Imaging and pathologic features of non-calcified ductal carcinoma in situ: can sonography predict upgrade?

OBJECTIVE: The purpose of this study was to evaluate the imaging and pathologic features and upgrade rate of non-calcified ductal carcinoma in situ (NCDCIS). The study tested the hypothesis that lesions with sonographic findings have higher upgrade rate compared to lesions seen on mammography or MRI only. METHODS: This retrospective study included patients with ductal carcinoma in situ (DCIS) diagnosed by image-guided core breast biopsy from December 2009 to April 2018. Patients with microcalcifications on mammography or concurrent ipsilateral cancer on core biopsy were excluded. An upgrade was defined as surgical pathology showing microinvasive or invasive cancer. RESULTS: A total of 71 lesions constituted the study cohort. 62% of cases (44/71) had a mammographic finding, and 38% (27/71) of mammographically occult lesions had findings on either ultrasound, MRI, or both. Of the 67 cases that underwent sonography, a mass was noted in 56/67 (83.6%) cases and no sonographic correlate was identified in 11/67 (16.4%) cases. 21% (15/71) of lesions were upgraded on final surgical pathology. The upgrade rate of patients with sonographic correlate was 27% (15/56) vs with mammographic findings only was 0% (0/11). CONCLUSION: DCIS should be considered in the differential diagnosis of architectural distortion, asymmetries, focal asymmetries, and masses, even in the absence of microcalcifications. NCDCIS diagnosed by ultrasound may be an independent risk factor for upgrade. ADVANCES IN KNOWLEDGE: Radiologists must be aware of imaging features of DCIS and consider increased upgrade rate when NCDCIS is diagnosed by ultrasound.

Racial Disparities in Diagnostic Delay Among Women With Breast Cancer.

PURPOSE: Early diagnosis is fundamental to reducing breast cancer (BC) mortality, and understanding potential barriers from initial screening to confirmed diagnosis is essential. The aim of this study was to evaluate patient characteristics that contribute to delay in diagnosis of screen-detected cancers and the contribution of delay to tumor characteristics and BC mortality. METHODS: Three hundred sixty-two White and 368 Black women were identified who were screened and received subsequent BC diagnoses within Emory Healthcare, a part of Emory University health care system (2010-2014). Multivariable-adjusted logistic regression was used to calculate the odds ratios (ORs) and 95% confidence intervals (CIs) associating patient characteristics with delay to diagnostic evaluation (≥30 versus <30 days), delay to biopsy (≥15 versus <15 days), and total delay (≥45 versus <45 days). Additionally, the ORs and 95% CIs associating delay with tumor characteristics and BC mortality were computed. RESULTS: Black women and women diagnosed at later stages, with larger tumor sizes, and with triple-negative tumors were more likely to experience ≥45 days to diagnosis. In multivariable-adjusted models, Black women had at least a two-fold increase in the odds of delay to diagnostic evaluation (OR, 1.98; 95% CI, 1.45-2.71), biopsy delays (OR, 2.41; 95% CI, 1.67-3.41), and total delays ≥45 days (OR, 2.22; 95% CI, 1.63-3.02) compared with White women. A 1.6-fold increased odds of BC mortality was observed among women who experienced total delays ≥45 days compared with women without delays in diagnosis (OR, 1.57, 95% CI, 0.96-2.58). CONCLUSIONS: The study demonstrated racial disparities in delays in the diagnostic process for screen-detected malignancies. Total delay in diagnosis was associated with an increase in BC mortality.

Single incision for oncologic breast conserving surgery and sentinel node biopsy in early stage breast cancer: A minimally invasive approach.

INTRODUCTION: Breast conserving surgery (BCS) has a postoperative morbidity up to 30%. We report the feasibility of a single-incision approach for tumor excision and axillary sentinel node biopsy (SNB) sampling intended to minimize patient morbidity and complications. MATERIALS AND METHODS: A tertiary surgical oncology single surgeon database was retrospectively reviewed for all patients undergoing BCS and SNB between January 2013 and December 2015. The single-incision approach used a single breast incision to resect the tumor and the Lymphazurin-tagged SNB. The multi-incision group used a breast incision and a separate axillary incision. RESULTS: The single-incision approach was associated with shorter operative time (56 vs 64 minutes, P = 0.026). Sentinel node retrieval was achieved in 100% in both groups. The single-incision technique was used primarily in the upper outer quadrant (N = 41, 85.4%), but was also selectively applied in other quadrants (N = 5). There was no significant difference in complication rates between the two procedures (P = 0.425), and there were no instances of conversion from single-incision to standard BCS-SNB. CONCLUSIONS: Minimally invasive breast conserving surgery is feasible for patients with early breast cancer located in the upper outer quadrants. This technique may reduce postoperative morbidity and improved cosmetic result.

