JOURNAL CLUB: Scatter Radiation Dose From Digital Screening Mammography Measured in a Representative Patient Population.

OBJECTIVE: The purpose of this study was to quantify the amount of scatter radiation received at the skin surface overlying the thyroid gland, salivary gland, lens of the eye, sternum, and uterus during a routine screening digital mammographic examination measured in a representative patient population. SUBJECTS AND METHODS: The subjects were 207 women without symptoms with varied body mass indexes who underwent annual screening mammography while wearing six optically stimulated luminescence dosimeters placed at the bridge of the nose, right submandibular gland, right and left thyroid lobes, mid sternum, and 2 cm caudal to the umbilicus to assess scatter radiation dose to the skin. RESULTS: The average scatter radiation doses at the skin surface during digital screening mammography in the representative population of women were as follows: overlying the right lobe of the thyroid, 0.24 mGy; left lobe of the thyroid, 0.25 mGy; salivary gland, 0.2 mGy; bridge of the nose, 0.025 mGy; sternum, 0.87 mGy; and umbilicus, 0.011 mGy. The scatter radiation doses at the umbilicus and the bridge of the nose were too low to measure with statistical confidence. Scatter radiation dose increased with increasing body mass index and increasing breast compression thickness. CONCLUSION: Scatter radiation dose at the skin overlying organs of interest is a small fraction of the entrance skin dose to the breast. The low levels of scatter radiation measured do not support delaying clinically indicated mammography during early pregnancy.

Nonpuerperal mastitis and subareolar abscess of the breast.

OBJECTIVE: The purpose of this article is to show radiologists how to readily recognize nonpuerperal subareolar abscess and its complications in order to help reduce the time to definitive therapy and improve patient care. To achieve this purpose, the various theories of pathogenesis and the associated histopathologic features are reviewed; the typical clinical characteristics are detailed in contrast to those seen in lactational abscess and inflammatory breast cancer; the common imaging findings are described with emphasis on the sonographic features; correlative pathologic findings are presented to reinforce the imaging findings as they pertain to disease origins; and the various treatment options are reviewed. CONCLUSION: Nonpuerperal subareolar mastitis and abscess is a benign breast entity often associated with prolonged morbidity. Through better understanding of the underlying disease process the imaging, physical, and clinical findings of this rare process can be more readily recognized and treatment options expedited, improving patient care.

Tips for Addressing Screening Concerns: "Harms of Screening".

Early detection decreases deaths from breast cancer. Yet, there are conflicting recommendations about screening mammography by major professional medical organizations, including the age and frequency with which women should be screened. The controversy over breast cancer screening is centered on 3 main points: the impact on mortality, overdiagnosis, and false positive results. Some studies claim that adverse psychological effects such as anxiety or distress are caused by screening mammography. The purpose of this article is to address negative breast cancer screening concerns including overdiagnosis and overtreatment, effect on mortality, false positive results, mammography-related anxiety, and fear of radiation.

Pediatric and adolescent breast masses: a review of pathophysiology, imaging, diagnosis, and treatment.

OBJECTIVE: Pediatric breast masses are relatively rare and most are benign. Most are either secondary to normal developmental changes or neoplastic processes with a relatively benign behavior. To fully understand pediatric breast disease, it is important to have a firm comprehension of normal development and of the various tumors that can arise. Physical examination and targeted history (including family history) are key to appropriate patient management. When indicated, ultrasound is the imaging modality of choice. The purpose of this article is to review the benign breast conditions that arise as part of the spectrum of normal breast development, as well as the usually benign but neoplastic process that may develop within an otherwise normal breast. Rare primary carcinomas and metastatic lesions to the pediatric breast will also be addressed. The associated imaging findings will be reviewed, as well as treatment strategies for clinical management of the pediatric patient with signs or symptoms of breast disease. CONCLUSION: The majority of breast abnormalities in the pediatric patient are benign, but malignancies do occur. Careful attention to patient presentation, history, and clinical findings will help guide appropriate imaging and therapeutic decisions.

Hematoma formation during breast core needle biopsy in women taking antithrombotic therapy.

