The Member Newsletter of the Society of Breast Imaging SBINews NEWSLETTER PDF... · ii 2014 Issue 2...

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The Member Newsletter of the Society of Breast Imaging

SBINews 2014 Issue 2 i

SBINewsThe Member Newsletter of the Society of Breast Imaging 2014 ISSUE 2

Society of Breast Imaging • 1891 Preston White Drive • Reston, VA 20191

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Editor’s Note

Gary J. Whitman, MD, FACR, FSBI

Copyright 2014. Society of Breast Imaging.

Newsletter Editor: Gary J. Whitman, MD, FACR, FSBI, Chair

SBI Newsletter Committee: Phan Huynh, MD, FACR, FSBIBernadette Redd, MD, BSNStamatia Destounis, MD, FACR, FSBISally Herschorn, MDCarl D’Orsi, MD, FACR, FSBIJames Vasek, MDPeter Eby, MD, FSBI

John Boone, PhD, FACR, FSBIWendy DeMartini, MD, FSBIJohn Lewin, MD, FACR, FSBILiane Philpotts, MD, FSBILisa Arnall, RDMSMichael Linver, MD, FACR, FSBIMurray Rebner, MD, FACR, FSBI

Layout & Design: Susan Scott Meredith

T his editor’s note is written with a different perspective compared to my previous messages. This note is written from the

perspective of a patient. At the end of March, I developed cellulitis in my right leg, requiring intravenous antibiotics and surgery. This was my first hospitalization and my first non-elective surgery. Furthermore, I think that it was the first time that I missed work or school for my own health problems since I had chicken pox in the fourth grade. Luckily, thanks to a team of skilled practitioners, I am recovering well and getting stronger each day.

How does an inpatient hospitalization relate to day-to-day outpatient breast imaging? First, I think that all providers (in all ranks and job categories) should introduce themselves to the patient and indicate their role. For example, “Hi. I am Dr. Whitman. I am a breast radiologist, and I will be performing your ultrasound today.” Second, I think that it is helpful if the provider ask if the patient needs anything. This greeting can be as simple as, “May I get you anything?”

One of the problems in inpatient areas and in some outpatient areas is that in the current era of cost containment and efficiency, more work is being done by less skilled personnel. For example, on the inpatient floor, my nurses were responsible for taking my vital signs, drawing my blood, and

administering my medications. On most days, these three activities took about 30 minutes. Anything else that was needed for a patient confined to bed for the remaining 23.5 hours each day was the responsibility of the nursing aides, a diverse group with various backgrounds and a range of attitudes. Some of the aides were very attentive, caring, and engaged in my care. Others were marginally skilled, disinterested, and probably burnt out.

The nursing aides were the face of my inpatient experience. In outpatient breast imaging, we need to pay more attention to the face of our practices. Our face includes the schedulers, the front desk personnel, the clerks, the aides, the mammography technologists, the sonographers, the physicians, the navigators, and the administrators. In order to create a better face for our practices, we need to set high expectations and lead by example. While we strive to do excellent clinical work, we cannot forget the importance of caring—it is the face of our practice.

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SBINews 2014 Issue 2 1

Table of Contents2 | President’s Column: Meet the PressMurray Rebner, MD, FACR, FSBI

4 | Affordable Care Act UpdateBy Bernadette Redd, MD

6 | NAPBC UpdateCarl J. D’Orsi, MD, FACR, FSBI

8 | Image-Guided Biopsy PaymentsBy Geraldine McGinty, MD, MBA, FACR

8 | Upcoming Events & Activities

9 | SBI Tomosynthesis Course is a Resounding SuccessBy Laurie L. Fajardo, MD, MBA, FACR, FSBI

10 | Training Sonographers in Breast ImagingBy Lisa Arnall, RDMS

12 | Breast Imaging: A Satisfying CareerGary J. Whitman, MD, FACR, FSBI

13 | Educating Physicians About Screening Mammography in CanadaBy Jean Seely, MD

16 | Public Education on Breast ScreeningBy Jiyon Lee, MD

17 | Breast MRI Accreditation UpdateStamatia Destounis, MD, FACR, FSBI

20 | Tips for Optimizing Cancer Detection with Breast MRIBy R. Edward Hendrick, Ph.D., FACR, FSBI

23 | Stereo-Mammography UpdateBy Carl J. D’Orsi, MD, FACR, FSBI

24 | ACR Announces the Birth of the 5th of BI-RADSCarl D’Orsi, MD, FACR, FSBI and Edward A. Sickles, MD, FACR, FSBI

28 | Genomic Testing in Breast CancerBy Michael N. Linver, MD, FSBI

Case-Based Review & Advanced Breast Imaging Course: DIGITAL BREAST TOMOSYNTHESIS

2014

September 20-21, 2014Las Vegas, NV

http://www.sbi-online.org/MEETINGS/CurrentandFutureCoursesMeetings/DigitalBreastTomosynthesis.aspx

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President’s Column: Meet the Press

One of the hallmarks of a democratic society is freedom of speech. Noted journalist Bill Moyers recently commented, “There is no

more important struggle for American democracy than ensuring a diverse, independent and free media. Free press is at the heart of that struggle.” Clearly, the right to express one’s thoughts has been cherished since the birth of our country. However, for the media, with that privilege also comes great responsibility.

Unfortunately, when the issue is screening mammography, the responsibility of balanced reporting has been ignored by the vast majority of writers, journalists and broadcasters. One only has to skim the recent publications and television news segments to see how mammography is overly criticized. Our public relations firm, Amplify, provides Society of Breast Imaging (SBI) staff and Board members with a weekly synopsis of breast cancer and breast imaging news items. Here are some representative stories which have appeared since the start of this year:

In February, United Press International reported on an article by O’Donoghue, which was published in the Annals of Internal Medicine (1). The article noted that screening older women every other year instead of annually would save billions of dollars in healthcare costs. The authors failed to look at the costs of not screening annually, which were even more expensive, not to the mention that the benefit of saving a life from breast cancer is priceless.

Also in February, the British Medical Journal published an article by Miller and colleagues which looked at the 25 year follow-up results from the Canadian National Breast Screening Study (2). The authors concluded that there was no mortality benefit from undergoing screening mammography and that one in 424 women who had mammograms received unnecessary treatment. Headlines from various media outlets demonstrated

the one-sided reporting:

• New York Times: Vast study casts doubt on value of mammograms;

• Los Angeles Times: Cancer screening expert to radiologists: stop lying about mammograms;

• Fox News: Mammograms do not reduce breast cancer deaths;

• NBC News: New study causes doubt on the value of mammograms;

• Huffington Post: Early detection does not save lives.

Interviews with experts such as Drs. Daniel Kopans, Barbara Monsees and Carol Lee as well as statements by the American College of Radiology (ACR) and the SBI, which refuted the results of the Canadian study due to the improper randomization process and the poor quality of the mammograms, received minimal attention. What is more upsetting is that not one report considered the Canadian study to be an outlier given that every other randomized mammography screening trial demonstrated a mortality benefit.

There are some exceptions. The Wall Street Journal published an op-ed piece by Drs. Emanuel and Hayes (3). The authors noted that the confusion and angst over screening mammography is not needed. They stated, “Women can find relief in reviewing what we already know about mammography: Screening works for all women…… helping to reduce breast cancer mortality and making treatment less onerous.”

It is also important to observe what receives no media coverage. An article written by Christiansen and colleagues in Acta Oncologica was published

Murray Rebner, MD, FACR, FSBI


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this year (4). It reviewed the Danish National Screening Program and noted that since screening mammography was offered in a widespread fashion to the population, breast cancer mortality decreased by 25%. Moreover, another major criticism of screening, overdiagnosis (incorrectly reported by some authors to be as high as 50%), was found to be only 4%.The results of this important study were not publicized in the United States media. It is ironic since some of the most vehement, public criticisms of mammographic screening come from the Nordic Cochrane Centre in Denmark.

As a result, with Amplify’s assistance, the SBI leadership decided that it would be beneficial for our society to meet in person with some of the media. The annual American Health Care Journalists meeting took place at the end of March this year in Denver, Colorado. Dr. Kopans, our SBI staff members Abray Stillson and Catherine Dexter, and I attended as exhibitors. The SBI set up a booth which provided the attendees with the opportunity to talk with Dan, me and our staff about the inaccuracies of screening mammography reporting. We provided the journalists with fact sheets about the benefits of mammographic screening and with several articles which dealt with the flawed United States Preventive Services Task Force (USPSTF) recommendations as well as the disastrous article by Bleyer and Welch, which was published in the New England Journal of Medicine (5).

