Multiparametric MRI and Radiomics for the Prediction of HER2-Zero, -Low, and -Positive Breast Cancers.

Background Half of breast cancers exhibit low expression levels of human epidermal growth factor receptor 2 (HER2) and can be targeted by new antibody-drug conjugates. The imaging differences between HER2-zero (immunohistochemistry [IHC] score of 0), HER2-low (IHC score of 1+ or 2+ with negative findings at fluorescence in situ hybridization [FISH]), and HER2-positive (IHC score of 2+ with positive findings at FISH or IHC score of 3+) breast cancers were unknown. Purpose To assess whether multiparametric dynamic contrast-enhanced MRI-based radiomic features can help distinguish HER2 expressions in breast cancer. Materials and Methods This study included women with breast cancer who underwent MRI at two different centers between December 2020 and December 2022. Tumor segmentation and radiomic feature extraction were performed on T2-weighted and dynamic contrast-enhanced T1-weighted images. Unsupervised correlation analysis of reproducible features and least absolute shrinkage and selector operation were used for the selection of features to build a radiomics signature. The area under the receiver operating characteristic curve (AUC) was used to assess the performance of the radiomic signature. Multivariable logistic regression was used to identify independent predictors for distinguishing HER2 expressions in both the training and prospectively acquired external data set. Results The training set included 208 patients from center 1 (mean age, 53 years ± 14 [SD]), and the external test set included 131 patients from center 2 (mean age, 54 years ± 13). In the external test data set, the radiomic signature achieved an AUC of 0.80 (95% CI: 0.71, 0.89) for distinguishing HER2-low and -positive tumors versus HER2-zero tumors and was a significant predictive factor for distinguishing these two groups (odds ratio = 7.6; 95% CI: 2.9, 19.8; P < .001). Among HER2-low or -positive breast cancers, histology type, associated nonmass enhancement, and multiple lesions at MRI had an AUC of 0.77 (95% CI: 0.68, 0.86) in the external test set for the prediction of HER2-positive versus HER2-low cancers. Conclusion The radiomic signature and tumor descriptors from multiparametric breast MRI may predict distinct HER2 expressions of breast cancers with therapeutic implications. © RSNA, 2023 Supplemental material is available for this article. See also the editorial by Kataoka and Honda in this issue.

Prospective Evaluation of Ultrafast Breast MRI for Predicting Pathologic Response after Neoadjuvant Therapies.

Background Ultrafast dynamic contrast-enhanced (DCE) MRI parameters are associated with breast cancer aggressiveness. However, the role of these parameters as predictive biomarkers for pathologic response after neoadjuvant chemotherapy (NAC) has been poorly investigated. Purpose To assess whether semiquantitative perfusion parameters calculated at initial ultrafast DCE MRI are associated with early prediction for pathologic response after NAC in participants with breast cancer. Materials and Methods This prospective single-center study included consecutive women with nonmetastatic invasive breast cancer treated with NAC followed by surgery who underwent initial ultrafast DCE MRI between December 2020 and August 2021. Six semiquantitative ultrafast DCE MRI parameters were calculated for each participant from the fitted time-signal intensity curve. Multivariable logistic regression was used to identify independent predictors of pathologic complete response (pCR) and residual cancer burden (RCB). Results Fifty women (mean age, 49 years ± 12 [SD]) were included in the study; 20 achieved pCR and 25 achieved low RCB (RCB-0 and I). A wash-in slope (WIS) cutoff value of 1.6% per second had a sensitivity of 94% (17 of 18 participants) and a specificity of 59% (19 of 32 participants) for pCR. A WIS of more than 1.6% per second (odds ratio [OR], 8.4 [95% CI: 1.5, 48.2]; P = .02), human epidermal growth factor receptor 2 (HER2) positivity (OR, 6.3 [95% CI: 1.5, 27.4]; P = .01), and tumor-infiltrating lymphocytes of more than 10% (OR, 6.9 [95% CI: 1.3, 37.7]; P = .03) were independent predictive factors of pCR. The area under the receiver operating characteristic curve of the three-component model, which included WIS, tumor-infiltrating lymphocytes, and HER2 positivity, was 0.92 (95% CI: 0.84, 0.99). A WIS of more than 1.6% per second was associated with higher pCR rates in the HER2-positive (OR, 21.7 [95% CI: 1.8, 260.6]; P = .02) breast cancer subgroup. For luminal HER2-negative and triple-negative breast cancers, a WIS of more than 1.6% per second was associated with low RCB (OR, 11.0 [95% CI: 1.1, 106.4]; P = .04). Conclusion The wash-in slope (WIS) assessment at initial ultrafast dynamic contrast-enhanced MRI may be used to predict pathologic complete response (pCR) in participants with breast cancer. The WIS value was used to identify two subsets of human epidermal growth factor receptor 2-positive cancers with distinct pCR rates. © RSNA, 2022 Online supplemental material is available for this article. See also the editorial by Lee and Moy in this issue.

