Search

Breast cancer screening has been highly successful in women in reducing mortality through early detection. In comparison, clinical detection of breast cancer remains the norm in men, and delay in diagnosis is reflected by a persistent survival disparity compared to women despite advances in modern therapy. Male breast cancer presents an interesting dilemma. While mammography is highly sensitive and specific for male breast cancer, routine screening is not justified by the overall low disease incidence. Yet there has been interest in leveraging mammography in targeted screening of men with identifiable risk factors to allow early detection, and early data may support this approach. The purpose of this article is to explore the potential utility of targeted breast cancer screening in men by examining unique clinical and biologic characteristics of male breast cancers that may lend themselves to mammographic detection. We will also discuss available evidence in screening outcomes in men and summarize recent updates in risk management recommendations in Society guidelines.

Please see the Editorial Comment by Priscilla J. Slanetz discussing this article. Background: Screening US has limited specificity but is increasingly performed given widening state and federal bre...

Breast cancer screening recommendations for transgender and gender nonconforming individuals are based on the sex assigned at birth, risk factors, and use of exogenous hormones. Insufficient evidence exists to determine whether transgender people undergoing hormone therapy have an overall lower, average, or higher risk of developing breast cancer compared to birth-sex controls. Furthermore, there are no longitudinal studies evaluating the efficacy of breast cancer screening in the transgender population. In the absence of definitive data, current evidence is based on data extrapolated from cisgender studies and a limited number of cohort studies and case reports published on the transgender community. 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.

Neoadjuvant therapy is increasingly being used to treat early-stage triple-negative and human epidermal growth factor 2-overexpressing breast cancers, as well as locally advanced and inflammatory breast cancers. The rationales for neoadjuvant therapy are to shrink tumor size and potentially decrease the extent of surgery, to serve as an in vivo test of response to therapy, and to reveal prognostic information for the patient. MRI is the most accurate modality to demonstrate response to therapy and to help ensure accurate presurgical planning. Changes in lesion diameter, volume, and enhancement are used to predict complete response, partial response, or nonresponse to therapy. However, residual disease may be overestimated or underestimated at MRI. Fibrosis, necrotic tumors, and residual benign masses may be causes of overestimation of residual disease. Nonmass lesions, invasive lobular carcinoma, hormone receptor-positive tumors, nonconcentric shrinkage patterns, the use of antiangiogenic therapy, and late-enhancing foci may be causes of underestimation of residual disease. In patients with known axillary lymph node metastasis, neoadjuvant therapy may be followed by targeted axillary dissection to avoid the potential morbidity associated with an axillary lymph node dissection. Diffusion-weighted imaging, radiomics, machine learning, and deep learning methods are under investigation to improve MRI accuracy in predicting treatment response.©RSNA, 2021.

Ductal carcinoma in situ (DCIS), breast cancer confined to the milk ducts, is a heterogeneous entity. The question of how and when a case of DCIS will extend beyond the ducts to become invasive breast cancer has implications for both patient prognosis and optimal treatment approaches. The natural history of DCIS has been explored through a variety of methods, from mouse models to biopsy specimen reviews to population-based screening data to modeling studies. This article will review the available evidence regarding progression pathways and will also summarize current trials designed to assess DCIS progression.

Magnetic Resonance (MR) imaging is the most sensitive modality for breast cancer detection but is currently limited to screening women at high risk due to limited specificity and test accessibility. However, specificity of MR imaging improves with successive rounds of screening, and abbreviated approaches have the potential to increase access and decrease cost. There is growing evidence to support supplemental MR imaging in moderate-risk women, and current guidelines continue to evolve. Functional imaging has the potential to maximize survival benefit of screening. Leveraging MR imaging as a possible primary screening tool is therefore also being investigated in average-risk women.

Transgender is the umbrella term for individuals whose gender identity and/or gender expression differs from their assigned sex at birth. With the rise in patients undergoing gender-affirming hormone therapy and gender-affirming surgery, it is increasingly important for radiologists to be aware of breast imaging considerations for this population. While diagnostic imaging protocols for transgender individuals are generally similar to those for cisgender women, screening guidelines are more variable. Currently, several professional and institutional guidelines have been created to address breast cancer screening in the transgender population, specifically screening mammography in transfeminine individuals who undergo hormone therapy. This article defines appropriate terminology with respect to the transgender population, reviews evidence for breast cancer risk and screening in transgender individuals, considers diagnostic breast imaging approaches, and discusses special considerations and challenges with regard to health care access and public education for these individuals. ©RSNA, 2019.

