Continuity of Radiologists Between Diagnostic Breast Imaging and Image-Guided Breast Biopsy: Impact on Patient-Reported Biopsy Morbidity Experiences.

OBJECTIVE: To determine whether continuity of care between diagnostic breast imaging and subsequent image-guided breast biopsy could reduce patient-reported biopsy-related morbidity. METHODS: This was a prospective, pragmatically randomized, 2-arm health utilities analysis of 200 women undergoing diagnostic breast imaging followed by US- or stereotactic-guided breast biopsy at a single quaternary care center from September 3, 2019, to April 10, 2023. Breast biopsy-naive women with a BI-RADS 4 or 5 finding at diagnostic imaging were randomly scheduled for the typically first available biopsy appointment. One day after biopsy, enrolled patients were administered the Testing Morbidities Index (TMI). The primary outcome was the difference in TMI summary utility scores in patients who did vs did not have the same radiologist perform diagnostic imaging and biopsy. RESULTS: Response rates were 63% (100/159) for the different radiologist cohort and 71% (100/140) for the same radiologist cohort; all respondents answered all questions in both arms. Mean time to biopsy was 7 ± 6 days and 10 ± 9 days, and the number of participating radiologists was 11 and 18, respectively. There was no difference in individual measured domains (pain, fear, or anxiety before procedure; pain, embarrassment, fear, or anxiety during procedure; mental or physical impact after procedure; all P >.00625) or in overall patient morbidity (0.83 [95% CI, 0.81-0.85] vs 0.82 [95% CI: 0.80-0.84], P = .66). CONCLUSION: Continuity of care between diagnostic breast imaging and image-guided breast biopsy did not affect morbidity associated with breast biopsy, suggesting that patients should be scheduled for the soonest available biopsy appointment rather than waiting for the same radiologist.

Breast care problems on call: training residents to manage effectively.

PURPOSE: Our aim was to assess and address the challenges radiology residents face when managing breast imaging emergencies on call and to determine if targeted educational interventions improved resident confidence and knowledge. METHODS: We created surveys to determine resident comfort level with and knowledge of appropriate management of breast imaging emergencies. We also created structured educational interventions to improve resident confidence and knowledge. The effectiveness of these interventions was assessed with pre- and post-intervention surveys given to the 43 residents at our institution. RESULTS: Thirty-six of the 43 residents at our institution completed both surveys. The results showed that 33 of 36 residents (91.7%) felt an increase in their comfort level after utilizing one or both of the interventions. There was also significant improvement in resident knowledge; the average resident score on the knowledge questions improved from 40 to 68% (p < 0.0001). CONCLUSION: Managing breast imaging emergencies on call can be challenging and stressful for residents. Educational interventions such as our targeted teaching tools can significantly improve resident confidence and knowledge. Presenting dedicated teaching materials directed at a previously identified knowledge deficit and source of stress significantly improved resident knowledge base and confidence in managing breast imaging emergencies on call.

Harms of Restrictive Risk-Based Mammographic Breast Cancer Screening.

OBJECTIVE: The objective of this study was to determine if restrictive risk-based mammographic screening could miss breast cancers that population-based screening could detect. MATERIALS AND METHODS: Through a retrospective search of records at a single institution, we identified 552 screen-detected breast cancers in 533 patients. All in situ and invasive breast cancers detected at screening between January 1, 2011, and December 31, 2014, were included. Medical records were reviewed for history, pathology, cancer size, nodal status, breast density, and mammographic findings. Mammograms were interpreted by one of 14 breast imaging radiologists with 3-30 years of experience, all of whom were certified according to the Mammography Quality Standards Act. Patient ages ranged from 36 to 88 years (mean, 61 years). The breast cancer risks evaluated were family history of breast cancer and dense breast tissue. Positive family history was defined as a first-degree relative with breast cancer. Dense breast parenchyma was either heterogeneously or extremely dense. RESULTS: Group 1 consisted of the 76.7% (409/533) of patients who had no personal history of breast cancer. Of these patients, 75.6% (309/409) had no family history of breast cancer, and 56% (229/409) had nondense breasts. Group 2 consisted of the 16.7% (89/533) of patients who were 40-49 years old. Of these patients, 79.8% (71/89) had no family history of breast cancer, and 30.3% (27/89) had nondense breasts. Ductal carcinoma in situ made up 34.6% (191/552) of the cancers; 65.4% (361/552) were invasive. The median size of the invasive cancers was 11 mm. Of the screen-detected breast cancers, 63.8% (352/552) were minimal cancers. CONCLUSION: Many screen-detected breast cancers occurred in women without dense tissue or a family history of breast cancer. Exclusive use of restrictive risk-based screening could result in delayed cancer detection for many women.

