A predictive model using MRI and clinicopathologic features for breast cancer recurrence in young women treated with upfront surgery.

OBJECTIVES: To identify preoperative breast MR imaging and clinicopathological variables related to recurrence and develop a risk prediction model for recurrence in young women with breast cancer treated with upfront surgery. METHODS: This retrospective study analyzed 438 consecutive women with breast cancer aged 35 years or younger between January 2007 and December 2016. Breast MR images before surgery were independently reviewed by breast radiologists blinded to patient outcomes. The clinicopathological data including patient demographics, clinical features, and tumor characteristics were reviewed. Univariate and multivariate logistic regression analyses were used to identify the independent factors associated with recurrence. The risk prediction model for recurrence was developed, and the discrimination and calibration abilities were assessed. RESULTS: Of 438 patients, 95 (21.7%) developed recurrence after a median follow-up of 65 months. Tumor size at MR imaging (HR = 1.158, p = 0.006), multifocal or multicentric disease (HR = 1.676, p = 0.017), and peritumoral edema on T2WI (HR = 2.166, p = 0.001) were identified as independent predictors of recurrence, while adjuvant endocrine therapy (HR = 0.624, p = 0.035) was inversely associated with recurrence. The prediction model showed good discrimination ability in predicting 5-year recurrence (C index, 0.707 in the development cohort; 0.686 in the validation cohort) and overall recurrence (C index, 0.699 in the development cohort; 0.678 in the validation cohort). The calibration plot demonstrated an excellent correlation (concordance correlation coefficient, 0.903). CONCLUSION: A prediction model based on breast MR imaging and clinicopathological features showed good discrimination to predict recurrence in young women with breast cancer treated with upfront surgery, which could contribute to individualized risk stratification. CLINICAL RELEVANCE STATEMENT: Our prediction model, incorporating preoperative breast MR imaging and clinicopathological features, predicts recurrence in young women with breast cancer undergoing upfront surgery, facilitating personalized risk stratification and informing tailored management strategies. KEY POINTS: Younger women with breast cancer have worse outcomes than those diagnosed at more typical ages. The described prediction model showed good discrimination performance in predicting 5-year and overall recurrence. Incorporating better risk stratification tools in this population may help improve outcomes.

Use of a commercial artificial intelligence-based mammography analysis software for improving breast ultrasound interpretations.

OBJECTIVES: To evaluate the use of a commercial artificial intelligence (AI)-based mammography analysis software for improving the interpretations of breast ultrasound (US)-detected lesions. METHODS: A retrospective analysis was performed on 1109 breasts that underwent both mammography and US-guided breast biopsy. The AI software processed mammograms and provided an AI score ranging from 0 to 100 for each breast, indicating the likelihood of malignancy. The performance of the AI score in differentiating mammograms with benign outcomes from those revealing cancers following US-guided breast biopsy was evaluated. In addition, prediction models for benign outcomes were constructed based on clinical and imaging characteristics with and without AI scores, using logistic regression analysis. RESULTS: The AI software had an area under the receiver operating characteristics curve (AUROC) of 0.79 (95% CI, 0.79-0.82) in differentiating between benign and cancer cases. The prediction models that did not include AI scores (non-AI model), only used AI scores (AI-only model), and included AI scores (integrated model) had AUROCs of 0.79 (95% CI, 0.75-0.83), 0.78 (95% CI, 0.74-0.82), and 0.85 (95% CI, 0.81-0.88) in the development cohort, and 0.75 (95% CI, 0.68-0.81), 0.82 (95% CI, 0.76-0.88), and 0.84 (95% CI, 0.79-0.90) in the validation cohort, respectively. The integrated model outperformed the non-AI model in the development and validation cohorts (p < 0.001 for both). CONCLUSION: The commercial AI-based mammography analysis software could be a valuable adjunct to clinical decision-making for managing US-detected breast lesions. CLINICAL RELEVANCE STATEMENT: The commercial AI-based mammography analysis software could potentially reduce unnecessary biopsies and improve patient outcomes. KEY POINTS: • Breast US has high rates of false-positive interpretations. • A commercial AI-based mammography analysis software could distinguish mammograms having benign outcomes from those revealing cancers after US-guided breast biopsy. • A commercial AI-based mammography analysis software may improve interpretations for breast US-detected lesions.

Mammographic density assessment: comparison of radiologists, automated volumetric measurement, and artificial intelligence-based computer-assisted diagnosis.

