Tips and Tricks for Image-Guided Breast Biopsies: Technical Factors for Success.

Image-guided biopsy is an integral step in the diagnosis and management of suspicious image-detected breast or axillary lesions, allowing for accurate diagnosis and, if indicated, treatment planning. Tissue sampling can be performed under guidance of a full spectrum of breast imaging modalities, including stereotactic, tomosynthesis, sonographic, and MRI, each with its own set of advantages and limitations. Procedural planning, which includes consideration of technical, patient, and lesion factors, is vital for diagnostic accuracy and limitation of complications. The purpose of this paper is to review and provide guidance for breast imaging radiologists in selecting the best procedural approach for the individual patient to ensure accurate diagnosis and optimal patient outcomes. Common patient and lesion factors that may affect successful sampling and contribute to postbiopsy complications are reviewed and include obesity, limited patient mobility, patient motion, patients prone to vasovagal reactions, history of anticoagulation, and lesion location, such as proximity to vital structures or breast implant.

Breaking Bad News in Breast Imaging: Keys to Success.

The radiologist's ability to effectively communicate with patients is crucial in breast imaging. Having to tell a patient that she or he requires a biopsy procedure or has a new diagnosis of breast cancer is both a challenging task and a daily reality for many practicing breast radiologists. Despite this, communication in breast imaging is often not formally taught in most training programs, leading many breast radiologists to obtain their skills through on-the-job experience. We discuss the importance of effective communication with patients and a breast imaging-specific method for delivering bad news, adapted from approaches used in medical oncology. A conversation "script" or guide is provided along with the rationale for how to best handle these difficult conversations. Lastly, we review how to teach effective communication to those in training using our breast imaging fellowship program and recent survey results as an example.

Pathologic Outcomes in Single Versus Multiple Areas of Architectural Distortion on Digital Breast Tomosynthesis.

BACKGROUND. Digital breast tomosynthesis (DBT) has led to increased detection of architectural distortion (AD). Management of patients with multiple areas of AD is not established. OBJECTIVE. The purpose of this article is to compare pathologic outcomes between single and multiple areas of AD identified on DBT. METHODS. This retrospective study included 402 patients (mean age, 56 years) who underwent image-guided core needle biopsy of AD visualized on DBT between April 7, 2017, and April 16, 2019. Patients were classified as having a single or multiple areas of AD according to the presence of distinct areas of AD described in the clinical radiology reports. The pathologic diagnosis for each AD was on the basis of the most aggressive pathology identified on either biopsy or surgical excision, if performed. Patients with single and multiple areas of AD were compared. RESULTS. The sample included 372 patients with a single AD (145 benign, 121 high risk, 105 malignant, one other) and 30 patients with multiple visualized ADs, including 66 biopsied ADs (10 benign, 35 high risk, 21 malignant). At pathologic assessment on a per-lesion basis, multiple compared with single ADs showed higher frequency of high-risk pathology (53.0% vs 32.5%, p = .002) but no difference in frequency of malignancy (31.8% vs 28.2%, p = .56). In multivariable analysis of a range of patient-related characteristics, the presence of single versus multiple areas of AD was not independently associated with malignancy (p = .51). In patients with multiple areas of AD, the most aggressive pathology (benign, high risk, or malignant) across all ADs was not associated with the number of ADs (p = .73). In 8 of 24 patients with at least two ipsilateral biopsied ADs, the ipsilateral areas varied in terms of most aggressive pathology; in 5 of 10 patients with contralateral biopsied ADs, the contralateral areas varied in most aggressive pathology. CONCLUSION. The presence of multiple areas of AD, compared with a single AD, was significantly more likely to yield high-risk pathology but was not significantly different in yield of malignancy. In patients with multiple ADs, multiple ipsilateral or contralateral ADs commonly varied in pathologic classification (benign, high risk, or malignant). CLINICAL IMPACT. These findings may help guide management of AD visualized by DBT, including multiple ADs. For patients with multiple areas of AD, biopsy of all areas may be warranted given variation in pathologic diagnoses.

