Outcome of Architectural Distortion Detected Only at Breast Tomosynthesis versus 2D Mammography.

Purpose To compare the outcome of architectural distortion (AD) without associated mass only on digital breast tomosynthesis (DBT) with AD seen at two-dimensional (2D) mammography and to evaluate if the incidence of malignancy is influenced by the presence of a correlate at ultrasonography (US). Materials and Methods This retrospective study had institutional review board approval and was HIPAA compliant. All consecutive cases in which patients with AD were ultimately assigned Breast Imaging Reporting and Data System (BI-RADS) 4 or 5 categories from 2009 to 2016 were reviewed by three readers for visibility (2D vs DBT). The level of suspicion was assigned using a Likert scale. Pathologic results were compared between 2D-detected and DBT-detected AD. Frequencies were compared by using the McNemar and Pearson χ2 exact tests. Results One hundred eighty-one AD lesions were included; 122 (67.4%) were 2D visible while 59 (32.6%) were DBT detected. Forty-two women (with 43 lesions) underwent 2D mammography prior to initiation of DBT. In 117 women with 121 AD lesions who underwent 2D mammography plus DBT, 59 lesions (48.8%) were detected only with DBT. The malignancy rate based on final pathology was significantly higher for 2D-detected AD (53 [43.4%] of 122) compared with DBT (six [10.2%] of 59) (P < .001). A US correlate was more frequent with 2D-detected AD (103 [84.4%] of 122) than DBT (33 [55.9%] of 59) (P < .001). Malignancy rate was not different for DBT-detected AD with (four [12.1%] of 33; 95% confidence interval [CI]: 3.4%, 28.2%]) or without (two [7.7%] of 26; 95% CI: 0.9%, 25.1%]) a US correlate. NPV based on radiologists' level of suspicion was high (91.8%-98.0%) but not sufficient enough to forgo biopsy. Conclusion DBT-detected suspicious AD has a lower malignancy outcome compared with 2D mammography-detected suspicious AD, although still high enough to warrant biopsy. © RSNA, 2018 Online supplemental material is available for this article.

Comparison Between Digital and Synthetic 2D Mammograms in Breast Density Interpretation.

OBJECTIVE: The purpose of this study was to compare assessments of breast density on synthetic 2D images as compared with digital 2D mammograms. MATERIALS AND METHODS: This retrospective study included consecutive women undergoing screening with digital 2D mammography and tomosynthesis during May 2015 with a negative or benign outcome. In separate reading sessions, three radiologists with 5-25 years of clinical experience and 1 year of experience with synthetic 2D mammography read digital 2D and synthetic 2D images and assigned breast density categories according to the 5th edition of BI-RADS. Inter- and intrareader agreement was assessed for each BI-RADS density assessment and combined dense and nondense categories using percent agreement and Cohen kappa coefficient for consensus and all reads. RESULTS: A total of 309 patients met study inclusion criteria. Agreement between consensus BI-RADS density categories assigned for digital and synthetic 2D mammography was 80.3% (95% CI, 75.4-84.5%) with κ = 0.73 (95% CI, 0.66-0.79). For combined dense and nondense categories, agreement reached 91.9% (95% CI, 88.2-94.7%). For consensus readings, similar numbers of patients were shifted between nondense and dense categories (11 and 14, respectively) with the synthetic 2D compared with digital 2D mammography. Interreader differences were apparent; assignment to dense categories was greater with digital 2D mammography for reader 1 (odds ratio [OR], 1.26; p = 0.002), the same for reader 2 (OR, 0.91; p = 0.262), and greater with synthetic 2D mammography for reader 3 (OR, 0.86; p = 0.033). CONCLUSION: Overall, synthetic 2D mammography is comparable with digital 2D mammography in assessment of breast density, though there is some variability by reader. Practices can readily adopt synthetic 2D mammography without concern that it will affect density assessment and subsequent recommendations for supplemental screening.

Extranodal Lymphoma of the Breast.

Extranodal lymphoma represents fewer than 0.5% of all breast malignancies. Secondary involvement of the breast with lymphoma is more common than primary breast lymphoma. The most common primary breast lymphoma is B-cell lymphoma. The initial imaging study of choice for a woman with a new breast mass is a diagnostic mammogram. In younger women ultrasound is more commonly the first imaging modality performed. Diagnosis is made from image-guided or physical examination-directed needle biopsy. Treatment is different from that for breast cancer, in that surgery is not the mainstay. Patients with breast lymphoma are treated primarily with chemotherapy and radiation.

