Pilot study: A simple CAD-based tool to detect breast cancer on MRI of the breast.

PURPOSE: This pilot-study aims to assess, whether quantitatively assessed enhancing breast tissue as a percentage of the entire breast volume can serve as an indicator of breast cancer at breast MRI and whether the contrast-agent employed affects diagnostic efficacy. MATERIALS: This retrospective IRB-approved study, included 39 consecutive patients, that underwent two subsequent breast MRI exams for suspicious findings at conventional imaging with 0.1 mmol/kg gadobenic and gadoteric acid. Two independent readers, blinded to the histopathological outcome, assessed unenhanced and early post-contrast images using computer-assisted software (Brevis, Siemens Healthcare). Diagnostic performance was statistically determined for percentage of ipsilateral voxel volume enhancement and for percentage of contralateral enhancing voxel volume subtracted from ipsilateral enhancing voxel volume after crosstabulation with the dichotomized histological outcome (benign/malignant). RESULTS: Ipsilateral enhancing voxel volume versus histopathological outcome resulted in an AUC of 0.707 and 0.687 for gadobenic acid, reader 1 and 2, respectively and in an AUC of 0.778 and 0.773 for gadoteric acid, reader 1 and 2, respectively. Accounting for background parenchymal enhancement by subtracting contralateral enhancing volume from ipsilateral enhancing voxel volume versus histolopathological outcome resulted in an AUC of 0.793 and 0.843 for gadobenic acid, reader 1 and 2, respectively and in an AUC of 0.692 and 0.662 for gadoteric acid, reader 1 and 2, respectively. Pairwise testing yielded no statistically significant difference both between readers and between contrast agents employed (p > 0.05). CONCLUSION: Our proposed CAD algorithm, which quantitatively assesses enhancing breast tissue as a percentage of the entire breast volume, allows indicating the presence of breast cancer.

Added value of clinical decision rules for the management of enhancing breast MRI lesions: A systematic comparison of the Kaiser score and the Göttingen score.

PURPOSE: We investigated the added value of two internationally used clinical decision rules in the management of enhancing lesions on breast MRI. METHODS: This retrospective, institutional review board approved study included consecutive patients from two different populations. Patients received breast MRI according to the recommendations of the European Society of Breast Imaging (EUSOBI). Initially, all examinations were assessed by expert readers without using clinical decision rules. All lesions rated as category 4 or 5 according to the Breast Imaging Reporting and Data System were histologically confirmed. These lesions were re-evaluated by an expert reader blinded to the histology. He assigned each lesion a Göttingen score (GS) and a Kaiser score (KS) on different occasions. To provide an estimate on inter-reader agreement, a second fellowship-trained reader assessed a subset of these lesions. Subgroup analyses based on lesion type (mass vs. non-mass), size (>1 cm vs. ≤ 1 cm), menopausal status, and significant background parenchymal enhancement were conducted. The areas under the ROC curves (AUCs) for the GS and KS were compared, and the potential to avoid unnecessary biopsies was determined according to previously established cutoffs (KS > 4, GS > 3) RESULTS: 527 lesions in 506 patients were included (mean age: 51.8 years, inter-quartile-range: 43.0-61.0 years). 131/527 lesions were malignant (24.9 %; 95 %-confidence-interval: 21.3-28.8). In all subgroups, the AUCs of the KS (median = 0.91) were higher than those of the GS (median = 0.83). Except for "premenopausal patients" (p = 0.057), these differences were statistically significant (p ≤ 0.01). Kappa agreement was higher for the KS (0.922) than for the GS (0.358). CONCLUSION: Both the KS and the GS provided added value for the management of enhancing lesions on breast MRI. The KS was superior to the GS in terms of avoiding unnecessary biopsies and showed superior inter-reader agreement; therefore, it may be regarded as the clinical decision rule of choice.

Third International Consensus Conference on lesions of uncertain malignant potential in the breast (B3 lesions).

