Maximizing Mentorship Throughout Your Breast Imaging Career.

Unlike many other subspecialties in radiology, breast radiologists practice in a patient-facing and interdisciplinary environment where team building, communication, and leadership skills are critical. Although breast radiologists can improve these skills over time, strong mentorship can accelerate this process, leading to a more successful and satisfying career. In addition to providing advice, insight, feedback, and encouragement to mentees, mentors help advance the field of breast radiology by contributing to the development of the next generation of leaders. During the mentorship process, mentors continue to hone their listening, problem-solving, and networking skills, which in turn creates a more supportive and nurturing work environment for the entire breast care team. This article reviews important mentorship skills that are essential for all breast radiologists. Although some of the principles apply to all mentoring relationships, ensuring that every breast radiologist has the skills to be both an effective mentor and mentee is key to the future of the profession.

Cholesterol granuloma of the breast: A case report.

Cholesterol granuloma of the breast is a rare entity that can be indistinguishable from cancer on physical exam and imaging. We present the case of a 58-year-old woman who developed a new enhancing mass on high-risk screening magnetic resonance imaging (MRI). Interestingly, this mass developed in the same area as a previously noted benign-appearing inflammatory cyst that had been decreasing in size on MRI and mammogram over many years. Ultrasound-guided biopsy was performed which revealed cholesterol granuloma. We will discuss the nonspecific imaging findings and the characteristic histopathological features that confirm diagnosis.

Breast cancer in a transgender woman undergoing gender-affirming exogenous hormone therapy.

Gender-affirming hormone therapy may be utilized by transgender women hoping to induce feminizing changes and suppress the effects of endogenous testosterone. It is well established that exogenous hormone use increases risk of breast cancer in cisgender women; however, a link in the transgender population is less clear. Our case presents a transgender woman undergoing gender-affirming exogenous hormone therapy who subsequently developed breast cancer. We review the available literature regarding risks of exogenous hormone therapy with regards to breast cancer development. Additionally, we present current societal guidelines and recommendations for screening in this population.

Encapsulated papillary carcinoma of the breast: A case report.

Breast malignancies diagnosed from screening mammography most commonly present as a new or enlarging lesion at the time of diagnosis. We present the unusual case of an encapsulated papillary carcinoma that demonstrated decreasing size on mammogram over several subsequent years. We review the unique imaging and histologic findings of papillary carcinoma that make this imaging conundrum possible.

Use of Artificial Intelligence for Digital Breast Tomosynthesis Screening: A Preliminary Real-world Experience.

OBJECTIVE: The purpose of this study is to assess the "real-world" impact of an artificial intelligence (AI) tool designed to detect breast cancer in digital breast tomosynthesis (DBT) screening exams following 12 months of utilization in a subspecialized academic breast center. METHODS: Following IRB approval, mammography audit reports, as specified in the BI-RADS atlas, were retrospectively generated for five radiologists reading at three locations during a 12-month time frame. One location had the AI tool (iCAD ProFound AI v2.0), and the other two locations did not. The co-primary endpoints were cancer detection rate (CDR) and abnormal interpretation rate (AIR). Secondary endpoints included positive predictive values (PPVs) for cancer among screenings with abnormal interpretations (PPV1) and for biopsies performed (PPV3). Odds ratios (OR) with two-sided 95% confidence intervals (CIs) summarized the impact of AI across radiologists using generalized estimating equations. RESULTS: Nonsignificant differences were observed in CDR, AIR, and PPVs. The CDR was 7.3 with AI and 5.9 without AI (OR 1.3, 95% CI: 0.9-1.7). The AIR was 11.7% with AI and 11.8% without AI (OR 1.0, 95% CI: 0.8-1.3). The PPV1 was 6.2% with AI and 5.0% without AI (OR 1.3, 95% CI: 0.97-1.7). The PPV3 was 33.3% with AI and 32.0% without AI (OR 1.1, 95% CI: 0.8-1.5). CONCLUSION: Although we are unable to show statistically significant changes in CDR and AIR outcomes in the two groups, the results are consistent with prior reader studies. There is a nonsignificant trend toward improvement in CDR with AI, without significant increases in AIR.

Can COVID-19 worsen racial disparities in breast cancer screening and diagnosis?

