sign in sign up
<<
Home , Breast ultrasound, Lumpectomy, Mastectomy, Xeromammography

The Member Newsletter of the Society of Imaging 2015 ISSUE 2 Gary J. Whitman, MD, FACR, FSBI

Copyright 2015. Society of .

ii Table of Contents 2 | President’s Column: The Evolving 16 | Interesting Case: The Importance Relationship Between Breast Imaging of Mammographic Margins and Industry By Peter Eby, MD, FSBI By Murray Rebner, MD, FACR, FSBI 18 | What to Look for in a Breast 4 | NAPBC Update Imaging Fellowship By Gary J. Whitman, MD, FACR, FSBI By Ann M. Leylek, MD

5 | Repeats, Rejects and Recalls: 21 | Breast Risk Assessment: How Many is Too Many? Should This Be Part of Our Practice? By Louise C. Miller, ARRT, CRT, RTRM By Jennifer Harvey, MD, FACR, FSBI

7 | SBI/ACR Breast Imaging 23 | Mergers and Acquisitions Symposium 2015 By Christiane M. Hakim, MD

8 | Nipple Sparing 25 | Microbubble Contrast-Enhanced By John Lewin, MD, FACR, FSBI Ultrasound in By Basak Erguvan-Dogan, MD 10 | Team Building By Michael N. Linver, MD, FACR, FSBI 27 | Physician Stress: Let’s Stop Wearing It as a Badge of Honor 12 | SBI DBT Course: A September By Warren L. Holleman, PhD Spectacular! By Michael N. Linver, MD, FSBI – Chair, 29 | The Accountable Care Organization SBI DBT Course Model: An Update By Bernadette Redd, MD 13 | : An Update By Stephanie J. Jeske, MD, MSc and Jessica W. T. Leung, MD, FACR, FSBI

Newsletter Editor: Wendy DeMartini, MD, FSBI Louise C. Miller, ARRT, CRT, RTRM Gary J. Whitman, MD, FACR, FSBI, Chair Stamatia V. Destounis, MD, FACR, FSBI Robert Nishikawa, PhD, FSBI Peter R. Eby, MD, FSBI Liane E. Philpotts, MD, FSBI SBI Newsletter Committee: Jessica W. T. Leung, MD, FACR, FSBI Murray Rebner, MD, FACR, FSBI Shadi A. Shakeri, MD John M. Lewin, MD, FACR, FSBI Layout & Design: Jay A. Baker, MD, FSBI Ann M. Leylek, MD Graphic Design Associates, Inc. Jade de Guzman, MD Michael N. Linver, MD, FACR, FSBI

1 President’s Column: The Evolving Relationship Between Breast Imaging and Industry his topic might seem more appropriate for a lecture at a business managers course; however, I believe that it also has relevance for us as breast imagers. As the T consumers of breast-imaging equipment, physicians have always had a close relationship with the manufacturers and vendors of these products. In the early 1970s, Xerox Corporation introduced machines based on the pioneering work of Dr. John Wolfe. Prior to this, some facilities had been doing film without full clinical effectiveness (1, 2).Thanks to the excellent ground-breaking work of Robert Egan in the early 1960s, Charles Gros of France, along Murray Rebner, MD, with the general radiology company, CGR, developed the first dedicated film-screen FACR, FSBI mammography machine in 1965. This machine spawned companies which produced critical ancillary equipment such as mammography films and screens, film processors and their associated chemicals, film viewing systems, dark room lights and even magnifying glasses. The passage of the Mammography Quality Standards Act (MQSA) in 1992 mandated that manufacturers produce equipment meeting requirements to produce high quality images. This helped ensure that radiologists acquired reliable equipment and women received quality examinations. With the advent of digital mammography at the beginning of the twenty-first century, breast imagers had to engage with companies which produced dedicated mammography monitors, computer systems to store and retrieve images, as well as radiology and hospital information systems. Advancements in and magnetic resonance imaging (MRI) led to the creation of new computer-based products from different vendors. We have also seen a continuous evolution of our interventional products which include grids, tables, needles, vacuum-assisted devices, and more. As you are well aware, we are now beginning a transition from standard digital mammography to digital breast (DBT). Breast imagers (as well as radiologists in other subspecialties) have always been concerned about the compatibility and communication between company A, which makes one product in an imaging chain, and company B, which makes a different product. After many years of frustration, Integrating the Healthcare Enterprise (IHE) was created in 1998 as a joint effort of the Radiological Society of North America (RSNA) and the Healthcare Information and Management Systems Society (HIMSS). IHE is an initiative by healthcare professionals and industry to improve the way computer systems in healthcare share information. This working group has helped manufacturers create products which interface better and are far more user-friendly to the breast imager. IHE now involves multiple specialties in and numerous data-oriented companies. How does all of the above relate to the Society of Breast Imaging (SBI)? The SBI has always considered education to be one of its major goals. We stress the importance of using evidence-based medicine to help guide the purchase and use of new technologies. Our courses are created to be vendor neutral; we choose speakers without conflicts of interest who will present data which show the strengths and weaknesses of new modalities. We also present lectures which discuss cutting edge technologies. In 2013, we were cautious not to endorse DBT until more robust data were published. After two years of further research, the publications clearly demonstrate that the initial results were accurate and the SBI along with the American College of Radiology (ACR), openly support the technology.

2 President’s Column, continued from previous page

Our previous weekend and postgraduate courses as well as our upcoming symposia offer vendors the opportunity to showcase their breast imaging wares. This allows our attendees to view and discuss these products with the sellers and with their peers. Some of the monies which we derive from selling space to our vendors are also used for future educational endeavors. There will always be scenarios where the demand for new technology precedes the science which demonstrates its efficacy. For those old enough to remember, this occurred when image-guided core was introduced. Many of the relevant questions related to the technology (what constitutes a discordant diagnosis for different lesions?, what is the appropriate follow-up interval for benign lesions?, etc.). However, breast imagers saw the significant advantages of core biopsy over fine needle aspiration and started to perform the procedures. We cannot control the demands of the breast imaging marketplace, but we believe that the educated breast imager is a wiser consumer. We at the SBI will continue to provide our members with evidence-based information which will help in your future equipment acquisition decisions. This is my final president’s column. I have enjoyed communicating my thoughts about relevant breast imaging issues to you. I want to thank Dr. Gary Whitman for his excellent work as editor as well as his entire newsletter committee who have produced such fine articles. Kudos to our SBI staff for making the publication process run so smoothly. I want to welcome Dr. Peter Eby as the new editor - he will do a great job. The next president’s column will be written by Dr. Elizabeth Morris. I pass her the “president’s pen;” I know she will use it well.

Murray Rebner, MD, FACR, FSBI President, Society of Breast Imaging

REFERENCES 1. Cooperman LR, Seltzer RA, Reimer GW, Rossiter SB. Xeromammography in the early detection of breast cancer. Community hospital experience and approach. West J Med 1975;123:360-366. 2. Wolfe JN. History and recent developments in of the breast. Radiol Clin North Am 1987; 25:929-937.

