ACR Appropriateness Criteria® Female Breast Cancer Screening: 2023 Update.

Early detection of breast cancer from regular screening substantially reduces breast cancer mortality and morbidity. Multiple different imaging modalities may be used to screen for breast cancer. Screening recommendations differ based on an individual's risk of developing breast cancer. Numerous factors contribute to breast cancer risk, which is frequently divided into three major categories: average, intermediate, and high risk. For patients assigned female at birth with native breast tissue, mammography and digital breast tomosynthesis are the recommended method for breast cancer screening in all risk categories. In addition to the recommendation of mammography and digital breast tomosynthesis in high-risk patients, screening with breast MRI is recommended. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Fibrocystic Change.

Fibrocystic changes are commonly seen in clinically symptomatic patients and during imaging workup of screening-detected findings. The term "fibrocystic changes" encompasses a broad spectrum of specific benign pathologic entities. Recognition of classically benign findings of fibrocystic changes, including cysts and layering calcifications, can prevent unnecessary follow-ups and biopsies. Imaging findings such as solid masses, nonlayering calcifications, and architectural distortion may require core needle biopsy for diagnosis. In these cases, understanding the varied appearances of fibrocystic change aids determination of radiologic-pathologic concordance. Management of fibrocystic change is typically conservative.

Feasibility of Prospective Assignment of Initial Method of Detection of Breast Cancer: A Multicenter Pilot Study.

OBJECTIVE: To determine the feasibility of standardized, prospective assignment of initial method of detection (MOD) of breast cancer by radiologists in diverse practice settings. METHODS: This multicenter, retrospective study analyzed the rate of assignment of MOD in four geographically varied health systems. A universal protocol for basic MOD assignment was agreed upon by the authors before start of the pilot study. Radiologists at each site were instructed how to assign MOD. Charts were then reviewed to determine the frequency and accuracy of MOD assignment for all cases subsequently diagnosed with breast cancer. When available, data regarding frequency of tumor registry abstraction were also reviewed for frequency and accuracy. RESULTS: A total of 2,328 patients with a new diagnosis of breast cancer were evaluated across the sites over the study period. Of these patients, initial MOD was prospectively assigned by the radiologist in 94% of cases. Of the cases in which MOD was assigned, retrospective review confirmed accurate assignment in 96% of cases. CONCLUSIONS: Prospective, standardized assignment of initial MOD of breast cancer is feasible across different practice sites and can be accurately captured in tumor registries. Standard collection of MOD would provide critical data about the impact of screening mammography in the United States.

Pectoral muscle removal in mammogram images: A novel approach for improved accuracy and efficiency.

PURPOSE: Accurate pectoral muscle removal is critical in mammographic breast density estimation and many other computer-aided algorithms. We propose a novel approach to remove pectoral muscles form mediolateral oblique (MLO) view mammograms and compare accuracy and computational efficiency with existing method (Libra). METHODS: A pectoral muscle identification pipeline was developed. The image is first binarized to enhance contrast and then the Canny algorithm was applied for edge detection. Robust interpolation is used to smooth out the pectoral muscle region. Accuracy and computational speed of pectoral muscle identification was assessed using 951 women (1,902 MLO mammograms) from the Joanne Knight Breast Health Cohort at Washington University School of Medicine. RESULTS: Our proposed algorithm exhibits lower mean error of 12.22% in comparison to Libra's estimated error of 20.44%. This 40% gain in accuracy was statistically significant (p < 0.001). The computational time for the proposed algorithm is 5.4 times faster when compared to Libra (5.1 s for proposed vs. 27.7 s for Libra per mammogram). CONCLUSION: We present a novel approach for pectoral muscle removal in mammogram images that demonstrates significant improvement in accuracy and efficiency compared to existing method. Our findings have important implications for the development of computer-aided systems and other automated tools in this field.

NCCN Guidelines® Insights: Breast Cancer Screening and Diagnosis, Version 1.2023.

The NCCN Guidelines for Breast Cancer Screening and Diagnosis provide health care providers with a practical, consistent framework for screening and evaluating a spectrum of clinical presentations and breast lesions. The NCCN Breast Cancer Screening and Diagnosis Panel is composed of a multidisciplinary team of experts in the field, including representation from medical oncology, gynecologic oncology, surgical oncology, internal medicine, family practice, preventive medicine, pathology, diagnostic and interventional radiology, as well as patient advocacy. The NCCN Breast Cancer Screening and Diagnosis Panel meets at least annually to review emerging data and comments from reviewers within their institutions to guide updates to existing recommendations. These NCCN Guidelines Insights summarize the panel's decision-making and discussion surrounding the most recent updates to the guideline's screening recommendations.

ACR Appropriateness Criteria® Palpable Breast Masses: 2022 Update.

