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Ipsilateral axillary lymphadenopathy is a well-documented finding associated with COVID-19 vaccination. Varying guidelines have been published for the management of asymptomatic patients who have a history of recent vaccination and present with incidental lymphadenopathy at screening mammography. Some experts recommend follow-up imaging, and others suggest that clinical management, rather than repeat imaging or biopsy, is appropriate. Symptomatic patients with lymphadenopathy and/or additional abnormal imaging findings should be treated differently depending on risk factors and clinical scenarios. Although ipsilateral lymphadenopathy is well documented, ipsilateral breast edema after COVID-19 vaccination has been rarely reported. The combination of ipsilateral lymphadenopathy and diffuse breast edema after COVID-19 vaccination presents a clinical management challenge because edema can obscure underlying abnormalities at imaging. For symptomatic patients with lymphadenopathy and associated breast parenchymal abnormality, prompt action is appropriate, including diagnostic evaluation and consideration of tissue sampling. This approach may prevent delays in diagnosis and treatment of patients with malignancy masked by symptoms from the vaccination.

Background: Screening mammography facilities closed during the COVID-19 pandemic in spring 2020. Recovery of screening volumes has varied across patient subgroups and facilities. Objective: We compared screening mammography volumes, as well as patient and facility characteristics, between pre-COVID-19 periods and early and later post-closure recovery periods. Methods: This retrospective study included screening mammograms performed in the same 2-month period (May 26-July 26) in 2019 (pre-COVID-19), 2020 (early recovery) and 2021 (late recovery, following targeted interventions to expand access), across multiple facility types (urban, suburban, community health center). Suburban sites had highest proportion of White patients as well as greatest scheduling flexibility and expanded appointments during initial reopening. Findings were compared across years. Results: For White patients, volumes decreased 36.6% from 6550 in 2019 to 4384 in 2020, and then increased 61.0% to 6579 in 2021; for patients with races other than White, volumes decreased 53.9% from 1321 in 2019 to 609 in 2020, and then increased 136.8% to 1442 in 2021. Percentage of mammograms in patients with races other than White was 16.9% in 2019, 12.2% in 2020, and 18.0% in 2021. Proportion performed at the urban center was 55.3% in 2019, 42.2% in 2020, and 45.9% in 2021; proportion at suburban sites was 34.0% in 2019, 49.2% in 2020, and 43.5% in 2021. Pre-COVID-19 volumes were reached by the sixth week after reopening for suburban sites, but not reached during early recovery for other sites. Proportion performed on Saturdays for suburban sites was similar across periods, while for the urban site was 7.6% in 2019, 5.3% in 2020, and 8.8% in 2021; the community health center did not offer Saturday appointments during recovery. Conclusion: After reopening, screening shifted from urban to suburban settings, with disproportionate screening decrease in patients with races other than White. Initial delayed access at facilities serving underserved populations exacerbated disparities. Interventions to expand access resulted in late recovery volumes exceeding prepandemic volumes in patients with races other than White. Clinical Impact: Interventions to support equitable access across facilities serving diverse patient populations may mitigate potential widening disparities in breast cancer diagnosis during the pandemic.

Please see the Editorial Comment by Bethany L. Niell discussing this article. BACKGROUND. The success of adjunct breast cancer screening of women with dense breasts can be enhanced by identifying a...

BACKGROUND. Patients with a history of breast cancer are at higher risk of subsequent breast cancers and need close clinical and imaging follow-up. Limited data are available on screening of these ...

Please see the Editorial Comment by Sally H. Goudreau discussing this article. BACKGROUND. Advantages of radiofrequency tags for preoperative breast lesion localization include decoupling of tag pl...

The standardization of the AJCC TNM staging system for breast cancer allows physicians to evaluate patients with breast cancer using standard language and criteria, assess treatment response, and c...

