Exploiting the advantages of a wireless seed localization system that differentiates between the seeds: Breast cancer resection following neoadjuvant chemotherapy.

BACKGROUND: Most wireless localization methods utilize only one means of detection for the surgeon, sufficient to localize a single small breast lesion for excision. Complex cases requiring bracketing of a larger lesion or localization of two or more close lesions can superimpose the signal from separate "seeds" with such methods. The lack of discernment between the localization "seeds" can disorient the surgeon, risking a missed lesion on excision and longer operative times. with the use of neoadjuvant chemotherapy prior to breast surgery, the necessity of localizing both a breast lesion and an axillary lymph node previously biopsied is becoming frequent. CASE: A 44 year-old woman underwent neoadjuvant chmotherapy for a breast cancer the did not express estrogen receptor, progesterone receptor, or HER2 receptor. In establishing the extent of disease, a suspicious ipsilateral lymph node was biopsied and found to contain metastatic disease. She had an excellent response to the chemotherapy, with decreased size of the primary tumor and the previously biopsied lymph node. The patient desired breast conservation. The primary tumor and associated calcifications were bracketed using two different Smartclips™, with a third localizing the lymph node biopsied. CONCLUSION: This report illustrates how the use of three SmartClips™, within the EnVisioTM system, allowed for separate tracking of each "seed" throughout a complex surgery in a patient following neoadjuvant chemotherapy. This resulted in successful resection of both the tumor and the tagged lymph node.

Characterization of common breast MRI abnormalities: comparison between abbreviated and full MRI protocols.

RATIONALE AND OBJECTIVES: To evaluate the diagnostic performance of abbreviated MRI (AB-MRI) in comparison to a full protocol MRI (FP-MRI) when evaluating common MRI abnormalities of a mass, non-mass enhancement and focus. MATERIALS AND METHODS: This retrospective reader study was Institutional Review Board approved and Health Insurance Portability and Accountability Act (HIPAA) compliant. AB-MRIs were reviewed from May 2018-December 2019 to identify women with an abnormal AB-MRI, FP-MRI within six months of the AB-MRI and an elevated risk for breast cancer. Six breast radiologists initially interpreted and recorded findings from the AB-MRI. Immediately after reviewing the AB-MRI, the same radiologists interpreted and recorded findings from the FP-MRI. Findings were recorded in an electronic data collection form. Cohen's Kappa test was used to calculate agreement. P < 0.05 was considered statistically significant. RESULTS: Of 119 patients who had an AB-MRI, our final study comprised of 32 patients who had 64 breast MRIs (32 AB-MRI and 32 FP-MRI). The amount of fibroglandular tissue for AB-MRI and FP-MRI showed excellent intra-reader agreement [Kappa: 0.89-1.00 (P < 0.0001)]. Substantial to excellent intra-reader agreement [Kappa: 0.74-0.93 (P < 0.0001)] was demonstrated for all 6 readers when identifying abnormalities seen on AB-MRI and FP-MRI. Moderate to excellent intra-reader agreement [Kappa: 0.41-0.87(P < 0.0001)] was demonstrated between the AB-MRI and FP-MRI for the final BI-RADS assessment. CONCLUSION: AB-MRI has acceptable intra-reader agreement with FP-MRI when characterizing common MRI abnormalities such as a mass, non-mass enhancement and focus suggesting that subsequent FP-MRI may not be needed.

Analysis of 612 Benign Papillomas Diagnosed at Core Biopsy: Rate of Upgrade to Malignancy, Factors Associated With Upgrade, and a Proposal for Selective Surgical Excision.

BACKGROUND. Despite numerous published studies, management of benign papillomas without atypia remains controversial. OBJECTIVE. The purpose of this study was to determine the malignancy upgrade rate of benign papillomas, identify risk factors for upgrade, and formulate criteria for selective surgery. METHODS. This retrospective study included benign papillomas without atypia diagnosed on percutaneous biopsy between December 1, 2000, and December 31, 2019. Papillomas that did not undergo surgical excision or at least 2 years of imaging and/or clinical follow-up were excluded. Clinical, imaging, and histopathologic features were extracted from the electronic medical record. Features associated with upgrade to malignancy were identified. Multivariable logistic regression was performed. RESULTS. The study included 612 benign papillomas in 543 women (mean age, 54.5 ± 12.1 [SD] years); 466 papillomas were excised, and 146 underwent imaging or clinical surveillance. The upgrade rate to malignancy was 2.3% (14/612). Upgrade rate was associated (p < .05) with radiology-pathology correlation (50.0% if discordant vs 2.1% if concordant), patient age (5.6% for 60 years and older vs 0.7% for younger than 60 years), presenting symptoms (6.7% if palpable mass or pathologic nipple discharge vs 1.3% if no symptoms), and lesion size (7.3% if ≥ 10 mm vs 0.6% if < 10 mm). Three of 14 upgraded papillomas were associated with four or more metachronous or concurrent peripheral papillomas. No incidental papilloma or papilloma reported as completely excised on core biopsy histopathologic analysis was upgraded. A predictive model combining radiology-pathology discordance, symptoms (palpable mass or nipple discharge), age 60 years old and older, size 10 mm or larger, and presence of four or more metachronous or concurrent peripheral papillomas achieved an AUC of 0.91, sensitivity of 79%, and spec-ificity of 89% for upgrade. Selective surgery based on presence of any of these five factors, although excluding from surgery incidental papillomas and papillomas reported as completely excised on histopathology, would have spared 294 of 612 lesions from routine excision and identified all 14 upgraded lesions. CONCLUSION. Benign nonatypical papillomas have a low malignancy upgrade rate; routine surgical excision may not be necessary. Selective excision is recommended for lesions satisfying any of the five criteria. Incidental papillomas or papillomas completely excised on histopathology may undergo imaging follow-up. CLINICAL IMPACT. The proposed criteria for selective surgery of benign papillomas on core biopsy would reduce surgeries without delaying diagnosis of malignancy.

