The Impact of Mammographic, Radiologist, and Patient Factors on the Likelihood of Probably Benign (BI-RADS 3) Assessment at Diagnostic Mammography.

OBJECTIVE: To evaluate the association of mammographic, radiologist, and patient factors on BI-RADS 3 assessment at diagnostic mammography in patients recalled from screening mammography. METHODS: This Institutional Review Board-approved retrospective study of consecutive unique diagnostic mammography examinations in asymptomatic patients recalled from screening mammography March 5, 2014, to December 31, 2019, was conducted in a single large United States health care institution. Mammographic features (mass, calcification, distortion, asymmetry), breast density, prior examination, and BI-RADS assessment were extracted from reports by natural language processing. Patient age, race, and ethnicity were extracted from the electronic health record. Radiologist years in practice, recall rate, and number of interpreted diagnostic mammograms were calculated. A mixed effect logistic regression model evaluated factors associated with likelihood of BI-RADS 3 compared with other BI-RADS assessments. RESULTS: A total of 12 080 diagnostic mammography examinations were performed during the study period, yielding 2010 (16.6%) BI-RADS 3 and 10 070 (83.4%) other BI-RADS assessments. Asymmetry (odds ratio [OR] = 6.49, P <.001) and calcification (OR = 5.59, P <.001) were associated with increased likelihood of BI-RADS 3 assessment; distortion (OR = 0.20, P <.001), dense breast parenchyma (OR = 0.82, P <.001), prior examination (OR = 0.63, P = .01), and increasing patient age (OR = 0.99, P <.001) were associated with decreased likelihood. Mass, patient race or ethnicity, and radiologist factors were not significantly associated with BI-RADS 3 assessment. Malignancy rate for BI-RADS 3 lesions was 1.6%. CONCLUSION: Asymmetry and calcifications had an increased likelihood of BI-RADS 3 assessment at diagnostic evaluation with low likelihood of malignancy, while radiologist features had no association.

Peri-surgical imaging of intersex and gender diverse youths.

This publication provides an overview of current imaging indications and practices for patients undergoing gender-affirming surgery, with an emphasis on the importance of tailored, patient-specific care. Gender-affirming surgeries are performed with personalized approaches at various stages of life for those with intersex traits or differences in sex development (I/DSD) and transgender and gender diverse (TGD) individuals. For I/DSD patients, ultrasound, genitography, or MRI occurs during infancy and puberty to evaluate genital and gonadal anatomy. Facial harmonization involves bony and soft tissue modifications, guided by maxillofacial computerized tomography (CT) with three-dimensional reconstruction. Ultrasound is the main modality in assessing hormone-related and post-surgical changes in the chest. Imaging for genital reconstruction uses cross-sectional images and fluoroscopy to assess neoanatomy and complications.

Imaging characteristics of interval cancers detected on Full Field Digital Mammography (FFDM) versus Digital Breast Tomosynthesis (DBT).

OBJECTIVE: To compare imaging features of interval cancers detected in patients screened with full field digital mammography (FFDM) versus digital breast tomosynthesis (DBT). MATERIALS/METHODS: This retrospective observational study consisted of female patients undergoing screening DM or FFDM at an academic medical center and two outpatient imaging facilities between January 2012 and June 2017. A natural language processing algorithm queried breast imaging reports for breast density and BI-RADS category. This was cross-referenced to an institutional breast cancer registry to identify interval cancers. Retrospective consensus review of the cases was done to categorize imaging features of interval cancers on FFDM vs DBT. RESULTS: The rate of interval cancers was comparable in patients screened with FFDM (30/39793) and DBT (29/32180) (p = 0.58). There was no significant difference in the rate, histopathology, or imaging features of interval cancers in patients screened with FFDM versus DBT. The most common mammographic features on diagnostic imaging across both groups was the presence of a mass (13/47). Almost equally common was negative diagnostic mammogram with mass detected only on ultrasound (11/47). The rate of interval cancers detected by high-risk surveillance breast MRI was increased in patients who previously had screening with DBT relative to those who had screening with FFDM (p = 0.0419). CONCLUSION: There is no significant difference in rate of detection, histopathology, or imaging features of interval cancers in patients screened with FFDM versus DBT. However, across both cohorts, the most common features on diagnostic mammogram were either the presence of a mass or a negative mammogram.