OBJECTIVE. Our previous work showed that variation measures, which represent breast architecture derived from mammograms, were significantly associated with breast cancer. For replication purposes, we examined the association of three variation measures (variation [V], which is measured in the image domain, and P1 and p1 [a normalized version of P1], which are derived from restricted regions in the Fourier domain) with breast cancer risk in an independent population. We also compared these measures to volumetric density measures (volumetric percent density [VPD] and dense volume [DV]) from a commercial product. MATERIALS AND METHODS. We examined 514 patients with breast cancer and 1377 control patients from a screening practice who were matched for age, date of examination, mammography unit, facility, and state of residence. Spearman rank-order correlation was used to evaluate the monotonic association between measures. Breast cancer associations were estimated using conditional logistic regression, after adjustment for age and body mass index. Odds ratios were calculated per SD increment in mammographic measure. RESULTS. These variation measures were strongly correlated with VPD (correlation, 0.68-0.80) but not with DV (correlation, 0.31-0.48). Similar to previous findings, all variation measures were significantly associated with breast cancer (odds ratio per SD: 1.30 [95% CI, 1.16-1.46] for V, 1.55 [95% CI, 1.35-1.77] for P1, and 1.51 [95% CI, 1.33-1.72] for p1). Associations of volumetric density measures with breast cancer were similar (odds ratio per SD: 1.54 [95% CI, 1.33-1.78] for VPD and 1.34 [95% CI, 1.20-1.50] for DV). When DV was included with each variation measure in the same model, all measures retained significance. CONCLUSION. Variation measures were significantly associated with breast cancer risk (comparable to the volumetric density measures) but were independent of the DV.

OBJECTIVE. The objective of this study was to assess to the role of contrast-enhanced digital mammography (CEDM) as a screening tool in women at intermediate risk for developing breast cancer due to a personal history of lobular neoplasia without additional risk factors. MATERIALS AND METHODS. In this institutional review board-approved, observational, retrospective study, we reviewed our radiology department database to identify patients with a personal history of breast biopsy yielding lobular neoplasia who underwent screening CEDM at our institution between December 2012 and February 2019. A total of 132 women who underwent 306 CEDM examinations were included. All CEDM examinations were interpreted by dedicated breast imaging radiologists in conjunction with a review of the patient’s clinical history and available prior breast imaging. In statistical analysis, sensitivity, specificity, NPV, positive likelihood ratio, and accuracy of CEDM in detecting cancer were determined, with pathology or 12-month imaging follow-up serving as the reference standard. RESULTS. CEDM detected cancer in six patients and showed an overall sensitivity of 100%, specificity of 88% (95% CI, 84–92%), NPV of 100%, and accuracy of 88% (95% CI, 84–92%). The positive likelihood ratio of 8.33 suggested that CEDM findings are 8.3 times more likely to be positive in an individual with breast cancer when compared with an individual without the disease. CONCLUSION. CEDM shows promise as a breast cancer screening examination in patients with a personal history of lobular neoplasia. Continued investigation with a larger patient population is needed to determine the true sensitivity and positive predictive value of CEDM for these patients.

During pregnancy and lactation, the breast undergoes unique changes that manifest as varied clinical and imaging findings. Understanding the expected physiologic changes of the breast as well as recognizing the best imaging modalities for a given clinical scenario can help the radiologist identify the abnormalities arising during this time. Discussion with the patient about the safety of breast imaging can reassure patients and improve management. This article reviews the physiologic changes of the breast during pregnancy and lactation; the safety and utility of various imaging modalities; upto-date consensus on screening guidelines; recommendations for diagnostic evaluation of breast pain, palpable abnormalities, and nipple discharge; and recommendations regarding advanced modalities such as breast MRI. In addition, the commonly encountered benign and malignant entities affecting these patients are discussed.

