Diagnostic accuracy of digital breast tomosynthesis and digital mammography in women with dense or non-dense breast tissue: A systematic review and meta-analysis.

BACKGROUND: Despite its excellent screening effectiveness and sensitivity for breast cancer (BC), digital breast tomosynthesis (DBT) is controversial due to its high radiation exposure and long reading time. This study examines the diagnostic accuracy of DBT and digital mammography (DM) for BC screening and diagnosis in women with dense or non-dense breast tissue. MATERIAL AND METHODS: PRISMA-compliant searches were performed on Medline, Embase, PubMed, Web of Science, and the Cochrane databases for articles comparing DBT and DM for BC screening until March 2023. Meta-analysis was performed using RevMan sofware, and the Cochrane Risk of Bias Assessment Tool was employed to assess study quality. RESULTS: This meta-analysis included 11 trials with a total of 2,124,018 individuals. Screening with DBT resulted in a greater cancer detection rate, as demonstrated by a risk ratio (RR) of 1.27 (95% confidence interval (95% CI): 1.14-1.41). Digital breast tomosynthesis also had a reduced recall rate, with a RR of 0.88 (95% CI: 0.78-0.99), higher sensitivity and specificity values (pooled sensitivity of 0.91 (95% CI: 0.59-0.99)) and pooled specificity of 0.90 (95% CI: 0.42-1.0)) than DM (pooled sensitivity of 0.86 (95% CI: 0.52-1.0) and pooled specificity of 0.81 (95% CI: 0.12-1.0)). All acquired data exhibited reliability, lack of bias and statistical significance (p < 0.05). CONCLUSION: Digital breast tomosynthesis is a more effective screening and diagnostic assessment tool for women with dense or non-dense breasts than DM in terms of incremental cancer detection, sensitivity and recall rate.

Capability and reliability of deep learning models to make density predictions on low-dose mammograms.

Purpose: Breast density is associated with the risk of developing cancer and can be automatically estimated using deep learning models from digital mammograms. Our aim is to evaluate the capacity and reliability of such models to predict density from low-dose mammograms taken to enable risk estimates for younger women. Approach: We trained deep learning models on standard-dose and simulated low-dose mammograms. The models were then tested on a mammography dataset with paired standard- and low-dose images. The effect of different factors (including age, density, and dose ratio) on the differences between predictions on standard and low doses is analyzed. Methods to improve performance are assessed, and factors that reduce the model quality are demonstrated. Results: We showed that, although many factors have no significant effect on the quality of low-dose density prediction, both density and breast area have an impact. The correlation between density predictions on low- and standard-dose images of breasts with the largest breast area is 0.985 (0.949 to 0.995), whereas that with the smallest is 0.882 (0.697 to 0.961). We also demonstrated that averaging across craniocaudal-mediolateral oblique (CC-MLO) images and across repeatedly trained models can improve predictive performance. Conclusions: Low-dose mammography can be used to produce density and risk estimates that are comparable to standard-dose images. Averaging across CC-MLO and model predictions should improve this performance. The model quality is reduced when making predictions on denser and smaller breasts.

A Comparative Analysis of Mammography Uptake between Migrant and Non-Migrant Women in Austria-Results of the Austrian Health Interview Survey.

Mammography can reduce breast cancer incidence and mortality. Studies on the utilization of mammography among migrant and non-migrant women are inconsistent. Many of these studies do not take the heterogeneity of migrants in terms of ethnicity and country of origin into account. The aim of the present study was to examine disparities in the use of mammography between non-migrant women and the five largest migrant groups in Austria. The study used data from a nationwide population-based survey of 5118 women aged 45 years and older and analyzed the participation in mammography as a dependent variable. Multivariable logistic regression was used to compare mammography uptake between the aforementioned groups of women, while adjusting for socioeconomic and health variables. The study shows that all migrant groups involved tended to use mammography less frequently than non-migrant women; statistically significant differences, however, were only observed for Hungarian migrant women (adjusted OR = 0.36; 95%-CI: 0.13, 0.95; p = 0.038) and women from a Yugoslavian successor state (adjusted OR = 0.55; 95%-CI: 0.31, 0.99; p = 0.044). These findings are consistent with other studies in Europe and beyond, highlighting the heterogeneity of migrant populations and emphasizing the need for a diversity-sensitive approach to health care.

