Abbreviated Breast MRI for Supplemental Screening in Patients With Dense Breasts: Comparison of Baseline Versus Subsequent-Round Examinations.

BACKGROUND. Abbreviated breast MRI (AB-MRI) achieves a higher cancer detection rate (CDR) than digital breast tomosynthesis when applied for baseline (i.e., first-round) supplemental screening of individuals with dense breasts. Limited literature has evaluated subsequent (i.e., sequential) AB-MRI screening rounds. OBJECTIVE. This study aimed to compare outcomes between baseline and subsequent rounds of screening AB-MRI in individuals with dense breasts who otherwise had an average risk for breast cancer. METHODS. This retrospective study included patients with dense breasts who otherwise had an average risk for breast cancer and underwent AB-MRI for supplemental screening between December 20, 2016, and May 10, 2023. The clinical interpretations and results of recommended biopsies for AB-MRI examinations were extracted from the EMR. Baseline and subsequent-round AB-MRI examinations were compared. RESULTS. The final sample included 2585 AB-MRI examinations (2007 baseline and 578 subsequent-round examinations) performed for supplemental screening of 2007 women (mean age, 57.1 years old) with dense breasts. Of 2007 baseline examinations, 1658 (82.6%) were assessed as BI-RADS category 1 or 2, 171 (8.5%) as BI-RADS category 3, and 178 (8.9%) as BI-RADS category 4 or 5. Of 578 subsequent-round examinations, 533 (92.2%) were assessed as BI-RADS category 1 or 2, 20 (3.5%) as BI-RADS category 3, and 25 (4.3%) as BI-RADS category 4 or 5 (p < .001). The abnormal interpretation rate (AIR) was 17.4% (349/2007) for baseline examinations versus 7.8% (45/578) for subsequent-round examinations (p < .001). For baseline examinations, PPV2 was 21.3% (38/178), PPV3 was 26.6% (38/143), and the CDR was 18.9 cancers per 1000 examinations (38/2007). For subsequent-round examinations, PPV2 was 28.0% (7/25) (p = .45), PPV3 was 29.2% (7/24) (p = .81), and the CDR was 12.1 cancers per 1000 examinations (7/578) (p = .37). All 45 cancers diagnosed by baseline or subsequent-round AB-MRI were stage 0 or 1. Seven cancers diagnosed by subsequent-round AB-MRI had a mean interval of 872 ± 373 (SD) days since prior AB-MRI and node-negative status at surgical axillary evaluation; six had an invasive component, all measuring 1.2 cm or less. CONCLUSION. Subsequent rounds of AB-MRI screening of individuals with dense breasts had lower AIR than baseline examinations while maintaining a high CDR. All cancers detected by subsequent-round examinations were early-stage node-negative cancers. CLINICAL IMPACT. The findings support sequential AB-MRI for supplemental screening in individuals with dense breasts. Further investigations are warranted to optimize the screening interval.

Association of Breast Cancer Odds with Background Parenchymal Enhancement Quantified Using a Fully Automated Method at MRI: The IMAGINE Study.

Background Background parenchymal enhancement (BPE) at breast MRI has been associated with increased breast cancer risk in several independent studies. However, variability of subjective BPE assessments have precluded its use in clinical practice. Purpose To examine the association between fully objective measures of BPE at MRI and odds of breast cancer. Materials and Methods This prospective case-control study included patients who underwent a bilateral breast MRI examination and were receiving care at one of three centers in the United States from November 2010 to July 2017. Breast volume, fibroglandular tissue (FGT) volume, and BPE were quantified using fully automated software. Fat volume was defined as breast volume minus FGT volume. BPE extent was defined as the proportion of FGT voxels with enhancement of 20% or more. Spearman rank correlation between quantitative BPE extent and Breast Imaging Reporting and Data System (BI-RADS) BPE categories assigned by an experienced board-certified breast radiologist was estimated. With use of multivariable logistic regression, breast cancer case-control status was regressed on tertiles (low, moderate, and high) of BPE, FGT volume, and fat volume, with adjustment for covariates. Results In total, 536 case participants with breast cancer (median age, 48 years [IQR, 43-55 years]) and 940 cancer-free controls (median age, 46 years [IQR, 38-55 years]) were included. BPE extent was positively associated with BI-RADS BPE (rs = 0.54; P < .001). Compared with low BPE extent (range, 2.9%-34.2%), high BPE extent (range, 50.7%-97.3%) was associated with increased odds of breast cancer (odds ratio [OR], 1.74 [95% CI: 1.23, 2.46]; P for trend = .002) in a multivariable model also including FGT volume (OR, 1.39 [95% CI: 0.97, 1.98]) and fat volume (OR, 1.46 [95% CI: 1.04, 2.06]). The association of high BPE extent with increased odds of breast cancer was similar for premenopausal and postmenopausal women (ORs, 1.75 and 1.83, respectively; interaction P = .73). Conclusion Objectively measured BPE at breast MRI is associated with increased breast cancer odds for both premenopausal and postmenopausal women. Clinical trial registration no. NCT02301767 © RSNA, 2023 Supplemental material is available for this article. See also the editorial by Bokacheva in this issue.

