Digital Breast Tomosynthesis Plus Ultrasound Versus Digital Mammography Plus Ultrasound for Screening Breast Cancer in Women With Dense Breasts

Objective@#To compare the outcomes of digital breast tomosynthesis (DBT) screening combined with ultrasound (US) with those of digital mammography (DM) combined with US in women with dense breasts. @*Materials and Methods@#A retrospective database search identified consecutive asymptomatic women with dense breasts who underwent breast cancer screening with DBT or DM and whole-breast US simultaneously between June 2016 and July 2019. Women who underwent DBT + US (DBT cohort) and DM + US (DM cohort) were matched using 1:2 ratio according to mammographic density, age, menopausal status, hormone replacement therapy, and a family history of breast cancer. The cancer detection rate (CDR) per 1000 screening examinations, abnormal interpretation rate (AIR), sensitivity, and specificity were compared. @*Results@#A total of 863 women in the DBT cohort were matched with 1726 women in the DM cohort (median age, 53 years; interquartile range, 40–78 years) and 26 breast cancers (9 in the DBT cohort and 17 in the DM cohort) were identified. The DBT and DM cohorts showed comparable CDR (10.4 [9 of 863; 95% confidence interval {CI}: 4.8–19.7] vs. 9.8 [17 of 1726;95% CI: 5.7–15.7] per 1000 examinations, respectively; P = 0.889). DBT cohort showed a higher AIR than the DM cohort (31.6% [273 of 863; 95% CI: 28.5%–34.9%] vs. 22.4% [387 of 1726; 95% CI: 20.5%–24.5%]; P < 0.001). The sensitivity for both cohorts was 100%. In women with negative findings on DBT or DM, supplemental US yielded similar CDRs in both DBT and DM cohorts (4.0 vs. 3.3 per 1000 examinations, respectively; P = 0.803) and higher AIR in the DBT cohort (24.8% [188 of 758; 95% CI: 21.8%–28.0%] vs. 16.9% [257 of 1516; 95% CI: 15.1%–18.9%; P < 0.001). @*Conclusion@#DBT screening combined with US showed comparable CDR but lower specificity than DM screening combined with US in women with dense breasts.

Comparison of Abbreviated MRI and Full Diagnostic MRI in Distinguishing between Benign and Malignant Lesions Detected by Breast MRI: A Multireader Study

Objective@#To compare the performance of simulated abbreviated breast MRI (AB-MRI) and full diagnostic (FD)-MRI in distinguishing between benign and malignant lesions detected by MRI and investigate the features of discrepant lesions of the two protocols. @*Materials and Methods@#An AB-MRI set with single first postcontrast images was retrospectively obtained from an FD-MRI cohort of 111 lesions (34 malignant, 77 benign) detected by contralateral breast MRI in 111 women (mean age, 49.8. ± 9.8;range, 28–75 years) with recently diagnosed breast cancer. Five blinded readers independently classified the likelihood of malignancy using Breast Imaging Reporting and Data System assessments. McNemar tests and area under the receiver operating characteristic curve (AUC) analyses were performed. The imaging and pathologic features of the discrepant lesions of the two protocols were analyzed. @*Results@#The sensitivity of AB-MRI for lesion characterization tended to be lower than that of FD-MRI for all readers (58.8– 82.4% vs. 79.4–100%), although the findings of only two readers were significantly different (p 0.05). Fifteen percent (5/34) of the cancers were false-negatives on AB-MRI. More suspicious margins or internal enhancement on the delayed phase images were related to the discrepancies. @*Conclusion@#The overall performance of AB-MRI was similar to that of FD-MRI in distinguishing between benign and malignant lesions. AB-MRI showed lower sensitivity and higher specificity than FD-MRI, as 15% of the cancers were misclassified compared to FD-MRI.

Utility and Diagnostic Performance of Automated Breast Ultrasound System in Evaluating Pure Non-Mass Enhancement on Breast Magnetic Resonance Imaging

Objective@#To compare the utility and diagnostic performance of automated breast ultrasound system (ABUS) with that of handheld ultrasound (HHUS) in evaluating pure non-mass enhancement (NME) lesions on breast magnetic resonance imaging (MRI). @*Materials and Methods@#One hundred twenty-six consecutive MRI-visible pure NME lesions of 122 patients with breast cancer were assessed from April 2016 to March 2017. Two radiologists reviewed the preoperative breast MRI, ABUS, and HHUS images along with mammography (MG) findings. The NME correlation rate and diagnostic performance of ABUS were compared with that of HHUS, and the imaging features associated with ABUS visibility were analyzed. @*Results@#Among 126 pure NME lesions, 100 (79.4%) were malignant and 26 (20.6%) were benign. The overall correlation rate was 87.3% (110/126) in ABUS and 92.9% (117/126) in HHUS. The sensitivity and specificity were 87% and 50% for ABUS and 92% and 42.3% for HHUS, respectively, with no significant differences (p = 0.180 and 0.727, respectively). Malignant NME was more frequently visualized than benign NME lesions on ABUS (93% vs. 65.4%, p = 0.001). Significant factors associated with the visibility of ABUS were the size of NME lesions on MRI (p < 0.001), their distribution pattern (p < 0.001), and microcalcifications on MG (p = 0.027). @*Conclusion@#ABUS evaluation of pure NME lesions on MRI in patients with breast cancer is a useful technique with high visibility, especially in malignant lesions. The diagnostic performance of ABUS was comparable with that of conventional HHUS in evaluating NME lesions.

