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Objective Assess the impact of COVID-19 on patient-breast radiologist interactions and evaluate the relationship between safety measure–constrained communication and physician wellbeing. Methods A 41-question survey on the perceived effect of COVID-19 on patient care was distributed from June 2020 to September 2020 to members of the Society of Breast Imaging and the National Consortium of Breast Centers. Non-radiologists and international members were excluded. Anxiety and psychological distress scores were calculated. A multivariable logistic model was used to identify demographic and mental health factors associated with responses. Results Five hundred twenty-five surveys met inclusion criteria (23% response rate). Diminished ability to fulfill patients’ emotional needs was reported by 46% (221/479), a response associated with younger age (OR, 0.8 per decade; P Conclusion The majority of breast radiologists reported that COVID-19 has had a negative impact on patient care. This perception was more likely among younger radiologists and those with higher levels of anxiety and psychological distress.

Objective Second-opinion interpretations of outside facility breast imaging provide value-added care but are operationally challenging for breast radiologists. Our objective was to survey members of the Society of Breast Imaging (SBI) to assess practice patterns and perceived barriers to performing outside study interpretations (OSIs). Methods An anonymous survey was developed by the Patient Care and Delivery Committee of the SBI and distributed via e-mail to SBI radiologist members. Survey questions included practice demographics and OSI volumes, billing practices, clinical scenarios, and imaging modalities, logistics, and barriers. Responses were aggregated and comparisons were made by univariate analysis using likelihood ratio tests, t-tests, and Spearman’s rank correlation tests as appropriate. Ordinal or nominal logistic modeling and linear regression modeling was also performed. Results There were 371 responses (response rate of 13%). Most respondents practice at an affiliated specialty breast care center (306/371, 83%) and said their practice performed OSIs (256/371, 69%). Academic practices reported the highest OSI volumes (median 75 per month) and were most likely to indicate increases in OSI volumes over time (100/144, 69%). The most common indication for OSI was second opinion for a biopsy recommendation (245/256, 96%). Most practices provide a final BI-RADS assessment (183/261, 70%). The most cited barrier to performing OSIs was physician time constraints (252/369, 68%). Conclusion Breast imaging OSI practice patterns are variable among SBI members with notable differences by practice setting and multiple barriers identified. More unified guidelines and recommendations may be needed for radiologists to better perform this valuable task.

Background. Mammographic features on digital breast tomosynthesis (DBT) have not yet been incorporated in any breast cancer risk model. In breast cancer screening, a large proportion of cancers is not detected in screening but develop in between two screening cycles or are missed and detected at later stages. We developed a risk model that identifies women who, after presenting with a negative DBT, are likely to be diagnosed with breast cancer before or at the next screening. Materials and Methods. The study was based on women of multi-ethnic origin attending screening using DBT at four U.S. screening sites in 2014-2019. In a nested case-control study subset, women were followed from last negative DBT through next scheduled screening visit one year later. Breast cancer status was collected from retrospective medical records. An image-based risk model was developed using iCAD artificial intelligence mammographic features (density, masses, microcalcifications), left-right breast differences, and age. Age-adjusted relative risks for mammographic features were estimated using logistic regression and nested cross-validation. Absolute risks were estimated using relative risks, mammographic feature distributions, and U.S. incidence and competing mortality risks. The risk model was validated in four independent sub-cohorts. Results. In all, 5,978 women were included, 805 incident breast cancers and 5,137 healthy women (age 58 +/- 10 years). In the validation set, the risk model reached an area under the curve (AUC) of 0.82 (95% CI 0.79,0.85) at baseline screen. The average 1-year breast cancer incidence rate was 0.28%. By the USPSTF guidelines, 14% of the women were considered at high-risk of breast cancer, Table 1. The high-risk women had a 20-fold increased breast cancer risk compared to the women at general risk. The model showed good fit (le Cessie-Hosmer p = 0.7). In the high-risk group, 83% of the stage 2 and stage 3 cancers and 59% of the stage 0 cancers were observed, p Table 1. Percentages of women at risk using the USPSTF breast cancer risk categorization adapted to 1-year risks.Risk group1Percent women at riskAbsolute 1-year risk (%)Risk stratificationGeneral ( Citation Format: Mikael Eriksson, Stamatia Destounis, Kathy Schilling. A risk tool for digital breast tomosynthesis to predict breast cancer and guide clinical follow-up [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P2-11-20.

PURPOSE: The purpose of this study was to evaluate the emotional and financial impact of coronavirus disease 2019 (COVID-19) on breast radiologists to understand potential consequences on physician wellness and gender disparities in radiology. METHODS: A 41-question survey was distributed from June to September 2020 to members of the Society of Breast Imaging and the National Consortium of Breast Centers. Psychological distress and financial loss scores were calculated on the basis of survey responses and compared across gender and age subgroups. A multivariate logistic model was used to identify factors associated with psychological distress scores. RESULTS: A total of 628 surveys were completed (18% response rate); the mean respondent age was 52 ± 10 years, and 79% were women. Anxiety was reported by 68% of respondents, followed by sadness (41%), sleep problems (36%), anger (25%), and depression (23%). A higher psychological distress score correlated with female gender (odds ratio [OR], 1.9; P = .001), younger age (OR, 0.8 per SD; P = .005), and a higher financial loss score (OR, 1.4; P < .0001). Participants whose practices had not initiated wellness efforts specific to COVID-19 (54%) had higher psychological distress scores (OR, 1.4; P = .03). Of those with children at home, 38% reported increased childcare needs, higher in women than men (40% versus 29%, P < .001). Thirty-seven percent reported that childcare needs had adversely affected their jobs, which correlated with higher psychological distress scores (OR, 2.2-3.3; P < .05). CONCLUSIONS: Psychological distress was highest among younger and female respondents and those with greater pandemic-specific childcare needs and financial loss. Practice-initiated COVID-19-specific wellness efforts were associated with decreased psychological distress. Policies are needed to mitigate pandemic-specific burnout and worsening gender disparities.

OBJECTIVE. Dense breast tissue is an established risk factor for the development of breast cancer. Methods for reliable and reproducible identification of breast density have been developed and are increasingly being adopted into clinical practice, allowing enhanced identification of patients who will benefit from supplemental screening. Breast density is being used for patient risk stratification through incorporation into risk models, leading to more precise management and improved decision making regarding personalized screening strategies. CONCLUSION. This review provides an update on breast density assessment, evaluation of patient's risk status, and the use of supplemental screening.

