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.

Clinical Diagnoses and Outcomes After Diagnostic Breast Ultrasound by Nurses and General Practitioner Physicians in Rural Rwanda.

PURPOSE: To scale up early detection of breast cancer in low- and middle-income countries, research is needed to inform the role of diagnostic breast ultrasound performed by nonradiologists in resource-constrained settings. The authors examined 2-year clinical follow-up and outcomes among women who underwent diagnostic breast ultrasound performed by nonradiologist clinicians participating in a breast ultrasound training and mentorship program at a rural Rwandan hospital. METHODS: Imaging findings, management plans, and pathologic results were prospectively collected during the training using a standardized form. Data on follow-up and outcomes for patients receiving breast ultrasound between January 2016 and March 2017 were retrospectively collected through medical record review. RESULTS: Two hundred twenty-nine breast palpable findings (199 patients) met the study's eligibility criteria. Of 104 lesions initially biopsied, 38 were malignant on initial biopsy; 3 lesions were identified as malignant on repeat biopsy. All 34 patients ultimately diagnosed with cancer received initial recommendations for either biopsy or aspiration by trainees. The positive predictive value of trainee biopsy recommendation was 34.8% (95% confidence interval, 24.8%-45.0%). The sensitivity of trainees' biopsy recommendation for identifying malignant lesions was 92.7% (95% confidence interval, 84.2%-100%). Of 46 patients who did not receive biopsy and were told to return for clinical or imaging follow-up, 37.0% did not return. CONCLUSIONS: Trained nonradiologist clinicians in Rwanda successfully identified suspicious breast lesions on diagnostic breast ultrasound. Loss to follow-up was common among patients instructed to return for surveillance, so lower biopsy thresholds, decentralized surveillance, or patient navigation should be considered for patients with low- or intermediate-suspicion lesions.

Breast lesions associated with mammographic architectural distortion: a study of 588 core needle biopsies.

Architectural distortion (AD) on mammography is a localized alteration in the uniform texture of the breast characterized by lines radiating from a central point. Radiologic/pathologic correlation is challenging because the types of lesions associated with AD are not well defined and, thus, what signifies a discordant finding requiring excision is less clear. This retrospective case series was performed to elucidate the pathologic lesions associated with AD. Over a 6-year period, 588 core needle biopsies (CNBs) were performed for AD. Thirty-eight percent of the lesions were AD alone (single feature AD) and 62% had additional imaging features (multi-feature AD). Overall, 31% showed invasive carcinoma or ductal carcinoma in situ (DCIS), 37% showed benign lesions likely to correlate with AD, and 32% showed nonspecific benign findings. The invasive carcinomas tended to be low-grade (60%), ER-positive (98%), HER2-negative (98%), and often had lobular features (52%). Ninety-two percent were AJCC pathologic stage group I. Ninety-four cases of benign findings that correlated with AD without atypia underwent excision, and only one was found to have DCIS adjacent to the sclerosing lesion (1%). The remaining cases had benign findings without a clear correlate for AD. Sixty-eight cases without atypia underwent excision, and six multi-feature AD were upgraded to invasive carcinoma (9%). In conclusion, about one-third of CNBs for lesions associated with AD reveal carcinomas that are predominantly invasive, low-grade, ER-positive, HER2-negative, and low stage. Single-feature AD differed from multi-feature AD due to a lower number of carcinomas on CNB (18% vs 39%). For CNBs showing benign lesions on biopsy with a correlate for AD, the finding of malignancy on excision is low (1%). Radiologic/pathologic correlation and decisions to recommend excision will continue to be a challenge after CNB reveals nonspecific findings as some patients with multi-feature AD were found to have undetected invasive carcinomas.

Use of Real Time Specimen Radiography to Evaluate the Number of Stereotactic Core Biopsy Specimens Containing Calcifications Required for Diagnosis.

OBJECTIVE: To determine the minimum number of stereotactic biopsy specimens containing calcifications sufficient for pathologic diagnosis and the minimum number of specimens containing calcifications sufficient for immunohistochemistry (IHC) in cases of malignancy. METHODS: In this IRB-exempt quality assurance initiative, individual specimens from 126 patients with 129 calcified targets retrieved using a stereotactic system with real time specimen imaging were prospectively analyzed. Pathology was reported independently for each specimen containing calcifications. In every case, the pathologist reported which specimen containing calcifications was sufficient for diagnosis and, in cases of malignancy, which calcified specimen was sufficient for diagnosis and IHC. RESULTS: A diagnosis was made from the first calcified specimen in 74% of cases (95/129), from the first two calcified specimens in 92% (119/129) of cases, and from the first three calcified specimens in 100% of cases. Pathology was benign in 66% (85/129) of cases, with the diagnosis made from the first calcified specimen in 78% (66/85) of cases. High-risk lesions were the primary pathology in 8% (11/129) of cases, with 55% (6/11) diagnosed from the first calcified specimen. Pathology was malignant in 26% (33/129) of cases. The first calcified specimen was sufficient for diagnosis and IHC in 73% (24/33) of malignancies and the first three calcified specimens were sufficient for diagnosis and IHC in all cases of malignancy. CONCLUSION: Three cores verified to contain calcifications on real time specimen imaging were sufficient to make a diagnosis in all cases and to make a diagnosis and obtain IHC in nearly all cases of malignancy.