Surgical biopsy is still necessary for BI-RADS 4 calcifications found on digital mammography that are technically too faint for stereotactic core biopsy.

The purpose of this study was to evaluate the outcome of faint BI-RADS 4 calcifications detected with digital mammography that were not amenable to stereotactic core biopsy due to suboptimal visualization. Following Institutional Review Board approval, a HIPAA compliant retrospective search identified 665 wire-localized surgical excisions of calcifications in 606 patients between 2007 and 2010. We included all patients that had surgical excision for initial diagnostic biopsy due to poor calcification visualization, whose current imaging was entirely digital and performed at our institution and who did not have a diagnosis of breast cancer within the prior 2 years. The final study population consisted of 20 wire-localized surgical biopsies in 19 patients performed instead of stereotactic core biopsy due to poor visibility of faint calcifications. Of the 20 biopsies, 4 (20% confidence intervals 2, 38%) were malignant, 5 (25%) showed atypia and 11 (55%) were benign. Of the malignant cases, two were invasive ductal carcinoma (2 and 1.5 mm), one was intermediate grade DCIS and one was low-grade DCIS. Malignant calcifications ranged from 3 to 12 mm. The breast density was scattered in 6/19 (32%), heterogeneously dense in 11/19 (58%) and extremely dense in 2/19 (10%). Digital mammography-detected faint calcifications that were not amenable to stereotactic biopsy due to suboptimal visualization had a risk of malignancy of 20%. While infrequent, these calcifications should continue to be considered suspicious and surgical biopsy recommended.

Morphologic Mimics of Invasive Lobular Carcinoma.

Invasive lobular carcinoma of the breast is a relatively common diagnosis. However, other carcinomatous as well as noncarcinomatous neoplasms, either primary or metastatic to the breast, may mimic invasive lobular carcinoma. As treatment may differ, establishing the correct diagnosis is paramount to providing the appropriate care for these patients. This review outlines important mimics of invasive lobular carcinoma and the key clinicopathologic and immunohistochemical features as well as additional studies helpful in establishing their diagnoses.

Outcomes of solid palpable masses assessed as BI-RADS 3 or 4A: a retrospective review.

The purpose of this study was to evaluate the outcomes and cancer rate in solid palpable masses with benign features assessed as BI-RADS 3 or 4A. This study was Institutional Review Board approved. Mammography and breast ultrasound reports in our Radiology Information System were searched for solid, palpable masses with benign features described from 1/1/2000 to 12/31/2009, and retrospectively reviewed. Those masses prospectively assessed as BI-RADS 3 or 4A, or suggestive of a fibroadenoma or other benign pathology were retrieved. Chart review was used to assess outcomes and cancer rate. Basic summary measures were summarized and compared between BI-RADS 3 and 4A groups using Wilcoxon Rank Sum test for continuous data or Fisher's exact test for categorical data. The cancer rate across age quartiles was assessed using Cochran-Armitage trend test. 573 solid palpable masses with benign features in 487 women were identified. There were 197 BI-RADS 3 and 376 BI-RADS 4A masses. The overall cancer rate was 1.6 % (9/573). All cancers were BI-RADS 4A (cancer rate 2.4 %-9/376). Smaller mean size and younger age at presentation in BI-RADS 3 women was found compared to BI-RADS 4A (P < 0.0001). There was a significant increase in cancer rate across age quartiles (P = 0.03124). The cancer rate is very low in solid palpable masses with benign features. In particular, BI-RADS 3 palpable masses in young women may undergo close surveillance without immediate biopsy, confirming what other investigators have found. All cancers were in the BI-RADS 4A group with increasing incidence with age, with over half occurring in women over 40 years old. Palpable masses in women 40 and older with benign features should be considered for immediate biopsy.