3 NAPBC Update By Gary J. Whitman, MD, FACR, FSBI

he National Accreditation Program for Breast Centers (NAPBC) Board of Directors held a conference call on February 24, 2015. The call was led by the new NAPBC chair, Dr. James L. Connally, a pathologist at Beth Israel T Deaconess Medical Center in Boston. International NAPBC activities are gaining momentum. Recently, the first non-United States accreditation survey was completed at Tawam Hospital, a Johns Hopkins affiliate, in the United Arab Emirates. Tawam Hospital was accredited through a combined Skype/on-site process. Overall, the process went smoothly, and the Skype sessions before the on-site survey were particularly valuable. In the next year, surveys in Canada and Great Britain are planned. Another area of focus is accreditation of geographically remote centers in the United States. The NAPBC recently launched a task force to study low volume and geographically remote sites. Dr. Connolly announced the official integration of the National Consortium of Breast Centers and the American Society of Breast Diseases (ASBD). The combined organization will exist as the National Consortium of Breast Centers (NCBC) with the goals of advancing the interdisciplinary team approach to breast care, positively impacting quality and being sensitive to evidence-based, value-based care. Dr. David P. Winchester, Medical Director of Cancer Programs at the American College of Surgeons (ACS) discussed possible integration of the Commission on Cancer (CoC) and The NAPBC. This proposal would allow for program consolidation and efficiencies in staffing, planning, and marketing and eliminate some redundancies at the ACS. A discussion followed, noting that while Dr. Winchester’s proposal may offer advantages for the ACS, the plan may not necessarily be advantageous to the NAPBC, which aims to improve multidisciplinary breast care. Efforts are underway to try to increase the public visibility of the NAPBC. The NAPBC is placing greater emphasis on social media, including Twitter, Facebook, and blogs. Also, the NAPBC plans to emphasize educational materials for patients. For example, an educational pamphlet for contralateral mastectomy may lead to more informed patient decision-making. The Educational Resources Standard (2.17) is currently undergoing revision. Also, the Genetic Evaluation and Management Standard (2.16) is being revised. The Board of Directors will next meet face-to-face in June in Chicago.

2015 Case-Based Review & Advanced Breast Imaging September 26 - 27- San Diego, CA Course: Digital Breast Tomosynthesis November 29 - December 4 – Chicago, IL Radiological Society of North America (RSNA)

For a listing of other society events please check out the SBI Calendar of Events at www.sbi-online.org

4 Repeats, Rejects and Recalls: How Many is Too Many? By Louise C. Miller, ARRT, CRT, RTRM ecently, I was asked to work in a breast imaging facility and conduct an on-site positioning workshop. The radiologist said that the facility had a high level of “TCBs,” and he worried about Rthe increased, unnecessary additional radiation dose to the patients. I was embarrassed as I had never heard that acronym used and was not sure what it stood for. It meant: Technical Call Backs. Ahh…no wonder…we rarely have TCBs. I spent a week at the facility. A year later, he emailed me and said that they had reduced TCBs by 50%! Unfortunately, the data were not published. I was surprised when several technologists at another breast center informed me that exaggerated craniocaudal to the lateral (XCCL) views were performed on approximately one third of their patients. Their radiologist wanted them. This was not just at one site, but at many: too many extra views on patients who did not require them. The standard screening mammogram had become a six or eight view exam. This was odd as all repeat/reject rates were well within compliance at these facilities. Many technologists are told that they MUST repeat every image that does not show the inframammary fold (IMF) or those that show /fat folds. So they obtain the repeat images and are still in “compliance.” Technologists have many options to choose from when stating the “cause” of the repeat/reject; one can unknowingly skew the statistics based on several options selected prior to the exam being performed. The technologists are also unnecessarily exposing the patients to additional radiation and anxiety. Unfortunately, very little data have been published on these issues. One of the last studies predates the implementation of full field digital mammography (FFDM) and digital breast tomosynthesis (DBT). In 1993, Bassett et al. evaluated 2000 film-screen (FS) mammograms and created a standard for excellence in image quality (1). Interestingly, none of the criteria were met 100% of the time. However, after the technologist received “standardized” positioning training, image quality improved by 68% (1). Still, overall image quality standards were met only 64% of the time (1). Currently, there seems to be an expectation from many radiologists that all images should be of American College of Radiology (ACR) quality every time, which is quite an unreal expectation, given that most of us search for weeks to find the “perfect” fatty and dense to submit for accreditation. There have been marked changes and technologies since the study by Bassett et al. was published (1). Image receptors and face shields have increased in size. The imaging format is completely different. These factors often provide a challenge for technologists and radiologists.

5 Repeats, Rejects and Recalls: How Many is Too Many?, continued from previous page

Common Causes and Solutions for Repeat and Reject Images and Unnecessary Additional Views • Skin/fat folds/attenuation of the beam (bright spots in the skin) are indigenous to the digital imaging process. If the skin or fat fold obscures visualization of an area of concern and the skin or fat fold cannot be windowed and leveled, the view should be repeated for better visualization. However, skin and fat folds are present on the majority of mediolateral oblique (MLO) views and should not be repeated unnecessarily. • The XCCL view should not be a part of a standard screening mammogram unless: 1. It is a baseline mammogram and prominent glandular tissue is missing on the mammogram; OR 2. An area of concern is seen in the lateral posterior breast tissue. On subsequent screening exams, if breast tissue is visualized back to the retromammary fat space, an XCCL view is unnecessary. Cardenosa noted that XCCL views should be needed in about 10% of cases (2). If your technologists are producing XCCL views more frequently, perhaps a retrospective study should be undertaken to see how many were found on the XCCL views. No such study has ever been published regarding this topic, and a study would be of value to our profession. • Motion is a common problem with digital technology. Often, it is difficult for the technologists to detect motion due to the lower resolution of their work monitors and bright lighting in the exam room. Giving breathing instructions such as, “stop breathing” for FFDM and “breathe very slowly” for DBT exposures can help to decrease motion artifacts. • Failure to include the IMF is a common complaint of many radiologists, but the IMF is often a difficult part of the patient’s anatomy to include. If there is a skin fold in the IMF, the technologist can learn to overcome this most of the time, but this problem is also indigenous to FFDM. • Poor positioning is a common problem due to the lack of standardized positioning techniques. Newer technologists find it even more confusing as the more experienced technologists position differently. This can confuse technologists coming into the field. Standardized positioning training facilitates consistent and ergonomically sound techniques that increase efficiency and productivity while creating reproducible comparisons from year to year. Training also reduces workman’s compensation claims and keeps the technologists healthy and energetic throughout their careers.

REFERENCES 1. Bassett LW, Hirbawl IA, DeBruhl N, Hayes MK. Mammographic positioning: evaluation from the view box. Radiology 1993;188:803-806. 2. Cardenosa G. Breast Imaging Companion (Third Edition). Wolters Kluwer, Alphen aan den Rijn, The Netherlands, 2007.

6 SBI/ACR Breast Imaging Symposium 2015

n Sunday, April 26th, with 999 registered attendees, the SBI presented the 2015 Gold medal to W. Phil Evans, III, MD, FSBI, FACR. Dr. Evan’s many accomplishments include opening the first breast center in O Texas in 1984. He is a past president of the American Cancer Society and the Society of Breast Imaging. Dr. Evans recounted his serendipitous trip to Colorado in 1980, at the behest of his department chair, to evaluate a water-tank screening breast ultrasound machine that changed the course of his career. In a sentiment that we can all relate to, Dr. Evans quoted Rudyard Kipling when he said: “He who rides the tiger cannot dismount at will.” Martin Yaffe, PhD, from the University of Toronto and the Sunnybrook Research Institute was named an honorary fellow of the SBI. Dr. Yaffe, a physicist, directs a group of 28 research scientists and has been instrumental in developing high quality low dose breast imaging. He was also a key evaluator of the quality of mammography in the Canadian National Breast Screening Study in the 1980s and the 1990s. A Special Recognition Award was bestowed upon Marc J Homer, MD, FSBI, FACR and founding member of the SBI. Dr. Homer was the first and longest serving president of the SBI. Dr. Ed Sickles, MD, FSBI, FACR, credited the survival of the SBI to Dr. Homer and compared his stewardship of the society to George Washington’s leadership in Valley Forge during the revolutionary war. It is amazing to consider how far the society has come since its inception with over 2700 current members and nearly 1000 attendees at the 2015 meeting.

