BI-RADS Category Assignments by GPT-3.5, GPT-4, and Google Bard: A Multilanguage Study.

Background The performance of publicly available large language models (LLMs) remains unclear for complex clinical tasks. Purpose To evaluate the agreement between human readers and LLMs for Breast Imaging Reporting and Data System (BI-RADS) categories assigned based on breast imaging reports written in three languages and to assess the impact of discordant category assignments on clinical management. Materials and Methods This retrospective study included reports for women who underwent MRI, mammography, and/or US for breast cancer screening or diagnostic purposes at three referral centers. Reports with findings categorized as BI-RADS 1-5 and written in Italian, English, or Dutch were collected between January 2000 and October 2023. Board-certified breast radiologists and the LLMs GPT-3.5 and GPT-4 (OpenAI) and Bard, now called Gemini (Google), assigned BI-RADS categories using only the findings described by the original radiologists. Agreement between human readers and LLMs for BI-RADS categories was assessed using the Gwet agreement coefficient (AC1 value). Frequencies were calculated for changes in BI-RADS category assignments that would affect clinical management (ie, BI-RADS 0 vs BI-RADS 1 or 2 vs BI-RADS 3 vs BI-RADS 4 or 5) and compared using the McNemar test. Results Across 2400 reports, agreement between the original and reviewing radiologists was almost perfect (AC1 = 0.91), while agreement between the original radiologists and GPT-4, GPT-3.5, and Bard was moderate (AC1 = 0.52, 0.48, and 0.42, respectively). Across human readers and LLMs, differences were observed in the frequency of BI-RADS category upgrades or downgrades that would result in changed clinical management (118 of 2400 [4.9%] for human readers, 611 of 2400 [25.5%] for Bard, 573 of 2400 [23.9%] for GPT-3.5, and 435 of 2400 [18.1%] for GPT-4; P < .001) and that would negatively impact clinical management (37 of 2400 [1.5%] for human readers, 435 of 2400 [18.1%] for Bard, 344 of 2400 [14.3%] for GPT-3.5, and 255 of 2400 [10.6%] for GPT-4; P < .001). Conclusion LLMs achieved moderate agreement with human reader-assigned BI-RADS categories across reports written in three languages but also yielded a high percentage of discordant BI-RADS categories that would negatively impact clinical management. © RSNA, 2024 Supplemental material is available for this article.

Current use and future perspectives of contrast-enhanced mammography (CEM): a survey by the European Society of Breast Imaging (EUSOBI).

OBJECTIVES: To perform a survey among members of the European Society of Breast Imaging (EUSOBI) regarding the use of contrast-enhanced mammography (CEM). METHODS: A panel of nine board-certified radiologists developed a 29-item online questionnaire, distributed to all EUSOBI members (inside and outside Europe) from January 25 to March 10, 2023. CEM implementation, examination protocols, reporting strategies, and current and future CEM indications were investigated. Replies were exploratively analyzed with descriptive and non-parametric statistics. RESULTS: Among 434 respondents (74.9% from Europe), 50% (217/434) declared to use CEM, 155/217 (71.4%) seeing less than 200 CEMs per year. CEM use was associated with academic settings and high breast imaging workload (p < 0.001). The lack of CEM adoption was most commonly due to the perceived absence of a clinical need (65.0%) and the lack of resources to acquire CEM-capable systems (37.3%). CEM protocols varied widely, but most respondents (61.3%) had already adopted the 2022 ACR CEM BI-RADS® lexicon. CEM use in patients with contraindications to MRI was the most common current indication (80.6%), followed by preoperative staging (68.7%). Patients with MRI contraindications also represented the most commonly foreseen CEM indication (88.0%), followed by the work-up of inconclusive findings at non-contrast examinations (61.5%) and supplemental imaging in dense breasts (53.0%). Respondents declaring CEM use and higher CEM experience gave significantly more current (p = 0.004) and future indications (p < 0.001). CONCLUSIONS: Despite a trend towards academic high-workload settings and its prevalent use in patients with MRI contraindications, CEM use and progressive experience were associated with increased confidence in the technique. CLINICAL RELEVANCE STATEMENT: In this first survey on contrast-enhanced mammography (CEM) use and perspectives among the European Society of Breast Imaging (EUSOBI) members, the perceived absence of a clinical need chiefly drove the 50% CEM adoption rate. CEM adoption and progressive experience were associated with more extended current and future indications. KEY POINTS: • Among the 434 members of the European Society of Breast Imaging who completed this survey, 50% declared to use contrast-enhanced mammography in clinical practice. • Due to the perceived absence of a clinical need, contrast-enhanced mammography (CEM) is still prevalently used as a replacement for MRI in patients with MRI contraindications. • The number of current and future CEM indications marked by respondents was associated with their degree of CEM experience.

O-RADS MRI: A Systematic Review and Meta-Analysis of Diagnostic Performance and Category-wise Malignancy Rates.