Over the course of two days, we spoke with approximately 40 people. Many others passed by the booth and just picked up literature. The majority of participants were women from the print media — newspapers, magazines and blogs. Some of them were breast cancer survivors. Only a few viewed our presence as self-promoting. Many were unaware of the flaws of the recently published Canadian National Breast Screening Study update (2). Others did not know that there were no breast cancer experts with clinical experience on the USPSTF. Most

of the journalists we spoke with exchanged business cards, thanked us for our time and said they would contact us for our opinions on future stories. Two have already done so.

Clearly, our presence at this meeting is not going to change every journalist’s mind about the benefits of screening mammography. However, we believe that we have provided some health care reporters with a more balanced picture of the controversy. Hopefully, they will take responsibility and put this information to good use. Perhaps, then we can end the confusion about screening mammography.

Murray Rebner, MD, FACR, FSBIPresident, Society of Breast Imaging

References 1. O’Donoghue C, Eklund M, Ozanne E, Esserman LJ. Aggregate cost of mammography screening in the United States: comparison of current practice and advocated guidelines. Ann Intern Med 2014;160:145-153.

2. Miller AB, Wall C, Baines CJ, Sun P, To P, Narod SA. Twenty five year follow-up for breast cancer incidence and mortality of the Canadian National Breast Screening Study: randomized screening trial. BMJ. Electronic publication, February 11, 2014.

3. Emanuel FJ, Hayes DF. Mammograms aren’t perfect but they still save lives. The Wall Street Journal. February 26, 2014.

4. Christiansen P, Vejborg I, Kroman N, et al. Position paper: breast cancer screening, diagnosis, and treatment in Denmark. Acta Oncol. Electronic publication, February 5, 2014.

5. Bleyer A, Welch HG. Effect of three decades of screening mammography in breast-cancer incidence. N Engl J Med 2012;367:1998-2005.

President’s Column, continued from previous page



Affordable Care Act Update

The Patient Protection and Affordable Care Act (ACA) was signed into law on March 23, 2010. The law has multiple provisions aimed at expanding coverage, controlling healthcare costs, and improving the health care delivery system (1).

By Bernadette Redd, MD

How is coverage expanded by the ACA?A four-pronged approach has been legislated to increase coverage. All United States citizens and legal residents are required by the ACA law to have health care coverage starting in 2014. Those who do not have coverage will have to pay a tax penalty. The Internal Revenue Service will assess the first tax penalty when an individual or a family files a tax return for calendar year 2014. The penalty is initially $95 or 1.0% of taxable income for 2014. The annual penalty increases each year after 2014. Penalty exemptions can be granted for several reasons, including exemptions for individuals for whom the lowest-cost plan option exceeds 8% of their income.

The second way in which coverage is increased is through an employer requirement that requires any business with 50 or more full-time employees to offer employees healthcare coverage or pay a Shared Responsibility Payment. This provision requiring employers to provide health insurance, originally supposed to go into effect in January 2014, has been delayed until 2015 for businesses with 100 or more employees and until 2016 for businesses with 50 to 99 employees (2).

Third, health coverage has been increased by expanding Medicaid coverage to all non-Medicare individuals under age 65 years with incomes up to 133% of the federal poverty level. On June 28, 2012, the United States Supreme Court upheld the ACA as constitutional. At that time, the court also upheld as constitutional expansion of Medicaid by the federal government, but made expansion by

states optional. Currently, 26 states and the District of Columbia have opted o expand Medicaid coverage (3).

Finally, the ACA mandates that insurance companies allow children to be covered under a parent’s health plan until they are 26 years of age.

For those who do not have an employer-based health insurance plan and are not eligible for Medicare or Medicaid health insurance, insurance exchanges or marketplaces are available to sell federally-subsidized healthcare policies to those who qualify. Individuals and families making between 100-400% of the federal poverty level are eligible for healthcare subsidies on insurance plans purchased through a healthcare exchange. The healthcare exchanges are state- specific online health care markets run by the state, the federal government, or both.

The insurance plan options or “metal plans” include bronze, silver, gold, and platinum. In general the least expensive plan has the lowest premiums, the highest out-of-pocket costs, and the lowest actuarial cost. Bronze plans have an actuarial cost of 60%, meaning that the insurance company pays 60% of medical costs and the insured pays 40% (4). Platinum plans have the highest premiums, but they have an actuarial cost of 90%. In addition to the individual market exchange sites, the ACA also created the Small

Bernadette Redd, MD, BSN


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Business Health Options Program or SHOP as an online marketplace for small businesses with fewer than 50 full-time employees to shop for group health plans. Online enrollment for this program, which was initially planned for October 2013, has been delayed until November 2014 (5). Small businesses with fewer than 25 employees are also eligible for premium subsidies (1).

How do ACA provisions attempt to control health costs and improve the health care delivery system?

The ACA levies a 40% excise tax on insurance plans with high individual and family premiums, giving employers an incentive to reduce generous benefits and thereby control insurance premium growth. The Independent Payment Advisory Board was established by the ACA to limit Medicare cost increases. The ACA encourages the formation of accountable care organizations, which are intended to better coordinate care and reduce costs. Incentive programs for hospitals and physicians, such as pay-for-performance, are intended to increase cost-effective care. Prevention and wellness programs have guaranteed benefits under the ACA, and bring possible long-term cost savings benefits. The ACA increases the government’s ability to uncover and punish fraud, waste, and abuse in Medicare and Medicaid, also expected to provide cost savings (6).

What do we know so far about the impact of the ACA?Very preliminary results regarding the impact of the ACA on the number of uninsured and the growth of health care spending suggest a mixed picture. A study by the RAND American Life Panel estimates that the number of insured American

adults increased from September 2013 to mid-March 2014, causing the percentage of uninsured adults to fall from 20.5% to 15.8%: “Of the 40.7 million who were uninsured in 2013, 14.5 million gained coverage, but 5.2 million of the insured lost coverage, for a net gain in coverage of approximately 9.3 million. This represents a drop in the share of the population that is uninsured from 20.5 percent to 15.8 percent”(7). The 95% confidence interval for the net gain in coverage estimate of 9.3 million was 5.8 million to 12.8 million (7). However, a recent analysis of health care spending costs for 2013 noted an increase in the rate of growth of health care spending, most notably in the fourth quarter (8). The ACA remains highly controversial and will likely be debated well into the future. Much more time and study is needed to fully understand the overall effect of the ACA on the United States health care system.

References 1. http://kaiserfamilyfoundation.files.wordpress.com/2011/04/8061-021.pdf Accessed on April 20, 2014.

2. http://www.treasury.gov/press-center/press-releases/Documents/Fact Sheet 021014.pdf Accessed on April 20, 2014.

3. http://kff.org/health-reform/slide/current-status-of-the-medicaid-expansion-decision. Accessed on April 20, 2014.

4. http://kaiserfamilyfoundation.files.wordpress.com/2013/01/8177.pdf Accessed on April 20, 2014.

5. http://www.washingtonpost.com/blogs/wonkblog/wp/2013/11/27/obamacares-online-exchange-for-small-businesses-is-delayed-by-one-year. Accessed on April 20, 2014.

6. http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2011/rwjf71451. Accessed on April 20, 2014.

Affordable Care Act Update, continued from previous page

http://kaiserfamilyfoundation.files.wordpress.com/2011/04/8061-021.pdf

http://kaiserfamilyfoundation.files.wordpress.com/2011/04/8061-021.pdf

http://www.treasury.gov/press-center/press-releases/Documents/Fact Sheet 021014.pdf

http://www.treasury.gov/press-center/press-releases/Documents/Fact Sheet 021014.pdf

http://kff.org/health-reform/slide/current-status-of-the-medicaid-expansion-decision

http://kff.org/health-reform/slide/current-status-of-the-medicaid-expansion-decision

http://kaiserfamilyfoundation.files.wordpress.com/2013/01/8177.pdf

http://kaiserfamilyfoundation.files.wordpress.com/2013/01/8177.pdf

http://www.washingtonpost.com/blogs/wonkblog/wp/2013/11/27/obamacares-online-exchange-for-small-businesses-is-delayed-by-one-year



http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2011/rwjf71451.

http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2011/rwjf71451.



NAPBC UpdateBy Carl J. D’Orsi, MD, FACR, FSBI

T he National Accreditation Program for Breast Centers (NAPBC) is a consortium of national, professional organizations focused on breast

health for the improvement of the care and the outcomes of patients with diseases of the breast through evidence-based standards and patient and professional education. It was established in 2005 under the administrative aegis of the American College of Surgeons (ACS). Although there was some disagreement previously between the American College of Radiology (ACR) and the NAPBC, there are now eight diagnostic radiologists with specific interest and expertise in breast imaging who serve on the various committees and the Board of the NAPBC.