Optimizing Ergonomics in Breast Imaging.

Breast imaging radiologists spend many hours seated at workstations and are therefore at high risk for repetitive strain injuries and computer vision syndrome. In addition, many perform hand-held sonography and image-guided procedures, which may present additional ergonomic challenges. In this article, we describe optimal ergonomics for breast imaging radiologists and discuss additional strategies to mitigate risks from work-related injury and improve overall physical well-being.

Radiologists and Social Media: Do Not Forget About Facebook.

PURPOSE: Facebook (Facebook, Inc, Menlo Park, California, USA) is the most popular social networking platform worldwide. Facebook groups are virtual communities of people who share a common interest. Breast Imaging Radiologists is a Facebook group for radiologists with an interest in breast imaging. The purpose of this study was to analyze the membership and activity of the Breast Imaging Radiologists Facebook group (BIRFG) for 2 years since its inception. METHODS: Using both the Grytics (www.grytics.com) and Sociograph (www.sociograph.io) analytic engines, the activity of the BIRFG was analyzed retrospectively from its inception on February 11, 2015, through February 12, 2017. Activity data were exported for further qualitative and quantitative analysis using Excel (Microsoft, Redmond, Washington, USA). Member demographic data were obtained by querying public Facebook profiles, US News Doctor Finder (US News & World Report, Washington, DC, USA), Doximity (Doximity, San Francisco, California, USA), and Google (Google Inc, Mountain View, California, USA). RESULTS: Membership grew from 1 to 774 over the study period, and 84% of the members were female. There were 493 posts, 3,253 comments, and 1,732 reactions; 92% of posts received either comments or reactions. Each post received an average of 6.6 comments, and 55% of members were active over the study period. There was an increase in all measures of activity from year 1 to year 2. CONCLUSIONS: Our findings indicate that radiologists find value in using Facebook groups as a forum to network and exchange information about breast imaging. This may be generalizable to other radiology subspecialties. Given the popularity and accessibility of Facebook for personal use, it may prove a more comfortable social medium for radiologists to interact professionally.

The Agony of It All: Musculoskeletal Discomfort in the Reading Room.

PURPOSE: The purpose of this study was to determine the extent and severity of musculoskeletal discomfort in radiologists using a standardized tool, the Cornell Musculoskeletal Discomfort Questionnaire (CMDQ). In addition, we evaluated the influence of demographic factors on the frequency of symptoms, degree of discomfort, interference of symptoms with ability to work, and overall pain. METHODS: The CMDQ was distributed via an anonymous link to all radiology trainees and faculty at our institution. The questionnaire assessed frequency and location of pain, severity of symptoms, and degree to which discomfort interfered with work. In addition, demographic data were collected. RESULTS: The survey was completed by 99 radiologists (39% response rate). The majority (80%) of respondents spent greater than 7 hours per workday at a diagnostic workstation. The neck (66%), lower back (61%), upper back (43%), right shoulder (36%), and right wrist (33%) were the areas where radiologists most frequently reported ache, pain, or discomfort at least once per week. More than 7 hours per day at a computer workstation was significantly associated with higher total pain. CONCLUSIONS: Musculoskeletal discomfort in the week before the survey was reported by the majority of radiologists and was significantly influenced by demographic factors. Further investigation is needed to understand the causes of radiologists' discomfort at work and to evaluate interventions to ameliorate these symptoms.

X-ray scatter correction in breast tomosynthesis with a precomputed scatter map library.

