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Annual surveillance mammography is recommended for breast cancer survivors on the basis of observational studies and meta-analyses showing reduced breast cancer mortality and improved quality of life. However, breast cancer survivors are at higher risk of subsequent breast cancer and have a fourfold increased risk of interval breast cancers compared with individuals without a personal history of breast cancer. Supplemental surveillance modalities offer increased cancer detection compared with mammography alone, but utilization is variable, and benefits must be balanced with possible harms of false-positive findings. In this review, we describe the current state of mammographic surveillance, summarize evidence for supplemental surveillance in breast cancer survivors, and explore a risk-based approach to selecting surveillance imaging strategies. Further research identifying predictors associated with increased risk of interval second breast cancers and development of validated risk prediction tools may help physicians and patients weigh the benefits and harms of surveillance breast imaging and decide on a personalized approach to surveillance for improved breast cancer outcomes.

Letters of recommendation are essential for residency applications. Traditionally, narrative letters have been used. Standardized letters of recommendation (SLOR) have been developed and have benefits to the writer and reader. The goal was to develop an informative, meaningful, and efficient SLOR for the radiology residency Match and to assess its early use.An Association of University Radiologists (AUR) Research and Education Venture Fund Grant was awarded for the development of a SLOR for use in the radiology residency Match. Grant recipients developed the letter and modifications were based on feedback from the Alliance of Medical Student Educators in Radiology (AMSER) SLOR task force and a larger task force including additional AUR and Association of Program Directors in Radiology (APDR) members. AUR and APDR members were surveyed in 2020 to assess the radiology SLOR.The radiology SLOR became available for use in September 2018. It highlights the top six traits or abilities deemed most valued in a resident candidate and guides the writer to develop a concrete narrative. Top perceived benefits of the Radiology SLOR are ease of reading and interpretation. Top perceived drawbacks are an impersonal format and concerns regarding program directors' perceptions of the new SLOR. SLOR utilization increased in the second year of availability.The radiology SLOR was developed and first used in 2018. Its use increased over two years and will likely continue to increase given the perceived benefits and increasing awareness of the SLOR.

Background Digital breast tomosynthesis (DBT) image interpretation might be more cognitively demanding than interpretation of digital mammography (DM) images. The time of day of interpretation might affect recall and false-positive (FP) rates, especially for DBT. Purpose To determine whether recall and FP rates vary by time of day of interpretation for screening mammography for breast cancer performed with DM and DBT. Materials and Methods This is a retrospective study examining 97 671 screening mammograms interpreted by 18 radiologists between January 2018 and December 2019 at one of 12 community radiology sites. The association between the time of day of interpretation, the type of image interpreted (DM vs DBT), and radiologist experience (≤5 posttraining years vs5 posttraining years) and the likelihood of a patient being recalled from screening mammography and the likelihood of whether the interpretation was FP or true positive were analyzed. Analyses were conducted using generalized linear mixed modeling with a binary distribution and sandwich estimation where observations were nested by radiologist. Results Screening mammograms interpreted by 18 radiologists were reviewed (40 220 DBTs, 57 451 DMs). Nine radiologists had 5 or fewer posttraining years of experience, and nine had more than 5 posttraining years of experience. The overall recall rates for DM (10.2%) and DBT (9.0%) were different (

Figure S3: Breakdown of subjects excluded in the Provista-002 trial. Reasons for exclusion shown in legend.

Purpose:With improvements in breast cancer imaging, there has been a corresponding increase in false-positives and avoidable biopsies. There is a need to better differentiate when a breast biopsy is warranted and determine appropriate follow-up. This study describes the design and clinical performance of a combinatorial proteomic biomarker assay (CPBA), Videssa Breast, in women over age 50 years.Experimental Design:A BI-RADS 3, 4, or 5 assessment was required for clinical trial enrollment. Serum was collected prior to breast biopsy and subjects were followed for 6–12 months and clinically relevant outcomes were recorded. Samples were split into training (70%) and validation (30%) cohorts with an approximate 1:4 case:control ratio in both arms.Results:A CPBA that combines biomarker data with patient clinical data was developed using a training cohort (469 women, cancer incidence: 18.5%), resulting in 94% sensitivity and 97% negative predictive value (NPV). Independent validation of the final algorithm in 194 subjects (breast cancer incidence: 19.6%) demonstrated a sensitivity of 95% and a NPV of 97%. When combined with previously published data for women under age 50, Videssa Breast achieves a comprehensive 93% sensitivity and 98% NPV in a population of women ages 25–75. Had Videssa Breast results been incorporated into the clinical workflow, approximately 45% of biopsies might have been avoided.Conclusions:Videssa Breast combines serum biomarkers with clinical patient characteristics to provide clinicians with additional information for patients with indeterminate breast imaging results, potentially reducing false-positive breast biopsies.

