Screening the Implant-Augmented Breast with Digital Breast Tomosynthesis: Is Tomosynthesis Necessary for Non-implant-Displaced Views?

OBJECTIVE: To determine cancer visualization utility and radiation dose for non-implant-displaced (ID) views using standard protocol with digital breast tomosynthesis (DBT) vs alternative protocol with 2D only when screening women with implant augmentation. METHODS: This retrospective cohort study identified women with implants who underwent screening DBT examinations that had abnormal findings from July 28, 2014, to December 31, 2021. Three fellowship-trained breast radiologists independently reviewed examinations retrospectively to determine if the initially identified abnormalities could be visualized on standard protocol (DBT with synthesized 2D (S2D) for ID and non-ID views) and alternate protocol (DBT with S2D for ID and only the S2D images for non-ID views). Estimated exam average glandular dose (AGD) and associations between cancer visualization with patient and implant characteristics for both protocols were evaluated. RESULTS: The study included 195 patients (mean age 55 years ± 10) with 223 abnormal findings. Subsequent biopsy was performed for 86 abnormalities: 59 (69%) benign, 8 (9%) high risk, and 19 (22%) malignant. There was no significant difference in malignancy visualization rate between standard (19/223, 8.5%) and alternate (18/223, 8.1%) protocols (P = .92), but inclusion of the DBT for non-ID views found one additional malignancy. Total examination AGD using standard protocol (21.9 mGy ± 5.0) was significantly higher than it would be for estimated alternate protocol (12.6 mGy ± 5.0, P <.001). This remained true when stratified by breast thickness: 6.0-7.9 cm, 8.0-9.9 cm, >10.0 cm (all P <.001). CONCLUSION: The inclusion of DBT for non-ID views did not significantly increase the cancer visualization rate but did significantly increase overall examination AGD.

Retained Biopsy Site Markers After Breast Lesion Surgical Resection: Associations With Residual Malignancy.

BACKGROUND. Biopsy site markers (BSMs) placed during image-guided core needle biopsy (CNB) are typically targeted for surgical excision, along with the breast imaging abnormality. Retained BSMs raise concern of incomplete resection of the breast abnormality. OBJECTIVE. The purpose of our study was to assess the frequency of residual malignancy in patients with retained BSMs identified on the initial mammography performed after breast lesion surgical excision. METHODS. This retrospective study included 30 patients (median age, 59 years) who underwent surgical resection between August 2015 and April 2022 of a borderline, high-risk, or malignant breast lesion after CNB and technically adequate preoperative image-guided localization, in whom the initial postoperative mammography report described a retained nonmigrated BSM. EMR data were extracted. The index pathology from CNB and initial surgical resection was classified as malignant or nonmalignant. The presence of residual malignancy after initial surgical resection required pathologic confirmation from subsequent tissue sampling; the absence of residual malignancy required 2 years of benign imaging follow-up. RESULTS. Thirteen specimen radiographs were interpreted intraoperatively by a surgeon with later radiologist interpretation, and 17 underwent real-time radiologist interpretation. Eighteen patients had malignant index pathology from the initially resected lesion. The frequency of residual malignancy on subsequent follow-up after initial surgical resection was higher in patients with malignant than nonmalignant index pathology (39% [7/18] vs 0% [0/12], respectively; p = .02). Among patients with malignant index pathology, the frequency of residual malignancy was higher in those without, than with, malignancy in the initial surgical specimen (80% [4/5] vs 23% [3/13]; p = .047). Also in these patients, the frequency of a positive interpretation of the initial postoperative mammography (BI-RADS category 4 or 6) was not significantly different between those with and without residual malignancy (57% [4/7] vs 55% [6/11]; p > .99). CONCLUSION. Patients with retained BSMs associated with malignant index lesions are at substantial risk of having residual malignancy. Initial postoperative mammography is not sufficient for excluding residual malignancy. CLINICAL IMPACT. Retained BSMs associated with index malignancy should be considered suspicious for residual malignancy. In this scenario, timely additional tissue sampling targeting the retained BSM is warranted, given the greater-than-2% chance of malignancy. Active surveillance is a reasonable management strategy in patients with retained BSMs from nonmalignant index lesions.

