Detailed Image Data Quality and Cleaning Practices for Artificial Intelligence Tools for Breast Cancer.

Standardizing image-data preparation practices to improve accuracy/consistency of AI diagnostic tools.

Breast Cancer Disparity and Outcomes in Underserved Women.

Women in the United States who continue to face obstacles accessing health care are frequently termed an underserved population. Safety-net health care systems play a crucial role in mitigating health disparities and reducing burdens of disease, such as breast cancer, for underserved women. Disparities in health care are driven by various factors, including race and ethnicity, as well as socioeconomic factors that affect education, employment, housing, insurance status, and access to health care. Underserved women are more likely to be uninsured or underinsured throughout their lifetimes. Hence they have greater difficulty gaining access to breast cancer screening and are less likely to undergo supplemental imaging when needed. Therefore, underserved women often experience significant delays in the diagnosis and treatment of breast cancer, leading to higher mortality rates. Addressing disparities requires a multifaceted approach, with formal care coordination to help at-risk women navigate through screening, diagnosis, and treatment. Mobile mammography units and community outreach programs can be leveraged to increase community access and engagement, as well as improve health literacy with educational initiatives. Radiology-community partnerships, comprised of imaging practices partnered with local businesses, faith-based organizations, homeless shelters, and public service departments, are essential to establish culturally competent breast imaging care, with the goal of equitable access to early diagnosis and contemporary treatment. Published under a CC BY 4.0 license. Test Your Knowledge questions are available in the Online Learning Center. See the invited commentary by Leung in this issue.

Imaging and Management of Fibroepithelial Lesions of the Breast: Radiologic-Pathologic Correlation.

Fibroepithelial lesions (FELs) are among the most common breast masses encountered by breast radiologists and pathologists. They encompass a spectrum of benign and malignant lesions, including fibroadenomas (FAs) and phyllodes tumors (PTs). FAs are typically seen in young premenopausal women, with a peak incidence at 20-30 years of age, and have imaging features of oval circumscribed hypoechoic masses. Although some FA variants are especially sensitive to hormonal influences and can exhibit rapid growth (eg, juvenile FA and lactational adenomas), most simple FAs are slow growing and involute after menopause. PTs can be benign, borderline, or malignant and are more common in older women aged 40-50 years. PTs usually manifest as enlarging palpable masses and are associated with a larger size and sometimes with an irregular shape at imaging compared with FAs. Although FA and FA variants are typically managed conservatively unless large and symptomatic, PTs are surgically excised because of the risk of undersampling at percutaneous biopsy and the malignant potential of borderline and malignant PTs. As a result of the overlap in imaging and histologic appearances, FELs can present a diagnostic challenge for the radiologist and pathologist. Radiologists can facilitate accurate diagnosis by supplying adequate tissue sampling and including critical information for the pathologist at the time of biopsy. Understanding the spectrum of FELs can facilitate and guide appropriate radiologic-pathologic correlation and timely diagnosis and management of PTs. Published under a CC BY 4.0 license. Online supplemental material is available for this article. Quiz questions for this article are available through the Online Learning Center.

Surviving the COVID-19 pandemic: navigating the recovery of breast imaging services in a safety-net hospital.

PURPOSE: The purpose of this study was to determine the impact of COVID-19 on county safety-net breast imaging services and describe the steps taken to actively manage and mitigate delays. METHODS: This was an IRB exempt retrospective review of our county safety-net breast imaging practice analyzed for 4 distinct time periods: (1) "Shut-down period": March 17, 2020 to May 17, 2020; (2) "Phased re-opening": May 18, 2020 to June 30, 2020; (3) "Ramp-up": July 1, 2020 to September 30, 2020; and (4) "Current state": October 1, 2020 to September 30, 2021. These time periods were compared to identical time periods 1 year prior. For "Current state," given that the 1-year prior comparison encompassed the first 3 periods of the pandemic, the identical time period 2 years prior was also compared. RESULTS: Our safety-net practice sustained significant volume losses during the first 3 time periods with a 99% reduction in screening mammography in the shut-down period. Cancers diagnosed decreased by 17% in 2020 (n = 229) compared to 2019 (n = 276). By implementing multiple initiatives that targeted improved access to care, including building community-hospital partnerships and engagement through outreach events and a community education roadshow, we were able to recover and significantly exceed our pandemic screening volumes by 48.1% (27,279 vs 18,419) from October 1, 2020 to September 30, 2021 compared to the identical time period 1 year prior, and exceed our pre-pandemic screening volume by 17.4% (27,279 vs 23,234) compared to the identical time period 2 years prior. CONCLUSION: Through specific community outreach programs and optimized navigation, our safety-net breast imaging practice was able to mitigate the impact of COVID-19 on our patient population by increasing patient engagement and breast imaging services.

