Breast Imaging
Stony Brook University Radiology Residency
Breast Imaging Curriculum, Goals and Objectives
Goals and Objectives
The residents will participate in the day-to-day interpretation of Diagnostic and Screening mammography, and problem solving involving Breast U/S, CAD, and breast MRI. The resident will become familiar with the fundamental of mammographic positioning, technique, and Quality Control, and will use MQSA-approved BIRADS lexicon in generating reports. We will give hand-on training on Breast U/S, and we expect that the resident will participate directly in scanning patients, as well as in interventional U/S procedures, including cyst aspiration, core biopsies and needle localization guided by U/S.
Residents are expected to participate in all the clinical activities of the Breast Imaging Service, including the real time monitoring of studies, and all interventional procedures including stereotactic biopsies and mammographic needle pre-operative localizations. Attendance at the Weekly Breast Multi-disciplinary Conference is mandatory, and the resident will have the primary responsibility of presenting cases at the conference. This will enrich the resident's understanding of the clinical, pathologic, and therapeutic issues surrounding Breast Imaging.
Epidemiology
Risk factors and incidence
Staging in survival rates
Breast Anatomy, Pathology, and Physiology
Breast development
Normal breast anatomy and histology; alteration with the age, pregnancy, menstrual cycle, and hormonal effects
Pathological and mammographic appearance and clinical significance of benign breast conditions, such as fibroadenoma, cysts, papilloma, hamartoma, lipoma, ductal ectasia, radial scar, and fat necrosis
Atypical ductal hyperplasia, lobular neoplasia, and other histologic risk factors
Pathologic and mammographic appearance, clinical features' significance, and prognosis of ductal carcinoma in situ
Pathologic and mammographic appearance, critical features and prognosis of invasive carcinoma, including invasive ductal carcinoma not otherwise specified, mucinous, medullary, papillary, tubular subtypes, and invasive lobular carcinoma
Other manifestations of breast cancer, such as Paget's disease and inflammatory carcinoma
Histologic grading
Pathologic staging
Multi-focal and multicentral carcinoma
Margin analysis for specimens containing ductal carcinoma In Situ.
Mammographic equipment and technique
Features of mammographic equipment units including target, filtration, automatic exposure control, and grids
Equipment requirements for American College of Radiology accreditation and Mammography Quality Standards Act (MQSA) certification
Familiarity with American College of Radiology recommended specifications for new mammography equipment
Characteristics of mammographic film screen systems
Positioning technique for cranio-caudal and medio-lateral oblique views
View box criteria for assessment of positioning, compression, exposure, contrast, sharpness, and noise
Rationale for breast compression
Selection of technical factors, including effects of milliampere seconds (MAs), Kilovolt peak (kVp) and density settings on image quality
Film processing
Factors affecting exposure contrast, noise, and sharpness
Need for dedicated high intensity view boxes, view box masking, and magnifying glass
Standardized labeling of images
Mammography quality control
Purpose and frequency of performance of those quality control tests performed by technologist including phantom images and processor sensitometry
Appearance and causes of artifacts, such as roller marks, grid lines, motion sharpness, dust, poor screen-film contact, pickoff, and scratches
Requirements and standards for American College of Radiology Mammography Accreditation and the Food and Drug Administration MQSA certification
Familiarity with the American College of Radiology mammography quality control manual
Mammographic interpretation
Normal mammographic anatomy and parenchymal patterns
Mammographic features of typically benign calcifications, such as those caused by sclerosing adenosis, fibroadenoma, fat necrosis, secretory disease, sebaceous gland calcification, dystrophic calcification
Mammographic features of calcification of intermediate concern and those having a higher probability of malignancy
Significance of distribution of calcifications
Mammographic features of benign masses and densities, such as asymmetric breast tissue, radial scar, hematoma, abscess, cysts, fibroadenoma, intramammary lymph node, hormonal replacement therapy, phylloides tumor, hamartoma, gynecomastia, lipoma, fat necrosis, edema, ductal ectasia, intracystic papilloma, and Mondor's disease
Mammographic appearance of malignant masses, densities and architectural distortion caused by In Situ and invasive ductal carcinoma, invasive lobular carcinoma, and metastases to the breast
Knowledge of the ACR BI-RADS - lexicon
Problem solving mammography
ACR Practice standard for the performance of diagnostic mammography
Technique, value, and indications for supplementary mammographic views, such as tangential, 90 degree medio-lateral, spot compression, exaggerated rotated cranio-caudal, cleavage; blind areas of the breast
Technique for documentation of clustered skin calcifications
Criteria and methods for distinguishing focal asymmetric densities, asymmetric breast tissue, and breast masses
Technique for evaluation of implants, breast parenchyma, and implant leakage
