Suspicious Ultrasound-Occult Non-Calcified Mammographic Masses, Asymmetries, and Architectural Distortions Are Moderate Probability for Malignancy.

Suspicious non-calcified mammographic findings have not been evaluated with modern mammographic technique, and the purpose of this work is to compare the likelihood of malignancy for those findings. To do this, 5018 consecutive mammographically guided biopsies performed during 2016-2019 at a large metropolitan, community-based hospital system were retrospectively reviewed. In total, 4396 were excluded for targeting calcifications, insufficient follow-up, or missing data. Thirty-seven of 126 masses (29.4%) were malignant, 44 of 194 asymmetries (22.7%) were malignant, and 77 of 302 architectural distortions (AD, 25.5%) were malignant. The combined likelihood of malignancy was 25.4%. Older age was associated with a higher likelihood of malignancy for each imaging finding type (all p ≤ 0.006), and a possible ultrasound correlation was associated with a higher likelihood of malignancy when all findings were considered together (p = 0.012). Two-view asymmetries were more frequently malignant than one-view asymmetries (p = 0.03). There were two false-negative biopsies (98.7% sensitivity and 100% specificity). In conclusion, the 25.4% likelihood of malignancy confirms the recommendation for biopsy of suspicious, ultrasound-occult, mammographic findings. Mammographically guided biopsies were highly sensitive and specific in this study. Older patient age and a possible ultrasound correlation should raise concern given the increased likelihood of malignancy in those scenarios.

Stepwise Implementation of 2D Synthesized Screening Mammography and Its Effect on Stereotactic Biopsy of Microcalcifications.

RATIONALE AND OBJECTIVES: Information evaluating the efficacy of 2D synthesized mammography (2Ds) reconstructions in microcalcification detection is limited. This study used stereotactic biopsy data for microcalcifications to evaluate the stepwise implementation of 2Ds in screening mammography. The study aim was to identify whether 2Ds + digital breast tomosynthesis (DBT) is non-inferior to 2D digital mammography (2DM) + 2Ds + DBT, 2DM + DBT, and 2DM in identifying microcalcifications undergoing further diagnostic imaging and stereotactic biopsy. MATERIALS AND METHODS: Retrospective stereotactic biopsy data were extracted following 151,736 screening mammograms of healthy women (average age, 56.3 years; range, 30-89 years), performed between 2012 and 2019. The stereotactic biopsy data were separated into 2DM, 2DM + DBT, 2DM + 2Ds + DBT, and 2Ds + DBT arms and examined using Fisher's exact test to compare the detection rates of all cancers, invasive cancers, DCIS, and ADH between modalities for patients undergoing stereotactic biopsy of microcalcifications. RESULTS: No statistical significance in cancer detection was seen for 2Ds + DBT among those calcifications that underwent stereotactic biopsy when comparing the 2Ds + DBT to 2DM, 2DM + DBT, and 2DM + 2Ds + DBT imaging combinations. CONCLUSION: These data suggest that 2Ds + DBT is non-inferior to 2DM + DBT in detecting microcalcifications that will undergo stereotactic biopsy.

The disruptive radiologist.

Hospital and regulatory organizations recognize the downstream impact of interpersonal relationships on patient safety. There are many contributors to interpersonal dynamics, one of which includes disruptive physicians. This can stem from overt or passive behaviors and has been categorized in the literature by terms that include disruptive physicians, professionalism and burnout. The contributing factor factors to such behavior are varied and may include burnout, stress, skill deficiencies, and impairment. These behaviors can be impacted through personal and systemic influences that are difficult for administrators to elucidate due to physician and organizational confidentiality concerns. However, there are opportunities and tools where radiology practice leaders and organizations can intervene to assist the disruptive radiologist. These include during residency/fellowship training, clarifying employee expectations during the time of radiologist hiring, offering interventions during practice, providing resources such as employee assistance programs, and addressing systemic challenges. Utilizing these tool sets can improve healthcare team dynamics and increase both staff and physician retention.

Peer learning in breast imaging.

With the increasing focus on quality and safety in medicine, radiology practices are increasingly transitioning from traditional score-based peer review to peer learning. Participation in a peer learning program can increase learning, practice improvement, and cultivation of interpersonal relationships in a non-punitive environment. As breast imaging errors are the most cited in medical malpractice cases, learning and attention to and reduction of these errors in breast imaging are especially important. We describe the strengths of a peer learning program, implementation process in a breast imaging program, challenges to overcome, and strategies to support success.

