Short-Term Strategies for Augmenting the National Radiologist Workforce.

The current radiology landscape has an imbalance between the rising demand for radiology services and the national radiologist workforce available. More vacant radiology positions exist than graduating radiology trainees. The origins of this problem are complex and require long-term solutions. Rather than working longer and/or faster, radiologists can work smarter. In this article, we present multiple short-term strategies to increase the effective radiologist workforce and/or increase workforce efficiency, to alleviate the current workload challenges. These strategies are derived from an analysis of possible practice-level changes in personnel, process, and physical plant. The impacts of the potential changes are estimated. No single change addresses the mismatch between supply and demand for radiology services. By creating an inventory of potential solutions, practices can choose the potential mechanism(s) to address the workforce shortage that best fit their needs and local environment.

Evaluation of a hydrogen peroxide-based system for high-level disinfection of vaginal ultrasound probes.

OBJECTIVES: Because of the complex process and the risk of errors associated with the glutaraldehyde-based solutions previously used at our institution for disinfection, our department has implemented a new method for high-level disinfection of vaginal ultrasound probes: the hydrogen peroxide-based Trophon system (Nanosonics, Alexandria, New South Wales, Australia). The aim of this study was to compare the time difference, safety, and sonographers' satisfaction between the glutaraldehyde-based Cidex (CIVCO Medical Solutions, Kalona, IA) and the hydrogen peroxide-based Trophon disinfection systems. METHODS: The Institutional Review Board approved a 14-question survey administered to the 13 sonographers in our department. Survey questions addressed a variety of aspects of the disinfection processes with graded responses over a standardized 5-point scale. A process diagram was developed for each disinfection method with segmental timing analysis, and a cost analysis was performed. RESULTS: Nonvariegated analysis of the survey data with the Wilcoxon signed rank test showed a statistical difference in survey responses in favor of the hydrogen peroxide-based system over the glutaraldehyde-based system regarding efficiency (P = .0013), ease of use (P = .0013), ability to maintain work flow (P = .026), safety (P = .0026), fixing problems (P = .0158), time (P = .0011), and overall satisfaction (P = .0018). The glutaraldehyde-based system took 32 minutes versus 14 minutes for the hydrogen peroxide-based system; the hydrogen peroxide-based system saved on average 7.5 hours per week. The cost of the hydrogen peroxide-based system and weekly maintenance pays for itself if 1.5 more ultrasound examinations are performed each week. CONCLUSIONS: The hydrogen peroxide-based disinfection system was proven to be more efficient and viewed to be easier and safer to use than the glutaraldehyde-based system. The adoption of the hydrogen peroxide-based system led to higher satisfaction among sonographers.

The Economic Impact of AI on Breast Imaging.

This article explores the development of computer-aided detection (CAD) and artificial or augmented intelligence (AI) for breast radiology examinations and describes the current applications of AI in breast imaging. Although radiologists in other subspecialties may be less familiar with the use of these technologies in their practices, CAD has been used in breast imaging for more than two decades, as mammography CAD programs have been commercially available in the United States since the late 1990s. Likewise, breast radiologists have seen payment for CAD in mammography and breast MRI evolve over time. With the rapid expansion of AI products in radiology in recent years, many new applications for these technologies in breast imaging have emerged. This article outlines the current state of reimbursement for breast radiology AI algorithms within the traditional fee-for-service model used by Medicare and commercial insurers as well as potential future payment pathways. In addition, the inherent challenges of employing the existing payment framework in the United States to AI programs in radiology are detailed for the reader. This article aims to give breast radiologists a better understanding of how AI will be reimbursed as they seek to further incorporate these emerging technologies into their practices to advance patient care and improve workflow efficiency.

Reporting and Perceptions of Breast Arterial Calcification on Mammography: A Survey of ACR Radiologists.

