Abstract
Myeloid sarcoma (MS) is a rare extramedullary solid tumor arising most often in patients with current or subsequent acute myeloid leukemia (AML). Patients of all ages may present with involvement of the skin, lymph nodes, intestinal tract, bone, and/or central nervous system. Isolated involvement of the breast is rare, and only a small number of cases have been described in the literature. Breast MS may present as a palpable mass on clinical evaluation. In this broad literature review from 2010 to 2022, the most common findings on mammography are either solitary or multiple masses, followed by architectural distortion and, less commonly, no discrete findings. Sonography may demonstrate hypoechoic or mixed echogenicity mass(es) with circumscribed or indistinct, not discrete margins. Myeloid sarcoma may present as an enhancing mass or nonmass enhancement on breast MRI and is typically moderately radiotracer avid on 18F-fluorodeoxyglucose-PET. At histopathology, MS is characterized by myeloid blasts in varying stages of granulocytic or neutrophilic maturation; diagnosis typically requires immunophenotyping. There is no consensus for treatment of MS, although systemic chemotherapy for AML is often used as MS is considered the tissue equivalent of AML. This article will discuss and illustrate imaging and pathology findings when the breast is involved by MS.
Myeloid sarcoma is a rare extramedullary tumor mass associated with acute myeloid leukemia. Breast involvement by MS is an entity that radiologists need to be aware of because the imaging findings are nonspecific and the histologic diagnosis is challenging. A high index of clinical suspicion, in the setting of an underlying hematopoietic abnormality, is helpful for definitive diagnosis.
Myeloid sarcoma is fluorodeoxyglucose avid: PET-CT is useful for initial staging and evaluating treatment response.
Introduction
Myeloid sarcoma (MS), also called chloroma or granulocytic sarcoma, is a rare extramedullary presentation of myeloid blasts. It may occur at any age from 1 month to 89 years (median 56 years) with a slight male predominance of 1.2:1 (1). Myeloid sarcoma is most commonly diagnosed in patients with known acute myeloid leukemia (AML) but has also been described as a blastic transformation of other myeloproliferative diseases such as chronic myeloid leukemia and myelodysplastic syndrome (MDS) (1,2).
Myeloid sarcoma can occur anywhere in the body; thus, the clinical presentation of MS depends on the tumor location. Common sites of MS involvement include bone, lymph nodes, skin, and soft tissues (1). Breast involvement is uncommon and, when it occurs, may present as a solitary mass or bilateral palpable masses (Table 1, Figure 1). Clinically, breast MS usually presents as a painless palpable mass. As an extramedullary manifestation of a hematologic malignancy, MS can cause significant diagnostic dilemmas from both a radiologic and pathologic perspective.
Summary of Reported Imaging Findings of 164 Cases of Myeloid Sarcoma Published in PubMed From 2010 to September 2022a
| Study | Total Patients (N = 164) | Mammographic Findings (Patients Excluding Cases in Which Mammogram Was Not Obtained n = 52) | US Findings (Patients Excluding Cases in Which US Was Not Obtained n = 61) | MRI Findings (Patients Excluding Cases in Which MRI Was Not Obtained n = 14) |
|---|---|---|---|---|
| This study | 3 | No mammographic findings (1) Multiple masses (1) Mammogram not obtained (1) | No US findings (1) Multiple masses (2) | N/A |
| Surov et al (3) | 139 | Multiple masses (28) Architectural distortion (5) No mammographic findings (6) Mammogram not obtained (100) | Solitary or multiple masses (37) “Architectural distortion” (3) US not obtained (99) | Enhancing “lesions” (5) MRI not obtained (134) |
| Kim et al (4) | 2 | Multiple masses (1) Mammogram not obtained (1) | Multiple masses (2) | Enhancing masses (1) MRI not obtained (1) |
