Society of Breast Imaging residency and fellowship training curriculum.

A recently developed Society of Breast Imaging curriculum for residency training is intended to provide guidance to residents and their mentors, and to practicing radiologists who want to keep up to date in screening, diagnosis, and interventional procedures. The curriculum contains lists of key concepts in 14 subject areas: epidemiology; anatomy; pathology, and physiology; equipment and technique; quality control; interpretation; problem-solving mammography; ultrasound; interventional procedures; reporting and medicolegal aspects; screening; MR imaging; therapeutic considerations; and patient management principles. The curriculum also makes recommendations about residency training, including the number of examinations the resident should interpret, and the time the resident should spend in breast imaging. Recommendations for fellowship training are also discussed.

Mammographic halo sign revisited.

PURPOSE: To determine whether increased silver halide deposition accounts for some curvilinear areas of hyperlucency (halo signs) that surround breast masses on screen-film mammograms. MATERIALS AND METHODS: Breast images obtained in 43 women (aged 30-67 years; mean, 48.6 years) that showed a halo sign were selected from the authors' teaching files. Optical magnification (x8.0-12.5) of the masses with halos was used to establish the pattern of silver halide deposition in the film emulsion. RESULTS: True radiolucent halos, differentiated from Mach bands by means of the increased silver halide deposition in the film emulsion, were identified in 44 masses in 36 women. Partial true radiolucent halos were identified in 32 (73%) of 44 masses. Thirty-eight (86%) of the 44 masses were cysts; three (7%), fibroadenomas; two (4%), infiltrating ductal carcinomas; and one (2%), axillary lymph node metastasis. True radiolucent halos were more common in growing benign and malignant lesions. CONCLUSION: A halo is not always a perceptual illusion.

Percutaneous large-core breast biopsy: a multi-institutional study.

PURPOSE: To assess the reliability and reproducibility of automated large-core breast biopsy. MATERIALS AND METHODS: A consortium of 20 institutions reported, in a standardized fashion, their core breast biopsy data. All biopsies were performed with "long-throw" (2.3-cm) automated core biopsy devices fitted with 14-gauge needles. Needle guidance was accomplished by means of either a dedicated, stereotaxic device, in which the patient lies in the prone position, or high-frequency electronically focused ultrasound equipment. RESULTS: The data in 6,152 lesions were gathered. Clinical or surgical follow-up was available in 3,765 lesions; 1,363 of these lesions were subsequently surgically excised, and the core histologic study showed cancer in 910 lesions, mammary intraepithelial neoplasia in 173 lesions, and benign disease in 280 lesions. In these 280 lesions, there were 15 false-negative core biopsies. CONCLUSION: The data show that percutaneous large-core breast biopsy is a reproducible and reliable alternative to surgical biopsy.

Mucinous (colloid) breast cancer: clinical and mammographic findings in 10 patients.

OBJECTIVE: The purpose of this study was to review the clinical and mammographic findings in patients with mucinous (colloid) breast cancer. MATERIALS AND METHODS: We retrospectively reviewed the pathology reports of 444 women with breast cancers diagnosed between May 1988 and October 1993 after mammographic evaluation. Of these, 10 women 31-88 years old (mean, 67 years) had pure mucinous adenocarcinoma of the breast. We reviewed the clinical and mammographic findings in these 10 patients. RESULTS: Three patients (30%) had palpable masses. Mammographic abnormalities were detected on screening studies in the seven patients (70%) who were asymptomatic. The mammographic findings included poorly defined, lobulated, solitary masses in seven patients, poorly defined, clustered masses in two patients, and a well-circumscribed mass in one patient. No tumors had calcifications as the primary finding, and only one tumor had a few scattered, round, calcifications associated with clustered masses. Two patients had areas of noncomedo ductal carcinoma in situ without calcifications adjacent to the invasive mucinous adenocarcinoma. The tumors were 7-35 mm in diameter. No metastases were found in the axillary lymph nodes in the eight patients in whom biopsies of these nodes were done. CONCLUSION: The most common and distinctive mammographic feature of mucinous breast carcinoma is a poorly defined, lobulated mass. The absence of axillary nodal metastases, even in patients with large palpable tumors, supports the notion that biologically, mucinous carcinomas are slower growing, less aggressive tumors than infiltrating ductal carcinomas not otherwise specified.

Ductography of the breast: technique and findings.

The evaluation of spontaneous nipple discharge is controversial. Many surgeons advocate major subareolar duct excision for postmenopausal patients or solitary duct excision for premenopausal women with this symptom, without preoperative diagnostic imaging. There is no dispute that as a symptom, nipple discharge can be eliminated by severing the major subareolar ducts. However, this decision requires generous assumptions on the part of the surgeons: first, that the abnormal duct can be identified correctly; second, that the segmental area or areas of the breast drained by the duct can be predicted accurately; and third, that the amount of tissue that needs to be excised to ensure inclusion of the lesion or lesions can be defined. Ductography can show the course of abnormal ducts, as well as the variability in location and extent of intraductal lesions. Preoperative mapping of the abnormal duct can expedite surgery, facilitate accurate minimal-volume breast biopsies, and alert the surgeon to the existence of an extensive ductal lesion or multiple lesions. In patients with fibrocystic changes or duct ectasia on ductography, surgery might be averted altogether. In an effort to demonstrate the usefulness of ductography and encourage its increased use, we review the technique and illustrate normal and abnormal findings.

