Comparison of the Diagnostic Efficacy of Ultrasound-Guided Core Needle Biopsy With 18- Versus 20-Gauge Needles for Thyroid Nodules.

OBJECTIVES: To compare the diagnostic efficacy, complication rate, and core needle biopsy (CNB) specimen yield in 18- versus 20-gauge ultrasound (US)-guided CNB for diagnosis of thyroid nodules. METHODS: We included 81 consecutive thyroid nodules with US-guided biopsy by a 20-gauge core needle and 86 consecutive thyroid nodules with US-guided biopsy by an 18-gauge core needle during 2 years. The rate of inconclusive results, including nondiagnostic or atypia/follicular lesion of undetermined significance, was compared. The diagnostic performance for malignancy was assessed in nodules with a final diagnosis. The complication rate and CNB specimen yield were also compared. RESULTS: Eighteen-gauge CNB showed a lower rate of nondiagnostic results (1.2% versus 8.6%; P = .024) than 20-gauge CNB; however, the rates of atypia/follicular lesion of undetermined significance and inconclusive results were not significantly different between the groups (P > .05). In addition, 18-gauge CNB showed higher sensitivity (75.0% versus 66.7%), a higher negative predictive value (83.9% versus 75.9%), and higher accuracy (78.3% versus 74.4%) for detecting malignancy than 20-gauge CNB, although the results did not achieve statistical significance. No major complications occurred in either of the CNB groups. The 18-gauge needle group had significantly fewer CNBs and larger specimen diameters (P < .001). CONCLUSIONS: Core needle biopsy with an 18-gauge needle could be more effective for the diagnosis of thyroid nodules than CNB with a 20-gauge needle.

Comparison and Combination of Strain and Shear Wave Elastography of Breast Masses for Differentiation of Benign and Malignant Lesions by Quantitative Assessment: Preliminary Study.

OBJECTIVES: To compare the diagnostic performance of strain and shear wave elastography of breast masses for quantitative assessment in differentiating benign and malignant lesions and to evaluate the diagnostic accuracy of combined strain and shear wave elastography. METHODS: Between January and February 2016, 37 women with 45 breast masses underwent both strain and shear wave ultrasound (US) elastographic examinations. The American College of Radiology Breast Imaging Reporting and Data System (BI-RADS) final assessment on B-mode US imaging was assessed. We calculated strain ratios for strain elastography and the mean elasticity value and elasticity ratio of the lesion to fat for shear wave elastography. Diagnostic performances were compared by using the area under the receiver operating characteristic curve (AUC). RESULTS: The 37 women had a mean age of 47.4 years (range, 20-79 years). Of the 45 lesions, 20 were malignant, and 25 were benign. The AUCs for elasticity values on strain and shear wave elastography showed no significant differences (strain ratio, 0.929; mean elasticity, 0.898; and elasticity ratio, 0.868; P > .05). After selectively downgrading BI-RADS category 4a lesions based on strain and shear wave elastographic cutoffs, the AUCs for the combined sets of B-mode US and elastography were improved (B-mode + strain, 0.940; B-mode + shear wave; 0.964; and B-mode, 0.724; P < .001). Combined strain and shear wave elastography showed significantly higher diagnostic accuracy than each individual elastographic modality (P = .031). CONCLUSIONS: These preliminary results showed that strain and shear wave elastography had similar diagnostic performance. The addition of strain and shear wave elastography to B-mode US improved diagnostic performance. The combination of strain and shear wave elastography results in a higher diagnostic yield than each individual elastographic modality.

Distinguishing benign from malignant thyroid nodules using thyroid ultrasonography: utility of adding superb microvascular imaging and elastography.