Breast MRI: False-Negative Results and Missed Opportunities.

Breast MRI is the most sensitive modality for the detection of breast cancer. However, false-negative cases may occur, in which the cancer is not visualized at MRI and is instead diagnosed with another imaging modality. The authors describe the causes of false-negative breast MRI results, which can be categorized broadly as secondary to perceptual errors or cognitive errors, or nonvisualization secondary to nonenhancement of the tumor. Tips and strategies to avoid these errors are discussed. Perceptual errors occur when an abnormality is not prospectively identified, yet the examination is technically adequate. Careful development of thorough search patterns is critical to avoid these errors. Cognitive errors occur when an abnormality is identified but misinterpreted or mischaracterized as benign. The radiologist may avoid these errors by utilizing all available prior examinations for comparison, viewing images in all planes to better assess the margins and shapes of abnormalities, and appropriately integrating all available information from the contrast-enhanced, T2-weighted, and T1-weighted images as well as the clinical history. Despite this, false-negative cases are inevitable, as certain subtypes of breast cancer, including ductal carcinoma in situ, invasive lobular carcinoma, and certain well-differentiated invasive cancers, may demonstrate little to no enhancement at MRI, owing to differences in angiogenesis and neovascularity. MRI is a valuable diagnostic tool in breast imaging. However, MRI should continue to be used as a complementary modality, with mammography and US, in the detection of breast cancer. ©RSNA, 2021.

Association of breast cancer with MRI background parenchymal enhancement: the IMAGINE case-control study.

BACKGROUND: Background parenchymal enhancement (BPE) on breast magnetic resonance imaging (MRI) may be associated with breast cancer risk, but previous studies of the association are equivocal and limited by incomplete blinding of BPE assessment. In this study, we evaluated the association between BPE and breast cancer based on fully blinded assessments of BPE in the unaffected breast. METHODS: The Imaging and Epidemiology (IMAGINE) study is a multicenter breast cancer case-control study of women receiving diagnostic, screening, or follow-up breast MRI, recruited from three comprehensive cancer centers in the USA. Cases had a first diagnosis of unilateral breast cancer and controls had no history of or current breast cancer. A single board-certified breast radiologist with 12 years' experience, blinded to case-control status and clinical information, assessed the unaffected breast for BPE without view of the affected breast of cases (or the corresponding breast laterality of controls). The association between BPE and breast cancer was estimated by multivariable logistic regression separately for premenopausal and postmenopausal women. RESULTS: The analytic dataset included 835 cases and 963 controls. Adjusting for fibroglandular tissue (breast density), age, race/ethnicity, BMI, parity, family history of breast cancer, BRCA1/BRCA2 mutations, and other confounders, moderate/marked BPE (vs minimal/mild BPE) was associated with breast cancer among premenopausal women [odds ratio (OR) 1.49, 95% CI 1.05-2.11; p = 0.02]. Among postmenopausal women, mild/moderate/marked vs minimal BPE had a similar, but statistically non-significant, association with breast cancer (OR 1.45, 95% CI 0.92-2.27; p = 0.1). CONCLUSIONS: BPE is associated with breast cancer in premenopausal women, and possibly postmenopausal women, after adjustment for breast density and confounders. Our results suggest that BPE should be evaluated alongside breast density for inclusion in models predicting breast cancer risk.

Five Consecutive Years of Screening with Digital Breast Tomosynthesis: Outcomes by Screening Year and Round.