BACKGROUND. Background parenchymal uptake (BPU) on molecular breast imaging (MBI) was identified in a case-control study as a breast cancer risk factor beyond mammographic density. To our knowledge, this finding has not yet been confirmed in a cohort study. OBJECTIVE. The objectives of this study were to examine the association of BPU with breast cancer and to estimate the absolute risk and discriminatory accuracy of BPU in a cohort study. METHODS. A retrospective cohort was established that included women without a history of breast cancer who underwent MBI from 2004 to 2015. Radiologists who were blinded to future breast cancer diagnoses assessed BPU on baseline MBI examinations as low (photopenic or minimal) or elevated (mild, moderate, or marked). Associations of BPU with breast cancer were estimated using multivariable Cox proportional hazards models of the time to diagnosis. The 5-year absolute risk was calculated for study subgroups. The discriminatory accuracy of BPU was also assessed. RESULTS. Among 2992 women (mean age, 56.3 years; SD, 10.6 years) who underwent MBI, breast cancer events occurred in 144 women (median follow-up, 7.3 years). Median time to diagnosis after MBI was 4.2 years (range, 0.5-11.6 years). Elevated BPU was associated with a greater breast cancer risk (hazard ratio [HR], 2.39; 95% CI, 1.68-3.41; p ≤ .001). This association remained in postmenopausal women (HR, 3.50; 95% CI, 2.31-5.31; p < .001) but was not significant in premenopausal women (HR, 1.29; 95% CI, 0.72-2.32; p = .39). The 5-year absolute risk of breast cancer was 4.3% (95% CI, 2.9-5.7%) for women with elevated BPU versus 2.5% (95% CI, 1.8-3.1%) for those with low BPU. Postmenopausal women with dense breasts and elevated BPU had a 5-year absolute risk of 8.1% (95% CI, 4.3-11.8%) versus 2.8% (1.8-3.8%) for those with low BPU. Among postmenopausal women, discriminatory accuracy for invasive cancer was improved with the addition of BPU versus use of the Gail risk score alone (C statistic, 65.1 vs 59.1; p = .04) or use of the Breast Cancer Surveillance Consortium risk score alone (C statistic, 66.4 vs 60.4; p = .04). CONCLUSION. BPU on MBI is an independent risk factor for breast cancer, with the strongest association observed among postmenopausal women with dense breasts. In postmenopausal women, BPU provides incremental discrimination in predicting breast cancer when combined with either the Gail model or the Breast Cancer Surveillance Consortium model. CLINICAL IMPACT. Observation of elevated BPU on MBI may identify a subset of women with dense breasts who would benefit most from supplemental screening or preventive options.

BI-RADS is a communication and data tracking system that has evolved since its inception as a brief mammography lexicon and reporting guide into a robust structured reporting platform and comprehensive quality assurance tool for mammography, ultrasound, and MRI. Consistent and appropriate use of the BI-RADS lexicon terminology and assessment categories effectively communicates findings, estimates the risk of malignancy, and provides management recommendations to patients and referring clinicians. The impact of BI-RADS currently extends internationally through six language translations. A condensed version has been proposed to facilitate a phased implementation of BI-RADS in resource-constrained regions. The primary advance of the 5th edition of BI-RADS is harmonization of the lexicon terms across mammography, ultrasound, and MRI. Harmonization has also been achieved across these modalities for the reporting structure, assessment categories, management recommendations, and data tracking system. Areas for improvement relate to certain common findings that lack lexicon descriptors and a need for further clarification of proper use of category 3. BI-RADS is anticipated to continue to evolve for application to a range of emerging breast imaging modalities.

OBJECTIVE. One central question pertaining to mammography quality relates to discerning the optimal recall rate to maximize cancer detection while minimizing unnecessary downstream diagnostic imaging and breast biopsies. We examined the trade-offs for higher recall rates in terms of biopsy recommendations and cancer detection in a single large health care organization. MATERIALS AND METHODS. We included 2D analog, 2D digital, and 3D digital (tomosynthesis) screening mammography examinations among women 40-79 years old performed between January 1, 2005, and December 31, 2017, with cancer follow-up through 2018. There were 36, 67, and 38 radiologists who read at least 1000 2D analog examinations, 2D digital examinations, and 3D tomosynthesis examinations, respectively, who were included in these analyses. Using logistic regression with marginal standardization, we estimated radiologist-specific mean recall (abnormal interpretations/1000 mammograms), biopsy recommendation, cancer detection (screening-detected in situ and invasive cancers/1000 mammograms), and minimally invasive cancer detection rates while adjusting for differences in patient characteristics. RESULTS. Among 1,060,655 screening mammograms, the mean recall rate was 10.7%, the cancer detection rate was 4.0/1000 mammograms, and the biopsy recommendation rate was 1.60%. Recall rates between 7% and 9% appeared to maximize cancer detection while minimizing unnecessary biopsies. CONCLUSION. The results of this investigation are in contrast to those of a recent study suggesting appropriateness of higher recall rates. The "sweet spot" for optimal cancer detection appears to be in the recall rate range of 7-9% for both 2D digital mammography and 3D tomosynthesis. Too many women are being called back for diagnostic imaging, and new benchmarks could be set to reduce this burden.

