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.

Artificial Intelligence Decision Support for Triple-Negative Breast Cancers on Ultrasound.

OBJECTIVE: To assess performance of an artificial intelligence (AI) decision support software in assessing and recommending biopsy of triple-negative breast cancers (TNBCs) on US. METHODS: Retrospective institutional review board-approved review identified patients diagnosed with TNBC after US-guided biopsy between 2009 and 2019. Artificial intelligence output for TNBCs on diagnostic US included lesion features (shape, orientation) and likelihood of malignancy category (benign, probably benign, suspicious, and probably malignant). Artificial intelligence true positive was defined as suspicious or probably malignant and AI false negative (FN) as benign or probably benign. Artificial intelligence and radiologist lesion feature agreement, AI and radiologist sensitivity and FN rate (FNR), and features associated with AI FNs were determined using Wilcoxon rank-sum test, Fisher's exact test, chi-square test of independence, and kappa statistics. RESULTS: The study included 332 patients with 345 TNBCs. Artificial intelligence and radiologists demonstrated moderate agreement for lesion shape and orientation (k = 0.48 and k = 0.47, each P <.001). On the set of examinations using 6 earlier diagnostic US, radiologists recommended biopsy of 339/345 lesions (sensitivity 98.3%, FNR 1.7%), and AI recommended biopsy of 333/345 lesions (sensitivity 96.5%, FNR 3.5%), including 6/6 radiologist FNs. On the set of examinations using immediate prebiopsy diagnostic US, AI recommended biopsy of 331/345 lesions (sensitivity 95.9%, FNR 4.1%). Artificial intelligence FNs were more frequently oval (q < 0.001), parallel (q < 0.001), circumscribed (q = 0.04), and complex cystic and solid (q = 0.006). CONCLUSION: Artificial intelligence accurately recommended biopsies for 96% to 97% of TNBCs on US and may assist radiologists in classifying these lesions, which often demonstrate benign sonographic features.

Contrast-Enhanced Mammography for Women with Palpable Breast Abnormalities.

RATIONALE AND OBJECTIVES: To examine the role of contrast-enhanced mammography (CEM) in the work-up of palpable breast abnormalities. MATERIALS AND METHODS: In this single-center combination prospective-retrospective study, women with palpable breast abnormalities underwent CEM evaluation prospectively, comprising the acquisition of low energy (LE) images and recombined images (RI) which depict enhancement, followed by targeted ultrasound (US). Two independent readers retrospectively reviewed the imaging and assigned BI-RADS assessment based on LE alone, LE plus US, RI with LE plus US (CEM plus US), and RI alone. Pathology results or 1-year follow-up imaging served as the reference standard. RESULTS: 237 women with 262 palpable abnormalities were included (mean age, 51 years). Of the 262 palpable abnormalities, 116/262 (44%) had no imaging correlate and 242/262 (92%) were benign. RI alone had better specificity compared to LE plus US (Reader 1, 94% versus 89% (p = 0.009); Reader 2, 93% versus 88% (p = 0.03)), better positive predictive value (Reader 1, 52% versus 42% (p = 0.04); Reader 2, 53% versus 42% (p = 0.04)), and better accuracy (Reader 1, 93% versus 89% (p = 0.05); Reader 2, 93% versus 90% (p = 0.06)). CEM plus US was not significantly different in performance metrics versus LE plus US. CONCLUSION: RI had better specificity compared to LE in combination with US. There was no difference in performance between CEM plus US and LE plus US, likely reflecting the weight US carries in radiologist decision-making. However, the results indicate that the absence of enhancement on RI in the setting of palpable lesions may help avoid benign biopsies.

A role for breast ultrasound Artificial Intelligence decision support in the evaluation of small invasive lobular carcinomas.

OBJECTIVE: To evaluate the diagnostic performance of an Artificial Intelligence (AI) decision support (DS) system in the ultrasound (US) assessment of invasive lobular carcinoma (ILC) of the breast, a cancer that can demonstrate variable appearance and present insidiously. METHODS: Retrospective review was performed of 75 patients with 83 ILC diagnosed by core biopsy or surgery between November 2017 and November 2019. ILC characteristics (size, shape, echogenicity) were recorded. AI DS output (lesion characteristics, likelihood of malignancy) was compared to radiologist assessment. RESULTS: The AI DS system interpreted 100% of ILCs as suspicious or probably malignant (100% sensitivity, and 0% false negative rate). 99% (82/83) of detected ILCs were initially recommended for biopsy by the interpreting breast radiologist, and 100% (83/83) were recommended for biopsy after one additional ILC was identified on same-day repeat diagnostic ultrasound. For lesions in which the AI DS output was probably malignant, but assigned a BI-RADS 4 assessment by the radiologist, the median lesion size was 1 cm, compared with a median lesion size of 1.4 cm for those given a BI-RADS 5 assessment (p = 0.006). These results suggest that AI may offer more useful DS in smaller sub-centimeter lesions in which shape, margin status, or vascularity is more difficult to discern. Only 20% of patients with ILC were assigned a BI-RADS 5 assessment by the radiologist. CONCLUSION: The AI DS accurately characterized 100% of detected ILC lesions as suspicious or probably malignant. AI DS may be helpful in increasing radiologist confidence when assessing ILC on ultrasound.