Diagnostic chest X-rays and breast cancer risk among women with a hereditary predisposition to breast cancer unexplained by a BRCA1 or BRCA2 mutation.

BACKGROUND: Diagnostic ionizing radiation is a risk factor for breast cancer (BC). BC risk increases with increased dose to the chest and decreases with increased age at exposure, with possible effect modification related to familial or genetic predisposition. While chest X-rays increase the BC risk of BRCA1/2 mutation carriers compared to non-carriers, little is known for women with a hereditary predisposition to BC but who tested negative for a BRCA1 or BRCA2 (BRCA1/2) mutation. METHODS: We evaluated the effect of chest X-rays from diagnostic medical procedures in a dataset composed of 1552 BC cases identified through French family cancer clinics and 1363 unrelated controls. Participants reported their history of X-ray exposures in a detailed questionnaire and were tested for 113 DNA repair genes. Logistic regression and multinomial logistic regression models were used to assess the association with BC. RESULTS: Chest X-ray exposure doubled BC risk. A 3% increased BC risk per additional exposure was observed. Being 20 years old or younger at first exposure or being exposed before first full-term pregnancy did not seem to modify this risk. Birth after 1960 or carrying a rare likely deleterious coding variant in a DNA repair gene other than BRCA1/2 modified the effect of chest X-ray exposure. CONCLUSION: Ever/never chest X-ray exposure increases BC risk 2-fold regardless of age at first exposure and, by up to 5-fold when carrying 3 or more rare variants in a DNA repair gene. Further studies are needed to evaluate other DNA repair genes or variants to identify those which could modify radiation sensitivity. Identification of subpopulations that are more or less susceptible to ionizing radiation is important and potentially clinically relevant.

Tumor-infiltrating lymphocytes are associated with poor prognosis in invasive lobular breast carcinoma.

The prognostic impact of tumor-infiltrating lymphocytes (TILs) within invasive lobular carcinoma (ILC) remains to be better characterized. In estrogen receptor (ER)-negative invasive ductal carcinomas of no special type (IDC-NST), TILs are associated with good prognosis. The aim of this study was to examine TILs in ILC, with particular focus on prognostic and clinicopathologic features. A cohort comprising 459 consecutive ILCs diagnosed in a single institution from 2005 to 2008 met the eligibility criteria for this study. The percentage of tumor area occupied by TILs was quantified by two breast pathologists and categorized into three groups: no TILs, ≤5%, >5%. Clinicopathologic features were tested by Fisher's exact tests or Chi2 tests. Overall survival (OS) and invasive disease-free survival (iDFS) were estimated by Kaplan-Meier and Cox proportional hazard statistics. There were 239 TIL-negative cases, 185 cases with ≤5% TILs, and 35 cases with >5% TILs. TILs were associated with younger age, larger tumors, lymph node involvement, poor Nottingham prognostic index, HER2 amplification, multinucleation, and prominent nucleoli (p < 0.05). Poor OS was significantly associated with increasing TILs in the univariate Cox proportional hazards model (p < 0.001) and Kaplan-Meier estimator (p < 0.05, log-rank test). Similar results were observed for iDFS (p = 0.004 for Cox univariate and p = 0.005 for log-rank test). Notably, TILs can identify a subset of ILC patients with poor OS independently of molecular subtype and lymph node metastases (multivariate Cox, p < 0.001, OS hazard ratio (HR) = 4.38 and HR = 6.15, for ≤5% and >5% TILs, respectively, vs. absence of TILs). Prominent nucleoli was the only nuclear feature associated with poor OS (p = 0.05) and iDFS (p = 0.05) in univariate Cox survival analysis. TILs represent a promising new morphologic biomarker associated with poor outcome of ILC, in contrast with that observed in ER-negative IDC-NST.

