Alison L. Chetlen

RADPEER Peer Review: Relevance, Use, Concerns, Challenges, and Direction Forward

RADPEER is a product developed by the ACR that aims to assist radiologists with quality assessment and improvement through peer review. The program opened in 2002, was initially offered to physician groups in 2003, developed an electronic version in 2005 (eRADPEER), revised the scoring system in 2009, and first surveyed the RADPEER membership in 2010. In 2012, a survey was sent to 16,000 ACR member radiologists, both users and nonusers of RADPEER, with the goal of understanding how to make RADPEER more relevant to its members. A total of 31 questions were used, some of which were repeated from the 2010 survey. The ACRs RADPEER committee has published 3 papers on the program since its inception. In this report, the authors summarize the survey results and suggest future opportunities for making RADPEER more useful to its membership.

Nonpuerperal mastitis and subareolar abscess of the breast.

OBJECTIVE The purpose of this article is to show radiologists how to readily recognize nonpuerperal subareolar abscess and its complications in order to help reduce the time to definitive therapy and improve patient care. To achieve this purpose, the various theories of pathogenesis and the associated histopathologic features are reviewed; the typical clinical characteristics are detailed in contrast to those seen in lactational abscess and inflammatory breast cancer; the common imaging findings are described with emphasis on the sonographic features; correlative pathologic findings are presented to reinforce the imaging findings as they pertain to disease origins; and the various treatment options are reviewed. CONCLUSION Nonpuerperal subareolar mastitis and abscess is a benign breast entity often associated with prolonged morbidity. Through better understanding of the underlying disease process the imaging, physical, and clinical findings of this rare process can be more readily recognized and treatment options expedited, improving patient care.

Conventional Medical Education and the History of Simulation in Radiology

Simulation is a promising method for improving clinician performance, enhancing team training, increasing patient safety, and preventing errors. Training scenarios to enrich medical student and resident education, and apply toward competency assessment, recertification, and credentialing are important applications of simulation in radiology. This review will describe simulation training for procedural skills, interpretive and noninterpretive skills, team-based training and crisis management, professionalism and communication skills, as well as hybrid and in situ applications of simulation training. A brief overview of current simulation equipment and software and the barriers and strategies for implementation are described. Finally, methods of measuring competency and assessment are described, so that the interested reader can successfully implement simulation training into their practice.

Breast cancer screening controversies: who, when, why, and how?

Mammographic screening is effective in reducing mortality from breast cancer. The issue is not whether mammography is effective, but whether the false positive rate and false negative rates can be reduced. This review will discuss controversies including the reduction in breast cancer mortality, overdiagnosis, the ideal screening candidate, and the optimal imaging modality for breast cancer screening. The article will compare and contrast screening mammography, tomosynthesis, whole-breast screening ultrasound, magnetic resonance imaging, and molecular breast imaging. Though supplemental imaging modalities are being utilized to improve breast cancer diagnosis, mammography still remains the gold standard for breast cancer screening.

Hematoma Formation During Breast Core Needle Biopsy in Women Taking Antithrombotic Therapy

OBJECTIVE The purpose of this study was to compare hematoma formation after breast core needle biopsy performed on patients undergoing and those not undergoing concurrent antithrombotic therapy. SUBJECTS AND METHODS A prospective assessment of core needle biopsies (stereotactic, ultrasound guided, or MRI guided) performed on patients enrolled between September 2011 and July 2012 formed the basis of this study. Postprocedure mediolateral and craniocaudal mammograms were evaluated for the presence and size of hematomas. Patients were clinically evaluated for complications 24-48 hours after the procedure through telephone call or face-to-face consultation. Needle size, type of biopsy, and presence of hematoma and documented complications were correlated with use of antithrombotic agents (including aspirin, warfarin, clopidogrel, and daily nonsteroidal antiinflammatory medications). RESULTS No clinically significant hematomas or bleeding complications were found. Eighty-nine of 617 (14.4%) non-clinically significant hematomas were detected on postprocedure mammograms. The probability of development of a non-clinically significant hematoma was 21.6% for patients taking antithrombotics and 13.0% for those not taking antithrombotics. Concurrent antithrombotic therapy and larger needle gauge were significant factors contributing to the probability of hematoma formation. The volume of the hematoma was not related to needle gauge or presence of antithrombotic therapy. CONCLUSION No clinically significant hematomas were found. Because there are potential life-threatening risks to stopping antithrombotic therapy before breast biopsy, withholding antithrombotic therapy for core needle breast biopsy is not recommended because the incidence of non-clinically significant hematoma is low.

Online Social Networking for Radiology

Online social networking services have changed the way we interact as a society and offer many opportunities to improve the way we practice radiology and medicine in general. This article begins with an introduction to social networking. Next, the latest advances in online social networking are reviewed, and areas where radiologists and clinicians may benefit from these new tools are discussed. This article concludes with several steps that the interested reader can take to become more involved in online social networking.

