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Whether beginning a new career in breast imaging or switching into a different breast imaging practice for personal or professional advancement, a leadership opportunity, a need to relocate geographically, or simply a better opportunity, it is critical to transition between positions as smoothly as possible. Thoroughly reflecting on your career priorities and goals is essential prior to undertaking any career transition. Once the decision has been made to move to a new position, it is imperative to learn about the dynamics of the new practice and practice environment. Here, we provide suggestions on how to hit the ground running when joining a new breast imaging practice.

Objective The objective was to evaluate outcomes of mammographic architectural distortion (AD) with and without MRI and US correlates. Methods A retrospective review of unexplained mammographic AD with subsequent MRI from January 1, 2007 to September 30, 2017 was performed using a reader-based study design. Mammographic, MRI, and US features and outcomes were documented. Truth was based on biopsy results or minimum two-year imaging follow-up. Measures of diagnostic accuracy were calculated. Results Fifty-six cases of AD were included: 29 (51.8%) detected on 2D mammogram and 27 (48.2%) detected on digital breast tomosynthesis. Of 35.7% (20/56) with MRI correlate, 40.0% (8/20) were enhancing masses, 55.0% (11/20) were non-mass enhancement (NME), and 5.0% (1/20) were nonenhancing AD. Of eight enhancing masses, 75.0% (6/8) were invasive cancers, and 25.0% (2/8) were high-risk lesions. Of 11 NME, 18.2% (2/11) were ductal carcinoma in situ, 36.4% (4/11) were high-risk lesions, and 45.4% (5/11) were benign. Of 64.3% (36/56) without MRI correlate, 94.4% (34/36) were benign by pathology or follow-up, one (2.8%, 1/36) was a 4-mm focus of invasive cancer with US correlate, and one (1/36, 2.8%) was a high-risk lesion. Of cases without MRI and US correlates, one (3.0%, 1/33) was a high-risk lesion and 97.0% (32/33) were benign. The negative predictive value of mammographic AD without MRI correlate was 97.2% (35/36) and without both MRI and US correlates was 100.0% (33/33). Conclusion Mammographic AD without MRI or US correlate was not cancer in our small cohort and follow-up could be considered, reducing interventions.

Our purpose is to understand patient preferences towards contrast-enhanced imaging such as CEM or MRI for breast cancer screening.An anonymous survey was offered to all patients having screening mammography at a single academic institution from December 27 th 2019 to March 6 th 2020. Survey questions related to: (1) patients' background experiences (2) patients' concern for aspects of MRI and CEM measured using a 5-point Likert scale, and (3) financial considerations.75% (1011/1349) patients completed the survey. 53.0% reported dense breasts and of those, 47.6% had additional screening. 49.6% had experienced a callback, 29.0% had a benign biopsy, and 13.7% had prior CEM/MRI. 34.7% were satisfied with mammography for screening. A majority were neutral or not concerned with radiation exposure, contrast allergy, IV line placement, claustrophobia, and false positive exams. 54.7% were willing to pay at least $250-500 for screening MRI. Those reporting dense breasts were less satisfied with mammography for screening (p0.001) and willing to pay more for MRI (p0.001). If patients had prior CEM/MRI, there was less concern for an allergic reaction (p0.001), IV placement (p=0.025), and claustrophobia (p=0.006). There was less concern for false positives if they had a prior benign biopsy (p=0.029) or prior CEM/MRI (p=0.005) and less concern for IV placement if they had dense breasts (p=0.007) or a previous callback (p=0.013).The screening population may accept CEM or MRI as a screening exam despite its risks and cost, especially patients with dense breasts and patients who have had prior CEM/MRI.

Objective Low-energy (LE) images of contrast-enhanced mammography (CEM) have been shown to be noninferior to digital mammography. However, our experience is that LE images are superior to 2D mammography. Our purpose was to compare cancer appearance on LE to 2D images. Methods In this IRB-approved retrospective study, seven breast radiologists evaluated 40 biopsy-proven cancer cases on craniocaudal (CC) and mediolateral oblique (MLO) LE images and recent 2D images for cancer visibility, confidence in margins, and conspicuity of findings using a Likert scale. Objective measurements were performed using contrast-to-noise ratio (CNR) estimated from regions of interest placed on tumor and background parenchyma. Reader agreement was evaluated using Fleiss kappa. Per-reader comparisons were performed using Wilcoxon test and overall comparisons used three-way analysis of variance. Results Low-energy images showed improved performance for visibility (CC LE 4.0 vs 2D 3.5, P Conclusion Our results suggest that cancers may be better visualized on the LE CEM images compared with the 2D digital mammogram.

In the United States, silicone and saline breast implants with their familiar radiologic appearance are the mainstays of breast augmentation. However, less well-known sequelae of unconventional injected materials introduced for cosmetic and noncosmetic purposes may also be encountered on breast imaging—for example, free silicone, paraffin and/or oil, polyacrylamide gel, autologous fat, and hyaluronic acid, which are encountered in the setting of breast augmentation. Breast injection of go-yak is not cosmetic but also results in characteristic imaging findings. Breast changes due to extravasation of chemotherapy or interstitial brachytherapy can mimic the appearance of injected noncosmetic materials. Because many of these materials can mimic or obscure imaging findings of breast cancer, it is important to recognize their varied appearances and the limitations of imaging alone in delineating breast injection material from cancer. Given the relatively uncommon incidence of injected materials into the breast, this article aims to review the imaging appearance in order to aid radiologists in maximizing cancer detection and ensuring optimal patient management.