The heterogeneous group of B3 lesions in the breast harbors lesions with different malignant potential and progression risk. As several studies about B3 lesions have been published since the last Consensus in 2018, the 3rd International Consensus Conference discussed the six most relevant B3 lesions (atypical ductal hyperplasia (ADH), flat epithelial atypia (FEA), classical lobular neoplasia (LN), radial scar (RS), papillary lesions (PL) without atypia, and phyllodes tumors (PT)) and made recommendations for diagnostic and therapeutic approaches. Following a presentation of current data of each B3 lesion, the international and interdisciplinary panel of 33 specialists and key opinion leaders voted on the recommendations for further management after core-needle biopsy (CNB) and vacuum-assisted biopsy (VAB). In case of B3 lesion diagnosis on CNB, OE was recommended in ADH and PT, whereas in the other B3 lesions, vacuum-assisted excision was considered an equivalent alternative to OE. In ADH, most panelists (76%) recommended an open excision (OE) after diagnosis on VAB, whereas observation after a complete VAB-removal on imaging was accepted by 34%. In LN, the majority of the panel (90%) preferred observation following complete VAB-removal. Results were similar in RS (82%), PL (100%), and FEA (100%). In benign PT, a slim majority (55%) also recommended an observation after a complete VAB-removal. VAB with subsequent active surveillance can replace an open surgical intervention for most B3 lesions (RS, FEA, PL, PT, and LN). Compared to previous recommendations, there is an increasing trend to a de-escalating strategy in classical LN. Due to the higher risk of upgrade into malignancy, OE remains the preferred approach after the diagnosis of ADH.

Deep learning for predicting future lesion emergence in high-risk breast MRI screening: a feasibility study.

BACKGROUND: International societies have issued guidelines for high-risk breast cancer (BC) screening, recommending contrast-enhanced magnetic resonance imaging (CE-MRI) of the breast as a supplemental diagnostic tool. In our study, we tested the applicability of deep learning-based anomaly detection to identify anomalous changes in negative breast CE-MRI screens associated with future lesion emergence. METHODS: In this prospective study, we trained a generative adversarial network on dynamic CE-MRI of 33 high-risk women who participated in a screening program but did not develop BC. We defined an anomaly score as the deviation of an observed CE-MRI scan from the model of normal breast tissue variability. We evaluated the anomaly score's association with future lesion emergence on the level of local image patches (104,531 normal patches, 455 patches of future lesion location) and entire CE-MRI exams (21 normal, 20 with future lesion). Associations were analyzed by receiver operating characteristic (ROC) curves on the patch level and logistic regression on the examination level. RESULTS: The local anomaly score on image patches was a good predictor for future lesion emergence (area under the ROC curve 0.804). An exam-level summary score was significantly associated with the emergence of lesions at any location at a later time point (p = 0.045). CONCLUSIONS: Breast cancer lesions are associated with anomalous appearance changes in breast CE-MRI occurring before the lesion emerges in high-risk women. These early image signatures are detectable and may be a basis for adjusting individual BC risk and personalized screening. RELEVANCE STATEMENT: Anomalies in screening MRI preceding lesion emergence in women at high-risk of breast cancer may inform individualized screening and intervention strategies. KEY POINTS: • Breast lesions are associated with preceding anomalies in CE-MRI of high-risk women. • Deep learning-based anomaly detection can help to adjust risk assessment for future lesions. • An appearance anomaly score may be used for adjusting screening interval times.

Is the Level of Contrast Enhancement on Contrast-Enhanced Mammography (CEM) Associated with the Presence and Biological Aggressiveness of Breast Cancer?

There is limited information about whether the level of enhancement on contrast-enhanced mammography (CEM) can be used to predict malignancy. The purpose of this study was to correlate the level of enhancement with the presence of malignancy and breast cancer (BC) aggressiveness on CEM. This IRB-approved, cross-sectional, retrospective study included consecutive patients examined with CEM for unclear or suspicious findings on mammography or ultrasound. Excluded were examinations performed after biopsy or during neoadjuvant treatment for BC. Three breast radiologists who were blinded to patient data evaluated the images. The enhancement intensity was rated from 0 (no enhancement) to 3 (distinct enhancement). ROC analysis was performed. Sensitivity and negative likelihood ratio (LR-) were calculated after dichotomizing enhancement intensity as negative (0) versus positive (1-3). A total of 156 lesions (93 malignant, 63 benign) in 145 patients (mean age 59 ± 11.6 years) were included. The mean ROC curve was 0.827. Mean sensitivity was 95.4%. Mean LR- was 0.12%. Invasive cancer presented predominantly (61.8%) with distinct enhancement. A lack of enhancement was mainly observed for ductal carcinoma in situ. Stronger enhancement intensity was positively correlated with cancer aggressiveness, but the absence of enhancement should not be used to downgrade suspicious calcifications.