It is important that we maintain a connection with this organization in order to ensure that quality standards for breast imaging are maintained and universally recognized. NAPBC-accredited centers demonstrate the following services:

• A multidisciplinary, team approach to coordinate the best care and treatment options available;

• Access to breast cancer-related information, education, and support;

• Breast cancer data collection on quality indicators for all subspecialties involved in breast cancer diagnosis and treatment;

• Ongoing monitoring and improvement of care;

• Information about clinical trials and new treatment options.

Acceptance into the NAPBC involves a two stage process. The first step involves completing a Survey Application Record (SAR) which tabulates the metrics and services a facility offers. The second step is a facility visit by a team of NAPBC surveyors with a review of the medical records of a sample of patients with breast disease. There are currently approximately 300 centers that have achieved NAPBC accreditation. While the radiologists serve on various committees we, of course, are especially interested in the diagnostic imaging, needle biopsy and ultrasound standards. Although the initial “knee jerk” reaction may be one of turf wars, there is desire among all the specialties involved to promulgate

Carl J. D’Orsi, MD, FACR, FSBI


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standards that are not biased or diluted to meet the needs of any specific group of physicians. We certainly have no control over what any individual physician does at a facility, but we can certainly suggest uniform standards that all must meet in order to be classified as a member of the NAPBC.

The ACR realized years ago, that due to many issues, including access, a comparable set of standards for diagnostic breast ultrasound and ultrasound-guided biopsy as well as stereotactic biopsy should be developed for radiologists and for non-radiologists. These standards are used to evaluate ACR accredited facilities for breast ultrasound and stereotactic biopsy. If a facility also meets criteria for breast magnetic resonance imaging (MRI) accreditation (no non-radiologist standards) the facility receives a Breast Imaging Center of Excellence (BICOE) status. One of the professional organizations within the NAPBC, the American Society of Breast Surgeons (ASBS) also has standards for the surgeon who does image-guided needle breast biopsy and, while presently not completely comparable to ACR standards, at least address some of the components required to perform image-guided biopsies. Of about 3000 surgeons in the ASBS, only about 300 have qualified for ASBS

certification to perform these biopsies. Presently, both ACR and ASBS accreditation is accepted to satisfy NAPBC standards for image-guided biopsy. Thus, as I see it, a major thrust for the imagers representing various breast-centered imaging societies and organizations is to reconcile these non-radiologist standards (ASBS and ACR standards) into a single uniform set for the non-radiologist.

The NAPBC has supported us in our battles over screening mammography, and with such a diverse set of organizations involved in the NAPBC, it certainly will not be perceived as a vested interest supporting screening mammography. I think that our involvement with the NAPBC is important and will help maintain the excellence needed for the major part that imaging and image-guided biopsy currently play in the management of breast disease.

NAPBC Update, continued from previous page

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I f you perform image-guided breast biopsies, you have probably been alarmed by the reductions in payments for 2014. The hardest

hit codes have been the stereotactic biopsy codes, with a 40% relative value unit (RVU) reduction and a 10% reduction in payments. Ultrasound-guided biopsy saw a 30% RVU reduction and an 8% payment cut (average figures).The cuts are a result of a mandate from Medicare to create bundled codes combined with an assumption from Medicare that bundling must be associated with a reduction in value. The American College of Radiology (ACR) had little choice in this; we could have refused to comply with the mandate from the Centers for Medicare & Medicaid Services (CMS), but CMS has the ultimate authority to set the values for the Medicare Physician Fee Schedule, and CMS could have made much more stringent cuts without our input.

As background, we have traditionally used what is called component coding. Each component reflected only the physician work and resources needed to perform that component. So, for a stereotactic biopsy, we would typically bill four Current Procedural Terminology (CPT) codes: the image guidance, the needle biopsy, the specimen radiograph and the post-procedure

mammogram. Now we bill two: the bundled code for the biopsy including the specimen radiograph and the post-procedure mammogram.

Our ACR team was hampered by the fact that a large new family of codes was created in order to have a code for every possible scenario. Practicing radiologists were surveyed about the time and effort it takes to perform a service and those data helped us to craft our submission. The physicians being surveyed were frustrated trying to assess services they had never done (like placing a second clip under magnetic resonance imaging (MRI) guidance into a previously biopsied lesion), and this led to lower than optimal response rates. With all the biopsy codes being reviewed, we also could not provide relevant comparisons to help respondents who had to pick from choices such as a liver biopsy. Our ACR team fought valiantly to try to convince the “jury” (the American Medical Association (AMA) Relative Value Update Committee, which hears the specialty societies’ submissions and sends valuation recommendations to Medicare) of the value of these biopsies, but the values they were able to achieve were lower than what we would have hoped for.

Image-Guided Biopsy PaymentsBy Geraldine McGinty, MD, MBA, FACR

Upcoming Events & Activities2014

June 21 – Chicago, IL Society of Breast Imaging Board of Directors Meeting

September 20-21 – Las Vegas, NV

2014 Case-Based Review & Advanced Breast Imaging Course: Digital Breast Tomosynthesis

2015

April 25-28 – Orlando, FL SBI/ACR Breast Imaging Symposium


www.SBI-online.org



T he initial offering of the Society of Breast Imaging (SBI) Course on Digital Breast Tomosynthesis (DBT), held in Orlando, FL in

January 2014, was attended by 140 national and international radiologists. This course included presentations on the physics, engineering and other approaches to the design of DBT systems; an extensive review of published series and clinical trials reporting on the performance of DBT; applications of DBT for both screening and diagnostic breast imaging; and workflow considerations and integration of DBT into clinical practice.

The sessions were very interactive and incorporated a high level of audience participation via an audience response system and several panels and question and answer sessions.

Feedback on this course has been tremendously positive. Participants cited the information presented on approaches and “pearls” to DBT interpretation and the case presentation sessions as extremely helpful in planning to implement DBT in their practices.

Participants received a comprehensive, 372-page electronic syllabus and also received access to the actual lectures, which were recorded during

SBI Tomosynthesis Course is a Resounding SuccessBy Laurie L. Fajardo, MD, MBA, FACR, FSBI

These reductions came on the heels of a cascade of cuts to imaging services, mostly to computed tomography (CT) and MRI. Radiology practices are hurting. As a breast imager, I am worried that access to image-guided breast biopsy may decrease as practices have to make difficult choices to cut back on services that are no longer cost effective. I am worried that we may see delays in scheduling that may force patients to undergo surgical biopsy for diagnosis. That is a reversal of the progress that we

have made in the safe, early diagnosis of breast cancer, and it is bad for our patients.

With healthcare costs spiraling, everyone is searching for value. I get that, but these bundled codes have, in my opinion, missed the mark. Sure CMS will pay less for an image-guided biopsy today, but will we see more surgical biopsies to compensate for reductions in access tomorrow? Worse still, will we see an erosion of the gains we have made in diagnosing breast cancer?

So what can you do? The chipping away at our breast cancer diagnosis program will be insidious and we need your help to make our case. If we wait until we can analyze Medicare claims data (typically a couple of years after the service), it might be too late. Are there practices in your area no longer offering image-guided breast biopsy? Is the wait time going up? Please share your stories with me at [email protected]. Our patients are depending on us to be their advocates.

Image-Guided Biopsy Payments, continued from previous page


2014



the two day (Saturday and Sunday) symposium. At several time points during the course, attendees answered Self-Assessment Modules (SAMs) questions and subsequently received detailed and referenced discussions of each question in electronic format.

Faculty for this course included: Dr. Margarita Zuley, Dr. Michael Linver, Dr. Chris Comstock and Dr. Laurie Fajardo (program director). A highlight of the meeting was a vocal solo by Dr. Linver about breast papillomas that he sang, apropos to the Orlando/Disney venue, to the tune of Supercalifragilisticexpialidocious (Lyrics can be found on SBI’s Facebook and Twitter accounts).

Here’s what attendees are saying about the January course:

“The lectures were well organized and cases were well chosen.”

“This was an excellent course with very practical, real-world advice.”

“I found this meeting very helpful in the picture of incorporation of breast tomosynthesis into a breast imaging practice.”

“Terrific tomosynthesis lectures!”

This course fulfilled the eight hour training required by the Food and Drug Administration (FDA) for Mammography Quality Standards Act (MQSA) Radiologist DBT certification. In addition, participants earned up to 11.5 American Medical Association (AMA) Physician’s Recognition Award (PRA) Category 1 continuing medical education credits and 8.5 SAM credits toward fulfilling the requirements of the American Board of Radiology (ABR) Maintenance of Certification program.

