Comparison of prone and upright, stereotactic, and tomosynthesis-guided biopsies with secondary analysis of ultrasound-occult architectural distortions.

OBJECTIVES: Compare prone and upright, stereotactic, and tomosynthesis-guided vacuum-assisted breast biopsies (prone DM-VABB, prone DBT-VABB, upright DM-VABB, and upright DBT-VABB) in a community-practice setting and review outcomes of ultrasound-occult architectural distortions (AD). METHODS: Consecutive biopsies performed at two community-based breast centers from 2016 to 2019 were retrospectively reviewed. Technical details of each procedure and patient outcomes were recorded. Separate analyses were performed for ultrasound-occult ADs. Two sample t-tests and Fisher's exact test facilitated comparisons. RESULTS: A total of 1133 patients underwent 369 prone DM-VABB, 324 prone DBT-VABB, 437 upright DM-VABB, and 123 upright DBT-VABB with 99.2%, 100%, 99.3%, and 99.2% success, respectively (p-values > 0.25). Mean lesion targeting times were greater for prone biopsy (minutes: 6.94 prone DM-VABB, 8.54 prone DBT-VABB, 5.52 upright DM-VABB, and 5.51 upright DBT-VABB; p-values < 0.001), yielding longer total prone procedure times for prone biopsy (p < 0.001). Compared to DM-VABB, DBT-VABB used fewer exposures (p < 0.001) and more commonly targeted AD, asymmetries, or masses (p < 0.001). Malignancy rates were similar between procedures: prone DM-VABB 22.4%, prone DBT-VABB 21.9%, upright DM-VABB 22.8%, and upright DBT-VABB 17.2% (p-values > 0.19). One hundred forty of the 1133 patients underwent 145 biopsies for ultrasound-occult AD (143 DBT-VABB and 2 DM-VABB). Biopsy yielded 27 malignancies and 47 high-risk lesions (74 of 145, 51%). Malignancy rate was 20.7% after surgical upgrade of one benign-discordant and two high-risk lesions. CONCLUSIONS: All biopsy procedure types were extremely successful. The 20.7% malignancy rate for ultrasound-occult AD confirms a management recommendation for tissue diagnosis. Upright biopsy was faster than prone biopsy, and DBT-VABB used fewer exposures than DM-VABB. CLINICAL RELEVANCE: Our results highlight important differences between prone DM-VABB, prone DBT-VABB, upright DM-VABB, and upright DBT-VABB. Moreover, the high likelihood of malignancy for ultrasound-occult AD will provide confidence in recommending tissue diagnosis in lieu of observation or clinical follow-up. KEY POINTS: • Upright and prone stereotactic and tomosynthesis-guided breast biopsies were safe and effective in the community-practice setting. • The malignancy rate for ultrasound-occult architectural distortion of 20.7% confirms the management recommendation for biopsy. • Upright procedures were faster than prone procedures, and tomosynthesis-guided biopsy used fewer exposures than stereotactic biopsy.

Axillary Nodal Metastases in Invasive Lobular Carcinoma Versus Invasive Ductal Carcinoma: Comparison of Node Detection and Morphology by Ultrasound.

