ACR Appropriateness Criteria® Female Breast Cancer Screening: 2023 Update.

Early detection of breast cancer from regular screening substantially reduces breast cancer mortality and morbidity. Multiple different imaging modalities may be used to screen for breast cancer. Screening recommendations differ based on an individual's risk of developing breast cancer. Numerous factors contribute to breast cancer risk, which is frequently divided into three major categories: average, intermediate, and high risk. For patients assigned female at birth with native breast tissue, mammography and digital breast tomosynthesis are the recommended method for breast cancer screening in all risk categories. In addition to the recommendation of mammography and digital breast tomosynthesis in high-risk patients, screening with breast MRI is recommended. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

The Los Angeles motor scale (LAMS) is independently associated with CT perfusion collateral status markers.

BACKGROUND AND AIM: The Los Angeles Motor Scale (LAMS) is an objective tool that has been used to rapidly assess and predict the presence of large vessel occlusion (LVO) in the pre-hospital setting successfully in several studies. However, studies assessing the relationship between LAMS score and CT perfusion collateral status (CS) markers such as cerebral blood volume (CBV) index, and hypoperfusion intensity ratio (HIR) are sparse. Our study therefore aims to assess the association of admission LAMS score with established CTP CS markers CBV Index and HIR in AIS-LVO cases. MATERIALS AND METHODS: In this prospectively collected, retrospectively reviewed analysis, inclusion criteria were as follows: a) CT angiography (CTA) confirmed anterior circulation LVO from 9/1/2017 to 10/01/2023, and b) diagnostic CT perfusion (CTP). Logistic regression analysis was performed to assess the relationship between admission LAMS with CTP CS markers HIR and CBV Index. p ≤ 0.05 was considered significant. RESULTS: In total, 285 consecutive patients (median age = 69 years; 56 % female) met our inclusion criteria. Multivariable logistic regression analysis adjusting for sex, age, ASPECTS, tPA, premorbid mRS, admission NIH stroke scale, prior history of TIA, stroke, atrial fibrillation, diabetes mellitus, hyperlipidemia, coronary artery disease and hypertension, admission LAMS was found to be independently associated with CBV Index (adjusted OR:0.82, p < 0.01), and HIR (adjusted OR:0.59, p < 0.05). CONCLUSION: LAMS is independently associated with CTP CS markers, CBV index and HIR. This finding suggests that LAMS may also provide an indirect estimate of CS.

Facilitating Culturally Competent Breast Imaging Care in South Asian Patients.

South Asians are a rapidly growing subset of the Asian population in the United States. They comprise people from multiple countries with diverse beliefs, languages, and cultural identities and values. The incidence of breast cancer is rising in South Asian women in the United States, with earlier onset and predilection for HER2-enriched tumors. Despite the rising incidence of breast cancer, participation in screening remains lower than other populations. Health care inequities in South Asian women are multifactorial and may be due to traditional health beliefs and practices, language barriers, cultural differences, and lack of overall awareness. Developing a culturally sensitive environment in breast imaging clinic practice can lead to improved patient care and adherence. Given the scarcity of data specific to the South Asian population in United States, there is a need for health service researchers and practice leaders to obtain more high-quality data to understand the needs of South Asian patient populations.

Appropriate Use of Medical Interpreters in the Breast Imaging Clinic.

More than 25 million Americans have limited English-language proficiency (LEP) according to the U.S. Census Bureau. This population experiences challenges accessing health care and is least likely to receive preventive health care, including screening mammogram. In a setting where the breast radiologist does not speak the language of their patient, using certified medical interpreter services is fundamental. Medical interpreter use is associated with improved clinical care and patient satisfaction and can potentially increase adherence to screening mammograms and follow-up in patients with LEP. Title VI of the Civil Rights Act requires interpreter services for patients with LEP who are receiving federal financial assistance. Failure to provide interpretative services when necessary is considered discriminatory and illegal. The use of untrained medical interpreters, including ad hoc interpreters (eg, family, friends, or untrained staff), is associated with more medical errors, violation of confidentiality, and poor health outcomes. Types of medical interpretation services available to address language barriers include in-person interpretation, telephone and video remote interpretation, and qualified bilingual staff. Proper training and certification of medical interpreters is essential to prevent misinterpretations and ensure patient safety. When using an interpreter service, speak to and maintain eye contact with the patient, address the patient directly and seat the interpreter next to or slightly behind the patient, use visual aids whenever possible, and have the patient repeat the information to verify comprehension. Breast radiologists can address disparities in breast cancer screening and treatment by promoting effective communication.