Role of digital breast tomosynthesis in the evaluation of focal breast pain.

RATIONAL AND OBJECTIVE: To investigate the utility of digital breast tomosynthesis (DBT) in the evaluation of focal breast pain, considering breast density and breast cancer risk. METHODS: Ninety-one cases of focal breast pain evaluated with DBT and ultrasound (US) from 12/30/2014 to 11/9/2017 with 2-year follow-up were identified. Exclusion criteria were non-focal, axillary, or radiating pain; palpable or skin changes; pregnancy or lactation; and history of ipsilateral cancer, trauma, or infection. Demographic data, Tyrer-Cuzick Score (TCS), medical history, breast density, imaging results, and pathology were recorded. Descriptive statistics were reported. RESULTS: Eighteen percent (16/91) of cases demonstrated findings, all benign. Of these, 6% (1/16) were detected by DBT only, 88% (14/16) by US only, and 6% (1/16) by DBT and US. US resulted in 3 benign biopsies. Ninety-nine percent (75/76) of cases with no findings at the site of pain on US also had no findings on DBT. Ninety-eight percent (89/91) of cases with no cancer detected at the site of pain on US also did not have cancer on DBT. DBT detected 2 incidental cancers not associated with pain. DBT and US agreed that there was no finding at the site of pain in 82% (75/91) of cases. A high degree of agreement between DBT and US was seen when stratified by breast density and TCS. CONCLUSION: DBT may be appropriate for the evaluation of focal pain. Low breast cancer incidence was observed at the site of focal pain across all mammographic breast densities and breast cancer risks.

Molecular Subtypes of Breast Cancer: A Review for Breast Radiologists.

Gene expression profiling has reshaped our understanding of breast cancer by identifying four molecular subtypes: (1) luminal A, (2) luminal B, (3) human epidermal growth factor receptor 2 (HER2)-enriched, and (4) basal-like, which have critical differences in incidence, response to treatment, disease progression, survival, and imaging features. Luminal tumors are most common (60%-70%), characterized by estrogen receptor (ER) expression. Luminal A tumors have the best prognosis of all subtypes, whereas patients with luminal B tumors have significantly shorter overall and disease-free survival. Distinguishing between these tumors is important because luminal B tumors require more aggressive treatment. Both commonly present as irregular masses without associated calcifications at mammography; however, luminal B tumors more commonly demonstrate axillary involvement at diagnosis. HER2-enriched tumors are characterized by overexpression of the HER2 oncogene and low-to-absent ER expression. HER2+ disease carries a poor prognosis, but the development of anti-HER2 therapies has greatly improved outcomes for women with HER2+ breast cancer. HER2+ tumors most commonly present as spiculated masses with pleomorphic calcifications or as calcifications alone. Basal-like cancers (15% of all invasive breast cancers) predominate among "triple negative" cancers, which lack ER, progesterone receptor (PR), and HER2 expression. Basal-like cancers are frequently high-grade, large at diagnosis, with high rates of recurrence. Although imaging commonly reveals irregular masses with ill-defined or spiculated margins, some circumscribed basal-like tumors can be mistaken for benign lesions. Incorporating biomarker data (histologic grade, ER/PR/HER2 status, and multigene assays) into classic anatomic tumor, node, metastasis (TNM) staging can better inform clinical management of this heterogeneous disease.

Awareness of implicit bias mitigates discrimination in radiology resident selection.