BACKGROUND. Invasive lobular carcinoma is more subtle on imaging compared with invasive ductal carcinoma; nodal metastases may also differ on imaging between these two. OBJECTIVE. The purpose of this study was to determine whether invasive lobular carcinoma and invasive ductal carcinoma differ in the detection rate by ultrasound (US) of metastatic axillary nodes and in the metastatic nodes' US characteristics. METHODS. This retrospective study included 695 women (median age, 53 years) who had breast cancer in a total of 723 breasts (76 lobular, 586 ductal, 61 mixed ductal and lobular histology) with biopsy-proven axillary nodal metastases and who underwent pretreatment US. A single breast radiologist reviewed US images in patients with suspicious nodes on US and classified number of nodes, size, and morphology. Morphologic assessment used a previously described classification according to the relationship between node cortex and hilum. Nodal findings were compared between lobular and ductal carcinoma. A second radiologist independently classified node morphology in 241 cancers to assess interreader agreement. RESULTS. A total of 99 metastatic axillary nodes (15 lobular, 66 ductal, 18 mixed histology) were not visualized on US and were diagnosed by surgical biopsy. The remaining 624 metastatic nodes (61 lobular, 520 ductal, 43 mixed ductal and lobular histology) were visualized on US and diagnosed by US-guided fine-needle aspiration. US detected the metastatic nodes in 80.3% for lobular carcinoma versus 88.7% for ductal carcinoma (p = .04). Among metastatic nodes detected by US, retrospective review identified three or more abnormal nodes in 50.8% of lobular carcinoma versus 69.2% of ductal carcinoma (p = .003); node size was 2.0 cm or smaller in 65.6% for lobular carcinoma versus 47.3% for ductal carcinoma (p = .03); morphology was type III or IV (diffuse cortical thickening without hilar mass effect) rather than type V or VI (marked cortical thickening with hilar mass effect) in 68.9% for lobular carcinoma versus 28.8% for ductal carcinoma (p < .001). Interreader agreement assessment for morphology exhibited a kappa coefficient of 0.63 (95% CI, 0.54-0.73). CONCLUSION. US detects a lower percentage of nodal metastases in lobular than in ductal carcinoma. Nodal metastases in lobular carcinoma more commonly show diffuse cortical thickening and with less hilar mass effect. CLINICAL IMPACT. A lower threshold may be warranted to recommend biopsy of suspicious axillary nodes detected on US in patients with lobular carcinoma.

The first BGICC consensus and recommendations for breast cancer awareness, early detection and risk reduction in low- and middle-income countries and the MENA region.

In low-middle income countries (LMICs) and the Middle East and North Africa (MENA) region, there is an unmet need to establish and improve breast cancer (BC) awareness, early diagnosis and risk reduction programs. During the 12th Breast, Gynecological & Immuno-oncology International Cancer Conference - Egypt 2020, 26 experts from 7 countries worldwide voted to establish the first consensus for BC awareness, early detection and risk reduction in LMICs/MENA region. The panel advised that there is an extreme necessity for a well-developed BC data registries and prospective clinical studies that address alternative modalities/modified BC screening programs in areas of limited resources. The most important recommendations of the panel were: (a) BC awareness campaigns should be promoted to public and all adult age groups; (b) early detection programs should combine geographically distributed mammographic facilities with clinical breast examination (CBE); (c) breast awareness should be encouraged; and (d) intensive surveillance and chemoprevention strategies should be fostered for high-risk women. The panel defined some areas for future clinical research, which included the role of CBE and breast self-examination as an alternative to radiological screening in areas of limited resources, the interval and methodology of BC surveillance in women with increased risk of BC and the use of low dose tamoxifen in BC risk reduction. In LMICs/MENA region, BC awareness and early detection campaigns should take into consideration the specific disease criteria and the socioeconomic status of the target population. The statements with no consensus reached should serve as potential catalyst for future clinical research.

Tumor necrosis by pretreatment breast MRI: association with neoadjuvant systemic therapy (NAST) response in triple-negative breast cancer (TNBC).

PURPOSE: To determine if tumor necrosis by pretreatment breast MRI and its quantitative imaging characteristics are associated with response to NAST in TNBC. METHODS: This retrospective study included 85 TNBC patients (mean age 51.8 ± 13 years) with MRI before NAST and definitive surgery during 2010-2018. Each MRI included T2-weighted, diffusion-weighted (DWI), and dynamic contrast-enhanced (DCE) imaging. For each index carcinoma, total tumor volume including necrosis (TTV), excluding necrosis (TV), and the necrosis-only volume (NV) were segmented on early-phase DCE subtractions and DWI images. NV and %NV were calculated. Percent enhancement on early and late phases of DCE and apparent diffusion coefficient were extracted from TTV, TV, and NV. Association between necrosis with pathological complete response (pCR) was assessed using odds ratio (OR). Multivariable analysis was used to evaluate the prognostic value of necrosis with T stage and nodal status at staging. Mann-Whitney U tests and area under the curve (AUC) were used to assess performance of imaging metrics for discriminating pCR vs non-pCR. RESULTS: Of 39 patients (46%) with necrosis, 17 had pCR and 22 did not. Necrosis was not associated with pCR (OR, 0.995; 95% confidence interval [CI] 0.4-2.3) and was not an independent prognostic factor when combined with T stage and nodal status at staging (P = 0.46). None of the imaging metrics differed significantly between pCR and non-pCR in patients with necrosis (AUC < 0.6 and P > 0.40). CONCLUSION: No significant association was found between necrosis by pretreatment MRI or the quantitative imaging characteristics of tumor necrosis and response to NAST in TNBC.