Background Despite the increasing use of contrast-enhanced mammography (CEM), there are limited data on the evaluation of findings on recombined images and the association with malignancy. Purpose To determine the rates of malignancy of enhancement findings on CEM images in the presence or absence of low-energy findings using the Breast Imaging Reporting and Data System (BI-RADS) lexicon developed for mammography and MRI. Materials and Methods All diagnostic CEM examinations performed at one academic institution between December 2015 and December 2019 had low-energy and recombined images retrospectively. Data were independently reviewed by three breast imaging radiologists with 5-25 years of experience using the BI-RADS mammography and MRI lexicon. Outcome was determined with pathologic analysis or 1-year imaging or clinical follow-up. The χ

Contrast-enhanced mammography (CEM) is gaining rapid traction following the U.S. Food and Drug Administration approval for diagnostic indications. Contrast-enhanced mammography is an alternative form of mammography that uses a dual-energy technique for image acquisition after the intravenous administration of iodinated contrast material. The resulting exam includes a dual set of images, one that appears similar to a routine 2D mammogram and one that highlights areas of contrast uptake. Studies have shown improved sensitivity compared to mammography and similar performance to contrast-enhanced breast MRI. As radiology groups incorporate CEM into clinical practice they must first select the indications for which CEM will be used. Many practices initially use CEM as an MRI alternative or in cases recommended for biopsy. Practices should then define the CEM clinical workflow and patient selection to include ordering, scheduling, contrast safety screening, and managing imaging on the day of the exam. The main equipment requirements for performing CEM include CEM-capable mammography equipment, a power injector for contrast administration, and imaging-viewing capability. The main staffing requirements include personnel to place the intravenous line, perform the CEM exam, and interpret the CEM. To safely and appropriately perform CEM, staff must be trained in their respective roles and to manage potential contrast-related events. Lastly, informing referring colleagues and patients of CEM through marketing campaigns is helpful for successful implementation.

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.

Context.— Dynamic, contrast-enhanced magnetic resonance imaging (MRI) is a highly sensitive imaging modality used for screening and diagnostic purposes. Nonmass enhancement (NME) is commonly seen on MRI of the breast. However, the pathologic correlates of NME have not been extensively explored. Consequently, concordance between MRI and pathologic findings in such cases may be uncertain and this uncertainty may cause the need for additional procedures. Objective.— To examine the histologic alterations that correspond to NME on MRI. Design.— We performed a retrospective search for women who underwent breast MRI between March 2014 and December 2016 and identified 130 NME lesions resulting in biopsy. The MRI findings and pathology slides for all cases were reviewed. The follow-up findings on any subsequent excisions were also noted. Results.— Among the 130 cases, the core needle biopsy showed 1 or more benign lesions without atypia in 80 cases (62%), atypical lesions in 21 (16%), ductal carcinoma in situ in 22 (17%), and invasive carcinoma in 7 (5%). Review of the imaging features demonstrated some statistically significant differences in lesions that corresponded to malignant lesions as compared with benign alterations, including homogeneous or clumped internal enhancement, type 3 kinetics, and T2 dark signal; however, there was considerable overlap of features between benign and malignant lesions overall. Of 130 cases, 54 (41.5%) underwent subsequent excision with only 6 cases showing a worse lesion on excision. Conclusions.— This study illustrates that NME can be associated with benign, atypical, and/or malignant pathology and biopsy remains indicated given the overlap of radiologic features.

Breast imaging is an important field within radiology, having made significant strides in helping reduce morbidity and mortality from breast cancer. Historically, breast imaging radiologists learned mammography and ultrasound skills on the job as a part of general radiology training. However, breast imaging as a subspecialty has grown over time with the emergence of breast imaging fellowships across the country. Despite this growth, breast imaging fellowships remain nonaccredited through the American College of Graduate Medical Education, and as a result, there are significant variations in training programs throughout the country. In this article, we will provide guidelines on organizing a breast imaging fellowship to help standardize the experience of fellows entering the breast imaging community. This will include guidelines regarding providing adequate clinical exposure, developing a fund of knowledge, fostering extra-clinical interests, and providing constructive feedback for ongoing improvement.

The purpose of this paper is to characterize true and false positive findings on contrast-enhanced mammography (CEM) and correlate enhancement pattern and method of detection with pathology outcomes.This was an IRB-approved retrospective review of diagnostic CEM performed from December 2015 through December 2019 for which biopsy was recommended. Background parenchymal enhancement, tissue density, finding features, pathologic/clinical outcomes, and method of detection were captured. CEM includes low-energy images (LE), similar to standard 2D mammography, and recombined images (RI) that show enhancement. 'MG-detected' findings were identified on mammography or LE. 'RI-detected' findings were identified due to enhancement on RI. The positive predictive value (PPV2) was calculated on a per-case and a per-finding level. Comparisons were performed using Pearson chi-square and Fisher exact tests.One hundred sixty CEM cases with 220 findings were evaluated with a case PPV2 of 58.1%. 32.3% (71/220) of lesions were RI-detected. The PPV2 of RI-detected enhancement was 40.8% with subanalysis revealing PPV2 of 22.2%, 32%, and 51.4% for foci, NME, and masses, respectively. The PPV2 of MG-detected enhancement was 73.5% with subanalysis revealing PPV2 of 50%, 54.1%, and 83.8% for foci, NME, and masses, respectively. There were 100 false positives findings, 42 of which were RI-detected.PPV2 of diagnostic CEM is within the range of other diagnostic breast imaging exams. However false positives remain a challenge, especially for RI-detected findings. Additional efforts to improve specificity of RI-detected findings are worthwhile.

Purpose: To characterize a cohort of transgender men and masculine-centered gender nonconforming individuals who underwent gender-affirming chest-contouring surgeries at our institution between 2013 and 2018. Methods: Demographics, medical history, and breast histopathological assessment for 340 patients were retrieved from medical records. Results: Most of our patients were white, non-Hispanic (75.0%), were taking testosterone (83.2%), and opted for chest-contouring surgery after 12–14 months of testosterone therapy. Ten patients were parous (2.9%). Seventy-nine (23.2%) and 27 (7.9%) patients had a family history of breast cancer or ovarian cancer, respectively. One transgender man was incidentally diagnosed with ductal carcinoma in situ at chest-contouring surgery. Conclusion: Future studies on this cohort will provide valuable insights about the impact of testosterone on breast physiology.

