The Mammography Quality Standards Act. An overview of the regulations and guidance.

The MQSA has imposed a set of federal regulations on every facility and radiologist that performs or interprets mammograms. Because annual inspections and paperwork are somewhat burdensome, many hope that in the future the process of FDA inspections might be streamlined for facilities with good track records and few, if any, findings at inspection. This would serve to reduce facility inconvenience and the costs of regulatory compliance without compromising patient care and outcomes. Currently, however, although not all personnel are required to be familiar with the regulations, key individuals should be conversant with the rules, FDA guidance, and methods that the facility has devised to comply with the regulations.

Learn, share, and live: breast cancer education for older, urban minority women.

Among older urban minority women, for whom breast cancer risk is high and the propensity to be screened is low, both social support and breast cancer knowledge have been linked to mammography use. The authors describe a theory-based breast cancer education program implemented via an existing informal network for low-income urban elderly coordinated by a social service agency. The program is both structured and flexible. Core education sessions include delineated content and methods and are led by health professionals. Participants choose from a variety of follow-up activities to promote screening within their community. Pre- and posttests administered among 80 program attendees in two sites indicate significant improvement in knowledge (p < .001). Program attendees in each site also planned and participated in follow-up activities to promote screening among their peers. Learn, Share, and Live seems to be an effective program for promoting breast cancer screening among older, urban, primarily minority women.

Invasive breast cancer: mammographic measurement.

PURPOSE: To establish the accuracy of mammographic measurement of tumor size for invasive carcinoma. MATERIALS AND METHODS: For 85 invasive cancers, mammographic tumor size was determined as the largest dimension observed on any mammographic projection (craniocaudal, lateral, or mediolateral oblique). This was then compared with the largest tumor dimension in the gross specimen. RESULTS: The relationship between the mammographic size and the pathologic size was almost exactly 1:1, with low variability. Mammographic measurements were larger by an average of about 1 mm. Neither breast parenchymal pattern nor the presence of accompanying ductal carcinoma in situ affected accuracy. CONCLUSION: Mammography can allow tumor size to be measured accurately and can be used as an alternative when pathologic staging is not possible.

Evaluation of breast microcalcifications.

As screening mammography has become more widespread, the urgency to provide more sensitive and more specific interpretations has also increased. Although many calcifications detected on mammograms are characteristically benign and need no further evaluation, there are many microcalcifications that warrant further evaluation with special views. The importance of their detection lies in the fact that many malignancies are mammographically manifested solely as microcalcifications. Once detected, radiologists have attempted to characterize and stratify microcalcifications by their level of suspicion to improve the predictive value of biopsy recommendations as depicted in Table 1. This is an important endeavor because the cost to society, especially in this era of limited resources, and the collective anxiety produced by benign breast biopsies are both great. When a biopsy is recommended, the breast team, which includes the surgeon, radiologist, and pathologist should ensure that histopathologic correlation is achieved. By participating in this process, keeping track of the results of biopsies generated from our practices, and learning from our colleagues, we can fine tune our interpretive skills. Communication among us and our colleagues from other specialties should be encouraged and can be fostered by the use of the BI-RADS lexicon.

The relative radiolucencies of breast implant filler materials.

Breast implants in current use utilize silicone gel for filler material. One substantial drawback of silicone gel is its radiodensity, resulting in the obscuration of breast tissue on mammography. The relative radiolucencies of silicone gel, saline, breast tissue equivalent, triglycerides (peanut oil), and polyvinylpyrrolidone (Bio-Oncotic gel) were determined by using standard mammographic equipment. Visibility through these materials was compared by using a standard breast phantom as background. The x-ray dosage necessary to create each mammographic image was measured. Peanut oil provided the clearest image of the phantom artifacts, required the least radiation exposure, and was approximately four times more radiolucent than the saline or Bio-Oncotic gel and about 45 times more radiolucent than silicone gel. As improved implant filler materials are being sought, triglycerides maintain superior radiographic properties.

Screening mammography in 350 women with breast implants: prevalence and findings of implant complications.

OBJECTIVE: A series of screening mammograms in asymptomatic women with breast implants was reviewed to determine the prevalence of clinically silent sequelae of breast augmentation and to analyze the mammographic findings. MATERIALS AND METHODS: The screening mammograms of 350 consecutive women with implants were reviewed retrospectively by experienced mammographers. Any women who reported problems had a diagnostic examination and therefore were not included in our sample. Mammographic features of sequelae specific to implantation such as development of a fibrous capsule, periprosthetic calcification, implant herniation, and silicone leaks were tabulated. Additionally, modified compression (push-back) views, when obtained, were evaluated for their usefulness. RESULTS: Fibrous encapsulation of breast implants was seen in 257 (73%) of 350 women. Periprosthetic calcification was seen in 90 (26%), and 60 women (17%) had implant herniations. Sixteen women (5%) had implant failure as evidenced by silicone leak. Two of these women had bilateral implant failures. Surgical confirmation was attainable in only five of 16 women. Analysis of modified compression views demonstrated an overall improvement in visualization of breast tissue with this technique. Although the sample size is small, there was a significant increase in the amount of breast tissue seen with push-back views in women with submuscular implants. CONCLUSION: Our analysis revealed a wide range of mammographic findings in this group of asymptomatic women with breast augmentation. Especially worrisome is the 5% prevalence of unsuspected silicone extravasation. Additionally, we have demonstrated the usefulness of push-back views in this screening group, especially in women with submuscular implants.

Mammographic appearance following implant removal.