Table S1. Enrollment Criteria Table S2. Enrollment Sites Table S3. Serum protein biomarkers (SPB) and tumor-associated autoantibodies (TAAb) evaluated in the current study. Table S4: Clinical conditions and criteria for inclusion. Table S5: Comparison of biomarker measurements between women divided by age and by FSH. Table S6: Clinical performance of Videssa Breast in all samples categorized by breast density (dense: categories a and b, non-dense: categories c and d) and by health exclusion. Table S7: Clinical performance of Videssa Breast in subjects ages 25-49.

The ideal practice routine for screening mammography would optimize performance metrics and minimize costs, while also maximizing patient satisfaction. The main approaches to screening mammography interpretation include batch offline, non-batch offline, interrupted online, and uninterrupted online reading, each of which has its own advantages and drawbacks. This article reviews the current literature on approaches to screening mammography interpretation, potential effects of newer technologies, and promising artificial intelligence resources that could improve workflow efficiency in the future.

CT angiography (CTA) is essential in acute stroke to detect emergent large vessel occlusions (ELVO) and must be interpreted by radiologists with and without subspecialized training. Additionally, grayscale inversion has been suggested to improve diagnostic accuracy in other radiology applications. This study examines diagnostic performance in ELVO detection between neuroradiologists, non-neuroradiologists, and radiology residents using standard and grayscale inversion viewing methods.A random, counterbalanced experimental design was used, where 18 radiologists with varying experiences interpreted the same patient images with and without grayscale inversion. Confirmed positive and negative ELVO cases were randomly ordered using a balanced design. Sensitivity, specificity, positive and negative predictive values as well as confidence, subjective assessment of image quality, time to ELVO detection, and overall interpretation time were examined between grayscale inversion (on/off) by experience level using generalized mixed modeling assuming a binary, negative binomial, and binomial distributions, respectively.All groups of radiologists had high sensitivity and specificity for ELVO detection (all .94). Neuroradiologists were faster than non-neuroradiologists and residents in interpretation time, with a mean of 47 s to detect ELVO, as compared with 59 and 74 s, respectively. Residents were subjectively less confident than attending physicians. With respect to grayscale inversion, no differences were observed between groups with grayscale inversion vs. standard viewing for diagnostic performance (p = 0.30), detection time (p = .45), overall interpretation time (p = .97), and confidence (p = .20).Diagnostic performance in ELVO detection with CTA was high across all levels of radiologist training level. Grayscale inversion offered no significant detection advantage.• Stroke is an acute vascular syndrome that requires acute vascular imaging. • Proximal large vessel occlusions can be identified quickly and accurately by radiologists across all training levels. • Grayscale inversion demonstrated minimal detectable benefit in the detection of proximal large vessel occlusions.

