Multimodality Imaging of Postmastectomy Breast Reconstruction Techniques, Complications, and Tumor Recurrence.

For women undergoing mastectomy, breast reconstruction can be performed by using implants or autologous tissue flaps. Mastectomy options include skin- and nipple-sparing techniques. Implant-based reconstruction can be performed with saline or silicone implants. Various autologous pedicled or free tissue flap reconstruction methods based on different tissue donor sites are available. The aesthetic outcomes of implant- and flap-based reconstructions can be improved with oncoplastic surgery, including autologous fat graft placement and nipple-areolar complex reconstruction. The authors provide an update on recent advances in implant reconstruction techniques and contemporary expanded options for autologous tissue flap reconstruction as it relates to imaging modalities. As breast cancer screening is not routinely performed in this clinical setting, tumor recurrence after mastectomy and reconstruction is often detected by palpation at physical examination. Most local recurrences occur within the skin and subcutaneous tissue. Diagnostic breast imaging continues to have a critical role in confirmation of disease recurrence. Knowledge of the spectrum of benign and abnormal imaging appearances in the reconstructed breast is important for postoperative evaluation of patients, including recognition of early and late postsurgical complications and breast cancer recurrence. The authors provide an overview of multimodality imaging of the postmastectomy reconstructed breast, as well as an update on screening guidelines and recommendations for this unique patient population. ©RSNA, 2024 Test Your Knowledge questions for this article are available in the supplemental material.

Optimizing the Patient Experience in Breast Imaging Facilities: AJR Expert Panel Narrative Review.

Breast imaging studies are complex examinations for patients and providers. Breast imaging providers and organizations invest significant resources in educating patients and referring providers to address variability in changing breast cancer screening recommendations, cultural biases, and socioeconomic barriers for patients. The breast imaging examination frequently involves multiple imaging modalities including interventional procedures, thus requiring multiple room types. Practices need to consider variables that affect workflow efficiency throughout the process of scheduling, examination performance, interpretation, and results delivery, as well as options in facilities design to create inviting yet functional environments for patients. Breast imaging appointments provide opportunity to capture individual breast cancer risk and to engage patients in health education and breast screening awareness. This AJR Expert Panel Narrative Review discusses ways in which breast imaging facilities can optimize patient experience throughout the complex process of a breast imaging examination, based on the authors' observations and opinions that include private and academic breast imaging experience.

Letter to the editor on article by Dinh et al. Is it ethical to incentivize mammography screening in Medicaid populations? - A policy review and conceptual analysis. By Stamatia Destounis, MD and Sarah Friedewald MD.

Letter to the Editor on article by Dinh et al- response to the authors comments on " Is it ethical to incentivize mammography screening in Medicaid populations? - A policy review and conceptual analysis".

Update on Breast Density, Risk Estimation, and Supplemental Screening.

OBJECTIVE. Dense breast tissue is an established risk factor for the development of breast cancer. Methods for reliable and reproducible identification of breast density have been developed and are increasingly being adopted into clinical practice, allowing enhanced identification of patients who will benefit from supplemental screening. Breast density is being used for patient risk stratification through incorporation into risk models, leading to more precise management and improved decision making regarding personalized screening strategies. CONCLUSION. This review provides an update on breast density assessment, evaluation of patient's risk status, and the use of supplemental screening.

A Review of the Role of Augmented Intelligence in Breast Imaging: From Automated Breast Density Assessment to Risk Stratification.

OBJECTIVE: The goal of augmented intelligence is to increase efficiency and effectiveness in practice. To achieve this, augmented intelligence technologies are being asked to perform a range of tasks, from simple to complex and quantitative. The development of these systems is increasingly important as screening becomes more personalized. This article will provide an overview of augmented intelligence in a variety of breast imaging applications. CONCLUSION: The incorporation of AI and ML techniques in breast imaging provides important new tools that will deliver ways to "sharpen" trusted familiar tools (so-called "augmented intelligence") to support radiologists, not replace them. The first wave of medical imaging systems based on AI and ML has primarily used ML to fix the values of key imaging parameters to be adapted to the individual as part of personalized medicine. Artificial intelligence is the new tool in the radiologist's arsenal but will never replace the human qualities that are important in medicine-intellectual curiosity, passion, and drive.

