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Breast cancer is the most prevalent cancer in women in Europe, and while all European countries have some form of screening for breast cancer, disparities in organization and implementation exist. Breast density is a well-established risk factor for breast cancer; however, most countries in Europe do not have recommendations in place for notification of breast density or additional supplementary imaging for women with dense breasts. Various supplemental screening modalities have been investigated in Europe, and when comparing modalities, MRI has been shown to be superior in cancer detection rate and in detecting small invasive disease that may impact long-term survival, as demonstrated in the Dense Tissue and Early Breast Neoplasm Screening (DENSE) trial in the Netherlands. Based on convincing evidence, the European Society of Breast Imaging issued recommendations that women with category D density undergo breast MRI from ages 50 to 70 years at least every 4 years and preferably every 2 to 3 years. However, currently no countries in Europe routinely offer women with BI-RADS category D density breasts MRI as supplemental imaging. The reasons for lack of implementation of MRI screening are multifactorial. Concerns regarding increased recalls have been cited, as have cost and lack of resources. However, studies have demonstrated breast MRI in women with BI-RADS category D density breasts to be cost-effective compared with the current breast cancer screening standard of biannual mammography. Furthermore, abbreviated MRI protocols could facilitate more widespread use of affordable MRI screening. Women's perception on breast density notification and supplemental imaging is key to successful implementation., (© Society of Breast Imaging 2025. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Background: Surgical axillary staging of the axilla is a topic of debate regarding the potential of de-escalation in clinically node negative (cN0) early breast cancer patients treated with breast-conserving therapy. Axillary ultrasound is important to determine clinical nodal status. The aim of the current narrative review is to provide an overview of prospective trials on de-escalating axillary surgical staging in cN0 early breast cancer patients, with an emphasis on axillary ultrasound protocols., Methods: This narrative review provides an overview of the prospective de-escalating axillary surgical staging trials, in terms of comparing sentinel lymph node biopsy (SLNB) versus complete omission of SLNB, in cT1/2N0 patients treated with breast-conserving therapy. Information from each trial was collected, including reported axillary ultrasound protocols (including cortical thickness cut-off value) and axillary ultrasound-guided biopsy technique (fine-needle aspiration or core-needle biopsy)., Results: There is one recently published prospective trial and three ongoing prospective trials within the topic of this narrative review. Number of included patients in these trials ranges from 1405 to 5505 patients. The included trials differed whether or not to include patients with suspicious axillary ultrasound findings and a negative ultrasound-guided biopsy. Cortical thickness cut-off value ranged from 2.3 mm to 3.0 mm. Different ultrasound-guided biopsy techniques were performed among the included trials., Conclusion: Prospective de-escalating axillary surgical staging trials in clinically node negative early breast cancer patients treated with breast-conserving therapy do report differences in terms of axillary ultrasound protocols and ultrasound-guided biopsy techniques. Axillary ultrasound protocols do require uniformity in order to improve extrapolation of these trial results., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Author(s). Published by Elsevier B.V. All rights reserved.)