Raising Cultural Awareness and Addressing Barriers to Breast Imaging Care for Black Women.

Health care disparities, which are differences in the attainment of full health potential among population groups, have been documented across medical conditions, clinical settings, and diagnostic and treatment modalities. Deeply rooted health care disparities due to many factors have affected how Black women (BW) view medical care including screening mammography. This article explores health care disparities around breast cancer in BW and how patient distrust, provider biases, race, and social determinants of health continue to have negative effects on breast cancer outcomes in BW, despite medical advances in breast cancer detection and management. In addition, this article addresses the importance of culturally competent care for BW around breast cancer awareness, screening, and treatment, and offers strategies to address disparities and rebuild trust.

ACR Appropriateness Criteria® Breast Implant Evaluation: 2023 Update.

This document discusses the appropriate initial imaging in both asymptomatic and symptomatic patients with breast implants. For asymptomatic patients with saline implants, no imaging is recommended. If concern for rupture exists, ultrasound is usually appropriate though saline rupture is often clinically evident. The FDA recently recommended patients have an initial ultrasound or MRI examination 5 to 6 years after initial silicone implant surgery and then every 2 to 3 years thereafter. In a patient with unexplained axillary adenopathy with current or prior silicone breast implants, ultrasound and/or mammography are usually appropriate, depending on age. In a patient with concern for silicone implant rupture, ultrasound or MRI without contrast is usually appropriate. In the setting of a patient with breast implants and possible implant-associated anaplastic large cell lymphoma, ultrasound is usually appropriate as the initial imaging. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Breast Imaging Fellowship Training in the United States: A National Survey of Fellowship Program Directors.

OBJECTIVE: To provide an updated characterization of breast imaging fellowship programs in the United States to identify opportunities for improvement and standardization. METHODS: An anonymous survey was e-mailed to program directors of breast imaging fellowship programs listed on the Society of Breast Imaging website. The survey was open from April 23, 2021, through May 27, 2021. The survey was deemed exempt by the IRB. RESULTS: Forty-seven of 80 (59%) program directors responded, of which 36/47 (77%) represented programs dedicated 100% to breast imaging, and 11/47 (23%) represented programs dedicated 50%-75% to breast imaging. Common elements to most programs include tumor boards (47/47, 100%), journal clubs (39/47, 83%), case-based teaching sessions (35/47, 74%), didactic lectures (40/47, 85%), and participation in radiology-pathology conferences (29/47, 62%). Mammography Quality and Standards Act audit training (22/47, 47%), mammography quality control training (22/47, 47%), and formal communication training (19/47, 40%) were less common. Most programs provide exposure to wire (42/47, 89%) and wire-free localization procedures (45/47, 96%), but exposure to contrast-enhanced mammography (13/47, 28%) and molecular breast imaging (4/47, 9%) was limited. A small majority of programs (25/47, 53%) do not require weekday call; however, more (31/47, 66%) have weekend call responsibilities. Many programs (29/47, 62%) offer at least 3 weeks of elective time, which may be clinical or nonclinical. CONCLUSION: Breast imaging fellowship programs vary in curricula, modality exposure, and academic policies. The results of this survey can help guide further efforts to standardize and optimize fellowship training.

Imaging Preferences in Women With a History of Breast Cancer Receiving Contrast-Enhanced Mammography.

OBJECTIVE: There is interest in contrast-enhanced mammography (CEM) to screen breast cancer survivors, yet it is unclear whether they would accept CEM as their annual exam. The purpose of this study was to understand patient preferences to guide CEM implementation for screening. METHODS: Consecutive women with breast cancer history who had CEM as their annual mammogram from July 2020 to August 2021 at a single academic institution completed an 18-question survey regarding prior contrast imaging, CEM experience, and comparison to other breast imaging exams. Response proportions were calculated, and chi-square or Fisher's exact test were used to evaluate associations of demographics with responses. RESULTS: A total of 78% (104/133) of women undergoing CEM provided results. Most were satisfied with CEM (99%, 103/104), had nothing to complain about (87%, 90/104), did not find CEM anxiety provoking (69%, 72/104), felt comfortable having contrast for annual imaging (94%, 98/104), were willing to accept the small risk of a contrast reaction if CEM would find their cancer (93%, 97/104), and would like to have CEM for their exam next year (95%, 99/104). Compared with mammography, 23% (24/104) reported CEM was a better experience, and 63% (66/104) reported CEM was about the same. Of those who had prior MRI, the majority reported CEM was better (53%, 29/55) and would prefer CEM if both MRI and CEM had an equal chance of detecting cancer (73%, 41/56). Most preferences did not differ significantly according to demographics. CONCLUSION: Most women surveyed considered CEM to be satisfactory and preferred compared to other breast screening modalities.