A Pivotal Study of Optoacoustic Imaging to Diagnose Benign and Malignant Breast Masses: A New Evaluation Tool for Radiologists.

Purpose To compare the diagnostic utility of an investigational optoacoustic imaging device that fuses laser optical imaging (OA) with grayscale ultrasonography (US) to grayscale US alone in differentiating benign and malignant breast masses. Materials and Methods This prospective, 16-site study of 2105 women (study period: 12/21/2012 to 9/9/2015) compared Breast Imaging Reporting and Data System (BI-RADS) categories assigned by seven blinded independent readers to benign and malignant breast masses using OA/US versus US alone. BI-RADS 3, 4, or 5 masses assessed at diagnostic US with biopsy-proven histologic findings and BI-RADS 3 masses stable at 12 months were eligible. Independent readers reviewed US images obtained with the OA/US device, assigned a probability of malignancy (POM) and BI-RADS category, and locked results. The same independent readers then reviewed OA/US images, scored OA features, and assigned OA/US POM and a BI-RADS category. Specificity and sensitivity were calculated for US and OA/US. Benign and malignant mass upgrade and downgrade rates, positive and negative predictive values, and positive and negative likelihood ratios were compared. Results Of 2105 consented subjects with 2191 masses, 100 subjects (103 masses) were analyzed separately as a training population and excluded. An additional 202 subjects (210 masses) were excluded due to technical failures or incomplete imaging, 72 subjects (78 masses) due to protocol deviations, and 41 subjects (43 masses) due to high-risk histologic results. Of 1690 subjects with 1757 masses (1079 [61.4%] benign and 678 [38.6%] malignant masses), OA/US downgraded 40.8% (3078/7535) of benign mass reads, with a specificity of 43.0% (3242/7538, 99% confidence interval [CI]: 40.4%, 45.7%) for OA/US versus 28.1% (2120/7543, 99% CI: 25.8%, 30.5%) for the internal US of the OA/US device. OA/US exceeded US in specificity by 14.9% (P < .0001; 99% CI: 12.9, 16.9%). Sensitivity for biopsied malignant masses was 96.0% (4553/4745, 99% CI: 94.5%, 97.0%) for OA/US and 98.6% (4680/4746, 99% CI: 97.8%, 99.1%) for US (P < .0001). The negative likelihood ratio of 0.094 for OA/US indicates a negative examination can reduce a maximum US-assigned pretest probability of 17.8% (low BI-RADS 4B) to a posttest probability of 2% (BI-RADS 3). Conclusion OA/US increases the specificity of breast mass assessment compared with the device internal grayscale US alone. Online supplemental material is available for this article. © RSNA, 2017.

Age to Begin and Intervals for Breast Cancer Screening: Balancing Benefits and Harms.

OBJECTIVE: Screening mammography has been widely used for breast cancer detection and has been found to decrease mortality, but debate continues. The purpose of this article is to review screening recommendations and the benefits and perceived harms of earlier and more frequent screening. CONCLUSION: Annual mammography beginning at age 40 decreases mortality. Clinicians should educate women and preserve recommendations for early and annual screening.

Downgrading and Upgrading Gray-Scale Ultrasound BI-RADS Categories of Benign and Malignant Masses With Optoacoustics: A Pilot Study.

