Breast Imaging and Intervention during Pregnancy and Lactation.

Physiologic changes that occur in the breast during pregnancy and lactation create challenges for breast cancer screening and diagnosis. Despite these challenges, imaging evaluation should not be deferred, because delayed diagnosis of pregnancy-associated breast cancer contributes to poor outcomes. Both screening and diagnostic imaging can be safely performed using protocols based on age, breast cancer risk, and whether the patient is pregnant or lactating. US is the preferred initial imaging modality for the evaluation of clinical symptoms in pregnant women, followed by mammography if the US findings are suspicious for malignancy or do not show the cause of the clinical symptom. Breast MRI is not recommended during pregnancy because of the use of intravenous gadolinium-based contrast agents. Diagnostic imaging for lactating women is the same as that for nonpregnant nonlactating individuals, beginning with US for patients younger than 30 years old and mammography followed by US for patients aged 30 years and older. MRI can be performed for high-risk screening and local-regional staging in lactating women. The radiologist may encounter a wide variety of breast abnormalities, some specific to pregnancy and lactation, including normal physiologic changes, benign disorders, and malignant neoplasms. Although most masses encountered are benign, biopsy should be performed if the imaging characteristics are suspicious for cancer or if the finding does not resolve after a short period of clinical follow-up. Knowledge of the expected imaging appearance of physiologic changes and common benign conditions of pregnancy and lactation is critical for differentiating these findings from pregnancy-associated breast cancer. ©RSNA, 2023 Online supplemental material is available for this article. Quiz questions for this article are available through the Online Learning Center.

Community-based Participatory Research: A Practical Guide for Radiologists.

Community-based participatory research (CBPR) is defined by the Kellogg Community Health Scholars Program as a collaborative process that equitably involves all partners in the research process and recognizes the unique strengths that each community member brings. The CBPR process begins with a research topic of importance to the community, with the goal of combining knowledge and action with social change to improve community health and eliminate health disparities. CBPR engages and empowers affected communities to collaborate in defining the research question; sharing the study design process; collecting, analyzing, and disseminating the data; and implementing solutions. A CBPR approach in radiology has several potential applications, including removing limitations to high-quality imaging, improving secondary prevention, identifying barriers to technology access, and increasing diversity in the research participation for clinical trials. The authors provide an overview with the definitions of CBPR, explain how to conduct CBPR, and illustrate its applications in radiology. Finally, the challenges of CBPR and useful resources are discussed in detail. ©RSNA, 2023 Quiz questions for this article are available in the supplemental material.

A Pilot of Data-Driven Modeling to Assess Potential for Improved Efficiency in an Academic Breast-Imaging Center.

Patient satisfaction and department efficiency are central pillars in defining quality in medicine. Patient satisfaction is often linked to wait times. We describe a novel method to study workflow and simulate solutions to improve efficiency, thereby decreasing wait times and adding value. We implemented a real-time location system (RTLS) in our academic breast-imaging department to study workflow, including measuring patient wait time, quantifying equipment utilization, and identifying bottlenecks. Then, using discrete event simulation (DES), we modeled solutions with changes in staffing and equipment. Nine hundred and ninety-nine patient encounters were tracked over a 10-week period. The RTLS system recorded 551,512 raw staff and patient time stamps, which were analyzed to produce 17,042 staff and/or patient encounter time stamps. Mean patient wait time was 27 min. The digital breast tomosynthesis (DBT) unit had the highest utilization rate and was identified as a bottleneck. DES predicts a 19.2% reduction in patient length of stay with replacement of a full field digital mammogram (FFDM) unit by a DBT unit and the addition of technologists. Through integration of RTLS with discrete event simulation testing, we created a model based on real-time data to accurately assess patient wait times and patient progress through an appointment, evaluate patient staff-interaction, identify system bottlenecks, and quantitate potential solutions. This quality improvement initiative has important implications, potentially allowing data-driven decisions for staff hiring, equipment purchases, and department layout.

CT severity of post-ERCP pancreatitis: results from a single tertiary medical center.