Comparison of Contrast-enhanced Mammography with MRI Utilizing an Enriched Reader Study: A Breast Cancer Study (CONTRRAST Trial).

Background Despite growing interest in using contrast-enhanced mammography (CEM) for breast cancer screening as an alternative to breast MRI, limited literature is available. Purpose To determine whether CEM is noninferior to breast MRI or abbreviated breast MRI (AB MRI) and superior to two-dimensional mammography in an asymptomatic population simulating those who would present for screening and then undergo diagnostic work-up. Materials and Methods This enriched reader study used CEM and MRI data prospectively collected from asymptomatic individuals at a single institution from December 2014 to March 2020. Case sets were obtained at screening, as part of work-up for a screening-detected finding, or before biopsy of a screening-detected abnormality. All images were anonymized and randomized, and all 12 radiologists interpreted them. For CEM interpretation, readers were first shown low-energy images as a surrogate for digital mammography and asked to give a forced Breast Imaging Reporting and Data System score for up to three abnormalities. The highest score was used as the case score. Readers then reviewed the full CEM examination and scored it similarly. After a minimum 1-month washout, the readers similarly interpreted AB MRI and full MRI examinations. Receiver operating characteristic analysis, powered to test CEM noninferiority to full MRI, was performed. Results The study included 132 case sets (14 negative, 74 benign, and 44 malignant; all female participants; mean age, 54 years ± 12 [SD]). The mean areas under the receiver operating characteristic curve (AUCs) for digital mammography, CEM, AB MRI, and full MRI were 0.79, 0.91, 0.89, and 0.91, respectively. CEM was superior to digital mammography (P < .001). No evidence of a difference in AUC was found between CEM and AB MRI and MRI. Conclusion In an asymptomatic study sample, CEM was noninferior to full MRI and AB MRI and was superior to digital mammography. Clinical trial registration no. NCT03482557 and NCT02275871 © RSNA, 2023 Supplemental material is available for this article.

Simultaneous isolation of hormone receptor-positive breast cancer organoids and fibroblasts reveals stroma-mediated resistance mechanisms.

Recurrent hormone receptor-positive (HR+) breast cancer kills more than 600,000 women annually. Although HR+ breast cancers typically respond well to therapies, approximately 30% of patients relapse. At this stage, the tumors are usually metastatic and incurable. Resistance to therapy, particularly endocrine therapy is typically thought to be tumor intrinsic (e.g., estrogen receptor mutations). However, tumor-extrinsic factors also contribute to resistance. For example, stromal cells, such as cancer-associated fibroblasts (CAFs), residing in the tumor microenvironment, are known to stimulate resistance and disease recurrence. Recurrence in HR+ disease has been difficult to study due to the prolonged clinical course, complex nature of resistance, and lack of appropriate model systems. Existing HR+ models are limited to HR+ cell lines, a few HR+ organoid models, and xenograft models that all lack components of the human stroma. Therefore, there is an urgent need for more clinically relevant models to study the complex nature of recurrent HR+ breast cancer, and the factors contributing to treatment relapse. Here, we present an optimized protocol that allows a high take-rate, and simultaneous propagation of patient-derived organoids (PDOs) and matching CAFs, from primary and metastatic HR+ breast cancers. Our protocol allows for long-term culturing of HR+ PDOs that retain estrogen receptor expression and show responsiveness to hormone therapy. We further show the functional utility of this system by identifying CAF-secreted cytokines, such as growth-regulated oncogene α , as stroma-derived resistance drivers to endocrine therapy in HR+ PDOs.

Impact of imaging nurse navigation on breast interventions: Direct and closed-loop patient communication and documentation.

