Current use and future perspectives of contrast-enhanced mammography (CEM): a survey by the European Society of Breast Imaging (EUSOBI).

OBJECTIVES: To perform a survey among members of the European Society of Breast Imaging (EUSOBI) regarding the use of contrast-enhanced mammography (CEM). METHODS: A panel of nine board-certified radiologists developed a 29-item online questionnaire, distributed to all EUSOBI members (inside and outside Europe) from January 25 to March 10, 2023. CEM implementation, examination protocols, reporting strategies, and current and future CEM indications were investigated. Replies were exploratively analyzed with descriptive and non-parametric statistics. RESULTS: Among 434 respondents (74.9% from Europe), 50% (217/434) declared to use CEM, 155/217 (71.4%) seeing less than 200 CEMs per year. CEM use was associated with academic settings and high breast imaging workload (p < 0.001). The lack of CEM adoption was most commonly due to the perceived absence of a clinical need (65.0%) and the lack of resources to acquire CEM-capable systems (37.3%). CEM protocols varied widely, but most respondents (61.3%) had already adopted the 2022 ACR CEM BI-RADS® lexicon. CEM use in patients with contraindications to MRI was the most common current indication (80.6%), followed by preoperative staging (68.7%). Patients with MRI contraindications also represented the most commonly foreseen CEM indication (88.0%), followed by the work-up of inconclusive findings at non-contrast examinations (61.5%) and supplemental imaging in dense breasts (53.0%). Respondents declaring CEM use and higher CEM experience gave significantly more current (p = 0.004) and future indications (p < 0.001). CONCLUSIONS: Despite a trend towards academic high-workload settings and its prevalent use in patients with MRI contraindications, CEM use and progressive experience were associated with increased confidence in the technique. CLINICAL RELEVANCE STATEMENT: In this first survey on contrast-enhanced mammography (CEM) use and perspectives among the European Society of Breast Imaging (EUSOBI) members, the perceived absence of a clinical need chiefly drove the 50% CEM adoption rate. CEM adoption and progressive experience were associated with more extended current and future indications. KEY POINTS: • Among the 434 members of the European Society of Breast Imaging who completed this survey, 50% declared to use contrast-enhanced mammography in clinical practice. • Due to the perceived absence of a clinical need, contrast-enhanced mammography (CEM) is still prevalently used as a replacement for MRI in patients with MRI contraindications. • The number of current and future CEM indications marked by respondents was associated with their degree of CEM experience.

Chest Radiograph Scoring Alone or Combined with Other Risk Scores for Predicting Outcomes in COVID-19.

Background Radiographic severity may help predict patient deterioration and outcomes from COVID-19 pneumonia. Purpose To assess the reliability and reproducibility of three chest radiograph reporting systems (radiographic assessment of lung edema [RALE], Brixia, and percentage opacification) in patients with proven SARS-CoV-2 infection and examine the ability of these scores to predict adverse outcomes both alone and in conjunction with two clinical scoring systems, National Early Warning Score 2 (NEWS2) and International Severe Acute Respiratory and Emerging Infection Consortium: Coronavirus Clinical Characterization Consortium (ISARIC-4C) mortality. Materials and Methods This retrospective cohort study used routinely collected clinical data of patients with polymerase chain reaction-positive SARS-CoV-2 infection admitted to a single center from February 2020 through July 2020. Initial chest radiographs were scored for RALE, Brixia, and percentage opacification by one of three radiologists. Intra- and interreader agreement were assessed with intraclass correlation coefficients. The rate of admission to the intensive care unit (ICU) or death up to 60 days after scored chest radiograph was estimated. NEWS2 and ISARIC-4C mortality at hospital admission were calculated. Daily risk for admission to ICU or death was modeled with Cox proportional hazards models that incorporated the chest radiograph scores adjusted for NEWS2 or ISARIC-4C mortality. Results Admission chest radiographs of 50 patients (mean age, 74 years ± 16 [standard deviation]; 28 men) were scored by all three radiologists, with good interreader reliability for all scores, as follows: intraclass correlation coefficients were 0.87 for RALE (95% CI: 0.80, 0.92), 0.86 for Brixia (95% CI: 0.76, 0.92), and 0.72 for percentage opacification (95% CI: 0.48, 0.85). Of 751 patients with a chest radiograph, those with greater than 75% opacification had a median time to ICU admission or death of just 1-2 days. Among 628 patients for whom data were available (median age, 76 years [interquartile range, 61-84 years]; 344 men), opacification of 51%-75% increased risk for ICU admission or death by twofold (hazard ratio, 2.2; 95% CI: 1.6, 2.8), and opacification greater than 75% increased ICU risk by fourfold (hazard ratio, 4.0; 95% CI: 3.4, 4.7) compared with opacification of 0%-25%, when adjusted for NEWS2 score. Conclusion Brixia, radiographic assessment of lung edema, and percentage opacification scores all reliably helped predict adverse outcomes in SARS-CoV-2 infection. © RSNA, 2021 Online supplemental material is available for this article. See also the editorial by Little in this issue.

