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Background To evaluate the chest CT appearance of patients with a clinicopathologic diagnosis of hypersensitivity pneumonia. Methods IRB approval was obtained for a retrospective review of patients with a preoperative CT scan, a surgical pathology report from a transbronchial biopsy or wedge resection consistent with hypersensitivity pneumonitis, and a pulmonary consultation, which also supported the diagnosis. The pathology report was evaluated for granulomas, airway-centered fibrosis, microscopic honeycombing, and fibroblast foci. The medical records were reviewed for any known antigen exposure. Patients were separated into two groups; those with and without a known antigen exposure. The CT scans were assessed for distribution of fibrosis: upper lobe or lower lobe predominance, airway-centered versus peripheral distribution, three-density pattern, and honeycombing. Results 264 pathology reports included the term chronic hypersensitivity pneumonitis (CHP). Thirty-eight of the patients had a pulmonologist who gave the patient a working diagnosis of CHP. The average age of these patients was 64 years, and 21/38 were women. Seventeen of the 38 patients had at least one antigen exposure described in the medical records. All the patients had fibrosis along the airways on chest CT. Both known antigen exposure and no known antigen patients had upper and lower lung-predominant fibrosis. There were more patients with hiatal hernias in the unknown antigen group. Honeycombing was an uncommon finding. Conclusion Airway-centered fibrosis was present on chest CT in all 38 patients with CHP (100%), with or without known antigen exposure.

BACKGROUND Chest CT scans are routinely obtained to monitor disease progression in pulmonary fibrosis. However, radiologists do not employ a standardized system for quantitative description of the severity of the disease. Development and validation of a grading system offers potential for enhancing the information that radiologists provide clinicians. STUDY DESIGN AND METHODS Our retrospective review analyzed 100 sequential patients with usual interstitial pneumonitis (UIP) on HRCT scans from 2018 and 2019. A radiologic scoring system evaluated the percent of normal lung on the basis of a 0-5 point scale per lobe (findings for the right middle lobe were included in the right upper lobe score), yielding an overall additive numerical score on a scale of 20 (completely normal lung) to 0 (no normal lung). Two radiologists quantified the percentage of normal lung by consensus agreement. Percent DLCO as well as demographic data were obtained from the medical record. Statistical analysis was performed using Spearman correlation to assess correlation between grade and percent DLCO. RESULTS 96 patients met the inclusion criteria; average age was 71, 68% were male. Score on CT scan ranged from 18 to 4; average 10.9, SD 3.58. The single-breath diffusing capacity (percent DLCO) ranged from 88% to 17%; mean 44.5%, SD 14.3%. Spearman's correlation for CT score and percent DLCO was 0.622, P

Rationale: The computed tomography (CT) pattern of definite or probable usual interstitial pneumonia (UIP) can be diagnostic of idiopathic pulmonary fibrosis and may obviate the need for invasive surgical biopsy. Few machine-learning studies have investigated the classification of interstitial lung disease (ILD) on CT imaging, but none have used histopathology as a reference standard. Objectives: To predict histopathologic UIP using deep learning of high-resolution computed tomography (HRCT). Methods: Institutional databases were retrospectively searched for consecutive patients with ILD, HRCT, and diagnostic histopathology from 2011 to 2014 (training cohort) and from 2016 to 2017 (testing cohort). A blinded expert radiologist and pulmonologist reviewed all training HRCT scans in consensus and classified HRCT scans based on the 2018 American Thoracic Society/European Respriatory Society/Japanese Respiratory Society/Latin American Thoracic Association diagnostic criteria for idiopathic pulmonary fibrosis. A convolutional neural network (CNN) was built accepting 4 × 4 × 2 cm virtual wedges of peripheral lung on HRCT as input and outputting the UIP histopathologic pattern. The CNN was trained and evaluated on the training cohort using fivefold cross validation and was then tested on the hold-out testing cohort. CNN and human performance were compared in the training cohort. Logistic regression and survival analyses were performed. Results: The CNN was trained on 221 patients (median age 60 yr; interquartile range [IQR], 53–66), including 71 patients (32%) with UIP or probable UIP histopathologic patterns. The CNN was tested on a separate hold-out cohort of 80 patients (median age 66 yr; IQR, 58–69), including 22 patients (27%) with UIP or probable UIP histopathologic patterns. An average of 516 wedges were generated per patient. The percentage of wedges with CNN-predicted UIP yielded a cross validation area under the curve of 74% for histopathological UIP pattern per patient. The optimal cutoff point for classifying patients on the training cohort was 16.5% of virtual lung wedges with CNN-predicted UIP and resulted in sensitivity and specificity of 74% and 58%, respectively, in the testing cohort. CNN-predicted UIP was associated with an increased risk of death or lung transplantation during cross validation (hazard ratio, 1.5; 95% confidence interval, 1.1–2.2; P = 0.03). Conclusions: Virtual lung wedge resection in patients with ILD can be used as an input to a CNN for predicting the histopathologic UIP pattern and transplant-free survival.

