Impact of the COVID-19 pandemic on breast cancer screening volumes and patient screening behaviors.

PURPOSE: In order to facilitate targeted outreach, we sought to identify patient populations with a lower likelihood of returning for breast cancer screening after COVID-19-related imaging center closures. METHODS: Weekly total screening mammograms performed throughout 2019 (baseline year) and 2020 (COVID-19-impacted year) were compared. Demographic and clinical characteristics, including age, race, ethnicity, breast density, breast cancer history, insurance status, imaging facility type used, and need for interpreter, were compared between patients imaged from March 16 to October 31 in 2019 (baseline cohort) and 2020 (COVID-19-impacted cohort). Census data and an online map service were used to impute socioeconomic variables and calculate travel times for each patient. Logistic regression was used to identify patient characteristics associated with a lower likelihood of returning for screening after COVID-19-related closures. RESULTS: The year-over-year cumulative difference in screening mammogram volumes peaked in week 21, with 2962 fewer exams in the COVID-19-impacted year. By week 47, this deficit had reduced by 49.4% to 1498. A lower likelihood of returning for screening after COVID-19-related closures was independently associated with younger age (odds ratio (OR) 0.78, p < 0.001), residence in a higher poverty area (OR 0.991, p = 0.014), lack of health insurance (OR 0.65, p = 0.007), need for an interpreter (OR 0.68, p = 0.029), longer travel time (OR 0.998, p < 0.001), and utilization of mobile mammography services (OR 0.27, p < 0.001). CONCLUSION: Several patient factors are associated with a lower likelihood of returning for screening mammography after COVID-19-related closures. Knowledge of these factors can guide targeted outreach to vulnerable patients to facilitate breast cancer screening.

Outcome of Architectural Distortion Detected Only at Breast Tomosynthesis versus 2D Mammography.

Purpose To compare the outcome of architectural distortion (AD) without associated mass only on digital breast tomosynthesis (DBT) with AD seen at two-dimensional (2D) mammography and to evaluate if the incidence of malignancy is influenced by the presence of a correlate at ultrasonography (US). Materials and Methods This retrospective study had institutional review board approval and was HIPAA compliant. All consecutive cases in which patients with AD were ultimately assigned Breast Imaging Reporting and Data System (BI-RADS) 4 or 5 categories from 2009 to 2016 were reviewed by three readers for visibility (2D vs DBT). The level of suspicion was assigned using a Likert scale. Pathologic results were compared between 2D-detected and DBT-detected AD. Frequencies were compared by using the McNemar and Pearson χ2 exact tests. Results One hundred eighty-one AD lesions were included; 122 (67.4%) were 2D visible while 59 (32.6%) were DBT detected. Forty-two women (with 43 lesions) underwent 2D mammography prior to initiation of DBT. In 117 women with 121 AD lesions who underwent 2D mammography plus DBT, 59 lesions (48.8%) were detected only with DBT. The malignancy rate based on final pathology was significantly higher for 2D-detected AD (53 [43.4%] of 122) compared with DBT (six [10.2%] of 59) (P < .001). A US correlate was more frequent with 2D-detected AD (103 [84.4%] of 122) than DBT (33 [55.9%] of 59) (P < .001). Malignancy rate was not different for DBT-detected AD with (four [12.1%] of 33; 95% confidence interval [CI]: 3.4%, 28.2%]) or without (two [7.7%] of 26; 95% CI: 0.9%, 25.1%]) a US correlate. NPV based on radiologists' level of suspicion was high (91.8%-98.0%) but not sufficient enough to forgo biopsy. Conclusion DBT-detected suspicious AD has a lower malignancy outcome compared with 2D mammography-detected suspicious AD, although still high enough to warrant biopsy. © RSNA, 2018 Online supplemental material is available for this article.

Comparison Between Digital and Synthetic 2D Mammograms in Breast Density Interpretation.