Potential complications of augmentation mammaplasty with silicone gel breast implants have been the subject of much recent debate in the medical and lay communities. Some women have undergone implant removal, and others may follow. The mammographic appearance following submammary implant removal in four women and the histologic appearance in one case are described. Bilateral symmetric soft-tissue masses posterior to the glandular tissue with accompanying calcifications should suggest the diagnosis. The radiologist should be familiar with the mammographic appearance following implant removal. Such knowledge may prevent unnecessary concern and unwarranted biopsy.

A screening mammography program. Staying alive and making it work.

The success of a mammography screening program requires thorough planning. A dependably high volume and a streamlined efficient operation are essential to survival of the program. Factors that warrant consideration prior to designing such a program include the following: Distinction between screening and diagnostic mammography examinations. Selection of a site that will meet the needs of the community and yet provide a consistently high volume. Low examination cost for screening mammography coupled with a detailed financial analysis and reappraisal on an ongoing basis. A customized marketing program that incorporates methods to increase awareness, compliance, and utilization by women and referring physicians. Well-trained, efficient, and dedicated personnel. An operation that is designed for rapid throughput and expeditious patient flow. An efficient plan for film handling, interpretation, reporting, and storage. Timely communication of examination results. A reliable mechanism for follow-up evaluation and outcome data collection. Establishment of a consistent and reliable quality assurance program and the production of high quality mammograms.

Calcium oxalate microcalcifications in the breast.

Calcium oxalate calcifications can be difficult to detect with routine histologic procedures. In the reported case, microcalcifications that were evident with radiography of the specimen and of the paraffin blocks could not be detected with light microscopy. Polarized light microscopy, however, revealed the calcifications to be calcium oxalate crystals. Use of polarized light microscopy may resolve radiologic-pathologic discrepancies in such cases.

Photostimulable phosphor digital radiography of the extremities: diagnostic accuracy compared with conventional radiography.

A direct comparison was made between digital and conventional radiographs to assess the relative accuracy of a photostimulable phosphor digital imaging system in detecting and localizing minor trauma in the extremities. Matched sets of images were obtained on 103 patients who came to the emergency department for radiographs of the hand, wrist, foot, or ankle. One set was obtained with a conventional screen/film system. The other set was obtained with photostimulable phosphor digital cassettes. The two sets of images of each patient were independently interpreted by three radiologists in a blinded fashion. The findings of each of these three readers were compared with the consensus opinion of two different radiologists. Receiver-operating-characteristic (ROC) curves were plotted for each of the three readers, areas under the curves were calculated, and true-positive fractions were determined at false-positive fractions of 0.1. Although no significant differences in the areas under the ROC curves for the two imaging systems were detected, conventional radiography showed a slight advantage. However, when true-positive fractions for fracture detection were compared at false-positive fractions of 0.1 a statistically significant difference was shown, with conventional screen/film radiography being more sensitive. This study raises questions about the use of currently available photostimulable phosphor systems for imaging trauma of the extremities and suggests that those systems should not be used exclusively.

Calcaneal and pelvic fractures: diagnostic evaluation by three-dimensional computed tomography scans.

A major application of three-dimensional (3D) computed tomography (CT) is in the imaging of the skeleton. 3D CT has a potentially important role in determining the presence, type, and extent of fractures, especially of the calcaneus and pelvis. The objective of this study was to compare the diagnostic sensitivity and specificity of 3D CT, CT slices, and plain radiography in the detection and characterization of calcaneal and pelvic fractures. 3D CT reconstructions were obtained by two methods, surface reconstruction and volumetric techniques. Twenty-eight patients were imaged with CT, 3D CT, and plain radiography. The opinion of a musculoskeletal radiologist with access to all images plus clinical history, surgical findings, and follow-up findings was taken as truth. Four additional musculoskeletal radiologists read these cases in a blinded fashion and ranked the modalities with regard to perceived utility. Receiver operating characteristic analysis was used to determine the relative value of each modality in terms of diagnostic quality. All imaging modalities performed comparably in the diagnosis of fractures. CT slices and plain-films were the most useful for more difficult diagnostic tasks such as fracture stability, and the presence of comminution and estimation of the number of fragments. The results suggest that for skeletal areas with complicated anatomy (such as the pelvis and calcaneus), the diagnostic value of 3D CT is often equivalent to that of conventional methods.

Carcinoma within fibroadenomas: mammographic features.

The mammographic features of carcinoma originating within a fibroadenoma in 24 patients were studied by means of retrospective review of pathologic slides. Histologic examination showed that the lesions were lobular carcinoma in situ (LCIS) (seven patients), ductal carcinoma in situ (DCIS) (13 patients), synchronous LCIS and invasive lobular carcinoma (one patient), and synchronous LCIS and DCIS (three patients). In all patients the mammographic manifestation was a mass 1.0 cm or greater in diameter; 14 masses were 1-2 cm in diameter, and the remainder were more than 2 cm in diameter. Features that were considered suspect included large size, indistinct margins, and clustered microcalcifications. In three patients, microcalcifications within the mass raised suspicion of malignancy. At histologic examination these microcalcifications were associated with the intraductal carcinoma harbored in the fibroadenoma in only one of these patients. Fibroadenomas that harbor carcinoma may be indistinguishable from common benign fibroadenomas, but their occurrence is rare. In this study, a single patient had invasive lobular carcinoma; all the other lesions were in situ lesions.

Radiogenic breast cancer effects of mammographic screening.

The radiocarcinogenic implications of published breast-screening policies were compared. With the use of radioepidemiologic data published recently by the National Institutes of Health, expected excess breast cancers were projected. With a base-line mammogram at age 35 and annual mammography after age 40, as few as 150 or as many as 1,000 radiogenic breast cancers were projected for a screening population of 1 million women, depending on the mammographic system employed and the screening schedule.