Feasibility of Imaging and Treatment Monitoring of Breast Lesions with Three-Dimensional Shear Wave Elastography.

Purpose Firstly to evaluate the feasibility and diagnostic performance of three-dimensional (3 D) shear wave elastography (SWE) volume measurements in patients with breast lesions compared to breast dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) lesion volumes and 3D-US B-mode volumes. Secondly to assess the treatment monitoring performance of 3D-SWE in patients under neoadjuvant chemotherapy for breast cancer by comparing it to 3D-US lesion volume. Materials and Methods This prospective study was approved by the institutional review board. Informed consent was provided. 33 patients with 33 lesions were included. The feasibility of 3D-SWE was evaluated in 23 patients. In the 10 remaining patients receiving neoadjuvant chemotherapy, 3D-SWE was evaluated before and during treatment. Tumor volume and qualitative and quantitative elasticity analysis measurements were performed and compared to the tumor volume as estimated by 3D-US and DCE-MRI. Statistical analysis was performed using the Pearson correlation coefficient. Results 3D-SWE was feasible in patients with breast lesions. Tumor volume calculated with 3D-US and 3D-SWE showed very good and moderate concordances with DCE-MRI volume, respectively (Pearson correlation coefficients equal to ρ = r = 0.88, p < 0.00 002 and ρ = r = 0.5, p = 0.32, respectively). Modification of tumor elasticity and heterogeneity was correlated with response to treatment. In good responders, elasticity and elasticity heterogeneity diminished. Conclusion Tumor 3D-US volume measurements showed very good concordance with DCE-MRI volume. 3D-SWE can provide valuable information: reduction of tissue stiffness during treatment could be a potential indicator of response. These preliminary results should be confirmed on a larger number of patients.

Initial MRI findings predictive of a pathological complete response to neoadjuvant treatments in HER2-positive breast cancers.

PURPOSE: This study aimed to determine if initial MRI findings could predict a pathological complete response (pCR) following neoadjuvant systemic therapy (NST) in HER2-positive breast cancers. METHODS: The study retrospectively included 111 patients (Center 1, training set) and 71 patients (Center 2, validation set) with HER2-positive cancer who underwent NST. Initial clinicopathological data and MRI findings were recorded. Continuous variables were analyzed using the Mann-Whitney and Student's t-tests, while categorical variables were analyzed using the χ2 or Fisher's exact test. Univariate analysis was conducted to determine the associations between these variables and pathological complete response (pCR), defined as the absence of invasive malignant cells in the breast and lymph nodes. Interobserver reproducibility was assessed for associated non-mass enhancement (NME) parameter by analyzing 50 MR studies (intraclass correlation coefficient). RESULTS: pCR was achieved in 67 patients, 51 (46 %) from Center 1 and 16 (23%) from Center 2 (p = 0.003), with significant differences between Centers 1 and 2 in tumor-infiltrating lymphocyte levels and lymphovascular invasion (p < 0.001). The initial presence of suspicious associated NME was the only significant parameter predictive of pCR (p < 0.001 for Center 1 and 0.04 for Center 2). The inter-observer reproducibility for this MRI feature was good, with an intraclass correlation coefficient of 0.872 (95 % CI: 0.73-1.00). CONCLUSION: The presence of suspicious associated NME in HER2-positive cancers on the initial MRI study was predictive of achieving pCR after NST. This significant preliminary finding warrants confirmation through prospective multicenter studies.

Biopathologic Characterization and Grade Assessment of Breast Cancer With 3-D Multiparametric Ultrasound Combining Shear Wave Elastography and Backscatter Tensor Imaging.

