Deborah O. Jeffries

Digital breast tomosynthesis is comparable to mammographic spot views for mass characterization.

PURPOSE To determine if digital breast tomosynthesis (DBT) performs comparably to mammographic spot views (MSVs) in characterizing breast masses as benign or malignant. MATERIALS AND METHODS This IRB-approved, HIPAA-compliant reader study obtained informed consent from all subjects. Four blinded Mammography Quality Standards Act-certified academic radiologists individually evaluated DBT images and MSVs of 67 masses (30 malignant, 37 benign) in 67 women (age range, 34-88 years). Images were viewed in random order at separate counterbalanced sessions and were rated for visibility (10-point scale), likelihood of malignancy (12-point scale), and Breast Imaging Reporting and Data System (BI-RADS) classification. Differences in mass visibility were analyzed by using the Wilcoxon matched-pairs signed-ranks test. Reader performance was measured by calculating the area under the receiver operating characteristic curve (A(z)) and partial area index above a sensitivity threshold of 0.90 (A(z)(0.90)) by using likelihood of malignancy ratings. Masses categorized as BI-RADS 4 or 5 were compared with histopathologic analysis to determine true-positive results for each modality. RESULTS Mean mass visibility ratings were slightly better with DBT (range, 3.2-4.4) than with MSV (range, 3.8-4.8) for all four readers, with one readers improvement achieving statistical significance (P = .001). The A(z) ranged 0.89-0.93 for DBT and 0.88-0.93 for MSV (P ≥ .23). The A(z)((0.90)) ranged 0.36-0.52 for DBT and 0.25-0.40 for MSV (P ≥ .20). The readers characterized seven additional malignant masses as BI-RADS 4 or 5 with DBT than with MSV, at a cost of five false-positive biopsy recommendations, with a mean of 1.8 true-positive (range, 0-3) and 1.3 false-positive (range, -1 to 4) assessments per reader. CONCLUSION In this small study, mass characterization in terms of visibility ratings, reader performance, and BI-RADS assessment with DBT was similar to that with MSVs. Preliminary findings suggest that MSV might not be necessary for mass characterization when performing DBT.

Accuracy of Diagnostic Mammography and Breast Ultrasound During Pregnancy and Lactation

OBJECTIVE The purpose of this article is to determine the accuracy of mammography and sonography in evaluating pregnant, lactating, and postpartum women. MATERIALS AND METHODS We retrospectively reviewed diagnostic breast imaging examinations of 155 pregnant, lactating, and postpartum women with 164 lesions presenting to our breast imaging department from 2004 to 2005. Records were reviewed for clinical presentation, reported sonographic or mammographic findings with BI-RADS assessment, histologic results, and clinical outcomes. Examinations rated as BI-RADS categories 4 and 5 were considered positive. One hundred thirty-four (82%) of 164 lesions had pathology results available or longer than 12 months follow-up in our study group. Of these lesions, 12 (9%) were evaluated by mammography alone, 49 (37%) were evaluated by ultrasound alone, and 73 (54%) were evaluated by both techniques. RESULTS Of 134 lesions, 87 (65%) were in patients who presented during lactation, 34 (25%) who presented during pregnancy, and 13 (10%) who presented postpartum. The presenting symptom for 86 lesions (64%) was a palpable mass. Biopsies were performed for 40 lesions. Of these lesions, four were malignant and 36 were benign. Mammograms were dense or heterogeneously dense in 88% of patients. All four malignancies were BI-RADS category 4 or 5 according to both mammography and ultrasound. For the 85 lesions evaluated with mammography, there was 100% sensitivity, 93% specificity, 40% positive predictive value, and 100% negative predictive value. For the 122 lesions evaluated with sonography, there was 100% sensitivity, 86% specificity, 19% positive predictive value, and 100% negative predictive value. CONCLUSION Among lactating and pregnant women, both mammography and sonography had a negative predictive value of 100% and accurately revealed the few cancers that were present in our study group.

Does digital mammography increase detection of high-risk breast lesions presenting as calcifications?