Screening mammography reduces breast cancer mortality; however, when used to examine women with dense breasts, its performance and resulting benefits are reduced. Increased breast density is an independent risk factor for breast cancer. Digital breast tomosynthesis (DBT), ultrasound (US), molecular breast imaging (MBI), MRI, and contrast-enhanced mammography (CEM) each have shown improved cancer detection in dense breasts when compared with 2D digital mammography (DM). DBT is the preferred mammographic technique for producing a simultaneous reduction in recalls (i.e., additional imaging). US further increases cancer detection after DM or DBT and reduces interval cancers (cancers detected in the interval between recommended screening examinations), but it also produces substantial additional false-positive findings. MBI improves cancer detection with an effective radiation dose that is approximately fourfold that of DM or DBT but is still within accepted limits. MRI provides the greatest increase in cancer detection and reduces interval cancers and late-stage disease; abbreviated techniques will reduce cost and improve availability. CEM appears to offer performance similar to that of MRI, but further validation is needed. Dense breast notification will soon be a national standard; therefore, understanding the performance of mammography and supplemental modalities is necessary to optimize screening for women with dense breasts.

OBJECTIVE. The purpose of this study was to determine the relationship between background parenchymal enhancement (BPE) on contrast-enhanced mammography (CEM) and breast tissue density, menstrual status, endocrine therapy, and risk factors for breast cancer and also to evaluate interreader agreement on classification of BPE on CEM. MATERIALS AND METHODS. Five subspecialty-trained breast radiologists independently and blindly graded tissue density (with fatty tissue and scattered fibroglandular tissue classified as nondense tissue and with heterogeneously dense and extremely dense classified as dense tissue) and BPE (with minimal or mild BPE categorized as low BPE and moderate or marked BPE categorized as high BPE) on CEM examinations performed from 2014 to 2018. Electronic medical charts were reviewed for information on menstrual status, endocrine therapy, history of breast surgery, and other risk factors for breast cancer. Comparisons were performed using the Kruskal-Wallis test, Mann-Whitney test, and Spearman rank correlation. Interreader agreement was estimated using the Fleiss kappa test. RESULTS. A total of 202 patients (mean [± SD] age, 54 ± 10 years; range, 25-84 years) underwent CEM. Tissue density was categorized as fatty in two patients (1%), scattered fibroglandular in 67 patients (33%), heterogeneously dense in 117 patients (58%), and extremely dense in 16 patients (8%). Among the 202 patients, BPE was minimal in 77 (38%), mild in 80 (40%), moderate in 31 (15%), and marked in 14 (7%). Dense breasts, younger age, premenopausal status, no history of endocrine therapy, and no history of breast cancer were significantly associated with high BPE. Among premenopausal patients, no association was found between BPE and time from last menstrual period to CEM. Overall interreader agreement on BPE was moderate (κ = 0.41; 95% CI, 0.40-0.42). Interreader agreement on tissue density was substantial (κ = 0.67; 95% CI, 0.66-0.69). CONCLUSION. Women with dense breasts, premenopausal status, and younger age are more likely to have greater BPE. Targeting CEM to the last menstrual period is not indicated.

Reports of patients with axillary adenopathy identified on breast imaging after coronavirus disease (COVID-19) vaccination are rising. We propose a pragmatic management approach based on clinical presentation, vaccination delivery, and imaging findings. In the settings of screening mammography, screening MRI, and diagnostic imaging workup of breast symptoms, with no imaging findings beyond unilateral axillary adenopathy ipsilateral to recent (within the past 6 weeks) vaccination, we report the adenopathy as benign with no further imaging indicated if no nodes are palpable 6 weeks after the last dose. For patients with palpable axillary adenopathy in the setting of ipsilateral recent vaccination, clinical follow-up of the axilla is recommended. In all these scenarios, axillary ultrasound is recommended if clinical concern persists 6 weeks after vaccination. In patients with a recent breast cancer diagnosis in the pre- or peritreatment setting, prompt recommended imaging is encouraged as well as vaccination (in the thigh or contralateral arm). Our recommendations align with the ACR BI-RADS Atlas and aim to reduce patient anxiety, provider burden, and costs of unnecessary evaluation of enlarged nodes in the setting of recent vaccinations and, also, to avoid further delays in vaccinations and breast cancer screening during the pandemic.