Background: Health disparities among minority groups, especially African Americans, can limit their access to quality medical care and lead to disproportionate medical management and disease outcomes. The aim of this study was to compare the COVID-19-related change in mammogram volumes and cancer detection at two affiliated academic breast centers, one that serves a predominantly African American patient population and one that serves a predominantly non-African American patient population. Materials and methods: For the purpose of anonymity, racial demographics were collected and the center with a higher African American patient population was designated as institution A, while the center with a higher non-African American patient population was designated as institution B. Careful selection of the two breast centers was instituted in order to limit the impact of potential confounders other than race.An Institutional Review Board (IRB) exemption was obtained and two Mammography Quality Standards Act (MQSA) reports were generated; one for March 2020 through September 2020, during the height of the COVID-19 pandemic, and one for March 2019 through September 2019 to serve as the pre-pandemic control group. The i2b2 Query Analysis Tool® was used to obtain racial demographic data and compare the percent change in screening and diagnostic mammograms, image-guided biopsies, total cancers diagnosed by imaging, and percent of minimal cancers for both institutions. Results: Screening mammograms and breast cancer detection decreased in 2020 compared to 2019 at both institutions. However, the percent change from 2019 to 2020 was greater at institution A than at institution B. Percent minimal cancers, an indicator of early-stage breast cancer also decreased more drastically at institution A than at institution B. Interestingly, the total number of diagnostic exams and image-guided biopsies increased in 2020 at institution B, whereas both decreased at institution A. Conclusion: The COVID-19 pandemic may lead to worsening racial disparities in breast cancer screening. In an effort to narrow future disparity, it is crucial for radiologists and other health care providers to be aware of this inequality and educate all women on the importance of obtaining routine screening mammography. More studies are needed.

Locally advanced invasive lobular carcinoma presenting as skin erythema, with multimodality imaging correlation.

Invasive lobular carcinoma comprises 10-15% of invasive carcinomas of the breast. Its inconspicuous pattern of proliferation may lead to tumor manifestations that can be challenging to detect on mammography and clinical exam, which can result in tumor detection at advanced size and stage. This case demonstrates a locally advanced invasive lobular carcinoma and its subtle growth pattern illustrated on several imaging modalities, as well as its unique initial clinical presentation of skin erythema mistaken for rash.

Muscular variant presenting as an asymmetry on mammogram.

Anatomic variants in chest wall musculature can pose a potential diagnostic dilemma when visible on a mammogram. A few variants have been commonly reported in the literature and can be confidently identified by appearance and location. We present a case of a pectoralis muscle variant, not previously described in radiology literature that presented as a unilateral asymmetry on a screening mammogram. This article reviews common imaging appearances of muscular variants seen mammographically and provides a diagnostic algorithm to avoid unnecessary workup or biopsy.

Multireader evaluation of radiologist performance for COVID-19 detection on emergency department chest radiographs.

BACKGROUND: Chest radiographs (CXR) are frequently used as a screening tool for patients with suspected COVID-19 infection pending reverse transcriptase polymerase chain reaction (RT-PCR) results, despite recommendations against this. We evaluated radiologist performance for COVID-19 diagnosis on CXR at the time of patient presentation in the Emergency Department (ED). MATERIALS AND METHODS: We extracted RT-PCR results, clinical history, and CXRs of all patients from a single institution between March and June 2020. 984 RT-PCR positive and 1043 RT-PCR negative radiographs were reviewed by 10 emergency radiologists from 4 academic centers. 100 cases were read by all radiologists and 1927 cases by 2 radiologists. Each radiologist chose the single best label per case: Normal, COVID-19, Other - Infectious, Other - Noninfectious, Non-diagnostic, and Endotracheal Tube. Cases labeled with endotracheal tube (246) or non-diagnostic (54) were excluded. Remaining cases were analyzed for label distribution, clinical history, and inter-reader agreement. RESULTS: 1727 radiographs (732 RT-PCR positive, 995 RT-PCR negative) were included from 1594 patients (51.2% male, 48.8% female, age 59 ± 19 years). For 89 cases read by all readers, there was poor agreement for RT-PCR positive (Fleiss Score 0.36) and negative (Fleiss Score 0.46) exams. Agreement between two readers on 1638 cases was 54.2% (373/688) for RT-PCR positive cases and 71.4% (679/950) for negative cases. Agreement was highest for RT-PCR negative cases labeled as Normal (50.4%, n = 479). Reader performance did not improve with clinical history or time between CXR and RT-PCR result. CONCLUSION: At the time of presentation to the emergency department, emergency radiologist performance is non-specific for diagnosing COVID-19.

Abbreviated Molecular Breast Imaging: Feasibility and Future Considerations.

