Ultrasound-Guided Breast Cancer Cryoablation.

OBJECTIVE. Percutaneous ultrasound-guided breast cryoablation is a minimally invasive technique that kills targeted tissue with extreme cold, requires only local anesthesia, and takes less than 45 minutes to complete. CONCLUSION. We discuss the indications for breast cryoablation, the mechanism of cell death, and types of commercially available devices; illustrate procedural technique; and review expected follow-up imaging findings in treated primary breast cancer.

Screening Digital Mammography Recall Rate: Does It Change with Digital Breast Tomosynthesis Experience?

Purpose To compare screening mammography recall rate, cancer detection rate (CDR), and positive predictive values (PPVs) for digital mammography before and after radiologist experience with digital breast tomosynthesis (DBT). Materials and Methods This retrospective study was approved by the institutional review board and compliant with HIPAA. The authors reviewed screening mammography audit data obtained from 2009 to 2014, during which 108 276 digital mammographic examinations were performed (50 062 before and 58 214 after experience with DBT). Recall rate, CDR, PPV of positive screening result (PPV1), PPV of biopsy recommendation (PPV2), and PPV of biopsies performed (PPV3) of digital mammography for six radiologists were compared before (2009-2011) and after (2012-2014) experience with DBT. Radiologists worked in both a community setting, in which only digital mammography was available, and in two tertiary breast imaging centers, where they interpreted DBT images starting in 2012. Data were examined by using generalized linear mixed modeling wherein observations were nested for each radiologist over time. P < .05 was considered indicative of a statistically significant difference; 95% confidence intervals (CIs) were calculated. Results The average recall rate was 6.8% (range, 3.6%-9.7%) before experience with DBT and 7.9% (range, 5.5%-9.5%) after (P = .0316). Before experience with DBT, the recall rate increased only 0.01% for each year from 2009 to 2011 (P = .9727). After experience with DBT, the recall rate increased 0.65% for each year from 2012 to 2014 (P < .0127). CDR increased from 2.5 per 1000 examinations (95% CI: 2.2, 2.9) to 3.5 per 1000 examinations (95% CI: 3.0, 4.0; P = .0203). PPV2 and PPV3 increased significantly after experience with DBT, from 26.9% (95% CI: 19.9%, 35.3%) to 36.1% (95% CI: 31.7%, 40.7%; P = .0212) for PPV2 and from 31.2% (95% CI: 24.0%, 39.3%) to 40.0% (95% CI: 35.5%, 44.6%; P = .0290) for PPV3. Conclusion Recall rate, CDR, PPV2, and PPV3 of digital mammography increased after radiologist experience with DBT. © RSNA, 2017.

Comparison of digital mammography and digital breast tomosynthesis in the detection of architectural distortion.

OBJECTIVES: To compare interobserver variability (IOV), reader confidence, and sensitivity/specificity in detecting architectural distortion (AD) on digital mammography (DM) versus digital breast tomosynthesis (DBT). METHODS: This IRB-approved, HIPAA-compliant reader study used a counterbalanced experimental design. We searched radiology reports for AD on screening mammograms from 5 March 2012-27 November 2013. Cases were consensus-reviewed. Controls were selected from demographically matched non-AD examinations. Two radiologists and two fellows blinded to outcomes independently reviewed images from two patient groups in two sessions. Readers recorded presence/absence of AD and confidence level. Agreement and differences in confidence and sensitivity/specificity between DBT versus DM and attendings versus fellows were examined using weighted Kappa and generalised mixed modeling, respectively. RESULTS: There were 59 AD patients and 59 controls for 1,888 observations (59 × 2 (cases and controls) × 2 breasts × 2 imaging techniques × 4 readers). For all readers, agreement improved with DBT versus DM (0.61 vs. 0.37). Confidence was higher with DBT, p = .001. DBT achieved higher sensitivity (.59 vs. .32), p < .001; specificity remained high (>.90). DBT achieved higher positive likelihood ratio values, smaller negative likelihood ratio values, and larger ROC values. CONCLUSIONS: DBT decreases IOV, increases confidence, and improves sensitivity while maintaining high specificity in detecting AD. KEY POINTS: • Digital breast tomosynthesis decreases interobserver variability in the detection of architectural distortion. • Digital breast tomosynthesis increases reader confidence in the detection of architectural distortion. • Digital breast tomosynthesis improves sensitivity in the detection of architectural distortion.

