Genetic Testing and Screening Recommendations for Patients with Hereditary Breast Cancer.

Professionals who specialize in breast imaging may be the first to initiate the conversation about genetic counseling with patients who have a diagnosis of premenopausal breast cancer or a strong family history of breast and ovarian cancer. Commercial genetic testing panels have gained popularity and have become more affordable in recent years. Therefore, it is imperative for radiologists to be able to provide counseling and to identify those patients who should be referred for genetic testing. The authors review the process of genetic counseling and the associated screening recommendations for patients at high and moderate risk. Ultimately, genetic test results enable appropriate patient-specific screening, which allows improvement of overall survival by early detection and timely treatment. The authors discuss pretest counseling, which involves the use of various breast cancer risk assessment tools such as the Gail and Tyrer-Cuzick models. The most common high- and moderate-risk gene mutations associated with breast cancer are also reviewed. In addition to BRCA1 and BRCA2, several high-risk genes, including TP53, PTEN, CDH1, and STK11, are discussed. Moderate-risk genes include ATM, CHEK2, and PALB2. The imaging appearances of breast cancer typically associated with each gene mutation, as well as the other associated cancers, are described. ©RSNA, 2020 See discussion on this article by Butler (pp 937-940).

Performance of a Deep Learning Algorithm for Automated Segmentation and Quantification of Traumatic Pelvic Hematomas on CT.

The volume of pelvic hematoma at CT has been shown to be the strongest independent predictor of major arterial injury requiring angioembolization in trauma victims with pelvic fractures, and also correlates with transfusion requirement and mortality. Measurement of pelvic hematomas (unopacified extraperitoneal blood accumulated from time of injury) using semi-automated seeded region growing is time-consuming and requires trained experts, precluding routine measurement at the point of care. Pelvic hematomas are markedly variable in shape and location, have irregular ill-defined margins, have low contrast with respect to viscera and muscle, and reside within anatomically distorted pelvises. Furthermore, pelvic hematomas occupy a small proportion of the entire volume of a chest, abdomen, and pelvis (C/A/P) trauma CT. The challenges are many, and no automated methods for segmentation and volumetric analysis have been described to date. Traditional approaches using fully convolutional networks result in coarse segmentations and class imbalance with suboptimal convergence. In this study, we implement a modified coarse-to-fine deep learning approach-the Recurrent Saliency Transformation Network (RSTN) for pelvic hematoma volume segmentation. RSTN previously yielded excellent results in pancreas segmentation, where low contrast with adjacent structures, small target volume, variable location, and fine contours are also problematic. We have curated a unique single-institution corpus of 253 C/A/P admission trauma CT studies in patients with bleeding pelvic fractures with manually labeled pelvic hematomas. We hypothesized that RSTN would result in sufficiently high Dice similarity coefficients to facilitate accurate and objective volumetric measurements for outcome prediction (arterial injury requiring angioembolization). Cases were separated into five combinations of training and test sets in an 80/20 split and fivefold cross-validation was performed. Dice scores in the test set were 0.71 (SD ± 0.10) using RSTN, compared to 0.49 (SD ± 0.16) using a baseline Deep Learning Tool Kit (DLTK) reference 3D U-Net architecture. Mean inference segmentation time for RSTN was 0.90 min (± 0.26). Pearson correlation between predicted and manual labels was 0.95 with p < 0.0001. Measurement bias was within 10 mL. AUC of hematoma volumes for predicting need for angioembolization was 0.81 (predicted) versus 0.80 (manual). Qualitatively, predicted labels closely followed hematoma contours and avoided muscle and displaced viscera. Further work will involve validation using a federated dataset and incorporation into a predictive model using multiple segmented features.

Digital Breast Tomosynthesis: Physics, Artifacts, and Quality Control Considerations.

As digital breast tomosynthesis (DBT) becomes widely used, radiologists must understand the basic principles of (a) image acquisition, (b) artifacts, and (c) quality control (QC) that are specific to DBT. Standard acquisition parameters common to both full-field digital mammography (FFDM) and DBT are combinations of x-ray tube voltage, current exposure time, and anode target and filter combinations. Image acquisition parameters specific to DBT include tube motion, sweep angle, and number of projections. Continuous tube motion or x-ray emission decreases imaging time but leads to focal spot blurring when compared with step-and-shoot techniques. The sweep angle and number of projections determines resolution. Wider sweep angles allow greater out-of-plane (z-axis) resolution, improving visualization of masses and architecture distortion. A greater number of projections increases in-plane or x-y axis resolution, improving visualization of microcalcifications. Artifacts related to DBT include blurring-ripple, truncation, and loss of skin and superficial tissue resolution. Motion artifacts are difficult to recognize because of inherent out-of-plane blurring. To maintain optimal image quality and an "as low as reasonably achievable" (ALARA) radiation dose, regular QC must be performed. DBT is considered a new imaging modality; therefore, breast imaging facilities are required to obtain a separate certification in addition to that in FFDM, and all personnel (radiologists, technologists, and medical physicists) are mandated to complete initial DBT training and maintain appropriate continuing medical education credits. ©RSNA, 2019.