OBJECTIVE: Despite recent improvements in medical imaging, the final diagnosis and biopathologic characterization of breast cancers currently still requires biopsies. Ultrasound is commonly used for clinical examination of breast masses. B-Mode and shear wave elastography (SWE) are already widely used to detect suspicious masses and differentiate benign lesions from cancers. But additional ultrasound modalities such as backscatter tensor imaging (BTI) could provide relevant biomarkers related to tissue organization. Here we describe a 3-D multiparametric ultrasound approach applied to breast carcinomas in the aims of (i) validating the ability of BTI to reveal the underlying organization of collagen fibers and (ii) assessing the complementarity of SWE and BTI to reveal biopathologic features of diagnostic interest. METHODS: Three-dimensional SWE and BTI were performed ex vivo on 64 human breast carcinoma samples using a linear ultrasound probe moved by a set of motors. Here we describe a 3-D multiparametric representation of the breast masses and quantitative measurements combining B-mode, SWE and BTI. RESULTS: Our results reveal for the first time that BTI can capture the orientation of the collagen fibers around tumors. BTI was found to be a relevant marker for assessing cancer stages, revealing a more tangent tissue orientation for in situ carcinomas than for invasive cancers. In invasive cases, the combination of BTI and SWE parameters allowed for classification of invasive tumors with respect to their grade with an accuracy of 95.7%. CONCLUSION: Our results highlight the potential of 3-D multiparametric ultrasound imaging for biopathologic characterization of breast tumors.

Digital breast tomosynthesis versus mammography and breast ultrasound: a multireader performance study.

OBJECTIVES: To compare the diagnostic performance of single-view breast tomosynthesis (BT) with that of dual-view mammography (MX); to assess the benefit of adding the craniocaudal (CC) mammographic view to BT, and of adding BT to MX plus breast ultrasound, considered to be the reference work-up. METHODS: One hundred and fifty-five consenting patients with unresolved mammographic and/or ultrasound findings or breast symptoms underwent conventional work-up plus mediolateral oblique-view BT of the affected breast. The final study set in 130 patients resulted in 55 malignant and 76 benign and normal cases. Seven breast radiologists rated the cases through five sequential techniques using a BIRADS-based scale: MX, MX + ultrasound, MX + ultrasound + BT, BT, BT + MX(CC). Multireader, multicase receiver operating characteristic (ROC) analysis was performed and performance of the techniques was assessed from the areas under ROC curves. The performance of BT and of BT + MX(CC) was tested versus MX; the performance of MX + ultrasound + BT tested versus MX + ultrasound. RESULTS: Tomosynthesis was found to be non-inferior to mammography. BT + MX(CC) did not appear to be superior to MX, and MX + ultrasound + BT not superior to MX + ultrasound. CONCLUSIONS: Overall, none of the five techniques tested outperformed the others. Further clinical studies are needed to clarify the role of BT as a substitute for traditional work-up in the diagnostic environment. KEY POINTS: • Digital breast tomosynthesis is a new adjunct to mammography and breast ultrasound. • We compared the diagnostic performance of these investigations in an experimental observer study. • Single-view breast tomosynthesis was confirmed as non-inferior to dual-view mammography. • None of the investigations (or combinations) tested outperformed the others. • Further prospective studies are needed to clarify precise role of tomosynthesis for diagnostic application.

Dual-energy contrast-enhanced digital mammography: initial clinical results of a multireader, multicase study.

INTRODUCTION: The purpose of this study was to compare the diagnostic accuracy of dual-energy contrast-enhanced digital mammography (CEDM) as an adjunct to mammography (MX) ± ultrasonography (US) with the diagnostic accuracy of MX ± US alone. METHODS: One hundred ten consenting women with 148 breast lesions (84 malignant, 64 benign) underwent two-view dual-energy CEDM in addition to MX and US using a specially modified digital mammography system (Senographe DS, GE Healthcare). Reference standard was histology for 138 lesions and follow-up for 12 lesions. Six radiologists from 4 institutions interpreted the images using high-resolution softcopy workstations. Confidence of presence (5-point scale), probability of cancer (7-point scale), and BI-RADS scores were evaluated for each finding. Sensitivity, specificity and ROC curve areas were estimated for each reader and overall. Visibility of findings on MX ± CEDM and MX ± US was evaluated with a Likert scale. RESULTS: The average per-lesion sensitivity across all readers was significantly higher for MX ± US ± CEDM than for MX ± US (0.78 vs. 0.71 using BIRADS, p = 0.006). All readers improved their clinical performance and the average area under the ROC curve was significantly superior for MX ± US ± CEDM than for MX ± US ((0.87 vs 0.83, p = 0.045). Finding visibility was similar or better on MX ± CEDM than MX ± US in 80% of cases. CONCLUSIONS: Dual-energy contrast-enhanced digital mammography as an adjunct to MX ± US improves diagnostic accuracy compared to MX ± US alone. Addition of iodinated contrast agent to MX facilitates the visualization of breast lesions.