W. Phil Evans, III, MD, FSBI, FACR Martin Yaffe, PhD Marc J. Homer, MD, FSBI, FACR

7 Nipple Sparing Mastectomy By John Lewin, MD, FACR, FSBI

he use of following mastectomy has greatly increased in the last 20 to 30 years. The change is largely due to improvements in plastic techniques that enable the reconstructed breast T to have an appearance rivaling that of the native breast. Additional improvement in cosmesis has come from changes in the mastectomy procedure. The skin-sparing mastectomy (SSM) was introduced in the early 1990s and grew to be the most common type of mastectomy in cases where reconstruction was planned. In SSM, much of the overlying skin is preserved but the nipple-areolar complex (NAC) is removed, as well as skin involved with tumor or involved in a malignant surgical biopsy. Compared to total mastectomy, SSM eliminates the need for a skin graft for reconstruction, therefore allowing for improved cosmesis. If a nipple is desired after SSM, it must be reconstructed from the surrounding skin. The reconstructed nipple and a circle of surrounding skin may then be tattooed a darker color to create the appearance of a native NAC. The results of nipple reconstruction are often disappointing. For this reason nipple-sparing mastectomy (NSM), in which the skin of the NAC is retained, has been proposed as an alternative to SSM and is increasing in use both for cancer treatment and prophylaxis. NSM has the potential for improved cosmesis but has inherent drawbacks, both in terms of technical success and, potentially, local recurrence. NSM is similar to subcutaneous mastectomy, first described in the 1960s. Subcutaneous mastectomy was not considered adequate for cancer treatment because a small amount of subareolar tissue is necessarily retained, potentially serving as a site for a new or recurrent cancer. In modern NSM, the goal is to remove as much subareolar tissue as possible, while retaining viable skin. The limitation is that shaving the tissue flap too thin can compromise the blood supply to the nipple, resulting in ischemic necrosis. Rates of necrosis are highly variable, but one review of the literature found average rates of 2.9% and 6.3% for full and partial thickness necrosis, respectively (1). Tools such as Doppler ultrasound and optical laser can be employed intraoperatively to evaluate tissue perfusion, but none is perfectly predictive of eventual viability. As with other surgical margins, the subareolar margin must be cancer-free on pathologic evaluation. Involvement of the NAC can be occult on both imaging and clinical evaluation. Multiple investigators have

8 Nipple Sparing Mastectomy, continued from previous page attempted to ascertain the frequency of occult NAC involvement in mastectomy specimens. The published rates are highly variable, ranging from 0 to 58% (2). There is agreement as to the important characteristics associated with a tumor-free NAC in these papers. Characteristics of a tumor-free NAC include small tumor size, unifocality, and a tumor-nipple distance of at least 2 cm, as well as negative lymph nodes and favorable prognostic markers. Given the importance of assessing the extent of disease and tumor-nipple distance prior to selecting a patient for NSM, preoperative magnetic resonance imaging (MRI) is commonly performed on patients considering NSM. There is no prospective data comparing local recurrence rates for NSM with those of SSM or other procedures. The evidence for safety of NSM comes from multiple retrospective single institution series. These series do show low recurrence rates, but are limited by short follow-up periods, typically between two and three years. A review of the literature shows an average nipple recurrence rate of 0.9% and an average skin flap recurrence rate of 4.2% (1). In one retrospective matched case-control series, NSM resulted in fewer local recurrences than did SSM (0 vs 4.2%) (3). The increased local recurrences for the SSM group presumably reflect the selection of patients with more favorable tumors for NSM. Despite no definitive study to show its safety, NSM continues to grow in popularity. Hopefully, series with longer follow-up periods will be published and will confirm the low rates of recurrence seen in the currently available literature. Imaging plays an important role in patient selection for NSM and preoperative MRI is the best technique for evaluating tumor extent and proximity to the NAC.

REFERENCES 1. Mallon P, Feron JG, Couturaud B, et al.. The role of nipple-sparing mastectomy in breast cancer: a comprehensive review of the literature. Plast Reconstr Surg 2013;131:969-984. 2. Munhoz AM, Montag E, Filassi JR, Gemperli R. Immediate nipple-areola-sparing mastectomy reconstruction: an update on oncological and reconstruction techniques. World J Clin Oncol 2014;5:478-494. 3. Adam H, Bygdeson M, de Boniface J. The oncological safety of nipple-sparing mastectomy - a Swedish matched cohort study. Eur J Surg Oncol 2014;40:1209-1215.

9 Team Building By Michael N. Linver, MD, FACR, FSBI owhere in radiology is the role of the team as a well-oiled functioning unit more important than in breast imaging. Every team member plays a vital part: the radiologist, the technologist, the technologist aide (or Nmedical assistant), the nurse navigator, the receptionist, and on down the line. Breast imagers have led the rest of radiology in establishing a patient-centered, service-oriented approach that is now being initiated throughout our specialty through the campaign of the American College of Radiology (ACR) known as Imaging 3.0. We breast imagers know the real value of building a strong team, but can we build it even stronger? We can indeed, with the help of some very basic principles. Most of these are intuitive, but their value should never be underestimated: • Identify all members of the team, and establish definitive roles for each. However, at the same time, make it clear that each team member should be willing to step out of his or her specific role to help each other, if needed. • As the team leader, the radiologist should establish a set of core values for the team. These should prioritize patient care, courtesy, and service. All team members must be willing to buy into these values, and embrace them as their own. If they cannot, then the team will surely fail. As the author of If Disney Ran Your Hospital put it, “Unless courtesy comes ahead of something, it will come ahead of nothing” (1). • Each team member, particularly the radiologist, should show mutual respect for every other team member. Further, each patient should be given the same measure of respect, and treated with the same degree of dignity. This is the cornerstone of any team’s success! • All discussions with other team members should be face-to-face, as much as possible. Great efforts should be made to humanize team relationships. • Create an atmosphere which nurtures and promotes feedback and open discussion of even the most contentious issues among team members, especially between the radiologists and the technologists. Only through such discussions can problems be solved for the team to truly grow and prosper. • Give positive feedback when other team members perform well, and thank them for a job well done. Nothing motivates like a well-placed legitimate compliment. • Develop a culture of cooperation and unity of purpose. For the radiologist, he or she should actively engage in educating, not only though more formal talks to the entire staff, but in one-on-one conversations with each technologist. The more the staff members understand what the radiologist is attempting to accomplish, the better they will be at helping him or her do so. • Establish a service culture throughout the entire center. Try to make the staff see through the eyes of the patients, and develop the empathy necessary to make the patients always feel welcome. The Disney company does this better than any other organization, and its philosophy of service translates seamlessly to the breast imaging team members. The seven Disney service guidelines are:

10 Team Building, continued from previous page

1. Make eye contact and smile! 2. Greet and welcome every guest. 3. Seek out guest contact. 4. Provide immediate service recovery. 5. Display appropriate body language. 6. Preserve the “magical” guest experience. 7. Thank every guest (2). These may seem trivial, but they are the basis upon which Disney has not just satisfied its customers, but has won their loyalty. It is the job of the breast imaging team to do just that. If a patient does not return for her next screening mammogram out of dissatisfaction with her service, the opportunity to find her early curable cancer may have been lost, and the team will have failed. When women’s lives are at stake, failure is not an option. Every breast imager must strive to create a team culture that serves the patient’s needs not only as a client, but as a human being. The Disney approach to team building should be ours as well: “Keep it clean, keep it friendly, and provide a quality service worth remembering. All that is required is compassion, a keen eye for detail, and a little (mammographic) magic!” (2).

REFERENCES 1. Lee F. If Disney ran your hospital: 9 ½ things you would do differently. Second River Healthcare. May 30, 2004. 2. Lam DL, McNeeley MF, Bhargava P. Lessons from the happiest place on earth. J Am Coll Radiol 2015;12:6-8.