CT Prediction Model for Major Arterial Injury after Blunt Pelvic Ring Disruption.

Purpose To develop and test a computed tomography (CT)-based predictive model for major arterial injury after blunt pelvic ring disruptions that incorporates semiautomated pelvic hematoma volume quantification. Materials and Methods A multivariable logistic regression model was developed in patients with blunt pelvic ring disruptions who underwent arterial phase abdominopelvic CT before angiography from 2008 to 2013. Arterial injury at angiography requiring transarterial embolization (TAE) served as the outcome. Areas under the receiver operating characteristic (ROC) curve (AUCs) for the model and for two trauma radiologists were compared in a validation cohort of 36 patients from 2013 to 2015 by using the Hanley-McNeil method. Hematoma volume cutoffs for predicting the need for TAE and probability cutoffs for the secondary outcome of mortality not resulting from closed head injuries were determined by using ROC analysis. Correlation between hematoma volume and transfusion was assessed by using the Pearson coefficient. Results Independent predictor variables included hematoma volume, intravenous contrast material extravasation, atherosclerosis, rotational instability, and obturator ring fracture. In the validation cohort, the model (AUC, 0.78) had similar performance to reviewers (AUC, 0.69-0.72; P = .40-.80). A hematoma volume cutoff of 433 mL had a positive predictive value of 87%-100% for predicting major arterial injury requiring TAE. Hematoma volumes correlated with units of packed red blood cells transfused (r = 0.34-0.57; P = .0002-.0003). Predicted probabilities of 0.64 or less had a negative predictive value of 100% for excluding mortality not resulting from closed head injuries. Conclusion A logistic regression model incorporating semiautomated hematoma volume segmentation produced objective probability estimates of major arterial injury. Hematoma volumes correlated with 48-hour transfusion requirement, and low predicted probabilities excluded mortality from causes other than closed head injury. © RSNA, 2018 Online supplemental material is available for this article.

Quantitative MDCT assessment of binder effects after pelvic ring disruptions using segmented pelvic haematoma volumes and multiplanar caliper measurements.

OBJECTIVE: To assess effects of pelvic binders for different instability grades using quantitative multidetector computed tomography (MDCT) parameters including segmented pelvic haematoma volumes and multiplanar caliper measurements. METHODS: CT examinations of 49 patients with binders and 49 controls performed from January 2008-June 2016, and matched 1:1 for Tile instability grade and Pennal/Young-Burgess force vector, were compared for differences in pubic symphysis and sacroiliac displacement using caliper measurements in three orthogonal planes. Pelvic haematoma volumes (ml) were derived using semi-automated seeded region-growing segmentation. Median caliper measurements and volumes were compared using the Mann-Whitney U test, and correlations assessed with Pearson's correlation coefficient. Relevant caliper measurement cutoffs were established using ROC analysis. RESULTS: Rotationally unstable (Tile B) patients with binders showed significant decreases in sacroiliac diastasis (2.7 mm vs. 4.5 mm; p=0.003) and haematoma volumes (135 ml vs. 295 ml; p=0.008). Globally unstable (Tile C) binder patients showed decreased sacroiliac diastasis (4.7 mm vs. 6.4 mm, p=0.04), without significant difference in haematoma volumes (284 ml vs. 234 ml, p=0.34). Four Tile C patients with binders demonstrated over-reduction resulting in pubic body over-ride. CONCLUSION: Rotationally unstable patients with binders have significantly less sacroiliac diastasis versus controls, corresponding with significantly lower haematoma volumes. KEY POINTS: • Haematoma segmentation and multiplanar caliper measurements provide new insights into binder effects. • Binder reduction corresponds with decreased pelvic haematoma volume in rotationally unstable injuries. • Discrimination between rotational and global instability is important for management. • Several caliper measurement cut-offs discriminate between rotationally and globally unstable injuries. • Pubic symphysis over-ride is suggestive of binder over-reduction in globally unstable injuries.

