Enhancing foci on breast MRI: Identifying criteria that increase levels of suspicion.

OBJECTIVE: Prior studies evaluating features of foci associated with malignancy have not been conclusive. This study evaluates foci that were deemed suspicious and assesses multiple imaging and clinical findings with the goal of identifying criteria that can increase diagnostic confidence when evaluating foci on breast MRI. METHODS: After Institutional Review Board approval, a retrospective chart review was performed to identify patients who underwent an image-guided biopsy of an enhancing focus. To be included in the study, a breast MRI performed between 2012 and 2019 must have been classified as suspicious for an enhancing focus or foci, and a biopsy using imaging guidance must have been subsequently performed. Patient and imaging characteristics as well as the corresponding biopsy results were recorded and statistically analyzed. RESULTS: There were 74 patients with 85 foci of enhancement who underwent biopsy within the study period. Thirteen of the 85 foci yielded malignant results for an overall positive predictive value of 15.3% (95% confidence interval: 7.7-22.9%). Additionally, twenty-six of the 85 cases (30.6%) yielded high risk lesions. There was a statistically significant negative correlation between screening breast MRIs and biopsies that yielded cancer or atypia (p = 0.04). There was also a significant association between foci and malignant results if the focus was in the same quadrant of a known malignancy (p = 0.001). CONCLUSION: Clinical information, such as the indication for a breast MRI or the location of a focus relative to a known cancer, can play an important role in evaluating foci of enhancement. Diagnostic confidence in identifying suspicious foci can be aided by incorporating clinical context with imaging findings deemed suspicious by prior research studies.

Unveiling the histopathologic spectrum of MRI-guided breast biopsies: an institutional pathological-radiological correlation.

PURPOSE: Breast magnetic resonance imaging (MRI) has high sensitivity but suffers from low specificity, resulting in many benign breast biopsies for MRI-detected lesions. We sought to compare histologic findings between patients who underwent MRI-guided breast biopsy versus biopsy via other imaging modalities as well as to examine features associated with malignancy in the MRI cohort to help inform MRI-biopsy practice. METHODS: A 2-year (2018-2019) retrospective review of breast biopsies at our enterprise was conducted. Biopsies were categorized as stereotactic, ultrasound, MRI, or palpation guided. Pathology was categorized as benign (further divided into nine categories), atypical, or malignant (subdivided into in situ and invasive carcinoma). Pathology was compared between biopsy groups. Clinical, pathologic, and imaging features were compared between pathology groups within the MRI cohort. RESULTS: 5828 biopsies from 4154 patients were reviewed, including 548 MRI-guided biopsies with stratification of MRI-biopsy pathology as follows: 69% benign, 13.8% atypical, and 17.2% malignant. Among benign MRI biopsies, there was higher frequency of "clustered cysts with papillary apocrine metaplasia" (56/548; 10.2%) and lower rate of fibroadenoma/fibroadenomatous change (55/548; 10%) compared to other modalities (158 or 3% and 1144 or 21.7% of 5280 biopsies, respectively). Multivariate analysis revealed indication of breast cancer (p < .0001), ipsilateral cancer (p < .0001) and rapid initial phase kinetics (p = .017) to remain significantly associated with malignant MRI-biopsy pathology. CONCLUSIONS: A concurrent or recent breast cancer diagnosis was most predictive of malignancy on MRI-guided breast biopsy. Combined MRI feature evaluation and radiologic-pathologic concordance activities may allow for prognostic refinement and improved risk stratification.

Missed Breast Cancer: What Can We Learn?

Multiple studies have shown that screening mammography helps to reduce mortality and morbidity from advanced breast cancer. However mammography does have its own limitations, and unfortunately, there are a fair number of false-negative mammograms. We are all aware that the sensitivity of mammography is inversely proportional to the breast density. With many states passing mandatory breast density reporting legislation, there has been an emphasis on using additional and alternative screening methods such as whole breast ultrasound and screening magnetic resonance imaging. Many cancers are simply not detected on mammography, even in retrospect. However, many of the breast cancers are actually visible retrospectively on the prior mammogram. It is these small and often subtle cancers that are perceptible but often missed, that provide a valuable learning opportunity. Studying the imaging findings of cancers that went undetected is a good learning exercise for the radiologist to identify common patterns and mistakes that lead to a missed cancer. This allows the radiologist to improve mammographic sensitivity and overall diagnostic accuracy. This article discusses some of the limitations of mammography, common sources of error which may lead to an undetected cancer, and also discuss a few pearls to prevent these common errors.

Practice policy and quality initiatives: using lean principles to improve screening mammography workflow.

The "lean" approach is a quality improvement method that focuses on maximizing activities that are valued by the customer and eliminating waste that impedes efficiency in the workplace. The unique philosophy of the lean approach encourages all members of the team to be directly involved in identifying areas of waste and generating solutions to eliminate them. When the breast imaging section at the authors' institution became part of a multispecialty breast care center, the result was escalating examination volumes, more complex cases, and overall increased demand on radiologists' time. After several unsuccessful attempts to improve the efficiency of the section, including evaluation by outside consultants, the decision was made to embark on a comprehensive quality improvement program using the lean approach. A team of radiologists, technologists, file room personnel, information technology (IT) representatives, and administrators from the breast imaging section met twice a month to learn about lean principles and how to apply them to screening mammography workflows. Sources of inefficiency (waste) were identified, and potential solutions were generated. Multiple trials were performed to test these solutions. Throughout the process, all team members were engaged in identifying the problems, suggesting solutions, and implementing change. Most of the tested solutions were successful and resulted in decreased patient wait times, improved efficiency for the technologists and radiologists, faster report turnaround, and advances in IT. In addition, staff members were introduced to the lean philosophy and became actively involved in improving their workplace, resulting in a more cohesive section.