One view or two views for wide-angle tomosynthesis with synthetic mammography in the assessment setting?

OBJECTIVES: To evaluate the diagnostic performance in the assessment setting of three protocols: one-view wide-angle digital breast tomosynthesis (WA-DBT) with synthetic mammography (SM), two-view WA-DBT/SM, and two-view digital mammography (DM). METHODS: Included in this retrospective study were patients who underwent bilateral two-view DM and WA-DBT. SM were reconstructed from the WA-DBT data. The standard of reference was histology and/or 2 years follow-up. Included were 205 women with 179 lesions (89 malignant, 90 benign). Four blinded readers randomly evaluated images to assess density, lesion type, and level of suspicion according to BI-RADS. Three protocols were evaluated: two-view DM, one-view (mediolateral oblique) WA-DBT/SM, and two-view WA-DBT/SM. Detection rate, sensitivity, specificity, and accuracy were calculated and compared using multivariate analysis. Reading time was assessed. RESULTS: The detection rate was higher with two-view WA-DBT/SM (p = 0.063). Sensitivity was higher for two-view WA-DBT/SM compared to two-view DM (p = 0.001) and one-view WA-DBT/SM (p = 0.058). No significant differences in specificity were found. Accuracy was higher with both one-view WA-DBT/SM and two-view WA-DBT/SM compared to DM (p = 0.003 and > 0.001, respectively). Accuracy did not differ between one- and two-view WA-DBT/SM. Two-view WA-DBT/SM performed better for masses and asymmetries. Reading times were significantly longer when WA-DBT was evaluated. CONCLUSIONS: One-view and two-view WA-DBT/SM can achieve a higher diagnostic performance compared to two-view DM. The detection rate and sensitivity were highest with two-view WA-DBT/SM. Two-view WA-DBT/SM appears to be the most appropriate tool for the assessment of breast lesions. KEY POINTS: • Detection rate with two-view wide-angle digital breast tomosynthesis (WA-DBT) is significantly higher than with two-view digital mammography in the assessment setting. • Diagnostic accuracy of one-view and two-view WA-DBT with synthetic mammography (SM) in the assessment setting is higher than that of two-view digital mammography. • Compared to one-view WA-DBT with SM, two-view WA-DBT with SM seems to be the most appropriate tool for the assessment of breast lesions.

Microstructural breast tissue characterization: A head-to-head comparison of Diffusion Weighted Imaging and Acoustic Radiation Force Impulse elastography with clinical implications.

PURPOSE: Head-to-head comparison of Diffusion Weighted Imaging (DWI) and Acoustic Radiation Force Impulse (ARFI) elastography regarding the characterization of breast lesions in an assessment setting. METHOD: Patients undergoing an ultrasound examination including ARFI and an MRI protocol including DWI for the characterization of a BI-RADS 3-5 breast lesion between 06/2013 and 10/2016 were eligible for inclusion in this retrospective, IRB-approved study. 60 patients (30-84 years, median 50) with a median lesion size of 16 mm (range 5-55 mm) were included. The maximum shear wave velocity (SWVmax) and mean apparent diffusion coefficient (ADCmean) for each lesion were retrospectively evaluated by a radiologist experienced in the technique. Histology was the reference standard. Diagnostic performances of ARFI and DWI were assessed using ROC curve analysis. Spearman's rank correlation coefficient and multivariate logistic regression were used to investigate the independence of both tests regarding their diagnostic information to distinguish benign from malignant lesions. RESULTS: Corresponding areas under the ROC curve for differentiation of benign (n = 16) and malignant (n = 49) lesions were 0.822 (ARFI) and 0.871 (DWI, p-value = 0.48). SWVmax and ADCmean values showed a significant negative correlation (ρ = -0.501, p-value < 0.001). In multivariate analysis, combination of ARFI and DWI did not improve the results of each single modality, thus no significant independent diagnostic information was present. CONCLUSION: Significant correlation between quantitative findings of ARFI and DWI in breast lesions exists. Thus, ARFI provides similar diagnostic information as a DWI-including protocol of an additional "problem-solving" MRI for the characterization of a sonographically evident breast lesion, improving the immediate patient management in the assessment setting.

Extraosseous osteoblastoma: A rare cause of breast mass in a prepubertal girl.

