Kelly S. Myers

Atherosclerosis Inflammation Imaging with 18F-FDG PET: Carotid, Iliac, and Femoral Uptake Reproducibility, Quantification Methods, and Recommendations

Atherosclerosis imaging with 18F-FDG PET is useful for tracking inflammation within plaque and monitoring the response to drug therapy. Short-term reproducibility of this technique in peripheral artery disease has not been assessed, and the optimal method of 18F-FDG quantification is still debated. We imaged 20 patients with vascular disease using 18F-FDG PET twice, 14 d apart, and used these data to assess reproducibility measures and compare 2 methods of 18F-FDG uptake measurement. We also reviewed the literature on quantification methods to determine the optimal measures of arterial 18F-FDG uptake for future studies. Methods: Twenty patients with vascular disease underwent PET/CT of the iliac, femoral, and carotid arteries 90 min after 18F-FDG administration. In 19 patients, repeat testing was performed at 2 wk. Coregistration and attenuation correction were performed with CT. Vessel 18F-FDG uptake was measured as both the mean and maximum blood-normalized standardized uptake value (SUV), known as the target-to-background ratio (TBR). We assessed interscan, interobserver, and intraobserver agreement. Results: Nineteen patients completed both imaging sessions. The carotid and peripheral arteries all have excellent short-term reproducibility of the 18F-FDG signal, with intraclass correlation coefficients all greater than 0.8 for all measures of reproducibility. Both mean and maximum TBR measurements for quantifying 18F-FDG uptake are equally reproducible. 18F-FDG uptake was significantly higher in the carotid arteries than in both iliac and femoral vessels (P < 0.001 for both). Conclusion: We found that both mean and maximum TBR in the carotid, iliac, and femoral arteries were highly reproducible. We suggest the mean TBR be used for tracking systemic arterial therapies, whereas the maximum TBR is optimal for detecting and monitoring local, plaque-based therapy.

Relationships among regional arterial inflammation, calcification, risk factors, and biomarkers: a prospective fluorodeoxyglucose positron-emission tomography/computed tomography imaging study.

