Renee W. Pinsky

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.

Recurrent Cancer After Breast-Conserving Surgery with Radiation Therapy for Ductal Carcinoma in Situ: Mammographic Features, Method of Detection, and Stage of Recurrence

OBJECTIVE The purpose of our study was to determine the mammographic appearance, detection method, and stage of ipsilateral breast tumor recurrence in women treated with breast-conserving surgery and whole-breast radiation therapy for ductal carcinoma in situ (DCIS). MATERIALS AND METHODS Following institutional review board approval, records of women treated with breast-conserving surgery and radiation therapy for DCIS who developed an ipsilateral breast tumor recurrence from 1981 to 2003 were reviewed retrospectively. Multiinstitutional database records showed 513 women were treated, of whom 42 (8.2%) developed local recurrence. Study criteria were fulfilled and complete records were available for 32 women. Mean age at initial diagnosis was 49 years (range, 26-73 years). RESULTS Of the 32 patients included in our study, 31 (97%) recurrences were mammographically apparent. Twenty-nine (91%) of 32 were diagnosed exclusively by mammography. Mammographic findings at recurrence were calcifications in 24 (75%) of 32, mass in six (19%) of 32, and distortion in one (3%) of 32. The mean time to recurrence was 4.5 years. Twelve (40%) of 30 had the recurrence in a remote quadrant from the original cancer. Recurrences were DCIS in 17 (53%) of 32, DCIS with microinvasion in six (19%) of 32, invasive ductal cancer in three (9%) of 32, invasive lobular cancer in two (6%) of 32, and mixed DCIS and invasive cancer in four (13%) of 32. Six (67%) of nine patients with invasive cancer (excluding microinvasion) had tumors smaller than 1 cm. Ninety-one percent of recurrences were minimal cancers. All recurrences were stage 0 or 1. CONCLUSION Mammography successfully detected ipsilateral breast tumor recurrence, predominantly as calcifications or masses, after breast-conserving surgery with radiation therapy for DCIS in 97% of cases. The recurrences were located at variable distances from the lumpectomy site. Ninety-one percent of recurrences were minimal cancers and all were early stage, connoting excellent prognosis.

Cross-Sectional Imaging of Primary Thoracic Sarcomas with Histopathologic Correlation: A Review for the Radiologist

Numerous forms of primary sarcoma can arise from the heart, pericardium, great vessels, lungs, chest wall, and breasts. Magnetic resonance imaging and computed tomography currently play important roles in determining the extent of primary thoracic sarcoma involvement, potential for resectability, and response to therapy. The purpose of this article is to review the various forms of primary sarcoma that may affect the thorax as well as illustrate pertinent cross-sectional radiologic findings with histopathologic correlation.

Local compression in automated breast ultrasound in the mammographic geometry

Background, Motivation and Objective: Automated ultrasound scanning (AUS) of the breast has developed more slowly than anticipated. The main limitation, beyond achieving adequate acoustic coupling to the breast, has been excessive shadow artifacts, as reflecting structures at acute angles to the ultrasound beam are not flattened by the transducer as well as in manual scanning. We believe that imaging of the breast in near mammographic compression provides much of the needed flattening. The question under initial study in this effort is, whether in breast AUS under very light mammographic compression, local compression by the transducer might flatten the acutely oriented structures further and reduce the acoustic path length to key structures in the breast. We suspect these improvements will be possible without distorting the breast so dramatically that the lesion registration advantages of scanning the breast in the same system as mammography or digital breast tomosynthesis (DBT) are not realized. Preliminary tests are reported here, as well as design of a system for a more refined human study. Statement of Contribution/Methods: Initial imaging tests were performed in our combined AUS/DBT system. A fiber mesh, loosened slightly in its frame, replaced the standard plastic mammography compression paddle. The transducer, in contact with the mesh and the breast, was translated by motors. The compression force of the linear array transducer on its vertical was manually controlled. Breast phantoms and the breasts of three women were scanned with usual compression by the mesh paddle and then with less global, but added local, compression. Results: Examples of flattened structures were observed more brightly in the locally compressed breasts, and acoustic paths longer than 35 mm were reduced, by ∼10 mm. In many areas image penetration was 3 cm greater. In one case, image volumes w/wo local compression were spatially aligned by nonlinear image registration software. Discussion and Conclusions: Visual indicators of image features expected to provide improved ultrasonic imaging were observed with local compression and lateral movement of tissues appeared acceptable. These results motivated design and construction of an apparatus to make local compression practical and safe. It utilizes joystick control of the vertical compression force during scanning, realized by pneumatic actuators attached to the transducer. The air pressure applied to these actuators is also applied to actuators in the joystick for force feedback to the operator. Two miniature vibrators attached to the joystick provide vibrotactile feedback of the reaction torques computed from the measurements of 6 force sensors on the transducer holder. The fail-safe system design insures no pneumatic compression force application to the breast in case of power loss or emergency shutdown.