Pilot study of a new comprehensive radiology report categorization (RADCAT) system in the emergency department.

PURPOSE: The purpose of this study was to describe a new, broadly applicable radiology report categorization (RADCAT) system that was developed collaboratively between radiologists and emergency department (ED) physicians, and to establish its usability and performance by interobserver variation. METHODS: In collaboration with our ED colleagues, we developed the RADCAT system for all imaging studies performed in our level-1 trauma center, including five categories that span the spectrum of normal through emergent life-threatening findings. During a pilot phase, four radiologists used the system real-time to categorize a minimum of 400 reports in the ED. From this pool of categorized studies, 58 reports were then selected semi-randomly, de-identified, stripped of their original categorization, and recategorized based on the narrative radiology report by 12 individual reviewers (6 radiologists, and 6 ED physicians). Interobserver variation between all reviewers, radiologists only, and ED physicians only was calculated using Cohen's Kappa statistic and Kendall's coefficient of concordance. RESULTS: Altogether, agreement among radiologists and ED physicians was substantial (κ = 0.73, p < 0.0001) and agreement for each category was substantial (all κ > 0.60, p < 0.0001). The lowest agreement was observed with RADCAT-3 (κ > 0.61, p < 0.0001) and the highest agreement with RADCAT-1 (κ > 0.85, p < 0.0001). A high trend in agreement was observed for radiologists and ED physicians and their combination (all W > 0.90, p < 0.0001). CONCLUSIONS: Our RADCAT system is understandable between radiologists and ED physicians for categorizing a wide range of imaging studies, and warrants further assessment and validation. Based upon these pilot results, we plan to adopt this RADCAT scheme and further assess its performance.

Changes in recall type and patient treatment following implementation of screening digital breast tomosynthesis.

PURPOSE: To compare recall rate, types of abnormalities recalled, additional imaging required, biopsy positive predictive value (PPV), and cancer detection rate before and after implementation of screening digital breast tomosynthesis (DBT). MATERIALS AND METHODS: This retrospective analysis was approved by the institutional review board and complied with HIPAA. The requirement to obtain informed consent was waived. Results from all screening digital mammography (DM) examinations performed without tomosynthesis from March 1, 2011, through February 29, 2012, and DBT examinations performed from March 1, 2012, through February 28, 2013, were reviewed to identify all Breast Imaging Reporting and Data System (BI-RADS) category 0 examinations (needs additional imaging). Radiology and pathology reports were reviewed. The recall rate, biopsy PPV, and cancer detection rate were calculated. Statistical analysis was performed by using a two-proportions z test. RESULTS: The recall rate was 9.3% (1175 of 12 577 examinations; 95% confidence interval [CI]: 8.8%, 9.9%) for DM and 6.4% (827 of 12 921 examinations; 95% CI: 6.0%, 6.8%) for DBT, an overall reduction of 31% (P < .00001). The recall rate was lower with DM than with DBT for masses (8.9% vs 26.8%, respectively), distortions (0.6% vs 5.3%), and calcifications (13.4% vs 20.3%) (P < .0001 for all). The recall rate was lower with DBT than with DM for asymmetries (13.3% vs 32.2%, respectively) and focal asymmetries (18.2% vs 32.2%) (P < .0001 for both). Diagnostic evaluation with ultrasonography (US) increased with DBT at the time of additional imaging (2.6% for DM vs 28.3% for DBT, P < .0001). There was no significant difference between DM and DBT with regard to biopsy PPV (30.2% vs 23.8%, P = .21) or cancer detection rate per 1000 patients (5.4 vs 4.6, P = .44). CONCLUSION: With DBT, the recall rate decreased and the biopsy PPV and cancer detection rate did not decrease. The distribution of recalled abnormalities changed, and more patients were evaluated with US only.