Positive predictive value of axillary lymph node cortical thickness and nodal, clinical, and tumor characteristics in newly diagnosed breast cancer patients.

PURPOSE: Axillary lymph nodes (LNs) with cortical thickness > 3 mm have a higher likelihood of malignancy. To examine the positive predictive value (PPV) of axillary LN cortical thickness in newly diagnosed breast cancer patients, and nodal, clinical, and tumor characteristics associated with axillary LN metastasis. METHODS: Retrospective review of axillary LN fine needle aspirations (FNAs) performed 1/1/2018-12/31/2019 included 135 axillary FNAs in 134 patients who underwent axillary surgery. Patient demographics, clinical characteristics, histopathology, and imaging features were obtained from medical records. Hypothesis testing was performed to identify predictors of axillary LN metastasis. RESULTS: Cytology was positive in 72/135 (53.3%), negative in 61/135 (45.2%), and non-diagnostic in 2/135 (1.5%). At surgery, histopathology was positive in 84 (62.2%) and negative in 51 (37.8%). LN cortices were thicker in metastatic compared to negative nodes (p < 0.0001). PPV of axillary LNs with cortical thickness ≥ 3 mm, ≥ 3.5 mm, ≥ 4 mm and, ≥ 4.25 mm was 0.62 [95% CI 0.53, 0.70], 0.63 [0.54, 0.72], 0.67 [0.57, 0.76] , and 0.74 [0.64, 0.83], respectively. At multivariable analysis, abnormal hilum (OR = 3.44, p = 0.016) and diffuse cortical thickening (OR = 2.86, p = 0.038) were associated with nodal metastasis. CONCLUSION: In newly diagnosed breast cancer patients, increasing axillary LN cortical thickness, abnormal fatty hilum, and diffuse cortical thickening are associated with nodal metastasis. PPV of axillary LN cortical thickness ≥ 3 mm and ≥ 3.5 mm is similar but increases for cortical thickness ≥ 4 mm. FNA of axillary LNs with cortex < 4 mm may be unnecessary for some patients undergoing sentinel LN biopsy.

Discriminative Factors of Malignancy of Ipsilateral Nonmass Enhancement in Women With Newly Diagnosed Breast Cancer on Initial Staging Breast MRI.

BACKGROUND: Nonmass enhancement (NME) on breast MRI impacts surgical planning. PURPOSE: To evaluate positive predictive values (PPVs) and identify malignancy discriminators of NME ipsilateral to breast cancer on initial staging MRI. STUDY TYPE: Retrospective. SUBJECTS: Eighty-six women (median age, 48 years; range, 26-75 years) with 101 NME lesions (BI-RADS 4 and 5) ipsilateral to known cancers and confirmed histopathology. FIELD STRENGTH/SEQUENCE: 1.5 T and 3.0 T dynamic contrast-enhanced fat-suppressed T1-weighted fast spoiled gradient-echo. ASSESSMENT: Three radiologists blinded to pathology independently reviewed MRI features (distribution, internal enhancement pattern, and enhancement kinetics) of NME, locations relative to index cancers (contiguous, non-contiguous, and different quadrants), associated mammographic calcifications, lymphovascular invasion (LVI), axillary node metastasis, and radiology-pathology correlations. Clinical factors, NME features, and cancer characteristics were analyzed for associations with NME malignancy. STATISTICAL TESTS: Fisher's exact, Chi-square, Wilcoxon rank sum tests, and mixed-effect multivariable logistic regression were used. Significance threshold was set at P < 0.05. RESULTS: Overall NME malignancy rate was 48.5% (49/101). Contiguous NME had a significantly higher malignancy rate (86.7%) than non-contiguous NME (25.0%) and NME in different quadrants (10.7%), but no significant difference was observed by distance from cancer for non-contiguous NME, P = 0.68. All calcified NME lesions contiguous to the calcified index cancer were malignant. NME was significantly more likely malignant when index cancers were masses compared to NME (52.9% vs. 21.4%), had mammographic calcifications (63.2% vs. 39.7%), LVI (81.8% vs. 44.4%), and axillary node metastasis (70.8% vs. 41.6%). NME features with highest PPVs were segmental distribution (85.7%), clumped enhancement (66.7%), and nonpersistent kinetics (77.1%). On multivariable analysis, contiguous NME, segmental distribution, and nonpersistent kinetics were associated with malignancy. DATA CONCLUSION: Malignancy discriminators of ipsilateral NME on staging MRI included contiguous location to index cancers, segmental distribution, and nonpersistent kinetics. EVIDENCE LEVEL: 3 TECHNICAL EFFICACY: Stage 2.