OBJECTIVE. Precision medicine in oncology aims to individualize the patient's treatment and management regimen according to the accurate assessment of diagnosis, risk of recurrence, or progression. In this review, we will discuss the evolving role of molecular imaging (breast-specific gamma imaging and positron emission mammography) toward precision medicine in patients with breast cancer. CONCLUSION. Incorporating molecular imaging for breast cancer will lead to precision medicine, which holds promise to facilitate appropriate personalized treatment in patients with breast cancer.

OBJECTIVE. Patients with dense breast tissue are seeking supplemental screening because of the limited sensitivity of mammography. Abbreviated protocol (AP) breast MRI is attractive because it offers a higher cancer detection rate, shorter scan time, and lower cost than full MRI. This article explores the issues of balancing the benefits of AP MRI with safety concerns about gadolinium-based contrast agents, lack of standardization of protocols and field strengths, potential decrease in performance metrics, and potential for overdiagnosis. CONCLUSION. Important questions need to be addressed before AP MRI can be used routinely for breast cancer screening. Evidence is lacking from well-designed prospective trials that can confirm the accuracy and efficacy of AP MRI are comparable with those of other breast imaging modalities. Determining which patients benefit most from AP MRI will help shape future screening guidelines.

OBJECTIVE. The purpose of this study was to assess the performance of diagnostic mammography alone for evaluation of palpable symptoms in women with almost entirely fatty breast composition. MATERIALS AND METHODS. All diagnostic mammograms performed for palpable symptoms in women who had been assigned a breast density of "almost entirely fatty" over an 8-year period (2009-2017) at an academic breast center were retrospectively identified. Each symptomatic breast was considered a separate case and analyses were performed at the case level. Clinical, imaging, and pathologic results were reviewed. Descriptive statistics and 2 × 2 contingency table analyses were performed. RESULTS. The study cohort included 323 cases evaluated with mammography. Of these, 294 (91%) had undergone targeted ultrasound. At mammography, 240 (74%) had no correlate to the palpable lump; 38 (12%), a benign correlate; and 45 (14%), a suspicious correlate. Three cases had incidental suspicious mammographic findings, for a total of 48 positive mammography cases. Twenty-seven (8%) cases were malignant. Mammography alone detected all but one cancer, which was detected by ultrasound. In retrospect, the woman from whom this single false-negative mammogram was obtained did not have almost entirely fatty breast density. Mammography alone yielded a negative predictive value of 99.6%, percentage of diagnostic examinations recommended for biopsy that resulted in a tissue diagnosis of malignancy within 1 year of 54%, sensitivity of 96%, and specificity of 93%. Adjunct ultrasound contributed to 11 false-positives but also identified benign correlates in eight cases with no mammographic finding. CONCLUSION. In patients with almost entirely fatty breast tissue presenting with palpable symptoms, mammography alone had a high sensitivity and specificity. Our results support that mammography alone may be sufficient for evaluation of palpable symptoms in these women as long as density criteria are strictly applied.

OBJECTIVE. The purpose of this study was to compare the cancer detection rates (CDRs), tumor types, and characteristics between screening digital breast tomosynthesis (DBT) and screening full-field digital mammography (FFDM) in a matched patient population in a large academic breast imaging practice with mixed DBT and FFDM technology. MATERIALS AND METHODS. In this retrospective study, we reviewed consecutive screening FFDM and DBT examinations performed between October 2012 and September 2014. To control for nonrandomized selection of FFDM versus DBT examinations, we applied propensity score matching on the basis of patient age, imaging site, and prior imaging findings. An institutional breast cancer registry identified cancer diagnoses. CDR and tumor type, grade, receptor, nodal status, and size were compared between matched FFDM and DBT groups. RESULTS. Sixty-one cancers were detected in the matched screening cohort of DBT (n = 9817) and FFDM (n = 14,180) examinations. CDR was higher with DBT than with FFDM for invasive cancers (2.8 vs 1.3, p = 0.01), minimal cancers (2.4 vs 1.2, p = 0.03), estrogen receptor-positive invasive cancers (2.6 vs 1.1, p = 0.01), and node-negative invasive cancers (2.3 vs 1.1, p = 0.02.), respectively. The ratio of screen-detected invasive cancers to ductal carcinoma in situ on DBT (3.0) was not significantly different from that on FFDM (2.6) (p = 0.79). CONCLUSION. DBT results in an overall increase in CDR irrespective of the tumor type, size, or grade of cancer.