Background—Fluorodeoxyglucose positron-emission tomography (FDG PET) imaging of atherosclerosis has been used to quantify plaque inflammation and to measure the effect of plaque-stabilizing drugs. We explored how atherosclerotic plaque inflammation varies across arterial territories and how it relates to arterial calcification. We also tested the hypotheses that the degree of local arterial inflammation measured by PET is correlated with the extent of systemic inflammation and presence of risk factors for vascular disease. Methods and Results—Forty-one subjects underwent vascular PET/computed tomography imaging with FDG. All had either vascular disease or multiple risk factors. Forty subjects underwent carotid imaging, 27 subjects underwent aortic, 24 subjects iliac, and 13 subjects femoral imaging. Thirty-three subjects had a panel of biomarkers analyzed. We found strong associations between FDG uptake in neighboring arteries (left versus right carotid, r=0.91, P<0.001; ascending aorta versus aortic arch, r=0.88, P<0.001). Calcification and inflammation rarely overlapped within arteries (carotid artery FDG uptake versus calcium score, r=−0.42, P=0.03). Carotid artery FDG uptake was greater in those with a history of coronary artery disease (target-to-background ratio, 1.83 versus 1.61, P<0.01) and in males versus females (target-to-background ratio, 1.83 versus 1.63, P<0.05). Similar findings were also noted in the aorta and iliac arteries. Subjects with the highest levels of FDG uptake also had the greatest concentrations of inflammatory biomarkers (descending aorta target-to-background ratio versus matrix metalloproteinase 3, r=0.53, P=0.01; carotid target-to-background ratio versus matrix metalloproteinase 9, r=0.50, P=0.01). Nonsignificant positive trends were seen between FDG uptake and levels of interleukin-18, fibrinogen, and C-reactive protein. Finally, we found that the atheroprotective biomarker adiponectin was negatively correlated with the degree of arterial inflammation in the descending aorta (r=−0.49, P=0.03). Conclusions—This study shows that FDG PET imaging can increase our knowledge of how atherosclerotic plaque inflammation relates to calcification, serum biomarkers, and vascular risk factors. Plaque inflammation and calcification rarely overlap, supporting the theory that calcification represents a late, burnt-out stage of atherosclerosis. Inflammation in one arterial territory is associated with inflammation elsewhere, and the degree of local arterial inflammation is reflected in the blood levels of several circulating biomarkers. We suggest that FDG PET imaging could be used as a surrogate marker of both atherosclerotic disease activity and drug effectiveness. Prospective, event-driven studies are now underway to determine the role of this technique in clinical risk prediction.Background— Fluorodeoxyglucose positron-emission tomography (FDG PET) imaging of atherosclerosis has been used to quantify plaque inflammation and to measure the effect of plaque-stabilizing drugs. We explored how atherosclerotic plaque inflammation varies across arterial territories and how it relates to arterial calcification. We also tested the hypotheses that the degree of local arterial inflammation measured by PET is correlated with the extent of systemic inflammation and presence of risk factors for vascular disease. Methods and Results— Forty-one subjects underwent vascular PET/computed tomography imaging with FDG. All had either vascular disease or multiple risk factors. Forty subjects underwent carotid imaging, 27 subjects underwent aortic, 24 subjects iliac, and 13 subjects femoral imaging. Thirty-three subjects had a panel of biomarkers analyzed. We found strong associations between FDG uptake in neighboring arteries (left versus right carotid, r =0.91, P <0.001; ascending aorta versus aortic arch, r =0.88, P <0.001). Calcification and inflammation rarely overlapped within arteries (carotid artery FDG uptake versus calcium score, r =−0.42, P =0.03). Carotid artery FDG uptake was greater in those with a history of coronary artery disease (target-to-background ratio, 1.83 versus 1.61, P <0.01) and in males versus females (target-to-background ratio, 1.83 versus 1.63, P <0.05). Similar findings were also noted in the aorta and iliac arteries. Subjects with the highest levels of FDG uptake also had the greatest concentrations of inflammatory biomarkers (descending aorta target-to-background ratio versus matrix metalloproteinase 3, r =0.53, P =0.01; carotid target-to-background ratio versus matrix metalloproteinase 9, r =0.50, P =0.01). Nonsignificant positive trends were seen between FDG uptake and levels of interleukin-18, fibrinogen, and C-reactive protein. Finally, we found that the atheroprotective biomarker adiponectin was negatively correlated with the degree of arterial inflammation in the descending aorta ( r =−0.49, P =0.03). Conclusions— This study shows that FDG PET imaging can increase our knowledge of how atherosclerotic plaque inflammation relates to calcification, serum biomarkers, and vascular risk factors. Plaque inflammation and calcification rarely overlap, supporting the theory that calcification represents a late, burnt-out stage of atherosclerosis. Inflammation in one arterial territory is associated with inflammation elsewhere, and the degree of local arterial inflammation is reflected in the blood levels of several circulating biomarkers. We suggest that FDG PET imaging could be used as a surrogate marker of both atherosclerotic disease activity and drug effectiveness. Prospective, event-driven studies are now underway to determine the role of this technique in clinical risk prediction. Received August 3, 2008; accepted December 23, 2008. # CLINICAL PERSPECTIVE {#article-title-2}Background —Fluorodeoxyglucose positron emission tomography (FDG PET) imaging of atherosclerosis has been used to quantify plaque inflammation and to measure the effect of plaque stabilizing drugs. Here we explore how atherosclerotic plaque inflammation varies across arterial territories and how it relates to arterial calcification. We also test the hypotheses that the degree of local arterial inflammation measured by PET is correlated with the extent of systemic inflammation and presence of risk factors for vascular disease. Methods and Results —Forty-one subjects underwent vascular PET/CT imaging with FDG. All had either vascular disease or multiple risk factors for it. Forty subjects underwent carotid imaging, twenty-seven underwent aortic, twenty-four iliac and thirteen femoral imaging. Thirty-three subjects had a panel of biomarkers analyzed. We found strong associations between FDG uptake in neighboring arteries (left vs. right carotid r=0.91, p<0.001, ascending aorta vs. aortic arch r=0.88, p<0.001). Calcification and inflammation rarely overlapped within arteries — carotid artery FDG uptake vs. calcium score r=-0.42, p=0.03). Carotid artery FDG uptake was greater in those with a history of coronary artery disease (target to background ratio (TBR) 1.83 vs. 1.61, p<0.01), and in males vs. females (TBR 1.83 vs. 1.63, p<0.05). Similar findings were also noted in the aorta and iliac arteries. Subjects with the highest levels of FDG uptake also had the greatest concentrations of inflammatory biomarkers: descending aorta TBR vs. matrix metalloproteinase 3 (MMP 3): r=0.53, p=0.01 and carotid TBR vs. MMP 9: r=0.50, p=0.01. Non-significant positive trends were seen between FDG uptake and levels of interleukin 18, fibrinogen and C-reactive protein. Finally, we found that the atheroprotective biomarker adiponectin was negatively correlated with the degree of arterial inflammation in the descending aorta: r=-0.49, p=0.03). Conclusions —This study shows that FDG PET imaging can increase our knowledge of how atherosclerotic plaque inflammation relates to calcification, serum biomarkers and vascular risk factors. Plaque inflammation and calcification rarely overlap, supporting the theory that calcification represents a late, burnt-out stage of atherosclerosis. Inflammation in one arterial territory is associated with inflammation elsewhere, and the degree of local arterial inflammation is reflected in the blood levels of several circulating biomarkers. We suggest that FDG PET imaging could be used as a surrogate marker of both atherosclerotic disease activity and drug effectiveness. Prospective, event driven studies are now underway to determine the role of this technique in clinical risk prediction.