To perform a pilot evaluation of contrast-enhanced mammography (CEM) for screening to determine whether it can improve accuracy and reader confidence in diagnosis.This institutional review board-approved reader study was comprised of 64 de-identified CEM cases acquired from December 1, 2014, to June 7, 2016, including 48 negative, 5 biopsy-proven benign, and 11 biopsy-proven malignancies. Negative cases were followed for at least 2 years without evidence of cancer. Ten breast imagers of varying experience first rated the low-energy (LE) mammogram and then the CEM examination using BI-RADS categories and a 5-point Likert scale for confidence in diagnosis.There were 635 out a total possible 640 complete reader interpretations included in this analysis. The remaining five incomplete interpretations were excluded. Median sensitivity and specificity improved with the addition of CEM (sensitivity: 0.86 [95% confidence interval {CI}: 0.74-0.95] versus 1 [95% CI: 0.83-1.00], specificity: 0.85 [95% CI: 0.64-0.94] versus 0.88 [95% CI: 0.80-0.92]). Individual receiver operating characteristic curves showed significant improvement with CEM (mean area under the curve increase = 0.056 [95% CI: 0.015-0.097], P = .002). The addition of CEM significantly improved average confidence in 5 of 10 readers when compared with LE (P.0001) and improved pooled confidence across all tissue density categories, except the almost entirely fatty category. There was a trend toward improved confidence with increasing tissue density with CEM. Degree of background parenchymal enhancement did not affect readers' level of improvement in confidence when interpreting CEM.CEM improved reader performance and confidence compared with viewing only LE, suggesting a role for CEM in breast cancer screening for which larger trials are warranted.

Gender-affirming surgeries expand the options for physical transition among transgender patients, those whose gender identity is incongruent with the sex assigned to them at birth. Growing medical insight, increasing public acceptance, and expanding insurance coverage have improved the access to and increased the demand for gender-affirming surgeries in the United States. Procedures for transgender women, those patients with feminine gender identity, include breast augmentation using implants and genital reconstruction with vaginoplasty. Some transgender women receive medically unapproved silicone injections for breast augmentation or other soft-tissue contouring procedures that can lead to disfigurement, silicone pulmonary embolism, systemic reactions, and even death. MRI is preferred over CT for postvaginoplasty evaluation given its superior tissue contrast resolution. Procedures for transgender men, patients with a masculine gender identity, include chest masculinization (mastectomy) and genital reconstruction (phalloplasty or metoidioplasty, scrotoplasty, and erectile device implantation). Urethrography is the standard imaging modality performed to evaluate neourethral patency and other complications, such as leaks and fistulas. Despite a sizeable growth in the surgical literature about gender-affirming surgeries and their outcomes, detailed descriptions of the imaging features following these surgeries remain sparse. Radiologists must be aware of the wide variety of anatomic and pathologic changes unique to patients who undergo gender-affirming surgeries to ensure accurate imaging interpretation.

The purpose is to determine whether an abbreviated MRI protocol (ABMR) is ready to be used for breast cancer screening in an academic practice setting. Two hundred and fifty nine breast MRIs from 1/1/2012 to 6/30/2012 were retrospectively reviewed using ABMR (MIP, Pre-contrastT1, single dynamic post-contrastT1, and subtraction). Five breast radiologists (4-28 year-expr) participated in this reader study performed in two phases: Phase1 - radiologist's privy to clinical history but not to comparison imaging. Phase2 - radiologists provided comparison imaging. For phase1, studies were reviewed using three steps: (a) MIP only (positive/negative/intermediate); (b) ABMR (recall/no recall) and (c) With T2 (for changes in recommendations). Radiologist also recorded total time for interpretation. In Phase2 the MRIs coded as "recall" were re-reviewed with available comparison studies, noting changes in final recommendation. The abnormal interpretation rates (AIRs) were calculated for phase1 and phase2 results with comparison to the original full protocol. Of the 259 patients (avg. age-52 years; range 26-78), there were seven cancers (three invasive, three DCIS and one breast lymphoma). Acquisition time for ABMR was 3 minutes, ABMR + T2-8 minutes, and original full protocol 16 minutes. Average MIP was positive or indeterminate in 86% (6/7) and negative in 14% (1/7) cancers. The average AIR for MIP only was 20.8% (sens-77.1%; spec-80.8%. The AIR w/o comparisons was 25.6% (sens-91.4%; spec- 76.2%); however the average AIR decreased in phase 2 with comparisons to 13.7% (sens-91.4%; spec-88.5%). The AIR of the original full protocol read was 16.2% (sens-100%; spec-85.7%). Addition of T2 changed assessment in only 3% (1.2%-6.5%). Avg. read time for ABMR including T2 was 2.5 minutes (1.6-4.0 minutes). ABMR is reliable for breast cancer screening, with acceptable interpretation time and acceptable AIR.

Contrast-enhanced mammography (CEM) is a promising new imaging modality that uses a dual-energy acquisition to provide both morphologic and vascular assessment of breast lesions. Although no official BI-RADS lexicon exists, interpretation entails using the mammographic BI-RADS lexicon in combination with that for breast MRI. CEM has comparable performance to breast MRI, with sensitivity of 93–100% and specificity of 80–94%. Currently FDA approved for diagnostic imaging, this technology can be helpful in determining disease extent in patients with newly diagnosed breast malignancy, monitoring response to neoadjuvant therapy, identifying mammographically occult malignancies, and diagnostic problem-solving. Studies are ongoing about its role in screening, especially in women with dense breasts or at elevated risk. There are some challenges to successful implementation into practice, but overall, patients tolerate the study well, and exam times are less than the full breast MRI protocol.