OBJECTIVE: A breast imaging nurse navigator (NN) was established with the goals to enhance the patient experience after biopsy, improve care timeliness, accuracy, and coordination, facilitate direct communication to patients, and increase care retention within our system. Our aim was to determine the impact of NN on patient care time metrics, communication, documentation, compliance, and care retention at our institution after breast biopsy. METHODS: Retrospective review of a six-month period before (5/1/17-10/31/17) and after (5/1/19-10/31/19) establishment of a nurse navigator in our breast imaging department was performed, including 498 patients in the pre-navigation (pre-NN) group and 526 patients in the post-navigation (post-NN) group. Data was gathered from the electronic medical record and collected using REDCap. RESULTS: Biopsy pathology results were communicated directly to the patient more often post-NN (71%, 374/526) compared to pre-NN (4%, 21/498) (p < 0.0001), without change in overall time of result communication (p = 0.08). Due to factors outside of imaging, most care time metrics were longer post-NN, including days from biopsy to pathology report (p < 0.001), result communication to initiation of care (p < 0.001), and biopsy to surgery (p < 0.001). There was no difference and high compliance (p = 1) and care retention (p = 0.015) in both groups. There was improved documentation of pathology results, recommendations, and communication post-NN (0/526 vs 10/498, p = 0.001). CONCLUSION: Imaging nurse navigation added greatest value by communicating breast biopsy results and recommendations directly to patients and ensuring documentation. Compliance and retention were high in both groups. Factors outside of Radiology influenced time metrics, requiring further investigation of multidisciplinary collaboration.

ACR Appropriateness Criteria® Palpable Breast Masses: 2022 Update.

Palpable masses in women are the most common symptom associated with breast cancer. This document reviews and evaluates the current evidence for imaging recommendations of palpable masses in women less than 30 to over 40 years of age. There is also a review of several different scenarios and recommendations after initial imaging. Ultrasound is usually the appropriate initial imaging for women under 30 years of age. If ultrasound findings are suspicious or highly suggestive of malignancy (BIRADS 4 or 5), it is usually appropriate to continue with diagnostic tomosynthesis or mammography with image-guided biopsy. No further imaging is recommended if the ultrasound is benign or negative. The patient under 30 years of age with a probably benign ultrasound may undergo further imaging; however, the clinical scenario plays a role in the decision to biopsy. For women between 30 to 39 years of age, ultrasound, diagnostic mammography, tomosynthesis, and ultrasound are usually appropriate. Diagnostic mammography and tomosynthesis are the appropriate initial imaging for women 40 years of age or older, as ultrasound may be appropriate if the patient had a negative mammogram within 6 months of presentation or immediately after mammography findings are suspicious or highly suggestive of malignancy. If the diagnostic mammogram, tomosynthesis, and ultrasound findings are probably benign, no further imaging is necessary unless the clinical scenario indicates a biopsy. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Cultural Competence in the Care of LGBTQ+ Patients: A Primer for Breast/Chest Centers.

The number of individuals identifying as lesbian, gay, bisexual, transgender, queer/questioning (LGBTQ+) has doubled over the past 10 years, and this figure continues to rise. The LGBTQ+ community is diverse, encompassing a vast array of differences in gender identity and sexual orientation. Additionally, it is inclusive of people from all races, ethnicities, religions, and socioeconomic backgrounds. This intersectionality of identities and experiences impacts both access to health care and its delivery. Barriers to care for this population are multifactorial and include stigma, discrimination, bias, limited role models, issues with insurance coverage, lack of education and training for health care providers, and lack of research on LGBTQ+ health-related issues. Specific to breast cancer, the screening recommendations for this group are influenced not only by risk but also by gender-affirming hormonal and surgical therapies. This article will provide an overview of the LGBTQ+ population, review breast cancer screening compliance and recommendations, summarize the multitude of health disparities, and offer potential interventions to improve care delivery at the individual, facility, organizational, and health policy levels.

Culturally Competent Care in the Breast Imaging Clinic: Hispanic/Latino Patients.

Hispanic/Latino people represent 19% of the U.S. population, and this proportion is expected to increase to 26% by 2050. Hispanic/Latino people comprise a diverse ethnic group that includes individuals from all races, religions, languages, cultural identities, and nationalities. Barriers to health care that have created significant disparities in this community include language, low socioeconomic status, and inability to afford health insurance. Health coverage for Hispanic/Latino people has been a longstanding problem in the U.S., stopping many of these patients from seeking preventive care such as screening mammography. Breast cancer is the most common cancer among Hispanic/Latino women in the U.S. and the leading cause of cancer death in this group. Five-year breast cancer survival in Hispanic/Latino women is slightly lower than that in non-Hispanic White women. Some of the factors that account for the ethnic disparities in breast cancer include lower levels of adherence to screening mammography of Hispanic/Latino women as a consequence of inadequate insurance coverage, language barriers, lack of transportation, being unable to leave work, and lack of childcare. By promoting a culturally sensitive clinical environment, breast radiologists can increase patient engagement, utilization of preventive services, treatment adherence rates, and overall health status.

A Needs Assessment for Inclusion, Diversity, and Equity: Survey Results of the Society of Breast Imaging.

