Improving resource utilization: Axillary lymph node core biopsy triaging for lymphoma.

OBJECTIVES: To evaluate the utilization of hematopathology resources within our enterprise on axillary lymph node core biopsy (AxLNCB) specimens, particularly those obtained in the context of breast cancer screening. METHODS: The utilization of hematopathology resources was determined for all AxLNCB specimens over a 30-month period from across our enterprise, and chart review was performed for select patient demographics and radiographic features. The AxLNCB cases with benign histology were reviewed for subtyping of histologic patterns. RESULTS: Of the total 594 AxLNCB specimens, 61.6% were benign and 38.6% malignant. Of malignant cases, only 9.3% contained any hematologic malignancy, yet 94% of all cases received tissue triage for lymphoma, and 81% were reviewed at least in part by a hematopathologist. Six clinical parameters were found to independently predict risk of hematologic malignancy: male sex (P = .041), bilateral lymphadenopathy (P = .004), diffuse cortical thickening (P = .005), lack of breast cancer (P = .001), older age (P < .001), and history of hematologic malignancy (P < .001). CONCLUSIONS: Our enterprise overused hematopathology resources in the evaluation of AxLNCB performed in the study period. Our process could improve from the application of a simple tool generated from this cohort to predict percent risk of the specimen containing hematologic malignancy using patient characteristics easily found via routine chart review.

Enhancing foci on breast MRI: Identifying criteria that increase levels of suspicion.

OBJECTIVE: Prior studies evaluating features of foci associated with malignancy have not been conclusive. This study evaluates foci that were deemed suspicious and assesses multiple imaging and clinical findings with the goal of identifying criteria that can increase diagnostic confidence when evaluating foci on breast MRI. METHODS: After Institutional Review Board approval, a retrospective chart review was performed to identify patients who underwent an image-guided biopsy of an enhancing focus. To be included in the study, a breast MRI performed between 2012 and 2019 must have been classified as suspicious for an enhancing focus or foci, and a biopsy using imaging guidance must have been subsequently performed. Patient and imaging characteristics as well as the corresponding biopsy results were recorded and statistically analyzed. RESULTS: There were 74 patients with 85 foci of enhancement who underwent biopsy within the study period. Thirteen of the 85 foci yielded malignant results for an overall positive predictive value of 15.3% (95% confidence interval: 7.7-22.9%). Additionally, twenty-six of the 85 cases (30.6%) yielded high risk lesions. There was a statistically significant negative correlation between screening breast MRIs and biopsies that yielded cancer or atypia (p = 0.04). There was also a significant association between foci and malignant results if the focus was in the same quadrant of a known malignancy (p = 0.001). CONCLUSION: Clinical information, such as the indication for a breast MRI or the location of a focus relative to a known cancer, can play an important role in evaluating foci of enhancement. Diagnostic confidence in identifying suspicious foci can be aided by incorporating clinical context with imaging findings deemed suspicious by prior research studies.

Architectural Distortion on Screening Digital Breast Tomosynthesis: Pathologic Outcomes and Indicators of Malignancy.

OBJECTIVE: Digital breast tomosynthesis (DBT) has significantly improved cancer detection capabilities through its identification of subtle findings often imperceptible on 2D digital mammography, particularly architectural distortion (AD). The purpose of this study was to analyze of suspicious AD detected on screening DBT to evaluate the incidence of malignancy and to determine other patient or imaging characteristics in these cases as possible predictors of malignancy. METHODS: This was an IRB approved retrospective analysis of subjects with AD detected on DBT screening mammography who were given a biopsy recommendation between January 1, 2016, and June 30, 2018. Univariate analysis of various imaging characteristics and patient high-risk factors was performed for statistical correlation with diagnosis of malignancy. RESULTS: In the 218 DBT-detected AD findings with a final BI-RADS assessment of 4 or 5 on diagnostic workup, 94 (43.1%) yielded malignancy, 57 (26.2%) were classified as high-risk, and 67 (30.7%) were benign. There was a strong statistically significant association with malignancy in the cases with an US correlate (P < 0.0001). There was a statistically significant inverse correlation between malignancy and one-view findings (P = 0.0002). The presence of AD on 2D (P = 0.005) or synthetic 2D views (P = 0.002) showed statistically significant correlations with malignancy, whereas breast density or high-risk factors (P = 0.316) did not. CONCLUSION: AD detected on DBT that persists on further workup and has no explainable cause should be considered suspicious for malignancy. Identification of the AD on both standard mammographic views and the presence of an US correlate significantly increase the probability of malignancy.

Primary lymphoma of the breast: A case series.

Primary breast lymphoma has been defined as localized involvement of one or both breasts with or without ipsilateral axillary nodal involvement, usually as a rare manifestation of extranodal non-Hodgkin's lymphoma. We describe three cases of this uncommon disease seen at our institution. Two of these cases presented as palpable breast lumps and one was screening detected. None of the patients had a prior history of lymphoma; only one reported B symptoms night sweats and weight loss. Diagnosis was established on ultrasound-guided core biopsy and no evidence of metastatic disease was identified. Even though the imaging features are not specific to this diagnosis, the radiologists should be aware of the clinical and imaging presentation of this rare malignancy to recommend appropriate management and establish radiologic-pathologic concordance.

Missed Breast Cancer: What Can We Learn?

Multiple studies have shown that screening mammography helps to reduce mortality and morbidity from advanced breast cancer. However mammography does have its own limitations, and unfortunately, there are a fair number of false-negative mammograms. We are all aware that the sensitivity of mammography is inversely proportional to the breast density. With many states passing mandatory breast density reporting legislation, there has been an emphasis on using additional and alternative screening methods such as whole breast ultrasound and screening magnetic resonance imaging. Many cancers are simply not detected on mammography, even in retrospect. However, many of the breast cancers are actually visible retrospectively on the prior mammogram. It is these small and often subtle cancers that are perceptible but often missed, that provide a valuable learning opportunity. Studying the imaging findings of cancers that went undetected is a good learning exercise for the radiologist to identify common patterns and mistakes that lead to a missed cancer. This allows the radiologist to improve mammographic sensitivity and overall diagnostic accuracy. This article discusses some of the limitations of mammography, common sources of error which may lead to an undetected cancer, and also discuss a few pearls to prevent these common errors.

Practice policy and quality initiatives: using lean principles to improve screening mammography workflow.

The "lean" approach is a quality improvement method that focuses on maximizing activities that are valued by the customer and eliminating waste that impedes efficiency in the workplace. The unique philosophy of the lean approach encourages all members of the team to be directly involved in identifying areas of waste and generating solutions to eliminate them. When the breast imaging section at the authors' institution became part of a multispecialty breast care center, the result was escalating examination volumes, more complex cases, and overall increased demand on radiologists' time. After several unsuccessful attempts to improve the efficiency of the section, including evaluation by outside consultants, the decision was made to embark on a comprehensive quality improvement program using the lean approach. A team of radiologists, technologists, file room personnel, information technology (IT) representatives, and administrators from the breast imaging section met twice a month to learn about lean principles and how to apply them to screening mammography workflows. Sources of inefficiency (waste) were identified, and potential solutions were generated. Multiple trials were performed to test these solutions. Throughout the process, all team members were engaged in identifying the problems, suggesting solutions, and implementing change. Most of the tested solutions were successful and resulted in decreased patient wait times, improved efficiency for the technologists and radiologists, faster report turnaround, and advances in IT. In addition, staff members were introduced to the lean philosophy and became actively involved in improving their workplace, resulting in a more cohesive section.