Multimodality Imaging of Benign and Malignant Diseases of the Nipple-Areolar Complex.

The nipple-areolar complex (NAC), a unique anatomic structure of the breast, encompasses the terminal intramammary ducts and skin appendages. Several benign and malignant diseases can arise within the NAC. As several conditions have overlapping symptoms and imaging findings, understanding the distinctive nipple anatomy, as well as the clinical and imaging features of each NAC disease process, is essential. A multimodality imaging approach is optimal in the presence or absence of clinical symptoms. The authors review the ductal anatomy and anomalies, including congenital abnormalities and nipple retraction. They then discuss the causes of nipple discharge and highlight best practices for the imaging workup of pathologic nipple discharge, a common condition that can pose a diagnostic challenge and may be the presenting symptom of breast cancer. The imaging modalities used to evaluate and differentiate benign conditions (eg, dermatologic conditions, epidermal inclusion cyst, mammary ductal ectasia, periductal mastitis, and nonpuerperal abscess), benign tumors (eg, papilloma, nipple adenoma, and syringomatous tumor of the nipple), and malignant conditions (eg, breast cancer and Paget disease of the breast) are reviewed. Breast MRI is the current preferred imaging modality used to evaluate for NAC involvement by breast cancer and select suitable candidates for nipple-sparing mastectomy. Different biopsy techniques (US -guided biopsy and stereotactic biopsy) for sampling NAC masses and calcifications are described. This multimodality imaging approach ensures an accurate diagnosis, enabling optimal clinical management and patient outcomes. ©RSNA, 2024 Test Your Knowledge questions for this article are available in the supplemental material.

Triple-Negative Breast Cancer: Histopathologic Features, Genomics, and Treatment.

Triple-negative breast cancer (TNBC) is a heterogeneous and aggressive group of tumors that are defined by the absence of estrogen and progesterone receptors and lack of ERBB2 (formerly HER2 or HER2/neu) overexpression. TNBC accounts for 8%-13% of breast cancers. In addition, it accounts for a higher proportion of breast cancers in younger women compared with those in older women, and it disproportionately affects non-Hispanic Black women. TNBC has high metastatic potential, and the risk of recurrence is highest during the 5 years after it is diagnosed. TNBC exhibits benign morphologic imaging features more frequently than do other breast cancer subtypes. Mammography can be suboptimal for early detection of TNBC owing to factors that include the fast growth of this cancer, increased mammographic density in young women, and lack of the typical features of malignancy at imaging. US is superior to mammography for TNBC detection, but benign-appearing features can lead to misdiagnosis. Breast MRI is the most sensitive modality for TNBC detection. Most cases of TNBC are treated with neoadjuvant chemotherapy, followed by surgery and radiation. MRI is the modality of choice for evaluating the response to neoadjuvant chemotherapy. Survival rates for individuals with TNBC are lower than those for persons with hormone receptor-positive and human epidermal growth factor receptor 2-positive cancers. The 5-year survival rates for patients with localized, regional, and distant disease at diagnosis are 91.3%, 65.8%, and 12.0%, respectively. The early success of immunotherapy has raised hope regarding the development of personalized strategies to treat TNBC. Imaging and tumor biomarkers are likely to play a crucial role in the prediction of TNBC treatment response and TNBC patient survival in the future. ©RSNA, 2023 Quiz questions for this article are available in the supplemental material.

The Wire and Beyond: Recent Advances in Breast Imaging Preoperative Needle Localization.

Many patients with breast cancer are candidates for breast conservation therapy. This group includes individuals with small nonpalpable tumors detected at screening mammography and those with sufficient tumor shrinkage after neoadjuvant chemotherapy. Breast conservation surgery often requires the use of an imaging-guided preoperative localization procedure, during which a device is placed within or adjacent to the target lesion to guide the surgeon intraoperatively. For decades, wire localization has been the standard for preoperative localization in breast imaging. With this method, a wire is placed in the breast percutaneously, with the distal wire segment positioned adjacent to the abnormality and the proximal wire segment remaining outside the breast. Because of the external component of the wire, the patient must be compliant, and care must be taken to not disturb the wire's position before surgery. Scheduling flexibility is also limited because the wire localization must be performed on the same day as the subsequent surgery. More recently, the available options for performing preoperative localization have expanded greatly and now include the use of nonwire devices such as radioactive and magnetic seeds, radar reflectors, and radiofrequency identification tags. Nonwire localization devices can be placed days in advance of the surgery, at the patient's convenience, to avoid wire-related challenges and complications. They are placed percutaneously within or adjacent to the target breast lesion and detected intraoperatively by using a probe outside the breast.©RSNA, 2019.