3D-MR Ductography and Contrast-Enhanced MR Mammography in Patients with Suspicious Nipple Discharge; a Feasibility Study.

We evaluated contrast-enhanced magnetic resonance (ce-MR) imaging and an indirect MR galactogram (MRG) sequence against conventional galactography (CG) in women with suspicious nipple discharge who underwent histologic diagnosis. This study was Institutional Review Board approved and HIPAA compliant. Women with suspicious nipple discharge recommended for CG were recruited for our study. Patients underwent both a ce-MR as well as MRG (MRG-1 and MRG-2, variations in isotropic spatial resolution) followed by CG within 60 days. The ce-MR and MRG studies were interpreted together by a single radiologist separately from CG. Pathology was used as our gold standard and was obtained via image-guided core needle biopsy or surgery with papilloma, atypia, and malignancy considered positive. Of the 21 patients recruited for the study, 20 patients had known histology results for 26 lesions; 18 patients (90.0%) had successful CG, 20 (100.0%) ce-MRI, 20 (100.0%) MRG-1, and 19 (95.0%) MRG-2. Histology showed 5 cancers (4 women), 15 papillomas (2 with atypia) (11 women), and 6 additional benign lesions (6 women). Five patients (25.0%) had additional lesions detected by ce-MR that influenced surgical management. Sensitivity, specificity, positive (PPV), and negative predicted values (NPV) for CG, ce-MRI, MRG-1 were 65.0, 33.3, 76.5, and 22.2; 95.0, 66.7, 90.5, and 80.8; 55.0, 66.7, 84.6, and 30.8, respectively. ce-MR had the highest sensitivity, PPV, and NPV compared with CG or MRG. Our MRG protocols show promise, but were not as sensitive as ce-MRI for women with suspicious nipple discharge.

A milestone-based approach to breast imaging instruction for residents.

Residency is historically an apprenticeship, learning through observation and instruction with varying degrees of structure. Since July 2013, the Next Accreditation System (NAS) of the ACGME has required the use of progressive milestones for each radiology residency rotation. The authors describe how a breast imaging curriculum can be structured to comply with the NAS. The breast imaging rotations move from basic recognition and management of suspicious findings, through the detection of more subtle findings and learning of biopsy skills, and finally to the synthesis and management of more advanced findings. Likewise, patient communication moves from sharing imaging findings to the more challenging situation of breaking the bad news of a cancer diagnosis. This progression of skills mirrors the objectives of levels 1 to 4 of the NAS. Learning objectives have been adapted to form very specific milestones for each rotation, which results in a shared responsibility between residents and faculty members. Using clear expectations may improve the uniformity of teaching, resident satisfaction, and facilitate performance review for residents who are struggling. Didactic lectures, case-based conferences, teaching file cases, and assigned readings provide different approaches to education, allowing variation in learning styles. Performance on the breast imaging section on the ACR Diagnostic Radiology In-Training examination at our institution has risen from below the 50th percentile to around the 80th percentile beginning in 2011.

The next accreditation system in radiology: a report from the APDR residency structure committee.

In a move to emphasize the educational outcomes of training programs, the ACGME has created the Next Accreditation System (NAS). The stated goals of NAS include aiding the ACGME in the accreditation of programs based on educational outcome measures, decreasing program burdens associated with the conventional process-based approach to ACGME accreditation, allowing good programs to innovate while enabling struggling programs to steadily improve, and providing public accountability for outcomes. Diagnostic radiology is among the first group of specialties to undergo NAS implementation and began operating under the NAS in July 2013. This article describes the various components of the NAS and explains the new elements, including the clinical learning environment review program, the milestones, the clinical competency committee, and the self-study visits.

Interactive case review of radiologic and pathologic findings from breast biopsy: are they concordant? How do I manage the results?

The number of imaging-guided percutaneous breast biopsies performed has steadily increased as imaging techniques have improved. Percutaneous biopsy is becoming more commonplace and supplanting excisional biopsy as the preferred diagnostic tool. The radiologist's role in caring for patients who undergo breast biopsy extends beyond imaging to identifying lesions for biopsy and then performing the procedure. Radiologists must also be cognizant of radiologic-pathologic correlation to determine whether biopsy results are concordant with imaging findings and make management recommendations. Management of microcalcifications, masses, and areas of asymmetry begins with recognizing and characterizing the findings with the proper Breast Imaging Reporting and Data System (BI-RADS) lexicon. Determining concordance between imaging findings and histologic results is equally important. The decision to recommend surgical excision or short-term follow-up relies heavily on whether the histologic diagnosis correlates with the imaging findings, a determination that is part of the radiologist's responsibilities if he or she performs the biopsy. Supplemental material available at http://radiographics.rsna.org/lookup/suppl/doi:10.1148/rg.334125123/-/DC1.

