[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%.

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.

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.

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.

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.

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.

The risk of contralateral breast cancer in patients from BRCA1/2 negative high risk families as compared to patients from BRCA1 or BRCA2 positive families: a retrospective cohort study.

INTRODUCTION: While it has been reported that the risk of contralateral breast cancer in patients from BRCA1 or BRCA2 positive families is elevated, little is known about contralateral breast cancer risk in patients from high risk families that tested negative for BRCA1/2 mutations. METHODS: A retrospective, multicenter cohort study was performed from 1996 to 2011 and comprised 6,235 women with unilateral breast cancer from 6,230 high risk families that had tested positive for BRCA1 (n = 1,154) or BRCA2 (n = 575) mutations or tested negative (n = 4,501). Cumulative contralateral breast cancer risks were calculated using the Kaplan-Meier product-limit method and were compared between groups using the log-rank test. Cox regression analysis was applied to assess the impact of the age at first breast cancer and the familial history stratified by mutation status. RESULTS: The cumulative risk of contralateral breast cancer 25 years after first breast cancer was 44.1% (95%CI, 37.6% to 50.6%) for patients from BRCA1 positive families, 33.5% (95%CI, 22.4% to 44.7%) for patients from BRCA2 positive families and 17.2% (95%CI, 14.5% to 19.9%) for patients from families that tested negative for BRCA1/2 mutations. Younger age at first breast cancer was associated with a higher risk of contralateral breast cancer. For women who had their first breast cancer before the age of 40 years, the cumulative risk of contralateral breast cancer after 25 years was 55.1% for BRCA1, 38.4% for BRCA2, and 28.4% for patients from BRCA1/2 negative families. If the first breast cancer was diagnosed at the age of 50 or later, 25-year cumulative risks were 21.6% for BRCA1, 15.5% for BRCA2, and 12.9% for BRCA1/2 negative families. CONCLUSIONS: Contralateral breast cancer risk in patients from high risk families that tested negative for BRCA1/2 mutations is similar to the risk in patients with sporadic breast cancer. Thus, the mutation status should guide decision making for contralateral mastectomy.

Detection and classification of contrast-enhancing masses by a fully automatic computer-assisted diagnosis system for breast MRI.

PURPOSE: To evaluate a fully automatic computer-assisted diagnosis (CAD) method for breast magnetic resonance imaging (MRI), which considered dynamic as well as morphologic parameters and linked those to descriptions laid down in the Breast Imaging Reporting and Data System (BI-RADS) MRI atlas. MATERIALS AND METHODS: MR images of 108 patients with 141 histologically proven mass-like lesions (88 malignant, 53 benign) were included. The CAD system automatically performed the following processing steps: 3D nonrigid motion correction, detection of lesions by a segmentation algorithm, extraction of multiple dynamic and morphologic parameters, and classification of lesions. As one final result, the lesions were categorized by defining their probability of malignancy; this so-called morpho-dynamic index (MDI) ranged from 0%-100%. The results of the CAD system were correlated with histopathologic findings. RESULTS: The CAD system had a high detection rate of the histologically proven lesions, missing only two malignancies of invasive multifocal carcinomas and four benign lesions (three fibroadenomas, one atypical ductal hyperplasia). The 86 detected malignant lesions showed a mean MDI of 86.1% (± 15.4%); the mean MDI of the 49 coded benign lesions was 41.8% (± 22.0%; P < 0.001). Based on receiver-operating characteristic analysis, the diagnostic accuracy of the CAD system was 93.5%. Using an appropriate cutoff value (MDI 50%), sensitivity was 96.5% combined with specificity of 75.5%. CONCLUSION: The fully automatic CAD technique seems to reliably distinguish between benign and malignant mass-like breast tumors. Observer-independent CAD may be a promising additional tool for the interpretation of breast MRI in the clinical routine.

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.

Development of low-dose photon-counting contrast-enhanced tomosynthesis with spectral imaging.