Palpable masses in women are the most common symptom associated with breast cancer. This document reviews and evaluates the current evidence for imaging recommendations of palpable masses in women less than 30 to over 40 years of age. There is also a review of several different scenarios and recommendations after initial imaging. Ultrasound is usually the appropriate initial imaging for women under 30 years of age. If ultrasound findings are suspicious or highly suggestive of malignancy (BIRADS 4 or 5), it is usually appropriate to continue with diagnostic tomosynthesis or mammography with image-guided biopsy. No further imaging is recommended if the ultrasound is benign or negative. The patient under 30 years of age with a probably benign ultrasound may undergo further imaging; however, the clinical scenario plays a role in the decision to biopsy. For women between 30 to 39 years of age, ultrasound, diagnostic mammography, tomosynthesis, and ultrasound are usually appropriate. Diagnostic mammography and tomosynthesis are the appropriate initial imaging for women 40 years of age or older, as ultrasound may be appropriate if the patient had a negative mammogram within 6 months of presentation or immediately after mammography findings are suspicious or highly suggestive of malignancy. If the diagnostic mammogram, tomosynthesis, and ultrasound findings are probably benign, no further imaging is necessary unless the clinical scenario indicates a biopsy. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Longitudinal Analysis of Change in Mammographic Density in Each Breast and Its Association With Breast Cancer Risk.

Importance: Although breast density is an established risk factor for breast cancer, longitudinal changes in breast density have not been extensively studied to determine whether this factor is associated with breast cancer risk. Objective: To prospectively evaluate the association between change in mammographic density in each breast over time and risk of subsequent breast cancer. Design, Setting, and Participants: This nested case-control cohort study was sampled from the Joanne Knight Breast Health Cohort of 10 481 women free from cancer at entry and observed from November 3, 2008, to October 31, 2020, with routine screening mammograms every 1 to 2 years, providing a measure of breast density. Breast cancer screening was provided for a diverse population of women in the St Louis region. A total of 289 case patients with pathology-confirmed breast cancer were identified, and approximately 2 control participants were sampled for each case according to age at entry and year of enrollment, yielding 658 controls with a total number of 8710 craniocaudal-view mammograms for analysis. Exposures: Exposures included screening mammograms with volumetric percentage of density, change in volumetric breast density over time, and breast biopsy pathology-confirmed cancer. Breast cancer risk factors were collected via questionnaire at enrollment. Main Outcomes and Measures: Longitudinal changes over time in each woman's volumetric breast density by case and control status. Results: The mean (SD) age of the 947 participants was 56.67 (8.71) years at entry; 141 were Black (14.9%), 763 were White (80.6%), 20 were of other race or ethnicity (2.1%), and 23 did not report this information (2.4%). The mean (SD) interval was 2.0 (1.5) years from last mammogram to date of subsequent breast cancer diagnosis (10th percentile, 1.0 year; 90th percentile, 3.9 years). Breast density decreased over time in both cases and controls. However, there was a significantly slower decrease in rate of decline in density in the breast that developed breast cancer compared with the decline in controls (estimate = 0.027; 95% CI, 0.001-0.053; P = .04). Conclusions and Relevance: This study found that the rate of change in breast density was associated with the risk of subsequent breast cancer. Incorporation of longitudinal changes into existing models could optimize risk stratification and guide more personalized risk management.

A comparison of the imaging appearance of breast cancer in African American women with non-Latina white women.

PURPOSE: To assess differences in the mammographic and sonographic appearance of breast cancer in African American (AA) and Non-Latina White (NLW) women. METHODS: We identified AA and NLW women with biopsy proven ductal carcinoma in situ or invasive breast cancer between June 1, 2015 and May 31, 2018. Racial differences in Breast Imaging and Reporting Data System (BI-RADS) imaging features were analyzed by imaging cohorts, i.e. screen detected vs. clinical presentation, using logistic regression adjusted for histology and molecular subtypes. RESULTS: We analyzed 270 AA women with 278 cancers (166 screen detected, 112 clinical) and 586 NLW women with 599 cancers (397 screen detected, 202 clinical). Compared with NLW women, AA women had higher rates of non-dense breast composition (almost entirely fatty 12.0% vs. 4.6%, scattered fibroglandular 50.9% vs. 45.2%; overall P < 0001) in both cohorts and were less likely to have screen detected architectural distortion, (odds ratio (OR) = 0.38, 95% CI 0.18-0.80). AA women were less likely than NLW women to have screen detected irregular than oval/round masses (mammography: OR = 0.36, 95% CI 0.19-0.68; sonography: OR = 0.48, 95% CI 0.24-0.94), and more likely to present clinically with high density masses (OR = 3.03, 95% CI 1.12-8.20) demonstrating posterior enhancement (OR = 3.02, 95% CI 1.11-8.27). CONCLUSION: There are racial differences in the mammographic and sonographic appearance of breast cancer even after accounting for higher rates of triple negative breast cancer in AA women. Understanding these differences may provide breast imagers with a framework to approach breast cancer diagnosis in the AA population in clinical practice.