Correlation between arterial FDG uptake and biomarkers in peripheral artery disease.

OBJECTIVES A prospective, multicenter (18)fluorine-fluorodeoxyglucose ((18)F-FDG) positron emission tomography (PET)/computed tomography (CT) imaging study was performed to estimate the correlations among arterial FDG uptake and atherosclerotic plaque biomarkers in patients with peripheral artery disease. BACKGROUND Inflammation within atherosclerotic plaques is associated with instability of the plaque and future cardiovascular events. Previous studies have shown that (18)F-FDG-PET/CT is able to quantify inflammation within carotid artery atherosclerotic plaques, but no studies to date have investigated this correlation in peripheral arteries with immunohistochemical confirmation. METHODS Thirty patients across 5 study sites underwent (18)F-FDG-PET/CT imaging before SilverHawk atherectomy (FoxHollow Technologies, Redwood City, California) for symptomatic common or superficial femoral arterial disease. Vascular FDG uptake (expressed as target-to-background ratio) was measured in the carotid arteries and aorta and femoral arteries, including the region of atherectomy. Immunohistochemistry was performed on the excised atherosclerotic plaque extracts, and cluster of differentiation 68 (CD68) level as a measure of macrophage content was determined. Correlations between target-to-background ratio of excised lesions, as well as entire arterial regions, and CD68 levels were determined. Imaging was performed during the 2 weeks before surgery in all cases. RESULTS Twenty-one patients had adequate-quality (18)F-FDG-PET/CT peripheral artery images, and 34 plaque specimens were obtained. No significant correlation between lesion target-to-background ratio and CD68 level was observed. CONCLUSIONS There were no significant correlations between CD68 level (as a measure of macrophage content) and FDG uptake in the peripheral arteries in this multicenter study. Differences in lesion extraction technique, lesion size, the degree of inflammation, and imaging coregistration techniques may have been responsible for the failure to observe the strong correlations with vascular FDG uptake observed in previous studies of the carotid artery and in several animal models of atherosclerosis.