Breast Cancer Tissue Markers, Genomic Profiling, and Other Prognostic Factors: A Primer for Radiologists.

An understanding of prognostic factors in breast cancer is imperative for guiding patient care. Increased tumor size and more advanced nodal status are established independent prognostic factors of poor outcomes and are incorporated into the American Joint Committee on Cancer (AJCC) TNM (primary tumor, regional lymph node, distant metastasis) staging system. However, other factors including imaging findings, histologic evaluation results, and molecular findings can have a direct effect on a patient's prognosis, including risk of recurrence and relative survival. Several microarray panels for gene profiling of tumors are approved by the U.S. Food and Drug Administration and endorsed by the American Society of Clinical Oncology. This article highlights prognostic factors currently in use for individualizing and guiding breast cancer therapy and is divided into four sections. The first section addresses patient considerations, in which modifiable and nonmodifiable prognostic factors including age, race and ethnicity, and lifestyle factors are discussed. The second part is focused on imaging considerations such as multicentric and/or multifocal disease, an extensive intraductal component, and skin or chest wall involvement and their effect on treatment and prognosis. The third section is about histopathologic findings such as the grade and presence of lymphovascular invasion. Last, tumor biomarkers and tumor biology are discussed, namely hormone receptors, proliferative markers, and categorization of tumors into four recognized molecular subtypes including luminal A, luminal B, human epidermal growth factor receptor 2-enriched, and triple-negative tumors. By understanding the clinical effect of these prognostic factors, radiologists, along with a multidisciplinary team, can use these tools to achieve individualized patient care and to improve patient outcomes. ©RSNA, 2018.

Penetrating Colorectal Injuries: Diagnostic Performance of Multidetector CT with Trajectography.

Purpose To determine the diagnostic performance of multidetector computed tomography (CT) with trajectography for penetrating colorectal injuries. Materials and Methods This institutional review board-approved and HIPAA-compliant study was a 6-year blinded retrospective review by two independent readers of 182 consecutive patients who preoperatively underwent 40- or 64-row multidetector CT for penetrating torso trauma below the diaphragm and had surgically confirmed findings. Colorectal perforation was present in 42 patients. Trajectory analysis with postprocessing software was used for all studies. Additional signs evaluated were rectal contrast agent leak, collections of extruded fecal material, mural defect, wall thickening, abnormal enhancement, free fluid or stranding, and free air. The quality of the colorectal contrast agent administration was recorded. Sensitivity, specificity, predictive values, areas under the receiver operating characteristic curves (AUCs), and Cohen κ were determined. Results In patients with rectal contrast agent administration (n = 151), AUCs were 0.90-0.91, which indicated excellent accuracy. Trajectory was sensitive (88%-91%). For single wounds (n = 104), sensitivity of trajectory was 96% for both readers, but was only 80% for multiple wounds (n = 47). Contrast agent leak was highly specific (96%-98%), but insensitive (42%-46%). Improved diagnostic performance was observed in patients with poor colonic distension or opacification. Accuracy remained high (AUC, 0.86-0.99) in the group without rectal contrast agent administration (n = 31). Conclusion Trajectory had excellent sensitivity, while rectal contrast agent leak was specific but insensitive. Sensitivity of trajectory was lower for multiple wounds. Accuracy remained high in patients without rectal contrast agent administration. © RSNA, 2016.

Can MDCT Unmask Instability in Binder-Stabilized Pelvic Ring Disruptions?

OBJECTIVE: Pelvic binders may hinder radiologic assessment of pelvic instability after trauma, and avulsive injuries can potentially unmask instability in this setting. We compare the performance of MDCT for the detection of pelvic disruptions in patients with binders to a matched cohort without binders, and we assess the utility of avulsive injuries as signs of pelvic instability. MATERIALS AND METHODS: MDCT examinations of 56 patients with binders were compared with MDCT examinations of 54 patients without binders. Tile grading by an experienced orthopedic surgeon was used as the reference standard (A, stable; B, rotationally unstable; C, rotationally and vertically unstable). Two radiologists performed blinded reviews of CT studies in two reading sessions (sessions 1 and 2). In session 1, Tile grade was predicted on the basis of established signs of instability, including pubic symphysis and sacroiliac (SI) joint widening. In session 2, readers could change the Tile grade when avulsive injuries were seen. Diagnostic performance for predicting rotational instability and vertical instability was assessed. RESULTS: In the binder group, AUCs under the ROC curves for rotational instability increased from fair (0.73-0.77) to good (0.82-0.89) when avulsive signs were considered. In the control group, AUCs were good in both sessions. AUCs for vertical instability were fair with binders in both sessions. Agreement with the reference standard increased from fair (0.30-0.32) to moderate (0.46-0.54) when avulsive signs were considered in the binder group but were in the moderate range for both sessions in the control group. Combined evaluation for inferolateral sacral fractures, ischial spine fractures, and rectus abdominis avulsions resulted in optimal discrimination of rotational instability. CONCLUSION: Evaluation for avulsive signs improves MDCT sensitivity for the detection of rotational instability but not vertical instability in patients with binders.

