN: Patients with a diagnosis of radial scar in a needle core biopsy who underwent excision of the biopsied area were identified. Radial scars greater than 5 mm in size and those with coexisting atypia, carcinoma, and papillary lesions were excluded. After histologic-radiographic correlation, rates of pathologic upgrade were assessed. RESULTS: Seventy-seven radial scars diagnosed in 66 patients were included. Overall, 9 of 77 (12%) showed upgrade to a high-risk lesion (6 lobular carcinoma in situ, 2 atypical ductal hyperplasia, 1 atypical lobular hyperplasia), while none (0%) showed upgrade to invasive carcinoma or ductal carcinoma in situ. One of 22 incidental radial scars (4.5%) showed upgrade on excision versus 6 of 36 (16.7%) for radial scars considered to be the radiographic target (P = .23). Older age was associated with upgrade (P < .001). CONCLUSIONS: No incidental or small (≤5 mm) radial scars excised revealed invasive carcinoma or ductal carcinoma in situ on excision. Provided there is good pathologic-radiologic concordance, it appears reasonable for these patients to be managed conservatively.

Seroma is an expected consequence and not a complication of MammoSite brachytherapy.

Seroma has long been listed as a complication of MammoSite brachytherapy. Palpable abnormalities are clinically apparent months after treatment and a vast majority of patients demonstrate seroma formation in radiologic studies. We embarked on this study to evaluate the actual sonographic incidence and eventual sonographic resolution, possible contributing factors, cosmesis, pain, and local control associated with seroma formation after MammoSite partial breast irradiation (PBI). We investigated 160 patients who underwent MammoSite PBI from 2002 to 2006 of whom 100 patients had serial sonographic information. Clinical and tumor variables, infection, pain, and cosmesis were investigated. Dosimetric data including volume of balloon, dose at balloon surface, and at skin were analyzed. After a median follow-up of 36 months, the incidence of sonographically confirmed post-radiation seroma was 78% within the first 1 year following radiation and steadily decreased with time. The average size of a seroma cavity was 2.3 cm (range 0.6-6 cm) with a decline to an average of 1.4 cm after 1 year, with complete resolution in 65% of patients at 2 years. No statistically significant correlation was found between patient characteristics, tumor variables, and volumetric or dosimetric data for seroma formation. Excellent/good cosmetic scores were achieved in 94% of women with and 92% without seroma. Local control was equivalent between patients with and without seroma. Consecutive sonographic imaging reveals a high rate of seroma formation after MammoSite PBI, with resolution in 65% of patients by 2 years without intervention. Seroma formation does not prevent an excellent cosmetic result or alter local control.