A second offering of this course will occur September 20-21, 2014 in Las Vegas, NV at the Bellagio hotel. In addition, the course will be offered on January 17-18, 2015 in Orlando. Information about registration can be found at: www.sbi-online.org.

SBI Tomosynthesis Course, continued from previous page

Training Sonographers in Breast ImagingBy Lisa Arnall, RDMS

A s a sonographer moves into his or her career, the sonographer may find his or her scanning interests gravitating towards a

particular aspect of the body or a particular patient group (for example, fetal echocardiography, vascular ultrasound, pediatric ultrasound, or breast ultrasound). For me, my area of interest is breast ultrasound. While in sonography school, if you had asked me if I would be interested in specializing in breast imaging, I would have likely said, no; thinking it too mundane to be evaluating the same part of the body, day in and day out. Now, having been a dedicated breast sonographer

for a little over seven years, I find my current thoughts to be quite the contrary.

Breast imaging requires meticulous and methodical scanning skills, a knowledgeable and compassionate bedside manner, and confident delivery of information to the patient and the radiologist. Every patient is unique, as is every breast being scanned. The basic components of the breast consist of fatty and fibrograndular tissue. However, the organization and “landscape” of each breast varies from patient to patient, which may or may not create a challenging study for the sonographer.


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When training a sonographer in breast imaging, various aspects should be addressed. Familiarizing the sonographer with protocols and basic imaging differences from general ultrasound is a good place to start. For example, in breast imaging findings are often evaluated in the radial and the anti-radial planes, as opposed to the transverse and the sagittal planes routinely used when scanning other organs. In breast ultrasound, it is important that the patient be positioned appropriately. Placing the patient in a right posterior oblique or a left posterior oblique position with the assistance of a foam wedge, while having the patient raise her arm above her head is most typical, depending on the area in the breast being evaluated. Careful and diligent scanning of the area of interest is crucial.

In addition, the sonographer must be aware of the patient’s emotional state. One unique aspect of breast imaging is the high level of anxiety each patient exhibits. The anxiety could be based upon findings from a mammogram or clinical symptoms, such as a palpable abnormality. It is important to pay attention to the patient’s body language, facial expressions, and any other cues which may give you insight as to how the patient is feeling. Talk with the patient. Invite the patient to ask questions and help to give her a better understanding as to why she has been called back for additional imaging. Keep in mind, the patient is in a very vulnerable physical position, in addition to her high anxiety level. Empowering the patient and gaining her trust are important goals.

When scanning, aim to determine if a finding you locate correlates with a mammographic finding. For example, if the radiologist would like you to find a mass in the retromammary area, but you identify a mass in the anterior portion of the parenchyma, the anterior finding is most likely an incidental finding, not the finding that correlates with the mammographic abnormality. As a breast

sonographer, it is important to become confident when comparing a sonographic finding to the mammographic area of interest. Another component unique to breast imaging is sharing the results of the ultrasound with the patient after a radiologist has reviewed the images. Quite often, the sonographer will discuss the ultrasound findings with the patient for Breast Imaging Data and Reporting System (BI-RADS®) category 0, 1, 2, and 3 findings (1). It is important for the sonographer to feel self-assured in not only sharing the information with the patient, but also in answering any questions that the patient may have.

Over the years, I have found specializing in breast imaging to be incredibly rewarding and challenging. The many facets of patient care create an opportunity to touch the lives of the patients we serve.

References 1. D’Orsi CJ, Sickles EA, Mendelson EB, Morris EA, et al. ACR BI-RADS® Atlas. Breast Imaging Reporting and Data System. Reston, VA, American College of Radiology, 2013.

Training Sonographers, continued from previous page

http://www.acr.org/Quality-Safety/Resources/BIRADS

Despite an increasing workload, declining reimbursement, and constant attacks on the efficacy of screening mammography, breast

imaging has provided me with a satisfying career. When I was a resident, I once asked a prominent breast imager if he was happy doing breast imaging all day long. He replied that he was very stimulated and very satisfied with breast imaging as a subspecialty. A few years later, when I decided to concentrate on breast imaging, several friends and colleagues asked, “Are you going to do JUST breast imaging?” Nowadays, doing JUST breast imaging is a very busy job! Over the past 20 years, the field has progressed from xeroradiography to film-screen mammography to digital mammography to tomosynthesis. In addition, we use several modalities on a daily basis, including ultrasound (1) and magnetic resonance imaging (MRI) (2). These developments have allowed for patient-centered advances. For example, in 2014, there is really no reason to perform an excisional breast biopsy; nearly all breast biopsies should be performed with percutaneous techniques developed by breast imagers. In addition to being patient-centered, breast imaging is a subspecialty with a major goal: finding breast cancers. In breast imaging, there is patient-physician interaction and communication in many areas, especially in procedures, ultrasound, and diagnostic mammography. Our patient-physician interactions are focused, designed to solve problems (or recommend the appropriate next steps) and classify the findings according to a reporting system, the American College of Radiology’s Breast Imaging Reporting and Data System (BI-RADS®) (3), which serves as a model for other radiology subspecialty groups that are developing lexicons and reporting systems (4).

In breast imaging, another source of satisfaction is the interactions with other members of the breast care team, including surgeons, oncologists, pathologists, and radiation oncologists. Breast imagers are not JUST along for the ride; we play an integral role in modern breast care. Our findings are critical in determining what is needed for the patient and in determining what other specialists need to do. If breast imaging went on strike, the surgeons would not know where to operate, the oncologists and the radiation oncologists would not know where to treat, and the pathologists would not know where to find the cancers. Breast imaging is challenging—but immensely satisfying. If you are looking for an easy job, breast imaging is probably not the right choice for you. We are lucky that so many of our colleagues have worked so hard, some with fanfare and others quietly toiling away in virtual darkness, to advance the field over the last 20 years. I recently read an article by Drs. Ferris Hall, Daniel Kopans, Norman Sadowsky, and Marc Homer on how they developed mammographically-guided needle localization techniques in Boston in the 1970s. All four physicians developed effective methods to solve a clinical problem: localization of nonpalpable breast lesions. These developments changed breast imaging in a major way, improving care for countless patients around the world (5). Now, other investigators are pushing the envelope farther with radioactive seed localization techniques (6). Seed localizations are easier on the patients than needles and wires, and many

Gary J. Whitman, MD, FACR, FSBI



Breast Imaging: A Satisfying CareerBy Gary J. Whitman, MD, FACR, FSBI


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Breast Imaging, continued from previous page

Educating Physicians About Screening Mammography in CanadaBy Jean Seely, MD

scheduling problems are simplified or eliminated with seeds. Twenty years from now, will we be doing exclusively seed localizations? Will our trainees and younger colleagues know what a needle localization was? Breast imaging continues to progress in a patient-centered direction. Breast imaging has all the ingredients for physician satisfaction. Breast imaging is patient-centered with a specific focus (finding breast cancers), and breast imagers play an integral role in current breast care. Plus, there are several modalities (ultrasound and MRI in addition to mammography) and a well established reporting system (BI-RADS®) (3). In addition, nothing is static in breast imaging; the field is constantly advancing and improving.

References 1. Hooley RJ, Scoutt LM, Philpotts LE. Breast ultrasonography: state of the art. Radiology 2013;268:642-659.2. Saslow D, Boates C, Burke W, et al. American Cancer Society guidelines for breast screening with MRI as an adjunct to mammography. CA Cancer J Clin 2007;57:75-89.3. D’Orsi CJ, Sickles EA, Mendelson EB, Morris EA, et al. ACR BI-RADS® Atlas, Breast Imaging Reporting and Data System. Reston, VA, American College of Radiology; 2013.4. Wintermark M, Riedy G, Sanelli P. Radiologists standardize traumatic brain injury to improve patient care and outcomes. InPractice 2014;8:5-6, 18.5. Hall FM, Kopans DB, Sadowsky NJ, Homer MJ. Development of wire localization for occult breast lesions: Boston remembrances. Radiology 2013;268:622-627.6. Murphy JO, Moo TA, King TA, et al. Radioactive seed localization compared to wire localization in breast-conserving surgery: initial 6-month experience. Ann Surg Oncol 2013;20:4121-4127.

W ith every negative media attack on screening mammography, there is a potential for a decrease in the number

of patients referred for screening mammography.. After the Canadian Task Force on Preventive Health published its guidelines in 2011, many physicians stopped recommending routine screening mammograms. The recent release of the Canadian National Breast Cancer Screening study (CNBSS) resulted in many emails from colleagues all over the world questioning if we still offer screening mammography in Canada (1).