Combined photoacoustic and acoustic imaging of human breast specimens in the mammographic geometry.

A photoacoustic volume imaging (PAVI) system was designed to study breast cancer detection and diagnosis in the mammographic geometry in combination with automated 3-D ultrasound (AUS). The goal of the work described here was to validate the design and evaluate its performance in human breast tissues for non-invasive imaging of deeply positioned structures covering such geometry. The good penetration of near-infrared light and high receiving sensitivity of a broad-bandwidth, 572-element, 2-D polyvinylidene fluoride (PVDF) array at a low center frequency of 1 MHz were used with 20 channel simultaneous acquisition. Pseudo-lesions filled with dilute blood were imaged in three human breast specimens at various depths up to 49 mm. With near-infrared light illumination and 256-sample averaging, the extrapolated maximum depth in imaging a 2.4-mm blood-rich lesion with a 3-dB contrast-to-noise ratio in a compressed breast was 54 mm. Three-dimensional photoacoustic volume image stacks of the breasts were co-registered with 3-D ultrasound image stacks, suggesting for the first time that PAVI, based on the intrinsic tissue contrast, can visualize tissue interfaces other than those with blood, including the inner skin surface and connective tissue sheets. With the designed system, PAVI revealed satisfactory imaging depth and sensitivity for coverage of the entire breast when imaged from both sides in the mammographic geometry with mild compression.

Breast mass characterization using 3-dimensional automated ultrasound as an adjunct to digital breast tomosynthesis: a pilot study.

OBJECTIVES: The purpose of this study was to retrospectively evaluate the effect of 3-dimensional automated ultrasound (3D-AUS) as an adjunct to digital breast tomosynthesis (DBT) on radiologists' performance and confidence in discriminating malignant and benign breast masses. METHODS: Two-view DBT (craniocaudal and mediolateral oblique or lateral) and single-view 3D-AUS images were acquired from 51 patients with subsequently biopsy-proven masses (13 malignant and 38 benign). Six experienced radiologists rated, on a 13-point scale, the likelihood of malignancy of an identified mass, first by reading the DBT images alone, followed immediately by reading the DBT images with automatically coregistered 3D-AUS images. The diagnostic performance of each method was measured using receiver operating characteristic (ROC) curve analysis and changes in sensitivity and specificity with the McNemar test. After each reading, radiologists took a survey to rate their confidence level in using DBT alone versus combined DBT/3D-AUS as potential screening modalities. RESULTS: The 6 radiologists had an average area under the ROC curve of 0.92 for both modalities (range, 0.89-0.97 for DBT and 0.90-0.94 for DBT/3D-AUS). With a Breast Imaging Reporting and Data System rating of 4 as the threshold for biopsy recommendation, the average sensitivity of the radiologists increased from 96% to 100% (P > .08) with 3D-AUS, whereas the specificity decreased from 33% to 25% (P > .28). Survey responses indicated increased confidence in potentially using DBT for screening when 3D-AUS was added (P < .05 for each reader). CONCLUSIONS: In this initial reader study, no significant difference in ROC performance was found with the addition of 3D-AUS to DBT. However, a trend to improved discrimination of malignancy was observed when adding 3D-AUS. Radiologists' confidence also improved with DBT/3DAUS compared to DBT alone.

Digital breast tomosynthesis is comparable to mammographic spot views for mass characterization.

