Breast lymphedema following breast-conserving treatment for breast cancer: current status and future directions.

PURPOSE: To examine the current evidence on breast lymphedema (BL) diagnosis and treatment after breast-conserving surgery, identify gaps in the literature, and propose future research directions. METHODS: A comprehensive literature review was conducted using Ovid, PubMed, and Cochrane, including studies published between 2000 and 2023. References were reviewed manually for eligible studies. Inclusion criteria were as follows: patients who underwent breast conserving treatment (surgery ± radiation) for breast cancer, goals of the paper included analyzing or reviewing BL measurement with ultrasound or tissue dielectric constant, or BL treatment. Twenty-seven manuscripts were included in the review. RESULTS: There is variation in incidence, time course, and risk factors for BL. Risk factors for BL included breast size, primary and axillary surgery extent, radiation, and chemotherapy but require further investigation. Diagnostic methods for BL currently rely on patient report and lack standardized criteria. Tissue dielectric constant (TDC) and ultrasound (US) emerged as promising ambulatory BL assessment tools; however, diagnostic thresholds and validation studies with ICG lymphography are needed to establish clinical utility. The evidence base for treatment of BL is weak, lacking high-quality studies. CONCLUSION: The natural history of BL is not well defined. TDC and US show promise as ambulatory assessment tools for BL; however, further validation with lymphatic imaging is required. BL treatment is not established in the literature. Longitudinal, prospective studies including pre-radiation measurements and validating with lymphatic imaging are required. These data will inform screening, diagnostic criteria, and evidence-based treatment parameters for patients with BL after breast-conserving surgery and radiation.

Multimodality Imaging of Postmastectomy Breast Reconstruction Techniques, Complications, and Tumor Recurrence.

For women undergoing mastectomy, breast reconstruction can be performed by using implants or autologous tissue flaps. Mastectomy options include skin- and nipple-sparing techniques. Implant-based reconstruction can be performed with saline or silicone implants. Various autologous pedicled or free tissue flap reconstruction methods based on different tissue donor sites are available. The aesthetic outcomes of implant- and flap-based reconstructions can be improved with oncoplastic surgery, including autologous fat graft placement and nipple-areolar complex reconstruction. The authors provide an update on recent advances in implant reconstruction techniques and contemporary expanded options for autologous tissue flap reconstruction as it relates to imaging modalities. As breast cancer screening is not routinely performed in this clinical setting, tumor recurrence after mastectomy and reconstruction is often detected by palpation at physical examination. Most local recurrences occur within the skin and subcutaneous tissue. Diagnostic breast imaging continues to have a critical role in confirmation of disease recurrence. Knowledge of the spectrum of benign and abnormal imaging appearances in the reconstructed breast is important for postoperative evaluation of patients, including recognition of early and late postsurgical complications and breast cancer recurrence. The authors provide an overview of multimodality imaging of the postmastectomy reconstructed breast, as well as an update on screening guidelines and recommendations for this unique patient population. ©RSNA, 2024 Test Your Knowledge questions for this article are available in the supplemental material.

Spectrum of Mucin-containing Lesions of the Breast: Multimodality Imaging Review with Pathologic Correlation.

Mucin-containing lesions of the breast encompass a wide range of benign and malignant processes. The spectrum of histologic findings includes incidental mucus-filled benign cysts or ducts, mucocele-like lesions (MLLs), mucin-producing ductal carcinoma in situ, and invasive mucinous carcinoma. MLL is characterized by the presence of mucin-containing cysts that are typically associated with extravasated stromal mucin. MLL is often benign but can be associated with epithelial atypia or malignancy. Mucinous carcinoma represents the malignant end of the spectrum of mucinous lesions of the breast. Evidence-based literature supports a conservative approach for benign MLLs without associated atypia or malignancy, reserving excision for those lesions exhibiting such pathologic features. The most common imaging finding for MLL is microcalcifications at mammography. No specific imaging feature is predictive of malignant outcome at surgical excision. Invasive mucinous carcinoma is a heterogeneous breast tumor subtype, as defined according to the World Health Organization criteria. Mucinous carcinomas are categorized into pure (>90% mucinous component) or mixed (10%-90% mucinous component) subtypes. Pure mucinous carcinomas are generally associated with excellent prognosis and survival, with a few exceptions. Mixed mucinous carcinomas do not have the same favorable prognosis and instead behave similarly to invasive breast carcinomas of no special type. Characteristic diagnostic imaging features can be identified for mucinous carcinoma based on its mucinous and nonmucinous contents. ©RSNA, 2023 Online supplemental material is available for this article. Quiz questions for this article are available through the Online Learning Center.

