Designing a Collaborative Breast Radiology Training Program to Tackle Tanzania's Breast Cancer Crisis.

Breast cancer incidence and mortality continue to increase in Africa. In Tanzania, breast cancer is the second leading cause of cancer death for women, and breast cancer incidence and mortality are projected to increase by 80% by 2030. Education gaps among health care workers, delayed presentation, limited screening, and low health literacy all pose significant challenges to providing optimal breast cancer care. Considering these factors, it is imperative to train expert breast radiologists. We present a collaborative breast radiology training program in Tanzania aimed at building local capacity to address national breast cancer challenges. Although cancer control in Africa faces many challenges, developing customized training programs for breast radiology, in conjunction with national cancer programs, may represent a key strategy for addressing breast cancer.

Patient Experience of Women With Dense Breasts Undergoing Screening Contrast-Enhanced Mammography.

OBJECTIVE: We investigated patient experience with screening contrast-enhanced mammography (CEM) to determine whether a general population of women with dense breasts would accept CEM in a screening setting. METHODS: In this institutional review board-approved prospective study, patients with heterogeneous and extremely dense breasts on their mammogram were invited to undergo screening CEM and complete pre-CEM and post-CEM surveys. On the pre-CEM survey, patients were asked about their attitudes regarding supplemental screening in general. On the post-CEM survey, patients were asked about their experience undergoing screening CEM, including causes and severity of any discomfort and whether they would consider undergoing screening CEM again in the future or recommend it to a friend. RESULTS: One hundred sixty-three women were surveyed before and after screening CEM. Most patients, 97.5% (159/163), reported minimal or no unpleasantness associated with undergoing screening CEM. In addition, 91.4% (149/163) said they would probably or very likely undergo screening CEM in the future if it cost the same as a traditional screening mammogram, and 95.1% (155/163) said they would probably or very likely recommend screening CEM to a friend. Patients in this study, who were all willing to undergo CEM, more frequently reported a family history of breast cancer than a comparison cohort of women with dense breasts (58.2% vs 47.1%, P = .027). CONCLUSION: Patients from a general population of women with dense breasts reported a positive experience undergoing screening CEM, suggesting screening CEM might be well received by this patient population, particularly if the cost was comparable with traditional screening mammography.

Utility of MRI-Directed Contrast-Enhanced Mammography for Biopsy Planning for Suspicious MRI-Detected Breast Lesions.

BACKGROUND. Suspicious lesions detected on contrast-enhanced breast MRI often undergo targeted ultrasound evaluation to determine whether they are amenable to ultrasound-guided biopsy. OBJECTIVE. The purpose of this study is to assess the utility of MRI-directed contrast-enhanced mammography (CEM) performed for biopsy planning for suspicious MRI-detected breast lesions and to compare its use with that of MRI-directed ultrasound. METHODS. This retrospective study included 120 patients (median age, 50.3 years) who underwent MRI-directed CEM from September 2014 to July 2020 for biopsy planning for a total of 140 suspicious breast MRI lesions; 109 lesions were also evaluated by MRI-directed ultrasound at the same visit. The reference standard was histopathology or at least 2 years of imaging follow-up for benign lesions. Rates of detecting a correlate for the MRI lesion, among all lesions and among malignant lesions, were compared between MRI-directed CEM, MRI-directed ultrasound, and combined MRI-directed CEM and ultrasound (i.e., with the correlate detected on either modality), by use of the McNemar test. The frequencies with which imaging modalities were used for biopsy guidance after MRI-directed imaging were determined. RESULTS. Twenty-three of 109 lesions were malignant. The lesion detection rate was higher for MRI-directed CEM than for MRI-directed ultrasound (69.7% [76/109] vs 45.9% [50/109]; p < .001) and higher for combined MRI-directed CEM and ultrasound (77.1% [84/109]) than for either MRI-directed CEM (p = .008) or MRI-directed ultrasound (p < .001). The rate of detection of malignant lesions was not significantly different between MRI-directed CEM and MRI-directed ultrasound (95.7% [22/23] vs 78.3% [18/23]; p = .13). A total of 31.2% (34/109) of lesions were seen on MRI-directed CEM only, and 7.3% (8/109) were seen on MRI-directed ultrasound only. A total of 17.4% (4/23) of malignant lesions were seen on MRI-directed CEM only, and none were seen on MRI-directed ultrasound only. Among lesions recommended for biopsy, stereotactic- or tomosynthesis-guided biopsy was recommended for 25.2% (26/103), ultrasound-guided biopsy for 35.9% (37/103), and MRI-guided biopsy for 38.8% (40/103). CONCLUSION. MRI-directed CEM detects a higher fraction of suspicious MRI lesions than does MRI-directed ultrasound. Combined MRI-directed CEM and ultrasound detects a higher fraction than either method does individually. CLINICAL IMPACT. MRI-directed CEM may be a useful alternate or complementary tool to MRI-directed ultrasound in biopsy planning for suspicious MRI lesions, facilitating the use of biopsy guidance methods other than MRI guidance.