OBJECTIVE: Thyroid nodules are common; however, malignancy is less than 7%. Therefore, additional techniques such as Doppler ultrasonography or elastography are used to improve diagnostic performance of conventional ultrasonography. We want to prospectively investigate the use of additional superb microvascular imaging (SMI) and strain elastography to B-mode ultrasound in thyroid nodules in distinguishing benign from malignant thyroid nodules. METHODS: We analyzed 52 thyroid nodules (malignant = 26, benign = 26) and reviewers scored the likelihood of malignancy for three data sets (i.e., B-mode ultrasonography alone, B-mode ultrasonography + SMI, and B-mode ultrasonography + strain elastography). The area under the receiver-operating characteristic curve (Az) values, sensitivities, and specificities were compared. RESULTS: A comparison of the data sets revealed that area under the receiver-operating characteristic curve values were similar without statistical difference. However, on comparing sensitivity and specificity based on the management decision of whether to conduct fine-needle aspiration (FNA) after combining information from all three types of imaging (B-mode ultrasonography + SMI + strain elastography), specificity was significantly higher for the combined technique (34.6%) than for B-mode ultrasonography alone (11.5%), without decrease in sensitivity (P = 0.032). CONCLUSION: Additional use of SMI and strain elastography could potentially lead to increase in specificity in thyroid ultrasonography.

Diagnostic performance of tomosynthesis and breast ultrasonography in women with dense breasts: a prospective comparison study.

PURPOSE: To compare the diagnostic performances of tomosynthesis and ultrasonography as adjunctives to digital mammography in women with dense breasts. METHODS: A total of 778 women with dense breasts underwent digital mammography with tomosynthesis and ultrasonography for screening and diagnostic purposes. The findings of tomosynthesis and ultrasonography were evaluated independently. The primary endpoint was overall diagnostic accuracy determined by area under the receiver operating characteristic curve (AUC). Secondary endpoints included sensitivity, specificity, and predictive values. RESULTS: Of the 778 participants, 698 women (140 breast cancers) were included in the analysis. Based on the AUC findings, the non-inferiority of tomosynthesis to ultrasonography was established in the overall group as well as in all subgroups except for that comprising women with extremely dense breast composition. There were no significant differences in AUC between tomosynthesis and ultrasonography among asymptomatic participants and participants who underwent imaging for screening (0.912 vs. 0.934 [P = 0.403] and 0.987 vs. 0.950 [P = 0.270], respectively). Tomosynthesis exhibited lower sensitivity (91.4 vs. 96.4%; P = 0.039), and higher specificity (83.9 vs. 70.4%; P < 0.001) and positive predictive value (58.7 vs. 45.0%; P < 0.001) than ultrasonography. CONCLUSIONS: Tomosynthesis exhibits comparable performance to ultrasonography as an adjunct to mammography for diagnosis of breast cancer, except among women with extremely dense breasts.

Management for BI-RADS category 3 lesions detected in preoperative breast MR imaging of breast cancer patients.

OBJECTIVE: To retrospectively evaluate characteristics of and determine appropriate follow-up recommendations for BI-RADS category 3 lesions detected in preoperative MRI of breast cancer patients. METHODS: BI-RADS category 3 assessments were identified from the breast MRI database for 5,110 consecutive breast cancer patients who had undergone preoperative MRI and surgery. Patient and lesion characteristics, malignancy rate, and interval between lesion detection and cancer diagnosis were analysed. Histopathological results or imaging at or after 2-year follow-up were used as reference standards. RESULTS: Of the 626 lesions, morphological features included a single focus in 26.5% (n = 166), multiple foci in 47.1% (n = 295), mass in 21.7% (n = 136) and non-mass enhancement in 4.6% (n = 29). Cancer was found in 0.8% (5/626) at a median interval of 50 months (range, 29-66 months). Malignancy rate according to morphological feature was: 1.8% (3/166) in a single focus, 0.7% (1/136) in mass and 3.4% (1/29) in non-mass enhancement. All detected cancers were stage 0 or IA. CONCLUSIONS: Annual follow-up might be adequate for BI-RADS category 3 lesions detected at preoperative MRI because of the 0.8% (5/626) malignancy rate, long interval between lesion detection and cancer diagnosis, and early stage of diagnosed cancers. KEY POINTS: • BI-RADS category 3 lesions on preoperative MRI had 0.8% malignancy rate. • All cancer diagnoses from BI-RADS 3 occurred after 24-month follow-up. • Annual follow-up might be adequate for BI-RADS 3 detected on preoperative MRI.

Impact of prior mammograms on combined reading of digital mammography and digital breast tomosynthesis.

