Journal of Breast Imaging

Harvey, Jennifer A

doi: 10.1093/jbi/wbac023pmid: 38416974

I have only ever regretted not placing a breast biopsy marker. I had a patient many years ago who really did not want to have a marker placed. She was having a stereotactic biopsy of regional calcifications that had increased. We discussed the risks and benefits of placing the marker, but she declined having one placed. We did not obtain a post-biopsy mammogram since we did not place a marker. The calcifications were associated with a benign process—usual ductal hyperplasia as I recall—but the biopsy also showed invasive lobular carcinoma. I did not know where within the regional calcifications the samples had been taken. An MRI did not show any abnormal findings or a biopsy track. The patient decided to have a mastectomy. Fortunately, we had discussed that this could rarely happen, and the patient understood. Occasionally, patients have significant concerns about having a biopsy marker placed. In this issue of the Journal of Breast Imaging, Kutay et al (1) developed an educational handout on biopsy markers and studied the effect on patients. They found that more than 60% of women had more knowledge about markers and about a quarter of women felt more comfortable with having a marker placed after reviewing the handout. Also in this issue, Goudreau et al (2) provide a scientific review of bleeding complications after breast core-needle biopsy that includes the different types of antithrombin therapy. My practice has generally been to stop antithrombin therapies if possible. However, patients are taking these medications for valid reasons, so the risk of significant bleeding in the breast due to needle biopsy must be balanced against the risk of stroke, deep venous thrombosis, or other clot-mediated bad outcome. I am revising my approach based on this excellent review. Figure 3 is going up on the bulletin board in the reading room. The COVID-19 pandemic has deeply affected our practices. Carnahan et al (3) performed a multi-institutional survey study of 1086 women at six sites (five U.S. and one Singapore) from October 2020 to March 2021, finding that anxiety regarding having a mammogram during the pandemic was associated with having one or more risk factors for either breast cancer or severe COVID infection. The anxiety declined significantly after the mammogram was complete. Many of the life changes due to the pandemic are not going back into the box. It’s a bit like trying to return something to Ikea after you’ve opened it. Our Training and Professional Development article for this issue is an original research survey study of breast imaging fellowship program directors and applicants who attended either an in-person or virtual interview during the COVID-19 pandemic (4). The program directors report no significant differences in the number of applications received, applicants interviewed, geographic distribution, or the number of interview days offered. Both virtual and in-person applicants report applying to a similar number of programs, but interestingly, virtual applicants completed more interviews and at lower cost. Both program directors and applicants thought that the virtual format allowed each to adequately know each other. It is highly likely that virtual interviews will continue in the future. Many of us may have had college students who are interested in medicine shadow us in practice prior to the pandemic. The reading rooms have had reduced access to observers during the pandemic. Chan et al took a very creative approach in response by developing a virtual shadowing program about breast imaging and promoting the program on Instagram (@virtual shadowing) (5). The survey study showed an increase in reported knowledge of radiology and what a radiologist does, as well as interest in pursuing radiology as a career. The recorded session now has over 6000 views on YouTube! MRI is clearly our best tool for the detection of breast cancer. Should we be using it for more patients? Our Science of Screening article by Bahl (6) reviews the utility of screening MRI for women at intermediate risk of breast cancer. Our Educational Review in this issue by Mercado et al (7) beautifully demonstrates the use of breast MRI in the setting of neoadjuvant chemotherapy, including its variable performance by molecular subtype. I have often been surprised about how much residual hormone receptor (HR) positive, human epidermal growth factor 2 (HER2) negative tumor is present after neoadjuvant chemotherapy with what appears to be a complete response on imaging. An original research study by Weinfurtner et al (8) evaluated the performance of quantitative MRI in predicting residual disease after stereotactic-guided focused radiotherapy of HR+ HER2− breast cancer. They found that a decrease in percent tumor volume as well as a decrease in high maximum enhancement correlated well with pathologic response. It will be interesting to see whether these techniques may be useful in the setting of neoadjuvant chemotherapy as well. Artificial intelligence (AI) is also changing how we provide care. Our Clinical Practice article by Smetherman (9) reviews the economics of artificial impact on breast imaging. While Medicare and other carriers reimbursed for traditional computer-aided detection (CAD) between 2001 and 2017, similar reimbursement is not currently available for contemporary AI programs. Those that improve workflow may be worth the investment because of increased efficiency. Those AI programs that improve detection may or may not improve patient care, as we learned with CAD. Detecting architectural distortion is one of the biggest challenges in breast imaging. The study by Feliciano-Rivera et al (10) reinforces this, demonstrating an inter-radiologist overall agreement for the presence of architectural distortion on tomosynthesis that was only fair. This result is important given how common a finding architectural distortion—or possible architectural distortion—is on mammography. In contrast, our radiology-pathology article reviews myofibroblastoma (11), which is quite rare but can mimic fibroadenoma. Another rare relatively newly described entity, ALK-positive histocytosis in the breast, is one of our Image Spotlight articles in this issue (12). So, what do you do when a patient declines having a breast biopsy marker placed? References 1. Kutay E , Milch H, Sayre J, et al. Fear of the unknown: the benefits of a patient educational handout on breast biopsy markers . J Breast Imag 2022 ; 4 ( 3 ): XX – XX . (This issue). Google Scholar OpenURL Placeholder Text WorldCat 2. Goudreau S , Grimm LJ, Srinivasan A, et al. Bleeding complications after breast core-needle biopsy—an approach to managing patients on antithrombotic therapy . J Breast Imag 2022 ; 4 ( 3 ): XX – XX . (This issue). Google Scholar OpenURL Placeholder Text WorldCat 3. Carnahan MB , Sharpe RE, Oluyemi E, et al. Women’s experience with screening mammography during the COVID-19 pandemic: a multi-institutional prospective survey study . J Breast Imag 2022 ; 4 ( 3 ): XX – XX . (This issue). Google Scholar OpenURL Placeholder Text WorldCat 4. Mullen LA , Nguyen DL, Katzen JT, Brem RF, Ambinder EB. Virtual interviews for breast imaging fellowship during the COVID-19 pandemic: perspectives of program directors and applicants . J Breast Imag 2022 ; 4 ( 3 ): XX – XX . (This issue). Google Scholar OpenURL Placeholder Text WorldCat 5. Chan TL , De R, Sayre J, Reno E. Breast imaging and social media: a model specialty for increasing interest and awareness of radiology in pre-medical students . J Breast Imag 2022 ; 4 ( 3 ): XX – XX . (This issue). Google Scholar OpenURL Placeholder Text WorldCat 6. Bahl M. Screening MRI in women at intermediate breast cancer risk: an update of the recent literature . J Breast Imag 2022 ; 4 ( 3 ): XX – XX . (This issue). Google Scholar OpenURL Placeholder Text WorldCat 7. Mercado C , Chhor C, Scheel JR. MRI in the setting of neoadjuvant treatment of breast cancer . J Breast Imag 2022 ; 4 ( 3 ): XX – XX . (This issue). Google Scholar OpenURL Placeholder Text WorldCat 8. Weinfurtner RJ , Abdalah M, Stringfield O, et al. Quantitative changes in intratumoral habitats on MRI correlate with pathologic response in early-stage ER/PR+ HER2− breast cancer treated with preoperative stereotactic ablative body radiotherapy . J Breast Imag 2022 ; 4 ( 3 ): XX – XX . (This issue). Google Scholar OpenURL Placeholder Text WorldCat 9. Smetherman D , Golding L, Moy L, Rubin E. The economic impact of AI on breast imaging . J Breast Imag 2022 ; 4 ( 3 ): XX – XX . (This issue). Google Scholar OpenURL Placeholder Text WorldCat 10. Feliciano-Rivera YZ , Net J, Velamuri S, Pluguez-Turull C, Yepes MM. The challenge of architectural distortion of the breast detected on digital breast tomosynthesis: pathological outcomes, radiologic and clinical predictors of malignancy . J Breast Imag 2022 ; 4 ( 3 ): XX – XX . (This issue). Google Scholar OpenURL Placeholder Text WorldCat 11. Zamora KW , Talley R, Hermecz BN, Wei S. Myofibroblastoma of the breast: diagnosis, pathology, and management . J Breast Imag 2022 ; 4 ( 3 ): XX – XX . (This issue). Google Scholar OpenURL Placeholder Text WorldCat 12. Sharma N , Gaudin PB. ALK-positive histiocytosis presenting as breast masses . J Breast Imag 2022 ; 4 ( 3 ): XX – XX . (This issue). Google Scholar OpenURL Placeholder Text WorldCat © Society of Breast Imaging 2022. All rights reserved. For permissions, please e-mail: [email protected] This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)