A pilot multi-institutional study to evaluate the accuracy of a supine MRI based guidance system, the Breast Cancer Locator™, in patients with palpable breast cancer.

BACKGROUND: Evaluate whether the Breast Cancer Locator™ (BCL), a novel guidance system based on supine MRI images, can be safely and effectively deployed by several surgeons at multiple sites. METHODS: Patients with palpable breast cancer underwent supine MRI at their local institution. A three dimensional (3D) digital image of the tumor in the breast was derived from supine MRI images and used to generate 1) an interactive 3D virtual image of the tumor in the breast (Visualizer) and 2) a plastic bra-like form that allowed the surgeon to place a central wire and bracketing wires in the breast (BCL). The primary objective was to determine the proportion of patients who had the central localization wire deployed within the cancer on specimen mammogram. RESULTS: Fourteen patients were enrolled at 4 different sites by 6 surgeons. BCLs were successfully manufactured for all patients. The central wire was deployed within the tumor on specimen mammogram in 12 of the 13 patients who had a central wire placed (92%). The cancer was excised with negative margins in 14/14 cases (100%). No adverse events occurred. CONCLUSIONS: Supine MRI image acquisition was accomplished successfully across multiple sites. Multiple surgeons utilized the BCL system to localize cancers accurately and safely.

Persistent post-galactogram intraductal iodinated contrast detected on contrast-enhanced mammography (CEM) in a patient with nipple discharge.

Nipple discharge is a common complaint among adult women and is often evaluated by galactography. Contrast-enhanced mammography (CEM) is an emerging breast imaging modality that is useful in the evaluation of patients with nipple discharge who have a negative galactogram, especially if they are not good candidates for contrast-enhanced MRI. Here we present a case of a 37-year-old female who was 22 weeks pregnant and presented with suspicious nipple discharge. The patient initially underwent galactography, which was negative, and was subsequently referred for CEM for further evaluation. One week after the galactogram, the patient underwent CEM which revealed persistent intraductal iodinated contrast from the galactogram. The retained intraductal contrast obscured the area of concern on the CEM and limited evaluation for underlying areas of enhancement. Given the increasing popularity of CEM in breast imaging practice and its utility in the evaluation of patients with nipple discharge, recognition of retained intraductal contrast as a source of artifact on CEM is important so that steps can be taken to prevent acquiring a limited and/or non-diagnostic CEM. We suggest several practical steps the radiologist can take when planning the diagnostic workup of patients with nipple discharge to ensure the patient will be able to successfully undergo CEM, if needed. These steps will help reduce unnecessary patient exposure to radiation and intravenous contrast and avoid a delay in diagnosis and treatment.

Increasing Applicant Engagement During the 2020-2021 Virtual Residency Interview Cycle and Beyond: The Dartmouth-Hitchcock Radiology Residency Video Project.