Correlations of Imaging and Therapy in Breast Cancer Based on Molecular Patterns: An Important Issue in the Diagnosis of Breast Cancer.

Breast cancer is a global health issue affecting countries worldwide, imposing a significant economic burden due to expensive treatments and medical procedures, given the increasing incidence. In this review, our focus is on exploring the distinct imaging features of known molecular subtypes of breast cancer, underlining correlations observed in clinical practice and reported in recent studies. The imaging investigations used for assessment include screening modalities such as mammography and ultrasonography, as well as more complex investigations like MRI, which offers high sensitivity for loco-regional evaluation, and PET, which determines tumor metabolic activity using radioactive tracers. The purpose of this review is to provide a better understanding as well as a revision of the imaging differences exhibited by the molecular subtypes and histopathological types of breast cancer.

Incidence-Based Breast Cancer Mortality Trends in Estonia Before and After the Introduction of Organized Mammography Screening: A Register-Based Study.

BACKGROUND: Despite the relatively low breast cancer incidence in Estonia, mortality remains high, and participation in mammography screening is below the recommended 70%. The objective of this register-based study was to evaluate incidence-based (IB) breast cancer mortality before and after the introduction of organized mammography screening in 2004. METHODS: Breast cancer deaths individually linked to breast cancer diagnosis were obtained from the Estonian Cancer Registry and used for calculating IB mortality. We compared age-specific IB mortality rates across 5-year birth cohorts and 5-year periods. Poisson regression was used to compare IB mortality for one age group invited to screening (50-63) and three age groups not invited to screening (30-49, 65-69, and 70+) during two periods before and after screening initiation (1993-2003 and 2004-2014). Joinpoint regression was used for age-standardized incidence and IB mortality trends. RESULTS: Age-standardized IB mortality has been decreasing since 1997. Age-specific IB mortality for birth cohorts never exposed to screening showed a continuous increase with age, while in cohorts exposed to organized screening the mortality curve flattened or declined after the age of first invitation. Significant decreases in mortality from 1993-2003 to 2004-2014 were seen in the 30-49 (age-adjusted rate ratio 0.51, 95% CI 90.42-0.63) and 50-63 (0.65, 95% CI 0.56-0.74) age groups, while no decline was seen in the 65-69 and 70+ age groups. CONCLUSIONS: The age specific IB mortality curves in birth cohorts exposed to screening and the significant mortality decline in the target age group after the initiation of the organized program suggest a beneficial effect of screening. Improved treatment without screening has not reduced mortality in older age groups. Our results support raising the upper screening age limit to 74 years.

Case report: Possible role of low-dose PEM for avoiding unneeded procedures associated with false-positive or equivocal breast MRI results.

Contrast-enhanced breast magnetic resonance imaging (MRI) is currently recommended as a screening tool for high-risk women and has been advocated for women with radiologically dense breast tissue. While breast MRI is acknowledged for its high sensitivity (with an exception for lower-grade ductal carcinoma in situ (DCIS) where emerging techniques like diffusion-weighted imaging offer improvement), its limitations include sensitivity to hormonal changes and a relatively high false-positive rate, potentially leading to overdiagnosis, increased imaging uncertainty, and unnecessary biopsies. These factors can exacerbate patient anxiety and impose additional costs. Molecular imaging with breast-targeted Positron Emission Tomography (PET) has shown the capability to detect malignancy independent of breast density and hormonal changes. Furthermore, breast-targeted PET has shown higher specificity when compared with MRI. However, traditional PET technology is associated with high radiation dose, which can limit its widespread use particularly in repeated studies or for undiagnosed patients. In this case report, we present a clinical application of low-dose breast imaging utilizing a breast-targeted PET camera (Radialis PET imager, Radialis Inc). The case involves a 33-year-old female patient who had multiple enhanced lesions detected on breast MRI after surgical removal of a malignant phyllodes tumor from the right breast. A benign core biopsy was obtained from the largest lesion seen in the left breast. One month after the MRI, 18F-fluorodeoxyglucose (18F-FDG) PET imaging session was performed using the Radialis PET Imager. Although the Radialis PET Imager has proven high count sensitivity and the capability to detect breast lesions with low metabolic activity (at a dose similar to mammography), no areas of increased 18F-FDG uptake were visualized in this particular case. The patient underwent a right-sided nipple-sparing mastectomy and left-sided lumpectomy, with bilateral reconstruction. The excised left breast tissue was completely benign, as suggested by both core biopsy and the PET results. The case presented highlights a promising clinical application of low-dose breast-targeted PET imaging to mitigate the uncertainty associated with MRI while keeping radiation doses within the safe range typically used in X-ray mammography.