RATIONALE AND OBJECTIVES: The ACR Breast Commission conducted a member survey to evaluate current practices of reporting breast arterial calcification (BAC) on mammography and to determine perceptions about the value of BAC communication and follow-up recommendations among radiologists. MATERIALS AND METHODS: In September 2020, an 18-item online survey was emailed to radiologist members of the American College of Radiology (ACR). Questions included radiologist demographics, current BAC reporting practices, follow-up recommendations, and perceptions about BAC. Five-point Likert scales were used and multivariate analysis was performed. RESULTS: Of 598 completed survey responses, up to 87% (522/598) of ACR radiologist members include BAC in mammogram reports. However, only 41% (212/522) of respondents report BAC 'always' or 'most of the time'. Radiologist factors significantly associated with BAC reporting include years in practice and fellowship training with those in practice longer more likely to report BAC (OR 1.10, 95% CI, [1.01-1.20], p = 0.023) and those with fellowship training less likely to report BAC (OR 0.63, 95% CI, [0.42-0.94], p = 0.024). When BAC is reported, 69% (360/522) simply indicate the presence of BAC, 23% (121/522) provide a subjective grading of BAC burden, and 1% (6/522) calculate a BAC score. Among the radiologists reporting BAC, 58% (301/522) make no subsequent recommendations, while the remainder recommend primary care follow-up (39%; 204/522), cardiology evaluation (13%; 68/522), and/or coronary calcium scoring CT (11%; 59/522). Overall, there was agreement from 66% (392/598) of respondents that BAC is a cardiovascular risk factor. However, there was no consensus on whether patients and/or providers should be informed about BAC or whether reporting of BAC should become a standardized practice in breast imaging. Older and more experienced radiologists are more likely to agree that BAC is a cardiovascular risk factor (p = 0.022), providers should be informed about BAC (p = 0.002 and 0.006), BAC reporting should be a standardized practice (p = 0.004 and 0.001), and feel more comfortable informing patients about BAC (p = 0.001 and 0.003). CONCLUSION: Radiologists' reporting practices and perceptions regarding BAC are not homogeneous. Although many radiologists report BAC to varying degrees, it is not routinely reported or recommended for follow-up in mammogram reports. Experienced radiologists are more likely to include and value BAC in their breast imaging practice.

Breast Cancer Screening and the COVID-19 Pandemic.

The novel SARS-CoV2 (COVID-19) pandemic has had a major impact on breast radiology practices. Initially, nonessential imaging studies, including screening mammography, were curtailed and even temporarily halted when lockdowns were instituted in many parts of the United States. As a result, imaging volumes plummeted while health care institutions worked to ensure safety measures were in place to protect patients and personnel. As COVID-19 infection levels started to stabilize in some areas, breast radiology practices sought guidance from national organizations, such as the Centers for Disease Control and Prevention, the Centers for Medicare and Medicaid Services, and radiology specialty societies, to develop strategies for patients to safely return for screening mammograms and other outpatient imaging studies. Postponement of breast cancer screening has led to delays in cancer diagnosis and treatment that could negatively affect patient outcomes for years to come. In order to continue to provide necessary imaging services, breast radiologists will need to face and overcome ongoing practical challenges related to the pandemic, such as negative financial impacts on practices and patients, the need for modifications in delivery of imaging services and trainee education, and differences in the health care system as a whole, including the shift to telehealth for clinical care. Nonetheless, despite the disruption the COVID-19 pandemic has caused, the need for breast radiology procedures, including breast cancer screening, remains strong.

Multicentric Breast Abscesses in a Patient Who Had COVID-19.

Background: Coronavirus disease 2019 (COVID-19) is recognized as a multisystem disease affecting the whole body, with new complications from the disease being described on an almost-daily basis. Case Report: We report the case of a 50-year-old female with a medical history of diabetes and silicone breast implants who developed right-sided, multicentric breast masses after a prolonged hospitalization for COVID-19 infection complicated by renal failure requiring dialysis. The patient noted an onset of breast pain and masses, and subsequent imaging demonstrated multiple similar oval masses. She underwent biopsy and operative debridement of the lesions and recovered appropriately. Results were consistent with sterile abscesses that were considered secondary to a vasculitis-like process associated with COVID-19 infection. Conclusion: To our knowledge, this case is the first account of breast pathology associated with a diagnosis of COVID-19 in the medical literature and encourages systematic evaluations of patients with coronavirus infections, including breast examinations.

