Radiology advocacy: Promoting collaboration between trainees and professional societies.

From mammographic screening guidelines to resident work hour regulations, public policy affects every aspect of the practice of radiology and ultimately determines how radiological care is delivered to patients. Shaping public policy through advocacy is therefore critical to ensure patient access to equitable, high-quality radiological care. In advocacy, individual practicing radiologists and radiology trainees can increase the scope of their influence by collaborating with professional radiology societies. When radiology trainees participate in organized radiology advocacy, they learn about regulatory and legislative issues that will affect their careers, and they learn how to effect policy change. Radiology societies in turn benefit from trainee involvement, as engaging trainees early in their careers leads to more robust future participation and leadership. To encourage trainee involvement, radiology societies can engage individual residency programs and medical student radiology interest groups, invest in trainee-focused events, and maximize the number of positions of responsibility open to trainees. To circumvent the barriers to participation that many trainees face, radiology societies can make meeting proceedings free and available through virtual mediums. Through active collaboration, trainees and professional societies can help assure a bright future for radiologists and patients in need of radiological care.

Comparison of Axillary Lymph Nodes on Breast MRI Before and After COVID-19 Booster Vaccination.

RATIONALE AND OBJECTIVES: Vaccine-related lymphadenopathy is a frequent finding following initial coronavirus disease 2019 (COVID-19) vaccination, but the frequency after COVID-19 booster vaccination is still unknown. In this study we compare axillary lymph node morphology on breast MRI before and after COVID-19 booster vaccination. MATERIALS AND METHODS: This retrospective, single-center, IRB-approved study included patients who underwent breast MRI between October 2021 and December 2021 after the COVID-19 booster vaccination. The axillary lymph node with the greatest cortical thickness ipsilateral to the side of vaccination was measured on MRI after booster vaccination and before initial COVID-19 vaccination. Comparisons were made between patients with and without increase in cortical thickness of ≥ 0.2 cm. Continuous covariates were compared using Wilcoxon rank-sum test and categorical covariates were compared using Fisher's exact test. Multiple comparison adjustment was made using the Benjamini-Hochberg procedure. RESULTS: All 128 patients were included. Twenty-four of 128 (19%) displayed an increase in lymph node cortical thickness of ≥ 0.2 cm. Patients who received the booster more recently were more likely to present cortical thickening, with a median of 9 days (IQR 5, 20) vs. 36 days (IQR 18, 59) (p < 0.001). Age (p = 0.5) and type of vaccine (p = 0.7) were not associated with thickening. No ipsilateral breast cancer or malignant lymphadenopathy were diagnosed on follow-up. CONCLUSION: Axillary lymphadenopathy on breast MRI following COVID-19 booster vaccination is a frequent finding, especially in the first 3 weeks after vaccination. Additional evaluation or follow-up may be omitted in patients with low concern for malignancy.

High-Temporal/High-Spatial Resolution Breast Magnetic Resonance Imaging Improves Diagnostic Accuracy Compared With Standard Breast Magnetic Resonance Imaging in Patients With High Background Parenchymal Enhancement.

PURPOSE: To compare breast magnetic resonance imaging (MRI) diagnostic performance using a standard high-spatial resolution protocol versus a simultaneous high-temporal/high-spatial resolution (HTHS) protocol in women with high levels of background parenchymal enhancement (BPE). MATERIALS AND METHODS: We conducted a retrospective study of contrast-enhanced breast MRIs performed at our institution before and after the introduction of the HTHS protocol. We compared diagnostic performance of the HTHS and standard protocol by comparing cancer detection rate (CDR) and positive predictive value of biopsy (PPV3) among women with high BPE (ie, marked or moderate). RESULTS: Among women with high BPE, the HTHS protocol demonstrated increased CDR (23.6 per 1,000 patients v 7.9 per 1,000 patients; P = 0. 013) and increased PPV3 (16.0% v 6.3%; P = .021) compared with the standard protocol. This corresponded to a 9.8% (95% CI, 1.29 to 18.3) decrease in the proportion of unnecessary biopsies among high-BPE patients and an additional cancer yield of 15.7 per 1,000 patients (95% CI, 1.3 to 18.3). CONCLUSION: Among women with high BPE, HTHS MRI improved diagnostic performance, leading to an additional cancer yield of 15.7 cancers per 1,000 women and concomitantly decreasing unnecessary biopsies by 9.8%. A multisite prospective trial is warranted to confirm these findings and to pave the way for more widespread clinical implementation.

