Evolving Treatment Paradigms for Low-Risk Ductal Carcinoma In Situ: Imaging Needs.

Ductal carcinoma in situ (DCIS) is a nonobligate precursor to invasive cancer that classically presents as asymptomatic calcifications on screening mammography. The increase in DCIS diagnoses with organized screening programs has raised concerns about overdiagnosis, while a patientcentric push for more personalized care has increased awareness about DCIS overtreatment. The standard of care for most new DCIS diagnoses is surgical excision, but nonsurgical management via active monitoring is gaining attention, and multiple clinical trials are ongoing. Imaging, along with demographic and pathologic information, is a critical component of active monitoring efforts. Commonly used imaging modalities including mammography, ultrasound, and MRI, as well as newer modalities such as contrast-enhanced mammography and dedicated breast PET, can provide prognostic information to risk stratify patients for DCIS active monitoring eligibility. Furthermore, radiologists will be responsible for closely surveilling patients on active monitoring and identifying if invasive progression occurs. Active monitoring is a paradigm shift for DCIS care, but the success or failure will rely heavily on the interpretations and guidance of radiologists.

Relationship between body mass index and malignancy rates of MRI-guided breast biopsies: impact of clinicodemographic factors.

PURPOSE: To determine the positive predictive value (PPV) of magnetic resonance imaging (MRI)-guided breast biopsy stratified by body mass index (BMI). Secondary endpoints include evaluation of indications for breast MRI and identification of factors associated with malignant biopsy. METHODS: We retrospectively analyzed results of MRI-guided breast biopsies in a consecutive cohort of women at a single institution between 2014 and 2019. The PPV was compared between BMI subgroups and the overall group by the one-sample z-test. Factors associated with malignant biopsy were analyzed using multivariate regression analysis. RESULTS: Among 427 MRI-guided breast biopsies, the PPV was significantly higher in patients with a BMI ≥ 35 compared to BMI < 35 (38.6% versus 24.5%, p = 0.043). This remained true in the 180 biopsies from high-risk screening studies, but there was no difference in PPV by BMI in the 205 biopsies performed to evaluate extent of known disease. Among this cohort who underwent MRI-guided breast biopsy, the underlying indication for MRI was less likely to be high-risk screening in those with a higher BMI or Black or Hispanic race (p = 0.015 and p < 0.001, respectively). For high-risk screening studies, only BMI ≥ 35 was associated with malignant biopsies (OR 37.5, p = 0.003). For evaluation of extent of disease studies, only increased lesion size was a significant predictor of malignant result (OR 1.01, p = 0.04). CONCLUSIONS: Among women who underwent MRI-guided breast biopsy, elevated BMI was associated with increased PPV and malignant biopsies. Patients with a higher BMI or Black or Hispanic race who had MRI-guided biopsy were less likely to be undergoing high-risk screening and more likely to have breast MRI to evaluate extent of known disease.

US as the Primary Imaging Modality in the Evaluation of Palpable Breast Masses in Breastfeeding Women, Including Those of Advanced Maternal Age.

Background Women are increasingly delaying childbearing, and thus lactation, into their 30s and 40s, when mammography would typically be the initial imaging modality to evaluate palpable masses in the general population. Current guidelines recommend US as the first-line imaging modality for palpable masses in pregnant and lactating women, but data regarding breastfeeding women age 30 years and older are near nonexistent. Purpose To evaluate the diagnostic performance of targeted US as the primary imaging modality for the evaluation of palpable masses in lactating women, including those of advanced maternal age. Materials and Methods Lactating women with palpable breast masses evaluated at targeted US over a 17-year period (January 2000 to July 2017) were retrospectively identified. All US evaluations were performed at diagnostic evaluation, and mammography was performed at the discretion of the interpreting radiologist. Breast Imaging Reporting and Data System assessments, imaging, and pathology results were collected. Descriptive statistics and 2 × 2 contingency tables were assessed at the patient level. Results There were 167 women (mean age, 35 years ± 5 [standard deviation]), 101 of whom (60%) were of advanced maternal age (≥35 years). All women underwent targeted US, and 98 (59%) underwent mammography in addition to US. The frequency of malignancy was five of 167 (3.0%). Targeted US demonstrated a sensitivity and specificity of five of five (100%; 95% confidence interval [CI]: 48%, 100%) and 114 of 162 (70%; 95% CI: 63%, 77%), respectively. Negative predictive value, positive predictive value of an abnormal examination, and positive predictive value of biopsy were 114 of 114 (100%; 95% CI: 97%, 100%), five of 53 (9.4%; 95% CI: 3%, 21%), and five of 50 (10%; 95% CI: 3%, 22%), respectively. In the subset of 98 women who underwent mammography in addition to US, mammography depicted seven incidental suspicious findings, which lowered the specificity from 62 of 93 (67%; 95% CI: 56%, 76%) to 57 of 93 (61%; 95% CI: 51%, 71%) (P = .02). Conclusion Targeted US depicted all malignancies in lactating women with palpable masses. Adding mammography increased false-positive findings without any additional cancer diagnoses. © RSNA, 2020 See also the editorial by Newell in this issue.

