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.

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.

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.

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.

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.

Asymmetric Ductal Ectasia: An Often Overlooked Sign of Malignancy.

OBJECTIVE. The objective of this article is to define the clinical significance of asymmetric ductal ectasia by a review of literature and to describe the imaging findings. CONCLUSION. Asymmetric ductal ectasia has a significant risk for malignancy and high-risk lesions. The findings on conventional imaging may be subtle and easily overlooked. Asymmetric ductal ectasia should be included in the search pattern during image interpretation. Tissue sampling is usually warranted. Ultrasound is critical in identifying ductal abnormalities to guide biopsy.

Postoperative enhancement on breast MRI: Time course and pattern of changes.

Expected postoperative enhancement on breast MRI can appear similar to enhancement seen in recurrent or residual malignancy. Our aim was to assess the time course and patterns of enhancement at the surgical site, thereby helping to distinguish between benign and malignant postoperative enhancement. In 200 MRI scans performed in 153 patients after breast conservation treatment, 43 after surgical excision of atypia, and 4 patients after benign excisional biopsy were categorized by postoperative time interval. We defined 4 patterns of morphologic enhancement on MRI: cavity wall/seroma (Pattern I); thin linear (Pattern II); mass (Pattern III); and fat necrosis (Pattern IV). Of 200 MRI scans, 66 (33%) demonstrated enhancement at the surgical site. Enhancement typically decreased through the postoperative follow-up period. Enhancement was observed in 41% (28/68) of cases beyond the 18-month interval but was uncommon after 5 years. Pattern III enhancement was the morphologic pattern seen most commonly with malignancy (5/19 cases, 26%). When associated with delayed washout kinetics, it was even more strongly predictive of malignancy (4/5 cases, 80%). In patients with a history of excisional biopsy and no prior radiation treatment, the percentage of MRI scans showing enhancement was significantly lower than (21% vs 49% with P-value .0027) in patients who had undergone radiation. Enhancement at the surgical site occurred in one-third of cases up to 5 years after surgery, particularly in patients who underwent both radiation and surgery. Mass enhancement, particularly in conjunction with delayed washout kinetics, is most predictive of malignancy and should prompt biopsy or re-excision.

Patient-centered Radiology: Where Are We, Where Do We Want to Be, and How Do We Get There?

Purpose The objectives of the Radiological Society of North America (RSNA) Patient-Centered Radiology Steering Committee survey were to (a) assess RSNA members' general attitudes and experiences concerning patient-centered radiology, with specific attention paid to radiologist-to-patient communication; (b) examine the members' barriers to communicating more directly with patients; and (c) explore their perceptions of how such barriers can be overcome. Materials and Methods A total of 5999 radiologists were invited by e-mail to complete an anonymous electronic survey developed by the Steering Committee and the RSNA Department of Research. Participants were asked to identify aspects of patient-centered care important to their practice, report on their interactions with patients, and share their opinions on radiologist-patient communication. Statistical analyses were performed by using the χ2 test and analysis of variance. Results The response rate was 12% (n = 694, 109 invitations were undeliverable). Most respondents (89%, 611 of 684) agreed that promoting awareness of the role of radiology in patients' overall health care is important to how they practice. The majority (73%, 421 of 575) reported that time or workload frequently prevented them from communicating directly with patients. The majority (74%, 423 of 572) reported that a personal sense of satisfaction was likely to motivate them to communicate more directly with patients, but many commented that changes to reimbursement and compensation would help them communicate with patients more directly. Conclusion Many radiologists support the concept of communicating more directly with patients but report they are constrained by time or workload. Changes to reimbursement schemes may help mitigate these barriers to one crucial aspect of patient-centered care. © RSNA, 2017 Online supplemental material is available for this article.

The Management of Benign Concordant MRI-guided Brest Biopsies: Lessons Learned.

After benign concordant magnetic resonance imaging (MRI)-guided breast biopsy, initial follow-up MRI at 6 months is often recommended for confirmation. This study was undertaken to determine the proper management of stable lesions on initial follow-up MRI and whether such follow-up can be safely deferred to 12 months. Retrospective review of 240 MRI-guided biopsies identified 156 benign concordant lesions. 85 eligible cases received follow-up MRI and constitute the study population. On initial follow-up MRI, 72 of 85 lesions appeared adequately sampled, 12 were stable and underwent further MRI follow-up, and 1 was benign on subsequent surgery. No cancers were diagnosed at the biopsy sites on either 6- or 12-month follow-up MRI. Among the 12 stable lesions, four were masses and eight were nonmass enhancements. One of the stable masses enlarged on 24-month follow-up MRI and proved malignant. All stable nonmass lesions were benign on long-term follow-up. After benign concordant MRI-guided breast biopsy, a stable mass has a 25% probability of malignancy in our series. Re-biopsy of such masses should be strongly considered. Stable nonmass lesions may be followed with subsequent MRI without rebiopsy. Deferral of initial follow-up MRI to 12 months may be acceptable.

Contralateral prophylactic mastectomy in the American College of Radiology Imaging Network 6667 trial: effect of breast MR imaging assessments and patient characteristics.