The incidence of breast cancer in younger women is rising. Although early-onset breast cancer is highly associated with biologically aggressive tumors such as triple-negative and human epidermal growth factor 2 (HER2)-positive cancers, the more recent increase is disproportionately driven by an increase in the incidence of luminal cancer. In particular, the increase in de novo stage IV disease and the inherent age-based poorer survival rate among younger women with even early-stage luminal cancers suggest underlying distinct biologic characteristics that are not well understood. Further contributing to the higher number of early-onset breast cancers is pregnancy-associated breast cancer (PABC), which is attributed to persistent increases in maternal age over time. Although guidelines for screening of patients who carry a

Contrast-enhanced breast MRI is a standard evidence-based component of supplemental screening in conjunction with mammography for higher-risk populations because of its high sensitivity for detecting breast cancer; the use of breast MRI for screening in high-risk populations is recommended in multiple national and international guidelines. The current MRI exam, however, is expensive relative to other screening technologies such as mammography, and relatively more time-intensive. Recent investigations have focused on techniques that have the potential for improving efficiency of the breast MRI exam, decreasing acquisition and reading times, without impacting diagnostic accuracy. The purpose of this article is therefore to provide an overview of current MRI guidelines for screening for breast cancer and to discuss evolving technological approaches to breast MRI, in particular abbreviated and ultrafast MRI protocols, as well as MRI protocols without contrast that have the potential to improve MRI screening. Level of Evidence: 5 Technical Efficacy Stage: 2 J. Magn. Reson. Imaging 2019;49:1212-1221.

Digital breast tomosynthesis (DBT) has been widely adopted in breast imaging in both screening and diagnostic settings. The benefits of DBT are well established. Compared with two-dimensional digital mammography (DM), DBT preferentially increases detection of invasive cancers without increased detection of in-situ cancers, maximizing identification of biologically significant disease, while mitigating overdiagnosis. The higher sensitivity of DBT for architectural distortion allows increased diagnosis of invasive cancers overall and particularly improves the visibility of invasive lobular cancers. Implementation of DBT has decreased the number of recalls for false-positive findings at screening, contributing to improved specificity at diagnostic evaluation. Integration of DBT in diagnostic examinations has also resulted in an increased percentage of biopsies with positive results, improving diagnostic confidence. Although individual DBT examinations have a longer interpretation time compared with that for DM, DBT has streamlined the diagnostic workflow and minimized the need for short-term follow-up examinations, redistributing much-needed time resources to screening. Yet DBT has limitations. Although improvements in cancer detection and recall rates are seen for patients in a large spectrum of age groups and breast density categories, these benefits are minimal in women with extremely dense breast tissue, and the extent of these benefits may vary by practice environment and by geographic location. Although DBT allows detection of more invasive cancers than does DM, its incremental yield is lower than that of US and MRI. Current understanding of the biologic profile of DBT-detected cancers is limited. Whether DBT improves breast cancer-specific mortality remains a key question that requires further investigation. ©RSNA, 2021.

Pathologic nipple discharge (PND) is typically unilateral, spontaneous, involves a single duct, and is serous or bloody in appearance. In patients with PND, breast MRI can be helpful as an additional diagnostic tool when conventional imaging with mammogram and ultrasound are negative. MRI is able to detect the etiology of nipple discharge in 56–61% of cases when initial imaging with mammogram and ultrasound are negative. Advantages to using MRI in evaluation of PND include good visualization of the retroareolar breast and better evaluation of posterior lesions which may not be well evaluated on mammograms and galactograms. It is also less invasive compared to central duct excision. Papillomas and nipple adenomas are benign breast masses that can cause PND and are well visualized on MRI. Ductal ectasia, and infectious etiologies such as mastitis, abscess, and fistulas are additional benign causes of PND that are well evaluated with MRI. MRI is also excellent for evaluation of malignant causes of PND including Paget’s disease, ductal carcinoma in-situ and invasive carcinoma. MRI’s high negative predictive value of 87–98.2% is helpful in excluding malignant etiologies of PND.

This study aimed to evaluate the effect of an artificial intelligence (AI) support system on breast ultrasound diagnostic accuracy.In this Health Insurance Portability and Accountability Act-compliant, institutional review board-approved retrospective study, 200 lesions (155 benign, 45 malignant) were randomly selected from consecutive ultrasound-guided biopsies (June 2017-January 2019). Two readers, blinded to clinical history and pathology, evaluated lesions with and without an Food and Drug Administration-approved AI software. Lesion features, Breast Imaging Reporting and Data System (BI-RADS) rating (1-5), reader confidence level (1-5), and AI BI-RADS equivalent (1-5) were recorded. Statistical analysis was performed for diagnostic accuracy, negative predictive value, positive predictive value (PPV), sensitivity, and specificity of reader versus AI BI-RADS. Generalized estimating equation analysis was used for reader versus AI accuracy regarding lesion features and AI impact on low-confidence score lesions. Artificial intelligence effect on false-positive biopsy rate was determined. Statistical tests were conducted at a 2-sided 5% significance level.There was no significant difference in accuracy (73 vs 69.8%), negative predictive value (100% vs 98.5%), PPV (45.5 vs 42.4%), sensitivity (100% vs 96.7%), and specificity (65.2 vs 61.9; P = 0.118-0.409) for AI versus pooled reader assessment. Artificial intelligence was more accurate than readers for irregular shape (74.1% vs 57.4%, P = 0.002) and less accurate for round shape (26.5% vs 50.0%, P = 0.049). Artificial intelligence improved diagnostic accuracy for reader-rated low-confidence lesions with increased PPV (24.7% AI vs 19.3%, P = 0.004) and specificity (57.8% vs 44.6%, P = 0.008).Artificial intelligence decision support aid may help improve sonographic diagnostic accuracy, particularly in cases with low reader confidence, thereby decreasing false-positives.