A 64-year-old female nonsmoker with a history of hypertension, obesity, type II diabetes, and recurrent urinary tract infections secondary to chronic kidney stones presented to an outpatient pulmonology clinic with new onset shortness of breath and cough. Her pulmonary history was unremarkable, with no history of asthma, tuberculous, emphysema or pulmonary fibrosis. She denied any farm or factory exposure and reported no exposure to other potential respiratory irritants such as bird or mould; she had no pets. Her home was a townhouse with a forced hot air system and she had worked in an office for the length of her career. Her family history was similarly noncontributory; her parents had passed away from nonrespiratory causes. She was one of 11 children, none of which had a history of asthma, COPD, pulmonary fibrosis, or tuberculous. Her two grown children also had no history of pulmonary disease., Nitrofurantoin is a cause of drug-induced pneumonitis and can result in clinically significant respiratory symptoms manifesting as interstitial lung disease on chest CT, even if the patient has been taking the drug chronically without side-effects https://bit.ly/3v2m29h

Objective To assess causative factors, associated imaging findings, and CT course of round atelectasis (RA). Materials and methods We retrospectively reviewed CT reports for “round” or “rounded atelectasis” over a 5-year time frame. Patients with at least 2 CT scans a minimum of 6 months apart were included. Electronic medical records and clinical and imaging follow-up was reviewed for all cases. Results Study population included 50 individuals with mean age of 63 years, and 59 unique instances of RA. The most commonly associated etiologies were hepatic hydrothorax (26%, n = 13) and asbestos exposure (26%), followed by post-infectious pleural inflammation (22%), congestive heart failure (12%), and end stage renal disease (8%). RA was found in the right lower lobe in over half of cases (n = 30). Association with one or more pleural abnormality was identified in all cases, including thickening (88%), fluid (60%), or calcification (40%). Nearly one third (n = 19) demonstrated intra-lesional calcification. In those who underwent PET/CT (20%), lesions demonstrated an average SUV of 2.2 (range 0–7.8). CT course over mean follow up of 32 months (range 6–126 months), demonstrated RA to remain stable (n = 26) or decrease (n = 26) in size in the majority (88%) of cases. Conclusion Round atelectasis may arise from diverse etiologies beyond asbestos, and will most often decrease or remain stable in size over serial exams. Accurate identification may obviate the need for added diagnostic interventions.

The benefits of early diagnosis and treatment of breast cancer are well established. Thoracic CT which is performed with increased frequency for lung cancer screening can diagnose breast cancer earlier then might be possible clinically. The imaged and radiation exposed breasts must be included in their entirety on images which are reviewed by the radiologist. Because of concerns about how altering the field of view might affect image quality, we advocate for inclusion of the entire breast on the soft tissue series, which can be viewed on mediastinal window settings and expose the patient to no additional radiation.

Purpose To determine patterns of progression of probable Usual Interstitial Pneumonitis (UIP). Methods This HIPPA compliant, IRB-approved study draws patients from our Fibrosis Registry. All patients with a consensus diagnosis of Idiopathic Pulmonary Fibrosis (IPF) were included. Most recent CT scans and all earlier CT scans were reviewed to determine the fibrosis grade in each lobe based on probable UIP (pUIP) findings of ground glass opacities, traction bronchiolectasis and reticulations or UIP findings of subpleural basilar predominant fibrosis with honeycombing (HC) and absence of features that would suggest an alternative diagnosis. Results 103 patients with a working diagnosis of IPF are the focus of this report. Among the 68 with pUIP on the initial CT, 32 (47%) progressed; median time to progression was 51 months. The risk of HC progression, adjusted for gender, of patients with emphysema was 2.53 times higher than patients without emphysema (HR = 2.53, 95% CI: 1.06–6.02). Among the 35 with HC on the initial CT scan, 20 (57%) progressed to more advanced HC; median time to progression was 31 months. Increased pulmonary artery size was significantly associated with an elevated risk for more advanced HC progression (HR = 1.16, 95% CI: 1.04–1.31). Conclusion Ground glass opacities, traction bronchiolectasis and reticulations, a “Probable UIP Pattern” by ATS criteria progressed to UIP in 47% of patients on follow-up imaging.