Imaging Appearance and Clinical Impact of Preoperative Breast MRI in Pregnancy-Associated Breast Cancer

OBJECTIVE The purpose of this study is to describe the imaging features of pregnancy-associated breast cancer (PABC) on breast MRI and to consider the impact of preoperative MRI on patient management. MATERIALS AND METHODS A retrospective review of medical records from January 1994 to May 2014 identified 183 women who presented with a new diagnosis of breast cancer during pregnancy or within 1 year postpartum. MR images were available for 53 of these patients, all of whom were included in the study. Clinical history and available breast images were reviewed. The clinical impact of preoperative breast MRI was also recorded. RESULTS Of the 53 women, nine (17%) presented during pregnancy and 44 (83%) presented during the first year postpartum. The sensitivity of MRI was 98% (52/53). Among the 53 patients, the most common findings of PABC on MRI included a solitary mass (29 patients [55%]), nonmass enhancement (12 patients [23%]), and multiple masses (eight patients [15%]). For 12 patients (23%), MRI showed a pathologically proven larger tumor size or greater extent of disease than did mammography or ultrasound, with an additional eight patients (15%) having findings suspicious for greater extent of disease but having unavailable pathologic data. Breast MRI changed surgical management for 15 patients (28%), with four patients (8%) requiring a larger lumpectomy, seven (13%) no longer being considered candidates for lumpectomy, two (4%) having contralateral disease, and two (4%) having unsuspected metastasis. CONCLUSION Breast MRI had a high sensitivity for PABC in our study population. MRI may play an important role in PABC because it changed the surgical management of 28% of patients.

Multimodality imaging of atherosclerosis (magnetic resonance imaging/computed tomography/positron emission tomography-computed tomography).

This review discusses the field of atherosclerosis imaging with magnetic resonance imaging, computed tomography and positron emission tomography techniques, and highlights important publications in this area. Future directions and challenges ahead for plaque imaging are also highlighted.

MRI-Guided Breast Biopsy: Outcomes and Effect on Patient Management

INTRODUCTION The purpose of this study was to correlate the pathology results of MRI-guided breast biopsies at our institution with MRI findings and patient clinical history characteristics. The effect of MRI-guided breast biopsies on surgical management in patients with a new diagnosis of breast cancer was also assessed. PATIENTS AND METHODS In this Health Insurance Portability and Accountability Act-compliant study we retrospectively reviewed all MRI-guided breast biopsies performed from March 2006 to May 2012. Clinical history, MRI features, and pathology outcomes were reviewed. In patients who underwent breast MRI to evaluate extent of disease, any change in surgical management resulting from the MRI-guided biopsy was recorded. Statistical analysis included binary logistic regression and independent Student t test. RESULTS Two-hundred fifteen lesions in 168 patients were included, of which 23 (10.7%) were malignant, 43 (20%) were high-risk, and 149 (69.3%) were benign. No clinical characteristic was associated with malignancy in our cohort. MRI features associated with malignancy were: larger size (mean 2.6 cm vs. 1.3 cm; P = .046), washout kinetics (18% malignancy rate; P = .02), and marked background parenchymal enhancement (40% malignancy rate; P < .001-.03). Nineteen (28%) of the 67 patients with a new diagnosis of breast cancer who underwent MRI-guided breast biopsy had a change in surgical management based on the biopsy result. CONCLUSION Malignancy rate was associated with lesion size, washout kinetics, and marked background enhancement of the breast parenchyma but was not associated with any clinical history characteristics. Preoperative MRI-guided breast biopsies changed surgical management in 28% of women with a new diagnosis of breast cancer.

The Relationships Between Regional Arterial Inflammation, Calcification, Risk Factors and Biomarkers – A Prospective FDG PET/CT Imaging Study