Background US-indeterminate adnexal lesions remain an important indication for gynecologic surgery. MRI can serve as a problem-solving tool through the use of the Ovarian-Adnexal Imaging Reporting and Data System (O-RADS) MRI lexicon, which is based on the ADNEX MR scoring system. Purpose To perform a systematic review and meta-analysis of the diagnostic performance of pelvic MRI interpreted using the ADNEX or O-RADS MRI stratification systems to characterize US-indeterminate adnexal lesions and of the category-wise malignancy rates. Materials and Methods A systematic literature search from May 2013 (publication of the ADNEX MR score) to September 2022 was performed. Studies reporting the use of pelvic MRI interpreted with the ADNEX or O-RADS MRI systems to characterize US-indeterminate adnexal lesions, with pathologic examination and/or follow-up as the reference standard, were included. Summary estimates of diagnostic performance were obtained with the bivariate random-effects model, while category-wise summary malignancy rates of O-RADS MRI 2, 3, 4, and 5 lesions were obtained with a random-effects model. Effects of covariates on heterogeneity and diagnostic performance were investigated through meta-regression. Results Thirteen study parts from 12 studies (3731 women, 4520 adnexal lesions) met the inclusion criteria. Diagnostic performance meta-analysis for 4012 lesions found a 92% summary sensitivity (95% CI: 88, 95) and a 91% summary specificity (95% CI: 89, 93). The meta-analysis of malignancy rates for 3641 lesions showed summary malignancy rates of 0.1% (95% CI: 0, 1) among O-RADS MRI 2 lesions, 6% (95% CI: 3, 9) among O-RADS MRI 3 lesions, 60% (95% CI: 52, 67) among O-RADS MRI 4 lesions, and 96% (95% CI: 92, 99) among O-RADS MRI 5 lesions. Conclusion Pelvic MRI interpreted with the Ovarian-Adnexal Reporting and Data System (O-RADS) MRI lexicon had high diagnostic performance for the characterization of US-indeterminate adnexal lesions. Summary estimates of malignancy rates in the O-RADS MRI 4 and O-RADS MRI 5 categories were higher than predicted ones. © RSNA, 2022 Supplemental material is available for this article. See also the editorial by Lee and Kang in this issue.

Contrast-enhanced mammography-guided biopsy: why, when, and where we need it.

KEY POINTS: • The use of CEM-guided biopsy is spreading after initial experiences in a few pilot centers.• CEM-guided biopsy has the potential to ensure fast, low-cost, and effective tissue sampling of MRI-detected and CEM-detected lesions that do not have a corresponding finding at morphological imaging.• The need and utility of CEM-guided biopsy are warranted by the impending expansion of morpho-functional imaging towards breast cancer screening for women with extremely dense breasts.

Detection and quantification of breast arterial calcifications on mammograms: a deep learning approach.

OBJECTIVE: Breast arterial calcifications (BAC) are a sex-specific cardiovascular disease biomarker that might improve cardiovascular risk stratification in women. We implemented a deep convolutional neural network for automatic BAC detection and quantification. METHODS: In this retrospective study, four readers labelled four-view mammograms as BAC positive (BAC+) or BAC negative (BAC-) at image level. Starting from a pretrained VGG16 model, we trained a convolutional neural network to discriminate BAC+ and BAC- mammograms. Accuracy, F1 score, and area under the receiver operating characteristic curve (AUC-ROC) were used to assess the diagnostic performance. Predictions of calcified areas were generated using the generalized gradient-weighted class activation mapping (Grad-CAM++) method, and their correlation with manual measurement of BAC length in a subset of cases was assessed using Spearman ρ. RESULTS: A total 1493 women (198 BAC+) with a median age of 59 years (interquartile range 52-68) were included and partitioned in a training set of 410 cases (1640 views, 398 BAC+), validation set of 222 cases (888 views, 89 BAC+), and test set of 229 cases (916 views, 94 BAC+). The accuracy, F1 score, and AUC-ROC were 0.94, 0.86, and 0.98 in the training set; 0.96, 0.74, and 0.96 in the validation set; and 0.97, 0.80, and 0.95 in the test set, respectively. In 112 analyzed views, the Grad-CAM++ predictions displayed a strong correlation with BAC measured length (ρ = 0.88, p < 0.001). CONCLUSION: Our model showed promising performances in BAC detection and in quantification of BAC burden, showing a strong correlation with manual measurements. CLINICAL RELEVANCE STATEMENT: Integrating our model to clinical practice could improve BAC reporting without increasing clinical workload, facilitating large-scale studies on the impact of BAC as a biomarker of cardiovascular risk, raising awareness on women's cardiovascular health, and leveraging mammographic screening. KEY POINTS: • We implemented a deep convolutional neural network (CNN) for BAC detection and quantification. • Our CNN had an area under the receiving operator curve of 0.95 for BAC detection in the test set composed of 916 views, 94 of which were BAC+ . • Furthermore, our CNN showed a strong correlation with manual BAC measurements (ρ = 0.88) in a set of 112 views.

Screening and diagnostic breast MRI: how do they impact surgical treatment? Insights from the MIPA study.