Background Although digital breast tomosynthesis (DBT) is an emerging technique yielding higher sensitivity and specificity compared to digital mammography (DM) alone, relative contribution of prior mammograms on the interpretation of DBT combined with DM has not been investigated. Purpose To retrospectively compare the diagnostic performances of DM, DM + DBT, and DM + DBT with prior mammograms. Material and Methods Three breast radiologists independently reviewed images of 116 patients with 24 cancers in the sequential order of DM, DM + DBT, and DM + DBT with prior mammograms using Breast Imaging Reporting and Data System (BI-RADS) assessment categories. Results The average areas under the receiver operating characteristic curve (AUC) of DM, DM + DBT, and DM + DBT with prior mammograms were 0.712, 0.777, and 0.816, respectively. Adding prior mammograms did not significantly affect the AUC of DM + DBT ( P = 0.108), whereas adding DBT significantly increased the AUC of DM ( P = 0.009). Sensitivity for DM, DM + DBT, and DM + DBT with prior mammograms was 58.3%, 69.4%, and 69.4%, and specificities were 84.1%, 85.9%, and 93.8%, respectively. Addition of DBT significantly increased the sensitivity ( P = 0.0090) of DM. Prior mammograms significantly improved the specificity of DM + DBT ( P = 0.0004), whereas adding prior mammogram did not affect sensitivity of DM + DBT ( P = 1.000). Conclusion DBT significantly increases the overall sensitivity and diagnostic performance of DM. Prior mammograms significantly increase the specificity of DM + DBT but have no significant effect on sensitivity and overall diagnostic performance.

Risk Factors for False-Negative and False-Positive Results of Magnetic Resonance Computer-Aided Evaluation in Axillary Lymph Node Staging.

PURPOSE: The aims of this study were to investigate the false-negative and false-positive results on magnetic resonance (MR) computer-aided evaluation (CAE) in axillary lymph node (ALN) staging and to evaluate the related factors in patients with invasive breast cancer. METHODS: From July 2011 to May 2014, 103 invasive breast cancer patients who underwent preoperative MR-CAE were included. False MR-CAE results in ALN staging were compared in terms of clinicopathologic features, baseline mammography, and breast ultrasonography. Logistic regression analyses were used to evaluate independent factors related to false results. RESULTS: For MR-CAE, the false-negative and false-positive results of ALN metastasis were 6.8% and 33.3%, respectively. On multivariate analysis, spiculated tumor margin (P = 0.016) and positive lymphovascular invasion (P = 0.020) were associated with false-negative results, and circumscribed tumor margin (P = 0.017) and negative lymphovascular invasion (P = 0.036) were associated with false-positive results for ALN metastasis. CONCLUSIONS: Tumor margin and lymphovascular invasion are the key factors that affect the false MR-CAE results in ALN staging.

Comparative evaluation of average glandular dose and breast cancer detection between single-view digital breast tomosynthesis (DBT) plus single-view digital mammography (DM) and two-view DM: correlation with breast thickness and density.

OBJECTIVES: To compare the average glandular dose (AGD) and diagnostic performance of mediolateral oblique (MLO) digital breast tomosynthesis (DBT) plus cranio-caudal (CC) digital mammography (DM) with two-view DM, and to evaluate the correlation of AGD with breast thickness and density. METHODS: MLO and CC DM and DBT images of both breasts were obtained in 149 subjects. AGDs of DBT and DM per exposure were recorded, and their correlation with breast thickness and density were evaluated. Paired data of MLO DBT plus CC DM and two-view DM were reviewed for presence of malignancy in a jack-knife alternative free-response ROC (JAFROC) method. RESULTS: The AGDs of both DBT and DM, and differences in AGD between DBT and DM (ΔAGD), were correlated with breast thickness and density. The average JAFROC figure of merit (FOM) was significantly higher on the combined technique than two-view DM (P = 0.005). In dense breasts, the FOM and sensitivity of the combined technique was higher than that of two-view DM (P = 0.003) with small ΔAGD. CONCLUSIONS: MLO DBT plus CC DM provided higher diagnostic performance than two-view DM in dense breasts with a small increase in AGD. KEY POINTS: • DBT has higher diagnostic performance and potential to overcome limitations of DM. • Dose differences (DBT-DM, ΔAGD) were inversely correlated with breast thickness and density. • Figure of merit of MLO-DBT/CC-DM was higher than that of two-view DM. • In dense breasts, MLO-DBT/CC-DM provides better diagnostic performance with a small AGD increase.