Preoperative Breast MRI for Newly Diagnosed Ductal Carcinoma in Situ: Imaging Features and Performance in a Multicenter Setting (ECOG-ACRIN E4112 Trial).

Background There are limited data from clinical trials describing preoperative MRI features and performance in the evaluation of mammographically detected ductal carcinoma in situ (DCIS). Purpose To report qualitative MRI features of DCIS, MRI performance in the identification of additional disease, and associations of imaging features with pathologic, genomic, and surgical outcomes from the Eastern Cooperative Oncology Group-American College of Radiology Imaging Network (ECOG-ACRIN) E4112 trial. Materials and Methods Secondary analyses of a multicenter prospective clinical trial from the ECOG-ACRIN Cancer Research Group included women with DCIS diagnosed with conventional imaging techniques (mammography and US), confirmed via core-needle biopsy (CNB), and enrolled between March 2015 and April 2016 who were candidates for wide local excision (WLE) based on conventional imaging and clinical examination results. DCIS MRI features and pathologic features from CNB and excision were recorded. Each woman without invasive upgrade of the index DCIS at WLE received a 12-gene DCIS score. MRI performance metrics were calculated. Associations of imaging features with invasive upgrade, dichotomized DCIS score (<39 vs ≥39), and single WLE success were estimated in uni- and multivariable analyses. Results Among 339 women (median age, 60 years; interquartile range, 51-66 years), most DCIS cases showed nonmass enhancement (NME) (195 of 339 [58%]) on MRI scans with larger median size than on mammograms (19 mm vs 12 mm; P < .001). Positive predictive value of MRI-prompted CNBs was 32% (21 of 66) (95% CI: 22, 44), yielding an additional cancer detection rate of 6.2% (21 of 339) (95% CI: 4.1, 9.3). MRI false-positive rate was 14.2% (45 of 318) (95% CI: 10.7, 18.4). No imaging features were associated with invasive upgrade or DCIS score (P = .05 to P = .95). Smaller size and focal NME distribution at MRI were linked to single WLE success (P < .001). Conclusion Preoperative MRI depicted ductal carcinoma in situ (DCIS) diagnosed with conventional imaging most commonly as nonmass enhancement, with larger median span than mammography, and additional cancer detection rate of 6.2%. MRI features of this subset of DCIS did not enable prediction of pathologic or genomic outcomes. Clinical trial registration no. NCT02352883 © RSNA, 2021 Online supplemental material is available for this article. See also the editorial by Kuhl in this issue. An earlier incorrect version of this article appeared online. This article was corrected on August 4, 2021.

Shear-Wave Elastography of the Breast: Impact of Technical Image Quality Parameters on Diagnostic Accuracy.

