Patient-centered radiology: a roadmap for outpatient imaging.

Creating a patient-centered experience is becoming increasingly important for radiology departments around the world. The goal of patient-centered radiology is to ensure that radiology services are sensitive to patients' needs and desires. This article provides a framework for addressing the patient's experience by dividing their imaging journey into three distinct time periods: pre-exam, day of exam, and post-exam. Each time period has aspects that can contribute to patient anxiety. Although there are components of the patient journey that are common in all regions of the world, there are also unique features that vary by location. This paper highlights innovative solutions from different parts of the world that have been introduced in each of these time periods to create a more patient-centered experience. CLINICAL RELEVANCE STATEMENT: Adopting innovative solutions that help patients understand their imaging journey and decrease their anxiety about undergoing an imaging examination are important steps in creating a patient centered imaging experience. KEY POINTS: • Patients often experience anxiety during their imaging journey and decreasing this anxiety is an important component of patient centered imaging. • The patient imaging journey can be divided into three distinct time periods: pre-exam, day of exam, and post-exam. • Although components of the imaging journey are common, there are local differences in different regions of the world that need to be considered when constructing a patient centered experience.

Utility and Costs During the Initial Year of 3D Printing in an Academic Hospital.

OBJECTIVE: There is a paucity of utility and cost data regarding the launch of 3D printing in a hospital. The objective of this project is to benchmark utility and costs for radiology-based in-hospital 3D printing of anatomic models in a single, adult academic hospital. METHODS: All consecutive patients for whom 3D printed anatomic models were requested during the first year of operation were included. All 3D printing activities were documented by the 3D printing faculty and referring specialists. For patients who underwent a procedure informed by 3D printing, clinical utility was determined by the specialist who requested the model. A new metric for utility termed Anatomic Model Utility Points with range 0 (lowest utility) to 500 (highest utility) was derived from the specialist answers to Likert statements. Costs expressed in United States dollars were tallied from all 3D printing human resources and overhead. Total costs, focused costs, and outsourced costs were estimated. The specialist estimated the procedure room time saved from the 3D printed model. The time saved was converted to dollars using hospital procedure room costs. RESULTS: The 78 patients referred for 3D printed anatomic models included 11 clinical indications. For the 68 patients who had a procedure, the anatomic model utility points had an overall mean (SD) of 312 (57) per patient (range, 200-450 points). The total operation cost was $213,450. The total cost, focused costs, and outsourced costs were $2,737, $2,180, and $2,467 per model, respectively. Estimated procedure time saved had a mean (SD) of 29.9 (12.1) min (range, 0-60 min). The hospital procedure room cost per minute was $97 (theoretical $2,900 per patient saved with model). DISCUSSION: Utility and cost benchmarks for anatomic models 3D printed in a hospital can inform health care budgets. Realizing pecuniary benefit from the procedure time saved requires future research.

Reporting and Perceptions of Breast Arterial Calcification on Mammography: A Survey of ACR Radiologists.