Background Limited data exist beyond prevalence rounds of digital breast tomosynthesis (DBT) screening. Purpose To compare DBT outcomes over multiple years and rounds to outcomes of digital mammography (DM) screening. Materials and Methods Retrospective analysis included 1 year of DM and 5 years of DBT screening (September 2011 to September 2016); 67 350 examinations were performed in 29 310 women. Recall rate (RR) percentage, cancer detection rate (CDR) per 1000 women screened, false-negative rate per 1000 women screened, positive predictive value of recall (PPV1) percentage, positive predictive value of biopsies performed percentage, sensitivity, and specificity were calculated. Cancers diagnosed within 1 year of screening were captured by means of linkage to state cancer registry, and biologic characteristics were grouped by prognostic factors. Performance trends across DBT rounds were compared with those from DM rounds by using logistic regression to account for examinations in the same woman. Analyses were adjusted for age, race, breast density, baseline examination, and reader. Results There were 56 839 DBT and 10 511 DM examinations. The mean patient age (± standard deviation) was 56 years ±11 for the entire cohort, 55 years ±11 for the DBT group, and 57 years ±11 for the DM group. RRs were significantly lower for the DBT group (8.0%, 4522 of 56 839; 95% confidence interval [CI]: 7.7, 8.2) than for the DM group (10.4%, 1094 of 10 511; 95% CI: 9.8, 11.0) (P < .001). CDRs were higher with DBT (6.0 per 1000 women screened; 95% CI: 5.4, 6.7 per 1000 women screened; 340 of 56 839) than with DM (5.1 per 1000 women screened; 95% CI: 3.9, 6.6 per 1000 women screened; 54 of 10 511) (P = .25), but this difference was not statistically significant. Both RR and CDR remained improved compared with DM for 5 years of DBT at the population level. False-negative rates were slightly lower for DBT (0.6 per 1000 women screened; 95% CI: 0.4, 0.8 per 1000 women screened; 33 of 56 839) than DM (0.9 per 1000 women screened; 0.4, 1.6 per 1000 women screened; nine of 10 511) overall (P = .30), but the difference was not statistically significant. In adjusted analyses, RR, biopsy recommendation rates, and PPV1 were improved for DBT versus DM (P ≤ .001). Compared with DM, a higher proportion of DBT-detected cancers were invasive (70% [238 of 340] vs 68.5% [37 of 54]) and had poor prognoses characteristics (32.6% [76 of 233] vs 25.0% [nine of 36]). Conclusion Favorable outcomes with digital breast tomosynthesis screening were sustained over multiple years and rounds. Digital breast tomosynthesis screening was associated with detection of a higher proportion of poor-prognosis cancers than was digital mammography. © RSNA, 2020 Online supplemental material is available for this article. See also the editorial by Moy and Heller in this issue.

Digital Breast Tomosynthesis: Concepts and Clinical Practice.

Digital breast tomosynthesis (DBT) is emerging as the standard of care for breast imaging based on improvements in both screening and diagnostic imaging outcomes. The additional information obtained from the tomosynthesis acquisition decreases the confounding effect of overlapping tissue, allowing for improved lesion detection, characterization, and localization. In addition, the quasi three-dimensional information obtained from the reconstructed DBT data set allows a more efficient imaging work-up than imaging with two-dimensional full-field digital mammography alone. Herein, the authors review the benefits of DBT imaging in screening and diagnostic breast imaging.

Breast Cancer Conspicuity on Simultaneously Acquired Digital Mammographic Images versus Digital Breast Tomosynthesis Images.

