Debra L. Monticciolo

Breast Cancer Screening With Imaging: Recommendations From the Society of Breast Imaging and the ACR on the Use of Mammography, Breast MRI, Breast Ultrasound, and Other Technologies for the Detection of Clinically Occult Breast Cancer

Screening for breast cancer with mammography has been shown to decrease mortality from breast cancer, and mammography is the mainstay of screening for clinically occult disease. Mammography, however, has well-recognized limitations, and recently, other imaging including ultrasound and magnetic resonance imaging have been used as adjunctive screening tools, mainly for women who may be at increased risk for the development of breast cancer. The Society of Breast Imaging and the Breast Imaging Commission of the ACR are issuing these recommendations to provide guidance to patients and clinicians on the use of imaging to screen for breast cancer. Wherever possible, the recommendations are based on available evidence. Where evidence is lacking, the recommendations are based on consensus opinions of the fellows and executive committee of the Society of Breast Imaging and the members of the Breast Imaging Commission of the ACR.

Professional and economic factors affecting access to mammography: a crisis today, or tomorrow? Results from a national survey.

Objective data and anecdotal reports have suggested that access to mammography may be declining because of facility closures and difficulty in recruiting and retaining radiologists and radiologic technologists. To gain insight into the practice patterns, use of emerging technologies, and concerns of breast imagers in current practice, the Society of Breast Imaging (SBI) conducted a national survey of breast imaging practices in the U.S.

Invasive Lobular Carcinoma: Spectrum of Enhancement and Morphology on Magnetic Resonance Imaging

Abstract: Invasive lobular carcinoma (ILC) may be a difficult tumor to detect early by physical examination, mammography, or ultrasound. We undertook this study to describe the spectrum of gadolinium enhancement and morphologic features of ILC on magnetic resonance imaging (MRI). Nineteen patients with ILC who presented with a palpable mass, a mammographically visible abnormality, or an unknown primary underwent preoperative MRI of both breasts using a T1‐weighted high‐resolution gradient echo sequence (pre‐ and postcontrast), and an echoplanar sequence during the administration of gadolinium. Using a quantitative measure of gadolinium uptake over time, called the extraction flow (EF) product, and a normal tissue threshold EF level of 25 or less, enhancement for 15 of the 19 cancers was characterized. By consensus, three radiologists categorized the morphologic features of the lesions. For the 15 cases of ILC that had echoplanar data, analysis showed peak EFs ranging between 25 and 120, and the majority showed EFs in the 30s. A substantial portion of two tumors enhanced in a similar fashion to normal breast tissue, with EFs in the low 20s. Morphologically MRI showed a focal mass in eight cases, regional enhancement in five, segmental enhancement in one, segmental enhancement with multiple small nodules in one, a mixture of a focal mass and regional enhancement in one, diffuse enhancement in one, multiple small nodules in one, and bilateral disease in one. Of the focal masses, seven were irregular in shape and one was round; six had ill‐defined margins and two had spiculated margins. All eight enhanced heterogeneously. Four cases had multifocal disease and one case had unsuspected contralateral disease discovered only on MRI. MRI using a combination of morphology and a quantitative measure of gadolinium uptake was able to detect the majority of cases of ILC. However, there was a variable morphologic appearance and contrast enhancement pattern on MRI. A few lesions were difficult to distinguish from normal tissue. This suggests that some cases of ILC may be difficult to detect on MRI. 

The American College of Radiology's BI-RADS 3 Classification in a Nationwide Screening Program: current assessment and comparison with earlier use.

Abstract:   The Breast Imaging Reporting and Data System allows radiologists to classify lesions as “probably benign—short interval follow‐up suggested” (category 3). The purpose of this study is to evaluate the recent use of the category 3 designation in a national cancer detection program. We analyzed data from the National Breast and Cervical Cancer Early Detection Program, a nationwide collaboration between the Centers for Disease Control and Prevention (CDC) and local health agencies that provides cancer screening for low‐income, uninsured women. The study population included all women at least 40 years old who had mammograms in the program through September 1999 (n = 826,424). Of the 826,424 mammograms, the percentage classified as category 3 in the initial phase (1991–1996, previously reported, n = 372,760) was 7.7%; of the most recent 453,664 mammograms (1996–1999), 6.0% were given this designation. During the same periods, the percentage of abnormal mammograms decreased from 2.6% to 2.1% and those needing “additional imaging” (category 0) increased from 5.0% to 6.9%. The percentage receiving a category 3, category 0, or abnormal designation decreased with increasing age for each classification. The percentage of category 3 mammograms varied by site from 1.1% to 12.2%. Overall the proportions of category 3 mammograms decreased over time, while requests for additional examinations increased. This suggests that patients were more likely than before to receive additional examinations prior to their final designation. The persistent wide variability in category 3 indicates further education and attention to the use of this category is warranted. 