PURPOSE: To assess which patient and magnetic resonance (MR) imaging factors are associated with the likelihood of contralateral prophylactic mastectomy (CPM) in patients with newly diagnosed breast cancer. MATERIALS AND METHODS: The American College of Radiology Imaging Network 6667 trial was compliant with HIPAA; institutional review board approval was obtained at each site. All patients provided written informed consent. This study was a retrospective review of data from 934 women enrolled in the trial who did not have a known contralateral breast cancer at the time of surgical planning. The authors assessed age, menopausal status, index breast cancer histologic results, contralateral breast histologic results, breast density, family history, race and/or ethnicity, MR imaging Breast Imaging Reporting and Data System (BI-RADS) assessment, and number of MR imaging lesions for association with CPM by using the Fisher exact test, exact χ(2) test, and multivariate logistic regression analyses. RESULTS: Eighty-six of the 934 (9.2%) women underwent CPM and were more likely to be younger (mean age, 48 years [range, 27-78 years] vs mean age, 54 years [range, 25-86 years]; P < .0001), be premenopausal (55 of 86 [64%] vs 349 of 845 [41%], P < .0001), have ductal carcinoma in situ (DCIS) in the index breast (31% [27 of 86] vs 19% [164 of 848], P = .02), have greater breast density (71 of 86 [83%] vs 572 of 848 [68%], P = .004), and have a family history of breast cancer (44 of 86 [30%] vs 150 of 488 [18%], P = .01) than those who did not undergo CPM. Distributions of race and/or ethnicity, contralateral lesion pathologic results, and number of MR imaging lesions were similar in both groups. With multivariate modeling, younger age, greater breast density, DCIS index cancer, and family history remained significant, whereas menopausal status did not. Positive MR imaging assessments were not significantly more frequent in the CPM group than in the group of women who did not undergo CPM (14 of 86 [16.3%] vs 113 of 848 [13.3%], P = .43). CONCLUSION: In patients with newly diagnosed breast cancer who underwent breast MR imaging at which a contralateral breast cancer was not identified, patient factors and not breast MR imaging BI-RADS scores were chief determinants in decisions regarding CPM. Online supplemental material is available for this article.

Positron emission mammography: diagnostic imaging and biopsy on the same day.

OBJECTIVE: The purpose of this study was to determine the feasibility and potential advantages of performing positron emission mammography (PEM)-guided biopsy after diagnostic PEM on the same day. SUBJECTS AND METHODS: A prospective study included patients with highly suspicious breast lesions identified at mammography or ultrasound (index lesions) and requiring biopsy. Diagnostic PEM was performed with IV injection of 10 mCi of (18)F-FDG. When possible, PEM-guided biopsies were performed on both the index lesion and the additional suspicious PEM-visualized lesions using the biopsy navigation accessory. All index lesions and occult malignant lesions detected with PEM were surgically excised and correlated with biopsy results. Radiation doses to medical staff were recorded. RESULTS: The study included 20 patients in whom 26 of 27 lesions (96%) were adequately visualized to allow PEM-guided biopsy, which was performed on 24 of the 26 lesions. Twenty-one of the 24 (88%) biopsies had concordant results: 17 malignant tumors, one high-risk lesion, and three benign lesions. Three of 24 (13%) PEM-guided biopsies had discordant results, for which ultrasound-guided biopsy was performed. Additional occult malignancy was identified in 3 of 19 breast cancer patients (16%), resulting in two wide local excisions and one mastectomy. Staff doses ranged from 0.8 to 2.0 mrem (0.008-0.02 mSv) per case. CONCLUSION: Same-day PEM-guided biopsy is feasible for most patients, decreases the radiation dose to both the patient and the medical staff (compared with returning for biopsy another day), and expedites the patient's preoperative staging workup for cancer.

Breast emergencies: types, imaging features, and management.

OBJECTIVE: The objective of this article is to describe the types of breast emergencies that can be encountered in a breast imaging practice, discuss the characteristic imaging features of these emergencies, and explain the most common methods and interventions used for the treatment of breast emergencies and complications. CONCLUSION: Breast emergencies are uncommon but require prompt identification and management when they do occur. Patients with mastitis or a breast abscess may be seen for either diagnosis or treatment. Most complications are the result of interventional procedures. Pseudoaneurysms, postbiopsy hematoma, and localization wire migration are the most common situations encountered. A milk fistula resulting from a core biopsy is uncommon. Fortunately, seat-belt injuries to the breast are rare. Knowledge of these entities--of the usual presentation, management, and appropriate follow-up protocols--is essential for breast imagers.

Breast intervention: how I do it.

Breast imaging has undergone many changes since the early years of mammography. Screening mammography is credited with contributing to the substantial decrease in breast cancer mortality through early detection. Screening mammography programs allow depiction of nonpalpable, suspicious findings requiring histologic evaluation, but most of which eventually are proved benign. Widespread acceptance of percutaneous breast biopsy techniques represents the most important practice-changing development in breast imaging. The radiologist now plays a vital role not only in the detection and evaluation of breast disease, but also in the diagnosis and management of breast cancer. Descriptions of the advantages of percutaneous breast biopsy and the techniques of performing breast intervention are the focus of this review.