Radial Scars Without Atypia Diagnosed at Percutaneous Core Needle Breast Biopsy: Support for Imaging Surveillance.

Objective: Radial scar (RS) is a low-risk breast lesion that can be associated with or mimic malignancy. Management guidelines remain controversial for patients with RS without atypia on core needle biopsy (CNB). The aim was to evaluate the upgrade rate of these lesions and factors associated with malignancy risk and excision rate to more definitively guide management. Materials and Methods: In this retrospective study, 123 patients with RS without atypia, diagnosed with CNB between January 2008 to December 2014 who were either referred for surgical excision or followed-up with imaging, were reviewed. The differences in clinical presentation, imaging features, and biopsy technique among the benign RS patients and those upgraded, as well as the excised versus the observed patients were compared. Results: Of 123 RS reviewed, 93 cases of RS without atypia as the highest-grade lesion in the ipsilateral breast and with either 24-month imaging follow-up or surgical correlation were included. Seventy-four (79.6%) lesions were surgically excised and 19 (20.4%) were followed-up for at least 24 months. A single upgrade to malignancy (1%) and 15 upgrades to high-risk lesions (16%) were found. There was no association of any upgraded lesion with presenting symptoms or imaging features. The use of vacuum-assistance and larger biopsy needles, along with obtaining a higher number of samples, was associated with fewer upgrades and lower surgical excision rates. Conclusion: The upgrade rate of RS without atypia in our population was low, regardless of the imaging features and biopsy technique utilized. Close imaging surveillance is an acceptable alternative to surgical excision in these patients.

Optoacoustic Imaging With Decision Support for Differentiation of Benign and Malignant Breast Masses: A 15-Reader Retrospective Study.

BACKGROUND. Overlap in ultrasound features of benign and malignant breast masses yields high rates of false-positive interpretations and benign biopsy results. Optoacoustic imaging is an ultrasound-based functional imaging technique that can increase specificity. OBJECTIVE. The purpose of this study was to compare specificity at fixed sensitivity of ultrasound images alone and of fused ultrasound and optoacoustic images evaluated with machine learning-based decision support tool (DST) assistance. METHODS. This retrospective Reader-02 study included 480 patients (mean age, 49.9 years) with 480 breast masses (180 malignant, 300 benign) that had been classified as BI-RADS category 3-5 on the basis of conventional gray-scale ultrasound findings. The patients were selected by stratified random sampling from the earlier prospective 16-site Pioneer-01 study. For that study, masses were further evaluated by ultrasound alone followed by fused ultrasound and optoacoustic imaging between December 2012 and September 2015. For the current study, 15 readers independently reviewed the previously acquired images after training in optoacoustic imaging interpretation. Readers first assigned probability of malignancy (POM) on the basis of clinical history, mammographic findings, and conventional ultrasound findings. Readers then evaluated fused ultrasound and optoacoustic images, assigned scores for ultrasound and optoacoustic imaging features, and viewed a POM prediction score derived by a machine learning-based DST before issuing final POM. Individual and mean specificities at fixed sensitivity of 98% and partial AUC (pAUC) (95-100% sensitivity) were calculated. RESULTS. Averaged across all readers, specificity at fixed sensitivity of 98% was significantly higher for fused ultrasound and optoacoustic imaging with DST assistance than for ultrasound alone (47.2% vs 38.2%; p = .03). Across all readers, pAUC was higher (p < .001) for fused ultrasound and optoacoustic imaging with DST assistance (0.024 [95% CI, 0.023-0.026]) than for ultrasound alone (0.021 [95% CI, 0.019-0.022]). Better performance using fused ultrasound and optoacoustic imaging with DST assistance than using ultrasound alone was observed for 14 of 15 readers for specificity at fixed sensitivity and for 15 of 15 readers for pAUC. CONCLUSION. Fused ultrasound and optoacoustic imaging with DST assistance had significantly higher specificity at fixed sensitivity than did conventional ultrasound alone. CLINICAL IMPACT. Optoacoustic imaging, integrated with reader training and DST assistance, may help reduce the frequency of biopsy of benign breast masses.