11 SBI DBT Course: A September Spectacular! By Michael N. Linver, MD, FSBI – Chair, SBI DBT Course

igital Breast Tomosynthesis (DBT) is quickly becoming the new standard in mammography. As of April of 2015, the majority of breast imaging facilities have either added DBT, or are about to D do so. With three DBT vendors now FDA-approved (Hologic, GE, and recently Siemens), the need for an objective world-class DBT course is more pressing than ever! SBI can meet that need in spectacular fashion by offering the 8 hours of FDA required DBT training and much, much more along with the balmy breezes of the San Diego shoreline on Sepetember 26 and 27. Rita Zuley, Chris Comstock, and Steve Poplack comprise a teaching faculty of unparalleled quality and experience. They will provide not only a superb didactic overview of the mechanics of DBT adaptation and interpretation, but will offer the opportunity for one-on-one interaction with attendees to address their specific DBT needs. All three DBT vendors will be displaying their systems and offering hands-on review of real-world cases at their workstations as well. The vendor-specific DBT training required by the FDA will also be available. Faculty lectures will include theoretical and practical DBT considerations, approaches to basic and advanced DBT interpretation and intermodality integration, and multiple interactive case review sessions utilizing a user-friendly audience response system. As an added bonus, lectures on the new BI-RADS atlas and cutting-edge advances in MRI and Contrast-Enhanced Digital Mammography will complement the DBT core curriculum to provide 11.5 hours of CME credit (and 8.5 SAM credits) in this idyllic Southern California destination. All who attend will leave with a thorough understanding of the critical issues related to DBT: when and how to apply DBT in both the screening and diagnostic environments, how to approach and solve the consequent and often dramatic changes in radiologist and technologist workflow, and how to promote and grow a DBT practice. Do not miss the chance to fulfill the initial FDA requirements in DBT while building your DBT skills on the shoulders of a faculty second to none: come and avail yourself of their expertise and extensive DBT experience in a unique vendor-neutral DBT environment under the quality standard of SBI

To register, click this box!

12 Breast Cancer Management: An Update By Stephanie J. Jeske, MD, MSc and Jessica W. T. Leung, MD, FACR, FSBI

reast cancer is the most frequent cancer in women in the United States. Fortunately, improved pathophysiological understanding and earlier detection have led to improved therapies and B declining mortality rates since 1990 (1). Tumor biology Breast cancer is a heterogeneous disease and it varies in both grade and histopathology. Our understanding of these differences first relied on receptors such as estrogen, progesterone and, later, human epidermal growth factor receptor 2 (HER2/neu) and has been further refined by gene expression patterns derived from deoxyribonucleic acid (DNA) microarrays classifying tumors into clinically relevant subtypes (2). This classification system now helps to direct personalized decisions about , leading to the potential of “precision medicine.” Advances in adjuvant therapy Refinement of administration and selection Three genomic assays are currently available to guide decisions about adjuvant therapy: Oncotype Dx, Mammaprint, and Mammastat. Oncotype Dx has been widely adopted for evaluating the risk of recurrence and the benefit of chemotherapy in hormone receptor positive, HER2/neu negative, negative disease. The Trial Assigning Individualized Options for Treatment (Rx) (TAILORx trial), now in the follow-up period after enrollment completed in 2010, will provide prospective evidence of the utility of Oncotype Dx for node negative patients. The ongoing SWOG Rx for Positive Node, Endocrine Responsive Breast Cancer (RxPONDER) trial further broadens the use of Oncotype Dx to patients with limited nodal involvement. Endocrine therapy The duration of adjuvant endocrine therapy has now been extended to 10 years for many patients. Data released from the Adjuvant Tamoxifen Longer Against Shorter (ATLAS) and the Adjuvant Tamoxifen –To Offer More? (aTTom) trials demonstrate an additional 25% reduction in recurrence and improved overall survival when using tamoxifen for 10 years instead of five years (3). Premenopausal breast cancer patients are likely to derive the greatest benefit. Sequential therapy with tamoxifen for two to five years followed by five years of an aromatase inhibitor shows benefit for perimenopausal and postmenopausal women. Trials are now underway evaluating the efficacy of 10 years of aromatase inhibitor therapy for postmenopausal women, but this is not yet standard of practice. The use of ovarian suppression can now be considered for high-risk premenopausal women with hormone positive disease requiring adjuvant chemotherapy. The large international Suppression of Ovarian Function Trial (SOFT) demonstrated a 22% reduction in breast cancer recurrence with the addition of ovarian suppression to tamoxifen versus tamoxifen alone. An even greater reduction of 35% was seen with plus ovarian function suppression (4).

13 Breast Cancer Management: An Update, continued from previous page

Expanding HER2/neu therapeutic options Treatment options for HER2/neu positive patients continue to expand. Trastuzumab emtansine (T-DM1) is a monoclonal antibody-drug conjugate targeting HER2/neu positive cells; the potent cytotoxic agent emtansine (conjugated to trastuzumab) is released upon internalization of the agent. Two large trials (EMILIA and TH3RESA) evaluated T-DM1 in patients with metastatic HER2/neu positive disease previously treated with trastuzumab. They demonstrated a 3.2 and 2.9 month progression free survival benefit, respectively, over alternative therapies. The EMILIA trial also demonstrated a survival benefit for T-DM1 over lapatinib and capecitabine of 30.9 versus 25.1 months (5). Toxicity profiles were favorable for T-DM1 over the standard therapeutic arms. Pertuzumab is a monoclonal antibody that blocks heterodimerization of HER2/neu with other HER family members. It is thought to work synergistically with trastuzumab with minimal added toxicity. Unprecedented benefits in survival were seen with the addition of pertuzumab to trastuzumab and chemotherapy for patients with metastatic HER2/neu positive breast cancer. An overall survival benefit of 15.7 months was seen with dual HER2/neu blockade as compared to trastuzumab alone (6). The MARIANNE trial is underway to study T-DM1 and pertuzumab combination therapy as first-line metastatic therapy. Pertuzumab is approved for neoadjuvant therapy based on the NeoSphere trial, showing an improved pathologic complete response (45.8% versus 29%) (7). Data regarding survival are still pending with ongoing trials in the neoadjuvant and the adjuvant settings. Localized management Axilla Axillary lymph node involvement remains one of the most important prognostic factors in breast cancer, with the biopsy a mainstay of primary therapy. However, management of the remainder of the axilla is changing, as improvements in systemic and are thought to be more effective in clearing microscopic residual disease. The American College of Surgeons Oncology Group (ACOSOG) Z0011 trial demonstrated no difference in locoregional recurrence or survival for axillary lymph node dissection versus no further surgery in women undergoing and radiation with three or fewer involved lymph nodes (8). The European Organisation for Research and (EORTC) 10981 trial confirmed the comparable efficacy of adjuvant axillary radiotherapy with lower toxicity in this population (9). Primary breast tumor The proper surgical margin in management of the primary tumor has long been debated. The Society of Surgical Oncology and the American Society of Radiation Oncology released guidelines in 2014 (endorsed by the American Society of Clinical Oncology), stating that an adequate margin for women with invasive breast cancer treated with lumpectomy and whole breast radiation therapy should be considered as “no ink on tumor (10).”

14 Breast Cancer Management: An Update, continued from previous page

We remain encouraged by progress in breast cancer management and hopeful for expanding treatment options with reductions in mortality, morbidity and side effects for our patients.

REFERENCES 1. Siegel R, Ma J, Zou Z, Jemal A. Cancer statistics, 2014. CA Cancer J Clin 2014;64:9-29. 2. Sorlie T, Tibshirani R, Parker J, et al.. Repeated observation of breast tumor subtypes in independent gene expression data sets. Proc Natl Acad Sci U S A 2003;100:8418-8423. 3. Davies C, Pan H, Godwin J, et al.. Long-term effects of continuing adjuvant tamoxifen to 10 years versus stopping at 5 years after diagnosis of oestrogen receptor-positive breast cancer: ATLAS, a randomised trial. Lancet 2013;381:805-816. 4. Francis PA, Regan MM, Fleming GF, et al.. Adjuvant ovarian suppression in premenopausal breast cancer. N Engl J Med 2015;372:436-446. 5. Verma S, Miles D, Gianni L, et al.. Trastuzumab emtansine for HER2-positive advanced breast cancer. N Engl J Med 2012;367:1783-1791. 6. Swain S, Kim S, Cortes J, et al.. 2014, ESMO Abstract 3500. 7. Gianni L, Pienkowski T, Im YH, et al.. Efficacy and safety of neoadjuvant pertuzumab and trastuzumab in women with locally advanced, inflammatory, or early HER2-positive breast cancer (NeoSphere): a randomised multicentre, open-label, phase 2 trial. Lancet Oncol 2012;13:25-32. 8. Giuliano AE, Hunt KK, Ballman KV, et al.. Axillary dissection vs no axillary dissection in women with invasive breast cancer and sentinel node : a randomized clinical trial. JAMA 2011;305:569-575. 9. Donker M, van Tienhoven G, Straver ME, et al.. Radiotherapy or surgery of the axilla after a positive sentinel node in breast cancer (EORTC 10981-22023 AMAROS): a randomised, multicentre, open-label, phase 3 non-inferiority trial. Lancet Oncol 2014;15:1303-1310. 10. Moran MS, Schnitt SJ, Giuliano AE, et al.. Society of Surgical Oncology-American Society for Radiation Oncology consensus guidelines on margins for breast-conserving surgery with whole-breast irradiation in stages I and II invasive breast cancer. Ann Surg Oncol 2014;21:704-716.