| Stewart et al (5) | 1 | Solitary mass (1) | Solitary mass (1) | N/A |
| Kinoshita et al (6) | 1 | Multiple masses (1) | Multiple masses (1) | Multiple enhancing masses (1) |
| Huang et al (7) | 1 | Solitary mass (1) | N/A | Solitary T2 hyperintense mass (1) |
| Fernandes Vieira et al (8) | 1 | Multiple masses (1) | Multiple masses (1) | Multiple T2 hyperintense enhancing masses (1) |
| Wu et al (9) | 1 | Solitary mass (1) | N/A | Solitary T2 hyperintense mass (1) |
| Sosa et al (10) | 1 | Multiple masses (1) | Multiple masses (1) | N/A |
| Amiraian et al (11) | 1 | Multiple masses (1) | Multiple masses (1) | N/A |
| Aznab et al (12) | 1 | Multiple masses (1) | N/A | N/A |
| Pitini et al (13) | 1 | Solitary mass (1) | N/A | N/A |
| Zhai et al (14) | 1 | Multiple masses (1) | Multiple masses (1) | N/A |
| Ozsoy et al (15) | 1 | N/A | Multiple masses (1) | N/A |
| Kim et al (16) | 1 | N/A | Solitary mass (1) | N/A |
| Kim et al (17) | 1 | N/A | Solitary mass (1) | Both nonmass enhancement and enhancing mass (1) |
| Huang et al (18) | 1 | N/A | Multiple masses (1) | Enhancing masses (1) |
| Khoshnaw et al (19) | 1 | N/A | Multiple masses (1) | Multiple T2 hyperintense masses (1) |
| Li et al (20) | 1 | N/A | Solitary mass (1) | N/A |
| Fu et al (21) | 2 | N/A | Solitary mass (2) | N/A |
| Gunduz et al (22) | 1 | N/A | Multiple masses (1) | N/A |
| Sharma et al (23) | 1 | N/A | Multiple masses (1) | N/A |
| Study | Total Patients (N = 164) | Mammographic Findings (Patients Excluding Cases in Which Mammogram Was Not Obtained n = 52) | US Findings (Patients Excluding Cases in Which US Was Not Obtained n = 61) | MRI Findings (Patients Excluding Cases in Which MRI Was Not Obtained n = 14) |
|---|---|---|---|---|
| This study | 3 | No mammographic findings (1) Multiple masses (1) Mammogram not obtained (1) | No US findings (1) Multiple masses (2) | N/A |
| Surov et al (3) | 139 | Multiple masses (28) Architectural distortion (5) No mammographic findings (6) Mammogram not obtained (100) | Solitary or multiple masses (37) “Architectural distortion” (3) US not obtained (99) | Enhancing “lesions” (5) MRI not obtained (134) |
| Kim et al (4) | 2 | Multiple masses (1) Mammogram not obtained (1) | Multiple masses (2) | Enhancing masses (1) MRI not obtained (1) |
| Stewart et al (5) | 1 | Solitary mass (1) | Solitary mass (1) | N/A |
| Kinoshita et al (6) | 1 | Multiple masses (1) | Multiple masses (1) | Multiple enhancing masses (1) |
| Huang et al (7) | 1 | Solitary mass (1) | N/A | Solitary T2 hyperintense mass (1) |
| Fernandes Vieira et al (8) | 1 | Multiple masses (1) | Multiple masses (1) | Multiple T2 hyperintense enhancing masses (1) |
| Wu et al (9) | 1 | Solitary mass (1) | N/A | Solitary T2 hyperintense mass (1) |
| Sosa et al (10) | 1 | Multiple masses (1) | Multiple masses (1) | N/A |
| Amiraian et al (11) | 1 | Multiple masses (1) | Multiple masses (1) | N/A |
| Aznab et al (12) | 1 | Multiple masses (1) | N/A | N/A |
| Pitini et al (13) | 1 | Solitary mass (1) | N/A | N/A |
| Zhai et al (14) | 1 | Multiple masses (1) | Multiple masses (1) | N/A |
| Ozsoy et al (15) | 1 | N/A | Multiple masses (1) | N/A |
| Kim et al (16) | 1 | N/A | Solitary mass (1) | N/A |
| Kim et al (17) | 1 | N/A | Solitary mass (1) | Both nonmass enhancement and enhancing mass (1) |
| Huang et al (18) | 1 | N/A | Multiple masses (1) | Enhancing masses (1) |
| Khoshnaw et al (19) | 1 | N/A | Multiple masses (1) | Multiple T2 hyperintense masses (1) |
| Li et al (20) | 1 | N/A | Solitary mass (1) | N/A |
| Fu et al (21) | 2 | N/A | Solitary mass (2) | N/A |
| Gunduz et al (22) | 1 | N/A | Multiple masses (1) | N/A |
| Sharma et al (23) | 1 | N/A | Multiple masses (1) | N/A |
Abbreviation: N/A, not applicable.
aPublications were excluded from the table if findings on available imaging were not detailed.