PURPOSE To assess the percentage of papillomas from all biopsies performed, comparing differences in patient age and race at a single institution. To assess trends in biopsied papillomas at institutions throughout the United States (US). METHODS This is a HIPPA-compliant IRB-approved single-institution (Southern1) retrospective review to assess race and age of all-modality-biopsied non-malignant papillomas as a percentage of all biopsies (percentage papillomas calculated as papilloma biopsies/all biopsies) from January 2012 to December 2019. To assess national variation, several academic or large referral centers were contacted to provide data regarding papilloma percentages, biopsy modalities, and trends in case numbers. Trends were estimated using the method of analysis of variance (ANOVA). Comparisons of differences in trends were assessed. RESULTS Southern1 institution demonstrated a significant association between race and percentage of papillomas (p

The aim of this study was to investigate breast radiologists' practices related to recording sex and gender in the electronic medical record, knowledge and attitudes about breast cancer screening recommendations for transgender individuals, and experience and willingness to enter screening mammography data from transgender patients into databases that document service provision and outcomes of cancer detection protocols.A 19-question anonymous survey was distributed by e-mail to all active physician members of the Society of Breast Imaging. Response characteristics were assessed as frequencies and percentages and compared between groups using the Fisher exact test or χFour hundred one radiologists across the United States and Canada responded (response rate 18%). Recording birth-assigned sex distinct from gender identity was reported by 44 of 352 respondents (13%). Depending on geographic region, 38% to 62% of breast radiologists followed screening guidelines for transgender women, and 226 of 349 (65%) did not provide screening recommendations for transgender men. Of 400, 324 (81%) believed that the evidence base for screening transgender individuals is incomplete, and 247 of 352 (70%) were either unsure of or had no Lesbian, Gay, Bisexual, Transgender, Queer competency training. A majority (247 of 401 [62%]) of respondents reported that they would enroll transgender patients in existing or novel national databases.In the practice of breast imaging, there is a substantial need to record transgender and other gender-nonconforming information. Breast radiologists differ in their practice and knowledge regarding screening of transgender women and men but expressed interest in contributing data to facilitate longitudinal databases needed to inform cancer screening guidelines.

Objective Patient screening mammography records performed in women aged 75 years and older were reviewed to evaluate the value of screening in this population, by determining the incidence of cancer diagnosed and associated outcomes. Methods Data from patients aged 75 years and older who presented for screening mammography and underwent biopsy with resultant malignant pathology were retrospectively collected and analyzed to record patient demographics and outcomes. Results From 2007–2017, there were 763,256 screening mammography appointments in 130,232 patients, with 3716 patients diagnosed with 4412 screen-detected malignancies (5.8 per 1000 cancers). In women aged 75 years and older, 76,885 (76,885 per 130,232, 10.1%) screening mammograms were performed in 18,497patients, with 643 malignancies diagnosed in 614 women eligible for study inclusion (8.4 per 1000 cancers). Lesions frequently presented as a mass with or without calcifications (472 per 643, 73%). A majority (529 per 643, 82%) was invasive; 79% (507 per 643) stage 0 or 1, and 63% (407 per 643) grade 2 or 3. Lymph node–positive status was confirmed in 7% of patients (46 per 614). Surgical intervention was pursued by 98% of patients (599 per 614). Conclusion Screening mammograms in women aged 75 years and older comprise a small percentage of the total screening examinations; however, they represented a significant portion of all patients diagnosed with screen-detected cancers, showing a substantial cancer detection rate. Most tumors were low stage, intermediate to high grade, and invasive. The majority had treatment involving surgery, suggesting these women are in good health and want to pursue surgical intervention. Screening mammography should be performed in this age group.

Purpose To assess breast imaging radiologists’ perceptions of the adequacy of provider–patient discussions regarding the benefits and risks of screening mammography and supplemental screening in women with elevated risk and dense breasts. Methods A 36-item questionnaire developed by the Society of Breast Imaging Patient Care and Delivery Task Force was distributed electronically to Society of Breast Imaging members to evaluate patient communication, education, and screening practices. Data from the 11 items specifically pertaining to screening practices were analyzed. Results The response rate was 14% (275/1992). Seventy-four percent of survey respondents perceived provider–patient discussions regarding mammography screening guidelines as inadequate, and they agreed that provider–patient discussions regarding screening guidelines (82%) and supplemental screening for increased breast density (74%) should be standardized. Only 38% indicated that mammography screening guidelines are officially endorsed by their institution. Similarly, 37% reported that recommendations were up to the primary provider. Although most respondents include information about breast density in lay letters (73%) and radiology reports (89%), many feel that further patient education regarding breast density, supplemental screening, risk assessment, and screening guidelines should be performed by radiologists, and they are willing to provide additional patient education in these areas in practice. Conclusions Survey respondents perceived current provider–patient discussions about the risks and benefits of breast cancer mammography screening and supplemental screening as inadequate and felt that standards should be developed. Respondents reported a willingness to take on patient education as part of their daily practice. These findings could inform future initiatives for radiologists to contribute to enhancing provider–patient education.

Breast cancer remains the most common nonskin cancer, the second leading cause of cancer deaths, and the leading cause of premature death in US women. Mammography screening has been proven effective in reducing breast cancer deaths in women age 40 years and older. A mortality reduction of 40% is possible with regular screening. Treatment advances cannot overcome the disadvantage of being diagnosed with an advanced-stage tumor. The ACR and Society of Breast Imaging recommend annual mammography screening beginning at age 40, which provides the greatest mortality reduction, diagnosis at earlier stage, better surgical options, and more effective chemotherapy. Annual screening results in more screening-detected tumors, tumors of smaller sizes, and fewer interval cancers than longer screening intervals. Screened women in their 40s are more likely to have early-stage disease, negative lymph nodes, and smaller tumors than unscreened women. Delaying screening until age 45 or 50 will result in an unnecessary loss of life to breast cancer and adversely affects minority women in particular. Screening should continue past age 74 years, without an upper age limit unless severe comorbidities limit life expectancy. Benefits of screening should be considered along with the possibilities of recall for additional imaging and benign biopsy and the less tangible risks of anxiety and overdiagnosis. Although recall and biopsy recommendations are higher with more frequent screening, so are life-years gained and breast cancer deaths averted. Women who wish to maximize benefit will choose annual screening starting at age 40 years and will not stop screening prematurely.

Letter to the Editor on article by Dinh et al- response to the authors comments on " Is it ethical to incentivize mammography screening in Medicaid populations? - A policy review and conceptual analysis".