Although the majority of male breast problems are benign with gynecomastia as the most common etiology, men with breast symptoms and their referring providers are typically concerned about whether or not it is due to breast cancer. If the differentiation between benign disease and breast cancer cannot be made on the basis of clinical findings, or if the clinical presentation is suspicious, imaging is indicated. The panel recommends the following approach to breast imaging in symptomatic men. In men with clinical findings consistent with gynecomastia or pseudogynecomastia, no imaging is routinely recommended. If an indeterminate breast mass is identified, the initial recommended imaging study is ultrasound in men younger than age 25, and mammography or digital breast tomosynthesis in men age 25 and older. If physical examination is suspicious for a male breast cancer, mammography or digital breast tomosynthesis is recommended irrespective of patient age. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Breast implant imaging varies depending on patient age, implant type, and symptoms. For asymptomatic patients (any age, any implant), imaging is not recommended. Rupture of saline implants is often clinically evident, as the saline is resorbed and there is a change in breast contour. With saline implants and equivocal clinical findings, ultrasound (US) is the examination of choice for patients less than 30 years of age, either mammography/digital breast tomosynthesis or US may be used for those 30 to 39 years of age, and mammography/digital breast tomosynthesis is used for those 40 years and older. For patients with suspected silicone implant complication, MRI without contrast or US is used for those less than 30 years of age; MRI without contrast, mammography/digital breast tomosynthesis, or US may be used for those 30 to 39 years of age; and MRI without contrast or mammography/digital breast tomosynthesis is used for those 40 years and older. Patients with unexplained axillary adenopathy and silicone implants (current or prior) are evaluated with axillary US. For patients 30 years and older, mammography/digital breast tomosynthesis is performed in conjunction with US. Last, patients with suspected breast implant-associated anaplastic large-cell lymphoma are first evaluated with US, regardless of age or implant type. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Breast cancer screening recommendations are based on risk factors. For average-risk women, screening mammography and/or digital breast tomosynthesis is recommended beginning at age 40. Ultrasound (US) may be useful as an adjunct to mammography for incremental cancer detection in women with dense breasts, but the balance between increased cancer detection and the increased risk of a false-positive examination should be considered in the decision. For intermediate-risk women, US or MRI may be indicated as an adjunct to mammography depending upon specific risk factors. For women at high risk due to prior mantle radiation between the ages of 10 to 30, mammography is recommended starting 8 years after radiation therapy but not before age 25. For women with a genetic predisposition, annual screening mammography is recommended beginning 10 years earlier than the affected relative at the time of diagnosis but not before age 30. Annual screening MRI is recommended in high-risk women as an adjunct to mammography. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Breast cancer is the most common female malignancy and the second leading cause of female cancer death in the United States. Although the majority of palpable breast lumps are benign, a new palpable breast mass is a common presenting sign of breast cancer. Any woman presenting with a palpable lesion should have a thorough clinical breast examination, but because many breast masses may not exhibit distinctive physical findings, imaging evaluation is necessary in almost all cases to characterize the palpable lesion. Recommended imaging options in the context of a palpable mass include diagnostic mammography and targeted-breast ultrasound and are dependent on patient age and degree of radiologic suspicion as detailed in the document Variants. There is little role for advanced technologies such as MRI, positron emission mammography, or molecular breast imaging in the evaluation of a palpable mass. When a suspicious finding is identified, biopsy is indicated. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

This study aimed to assess radiologists' knowledge about breast density legislation as well as perceived practice changes resulting from the enactment of breast density legislation.This is an institutional review board-exempt anonymous email survey of 523 members of the New England Roentgen Ray Society. In addition to radiologist demographics, survey questions addressed radiologist knowledge of breast density legislation, knowledge of breast density as a risk factor for breast cancer, recommendations for supplemental screening, and perceived practice changes resulting from density notification legislation.Of the 523 members, 96 responded, yielding an 18% response rate. Seventy-three percent of respondents practiced in a state with breast density legislation. Sixty-nine percent felt that breast density notification increased patient anxiety about breast cancer, but also increased patient (74%) and provider (66%) understanding of the effect of breast density on mammographic sensitivity. Radiologist knowledge of the relative risk of breast cancer when comparing breasts of different density was variable.Considerable confusion and controversy regarding breast density persists, even among practicing radiologists.

Appropriate imaging evaluation of nipple discharge depends the nature of the discharge. Imaging is not indicated for women with physiologic nipple discharge. For evaluation of pathologic nipple discharge, multiple breast imaging modalities are rated for evidence-based appropriateness under various scenarios. For women age 40 or older, mammography or digital breast tomosynthesis (DBT) should be the initial examination. Ultrasound is usually added as a complementary examination, with some exceptions. For women age 30 to 39, either mammogram or ultrasound may be used as the initial examination on the basis of institutional preference. For women age 30 or younger, ultrasound should be the initial examination, with mammography/DBT added when ultrasound shows suspicious findings or if the patient is predisposed to developing breast cancer. For men age 25 or older, mammography/DBT should be performed initially, with ultrasound added as indicated, given the high incidence of breast cancer in men with pathologic nipple discharge. Although MRI and ductography are not usually appropriate as initial examinations, each may be useful when the initial standard imaging evaluation is negative. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Breast pain (or tenderness) is a common symptom, experienced by up to 80% of women at some point in their lives. Fortunately, it is rarely associated with breast cancer. However, breast pain remains a common cause of referral for diagnostic breast imaging evaluation. Appropriate workup depends on the nature and focality of the pain, as well as the age of the patient. Imaging evaluation is usually not indicated if the pain is cyclic or nonfocal. For focal, noncyclic pain, imaging may be appropriate, mainly for reassurance and to identify treatable causes. Ultrasound can be the initial examination used to evaluate women under 30 with focal, noncyclic breast pain; for women 30 and older, diagnostic mammography, digital breast tomosynthesis, and ultrasound may all serve as appropriate initial examinations. However, even in the setting of focal, noncyclic pain, cancer as an etiology is rare. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer-reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