OBJECTIVE. The purpose of this study is to determine the impact of shear-wave elastography (SWE) image quality parameters on the diagnostic performance of elasticity measurements in classifying breast lesions. MATERIALS AND METHODS. This retrospective study included 281 breast lesions that underwent SWE and ultrasound-guided biopsy performed between October 1, 2017, and August 31, 2018. Three readers who were blinded to pathologic outcomes independently scored the image quality of each SWE image (with low quality denoted by a score of 0 and high quality indicated by a score of 1) on the basis of five parameters: B-mode visualization of the lesion on a dual-panel display, SWE red pattern (denoting high stiffness) in the near field of the FOV, appearance of the surrounding tissue, FOV placement, and ROI placement for the maximum (Emax), minimum (Emin), mean (Emean), and SD (ESD) of Young modulus elasticity measurements. Using ROC analysis, we compared the performance of Emax, Emean, and ESD in diagnosing malignancy on low- and high-quality images on the basis of consensus (i.e., majority) scores for each individual quality parameter as well as two models combining a few of the quality parameters. RESULTS. Three quality parameters (B-mode visualization of the lesion, presence of a near-field red pattern, and the appearance of the surrounding tissue) showed moderate-to-substantial interobserver agreement. SWE images were considered high quality (n = 167) if both B-mode visualization and near-field red pattern received a consensus score of 1, and they were considered low quality (n = 114) if either parameter received a consensus score of 0. High-quality images had a statistically higher AUC value than low-quality images when Emax (p < .001), Emean (p = .002), and ESD (p < .001) were used as classifiers of malignancy. CONCLUSION. Quality parameters can support radiologists who are performing and interpreting breast SWE images. These quality parameters have the potential to improve the accuracy of SWE in differentiating malignant from benign breast lesions.

Data Engineering for Machine Learning in Women's Imaging and Beyond.

OBJECTIVE. Data engineering is the foundation of effective machine learning model development and research. The accuracy and clinical utility of machine learning models fundamentally depend on the quality of the data used for model development. This article aims to provide radiologists and radiology researchers with an understanding of the core elements of data preparation for machine learning research. We cover key concepts from an engineering perspective, including databases, data integrity, and characteristics of data suitable for machine learning projects, and from a clinical perspective, including the HIPAA, patient consent, avoidance of bias, and ethical concerns related to the potential to magnify health disparities. The focus of this article is women's imaging; nonetheless, the principles described apply to all domains of medical imaging. CONCLUSION. Machine learning research is inherently interdisciplinary: effective collaboration is critical for success. In medical imaging, radiologists possess knowledge essential for data engineers to develop useful datasets for machine learning model development.

Value of Mammography for Women 30-39 Years Old Presenting With Breast Symptoms.

OBJECTIVE: The purpose of this study was to determine the performance and added value of bilateral mammography in identifying cancers distant from sites of presenting breast symptoms in women 30-39 years old. MATERIALS AND METHODS: A search identified consecutively registered women 30-39 years old who underwent mammography and ultrasound to evaluate focal breast symptoms between June 2006 and August 2016. Outcomes were determined by imaging and pathologic analysis through linkage with a tumor registry. Medical records were reviewed to determine the presence of breast cancer risk factors. Lifetime breast cancer risk was calculated with the International Breast Cancer Intervention Study model. RESULTS: The study included 4426 diagnostic examinations of 3997 women 30-39 years old. Sixty-eight breast cancers were diagnosed (cancer detection rate, 15.4 per 1000 examinations). Sixty examinations led to biopsy of a finding distant from the presenting symptom site, yielding nine incidental malignancies (positive predictive value, 15.0%; incidental cancer detection rate, 2.0 per 1000 examinations [9/4426]). Among the other 59 cancers diagnosed in the symptomatic area, bilateral mammography depicted multicentric or contra-lateral disease in seven (11.9%). Average lifetime risk of breast cancer among the 68 women with cancer was significantly higher than that among age-matched control subjects (22.8% vs 13.1%, p < 0.001); 45 of these 68 women (66.2%) had identifiable risk factors. Lifetime risk among the nine women with incidental cancers was higher than that of age-matched control subjects, although without statistical significance (24.9% vs 13.2%, p = 0.07). CONCLUSION: Bilateral mammographic evaluation of women 30-39 years old presenting with breast symptoms yielded an additional 2.0 incidental cancers per 1000 examinations. The low added cancer yield may support the judicious rather than routine use of mammography in this patient cohort.

Computer-aided heterogeneity analysis in breast MR imaging assessment of ductal carcinoma in situ: Correlating histologic grade and receptor status.