Responsive Web-based Breast Imaging Core Curriculum for International Radiology Residents with Self-Assessment: A Pilot Study.

RATIONALE AND OBJECTIVES: Lack of uniformity in radiology resident education is partially attributable to variable access to subspecialty education. Web-based courses improve standardization, but with growing emphasis on competency based education, more evaluation of their effectiveness is needed. We created a responsive web-based breast imaging curriculum for radiology residents including self-assessment and a satisfaction survey. MATERIALS AND METHODS: Two global academic institutions collaboratively developed a breast imaging curriculum to address radiology residents' educational needs. This virtual course comprised 11 video lectures, nine didactic (with attached pre-test and post-test assessments) and two case review sessions. In April 2020, this optional curriculum was made available to all 56 radiology residents in one residency program cluster in Singapore, to be accessed alongside the breast imaging rotation as a supplement. A voluntary anonymous satisfaction survey was provided upon completion. RESULTS: A total of 39 of the 56 radiology residents (70%) completed the course. For the average score of nine lectures (maximum score 5), there was a significant increase in mean pre and post - test scores (mean = 2.2, SD = 0.7), p < 0.001. The proportion of residents with improvement between the pre-test score and the post-test score ranged from 74% to 100% (mean, 84%). Thirty three of the 39 participants (85%) completed the satisfaction survey, and all agreed or strongly agreed that the curriculum increased their knowledge of breast imaging. CONCLUSION: This web based breast imaging curriculum supplement was viewed positively by participating residents and improved their self-assessed knowledge. Curriculum access could be expanded to improve global radiology education.

Does lateral arm technique decrease the rate of clip migration in stereotactic and tomosynthesis-guided biopsies?

BACKGROUND: Mammography-guided vacuum-assisted biopsies (MGVAB) can be done with stereotaxis or digital breast tomosynthesis guidance. Both methods can be performed with a conventional (CBA) or a lateral arm biopsy approach (LABA). Marker clip migration is relatively frequent in MGVAB (up to 44%), which in cases requiring surgery carries a risk of positive margins and re-excision. We aimed to compare the rates of clip migration and hematoma formation between the CBA and LABA techniques of prone MGVAB. Our HIPAA compliant retrospective study included all consecutive prone MGVAB performed in a single institution over a 20-month period. The LABA approach was used with DBT guidance; CBA utilized DBT or stereotactic guidance. The tissue sampling techniques were otherwise identical. RESULTS: After exclusion, 389 biopsies on 356 patients were analyzed. LABA was done in 97 (25%), and CBA in 292 (75%) cases. There was no statistical difference in clip migration rate with either 1 cm or 2 cm distance cut-off [15% for CBA and 10% for LABA for 1 cm threshold (p = 0.31); 5.8% or CBA and 3.1% or LABA for 2 cm threshold (p = 0.43)]. There was no difference in the rate of hematoma formation (57.5% in CDB and 50.5% in LABA, p = 0.24). The rates of technical failure were similar for both techniques (1.7% for CBA and 3% for LABA) with a combined failure rate of 1%. CONCLUSIONS: LABA and CBA had no statistical difference in clip migration or hematoma formation rates. Both techniques had similar success rates and may be helpful in different clinical situations.

Breast cancer screening in women with and without implants: retrospective study comparing digital mammography to digital mammography combined with digital breast tomosynthesis.