The purpose of this study was to evaluate providers' ordering practices and perceptions of breast magnetic resonance imaging (MRI) in an academic network in order to better understand and educate a referral base. An online survey was distributed to primary care providers (PCPs) and specialists in our hospital and community practices. Questions included provider demographics, current ordering practices, challenges to ordering, and perceptions about breast MRI. Of 525 ordering providers, 134 responded (26% response rate). Of 134 providers, 57 (42%) order breast MRI in practice. Of those who do not, the most consistent reason was a lack of familiarity with the use of breast MRI (32/77 [42%] of cases). Of 57 cases, 45 (79%) order less than 10 exams annually. The most frequent indication is for high-risk screening (40/47 [84%]). PCPs order fewer breast MRI compared with specialists (P = 0.01). Both PCPs and specialists have mixed perceptions of the clinical utility of breast MRI. However, 30% of all providers are ordering more breast MRI since the enactment of breast density legislation in Massachusetts. Furthermore, 29% report they would order breast MRI more often to screen women with dense breasts if there was a low cost option. Referring provider surveys are useful tools for assessing a radiology practice. Our study suggests a growing clinical interest in breast MRI for screening; however, there is a need for provider education on the clinical utility of breast MRI. Increasing the radiologist's role in targeted educational interventions may help improve awareness and lead to more appropriate utilization of resources.

The purpose of this article is to discuss the essential steps involved in performing, interpreting, managing, and reporting findings on contrast-enhanced mammography for successful implementation into clinical practice.To successfully implement contrast-enhanced mammography into clinical practice, an understanding about the acquisition of images, image interpretation, and reporting of the spectrum of negative, benign, and malignant findings is essential.

Objective To determine upgrade rates of lobular neoplasia (LN) to malignancy and evaluate factors that may predict upgrade. Methods From 5/1/2003 to 12/30/2015, breast lesions diagnosed as LN (atypical lobular hyperplasia [ALH] or classic lobular carcinoma in-situ [LCIS]) on core biopsy that underwent surgical excision or at least 2 years imaging follow-up were identified. A subspecialty trained breast radiologist and pathologist reviewed imaging and pathology slides to confirm diagnosis and to determine if LN represented the target lesion, part of the target lesion, or an incidental finding. Imaging features, original BI-RADS final assessment category, biopsy method, biopsy device and final pathologic diagnosis were documented. Cases with both ALH and LCIS were classified as LCIS for analysis. Reason for biopsy of BI-RADS 2-3 was patient or referring physician preference. Upgrade rates to malignancy were determined for all cases. Results In this study 73.7% (115/156) lesions were ALH and 26.3% (41/156) were LCIS+/-ALH. Surgical excision and imaging follow-up were performed in 71.2% (111/156) and 28.8% (45/156), respectively. Upgrade rates for ALH and LCIS were 0.0% (0/115) and 7.3% (3/41), respectively. Cancer developed at a site separate from core biopsy in 1.7% (2/115) ALH and 7.3% (3/41) LCIS cases. We found no association of upgrade rate with biopsy type, BI-RADS or target/part of target lesion versus incidental. Conclusion Our study supports consideration of excision for LCIS, given 7.3% upgrade rate. Conversely, imaging surveillance might be appropriate following diagnosis of ALH alone.

PURPOSE To develop a scheme to quantitatively assess localization accuracy of tomosynthesis-guided vacuum-assisted breast biopsy apparatus. METHODS A phantom containing a metallic pellet on a flexible plastic shaft was constructed and was tested in cranio-caudal (CC) and lateral (LAT) arm biopsy geometries following the standard clinical breast biopsy workflow. Three points were manually digitized on tomosynthesis images including: the center of the target, and the tip of the needle in pre- and postfire positions. The needle trajectory was determined and four error metrics were defined: (1) stroke length error (difference between the nominal and measured stroke lengths); (2) Euclidian distance between the target and center of trough (i.e., aperture); (3) longitudinal distance between target and center of trough; and (4) lateral distance between target and needle. The proposed methodology was also evaluated on a breast gel phantom and the complete biopsy procedure, including vacuum-assisted biopsy was performed. RESULTS Three biopsy geometries were investigated: (i) LAT arm on a prone table unit (Hologic, Affirm Prone), (ii) CC- and (iii) LAT arm in an upright unit (Hologic Affirm Upright). Both biopsy units passed the vendor-provided daily localization accuracy test, with

The purpose of this study is to provide a more accurate estimation of the radiation dose of contrast-enhanced spectral mammography (CESM) relative to that of 2D digital mammography and tomosynthesis using phantom and patient data and an accepted dosimetry protocol that eliminates vendor-specific average glandular dose (AGD) estimates while including breast density.Patient and phantom AGD estimation was performed using two vendors (system 1 and system 2) in five imaging modes, including 2D, 3D, and CESM imaging. Patient AGD was retrospectively estimated from 45 patients who underwent mammography with all imaging modes during 2012-2016. Patient and phantom AGD were estimated using accepted European and International Atomic Energy Agency protocols for dosimetry and were compared across imaging modes using a paired t test with Bonferroni correction.Phantom data showed that the imaging modes with the lowest to highest AGDs were system 1 2D, followed by system 2 2D and system 2 3D, which had comparable values (p = 0.6), followed by system 1 CESM, and then by system 2 2D plus 3D. One hundred eighty views in 45 patients showed that the system 1 CESM AGD was 1.8 times greater than the system 1 2D AGD (p0.001), 1.2 times greater than the system 2 2D AGD (p0.001), 1.2 times greater than the system 2 3D AGD (p0.001), and 0.6 times less than the system 2 2D plus 3D AGD (p0.001).The CESM dose for system 1 is within an acceptable range as compared with other commonly performed mammographic examinations and should not preclude its use as a diagnostic breast imaging tool.