Background: Breast cancer in pediatric patients is rare, but ultrasound (US) is widely utilized for symptomatic cases., Purpose: To determine biopsy and cancer detection rates of pediatric patients and to assess if breast US can be omitted., Material and Methods: A retrospective review of a 5-year period was conducted of single-center breast US performed in patients aged <19 years. Data regarding presentation, clinical opinion (P1-5 score), and US (U1-5 score) were collected. If biopsy or surgery was performed, pathology was reviewed (B1-5 score)., Results: In total, 579 patients were included (19 boys, 560 girls; mean age=16.2±1.9 years; age range=0-18 years). Clinical examination was normal or benign (P1/P2) in all boys (100%) and 557/560 (99.5%) girls, and P3 in 3 (0.5%) girls. Of US, 52% demonstrated normal findings (U1) for both sexes (300/579); in the remaining cases, the most frequent findings were gynecomastia in 12/19 boys and well-defined breast masses in 208/560 girls. Of the 560 girls, 6 (1%) underwent US-guided biopsy, with final histology of fibroadenoma (B2) in all cases, while 27 (5%) had a surgical excision, with final histology of fibroadenoma (22/27, 81.5%), hamartoma (2/27, 7.4%), benign phyllodes tumor (2/27, 7.4%), and angiomyxoma skin lesion (1/27, 3.7%). No malignant lesions were diagnosed at the time of clinical referral or during the 18-month follow-up in patients with a well-defined mass on US., Conclusion: Breast malignancy is extremely rare in pediatric population. US can be safely omitted if clinical examination is normal; this approach would have avoided breast US in 52% of patients in this study., Competing Interests: Declaration of conflicting interestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Importance: Breast cancer is one of the leading causes of negligence claims in radiology. The objective of this document is to describe the specific main causes of errors in breast imaging and provide European Society of Breast Imaging (EUSOBI) recommendations to try to minimize these., Observations: Technical failures represent 17% of all mammographic diagnostic negligence claims. Mammography quality control protocol and dedicated training for technologists and radiologists are essential. Lack of consideration of the clinical context is a second critical issue, as a clinical abnormality is found in 80% of malpractice claims. EUSOBI emphasizes the importance of communication and clinical examination before the diagnostic investigation. Detection errors or misapplications of the lexicon or Breast Imaging Reporting Data System (BI-RADS) score account for 5% of malpractice claims and should be reduced by limiting radiologists' distraction or fatigue, and being aware of satisfaction of search errors and the importance of a personal systematic review. Errors related to pathological concordance and MDT review can be limited by the use of markers after biopsy and the use of standardized reports, which can aid communication with other specialities. Finally, errors related to tumor or patient factors should be discussed, considering the use of contrast-enhanced mammography and magnetic resonance imaging., Conclusion: Several factors are responsible for misdiagnosis in breast cancer, including errors in the practice of the technician and/or radiologist (technical failures, lack of consideration of the clinical context, incorrect application of the BI-RADS score, false reassurances), lack of communication with other specialists or with the patient, and the type of tumor and breast parenchyma., Key Points: Question What factors most contribute to and what implications stem from misdiagnosis in breast imaging? Findings Ongoing training and education for radiologists and other healthcare providers, as well as interdisciplinary collaboration and communication is paramount. Clinical relevance Misdiagnosis in breast imaging can have significant implications for patients, healthcare providers, and the entire healthcare system., Competing Interests: Compliance with ethical standards Guarantor The scientific guarantor of this publication is Isabelle Thomassin-Naggara. Conflict of interest The authors declare the following disclosure: Isabelle Thomassin-Naggara: speakers bureaus—European Society of Breast Imaging (active), Société d’imagerie de la femme (active), Amercian College of Radiology O-RADS (active), Bayer (ended), Siemens Healthineers (ended), Guerbet (ended), Bard (ended); Ponctual remunerated lectures—GE, Siemens, Guerbet, Hologic, Canon, Guebet, Bracco, GSD, Samsung, Fujifilm, Incepto, ICAD; Research grants—ASCORDIA: ADNEX MR Scoring System: Impact of an MR scoring system on therapeutic strategy of pelvic adnexal masses PHRC ID RCB 2015-A01593-46. Katia Pinker-Domenig: speakers bureaus—European Society of Breast Imaging (active), Bayer (ended), Siemens Healthineers (ended), DKD 2019 (ended), Olea Medical (ended), Roche (ended), MedScape (ended). Consulting, Advisory: Consultant—Genentech, Inc., 05/19–present (non-monetary); Consultant—Merantix Healthcare, 05/20–1/2014; Consultant—AURA Health Technologies GmbH, 04/21–2/24; Consultant—Guerbet, 05/2023–1/2024; Consultant—Neodynamics, 12/20223–present. Research grants: Digital Hybrid Breast PET/MRI for Enhanced Diagnosis of Breast Cancer (HYPMED) H2020—Research and Innovation Framework Program PHC-11-2015 # 667211-2; A Body Scan for Cancer Detection using Quantum Technology (CANCERSCAN) H2020-FETOPEN # 828978; Multiparametric 18F-Fluoroestradiol PET/MRI coupled with Radiomics Analysis and Machine Learning for Prediction and Assessment of Response to Neoadjuvant Endocrine Therapy in Patients with Hormone Receptor +/HER2 − Invasive Breast Cancer Jubiläumsfonds of the Austrian National Bank # Nr: 18207; Deciphering breast cancer heterogeneity and tackling the hypoxic tumor microenvironment challenge with PET/MRI, MSI and radiomics The Vienna Science and Technology Fund LS19-046; MSKCC 2020 Molecularly Targeted Intra-Operative Imaging Award 07/2020–06/2021; Breast Cancer Research Foundation 06/2019–05/2021; NIH R01 Breast Cancer Intravoxel-Incoherent-Motion MRI Multisite (BRIMM) 09/01/2020–08/30/2025 UG3 CA239861; NIH R01 subaward: Abbreviated Non-Contrast-Enhanced MRI for Breast Cancer Screening 09/01/2023–08/31/2025 R01 CA249893; NIH RO1: Deciphering the Acidic Tumor Environment: A Phase I/IIa Study of Pre-Operative Multiparametric MRI and pHLIP® ICG Intra-Operative Fluorescence Imaging of Primary Breast Cancer 03/01/2023-02/29/2024 1R01CA270018-01A1. Katja Pinker is supported in part through the NIH/NCI Cancer Center Support Grant P30 CA008748. All other authors have nothing to disclose directly related to the article. Statistics and biometry No complex statistical methods were necessary for this paper. Informed consent Written informed consent was not required for this study. Ethical approval Institutional Review Board approval was not required. Study subjects or cohorts overlap Not applicable. Methodology Review, (© 2024. The Author(s), under exclusive licence to European Society of Radiology.)