RATIONALE AND OBJECTIVES: To explore the effectiveness of the video medium and YouTube platform in conveying residency program and community information to prospective applicants during the 2020-2021 virtual residency interview cycle. To garner insights on the virtual-only residency interview experience and our video-centered approach through survey data collected from interviewing candidates for potential implementation in future application cycles. MATERIALS AND METHODS: 13 custom content videos were produced highlighting our radiology residency program and uploaded onto a newly created YouTube channel and the institutional website during the late summer through fall of the 2020-2021 residency interview cycle. Feedback on the videos was generated using YouTube analytics and an anonymous 10-question survey sent to interviewing candidates. RESULTS: As of September 29, 2021, the date when residency programs could begin reviewing ERAS applications for the 2021-2022 cycle, the videos amassed 4487 views with over 149 hours' worth of material viewed. 57 of 114 interviewed candidates responded to the survey. Feedback was overwhelmingly positive with 84% of respondents agreeing that the videos positively influenced their decision to apply to our program, 77% of respondents judging our video-based format to be overall more effective in delivering residency program information than text-based media (website, email etc.), and 86% feeling adequately informed about the program through the virtual interview process and provided electronic resources. 79% of respondents felt our videos to be more informative than the resources from other radiology programs encountered during the interviewing cycle. Finally, a majority 72% of respondents are open to virtual interviewing in the future. CONCLUSIONS: Our program's video-centered approach was one of many creative media solutions employed by residency programs across the nation to help make virtual interviewing an adequate replacement to the traditional in-person interviewing experience. While further investigation is needed to determine which methods communicate residency program information best in the virtual setting, our initial experience and data show the video-centered approach to be overwhelmingly positive with applicants and at a minimum, we've established a baseline process and aesthetic for others to improve upon.

Breast Imaging and Image-guided Intervention in Tanzania: Initial Experience.

Breast imaging capacity in Tanzania is currently very limited. In a country of almost 60 million people, mammographic units are exceedingly rare. The few existing units are compromised by lack of maintenance and quality control and extremely limited technologist training. Breast cancer incidence continues to increase in East Africa, while the ability to accurately diagnose and differentiate benign and malignant breast disease remains a challenge. However, as ultrasound technology improves and becomes more affordable, there is increased access to devices including hand-held point of care ultrasound. Additionally, there has been a recent expansion in the training of academic radiologists in Tanzania, creating an opportunity for possible sustainable improvement of breast imaging and intervention. Our initial efforts at the Muhimbili Academic Medical Center (MAMC) included social media advertising for symptomatic and asymptomatic women, followed by screening (clinical breast exam) and subsequent ultrasound imaging of symptomatic women. We then initiated a workflow for ultrasound-guided breast intervention, performed biopsies, reviewed results by local pathologists, and brought the postbiopsy patients back for radiologic-pathologic correlation, wound assessment, and coordination of follow-up and treatment.

A Randomized Prospective Trial of Supine MRI-Guided Versus Wire-Localized Lumpectomy for Breast Cancer.

BACKGROUND: Wire-localized excision of non-palpable breast cancer is imprecise, resulting in positive margins 15-35% of the time. METHODS: Women with a confirmed diagnosis of non-palpable invasive breast cancer (IBC) or ductal carcinoma in situ (DCIS) were randomized to a new technique using preoperative supine magnetic resonance imaging (MRI) with intraoperative optical scanning and tracking (MRI group) or wire-localized (WL group) partial mastectomy. The main outcome measure was the positive margin rate. RESULTS: In this study, 138 patients were randomly assigned. Sixty-six percent had IBC and DCIS, 22% had IBC, and 12% had DCIS. There were no differences in patient or tumor characteristics between the groups. The proportion of patients with positive margins in the MRI-guided surgery group was half that observed in the WL group (12 vs. 23%; p = 0.08). The specimen volumes in the MRI and WL groups did not differ significantly (74 ± 33.9 mL vs. 69.8 ± 25.1 mL; p = 0.45). The pathologic tumor diameters were underestimated by 2 cm or more in 4% of the cases by MRI and in 9% of the cases by mammography. Positive margins were observed in 68% and 58% of the cases underestimated by 2 cm or more using MRI and mammography, respectively, and in 15% and 14% of the cases not underestimated using MRI and mammography, respectively. CONCLUSIONS: A novel system using supine MRI images co-registered with intraoperative optical scanning and tracking enabled tumors to be resected with a trend toward a lower positive margin rate compared with wire-localized partial mastectomy. Margin positivity was more likely when imaging underestimated pathologic tumor size.