Improving outcomes of screening breast MRI with practice evolution: initial clinical experience with 3T compared to 1.5T.

PURPOSE: To determine if changing from 1.5T to 3T breast magnetic resonance imaging (MRI) is associated with a change in BI-RADS categories, positive predictive value of biopsy recommendation, or cancer detection rates in high-risk screening breast MRI. MATERIALS AND METHODS: Institutional Review Board (IRB) approval was obtained for this Health Insurance Portability and Accountability Act (HIPAA)-compatible retrospective review. Prior to October 2010, breast MRI was performed at 1.5T and after October 2010 breast MRI was performed at 3T. Reports of 495 consecutive screening 3T breast MRI exams from October 2010 through October 2011 were reviewed. Comparison was made to previously collected data on 650 screening breast MRI exams at 1.5T. Data were analyzed for statistical significance using the two-sample test of proportions. RESULTS: There were 495 screening breast MRI exams. There were 419 (84.6%) BI-RADS 1/2 results, 35 (7.1%) BI-RADS 3 results, and 41 (8.3%) BI-RADS 4/5 results. BI-RADS 4/5 results increased at 3T (P=0.04). The positive predictive value for BI-RADS 4/5 was 29.3% (12/41) at 3T, compared with 17.6% at 1.5T (P<0.001). Cancer detection rate was 2.6% at 3T, compared with 0.9% at 1.5T (P=0.02). CONCLUSION: Transition to 3T breast MRI in a screening population resulted in increased BI-RADS 4/5 interpretations, positive predictive value of biopsy recommendations, and cancer detection rate.

Probably benign breast MRI lesions: frequency, lesion type, and rate of malignancy.

PURPOSE: To determine the frequency, malignancy rate, and imaging characteristics of BI-RADS (Breast Imaging Reporting and Data System) 3 MRI detected lesions. MATERIALS AND METHODS: A total of 4370 consecutive contrast-enhanced breast MRI exams from March 1, 2004, to March 1, 2009, were retrospectively reviewed. The study was HIPAA (Health Insurance Portability Accountability Act) compliant and Institutional Review Board approved. The frequency of BI-RADS 3 MRI interpretations and lesion type, as well as malignancy rate at follow-up were calculated. RESULTS: There were 348/4370 (8%) BI-RADS 3 exams performed on 345 patients. There were 125 foci (35.9%), 52 non-masslike enhancements (14.9%), and 171 masses (49.1%). There were 207 lesions with biopsy or imaging follow-up of at least 24 months (mean, 32 months; range, 6-77 months) of the BI-RADS 3 lesion. Five of these 207 (2.4%) lesions were found to be malignant. CONCLUSION: Rate of malignancy among BI-RADS 3 MRI exams with follow-up was 2.4%. Types of lesions assigned as probably benign were 35.9% foci, 14.9% non-masslike enhancements, and 49.1% masses.

Detection of mammographically occult architectural distortion on digital breast tomosynthesis screening: initial clinical experience.