Summary of Reported Imaging Findings of 164 Cases of Myeloid Sarcoma Published in PubMed From 2010 to September 2022a
| Study | Total Patients (N = 164) | Mammographic Findings (Patients Excluding Cases in Which Mammogram Was Not Obtained n = 52) | US Findings (Patients Excluding Cases in Which US Was Not Obtained n = 61) | MRI Findings (Patients Excluding Cases in Which MRI Was Not Obtained n = 14) |
|---|---|---|---|---|
| This study | 3 | No mammographic findings (1) Multiple masses (1) Mammogram not obtained (1) | No US findings (1) Multiple masses (2) | N/A |
| Surov et al (3) | 139 | Multiple masses (28) Architectural distortion (5) No mammographic findings (6) Mammogram not obtained (100) | Solitary or multiple masses (37) “Architectural distortion” (3) US not obtained (99) | Enhancing “lesions” (5) MRI not obtained (134) |
| Kim et al (4) | 2 | Multiple masses (1) Mammogram not obtained (1) | Multiple masses (2) | Enhancing masses (1) MRI not obtained (1) |
| Stewart et al (5) | 1 | Solitary mass (1) | Solitary mass (1) | N/A |
| Kinoshita et al (6) | 1 | Multiple masses (1) | Multiple masses (1) | Multiple enhancing masses (1) |
| Huang et al (7) | 1 | Solitary mass (1) | N/A | Solitary T2 hyperintense mass (1) |
| Fernandes Vieira et al (8) | 1 | Multiple masses (1) | Multiple masses (1) | Multiple T2 hyperintense enhancing masses (1) |
| Wu et al (9) | 1 | Solitary mass (1) | N/A | Solitary T2 hyperintense mass (1) |
| Sosa et al (10) | 1 | Multiple masses (1) | Multiple masses (1) | N/A |
| Amiraian et al (11) | 1 | Multiple masses (1) | Multiple masses (1) | N/A |
| Aznab et al (12) | 1 | Multiple masses (1) | N/A | N/A |
| Pitini et al (13) | 1 | Solitary mass (1) | N/A | N/A |
| Zhai et al (14) | 1 | Multiple masses (1) | Multiple masses (1) | N/A |
| Ozsoy et al (15) | 1 | N/A | Multiple masses (1) | N/A |
| Kim et al (16) | 1 | N/A | Solitary mass (1) | N/A |
| Kim et al (17) | 1 | N/A | Solitary mass (1) | Both nonmass enhancement and enhancing mass (1) |
| Huang et al (18) | 1 | N/A | Multiple masses (1) | Enhancing masses (1) |
| Khoshnaw et al (19) | 1 | N/A | Multiple masses (1) | Multiple T2 hyperintense masses (1) |
| Li et al (20) | 1 | N/A | Solitary mass (1) | N/A |
| Fu et al (21) | 2 | N/A | Solitary mass (2) | N/A |
| Gunduz et al (22) | 1 | N/A | Multiple masses (1) | N/A |
| Sharma et al (23) | 1 | N/A | Multiple masses (1) | N/A |
| Study | Total Patients (N = 164) | Mammographic Findings (Patients Excluding Cases in Which Mammogram Was Not Obtained n = 52) | US Findings (Patients Excluding Cases in Which US Was Not Obtained n = 61) | MRI Findings (Patients Excluding Cases in Which MRI Was Not Obtained n = 14) |
|---|---|---|---|---|
| This study | 3 | No mammographic findings (1) Multiple masses (1) Mammogram not obtained (1) | No US findings (1) Multiple masses (2) | N/A |
| Surov et al (3) | 139 | Multiple masses (28) Architectural distortion (5) No mammographic findings (6) Mammogram not obtained (100) | Solitary or multiple masses (37) “Architectural distortion” (3) US not obtained (99) | Enhancing “lesions” (5) MRI not obtained (134) |
| Kim et al (4) | 2 | Multiple masses (1) Mammogram not obtained (1) | Multiple masses (2) | Enhancing masses (1) MRI not obtained (1) |
| Stewart et al (5) | 1 | Solitary mass (1) | Solitary mass (1) | N/A |
| Kinoshita et al (6) | 1 | Multiple masses (1) | Multiple masses (1) | Multiple enhancing masses (1) |
| Huang et al (7) | 1 | Solitary mass (1) | N/A | Solitary T2 hyperintense mass (1) |
