Factors Associated With Ultrasound Color Doppler Twinkling by Breast Biopsy Markers: In Vitro and Ex Vivo Evaluation of 35 Commercially Available Markers.

BACKGROUND. Targeted axillary lymph node dissection after neoadjuvant systemic therapy (NST) for breast cancer depends on identifying marked metastatic lymph nodes. However, ultrasound visualization of biopsy markers is challenging. OBJECTIVE. The purpose of our study was to identify biopsy markers that show actionable twinkling in cadaveric breast and to assess the association of actionable twinkling with markers' surface roughness. METHODS. Commercial breast biopsy markers were evaluated for twinkling artifact in various experimental conditions relating to scanning medium (solid gel phantom, ultrasound coupling gel, cadaveric breast), transducer (ML6-15, 9L, C1-6), and embedding material (present vs absent). Markers were assigned twinkling scores from 0 (confident in no twinkling) to 4 (confident in exuberant twinkling); a score of 3 or greater represented actionable twinkling (sufficient confidence to rely solely on twinkling for target localization). Markers were hierarchically advanced to evaluation with increasingly complex media if showing at least minimal twinkling for a given medium. A 3D coherence optical profiler measured marker surface roughness. Mixed-effects proportional odds regression models assessed associations between twinkling scores and transducer and embedding material; Wilcoxon rank sum test evaluated associations between actionable twinkling and surface roughness. RESULTS. Thirty-five markers (21 with embedding material) were evaluated. Ten markers without embedding material advanced to evaluation in cadaveric breast. Higher twinkling scores were associated with presence of embedding material (odds ratio [OR] = 5.05 in solid gel phantom, 9.84 in coupling gel) and transducer (using the C1-6 transducer as reference; 9L transducer: OR = 0.36, 0.83, and 0.04 in solid gel phantom, ultrasound coupling gel, and cadaveric breast; ML6-15 transducer: OR = 0.07, 0.18, and 0.00 respectively; post hoc p between 9L and ML6-15: p < .001, p = .02, and p = .04). In cadaveric breast, three markers (Cork, Professional Q, MRI [Flex]) exhibited actionable twinkling for two or more transducers; surface roughness was significantly higher for markers with than without actionable twinkling for C1-6 (median values: 0.97 vs 0.35, p = .02) and 9L (1.75 vs 0.36; p = .002) transducers. CONCLUSION. Certain breast biopsy markers exhibited actionable twinkling in cadaveric breast. Twinkling was observed with greater confidence for the C1-6 and 9L transducers than the ML6-15 transducer. Actionable twinkling was associated with higher marker surface roughness. CLINICAL IMPACT. Use of twinkling for marker detection could impact preoperative or intraoperative localization after NST.

Pictorial Review of Common and Uncommon Pediatric Breast Lesions.

Breast masses in children and adolescents are uncommon, and the spectrum of pediatric breast masses is predominantly benign and different from that in adults. Knowledge of the clinical presentation and imaging features of the various stages of normal development and mass-forming lesions in the pediatric breast can guide a tailored imaging approach and help the radiologist make a definitive diagnosis. Breast development begins during fetal gestation along the embryologic milk lines and continues through puberty as the breast matures through the Tanner stages of development. Normal and developmental variants and benign neoplastic and nonneoplastic lesions in the pediatric breast are common causes of concern. Malignant breast masses in children are rare and are more often due to metastasis than primary breast cancer. When clinically warranted, US is the mainstay for imaging the pediatric breast and requires careful correlation of sonographic findings with patient age and history. Breast MRI can be used to further characterize lesions and evaluate the extent of disease. Biopsy should be considered only for suspicious findings and must be weighed against the risk of iatrogenic injury to the developing breast. Given that the majority of mass-forming lesions in the pediatric breast are benign, the diagnostic and management approach should emphasize "first do no harm." Knowledge of the imaging appearance of normal breast development and the spectrum of benign and malignant pediatric breast masses is necessary to make the correct diagnosis. © RSNA, 2022.

False-Positive and False-Negative Contrast-enhanced Mammograms: Pitfalls and Strategies to Improve Cancer Detection.

Contrast-enhanced mammography (CEM) is a relatively new breast imaging modality that uses intravenous contrast material to increase detection of breast cancer. CEM combines the structural information of conventional mammography with the functional information of tumor neovascularity. Initial studies have demonstrated that CEM and MRI perform with similar accuracies, with CEM having a slightly higher specificity (fewer false positives), although larger studies are needed. There are various reasons for false positives and false negatives at CEM. False positives at CEM can be caused by benign lesions with vascularity, including benign tumors, infection or inflammation, benign lesions in the skin, and imaging artifacts. False negatives at CEM can be attributed to incomplete or inadequate visualization of lesions, marked background parenchymal enhancement (BPE) obscuring cancer, lack of lesion contrast enhancement due to technical issues or less-vascular cancers, artifacts, and errors of lesion perception or characterization. When possible, real-time interpretation of CEM studies is ideal. If additional views are necessary, they may be obtained while contrast material is still in the breast parenchyma. Until recently, a limitation of CEM was the lack of CEM-guided biopsy capability. However, in 2020, the U.S. Food and Drug Administration cleared two devices to support CEM-guided biopsy using a stereotactic biopsy technique. The authors review various causes of false-positive and false-negative contrast-enhanced mammograms and discuss strategies to reduce these diagnostic errors to improve cancer detection while mitigating unnecessary additional imaging and procedures. ©RSNA, 2023 Quiz questions for this article are available in the supplemental material.