OBJECTIVE The objective of our study was to evaluate whether the transition from film-screen mammography (FSM) to digital mammography (DM) was associated with increased detection of high-risk breast lesions. MATERIALS AND METHODS A retrospective search identified 142 cases of atypia or lobular neoplasia (LN) diagnosed in women with mammographic calcifications between January 2004 and August 2010. We excluded lesions upgraded to cancer at excisional biopsy, lesions in women with ipsilateral cancer within 2 years of mammography, and lesions that presented as a mass only. The cases included in the cohort were 82 (57.7%) cases of atypical ductal hyperplasia; 17 (12%) atypical lobular hyperplasia; 25 (17.6%) lobular carcinoma in situ (LCIS); 12 (8.5%) atypia and LCIS; and six (4.2%) other atypia. The institution transitioned from predominantly performing FSM in 2004 to performing only DM by 2010. Pathology was interpreted by breast pathologists. The annual detection rate was calculated by dividing the number of high-risk lesions by mammography volume. RESULTS Of the 142 cases of atypia or LN, 52 (36.6%) were detected using FSM and 90 (63.4%) were detected using DM. The detection rate was higher with DM (1.24/1000 mammographic studies) than FSM (0.37/1000 mammographic studies). The detection rate by year ranged between 0.21 and 0.64 per 1000 mammographic studies for FSM and between 0.32 and 1.49 per 1000 mammographic studies for DM. The median size of the calcifications was 8 mm on DM and 7 mm on FSM. The most common appearance was clustered amorphous or indistinct calcifications on both FSM and DM. CONCLUSION The transition from FSM to DM was associated with a threefold increase in the detection rate of high-risk lesions. Improved detection may allow enhanced screening, risk reduction treatment, and possibly breast cancer prevention. However, increased detection of high-risk lesions may also result in oversurveillance and treatment.

Localization for Breast Surgery: The Next Generation

CONTEXT - Preoperative localization of nonpalpable breast lesions using image-guided wire placement has been a standard of breast imaging, diagnosis, and treatment since its development in the 1970s. With this technique, coordinated, same-day wire placement by the radiologist and surgery are required, which can lead to significant inefficiencies in workflow. Other disadvantages of wire localization (WL) include limitations in surgical incision and dissection route and protruding wires that can be both bothersome for the patient and have risk of displacement. OBJECTIVE - To outline several recently developed techniques that could replace traditional WL and eliminate its disadvantages. The first developed was radioactive seed localization (RSL) using I-125, a technique adopted by many institutions during the last few years. The challenge to this method, however, is the strict nuclear regulatory requirements, which can be a significant burden and limitation. The disadvantages of WL and RSL have provided incentive for the development of other types of preoperative localization procedures. Two of these are recently US Food and Drug Administration-cleared, nonradioactive, non-wire location technologies emerging as alternatives to WL and RSL; SAVI SCOUT (Cianna Medical Inc, Aliso Viejo, California), which uses infrared light and a microimpulse radar reflector, and Magseed (Endomagnetics Inc, Austin, Texas), which uses a magnetic seed for localization. DATA SOURCES - We review the published literature on non-wire location technologies for breast tissue resection. CONCLUSIONS - Non-wire location techniques are beneficial, allowing image-guided placement before the day of surgery and resulting in improved workflows. These techniques also eliminate bothersome protruding wires, risk of dislodging, and allow the incision site to be independent from the localization site.

Characterization of Breast Masses in Digital Breast Tomosynthesis and Digital Mammograms: An Observer Performance Study

RATIONALE AND OBJECTIVES This study aimed to compare Breast Imaging Reporting and Data System (BI-RADS) assessment of lesions in two-view digital mammogram (DM) to two-view wide-angle digital breast tomosynthesis (DBT) without DM. MATERIALS AND METHODS With Institutional Review Board approval and written informed consent, two-view DBTs were acquired from 134 subjects and the corresponding DMs were collected retrospectively. The study included 125 subjects with 61 malignant (size: 3.9-36.9 mm, median: 13.4 mm) and 81 benign lesions (size: 4.8-43.8 mm, median: 12.0 mm), and 9 normal subjects. The cases in the two modalities were read independently by six experienced Mammography Quality Standards Act radiologists in a fully crossed counterbalanced manner. The readers were blinded to the prevalence of malignant, benign, or normal cases and were asked to assess the lesions based on the BI-RADS lexicon. The ratings were analyzed by the receiver operating characteristic methodology. RESULTS Lesion conspicuity was significantly higher (P << .0001) and fewer lesion margins were considered obscured in DBT. The mean area under the receiver operating characteristic curve for the six readers increased significantly (P = .0001) from 0.783 (range: 0.723-0.886) for DM to 0.911 (range: 0.884-0.936) for DBT. Of the 366 ratings for malignant lesions, 343 on DBT and 278 on DM were rated as BI-RADS 4a and above. Of the 486 ratings for benign lesions, 220 on DBT and 206 on DM were rated as BI-RADS 4a and above. On average, 17.8% (65 of 366) more malignant lesions and 2.9% (14 of 486) more benign lesions would be recommended for biopsy using DBT. The inter-radiologist variability was reduced significantly. CONCLUSION With DBT alone, the BI-RADS assessment of breast lesions and inter-radiologist reliability were significantly improved compared to DM.

