Predicting the response to neoadjuvant chemotherapy. Can the addition of tomosynthesis improve the accuracy of contrast-enhanced spectral mammography? A comparison with breast MRI.

OBJECTIVES: Image monitoring is essential to monitor response to neoadjuvant chemotherapy (NACT). Whilst breast MRI is the gold-standard technique, evidence suggests contrast-enhanced spectral mammography (CESM) is comparable. We investigate whether the addition of digital breast tomosynthesis (DBT) to CESM increases the accuracy of response prediction. METHODS: Women receiving NACT for breast cancer were included. Imaging with CESM+DBT and MRI was performed post-NACT. Imaging appearance was compared with pathological specimens. Accuracy for predicting pathological complete response (pCR) and concordance with size of residual disease was calculated. RESULTS: Sixteen cancers in 14 patients were included, 10 demonstrated pCR. Greatest accuracy for predicting pCR was with CESM enhancement (accuracy: 81.3%, sensitivity: 100%, specificity: 57.1%), followed by MRI (accuracy: 62.5%, sensitivity: 44.4%, specificity: 85.7%). Concordance with invasive tumour size was greater for CESM enhancement than MRI, concordance-coefficients 0.70 vs 0.66 respectively. MRI demonstrated greatest concordance with whole tumour size followed by CESM+microcalcification, concordance coefficients 0.86 vs 0.69. DBT did not improve accuracy for prediction of pCR or residual disease size. CESM+DBT underestimated size of residual disease, MRI overestimated but no significant differences were seen (p>0.05). CONCLUSIONS: CESM is similar to MRI for predicting residual disease post-NACT. Size of enhancement alone demonstrates best concordance with invasive disease. Inclusion of residual microcalcification improves concordance with ductal carcinoma in situ. The addition of DBT to CESM does not improve accuracy. ADVANCES IN KNOWLEDGE: The addition ofDBT to CESM does not improve NACT response prediction. CESM enhancement has greatest accuracy for residual invasive disease, CESM+calcification has greater accuracy for residual in situ disease.

Radiomic analysis in contrast-enhanced mammography using a multivendor data set: accuracy of models according to segmentation techniques.

OBJECTIVE: Radiomic analysis of contrast-enhanced mammographic (CEM) images is an emerging field. The aims of this study were to build classification models to distinguish benign and malignant lesions using a multivendor data set and compare segmentation techniques. METHODS: CEM images were acquired using Hologic and GE equipment. Textural features were extracted using MaZda analysis software. Lesions were segmented with freehand region of interest (ROI) and ellipsoid_ROI. Benign/Malignant classification models were built using extracted textural features. Subset analysis according to ROI and mammographic view was performed. RESULTS: 269 enhancing mass lesions (238 patients) were included. Oversampling mitigated benign/malignant imbalance. Diagnostic accuracy of all models was high (>0.9). Segmentation with ellipsoid_ROI produced a more accurate model than with FH_ROI, accuracy:0.947 vs 0.914, AUC:0.974 vs 0.86, p < 0.05. Regarding mammographic view all models were highly accurate (0.947-0.955) with no difference in AUC (0.985-0.987). The CC-view model had the greatest specificity:0.962, the MLO-view and CC + MLO view models had higher sensitivity:0.954, p < 0.05. CONCLUSIONS: Accurate radiomics models can be built using a real-life multivendor data set segmentation with ellipsoid-ROI produces the highest level of accuracy. The marginal increase in accuracy using both mammographic views, may not justify the increased workload. ADVANCES IN KNOWLEDGE: Radiomic modelling can be successfully applied to a multivendor CEM data set, ellipsoid_ROI is an accurate segmentation technique and it may be unnecessary to segment both CEM views. These results will help further developments aimed at producing a widely accessible radiomics model for clinical use.

Contrast-enhanced digital breast tomosythesis and breast MRI to monitor response to neoadjuvant chemotherapy: patient tolerance and preference.