Shear-wave elastography improves the specificity of breast US: the BE1 multinational study of 939 masses.

PURPOSE: To determine whether adding shear-wave (SW) elastographic features could improve accuracy of ultrasonographic (US) assessment of breast masses. MATERIALS AND METHODS: From September 2008 to September 2010, 958 women consented to repeat standard breast US supplemented by quantitative SW elastographic examination in this prospective multicenter institutional review board-approved, HIPAA-compliant protocol. B-mode Breast Imaging Reporting and Data System (BI-RADS) features and assessments were recorded. SW elastographic evaluation (mean, maximum, and minimum elasticity of stiffest portion of mass and surrounding tissue; lesion-to-fat elasticity ratio; ratio of SW elastographic-to-B-mode lesion diameter or area; SW elastographic lesion shape and homogeneity) was performed. Qualitative color SW elastographic stiffness was assessed independently. Nine hundred thirty-nine masses were analyzable; 102 BI-RADS category 2 masses were assumed to be benign; reference standard was available for 837 category 3 or higher lesions. Considering BI-RADS category 4a or higher as test positive for malignancy, effect of SW elastographic features on area under the receiver operating characteristic curve (AUC), sensitivity, and specificity after reclassifying category 3 and 4a masses was determined. RESULTS: Median participant age was 50 years; 289 of 939 (30.8%) masses were malignant (median mass size, 12 mm). B-mode BI-RADS AUC was 0.950; eight of 303 (2.6%) BI-RADS category 3 masses, 18 of 193 (9.3%) category 4a lesions, 41 of 97 (42%) category 4b lesions, 42 of 57 (74%) category 4c lesions, and 180 of 187 (96.3%) category 5 lesions were malignant. By using visual color stiffness to selectively upgrade category 3 and lack of stiffness to downgrade category 4a masses, specificity improved from 61.1% (397 of 650) to 78.5% (510 of 650) (P<.001); AUC increased to 0.962 (P=.005). Oval shape on SW elastographic images and quantitative maximum elasticity of 80 kPa (5.2 m/sec) or less improved specificity (69.4% [451 of 650] and 77.4% [503 of 650], P<.001 for both), without significant improvement in sensitivity or AUC. CONCLUSION: Adding SW elastographic features to BI-RADS feature analysis improved specificity of breast US mass assessment without loss of sensitivity.

Anxiety and specific distress in women at intermediate and high risk of breast cancer before and after surveillance by magnetic resonance imaging and mammography versus standard mammography.

BACKGROUND: Intensive surveillance in women at intermediate and high breast cancer risk is currently investigated in a French prospective, non-randomized, multicentre study. Two surveillance modalities, standard imaging-mammography ± ultrasound ('Mx')-or standard imaging with magnetic resonance imaging ('MRI'), provided according to the level of breast cancer risk, are compared on psychological distress. METHODS: A total of 1561 women were invited to complete the State-Trait Anxiety Inventory (STAI), Impact of Event Scale (IES) Intrusion and Avoidance subscales and breast cancer-risk perception items at T0 (before examination) and T2 (1 to 3 months later) and the STAI-State anxiety at T1 (just after examination). Multiple regression analyses were performed. RESULTS: Baseline compliance was high (>91%). Between surveillance modalities, women differed significantly for age, education level, breast cancer-risk objective estimates and subjective perception. Mean STAI-State anxiety scores reflected low to moderate distress in both surveillance modalities. At baseline, MRI was associated with lower STAI-State anxiety (p ≤ 0.001) and Avoidance scores (p = 0.02), but at T1 and T2, no difference between surveillance modalities was observed on psychological outcomes. Abnormal surveillance result was associated with a higher STAI-State anxiety (p ≤ 0.01) and IES-Intrusion (p ≤ 0.01) scores; a personal history of breast cancer and higher risk perception was associated with higher psychological distress at T1 and T2. CONCLUSION: Standard breast imaging including MRI does not seem to convey more harmful psychological effects than standard imaging alone. Higher psychological distress observed in the case of history of breast cancer or higher breast cancer-risk perception evidences women with needs for specific support and information.