PURPOSE: To demonstrate the feasibility of low-dose photon-counting tomosynthesis in combination with a contrast agent (contrast material-enhanced tomographic mammography) for the differentiation of breast cancer. MATERIALS AND METHODS: All studies were approved by the institutional review board, and all patients provided written informed consent. A phantom model with wells of iodinated contrast material (3 mg of iodine per milliliter) 1, 2, 5, 10, and 15 mm in diameter was assessed. Nine patients with malignant lesions and one with a high-risk lesion (atypical papilloma) were included (all women; mean age, 60.7 years). A multislit photon-counting tomosynthesis system was utilized (spectral imaging) to produce both low- and high-energy tomographic data (below and above the k edge of iodine, respectively) in a single scan, which allowed for dual-energy visualization of iodine. Images were obtained prior to contrast material administration and 120 and 480 seconds after contrast material administration. Four readers independently assessed the images along with conventional mammograms, ultrasonographic images, and magnetic resonance images. Glandular dose was estimated. RESULTS: Contrast agent was visible in the phantom model with simulated spherical tumor diameters as small as 5 mm. The average glandular dose was measured as 0.42 mGy per complete spectral imaging tomosynthesis scan of one breast. Because there were three time points (prior to contrast medium administration and 120 and 480 seconds after contrast medium administration), this resulted in a total dose of 1.26 mGy for the whole procedure in the breast with the abnormality. Seven of 10 cases were categorized as Breast Imaging Reporting and Data System score of 4 or higher by all four readers when reviewing spectral images in combination with mammograms. One lesion near the chest wall was not captured on the spectral image because of a positioning problem. CONCLUSION: The use of contrast-enhanced tomographic mammography has been demonstrated successfully in patients with promising diagnostic benefit. Further studies are necessary to fully assess diagnostic sensitivity and specificity.

Breast tomosynthesis.

Digital mammography has been well-evaluated for the diagnosis of breast cancer. The scientific data show that mammography alone, especially in dense breast parenchyma, has its weaknesses. These weaknesses are due to the low contrast of tumors in comparison with the surrounding parenchyma and the overlying structures that mask tumors. The initial results from tomosynthesis studies show a tendency for better imaging and higher accuracy and lower recall rates with tomosynthesis. We present in this article a literature review of the development of breast tomosynthesis and follow it with case examples.

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.

Thick slices from tomosynthesis data sets: phantom study for the evaluation of different algorithms.

Tomosynthesis is a 3-dimensional mammography technique that generates thin slices separated one to the other by typically 1 mm from source data sets. The relatively high image noise in these thin slices raises the value of 1-cm thick slices computed from the set of reconstructed slices for image interpretation. In an initial evaluation, we investigated the potential of different algorithms for generating thick slices from tomosynthesis source data (maximum intensity projection-MIP; average algorithm-AV, and image generation by means of a new algorithm, so-called softMip). The three postprocessing techniques were evaluated using a homogeneous phantom with one textured slab with a total thickness of about 5 cm in which two 0.5-cm-thick slabs contained objects to simulate microcalcifications, spiculated masses, and round masses. The phantom was examined by tomosynthesis (GE Healthcare). Microcalcifications were simulated by inclusion of calcium particles of four different sizes. The slabs containing the inclusions were examined in two different configurations: adjacent to each other and close to the detector and with the two slabs separated by two 1-cm thick breast equivalent material slabs. The reconstructed tomosynthesis slices were postprocessed using MIP, AV, and softMip to generate 1-cm thick slices with a lower noise level. The three postprocessing algorithms were assessed by calculating the resulting contrast versus background for the simulated microcalcifications and contrast-to-noise ratios (CNR) for the other objects. The CNRs of the simulated round and spiculated masses were most favorable for the thick slices generated with the average algorithm, followed by softMip and MIP. Contrast of the simulated microcalcifications was best for MIP, followed by softMip and average projections. Our results suggest that the additional generation of thick slices may improve the visualization of objects in tomosynthesis. This improvement differs from the different algorithms for microcalcifications, speculated objects, and round masses. SoftMip is a new approach combining features of MIP and average showing image properties in between MIP and AV.

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.

Contrast-to-noise ratios of different elements in digital mammography: evaluation of their potential as new contrast agents.