Importance: Misdiagnosis in breast imaging can have significant implications for patients, healthcare providers, and the healthcare system as a whole., Observations: Some of the potential implications of misdiagnosis in breast imaging include delayed diagnosis or false reassurance, which can result in a delay in treatment and potentially a worse prognosis. Misdiagnosis can also lead to unnecessary procedures, which can cause physical discomfort, anxiety, and emotional distress for patients, as well as increased healthcare costs. All these events can erode patient trust in the healthcare system and in individual healthcare providers. This can have negative implications for patient compliance with screening and treatment recommendations, as well as overall health outcomes. Moreover, misdiagnosis can also result in legal consequences for healthcare providers, including medical malpractice lawsuits and disciplinary action by licensing boards., Conclusion and Relevance: To minimize the risk of misdiagnosis in breast imaging, it is important for healthcare providers to use appropriate imaging techniques and interpret images accurately and consistently. This requires ongoing training and education for radiologists and other healthcare providers, as well as collaboration and communication among healthcare providers to ensure that patients receive appropriate and timely care. If a misdiagnosis does occur, it is important for healthcare providers to communicate with patients and provide appropriate follow-up care to minimize the potential implications of the misdiagnosis. This may include repeat imaging, additional biopsies or other procedures, and referral to specialists for further evaluation and management., Key Points: Question What factors most contribute to and what implications stem from misdiagnosis in breast imaging? Findings Ongoing training and education for radiologists and other healthcare providers, as well as interdisciplinary collaboration and communication, is paramount. Clinical relevance Misdiagnosis in breast imaging can have significant implications for patients, healthcare providers, and the entire healthcare system., Competing Interests: Compliance with ethical standards Guarantor The scientific guarantor of this publication is Isabelle Thomassin-Naggara. Conflict of interest The authors declare the following disclosures: Isabelle Thomassin-Naggara: speakers bureaus—European Society of Breast Imaging (active), Société d’imagerie de la femme (active), American College of Radiology O-RADS (active), Bayer (ended), Siemens Healthineers (ended), Guerbet (ended), Bard (ended); Ponctual remunerated lectures: GE, Siemens, Guerbet, Hologic, Canon, Guebet, Bracco, GSD, Samsung, Fujifilm, Incepto, ICAD; Research grants: ASCORDIA: ADNEX MR Scoring System: Impact of an MR scoring system on the therapeutic strategy of pelvic adnexal masses PHRC ID RCB 2015-A01593-46. Katia Pinker-Domenig:speakers bureaus—European Society of Breast Imaging (active), Bayer (ended), Siemens Healthineers (ended), DKD 2019 (ended), Olea Medical (ended), Roche (ended), MedScape (ended). Consulting, Advisory:Consultant—Genentech, Inc.: 05/19–present (non-monetary); Consultant—Merantix Healthcare: 05/20–1/2014; Consultant: AURA Health Technologies GmbH: 04/21–2/24; Consultant—Guerbet; 05/2023–1/2024; Consultant—Neodynamics: 12/20223–present. Research grants: Digital Hybrid Breast PET/MRI for Enhanced Diagnosis of Breast Cancer (HYPMED) H2020—Research and Innovation Framework Program PHC-11-2015 #667211-2, A Body Scan for Cancer Detection using Quantum Technology (CANCERSCAN) H2020-FETOPEN # 828978; Multiparametric 18F-Fluoroestradiol PET/MRI coupled with Radiomics Analysis and Machine Learning for Prediction and Assessment of Response to Neoadjuvant Endocrine Therapy in Patients with Hormone Receptor +/HER2 − Invasive Breast Cancer Jubiläumsfonds of the Austrian National Bank # Nr: 18207; Deciphering breast cancer heterogeneity and tackling the hypoxic tumor microenvironment challenge with PET/MRI, MSI and radiomics The Vienna Science and Technology Fund LS19-046; MSKCC 2020 Molecularly Targeted Intra-Operative Imaging Award 07/2020–06/2021, Breast Cancer Research Foundation 06/2019–05/2021; NIH R01 Breast Cancer Intravoxel-Incoherent-Motion MRI Multisite (BRIMM) 09/01/2020–08/30/2025 UG3 CA239861; NIH R01 subaward: Abbreviated Non-Contrast-Enhanced MRI for Breast Cancer Screening 09/01/2023–08/31/2025 R01 CA249893; NIH RO1: Deciphering the Acidic Tumor Environment: A Phase I/IIa Study of Pre-Operative Multiparametric MRI and pHLIP® ICG Intra-Operative Fluorescence Imaging of Primary Breast Cancer 03/01/2023–02/29/2024 1R01CA270018-01A1. Katja Pinker is supported in part through the NIH/NCI Cancer Center Support Grant P30 CA008748. All other authors have nothing to disclose directly related to the article. Statistics and biometry No complex statistical methods were necessary for this paper. Informed consent Written informed consent was not required for this study. Ethical approval Institutional Review Board approval was not required. Study subjects or cohorts overlap Not applicable. Methodology Review, (© 2024. The Author(s), under exclusive licence to European Society of Radiology.)