Objective To assess the impact of the COVID-19 pandemic on breast imaging facilities’ operations and recovery efforts across North America. Methods A survey on breast imaging facilities’ operations and strategies for recovery during the COVID-19 pandemic was distributed to the membership of the Society of Breast Imaging and National Consortium of Breast Centers from June 4, 2020, to July 14, 2020. A descriptive summary of responses was performed. Comparisons were made between demographic variables of respondents and questions of interest using a Pearson chi-square test. Results There were 473 survey respondents (response rate of 13%). The majority of respondents (70%; 332/473) reported 80%–100% breast imaging volume reduction, with 94% (447/473) reporting postponement of screening mammography. The majority of respondents (97%; 457/473) continued to perform biopsies. There were regional differences in safety measures taken for staff (P = 0.004), with practices in the West more likely reporting no changes in the work environment compared to other regions. The most common changes to patients’ experience included spacing out of furniture in waiting rooms (94%; 445/473), limiting visitors (91%; 430/473), and spacing out appointments (83%). A significantly higher proportion of practices in the Northeast (95%; 104/109) initiated patient scheduling changes compared to other regions (P = 0.004). Conclusion COVID-19 had an acute impact on breast imaging facilities. Although common national operational patterns emerged, geographic variability was notable in particular in recovery efforts. These findings may inform future best practices for delivering breast imaging care amid the ongoing and geographically shifting COVID-19 pandemic.

Purpose Review of outcomes of screening patients imaged with both digital breast tomosynthesis (DBT) and screening ultrasound (US) to compare the cancer detection rates and characteristics of cancers detected by the imaging modalities. Material and Methods This retrospective study reviewed a total of 24,787 screening US exams performed in the time period of January 2013 through December 2017. These exams were in patients with heterogeneously dense or extremely dense breast tissue. In this population, 21,220 (86%) had DBT screening mammography. These cases were further reviewed to identify any pathology-proven malignancy detected with US and/or DBT. Results The study cohort consisted of 115 breast cancers in patients having screening US and DBT. Of the 115 cancers, 100 were invasive cancers and 15 were ductal carcinoma in situ: 64/115 were seen on DBT, 9 of which were seen only on DBT, and 106 were seen on US, with 51 seen only on US. The cancer detection rate of DBT only was 0.4/1000 (9/21,220) and 3.0/1000 (64/21,220) for those detected on DBT whether with or without additional US, with detection on US only having an incremental cancer detection rate of 2.4/1000 (51/21,220) above DBT detected malignancies. Differences in DBT-detected lesions and US only lesions when comparing median lesion size, lesion type, tumor type (invasive vs noninvasive) and tumor stage were statistically significant (p = 0.0045, p = 0.0113, p = 0.0003, and p = 0.0153, respectively). Conclusion In review of the outcomes of a screening US program, we found a similar number of breast cancers were detected by DBT and US, and US alone (47.8% vs 44.3%, respectively). Ninety-six percent of the cancers detected by US alone were invasive; 89% of those seen on both modalities were invasive, while most of the breast cancers seen on DBT only were in situ carcinoma. Statistically significant differences between DBT and US, and US alone were found for many lesion characteristics including lesion size, type, tumor size, and tumor stage.

Purpose To understand how breast radiologists perceive ductal carcinoma in situ (DCIS). Materials and Methods A 19-item survey was developed by the Society of Breast Imaging Patient Care and Delivery Committee and distributed to all Society of Breast Imaging members. The survey queried respondents’ demographics, knowledge of DCIS biology, language used to discuss a new diagnosis of DCIS, and perspectives on active surveillance for DCIS. Five-point Likert scales (1 = strongly disagree, 3 = neutral, 5 = strongly agree) were used. Results There were 536 responses for a response rate of 41%. There was agreement that DCIS is the primary driver of overdiagnosis in breast cancer screening (median 4), and respondents provided mean and median overdiagnosis estimates of 29.7% and 25% for low-grade DCIS as well as 4.2% and 0% for high-grade DCIS, respectively. Responses varied in how to describe DCIS but most often used the word “cancer” with a qualifier such as “early” (32%) or “pre-invasive” (25%). Respondents disagreed (median 2) with removing the word “carcinoma” from DCIS. Finally, there was agreement that current standard of care therapy for some forms of DCIS is overtreatment (median 4) and that active surveillance as an alternative management strategy should be studied (mean 4), but felt that ultrasound (median 4) and MRI (median 4) should be used to exclude women with occult invasive disease before active surveillance. Conclusions Breast radiologists’ opinions about DCIS biology, language, and active surveillance are not homogenous, but general trends exist that can be used to guide research, education, and advocacy efforts.

Digital breast tomosynthesis is quickly becoming the standard of care in breast cancer screening and diagnosis. Since its introduction to the clinical landscape in 2011, radiologists specializing in breast disease diagnosis around the country have made the decision to adopt the technology for both screening and diagnostic applications; with adoption growing substantially in present day. Users of the technology have attested to the benefits the technology affords, both in screening and the diagnostic evaluation of patients, through peer-reviewed publications and scientific presentations in recent years. This review article will describe the history of digital breast tomosynthesis and its implementation; from the early days of research, through Food and Drug Administration approval, to integration into the clinical workflow, in the setting of screening and diagnostic evaluation.

Purpose of Review The purpose of this study is to review recent and classic references on digital breast tomosynthesis to evaluate the clinical utility of the technology in both the screening and diagnostic evaluation of women.

Objectives To evaluate the impact on breast cancer detection from screening breast sonography performed in women with mammographically dense breasts. Methods This study used a retrospective chart review. Data collected included total number of screening mammograms, total number of dense breast screening sonograms, total number of procedures performed, biopsy results, and demographic data. Data were obtained from January 1, 2013, through August 31, 2015. During this period, there were a total of 195,982 screening mammographic examinations performed at our facility. Of these, 83,234 patients (42.5%) were informed that their breast tissue was heterogeneously dense or extremely dense. We specifically reviewed cases to identify those with findings on sonography only. The positive predictive value, biopsy rate, and cancer detection rate were determined. Results During the study period, 5434 screening sonographic examinations were performed in 4898 women with heterogeneously dense or extremely dense breasts. Most (95.7%) of the sonographic examinations resulted in an American College of Radiology Breast Imaging Reporting and Data System (BI-RADS) category 1 or 2 designation. A total of 101 lesions were given a BI-RADS 3 designation; 134 suspicious findings were given a BI-RADS 4 or 5 designation; and 100 of these were seen on sonography only, all of which underwent tissue sampling, resulting in the diagnosis of 18 malignancies; all were invasive. In evaluating screening sonographic findings, we found a positive predictive value of 18.0%, with an overall biopsy rate of 2.0% and a cancer detection rate of 3.3 per 1000. Conclusions The results of our continued evaluation of our screening sonography program confirm that screening breast sonography in women with dense breast tissue can detect otherwise occult malignancy, with a low biopsy rate.

