Dorothy A. Sippo

An Abbreviated Protocol for High-Risk Screening Breast MRI Saves Time and Resources

PURPOSE To review the ability of an abbreviated, high-risk, screening, breast MRI protocol to detect cancer and save resources. METHODS High-risk screening breast MR images were reviewed, from both an abbreviated protocol and a full diagnostic protocol. Differences in cancer detection, scanner utilization, interpretation times, and need for additional imaging were recorded in an integrated data form, and reviewed and compared. RESULTS A total of 568 MRI cases were reviewed, with the abbreviated and full protocols. No difference was found in the number of cancers detected. Scan times were decreased by 18.8 minutes per case, for a total of 10,678 minutes (178 hours). Interpretation time, on average, was 1.55 minutes for the abbreviated protocol, compared with 6.43 minutes for the full protocol. Review of the full protocol led to a significant change in the final BI-RADS(®) assessment in 12 of 568 (2.1%) cases. CONCLUSIONS Abbreviated MRI is as effective as full-protocol MRI for demonstration of cancers in the high-risk screening setting, with only 12 (2.1%) cases recommended for additional MRI evaluation. The efficiency and resource savings of an abbreviated protocol would be significant, and would allow for opportunities to provide MRI for additional patients, as well as improved radiologist time management and workflow, with the potential to add real-time MRI interpretation or double reading.

Screening Breast MRI in Patients Previously Treated for Breast Cancer: Diagnostic Yield for Cancer and Abnormal Interpretation Rate.

RATIONALE AND OBJECTIVES To determine the cancer detection rate and abnormal interpretation rate of screening breast magnetic resonance imaging (MRI) in previously treated breast cancer patients. MATERIALS AND METHODS Institutional review board-approved retrospective review of the breast MRI database from 2009 to 2011 identified a total of 3297 screening examinations. After excluding genetic mutation carriers, untested first-degree relatives of known mutation carriers, and patients with a history of chest irradiation, there were 1194 (36.2%) examinations in 691 patients previously treated for breast cancer. MRI reports were reviewed to determine MRI findings and breast imaging reporting and data system (BI-RADS) assessments. The longitudinal medical record was reviewed to determine patient demographics and outcomes of imaging surveillance and biopsy. RESULTS Mean patient age at initial cancer diagnosis was 46.1 years, and mean patient age during the study interval was 52 years. Cancer detection rate was 10 per 1000 (1%; 95% confidence interval [CI], 0.5%-1.8%]; 12 of 1194 examinations). Overall 10.7% (128 of 1194) of examinations received an abnormal interpretation, including 5.4% (65 of 1194) BI-RADS 4 or 5 and 5.3% (63 of 1194) BI-RADS 3 assessments with a 9.4% positive predictive value (PPV1; 12 of 128 examinations) and a 17.9% PPV3 (12 malignancies per 67 biopsies). CONCLUSIONS Screening breast MRI in women previously treated for breast cancer detected cancer in 1.0% of examinations, with a 10.7% abnormal interpretation rate, and a PPV for malignancy of 17.9%.

Characteristics, Malignancy Rate, and Follow-up of BI-RADS Category 3 Lesions Identified at Breast MR Imaging: Implications for MR Image Interpretation and Management

Purpose To (a) evaluate the frequency of Breast Imaging Reporting and Data System (BI-RADS) category 3 assessment in screening and diagnostic breast magnetic resonance (MR) imaging, (b) review findings considered indicative of BI-RADS category 3, and (c) determine outcomes of BI-RADS category 3 lesions, including upgrades, downgrades, and malignancy rates. Materials and Methods This retrospective study was approved by the institutional review board and compliant with HIPAA. The authors retrospectively reviewed the breast MR imaging database (2009-2011) to identify breast MR images classified as showing BI-RADS category 3 lesions. There were 9216 BI-RADS assessments in 5778 examinations (3360 women). Of the 9216 assessments, 567 (6%) in 483 women (average age, 47.2 years; median age, 47.0 years) were assigned BI-RADS category 3. In women with more than one BI-RADS category 3 lesion, the first lesion reported in the impression was used for data analysis. Outcomes data were available for 435 of the 483 women (90.1%). These women comprised the study cohort. Medical records from January 1, 2009, to May 31, 2015, were reviewed to obtain demographic characteristics and outcomes. χ(2) statistics and 95% exact confidence intervals (CIs) were constructed. Results MR imaging was performed for high-risk screening in 240 of the 435 patients (55.2%) and for diagnostic purposes in 195 (44.8%). Findings included mass (n = 125, 28.7%), focus (n = 111, 25.5%), nonmass enhancement (n = 80, 18.3%), moderate or marked background parenchymal enhancement (BPE) (n = 91, 20.9%), posttreatment changes (n = 16, 3.8%), and other findings (n = 12, 2.8%). Outcomes were as follows: 339 of the 435 patients (78%) did not have evidence of malignancy at more than 24 months, 28 (6.4%) underwent mastectomy (all benign), and 68 (15.6%) had lesion upgrades, with 11 cancers (2.5%). All 11 cancers were diagnosed in women with a genetic mutation or a personal history of breast cancer. No cancer was detected in cases of moderate or marked BPE. Conclusion Six percent of all breast MR imaging assessments were categorized as BI-RADS category 3, with a cancer rate of 2.5% (95% CI: 1.3%, 4.5%). All cancers were in women with a genetic mutation or personal history of breast cancer. Marked BPE does not necessitate a BI-RADS 3 assessment. (©) RSNA, 2016.