Discussions with non-breast imaging radiology colleagues demonstrated confusion on the value of screening mammography. At physician leadership conferences, I noted a lack of knowledge about the value of screening mammography, particularly among young female non-radiologist physicians. Surveys have shown that the majority of women are unaware of the benefits of mortality reduction in breast cancer mortality due to screening mammography.

The barrage of negative publicity is not new to us in breast imaging, but there is a need for action to counteract the misinformation. Otherwise, the only message received by the general population is that screening mammography is not useful and may, in fact, be harmful. Many of our national organizations are striving to send out more positive messages. However, at a more local level, it is essential that we educate our referring physicians and patients to inform them of the



reasons for regular screening mammography. This education is critical to counteract the negative messages heard on radio, television and seen in newspapers.

I would like to share how I have worked to educate family physicians in our region. I noted important deficiencies in education provided to family physicians at the university, hospital, and community levels. In 2011, a one hour course was all that was offered in breast imaging to medical students at the University of Ottawa Medical School. Annual education updates for family physicians from the university and in the region did not include any information on screening mammography or breast imaging. This resulted in a number of events to increase the education of family physicians. Specifically, I have:

• Spoken at informal lunchtime meetings with hospital family physician groups.

• Enlisted the help of other specialists.• Requested a letter from the head of breast

oncology to outline the benefits of earlier detection of breast cancer and its impact on decreased treatment costs.

• Obtained help from the surgical director of our breast health center to increase the number of hours allotted to the breast imaging curriculum at the medical school, which resulted in an increase of five hours

• Added a lecture on the mortality benefits of screening mammography to the University of Ottawa Annual Education Update for 450 family physicians

• Offered breast imaging in the curriculum at our continuing medical education (CME) conference directed to family physicians in the community, attracting 160-200 physicians annually.

Although a good start, the time for these initiatives did not allow for sufficient information. Feedback was that the information was valuable but that more detail was desired. In January 2014, I planned

a two hour evening educational event for 200 family physicians entitled “The Impact of Early Diagnosis of Breast Cancer.” To reach the largest audience, we advertised through a massive mailing to all family physicians in the region. We established a formal collaboration with the Academy of Physicians of Ottawa and linked through their network to advertise the event. We obtained funding from the Provincial Screening Program to sponsor the event. The event was teleconferenced to reach remote areas. I spoke about the benefits of breast cancer mortality reduction and the role of breast imaging in the diagnosis of breast cancer. I invited one of our breast surgeons to speak on the impact of early diagnosis on surgical treatment; she emphasized the reductions in morbidity and costs when a smaller tumor is removed. When a breast surgeon tells a family physician that a tumor identified on screening mammography results in less extensive, deforming surgery, it results in a powerful message. Reviews from this event were outstanding; the recurrent themes were “Why haven’t we heard this before?” and “I’ve learned to screen, screen, screen!” Our efforts have largely been successful; in the past year, our annual volumes for mammography have increased by 5.1%. With over 62,000 screening studies performed per year in our region, this is a significant improvement in reaching our target population.

To educate the general population, the message must be simple: we strive as radiologists to save patients’ lives, and screening mammography reduces breast cancer mortality. There is a need to educate our referring physicians; they are not learning about the importance of screening in medical school or at conferences. The message should come as a united front; collaboration with other physicians from other specialties is essential to generate a credible message. We have to be comfortable speaking to the media, taking time for interviews and educating

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Educating Physicians, continued from previous page

others. This may require learning leadership and communication skills. Ultimately, our job is not only to perform breast imaging, but also to encourage and inspire others about the importance of screening. As breast imagers, our patients’and their families’ futures depend on access to high quality screening mammography.

References 1. Miller AB, Wall C, Baines CJ, Sun P, To T, Narod SA. Twenty five year follow-up for breast cancer incidence and mortality of the Canadian National Breast Screening Study: randomised screening trial. BMJ. Electronic publication, February 11, 2014.

April 25-28, 2015

Hilton Bonnet Creek Orlando, Florida

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Breast Imaging Symposium2 0 1 5

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My public education lectures over the past three years have all had the same practical intent. Rather than pedantic

lectures about “why you (the audience member) should get screening mammography,” I suggest telling a friendly story—a true story—about why breast imagers recommend what we recommend and why we follow our own recommendations. Women are then more empowered to make their own decisions and filter the information that continues to swirl around the topic.

Here are a few overarching concepts to consider when presenting public education lectures:

1 Anxiety and gratitude: Acknowledge the anxiety. Uncertainty is normal with any medical

test. But also appropriate is an attitude of gratitude that we can screen effectively for a disease that still remains significant for American women.

2Introduce statistics, vocabulary, and common management themes: The cancer statistics

and our medical terms sound scary, we know, but your message should be upbeat and empowering as you lead your audience through your illustrated lecture. The statistics provide the serious context of why and how screening has helped, and why we recommend screening mammography for every woman over age 40 years. The vocabulary, along with lay language, gives the attendees some understanding because hearing a good explanation from you will help when they hear the terms again. Images of breast anatomy, examples of breast density and imaging findings (and mentioning benign mimickers), and images of our screening modalities help to demystify the screening mammography experience. Defining call backs and false positives in your own words helps to diminish anxiety.

Explain why submitting prior exams helps to reduce the recall rate and that there is still a supplemental role for physical exam/awareness.

3It is a matter of semantics, but the semantics do matter: Whether in a lecture or a patient

encounter, be mindful of the language you use (e.g., in expressions that could undermine the validity of the patient’s experience or limit the potential benefit of a teachable moment). The expressions “it just might be nothing” or “it was nothing” are commonly used to reference a finding that turns out to be benign. The goal is to reassure the patient. I propose that a finding is never “nothing”—it always has to be something. Otherwise why did we recheck in six months? Or biopsy it? It is important to do some reasonable education, because you can influence the beneficial ripple effect of that education as women talk to other women.

4Sandwiching the topic and prioritizing health behaviors: The purpose of your talk is to

highlight the importance of screening. But keep it reasonable and durable, rather than allowing it to expand to something bigger than life (“overselling” mammography). You can “sandwich” the topic between other health topics in two ways-- within your own lecture and by partnering with other speakers. So, remind the attendees about the American Cancer Society guidelines on exercise and nutrition, which are important for minimizing cancer risks in addition to optimizing heart health and other benefits. Good habits engender good habits. Women are notorious for prioritizing everyone else before themselves. Remind the attendees that their health is important and that only they can tend to it, and where screening fits in the big scheme of good health behavior.

Public Education on Breast Screening By Jiyon Lee, MD


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A s of January 1, 2012, all outpatient imaging centers that bill for breast magnetic resonance imaging (MRI) under

Medicare Part B must be accredited to receive reimbursement for the exam’s technical component. This article outlines the requirements for American College of Radiology (ACR) breast MRI accreditation. The ACR breast MRI accreditation website (1) should be the primary reference when getting started with the breast MRI accreditation process. The ACR program not only provides facilities with a review of the submission, but also provides constructive feedback on all aspects of the process, such as staffing qualifications, equipment requirements, quality control (QC), quality assurance (QA), MRI safety policies and image quality.

The supervising MRI physician will be closely involved and approve all aspects of the testing materials before submission to the ACR. Also, the MRI medical physicist who is responsible for supervising the weekly QC and annual testing should be closely involved with the phantom portion of the submission. Lastly, an administrative contact should be involved to ensure that the aforementioned staff members have the tools at hand for a successful submission.

ACR breast MRI accreditation is a two-step process; the first step involves providing the ACR with information regarding each site and equipment. After the accreditation application is approved, the testing materials and labels are sent out. These items are necessary for the second step, which involves sending clinical images, scanning protocols, and QC and QA documentation to the ACR. Upon approval of the application, the facility will have a 45 day time frame to get the second step completed. This short time frame allows facilities to get through the accreditation process in a timely manner. However, if more time is needed, the ACR will usually grant an extension.

Personnel QualificationsInterpreting physicians and technologists performing breast MRI examinations must meet specific qualifications. The requirements are based on the preceding three full calendar years. For example, if a site is applying or renewal in April

5 Cobbler’s children syndrome: I recently met two clinicians (early 40’s, post-partum) who

were unaware of the screening mammography guidelines. A medical degree does not equal

adequate awareness. We need to educate and care for our colleagues. And in doing so, our educated colleagues will become ambassadors in raising appropriate awareness too.