RATIONALE AND OBJECTIVES: The ACR Breast Commission conducted a member survey to evaluate current practices of reporting breast arterial calcification (BAC) on mammography and to determine perceptions about the value of BAC communication and follow-up recommendations among radiologists. MATERIALS AND METHODS: In September 2020, an 18-item online survey was emailed to radiologist members of the American College of Radiology (ACR). Questions included radiologist demographics, current BAC reporting practices, follow-up recommendations, and perceptions about BAC. Five-point Likert scales were used and multivariate analysis was performed. RESULTS: Of 598 completed survey responses, up to 87% (522/598) of ACR radiologist members include BAC in mammogram reports. However, only 41% (212/522) of respondents report BAC 'always' or 'most of the time'. Radiologist factors significantly associated with BAC reporting include years in practice and fellowship training with those in practice longer more likely to report BAC (OR 1.10, 95% CI, [1.01-1.20], p = 0.023) and those with fellowship training less likely to report BAC (OR 0.63, 95% CI, [0.42-0.94], p = 0.024). When BAC is reported, 69% (360/522) simply indicate the presence of BAC, 23% (121/522) provide a subjective grading of BAC burden, and 1% (6/522) calculate a BAC score. Among the radiologists reporting BAC, 58% (301/522) make no subsequent recommendations, while the remainder recommend primary care follow-up (39%; 204/522), cardiology evaluation (13%; 68/522), and/or coronary calcium scoring CT (11%; 59/522). Overall, there was agreement from 66% (392/598) of respondents that BAC is a cardiovascular risk factor. However, there was no consensus on whether patients and/or providers should be informed about BAC or whether reporting of BAC should become a standardized practice in breast imaging. Older and more experienced radiologists are more likely to agree that BAC is a cardiovascular risk factor (p = 0.022), providers should be informed about BAC (p = 0.002 and 0.006), BAC reporting should be a standardized practice (p = 0.004 and 0.001), and feel more comfortable informing patients about BAC (p = 0.001 and 0.003). CONCLUSION: Radiologists' reporting practices and perceptions regarding BAC are not homogeneous. Although many radiologists report BAC to varying degrees, it is not routinely reported or recommended for follow-up in mammogram reports. Experienced radiologists are more likely to include and value BAC in their breast imaging practice.

Analysis of Gender Disparity in US and Canadian Radiology Residency Programs.

BACKGROUND: Equity, diversity, and inclusion in academic radiology are a work in progress and although the gender gap has decreased, there remains a paucity of studies examining female representation among radiology trainees over the past decade. OBJECTIVE: The aim of our undertaking was to evaluate gender parity in United States (US) and Canadian radiology residency programs and to suggest future directions to improve female representation MATERIALS AND METHODS: Retrospective analysis of publicly available data on radiology residents from the US and Canada was performed from 2007to 2019. Data on diagnostic radiology residents was collected from the Accreditation Council for Graduate Medical Education for the US and the Canadian Post M.D. Education Registry for Canada. Statistical tests including regression and ANOVA were used to study the gender proportions from 2007to 2019. RESULTS: There has been little progress in bridging the gender gap in the last 12 years. The proportion of female residents pursuing radiology has remained at an average of 26.74% (n = 1,238of 4,629) in US programs and 31.78% (n = 28 of88) in Canadian programs. The average change in the percentage of female residents was 0.0% per year (P = 0.0) for US programs and -2.9% per year (P = 0.3) for Canadian programs. DISCUSSION: Despite a higher proportion of females in North American medical schools, gender disparity persists among radiology residents. More research is needed to identify barriers limiting female representation and improve gender parity across North American radiology programs.

"Managing Up": Cultivating Relationships With Practice Leaders.

"Managing up" for the radiologist means developing and cultivating work relationships to benefit high-level stakeholders and the institution at large, and to maximize one's own effectiveness. Today's breast radiologists are responsible for more than image interpretation and image-guided interventions. Radiologists' roles and responsibilities have evolved to include clinical initiatives, staff development, quality improvement, and administrative tasks where management skills are needed. To be successful in these roles, developing skills to manage up will allow radiologists to be more effective team members. In this article, we discuss tactics to start developing strategies for managing up, including how to understand practice leaders and create meaningful relationships; explain various work style personalities and how to navigate them; describe how to understand oneself, including strengths and weaknesses; and, finally, provide tips on how to begin to cultivate managing up skills.

Upright Tomosynthesis-guided Breast Biopsy: Tips, Tricks, and Troubleshooting.