Extraosseous osteoblastoma of the breast, a rare disease, was diagnosed in a prepubertal girl. After tumor excision, the patient recovered well and an optimal cosmetic result was achieved. Interdisciplinary discussions about the case are essential.

"Anemia and Response to Neoadjuvant Chemotherapy in Breast Cancer Patients".

We analyzed the effect of anemia on tumor response of patients with primary invasive breast cancer (BC) receiving neoadjuvant chemotherapy (NACT). The patient collective was very homogenous; finally, 74 BC patients with identical medication and duration of NACT were enrolled. After completion of NACT, 49 patients (66.2%) had a post-NACT Hb level <12 g/dl. In the anemic group, we found a tendency of lower median tumor response compared to nonanemic patients at this time (15 versus 17 mm, retrospectively, p = 0.18). Age at diagnosis significantly correlated with the difference of Hb [before initiation - after completion of NACT] (correlation coefficient = 0.40, p < 0.001).

The Kaiser score reliably excludes malignancy in benign contrast-enhancing lesions classified as BI-RADS 4 on breast MRI high-risk screening exams.

OBJECTIVES: MRI is an integral part of breast cancer screening in high-risk patients. We investigated whether the application of the Kaiser score, a clinical decision-support tool, may be used to exclude malignancy in contrast-enhancing lesions classified as BI-RADS 4 on breast MRI screening exams. METHODS: This retrospective study included 183 consecutive, histologically proven, suspicious (MR BI-RADS 4) lesions detected within our local high-risk screening program. All lesions were evaluated according to the Kaiser score for breast MRI by three readers blinded to the final histopathological diagnosis. The Kaiser score ranges from 1 (lowest, cancer very unlikely) to 11 (highest, cancer very likely) and reflects increasing probabilities of malignancy, with scores greater than 4 requiring biopsy. Receiver operating characteristic (ROC) curve analysis was used to evaluate diagnostic accuracy. RESULTS: There were 142 benign and 41 malignant lesions, diagnosed in 159 patients (mean age, 43.6 years). Median Kaiser scores ranged between 2 and 5 in benign and 7 and 8 in malignant lesions. For all lesions, the Kaiser score's accuracy, represented by the area under the curve (AUC), ranged between 86.5 and 90.2. The sensitivity of the Kaiser score was high, between 95.1 and 97.6% for all lesions, and was best in mass lesions. Application of the Kaiser score threshold for malignancy (≤ 4) could have potentially avoided 64 (45.1%) to 103 (72.5%) unnecessary biopsies in 142 benign lesions previously classified as BI-RADS 4. CONCLUSIONS: The use of Kaiser score in high-risk MRI screening reliably excludes malignancy in more than 45% of contrast-enhancing lesions classified as BI-RADS 4. KEY POINTS: • The Kaiser score shows high diagnostic accuracy in identifying malignancy in contrast-enhancing lesions in patients undergoing high-risk screening for breast cancer. • The application of the Kaiser score may avoid > 45% of unnecessary breast biopsies in high-risk patients. • The Kaiser score aids decision-making in high-risk breast cancer MRI screening programs.

Can second-look ultrasound downgrade MRI-detected lesions? A retrospective study.

PURPOSE: To determine whether MRI-detected suspicious (BIRADS 4 & 5) breast lesions can be downgraded using second-look ultrasound (SLU) and thus reduce unnecessarily performed breast biopsies. MATERIALS METHODS: A retrospective single-center review of consecutive patients, who underwent breast MRI studies during a 12-month time period was performed. 94 patients with 103 lesions undergoing SLU of incidentally detected MRI BI-RADS 4&5 lesions which were not identified on previous ultrasound were included in the study. The SLU detection rate and SLU features of the lesions were assessed. Histology (91/103) or two year follow up (n = 12) were defined as the reference standard for lesion diagnosis. RESULTS: 57 (55.3 %) of the 103 lesions were identified on SLU. 17 of the identified lesions were malignant (29.8 %). Lesions detected on ultrasound presented on MRI as masses in 66.7 % (38/57) and non-mass in 33.3 % (19/57). Our findings showed that it is possible to distinguish between malignant and benign lesions with SLU. The results were significant (p < 0.05) for the following morphological features: shape, orientation, margins, architectural distortion, hyperechoic rim/ edema. All lesions classified as SLU BI-RADS 2 in our study were benign and thus, 30 % of all unnecessary biopsies could potentially have been avoided. Including SLU BI-RADS 3 lesions, this rate increased to 60 %, while yielding one (of 17, 5.8 %) false negative result. All three BI-RADS 5 lesions detected by SLU presented as malignant on ultrasound. CONCLUSION: SLU can potentially downgrade incidental MRI BIRADS 4 lesions. This may reduce the number of unnecessarily performed biopsies by 30-60 %, thus simplifying patient management.

