ACR Appropriateness Criteria® Monitoring Response to Neoadjuvant Systemic Therapy for Breast Cancer: 2022 Update.

Imaging plays a vital role in managing patients undergoing neoadjuvant chemotherapy, as treatment decisions rely heavily on accurate assessment of response to therapy. This document provides evidence-based guidelines for imaging breast cancer before, during, and after initiation of neoadjuvant chemotherapy. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

ACR Appropriateness Criteria® Evaluation of Nipple Discharge: 2022 Update.

The type of nipple discharge dictates the appropriate imaging study. Physiologic nipple discharge is common and does not require diagnostic imaging. Pathologic nipple discharge in women, men, and transgender patients necessitates breast imaging. Evidence-based guidelines were used to evaluate breast imaging modalities for appropriateness based on patient age and gender. For an adult female or male 40 years of age or greater, mammography or digital breast tomosynthesis (DBT) is performed initially. Breast ultrasound is usually performed at the same time with rare exception. For males or females 30 to 39 years of age, mammography/DBT or breast ultrasound is performed based on institutional preference and individual patient considerations. For young women less than 30 years of age, ultrasound is performed first with mammography/DBT added if there are suspicious findings or if the patient is at elevated lifetime risk for developing breast cancer. There is a high incidence of breast cancer in males with pathologic discharge. Men 25 years and older should be evaluated using mammography/DBT and ultrasound added when indicted. In transfeminine (male-to-female) patients, mammography/DBT and ultrasound are useful due to the increased incidence of breast cancer. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer-reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which peer-reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

ACR Appropriateness Criteria® Imaging of the Axilla.

This publication reviews the current evidence supporting the imaging approach of the axilla in various scenarios with broad differential diagnosis ranging from inflammatory to malignant etiologies. Controversies on the management of axillary adenopathy results in disagreement on the appropriate axillary imaging tests. Ultrasound is often the appropriate initial imaging test in several clinical scenarios. Clinical information (such as age, physical examinations, risk factors) and concurrent complete breast evaluation with mammogram, tomosynthesis, or MRI impact the type of initial imaging test for the axilla. Several impactful clinical trials demonstrated that selected patient's population can received sentinel lymph node biopsy instead of axillary lymph node dissection with similar overall survival, and axillary lymph node dissection is a safe alternative as the nodal staging procedure for clinically node negative patients or even for some node positive patients with limited nodal tumor burden. This approach is not universally accepted, which adversely affect the type of imaging tests considered appropriate for axilla. This document is focused on the initial imaging of the axilla in various scenarios, with the understanding that concurrent or subsequent additional tests may also be performed for the breast. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

ACR Appropriateness Criteria® Supplemental Breast Cancer Screening Based on Breast Density.

Mammography remains the only validated screening tool for breast cancer, however, there are limitations to mammography. One of the limitations of mammography is the variable sensitivity based on breast density. Supplemental screening may be considered based on the patient's risk level and breast density. For average-risk women with nondense breasts, the sensitivity of digital breast tomosynthesis (DBT) screening is high; additional supplemental screening is not warranted in this population. For average-risk women with dense breasts, given the decreased sensitivity of mammography/DBT, this population may benefit from additional supplemental screening with contrast-enhanced mammography, screening ultrasound (US), breast MRI, or abbreviated breast MRI. In intermediate-risk women, there is emerging evidence suggesting that women in this population may benefit from breast MRI or abbreviated breast MRI. In intermediate-risk women with dense breasts, given the decreased sensitivity of mammography/DBT, this population may benefit from additional supplemental screening with contrast-enhancedmammography or screening US. There is strong evidence supporting screening high-risk women with breast MRI regardless of breast density. Contrast-enhanced mammography, whole breast screening US, or abbreviated breast MRI may be also considered. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

High-risk lesions at MRI-guided breast biopsy: frequency and rate of underestimation.