PURPOSE: To identify breast MR imaging biomarkers to predict histologic grade and receptor status of ductal carcinoma in situ (DCIS). MATERIALS AND METHODS: Informed consent was waived in this Health Insurance Portability and Accountability Act-compliant Institutional Review Board-approved study. Case inclusion was conducted from 7332 consecutive breast MR studies from January 1, 2009, to December 31, 2012. Excluding studies with benign diagnoses, studies without visible abnormal enhancement, and pathology containing invasive disease yielded 55 MR-imaged pathology-proven DCIS seen on 54 studies. Twenty-eight studies (52%) were performed at 1.5 Tesla (T); 26 (48%) at 3T. Regions-of-interest representing DCIS were segmented for precontrast, first and fourth postcontrast, and subtracted first and fourth postcontrast images on the open-source three-dimensional (3D) Slicer software. Fifty-seven metrics of each DCIS were obtained, including distribution statistics, shape, morphology, Renyi dimensions, geometrical measure, and texture, using the 3D Slicer HeterogeneityCAD module. Statistical correlation of heterogeneity metrics with DCIS grade and receptor status was performed using univariate Mann-Whitney test. RESULTS: Twenty-four of the 55 DCIS (44%) were high nuclear grade (HNG); 44 (80%) were estrogen receptor (ER) positive. Human epidermal growth factor receptor-2 (HER2) was amplified in 10/55 (18%), nonamplified in 34/55 (62%), unknown/equivocal in 8/55 (15%). Surface area-to-volume ratio showed significant difference (P < 0.05) between HNG and non-HNG DCIS. No metric differentiated ER status (0.113 < p ≤ 1.000). Seventeen metrics showed significant differences between HER2-positive and HER2-negative DCIS (0.016 < P < 0.050). CONCLUSION: Quantitative heterogeneity analysis of DCIS suggests the presence of MR imaging biomarkers in classifying DCIS grade and HER2 status. Validation with larger samples and prospective studies is needed to translate these results into clinical applications. LEVEL OF EVIDENCE: 3 Technical Efficacy: Stage 3 J. Magn. Reson. Imaging 2017;46:1748-1759.

Performance of DWI as a Rapid Unenhanced Technique for Detecting Mammographically Occult Breast Cancer in Elevated-Risk Women With Dense Breasts.

OBJECTIVE: The objective of our study was to evaluate the performance of DWI to detect mammographically occult breast cancer in elevated-risk women with dense breasts. MATERIALS AND METHODS: We retrospectively reviewed all women who underwent screening breast MRI at our institution from January 2007 through May 2013. We created a case-control cohort composed of 48 subjects with mammographically dense breasts: 24 with mammographically occult cancer detected on MRI and 24 healthy women with negative MRI findings who were matched to the subjects with breast cancer patients for age, breast density, and MRI protocol. The contrast-to-noise ratio (CNR), apparent diffusion coefficient (ADC), and conspicuity score (range, 1-5) were assessed on DWI for all malignancies. Lesions and normal tissue were compared using the Wilcoxon signed rank test; associations with clinical characteristics were evaluated using the Mann-Whitney U test. Three experienced breast imagers who were blinded to medical records and contrast-enhanced MRI findings independently evaluated the unenhanced MRI scans of the 48 women for the presence of cancer. RESULTS: Mammographically occult breast cancers (invasive carcinoma, n = 16; ductal carcinoma in situ, n = 8) in women with dense breasts typically exhibited higher signal intensity on DWI than normal parenchyma (median CNR of cancers, 1.4; median conspicuity score of cancers, 4) and a lower ADC (median, 1.31 vs 1.79 × 10(-3) mm(2)/s, respectively) (p < 0.0001). The conspicuity score, CNR, and ADC were not associated with patient age, menopausal status, lesion size, morphologic type, or histology (p > 0.05). Average reader performance using unenhanced MRI was 45% sensitivity, 91% specificity, 62% positive predictive value, and 83% negative predictive value. CONCLUSION: In elevated-risk women with dense breasts, DWI can reveal cancers in addition to those detected on mammography alone with a low false-positive rate; these results suggest that DWI may have potential as a rapid supplemental screening tool.

Digital Tomosynthesis to Evaluate Fracture Healing: Prospective Comparison With Radiography and CT.