Effectiveness of percutaneous vacuum-assisted excision (VAE) of breast lesions of uncertain malignant potential (B3 lesions) as an alternative to open surgical biopsy.

OBJECTIVES: Traditionally B3 breast lesions are treated surgically, but overtreatment is a concern, as the majority have a final benign diagnosis. A national screening program introduced vacuum-assisted excision (VAE) for managing B3 lesions in late 2016. This retrospective study aimed to assess the outcomes associated with this approach. METHODS: All B3 lesions diagnosed between 01/2017 and 12/2019 were identified at two centres. Information was obtained on the initial biopsy and final histology, and method of VAE image guidance, needle size and number of cores. Lesions were excluded if there was cancer elsewhere in the breast at the time of diagnosis; the lesion was not suitable for VAE due to position in the breast or had B3 pathology for which open biopsy was still required. The final decision to offer VAE was always made at a multidisciplinary meeting (MDM). Risk difference was used to test the significance at p ≤ .05. RESULTS: In total, 258 B3 lesions were diagnosed, 105 (40.7%) met the inclusion criteria and underwent VAE. VAE was performed under X-ray (89/105) or ultrasound guidance (16/105), taking an average of 18.5 cores with the 10-G needle or 10.8 cores with the 7-G needle. Nine cases (8.6%) were upgraded to a malignant diagnosis following VAE. Malignancy was found in 15.5% (9/58) of B3 lesions with epithelial atypia, but in none without atypia (0/47) (p = .004). No new lesions or malignancy has occurred at the site of the VAE with an average mammographic follow-up of 2.2 years. CONCLUSION: Upgrade to malignancy following VAE was uncommon (8.6%) and associated with atypia in the initial biopsy. VAE is an alternative approach to the management of B3 lesions, reducing open surgical procedures. KEY POINTS: • Upgrade to malignancy after a vacuum-assisted excision of a B3 breast lesion is uncommon with an 8.6% upgrade rate. • The risk of a malignant diagnosis after a vacuum-assisted excision was significantly higher for B3 lesions with atypia compared to those without (+15.5% difference, p = .004).

Role of preoperative breast MRI in ductal carcinoma in situ for prediction of the presence and assessment of the extent of occult invasive component.

Ductal carcinoma in situ (DCIS) is a common neoplasm that may be associated with focal invasive breast cancer lesions. The aim of our study was to evaluate the role of preoperative magnetic resonance imaging (MRI) in determining occult invasive presence and disease extent in patients with preoperative diagnosis of pure DCIS. We analyzed 125 patients with postoperative pure DCIS (n = 91) and DCIS plus invasive component (n = 34). Diagnostic mammography (MRX) showed a size underestimation rate of 30.4% while MRI showed an overestimation rate of 28.6%. Comparing the mean absolute error between preoperative MRI and MRX evaluations and final disease extent, MRI showed an improved accuracy of 51.2%. In our analysis preoperative breast MRI showed a better accuracy in predicting postoperative pathologic extent of disease, adding strength to the growing evidences that preoperative MRI can lead to a more appropriate management of DCIS patients.

Promoting simulation-based training in radiology: a homemade phantom for the practice of ultrasound-guided procedures.