PURPOSE: To determine the contrast-to-noise ratios (CNRs) of different elements at different energies using various anode/filter combinations currently employed in digital mammography. The elements investigated included not only elements already used in conventional contrast agents such as gadolinium and iodine but also other elements to investigate their potential as mammographic contrast agents. MATERIALS AND METHODS: The CNRs of 20 mmol/L bismuth (Bi), gadolinium (Gd), ytterbium (Yb), dysprosium (Dy), and iodine (I) were determined at different slice thicknesses (0.25, 0.5, and 1 cm) of the element solution with an additional 4-cm Plexiglas in relation to water (to simulate dense glandular tissue), oil, and air. The following anode/filter combinations were used: Mo/Mo in the range of 22-34 kVp, Mo/Rh in the range of 36-40 kVp, Rh/Rh in the range of 42-46 kVp, and Mo/Cu in the range of 47-49 kVp. In the range of 22-46 kVp, the mAs were chosen to achieve a fairly uniform dose range (of 4.38-4.71 mGy). Doses were measured using the PTW DIADOS diagnostic dosimeter. The element solutions were examined with a GE Senographe 2000D. RESULTS: Bismuth showed the best CNR for all energies investigated and in relation to both water and oil. In the energy range below 46 kVp, bismuth (CNR at 30 kVp/50 mAs and 1/0.5/0.25 cm slice thickness: 9.9/6.1/3.4) was followed by Yb (5.9/3.5/2.0), Dy (5.3/3.2/1.9), Gd (4.2/2.5/1.6), and iodine (2.4/1.8/1.5). Bismuth had the best CNR relative to both water (values given above) and oil (Bi: 20.7/11.2/5; Yb: 16.9/8.6/3.6; Dy: 16.6/8.4/3.5; Gd: 15.21/7.5/3.2; I: 13.8/6.3/3.2). The CNR of Bi was also superior to that of the other elements investigated at high energy in combination with copper filters (eg, CNR at 49 kVp Mo/Cu at slice thicknesses of 1/0.5/0.25 cm, relative to water: 9.6/6.0/4.0) but now followed by iodine (7.9/5.3/3.5), Yb (5.8/4.0/2.9), Dy (5.4/3.7/2.8), and Gd (4.7/3.2/2.7). Iodine was the only element of those investigated whose contrast-to-noise ratio was improved with the use of a copper filter at high energies based on its K-edge (increase in CNR from 2.9 to 7.9 from 40 to 49 kVp at 1-cm slice thickness). Nevertheless, the improved CNR of iodine was below that of Bi at low energies and for Mo/Mo or Mo/Rh filters. The contrast of water/fat tended to decrease slightly at higher energies (CNR of water/air at 42 kVp: 33.9, at 48 kVp: 25.6; CNR of oil/air at 42 kVp: 23.8, at 48 kVp: 21.9). CONCLUSION: Copper filters and higher energies are useful for visualizing iodine-based contrast agents in contrast-enhanced mammography because they markedly improve the CNR relative to water. This technique further benefits from the fact that the CNR of water and fat relative to air markedly decreases at higher energies and with the use of copper filters. Bismuth was found to have a much better CNR than iodine for all energies investigated including the low energy ranges typically used in mammography. These results suggest that bismuth is a potential candidate for a specific mammographic contrast agent.

Evaluation of 11-gauge and 9-gauge vacuum-assisted breast biopsy systems in a breast parenchymal model.

RATIONALE AND OBJECTIVES: To compare three commercially available vacuum-assisted breast biopsy systems for tissue yield, length and fragmentation of specimens. MATERIALS AND METHODS: Specimens were acquired from radiolucent (bacon) and radioopaque (turkey breast) tissue using three different commercially available vacuum-assisted breast biopsy devices. Two systems (system 1 and 2) were equipped with 11 G needles, one system (system 3) with a 9 G needle. As for systems 1 and 2 a second chamber for applying the vacuum is attached to the needle, the external maximum diameter was identical for all three systems. 48 specimens were taken out for each tissue type and for each device. Specimens were measured for total weight, individual length, and number of fragments. Differences between groups were analyzed using analysis of variance (ANOVA) and Student's t-test. RESULTS: For both tissue types, system 1 and 2 showed similar results, for system 3 tissue weight and length of specimens were larger. Differences in lengths and weight were statistically significant between system 1 and 3 and system 2 and 3 (ANOVA, P < 0.05). Differences between length and weight were statistically significant between tissue 1 and 2 for all devices (t-Test < 0.05). CONCLUSION: As for system 3 a larger tissue yield was obtained with the same number of specimens compared to systems 1 and 2, it can be assumed that the same diagnostic accuracy as for systems 1 and 2 may be achieved for system 3 with less passes through tissue.