Public Education, continued from previous page

Breast MRI Accreditation UpdateBy Stamatia Destounis, MD, FACR, FSBI

Stamatia Destounis, MD, FSBI



Breast MRI Accreditation Update, continued from previous page

2014, the site must have met the full requirements and have documentation for January 2011 to December 2013. The physician requirements are detailed in tables in the MRI accreditation requirements document and these tables address initial qualifications as well as continuing medical education requirements. The facility should maintain the detailed MRI training documentation for all staff members and also must continue to maintain an updated list of all physicians, medical physicists and technologists working with the MRI unit. In addition, the supervising physician will have additional responsibilities such as MRI safety, contrast use, sedation use, and QC, as well as being the ACR contact. Detailed information pertaining to the list of requirements is found on the ACR website.

The technologists involved with breast MRI examinations must meet and document specific criteria for accreditation. The ACR recommends that technologists be registered, and hold a current Life Support certification with the ability to use an automatic external defibrillator. The tables detailing technologist requirements can also be found on the website. The medical physicist conducting testing must be familiar with MRI safety for patients, personnel, and the public. The physicist must be knowledgeable in the field of MRI physics and all aspects of MRI technology, including imaging protocols. The medical physicist is responsible for testing and surveying the equipment. The website shows the minimum criteria necessary for a medical physicist.

Breast MRI EquipmentTo date, there is not a minimum field strength requirement that has been set, however there are specifications that the MRI equipment must meet. A dedicated bilateral breast coil is required, and

there must be simultaneous bilateral imaging capabilities. The MRI unit must meet all state and federal performance requirements regarding field strength, radiofrequency power deposition, and noise levels. A prerequisite for breast MRI facilities is that they must have the capacity to perform mammographic correlation, directed breast ultrasound, and MRI-guided intervention, or have a referral arrangement in place with a cooperating facility that could provide these services (the ACR strongly recommends that the cooperating facility be accredited).

Quality Control (QC)QC documentation is required as part of the application. Instructions for QC are listed in the 2004 ACR Magnetic Resonance Imaging (MRI) Quality Control Manual.

Some of the required elements are included in the site’s most recent Annual MRI System Performance Evaluation report.

Clinical Images for AccreditationFacilities must submit one breast MRI case with a known enhancing, biopsy-proven carcinoma. The case should be sent in Digital Imaging and Communications in Medicine (DICOM) format on a computer disk (CD) or a digital video disk (DVD) for review. This case should represent the site’s best work and not be older than six months from the date of the testing memorandum. There are additional case requirements listed in the requirements document. Currently, phantom images are not required, but phantom images may be required in the future.


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Breast MRI Accreditation Update, continued from previous page

Conclusion The ACR breast MRI accreditation process is an extensive one. The ACR has provided valuable guidance to aid a new facility going through the accreditation steps. The best part of this process is that it is completed entirely online, except for the images (they will be sent by mail). This does help

to speed up the process, although it remains quite time-consuming and labor-intensive.striving to send out more positive messages.

References 1. www.acr.org/Quality-Safety/Accreditation/BreastMRI (accessed May 1, 2014)


2015

September 26-27, 2015San Diego, CA

January 17-18, 2015Orlando, FL

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http://www.acr.org/Quality-Safety/Accreditation/BreastMRI

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Tips for Optimizing Cancer Detection with Breast MRIBy R. Edward Hendrick, Ph.D., FACR, FSBI

Here are some important points for optimizing breast magnetic resonance imaging (MRI) exams for cancer detection:

Given the history of ipsilateral multifocal invasive cancer, additional evaluation with breast magnetic resonance imaging (MRI) was recommended as the next step.

1 Breast positioning is as important in breast MRI as it is in mammography. An excellent article

on breast positioning that every radiologist and MRI technologist should read was recently published by Dr. Eren Yeh et al (1).

2 Follow contrast agent label recommendations by administering gadolinium-chelate contrast

agents based on patient weight or body mass: 0.1 millimole per kilogram (mmol/kg) of patient body mass. Administering contrast agent based on patient body mass makes time-enhancement patterns of suspicious lesions more consistent from patient to patient and from study to study in the same patient. Contrast agents should be administered at a constant rate (e.g., 2 milliliters per second (mL/s)) with an MRI-compatible power injector, followed by an adequate saline flush (e.g., 20 mL). Always compare pre- and post-contrast T1-weighted (T1W) series to ensure that the contrast agent is clearly visible in the heart and the blood vessels of the breast on the early post-contrast series.

3 Use fat-suppression on T2-weighted (T2W) and multiphase T1W series to make sure that

bright fluid is easily seen on T2W series and enhancing vessels and lesions are easily detected on T1W post-contrast series. The presence of unsuppressed fat on T2W series makes bright fluid more difficult to detect because fat and bright

fluids have similar signal intensities. The presence of unsuppressed fat on multiphase T1W series makes enhancing lesions more difficult to see on post-contrast T1W series and adds structured noise to subtracted (post-contrast minus pre-contrast) T1W series, making it more difficult to detect small or non-mass-like lesions, especially when misregistration of pre-and post-contrast series occurs due to patient motion.

4 Make sure that the multiphase T1W series used for pre- and post-contrast imaging:

a) Have adequately small in-plane pixels of 1.0 mm or less in both in-plane directions. Achieving this means that for a 30 cm x 30 cm (300 mm x 300 mm) axial field-of-view (FOV), the acquisition matrix should be at least 300 x

Figure 1: Excessively large FOV, decreasing spatial resolution and sacrificing edge detail in the enhancing lesions in the lateral left breast, adjacent to the external marker. Breast positioning is also suboptimal.


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A

C

B

D

Figure 2: Unsubtracted 1st post-contrast (a) and subtracted (b) images with low SNR, which compromise conspicuity of the enhancing invasive ductal carcinoma near the chest wall in the left breast. Adequate SNR unsubtracted 1st post-contrast (c) and subtracted (d) images of an enhancing invasive ductal carcinoma in a different patient acquired with similar parameters, except for the acquisition matrix, which used somewhat larger voxels in (c) and (d), but still has spatial resolution less than 1 mm in each in-plane direction. Other factors, such as the breast receiver coil, receiver bandwidth, and the presence of ferromagnetic metal in the magnet, can also affect the SNR.

Tips for Optimizing Cancer Detection, continued from previous page




300. Increasing the FOV for larger patients means using a larger matrix to ensure that the in-plane pixel size remains at or below 1.0 mm in both the frequency-encoding and the phase-encoding directions. It is important to adjust the FOV based on body habitus, using smaller FOVs for smaller patients (Figure 1). With the same matrix (and scan time), this will improve spatial resolution and resulting specificity for smaller patients.

b) Have adequately thin slice thickness. Slices greater than 3 mm thick compromise the detection of subtle enhancing masses and non-mass-like lesions by increasing partial volume effects. Partial voluming occurs where signal is averaged over both enhancing and non-enhancing tissues in a voxel. Thin slices minimize partial voluming. Adequately thin slices (e.g., 1 mm) also make voxels nearly isotropic (the same size in each direction), so post-contrast or subtracted T1W series can be reformatted in any plane without a loss of spatial resolution. This eliminates the need to

acquire post-contrast series in other planes.

c) Have adequate temporal resolution. T1W series should be fast enough to correctly capture the time-enhancement curve shape of enhancing lesions (3 minutes or less per series), but not so fast that the signal-to-noise ratio (SNR) per voxel is so low that detection of weakly-enhancing or non-mass-like cancers is compromised (Figure 2). This means maximizing spatial resolution within the constraint of obtaining a multiphase series every 2-3 minutes.

5 Look for the presence of small vessels in three-dimensional maximum intensity projection

images (3D MIPs) of early subtracted series to confirm that the SNR is adequate (Figure 3). The inability to see small vessels on MIPs suggests the inability to detect small or subtle cancers.

Reference

1. Yeh ED, Georgian-Smith D, Raza S, Bussolari L, Pawlisz-Hoff J, Birdwell RL. Positioning in breast MR imaging to optimize image quality. RadioGraphics 2014;34:E1-E17.

A B

Figure 3: Bad (a) and good (b) axial MIPs in different patients. In (a), no enhancing vessels are visible. In (b), enhancing vessels down to a few millimeters are evident, as is an enhancing invasive ductal carcinoma in the same patient shown in Figures 2c and 2d.


