Louisiana State University Health Sciences Center – Shreveport Radiology Residency Program

Breast Imaging Curriculum, Goals and Objectives

The Breast Imaging resident will cover all breast cases at LSU Health Sciences Center including the Feist-Wieller Cancer Center. The workday is generally 07:30 a.m. – 4:00 p.m. The resident is expected to attend the 07:30 a.m. morning conference, and then report to the Breast imaging area. If a procedure is scheduled, the resident may leave morning conference early to participate. The resident will be allowed to leave in the late morning to get their lunch and attend the noon conference.

During each rotation, the resident is expected to:- Be back by 1:30 PM after the noon conference.- Call the breast center at 3-1327 for any 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- Prepare for and attend the weekly Breast Tumor Board at 1:00 PM on Thursdays

in the Tiger Room at the Cancer Center.- All diagnostic mammograms and U/S should be dictated before leaving, after reviewing with the staff attending.

General Goals and Objectives for ALL:

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.

Rotation Description:

In accordance with the ACR requirements, on the last day of the rotation, the educational goals will be reviewed with the resident orally and in writing with documentation placed in the resident’s file.

Assessment/Evaluation of Residents

1) Electronic evaluation by attending faculty each month after the rotation and Written evaluation every 6 Months with the Program Director

2) ACR in-training examination

3) ABR Core Exam

Expectations/Goals and Objectives of the Residents Assigned to Breast Imaging Using the 6 General Competencies Based on Level of Training

Patient Care

Expectations of Residents' First Rotation at LSUHSC-S (PGY 2/3):

1) Understand the difference between screening and diagnostic mammograms and the appropriate use/indications of screening versus diagnostic evaluation.

2) Demonstrate knowledge of and ability to use electronic patient information systems, including the radiology information system and appropriate use of electronic systems to obtain patient laboratory data, etc., to integrate with imaging findings to assist in an accurate diagnosis.

3) Understand the indications for each imaging examination performed and the specific indications for any examination performed on an individual patient.

4) Technical aspects of breast imaging should be understood and the ability to design a specific protocol to address the clinical question at hand should be mastered.

5) Demonstrate the ability to use the Internet as a tool for teaching and learning including access to information to improve knowledge in patient care situations.

Expectations of Residents' Second and Third Rotations at LSUHSC-S (PGY 4/5):

1) All of the objectives listed for first year rotation residents should be reviewed with increased mastery.

Assessment/Evaluation of Residents

2) Demonstrate knowledge of the levels of ionizing radiation related to specific imaging procedures. With knowledge of levels of ionizing radiation related to specific imaging procedures, employ measures to minimize radiation dose to the patient.

3) Demonstrate ability to integrate laboratory findings and other clinical parameters in recommending appropriate patient specific imaging strategies for diagnostic purposes.

4) Be able to run the breast imaging service with less direction from attending staff.

5) The resident should become a resource to medical students and junior residents in achieving the above objectives.

6) Increased emphasis should be placed on integration of Mammography with other clinical imaging, (MRI, Ultrasound, etc.) and laboratory findings in arriving at as specific a diagnosis as possible.

7) Increased familiarity with the spectrum of breast imaging procedures, performance, and interpretation should be demonstrated.

Medical Knowledge

Expectations of Residents' First Rotation at LSUHSC-S (PGY 2/3):

1) Be able to differentiate the proper indications for a screening versus a diagnostic mammogram and have a general understanding of the indications for breast ultrasound, breast MRI, and breast biopsy.

2) Accurately assess films for quality and know, in general, what to do to correct technical difficulties.

3) Detect abnormalities on screening examinations.

4) Accurately use the American College of Radiology lexicon terminology to describe abnormalities.

5) Know the basic anatomy of the breast on mammography and ultrasound, as well as begin to develop an understanding of the pathologic basis for breast disease.

6) Perform breast ultrasound.

7) Begin to learn the diagnostic work-up of breast disease.

8) Begin to learn interventional breast procedures.

9) Understand and participate in the auditing process of a breast practice.