Role of Breast MRI in the Evaluation and Detection of DCIS: Opportunities and Challenges.

Historically, breast magnetic resonance imaging (MRI) was not considered an effective modality in the evaluation of ductal carcinoma in situ (DCIS). Over the past decade this has changed, with studies demonstrating that MRI is the most sensitive imaging tool for detection of all grades of DCIS. It has been suggested that not only is breast MRI the most sensitive imaging tool for detection but it may also detect the most clinically relevant DCIS lesions. The role and outcomes of MRI in the preoperative setting for patients with DCIS remains controversial; however, several studies have shown benefit in the preoperative evaluation of extent of disease as well as predicting an underlying invasive component. The most common presentation of DCIS on MRI is nonmass enhancement (NME) in a linear or segmental distribution pattern. Maximizing breast MRI spatial resolution is therefore beneficial, given the frequent presentation of DCIS as NME on MRI. Emerging MRI techniques, such as diffusion-weighted imaging (DWI), have shown promising potential to discriminate DCIS from benign and invasive lesions. Future opportunities including advanced imaging visual techniques, radiomics/radiogenomics, and machine learning / artificial intelligence may also be applicable to the detection and treatment of DCIS. Level of Evidence: 3 Technical Efficacy Stage: 3 J. Magn. Reson. Imaging 2019. J. Magn. Reson. Imaging 2020;52:697-709.

Combined Benefit of Quantitative Three-Compartment Breast Image Analysis and Mammography Radiomics in the Classification of Breast Masses in a Clinical Data Set.

Purpose To investigate the combination of mammography radiomics and quantitative three-compartment breast (3CB) image analysis of dual-energy mammography to limit unnecessary benign breast biopsies. Materials and Methods For this prospective study, dual-energy craniocaudal and mediolateral oblique mammograms were obtained immediately before biopsy in 109 women (mean age, 51 years; range, 31-85 years) with Breast Imaging Reporting and Data System category 4 or 5 breast masses (35 invasive cancers, 74 benign) from 2013 through 2017. The three quantitative compartments of water, lipid, and protein thickness at each pixel were calculated from the attenuation at high and low energy by using a within-image phantom. Masses were automatically segmented and features were extracted from the low-energy mammograms and the quantitative compartment images. Tenfold cross-validations using a linear discriminant classifier with predefined feature signatures helped differentiate between malignant and benign masses by means of (a) water-lipid-protein composition images alone, (b) mammography radiomics alone, and (c) a combined image analysis of both. Positive predictive value of biopsy performed (PPV3) at maximum sensitivity was the primary performance metric, and results were compared with those for conventional diagnostic digital mammography. Results The PPV3 for conventional diagnostic digital mammography in our data set was 32.1% (35 of 109; 95% confidence interval [CI]: 23.9%, 41.3%), with a sensitivity of 100%. In comparison, combined mammography radiomics plus quantitative 3CB image analysis had PPV3 of 49% (34 of 70; 95% CI: 36.5%, 58.9%; P < .001), with a sensitivity of 97% (34 of 35; 95% CI: 90.3%, 100%; P < .001) and 35.8% (39 of 109) fewer total biopsies (P < .001). Conclusion Quantitative three-compartment breast image analysis of breast masses combined with mammography radiomics has the potential to reduce unnecessary breast biopsies. © RSNA, 2018 Online supplemental material is available for this article.

Feasibility of Magnetic Seeds for Preoperative Localization of Axillary Lymph Nodes in Breast Cancer Treatment.