Objectives: To compare the agreement and interobserver variability of diagnostic handheld ultrasound (US) and a single volume on an automated breast volume scanner (ABVS) and to determine whether there was a significant difference if the ABVS was used by a sonographer or mammographic technologist. Methods: Ninety patients scheduled for diagnostic US examinations were randomized to either handheld US or the ABVS first. The AVBS was randomized between a sonographer and a mammographic technologist performing the study. The studies were blinded, randomized, and read by 2 radiologists. The lesion with the highest Breast Imaging Reporting and Data System (BI-RADS) score was used in the analysis. Final diagnoses were made by core biopsy or follow-up for 2 years. Lesions included 9 malignant and 81 benign. Results: The 90 patients had a mean age ± SD of 53.1 ± 16.3 years. The κ value for agreement between the ABVS and handheld US was 0.831 (95% confidence interval, 0.744-0.925), whereas the global agreement for a 7-point BI-RADS score was 0.488 (0.372-0.560). The agreement between the ABVS and handheld US was nearly the same when the ABVS was used by a mammographic technologist (κ = 0.858 [0.723-0.963]) or sonographer (κ = 0.803 [0.596-1.000]; P = .47). The areas under the receiver operating characteristic curves for characterization by the ABVS were 0.91 (0.84-0.96) for reader 1 and 0.91 (0.83-0.96) for reader 2; those for handheld US were 0.91 (0.84-0.96) for reader 1 and 0.83 (0.74-0.90) for reader 2, with no statistical difference. The agreement based on pathologic images was κ = 0.831 (0.718-0.944); for handheld US, κ = 0.795 (0.623-0.967); and for the AVBS, κ = 0.869 (0.725-1.000). Conclusions: Performing a single-view diagnostic ABVS examination has good agreement with a handheld diagnostic US workup. There is no difference if the ABVS is used by a sonographer or mammographic technologist.

With the increasing use of digital breast tomosynthesis (DBT) in breast imaging practices, a growing number of lesions are being identified by DBT only. DBT-guided biopsies, both upright and prone, have become proven methods for accurate tissue sampling of these DBT-only lesions. This chapter reviews the DBT-guided biopsy options, the procedure, and related research.

The goal of augmented intelligence is to increase efficiency and effectiveness in practice. To achieve this, augmented intelligence technologies are being asked to perform a range of tasks, from simple to complex and quantitative. The development of these systems is increasingly important as screening becomes more personalized. This article will provide an overview of augmented intelligence in a variety of breast imaging applications.The incorporation of AI and ML techniques in breast imaging provides important new tools that will deliver ways to "sharpen" trusted familiar tools (so-called "augmented intelligence") to support radiologists, not replace them. The first wave of medical imaging systems based on AI and ML has primarily used ML to fix the values of key imaging parameters to be adapted to the individual as part of personalized medicine. Artificial intelligence is the new tool in the radiologist's arsenal but will never replace the human qualities that are important in medicine-intellectual curiosity, passion, and drive.

Optoacoustic ultrasound breast imaging is a fused anatomic and functional modality that shows morphologic features, as well as hemoglobin amount and relative oxygenation within and around breast masses. The purpose of this study is to investigate the positive predictive value (PPV) of optoacoustic ultrasound features in benign and malignant masses.In this study, 92 masses assessed as BI-RADS category 3, 4, or 5 in 94 subjects were imaged with optoacoustic ultrasound. Each mass was scored by seven blinded independent readers according to three internal features in the tumor interior and two external features in its boundary zone and periphery. Mean and median optoacoustic ultrasound scores were compared with histologic findings for biopsied masses and nonbiopsied BI-RADS category 3 masses, which were considered benign if they were stable at 12-month follow-up. Statistical significance was analyzed using a two-sided Wilcoxon rank sum test with a 0.05 significance level.Mean and median optoacoustic ultrasound scores for all individual internal and external features, as well as summed scores, were higher for malignant masses than for benign masses (p0.0001). High external scores, indicating increased hemoglobin and deoxygenation and abnormal vessel morphologic features in the tumor boundary zone and periphery, better distinguished benign from malignant masses than did high internal scores reflecting increased hemoglobin and deoxygenation within the tumor interior.High optoacoustic ultrasound scores, particularly those based on external features in the boundary zone and periphery of breast masses, have high PPVs for malignancy and, conversely, low optoacoustic ultrasound scores have low PPV for malignancy. The functional component of optoacoustic ultrasound may help to overcome some of the limitations of morphologic overlap in the distinction of benign and malignant masses.

False-positive findings remain challenging in breast imaging. This study investigates the incremental value of optoacoustic imaging in improving BI-RADS categorization of breast masses at ultrasound.The study device is an optoacoustic breast imaging device with a handheld duplex laser and internal gray-scale ultrasound probe, fusing functional and morphologic information (optoacoustic ultrasound). In this prospective multisite study, breast masses assessed as BI-RADS category 3, 4A, 4B, 4C, or 5 by site radiologists underwent both gray-scale ultrasound and optoacoustic imaging with the study device. Independent reader radiologists assessed internal gray-scale ultrasound and optoacoustic ultrasound features for each mass and assigned a BI-RADS category. The percentage of mass reads for which optoacoustic ultrasound resulted in a downgrade or upgrade of BI-RADS category relative to internal gray-scale ultrasound was determined.Of 94 total masses, 39 were biopsy-proven malignant, 44 were biopsy-proven benign, and 11 BI-RADS category 3 masses were stable at 12-month follow-up. The sensitivity of both optoacoustic ultrasound and internal gray-scale ultrasound was 97.1%. The specificity was 44.3% for optoacoustic ultrasound and 36.4% for internal gray-scale ultrasound. Using optoacoustic ultrasound, 41.7% of benign masses or BI-RADS category 3 masses that were stable at 12-month follow-up were downgraded to BI-RADS category 2 by independent readers; 36.6% of masses assigned BI-RADS category 4A were downgraded to BI-RADS category 3 or 2, and 10.1% assigned BI-RADS category 4B were downgraded to BI-RADS category 3 or 2. Using optoacoustic ultrasound, independent readers upgraded 75.0% of the malignant masses classified as category 4A, 4B, 4C, or 5, and 49.4% of the malignant masses were classified as category 4B, 4C, or 5.Optoacoustic ultrasound resulted in BI-RADS category downgrading of benign masses and upgrading of malignant masses compared with gray-scale ultrasound.