Reduction of False-Positive Markings on Mammograms: a Retrospective Comparison Study Using an Artificial Intelligence-Based CAD.

The aim was to determine whether an artificial intelligence (AI)-based, computer-aided detection (CAD) software can be used to reduce false positive per image (FPPI) on mammograms as compared to an FDA-approved conventional CAD. A retrospective study was performed on a set of 250 full-field digital mammograms between January 1, 2013, and March 31, 2013, and the number of marked regions of interest of two different systems was compared for sensitivity and specificity in cancer detection. The count of false-positive marks per image (FPPI) of the two systems was also evaluated as well as the number of cases that were completely mark-free. All results showed statistically significant reductions in false marks with the use of AI-CAD vs CAD (confidence interval = 95%) with no reduction in sensitivity. There is an overall 69% reduction in FPPI using the AI-based CAD as compared to CAD, consisting of 83% reduction in FPPI for calcifications and 56% reduction for masses. Almost half (48%) of cases showed no AI-CAD markings while only 17% show no conventional CAD marks. There was a significant reduction in FPPI with AI-CAD as compared to CAD for both masses and calcifications at all tissue densities. A 69% decrease in FPPI could result in a 17% decrease in radiologist reading time per case based on prior literature of CAD reading times. Additionally, decreasing false-positive recalls in screening mammography has many direct social and economic benefits.

Overutilization of Health Care Resources for Breast Pain.

OBJECTIVE: The objective of this study is to analyze the incidence of women with breast pain who present to an imaging center and assess the imaging findings, outcomes, and workup costs at breast imaging centers affiliated with one institution. MATERIALS AND METHODS: Demographic characteristics of and imaging findings for female patients presenting with breast pain at three community breast imaging centers between January 1, 2014, and December 31, 2014, were reviewed. Patients who were pregnant, were lactating, had a history of breast cancer, or presented with palpable nipple or skin findings were excluded. RESULTS: A total of 799 patients met the study criteria. Pain was diffuse in 30%, was focal in 30%, and was not localized in 40%. Of the 799 patients with breast pain, 790 (99%) presented for a diagnostic evaluation; 759 (95%) of these evaluated patients had negative findings. A benign sonographic correlate was detected in the area of pain in 5% of patients (39/799). One patient had a single cancer detected in the contralateral asymptomatic breast. When correlations between breast pain and the presence of cancer in the study patients were compared with the concurrent cancer detection rate in the screening population (5.5 cases per 1000 examinations performed), breast pain was not found to be a sign of breast cancer (p = 0.027). Patients younger than 40 years (316/799) underwent a total of 454 workup studies for breast pain; all findings were benign, and the cost of these studies was $87,322. Patients 40 years or older (483/799) underwent 745 workup studies, for a cost of $152,732. CONCLUSION: Breast pain represents an area of overutilization of health care resources. For female patients who present with pure breast pain, breast imaging centers should consider the following imaging protocols and education for referring physicians: an annual screening mammogram should be recommended for women 40 years or older, and reassurance without imaging should be offered to patients younger than 40 years.

Twenty-first-Century Skills: Teaching Empathy to Health Professions Students.

A key component of therapeutic relationships is the ability of medical professionals to empathize with patients, as research indicates a link between a healthcare worker's ability to empathize with patients and improved patient outcomes. Empathy - the ability to perceive the meaning and feelings of another and to communicate those feelings to others - may be an innate concept, but it is shaped through behaviours and experiences. It is imperative, then, that post-secondary students entering the medical field be taught to develop empathy in order to facilitate positive patient outcomes. Embedding empathy-based education in the curriculum of medical, nursing, and allied health programs early in the course of study can help students understand the patient's perspective and facilitate positive therapeutic relationships early in students' professional careers. The shift from traditional teaching and learning styles to online learning has created deficiencies such as gaps in communication, empathy, and the development of emotional intelligence. To address these gaps, new and innovative ways to teach empathy, such as simulation, can be employed.