Background—Fluorodeoxyglucose positron-emission tomography (FDG PET) imaging of atherosclerosis has been used to quantify plaque inflammation and to measure the effect of plaque-stabilizing drugs. We explored how atherosclerotic plaque inflammation varies across arterial territories and how it relates to arterial calcification. We also tested the hypotheses that the degree of local arterial inflammation measured by PET is correlated with the extent of systemic inflammation and presence of risk factors for vascular disease. Methods and Results—Forty-one subjects underwent vascular PET/computed tomography imaging with FDG. All had either vascular disease or multiple risk factors. Forty subjects underwent carotid imaging, 27 subjects underwent aortic, 24 subjects iliac, and 13 subjects femoral imaging. Thirty-three subjects had a panel of biomarkers analyzed. We found strong associations between FDG uptake in neighboring arteries (left versus right carotid, r=0.91, P<0.001; ascending aorta versus aortic arch, r=0.88, P<0.001). Calcification and inflammation rarely overlapped within arteries (carotid artery FDG uptake versus calcium score, r=−0.42, P=0.03). Carotid artery FDG uptake was greater in those with a history of coronary artery disease (target-to-background ratio, 1.83 versus 1.61, P<0.01) and in males versus females (target-to-background ratio, 1.83 versus 1.63, P<0.05). Similar findings were also noted in the aorta and iliac arteries. Subjects with the highest levels of FDG uptake also had the greatest concentrations of inflammatory biomarkers (descending aorta target-to-background ratio versus matrix metalloproteinase 3, r=0.53, P=0.01; carotid target-to-background ratio versus matrix metalloproteinase 9, r=0.50, P=0.01). Nonsignificant positive trends were seen between FDG uptake and levels of interleukin-18, fibrinogen, and C-reactive protein. Finally, we found that the atheroprotective biomarker adiponectin was negatively correlated with the degree of arterial inflammation in the descending aorta (r=−0.49, P=0.03). Conclusions—This study shows that FDG PET imaging can increase our knowledge of how atherosclerotic plaque inflammation relates to calcification, serum biomarkers, and vascular risk factors. Plaque inflammation and calcification rarely overlap, supporting the theory that calcification represents a late, burnt-out stage of atherosclerosis. Inflammation in one arterial territory is associated with inflammation elsewhere, and the degree of local arterial inflammation is reflected in the blood levels of several circulating biomarkers. We suggest that FDG PET imaging could be used as a surrogate marker of both atherosclerotic disease activity and drug effectiveness. Prospective, event-driven studies are now underway to determine the role of this technique in clinical risk prediction.Background— Fluorodeoxyglucose positron-emission tomography (FDG PET) imaging of atherosclerosis has been used to quantify plaque inflammation and to measure the effect of plaque-stabilizing drugs. We explored how atherosclerotic plaque inflammation varies across arterial territories and how it relates to arterial calcification. We also tested the hypotheses that the degree of local arterial inflammation measured by PET is correlated with the extent of systemic inflammation and presence of risk factors for vascular disease. Methods and Results— Forty-one subjects underwent vascular PET/computed tomography imaging with FDG. All had either vascular disease or multiple risk factors. Forty subjects underwent carotid imaging, 27 subjects underwent aortic, 24 subjects iliac, and 13 subjects femoral imaging. Thirty-three subjects had a panel of biomarkers analyzed. We found strong associations between FDG uptake in neighboring arteries (left versus right carotid, r =0.91, P <0.001; ascending aorta versus aortic arch, r =0.88, P <0.001). Calcification and inflammation rarely overlapped within arteries (carotid artery FDG uptake versus calcium score, r =−0.42, P =0.03). Carotid artery FDG uptake was greater in those with a history of coronary artery disease (target-to-background ratio, 1.83 versus 1.61, P <0.01) and in males versus females (target-to-background ratio, 1.83 versus 1.63, P <0.05). Similar findings