OBJECTIVE: The purpose of this study was to compare assessments of breast density on synthetic 2D images as compared with digital 2D mammograms. MATERIALS AND METHODS: This retrospective study included consecutive women undergoing screening with digital 2D mammography and tomosynthesis during May 2015 with a negative or benign outcome. In separate reading sessions, three radiologists with 5-25 years of clinical experience and 1 year of experience with synthetic 2D mammography read digital 2D and synthetic 2D images and assigned breast density categories according to the 5th edition of BI-RADS. Inter- and intrareader agreement was assessed for each BI-RADS density assessment and combined dense and nondense categories using percent agreement and Cohen kappa coefficient for consensus and all reads. RESULTS: A total of 309 patients met study inclusion criteria. Agreement between consensus BI-RADS density categories assigned for digital and synthetic 2D mammography was 80.3% (95% CI, 75.4-84.5%) with κ = 0.73 (95% CI, 0.66-0.79). For combined dense and nondense categories, agreement reached 91.9% (95% CI, 88.2-94.7%). For consensus readings, similar numbers of patients were shifted between nondense and dense categories (11 and 14, respectively) with the synthetic 2D compared with digital 2D mammography. Interreader differences were apparent; assignment to dense categories was greater with digital 2D mammography for reader 1 (odds ratio [OR], 1.26; p = 0.002), the same for reader 2 (OR, 0.91; p = 0.262), and greater with synthetic 2D mammography for reader 3 (OR, 0.86; p = 0.033). CONCLUSION: Overall, synthetic 2D mammography is comparable with digital 2D mammography in assessment of breast density, though there is some variability by reader. Practices can readily adopt synthetic 2D mammography without concern that it will affect density assessment and subsequent recommendations for supplemental screening.

Digital Breast Tomosynthesis in the Diagnostic Setting: Indications and Clinical Applications.

Digital breast tomosynthesis (DBT) is an emerging technology used in diagnostic breast imaging to evaluate potential abnormalities. In DBT, the compressed breast tissue is imaged in a quasi-three-dimensional manner by performing a series of low-dose radiographic exposures and using the resultant projection image dataset to reconstruct cross-sectional in-plane images in standard mammographic views. Improved visualization of breast detail at diagnostic DBT allows improved characterization of findings, including normal structures and breast cancer. This technology reduces the summation of overlapping breast tissue, which can mimic breast cancer, and provides improved detail of noncalcified mammographic findings seen in breast cancer. It also assists in lesion localization and determining mammographic extent of disease in women with known or suspected breast cancer. The authors review the potential uses, benefits, and limitations of DBT in the diagnostic setting and discuss how radiologists can best use DBT to characterize lesions, localize potential abnormalities, and evaluate the extent of known or suspected breast cancer. The authors' experience shows that DBT can be implemented effectively in the diagnostic workflow to evaluate and localize potential lesions more efficiently. DBT may potentially replace conventional supplemental mammography at diagnostic workup and obviate ultrasonography in select cases.

Patient Experience of Women With Dense Breasts Undergoing Screening Contrast-Enhanced Mammography.

OBJECTIVE: We investigated patient experience with screening contrast-enhanced mammography (CEM) to determine whether a general population of women with dense breasts would accept CEM in a screening setting. METHODS: In this institutional review board-approved prospective study, patients with heterogeneous and extremely dense breasts on their mammogram were invited to undergo screening CEM and complete pre-CEM and post-CEM surveys. On the pre-CEM survey, patients were asked about their attitudes regarding supplemental screening in general. On the post-CEM survey, patients were asked about their experience undergoing screening CEM, including causes and severity of any discomfort and whether they would consider undergoing screening CEM again in the future or recommend it to a friend. RESULTS: One hundred sixty-three women were surveyed before and after screening CEM. Most patients, 97.5% (159/163), reported minimal or no unpleasantness associated with undergoing screening CEM. In addition, 91.4% (149/163) said they would probably or very likely undergo screening CEM in the future if it cost the same as a traditional screening mammogram, and 95.1% (155/163) said they would probably or very likely recommend screening CEM to a friend. Patients in this study, who were all willing to undergo CEM, more frequently reported a family history of breast cancer than a comparison cohort of women with dense breasts (58.2% vs 47.1%, P = .027). CONCLUSION: Patients from a general population of women with dense breasts reported a positive experience undergoing screening CEM, suggesting screening CEM might be well received by this patient population, particularly if the cost was comparable with traditional screening mammography.