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Stereo-Mammography UpdateBy Carl J. D’Orsi, MD, FACR, FSBI

S tereo-Mammagraphy follows from the way that we perceive the world. Each of our eyes, set apart from each other by about 6 cm,

views objects from slightly different perspectives. This difference allows us to recognize depth. In order to apply this to mammography, x-ray exposures of the breast in both the craniocaudal and the mediolateral oblique projections are taken at zero degrees and 6-10 degrees from zero degrees. This produces two slightly separated images. If we were to view these images, we would perceive basically a double image. In order to appreciate depth, each eye must receive only one of the two images. In order to accomplish this, each Image is polarized and a set of viewing lenses, cross-polarized to the images, is worn. In this way each eye now only sees one image and our brain does the rest, presenting us with an in depth mammogram.

The reason to even consider this technique came from an analysis of false positives and false negatives in mammography. One cause for false positives in screening mammography is overlapping tissue density. With stereo techniques, we may be able to determine overlapping without initiating a patient recall. Using similar logic, findings obscured by tissue above and below may hide a potential malignancy. Again by allowing depth perception, the potential malignancy may be better perceived. If we look at tomosynthesis, a similar separation of tissue density occurs but is accomplished by “slicing” a reconstructed data set into slices. The tomosynthesis data is not true three-dimensional (3D) data since the arc over which the tomosynthesis images are obtained is not 360 degrees but much less (it varies with the manufacturer) and therefore is not isotropic. We can immediately understand that a stereo mammogram will require much less time to

evaluate than a set of tomographic slices with an associated two-dimensional (2D) image. Stereo-mammography and tomosynthesis both perform in a similar fashion.

We reported our experience with stereo-mammography using a prospective paired study design of 1298 exams in 779 patients, comparing standard 2D digital mammography with digital stereo-mammography (1). There was a significant decrease in the recall rate for stereo-mammography compared to standard 2D mammography (9.6% versus 12.9%, respectively). There was no significant difference in sensitivity for stereo-mammography and standard 2D mammography (68.4% versus 63.2%, respectively) (1). A comparison of standard digital mammography and digital mammography with tomosynthesis was recently reported (2). This was an interim report for an ongoing screening trial conducted in Oslo, Norway. The false positive rate was 15% less with tomosynthesis and 2D mammography than with 2D mammography alone. There was also an increase of 27% in the cancer detection rate with tomosynthesis and 2D mammography compared to 2D mammography alone. Both findings were statistically significant (2).

What are the advantages and disadvantages of these technologies? The time required to read a stereo-mammogram is much less than the time needed to interpret a 2D mammogram and tomosynthesis images. Tomosynthesis studies have a dose higher than that of a 2D mammogram alone due to the 2D exam plus the images taken over the

Carl J. D’Orsi, MD, FACR, FSBI



arc of travel, each of which is much lower than the standard image. Currently, a synthetic digital 2D image can be created from the individual images obtained over the arc of travel for tomosynthesis, resulting in significant dose reduction.

Our stereo-mammography study used full dosage for each of the angled views, thus delivering twice the dose of a standard mammogram. In the stereo-mammography trial, a second set of stereo images was acquired in cooperation with Fuji, capped at the dose for a single view in order to ascertain if dose contributed to the results of the stereo-

mammography evaluation. A preliminary reading was done which did not show an advantage of stereo-mammography over standard mammography. However, the reader design was flawed, first showing the reader the standard 2D image for which an evaluation was made and then introducing the off zero image for a stereo read. This is not the way stereo is meant to be used. Both images must be presented at the same time so that the reader can adjust to the depth perception only once instead of for each exam. It is hoped that the study will be repeated using the correct reader design, but this has been

placed on the back burner by Fuji so that Fuji can focus on entering the competitive tomosynthesis market.

References 1. D’Orsi CJ, Getty DJ, Pickett RM, et al. Stereoscopic digital mammography: improved specificity and reduced rate of recall in a prospective trial. Radiology 2013;266:81-88.2. Skaane P, Bandos AI, Gullien R, et al. Comparison of digital mammography alone and digital mammography plus tomosynthesis in a population-based screening program. Radiology 2013;267:47-56.


ACR Announces the Birth of the 5th Edition of BI-RADSBy Carl J. D’Orsi, MD, FACR, FSBI and Edward A. Sickles, MD, FACR, FSBI

T he gestation period is over! The 5th edition of the American College of Radiology (ACR) Breast Imaging and Reporting System (BI-RADS®) (copyright 2013) was delivered early in April, 2014, weighing 4 pounds and 12 ounces (1). The offspring is robust. Its proud parents are happy but

exhausted. There are numerous additions, in general and specifically, to each of the breast imaging modalities. The line drawings have been eliminated and there are now approximately 700 images.

The assessment categories derive from analysis of the imaging findings only and at times do not properly fit with the associated management suggestions. As an example, there may be an oval circumscribed, solid mass in a young woman properly assigned a category 3. However, the woman insists on biopsy. The assessment category should not be elevated to a 4A simply due to the patient’s insistence on biopsy. A simple statement describing the correct assessment and the “mismatched” management can be supplied.

A concerted effort was made to ensure that all modality sections were consistent with each other and, toward this end, lexicon terms and definitions were revised. For the first time, there will be an electronic version. In this version each section is cross-linked, where applicable, and references are either linked to


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articles in the public domain or to abstracts in PubMed.

As is to be expected, the Mammography section, chaired by Dr. Sickles, had the fewest revisions since it is the most mature section. A major change is the dropping of the percentages of glandular tissue, previously included in the density descriptors, since accurate measurement requires isotropic three-dimensional (3D) imaging.

The Ultrasound section, chaired by Dr Mendelson, has revamped the atlas from the previous edition of BI-RADS. There is now a General Considerations section that includes anatomy, tissue composition, image quality, labelling/measurement and documentation. The differention between micro-and macro calcifications has been eliminated. Now, only one term is used: “microcalcifications.” The addition of descriptors for intraductal calcifications has been added since this can be an important indicator of ductal carcinoma in situ (DCIS) and supports the distribution terms used for mammography. Several “Special Cases” are now described, including simple cysts, fat necrosis and post-surgical fluid collections.

The MRI section, chaired by Dr. Morris, had the task of bringing MRI up to speed with the other modalities. Of interest and importance is a subsection on implants, clear definitions of background parenchymal enhancement and an expanded discussion of “Focus.”

Also, in this edition, there is a section devoted to “Outcome and Monitoring,” written by Dr. Sickles. Previously, this topic was limited to the mammography section. Many of the definitions and audit procedures used in the literature for ultrasound and MRI were anecdotal and thus not comparable across all facilities. These definitions and procedures have now been reconciled with accepted standards of auditing and so, for the first time, we can confidently compare outcomes within and across all modalities, leading to improvement in the usage of our breast imaging technologies and the quality of patient care.

Finally, I want to take this opportunity to thank the many members of the subcommittees and their chairs for the incredible amount of work needed to produce the latest edition. Special thanks and gratitude go to Dr. Sickles, who read the entire document many times with me to ensure that the definitions were reconciled among all the sections and for production of a set of universally accepted audit rules to accurately measure how we utilize these technologies.

References 1. D’Orsi CJ, Sickles EA, Mendelson EB, Morris EA, et al. ACR BI-RADS® Atlas, Breast Imaging Reporting and Data System, Reston, VA, American College of Radiology, 2013.

5th Edition of BI-RADS, continued from previous page

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MAMMOGRAPHY ULTRASOUND

Breast composition

a. The breasts are almost entirely fatty Tissue composition (screening only)

a. Homogeneous background echotexture – fat

b. There are scattered areas of fibroglandular density b. Homogeneous background echotexture – fibroglandular

c. The breasts are heterogeneously dense, which may obscure small masses

c. Heterogeneous background echotexture

d. The breasts are extremely dense, which lowers the sensitivity of mammography

Masses Shape Oval Masses Shape Oval Round Round

Irregular Irregular Margin Circumscribed Orientation Parallel

Obscured Not parallel

Microlobulated Margin Circumscribed

Indistinct Not circumscribedSpiculated - Indistinct

Density High density - Angular

Equal density - Microlobulated Low density - Spiculated Fat-containing Echo pattern Anechoic

Calcifications Typically benign

Skin Hyperechoic Vascular Complex cystic and solid Coarse or “popcorn-like” Hypoechoic Large rod-like Isoechoic Round Heterogeneous

Rim Posterior features

No posterior features

Dystrophic Enhancement Milk of calcium Shadowing Suture Combined pattern

Suspicious morphology

Amorphous Calcifications Calcifications in a mass

Coarse heterogeneous Calcifications outside of a mass

Fine pleomorphic Intraductal calcifications

Fine linear or fine-linear branching Associated features

Architectural distortionDistribution Diffuse Duct changes

Regional Skin changes Skin thickening

Grouped Skin retraction

Linear Edema

Segmental Vascularity Absent

Architectural distortion Internal vascularityAsymmetries Asymmetry Vessels in rim

