Non-sclerosing (T-cell) and sclerosing (B-cell) lymphocytic lobulitis in diagnostic breast biopsies: Clinical, imaging, and pathologic features.

Lymphocytic lobulitis (LL) is characterized by prominent lymphocytic infiltrates centered on lobules. Sclerosing lymphocytic lobulitis (SCLL) associated with diabetes mellitus (DM) or autoimmune disease (AI) was the first type to be described. Subsequently, non-sclerosing LL (NSCLL) was reported as an incidental finding in prophylactic mastectomies due to high risk germline mutations or a family history of breast cancer. The two types of LL were distinguished by stromal features and a predominant population of B-cells in the former and T-cells in the latter. In this study, 8 cases of NSCLL detected clinically or by screening were compared to 44 cases of SCLL. One case of NSCLL presented as a palpable mass, 2 as masses on screening, and 5 as MRI enhancement. In contrast, 80% of SCLL cases presented as palpable masses. Half the cases of NSCLL were associated with a BRCA1 or 2 mutation compared to 1 case of SCLL (2%). Three additional cases of NSCLL were associated with a strong family and/or personal history of breast cancer. Almost half (52%) of SCLL cases were associated with DM or AI, but only 25% of NSCLL. Immunoperoxidase studies confirmed a predominance of T-cells in NSCLL and B-cells in SCLL associated with DM or AI. It is important for pathologists to be aware of this new observation that NSCLL can be detected as a palpable mass or an imaging finding in diagnostic biopsies, as its presence can be indicative of a significant risk for breast cancer.

Current Practices in Anticoagulation Management for Patients Undergoing Percutaneous Image-guided Breast Procedures.

Objective: Given variability in how practices manage patients on antithrombotic medications, we undertook this study to understand the current practice of antithrombotic management for patients undergoing percutaneous breast and axillary procedures. Methods: A 20-item survey with multiple-choice and write-in options was emailed to 2094 active North American members of the Society of Breast Imaging (SBI) in March 2021. Data were collected anonymously and analyzed quantitatively, with free-text responses categorized by themes. Results: Three-hundred twenty-six of 2094 members (15.6%) completed the survey. Eighty-seven percent (274/313) reported having a policy for managing antithrombotic medications. Fifty-nine percent (185/312) reported routinely withholding medications before biopsy, more commonly in the Northeast and South (P = 0.08). Withholding of medications did not vary by lesion location (182/308, 59%, breast vs 181/308, 58.7%, axillary; P = 0.81). Respondents were statistically more likely to withhold medications if using a vacuum-assisted device for all classes of antithrombotic medications (P < 0.001). Up to 50.2% (100/199) on warfarin and 33.6% (66/196) on direct oral anticoagulants had medications withheld more stringently than guidelines suggest. Conclusion: Based on a survey of SBI members, breast imaging practices vary widely in antithrombotic management for image-guided breast and axillary procedures. Of the 60% who withhold antithrombotic medications, a minority comply with recommended withhold guidelines, placing at least some patients at potential risk for thrombotic events. Breast imaging radiologists should weigh the risks and benefits of withholding these medications, and if they elect to withhold should closely follow evidence-based guidelines to minimize the risks of this practice.

Transitioning From the Traditional Wire Localization to the Wireless Technology for Surgical Guidance at Lumpectomies: Part A. Radioseed Localization.

Iodine-125 (I-125) labelled radioactive seeds were the first published wireless pre-operative image-guided breast localization technique. Radioseeds offer benefit to radiologists as a relatively intuitive procedure with precise mammographic or sonographic-guided localization and improved patient experience. Localization and surgical dates can be uncoupled, which facilitates efficient scheduling for radiologists and surgeons. Surgeons can better tailor their surgery with intra-operative localization using a special probe to detect the emitted gamma energy. Due to radioactivity, implementation of a radioseed program requires compliance with the National Regulatory Commission and therefore multidisciplinary involvement. Seeds have a high placement success rate, and comparable surgical success and re-excision rate to wires.

