Primary Prevention and Early Detection of Hereditary Breast Cancer.

Background: Primary prevention and early detection of hereditary breast cancer has been one of the main topics of breast cancer research in recent decades. The knowledge of risk factors for breast cancer has been increasing continuously just like the recommendations for risk management. Pathogenic germline variants (mutations, class 4/5) of risk genes are significant susceptibility factors in healthy individuals. At the same time, germline mutations serve as biomarkers for targeted therapy in breast cancer treatment. Therefore, management of healthy mutation carriers to enable primary prevention is in the focus as much as the consideration of pathogenic germline variants for therapeutic decisions. Since 1996, the German Consortium has provided quality-assured care for counselees and patients with familial burden of breast and ovarian cancer. Summary: Currently, there are 23 university centers with over 100 cooperating DKG-certified breast and gynecological cancer centers. These centers provide standardized, evidence-based, and knowledge-generating care, which includes aspects of primary as well as secondary and tertiary prevention. An important aspect of quality assurance and development was the inclusion of the HBOC centers in the certification system of the German Cancer Society (GCS). Since 2020, the centers have been regularly audited and their quality standards continuously reviewed according to quality indicators adapted to the current state of research. The standard of care at GC-HBOC' centers involves the evaluation as well as evolution of various aspects of care like inclusion criteria, identification of new risk genes, management of variants of unknown significance (class 3), evaluation of risk-reducing options, intensified surveillance, and communication of risks. Among these, the possibility of intensified surveillance in the GC-HBOC for early detection of breast cancer is an important component of individual risk management for many counselees. As has been shown in recent years, in carriers of pathogenic variants in high-risk genes, this approach enables the detection of breast cancer at very early, more favorable stages although no reduction of mortality has been demonstrated yet. The key component of the intensified surveillance is annual contrast-enhanced breast MRI, supplemented by up to biannual breast ultrasound and mammography usually starting at age 40. Key Messages: Apart from early detection, the central goal of care is the prevention of cancer. By utilizing individualized risk calculation, the optimal timeframe for risk-reducing surgery can be estimated, and counselees can be supported in reaching preference-sensitive decisions.

Development and validation of a four-dimensional registration technique for DCE breast MRI.

BACKGROUND: Patient motion can degrade image quality of dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) due to subtraction artifacts. By objectively and subjectively assessing the impact of principal component analysis (PCA)-based registration on pretreatment DCE-MRIs of breast cancer patients, we aim to validate four-dimensional registration for DCE breast MRI. RESULTS: After applying a four-dimensional, PCA-based registration algorithm to 154 pretreatment DCE-MRIs of histopathologically well-described breast cancer patients, we quantitatively determined image quality in unregistered and registered images. For subjective assessment, we ranked motion severity in a clinical reading setting according to four motion categories (0: no motion, 1: mild motion, 2: moderate motion, 3: severe motion with nondiagnostic image quality). The median of images with either moderate or severe motion (median category 2, IQR 0) was reassigned to motion category 1 (IQR 0) after registration. Motion category and motion reduction by registration were correlated (Spearman's rho: 0.83, p < 0.001). For objective assessment, we performed perfusion model fitting using the extended Tofts model and calculated its volume transfer coefficient Ktrans as surrogate parameter for motion artifacts. Mean Ktrans decreased from 0.103 (± 0.077) before registration to 0.097 (± 0.070) after registration (p < 0.001). Uncertainty in perfusion quantification was reduced by 7.4% after registration (± 15.5, p < 0.001). CONCLUSIONS: Four-dimensional, PCA-based image registration improves image quality of breast DCE-MRI by correcting for motion artifacts in subtraction images and reduces uncertainty in quantitative perfusion modeling. The improvement is most pronounced when moderate-to-severe motion artifacts are present.

Artificial intelligence and machine learning in cancer imaging.

An increasing array of tools is being developed using artificial intelligence (AI) and machine learning (ML) for cancer imaging. The development of an optimal tool requires multidisciplinary engagement to ensure that the appropriate use case is met, as well as to undertake robust development and testing prior to its adoption into healthcare systems. This multidisciplinary review highlights key developments in the field. We discuss the challenges and opportunities of AI and ML in cancer imaging; considerations for the development of algorithms into tools that can be widely used and disseminated; and the development of the ecosystem needed to promote growth of AI and ML in cancer imaging.