Use of Screening Mammography to Detect Occult Malignancy in Autologous Breast Reconstructions: A 15-year Experience

Purpose To examine how often screening mammography depicts clinically occult malignancy in breast reconstruction with autologous myocutaneous flaps (AMFs). Materials and Methods Between January 1, 2000, and July 15, 2015, the authors retrospectively identified 515 women who had undergone mammography of 618 AMFs and who had at least 1 year of clinical follow-up. Of the 618 AMFs, 485 (78.5%) were performed after mastectomy for cancer and 133 (21.5%) were performed after prophylactic mastectomy. Medical records were used to determine the frequency, histopathologic characteristics, presentation, time to recurrence, and detection modality of malignancy. Cancer detection rate (CDR), sensitivity, specificity, positive predictive value, and false-positive biopsy rate were calculated. Results An average of 6.7 screening mammograms (range, 1-16) were obtained over 15.5 years. The frequency of local-regional recurrence (LRR) was 3.9% (20 of 515 women; 95% confidence interval [CI]: 2.2%, 5.6%); all LRRs were invasive, and none were detected in the breast mound after prophylactic mastectomy. Of the 20 women with LRR, 13 (65%) were screened annually before the diagnosis. Seven of those 13 women (54%) had clinically occult LRR, and mammography depicted five. Five of the six clinically evident recurrences (83%) were interval cancers. The median time between reconstruction and first recurrence was 4.4 years (range, 0.8-16.2 years). The CDR per AMF was 1.5 per 1000 screening mammograms (five of 3358; 95% CI: 0.18, 2.8) after mastectomy for cancer and 0 of 1000 examinations (0 of 805 mammograms; 95% CI: 0, 5) after prophylactic mastectomy. Sensitivity, specificity, positive predictive value, and false-positive biopsy rate were 42% (five of 12), 99.4% (4125 of 4151), 16% (five of 31), and 0.6% (26 of 4151), respectively. Conclusion The CDR of screening mammography (1.5 per 1000 screening mammograms) of the AMF after mastectomy for cancer is comparable to that for one native breast of an age-matched woman. Screening mammography adds little value after prophylactic mastectomy.

Breast care problems on call: training residents to manage effectively

PurposeOur aim was to assess and address the challenges radiology residents face when managing breast imaging emergencies on call and to determine if targeted educational interventions improved resident confidence and knowledge.MethodsWe created surveys to determine resident comfort level with and knowledge of appropriate management of breast imaging emergencies. We also created structured educational interventions to improve resident confidence and knowledge. The effectiveness of these interventions was assessed with pre- and post-intervention surveys given to the 43 residents at our institution.ResultsThirty-six of the 43 residents at our institution completed both surveys. The results showed that 33 of 36 residents (91.7%) felt an increase in their comfort level after utilizing one or both of the interventions. There was also significant improvement in resident knowledge; the average resident score on the knowledge questions improved from 40 to 68% (p < 0.0001).ConclusionManaging breast imaging emergencies on call can be challenging and stressful for residents. Educational interventions such as our targeted teaching tools can significantly improve resident confidence and knowledge.Summary statementPresenting dedicated teaching materials directed at a previously identified knowledge deficit and source of stress significantly improved resident knowledge base and confidence in managing breast imaging emergencies on call.

Pleomorphic Lobular Carcinoma In Situ: Imaging Features, Upgrade Rate, and Clinical Outcomes