Metastatic Disease to the Breast From Extramammary Malignancies: A Multimodality Pictorial Review

This pictorial review demonstrates imaging features of extramammary malignancies metastatic to the breast seen with multiple modalities, including mammography, ultrasound, computed tomography (CT), positron emission tomography, and magnetic resonance imaging. Although rare, metastases to the breast may have a distinct imaging appearance from the appearance of primary breast cancers. They are important to identify because they can mimic benign breast disease and their treatment differs from that of primary breast cancer. Metastatic disease to the breast most commonly appears as a single round or oval mass with circumscribed margins. Sonographically it is usually hypoechoic, and with CT or magnetic resonance imaging it usually enhances. In contrast with primary breast cancer, breast metastases do not demonstrate spiculated margins and rarely have associated calcifications. A variety of clinical presentations of breast metastases are reviewed, including presentation with a palpable mass, detection at screening mammography, and detection with CT or positron emission tomography.

Breast MR Imaging for Equivocal Mammographic Findings: Help or Hindrance?

Breast magnetic resonance (MR) imaging, because of its extremely high sensitivity in detecting invasive breast cancers, is sometimes used as a diagnostic tool to evaluate equivocal mammographic findings. However, breast MR imaging should never substitute for a complete diagnostic evaluation or for biopsy of suspected, localizable suspicious mammographic lesions, whenever possible. The modalitys high cost, in addition to only moderate specificity, mandate that radiologists use it sparingly and with discrimination for problematic mammographic findings. It is rare that the reality or significance of a noncalcified mammographic finding remains equivocal or problematic at diagnostic mammography evaluation, which usually includes targeted ultrasonography (US). There are several reasons for this infrequent occurrence: (a) an asymmetry may persist on diagnostic views but be visible only on craniocaudal or mediolateral oblique projections, precluding three-dimensional localization for US or biopsy, or a lesion may persist on some diagnostic spot views but dissipate or efface on others; (b) uncertainty may exist as to whether apparent change is clinically important or owing to technical factors such as compression or positioning differences; or (c) a lesion may be suspected but biopsy options are limited owing to lack of a US correlate and lesion inaccessibility for stereotactic biopsy, or biopsy of a vague or questionably real lesion has been attempted unsuccessfully. This article will discuss the indications for problem-solving MR imaging for equivocal mammographic findings, present cases illustrating appropriate and inappropriate uses of problem-solving MR imaging, and present false-positive and false-negative cases affecting the specificity of breast MR imaging. (©)RSNA, 2016.

Clinical Utility of Breast MRI in the Diagnosis of Malignancy After Inconclusive or Equivocal Mammographic Diagnostic Evaluation

OBJECTIVE The purpose of this study was to determine the clinical utility of breast MRI for diagnosing malignancy in women with equivocal mammographic findings but no symptoms. MATERIALS AND METHODS Retrospective review of an institutional MRI database of 7332 contrast-enhanced breast MRI examinations from January 1, 2009, through December 31, 2012, yielded the records of 296 (4.0%) examinations of 294 women without symptoms who underwent MRI for mammographic findings uncertain at diagnostic evaluation. Imaging findings, histopathologic results, and patient demographics were obtained from the electronic medical record. RESULTS The mean patient age was 55 years (range, 29-83 years). Mammographic lesion type (n = 294) included 89 focal asymmetries, 76 asymmetries, 64 masses, 44 architectural distortions, 17 surgical scar versus lesion, and four miscellaneous lesions. Diagnostic ultrasound, performed on 286 of 294 (97.3%) lesions at mammographic evaluation, showed an ultrasound correlate in 37 (12.9%) lesions, equivocal correlate in 48 (16.8%), and no ultrasound correlate in 201 (70.3%). MRI examination of 294 index lesions showed a correlate in 133 (45.2%) and no correlate in 161 (54.8%). Forty of 294 (13.6%) index lesions were malignant, 37 (92.5%) with an MRI correlate and three (7.5%) without an MRI correlate. Among 250 patients who underwent biopsy or had 2 or more years of imaging stability, the sensitivity, specificity, negative predictive value, and positive predictive value of breast MRI for malignancy were 92.5%, 62.4%, 97.8%, and 31.9%. Forty-four of 294 (15.0%) patients had lesions incidentally found at MRI; 7 of 41 (17.1%) lesions that were biopsied or were stable for at least 1 year were malignant. CONCLUSION Problem-solving breast MRI for inconclusive mammographic findings helps identify malignancies with high sensitivity and a high negative predictive value.