Racial and Ethnic Disparities in Breast Cancer: A Collaboration Between the American College of Radiology Commissions on Women and Diversity and Breast Imaging.

Since the 1980s, the mortality rate from breast cancer in the United States has dropped almost 40%. The quality of life and survival gains from early detection and improved treatment have not been shared equally by all ethnic groups, however. Many factors, including social determinants of health, unequal access to screening and oncologic care, and differences in incidence, tumor biology, and risk factors, have contributed to these unequal breast cancer outcomes. As breast radiologists approach their own patients, they must be aware that minority women are disproportionately affected by breast cancer at earlier ages and that non-Hispanic Black and Hispanic women are impacted by greater severity of disease than non-Hispanic White women. Guidelines that do not include women younger than 50 and/or have longer intervals between examinations could have a disproportionately negative impact on minority women. In addition, the COVID-19 pandemic could worsen existing disparities in breast cancer mortality. Increased awareness and targeted efforts to identify and mitigate all of the underlying causes of breast cancer disparities will be necessary to realize the maximum benefit of screening, diagnosis, and treatment and to optimize quality of life and mortality gains for all women. Breast radiologists, as leaders in breast cancer care, have the opportunity to address and reduce some of these disparities for their patients and communities.

Breast Cancer Screening Recommendations Inclusive of All Women at Average Risk: Update from the ACR and Society of Breast Imaging.

Breast cancer remains the most common nonskin cancer, the second leading cause of cancer deaths, and the leading cause of premature death in US women. Mammography screening has been proven effective in reducing breast cancer deaths in women age 40 years and older. A mortality reduction of 40% is possible with regular screening. Treatment advances cannot overcome the disadvantage of being diagnosed with an advanced-stage tumor. The ACR and Society of Breast Imaging recommend annual mammography screening beginning at age 40, which provides the greatest mortality reduction, diagnosis at earlier stage, better surgical options, and more effective chemotherapy. Annual screening results in more screening-detected tumors, tumors of smaller sizes, and fewer interval cancers than longer screening intervals. Screened women in their 40s are more likely to have early-stage disease, negative lymph nodes, and smaller tumors than unscreened women. Delaying screening until age 45 or 50 will result in an unnecessary loss of life to breast cancer and adversely affects minority women in particular. Screening should continue past age 74 years, without an upper age limit unless severe comorbidities limit life expectancy. Benefits of screening should be considered along with the possibilities of recall for additional imaging and benign biopsy and the less tangible risks of anxiety and overdiagnosis. Although recall and biopsy recommendations are higher with more frequent screening, so are life-years gained and breast cancer deaths averted. Women who wish to maximize benefit will choose annual screening starting at age 40 years and will not stop screening prematurely.

Common Current Procedural Terminology Codes in Breast Imaging.

This article reviews the common Current Procedural Terminology (CPT) codes for frequently performed breast imaging procedures. The CPT codes for breast radiology services, including the revised codes for mammography, computer-assisted detection (CAD), breast ultrasound, breast magnetic resonance imaging (MRI), and imaging-guided breast interventional procedures and the new codes for digital breast tomosynthesis (DBT) and marker placement in axillary lymph nodes are outlined. The application of basic CPT coding principles, such as the use of modifiers and the different structure of code families in breast radiology services, is also discussed. CPT codes are updated on an ongoing basis to reflect the evolution of medical practice, and the CPT codes for breast imaging procedures have changed significantly in the past 5 years. These modifications can affect the distribution of work and utilization of resources in radiology departments. A working knowledge of coding practices will facilitate compliance with billing regulations and help ensure breast radiologists are appropriately paid for their work.

Understanding the Current Procedural Terminology Process.

This article describes the method by which U.S. health care services are valued and reimbursed, and the essential role practicing physicians, including breast imaging radiologists, and medical specialty societies play in this process. The American Medical Association has described the method for developing new and revised Current Procedural Terminology (CPT) codes as a 3-legged stool, with patient care as the seat supported by its legs: the CPT process (where the work is described), the Relative Value Scale Update Committee (RUC) process (where the work is valued), and coverage by Medicare (where the work is paid). Although the future direction of health care payment policy in the USA is uncertain and difficult to predict, CPT codes remain the foundation for the reimbursement of physician services. A working knowledge of the CPT process can be valuable to breast imaging radiologists, both for managing their practices at the current time and preparing them for future changes in payment policy.

