Editorial Comment: Fostering Gender Diversity in the Radiology Workplace.

This Editorial Comment discusses the following AJR article: Beyond the Binary: Moving the Radiology Workforce Toward Gender Inclusion, From the AJR Special Series on DEI.

Variable Appearances of Ductal Carcinoma In Situ Calcifications on Digital Mammography, Synthesized Mammography, and Tomosynthesis: A Pictorial Essay.

This pictorial essay demonstrates the variable appearances of ductal carcinoma in situ on full-field digital mammography, synthesized mammography, and digital breast tomosynthesis. The spectrum of intercase and intracase variability suggests further refinement of reconstruction algorithms for synthesized mammography may be necessary to maximize early detection of ductal carcinoma in situ.

Incremental Role of Mammography in the Evaluation of Gynecomastia in Men Who Have Undergone Chest CT.

OBJECTIVE: The purpose of this study was to determine whether additional breast imaging is clinically valuable in the evaluation of patients with gynecomastia incidentally observed on CT of the chest. MATERIALS AND METHODS: In a retrospective analysis, 62 men were identified who had a mammographic diagnosis of gynecomastia and had also undergone CT within 8 months (median, 2 months). We compared the imaging findings of both modalities and correlated them with the clinical outcome. RESULTS: Gynecomastia was statistically significantly larger on mammograms than on CT images; however, there was a high level of concordance in morphologic features and distribution of gynecomastia between mammography and CT. In only one case was gynecomastia evident on mammographic but not CT images, owing to cachexia. Two of the 62 men had ductal carcinoma, which was obscured by gynecomastia. Both of these patients had symptoms suggesting malignancy. CONCLUSION: The appearance of gynecomastia on CT scans and mammograms was highly correlated. Mammography performed within 8 months of CT is unlikely to reveal cancer unless there is a suspicious clinical finding or a breast mass eccentric to the nipple. Men with clinical symptoms of gynecomastia do not need additional imaging with mammography to confirm the diagnosis if they have undergone recent cross-sectional imaging.

Breast cancer in male-to-female transsexuals: use of breast imaging for detection.

OBJECTIVE: The purposes of this article are to describe two cases of breast cancer in male-to-female transsexuals and to review eight cases previously reported in the literature. CONCLUSION: Breast cancer occurs in male-to-female transsexuals who receive high doses of exogenous estrogen and develop breast tissue histologically identical to that of a biologically female breast. This exposure to estrogen results in increased risk of breast cancer. The first patient described is a male-to-female transsexual with screening-detected ductal carcinoma in situ and a family history of breast cancer. The other patient is a male-to-female transsexual with invasive ductal carcinoma that was occult on diagnostic digital mammographic and ultrasound findings but visualized on digital breast tomosynthesis and breast MR images. The analysis of the eight previously reported cases showed that breast cancer in male-to-female transsexuals occurs at a younger age and is more frequently estrogen receptor negative than breast cancer in others born biologically male. Screening for breast cancer in male-to-female transsexuals should be undertaken for those with additional risk factors (e.g., family history, BRCA2 mutation, Klinefelter syndrome) and should be available to those who desire screening, preferably in a clinical trial.

Breast MRI for Extent of Disease: Association of Demographic Factors and Biopsy Compliance on Surgical Decisions in Patients with BI-RADS 4 and 5 Findings.

BACKGROUND: The decision to pursue bilateral mastectomy without pathological confirmation of additional preoperative MRI lesions is likely multifactorial. We investigated the association of demographic factors and biopsy compliance following preoperative breast MRI with changes in surgical management in patients with newly diagnosed breast cancer. METHODS: A retrospective review of BI-RADS 4 and 5 MRIs performed across a health system from March 2018 to November 2021 for assessment of disease extent and preoperative planning. Patient characteristics, including demographics, Tyrer-Cuzick risk score, pathology from index cancer and biopsy of MRI findings, and pre- and post-MRI surgical plans were recorded. Analysis compared patients who underwent biopsy with those who did not. RESULTS: The final cohort included 323 patients who underwent a biopsy and 89 who did not. Of patients who underwent a biopsy, 144/323 (44.6%) had additional cancer diagnoses. MRI did not change management in 179/323 patients (55.4%) who underwent biopsy and in 44/89 patients (51.7%) who did not. Patients with a biopsy were more likely to have additional breast conservation surgery (P < .001) and patients without a biopsy were more likely to have a change in management to bilateral mastectomy P = .009). Patients without a biopsy who underwent a management change to bilateral mastectomy were significantly younger (47.2 vs 58.6; P < .001) and more likely to be white (P = .02) compared to those choosing bilateral mastectomy after biopsy. DISCUSSION: Biopsy compliance is associated with changes in surgical decisions, and younger, white women are more likely to pursue aggressive surgical management without definitive pathologic diagnoses.

Breast Imaging for Transgender Individuals: Assessment of Current Practice and Needs.