OBJECTIVES: Compare four groups being screened: women without breast implants undergoing digital mammography (DM), women without breast implants undergoing DM with digital breast tomosynthesis (DM/DBT), women with implants undergoing DM, and women with implants undergoing DM/DBT. METHODS: Mammograms from February 2011 to March 2017 were retrospectively reviewed after 13,201 were excluded for a unilateral implant or prior breast cancer. Patients had been allowed to choose between DM and DM/DBT screening. Mammography performance metrics were compared using chi-square tests. RESULTS: Six thousand forty-one women with implants and 91,550 women without implants were included. In mammograms without implants, DM (n = 113,973) and DM/DBT (n = 61,896) yielded recall rates (RRs) of 8.53% and 6.79% (9726/113,973 and 4204/61,896, respectively, p < .001), cancer detection rates per 1000 exams (CDRs) of 3.96 and 5.12 (451/113,973 and 317/61,896, respectively, p = .003), and positive predictive values for recall (PPV1s) of 4.64% and 7.54% (451/9726 and 317/4204, respectively, p < .001), respectively. In mammograms with implants, DM (n = 6815) and DM/DBT (n = 5138) yielded RRs of 5.81% and 4.87% (396/6815 and 250/5138, respectively, p = .158), CDRs of 2.49 and 2.92 (17/6815 and 15/5138, respectively, p > 0.999), and PPV1s of 4.29% and 6.0% (17/396 and 15/250, respectively, p > 0.999), respectively. CONCLUSIONS: DM/DBT significantly improved recall rates, cancer detection rates, and positive predictive values for recall compared to DM alone in women without implants. DM/DBT performance in women with implants trended towards similar improvements, though no metric was statistically significant. KEY POINTS: • Digital mammography with tomosynthesis improved recall rates, cancer detection rates, and positive predictive values for recall compared to digital mammography alone for women without implants. • Digital mammography with tomosynthesis trended towards improving recall rates, cancer detection rates, and positive predictive values for recall compared to digital mammography alone for women with implants, but these trends were not statistically significant - likely related to sample size.

Batch Reading and Interrupted Interpretation of Digital Screening Mammograms Without and With Tomosynthesis.

OBJECTIVE: To compare batch reading and interrupted interpretation for modern screening mammography. METHODS: We retrospectively reviewed digital mammograms without and with tomosynthesis that were originally interpreted with batch reading or interrupted interpretation between January 2015 and June 2017. The following performance metrics were compared: recall rate (per 100 examinations), cancer detection rate (per 1,000 examinations), and positive predictive values for recall and biopsy. RESULTS: In all, 9,832 digital mammograms were batch read, yielding a recall rate of 9.98%, cancer detection rate of 4.27, and positive predictive values for recall and biopsy of 4.40% and 35.5%, respectively. There were 49,496 digital mammograms that were read with interrupted interpretation, yielding a recall rate of 11.3%, cancer detection rate of 4.44, and positive predictive values for recall and biopsy of 3.92% and 30.1%, respectively. Of the digital mammograms with tomosynthesis, 7,075 were batch read, yielding a recall rate of 6.98%, cancer detection rate of 5.37, and positive predictive values for recall and biopsy of 7.69% and 38.0%, respectively. Of the digital mammograms with tomosynthesis, 24,380 were read with interrupted interpretation, yielding a recall rate of 8.30%, cancer detection rate of 5.41, and positive predictive values for recall and biopsy of 6.52% and 33.3%, respectively. For both digital mammograms without and with tomosynthesis, recall rates improved with batch reading compared with interrupted interpretation (P < .001), but no significant differences were seen for other metrics. DISCUSSION: Batch reading digital mammograms without and with tomosynthesis improves recall rates while maintaining cancer detection rates and positive predictive values compared with interrupted interpretation.

Community outreach and integration of breast radiologists.

With the increased emphasis on patient experience and shift toward patient- and family-centered care in health care, balancing the daily practice of radiology and devoting time to community outreach and engagement can seem challenging. We describe various methods of community outreach and integration attainable by breast imagers and how these can be used to develop relations with patients and providers, improve patient access, and inspire future breast imagers. Engagement in community outreach by the breast imager can positively impact breast radiologists, their radiology groups, and patients.

Optimizing patient experience scores in outpatient breast centers.

High patient experience scores in outpatient radiology is a goal that impacts patient care and compliance. There are secondary positive effects on employee engagement and retention as well as reimbursement and increased market share. Effective administrative and physician leadership is critical in obtaining employee buy-in to the importance of customer experience. Training for employees at all levels in understanding the patient psyche empowers them to offer personalized care to a diverse patient population. Given the multiple benefits of high patient experience scores, a leading patient experience survey was assessed in detail to assist radiologists in breast imaging and other subspecialties, to understand and implement steps to optimize their own patient experience scores.

Enhancing Quality Using the Inspection Program (EQUIP): A Primer for Radiologists.

The new Enhancing Quality Using the Inspection Program (EQUIP) law places more responsibility for quality assurance on the interpreting radiologists and the lead interpreting physician (LIP). Compliance with the law will require addressing three specific questions related to quality assurance and clinical image corrective action, continued compliance, and ensuring LIP oversight. This process enables the radiologist to exemplify added value through physician leadership, team integration, and improved patient care.

Supplemental ultrasound screening in patients with a history of lobular neoplasia.