Functional Tumor Volume by Fast Dynamic Contrast-Enhanced MRI for Predicting Neoadjuvant Systemic Therapy Response in Triple-Negative Breast Cancer.

BACKGROUND: Dynamic contrast-enhanced (DCE) MRI is useful for diagnosis and assessment of treatment response in breast cancer. Fast DCE MRI offers a higher sampling rate of contrast enhancement curves in comparison to conventional DCE MRI, potentially characterizing tumor perfusion kinetics more accurately for measurement of functional tumor volume (FTV) as a predictor of treatment response. PURPOSE: To investigate FTV by fast DCE MRI as a predictor of neoadjuvant systemic therapy (NAST) response in triple-negative breast cancer (TNBC). STUDY TYPE: Prospective. POPULATION/SUBJECTS: Sixty patients with biopsy-confirmed TNBC between December 2016 and September 2020. FIELD STRENGTH/SEQUENCE: A 3.0 T/3D fast spoiled gradient echo-based DCE MRI ASSESSMENT: Patients underwent MRI at baseline and after four cycles (C4) of NAST, followed by definitive surgery. DCE subtraction images were analyzed in consensus by two breast radiologists with 5 (A.H.A.) and 2 (H.S.M.) years of experience. Tumor volumes (TV) were measured on early and late subtractions. Tumors were segmented on 1 and 2.5-minute early phases subtractions and FTV was determined using optimized signal enhancement thresholds. Interpolated enhancement curves from segmented voxels were used to determine optimal early phase timing. STATISTICAL TESTS: Tumor volumes were compared between patients who had a pathologic complete response (pCR) and those who did not using the area under the receiver operating curve (AUC) and Mann-Whitney U test. RESULTS: About 26 of 60 patients (43%) had pCR. FTV at 1 minute after injection at C4 provided the best discrimination between pCR and non-pCR, with AUC (95% confidence interval [CI]) = 0.85 (0.74,0.95) (P < 0.05). The 1-minute timing was optimal for FTV measurements at C4 and for the change between C4 and baseline. TV from the early phase at C4 also yielded a good AUC (95%CI) of 0.82 (0.71,0.93) (P < 0.05). DATA CONCLUSION: FTV and TV measured at 1 minute after injection can predict response to NAST in TNBC. LEVEL OF EVIDENCE: 1 TECHNICAL EFFICACY: 4.

Breast cancer screening in women with and without implants: retrospective study comparing digital mammography to digital mammography combined with digital breast tomosynthesis.