The advent and implementation of digital breast tomosynthesis (DBT) have had a significant effect on breast cancer detection and image-guided breast procedures. DBT has been shown to improve the visualization of architectural distortions and noncalcified masses. With the incorporation of DBT imaging, biopsy of those findings seen only with DBT is feasible, and the need for localization and surgical excision to determine the pathologic diagnosis is avoided. The additional benefits of reduced procedural time, better localization, and increased technical success support the use of DBT for breast biopsy. DBT-guided biopsy can be performed with the patient prone or upright, depending on the table or unit used. Upright positioning enables improved patient comfort, particularly in patients who have restricted mobility, weight-related limitations, and/or difficulty lying prone for an extended period. Upright DBT-guided breast procedures require a cohesive team approach with overlapping radiologist and technologist responsibilities. Since this is a common breast procedure, the radiologist should be familiar with preprocedural considerations, patient preparations, and use of the biopsy equipment. The basic principles of upright DBT-guided breast biopsy are described in this comprehensive review. The various procedural components, including alternative approaches and techniques, are discussed. Tips and tricks for navigating the biopsy procedure to minimize complications, imaging examples of crucial steps, and supporting diagrams are provided. In addition, the challenges of performing upright DBT-guided biopsy, with troubleshooting techniques to ensure a successful procedure, are reviewed. ©RSNA, 2021.

Characterization of common breast MRI abnormalities: comparison between abbreviated and full MRI protocols.

RATIONALE AND OBJECTIVES: To evaluate the diagnostic performance of abbreviated MRI (AB-MRI) in comparison to a full protocol MRI (FP-MRI) when evaluating common MRI abnormalities of a mass, non-mass enhancement and focus. MATERIALS AND METHODS: This retrospective reader study was Institutional Review Board approved and Health Insurance Portability and Accountability Act (HIPAA) compliant. AB-MRIs were reviewed from May 2018-December 2019 to identify women with an abnormal AB-MRI, FP-MRI within six months of the AB-MRI and an elevated risk for breast cancer. Six breast radiologists initially interpreted and recorded findings from the AB-MRI. Immediately after reviewing the AB-MRI, the same radiologists interpreted and recorded findings from the FP-MRI. Findings were recorded in an electronic data collection form. Cohen's Kappa test was used to calculate agreement. P < 0.05 was considered statistically significant. RESULTS: Of 119 patients who had an AB-MRI, our final study comprised of 32 patients who had 64 breast MRIs (32 AB-MRI and 32 FP-MRI). The amount of fibroglandular tissue for AB-MRI and FP-MRI showed excellent intra-reader agreement [Kappa: 0.89-1.00 (P < 0.0001)]. Substantial to excellent intra-reader agreement [Kappa: 0.74-0.93 (P < 0.0001)] was demonstrated for all 6 readers when identifying abnormalities seen on AB-MRI and FP-MRI. Moderate to excellent intra-reader agreement [Kappa: 0.41-0.87(P < 0.0001)] was demonstrated between the AB-MRI and FP-MRI for the final BI-RADS assessment. CONCLUSION: AB-MRI has acceptable intra-reader agreement with FP-MRI when characterizing common MRI abnormalities such as a mass, non-mass enhancement and focus suggesting that subsequent FP-MRI may not be needed.

Analysis of 612 Benign Papillomas Diagnosed at Core Biopsy: Rate of Upgrade to Malignancy, Factors Associated With Upgrade, and a Proposal for Selective Surgical Excision.