OBJECTIVE: Radiography, currently the standard for postoperative fracture imaging, is limited by overlapping bone and hardware. Tomosynthesis has the benefit of level-by-level imaging without the disadvantages of metal artifacts, increased radiation, and higher costs of CT, the current problem-solving tool. The purpose of this study was to compare tomosynthesis with radiography for evaluating fracture healing. SUBJECTS AND METHODS: In a prospective study, patients within 1 year of wrist hardware fixation underwent radiography, tomosynthesis, and CT, and the images were interpreted by three readers. The diagnostic accuracy of radiology and tomosynthesis was assessed with ROC curves, and interreader agreement was assessed with Cohen kappa. Fracture scores were correlated with Disabilities of the Arm, Shoulder, and Hand (DASH) and pain scores. RESULTS: The study participants were 49 patients with 51 fractures. The most common fracture sites were distal radius (43%), scaphoid (18%), and metacarpals (18%). Rates of cortex obscuration by hardware were 2% for CT, 8% for tomosynthesis, and 15% for radiography (p < 0.01 between one modality and another). Detection of cortical fracture lines was significantly better with tomosynthesis than with radiography (AUC, 0.84 vs 0.76, p = 0.01). Inter-reader agreement was moderate for both radiography and tomosynthesis (κ = 0.44 vs 0.55, p = 0.051). There was no significant correlation between fracture scores and DASH scores. There was significant correlation between reported pain levels and both tomosynthesis (r = 0.28, p = 0.03) and CT (r = 0.29, p = 0.04) fracture scores. CONCLUSION: Tomosynthesis provides diagnostic information superior to that of ra diography in postoperative evaluation of wrist fractures with lower cost and radiation than CT and should be considered in fracture follow-up imaging of other bones.

Pulmonary effects of i.v. injection of crushed oral tablets: "excipient lung disease".

OBJECTIVE: When crushed oral tablets are injected i.v., their filler material (excipient) can induce a potentially fatal foreign-body reaction in pulmonary arterioles, presenting as dyspnea and pulmonary hypertension with centrilobular nodules on CT. We will describe the imaging and pathologic features of "excipient lung disease." CONCLUSION: The radiologist has a critical role in recognizing and reporting excipient lung disease because the referring clinician may be unaware of the patient's i.v. drug abuse.

Digital tomosynthesis of the chest: current and emerging applications.

Digital tomosynthesis (DTS) of the chest is a technique whose basic components are similar to those of digital radiography, but that also provides some of the benefits of computed tomography (CT). The major advantages of DTS over conventional chest radiography are improved visibility of the pulmonary parenchyma and depiction of abnormalities such as pulmonary nodules. Calcifications, vessels, airways, and chest wall abnormalities are also much more readily visualized at DTS than at chest radiography. DTS could potentially be combined with chest radiography to follow up known nodules, confirm or rule out suspected nodules seen at radiography, or evaluate individuals who are at high risk for lung cancer or pulmonary metastases. DTS generates coronal "slices" through the chest whose resolution is superior to that of coronal reconstructed CT images, but it is limited by its suboptimal depth resolution and susceptibility to motion; consequently, potential pitfalls in recognizing lesions adjacent to the pleura, diaphragm, central vessels, and mediastinum can occur. However, the radiation dose and projected cost of chest DTS are lower than those of standard chest CT. Besides pulmonary nodule detection, specific applications of DTS that are under investigation include evaluation of pulmonary tuberculous and nontuberculous mycobacterial disease, cystic fibrosis, interstitial lung disease, and asbestos-related thoracic diseases. A basic understanding of chest DTS and of the emerging applications of this technique can prove useful to the radiologist. Online supplemental material is available for this article.

Thoracic diseases associated with HIV infection in the era of antiretroviral therapy: clinical and imaging findings.