Imaging of COVID-19 Vaccine-Related Axillary Lymphadenopathy: Initial Outcomes Based on US Features of Axillary Lymph Nodes.

OBJECTIVE: The purpose of this study is to describe the imaging characteristics and outcomes of COVID-19 vaccine-related axillary adenopathy and subsequent follow-up. METHODS: This was an IRB-approved, retrospective study of patients with imaging evidence of axillary lymphadenopathy who had received at least one dose of a COVID-19 vaccine and presented between January 1, 2021, and February 28, 2021. Sonographic cortical thickness and morphology was evaluated. A mixed effects model was used to model lymph node cortical thickness decrease over time. RESULTS: A total of 57 women were identified with lymphadenopathy and a COVID vaccination during the study period with 51 (89.5%) women completing imaging surveillance or undergoing tissue sampling of a lymph node. Three women (5.9%) were diagnosed with metastatic breast cancer to an axillary node. There was a statistically significant correlation with cortical thickness at initial US evaluation and malignancy (7.7 mm [SD ±â€…0.6 mm] for metastatic nodes and 5 mm [SD ±â€…2 mm] for benign nodes, P = 0.02). Suspicious morphological features (effacement of fatty hilum, P = 0.02) also correlated with malignancy. Time to resolution of lymphadenopathy can be prolonged with estimated half-life of the rate of decrease in cortical thickness modeled at 77 days (95% CI, 59-112 days). Diffuse, smooth cortical thickening over 3 mm was the most common lymph node morphology. CONCLUSION: Malignant lymph node morphology and cortical thickness best predicted malignancy. Benign hyperplastic lymph nodes were the most common morphology observed after COVID-19 vaccination. Lymphadenopathy after vaccination is slow to resolve.

Axillary Lymphadenopathy in the COVID-19 Era: What the Radiologist Needs to Know.

Axillary lymphadenopathy caused by the high immunogenicity of messenger RNA (mRNA) COVID-19 vaccines presents radiologists with new diagnostic dilemmas in differentiating vaccine-related benign reactive lymphadenopathy from that due to malignant causes. Understanding axillary anatomy and lymphatic drainage is key to radiologic evaluation of the axilla. US plays a critical role in evaluation and classification of axillary lymph nodes on the basis of their cortical and hilar morphology, which allows prediction of metastatic disease. Guidelines for evaluation and management of axillary lymphadenopathy continue to evolve as radiologists gain more experience with axillary lymphadenopathy related to COVID-19 vaccines. General guidelines recommend documenting vaccination dates and laterality and administering all vaccine doses contralateral to the site of primary malignancy whenever applicable. Guidelines also recommend against postponing imaging for urgent clinical indications or for treatment planning in patients with newly diagnosed breast cancer. Although conservative management approaches to axillary lymphadenopathy initially recommended universal short-interval imaging follow-up, updates to those approaches as well as risk-stratified approaches recommend interpreting lymphadenopathy in the context of both vaccination timing and the patient's overall risk of metastatic disease. Patients with active breast cancer in the pretreatment or peritreatment phase should be evaluated with standard imaging protocols regardless of vaccination status. Tissue sampling and multidisciplinary discussion remain useful in management of complex cases, including increasing lymphadenopathy at follow-up imaging, MRI evaluation of extent of disease, response to neoadjuvant treatment, and potentially confounding cases. An invited commentary by Weinstein is available online. ©RSNA, 2022.