PURPOSE: To determine if digital breast tomosynthesis (DBT) performs comparably to mammographic spot views (MSVs) in characterizing breast masses as benign or malignant. MATERIALS AND METHODS: This IRB-approved, HIPAA-compliant reader study obtained informed consent from all subjects. Four blinded Mammography Quality Standards Act-certified academic radiologists individually evaluated DBT images and MSVs of 67 masses (30 malignant, 37 benign) in 67 women (age range, 34-88 years). Images were viewed in random order at separate counterbalanced sessions and were rated for visibility (10-point scale), likelihood of malignancy (12-point scale), and Breast Imaging Reporting and Data System (BI-RADS) classification. Differences in mass visibility were analyzed by using the Wilcoxon matched-pairs signed-ranks test. Reader performance was measured by calculating the area under the receiver operating characteristic curve (A(z)) and partial area index above a sensitivity threshold of 0.90 (A(z)(0.90)) by using likelihood of malignancy ratings. Masses categorized as BI-RADS 4 or 5 were compared with histopathologic analysis to determine true-positive results for each modality. RESULTS: Mean mass visibility ratings were slightly better with DBT (range, 3.2-4.4) than with MSV (range, 3.8-4.8) for all four readers, with one reader's improvement achieving statistical significance (P = .001). The A(z) ranged 0.89-0.93 for DBT and 0.88-0.93 for MSV (P ≥ .23). The A(z)((0.90)) ranged 0.36-0.52 for DBT and 0.25-0.40 for MSV (P ≥ .20). The readers characterized seven additional malignant masses as BI-RADS 4 or 5 with DBT than with MSV, at a cost of five false-positive biopsy recommendations, with a mean of 1.8 true-positive (range, 0-3) and 1.3 false-positive (range, -1 to 4) assessments per reader. CONCLUSION: In this small study, mass characterization in terms of visibility ratings, reader performance, and BI-RADS assessment with DBT was similar to that with MSVs. Preliminary findings suggest that MSV might not be necessary for mass characterization when performing DBT.

Breast imaging and intervention in the overweight and obese patient.

OBJECTIVE: This article comments on the challenges and coping mechanisms for evaluating overweight and obese patients with breast imaging and diagnostic techniques. With the prevalence of obesity in society, the obstacles that arise regarding patients' adherence to screening guidelines are important to address. CONCLUSION: This article discusses social factors and physical limitations that influence these patients' desires and ability to seek health care, specifically breast care and the problems that arise during imaging and interventional procedures.

Mammographic breast density: effect on imaging and breast cancer risk.

Mammographic breast density has been studied for more than 30 years. Greater breast density not only is related to decreased sensitivity of mammograms because of a masking effect but also is a major independent risk factor for breast cancer. This article defines breast density and reviews literature on quantification of mammographic density that is key to future clinical and research protocols. Important influences on breast density are addressed, including age, menopausal status, exogenous hormones, and genetics of density. Young women with dense breasts benefit from digital mammographic technique. The potential use of supplemental MRI and ultrasound screening techniques in high-risk women and women with dense breasts is explored, as are potential risk reduction strategies.

Cross-sectional imaging of primary thoracic sarcomas with histopathologic correlation: a review for the radiologist.

Numerous forms of primary sarcoma can arise from the heart, pericardium, great vessels, lungs, chest wall, and breasts. Magnetic resonance imaging and computed tomography currently play important roles in determining the extent of primary thoracic sarcoma involvement, potential for resectability, and response to therapy. The purpose of this article is to review the various forms of primary sarcoma that may affect the thorax as well as illustrate pertinent cross-sectional radiologic findings with histopathologic correlation.

Multi-modality CADx: ROC study of the effect on radiologists' accuracy in characterizing breast masses on mammograms and 3D ultrasound images.

RATIONALE AND OBJECTIVES: To investigate the effect of a computer-aided diagnosis (CADx) system on radiologists' performance in discriminating malignant and benign masses on mammograms and three-dimensional (3D) ultrasound (US) images. MATERIALS AND METHODS: Our dataset contained mammograms and 3D US volumes from 67 women (median age, 51; range: 27-86) with 67 biopsy-proven breast masses (32 benign and 35 malignant). A CADx system was designed to automatically delineate the mass boundaries on mammograms and the US volumes, extract features, and merge the extracted features into a multi-modality malignancy score. Ten experienced readers (subspecialty academic breast imaging radiologists) first viewed the mammograms alone, and provided likelihood of malignancy (LM) ratings and Breast Imaging and Reporting System assessments. Subsequently, the reader viewed the US images with the mammograms, and provided LM and action category ratings. Finally, the CADx score was shown and the reader had the opportunity to revise the ratings. The LM ratings were analyzed using receiver-operating characteristic (ROC) methodology, and the action category ratings were used to determine the sensitivity and specificity of cancer diagnosis. RESULTS: Without CADx, readers' average area under the ROC curve, A(z), was 0.93 (range, 0.86-0.96) for combined assessment of the mass on both the US volume and mammograms. With CADx, their average A(z) increased to 0.95 (range, 0.91-0.98), which was borderline significant (P = .05). The average sensitivity of the readers increased from 98% to 99% with CADx, while the average specificity increased from 27% to 29%. The change in sensitivity with CADx did not achieve statistical significance for the individual radiologists, and the change in specificity was statistically significant for one of the radiologists. CONCLUSIONS: A well-trained CADx system that combines features extracted from mammograms and US images may have the potential to improve radiologists' performance in distinguishing malignant from benign breast masses and making decisions about biopsies.