Purpose The aim of this study was to assess variability in radiologist-patient communication practices and barriers to communication among members of the Society of Breast Imaging (SBI). Methods A 36-item questionnaire developed by the SBI Patient Care and Delivery Task Force was distributed electronically to SBI members to evaluate patient communication, education, and screening practices. Data from 14 items investigating patient communication (eg, practices, comfort, barriers to communication) were analyzed and compared with demographic variables using χ2 or independent t tests as appropriate. Results Ninety-three percent of radiologists reported that they directly communicate abnormal results of diagnostic mammographic examinations that require biopsy and malignant or high-risk biopsy results that require surgery. Radiologists (66%) and technologists (57%) often provide normal or negative diagnostic mammographic results. Most respondents were completely comfortable discussing the need for additional imaging, recommending biopsy, and discussing biopsy results directly with patients, and 71% rated their communication skills as excellent. Radiologists who spend less time in breast imaging reported only average communication skills. The most frequent barriers to communication were that practices were not set up for direct communication (loss of revenue) and discomfort with angry patients. Conclusions Although variation in breast imaging communication practices exists among radiologists and practice types, the majority of radiologists directly communicate the most distressing results to patients, such as those regarding abnormal diagnostic mammographic findings requiring biopsies and abnormal biopsy results leading to cancer diagnoses and surgery. The majority of radiologists are completely comfortable with these conversations, but all feel that enhancing communication with patients will lead to greater patient satisfaction.

The Centers of Disease Control and Prevention has reported that breast cancer is currently the second leading cause of cancer death among women. Mammography is considered the gold standard for detecting breast cancer and the only proven screening tool to reduce mortality. When the breast tissue is dense, it may lower breast cancer detection with mammography. Digital breast tomosynthesis (DBT) was developed to aid in the detection of lesions in dense breast tissue. DBT has the ability to partially remove tissues that are above and below the plane of the lesion. Thus, offering improved visualization and characterization of abnormalities that are seen within the breast and evaluation of dense breast tissue. Imaging and diagnosis of breast cancer is very complex. This article will help radiology nurses understand the role of DBT in increasing diagnostic accuracy. Full-field digital mammography and DBT will be compared. The radiology nurse who is knowledgeable in breast disease evaluation and the technology available will be well prepared to assist patients with understanding the diagnosis of their disease.

Objectives The purpose of this study was to review our initial experience with the New York State breast density inform law (New York public health law, S2404-C) at our outpatient breast center. We sought to review the findings in patients returning for screening breast sonography after a screening mammogram revealed heterogeneously dense or extremely dense breast tissue. Methods From January 1, 2013, through May 31, 2014, 102,841 patients who underwent screening mammography were seen at our institution. Of these, 35,153 were determined to have heterogeneously dense breast tissue, and 11,864 were determined to have extremely dense breast tissue. Due to the New York State breast density inform law, these 47,017 patients were notified of their breast density, with 935 patients (2%) returning for 971 screening breast sonographic examinations. Results Heterogeneously dense breast tissue was noted in 66% of the patients (619), and extremely dense breast tissue was noted in 34% (316). Thirty-one percent of the patients (290) reported no additional risk factors; 68% (635) presented with 1 or more additional risk factors; and 1% (10) were adopted, and the risk status could not be assessed. Twenty-five procedures (2.6%) were performed after screening breast sonography, resulting in 22 benign findings, 1 atypical finding, and 2 malignancies. The overall positive predictive value was 8% (2 of 25), and the overall cancer detection rate was 2.1 per 1000 (2 of 935). Conclusions Handheld screening breast sonography performed in women with dense breast tissue can aid in the detection of otherwise occult breast cancer, as we found 2 cancers in the study population, with an overall positive predictive value of 8%. The addition of screening sonography in this cohort did lead to an increase in minimally invasive procedures in 2.6%.

OBJECTIVE. Digital breast tomosynthesis (DBT) is a recent imaging technology that was developed to address the limitations of conventional 2D mammography. The limitations of standard mammography are well known and include reduced sensitivity in dense breasts. Clinical research studies of DBT and the implementation of DBT have revealed that DBT has potential benefits for evaluating patients with dense breasts. This article will discuss the benefits and limitations of DBT as a screening alternative for women with dense breasts. CONCLUSION. Studies to date have revealed that the use of DBT reduces recall rates and increases cancer detection rates. This has been demonstrated with the use of DBT for both screening and diagnostic purposes, as well as with imaging dense breasts. DBT has the ability to reduce breast tissue overlap, thus potentially revealing lesions that would otherwise have been missed. The limitations of DBT include longer interpretation times, higher costs, and increased radiation dose. These limitations present challenges that radiologists must consider before DBT implementation.

The use of breast magnetic resonance imaging (MRI) has grown for the past decade and, along with the increase in use, there has been a progression in the indications for use. Breast MRI has been shown to be a valuable additional tool for breast imagers to use to provide optimal patient care. Because of the benefit that MRI can provide, the technology is now being used for a wide variety of indications, from evaluation of the extent of disease to evaluation of the high-risk patient, evaluation of tumor response to chemotherapy, and search for occult primary tumor. This review will cover the various indications for breast MRI, discuss research to date, as well as provide case examples.