OBJECTIVE. The objective of this study was to evaluate the feasibility of using a magnetic seed system for preoperative localization of axillary lymph nodes in patients with breast cancer. MATERIALS AND METHODS. We performed a retrospective analysis that included patients with breast cancer who underwent preoperative magnetic seed localization of axillary lymph nodes at our institution between January 1, 2017, and January 1, 2019. Magseed (Endomag) is a nonradioactive inducible magnetic seed that is induced to become a magnet when under the influence of its detector in the operating room. Clinical history, prior axillary sampling and clip placement, and procedure details and surgical outcomes were determined from a search of our PACS and electronic medical records. RESULTS. Thirty-five patients (34 women and one man) composed our study cohort. The mean patient age was 56 years (range, 32-78 years). One patient underwent two separate consecutive localizations for two separate operations, and another patient had bilateral lesions, for a total of 37 axillary lymph node localizations. One case of seed misplacement occurred during the ultrasound-guided localization procedure, resulting in immediate placement of a second seed, for a total of 38 Magseeds placed. All seeds were placed under ultrasound guidance. The mean number of days from seed placement to surgery was 5 days (range, 0-31 days). Thirty-seven of 38 Magseeds (97%) were documented to be successfully retrieved in the operating room. CONCLUSION. Magseed localization appears to be a safe, nonradioactive way to accurately localize axillary lymph nodes preoperatively.

Effect of Background Parenchymal Enhancement on Breast MR Imaging Interpretive Performance in Community-based Practices.

Purpose To evaluate the effect of background parenchymal enhancement (BPE) on breast magnetic resonance (MR) imaging interpretive performance in a large multi-institutional cohort with independent analysis of screening and diagnostic MR studies. Materials and Methods Analysis of 3770 breast MR studies was conducted. Examinations were performed in 2958 women at six participating facilities in the San Francisco Bay Area from January 2010 to October 2012. Findings were recorded prospectively in the San Francisco Mammography Registry. Performance measures were compared between studies with low BPE (mild or minimal) and those with high BPE (moderate or marked) by using binomial tests of proportions. Results Of 1726 MR imaging studies in the screening group, 1301 were classified as having low BPE and 425 were classified as having high BPE (75% vs 25%, respectively; P < .001). Of 2044 MR imaging studies in the diagnostic group, 1443 were classified as having low BPE and 601 were classified as having high BPE (71% vs 29%, respectively; P < .001). For low versus high BPE groups at screening, abnormal interpretation rate was 157 of 1301 versus 111 of 424 (12% vs 26%, P < .001); biopsy recommendation rate was 85 of 1301 versus 54 of 424 (7% vs 13%, P < .001); and specificity was 89% (95% confidence interval [CI]: 87, 91) versus 75% (95% CI: 71, 80) (P = .01). For the low versus high BPE groups at diagnostic MR imaging, biopsy recommendation rate was 325 of 1443 versus 195 of 601 (23% vs 32%, P < .001); and specificity was 86% (95% CI: 84, 88) versus 75% (95% CI: 74, 82) (P < .001). There were no significant differences between studies with low versus high BPE in sensitivity for screening (76% [95% CI: 55, 91] vs 83% [95% CI: 52, 98]; P = .94) or diagnostic (93% [95% CI: 87, 97] vs 96% [95% CI: 87, 99]; P = .69) MR imaging, nor were there significant differences in cancer detection rate per 1000 patients between the low BPE versus high BPE groups for screening (15 per 1000 vs 24 per 1000, P = .30) or diagnostic (78 per 1000 vs 85 per 1000, P = .64) MR imaging. Conclusion Relative to MR studies with minimal or mild BPE, those with moderate or marked BPE were associated with higher abnormal interpretation and biopsy rates and lower specificity, with no difference in cancer detection rate. © RSNA, 2017 Online supplemental material is available for this article.

Sonographic-MRI Correlation After Percutaneous Sampling of Targeted Breast Ultrasound Lesions: Initial Experiences With Limited-Sequence Unenhanced MRI for Postprocedural Clip Localization.