[French breast cancer screening: What's the place of artificial intelligence?] / Intelligence artificielle : Place dans le dépistage du cancer du sein en France.

This paper deals with the place in 2021 of artificial intelligence for screening of breast cancer in France et discusses of the different types of use and their performance in the literature (Standalone, Augmented radiologist, triage). Moreover, this paper will give an overview of the potential applications of AI in the future (Personalized screening, prediction of interval cancers).

Proof of Concept of 3-D Backscatter Tensor Imaging Tomography for Non-invasive Assessment of Human Breast Cancer Collagen Organization.

Tumor growth, similarly to several other pathologies, tends to change the structural orientation of soft tissue fibers, which can become relevant markers for diagnosis. Current diagnosis protocols may require a biopsy for histological analysis, which is an invasive, painful and stressful procedure with a minimum turnaround time of 2 d. Otherwise, diagnosis may involve the use of complex methods with limited availability such as diffusion tensor imaging (magnetic resonance diffusion tensor imaging), which is not widely used in medical practice. Conversely, advanced methodologies in ultrasound imaging such as backscatter tensor imaging (BTI) might become a routine procedure in clinical practice at a limited cost. This method evaluates the local organization of soft tissues based on the spatial coherence of their backscattered ultrasonic echoes. Previous work has proven that BTI applied with matrix probes enables measurement of the orientation of soft tissue fibers, especially in the myocardium. The aims of the study described here were (i) to present for the first time a methodology for performing BTI in a volume on ex vivo human breast tumors using a linear probe and (ii) to display a first proof of concept of the link between BTI measurements and the orientation of collagen fibers.

[Second reading in breast cancer screening program: State of knowledge and future]. / Seconde lecture en dépistage organisé du cancer du sein. États des lieux et perspectives d'évolution.

Second reading is an important part of breast cancer organized screening program. Image quality control and detection of non-diagnosed cancer by first reader are the two goals of this process. In France, 6 % of all screening cancer are diagnosed by second reading, actually done on screen film. With the technologic evolution (Digital breast tomosynthesis, Artificial intelligence) and societal digitalization, this process need to evolve. After some report about organization and results for second reading in France and outside, current and future shortcomings, proposition from professionals involved in breast cancer screening are made to improve this public health program.

Lipid-Associated Macrophages Are Induced by Cancer-Associated Fibroblasts and Mediate Immune Suppression in Breast Cancer.

Tumor-associated macrophages (TAM) play a detrimental role in triple-negative breast cancer (TNBC). In-depth analysis of TAM characteristics and interactions with stromal cells, such as cancer-associated fibroblast (CAF), could provide important biological and therapeutic insights. Here we identify at the single-cell level a monocyte-derived STAB1+TREM2high lipid-associated macrophage (LAM) subpopulation with immune suppressive capacities that is expanded in patients resistant to immune checkpoint blockade (ICB). Genetic depletion of this LAM subset in mice suppressed TNBC tumor growth. Flow cytometry and bulk RNA sequencing data demonstrated that coculture with TNBC-derived CAFs led to reprogramming of blood monocytes towards immune suppressive STAB1+TREM2high LAMs, which inhibit T-cell activation and proliferation. Cell-to-cell interaction modeling and assays in vitro demonstrated the role of the inflammatory CXCL12-CXCR4 axis in CAF-myeloid cell cross-talk and recruitment of monocytes in tumor sites. Altogether, these data suggest an inflammation model whereby monocytes recruited to the tumor via the CAF-driven CXCL12-CXCR4 axis acquire protumorigenic LAM capacities to support an immunosuppressive microenvironment. SIGNIFICANCE: This work identifies a novel lipid-associated macrophage subpopulation with immune suppressive functions, offering new leads for therapeutic interventions in triple-negative breast cancer.

Dual-energy contrast-enhanced digital mammography: initial clinical results.