Reducing False Negatives in Biopsy of Suspicious MRI Findings.

Breast MRI is a highly sensitive imaging modality that often detects findings that are occult on mammography and US. Given the overlap in appearance of benign and malignant lesions, an accurate method of tissue sampling for MRI-detected findings is essential. Although MRI-directed US and correlation with mammography can be helpful for some lesions, a correlate is not always found. MRI-guided biopsy is a safe and effective method of tissue sampling for findings seen only on MRI. The unique limitations of this technique, however, contribute to false negatives, which can result in delays in diagnosis and adverse patient outcomes; this is of particular importance as most MRI examinations are performed in the high-risk or preoperative setting. Here, we review strategies to minimize false negatives in biopsy of suspicious MRI findings, including appropriate selection of biopsy modality, use of meticulous MRI-guided biopsy technique, management after target nonvisualization, assessment of adequate lesion sampling, and determination of radiology-pathology concordance. A proposed management algorithm for MRI-guided biopsy results will also be discussed.

A multidisciplinary approach to axillary lymph node staging with ultrasound in the setting of a highly suggestive or suspicious breast mass.

The radiologists' role in axillary imaging in the setting of a suspicious breast mass is evolving in light of the Z0011 trial leading to expected practice variation. The purpose of our project was to generate a standardized algorithm guiding the utilization of axillary ultrasound in the setting of a highly suggestive or highly suspicious breast mass (BI-RADS 4C or 5) without a known cancer diagnosis. The algorithm was created with Z0011 practices in mind while reflecting the clinical preferences of our radiology and surgical teams. The four breast surgeons at our academic institution were individually queried regarding their preferred axillary imaging and biopsy approach. The best practices for axillary imaging were then developed in a breast imaging intradepartmental meeting. There was agreement among the surgical group that the presence of suspicious axillary lymph node (s) on ultrasound could be used for treatment planning and patient discussion but would not be used for surgical planning in most cases. They also agreed that an ultrasound-guided core needle biopsy of a suspicious axillary lymph node should be deferred until after surgical consultation. Discussion among our breast radiologists resulted in the consensus that axillary ultrasound in the setting of a BIRADS 4 or 5 mass should be deferred at its initial presentation unless there is palpable lymphadenopathy, suspicious lymph node on mammography, or a tumor is at least stage T3, presumably excluding them from Z0011 criteria. The decision was also made to defer biopsies of suspicious axillary lymph nodes without prior surgical consultation/discussion.

High-Resolution Full-3D Specimen Imaging for Lumpectomy Margin Assessment in Breast Cancer.

BACKGROUND: Two-dimensional (2D) specimen radiography (SR) and tomosynthesis (DBT) for breast cancer yield data that lack high-depth resolution. A volumetric specimen imager (VSI) was developed to provide full-3D and thin-slice cross-sectional visualization at a 360° view angle. The purpose of this prospective trial was to compare VSI, 2D SR, and DBT interpretation of lumpectomy margin status with the final pathologic margin status of breast lumpectomy specimens. METHODS: The study enrolled 200 cases from two institutions. After standard imaging and interpretation was performed, the main lumpectomy specimen was imaged with the VSI device. Image interpretation was performed by three radiologists after surgery based on VSI, 2D SR, and DBT. A receiver operating characteristic (ROC) curve was created for each method. The area under the curve (AUC) was computed to characterize the performance of the imaging method interpreted by each user. RESULTS: From 200 lesions, 1200 margins were interpreted. The AUC values of VSI for the three radiologists were respectively 0.91, 0.90, and 0.94, showing relative improvement over the AUCs of 2D SR by 54%, 13%, and 40% and DBT by 32% and 11%, respectively. The VSI has sensitivity ranging from 91 to 94%, specificity ranging from 81 to 85%, a positive predictive value ranging from 25 to 30%, and a negative predicative value of 99%. CONCLUSIONS: The ROC curves of the VSI were higher than those of the other specimen imaging methods. Full-3D specimen imaging can improve the correlation between the main lumpectomy specimen margin status and surgical pathology. The findings from this study suggest that using the VSI device for intraoperative margin assessment could further reduce the re-excision rates for women with malignant disease.