Imaging Characteristics of and Multidisciplinary Management Considerations for Atypical Ductal Hyperplasia and Flat Epithelial Atypia: Review of Current Literature.

High-risk lesions of the breast are frequently encountered in percutaneous biopsy specimens. While benign, these lesions have historically undergone surgical excision due to their potential to be upgraded to malignancy. However, there is emerging evidence that a tailored management approach should be considered to reduce overtreatment of these lesions. Flat epithelial atypia (FEA) and atypical ductal hyperplasia (ADH) are two of the most commonly encountered high-risk lesions. FEA has been shown to have a relatively low rate of progression to malignancy, and some guidelines are now recommending observation over routine excision in select cases. Selective observation may be reasonable in cases where the target lesion is small and completely removed at biopsy and when there are no underlying risk factors, such as a history of breast cancer or genetic mutation or concurrent ADH. ADH has the highest potential upgrade rate to malignancy of all the high-risk lesions. Most society guidelines continue to recommend surgical excision of this lesion. More recently, some literature suggests that ADH lesions that appear completely removed at biopsy, involve limited foci (less than two or three) with no necrosis or significant atypia, manifest as a small group of mammographic calcifications, or demonstrate no enhancement at MRI may be reasonable for observation. Ultimately, management of all high-risk lesions must be based on a multidisciplinary approach that considers all patient, radiologic, clinical, and histopathologic factors. ©RSNA, 2023 Quiz questions for this article are available in the supplemental material.

Ultrasound-Guided Breast Biopsies: Basic and New Techniques.

Ultrasound-guided breast biopsies can be challenging to perform, especially when the target is adjacent to the nipple, skin, or implant or when the target is small and in very posterior, dense fibroglandular tissue. Oftentimes, a slightly modified approach can result in a diagnostic biopsy specimen with minimal complications. After a brief review of basic techniques for ultrasound-guided breast biopsies that includes a review of conventional breast biopsy devices, a presentation of procedural modifications and techniques to consider for more challenging cases is described. In particular, novel open-trough and tandem-needle techniques are detailed. Several cases using these techniques are then presented.

Imaging Features and Treatment Options for Breast Pseudoaneurysms After Biopsy: A Case-Based Pictorial Review.

Pseudoaneurysm (PSA) formation is a potential complication of breast biopsies. Ultrasound is the most common imaging modality used for evaluation and treatment of a PSA. Color Doppler images show a cystic structure with swirling flow inside in a "to-and-fro" pattern. Treatment options for PSA include observation, ultrasound-guided focused compression, thrombin injection, open surgical repair, and percutaneous embolization. The risks and benefits of these treatment options will be discussed in the following cases.

Acute ocular traumatic imaging: what the radiologist should know [corrected].

Acute ocular trauma accounts for a substantial number of emergency department visits in the USA, and represents a significant source of disability to patients; however, the orbits remain a potential blind spot for radiologists. The goal of this article is to review the relevant anatomy of the orbit and imaging findings associated with commonly encountered acute ocular traumatic pathology, while highlighting the salient information which should be reported to the ordering clinician. Topics discussed include trauma to the anterior and posterior chamber, lens dislocations, intraocular foreign bodies, and open and contained globe injuries.

A perspective on how to optimize breast imaging rotations for medical students.

As educators we try to acquire and retain the attention of medical students who rotate through radiology in hopes to improve recruitment. There are various ways to optimize a medical student rotation in breast imaging. We review our methods of identifying their medical interest, highlighting the steps in breast intervention, selecting key cases for review, and providing meaningful feedback.

Tumor Doubling Time and Screening Interval.

The goal of screening is to detect breast cancers when still curable to decrease breast cancer-specific mortality. Breast cancer screening in the United States is routinely performed with digital mammography and digital breast tomosynthesis. This article reviews breast cancer doubling time by tumor subtype and examines the impact of doubling time on breast cancer screening intervals. By the article's end, the reader will be better equipped to have informed discussions with patients and medical professionals regarding the benefits and disadvantages of the currently recommended screening mammography intervals.

The "teacup sign": Significance in breast imaging.