OBJECTIVE: False-positive findings remain challenging in breast imaging. This study investigates the incremental value of optoacoustic imaging in improving BI-RADS categorization of breast masses at ultrasound. SUBJECTS AND METHODS: The study device is an optoacoustic breast imaging device with a handheld duplex laser and internal gray-scale ultrasound probe, fusing functional and morphologic information (optoacoustic ultrasound). In this prospective multisite study, breast masses assessed as BI-RADS category 3, 4A, 4B, 4C, or 5 by site radiologists underwent both gray-scale ultrasound and optoacoustic imaging with the study device. Independent reader radiologists assessed internal gray-scale ultrasound and optoacoustic ultrasound features for each mass and assigned a BI-RADS category. The percentage of mass reads for which optoacoustic ultrasound resulted in a downgrade or upgrade of BI-RADS category relative to internal gray-scale ultrasound was determined. RESULTS: Of 94 total masses, 39 were biopsy-proven malignant, 44 were biopsy-proven benign, and 11 BI-RADS category 3 masses were stable at 12-month follow-up. The sensitivity of both optoacoustic ultrasound and internal gray-scale ultrasound was 97.1%. The specificity was 44.3% for optoacoustic ultrasound and 36.4% for internal gray-scale ultrasound. Using optoacoustic ultrasound, 41.7% of benign masses or BI-RADS category 3 masses that were stable at 12-month follow-up were downgraded to BI-RADS category 2 by independent readers; 36.6% of masses assigned BI-RADS category 4A were downgraded to BI-RADS category 3 or 2, and 10.1% assigned BI-RADS category 4B were downgraded to BI-RADS category 3 or 2. Using optoacoustic ultrasound, independent readers upgraded 75.0% of the malignant masses classified as category 4A, 4B, 4C, or 5, and 49.4% of the malignant masses were classified as category 4B, 4C, or 5. CONCLUSION: Optoacoustic ultrasound resulted in BI-RADS category downgrading of benign masses and upgrading of malignant masses compared with gray-scale ultrasound.

Optoacoustic Breast Imaging: Imaging-Pathology Correlation of Optoacoustic Features in Benign and Malignant Breast Masses.

OBJECTIVE: Optoacoustic ultrasound breast imaging is a fused anatomic and functional modality that shows morphologic features, as well as hemoglobin amount and relative oxygenation within and around breast masses. The purpose of this study is to investigate the positive predictive value (PPV) of optoacoustic ultrasound features in benign and malignant masses. SUBJECTS AND METHODS: In this study, 92 masses assessed as BI-RADS category 3, 4, or 5 in 94 subjects were imaged with optoacoustic ultrasound. Each mass was scored by seven blinded independent readers according to three internal features in the tumor interior and two external features in its boundary zone and periphery. Mean and median optoacoustic ultrasound scores were compared with histologic findings for biopsied masses and nonbiopsied BI-RADS category 3 masses, which were considered benign if they were stable at 12-month follow-up. Statistical significance was analyzed using a two-sided Wilcoxon rank sum test with a 0.05 significance level. RESULTS: Mean and median optoacoustic ultrasound scores for all individual internal and external features, as well as summed scores, were higher for malignant masses than for benign masses (p < 0.0001). High external scores, indicating increased hemoglobin and deoxygenation and abnormal vessel morphologic features in the tumor boundary zone and periphery, better distinguished benign from malignant masses than did high internal scores reflecting increased hemoglobin and deoxygenation within the tumor interior. CONCLUSION: High optoacoustic ultrasound scores, particularly those based on external features in the boundary zone and periphery of breast masses, have high PPVs for malignancy and, conversely, low optoacoustic ultrasound scores have low PPV for malignancy. The functional component of optoacoustic ultrasound may help to overcome some of the limitations of morphologic overlap in the distinction of benign and malignant masses.

Using Volumetric Breast Density to Quantify the Potential Masking Risk of Mammographic Density.