| Fernandes Vieira et al (8) | 1 | Multiple masses (1) | Multiple masses (1) | Multiple T2 hyperintense enhancing masses (1) |
| Wu et al (9) | 1 | Solitary mass (1) | N/A | Solitary T2 hyperintense mass (1) |
| Sosa et al (10) | 1 | Multiple masses (1) | Multiple masses (1) | N/A |
| Amiraian et al (11) | 1 | Multiple masses (1) | Multiple masses (1) | N/A |
| Aznab et al (12) | 1 | Multiple masses (1) | N/A | N/A |
| Pitini et al (13) | 1 | Solitary mass (1) | N/A | N/A |
| Zhai et al (14) | 1 | Multiple masses (1) | Multiple masses (1) | N/A |
| Ozsoy et al (15) | 1 | N/A | Multiple masses (1) | N/A |
| Kim et al (16) | 1 | N/A | Solitary mass (1) | N/A |
| Kim et al (17) | 1 | N/A | Solitary mass (1) | Both nonmass enhancement and enhancing mass (1) |
| Huang et al (18) | 1 | N/A | Multiple masses (1) | Enhancing masses (1) |
| Khoshnaw et al (19) | 1 | N/A | Multiple masses (1) | Multiple T2 hyperintense masses (1) |
| Li et al (20) | 1 | N/A | Solitary mass (1) | N/A |
| Fu et al (21) | 2 | N/A | Solitary mass (2) | N/A |
| Gunduz et al (22) | 1 | N/A | Multiple masses (1) | N/A |
| Sharma et al (23) | 1 | N/A | Multiple masses (1) | N/A |
Abbreviation: N/A, not applicable.
aPublications were excluded from the table if findings on available imaging were not detailed.
Pie graphs of the imaging findings of myeloid sarcoma on mammography (A), US (B), and MRI (C) as presented in Table 1.
Imaging Findings
Breast MS is extremely rare; thus, much of the knowledge regarding imaging findings derives from small series or case reports as summarized in Table 1 and Figure 1. Most patients will present clinically with a solitary (Figure 2) or multiple palpable masses (Figure 3). The initial imaging workup for any palpable findings should begin with mammography and/or targeted US depending on the age at presentation. In a literature review of mammographic findings in 52 patients with MS from 2010 to September 2022, the most frequently encountered mammographic finding was a breast mass or masses (78%), followed by no abnormality (12%) or architectural distortion (10%). In a review of 39 patients with MS by Surov et al (3), unilateral axillary lymphadenopathy was noted in 17% of cases. Breast Imaging Reporting and Data System (BI-RADS) descriptors of the breast mass(es) are variable, with some being described as circumscribed and others obscured or indistinct (4–14). Microcalcifications were present in 2 out of 5 patients for whom calcifications were described (3,6,7,14).
A 23-year-old woman presented with fevers and headaches and was found to be pancytopenic. She was diagnosed with acute myelogenous leukemia on bone marrow biopsy, completed high-dose cytarabine consolidation therapy and intrathecal treatments, and was declared in remission. Surveillance CT in the axial (A) and sagittal planes (B) 7 months after remission was notable for a new mass in the left breast (arrows). Targeted US in the transverse (C), long (D), and color Doppler (E) of the mass demonstrated an oval mixed echogenicity retroareolar mass with indistinct margins (arrows), internal vascularity (arrowhead), and echogenic rim. On the patient’s return for US-guided biopsy of the mass 10 days later, the mass (arrows) had almost tripled in volume (long axis, F). A 40× magnification hematoxylin and eosin stain (G) revealed proliferation of a large population of atypical cells with several mitotic figures (arrows). These atypical cells were diffusely positive on 10× immunostaining for myeloid markers including CD117 (H), consistent with breast myeloid sarcoma.