Prevalence of Women with Dense Breasts in Korea: Results from a Nationwide Cross-sectional Study / Journal of the Korean Cancer Association, 대한암학회지

PURPOSE: Women with dense breast are known to be at high risk for breast cancer, but their prevalence and number of Korean women are unknown. The current study was to investigate the distribution of mammographic breast density by age of women undergoing screening mammography, and to estimate the prevalence of Korean women with dense breasts, quantitatively. MATERIALS AND METHODS: For obtaining a nationwide representative sample, 6,481 mammograms were collected from 86 screening units participated in the National Cancer Screening Program for breast cancer. Based on the American College of Radiology Breast Imaging Reporting and Data System classification, breast density was evaluated by six breast radiologists, qualitatively. We applied these breast density distributions to age-specific counts of the Korean women population derived to mid-year 2017 to estimate the number of Korean women with dense breasts. RESULTS: Overall, 54.4% (95% confidence interval [CI], 52.9% to 55.8%) of women 40 to 69 years of age had heterogeneously or extremely dense breasts, and this proportion was inversely associated with age. Based on the age distribution of Korean women, we estimated that 6,083,000 women (95% CI, 5,919,600 to 6,245,600) age 40-69 years in Korean have dense breasts. Women aged 40-49 years (n=3,450,000) accounted for 56.7% of this group. CONCLUSION: More than half of Korean women aged 40 and over have dense breasts. To prevent breast cancer effectively and efficiently, it is necessary to develop a new personalized prevention strategy considering her status of breast density.

Various Modifications of Muller's Muscle-Conjunctival Resection for Ptosis Repair

BACKGROUND: The posterior approach for ptosis, including the Fasanella-Servat procedure and Muller's muscle-conjunctival resection (MMCR), has been proven effective for mild- to moderately affected patients whose levator muscle function remains relatively intact. Traditionally, MMCR was reserved for phenylephrine test-positive patients for whom various modifications and several nomograms have been developed. METHODS: We reviewed the literature for the Fasanella-Servat procedure and MMCR. The methods and results of the different modifications were analyzed and compared. Nomograms of these two procedures were summarized. RESULTS: MMCR mainly involved resection of Muller's muscle and conjunctiva in the original design by Putterman and co-workers. The suggested resection ranged from 8 to 9 mm for the achievement of the maximal effect produced by topical epinephrine. Perry included tarsectomy in his procedure and developed a new nomogram that included a 1:1 ratio of the ptosis correction to the amount of tarsus resection. The effect of tarsectomy for the Fasanella-Servat procedure in terms of eyelid elevation was approximately one-half the value seen in phenylephrine test-negative patients. We've performed MMCR with tarsectomy regardless of the response to phenylephrine with similar results to Perry. Surgical indications and possible complications of MMCR with tarsectomy for Asian patients are discussed. CONCLUSIONS: MMCR is an effective and simple method for the correction of ptosis. With baseline MMCR, the additional tarsectomy has proven to be a powerful tool for ptosis correction irrespective of phenylephrine test results.

Characterization of Breast Lesions: Comparison of Digital Breast Tomosynthesis and Ultrasonography

OBJECTIVE: To compare the diagnostic performance of digital breast tomosynthesis (DBT) and conventional breast ultrasound (US) to characterize breast lesions as benign or malignant. MATERIALS AND METHODS: A total of 332 women, presenting for screening examinations or for breast biopsy between March and June 2012 were recruited to undergo digital mammography (DM), DBT, and breast US examination. Among them, 113 patients with 119 breast lesions depicted on DM were finally included. Three blinded radiologists performed an enriched reader study and reviewed the DBT and US images. Each reader analyzed the lesions in random order, assigned Breast Imaging Reporting and Data System (BI-RADS) descriptors, rated the images for the likelihood of malignancy (%) and made a BI-RADS final assessment. Diagnostic accuracy, as assessed by the area under the receiver operating characteristic curve, sensitivity, and specificity of DBT and US were compared. RESULTS: Among the 119 breast lesions depicted on DM, 75 were malignant and the remaining 44 were benign. The average diagnostic performance for characterizing breast lesions as benign or malignant in terms of area under the curve was 0.899 for DBT and 0.914 for US (p = 0.394). Mean sensitivity (97.3% vs. 98.7%, p = 0.508) and specificity (44.7% vs. 39.4%, p = 0.360) were also not significantly different. CONCLUSION: Digital breast tomosynthesis may provide similar reader lesion characterization performance to that of US for breast lesions depicted on DM.