were also noted in the aorta and iliac arteries. Subjects with the highest levels of FDG uptake also had the greatest concentrations of inflammatory biomarkers (descending aorta target-to-background ratio versus matrix metalloproteinase 3, r =0.53, P =0.01; carotid target-to-background ratio versus matrix metalloproteinase 9, r =0.50, P =0.01). Nonsignificant positive trends were seen between FDG uptake and levels of interleukin-18, fibrinogen, and C-reactive protein. Finally, we found that the atheroprotective biomarker adiponectin was negatively correlated with the degree of arterial inflammation in the descending aorta ( r =−0.49, P =0.03). Conclusions— This study shows that FDG PET imaging can increase our knowledge of how atherosclerotic plaque inflammation relates to calcification, serum biomarkers, and vascular risk factors. Plaque inflammation and calcification rarely overlap, supporting the theory that calcification represents a late, burnt-out stage of atherosclerosis. Inflammation in one arterial territory is associated with inflammation elsewhere, and the degree of local arterial inflammation is reflected in the blood levels of several circulating biomarkers. We suggest that FDG PET imaging could be used as a surrogate marker of both atherosclerotic disease activity and drug effectiveness. Prospective, event-driven studies are now underway to determine the role of this technique in clinical risk prediction. Received August 3, 2008; accepted December 23, 2008. # CLINICAL PERSPECTIVE {#article-title-2}Background —Fluorodeoxyglucose positron emission tomography (FDG PET) imaging of atherosclerosis has been used to quantify plaque inflammation and to measure the effect of plaque stabilizing drugs. Here we explore how atherosclerotic plaque inflammation varies across arterial territories and how it relates to arterial calcification. We also test the hypotheses that the degree of local arterial inflammation measured by PET is correlated with the extent of systemic inflammation and presence of risk factors for vascular disease. Methods and Results —Forty-one subjects underwent vascular PET/CT imaging with FDG. All had either vascular disease or multiple risk factors for it. Forty subjects underwent carotid imaging, twenty-seven underwent aortic, twenty-four iliac and thirteen femoral imaging. Thirty-three subjects had a panel of biomarkers analyzed. We found strong associations between FDG uptake in neighboring arteries (left vs. right carotid r=0.91, p<0.001, ascending aorta vs. aortic arch r=0.88, p<0.001). Calcification and inflammation rarely overlapped within arteries — carotid artery FDG uptake vs. calcium score r=-0.42, p=0.03). Carotid artery FDG uptake was greater in those with a history of coronary artery disease (target to background ratio (TBR) 1.83 vs. 1.61, p<0.01), and in males vs. females (TBR 1.83 vs. 1.63, p<0.05). Similar findings were also noted in the aorta and iliac arteries. Subjects with the highest levels of FDG uptake also had the greatest concentrations of inflammatory biomarkers: descending aorta TBR vs. matrix metalloproteinase 3 (MMP 3): r=0.53, p=0.01 and carotid TBR vs. MMP 9: r=0.50, p=0.01. Non-significant positive trends were seen between FDG uptake and levels of interleukin 18, fibrinogen and C-reactive protein. Finally, we found that the atheroprotective biomarker adiponectin was negatively correlated with the degree of arterial inflammation in the descending aorta: r=-0.49, p=0.03). Conclusions —This study shows that FDG PET imaging can increase our knowledge of how atherosclerotic plaque inflammation relates to calcification, serum biomarkers and vascular risk factors. Plaque inflammation and calcification rarely overlap, supporting the theory that calcification represents a late, burnt-out stage of atherosclerosis. Inflammation in one arterial territory is associated with inflammation elsewhere, and the degree of local arterial inflammation is reflected in the blood levels of several circulating biomarkers. We suggest that FDG PET imaging could be used as a surrogate marker of both atherosclerotic disease activity and drug effectiveness. Prospective, event driven studies are now underway to determine the role of this technique in clinical risk prediction.