OBJECTIVE: The purposes of this study were to compare BI-RADS density categories with quantitative volumetric breast density (VBD) for the reporting of mammographic sensitivity and to identify which patient factors are most predictive of a diagnosis of interval cancer of the breast versus screen-detected cancer. MATERIALS AND METHODS: This retrospective study included screen-detected cancers (n = 652) and interval cancers (n = 119) identified between January 2009 and December 2012. Multivariate logistic regression analysis was used to determine which patient factors are predictive of a diagnosis of interval cancer. Sensitivity (screen-detected cancer / [screen-detected cancer + interval cancer]) was determined with the BI-RADS 4th edition density categories and an automated equivalent density grade obtained with a proprietary tool. Sensitivity changes within automated density grade categories were investigated by use of quantitative thresholds at the midpoints of each category. RESULTS: In univariate analysis, age, menopausal status, and breast density were associated with a diagnosis of interval cancer. Of these risk factors, breast density was the only independent factor whether it was assessed by visual BI-RADS category (odds ratio, 3.54; 95% CI, 1.55-8.10), automated density grade (odds ratio, 4.68; 95% CI, 2.26-9.67), or VBD (odds ratio, 4.51; 95% CI, 1.92-10.61). Sensitivity decreased consistently across increasing automated density grade categories from fatty to extremely dense (95%, 89%, 83%, 65%) and less so for visual BI-RADS (82%, 90%, 84%, 66%). Further dichotomization with VBD cutoffs showed a striking linear relation between VBD and sensitivity (R2 = 0.959). CONCLUSION: In this study, breast density was the only risk factor significantly associated with a diagnosis of interval cancer versus screen-detected cancer. Quantitative VBD captures the potential masking risk of breast density more precisely than does the widely used visual BI-RADS density classification system.

New York State Breast Density Mandate: Follow-up Data With Screening Sonography.

OBJECTIVES: To evaluate the impact on breast cancer detection from screening breast sonography performed in women with mammographically dense breasts. METHODS: This study used a retrospective chart review. Data collected included total number of screening mammograms, total number of dense breast screening sonograms, total number of procedures performed, biopsy results, and demographic data. Data were obtained from January 1, 2013, through August 31, 2015. During this period, there were a total of 195,982 screening mammographic examinations performed at our facility. Of these, 83,234 patients (42.5%) were informed that their breast tissue was heterogeneously dense or extremely dense. We specifically reviewed cases to identify those with findings on sonography only. The positive predictive value, biopsy rate, and cancer detection rate were determined. RESULTS: During the study period, 5434 screening sonographic examinations were performed in 4898 women with heterogeneously dense or extremely dense breasts. Most (95.7%) of the sonographic examinations resulted in an American College of Radiology Breast Imaging Reporting and Data System (BI-RADS) category 1 or 2 designation. A total of 101 lesions were given a BI-RADS 3 designation; 134 suspicious findings were given a BI-RADS 4 or 5 designation; and 100 of these were seen on sonography only, all of which underwent tissue sampling, resulting in the diagnosis of 18 malignancies; all were invasive. In evaluating screening sonographic findings, we found a positive predictive value of 18.0%, with an overall biopsy rate of 2.0% and a cancer detection rate of 3.3 per 1000. CONCLUSIONS: The results of our continued evaluation of our screening sonography program confirm that screening breast sonography in women with dense breast tissue can detect otherwise occult malignancy, with a low biopsy rate.

Agreement Between an Automated Volume Breast Scanner and Handheld Ultrasound for Diagnostic Breast Examinations.

OBJECTIVES: To compare the agreement and interobserver variability of diagnostic handheld ultrasound (US) and a single volume on an automated breast volume scanner (ABVS) and to determine whether there was a significant difference if the ABVS was used by a sonographer or mammographic technologist. METHODS: Ninety patients scheduled for diagnostic US examinations were randomized to either handheld US or the ABVS first. The AVBS was randomized between a sonographer and a mammographic technologist performing the study. The studies were blinded, randomized, and read by 2 radiologists. The lesion with the highest Breast Imaging Reporting and Data System (BI-RADS) score was used in the analysis. Final diagnoses were made by core biopsy or follow-up for 2 years. Lesions included 9 malignant and 81 benign. RESULTS: The 90 patients had a mean age ± SD of 53.1 ± 16.3 years. The κ value for agreement between the ABVS and handheld US was 0.831 (95% confidence interval, 0.744-0.925), whereas the global agreement for a 7-point BI-RADS score was 0.488 (0.372-0.560). The agreement between the ABVS and handheld US was nearly the same when the ABVS was used by a mammographic technologist (κ = 0.858 [0.723-0.963]) or sonographer (κ = 0.803 [0.596-1.000]; P = .47). The areas under the receiver operating characteristic curves for characterization by the ABVS were 0.91 (0.84-0.96) for reader 1 and 0.91 (0.83-0.96) for reader 2; those for handheld US were 0.91 (0.84-0.96) for reader 1 and 0.83 (0.74-0.90) for reader 2, with no statistical difference. The agreement based on pathologic images was κ = 0.831 (0.718-0.944); for handheld US, κ = 0.795 (0.623-0.967); and for the AVBS, κ = 0.869 (0.725-1.000). CONCLUSIONS: Performing a single-view diagnostic ABVS examination has good agreement with a handheld diagnostic US workup. There is no difference if the ABVS is used by a sonographer or mammographic technologist.