Background Digital breast tomosynthesis (DBT) has been shown to improve screening outcomes compared with digital mammography (DM) alone. However, little is known about differences in breast cancer conspicuity between DM and DBT or by mammographic view. Purpose To compare conspicuity of breast cancers at DM versus DBT and by mammographic view, craniocaudal (CC) versus mediolateral oblique (MLO). Materials and Methods Lesion conspicuity was graded by three readers by using a 0-5 numerical scale on both DM and DBT images from combined DM and DBT studies for 197 consecutive screening-detected cancers in women (mean age, 60.4 years ± 11.1 [standard deviation]) from October 1, 2011, through December 31, 2014. Intermodality (ie, DM vs DBT) and intramodality (ie, CC vs MLO) analyses were performed. For intramodality analyses, conspicuity was analyzed by view, CC versus MLO, within the same modality. Conspicuity grades were dichotomized into low (scores 0-3) and high (scores 4 and 5) conspicuity. This binary result was assessed by using a generalized linear mixed-effects model with logit link function, random-effect intercept for reader, and compound symmetry covariance structure for lesion. Results Cancers were more likely to be high conspicuity at DBT than at DM (odds ratio [OR], 2.4; 95% confidence interval [CI]: 1.9, 3.0; P < .01). At both DM and DBT, cancers were more likely to be high conspicuity at the CC than the MLO view (DM vs DBT OR, 1.6 [95% CI: 1.3, 1.9] vs 1.7 [95% CI: 1.3, 2.1], respectively; P < .01 for both). Cancers seen at one view only were more often detected at CC than MLO for both DM and DBT (DM vs DBT OR, 1.6 [95% CI: 1.2, 2.0] vs 3.6 [95% CI: 1.9, 7.0], respectively; P < .01.). Conclusion Cancers were more conspicuous at digital breast tomosynthesis than at digital mammography. Cancers may only be detected at one of two views, and they are more likely to be seen at the craniocaudal view. © RSNA, 2019.

BI-RADS Category 3 Comparison: Probably Benign Category after Recall from Screening before and after Implementation of Digital Breast Tomosynthesis.

Purpose To evaluate Breast Imaging Reporting and Data System (BI-RADS) category 3 assessment at diagnostic examination after recall from screening in a large urban population after implementation of digital breast tomosynthesis (DBT) by focusing both on overall use and use stratified by recalled finding type and outcome at 2 years. Materials and Methods This was an intuitional review board-approved and HIPAA-compliant retrospective review of 10 728 digital mammography (DM) examinations from September 1, 2010, to August 30, 2011, and 15 571 screening DBT examinations from October 1, 2011, to February 28, 2013. The recall populations for DM and DBT were 1112 of 10 728 (10.4% of women screened) and 1366 of 15 571 (8.8% of women screened), respectively. Recall examinations were classified according to finding type: calcifications, asymmetry or focal asymmetry, mass, and architectural distortion. Differences between groups were compared by using the χ2 test. Results Although there was no significant change in the utilization rate of BI-RADS category 3 in those patients screened with DM compared with DBT (168 of 10 728, 1.6% for DM vs 206 of 15 571, 1.3% for DBT; P = .102), there was a mean overall reduction of 2.4 women per 1000 (95% confidence interval [CI]: -0.5, 5.4) recommended for short-term follow-up. Lesion types given a BI-RADS category 3 assessment after diagnostic work-up did not change. The distribution of recalled finding types significantly changed with DBT, with increased recall examinations for architectural distortion and mass (P < .001) and decreased recall examinations for asymmetries (P ≤ .001). There was no change in recall examinations for calcifications (P = .977). Conclusion Screening with DBT did not significantly change the utilization rate of BI-RADS category 3 classification; however, the overall number of patients recommended for short-interval follow-up decreased by a mean of 2.4 women per 1000 (95% CI: -0.5, 5.4). © RSNA, 2017 Online supplemental material is available for this article.

Imaging With Synthesized 2D Mammography: Differences, Advantages, and Pitfalls Compared With Digital Mammography.

OBJECTIVE: Synthesized 2D (s2D) mammography is rapidly replacing digital mammography in breast imaging with digital breast tomosynthesis (DBT) to reduce radiation dose and maintain screening outcomes. We illustrate variations in the appearance of s2D and digital mammograms to aid in implementation of this technology. CONCLUSION: Despite subjective differences in the appearance of s2D and digital mammograms, early outcomes of screening using s2D mammography and DBT are not inferior to those achieved with digital mammography and DBT. Understanding these variations may aid in implementing this technique and improving patient outcomes.

Fully Automated Quantitative Estimation of Volumetric Breast Density from Digital Breast Tomosynthesis Images: Preliminary Results and Comparison with Digital Mammography and MR Imaging.