PURPOSE: To evaluate the CT severity of post-ERCP pancreatitis (PEP) and determine the association between radiographic and clinical severity. METHODS: There were 1332 patients admitted to the hospital with suspicion for PEP after undergoing ERCP as outpatients over a 10-year period, of whom 84 (6.3%) patients underwent at least one contrast-enhanced CT scan while hospitalized were evaluated. All CT scans were evaluated by two radiologists, and the modified CT severity index (MCTSI) score was calculated. Demographic, clinical, and procedural data as well as clinical severity parameters including systemic inflammatory response syndrome, organ failure, need for ICU, need for intervention, length of hospital stay, and mortality were recorded. Statistical analysis was performed using the χ (2) and Student's t test or ANOVA and logistic regression analysis. RESULTS: Patients were predominantly females (70%) with a mean age of 46.5 years (range 20-86). The most common indication for ERCP was sphincter of Oddi dysfunction. MCTSI was graded as mild in 45 (53.6%), moderate in 36 (42.8%), and severe in 3 (3.6%) patients. The interobserver agreement was excellent (κ: 0.91, p < 0.0001) for MCTSI. The duration of ERCP (p = 0.005) was the only risk factor for PEP that significantly correlated with the MCTSI score. Increasing MCTSI was significantly associated with hospital length of stay. CONCLUSIONS: PEP is typically a mild disease by radiologic and clinical criteria. Longer duration of ERCP is a risk factor for severe radiologic PEP. Severe radiographic PEP is associated with significantly longer hospital length of stay.

Multimodality imaging review of metastatic melanoma involving the breast.

Melanoma is among the most commonly reported non-mammary primary tumors to metastasize to the breast. Unfortunately, evidence of melanoma metastasis to any site portends a poor prognosis. Imaging studies can be useful in the early detection of metastatic melanoma which is essential for appropriate management of this disease. There have been very few previous studies on the imaging findings of metastatic melanoma especially across multiple imaging modalities. This review aims to describe these imaging features seen on mammography, ultrasound, magnetic resonance imaging (MRI) and fluorodeoxyglucose-positron emission tomography computed tomography (FDG PET/CT) using three case examples. Our findings, consistent with previous studies, describe melanoma metastases to the breast as largely non-specific, round or oval masses with circumscribed margins and homogeneous internal enhancement.

NAM National Plan for Health Workforce Well-being: Applications for Radiology.

The National Academy of Medicine Plan for Health Workforce Well-Being identifies seven priority areas, including creating positive work environments, addressing burnout and stress, promoting transparency and equity in compensation, providing education and training to promote resilience, enhancing community and social support systems, addressing the stigma associated with seeking help for mental health and substance use disorders and fostering leadership commitment and accountability for workforce well-being. This paper will explore the National Plan for Health Workforce Well-Being, providing an overview of the seven priority areas and offering strategies for implementation in radiology.

The mammographic density of a mass is a significant predictor of breast cancer.

PURPOSE: To determine whether the mammographic density of noncalcified solid breast masses is associated with malignancy and to measure the agreement between prospective and retrospective assessment. MATERIALS AND METHODS: The institutional review board approved this study and waived informed consent. Three hundred forty-eight consecutive breast masses in 328 women who underwent image-guided or surgical biopsy between October 2005 and December 2007 were included. All 348 biopsy-proved masses were randomized and assigned to a radiologist who was blinded to biopsy results for retrospective assessment by using the Breast Imaging Reporting and Data System (retrospectively assessed data set). Clinical radiologists prospectively assessed the density of 180 of these masses (prospectively assessed data set). Pathologic result at biopsy was the reference standard. Benign masses were followed for at least 1 year by linking each patient to a cancer registry. Univariate analyses were performed on the retrospectively assessed data set. The association of mass density and malignancy was examined by creating a logistic model for the prospectively assessed data set. Agreement between prospective and retrospective assessments was calculated by using the κ statistic. RESULTS: In the retrospectively assessed data set, 70.2% of high-density masses were malignant, and 22.3% of the isodense or low-density masses were malignant (P < .0001). In the prospective logistic model, high density (odds ratio, 6.6), irregular shape (odds ratio, 9.9), spiculated margin (odds ratio, 20.3), and age (ß = 0.09, P < .0001) were significantly associated with the probability of malignancy. The κ value for prospective-retrospective agreement of mass density was 0.53. CONCLUSION: High mass density is significantly associated with malignancy in both retrospectively and prospectively assessed data sets, with moderate prospective-retrospective agreement. Radiologists should consider mass density as a valuable descriptor that can stratify risk. SUPPLEMENTAL MATERIAL: http://radiology.rsna.org/lookup/suppl/doi:10.1148/radiol.10100328/-/DC1.