Live Mammographic Screening Interpretation Versus Offline Same-Day Screening Interpretation at a Tertiary Cancer Center.

OBJECTIVES: The aim of this study was to compare screening mammography performance metrics for immediate (live) interpretation versus offline interpretation at a cancer center. METHODS: An institutional review board-approved, retrospective comparison of screening mammography metrics at a cancer center for January 1, 2018, to December 31, 2019 (live period), and September 1, 2020, to March 31, 2022 (offline period), was performed. Before July 2020, screening examinations were interpreted while patients waited (live period), and diagnostic workup was performed concurrently. After the coronavirus disease 2019 shutdown from March to mid-June 2020, offline same-day interpretation was instituted. Patients with abnormal screening results returned for separate diagnostic evaluation. Screening metrics of positive predictive value 1 (PPV1), cancer detection rate (CDR), and abnormal interpretation rate (AIR) were compared for 17 radiologists who interpreted during both periods. Statistical significance was assessed using χ2 analysis. RESULTS: In the live period, there were 7,105 screenings, 635 recalls, and 51 screen-detected cancers. In the offline period, there were 7,512 screenings, 586 recalls, and 47 screen-detected cancers. Comparison of live screening metrics versus offline metrics produced the following results: AIR, 8.9% (635 of 7,105) versus 7.8% (586 of 7,512) (P = .01); PPV1, 8.0% (51 of 635) versus 8.0% (47 of 586); and CDR, 7.2/1,000 versus 6.3/1,000 (P = .50). When grouped by >10% AIR or <10% AIR for the live period, the >10% AIR group showed a significant decrease in AIR for offline interpretation (from 12.7% to 9.7%, P < .001), whereas the <10% AIR group showed no significant change (from 7.4% to 6.7%, P = .17). CONCLUSIONS: Conversion to offline screening interpretation from immediate interpretation at a cancer center was associated with lower AIR and similar CDR and PPV1. This effect was seen largely in radiologists with AIR > 10% in the live setting.

Breast Cancer Screening in High-risk Women During Pregnancy and Lactation.

Women who are at high risk of developing breast cancer warrant screening that is often initiated at younger ages than in average-risk women; this is usually with a combination of annual mammography and breast MRI. Compared to average-risk women, those at high risk are more frequently recommended to undergo screening during childbearing age and thus potentially during pregnancy and lactation. Understanding the appropriate use of screening breast imaging during pregnancy and lactation can be challenging due to limited data defining the evidence-based roles of the different imaging modalities, including mammography, US, and MRI. There have also been assumptions about the diagnostic accuracy of these modalities secondary to physiological changes. This scientific review discusses the current state of evidence- and expert-based guidelines and data for breast imaging screening of high-risk pregnant and/or lactating women, and the clinical and imaging presentations of breast cancer for these women.

Lesion conspicuity on synthetic screening mammography compared to full field digital screening mammography.

OBJECTIVE: To compare lesion conspicuity on synthetic screening mammography (SM) plus digital breast tomosynthesis (DBT) versus full field digital mammography (FFDM) plus DBT. MATERIALS AND METHODS: Seven breast imagers each prospectively evaluated 107-228 screening mammograms (FFDM, DBT, and SM; total 1206 examinations) over 12 weeks in sets of 10-50 consecutive examinations. Interpretation sessions alternated as follows: SM + DBT, then FFDM, or FFDM + DBT, then SM. Lesion conspicuity on SM versus FFDM (equal/better versus less) was assessed using proportions with 95% confidence intervals. DBT-only findings were excluded. RESULTS: Overall 1082 of 1206 (89.7%) examinations were assessed BI-RADS 1/2, and 124 of 1206 (10.3%) assessed BI-RADS 0. There were 409 evaluated findings, including 134 masses, 119 calcifications, 72 asymmetries, 49 architectural distortion, and 35 focal asymmetries. SM conspicuity compared to FFDM conspicuity for lesions was rated 1) masses: 77 (57%) equal or more conspicuous, 57 (43%) less conspicuous; 2) asymmetries/focal asymmetries: 61 (57%) equal or more conspicuous, and 46 (43%) less conspicuous; 3) architectural distortion: 46 (94%) equal or more conspicuous, 3 (6%) less conspicuous; 4) calcifications: 115 (97%) equal or more conspicuous, 4 (3%) less conspicuous. SM had better conspicuity than FFDM for calcifications and architectural distortion and similar conspicuity for most masses and asymmetries. CONCLUSION: Compared to FFDM, SM has better conspicuity for calcifications and architectural distortion and similar conspicuity for most masses and asymmetries.