15 Interesting Case: The Importance of Mammographic Margins By Peter Eby, MD, FSBI

54-year-old woman underwent screening mammography. The right A breast was normal. A new round equal density circumscribed mass had appeared in the left breast at 12-1 o’clock (Figure 1). The radiologist assessed the left breast as BI-RADS 0 and asked the patient to return for a diagnostic work-up. Additional mammographic views were not performed. The work up began with a diagnostic ultrasound which found a circumscribed oval anechoic simple cyst at 12 o’clock, 7 cm from the nipple (Figure 2). The radiologist concluded that the sonographic finding explained the mammographic mass Figure 1. Left CC and MLO views show a mass at 12-1 and a final assessment of BI-RADS 2, benign, o’clock (arrow) was rendered. The patient was dismissed and advised to return in one year for screening. Twelve months and 11 days later the patient arrived for her annual screening mammogram. Like the last screening mammogram, CC and MLO views demonstrated a mass at 12-1 o’clock, posterior depth (Figure 3). Does this finding represent the known cyst? Can this be called benign and assessed as BI-RADS 2 based on the previous work-up? The radiologist noticed that the margins of this mass were not circumscribed as they were on the exam from the prior year. The margins were indistinct. The exam was assessed a BI-RADS 0, and additional imaging was recommended. Figure 2. Diagnostic ultrasound reveals a simple cyst cor- responding to the mammographic mass.

16 Interesting Case, continued from previous page The diagnostic mammogram showed an irregular mass with indistinct margins in the left breast at 12 o’clock (Figure 4). Ultrasound confirmed an irregular hypoechoic mass with angular margins (Figure 5). The mass was assessed BI-RADS 4, and biopsy was recommended and performed. The tissue samples contained invasive ductal carcinoma. The patient was referred for multidisciplinary conference. The non- radiologist members of the conference questioned the interpretation of the examinations from the previous year and wondered if there was an avoidable delay in diagnosis. An additional image from the ultrasound examination demonstrated the Figure 3. CC and MLO images from the screening mam- mass separate from the nearly resolved cyst mogram one year after a diagnostic work-up found a cyst at 12 o’clock in the left breast. There is a mass in the 12-1 (Figure 6). This confirmed that the two o’clock location again (arrow).

Figure 4. CC and MLO spot magnification views confirm a persistent equal density mass (white arrow) with indistinct and irregular margins.

17 Interesting Case, continued from previous page findings were separate; the radiologist did not mistake a mass for a cyst on ultrasound. However, further evaluation of the first screening mammogram allows for retrospective identification of the faint asymmetry posterior to the cyst that represented the cancer (Figure 1). Teaching points: Margins are a critical feature of mammographic masses (1). It can be tempting to proceed directly to ultrasound when a mass is surrounded by fat on a screening mammogram. And many times this strategy will be adequate. However, spot or Figure 5. Diagnostic ultrasound confirms an irregular mass with angular margins corresponding to the mam- magnification views can reveal features, such mographic finding. as indistinct margins, that significantly change one’s level of suspicion prior to the ultrasound. If magnification views had been performed during the first work-up, the cancer may have become perceptible posterior to the cyst. But we will never know for sure. Fortunately, the delay in diagnosis did not change the patient’s treatment or prognosis.

REFERENCE 1. Sickles, EA, D’Orsi CJ, Bassett LW, et al. ACR BI-RADS® Mammography. In: ACR BI-RADS® Atlas, Breast Imaging Reporting and Data System. Reston, VA, American College of Radiology; 2013.

Figure 6. Diagnostic ultrasound shows that the irregular hypoechoic mass with angular margins (circle) is close but distinct from the shrinking benign cyst (arrow).

18 What to Look for in a Breast Imaging Fellowship By Ann M. Leylek, MD

ongratulations to those of you in the fortunate position of considering fellowship programs in breast imaging. It is a field with many rewards in practice, not the least of which are C meaningful work and the promise of gainful employment. For these and a variety of other reasons, breast imaging fellowships are in higher demand than in years past (1). My personal experience applying in 2013 and anecdotal evidence from friends and colleagues across the country support this notion. In a competitive marketplace, the prevailing advice has been to take what you can get. However, there are important factors to consider in a fellowship that can influence your ultimate career success. The following is my advice so take it with a grain of salt: Know your options (as best you can). First and foremost is finding an open position. Start by getting a list of fellowship programs from the SBI Fellowships and Curriculum website (2), which lists most United States programs and contacts by state. Keep in mind that not all programs are listed on the website, but it is the only central resource at present. Also, realize that the true number of available positions cannot be predicted in a given application year since many spots are filled internally and updates to the website are not regularly scheduled. This is one reason to seriously consider your home institution if you are in the enviable position of training at a program with a breast imaging fellowship. In any case, do not lose hope! Each year a handful of programs will announce unexpected openings after the standard application cycle. Location, location, location. Fellowship is a year of your life. On one hand, the short duration can justify staying put to avoid a painful or expensive move. Alternatively, you could conceivably move anywhere for “just a year” including somewhere less desirable or somewhere you have always wanted to explore. The most important consideration is how location pertains to a future job. If you know where you want to practice, target that region of the country in your fellowship search. You will be able to network most effectively wherever you are physically located. Many chairmen and practice leaders openly admit that local applicants are considered much more favorably; verbal recommendations between people that have a trusted relationship carry significant weight. Reputation and prestige. Arguably synonymous with quality, training at a reputable and prestigious institution can improve your odds of finding employment. Consider a big name in the field if you are flexible about your eventual location or unsure of your ultimate career goals. Specific goals of training. The purpose of fellowship is to acquire a marketable skillset that can be parlayed into a future career. Approach your evaluation of fellowships with a mind towards what you can leverage to obtain

19 What to Look for in a Breast Imaging Fellowship, continued from previous page a job. Alternatively, use a fellowship to bolster a skill that your residency may have lacked. Valuable experience may include exposure to various technologies (i.e., digital tomosynthesis or molecular breast imaging), practice setup (major academic center versus community practice), volume of certain studies (magnetic resonance imaging (MRI)) or interventional procedures, and dual training (with body or obstetric/gynecological imaging). Mentoring. Do not discount the important relationships you will form in your fellowship. Your colleagues during the year will substantially shape your future practice and help you to find a job, so look for role models, mentors, and sponsors early in the process. If a particular area of research interests you, look for a leader in that field. Multidisciplinary experience. The cornerstone of breast imaging is strong clinical collaboration. Look for programs that will help you develop excellent clinical consultant skills. Inquire about opportunities to participate in breast tumor boards or radiologic-pathologic correlation conferences. These experiences are particularly important for radiologists who want to become full time breast imagers. Academic or elective time. Flexible time in your schedule can allow you to tailor your fellowship experience. Dedicated non-clinical time can be utilized for a variety of purposes, including teaching, preparing for clinical conferences, communicating results, conducting a research project, and attending regional or national meetings. Elective time in the latter half of fellowship can be useful for honing additional skills necessary for a particular job (i.e., brushing up on reading chest radiographs) or enhancing your breast care experience with rotations in breast and/or , breast pathology, and radiation oncology. Don’t take my word for it. Seek out advice from your mentors and those who know you well. Good luck in your search for a fellowship!