OBJECTIVE: Digital breast tomosynthesis (DBT) has been shown to improve the sensitivity of screening mammography. DBT may have the most potential impact in cases of subtle mammographic findings such as architectural distortion (AD). The objective of our study was to determine whether DBT provides better visualization of AD than digital mammography (DM) and whether sensitivity for cancer detection is increased by the addition of DBT as it relates to cases of mammographically occult AD. MATERIALS AND METHODS: Retrospective review of BI-RADS category 0 reports from 9982 screening DM examinations with adjunct DBT were searched for the term "architectural distortion" and were reviewed in consensus by three radiologists. ADs were classified by whether they were seen better on DM or DBT, were seen equally well on both, or were occult on either modality. The electronic medical record was reviewed to identify additional imaging studies, biopsy results, and surgical excision pathology results. RESULTS: Review identified 26 cases of AD, 19 (73%) of which were seen only on the DBT images. Of the remaining seven ADs, six were seen better on DBT than DM. On diagnostic workup, nine lesions were assigned to BI-RADS category 4 or 5. Surgical pathology revealed two invasive carcinomas, two ductal carcinoma in situ lesions, three radial scars, and two lesions showing atypia. The cancer detection rate of DBT in mammographically occult AD was 21% (4/19). The positive predictive value of biopsy was 44%. CONCLUSION: DBT provides better visualization of AD than DM and identifies a subset of ADs that are occult on DM. Identification of additional ADs on DBT increases the cancer detection rate.

Review of outside studies by radiology residents: national survey of chief residents.

The purpose of this study was to establish practice patterns of radiology residents in regards to interpretation and reporting of outside studies for transferred patients. We performed a national survey of radiology residency chief residents, administered by email through the Association of Program Directors in Radiology (APDR). There were 81 chief resident respondents, representing 42.8 % of 187 total Accreditation Council for Graduate Medical Education (ACGME)-approved radiology residency training programs in the USA. In 97.5 % of programs, residents perform interpretations of outside studies. Up to 76.7 % of respondents state that when outside studies are reviewed by residents, an original report is available in less than one quarter of cases. While 55.1 % of respondents state that there is a mechanism for recording their findings and impressions for outside studies, only 32.1 % are aware of a policy requiring documentation. Of the respondents, 42.3 % report they have no means for documenting their findings and impressions on outside studies. Further, 65.4 % state that there is no policy requiring an attending to review and document agreement with their interpretation of outside studies. There is wide institutional variation in both policy and practice regarding reinterpretation of outside studies for patients transferred to academic hospitals. While the majority of radiology residents are providing the service of reinterpreting outside studies, only a minority of residency programs have a policy requiring (1) documentation of their impressions or (2) attending oversight and documentation of discrepant opinions.

Should I Stay, or Should I Go? Early Phase Instrument Development of Workforce Movement-A Pilot Study with Breast Radiologists.

OBJECTIVE: The goal of this study was to develop a psychometrically valid survey on workplace satisfaction and examine predictors of workforce movement among breast radiologists. METHODS: Actively practicing members of the Society of Breast Imaging were invited to complete a survey on workplace satisfaction. Radiologists also indicated whether they had recently left their practice or were thinking of leaving their practice. RESULTS: In total, 228 breast radiologists provided valid responses (8.7% response rate); 45% were thinking of leaving or had left their practice. Factor analysis yielded five factors, and discriminant function analysis found six main aspects associated with workforce movement in breast radiologists: (1) not enough work-life balance; (2) salary too low; (3) not feeling valued; (4) wanting a different challenge and/or more growth opportunity; (5) safety concerns; and (6) not feeling respected by physician leadership. CONCLUSIONS: Pending further validation in larger and different cohorts, the survey created here can be administered by radiology practices to predict when breast radiologists are vulnerable to quitting. Atlhough this measure was designed for breast radiologists specifically, it could be adapted for other subspecialties.

Screening mammography recall rate: does practice site matter?