This study aimed to evaluate the effectiveness of an iPad app for teaching healthcare economics milestones.Institutional review board-approved, Health Insurance Portability and Accountability Act-compliant survey assessment of radiology residents' knowledge of healthcare economics before and following review of the Healthcare Economics iPad app was undertaken at two residencies. Residents received an electronic link to the pre survey, answered 13 general knowledge questions, rated their knowledge of healthcare economics milestones, and reported any prior economics/business background. During the conference, residents reviewed the app on their iPads. They then received a link to the post survey. Responses were entered using REDCap and a unique yet anonymous code was used to link each resident's pre and post results. A follow-up survey was completed at 3 months using REDCap.Sixty-two of 69 (90%) residents completed the pre survey. Mean and median age was 30 years. Thirty-two of 62 (52%) were men and 30/62 (48%) were women. Twenty-nine percent (18/62) were postgraduate year (PGY) 2, 24% (15/62) PGY 3, 19% (12/62) PGY 4, 26% (16/62) PGY 5, and 1.6% (1/62) PGY 6. Thirty-four percent (21/62) reported some economics/business background. Residents' mean self-assessment of their knowledge of healthcare economics milestones was fair on the pre survey, significantly improved on the post survey, and plateaued at 3 months. Fifty-nine residents completed the post survey; 60 completed the 3-month follow-up. Residents demonstrated a significant increase in healthcare economics knowledge on post survey. At 3-month follow-up, significant decreases in gained knowledge were observed only in residents for whom the material was not integrated into the curriculum.Teaching with iPad apps offers an alternative, effective way to teach basics of healthcare economics milestones.

To determine the frequency, malignancy rate, and imaging characteristics of BI-RADS (Breast Imaging Reporting and Data System) 3 MRI detected lesions.A total of 4370 consecutive contrast-enhanced breast MRI exams from March 1, 2004, to March 1, 2009, were retrospectively reviewed. The study was HIPAA (Health Insurance Portability Accountability Act) compliant and Institutional Review Board approved. The frequency of BI-RADS 3 MRI interpretations and lesion type, as well as malignancy rate at follow-up were calculated.There were 348/4370 (8%) BI-RADS 3 exams performed on 345 patients. There were 125 foci (35.9%), 52 non-masslike enhancements (14.9%), and 171 masses (49.1%). There were 207 lesions with biopsy or imaging follow-up of at least 24 months (mean, 32 months; range, 6-77 months) of the BI-RADS 3 lesion. Five of these 207 (2.4%) lesions were found to be malignant.Rate of malignancy among BI-RADS 3 MRI exams with follow-up was 2.4%. Types of lesions assigned as probably benign were 35.9% foci, 14.9% non-masslike enhancements, and 49.1% masses.

To determine if changing from 1.5T to 3T breast magnetic resonance imaging (MRI) is associated with a change in BI-RADS categories, positive predictive value of biopsy recommendation, or cancer detection rates in high-risk screening breast MRI.Institutional Review Board (IRB) approval was obtained for this Health Insurance Portability and Accountability Act (HIPAA)-compatible retrospective review. Prior to October 2010, breast MRI was performed at 1.5T and after October 2010 breast MRI was performed at 3T. Reports of 495 consecutive screening 3T breast MRI exams from October 2010 through October 2011 were reviewed. Comparison was made to previously collected data on 650 screening breast MRI exams at 1.5T. Data were analyzed for statistical significance using the two-sample test of proportions.There were 495 screening breast MRI exams. There were 419 (84.6%) BI-RADS 1/2 results, 35 (7.1%) BI-RADS 3 results, and 41 (8.3%) BI-RADS 4/5 results. BI-RADS 4/5 results increased at 3T (P=0.04). The positive predictive value for BI-RADS 4/5 was 29.3% (12/41) at 3T, compared with 17.6% at 1.5T (P0.001). Cancer detection rate was 2.6% at 3T, compared with 0.9% at 1.5T (P=0.02).Transition to 3T breast MRI in a screening population resulted in increased BI-RADS 4/5 interpretations, positive predictive value of biopsy recommendations, and cancer detection rate.