REFERENCES 1. Farria DM, Salcman J, Monticciolo DL, Monsees BS, Rebner M, Bassett LW. A survey of breast imaging fellowship programs: current status of training in the United States and Canada. J Am Coll Radiol 2014;11:894-898. 2. http://www.sbi-online.org/RESOURCES/BreastImagingFellowshipsand Curriculum.aspx Accessed on March 12, 2015.

20 Breast Cancer Risk Assessment: Should This Be Part of Our Practice? By Jennifer Harvey, MD, FACR, FSBI

or decades, in the United States has been population based. The vast majority of women are recommended to undergo annual screening mammography beginning F at age 40 years. Women at very high risk (lifetime risk of greater than 20%) are recommended to also undergo annual breast magnetic resonance imaging (MRI) beginning as early as age 25 years. Women and their health care providers may not recognize that they are at elevated risk, but breast imaging radiologists are in an ideal situation to identify these women as we already routinely collect risk factor information. Radiologists may feel that communication of breast cancer risk is outside of their realm of care. However, many radiologists already play a primary role in the management of breast disease. Communication of risk can be viewed as an extension of physician and patient education. If risk is included in reports or in patient letters, physicians and patients will also value inclusion of the implications of different risk levels. Breast cancer risk assessment can be performed using one of several models. These models vary by ease of use and accuracy. All models are relatively well calibrated, meaning that they measure overall risk in a given population well. The ability of a model to determine which women are at higher versus lower risk is model discrimination, and is measured using a receiver operating curve (ROC) with a scale of 0.50 - 1.00. The Gail model was developed using data from early screening trials, but is not commonly used today. As breast cancer risk data became better understood, the Gail model was modified to include or weight factors differently. The National Cancer Institute (NCI) Breast Cancer Risk Assessment Tool (BCRiskTool) is probably the most commonly used modified Gail model (1). This is the only model that is validated for African-American women and it can adjust for Asian-American ethnicity. The Breast Cancer Surveillance Consortium has also developed a risk calculator based on the Gail model that includes American College of Radiology (ACR) Breast Imaging Reporting and Data System (BI-RADS®) density (2). The original and modified Gail models have the advantage of including eight or fewer questions, making them very easy to use. However, these models only include primary relatives with breast cancer so they should not be used for women with a strong family history of breast cancer. Likewise, women with a history of lobular carcinoma in situ (LCIS), atypical lobular hyperplasia (ALH), or (DCIS) will not have an accurate risk assessment using modified Gail models. Discrimination of Gail and modified Gail models is low, ranging from 0.58 to 0.68. Pedigree-based models, such as the Claus, BRCAPro, and BOADICEA models, are very good at identifying women who may carry a BRCA mutation. They do not include other risk factors so they are best used for women whose risk is predominantly due to a strong family history of breast or ovarian cancer. These models may underestimate risk for women with non-familial breast cancer risk factors.

21 Breast Cancer Risk Assessment, continued from previous page

When used in the general population, model discrimination is low, ranging from 0. 58 to 0.60. The Tyrer-Cuzick model was developed from the United Kingdom (UK) tamoxifen prevention trials, such as the International Breast Cancer Intervention Study I (IBIS-I). This model is comprehensive including extensive risk factors as well as pedigrees. Because the Tyrer-Cuzick model is a comprehensive model, it is time-consuming, but it also has fewer limitations. This model has been improved but it still has only moderate discrimination, ranging from 0.68 to 0.74. Risk information is only useful if it will affect practice. Identification of high risk women has relatively straightforward implications. Be forewarned though that a recommendation of additional screening by radiologists may be seen as self-serving. Women identified as high risk may be best evaluated in a high risk clinic or by a provider who can make independent recommendations for ancillary screening. This also allows for full risk management, including discussion of , systemic anti-estrogen therapy, and screening for cancers other than breast cancer. Implications of risk assessment for moderate risk women are less clear. Ancillary screening is often not a covered expense and may become only available to those who can afford it. In addition, it is unknown if the best use of ancillary screening would be for women at moderate risk or for women with lower sensitivity for mammography. As we look to the future, can we use risk to recommend who gets screened and when? No. Well, not yet. Current risk models do not discriminate well enough to predict which women are at low enough risk to reduce or delay screening. Model discrimination must be considerably higher to make a risk-based screening program reasonable.

REFERENCES 1. National Cancer Institute Breast Cancer Risk Assessment Tool. http://www.cancer.gov/BCRISKTOOL/ accessed April 8, 2015. 2. Breast Cancer Surveillance Consortium Risk Calculator. https://tools.bcsc-scc.org/BC5yearRisk/calculator.htm accessed April 8, 2015

22 Mergers and Acquisitions By Christiane M. Hakim, MD

ighteen years ago, when I started at Magee-Womens Hospital/University of Pittsburgh Medical Center (UPMC), our main breast imaging center was an outpatient facility next to the hospital, with four Eoutlying imaging centers. Only diagnostic studies, stereotactic and needle localizations were done in the hospital. Over the next few years, following renovations, the main outpatient breast center moved into the hospital along with all breast procedures. In 2005, there was a merger with a prominent cancer center containing our high risk clinic at a nearby hospital within the university system. A few years passed, some of the ultrasound procedures moved back to the centers, and another hospital and another outpatient facility were added. More recently, three additional hospitals have been added that include part of our breast imaging operations, with obstetrical/gynecological ultrasound and dual-energy x-ray absorptiometry (DXA) imaging at most sites. For purposes of this article, I will focus only on changes in breast imaging over time. As we grew, we learned. As we learned, we improved. As we improved, we became more efficient. The technical challenges of growth and merging involved equipment upgrades, data sharing, and operations. Repeated upgrades were required as equipment needs changed. As a large consumer, we leveraged our volume to sway expense negotiations in our favor. Our dedication to research provided opportunities to acquire novel ideas and prototypes, participate in development, and be a beta test site. The size and number of our satellite centers brought database challenges to digital mammography vendors that they had never encountered. Not all centers have a radiologist every day and not all centers provide every test. With trial and error, many headaches, and persistence, our database now allows us to shift work from one site to another to maintain productivity and timely interpretation of screening studies. We constantly track and adapt to numerous factors such as patient preferences, work flow, recall rates, next available appointment times, types of exams required, surgeon and referring physician needs, and the ever changing Find the economic climate, in order to succeed. people and Communication is critical because Since 1985 our schedule incorporates all the careers driving technologists and all the radiologists from each site. While no one physician innovation. or technologist goes to every center, Visit the Society of Breast Imaging each usually travels among two or Career Center, where we’re bringing Visit the three sites. Radiologists are assigned to professionals and employers SBI Career Center the sites close to their homes whenever together in the radiology community. today! possible. When new centers, whether Recruit top talent, find jobs and get sbi-online.org free-standing or within a hospital, are connected.

23 Mergers and Acquisitions, continued from previous page brought into our system, communication with the parent facility is critical. Merging with a new center brings responsibilities of handling staffing, scheduling of patients and physicians, data management and tracking, quality control, communication with referring clinicians, education in new modalities and procedures—essentially­­ everything required for one center, but on a much larger scale. As facilities are added, the new doctors are rotated to our main site to gain familiarity with our usual operations and provide an opportunity to discuss questions and concerns. This interaction and sharing improves patient care. The multi-site exposure supports a robust women’s imaging fellowship and a highly successful radiology residency program. Our weekly multidisciplinary conference includes one conference per month where all sites log in to share and discuss cases. Ideally, having each breast imager perform diagnostic studies, screening studies, and interventional procedures will improve the skills of each radiologist and the group overall. This remains an ongoing challenge for us. The administration and oversight of our facilities has changed along with the growing demands of our operations. On the non-physician side, there is a director, whose responsibilities include monitoring interactions among the sites and patient flow, marketing, producing informational products, and creating budgets. There are two managers who handle the technologists along with recruitment, disciplinary actions, schedules, monthly meetings, and quality control. Coordinators, of which there are several, handle oversight of up to three centers, and each reports to a manager and contributes to identifying impending issues and problem solving. Each center has a lead technologist who handles ordering of supplies, schedule changes, urgent add-ons, staffing issues, and vacation requests. Frequent meetings between technologists, administrators, and doctors are paramount to success. In order to make attendance for the physicians a priority, the schedules are blocked and phone conference lines are available at the end of the day. Communicating with each and every person involved with our vast arrangement in a way that is respectful, dignified, and considerate is crucial to our success. The day we stop listening to one another will be the day we fail. While we have our challenges, the ability to advance the quality of care we provide to our patients is our driving force. After all, isn’t that why we are here?