Screening for dense breasts: digital breast tomosynthesis.

OBJECTIVE. Digital breast tomosynthesis (DBT) is a recent imaging technology that was developed to address the limitations of conventional 2D mammography. The limitations of standard mammography are well known and include reduced sensitivity in dense breasts. Clinical research studies of DBT and the implementation of DBT have revealed that DBT has potential benefits for evaluating patients with dense breasts. This article will discuss the benefits and limitations of DBT as a screening alternative for women with dense breasts. CONCLUSION. Studies to date have revealed that the use of DBT reduces recall rates and increases cancer detection rates. This has been demonstrated with the use of DBT for both screening and diagnostic purposes, as well as with imaging dense breasts. DBT has the ability to reduce breast tissue overlap, thus potentially revealing lesions that would otherwise have been missed. The limitations of DBT include longer interpretation times, higher costs, and increased radiation dose. These limitations present challenges that radiologists must consider before DBT implementation.

Initial experience with the New York State breast density inform law at a community-based breast center.

OBJECTIVES: The purpose of this study was to review our initial experience with the New York State breast density inform law (New York public health law, S2404-C) at our outpatient breast center. We sought to review the findings in patients returning for screening breast sonography after a screening mammogram revealed heterogeneously dense or extremely dense breast tissue. METHODS: From January 1, 2013, through May 31, 2014, 102,841 patients who underwent screening mammography were seen at our institution. Of these, 35,153 were determined to have heterogeneously dense breast tissue, and 11,864 were determined to have extremely dense breast tissue. Due to the New York State breast density inform law, these 47,017 patients were notified of their breast density, with 935 patients (2%) returning for 971 screening breast sonographic examinations. RESULTS: Heterogeneously dense breast tissue was noted in 66% of the patients (619), and extremely dense breast tissue was noted in 34% (316). Thirty-one percent of the patients (290) reported no additional risk factors; 68% (635) presented with 1 or more additional risk factors; and 1% (10) were adopted, and the risk status could not be assessed. Twenty-five procedures (2.6%) were performed after screening breast sonography, resulting in 22 benign findings, 1 atypical finding, and 2 malignancies. The overall positive predictive value was 8% (2 of 25), and the overall cancer detection rate was 2.1 per 1000 (2 of 935). CONCLUSIONS: Handheld screening breast sonography performed in women with dense breast tissue can aid in the detection of otherwise occult breast cancer, as we found 2 cancers in the study population, with an overall positive predictive value of 8%. The addition of screening sonography in this cohort did lead to an increase in minimally invasive procedures in 2.6%.

Comparison of breast cancers diagnosed in screening patients in their 40s with and without family history of breast cancer in a community outpatient facility.

OBJECTIVE: The purpose of this study was to compare invasive breast cancer in patients in their 40s with and without a family history of breast cancer as well as the lymph node meta-static rate and mastectomy rate. MATERIALS AND METHODS: From 2000 to 2011, a total of 793,827 examinations were performed; 221,541 (28%) were women between 40 and 49 years old. A total of 6965 cancers were found in 6511 patients. Specifically, 1207 cancers (17.3%) were detected in 1162 patients in their 40s. Patients presenting for diagnostic evaluation and those with a personal history of breast cancer were excluded, leaving 388 cancers available for study; 238 (61%) cancers were in patients with no family history of breast cancer, and 150 (39%) were in patients with a family history of breast cancer. Pearson chi-square, Fisher exact, and Student t tests were used for between-group comparisons for qualitative data. A two-sided p value was reported for all tests. RESULTS: The difference in lesions detected by imaging was not statistically significant (p = 0.17); 65% (154/238) had invasive and 35% (84/238) noninvasive disease in the no family history of breast cancer group and 65% (98/150) and 35% (52/150), respectively, in the family history of breast cancer group (p = 0.90). The mastectomy rate was not statistically significantly different (p = 0.14). Fifteen percent (35/238) of the no family history of breast cancer patients and 12% (18/150) of the family history of breast cancer patients had positive lymph nodes (p = 0.45). CONCLUSION: In patients in their 40s with or without a family history of breast cancer, no differences were detected in the proportion of invasive versus noninvasive cancers diagnosed, lymph node metastases, or mastectomy rates. Screening mammography should be performed in this age group regardless of family history.