Evaluating acute nipple inversion, imaging findings and outcomes.

PURPOSE: Acute nipple inversion can be unsettling for patients and is sometimes associated with an underlying breast malignancy. It also poses a diagnostic challenge with lack of consensus management guidelines. This study reviewed institutional experience with new nipple inversion, including malignant association, imaging utilization, and outcomes, in an effort to improve management. METHODS: A multisite institutional retrospective review was conducted of all breast imaging reports from 1/2010 to 6/2022 mentioning nipple inversion as an indication or finding. Patients with new nipple inversion, defined as arising since the time of last breast imaging exam or if reported as new by the patient/provider, were included for analysis. Retroareolar imaging findings, BI-RADS assessments/recommendations, pathology obtained from percutaneous or excisional biopsies, and follow-up imaging and clinical exams were collated. Cases of chronic or stable nipple inversion were excluded. Descriptive statistics were performed. RESULTS: A total of 414 patients had new nipple inversion, 387/414 (93.5 %) with benign or negative results at initial imaging and 27/414 (6.5 %) with malignant lesions. Diagnostic mammography/ultrasound detected 25/27 (92.6 %) cancers (sensitivity 92.6 %, specificity 75.5 %, PPV 20.8 %, NPV 99.3 %). Of 62 breast MRI exams performed in patients with negative mammogram/ultrasound, no cancers were detected in the retroareolar space with 2 incidental malignant lesions discovered distant from the nipple. CONCLUSION: Diagnostic mammography/ultrasound is reliable in workups of acute nipple inversion, with a high sensitivity and NPV for excluding malignancy. Breast MRI and surgical referral should be reserved for patients with suspicious associated symptoms or clinical findings.

The Chiraiya project: a retrospective analysis of breast cancer detection gaps addressed via mobile mammography in Jammu Province, India.

BACKGROUND: Breast cancer remains a pervasive threat to women worldwide, with increasing incidence rates necessitating effective screening strategies. Timely detection with mammography has emerged as the primary tool for mass screening. This retrospective study, which is part of the Chiraiya Project, aimed to evaluate breast lesion patients identified during opportunistic mammography screening camps in Jammu Province, India. METHODS: A total of 1505 women aged 40 years and older were screened using a mobile mammographic unit over a five-year period, excluding 2020 and 2021 due to the COVID-19 pandemic. The inclusion criterion was women in the specified age group, while the exclusion criterion was women with open breast wounds, history of breast cancer or a history of breast surgery. The screening process involved comprehensive data collection using a detailed Proforma, followed by mammographic assessments conducted within strategically stationed mobile units. Radiological interpretations utilizing the BI-RADS system were performed, accompanied by meticulous documentation of patient demographics, habits, literacy, medical history, and breastfeeding practices. Participants were recruited through collaborations with NGOs, army camps, village panchayats, and urban cooperatives. Screening camps were scheduled periodically, with each camp accommodating 90 patients or fewer. RESULTS: Among the 1505 patients, most were aged 45-50 years. The number of screenings increased yearly, peaking at 441 in 2022. The BI-RADS II was the most common finding (48.77%), indicating the presence of benign lesions, while the BI-RADS 0 (32.96%) required further evaluation. Higher-risk categories (BI-RADS III, IV, V) were less common, with BI-RADS V being the rarest. Follow-up adherence was highest in the BI-RADS III, IV, and V categories, with BI-RADS V achieving 100% follow-up. However, only 320 of 496 BI-RADS 0 patients were followed up, indicating a gap in continuity of care. The overall follow-up rate was 66.89%. Compared to urban areas, rural areas demonstrated greater screening uptake but lower follow-up rates, highlighting the need for tailored interventions to improve follow-up care access, especially in rural contexts. CONCLUSION: This study underscores the efficacy of a mobile mammographic unit in reaching marginalized populations. Adherence to screening protocols has emerged as a linchpin for early detection, improved prognosis, and holistic public health enhancement. Addressing misconceptions surrounding mammographic screenings, especially in rural settings, is crucial. These findings call for intensified efforts in advocacy and education to promote the benefits of breast cancer screening initiatives. Future interventions should prioritize improving access to follow-up care and addressing screening to enhance breast cancer management in Jammu Province.