OBJECTIVES: To report mastectomy and reoperation rates in women who had breast MRI for screening (S-MRI subgroup) or diagnostic (D-MRI subgroup) purposes, using multivariable analysis for investigating the role of MRI referral/nonreferral and other covariates in driving surgical outcomes. METHODS: The MIPA observational study enrolled women aged 18-80 years with newly diagnosed breast cancer destined to have surgery as the primary treatment, in 27 centres worldwide. Mastectomy and reoperation rates were compared using non-parametric tests and multivariable analysis. RESULTS: A total of 5828 patients entered analysis, 2763 (47.4%) did not undergo MRI (noMRI subgroup) and 3065 underwent MRI (52.6%); of the latter, 2441/3065 (79.7%) underwent MRI with preoperative intent (P-MRI subgroup), 510/3065 (16.6%) D-MRI, and 114/3065 S-MRI (3.7%). The reoperation rate was 10.5% for S-MRI, 8.2% for D-MRI, and 8.5% for P-MRI, while it was 11.7% for noMRI (p ≤ 0.023 for comparisons with D-MRI and P-MRI). The overall mastectomy rate (first-line mastectomy plus conversions from conserving surgery to mastectomy) was 39.5% for S-MRI, 36.2% for P-MRI, 24.1% for D-MRI, and 18.0% for noMRI. At multivariable analysis, using noMRI as reference, the odds ratios for overall mastectomy were 2.4 (p < 0.001) for S-MRI, 1.0 (p = 0.957) for D-MRI, and 1.9 (p < 0.001) for P-MRI. CONCLUSIONS: Patients from the D-MRI subgroup had the lowest overall mastectomy rate (24.1%) among MRI subgroups and the lowest reoperation rate (8.2%) together with P-MRI (8.5%). This analysis offers an insight into how the initial indication for MRI affects the subsequent surgical treatment of breast cancer. KEY POINTS: • Of 3065 breast MRI examinations, 79.7% were performed with preoperative intent (P-MRI), 16.6% were diagnostic (D-MRI), and 3.7% were screening (S-MRI) examinations. • The D-MRI subgroup had the lowest mastectomy rate (24.1%) among MRI subgroups and the lowest reoperation rate (8.2%) together with P-MRI (8.5%). • The S-MRI subgroup had the highest mastectomy rate (39.5%) which aligns with higher-than-average risk in this subgroup, with a reoperation rate (10.5%) not significantly different to that of all other subgroups.

Preoperative breast MRI positively impacts surgical outcomes of needle biopsy-diagnosed pure DCIS: a patient-matched analysis from the MIPA study.

OBJECTIVES: To investigate the influence of preoperative breast MRI on mastectomy and reoperation rates in patients with pure ductal carcinoma in situ (DCIS). METHODS: The MIPA observational study database (7245 patients) was searched for patients aged 18-80 years with pure unilateral DCIS diagnosed at core needle or vacuum-assisted biopsy (CNB/VAB) and planned for primary surgery. Patients who underwent preoperative MRI (MRI group) were matched (1:1) to those who did not receive MRI (noMRI group) according to 8 confounding covariates that drive referral to MRI (age; hormonal status; familial risk; posterior-to-nipple diameter; BI-RADS category; lesion diameter; lesion presentation; surgical planning at conventional imaging). Surgical outcomes were compared between the matched groups with nonparametric statistics after calculating odds ratios (ORs). RESULTS: Of 1005 women with pure unilateral DCIS at CNB/VAB (507 MRI group, 498 noMRI group), 309 remained in each group after matching. First-line mastectomy rate in the MRI group was 20.1% (62/309 patients, OR 2.03) compared to 11.0% in the noMRI group (34/309 patients, p = 0.003). The reoperation rate was 10.0% in the MRI group (31/309, OR for reoperation 0.40) and 22.0% in the noMRI group (68/309, p < 0.001), with a 2.53 OR of avoiding reoperation in the MRI group. The overall mastectomy rate was 23.3% in the MRI group (72/309, OR 1.40) and 17.8% in the noMRI group (55/309, p = 0.111). CONCLUSIONS: Compared to those going directly to surgery, patients with pure DCIS at CNB/VAB who underwent preoperative MRI had a higher OR for first-line mastectomy but a substantially lower OR for reoperation. CLINICAL RELEVANCE STATEMENT: When confounding factors behind MRI referral are accounted for in the comparison of patients with CNB/VAB-diagnosed pure unilateral DCIS, preoperative MRI yields a reduction of reoperations that is more than twice as high as the increase in overall mastectomies. KEY POINTS: • Confounding factors cause imbalance when investigating the influence of preoperative MRI on surgical outcomes of pure DCIS. • When patient matching is applied to women with pure unilateral DCIS, reoperation rates are significantly reduced in women who underwent preoperative MRI. • The reduction of reoperations brought about by preoperative MRI is more than double the increase in overall mastectomies.

Barriers to Implementation of Contrast-Enhanced Mammography in Clinical Practice: AJR Expert Panel Narrative Review.