OBJECTIVES: Implicit bias is common and is thought to drive discriminatory behaviour. Having previously demonstrated discrimination against specific applicant demographics by academic radiology departments in a simulated resident selection process, the authors sought to better understand the relationship between implicit bias and discrimination, as well as the potential and mechanisms for their mitigation. METHODS: A total of 51 faculty reviewers at three academic radiology departments, who had participated in a 2017 audit study in which they were shown to treat applicants differently based on race or ethnicity and physical appearance, were invited to complete testing for implicit racial and weight bias using the Implicit Association Test in 2019. Respondents were also surveyed regarding awareness of their own personal racial and weight biases, as well as any prior participation in formal diversity training. Comparisons were made between implicit bias scores and applicant ratings, as well as between diversity training and self-awareness of bias. RESULTS: A total of 31 out of 51 faculty reviewers (61%) completed and submitted results of race and weight Implicit Association Tests. A total of 74% (23/31) reported implicit anti-obese bias, concordant with discrimination demonstrated in the resident selection simulation, in which obese applicants were rated 0.40 standard deviations (SDs) lower than non-obese applicants (P < .001). A total of 71% (22/31) reported implicit anti-Black bias, discordant with application ratings, which were 0.47 SDs higher for Black than for White applicants (P < .001). A total of 84% (26/31) of participants reported feeling self-aware of potential racial bias at the time of application review, significantly higher than the 23% (7/31) reporting self-awareness of potential anti-obese bias (P < .001). Participation in formal diversity training was not associated with implicit anti-Black or anti-fat bias, nor with self-reported awareness of potential racial or weight-based bias (all P > .2). CONCLUSIONS: These findings suggest that implicit bias, as measured by the Implicit Association Test, does not inevitably lead to discrimination, and that personal awareness of implicit biases may allow their mitigation.

Bias in Radiology Resident Selection: Do We Discriminate Against the Obese and Unattractive?

PURPOSE: To evaluate for appearance-based discrimination in the selection of radiology residents. METHOD: A deception study simulating the resident selection process examined the impact of attractiveness and obesity on resident selection. Seventy-four core faculty from 5 academic radiology departments reviewed mock residency applications in September and October 2017. Each application included demographic information and a photograph, representing a prespecified distribution of facial attractiveness and obesity, combined with randomized academic and supporting variables. Reviewers independently scored applications for interview desirability. Reviewer scores and application variables were compared using linear mixed fixed- and random-effects models. RESULTS: Reviewers evaluated 5,447 applications (mean: 74 applications per reviewer). United States Medical Licensing Examination Step 1 scores were the strongest predictor of reviewer rating (B = 0.35 [standard error (SE) = 0.029]). Applicant facial attractiveness strongly predicted rating (attractive vs unattractive, B = 0.30 [SE = 0.056]; neutral vs unattractive, B = 0.13 [SE = 0.028]). Less influential but still significant predictors included race/ethnicity (B = 0.25 [SE = 0.059]), preclinical class rank (B = 0.25 [SE = 0.040]), clinical clerkship grades (B = 0.23 [SE = 0.034]), Alpha Omega Alpha membership (B = 0.21 [SE = 0.032]), and obesity (vs not obese) (B = -0.14 [SE = 0.024]). CONCLUSIONS: Findings provide preliminary evidence of discrimination against facially unattractive and obese applicants in radiology resident selection. Obesity and attractiveness were as influential in applicant selection for interview as traditional medical school performance metrics. Selection committees should invoke strategies to detect and manage appearance-based bias.

A Proposal to Define Three New Breast Calcification Shapes: Square, Sandwich, and Teardrop, Pill & Capsule.

OBJECTIVE: To define and illustrate three new descriptors for microcalcification morphology on mammography, and provide a preliminary assessment of their potential clinical value. METHODS: The institutional review board approved this retrospective study and waived the requirement for informed consent. One thousand consecutive biopsy-proven cases of microcalcifications were retrospectively reviewed by the index study observer, a fellowship-trained breast radiologist blinded to histologic outcome. Each case was evaluated for traditional Breast Imaging Reporting and Data System (BI-RADS) morphology descriptors, as well as for the presence of one of three proposed new calcification morphology descriptors: (1) square, (2) sandwich, and (3) teardrop, pill & capsule. Positive predictive value (PPV) for each proposed shape was calculated. Interobserver variability was calculated on a subset of 200 cases, which were evaluated by two additional breast radiologists blinded to the interpretation of the index observer. RESULTS: Of 1000 cases, 702 (70.2%) were benign, and 298 (29.8%) were malignant. There were 51 (5.1%) square and 60 (6.0%) sandwich calcification cases, which were all benign at biopsy (PPV, 0%). Of the 106 (10.6%) cases that included teardrop, pill & capsule calcifications, 90 were malignant (PPV, 84.9%). Interobserver variability for the traditional BI-RADS morphology descriptors (κ = 0.40) was comparable to observer variability of the proposed new morphologies: square (κ = 0.39), sandwich (κ = 0.47), and teardrop, pill & capsule (κ = 0.49). CONCLUSION: The proposed calcification descriptors square and sandwich-shaped had a PPV of 0%, and they may represent new typically benign morphologies. In contrast, teardrop, pill & capsule-shaped calcifications indicate a higher likelihood of malignancy than that of previously established descriptors.