Incidental Internal Mammary Lymph Nodes Visualized on Screening Breast MRI

OBJECTIVE The frequency of visualization and size of internal mammary lymph nodes in women undergoing high-risk screening breast MRI is unknown. When these nodes are discovered on staging MRI of newly diagnosed breast cancer patients, management could present a treatment dilemma because normal size criteria do not exist. The aim of this study was to establish the average size and frequency of internal mammary lymph nodes observed in asymptomatic high-risk women undergoing screening breast MRI. MATERIALS AND METHODS We conducted a retrospective review of 108 women at high risk for breast cancer who underwent screening breast MRI between January 2010 and January 2014. Patients with new or previous diagnosis of breast cancer, prior nonbreast malignancy affecting the thorax or mediastinum, or previous radiation to the thorax were excluded. The presence, diameter, laterality, intercostal space, relationship to the internal mammary vessels, age, morphology, and clinical history of internal mammary lymph nodes were recorded. RESULTS Internal mammary lymph nodes were visualized in 50 of 108 high-risk patients, with an average size of 4.5 mm (range [± SD], 2-9 ± 1.59 mm). In the 50 women who had internal mammary lymph nodes visible on MRI, an average of 1.4 nodes (range, 1-3 nodes) were present. Internal mammary lymph nodes were more frequently visualized on the left (p < 0.001), at the second and third intercostal spaces (p = 0.007), and medial to the internal mammary vessels (p < 0.001). CONCLUSION In this small cohort, 1-3 presumed normal internal mammary lymph nodes measuring 2-9 mm (mean diameter 4.5 mm) were detected in about half of asymptomatic high-risk women presenting for screening MRI of the breasts.

Nodular Fasciitis in the Axillary Tail of the Breast

Nodular fasciitis is a benign proliferation of myofibroblasts which presents clinically as a rapidly growing mass with nonspecific features on imaging and high cellular activity on histopathology. Nodular fasciitis can be mistaken for malignant fibrous lesions such as soft tissue sarcoma or breast carcinoma when located within breast tissue. This presents a problem for appropriate treatment planning as the natural history of nodular fasciitis is spontaneous regression. We present the mammographic, sonographic, computed tomography, and histopathologic characteristics of nodular fasciitis in a 68 year female initially presenting with a rapidly enlarging right axillary mass.

Another Time, Another Space: The Evolution of the Virtual Journal Club.

Virtual journal clubs (VJCs) provide a standardized, easily accessible forum for evidence-based discussion. The new virtual reality setting in which journal clubs and other online education events now take place offers great advantages and new opportunities for radiologists in academic medicine and private practice. VJCs continue to evolve, largely due to many emerging technologies and platforms. VJCs will continue to play an increasingly important role in medical education, interdisciplinary interaction, and multi-institutional collaboration. In this article, we discuss how to conduct and lead a critical review of medical literature in the setting of a virtual or traditional journal club. We discuss the current applications of VJCs in medical and graduate medical education and continued lifelong learning. We also explain the advantages and disadvantages of VJCs over traditional venues. Finally, the reader will be given the tools to successfully implement and run a VJC.

A Simulation Screening Mammography Module Created for Instruction and Assessment: Radiology Residents vs National Benchmarks

RATIONALE AND OBJECTIVES To improve mammographic screening training and breast cancer detection, radiology residents participated in a simulation screening mammography module in which they interpreted an enriched set of screening mammograms with known outcomes. This pilot research study evaluates the effectiveness of the simulation module while tracking the progress, efficiency, and accuracy of radiology resident interpretations and also compares their performance against national benchmarks. MATERIALS AND METHODS A simulation module was created with 266 digital screening mammograms enriched with high-risk breast lesions (seven cases) and breast malignancies (65 cases). Over a period of 27 months, 39 radiology residents participated in the simulation screening mammography module. Resident sensitivity and specificity were compared to Breast Cancer Surveillance Consortium (BCSC data through 2009) national benchmark and American College of Radiology (ACR) Breast Imaging Reporting and Data System (BI-RADS) acceptable screening mammography audit ranges. RESULTS The sensitivity, the percentage of cancers with an abnormal initial interpretation (BI-RADS 0), among residents was 84.5%, similar to the BCSC benchmark sensitivity of 84.9% (sensitivity for tissue diagnosis of cancer within 1 year following the initial examination) and within the acceptable ACR BI-RADS medical audit range of ≥75%. The specificity, the percentage of noncancers that had a negative image interpretation (BI-RADS 1 or 2), among residents was 83.2% compared to 90.3% reported in the BCSC benchmark data, but lower than the suggested ACR BI-RADS range of 88%-95%. CONCLUSIONS Using simulation modules for interpretation of screening mammograms is a promising method for training radiology residents to detect breast cancer and to help them achieve competence toward national benchmarks.