Screening Digital Breast Tomosynthesis: Radiation Dose Among Patients With Breast Implants.

OBJECTIVE: To compare the mean glandular dose (MGD), cancer detection rate (CDR), and recall rate (RR) among screening examinations of patients with breast implants utilizing various digital breast tomosynthesis (DBT)-based imaging protocols. METHODS: This IRB-approved retrospective study included 1998 women with breast implants who presented for screening mammography between December 10, 2013, and May 29, 2020. Images were obtained using various protocol combinations of DBT and 2D digital mammography. Data collected included MGD, implant type and position, breast density, BI-RADS final assessment category, CDR, and RR. Statistical analysis utilized type II analysis of variance and the chi-square test. RESULTS: The highest MGD was observed in the DBT only protocol, while the 2D only protocol had the lowest (10.29 mGy vs 5.88 mGy, respectively). Statistically significant difference in MGD was observed across protocols (P < 0.0001). The highest per-view MGD was among DBT full-field (FF) views in both craniocaudal and mediolateral oblique projections (P < 0.0001). No significant difference was observed in RR among protocols (P = 0.17). The combined 2D (FF only) + DBT implant-displaced (ID) views protocol detected the highest number of cancers (CDR, 7.2 per 1000), but this was not significantly different across protocols (P = 0.48). CONCLUSION: The combination of 2D FF views and DBT ID views should be considered for women with breast implants in a DBT-based screening practice when aiming to minimize radiation exposure without compromising the sensitivity of cancer detection. Avoidance of DBT FF in this patient population is recommended to minimize radiation dose.

Informatics in radiology: comparison of logistic regression and artificial neural network models in breast cancer risk estimation.

Computer models in medical diagnosis are being developed to help physicians differentiate between healthy patients and patients with disease. These models can aid in successful decision making by allowing calculation of disease likelihood on the basis of known patient characteristics and clinical test results. Two of the most frequently used computer models in clinical risk estimation are logistic regression and an artificial neural network. A study was conducted to review and compare these two models, elucidate the advantages and disadvantages of each, and provide criteria for model selection. The two models were used for estimation of breast cancer risk on the basis of mammographic descriptors and demographic risk factors. Although they demonstrated similar performance, the two models have unique characteristics-strengths as well as limitations-that must be considered and may prove complementary in contributing to improved clinical decision making.

Validation of results from knowledge discovery: mass density as a predictor of breast cancer.

The purpose of our study is to identify and quantify the association between high breast mass density and breast malignancy using inductive logic programming (ILP) and conditional probabilities, and validate this association in an independent dataset. We ran our ILP algorithm on 62,219 mammographic abnormalities. We set the Aleph ILP system to generate 10,000 rules per malignant finding with a recall >5% and precision >25%. Aleph reported the best rule for each malignant finding. A total of 80 unique rules were learned. A radiologist reviewed all rules and identified potentially interesting rules. High breast mass density appeared in 24% of the learned rules. We confirmed each interesting rule by calculating the probability of malignancy given each mammographic descriptor. High mass density was the fifth highest ranked predictor. To validate the association between mass density and malignancy in an independent dataset, we collected data from 180 consecutive breast biopsies performed between 2005 and 2007. We created a logistic model with benign or malignant outcome as the dependent variable while controlling for potentially confounding factors. We calculated odds ratios based on dichomotized variables. In our logistic regression model, the independent predictors high breast mass density (OR 6.6, CI 2.5-17.6), irregular mass shape (OR 10.0, CI 3.4-29.5), spiculated mass margin (OR 20.4, CI 1.9-222.8), and subject age (ß = 0.09, p < 0.0001) significantly predicted malignancy. Both ILP and conditional probabilities show that high breast mass density is an important adjunct predictor of malignancy, and this association is confirmed in an independent data set of prospectively collected mammographic findings.