Optimizing the Patient Experience during Breast Biopsy.

For years, breast imaging has been the model in radiology for patient communication, and more recently, it has been a leader in the growing patient- and family-centered approach to care. To maintain high levels of patient satisfaction during image-guided core-needle breast biopsies, the radiologist should understand patient perspectives so that interventions can be developed to manage patient concerns. This article reviews patient perspectives before, during, and after imaging-guided breast biopsies, and it describes strategies to help optimize the experiences of patients as they navigate the process.

Normal Axillary Lymph Node Variability Between White and Black Women on Breast MRI.

RATIONALE AND OBJECTIVES: This study aimed to determine if there were differences in the imaging features of normal lymph nodes between white and black women using magnetic resonance imaging. MATERIALS AND METHODS: Following institutional review board approval, we identified white and black women who underwent breast magnetic resonance imaging from November 1, 2008 to December 31, 2013 at our institution. To identify normal lymph nodes for measurement, patients with any benign or malignant causes for lymph node enlargement and patients with any subsequent breast cancer in the following 2 years were excluded. Black and white women were age matched at a 1:2 ratio. The largest lymph node in each axilla was measured for the long-axis length and maximal cortical thickness. Comparisons were made between white and black women using a conditional logistic regression to control for matching. RESULTS: There were 55 black women and 110 white women for analysis. The mean lymph node long-axis length was 14.7 ± 5.3 mm for black women and 14.4 ± 6.4 mm for white women (P = .678). The mean maximum cortical thickness was 3.3 ± 1.6 mm for black women and 2.6 ± 1.4 mm for Caucasian women (P < .001). A significantly higher percentage of black than white women had cortical thicknesses greater than threshold values of 3, 4, 5, 6, and 7 mm (P < .01 for all). CONCLUSIONS: The normal lymph node cortical thickness in black women is significantly greater than in white women, which should be considered when deciding to recommend a lymph node biopsy.

Relationships Between MRI Breast Imaging-Reporting and Data System (BI-RADS) Lexicon Descriptors and Breast Cancer Molecular Subtypes: Internal Enhancement is Associated with Luminal B Subtype.

The aim of this study was to determine the associations between breast MRI findings using the Breast Imaging-Reporting and Data System (BI-RADS) lexicon descriptors and breast cancer molecular subtypes. In this retrospective, IRB-approved, single institution study MRIs from 278 women with breast cancer were reviewed by one of six fellowship-trained breast imagers. Readers reported BI-RADS descriptors for breast masses (shape, margin, internal enhancement) and non-mass enhancement (distribution, internal enhancement). Pathology reports were reviewed for estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor-2 (HER2). Surrogates were used to categorize tumors by molecular subtype: ER/PR+, HER2- (luminal A); ER/PR+, HER2+ (luminal B); ER/PR-, HER2+ (HER2); ER/PR/HER2- (basal). A univariate logistic regression model was developed to identify associations between BI-RADS descriptors and molecular subtypes. Internal enhancement for mass and non-mass enhancement was combined for analysis. There was an association between mass shape and basal subtype (p = 0.039), which was more frequently round (17.1%) than other subtypes (range: 0-8.3%). In addition, there was an association between mass margin and HER2 subtype (p = 0.040), as HER2 cancers more frequently had a smooth margin (33.3%) than other subtypes (range: 4.2-17.1%). Finally, there was an association between internal enhancement and luminal B subtype (p = 0.003), with no cases of luminal B cancer demonstrating homogeneous internal enhancement versus a range of 10.9-23.5% for other subtypes. There are associations between breast cancer molecular subtypes and lesion appearance on MRI using the BI-RADS lexicon.

