Management of early stage HER2 positive breast cancer and increased implementation of axillary imaging to improve identification of nodal metastasis.

BACKGROUND AND OBJECTIVES: Given the significant benefit of targeted therapies for HER2+ breast cancer patients in both the neoadjuvant and adjuvant settings, it is critical to identify all eligible patients for these treatments. We sought to investigate cT1cN0 HER2+ patients to determine the rate of postsurgical nodal positivity, and to identify presurgical factors associated with nodal positivity. We hypothesize there is a subset of underdiagnosed HER2+ patients who would benefit from preoperative axillary imaging and inclusion in neoadjuvant chemotherapy regimens. METHODS: We performed a 10-year retrospective analysis of T1 HER2+ breast cancer patients. Clinicopathologic characteristics were evaluated based on surgical nodal data. RESULTS: We identified 38 patients with cT1cN0 HER2+ cancer. Of this cohort, 24% had positive lymph nodes on final pathology. High tumor grade (p = 0.035) on core needle biopsy and the presence of lymphovascular invasion (p = 0.0036) were associated with an increased likelihood of lymph node positivity. The majority (66%) of lymph node positive patients were clinically T1c. CONCLUSIONS: We identified a 24% nodal positivity rate in clinically node negative T1 HER2+ breast cancer patients. In particular, HER2+ patients with high-grade T1c cancers should undergo preoperative diagnostic axillary imaging to expand potential benefit from targeted therapies.

Breast Arterial Calcification in the Mammogram Report: The Patient Perspective.

OBJECTIVE: The purpose of this study was to determine patient attitudes about mammographic reporting of breast arterial calcification (BAC), result communication, and action. SUBJECTS AND METHODS: A self-administered survey was created for this project and was offered to mammography patients presenting for screening or diagnostic mammography over a 1-month period. RESULTS: Among those who accepted questionnaires, 61.8% (419/678) responded with varying response rates to specific questions. A large percentage (95.8% [363/379]) preferred to have BAC reported. All 107 patients who were unaware of a personal history of heart disease wanted notification about BAC. There were 552 communication responses from 354 women. Among these responses, 62.5% (345/552) indicated a preference for notification from the radiology department by letter or telephone call. Among those who had a single preference, 76.6% (180/235) preferred notification by the radiology department in the patient results letter or by telephone call. Of those who chose one action option, 87.4% (181/207) indicated that they would undergo coronary artery CT before making a decision. Among those who selected multiple options, 53.2% (272/511) expressed a desire for coronary artery CT before making a decision. Age, level of education, and race were not associated with patients' attitudes toward BAC. CONCLUSION: Patients had an overwhelming preference to be informed about BAC found at mammography. Given the ease of reporting BAC and the calls by preventive cardiologists to have the information, the widespread adoption of BAC reporting on mammography reports can promote prevention, diagnosis, and if needed, treatment of cardiovascular disease.

US of Pediatric Superficial Masses of the Head and Neck.

Superficial palpable masses of the head and neck are common in the pediatric population, with the vast majority of the lesions ultimately proven to be benign. Duplex ultrasonography (US) has emerged as the first-line imaging modality for the evaluation of superficial pediatric masses. Without utilizing radiation, iodinated contrast material, or sedation and/or anesthesia, US provides a means for quick and cost-effective acquisition of information, including the location, size, shape, internal content, and vascularity of the mass. In this review, the US findings are described for a variety of common and uncommon pediatric head and neck masses diagnosed in our practice. Specifically, the entities covered include neonatal scalp hematoma, craniosynostosis, dermoid and epidermoid cysts, Langerhans cell histiocytosis, lymph nodes and their complications, fibromatosis colli, thyroglossal duct cyst, branchial cleft cyst, cervical thymus, congenital goiter, thyroid papillary carcinoma, parathyroid adenoma, hemangioma, lymphangioma, jugular vein phlebectasia, Lemierre syndrome, acute parotitis and parotid abscess, leukemia and/or lymphoma, neurogenic tumor, and rhabdomyosarcoma. Ultimately, in situations in which the head or neck mass is too large, deep, or hyperechoic to be fully assessed within the US field of view, or if malignancy or a high-flow vascular lesion is suspected, then further evaluation with cross-sectional imaging is warranted. Online supplemental material is available for this article. ©RSNA, 2018.

Outcomes of High-Risk Breast MRI Screening in Women Without Prior History of Breast Cancer: Effectiveness Data from a Tertiary Care Center.