Image-based screening for men at high risk for breast cancer: Benefits and drawbacks.

Male breast cancer is a rare malignancy. Due to low prevalence and limited data to support male breast cancer screening, there are currently no recommendations for image-based screening in asymptomatic men and few recommendations for men at high risk for breast cancer. However, symptomatically diagnosed cancers in men are typically advanced, suggesting that earlier detection may improve outcomes. In this article we briefly review the risk factors for male breast cancer, and discuss the potential benefits and possible drawbacks of routine image-based screening for men at high risk for breast cancer.

A Review of Options for Localization of Axillary Lymph Nodes in the Treatment of Invasive Breast Cancer.

Invasive breast cancer is a common disease, and the most common initial site of metastatic disease are the axillary lymph nodes. As the standard of care shifts towards less invasive surgery in the axilla for patients with invasive breast cancer, techniques have been developed for axillary node localization that allow targeted dissection of specific lymph nodes without requiring full axillary lymph node dissection. Many of these techniques have been adapted from technologies developed for localization of lesions within the breast and include marker clip placement with intraoperative ultrasound, carbon-suspension liquids, localization wires, radioactive seeds, magnetic seeds, radar reflectors, and radiofrequency identification devices.The purpose of this article is to summarize these methods and describe benefits and drawbacks of each method for performing localization of lymph nodes in the axilla.

Development of Breast Imaging Specific Entrustable Professional Activities Using a Double Delphi Technique.

RATIONAL AND OBJECTIVES: To develop subspecialty-specific entrustable professional activities for breast imaging radiology (EPA-BRs) through the use of a double consensus-driven, validity-enhancing methodology that may be relevant to other subspecialties in radiology and medicine in general. MATERIALS AND METHODS: A six-step methodology was used to develop EPA-BRs via a double Delphi process followed by educational theorist's refinement. Two groups of experts completed each Delphi process: the core group of breast imaging educators and an expert panel of national experts in breast imaging standards and appropriateness. RESULTS: Five EPA-BRs were developed, with eight nested EPA-BRs, one of which is elective. This comprehensive list of EPA-BRs covers the role of a breast imaging radiologist in the care of a patient from detection of breast cancer to post-treatment follow-up. CONCLUSION: A combined modified and classic double Delphi approach can be utilized by other graduate medical education (GME) specialties and subspecialties as a method by which GME education can be transformed into a clinical framework that more closely bridges individual competencies and real-world clinical practice.

Digital breast tomosynthesis: Image acquisition principles and artifacts.

Digital breast tomosynthesis (DBT) is a new technology that is being used more frequently for both breast cancer screening and diagnostic purposes and its utilization is likely to continue to increase over time. The major benefit of tomosynthesis over 2D-mammography is that it allows radiologists to view breast tissue using a three-dimensional dataset and improves diagnostic accuracy by facilitating differentiation of potentially malignant lesions from overlap of normal tissue. In addition, image processing techniques allow reconstruction of two dimensional synthesized mammograms (SM) from DBT data, which eliminates the need for acquiring two dimensional full field digital mammography (FFDM) in addition to tomosynthesis and thereby reduces the radiation dose. DBT systems incorporate a moveable x-ray tube, which moves in a prescribed way over a limited angular range to obtain three-dimensional data of patients' breasts, and utilize reconstruction algorithms. The limited angular range for DBT leads to incomplete sampling of the object, and a movable x-ray tube prolongs the imaging time, both of which make DBT and SM susceptible to artifacts. Understanding the etiology of these artifacts should help radiologists in reducing the number of artifacts and in differentiating a true finding from one related to an artifact, thus potentially decreasing recall rates and false positive rates. This is becoming especially important with increased incorporation of DBT in practices around the world. The goal of this article is to review the physics principles behind DBT systems and use these principles to explain the origin of artifacts that can limit diagnostic evaluation.