In the mid-1990s, the identification of BRCA1/2 genes for breast cancer susceptibility led to testing breast MRI accuracy in screening women at increased risk. From 2000 onwards, ten intraindividual comparative studies showed the marked superiority of MRI: the sensitivity ranged 25-58% for mammography, 33-52% for ultrasound, 48-67% for mammography plus ultrasound, and 71-100% for MRI; specificity 93-100%, 91-98%, 89-98%, and 81-98%, respectively. Based on the available evidence, in 2006-2007, the UK National Institute for Clinical Excellence and the American Cancer Society recommended MRI screening of high-risk women, followed by other international guidelines. Despite evidence-based medicine ideally requiring randomised controlled trials (RCTs) for policy changes regarding screening procedures, breast MRI for high-risk screening was adopted in many countries worldwide. In 2019, the results of the "DENSE" RCT were published in favour of breast MRI screening of women with extremely dense breasts compared to mammography alone, showing a reduction of more than 80% of the interval cancer rate in women who attended MRI screening. Even though international recommendations in favour of this practice were issued, substantial obstacles still prevent health systems from adopting breast MRI for screening women with extremely dense breasts. A paradox is evident: we adopted a screening procedure without evidence from RCTs, and now that we have this level-1 evidence for the same procedure, we fail to do so. This critical review tries to explain the differences between the two cases, as examples of the complex pathways of translating radiological research into everyday practice.Critical relevance statement The high-level evidence in favour of breast MRI screening of women with extremely dense breasts is failing to persuade policy makers to translate this into clinical practice.Key points• Breast MRI screening of high-risk women was adopted on basis of the evidence provided by test accuracy comparative studies showing an MRI performance greatly superior to that of mammography.• Breast MRI screening of women with extremely dense breasts has not been adopted although the evidence of a large reduction in interval cancer rate from a RCT.• We illustrate the differences between the two cases, as an example of the complex ways of translation of radiological research in clinical practice according to the EBM theory., (© 2024. The Author(s).)

Axillary lymphadenopathy is a common side effect of COVID-19 vaccination, leading to increased imaging-detected asymptomatic and symptomatic unilateral axillary lymphadenopathy. This has threatened to negatively impact the workflow of breast imaging services, leading to the release of ten recommendations by the European Society of Breast Imaging (EUSOBI) in August 2021. Considering the rapidly changing scenario and data scarcity, these initial recommendations kept a highly conservative approach. As of 2023, according to newly acquired evidence, EUSOBI proposes the following updates, in order to reduce unnecessary examinations and avoid delaying necessary examinations. First, recommendation n. 3 has been revised to state that breast examinations should not be delayed or rescheduled because of COVID-19 vaccination, as evidence from the first pandemic waves highlights how delayed or missed screening tests have a negative effect on breast cancer morbidity and mortality, and that there is a near-zero risk of subsequent malignant findings in asymptomatic patients who have unilateral lymphadenopathy and no suspicious breast findings. Second, recommendation n. 7 has been revised to simplify follow-up strategies: in patients without breast cancer history and no imaging findings suspicious for cancer, symptomatic and asymptomatic imaging-detected unilateral lymphadenopathy on the same side of recent COVID-19 vaccination (within 12 weeks) should be classified as a benign finding (BI-RADS 2) and no further work-up should be pursued. All other recommendations issued by EUSOBI in 2021 remain valid., (© 2023. The Author(s).)