PURPOSE: To develop and evaluate the impact on lesion conspicuity of a software-based x-ray scatter correction algorithm for digital breast tomosynthesis (DBT) imaging into which a precomputed library of x-ray scatter maps is incorporated. METHODS: A previously developed model of compressed breast shapes undergoing mammography based on principal component analysis (PCA) was used to assemble 540 simulated breast volumes, of different shapes and sizes, undergoing DBT. A Monte Carlo (MC) simulation was used to generate the cranio-caudal (CC) view DBT x-ray scatter maps of these volumes, which were then assembled into a library. This library was incorporated into a previously developed software-based x-ray scatter correction, and the performance of this improved algorithm was evaluated with an observer study of 40 patient cases previously classified as BI-RADS® 4 or 5, evenly divided between mass and microcalcification cases. Observers were presented with both the original images and the scatter corrected (SC) images side by side and asked to indicate their preference, on a scale from -5 to +5, in terms of lesion conspicuity and quality of diagnostic features. Scores were normalized such that a negative score indicates a preference for the original images, and a positive score indicates a preference for the SC images. RESULTS: The scatter map library removes the time-intensive MC simulation from the application of the scatter correction algorithm. While only one in four observers preferred the SC DBT images as a whole (combined mean score = 0.169 ± 0.37, p > 0.39), all observers exhibited a preference for the SC images when the lesion examined was a mass (1.06 ± 0.45, p < 0.0001). When the lesion examined consisted of microcalcification clusters, the observers exhibited a preference for the uncorrected images (-0.725 ± 0.51, p < 0.009). CONCLUSIONS: The incorporation of the x-ray scatter map library into the scatter correction algorithm improves the efficiency of the algorithm. The observer study presented here is also the first test of the scatter correction algorithm with patient images and human observers, and demonstrates its potential to improve the clinical performance of DBT.

Pay for performance: survey of diagnostic radiology faculty and trainees.

PURPOSE: Pay-for-performance (P4P) programs have been implemented in many health care markets in the United States. The purpose of this study was to survey faculty members and trainees regarding familiarity with the P4P model and their interest in further education. METHODS: An eight-question survey designed to explore faculty member and trainee awareness of and attitudes toward P4P was distributed. Data were analyzed using Microsoft Excel. RESULTS: One hundred four of 144 questionnaires distributed to faculty members (50 of 70) and trainees (54 of 74) were returned. Sixty-one percent of trainees stated that they had never heard of the P4P model. Seventeen percent of trainees and 26% of attending radiologists were aware that P4P programs have already been instituted. Although 74% of trainees agreed that P4P will influence their reimbursement in the future, only 42% of attending radiologists agreed. A minority of trainees and attending radiologists (35%) felt that P4P improves the quality of care, whereas 42% were neutral. A majority were interested in further education. CONCLUSION: Faculty members and trainees in diagnostic radiology in a university-based program were unfamiliar with the P4P model of reimbursement and were interested in learning more. Additional investigation is needed to ascertain whether this knowledge gap is widespread. This could influence future education about P4P on a national level.

Until the chemist opens - palliation from the doctor's bag.

BACKGROUND: People with a life limiting illness may have unpredictable exacerbations of their symptoms requiring after hours care by general practitioners using medications that are readily accessible. All doctors are provided with injectable 'doctor's bag' emergency drugs for use in such a crisis. OBJECTIVE: This article aims to: identify which medications from the doctor's bag can be used in the palliative care crises that are most frequently encountered, present the best possible evidence for these indications, and to provide GPs caring for palliative care patients after hours with management strategies so, whenever appropriate, they can continue to be managed at home. DISCUSSION: The clinical context, including disease trajectory and patient and caregivers' wishes, must be assessed in palliative care crises. Having excluded reversible problems, symptoms can be treated using doctor's bag medications. Attention must be given to route of administration, duration of effect, and appropriate doses for effective palliation.

Paying for performance in diagnostic imaging: current challenges and future prospects.

As concerns regarding medical errors and patient safety continue to escalate, policy makers and purchasers of care are developing novel methods to improve health care quality. One strategy for encouraging quality improvement uses financial incentives to reward physicians and hospitals for meeting or exceeding benchmarks of quality. This model, known as "paying for performance," is currently being implemented in a number of health care markets. Although most of these programs focus on primary care physicians and hospital care, it is only a matter of time until pay-for-performance incentives will be designed for diagnostic imaging groups. This article describes the pay-for-performance model and discusses its implications for the field of radiology.