Feasibility of contrast-enhanced mammography in women with breast implants.

Contrast-enhanced mammography (CEM) may provide an alternative to magnetic resonance imaging as a diagnostic exam in women with known or suspected breast cancer or as a screening exam in women at increased risk of breast cancer. Women with breast augmentation, either for oncologic or cosmetic reasons, may fall into this increased risk population and need safe and effective screening and diagnostic imaging tools. Here, we present our clinical practice data in order to demonstrate the feasibility of CEM in women with breast implants. An institutional review board-approved, Health Insurance Portability and Accountability Act-compliant, retrospective review of our tertiary cancer center's database yielded 104 women with breast implants who underwent 198 CEM exams from November 2014 to March 2020. All 198/198 (100%) exams were successfully completed in 104 women. Exam indications included: 174/198 (88%) screening due to increased risk, 10/198 (5%) to evaluate a palpable abnormality, 9/198 (<5%) to evaluate disease extent following neoadjuvant chemotherapy for a known breast malignancy, and 5/198 (<3%) for a 6-month follow-up. 97/104 (93%) women had dense breasts. Routine and implant-displaced low-energy views were obtained with contrast-enhanced images obtained on displaced views for all patients. 197/198 (99.5%) exams yielded no complications. In one exam, the patient experienced mild vasovagal symptoms following the administration of contrast. In conclusion, it is feasible to utilize CEM in both diagnostic and screening capacities in women with breast implants.

Comparison of False-Positive Versus True-Positive Findings on Contrast-Enhanced Digital Mammography.

BACKGROUND. Contrast-enhanced digital mammography (CEDM) has been shown to outperform standard mammography while performing comparably to contrast-enhanced MRI. OBJECTIVE. The purpose of our study was to compare imaging characteristics of false-positive and true-positive findings on CEDM. METHODS. This retrospective study included women who underwent baseline screening CEDM between January 2013 and December 2018 assessed as BI-RADS category 0, 3, 4, or 5 and who underwent biopsy with histopathologic diagnosis or had a 2-year imaging follow-up. Lesion characteristics were extracted from CEDM reports. A true-positive finding was defined as a lesion in which biopsy yielded malignancy. A false-positive finding was defined as a lesion in which biopsy yielded benign or benign high-risk pathology or in which 2-year imaging follow-up was negative. RESULTS. Of 157 patients (median age, 52 years), 24 had a total of 26 true-positive lesions, and 133 had a total of 147 false-positive lesions. Of the 26 true-positive lesions, one (4%) exhibited only a mammographic finding on low-iodine images, 13 (50%) exhibited only a contrast finding on iodine images, and 12 (46%) exhibited both a mammographic finding on low-energy images and a contrast finding on iodine images. A true-positive result was more likely (p = .02) for lesions present on both low-energy images and iodine images (31%) than on low-energy images only (4%) or iodine images only (12%). Among lesions present on both low-energy and iodine images, a true-positive result was more likely (p < .001) when the type of mammographic finding was an asymmetry (46%) or calcification (80%) than a mass (11%) or distortion (0%). A true-positive result was more likely (p = .01) among those with, versus those without, an ultrasound correlate (36% vs 9%) and also was more likely (p = .02) among those with, versus those without, an MRI correlate (18% vs 2%). Of 25 false-positive calcifications, 24 had no associated mammographic enhancement; of five true-positive calcifications, four had mammographic enhancement. CONCLUSION. A low-energy mammographic finding with associated enhancement or a finding with a sonographic or MRI correlate predicts a true-positive result. Calcifications with associated enhancement had a high malignancy rate. Nonetheless, half of true-positive lesions enhanced on iodine images without a mammographic finding on low-energy images. CLINICAL IMPACT. These observations inform radiologists' management of abnormalities detected on screening CEDM.

Contrast-Enhanced Digital Mammography Screening for Intermediate-Risk Women With a History of Lobular Neoplasia.

