OBJECTIVE:To evaluate the additive role of breast MRI in axillary nodal staging following a benign axillary US and compare diagnostic performance of US-first versus MRI-first imaging sequences. METHODS:This retrospective study included 524 patients with stage I-III breast cancer who underwent preoperative breast MRI and axillary surgery. Imaging assessments were categorized as US-first (n = 367) or MRI-first (n = 157). Diagnostic performance metrics were calculated based on the first modality used to evaluate the axilla. Incremental detection by MRI after benign US was assessed. Associations between false-negative results and clinicopathologic factors were analyzed. RESULTS:US-first patients were younger (51.8 vs 55.2 years, P = 0.002), had larger tumors (37.8 mm vs 26.0 mm, P < 0.001), and higher Ki-67 indices (42.6% vs 33.0%, P < 0.001) compared to MRI-first. Sensitivity for nodal metastasis was higher for US-first (71.7%) than MRI-first (50%, P = 0.01), while MRI-first demonstrated greater specificity (85.6% vs 74.6%, P = 0.02) and negative predictive value (87.0% vs 69.2%, P < 0.001). Among 182 axillae assessed as benign on initial US, MRI identified 24 additional abnormal cases (13.2%), of which 15 were true positives, yielding an incremental detection rate of 8.2%. False-negative results were associated with younger age in both groups and with larger tumor size and multifocality in US-first cases. CONCLUSION:MRI provided clinically relevant incremental detection of axillary metastases after benign US and demonstrated higher negative predictive value when performed first. False-negative results were more common in patients with younger age, larger tumors, and multifocal disease, highlighting the need to consider these factors when interpreting axillary imaging.
Interval breast cancers are diagnosed between screening rounds. Because they portend a worse diagnosis than screen-detected cancers, decreasing the interval cancer rate is a key measure of screening program effectiveness. Artificial intelligence (AI) tools for breast cancer detection are rapidly emerging with potential to provide earlier detection or even prediction of interval cancers. This article reviews the importance of interval cancers in screening mammography, current evidence for AI performance related to interval cancers, and considerations for interpreting the findings and implications of the current literature.
Given the increasing frequency of reduction mammoplasty (RM) procedures, it is essential for radiologists to develop expertise in the accurate evaluation and interpretation of postoperative breast imaging findings. This pictorial essay reviews common RM surgical techniques with the resultant expected imaging findings on mammography, ultrasound, and MRI. Findings include symmetric parenchymal redistribution, architectural distortion and scar tissue, benign calcifications, and fat necrosis. Recognizing these patterns is essential to avoid misinterpreting benign postoperative changes as malignancy as well as to identify suspicious findings that require further evaluation. Diagnostic challenges include differentiating post-surgical scarring from malignancy, especially in the lower half of the breast. Cases of breast malignancy after RM are presented to highlight important differentiation between expected postoperative changes and breast cancer.
OBJECTIVE:This study evaluates concordance between abbreviated protocol breast MRIs (abMRI) and standard full-protocol MRI in the post-neoadjuvant chemotherapy (NAC) setting. METHODS:This multi-site single institution retrospective study included breast cancer patients with pre- and post-NAC breast MRI during 2016-2023. The abMRI sequences included localizers, pre-contrast fat sat T1, fat sat first post-contrast phase, reconstructed first post-contrast phase subtraction, and maximum-intensity projection images from the institution's standard protocol. Four breast radiologists interpreted abMRIs and full MRIs after a washout period of at least 1 month. Residual tumor size (RTS) was compared to pathology. Statistical analysis with multivariable logistic regression, Receiver Operating Curve analysis, Kappa analysis, and paired t-tests were performed. RESULTS:Ninety-two of 237 patients (38.8%; mean age, 52.6 years) had pathologic complete response (pCR). There was no significant difference between abMRI and full MRI for predicting pCR for any reader individually (P-value range 0.30-0.91) with overall area under curve (AUC) = 0.70. Intraobserver and interobserver agreement for abMRI and full MRI was moderate to good (κ = 0.52-0.78). There was concordance between abMRI and full MRI for predicting pCR when stratified by menopause status, background parenchymal enhancement, tumor stage, tumor biomarkers, and Ki-67. When compared to pathology, all readers demonstrated no significant difference in RTS with abMRI, and one reader underestimated RTS on full MRI by 7 mm (P = 0.005). CONCLUSION:Our study found no significant difference in diagnostic performance between abMRI and full MRI when compared to pathology for evaluating post-NAC patients for pCR and evaluation of residual disease in the breast. Abbreviated MRI and full MRI show similar effectiveness in predicting complete tumor response and assessing residual disease on post-NAC assessment.