PURPOSE: To determine whether the screening mammography recall rate for individual radiologists varies as a function of imaging site. MATERIALS AND METHODS: Institutional review board-approved, HIPAA-compliant retrospective review of mammography audit data was performed between May 1, 2008, and September 1, 2011, for five radiologists with expertise in breast imaging interpreting mammograms at a community office practice and an academic referral hospital. Informed consent was waived. Both sites used full-field digital mammography and batch screening interpretation. Recall rates were calculated from audit data. Breast density, history of surgery or biopsy, and availability of prior mammograms were compared in a sample of 500 mammograms from each site by using χ(2) and two-sample t tests. RESULTS: Radiologists interpreted a total of 74 297 screening mammograms between both sites during the study. The overall mean recall rate was 7.8% ± 0.2 (standard deviation). Overall recall rate at the community site was significantly lower than at the hospital site (6.9% ± 0.3 vs 8.6% ± 0.3, P < .001). Recall rates for each radiologist were also lower at the community site: 3.7% versus 6.5% (P < .001), 9.6% versus 12.0% (P < .001), 7.5% versus 9.1% (P = .01), 7.6% versus 11.5% (P < .001), and 5.6% versus 8.0% (P = .02). There was a significantly higher proportion of patients at the hospital site with a history of surgery (13.4% vs 5.6%, P < .001) and biopsy (7.0% vs 1.4%, P < .001) but no difference in the percentage with dense breasts or in the percentage with availability of prior mammograms. Mean patient age was lower at the hospital site: 56.1 versus 62.9 years (P < .001). CONCLUSION: Recall rates were higher at the hospital site, probably primarily caused by patient population factors.

A pre-post study of stressors and burnout affecting breast radiologists before and during the COVID-19 pandemic.

Rationale and objective: To compare burnout and stressors of breast radiologists prior to and during the COVID-19 pandemic. Materials and methods: Members of the Society of Breast Imaging were emailed an IRB-approved survey in January 2021 during the COVID-19 pandemic. Survey included questions from the Maslach Burnout Inventory and specific stressors including work pace, work-life balance, care of dependents, and financial strain. Data were compared to previous surveys prior to the pandemic. Results: The response rate was 25% (261/1061) for those who opened the email. Of the respondents, 74% (194/261) were female, 82% (214/261) were white, 73% (191/261) were full time, 71% (185/261) were fellowship trained, 41% (106/261) had more than 20 years of experience, and 30% (79/261) were in academic practice.Respondents in 2021 reported frequent levels of depersonalization (2.2) and emotional exhaustion (3.4) while reporting frequent levels of personal accomplishment (5.3), a protective factor. These values were nearly identical before the pandemic in 2020: (2.2, 3.5, 5.3, respectively, p = .9). Respondents rated practicing faster than they would like as the highest stressor; however, 5 of the 6 stressors improved after the pandemic onset (p < .05). Conversely, participants perceived these stresses had gotten slightly worse since the pandemic (p < .01). Almost 50% of respondents reported they were considering leaving their practice; the most common reason was work/life balance. Conclusion: Burnout in breast radiologists remains frequent but unchanged during the COVID-19 pandemic. While participants perceived that some stressors were worse during the pandemic, there was slight improvement in most stressors between the pre-pandemic and pandemic cohorts.

Utility of targeted sonography in management of probably benign breast lesions identified on magnetic resonance imaging.

OBJECTIVES: The purpose of this study was to determine the utility of targeted sonography in the management of probably benign breast lesions detected on magnetic resonance imaging (MRI). METHODS: A total of 4370 consecutive contrast-enhanced breast MRI examinations from March 1, 2004, to March 1, 2009, were retrospectively reviewed. The study was Health Insurance Portability and Accountability Act compliant and Institutional Review Board approved. When targeted sonography was recommended for a Breast Imaging Reporting and Data System (BI-RADS) category 3 examination, results of the sonography and any subsequent breast pathologic examinations were recorded. The frequency of identifying the MRI-detected lesions and the rate at which the BI-RADS category was changed by sonography were calculated for mass and non-mass-like lesions. RESULTS: Of the 4370 examinations, 349 (8%) had BI-RADS 3 findings in 346 patients. One hundred eighteen lesions underwent targeted sonography for evaluation of 85 masses and 33 areas of non-mass-like enhancement. Of these 118 lesions, 54 (46%) were seen on sonography. No cancers were detected on sonography in the areas of non-mass-like enhancement. Two of the 85 masses (2.4%) evaluated with targeted sonography had a malignant diagnosis before initiation of follow-up. CONCLUSIONS: Selective use of targeted sonography, particularly in masses, may help identify some malignancies before initiating short-interval follow-up for MRI-detected BI-RADS 3 lesions.