Objectives: High-grade DCIS (HG DCIS) is associated with upgrade to invasive disease but few studies evaluate the role of MRI in this subset of DCIS. This study compared surgical outcomes of females with HG DCIS on biopsy who had pre-operative MRI with those that proceeded directly to surgery., Methods: This single-centre retrospective, observational study identified patients with pure HG DCIS on pre-operative biopsy from the pathology database. Surgical outcomes, clinicopathological and radiological features were obtained for all patients., Results: From August 2015 to February 2020, 217 patients had HG DCIS on biopsy. Pre-operative MRI was performed in 40 (MRI group) and not in 88 (No MRI group) patients. Initial mastectomy was performed in 25/40 (63%) women in the MRI group and 20/88 (23%) women in the no MRI group ( p < 0.0001). No difference was observed in re-operation rate between the two groups, 15% in MRI group vs 22% in No MRI group ( p = 0.4749). Mean tumour size on histology was larger in mastectomy cases in the MRI group (73.4 mm, range 6-140 mm), than the total MRI group, (58.3 mm, range 0-140 mm) or no MRI group (30.7 mm, range 0-130 mm) ( p < 0.0001)., Conclusions: Pre-operative MRI in HG DCIS is associated with higher mastectomy rates, possibly due to patient selection for MRI, as tumours on final histology were significantly larger. Fewer re-operations were observed in the MRI group although this was not significant., Advances in Knowledge: Breast MRI performed pre-operatively in HG DCIS is associated with higher mastectomy rates and fewer re-operation rates.

The correct N-staging in breast cancer is crucial to tailor treatment and stratify the prognosis. N-staging is based on the number and the localization of suspicious regional nodes on physical examination and/or imaging. Since clinical examination of the axillary cavity is associated with a high false negative rate, imaging modalities play a central role. In the presence of a T1 or T2 tumor and 0-2 suspicious nodes, on imaging at the axillary level I or II, a patient should undergo sentinel lymph node biopsy (SLNB), whereas in the presence of three or more suspicious nodes at the axillary level I or II confirmed by biopsy, they should undergo axillary lymph node dissection (ALND) or neoadjuvant chemotherapy according to a multidisciplinary approach, as well as in the case of internal mammary, supraclavicular, or level III axillary involved lymph nodes. In this scenario, radiological assessment of lymph nodes at the time of diagnosis must be accurate. False positives may preclude a sentinel lymph node in an otherwise eligible woman; in contrast, false negatives may lead to an unnecessary SLNB and the need for a second surgical procedure. In this review, we aim to describe the anatomy of the axilla and breast regional lymph node, and their diagnostic features to discriminate between normal and pathological nodes at Ultrasound (US) and Magnetic Resonance Imaging (MRI). Moreover, the technical aspects, the advantage and limitations of MRI versus US, and the possible future perspectives are also analyzed, through the analysis of the recent literature.

Aim: To review outcomes of male patients attending the breast unit, evaluate effectiveness of imaging and examination in detecting breast cancer and review adherence to guidelines for male breast imaging., Materials and Methods: A retrospective review was undertaken of male patients attending Cambridge Breast Unit from 1 January 2015 to 31 December 2019. Patient electronic records and imaging were reviewed to establish demographics, clinical findings, imaging, biopsy, and pathology outcomes., Results: Of 1,362 male patients attending the breast unit, 1,028 (75%) had imaging performed. Biopsy was performed in 41 men (3%), with 14 cancers diagnosed (1%). Clinical examination showed 42.7% sensitivity, 99.6% specificity, 54.6% positive predictive value (PPV) and 99.4% negative predictive value (NPV) for detection of cancer. Mammogram demonstrated 84.6% sensitivity, 99.4% specificity, 69.8% PPV, and 99.8% NPV for detection of malignancy. Ultrasound demonstrated 78.6% sensitivity, 98.9% specificity, 73.3% PPV and 99.2% NPV for detection of cancer. Forty-one percent of patients <40 years and 51% < 50 years were imaged, who according to local and Royal College of Radiologists (RCR) guidelines did not require imaging based on age and clinical score., Conclusion: Male patients account for a small proportion of referrals to the breast unit but generate significant workload. Imaging protocols, incorporating clinical score and age cut-off at 40 years remains robust for detecting malignancy. Clinician awareness of the imaging protocol, and close liaison with radiologists is essential to minimise additional radiology workload., (Crown Copyright © 2021. Published by Elsevier Ltd. All rights reserved.)