The human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) pandemic has entered its 4th decade. Since the introduction of combination antiretroviral therapy (ART) in 1996, the number of AIDS-related deaths has plateaued worldwide. Today, owing to the effectiveness of ART, the HIV-infected population is aging and HIV infection has become a chronic illness. Non-AIDS comorbidities are increasing, and the spectrum of HIV-related thoracic diseases is evolving. In developed countries, bacterial pneumonia has become more common than Pneumocystis pneumonia. Its imaging appearance depends on the responsible organism, most commonly Streptococcus pneumoniae. Mycobacterium tuberculosis continues to be a major threat. Its imaging patterns vary depending on CD4 count. Primary lung cancer and Hodgkin lymphoma are two important non-AIDS-defining malignancies that are increasingly encountered at chest imaging. Human herpesvirus 8, also known as Kaposi sarcoma-associated herpesvirus (KSHV), is strongly linked to HIV-related diseases, including Kaposi sarcoma, multicentric Castleman disease, KSHV inflammatory cytokine syndrome, and primary effusion lymphoma. Immune reconstitution inflammatory syndrome is a direct complication of ART whose manifestations vary with the underlying disease. Given the high rate of smoking among HIV-infected patients, chronic obstructive pulmonary disease is another important cause of morbidity and mortality. A high degree of suspicion is required for the early diagnosis of pulmonary arterial hypertension and lymphocytic interstitial pneumonia, given their nonspecific manifestations. Finally, multilocular thymic cyst manifests as a cystic anterior mediastinal mass. Recognition of the clinical and radiologic manifestations of these less traditional HIV-related diseases can expedite diagnosis and treatment in the ART era.

Framework for Successful Integration of Health Services Research Into a Breast Imaging Career.

Health services research (HSR) is a multidisciplinary field of inquiry that examines how health care is structured, providing valuable data on health care outcomes and delivery. Over the past few decades, a shift in the U.S. health care system toward value-based care has placed a priority on health services topics. Health services research has been central to the evolution of breast imaging over this period, with increased emphasis placed on the following: (1) design of appropriate-use criteria for imaging services; (2) determination of cost-effectiveness of imaging protocols and screening regimens guiding policy; and (3) evaluation of policy related to reimbursement for diagnostic imaging and image-guided procedures. Examples of HSR topics that can be applied directly to breast imaging include evaluation of health care availability and accessibility, analysis of health care use patterns, exploration of patient preferences, assessment of technological innovation, development and implementation of clinical practice guidelines and screening strategies, and examination of health care organization and delivery models. Breast imaging radiologists who perform HSR are uniquely positioned to advocate for patients, to promote transformative health care interventions, and to influence policy changes and public health initiatives in breast imaging through analysis of health care data and translation of their research findings. In this Training and Professional Development article, we aim to provide practical approaches to explore interest in HSR and to describe a framework for successful integration of HSR into a breast imaging career.

Artificial Intelligence for Breast US.

US is a widely available, commonly used, and indispensable imaging modality for breast evaluation. It is often the primary imaging modality for the detection and diagnosis of breast cancer in low-resource settings. In addition, it is frequently employed as a supplemental screening tool via either whole breast handheld US or automated breast US among women with dense breasts. In recent years, a variety of artificial intelligence systems have been developed to assist radiologists with the detection and diagnosis of breast lesions on US. This article reviews the background and evidence supporting the use of artificial intelligence tools for breast US, describes implementation strategies and impact on clinical workflow, and discusses potential emerging roles and future directions.

Breast Cancer Screening in Women With Dense Breasts: Current Status and Future Directions for Appropriate Risk Stratification and Imaging Utilization.

Breast density continues to be a prevailing topic in the field of breast imaging, with continued complexities contributing to overall confusion and controversy among patients and the medical community. In this article, we explore the current status of breast cancer screening in women with dense breasts including breast density legislation. Risk-based approaches to supplemental screening may be more financially cost-effective. While all advanced imaging modalities detect additional primarily invasive, node-negative cancers, the degree to which this occurs can vary by density category. Future directions include expanding the use of density-inclusive risk models with appropriate risk stratification and imaging utilization. Further research is needed, however, to better understand how to optimize population-based screening programs with knowledge of patients' individualized risk, including breast density assessment, to improve the benefit-to-harm ratio of breast cancer screening.