ACR Appropriateness Criteria® Imaging After Breast Surgery.

Given that 20% to 40% of women who have percutaneous breast biopsy subsequently undergo breast surgery, knowledge of imaging women with a history of benign (including high-risk) disease or breast cancer is important. For women who had surgery for nonmalignant pathology, the surveillance recommendations are determined by their overall risk. Higher-than-average risk women with a history of benign surgery may require screening mammography starting at an earlier age before 40 and may benefit from screening MRI. For women with breast cancer who have undergone initial excision and have positive margins, imaging with diagnostic mammography or MRI can sometimes guide additional surgical planning. Women who have completed breast conservation therapy for cancer should get annual mammography and may benefit from the addition of MRI or ultrasound to their surveillance regimen. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Joanne Knight Breast Health Cohort at Siteman Cancer Center.

PURPOSE: The Joanne Knight Breast Health Cohort was established to link breast cancer risk factors, mammographic breast density, benign breast biopsies and associated tissue markers, and blood markers in a diverse population of women undergoing routine mammographic screening to study risk factors and validate models for breast cancer risk prediction. METHODS: Women were recruited from November 2008 to April 2012 through the mammography service at the Joanne Knight Breast Health Center at Washington University in St. Louis, Missouri. Baseline questionnaire risk factors, blood, and screening mammograms were collected from 12,153 women. Of these, 1,672 were excluded for prior history of any cancer (except non-melanoma skin) or diagnosis of breast cancer within 6 months of blood draw/registration for the study, for a total of 10,481 women. Follow-up is through linking to electronic health records, tumor registry, and death register. Routine screening mammograms are collected every 1-2 years and incident benign breast biopsies and cancers are identified through record linkage to pathology and tumor registries. Formal fixed tissue samples are retrieved and stored for analysis. County-level measures of structural inequality were derived from publicly available resources. RESULTS: Cohort Composition: median age at entry was 54.8 years and 26.7% are African American. Through 2020, 74% of participants have had a medical center visit within the past year and 80% within the past 2 years representing an average of 9.7 person-years of follow-up from date of blood draw per participant. 9,997 women are continuing in follow-up. Data collected at baseline include breast cancer risk factors, plasma and white blood cells, and mammograms prior to baseline, at baseline, and during follow-up. CONCLUSION: This cohort assembled and followed in a routine mammography screening and care setting that serves a diverse population of women in the St. Louis region now provides opportunities to integrate study of questionnaire measures, plasma and DNA markers, benign and malignant tissue markers, and repeated breast image features into prospective evaluation for breast cancer etiology and outcomes.

Magnetic Resonance Imaging in Screening of Breast Cancer.

Magnetic Resonance (MR) imaging is the most sensitive modality for breast cancer detection but is currently limited to screening women at high risk due to limited specificity and test accessibility. However, specificity of MR imaging improves with successive rounds of screening, and abbreviated approaches have the potential to increase access and decrease cost. There is growing evidence to support supplemental MR imaging in moderate-risk women, and current guidelines continue to evolve. Functional imaging has the potential to maximize survival benefit of screening. Leveraging MR imaging as a possible primary screening tool is therefore also being investigated in average-risk women.

Comparison of Narrow-angle and Wide-angle Digital Breast Tomosynthesis Systems in Clinical Practice.

Digital breast tomosynthesis (DBT) is a pseudo 3D mammography imaging technique that has become widespread since gaining Food and Drug Administration approval in 2011. With this technology, a variable number of tomosynthesis projection images are obtained over an angular range between 15° and 50° for currently available clinical DBT systems. The angular range impacts various aspects of clinical imaging, such as radiation dose, scan time, and image quality, including visualization of calcifications, masses, and architectural distortion. This review presents an overview of the differences between narrow- and wide-angle DBT systems, with an emphasis on their applications in clinical practice. Comparison examples of patients imaged on both narrow- and wide-angle DBT systems illustrate these differences. Understanding the potential variable appearance of imaging findings with narrow- and wide-angle DBT systems is important for radiologists, particularly when comparison images have been obtained on a different DBT system. Furthermore, knowledge about the comparative strengths and limitations of DBT systems is needed for appropriate equipment selection.

Malignant Phyllodes Tumor: Imaging Features With Histopathologic Correlation.