BACKGROUND: Artificial intelligence-based computer-assisted diagnosis (AI-CAD) is increasingly used for mammographic exams, and its role in mammographic density assessment should be evaluated. PURPOSE: To assess the inter-modality agreement between radiologists, automated volumetric density measurement program (Volpara), and AI-CAD system in breast density categorization using the Breast Imaging-Reporting and Data System (BI-RADS) density categories. MATERIAL AND METHODS: A retrospective review was conducted on 1015 screening digital mammograms that were performed in Asian female patients (mean age = 56 years ± 10 years) in our health examination center between December 2022 and January 2023. Four radiologists with two different levels of experience (expert and general radiologists) performed density assessments. Agreement between the radiologists, Volpara, and AI-CAD (Lunit INSIGHT MMG) was evaluated using weighted kappa statistics and matched rates. RESULTS: Inter-reader agreement between expert and general radiologists was substantial (k = 0.65) with a matched rate of 72.8%. The agreement was substantial between expert or general radiologists and Volpara (k = 0.64-0.67) with a matched rate of 72.0% but moderate between expert or general radiologists and AI-CAD (k = 0.45-0.58) with matched rates of 56.7%-67.0%. The agreement between Volpara and AI-CAD was moderate (k = 0.53) with a matched rate of 60.8%. CONCLUSION: The agreement in breast density categorization between radiologists and automated volumetric density measurement program (Volpara) was higher than the agreement between radiologists and AI-CAD (Lunit INSIGHT MMG).

Randomized phase III trial of a neoadjuvant regimen of four cycles of adriamycin plus cyclophosphamide followed by four cycles of docetaxel (AC4-D4) versus a shorter treatment of three cycles of FEC followed by three cycles of docetaxel (FEC3-D3) in node-positive breast cancer (Neo-shorter; NCT02001506).

PURPOSE: To determine whether six cycles of FEC3-D3 has a comparable efficacy to eight of AC4-D4. METHODS: The enrolled patients (pts) were clinically diagnosed with stage II or III breast cancer. The primary endpoint was a pathologic complete response (pCR), and the secondary endpoints were 3 year disease-free survival (3Y DFS), toxicities, and health-related quality of life (HRQoL). We calculated that 252 pts were needed in each treatment group to enable the detection of non-inferiority (non-inferiority margin of 10%). RESULTS: In terms of ITT analysis, 248 pts were finally enrolled. The 218 pts who completed the surgery were included in the current analysis. The baseline characteristics of these subjects were well balanced between the two arms. By ITT analysis, pCR was achieved in 15/121 (12.4%) pts in the FEC3-D3 arm and 18/126 (14.3%) in the AC4-D4 arm. With a median follow up of 64.1 months, the 3Y DFS was comparable between the two arms (75.8% in FEC3-D3 vs. 75.6% in AC4-D4). The most common adverse event (AE) was Grade 3/4 neutropenia, which arose in 27/126 (21.4%) AC4-D4 arm pts vs 23/121 (19.0%) FEC3-D3 arm cases. The primary HRQoL domains were similar between the two groups (FACT-B scores at baseline, P = 0.35; at the midpoint of NACT, P = 0.20; at the completion of NACT, P = 0.44). CONCLUSION: Six cycles of FEC3-D3 could be an alternative to eight of AC4-D4. Trial registration ClinicalTrials.gov NCT02001506. Registered December 5,2013. https://clinicaltrials.gov/ct2/show/NCT02001506.

Effects of Preoperative Breast MRI on Breast Cancer Survival Outcomes in Women Aged 35 Years and Younger.

Background The impact of preoperative breast MRI on the long-term outcomes in patients with breast cancer who are 35 years and younger has not been established. Purpose To evaluate the impact of preoperative breast MRI on recurrence-free survival (RFS) and overall survival (OS) in women with breast cancer who are 35 years and younger by using propensity score matching. Materials and Methods A total of 708 women who were 35 years and younger (mean age, 32 years ± 3 [SD]) and diagnosed with breast cancer from 2007 to 2016 were retrospectively identified. Patients who underwent preoperative MRI (MRI group) were matched with those who did not (no MRI group) according to 23 patient and tumor characteristics. RFS and OS were compared using the Kaplan-Meier method. Cox proportional hazards regression analysis was used to estimate the hazard ratios (HRs). Results Of 708 women, 125 patient pairs were matched. In the MRI group versus the no MRI group, the mean follow-up time was 82 months ± 32 versus 106 months ± 42, and the rates of total recurrence and death were 22% (104 of 478 patients) versus 29% (66 of 230 patients) and 5% (25 of 478 patients) versus 12% (28 of 230 patients), respectively. The time to recurrence was 44 months ± 33 in the MRI group and 56 months ± 42 in the no MRI group. After propensity score matching, the MRI and no MRI groups did not show significant differences in total recurrence (HR, 1.0; P = .99), local-regional recurrence (HR, 1.3; P = .42), contralateral breast recurrence (HR, 0.7; P = .39), or distant recurrence (HR, 0.9; P = .79). The MRI group showed a tendency toward better OS, but this was not statistically significant (HR, 0.47; P = .07). In the entire unmatched cohort, MRI was not an independent significant factor for predicting RFS or OS. Conclusion Preoperative breast MRI was not a significant prognostic factor for recurrence-free survival in women 35 years and younger with breast cancer. A tendency toward better overall survival was observed in the MRI group, but this was not significant. © RSNA, 2023 Supplemental material is available for this article. See also the editorial by Kim and Moy in this issue.