The utility of magnetic resonance imaging in early-stage breast cancer survivors-An institutional experience and literature review.

The role of breast magnetic resonance imaging (MRI) in the screening of breast cancer survivors with remaining breast tissue is not well studied. We sought to evaluate the outcomes of screening breast MRI in a cohort of breast cancer survivors. A population of patients with history of stage I-IIIa breast cancer and ≥1 MRI a year or later from diagnosis between 2006-2008 were identified using the National Comprehensive Cancer Network data base from two large Boston-area cancer centers. Patient and disease characteristics were obtained from the data base, and medical records were reviewed to identify the index MRI (first eligible), indications, and two-year outcomes. Overall, 647 patients had breast MRI scans during the study period including 342 eligible patients whose index MRIs were done for breast screening purposes. 47/342 (13.7%) were abnormal, and 3.8% (13/342) underwent biopsy, resulting in the detection of 3 cases of locoregional recurrence or new primary breast cancer (0.9%, 95% CI = 0.2%-2.5%). Of 295 patients with a normal index screening MRI, 12 had a breast cancer recurrence diagnosed within 2 years (4.1% 95%CI = 2.1%-7.0%), and 5 of these recurrences were limited to MRI-screened breast tissue. No statistically significant difference in the rate of 2-year locoregional or distant recurrence was observed between patients with an abnormal screening MRI and those with a normal scan. Adjunct single breast MRI surveillance in a general population of breast cancer survivors one year after diagnosis detected few recurrences, and its effect on short-term outcomes was unclear.

Patterns of breast reconstruction in patients diagnosed with inflammatory breast cancer: The Dana-Farber Cancer Institute's Inflammatory Breast Cancer Program experience.

Inflammatory breast cancer (IBC) exhibits dermal lymphatic involvement at presentation, and thus, the standard surgical approach is a nonskin-sparing modified radical mastectomy (MRM) without breast reconstruction (BR). In this study, we evaluated immediate and delayed BR receipt and its outcomes in IBC. Using an IRB-approved database, we retrospectively evaluated stage III IBC patients who received trimodality therapy (preoperative systemic therapy, followed by MRM and postmastectomy chest wall/regional nodal radiation). Patients with an insufficient response to preoperative systemic therapy and/or who required preoperative radiotherapy were excluded. BR receipt, timing, and morbidity were evaluated. Among 240 stage III IBC patients diagnosed between 1997 and 2016, 40 (17%) underwent BR. Thirteen (33%) had immediate, and 27 (67%) had delayed BR. Four patients had complications (1 [8%] immediate BR and 3 [11%] delayed BR); only 1 BR (delayed) was unsuccessful. From the MRM date, the median time to recurrence was 35 months (<1-212) and median overall survival was 87 months (<1-212). In this cohort of stage III IBC patients, only 11% pursued delayed BR following trimodality therapy, possibly attributable to the observed high recurrence rates hindering BR. Further studies addressing BR outcomes in IBC are needed for better counseling patients regarding their reconstructive options.

Conspicuity of Screen-Detected Malignancies on Full Field Digital Mammography vs. Synthetic Mammography.