OBJECTIVE: Molecular breast imaging (MBI) is a supplemental screening modality consistently demonstrating incremental cancer detection over mammography alone; however, its lengthy duration may limit widespread utilization. The study purpose was to assess feasibility of an abbreviated MBI protocol, providing readers with mediolateral oblique (MLO) projections only and assessing performance in lesion detection and localization. METHODS: Retrospective IRB-exempt blinded reader study administered to 5 fellowship-trained breast imaging radiologists. Independent reads performed for 124 screening MBI cases, half abnormal and half negative/normal. Readers determined whether an abnormality was present, side of abnormality, and location of abnormality (medial/lateral). Abnormal cases had confirmatory biopsy or surgical pathology; normal cases had imaging follow-up ensuring true negative results. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated to assess performance. A false negative result indicated that a reader failed to detect abnormal uptake; a false positive result indicated a reader incorrectly called an abnormality for a negative case. Tests for association included chi-square, Fisher-exact, and analysis of variance. RESULTS: Mean reader performance for detecting abnormal uptake: sensitivity 96.8%, specificity 98.7%, PPV 98.8%, and NPV 96.9%. Accuracy in localizing lesions to the medial or lateral breast was 100%. There were no associations in reader performance with reader experience, reader technique, lesion morphology, or lesion pathology. Median lesion size was 1.0 cm (range: 0.4-8.0 cm). All readers correctly identified 97.7% (42/43) of lesions with malignant or elevated risk pathology. CONCLUSION: An abbreviated MBI protocol (MLO images only) maintained high accuracy in lesion detection and localization.

MRI Virtual Biopsy of T2 Hyperintense Breast Lesions.

A wide variety of benign and malignant breast processes may generate hyperintense signal at T2-weighted magnetic resonance imaging (MRI). MRI has been traditionally used in the pre-treatment planning of breast cancer, in assessing treatment response and detecting recurrence. In this comprehensive review, we describe and illustrate the MRI features of a few common and uncommon T2 hyperintense breast lesions, with an emphasis on MRI features that help to characterize lesions based on morphological features, specific appearances on T1-and T2-weighted imaging, and enhancement characteristics on the dynamic post-contrast phase that are either diagnostic or aid in narrowing the differential diagnosis.

It's Not Always Gynecomastia: A Case of Diffuse Large B-Cell Lymphoma Presenting as Breast Mass in a Male Patient.

We report a case of diffuse large B-cell breast lymphoma that presented as a palpable breast lump in a male patient evaluated with digital mammography and targeted breast ultrasound (US) but ultimately confirmed by US-guided core needle biopsy. We will discuss the appropriate workup algorithm for a palpable breast lump in a male patient as outlined by the American College of Radiology (ACR) Appropriateness Criteria. While gynecomastia is the most common reason for a new palpable breast lump in a male patient, male breast cancer (including lymphoma and metastasis) can have a similar appearance on imaging. Our goal is to provide clarity on proper radiographic assessment protocols and imaging features of palpable breast masses in men by emphasizing the role of anatomical location and symmetry in distinguishing it from more common causes, such as gynecomastia, in future diagnostic imaging scenarios.

Spectrum of CT Findings Related to Bowel Adhesions Without Bowel Obstruction: A Comprehensive Imaging Review.

Post-operative adhesions can occur following abdominal or pelvic surgery and are a significant cause of morbidity and mortality. Adhesions are an important cause of abdominal complaints, especially chronic abdominal pain, infertility, and bowel obstruction; responsible for an estimated $2.3 billion annual burden in the United States alone. There is a paucity of literature describing CT findings indicative of the presence of adhesions, however, findings suggestive of this entity may be discovered by a discerning eye. Early recognition and diagnosis may be beneficial for reducing consumption of health-care resources related to abdominal complaints. In addition, these findings may impact surgical planning and facilitate recognition of adhesion-related complications, said to be responsible for a significant number of malpractice claims. The following review discusses various CT findings which may indicate the presence of adhesions. These findings may initially be overlooked, but remain valuable as the clinical presentation evolves to become consistent with adhesive disease. Detection of bowel and peritoneal adhesions can be recognized on imaging modalities based on distortion of bowel loops. This pictorial review illustrates the spectrum of findings related to bowel adhesions encountered on computed tomography imaging.

Radiation-Induced Rib Fractures on Magnetic Resonance Imaging Following Proton Therapy for Breast Cancer With Pencil Beam Scanning.

Radiation-induced rib fractures (RIRF) are long-term complications associated with irradiation of the chest/chest wall. RIRFs are commonly seen in lung- or breast-cancer patients treated with stereotactic body radiotherapy (SBRT) or conventional external beam radiation therapy (EBRT), respectively. We report a case of a 31-year-old female presenting with pathological fractures of the third, fourth, and fifth ribs discovered on magnetic resonance imaging (MRI) as a complication from pencil beam scanning (PBS) proton therapy (PT), of the whole left breast and regional lymph nodes. To our knowledge, this presentation is the first to be initially reported on MRI in radiological literature.