PURPOSE: To assess a fully automated method for volumetric breast density (VBD) estimation in digital breast tomosynthesis (DBT) and to compare the findings with those of full-field digital mammography (FFDM) and magnetic resonance (MR) imaging. MATERIALS AND METHODS: Bilateral DBT images, FFDM images, and sagittal breast MR images were retrospectively collected from 68 women who underwent breast cancer screening from October 2011 to September 2012 with institutional review board-approved, HIPAA-compliant protocols. A fully automated computer algorithm was developed for quantitative estimation of VBD from DBT images. FFDM images were processed with U.S. Food and Drug Administration-cleared software, and the MR images were processed with a previously validated automated algorithm to obtain corresponding VBD estimates. Pearson correlation and analysis of variance with Tukey-Kramer post hoc correction were used to compare the multimodality VBD estimates. RESULTS: Estimates of VBD from DBT were significantly correlated with FFDM-based and MR imaging-based estimates with r = 0.83 (95% confidence interval [CI]: 0.74, 0.90) and r = 0.88 (95% CI: 0.82, 0.93), respectively (P < .001). The corresponding correlation between FFDM and MR imaging was r = 0.84 (95% CI: 0.76, 0.90). However, statistically significant differences after post hoc correction (α = 0.05) were found among VBD estimates from FFDM (mean ± standard deviation, 11.1% ± 7.0) relative to MR imaging (16.6% ± 11.2) and DBT (19.8% ± 16.2). Differences between VDB estimates from DBT and MR imaging were not significant (P = .26). CONCLUSION: Fully automated VBD estimates from DBT, FFDM, and MR imaging are strongly correlated but show statistically significant differences. Therefore, absolute differences in VBD between FFDM, DBT, and MR imaging should be considered in breast cancer risk assessment.

Implementation of Synthesized Two-dimensional Mammography in a Population-based Digital Breast Tomosynthesis Screening Program.

Purpose To evaluate the early implementation of synthesized two-dimensional (s2D) mammography in a population screened entirely with s2D and digital breast tomosynthesis (DBT) (referred to as s2D/DBT) and compare recall rates and cancer detection rates to historic outcomes of digital mammography combined with DBT (referred to as digital mammography/DBT) screening. Materials and Methods This was an institutional review board-approved and HIPAA-compliant retrospective interpretation of prospectively acquired data with waiver of informed consent. Compared were recall rates, biopsy rates, cancer detection rates, and radiation dose for 15 571 women screened with digital mammography/DBT from October 1, 2011, to February 28, 2013, and 5366 women screened with s2D/DBT from January 7, 2015, to June 30, 2015. Two-sample z tests of equal proportions were used to determine statistical significance. Results Recall rate for s2D/DBT versus digital mammography/DBT was 7.1% versus 8.8%, respectively (P < .001). Biopsy rate for s2D/DBT versus digital mammography/DBT decreased (1.3% vs 2.0%, respectively; P = .001). There was no significant difference in cancer detection rate for s2D/DBT versus digital mammography/DBT (5.03 of 1000 vs 5.45 of 1000, respectively; P = .72). The average glandular dose was 39% lower in s2D/DBT versus digital mammography/DBT (4.88 mGy vs 7.97 mGy, respectively; P < .001). Conclusion Screening with s2D/DBT in a large urban practice resulted in similar outcomes compared with digital mammography/DBT imaging. Screening with s2D/DBT allowed for the benefits of DBT with a decrease in radiation dose compared with digital mammography/DBT. © RSNA, 2016 An earlier incorrect version of this article appeared online. This article was corrected on August 11, 2016.

Strategies to Increase Cancer Detection: Review of True-Positive and False-Negative Results at Digital Breast Tomosynthesis Screening.

Digital breast tomosynthesis (DBT) represents a valuable addition to breast cancer screening by decreasing recall rates while increasing cancer detection rates. The increased accuracy achieved with DBT is due to the quasi-three-dimensional format of the reconstructed images and the ability to "scroll through" breast tissue in the reconstructed images, thereby reducing the effect of tissue superimposition found with conventional planar digital mammography. The margins of both benign and malignant lesions are more conspicuous at DBT, which allows improved lesion characterization, increased reader confidence, and improved screening outcomes. However, even with the improvements in accuracy achieved with DBT, there remain differences in breast cancer conspicuity by mammographic view. Early data suggest that breast cancers may be more conspicuous on craniocaudal (CC) views than on mediolateral oblique (MLO) views. While some very laterally located breast cancers may be visualized on only the MLO view, the increased conspicuity of cancers on the CC view compared with the MLO view suggests that DBT screening should be performed with two-view imaging. Even with the improved conspicuity of lesions at DBT, there may still be false-negative studies. Subtle lesions seen on only one view may be discounted, and dense and/or complex tissue patterns may make some cancers occult or extremely difficult to detect. Therefore, radiologists should be cognizant of both perceptual and cognitive errors to avoid potential pitfalls in lesion detection and characterization. ©RSNA, 2016 Online supplemental material is available for this article.