Accumulating evidence shows that contrast-enhanced mammography (CEM) has higher diagnostic performance than digital mammography and ultrasound and comparable diagnostic performance to MRI for various indications. CEM also offers certain practical advantages for patients. Nevertheless, the clinical implementation of CEM has been limited because of a range of factors. This AJR Expert Panel Narrative Review explores such factors hindering CEM implementation. These factors include the following: the risks of iodinated contrast media, increased radiation exposure, indications for which CEM is not the preferred test or for which further evidence is needed, workflow adjustments needed when performing CEM examinations, incomplete availability of CEM-guided biopsy systems, and reimbursement challenges. Considerations that currently mitigate or are expected to mitigate these factors are also highlighted.

Immune checkpoint inhibitor-related pneumonitis and COVID-19: a case-matched comparison of CT findings.

OBJECTIVES: To compare the radiological findings of immune checkpoint inhibitor-related pneumonitis (IRP) and COVID-19 pneumonia, evaluating the potential of the CO-RADS score to differentiate between them. METHODS: Two readers blindly reviewed chest CTs from age- and sex-matched groups of 33 patients with IRP and 33 patients with COVID-19 pneumonia. Each examiner evaluated the presence of 13 CT features, semiquantitatively scored lung involvement, and assigned a CO-RADS score. Inter-reader reliability in the assessment of CT features and CO-RADS categories was evaluated with Cohen's κ. Distribution differences between groups were evaluated with the χ2, Fisher's, and Mann-Whitney U tests. RESULTS: Substantial or higher inter-reader reliability was found in CO-RADS assignments (κ = 0.664) and in the evaluation of CT features (κ ≥ 0.638), among which the sole feature found to significantly differentiate IRP from COVID-19 pneumonia was unilateral presentation (p < 0.001). Lung involvement semiquantitative scores and CO-RADS scores were significantly higher (p < 0.001) in COVID patients (median involvement score 4, IQR 4-6; median CO-RADS score 5, IQR 4-5) than in IRP patients (median involvement score 2.5, IQR 2-4; median CO-RADS score 3, IQR 3-4) but exploratory analysis of CO-RADS specificity revealed comparatively low values, ranging between 51.5% (Reader 1) and 54.6% (Reader 2). CONCLUSIONS: CT features of IRP and COVID-19 pneumonia frequently overlap, save for the extent of lung involvement and bilaterality. In the current SARS-CoV-2 pandemic, the low specificity of the CO-RADS score for the differential diagnosis of COVID-19 pneumonia and IRP may prompt to reconsider the role of imaging in IRP work-up.

Efficacy and safety of vacuum-assisted excision (VAE) of fibroadenomas: experience in a tertiary centre.

PURPOSE: To evaluate the technical success and efficacy rates of US-guided percutaneous vacuum-assisted excision (VAE) of breast fibroadenomas, also assessing procedural complications and long-term patient satisfaction rates. MATERIALS AND METHODS: The institutional database of a tertiary breast cancer referral centre was retrospectively reviewed to retrieve all women with fibroadenomas who underwent US-guided VAE between May 2011 and September 2019. We subsequently included in this study all fibroadenomas with a maximum diameter of 3 cm at US and an available histological confirmation obtained by core-needle biopsy before VAE. Immediately after VAE, technical success (defined as the correct VAE execution) and the occurrence of procedural complications were evaluated. Imaging follow-up (US ± mammography) after 6, 12, 24 and 36 months was performed to evaluate technical efficacy (defined as the absence of fibroadenoma recurrence at 6-month follow-up). Long-term patient satisfaction was evaluated with telephonic interviews in October 2022. RESULTS: We retrospectively included 108 women (median age 46 years) with 110 fibroadenomas diagnosed at core-needle biopsy with a median lesion size at US of 12 mm. Technical success was obtained in 110/110 VAEs (100%). Minor procedural complications (haematomas) occurred in 7/110 VAEs (6%), whereas 8/110 patients had a fibroadenoma recurrence at 6-month follow-up, resulting in a 93% technical efficacy (102/110 VAEs). All patients available for telephonic follow-up (104/104, 100%) reported high satisfaction with VAE results. CONCLUSION: US-guided VAE is a safe and effective procedure for the excision of fibroadenomas, representing a viable alternative to surgery, with a low complication rate and high patient satisfaction.

Impact of DWI and ADC values in Ovarian-Adnexal Reporting and Data System (O-RADS) MRI score.

PURPOSE: Introduce DWI and quantitative ADC evaluation in O-RADS MRI system and observe how diagnostic performance changes. Assess its validity and reproducibility between readers with different experience in female pelvic imaging. Finally, evaluate any correlation between ADC value and histotype in malignant lesions. MATERIALS AND METHODS: In total, 173 patients with 213 indeterminate adnexal masses (AMs) on ultrasound were subjected to MRI examination, from which 140 patients with 172 AMs were included in the final analysis. Standardised MRI sequences were used, including DWI and DCE sequences. Two readers, blinded to histopathological data, retrospectively classified AMs according to the O-RADS MRI scoring system. A quantitative analysis method was applied by placing a ROI on the ADC maps obtained from single-exponential DWI sequences. AMs considered benign (O-RADS MRI score 2) were excluded from the ADC analysis. RESULTS: Excellent inter-reader agreement was found in the classification of lesions according to the O-RADS MRI score (K = 0.936; 95% CI). Two ROC curves were created to determine the optimal cut-off value for the ADC variable between O-RADS MRI categories 3-4 and 4-5, respectively, 1.411 × 10-3 mm2/sec and 0.849 × 10-3 mm2/sec. Based on these ADC values, 3/45 and 22/62 AMs were upgraded, respectively, to score 4 and 5, while 4/62 AMs were downgraded to score 3. ADC values correlated significantly with the ovarian carcinoma histotype (p value < 0.001). CONCLUSION: Our study demonstrates the prognostic potential of DWI and ADC values in the O-RADS MRI classification for better radiological standardisation and characterisation of AMs.

