Reni Butler

Breast Imaging of the Pregnant and Lactating Patient: Imaging Modalities and Pregnancy-Associated Breast Cancer

OBJECTIVE The purpose of this article is to review key clinical, histologic, and imaging features of pregnancy-associated breast cancer. A discussion of imaging modalities, including mammography, ultrasound, and MRI, and imaging-based interventions available for evaluating this population is provided. CONCLUSION Successful detection of pregnancy-associated breast cancer requires knowledge of key clinical and imaging features of pregnancy-associated breast carcinoma and selection of the appropriate imaging workup and intervention.

Breast Imaging of the Pregnant and Lactating Patient: Physiologic Changes and Common Benign Entities

OBJECTIVE The purpose of this article is to review key clinical, histologic, and imaging features of expected physiologic changes within the breast and common benign breast disease in the pregnant and lactating patient. CONCLUSION A thorough understanding of expected physiologic changes and common benign breast abnormalities of pregnancy and lactation is required to differentiate these entities from pregnancy-associated breast cancer and to appropriately guide patient management.

Tomosynthesis in the Diagnostic Setting: Changing Rates of BI-RADS Final Assessment over Time

Purpose To evaluate the effect of tomosynthesis in diagnostic mammography on the Breast Imaging Reporting and Data System (BI-RADS) final assessment categories over time. Materials and Methods This retrospective study was approved by the institutional review board. The authors reviewed all diagnostic mammograms obtained during a 12-month interval before (two-dimensional [2D] mammography [June 2, 2010, to June 1, 2011]) and for 3 consecutive years after (tomosynthesis year 1 [2012], tomosynthesis year 2 [2013], and tomosynthesis year 3 [2014]) the implementation of tomosynthesis. The requirement to obtain informed consent was waived. The rates of BI-RADS final assessment categories 1-5 were compared between the 2D and tomosynthesis groups. The positive predictive values after biopsy (PPV3) for BI-RADS category 4 and 5 cases were compared. The mammographic features (masses, architectural distortions, calcifications, focal asymmetries) of lesions categorized as probably benign (BI-RADS category 3) and those for which biopsy was recommended (BI-RADS category 4 or 5) were reviewed. The χ(2) test was used to compare the rates of BI-RADS final assessment categories 1-5 between the two groups, and multivariate logistic regression analysis was performed to compare all diagnostic studies categorized as BI-RADS 3-5. Results There was an increase in the percentage of cases reported as negative or benign (BI-RADS category 1 or 2) with tomosynthesis (58.7% with 2D mammography vs 75.8% with tomosynthesis at year 3, P < .0001). A reduction in the percentage of probably benign (BI-RADS category 3) final assessments also occurred (33.3% with 2D mammography vs 16.4% with tomosynthesis at year 3, P < .0001). Although the rates of BI-RADS 4 or 5 assessments did not change significantly with tomosynthesis (8.0% with 2D mammography vs 7.8% with tomosynthesis at year 3, P = .2), there was a significant increase in the PPV3 (29.6% vs 50%, respectively; P < .0001). These trends increased during the 3 years of tomosynthesis use. Conclusion Tomosynthesis in the diagnostic setting resulted in progressive shifts in the BI-RADS final assessment categories over time, with a significant increase in the proportion of studies classified as normal, a continued decrease in the rate of studies categorized as probably benign, and improved diagnostic confidence in biopsy recommendations. (©) RSNA, 2016.

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.

3.0 Tesla vs 1.5 Tesla breast magnetic resonance imaging in newly diagnosed breast cancer patients.

AIM To compare 3.0 Tesla (T) vs 1.5T magnetic resonance (MR) imaging systems in newly diagnosed breast cancer patients. METHODS Upon Institutional Review Board approval, a Health Insurance Portability and Accountability Act-compliant retrospective review of 147 consecutive 3.0T MR examinations and 98 consecutive 1.5T MR examinations in patients with newly diagnosed breast cancer between 7/2009 and 5/2010 was performed. Eleven patients who underwent neoadjuvant chemotherapy in the 3.0T group were excluded. Mammographically occult suspicious lesions (BIRADS Code 4 and 5) additional to the index cancer in the ipsilateral and contralateral breast were identified. Lesion characteristics and pathologic diagnoses were recorded, and results achieved with both systems compared. Statistical significance was analyzed using Fishers exact test. RESULTS In the 3.0T group, 206 suspicious lesions were identified in 55% (75/136) of patients and 96% (198/206) of these lesions were biopsied. In the 1.5T group, 98 suspicious lesions were identified in 53% (52/98) of patients and 90% (88/98) of these lesions were biopsied. Biopsy results yielded additional malignancies in 24% of patients in the 3.0T group vs 14% of patients in the 1.5T group (33/136 vs 14/98, P = 0.07). Average size and histology of the additional cancers was comparable. Of patients who had a suspicious MR imaging study, additional cancers were found in 44% of patients in the 3.0T group vs 27% in the 1.5T group (33/75 vs 14/52, P = 0.06), yielding a higher positive predictive value (PPV) for biopsies performed with the 3.0T system. CONCLUSION 3.0T MR imaging detected more additional malignancies in patients with newly diagnosed breast cancer and yielded a higher PPV for biopsies performed with the 3.0T system.

Where does radioimmunotherapy fit in the management of breast cancer

Breast cancer is one of the most commonly diagnosed malignancies and is the main cause of death in women aged 40-49 years. Metastatic breast cancer is a heterogeneous disease that has a variety of different clinical presentations, ranging from solitary metastatic lesion to diffuse and multiple organ involvement. The biological heterogeneity of metastatic breast cancer has led to its unpredictable clinical behavior. One of the major challenges, therefore, is to identify predictive and prognostic models facilitating the selection of patients who can benefit from more aggressive and potentially curative options. This article provides an overview of the current management of metastatic breast cancer with focused emphasis on radioimmunotherapy.

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.

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.