Quality assurance in Mammography: An overview.

Since 1989, hundreds of thousands of lives have been saved worldwide by the widespread use of screening mammography alongside new developments in breast cancer treatment [1]. The ability of screening mammography to detect cancer early, when treatment is most effective, is optimized when it is performed in the highest quality manner and accessed by all eligible candidates. Currently, worldwide, there are over 14 guidance documents for mammographic quality [2]. Some countries, such as the United Kingdom (UK), monitor quality through a national screening program. In the United States (US), where 39 million mammograms are performed annually [3], there is not a national screening program, but the federal government mandates minimum quality standards for the performance of mammography. Among a consortium of European countries, the European Reference Organisation for Quality Assured Breast Screening and Diagnostic Services (EUREF) promotes voluntary adherence to European mammography quality standards. Setting quality standards at national or international levels ensures the uniformity of practice and identifies substandard practices in need of improvement, ultimately maximizing the benefit of screening mammography.

Frequency and outcomes of MRI-detected axillary adenopathy following COVID-19 vaccination.

OBJECTIVES: To assess the frequency of ipsilateral axillary adenopathy on breast MRI after COVID-19 vaccination. To investigate the duration, outcomes, and associated variables of vaccine-related adenopathy. METHODS: In this retrospective cohort study, our database was queried for patients who underwent breast MRI following COVID-19 vaccination from January 22, 2021, to March 21, 2021. The frequency of ipsilateral axillary adenopathy and possible associated variables were evaluated, including age, personal history of ipsilateral breast cancer, clinical indication for breast MRI, type of vaccine, side of vaccination, number of doses, and number of days between the vaccine and the MRI exam. The outcomes of the adenopathy were investigated, including the duration of adenopathy and biopsy results. RESULTS: A total of 357 patients were included. The frequency of adenopathy on breast MRI was 29% (104/357 patients). Younger patients and shorter time intervals from the second dose of the vaccine were significantly associated with the development of adenopathy (p = 0.002 for both). Most adenopathy resolved or decreased on follow-up, with 11% of patients presenting persistence of adenopathy up to 64 days after the second dose of the vaccine. Metastatic axillary carcinoma was diagnosed in three patients; all three had a current ipsilateral breast cancer diagnosis. CONCLUSIONS: Vaccine-related adenopathy is a frequent event after COVID-19 vaccination; short-term follow-up is an appropriate clinical approach, except in patients with current ipsilateral breast cancer. Adenopathy may often persist 4-8 weeks after the second dose of the vaccine, thus favoring longer follow-up periods. KEY POINTS: • MRI-detected ipsilateral axillary adenopathy is a frequent benign finding after mRNA COVID-19 vaccination. • Axillary adenopathy following COVID-19 vaccination often persists > 4 weeks after vaccination, favoring longer follow-up periods. • In patients with concurrent ipsilateral breast cancer, axillary adenopathy can represent metastatic carcinoma and follow-up is not appropriate.

Bone Lesions Detected on Breast MRI: Clinical Outcomes and Features Associated with Metastatic Breast Cancer.