Mastectomy may be performed to treat breast cancer or as a prophylactic approach in women with a high risk of developing breast cancer. In addition, mastectomies may be performed with or without reconstruction. Reconstruction approaches differ and may be autologous, involving a transfer of tissue (skin, subcutaneous fat, and muscle) from other parts of the body to the chest wall. Reconstruction may also involve implants. Implant reconstruction may occur as a single procedure or as multistep procedures with initial use of an adjustable tissue expander allowing the mastectomy tissues to be stretched without compromising blood supply. Ultimately, a full-volume implant will be placed. Reconstructions with a combination of autologous and implant reconstruction may also be performed. Other techniques such as autologous fat grafting may be used to refine both implant and flap-based reconstruction. This review of imaging in the setting of mastectomy with or without reconstruction summarizes the literature and makes recommendations based on available evidence. 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.

We present an analysis of how children between 4-and 9-years-old give directions to a robot. Thirty-eight children in this age range participated in a direction giving game with a virtual robot and with their caregiver. We considered two different viewpoints (aerial and in-person) and three different affordances (non-humanoid robot, caregiver with eyes closed, and caregiver with eyes open). We report on the frequency of commands that children used, the complexity of the commands, and the navigation styles children used at different ages. We found that pointing and gesturing decreased with age, while “left-right” directions and the use of distances increased with age. From this, we make several recommendations for robot design that would enable a robot to successfully follow directions from children of different ages, and help advance children's direction giving.

Abbreviated and ultrafast breast MRI are emerging techniques that are now entering clinical practice and reflect an increasing understanding of breast cancer heterogeneity. These techniques may represent potential answers to shortcomings of mammographic screening, providing an opportunity to curb interval cancers, maximize diagnostic accuracy, and minimize overdiagnosis. Targeting more aggressive tumor subtypes may play a role in evidence-based de-escalation of breast cancer management, and abbreviated techniques have proved promising in early noninferiority studies. Functional characterization of tumors at MRI also has the potential for noninvasive tumor subtyping based on radiomics and radiogenomics and may ultimately streamline increasingly individualized breast cancer care. The purpose of this article is to describe techniques of abbreviated and ultrafast breast MRI, recognize their pros and cons, and discuss clinical applications and implications. The goals are to define terminology, consider diagnostic parameters, and emphasize key concepts. As these novel techniques enter clinical care and continue to evolve, it is essential that the radiologist understands the rationale and limitations behind these approaches and how and why interpretation may differ from that of conventional MRI. ©RSNA, 2020.

Purpose Emerging data suggest screening mammography may be effective in detecting breast cancer early in high risk men. The purpose of this study is to evaluate current screening recommendations as a risk management strategy in men at elevated risk for breast cancer. Materials and Methods This IRB-approved HIPAA-compliant study reviewed consecutive men who underwent genetic counseling and MGPT for breast cancer risk assessment at our institution between 2012-2018. Patient risk factors, test indications, MGPT outcomes were recorded, and correlated with screening recommendations using either clinical breast exam (CBE) or screening mammography. Recommendation consistency among practitioners was evaluated. Patient adherence to screening mammography (defined as undergoing screening mammography as recommended) was assessed. Statistical analysis was performed at the two-sided 5% significance level. Results A total of 414 asymptomatic men underwent both genetic counseling and MGPT (mean age 47; range, 18-91) for breast cancer risk assessment. Of this group, 18 (4.3%; 18/414) had a personal history of breast cancer, and 159 (38.4%; 159/414) had family history of breast cancer prior to MGPT. Among men with positive MGPT results (n=112), BRCA1/2 mutations were the most common (56.3%; 63/112). Most BRCA mutation carriers (80.9%, 51/63) were recommended CBE only. Only 5.9% (2/34) BRCA2 and 10.3% (3/29) BRCA1 carriers were recommended screening mammograms (5/63; 7.9% of all BRCA carriers). Among men with personal history of breast cancer, only 9/18 (50%) were recommended screening mammograms. Overall adherence to screening mammogram in men was 71.4% (10/14), which ultimately yielded two cancers. Breast cancer screening recommendations varied widely among practitioners, with some recommending CBE only, and others recommending also mammography. Conclusion Men determined to be at elevated risk for breast cancer following genetic counseling and testing currently receive relatively inconsistent screening recommendations. Clinical relevance Male breast cancer incidence is increasing. Although there is evidence that screening mammography may be effective in early breast cancer detection in high risk men, it is currently inconsistently prescribed.