High Peritumoral and Intratumoral T2 Signal Intensity in HER2-Positive Breast Cancers on Preneoadjuvant Breast MRI: Assessment of Associations With Histopathologic Characteristics.

BACKGROUND. Intratumoral necrosis and peritumoral edema are features of aggressive breast cancer that may present as high T2 signal intensity (T2 SI). Implications of high T2 SI in HER2-positive cancers are unclear. OBJECTIVE. The purpose of this study was to assess associations with histopathologic characteristics of high peritumoral T2 SI and intratumoral T2 SI of HER2-positive breast cancer on MRI performed before initiation of neoadjuvant therapy. METHODS. This retrospective study included 210 patients (age, 24-82 years) with 211 HER2 breast cancers who, from January 1, 2015, to July 30, 2022, underwent breast MRI before receiving neoadjuvant therapy. Two radiologists independently assessed cancers for high peritumoral T2 SI and high intratumoral T2 SI on fat-suppressed T2-weighted imaging and classified patterns of high peritumoral T2 SI (adjacent to tumor vs prepectoral extension). A third radiologist resolved discrepancies. Multivariable logistic regression analyses were performed to identify associations of high peritumoral and intratumoral T2 SI with histopathologic characteristics (associated ductal carcinoma in situ, hormone receptor status, histologic grade, lymphovascular invasion, and axillary lymph node metastasis). RESULTS. Of 211 HER2-positive cancers, 81 (38.4%) had high peritumoral T2 SI, and 95 (45.0%) had high intratumoral T2 SI. A histologic grade of 3 was independently associated with high peritumoral T2 SI (OR = 1.90; p = .04). Otherwise, none of the five assessed histopathologic characteristics were independently associated with high intratumoral T2 SI or high peritumoral T2 SI (p > .05). Cancers with high T2 SI adjacent to the tumor (n = 29) and cancers with high T2 SI with prepectoral extension (n = 52) showed no significant difference in frequency for any of the histopathologic characteristics (p > .05). Sensitivities and specificities for predicting the histopathologic characteristics ranged from 35.6% to 43.7% and from 59.7% to 70.7%, respectively, for high peritumoral T2 SI, and from 37.3% to 49.6% and from 49.3% to 62.7%, respectively, for high intratumoral T2 SI. Interreader agreement was almost perfect for high peritumoral T2 SI (Gwet agreement coefficient [AC] = 0.93), high intratumoral T2 SI (Gwet AC = 0.89), and a pattern of high peritumoral T2 SI (Gwet AC = 0.95). CONCLUSION. The only independent association between histopathologic characteristics and high T2 SI of HER2-positive breast cancer was observed between a histologic grade of 3 and high peritumoral T2 SI. CLINICAL IMPACT. In contrast with previously reported findings in broader breast cancer subtypes, peritumoral and intratumoral T2 SI had overall limited utility as prognostic markers of HER2-positive breast cancer.

Synthetic Mammography: Benefits, Drawbacks, and Pitfalls.