Improving mammography interpretation for both novice and experienced readers: a comparative study of two commercial artificial intelligence software.

OBJECTIVES: To evaluate the improvement of mammography interpretation for novice and experienced radiologists assisted by two commercial AI software. METHODS: We compared the performance of two AI software (AI-1 and AI-2) in two experienced and two novice readers for 200 mammographic examinations (80 cancer cases). Two reading sessions were conducted within 4 weeks. The readers rated the likelihood of malignancy (range, 1-7) and the percentage probability of malignancy (range, 0-100%), with and without AI assistance. Differences in AUROC, sensitivity, and specificity were analyzed. RESULTS: Mean AUROC increased in both novice (0.86 to 0.90 with AI-1 [p = 0.005]; 0.91 with AI-2 [p < 0.001]) and experienced readers (0.87 to 0.92 with AI-1 [p < 0.001]; 0.90 with AI-2 [p = 0.004]). Sensitivities increased from 81.3 to 88.8% with AI-1 (p = 0.027) and to 91.3% with AI-2 (p = 0.005) in novice readers, and from 81.9 to 90.6% with AI-1 (p = 0.001) and to 87.5% with AI-2 (p = 0.016) in experienced readers. Specificity did not decrease significantly in both novice (p > 0.999, both) and experienced readers (p > 0.999 with AI-1 and 0.282 with AI-2). There was no significant difference in the performance change depending on the type of AI software (p > 0.999). CONCLUSION: Commercial AI software improved the diagnostic performance of both novice and experienced readers. The type of AI software used did not significantly impact performance changes. Further validation with a larger number of cases and readers is needed. CLINICAL RELEVANCE STATEMENT: Commercial AI software effectively aided mammography interpretation irrespective of the experience level of human readers. KEY POINTS: • Mammography interpretation remains challenging and is subject to a wide range of interobserver variability. • In this multi-reader study, two commercial AI software improved the sensitivity of mammography interpretation by both novice and experienced readers. The type of AI software used did not significantly impact performance changes. • Commercial AI software may effectively support mammography interpretation irrespective of the experience level of human readers.

A Propensity Score-matched Analysis of Long-term Oncologic Outcomes After Nipple-sparing Versus Conventional Mastectomy for Locally Advanced Breast Cancer.

OBJECTIVES: To compare the long-term oncologic outcomes of nipple-sparing mastectomy (NSM) with those of conventional mastectomy (CM) in patients with locally advanced breast cancer (LABC) receiving neoadjuvant chemotherapy (NACT). SUMMARY OF BACKGROUND DATA: NSM has been increasingly implemented in patients with breast cancer. However, oncologic efficacy of NSM in patients with LABC has not been sufficiently demonstrated. METHODS: The study group comprised 850 patients with clinical stage IIB to IIIC breast cancer who underwent NACT followed by either NSM and immediate breast reconstruction or CM alone. After propensity score-matching, 418 patients were included in the analysis. Local recurrence-free survival, disease-free survival (DFS), distant metastasis-free survival, and overall survival (OS) rates were calculated using the Kaplan-Meier method and compared using log-rank tests between the NSM and CM groups. RESULTS: After matching, the mean follow-up period was 70 ± 25 months for the NSM group and 74 ± 27 months for the CM group ( P = 0.181). There were no significant differences between the groups in terms of 6-year local recurrence-free survival (91.6% vs. 95.8%; P = 0.239), DFS (70.5% vs. 73.4%; P = 0.583), distant metastasis-free survival (79.8% vs. 77.4%; P = 0.320), or OS (87.6% vs. 84.8%; P = 0.465) rates. Additionally, we identified 30 patients in the NSM group who initially presented with tumor extension in the subareolar area; the nipple-areola complex was successfully preserved after NACT, and no recurrence at the nipple was observed in these patients. CONCLUSIONS: In this matched control study, we demonstrated comparable long-term oncologic outcomes between NSM with immediate reconstruction and CM alone after NACT for LABC. In patients who had tumors extending to the subareolar area before NACT, NSM can be tried if tumor involvement of the nipple-areola complex appears resolved on imaging studies after chemotherapy.

Breast cancer outcomes following immediate breast reconstruction with implants versus autologous flaps: a propensity score-matched study.