Comparing Breast Hemangiomas to Breast Angiosarcomas: An Imaging Based Review.

Vascular tumors of the breast are rare, and most can be classified as either hemangiomas or angiosarcomas. Breast hemangiomas are benign vascular tumors that are often found incidentally at pathologic examination. Breast hemangiomas may mimic low grade angiosarcomas, which are malignant vascular tumors. This article illustrates the imaging characteristics of breast hemangiomas and breast angiosarcomas across multiple imaging modalities.

Impact of COVID-19 on healthcare system in India: A systematic review.

Despite an extensive healthcare system in India, the COVID-19 Pandemic created havoc upon the existing Indian healthcare system by disrupting the supply of essential healthcare services to patients. It has also highlighted the significant-quality discrepancies of healthcare facilities between the rural-urban areas and between public and private healthcare providers. The not so advanced healthcare system of India was exposed through the lack of oxygen and essential drugs required for the treatment of COVID-19. Additionally, during the pandemic period there was a drastic decline in seeking non-COVID-19 disease related healthcare services. The objective of this systematic review is to determine whether COVID-19 has impacted the healthcare system in India.

Breast Angiosarcoma: Imaging Features With Histopathologic Correlation.

Breast angiosarcoma is a rare malignancy of endothelial origin that can be categorized as primary angiosarcoma (PAS) or secondary angiosarcoma (SAS) based on etiology. Primary angiosarcoma typically affects younger women with no known risk factors, whereas SAS of the breast typically develops in older women who have undergone breast cancer treatment. There are two types of SAS, one that develops in the setting of chronic lymphedema and one that develops as a radiation-associated neoplasm after breast-conserving therapy (BCT). Clinically, PAS often presents as a palpable mass that may be rapidly growing, whereas SAS presents with skin changes such as erythematous plaques or nodules or with areas of skin discoloration. Mammographically, the appearance of PAS can be nonspecific and may be obscured by the dense tissue that is characteristic of the young patient population it typically affects. Cases of mammographically occult PAS have been visible at US and MRI. Mammography and US have been found to be less sensitive than MRI for the diagnosis of secondary radiation-associated angiosarcoma. Angiosarcomas, both PAS and SAS, are graded, depending on degree of differentiation, as low, intermediate, or high grade. Endothelial markers such as ERG and CD31 immunohistochemical stains are used to support the diagnosis of angiosarcomas. In this article, we review the clinical presentation, imaging findings, associated histopathology, and treatment of primary and secondary breast angiosarcoma.

The Post-Operative Mammographic Appearance of Lymphovenous Bypass and Vascularized Lymph Node Transfer.

The postoperative mammographic imaging appearance related to lymphovenous bypass and vascularized lymph node transfer has not been described. It is important for breast imagers to become familiar with the expected appearance of surgical changes that can be seen in the follow up imaging of breast cancer survivors in order to create accurate reports and adjust imaging protocols to improve imaging quality and lessen patient discomfort as needed.

Responsive Web-based Breast Imaging Core Curriculum for International Radiology Residents with Self-Assessment: A Pilot Study.