Comparison of screening full-field digital mammography and digital breast tomosynthesis technical recalls.

Enhancing quality using the inspection program (EQUIP) augments the FDA/MQSA program ensuring image quality review and implementation of corrective processes. We compared technical recalls between digital breast tomosynthesis (DBT) and full-field digital mammography (FFDM). Prospectively recorded technical recalls of consecutive screening mammograms (10/2013 - 12/2017) were compared for imaging modality [FFDM, DBT + FFDM, DBT + synthesized mammography (SynM)], images requested, and indication(s) (motion, positioning, technical/artifact). Chi-squared tests evaluated statistical significance between proportions. Of 48,324 screening mammograms, 277 (0.57%) patients were recalled for 360 indications with 371 repeated views. DBT exams had significantly less recalls compared to FFDM ( X 2 = 25.239 ; p = 0 < 0.001 ). 98 (27.2%) recalls were for motion, 192 (53.3%) positioning, and 70 (19.4%) technique/artifacts. Theses indications for technical recall were compared for FFDM, DBT + FFDM, and DBT + SynM. There were significant differences in the indications for technical recall prior to and after implementing DBT + SynM ( X 2 = 18.719 ; p < 0.001 ). Technical recalls declined significantly with the inclusion of DBT (SynM/FFDM) compared to FFDM alone. Recalls for motion demonstrated the greatest decrease. Positioning remains a dominant factor for technical recall regardless of modality, supporting the opportunity for continued technologist education in positioning to decrease technical recalls.

Longitudinal association between infant disorganized attachment and childhood posttraumatic stress symptoms.

The purpose of this study was to evaluate whether children with a history of disorganized attachment in infancy were more likely than children without a history of disorganized attachment to exhibit symptoms of posttraumatic stress disorder (PTSD) at school age following trauma exposure. The sample consisted of 78 8.5-year-old children from a larger, ongoing prospective study evaluating the effects of intrauterine cocaine exposure (IUCE) on children's growth and development from birth to adolescence. At the 12-month visit, children's attachment status was scored from videotapes of infant-caregiver dyads in Ainsworth's strange situation. At the 8.5-year visit, children were administered the Violence Exposure Scale-Revised, a child-report trauma exposure inventory, and the Diagnostic Interview for Children and Adolescents by an experienced clinical psychologist masked to children's attachment status and IUCE status. Sixteen of the 78 children (21%) were classified as insecure-disorganized/insecure-other at 12 months. Poisson regressions covarying IUCE, gender, and continuity of maternal care indicated that disorganized attachment status at 12 months, compared with nondisorganized attachment status, significantly predicted both higher avoidance cluster PTSD symptoms and higher reexperiencing cluster PTSD symptoms. These findings suggest that the quality of early dyadic relationships may be linked to differences in children's later development of posttraumatic stress symptoms following a traumatic event.

Synthesized Mammography: The New Standard of Care When Screening for Breast Cancer with Digital Breast Tomosynthesis?

RATIONALE AND OBJECTIVES: This study aims to evaluate the screening performance of digital breast tomosynthesis (DBT) combined with synthesized mammography (SM) vs combined with full-field digital mammography (FFDM). MATERIALS AND METHODS: We retrospectively reviewed all screening studies utilizing FFDM + DBT (n = 7845) and SM + DBT (n = 14,776) between April 1, 2013, and February 15, 2016. Recall rate, biopsy rate, positive predictive value 1 (PPV1), positive predictive value 3 (PPV3), and cancer detection rate (CDR) were compared between the two groups. A generalized linear mixed model specifying the reading radiologist as the random effect and controlling for age was used to compare clinical outcomes between the two groups. RESULTS: The overall recall rate was significantly lower in the SM + DBT cohort compared to the FFDM + DBT cohort (7.06% vs 7.63%, P = .04). There was no difference in biopsy rate, PPV1, PPV3, or CDR between the two groups. CONCLUSIONS: When DBT is performed for screening, the use of SM rather than acquiring an additional FFDM has no significant effect on biopsy rate, PPV1, PPV3, or CDR. We found a decrease in recall rate in the SM + DBT group, which may be related to the learning curve of interpreting DBT. These findings support the use of SM for patients undergoing screening with DBT.