Factors associated with perceived personal risk for breast cancer among women with dense breasts.

PURPOSE: To determine what patient factors are associated with a high or an accurate perceived personal risk (PPR) for breast cancer. METHODS: An IRB-approved survey study of women with dense breasts presenting for annual screening mammography was previously conducted from March 2017 to February 2018. Patients were asked to estimate their personal risk for breast cancer and to answer questions about prior breast care-related medical interactions. Survey data were combined post hoc with demographic and clinical data, including breast cancer risk status, and socioeconomic data imputed for each patient from census data. Logistic regression was used to determine which patient factors were associated with a high or accurate PPR. RESULTS: Surveys were completed by 508 women with dense breasts (median age 59.0 years). A high PPR was independently associated with younger age (AOR, 1.71 [95% CI, 1.13, 2.60]), family history of breast cancer (AOR 4.27 [95% CI, 2.81-7.34]), having a clinical "high-risk" designation (AOR, 3.43 [95% CI, 1.13-10.39], and having been called back from screening (AOR, 1.94 [95% CI, 1.14-3.32]). A lower accuracy of PPR was independently associated with a family history of breast cancer (AOR, 0.25 [95% CI, 0.14-0.42]) and having been called back from screening (AOR, 0.58 [95% CI, 0.35-0.98]). CONCLUSION: Women with dense breasts who had a family history of breast cancer or who had been called back from screening had a higher but less accurate PPR. Women with a "high-risk" clinical designation had a higher PPR, even when controlling for family history.

Advantages and Challenges of Using Breast Biopsy Markers.

Percutaneous image-guided biopsy procedures are the standard of care for histologic assessment of suspicious breast lesions. Post-biopsy tissue markers (clips) optimize patient management by allowing for assessment on follow-up imaging and precise lesion localization. Markers are used to ensure accurate correlation between imaging modalities, guide preoperative localization for malignant and high-risk lesions, and facilitate accurate identification of benign lesions at follow-up. Local practices differ widely, and there are no data detailing the exact frequency of use of clips for different breast biopsies. There are many indications for biopsy marker deployment, and some difficulties may be encountered after placement. The placement of biopsy markers has many advantages and few disadvantages, such that deployment should be routinely used after percutaneous biopsy procedures with rare exception.

"What Do You Mean It's Not Cancer?" A Review of Autoimmune and Systemic Inflammatory Diseases Involving the Breast.

Autoimmune and systemic inflammatory diseases represent a heterogeneous group of immune-mediated conditions with a wide range of clinical presentations and various affected organs. Autoimmune diseases can present in the breast as localized disease or as part of systemic involvement. Although breast involvement is uncommon, the spectrum of imaging findings can include breast masses, axillary adenopathy, calcifications, and skin changes, the appearance of which can mimic breast cancer. Common etiologies include diabetic mastopathy, systemic lupus erythematosus, scleroderma, rheumatoid arthritis, idiopathic granulomatous mastitis, sarcoidosis, and Immunoglobulin-G4 related mastopathy. This educational review will present multimodality imaging findings of breast manifestations of systemic inflammatory and autoimmune diseases and coexisting complications. It will also review how these disorders may affect breast cancer risk and breast cancer treatment options, including radiation therapy.

Treatment of Breast Fibroadenoma with Ultrasound-Guided High-Intensity Focused Ultrasound Ablation: A Feasibility Study.