10) Knowledge associated with these objectives should be demonstrated through teaching to referring clinicians, medical students, and junior residents.

11) Participate in the monthly Journal Club and the Radiation safety lectures (C. Killgore, DABR)

Expectations of Residents' Second and Third Rotations at LSUHSC-S (PGY 4/5):

1) Review, re-reinforce, and master the above junior level skills.

2) Appropriately and confidently handle diagnostic cases.

3) Know the indications for breast biopsy (including the best type of biopsy for a particular case i.e. ultrasound, stereotactic, needle localization/excisional biopsy).

4) Be confident and accurate in performing interventional breast procedures, including needle localizations (mammographic and ultrasound guided), core biopsies, fine needle aspirations, and galactrograms.

5) Better understand and actively participate in the auditing process of a breast practice.

6) Increase the understanding of physics, anatomy, and pathology as they relate to breast disease.

Assessment of Achievement of These Goals:

1) Daily review of cases with the attending physicians.

2) Review of teaching files with the attending physicians.

3) End of rotation verbal and written assessment by the attending physicians.

Interpersonal and Communication Skills

Expectations of Residents' First Rotation at LSUHSC-S (PGY 2/3):

1) Work to structure written reports of imaging studies to accurately and effectively transmit results and recommendations to referring clinicians.

2) Work with attending staff to develop techniques for effective oral communication with patients, referring clinicians, and support personnel in radiology.

3) Demonstrate appropriate phone communication skills.

Expectations of Residents' Second and Third Rotations at LSUHSC-S (PGY 4/5):

1) All of the objectives listed for first year residents should be reviewed with increased mastery demonstrated.

2) Demonstrate increased skill in the ability to communicate clearly and concisely communicating via the radiology written report.

3) Demonstrate a leadership role in communications/interactions with technical personnel and patients, including explanation of delays related to emergencies.

4) Demonstration of the knowledge associated with these objectives should be demonstrated with teaching to medical students and junior residents.

Professionalism

Expectations of Residents' First Rotation at LSUHSC-S (PGY 2/3):

1) Demonstrate compassion, honesty and ability to provide care/interact with others without regard to religion, ethnic, sexual, or educational differences and without employing sexual or other types of harassment.

2) Demonstrate understanding of the principles of patient confidentiality by compliance with the HIPAA Privacy Rule.

3) Demonstrate completion of medical records, including review/signoff of radiology reports, according to departmental/hospital guidelines.

4) Demonstrate positive work habits, including punctuality and professional appearance.

5) Demonstrate honesty with patients and all members of the health care team.

Expectations of Residents' Second and Third Rotations at LSUHSC-S (PGY 4/5):

1) All of the objectives listed for residents' first rotation should be reviewed with increased mastery.

2) Demonstrate altruism (putting the interests of patients and others above own self-interest).

3) The resident should teach the above objectives to medical students and junior residents directly, as well as by modeling behavior consistent with these objectives.

Practice-Based Learning and Improvement

Expectations of Residents' First Rotation at LSUHSC-S (PGY 2/3):

1) Analyze practice experience and perform practice-based improvement in cognitive knowledge, observational skills, formulating a synthesis and impression, and procedural skills. Demonstrate this by active review and performance modification related to on-call discrepancies and active participation in morbidity and mortality/ misses conferences.

2) Demonstrate use of multiple sources, including information technology, to optimize life long learning and support patient care decisions.

3) Demonstrate knowledge of and apply the principles of evidence-based medicine in practice

4) Demonstrate critical assessment of the scientific literature

Expectations of Residents' Second and Third Rotations at LSUHSC-S (PGY 4/5):

1) All of the objectives listed for first rotation should be reviewed with increased mastery.

2) Demonstrate knowledge of the above objectives by supervision of medical students and junior residents, as well as by directly teaching these objectives.

Systems-Based Practice

Expectations of Residents' First Rotation at LSUHSC-S (PGY 2/3):

1) Begin to acquire knowledge regarding the costs of imaging studies and impact of costs on appropriate choices for clinical use.