The purpose of this study was to assess the frequencies of identifying participants with part-solid nodules, of diagnostic pursuit, of diagnoses of lung cancer, and long-term lung cancer survival in baseline and annual repeat rounds of CT screening in the International Early Lung Cancer Action Project.Screenings were performed under a common protocol. Participants with solid, nonsolid, and part-solid nodules and the diagnoses of lung cancer were documented.Part-solid nodules were identified in 2892 of 57,496 (5.0%) baseline screening studies; 567 (19.6%) of these nodules resolved or decreased in size. Diagnostic pursuit led to the diagnosis of adenocarcinoma in 79 cases, all clinical stage I. At resection, one nodule (12-mm solid component) had a single N2 metastasis. A new part-solid nodule was identified in 541 of 64,677 (0.8%) annual repeat screenings; 377 (69.7%) of these nodules resolved or decreased in size. In eight cases among the 541, the diagnosis of adenocarcinoma manifesting as a part solid nodule was made; on retrospective review the nodule originally had been a nonsolid nodule. In another 20 cases, the cancer originally had manifested as a nonsolid nodule but had progressed to become part-solid at annual repeat screening before any diagnosis was pursued. These 28 annual repeat cases of lung cancer were all pathologic stage IA. Of the 107 cases of lung cancer (79 baseline cases and 28 annual repeat cases), 106 were surgically resected, and one baseline case was followed up with imaging for 4 years. The lung cancer survival rate was 100% with a median follow-up period from diagnosis of 89 months (interquartile range, 52-134 months).Lung cancers manifesting as part-solid nodules at repeat screening studies all started as nonsolid nodules. Among 107 cases of adenocarcinoma manifesting as a part-solid nodule, a single lymph node metastasis was found in a single case (solid component, 12 mm).

The purposes of this study were to determine the prevalence of interstitial lung disease (ILD) in a cohort undergoing low-dose CT screening for lung cancer, to identify the CT patterns of fibrosis, and to determine prognostic factors of disease progression.The study drew from a database of 951 participants in a lung cancer screening program between 2010 and 2014. Three thoracic radiologists reviewed CT scans to identify the ILD findings, defined as traction bronchiectasis, ground-glass opacities with traction bronchiectasis, reticulations with traction bronchiectasis, and honeycombing. Evidence of ILD was considered present if at least two of three reviewing radiologists agreed. Age, smoking history, and CT evidence of emphysema were also documented.Of the 951 participants, 63 (6.6%) had CT evidence of ILD, and 16 of the 63 (1.7% of the total cohort) had honeycombing. Significant univariate predictors of ILD were male sex (p = 0.003), older age (p0.0001), higher number of pack-years of cigarette smoking (p = 0.0003), and greater severity of emphysema (p = 0.004), but only age and male sex remained significant in the multivariate analysis. The most common pattern of ILD was peripheral fibrosis without honeycombing involving multiple lobes. The presence of honeycombing was significantly associated with progression of fibrosis score (p = 0.0001) and extent of fibrosis (p = 0.005).A potential added benefit of CT screening is earlier diagnosis of ILD in older smokers, who are at increased risk. Radiologists should recognize the earliest findings of ILD and understand the importance of early recognition.

There are three major pathologic patterns of pulmonary fibrosis; usual interstitial pneumonia (UIP), nonspecific interstitial pneumonia (NSIP) and airway-centered fibrosis (ACF). These pathologic patterns correspond with radiographic patterns of UIP, NSIP, and chronic hypersensitivity pneumonitis (CHP). Previous studies have demonstrated that the radiologic diagnosis is correct approximately 50% of the time for these fibrotic lung diseases. Understanding the microscopic pathologic patterns that are recapitulated at a macroscopic level in the high resolution CT scan is key to radiologists' ability to correctly diagnose pulmonary fibrosis and thus improve patient outcomes with early diagnosis and avoidance of biopsy. We investigate the similarities between the pathology and radiology features of UIP, NSIP, and ACF.