Objective In 2013, the ACR and Society of Breast Imaging created a curriculum to standardize the knowledge of graduates from breast imaging fellowships. Despite this, however, there remains a need to provide guidance to programs as to how to structure and organize the fellowship. In this article, we review key elements of a breast imaging fellowship to ensure that programs graduate radiologists that are well prepared to practice safely and independently. Such a program would provide a developmental framework using the Dreyfus model of skill acquisition. The training should be comprised of multiple and varied opportunities that promote active learning with appropriate supervision but progressive independence. Summary A successful fellowship program in breast imaging should embrace developmental milestones to ensure mastery of both basic and complex skills. Organized rotations, regular feedback, structured and self-directed learning activities, and participation in local, regional, and national meetings and organizations contribute to well-rounded graduates.

Purpose Incidental hepatic lesions identified on breast MR can be a diagnostic dilemma due to concern for liver metastases or other significant hepatic lesions. The purpose of this study was to identify the incidence and nature of liver lesions seen on breast MR, and determine if additional imaging is necessary. Methods and materials Imaging reports of all breast MR examinations performed at our institution from January 1, 2010 to December 31, 2011 were reviewed to identify reports with hepatic abnormalities. Lesion characteristics, subsequent diagnosis, duration of follow up and additional imaging results (if performed) were all recorded. Results Of 1664 breast MRs, incidental hepatic lesions were seen in 207 studies (12.4%) in 169 patients. In 154 of 169 patients (91.1%) the lesions were characterized as T2 hyperintense and clearly as bright as adjacent fat on T2-weighted or localizer sequences. 0 of these 154 lesions were clinically significant at clinical or radiological follow-up. In the remaining 8.9% (15 of 169), lesions were characterized as not as bright as adjacent fat on T2 weighted or localizer imaging. In two cases, lesions were confirmed as incidental hepatic metastatic disease. Conclusion 91.1% of incidental hepatic lesions were circumscribed, T2 hyperintense lesions and characterised as clearly as bright as adjacent fat on T2 weighted imaging at additional review. None of which were clinically significant at clinical or radiological follow-up. We advocate that circumscribed T2 hyperintense lesions which are clearly as bright as adjacent fat on T2 weighted imaging are of unlikely clinical significance and follow-up imaging should not be recommended, reducing the rate of additional imaging from 37.3% to 5.3%.

Purpose Our study evaluates patient preferences toward screening CESM versus MRI. Materials and methods As part of a prospective study, high-risk patients had breast MRI and CESM. Patients completed an anonymous survey to evaluate preferences regarding the two modalities. Results 88% of participants completed the survey. 79% preferred CESM over MRI if the exams had equal sensitivity. 89% would be comfortable receiving contrast as part of an annual screening test. Conclusion High-risk populations may accept CESM as a screening exam and may prefer it over screening MRI if ongoing trials demonstrate screening CESM to be clinically non-inferior MRI.

Contrast-enhanced mammography (CEM) is a developing modality used for the workup and management of breast cancer. Although diagnostic imaging modalities such as mammography and US have historically been the mainstays of initial breast cancer workup, recent advances in breast MRI have allowed better disease evaluation. However, MRI is not always readily available, can be time consuming, and is contraindicated in certain patients. CEM is an alternative to US and MRI, and it can be used to obtain contrast material-enhanced information and standard mammograms simultaneously. A CEM examination is shorter than that of MRI, and the modalities have similar rates of sensitivity to detect lesions. CEM also costs less than MRI. The authors evaluate clinical uses of CEM and discuss the literature supporting these indications.©RSNA, 2019.

International audience; OBJECTIVES:Gender dysphoria is defined as a conflict between the biological gender and the gender with which the person identifies. Gender reassignment therapy can alter external sexual features to resemble those of the desired gender and are broadly classified into two types, female to male (FTM) and male to female (MTF). In this paper we describe expected findings and complications of gender reassignment therapy.METHODS:Collaborative multi-institutional project supported by Ovarian and Uterine Cancer Disease Focused panel of Society of Abdominal Radiology.RESULTS:Gender dysphoria is defined as a conflict between the biological gender and the gender with which the person identifies. Gender reassignment therapy can alter external sexual features to resemble those of the desired gender and are broadly classified into two types, female to male (FTM) and male to female (MTF). These therapies include hormonal treatment as well as surgical procedures. FTM genital reconstructive therapy includes creation of a neophallus, which can be achieved by metoidioplasty or phalloplasty with mastectomy, along with testosterone administration. MTF gender reassignment surgery includes complete removal of external genitalia with penectomy and orchiectomy, with vaginoplasty, clitoroplasty, labiaplasty, and breast augmentation along with estrogen supplements.CONCLUSION:Surgical techniques alter the standard anatomy and make imaging interpretation challenging if radiologists are unfamiliar with expected post-operative appearances. It is important to recognize the complications related to surgical and non-surgical treatment of gender dysphoria to avoid interpretation errors. Furthermore, increasing the prevalence of transgender patients requires increased sensitivity when interpreting imaging studies to reduce the potential for misdiagnoses in reporting due to frequently incomplete available clinical history.

Contrast-enhanced mammography (CEM) is an imaging tool that is increasingly being used to evaluate for breast cancer. It is important for breast groups to understand how this system works and its impact on clinical workflow prior to implementation to ensure a smooth transition. In this chapter, we will review the equipment, physical space, and data storage requirements; the most common indications for use and the patient selection process; how CEM images are acquired and the steps involved in planning and performing the exam; the necessary staff training; and lastly strategies for marketing your new CEM system.