[High-risk screening using magnetic resonance imaging]. / Intensivierte Früherkennung mittels Magnetresonanztomographie in der Hochrisikosituation.

BACKGROUND: Specialized breast cancer early detection programs with magnetic resonance imaging (MRI) in high-risk patients are by now well established in several countries. In Germany, such a program has been running as part of routine care since 2005. OBJECTIVES: This review article will summarize current developments in high-risk screening with MRI. MATERIALS AND METHODS: Experiences with the high-risk screening program in Germany over now more than 10 years as well as a review of the current literature will form the basis for this article. RESULTS: The MRI of the breast is by far the most sensitive imaging modality for the detection of breast cancer and represents the back bone of high-risk screening. More than 90% of cancers detected at high-risk screening are visible on the MRI and more than 30% of cancers are detected primarily by MRI alone. However, a prerequisite for effective screening with MRI is a sufficiently high breast cancer incidence in the screened population. This is demonstrated by the fact that the positive predictive value of screening with MRI in women without a BRCA1/2 mutation in the age group between 30 and 39 years is unacceptably low with 2.9%. CONCLUSIONS: In high-risk screening, MRI is the primary imaging tool with mammography and/or ultrasound added as adjunct if necessary. In women with a strong family history of breast cancer but no proven pathogenic mutation in one of the known risk genes in the index patient in the family, the high-risk screening should not routinely start at age 30, but should be postponed until the 10-year breast cancer risk passes a threshold of 5%.

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.

Breast cancer risk in BRCA1/2 mutation carriers and noncarriers under prospective intensified surveillance.

Comparably little is known about breast cancer (BC) risks in women from families tested negative for BRCA1/2 mutations despite an indicative family history, as opposed to BRCA1/2 mutation carriers. We determined the age-dependent risks of first and contralateral breast cancer (FBC, CBC) both in noncarriers and carriers of BRCA1/2 mutations, who participated in an intensified breast imaging surveillance program. The study was conducted between January 1, 2005, and September 30, 2017, at 12 university centers of the German Consortium for Hereditary Breast and Ovarian Cancer. Two cohorts were prospectively followed up for incident FBC (n = 4,380; 16,398 person-years [PY], median baseline age: 39 years) and CBC (n = 2,993; 10,090 PY, median baseline age: 42 years). Cumulative FBC risk at age 60 was 61.8% (95% CI 52.8-70.9%) for BRCA1 mutation carriers, 43.2% (95% CI 32.1-56.3%) for BRCA2 mutation carriers and 15.7% (95% CI 11.9-20.4%) for noncarriers. FBC risks were significantly higher than in the general population, with incidence rate ratios of 23.9 (95% CI 18.9-29.8) for BRCA1 mutation carriers, 13.5 (95% CI 9.2-19.1) for BRCA2 mutation carriers and 4.9 (95% CI 3.8-6.3) for BRCA1/2 noncarriers. Cumulative CBC risk 10 years after FBC was 25.1% (95% CI 19.6-31.9%) for BRCA1 mutation carriers, 6.6% (95% CI 3.4-12.5%) for BRCA2 mutation carriers and 3.6% (95% CI 2.2-5.7%) for noncarriers. CBC risk in noncarriers was similar to women with unilateral BC from the general population. Further studies are needed to confirm whether less intensified surveillance is justified in women from BRCA1/2 negative families with elevated risk.

High-risk breast cancer surveillance with MRI: 10-year experience from the German consortium for hereditary breast and ovarian cancer.