OBJECTIVE: The purpose of this study is to determine the frequency of correlation of sonographic and MRI findings after percutaneous sampling of presumed ultrasound correlates to suspicious lesions detected on breast MRI and to describe our initial experiences with limited-sequence MRI for postprocedural clip verification. MATERIALS AND METHODS: Between January 1, 2014, and March 31, 2016, a total of 1947 contrast-enhanced breast MRI examinations were performed, and 245 targeted ultrasound examinations were conducted to identify correlates to suspicious MRI findings. We retrospectively identified all lesions that underwent ultrasound-guided sampling of a presumed sonographic correlate and for which a subsequent postprocedural limited-sequence unenhanced MR image for clip localization was available. This consisted of a T1-weighted non-fat-saturated and a T2-weighted fat-saturated sequence. Frequencies of sonographic-MRI correlation were quantified. RESULTS: The study cohort consisted of 35 patients with 38 presumed correlates that underwent ultrasound-guided sampling with postprocedural MRI for clip verification. The mean time from percutaneous sampling to postprocedural MRI examination was 1 day. Ten presumed sonographic correlates (26%) were found to localize to a site distinct from the lesion originally identified on MRI. One of these discordant cases revealed malignancy on subsequent MRI-guided biopsy, whereas the presumed sonographic correlate was found to be benign. No patient or lesion characteristics were associated with significantly different frequencies of correlation. CONCLUSION: In our initial experiences with MRI performed for postprocedural clip verification, 26% of presumed correlates to suspicious lesions detected on MRI were not the actual correlate, and 10% of these discordant cases ultimately revealed malignancy. Radiologists should take caution presuming that lesions identified on ultrasound actually represent the suspicious lesions detected on MRI. MRI for clip verification may be useful if ultrasound-guided sampling is pursued.

Clustered Microcysts on Breast Ultrasound: What Is an Appropriate Management Recommendation?

OBJECTIVE: The objective of our study was to determine outcomes of lesions identified as clustered microcysts on breast ultrasound to augment the existing literature and help guide appropriate management recommendations. MATERIALS AND METHODS: We retrospectively identified cases at our institution, from January 2003 through December 2013, of all lesions classified as clustered microcysts at breast ultrasound. Breast ultrasound examinations were performed by the interpreting physician. If ultrasound-guided sampling was performed, results were obtained from the pathology or cytology reports. If sampling was not performed, only lesions with at least 24 months of imaging follow-up or any imaging follow-up with interval resolution or decrease in size were included in the study. Outcomes and frequency of malignancy were determined by reviewing the electronic medical records and our PACS. RESULTS: Of 144 patients with 148 lesions classified as clustered microcysts on ultrasound, 93 patients with 95 lesions had adequate follow-up and were included in our study population. The mean patient age was 50 years (range, 32-72 years). Of the 16 lesions that underwent percutaneous sampling, none (0% [95% CI, 0-21%]) yielded malignancy. Fourteen (88%) sampled lesions were benign, and two (12%) of the sampled lesions revealed atypical ductal hyperplasia at percutaneous sampling but no atypia or upgrade at subsequent surgical excision. In total, 0 of 95 lesions (0% [95% CI, 0-3.8%]) showed malignancy at sampling or imaging follow-up. CONCLUSION: Our results support that lesions sonographically characterized as clustered microcysts carry an extremely low risk of malignancy, and biopsy should be avoided.

Outcome of high-risk lesions at MRI-guided 9-gauge vacuum- assisted breast biopsy.

OBJECTIVE: The purposes of this study were to determine the frequency of underestimation of high-risk lesions at MRI-guided 9-gauge vacuum-assisted breast biopsy and to determine the imaging and demographic characteristics predictive of lesion upgrade after surgery. MATERIALS AND METHODS: We retrospectively reviewed consecutively detected lesions that were found only at MRI and biopsied under MRI guidance from May 2007 to April 2012. Imaging indications, imaging features, and histologic findings were reviewed. The Fisher exact test was used to assess the association between characteristics and lesion upgrade. Patients lost to follow-up or who underwent mastectomy were excluded, making the final study cohort 140 women with 151 high-risk lesions, 147 of which were excised. RESULTS: A database search yielded the records of 1145 lesions in 1003 women. Biopsy yielded 252 (22.0%) malignant tumors, 184 (16.1%) high-risk lesions, and 709 (61.9%) benign lesions. Thirty of the 147 (20.4%) excised high-risk lesions were upgraded to malignancy. The upgrade rate was highest for atypical ductal hyperplasia, lobular carcinoma in situ, and radial scar. No imaging features were predictive of upgrade. However, there was a significantly higher risk that a high-risk lesion would be upgraded to malignancy if the current MRI-detected high-risk lesion was in the same breast as a malignant tumor previously identified in the remote history, a recently diagnosed malignant tumor, or a high-risk lesion previously identified in the remote history (p = 0.0001). The upgrade rate was significantly higher for women with a personal cancer history than for other indications combined (p = 0.0114). CONCLUSION: The rate of underestimation of malignancy in our series was 20%. No specific imaging features were seen in upgraded cases. Surgical excision is recommended for high-risk lesions found at MRI biopsy and may be particularly warranted for women with a personal history of breast cancer.

