Training Radiologists to Interpret Contrast-enhanced Mammography: Toward a Standardized Lexicon

Using terms adapted from the BI-RADS Mammography and MRI lexicons, we trained radiologists to interpret contrast-enhanced mammography (CEM) and assessed reliability of their description and assessment.

A 60-minute presentation on CEM and terminology was reviewed independently by 21 breast imaging radiologist observers. For 21 CEM exams with 31 marked findings, observers recorded background parenchymal enhancement (BPE) (minimal, mild, moderate, marked), lesion type (oval/round or irregular mass, or non-mass enhancement), intensity of enhancement (none, weak, medium, strong), enhancement quality (none, homogeneous, heterogeneous, rim), and BI-RADS assessment category (2, 3, 4A, 4B, 4C, 5). "Expert" consensus of 3 other radiologists experienced in CEM was developed. Kappa statistic was used to assess agreement between radiologists and expert consensus, and between radiologists themselves, on imaging feature categories and final assessments. Reproducibility of specific feature descriptors was assessed as fraction of consensus-concordant responses.

Radiologists demonstrated moderate agreement for BPE, (mean kappa, 0.43; range, 0.05-0.69), and lowest reproducibility for "minimal." Agreement was substantial for lesion type (mean kappa, 0.70; range, 0.47-0.93), moderate for intensity of enhancement (mean kappa, 0.57; range, 0.44-0.76), and moderate for enhancement quality (mean kappa, 0.59; range, 0.20-0.78). Agreement on final assessment was fair (mean kappa, 0.26; range, 0.09-0.44), with BI-RADS category 3 the least reproducible. Decision to biopsy (BI-RADS 2-3 vs 4-5) showed moderate agreement with consensus (mean kappa, 0.54; range, -0.06-0.87).

With minimal training, agreement for description of CEM findings by breast imaging radiologists was comparable to other BI-RADS lexicons.