Quantitative assessment of background parenchymal enhancement in breast MRI predicts response to risk-reducing salpingo-oophorectomy: preliminary evaluation in a cohort of BRCA1/2 mutation carriers.

INTRODUCTION: We present a fully automated method for deriving quantitative measures of background parenchymal enhancement (BPE) from breast dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) and perform a preliminary evaluation of these measures to assess the effect of risk-reducing salpingo-oophorectomy (RRSO) in a cohort of breast cancer susceptibility gene 1/2 (BRCA1/2) mutation carriers. METHODS: Breast DCE-MRI data from 50 BRCA1/2 carriers were retrospectively analyzed in compliance with the Health Insurance Portability and Accountability Act and with institutional review board approval. Both the absolute (| |) and relative (%) measures of BPE and fibroglandular tissue (FGT) were computed from the MRI scans acquired before and after RRSO. These pre-RRSO and post-RRSO measures were compared using paired Student's t test. The area under the curve (AUC) of the receiver operating characteristic (ROC) was used to evaluate the performance of relative changes in the BPE and FGT measures in predicting breast cancer that developed in these women after the RRSO surgery. RESULTS: For the 44 women who did not develop breast cancer after RRSO, the absolute volume of BPE and FGT had a significant decrease (P < 0.05) post-RRSO, whereas for the 6 women who developed breast cancer, there were no significant changes in these measures. Higher values in all BPE and FGT measures were also observed post-RRSO for the women who developed breast cancer, compared with women who did not. Relative changes in BPE percentage were most predictive of women who developed breast cancer after RRSO (P < 0.05), whereas combining BPE percentage and |FGT| yielded an AUC of 0.80, higher than BPE percentage (AUC = 0.78) or |FGT| (AUC = 0.66) alone (both P > 0.02). CONCLUSIONS: Quantitative measures of BPE and FGT are different before and after RRSO, and their relative changes are associated with prediction of developing breast cancer, potentially indicative of women who are more susceptible to develop breast cancer after RRSO in BRCA1/2 mutation carriers.

Deformable registration for quantifying longitudinal tumor changes during neoadjuvant chemotherapy.

PURPOSE: To evaluate DRAMMS, an attribute-based deformable registration algorithm, compared to other intensity-based algorithms, for longitudinal breast MRI registration, and to show its applicability in quantifying tumor changes over the course of neoadjuvant chemotherapy. METHODS: Breast magnetic resonance images from 14 women undergoing neoadjuvant chemotherapy were analyzed. The accuracy of DRAMMS versus five intensity-based deformable registration methods was evaluated based on 2,380 landmarks independently annotated by two experts, for the entire image volume, different image subregions, and patient subgroups. The registration method with the smallest landmark error was used to quantify tumor changes, by calculating the Jacobian determinant maps of the registration deformation. RESULTS: DRAMMS had the smallest landmark errors (6.05 ± 4.86 mm), followed by the intensity-based methods CC-FFD (8.07 ± 3.86 mm), NMI-FFD (8.21 ± 3.81 mm), SSD-FFD (9.46 ± 4.55 mm), Demons (10.76 ± 6.01 mm), and Diffeomorphic Demons (10.82 ± 6.11 mm). Results show that registration accuracy also depends on tumor versus normal tissue regions and different patient subgroups. CONCLUSIONS: The DRAMMS deformable registration method, driven by attribute-matching and mutual-saliency, can register longitudinal breast magnetic resonance images with a higher accuracy than several intensity-matching methods included in this article. As such, it could be valuable for more accurately quantifying heterogeneous tumor changes as a marker of response to treatment.

Digital breast tomosynthesis: lessons learned from early clinical implementation.