Digital breast tomosynthesis (DBT) allows three-dimensional assessment of breast tissue; however, DBT requires a two-dimensional (2D) image for comparison with prior mammograms and accurate interpretation of calcifications. Traditionally, full-field digital mammography (FFDM) has been performed after the DBT image acquisition. Synthetic mammography (SM), the 2D reconstruction of the tomosynthesis slice dataset, has been designed to replace FFDM. Advantages of SM include decreased image acquisition time and decreased radiation exposure, with maintained or improved screening performance metrics. Because SM algorithms give extra weight to lesion-like characteristics (eg, calcifications and architectural distortions), they may enable increased visibility of these characteristics relative to that at FFDM. Although SM algorithms were designed to improve lesion identification, they have led to varied outcomes in studies reported in the literature. Compared with FFDM, SM has been reported to be associated with a higher false-positive rate for calcifications, decreased conspicuity of asymmetries, lower breast density assessments, and imaging artifacts (eg, metallic artifact, bright-band artifact, blurring of the axilla, and truncation artifact). The authors review the literature on SM, including its implementation, benefits, and artifacts. ©RSNA, 2023 Quiz questions for this article are available through the Online Learning Center.

NCCN Guidelines® Insights: Breast Cancer Screening and Diagnosis, Version 1.2023.

The NCCN Guidelines for Breast Cancer Screening and Diagnosis provide health care providers with a practical, consistent framework for screening and evaluating a spectrum of clinical presentations and breast lesions. The NCCN Breast Cancer Screening and Diagnosis Panel is composed of a multidisciplinary team of experts in the field, including representation from medical oncology, gynecologic oncology, surgical oncology, internal medicine, family practice, preventive medicine, pathology, diagnostic and interventional radiology, as well as patient advocacy. The NCCN Breast Cancer Screening and Diagnosis Panel meets at least annually to review emerging data and comments from reviewers within their institutions to guide updates to existing recommendations. These NCCN Guidelines Insights summarize the panel's decision-making and discussion surrounding the most recent updates to the guideline's screening recommendations.

Experience of a single healthcare system with screening mammography before and after COVID-19 shutdown.

PURPOSE: To evaluate COVID-19's longitudinal impact on screening mammography volume trends. METHODS: HIPAA-compliant, IRB-approved, single institution, retrospective study of screening mammogram volumes before (10/21/2016-3/16/2020) and greater than two years after (6/17/2020-11/30/2022) a state-mandated COVID-19 shutdown (3/17/2020-6/16/2020) were reviewed. A segmented quasi-poisson linear regression model adjusting for seasonality and network and regional population growth compared volume trends before and after the shutdown of each variable: age, race, language, financial source, risk factor for severe COVID-19, and examination location. RESULTS: Adjusted model demonstrated an overall increase of 65 screening mammograms per month before versus a persistent decrease of 5 mammograms per month for >2 years after the shutdown (p < 0.0001). In subgroup analysis, downward volume trends were noted in all age groups <70 years (age < 50: +9/month before vs. -7/month after shutdown; age 50-60: +17 vs. -7; and age 60-70: +21 vs. -2; all p < 0.001), those identifying as White (+55 vs. -8, p < 0.0001) and Black (+4 vs. +1, p = 0.009), all financial sources (Medicare: +22 vs. -3, p < 0.0001; Medicaid: +5 vs. +2, p = 0.006; private insurance/self-pay: +38 vs. -4, p < 0.0001), women with at least one risk factor for severe COVID-19 (+30 vs. -48, p < 0.0001), and screening mammograms performed at a hospital-based location (+48 vs. -14, p = 0.0001). CONCLUSION: The screening mammogram volume trend more than two years after the COVID-19 shutdown has continued to decline for most patient populations. Findings highlight the need to identify additional areas for education and outreach.

Impact of Neoadjuvant Paclitaxel/Trastuzumab/Pertuzumab on Breast Tumor Downsizing for Patients with HER2+ Breast Cancer: Single-Arm Prospective Clinical Trial.