Breast Imaging Second Opinion Consultation: A Single Institution's Process of Improvement and Reform.

OBJECTIVE: To review a single institution's second opinion breast imaging process, data tracking, and metrics before and after implementing quality improvement changes and the effect on report turnaround time. METHODS: This Institutional Review Board approved retrospective quality improvement project was performed at a tertiary-care academic medical center and included patients 18 years or older who submitted their outside facility imaging for reinterpretation (any combination of mammography, breast ultrasonography, and/or magnetic resonance imaging performed within the last six months) with finalized second opinion reports between June 1, 2016, and July 17, 2017. Significant intradepartmental changes were implemented March 2017 with the goal to improve second opinion report turnaround time. Key metrics from 399 studies were analyzed before and after implemented changes. Two-sided Fisher's exact test was used to assess the significance of results. RESULTS: After department interventions, the percentage of outside reports available at the time of surgical consultation improved from 82% (213/259) to 91% (127/140), an 11% improvement (P < 0.05). The average number of days from initial second opinion consultation to the availability of final report improved from 10.2 days to 9 days, a 12% improvement. Prior to the changes, the number of days it took a radiologist to complete a report varied from 1 to 4 days, but afterwards was consistently 1 day or less. CONCLUSION: Implementation of second opinion intradepartmental changes demonstrated a significant improvement in report turnaround time and the number of finalized reports available at the time of surgical consultation. An efficient second opinion process is crucial to a breast imaging center, as it ultimately expedites patient surgical and oncological care.

Digital Breast Tomosynthesis: Clinical Operations.

Digital breast tomosynthesis (DBT) is rapidly becoming the standard of care for breast cancer screening. Implementing DBT into practice is relatively straightforward. However, there are important elements of the transition that one must consider to facilitate this process. Understanding the Digital Imaging and Communications in Medicine (DICOM) standard for DBT, as well as how images are displayed, is critical to a successful transition. Standardization of these processes will allow easier transmission of images from facility to facility, and limit the potential for errors in interpretation. Additionally, recent changes in federal regulations will require compliance with mandated training for the radiologist, technologist, and physicist, as well as accreditation for each DBT unit. These regulations aim to ensure high-quality imaging across the country as has been previously seen with standard digital mammography. Synthesized imaging is the most recent improvement for DBT, potentially obviating the need for a simultaneous traditional digital mammogram exposure. Studies have demonstrated near equivalent performance when comparing the combination imaging of DBT and digital mammography versus DBT combined with synthetic imaging. As the quality of the synthetic images continues to improve, it is increasingly likely that it will replace the traditional mammogram. Adherence to DBT-specific parameters will enhance the physician experience and ultimately translate to increased cancer detection and fewer false positive examinations, benefiting all women who are screened for breast cancer.

Synchronous breast cancer and alveolar rhabdomyosarcoma bone marrow metastases.

Alveolar rhabdomyosarcoma (RMS) is primarily a malignancy of childhood and adolescence. While RMS is rare in adults, the breast and the bone marrow are known but uncommon sites for metastatic disease. Bone marrow is also a known sanctuary site for metastatic breast cancer. We present the case of a woman with a remote history of breast cancer and RMS who developed anemia and thrombocytopenia of unknown etiology. Additional laboratory tests were negative for a cause; therefore, the decision was made to proceed with a bone marrow biopsy. The initial biopsy results were consistent with breast cancer metastasis. Subsequent diagnostic imaging of the breast led to biopsy of an enlarging morphologically benign breast mass, unexpectedly yielding alveolar RMS. This unanticipated diagnosis led to revaluation of the bone marrow, this time showing synchronous metastases from breast carcinoma and alveolar RMS. Imaging findings of this patient, along with literature review of RMS imaging characteristics, will be reviewed.