Zamora, Kathryn W

Abstract High-risk breast lesions (HRLs) encompass a heterogeneous group of pathologies that coexist with an adjacent or synchronous malignancy, confer an increased risk of future breast cancer, or warrant surgical consideration because of upgrade potential or local behavior. Despite their clinical importance, management of HRLs remains variable. The American Society of Breast Surgeons (ASBrS) and the Society of Breast Imaging are collaborating to establish unified, evidence-based guidelines for managing these lesions. While these recommendations are currently in development, this review summarizes the existing literature and current guidance, including ASBrS recommendations, to provide context for multidisciplinary management. The article reviews the histopathologic features, imaging appearance, and management strategies for HRLs, including atypical ductal hyperplasia (ADH), atypical lobular hyperplasia (ALH), lobular carcinoma in situ (LCIS), flat epithelial atypia (FEA), papillomas with and without atypia, radial scar/complex sclerosing lesion (RS/CSL), mucocele-like lesion (MLL), desmoid tumor, and pseudoangiomatous stromal hyperplasia (PASH). Recent literature supports nonoperative management for specific radiologic-pathologic concordant lesions, particularly limited ADH, pure FEA, and pure RS, highlighting the important role of multidisciplinary discussion for personalized care. Lesions such as LCIS subtypes, papilloma with atypia, and MLL with atypia continue to warrant excision due to higher reported upgrade rates to malignancy. Beyond short-term management, HRLs such as ADH, ALH, and LCIS serve as biomarkers of long-term breast cancer risk, informing recommendations for surveillance, risk assessment, and chemoprevention counseling. Achieving a consensus among radiology, pathology, and surgical disciplines is essential to ensure oncologic safety while minimizing overtreatment in the era of precision breast care.

Abstract Over the last 30 years, axillary surgery in patients with breast cancer has undergone a consistent patient-centered, evidence-based de-escalation of surgical intervention, including considerable practice changes over the last decade. As surgical approaches change, the role of breast imaging radiologists and axillary imaging must also evolve. Axillary imaging remains variable across radiology practices, with implementation of new protocols occurring at various speeds. Breast radiologists must be aware of recent trials and remain agile in adopting or responding to changing treatment paradigms. Breakthrough studies, such as the SOUND (Sentinel Node Vs Observation After Axillary Ultra-souND) trial, must be vetted and evaluated by individual practices before adoption. Breast radiologists should play a key role in multidisciplinary collaboration with colleagues involved in breast cancer care to assist with strategic planning and appropriate resource utilization.

Abstract Breast image-guided procedures play a critical role in the diagnosis and management of breast cancer, serving as the gold standard for tissue sampling and preoperative localization. These minimally invasive procedures carry a very low risk of complications, with postprocedural infections occurring in fewer than 0.2% of cases. However, given the high volume of breast interventions performed annually, the potential impact of infections remains significant. Despite this, published guidelines addressing procedural cleanliness techniques in breast imaging are sparse and often provide conflicting recommendations, leading to variability in clinical practice and resource utilization. The lack of clear and specific guidance creates challenges for radiologists navigating institutional policies and best practice implementation. This review synthesizes existing standards and guidelines, evaluating the supporting evidence to propose an evidence-based best practice approach for maintaining clean techniques in breast image-guided procedures. By standardizing cleanliness protocols, we aim to enhance patient care, optimize procedural success, and promote consistency across breast imaging practices.

Abstract To assess breast imaging fellowship program directors’ perspectives of the outcomes of the first-ever virtual interview season. A 19-question survey was constructed by members of the Fellowship Match Committee of the Society of Breast Imaging and distributed via email to 103 program directors. An initial email with a link to the survey was distributed on May 17, 2023, with 2 reminder emails sent on May 31, 2023, and June 20, 2023. The survey was closed on June 26, 2023. Results were compiled, and a descriptive statistical analysis was performed using Excel. There were 36 total responses yielding a response rate of 35% (36/103). The majority of programs, 61% (22/36), did not fill positions with any internal candidates. Overall, 72% answered that the perception of their fellow’s performance was equal to or higher than those in prior years. Despite the effects of the pandemic on clinical exposure for this cohort, 73% of programs stated that the fellow’s foundational knowledge was equivalent or better. Remarkably, 81% of respondents stated that procedural skills were equivalent or better, and 78% stated that communication skills were equivalent or better. This is the first study to investigate the outcomes of the unexpected pivot to virtual interviews. Despite the lack of preparation for this operational shift, it does not appear to have negatively impacted the program directors’ impressions of their matched fellows.

Abstract Purpose: Low-dose tamoxifen reduces breast cancer risk, but remains untested in chest-irradiated cancer survivors—a population with breast cancer risk comparable with BRCA mutation carriers. We hypothesized that low-dose tamoxifen would be safe and efficacious in reducing radiation-related breast cancer risk. Patients and Methods: We conducted an investigator-initiated, randomized, phase IIb, double-blinded, placebo-controlled trial (FDA IND107367) between 2010 and 2016 at 15 U.S. sites. Eligibility included ≥12 Gy of chest radiation by age 40 years and age at enrollment ≥25 years. Patients were randomized 1:1 to low-dose tamoxifen (5 mg/day) or identical placebo tablets for 2 years. The primary endpoint was mammographic dense area at baseline, 1 and 2 years. IGF-1 plays a role in breast carcinogenesis; circulating IGF-1 and IGF-BP3 levels at baseline, 1 and 2 years served as secondary endpoints. Results: Seventy-two participants (low-dose tamoxifen: n = 34, placebo: n = 38) enrolled at a median age of 43.8 years (35–49) were evaluable. They had received chest radiation at a median dose of 30.3 Gy. Compared with the placebo arm, the low-dose tamoxifen arm participants had significantly lower mammographic dense area (P = 0.02) and IGF1 levels (P < 0.0001), and higher IGFBP-3 levels (P = 0.02). There was no difference in toxicity biomarkers (serum bone-specific alkaline phosphatase, lipids, and antithrombin III; urine N-telopeptide cross-links) between the treatment arms. We did not identify any grade 3–4 adverse events related to low-dose tamoxifen. Conclusions: In this randomized trial in chest-irradiated cancer survivors, we find that low-dose tamoxifen is effective in reducing established biomarkers of breast cancer risk and could serve as a risk-reduction strategy.