24 Microbubble Contrast-Enhanced Ultrasound in Breast Cancer By Basak Erguvan-Dogan, MD

igh-resolution conventional gray-scale ultrasound (US) is an essential part of breast and axillary imaging, especially in young patients and in women with mammographically dense breasts (1). HHowever, overlap in the appearance of benign and malignant masses exists, resulting in unwarranted biopsies. Contrast-enhanced ultrasound (CEUS) is the application of microbubbles to traditional US imaging, originally designed to improve visualization in (2). Microbubble contrast agents are gas-filled microspheres given intravenously and sized to pass through the smallest capillaries (<5 microns) to increase the signal strength of US (3). Because of their size, bubbles do not traverse the vascular endothelium and thus provide a pure intravascular contrast agent, delineating blood vessels or lymphatic channels. When imaged using low mechanical index (MI) values (0.2 - 0.5) to reduce microbubble destruction, the resultant oscillation leads to a stronger signal. Optison™ (GE Healthcare, Waukesha, WI) and Definity® (Lantheus , North Billerica, MA) are United States Food and Drug Administration (FDA)-approved US contrast agents for cardiac imaging in the United States. Sonovue (Bracco Imaging, Milan, Italy) is commercially available in Europe for imaging tumors and organs throughout the body. CEUS does not require ionizing radiation or cause nephrotoxicity. Despite the advantages of enhanced vascular visualization with CEUS, the technique has not resulted in better differentiation of malignant and benign breast masses (4, 5). More recent technical developments in US devices have allowed for the identification of slow flow, and high frequency probes have led to improved spatial resolution. The availability of new generation contrast media, and adaptation of dedicated CEUS software will lead to improved qualitative and quantitative CEUS assessment. Many uses of CEUS in breast cancer have been explored and are still under review worldwide. One such application is targeted imaging of overexpressed tumor proteins to assess response to anti- angiogenic therapy (6, 7). Investigators are using microbubble targeting to breast cancer cellular receptors to enhance cancer detection. These early studies in animal models are promising, and they show potential for targeted personalized imaging and monitoring the effectiveness of tailored neoadjuvant therapy in breast cancer patients with CEUS. A growing body of research involves sentinel lymph node (SLN) detection in breast cancer patients using CEUS. Multiple single institution studies using CEUS lymphosonography in breast cancer patients have revealed a high correlation rate with subsequent SLN identification (8-11). The imaging technique relies on the intradermal injection of 0.2 - 0.5 ml of SonoVue in the periareolar region, real-time monitoring of contrast uptake by the subdermal and the intraparenchymal lymphatic channels, and documenting the draining SLN, followed by percutaneous needle biopsy. The SLN identification rate has ranged from 87% to 89% in these studies. However, CEUS-guided SLN biopsy results were less accurate. Following proof of

25 Microbubble Contrast-Enhanced Ultrasound in Breast Cancer, continued from previous page concept research involving small patient groups by Sever et al. (8, 9), Cox and colleagues studied a cohort of 347 patients (10). In the study by Cox et al., SLNs were identified and percutaneous needle biopsy was performed in 87% of patients, with a sensitivity of 61% and specificity of 100%, compared with final axillary surgery (10). Recent technical enhancements in US, higher frequency probes with better spatial resolution, the availability of new generation contrast media, and the adaptation of dedicated software have led to renewed interest in CEUS in breast imaging. Promising applications of CEUS in monitoring response to neoadjuvant therapy and in guiding percutaneous SLN biopsy still need further validation and development to replace standard-of-care imaging and interventional techniques.

REFERENCES 1. Skaane P, Sager EM, Olsen JB et al.. Diagnostic value of ultrasonography in patients with palpable mammographically noncalcified breast tumors. Acta Radiol 1996;40:163–168. 2. Cosgrove D. Echo enhancers and ultrasound imaging. Eur J Radiol 1997:26:64–76. 3. Delorme S, Krix M. Contrast-enhanced ultrasound for examining tumor biology. Cancer Imaging 2006;6:148–152. 4. Kedar RP, Cosgrove D, McCready VR, Bamber JC, Carter ER Microbubble contrast agent for color Doppler US: effect on breast masses. Work in progress. Radiology 1996;198:679–686. 5. Sorelli PG, Cosgrove DO, Svensson WE, et al.. Can contrast-enhanced sonography distinguish benign from malignant breast masses? J Clin Ultrasound 2010;38:177-181. 6. Warram JM, Sorace AG, Saini R, Umphrey HR, Zinn KR, Hoyt K. A triple-targeted ultrasound contrast agent provides improved localization to tumor vasculature. J Ultrasound Med 2011;30:921–931. 7. Sorace AG, Saini R, Mahoney M, Hoyt K. Molecular ultrasound imaging using a targeted contrast agent for assessing early tumor response to antiangiogenic therapy. J Ultrasound Med 2012;31:1543-1550. 8. Sever A, Jones S, Cox K, Weeks J, Mills, Jones P. Preoperative localization of sentinel lymph nodes using intradermal microbubbles and contrast- enhanced ultrasonography in patients with breast cancer. Br J Surg 2009;96:1295–1299. 9. Sever AR, Mills P, Jones SE, et al.. Preoperative sentinel node identification with ultrasound using microbubbles in patients with breast cancer. AJR Am J Roentgenol 2011:196: 251–256. 10. Cox K, Sever A, Jones S, et al.. Validation of a technique using microbubbles and contrast enhanced ultrasound (CEUS) to biopsy sentinel lymph nodes (SLN) in pre-operative breast cancer patients with a normal grey-scale axillary ultrasound. Eur J Surg Oncol 2013;39:760–765. 11. Sever A, Mills P, Hyvelin JM, et al.. Percutaneous removal of sentinel lymph nodes in a swine model using a breast lesion excision system and contrast-enhanced ultrasound. Eur Radiol 2012; 22:545–550.

26 Physician Stress: Let’s Stop Wearing It as a Badge of Honor By Warren L. Holleman, PhD

e all know, or ought to know, that chronic stress is bad for us and also bad for the patients we treat. It harms our mental and emotional health. It impairs our relationships: personal and family W relationships and perhaps those with patients and colleagues as well. Doctors and nurses who suffer severe stress and burnout are significantly more likely to make life-threatening mistakes than those who are not (1, 2). When we are severely stressed or burned out our hearts—metaphorically speaking—are damaged goods. We have little capacity for empathy, to care for others, to feel love and concern, or anything else, for that matter. We’re just going through the motions. Now there is strong evidence that job-related stress impairs our actual, physical heart as well. In a meta-analysis published recently in Lancet, researchers found that job-related stress is associated with a 25% increased risk of coronary artery disease (3). The risk does not appear to be as high as, say, the risk of smoking, but it is nothing to sneeze at either. This particular meta-analysis used just one baseline assessment. The authors suggested that “cumulative exposure to job strain, ascertained by several assessments repeated in time, could be a stronger predictor of coronary heart disease.” In other words, when some future study measures risk based on job strain over a period of time, we might find that job-related stress really is as harmful as smoking (3). We all work hard, and that is a good thing, but there is a fine line between working hard and being a workaholic. Common sense suggests we should draw the line somewhere short of emotional exhaustion and coronary artery disease. Lest there be any misunderstanding, when I talk about the dangers of job-related stress, I am not talking about tolerable doses of stress. In manageable doses, job stress can be a good thing because it keys us up to perform at our best. But in heavy doses over long periods of time, it breaks us down and kills us softly—through burnout, depression, sleep deprivation, relationship problems, and, as the evidence now indicates, heart disease. Have you ever noticed how often we tell each other how busy we are? How it sounds like we are complaining but actually we are bragging? Somewhere along the way we have developed the mistaken impression that it is a virtue to wear that hard work, and the stress that goes with it, as badges of our professional honor. Where is it written, in the Hippocratic Oath or anywhere else, that to prove our worth, we must offer ourselves as human sacrifices to the gods of work and worry? Wouldn’t it be ironic and tragic if, in helping others improve their health and happiness, we destroyed our own health and happiness, and that of our families? This happens more often than most of us would care to admit. At my 35th college reunion, I met a classmate and business executive who told me that after turning 50 he lost 75 pounds. He stopped working 12 hour days and started taking long breaks to exercise. He