Focal Breast Pain: Does Breast Density Affect the Need for Ultrasound?

RATIONALE AND OBJECTIVES: This study aimed to determine the utility of directed ultrasound and digital mammogram for evaluating focal breast pain in women with different mammographic breast densities. MATERIALS AND METHODS: This institutional review board-approved and Health Insurance Portability and Accountability Act-compliant retrospective study included 413 cases of focal breast pain in 369 women (mean age 53 years). All cases were evaluated with both mammogram and ultrasound and had at least 2 years of imaging follow-up. Exclusion criteria were non-focal, axillary, or radiating pain; palpable or skin changes; pregnancy or lactation; and history of trauma or infection. Breast density, imaging findings, and biopsy results were recorded. Specificity, positive predictive values, and negative predictive values were calculated. RESULTS: Eighteen percent (76 of 413) of cases demonstrated an imaging correlate. Of these, 74% (56 of 76) occurred in dense breasts and 26% (20 of 76) in nondense breasts. Seventy percent (14 of 20) of lesions in nondense breasts were seen with mammography and ultrasound, whereas 30% (6 of 20) were detected only with ultrasound. Of lesions detected in dense breasts, 29% (16 of 56) were seen with mammography and ultrasound, whereas 71% (40 of 56) were detected only with ultrasound. Thirty-one percent (24 of 76) of cases were biopsied, 42% (10 of 24) of which were detected by ultrasound only. No cancer was detected in initial workup. At 2-year follow-up, three women, all with dense breasts, developed cancer in the same quadrant as the initial pain. CONCLUSIONS: Directed ultrasound, when performed in conjunction with digital mammography for the evaluation of focal breast pain in women with nondense breasts, is of low utility and may contribute to unnecessary intervention as a result of incidental findings.

Positive and negative mood following imaging-guided core needle breast biopsy and receipt of biopsy results.

Positive and negative mood are independent psychological responses to stressful events. Negative mood negatively impacts well-being and co-occurring positive mood leads to improved adjustment. Women undergoing core needle breast biopsies (CNB) experience distress during CNB and awaiting results; however, influences of mood are not well known. This longitudinal study examines psychosocial and biopsy- and spirituality-related factors associated with mood in patients day of CNB and one week after receiving results. Ninety women undergoing CNB completed questionnaires on psychosocial factors (chronic stress, social support), biopsy experiences (pain, radiologist communication), and spirituality (peace, meaning, faith) day of CNB. Measures of positive and negative mood were completed day of CNB and one week after receiving results (benign n = 50; abnormal n = 25). Multiple linear regression analyses were conducted. Greater positive mood correlated with greater peace (ß = .25, p = .02) day of CNB. Lower negative mood correlated with greater peace (ß = -.29, p = .004) and there was a trend for a relationship with less pain during CNB (ß = .19, p = .07). For patients with benign results, day of CNB positive mood predicted positive mood post-results (ß = .31, p = .03) and only chronic stress predicted negative mood (ß = .33, p = .03). For women with abnormal results, greater meaning day of CNB predicted lower negative mood post-results (ß = -.45, p = .03). Meaning and peace may be important for women undergoing CNB and receiving abnormal results.

Suspicious breast calcifications undergoing stereotactic biopsy in women ages 70 and over: Breast cancer incidence by BI-RADS descriptors.