Low-Dose, Contrast-Enhanced Mammography Compared to Contrast-Enhanced Breast MRI: A Feasibility Study.

Contrast-enhanced MRI (CE-MRI) is the most sensitive technique for breast cancer detection. Contrast-enhanced mammography (CEM) is emerging as a possible alternative to CE-MRI. PURPOSE: To evaluate the diagnostic performance of a low radiation dose contrast-enhanced mammography (L-CEM) in women with suspicious findings on conventional imaging compared to CE-MRI of the breast. STUDY TYPE: Prospective, single center. POPULATION: Women with suspicious findings on mammography, tomosynthesis, or ultrasound, and no contraindications for L-CEM or CE-MRI. Eighty women were included. FIELD STRENGTH/SEQUENCE: 1.5 and 3T CE-MRI, standard protocol for breast, with dedicated coils, according to international guidelines. L-CEM was performed using a dedicated prototype. ASSESSMENT: Three, off-site, blinded readers evaluated the images according to the BI-RADS lexicon in a randomized order, each in two separate reading sessions. Histology served as a gold standard. STATISTICAL TEST: Lesion detection rate, sensitivity, specificity, and negative and positive predictive values (NPV, PPV) were calculated and compared with multivariate statistics. RESULTS: Included were 80 women (mean age, 54.3 years ±11.2 standard deviation) with 93 lesions (32 benign, 61 malignant). The detection rate was significantly higher with CE-MRI (92.5-94.6%; L-CEM 79.6-91.4%, P = 0.014). Sensitivity (L-CEM 65.6-90.2%; CE-MRI 83.6-93.4%, P = 0.086) and NPV (L-CEM 59.6-71.4%; CE-MRI 63.0-76.5%, P = 0.780) did not differ between the modalities. Specificity (L-CEM 46.9-96.9%; CE-MRI 37.5-53.1%, P = 0.001) and PPV (L-CEM 76.4-97.6%; CE-MRI 73.3-77.3%, P = 0.007) were significantly higher with L-CEM. Variations between readers were significant for sensitivity and NPV. The accuracy of L-CEM was as good as CE-MRI (75.3-76.3% vs. 72.0-75.3%, P = 0.514). DATA CONCLUSION: L-CEM showed a high sensitivity and accuracy in women with suspicious findings on conventional imaging. Compared to CE-MRI, L-CEM has the potential to increase specificity and PPV. L-CEM might help to reduce false-positive biopsies while obtaining sensitivity comparable to that of CE-MRI LEVEL OF EVIDENCE: 1 TECHNICAL EFFICACY STAGE: 2 J. Magn. Reson. Imaging 2020;52:589-595.

Image-guided breast biopsy and localisation: recommendations for information to women and referring physicians by the European Society of Breast Imaging.

We summarise here the information to be provided to women and referring physicians about percutaneous breast biopsy and lesion localisation under imaging guidance. After explaining why a preoperative diagnosis with a percutaneous biopsy is preferred to surgical biopsy, we illustrate the criteria used by radiologists for choosing the most appropriate combination of device type for sampling and imaging technique for guidance. Then, we describe the commonly used devices, from fine-needle sampling to tissue biopsy with larger needles, namely core needle biopsy and vacuum-assisted biopsy, and how mammography, digital breast tomosynthesis, ultrasound, or magnetic resonance imaging work for targeting the lesion for sampling or localisation. The differences among the techniques available for localisation (carbon marking, metallic wire, radiotracer injection, radioactive seed, and magnetic seed localisation) are illustrated. Type and rate of possible complications are described and the issue of concomitant antiplatelet or anticoagulant therapy is also addressed. The importance of pathological-radiological correlation is highlighted: when evaluating the results of any needle sampling, the radiologist must check the concordance between the cytology/pathology report of the sample and the radiological appearance of the biopsied lesion. We recommend that special attention is paid to a proper and tactful approach when communicating to the woman the need for tissue sampling as well as the possibility of cancer diagnosis, repeat tissue sampling, and or even surgery when tissue sampling shows a lesion with uncertain malignant potential (also referred to as "high-risk" or B3 lesions). Finally, seven frequently asked questions are answered.