Diagnostic Evaluation of Recalled Noncalcified Lesions Using Ultrasound Alone Versus Ultrasound Plus Additional Mammographic Views: A Prospective Study.

BACKGROUND. The diagnostic performance of digital breast tomosynthesis (DBT) has been shown to be equal to that of diagnostic mammography. However, the value of additional mammographic views in diagnostic evaluations remains unclear. OBJECTIVE. The purpose of this study was to compare the performance of diagnostic breast ultrasound (US) alone with that of combined US and diagnostic mammography for specific noncalcified recalled abnormalities detected on screening DBT. METHODS. This was a prospective study with a single-arm management strategy. Women recalled for noncalcified lesions on screening DBT underwent initial diagnostic US as part of the study protocol. Additional diagnostic mammography was performed at the discretion of the radiologist. Imaging assessment decisions determined by BI-RADS assessments and management recommendations, biopsy outcomes, and follow-up were recorded using case report forms completed on the day of the diagnostic evaluation and stored in the electronic medical record. RESULTS. From July 10, 2017, to June 6, 2019, a total of 430 recalled noncalcified lesions in 399 women (mean age, 60 ± 12 [SD] years) were included. US alone was performed for 71.2% (306/430) of lesions, whereas US with diagnostic mammography was performed for 28.8% (124/430). Of the recalled lesions, 93.7% (178/190) of masses, 60.0% (51/85) of focal asymmetries, 46.1% (53/115) of asymmetries, 69.2% (9/13) of developing asymmetries, and 55.6% (15/27) of architectural distortions were evaluated with US alone. Of 93 lesions that underwent needle biopsy, 40.9% (38/93) were cancers, all of which were invasive. Thirty-five of 38 (92.1%) cancers were evaluated by US alone, whereas three (7.9%) were evaluated with US and diagnostic mammography. At a median follow-up of 25 months, six cancers were identified (three with US alone and three with US plus diagnostic mammography) in patients with initially benign workup. US alone had two false-negative cancers (one architectural distortion identified at follow-up and one mass biopsied stereotactically at initial detection). CONCLUSION. US alone is effective in the diagnostic evaluation of noncalcified masses recalled on screening tomosynthesis. For asymmetries, diagnostic mammography may be best without the need for additional US, whereas architectural distortions still warrant diagnostic mammography and US. CLINICAL IMPACT. Radiologists should consider performing US first for DBT-recalled noncalcified masses. Omitting diagnostic mammography when US is negative has a low false-negative rate.

Multimodality Review of Imaging Features Following Breast Reduction Surgery.

Reduction mammoplasty is a common surgical procedure that removes a significant portion of the breast, and the resulting changes to the breast parenchyma are frequently seen on breast imaging studies. Any radiologist who interprets breast imaging studies must be able to recognize these changes in order to avoid unnecessary recall from screening and/or breast biopsy. The surgical techniques used in reduction mammoplasty are discussed in order to provide relevant background information for understanding the resulting imaging features. These imaging characteristics are presented for the most common breast imaging modalities, including mammography, ultrasound, and magnetic resonance imaging. Additionally, tips for distinguishing malignancy from postsurgical change are provided, as are potential pitfalls in imaging interpretation. To avoid unnecessary patient morbidity, it is critical to differentiate between the classic, benign imaging appearance of the breast after reduction mammoplasty and findings that indicate a potential malignancy.

Quality of Anatomic Staging of Breast Carcinoma in Hospitals in the United States, With Focus on Measurement of Tumor Dimension.

OBJECTIVES: We investigated the accuracy of clinical breast carcinoma anatomic staging and the greatest tumor dimension measurements. METHODS: We compared clinical stage and greatest dimension values with the pathologic reference standard values using 57,747 cases from the 2016 US National Cancer Institute Surveillance, Epidemiology, and End Results program who were treated by surgical resection without prior neoadjuvant therapy. RESULTS: Agreement for clinical vs pathologic anatomic TNM group stage, overall, is 74.3% ± 0.4%. Lymph node N staging overall agrees very well (85.1% ± 0.4%). Based on tumor dimension and location, T staging has an agreement of only 64.2% ± 0.4%, worsening to 55% without carcinoma in situ (Tis) cases. In approximately 25% of cases, pathologic T stage is higher than clinical T stage. The mean difference in the greatest dimension is 1.36 ± 9.59 mm with pathologic values being generally larger than clinical values; pathologic and clinical measurements correlate well. T-stage disagreement is associated with histology, tumor grade, tumor size, N stage, patient age, periodic biases in tumor size measurements, and overuse of family T-stage categories. Pathologic measurement biases include rounding and specimen-slicing intervals. CONCLUSIONS: Clinical and pathologic T-staging values agree only moderately. Pathologists face challenges in increasing the precision of gross tumor measurements, with the goal of improving the accuracy of clinical T staging and measurement.