Bracketed Radioactive Seed Localization for Breast Conservation Surgery.

We aimed to evaluate the surgical margin outcomes and re-excision rates in patients undergoing bracketed seed localization of biopsy-proven breast cancer detected on screening mammogram. After approval by our Institutional Review Board, we retrospectively identified patients who had undergone iodine-125 seed localized lumpectomy at our institution from January 2010 to June 2017 by one of two fellowship-trained breast surgeons. Of those patients, a subset of 25 patients were identified who had undergone bracketed seed localization, defined as two or more seeds used to delineate the radiographic borders of the area of concern. All patients had originally presented with calcifications identified on screening mammogram that were subsequently diagnosed as ductal carcinoma in situ and/or invasive ductal carcinoma by image-guided biopsy performed at our institution. Eight patients had one positive margin on final surgical pathology and required re-excision (32%). One patient was converted to mastectomy. Of the patients requiring re-excision, the average maximum linear extent of calcifications was 3.4 cm (SD 0.97), whereas it was 3.1 cm (SD 1.2) in patients with negative surgical margins (P = 0.5). Bracketing calcifications with radioactive seeds can potentially allow more patients to undergo breast conservation surgery.

Juvenile myelomonocytic leukemia presenting as bilateral breast masses.

An 8-year-old girl presented with bilateral breast masses and was subsequently diagnosed with juvenile myelomonocytic leukemia. Juvenile myelomonocytic leukemia is a rare myelodysplastic syndrome that typically presents in boys younger than 3 years of age with splenomegaly, lymphadenopathy and skin findings. Bilateral breast masses in a child are rare and, as such, present a diagnostic dilemma due to the relative paucity of cases in the literature. We present a case of granulocytic sarcoma of the breasts in a patient with juvenile myelomonocytic leukemia. The authors hope that increased reporting and research regarding pediatric breast masses will help create awareness for such cases.

Recurrent radiation-induced osteosarcoma of the sternum in a patient with remote radiation therapy for breast cancer.

BACKGROUND: Recurrent radiation-induced osteosarcoma of the sternum following remote radiation therapy for breast cancer and sternal reconstruction. CASE: A 51-year-old woman presents with recurrent, radiation-induced sternal osteosarcoma 11 years after receiving both radiation therapy for breast cancer and sternal reconstruction. The case details both her work-up and subsequent course, including reconstructive and curative efforts. DISCUSSION: An uncommon side effect of radiation therapy for breast cancer is development of osteosarcoma of the chest wall. Even rarer is recurrence of the osteosarcoma following sternal reconstruction.

Image quality and dose differences caused by vendor-specific image processing of neonatal radiographs.

BACKGROUND: Image processing plays an important role in optimizing image quality and radiation dose in projection radiography. Unfortunately commercial algorithms are black boxes that are often left at or near vendor default settings rather than being optimized. OBJECTIVE: We hypothesize that different commercial image-processing systems, when left at or near default settings, create significant differences in image quality. We further hypothesize that image-quality differences can be exploited to produce images of equivalent quality but lower radiation dose. MATERIALS AND METHODS: We used a portable radiography system to acquire images on a neonatal chest phantom and recorded the entrance surface air kerma (ESAK). We applied two image-processing systems (Optima XR220amx, by GE Healthcare, Waukesha, WI; and MUSICA(2) by Agfa HealthCare, Mortsel, Belgium) to the images. Seven observers (attending pediatric radiologists and radiology residents) independently assessed image quality using two methods: rating and matching. Image-quality ratings were independently assessed by each observer on a 10-point scale. Matching consisted of each observer matching GE-processed images and Agfa-processed images with equivalent image quality. A total of 210 rating tasks and 42 matching tasks were performed and effective dose was estimated. RESULTS: Median Agfa-processed image-quality ratings were higher than GE-processed ratings. Non-diagnostic ratings were seen over a wider range of doses for GE-processed images than for Agfa-processed images. During matching tasks, observers matched image quality between GE-processed images and Agfa-processed images acquired at a lower effective dose (11 ± 9 µSv; P < 0.0001). CONCLUSION: Image-processing methods significantly impact perceived image quality. These image-quality differences can be exploited to alter protocols and produce images of equivalent image quality but lower doses. Those purchasing projection radiography systems or third-party image-processing software should be aware that image processing can significantly impact image quality when settings are left near default values.