OBJECTIVES: To determine the malignancy rate overall and for specific BI-RADS descriptors in women ≥70 years who undergo stereotactic biopsy for calcifications. METHODS: We retrospectively reviewed 14,577 consecutive mammogram reports in 6839 women ≥70 years to collect 231 stereotactic biopsies of calcifications in 215 women. Cases with missing images or histopathology and calcifications associated with masses, distortion, or asymmetries were excluded. Three breast radiologists determined BI-RADS descriptors by majority. Histology, hormone receptor status, and lymph node status were correlated with BI-RADS descriptors. RESULTS: There were 131 (57 %) benign, 22 (10 %) atypia/lobular carcinomas in situ, 55 (24 %) ductal carcinomas in situ (DCIS), and 23 (10 %) invasive diagnoses. Twenty-seven (51 %) DCIS cases were high-grade. Five (22 %) invasive cases were high-grade, two (9 %) were triple-negative, and three (12 %) were node-positive. Malignancy was found in 49 % (50/103) of fine pleomorphic, 50 % (14/28) of fine linear, 25 % (10/40) of amorphous, 20 % (3/15) of round, 3 % (1/36) of coarse heterogeneous, and 0 % (0/9) of dystrophic calcifications. CONCLUSIONS: Among women ≥70 years that underwent stereotactic biopsy for calcifications only, we observed a high rate of malignancy. Additionally, coarse heterogeneous calcifications may warrant a probable benign designation. KEY POINTS: • Cancer rates of biopsied calcifications in women ≥70 years are high • Radiologists should not dismiss suspicious calcifications in older women • Coarse heterogeneous calcifications may warrant a probable benign designation.

Imaging-Guided Core-Needle Breast Biopsy: Impact of Meditation and Music Interventions on Patient Anxiety, Pain, and Fatigue.

PURPOSE: To evaluate the impact of guided meditation and music interventions on patient anxiety, pain, and fatigue during imaging-guided breast biopsy. METHODS: After giving informed consent, 121 women needing percutaneous imaging-guided breast biopsy were randomized into three groups: (1) guided meditation; (2) music; (3) standard-care control group. During biopsy, the meditation and music groups listened to an audio-recorded, guided, loving-kindness meditation and relaxing music, respectively; the standard-care control group received supportive dialogue from the biopsy team. Immediately before and after biopsy, participants completed questionnaires measuring anxiety (State-Trait Anxiety Inventory Scale), biopsy pain (Brief Pain Inventory), and fatigue (modified Functional Assessment of Chronic Illness Therapy-Fatigue). After biopsy, participants completed questionnaires assessing radiologist-patient communication (modified Questionnaire on the Quality of Physician-Patient Interaction), demographics, and medical history. RESULTS: The meditation and music groups reported significantly greater anxiety reduction (P values < .05) and reduced fatigue after biopsy than the standard-care control group; the standard-care control group reported increased fatigue after biopsy. The meditation group additionally showed significantly lower pain during biopsy, compared with the music group (P = .03). No significant difference in patient-perceived quality of radiologist-patient communication was noted among groups. CONCLUSIONS: Listening to guided meditation significantly lowered biopsy pain during imaging-guided breast biopsy; meditation and music reduced patient anxiety and fatigue without compromising radiologist-patient communication. These simple, inexpensive interventions could improve women's experiences during core-needle breast biopsy.

Radiology Trainee Performance in Digital Breast Tomosynthesis: Relationship Between Difficulty and Error-Making Patterns.

PURPOSE: The aim of this study was to better understand the relationship between digital breast tomosynthesis (DBT) difficulty and radiology trainee performance. METHODS: Twenty-seven radiology residents and fellows and three expert breast imagers reviewed 60 DBT studies consisting of unilateral craniocaudal and medial lateral oblique views. Trainees had no prior DBT experience. All readers provided difficulty ratings and final BI-RADS(®) scores. Expert breast imager consensus interpretations were used to determine the ground truth. Trainee sensitivity, specificity, and area under the receiver operating characteristic curve (AUC) were calculated for low- and high-difficulty subsets of cases as assessed by each trainee him or herself (self-assessed difficulty) and consensus expert-assessed difficulty. RESULTS: For self-assessed difficulty, the trainee AUC was 0.696 for high-difficulty and 0.704 for low-difficulty cases (P = .753). Trainee sensitivity was 0.776 for high-difficulty and 0.538 for low-difficulty cases (P < .001). Trainee specificity was 0.558 for high-difficulty and 0.810 for low-difficulty cases (P < .001). For expert-assessed difficulty, the trainee AUC was 0.645 for high-difficulty and 0.816 for low-difficulty cases (P < .001). Trainee sensitivity was 0.612 for high-difficulty and .784 for low-difficulty cases (P < .001). Trainee specificity was 0.654 for high-difficulty and 0.765 for low-difficulty cases (P = .021). CONCLUSIONS: Cases deemed difficult by experts were associated with decreases in trainee AUC, sensitivity, and specificity. In contrast, for self-assessed more difficult cases, the trainee AUC was unchanged because of increased sensitivity and compensatory decreased specificity. Educators should incorporate these findings when developing educational materials to teach interpretation of DBT.