Thirty-six-year-old woman with recurrent fevers and fatigue and was found to have hyperleukocytosis. She was diagnosed with acute myelogenous leukemia on bone marrow biopsy, then 1 week later developed multiple palpable breast masses due to myeloid sarcoma (MS). Mediolateral oblique digital breast tomosynthesis of the left breast (A) and right breast (B) demonstrated multiple irregular, hyper- and iso-dense masses (arrows) with circumscribed and partially obscured margins correlating with her palpable abnormalities; several additional nonpalpable masses were also identified. Two representative palpable masses on US in the left breast at 3 o’clock position (C, arrows) and left breast 4 o’clock position (D, arrows) show heterogeneous echotexture, indistinct margins, and internal vascularity (arrowheads); an echogenic rim is also seen (D). The patient was given a BI-RADS 5 assessment for the bilateral masses, and two of the largest masses were selected for US-guided core-needle biopsy. A 20× magnification hematoxylin and eosin stain (E) revealed a diffuse cellular infiltrate with a large population of blasts with several mitotic figures (arrows) and stained diffusely positive for myeloid markers including CD117 (F, 10×; images courtesy of Dr Monica Abdelmalak), consistent with breast MS. Coronal and left posterior oblique maximal intensity projection images from staging fluorodeoxyglucose (FDG) PET-CT (G) showed multiple hypermetabolic breast masses (arrows) and left axillary lymph nodes (arrowheads). Axial fused FDG PET-CT of the chest (H) shows intense FDG uptake in the breast MS (arrow) with a maximum standard uptake value of 6.9, much higher than the liver background. FDG PET-CT was also obtained after treatment to assess response and to monitor disease burden in this patient.
On US, a hypoechoic mass with indistinct or microlobulated margins and heterogenous internal echotexure is most commonly observed (Figure 4). BI-RADS US descriptors of breast MS include heterogenous mixed hypo- and hyperechoic masses; margins were circumscribed in 9 out of 55 cases with mass(es) (3–6,8,10,11,14–23). An echogenic rim is frequently observed (Figures 2, 3). Occasionally, the mass margins are not very discrete (Figure 4). Vascularity is described as increased when assessed (Figure 3). Elastography features of breast MS vary, with some MS masses relatively soft and others stiff (16).
A 21-year-old woman initially presented with fever and pancytopenia and was diagnosed with myelodysplastic syndrome via bone marrow biopsy. Fourteen months later, she developed a rapidly enlarging palpable mass in the right breast diagnosed as myeloid sarcoma (MS). Targeted US (A) shows an ill-defined mass with mixed hypoechoic and hyperechoic echotexture (arrow) initially interpreted as heterogeneous tissue at the palpable site. Mediolateral oblique and craniocaudal diagnostic digital breast tomosynthesis of the right breast (B) demonstrated extremely dense breast tissue and a vague asymmetry at the site of palpable abnormality (triangle marker). A biopsy was recommended because of the palpable mass on exam, BI-RADS 4A. At the time of her scheduled US-guided biopsy, the patient described interval development of multiple additional palpable masses bilaterally—all with similar appearances as the index mass on sonography. US-guided core-needle biopsy of the palpable areas of concern revealed a dense monocytic cell infiltrate on 40× hematoxylin and eosin stain (C), and immunostains were positive for leukocyte markers (such as CD4 and CD43), consistent with breast MS. Peripheral flow cytometry confirmed that the patient had myelodysplastic syndrome that had transformed to acute myelogenous leukemia. Fluorodeoxyglucose PET-CT was not obtained in this patient.
Myeloid sarcoma on contrast-enhanced MRI may manifest as heterogeneously enhancing masses with variable margins or regional nonmass enhancement with plateau or washout kinetics, similar to a primary breast malignancy. However, unlike typical breast cancers, MS lesions are commonly T2 hyperintense. Restricted diffusion has been reported on diffusion-weighted imaging (3,4,6,8–10,17–19).
On 18F-fluorodeoxyglucose (FDG) PET-CT, breast MS demonstrates increased radiotracer uptake with maximum standardized uptake values ranging from 2.6 to 9.7 (2) (Figure 3). As a whole-body imaging modality and because of the moderate FDG avidity, FDG PET-CT has greater utility than mammography, US, or MRI for initial staging of disease and for evaluating treatment response.
The differential diagnosis of a solid solitary breast mass may include any benign or malignant mass-forming lesion because of the variable appearance. If bilateral findings are present, extramedullary hematopoiesis should be considered in the appropriate clinical setting, such as a history of severe anemia. Ultimately, definitive diagnosis is only possible after biopsy and clinicopathologic correlation.