Quantitative MRI morphology of invasive breast cancer: correlation with immunohistochemical biomarkers and subtypes.

BACKGROUND: Breast cancer is a heterogeneous disease with intrinsic molecular subtypes. The different biology and histology of breast cancer exhibit different tumor morphology at breast magnetic resonance imaging (MRI). However, few studies have examined the quantitative relationship between the MRI morphological and immunohistochemical features in breast cancer. PURPOSE: To investigate the correlations between tumor roundness, as quantitatively assessed with MRI and biomarkers or subtypes of breast cancer. MATERIAL AND METHODS: A total of 280 women (mean age, 51 years; range, 28-79 years) with 282 invasive breast cancers (<5 cm) were included. The associations between the tumor roundness (1-100%), as measured using MRI software, and immunohistochemical (e.g. estrogen receptor [ER], progesterone receptor [PR], human epidermal growth factor receptor 2 [HER2], and Ki67) features were evaluated using Pearson's or Spearman's rank correlation coefficients and multiple linear regression analysis. RESULTS: An inverse correlation was observed between the ER (r = -0.408, P < 0.001) or PR (r = -0.248, P < 0.001) scores and tumor roundness, whereas a positive correlation was observed between the Ki67 index and tumor roundness (r = 0.354, P < 0.001). In multiple linear regression, the ER score (P < 0.001) and Ki67 index (P = 0.003) were independent factors determining tumor roundness. Triple-negative tumors (ER, PR, and HER2 negative) showed the highest mean roundness scores compared with the other subtypes (e.g. 67.3% for triple-negative, relative to 55.9% for HER2-enriched, 53.8% for luminal B, and 51.7% for luminal A, P < 0.001). CONCLUSION: Our results suggest that breast tumors with lower ER expression and higher cellular proliferation or biologically aggressive triple-negative tumors are likely to manifest with relatively benign morphologic features.

Background parenchymal signal enhancement ratio at preoperative MR imaging: association with subsequent local recurrence in patients with ductal carcinoma in situ after breast conservation surgery.

PURPOSE: To retrospectively investigate whether the background parenchymal features around a tumor at preoperative dynamic contrast material-enhanced magnetic resonance (MR) imaging are associated with ipsilateral breast tumor recurrence (IBTR)-free survival in patients with ductal carcinoma in situ (DCIS) after breast conservation surgery. MATERIALS AND METHODS: The institutional review board approved this study, and the requirement for informed consent was waived. Between 2004 and 2009, 215 consecutive women with pure DCIS who had undergone preoperative dynamic contrast-enhanced MR imaging and curative breast conservation surgery were identified. Clinical-pathologic features (age, menopausal status, presentation of clinical findings, biopsy method, tumor size, nuclear grade, hormonal receptor status, margin status, and adjuvant therapy) and MR imaging features (lesion size, background parenchymal enhancement grade, fibroglandular density, parenchymal signal enhancement ratio [SER] around the tumor, lesion type, and lesion kinetics) were analyzed. A Cox proportional hazards model was used to determine the association between MR imaging variables and IBTR-free survival after controlling for clinical-pathologic variables. Reproducibility of SER measurements was evaluated by using the intraclass correlation coefficient. RESULTS: There were 15 of 215 (7.0%) IBTR cases (nine DCIS cases and six invasive cases) at a median of 36 months (range, 11-61 months). Multivariate analysis showed that higher parenchymal SER (hazard ratio [HR] = 2.028, P < .001 for reader 1; HR = 1.652, P < .001 for reader 2) and larger histologic tumor size (HR = 1.360, P = .009 for reader 1; HR = 1.402, P = .006 for reader 2) were independent factors associated with worse IBTR-free survival. The intraclass correlation coefficient of SER measurements between two readers was 0.852 (95% confidence interval: 0.811, 0.885). CONCLUSION: Higher parenchymal SER around the tumor at preoperative dynamic contrast-enhanced MR imaging and larger histologic tumor size were independent factors associated with worse IBTR-free survival in patients with DCIS after breast conservation surgery.