RATIONALE AND OBJECTIVES: Lack of uniformity in radiology resident education is partially attributable to variable access to subspecialty education. Web-based courses improve standardization, but with growing emphasis on competency based education, more evaluation of their effectiveness is needed. We created a responsive web-based breast imaging curriculum for radiology residents including self-assessment and a satisfaction survey. MATERIALS AND METHODS: Two global academic institutions collaboratively developed a breast imaging curriculum to address radiology residents' educational needs. This virtual course comprised 11 video lectures, nine didactic (with attached pre-test and post-test assessments) and two case review sessions. In April 2020, this optional curriculum was made available to all 56 radiology residents in one residency program cluster in Singapore, to be accessed alongside the breast imaging rotation as a supplement. A voluntary anonymous satisfaction survey was provided upon completion. RESULTS: A total of 39 of the 56 radiology residents (70%) completed the course. For the average score of nine lectures (maximum score 5), there was a significant increase in mean pre and post - test scores (mean = 2.2, SD = 0.7), p < 0.001. The proportion of residents with improvement between the pre-test score and the post-test score ranged from 74% to 100% (mean, 84%). Thirty three of the 39 participants (85%) completed the satisfaction survey, and all agreed or strongly agreed that the curriculum increased their knowledge of breast imaging. CONCLUSION: This web based breast imaging curriculum supplement was viewed positively by participating residents and improved their self-assessed knowledge. Curriculum access could be expanded to improve global radiology education.

Fluid-filled breast: A unique clinical presentation of invasive micropapillary carcinoma.

Invasive micropapillary carcinoma is a rare variant of invasive ductal carcinoma of the breast. This variant has been described as clinically aggressive due to its high frequency of lymphovascular invasion, axillary nodal metastases, and a greater degree of loco-regional recurrence. Invasive micropapillary carcinoma can have a variety of imaging presentations, typically presenting as an irregular mass. This case report describes a unique presentation of invasive micropapillary carcinoma and illustrates the propensity of invasive micropapillary carcinoma to secrete fluid and have a lack of regional lymphadenopathy. The challenges of the accompanying diagnostic imaging-work up are discussed.

Transitioning to Practice: Getting up to Speed in Efficiency and Accuracy.

The transition from trainee to breast radiologist is challenging. The many new responsibilities that breast radiologists acquire while establishing themselves as clinicians may increase stress and anxiety. Taking inventory of existing knowledge and skills and addressing deficits toward the end of one's training can be beneficial. New breast radiologists should expect to be slower and gain proficiency in the first several years out of training. Having realistic expectations for oneself with respect to screening mammography interpretation and following up on the subsequent diagnostic imaging workup of screening callback examinations can increase competence and confidence. Familiarity with the available literature to guide management in the diagnostic setting can increase efficiency. Planning ahead for localizations and biopsies also allows for efficiency while alleviating anxiety. Ultimately, adapting to a new work environment using a collaborative approach with primary healthcare providers, pathologists, and surgeons while remembering to have mentors within and beyond the field of radiology allows for a more successful transition.

Ultrasound Evaluation of the Axilla in the Breast Imaging Setting.

ABSTRACT: Ultrasound evaluation of the axilla plays a critical role in the setting of newly diagnosed breast cancer as surgical management evolves toward more targeted axillary nodal resection. Regional nodal involvement by metastatic carcinoma is one of most important prognostic factors in breast cancer and guides local, regional, and systemic treatment. Ultrasound also evaluates response to neoadjuvant chemotherapy. This article will review ultrasound techniques and the anatomy and the morphology of axillary lymph nodes. Lymph node staging in breast cancer will also be discussed. Ultrasound-guided interventions and localizations and emerging technologies of elastography and contrast-enhanced ultrasound will be discussed. In addition, this article will discuss the role of ultrasound as it applies to management of the axilla since the American College of Surgeons Oncology Group Z011 and Z1071 trials. Finally, other causes of benign and malignant axillary lymphadenopathy, not related to breast cancer, are discussed.

Team Science: A Practical Approach to Starting Collaborative Projects.

A collaborative approach to treating patients is well taught in medical training. However, collaboration and team building in clinical and laboratory research may have been given less emphasis. More scientific discoveries are now being made with multidisciplinary teams, requiring a thoughtful approach in order to achieve research goals while mitigating potential conflicts. Specific steps for a successful team science project include building the team, assigning roles and responsibilities, allocating rules, and discussing authorship guidelines. Building a team involves bringing individuals together and developing a common research goal while establishing psychological safety for all members of the team. Clear assignment of roles and responsibilities avoids confusion and allows each member's contributions to be acknowledged. Allocating rules involves discussing how decisions in the team will be made, how data and knowledge sharing will occur, and how potential conflicts will be resolved. Discussing authorship at the start of the project ensures that the entire team knows what work must be completed for authorship to be obtained.

