Priscilla J. Slanetz

Physiologic Changes in Breast Magnetic Resonance Imaging during the Menstrual Cycle: Perfusion Imaging, Signal Enhancement, and Influence of the T1 Relaxation Time of Breast Tissue

Abstract:  This study was undertaken to determine the best time during the menstrual cycle to perform dynamic breast magnetic resonance imaging (MRI). The contralateral “normal” breast of 50 premenopausal women (mean age 40.4 ± 6.4 years, range 30–52 years) were enrolled in a protocol designed to correlate an ipsilateral suspicious breast lesion with pathology. The contralateral breast in each patient was examined with palpation and mammography prior to MRI on a 1.5T scanner using gradient echo and dynamic contrast‐enhanced echo‐planar without and following gadolinium diethylenetriaminepentaacetic acid (Gd‐DTPA) injection. Pre‐contrast T1 relaxation times were measured before calculating extraction flow product (EFP) maps using a multicompartmental model. T1, EFP, and enhancement were measured in the control breast on four slices centered around the nipple and recorded as a function of the phases of the menstrual cycle. Lesions or areas with focal enhancement were excluded. Analysis of variance and Fishers tests were performed. The cyclic changes in T1 relaxation time were not significant (p > 0.2). EFP and enhancement varied significantly during the cycle (p < 0.003 and p < 0.004, respectively), with low values during the first half of the cycle and high values during the second half. The lowest values of EFP and enhancement (5.5 ± 2.9 ml/100 g/min and 26 ± 17%) were observed during the proliferative phase (days 3–7), and the highest values (17 ± 10.2 ml/100 g/min and 104 ± 28%) were observed during the secretory phase (days 21–27) (p < 0.0006 and p < 0.0008, respectively). Dynamic breast MRI should be performed during first half of the menstrual cycle (days 3–14) in order to minimize interpretative difficulties related to the uptake of gadolinium in normal breast tissue due to hormonal fluctuations during the menstrual cycle.

The Lactating Breast: MRI Findings and Literature Review

Abstract: Normal physiologic changes in the breast related to pregnancy and lactation can reduce the sensitivity of imaging modalities, such as mammography. This is likely to be true for other breast imaging techniques such as magnetic resonance imaging (MRI). Although malignancy is relatively uncommon in lactating breasts, patients may develop palpable abnormalities that require imaging evaluation. Physiologic changes from pregnancy and lactation can complicate breast imaging. We report the MRI appearance of the lactating breast and address potential difficulties that may be encountered in this clinical situation.

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. 

Increased Cancer Detection Rate and Variations in the Recall Rate Resulting from Implementation of 3D Digital Breast Tomosynthesis into a Population-based Screening Program

PURPOSE To compare the recall and cancer detection rates (CDRs) at screening with digital breast tomosynthesis (DBT) with those at screening with two-dimensional (2D) mammography and to evaluate variations in the recall rate (RR) according to patient age, risk factors, and breast density and among individual radiologists at a single U.S. academic medical center. MATERIALS AND METHODS This institutional review board-approved, HIPAA-compliant prospective study with a retrospective cohort included 85 852 asymptomatic women who presented for breast cancer screening over a 3-year period beginning in 2011. A DBT unit was introduced into the existing 2D mammography screening program, and patients were assigned to the first available machine. Ten breast-subspecialized radiologists interpreted approximately 90% of the examinations. RRs were calculated overall and according to patient age, breast density, and individual radiologist. CDRs were calculated. Single and multiple mixed-effect logistic regression analyses, χ(2) tests, and Bonferroni correction were utilized, as appropriate. RESULTS The study included 5703 (6.6%) DBT examinations and 80 149 (93.4%) 2D mammography examinations. The DBT subgroup contained a higher proportion of patients with risk factors for breast cancer and baseline examinations. DBT was used to detect 54.3% more carcinomas (+1.9 per 1000, P < .0018) than 2D mammography. The RR was 7.51% for 2D mammography and 6.10% for DBT (absolute change, 1.41%; relative change, -18.8%; P < .0001). The DBT subgroup demonstrated a significantly lower RR for patients with extremely or heterogeneously dense breasts and for patients in their 5th and 7th decades. CONCLUSION Implementing DBT into a U.S. breast cancer screening program significantly decreased the screening RR overall and for certain patient subgroups, while significantly increasing the CDR. These findings may encourage more widespread adoption and reimbursement of DBT and facilitate improved patient selection.

Teaching evidence-based imaging in the radiology clerkship using the ACR appropriateness criteria.

