Stereotactic breast biopsy: comparison of histologic underestimation rates with 11- and 9-gauge vacuum-assisted breast biopsy.

OBJECTIVE: The purpose of this study was to compare histologic underestimations at stereotactic 11- and 9-gauge vacuum-assisted breast biopsy. MATERIALS AND METHODS: The reports of 1,223 consecutive stereotactic vacuum-assisted breast biopsies were retrospectively reviewed. An 11-gauge device was used to perform 828 and a 9-gauge device to perform 395 biopsies. The pathologic results were reviewed for all cases. Biopsy results of atypical ductal hyperplasia and ductal carcinoma in situ were compared with the pathologic results after surgical excision. Underestimation was defined as the need to upgrade atypical ductal hyperplasia to ductal carcinoma in situ or invasive carcinoma at surgery and to upgrade ductal carcinoma in situ to invasive carcinoma. Statistical significance was determined with the chi-square test and 95% CI. RESULTS: In the 11-gauge group, 12 (26%) of 46 cases of atypical ductal hyperplasia were upgraded to ductal carcinoma in situ and one (2%) of the cases to invasive carcinoma. In the 9-gauge group, six (22%) of 27 cases of atypical ductal hyperplasia were upgraded to ductal carcinoma in situ and two (7%) of the cases to invasive carcinoma. In the 11-gauge group, 35 (28.7%) of 122 cases of ductal carcinoma in situ were upgraded to invasive carcinoma. In the 9-gauge group, 10 (23%) of 44 cases of ductal carcinoma in situ were upgraded to invasive carcinoma. CONCLUSION: There was no statistically significant difference between 11-gauge biopsy and 9-gauge biopsy in underestimation of atypical ductal hyperplasia and ductal carcinoma in situ.

BI-RADS lexicon for US and mammography: interobserver variability and positive predictive value.

PURPOSE: To retrospectively evaluate interobserver variability between breast radiologists by using terminology of the fourth edition of the Breast Imaging Reporting and Data System (BI-RADS) to categorize lesions on mammograms and sonograms and to retrospectively determine the positive predictive value (PPV) of BI-RADS categories 4a, 4b, and 4c. MATERIALS AND METHODS: Institutional review board approval was obtained; informed consent was not required. This study was HIPAA compliant. Ninety-four consecutive lesions in 91 women who underwent image-guided biopsy comprised 59 masses, 32 calcifications, and three masses with calcification. Five radiologists retrospectively reviewed these lesions. Each observer described each lesion with BI-RADS terminology and assigned a final BI-RADS category. Interobserver variability was assessed with the Cohen kappa statistic. A pathologic diagnosis was available for all 94 lesions; 30 (32%) were malignant and 64 (68%) were benign. Pathologic analysis of benign lesions was performed on tissue obtained with image-guided core-needle biopsy. In cases referred for excisional biopsy after needle biopsy because of atypia or discordance, final surgical pathologic analysis was used for correlation with imaging findings. PPV for category 4 or 5 lesions was determined for all readers combined. RESULTS: For ultrasonographic (US) descriptors, substantial agreement was obtained for lesion orientation, shape, and boundary (kappa = 0.61, 0.66, and 0.69, respectively). Moderate agreement was obtained for lesion margin and posterior acoustic features (kappa = 0.40 for both). Fair agreement was obtained for lesion echo pattern (kappa = 0.29). For mammographic descriptors, moderate agreement was obtained for mass shape, mass margin, and calcification distribution (kappa = 0.48, 0.48, and 0.50, respectively). Fair agreement was obtained for calcification description (kappa = 0.32). Slight agreement was obtained for mass density (kappa = 0.18). Fair agreement was obtained for final assessment category (kappa = 0.28). PPVs of BI-RADS category 4 and 5 assignments were as follows: category 4a, six (6%) of 102; category 4b, 17 (15%) of 110; category 4c, 48 (53%) of 91; and category 5, 71 (91%) of 78. CONCLUSION: Interobserver agreement with the new BI-RADS terminology is good and validates the US lexicon. Subcategories 4a, 4b, and 4c are useful in predicting the likelihood of malignancy.

Characterization of breast masses with sonography: can biopsy of some solid masses be deferred?

OBJECTIVE: To determine whether sonography can be used to categorize some solid breast masses as probably benign so that biopsy can be deferred. METHODS: We prospectively characterized 844 sonographically visible solid breast masses referred for biopsy. Mammographic and sonographic features of the masses were recorded, and all masses were categorized by American College of Radiology Breast Imaging Reporting and Data System classification before biopsy. Of the 844 masses, 148 were categorized as probably benign (Breast Imaging Reporting and Data System category 3). Sonographically guided biopsy (n = 804) or fine-needle aspiration (n = 40) was performed for pathologic correlation. RESULTS: Of the 148 masses that met the sonographic criteria for probably benign masses, there was 1 malignancy, for a negative predictive value of 99.3%. CONCLUSIONS: Follow-up can be an acceptable alternative to biopsy for sonographically probably benign solid masses.