CT-based body composition in diffuse large B cell lymphoma patients: changes after treatment and association with survival.

PURPOSE: Primary purpose was to assess changes of bone mineral density (BMD) in diffuse large B cell lymphoma (DLBCL) patients treated with rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone R-CHOP (like) chemotherapy regimen. Secondary purposes were to assess other body composition features changes and to assess the association of pre-therapy values and their changes over time with survival. MATERIAL AND METHODS: Patients selected underwent R-CHOP(like) regimen for DLBCL, and underwent PET-CT before and after treatment. Main clinical data collected included body mass index, date of last follow-up, date of progression, and date of death. From the low-dose CT images, BMD was assessed at the L1 level; the other body composition values, including muscle and fat distribution, were assessed at the L3 level by using a dedicated software. Descriptive statistics were reported as median and interquartile range, or frequencies and percentages. Statistical comparisons of body composition variables between pre- and post-treatment assessments were performed using the Wilcoxon matched pairs signed rank test. Non-normal distribution of variables was tested with the Shapiro-Wilk test. For qualitative variables, the Fisher exact test was used. Log rank test was used to compare survival between different subgroups of the study population defined by specific body composition cutoffs. The significance level was set at p < 0.05. RESULTS: Eighty-two patients were included. The mean follow-up was 37.5 ± 21.4 months. A significant difference was found in mean BMD before and after R-CHOP(like) treatment (p < 0.0001). The same trend was observed for mean skeletal muscle area (SMA) (p = 0.004) and mean skeletal muscle index (SMI) (p = 0.006). No significant association was demonstrated between body composition variables, PFS and OS. CONCLUSION: R-CHOP(like) treatment in DLBCL patients was associated with significant reduction of BMD, SMA and SMI.

Contrast-enhanced Mammography: A Systematic Review and Meta-Analysis of Diagnostic Performance.

Background Contrast-enhanced mammography (CEM) is a promising technique for breast cancer detection, but conflicting results have been reported in previous meta-analyses. Purpose To perform a systematic review and meta-analysis of CEM diagnostic performance considering different interpretation methods and clinical settings. Materials and Methods The MEDLINE, EMBASE, Web of Science, and Cochrane Library databases were systematically searched up to July 15, 2021. Prospective and retrospective studies evaluating CEM diagnostic performance with histopathology and/or follow-up as the reference standard were included. Study quality was assessed with the Quality Assessment of Diagnostic Accuracy Studies 2 tool. Summary diagnostic odds ratio and area under the receiver operating characteristic curve were estimated with the hierarchical summary receiver operating characteristic (HSROC) model. Summary estimates of sensitivity and specificity were obtained with the hierarchical bivariate model, pooling studies with the same image interpretation approach or focused on the same findings. Heterogeneity was investigated through meta-regression and subgroup analysis. Results Sixty studies (67 study parts, 11 049 CEM examinations in 10 605 patients) were included. The overall area under the HSROC curve was 0.94 (95% CI: 0.91, 0.96). Pooled diagnostic odds ratio was 55.7 (95% CI: 42.7, 72.7) with high heterogeneity (τ2 = 0.3). At meta-regression, CEM interpretation with both low-energy and recombined images had higher sensitivity (95% vs 94%, P < .001) and specificity (81% vs 71%, P = .03) compared with recombined images alone. At subgroup analysis, CEM showed a 95% pooled sensitivity (95% CI: 92, 97) and a 78% pooled specificity (95% CI: 66, 87) from nine studies in patients with dense breasts, while in 10 studies on mammography-detected suspicious findings, CEM had a 92% pooled sensitivity (95% CI: 89, 94) and an 84% pooled specificity (95% CI: 73, 91). Conclusion Contrast-enhanced mammography demonstrated high performance in breast cancer detection, especially with joint interpretation of low-energy and recombined images. © RSNA, 2021 Online supplemental material is available for this article. See also the editorial by Bahl in this issue.

Contrast-enhanced mammography for the assessment of screening recalls: a two-centre study.