Practice guideline for the performance of breast ultrasound elastography

Ultrasound (US) elastography is a valuable imaging technique for tissue characterization. Two main types of elastography, strain and shear-wave, are commonly used to image breast tissue. The use of elastography is expected to increase, particularly with the increased use of US for breast screening. Recently, the US elastographic features of breast masses have been incorporated into the 2nd edition of the Breast Imaging Reporting and Data System (BI-RADS) US lexicon as associated findings. This review suggests practical guidelines for breast US elastography in consensus with the Korean Breast Elastography Study Group, which was formed in August 2013 to perform a multicenter prospective study on the use of elastography for US breast screening. This article is focused on the role of elastography in combination with B-mode US for the evaluation of breast masses. Practical tips for adequate data acquisition and the interpretation of elastography results are also presented.

A New Full-Field Digital Mammography System with and without the Use of an Advanced Post-Processing Algorithm: Comparison of Image Quality and Diagnostic Performance

OBJECTIVE: To compare new full-field digital mammography (FFDM) with and without use of an advanced post-processing algorithm to improve image quality, lesion detection, diagnostic performance, and priority rank. MATERIALS AND METHODS: During a 22-month period, we prospectively enrolled 100 cases of specimen FFDM mammography (Brestige(R)), which was performed alone or in combination with a post-processing algorithm developed by the manufacturer: group A (SMA), specimen mammography without application of "Mammogram enhancement ver. 2.0"; group B (SMB), specimen mammography with application of "Mammogram enhancement ver. 2.0". Two sets of specimen mammographies were randomly reviewed by five experienced radiologists. Image quality, lesion detection, diagnostic performance, and priority rank with regard to image preference were evaluated. RESULTS: Three aspects of image quality (overall quality, contrast, and noise) of the SMB were significantly superior to those of SMA (p < 0.05). SMB was significantly superior to SMA for visualizing calcifications (p < 0.05). Diagnostic performance, as evaluated by cancer score, was similar between SMA and SMB. SMB was preferred to SMA by four of the five reviewers. CONCLUSION: The post-processing algorithm may improve image quality with better image preference in FFDM than without use of the software.

Sonoelastography in Distinguishing Benign from Malignant Complex Breast Mass and Making the Decision to Biopsy

OBJECTIVE: To evaluate the additional effect of sonoelastography on the radiologist's ability for distinguishing benign from malignant complex breast masses and to decide whether to perform biopsy by B-mode US. MATERIALS AND METHODS: One hundred eighteen complex breast masses (15 malignant lesions, 103 benign lesions) were included. Five blinded readers independently assessed the likelihood of the malignancy score from 1 to 5 for two data sets (B-mode ultrasound alone and B-mode ultrasound with sonoelastography). Elasticity scores were categorized as 0, 1, or 2 based on the degree and distribution of strain of the echogenic component within complex masses. The readers were asked to downgrade the likelihood of the malignancy score when an elasticity score of 0 was assigned and to upgrade the likelihood of the malignancy score when an elasticity score of 2 was assigned. The likelihood of the malignancy score was maintained as it was for the lesions with an elasticity score of 1. The Az values, sensitivities, and specificities were compared. RESULTS: The Az value of B-mode ultrasound with sonoelastography (mean, 0.863) was greater than that of B-mode ultrasound alone (mean, 0.731; p = 0.001-0.007) for all authors. The specificity of B-mode ultrasound with sonoelastography (mean, 37.1%) was greater than that of B-mode ultrasound alone (mean, 3.8%; p < 0.001) for all readers. The addition of sonoelastography led to changes in decisions. A mean of 33.6% of benign masses were recommended for follow-up instead of biopsy. CONCLUSION: For complex breast masses, sonoelastography allows increase in both the accuracy in distinguishing benign from malignant lesions and the specificity in deciding whether to perform biopsy.