Developing a comprehensive database management system for organization and evaluation of mammography datasets.

We aimed to design and develop a comprehensive mammography database system (CMDB) to collect clinical datasets for outcome assessment and development of decision support tools. A Health Insurance Portability and Accountability Act (HIPAA) compliant CMDB was created to store multi-relational datasets of demographic risk factors and mammogram results using the Breast Imaging Reporting and Data System (BI-RADS) lexicon. The CMDB collected both biopsy pathology outcomes, in a breast pathology lexicon compiled by extending BI-RADS, and our institutional breast cancer registry. The audit results derived from the CMDB were in accordance with Mammography Quality Standards Act (MQSA) audits and national benchmarks. The CMDB has managed the challenges of multi-level organization demanded by the complexity of mammography practice and lexicon development in pathology. We foresee that the CMDB will be useful for efficient quality assurance audits and development of decision support tools to improve breast cancer diagnosis. Our procedure of developing the CMDB provides a framework to build a detailed data repository for breast imaging quality control and research, which has the potential to augment existing resources.

Online support: Impact on anxiety in women who experience an abnormal screening mammogram.

OBJECTIVES: To determine whether an online support tool can impact anxiety in women experiencing an abnormal mammogram. MATERIALS AND METHODS: We developed an online support system using the Comprehensive Health Enhancement Support System (CHESS) designed for women experiencing an abnormal mammogram as a model. Our trial randomized 130 of these women to online support (the intervention group) or to a list of five commonly used Internet sites (the comparison group). Surveys assessed anxiety and breast cancer worry, and patient satisfaction at three important clinical time points: when women were notified of their abnormal mammogram, at the time of diagnostic imaging, and at the time of biopsy (if biopsy was recommended). RESULTS: Study participants in the intervention group showed a significant decrease in anxiety at the time of biopsy compared to the comparison group (p = 0.017). However, there was no significant difference in anxiety between the intervention group and the comparison group at the time of diagnostic work-up. We discontinued assessment of patient satisfaction after finding that many women had substantial difficulty answering the questions that referenced their physician, because they did not understand who their physician was for this process of care. CONCLUSION: The combination of the inability to identify the physician providing care during the mammography work-up and anxiety effects seen only after an interaction with the breast imaging team may indicate that online support only decreases the anxiety of women in concert with direct interpersonal support from the healthcare team.

Evaluating the completeness of RadLex in the chest radiography domain.

RATIONALE AND OBJECTIVES: RadLex was developed to create a unified language for radiologists. Despite the large number of terms, little research has evaluated the degree to which RadLex contains terms frequently used in clinical practice. The purposes of this project are to estimate the completeness of RadLex in the chest radiography domain and to characterize the absent terms. We chose chest radiography because it is a common exam generating a large number of reports, and the terms used represent a relatively well-circumscribed set of terms compared to other anatomic regions and modalities. MATERIALS AND METHODS: We collected a random sample of 100 chest radiograph reports from 1 month of routine clinical practice of three board-certified radiologists. We parsed each report's findings and impression sections into individual objects. An "object" was defined as any discrete physical object, body part, observation, descriptive modifier, diagnosis, or procedure. Objects were compared to RadLex by entering the object into the RadLex Term Browser. We calculated descriptive statistics and compared the match rate across RadLex categories. RESULTS: We identified 339 unique objects, with an overall match rate of 62%. The match rate for each category was anatomic object, 77%; physiological condition, 73%; physical object, 65%; imaging observation, 47%; procedure, 0%; other, 41% (P < .0005). CONCLUSIONS: Our study shows that despite the large number of terms in RadLex, terms are still absent and complexities in the definitions of terms exist. However, increasing the completeness and refining the definitions in RadLex is easily surmountable, possibly using manual methods.