Added value of shear-wave elastography for evaluation of breast masses detected with screening US imaging.

PURPOSE: To evaluate the additional value of shear-wave elastography (SWE) to B-mode ultrasonography (US) and to determine an appropriate guideline for the combined assessment of screening US-detected breast masses. MATERIALS AND METHODS: This study was conducted with institutional review board approval, and written informed consent was obtained. From March 2010 to February 2012, B-mode US and SWE were performed in 159 US-detected breast masses before biopsy. For each lesion, Breast Imaging Reporting and Data System (BI-RADS) category on B-mode US images and the maximum stiffness color and elasticity values on SWE images were assessed. A guideline for adding SWE data to B-mode US was developed with the retrospective cohort to improve diagnostic performance in sensitivity and specificity and was validated in a distinct prospective cohort of 207 women prior to biopsy. RESULTS: Twenty-one of 159 masses in the development cohort and 12 of 207 breast masses in the validation cohort were malignant. In the development cohort, when BI-RADS category 4a masses showing a dark blue color or a maximum elasticity value of 30 kPa or less on SWE images were downgraded to category 3, specificity increased from 9.4% (13 of 138) to 59.4% (82 of 138) and 57.2% (79 of 138) (P < .001), respectively, without loss in sensitivity (100% [21 of 21]). In the validation cohort, specificity increased from 17.4% (34 of 195) to 62.1% (121 of 195) and 53.3% (104 of 195) (P < .001) respectively, without loss in sensitivity (91.7% [11 of 12]). CONCLUSION: The addition of SWE to B-mode US improved diagnostic performance with increased specificity for screening US-detected breast masses. BI-RADS category 4a masses detected at US screening that showed a dark blue color or a maximum elasticity value of 30 kPa or less on SWE images can be safely followed up instead of performing biopsy.

Breast cancer detected with screening US: reasons for nondetection at mammography.

PURPOSE: To retrospectively review the mammograms of women with breast cancers detected at screening ultrasonography (US) to determine the reasons for nondetection at mammography. MATERIALS AND METHODS: This study received institutional review board approval, and informed consent was waived. Between 2003 and 2011, a retrospective database review revealed 335 US-depicted cancers in 329 women (median age, 47 years; age range, 29-69 years) with Breast Imaging Reporting and Data System breast density type 2-4. Five blinded radiologists independently reviewed the mammograms to determine whether the findings on negative mammograms should be recalled. Three unblinded radiologists re-reviewed the mammograms to determine the reasons for nondetection by using the reference location of the cancer on mammograms obtained after US-guided wire localization or breast magnetic resonance imaging. The number of cancers recalled by the blinded radiologists were compared with the reasons for nondetection determined by the unblinded radiologists. RESULTS: Of the 335 US-depicted cancers, 63 (19%) were recalled by three or more of the five blinded radiologists, and 272 (81%) showed no mammographic findings that required immediate action. In the unblinded repeat review, 263 (78%) cancers were obscured by overlapping dense breast tissue, and nine (3%) were not included at mammography owing to difficult anatomic location or poor positioning. Sixty-three (19%) cancers were considered interpretive errors. Of these, 52 (82%) were seen as subtle findings (46 asymmetries, six calcifications) and 11 (18%) were evident (six focal asymmetries, one distortion, four calcifications). CONCLUSION: Most breast cancers (81%) detected at screening US were not seen at mammography, even in retrospect. In addition, 19% had subtle or evident findings missed at mammography.

Tumour volume doubling time of molecular breast cancer subtypes assessed by serial breast ultrasound.