Objective: To determine prevalence and frequency of malignancy among bone lesions detected on breast MRI and to identify clinical and imaging features associated with bone metastases from breast cancer (BC), as bone lesions are suboptimally evaluated on breast imaging protocols and can present a diagnostic challenge. Methods: This IRB-approved retrospective review of breast MRIs performed from June 2009 to June 2018 identified patients with bone lesions. Demographic, clinical, and MRI features were reviewed. Clinical outcome of bone lesions was determined based on pathology and/or additional diagnostic imaging. All benign lesions had ≥ 2 years of imaging follow-up. Statistics were computed with Fisher's exact and Wilcoxon rank sum tests. Results: Among all patients with breast MRI, 1.2% (340/29 461) had bone lesions. Of these, 224 were confirmed benign or metastatic BC by pathology or imaging follow-up, with 70.1% (157/224) be- nign and 29.9% (67/224) metastatic. Bone metastases were associated with BC history (P < 0.001), with metastases occurring in 58.2% (53/91) of patients with current BC, 17.9% (14/78) patients with prior BC, and 0.0% (0/55) without BC. Bone metastases were associated with invasive and ad- vanced stage BC and, on MRI, with location in sternum, ribs, or clavicles, larger size, multiplicity, andT1 hypointensity (all P < 0.01 in tests of overall association). Conclusion: Of clinically confirmed breast MRI-detected bone lesions, 30% were bone metastases; all were detected in patients with current or prior BC. Metastases were associated with advanced stage, invasive carcinoma, larger lesion size, multiplicity, low T1 signal, and non-spine location.

Multidisciplinary Recommendations Regarding Post-Vaccine Adenopathy and Radiologic Imaging: Radiology Scientific Expert Panel.

Vaccination-associated adenopathy is a frequent imaging finding after administration of COVID-19 vaccines that may lead to a diagnostic conundrum in patients with manifest or suspected cancer, in whom it may be indistinguishable from malignant nodal involvement. To help the medical community address this concern in the absence of studies and evidence-based guidelines, this special report offers recommendations developed by a multidisciplinary panel of experts from three of the leading tertiary care cancer centers in the United States. According to these recommendations, some routine imaging examinations, such as those for screening, should be scheduled before or at least 6 weeks after the final vaccination dose to allow for any reactive adenopathy to resolve. However, there should be no delay of other clinically indicated imaging (eg, for acute symptoms, short-interval treatment monitoring, urgent treatment planning or complications) due to prior vaccination. The vaccine should be administered on the side contralateral to the primary or suspected cancer, and both doses should be administered in the same arm. Vaccination information-date(s) administered, injection site(s), laterality, and type of vaccine-should be included in every preimaging patient questionnaire, and this information should be made readily available to interpreting radiologists. Clear and effective communication between patients, radiologists, referring physician teams, and the general public should be considered of the highest priority when managing adenopathy in the setting of COVID-19 vaccination.

MRI appearance of invasive subcentimetre breast carcinoma: benign characteristics are common.

OBJECTIVE: This study was undertaken to examine the characteristics of cancers detected at the earliest possible point on MRI and to determine their significance. METHODS: This institutional review board-approved Health Insurance Portability and Accountability Act-compliant retrospective study evaluated invasive breast cancers ≤1 cm histologically. MRI was performed within 6 months before diagnosis. Between 1 January 2005 and 31 December 2015, 163 cancers in 161 patients were evaluated. Breast Imaging-Reporting and Data System lesion characteristics were assessed by two radiologists independently. In cases of disagreement, arbitration by a third reader was performed. RESULTS: Cancers ≤1 cm became more obviously malignant as they enlarged with regard to shape (p = 0.021), margin (p = 0.0006), internal enhancement (p = 0.0158) and kinetics (p = 0.0001). Cancers ≤5 mm had benign characteristics of circumscribed margins in 71% (71/100), round/oval shape in 67% (67/100) and persistent enhancement in 41% (41/100). High T2 signal was found in 17% (28/62), distributed equally among different sizes (p = 0.3920). In ≤5-mm cancers (59%, 12/29), a comparison study to show interval growth was more often needed to determine the need for biopsy. When interval growth determined biopsy, this was evident within 24 months and cancers remained node negative despite this delay. CONCLUSION: Benign characteristics are present in most invasive cancers ≤5 mm. Small cancers on MRI may need to demonstrate growth to determine need for biopsy. Advances in knowledge: MR lesion characteristics may not be helpful in determining whether small lesions on MR are benign or malignant. However, as 97% of cancers in our study showed interval change when a prior MR for comparison was available, new lesions or increasing size should lead to consideration of biopsy.

Phase II trial of bicalutamide in patients with androgen receptor-positive, estrogen receptor-negative metastatic Breast Cancer.