Variability in the Management Recommendations Given for High-risk Breast Lesions Detected on Image-guided Core Needle Biopsy at U.S. Academic Institutions

The purpose of this study was to describe and compare the management recommendations provided in the setting of a high-risk lesion diagnosed on core needle biopsy of the breast at academic institutions across the United States. We contacted breast imagers at U.S. academic institutions via email and asked them to complete a voluntary online survey. The survey consisted of eight questions regarding the management recommendations given when core biopsy yields various high-risk lesions. We received survey responses from 41 of the 59 institutions contacted (69% response rate). Surgical excision was the most frequently reported recommendation given for all high-risk lesions; however, the proportion varied from 95% for atypical ductal hyperplasia and papilloma with associated atypia, 76% for flat epithelial atypia, 73% for radial scar/complex sclerosing lesion, 71% for lobular carcinoma in-situ, 61% for atypical lobular hyperplasia, to 39% for intraductal papilloma without atypia. Our study demonstrates inconsistency in the management recommendations given for high-risk lesions detected on core needle biopsy at academic institutions nationally. This outcome suggests that patients may benefit from the creation of consensus recommendations for the management of high-risk lesions detected on core needle biopsy.

Characteristics and Outcomes of BI-RADS 3 Lesions on Breast MRI

Micro‐Abstract In a study of the imaging findings prompting a Breast Imaging Reporting and Data System (BI‐RADS) 3 assessment and reports of their outcomes, we assessed 199 breast MRI lesions assigned a BI‐RADS 3 assessment. Of these, 80 (40%) of 199 were non–mass enhancement, 61 (31%) of 199 were a single focus and 58 (29%) of 199 were masses; of the 131 lesions with appropriate follow‐up, 4 (3%) were diagnosed as malignant within a 2‐year follow‐up period. Despite limited data on the use of BI‐RADS 3 at breast MRI, there is a low malignancy rate of 3%. Background: There are few data regarding the use and outcomes of Breast Imaging Reporting and Data System (BI‐RADS) 3 assessment on breast magnetic resonance imaging (MRI). The aim of this study was to describe the imaging findings prompting a BI‐RADS 3 assessment and to report their outcomes, including the timing of follow‐up examinations. Patients and Methods: We performed a retrospective study evaluating 199 breast lesions in 186 patients who were assigned a BI‐RADS 3 assessment on breast MRI over a 5‐year period. Clinical and imaging features were recorded. For outcomes analysis, lesions were considered benign if they showed 2 years of MRI stability, if they were declared benign during follow‐up, or if the patient underwent biopsy with benign pathology results. Clinical and imaging features of BI‐RADS 3 lesions associated with malignancy were assessed by the Fisher exact test, with P < .05 considered significant. Results: Of the 199 breast MRI lesions assigned a BI‐RADS 3 assessment, 80 (40%) of 199 were non–mass enhancement, 61 (31%) were a single focus, and 58 (29%) were masses. A total of 131 lesions (66%) were eligible for outcome analysis after excluding those lost to follow‐up; 4 (3%) were diagnosed as malignant within the 2‐year follow‐up. Masses assigned a BI‐RADS 3 assessment were more likely to be malignant during follow‐up than non–mass enhancement or single focus (P < .05). Conclusion: Despite limited data on the use of BI‐RADS 3 at breast MRI, there is a low malignancy rate of 3% at our institution. Additional studies are needed to further define the appropriate use of BI‐RADS 3 on breast MRI.

Impact of insurance coverage and socioeconomic factors on screening mammography patients’ selection of digital breast tomosynthesis versus full-field digital mammography

Digital breast tomosynthesis (DBT) is a recent technological advancement in mammography and is performed by obtaining tomographic images of the breast, which are acquired by low‐dose exposures along an arc and are reconstructed into a series of thin images that can be viewed consecutively. Several studies have shown that DBT increases the cancer detection rate and reduces the recall rate associated with screening mammography, compared to full‐field digital mammography (FFDM), improving both sensitivity and specificity. DBT has two main potential disadvantages, one of which is increased radiation. Since DBT is traditionally performed as a combined examination with FFDM, there is an increased radiation dose compared to FFDM alone. To reduce radiation dose, many institutions (including ours) perform DBT with a synthetic 2D mammogram (instead of FFDM), obtained via an algorithm that reconstructs the DBT images. The advantage of performing DBT with a synthetic 2D mammogram is that the radiation dose is similar to that of FFDM alone. The second potential disadvantage of DBT is the cost to patients. Although Medicare and Medicaid cover DBT, it is not universally covered by private insurance; therefore, some women may have to pay for it out‐of‐pocket. At many institutions (including ours), patients who present for screening mammography are given the choice of DBT or FFDM. The purpose of our study was to evaluate the impact of insurance coverage and other socioeconomic factors on patients’ choice of screening mammography type. We also assessed patients’ main reasons for selecting DBT versus FFDM. This study was approved by the Institutional Review Board and was performed over a 6‐month period (July 11, 2016 to January 13, 2017) at the four outpatient clinics at our academic medical institution that offered both DBT and FFDM. All women who presented for screening mammography were given an anonymous paper survey (Figure 1) upon arrival to voluntarily complete during the visit. Patients were informed that they would receive a bill (typically