RATIONALE AND OBJECTIVES: To evaluate conspicuity of screen-detected cancers on two-dimensional synthetic mammography (SM) reconstructed from digital breast tomosynthesis (DBT) compared to two-dimensional full field digital mammography (FFDM). MATERIALS AND METHODS: IRB-approved retrospective review of consecutive screen-detected cancers from October 1, 2015 to June 30, 2017 was performed. All examinations were reviewed by three radiologists in consensus (n = 224); a score of 1-3 was given to each screen-detected cancer on SM vs. FFDM [1 = FFDM more conspicuous than SM, 2 = FFDM equivalent to SM, and 3 = SM more conspicuous than FFDM]. Findings considered only visible on tomosynthesis (n = 40), without medical history (n = 2), and with skin thickening only (n = 1) were excluded, leaving 181 cases as the study population. The longitudinal medical record was reviewed to determine patient demographics and outcomes of imaging surveillance and biopsy. RESULTS: Mammographic features on SM (n = 181) were calcifications (n = 68, 37.8%), masses (n = 51, 27.8%), asymmetries (n = 50, 27.6% [11 focal asymmetries]), and distortion (n = 12, 6.8%). The majority (76%, 137/181) of findings were equal or more conspicuous on SM vs. FFDM. However, calcifications and distortion greater than 2 cm were more conspicuous on SM and asymmetries were less conspicuous on SM vs. FFDM, controlling for menopausal status, family or personal history of breast cancer, BRCA status, and breast density. CONCLUSION: Although the majority of screen-detected cancers are equal to more conspicuous on SM when compared to FFDM, calcifications and asymmetries <2cm were less conspicuous on SM than FFDM. When SM + DBT is used as an alternative to FFDM + DBT in breast cancer screening, caution should be taken when assessing one-view asymmetries and findings <2cm on SM.

Variability in the Use of Simulation for Procedural Training in Radiology Residency: Opportunities for Improvement.

OBJECTIVE: Increased attention to quality and safety has led to a re-evaluation of the classic apprenticeship model for procedural training. Many have proposed simulation as a supplementary teaching tool. The purpose of this study was to assess radiology resident exposure to procedural training and procedural simulation. MATERIALS AND METHODS: An IRB-exempt online survey was distributed to current radiology residents in the United States by e-mail. Survey results were summarized using frequency and percentages. Chi-square tests were used for statistical analysis where appropriate. RESULTS: A total of 353 current residents completed the survey. 37% (n = 129/353) of respondents had never used procedure simulation. Of the residents who had used simulation, most did not do so until after having already performed procedures on patients (59%, n = 132/223). The presence of a dedicated simulation center was reported by over half of residents (56%, n = 196/353) and was associated with prior simulation experience (P = 0.007). Residents who had not had procedural simulation were somewhat likely or highly likely (3 and 4 on a 4-point Likert-scale) to participate if it were available (81%, n = 104/129). Simulation training was associated with higher comfort levels in performing procedures (P < 0.001). CONCLUSIONS: Although procedural simulation training is associated with higher comfort levels when performing procedures, there is variable use in radiology resident training and its use is not currently optimized. Given the increased emphasis on patient safety, these results suggest the need to increase procedural simulation use during residency, including an earlier introduction to simulation before patient exposure.

The Impact of Residual Disease After Preoperative Systemic Therapy on Clinical Outcomes in Patients with Inflammatory Breast Cancer.