OBJECTIVES: Compare four groups being screened: women without breast implants undergoing digital mammography (DM), women without breast implants undergoing DM with digital breast tomosynthesis (DM/DBT), women with implants undergoing DM, and women with implants undergoing DM/DBT. METHODS: Mammograms from February 2011 to March 2017 were retrospectively reviewed after 13,201 were excluded for a unilateral implant or prior breast cancer. Patients had been allowed to choose between DM and DM/DBT screening. Mammography performance metrics were compared using chi-square tests. RESULTS: Six thousand forty-one women with implants and 91,550 women without implants were included. In mammograms without implants, DM (n = 113,973) and DM/DBT (n = 61,896) yielded recall rates (RRs) of 8.53% and 6.79% (9726/113,973 and 4204/61,896, respectively, p < .001), cancer detection rates per 1000 exams (CDRs) of 3.96 and 5.12 (451/113,973 and 317/61,896, respectively, p = .003), and positive predictive values for recall (PPV1s) of 4.64% and 7.54% (451/9726 and 317/4204, respectively, p < .001), respectively. In mammograms with implants, DM (n = 6815) and DM/DBT (n = 5138) yielded RRs of 5.81% and 4.87% (396/6815 and 250/5138, respectively, p = .158), CDRs of 2.49 and 2.92 (17/6815 and 15/5138, respectively, p > 0.999), and PPV1s of 4.29% and 6.0% (17/396 and 15/250, respectively, p > 0.999), respectively. CONCLUSIONS: DM/DBT significantly improved recall rates, cancer detection rates, and positive predictive values for recall compared to DM alone in women without implants. DM/DBT performance in women with implants trended towards similar improvements, though no metric was statistically significant. KEY POINTS: • Digital mammography with tomosynthesis improved recall rates, cancer detection rates, and positive predictive values for recall compared to digital mammography alone for women without implants. • Digital mammography with tomosynthesis trended towards improving recall rates, cancer detection rates, and positive predictive values for recall compared to digital mammography alone for women with implants, but these trends were not statistically significant - likely related to sample size.

Breast Cancer Skip Metastases: Frequency, Associated Tumor Characteristics, and Role of Staging Nodal Ultrasound in Detection.

BACKGROUND. Staging nodal ultrasound (US) evaluates locations beyond those assessed during routine surgical dissection and has an increasing role in breast cancer management given the growing use of neoadjuvant systemic therapy before surgical staging. OBJECTIVE. The purpose of this study is to identify the patterns of nodal spread of breast cancer observed at staging nodal US and to determine the frequency of skip metastases and associated tumor characteristics. METHODS. This retrospective study included 1269 consecutive patients (31 with bilateral synchronous cancers) who had 1300 newly diagnosed, untreated, invasive breast cancers and underwent US examination of the ipsilateral regional nodal basins from January 2016 through March 2017. Cases with suspicious nodes on US underwent fine-needle aspiration (FNA) biopsy. Cases with benign results on FNA and no suspicious nodes on US underwent sentinel lymph node biopsy. Results of US with FNA were compared with final surgical pathology. Skip metastases were defined as spread across discontiguous nodal levels or distant metastases in the absence of ipsilateral nodal metastases. The incidence and patterns of spread of skip metastases were summarized; associations with tumor characteristics were tested using the Fisher exact test. RESULTS. A total of 591 metastatic cases (45.5%) were confirmed by needle biopsy or sentinel lymph node biopsy, comprising 463 nodal metastases (N+) confirmed by FNA, 121 nodal metastases (N+) confirmed by sentinel lymph node biopsy, and seven distant organ metastases without nodal metastases (N0M1) confirmed by CT-guided biopsy. US with FNA had sensitivity of 86.0%, specificity of 100.0%, PPV of 100.0%, NPV of 89.5%, and accuracy of 93.6%. There were 34 skip metastases, for an incidence of 2.6% (34/1300) (95% CI, 1.8-3.6%) among all invasive cancers and 7.2% (34/470) (95% CI, 5.1-9.9%) among metastatic cancers detected by US and FNA. Skip metastases occurred to axillary level III (n = 4), the supraclavicular nodal basin (n = 21), the contralateral axilla (n = 2), and distant organs (n = 7). Cancers with skip metastases, compared with those with nonskip metastases, had higher rates (p = .005) of lobular histology (23.5% vs 6.7%) and mixed ductal and lobular histology (11.8% vs 6.7%). Skip metastases were not associated with grade, T category, or molecular subtype (p > .05). CONCLUSION. Skip metastases to locations beyond standard surgical axillary dissection occur in 7.2% of metastatic breast cancers. CLINICAL IMPACT. Staging nodal US identifies skip metastases that otherwise would be undetected, helping to achieve more accurate staging and minimize undertreatment.