Machine learning for noise removal on breast ultrasound images

This study assessed the utility of machine learning for isolating noise and artifacts in breast ultrasound images. Such corrupt image regions (ROIs) can be automatically excluded when registering images acquired from different angles. Artifacts included posterior acoustic shadowing and enhancement arising from cancers and cysts respectively. Images were obtained on a breast-mimicking phantom containing multiple cysts and lesions with variable speed of sound and attenuation properties. In vivo breast images of cysts and cancers were also available. Results show that the classifiers were able to identify the regions of corrupt data accurately.

Role of Screening Mammography in Early Detection/Outcome of Breast Cancer

Mammography is the gold standard for breast cancer screening. This chapter addresses the historic scientific randomized controlled trials demonstrating the benefit of screening mammography in the early detection of invasive breast cancer and ductal carcinoma in situ (DCIS) and the numerous recent observational and computer modeling studies that have confirmed this positive effect. Since screening began in the 1980s, mammography has been shown to decrease mortality from breast cancer by anywhere from 15 to 58 %. Late-stage disease and node positivity have similarly decreased. Controversy as to the extent of benefit and the harms of mammography exists and the controversy regarding mammographic screening is presented. Major US medical societies agree that screening mammography is beneficial and they have issued guidelines for screening. The greatest discussions exist regarding when to start and how frequently it should be performed. Scientific analysis of different schedules of age to start and screening interval is presented. Overdiagnosis of breast cancer is discussed.

Morphologic Mimics of Invasive Lobular Carcinoma

Invasive lobular carcinoma of the breast is a relatively common diagnosis. However, other carcinomatous as well as noncarcinomatous neoplasms, either primary or metastatic to the breast, may mimic invasive lobular carcinoma. As treatment may differ, establishing the correct diagnosis is paramount to providing the appropriate care for these patients. This review outlines important mimics of invasive lobular carcinoma and the key clinicopathologic and immunohistochemical features as well as additional studies helpful in establishing their diagnoses.

Combined photoacoustic and ultrasound imaging of human breast in vivo in the mammographic geometry

This photoacoustic volume imaging (PAVI) system is designed to study breast cancer detection and diagnosis in the mammographic geometry in combination with automated 3D ultrasound (AUS). The good penetration of near-infrared (NIR) light and high receiving sensitivity of a broad bandwidth, 572 element, 2D PVDF array at a low center-frequency of 1MHz were utilized with 20 channel simultaneous acquisition. The feasibility of this system in imaging optically absorbing objects in deep breast tissues was assessed first through experiments on ex vivo whole breasts. The blood filled pseudo lesions were imaged at depths up to 49 mm in the specimens. In vivo imaging of human breasts has been conducted. 3D PAVI image stacks of human breasts were coregistered and compared with 3D ultrasound image stacks of the same breasts. Using the designed system, PAVI shows satisfactory imaging depth and sensitivity for coverage of the entire breast when imaged from both sides with mild compression in the mammographic geometry. With its unique soft tissue contrast and excellent sensitivity to the tissue hemodynamic properties of fractional blood volume and blood oxygenation, PAVI, as a complement to 3D ultrasound and digital tomosynthesis mammography, might well contribute to detection, diagnosis and prognosis for breast cancer.

Costs of Achieving High Patient Compliance After Recall from Screening Mammography

OBJECTIVE The purpose of our study was to document the hidden costs in achieving high recall patient compliance from an off-site screening mammography program. MATERIALS AND METHODS This study was approved by our institutional review board. At our institution, no patient was placed in final BI-RADS assessment category 3, 4, or 5 without a diagnostic study. Each incomplete study, in addition to the formal report, was flagged on the day sheet, letters were sent to the referring physician and patient, and an incomplete computer code was added. Working from the day sheets, a clerk contacted the patient by telephone within 2 working days to schedule the diagnostic study. Diagnostic slots were purposely left open to accommodate these cases. An ongoing computer tickler file of incomplete codes provided a further check. A time study of clerical performance with recalled patients was measured prospectively for 100 consecutive cases. RESULTS For the years 2002-2004, 4,025 (13%) of 30,286 screening patients were recalled for diagnostic mammography. After an average of 2.2 telephone calls per patient, (3.64 minutes of clerical time), 3,977 of 4,005 patients returned for a diagnostic study. Forty-eight of 4,025 initially noncompliant patients received an average of six telephone calls (4.7 minutes) and a registered letter. One of the 28 initially noncompliant patients went on to biopsy that revealed a breast cancer. Patient compliance was 4,005 (99.5%) of 4,025. The additional cost for this program was

Image processing and registration of opposed view 3d breast ultrasound

4,724 divided by 30,286 screening patients, or 16 cents per screening patient. CONCLUSION The radiology department assumed responsibility for contacting patients who needed recall for additional diagnostic imaging. Using strict documentation of the incomplete breast imaging evaluations, computer checks, clerical support, and prompt scheduling, we achieved 99.5% compliance. The additional cost was small, 16 cents per screening patient.