OBJECTIVE: Ultrasound-guided intervention is an essential skill for many radiologists and critical for accurate diagnosis and treatment in many radiology subspecialties. Simulation using phantoms have demonstrated statistically significant benefits for trainees within the literature. We propose a novel phantom model which the authors feel is ideal for training clinical radiology trainees in the performance of ultrasound-guided procedures. METHODS: The recipe to prepare a homemade phantom is described. Results of a local survey from trainees preparing and using the phantom are also presented. RESULTS: This realistic training simulation model can be adapted to suit a variety of biopsy devices and procedures including soft tissue biopsy and cyst aspiration. The phantom mimics the sonographic appearances of soft tissue and biopsy targets can be concealed within. The phantom was easily prepared by 22 trainees (Likert score 4.5) and it functioned well (Likert score of 4.7). CONCLUSION: In summary, our phantom model is ideal for training clinical radiology trainees in the performance of ultrasound-guided core biopsy. The availability and low cost of the model, combined with the ease of preparation and reproducibility, make this an efficient and effective addition to the training process. ADVANCES IN KNOWLEDGE: A low cost easily handmade phantom recipe is described that could be easily implemented in training schemes.

The Evolving Role of Ultrasound Guided Percutaneous Laser Ablation in Elderly Unresectable Breast Cancer Patients: A Feasibility Pilot Study.

BACKGROUND AND OBJECTIVES: Breast-conserving surgery represents the standard of care for the treatment of small breast cancers. However, there is a population of patients who cannot undergo the standard surgical procedures due to several reasons such as age, performance status, or comorbidity. Our aim was to investigate the feasibility and safety of percutaneous US-guided laser ablation for unresectable unifocal breast cancer (BC). METHODS: Between December 2012 and March 2017, 12 consecutive patients underwent percutaneous US-guided laser ablation as radical treatment of primary inoperable unifocal BC. RESULTS: At median follow-up of 28.5 months (range 6-51), no residual disease or progression occurred; the overall success rate for complete tumor ablation was therefore 100%. No significant operative side effects were observed, with only 2 (13.3%) experiencing slight to mild pain during the procedure, and all patients complained of a mild dull aching pain in the first week after procedure. CONCLUSIONS: Laser ablation promises to be a safe and feasible approach in those patients who are not eligible to the standard surgical approach. However, longer follow-up results and larger studies are strongly needed.

Stereotactic vacuum-assisted breast biopsy: Comparison between 11- and 8-gauge needles.

PURPOSE: The 11-gauge (11G) stereotactic vacuum-assisted breast biopsy (VABB) showed a better profile than 14G-VABB in terms of feasibility, safety, microcalcification sampling, and accuracy. Underestimation rates were significantly lower with 11G-VABB than with 14G-VABB. Thus, the introduction of an even larger needle at the VABB procedure could reduce this rate further. The purpose of this study was to compare the overall performance of stereotactic VABB with 8G and 11G needles. MATERIALS AND METHODS: Four hundred and three VABBs performed between July 2012 and February 2015 at the Breast Diagnostic Unit of Careggi Hospital in Florence were retrospectively analyzed; 197 were performed with 11G-VABB and 206 with 8G-VABB. Lesions were classified according to mammographical patterns in microcalcifications, architectural distortions, or opacities, and all biopsy targets were classified according to BIRADS classification as BIRADS III, IV or V. Data were collected on radiological classification of targets, imaging presentation, procedure time, number of specimens per procedure, and microcalcification retrieval on histological findings. Surgery was always performed when high-risk or malignant lesions (B3 or B5) were detected; the final diagnosis was made on surgical pathology. RESULTS: Compared to VABB with an 11G needle, 8G-VABB allows a reduction in the time needed to complete the procedure (20.6 versus 27.4, P < 0.00001) and the number of specimens collected per lesion (21.6 versus 12.2, P < 0.00001). Moreover, 8G-VABB resulted in the same diagnostic accuracy, and the underestimation rates were comparable between the two groups for both B3 and DCIS lesions. CONCLUSIONS: The 8G needle should be considered as a valid alternative option in VABB for breast lesions.

Anisotropy of Solid Breast Lesions in 2D Shear Wave Elastography is an Indicator of Malignancy.