Mammographic findings in pseudoxanthoma elasticum.

BACKGROUND: There have been isolated case reports of arterial and skin calcification in mammograms of patients with pseudoxanthoma elasticum (PXE), and unpublished anecdotes of many women with PXE undergoing breast biopsy for evaluation of microcalcifications. OBJECTIVE: Our aim was to systematically evaluate mammography and breast pathology in PXE. METHODS: The mammograms of 51 women with confirmed PXE were compared with those of a control sample of 109 women without PXE, noting each of the following characteristics on each mammogram: breast density, skin thickening, skin microcalcifications, vascular calcification, breast microcalcifications and macrocalcifications, and masses. The characteristics of the 2 samples were compared using the 2-tailed t test with a pooled estimate of variance. The indications for mammography and data for each of the mammographic findings were analyzed using the chi(2) test. Available breast biopsy material was reviewed. RESULTS: The PXE and control groups were similar in age and indications for mammography. There was a statistically significant increase in skin thickening, vascular calcification, and breast microcalcifications in the PXE group (P <.001 each). Breast density, masses, macrocalcifications, and skin calcification did not differ statistically in the 2 groups, but no control patient had axillary calcification, or both vascular calcification and microcalcifications (P <.001). Nearly 1 in 7 of the patients with PXE demonstrated at least 3 of the following: microcalcifications, skin calcifications, vascular calcification, and skin thickening; whereas none of the control group did. Histopathologic findings of breast tissue showed calcification of dermal elastic fibers, subcutaneous arteries, and elastic fibers of the deep fascia and interlobular septae of the fat adjacent to breast parenchyma. CONCLUSION: Breast microcalcification and arterial calcification are not rare in the normal population and are not of diagnostic value. The presence of both of these findings, especially with skin thickening or axillary skin calcification, should suggest a diagnosis of PXE. The majority of breast calcifications in PXE are benign.

Preferential use of sonographically guided biopsy to minimize patient discomfort and procedure time in a percutaneous image-guided breast biopsy program.

OBJECTIVE: To determine whether preferential use of sonographic guidance for percutaneous biopsy of breast masses results in a subset of patients with a shorter procedure time and less discomfort compared with patients undergoing stereotactic biopsy. METHODS: A prospective observational study was performed on 193 women undergoing percutaneous image-guided breast biopsy between 1997 and 1999. Data were collected on room time, physician time, and patient comfort levels for 122 stereotactic and 71 sonographically guided biopsies. Differences between stereotactic and sonographically guided biopsy for all lesions and for masses were analyzed for statistical significance. RESULTS: Mean room times were 62.2 minutes for stereotactic biopsy and 39.4 minutes for sonographically guided biopsy (P < .0001). Mean physician times were 23.0 minutes for stereotactic biopsy and 15.8 minutes for sonographically guided biopsy (P < .0001). When we limited our analyses to women undergoing biopsy for masses, the difference in physician time largely disappeared, but the difference in room time remained (P < .0001). Women undergoing stereotactic biopsy were more likely to report discomfort due to body positioning than were women undergoing sonographically guided biopsy (P < .001). These differences existed whether we included all lesions or restricted our analyses to masses. CONCLUSIONS: Preferential use of sonographically guided breast biopsy for masses results in shorter procedure times and less patient discomfort compared with prone stereotactic biopsy.

Data from a professional society placement service as a measure of the employment market for physicians.

PURPOSE: To determine whether data from a professional society placement service--the Professional Bureau of the American College of Radiology--are a valid measure of the employment market. MATERIALS AND METHODS: For the United States from 1990 to 1998, the authors compared three placement service measures-the annual number of job listings, job seekers, and listings per seeker-with two presumably valid measures of the employment market-annual total jobs available (which was ascertained from surveys of hiring) and radiologist median income relative to the all-physician median. For the comparisons, both graphic displays of the data and correlation were used. RESULTS: In graphs, patterns of change were similar. The correlation of job listings, which measure demand, with total jobs, which also measure demand, was 0.84 (P =.04). The correlation of (a) job seekers, a measure of supply, and (b) listings per seeker, which involve both supply and demand, with total jobs was substantial but lower: 0.58 (P =.23) and 0.76 (P =.08), respectively. Correlation of the three placement service measures with relative income, which presumably depends on both supply and demand, was 0.80-0.88 (P <.05 for each measure). CONCLUSION: The statistical significance levels of the correlations and the pattern of findings--namely, stronger correlations among measures of the same aspect of the employment market--indicate that these placement service data are valid and reasonably accurate measures of the employment market.

Radiation oncologists in 2000: demographic, professional, and practice characteristics.