Breast imaging during pregnancy and lactation is challenging due to unique physiologic and structural breast changes that increase the difficulty of clinical and radiological evaluation. Pregnancy-associated breast cancer (PABC) is increasing as more women delay child bearing into the fourth decade of life, and imaging of clinical symptoms should not be delayed. PABC may present as a palpable lump, nipple discharge, diffuse breast enlargement, focal pain, or milk rejection. Breast imaging during lactation is very similar to breast imaging in women who are not breast feeding. However, breast imaging during pregnancy is modified to balance both maternal and fetal well-being; and there is a limited role for advanced breast imaging techniques in pregnant women. Mammography is safe during pregnancy and breast cancer screening should be tailored to patient age and breast cancer risk. Diagnostic breast imaging during pregnancy should be obtained to evaluate clinical symptoms and for loco-regional staging of newly diagnosed PABC. 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.

PURPOSE: To retrospectively assess whether there is an association between screening mammography and the use of a variety of preventive services in women who are enrolled in Medicare. MATERIALS AND METHODS: U.S. Medicare claims from 2010 to 2014 Research Identifiable Files were reviewed to retrospectively identify a group of women who underwent screening mammography and a control group without screening mammography in 2012. The screened group was divided into positive versus negative results at screening, and the positive subgroup was divided into false-positive and true-positive findings. Multivariate logistic regression models and inverse probability of treatment weighting were used to examine the relationship between screening status and the probabilities of undergoing Papanicolaou test, bone mass measurement, or influenza vaccination in the following 2 years. RESULTS: The cohort consisted of 555 705 patients, of whom 185 625 (33.4%) underwent mammography. After adjusting for patient demographics, comorbidities, geographic covariates, and baseline preventive care, women who underwent index screening mammography (with either positive or negative results) were more likely than unscreened women to later undergo Papanicolaou test (odds ratio [OR], 1.49; 95% confidence interval: 1.40, 1.58), bone mass measurement (OR, 1.70; 95% confidence interval: 1.63, 1.78), and influenza vaccine (OR, 1.45; 95% confidence interval: 1.37, 1.53). In women who had not undergone these preventive measures in the 2 years before screening mammography, use of these three services after false-positive findings at screening was no different than after true-negative findings at screening. CONCLUSION: In beneficiaries of U.S. Medicare, use of screening mammography was associated with higher likelihood of adherence to other preventive guidelines, without a negative association between false-positive results and cervical cancer screening. © RSNA, 2018 Online supplemental material is available for this article.

Rationale and Objective The objective of this study was to evaluate breast lesion outcomes in patients after canceled MRI-guided breast biopsy due to lesion nonvisualization. Materials and Methods Electronic medical records (January 2007–December 2014) were searched for patients with canceled magnetic resonance imaging (MRI)-guided breast biopsies due to lesion nonvisualization. A total of 1403 MRI-detected lesions were scheduled for MRI-guided biopsy and 89 were canceled because of nonvisualization. Imaging studies and medical records were reviewed for patient demographics, lesion characteristics, and subsequent malignancy. Patients without adequate MRI follow-up imaging were excluded. Statistical analysis was employed to determine if patient demographics or lesion characteristics were predictive of lesion resolution or lesion biopsy after subsequent follow-up. Results Eighty-nine (6.3% [89/1403]; 95% confidence interval, 5.2%–7.7%) biopsies in 89 women were canceled because of nonvisualization. Follow-up MRIs greater than 5.5 months were available for 60.7% (54/89) of women. In 74.1% (40/54) of these patients, the lesions completely resolved on follow-up. In 25.9% (14/54) of the patients, the lesion persisted on follow-up; 42.9% (6/14) of these patients underwent biopsy. One case (1.9% [1/54]) yielded ductal carcinoma in situ with microinvasion at the 6-month follow-up. No patient demographics or lesion features were associated with lesion resolution or lesion biopsy. Conclusions The majority of canceled MRI-guided biopsy lesions resolved on later follow-up; however, because of the small possibility of a missed malignancy, follow-up MRI imaging at 6 months is recommended.