OBJECTIVES: The aim of our study was to evaluate the tumour volume doubling time (TVDT) of molecular breast cancer subtypes by serial ultrasound (US). METHODS: Sixty-six patients (mean age, 50 years; range, 29-78 years) with invasive breast cancer underwent initial and follow-up breast US examinations (at least three months apart) with no intervention. TVDT was determined using the tumours' greatest dimensions in two orthogonal planes. The results were compared with clinical, imaging, and tumour variables and molecular subtypes (oestrogen receptor [ER]-positive, human epidermal growth factor receptor 2 [HER2]-positive, and triple negative) using a multiple linear regression analysis. RESULTS: TVDT exhibited a wide range (46-825 days; median, 141 days) with an overall mean of 193 ± 141 days and mean values of 241 ± 166 days for ER-positive tumours (n = 37), 162 ± 60 days for HER2-positive tumours (n = 12), and 103 ± 43 days for triple-negative tumours (n = 17) (P < 0.0001). In a multivariate regression analysis, compared to other features, only the different molecular breast cancer subtypes showed significant difference in TVDT (P < 0.0001). CONCLUSIONS: TVDT differed significantly among the three molecular breast cancer subtypes, with the triple-negative tumours showing the fastest growth. KEY POINTS: Knowledge of tumour volume doubling time provides clues for improving screening. TVDT assessed by serial US differed significantly between breast cancer subtypes. Triple-negative tumours had 2.4-fold shorter TVDT compared to ER-positive tumours. Tumours classified as BI-RADS 3 had shorter TVDT than BI-RADS 4.

Computer-aided evaluation as an adjunct to revised BI-RADS Atlas: improvement in positive predictive value at screening breast MRI.

OBJECTIVES: To investigate whether kinetic features via magnetic resonance (MR)-computer-aided evaluation (CAE) can improve the positive predictive value (PPV) of morphological descriptors for suspicious lesions at screening breast MRI. METHODS: One hundred and sixteen consecutive, suspiciously enhancing lesions detected at contralateral breast MRI screening in 116 women with newly-diagnosed breast cancers were included. Morphological descriptors according to the revised BI-RADS Atlas and kinetic features from MR-CAE were analysed. The PPV of each descriptor was analysed to identify subgroups in which PPV could be improved by the addition of MR-CAE. RESULTS: When biopsy recommendations were downgraded to follow-up in cases where there were both the absence of enhancement at a 50% threshold and the absence of delayed washout, PPV increased from 0.328 (95% CI, 0.249-0.417) to 0.500 (95% CI, 0.387- 0.613). Two ductal carcinoma in situ (DCIS) non-mass enhancement (NME) lesions were missed. Application of downgrading criteria to foci or masses led to increased PPV from 0.310 (95% CI, 0.216-0.419) to 0.437 (95% CI, 0.331-0.547) without missing cancers. CONCLUSIONS: MR-CAE has the potential to improve the PPV of breast MR imaging by reducing the number of false positives. When suspicious mass lesions do not show enhancement at a 50% threshold nor delayed washout, follow-up rather than biopsy can be considered. KEY POINTS: • MR-CAE has the potential to increase PPV at breast MRI screening. • Lesions without enhancement at 50% threshold and washout might be downgraded. • DCIS non-mass lesions might be false-negative cases at MR-CAE.

18F-FDG uptake in breast cancer correlates with immunohistochemically defined subtypes.

OBJECTIVES: To determine whether a correlation exists between maximum standardized uptake value (SUVmax) on (18)F-fluorodeoxyglucose positron emission tomography (FDG-PET) and the subtypes of breast cancer. METHODS: This retrospective study involved 548 patients (mean age 51.6 years, range 21-81 years) with 552 index breast cancers (mean size 2.57 cm, range 1.0-14.5 cm). The correlation between (18)F-FDG uptake in PET/CT, expressed as SUVmax, and immunohistochemically defined subtypes (luminal A, luminal B, human epidermal growth factor receptor 2 (HER2) positive and triple negative) was analyzed. RESULTS: The mean SUVmax value of the 552 tumours was 6.07 ± 4.63 (range 0.9-32.8). The subtypes of the 552 tumours were 334 (60%) luminal A, 66 (12%) luminal B, 60 (11%) HER2 positive and 92 (17%) triple negative, for which the mean SUVmax values were 4.69 ± 3.45, 6.51 ± 4.18, 7.44 ± 4.73 and 9.83 ± 6.03, respectively. In a multivariate regression analysis, triple-negative and HER2-positive tumours had 1.67-fold (P < 0.001) and 1.27-fold (P = 0.009) higher SUVmax values, respectively, than luminal A tumours after adjustment for invasive tumour size, lymph node involvement status and histologic grade. CONCLUSION: FDG uptake was independently associated with subtypes of invasive breast cancer. Triple-negative and HER2-positive breast cancers showed higher SUVmax values than luminal A tumours. KEY POINTS: • (18) F-FDG PET demonstrates increased tissue glucose metabolism, a hallmark of cancers. • Immunohistochemically defined subtypes appear significantly associated with FDG uptake (expressed as SUV max ). • Triple-negative tumours had 1.67-fold higher SUV max values than luminal A tumours. • HER2-positive tumours had 1.27-fold higher SUV max values than luminal A tumours.