OBJECTIVES: To evaluate the potential of contrast-enhanced mammography (CEM) for reducing the biopsy rate of screening recalls. METHODS: Recalled women were prospectively enrolled to undergo CEM alongside standard assessment (SA) through additional views, tomosynthesis, and/or ultrasound. Exclusion criteria were symptoms, implants, allergy to contrast agents, renal failure, and pregnancy. SA and CEM were independently evaluated by one of six radiologists, who recommended biopsy or 2-year follow-up. Biopsy rates according to SA or recombined CEM (rCEM) were compared with the McNemar's test. Diagnostic performance was calculated considering lesions with available final histopathology. RESULTS: Between January 2019 and July 2021, 220 women were enrolled, 207 of them (median age 56.6 years) with 225 suspicious findings analysed. Three of 207 patients (1.4%) developed mild self-limiting adverse reactions to iodinated contrast agent. Overall, 135/225 findings were referred for biopsy, 90/225 by both SA and rCEM, 41/225 by SA alone and 4/225 by rCEM alone (2/4 being one DCIS and one invasive carcinoma). The rCEM biopsy rate (94/225, 41.8%, 95% CI 35.5-48.3%) was 16.4% lower (p < 0.001) than the SA biopsy rate (131/225, 58.2%, 95% CI 51.7-64.5%). Considering the 124/135 biopsies with final histopathology (44 benign, 80 malignant), rCEM showed a 93.8% sensitivity (95% CI 86.2-97.3%) and a 65.9% specificity (95% CI 51.1-78.1%), all 5 false negatives being ductal carcinoma in situ detectable as suspicious calcifications on low-energy images. CONCLUSIONS: Compared to SA, the rCEM-based work-up would have avoided biopsy for 37/225 (16.4%) suspicious findings. Including low-energy images in interpretation provided optimal overall CEM sensitivity. KEY POINTS: • The work-up of suspicious findings detected at mammographic breast cancer screening still leads to a high rate of unnecessary biopsies, involving between 2 and 6% of screened women. • In 207 recalled women with 225 suspicious findings, recombined images of contrast-enhanced mammography (CEM) showed a 93.8% sensitivity and a 65.9% specificity, all 5 false negatives being ductal carcinoma in situ detectable on low-energy images as suspicious calcifications. • CEM could represent an easily available one-stop shop option for the morphofunctional assessment of screening recalls, potentially reducing the biopsy rate by 16.4%.

Mammography self-evaluation online test for screening readers: an Italian Society of Medical Radiology (SIRM) initiative.

OBJECTIVES: To report and analyse the characteristics and performance of the first cohort of Italian radiologists completing the national mammography self-evaluation online test established by the Italian Society of Medical Radiology (SIRM). METHODS: A specifically-built dataset of 132 mammograms (24 with screen-detected cancers and 108 negative cases) was preliminarily tested on 48 radiologists to define pass thresholds (62% sensitivity and 86% specificity) and subsequently made available online to SIRM members during a 13-month timeframe between 2018 and 2019. Associations between participants' characteristics, pass rates, and diagnostic accuracy were then investigated with descriptive statistics and univariate and multivariable regression analyses. RESULTS: A total of 342 radiologists completed the test, 151/342 (44.2%) with success. All individual variables, except gender, showed a significant correlation with pass rates and diagnostic sensitivity, confirmed by univariate logistic regression, while only involvement in organised screening programs and number of mammograms read per year showed a positive association with specificity at univariate logistic regression. In the multivariable regression analysis, fewer variables remained significant: > 3000 mammograms read per year for success rate; female gender, public practice setting, and higher experience self-judgement for sensitivity; no variables were significantly associated with specificity. CONCLUSIONS: This national self-evaluation test effectively differentiated multiple aspects of mammographic reading experience, but specific breast imaging experience was shown not to strictly guarantee good diagnostic accuracy. Due to its easy use and the validity of obtained results, this test could be extended to all Italian breast radiologists, regardless of their experience, also as a Breast Unit accreditation criterion. KEY POINTS: • This self-evaluation test was found to be able to differentiate various degrees of mammographic interpretation experience. • Breast cancer screening readers should undergo a self-assessment test, since experience parameters alone do not guarantee diagnostic ability.

Magnetic resonance imaging before breast cancer surgery: results of an observational multicenter international prospective analysis (MIPA).

OBJECTIVES: Preoperative breast magnetic resonance imaging (MRI) can inform surgical planning but might cause overtreatment by increasing the mastectomy rate. The Multicenter International Prospective Analysis (MIPA) study investigated this controversial issue. METHODS: This observational study enrolled women aged 18-80 years with biopsy-proven breast cancer, who underwent MRI in addition to conventional imaging (mammography and/or breast ultrasonography) or conventional imaging alone before surgery as routine practice at 27 centers. Exclusion criteria included planned neoadjuvant therapy, pregnancy, personal history of any cancer, and distant metastases. RESULTS: Of 5896 analyzed patients, 2763 (46.9%) had conventional imaging only (noMRI group), and 3133 (53.1%) underwent MRI that was performed for diagnosis, screening, or unknown purposes in 692/3133 women (22.1%), with preoperative intent in 2441/3133 women (77.9%, MRI group). Patients in the MRI group were younger, had denser breasts, more cancers ≥ 20 mm, and a higher rate of invasive lobular histology than patients who underwent conventional imaging alone (p < 0.001 for all comparisons). Mastectomy was planned based on conventional imaging in 22.4% (MRI group) versus 14.4% (noMRI group) (p < 0.001). The additional planned mastectomy rate in the MRI group was 11.3%. The overall performed first- plus second-line mastectomy rate was 36.3% (MRI group) versus 18.0% (noMRI group) (p < 0.001). In women receiving conserving surgery, MRI group had a significantly lower reoperation rate (8.5% versus 11.7%, p < 0.001). CONCLUSIONS: Clinicians requested breast MRI for women with a higher a priori probability of receiving mastectomy. MRI was associated with 11.3% more mastectomies, and with 3.2% fewer reoperations in the breast conservation subgroup. KEY POINTS: • In 19% of patients of the MIPA study, breast MRI was performed for screening or diagnostic purposes. • The current patient selection to preoperative breast MRI implies an 11% increase in mastectomies, counterbalanced by a 3% reduction of the reoperation rate. • Data from the MIPA study can support discussion in tumor boards when preoperative MRI is under consideration and should be shared with patients to achieve informed decision-making.

