LouisianaStateUniversityHealthSciencesCenter – 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.
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.
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 ofResidents' 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 AmericanCollege 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 therecruitment, 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.
Mammographic equipment and technique
Features of mammographic equipment units including target, filtration, automatic exposure control, and grids
Equipment requirements for AmericanCollege of Radiology accreditation and Mammography Quality Standards Act (MQSA) certification
Familiarity with AmericanCollege 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 sclerosingadenosis, 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 aspiration
Ultrasound 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 AmericanCollege 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 posttreatment follow up
Basic understanding of breast cancer treatment options