OBJECTIVE. The objective of this study was to assess to the role of contrast-enhanced digital mammography (CEDM) as a screening tool in women at intermediate risk for developing breast cancer due to a personal history of lobular neoplasia without additional risk factors. MATERIALS AND METHODS. In this institutional review board-approved, observational, retrospective study, we reviewed our radiology department database to identify patients with a personal history of breast biopsy yielding lobular neoplasia who underwent screening CEDM at our institution between December 2012 and February 2019. A total of 132 women who underwent 306 CEDM examinations were included. All CEDM examinations were interpreted by dedicated breast imaging radiologists in conjunction with a review of the patient's clinical history and available prior breast imaging. In statistical analysis, sensitivity, specificity, NPV, positive likelihood ratio, and accuracy of CEDM in detecting cancer were determined, with pathology or 12-month imaging follow-up serving as the reference standard. RESULTS. CEDM detected cancer in six patients and showed an overall sensitivity of 100%, specificity of 88% (95% CI, 84-92%), NPV of 100%, and accuracy of 88% (95% CI, 84-92%). The positive likelihood ratio of 8.33 suggested that CEDM findings are 8.3 times more likely to be positive in an individual with breast cancer when compared with an individual without the disease. CONCLUSION. CEDM shows promise as a breast cancer screening examination in patients with a personal history of lobular neoplasia. Continued investigation with a larger patient population is needed to determine the true sensitivity and positive predictive value of CEDM for these patients.

Benefits of digital breast tomosynthesis: A lesion-level analysis.

OBJECTIVE: To compare outcome metrics of digital breast tomosynthesis (DBT) breast cancer screening with full-field digital mammogram (FFDM); specifically, to compare recall rates by the type of recalled finding, and to assess if screening with DBT versus FFDM changes biopsy recommendations and if the likelihood of malignancy varied by lesion type, if detected on DBT or FFDM screening mammogram. METHODS: The outcomes of 22,055 FFDM and DBT screening mammograms were retrospectively reviewed. The exams were performed at an academic institution between August 2015 and September 2016. Performance of screening with FFDM versus DBT was compared in terms of recall rate and percentage of recalled lesions resulting in a cancer diagnosis, with subset analyses performed for specific mammographic findings. RESULTS: The recall rate was 10.6% for FFDM and 8.0% for DBT (p < 0.001). Architectural distortion was more likely to be recalled on DBT screening than FFDM (p = 0.002), and was associated with an increased likelihood of malignancy (p = 0.008). Asymmetries were less likely to be recalled on DBT than FFDM (p < 0.001) screening mammogram, but more likely to be recommended for biopsy when detected on DBT. Calcifications more frequently required short-term follow-up or biopsy on both DBT and FFDM. CONCLUSIONS: DBT screening confers an advantage in detection of architectural distortion representing malignancy. Recall rate of asymmetries are reduced with screening DBT, probably due to reduction of tissue superimposition. Calcifications pose a particularly difficult diagnostic challenge for breast imagers, regardless of screening mammogram type.

Factors Impacting False Positive Recall in Screening Mammography.

RATIONALE AND OBJECTIVES: Our objective was to identify factors impacting false positive recalls in screening mammography. MATERIALS AND METHODS: We retrospectively reviewed our screening mammography database from August 31, 2015 to September 30, 2016, including full field digital mammograms (FFDM) and digital breast tomosynthesis (DBT) mammograms. False positive (FP) exams were defined as Breast Imaging-Reporting and Data System (BI-RADS) 1 or 2 assessments at diagnostic imaging with 1 year cancer-free follow-up, Breast Imaging-Reporting and Data System 3 assessment at diagnostic imaging with 2 years cancer free follow-up, or biopsy with benign pathology. True positives were defined as malignant pathology on biopsy or surgical excision. We evaluated the association of FP recalls with multiple patient-level factors and imaging features. RESULTS: A total of 22,055 screening mammograms were performed, and 1887 patients were recalled (recall rate 8.6%). Recall rate was lower for DBT than full field digital mammograms (8.0% vs 10.6%, p < 0.001). FP results were lower if prior mammograms were available (90.8% vs 95.8%, p = 0.02), and if there was a previous benign breast biopsy (87.6% vs 92.9%, p = 0.01). Mean age for the FP group was lower than the true positive group (56.1 vs 62.9 years, p < 0.001). There were no significant differences in FP recalls based on history of high-risk lesions, family history of breast or ovarian cancer, hormone use, breast density, race, or body mass index. CONCLUSION: FP recalls were significantly less likely with DBT, in older women, in patients with prior mammograms available for comparison, and in patients with histories of benign breast biopsy. This study supports the importance of using DBT in the screening setting and obtaining prior mammograms for comparison.

A Pilot of Data-Driven Modeling to Assess Potential for Improved Efficiency in an Academic Breast-Imaging Center.