OBJECTIVE: The purpose of this article is to determine the underestimation rate of high-risk lesions diagnosed at MRI-guided breast biopsy. MATERIALS AND METHODS: This was a retrospective review of 446 MRI-guided breast biopsies from January 2006 through December 2010. Data were collected on examination indication, lesion size and type, and pathology results. Biopsies were performed with a 9-gauge vacuum-assisted device. Biopsy results of atypical ductal hyperplasia (ADH), papillary lesion, radial scar, lobular neoplasia, and atypia were identified and compared with final excisional pathology results. Underestimation rates were calculated and data were compared by patient and lesion characteristics using chi-square analysis. RESULTS: Of the 446 MRI-guided biopsies, 96 (21.5%) were high-risk lesions. Forty-two of 96 lesions (44%) were masses, and 54 (56%) showed nonmass enhancement. Twenty of 96 lesions (20.8%) were ADH, nine (9.4%) were lobular neoplasia, 27 (28.1%) were papillary lesions, 20 (20.8%) were radial scar, and 20 (20.8%) were other atypias. Sixty-nine of 96 lesions (71.9%) had surgical excisional pathology results available. Sixteen of 69 (23.2%) lesions were upgraded to malignancy; 11 of the 16 (68.8%) were upgraded to ductal carcinoma in situ (DCIS) and five (31.2%) were upgraded to invasive carcinoma. The underestimation rate was 31.6% (6/19) for ADH, 5.9% (1/17) for papillary lesions, 23.1% (3/13) for radial scar, 28.6% (2/7) for lobular neoplasia, and 30.8% (4/13) for other atypias (p = 0.43). There was no statistically significant difference in underestimation rate by lesion type, size, or history of newly diagnosed breast cancer. CONCLUSION: MRI-guided breast biopsy yielded high-risk lesions in 21.5% of cases, and the underestimation rate was 23.2%. No patient or lesion characteristics correlated with underestimation rate.

Magnetic resonance imaging findings in patients with fibular stress injuries.

OBJECTIVE: The objective was to evaluate magnetic resonance imaging (MRI) findings in patients with fibular stress injuries. MATERIALS AND METHODS: The study group consisted of 20 patients with clinically diagnosed fibular stress injuries who were evaluated with MRI. Radiographs were performed in 14 of the 20 patients. The MRI examinations and radiographs were retrospectively reviewed in consensus by two musculoskeletal radiologists. RESULTS: All 20 patients with clinically diagnosed fibular stress injuries had periosteal edema and bone marrow edema within the fibula on MRI. The periosteal reaction and bone marrow edema were present within the distal fibula in 14 patients, the middle fibula in 1 patient, and the proximal fibula in 5 patients. The periosteal reaction was located on the anterior cortex in 1 patient, the posterior cortex in 4 patients, the lateral cortex in 11 patients, and circumferentially distributed throughout the cortex in 4 patients. Nine patients had abnormal T1 and T2 signal intensity within the fibular cortex. Initial and follow-up radiographs showed periosteal reaction in 15% and 50% of patients with fibular stress injuries respectively. CONCLUSIONS: The majority of fibular stress injuries involve the lateral cortex of the distal fibula.

Diagnostic performance of primary 3-dimensional computed tomography colonography in the setting of colonic diverticular disease.

BACKGROUND & AIMS: Colonic diverticular disease (CDD) is a leading cause of nondiagnostic segmental evaluation at computed tomography colonography (CTC). The primary goal of this study was to evaluate the impact of CDD on polyp detection at primary 3-dimensional (3D) CTC. METHODS: The study group consisted of 280 asymptomatic average-risk adults (mean age, 58.1 y; 167 men, 113 women). All patients underwent CTC followed by same-day optical colonoscopy with segmental unblinding (reference standard). Primary 3D endoluminal evaluation with 2-dimensional correlation was used for initial polyp detection at CTC. Without knowledge of polyp findings, all colonic segments were reviewed for the presence of CDD and graded as absent, minimal, moderate, or extensive disease. RESULTS: Moderate or extensive CDD was present in 271 (12.1%) of 2240 colonic segments and 142 (50.7%) of 280 patients. CTC performance for polyps 6 mm or larger in the presence and absence of moderate-extensive CDD was as follows: by-segment sensitivity of 90.3% (28/31) and 79.4% (123/155); by-patient sensitivity of 86.5% (64/74) and 83.1% (54/65); by-segment specificity of 97.1% (233/240) and 97.7% (1772/1814); by-patient specificity of 83.8% (57/68) and 83.6% (61/73); by-segment positive predictive value of 80.0% (28/35) and 74.5% (123/165); by-patient positive predictive value of 85.3% (64/75) and 81.8% (64/66); by-segment negative predictive value of 98.7% (233/236) and 98.2% (1172/1804); and by-patient negative predictive value of 85.1% (57/67) and 84.7% (61/72), respectively (not significant, P > or = .15). CONCLUSIONS: CDD was common in this asymptomatic screening population, but its presence did not degrade the diagnostic performance of primary 3D CTC for polyp detection.