PURPOSE: The aim of this study was to investigate breast radiologists' practices related to recording sex and gender in the electronic medical record, knowledge and attitudes about breast cancer screening recommendations for transgender individuals, and experience and willingness to enter screening mammography data from transgender patients into databases that document service provision and outcomes of cancer detection protocols. METHODS: A 19-question anonymous survey was distributed by e-mail to all active physician members of the Society of Breast Imaging. Response characteristics were assessed as frequencies and percentages and compared between groups using the Fisher exact test or χ2 test. The degree of agreement between questions was assessed using the McNemar test. RESULTS: Four hundred one radiologists across the United States and Canada responded (response rate 18%). Recording birth-assigned sex distinct from gender identity was reported by 44 of 352 respondents (13%). Depending on geographic region, 38% to 62% of breast radiologists followed screening guidelines for transgender women, and 226 of 349 (65%) did not provide screening recommendations for transgender men. Of 400, 324 (81%) believed that the evidence base for screening transgender individuals is incomplete, and 247 of 352 (70%) were either unsure of or had no Lesbian, Gay, Bisexual, Transgender, Queer competency training. A majority (247 of 401 [62%]) of respondents reported that they would enroll transgender patients in existing or novel national databases. CONCLUSIONS: In the practice of breast imaging, there is a substantial need to record transgender and other gender-nonconforming information. Breast radiologists differ in their practice and knowledge regarding screening of transgender women and men but expressed interest in contributing data to facilitate longitudinal databases needed to inform cancer screening guidelines.

Variations and Challenges to Performing Outside Study Interpretations in Breast Imaging: A National Survey of the Society of Breast Imaging Membership.

OBJECTIVE: Second-opinion interpretations of outside facility breast imaging provide value-added care but are operationally challenging for breast radiologists. Our objective was to survey members of the Society of Breast Imaging (SBI) to assess practice patterns and perceived barriers to performing outside study interpretations (OSIs). METHODS: An anonymous survey was developed by the Patient Care and Delivery Committee of the SBI and distributed via e-mail to SBI radiologist members. Survey questions included practice demographics and OSI volumes, billing practices, clinical scenarios, and imaging modalities, logistics, and barriers. Responses were aggregated and comparisons were made by univariate analysis using likelihood ratio tests, t-tests, and Spearman's rank correlation tests as appropriate. Ordinal or nominal logistic modeling and linear regression modeling was also performed. RESULTS: There were 371 responses (response rate of 13%). Most respondents practice at an affiliated specialty breast care center (306/371, 83%) and said their practice performed OSIs (256/371, 69%). Academic practices reported the highest OSI volumes (median 75 per month) and were most likely to indicate increases in OSI volumes over time (100/144, 69%). The most common indication for OSI was second opinion for a biopsy recommendation (245/256, 96%). Most practices provide a final BI-RADS assessment (183/261, 70%). The most cited barrier to performing OSIs was physician time constraints (252/369, 68%). CONCLUSION: Breast imaging OSI practice patterns are variable among SBI members with notable differences by practice setting and multiple barriers identified. More unified guidelines and recommendations may be needed for radiologists to better perform this valuable task.

Communicating With Breast Imaging Patients During the COVID-19 Pandemic: Impact on Patient Care and Physician Wellness.

OBJECTIVE: Assess the impact of COVID-19 on patient-breast radiologist interactions and evaluate the relationship between safety measure-constrained communication and physician wellbeing. METHODS: A 41-question survey on the perceived effect of COVID-19 on patient care was distributed from June 2020 to September 2020 to members of the Society of Breast Imaging and the National Consortium of Breast Centers. Non-radiologists and international members were excluded. Anxiety and psychological distress scores were calculated. A multivariable logistic model was used to identify demographic and mental health factors associated with responses. RESULTS: Five hundred twenty-five surveys met inclusion criteria (23% response rate). Diminished ability to fulfill patients' emotional needs was reported by 46% (221/479), a response associated with younger age (OR, 0.8 per decade; P < 0.01), higher anxiety (OR, 2.3; P < 0.01), and higher psychological distress (OR, 2.2; P = 0.04). Personal protective equipment made patient communication more difficult for 88% (422/478), a response associated with younger age (OR, 0.8 per decade; P = 0.008), female gender (OR, 1.9; P < 0.01), and greater anxiety (OR, 2.6; P = 0.001). The inability to provide the same level of care as prior to COVID-19 was reported by 37% (177/481) and was associated with greater anxiety (OR, 3.4; P < 0.001) and psychological distress (OR, 1.7; P = 0.03). CONCLUSION: The majority of breast radiologists reported that COVID-19 has had a negative impact on patient care. This perception was more likely among younger radiologists and those with higher levels of anxiety and psychological distress.

MRI Features of Free Liquid Silicone in the Transgender Female Breast.