The visualized soft tissues on chest CT include the breast tissue, muscles, and subcutaneous tissue and should be viewed on mediastinal window settings on axial images (Level 40, Window 400). I recommend beginning with the right side and scrolling from superior to inferior and then left side inferior to superior. Women are having fewer mammograms currently. The indications for chest CT are increasing as lung cancer screening received approval for reimbursement by Medicare (www.Medicare.gov). Therefore, the only opportunity we may have to diagnose breast cancer early is on a CT scan of the chest. It is imperative that the scanned breast be included on the images provided to the radiologist for interpretation and they are often not included so that the field of view for evaluating the lung parenchyma is not compromised. A viable solution is to include the entire breast on soft tissue windows only and allow lung windows to be optimized for evaluation of the lung.

The mediastinal structures on chest CT which include the thyroid gland, lymph nodes, heart, great vessels, and esophagus should be viewed on mediastinal window settings (Level 40, Window 400). I recommend reviewing each organ individually as you scroll up and down through the organ.

The upper abdomen to the level of the adrenal glands is routinely included on CT scans of the chest. The organs are usually suboptimally evaluated because contrast is not commonly used for chest CT scans; however one must look carefully to make sure that pathology is not missed. The abdominal structures on chest CT which include the liver, spleen, gallbladder, pancreas, adrenals, kidneys, and bowel should be viewed on mediastinal window settings (Level 40, Window 400). I recommend reviewing each organ individually as you scroll up and down through the organ.

Purpose To assess the ability of chest CT to identify patients needing further evaluation of the breasts. Methods IRB approval was obtained with a waiver of consent. Women with chest CT and mammogram within 12 months formed the cohort. A breast assessment and recommendation CT score (BARCS) analogous to mammographic BI-RADS was created and compared to the mammogram BI-RADS. Results BARCS and mammographic BI-RADS management recommendations were concordant for 77.1%. 11 invasive cancers were detected; all by mammogram while CT missed 2. Conclusion BARCS score should be studied in prospective trials. Chest CT might be the earliest opportunity to detect breast cancer.

Differences in results of baseline and subsequent annual repeat rounds provide important information for optimising the regimen of screening. A prospective cohort study of 65,374 was reviewed to examine the frequency/percentages of the largest noncalcified nodule (NCN), lung cancer cell types and Kaplan–Meier (K-M) survival rates, separately for baseline and annual rounds. Of 65,374 baseline screenings, NCNs were identified in 28,279 (43.3%); lung cancer in 737 (1.1%). Of 74,482 annual repeat screenings, new NCNs were identified in 4959 (7%); lung cancer in 179 (0.24%). Only adenocarcinoma was diagnosed in subsolid NCNs. Percentages of lung cancers by cell type were significantly different (p < 0.0001) in the baseline round compared with annual rounds, reflecting length bias, as were the ratios, reflecting lead times. Long-term K-M survival rate was 100% for typical carcinoids and for adenocarcinomas manifesting as subsolid NCNs; 85% (95% CI 81–89%) for adenocarcinoma, 74% (95% CI 63–85%) for squamous cell, 48% (95% CI 34–62%) for small cell. The rank ordering by lead time was the same as the rank ordering by survival rates. The significant differences in the frequency of NCNs and frequency and aggressiveness of diagnosed cancers in baseline and annual repeat need to be recognised for an optimal regimen of screening. • Lung cancer aggressiveness varies considerably by cell type and nodule consistency. • Kaplan–Meier survival rates varied by cell type between 100% and 48%. • The percentages of lung cancers by cell type in screening rounds reflect screening biases. • Rank ordering by cell type survival is consistent with that by lead times. • Empirical evidence provides critical information for the regimen of screening.