Multidetector CT of Mandibular Fractures, Reductions, and Complications: A Clinically Relevant Primer for the Radiologist.

After the nasal bones, the mandible is the second most common site of facial fractures, and mandibular fractures frequently require open reduction. In the trauma injury setting, multidetector computed tomography (CT) has become the cornerstone imaging modality for determining the most appropriate treatment management, fixation method, and surgical approach. Multidetector CT is also used to assess the adequacy of the reduction and evaluate potential complications in the postoperative period. For successful restoration of the mandible's form and function, as well as management of posttraumatic and postoperative complications, reconstructive surgeons are required to have a detailed understanding of mandibular biomechanics, occlusion, and anatomy. To provide added value in the diagnosis, treatment planning, and follow-up of mandibular fractures, radiologists should be aware of these concepts. Knowledge of the techniques commonly used to achieve occlusal and anatomic reduction and of the rationale behind the range of available treatment options for different injury patterns-from isolated and nondisplaced fractures to multisite and comminuted fractures-also is essential. This article focuses on the use of multidetector CT for pre- and postoperative evaluation of mandibular fractures and outlines fundamental concepts of diagnosis and management-beginning with an explanation of common fracture patterns and their biomechanical underpinnings, and followed by a review of the common postoperative appearances of these fractures after semirigid and rigid fixation procedures. Specific considerations regarding fractures in different regions of the tooth-bearing and non-tooth-bearing mandible and the unique issues pertaining to the edentulous atrophic mandible are reviewed, and key features that distinguish major from minor complications are described. (©)RSNA, 2016.

Uncommon Implantation Sites of Ectopic Pregnancy: Thinking beyond the Complex Adnexal Mass.

Ectopic pregnancy occurs when implantation of the blastocyst takes place in a site other than the endometrium of the uterine cavity. Uncommon implantation sites of ectopic pregnancy include the cervix, interstitial segment of the fallopian tube, scar from a prior cesarean delivery, uterine myometrium, ovary, and peritoneal cavity. Heterotopic and twin ectopic pregnancies are other rare manifestations. Ultrasonography (US) plays a central role in diagnosis of uncommon ectopic pregnancies. US features of an interstitial ectopic pregnancy include an echogenic interstitial line and abnormal bulging of the myometrial contour. A gestational sac that is located below the internal os of the cervix and that contains an embryo with a fetal heartbeat is indicative of a cervical ectopic pregnancy. In a cesarean scar ectopic pregnancy, the gestational sac is implanted in the anterior lower uterine segment at the site of the cesarean scar, with thinning of the myometrium seen anterior to the gestational sac. An intramural gestational sac implants in the uterine myometrium, separate from the uterine cavity and fallopian tubes. In an ovarian ectopic pregnancy, a gestational sac with a thick hyperechoic circumferential rim is located in or on the ovarian parenchyma. An intraperitoneal gestational sac is present in an abdominal ectopic pregnancy. Intra- and extrauterine gestational sacs are seen in a heterotopic pregnancy. Two adnexal heartbeats suggest a live twin ectopic pregnancy. Recognition of the specific US features will help radiologists diagnose these uncommon types of ectopic pregnancy.

Imaging Pregnant and Lactating Patients.

