Charmi Vijapura

Opportunities exist to provide high-quality breast imaging fellowship training in the community setting. Various challenges exist, however, including obtaining funding for a fellowship position, creating an educational curriculum in a potentially nonacademic environment, and developing an overall competitive program that will attract radiology trainees. Here, we explore factors that contribute to the establishment of an academic breast imaging fellowship program in the community setting based on experience, including (1) providing guidance on how to secure funding for a breast imaging fellowship position; (2) developing a training curriculum based on established guidelines from the Accreditation Council for Graduate Medical Education, American College of Radiology, and Society of Breast Imaging; and (3) navigating the landscape of the recruitment process, from program branding to matching applicants.

Dense breast tissue at mammography is associated with higher breast cancer incidence and mortality rates, which have prompted new considerations for breast cancer screening in women with dense breasts. The authors review the definition and classification of breast density, density assessment methods, breast cancer risk, current legislation, and future efforts and summarize trials and key studies that have affected the existing guidelines for supplemental screening. Cases of breast cancer in dense breasts are presented, highlighting a variety of modalities and specific imaging findings that can aid in cancer detection and staging. Understanding the current state of breast cancer screening in patients with dense breasts and its challenges is important to shape future considerations for care. Shifting the paradigm of breast cancer detection toward early diagnosis for women with dense breasts may be the answer to reducing the number of deaths from this common disease. ^©RSNA, 2023 Online supplemental material is available for this article. Quiz questions for this article are available through the Online Learning Center. See the invited commentary by Yeh in this issue.

Creating a comprehensive didactic curriculum for breast imaging fellows can be a demanding undertaking, especially considering that most breast practices are understaffed because of the COVID-19 pandemic and amid rising clinical volumes. This leaves little time for didactic education. In this article, we present our approach to creating a collaborative weekly multidisciplinary didactic lecture series involving multiple institutions, using the Society of Breast Imaging’s suggested fellowship curriculum as the foundation. We discuss the advantages for both trainees and faculty, including fostering camaraderie, networking, and engagement among breast imaging fellows. Faculty have the opportunity for professional development by leveraging their clinical expertise through selecting didactic topics in their niche. This creates a pathway for speaking faculty to be recognized as regional and national experts.

Breast density continues to be a prevailing topic in the field of breast imaging, with continued complexities contributing to overall confusion and controversy among patients and the medical community. In this article, we explore the current status of breast cancer screening in women with dense breasts including breast density legislation. Risk-based approaches to supplemental screening may be more financially cost-effective. While all advanced imaging modalities detect additional primarily invasive, node-negative cancers, the degree to which this occurs can vary by density category. Future directions include expanding the use of density-inclusive risk models with appropriate risk stratification and imaging utilization. Further research is needed, however, to better understand how to optimize population-based screening programs with knowledge of patients’ individualized risk, including breast density assessment, to improve the benefit-to-harm ratio of breast cancer screening.

Adenoid cystic carcinoma (ACC) is an uncommon malignancy occurring most frequently in the salivary glands. Breast ACC is rare. Pain is common at the site of ACC; otherwise, presentation is similar to other primary breast cancers. Adenoid cystic carcinomas classically lack calcifications; the imaging manifestations of ACC are otherwise highly variable, likely related to multiple pathologic growth patterns. While ACC in other regions of the body tends to be more aggressive, ACC involving the breast typically has less aggressive biologic characteristics. Classic-type breast ACC has a lower tendency to recur locally with radiation, metastasize to regional lymph nodes, and spread to other parts of the body. Perineural spread of disease can be seen but is not common. The rarer solid basaloid–type has a higher tendency for local or distant spread and recurrence. Although ACC is usually triple receptor–negative (estrogen receptor, progesterone receptor, human epidermal growth factor-2 receptor), the indolent nature of this tumor dictates its management. With classic-type ACC, the inclusion of axillary surgery has no consensus and the use of chemotherapy or hormonal therapy is rare. Axillary nodal surgery and chemotherapy are often included in management of the more aggressive solid basaloid–type. An understanding of the breast imaging, histopathology, and clinical course is key for appropriate treatment and follow-up of ACC.

A 24-year-old woman with a history of chest wall birthmark and recent 70-pound weight loss presented with a mass in her upper inner right breast that was more pronounced when she engaged her pectoral muscles. Clinical examination revealed multiple prominent, compressible, superficial vessels extending across the upper central and outer breast. A few small telangiectasias were also present. Targeted US demonstrated an irregular indistinct mass causing enlargement of the pectoralis major muscle with numerous internal blood vessels ( Figure 1). A few hyperechoic foci with posterior acoustic shadowing were present representing calcifications. Breast MRI showed a network of dilated, superficial vessels within the upper breast interconnecting multiple lobulated T2 hyperintense, T1 isointense, and progressively enhancing masses ( Figure 2). The subcutaneous and pectoral masses demonstrated fluid-fluid levels and rounded foci of susceptibility artifact, representing phleboliths. Imaging findings were consistent with multiple venous malformations involving the right breast and chest wall.