Purpose To compare the diagnostic utility of an investigational optoacoustic imaging device that fuses laser optical imaging (OA) with grayscale ultrasonography (US) to grayscale US alone in differentiating benign and malignant breast masses. Materials and Methods This prospective, 16-site study of 2105 women (study period: 12/21/2012 to 9/9/2015) compared Breast Imaging Reporting and Data System (BI-RADS) categories assigned by seven blinded independent readers to benign and malignant breast masses using OA/US versus US alone. BI-RADS 3, 4, or 5 masses assessed at diagnostic US with biopsy-proven histologic findings and BI-RADS 3 masses stable at 12 months were eligible. Independent readers reviewed US images obtained with the OA/US device, assigned a probability of malignancy (POM) and BI-RADS category, and locked results. The same independent readers then reviewed OA/US images, scored OA features, and assigned OA/US POM and a BI-RADS category. Specificity and sensitivity were calculated for US and OA/US. Benign and malignant mass upgrade and downgrade rates, positive and negative predictive values, and positive and negative likelihood ratios were compared. Results Of 2105 consented subjects with 2191 masses, 100 subjects (103 masses) were analyzed separately as a training population and excluded. An additional 202 subjects (210 masses) were excluded due to technical failures or incomplete imaging, 72 subjects (78 masses) due to protocol deviations, and 41 subjects (43 masses) due to high-risk histologic results. Of 1690 subjects with 1757 masses (1079 [61.4%] benign and 678 [38.6%] malignant masses), OA/US downgraded 40.8% (3078/7535) of benign mass reads, with a specificity of 43.0% (3242/7538, 99% confidence interval [CI]: 40.4%, 45.7%) for OA/US versus 28.1% (2120/7543, 99% CI: 25.8%, 30.5%) for the internal US of the OA/US device. OA/US exceeded US in specificity by 14.9% (P < .0001; 99% CI: 12.9, 16.9%). Sensitivity for biopsied malignant masses was 96.0% (4553/4745, 99% CI: 94.5%, 97.0%) for OA/US and 98.6% (4680/4746, 99% CI: 97.8%, 99.1%) for US (P < .0001). The negative likelihood ratio of 0.094 for OA/US indicates a negative examination can reduce a maximum US-assigned pretest probability of 17.8% (low BI-RADS 4B) to a posttest probability of 2% (BI-RADS 3). Conclusion OA/US increases the specificity of breast mass assessment compared with the device internal grayscale US alone. Online supplemental material is available for this article. © RSNA, 2017.

Screening mammography has been widely used for breast cancer detection and has been found to decrease mortality, but debate continues. The purpose of this article is to review screening recommendations and the benefits and perceived harms of earlier and more frequent screening.Annual mammography beginning at age 40 decreases mortality. Clinicians should educate women and preserve recommendations for early and annual screening.

Mammographic breast density (MBD) has been proven to be an important risk factor for breast cancer and an important determinant of mammographic screening performance. The measurement of density has changed dramatically since its inception. Initial qualitative measurement methods have been found to have limited consistency between readers, and in regards to breast cancer risk. Following the introduction of full-field digital mammography, more sophisticated measurement methodology is now possible. Automated computer-based density measurements can provide consistent, reproducible, and objective results. In this review paper, we describe various methods currently available to assess MBD, and provide a discussion on the clinical utility of such methods for breast cancer screening.

The purpose of this study was to compare invasive breast cancer in patients in their 40s with and without a family history of breast cancer as well as the lymph node meta-static rate and mastectomy rate.From 2000 to 2011, a total of 793,827 examinations were performed; 221,541 (28%) were women between 40 and 49 years old. A total of 6965 cancers were found in 6511 patients. Specifically, 1207 cancers (17.3%) were detected in 1162 patients in their 40s. Patients presenting for diagnostic evaluation and those with a personal history of breast cancer were excluded, leaving 388 cancers available for study; 238 (61%) cancers were in patients with no family history of breast cancer, and 150 (39%) were in patients with a family history of breast cancer. Pearson chi-square, Fisher exact, and Student t tests were used for between-group comparisons for qualitative data. A two-sided p value was reported for all tests.The difference in lesions detected by imaging was not statistically significant (p = 0.17); 65% (154/238) had invasive and 35% (84/238) noninvasive disease in the no family history of breast cancer group and 65% (98/150) and 35% (52/150), respectively, in the family history of breast cancer group (p = 0.90). The mastectomy rate was not statistically significantly different (p = 0.14). Fifteen percent (35/238) of the no family history of breast cancer patients and 12% (18/150) of the family history of breast cancer patients had positive lymph nodes (p = 0.45).In patients in their 40s with or without a family history of breast cancer, no differences were detected in the proportion of invasive versus noninvasive cancers diagnosed, lymph node metastases, or mastectomy rates. Screening mammography should be performed in this age group regardless of family history.

To compare the agreement and interobserver variability of diagnostic handheld ultrasound (US) and a single volume on an automated breast volume scanner (ABVS) and to determine whether there was a significant difference if the ABVS was used by a sonographer or mammographic technologist.Ninety patients scheduled for diagnostic US examinations were randomized to either handheld US or the ABVS first. The AVBS was randomized between a sonographer and a mammographic technologist performing the study. The studies were blinded, randomized, and read by 2 radiologists. The lesion with the highest Breast Imaging Reporting and Data System (BI-RADS) score was used in the analysis. Final diagnoses were made by core biopsy or follow-up for 2 years. Lesions included 9 malignant and 81 benign.The 90 patients had a mean age ± SD of 53.1 ± 16.3 years. The κ value for agreement between the ABVS and handheld US was 0.831 (95% confidence interval, 0.744-0.925), whereas the global agreement for a 7-point BI-RADS score was 0.488 (0.372-0.560). The agreement between the ABVS and handheld US was nearly the same when the ABVS was used by a mammographic technologist (κ = 0.858 [0.723-0.963]) or sonographer (κ = 0.803 [0.596-1.000]; P = .47). The areas under the receiver operating characteristic curves for characterization by the ABVS were 0.91 (0.84-0.96) for reader 1 and 0.91 (0.83-0.96) for reader 2; those for handheld US were 0.91 (0.84-0.96) for reader 1 and 0.83 (0.74-0.90) for reader 2, with no statistical difference. The agreement based on pathologic images was κ = 0.831 (0.718-0.944); for handheld US, κ = 0.795 (0.623-0.967); and for the AVBS, κ = 0.869 (0.725-1.000).Performing a single-view diagnostic ABVS examination has good agreement with a handheld diagnostic US workup. There is no difference if the ABVS is used by a sonographer or mammographic technologist.