PURPOSE: To report on 10 years of high-risk service screening with annual MRI in the German Consortium for Hereditary Breast and Ovarian Cancer (GC-HBOC). METHODS: A cohort of 4,573 high-risk, previously unaffected women (954 BRCA1 carriers, 598 BRCA2 carriers, 3021 BRCA1/2 non-carriers) participating in the GC-HBOC surveillance program was prospectively followed. Screening outcomes for 14,142 screening rounds with MRI between 2006 and 2015 were analyzed and stratified by risk group, type of screening round, and age. RESULTS: A total of 221 primary breast cancers (185 invasive, 36 in situ) were diagnosed within 12 months of an annual screening round with MRI. Of all cancers, 84.5% (174/206, 15 unknown) were stage 0 or I. In BRCA1 carriers, 16.9% (10/59, 5 unknown) of all incident cancers (screen-detected and interval cancers combined) and in BRCA2 carriers 12.5% (3/24, 4 unknown) were stage IIA or higher, compared to only 4.8% (2/42, 2 unknown) in high-risk BRCA1/2 non-carriers. Program sensitivity was 89.6% (95% CI 84.9-93.0) with no significant differences in sensitivity between risk groups or by age. Specificity was significantly lower in the first screening round (84.6%, 95% CI 83.6-85.7) than in subsequent screening rounds (91.1%, 95% CI 90.6-91.7), p < 0.001. Cancer detection rates (CDRs) and as a result positive predictive values were strongly dependent on type of screening round, risk group and patient age. CDRs ranged from 43.5‰ (95% CI 29.8-62.9) for the first screening round in BRCA2 carriers to 2.9‰ (95% CI 1.3-6.3) for subsequent screening rounds in high-risk non-carriers in the age group 30 to 39 years. CONCLUSIONS: High-risk screening with MRI was successfully implemented in the GC-HBOC with high sensitivity and specificity. Risk prediction and inclusion criteria in high-risk non-carriers need to be adjusted to improve CDRs and thus screening efficacy in these patients.

Breast ultrasound: recommendations for information to women and referring physicians by the European Society of Breast Imaging.

This article summarises the information that should be provided to women and referring physicians about breast ultrasound (US). After explaining the physical principles, technical procedure and safety of US, information is given about its ability to make a correct diagnosis, depending on the setting in which it is applied. The following definite indications for breast US in female subjects are proposed: palpable lump; axillary adenopathy; first diagnostic approach for clinical abnormalities under 40 and in pregnant or lactating women; suspicious abnormalities at mammography or magnetic resonance imaging (MRI); suspicious nipple discharge; recent nipple inversion; skin retraction; breast inflammation; abnormalities in the area of the surgical scar after breast conserving surgery or mastectomy; abnormalities in the presence of breast implants; screening high-risk women, especially when MRI is not performed; loco-regional staging of a known breast cancer, when MRI is not performed; guidance for percutaneous interventions (needle biopsy, pre-surgical localisation, fluid collection drainage); monitoring patients with breast cancer receiving neo-adjuvant therapy, when MRI is not performed. Possible indications such as supplemental screening after mammography for women aged 40-74 with dense breasts are also listed. Moreover, inappropriate indications include screening for breast cancer as a stand-alone alternative to mammography. The structure and organisation of the breast US report and of classification systems such as the BI-RADS and consequent management recommendations are illustrated. Information about additional or new US technologies (colour-Doppler, elastography, and automated whole breast US) is also provided. Finally, five frequently asked questions are answered. TEACHING POINTS: • US is an established tool for suspected cancers at all ages and also the method of choice under 40. • For US-visible suspicious lesions, US-guided biopsy is preferred, even for palpable findings. • High-risk women can be screened with US, especially when MRI cannot be performed. • Supplemental US increases cancer detection but also false positives, biopsy rate and follow-up exams. • Breast US is inappropriate as a stand-alone screening method.

Diagnostic Performance of Automated Breast Volume Scanning (ABVS) Compared to Handheld Ultrasonography With Breast MRI as the Gold Standard.

RATIONALE AND OBJECTIVES: This study aimed to compare the diagnostic value of automated breast volume scanning (ABVS) to that of handheld ultrasonography (HHUS) using breast magnetic resonance imaging (MRI) as the gold standard. MATERIALS AND METHODS: Twenty-eight patients with 39 examined breasts with at least one lesion visible in breast MRI underwent HHUS and ABVS. Detection rate, localization, maximum diameter, and Breast Imaging Reporting and Data System classification were compared. Sensitivity, specificity, diagnostic accuracy, positive predictive value, and negative predictive value were calculated for HHUS and ABVS. Lesion localization and maximum diameters based on HHUS and ABVS were compared to size measurement in MRI. Breast Imaging Reporting and Data System categories based on each method were compared to the MRI diagnosis (malignant or benign) or, if available (21 cases), with the histologic diagnosis. RESULTS: MRI detected 72 lesions, ABVS 59 lesions, and HHUS 54 lesions. Malignancy was proven histopathologically in 15 cases. There was no significant difference between ABVS and HHUS in terms of sensitivity (93.3% vs. 100%), specificity (83.3% vs. 83.3%), diagnostic accuracy (87.2% vs. 89.7%), positive predictive value (77.8% vs. 78.9%), and negative predictive value (95.2% vs. 100%). Agreement regarding lesion localization (same quadrant) was 94.3% for ABVS and MRI and 91.2% for HHUS and MRI. Lesion size compared to MRI lesion size was assessed correctly (+/- 3 mm) in 79.4% (HHUS) and 80% (ABVS). The correlation of size measurement was slightly higher for ABVS-MRI (r = 0.89) than for HHUS-MRI (r = 0.82) with P < .001. CONCLUSIONS: ABVS can be used as an alternative to HHUS. ABVS has the advantage of operator independence and better reproducibility although it is limited in evaluating axillary lymph nodes and lacks Doppler or elastrography capabilities, which sometimes provide important supplementary information in HHUS.