There is lack of consensus on managing papillomas due to varied upgrade rates in the literature related to variability in the studied populations. We specifically studied upgrade rates of pure papilloma diagnosed with ultrasound core biopsy (UCB) using spring-loaded (SLB) and vacuum-assisted (VAB) biopsy devices in patients with low-to-intermediate pre-test probability for malignancy on imaging.From 01/01/2008 to 06/30/2016, 227 patients with 248 pure papillomas classified as BI-RADS 3, 4a, and 4b were diagnosed by UCB and underwent surgical excision or clinical and/or imaging follow-up. Imaging features, biopsy device, and final pathology were documented.177 lesions were biopsied with SLB (14-gauge) and 71 lesions with VAB (9-13 gauges). At surgery, upgrade rates to high-risk lesions and malignancy for SLB were 14.3% (22/154) and 1.9% (3/154), and for VAB were 3.5% (2/57) and 0% (0/57), respectively (p0.05). The combined surgical upgrade rate to high-risk lesions and malignancy was 11.4% (24/211) and 1.4% (3/211), respectively. The overall upgrade rate (including surgical and clinical and/or imaging follow-up) to high-risk lesions and malignancy was 9.7% (24/248) and 1.2% (3/248), respectively. No ultrasound features were predictive of upgrade. Rates of complete excision were 7.1% (11/154) for SLB and 19.3% (11/57) for VAB (p0.05).BI-RADS 3, 4a, or 4b masses biopsied with UCB revealed pure papilloma upgrade to malignancy in less than 2% of cases. SLB was associated with greater upgrades compared with VAB. Therefore, follow-up imaging is a reasonable alternative to excision, particular in those sampled by VAB. Excision could be considered if the diagnosis of a high-risk lesion would change clinical management.

Introduction The introduction of new technologies and teaching strategies to educate the digital learner creates the potential for a better and more standardized training experience across programs. Thus, we sought to create an instructional video on stereotactic core breast biopsy that simulates best practices and could be readily accessed by training programs to improve and standardize resident education. Methods At our institution, we use the video and questions as part of a flipped classroom educational activity. Residents are requested to complete the questions at home and watch the video. They then take the posttest questions during the lecture period, at which time the answers are reviewed and there is additional discussion of the procedure. The tests contain both video-related questions and control questions. Results After viewing the video, there was a 30% mean improvement in the video-related questions compared to a 0% improvement in the control set of questions. Discussion An instructional video on stereotactic core biopsy was created with associated assessment questions that can be used at any institution for the purposes of improving and standardizing training in breast imaging procedures. This resource can be especially useful for programs where trainees have limited procedure exposure.

An understanding of the types of breast augmentation and possible complications is critical to providing appropriate care to patients and ensuring proper management.

The purpose of this study was to determine whether mammography adds clinical value in the diagnostic imaging workup of women 30 years old and older who present with palpable breast lumps.We retrospectively identified the records of all women 30 years old and older who underwent imaging evaluation with mammography and ultrasound for a palpable lump between January 1, 2009, and December 31, 2010. Imaging reports were reviewed for findings related to the lump and for incidental nonpalpable findings. Benign versus malignant outcomes were determined by pathologic analysis or 24-month imaging or clinical follow-up. The contribution of mammography to final diagnosis was assessed on the basis of objective criteria to determine the clinical impact of mammographic findings.The study cohort included 861 patients presenting with 935 palpable lumps. Imaging correlates were reported for 568 of 935 (60.7%) lumps, and imaging findings were negative in 367 of 935 (39.3%). Of the 935 palpable lumps, 858 (91.8%) were benign and 77 (8.2%) were malignant. Mammography added clinical value in the evaluation of 27 of 77 (35.0%) malignant lumps by better delineating extent of disease and in the evaluation of 26 of 858 benign lumps (3.0%) by confirming benignity. Fifty-two of 861 (6.0%) patients had incidental findings that led to a recommendation for biopsy. Twenty-nine of the 52 findings were originally seen with mammography and 23 with ultrasound. Mammography also depicted seven incidental malignancies in nonpalpable areas, and ultrasound depicted one incidental malignancy.Adjunct mammography is warranted for evaluation of palpable breast lumps in women 30 years old and older because of the value added to clinical management. In all age cohorts, mammography contributed to delineation of disease extent, detection of incidental malignancies, and confirmation of benign diagnoses.

OBJECTIVE. Limited information exists regarding breast health in the transgender population. In this article, we review transgender terminology, barriers faced by transgender patients, current breast care screening recommendations, and normal and abnormal imaging findings in this population. CONCLUSION. Health disparities in the transgender population continue. Educating physicians on the breast health care needs of transgender patients is important for improving their care.

To compare the recall and cancer detection rates (CDRs) at screening with digital breast tomosynthesis (DBT) with those at screening with two-dimensional (2D) mammography and to evaluate variations in the recall rate (RR) according to patient age, risk factors, and breast density and among individual radiologists at a single U.S. academic medical center.This institutional review board-approved, HIPAA-compliant prospective study with a retrospective cohort included 85 852 asymptomatic women who presented for breast cancer screening over a 3-year period beginning in 2011. A DBT unit was introduced into the existing 2D mammography screening program, and patients were assigned to the first available machine. Ten breast-subspecialized radiologists interpreted approximately 90% of the examinations. RRs were calculated overall and according to patient age, breast density, and individual radiologist. CDRs were calculated. Single and multiple mixed-effect logistic regression analyses, χ(2) tests, and Bonferroni correction were utilized, as appropriate.The study included 5703 (6.6%) DBT examinations and 80 149 (93.4%) 2D mammography examinations. The DBT subgroup contained a higher proportion of patients with risk factors for breast cancer and baseline examinations. DBT was used to detect 54.3% more carcinomas (+1.9 per 1000, P.0018) than 2D mammography. The RR was 7.51% for 2D mammography and 6.10% for DBT (absolute change, 1.41%; relative change, -18.8%; P.0001). The DBT subgroup demonstrated a significantly lower RR for patients with extremely or heterogeneously dense breasts and for patients in their 5th and 7th decades.Implementing DBT into a U.S. breast cancer screening program significantly decreased the screening RR overall and for certain patient subgroups, while significantly increasing the CDR. These findings may encourage more widespread adoption and reimbursement of DBT and facilitate improved patient selection.