PURPOSE: A large proportion of patients with breast cancer who had mastectomy had undergone breast reconstruction with implants or autologous flaps. However, only a few studies have compared the breast cancer outcomes between the implant-based reconstruction (IBR) and autologous flap reconstruction (AFR). In this study, we retrospectively compared the local recurrence rates, distant metastasis rates, and survival outcomes between immediate IBR and AFR. METHODS: A total of 1530 patients with primary breast cancer who underwent IBR or AFR with nipple-/skin-sparing mastectomy were included. Patients who underwent neoadjuvant systemic therapy were excluded from the study. After propensity score matching by age at diagnosis, T stage, N stage, molecular subtype, mastectomy type, adjuvant radiotherapy status, and follow-up period, 938 patients were 1:1 matched, comprising the well-balanced IBR and AFR groups. Locoregional recurrence-free survival (LRRFS), disease-free survival (DFS), distant metastasis-free survival (DMFS), and breast cancer-specific survival (BCSS) were compared between the matched groups. RESULTS: After matching, the median follow-up periods were 68 months and 71 months for the IBR and AFR groups, respectively. No significant differences were observed between the IBR and AFR groups regarding the local recurrence (7.2% vs. 5.1%; P = 0.175), regional recurrence (2.1% vs. 1.5%; P = 0.463), or distant metastasis (3.2% vs. 3.2%; P = 1.000) rates. Moreover, no significant difference was observed between the IBR and AFR groups in the LRRFS (hazard ratio, 0.691; 95% CI, 0.433-1.102; P = 0.118), DFS (hazard ratio, 0.709; 95% CI, 0.468-1.076; P = 0.104), DMFS (hazard ratio, 1.006; 95% CI, 0.491-2.059; P = 0.987), or BCSS (hazard ratio, 0.445; 95% CI, 0.111-1.786; P = 0.659). CONCLUSION: In this propensity score-matched analysis of oncologic outcomes in patients with primary breast cancer who underwent immediate breast reconstruction with nipple-/skin-sparing mastectomy, no significant differences were observed between the IBR and AFR groups.

Oncologic Outcomes of Nipple-sparing Mastectomy and Immediate Reconstruction After Neoadjuvant Chemotherapy for Breast Cancer.

OBJECTIVES: To evaluate the oncologic outcomes and risk factors for locoregional recurrence (LRR) and nipple-areola complex recurrence (NR) in a large series of breast cancer patients who underwent nipple-sparing mastectomy (NSM) and immediate reconstruction after neoadjuvant chemotherapy (NACT). SUMMARY OF BACKGROUND DATA: The use of NSM and immediate reconstruction in breast cancer patients receiving NACT is increasing. However, the oncologic safety of this approach is unclear. PATIENTS AND METHODS: A total of 310 breast cancer patients (319 breasts) who underwent NACT and NSM between February 2010 and November 2016 were retrospectively analyzed. Clinical and pathologic factors associated with increased risks of LRR and NR were analyzed using univariate (Chi-square or Fisher exact test) and multivariate (Cox proportional hazard regression model) analyses. RESULTS: During a mean follow-up of 63 ± 22 months, 38 cases had LRR as the first event, including 6 cases of NR as the first event. The 5-year cumulative LRR and NR rates were 11.0% and 1.9%, respectively. In univariate analysis, clinical T stage, pathologic nodal status, histologic grade, lymphovascular invasion, and post-NACT Ki67 status were associated with increased LRR risk, and post-NACT Ki67 status was the only significant risk factor for NR. In multivariate analysis, post-NACT Ki67 ≥10% (hazard ratio, 4.245; 95% confidence interval, 1.865-9.663; P = 0.001) was an independent risk factor for LRR. CONCLUSIONS: NSM and immediate reconstruction seem to be oncologically safe with acceptable LRR and NR rates for appropriately selected breast cancer patients treated with NACT. Post-NACT Ki67 ≥10% was associated with increased risk of LRR or NR, and therefore, necessitates cautious follow-up.

A propensity score-matched comparison of recurrence outcomes after immediate implant vs autologous flap reconstruction in patients receiving neoadjuvant chemotherapy for breast cancer.

PURPOSE: We compared oncologic outcomes between breast cancer patients who underwent immediate implant-based breast reconstruction (IBBR) and those who underwent autologous flap reconstruction (AFR) after neoadjuvant chemotherapy (NACT). METHODS: The study group comprised 536 patients with primary breast cancer who underwent NACT followed by immediate IBBR or AFR. After propensity score matching, 138 patients in the IBBR group and 276 patients in the AFR group were selected for comparisons of locoregional recurrence-free survival (LRRFS), disease-free survival (DFS), distant metastasis-free survival (DMFS), and breast cancer-specific survival (BCSS). RESULTS: No significant differences were observed between the matched groups in locoregional recurrence rates (IBBR vs. AFR: 12.3% vs. 12%; P = 0.915) and distant metastasis (13% vs. 17%; P = 0.293). There was also no significant difference between the groups in LRRFS (P = 0.956), DFS (P = 0.606), DMFS (P = 0.283), or BCSS (P = 0.121). The 5- and 10-year LRRFS rates were 87.6% and 85.9% in the IBBR group, and 87.7% and 86.1% in the AFR group; the 5- and 10-year DFS rates were 79% and 77.5% in the IBBR group, and 77% and 75% in the AFR group; the 5- and 10-year DMFS rates were 85.9% and 85.9% in the IBBR group, and 83.2% and 81.8% in the AFR group; and the 5- and 10-year BCSS rates were 97.8% and 91.3% in the IBBR group, and 91.8% and 86% in the AFR group, respectively. CONCLUSIONS: In this propensity score-matched analysis of oncologic outcomes in breast cancer patients who underwent immediate reconstruction after NACT, no significant differences were observed between the IBBR and AFR groups.