Contrast-enhanced spectral mammography vs. mammography and MRI - clinical performance in a multi-reader evaluation.

OBJECTIVES: To compare the diagnostic performance of contrast-enhanced spectral mammography (CESM) to digital mammography (MG) and magnetic resonance imaging (MRI) in a prospective two-centre, multi-reader study. METHODS: One hundred seventy-eight women (mean age 53 years) with invasive breast cancer and/or DCIS were included after ethics board approval. MG, CESM and CESM + MG were evaluated by three blinded radiologists based on amended ACR BI-RADS criteria. MRI was assessed by another group of three readers. Receiver-operating characteristic (ROC) curves were compared. Size measurements for the 70 lesions detected by all readers in each modality were correlated with pathology. RESULTS: Reading results for 604 lesions were available (273 malignant, 4 high-risk, 327 benign). The area under the ROC curve was significantly larger for CESM alone (0.84) and CESM + MG (0.83) compared to MG (0.76) (largest advantage in dense breasts) while it was not significantly different from MRI (0.85). Pearson correlation coefficients for size comparison were 0.61 for MG, 0.69 for CESM, 0.70 for CESM + MG and 0.79 for MRI. CONCLUSIONS: This study showed that CESM, alone and in combination with MG, is as accurate as MRI but is superior to MG for lesion detection. Patients with dense breasts benefitted most from CESM with the smallest additional dose compared to MG. KEY POINTS: • CESM has comparable diagnostic performance (ROC-AUC) to MRI for breast cancer diagnostics. • CESM in combination with MG does not improve diagnostic performance. • CESM has lower sensitivity but higher specificity than MRI. • Sensitivity differences are more pronounced in dense and not significant in non-dense breasts. • CESM and MRI are significantly superior to MG, particularly in dense breasts.

Position paper on screening for breast cancer by the European Society of Breast Imaging (EUSOBI) and 30 national breast radiology bodies from Austria, Belgium, Bosnia and Herzegovina, Bulgaria, Croatia, Czech Republic, Denmark, Estonia, Finland, France, Germany, Greece, Hungary, Iceland, Ireland, Italy, Israel, Lithuania, Moldova, The Netherlands, Norway, Poland, Portugal, Romania, Serbia, Slovakia, Spain, Sweden, Switzerland and Turkey.

EUSOBI and 30 national breast radiology bodies support mammography for population-based screening, demonstrated to reduce breast cancer (BC) mortality and treatment impact. According to the International Agency for Research on Cancer, the reduction in mortality is 40 % for women aged 50-69 years taking up the invitation while the probability of false-positive needle biopsy is <1 % per round and overdiagnosis is only 1-10 % for a 20-year screening. Mortality reduction was also observed for the age groups 40-49 years and 70-74 years, although with "limited evidence". Thus, we firstly recommend biennial screening mammography for average-risk women aged 50-69 years; extension up to 73 or 75 years, biennially, is a second priority, from 40-45 to 49 years, annually, a third priority. Screening with thermography or other optical tools as alternatives to mammography is discouraged. Preference should be given to population screening programmes on a territorial basis, with double reading. Adoption of digital mammography (not film-screen or phosphor-plate computer radiography) is a priority, which also improves sensitivity in dense breasts. Radiologists qualified as screening readers should be involved in programmes. Digital breast tomosynthesis is also set to become "routine mammography" in the screening setting in the next future. Dedicated pathways for high-risk women offering breast MRI according to national or international guidelines and recommendations are encouraged. KEY POINTS: • EUSOBI and 30 national breast radiology bodies support screening mammography. • A first priority is double-reading biennial mammography for women aged 50-69 years. • Extension to 73-75 and from 40-45 to 49 years is also encouraged. • Digital mammography (not film-screen or computer radiography) should be used. • DBT is set to become "routine mammography" in the screening setting in the next future.