The purpose of this study was to investigate county-level geographic patterns of mammographic screening uptake throughout the United States and to determine the impact of rural versus urban settings on breast cancer screening uptake.This descriptive study used County Health Rankings data to identify the percentage of Medicare enrollees 67-69 years old per county who had at least one mammogram in 2013 or 2012 (uptake). Uptake was matched with U.S. Department of Agriculture Atlas of Rural and Small Town America categorizations along a rural-urban continuum scale from 1 to 9 based on county population size (large urban, population ≥ 20,000 people; small urban,20,000 people) and proximity to a metropolitan area. Univariable and multivariable analyses were performed.In all, 2,243,294 Medicare beneficiaries were eligible for mammograms. National mean uptake per county was 60.5% (range, 26.0-86.0%). Uptake was significantly higher in metropolitan and large urban counties in 25 states and lower in only one. County-level mammographic uptake was moderately positively correlated with percentage of residents with some college education (r = 0.40, p0.001) and moderately negatively correlated with age-adjusted mortality (r = -0.41, p0.001). Multivariable analysis showed that percentage of white and black residents and age-adjusted mortality rate were the strongest significant independent predictors of uptake.Uptake of mammographic screening services in a Medicare population varies widely at the county level and is generally lowest in rural counties and urban counties with fewer than 20,000 people.

In detection, treatment, and follow-up, male breast cancer has historically lagged behind female breast cancer. On the whole, breast cancer is less common among men than among women, limiting utility of screening, yet the incidence of male breast cancer is rising, and there are men at high risk for breast cancer. While women at high risk for breast cancer are well characterized, with clearly established guidelines for screening, supplemental screening, risk prevention, counseling, and advocacy, men at high risk for breast cancer are poorly identified and represent a blind spot in public health. Today, more standardized genetic counseling and wider availability of genetic testing are allowing identification of high-risk male relatives of women with breast cancer, as well as men with genetic mutations predisposing to breast cancer. This could provide a new opportunity to update our approach to male breast cancer. This article reviews male breast cancer demographics, risk factors, tumor biology, and oncogenetics; recognizes how male breast cancer differs from its female counterpart; highlights its diagnostic challenges; discusses the implications of the widening clinical use of multigene panel testing; outlines current National Comprehensive Cancer Network guidelines (version 1, 2018) for high-risk men; and explores the possible utility of targeted screening and surveillance. Understanding the current state of male breast cancer management and its challenges is important to shape future considerations for care. Shifting the paradigm of male breast cancer detection toward targeted precision medicine may be the answer to improving clinical outcomes of this uncommon disease.

Breast density, fibroglandular tissue, and background parenchymal enhancement (BPE) are recognized independent biomarkers for breast cancer risk. For this reason, reproducibility and consistency in objective assessment of these parameters at mammography (breast density) and at magnetic resonance imaging (fibroglandular tissue and BPE) are clinically relevant. However, breast density, fibroglandular tissue, and BPE are manifestations of dynamic physiologic processes and may change in response to both endogenous and exogenous hormonal stimulation. It is therefore important for the radiologist to recognize settings in which hormonal stimulation may alter the appearance of these biomarkers at imaging and to appreciate how such changes may affect risk assessment, cancer detection, and even prognosis. The purpose of this review article is therefore to review key features and means of evaluating breast density, fibroglandular tissue, and BPE at imaging; to detail how endogenous and exogenous hormonal stimuli may affect breast density, fibroglandular tissue, and BPE, potentially affecting radiologic interpretation; and, finally, to provide an update regarding current hormone treatment guidelines and indications that may result in imaging changes through hormone modulation. ©RSNA, 2018.

To assess patterns of parenchymal tissue on mammography in women with dense breasts and to determine how this varies with age and affects recall to assessment and cancer diagnosis. Breast density data was obtained in women attending routine mammographic screening from April 2013 to March 2015 using automated breast density assessment software. Women with the densest breasts were selected for visual interpretation of parenchymal pattern (PP). One hundred non-assessed women, aged 50, 55, 60, 65 and 69-71 years (total = 500), provided controls. Cases included women recalled for assessment (mastectomy or implants excluded) (total = 280). Mammograms reviewed by ten readers and PP classified as: (1) very smooth; (2) mainly smooth; (3) mixed; (4) mainly nodular; (5) very nodular. The ratio of women in each category at each age and screening outcomes were compared by Pearson’s chi-squared test. Reader agreement for scoring PP was good (intraclass correlation = 0.6302). Proportions of women in each PP category were similar at all ages for controls (p = 0.147) and cases (p = 0.657). The ratio of PP categories did not vary significantly with age in those who underwent biopsy (p = 0.484). Thirty-four cancers were diagnosed. There was a significant correlation between a diagnosis of cancer and nodular PP compared to not nodular PP (p = 0.043). The ratio of smooth to nodular pattern in women with the densest breasts did not vary with age. The PP of the breast tissue did not affect likelihood of recall to assessment or biopsy. There was a significant relationship between a nodular parenchymal pattern and diagnosis of cancer. • This paper shows that there is good agreement between mammogram readers when classifying mammographic PP on a five-point scale from very smooth to very nodular. • In non-assessed women with the densest breasts, there is no significant change in the proportions of smooth to nodular patterns with increasing age. • The likelihood of recall for further assessment or biopsy at assessment is not related to PP in women with highest breast density. • When recalled for further assessment, significantly more women are diagnosed with cancer in the group with nodular PP on mammography when compared with smooth and mixed patterns.

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.