BACKGROUND: Inflammatory breast cancer (IBC) is a rare and aggressive disease treated with multimodality therapy: preoperative systemic therapy (PST) followed by modified radical mastectomy (MRM), chest wall and regional nodal radiotherapy, and adjuvant biologic therapy and/or endocrine therapy when appropriate. In non-IBC, the degree of pathologic response to PST has been shown to correlate with time to recurrence (TTR) and overall survival (OS). We sought to determine if pathologic response correlates with oncologic outcomes of IBC patients. METHODS: Following review of IBC patients' records (1997-2014), we identified 258 stage III IBC patients; 181 received PST followed by MRM and radiotherapy and were subsequently analyzed. Pathologic complete response (pCR) to PST, hormone receptor and human epidermal growth factor receptor 2 (HER2) status, grade, and histology were evaluated as predictors of TTR and OS by Cox model. RESULTS: Overall, 95/181 (52%) patients experienced recurrence; 93/95 (98%) were distant metastases (median TTR 3.2 years). Seventy-three patients (40%) died (median OS 6.9 years). pCR was associated with improved TTR (hazard ratio [HR] 0.20, 95% confidence interval [CI] 0.09-0.46, p < 0.01, univariate; HR 0.17, 95% CI 0.07-0.41, p < 0.0001, multivariate) and improved OS (HR 0.26, 95% CI 0.11-0.65, p < 0.01, univariate). In patients with pCR, grade III (HR 1.91, 95% CI 1.16-3.13, p = 0.01), and triple-negative phenotype (HR 3.54, 95% CI 1.79-6.98, p = 0.0003) were associated with shorter TTR, while residual ductal carcinoma in situ was not (HR 0.85, 95% CI 0.53-1.35, p = 0.48, multivariate). CONCLUSIONS: In stage III IBC, pCR was associated with prognosis, further influenced by grade, hormone receptor, and HER2 status. Investigating mechanisms that contribute to better response to PST could help improve oncologic outcomes in IBC.

Avoiding Pitfalls, Maximizing Success at Image-guided Breast Interventions: A Pictorial Review.

Imaging and image-guided interventions have become increasingly important in the workup and treatment of breast lesions in the past 2 decades. Radiologists should be aware of potential pitfalls during the workup, the procedure itself, and in the postprocedure follow-up. In this pictorial review, we illustrate challenges related to technique and interpretation related to breast interventions, and suggest ways to maximize success.

Role of vascular density and normalization in response to neoadjuvant bevacizumab and chemotherapy in breast cancer patients.

Preoperative bevacizumab and chemotherapy may benefit a subset of breast cancer (BC) patients. To explore potential mechanisms of this benefit, we conducted a phase II study of neoadjuvant bevacizumab (single dose) followed by combined bevacizumab and adriamycin/cyclophosphamide/paclitaxel chemotherapy in HER2-negative BC. The regimen was well-tolerated and showed a higher rate of pathologic complete response (pCR) in triple-negative (TN)BC (11/21 patients or 52%, [95% confidence interval (CI): 30,74]) than in hormone receptor-positive (HR)BC [5/78 patients or 6% (95%CI: 2,14)]. Within the HRBCs, basal-like subtype was significantly associated with pCR (P = 0.007; Fisher exact test). We assessed interstitial fluid pressure (IFP) and tissue biopsies before and after bevacizumab monotherapy and circulating plasma biomarkers at baseline and before and after combination therapy. Bevacizumab alone lowered IFP, but to a smaller extent than previously observed in other tumor types. Pathologic response to therapy correlated with sVEGFR1 postbevacizumab alone in TNBC (Spearman correlation 0.610, P = 0.0033) and pretreatment microvascular density (MVD) in all patients (Spearman correlation 0.465, P = 0.0005). Moreover, increased pericyte-covered MVD, a marker of extent of vascular normalization, after bevacizumab monotherapy was associated with improved pathologic response to treatment, especially in patients with a high pretreatment MVD. These data suggest that bevacizumab prunes vessels while normalizing those remaining, and thus is beneficial only when sufficient numbers of vessels are initially present. This study implicates pretreatment MVD as a potential predictive biomarker of response to bevacizumab in BC and suggests that new therapies are needed to normalize vessels without pruning.

Inflammatory breast cancer and development of brain metastases: risk factors and outcomes.