OBJECTIVE: To assess the diagnostic accuracy of Dual-Energy Contrast-Enhanced Digital Mammography (CEDM) as an adjunct to mammography (MX) versus MX alone and versus mammography plus ultrasound (US). MATERIALS AND METHODS: 120 women with 142 suspect findings on MX and/or US underwent CEDM. A pair of low- and high-energy images was acquired using a modified full-field digital mammography system. Exposures were taken in MLO at 2 min and in CC at 4 min after the injection of 1.5 ml/kg of an iodinated contrast agent. One reader evaluated MX, US and CEDM images during 2 sessions 1 month apart. Sensitivity, specificity, and area under the ROC curve were estimated. RESULTS: The results from pathology and follow-up identified 62 benign and 80 malignant lesions. Areas under the ROC curves were significantly superior for MX+CEDM than it was for MX alone and for MX+US using BI-RADS. Sensitivity was higher for MX+CEDM than it was for MX (93% vs. 78%; p < 0.001) with no loss in specificity. The lesion size was closer to the histological size for CEDM. All 23 multifocal lesions were correctly detected by MX+CEDM vs. 16 and 15 lesions by MX and US respectively. CONCLUSION: Initial clinical results show that CEDM has better diagnostic accuracy than mammography alone and mammography+ultrasound.

Correlation of ultrasound, cytological, and histological features of 110 benign BI-RADS categories 4C and 5 nonpalpable breast lesions. The Institut Curie's experience.

BACKGROUND: The purpose of this study was to determine the pathological and ultrasound (US) features of benign nonpalpable breast lesions (NPBLs) classified as Breast Imaging Reporting and Data System (BI-RADS) category 4C or 5. METHODS: Between 2003 and 2007, 849 consecutive NPBLs detected at US and classified as BI-RADS category 4C (505) or 5 (344) initially underwent US-guided fine needle aspiration (FNA) at our institution. Benign diagnoses were established according to surgical excision findings or during a minimal 6-month imaging follow-up (mean, 3.7 years [SD, 2.6 years]). US BI-RADS features were reviewed and compared retrospectively using a chi-square test for the following pathological categories: epithelial and fibrous proliferation (EFP), cystic and papillary lesion (C&P), inflammatory lesion (IL), benign tumor (BT), intramammary lymph node (ILN), intraepithelial proliferative lesion (IPL), and nonspecific morphological alteration (NMA). The performance of FNA in the diagnosis of benignity was assessed. RESULTS: Of 849 NPBLs, 110 (12.9%) NPBLs were benign: 88 (17.4%) were BI-RADS category 4C, and 22 (6.4%) were BI-RADS category 5. Forty-four (40%) were EFPs, 21 (19%) were C&Ps, 13 (12%) were NMAs, 11 (10%) were ILs, 11 (10%) were BTs, 8 (7%) were IPLs, and 2 (2%) were ILNs. Lesion shape, US pattern distribution, and posterior features showed statistically significant differences between these categories (P < .05): 33 (75%) EFPs exhibited posterior shadowing, 18 (86%) C&Ps were homogenous, 9 (82%) ILs were heterogeneous, 11 (100%) BTs were homogeneous, 9 (82%) BTs were oval, and 6 (75%) IPLs were irregularly shaped. Of the 110 benign NPBLs, FNA diagnosis was falsely positive in 7 (6%), suspicious in 10 (9%), and benign in 90 (82%), and 3 (3%) were inadequate for diagnosis. CONCLUSION: A diverse array of benign NPBLs can be classified as BI-RADS category 4C or 5 on US, each showing specific imaging presentations.

Clinical management of atypical ductal hyperplasia on vacuum-assisted biopsy of microcalcifications: External validation study of a decision tree selecting patients eligible for surveillance.

BACKGROUND: Atypical lesions found on percutaneous breast biopsy raise specific management issues. The aim of this study was to validate the previous performance of a decision tree defined by Forgeard et al to select a subset of patients at low-risk of surgical diagnostic upgrade that would be eligible for surveillance. METHODS: A consecutive series of 211 patients diagnosed with ADH on vacuum-assisted biopsy (VAB) of clustered microcalcifications alone, then operated in our institution, was reviewed. Histological findings on percutaneous cores were compared with definitive diagnoses on surgical specimens. The rate of cancer underestimation on VAB was analyzed in the four arms and two management attitudes defined in the scheme, using size and quality of microcalcification removal and the number of ADH foci. RESULTS: Ninety-eight women with ADH met the inclusion criteria. Overall, 20 cancers were diagnosed at surgery, showing a malignancy rate of 44% (17/39 patients) in the surgery group and of 5% (3/59 patients) in the surveillance group, which was not significantly different from the 2% rate in the monitored reference group (p > 0.64). The malignancy rate increased significantly with the size of clustered microcalcifications (0% when < 6mm, 17% when between 6mm and 21 mm, 48% when > 21 mm, p < 0001) and the number of ADH foci on VAB (14% when ≤ 2, 45% when > 2, p < 0.005). CONCLUSION: Our results corroborate - within the limits of large confidence intervals - those obtained with the reference decision tree. Due to statistical uncertainty, however, they need to be prospectively validated in a broader series.

