What Every Pathologist Should Understand About Breast Imaging

This is Lab Medicine Rounds, a curated podcast for physicians, laboratory professionals and students. I'm your host, Justin Kreiter, a transfusion medicine pathologist and assistant professor of laboratory medicine and pathology at Mayo Clinic. Today we're rounding with Dr. Robert Fazio, assistant professor of radiology and division chair of breast Imaging at Mayo Clinic here in Rochester, Minnesota. Thanks for joining us today, Dr. Fazio. Well, thanks so much Dr. Coyer.

This is, this is fantastic. I've never been part of one of these before and so I'm, I'm looking forward to it. Oh, we're grateful for your time. I think, you know, I, I kind of, this topic came up because I remember fondly when I was in training and learning about kind of doing some breast needle diagnosis and such, like just remembering how important the conversation was with our radiologists. And so I maybe if we could kick things off.

I'm kind of curious from your perspective as a radiologist and,

and really a division chair of breast imaging, why is it important, do you think, for pathologists to understand a few fundamentals of breast imaging? Well, sure, no, I think that's a, that's a great question. Really kind of an open-ended question to get started, and I'd be interested in your thoughts as well, you know, after, after we talk through this a little bit.

But, you know, I think, I think that pathologists really, who understand the basics of our imaging really might be able to arrive at their diagnoses faster and, and with more confidence, you know, particularly if the cases are challenging. I think that both clinical and imaging information really about certain cases can be useful to narrow a differential diagnosis or even provide a more confident diagnosis.

You know, you and I are really both in the fields of, of turning shades of gray into black and white answers, you know, for our clinical colleagues. And I think imaging knowledge really can, can help you make those diagnosis and, and, and make that challenge happen.

I think, you know, ultimately our pathologist understanding of, of imaging fundamentals can aid in kind of the confidence of reporting and also aid in concordance reporting, which is essential for, for treatment planning, particularly in cancer cases. Wow. You know, that really resonates with me

because of Exactly, I, I think about the, the, what's the adage? The, the pot calling the kettle black. Sometimes pathologists, we kind of, you know, put, you know, great information in our comments and sometimes our, our colleagues don't exactly read our, our comments, just look at the, what we call the above the line diagnosis and, and we're saying like, oh, didn't you read our, our report? And I imagine the same thing is, is true in, in radiology.

And so it's probably, yeah, that impetus for having a little bit of fundamental knowledge probably goes a long way. Or sometimes we talk about when is it important to pick up the phone and call. Yeah, abso absolutely. I really, I really actually enjoy reading the comments.

I, I know that when I see an extra comment, you know, below the, the diagnosis, the official diagnosis, I know that, you know, that's a case that that maybe isn't as straightforward and you guys are thinking about, you know, thinking out of the box and doing some different things to make sure that your diagnosis is correct.

Y you know, and if I might ask where, where along in, in your, you know, training and development, did you kind of come to that kind of realization of, of kind of the comments and, and the role that it's playing in the PATH report?

Sure. Prob I, I suspect probably in my fellowship is when, when that sort of hit me a little bit, I think in residency, you know, you're all just, you're just trying to get through the rotations and do your best to, you know, to, to pass the courses and, and, and pass your exams. And in fellowship, you know, you really start becoming part of the team, I think, and you contribute and you provide those contributions.

And so, you know, that's where I kind of learned that, that some of these comments might be even more important than the actual above comment diagnosis.

Hmm. Wow. I think that's so important. You know, thinking about our audience physicians, laboratory professionals and students, this kind of goes to what you're saying, this kind of interprofessional understanding what others on the team are, are doing and how they're contributing. Maybe we can dive into that a little bit. You can kind of, you know, I'm curious, what are a few aspects of breast imaging that, you know, pathologists, it'd be, it'd be really helpful for them to appreciate?

Oh, sure, sure. You know, I, I think, I think there are a few things that are useful. I, I think, I think it can be helpful for pathologists to understand sort of the imaging impression of what we sample. And as this, I think can help narrow the differential in challenging cases.

I, I think it's useful for you guys to know if we're sampling, say, a mass lesion or calcifications or architectural distortion or whatnot, you know, because each of these things have rather unique imaging features and it can steer you down the right pathway when, when you're having challenges as well. I think it's useful for you guys to know our level of suspicion and also which modality we're, we're using for our imaging guidance.