To evaluate the impact on breast cancer detection from screening breast sonography performed in women with mammographically dense breasts.This study used a retrospective chart review. Data collected included total number of screening mammograms, total number of dense breast screening sonograms, total number of procedures performed, biopsy results, and demographic data. Data were obtained from January 1, 2013, through August 31, 2015. During this period, there were a total of 195,982 screening mammographic examinations performed at our facility. Of these, 83,234 patients (42.5%) were informed that their breast tissue was heterogeneously dense or extremely dense. We specifically reviewed cases to identify those with findings on sonography only. The positive predictive value, biopsy rate, and cancer detection rate were determined.During the study period, 5434 screening sonographic examinations were performed in 4898 women with heterogeneously dense or extremely dense breasts. Most (95.7%) of the sonographic examinations resulted in an American College of Radiology Breast Imaging Reporting and Data System (BI-RADS) category 1 or 2 designation. A total of 101 lesions were given a BI-RADS 3 designation; 134 suspicious findings were given a BI-RADS 4 or 5 designation; and 100 of these were seen on sonography only, all of which underwent tissue sampling, resulting in the diagnosis of 18 malignancies; all were invasive. In evaluating screening sonographic findings, we found a positive predictive value of 18.0%, with an overall biopsy rate of 2.0% and a cancer detection rate of 3.3 per 1000.The results of our continued evaluation of our screening sonography program confirm that screening breast sonography in women with dense breast tissue can detect otherwise occult malignancy, with a low biopsy rate.

Ultrasound elasticity imaging (EI) was introduced in the early 1990s but is still a relatively new technique in the field of breast ultrasound as it is not used routinely in the clinical setting. Elastography offers many different features that may help radiologists to obtain more information regarding a detected lesion. By using elastography, the radiologist may be able to distinguish between benign and malignant lesions. Despite the advantages that elastography may be able to offer, there are also some disadvantages of the technology such as operator variability, difficulty of elastography image interpretation, and many different looks of elastography images depending on vendor and also different types of the elastography technique. This article will provide insight on ultrasound EI for the radiology nurse who may assist with procedures or educate patients.

The purposes of this study were to compare BI-RADS density categories with quantitative volumetric breast density (VBD) for the reporting of mammographic sensitivity and to identify which patient factors are most predictive of a diagnosis of interval cancer of the breast versus screen-detected cancer.This retrospective study included screen-detected cancers (n = 652) and interval cancers (n = 119) identified between January 2009 and December 2012. Multivariate logistic regression analysis was used to determine which patient factors are predictive of a diagnosis of interval cancer. Sensitivity (screen-detected cancer / [screen-detected cancer + interval cancer]) was determined with the BI-RADS 4th edition density categories and an automated equivalent density grade obtained with a proprietary tool. Sensitivity changes within automated density grade categories were investigated by use of quantitative thresholds at the midpoints of each category.In univariate analysis, age, menopausal status, and breast density were associated with a diagnosis of interval cancer. Of these risk factors, breast density was the only independent factor whether it was assessed by visual BI-RADS category (odds ratio, 3.54; 95% CI, 1.55-8.10), automated density grade (odds ratio, 4.68; 95% CI, 2.26-9.67), or VBD (odds ratio, 4.51; 95% CI, 1.92-10.61). Sensitivity decreased consistently across increasing automated density grade categories from fatty to extremely dense (95%, 89%, 83%, 65%) and less so for visual BI-RADS (82%, 90%, 84%, 66%). Further dichotomization with VBD cutoffs showed a striking linear relation between VBD and sensitivity (RIn this study, breast density was the only risk factor significantly associated with a diagnosis of interval cancer versus screen-detected cancer. Quantitative VBD captures the potential masking risk of breast density more precisely than does the widely used visual BI-RADS density classification system.

Digital breast tomosynthesis (DBT) has shown improved breast cancer detection and reduction in recall rates in comparison to full-field digital mammography on many recent clinical trials. This article will provide an analysis of some of the DBT research to date regarding the benefits this technology affords for breast cancer detection, as well as review recent DBT technology updates, such as the synthetic view (C-view) and DBT-guided biopsy. This article will assess the current utilization of DBT for breast cancer screening, as well as its use in the diagnostic evaluation of breast disease. The limitations of the technology, such as the visualization and characterization of calcifications, will be discussed, as well as how the technology may change in the future.

The purpose of this study was to evaluate papillary lesions of the breast diagnosed at needle core biopsy and the outcomes of follow-up imaging and surgical findings.Retrospective review of 13,806 needle core biopsies performed from 2004 to 2010 revealed 352 patients with 368 papillary lesions; 137 of these lesions underwent surgical excision and 215 had a minimum of 2 year imaging follow-up. Outcomes of imaging follow-up and underestimation of carcinoma by comparison to surgical excision, as applicable, were determined. Patient demographics, clinical presentation, BI-RADS(®) breast density, palpability, biopsy methods, number of specimens, and pathology were recorded. A two-tailed Fisher exact test was used to assess associations between biopsy techniques and the results of surgical excision as well as the association between palpability and the results of surgical excision. SAS(®) V 9.1.3 was used to perform the calculations.One hundred and thirty-seven lesions proceeded to surgical excision. A total of 28 lesions were underestimated; 21 of these were underestimated carcinomas. When comparing biopsy devices in the underestimated group, 64 % were biopsied with directional vacuum-assisted devices and 36 % with automated large core devices (p0.0706). In total 18 % of the palpable lesions were underestimated, whereas 17 % of the nonpalpable lesions were underestimated (p0.6560); this was not a significant difference.Overall, carcinoma was underestimated at needle biopsy in 6 % (21/368) of papillary lesions diagnosed when compared to surgical excision. In cases that underwent excision, 34 % (47/137) revealed carcinoma; 45 % (21/47) of these were underestimated carcinomas. Lesion palpability and biopsy method did not affect underestimation in this study population.

The objective of our study was to show the importance of surgical excision after the diagnosis of lobular carcinoma in situ (LCIS) based on needle core biopsy.Retrospective evaluation of all cases of LCIS diagnosed at needle core biopsy from 2000 to 2011 was performed; 60 patients with 64 diagnoses of LCIS comprise the cohort. Data recorded included patient demographics, patient presentation, breast density, personal and family histories of breast cancer, lesion characteristics, biopsy method, and correlation of core results with surgical pathology or follow-up imaging. The pathology facility was recorded for all biopsies because the specimens from open surgical biopsy were frequently reviewed by a different laboratory.A total of 60 patients with 64 diagnoses of LCIS comprised the study cohort. The patients ranged in age from 36 to 93 years (average, 55 years). The lesions consisted of 39 calcifications, two masses with calcium, 10 masses, two asymmetries, two architectural distortions, two architectural distortions with calcifications, and seven MRI enhancements. Mammography detected lesions in 84% of the cases (n = 54) and 16% (n = 10) were not visualized. Sonography detected lesions in 30% of the cases (n = 19) and 70% (n = 45) were sonographically occult. Needle core biopsy was performed in all cases: 49 stereotactic biopsies (77%), 12 ultrasound-guided biopsies, and three MRI-guided biopsies. All but one case proceeded to surgery. Open surgical biopsy revealed 21 cancers (33%); of the remaining cases, 53% of the cases (n = 33) were atypical or high risk and 14% (n = 9) were benign.The diagnosis of LCIS at needle core biopsy, in this small study, revealed that 84% of lesions either were malignant or were atypical or high risk at surgery, of which 33% were found to be carcinoma. Our findings suggest that LCIS should be excised when noted at core biopsy.