CT-derived Chest Muscle Metrics for Outcome Prediction in Patients with COVID-19.

Background Lower muscle mass is a known predictor of unfavorable outcomes, but its prognostic impact on patients with COVID-19 is unknown. Purpose To investigate the contribution of CT-derived muscle status in predicting clinical outcomes in patients with COVID-19. Materials and Methods Clinical or laboratory data and outcomes (intensive care unit [ICU] admission and death) were retrospectively retrieved for patients with reverse transcriptase polymerase chain reaction-confirmed SARS-CoV-2 infection, who underwent chest CT on admission in four hospitals in Northern Italy from February 21 to April 30, 2020. The extent and type of pulmonary involvement, mediastinal lymphadenopathy, and pleural effusion were assessed. Cross-sectional areas and attenuation by paravertebral muscles were measured on axial CT images at the T5 and T12 vertebral level. Multivariable linear and binary logistic regression, including calculation of odds ratios (ORs) with 95% CIs, were used to build four models to predict ICU admission and death, which were tested and compared by using receiver operating characteristic curve analysis. Results A total of 552 patients (364 men and 188 women; median age, 65 years [interquartile range, 54-75 years]) were included. In a CT-based model, lower-than-median T5 paravertebral muscle areas showed the highest ORs for ICU admission (OR, 4.8; 95% CI: 2.7, 8.5; P < .001) and death (OR, 2.3; 95% CI: 1.0, 2.9; P = .03). When clinical variables were included in the model, lower-than-median T5 paravertebral muscle areas still showed the highest ORs for both ICU admission (OR, 4.3; 95%: CI: 2.5, 7.7; P < .001) and death (OR, 2.3; 95% CI: 1.3, 3.7; P = .001). At receiver operating characteristic analysis, the CT-based model and the model including clinical variables showed the same area under the receiver operating characteristic curve (AUC) for ICU admission prediction (AUC, 0.83; P = .38) and were not different in terms of predicting death (AUC, 0.86 vs AUC, 0.87, respectively; P = .28). Conclusion In hospitalized patients with COVID-19, lower muscle mass on CT images was independently associated with intensive care unit admission and in-hospital mortality. © RSNA, 2021 Online supplemental material is available for this article.

Breast arterial calcifications as a biomarker of cardiovascular risk: radiologists' awareness, reporting, and action. A survey among the EUSOBI members.

OBJECTIVES: To investigate the knowledge of radiologists on breast arterial calcifications (BAC) and attitude about BAC reporting, communication to women, and subsequent action. METHODS: An online survey was offered to EUSOBI members, with 17 questions focused on demographics, level of experience, clinical setting, awareness of BAC association with cardiovascular risk, mammographic reporting, modality of BAC assessment, and action habits. Descriptive statistics were used. RESULTS: Among 1084 EUSOBI members, 378 (34.9%) responded to the survey, 361/378 (95.5%) radiologists, 263 females (69.6%), 112 males (29.6%), and 3 (0.8%) who did not specify their gender. Of 378 respondents, 305 (80.7%) declared to be aware of BAC meaning in terms of cardiovascular risk and 234 (61.9%) to routinely include BAC in mammogram reports, when detected. Excluding one inconsistent answer, simple annotation of BAC presence was declared by 151/233 (64.8%), distinction between low versus extensive BAC burden by 59/233 (25.3%), and usage of an ordinal scale by 22/233 (9.5%) and of a cardinal scale by 1/233 (0.4%). Among these 233 radiologists reporting BAC, 106 (45.5%) declared to orally inform the woman and, in case of severe BAC burden, 103 (44.2%) to investigate cardiovascular history, and 92 (39.5%) to refer the woman to a cardiologist. CONCLUSION: Among EUSOBI respondents, over 80% declared to be aware of BAC cardiovascular meaning and over 60% to include BAC in the report. Qualitative BAC assessment predominates. About 40% of respondents who report on BAC, in the case of severe BAC burden, investigate cardiovascular history and/or refer the woman to a cardiologist. KEY POINTS: • Of 1084 EUSOBI members, 378 (35%) participated: 81% of respondents are aware of breast arterial calcification (BAC) cardiovascular meaning and 62% include BAC in the mammogram report. • Of those reporting BAC, description of presence was declared by 65%, low versus extensive burden distinction by 25%, usage of an ordinal scale by 10%, and of a cardinal scale by 0.4%; 46% inform the woman and, in case of severe BAC burden, 44% examine cardiovascular history, and 40% refer her to a cardiologist. • European breast radiologists may be ready for large-scale studies to ascertain the role of BAC assessment in the comprehensive framework of female cardiovascular disease prevention.