Masses: criteria and methods for assessment by mammography and sonography: likelihood of malignancy
Calcification: criteria for mammographic assessment
Magnification mammography: advantages and disadvantages, technique, does, and indications
Localization of lesions seen out only one view; triangulation
Criteria for biopsy and follow up of masses: calcifications, and soft tissue densities
Ability to perform breast physical examination
Evaluation and management of a palpable mass with no mammographic findings
Breast ultrasound
Equipment and physical principles
Technique
Hands-on experience
Indications
Normal sonographic anatomy
Features of cysts
Differential features of benign and malignant solid masses
Limitations: detection and differentiation of microcalcifications: screening
Need for correlation with mammography
Criteria and reliability for evaluation of implant rupture
ACR standard for the Performance of Breast Ultrasound
Interventional procedures
Principles, indications, and contra-indications, equipment, technique, advantages, disadvantages, accuracy, preparations, and follow up for the following:
Needle wire localization
Stereotactic core biopsy and fine needle aspiration
Ultrasound guided core biopsy and FNA; importance of correlation of pathologic, mammographic, and sonographic findings and history in determining patient management (the resident to does not necessarily need to know how to perform a stereotactic or ultrasound guided core biopsy)
Mammographic and sonographic guided cyst aspiration
Galactography
Specimen radiography, including paraffin block radiography
Pneumocystography
ACR standard for the performance of stereotactically guided breasts interventional procedures
ACR standard for the performance of ultrasound guided percutaneous breast interventional procedures
ACR image guided breast biopsy accreditation program
Mammographic reporting and medical legal aspects of mammography
American college of radiology BI-RADS terms for the following:
Mass: shape, margins, and density
Typically benign, intermediate concern, and higher probability of malignancy calcifications
Distribution modifiers for calcification
Associated findings
Lesion location
Categorization of breast composition
Final assessment categories
Medical legal aspects of screening, problem solving mammography, and interventional procedures
Screening mammography
ACR practice standards for screening mammography
Knowledge of practical aspects of performance and interpretation of screening mammography
Mammographic audit: definition and desirable goals for positive predictive value, percentage stage at the zero or stage one tumors,% minimal carcinomas,% note positivity, prevalent and incident cancer rates, recall rates, sensitivity, specificity, and false negative rate
Relative efficacy of physical examination, breast self examination, and mammography
Screening theory: lead time bias, length bias, selection bias, survival rates,
prevalence versus incidence screening, definition of lead time, and interval cancer
rate
Value of double reading
Radiation risk versus screening benefit
Cost effectiveness screening
Randomized clinical trials, case control studies, and follow-up studies: purpose, methods, and results
Controversies regarding screening women aged 40 to 49 years
Screening guidelines of the American College of Radiology, American Cancer Society, National Cancer Institute
Breast MRI
Indications
Technique
Characteristics of benign and malignant breast masses
Implant rupture
Therapeutic considerations
Role of breast imaging in selection and monitoring of breast cancer treatment and post treatment follow up
Basic understanding of breast cancer treatment options
ACR standard for diagnosis and management of Invasive Breast Carcinoma therapy
ACR standard for diagnosis and management of Ductal Carcinoma In Situ
Patient management principles
Patient interaction and communication
Informed consent for invasive procedures
Follow up procedures for positive findings
Yearly educational objectives
In light of the six general core competencies, as outlined by the ACGME and developed in depth by the APDR Education Committee, the following yearly curricula, including skill, education, and assessment tools are described.
During each rotation, a resident is expected to:
Arrive by 8:00 am for work
May leave at 11:40 AM for noon conference
Is expected back by 1:30 PM from conference
Call the breast center for changes in your schedule
Add a new case to the teaching file each week
All procedures performed primarily by the resident should be recorded in a procedure log, which will be reviewed at the end of the rotation
Attend the Friday AM Breast conference at 7:30 AM at the Anatomic Pathology conference room
All diagnostic mammograms and U/S should be dictated before leaving
Patient Care
Skills
Gather clinical and radiological data on patients with breast lesions
Develop diagnostic plan based on the clinical presentation and prior imaging
Oversee customized breast imaging workups
Counsel patients concerning exam preparations
Demonstrate basic knowledge of IDX-RAD and UHIS
Perform exams responsibly and safely, assuring that the correct exam is ordered and performed.
Demonstrate exam specific radiation doses and ALARA
Demonstrate the ability to use the Internet as an educational instrument
Education
Active participation with faculty in patient workup
Participation in Journal Club
Radiation safety lectures (T. Button, Ph.D.)