Widespread mammography screening has resulted in a significant decline in breast cancer deaths, but it is resource intensive. The WISDOM (Women Informed to Screen Depending on Measures of Risk) trial attempts to assess screening based on individual risk as an alternative to age-based screening (annual screening starting at age 40 years). In their initial report, the authors concluded that risk-based screening is safe and acceptable. Their results do not support this conclusion. The first primary endpoint to test the noninferiority of risk-based screening used the metric of stage IIB and higher breast cancers. Many of these cancers would be apparent on physical exam, thus eliminating some advantages of early detection and ignoring shortcomings of the risk-based approach. In addition, the study set an extremely weak noninferiority margin, compromising their conclusion concerning noninferiority. Details of mammography and MRI use in WISDOM reflect poor compliance with screening protocols in both arms of the study. Substantial non-compliance as well as out-of-study imaging in both cohorts resulted in two nearly identical protocols, rather than a comparison of different screening strategies. The study's findings of substantial non-compliance to the risk-based protocol make it difficult to justify risk-based screening being acceptable to women. The trial's second primary endpoint, to test whether risk-based screening yielded fewer biopsies than annual screening, failed. The risk-based screening protocol is labor intensive and would be challenging to implement in the typical primary care practice. The vast majority of breast cancers occur in average-risk women and could be missed in a risk-based system, especially in women under age 50 and minority women.
OBJECTIVE:To develop a hybrid model integrating morphological features with quantitative parameters from dual-layer spectral computed tomography (DSCT) to noninvasively differentiate benign breast lesions from breast cancer. METHODS:This retrospective study included patients with breast lesions incidentally detected on spectral CT between January 2020 and May 2024. Lesions were categorized as benign or malignant based on histopathology or greater than two years' stability on follow-up imaging. Clinical variables, morphological characteristics, and DSCT parameters were collected. The cohort was randomly divided into training, validation, and independent testing sets using stratified sampling. Feature selection was performed exclusively within the training set using univariate analysis, collinearity assessment, and least absolute shrinkage and selection operator regression with the one-standard-error criterion. Clinico-radiological, DSCT-based, and hybrid models were constructed using multivariate logistic regression. Model discrimination was evaluated using receiver operating characteristic analysis and, model stability was assessed using nested cross-validation. A nomogram was constructed based on the best-performing model. RESULTS:A total of 102 patients (mean age 52 ± 11 years) were included, including 27 patients (26%) with benign breast lesions and 75 patients (74%) with breast cancer. In the independent testing set, the DSCT-based model outperformed the clinical-radiological model (AUC = 0.967 vs 0.933), while the hybrid model achieved the highest diagnostic performance (AUC, 0.983). Calibration curves demonstrated strong concordance between predicted and observed outcomes. Decision curve analysis indicated favorable net benefit. CONCLUSION:The hybrid model demonstrated good diagnostic performance in noninvasively differentiating benign from malignant breast lesions detected preoperatively on DSCT.
OBJECTIVE:Allostatic load (AL) is an emerging framework quantifying physiological dysregulation from cumulative exposure to stressors over an individual's life. We evaluated the relationship between AL and malignant breast biopsy results in women across sociodemographic subgroups. METHODS:Women 18 years and older who underwent at least one image-guided breast biopsy at a safety-net hospital between April 2016 and December 2023 were identified. Consistent with prior studies, AL was defined as a score based on eight values: resting pulse rate, systolic blood pressure, diastolic blood pressure, body-mass index, serum albumin, creatinine, estimated glomerular filtration rate, and white blood cell count. Multivariable logistic regression models were used to assess the association between AL and malignant breast biopsy results among different sociodemographic groups. Effect modification by racial/ethnic category was then examined using stratified models. RESULTS:668 participants had data available for all eight biomarkers. Most participants were Hispanic (n = 376, 54.5%), reported English as their primary language (n = 423, 63.3%), and had Medicaid for insurance (n = 300, 44.9%). In stratified analyses, the association between AL and malignant breast biopsy result was significant in White, non-Hispanic patients. In White, non-Hispanic patients, after adjusting for age, every one-unit increase in AL was associated with a 46% increased likelihood of malignant breast biopsy result (OR 1.46, P = 0.03). CONCLUSION:AL was associated with malignant breast biopsy results in specific sociodemographic subgroups, potentially representing a modifiable risk factor for breast cancer prevention. Further research with large, diverse populations is required to evaluate additional factors impacting breast cancer outcomes across sociodemographic groups.