Preoperative Breast MRI in Women 35 Years of Age and Younger with Breast Cancer: Benefits in Surgical Outcomes by Using Propensity Score Analysis.

Background The role of preoperative MRI in women 35 years of age or younger with breast cancer remains controversial. Purpose To determine the association between preoperative MRI and surgical outcomes in women aged 35 years or younger with breast cancer by using propensity score (PS) analysis to investigate the impact of preoperative MRI. Materials and Methods Women 35 years of age or younger diagnosed with breast cancer between 2007 and 2017 who had or had not undergone preoperative breast MRI were retrospectively identified. The MRI detection rate of additional suspicious lesions was analyzed, and changes in surgical management were recorded. Inverse probability weighting (IPW) and PS matching were used to adjust 19 variables and to create a balance between the two groups. Surgical outcomes were compared by using univariable logistic regression. Results Among 964 women (mean age ± standard deviation, 32 years ± 3), 665 (69%) had undergone preoperative MRI (MRI group; mean age, 32 years ± 3) and 299 (31%) had not (no-MRI group; mean age, 32 years ± 3). In the MRI group, additional suspicious lesions were found in 178 of the 665 women (27%), with 88 of those 178 women (49%) having malignant lesions. The surgical management was changed in 99 of the 665 women (15%) due to MRI findings, which was appropriate for 62 of those 99 women (63%). In the IPW analysis, the MRI group showed lower odds of repeat surgery (odds ratio [OR], 0.13; 95% CI: 0.07, 0.21; P < .001) and higher odds of initial mastectomy (OR, 1.62; 95% CI: 1.17, 2.25; P = .004). However, there was no difference in the overall mastectomy rate (OR, 1.24; 95% CI: 0.91, 1.68; P = .17) compared with the no-MRI group. These results were consistent when using the PS matching method. Conclusion Preoperative MRI in young women with breast cancer is useful for detecting additional malignancy and improving surgical outcomes by reducing the repeat surgery rate, with a similar likelihood of overall mastectomy. © RSNA, 2021 Online supplemental material is available for this article.

Oncologic Safety of Nipple-Sparing Mastectomy in Patients with Breast Cancer and Tumor-to-Nipple Distance ≤ 1 cm: A Matched Cohort Study.

BACKGROUND: A short tumor-to-nipple distance (TND) is reported as a strong predictor of nipple-areola complex (NAC) involvement. Eligibility for nipple-sparing mastectomy (NSM) remains controversial, especially regarding TND. In this study, we compared long-term oncologic outcomes after NSM between patients with a TND ≤ 1 cm and those with a TND > 1 cm. METHODS: Overall, 1369 patients with primary breast cancer who underwent NSM with immediate reconstruction from March 2003 to December 2015 were included for analysis. After propensity score matching, 495 patients with a TND ≤ 1 cm (group A) and 495 patients with a TND > 1 cm (group B) on imaging were selected to compare long-term oncologic outcomes. RESULTS: After matching, the median follow-up periods for surviving patients were 109 months and 112 months for groups A and B, respectively. There were no significant differences between groups with respect to the 5-year cumulative local recurrence (8.1% vs. 6.3%; p = 0.268), NAC recurrence (5.1% vs. 2.8%; p = 0.072), regional recurrence (2.0% vs. 3.6%; p = 0.125), or distant recurrence (5.9% vs. 4.8%; p = 0.480) rates. Furthermore, no significant differences were observed between the groups with respect to the 10-year local recurrence-free survival (87.1% vs. 90.7%; p = 0.164) or disease-free survival (77.9% vs. 81.6%; p = 0.222) rates. CONCLUSIONS: A preoperative TND ≤ 1 cm on imaging should not be contraindicated to NSM as long as there is no involvement of NAC clinically or on imaging and if retroareolar margins are confirmed to be negative for tumor cells.

Automated breast US as the primary screening test for breast cancer among East Asian women aged 40-49 years: a multicenter prospective study.