Imaging Updates to Breast Cancer Lymph Node Management.

Metastatic lymph node involvement in breast cancer is a key determinant of the overall stage of disease and prognosis. Historically, lymph node status was determined by surgery first, with adjuvant treatments determined based on the results of the final surgical pathologic analysis. While this sequence is still applicable in many cases, neoadjuvant systemic treatment (NST) is increasingly being administered as the initial treatment. In cases that demonstrate good therapeutic response to drug therapies, NST may permit the option to perform less radical surgeries subsequently. Current breast cancer treatment has become multidisciplinary, with overlapping roles from the different disciplines. As surgery may be postponed, imaging and image-guided lymph node interventions have gained importance as the primary means of lymph node assessment. Imaging enables evaluation of all regional nodal basins, including locations where surgery is not usually performed. By differentiating limited versus extensive nodal involvement, imaging findings help determine whether initial treatment should be surgical or medical. If medical treatment with NST is indicated, imaging is performed to monitor the in vivo nodal response to drug therapy and ultimately to help determine the surgical technique to perform on the basis of the final imaging findings after NST. The authors discuss the imaging features of nodal metastases and the indications and techniques for the various image-guided procedures. The relative usefulness and shortcomings of the various imaging examinations are reviewed to discuss how they can be applied when biopsy results are not available. The role of imaging in the multidisciplinary team approach is emphasized based on past clinical trials of lymph node management and recent evolving knowledge of breast cancer staging. Online supplemental material is available for this article. ©RSNA, 2021.

Time to development and imaging features of new calcifications in the treated breast after breast-conserving therapy.

OBJECTIVE: The purpose of our study was to analyze the time to development, malignancy rate, location, and mammographic features of new calcifications in the treated breast after breast-conserving therapy (BCT). MATERIALS AND METHODS: In this HIPAA-complaint, IRB-approved retrospective study, we reviewed the records of patients treated with BCT at our institution with breast-conserving surgery performed between January 1, 2009 and December 31, 2010. A total of 735 breasts in 732 women were included in our study cohort. Factors analyzed included rate of development of new calcifications, malignancy rate of new calcifications, the time between completion of radiation therapy and development of new calcifications, imaging features of new calcifications, and location of the new calcifications in relation to the primary malignancy. RESULTS: During follow-up, new calcifications developed in 155 of the 735 treated breasts (21.1%) and 155 of the 732 women (21.2%). After excluding two cases that were lost to follow-up, the malignancy rate of new calcifications was 5.2% (8/153; 95% CI: 2.3% to 10.0%). The median time to development of the benign calcifications was 27 months (range, 2 to 91 months) and of the malignant calcifications was 41 months (range, 11 to 57 months). Of the 20 (13.1%) cases of new calcifications categorized as BI-RADS 3 (probably benign), all were benign on follow-up (19 cases) or on biopsy (1 case). Of the 51 BI-RADS 4 (suspicious) cases, 8 (16%) were biopsy-proven malignant. The malignancy rate was the highest in fine pleomorphic 100% (1/1), followed by amorphous 17%, (5/29), coarse heterogeneous 8% (2/26) and typically benign 0 (0/97) calcifications (p < 0.0001). The malignancy rate was 1.5% (2/137) for new calcifications within the lumpectomy site vs. 37.5% (6/16) for new calcifications outside the lumpectomy site (p < 0.0001) and was 3.4% (5/147) for new calcifications at or within the same quadrant as the lumpectomy site vs. 50.0% (3/6) for new calcifications in a different quadrant from the lumpectomy site (p=0.002). CONCLUSION: Most new calcifications that developed in the treated breast after BCT were benign. Evaluation of morphology and distribution of those calcifications is imperative. New calcifications in the treated breast outside the lumpectomy site are more likely to be malignant and should be viewed with greater suspicion. Benign calcifications developed earlier than malignant calcifications, but the time courses overlapped.

Axillary Nodal Evaluation in Breast Cancer: State of the Art.