BACKGROUND: The impact of abbreviated neoadjuvant regimens for HER2+ breast cancer on rates of breast conservation therapy (BCT) is unclear. We aimed to determine BCT rates in a single-arm prospective trial of neoadjuvant paclitaxel/trastuzumab/pertuzumab (THP) in patients with stage II or III HER2+ breast cancer. STUDY DESIGN: BCT eligibility was prospectively recorded before and after THP. Pre- and posttreatment mammogram and breast ultrasound were required; breast MRI was encouraged. Patients with a large tumor to breast size ratio were eligible for downsizing. Multifocal/multicentric tumors, extensive calcifications, and contraindications to radiation were considered BCT contraindications. RESULTS: Overall, 92 patients who received neoadjuvant THP on trial were included. At presentation, 39 (42.4%) were considered eligible for BCT and 53 (57.6%) were not. BCT-eligible patients were older (median 54 vs 47 years, respectively; p = 0.006) and had smaller tumors by palpation (median 2.5 vs 3 cm, respectively; p = 0.004). Of 53 BCT-ineligible patients, 28 were candidates for tumor downsizing, whereas 25 had contraindications to BCT. Overall, 51 (55.4%) patients underwent BCT. Of the 28 patients who were candidates for downsizing, 22 (78.6%) became BCT-eligible after THP and 18 of 22 (81.8%) underwent BCT. In total, 44 of 92 (47.8%) patients experienced breast pathologic complete response (ypT0), including 11 of 25 (44.0%) patients with BCT contraindications at presentation. CONCLUSIONS: De-escalated neoadjuvant systemic therapy led to high BCT rates in this cohort. The impact of de-escalated systemic therapy on local therapy and outcomes in early stage HER2+ breast cancer warrants further investigation.

Frequency and Outcomes of BI-RADS Category 3 Assessments in Patients With a Personal History of Breast Cancer: Full-Field Digital Mammography Versus Digital Breast Tomosynthesis.

BACKGROUND. Studies establishing the validity of BI-RADS category 3 excluded patients with personal history of breast cancer (PHBC). Use of category 3 in patients with PHBC may be impacted not only by this population's increased breast cancer risk, but also by adoption of digital breast tomosynthesis (DBT) over full-field digital mammography (FFDM). OBJECTIVE. The purpose of this article was to compare the frequency, outcomes, and additional characteristics of BI-RADS category 3 assessments between FFDM and DBT in patients with PHBC. METHODS. This retrospective study included 14,845 mammograms in 10,118 patients (mean age, 63 years) with PHBC who had undergone mastectomy and/or lumpectomy. Of these, 8422 examinations were performed by FFDM from October 2014 to September 2016, and 6423 examinations by FFDM with DBT from February 2017 to December 2018, after interval conversion of the center's mammography units. Information was extracted from the EHR and radiology reports. FFDM and DBT groups were compared in the entire sample and among index category 3 lesions (i.e., earliest category 3 assessment per lesion). RESULTS. The frequency of category 3 assessment was lower for DBT than FFDM (5.6% vs 6.4%; p = .05). DBT, compared with FFDM, showed a lower malignancy rate for category 3 lesions (1.8% vs 5.0%; p = .04), higher malignancy rate for category 4 lesions (32.0% vs 23.2%; p = .03), and no difference in malignancy rate for category 5 lesions (100.0% vs 75.0%; p = .24). Analysis of index category 3 lesions included 438 and 274 lesions for FFDM and DBT, respectively. For category 3 lesions, DBT, compared with FFDM, showed lower PPV3 (13.9% vs 36.1%; p = .02) and a more frequent mammographic finding of mass (33.2% vs 23.1%; p = .003). CONCLUSION. The malignancy rate for category 3 lesions in patients with PHBC was less than the accepted limit (2%) for DBT (1.8%), but not FFDM (5.0%). A lower malignancy rate for category 3 lesions but higher malignancy rate for category 4 lesions for DBT supports more appropriate application of category 3 assessment in patients with PHBC through use of DBT. CLINICAL IMPACT. These insights may help establish whether category 3 assessments in patients with PHBC are within benchmarks for early detection of second cancers and reduction of benign biopsies.

Multimodality Imaging Review of HER2-positive Breast Cancer and Response to Neoadjuvant Chemotherapy.