This article reviews new developments in breast imaging. There is growing interest in creating a shorter, less expensive MR protocol with broader applicability. There is an increasing focus on and consideration for the additive impact that functional analysis of breast pathology have on identifying and characterizing lesions. These developments apply to MR imaging and molecular imaging. This article reviews evolving breast imaging techniques with attention to strengths, weaknesses, and applications of these approaches. We aim to give the reader familiarity with the state of current developments in the field and to increase awareness of what to expect in breast imaging.

BACKGROUND Screening breast MRI has been shown to preferentially detect high-grade ductal carcinoma in situ (DCIS) and invasive carcinoma, likely due to increased angiogenesis resulting in early initial uptake of contrast. As interest grows in abbreviated screening breast MRI (AB-MRI), markers of early contrast washin that can predict tumor grade and potential aggressiveness are of clinical interest. PURPOSE To evaluate the feasibility of using the initial enhancement ratio (IER) as a surrogate marker for tumor grade, hormone receptor status, and prognostic markers, as an initial step to being incorporated into AB-MRI. STUDY TYPE Retrospective. SUBJECTS In all, 162 women (mean 55.0 years, range 32.8-87.7 years) with 187 malignancies imaged January 2012-November 2015. FIELD STRENGTH/SEQUENCE Images were acquired at 3.0T with a T1 -weighted gradient echo fat-suppressed-volume interpolated breath-hold sequence. ASSESSMENT Subjects underwent dynamic contrast-enhanced breast MRI with a 7-channel breast coil. IER (% signal increase over baseline at the first postcontrast acquisition) was assessed and correlated with background parenchymal enhancement, washout curves, stage, and final pathology. STATISTICAL TESTS Chi-square test, Spearman rank correlation, Mann-Whitney U-tests, Bland-Altman analysis, and receiver operating characteristic curve analysis. RESULTS IER was higher for invasive cancer than for DCIS (R1/R2, P < 0.001). IER increased with tumor grade (R1: r = 0.56, P < 0.001, R2: r = 0.50, P < 0.001), as ki-67 increased (R1: r = 0.35, P < 0.001; R2 r = 0.35, P < 0.001), and for node-positive disease (R1/R2, P = 0.001). IER was higher for human epidermal growth factor receptor two-positive and triple negative cancers than for estrogen receptor-positive / progesterone receptor-positive tumors (R1 P < 0.001-0.002; R2 P = 0.0.001-0.011). IER had higher sensitivity (80.6% vs. 75.5%) and specificity (55.8% vs. 48.1%) than washout curves for positive nodes, higher specificity (48.1% vs. 36.5%) and positive predictive value (70.2% vs. 66.7%) for high ki-67, and excellent interobserver agreement (intraclass correlation coefficient = 0.82). DATA CONCLUSION IER, a measurement of early contrast washin, is associated with higher-grade malignancies and tumor aggressiveness and might be potentially incorporated into an AB-MRI protocol. LEVEL OF EVIDENCE 3 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2018;47:1692-1700.

Patients with locally advanced invasive breast cancers are often treated with neoadjuvant chemotherapy prior to definitive surgical intervention. The primary aims of this approach are to: 1) reduce tumor burden thereby permitting breast conservation rather than mastectomy; 2) promptly treat possible metastatic disease, whether or not it is detectable on preoperative staging; and 3) potentially tailor future chemotherapeutic decisions by monitoring in-vivo tumor response. Accurate radiological assessment permits optimal management and planning in this population. However, assessment of tumor size and response to treatment can vary depending on the modality used, the measurement technique (such as single longest diameter, 3-D measurements, or calculated tumor volume), and varied response of different tumor subtypes to neoadjuvant chemotherapy (such as concentric shrinkage or tumor fragmentation). As discussed in further detail, digital mammography, digital breast tomosynthesis, US and MRI represent the key modalities with potential to help guide patient management. 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.