Axillary lymph node (LN) metastasis is the most important predictor of overall recurrence and survival in patients with breast cancer, and accurate assessment of axillary LN involvement is an essential component in staging breast cancer. Axillary management in patients with breast cancer has become much less invasive and individualized with the introduction of sentinel LN biopsy (SLNB). Emerging evidence indicates that axillary LN dissection may be avoided in selected patients with node-positive as well as node-negative cancer. Thus, assessment of nodal disease burden to guide multidisciplinary treatment decision making is now considered to be a critical role of axillary imaging and can be achieved with axillary US, MRI, and US-guided biopsy. For the node-positive patients treated with neoadjuvant chemotherapy, restaging of the axilla with US and MRI and targeted axillary dissection in addition to SLNB is highly recommended to minimize the false-negative rate of SLNB. Efforts continue to develop prediction models that incorporate imaging features to predict nodal disease burden and to select proper candidates for SLNB. As methods of axillary nodal evaluation evolve, breast radiologists and surgeons must work closely to maximize the potential role of imaging and to provide the most optimized treatment for patients.

Multiple Bilateral Circumscribed Breast Masses Detected at Imaging: Review of Evidence for Management Recommendations.

OBJECTIVE. Historically, management recommendations for multiple bilateral circumscribed breast masses encountered with breast imaging have varied. This article reviews the evidence and provides best-practice recommendations for managing these masses. CONCLUSION. Meticulous imaging technique and interpretation are required to correctly diagnose multiple bilateral circumscribed breast masses. Radiologists should classify such masses identified at mammography, digital breast tomosynthesis, or bilateral whole-breast sonography as benign and recommend annual follow-up. Elucidating the significance of these masses on MRI, contrast-enhanced mammography, or nuclear breast imaging requires further study.

Digital Breast Tomosynthesis for Intraoperative Margin Assessment during Breast-Conserving Surgery.

BACKGROUND: Intraoperative margin assessment for breast cancer patients undergoing segmental mastectomy (SM) enables identification of positive margins, with immediate excision of additional tissue to obtain negative margins. OBJECTIVE: The aim of this study was to determine the ability of digital breast tomosynthesis (DBT) to detect positive margins compared with an institution's standard extensive processing (SEP). METHODS: SM specimens underwent intraoperative SEP with two-dimensional (2D) imaging of the intact and sliced specimen, with review by a breast radiologist and gross assessment by a breast pathologist. Findings guided the surgeon to excise additional tissue. DBT images of intact specimens were prospectively obtained and retrospectively reviewed by a breast radiologist. A positive margin was defined as tumor at ink. RESULTS: Ninety-eight patients underwent 99 SMs. With SEP, 14 (14%) SM specimens had 19 positive margins. SEP did not detect 3 of the 19 positive margins, for a sensitivity of 84%, specificity of 78%, positive predictive value (PPV) of 11%, and negative predictive value (NPV) of 99%. Moreover, DBT did not detect 5 of the 19 positive margins, for a sensitivity of 74% (p > 0.05), specificity of 91% (p < 0.05), PPV of 21.5%, and NPV of 99%. With SEP guidance to excise additional tissue, six cases had final positive margins, with SEP not identifying three of these cases and DBT not identifying two. Pathology from the second surgery of these patients showed either no additional malignancy or only focal ductal carcinoma in situ. CONCLUSIONS: DBT is an accurate method for detecting positive margins in breast cancer patients undergoing SM, performing similar to institutional labor-intensive, intraoperative standard processing.

Impact of Artificial Intelligence on Women's Imaging: Cost-Benefit Analysis.

OBJECTIVE. The purpose of this article is to identify and discuss four areas in which artificial intelligence (AI) must excel to become clinically viable: performance, time, work flow, and cost. CONCLUSION. AI holds tremendous potential for transforming the practice of radiology, but certain metrics are needed to objectively quantify its impact. As patients, physicians, hospitals, and insurance companies look for value, AI must earn a role in medical imaging.

Reduction of False-Positive Markings on Mammograms: a Retrospective Comparison Study Using an Artificial Intelligence-Based CAD.