Clinical Non-Small Cell Lung Cancer Staging and Tumor Length Measurement Results From U.S. Cancer Hospitals.

RATIONALE AND OBJECTIVES: Examine the accuracy of clinical non-small cell lung cancer staging and tumor length measurements, which are critical to prognosis and treatment planning. MATERIALS AND METHODS: Compare clinical and pathological staging and lengths using 10,320 2016 National Cancer Institute Surveillance, Epidemiology, and End Results (SEER) and 559 2010-2018 non-SEER single-institute surgically-treated cases, and analyze modifiable causes of disagreement. RESULTS: The SEER clinical and pathological group-stages agree only 62.3% ± 0.9% over all stage categories. The lymph node N-stage agrees much better at 83.0% ± 1.0%, but the tumor length-location T-stage agrees only 57.7% ± 0.8% with approximately 29% of the cases having a greater pathology than clinical T-stage. Individual T-stage category agreements with respect to the number of pathology cases are Tis, T1a, T1b, T2a, T2b, T3, T4: 89.9% ± 10.0%; 78.7% ± 1.7%; 51.8% ± 1.9%; 46.1% ± 1.3%; 40.5% ± 3.1%; 44.1% ± 2.2%; 56.4% ± 4.7%, respectively. Most of the single-institute results statistically agree with SEER's. Excluding Tis cases, the mean difference in SEER tumor length is ∼1.18 ± 9.26 mm (confidence interval: 0.97-1.39 mm) with pathological lengths being longer than clinical lengths except for small tumors; the two measurements correlate well (Pearson-r >0.87, confidence interval: 0.86-0.87). Reasons for disagreement include the use of family-category descriptors (e.g., T1) instead of their subcategories (e.g., T1a and T1b), which worsens the T-stage agreement by over 15%. Disagreement is also associated with higher tumor grade, larger resected specimens, higher N-stage, patient age, and periodic biases in clinical and pathological tumor size measurements. CONCLUSIONS: By including preliminary non-small cell lung cancer clinical stage values in their evaluation, diagnostic radiologists can improve the accuracy of staging and standardize tumor-size measurements, which improves patient care.

Diagnosis, Management, and Percutaneous Sampling of Nipple-Areolar Calcifications: How Radiologists Can Help Patients Avoid the Operating Room.

OBJECTIVE: Both benign and malignant causes of calcifications in the nipple-areolar complex exist. BI-RADS terminology applies to the description and classification of nipple-areolar calcifications in the same way it does to calcifications elsewhere in the breast. Minimally invasive sampling can be performed safely and accurately with ultrasound-guided techniques, with a few technical modifications. CONCLUSION: This article provides insight regarding the management algorithm and image-guided interventional techniques for sampling nipple-areolar calcifications as an essential competency for breast imaging practices.

Simplified, standardized methods to assess the accuracy of clinical cancer staging.