Coaching: A Strategy for Breast Radiologists' Professional Development.

The continually increasing demands placed on physicians have led to high levels of burnout, and breast radiologists are no exception. Professional coaching is a means to guide and support the radiologist through a process of positive thinking, stress reduction, goal setting, mental growth, work-life balance, and behavioral change. Professional coaching may be effective in preparation for leadership roles or in response to workplace issues or conflict. The radiologist, with the help of a coach, establishes goals, expands perception and mindset, and collaboratively may find ways to resolve issues by taking new and different approaches. This article discusses why radiologists should seek out a certified coach and what a coach can offer radiologists during these trying times, as well as outlining the coaching process. Coaching has proven useful in addressing professional growth, workplace issues, and physician burnout. At the conclusion of the article, the readers will be able to discern whether coaching can support a better quality of life for them.

The ADVICER Template for Faculty Reviewer Letters for Promotion and Appointment.

RATIONALE AND OBJECTIVES: Promotion is an important milestone in the career of academic radiologists. Appointments, Promotion and Tenure (APT) committees require multiple letters of support from both internal and external referees. Traditional narrative letters are highly subjective, have high inter-reader variability, are time-intensive, and vulnerable to gender and other biases. The Alliance of Directors and Vice Chairs of Education in Radiology (ADVICER) recognized the need for a standardized template to assist academic faculty, letter writers, and APT committees. MATERIALS AND METHODS: An ADVICER ad hoc committee of six educators with experience serving as external referees was convened to create a standardized template. Committee members performed a search of the relevant literature and internet sites, spoke with stakeholders such as APT chairs, and ultimately developed a template for faculty reviewer letters using the common clinician-educator pathway as a focal point. RESULTS: An open source, modifiable, standardized, template was produced. The template has been made available to ADVICER members and is available on the Association of University Radiologists (AUR) website at: https://www.aur.org/resources/Template-for-Faculty-Reviewer-Letters-for-Promotion-and-Appointment CONCLUSION: This external referee template has the potential to reduce subjectivity, eliminate bias, and provide a flexible, modifiable, comprehensive faculty review letter template which will be useful for academic faculty, letter writers, and promotions committees.

Screening breast MR imaging: comparison of interpretation of baseline and annual follow-up studies.

PURPOSE: To determine whether baseline screening breast magnetic resonance (MR) imaging studies have a higher rate of follow-up or biopsy recommendation than do studies with prior MR images available for comparison. MATERIALS AND METHODS: This was an institutional review board-approved, HIPAA-compliant, retrospective study. Informed consent was waived. Reports from 650 consecutive screening breast MR imaging examinations performed in women between September 2007 and December 2008 were reviewed. All examinations were performed by using the same protocol, and images were interpreted by the same radiologists. Presence of comparison studies, Breast Imaging Reporting and Data System (BI-RADS) category, and biopsy results were recorded. Data were analyzed by using the χ(2) test, the two-sample test of proportions, and the Fisher exact test. RESULTS: Mean patient age was 51 years (range, 25-81 years). Of the baseline studies, findings in 31 of 307 (10.1%) were interpreted as BI-RADS category 3 and findings in 18 of 307 (5.9%) were interpreted as BI-RADS category 4 or 5. Of the examinations with findings classified as BI-RADS category 4 or 5, the results in two of 18 (11.1%) were positive for malignancy at biopsy. Of the examinations with prior MR images for comparison, findings in nine of 343 (2.6%) were interpreted as BI-RADS category 3 and findings in 16 of 343 (4.7%) were interpreted as BI-RADS category 4 or 5. Of the examinations with findings classified as BI-RADS category 4 or 5, the results in three of 16 (18.8%) were positive for malignancy at biopsy. The difference in the number of BI-RADS category 3 interpretations between the two groups was significant (P < .001), but there was no significant difference in BI-RADS category 4 or 5 interpretations or positive predictive values. CONCLUSION: Baseline screening MR imaging was associated with a higher likelihood of recommendation for short-interval follow-up than was MR imaging with prior images for comparison.