Radiology is undeniably male dominated. Alongside surgery and orthopedic surgery, academic radiology ranks near the bottom in having the lowest proportion of full-time female faculty members. Despite many efforts to recruit talented women, the pipeline entering the radiologic disciplines continues to flow at a trickle. One factor is the relative lack of role models for female medical students. Entrepreneurial women in radiology can lead the field with their innovation and creativity, courage, and commitment. In this article, the authors highlight two entrepreneurial female radiologists who shared their success stories at the American Association for Women Radiologists' session at the 2015 ACR annual meeting. Their successes underscore the potential for such women to serve as role models to female medical students and even college undergraduates. Despite the gender gap in radiology, the field has yielded some exceptional women who can take on challenges, overcome barriers and assume risks, create strategies and processes to operationalize their visions, secure funding, and expand their enterprises to make sustainable impacts both at home and abroad. As we move toward more patient- and family-centered care models and become increasingly visible to diverse populations, there is no better time for female leaders in radiology to inspire the next generation to join our essential and rewarding specialty.

Despite developments in surgical technique, radiation treatment, and chemotherapeutic agents, tumor recurrence and distant disease have remained a major concern in breast cancer management. Breast imaging after mastectomy in the screening arena remains a controversial topic for breast imagers. Many feel the yield of finding a recurrent cancer with imaging in the asymptomatic patient is too low to be beneficial; others believe imaging should be performed on these patients as the risk of recurrence exists. Patients after a mastectomy procedure are considered high risk and, when they present with clinical symptoms, will require evaluation by the radiologist. In this diagnostic/symptomatic scenario, imaging becomes the routine and current imaging tools, such as mammography, ultrasound, and magnetic resonance imaging (MRI), can easily be incorporated to diagnose recurrent cancer. Our facility has a large population of patients that undergo mastectomy after a carcinoma diagnosis as well as a number of patients that have undergone a mastectomy procedure because of their high-risk status (whether family history or genetic predisposition). A certain percentage of these patients have proceeded to reconstructive surgery. We image these patients routinely as part of our screening protocol. Over the years we have become familiar with the appearance of remaining tissue along the chest wall after mastectomy as well as the reconstructed breasts. This familiarity is important as the imaging of these patients with mammography and other modalities available today can be challenging. This manuscript will discuss the benefits and some limitations surrounding imaging these patients, in both the asymptomatic and symptomatic scenarios, as well as what imaging protocols can be integrated within a facility's standard evaluation.

As the field of medicine moves toward practicing patient-centered care, radiologists in breast imaging must continue to look for ways to increase the value of their practice in the eyes of patients. Providing adjunct screening of women with dense breasts provides such an opportunity. The presence of dense breast tissue is not only an independent risk factor for breast cancer but also a risk factor for the delayed diagnosis of breast cancer as dense tissue reduces the efficacy of screening mammograms due to the tissue masking effect. As legislation for notifying women of their breast density becomes commonplace, both women and referring physicians need to understand the risks of dense breast tissue as well as the benefits of additional screening affords. Breast radiologists can become integral to their patients’ care team by offering education to both referring providers and patients on the topic of dense breasts and supplemental screening solutions, such as screening breast ultrasound, which has been shown to have benefit in overcoming mammography’s shortcomings in this demographic of women.

hyllodes breast tumors are rare, representing 0.3% to 1.0% of all breast tumors.1,2 These tumors present a difficult management issue because of the chance of recurrence, which has been reported to occur in 15% of patients overall; therefore, careful clinical observation of these patients is recommended after surgical excision. Hajdu et al3 reported a high incidence of local relapse of phyllodes breast tumors, with an incidence of 18%. Phyllodes tumors are difficult to diagnose because these tumors can be extremely difficult to differentiate from fibroadenomas. These tumors may masquerade as fibroadenomas and may be difficult to assess, even at core biopsy. The patients affected by these tumors vary in age at presentation, most typically 30 to 70 years old.4,5 An article by Yohe and Yeh6 discussed features suggesting phyllodes tumors that the pathologist can look for when analyzing a specimen and stated that increased sampling of a large tumor will likely yield a more accurate diagnosis. We report a case of a rapidly growing phyllodes tumor in a 49-year-old patient. In this case, the tumor grew very quickly in a short time and initially required wide surgical excision; fast recurrence led to a mastectomy for complete removal and clear margins. Even in the spectrum of what may be considered benign disease, a phyllodes tumor can locally recur and can be troublesome to treat.2,3 This can lead to multiple diagnostic and invasive procedures and, as in this patient, mastectomy.

The clinical implementation of needle core biopsies has given radiologists an invaluable tool for the diagnostic evaluation of suspicious breast lesions. Despite improvements made to the technology of breast biopsy, the underestimation of disease in tissue samples retrieved continues. This can be attributed to many factors, including variability between different needle gauges. This study was undertaken to assess the pathological underestimation for 9 and 12 gauge breast needle core biopsies at surgical excision. A retrospective review of image-guided consecutive core needle biopsies performed from 2003 to 2006 yielded a total of 1,201 needle core biopsies: 837 twelve gauge and 364 nine gauge. Further analysis was completed to distinguish needle biopsies whose pathological outcome was underestimated at core needle biopsy when compared to their subsequent surgical excision. Ninety-seven lesions in 88 patients were reviewed and comprise the study cohort. Underestimation was found in 97 needle core procedures in 88 patients. Of the 97, 67 were performed with 12 gauge vacuum-assisted biopsy devices and 30 with 9 gauge vacuum-assisted biopsy devices, resulting in an underestimation rate of 8.00 and 8.24% for 12 gauge and 9 gauge, respectively. The difference in underestimation rate was not statistically significant per Pearson’s chi squared test (P = 0.8898). In this analysis, the underestimation of needle biopsy results with surgical pathology was found to be 8.00% for the 12 gauge group and 8.24% for the 9 gauge group. These results support our current clinical practice of utilizing either needle gauge.