Patient age and tumor size determine the cancer yield of preoperative bilateral breast MRI in women with ductal carcinoma in situ.

OBJECTIVE: The objective of our study was to determine the cancer yield of preoperative breast MRI in women with newly diagnosed ductal carcinoma in situ (DCIS) and to identify subgroups of DCIS patients for whom MRI is more likely to identify additional cancers. MATERIALS AND METHODS: A database search for patients with DCIS who had undergone breast surgery between 2007 and 2011 was performed. A total of 308 women (median age, 49 years; range, 25-82 years) with DCIS underwent mammography, sonography, and a preoperative evaluation with MRI. The cancer yield and positive biopsy rate were determined. Patient age at diagnosis, menopausal status, family history of breast cancer, mammographic breast density, index cancer size, nuclear grade, and estrogen receptor (ER) status were examined, and a multivariate logistic regression analysis was performed. RESULTS: The cancer yield was 8% (24/308), and the positive biopsy rate was 53% (24/45). Of the 24 additional cancers, 14 (58%) represented multifocal disease, two (8%) represented multicentric disease, and eight (33%) represented contralateral cancer. In a multivariate analysis, age and index cancer size were factors significantly associated with additional MRI-detected cancers. Compared with women≥50 years, women<50 years had a 3.2-fold higher frequency of detection (95% CI, 1.2-8.9; p=0.02). Compared with women with DCIS lesions smaller than 2.5 cm, women with DCIS lesions 2.5 cm or larger showed a 2.6-fold higher frequency of detection (95% CI, 1.1-6.3; p=0.04). CONCLUSION: Preoperative breast MRI can be considered in patients with DCIS who are <50 years old, have index cancers≥2.5 cm, or fulfill both criteria.

Columnar cell lesions without atypia initially diagnosed on breast needle biopsies: is imaging follow-up enough?

OBJECTIVE: The purpose of this study was to evaluate the underestimation rate and predictive factor of underestimation of columnar cell lesions (CCLs) without atypia diagnosed through breast core needle biopsies (CNBs). MATERIALS AND METHODS: From January 2007 through December 2011, 141 CCLs without atypia, including columnar cell change and columnar cell hyperplasia, were diagnosed in 138 women by CNB. Excisional (n = 16) or imaging follow-up (n = 125) findings were available in all cases. On a per-lesion basis, the underestimation rate and predictive factor of underestimation were evaluated. RESULTS: Among the 16 surgically excised lesions, there were two malignancies (one ductal carcinoma in situ and one invasive ductal carcinoma) and one lobular carcinoma in situ. Overall, the pooled underestimation rate of malignancy was 1.4% (2/141). With regard to lesion variables, the mean lesion size was significantly larger in the underestimation group of CCLs (p = 0.007). Fine pleomorphic morphology of microcalcifications (p < 0.001), the distribution of the microcalcifications (p = 0.007), BI-RADS final assessment (p = 0.001), and imaging-pathologic correlation (p < 0.001) were significantly associated with underestimation. Multivariate analysis showed that fine pleomorphic morphology of microcalcifications (p < 0.0001) was an independent predictor of underestimation in 58 lesions with microcalcifications on mammography. CONCLUSION: The overall underestimation rate of malignancy was 1.4%. Imaging follow-up is reasonable for CCLs without atypia at CNB, especially in small lesions with less suspicious imaging findings. Fine pleomorphic microcalcifications and higher BI-RADS category might be helpful in the prediction of underestimation of a high-risk lesion or malignancy.

Comparison of Diagnostic Performance of Ultrasonography and Magnetic Resonance Enterography in the Assessment of Active Bowel Lesions in Patients with Crohn's Disease: A Systematic Review and Meta-Analysis.