2) Demonstrate knowledge of funding sources

3) Demonstrate knowledge of reimbursement methods

4) Demonstrate knowledge of the regulatory environment

5) Demonstrate knowledge of basic management principles such as budgeting, record keeping, medical records, and the recruitment, hiring, supervision and management of staff

Expectations of Residents' Second and Third Rotations at LSUHSC-S (PGY 4/5):

1) All of the objectives listed for first rotation residents should be reviewed with increased mastery.

2) Demonstrate the ability to design cost-effective imaging strategies/care plans based on knowledge of best practices.

3) Demonstrate knowledge of hospital-based systems that effect physician practice, including physician code of ethics, medical staff bylaws, quality assurance committees, and credentialing processes. This includes knowledge of how these processes may affect the scope of practice of any one physician and competition among practitioners.

4) Demonstrate knowledge of how decisions about timing/availability of imaging studies may affect hospital length of stay, referral patterns for specific examinations, and use of diagnostic studies outside the Department of Radiology.

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.

Breast Imaging Curriculum

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 digital mammographic systems including tomosynthesis

Positioning technique for cranio-caudal and medio-lateral oblique views

Monitor 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

Factors affecting exposure contrast, noise, and sharpness

Need for dedicated high intensity monitors

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

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 and Savi Scout needle localization

Stereotactic core biopsy and fine needle aspirationUltrasound guided core biopsy and FNA; importance of correlation of pathologic, mammographic, and sonographic findings and history in determining patient management

Mammographic and sonographic guided cyst aspiration

Ductography

Specimen radiography

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

The following sections of the curriculum should be mastered during the First Rotation in the Breast Imaging Section:

EpidemiologyBreast Anatomy, Pathology, and Physiology

How to perform simple breast U/SMammographic equipment and techniqueMammographic interpretationProblem solving mammographyBreast ultrasoundScreening mammography

How to perform diagnostic breast U/SHow to dictate screening mammogramsHow to manage a diagnostic workup

Second Rotation:

Mammographic equipment and techniquesMammographic reporting and medical legal aspects of mammographyPatient management principles

How to perform needle/ Savi scout localizationsHow to perform U/S guided cyst aspirationHow to perform U/S guided needle localizations

Third (and subsequent) Rotations:

Mammographic quality controlInterventional proceduresBreast MRITherapeutic Consideration

How to perform U/S guided Core BiopsyHow to perform ductograms

Fourth year elective in mammography:

How to interpret breast MRIHow to perform stereotactic core biopsyHow to perform U/S guided core biopsy

BREAST IMAGING SUGGESTED READING:

1) ACR Breast Imaging Reporting and Data System, 5th edition. 2013.

2) Cardenosa, Gilda: Breast Imaging Comparison, 2nd edition. 2001. (First Rotation)

3) Ikeda, Debra M.: The Requisites. Breast Imaging, 2004.

4) Morris, Elizabeth A. and Laura Liberman: Breast MRI, 2005.

5) ACR Interpretive Skills Assessment – Mammography 1 and 2, 2001.

6) Tabar, Dean: Teaching Atlas of Mammography, 2001.

7) Shaw de Paredes, Atlas of Film-Screen Mammography, Second Edition, 1992

8) Dershaw, et al, Breast Imaging (Second Rotation)

9) Tabar, Breast Pathology (Third Rotation)

Association of Program Directors in Radiology (www.apdr.org)

AdHoc Committee on Resident and Fellow Education of the Society of Breast Imaging

University of Colorado Radiology Residency

Stony Brook University Radiology Residency

Epidemiology, anatomy, pathology and physiology

References:

Breast Imaging Core Lectures

1 2

Mammographic equipment, technique and quality control

3

Mammographic interpretation

4

The screening mammogram

5

Problem solving mammography

6

Breast ultrasound

7

Interventional procedures

8

Mammographic reports

9

Medico legal aspects

10

MRI

11

Therapeutic considerations

12

Patient management

13

Breast Tomosynthesis (3D Mammography)