Purpose To review mammographic, ultrasonographic (US), and magnetic resonance (MR) imaging features and pathologic characteristics of estrogen receptor (ER)-positive, lymph node-negative invasive breast cancer and to determine the relationship of these characteristics to Oncotype DX (Genomic Health, Redwood City, Calif) test recurrence scores (ODRS) for breast cancer recurrence. Materials and Methods This institutional review board-approved retrospective study was performed in a single large academic medical center. The study population included patients with ER-positive, lymph node-negative invasive breast cancer who underwent genomic testing from January 1, 2009, to December 31, 2013. Imaging features of the tumor were classified according to the Breast Imaging Reporting and Data System lexicon by breast imagers who were blinded to the ODRS. Mammography was performed in 86% of patients, US was performed in 84%, and MR imaging was performed in 33%, including morphologic and kinetic evaluation. Images from each imaging modality were evaluated. Each imaging finding, progesterone receptor (PR) and human epidermal growth factor receptor 2 (HER2) status, and tumor grade were then individually correlated with ODRS. Analysis of variance was used to determine differences for each imaging feature. Regression analysis was used to calculate prediction of recurrence on the basis of imaging features combined with histopathologic features. Results The 319 patients had a mean age ± standard deviation of 55 years ± 8.7 (range, 31-82 years). Imaging features with a positive correlation with ODRS included a well-circumscribed oval mass (P = .024) at mammography, vascularity (P = .047) and posterior enhancement (P = .004) at US, and lobulated mass (P = .002) at MR imaging. Recurrence scores were predicted by using these features in combination with PR and HER2 status and tumor grade by using the threshold of more than 30 as a high recurrence score. With a regression tree, there was correlation (r = 0.79) with 89% sensitivity and 83% specificity. Conclusion On the basis of preliminary data, information obtained routinely for breast cancer diagnosis can reliably be used to predict the ODRS with high sensitivity and specificity. (©) RSNA, 2016.

Using the iPad application Explain Everything™, the authors created a "how to" video for stereotactic breast core biopsy to enhance their breast imaging curriculum. The objective was to show that video integration into residency training enhances resident learning.A pretest was provided to all 40 radiology residents (postgraduate years 2-5) at the authors' institution. The test included 20 questions on the video content, 15 similarly framed control questions on material that was not included in the video, and four demographic questions. Questions were randomly ordered, and trainees were not informed that both types of questions were included. Residents were given one week to watch the 20-minute video before completing a posttest that included the same 35 content questions presented in a different order. Three logistical questions were also included. Results for the video and the control questions were analyzed separately and compared.Thirty of 40 residents (75%) participated (6-9 residents each year). The average scores for the video and control pretest were 7.7 of 20 (38.5%) and 7.8 of 15 (52%) and for the posttest were 13.8 of 20 (69%) and 7.8 of 15 (52%), respectively. This corresponds to a 30.7% mean improvement on the video-content questions compared with a 0% improvement for the control test (P.001). Similar improvement was seen across all four postgraduate years and on an individual level.This instructional video added significantly to resident learning in the short term. Further study on the long-term role of educational videos in radiology residency training seems warranted.

Objective To review radiation exposure during hysterosalpingography (HSG) examinations with use of a mobile C-arm fluoroscopic imaging system with advanced features including pulsed fluoroscopy and last-image-hold capability. Design Retrospective clinical study. Setting Freestanding outpatient radiology office. Patient(s) Two hundred consecutive patients who were referred for HSG examinations to evaluate fertility or status of tubal ligation. Intervention(s) Pulsed fluoroscopy (eight frames per second) and continuous fluoroscopy were used with automated exposure control and last image hold for static image capture. Main Outcome Measure(s) Fluoroscopy time (seconds), field of view (12 in., 9 in., 6 in.), mode (continuous, pulsed), and dose area product (mGycm 2 ) were recorded for each patient. The total estimated surface dose then was calculated. Result(s) One hundred forty-seven patients had normal results on hysterosalpingograms, and 57 patients had abnormal results on hysterosalpingograms. Selective salpingography was performed in 26 of the 38 patients with fallopian tube occlusions. Mean fluoroscopy time for normal, abnormal, and selective catheterization was 4.17, 14.3, and 56.1 seconds, respectively. Mean estimated surface dose for normal, abnormal, and selective catheterization was 2.6, 6.9, and 46.7 mGy, respectively. Conclusion(s) A mobile C-arm fluoroscopic imaging system with pulsed fluoroscopy and last-image-hold capability may be a desirable alternative for HSG to achieve lower radiation exposure with improved operator convenience and patient comfort.

Purpose: While many techniques exist to evaluate dose to regularly moving lung targets, there are few available to calculate dose at tumor positions not present in the 4DCT. We have previously developed a method that extrapolates an existing dose to a new tumor location. In this abstract, we present a novel technique that accounts for relative anatomical shifts at the chest wall interface. We also utilize this procedure to simulate breathing motion functions on a cohort of eleven patients. Amplitudes exceeding the original range of motion were used to evaluate coverage using several aperture and smearing beam settings. Methods: The water-equivalent depth (WED) technique requires an initial dose and CT image at the corresponding tumor position. Each dose volume was converted from its Cartesian geometry into a beam-specific radiological depth space. The sliding chest wall interface was determined by converting the lung contour into this same space. Any dose proximal to the initial boundary of the warped lung contour was held fixed, while the remaining distal dose was moved in the direction of motion along the interface. Results: V95 coverage was computed for each patient using the updated algorithm. Incorporation of the sliding motion yielded large dose differences, with gamma pass rates as low as 69.7% (3mm, 3%) and V95 coverage differences up to 2.0%. Clinical coverage was maintained for most patients with 5 mm excess simulated breathing motion, and up to 10 mm of excess motion was tolerated for a subset of patients and beam settings. Conclusion: We have established a method to determine the maximum allowable excess breathing motion for a given plan on a patient-by-patient basis. By integrating a sliding chest wall interface into our dose calculation technique, we have analyzed the robustness of breathing patterns that differ during treatment from at the time of 4DCT acquisition.