Incidental pleural effusions detected on screening breast MRI.

OBJECTIVE: Pleural effusions are a common complication of malignancy that must be differentiated from physiologic effusions identified on breast MRI. This study aimed to determine the incidence and reference range of physiologic pleural effusions observed in healthy women undergoing screening breast MRI. MATERIALS AND METHODS: A retrospective analysis of 200 consecutive women who underwent screening breast MRI between December 2007 and December 2008 was performed. Medical records were reviewed; patients with abnormal MRI findings resulting in a diagnosis of breast cancer, a prior malignancy, or cardiac or pulmonary disease were excluded. Patient age, the presence of pleural effusions, and, if present, the laterality were recorded. The largest size of effusions was measured at the anterior chest wall. A nonparametric Wilcoxon test was used to compare the sizes of right- and left-sided pleural effusions. RESULTS: Of the 200 patients, 174 (87%) had a pleural effusion; 124 (62%) were bilateral and 50 (25%) were unilateral. Compared with the left side, right-sided pleural effusions were more frequent (81.5% vs 67.5%, respectively; p < 0.001) and were slightly larger (mean, 3.3 vs 2.8 mm; p = 0.019). Effusions ranged from 1 to 12 mm on the right and from 1 to 8 mm on the left. The reference range for pleural effusions on breast MRI based on this healthy population is up to 7 mm on the right side and 5 mm on the left side. CONCLUSION: Small pleural effusions are a common physiologic finding in women undergoing screening breast MRI and should not prompt further testing.

Rim-enhancing breast masses with smooth or spiculated margins on magnetic resonance imaging: histopathology and clinical significance.

Rim enhancement is defined as enhancement that is more pronounced at the periphery of a mass. It can have varying appearances, ranging from a thin pattern to one that is thicker. This internal enhancement characteristic is an established characteristic of malignant lesions. Additionally, the use of combined descriptors, especially internal enhancement characteristics and the associated margin, can provide a more powerful predictive value than that of individual descriptors. The margin assessment of rim-enhancing masses is important and can vary in appearance from smooth to spiculated. Moreover, rim enhancement may be dynamic in that it changes appearance during the dynamic phases of contrast- enhanced breast magnetic resonance imaging (ce-MRI), and this feature can lead to confusion in the correct application of this lexicon. Rim-enhancing masses on ce-MRI are typically of two morphological types (i.e., a thin rim-enhancing mass with a smooth margin and a thick rim-enhancing mass with a spiculated margin). It is helpful to review and clarify the lexicon of rim enhancement using combined descriptors based on the pathological findings as doing so can help predict the likelihood of malignancy of ce-MRI lesions.

The new radiology residency fourth year under the new curriculum: a survey of current residents' thoughts and suggestions about its design and purpose.

RATIONALE AND OBJECTIVES: The ABR announced changes to the board examinations for the resident class entering in 2010. These changes can allow the fourth year to be focused on subspecialization. During the restructuring process at the authors' institution, residents were queried about fourth-year design. The goal was to create a curriculum that would best meet residents' expectations while balancing clinical and educational needs. MATERIALS AND METHODS: Issues from the literature about the fourth-year curriculum were identified. An anonymous and voluntary survey based on these was developed and sent to 36 residents who made up the study group. Answers were reviewed for trends and significant unique responses before curricular development. RESULTS: Twenty-two of 36 residents (61%) responded. The most often selected electives were cardiac (91%), body MRI (77%), body interventional procedures (68%), neuroradiologic MRI (59%), musculoskeletal procedures (59%), and musculoskeletal imaging (54%). Fifty percent wanted 6 months in one area. Forty-five percent felt that the length of time in one area (most with a threshold of 9 months) would affect their decisions to pursue fellowships. The majority (73%) planned to use the fourth year to do rotations different from their planned fellowship areas. CONCLUSION: The majority of residents indicate that they would like to have at least half of their fourth year in one area, and most selected similar rotations to one another. The ability to do this extended time on one service may result in a decrease in the number of residents pursuing fellowships. However, most saw the fourth year as a way to broaden their radiologic knowledge.

Short-term follow-up of palpable breast lesions with benign imaging features: evaluation of 375 lesions in 320 women.