OBJECTIVES The aim of this study was to assess the applicability of Dixon radial volumetric encoding (Dixon-RAVE) for comprehensive dynamic contrast-enhanced 3D magnetic resonance imaging (MRI) of the breast using a combination of radial sampling, model-based fat/water separation, compressed sensing, and parallel imaging. MATERIALS AND METHODS In this Health Insurance Portability and Accountability Act-compliant prospective study, 24 consecutive patients underwent bilateral breast MRI, including both conventional fat-suppressed and non-fat-suppressed precontrast T1-weighted volumetric interpolated breath-hold examination (VIBE). Afterward, 1 continuous Dixon-RAVE scan was performed with the proposed approach while the contrast agent was injected. This scan was immediately followed by the acquisition of 4 conventional fat-saturated VIBE scans. From the comprehensive Dixon-RAVE data set, different image contrasts were reconstructed that are comparable to the separate conventional VIBE scans.Two radiologists independently rated image quality, conspicuity of fibroglandular tissue from fat (FG), and degree of fat suppression (FS) on a 5-point Likert-type scale for the following 3 comparisons: precontrast fat-suppressed (pre-FS), precontrast non-fat-suppressed (pre-NFS), and dynamic fat-suppressed (dyn-FS) images. RESULTS When scores were averaged over readers, Dixon-RAVE achieved significantly higher (P < 0.001) degree of fat suppression compared with VIBE, for both pre-FS (4.25 vs 3.67) and dyn-FS (4.10 vs 3.46) images. Although Dixon-RAVE had lower image quality score compared with VIBE for the pre-FS (3.56 vs 3.67, P = 0.490), the pre-NFS (3.54 vs 3.88, P = 0.009), and the dyn-FS images (3.06 vs 3.67, P < 0.001), acceptable or better diagnostic quality was achieved (score ≥ 3). The FG score for Dixon-RAVE in comparison to VIBE was significantly higher for the pre-FS image (4.23 vs 3.85, P = 0.044), lower for the pre-NFS image (3.98 vs 4.25, P = 0.054), and higher for the dynamic fat-suppressed image (3.90 vs 3.85, P = 0.845). CONCLUSIONS Dixon-RAVE can serve as a one-stop-shop approach for comprehensive T1-weighted breast MRI with diagnostic image quality, high spatiotemporal resolution, reduced overall scan time, and improved fat suppression compared with conventional imaging.

Rationale and Objectives To evaluate uptake, patterns of use, and perception of digital breast tomosynthesis (DBT) among practicing breast radiologists. Materials and Methods Institutional Review Board exemption was obtained for this Health Insurance Portability and Accountability Act-compliant electronic survey, sent to 7023 breast radiologists identified via the Radiological Society of North America database. Respondents were asked of their geographic location and practice type. DBT users reported length of use, selection criteria, interpretive sequences, recall rate, and reading time. Radiologist satisfaction with DBT as a diagnostic tool was assessed (1–5 scale). Results There were 1156 (16.5%) responders, 65.8% from the United States and 34.2% from abroad. Of these, 749 (68.6%) use DBT; 22.6% in academia, 56.5% private, and 21% other. Participants are equally likely to report use of DBT if they worked in academics versus in private practice (78.2% [169 of 216] vs 71% [423 of 596]) (odds ratio, 1.10; 95% confidence interval: 0.87–1.40; P = 1.000). Of nonusers, 43% (147 of 343) plan to adopt DBT. No US regional differences in uptake were observed (P = 1.000). Although 59.3% (416 of 702) of DBT users include synthetic 2D (s2D) for interpretation, only 24.2% (170 of 702) use s2D alone. Majority (66%; 441 of 672) do not perform DBT-guided procedures. Radiologist (76.6%) (544 of 710) satisfaction with DBT as a diagnostic tool is high (score ≥ 4/5). Conclusions DBT is being adopted worldwide across all practice types, yet variations in examination indication, patient selection, utilization of s2D images, and access to DBT-guided procedures persist, highlighting the need for consensus and standardization.

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.

OBJECTIVES This study was performed to determine the frequency, predictors, and outcomes of ultrasound (US) correlates for non-mass enhancement. METHODS From January 2005 to December 2011, a retrospective review of 5837 consecutive breast magnetic resonance imaging examinations at our institution identified 918 non-mass enhancing lesions for which follow-up or biopsy was recommended. Retrospective review of the images identified 879 of 918 lesions (96%) meeting criteria for non-mass enhancement. Patient demographics, pathologic results, and the presence of an adjacent landmark were recorded. Targeted US examinations were recommended for 331 of 879 cases (38%), and 284 of 331 women (86%) underwent US evaluations. RESULTS The US correlate rate for non-mass enhancement was 23% (64 of 284). An adjacent landmark was significantly associated with a US correlate (P

The purpose of this study was to determine the rate, characteristics, and outcomes of discordant MRI-guided vacuum-assisted biopsy (VAB) in women with suspected breast cancer.This retrospective study reviewed 1314 MRI-guided VABs performed in 1211 women between 2007 and 2013 and yielded 25 discordant results in 24 women. MRI characteristics; BI-RADS assessments; whether the lesion was missed, partially sampled, or excised at biopsy; and biopsy and surgical pathology results were reviewed. Statistical analyses were performed using Fisher exact and Mann-Whitney U tests.Among 1314 lesions that underwent MRI-guided VAB, 25 results were discordant (1.9%; 95% CI, 1.2-2.8%), and nine lesions with discordant results (36.0%, 95% CI, 18.5-56.9%) were malignant at surgical excision (three invasive ductal carcinoma and six ductal carcinoma in situ). There was no significant association between malignancy and lesion type, size, enhancement pattern, BI-RADS assessment, or clinical indication. Forty-four percent (11/25) of discordant lesions were missed, 48.0% (12/25) were partially sampled, and 8.0% (2/25) appeared to have been excised. Of the nine malignant lesions, 44.4% (4/9) discordant malignant lesions were missed, 44.4% (4/9) were partially sampled, and 11.1% (1/9) appeared to have been excised. Lesion sizes and types were similar in the missed and partially excised groups.The potential for false-negative results at MRI-guided VAB underscores the importance of radiologic-histologic correlation and imaging review after biopsy. Rebiopsy or excision in discordant cases is therefore recommended.

