Faculty Bibliography

For asymptomatic patients with saline implants, no imaging is recommended. If there is suspected saline implant rupture, ultrasound is usually appropriate, though saline implant rupture is often clinically evident. For asymptomatic patients with silicone implants, the FDA recommends that patients have an initial ultrasound or MRI examination without contrast 5 to 6 years after initial silicone implant surgery and then every 2 to 3 years thereafter. In a patient with silicone implants and suspected implant complication, MRI without contrast is usually appropriate and ultrasound and/or mammography may be appropriate, depending on age. In a patient with unexplained axillary adenopathy with current or prior silicone breast implants, ultrasound and/or mammography are usually appropriate, depending on age. In the setting of a patient with breast implants of any type and suspected implant-associated malignancy, ultrasound or MRI without and with contrast is usually appropriate as initial imaging test. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

OBJECTIVE:Radiology residents require timely, personalized feedback to develop accurate image analysis and reporting skills. Increasing clinical workload often limits attendings' ability to provide guidance. This study evaluates a HIPAA-compliant Generative Pretrained Transformer (GPT)-4o system that delivers automated feedback on breast imaging reports drafted by residents in real clinical settings. METHODS:We analyzed 5,000 resident-attending report pairs from routine practice at a multisite US health system. GPT-4o was prompted with clinical instructions to identify common errors and provide feedback. A reader study using 100 report pairs was conducted. Four attending radiologists and four residents independently reviewed each pair, determined whether predefined error types were present, and rated GPT-4o's feedback as helpful or not. Agreement between GPT and readers was assessed using percent match. Interreader reliability was measured with Krippendorff's α. Educational value was measured as the proportion of cases rated helpful. RESULTS:Three common error types were identified: (1) omission or addition of key findings, (2) incorrect use or omission of technical descriptors, and (3) final assessment inconsistent with findings. GPT-4o showed strong agreement with attending consensus: 90.5%, 78.3%, and 90.4% (Cohen's κ: 0.790, 0.550, and 0.615) across error types. Interreader reliability among all eight readers showed moderate to substantial variability (α = 0.767, 0.595, 0.567). When each reader was individually replaced with GPT-4o and interreader agreement among seven readers and GPT was recalculated, the effect was not statistically significant (Δ = -0.004 to 0.002, all P > .05). GPT's feedback was rated helpful in most cases: 89.8%, 83.0%, and 92.0%. DISCUSSION/CONCLUSIONS:ChatGPT-4o can reliably identify key educational errors. It may serve as a scalable tool to support radiology education.

OBJECTIVE:Understand radiologists' opinions regarding remote breast imaging and determine whether having home workstations is associated with greater job satisfaction or less burnout. METHODS:A 43-question survey on remote breast imaging was distributed to Society of Breast Imaging members (July 6 to August 2, 2023). Questions regarding job satisfaction and burnout were included. Pearson's chi-squared tests compared demographic variables and responses. Multiple-variable logistic regression assessed associations between home workstations and job satisfaction or burnout. RESULTS:In total, 424 surveys were completed (response rate 13%, 424/3244). Among the third (31%, 132/424) of breast imaging radiologists with home workstations, top motivations included flexibility/work-life balance (67%; 88/132) and decreased commute time (51%, 67/132). Most felt that working from home improved their efficiency (65%, 86/132). Perceived drawbacks among all breast imaging radiologists included the inability to perform US or physical examination (71%, 300/424) and impaired patient contact (47%, 198/424). Most (57%, 240/424) wished for more breast imaging remote reading opportunities, and one-third (32%, 136/424) saw themselves in a 100% remote reading practice in the future. The majority (60%, 228/388) felt that remote reading would majorly or moderately improve radiologist wellness, but no significant association was found between having home workstations and job satisfaction (P = .301) or burnout (P = .140). CONCLUSION/CONCLUSIONS:The majority of breast imaging radiologists want more opportunities to work remotely, perceiving that it improves work-life balance and efficiency, albeit at the expense of patient contact. However, those currently working from home did not have higher job satisfaction or lower burnout.

OBJECTIVE:To assess the current perceptions of breast imaging staffing shortages and contributing factors among breast imaging radiologists. METHODS:A survey assessing current perception of breast radiologists regarding breast imaging-specific staffing shortages and contributing factors was developed by the Patient Care and Delivery Committee of the Society of Breast Imaging (SBI) and emailed to SBI active physician members. Bivariable analysis (chi-squared, t test) was performed between the survey demographics and survey response questions of interest. RESULTS:There were 309 responses (response rate of 15.7%). Most respondents perceived their practices to be short-staffed for breast radiologists (79%, 239/302), US technologists (74%, 216/290), mammography technologists (70%, 211/301), and support staff (66%, 201/302). Of the respondents who indicated they were short-staffed for breast imaging radiologists, 92% (226/246) believed it was due to insufficient number of radiologists, 67% (164/246) thought it was due to increase in volume, and 63% (154/246) attributed it to both increase in volume and insufficient number of breast imaging radiologists. Practices were more likely to be short-staffed if they had more practice sites (mean, 8.2 ± 7.1 vs 6.4 ± 8.4; P = .002), had fewer breast imaging radiologists (mean, 10.1 ± 9.6 vs 11.3 ± 11.5; P = .009), and were academic practices (35.1% vs 25.7%; P = .028). CONCLUSIONS:Most breast imaging radiologists perceive their current breast imaging practices to be short-staffed for radiologists, mammography technologists, US technologists, and support staff. Understanding contributing factors is crucial to addressing root causes and mitigating impact on patient care and burnout across breast imaging team members.