Screening in Women With BRCA Mutations Revisited.

Patients with BRCA1 or BRCA2 gene mutations are at high risk for the development of breast cancer. This article reviews the current evidence for breast cancer screening of patients with BRCA1 or BRCA2 pathogenic gene mutations if they have not undergone prophylactic mastectomy. It will review the current evidence-based imaging recommendations for different modalities and ages of screening initiation in screening this patient population at high risk. Special considerations in transgender BRCA1 and BRCA2 mutation carriers are also discussed.

Ductal carcinoma in situ of the breasts: review of MR imaging features.

The incidence of ductal carcinoma in situ (DCIS) has increased over the past few decades and now accounts for over 20% of newly diagnosed cases of breast cancer. Although the detection of DCIS has increased with the advent of widespread mammography screening, it is essential to have a more accurate assessment of the extent of DCIS for successful breast conservation therapy. Recent studies evaluating the detection of DCIS with magnetic resonance (MR) imaging have used high spatial resolution techniques and have increasingly been performed to screen a high-risk population as well as to evaluate the extent of disease. This work has shown that MR imaging is the most sensitive modality currently available for identifying DCIS and is more accurate than mammography in evaluating the extent of DCIS. MR imaging is particularly sensitive for identifying high-grade and intermediate-grade DCIS. DCIS may have variable morphologic features on MR images, with non-mass enhancement morphology being the most common manifestation. Less commonly, DCIS may also manifest as a mass on MR images, in which case it is most likely to be irregular. The kinetics of DCIS are also variable, with fast uptake and a plateau curve reported as the most common kinetic pattern. Additional MR imaging tools such as diffusion-weighted imaging and quantitative kinetic analysis combined with the benefit of high field strength, such as 3 T, may increase the sensitivity and specificity of breast MR imaging in the detection of DCIS.

Clinical significance of lung nodules reported on abdominal CT.

OBJECTIVE: The objective of our study was to identify the significance of lung nodules reported on abdominal CT. MATERIALS AND METHODS: Abdominal CT reports from a 1-year period were reviewed for the terms "nodule," "nodular," or "mass" in reference to the lung bases. Patients with prior chest or abdominal CT examinations were excluded; the study population included patients with an initial abdominal CT study and at least one follow-up chest or abdominal CT examination. Two thoracic radiologists characterized nodules in consensus. Radiology and clinical records were reviewed for nodule growth and clinical diagnoses. RESULTS: The term "nodule," "nodular," or "mass" in reference to the lung bases was reported in 364 of 12,287 abdominal CT studies (3%). Of 125 patients with no prior CT examination, 42 had undergone follow-up chest CT, abdominal CT, or both. Common imaging indications included abdominal pain (13/42, 31%) and preexisting malignancy (n = 7, 16.7%). Regardless of the indication for imaging, 16 (38.1%) had malignancy that was known (n = 13) or newly diagnosed (n = 3) on the initial abdominal CT. Three of 42 patients (7.1%) had malignant nodules representing metastatic disease: Nodule growth was seen in one patient with preexisting colon cancer, one patient with newly diagnosed metastatic pancreatic cancer, and a third with known bladder cancer. The latter patient had suspected lung metastases that were confirmed on chest CT 1 day later. Three of the 16 patients (18.8%) with preexisting or newly diagnosed cancer had malignant nodules. No malignant nodules were identified without such history. Six patients (14.3%) had an infection. CONCLUSION: Lung nodules incidentally detected on abdominal CT were rarely malignant and were seen only in the setting of an underlying abdominal malignancy. Knowledge of such history is of critical importance to both the clinician and the radiologist. Dedicated chest CT is most useful when assessing pulmonary nodules in patients with localized malignancy.