Brain metastases are associated with significant morbidity. Minimal research has been conducted on the risk factors for and incidence of brain metastases in women with inflammatory breast cancer (IBC). 210 women with Stage III or IV IBC diagnosed from 1997-2011 were identified. Competing risk analysis and competing risks regression were used to calculate the incidence of brain metastases and identify significant risk factors. After a median follow-up in surviving patients of 2.8 years (range 0.6-7.6) and 3.3 years (range 0.2-14.5) in the 47 and 163 patients with (MET) and without (non-MET) metastatic disease at diagnosis, 17 (36 %) and 30 (18 %) developed brain metastases, respectively. The cumulative incidence at 1, 2, and 3 years was 17 % [95 % confidence interval (CI), 8-30], 34 % (95 % CI, 20-48), and 37 % (95 % CI, 22-51) for the MET cohort. The corresponding non-MET values were 4 % (95 % CI, 2-8), 8 % (95 % CI 5-13), and 15 % (95 % CI, 10-22). Once non-MET patients developed extracranial distant metastases, the subsequent 1, 2, and 3 years cumulative incidence of brain metastases was 18 % (95 % CI, 10-28), 25 % (95 % CI, 15-36), and 31 % (95 % CI, 20-43). On multivariate analysis, brain metastases were associated with younger age [hazard ratio (HR), 0.73; 95 % CI, 0.53-1.00; P = 0.05] and distant metastases at diagnosis (HR, 2.33; 95 % CI, 1.11-4.89; P = 0.03). The incidence of brain metastases is high in women with IBC. Particularly for patients with extracranial distant metastases, routine screening with magnetic resonance imaging should be considered.

Inflammatory Breast Cancer: Patterns of Failure and the Case for Aggressive Locoregional Management.

BACKGROUND: Inflammatory breast cancer (IBC) is a rare and aggressive subtype. This study analyzes the patterns of failure in patients with IBC treated at our institution. METHODS: We retrospectively analyzed the records of 227 women with IBC presenting between 1997 and 2011. Survival analysis was used to calculate overall survival (OS) and disease-free survival. Competing risk analysis was used to calculate locoregional recurrence (LRR). RESULTS: A total of 173 patients had locoregional-only disease at presentation (non-MET). Median follow-up in the surviving patients was 3.3 years. Overall, 132 (76.3 %) patients received trimodality therapy with chemotherapy, surgery, and radiotherapy. Three-year OS was 73.1 % [95 % confidence interval (CI) 64.9-82.4]. Cumulative LRR was 10.1, 16.9, and 21.3 % at 1, 2, and 3 years, respectively. No variable was significantly associated with LRR. Fifty-four patients had metastatic disease at presentation (MET). Median follow-up in the surviving patients was 2.6 years. Three-year OS was 44.3 % (95 % CI 31.4-62.5). Twenty-four (44.4 %) patients received non-palliative local therapy (radiotherapy and/or surgery). For these patients, median OS after local therapy was 2 years. Excluding six patients who received local therapy for symptom palliation, the crude incidence of locoregional progression or recurrence (LRPR) was 17 % (4/24) for those who received local therapy compared with 57 % (13/23) for those who did not. CONCLUSIONS: For non-MET patients, LRR remains a problem despite trimodality therapy. More aggressive treatment is warranted. For MET patients, nearly 60 % have LRPR with systemic therapy alone. Local therapy should be considered in the setting of metastatic disease to prevent potential morbidity of progressive local disease.

Patient compliance and diagnostic yield of 18-month unilateral follow-up in surveillance of probably benign mammographic lesions.