Training Nonradiologist Clinicians in Diagnostic Breast Ultrasound in Rural Rwanda: Impact on Knowledge and Skills.

OBJECTIVE: To assess the effectiveness of diagnostic breast ultrasound training provided for general practitioners and nurses in Rwanda via intensive in-person and subsequent online supervision and mentorship. METHODS: Four breast radiologists from Brigham and Women's Hospital trained two general practitioner physicians and five nurses in Rwanda over 9 total weeks of in-person training and 20 months of remote mentorship using electronic image review with emailed feedback. Independently recorded assessments were compared to calculate the sensitivity and specificity of trainee assessments, with radiologist assessments as the gold standard. We compared performance in the first versus second half of the training. RESULTS: Trainees' performance on written knowledge assessments improved after training (57.7% versus 98.1% correct, P = .03). Mean sensitivity of trainee-performed ultrasound for identifying a solid breast mass was 90.6% (SD 4.2%) in the first half of the training (period 1) and 94.0% (SD 6.7%) in period 2 (P = .32). Mean specificity was 94.7% (SD 5.4%) in period 1 and 100.0% (SD 0) in period 2 (P = .10). Mean sensitivity for identifying a medium- or high-suspicion solid mass increased from 79.2% (SD 11.0%) in period 1 to 96.3% (SD 6.4%) in period 2 (P = .03). Specificity was 84.4% (SD 15.0%) in period 1 and 96.7% (SD 5.8%) in period 2 (P = .31). DISCUSSION: Nonradiologist clinicians (doctors and nurses) in a rural sub-Saharan African hospital built strong skills in diagnostic breast ultrasound over 23 months of combined in-person training and remote mentorship. The sensitivity of trainees' assessments in identifying masses concerning for malignancy improved after sustained mentorship. Assessment of impact on patient care and outcomes is ongoing.

Ultrasound visibility of select breast biopsy markers for targeted axillary node localization following neoadjuvant treatment: simulation using animal tissue models.

PURPOSE: To compare ultrasound visibility of selected biopsy markers in animal tissue models simulating axillary echotexture. METHODS: Four breast biopsy markers were selected based on size, shape, and composition and compared to an institutional standard for testing in beef steak and pork loin phantoms. BD® UltraCor™ Twirl™; Hologic® Tumark® Professional series Q, Vision, and X; and BD® UltraClip™ Dual Trigger wing-shaped (institutional standard) biopsy markers were deployed at superficial (0-2.0 cm) and deep (2.1-4.0 cm) depths in the animal models. An animal model without a biopsy marker served as control. Four participating breast imagers blinded to marker shape and location assessed ultrasound visibility of each biopsy marker using a handheld 5-12 MHz linear array transducer with a 4-point grading system (0, not visible; 1, unsure if visible; 2, visible with difficulty; 3, definite visibility). Each breast imager was asked to select the three most easily visualized biopsy markers. RESULTS: Total visibility scores with the four-point grading system demonstrate highest score for the Twirl™ (48/48 points), followed by the Tumark® Q (42/48) and Tumark® Vision (41/48) biopsy markers. Overall individual accuracy scores across all biopsy marker types ranged from 83.3 to 95.8%. Visibility scores based on subjective radiologist assessment also demonstrate the highest vote for the Twirl™ (11), followed by the Tumark® Vision (7) and Tumark® Q (6) biopsy markers. The wing-shaped biopsy marker had the lowest visibility and voter score. CONCLUSION: The Twirl™ followed by the Tumark® Q and Vision biopsy markers demonstrates the highest visibility scores using a four-point grading system and by radiologist vote.

Management of Male Breast Cancer: ASCO Guideline.