Breast MRI: EUSOBI recommendations for women's information.

UNLABELLED: This paper summarizes information about breast MRI to be provided to women and referring physicians. After listing contraindications, procedure details are described, stressing the need for correct scheduling and not moving during the examination. The structured report including BI-RADS® categories and further actions after a breast MRI examination are discussed. Breast MRI is a very sensitive modality, significantly improving screening in high-risk women. It also has a role in clinical diagnosis, problem solving, and staging, impacting on patient management. However, it is not a perfect test, and occasionally breast cancers can be missed. Therefore, clinical and other imaging findings (from mammography/ultrasound) should also be considered. Conversely, MRI may detect lesions not visible on other imaging modalities turning out to be benign (false positives). These risks should be discussed with women before a breast MRI is requested/performed. Because breast MRI drawbacks depend upon the indication for the examination, basic information for the most important breast MRI indications is presented. Seventeen notes and five frequently asked questions formulated for use as direct communication to women are provided. The text was reviewed by Europa Donna-The European Breast Cancer Coalition to ensure that it can be easily understood by women undergoing MRI. KEY POINTS: • Information on breast MRI concerns advantages/disadvantages and preparation to the examination • Claustrophobia, implantable devices, allergic predisposition, and renal function should be checked • Before menopause, scheduling on day 7-14 of the cycle is preferred • During the examination, it is highly important that the patient keeps still • Availability of prior examinations improves accuracy of breast MRI interpretation.

Intensified surveillance for early detection of breast cancer in high-risk patients.

Efforts for early detection of breast cancer play an important role in the care of high-risk women. This will include both women with a pathological mutation in one of the known breast cancer susceptibility genes as well as women with a high breast cancer risk based on family history only. Due to the much higher incidence of breast cancer in premenopausal women with a genetic predisposition or a familial background, to be most effective, imaging-based breast surveillance should start at an age as early as 25-30 years. There is now ample evidence that magnetic resonance imaging (MRI) is by far the most sensitive imaging modality in young high-risk women. With high-risk multimodality screening at least 30% of breast cancers will be detected primarily by MRI and would have been missed at regular screening without MRI. Therefore, most high-risk breast surveillance programs now offer annual MRI to eligible high-risk women from age 25 to 30, usually supplemented by regular mammography starting at least from age 40. The inclusion of clinical breast exam (CBE) and/or ultrasound in the high-risk surveillance has little impact on the detection of additional cancers, but may improve compliance and reduce unnecessary callbacks for nonspecific findings on MRI. To reduce advanced stage interval cancers, especially in BRCA1/2 mutation carriers, some programs offer additional semiannual CBE and/or ultrasound or alternate MRI and mammography every 6 months. How long regular MRI should be continued in high-risk women is a matter of considerable debate. It appears feasible that MRI can safely be discontinued even in BRCA1/2 mutation carriers between the age of 60 and 70, especially if mammographic breast density is low. Even though several cohort studies have now demonstrated a very favorable stage distribution of breast cancers found in women undergoing high-risk surveillance with MRI, data on long-term survival and mortality in these patients is still rare.

Intraindividual comparison of two methods of volumetric breast composition assessment.

RATIONALE AND OBJECTIVES: To compare the results of two software-based methods, Quantra and Volpara, for volumetric breast composition assessment. MATERIALS AND METHODS: Four hundred forty-five normal, bilateral, two-view, digital mammograms were included. Breast volume (BV), fibroglandular tissue volume (FTV), and percent density (PD) were measured using both methods and compared. Deming regression was performed to obtain linear equations for mapping the results of one software on the other. RESULTS: The median and quartile ranges of both methods agreed well for BV but were different for FTV and PD, with Quantra showing much higher values of FTV and PD. The correlation of results obtained by both methods for BV, FTV, and PD was 0.99, 0.91, and 0.94, respectively. Intraclass correlation in the assignment of quartiles of BV, FTV, and PD was 0.96, 0.86, and 0.90, respectively. Both methods showed a similar association of FTV and PD with patient age and similar left-to-right correlation. Mapping of results onto each other using linear equations removed the systematic differences. CONCLUSIONS: Although Quantra and Volpara use different models for analysis of volumetric breast composition and produce different nominal results of FTV and PD, both methods are highly correlated and show very good to excellent agreement in quartile assignment of all parameters measured. Both methods show a similar association with patient age and similar reproducibility. Both methods can be mapped onto each other using the equations suggested.