Unilateral axillary lymphadenopathy is a frequent mild side effect of COVID-19 vaccination. European Society of Breast Imaging (EUSOBI) proposes ten recommendations to standardise its management and reduce unnecessary additional imaging and invasive procedures: (1) in patients with previous history of breast cancer, vaccination should be performed in the contralateral arm or in the thigh; (2) collect vaccination data for all patients referred to breast imaging services, including patients undergoing breast cancer staging and follow-up imaging examinations; (3) perform breast imaging examinations preferentially before vaccination or at least 12 weeks after the last vaccine dose; (4) in patients with newly diagnosed breast cancer, apply standard imaging protocols regardless of vaccination status; (5) in any case of symptomatic or imaging-detected axillary lymphadenopathy before vaccination or at least 12 weeks after, examine with appropriate imaging the contralateral axilla and both breasts to exclude malignancy; (6) in case of axillary lymphadenopathy contralateral to the vaccination side, perform standard work-up; (7) in patients without breast cancer history and no suspicious breast imaging findings, lymphadenopathy only ipsilateral to the vaccination side within 12 weeks after vaccination can be considered benign or probably-benign, depending on clinical context; (8) in patients without breast cancer history, post-vaccination lymphadenopathy coupled with suspicious breast finding requires standard work-up, including biopsy when appropriate; (9) in patients with breast cancer history, interpret and manage post-vaccination lymphadenopathy considering the timeframe from vaccination and overall nodal metastatic risk; (10) complex or unclear cases should be managed by the multidisciplinary team., (© 2021. The Author(s).)

We summarise here the information to be provided to women and referring physicians about percutaneous breast biopsy and lesion localisation under imaging guidance. After explaining why a preoperative diagnosis with a percutaneous biopsy is preferred to surgical biopsy, we illustrate the criteria used by radiologists for choosing the most appropriate combination of device type for sampling and imaging technique for guidance. Then, we describe the commonly used devices, from fine-needle sampling to tissue biopsy with larger needles, namely core needle biopsy and vacuum-assisted biopsy, and how mammography, digital breast tomosynthesis, ultrasound, or magnetic resonance imaging work for targeting the lesion for sampling or localisation. The differences among the techniques available for localisation (carbon marking, metallic wire, radiotracer injection, radioactive seed, and magnetic seed localisation) are illustrated. Type and rate of possible complications are described and the issue of concomitant antiplatelet or anticoagulant therapy is also addressed. The importance of pathological-radiological correlation is highlighted: when evaluating the results of any needle sampling, the radiologist must check the concordance between the cytology/pathology report of the sample and the radiological appearance of the biopsied lesion. We recommend that special attention is paid to a proper and tactful approach when communicating to the woman the need for tissue sampling as well as the possibility of cancer diagnosis, repeat tissue sampling, and or even surgery when tissue sampling shows a lesion with uncertain malignant potential (also referred to as "high-risk" or B3 lesions). Finally, seven frequently asked questions are answered.

Breast magnetic resonance imaging (MRI) is the technique of choice in detection, local staging, and monitoring of breast cancer; however, breast MRI results in the detection of more indeterminate/suspicious lesions that need to be histopathologically proven to guide patient management than any other breast imaging method. If such abnormalities are not detectable in any of the conventional imaging tools (mammography (MMG) or ultrasound) then an MRI-guided biopsy needs to be performed to obtain a diagnosis. Breast MRI-guided biopsy is a time-consuming and complex procedure that requires specific equipment and experienced, well-trained staff. This review article explores and illustrates the indications, the currently available technologies, and the technique of breast MRI-guided biopsy, and explains the importance of careful imaging review and selection of cases. We correlate the radiological-pathological findings and highlight the impact on patient management in a multidisciplinary setting., (Copyright © 2018 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.)

Aim: To determine the impact of preoperative axillary ultrasound staging in a screen-detected breast cancer population., Materials and Methods: Ultrasound and needle biopsy staging results alongside reference standard sentinel lymph node biopsy and axillary lymph node dissection were extracted retrospectively from the unit's computer records between 1 April 2008 and 31 March 2015. Axillary staging was compared with final histopathology and treatment., Results: Of the 215,661 screening examinations performed, 780 invasive cancers were diagnosed, which had preoperative axillary staging data, of which 162 (20.7%) were node positive. Thirty-six (4.6%) had a heavy nodal burden (three or more nodes). Ninety (11.5%) had an abnormal axillary ultrasound and axillary biopsy of which 54 were positive for cancer (33.3% of the node positive cases) and triaged to axillary lymph node dissection avoiding a sentinel lymph node biopsy. Of these 22 (40.7%) had neoadjuvant treatment, and 32 (59.3%) proceeded directly to axillary lymph node dissection. The sensitivity of axillary ultrasound and biopsy to detect women with a heavy nodal burden (three or more nodes) was 41.7% (15 of 36); however, 17 (53%) of the 32 women with a positive axillary biopsy had a low burden of axillary disease (two or fewer positive nodes) at axillary lymph node dissection, the mean number of nodes obtained was 14.6., Conclusion: Significant numbers of women are being potentially overtreated or denied entry into positive sentinel node: adjuvant therapy only versus adjuvant therapy and clearance or axillary radiotherapy (POSNOC) because of routine preoperative axillary staging., (Copyright © 2017 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.)