Phyllodes tumors (PT) are rare fibroepithelial lesions of the breast that commonly present as rapidly enlarging, palpable masses. Phyllodes tumors may be classified as benign, borderline, or malignant on the basis of histopathologic analysis. Although malignant PT cannot be distinguished from benign PT on the basis of imaging findings alone, studies suggest that malignant PT tend to be larger and irregular in shape, and they are less likely to have circumscribed margins. If biopsy results are indeterminate, excisional biopsy should be performed. Malignant PT can be difficult to distinguish histologically from sarcomas and spindle cell metaplastic breast carcinoma; the distinction is important for prognosis and treatment. Malignant PT are treated surgically with wide local excision, without a clear role for adjuvant radiation or chemotherapy in most cases. Nearly one-third of malignant PT recur locally, usually within a few years after initial diagnosis. Distant metastatic disease is rare, and the five-year overall survival rate of malignant PT is close to 80%. The purpose of this article is to review the clinical presentation, imaging appearance, histopathology, and management of malignant PT.

Comparison of interval breast cancers with 2D digital mammography versus 3D digital breast tomosynthesis in a large community-based practice.

Incidence of interval cancers is an important outcome in assessing efficacy of screening. Our primary objective was to compare the incidence of interval cancers detected with two-dimensional digital mammography (DM) versus digital breast tomosynthesis (DBT) in a large community health system. Our secondary objectives were to compare the patient and tumor characteristics of interval cancers, cancer detection rate, and recall rate. Interval cancers before and after implementation of DBT (2012-2014 DM group; 2016-2018 DBT group) were reviewed. Patient factors (age, race, breast density, personal history of breast cancer, family history of breast cancer, known BRCA-1 or BRCA-2 genetic mutation, baseline mammogram, and presentation) and tumor characteristics (in situ versus invasive, grade, size, hormone receptor status, and nodal status) were compared with the chi-squared test or the MidP exact test. Rates (detection and recall) were compared using a z-score. The rates of interval cancers with DM (0.30 per 1000 [35/117 099]) and DBT (0.33 per 1000 [40/119 746]) were similar (P = .3). Proportion of node-positive interval cancers was lower in the DBT group (22.9% [8/35] vs 48% [15/31], p.01). Otherwise, the patient and tumor characteristics were similar. The cancer detection rate increased (5.9 per 1000 [709/119 746] vs 3.5 per 1000 [411/117 099], P = .0001), and the recall rate decreased with DBT (8.6% [10 347/119 746] versus 10.7% [12 508/117 099], (P < .0001). Although the cancer detection rate was higher with DBT, the rate of interval breast cancers was similar in both groups. Node-positive invasive interval cancers were decreased with DBT.

Music during image-guided breast biopsy reduces patient anxiety levels.

PURPOSE: Interventions to decrease anxiety associated with image-guided breast biopsy are needed. Music intervention has been shown to be helpful in other outpatient procedural settings but data are limited regarding its effectiveness in the setting of breast biopsy. The purpose of this study was to determine whether listening to self-selected music during image-guided breast biopsy lowers anxiety. MATERIALS AND METHODS: This randomized controlled trial was approved by the institutional review board and was HIPAA-compliant. 157 women between 18 and 75 (mean, 49.7 years) years of age, undergoing stereotactic or ultrasound-guided core biopsy, were enrolled in the study and were prospectively randomized to music or usual care. Patients in the music group listened to music of their choice during the biopsy. All patients completed the State Trait Anxiety Inventory (STAI) before and after the biopsy. Differences in pre-biopsy and post-biopsy anxiety levels were compared between the two groups using the Mann-Whitney U test. RESULTS: Baseline trait anxiety scores in the two groups were similar (34.0 music, 31.5 control, p = .11). Patients in both groups showed lower state anxiety levels after the biopsy (45.6 to 34.3 music, 41.0 to 33.8 control, p < .001 for both). Patients who listened to music showed a greater reduction in anxiety (mean decrease 11.2 music, 7.3 control, p = .03). Post-biopsy anxiety levels were similar to normative values for working women in the same age group. CONCLUSION: Listening to self-selected music reduces anxiety in patients undergoing breast biopsy.

Atypical gynecomastia mimicking breast malignancy on mammography, sonography, and 18F-fluciclovine PET/CT in the setting of biochemical recurrence of prostate cancer.

A 60-year-old man with metastatic prostate cancer presented with breast swelling for one year. Suspicious breast masses were identified in both breasts with mammography and ultrasound. Biopsy of both masses showed florid gynecomastia without malignancy. Sixteen months later, the patient underwent 18F-fluciclovine PET/CT for biochemical recurrence of prostate cancer; this showed focal radiotracer uptake in both breasts. Repeat mammogram and ultrasound showed these areas to correspond with the previously biopsied masses, which were stable. To our knowledge, this is the first reported case of gynecomastia mimicking malignancy on 18F-fluciclovine PET/CT.