Consensus Meeting of Breast Imaging: BI-RADS® and Beyond.

Organizers of medical educational courses are often confronted with questions that are clinically relevant yet trespassing the frontiers of scientifically proven, evidence-based medicine at the point of care. Therefore, since 2007 organizers of breast teaching courses in German language met biannually to find a consensus in clinically relevant questions that have not been definitely answered by science. The questions were prepared during the 3 months before the meeting according to a structured process and finally agreed upon the day before the consensus meeting. At the consensus meeting, the open questions concerning 2D/3D mammography, breast ultrasound, MR mammography, interventions as well as risk-based imaging of the breast were presented first for electronic anonymized voting, and then the results of the audience were separately displayed from the expert votes. Thereafter, an introductory statement of the moderator was followed by pros/cons of two experts, and subsequently the final voting was performed. With ≥75% of votes of the expert panel, an answer qualified as a consensus statement. Seventeen consensus statements were gained, addressing for instance the use of 2D/3D mammography, breast ultrasound in screening, MR mammography in women with intermediate breast cancer risk, markers for localization of pathologic axillary lymph nodes, and standards in risk-based imaging of the breast. After the evaluation, comments from the experts on each field were gathered supplementarily. Methodology, transparency, and soundness of statements achieve a unique yield for all course organizers and provide solid pathways for decision making in breast imaging.

Can we predict lesion detection rates in second-look ultrasound of MRI-detected breast lesions? A systematic analysis.

PURPOSE: To predict detection rates (DR) in second-look ultrasound of MRI-detected breast lesions by systematically combining clinical and anthropomorphic features. METHODS: A total of 104 suspicious breast-lesions, that were initially detected on breast MRI and underwent subsequent SLU from January 2013 through December 2013, were evaluated in this retrospective analysis. All images were reviewed by an experienced radiologist for this study. Both anthropomorphic, spatial and BI-RADS lesion features were recorded. Uni- and multivariate Classification and Regression Trees (CRT) statistics were used to predict SLU DR by these features. RESULTS: Among 104 MRI-detected lesions, 58 (55.8%) showed a correlate on SLU. In univariate analysis, homogeneous fatty or dense fibro-glandular-tissue-composition (FGT) as assessed by ultrasound, segmental non-mass-distribution pattern and small breast size as assessed by MRI were significantly associated with higher DR on SLU. The remaining BI-RADS features did not significantly affect SLU DR according to our data. The predictive model could stratify the likelihood of SLU correlates as high, intermediate and low according to FGT, lesion type, size and position. CONCLUSIONS: By systematically combining the features FGT, lesion type, size and position, we could predict SLU DR of MRI-detected breast lesions. This may help to decide the preferable method for lesion biopsy or follow-up in clinical practice.

Synthetic 2-Dimensional Mammography Can Replace Digital Mammography as an Adjunct to Wide-Angle Digital Breast Tomosynthesis.

OBJECTIVES: The aim of this study was to evaluate the detection rate and diagnostic performance of 2-dimensional synthetic mammography (SM) as an adjunct to wide-angle digital breast tomosynthesis (WA-DBT) compared with digital mammography (DM) alone or to DM in combination with WA-DBT. MATERIALS AND METHODS: There were 205 women with 179 lesions included in this retrospective reader study. Patients underwent bilateral, 2-view (2v) DM and WA-DBT between March and June 2015. The standard of reference was histology and/or 1-year stability at follow-up. Four blinded readers randomly evaluated images according to the BI-RADS lexicon from 3 different protocols: 2v DM alone, 2v DM with 2v WA-DBT, and 2v SM with 2v WA-DBT. Detection rate, sensitivity, specificity, and accuracy were calculated and compared using multivariate analysis. Readers' confidence and image quality were evaluated. RESULTS: The detection rate ranged from 68.7% to 79.9% for DM, 76.5% to 84.4% for DM with WA-DBT, and 73.2% to 84.9% for SM with WA-DBT. Sensitivity and accuracy were significantly higher when DBT was available (P < 0.001). Specificity did not differ significantly between DM only, DM with WA-DBT, or SM with WA-DBT (P ≥ 0.846). Wide-angle DBT combined readings did not differ between SM and DM in terms of sensitivity, specificity, and accuracy (P ≥ 0.341). Readers' confidence and image quality was rated good to excellent. CONCLUSIONS: Wide-angle DBT combined with DM or SM increases sensitivity and accuracy without reducing specificity compared with DM alone. Wide-angle DBT combined readings did not differ between SM and DM; therefore, SM should replace DM for combined readings with WA-DBT.