PURPOSE: To develop recommendations concerning the management of male breast cancer. METHODS: ASCO convened an Expert Panel to develop recommendations based on a systematic review and a formal consensus process. RESULTS: Twenty-six descriptive reports or observational studies met eligibility criteria and formed the evidentiary basis for the recommendations. RECOMMENDATIONS: Many of the management approaches used for men with breast cancer are like those used for women. Men with hormone receptor-positive breast cancer who are candidates for adjuvant endocrine therapy should be offered tamoxifen for an initial duration of five years; those with a contraindication to tamoxifen may be offered a gonadotropin-releasing hormone agonist/antagonist plus aromatase inhibitor. Men who have completed five years of tamoxifen, have tolerated therapy, and still have a high risk of recurrence may be offered an additional five years of therapy. Men with early-stage disease should not be treated with bone-modifying agents to prevent recurrence, but could still receive these agents to prevent or treat osteoporosis. Men with advanced or metastatic disease should be offered endocrine therapy as first-line therapy, except in cases of visceral crisis or rapidly progressive disease. Targeted systemic therapy may be used to treat advanced or metastatic cancer using the same indications and combinations offered to women. Ipsilateral annual mammogram should be offered to men with a history of breast cancer treated with lumpectomy regardless of genetic predisposition; contralateral annual mammogram may be offered to men with a history of breast cancer and a genetic predisposing mutation. Breast magnetic resonance imaging is not recommended routinely. Genetic counseling and germline genetic testing of cancer predisposition genes should be offered to all men with breast cancer.

A novel model to test accuracy and reproducibility of MDCT scan protocols for coronary calcium in vivo.

OBJECTIVES: We compared the accuracy and reliability of prospectively triggered, retrospectively ECG gated, and non-gated CT image reconstruction for measurements of coronary artery calcification (CAC) in vivo using a novel animal model. MATERIALS AND METHODS: In six Yorkshire farm pigs, prefabricated chains of cortical bone fragments were sutured over the epicardial bed of the major coronary arteries. Using a 4-slice MDCT scanner, each animal was imaged with two different protocols: sequential acquisition with prospective ECG triggering, and spiral acquisition with retrospectively ECG gated image reconstruction- non-gated reconstructions were also generated from these latter scans. Two independent observers measured the 'Agatston score' (AS), the calcified volume (CV), and mineral mass (MM). To calculate accuracy of MM measurements the ash weight of the burned bone fragments was compared to MDCT derived MM. RESULTS: Six pigs successfully underwent surgery and CT imaging (mean heart rate: 86+/-12 bpm). MM measurements from prospectively ECG triggered CT sequential scans were more accurate (p<0.02) and reproducible (p=0.05) than sequential CT scans without ECG triggering or spiral acquisition using retrospective ECG gating. CONCLUSIONS: At high heart rates prospective ECG triggered image reconstruction is more accurate and reproducible for CAC scoring than retrospective ECG gated reconstruction and non-gated reconstruction.

Vascular calcification in ex vivo carotid specimens: precision and accuracy of measurements with multi-detector row CT.

PURPOSE: To test the accuracy and precision of multi-detector row computed tomography (CT)-derived measurements of vascular calcification in ex vivo human carotid endarterectomy (CEA) specimens. MATERIALS AND METHODS: Sixteen ex vivo CEA specimens were imaged with multi-detector row CT. Multi-detector row CT-derived calcium scoring algorithms (ie, mineral mass and volume score) were compared with the mass and volume of ashed remnants of the CEA specimens. Bland-Altman analysis was performed to assess the mean (ie, bias) and SD (ie, precision) of differences between multi-detector row CT- and ashing-derived measurements. In addition, conventional Agatston score, volume score, mineral mass, and modified Agatston score were calculated for each specimen by using a number of scanning protocols. Images were obtained at a section thickness of 1.25 mm by using different tube energy settings and tube currents. Specimens were also imaged at different section thicknesses with fixed combinations of tube energy and tube current. To compare measurement variability of scoring methods, coefficients of variation for all protocols were calculated. RESULTS: Both mean multi-detector row CT-derived mineral mass and mean ashing-derived mineral mass were 0.129 g +/- 0.173 (r = 0.99, P <.001). Mean multi-detector row CT- and ashing-derived volumes were 339.94 mm3 +/- 395.4 and 39.48 mm3 +/- 55.76, respectively (r = 0.95, P <.001). Measurement bias relative to the reference ashing values was high (2,800.0%) for volume score and low (2.58%) for mineral mass. Measurement precision was 0.6% for volume score and greater than 0.0005% for mineral mass. Mean coefficients of variation for all CT protocols were 5.0% +/- 4.2 and 4.9% +/- 4.2 for mineral mass and modified Agatston score, respectively, and 16.0% +/- 9.2 and 14.5% +/- 3.9 for conventional Agatston and volume scores, respectively (P <.001). CONCLUSION: Compared with the conventional volume score, multi-detector row CT-derived mineral mass is a less biased and more precise measurement of the mineral content of nonmoving ex vivo CEA specimens. Mineral mass and modified Agatston score are more reproducible than conventional volume and Agatston scores.