The aim was to determine whether an artificial intelligence (AI)-based, computer-aided detection (CAD) software can be used to reduce false positive per image (FPPI) on mammograms as compared to an FDA-approved conventional CAD. A retrospective study was performed on a set of 250 full-field digital mammograms between January 1, 2013, and March 31, 2013, and the number of marked regions of interest of two different systems was compared for sensitivity and specificity in cancer detection. The count of false-positive marks per image (FPPI) of the two systems was also evaluated as well as the number of cases that were completely mark-free. All results showed statistically significant reductions in false marks with the use of AI-CAD vs CAD (confidence interval = 95%) with no reduction in sensitivity. There is an overall 69% reduction in FPPI using the AI-based CAD as compared to CAD, consisting of 83% reduction in FPPI for calcifications and 56% reduction for masses. Almost half (48%) of cases showed no AI-CAD markings while only 17% show no conventional CAD marks. There was a significant reduction in FPPI with AI-CAD as compared to CAD for both masses and calcifications at all tissue densities. A 69% decrease in FPPI could result in a 17% decrease in radiologist reading time per case based on prior literature of CAD reading times. Additionally, decreasing false-positive recalls in screening mammography has many direct social and economic benefits.

Biopsy Feasibility Trial for Breast Cancer Pathologic Complete Response Detection after Neoadjuvant Chemotherapy: Imaging Assessment and Correlation Endpoints.

PURPOSE: This study was designed to present the secondary imaging endpoints of the trial for evaluating mammogram (MMG), ultrasound (US) and image guided biopsy (IGBx) assessment of pathologic complete response (pCR) in breast cancer (BC) patients undergoing neoadjuvant chemotherapy (NAC). METHODS: Patients with T1-3, N0-3, M0 triple-negative or HER2-positive BC who received NAC were enrolled in an Institutional Review Board-approved prospective, clinical trial. Patients underwent US and MMG at baseline and after NAC. Images were evaluated for residual abnormality and to determine modality for IGBx [US-guided (USG) or stereotactic guided (SG)]. Fine-needle aspiration and 9-G, vacuum-assisted core biopsy (VACBx) of tumor bed was performed after NAC and was compared with histopathology at surgery. RESULTS: Forty patients were enrolled. Median age was 50.5 (range 26-76) years; median baseline tumor size was 2.4 cm (range 0.8-6.3) and 1 cm (range 0-5.5) after NAC. Nineteen patients had pCR: 6 (32%) had residual Ca2+ presurgery, 5 (26%) residual mass, 1 (5%) mass with calcifications, and 7 (37%) no residual imaging abnormality. Sensitivity, specificity, and accuracy of US, MMG, and IGBx for pCR were 47/95/73%, 53/90/73%, and 100/95/98%, respectively. Twenty-five (63%) patients had SGBx and 15 (37%) had US-guided biopsy (USGBx). Median number of cores was higher with SGBx (12, range 6-14) than with USGBx (8, range 4-12), p < 0.002. Positive predictive value for pCR was significantly higher for SG VACBx than for USG VACBx (100 vs. 60%, p < 0.05). CONCLUSIONS: SG VACBx is the preferred IGBx modality for identifying patients with pCR for trials testing the safety of eliminating surgery.

Biomarkers and Imaging of Breast Cancer.

OBJECTIVE: The goals of this review are to provide background information on the definitions and applications of the general term "biomarker" and to highlight the specific roles of breast imaging biomarkers in research and clinical breast cancer care. A search was conducted of the main electronic biomedical databases (PubMed, Cochrane, Embase, MEDLINE [Ovid], Scopus, and Web of Science). The search was focused on review literature in general radiology and biomedical sciences and on reviews and primary research articles on biomarkers in breast imaging over the 15 years ending in June 2017. The keywords included "biomarker," "trial endpoints," "breast imaging," "breast cancer," "radiomics," and "precision medicine" in the titles and abstracts of the papers. CONCLUSION: Clinical breast care and breast cancer-related research rely on imaging biomarkers for decision support. In the era of precision medicine and big data, the practice of radiology is likely to change. A closer integration of breast imaging with related biomedical fields and the creation of large integrated and shareable databases of clinical, molecular, and imaging biomarkers should allow the field to continue guiding breast cancer care and research.