Rosai-Dorfman disease of the breast and parotid gland.

Rosai-Dorfman disease or sinus histiocytosis with massive lymphadenopathy (SHML) is a histiocytic proliferative disorder that typically involves the cervical lymph nodes with or without extranodal involvement of the skin, soft tissues, respiratory tract, or virtually any other site of the body. We present a case report of SHML involving the cervical lymph nodes, parotid gland and breast. There is only one other Rosai-Dorfman registered case that involves both breast and parotid disease and no previously published case reports. The patient presented atypically with breast masses found on screening mammogram rather than massive cervical lymphadenopathy. We describe the subsequent radiographic and surgical pathologic evidence that led to the diagnosis of this rare disease.

Body Art Confounding a Case of Breast Cancer.

BACKGROUND: Heavy metals in tattoo ink can be deposited in axillary lymph nodes, mimicking malignant calcifications. High-density foci in axillary lymph nodes can be the sequelae of a benign or malignant process. CASE REPORT: A 34-year-old female presented with left breast discomfort. Mammography showed suspicious left breast calcifications for which biopsy revealed multicentric ductal carcinoma in situ. Imaging also showed high-density foci in her left axillary lymph nodes suspicious for nodal metastases; however, biopsy of the lymph nodes found the high-density foci to be pigment-laden histiocytes from tattoo ink metallic deposits. CONCLUSION: High-density foci in axillary lymph nodes on mammography can be evidence of calcifications or metal deposits and can be the manifestation of a benign or malignant process. Thus, this finding may warrant additional diagnostic workup (including mammography, ultrasound, and possibly biopsy) and correlation with clinical history.

Screening, imaging, and image-guided biopsy techniques for breast cancer.

Mammography remains the primary modality for breast cancer diagnosis. Other imaging studies, most commonly ultrasonography and magnetic resonance imaging, are also used to characterize breast lesions, stage breast cancer, and aid in surgical planning. Although mammography is the only screening examination demonstrated to decrease breast cancer mortality in the general population, other imaging studies have been shown to be beneficial for screening high-risk patients. In the future, new technologies may also improve the sensitivity and specificity of breast cancer screening and detection.

Shades of gray: a history of the development of diagnostic ultrasound in a large multispecialty clinic.

The Department of Radiology at the Ochsner Health System has been a central player in the development of ultrasound nationally and internationally for much of the history of this technology. In the following article, we review the progress of ultrasound in our institution.

Effect of breast core needle biopsy technique on detection of lobular intraepithelial neoplasia.

OBJECTIVE: Lobular intraepithelial neoplasia-atypical lobular hyperplasia and lobular carcinoma in situ-is a noninvasive breast lesion occasionally found in core needle biopsy and surgical biopsy specimens. The objective of this study is to identify the increased incidence of lobular carcinoma in situ with current stereotactic biopsy techniques. METHODS: Biopsy results from 1993 to 2004 were reviewed retrospectively. 2,940 stereotactic biopsies were performed using a 14-gauge gun-type needle; 1,807 stereotactic biopsies were performed using an 11-gauge vacuum-assisted needle; and 2,724 ultrasound-guided biopsies were performed using a 14-gauge gun-type needle. RESULTS: The incidence of lobular intraepithelial neoplasia was 0.4% using the stereotactic 14-gauge technique, 0.4% using the ultrasound-guided 14-gauge technique, and 1.7% using the 11-gauge stereotactic technique. The increased rate of detection of lobular carcinoma in situ with an 11-gauge needle was statistically significant (p<.0001). CONCLUSION: Lobular intraepithelial neoplasia is believed to be an incidental finding without specific imaging or clinical characteristics. Patients with detected lobular intraepithelial neoplasia have a significantly increased risk for subsequently developing breast cancer. Management recommendations can include no treatment, local excision, chemoprevention, and even bilateral prophylactic mastectomy. Radiologists and referring physicians need to be aware of the wide-ranging treatment recommendations, as lobular intraepithelial neoplasia is being identified more frequently.