Faculty Bibliography

RATIONALE AND OBJECTIVES/OBJECTIVE:The COVID-19 pandemic stresses the tenuous balance between domestic obligations and academic output for women across professions. Our investigation aims to evaluate the impact of the pandemic on the home duties and workplace productivity of academic radiologists with respect to gender. MATERIALS AND METHODS/METHODS:A 49-question survey was distributed to 926 members of Association of University Radiologists in October 2020. Several categories were addressed: demographics; workplace changes; stress levels and personal experiences with illness; time spent on domestic obligations; and perception of productivity during COVID-19. Statistical analyses were performed using SAS version 9.4 software (SAS Institute, Cary, NC). RESULTS:A total of 96 responses across 30 states, 53.1% male and 46.9% female were received. Women report spending more time on unpaid domestic duties than men prior to COVID-19, with men spending a median of 5-10 h/wk and women spending a median of 10-15 h/wk (p = 0.043). With pandemic onset, both genders reported that women did more of the homecare, when not split equally. Women with young children reported a significant decrease in work-from-home productivity compared to men with young children (p = 0.007). Men reported they had more time to be productive compared to women (p = 0.012). CONCLUSION/CONCLUSIONS:The COVID-19 pandemic threatens to disrupt the advancement of women in radiology leadership roles by creating disparate effects on productivity due to increased workloads at home for women. This could potentially lead to decreases in promotions and research productivity in years to come that far outlast the acute phases of the pandemic.

Neoadjuvant therapy is increasingly being used to treat early-stage triple-negative and human epidermal growth factor 2-overexpressing breast cancers, as well as locally advanced and inflammatory breast cancers. The rationales for neoadjuvant therapy are to shrink tumor size and potentially decrease the extent of surgery, to serve as an in vivo test of response to therapy, and to reveal prognostic information for the patient. MRI is the most accurate modality to demonstrate response to therapy and to help ensure accurate presurgical planning. Changes in lesion diameter, volume, and enhancement are used to predict complete response, partial response, or nonresponse to therapy. However, residual disease may be overestimated or underestimated at MRI. Fibrosis, necrotic tumors, and residual benign masses may be causes of overestimation of residual disease. Nonmass lesions, invasive lobular carcinoma, hormone receptor-positive tumors, nonconcentric shrinkage patterns, the use of antiangiogenic therapy, and late-enhancing foci may be causes of underestimation of residual disease. In patients with known axillary lymph node metastasis, neoadjuvant therapy may be followed by targeted axillary dissection to avoid the potential morbidity associated with an axillary lymph node dissection. Diffusion-weighted imaging, radiomics, machine learning, and deep learning methods are under investigation to improve MRI accuracy in predicting treatment response.^©RSNA, 2021.

Ductal carcinoma in situ (DCIS), breast cancer confined to the milk ducts, is a heterogeneous entity. The question of how and when a case of DCIS will extend beyond the ducts to become invasive breast cancer has implications for both patient prognosis and optimal treatment approaches. The natural history of DCIS has been explored through a variety of methods, from mouse models to biopsy specimen reviews to population-based screening data to modeling studies. This article will review the available evidence regarding progression pathways and will also summarize current trials designed to assess DCIS progression.

Ductal carcinoma in situ (DCIS), breast cancer confined to the milk ducts, is a heterogeneous entity. The question of how and when a case of DCIS will extend beyond the ducts to become invasive breast cancer has implications for both patient prognosis and optimal treatment approaches. The natural history of DCIS has been explored through a variety of methods, from mouse models to biopsy specimen reviews to population-based screening data to modeling studies. This article will review the available evidence regarding progression pathways and will also summarize current trials designed to assess DCIS progression.