Human epidermal growth factor receptor 2 (HER2/neu or ErbB2)-positive breast cancers comprise 15%-20% of all breast cancers. The most common manifestation of HER2-positive breast cancer at mammography or US is an irregular mass with spiculated margins that often contains calcifications; at MRI, HER2-positive breast cancer may appear as a mass or as nonmass enhancement. HER2-positive breast cancers are often of intermediate to high nuclear grade at histopathologic analysis, with increased risk of local recurrence and metastases and poorer overall prognosis. However, treatment with targeted monoclonal antibody therapies such as trastuzumab and pertuzumab provides better local-regional control and leads to improved survival outcome. With neoadjuvant treatments, including monoclonal antibodies, taxanes, and anthracyclines, women are now potentially able to undergo breast conservation therapy and sentinel lymph node biopsy versus mastectomy and axillary lymph node dissection. Thus, the radiologist's role in assessing the extent of local-regional disease and response to neoadjuvant treatment at imaging is important to inform surgical planning and adjuvant treatment. However, assessment of treatment response remains difficult, with the potential for different imaging modalities to result in underestimation or overestimation of disease to varying degrees when compared with surgical pathologic analysis. In particular, the presence of calcifications at mammography is especially difficult to correlate with the results of pathologic analysis after chemotherapy. Breast MRI findings remain the best predictor of pathologic response. The authors review the initial manifestations of HER2-positive tumors, the varied responses to neoadjuvant chemotherapy, and the challenges in assessing residual cancer burden through a multimodality imaging review with pathologic correlation. © RSNA, 2023 Quiz questions for this article are available through the Online Learning Center.

Live Mammographic Screening Interpretation Versus Offline Same-Day Screening Interpretation at a Tertiary Cancer Center.

OBJECTIVES: The aim of this study was to compare screening mammography performance metrics for immediate (live) interpretation versus offline interpretation at a cancer center. METHODS: An institutional review board-approved, retrospective comparison of screening mammography metrics at a cancer center for January 1, 2018, to December 31, 2019 (live period), and September 1, 2020, to March 31, 2022 (offline period), was performed. Before July 2020, screening examinations were interpreted while patients waited (live period), and diagnostic workup was performed concurrently. After the coronavirus disease 2019 shutdown from March to mid-June 2020, offline same-day interpretation was instituted. Patients with abnormal screening results returned for separate diagnostic evaluation. Screening metrics of positive predictive value 1 (PPV1), cancer detection rate (CDR), and abnormal interpretation rate (AIR) were compared for 17 radiologists who interpreted during both periods. Statistical significance was assessed using χ2 analysis. RESULTS: In the live period, there were 7,105 screenings, 635 recalls, and 51 screen-detected cancers. In the offline period, there were 7,512 screenings, 586 recalls, and 47 screen-detected cancers. Comparison of live screening metrics versus offline metrics produced the following results: AIR, 8.9% (635 of 7,105) versus 7.8% (586 of 7,512) (P = .01); PPV1, 8.0% (51 of 635) versus 8.0% (47 of 586); and CDR, 7.2/1,000 versus 6.3/1,000 (P = .50). When grouped by >10% AIR or <10% AIR for the live period, the >10% AIR group showed a significant decrease in AIR for offline interpretation (from 12.7% to 9.7%, P < .001), whereas the <10% AIR group showed no significant change (from 7.4% to 6.7%, P = .17). CONCLUSIONS: Conversion to offline screening interpretation from immediate interpretation at a cancer center was associated with lower AIR and similar CDR and PPV1. This effect was seen largely in radiologists with AIR > 10% in the live setting.

Patterns of Screening Recall Behavior Among Subspecialty Breast Radiologists.