Evaluation of malignant breast lesions in the diagnostic setting with cone beam breast computed tomography (Breast CT): feasibility study.

To investigate the feasibility of noncontrast and contrast-enhanced cone beam breast Computed Tomography (CT) in demonstrating malignant breast lesions in the diagnostic setting. This Institutional Review Board approved, Health Information Portability and Accountability Act compliant, prospective study enrolled BI-RADS four and five patients from 2008 to 2010. Eighty-seven subjects had noncontrast breast CT, 42 had contrast-enhanced breast CT (CE-breast CT) with 70 pathologically confirmed cancer diagnoses. All 70 comprise the study cohort for noncontrast breast CT, and 23 who had CE-breast CT comprise the cohort for CE-breast CT. All had diagnostic work-up. Patient age, breast density, lesion size and characteristics, biopsy method, and core pathology were recorded. A Fisher's exact test was used to detect a difference in detectability. For agreement in size measurement between the imaging modalities, a paired t-test was employed. Reported p-values were based on 2-sided tests. Two one-sided tests were calculated to determine equivalence within ±0.3 cm at a 90% significance level. Noncontrast breast CT identified 67 of 70 malignant lesions, detected by diagnostic work-up. CE-breast CT identified 23 of 23 index malignant lesions and in addition, found three malignant lesions in three cases not previously detected. Noncontrast breast CT demonstrated the index lesion in 67 of 70 cases and CE-breast CT demonstrated the index lesion in all 23 cases. An additional three new malignant lesions not seen with conventional diagnostic work-up were detected. In this preliminary study, breast CT with or without contrast was shown to be accurate at identifying malignant breast lesions in the diagnostic setting.

Patient Preferences of Breast Radiologists' Attire and Appearance.

RATIONALE AND OBJECTIVES: To assess patient preferences for breast radiologists' attire and appearance. MATERIALS AND METHODS: A multi-institutional anonymous, voluntary 19-question survey was administered to patients undergoing screening and diagnostic mammography examinations over a 5-week period. Using a 5-point Likert scale, respondents were asked about their preferences for gender-neutral attire (white coat), male-presenting attire (scrubs, dress shirt with tie, or dress shirt without tie), and female-presenting attire (scrubs, dress, blouse with pants, and blouse with skirt). Patient responses were compared to demographic data using bivariable analysis and multivariable regression. RESULTS: Response rate was 84.7% (957/1130). Mean respondent age was 57.2 years±11.9. Most respondents agreed/strongly agreed that the breast radiologist's appearance mattered (52.5%, 502/956) followed by being indifferent (28.1%, 269/956). Respondents with greater education levels felt less strongly (p=0.001) about the radiologist's appearance: 63.3% (70/110) less than college cared about appearance compared to 53.5% (266/497) college/vocational and 47.4% (165/348) graduate. Most respondents felt indifferent about a breast radiologist wearing a white coat (68.9%, 657/954) or about male-presenting breast radiologists wearing a tie (77.1%, 734/952) without significant demographic differences. Almost all respondents either prefer/strongly prefer (60.1%, 572/951) or were indifferent (39.6%, 377/951) to all breast radiologists wearing scrubs when performing procedures. While respondents approved of all attire choices overall, most respondents preferred scrubs for both male- and female-presenting breast radiologists (64.0%, 612/957 and 64.9%, 621/957, respectively). CONCLUSION: A variety of breast radiologists' attire can be worn while maintaining provider professionalism and without compromising patient expectations.