Mastalgia: Imaging Work-up Appropriateness.

RATIONALE AND OBJECTIVES: Radiologists frequently image women with the sole complaint of mastalgia (breast pain). We hypothesized that whereas the vast majority of women ultimately have no imaging explanation for their breast pain, a small percentage of patients may have a correlative imaging finding and confirm the current American College of Radiology Appropriateness Criteria recommendations. MATERIALS AND METHODS: In this Health Insurance Portability and Accountability Act (HIPAA)-compliant, institutional review board-approved retrospective review, we evaluated 236 women between the ages of 18 and 83 years who presented to our Breast Care Center in 2013 with the sole complaint of breast pain or tenderness. Patients' clinical presentation, diagnostic imaging work-up, and clinical and radiographic follow-up were documented. Outcomes of the diagnostic work-up were compared with the American College of Radiology Appropriateness Criteria recommendations. RESULTS: Of the 236 patients, 10 women had cyclical breast pain, 116 had noncyclical, nonfocal breast pain, and 110 had noncyclical, focal breast pain. No imaging correlates were discovered to explain the etiology of cyclical pain, supporting the American College of Radiology Appropriateness Criteria rating values. A definitive imaging correlate for breast pain was identified in seven women (3%) with noncyclical, focal pain, one of which was a cancer diagnosis (0.4%), which correlates with the American College of Radiology Appropriateness Criteria ratings. No imaging correlates were found in women with noncyclical, nonfocal pain, supporting the American College of Radiology Appropriateness Criteria ratings. CONCLUSION: There was no radiological imaging finding to explain the etiology of mastalgia in most women. Diagnostic imaging may be an appropriate diagnostic evaluation in patients with noncyclical, focal breast pain, supporting the American College of Radiology Appropriateness Criteria recommendations.

Spindle cell lesions of the breast: Multimodality imaging and clinical differentiation of pathologically similar neoplasms.

Spindle cell lesions of the breast comprise a wide-range of entities including reactive, benign and malignant proliferations. They can be pathologically challenging to differentiate as there is often immunohistochemical and morphologic similarities with characteristic spindle shaped cellular patterns. Radiological and pathological correlation is essential. Radiology detects, defines the size and extent, and assists in localizing the lesions. Pathology confirms the diagnosis and provides prognostic parameters. Familiarity with the clinicoradiological features of these diagnostically challenging lesions helps to establish an accurate pathological diagnosis and subsequent clinical decision making.

Phytopharmacological evaluation and anti-asthmatic activity of Ficus religiosa leaves.

OBJECTIVE: To discuss phytopharmacological potential and anti-asthmatic activity of Ficus religiosa (F. religiosa) (L.). METHODS: Fresh leaves of F. religiosa were obtained from Vastrapur Lake, Ahmedabad, and dried to obtain powder. Histamine and acetylcholine were used to guinea pigs to establish bronchospasm model. In in vivo study, the aqueous extract of F. religiosa leaves (AEFR) at doses of 150 and 300 mg/kg was administrated to guinea pigs, and the broncho-protective activity of AEFR was compared with aminophylline at 25 mg/kg. While in in vitro study, and 10 g/mL, 20 g/mL, 30 g/mL of AEFRL was administrated to guinea pigs, respectively, and mast cell stabilizing activity of AEFR was compared with ketotifen at 10 g/mL. RESULTS: In the in-vivo model, pre-treatment with aminophylline (25 mg/kg, ip.) could significantly delay the onset of histamine induced pre-convulsive dyspnea, compared with vehicle control. Administration of AEFRL (150 and 300 mg/kg, ip.) also produced significant effect on latency to develop histamine & acetylcholine induced pre-convulsive dyspnea. In the mast cell stabilizing model, AEFRL at 10, 20 and 30 µg/mL could significantly increase the number of intact cells. CONCLUSIONS: It can be concluded that AEFRL is effective on histamine & acetylcholine induced bronchospasm in guinea pigs. In addition, AEFRL can potentiate the number of intact cells in the mast cell stabilizing model.