PURPOSE: Patients with hormone receptor-negative breast cancer generally do not benefit from endocrine-targeted therapies. However, a subset with androgen receptor (AR) expression is predicted to respond to antiandrogen therapies. This phase II study explored bicalutamide in AR-positive, estrogen receptor (ER), and progesterone receptor (PgR)-negative metastatic breast cancer. EXPERIMENTAL DESIGN: Tumors from patients with ER/PgR-negative advanced breast cancer were tested centrally for AR [immunohistochemistry (IHC) > 10% nuclear staining considered positive]. If either the primary or a metastatic site was positive, patients were eligible to receive the AR antagonist bicalutamide at a dose of 150 mg daily. Clinical benefit rate (CBR), the primary endpoint, was defined as the total number of patients who show a complete response (CR), partial response (PR), or stable disease (SD) > 6 months; secondary endpoints included progression-free survival (PFS) and toxicity. Correlative studies included measurement of circulating endocrine markers and IHC surrogates for basal-like breast cancer. RESULTS: Of 424 patients with ER/PgR-negative breast cancer, 12% tested AR-positive. The 6-month CBR was 19% [95% confidence interval (CI), 7%-39%] for bicalutamide. The median PFS was 12 weeks (95% CI, 11-22 weeks). Bicalutamide was well-tolerated with no grade 4/5 treatment-related adverse events observed. CONCLUSION: AR was expressed in 12% of patients with ER/PgR-negative breast cancer screened for this trial. The CBR of 19% observed with bicalutamide shows proof of principle for the efficacy of minimally toxic androgen blockade in a select group of patients with ER/PgR-negative, AR-positive breast cancer.

Phase II trial of a novel capecitabine dosing schedule in combination with lapatinib for the treatment of patients with HER2-positive metastatic breast cancer.

Our group applied mathematical modeling to capecitabine dosing and predicted 7 days of treatment followed by 7 days of rest (7-7) would improve efficacy and minimize toxicity. The conventional schedule of capecitabine limits full dosing in combination with other agents due to toxicity. Lapatinib inhibits the tyrosine kinase of HER2 and has activity when added to conventionally scheduled capecitabine for the treatment of patients with trastuzumab-refractory, HER2-positive, metastatic breast cancer (MBC). We performed this study to evaluate the activity and tolerability of capecitabine 7-7 with lapatinib in patients with trastuzumab-refractory MBC. Eligible patients had measurable, HER2-positive, MBC that progressed following exposure to trastuzumab. Treatment consisted of capecitabine 2,000 mg orally twice daily, 7-7 and lapatinib 1,250 mg orally daily. The primary endpoint was response rate. Secondary endpoints included toxicity, progression-free survival, and stable disease ≥ 6 months. Twenty-three patients were treated on study. More than 60% had prior chemotherapy for MBC and all had prior trastuzumab. After a median of 23 weeks (range 2-96+), five patients had partial responses (23; 95 CI, 7-44%) and six (27; 95 CI, 10-48%) had stable disease ≥ 6 months. Median progression-free survival was 9.4 months. The most common treatment-related toxicities ≥ grade (gr) 2 were hand-foot syndrome (gr 2 43%; gr 3 4% gr 4 0%), diarrhea (gr 2 26%; gr 3/4 0%), elevated liver chemistries (gr 2 17%; gr 3/4 0%), and anemia (gr 2 13%; gr 3 4%; gr 4 4%). No grade ≥ 3 nausea, vomiting, or diarrhea events occurred. This study demonstrated feasibility and after meeting biostatistical requirements for continued accrual was terminated in anticipation of slow enrollment. Capecitabine 7-7 with lapatinib was well tolerated with minimal gastrointestinal toxicity. Antitumor activity was observed in patients with trastuzumab-refractory MBC.

Phase I study of a novel capecitabine schedule based on the Norton-Simon mathematical model in patients with metastatic breast cancer.