Recurrent cancer after breast-conserving surgery with radiation therapy for ductal carcinoma in situ: mammographic features, method of detection, and stage of recurrence.

OBJECTIVE: The purpose of our study was to determine the mammographic appearance, detection method, and stage of ipsilateral breast tumor recurrence in women treated with breast-conserving surgery and whole-breast radiation therapy for ductal carcinoma in situ (DCIS). MATERIALS AND METHODS: Following institutional review board approval, records of women treated with breast-conserving surgery and radiation therapy for DCIS who developed an ipsilateral breast tumor recurrence from 1981 to 2003 were reviewed retrospectively. Multiinstitutional database records showed 513 women were treated, of whom 42 (8.2%) developed local recurrence. Study criteria were fulfilled and complete records were available for 32 women. Mean age at initial diagnosis was 49 years (range, 26-73 years). RESULTS: Of the 32 patients included in our study, 31 (97%) recurrences were mammographically apparent. Twenty-nine (91%) of 32 were diagnosed exclusively by mammography. Mammographic findings at recurrence were calcifications in 24 (75%) of 32, mass in six (19%) of 32, and distortion in one (3%) of 32. The mean time to recurrence was 4.5 years. Twelve (40%) of 30 had the recurrence in a remote quadrant from the original cancer. Recurrences were DCIS in 17 (53%) of 32, DCIS with microinvasion in six (19%) of 32, invasive ductal cancer in three (9%) of 32, invasive lobular cancer in two (6%) of 32, and mixed DCIS and invasive cancer in four (13%) of 32. Six (67%) of nine patients with invasive cancer (excluding microinvasion) had tumors smaller than 1 cm. Ninety-one percent of recurrences were minimal cancers. All recurrences were stage 0 or 1. CONCLUSION: Mammography successfully detected ipsilateral breast tumor recurrence, predominantly as calcifications or masses, after breast-conserving surgery with radiation therapy for DCIS in 97% of cases. The recurrences were located at variable distances from the lumpectomy site. Ninety-one percent of recurrences were minimal cancers and all were early stage, connoting excellent prognosis.

Costs of achieving high patient compliance after recall from screening mammography.

OBJECTIVE: The purpose of our study was to document the hidden costs in achieving high recall patient compliance from an off-site screening mammography program. MATERIALS AND METHODS: This study was approved by our institutional review board. At our institution, no patient was placed in final BI-RADS assessment category 3, 4, or 5 without a diagnostic study. Each incomplete study, in addition to the formal report, was flagged on the day sheet, letters were sent to the referring physician and patient, and an incomplete computer code was added. Working from the day sheets, a clerk contacted the patient by telephone within 2 working days to schedule the diagnostic study. Diagnostic slots were purposely left open to accommodate these cases. An ongoing computer tickler file of incomplete codes provided a further check. A time study of clerical performance with recalled patients was measured prospectively for 100 consecutive cases. RESULTS: For the years 2002-2004, 4,025 (13%) of 30,286 screening patients were recalled for diagnostic mammography. After an average of 2.2 telephone calls per patient, (3.64 minutes of clerical time), 3,977 of 4,005 patients returned for a diagnostic study. Forty-eight of 4,025 initially noncompliant patients received an average of six telephone calls (4.7 minutes) and a registered letter. One of the 28 initially noncompliant patients went on to biopsy that revealed a breast cancer. Patient compliance was 4,005 (99.5%) of 4,025. The additional cost for this program was $4,724 divided by 30,286 screening patients, or 16 cents per screening patient. CONCLUSION: The radiology department assumed responsibility for contacting patients who needed recall for additional diagnostic imaging. Using strict documentation of the incomplete breast imaging evaluations, computer checks, clerical support, and prompt scheduling, we achieved 99.5% compliance. The additional cost was small, 16 cents per screening patient.