BACKGROUND: Hospitals lack intuitive methods to monitor their accuracy of clinical cancer staging, which is critical to treatment planning, prognosis, refinements, and registering quality data. METHODS: We introduce a tabulation framework to compare clinical staging with the reference-standard pathological staging, and quantify systematic errors. As an example, we analyzed 9,644 2016 U.S. National Cancer Institute SEER surgically-treated non-small cell lung cancer (NSCLC) cases, and computed concordance with different denominators to compare with incompatible past results. RESULTS: The concordance for clinical versus pathological lymph node N-stage is very good, 83.4 ± 1.0%, but the tumor length-location T-stage is only 58.1 ± 0.9%. There are intuitive insights to the causes of discordance. Approximately 29% of the cases are pathological T-stage greater than clinical T-stage, and 12% lower than the clinical T-stage, which is due partly to the fact that surgically-treated NSCLC are typically lower-stage cancer cases, which results in a bounded higher probability for pathological upstaging. Individual T-stage categories Tis, T1a, T1b, T2a, T2b, T3, T4 invariant percent-concordances are 85.2 ± 9.7 + 10.3%; 72.7 ± 1.6 + 11.3%; 46.6 ± 1.8 + 10.9%; 54.6 ± 1.6 - 20.5%; 41.6 ± 3.3 - 0.1%; 54.7 ± 2.8 - 24.1%; 55.2 ± 4.7 + 2.6%, respectively. Each percent-concordance is referenced to an averaged number of pathological and clinical cases. The first error number quantifies statistical fluctuations; the second quantifies clinical and pathological staging biases. Lastly, comparison of over and under staging versus clinical characteristics provides further insights. CONCLUSIONS: Clinical NSCLC staging accuracy and concordance with pathological values can improve. As a first step, the framework enables standardizing comparing staging results and detecting possible problem areas. Cancer hospitals and registries can implement the efficient framework to monitor staging accuracy.

Benign breast papillomas without atypia diagnosed with core needle biopsy: Outcome of surgical excision and imaging follow-up.

PURPOSE: To evaluate the surgical upgrade rate to malignancy and high-risk lesions in cases of papilloma without atypia diagnosed with imaging-guided percutaneous core needle biopsy (CNB) and to determine whether any lesion imaging features, biopsy techniques, and pathological factors can predict lesion upgrade to help guide clinical management. MATERIALS AND METHODS: Benign papillomas without atypia (n = 399) diagnosed with CNB were retrospectively reviewed. The surgical upgrade rate to malignancy or high-risk lesion (atypical ductal hyperplasia, atypical lobular hyperplasia, lobular carcinoma in-situ, flat epithelial atypia and atypical papilloma) was determined. Detection modality (i.e. mammography, ultrasonography (US), magnetic resonance imaging (MRI)), lesion type and size, biopsy-guidance modality (US, stereotactic, MRI), biopsy needle size (<14 G vs ≥14 G), use of vacuum assistance, and presenting symptoms were statistically analyzed. The reference standard for evaluation of upgrade was either excision or at least 24 months of imaging follow-up. Chi Square test and Fisher exact tests were performed for categorical variables, and the Mann-Whitney-U test was used for continuous variables. RESULTS: Ultrasound was the predominant biopsy modality (78.4 %, p < 0.001). Of the 399 benign papilloma lesions in 329 women, 239 (59.9 %) were excised and 93 others were followed for at least 24 months (total of 332). Of these 332 lesions, 7 (2.1 %) were upgraded to ductal carcinoma in-situ and 41 (12.3 %) to high-risk lesions at excision. Larger lesion size (≥15 mm, p = 0.009), smaller biopsy needle size (≥14 G, p = 0.027), and use of spring-loaded biopsy device (p = 0.012) were significantly associated with upgrade to atypia. Only lesion size (≥15 mm, p = 0.02) was associated with upgrade to cancer. CONCLUSION: Upgrade to malignancy of biopsy-proven benign papillomas without atypia at the time of surgery was sufficiently low (2.1 %) to support non-operative management. Surgery may be performed for selected cases- those with larger lesion size and those whose biopsies were performed with smaller spring-loaded biopsy needles.

Image improvement method for positron emission mammography.