As use of imaging in the evaluation of pregnant and lactating patients continues to increase, misperceptions of radiation and safety risks have proliferated, which has led to often unwarranted concerns among patients and clinicians. When radiologic examinations are appropriately used, the benefits derived from the information gained usually outweigh the risks. This review describes appropriateness and safety issues, estimated doses for imaging examinations that use iodizing radiation (ie, radiography, computed tomography, nuclear scintigraphy, and fluoroscopically guided interventional radiology), radiation risks to the mother and conceptus during various stages of pregnancy, and use of iodinated or gadolinium-based contrast agents and radiotracers in pregnant and lactating women. Maternal radiation risk must be weighed with the potential consequences of missing a life-threatening diagnosis such as pulmonary embolus. Fetal risks (ie, spontaneous abortion, teratogenesis, or carcinogenesis) vary with gestational age and imaging modality and should be considered in the context of the potential benefit of medically necessary diagnostic imaging. When feasible and medically indicated, modalities that do not use ionizing radiation (eg, magnetic resonance imaging) are preferred in pregnant and lactating patients. Radiologists should strive to minimize risks of radiation to the mother and fetus, counsel patients effectively, and promote a realistic understanding of risks related to imaging during pregnancy and lactation.

Evolving concepts in MDCT diagnosis of penetrating diaphragmatic injury.

This article reviews current and evolving concepts in the diagnosis of penetrating diaphragmatic injury with multidetector CT (MDCT). As criteria for nonoperative management in the setting of penetrating trauma become more inclusive, confident exclusion of penetrating diaphragmatic injury (PDI) has become imperative. Diagnostic performance of MDCT for PDI has improved substantially with the use of thin sections and multiplanar reformats. Evaluation of injury trajectory in nonstandard planes using 3D post-processing software can aid in the diagnosis. Contiguous injury and transdiaphragmatic trajectory are the best predictors of PDI. Careful appraisal of the diaphragm for defects should be undertaken in all patients with thoracoabdominal penetrating trauma.

Focal nodular hyperplasia within accessory liver: imaging findings at computed tomography and magnetic resonance imaging.

Accessory liver tissue is a rare but probably underreported entity that may harbor the same spectrum of pathology as that of the parent organ. The rarity and aberrant locations of such lesions cause confusion and may lower diagnostic confidence despite otherwise classic radiographic appearances. Focal nodular hyperplasia (FNH) is the most common non-hemangiomatous benign hepatic tumor, but to our knowledge, ectopic FNH has been reported only once before in the gastroenterology literature. We present the first case of ectopic FNH in the radiology literature.

Evaluating blunt pancreatic trauma at whole body CT: current practices and future directions.

Blunt pancreatic trauma almost always occurs in the setting of multiple severe injuries, and is usually diagnosed within the context of whole-body trauma CT. Associated injuries may flag the pancreas for greater scrutiny. Main duct laceration is the primary determinant of the need for surgical intervention. Characterization is improved with advanced post-processing techniques. We present useful diagnostic pearls, describe key pitfalls, and review advancements in the evaluation of pancreatic trauma at whole-body MDCT.

Does the Combination of Phone, Email and Text-Based Reminders Improve No-show Rates for Patients in Breast Imaging?

The issue of no-shows in radiology is complicated and challenging. Mammography and ultrasound have the highest rate of no-shows among radiologic exams. Screening mammography is one of the most cost-effective ways to reduce breast cancer related deaths. However, the benefit of screening is heavily dependent on patient compliance to routine exams. Enhancing patients' commitments to their scheduled appointments, thereby improving early detection and decreasing breast cancer related mortality. Retrospective analysis of no-show visits scheduled from August 2017 to December 2017 (before the implementation of combined phone, email and text-based reminders) and from August 2019 to December 2019 (after the implementation of reminder and follow-up phone calls after missed appointments by the coordinator) in an urban academic breast imaging center was conducted. There were 368 no-show patients in 2017 and 238 no-show patients in 2019. Percentage of no-shows, and delay time to the rescheduled missed appointment were calculated. Subgroup analysis of the type of studies that were missed and those who did not reschedule the missed appointment was conducted. Mann Whitney U test was used to analyze differences between group means. No-show visits decreased by 50% in 2019 when compared to 2017. The average wait time between the missed appointment and the rescheduled appointment decreased significantly from 30.7 weeks in 2017 to 12.1 weeks in 2019 (P = 0.047). The percentage of no-show visits was highest among the unemployed, patients scheduled for screening mammograms and patients with a high average of no-show visits. No-show visits adversely impact patient outcome and contribute to increased cost of healthcare. Through a deeper understanding of the factors contributing to no-shows, we can strive to make appropriate interventions to alleviate the consequences of no-shows.

In-situ cryo-immune engineering of tumor microenvironment with cold-responsive nanotechnology for cancer immunotherapy.