We aimed to evaluate and compare the diagnostic performances of ultrasonography (US) and magnetic resonance enterography (MRE) in assessing active bowel lesions in patients with Crohn's disease (CD). MATERIALS AND METHODS: We searched PubMed and EMBASE for studies in which US and MRE were used to assess active bowel lesions in CD patients. Bivariate random effect meta-analytic methods were used to estimate pooled sensitivity, specificity, and hierarchical summary receiver operating characteristic (HSROC) curves. We performed a meta-regression analysis to explore the source of study heterogeneity. RESULTS: Eleven studies involving 752 patients were included. US exhibited a pooled sensitivity of 86% (95% confidence interval (CI) 72-94), pooled specificity of 88% (95% CI 78-94), and HSROC of 0.93 in 10 studies. MRE exhibited a pooled sensitivity of 88% (95% CI 76-95), pooled specificity of 87% (95% CI 73-95), and an HSROC of 0.94 in eight studies. In seven studies comparing the diagnostic performances of US and MRE, the summary sensitivity of US and MRE were 86% (95% CI 65-96, I2 = 92.1) and 86% (95% CI 72-93, I2 = 88.1) (p = 0.841), respectively. The summary specificity of US and MRE were 87% (95% CI 78-93, I2 = 79.8%) and 84% (72-90, I2 = 72.5%) (p = 0.431), respectively, which showed no statistical differences. On meta-regression analysis, studies from Europe (p = 0.002), those that used linear US probes (p = 0.012), those on small bowel lesions (p = 0.01), and those with outcomes as combined features (active inflammation) reported higher US sensitivity than those from other regions, those that used both linear and convex US probes, those on small and large bowels, and those with outcome as one feature (bowel wall thickening or ulcer). Studies with pediatric patients (p = 0.001), those with reference standards including US (p = 0.001), and outcomes as combined features (p = 0.01) reported higher MRE specificity than those with adult populations, reference standards other than the US, and outcomes as one feature. CONCLUSIONS: In spite of considerable heterogeneity in the included studies, both US and MRE can diagnose active bowel lesions with comparable diagnostic accuracy in patients with CD. The study region, type of US probe, lesion location, investigated outcome for US sensitivity and study population, reference standards, and investigated outcomes for MRE specificity were potential sources of heterogeneity.

Radiomic models based on magnetic resonance imaging predict the spatial distribution of CD8+ tumor-infiltrating lymphocytes in breast cancer.

Infiltration of CD8+ T cells and their spatial contexture, represented by immunophenotype, predict the prognosis and therapeutic response in breast cancer. However, a non-surgical method using radiomics to evaluate breast cancer immunophenotype has not been explored. Here, we assessed the CD8+ T cell-based immunophenotype in patients with breast cancer undergoing upfront surgery (n = 182). We extracted radiomic features from the four phases of dynamic contrast-enhanced magnetic resonance imaging, and randomly divided the patients into training (n = 137) and validation (n = 45) cohorts. For predicting the immunophenotypes, radiomic models (RMs) that combined the four phases demonstrated superior performance to those derived from a single phase. For discriminating the inflamed tumor from the non-inflamed tumor, the feature-based combination model from the whole tumor (RM-wholeFC) showed high performance in both training (area under the receiver operating characteristic curve [AUC] = 0.973) and validation cohorts (AUC = 0.985). Similarly, the feature-based combination model from the peripheral tumor (RM-periFC) discriminated between immune-desert and excluded tumors with high performance in both training (AUC = 0.993) and validation cohorts (AUC = 0.984). Both RM-wholeFC and RM-periFC demonstrated good to excellent performance for every molecular subtype. Furthermore, in patients who underwent neoadjuvant chemotherapy (n = 64), pre-treatment images showed that tumors exhibiting complete response to neoadjuvant chemotherapy had significantly higher scores from RM-wholeFC and lower scores from RM-periFC. Our RMs predicted the immunophenotype of breast cancer based on the spatial distribution of CD8+ T cells with high accuracy. This approach can be used to stratify patients non-invasively based on the status of the tumor-immune microenvironment.