Aims: To assess the feasibility of undertaking microbubble-guided vacuum-assisted biopsy (VAB) of the sentinel lymph node (SLN) and determine its sensitivity in detecting metastases. Patient experience and the impact of VAB on subsequent axillary surgery were also evaluated., Materials and Methods: Patients with a normal axillary ultrasound or benign core biopsy planned for surgical SLN biopsy were recruited. Part 1 of the study was used to establish the technique of ultrasound microbubble contrast to detect the SLN. In Part 2 microbubble detection of the SLN was followed by 13 G VAB. All patients subsequently had surgical histological correlation., Results: One hundred and thirty-nine patients were recruited: 36 to Part 1 and 103 to Part 2. Of the 100 patients in Part 2 included for analysis, 82 (82%) underwent successful biopsy. Sensitivity for detecting metastases was 58.8% (95% confidence interval: 32.9%, 81.6%). The procedure was generally well tolerated; however, VAB interfered adversely with subsequent surgical SLN biopsy with surgeons reporting moderate or severe interference in 48% of patients and an additional 8.3% with complete failure of SLNB., Conclusion: It is possible to perform VAB of microbubble-detected SLNs. Although the sensitivity for detecting metastases was reasonable, the adverse effect on subsequent surgery was significant., (Copyright © 2017 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.)

Objectives: Round lesions are a common mammographic finding, which can contribute more than 20% of overall recalls at screening. Discrimination of cystic fluid from solid tissue by spectral x-ray imaging has been demonstrated in specimen experiments. This work translates these results into a clinical pilot study to investigate the feasibility of discriminating cystic from solid lesions using spectral mammography., Materials and Methods: Women undergoing mammography as part of their routine diagnostic workup were consented for analysis of spectral information obtained from a photon-counting mammography system. Images were analyzed retrospectively after diagnosis was confirmed with ultrasound and pathology. Well-defined solitary lesions were delineated independently by 3 expert radiologists. A breast lesion model is generated from the spectral mammography data using the energy-dependent x-ray attenuation of cyst fluid, carcinoma, and adipose and glandular tissue. From the breast lesion model, 2 spectral features are computed and combined in a 2-feature discrimination algorithm, which is evaluated in an analysis of the receiver operating characteristic curve for the task of identifying solid lesions ("positive result"). Expected outcomes on a screening population are extrapolated from this pilot study by cross-validation with bootstrapping using a 95% confidence interval (CI)., Results: The 2-feature discrimination algorithm was evaluated on the set of 119 eligible lesions (62 solids, 57 cysts) of diameter greater than 10 mm. The area under the receiver operating characteristic curve (AUC) was 0.88 with a specificity of 61% at the 99% sensitivity level on average over all expert radiologists. Cross-validation with bootstrapping of the clinical data revealed an AUC of 0.89 (95% CI, 0.79-0.96) and a specificity of 56% (95% CI, 33%-78%) when operating the algorithm at the 99% sensitivity level., Conclusions: Discriminating cystic from solid lesions with spectral mammography demonstrates promising results with the potential to reduce mammographic recalls. It is estimated that for each missed cancer at least 625 cystic lesions would have been correctly identified and hence would not have been needed to be recalled. Our results justify undertaking a larger reader study to refine the algorithm and determine clinically relevant thresholds to allow safe classification of cystic lesions by spectral mammography.

Knowledge of x-ray attenuation is essential for developing and evaluating x-ray imaging technologies. For instance, techniques to distinguish between cysts and solid tumours at mammography screening would be highly desirable to reduce recalls, but the development requires knowledge of the x-ray attenuation for cysts and tumours. We have previously measured the attenuation of cyst fluid using photon-counting spectral mammography. Data on x-ray attenuation for solid breast lesions are available in the literature, but cover a relatively wide range, likely caused by natural spread between samples, random measurement errors, and different experimental conditions. In this study, we have adapted a previously developed spectral method to measure the linear attenuation of solid breast lesions. A total of 56 malignant and 5 benign lesions were included in the study. The samples were placed in a holder that allowed for thickness measurement. Spectral (energy-resolved) images of the samples were acquired and the image signal was mapped to equivalent thicknesses of two known reference materials, which can be used to derive the x-ray attenuation as a function of energy. The spread in equivalent material thicknesses was relatively large between samples, which is likely to be caused mainly by natural variation and only to a minor extent by random measurement errors and sample inhomogeneity. No significant difference in attenuation was found between benign and malignant solid lesions. The separation between cyst-fluid and tumour attenuation was, however, significant, which suggests it may be possible to distinguish cystic from solid breast lesions, and the results lay the groundwork for a clinical trial. In addition, the study adds a relatively large sample set to the published data and may contribute to a reduction in the overall uncertainty in the literature.