An initial investigation into the use of virtual reality (VR) glasses on self-reported pain perception during mammography.

OBJECTIVE: Pain is one of the causes of refraining from mammography. This study aimed to investigate the use of virtual reality (VR) glasses for management of pain during mammography. METHODS: Fifty subjects who were referred to the radiology unit for mammography screening were invited to participate in the study. The study was approved by the hospital's ethics committee and participants provided written and oral informed consent. Craniocaudal (CC) and mediolateral oblique (MLO) views of the right breast were first acquired, followed by left CC and MLO mammographic views with the VR glasses on. After the examination, participants completed a questionnaire including a validated visual analog scale (VAS) scoring system to analyze pain scores. Data were analyzed using Spearman's rho and the Kruskal-Wallis test, as well as the Bland-Altman analysis to examine discrepancy. RESULTS: The association of the right breast pain score with the parameters of age, breast density, previous mammography, family history of breast cancer, educational attainment, and employment status was examined using a correlation test. All the parameters showed no significant correlation with the right breast pain score except age (p: 0.016, correlation coefficient: -.340). Apart from that this study demonstrated no significant correlation between the perceived pain experienced during mammography and the utilization of VR technology. CONCLUSION: The findings indicate an inverse correlation between participant's age and pain perception during mammography examinations. Moreover, the utilization of Virtual Reality (VR) did not demonstrate efficacy in reducing pain perception.

Localized AL amyloidosis of the breast in a geriatric female.

Localized breast amyloidosis is often found incidentally on mammography or ultrasound, as amyloid deposits can be calcified and mimic malignancy. Although rare, breast amyloidosis should be considered a possible etiology of abnormal mammography findings in older women.

Performance of Contrast-Enhanced Mammography (CEM) for Monitoring Neoadjuvant Chemotherapy Response among Different Breast Cancer Subtypes.

Neoadjuvant chemotherapy (NAT) plays a crucial role in breast cancer (BC) treatment, both in advanced BC and in early-stage BC, with different rates of pathological complete response (pCR) among the different BC molecular subtypes. Imaging monitoring is mandatory to evaluate the NAT efficacy. This study evaluates the diagnostic performance of Contrast-Enhanced Mammography (CEM) in BC patients undergoing NAT. This retrospective two-center study included 174 patients. The breast lesions were classified based on the molecular subtypes in hormone receptor (HR+)/HER2-, HER2+, and triple-negative breast cancer (TNBC). The histopathological analysis performed following surgery was used as a reference standard for the pCR. Sensitivity, specificity, PPV, and NPV were measured overall and for the different subtypes. We enrolled 174 patients, 79/174 (46%) HR+/HER2-, 59/174 (33.9%) HER2+, and 35/174 (20.1%) TNBC; the pCR was found in 64/174 (36.8%), of which 57.1% were TNBCs. In the total population, the CEM sensitivity and specificity were 66.2% and 75.2%, with a PPV of 61.4% and an NPV of 78.8%. The highest specificity (80.9%) and NPV (91.7%) were found in HR+/HER2-, while the highest sensitivity (70%) and PPV appeared (73.7%) in TNBC. The results indicate that CEM is a valid tool to assess the pCR, with different performances among the subtypes of BC.

AI-enhanced Mammography With Digital Breast Tomosynthesis for Breast Cancer Detection: Clinical Value and Comparison With Human Performance.