BACKGROUND. Despite numerous published studies, management of benign papillomas without atypia remains controversial. OBJECTIVE. The purpose of this study was to determine the malignancy upgrade rate of benign papillomas, identify risk factors for upgrade, and formulate criteria for selective surgery. METHODS. This retrospective study included benign papillomas without atypia diagnosed on percutaneous biopsy between December 1, 2000, and December 31, 2019. Papillomas that did not undergo surgical excision or at least 2 years of imaging and/or clinical follow-up were excluded. Clinical, imaging, and histopathologic features were extracted from the electronic medical record. Features associated with upgrade to malignancy were identified. Multivariable logistic regression was performed. RESULTS. The study included 612 benign papillomas in 543 women (mean age, 54.5 ± 12.1 [SD] years); 466 papillomas were excised, and 146 underwent imaging or clinical surveillance. The upgrade rate to malignancy was 2.3% (14/612). Upgrade rate was associated (p < .05) with radiology-pathology correlation (50.0% if discordant vs 2.1% if concordant), patient age (5.6% for 60 years and older vs 0.7% for younger than 60 years), presenting symptoms (6.7% if palpable mass or pathologic nipple discharge vs 1.3% if no symptoms), and lesion size (7.3% if ≥ 10 mm vs 0.6% if < 10 mm). Three of 14 upgraded papillomas were associated with four or more metachronous or concurrent peripheral papillomas. No incidental papilloma or papilloma reported as completely excised on core biopsy histopathologic analysis was upgraded. A predictive model combining radiology-pathology discordance, symptoms (palpable mass or nipple discharge), age 60 years old and older, size 10 mm or larger, and presence of four or more metachronous or concurrent peripheral papillomas achieved an AUC of 0.91, sensitivity of 79%, and spec-ificity of 89% for upgrade. Selective surgery based on presence of any of these five factors, although excluding from surgery incidental papillomas and papillomas reported as completely excised on histopathology, would have spared 294 of 612 lesions from routine excision and identified all 14 upgraded lesions. CONCLUSION. Benign nonatypical papillomas have a low malignancy upgrade rate; routine surgical excision may not be necessary. Selective excision is recommended for lesions satisfying any of the five criteria. Incidental papillomas or papillomas completely excised on histopathology may undergo imaging follow-up. CLINICAL IMPACT. The proposed criteria for selective surgery of benign papillomas on core biopsy would reduce surgeries without delaying diagnosis of malignancy.

Upgrade Rate of Pure Flat Epithelial Atypia Diagnosed at Core Needle Biopsy: A Systematic Review and Meta-Analysis.

Purpose: To perform a systematic review and meta-analysis to calculate the pooled upgrade rate of pure flat epithelial atypia (FEA) diagnosed at core needle biopsy (CNB). Materials and Methods: A PubMed and Embase database search was performed in December 2019. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. Study quality and publication bias were assessed. The upgrade rate of pure FEA to cancer, invasive carcinoma, and ductal carcinoma in situ (DCIS), as well as the co-occurrence rate of atypical ductal hyperplasia (ADH), with 95% CIs were calculated. A random effect model was used to integrate the proportions and their corresponding 95% CI. Study heterogeneity was calculated using τ2 and I 2 . Results: A total of 2482 cases of pure FEA across 42 studies (mean age range, 46-59 years) met inclusion criteria to be analyzed. Significant study heterogeneity was identified (τ2 = 0.001, I 2 = 67%). The pooled upgrade rates reported for pure FEA were 5% (95% CI: 3%, 6%) for breast cancer, 1% (95% CI: 0%, 2%) for invasive carcinoma, and 2% (95% CI: 1%, 3%) for DCIS. When more than 90% of calcifications were removed at CNB, the pooled upgrade rate was 0% (95% CI: 0%, 2%). The pooled co-occurrence rate of ADH at surgical excision was 17% (95% CI: 12%, 21%). Study quality was medium to high with a risk of publication bias (P < .01). Conclusion: Pure FEA diagnosed at CNB should be surgically excised due to the pooled upgrade rate of 5% for breast cancer. If more than 90% of the targeted calcifications are removed by CNB for pure FEA, close imaging follow-up is recommended.Keywords: Biopsy/Needle Aspiration, Breast, MammographySupplemental material is available for this article.© RSNA, 2021.

Diagnostic accuracy of MRI textural analysis in the classification of breast tumors.

