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Creating a comprehensive didactic curriculum for breast imaging fellows can be a demanding undertaking, especially considering that most breast practices are understaffed because of the COVID-19 pandemic and amid rising clinical volumes. This leaves little time for didactic education. In this article, we present our approach to creating a collaborative weekly multidisciplinary didactic lecture series involving multiple institutions, using the Society of Breast Imaging’s suggested fellowship curriculum as the foundation. We discuss the advantages for both trainees and faculty, including fostering camaraderie, networking, and engagement among breast imaging fellows. Faculty have the opportunity for professional development by leveraging their clinical expertise through selecting didactic topics in their niche. This creates a pathway for speaking faculty to be recognized as regional and national experts.

Adenoid cystic carcinoma (ACC) is an uncommon malignancy occurring most frequently in the salivary glands. Breast ACC is rare. Pain is common at the site of ACC; otherwise, presentation is similar to other primary breast cancers. Adenoid cystic carcinomas classically lack calcifications; the imaging manifestations of ACC are otherwise highly variable, likely related to multiple pathologic growth patterns. While ACC in other regions of the body tends to be more aggressive, ACC involving the breast typically has less aggressive biologic characteristics. Classic-type breast ACC has a lower tendency to recur locally with radiation, metastasize to regional lymph nodes, and spread to other parts of the body. Perineural spread of disease can be seen but is not common. The rarer solid basaloid–type has a higher tendency for local or distant spread and recurrence. Although ACC is usually triple receptor–negative (estrogen receptor, progesterone receptor, human epidermal growth factor-2 receptor), the indolent nature of this tumor dictates its management. With classic-type ACC, the inclusion of axillary surgery has no consensus and the use of chemotherapy or hormonal therapy is rare. Axillary nodal surgery and chemotherapy are often included in management of the more aggressive solid basaloid–type. An understanding of the breast imaging, histopathology, and clinical course is key for appropriate treatment and follow-up of ACC.

“Managing up” for the radiologist means developing and cultivating work relationships to benefit high-level stakeholders and the institution at large, and to maximize one’s own effectiveness. Today’s breast radiologists are responsible for more than image interpretation and image-guided interventions. Radiologists’ roles and responsibilities have evolved to include clinical initiatives, staff development, quality improvement, and administrative tasks where management skills are needed. To be successful in these roles, developing skills to manage up will allow radiologists to be more effective team members. In this article, we discuss tactics to start developing strategies for managing up, including how to understand practice leaders and create meaningful relationships; explain various work style personalities and how to navigate them; describe how to understand oneself, including strengths and weaknesses; and, finally, provide tips on how to begin to cultivate managing up skills.

Intimate partner violence (IPV) is defined as physical violence, sexual violence, stalking, or psychological harm by a current or former intimate partner. In the United States, one in three women will experience a form of IPV in their lifetime. Screening for IPV at breast imaging centers provides an important opportunity to identify and assist affected women. Breast imaging centers provide a private environment where passive and active IPV screening methods can be employed. In addition, when obtaining a mammogram or breast ultrasound, the patient’s upper chest is exposed, which could demonstrate patterns of abuse. This article discusses the need for IPV screening, via both passive and active methods, and implementation steps for breast imaging centers.

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.

Objective To determine the diagnostic accuracy of MRI textural analysis (TA) to differentiate malignant from benign axillary lymph nodes in patients with breast cancer. Methods This was an institutional review board–approved retrospective study of axillary lymph nodes in women with breast cancer that underwent ultrasound-guided biopsy and contrast-enhanced (CE) breast MRI from January 2015 to December 2018. TA of axillary lymph nodes was performed on 3D dynamic CE T1-weighted fat-suppressed, 3D delayed CE T1-weighted fat-suppressed, and T2-weighted fat-suppressed MRI sequences. Quantitative parameters used to measure TA were compared with pathologic diagnoses. Areas under the curve (AUC) were calculated using receiver operating characteristic curve analysis to distinguish between malignant and benign lymph nodes. Results Twenty-three biopsy-proven malignant lymph nodes and 24 benign lymph nodes were analyzed. The delayed CE T1-weighted fat-suppressed sequence had the greatest ability to differentiate malignant from benign outcome at all spatial scaling factors, with the highest AUC (0.84–0.93), sensitivity (0.78 [18/23] to 0.87 [20/23]), and specificity (0.76 [18/24] to 0.88 [21/24]). Kurtosis on the 3D delayed CE T1-weighted fat-suppressed sequence was the most prominent TA parameter differentiating malignant from benign lymph nodes (P < 0.0001). Conclusion This study suggests that MRI TA could be helpful in distinguishing malignant from benign axillary lymph nodes. Kurtosis has the greatest potential on 3D delayed CE T1-weighted fat-suppressed sequences to distinguish malignant and benign lymph nodes.