Digital breast tomosynthesis (DBT) has been widely adopted in breast imaging in both screening and diagnostic settings. The benefits of DBT are well established. Compared with two-dimensional digital mammography (DM), DBT preferentially increases detection of invasive cancers without increased detection of in-situ cancers, maximizing identification of biologically significant disease, while mitigating overdiagnosis. The higher sensitivity of DBT for architectural distortion allows increased diagnosis of invasive cancers overall and particularly improves the visibility of invasive lobular cancers. Implementation of DBT has decreased the number of recalls for false-positive findings at screening, contributing to improved specificity at diagnostic evaluation. Integration of DBT in diagnostic examinations has also resulted in an increased percentage of biopsies with positive results, improving diagnostic confidence. Although individual DBT examinations have a longer interpretation time compared with that for DM, DBT has streamlined the diagnostic workflow and minimized the need for short-term follow-up examinations, redistributing much-needed time resources to screening. Yet DBT has limitations. Although improvements in cancer detection and recall rates are seen for patients in a large spectrum of age groups and breast density categories, these benefits are minimal in women with extremely dense breast tissue, and the extent of these benefits may vary by practice environment and by geographic location. Although DBT allows detection of more invasive cancers than does DM, its incremental yield is lower than that of US and MRI. Current understanding of the biologic profile of DBT-detected cancers is limited. Whether DBT improves breast cancer-specific mortality remains a key question that requires further investigation. ^©RSNA, 2021.

Pathologic nipple discharge (PND) is typically unilateral, spontaneous, involves a single duct, and is serous or bloody in appearance. In patients with PND, breast MRI can be helpful as an additional diagnostic tool when conventional imaging with mammogram and ultrasound are negative. MRI is able to detect the etiology of nipple discharge in 56-61% of cases when initial imaging with mammogram and ultrasound are negative. Advantages to using MRI in evaluation of PND include good visualization of the retroareolar breast and better evaluation of posterior lesions which may not be well evaluated on mammograms and galactograms. It is also less invasive compared to central duct excision. Papillomas and nipple adenomas are benign breast masses that can cause PND and are well visualized on MRI. Ductal ectasia, and infectious etiologies such as mastitis, abscess, and fistulas are additional benign causes of PND that are well evaluated with MRI. MRI is also excellent for evaluation of malignant causes of PND including Paget's disease, ductal carcinoma in-situ and invasive carcinoma. MRI's high negative predictive value of 87-98.2% is helpful in excluding malignant etiologies of PND.

BACKGROUND:Emerging data suggest screening mammography may be effective in detecting breast cancer early in high-risk men. We evaluated current screening recommendations as a risk management strategy in men at elevated risk for breast cancer. PATIENTS AND METHODS/METHODS:This institutional review board-approved, Health Insurance Portability and Accountability Act (HIPAA)-compliant study reviewed consecutive men who underwent genetic counseling and multigene panel testing (MGPT) for breast cancer risk assessment at our institution between 2012 and 2018. Patient risk factors, test indications, and MGPT outcomes were recorded, then correlated with screening recommendations by either clinical breast examination or screening mammography. Recommendation consistency among practitioners was evaluated. Patient adherence to screening mammography (defined as undergoing screening mammography as recommended) was assessed. Statistical analysis was performed at the 2-sided 5% significance level. RESULTS:A total of 414 asymptomatic men underwent both genetic counseling and MGPT (mean age, 47 years; range, 18-91 years) for breast cancer risk assessment. Of this group, 18 (4.3%) of 414 had a personal history of breast cancer, and 159 (38.4%) of 414 had a family history of breast cancer before MGPT. Among 112 men with positive MGPT results, BRCA1/2 mutations were the most common (56.3%, 63/112). Most BRCA mutation carriers (80.9%, 51/63) were recommended clinical breast examination only. Only 5.9% (2/34) BRCA2 and 10.3% (3/29) BRCA1 carriers were recommended screening mammograms (7.9%, 5/63 of all BRCA carriers). Among men with a personal history of breast cancer, only 9 (50%) of 18 were recommended screening mammograms. Overall adherence to screening mammogram in men was 71.4% (10/14), which ultimately yielded two cancers. Breast cancer screening recommendations varied widely among practitioners, with some recommending clinical breast examination only, and others also recommending mammography. CONCLUSION/CONCLUSIONS:Men who are found to be at an elevated risk for breast cancer after undergoing genetic counseling and testing currently receive relatively inconsistent screening recommendations.

Magnetic Resonance (MR) imaging is the most sensitive modality for breast cancer detection but is currently limited to screening women at high risk due to limited specificity and test accessibility. However, specificity of MR imaging improves with successive rounds of screening, and abbreviated approaches have the potential to increase access and decrease cost. There is growing evidence to support supplemental MR imaging in moderate-risk women, and current guidelines continue to evolve. Functional imaging has the potential to maximize survival benefit of screening. Leveraging MR imaging as a possible primary screening tool is therefore also being investigated in average-risk women.