Contrast-enhanced spectral mammography: Does mammography provide additional clinical benefits or can some radiation exposure be avoided?

The purpose of this study was to compare contrast-enhanced spectral mammography (CESM) with mammography (MG) and combined CESM + MG in terms of detection and size estimation of histologically proven breast cancers in order to assess the potential to reduce radiation exposure. A total of 118 patients underwent MG and CESM and had final histological results. CESM was performed as a bilateral examination starting 2 min after injection of iodinated contrast medium. Three independent blinded radiologists read the CESM, MG, and CESM + MG images with an interval of at least 4 weeks to avoid case memorization. Sensitivity and size measurement correlation and differences were calculated, average glandular dose (AGD) levels were compared, and breast densities were reported. Fisher's exact and Wilcoxon tests were performed. A total of 107 imaging pairs were available for analysis. Densities were ACR1: 2, ACR2: 45, ACR3: 42, and ACR4: 18. Mean AGD was 1.89 mGy for CESM alone, 1.78 mGy for MG, and 3.67 mGy for the combination. In very dense breasts, AGD of CESM was significantly lower than MG. Sensitivity across readers was 77.9 % for MG alone, 94.7 % for CESM, and 95 % for CESM + MG. Average tumor size measurement error compared to postsurgical pathology was -0.6 mm for MG, +0.6 mm for CESM, and +4.5 mm for CESM + MG (p < 0.001 for CESM + MG vs. both modalities). CESM alone has the same sensitivity and better size assessment as CESM + MG and was significantly better than MG with only 6.2 % increase in AGD. The combination of CESM + MG led to systematic size overestimation. When a CESM examination is planned, additional MG can be avoided, with the possibility of saving up to 61 % of radiation dose, especially in patients with dense breasts.

MRI to X-ray mammography intensity-based registration with simultaneous optimisation of pose and biomechanical transformation parameters.

Determining corresponding regions between an MRI and an X-ray mammogram is a clinically useful task that is challenging for radiologists due to the large deformation that the breast undergoes between the two image acquisitions. In this work we propose an intensity-based image registration framework, where the biomechanical transformation model parameters and the rigid-body transformation parameters are optimised simultaneously. Patient-specific biomechanical modelling of the breast derived from diagnostic, prone MRI has been previously used for this task. However, the high computational time associated with breast compression simulation using commercial packages, did not allow the optimisation of both pose and FEM parameters in the same framework. We use a fast explicit Finite Element (FE) solver that runs on a graphics card, enabling the FEM-based transformation model to be fully integrated into the optimisation scheme. The transformation model has seven degrees of freedom, which include parameters for both the initial rigid-body pose of the breast prior to mammographic compression, and those of the biomechanical model. The framework was tested on ten clinical cases and the results were compared against an affine transformation model, previously proposed for the same task. The mean registration error was 11.6±3.8mm for the CC and 11±5.4mm for the MLO view registrations, indicating that this could be a useful clinical tool.

Comparison of gadoteric acid and gadobutrol for detection as well as morphologic and dynamic characterization of lesions on breast dynamic contrast-enhanced magnetic resonance imaging.