The limitations of mammography are well known and are partly related to the fact that with conventional imaging, the three-dimensional volume of the breast is imaged and presented in a two-dimensional format. Because normal breast tissue is similar in x-ray attenuation to some breast cancers, clinically relevant malignancies may be obscured by normal overlapping tissue. In addition, complex areas of normal tissue may be perceived as suspicious. The limitations of two-dimensional breast imaging lead to low sensitivity in detecting some cancers and high false-positive recall rates. Although mammographic screening has been shown to reduce breast cancer deaths by approximately 30%, controversy exists over when and how often screening mammography should occur. Digital breast tomosynthesis (DBT) is rapidly being implemented in breast imaging clinics around the world as early clinical data demonstrate that it may address some of the limitations of conventional mammography. With DBT, multiple low-dose x-ray images are acquired in an arc and reconstructed to create a three-dimensional image, thus minimizing the impact of overlapping breast tissue and improving lesion conspicuity. Early studies of screening DBT have shown decreased false-positive callback rates and increased rates of cancer detection (particularly for invasive cancers), resulting in increased sensitivity and specificity. In our clinical practice, we have completed more than 2 years of using two-view digital mammography combined with two-view DBT for all screening and select diagnostic imaging examinations (over 25,000 patients). Our experience, combined with previously published data, demonstrates that the combined use of DBT and digital mammography is associated with improved outcomes for screening and diagnostic imaging. Online supplemental material is available for this article.

Feasibility and Accuracy of Ultrasound-Guided Core Needle Biopsy for Nipple Lesions: A Pilot Study.

BACKGROUND: Due to the superficial location, suspicious findings of the nipple-areolar complex (NAC) are not amenable to stereotactic or MRI-guided sampling and have historically necessitated surgical biopsy or skin-punch biopsy. There are limited reports of US-guided core biopsy of the nipple (US-CBN). OBJECTIVE: We report our nearly 3-year pilot experience with US-CBN at an academic breast imaging center. METHODS: An institutional review board-exempt and HIPAA-compliant retrospective review was performed. We assessed patient demographics, breast imaging characteristics, procedural data, pathology, and outcomes. RESULTS: Nine female patients aged 27 to 64 underwent US-CBN from January 2021 to October 2023. Initial imaging abnormalities included abnormal MRI enhancement, mammographic calcifications, and sonographic masses. After initial or second-look US, all imaging findings had sonographic correlates for biopsy specimens, the majority of which were sonographic masses (8/9). US-CBN was performed by 6 breast radiologists using a variety of devices. All biopsy specimen results were concordant with sonographic abnormalities, although 1 was considered discordant from the initial abnormality seen on MRI. There were no complications, and discomfort during the procedure was well-treated. Two patients (22%, 2/9) were diagnosed with malignancy. CONCLUSION: This pilot study demonstrated that US-CBN can be performed by a breast radiologist for definitive diagnosis of suspicious nipple abnormalities seen on breast imaging, avoiding surgery, and maintaining nipple integrity. In our population, 22% (2/9) of US-CBNs revealed malignancy.

Behavioral Interventions to Improve Breast Cancer Screening Outreach: Two Randomized Clinical Trials.