And then finally, I think, I think it's useful for you to know how we performed the biopsy. You know, did we use a spring loaded device? Did we use a vacuum assisted device or did we perform an f n a, you know, for, for example, you know, let's say I see suspicious calcifications on a mammogram and we go on to biopsy those calcifications with vacuum assistance and get good samples, send calcifications.

And in our impression, you know, we say high suspicion calcifications, suspect D C I S, and you see D C I S I mean, that's a slam dunk, right? That's easy. Probably don't need a comment, comment Ab Absolutely. Where those, where those things all, all align. So I guess in the impression that's going

to be in the report, right, like you're saying mass calcs architecture, and you said also that level of suspicion, how, how should we interpret or receive that level of suspicion? Like is it, is that kind of a, a binary or should we really try to see that as a, as a, a shade of gray? I'm kind of thinking about in our world of like cytology, you know, there is kind of specific words that are used in this kind of shade of, of gray and how should we kind of interpret that?

Sure, sure. Well, usually when I send a clinical impression, I'll indicate high intermediate or low Suspicion and then whatever it is that I'm sampling. And, and so I try to, I try to make it a little bit black and white. I don't give high or low, I just high intermediate or low. If I'm pretty confident this is gonna be D C I S for example, and, and I say high suspicion calcifications and you, you report back fibrocystic changes, then you and I need to have a phone conversation probably.

And, and so I, I try to, I try to make it a little bit black and white for you guys as well. Oh, that's helpful. And can you elaborate a little bit on

you, you mentioned that modality is for what type of imaging is used and how that might be helpful for the pathologist to understand. Can you kind of elaborate on what you mean by that? 'cause as an outsider, I'm not sure if I'm really kind of picking up what you're talking about. Oh, absolutely, absolutely. So, you know, the common modalities that we use are mammograms, ultrasound, and M R i. Those are probably the top three.

And so if we're biopsying something with mammogram guidance, and so that would be something like a stereotactic breast biopsy or a tomosynthesis guided breast biopsy. You know, you're, we're we're usually aiming at something that could be D C I S or not. Could it be invasive or microinvasive? Absolutely. But, but when we're doing a, a stereotactic biopsy, we're thinking about D C I S the most. Whereas if we're using ultrasound or m r I guidance, we're probably targeting a mass.

And so that could be invasive malignancy or any of the benign masses that that, that can be diagnosed in the breast. And so that's sort of, that's sort of what I mean by useful to know kind of the modality. Ah, no, that, that's very helpful.

You know, we've been kind of playing around with this idea of kind of this interprofessional collaboration, like you said, in certain situations, you know, we need to have a phone call and, and talk things out. You know, knowing that the, the audience here, we have a lot of pathologists and and lab medicine folks that are listening to this and, and students along the pathway of hopefully playing this, this team sport of medicine.

You know, what are your thoughts on how pathologists could better collaborate with radiologists? And I, I really ask this question 'cause sometimes it's hard to know how do I get started collaborating with an outside group? And so, you know, your insights here are really appreciated. Oh, absolutely. You know, first and foremost, I really do think our collaboration efforts are, are fantastic.

And particularly in the clinical arena, we really are the only subspecialty that works with the breast pathologists that perform concordance reporting on our biopsy samples. I don't think anybody else does that. And so I, I think that our collaboration between our groups really, really facilitates this, the ability to do that. Otherwise, you know, as you mentioned on the clinical side, I think phone conversations are always helpful.

If you guys are con confused about the material that we send, certainly happy to take a conversation or if we can provide any additional, you know, information about what you might be seeing in a challenging case, happy, happy to discuss it at any time. You know, in addition, we're, we're starting our radiology patho pathology concordance conference backup. This is a conference that we run each week.

Our fellows run it, and we like to get as many people there as possible from the multidisciplinary team, but particularly radiologists and pathologists. So to sort of discuss some of the more challenging cases that we biopsied, maybe the week previous covid really kind of hit that conference hard and we sort of, it just sort of went away for about three years. But, but our current fellows are really excited to start it back up and we're, we're starting to do those conferences again.

I, I still remember, you know, some very, very eager pathology fellows that came to those conferences. They, they even bring PowerPoints with slides about, you know, the, the biopsy findings. And it was really, really useful. That was maybe four or five years ago, but you know, that that conference was really beneficial to our trainees and I think to your trainees as well. And we'd love, we'd love for you guys to, to come to those conferences again and I'm, I'm happy to try to facilitate that.

Yeah, that's fantastic and great for our audience to hear, right? 'cause we have a lot of audience outside of Mayo and they might be kind of thinking about how, how is this kind of play out in their own area? Some may have these conferences that are going or some might have some like ours where Covid kind of gave us a little bit of a, a pause and a skip.