Assessing Resident Performance in Screening Mammography: Development of a Quantitative Algorithm.

RATIONALE AND OBJECTIVES: This study aims to provide objective performance data and feedback, including examination volumes, recall rates, and concordance with faculty interpretations, for residents performing independent interpretation of screening mammography examinations. METHOD AND MATERIALS: Residents (r) and faculty (f) interpret screening mammograms separately and identify non-callbacks (NCBs) and callbacks (CBs). Residents review all discordant results. The number of concordant interpretations (fCB-rCB and fNCB-rNCB) and discordant interpretations (fCB-rNCB and fNCB-rCB) are entered into a macro-driven spreadsheet. These macros weigh the data dependent on the perceived clinical impact of the resident's decision. Weighted outcomes are combined with volumes to generate a weighted mammography performance score. Rotation-specific goals are assigned for the weighted score, screening volumes, recall rate relative to faculty, and concordance rates. Residents receive one point for achieving each goal. RESULTS: Between July 2013 and May 2017, 18,747 mammography examinations were reviewed by 31 residents, in 71 resident rotations, over 246 resident weeks. Mean resident recall rate was 9.9% and significantly decreased with resident level (R), R2 = 11.3% vs R3 = 9.4%, R4 = 9.2%. Mean resident-faculty discordance rate was 10% and significantly decreased from R2 = 12% to R4 = 9.6%. Weighted performance scores ranged from 1.1 to 2.0 (mean 1.6, standard deviation 0.17), but did not change with rotation experience. Residents had a mean goal achievement score of 2.6 (standard deviation 0.47). CONCLUSIONS: This method provides residents with easily accessible case-by-case individualized screening outcome data over the longitudinal period of their residency, and provides an objective method of assessing resident screening mammography performance.

A Patient-Specific 3D-Printed Form Accurately Transfers Supine MRI-Derived Tumor Localization Information to Guide Breast-Conserving Surgery.

BACKGROUND: Wire-localized excision of nonpalpable breast cancer is imprecise, resulting in positive margins 25-30% of the time. METHODS: Patients underwent preoperative supine magnetic resonance imaging (MRI). A radiologist outlined the tumor edges on consecutive images, creating a three-dimensional (3D) view of its location. Using 3D printing, a bra-like plastic form (the Breast Cancer Locator [BCL]) was fabricated, with features that allowed a surgeon to (1) mark the edges of the tumor on the breast surface; (2) inject blue dye into the breast 1 cm from the tumor edges; and (3) place a wire in the tumor at the time of surgery. RESULTS: Nineteen patients with palpable cancers underwent partial mastectomy after placement of surgical cues using patient-specific BCLs. The cues were in place in <5 min and no adverse events occurred. The BCL accurately localized 18/19 cancers. In the 18 accurately localized cases, all 68 blue-dye injections were outside of the tumor edges. Median distance from the blue-dye center to the pathologic tumor edge was 1.4 cm, while distance from the blue dye to the tumor edge was <5 mm in 4% of injections, 0.5-2.0 cm in 72% of injections, and >2 cm in 24% of injections. Median distance from the tumor center to the BCL-localized wire and to the clip placed at the time of diagnosis was similar (0.49 vs. 0.73 cm) on specimen mammograms. CONCLUSIONS: Information on breast cancer location and shape derived from a supine MRI can be transferred safely and accurately to patients in the operating room using a 3D-printed form.

Exercise-induced bilateral rectus sheath hematomas presenting as acute abdominal pain with scrotal swelling and pressure: case report and review.