OBJECTIVE: Breast fibroadenomas (FAs) are common, benign, and often bothersome. Current management includes observation or surgical excision. This study evaluated the safety and feasibility of ultrasound-guided high-intensity focused ultrasound ablation for the treatment of FAs. METHODS: Twenty women with a palpable, biopsy-confirmed FA were enrolled in a prospective trial, and they underwent treatment utilizing an ultrasound-guided high-intensity focused ultrasound ablation device. Tumors were greater than 1 cm in diameter, with volumes of 0.3-10 cc. Safety, treatment experience, toxicity, cosmesis, and change in tumor size on palpation and ultrasound measurement were obtained before and after treatment at 3, 6, and 12 months. RESULTS: All of the 20 patients completed therapy. Pretreatment mean tumor volume was 1.8 cc (standard deviation = 1.23, range 0.57-5.7). Half of the patients reported a painful mass before treatment. All adverse events were well tolerated and transient, with the most common being mild pain, reported by 15 of 20 patients during treatment, and 14 of 20 at the day-7 postprocedure follow-up. Mean pain score during treatment was 16, and at day 7, it was 12.2, on a scale from 0 to 100 (100 = worst pain). Mean patient satisfaction was 4.4 on a scale of 1-5 (5 = most satisfied). Mean likelihood of recommending treatment was 4.7 (5 = most likely). At the 12-month postprocedure follow-up, the mean reduction in volume of the FA was 65.5% on ultrasound; the mass was no longer palpable in 80% of the patients; no patients reported pain; and cosmesis was rated as excellent in all patients. CONCLUSION: Ultrasound-guided high-intensity focused ultrasound ablation appears to be effective, safe, and well tolerated for the treatment of FAs. A larger multicenter clinical trial is currently under way.

Erythematous, friable nipple with loss of protrusion · history of breastfeeding · Dx?

A 34-year-old healthy woman presented to the breast surgical oncology clinic with skin changes to her left nipple after being referred by her primary care provider. She attributed the skin changes to shearing from breastfeeding her third child 5 years earlier. Physical examination revealed an erythematous and friable nipple with loss of protrusion. The patient reported routine bleeding from her nipple, but said the skin changes had remained stable and denied any breast masses. The patient's last mammogram was 2.5 years earlier and had only been remarkable for bilateral benign calcifications.

A milestone-based approach to breast imaging instruction for residents.

Residency is historically an apprenticeship, learning through observation and instruction with varying degrees of structure. Since July 2013, the Next Accreditation System (NAS) of the ACGME has required the use of progressive milestones for each radiology residency rotation. The authors describe how a breast imaging curriculum can be structured to comply with the NAS. The breast imaging rotations move from basic recognition and management of suspicious findings, through the detection of more subtle findings and learning of biopsy skills, and finally to the synthesis and management of more advanced findings. Likewise, patient communication moves from sharing imaging findings to the more challenging situation of breaking the bad news of a cancer diagnosis. This progression of skills mirrors the objectives of levels 1 to 4 of the NAS. Learning objectives have been adapted to form very specific milestones for each rotation, which results in a shared responsibility between residents and faculty members. Using clear expectations may improve the uniformity of teaching, resident satisfaction, and facilitate performance review for residents who are struggling. Didactic lectures, case-based conferences, teaching file cases, and assigned readings provide different approaches to education, allowing variation in learning styles. Performance on the breast imaging section on the ACR Diagnostic Radiology In-Training examination at our institution has risen from below the 50th percentile to around the 80th percentile beginning in 2011.

Incidentally identified adrenal lipoma: case report and review of related literature.

OBJECTIVE: To report a case of an incidentally identified adrenal lipoma in a 68-year-old man with flank pain and hypertension. METHODS: The clinical, computed tomographic, and magnetic resonance imaging findings in this patient are described, and the pathologic features of the tumor are characterized. Moreover, the related literature is reviewed and summarized. RESULTS: The patient had undergone coronary artery bypass grafting, had a prosthetic heart valve, and required systemic anticoagulation. Computed tomography showed a well-circumscribed left adrenal lesion with evidence of scattered foci of macroscopic fat; these findings were confirmed on magnetic resonance imaging. After laparoscopic left adrenalectomy, pathologic examination revealed a well-circumscribed, fatty, 7-cm adrenocortical-based tumor, which weighed 135 g. Histologic sampling disclosed mature adipose tissue without evidence of myeloid heterotopy or features of malignant involvement, and adrenal lipoma was diagnosed. On the basis of our review of the English-language literature, this tumor is the 11th reported case of adrenal lipoma. The vast majority of these tumors have been asymptomatic and identified incidentally on imaging or at autopsy. A minority of patients have had a history of hypertension. CONCLUSION: With the increased utilization and sensitivity of abdominal imaging techniques, identification of nonfunctional adrenal tumors has become more frequent. Adrenal lipoma should be included in the differential diagnosis of lipomatous adrenal tumors.