OBJECTIVES: To prospectively evaluate the diagnostic performance of screening ABUS as the primary screening test for breast cancer among Korean women aged 40-49 years. METHODS: This prospective, multicenter study included asymptomatic Korean women aged 40-49 years from three academic centers between February 2017 and October 2019. Each participant underwent ABUS without mammography, and the ABUS images were interpreted at each hospital with double-reading by two breast radiologists. Biopsy and at least 1 year of follow-up was considered the reference standard. Diagnostic performance of ABUS screening and subgroup analyses according to patient and tumor characteristics were evaluated. RESULTS: Reference standard data were available for 959 women. The recall rate was 9.8% (95% confidence interval [CI]: 7.9%, 11.7%; 94 of 959 women) and the cancer detection yield was 5.2 per 1000 women (95% CI: -0.6, 11.1; 5 of 959 women). There was only one interval cancer. The sensitivity was 83.3% (95% CI: 53.5%, 100%; 5 of 6 cancers) and the specificity was 90.7% (95% CI: 88.8%, 92.5%; 864 of 95. women). The positive predictive values of biopsies performed (PPV3) was 20.0% (95% CI: 4.3%, 35.7%; 5 of 25 women). Women with heterogeneous background echotexture had a higher recall rate (p = .009) and lower specificity (p = .036). Women with body mass index values < 25 kg/m2 had a higher mean recall rate (p = .046). CONCLUSION: In East Asia, screening automated breast US may be an alternative to screening mammography for detecting breast cancers in women aged 40-49 years. KEY POINTS: • Automated breast US screening for breast cancer in asymptomatic women aged 40-49 is effective with 5.2 per 1000 cancer detection yield. • Women with heterogeneous background echotexture had a higher recall rate and lower specificity. • Women with body mass index < 25 kg/m2 had a higher recall rate.

Association of mammography and ultrasound features with MammaPrint in patients with estrogen receptor-positive, HER2-negative, node-positive invasive breast cancer.

BACKGROUND: MammaPrint is a 70-gene signature microarray assay that predicts the likelihood of recurrence of breast cancer and chemotherapeutic benefits. PURPOSE: To investigate the association between mammography and ultrasound (US) features and MammaPrint results in patients with estrogen receptor (ER)-positive, HER2-negative, node-positive invasive breast cancer, and to identify the predictive factors for high risk of recurrence. MATERIAL AND METHODS: This retrospective study included 251 patients with ER-positive, HER2-negative, 1-3 node-positive invasive breast cancer. Mammography and US findings were reviewed according to the BI-RADS criteria. The association between MammaPrint results and the clinicopathological and imaging features was evaluated. Logistic regression analysis was performed to identify independent predictors for high risk of recurrence. RESULTS: Of the patients, 143 (57.0%) and 108 (43.0%) had low and high risks for recurrence on MammaPrint, respectively. Young age (odds ratio [OR] 1.08; 95% confidence interval (CI) 1.04-1.12; P<0.001), posterior enhancement on US (OR 2.45; 95% CI 1.16-5.20; P = 0.019), absence of posterior shadowing on US (OR 3.19; 95% CI 1.17-8.62; P = 0.023), high histologic grade (OR 113.36; 95% CI 6.79-1893.53; P = 0.001), and high Ki-67 level (OR 4.90; 95% CI 2.62-9.17; P<0.001) were independently associated with high risk of recurrence on multivariate logistic regression analysis. CONCLUSION: Posterior features in US may predict a high risk of recurrence in patients with ER-positive, HER2-negative, node-positive invasive breast cancer, which may be useful in enhancing the diagnostic value of MammaPrint and aid in the decision-making process regarding treatment.

Analysis of false-negative findings of breast cancer on previous magnetic resonance imaging.

BACKGROUND: Despite the excellent contribution of contrast-enhanced breast magnetic resonance imaging (MRI), there are variable false-negative cases on MRI. PURPOSE: To evaluate the false-negative findings of breast cancer on previous MRI. MATERIAL AND METHODS: Between 2012 and 2016, we collected 132 patients who underwent surgery for a second primary cancer and had both current and previous MRI at an interval of <3 years. We included 45 patients; we excluded 38 patients who could not find a second cancer in the previous MRI and 49 patients who had a second cancer near to the original cancer and within within the same quadrant. Compared with current MRI, we retrospectively assessed the second primary cancer on previous MRI according to BI-RADS and analyzed the reasons of misinterpretation. RESULTS: Analysis of previous MRI revealed 26 (57.8%) masses (mean size 7.7 ± 2.25 mm), 12 (26.7%) non-mass enhancements (mean size 14.7 ± 4.76 mm), and 7 (15.5%) foci. At first reading, 24 (53.3%) were missed, 17 (37.8%) were assessed as BI-RADS category 2 or 3, and 4 (8.9%) were assessed as category 4. On current MRI, 39 (86.7%) lesions showed an increase in size and 22 (48.9%) showed a change in kinetics to wash-out pattern. CONCLUSION: On previous MRI, missed or misinterpreted cancers show variable findings of mass and non-mass enhancements with any types of kinetics. Careful application of BI-RADS is necessary as well as an appropriate biopsy. Any lesion that increases in size and changes in kinetics should not be underestimated.

Added Value of the Vascular Index on Superb Microvascular Imaging for the Evaluation of Breast Masses: Comparison With Grayscale Ultrasound.