I'm kind of curious, you know, there's a lot, because we have our, our student listeners, I'd be curious to kind of just hear your thoughts on, you know, how for these kind of interprofessional conferences, right? That's, that's where like I think you're highlighting some important learning is happening for how your radiology trainees are interacting with pathology trainees, pathology consultants. Are, are there any thoughts you've had over the years

for either, you know, how do you kind of prepare people for going into these environments or are there kind of some common feedbacks that you've given to trainees over the years to learn the most from these sorts of collaborations? Yeah, I mean, I, I think, I think there's a lot of good kind of on the fly discussion at these meetings that that can be beneficial to, to teach the interdisciplinary team about the others fields.

You know, ideally we would have breast pathology fellows rotate with us to visit our procedural practice as well. I, I'm not sure if that's happening right now. I think it has happened in the past. We, we do send our fellows to you and they're very, very complimentary of those weeks just to see, you know, see what they've biopsied under the microscope and, and how that compares to, you know, all of the other breast pathologies out there.

So rotating, I think in the other subspecialty is really helpful. Yeah, I think that's been wonderful.

As I've, you know, talking with our trainees over the years, this idea that they understand kind of the workflow with the other groups so they can understand where sometimes various pressures come up and certainly goes a long way for, you know, if, if you and I have have met in, in real life and shared a laugh or whatnot, like it, it makes it easier to pick up the phone and have those, those critical conversations. Yeah. I also think it's really, really useful.

I mean, if there's an interesting case that, that they can, you know, write up very quickly. I mean, case reports can happen pretty fast and you know, if you have a, a collaborative team on that between two fellows or two residents, I think those are fantastic opportunities. Oh, absolutely.

And you know, I'm grateful that you're highlighting how what might be originally perceived as maybe a clinical practice arena thing, a clinical domain, how it's filling roles in both education as well as the research shield. I I think that's a true statement. Can I maybe close with just kinda asking you, you know,

how might breast imaging change in the, in the coming years? I think a lot of our audience aren't necessarily, you know, don't, don't have your vantage point and perspectives and, and curious what you see in the coming years for breast imaging. Sure, sure. I, I think it's an exciting time to be honest. I, I think that there could be some changes in how screening is performed.

You know, right now everybody gets an annual mammogram starting at age 40 and you know, going into their eighties and nineties and every year they have to attend that mammogram. And you know, we detect a lot of, of tiny cancers on those mammograms now in the future, and people are working on this right now, but I think that there may be opportunities for blood tests as initial screening tools. Patients would get their annual blood test.

Those that are negative would be done for the rest of the year until their next annual test. Those that are positive would end up coming to us to, to get diagnostic imaging rather than a screening mammogram. The other thing I think could be exciting is that there are a lot of developments in M R I right now and abbreviated m r I might be the future of screening as well. It's much more sensitive and specific than mammography is. The trouble with, with m r I really is that the machines cost a lot.

You know, that the exams take a long time to perform. Patients need to have an IV placed with contrast. And so if we can get by some of those things and make the examination shorter to perform, I think that's, I think it has potential for sure. I think AI will be a, a, a factor in helping us provide diagnoses in the future. We're still working to try to figure out the best way to incorporate AI into our practice. You're probably doing the same thing.

I really hope that imaging specificity will improve, which, you know, would decrease really the need for biopsies in many cases. I've thought that this would happen for years and so far it hasn't happened. We do as many biopsies now as we have 10 years ago when, when I started on staff. A couple other things. I think, I think image guided percutaneous therapies like cryoablation has potential to reduce open surgical treatment. I think that has a, a future.

But, you know, having said, having said all that, I I, I do think that image guided biopsies are not going away anytime soon. And so you and I will have many years of collaboration ahead of us. I think I'm really looking forward to that and, and I really appreciate it is really quite an extensive list. You're, you're sharing with our listeners, which I I'm sure for that there's at least something that's kind of planted in every listener's mind in

that list that you mentioned. We've been rounding with Dr. Fazio talking about fundamentals of breast imaging and what pathologists need to know. Thanks for joining us today, Dr. Fazio. Absolutely. Dr. Corder, thanks so much for the invitation. And to all our listeners, thank you for joining us today. We invite you to share your thoughts and suggestions via email to MCL [email protected]. If you've enjoyed this podcast, please subscribe until our next rounds together.

We encourage you to continue to connect lab medicine and the clinical practice through educational conversations.