Preparation of cases for Multi-disciplinary Conference
Graduated responsibility in performing radiologic procedures
Assessment
Global ratings by faculty
Procedure Log
Medical Knowledge
Skills
Demonstrate sufficient knowledge of medicine and its proper application to generate meaningful differential diagnoses
Demonstrate progress during subsequent rotations
Demonstrate understanding of the principles of research project design and implementation
Demonstrate a clinically appropriate diagnostic treatment plan
Demonstrate the ability to use all relevant information resources to acquire evidence based data
Demonstrate the proper use of radiological equipment
Education
Required Reading:
(FIRST ROTATION)
Cardenosa, Breast Imaging Companion, Second Edition
(SECOND ROTATION)
Dershaw, et al, Breast Imaging
(THIRD ROTATION)
Tabar, Breast Pathology
Didactic lecture series (24 over two years)
Participation in case conferences (noon)
Participation in the clinical activities of the Breast Imaging Section
Assessment
Global ratings by faculty
Written examination based on required reading and curriculum
ACR in-training examination
Written ABR exam
Oral ABR exam
Raphex physics exam
Interpersonal and Communication
Skills
Provide a clear report based on BIRADS lexicon
Provide direct communication to referring physicians, and documenting communication in report
Demonstrate skills in obtaining informed consent, including effective communication to patients of the procedure, alternatives, and possible complications
Demonstrate the verbal and non-verbal skills necessary for face to face listening and speaking to physicians, families, and support personnel
Education
Participation as an active member of the radiology team by communicating with clinicians face to face, providing consults, answering phones, problem solving and decision-making
Act as contact person for technologists and nurses in managing patient and imaging issues
Practical experience in dictating radiological reports
Participation in weekly Breast Multi-disciplinary conference
Assessment
Global ratings by faculty
ABR Oral exam
If needed, record review
Professionalism Skills
Demonstrate altruism
Demonstrate compassion (be understanding and respectful of patient, their families, and medical colleagues)
Demonstrate excellence: perform responsibilities at the highest level and continue active learning throughout one's career
Demonstrate honesty with patients and staff
Demonstrate honor and integrity: avoid conflict of interests whenaccepting gifts from patients and vendors
Demonstrate sensitivity without prejudice on the basis of religious, ethnic, sexual or educational differences, and without employing sexual or other types of harassment
Demonstrate knowledge of issues of impairment
Demonstrate positive work habits, including punctuality and professional appearance
Demonstrate the broad principles of biomedical ethics
Demonstrate principles of confidentiality with all information transmitted during a patient encounter
Education
Discussion of above issues during daily clinical work
Training programs and/or videotapes on harassment and discrimination
Didactic presentations on "the impaired physician"
Participation in hospital based educational activities
Assessment
Global ratings by faculty
ABR written exam
Practice Based Learning and Improvement
Skills
Analyze and develop improvement plans in the clinical practice, including knowledge, observation, and procedural skills
Demonstrate knowledge of and apply the principles of evidence-based medicine in practice
Demonstrate critical assessment of the scientific literature
Help teaching of medical students, peers and other health care professionals
Education
Participate in Journal club, clinical conferences, and independent learning
Active participation in MQSA directed mammographic audit and QC
Assessment
Global ratings by faculty
ACR in-service exam
ABR written exam
Systems Based Practice
Skills
Demonstrate ability to design cost-effective care plans
Demonstrate knowledge of funding sources
Demonstrate knowledge of reimbursement methods
Demonstrate knowledge of the regulatory environment
Demonstrate knowledge of basic management principles such as budgeting, record keeping, medical records, and the recruitment, hiring, supervision and management of staff
Education
Review of literature, including ACR Appropriateness Criteria
Attendance and participation in multi-disciplinary conference
Interaction with department administrators
Membership and participation in local and national radiological societies
Assessment
Global ratings by faculty
ABR written exam
ACR in-training exam
Documented membership in societies
First and Second Year radiology residents
The following sections of the curriculum should be mastered during the first rotation in the Breast Imaging Section:
Epidemiology
Breast Anatomy, Pathology, and Physiology
How to hang mammograms
How to perform simple breast U/S
Mammographic equipment and technique
Mammographic interpretation
Problem solving mammography
Breast ultrasound
Screening mammography
How to perform diagnostic breast U/S
How to pre-dictate screening mammograms
How to manage a diagnostic workup
Third year radiology residents
Mammographic equipment and techniques
Mammographic reporting and medical legal aspects of mammography
Patient management principles
How to perform needle localizations
How to perform U/S guided cyst aspirations
How to perform U/S guided needle localizations
Fourth year radiology residents
Mammographic quality control
Interventional procedures
Breast MRI
Therapeutic Consideration
How to perform U/S guided FNA
How to perform galactograms
How to perform pneumocystograms
Fourth year elective in mammography
How to interpret breast MRI
How to perform stereotactic core biopsy
How to perform U/S guided core biopsy