The advent and implementation of digital breast tomosynthesis (DBT) have had a significant effect on breast cancer detection and image-guided breast procedures. DBT has been shown to improve the visualization of architectural distortions and noncalcified masses. With the incorporation of DBT imaging, biopsy of those findings seen only with DBT is feasible, and the need for localization and surgical excision to determine the pathologic diagnosis is avoided. The additional benefits of reduced procedural time, better localization, and increased technical success support the use of DBT for breast biopsy. DBT-guided biopsy can be performed with the patient prone or upright, depending on the table or unit used. Upright positioning enables improved patient comfort, particularly in patients who have restricted mobility, weight-related limitations, and/or difficulty lying prone for an extended period. Upright DBT-guided breast procedures require a cohesive team approach with overlapping radiologist and technologist responsibilities. Since this is a common breast procedure, the radiologist should be familiar with preprocedural considerations, patient preparations, and use of the biopsy equipment. The basic principles of upright DBT-guided breast biopsy are described in this comprehensive review. The various procedural components, including alternative approaches and techniques, are discussed. Tips and tricks for navigating the biopsy procedure to minimize complications, imaging examples of crucial steps, and supporting diagrams are provided. In addition, the challenges of performing upright DBT-guided biopsy, with troubleshooting techniques to ensure a successful procedure, are reviewed. ©RSNA, 2021.

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To evaluate the diagnostic performance of abbreviated MRI (AB-MRI) in comparison to a full protocol MRI (FP-MRI) when evaluating common MRI abnormalities of a mass, non-mass enhancement and focus.This retrospective reader study was Institutional Review Board approved and Health Insurance Portability and Accountability Act (HIPAA) compliant. AB-MRIs were reviewed from May 2018-December 2019 to identify women with an abnormal AB-MRI, FP-MRI within six months of the AB-MRI and an elevated risk for breast cancer. Six breast radiologists initially interpreted and recorded findings from the AB-MRI. Immediately after reviewing the AB-MRI, the same radiologists interpreted and recorded findings from the FP-MRI. Findings were recorded in an electronic data collection form. Cohen's Kappa test was used to calculate agreement. P 0.05 was considered statistically significant.Of 119 patients who had an AB-MRI, our final study comprised of 32 patients who had 64 breast MRIs (32 AB-MRI and 32 FP-MRI). The amount of fibroglandular tissue for AB-MRI and FP-MRI showed excellent intra-reader agreement [Kappa: 0.89-1.00 (P 0.0001)]. Substantial to excellent intra-reader agreement [Kappa: 0.74-0.93 (P 0.0001)] was demonstrated for all 6 readers when identifying abnormalities seen on AB-MRI and FP-MRI. Moderate to excellent intra-reader agreement [Kappa: 0.41-0.87(P 0.0001)] was demonstrated between the AB-MRI and FP-MRI for the final BI-RADS assessment.AB-MRI has acceptable intra-reader agreement with FP-MRI when characterizing common MRI abnormalities such as a mass, non-mass enhancement and focus suggesting that subsequent FP-MRI may not be needed.