PURPOSE: To evaluate in clinical use a rapidly converging, efficient iterative deconvolution algorithm (RSEMD) for improving the quantitative accuracy of previously reconstructed breast images by a commercial positron emission mammography (PEM) scanner. MATERIALS AND METHODS: The RSEMD method was tested on imaging data from clinical Naviscan Flex Solo II PEM scanner. This method was applied to anthropomorphic like breast phantom data and patient breast images previously reconstructed with Naviscan software to determine improvements in image resolution, signal to noise ratio (SNR) and contrast to noise ratio (CNR). RESULTS: In all of the patients' breast studies the improved images proved to have higher resolution, contrast and lower noise as compared with images reconstructed by conventional methods. In general, the values of CNR reached a plateau at an average of 6 iterations with an average improvement factor of about 2 for post-reconstructed Flex Solo II PEM images. Improvements in image resolution after the application of RSEMD have also been demonstrated. CONCLUSIONS: A rapidly converging, iterative deconvolution algorithm with a resolution subsets-based approach (RSEMD) that operates on patient DICOM images has been used for quantitative improvement in breast imaging. The RSEMD method can be applied to PEM images to enhance the resolution and contrast in cancer diagnosis to monitor the tumor progression at the earliest stages.

Magnetic resonance imaging characteristics of granulomatous mastitis.

Granulomatous mastitis (GM) is a benign chronic inflammatory condition of the breast. This study was performed to determine the utility of magnetic resonance imaging (MRI) in differentiating GM from malignancy. MRI findings in 12 women with clinical or histopathologically-proven GM were retrospectively reviewed. Non-mass enhancement on MRI was present in all 12 patients with clustered ring enhancement being the most common pattern (n=7, 58%). Architectural distortion (n=10, 83%), skin thickening (n=10, 83%) and focal skin enhancement (n=10, 83%) were also very common. MRI features of GM are often identical to features considered suspicious for malignancy on MRI.

Multimodality Imaging-based Evaluation of Single-Lumen Silicone Breast Implants for Rupture.

Breast implants are frequently encountered on breast imaging studies, and it is essential for any radiologist interpreting these studies to be able to correctly assess implant integrity. Ruptures of silicone gel-filled implants often occur without becoming clinically obvious and are incidentally detected at imaging. Early diagnosis of implant rupture is important because surgical removal of extracapsular silicone in the breast parenchyma and lymphatics is difficult. Conversely, misdiagnosis of rupture may prompt a patient to undergo unnecessary additional surgery to remove the implant. Mammography is the most common breast imaging examination performed and can readily depict extracapsular free silicone, although it is insensitive for detection of intracapsular implant rupture. Ultrasonography (US) can be used to assess the internal structure of the implant and may provide an economical method for initial implant assessment. Common US signs of intracapsular rupture include the "keyhole" or "noose" sign, subcapsular line sign, and "stepladder" sign; extracapsular silicone has a distinctive "snowstorm" or echogenic noise appearance. Magnetic resonance (MR) imaging is the most accurate and reliable means for assessment of implant rupture and is highly sensitive for detection of both intracapsular and extracapsular rupture. MR imaging findings of intracapsular rupture include the keyhole or noose sign, subcapsular line sign, and "linguine" sign, and silicone-selective MR imaging sequences are highly sensitive to small amounts of extracapsular silicone. ©RSNA, 2017.

Preoperative Radioactive Seed Localization for Nonpalpable Breast Lesions: Technique, Pitfalls, and Solutions.

Iodine 125 ((125)I) radioactive seed localization has emerged as a reliable and safe alternative to wire localization for guidance during the surgical resection of nonpalpable breast lesions. The breast imager has a responsibility to be familiar with the general principles of this evolving technique, including its advantages and disadvantages as well as the technical differences involved in placement of seeds versus traditional wire localization. Although placement of (125)I seeds is conceptually similar to wire placement, there are additional technical considerations and safety measures that need to be addressed and implemented when radioactive seeds are used. We draw from our experience with more than 1000 cases of radioactive seed localization since inception of our program in 2009 to provide illustrative examples of not only the proper technique of radioactive seed localization, but also mishaps that may occur during this procedure, along with practical suggestions to prevent these problems. We examine some of the difficulties that we have encountered during radioactive seed localization at our institution, including bone wax mimicking the seed, the inadvertent deployment of seeds, the need for multiple seeds or supplemental wires, problematic seed locations, and difficulty in surgical retrieval of the seed. Recognizing the potential pitfalls of radioactive seed localization and understanding the appropriate guidelines and precautions for the safe, secure handling and placement of radioactive seeds is essential for a successful radioactive seed localization program.