OBJECTIVE: The purpose of this study is to determine the patient compliance with and diagnostic yield of 18-month unilateral mammography in surveillance of probably benign (BI-RADS category 3) lesions. MATERIALS AND METHODS: This retrospective study identified lesions prospectively classified BI-RADS 3 in asymptomatic women from January 1, 2004, to December 31, 2008. Surveillance protocol for BI-RADS 3 lesions included 6-month (unilateral), 12-month (bilateral), 18-month (unilateral), and 24-month (bilateral) imaging, with subsequent annual screening. Demographics, surveillance data, BI-RADS upgrades and downgrades, and biopsy results were abstracted from the longitudinal medical record. RESULTS: One thousand one hundred eighty-eight lesions in 1077 patients (mean age, 51.5 years; age range, 26-89 years) had BI-RADS 3 assessment, representing 1.07% of all screening examinations. The compliance rates for follow-up at 6, 12, 18, and 24 months were 83.3%, 75.9%, 54.8%, and 53.9%, respectively. Sixty lesions were upgraded to BI-RADS 4 or 5 during surveillance. Biopsy revealed 15 cancers (cancer yield of 1.47%) from 1017 lesions with either 24-month imaging stability or tissue diagnosis available. Five, six, one, and three cancers were detected at 6, 12, 18, and 24 months, respectively. Cancers were all stage 0 or 1 except for one stage 2A cancer. Seven hundred forty-four of 1188 (62.6%) BI-RADS 3 lesions were downgraded before completing 2-year surveillance. CONCLUSION: Most (11/15 [73%]) breast cancers initially assessed as BI-RADS 3 are diagnosed at up to 12 months' surveillance. Eighteen-month unilateral mammography performed as BI-RADS 3 surveillance contributes minimally to cancer detection and has poor patient compliance.

Background parenchymal enhancement at breast MR imaging: normal patterns, diagnostic challenges, and potential for false-positive and false-negative interpretation.

At magnetic resonance (MR) imaging, both normal and abnormal breast tissue enhances after contrast material administration. The morphology and temporal degree of enhancement of pathologic breast tissue relative to normal breast tissue form the basis of MR imaging's diagnostic accuracy in the detection and diagnosis of breast disease. Normal parenchymal enhancement at breast MR imaging is termed background parenchymal enhancement (BPE). BPE may vary in degree and distribution in different patients as well as in the same patient over time. Typically BPE is minimal or mild in overall degree, with a bilateral, symmetric, diffuse distribution and slow early and persistent delayed kinetic features. However, BPE may sometimes be moderate or marked in degree, with an asymmetric or nondiffuse distribution and rapid early and plateau or washout delayed kinetic features. These patterns cause diagnostic difficulty because these features can be seen with malignancy. This article reviews typical and atypical patterns of BPE seen at breast MR imaging. The anatomic and physiologic influences on BPE in women undergoing diagnostic and screening breast MR imaging are reviewed. The potential for false-positive and false-negative interpretations due to BPE are discussed. Radiologists can improve their interpretive accuracy by increasing their understanding of various BPE patterns, influences on BPE, and the potential effects of BPE on MR imaging interpretation.

Positioning in breast MR imaging to optimize image quality.

Improper positioning of the breasts in a dedicated breast coil causes inhomogeneous fat saturation as well as other artifacts that decrease the sensitivity of breast magnetic resonance imaging. Improper positioning can create artifacts that can obscure a malignancy or cause it to be missed. Goals of proper positioning include imaging the maximum area of breast tissue, minimizing skin folds, and achieving homogeneous fat suppression and nondeformed breast parenchyma. Review of prior images gives the technologist an impression of what the positioning and imaging challenges may be in each patient before the patient enters the imaging unit. Checking the triplane localizer images and repositioning as necessary before any diagnostic or interventional imaging is key. Using a fat saturation pad, changing the arm position, or "rolling" the patient may be considered in difficult cases. Padding to support the patient in an oblique position, using angled sponges to increase breast compression thickness, and raising the grid to access posterior lesions may be helpful in targeting difficult-to-access lesions for biopsy. Using the presented positioning techniques and suggestions, in addition to strict attention to detail before imaging, will improve image quality, decrease imaging time and suboptimal images, and limit the need for repeat imaging studies.