Quality Improvement Projects for Value-Based Care in Breast Imaging

INTRODUCTION The Mammography Quality Standards Act [1], finalized in 1999, provides a strong foundation for demonstrating value-based patient care. The act requires an outcomes audit that correlates pathologic results with positive mammographic findings, requires the review of falsenegative mammographic results, and mandates that mammographic reports include an overall assessment of findings using structured terminology based on the ACR’s BI-RADS [2]. Now in its fifth edition, the 2013 BIRADS Atlas is a mature reporting lexicon, including finding descriptors across modalities and guidance on performing amedical outcomes audit. Mammography is particularly well suited for value-based care, with its focus on screening healthy populations. This creates continuity of care, with patients returning on an annual basis. Radiologists frequently explain diagnostic mammography and breast ultrasound results directly to patients and perform imagingguided procedures. Breast imaging is frequently practiced at multidisciplinary breast care centers, where radiologists, surgical oncologists, medical oncologists, and plastic surgeons are collocated and work in an integrated practice. In breast imaging, direct patient contact and close working relationships with related subspecialists create opportunities to identify patient-centered quality improvement (QI) projects. The ACR’s Imaging 3.0 initiative is a program that seeks to engage radiologists, referring physicians, and patients in a team-based approach to maintain the health of the population with high-quality care [3]. Value in health care is the health outcome per dollar of cost [4].With its long history

The Flexible Chain Saw During the American Civil War

”Cowards die many times before their deaths; the valiant never taste of death but once,” penned Shakespeare.1 The First Battle of Bull Run was also the first major land battle of the American Civil War and it was fought by many such valiant men. However, from the Union perspective, it would prove to be an inauspicious harbinger of things to come. A contemporary commentator wrote of this first of many Union defeats, “[Its] conception was unwise; the plan faulty; the execution imperfect.”2 Such a damning description might more aptly have summed up the appalling conditions under which young “surgeons” had to labor, often having just been plucked from their first year of medical school.3 Civil War films such as “Glory” and “Dances With Wolves” abound with portrayals of amputations as grisly affairs conducted by callous doctors insensitive to their patients’ emotional and physical anguish. In actuality, however, there was much hand-wringing, by those in charge, about the wretched state of affairs, as evidenced by the writings of the medical director of the Army of the Potomac, Dr. Jonathan Letterman: “The surgery of these battle-fields has been pronounced butchery...causing deep and heart-rending anxiety to those...who might...require the services of a surgeon....[T]hese sweeping denunciations...do injustice to a body of men who have labored faithfully....Some medical officers lost their lives in their devotion to duty...and others sickened from excessive labor.”4

Equilibrium radionuclide ventriculography with a large photopenic defect and displacement of the heart.

Equilibrium radionuclide ventriculography was performed in a 67-year-old woman with metastatic breast cancer. The patient was referred for baseline radionuclide ventriculography to evaluate ventricular function before initiating chemotherapy. The left anterior oblique view shows a large photondeficient area in the left lower chest extending cephalad to the level of the atria. This photopenic region appears to markedly displace the entire heart, in particular the left ventricle, to the middle of the chest (Figure 1). Otherwise, left and right ventricular volumes and regional wall motion were normal, and the left ventricular ejection fraction was 64%. The possible causes for this photopenic area were suspected to be a lung or diaphragmatic mass (primary malignancy vs metastasis), pleural effusion, atelectasis, pulmonary hypoplasia, lung resection, diaphragmatic hernia, intra-abdominal pathology, and elevated hemidiaphragm. Posteroanterior and lateral chest radiographs and a computed tomography scan of the chest (Figures 2 and 3) show a markedly elevated left hemidiaphragm that displaces the heart to the right, without other evidence of pulmonary or abdominal pathology. Radionuclide ventriculography is a useful imaging modality in the evaluation and monitoring of cardiac function in patients who receive cardiotoxic drugs. When this modality shows an unexpected heart position and associated photopenic defect, correlation with other imaging modalities, starting with chest radiographs, can be helpful to elucidate the etiology of this unexpected From the Division of Nuclear Medicine, St Luke’s Roosevelt Hospital Center, New York, NY. Reprint requests: Murali Meka, MD, Division of Nuclear Medicine, S & R 5, St Luke’s Hospital, 1111 Amsterdam Ave, New York, NY 10025; MMeka@chpnet.org. J Nucl Cardiol 2008;15:e21-e22. 1071-3581/

Automated Extraction of BI-RADS Final Assessment Categories from Radiology Reports with Natural Language Processing

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