OBJECTIVE: The purpose of this study was to compare hematoma formation after breast core needle biopsy performed on patients undergoing and those not undergoing concurrent antithrombotic therapy. SUBJECTS AND METHODS: A prospective assessment of core needle biopsies (stereotactic, ultrasound guided, or MRI guided) performed on patients enrolled between September 2011 and July 2012 formed the basis of this study. Postprocedure mediolateral and craniocaudal mammograms were evaluated for the presence and size of hematomas. Patients were clinically evaluated for complications 24-48 hours after the procedure through telephone call or face-to-face consultation. Needle size, type of biopsy, and presence of hematoma and documented complications were correlated with use of antithrombotic agents (including aspirin, warfarin, clopidogrel, and daily nonsteroidal antiinflammatory medications). RESULTS: No clinically significant hematomas or bleeding complications were found. Eighty-nine of 617 (14.4%) non-clinically significant hematomas were detected on postprocedure mammograms. The probability of development of a non-clinically significant hematoma was 21.6% for patients taking antithrombotics and 13.0% for those not taking antithrombotics. Concurrent antithrombotic therapy and larger needle gauge were significant factors contributing to the probability of hematoma formation. The volume of the hematoma was not related to needle gauge or presence of antithrombotic therapy. CONCLUSION: No clinically significant hematomas were found. Because there are potential life-threatening risks to stopping antithrombotic therapy before breast biopsy, withholding antithrombotic therapy for core needle breast biopsy is not recommended because the incidence of non-clinically significant hematoma is low.

Wireless Localization of Breast Lesions: An Update.

Non-wire breast lesion localizations offer several advantages, including dissociation of the breast localization procedure from the operative schedule, greater flexibility to the surgeon when choosing operative approach, and a better overall patient experience. The options for non-wire localization have variable effects on patients, pathologists, surgeons, radiologists and support personnel and cost varies considerably. This review will update the reader on two newer options available for non-wire localization, point out factors to assess when considering use of a non-wire localization device, and provide a table allowing comparison of multiple features between many of the more popular devices currently available.

Fibrocystic Changes of the Breast: Radiologic-Pathologic Correlation of MRI.

Breast MRI provides high sensitivity but modest positive predictive value for identifying breast cancers, with approximately 75% of MRI-guided biopsies returning benign pathologies. Fibrocystic change (FCC) is a descriptive term used colloquially by many radiologists (and falling out of favor with many pathologists) to refer to several benign entities encountered in the breast. Many of the benign entities believed to comprise FCC can show enhancement on MRI. Recognizing the pathologic correlates of these enhancing lesions should help guide management after such a result on MRI-guided biopsy. Premenopausal women may present with clinical symptoms attributed to FCC, including pain, nipple discharge, breast lumps, or discrete masses. Benign entities associated with FCC include proliferative lesions such as usual ductal hyperplasia and sclerosing adenosis, and nonproliferative lesions including cysts, apocrine metaplasia, and stromal fibrosis. Fibrocystic change can be diffuse or focal. Diffuse FCC usually presents as non-mass enhancement (NME), often with persistent kinetics. Focal FCC can present as an irregular mass or focus with variable enhancement patterns including washout kinetics. Following a benign concordant MRI-guided biopsy result of one or more of the above entities, follow-up with MRI in 12 months is reasonable. Accurate radiologic-pathologic correlation can be achieved when careful review of histologic findings is carried out in the context of MRI features.

Advancing Competency-Based Medical Education Through Assessment and Feedback in Breast Imaging.

Competency-based medical education (CBME) is a method of educating and assessing trainees that focuses on outcomes, rather than process. In this review, we inform radiologists involved in breast imaging training on the tenets of CBME and its relationship to the milestones, feedback and assessment. We also describe multiple methods for assessment specific to the breast imaging curriculum, and techniques for improving feedback to trainees in breast imaging.

Caring for the Deaf, Hard-of-Hearing, Blind, and Low-Vision Patients in the Breast Center.

Two heterogeneous populations with widely varying needs are being increasingly encountered in breast care facilities: blind or low vision patients and deaf or hard of hearing patients. The Americans with Disabilities Act and the Rehabilitation Act mandate that all governments, businesses, and not-for-profit organizations provide effective communication to those facing hearing, vision, or speech communication disabilities and that the provided communication is equally effective as that provided to those lacking communication disabilities. It is vitally important that breast center providers understand the requirements put forth by these acts in the provision of patient care, which includes interactions with the patient as well as their family members and partner. Breast center providers must identify each patient's individual needs and preferred method of communication. Options to assist in communication for the deaf or hard of hearing include the use of text conversations, preprinted or accessible video health care education material, and dedicated American Sign Language or video interpreters. Attention to breast imaging facility design, access to large print or braille documents, and the use of qualified readers can aid in improving access and communication for the blind or low-vision individual. All members of the breast health team, from scheduling staff to front office personnel, technologists, and breast imaging radiologists, should understand how to respectfully communicate with and identify the needs of patients facing these challenges.

Interview Techniques Utilized in Radiology Resident Selection-A Survey of the APDR.

