Calcifications, Cryoablation, and Much More

This issue of the Journal of Breast Imaging is our last of 2023, and overall is our 28th published issue. Thank you to our incredible editorial and publishing teams and our contributing authors, who make the journal possible and of high quality and value. Please consider submitting your own work to the Journal of Breast Imaging. Overall, the diverse articles in this issue highlight many ways we can continue to improve our breast imaging quality, patient care, and outcomes and also our fellowship training programs. I particularly appreciate that 2 articles describe newer ways that we can potentially de-escalate or minimize care in appropriately selected subsets of patients with breast cancer (1,2).

Among our original research articles, Vincoff et al describe their prospective study results on the important topic of breast arterial calcification (BAC) on mammography (3). Breast arterial calcification is associated with cardiovascular risk but is inconsistently included in mammography reports or disclosed to patients. The authors studied 494 patients who underwent screening mammography, were notified if they had BAC, and were then surveyed to determine if they undertook subsequent health actions. After notification about BAC, the majority (57.1%) reported discussing the results with a primary care physician or cardiologist, suggesting that providing patients with information about BAC may promote preventive cardiovascular health. These study results may help inform ongoing discussions for U.S. guidelines for BAC assessment and reporting.

Also in original research, the article by Nguyen et al reports their retrospective study results for biopsy outcomes of suspicious calcifications detected with screening mammography using digital breast tomosynthesis and synthetic 2D (DBT/SM) technique in one time period compared to those detected using full-field digital (DM) technique in an earlier time period (4). They found that calcifications detected with DBT/SM technique were significantly more likely to be malignant than those found using DM. Their results add to others suggesting that DBT/SM appropriately identifies clinically significant calcifications and can be used without obtaining concurrent DM images.

The original research article by Kozlov et al retrospectively investigates the ability of a technologist quality improvement coaching program to achieve sustained performance in mammographic quality over 5 years (5). The authors found that in their sustained coaching period, 90% of audited mammograms passed quality assessment based on multiple motion and positioning criteria, meeting their established quality goal. Such quality-focused efforts and results are important as we work to achieve high-quality mammography, which is essential for breast cancer detection. Of note, there is also interest in the role that automated software assessment programs may play in the future to aid in achieving mammographic quality.

Moravia et al in their original research article evaluate the use of contrast-enhanced mammography (CEM) for women with a personal history of treated breast cancer (6). Specifically, they retrospectively assessed the experiences and preferences of consecutive women in this population who had CEM as their annual mammogram. They found that 99% of study participants were satisfied with CEM, that most were comfortable having contrast for annual breast imaging, and that most would prefer CEM to MRI if the exams had equal chances of detecting cancer. These results are helpful as we continue to consider the most appropriate ways to utilize CEM in different patient populations and clinical scenarios.

The original research article by Bahl et al reports their results using machine learning models to predict risk of surgical upstage of ductal carcinoma in situ (DCIS) to invasive malignancy (1). In particular, they compared the proportion of patients who would be eligible for active surveillance in the COMET (Comparison of Operative versus Monitoring and Endocrine Therapy) trial using machine learning models compared to using the COMET clinical criteria. They found that machine learning identified a larger proportion of women (56%–87%) eligible for surveillance compared to clinical criteria (42%) while maintaining similar upstage rates. This is exciting work that exemplifies how machine learning has the potential to transform patient care and help us achieve better options and outcomes for patients. Further, this article highlights the important and evolving concept of de-escalation of therapy in selected patients, here with active surveillance over surgery.

The clinical practice article by Berg et al describes multiple practice considerations related to breast density reporting, risk assessment, supplemental screening, and breast imaging insurance coverage (7). Among the very noteworthy components of the article are explanations of the March 2023 Food and Drug Administration final rule under the Mammography Quality Standards Act for national dense breast reporting and of the proposed Find It Early Act, which would ensure that all health insurance plans cover no-cost screening and diagnostic breast imaging for women with dense breasts or otherwise at increased risk. Input on the Find It Early Act from constituents including members the radiology community would be valuable, so please consider sharing your support for this important endeavor.

The Science of Screening article by Coffey et al addresses the topic of breast cancer screening in women with a family history of breast cancer (8). The excellent review discusses the significance of family history on an individual’s risk of developing breast cancer and also the main risk assessment models. It further describes the current guidelines for screening this population, including the benefits and limitations of different imaging modalities.

Berg et al in their Radiologic–Pathologic Correlation article describe tubular adenoma of the breast (9). Only 40 cases have previously been described in the literature, and the authors review these and add an additional 5 cases from their institution. An organized review of the salient imaging and histopathology features is provided. Did you know that although tubular adenomas and fibroadenomas are indistinguishable on imaging, they are histologically distinct without common gene mutations? I always learn something new and interesting in our radiology–pathology articles.

Our Educational Review by Sharafi et al discusses pregnancy-associated breast cancer (PABC), benign breast entities that are also encountered during pregnancy and lactation, and the appropriate use of imaging in this patient population (10). This is an important topic for many reasons, including because the incidence of PABC is increasing. The authors highlight the spectrum of PABC imaging features, appropriate diagnostic workups, and potential diagnostic challenges in the context of normal peripartum breast imaging appearances.

The Scientific Review by Thai et al is an excellent description of cryoablation therapy for early-stage breast cancer (2). Image-guided cryoablation of breast cancer is an emerging nonsurgical treatment alternative to breast-conserving surgery in select patients with small, low-risk tumors. The review describes the current evidence, patient selection criteria, procedural technique, and pre- and postablation imaging for this method of therapy. There are many great example images, and Table 2 in the article is a valuable summary of the primary patient selection criteria for use of cryoablation. Along with the article by Bahl et al, this article highlights the important and evolving concept of de-escalation of therapy in selected patients, here with cryoablation over surgery.

Weinstein et al have authored a very interesting Training and Development article on the current state of breast imaging fellowship training in the United States, using a national survey of fellowship program directors (11). They found that breast imaging fellowship programs vary in curricula, modality exposure, and academic policies. For example, most programs provide exposure to both wire and wire-free localization procedures, but exposure to CEM and molecular breast imaging is limited. It is hoped that this article can help guide further efforts to standardize and optimize fellowship training.

And, finally, for what our founding Editor in Chief Dr Jennifer Harvey referred to as “the dessert,” we have terrific Unknown Challenge and Image Spotlight articles, authored by Lagumdzija et al (12), Sakla et al (13), and Kurumety et al (14).

References