Importance: Despite public health efforts, breast cancer screening rates remain below national goals. Objective: To evaluate whether bulk ordering, text messaging, and clinician endorsement increase breast cancer screening rates. Design, Setting, and Participants: Two concurrent, pragmatic, randomized clinical trials, each with a 2-by-2 factorial design, were conducted between October 25, 2021, and April 25, 2022, in 2 primary care regions of an academic health system. The trials included women aged 40 to 74 years with at least 1 primary care visit in the past 2 years who were eligible for breast cancer screening. Interventions: Patients in trial A were randomized in a 1:1 ratio to receive a signed bulk order for mammogram or no order; in a factorial design, patients were concurrently randomized in a 1:1 ratio to receive or not receive text message reminders. Patients in trial B were randomized in a 1:1 ratio to receive a message signed by their primary care clinician (clinician endorsement) or from the organization (standard messaging); in a factorial design, patients were concurrently randomized in a 1:1 ratio to receive or not receive text message reminders. Main Outcomes and Measures: The primary outcome was the proportion of patients who completed a screening mammogram within 3 months. Results: Among 24 632 patients included, the mean (SD) age was 60.4 (7.5) years. In trial A, at 3 months, 15.4% (95% CI, 14.6%-16.1%) of patients in the bulk order arm and 12.7% (95% CI, 12.1%-13.4%) in the no order arm completed a mammogram, showing a significant increase (absolute difference, 2.7%; 95% CI, 1.6%-3.6%; P < .001). In the text messaging comparison arms, 15.1% (95% CI, 14.3%-15.8%) of patients receiving a text message completed a mammogram compared with 13.0% (95% CI, 12.4%-13.7%) of those in the no text messaging arm, a significant increase (absolute difference of 2.1%; 95% CI, 1.0%-3.0%; P < .001). In trial B, at 3 months, 12.5% (95% CI, 11.3%-13.7%) of patients in the clinician endorsement arm completed a mammogram compared with 11.4% (95% CI, 10.3%-12.5%) of those in the standard messaging arm, which was not significant (absolute difference, 1.1%; 95% CI, -0.5% to 2.7%; P = .18). In the text messaging comparison arms, 13.2% (95% CI, 12.0%-14.4%) of patients receiving a text message completed a mammogram compared with 10.7% (95% CI, 9.7%-11.8%) of those in the no text messaging arm, a significant increase (absolute difference, 2.5%; 95% CI, 0.8%-4.0%; P = .003). Conclusions and Relevance: These findings show that text messaging women after initial breast cancer screening outreach via either electronic portal or mailings, as well as bulk ordering with or without text messaging, can increase mammogram completion rates. Trial Registration: ClinicalTrials.gov Identifier: NCT05089903.

ACR Appropriateness Criteria® Imaging of Invasive Breast Cancer.

As the proportion of women diagnosed with invasive breast cancer increases, the role of imaging for staging and surveillance purposes should be determined based on evidence-based guidelines. It is important to understand the indications for extent of disease evaluation and staging, as unnecessary imaging can delay care and even result in adverse outcomes. In asymptomatic patients that received treatment for curative intent, there is no role for imaging to screen for distant recurrence. Routine surveillance with an annual 2-D mammogram and/or tomosynthesis is recommended to detect an in-breast recurrence or a new primary breast cancer in women with a history of breast cancer, and MRI is increasingly used as an additional screening tool in this population, especially in women with dense breasts. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Overdose prevention centers: Innovative strategy or federal law violation?

Among the list of identified strategies to address substance use disorder, none is as controversial as overdose prevention centers. Also known as supervised injection sites, these centers provide clean needles, food, basic hygiene, medical care, referrals to treatment, and overdose reversal medication to people who use drugs, all in a supervised setting. Proponents of these centers argue they save lives and money, while opponents claim they perpetuate and normalize illegal drug use. Furthermore, the very existence of overdose prevention centers in cities across the United States is a blatant violation of an existing federal law, known as the "Crack House Statute." The future of overdose prevention centers in this country is murky at best, though a decision from the Biden Administration is expected in the coming months that may offer some guidance as to whether this particular harm reduction tool will maintain the unique distinction of being both an innovative approach to tackling the opioid epidemic while at the same time violating federal law.

Pervasiveness of Open Journal Invitations Across Radiology Specialties.

This study examines the patterns of faculty solicitations by open-access (OA) publishers in radiology. The purpose of the research is to determine the factors that predict the likelihood of receiving such solicitations. We recruited 6 faculty members from 7 subspecialties in radiology to collect emails from OA journals for 2 weeks. We assessed the number of publications by each faculty member in 2022 and 2023, the previous 5 years, and entire career in PubMed. For each email, the solicitation was categorized for article submission, article review, and editorial board membership. An invitation to submit a manuscript was the most common type of solicitation received, followed by editorial boards and reviewer invites. Faculty with more than 10 indexed articles in PubMed since January 2022 were significantly more likely to receive article solicitations than those with 10 or fewer publications. Additionally, scholars with more than 40 articles since 2018 were significantly more likely to receive more than 10 article solicitations. Full professors were significantly more likely to receive solicitations to serve on editorial boards. A multivariate linear regression model predicted that publications since 2022 had the highest predictive value for the number of article solicitations and total solicitations. This study provides insight into the patterns of mass communication and various solicitations by OA publishers in radiology. The study highlights the importance of publication productivity as a predictor of article and total email solicitations and of professorial rank for editorial board invitations.