OBJECTIVE: The purpose of this study was to evaluate the feasibility of short-term follow-up of palpable masses that have benign imaging features. MATERIALS AND METHODS: The cases of all women with round, oval, or lobular palpable masses with circumscribed margins and homogeneous ultrasound echotexture for which short-term follow-up was recommended from July 1997 through December 2003 were retrospectively identified. Evaluation was by ultrasound and/or mammography and focused clinical examination. Outcome was assessed with imaging or clinical follow-up lasting at least 12 months. The cancer incidence for palpable lesions was compared with that for nonpalpable lesions recommended for short-term follow-up. RESULTS: In 379 women, 443 palpable masses with benign features for which short-term follow-up was recommended were identified. Outcome data were available on 375 masses in 320 women. Lesions were evaluated with mammography and ultrasound (n = 186) or ultrasound alone (n = 189). Masses were typically identified only with ultrasound (n = 258, 68.8%); were oval (n = 275, 73.3%), of equal density to normal breast tissue on mammograms (n = 95 on 117 mammograms, 81.2%), and hypoechoic (n = 336 in 372 ultrasound examinations, 90.3%); and were prospectively believed to be fibroadenoma (n = 304, 81.1%). Eighty-five lesions (22.7%) were biopsied soon after evaluation, and one 1.5-mm ductal carcinoma in situ was diagnosed. At follow-up (mean, 2.7 years), 26 lesions (6.9%) had grown. Twenty-four of the 26 lesions were biopsied, and no cancer was diagnosed. The overall cancer prevalence was similar for palpable (0.3%) and nonpalpable (1.6%) masses. The cost of short-term follow-up was less than that of biopsy. CONCLUSION: Short-term follow-up is a reasonable alternative to biopsy of palpable breast lesions with benign imaging features, particularly for young women with probable fibroadenoma.

Radiologist/Educator knowledge of the audience response system and limitations to its use.

RATIONALE AND OBJECTIVES: Audience response systems (ARS) have been proven to increase residents' retention in the short and long terms. The purpose of this study was to determine what teaching faculty members know about the ARS at one institution, what the obstacles are to its use, and ways to increase its use. MATERIALS AND METHODS: An anonymous and voluntary survey was sent to teaching faculty members. Fifty-two faculty members received the survey request and were included in the study set. The survey included questions regarding the faculty members' prior use of, understanding of, and ideas about ways to improve the ARS, as well as obstacles to its use. RESULTS: Thirty of 52 faculty members (58%) responded. Eight (27%) reported prior use of the ARS. Impediments to using the system more, for infrequent users, included "no need for it again," that it was "a bit tedious to incorporate into lectures," and time limitations. However, most users felt that the system was overall easy to use, and they did so by incorporating it into existing lectures. Perceptions that residents learned more effectively with the ARS motivated faculty members to use it more. They noted that residents seemed to like the ARS lectures more and were more engaged than with other didactic techniques. Faculty members would increase their use of the ARS if more information technology support were available, if training sessions were held, and if they had knowledge that residents preferred this lecture format. CONCLUSIONS: Faculty members at the authors' academic institution used its ARS infrequently but expressed an overall desire to use it more. They suggested methods that would increase their use of the device and were particularly motivated by residents' satisfaction with their lectures. If their suggestions can be implemented, use of the ARS should increase.

Nipple-areolar complex: normal anatomy and benign and malignant processes.

The nipple-areolar complex may be affected by many normal variations in embryologic development and breast maturation as well as by abnormal processes of a benign or malignant nature. Benign processes that may affect the nipple-areolar complex include eczema, duct ectasia, periductal mastitis, adenomas, papillomas, leiomyomas, and abscesses; malignant processes include Paget disease, lymphoma, and invasive and noninvasive breast cancers. Radiologists should be aware of the best methods for evaluating each of these entities: Many disorders of the nipple-areolar complex are unique or differ in important ways from those that occur elsewhere in the breast, and they require a diagnostically specific imaging evaluation. Patients may present with benign developmental variations; inversion, retraction, or enlargement of the nipple, which may have either a benign or a malignant cause; a palpable mass; nipple discharge; skin changes in and around the nipple; infection with resultant nipple changes or a subareolar mass; or abnormal findings at routine mammographic screening. Further diagnostic imaging may include repeat mammography, breast ultrasonography, galactography, and magnetic resonance imaging. When skin changes are present, a clinical evaluation by the patient's primary care physician, dermatologist, or surgeon should be part of the diagnostic work-up.

Finding early invasive breast cancers: a practical approach.