Purpose To compare two deep learning-based commercially available artificial intelligence (AI) systems for mammography with digital breast tomosynthesis (DBT) and benchmark them against the performance of radiologists. Materials and Methods This retrospective study included consecutive asymptomatic patients who underwent mammography with DBT (2019-2020). Two AI systems (Transpara 1.7.0 and ProFound AI 3.0) were used to evaluate the DBT examinations. The systems were compared using receiver operating characteristic (ROC) analysis to calculate the area under the ROC curve (AUC) for detecting malignancy overall and within subgroups based on mammographic breast density. Breast Imaging Reporting and Data System results obtained from standard-of-care human double-reading were compared against AI results with use of the DeLong test. Results Of 419 female patients (median age, 60 years [IQR, 52-70 years]) included, 58 had histologically proven breast cancer. The AUC was 0.86 (95% CI: 0.85, 0.91), 0.93 (95% CI: 0.90, 0.95), and 0.98 (95% CI: 0.96, 0.99) for Transpara, ProFound AI, and human double-reading, respectively. For Transpara, a rule-out criterion of score 7 or lower yielded 100% (95% CI: 94.2, 100.0) sensitivity and 60.9% (95% CI: 55.7, 66.0) specificity. The rule-in criterion of higher than score 9 yielded 96.6% sensitivity (95% CI: 88.1, 99.6) and 78.1% specificity (95% CI: 73.8, 82.5). For ProFound AI, a rule-out criterion of lower than score 51 yielded 100% sensitivity (95% CI: 93.8, 100) and 67.0% specificity (95% CI: 62.2, 72.1). The rule-in criterion of higher than score 69 yielded 93.1% (95% CI: 83.3, 98.1) sensitivity and 82.0% (95% CI: 77.9, 86.1) specificity. Conclusion Both AI systems showed high performance in breast cancer detection but lower performance compared with human double-reading. Keywords: Mammography, Breast, Oncology, Artificial Intelligence, Deep Learning, Digital Breast Tomosynthesis © RSNA, 2024.

ESR Essentials: diagnostic work-up in patients with symptomatic breast disease-practice recommendations by the European Society of Breast Imaging.

Breast complaints are frequent reasons for consultations in primary care or breast clinics. Breast pain, breast lumps, and nipple discharge are the most common complaints. Less common symptoms such as skin changes and axillary abnormalities also require specific diagnostic approaches. Imaging the symptomatic breast should be performed by appropriately trained breast radiologists following the best practice guidelines and quality standards. Full-field digital mammography (FFDM), digital breast tomosynthesis (DBT), and breast ultrasound (US) are the main modalities used in this primary setting. The choice depends on the patient's age and symptoms. Women younger than 30-years-old are first imaged by US, whereas women over 40-years-old usually require both FFDM or DBT and US. For women between 30-years-old and 40-years-old, the US is the modality of choice, whereas FFDM or DBT might also be performed if needed. Pregnant or lactating women with palpable lesions or nipple discharge are imaged with US as the first method; FFDM or DBT can also be performed depending on the degree of suspicion as the dose to the fetus is minimal, and shielding may even further reduce the dose. More advanced techniques such as breast magnetic resonance imaging or contrast-enhanced mammography are not indicated in this first diagnostic setting and are reserved for cases of established malignancy (local staging) or rare cases of equivocal findings not otherwise resolved or inflammatory breast cancer. Last, but not least, male breast symptoms should also be addressed with US and/or FFDM. CLINICAL RELEVANCE STATEMENT: It is equally important to correctly diagnose an underlying malignancy and to avoid false positives that would lead to unnecessary biopsies, increased costs, and anxiety for the patient. Proper use of imaging modalities ensures optimal diagnostic approach and minimizes false negatives. KEY POINTS: Ultrasound, full-field digital mammography, or digital breast tomosynthesis are the main imaging modalities in the diagnostic setting, while MRI or contrast-enhanced mammography should be reserved to selected cases. Initial imaging modality includes ultrasound combined with mammography or digital breast tomosynthesis depending on women's age and the presence (or not) of inconclusive findings. A negative imaging evaluation should not deter biopsy when a highly suspicious finding is found on physical examination.