OBJECTIVE. Atypical ductal hyperplasia (ADH), atypical lobular hyperplasia (ALH), and lobular carcinoma in situ (LCIS) are among high-risk lesions that have been previously recommended for surgical excision when diagnosed on core needle biopsy. Recent studies have examined whether imaging surveillance is a reasonable alternative to surgical management for these lesions. This article synthesizes the evidence regarding management of atypical hyperplasia and LCIS diagnosed on core needle biopsy and clinical implications of these diagnoses on future breast cancer risk as well as highlights areas of further research needed to improve practice guidelines for these high-risk lesions. CONCLUSION. Although surgical excision is still recommended after diagnosis of ADH on core needle biopsy, in specific circumstances ALH and LCIS can safely be managed by imaging surveillance.

OBJECTIVE. Breast pain is a common complaint among women and a frequent reason they seek health care, including imaging. However, breast pain is infrequently associated with breast cancer. This article reports and synthesizes the evidence about the risk of malignancy with breast pain, the use of imaging to evaluate breast pain, the detection of treatable symptomatic lesions by imaging, and the ability of negative examination findings to reassure patients. Evidence-based guidance for the imaging evaluation of breast pain is presented, and areas that warrant further research are described. CONCLUSION. The studies evaluating the role of imaging in breast pain are limited and conflicting. The clinician and patient should discuss the drawbacks and benefits of imaging to decide whether it is worth pursuing. If imaging is performed, ultrasound, mammography, or both should be done depending on the age of the patient. Areas worthy of further research include larger studies using modern techniques to evaluate the utility of imaging in patients with breast pain, the best way to assist clinicians in avoiding unnecessarily imaging patients with breast pain, and the utility of imaging results to reassure patients with breast pain.

OBJECTIVE. Dense breast tissue is an established risk factor for the development of breast cancer. Methods for reliable and reproducible identification of breast density have been developed and are increasingly being adopted into clinical practice, allowing enhanced identification of patients who will benefit from supplemental screening. Breast density is being used for patient risk stratification through incorporation into risk models, leading to more precise management and improved decision making regarding personalized screening strategies. CONCLUSION. This review provides an update on breast density assessment, evaluation of patient's risk status, and the use of supplemental screening.

OBJECTIVE. The purpose of this study was to evaluate the impact of an information technology-enabled quality improvement initiative on timeliness of patient contact and scheduling of screening mammography recall. MATERIALS AND METHODS. The study was conducted in a screening practice (two ambulatory centers, A and B; two hospitals, C and D) that uses offline batch results (A, B, C) and same-day results (D) with on-site (A, C, D) or off-site (B) coordinators scheduling recalls. Before the intervention, radiologists at sites A, B, and C conveyed recalls via paper lists to coordinators after batch interpretation. At site D, coordinators received recall lists several times a day. In March 2017 an electronic alert system was implemented to notify coordinators of recall at report signing with required closed-loop acknowledgment once recall was scheduled. Mean time (hours, excluding weekends) to schedule diagnostic evaluation was compared for 4-month periods before and after intervention by two-tailed t test and statistical process control analyses. RESULTS. Recall rates were 9.5% (1356/14,315) before and 8.9% (1432/16,034) after the intervention (p = 0.10). Mean time to schedule screening decreased after the intervention as follows: site A from 86 to 65 hours (-24.4%, p = 0.01); site B, 116 to 70 hours (-39.7%, p < 0.0001); site C, 98 to 65 hours (-33.7%, p = 0.002); and site D, 49 to 42 hours (-14.3%, p = 0.21). Statistical process control analysis showed significant sustained improvements at sites A, B, and C in mean time to patient contact and scheduling of diagnostic evaluation. CONCLUSION. An information technology-enabled quality improvement initiative to notify coordinators of screening recalls in real time with required patient contact and scheduling acknowledgment reduced time to diagnostic scheduling in a multisite practice. The greatest impact was found at the site with off-site coordinators, the least at the site performing same-day interpretation.