OBJECTIVES: To evaluate the value of the vascular index (VI) on Superb Microvascular Imaging (SMI; Canon Medical Systems Corporation, Tokyo, Japan) in comparison with grayscale ultrasound (US) alone for assessing breast masses. METHODS: We evaluated a total of 70 breast masses (36 malignant and 34 benign lesions) in 70 consecutive patients using grayscale US and SMI. Two breast radiologists analyzed grayscale US alone and the combination of grayscale US and SMI. They also measured the VI based on SMI. The diagnostic performance of grayscale US alone and the combination of grayscale US and SMI was compared. The VI was compared between benign and malignant masses, and the optimal cutoff value was determined. In addition, the interobserver agreement in imaging analyses and the VI was assessed. RESULTS: The interobserver agreements in imaging analyses and the VI were almost perfect. The VI of malignant breast masses was significantly higher than that of benign lesions (P < .001). The optimal cutoff value of the VI for differentiating between malignant and benign breast masses was 2.95, with sensitivity of 86.1% and specificity of 91.2%. The diagnostic performance values of grayscale US alone and the combination of grayscale US and SMI were 0.824 and 0.912, respectively, for reader 1 (P = .028) and 0.795 and 0.853 for reader 2 (P = .101). CONCLUSIONS: The VI on SMI was significantly higher for malignant breast masses than for benign lesions, with high interobserver agreement. Our study suggests that the combination of grayscale US and SMI with the VI could improve the characterization of breast masses.

Surgical Outcomes for Ductal Carcinoma in Situ: Impact of Preoperative MRI.

Background The role of preoperative MRI for predicting surgical outcomes in patients diagnosed with ductal carcinoma in situ (DCIS) remains uncertain. Purpose To investigate the associations between preoperative MRI and surgical outcomes in DCIS confirmed by using US-guided core-needle biopsy (CNB) and to evaluate clinical-pathologic variables associated with a benefit from MRI. Materials and Methods Women with DCIS confirmed by using US-guided CNB between January 2012 and December 2016 were included in this retrospective study. Propensity score matching using 18 confounding covariates was used to create matched groups with MRI and without MRI, and surgical outcomes were compared. Clinical-pathologic variables were evaluated to determine women who benefited from MRI. Results A total of 541 women (mean age ± standard deviation, 50 years ± 10) were evaluated. Among 430 women who underwent MRI, 67 additional lesions (16%) were depicted, with 25 (37%) of the 67 additional lesions being malignant. Fifty-seven (13%) of the 430 women had a change in surgical plan because of their MRI findings; the change was appropriate for 31 (54%) women. In matched groups, the MRI group was associated with lower odds of positive resection margin (odds ratio [OR], 0.39; 95% confidence interval [CI]: 0.16, 0.93; P = .03) and repeat surgery (OR, 0.33; 95% CI: 0.12, 0.92; P = .03) compared with the non-MRI group. There was no difference in likelihood of initial mastectomy (OR, 1.2; 95% CI: 0.7, 2.0; P = .59) and overall mastectomy (OR, 0.93; 95% CI: 0.5, 1.6; P = .79). In the MRI group, low nuclear grade (90% [28 of 31] vs 69% [275 of 399]; P = .01), progesterone receptor positivity (81% [25 of 31] vs 61% [244 of 399]; P = .03), and human epidermal growth factor receptor 2 negativity (90% [28 of 31] vs 68% [270 of 399]; P = .01) were associated with a benefit from MRI versus no MRI. Conclusion Preoperative MRI depicted additional malignancy and reduced positive surgical margins and repeat surgery for ductal carcinoma in situ confirmed at US-guided biopsy without a higher mastectomy rate. © RSNA, 2020 Online supplemental material is available for this article. See also the editorial by Pinker in this issue.

Recurrence Outcomes After Nipple-Sparing Mastectomy and Immediate Breast Reconstruction in Patients with Pure Ductal Carcinoma In Situ.

BACKGROUND: Nipple-sparing mastectomy (NSM) has become increasingly prevalent for patients with ductal carcinoma in situ (DCIS) requiring mastectomy. However, few data regarding recurrence outcomes after NSM are available for this patient population. This study evaluated the locoregional recurrence (LRR) rate for patients with pure DCIS who underwent NSM followed by immediate breast reconstruction without adjuvant radiotherapy and investigated potential risk factors for LRR and/or nipple-areola complex recurrence (NR). METHODS: A retrospective chart review was performed for 199 consecutive patients with pure DCIS who underwent NSM and immediate breast reconstruction between March 2003 and December 2015. Risk factors for LRR and NR were analyzed using univariate (Chi square test) and multivariate (Cox model) methods. RESULTS: The median follow-up duration after surgery was 97 months (range, 39-186 months). At 10 years, the LRR rate was 4.5%, and the NR rate was 3%. The univariate analysis showed that high nuclear grade, negative receptor status, positive human epidermal growth factor receptor 2 (HER2) status, and negative hormone receptor/positive HER2 subtype were associated with increased risk for NR. The multivariate analysis demonstrated that negative progesterone receptor status was an independent risk factor for LRR. However, margin status and tumor-to-nipple distance (TND) were not associated with increased risk for either LRR or NR. CONCLUSIONS: The study findings suggest that NSM can be a feasible surgical option even for DCIS with a TND of 1 cm or less if the retroareolar resection margin is negative for malignancy. Determining the molecular subtype of DCIS might be helpful in identifying patients at high risk for recurrence.