Rectus sheath hematoma (RSH) is an uncommon but significant cause of acute abdominal pain in patients presenting to the Emergency Department. RSHs are often misdiagnosed as other more common causes of abdominal pain. This case describes a 23-year-old male presenting with acute abdominal pain, scrotal swelling, and associated scrotal pressure. The case highlights the uniqueness of this particular presentation and the clinical features, risk factors, diagnosis, and treatment of RSH.

An analysis of the rotator interval in patients with anterior, posterior, and multidirectional shoulder instability.

PURPOSE: To describe anatomic measurements of the rotator interval (RI) on magnetic resonance arthrogram (MRA) images and to assess the relationship between increased dimensions of the RI and instability conditions of the shoulder. METHODS: Three groups of patients with clinical instability were treated arthroscopically (anterior [A = 19 patients], posterior [P = 14 patients], and multidirectional [M = 13 patients]), and a group of 10 control patients without clinical instability were also identified. The MRAs of all groups were randomized, and 5 blinded reviewers recorded RI anatomic measurements of: (1) sagittal measures of the distance between the subscapularis (SSc) and supraspinatus (SS) tendons at 3 anatomic landmarks across the RI, and (2) the sagittal position of the long head of the biceps (LHB) relative to the most anterior aspect of the SS. RESULTS: The rotator interval distance between the SS and SSc tendons was nearly identical for all groups of instability, and was also not different from control groups. On the sagittal oblique sequences, the distance from the LHB tendon to the anterior edge of the SS tendon was significantly increased in posterior (7.4 mm) instability versus both the control group (2.4 mm; P = .025) and those with anterior instability (4.5 mm; P = .041), with the LHB in a consistent anterior position. The remainder of the measures was not statistically different between the groups. CONCLUSIONS: The distance between the SS and SSc and the overall size of the RI was well preserved in all instability patterns and control conditions. The LHB tendon assumes a more anterior position relative to the supraspinatus tendon in patients with posterior instability versus those patients with anterior instability or those without clinical instability. Additional work is necessary to further define objective radiographic evidence of RI insufficiency in patients with shoulder instability. LEVEL OF EVIDENCE: Level III, prognostic case-control study.

An analysis of capsular area in patients with anterior, posterior, and multidirectional shoulder instability.

BACKGROUND: Although increased capsular volume has been implicated in shoulder instability, there is a paucity of clinical evidence to quantify the size of the capsule with specific instability conditions of the shoulder. HYPOTHESIS: Shoulder capsular area, as measured by magnetic resonance arthrography, is increased with specific patterns of shoulder instability. STUDY DESIGN: Cross-sectional study; Level of evidence, 4. METHODS: During an 8-month period, all patients with a diagnosis of anterior (n = 19), posterior (n = 14), or multidirectional (n = 13) instability of the shoulder and who were assessed with a magnetic resonance arthrogram were reviewed. A group of 10 control patients without clinical instability were also identified. The magnetic resonance arthrograms of all groups were randomly mixed, and 5 reviewers recorded measures of capsular length and area and determined labral abnormalities. The magnetic resonance arthrogram measurements were compared between groups, and interobserver agreement was determined. RESULTS: The cross-sectional area of the capsule was increased in patients with posterior (P = .017) or multidirectional instability (P = .021) versus controls, but not in patients with anterior instability. Additionally, the posteroinferior cross-sectional area was increased in patients with posterior (P = .001), multidirectional (P = .003), and anterior (P = .008) instability. In patients with a posterior labral tear, the mean axial (P = .043) and mean posteroinferior sagittal cross-sectional area (P = .011) was increased, but there were no differences in cross-sectional area for those with an anterior labral tear. The overall interobserver reliability was very good (correlation coefficient range, 0.68-0.94). CONCLUSION: Our results reinforce the concept that capsular elongation and laxity, either preexisting or acquired, play a role in certain instability conditions of the shoulder. Additional work is needed to determine how to correlate surgical decision making with the cross-sectional area measurements demonstrated in this study.