RATIONALE AND OBJECTIVES: To investigate if anisotropy at two-dimensional shear wave elastography (SWE) suggests malignancy and whether it correlates with prognostic and predictive factors in breast cancer. MATERIALS AND METHODS: Study group A of 244 solid breast lesions was imaged with SWE between April 2013 and May 2014. Each lesion was imaged in radial and in antiradial planes, and the maximum elasticity, mean elasticity, and standard deviation were recorded and correlated with benign/malignant status, and if malignant, correlated with conventional predictive and prognostic factors. The results were compared to a study group B of 968 solid breast lesions, which were imaged in sagittal and in axial planes between 2010 and 2013. RESULTS: Neither benign nor malignant lesion anisotropy is plane dependent. However, malignant lesions are more anisotropic than benign lesions (P ≤ 0.001). Anisotropy correlates with increasing elasticity parameters, breast imaging-reporting and data system categories, core biopsy result, and tumor grade. Large cancers are significantly more anisotropic than small cancers (P ≤ 0.001). The optimal anisotropy cutoff threshold for benign/malignant differentiation of 150 kPa(2) achieves the best sensitivity (74%) with a reasonable specificity (63%). CONCLUSIONS: Anisotropy may be useful during benign/malignant differentiation of solid breast masses using SWE. Anisotropy also correlates with some prognostic factors in breast cancer.

Shear-wave elastography and greyscale assessment of palpable probably benign masses: is biopsy always required?

OBJECTIVE: To establish if palpable breast masses with benign greyscale ultrasound features that are soft on shear-wave elastography (SWE) (mean stiffness <50 kPa) have a low enough likelihood of malignancy to negate the need for biopsy or follow-up. METHODS: The study group comprised 694 lesions in 682 females (age range 17-95 years, mean age 56 years) presenting consecutively to our institution with palpable lesions corresponding to discrete masses at ultrasound. All underwent ultrasound, SWE and needle core biopsy. Static greyscale images were retrospectively assigned Breast Imaging Reporting and Data System (BI-RADS) scores by two readers blinded to the SWE and pathology findings, but aware of the patient's age. A mean stiffness of 50 kPa was used as the SWE cut-off for calling a lesion soft or stiff. Histological findings were used to establish ground truth. RESULTS: No cancer had benign characteristics on both modalities. 466 (99.8%) of the 467 cancers were classified BI-RADS 4a or above. The one malignant lesion classified as BI-RADS 3 was stiff on SWE. 446 (96%) of the 467 malignancies were stiff on SWE. No cancer in females under 40 years had benign SWE features. 74 (32.6%) of the 227 benign lesions were BI-RADS 3 and soft on SWE; so, biopsy could potentially have been avoided in this group. CONCLUSION: Lesions which appear benign on greyscale ultrasound and SWE do not require percutaneous biopsy or short-term follow-up, particularly in females under 40 years. ADVANCES IN KNOWLEDGE: None of the cancers had benign characteristics on both greyscale ultrasound and SWE, and 32% of benign lesions were BI-RADS 3 and soft on SWE; lesions that are benign on both ultrasound and SWE may not require percutaneous biopsy or short-term follow-up.

Radiological anatomy of the breast.

Breast cancer is the most frequent cancer site in women (28.8% of all cancer sites), the seconc most common in the world with an estimated 1.67 million new cases diagnosed in 2012 (25% of all cancers) and an estimated lifetime risk of 1/9 women. It is the fifth cause of tumor death overall (7.5%) and the first in women. Diagnostic senology has the purpose of the early diagno sis of breast cancer. The aim of this paper is to evaluate the role of all imaging techniques in studying the norma morphological anatomy of the breast. Knowing the normal anatomy of the breast is essentia to integrate all available imaging techniques in order to distinguish normal from pathologica structures.

Pilomatrixoma of the breast, a rare lesion simulating breast cancer: a case report.

Pilomatrixoma or calcifying epithelioma of Malherbe is a rare, benign, skin tumour originating from piliferous follicles; breast localization is considered to be very rare. These lesions can origin from the peri-areolar piliferous bulbs and, due to the clinical and imaging features, be easily misdiagnosed as a breast neoplasm. We present a case of pilomatrixoma of the left breast in a woman of 43 years appearing as a firm, deep nodule in the external quadrants. The lesion had mammographic and sonographic malignant features, but histological analysis on core-needle biopsy and surgical specimens revealed this unusual benign lesion.