Bahl, Manisha

doi: 10.1093/jbi/wbac021pmid: 35783682

Guidelines issued by the American Cancer Society (ACS) in 2007 recommend neither for nor against screening MRI in women at intermediate breast cancer risk (15%–20%), including those with dense breast tissue, a history of lobular neoplasia or atypical ductal hyperplasia (ADH), or a prior breast cancer, because of scarce supporting evidence about the utility of MRI in these specific patient populations. However, since the issuance of the ACS guidelines in 2007, multiple investigations have found that women at intermediate risk may be suitable candidates for screening MRI, given the high detection rates of early-stage cancers and acceptable false-positive rates. For women with dense breast tissue, the Dense Tissue and Early Breast Neoplasm Screening trial reported that the incremental cancer detection rate (CDR) by MRI exceeded 16 cancers per 1000 examinations but decreased in the second round of screening; this decrease in CDR, however, occurred alongside a marked decrease in the false-positive rate. For women with lobular neoplasia or ADH, single-institution retrospective analyses have shown CDRs mostly ranging from 11 to 16 cancers per 1000 MRI examinations, with women with lobular carcinoma in situ benefitting more than women with atypical lobular hyperplasia or ADH. For patients with a prior breast cancer, the cancer yield by MRI varies widely but mostly ranges from 8 to 20 cancers per 1000 examinations, with certain subpopulations more likely to benefit, such as those with dense breasts. This article reviews and summarizes more recent studies on MRI screening of intermediate-risk women.