RATIONALE AND OBJECTIVES: To evaluate interview techniques currently used in the selection of diagnostic radiology resident candidates and to identify factors influencing the use of alternative interview techniques. MATERIALS AND METHODS: An anonymous 25 question e-mail survey was provided to 319 active members of the Association of Program Directors in Radiology. The survey included questions on residency demographics, organization of resident applicant interviews, types of interview techniques utilized, scoring and ranking of applicants, and facets of the interview/application felt most important to the selection process. Statistical analysis was performed to identify factors associated with the use of alternative interview techniques. RESULTS: 93.7% of responding programs use traditional interview techniques, with 92% using unblinded, unstructured interviews, 8% blinded, unstructured interviews. Structured interview questions were incorporated in 22%. Few programs used alternative techniques like the multiple mini-interview. None of the programs used written prompts during the interview, 3% used casual visual cognitive testing, 10% used panel interview techniques, and none used formal personality testing. For ranking candidates in the match, the most important facets considered were USMLE Step scores, performance on the interview, clinical course grades, and letters of reference. Factors associated with use of alternative techniques were domains associated with program size and number of faculty. CONCLUSION: The majority of radiology training programs still rely upon the traditional unblinded interview technique. There is an opportunity for training programs to examine alternative techniques that reduce bias and may provide better insight into other aspects of the candidate that may not be as readily highlighted with the traditional, unblinded interview.

Supporting Our Team Through Creating Awareness: The Society of Radiologists in Ultrasound Sonographer Relations Committee Response to the 2016 Society of Diagnostic Medical Sonography Consensus Conference on Work Related Musculoskeletal Disorders.

Musculoskeletal injuries have been and remain a significant issue for sonographers. Despite its importance, the topic of musculoskeletal injury in sonographers has received little attention in the radiology literature. Our goal is to bring this extremely important issue to the forefront, with the hope of initiating conversations and actions leading to improved workplace practices for sonographers.

Factors associated with imaging and procedural events used to detect breast cancer after screening mammography.

OBJECTIVE: The purpose of this study was to characterize the type and frequency of diagnostic evaluations after screening mammography and to summarize their association with the likelihood of biopsy and subsequent breast cancer diagnosis. MATERIALS AND METHODS: The data source was 584,470 women with no previous breast cancer from six states in the Breast Cancer Surveillance Consortium. In this observational study, we linked data from 1,207,631 routine screening mammograms performed between January 1, 1996, and December 31, 2002, to data on additional imaging, interventional procedures, and biopsy outcome (benign or malignant). Additional examinations were categorized into diagnostic mammography, sonography, or both. Events were further subdivided by whether they were performed on the same day as the screening examination and whether patients reported breast symptoms. Logistic regression analysis was used to examine the association between additional evaluation performed and the likelihood of biopsy and the likelihood of subsequent breast cancer diagnosis after adjustment for patient and screening mammographic characteristics. RESULTS: Most (92%) of the screening examinations did not include additional imaging. The probability of biopsy ranged from 0.4% for examinations with no follow-up to 20.1% for those with diagnostic mammography and sonography on the same day as screening among women without symptoms and from 2.1% for those with no follow-up to 18.9% for those with diagnostic mammography and sonography on a day different from screening among women with symptoms. Thirty percent of women without symptoms who underwent biopsy had cancer, whereas 27.1% of women with symptoms who underwent biopsy had cancer. Women who underwent biopsy after screening mammography with diagnostic mammography and sonography on the same day had the highest probability of breast cancer (37.6% among women without symptoms, 36.4% among women with symptoms), whereas those who underwent only sonography performed at a later date had the lowest probability of breast cancer (11.9% among women without symptoms, 17.1% among women with symptoms). CONCLUSION: Women who undergo screening mammography followed by diagnostic mammography and sonography have a high probability of undergoing biopsy and having the biopsy result of breast cancer when follow-up imaging is performed on the same day as screening mammography whether or not breast symptoms are present. Biopsy performed after sonography in the absence of diagnostic mammography had a low yield of breast cancer.

Discovery of breast cancers within 1 year of a normal screening mammogram: how are they found?

PURPOSE: We sought to determine how breast cancers that occur within 1 year after a normal mammogram are discovered. METHODS: Using population-based mammography registry data from 2000-2002, we identified 143 women with interval breast cancers and 481 women with screen-detected breast cancers. We surveyed women's primary care clinicians to assess how the interval breast cancers were found and factors associated with their discovery. RESULTS: Women with interval cancers were twice as likely to have a personal history of breast cancer (30.1%) as women with screen-detected cancers (13.6%). Among women with interval cancers, one half of the invasive tumors (49.5%) were discovered when women initiated a health care visit because of a breast concern, and 16.8% were discovered when a clinician found an area of concern while conducting a routine clinical breast examination. Having a lump and both a personal and a family history of breast cancer was the most common reason why women initiated a health care visit (44%) (P <.01). CONCLUSIONS: Women with interval cancers are most likely to initiate a visit to a primary care clinician when they have 2 or more breast concerns. These concerns are most likely to include having a lump and a personal and/or family history of breast cancer. Women at highest risk for breast cancer may need closer surveillance by their primary care clinicians and may benefit from a strong educational message to come for a visit as soon as they find a lump.