Abbreviated screening protocol for breast MRI: a feasibility study.

RATIONALE AND OBJECTIVES: To compare the performance of two shortened breast magnetic resonance imaging (MRI) protocols to a standard MRI protocol for breast cancer screening. MATERIALS AND METHODS: In this Health Insurance Portability and Accountability Act compliant, institutional review board-approved pilot study, three fellowship-trained breast imagers evaluated 48 breast MRIs (24 normal, 12 benign, and 12 malignant) selected from a high-risk screening population. MRIs were presented in three viewing protocols, and a final Breast Imaging-Reporting and Data System assessment was recorded for each case. The first shortened protocol (abbreviated 1) included only fat-saturated precontrast T2-weighted, precontrast T1-weighted, and first pass T1-weighted postcontrast sequences. The second shortened protocol (abbreviated 2) included the abbreviated 1 protocol plus the second pass T1-weighted postcontrast sequence. The third protocol (full), reviewed after a 1-month waiting period, included a nonfat-saturated T1-weighted sequence, fat-saturated T2-weighted, precontrast T1-weighted, and three or four dynamic postcontrast sequences. Interpretation times were recorded for the abbreviated 1 and full protocols. Sensitivity and specificity were compared via a chi-squared analysis. This pilot study was designed to detect a 10% difference in sensitivity with a power of 0.8. RESULTS: There was no significant difference in sensitivity between the abbreviated 1 (86%; P = .22) or abbreviated 2 (89%; P = .38) protocols and the full protocol (95%). There was no significant difference in specificity between the abbreviated 1 (52%; P = 1) or abbreviated 2 (45%; P = .34) protocols and the full protocol (52%). The abbreviated 1 and full protocol interpretation times were similar (2.98 vs. 3.56 minutes). CONCLUSIONS: In this pilot study, reader performance comparing two shortened breast MRI protocols to a standard protocol in a screening cohort were similar, suggesting that a shortened breast MRI protocol may be clinically useful, warranting further investigation.

Does Breast Imaging Experience During Residency Translate Into Improved Initial Performance in Digital Breast Tomosynthesis?

PURPOSE: To determine the initial digital breast tomosynthesis (DBT) performance of radiology trainees with varying degrees of breast imaging experience. METHODS: To test trainee performance with DBT, we performed a reader study, after obtaining IRB approval. Two medical students, 20 radiology residents, 4 nonbreast imaging fellows, 3 breast imaging fellows, and 3 fellowship-trained breast imagers reviewed 60 unilateral DBT studies (craniocaudal and medio-lateral oblique views). Trainees had no DBT experience. Each reader recorded a final BI-RADS assessment for each case. The consensus interpretations from fellowship-trained breast imagers were used to establish the ground truth. Area under the receiver operating characteristic curve (AUC), sensitivity, and specificity were calculated. For analysis, first- through third-year residents were classified as junior trainees, and fourth-year residents plus nonbreast imaging fellows were classified as senior trainees. RESULTS: The AUCs were .569 for medical students, .721 for junior trainees, .701 for senior trainees, and .792 for breast imaging fellows. The junior and senior trainee AUCs were equivalent (P < .01) using a two one-sided test for equivalence, with a significance threshold of 0.1. The sensitivities and specificities were highest for breast imaging fellows (.778 and .815 respectively), but similar for junior (.631 and .714, respectively) and senior trainees (.678 and .661, respectively). CONCLUSIONS: Initial performance with DBT among radiology residents and nonbreast imaging fellows is independent of years of training. Radiology educators should consider these findings when developing educational materials.