PURPOSE: To describe the demographic, professional, and practice characteristics of radiation oncologists, emphasizing comparisons to data from a similar 1995 Survey. METHODS AND MATERIALS: In spring 2000, we surveyed 603 randomly selected radiation oncologists by mail, using a one-page questionnaire-455 responded. We weighted responses to make answers representative of all radiation oncologists in the United States. RESULTS: Approximately 45% of post-training, professionally active, radiation oncologists were <45 years old and 22% were women. Forty-two percent of radiation oncologists in training were women. Thirty-three percent of radiation-oncology-only practices were solo practices. The greatest percentage of post-training, professionally active, radiation oncologists were in nonacademic private radiation oncology practices. Fifty-three percent of post-training, professionally active, radiation oncologists reported that their workload was about right. Eighteen percent of individuals 60-64 years old and approximately two-thirds of those > or =65 years old were not working (retired). The full-time equivalency of those aged 55-74 fell by 12 percentage points between 1995 and 2000. CONCLUSIONS: Most demographic, professional, and practice characteristics remained relatively constant between 1995 and 2000, with the exception of work status patterns. Radiation oncologists reported a more balanced workload than that reported by diagnostic radiologists. The surplus of radiation oncologists, which was predicted in the mid-1990s, was not demonstrated.

Data from a professional society placement service as a measure of the employment market for radiation oncologists.

PURPOSE: To aid in understanding the employment market for radiation oncologists, we present annual data for 1991 to 2000 from the American College of Radiology's placement service, the Professional Bureau. This data series is twice as long as any previously available. Secondarily, we compare these data with other data on the employment market. METHODS AND MATERIALS: The trends in job listings, job seekers, and listings per seeker in the Bureau are tabulated and graphed. We calculate correlations and graph relationships between the last of these and measures of the job market calculated from annual surveys. RESULTS: Bureau data show listings per job seeker declined from 0.53 in 1991 to a nadir of 0.30 in 1995 and then recovered to 1.48 in 2000. Bureau listings and job seekers, each considered separately, show a similar pattern of job market decline and then eventual recovery to better than the 1991 situation. Bureau listings per job seeker correlate 0.895 with a survey-derived index of program directors' perceptions of the job market, but statistical significance is limited (p = 0.04), because very few years of survey data are available. CONCLUSIONS: The employment market for radiation oncologists weakened in the first half of the 1990s, as had been widely reported; we present the first systematic data showing this. Data from a professional society placement service provide useful and inexpensive information on the employment market.

Too few radiologists?

OBJECTIVE: The purpose of our study was to model the supply and demand for diagnostic radiologists over the next 30 years under alternative scenarios. MATERIALS AND METHODS: We used responses from the American College of Radiology's 2000 Survey of Diagnostic Radiologists and Radiation Oncologists to determine the current age distribution and activity of diagnostic radiologists. The numbers entering the profession were projected using three assumptions: no change in training programs, reduction of residency to 3 years (or otherwise increasing the annual number of graduates by one third), and elimination of most fellowship programs. Demand projections assume a 5% shortage in 2001 and depend on growth rates of the population, aging, scenarios of growth of age-standardized demand, and the effect of possibly productivity-enhancing technologies such as PACS (picture archiving and communication systems). RESULTS: Only a one-third increase in annual graduates materially increases the work-force relative to current training patterns. In all cases, the growth rate of the demand for radiologists far outstrips the supply over a 30-year horizon. In the shorter term, projections of current trends point to an increasing shortage, but rapid major productivity increases could produce a surplus. CONCLUSION: Those in the field of diagnostic radiology should consider measures to mitigate the increasing shortage, while monitoring developments that might signal departures from current trends in supply and demand.

Diagnostic radiologists in 2000: basic characteristics, practices, and issues related to the radiologist shortage.

OBJECTIVE: We sought to describe radiologists and their practices, emphasizing trends in retirement age, practice size, and perceived workload burden. MATERIALS AND METHODS: In spring 2000, we surveyed 3,027 randomly selected radiologists by mail, of whom 74% responded. We weighted responses to make answers representative of all radiologists and compared findings with a similar 1995 survey. RESULTS: Thirty percent of radiologists age 65-69 were working full-time; 21% were working part-time. Overall, the full-time equivalency of radiologists age 55-74 was 67.6%, not significantly different from 1995. If current patterns of retirement and production of graduates continue, the workforce will grow at a rate of approximately 2% annually. Fifty-one percent of radiologists said that recognizing that income depends largely on work done, they had "much too much work" or "somewhat too much work"; 5% reported "somewhat too little work" or "much too little work." Six percent of posttraining professionally active radiologists were in solo practice, down from 8% in 1995; 15% were in two-to-four-radiologists groups, down from 17%; and 38% were in groups of 15 or more, up from 30%. Sixteen percent of posttraining professionally active radiologists were women. The percentage was highest (29%) for those younger than age 35 but was lower (22%) among trainees. CONCLUSION: The findings of excess work are further evidence of a radiologist shortage. However, contrary to surveys of groups that are hiring, we found minimal evidence of earlier retirement. Nonetheless, workload currently is increasing faster than the workforce is likely to grow, so the shortage will probably intensify. The typical number of radiologists in a practice is increasing, but slowly.