Breast lesion detection and characterization with contrast-enhanced magnetic resonance imaging: Prospective randomized intraindividual comparison of gadoterate meglumine (0.15 mmol/kg) and gadobenate dimeglumine (0.075 mmol/kg) at 3T.

BACKGROUND: Contrast-enhanced magnetic resonance imaging (CE-MRI) of the breast is highly sensitive for breast cancer detection. Multichannel coils and 3T scanners can increase signal, spatial, and temporal resolution. In addition, the T1 -reduction effect of a gadolinium-based contrast agent (GBCA) is higher at 3T. Thus, it might be possible to reduce the dose of GBCA at 3T without losing diagnostic information. PURPOSE: To compare a three-quarter (0.075 mmol/kg) dose of the high-relaxivity GBCA gadobenate dimeglumine, with a 1.5-fold higher than on-label dose (0.15 mmol/kg) of gadoterate meglumine for breast lesion detection and characterization at 3T CE-MRI. STUDY TYPE: Prospective, randomized, intraindividual comparative study. POPULATION: Eligible were patients with imaging abnormalities (BI-RADS 0, 4, 5) on conventional imaging. Each patient underwent two examinations, 24-72 hours apart, one with 0.075 mmol/kg gadobenate and the other with 0.15 mmol/kg gadoterate administered in a randomized order. In all, 109 patients were prospectively recruited. FIELD STRENGTH/SEQUENCE: 3T MRI with a standard breast protocol (dynamic-CE, T2 w-TSE, STIR-T2 w, DWI). ASSESSMENT: Histopathology was the standard of reference. Three blinded, off-site breast radiologists evaluated the examinations using the BI-RADS lexicon. STATISTICAL TESTS: Lesion detection, sensitivity, specificity, and diagnostic accuracy were calculated per-lesion and per-region, and compared by univariate and multivariate analysis (Generalized Estimating Equations, GEE). RESULTS: Five patients were excluded, leaving 104 women with 142 histologically verified breast lesions (109 malignant, 33 benign) available for evaluation. Lesion detection with gadobenate (84.5-88.7%) was not inferior to gadoterate (84.5-90.8%) (P ≥ 0.165). At per-region analysis, gadobenate demonstrated higher specificity (96.4-98.7% vs. 92.6-97.3%, P ≤ 0.007) and accuracy (96.3-97.8% vs. 93.6-96.1%, P ≤ 0.001) compared with gadoterate. Multivariate analysis demonstrated superior, reader-independent diagnostic accuracy with gadobenate (odds ratio = 1.7, P < 0.001 using GEE). DATA CONCLUSION: A 0.075 mmol/kg dose of the high-relaxivity contrast agent gadobenate was not inferior to a 0.15 mmol/kg dose of gadoterate for breast lesion detection. Gadobenate allowed increased specificity and accuracy. LEVEL OF EVIDENCE: 1 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2019;49:1157-1165.

Imaging Phenotypes in Women at High Risk for Breast Cancer on Mammography, Ultrasound, and Magnetic Resonance Imaging Using the Fifth Edition of the Breast Imaging Reporting and Data System.

OBJECTIVE: To assess imaging phenotypes of familial breast cancer on mammography (MG), ultrasound (US), and magnetic resonance imaging (MRI) using the fifth edition of the BI-RADS; to investigate inter-observer agreement and to correlate imaging phenotypes with risk status, histopathology, and molecular subtypes derived by immunohistochemical surrogate. MATERIALS AND METHODS: Forty-nine women (BRCA-1/2 mutation carriers and women with >20% lifetime risk) were diagnosed with breast cancer within our high-risk screening program. BI-RADS MG, US, and MRI imaging descriptors were correlated with risk status, histopathology, and molecular subtypes derived by immunohistochemical surrogate. Inter-rater agreement for BI-RADS MG, US, and MRI categories was assessed. RESULTS: Fifty-two breast cancers were diagnosed and 98% were detectable in at least one modality. MRI detected more cancers (P < 0.001). No lesion had benign morphology on BI-RADS. BRCA-1 had triple-negative and high-grade tumors in the posterior part and in the upper-outer quadrant (P ≤ 0.01); positive-family-history patients had intermediate-grade neoplasms (P < 0.01) in the middle part (P = 0.04) and in the upper-outer quadrants (P = 0.05). There was moderate inter-rater agreement for the assigned BI-RADS assessment for MG (k = 0.554) and MRI (k = 0.512) and substantial inter-rater agreement for US (k = 0.741). CONCLUSIONS: Imaging phenotypes of familial breast cancers with BI-RADS are malignant in all imaging modalities. Risk status seems to influence cancer location.