Breast lesions: quantitative elastography with supersonic shear imaging--preliminary results.

PURPOSE: To determine the appearance of breast lesions at quantitative ultrasonographic (US) elastography by using supersonic shear imaging (SSI) and to assess the correlation between quantitative values of lesion stiffness and pathologic results, which were used as the reference standard. MATERIALS AND METHODS: This study was approved by the French National Committee for the Protection of Patients Participating in Biomedical Research Programs. All patients provided written informed consent. Conventional US and SSI quantitative elastography were performed in 46 women (mean age, 57.6 years; age range, 38-71 years) with 48 breast lesions (28 benign, 20 malignant; mean size, 14.7 mm); pathologic results were available in all cases. Quantitative lesion elasticity was measured in terms of the Young modulus (in kilopascals). Sensitivity, specificity, and area under the curve were obtained by using a receiver operating characteristic curve analysis to assess diagnostic performance. RESULTS: All breast lesions were detected at SSI. Malignant lesions exhibited a mean elasticity value of 146.6 kPa +/- 40.05 (standard deviation), whereas benign ones had an elasticity value of 45.3 kPa +/- 41.1 (P < .001). Complicated cysts were differentiated from solid lesions because they had elasticity values of 0 kPa (no signal was retrieved from liquid areas). CONCLUSION: SSI provides quantitative elasticity measurements, thus adding complementary information that potentially could help in breast lesion characterization with B-mode US.

Quantitative CT Extent of Lung Damage in COVID-19 Pneumonia Is an Independent Risk Factor for Inpatient Mortality in a Population of Cancer Patients: A Prospective Study.

Background: CT lung extent has emerged as a potential risk factor of COVID-19 pneumonia severity with mainly semiquantitative assessment, and outcome was not assessed in the specific oncology setting. The main goal was to evaluate the prognostic role of quantitative assessment of the extent of lung damage for early mortality of patients with COVID-19 pneumonia in cancer patients. Methods: We prospectively included consecutive cancer patients with recent onset of COVID-19 pneumonia assessed by chest CT between March 15, 2020, and April 20, 2020, and followed until May 1, 2020. Demographic, clinical, laboratory test data and imaging findings were recorded. Quantitative chest CT assessment of COVID-19 pneumonia was based on the density distribution of lung lesions using a freely available software recently released (Myrian XP-Lung). The association between extent of lung damage and overall survival was studied by univariate and multivariate Cox analysis. The Uno C-index was used to assess the discriminatory value of the quantitative CT extent of lung damage. Results: Seventy cancer patients with chest CT evidence of COVID-19 were included. After a median follow-up of 25 days, 17 patients (24%) had died. The median quantitative chest CT extent of COVID-19 was 20% (IQR = 14-35, range = 3-59) for non-survivors vs. 10% (IQR = 6-15, range = 2-55) for survivors (p = 0.002). The extent of COVID-19 pneumonia was correlated with inpatient management (p = 0.003) and oxygen therapy requirements (p < 0.001). Independent factors associated with death were performance status (PS) ≥2 (HR = 3.9, 95% CI = [1.1-13.8] p = 0.04) and extent of COVID-19 pneumonia ≥30% (HR = 12.0, 95% CI = [2.2-64.4] p = 0.004). No differences were found regarding the histology of cancer, cancer stage, metastases sites, or type of oncologic treatment between the survivor and non-survivor groups. The cross-validated Uno C-index of the model including PS and extent of COVID-19 pneumonia was 0.83, 95% CI = [0.73-0.93]. Conclusions: The quantitative chest CT extent of COVID-19 pneumonia was a strong independent prognostic factor of early inpatient mortality in a population of cancer patients.