OBJECTIVE: To evaluate the diagnostic performance outcomes of a breast MRI screening program in high-risk women without prior history of breast cancer. METHODS: Retrospective cohort study of 1 405 consecutive screening breast MRI examinations in 681 asymptomatic women with high risk of breast cancer without prior history of breast cancer from January 1, 2015, to December 31, 2019. Outcomes (sensitivity, specificity, positive predictive value, negative predictive value, false-negative rate [FNR], cancer detection rate [CDR]) and characteristics of cancers were determined based on histopathology or 12-month follow-up. MRI examinations performed, BI-RADS assessments, pathology outcomes, and CDRs were analyzed overall and by age decade. Results in incidence screening round (MRI in last 18 months) and nonincidence round were compared. RESULTS: Breast MRI achieved CDR 20/1000, sensitivity 93.3% (28/30), and specificity 83.4% (1 147/1375). Twenty-eight (28/1 405, CDR 20/1000) screen-detected cancers were identified: 18 (64.3%, 18/28) invasive and 10 (35.7%, 10/28) ductal carcinoma in situ. Overall, 92.9% (26/28) of all cancers were stage 0 or 1 and 89.3% (25/28) were node negative. All 14 incidence screening round malignancies were stage 0 or 1 with N0 disease. Median size for invasive carcinoma was 8.0 mm and for ductal carcinoma in situ was 9.0 mm. There were two false-negative exams for an FNR 0.1% (2/1 405). CONCLUSION: High-risk screening breast MRI was effective at detecting early breast cancer and associated with favorable outcomes.

Deep learning denoising of digital breast tomosynthesis: Observer performance study of the effect on detection of microcalcifications in breast phantom images.

BACKGROUND: The noise in digital breast tomosynthesis (DBT) includes x-ray quantum noise and detector readout noise. The total radiation dose of a DBT scan is kept at about the level of a digital mammogram but the detector noise is increased due to acquisition of multiple projections. The high noise can degrade the detectability of subtle lesions, specifically microcalcifications (MCs). PURPOSE: We previously developed a deep-learning-based denoiser to improve the image quality of DBT. In the current study, we conducted an observer performance study with breast radiologists to investigate the feasibility of using deep-learning-based denoising to improve the detection of MCs in DBT. METHODS: We have a modular breast phantom set containing seven 1-cm-thick heterogeneous 50% adipose/50% fibroglandular slabs custom-made by CIRS, Inc. (Norfolk, VA). We made six 5-cm-thick breast phantoms embedded with 144 simulated MC clusters of four nominal speck sizes (0.125-0.150, 0.150-0.180, 0.180-0.212, 0.212-0.250 mm) at random locations. The phantoms were imaged with a GE Pristina DBT system using the automatic standard (STD) mode. The phantoms were also imaged with the STD+ mode that increased the average glandular dose by 54% to be used as a reference condition for comparison of radiologists' reading. Our previously trained and validated denoiser was deployed to the STD images to obtain a denoised DBT set (dnSTD). Seven breast radiologists participated as readers to detect the MCs in the DBT volumes of the six phantoms under the three conditions (STD, STD+, dnSTD), totaling 18 DBT volumes. Each radiologist read all the 18 DBT volumes sequentially, which were arranged in a different order for each reader in a counter-balanced manner to minimize any potential reading order effects. They marked the location of each detected MC cluster and provided a conspicuity rating and their confidence level for the perceived cluster. The visual grading characteristics (VGC) analysis was used to compare the conspicuity ratings and the confidence levels of the radiologists for the detection of MCs. RESULTS: The average sensitivities over all MC speck sizes were 65.3%, 73.2%, and 72.3%, respectively, for the radiologists reading the STD, dnSTD, and STD+ volumes. The sensitivity for dnSTD was significantly higher than that for STD (p < 0.005, two-tailed Wilcoxon signed rank test) and comparable to that for STD+. The average false positive rates were 3.9 ± 4.6, 2.8 ± 3.7, and 2.7 ± 3.9 marks per DBT volume, respectively, for reading the STD, dnSTD, and STD+ images but the difference between dnSTD and STD or STD+ did not reach statistical significance. The overall conspicuity ratings and confidence levels by VGC analysis for dnSTD were significantly higher than those for both STD and STD+ (p ≤ 0.001). The critical alpha value for significance was adjusted to be 0.025 with Bonferroni correction. CONCLUSIONS: This observer study using breast phantom images showed that deep-learning-based denoising has the potential to improve the detection of MCs in noisy DBT images and increase radiologists' confidence in differentiating noise from MCs without increasing radiation dose. Further studies are needed to evaluate the generalizability of these results to the wide range of DBTs from human subjects and patient populations in clinical settings.