To (a) perform a pilot study comparing radiologists' reading of breast density at computed tomography (CT) of the chest with breast density readings from mammography performed in the same patient and (b) compare a subset of these with computer-derived measurements of breast density at CT.The institutional review board waived informed consent for this HIPAA-compliant retrospective review of mammograms and chest CT scans from 206 women obtained within 1 year of each other. Two radiologists with expertise in interpreting mammographic and CT findings independently reviewed the mammograms and CT scans and classified each case into one of the four breast density types defined by the Breast Imaging Reporting and Data System of the American College of Radiology. Interreader agreements for the mammographic density types and CT density grades were determined by using the Cohen weighted κ statistic. The intrareader correlation coefficient was determined in a subset of CT images. In another subset of 40 cases, the agreement of the semiautomated computer-derived measurements of breast density with the consensus of the two radiologists was assessed.Interreader agreement was higher for the CT density grades than for the mammographic density types, with 0.79 (95% confidence interval [CI]: 0.73, 0.85) versus 0.62 (95% CI: 0.54, 0.70). The intrareader reliability of breast density grades on CT images was 0.88. The computer-derived breast density measurements agreed with those of the radiologists in 36 (90%) cases. When four cases were manually adjusted for the complex anatomy, there was agreement for all cases.Preliminary results suggest that on further validation, breast density readings at CT may provide important additional risk information on CT of the chest and that computer-derived measurements may be helpful in such assessment.

The purpose of this study was to determine whether additional breast imaging is clinically valuable in the evaluation of patients with gynecomastia incidentally observed on CT of the chest.In a retrospective analysis, 62 men were identified who had a mammographic diagnosis of gynecomastia and had also undergone CT within 8 months (median, 2 months). We compared the imaging findings of both modalities and correlated them with the clinical outcome.Gynecomastia was statistically significantly larger on mammograms than on CT images; however, there was a high level of concordance in morphologic features and distribution of gynecomastia between mammography and CT. In only one case was gynecomastia evident on mammographic but not CT images, owing to cachexia. Two of the 62 men had ductal carcinoma, which was obscured by gynecomastia. Both of these patients had symptoms suggesting malignancy.The appearance of gynecomastia on CT scans and mammograms was highly correlated. Mammography performed within 8 months of CT is unlikely to reveal cancer unless there is a suspicious clinical finding or a breast mass eccentric to the nipple. Men with clinical symptoms of gynecomastia do not need additional imaging with mammography to confirm the diagnosis if they have undergone recent cross-sectional imaging.

A 59-YEAR-OLD MAN with severe aortic stenosis presented for valve replacement surgery. After uncomplicated induction of anesthesia, an introducer was placed into the left internal jugular vein, through which a pulmonary artery catheter (PAC) was easily directed into the pulmonary artery on the first attempt. The intraoperative course was uneventful. On postoperative day 1 in the intensive care unit, the following chest x-ray was obtained (Fig 1). What is the diagnosis?

The original version of this article unfortunately contained a mistake. The conflict of interest was incorrect.

The segmentation of whole breast serves as the first step towards automated breast lesion detection. It is also necessary for automatically assessing the breast density, which is considered to be an important risk factor for breast cancer. In this paper we present a fully automated algorithm to segment the whole breast in low-dose chest CT images (LDCT), which has been recommended as an annual lung cancer screening test. The automated whole breast segmentation and potential breast density readings as well as lesion detection in LDCT will provide useful information for women who have received LDCT screening, especially the ones who have not undergone mammographic screening, by providing them additional risk indicators for breast cancer with no additional radiation exposure. The two main challenges to be addressed are significant range of variations in terms of the shape and location of the breast in LDCT and the separation of pectoral muscles from the glandular tissues. The presented algorithm achieves robust whole breast segmentation using an anatomy directed rule-based method. The evaluation is performed on 20 LDCT scans by comparing the segmentation with ground truth manually annotated by a radiologist on one axial slice and two sagittal slices for each scan. The resulting average Dice coefficient is 0.880 with a standard deviation of 0.058, demonstrating that the automated segmentation algorithm achieves results consistent with manual annotations of a radiologist.

To determine if general radiologists can accurately measure breast density on low-dose chest computed tomographic (CT) scans, two board-certified radiologists with expertise in mammography and CT scan interpretation, and seven general radiologists performed retrospective review of 100 women's low-dose chest CT scans. CT breast density grade based on Breast Imaging Reporting and Data System grades was independently assigned for each case. Kappa statistic was used to compare agreement between the expert consensus grading and those of the general radiologists. Kappa statistics were 0.61-0.88 for the seven radiologists, showing substantial to excellent agreement and leading to the conclusion that general radiologists can be trained to determine breast density on chest CT.

