ammography is the primary imaging modality used for breast cancer screening and is the only imaging test shown to reduce mortality from breast cancer (1-3). Although effective, one major limitation of mammography is its limited sensitivity, especially in women with dense breasts. The sensitivity of mammography in young women with dense breasts is reported to be as low as 38%-50% (4,5).Breast MRI is known to be the most sensitive imaging modality to detect breast cancer. However, breast MRI is restricted to screening women at high risk and, more recently, women with a personal history of breast cancer and dense breasts or who are diagnosed before age 50 years primarily because of its high cost and limited availability (6-14). Contrast agent-enhanced digital mammography (DM)(CEDM) is a contrast agent-based imaging test performed by using a modified DM unit. Studies (15-18) have reported that CEDM had improved sensitivity and specificity compared with conventional mammography in the diagnostic setting. To our knowledge, only two studies have evaluated the use of screening CEDM. The first study ( 19) was a small study of 307 women that compared screening CEDM with breast MRI and found that both CEDM and MRI depicted cancers not seen at conventional mammography. A more recent study (20) evaluated the performance of screening CEDM in 611 women at intermediate risk. In that study, CEDM was more sensitive than standard DM, with the addition of contrast enhancement resulting in an incremental cancer detection rate of 13.1 of 1000. The overall cancer detection rate in that study was high, at 31 of 1000 (19 cancers in 611 women).CEDM has been offered as a screening test at our Comprehensive Cancer Center since December 2012. Referring physicians may order CEDM as an alternative screening examination to conventional mammography. CEDM is most commonly performed to screen women at intermediate risk such as women with a

Purpose To assess the extent of background parenchymal enhancement (BPE) at contrast material-enhanced (CE) spectral mammography and breast magnetic resonance (MR) imaging, to evaluate interreader agreement in BPE assessment, and to examine the relationships between clinical factors and BPE. Materials and Methods This was a retrospective, institutional review board-approved, HIPAA-compliant study. Two hundred seventy-eight women from 25 to 76 years of age with increased breast cancer risk who underwent CE spectral mammography and MR imaging for screening or staging from 2010 through 2014 were included. Three readers independently rated BPE on CE spectral mammographic and MR images with the ordinal scale: minimal, mild, moderate, or marked. To assess pairwise agreement between BPE levels on CE spectral mammographic and MR images and among readers, weighted κ coefficients with quadratic weights were calculated. For overall agreement, mean κ values and bootstrapped 95% confidence intervals were calculated. The univariate and multivariate associations between BPE and clinical factors were examined by using generalized estimating equations separately for CE spectral mammography and MR imaging. Results Most women had minimal or mild BPE at both CE spectral mammography (68%-76%) and MR imaging (69%-76%). Between CE spectral mammography and MR imaging, the intrareader agreement ranged from moderate to substantial (κ = 0.55-0.67). Overall agreement on BPE levels between CE spectral mammography and MR imaging and among readers was substantial (κ = 0.66; 95% confidence interval: 0.61, 0.70). With both modalities, BPE demonstrated significant association with menopausal status, prior breast radiation therapy, hormonal treatment, breast density on CE spectral mammographic images, and amount of fibroglandular tissue on MR images (P < .001 for all). Conclusion There was substantial agreement between readers for BPE detected on CE spectral mammographic and MR images. RSNA, 2016.

OBJECTIVE Second-opinion review of breast imaging studies can be a time-consuming and labor-intensive process. The purpose of this investigation was to determine whether reinterpretation of studies obtained at institutions outside a cancer center influences clinical management, specifically by revealing additional cancer and preventing unnecessary biopsy. MATERIALS AND METHODS A review was conducted of breast imaging studies of 200 patients who underwent ultrasound and MRI at community facilities and had the images submitted for second opinions at a cancer center between January and April 2014. Each case was evaluated for concordance between the original report and the second-opinion interpretation. Second-opinion review resulting in the recommendation and performance of new biopsies was further subdivided into benign, high-risk, and malignant categories based on the histopathologic results obtained at the cancer center. RESULTS Second-opinion review of the 200 cases showed a change in interpretation in 55 cases (28%; 95% CI, 21–34%). Overall, 26 recommendations (13%; 95% CI, 9–18%) led to a major change in management. Twenty new biopsies were performed, yielding 10 malignancies (5%; 95% CI, 2–9%) and four high-risk lesions (2%; 95% CI, 1–5%). Surgical management was changed to mastectomy for 6 of 10 patients (60%) with new sites of biopsy-proven malignancy. Eight biopsies were averted (4%; 95% CI, 2–8%) on the basis of benign interpretation of the imaging findings, and no disease was found at 1-year follow-up evaluation. CONCLUSION Reinterpretation of studies obtained outside a cancer center resulted in a change in interpretation in more than one-fourth of submitted studies. Additional cancer was detected in 5% of patients, and biopsy was averted for 4%. The practice of second-opinion review influences clinical management and adds value to patient care.

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RTUR was found to be an important tool in the management of patients at our comprehensive cancer center. Although additional false-positive lesions may be detected on RTUR, a great number of patients will benefit from RTUR in finding additional cancers or avoiding unnecessary biopsies.