Routine screening substantially reduces the risk of mortality and morbidity of breast cancer with early detection. Multiple different imaging modalities may be used to screen for breast cancer. Screening recommendations differ based on an individual's risk of developing breast cancer. Numerous factors contribute to breast cancer risk, which is frequently divided into three major categories: average, intermediate, and high risk. For patients assigned female at birth with native breast tissue, mammography and digital breast tomosynthesis are recommended for breast cancer screening in all risk categories. In high-risk patients, screening with breast MRI is recommended starting as early as 25 to 30 years of age and mammography and digital breast tomosynthesis with a variable starting age between 25 and 40 years of age, depending on the type of risk. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Breast cancer screening recommendations have been established historically for women, but, have been less clearly outlined for men. For average-risk men and younger men less than 25 year of age, imaging is not usually appropriate as a screening test for breast cancer. For men of higher-than-average risk, screening with mammography as annual surveillance imaging is usually appropriate. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

We used focus groups of radiologists who led the implementation of contrast-enhanced mammography (CEM) in their practice to identify barriers and strategies for adoption. Members of the Society of Breast Imaging in the United States who served as lead on CEM implementation were invited to participate in 2 separate focus groups. Ten breast imaging radiologists with varied geographic and practice type (60% academic, 30% private, and 10% community practice) participated. There were 4 major themes identified: patient selection, workflow, contrast, and billing. Patient selection varied widely among practices, with some limiting CEM to patients unable to obtain MRI and others routinely using CEM for diagnostic workup. Lack of Food and Drug Administration approval limited screening applications in some practices. Workflow challenges were numerous, and site-specific solutions were developed for ordering, scheduling, staffing, and intravenous access. There were universal concerns regarding contrast, including safe administration, response to reactions, and biopsy planning for findings only visible on CEM. Contrast reaction training, including conducting mock codes at some practices, helped alleviate concerns of the radiologists and technologists. Finally, billing was an administrative hurdle that influenced patient selection. Ample preparation is needed to successfully start a CEM program with particular attention to patient selection, workflow, contrast administration/reactions, and billing.

OBJECTIVE:Assess current practices and plans regarding home workstations and remote diagnostic breast imaging in the United States. METHODS:A 43-question survey relating to remote breast imaging was distributed to Society of Breast Imaging members from July 6, 2023, through August 2, 2023. A descriptive summary of responses was performed. Pearson's chi-squared test was used to compare demographic variables of respondents and questions of interest. RESULTS:In total, 424 surveys were completed (response rate 13%, 424/3244). One-third of breast imaging radiologists (31%, 132/424) reported reading examinations from home or a personal remote site for a median of 25% of their clinical time. The most common types of examinations read from home were screening mammography (90%, 119/132), screening US (58%, 77/132), diagnostic mammography and MRI (both 53%, 70/132), and diagnostic US (49%, 65/132). Respondents from private practices were more likely than those from academic practices to read diagnostic imaging from home (67%, 35/52 vs 29%, 15/52; P <.001). Respondents practicing in the West were less likely to read breast imaging examinations from home compared with those in other geographic regions (18%, 12/67 vs 28%-43% for other regions; P = .023). No differences were found among respondents' overall use of home workstations based on age, gender, or having dependents. Most respondents (75%, 318/424) felt that remote breast reading would be a significant practice pattern in the future. CONCLUSION/CONCLUSIONS:Home workstations for mammography and remote diagnostic breast imaging are a considerable U.S. practice pattern. Further research should explore radiologist preferences regarding remote breast imaging and its impact on clinical care and radiologist well-being.

Invasive lobular carcinoma (ILC) is the second-most common histologic subtype of breast cancer, constituting 5% to 15% of all breast cancers. It is characterized by an infiltrating growth pattern that may decrease detectability on mammography and US. The use of digital breast tomosynthesis (DBT) improves conspicuity of ILC, and sensitivity is 80% to 88% for ILC. Sensitivity of mammography is lower in dense breasts, and breast tomosynthesis has better sensitivity for ILC in dense breasts compared with digital mammography (DM). Screening US identifies additional ILCs even after DBT, with a supplemental cancer detection rate of 0 to 1.2 ILC per 1000 examinations. Thirteen percent of incremental cancers found by screening US are ILCs. Breast MRI has a sensitivity of 93% for ILC. Abbreviated breast MRI also has high sensitivity but may be limited due to delayed enhancement in ILC. Contrast-enhanced mammography has improved sensitivity for ILC compared with DM, with higher specificity than breast MRI. In summary, supplemental screening modalities increase detection of ILC, with MRI demonstrating the highest sensitivity.

Beyond the technical aspects, success and long-term patient outcomes of image-guided breast biopsies depend on the overall patient experience. Patient experience in turn is influenced by intangible factors, such as environmental features during the procedure; patient-centered communication prior to, during, and subsequent to the procedure; and management of expectations and biopsy complications. Here, we review evidence-based literature and results of a national Society of Breast Imaging survey on approaches to both mitigate and manage common image-guided core biopsy complications as well as nontechnical strategies to improve the patient biopsy experience.