Hormone therapies in women aged 40 and older: prevalence and correlates of use.

CONTEXT: The objective of this paper is to report the prevalence and correlates of both prescription and non-prescription hormone use. DESIGN/SETTING/SAMPLE: Cross-sectional baseline study from a prospective cohort of 30,448 women receiving mammography in New Hampshire. MAIN OUTCOME MEASURES: Odds of prescription hormone and non-prescription hormone use. RESULTS: 29,851 women were included; 62% reported some use of prescription hormone therapy, with current long-term prescription hormone therapy users representing the largest group (25%). Among ever-users, estrogen only was the most commonly used preparation (71% versus 30% for estrogen and progestin combined). Both single agent estrogen and estrogen and progestin combined regimens were taken primarily for treatment of menopausal symptoms or disease prevention. Correlates for prescription hormone use included a family history of breast cancer (associated with decreased use-OR 0.88; 95% CI: 0.84, 0.93), and family history of heart disease (associated with increased use-OR 1.11; 95% CI: 1.06, 1.17). Ten percent of women reported ever use of phytoestrogens (over-the-counter hormones). Family history of breast cancer was a correlate of over-the-counter hormone use (OR 1.10; 95% CI: 1.01, 1.19). CONCLUSION: Management of menopausal symptoms and disease prevention were the main reasons for using prescription hormones, and health histories were important correlates of both prescription and over-the-counter hormone exposures. As evidence changes regarding risks and benefits of hormone exposure, primary care physicians should help women reassess their use of hormonal agents.

Life spans and senescent phenotypes in two strains of Zebrafish (Danio rerio).

Zebrafish have become a widely used model organism in developmental biology research. In order to initiate an experimental foundation for aging studies, we have determined some basic gerontological parameters for populations of outbred zebrafish, and the golden sparse strain. Outbred zebrafish manifested a mean life span of about 42 months, with the longest living individual surviving for 66 months. The golden sparse populations had a mean life span of 36 months and a maximum longevity of 58 months. Skeletal length at death increased with age, suggestive of indeterminate growth. A common age-related phenotype was spinal curvature. Radiographic analysis excluded bony changes as the cause of the spinal curvature, suggesting muscle abnormalities as a primary mechanism. These data and a growing abundance of related biological resources suggest that the zebrafish may be a compelling model organism for studies on aging.

Teaching ultrasound professionalism.

Professionalism is part of the milestone program instituted by the Accreditation Council for Graduate Medical Education and the American Board of Radiology. A unique feature of ultrasound professionalism is the relationship between the radiologist and the sonographer. Because this relationship is important for sonographic quality and ultimately patient outcome, residents should be trained to achieve an optimal professional relationship with sonographers. This article describes milestones for ultrasound professionalism and suggests methods of implementation.

A succinct rating scale for radiology report quality.

CONTEXT: Poorly written radiology reports are common among residents and are a significant challenge for radiology education. While training may improve report quality, a professionally developed reliable and valid scale to measure report quality does not exist. OBJECTIVES: To develop a measurement tool for report quality, the quality of report scale, with rigorous validation through empirical data. METHODS: A research team of an experienced psychometrician and six senior radiologists conducted qualitative and quantitative studies. Five items were identified for the quality of report scale, each measuring a distinct aspect of report quality. Two dedicated training sessions were designed and implemented to help residents generate high-quality reports. In a blinded fashion, the quality of report scale was applied to 804 randomly selected reports issued before (n = 403) and after (n = 401) training. Full-scale psychometrical assessments were implemented onto the quality of report scale's item- and scale-scores from the reports. The quality of report scale scores were correlated with report professionalism and attendings' preference and were compared pre-/post-training. RESULTS: The quality of report scale showed sound psychometrical properties, with high validity and reliability. Reports with higher quality of report scale score were more professional and preferable by attendings. Training improved the quality of report scale score, empirically validating the quality of report scale further. CONCLUSION: While succinct and practitioner friendly, the quality of report scale is a reliable and valid measure of radiology report quality and has the potential to be easily adapted to other fields such as pathology, where similar training would be beneficial.