Knowledge, Age, and Perceived Social Barriers Regarding Mammography Screening Among Immigrant Arab Women in the United States: A Predictive and Associative Analysis.

Background: Ethnic minority women in the United States continue to experience racial disparities. Immigrant Arab women (IAW) underutilize mammography screening (MS) even compared with other ethnic minorities. This population still has gaps in knowledge regarding breast cancer (BC) and screening methods and encounters social barriers, highlighting the imperative role of the male figure and the family, which hinders screening. Materials and Methods: A cross-sectional design with an exploratory and predictive approach was employed to examine knowledge gaps and perceived social barriers associated with MS and to identify predictive factors of MS among IAW in California. The analysis included 316 women that met the eligibility criteria. Results: Familiarity with MS and awareness of screening recommendations were the specific areas of knowledge significantly associated with mammography uptake (odds ratio [OR] 15.4, 95% confidence interval [CI]: 5.6-40.8, p < 0.001) and (OR 12.07, 95% CI: 7-21, p < 0.001), respectively. Logistic regression revealed three MS predictors, the two knowledge areas and age. Perceived social barriers were significantly associated with age [F (3,312) = 4.684, p = 0.003]. There was a significant difference in social barriers between women in their 40s and those in their 60s (p = 0.002) and between women in their 50s and those in their 60s (p = 0.003), suggesting lower barriers among women in their 60s (M = 14.3). Living status was significantly associated with perceived social barriers [F (1,314) = 8.83, p = 0.003]. Conclusions: This study offered valuable insights for health care professionals, policymakers, and community organizations working to improve BC early detection in immigrant and ethnic women to reduce social disparities and reinforce social justice. Knowledge-deficit areas and social barriers must be analyzed and incorporated in awareness programs to improve screening practices of IAW.

Cat scratch disease unveils hidden breast carcinoma: A diagnostic twist.

Cat scratch disease is a rare condition that can present with different clinical manifestations, including axillary lymphadenopathy. Here, we report the case of a 45-year-old female who presented with axillary lymphadenopathy attributable to a process of differential diagnosis to cat scratch disease. During the thorough investigation of her condition, a routine mammogram was performed, due to the unilateral axillary lymphadenopathy, revealing the presence of previously undiagnosed breast carcinoma in situ; in fact, a DCIS (invasive ductal carcinoma with spread to the ipsilateral axillary nodes) was incidentally found. This case highlights the importance of comprehensive differential diagnosis and a multidisciplinary approach in managing patients with atypical presentations of common diseases, given that other alarming but unrelated findings are visible.

Breast calcifications on mammography from systemic amyloidosis: A case report.

Calcifications on mammography from systemic disease at times meet diagnostic criteria for histologic sampling to exclude malignancy. We present a case of bilateral groups of new calcifications on mammography that yielded amyloidosis on core biopsy. Awareness of our patient's known diagnosis of systemic light chain amyloidosis (AL) prompted use of Congo red staining to confirm the histologic diagnosis. Knowledge of systemic diseases with possible manifestations on mammography can facilitate cogent and clinically relevant radiology-pathology correlation.

Trabecular thickening on mammography post-COVID vaccine and RSV vaccine: Case report.

Ipsilateral axillary adenopathy post-COVID mRNA vaccine has been widely reported and guidelines for management have been established. Isolated changes of axillary tail trabecular thickening without associated adenopathy in the breast present a diagnostic dilemma and no official guidelines have thus far been reported. This finding has been reported after COVID mRNA vaccine and has never been reported with any other vaccine. We report on a patient with such changes on screening mammography 1.5 months after the fifth dose of a COVID-mRNA vaccine and 1 week after RSV vaccine. This raises the possibility that such changes can be seen with vaccines other than the COVID mRNA series of vaccines. The main differential diagnosis includes mastitis and inflammatory breast cancer. The transient nature of this finding with spontaneous resolution at diagnostic mammography and the vaccination history helps to establish the diagnosis and exclude breast cancer.

Unusual metastases to the breast from different extramammary malignancies: a multimodality imaging approach in a case series.