OBJECTIVE: To define MRI features of free liquid silicone injection (FLSI) of the breast in transgender women considering surgical management. METHODS: This study was IRB-approved. MRI images from transgender women with FLSI imaged between 2009 and 2019 were reviewed. Presence and location of fibrotic masses (FMs) in the breast(s) and pectoralis muscle and patterns of granulomas were correlated with clinicopathologic findings. Background enhancement was quantified. Comparisons were performed using two-tailed Fisher exact and Student's t test. RESULTS: Of 21 transgender women with FLSI (mean age 46.8 years), 13/21 (61.9%) had a dominant FM measuring over 4 cm; these were limited to breast and pectoralis in 6/21 (28.6%), breast in 9/21 (42.9%), and pectoralis only in 2/21 (9.5%). Four of 21 patients (19.0%) had no FMs, and 4/21 (19.0%) had masses under 4 cm. Mean size of the dominant FM was 7.4 cm (range 4-12 cm). FMs were enhancing in 5/13 (38.5%) and contained T2 high signal granulomas in 8/13 (61.5%). While 18/21 (85.8%) of cases showed mild to moderate overall background enhancement, the majority 7/13 (61.5%) of dominant FM were non-enhancing. About half of cases (11/21, 52.4%) had diffuse foci, and half (10/21, 47.6%) had diffuse foci and masses throughout the breast and pectoralis muscle. These foci and masses displayed T2 high signal in 13/21 (61.9%). There were no occult carcinomas observed. CONCLUSION: MRI performed on symptomatic FLSI patients considering surgical treatment is helpful in assessing the extent of silicone infiltration and fibrotic reaction of the breast and pectoralis muscle.

COVID-19 and Breast Radiologist Wellness: Impact of Gender, Financial Loss, and Childcare Need.

PURPOSE: The purpose of this study was to evaluate the emotional and financial impact of coronavirus disease 2019 (COVID-19) on breast radiologists to understand potential consequences on physician wellness and gender disparities in radiology. METHODS: A 41-question survey was distributed from June to September 2020 to members of the Society of Breast Imaging and the National Consortium of Breast Centers. Psychological distress and financial loss scores were calculated on the basis of survey responses and compared across gender and age subgroups. A multivariate logistic model was used to identify factors associated with psychological distress scores. RESULTS: A total of 628 surveys were completed (18% response rate); the mean respondent age was 52 ± 10 years, and 79% were women. Anxiety was reported by 68% of respondents, followed by sadness (41%), sleep problems (36%), anger (25%), and depression (23%). A higher psychological distress score correlated with female gender (odds ratio [OR], 1.9; P = .001), younger age (OR, 0.8 per SD; P = .005), and a higher financial loss score (OR, 1.4; P < .0001). Participants whose practices had not initiated wellness efforts specific to COVID-19 (54%) had higher psychological distress scores (OR, 1.4; P = .03). Of those with children at home, 38% reported increased childcare needs, higher in women than men (40% versus 29%, P < .001). Thirty-seven percent reported that childcare needs had adversely affected their jobs, which correlated with higher psychological distress scores (OR, 2.2-3.3; P < .05). CONCLUSIONS: Psychological distress was highest among younger and female respondents and those with greater pandemic-specific childcare needs and financial loss. Practice-initiated COVID-19-specific wellness efforts were associated with decreased psychological distress. Policies are needed to mitigate pandemic-specific burnout and worsening gender disparities.

Breast Imaging of Transgender Individuals: A Review.

PURPOSE: This review will inform radiologists about the evidence base regarding radiographic imaging for transgender individuals and considerations for providing culturally sensitive care for this population. FINDINGS: Transgender individuals are increasingly referred for both screening and diagnostic breast imaging. It is important that the clinic environment is welcoming, the medical staff utilize accepted terminology and patients are able to designate their gender and personal history to ensure appropriate care. Hormone and surgical treatments used for transition by many transgender women and men may change the approach to imaging. SUMMARY: Although not yet evidence-based, screening mammography is currently suggested for transgender women with risk factors, including those receiving hormone treatment over 5 years. The risk for breast cancer in transgender individuals is still being defined.

Cellular fibroadenoma on Core needle biopsy: management recommendations for the radiologist.

INTRODUCTION: Cellular fibroadenomas (CFA) are difficult to distinguish from phyllodes tumor (PT) at biopsy. This study's purpose was to determine what CFA characteristics were associated with recommendations to follow-up or excise and if the current algorithm was correct. MATERIALS AND METHODS: Databases from 2002 to 2014 were reviewed. Mass characteristics and post biopsy recommendations were recorded. RESULTS: 81 CFAs were diagnosed; 19 cellular and 62 with slightly cellular stroma. 21 masses were surgically excised with 2 PTs diagnosed. CONCLUSION: Larger mass size and increased histologic cellularity were associated with excision recommendation, but only clinical growth was associated with PT.

Digital breast tomosynthesis of gynecomastia and associated findings-a pictorial review.

Men referred for breast imaging most frequently present with a unilateral palpated breast lump or breast enlargement. In the vast majority of these cases, the cause is benign and the most common etiology is gynecomastia. This pictorial review illustrates the appearance by full field digital mammography and digital breast tomosynthesis of gynecomastia as well as additional findings in the male breast including sternalis muscle and hypertrophied pectoralis muscle, lipoma, intramammary lymph node, fat necrosis, breast cancer, and atypical ductal hyperplasia.