Screening Mammography Findings From One Standard Projection Only in the Era of Full-Field Digital Mammography and Digital Breast Tomosynthesis.

OBJECTIVE: The purpose of this article is to compare outcomes of findings seen on one view only from screening full-field digital mammography (FFDM) and FFDM plus digital breast tomosynthesis (DBT). MATERIALS AND METHODS: A retrospective review was performed of 103,070 consecutive screening mammograms obtained from February 2011 through June 2014 at two community-based breast centers. Recalled findings prospectively seen on one view only were analyzed. Pearson chi-square test and Fisher exact test were performed, and 95% CIs were determined. RESULTS: Mammograms were acquired using FFDM (n = 71,656) and FFDM-DBT (n = 31,414) during the study period, and 2213 FFDM (3.1%) and 433 FFDM-DBT (1.4%) mammograms were recalled for one-view-only findings (p < 0.0001). The final study population (1592 FFDM and 354 FFDM-DBT) was defined after 689 of these recalled FFDM and 92 of these recalled FFDM-DBT examinations were excluded for insufficient mammographic follow-up (< 24 months). Summation artifacts accounted for more one-view-only findings from FFDM (1067/1592; 67.0%) than FFDM-DBT (190/354; 53.7%) (p < 0.0001). In the FFDM cohort, 28 one-view-only findings proved malignant (24 invasive ductal carcinoma [IDC], one invasive lobular carcinoma [ILC], and three ductal carcinoma in situ [DCIS]). In the FFDM-DBT cohort, 14 one-view-only findings proved malignant (11 IDC, one ILC, and two DCIS). The positive predictive value (PPV) of a one-view-only finding was significantly lower for FFDM (1.8%) than for FFDM-DBT (4.0%) (p = 0.010). CONCLUSION: One-view-only findings occur with both FFDM and FFDM-DBT and remain an important but uncommon sign of malignancy. They are more frequent, are more likely to represent summation artifacts, and have a lower PPV with FFDM than with FFDM-DBT.

Joint relative risks for estrogen receptor-positive breast cancer from a clinical model, polygenic risk score, and sex hormones.

BACKGROUND: Models that predict the risk of estrogen receptor (ER)-positive breast cancers may improve our ability to target chemoprevention. We investigated the contributions of sex hormones to the discrimination of the Breast Cancer Surveillance Consortium (BCSC) risk model and a polygenic risk score comprised of 83 single nucleotide polymorphisms. METHODS: We conducted a nested case-control study of 110 women with ER-positive breast cancers and 214 matched controls within a mammography screening cohort. Participants were postmenopausal and not on hormonal therapy. The associations of estradiol, estrone, testosterone, and sex hormone binding globulin with ER-positive breast cancer were evaluated using conditional logistic regression. We assessed the individual and combined discrimination of estradiol, the BCSC risk score, and polygenic risk score using the area under the receiver operating characteristic curve (AUROC). RESULTS: Of the sex hormones assessed, estradiol (OR 3.64, 95% CI 1.64-8.06 for top vs bottom quartile), and to a lesser degree estrone, was most strongly associated with ER-positive breast cancer in unadjusted analysis. The BCSC risk score (OR 1.32, 95% CI 1.00-1.75 per 1% increase) and polygenic risk score (OR 1.58, 95% CI 1.06-2.36 per standard deviation) were also associated with ER-positive cancers. A model containing the BCSC risk score, polygenic risk score, and estradiol levels showed good discrimination for ER-positive cancers (AUROC 0.72, 95% CI 0.65-0.79), representing a significant improvement over the BCSC risk score (AUROC 0.58, 95% CI 0.50-0.65). CONCLUSION: Adding estradiol and a polygenic risk score to a clinical risk model improves discrimination for postmenopausal ER-positive breast cancers.