Assessing adequacy of mammographic image quality.

High-quality mammographic images enhance the radiologist's ability to interpret mammograms with high sensitivity for detecting abnormalities and high specificity for classifying lesions suspicious for malignancy. In addition to proper exposure, contrast, resolution, compression, and positioning, high-quality mammographic images must be accompanied by pertinent history and available comparison images. To avoid negating the benefits of technically ideal images, mammograms must be viewed under optimal viewing conditions. Constant attention to quality control, with every image evaluated for adherence to strict technical standards, is essential for maintaining image quality.

Effects of a defective filter on magnification image quality in mammography.

A defective molybdenum filter in a dedicated mammographic unit was found to have a detrimental effect on image quality. The authors present a simple method for testing of molybdenum filters and suggest that it be incorporated into the acceptance testing routine for new mammographic units and that it be used in annual quality control checks.

The art of mammographic positioning.

The discovery of clinically occult breast cancer creates an exciting opportunity to alter the natural history of one of the major killers of women in our society. The skills required for this endeavor depend on high-quality images that provide the mammographer with sufficient information to construct three-dimensional perceptions recognizable as departures from normal architecture. Altering the natural course of breast cancer depends on early detection. Early detection of breast cancer depends on high-quality imaging techniques. Paramount among the imaging techniques for breast cancer detection is mammographic positioning. Optimal mammographic positioning is achieved by understanding the capabilities of available dedicated mammographic equipment and applying this understanding to take full advantage of natural breast mobility in overcoming various anatomic limitations. Compression of breast tissue, essential for proper parenchymal imaging, is achieved by moving one surface of the breast toward the other. The concept of moving the mobile surface of the breast toward the more fixed and immobile surface has been stressed as an important principle in optimizing the amount of tissue that can be imaged on standard mammographic views. Visualizing the fine details of a lesion or the margins of an area of clinical or perceived radiographic concern may be crucial to determining the need for biopsy. Visualization of such details is best achieved by projecting the suspected lesion into interface with adjacent radiolucent fat through separation of overlapping parenchyma by using spot compression or by tangential imaging against subcutaneous fat. Unique problems require creative, tailored solutions. Such tailoring is made less difficult by understanding and using equipment capability with breast anatomy and mobility. The very small, very large, or very dense breast can be imaged properly with modified techniques. Likewise, the augmented breast, mastectomy site, or axilla can be imaged with specialized techniques. Artistic application of these mammographic positioning principles will be rewarded with high-quality images, fewer missed breast cancers, and more lives saved.

Benign papillary neoplasms of the breast: mammographic findings.

The clinical presentation, pathologic characteristics, and mammographic/ductographic (also known as galactographic) findings were reviewed in 77 patients with histologically proved benign papillary neoplasms of the breast. Patients were classified as having either solitary or multiple papillomas. Patients with multiple papillomas were further subclassified as having either central or peripheral papillomas. Fifty-one patients (66%) had solitary papillomas. Thirty-seven of these patients were symptomatic; 36 had spontaneous nipple discharge, and one had a palpable mass. Ductography was positive in 32 of the 35 patients who underwent the procedure. In the 14 asymptomatic patients, subareolar (n = 10) and peripheral (n = 4) mammographic abnormalities prompted biopsy. Fourteen patients (18%) had multiple peripheral papillomas, and one patient also had bilateral central solitary papillomas. Eleven of these patients were asymptomatic, while two presented with palpable abnormalities and one with spontaneous bilateral discharge. Mammographic findings included microcalcifications (n = 5) and clustering nodules (n = 2). Associated atypical ductal hyperplasia was found in six (43%) of the 14 patients with multiple peripheral papillomas. Some of these patients also had lobular carcinoma in situ and radical scars. Twelve patients had multiple central papillomas; all presented with spontaneous nipple discharge and had positive ductograms.

Rate of compliance with recommendations for additional mammographic views and biopsies.

All recommendations for immediate additional studies and biopsies following routine mammography during a 6-month period were reviewed retrospectively to establish compliance rates and determine the time intervals for completion of the recommendations. During this period, 5,693 mammograms were obtained. Additional mammographic studies and biopsies were recommended for 364 (6.4%) and 180 (3.2%) of all patients, respectively. The compliance rates were 99.7% (n = 363) for additional studies and 98.9% (n = 178) for biopsies. Additional studies and biopsies were completed within 30 days of the recommendations in 98.4% (n = 358) and 91.7% (n = 165) of the patients, respectively. Compliance with recommendations for additional studies within relatively short periods can be maximized by having the mammographic facility schedule examinations directly with the patients. Compliance with biopsy recommendations can be optimized by directly contacting the referring physician. Follow-up written reports should specifically state that a biopsy is recommended and that this has been discussed directly with the referring physician.

Paraffin block radiography following breast biopsies: use of orthogonal views.

Paraffin block radiography has been shown to be useful in helping identify lesions in biopsy specimens of breast tissue. Use of an orthogonal view enables determination of the approximate depth of a lesion within a paraffin block. This simple technique further guarantees histologic evaluation of the area of radiographic concern.