Extramammary metastases are uncommon and usually related to a poor prognosis, but the radiologist can suspect the diagnosis based on the patient's clinical history and specific imaging findings. Several imaging procedures may be used to evaluate breast metastases from different extramammary malignancies, including mammography, ultrasound, magnetic resonance imaging (MRI), computed tomography (CT), and positron emission tomography-CT (PET-CT). The clinical and imaging presentation of these metastases is contingent upon how the illness spreads, however, they have the potential to resemble either benign or malignant breast tumors. Metastases that disseminate hematologically tend to appear as a single round or oval mass with circumscribed margins. Sonographically, they are usually hypoechoic, and with CT or MRI, they usually enhance. Lymphatic dissemination, for example, frequently reveals significant asymmetry with skin thickening and diffuse breast edema, which is compatible with an inflammatory breast carcinoma. Knowing the many types of cancers that have the potential to spread to the breast as well as being able to accurately diagnose them is crucial to prevent a needless mastectomy and provide guidance for subsequent treatment. The purpose of this article is to provide a better understanding of the imaging features and immunohistochemistry (IHC) of secondary tumors of the breast by presenting eight distinctive cases, which will enable radiologists to recognize this entity.

The verification of the utility of a commercially available phantom combination for quality control in contrast-enhanced mammography.

Contrast-enhanced mammography is being increasingly implemented clinically, providing much improved contrast between tumour and background structures, particularly in dense breasts. Although CEM is similar to conventional mammography it differs via an additional exposure with high energy X-rays (≥ 40 kVp) and subsequent image subtraction. Because of its special operational aspects, the CEM aspect of a CEM unit needs to be uniquely characterised and evaluated. This study aims to verify the utility of a commercially available phantom set (BR3D model 020 and CESM model 022 phantoms (CIRS, Norfolk, Virginia, USA)) in performing key CEM performance tests (linearity of system response with iodine concentration and background subtraction) on two models of CEM units in a clinical setting. The tests were successfully performed, yielding results similar to previously published studies. Further, similarities and differences in the two systems from different vendors were highlighted, knowledge of which may potentially facilitate optimisation of the systems.

Relative timing of mammography and MRI for breast cancer screening: Impact on performance evaluation.

OBJECTIVE: Mammography and MRI screening typically occur in combination or in alternating sequence. We compared multimodality screening performance accounting for the relative timing of mammography and MRI and overlapping follow-up periods. METHODS: We identified 8,260 screening mammograms performed 2005-2017 in the Breast Cancer Surveillance Consortium, paired with screening MRIs within +/- 90 days (combined screening) or 91-270 days (alternating screening). Performance for combined screening [cancer detection rate (CDR) per 1000 examinations and sensitivity] was calculated with one-year follow-up for each modality, and with a single follow-up period treating the two tests as a single test. Alternating screening performance was calculated with one-year follow-up for each modality and also with follow-up ending at the next screen if within one year (truncated follow-up). RESULTS: For 3,810 combined screening pairs, CDR per 1000 screens was 6.8 (95%CI: 4.6-10.0) for mammography and 12.3 (95%CI: 9.3-16.4) for MRI as separate tests compared to 13.1 (95%CI: 10.0-17.3) as a single combined test. Sensitivity of each test was 48.1% (35.0%-61.5%) for mammography and 79.7% (95%CI: 67.7-88.0%) for MRI compared to 96.2% (95%CI: 85.9-99.0%) for combined screening. For 4,450 alternating screening pairs, mammography CDR per 1000 screens changed from 3.6 (95%CI: 2.2-5.9) to zero with truncated follow-up; sensitivity was incalculable (denominator=0). MRI CDR per 1000 screens changed from 12.1 (95%CI 9.3-15.8) to 11.7 (95%CI: 8.9-15.3) with truncated follow-up; sensitivity changed from 75.0% (95%CI 63.8-83.6%) to 86.7% (95%CI 75.5-93.2%). DISCUSSION: Updating auditing approaches to account for combined and alternating screening sequencing and to address outcome attribution issues arising from overlapping follow-up periods can improve the accuracy of multimodality screening performance evaluation.