OBJECTIVE Pleomorphic lobular carcinoma in situ (PLCIS) is an aggressive subtype of lobular carcinoma in situ treated similarly to ductal carcinoma in situ. The purpose of this study was to determine the imaging findings, upgrade rate of PLCIS at core needle biopsy (CNB), and the treatment and outcomes of these patients. MATERIALS AND METHODS This retrospective single-institution study included women with PLCIS at CNB or excisional biopsy without concomitant DCIS or invasive carcinoma between January 1, 1999, and July 20, 2016. Imaging findings, detection mode, treatment, and outcomes were reviewed. Retrospective review of the images was performed. Upgrade rate to ductal carcinoma in situ or invasive carcinoma at lumpectomy was calculated. RESULTS Twenty-one patients had a finding of PLCIS at CNB (n = 16) or excisional biopsy (n = 5). Four of 15 (27%; 95% CI, 4-49%) cases of PLCIS at CNB were upgraded to DCIS (two cases) or invasive lobular cancer (two cases) at lumpectomy (one patient declined excision). No unique mammographic features were predictive of need to upgrade or extent of disease. Among the patients with pure PLCIS (not upgraded), 13 of 16 (81%) presented with fine pleomorphic calcifications on screening mammograms, 1 of 16 (6%) with distortion and calcifications, 1 of 16 (6%) with a mass, and 1 of 16 (6%) with nonmass enhancement at MRI. The median imaging size was 11 mm (mean, 14 mm; range, 3-47 mm). Twelve of 16 (75%) patients were treated with lumpectomy and 4 of 16 (25%) with mastectomy. Eight of 16 (50%) patients received adjuvant hormonal therapy, and 2 of 16 (17%) received radiation. There were no local recurrences. CONCLUSION PLCIS most commonly presented as fine pleomorphic calcifications on mammograms and had a high upgrade rate after CNB. CNB diagnosis of PLCIS requires surgical excision.

Primary atypical lipomatous tumor/well-differentiated liposarcoma (ALT/WDL) of the breast

A middle-aged woman presented with a large mobile mass in her breast. She had no history of hormonal medication use and no family history of breast, ovarian, or prostate cancer. The patient complained of soreness and increase in size of the affected breast. Physical examination revealed that her breasts were asymmetric with the affected breast being 2-3 times larger than the other side. Imaging studies showed a heterogeneous mixed density mass arising in the breast with extension into the pectoralis major muscle (Figure 1). An ultrasound-guided core needle biopsy of the mass revealed large atypical hyperchromatic stromal cells admixed with a mature adipocytic component, histologically resembling atypical lipomatous tumor/well-differentiated liposarcoma (ALT/WDL) of soft tissue. The tumor was positive for MDM2 gene amplification by fluorescence in situ hybridization (FISH), supporting the diagnosis of a primary ALT/WDL of the breast. The patient subsequently underwent simple mastectomy which showed an approximately 28 cm, predominantly encapsulated mass consisting of lobulated adipose tissue admixed with bands of fibrous F IGURE 2 Intraoperative image of the breast mass Photo courtesy of Dr. Alfred Chang. [Color figure can be viewed at wileyonlinelibrary.com]

Breast Imaging Outcomes following Abnormal Thermography

RATIONALE AND OBJECTIVES The study aimed to determine the outcome of patients presenting for evaluation of abnormal breast thermography. MATERIALS AND METHODS Following Institutional Review Board approval, retrospective search identified 38 patients who presented for conventional breast imaging following a thermography-detected abnormality. Study criteria included women who had mammogram and/or breast ultrasound performed for evaluation of a thermography-detected abnormality between January 1, 2000, and December 31, 2015. Patients whose mammograms and ultrasounds were initiated at an outside institution or who did not have imaging at our institution were excluded. Records were reviewed for clinical history, thermography results, mammogram and/or ultrasound findings, and pathology. Mammograms and ultrasounds were prospectively interpreted by one of 14 Mammography Quality Standards Act-certified breast imaging radiologists with 3-30 years of experience. Patient outcomes were determined by biopsy or at least 1 year of follow-up. Patient ages ranged from 23 to 70 years (mean = 50 years). RESULTS Ninety-five percent (36 of 38) of patients did not have breast cancer. The two patients diagnosed with breast cancer had suspicious clinical symptoms including palpable mass and erythema. No asymptomatic woman had breast cancer. Negative predictive value was 100%. Of 38 patients, 79% (30 of 38) had Breast Imaging Reporting and Data System (BI-RADS) 1 or 2 assessments; 5% (2 of 38) had BI-RADS 3; and 16% (6 of 38) had BI-RADS 4 (n = 5) or BI-RADS 5 (n = 1) assessments. Two of six patients with biopsy recommendations were diagnosed with breast cancer (Positive predictive value 2 = 33.3%). All findings recommended for biopsy were ipsilateral to the reported thermography abnormality. CONCLUSIONS No cancer was diagnosed among asymptomatic women. The 5% of patients diagnosed with cancer had co-existing suspicious clinical findings. Mammogram and/or ultrasound were useful in accurately characterizing patients with abnormal thermography.