Tattoo pigment migration can appear on breast imaging, including mammography and ultrasound, where it may mimic malignant findings. In the literature, 19 cases have been reported. Here, we describe an additional three cases. Most published cases involve women undergoing screening mammography with incidental identification of pigment migration. On imaging, pigment can present as high-density deposits on mammography and echogenic foci on ultrasound, mimicking calcifications. Reported sites of deposition most commonly include axillary lymph nodes and intramammary nodes. If no other morphologic abnormalities are identified and the findings can be confidently attributed to tattoo pigment, biopsy is not necessary. Histopathologically, tattoo pigment appears as aggregates of granular exogenous material. If biopsy is performed and confirms pigment migration, patients may resume risk-appropriate screening without further intervention.
Breast MRI provides the highest sensitivity for breast cancer detection and is widely used for high-risk screening, assessment of disease extent, treatment monitoring, and evaluation of silicone implant integrity. Despite the central role of fat suppression and tissue-specific signal behavior in determining image quality, the underlying physics principles and mechanisms of failure for these techniques are often underrecognized in clinical practice. This review provides a practical primer on MR signal behavior in commonly used T1 and T2weighted breast MRI sequences and outlines the major techniques used to suppress or separate signals from fat, water, and silicone. We summarize the intrinsic MR properties of fibroglandular tissue, fat, saline and silicone implants, highlighting how differences in relaxation times and resonant frequencies shape image contrast. The operational principles, strengths, and limitations of subtraction, chemical shift selective suppression (CHESS) fat suppression, short tau inversion recovery (STIR), hybrid spectral inversion approaches (SPIR and SPAIR), silicone-specific STIR, and chemical shift encoded (CSE) methods are described, with emphasis on characteristic artifacts and strategies for troubleshooting. By integrating key physics concepts with practical examples, this article aims to equip breast imagers and technologists with a clearer understanding of how signal suppression techniques function, why they fail, and how to optimize MR sequence performance and image quality.
OBJECTIVE:To assess variability in parental leave and lactation policies affecting breast radiologists and examine their associations with job satisfaction and burnout. METHODS:An anonymous 43-question survey was distributed to U.S.-based physician members of the Society of Breast Imaging between December 2023 and February 2024. Questions assessed parental leave and lactation policies, workplace experiences, and validated items on job satisfaction and burnout. Descriptive statistics, chi-square tests, and multivariable linear regression were performed. RESULTS:262 respondents (8.0% [262/3275] response rate) completed the survey. The mean age was 47 ± 10.4 years, with an average of 14.6 ± 10 years of post-training experience; 86% (223/262) identified as women. Among respondents, 61% (160/262) were aware of their workplace's parental leave policy, which included a median of 6 weeks of paid leave (IQR 10). Forty percent (88/220) were unsure if a lactation policy existed, 57% (125/220) reported no dedicated lactation time, and 72% (147/220) were unaware of a designated lactation space. Most respondents (87% [191/219]) said these policies were not discussed during job interviews, though 59% (128/216) considered them important when choosing a job. One-third (72/262) had welcomed a child within the last five years. Among these, 39% (27/69) reported insufficient lactation support, and 26% (18/69) stopped breastfeeding earlier than desired due to work constraints. Lactation support was inversely correlated with burnout (r = -0.516, P < 0.001) and positively correlated with job satisfaction (r = 0.440, P < 0.001). CONCLUSION:Improved transparency and institutional investment in parental leave and lactation policies by radiology practices may support well-being and retention of breast radiologists.