Goudreau, Sally; Grimm, Lars J; Srinivasan, Ashmitha; Net, Jose; Yang, Roger; Dialani, Vandana; Dodelzon, Katerina

doi: 10.1093/jbi/wbac020pmid: 38416973

Image-guided core-needle breast and axillary biopsy (CNB) is the standard-of-care procedure for the diagnosis of breast cancer. Although the risks of CNB are low, the most common complications include bleeding and hematoma formation. Post-procedural bleeding is of particular concern in patients taking antithrombotic therapy, but there is currently no widely established standard protocol in the United States to guide antithrombotic therapy management. In the face of an increasing number of patients taking antithrombotic therapy and with the advent of novel classes of anticoagulants, the American College of Radiology guidelines recommend that radiologists consider cessation of antithrombotic therapy prior to CNB on a case-by-case basis. Lack of consensus results in disparate approaches to patients on antithrombotic therapy undergoing CNB. There is further heterogeneity in recommendations for cessation of antithrombotic therapy based on the modality used for image-guided biopsy, target location, number of simultaneous biopsies, and type of antithrombotic agent. A review of the available data demonstrates the safety of continuing antithrombotic therapy during CNB while highlighting additional procedural and target lesion factors that may increase the risk of bleeding. Risk stratification of patients undergoing breast interventional procedures is proposed to guide both pre-procedural decision-making and post-procedural management. Radiologists should be aware of antithrombotic agent pharmacokinetics and strategies to minimize post-procedural bleeding to safely manage patients.

Carnahan, Molly B; Sharpe, Richard E; Oluyemi, Eniola; Parra, Laura; Hippe, Daniel S; Lorans, Roxanne; Perry, Hannah; Moey, Tammy Hui Lin; Bagadiya, Neeti; Lee, Janie M

doi: 10.1093/jbi/wbac022pmid: 38416975

Feliciano-Rivera, Yara Z; Net, Jose; Velamuri, Sriram; Pluguez-Turull, Cedric; Yepes, Monica M

doi: 10.1093/jbi/wbac002pmid: 38416967

ObjectiveTo compare readers’ performances when detecting architectural distortion (AD) on digital breast tomosynthesis (DBT). To determine the risk of malignancy of DBT with synthetic mammogram (SM)–detected AD and evaluate imaging features that are associated with malignancy risk.MethodsThis IRB-approved retrospective review included all cases of DBT-detected AD that were recommended for biopsy from October 2013 to July 2019. Cases were reviewed by three breast radiologists and the overall agreement between radiologists was calculated. Medical records were reviewed for pathological outcomes and imaging findings. Statistical analyses used were Cohen’s kappa and its 95% confidence interval, and one-way analysis of variance.ResultsA total of 172 lesions were included. The overall agreement for the presence of AD in our study was fair (0.253). The majority (20/36, 55.5%) of the malignant ADs were associated with asymmetries (13/36, 36.1%), calcifications (4/36, 11.1%), or both (3/36, 8.3%), compared to nonmalignant ADs (40/136, 31.0%; P = 0.038). The positive predictive value (PPV) of DBT with SM-detected AD for malignancy was 21.8% (36/165), 18.8% (18/96) for DBT-detected AD, and 26.0% (18/69) for SM-detected AD, although the difference was not statistically significant (P = 0.258). A breast MRI correlate was identified for all malignant AD lesions (17/17, 100.0%; P = 0.004).ConclusionThe detection of AD remains a challenging task for radiologists, with moderate-to-fair interobserver agreement. With a PPV for malignancy of 21.8%, percutaneous biopsy and subsequent pathology-imaging correlation are necessary for AD to exclude the possibility of malignancy.