Pathologic Findings
Myeloid sarcoma is a misnomer in that it is not a sarcoma deriving from mesenchymal or epithelial tissue but rather a soft tissue leukemia. According to the World Health Organization, MS is a tumor mass that consists of myeloid blasts occurring in an extramedullary site (1). Core-needle biopsy is preferred because it yields more accurate results than fine-needle aspiration (24). The histologic diagnosis of MS is challenging; even with modern-day diagnostic methods, the estimated misdiagnosis rate ranges from 25% to 47% in the absence of systemic disease (25). Reserving tissue for molecular studies such as immunohistochemistry, flow cytometry (which requires specimens to be placed in saline or tissue culture medium at the time of core-needle biopsy), and fluorescence in situ hybridization (FISH) is essential for diagnosis.
Immunophenotype testing and flow cytometry may include markers for CD13, CD33, CD34, CD68, CD117, myeloperoxidase, and mutations such as aberrant NPM1 expression or FLT3 duplication. Fluorescence in situ hybridization analysis can detect chromosomal aberrations including but not limited to monosomy 7, trisomy 8, KMT2A rearrangement, or loss of 16q (1). Communicating to the pathologist any clinical history of an underlying hematopoietic condition is critical to diagnosis due to the rarity of these cases.
The appearance of MS on microscopy can vary, based on the degree of myeloid differentiation; the cells are typically blasts with round-oval nuclei and multiple mitotic figures (Figures 2, 3). The most common misdiagnoses include other malignant lymphoproliferative disorders or small round blue cell tumors (1). A potential pathologic pitfall for MS in the breast would be mistaking MS to be invasive lobular breast carcinoma because both malignancies can demonstrate single-cell infiltration patterns or cohesive nests. However, invasive lobular carcinoma would stain positive for estrogen or progesterone markers in most cases, as well as cytokeratin (5,11). Myeloid sarcoma is negative for cytokeratins and instead is strongly positive for myeloperoxidase and other myeloid markers (Figures 2, 3).
Management/Discussion
Myeloid sarcoma presenting as extramedullary palpable or nonpalpable breast masses is rare. Imaging evaluation should start with mammography and US. Once a biopsy is pursued and MS is determined to be the diagnosis, correlation with bone marrow biopsy is important to distinguish de novo occurrence in the breast versus associated systemic myeloid neoplasm. Staging with PET-CT may be helpful for determining extent of disease and for prognosis and treatment planning.
Because of the rarity of MS, the data on MS prognosis are limited. Additionally, the pathogenesis of extramedullary involvement of hematopoietic malignancies is not completely understood. Extramedullary disease has been shown to be associated with a poor prognosis and shorter survival, although the five-year survival rate of patients with MS is similar to that of AML in general, at between 20% and 30% (26). This contrasts with a significantly lower survival rate of patients with MS and MDS or other myeloproliferative neoplasms (27).
There are no consensus guidelines on MS treatment because of the rarity of the disease and lack of randomized controlled trials. Testing for molecular abnormalities may uncover a targetable mutation for therapeutic use and prognostic stratification in patients with AML (28). The most often reported mutation in MS is the NPM1 mutation (about 16% of cases), and this represents a potential immunotherapeutic target (1,24,28). The FLT3 internal tandem duplication is also present in a small minority of cases and is another promising therapeutic target (1,24).
It is important to promptly treat isolated MS as systemic therapy decreases progression to acute leukemia (24). Treatment typically follows protocols for AML, and most patients with isolated MS will develop AML within a median of 6–12 months if they did not have it at initial presentation (25). There are many factors to consider, including extent of disease, whether the MS represents initial or recurrent disease, and the patient’s age and baseline health status. Treatment may consist of chemotherapy, local therapy including surgery and radiation, stem cell transplant, and immunotherapy. Surgery or radiotherapy is considered when rapid symptom relief is required because of mass effect on adjacent structures or in cases of inadequate response to chemotherapy or recurrence. FDG PET-CT has been shown to be potentially useful in assessing treatment response and disease monitoring (2). Ultimately, understanding the underlying pathogenesis of extramedullary disease is important to develop novel therapies for specific treatment of MS.
Funding
R.F., R.S., and S.V.G. have disclosed a financial relationship (see Conflict of Interest Statement); all other authors have no relevant relationships to disclose.
Conflict of Interest Statement
R.F.: OncLive event with honorarium. R.S.: Contractual stipend with Allegheny Heath Network, Pittsburgh Breast Imaging Society leadership. S.V.G.: Consultant for Delphinus, Inc, NCRS/ACR leadership. All other authors have no relevant conflicts of interest to disclose.