Identifying Good Candidates for Active Surveillance of Ductal Carcinoma In Situ: Insights from a Large Neoadjuvant Endocrine Therapy Cohort.

Ductal carcinoma in situ (DCIS) is a biologically heterogenous entity with uncertain risk for invasive ductal carcinoma (IDC) development. Standard treatment is surgical resection often followed by radiation. New approaches are needed to reduce overtreatment. This was an observational study that enrolled patients with DCIS who chose not to pursue surgical resection from 2002 to 2019 at a single academic medical center. All patients underwent breast MRI exams at 3- to 6-month intervals. Patients with hormone receptor-positive disease received endocrine therapy. Surgical resection was strongly recommended if clinical or radiographic evidence of disease progression developed. A recursive partitioning (R-PART) algorithm incorporating breast MRI features and endocrine responsiveness was used retrospectively to stratify risk of IDC. A total of 71 patients were enrolled, 2 with bilateral DCIS (73 lesions). A total of 34 (46.6%) were premenopausal, 68 (93.2%) were hormone-receptor positive, and 60 (82.1%) were intermediate- or high-grade lesions. Mean follow-up time was 8.5 years. Over half (52.1%) remained on active surveillance without evidence of IDC with mean duration of 7.4 years. Twenty patients developed IDC, of which 6 were HER2 positive. DCIS and subsequent IDC had highly concordant tumor biology. Risk of IDC was characterized by MRI features after 6 months of endocrine therapy exposure; low-, intermediate-, and high-risk groups were identified with respective IDC rates of 8.7%, 20.0%, and 68.2%. Thus, active surveillance consisting of neoadjuvant endocrine therapy and serial breast MRI may be an effective tool to risk-stratify patients with DCIS and optimally select medical or surgical management. Significance: A retrospective analysis of 71 patients with DCIS who did not undergo upfront surgery demonstrated that breast MRI features after short-term exposure to endocrine therapy identify those at high (68.2%), intermediate (20.0%), and low risk (8.7%) of IDC. With 7.4 years mean follow-up, 52.1% of patients remain on active surveillance. A period of active surveillance offers the opportunity to risk-stratify DCIS lesions and guide decisions for operative management.

A review of equity issues in quantitative studies on health inequalities: the case of asthma in adults.

BACKGROUND: The term 'inequities' refers to avoidable differences rooted in injustice. This review examined whether or not, and how, quantitative studies identifying inequalities in risk factors and health service utilization for asthma explicitly addressed underlying inequities. Asthma was chosen because recent decades have seen strong increases in asthma prevalence in many international settings, and inequalities in risk factors and related outcomes. METHODS: A review was conducted of studies that identified social inequalities in asthma-related outcomes or health service use in adult populations. Data were extracted on use of equity terms (objective evidence), and discussion of equity issues without using the exact terms (subjective evidence). RESULTS: Of the 219 unique articles retrieved, 21 were eligible for inclusion. None used the terms equity/inequity. While all but one article traced at least partial pathways to inequity, only 52% proposed any intervention and 55% of these interventions focused exclusively on the more proximal, clinical level. CONCLUSIONS: Without more in-depth and systematic examination of inequities underlying asthma prevalence, quantitative studies may fail to provide the evidence required to inform equity-oriented interventions to address underlying circumstances restricting opportunities for health.

Population and public health ethics in Canada: a snapshot of current national initiatives and future issues.

To date, some work has been undertaken to define a code and stewardship framework for public health ethics. However, gaps in our understanding and application of ethics to the field of population and public health (PPH) remain. This paper presents the approach to building capacity for PPH ethics by three national-level organizations: the Canadian Institutes of Health Research-Institute of Population and Public Health, the National Collaborating Centre for Healthy Public Policy, and the Public Health Agency of Canada. By first looking at each of the organizations' respective activities and then across organizations, we synthesize our common approaches, highlight future directions and pose questions aimed at stimulating dialogue about the role of, and challenges confronting, the emerging field of PPH ethics in Canada.

Post-lumpectomy breast calcifications: Can original tumor features assist in determining need for biopsy?