RATIONALE AND OBJECTIVES Given escalating health care costs and limited resources, the effective utilization of imaging is essential to permit optimal patient care. Because only 21.4% of medical schools require radiology clerkships, most students do not understand the indications for and clinical effectiveness of most imaging tests. Therefore, the authors introduced two focused sessions on evidence-based imaging during the required radiology core clerkship at their institution. METHODS From June 2008 to September 2009, 259 students in the radiology core clerkship participated in a didactic session on principles of evidence-based imaging and/or a small-group session and self-directed learning exercise using the American College of Radiology (ACR) Appropriateness Criteria. Students evaluated the exercise on a five-point scale for its effectiveness in teaching imaging strategies and its impact on their future careers. RESULTS Two hundred twenty-eight of 259 students (88%; 93 third year, 135 fourth year) participated in the two sessions. Two hundred thirteen of 223 (96%) were not aware of the ACRs Web site as a resource prior to this exercise. Two hundred fourteen of 228 (94%) found the ACR Appropriateness Criteria a useful resource. Two hundred two of 228 (89%) stated that they would likely use this resource in other clinical rotations and future practice. Two hundred three of 228 (89%) reported having a solid understanding of the indications for imaging tests following the sessions. Students praised the ACRs Web site for its comprehensive coverage of different modalities and their relative radiation risks. They valued working collaboratively on common clinical scenarios. CONCLUSION The ACR Appropriateness Criteria are a valuable resource for teaching evidence-based imaging to medical students. A majority of students indicated that they plan to use this resource in the future.

Spectrum of disease in the male breast

OBJECTIVE The purpose of this article is to review the anatomy of the male breast and to describe the imaging findings of a variety of diseases that affect the male breast to better understand and recognize the imaging findings and underlying pathophysiology of diseases and conditions affecting this emerging subset of patients. CONCLUSION Understanding the anatomy of the male breast is central to developing a differential diagnosis and delivering optimal care in male patients presenting with breast complaints. Diseases in the male breast can affect the skin and subcutaneous tissues, stroma and glandular elements, and neurovascular and lymphatic structures. Although the most commonly encountered disease entity is gynecomastia, men can develop many other benign and neoplastic diseases, including primary breast cancer. By incorporating clinical presentation with imaging findings on mammography and ultrasound, the breast imager can more effectively establish the correct diagnosis in males.

Spectrum of Diseases Presenting as Architectural Distortion on Mammography: Multimodality Radiologic Imaging with Pathologic Correlation

Architectural distortion is the third most-common appearance of breast cancer and often is a subtle finding on mammography. In this article, we review a variety of breast diseases that may present as architectural distortion on mammography; review the utility of correlative imaging, such as ultrasound and magnetic resonance; and review appropriate management for these diagnoses. Primary causes include breast cancer, ductal carcinoma in situ, radial scar, complex sclerosing lesion, and fat necrosis. Secondary etiologies include previous breast surgery, trauma, and infection. Familiarity with imaging findings presenting as distortion on multimodality imaging will optimize detection and management of this subtle-yet-significant finding.

Breast-Density Legislation — Practical Considerations

A grassroots movement to inform women about their breast density has resulted in laws in 20 states mandating provision of that information. But the ability to detect breast cancer is affected by many factors, and evidence supporting supplemental screening is lacking.

Imaging Approaches to Diagnosis and Management of Common Ductal Abnormalities

Ductal disease is an important, often overlooked, and poorly understood issue in breast imaging that results in delays in diagnosis and patient care. The differential diagnosis for an intraductal mass is broad and includes inspissated secretions, infection, hemorrhage, solitary or multiple papillomas, and malignancy. Each breast is composed of eight or more ductal systems, with most disease arising in the terminal ductal-lobular unit. Imaging evaluation of the ductal system usually entails a combination of mammography, galactography, ultrasonography (US), and in some cases magnetic resonance (MR) imaging. The most common finding with all modalities is ductal dilatation with a focal or diffuse abnormality. Benign diseases of the ducts include duct ectasia, blocked ducts, inflammatory infiltrates, periductal mastitis, apocrine metaplasia, intraductal papillomas, and papillomatosis. Malignant diseases of the ducts include ductal carcinoma in situ, invasive ductal carcinoma, and Paget disease. Most commonly performed with US or MR imaging guidance, percutaneous biopsy methods are helpful in diagnosis and management of ductal findings. Because most findings are smaller than 1 cm, located within a duct, and thus sometimes not visible after a single pass, vacuum-assisted devices help improve the accuracy of sampling.

Teaching radiology in the millennial era.

E ven before Cicero’s time, teachers have been widely regarded as invaluable members of society. In medicine, radiologists serve as consummate teachers, playing a crucial role in the education of peers, physiciansin-training, medical students, nurses, and other health care providers. However, few radiologists undergo any formal training in educational theory, methods, or assessment. Despite advances in educational theory related to generational changes in learning, most radiologists still use the traditional lecture format as a means to impart knowledge and casebased conferences to enable learners to apply their knowledge. Few radiologists have taken the time to reflect on their own teaching or to adopt more innovative approaches to teaching that might better meet the needs of their learners. Hence, most radiologists remain teacher-centered rather than learner-centered. As the members of every generation possess unique traits that enable them to acquire and apply knowledge differently, more effective teaching comes from a predominantly learner-centered approach (1). A better understanding of the generational differences between learners and their teachers can only result in more effective teaching (1,2). Many educators have come to recognize specific generational groups who share experiences, values, and identity shaped by world social and cultural events. In the past century, four discrete groups have been described: the silent generation (1928–1945), the baby boomers (1946–1964), generation X (1965–1982), and the millennial generation (1982–2000) (1) (Table 1). An awareness of intergenerational differences in teaching techniques and learning styles can affect teaching effectiveness and learners’ mastery and application of medical information. With the rapid technological advances over the past two decades, millennial learners pose challenges for educators who are not as well versed in technology and do not share the same perspectives with regard to life, the world, and learning needs (1).