PURPOSE: This study was conducted to determine, in patients with advanced-stage breast cancer, the maximum tolerated dose (MTD) of capecitabine administered orally for 7 days followed by a 7-day rest (7/7), a schedule based on a mathematical method for the optimization of anticancer drug scheduling. PATIENTS AND METHODS: Eligible patients had measurable, metastatic breast cancer. There was no limit to number of prior treatments. A standard, three-patients-per-cohort dose-escalation scheme used flat-dose capecitabine beginning at 1,500 mg orally twice daily (bid) on a 7/7 schedule. Each cohort was monitored for 28 days before escalation to the next cohort to assess for delayed toxicity. Response was evaluated radiographically every 12 weeks; toxicity was assessed every 2 weeks. RESULTS: Twenty-one patients were treated on study. The most frequently reported treatment-related grade 2/3 adverse events were hand-foot syndrome (29%), leukopenia/neutropenia (24%), and fatigue (19%). Grade 3 toxicity was transient and easily managed. Three patients experienced grade 3 hand-foot syndrome; one of these patients had grade 3 diarrhea. There were no grade 4 events. The MTD of capecitabine 7/7 is 2,000 mg twice daily. CONCLUSION: As predicted by mathematical modeling, capecitabine dosing for 7 days followed by a 7-day rest is well tolerated. Efficacy of this schedule is being determined in a phase II clinical trial in patients with advanced breast cancer.

Clinical breast examination in a comprehensive breast cancer screening program: contribution and cost.

PURPOSE: To retrospectively evaluate the cost of clinical breast examination (CBE) and its contribution to screening mammography in the detection of breast cancer. MATERIALS AND METHODS: The study received a waiver of authorization from the institutional review board, informed patient consent was not required, and the study was compliant with HIPAA regulations. The records of 60 027 consecutive asymptomatic patients who underwent screening mammography were retrospectively reviewed. CBE was performed on all patients by a nurse practitioner. Patients with positive CBE findings were required to convert from screening to diagnostic evaluation; the number of cancer diagnoses that resulted was determined. The reports, four-view mammograms, or both of patients requiring conversion to diagnostic evaluation were reviewed to determine those patients likely to undergo diagnostic imaging on the basis of screening mammographic findings alone. The cost of CBE was calculated and divided by the number of cancers detected solely with CBE to determine the cost of CBE per additional cancer detected. RESULTS: Four hundred seventy-four (age range, 32-95) of 60 027 asymptomatic patients had positive CBE findings which required conversion to diagnostic evaluation. Forty-six cancers in 44 patients were subsequently diagnosed; 32 would have been detected with mammography alone, whereas 14 were imperceptible at screening mammography. The cost of CBE was $122 598 per cancer detected solely with positive CBE findings. CONCLUSION: CBE performed by nurse practitioners led to the diagnosis of 14 cancers in 13 patients with mammographically occult tumors (0.02% of the screening population and approximately 3% of all cancers diagnosed at the facility during this study). The cost of detecting these additional cancers is estimated to be $122 598 per cancer.

Hibernoma: Report emphasizing large intratumoral vessels and high T1 signal.

We present the computed tomography (CT) and magnetic resonance (MR) imaging features of a gluteal hibernoma found incidentally at CT in an 80-year-old woman. Large, tortuous vessels were demonstrated within a high-T1-signal mass at MR imaging, a combination of findings in hibernomas that has been illustrated but not emphasized in the literature. Such a constellation of findings should strongly suggest the diagnosis of hibernoma (rather than well-differentiated liposarcoma or other soft tissue tumor).

Mammary hibernoma.

We report the case of a 39-year-old asymptomatic woman who presented for screening mammography. Mammography revealed a round, partially circumscribed, partially indistinct, noncalcified 4.5 cm mass in upper outer right breast. This vaguely palpable mass appeared as a well-circumscribed, oval, hyperechoic, parallel, septated mass on sonography. Ultrasound-guided core biopsy led to the diagnosis of hibernoma. Few cases of hibernomas have been reported in the English literature, and their occurrence in the breast is particularly rare [Eur J Surg Oncol 26 (2000) 430; Am J Surg Pathol 25 (2001) 809]. To our knowledge, this is the first case of mammary hibernoma in which the ultrasonographic and mammographic features of this unusual entity are demonstrated.