Characterization of Cystic Breast Masses on Ultrasound: Comparative Study among Conventional, Tissue Harmonic, Compound, and a Combination of Tissue Harmonic and Compound Imaging

PURPOSE: This prospective study was to compare the image quality and diagnostic performance of breast cystic masses by conventional and advanced ultrasound (US) techniques including tissue harmonic, compound, and the combination of these techniques. MATERIALS AND METHODS: All 91 patients, collectively having 109 breast cystic masses were scanned using four US techniques (complicated cysts in 36, septated cysts in 33, and complex cysts in 40). Two breast radiologists independently assessed the image quality and possibility of malignancy. Image quality was evaluated in terms of contrast and clarity of the wall and internal echo pattern and then graded on a scale of 1 (poor) to grade 3 (satisfactory). The possibility of malignancy was graded on a scale of 1 (suggestive of benignancy) to 5 (suggestive of malignancy) using US images. The histopathological results and follow-up images were used as the reference standard for the assessment of diagnostic performance. Results were evaluated by Friedman's test and receiver operating characteristic (ROC) analyses. RESULTS: In terms of image quality, a grade of 3 was significantly more frequent in the three advanced US techniques than conventional US (p < 0.05). For assessment of diagnostic performance, areas under the ROC curves in three advanced techniques were significantly higher than in conventional US (p < 0.05). CONCLUSION: Advanced US techniques including compound and tissue harmonic US techniques provide a better image quality in breast cystic masses and also improve the diagnostic performance compared with conventional US.

Radiation-Induced Complications after Breast Cancer Radiation Therapy: a Pictorial Review of Multimodality Imaging Findings

The purpose of this pictorial essay is to illustrate the multimodality imaging findings of a wide spectrum of radiation-induced complications of breast cancer in the sequence of occurrence. We have classified radiation-induced complications into three groups based on the time sequence of occurrence. Knowledge of these findings will allow for the early detection of complications as well as the ability to differentiate tumor recurrence.

Autologous Fat Injection for Augmented Mammoplasty: Mammography and Breast Ultrasound Findings

Autologous fat injection is one of the methods utilized for augmented mammoplasty methods. In this surgical procedure, the fat for transfer is obtained from the donor site of the patient's own body by liposuction and the fat is then injected into the breast. We report here cases of three patients who underwent autologous fat injection. Two of the patients had palpable masses that were present after surgery. The serial imaging findings and surgical method of autologous fat transfer are demonstrated.

Sonographically Detected Architectural Distortion: linical Significance

PURPOSE: Architectural distortion is a suspicious abnormality for the diagnosis of breast cancer. The aim of this study was to investigate the clinical significance of sonographically detected architectural distortion. MATERIALS AND METHODS: From January 2006 to June 2008, 20 patients were identified who had sonographically detected architectural distortions without a history of trauma or surgery and abnormal mammographic findings related to an architectural distortion. All of the lesions were pathologically verified. We evaluated the clinical and pathological findings and then assessed the clinical significance of the sonographically detected architectural distortions. RESULTS: Based on the clinical findings, one (5%) of the 20 patients had a palpable lump and the remaining 19 patients had no symptoms. No patient had a family history of breast cancer. Based on the pathological findings, three (15%) patients had malignancies. The malignant lesions included invasive ductal carcinomas (n = 2) and ductal carcinoma in situ (n = 1). Four (20%) patients had high-risk lesions; atypical ductal hyperplasia (n = 3) and lobular carcinoma in situ (n = 1). The remaining 13 (65%) patients had benign lesions, however, seven (35%) out of 13 patients had mild-risk lesions (three intraductal papillomas, three moderate or florid epithelial hyperplasia and one sclerosing adenosis). CONCLUSION: Of the sonographically detected architectural distortions, 35% were breast cancers or high-risk lesions and 35% were mild-risk lesions. Thus, a biopsy might be needed for an architectural distortion without an associated mass as depicted on breast ultrasound, even though the mammographic findings are normal.

Immersion Ultrasonography of Excised Nonpalpable Breast Lesion Specimens after Ultrasound-Guided Needle Localization

OBJECTIVE: Ultrasound-guided needle localization has been used prior to the surgical excision of nonpalpable breast lesions. The aim of the study was to assess the feasibility of the use of a saline immersion specimen ultrasound technique (immersion-US) to confirm the successful removal of breast lesions. MATERIALS AND METHODS: The devised immersion-US technique was used to examine the excised tissues of 72 ultrasound-guided needle localized breast lesions of 58 patients (34 benign lesions, 30 high-risk lesions and 8 malignant lesions). Freshly excised specimens were placed in a container filled with saline and one radiologist scanned the surgically excised specimens using a high-frequency linear transducer. We evaluated successful lesion removal and the qualities of the immersion-US images. Miss rates were determined by the use of postoperative ultrasound during follow-up. RESULTS: All 72 lesions were identified by the use of immersion-US and satisfactory or excellent quality images were obtained for most lesions (70/72, 97%). Five (7%) lesions were initially identified as incompletely excised, based on the immersion-US findings, and prompt re-excision was undertaken. Follow-up ultrasound examinations showed no residual mass in the surgical field in any patient. CONCLUSION: The immersion-US technique was found straightforward and efficient to perform. Immersion-US was able to determine whether nonpalpable breast lesions had been successfully excised after ultrasound-guided needle localization.