Histologic Grading at Breast Core Needle Biopsy: Comparison with Results from the Excised Breast Specimen

Abstract:  The purpose of this study was to evaluate the correlation between histologic tumor grade obtained at breast core needle biopsy (CNB) with that obtained from the excised breast specimen. A total of 899 records from all patients with breast cancer from January 1999 to January 2003 were reviewed. Of these, 341 lesions had CNB for diagnosis and had pathology results prospectively graded for both the core and excised specimens. Patient age, lesion type and size, imaging method for biopsy, number of cores, core pathology, surgery performed, final diagnosis, nuclear grade, and combined grade were recorded. In 286 lesions (83.9%), nuclear grade was reported for both core and excised specimens. Of these, 219 (76.6%) were in agreement. Of the 67 that differed, 66 (98.5%) differed by one grade; 46 (68.7%) were upgraded. The groups did not differ in average tumor size, tumor pathology, or number of cores. In 288 lesions (84.5%), combined grade was reported for both core and excised specimens. Of these, 214 (74.3%) were in agreement. Of the 74 that differed, 71 (95.9%) differed by one grade and 50 (67.6%) were upgraded. Again, there were no significant differences in tumor size, type, or number of cores. Overall, nuclear grade and combined grade obtained at CNB each showed agreement with the corresponding excised specimen grading approximately 75% of the time. Grading obtained by CNB, if changed by pathologic evaluation of the excised tumor, is most commonly upgraded. Differences, when they occurred, could not be attributed to tumor size, type, or the number of cores obtained. 

Breast Cancer Screening for Average-Risk Women: Recommendations From the ACR Commission on Breast Imaging

Breast cancer is the most common non-skin cancer and the second leading cause of cancer death for women in the United States. Before the introduction of widespread mammographic screening in the mid-1980s, the death rate from breast cancer in the US had remained unchanged for more than 4 decades. Since 1990, the death rate has declined by at least 38%. Much of this change is attributed to early detection with mammography. ACR breast cancer screening experts have reviewed data from RCTs, observational studies, US screening data, and other peer-reviewed literature to update our recommendations. Mammography screening has consistently been shown to significantly reduce breast cancer mortality over a variety of study designs. The ACR recommends annual mammography screening starting at age 40 for women of average risk of developing breast cancer. Our recommendation is based on maximizing proven benefits, which include a substantial reduction in breast cancer mortality afforded by regular screening and improved treatment options for those diagnosed with breast cancer. The risks associated with mammography screening are also considered to assist women in making an informed choice.

The ACR/Society of Breast Imaging Resident and Fellowship Training Curriculum for Breast Imaging, Updated

The education committees of the ACR Commission on Breast Imaging and the Society of Breast Imaging have revised the resident and fellowship training curriculum to reflect the current state of breast imaging in the United States. The original curriculum, created by the Society of Breast Imaging in 2000, had been updated only once before, in 2006. Since that time, a number of significant changes have occurred in the way mammography is acquired, how adjunctive breast imaging methods are used, and how pathology is assessed. This curricular update is meant to reflect these and other changes and to offer guidance to educators and trainees in preparing those interested in providing breast imaging services.

Breast conserving therapy with accelerated partial breast versus external beam whole breast irradiation: comparison of imaging sequela and complications in a matched population.

Abstract:  Our purpose was to evaluate and compare the imaging sequela and complications of accelerated partial breast irradiation (APBI) with those occurring in patients treated with standard external beam therapy. Patient selection included those who met the criteria for possible ABPI: age 45 or older; cancer stage T1N0M0 or ductal carcinoma in situ 3 cm or less, and negative surgical margins. One hundred and ninety seven had complete records and films available for review. Ninety‐seven (49%) were treated with APBI (MammoSite) and 100(51%) were treated with external beam. Image findings for APBI versus external beam were: distortion 90(93%) versus 83(83%), seroma 67(69%) versus 7(7%), skin edema 52(54%) versus 47(47%), increased stroma 75(77%) versus 66(66%), calcifications 10(10%) versus 6(6%), and fat necrosis 12(12%) versus 6(6%). For APBI, skin and stromal edema was more commonly focal. At imaging, the seroma rate was statistically and significantly different between the two treatment modes (p < 0.0001). For patients treated with APBI, seroma formation was not related to balloon size and only weakly related to lumpectomy cavity size. The complication rate was significantly higher for those treated with APBI (36 versus 20%) and the types and treatment of complications differed. There were three recurrences among the APBI group and none among those treated with external beam radiation.

Postbiopsy Confirmation of MR-Detected Lesions Biopsied Using Ultrasound

OBJECTIVE The purpose of this article is to outline a quick and effective method of confirming MR-sonographic correlation for lesions detected with MRI but percutaneously biopsied using ultrasound. CONCLUSION Ensuring that a lesion seen on targeted ultrasound is the same as that detected at MRI can be difficult. For benign concordant lesions, a mismatch may only be discovered at 6-month postbiopsy MRI follow-up. However, lesion correlation can be established on the same day as biopsy by obtaining a single unenhanced T1-weighted non-fat-saturated pulse sequence just after percutaneous ultrasound-guided biopsy. Scanning time is less than 4 minutes. Postbiopsy changes and the biopsy clip are easily seen and help verify MR-sonographic lesion correlation.

Magnetic Resonance Imaging of the Breast for Cancer Diagnosis and Staging

Gadolinium-enhanced breast magnetic resonance imaging (MRI) is optimally suited for the diagnosis and assessment of breast cancer. The complete breast MRI examination, which includes select nonenhanced sequences, yields abundant information about the nature and stage of disease. In this article, we will explore cancer diagnosis by examining the main imaging features of breast malignancy as well as the assessment of surrounding structures. We will then discuss current ideas in the use of breast MRI in breast cancer, including high-risk screening, evaluation of extent of disease, role in surgical planning, and the use of MRI in the patient receiving neoadjuvant chemotherapy. Breast MRI plays an important role in the assessment of patients with breast malignancy-a role that is yet to be fully defined and used. By understanding the strengths and weakness of this imaging method in cancer evaluation, we hope to highlight the appropriate uses of the technique.