OBJECTIVE: Contrast-enhanced digital breast tomosynthesis (CE-DBT) is a novel imaging technique, combining contrast-enhanced spectral mammography and tomosynthesis. This may offer an alternative imaging technique to breast MRI for monitoring of response to neoadjuvant chemotherapy. This paper addresses patient experience and preference regarding the two techniques. METHODS: Conducted as part of a prospective pilot study; patients were asked to complete questionnaires pertaining to their experience of CE-DBT and MRI following pre-treatment and end-of-treatment imaging. Questionnaires consisted of eight questions answered on a categorical scale, two using a visual analogue scale (VAS), and a question to indicate preference of imaging technique. Statistical analysis was performed with Wilcoxon signed rank test and McNemar test for related samples using SPSS v. 25. RESULTS: 18 patients were enrolled in the pilot study. Matched CE-DBT and MRI questionnaires were completed after 22 patient episodes. Patient preference was indicated after 31 patient episodes. Overall, on 77% of occasions patients preferred CE-DBT with no difference between pre-treatment and end-of-treatment imaging. Overall experience (p = 0.008), non-breast pain (p = 0.046), anxiety measured using VAS (p = 0.003), and feeling of being put at ease by staff (p = 0.023) was better for CE-DBT. However, more breast pain was experienced during CE-DBT when measured on both VAS (p = 0.011) and categorical scale (p = 0.021). CONCLUSION: Our paper suggests that patients prefer CE-DBT to MRI, adding further evidence in favour of contrast-enhanced mammographic techniques. ADVANCES IN KNOWLEDGE: Contrast mammographic techniques offer an alternative, more accessible imaging technique to breast MRI. Whilst other studies have addressed patient experience of contrast-enhanced spectral mammography, this is the first study to directly explore patient preference for CE-DBT over MRI in the setting of neoadjuvant chemotherapy, finding that overall, patients preferred CE-DBT despite the relatively long breast compression.

Are baseline ultrasound and mammographic features associated with rates of pathological completes response in patients receiving neoadjuvant chemotherapy for breast cancer?

BACKGROUND: Increasing numbers of breast cancer patients receive neoadjuvant chemotherapy (NACT). We seek to investigate whether baseline mammographic and ultrasound features are associated with complete pathological response (pCR) after NACT. METHODS: A database of NACT patients was reviewed. Baseline imaging parameters assessed were ultrasound: posterior effect; echo pattern; margin and lesion diameter; mammography: spiculation and microcalcification. Core biopsy grade and immunophenotype were documented. Data were analysed for the whole study group and by immunophenotype. RESULTS: Of the 222 cancers, 83 (37%) were triple negative (TN), 61 (27%) ER positive/HER-2 negative and 78 (35%) HER-2 positive. A pCR occurred in 46 of 222 cancers (21%). For the whole group, response was associated with high core biopsy grade (grade 3 vs. grade 1 or 2) (26% vs. 9%, p = 0.0044), absence of posterior shadowing on ultrasound (26% vs. 10%, p <  0.001) and the absence of mammographic spiculation (26 vs. 6%, p <  0.001). Within the HER-2 positive group; the absence of shadowing and spiculation remained highly associated with pCR, in addition to small ultrasound size (AUC = 0.71, p < 0.001) and the absence of microcalcification (39% vs. 21%, p < 0.02). On multivariable analysis absence of spiculation and core grade remained significant for the whole cohort, size and absence of spiculation remained significant for HER-2 positive tumours. No feature predicted pCR in TN tumours. CONCLUSION: A pCR is less likely when there is mammographic spiculation. Small ultrasound size is associated with pCR in HER-2 positive tumours. These findings may be helpful when discussing NACT and surgical options with patients. TRIAL REGISTRATION: UK Clinical Trials Gateway: registration number 16712.

Incidence and Potential Significance of Internal Mammary Lymphadenopathy on Computed Tomography in Patients with a Diagnosis of Primary Breast Cancer.

INTRODUCTION: The importance of internal mammary nodes (IMNs) in the staging and treatment of breast cancer patients is controversial. METHODS: A retrospective cohort of patients diagnosed with primary breast cancer over a 4-year period (January 2009 to December 2012) was assessed. The number and size of any IMNs visible on spiral computed tomography (CT) were recorded. RESULTS: A total of 830 patients were diagnosed with primary breast cancer within the identified time frame, of which 150 patients met the inclusion criteria. Of these 42% (63) had IMNs present, although the majority were small (<5 mm). However, 16% (25) had larger nodes, greater than 5 mm in short axis, present on CT. Significantly more patients with the presence of large (>5 mm) IMNs had more advanced disease with CT evidence of other distant spread. CONCLUSION: We have demonstrated that IMNs are present in a substantial number of our primary breast cancer patients. We suggest that further histological research is required to establish reliable CT size criterion for pathological IMNs. In addition, routine imaging of the IM chain, as well as axilla, should be considered in the staging of breast cancer.