Global asymmetry Elasticity assessment

Soft

Focal asymmetry Intermediate

Developing asymmetry Hard

Intramammary lymph node Special cases Simple cyst

Skin lesion Clustered microcysts

Solitary dilated duct Complicated cyst Associated features

Skin retraction Mass in or on skin

Nipple retraction Foreign body including implants

Skin thickening Lymph nodes – intramammary

Trabecular thickening Lymph nodes – axillary

Axillary adenopathy Vascular abnormalities

AVMs (arteriovenous malformations/

Architectural distortion pseudoaneurysms)

Calcifications Mondor diseaseLocation of lesion

Laterality Postsurgical fluid collection

Quadrant and clock face Fat necrosis

Depth

Distance from the nipple

ACR BI-RADS® Atlas Fifth Edition QUICK REFERENCE


www.SBI-online.org



MAGNETIC RESONANCE IMAGING

Amount of fibroglandular tissue (FGT)

a. Almost entirely fat b. Scattered fibroglandular tissue c. Heterogeneous fibroglandular tissue d. Extreme fibroglandular tissue

Associated features

Nipple retraction Nipple invasion Skin retraction Skin thickening

Background parenchymal enhancement (BPE)

Level Minimal Skin invasion Direct invasionMild Inflammatory cancerModerate Axillary adenopathyMarked Pectoralis muscle invasion

Symmetric or asymmetric

Symmetric Chest wall invasionAsymmetric Architectural distortion

Focus Fat containing lesions

Lymph nodes NormalMasses Shape Oval Abnormal

Round Fat necrosisIrregular Hamartoma

Margin Circumscribed Postoperative seroma/hematoma with fatNot circumscribed Location of lesion Location

- Irregular Depth- Spiculated Kinetic curve

assessment Signal intensity (SI)/time curve description

Initial phase Slow

Internal enhancement characteristics

Homogeneous Medium

Heterogeneous Fast

Rim enhancement Delayed phase Persistent

Dark internal septations Plateau

WashoutNon-mass enhancement (NME)

Distribution Focal Implants Implant material and lumen type

Saline Linear Silicone

- Intact - Ruptured

Segmental RegionalMultiple regions Other implant materialDiffuse Lumen type

Internal enhancement patterns

Homogeneous Implant location Retroglandular

Heterogeneous RetropectoralClumped Abnormal implant

contour Focal bulge

Clustered ringIntramammary lymph node Intracapsular silicone

findings Radial folds

Skin lesion Subcapsular line

Non-enhancing findings

Ductal precontrast high signal on T1W Keyhole sign (teardrop, noose)

Cyst Linguine sign

Postoperative collections (hematoma/seroma)

Extracapsular silicone Breast

Post-therapy skin thickening and trabecular thickening

Lymph nodesWater droplets

Non-enhancing mass Peri-implant fluid

Architectural distortion

Signal void from foreign bodies, clips, etc.

BI-RADS® ASSESSMENT CATEGORIES

Category 0: Mammography: Incomplete – Need Additional Imaging Evaluation and/or Prior Mammograms for Comparison Ultrasound & MRI: Incomplete – Need Additional Imaging Evaluation

Category 1: Negative

Category 2: Benign

Category 3: Probably Benign

Category 4: Suspicious Mammography & Ultrasound:

Category 4A: Low suspicion for malignancy Category 4B: Moderate suspicion for malignancy Category 4C: High suspicion for malignancy

Category 5: Highly Suggestive of Malignancy

Category 6: Known Biopsy-Proven Malignancy

For the complete Atlas, visit acr.org/birads



It is well known that many early stage breast cancer patients treated with adjuvant chemotherapy (i.e., chemotherapy given

following surgery) do not derive any survival benefit from it, despite enduring significant chemotherapy-related toxicity. Clearly, it would be beneficial to have a way to determine which patients are most likely to benefit from adjuvant chemotherapy. Recently genomic testing of breast tumors has been shown to provide valuable information to help in making this determination.

The most widely used genomic test is OncotypeDX (www.genomichealth.com). This test is valid for early stage (i.e., stage 1 or 2), estrogen receptor positive (ER+), Her-2-neu negative (Her2-) tumors in patients with no positive axillary lymph nodes. OncotypeDX measures the expression of 21 genes (16 cancer-related genes and five reference genes) using reverse transcription polymerase chain reaction (RT-PCR). From a weighted sum of these measurements, a value from 0 to 100, the Recurrence Score, is calculated. This value predicts the ten year likelihood of distant recurrence and correlates with the probability of benefit from the use of adjuvant chemotherapy in addition to hormonal therapy. Although the Recurrence Score is on a continuous scale, it has been divided into three categories:

Low Risk: < 18Intermediate Risk: 18-31High Risk: > 31

In practice, a value of 26 is used as the lower end of the High Risk category, based on analysis of the National Surgical Adjuvant Breast and Bowel Project (NSABP) B-20 trial (1). Patients with a Recurrence Score of 26 and above are advised to have adjuvant chemotherapy plus hormonal therapy, while those with scores below 18 are advised to use hormonal therapy only. In the

NSAPB B-20 data, patients in the High Risk group derived a 28% survival benefit from adjuvant chemotherapy while those in the Low Risk group derived no benefit. For scores between 18 and 25, the test does not provide clear guidance. In this range, the survival benefit from adjuvant chemotherapy falls somewhere in the range of 0 to 4%. The uncertainty is partly because of a dearth of patients with these scores in the validation sets and partly because the benefit of chemotherapy is variable in this range. For these patients, the decision whether or not to undergo chemotherapy needs to be made on the basis of conventional factors (e.g., tumor grade and stage) and patient factors (e.g., age and comorbidity). The Trial Assigning Individualized Options for Treatment (Rx) (TAILORx trial), currently underway, is designed to answer the question of which patients in the 18-25 range benefit from adjuvant chemotherapy. The trial has recently completed accrual, enrolling 10,200 patients.

The second most commonly used test is MammaPrint (www.agendia.com). MammaPrint looks at a 70-gene profile and produces a classification of either high risk or low risk. This eliminates the quandary caused by having a middle classification. Unlike OncotypeDX, which was validated using archival tissue from a prospective randomized study of adjuvant chemotherapy, MammaPrint’s primary validation is the RASTER study, a prospective trial with only five year follow-up. Thus there is no long term validation for this test. In the RASTER trial, 85% of the low risk group chose not to undergo chemotherapy; 3% of those patients recurred within five years. This compares to a 9% recurrence rate in the patients deemed high risk who chose to have chemotherapy. In contrast to OncotypeDX, MammaPrint can be used for both

Genomic Testing in Breast CancerBy Michael N. Linver, MD, FSBI


www.SBI-online.org



ER+ and ER- tumors. The use of MammaPrint was originally limited by the need for fresh tissue, but the test can now be performed on either fresh or fixed paraffin-embedded tissue.

Other tests are also available. These include Mammostrat test, a five gene test used on hormone positive cancers and PAM50, a 50 gene assay.

OncotypeDx is the only genomic assay that has guideline (e.g., National Comprehensive Cancer Network (NCCN), American Society of Clinical Oncology (ASCO), and St. Galen) listing for clinical use in deciding on the use of adjuvant chemotherapy. Guideline use is only for early stage, lymph node negative tumors that are ER+ and Her2-. Preliminary data in patients with 1-3 positive lymph nodes is available, and the Southwest Oncology Group (SWOG) RxPONDER trial (S1007) is studying the utility of the test in predicting the survival benefit of adjuvant

chemotherapy in this population of women. Although the evidence is weak, some oncologists have started to use OncotypeDx outside of published guidelines in patients with 1-3 positive lymph nodes. An OncotypeDX test for ductal carcinoma in situ (DCIS) has also been introduced, but has no clear indication at this point.

Genomic tumor assays are in their infancy, and new assays are being developed not only for breast cancer, but for colon and other cancers as well. Meanwhile, the current tests continue to be refined and validated.

References 1. Tang G, Cuzick J, Costantino JP, et al. Risk of recurrence and chemotherapy benefit for patients with node-negative, estrogen receptor-positive breast cancer: recurrence score alone and integrated with pathologic and clinical factors. J Clin Oncol 2011;29:4365-4372.

Genomic Testing, continued from previous page

SAVE THE DATES!


2016

September 17-18, 2016San Diego, CA

January 16-17, 2016Orlando, FL

http://www.sbi-online.org

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