OBJECTIVE: In contrast to conventional breast imaging techniques, one major diagnostic benefit of breast magnetic resonance imaging (MRI) is the simultaneous acquisition of morphologic and dynamic enhancement characteristics, which are based on angiogenesis and therefore provide insights into tumor pathophysiology. The aim of this investigation was to intraindividually compare 2 macrocyclic MRI contrast agents, with low risk for nephrogenic systemic fibrosis, in the morphologic and dynamic characterization of histologically verified mass breast lesions, analyzed by blinded human evaluation and a fully automatic computer-assisted diagnosis (CAD) technique. MATERIALS AND METHODS: Institutional review board approval and patient informed consent were obtained. In this prospective, single-center study, 45 women with 51 histopathologically verified (41 malignant, 10 benign) mass lesions underwent 2 identical examinations at 1.5 T (mean time interval, 2.1 days) with 0.1-mmol kg doses of gadoteric acid and gadobutrol. All magnetic resonance images were visually evaluated by 2 experienced, blinded breast radiologists in consensus and by an automatic CAD system, whereas the morphologic and dynamic characterization as well as the final human classification of lesions were performed based on the categories of the Breast imaging reporting and data system MRI atlas. Lesions were also classified by defining their probability of malignancy (morpho-dynamic index; 0%-100%) by the CAD system. Imaging results were correlated with histopathology as gold standard. RESULTS: The CAD system coded 49 of 51 lesions with gadoteric acid and gadobutrol (detection rate, 96.1%); initial signal increase was significantly higher for gadobutrol than for gadoteric acid for all and the malignant coded lesions (P < 0.05). Gadoteric acid resulted in more postinitial washout curves and fewer continuous increases of all and the malignant lesions compared with gadobutrol (CAD hot spot regions, P < 0.05). Morphologically, the margins of the malignancies were different between the 2 agents, whereas gadobutrol demonstrated more spiculated and fewer smooth margins (P < 0.05). Lesion classifications by the human observers and by the morpho-dynamic index compared with the histopathologic results did not significantly differ between gadoteric acid and gadobutrol. CONCLUSIONS: Macrocyclic contrast media can be reliably used for breast dynamic contrast-enhanced MRI. However, gadoteric acid and gadobutrol differed in some dynamic and morphologic characterization of histologically verified breast lesions in an intraindividual, comparison. Besides the standardization of technical parameters and imaging evaluation of breast MRI, the standardization of the applied contrast medium seems to be important to receive best comparable MRI interpretation.

Breast cancer in young women after treatment for Hodgkin's disease during childhood or adolescence--an observational study with up to 33-year follow-up.

BACKGROUND: The treatment of Hodgkin's disease (HD; also called Hodgkin's lymphoma) in children and adolescents with radiotherapy and chemotherapy leads to high survival rates but has a number of late effects. The most serious one is the development of a secondary malignant tumor, usually in the field that was irradiated. In women, breast cancer can arise in this way. METHOD: Data on the occurrence of secondary breast cancer (sBC) were collected from 590 women who were treated in five consecutive pediatric HD treatment studies in the years 1978-1995 and then re-evaluated in a late follow-up study after a median interval of 17.8 years (maximum, 33.7 years). Information was obtained from 1999 onward by written inquiry to the participants and their treating physicians. The cumulative incidence of sBC was calculated by the Gooley method. RESULTS: By July 2012, sBC had been diagnosed in 26 of 590 female HD patients; the breast cancer was in the irradiated field in 25 of these 26 patients. Their age at the time of treatment for HD was 9.9 to 16.2 years (the pubertal phase), and sBC was discovered with a median latency of 20.7 years after HD treatment (shortest latency, 14.3 years) and at a median age of 35.3 years (youngest age, 26.8 years). The radiation dose to the supradiaphragmatic fields ranged from 20 to 45 Gy. The cumulative incidence for sBC 30 years after treatment for HD was 19% (95% confidence interval, 12% to 29%). For women aged 25 to 45 in this series, the frequency of breast cancer was 24 times as high as in the corresponding normal population. CONCLUSION: Women who were treated for HD in childhood or adolescence have an increased risk of developing breast cancer as young adults. The risk is associated with prior radiotherapy and with the age at which it was administered (the pubertal phase). Because of these findings, a structured breast cancer screening project for this high-risk group has been initiated in collaboration with the German Consortium for Hereditary Breast and Ovarian Cancer (Deutsches Konsortium für familiären Brust- und Eierstockkrebs).

Volumetric breast composition analysis: reproducibility of breast percent density and fibroglandular tissue volume measurements in serial mammograms.