OBJECTIVE:To evaluate the performance of radiologists' radiologic-pathologic (rad-path) assessment in BI-RADS 4C and 5 breast lesions with benign core biopsy pathology. METHODS:Institutional pathology records were reviewed, analyzing surgical excision results for benign core biopsies after BI-RADS 4C and 5 assessments from 2019 to 2024, and the rad-path correlation issued by the radiologist prior to excision was recorded. Pathologic diagnoses and imaging data were retrieved from the electronic medical record. RESULTS:A total of 523 BI-RADS 4C and 5 core biopsies were identified during the study period. The malignancy rate following BI-RADS 4C assessment was 74.1% and following BI-RADS 5 assessment was 93.2%. Fifty-one benign image-guided biopsies underwent radiology-pathology correlation analysis. Radiologists categorized 19/51 benign pathology results as radiology-pathology discordant, with an upgrade rate to malignancy of 47.3%, and 32/51 as concordant, with an upgrade rate of 9.4%. All concordant upgrades occurred in high-risk lesions (atypical ductal hyperplasia, papilloma) for which excision had been recommended at the time of concordance assessment. Discordant benign pathology upgraded to malignancy included diagnoses such as dense stromal fibrosis, fibrocystic change, chronic inflammation, atypical ductal hyperplasia, hematoma, and papilloma. CONCLUSION:Radiologist-performed rad-path correlation is highly reliable for benign BI-RADS 4C and 5 lesions. Radiology-pathology discordant benign biopsies carry a high risk of malignancy and warrant surgical excision. In contrast, radiology-pathology concordant benign results are highly predictive of final benign outcome, particularly when high-risk features are absent. These findings support the essential role of radiologist rad-path correlation in reducing unnecessary surgery and avoiding missed cancers.
Women represent a growing demographic within the United States military, both active duty and veterans. Breast cancer is the most prevalent non-dermatologic malignancy among female active duty members and veterans. Military service members, specifically women aged 40-59 years, have a higher incidence of breast cancer compared to the general population. Retrospective cohort studies of military members suggest that work-related reproductive factors, including higher frequency of contraceptive use and shorter duration of breastfeeding, may account for at least part of the higher incidence. The impact, if any, of military environmental exposures, such as volatile organic compounds, endocrine disrupting chemicals, pesticides, airborne hazards, and open burn pits, on breast cancer risk is an area of ongoing investigation. This article aims to advance understanding of breast cancer, risk, treatment, and outcomes in military populations while examining current screening practices and ongoing efforts to strengthen prevention and early detection among active duty service members and veterans. The potential of the SERVICE Act to increase screening access in certain military members under age 40 years will be emphasized. Efforts to improve breast cancer prevention and early detection for active duty service members and veterans are imperative for preserving military force readiness and essential for the health of the all-volunteer force of the United States military.
Women with a personal history of breast cancer (PHBC) remain at risk for ipsilateral breast tumor recurrence or a second primary tumor, with a cumulative incidence of 14.3% and reported annual risk of approximately 1-2%. Post-treatment changes can obscure imaging findings, making early recognition of recurrence a challenging, but critical skill for breast radiologists. Detection of early breast cancer recurrence, before it becomes symptomatic, is linked to improved survival, highlighting the need for multimodality surveillance imaging. This review summarizes key prognostic factors that influence recurrence risk and should inform imaging interpretation. Incorporating these prognostic factors into practice can aid imaging interpretation by heightening the attention to subtle changes that may reflect early recurrence. Illustrative cases are used to demonstrate the imaging spectrum of locoregional recurrence in post-lumpectomy and post-mastectomy patients. Recurrences often resemble the imaging features of the primary tumor but may also present subtly. The distinction between recurrence and benign post-treatment change is emphasized, with attention to imaging findings that warrant further evaluation. Finally, emerging evidence-based recommendations for risk-adapted surveillance incorporating tumor biology, receptor status, and stage are reviewed to support early detection and improved outcomes.