Cancer immunotherapy that deploys the host's immune system to recognize and attack tumors, is a promising strategy for cancer treatment. However, its efficacy is greatly restricted by the immunosuppressive (i.e., immunologically cold) tumor microenvironment (TME). Here, we report an in-situ cryo-immune engineering (ICIE) strategy for turning the TME from immunologically "cold" into "hot". In particular, after the ICIE treatment, the ratio of the CD8+ cytotoxic T cells to the immunosuppressive regulatory T cells is increased by more than 100 times in not only the primary tumors with cryosurgery but also distant tumors without freezing. This is achieved by combining cryosurgery that causes "frostbite" of tumor with cold-responsive nanoparticles that not only target tumor but also rapidly release both anticancer drug and PD-L1 silencing siRNA specifically into the cytosol upon cryosurgery. This ICIE treatment leads to potent immunogenic cell death, which promotes maturation of dendritic cells and activation of CD8+ cytotoxic T cells as well as memory T cells to kill not only primary but also distant/metastatic breast tumors in female mice (i.e., the abscopal effect). Collectively, ICIE may enable an efficient and durable way to leverage the immune system for combating cancer and its metastasis.

Breast papillomas in the United States: single institution data on underrepresented minorities with a multi-institutional update on incidence.

PURPOSE: To assess the percentage of papillomas from all biopsies performed, comparing differences in patient age and race at a single institution. To assess trends in biopsied papillomas at institutions throughout the United States (US). METHODS: This is a HIPPA-compliant IRB-approved single-institution (Southern1) retrospective review to assess race and age of all-modality-biopsied non-malignant papillomas as a percentage of all biopsies (percentage papillomas calculated as papilloma biopsies/all biopsies) from January 2012 to December 2019. To assess national variation, several academic or large referral centers were contacted to provide data regarding papilloma percentages, biopsy modalities, and trends in case numbers. Trends were estimated using the method of analysis of variance (ANOVA). Comparisons of differences in trends were assessed. RESULTS: Southern1 institution demonstrated a significant association between race and percentage of papillomas (p < 0.0001). After adjustment for multiple comparisons with Bonferroni correction at 5% type I family error, the percentage of biopsied papillomas in Black and Asian patients remained significantly higher than in White patients (p < 0.0001 and p = 0.0032, respectively) using a Chi-square test. The regional variation in percentage of papillomas was found to be 3-9%. Southern1 institution showed a 7-year significant trend of increase in percentage of papillomas. Other institutions showed a decreasing trend (p < 0.05). CONCLUSION: Black and Asian women had significantly higher papilloma percentages compared to white patients in our single institution review. This institution also showed a statistically significant trend of increasing percentage papillomas from 2012 to 2019. Multi-institutional survey found regional variation in percentage papillomas, ranging from 3% to 9%.

Excision or Observation: The Dilemma of Managing High-Risk Breast Lesions.

There is an enduring dilemma on the appropriate management of high-risk breast lesions; is surgical excision always warranted or can conservative management be utilized? We present cases of high-risk breast lesions diagnosed at core needle biopsy at our institution along with relevant factors to consider for appropriate management. We conclude that a nuanced approach is warranted over the broad stroke approach of surgical excision of all high-risk breast lesions.

Why Patients Decline Digital Breast Tomosynthesis? Results From a Patient Survey in an Urban Academic Breast Center.

BACKGROUND: Despite the advantages of reduced callback rates, higher sensitivity, and higher specificity associated with digital breast tomosynthesis (DBT) over traditional full-field digital mammography (FFDM), many patients declined DBT at our urban academic breast center. Most states also do not have mandated insurance coverage for DBT. METHODS: A patient survey was conducted at our breast center from February 2017 to April 2017. All patients were informed regarding the potential benefits of DBT as well as the potential additional charge related to DBT, which depended on the insurance coverage. The survey aimed to examine why the patient declined the DBT option. Reasons included cost, increased radiation risk, anxiety about newer technology, discomfort associated with the exam, lack of education about potential benefits, or patient belief that she will not benefit from DBT. We also inquired if patients would change their opinion about DBT if cost were removed. Patients answered each question by rating their responses on a scale of 1-5, from strongly disagree, disagree, neutral, agree, and strongly agree. RESULTS: Potential additional cost associated with tomosynthesis had the highest influence on patient decision to decline DBT with an average score of 4.68 out of 5. Other factors as described above had less impact on the patient decision with an average score ranging from 1.53-1.72 out of 5. CONCLUSION: Potential out-of-pocket cost for patients remains one of the major obstacles in adoption of DBT as standard of care for breast cancer screening.