Detection of early invasive breast cancer is important, as patient survival is high when the cancer is 2 cm or smaller. Invasive breast cancers typically manifest mammographically as focal asymmetries or masses. Strategies for detecting focal asymmetries and masses on screening mammograms include side-by-side comparison, looking for parenchymal contour deformity, close inspection of the retromammary fat, identifying the presence of associated findings, and comparison with prior mammograms. Focal asymmetries are often normal but are concerning when there is distortion of the normal breast architecture. Masses and focal asymmetries are best evaluated in the diagnostic setting by using spot compression and true lateral views and, frequently, ultrasonography. Management of a lesion depends on the worst imaging feature. Indications for an assessment of probably benign findings are very specific but are often misapplied. This review for residents provides a practical approach to the detection and management of breast masses and focal asymmetries.

Breaking bad news: a primer for radiologists in breast imaging.

The task of breaking bad news, whether news of need for biopsy or a new breast cancer diagnosis, is increasingly performed by breast imaging radiologists. Most radiologists have little exposure to didactic teaching or modeling for learning methods of breaking bad news. Understanding barriers for communicating bad news and general improvements in communication, such as avoiding jargon and active listening, are initial steps in learning this important task. Bad news should be communicated to a patient in a supportive environment and directly in simple, but not blunt, terms. The amount of news delivered at any one time must be judged by a patient's response. It may be preferable to deliver bad news in smaller portions to allow time for a patient to cope. The use of a "warning shot," particularly at the time of diagnostic imaging, can be helpful to alert patients to forthcoming bad news. Common patient responses to bad news include shock, disbelief, denial, fear, anger, and guilt. An empathetic response from a physician demonstrates support. In breast imaging, providing a patient with perspective about her risk for breast cancer or the characteristics of the cancer if early may instill hope without giving false reassurance. Establishing a plan, typically an appointment with a breast surgeon in the setting of breast cancer, allows a patient to have a sense of control over her disease. Offering additional support also demonstrates empathy. The task of delivering bad news is an important task that, if done well, improves patients' ability to cope with their disease.

Breast MR imaging artifacts: how to recognize and fix them.

Patient and technical factors may lead to unwanted artifacts at breast magnetic resonance (MR) imaging. Use of a properly functioning high-field-strength MR imaging system, a dedicated bilateral breast coil, and an optimal imaging protocol provides a solid framework for performing high-quality breast MR imaging. Problems related to breast positioning, selection of imaging volume, and phase-encoding direction can be overcome by training and providing feedback to MR imaging technologists. Common artifacts seen at breast MR imaging include motion, suboptimal fat suppression, metallic susceptibility, phase wrap, radiofrequency noise, and chemical shift. Once they are recognized, many of these artifacts can be corrected. Protocol monitoring and imaging-based feedback from the interpreting radiologist are essential for minimizing artifacts and optimizing breast MR imaging.

Accuracy of assigned BI-RADS breast density category definitions.

RATIONALE AND OBJECTIVES: Quantitative criteria for the Breast Imaging Reporting and Data System (BI-RADS) mammographic density categories have recently been defined as <25% dense for almost entirely fatty, 25%-50% dense for scattered fibroglandular densities, 51%-75% for heterogeneously dense, and >75% dense for the extremely dense category. The purpose of this study is to compare the range of percent mammographic densities with radiologist-assigned BI-RADS mammographic density categories and compare with the recently issued definitions. MATERIALS AND METHODS: In this study, 200 consecutive negative analog screening mammograms were assigned BI-RADS mammographic density categories independently by three radiologists blinded to the other readers' density assignment. Quantitative assessment of percent mammographic density was performed using previously validated software. RESULTS: All three readers agreed on BI-RADS mammographic density categories in 98 cases (49%), and two of three readers agreed in all 200 cases. Using two reader's consensus, median mammographic density (range) was 6.0% (0.5%-19.2%) for fatty, 14.8% (1.2%-52.7%) for scattered densities, 51.2% (15.9%-82.2%) for heterogeneously dense, and 78.4% (60.1%-87.9%) for extremely dense breasts. The percent mammographic density ranges for fatty and extremely dense breasts correlated well with BI-RADS definitions, whereas the ranges of densities in the scattered and heterogeneously dense categories were considerably broader. CONCLUSION: Fatty and extremely dense BI-RADS categories compare relatively well to defined criteria, and therefore may be helpful in breast cancer risk models. Scattered fibroglandular densities and heterogeneously dense categories have broad percent mammographic density ranges and may not function well in breast cancer risk models.