Screening Mammogram Results in the Digital Age: Video Messaging - A Pilot Study.

OBJECTIVE: To assess patients' preferences for receiving screening mammogram results via a video message from their radiologist versus the traditional methods. METHODS: The Institutional Review Board approved this prospective study which enrolled participants from March to May 2019, after written consent was obtained. Two breast radiologists prerecorded video results for normal and abnormal screening mammograms. Women 40 years and older presenting for a screening mammogram who had a prior mammogram and no clinical symptoms were invited to participate in the study. After their mammogram, participants were assigned to obtain results via video message or by traditional methods such as a mailed letter or phone call. Participants then completed an online survey asking questions regarding the method of results delivery. RESULTS: Around 80/94 participants ranging in age from 40 to 76 years old responded (85% response rate), of which 73% (58/80) preferred a video message from the radiologist for their mammogram results (p = 0.029). When analyzed by age, the video results were most liked by patients 40-60 years old. When analyzed by education level, participants with a Master's or Bachelor's degree liked receiving their results by video. DISCUSSION: Our study suggests that patients in the screening mammography setting may prefer a video message from their radiologist to the traditional methods of delivery, including mailed letters and receiving results from their primary care provider. Video results could potentially be utilized in the delivery of other results of standardized medical tests as a method to offer more timely delivery of results and a personal connection.

Asymmetric Ductal Ectasia: An Often Overlooked Sign of Malignancy.

OBJECTIVE. The objective of this article is to define the clinical significance of asymmetric ductal ectasia by a review of literature and to describe the imaging findings. CONCLUSION. Asymmetric ductal ectasia has a significant risk for malignancy and high-risk lesions. The findings on conventional imaging may be subtle and easily overlooked. Asymmetric ductal ectasia should be included in the search pattern during image interpretation. Tissue sampling is usually warranted. Ultrasound is critical in identifying ductal abnormalities to guide biopsy.

A comparison of full-field digital mammograms versus 2D synthesized mammograms for detection of microcalcifications on screening.

OBJECTIVES: To compare the observer agreement of microcalcification detection on synthetic 2D images to full field digital mammography (FFDM) at screening and determine if calcifications can be detected to the same degree and given the same BI-RADS assessment. MATERIAL AND METHODS: Two-experienced radiologists retrospectively reviewed synthetic 2D images and FFDM, in separate sessions, to detect microcalcifications and provide a BIRADS assessment. A third experienced breast radiologist reviewed the cases that were disagreed upon and gave a final assessment. Between March 2016-December 2016, 414 women obtained a screening mammogram with tomosynthesis and acquisition of FFDM. 71 cases had combined FFDM and tomosynthesis images, calcifications visible on FFDM or no calcifications present, which comprised the study group. Synthetic 2D images were constructed from the DBT images. During session 1, all synthetic 2D images for the 71 cases were reviewed. During session 2, all the FFDM images for the 71 cases were reviewed. Tomosynthesis images were not reviewed. The agreement of detection of calcifications and BIRADS assessment between radiologists for FFDM and synthetic 2D images were assessed using Cohen's kappa test. Fisher's exact test was used to detect the differences in calcification identification among various breast densities on FFDM and synthetic 2D images. RESULTS: For the detection of calcifications between synthetic 2D images and FFDM, there was moderate to substantial agreement (p-values < 0.0001) for the two radiologist. For the BIRADS assessments, the agreement between synthetic 2D imaging and FFDM was moderate (p-values < 0.0001). The inter-reader agreement for detection of calcifications was fair for using synthetic 2D and moderate for using FFDM (p-value < 0.0001). The final inter-reader agreement between FFDM and synthetic 2D images for the detection of calcifications was moderate (p-values < 0.0001) with the addition of the third reader. For the final BI-RADS assessment, there was moderate agreement between synthetic 2D imaging and FFDM (p-value < 0.0001). The two readers did not demonstrate a significant difference in the detection of microcalcifications for those who were dense or non-dense (p-value range 0.076-0.302). CONCLUSION: Radiologist interpreting synthetic 2D imaging and FFDM have similar frequency for detection of calcifications and BIRADS assessment. A synthetic 2D mammogram may be a sufficient replacement for FFDM at screening.