Dual-energy CT performance in acute pulmonary embolism: a meta-analysis.

OBJECTIVES: To evaluate the diagnostic performance of dual-energy computed tomography (DECT) with regard to its post-processing techniques, namely linear blending (LB), iodine maps (IM), and virtual monoenergetic (VM) reconstructions, in diagnosing acute pulmonary embolism (PE). METHODS: This meta-analysis was conducted according to PRISMA. A systematic search on MEDLINE and EMBASE was performed in December 2019, looking for articles reporting the diagnostic performance of DECT on a per-patient level. Diagnostic performance meta-analyses were conducted grouping study parts according to DECT post-processing methods. Correlations between radiation or contrast dose and publication year were appraised. RESULTS: Seventeen studies entered the analysis. Only lobar and segmental acute PE were considered, subsegmental acute PE being excluded from analysis due to data heterogeneity or lack of data. LB alone was assessed in 6 study parts accounting for 348 patients, showing a pooled sensitivity of 0.87 and pooled specificity of 0.93. LB and IM together were assessed in 14 study parts accounting for 1007 patients, with a pooled sensitivity of 0.89 and pooled specificity of 0.90. LB, IM, and VM together were assessed in 2 studies (for a total 144 patients) and showed a pooled sensitivity of 0.90 and pooled specificity of 0.90. The area under the curve for LB alone, and LB together with IM was 0.93 (not available for studies using LB, IM and VM because of paucity of data). Radiation and contrast dose did not decrease with increasing year of publication. CONCLUSIONS: Considering the published performance of single-energy CT in diagnosing acute PE, either dual-energy or single-energy computed tomography can be comparably used for the detection of acute PE. KEY POINTS: • Dual-energy CT displayed pooled sensitivity and specificity of 0.87 and 0.93 for linear blending alone, 0.89 and 0.90 for linear blending and iodine maps, and 0.90 and 0.90 for linear blending iodine maps, and virtual monoenergetic reconstructions. • The performance of dual-energy CT for patient management is not superior to that reported in literature for single-energy CT (0.83 sensitivity and 0.96 specificity). • Dual-energy CT did not yield substantial advantages in the identification of patients with acute pulmonary embolism compared to single-energy techniques.

Upgrade Rate of Percutaneously Diagnosed Pure Atypical Ductal Hyperplasia: Systematic Review and Meta-Analysis of 6458 Lesions.

Background Management of percutaneously diagnosed pure atypical ductal hyperplasia (ADH) is an unresolved clinical issue. Purpose To calculate the pooled upgrade rate of percutaneously diagnosed pure ADH. Materials and Methods A search of MEDLINE and EMBASE databases was performed in October 2018. Preferred Reporting Items for Systematic Reviews and Meta-Analyses, or PRISMA, guidelines were followed. A fixed- or random-effects model was used, along with subgroup and meta-regression analyses. The Newcastle-Ottawa scale was used for study quality, and the Egger test was used for publication bias. Results Of 521 articles, 93 were analyzed, providing data for 6458 ADHs (5911 were managed with surgical excision and 547 with follow-up). Twenty-four studies used core-needle biopsy; 44, vacuum-assisted biopsy; 21, both core-needle and vacuum-assisted biopsy; and four, unspecified techniques. Biopsy was performed with stereotactic guidance in 29 studies; with US guidance in nine, with MRI guidance in nine, and with mixed guidance in eight. Overall heterogeneity was high (I2 = 80%). Subgroup analysis according to management yielded a pooled upgrade rate of 29% (95% confidence interval [CI]: 26%, 32%) for surgically excised lesions and 5% (95% CI: 4%, 8%) for lesions managed with follow-up (P < .001). Heterogeneity was entirely associated with surgically excised lesions (I2 = 78%) rather than those managed with follow-up (I2 = 0%). Most variability was explained by guidance and needle caliper (P = .15). At subgroup analysis of surgically excised lesions, the pooled upgrade rate was 42% (95% CI: 31%, 53%) for US guidance, 23% (95% CI: 19%, 27%) for stereotactic biopsy, and 32% (95% CI: 22%, 43%) for MRI guidance, with heterogeneity (52%, 63%, and 56%, respectively) still showing the effect of needle caliper. When the authors considered patients with apparent complete lesion removal after biopsy (subgroups in 14 studies), the pooled upgrade rate was 14% (95% CI: 8%, 23%). Study quality was low to medium; the risk of publication bias was low (P = .10). Conclusion Because of a pooled upgrade rate higher than 2% (independent of biopsy technique, needle size, imaging guidance, and apparent complete lesion removal), atypical ductal hyperplasia diagnosed with percutaneous needle biopsy should be managed with surgical excision. © RSNA, 2019 Online supplemental material is available for this article. See also the editorial by Brem in this issue.