To investigate the role of ultrasound (US) screening as an adjunct to annual mammography (M) in breast cancer detection in women with a history of lobular neoplasia (LN) diagnosed following core needle or excisional biopsy. A retrospective review of our database was performed between 11/2006 and 11/2011 to identify patients diagnosed with LN, and underwent annual screening. Patients with a lifetime risk >20% per risk modeling were excluded. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and cancer detection rate (CDR) of each screening test were identified. Cancer type and detection modality were recorded. A total of 100 patients who had M and/or US screening were included. Mean patient age was 54.7 years (range 33-83). All 100 patients underwent a mean of 3.9 rounds of screening M and 93 (93%) received US screening (mean 3.3 rounds). Of 93 patients who received both M and US screening, 12 (13%) were diagnosed with breast cancer. Mammographic CDR was 4%. Incremental US CDR was 6.5%. The sensitivity, specificity, and NPV for M screening alone was 33% (10%, 65%), 77% (67%, 85%), and 89% (80%, 95%), respectively. US and mammography screening had a combined sensitivity: 83% (52%, 98%), Specificity: 72% (62%, 81%), NPV: 97% (89%, 100%). Supplemental US screening resulted in a significant increase in sensitivity, yielding 6.5% incremental CDR in this high-risk patient subgroup that does not fulfill ACS high-risk MRI screening criteria.

Screening Mammography Findings From One Standard Projection Only in the Era of Full-Field Digital Mammography and Digital Breast Tomosynthesis.

OBJECTIVE: The purpose of this article is to compare outcomes of findings seen on one view only from screening full-field digital mammography (FFDM) and FFDM plus digital breast tomosynthesis (DBT). MATERIALS AND METHODS: A retrospective review was performed of 103,070 consecutive screening mammograms obtained from February 2011 through June 2014 at two community-based breast centers. Recalled findings prospectively seen on one view only were analyzed. Pearson chi-square test and Fisher exact test were performed, and 95% CIs were determined. RESULTS: Mammograms were acquired using FFDM (n = 71,656) and FFDM-DBT (n = 31,414) during the study period, and 2213 FFDM (3.1%) and 433 FFDM-DBT (1.4%) mammograms were recalled for one-view-only findings (p < 0.0001). The final study population (1592 FFDM and 354 FFDM-DBT) was defined after 689 of these recalled FFDM and 92 of these recalled FFDM-DBT examinations were excluded for insufficient mammographic follow-up (< 24 months). Summation artifacts accounted for more one-view-only findings from FFDM (1067/1592; 67.0%) than FFDM-DBT (190/354; 53.7%) (p < 0.0001). In the FFDM cohort, 28 one-view-only findings proved malignant (24 invasive ductal carcinoma [IDC], one invasive lobular carcinoma [ILC], and three ductal carcinoma in situ [DCIS]). In the FFDM-DBT cohort, 14 one-view-only findings proved malignant (11 IDC, one ILC, and two DCIS). The positive predictive value (PPV) of a one-view-only finding was significantly lower for FFDM (1.8%) than for FFDM-DBT (4.0%) (p = 0.010). CONCLUSION: One-view-only findings occur with both FFDM and FFDM-DBT and remain an important but uncommon sign of malignancy. They are more frequent, are more likely to represent summation artifacts, and have a lower PPV with FFDM than with FFDM-DBT.

Interpretation of Breast MRI Utilizing the BI-RADS Fifth Edition Lexicon: How Are We Doing and Where Are We Headed?

The Breast Imaging Reporting and Data System (BI-RADS) was first initiated in the late 1980s in order to standardize reporting, improve report organization, and to monitor outcomes for more clear, concise, and uniform communication of breast imaging findings. In the BI-RADS 5th edition, several changes and new additions have been made to the magnetic resonance imaging (MRI) lexicon, reflecting increased utilization and availability of breast MRI in clinical practice. Understanding the role and appropriate utilization of breast MRI and the BI-RADS lexicon could help with interpretation and effective communication of MRI findings as well as preparing for incorporation of more advanced imaging techniques. In this comprehensive review of the changes and new descriptors in the MRI section of the fifth edition of BI-RADS with pictorial examples, the reader would be able to achieve improved understanding of the MRI BI-RADS lexicon and its appropriate applications.

BI-RADS update for breast cancer caregivers.

This review will discuss changes relevant to breast cancer caregivers in the fifth edition of the Breast Imaging Reporting and Data System.