Effect of Dose Level on Radiologists' Detection of Microcalcifications in Digital Breast Tomosynthesis: An Observer Study with Breast Phantoms.

OBJECTIVES: To compare radiologists' sensitivity, confidence level, and reading efficiency of detecting microcalcifications in digital breast tomosynthesis (DBT) at two clinically relevant dose levels. MATERIALS AND METHODS: Six 5-cm-thick heterogeneous breast phantoms embedded with a total of 144 simulated microcalcification clusters of four speck sizes were imaged at two dose modes by a clinical DBT system. The DBT volumes at the two dose levels were read independently by six MQSA radiologists and one fellow with 1-33 years (median 12 years) of experience in a fully-crossed counter-balanced manner. The radiologist located each potential cluster and rated its conspicuity and his/her confidence that the marked location contained a cluster. The differences in the results between the two dose modes were analyzed by two-tailed paired t-test. RESULTS: Compared to the lower-dose mode, the average glandular dose in the higher-dose mode for the 5-cm phantoms increased from 1.34 to 2.07 mGy. The detection sensitivity increased for all speck sizes and significantly for the two smaller sizes (p <0.05). An average of 13.8% fewer false positive clusters was marked. The average conspicuity rating and the radiologists' confidence level were higher for all speck sizes and reached significance (p <0.05) for the three larger sizes. The average reading time per detected cluster reduced significantly (p <0.05) by an average of 13.2%. CONCLUSION: For a 5-cm-thick breast, an increase in average glandular dose from 1.34 to 2.07 mGy for DBT imaging increased the conspicuity of microcalcifications, improved the detection sensitivity by radiologists, increased their confidence levels, reduced false positive detections, and increased the reading efficiency.

Screening Mammography: Guidelines versus Clinical Practice.

OBJECTIVE: To understand physicians' comprehension of breast cancer screening guidelines and the existing literature on breast cancer screening, and whether this contributes to how patient screening is implemented in clinical practice. METHODS: A survey of 18 questions was distributed across the United States via e-mail and social media resources to physicians and medical students of all disciplines and levels of training. Responses from 728 physicians and medical students were reviewed. Respondents were from over 200 different institutions and over 60 different medical specialties. RESULTS: Our survey demonstrates that more than half of the participants felt uncomfortable in their knowledge of breast cancer screening recommendations (399/728, 54.8%) and existing literature on breast cancer screening (555/728, 76.2%). When stratified based on level of training, those at the attending level reported a greater level of comfort in their knowledge of breast cancer screening recommendations (168/238, 70.6%) and literature (95/238, 39.9%) compared with respondents at the trainee level. Attending physicians are also more likely to recommend screening for patients between the ages of 40-49 years old (209/238, 87.7%) compared to those at the trainee level. Responses on whether to screen based on age were most consistent for patients ages 50-74, with greater than 90% of the respondents endorsing screening mammogram for this age group in all levels of training. There were greater inconsistencies in the support to screen age groups 40-49 and 75+ . CONCLUSIONS: The results showed a disparity in screening practices by clinicians in all levels of training, particularly for patients ages 40-49 and 75+ , and for the interval of screening. Later initiation with less frequent intervals between screens may reduce the impact of screening on mortality reduction.

BI-RADS 3: Current and Future Use of Probably Benign.

PURPOSE OF REVIEW: Probably benign (BI-RADS 3) causes confusion for interpreting physicians and referring physicians and can induce significant patient anxiety. The best uses and evidence for using this assessment category in mammography, breast ultrasound, and breast MRI will be reviewed; the reader will have a better understanding of how and when to use BI-RADS 3. RECENT FINDINGS: Interobserver variability in the use of BI-RADS 3 has been documented. The 5th edition of the BI-RADS atlas details the appropriate use of BI-RADS 3 for diagnostic mammography, ultrasound, and MRI, and discourages its use in screening mammography. Data mining, elastography, and diffusion weighted MRI have been evaluated to maximize the accuracy of BI-RADS 3. SUMMARY: BI-RADS 3 is an evolving assessment category. When used properly, it reduces the number of benign biopsies while allowing the breast imager to maintain a high sensitivity for the detection of early stage breast cancer.

The mammary ridge-A case report of multiple ectopic breast masses.

Ectopic or accessory breasts describe residual breast tissue that fails to regress during normal embryologic development anywhere outside the expected locations. Ectopic breast tissue is seen in 2-6% of the population and is categorized into two types: supernumerary and aberrant breast tissue . The extent of development of this accessory tissue varies from rudimentary to complete with organized glandular and ductal development. Given this, it is possible for the same pathology that affects normally positioned breast tissue to also affect accessory breast tissue.