BACKGROUND: Volumetric breast composition analysis represents a useful tool for assessing changes in breast composition over time. However, no data exist on the reproducibility of this method in serial mammograms. PURPOSE: To assess the reproducibility of two volumetric breast composition parameters, breast percent density (PD) and fibroglandular tissue volume (FTV), in consecutive mammograms. MATERIAL AND METHODS: Volumetric breast composition analysis to determine PD and FTV was performed in two consecutive unilateral mammograms of 211 patients. All mammograms were obtained on the same digital mammography unit within a maximum interval of 24 months. Volumetric data for analysis for both examinations were available for 174 patients. Thirty-two patients had successful volumetric analysis of additional consecutive examinations on a second digital mammography unit. Inter-examination correlation of measurements and absolute differences were analyzed. Bland-Altman analysis was performed to compare readings from different mammography units. RESULTS: Mean FTV remained constant over the study period. A reduction in PD of 0.5% and a mean increase in breast volume (BV) of 3% were observed. FTV measurements obtained on the same mammography unit were significantly more reproducible than PD measurements (Pearson correlation coefficients of 0.947 and 0.920, respectively; P < 0.05). A 15% difference between mean absolute volume measurements (FTV and BV) obtained on different mammography units was observed (P ≤ 0.001), while mean PD was close to the expected value. CONCLUSION: Volumetric breast composition analysis is highly reproducible in serial mammograms in normal women. FTV is a more reproducible parameter than PD, indicating that absolute quantification of breast parenchyma may be preferable to the measurement of relative parameters such as PD. However, a disadvantage of using FTV is that it is susceptible to systematic differences when measurements are obtained on different imaging platforms.

Pharmacokinetic approach for dynamic breast MRI to indicate signal intensity time curves of benign and malignant lesions by using the tumor flow residence time.

OBJECTIVE: The objective of this study was to evaluate a novel pharmacokinetic approach integrating a tumor model in a whole-body pharmacokinetic model to simulate contrast media-induced signal intensity time curves of breast tumors on dynamic contrast-enhanced magnetic resonance mammography. MATERIALS AND METHODS: A recently developed, whole-body pharmacokinetic model, which describes the distribution and excretion of renally discharged contrast media, has been expanded by integrating a tumor model. The parameters of the general approach including exchange between plasma and interstitium were set as fixed values; only 2 tumor-specific parameters, blood volume fraction Vblood and blood flow kt, were varied. These parameters were adjusted with regard to signal intensity time course data of histologically verified benign and malignant mass-like breast lesions on clinical magnetic resonance imaging examinations (1.5 T) using 2 different contrast media (gadopentetate dimeglumine and gadoterate meglumine) and 2 application doses (0.1 and 0.2 mmol kg body weight). Thus, measured signal intensity time curves were compared with simulated gadolinium (Gd) concentration time curves calculated by the pharmacokinetic model. RESULTS: Benign lesions showed continuous signal increase; malignant tumors presented fast initial signal increase followed by washout effect. According to the pharmacokinetic approach, the variation of the Vblood/kt ratio, which defined the tumor flow residence time τr, led to Gd concentration time curves congruent with the shapes of the measured signal intensity time curves. Low values of τr were characteristic for malignant tumors, and high values were typical for benign lesions; τr of 200 seconds best separated malignant from benign tumors. Thus, the dynamic magnetic resonance imaging data can be well approximated by the pharmacokinetic model considering 2 contrast media and application doses. The calculated Gd concentration time curves of 0.1 mmol kg body weight gadopentetate dimeglumine and gadoterate meglumine overlapped for benign lesions; the curve of gadoterate meglumine was by a factor of 0.8 below the curve of gadopentetate dimeglumine for malignant tumors. Doubling the application dose of gadopentetate dimeglumine from 0.1 to 0.2 mmol kg led to an increase in the Gd concentration time curves for benign lesions but not for malignant tumors. High Gd concentrations with values greater than 1 mmol L were calculated in the vessels of the malignant tumors, outside the determined range of the linear relationship between Gd concentration and signal intensity due to saturation effects. CONCLUSIONS: On the basis of this pharmacokinetic model, the contrast media-induced time curves on dynamic contrast-enhanced magnetic resonance mammography can be classified by a single kinetic parameter, the tumor flow residence time τr, into benign (τr >200 seconds) and malignant (τr <200 seconds) curve shapes. Possible clinical application of this model is to create pharmacokinetic maps, displaying tumor flow residence times, for computer-assisted diagnosis, which may be integrated into clinical routine for the diagnosis of breast lesions.