Background: Maximum intensity projection (MIP) images might be useful in helping to differentiate small pulmonary nodules from adjacent vessels on thoracic multidetector CT (MDCT)., Objective: The aim was to evaluate the benefits of axial MIP images over axial source images for the paediatric chest in an interobserver variability study., Materials and Methods: We included 46 children with extra-pulmonary solid organ malignancy who had undergone thoracic MDCT. Three radiologists independently read 2-mm axial and 10-mm MIP image datasets, recording the number of nodules, size and location, overall time taken and confidence., Results: There were 83 nodules (249 total reads among three readers) in 46 children (mean age 10.4 ± 4.98 years, range 0.3-15.9 years; 24 boys). Consensus read was used as the reference standard. Overall, three readers recorded significantly more nodules on MIP images (228 vs. 174; P < 0.05), improving sensitivity from 67% to 77.5% (P < 0.05) but with lower positive predictive value (96% vs. 85%, P < 0.005). MIP images took significantly less time to read (71.6 ± 43.7 s vs. 92.9 ± 48.7 s; P < 0.005) but did not improve confidence levels., Conclusion: Using 10-mm axial MIP images for nodule detection in the paediatric chest enhances diagnostic performance, improving sensitivity and reducing reading time when compared with conventional axial thin-slice images. Axial MIP and axial source images are complementary in thoracic nodule detection.

Eating disorders are a major challenge for health professionals, with many patients receiving ineffective care due to underdiagnosis or poor compliance with treatment. The incidence of eating disorders is increasing worldwide, producing an increasing burden on healthcare systems, and they most often affect young patients, with significant long-term complications. The effects of long-term malnutrition manifest in almost every organ system, and many can be detected radiologically, even without overt clinical findings. Musculoskeletal complications including osteoporosis result in a high incidence of insufficiency fractures, with long-term implications for bone health and growth, while respiratory complications are often recognized late due to disordered physiologic responses to infection. Gastrointestinal complications are numerous and in extreme cases may result in fatal outcomes after acute gastric dilatation and rupture subsequent to binge eating. In patients with severely disordered eating, in particular anorexia nervosa, marked derangement of electrolyte levels may result in refeeding syndrome, which requires emergent management. Recognition of such complications is critical to effective patient care and requires radiologists to be aware of the spectrum of imaging abnormalities that may be seen. Since many patients are reluctant to disclose their underlying condition, radiologists also play a critical role in identifying previously undiagnosed eating disorders., (©RSNA, 2013.)

The imaging of breast cancer has undergone significant progression in recent years. A multimodality approach is often required, with ongoing developments in mammography, ultrasound, magnetic resonance and nuclear medicine all contributing to breast cancer imaging. Here we review the literature to assess how advances in well-established technologies, such as mammography, have brought added benefits both in terms of diagnostic and practical benefits, as well as allowing the application of derived technologies, such as tomosynthesis and contrast-enhanced mammography. We consider how these newer technologies may fit into clinical practice, both in terms of general population screening as well as use as problem solving tools in specific patient groups, and where the limitations for these may lie. We aim to highlight some of the promising advances in imaging that are still in earlier stages, such as magnetic resonance elastography, as well as reviewing techniques that are already becoming incorporated into clinical practice., (Copyright © 2012 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.)

Desert locusts (Schistocerca gregaria) can transform reversibly between the swarming gregarious phase and a solitarious phase, which avoids other locusts. This transformation entails dramatic changes in morphology, physiology, and behavior. We have used the lobula giant movement detector (LGMD) and its postsynaptic target, the descending contralateral movement detector (DCMD), which are visual interneurons that detect looming objects, to analyze how differences in the visual ecology of the two phases are served by altered neuronal function. Solitarious locusts had larger eyes and a greater degree of binocular overlap than those of gregarious locusts. The receptive field to looming stimuli had a large central region of nearly equal response spanning 120 degrees x 60 degrees in both phases. The DCMDs of gregarious locusts responded more strongly than solitarious locusts and had a small caudolateral focus of even further sensitivity. More peripherally, the response was reduced in both phases, particularly ventrally, with gregarious locusts showing greater proportional decrease. Gregarious locusts showed less habituation to repeated looming stimuli along the eye equator than did solitarious locusts. By contrast, in other parts of the receptive field the degree of habituation was similar in both phases. The receptive field organization to looming stimuli contrasts strongly with the receptive field organization of the same neurons to nonlooming local-motion stimuli, which show much more pronounced regional variation. The DCMDs of both gregarious and solitarious locusts are able to detect approaching objects from across a wide expanse of visual space, but phase-specific changes in the spatiotemporal receptive field are linked to lifestyle changes.