OBJECTIVE: The objective of our study was to determine whether, in the digital era, imaging features of a primary breast tumor can be used to influence the decision to biopsy ipsilateral breast calcifications that occur following surgery in women treated with breast conservation surgery (BCS). MATERIALS AND METHODS: We retrospectively identified women treated with BCS who subsequently developed suspicious calcifications in the treated breast (BI-RADS 4 or 5) from January 2012 - December 2018. Only cases with histopathological diagnosis by stereotactic or surgical biopsy were included. Pathology reports were reviewed, and biopsy results were considered malignant if invasive carcinoma or ductal carcinoma in situ (DCIS) was found. All other results were considered benign. Fisher's exact test was done comparing frequencies of malignancy between those patients whose original tumor had calcifications versus those whose original tumors were not calcified. RESULTS: Of 90 women with suspicious calcifications on a post-BCS mammogram, 65 (72.2%) were biopsy proven benign and 25 (27.8%) were malignant. The original tumor presented without calcifications in 39 patients (43%), and 51 (57%) had calcifications with or without associated mass, focal asymmetry, or architectural distortion. New calcifications were less likely to be malignant if the original tumor presented without calcifications (5/39; 12.8%) as compared to original tumors with calcifications (20/51; 38.5%) [p-value < 0.05]. CONCLUSION: New calcifications after BCS are significantly less likely to be malignant if the original tumor presented without calcifications. However, with a PPV of 12.8%, even calcifications in a patient with a non-calcified primary tumor require biopsy.

Outcomes of screening mammography performed prior to fertility treatment in women ages 40-49.

OBJECTIVE: There are currently various conflicting recommendations for breast cancer screening with mammography in women between ages 40-49. There are no specific guidelines for breast cancer screening in women of this age group prior to assisted reproductive technology (ART) for the treatment of infertility. The purpose of our study was to evaluate outcomes of screening mammography, specifically ordered for the purpose of pre-fertility treatment clearance in women aged 40-49 years old. MATERIALS AND METHODS: This was an IRB approved retrospective study of women aged 40-49 presenting for screening mammography prior to ART between January 2010 and October 2018. Clinical history, imaging, and pathology results were gathered from the electronic medical record. Descriptive statistics were performed. RESULTS: Our study cohort consisted of 118 women with a mean age of 42 years (range 40-49). Sixteen of 118 (14%) women were recalled from screening for additional diagnostic work-up. Five of the 16 (31%) were recommended for biopsy (BI-RADS 4 or 5). One of 5 biopsies yielded a malignant result (PPV 20%). Overall cancer detection rate was 0.85% or 8.5 women per 1000 women screened. The single cancer in this cohort was an ER+ PR+ HER2- invasive ductal carcinoma. CONCLUSION: Screening mammography in women 40-49 performed prior to initiation of ART may identify asymptomatic breast malignancy. In accordance with ACR and SBI guidelines to screen women of this age group, women of this age group should undergo screening mammography prior to ART.

Dual-energy three-compartment breast imaging for compositional biomarkers to improve detection of malignant lesions.

Background: While breast imaging such as full-field digital mammography and digital breast tomosynthesis have helped to reduced breast cancer mortality, issues with low specificity exist resulting in unnecessary biopsies. The fundamental information used in diagnostic decisions are primarily based in lesion morphology. We explore a dual-energy compositional breast imaging technique known as three-compartment breast (3CB) to show how the addition of compositional information improves malignancy detection. Methods: Women who presented with Breast Imaging-Reporting and Data System (BI-RADS) diagnostic categories 4 or 5 and who were scheduled for breast biopsies were consecutively recruited for both standard mammography and 3CB imaging. Computer-aided detection (CAD) software was used to assign a morphology-based prediction of malignancy for all biopsied lesions. Compositional signatures for all lesions were calculated using 3CB imaging and a neural network evaluated CAD predictions with composition to predict a new probability of malignancy. CAD and neural network predictions were compared to the biopsy pathology. Results: The addition of 3CB compositional information to CAD improves malignancy predictions resulting in an area under the receiver operating characteristic curve (AUC) of 0.81 (confidence interval (CI) of 0.74-0.88) on a held-out test set, while CAD software alone achieves an AUC of 0.69 (CI 0.60-0.78). We also identify that invasive breast cancers have a unique compositional signature characterized by reduced lipid content and increased water and protein content when compared to surrounding tissues. Conclusion: Clinically, 3CB may potentially provide increased accuracy in predicting malignancy and a feasible avenue to explore compositional breast imaging biomarkers.