OBJECTIVE:Reconciling cutoff thresholds for short-term (5-year) and long-term (lifetime) breast cancer risk could support tailored and evidence-based approaches to supplemental screening and risk management most relevant to short-term clinical actions. This study aims to consistently classify women at increased risk and provide 5-year risk cutoff that corresponds to a 20% lifetime risk. METHODS:Using U.S. Surveillance, Epidemiology and End Results (SEER) program population incidence data for women 40 to 74 years of age, this study reports both lifetime and 5-year population-based risk estimates controlling for competing risk and age varying breast cancer incidence. A cut point for 5-year risk equivalent to lifetime risk of 20% which triggers increased screening is generated. This computation is a weighted average incorporating age, remaining life expectancy, and population risk distribution. The primary outcome is breast cancer incidence (in situ and invasive). RESULTS:A lifetime risk threshold of 20% corresponded to markedly age-dependent 5-year risk cut points, increasing from ∼1.3% at ages 40-44 to ∼10.9% at ages 70-74. For women 40-74, 20% lifetime risk corresponds to a 5-year risk cut-off of 3.16%. CONCLUSIONS:Aligning lifetime risk of ≥20% and the 5-year breast cancer risk cutoff enhances consistency of classification of women at increased risk and clinical decision-making. Women with a ≥3.16% 5-year risk of breast cancer have risk equivalent to a lifetime risk of ≥20% on average. This can facilitate rational and evidence-based approaches to short-term and long-term risk assessment results for both risk reduction and tailored screening.
Objective Breast arterial calcification (BAC) is a surrogate marker of cardiovascular disease (CVD); however, its associations with incident mortality and major adverse cardiovascular events (MACEs) have not been systematically evaluated. The association between BAC and incident MACE and whether this is influenced by the method of BAC assessment was examined. Methods PubMed, MEDLINE, and EMBASE were reviewed to June 2025 for studies comparing BAC status with incident MACE (composite of death, myocardial infarction [MI], stroke, heart failure). The primary outcome was all-cause mortality. Random-effects meta-analysis was performed using hazard ratios (HRs) with 95% CIs. Subgroup analysis was conducted by method of BAC measurement and restricted to screening mammography cohorts, PROSPERO registration (CRD42020202612). Results Of 1118 studies screened, 24 were included (236 475 participants; mean age 58.5 years). Breast arterial calcification presence associated with all-cause mortality (HR, 1.32; 95% CI, 1.20-1.45; P <.0001) (follow-up 0.55-26 years). Increased risk was observed for cardiovascular mortality (HR, 1.38; 95% CI, 1.14-1.66; P = .0009), heart failure (HR, 1.29; 95% CI, 1.20-1.37; P <.0001), stroke (HR, 1.2; 95% CI, 1.11-1.30; P <.0001), and MI (HR, 1.2; 95% CI, 1.15-1.26; P <.0001). When restricted to screening mammography cohorts without concurrent indications for cardiovascular investigation (5 studies, n = 85 647), associations remained significant for all-cause mortality (HR, 1.34; 95% CI, 1.14-1.58; P = .0004), cardiovascular mortality (HR, 1.38; 95% CI, 1.14-1.66; P = .0009), heart failure (HR, 1.48; 95% CI, 1.19-1.86; P = .0005), and stroke (HR, 1.34; 95% CI, 1.08-1.67; P = .008). Associations with incident outcomes were observed only in studies using quantitative BAC assessment (HR, 1.31; 95% CI, 1.19-1.44; P = .002). Conclusion Breast arterial calcification is a promising prognostic marker of mortality and CVD risk. Recognition of this incidental finding may enable timely identification of at-risk individuals.
PICK charts are Lean Six Sigma tools used to prioritize improvements based on effort required and potential impact. Our purpose was to conduct PICK chart prioritization exercises with a low income, diverse community advisory group to identify and prioritize patient and community centered interventions to reduce mammography screening disparities. Community advisory focus group was composed of 22 adults from low-income neighborhoods in Madison, Wisconsin. Included participants were from the Wisconsin Network for Research Support Community Advisory on Research Design and Strategies, recruited from community centers and food banks that serve individuals from diverse racial, socioeconomic, and educational backgrounds. Structured, divergent thinking brainstorming sessions were conducted to identify interventions to improve the mammography screening process. The idea generation process revealed 52 unique ideas across 7 process map domains. Among participants, the most highly cited ideas that were classified as high impact, low effort ideas included: reminders, sharing positive stories about mammography experiences, offering reassurance during mammograms, and reducing co-pays. Community centered prioritization exercises identify patient-centered, contextually relevant interventions to improve cancer screening percentages in medically underserved patient populations, including high-quality, patient centered communication about the mammography screening process and reduced costs.