OBJECTIVE: To assess and understand the inclusion, diversity, and equity (IDE) needs of the Society of Breast Imaging (SBI) membership to guide development of a strategic plan and goals for the Inclusion, Diversity, Equity Alliance (IDEA) of SBI. METHODS: A 23-question survey developed by IDEA was distributed electronically to all SBI members in November 2020 to assess and understand the society's IDE needs. Descriptive statistics were used to summarize the responses. Open-ended responses were reviewed by the authors and sorted into three categories: supportive, nonsupportive, or neutral suggestions. RESULTS: The response rate was 12% (453/3686). Only 55% (238/429) of respondents agreed that the diversity of SBI leadership reflected the diversity of the society, with stronger agreement that actions of SBI aligned with their core values of collaboration and collegiality (327/249,75%), and of respect for diversity and inclusiveness (303/429, 70%). Overall, 65% (172/264) of respondents were satisfied with the quality and diversity of speakers at the annual symposium; however, White respondents agreed more compared to non-White respondents (P = 0.035), and those practicing greater than 20 years agreed more compared to those practicing 6 to 10 years (P = 0.023). Of 88 total suggestions, three common themes were: more resources for recruitment, retention, and education for a diverse staff; further increase in diversity among leadership and membership; and more patient care resources. CONCLUSION: In addition to showing areas of agreement by SBI members, this survey also identified opportunities for SBI and IDEA to further incorporate IDE into our initiatives and organization.

ACR Appropriateness Criteria® Imaging After Breast Surgery.

Given that 20% to 40% of women who have percutaneous breast biopsy subsequently undergo breast surgery, knowledge of imaging women with a history of benign (including high-risk) disease or breast cancer is important. For women who had surgery for nonmalignant pathology, the surveillance recommendations are determined by their overall risk. Higher-than-average risk women with a history of benign surgery may require screening mammography starting at an earlier age before 40 and may benefit from screening MRI. For women with breast cancer who have undergone initial excision and have positive margins, imaging with diagnostic mammography or MRI can sometimes guide additional surgical planning. Women who have completed breast conservation therapy for cancer should get annual mammography and may benefit from the addition of MRI or ultrasound to their surveillance regimen. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Severe pulmonary hemorrhage in a 3-week-old neonate with COVID-19 infection: A case report.

Our patient is a 3-week-old female neonate, presented with complaints of low-grade fever and a congested nose for one day. Eventually, she developed progressive desaturation, hypotension, and poor perfusion due to severe pulmonary hemorrhage. Then, she developed cardiac arrest and was declared dead.

Enhancement Type at Contrast-enhanced Mammography and Association with Malignancy.

Background Despite the increasing use of contrast-enhanced mammography (CEM), there are limited data on the evaluation of findings on recombined images and the association with malignancy. Purpose To determine the rates of malignancy of enhancement findings on CEM images in the presence or absence of low-energy findings using the Breast Imaging Reporting and Data System (BI-RADS) lexicon developed for mammography and MRI. Materials and Methods All diagnostic CEM examinations performed at one academic institution between December 2015 and December 2019 had low-energy and recombined images retrospectively. Data were independently reviewed by three breast imaging radiologists with 5-25 years of experience using the BI-RADS mammography and MRI lexicon. Outcome was determined with pathologic analysis or 1-year imaging or clinical follow-up. The χ2 and Fisher exact tests were used for analysis. Results A total of 371 diagnostic CEM studies were performed in 371 women (mean age, 54 years ± 11[SD]). Sensitivity, specificity, positive predictive value (PPV), and negative predictive value of enhancement on CEM images was 95% (104 of 109 [95% CI: 90, 98]), 67% (176 of 262 [95% CI: 61, 73]), 55% (104 of 190 [95% CI: 47, 62]), and 97% (176 of 181 [95% CI: 94, 99]), respectively. Among 190 CEM studies with enhancing findings, enhancing lesions were more likely to be malignant when associated with low-energy findings (26% vs 59%, P < .001). Among enhancement types, mass enhancement composed 71% (99 of 140) of all malignancies with PPV of 63% when associated with low-energy findings. Foci, non-mass enhancement, and mass enhancement without low-energy findings had PPV of 6%, 24%, and 38%, respectively. Neither background parenchymal enhancement nor density was associated with enhancement type (P = .19 and P = .28, respectively). Conclusion Mass enhancement on recombined images using CEM was most commonly associated with malignancy, especially when associated with low-energy findings. Enhancement types were more likely to be benign when not associated with low-energy findings; however, they should still be viewed with suspicion, given the high association with malignancy. © RSNA, 2022 Online supplemental material is available for this article.