MRI-based quantification of residual fibroglandular tissue of the breast after conservative mastectomies.

PURPOSE: Skin-sparing and nipple-sparing mastectomies (SSM; NSM) remove the breast's fibroglandular tissue (FGT), thereby reducing breast cancer risk. The postoperative presence of residual FGT (RFGT) is associated with remaining cancer risk. This study evaluated the role of MRI in the quantitative assessment of RFGT and its impact on the estimation of the remaining breast cancer risk. METHODS: The postoperative MRI scans (following EUSOMA recommendations) of 58 patients who had undergone SSM or NSM between 2003 and 2013, as well as preoperative MRI scans that were available in 25 of these patients, were retrospectively evaluated for the presence and location of RFGT by three radiologists. Two different observers quantitatively assessed the volume and percentage of retromamillary and other RFGT (RFGTrm and RFGTother) were assessed. The Fisher's exact test, the Student's t-test, and intraclass coherence were used to compare patient groups and to assess reproducibility. RESULTS: RFGT was found in 20% of all breasts and significantly more frequently after NSM than SSM (50% vs. 13%, p = .003). RFGTrm and RFGTother were more prevalent after NSM (p < 0.001; p = .127). RFGT ranged from 0.5 to 26% of the preoperative FGT, with higher percentages after NSM than SSM (p = .181). CONCLUSIONS: The prevalence and percentage of RFGT found on MRI indicate a considerable remaining postoperative breast cancer risk in some women.

A Simple Ultrasound Based Classification Algorithm Allows Differentiation of Benign from Malignant Breast Lesions by Using Only Quantitative Parameters.

PURPOSE: We hypothesized that different quantitative ultrasound (US) parameters may be used as complementary diagnostic criteria and aimed to develop a simple classification algorithm to distinguish benign from malignant breast lesions and aid in the decision to perform biopsy or not. PROCEDURES: One hundred twenty-four patients, each with one biopsy-proven, sonographically evident breast lesion, were included in this prospective, IRB-approved study. Each lesion was examined with B-mode US, Color/Power Doppler US and elastography (Acoustic Radiation Force Impulse-ARFI). Different quantitative parameters were recorded for each technique, including pulsatility (PI) and resistive Index (RI) for Doppler US and lesion maximum, intermediate, and minimum shear wave velocity (SWVmax, SWVinterm, and SWVmin) as well as lesion-to-fat SWV ratio for ARFI. Receiver operating characteristic curve (ROC) analysis was used to evaluate the diagnostic performance of each quantitative parameter. Classification analysis was performed using the exhaustive chi-squared automatic interaction detection method. Results include the probability for malignancy for every descriptor combination in the classification algorithm. RESULTS: Sixty-five lesions were malignant and 59 benign. Out of all quantitative indices, maximum SWV (SWVmax), and RI were included in the classification algorithm, which showed a depth of three ramifications (SWVmax ≤ or > 3.16; if SWVmax ≤ 3.16 then RI ≤ 0.66, 0.66-0.77 or > 0.77; if RI ≤ 0.66 then SWVmax ≤ or > 2.71). The classification algorithm leads to an AUC of 0.887 (95 % CI 0.818-0.937, p < 0.0001), a sensitivity of 98.46 % (95 % CI 91.7-100 %), and a specificity of 61.02 % (95 % CI 47.4-73.5 %). By applying the proposed algorithm, a false-positive biopsy could have been avoided in 61 % of the cases. CONCLUSIONS: A simple classification algorithm incorporating two quantitative US parameters (SWVmax and RI) shows a high diagnostic performance, being able to accurately differentiate benign from malignant breast lesions and lower the number of unnecessary breast biopsies in up to 60 % of all cases, avoiding any subjective interpretation bias.