Jared Weinfurtner, R; Abdalah, Mahmoud; Stringfield, Olya; Ataya, Dana; Williams, Angela; Mooney, Blaise; Rosa, Marilin; Lee, Marie C; Khakpour, Nazanin; Laronga, Christine; Czerniecki, Brian; Diaz, Roberto; Ahmed, Kamran; Washington, Iman;

Kutay, Erin; Milch, Hannah; Sayre, James; Joines, Melissa; Hoyt, Anne; Li, Bo; Chan, Tiffany L

doi: 10.1093/jbi/wbac016pmid: 38416970

ObjectiveTo determine whether providing a biopsy marker informational handout to patients improves patient knowledge and comfort with receiving a marker.MethodsIn this IRB-exempt prospective study, a patient educational handout on breast biopsy markers was developed. A questionnaire was created with four questions asking patients to self-evaluate their knowledge of biopsy markers and their comfort level with marker placement before and after reading the handout. Technologists distributed the educational handouts to patients presenting for a percutaneous breast biopsy under any modality from December 11, 2020, to April 23, 2021. Data from the completed questionnaires were entered into a database. Statistical analyses included paired t-test and Wilcoxon analyses.ResultsIn total, 141 completed surveys were included in the analysis. The mean scores prior to reading the handout for knowledge and comfort were 2.59 and 3.40, respectively. After reading the handout, there was a significant increase in mean scores for knowledge and comfort (4.26 and 4.20, respectively) (P < 0.001). There was a 64% increase vs 23% increase for knowledge and comfort, respectively.ConclusionPatient-assessed knowledge of biopsy markers increased significantly after reading our educational handout. Patient-assessed comfort with biopsy marker placement also increased significantly after reading the educational handout, though to a lesser degree than knowledge. Although not included in our study, use of an educational handout may impact patient acceptance of marker placement. Future directions may include quantitatively assessing the effect of the handout on time to consent for a biopsy or influence on acceptance of marker placement.

Chan, Tiffany L; De, Rohit; Sayre, James; Reno, Elaine

doi: 10.1093/jbi/wbac014pmid: 38416969

ObjectiveTo assess how a virtual shadowing (VS) session on breast imaging (BI), shared through social media, can increase interest and awareness of radiology in pre-medical students.MethodsThis study was IRB exempt. A VS slide presentation on BI mentorship, didactic lecture, and deidentified image-rich, case-based learning was created. This session was advertised and presented live through an Instagram page (Pre-Health Virtual Shadowing, @virtualshadowing) geared toward pre-health students. Students were asked to complete a two-question self-assessment using a 5-point Likert scale on which 1 was “least” and 5 was “most.” Question 1 read: “Please rate your overall knowledge about radiology and what a radiologist does,” and question 2 read: “Please rate your interest in possibly looking into radiology as a potential career.”ResultsA total of 420 participants logged into the VS session; 82% (345/420) answered the pre-session survey and 48% (202/420) answered the post-session survey. Of post-survey respondents, 84% (170/202) were female and 70% (143/202) were 22 years old or younger. There was a significant difference in mean pre-session survey responses to question 1 when compared to mean post-session survey responses (2.67 vs 3.55, P < 0.001). There was also a significant difference in mean pre-session survey responses to question 2 when compared to mean post-session survey responses (3.16 vs 3.58, P < 0.001). Our VS session remains on YouTube and has 6157 views to date.ConclusionWhen shared through VS on social media, breast imaging can increase interest and awareness of radiology in pre-medical students.

Zamora, Kathryn W; Talley, Rachel; Hermecz, Brittany N; Wei, Shi

doi: 10.1093/jbi/wbac018pmid: 38416972

Myofibroblastomas are rare benign spindle cell tumors that occur within both male and female breasts. They are composed of fibroblasts and myofibroblasts and are not associated with malignant potential. On mammographic and sonographic imaging, these tumors may present as oval circumscribed masses that overlap with the appearance of many benign entities, including fibroadenomas. Occasionally, the tumors may demonstrate interval growth or mimic imaging features of malignancy and require biopsy. Correct pathologic diagnosis is important because many morphologic variants exist, which complicates pathologic interpretation. The purpose of this article is to review the range of imaging manifestations and histopathological findings and to discuss current management.

Smetherman, Dana; Golding, Lauren; Moy, Linda; Rubin, Eric

doi: 10.1093/jbi/wbac012pmid: 38416968

This article explores the development of computer-aided detection (CAD) and artificial or augmented intelligence (AI) for breast radiology examinations and describes the current applications of AI in breast imaging. Although radiologists in other subspecialties may be less familiar with the use of these technologies in their practices, CAD has been used in breast imaging for more than two decades, as mammography CAD programs have been commercially available in the United States since the late 1990s. Likewise, breast radiologists have seen payment for CAD in mammography and breast MRI evolve over time. With the rapid expansion of AI products in radiology in recent years, many new applications for these technologies in breast imaging have emerged. This article outlines the current state of reimbursement for breast radiology AI algorithms within the traditional fee-for-service model used by Medicare and commercial insurers as well as potential future payment pathways. In addition, the inherent challenges of employing the existing payment framework in the United States to AI programs in radiology are detailed for the reader. This article aims to give breast radiologists a better understanding of how AI will be reimbursed as they seek to further incorporate these emerging technologies into their practices to advance patient care and improve workflow efficiency.