Male patients with unilateral breast symptoms: an optimal imaging approach.

OBJECTIVES: To evaluate the usefulness of bilateral mammography in male patients with unilateral breast symptoms, including investigation of the diagnostic performance of unilateral and bilateral reviews and the average glandular dose (AGD) per exposure. METHODS: Two hundred seventy-one consecutive male patients (mean age, 57 years) with unilateral breast symptoms underwent bilateral mammography. Image interpretation was performed in two ways, first with a unilateral review of the symptomatic breast and then with a bilateral review. A modified BI-RADS scale (from 1 to 5) was used. The diagnostic performance of unilateral and bilateral reviews was compared, and contralateral breast abnormalities and the AGD per exposure were recorded. We also analyzed ultrasound (US) results and compared them with mammography. RESULTS: Of 271 male patients, 29 were pathologically diagnosed with breast cancer. There was no bilateral breast cancer. The sensitivity, specificity, positive and negative predictive values, and accuracy were 96.6%, 96.7%, 77.8%, 99.6%, and 96.7%, respectively, for unilateral review, and 96.6%, 95.9%, 73.7%, 99.6%, and 95.9% for bilateral review. Receiver operator characteristic analysis showed excellent diagnostic performance for both methods: the area under the curve (AUC) was 0.966 for unilateral review and 0.962 for bilateral review (p = 0.415). The mean AGD per exposure was 1.10 ± 0.29 mGy for symptomatic breast and 1.04 ± 0.30 mGy for contralateral breast (p < 0.001). Diagnostic performance parameters of US were not significantly different from bilateral or unilateral review of mammography. CONCLUSION: The diagnostic performance of unilateral mammography is comparable with bilateral mammography in male patients with unilateral breast symptoms. Unilateral mammography also has the advantage of reducing radiation exposure. KEY POINTS: • There is limited knowledge about standardized guidelines or recommendations for imaging the male breast. • Unilateral mammography for male patients with unilateral breast symptoms showed comparable diagnostic performance with bilateral mammography. • Both unilateral and bilateral mammography showed excellent diagnostic performance in the assessment of male patients with unilateral breast symptoms.

The role of MRI and clinicopathologic features in predicting the invasive component of biopsy-confirmed ductal carcinoma in situ.

BACKGROUND: The upgrade rate of biopsy-confirmed ductal carcinoma in situ (DCIS) to invasive carcinoma is up to 50% on final pathology. We investigated MRI and clinicopathologic predictors of the invasive components of DCIS diagnosed by preoperative biopsy and then compared MRI features between patients with DCIS, microinvasive ductal carcinoma (mIDC), and invasive ductal carcinoma (IDC) diagnosed on final pathology. METHODS: Two hundred and one patients with 206 biopsy-confirmed DCIS lesions were enrolled. MRI and clinicopathologic features were used to predict either mIDC or IDC via a cumulative logistic regression analysis. For the lesions detected on MRI, morphologic and kinetic analyses were performed using the Chi-square, Fisher's exact, and Kruskal-Wallis tests. RESULTS: Of all the lesions, 112 (54.4%) were diagnosed as DCIS, 50 (24.3%) were upgraded to mIDC, and 44 (21.4%) to IDC. The detection on MRI as mass (Odds ratio (OR) = 8.84, 95% confidence interval (CI) = 1.05-74.04, P = 0.045) or non-mass enhancement (NME; OR = 11.17, 95% CI = 1.35-92.36, P = 0.025), negative progesterone receptor (PR; OR = 2.40, 95% CI = 1.29-4.44, P = 0.006), and high Ki-67 level (OR = 2.42, 95% CI = 1.30-4.50, P = 0.005) were significant independent predictors of histologic upgrade. On MRI, 87 (42.2%) lesions appeared as mass and 107 (51.9%) as NME. Irregularly shaped, not-circumscribed, heterogeneous, or rim-enhancing masses with intratumoral high signal intensity or peritumoral edema, clumped or clustered ring-enhancing NMEs, and high peak enhancement were significantly associated with histologic upgrade (P < 0.001). CONCLUSION: MRI detection, negative PR, and high Ki-67 levels are associated with a histologic upgrade in patients with biopsy-confirmed DCIS. Suspicious MRI features are more frequent in such patients.