Background Male breast cancer incidence is rising. There may be a potential role in selective screening in men at elevated risk for breast cancer, but the effectiveness of such screening remains unexplored. Purpose To evaluate patterns of male breast imaging utilization, to determine high-risk screening outcomes, and to delineate risk factors associated with cancer diagnosis. Materials and Methods This retrospective study reviewed consecutive male breast imaging examinations over a 12-year period (between 2005-2017). Examination indications, biopsy recommendations, and pathologic results were correlated with patient characteristics. Fisher exact test, Mann-Whitney test, Spearman correlation, and logistic regression were used for statistical analysis. Results A total of 1869 men (median age, 55 years; range, 18-96 years) underwent 2052 examinations yielding 2304 breast lesions and resulting in 149 (6.5%) biopsies in 133 men; 41 (27.5%) were malignant and 108 (72.5%) were benign. There were 1781 (86.8%) diagnostic and 271 (13.2%) screening examinations. All men undergoing screening had personal or family history of breast cancer and/or genetic mutations. There was a significant increase in the number of examinations in men relative to the number of examinations in women over time (Spearman correlation

Background Although previous studies have focused on rural disparities in the use of screening mammography, city-level use throughout the United States has not been well evaluated even though more than 30 million women live in the 500 largest cities. Purpose To evaluate disparities in the city-level use of screening mammography and to identify factors that have an impact on screening utilization. Materials and Methods This retrospective study used data from large publicly available databases, the American Community Survey and Robert Wood Johnson Foundation 500 Cities Project, which includes screening mammography utilization data from the Behavioral Risk Factor Surveillance System. Databases were searched from January to March 2018. The use of screening mammography was evaluated at the city level by census region and division by using the Mann-Whitney

The purpose of this study was to assess the rate, type, and severity of complications related to 9-gauge stereotactic vacuum-assisted breast biopsy (SVAB) and to delineate associated factors that may contribute to a higher rate of complications.This retrospective study included 4776 patients who underwent SVAB between 2003 and 2016. A total of 319 patients with documented postbiopsy complications were identified. Complications were subcategorized as bleeding, pain, lightheadedness, bruising, and other complications, and their severity was classified as minor, moderate, or severe. Hematoma volumes were correlated with biopsy location and complication severity. A group of control subjects who underwent SVAB but had no complications was compared with the group of study patients with regard to age, biopsy location, lesion type, and pathologic findings. Postbiopsy screening adherence was assessed. Statistical analyses were performed using the Fisher exact, Mann-Whitney, Kruskal-Wallis, and Spearman rank correlation tests.Of the 319 patients with complications who were identified (representing 6.7% of the 4776 patients who underwent SVAB), 307 (96.2%) had mild complications, 12 (3.8%) had moderate complications, and no patients had severe complications. The most common complication was bleeding or hematoma (89.3% of patients [285/319]), followed by pain (6.9% [22/319]), lightheadedness (0.9% [3/319]), bruising (0.9% [3/319]), and other complications (1.9% [6/319]). No significant differences were noted between the study group and the control group in terms of age (p = 0.474), biopsy location (p = 0.065), histologic findings (p = 0.056), or lesion type (p = 0.568). Hematoma volume (median, 7.5 cmClinically significant complications associated with SVAB were exceedingly rare (0.3%) in this large study spanning 13 years.

Breast MRI is the most sensitive imaging modality for assessment of the nipple-areola complex (NAC), which is important both in cancer staging and in high-risk screening. However, the normal appearance of the nipple at MRI is not well defined because of a paucity of scientific literature on this topic. Hence, there is a lack of descriptive terminology and diagnostic criteria, which may account for the wide variability in interpretation among radiologists when assessing the NAC on MR images. In light of the current shift toward possible expanded use of abbreviated (ie, fast) breast MRI for screening in women at average risk for cancer in particular, and because an increasing number of women now undergo nipple-sparing mastectomy for therapeutic and/or prophylactic indications, careful assessment of the NAC at MRI is essential. In this article, the normal pattern of nipple enhancement at MRI is defined on the basis of findings observed in healthy individuals, normal nipple enhancement at MRI is correlated with the structural anatomy of the nipple at histopathologic analysis, and artifacts and pitfalls related to MRI of the NAC are reviewed. Understanding the normal range of nipple morphology and enhancement at MRI is important, as it enables radiologists to better differentiate between normal and abnormal nipple findings with increased diagnostic confidence. ©RSNA, 2018 See discussion on this article by Cohen and Holbrook .