What Causes the Most Stress in Breast Radiology Practice? A Survey of Members of the Society of Breast Imaging.

OBJECTIVE: The objective of this study is to determine the major stressors affecting practicing breast radiologists. METHODS: All members of the Society of Breast Imaging within the United States received an email invitation to complete an anonymous survey evaluating stressors that may contribute to physician burnout. Stressors evaluated included pace at work, work-life balance, care of dependents, job security, financial strain, decreasing reimbursement, new regulations, delivering bad news, fear of getting sued, and dealing with difficult patients, radiologists, and administrators. RESULTS: The overall response rate was 13.5% (312/2308). For those who opened the email, response rate was 24.6% (312/1269). The most prevalent stressors reported were working too fast (222/312, 71.2%), balancing demands of work with personal life (209/312, 70.0%), fear of getting sued (164/312, 52.6%), and dealing with difficult administrators (156/312, 50%). Prevalence of stress related to new regulation requirements, job security, financial strain, decreased reimbursement, dependent care, call, delivering bad news, and dealing with difficult patients, difficult referrers, and difficult radiologists were present in fewer than 50% of respondents. CONCLUSION: The most prevalent sources of stress in breast imaging radiologists relate to working too fast and balancing demands of work with time needed for personal life.

Axillary ultrasound and fine-needle aspiration in the preoperative evaluation of the breast cancer patient: an algorithm based on tumor size and lymph node appearance.

OBJECTIVE: The objective of our study was to evaluate the utility of ultrasound-guided fine-needle aspiration (FNA) of the axillary lymph nodes in breast cancer patients depending on the size of the primary tumor and the appearance of the lymph nodes. SUBJECTS AND METHODS: Data were collected about tumor size, lymph node appearance, and the results of ultrasound-guided FNA and axillary surgery of 224 patients with breast cancer undergoing 226 ultrasound-guided FNA. Lymph nodes were classified as benign if the cortex was even and measured < 3 mm, indeterminate if the cortex was even but measured ≥ 3 mm or measured < 3 mm but was focally thickened, and suspicious if the cortex was focally thickened and measured ≥ 3 mm or the fatty hilum was absent. The results of ultrasound-guided FNAs were analyzed by the sonographic appearance of the axillary lymph nodes and by the size of the primary tumor. The sensitivity and specificity of ultrasound-guided FNA were calculated with axillary surgery as the reference standard. The sensitivity and specificity of axillary ultrasound to predict the ultrasound-guided FNA result were calculated. RESULTS: Of the 224 patients, 51 patients (23%) had a positive ultrasound-guided FNA result, which yields an overall sensitivity of 59% and specificity of 100%. The sensitivity of ultrasound-guided FNA was 29% in patients with primary tumors ≤ 1 cm, 50% in patients with tumors > 1 to ≤ 2 cm, 69% in patients with tumors > 2 to ≤ 5 cm, and 100% in patients with tumors > 5 cm. The sensitivity of ultrasound-guided FNA in patients with normal-appearing lymph nodes was 11%; indeterminate lymph nodes, 44%; and suspicious lymph nodes, 93%. Sonographic characterization of lymph nodes as suspicious or indeterminate was 94% sensitive and 72% specific in predicting positive findings at ultrasound-guided FNA. CONCLUSION: Ultrasound-guided FNA of the axillary lymph nodes is most useful in the preoperative assessment of patients with large tumors (> 2 cm) or lymph nodes that appear abnormal.