OBJECTIVE: To investigate whether textural analysis (TA) of MRI heterogeneity may play a role in the clinical assessment and classification of breast tumors. MATERIALS AND METHODS: For this retrospective study, patients with breast masses ≥1 cm on contrast-enhanced MRI were obtained in 69 women (mean age: 51 years; range 21-78 years) with 77 masses (38 benign, 39 malignant) from 2006 to 2018. The selected single slice sagittal peak post-contrast T1-weighted image was analyzed with commercially available TA software [TexRAD Ltd., UK]. Eight histogram TA parameters were evaluated at various spatial scaling factors (SSF) including mean pixel intensity, standard deviation of the pixel histogram (SD), entropy, mean of the positive pixels (MPP), skewness, kurtosis, sigma, and Tx_sigma. Additional statistical tests were used to determine their predictiveness. RESULTS: Entropy showed a significant difference between benign and malignant tumors at all textural scales (p < 0.0001) and kurtosis was significant at SSF = 0-5 (p = 0.0026-0.0241). The single best predictor was entropy at SSF = 4 with AUC = 0.80, giving a sensitivity of 95% and specificity of 53%. An AUC of 0.91 was found using a model combining entropy with sigma, which yielded better performance with a sensitivity of 92% and specificity of 79%. CONCLUSION: TA of breast masses has the potential to assist radiologists in categorizing tumors as benign or malignant on MRI. Measurements of entropy, kurtosis, and entropy combined with sigma may provide the best predictability.

Improved Appropriateness of Advanced Diagnostic Imaging After Implementation of Clinical Decision Support Mechanism.

The Protecting Access to Medicare Act (PAMA) mandates clinical decision support mechanism (CDSM) consultation for all advanced imaging. There are a growing number of studies examining the association of CDSM use with imaging appropriateness, but a paucity of multicenter data. This observational study evaluates the association between changes in advanced imaging appropriateness scores with increasing provider exposure to CDSM. Each provider's first 200 consecutive anonymized requisitions for advanced imaging (CT, MRI, ultrasound, nuclear medicine) using a single CDSM (CareSelect, Change Healthcare) between January 1, 2017 and December 31, 2019 were collected from 288 US institutions. Changes in imaging requisition proportions among four appropriateness categories ("usually appropriate" [green], "may be appropriate" [yellow], "usually not appropriate" [red], and unmapped [gray]) were evaluated in relation to the chronological order of the requisition for each provider and total provider exposure to CDSM using logistic regression fits and Wald tests. The number of providers and requisitions included was 244,158 and 7,345,437, respectively. For 10,123 providers with ≥ 200 requisitions (2,024,600 total requisitions), the fraction of green, yellow, and red requisitions among the last 10 requisitions changed by +3.0% (95% confidence interval +2.6% to +3.4%), -0.8% (95% CI -0.5% to -1.1%), and -3.0% (95% CI 3.3% to -2.7%) in comparison with the first 10, respectively. Providers with > 190 requisitions had 8.5% (95% CI 6.3% to 10.7%) more green requisitions, 2.3% (0.7% to 3.9%) fewer yellow requisitions, and 0.5% (95% CI -1.0% to 2.0%) fewer red (not statistically significant) requisitions relative to providers with ≤ 10 requisitions. Increasing provider exposure to CDSM is associated with improved appropriateness scores for advanced imaging requisitions.

Screening Mammogram Results in the Digital Age: Video Messaging - A Pilot Study.

OBJECTIVE: To assess patients' preferences for receiving screening mammogram results via a video message from their radiologist versus the traditional methods. METHODS: The Institutional Review Board approved this prospective study which enrolled participants from March to May 2019, after written consent was obtained. Two breast radiologists prerecorded video results for normal and abnormal screening mammograms. Women 40 years and older presenting for a screening mammogram who had a prior mammogram and no clinical symptoms were invited to participate in the study. After their mammogram, participants were assigned to obtain results via video message or by traditional methods such as a mailed letter or phone call. Participants then completed an online survey asking questions regarding the method of results delivery. RESULTS: Around 80/94 participants ranging in age from 40 to 76 years old responded (85% response rate), of which 73% (58/80) preferred a video message from the radiologist for their mammogram results (p = 0.029). When analyzed by age, the video results were most liked by patients 40-60 years old. When analyzed by education level, participants with a Master's or Bachelor's degree liked receiving their results by video. DISCUSSION: Our study suggests that patients in the screening mammography setting may prefer a video message from their radiologist to the traditional methods of delivery, including mailed letters and receiving results from their primary care provider. Video results could potentially be utilized in the delivery of other results of standardized medical tests as a method to offer more timely delivery of results and a personal connection.