Milk of calcium (MOC) is a term used for sedimented calcifications within small cysts (Milk of Calcium - an overview|ScienceDirect Topics, n.d.). MOC in the breast is a benign entity and present in 4-6% of women that undergo diagnostic mammography (Park et al., 2008).2 Calcium particles within cysts produce 'teacup'-shaped calcifications on true lateral views, and smudged calcifications on craniocaudal (CC) views (Veloso Gomes et al., n.d.).3 On the CC projection, the calcifications will have a cloudlike or smudgy appearance like tea leaves in the bottom of a teacup (Milk of Calcium - an overview|ScienceDirect Topics, n.d.). Because this is a characteristic benign finding, there is no need for the patient to undergo a biopsy.

Eosinophilic mastitis mimicking a developing asymmetry.

Eosinophilic mastitis is a very rare form of mastitis with few reported cases in the literature. This is a case of eosinophilic mastitis in a 48-year-old woman which presented as a screen detected right breast developing asymmetry. No sonographic abnormalities were visualized on diagnostic workup, and subsequent tomosynthesis-guided biopsy was performed. Knowledge of this rare entity is helpful in the radiologic-pathologic correlation, diagnosis, and clinical management of future cases.

'Pasta-Bly' the best radiologic imaging sign-I saw the linguine sign.

The linguine sign is a radiologic sign seen on magnetic resonance imaging (MRI) that indicates intracapsular rupture of silicone breast implants. It refers to multiple curvilinear lines that appear on MRI, representing the outline of the elastomeric shell of the silicone implant floating freely within the silicone gel. The term first appeared in literature in 1992 when optimal imaging techniques and modalities for implant rupture were still unclear, and since then the term "linguine sign" has been widely used to describe evidence of intracapsular rupture.

Radiology Resident Education - Keys to Successful Workstation Learning: A Resident Perspective.

Medical education can be overwhelming for radiology residents, particularly when during the first year. Although there is no one single formula or set of resources for success as a resident, a universal and often overlooked educational experience is the readout at the workstation with the attending. Getting the most out of this key interaction requires forethought and engagement from both the attending and the resident. The aim of this article is to discuss helpful tips in maximizing this educational experience from the resident's perspective.

Urgent and emergent breast lesions - A primer for the general radiologist, on-call resident and sonographer.

There are very few true breast emergencies. While infrequent, women do present to emergency departments or urgent care centres with breast-related concerns. In this case-based review, both common and uncommon urgent and emergent breast lesions are presented, emphasising ultrasound characteristics and imaging optimisation to improve accurate diagnosis and appropriate recommendations.

Identifying women with increased risk of breast cancer and implementing risk-reducing strategies and supplemental imaging.

Breast cancer (BC) is the second most common cancer in women, affecting 1 in 8 women in the United States (12.5%) in their lifetime. However, some women have a higher lifetime risk of BC because of genetic and lifestyle factors, mammographic breast density, and reproductive and hormonal factors. Because BC risk is variable, screening and prevention strategies should be individualized after considering patient-specific risk factors. Thus, health care professionals need to be able to assess risk profiles, identify high-risk women, and individualize screening and prevention strategies through a shared decision-making process. In this article, we review the risk factors for BC, risk-assessment models that identify high-risk patients, and preventive medications and lifestyle modifications that may decrease risk. We also discuss the benefits and limitations of various supplemental screening methods.

Local Recurrence of Invasive Secretory Breast Carcinoma in a Gravid Patient Post-Mastectomy.

This is a case of locally recurrent invasive secretory carcinoma of the breast during pregnancy, detected as a palpable mass in the reconstructed right breast of a 32-year-old female at 24 weeks gestation. The patient was initially diagnosed with secretory carcinoma 8 years prior, for which she underwent nipple sparing mastectomy followed by adjuvant chemotherapy and endocrine therapy. Due to pregnancy, the recurrence was treated initially with conservative excision alone, followed by definitive management postpartum which included wide local excision, sentinel lymph node biopsy and adjuvant chest wall radiation. Secretory carcinoma of the breast is a rare cancer with a predilection for young age and indolent course. This case report describes an unusual case of recurrent secretory carcinoma, of interest due to both its diagnosis during pregnancy, and its recurrence after nipple sparing mastectomy.

Hydrodissection - Practical applications in ultrasound-guided breast interventions.

Hydrodissection is a procedural tactic utilized in various interventions. It is a technique which helps separate structures in order to safely perform a certain procedure. This article will provide a review of hydrodissection, how to perform this technique, and why it can be useful in breast interventions.

Mastitis and More: A Pictorial Review of the Red, Swollen, and Painful Breast.

Clinically, acute mastitis presents as a red, swollen, and painful breast. Targeted ultrasound can be performed to evaluate the extent of infection and for an underlying abscess. Noncomplicated mastitis or a small fluid collection may respond to oral antibiotics without further intervention, but a larger or more complex abscess may require single or serial percutaneous aspiration. Breast infections, particularly those complicated by an abscess, can have a prolonged clinical course, and close follow-up is required. Since the clinical presentation and imaging features of acute infectious mastitis can overlap with other etiologies, such as inflammatory breast cancer and idiopathic granulomatous mastitis, a percutaneous biopsy may be indicated to accurately diagnose patients.