27 Physician Stress: Let’s Stop Wearing It as a Badge of Honor, continued from previous page loves running and has completed nearly a dozen marathons. And that is not even the most interesting part. He said several doctors over the years had warned him about his bad health, but he ignored them because they all looked as tired, stressed, pasty, and flabby as he was. I asked what motivated him to make this monumental change in lifestyle and workstyle. Did something scare him, like a heart attack or the death of a loved one? No, he said, nothing like that. Rather, he saw a new doctor who looked healthy and happy and spoke enthusiastically of her zest for running. My classmate said he wanted whatever it was that she had. I spoke recently with a physician who started taking a one hour lunchtime break to exercise. He said he had recently been startled by a very sick patient who said, “Doc, are you okay? You look tired.” The physician looked at himself in the mirror and for the first time saw him the way his patients see him. Basketball star Charles Barkley infamously said it was not his job to be a role model for young people. What about physicians? What if physicians became role models of healthy living for their patients?

REFERENCES 1. Shanafelt TD, Balch CM, Bechamps G, et al.. Burnout and medical errors among American surgeons. Ann Surg 2010;251:995-1000. 2. Aiken LH, Clarke SP, Sloane DM, Sochalski J, Silber JH. Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. JAMA 2002;288:1987-1993. 3. Kivimäki M, Nyberg ST, Batty GD, et al.. Job strain as a risk factor for coronary heart disease: a collaborative meta-analysis of individual participant data. Lancet 2012;380:1491-1497.

28 The Accountable Care Organization Model: An Update By Bernadette Redd, MD

he Patient Protection and Affordable Care Act (PPACA) of 2010 brought about many significant changes to the health care delivery system in the United States, not the least of which was the T formal implementation of the accountable care organization (ACO) provisions. Two of the goals of the PPACA are to reduce the costs of health care and to maintain or improve the quality of care. The ACO provisions written into law as part of the PPACA are intended to address both goals simultaneously. For review, an ACO is a health care network of medical providers and health organizations responsible for providing coordinated care to a given population. The ACO is “accountable” for the total cost and quality of health care services for the defined population. Medical providers are incentivized to be members of the ACO through shared health care cost savings that are achieved while meeting defined quality metrics. The intended advantage for the patient is more coordinated, higher quality care. Results from the Centers for Medicare and Medicaid Services (CMS) pilot ACO program, the Physician Group Demonstration Project (PGDP), which ended in 2010, and CMS’ ACO Models, including the Pioneer ACO Model, are now available for consideration. The PGDP study results “demonstrate that the incentive- based methodology of the PGDP was successful in increasing compliance for measuring and performing quality metrics (1).” However, the financial results for the PGDP program were more disappointing. Bonus payments for achieving cost and quality goals were distributed 16 out of a possible 40 times (1), a rate seen as “small based on the high quality of the participating organizations. More specifically, only two of the PGDP participants surpassed the 2% savings threshold for the first year of the demonstration project and only one-half of participating organizations managed to exceed the threshold after 3 years (1).” Interestingly, at institutions participating in the PGDP programs, no significant reduction in imaging attributable to the program was noted (1). A decline in the growth rate for imaging studies and decreasing revenues during this time were thought to be related to non-ACO factors, such as bundling of Current Procedural Terminology (CPT) imaging codes, concerns about radiation dose from computed (CT), cost effectiveness, and the use of appropriateness guidelines rather than changes due to the PGDP/ ACO model (1). The PGDP’s approach focused on decreasing preventable admissions and readmissions, improved management of chronic conditions, and more coordinated care of complex patients, not on reducing the use of imaging. Appropriate use of imaging was perceived as a source of improved efficiency in care, not as an unnecessary expense (1). A report analyzing patient experiences with ACOs, discussed in the New England Journal of Medicine in October 2014, noted “In the first year, ACO contracts were associated with meaningful improvements in some measures of patients’ experience and with unchanged performance in others (2).” As with the PGDP results, a review of ACOs also demonstrated a disparity between clinical outcome goals and financial goals, although both were realized. Review of first year results for the Pioneer ACO noted that 13 of 32 (41%) participants earned bonus payments for meeting cost savings and quality metric goals, but four of the

29 The Accountable Care Organization Model: An Update, continued from previous page thirteen (31%) accounted for 2/3 of the savings. Additionally, nine of the 32 members (28%) stopped participating in the program (3). An opinion article in the Journal of the American College of Radiology (JACR) by Rosman et al. in April 2014 noted “the $240 per member saved by the Pioneer ACOs against the approximately $11,300 spent per beneficiary, amount[s] to a 2% savings.” In the same article, Rosman et al. noted that the Pioneer ACO programs were primarily focused on primary care and more effective management of the chronically ill and sickest patients as the means for cost savings. Similar to the PGDP program, limiting radiological services was not an emphasis of the program (4). Radiologists specifically questioned about changes in their practices reported no obvious changes. Metrics for how to evaluate specialists, such as radiologists, regarding contributions to cost savings and improved care were often not formulated (4). Early analysis of the results from experiences with ACOs and the CMS’ precursor to ACOs, PGDP, suggests cutting back imaging studies will not necessarily be one of the mainstays of cost savings, as has been feared. However, it is also clear that the ACO model is likely to be around for some time. Cost savings and improved quality of care will remain essential components of ACOs. Michael DiFiore, JD, in his article in JACR on ACOs, discussed ways radiologists can remain relevant in the ACO model. He notes appropriate use of imaging, guided by radiologists’ recommendations, may lead to more accurate diagnoses. Earlier initiation of appropriate treatment, a decrease in the number of unnecessary referrals to specialists, and reduced clinical costs related to imaging would also be direct benefits from radiologists’ involvement with ACOs (5). An important source of inappropriate imaging and, therefore, unnecessary imaging costs comes from self-referral (1). Radiologists need to be the primary source for appropriate imaging study selection, performance, and interpretation. Finally, radiologists will need to be able to prove a cost/benefit analysis relating imaging studies to improved clinical outcomes (6). Integration of imaging results into an electronic health record database may be useful in achieving this goal (7).

REFERENCES 1. Mukherji SK. The potential impact of accountable care organizations with respect to cost and quality with special attention to imaging. J Am Coll Radiol 2014;11:391-396. 2. McWilliams JM, Landon BE, Chernew ME, Zaslavsky AM. Changes in patients’experiences in Medicare Accountable Care Organizations. N Engl J Med 2014;371:1715-1724. 3. http://thehealthcareblog.com/blog/2013/08/16/pioneer-acos-disappointing-first-year. Accessed 1/19/15. 4. Rosman DA, Farinhas J, Kassing P, Pattie LN, McGinty G. Radiology in Pioneer Accountable Care Organizations: much ado about nothing? J Am Coll Radiol. April 9, 2014 Epub ahead of print. 5. DiFiore M. Accountable care organizations: what you need to know. J Am Coll Radiol. 2014;11:623-624. 6. http://www.radiologybusiness.com/topics/policy/radiology-and-aco-early-experiences. Accessed December 29, 2014. 7. http://www.healthcareitnews.com/news/acos-hamstrung-poor-data-exchange. Accessed December 29, 2014.

30 The Member Newsletter of the Society of Breast Imaging Click on this bar to return to Table of Contents