RATIONALE AND OBJECTIVES: Determine whether there are patterns of lesion recall among breast imaging subspecialists interpreting screening mammography, and if so, whether recall patterns correlate to morphologies of screen-detected cancers. MATERIALS AND METHODS: This Institutional Review Board-approved, retrospective review included all screening examinations January 3, 2012-October 1, 2018 interpreted by fifteen breast imaging subspecialists at a large academic medical center and two outpatient imaging centers. Natural language processing identified radiologist recalls by lesion type (mass, calcifications, asymmetry, architectural distortion); proportions of callbacks by lesion types were calculated per radiologist. Hierarchical cluster analysis grouped radiologists based on recall patterns. Groups were compared to overall practice and each other by proportions of lesion types recalled, and overall and lesion-specific positive predictive value-1 (PPV1). RESULTS: Among 161,859 screening mammograms with 13,086 (8.1%) recalls, Hierarchical cluster analysis grouped 15 radiologists into five groups. There was substantial variation in proportions of lesions recalled: calcifications 13%-18% (Chi-square 45.69, p < 0.00001); mass 16%-44% (Chi-square 498.42, p < 0.00001); asymmetry 13%-47% (Chi-square 660.93, p < 0.00001) architectural distortion 6%-20% (Chi-square 283.81, p < 0.00001). Radiologist groups differed significantly in overall PPV1 (range 5.6%-8.8%; Chi-square 17.065, p = 0.0019). PPV1 by lesion type varied among groups: calcifications 9.2%-15.4% (Chi-square 2.56, p = 0.6339); mass 5.6%-8.5% (Chi-square 1.31, p = 0.8597); asymmetry 3.4%-5.9% (Chi-square 2.225, p = 0.6945); architectural distortion 5.6%-10.8% (Chi-square 5.810, p = 0.2138). Proportions of recalled lesions did not consistently correlate to proportions of screen-detected cancer. CONCLUSION: Breast imaging subspecialists have patterns for screening mammography recalls, suggesting differential weighting of imaging findings for perceived malignant potential. Radiologist recall patterns are not always predictive of screen-detected cancers nor lesion-specific PPV1s.

Breast Cancer Screening in High-risk Women During Pregnancy and Lactation.

Women who are at high risk of developing breast cancer warrant screening that is often initiated at younger ages than in average-risk women; this is usually with a combination of annual mammography and breast MRI. Compared to average-risk women, those at high risk are more frequently recommended to undergo screening during childbearing age and thus potentially during pregnancy and lactation. Understanding the appropriate use of screening breast imaging during pregnancy and lactation can be challenging due to limited data defining the evidence-based roles of the different imaging modalities, including mammography, US, and MRI. There have also been assumptions about the diagnostic accuracy of these modalities secondary to physiological changes. This scientific review discusses the current state of evidence- and expert-based guidelines and data for breast imaging screening of high-risk pregnant and/or lactating women, and the clinical and imaging presentations of breast cancer for these women.

Impact of Electronic Procedural Protocoling on the Timeliness of Pre-operative Breast Localization Procedures.

OBJECTIVE: To evaluate the impact of a new electronic procedural protocol on start times of pre-operative breast localization procedures. METHODS: This HIPAA-compliant, Institutional Review Board-exempted, quality improvement initiative was performed at a large tertiary academic center. In May 2018, an electronic version of the pre-procedure protocol for breast localizations was created within the electronic health record; prior to this time, the protocol was completed manually on a paper form. Mean time between: (1) appointment time and procedure start time, (2) procedure begin-to-end time, and (3) arrival to appointment time were compared for all female patients undergoing pre-operative breast localization procedures during 4-month periods pre-implementation of the electronic procedural protocol (January-April 2018), and post-implementation (June-September 2018), excluding the May 2018 implementation month. Statistical analysis was done by two tailed t-test and statistical process control charting. RESULTS: Pre-implementation, 427 procedures were performed, and post-implementation 409 procedures were performed. Three pre-implementation cases performed more than 3 hours prior to appointment time were excluded (presumed to be rescheduled cases). Mean time between appointment time and procedure start time decreased from 2.7 minutes after to 5.6 minutes before appointment start time, an 8.3-minute improvement (P = 0.0001), with sustained improvement by statistical process control analysis. Mean time for procedure length increased by 4.7 minutes (P = 0.001). There was no significant difference in mean time of patient arrival to appointment time pre- and post-implementation. CONCLUSION: Implementation of an electronic protocol process for pre-operative breast localizations was associated with a significant and sustained reduction in time between appointment time and procedure start time.