Patients with both depression and drug dependence are at an elevated risk for suicide, yet suicide remains rare and difficult to predict. Clinical and demographic features associated with suicide risk among depressed opiate-dependent patients were examined using baseline data from the Addiction Severity Index and Hamilton Depression Scale. Female gender, violent behavior in the past thirty days and lifetime, and less education correlated with a history of suicide attempts. Family conflict and depression severity correlated with current suicidal ideation. When evaluating opiate-dependent patients with depressive disorders, these features should be considered in efforts to identify those at heightened risk for suicide and plan interventions.

Purpose: Due to its success in Radiation Oncology during the last decade, interest in proton therapy is on the rise. Unfortunately, despite the global enthusiasm in the field, there is presently no free, multiplatform and customizable Treatment Planning System (TPS) providing proton dose distributions in heterogenous medium. This restricts substantially the progress of clinical research for groups without access to a commercial Proton TPS. The latest implementation of our pencil beam dose calculation algorithm for proton beams within the 3D Slicer open-source environment fulfills all the conditions described above. Methods: The core dose calculation algorithm is based on the Hong algorithm (1), which was upgraded with the Kanematsu theory describing the evolution of the lateral scattering of proton beamlets in heterogeneous medium. This algorithm deals with both mono-energetic beams and Spread Out Bragg Peak (SOBP). In order to be user-friendly, we provide a graphical user interface implemented with the Qt libraries, and visualization with the 3D Slicer medical image analysis software. Two different pencil beam algorithms were developed, and the clinical proton beam line at our facility was modeled. Results: The dose distributions provided by our algorithms were compared to dose distributions coming from both commercialized XiO TPS and literature (dose measurements, GEANT4 and MCNPx) and turned out to be in a good agreement, with maximum dose discrepancies of 5% in homogeneous phantoms and 10% in heterogeneous phantoms. The algorithm of SOBP creation from an optimized weigthing of mono-energetic beams results in flat SOBP. Conclusion: We hope that our efforts in implementing this new, open-source proton TPS will help the research groups to have a free access to a useful, reliable proton dose calculation software.(1) L. Hong et al., A pencil beam algorithm for proton dose calculations, Phys. Med. Biol. 41 (1996) 1305–1330. This project is paid for by NCI/MGH Federal share as a research grant.

Purpose: Proton SBRT (stereotactic body radiation therapy) can be an effective modality for treatment of gastrointestinal tumors, but limited in practice due to sensitivity with respect to variation in the RPL (radiological path length). Small, intrafractional shifts in patient anatomy can lead to significant changes in the dose distribution. This study describes a tool designed to visualize uncertainties in radiological depth in patient CT's and aid in treatment plan design. Methods: This project utilizes the Shadie toolkit, a GPU-based framework that allows for real-time interactive calculations for volume visualization. Current SBRT simulation practice consists of a serial CT acquisition for the assessment of inter- and intra-fractional motion utilizing patient specific immobilization systems. Shadie was used to visualize potential uncertainties, including RPL variance and changes in gastric content. Input for this procedure consisted of two patient CT sets, contours of the desired organ, and a pre-calculated dose. In this study, we performed rigid registrations between sets of 4DCT's obtained from a patient with varying setup conditions. Custom visualizations are written by the user in Shadie, permitting one to create color-coded displays derived from a calculation along each ray. Results: Serial CT data acquired on subsequent days was analyzed for variation inmore » RPB and gastric content. Specific shaders were created to visualize clinically relevant features, including RPL (radiological path length) integrated up to organs of interest. Using pre-calculated dose distributions and utilizing segmentation masks as additional input allowed us to further refine the display output from Shadie and create tools suitable for clinical usage. Conclusion: We have demonstrated a method to visualize potential uncertainty for intrafractional proton radiotherapy. We believe this software could prove a useful tool to guide those looking to design treatment plans least insensitive to motion for patients undergoing proton SBRT in the GI tract.« less

Purpose: While 4DCT and deformable registration can be used to assess the dose delivered toregularly moving targets, there are currently few methods available for irregularly moving targets. This study describes a method for computing the dose delivered to irregularly moving targets basedon 1D or 3D waveforms captured at the time of delivery. Methods: The procedure requires 4DCT images for dose calculation, and 1D or 3D respiratorywaveforms to estimate target position at time of delivery. Dose volumes are converted from their Cartesian geometry into a beam‐specific radiological depth space, parameterized in 2D by the beamaperture, and longitudinally by the radiological depth. In this water‐equivalent depth space, the proton doses are translated according to the motion found in the 1D or 3D trajectory. These translated dose volumes are weighted and summed, then transformed back into Cartesian space,yielding an estimate of the dose that includes the effect of the measured breathing motion. Results: The method was validated using a synthetic lung CT phantom with a mobile tumor. Simulated 4DCT was generated for the phantom with 2 cm peak‐to‐peak motion. A passively‐scattered proton treatment plan was generated using a 7 mm smearing radius. The method wastested without motion, and with two simulated breathing signals: a 2 cm amplitude sinusoid, anda 2 cm amplitude sinusoid with 3 cm linear drift. Motion‐corrected dose was computed based onthe mid‐ventilation CT image. Gamma evaluation (3 mm, 3%) was 98.7% without motion, 92.9%for 2 cm sinusoidal motion, and 98.0% with 3 cm drift. Conclusion: We have demonstrated a method for accurately reproducing proton dose to anirregularly moving target from a single CT image. We believe this algorithm could prove a usefultool to study the dosimetric impact of baseline shifts either before or during treatment.