Patient satisfaction and department efficiency are central pillars in defining quality in medicine. Patient satisfaction is often linked to wait times. We describe a novel method to study workflow and simulate solutions to improve efficiency, thereby decreasing wait times and adding value. We implemented a real-time location system (RTLS) in our academic breast-imaging department to study workflow, including measuring patient wait time, quantifying equipment utilization, and identifying bottlenecks. Then, using discrete event simulation (DES), we modeled solutions with changes in staffing and equipment. Nine hundred and ninety-nine patient encounters were tracked over a 10-week period. The RTLS system recorded 551,512 raw staff and patient time stamps, which were analyzed to produce 17,042 staff and/or patient encounter time stamps. Mean patient wait time was 27 min. The digital breast tomosynthesis (DBT) unit had the highest utilization rate and was identified as a bottleneck. DES predicts a 19.2% reduction in patient length of stay with replacement of a full field digital mammogram (FFDM) unit by a DBT unit and the addition of technologists. Through integration of RTLS with discrete event simulation testing, we created a model based on real-time data to accurately assess patient wait times and patient progress through an appointment, evaluate patient staff-interaction, identify system bottlenecks, and quantitate potential solutions. This quality improvement initiative has important implications, potentially allowing data-driven decisions for staff hiring, equipment purchases, and department layout.

Imaging of Nonprostate Cancers Using PSMA-Targeted Radiotracers: Rationale, Current State of the Field, and a Call to Arms.

Prostate-specific membrane antigen (PSMA) is a type II transmembrane glycoprotein that is highly overexpressed on prostate cancer epithelial cells and for which there is a growing body of literature examining the role of small-molecule and antibody radiotracers targeted against this protein for prostate cancer detection and therapy. Despite its name, PSMA is also expressed, to varying degrees, in the neovasculature of a wide variety of nonprostate cancers; indeed, the pathology literature is replete with promising immunohistochemistry findings. Several groups have begun to correlate those pathology-level results with in vivo imaging and therapy in nonprostate cancers using the same PSMA-targeted agents that have been so successful in prostate cancer. The potential to leverage radiotracers targeted to PSMA beyond prostate cancer is a promising approach for many cancers, and PSMA-targeted agents may be able to supplement or fill gaps left by other agents. However, to date, most of the reported findings with PSMA-targeted radiotracers in nonprostate malignancies have been in case reports and small case series, and the field must adopt a more thorough approach to the design and execution of larger prospective trials to realize the potential of these promising agents outside prostate cancer.

Differential diagnosis of ventriculomegaly and brainstem kinking on fetal MRI.

BACKGROUND: Fetal ventriculomegaly is a common and frequently leading neuroimaging finding in complex brain malformations. Here we report on pre- and postnatal neuroimaging findings in three fetuses with prenatal ventriculomegaly and brainstem kinking. We aim to identify key neuroimaging features that may allow the prenatal differentiation between diseases associated with fetal ventriculomegaly and brainstem kinking. METHODS: All pre- and postnatal magnetic resonance imaging (MRI) data were qualitatively evaluated for infra- and supratentorial abnormalities. Data about clinical features and genetic findings were collected from clinical histories. RESULTS: In all three patients, fetal MRI showed ventriculomegaly and brainstem kinking. In two patients, postnatal MRI also showed supratentorial migration abnormalities and eye abnormalities were found. In these children, the diagnosis of α-dystroglycanopathy was genetically confirmed. In the third patient, basal ganglia had an abnormal shape on MRI suggesting a tubulinopathy. CONCLUSION: The differential diagnosis of prenatal ventriculomegaly and brainstem kinking includes α-dystroglycanopathies, X-linked hydrocephalus due to mutations in L1CAM, and tubulinopathies. The prenatal differentiation between these diseases may be difficult. The presence of ocular abnormalities on prenatal neuroimaging may favor α-dystroglycanopathies, while dysplastic basal ganglia may suggest a tubulinopathy. However, in some patients the final differentiation between these diseases is possible only postnatally.

Decreased vascularization of retroperitoneal kaposiform hemangioendothelioma induced by treatment with sirolimus explains relief of symptoms.

Kaposiform hemangioendothelioma (KHE) is a vascular tumor with poor prognosis. We present a child with progressive disability, extreme pain, and autonomic dysfunction due to a retroperitoneal KHE where radiologic characteristics were essential for diagnosis and monitoring of response to therapy. He received sirolimus, and the symptomatology resolved completely. Repeat MRIs revealed fast marked decrease in vascularity of the tumor, although the volume was not significantly affected. We suggest that the sirolimus-induced tumor de-vascularization may explain the clinical and coagulopathy improvement.