No. 399 Multidisciplinary interrater reliability of ventricle ratio screening for submassive pulmonary embolism on axial non-EKG-gated CT pulmonary angiography Z.L. Bercu, V.V. Patil, L. Azour, V.L. Bishay, M. Salvatore, J. Oropello, R.A. Lookstein, A.M. Fischman, E. Kim, S.F. Nowakowski, R.S. Patel; Division of Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, NY; Department of Radiology, Mount Sinai School of Medicine, New York, NY; Department of Surgical Critical Care, Icahn School of Medicine at Mount Sinai, New York, NY Purpose: A right ventricle (RV) to left ventricle (LV) ratio 40.9 and positive pulmonary embolism (PE) on computerized tomography pulmonary angiography (CTPA) is associated with doubled 30-day mortality [1]. If confirmed on echocardiography, patients may benefit from more aggressive therapy. RV:LV ratios on axial imaging may be comparable to reformated 4-chamber views [2]. The purpose is to assess the interrater reliability (IRR) of ventricle measurements for RV: LV ratio calculation among diverse readers. Materials and Methods: 17 patients with PE underwent axial non-gated CTPA between November 1, 2013 and March 31, 2014. Patient charts and imaging were reviewed for demographics, treatment, and PE burden using the Modified Miller Score (MMS). 4 readers measured maximum RV/LV diameters following a 5 minute training session. Reader 1 was a radiology resident with 1.5 years imaging experience. Reader 2 was a chest radiologist with 14 years experience. Reader 3 was an interventional radiologist with 7 years experience. Reader 4 was a critical care physician with 24 years experience treating PE. IRR was assessed using intra-class correlation (ICC). Results: 5 patients had malignancy. 5 had deep venous thrombosis. Average MMS was 4.6 (range: 0-16). 4 of 10 patients had right cardiac dysfunction on echocardiogram. 5, 2, and 1 received low molecular weight heparin, rivaroxiban, and warfarin, respectively. 6 received combination therapy either for bridging or complication. 2 were ineligible for anticoagulation. 1 underwent peripheral thrombolysis. 4 underwent filter placement. ICC was 0.870 (CI: 0.728-0.948) for the RV and 0.870 (CI: 0.728-0.948) for the LV. Readers 1, 2, 3, and 4 found 13, 9, 15, and 12 patients with RV:LV40.9, respectively. Conclusion: Detection of patients who may have submassive PE requires diverse physician coordination. The study population included a full spectrum of disease burden. High ICCs among multidisciplinary readers confers high accuracy. Slightly more patients were found with RV:LV40.9 than with right heart dysfunction on echo, suggesting its utility for screening for sicker patients.

Rationale and Objectives The purpose of this study was to evaluate the accuracy of ultrasound (US)–guided fine-needle aspiration (FNA), with radiographic follow-up or surgical excision, in conjunction with on-site cytopathologic support in the management of nonpalpable breast lesions. Materials and Methods The findings of 266 consecutive mammographically or sonographically identified, nonpalpable lesions (228 patients) that underwent US–guided FNA were examined retrospectively. Clustered microcalcifications did not undergo biopsy with this method. Patients who underwent follow-up excisional biopsy or mammography with a duration of at least 24 months were included in the study. Results In all, 117 lesions met criteria for inclusion, of which 85 (73%) were diagnosed as benign at cytopathologic evaluation and underwent mammographic follow-up of at least 24 months (range, 24–67 months; mean, 36 months). Thirty-two lesions (27%) had either malignant or atypical cytopathologic findings, for which surgery was recommended. Eleven (9%) of the 32 had malignant cytopathologic findings from initial US–guided FNA, which were confirmed at surgical excision. The remaining 21 lesions (18%) were diagnosed as atypical on the basis of US–guided FNA results. Of these, 18 lesions underwent excisional biopsy: Two were diagnosed as carcinoma (not otherwise specified), and 16 were diagnosed with a variety of benign disorders. The remaining three patients with atypical lesions chose mammographic follow-up rather than surgical diagnosis, and their conditions have remained stable for more than 24 months. Of the 85 benign cases, one changed during follow-up (12 months) and underwent repeat biopsy, with malignancy noted. The sensitivity of US–guided FNA in identifying malignant lesions was 93% (13 of 14), and the specificity of a benign finding was 100% (102 of 102). The positive and negative predictive values of US–guided FNA supported by on-site cytopathologic evaluation were 100% (13 of 13) and 99% (102 of 103), respectively. Conclusion Supported by appropriately trained on-site cytopathologists and in conjunction with follow-up mammography, US–guided FNA appears to be efficacious in the management of patients with abnormal radiographic findings. It is quick, relatively inexpensive, and minimally invasive, and, in the presence of competent cytopathologists, should be the modality of choice.