Transitioning from trainee to breast radiologist: A guide for a successful first year.

The transition from trainee to newly minted breast radiologist is exciting and daunting in equal measure. The early years in practice are pivotal to long-term success in breast imaging whether entering academic or nonacademic practice. Yet a paucity of literature exists to guide junior radiologists in their early career transition. New breast radiologists can successfully navigate the start of a prosperous and enriching career by implementing strategies adapted from the business world and collective wisdom from the radiology world. This article provides an outline of tips and habits for new radiologists to incorporate in their work lives as attendings to ensure that they will thrive in breast imaging for years to come.

Current Recommendations for Breast Imaging of the Pregnant and Lactating Patient.

During pregnancy and lactation, the breast undergoes unique changes that manifest as varied clinical and imaging findings. Understanding the expected physiologic changes of the breast as well as recognizing the best imaging modalities for a given clinical scenario can help the radiologist identify the abnormalities arising during this time. Discussion with the patient about the safety of breast imaging can reassure patients and improve management. This article reviews the physiologic changes of the breast during pregnancy and lactation; the safety and utility of various imaging modalities; upto-date consensus on screening guidelines; recommendations for diagnostic evaluation of breast pain, palpable abnormalities, and nipple discharge; and recommendations regarding advanced modalities such as breast MRI. In addition, the commonly encountered benign and malignant entities affecting these patients are discussed.

Intimate Partner Violence and the Role of Breast Imaging Centers.

Intimate partner violence (IPV) is defined as physical violence, sexual violence, stalking, or psychological harm by a current or former intimate partner. In the United States, one in three women will experience a form of IPV in their lifetime. Screening for IPV at breast imaging centers provides an important opportunity to identify and assist affected women. Breast imaging centers provide a private environment where passive and active IPV screening methods can be employed. In addition, when obtaining a mammogram or breast ultrasound, the patient's upper chest is exposed, which could demonstrate patterns of abuse. This article discusses the need for IPV screening, via both passive and active methods, and implementation steps for breast imaging centers.

MRI Evaluation of the Contralateral Breast in Women with Recently Diagnosed Breast Cancer: 2-Year Follow-up.

OBJECTIVE: The American College of Radiology Imaging Network Trial 6667 showed that MRI can detect cancer in the contralateral breast that is missed by mammography and clinical examination at the time of the initial breast cancer diagnosis, based on 1-year follow-up. This study is a continuation of the trial that evaluates the diagnostic accuracy of MRI for contralateral breast cancer after 2 years of follow-up. METHODS: In total, 969 women with a diagnosis of unilateral breast cancer and no clinical or imaging abnormalities in the contralateral breast underwent breast MRI. The cancer status of all participants was monitored for 2 years after the initial MRI. Follow-up included documentation of any clinical, imaging, or interventional procedures performed. A study participant was considered positive for cancer if she had a tissue diagnosis of in situ or invasive breast cancer in the contralateral breast within 730 days of her initial MRI. RESULTS: Three additional cancers were diagnosed in the study population in the second year of the trial. The diagnostic yield for MRI for the 2-year period was 3% (31/969). After 2 years of follow-up, breast MRI has a sensitivity of 86% and specificity of 88% for detection of contralateral breast cancer. Its negative predictive value was 99%, and its positive predictive value was 22%. These values did not change significantly from the 1-year data. CONCLUSION: A negative contralateral breast MRI has a very high and reliable negative predictive value over 2 years, and, therefore, is helpful in managing and counseling patients during the period of initial diagnosis and early treatment.