The nipple-areolar complex can be affected by a variety of benign and malignant entities that can present with non-specific symptoms. Benign pathologies commonly affecting the nipple-areolar complex include nipple calcifications, nipple adenoma, abscess of Montgomery tubercles, ductal ectasia, periductal mastitis, and papilloma. Malignant pathologies that affect the nipple-areolar complex include Paget's disease of the breast, ductal carcinoma in-situ, and invasive ductal carcinoma. Clinical history and examination, imaging, and tissue sampling when appropriate are co-dependent factors that guide the assessment of nipple-areolar pathologies. This article provides a review of the normal anatomy, common anatomical variants, benign and malignant pathologies, and imaging techniques to guide the diagnostic assessment of the nipple-areolar complex.

The objective of our study was to determine the ability of tomosynthesis (3D) to detect nonmalignant and malignant architectural distortion (AD) on 3D screening mammograms compared with digital mammography (2D) only and to correlate the 3D imaging features of nonmalignant and malignant AD with pathology findings.For this single-institution retrospective study, screening mammography reports from October 1, 2012, to December 1, 2016, that included AD as a finding were reviewed. Associated additional imaging studies and pathology results were also reviewed.Three-dimensional mammography showed statistically significant increased detection of both nonmalignant and malignant AD compared with 2D only (0.10% [24/24,902 examinations] vs 0.01% [1/9470 examinations], p0.05; and 0.21% [52/24,902 examinations] vs 0.07% [7/9470 examinations], p0.05, respectively). Higher percentages of nonmalignant AD (16%) were occult on ultrasound compared with malignant AD (3%). The pathologic diagnoses of nonmalignant AD included radial scar (42%), sclerosing adenosis (16%), stromal or dense fibrosis (16%), and other miscellaneous benign causes (25%). Morphologically, nonmalignant AD was more likely to show symmetric or spoke-wheel spiculation appearance (58% vs 2%, p0.05) and central lucency (25% vs 0%, p0.05) than malignant AD, whereas malignant AD was more likely to show asymmetric spiculation (98% vs 42%, p0.05) and central mass 60% vs 0%, p0.05) than nonmalignant AD.Malignant AD and nonmalignant AD are more readily detected by 3D mammography than 2D mammography. Three-dimensional imaging features of AD can help to distinguish nonmalignant types in which symmetric or spoke-wheel spiculation with central lucency are more often seen and are more often occult on ultrasound.

87 Background: The optimal number of lymph nodes that should be harvested in esophageal cancer patients remains to be defined, particularly in patients that receive neoadjuvant therapies. We investigated the impact of nodal resection and survival in esophageal cancer patients treated with neoadjuvant chemoradiation (NT). Methods: Using our comprehensive esophageal cancer database we identified patients treated with NT followed by esophagectomy between 2000-2011. Clinical and pathologic data were compared using Fisher’s exact and chi-square while, Kaplan Meier estimates were used for survival analysis. Overall (OS) and disease-free survival (DFS) were compared with varying numbers of lymph nodes resected Results: We identified 358 patients treated with NT and esophagectomy with a median follow-up of 18.5 months (range, 0-116 months). There was no survival benefit demonstrated for patients with increased lymph nodes removed during their surgery (ST-1 OS p=0.400, DFS p=0.8727; ST-2 OS p=0.6833, DFS p=0.6092; ST-3 OS p=0.1798, DFS p=0.4028). Patients were further stratified by pathologic response to NT and nodal harvest. There were no differences in OS or DFS in patients with increased nodal harvest when analyzed by complete (pCR) (ST-1 OS p=0.7278, DFS p=0.3602; ST-2 OS p=0.6182, DFS p=0.3592; ST-3 OS p=0.4489, DFS p=0.6976), partial (pPR) (ST-1 OS p=0.3762, DFS p=0.5061; ST-2 OS p=0.8036, DFS p=0.6497; ST-3 OS p=0.0890, DFS p=0.3364), or non response (pNR) (ST-1 OS p=0.6825, DFS p=0.7161; ST-2 OS p=0.7084, DFS p=0.8351; ST-3 OS p=0.5002, DFS p=0.7314) to NT. Multivariate analysis demonstrated that age (p=0.028), t-stage (p=0.006), pPR (p=0.025), and pNR (p Conclusions: In our experience, the number of lymph nodes resected was not predictive for overall or disease free survival in esophageal cancer patients treated with NT. In addition, extended lymph node resection did not improve survival for those with residual disease.