Automated breast ultrasound: Supplemental screening for average-risk women with dense breasts.

OBJECTIVE: We review ultrasound (US) options for supplemental breast cancer screening of average risk women with dense breasts. CONCLUSION: Performance data of physician-performed handheld US (HHUS), technologist-performed HHUS, and automated breast ultrasound (AUS) indicate that all are appropriate for adjunctive screening. Volumetric 3D acquisitions, reduced operator dependence, protocol standardization, reliable comparison with previous studies, independence of performance and interpretation, and whole breast depiction on coronal view may favor selection of AUS. Important considerations are workflow adjustments for physicians and staff.

Nipple Discharge: Current Clinical and Imaging Evaluation.

OBJECTIVE. Nipple discharge is a common complaint that is first evaluated with clinical assessment. Physiologic discharge does not require imaging other than routine screening mammography. Initial evaluation of pathologic nipple discharge involves mammography and ultrasound. evaluation of pathologic nipple discharge involves mammography and ultrasound. Because of its high sensitivity in detecting breast malignancy and its biopsy capability, MRI is increasingly used in lieu of ductography. CONCLUSION. The problem-solving algorithm for evaluating suspicious nipple discharge is evolving. When diagnostic imaging for evaluation of pathologic nipple discharge is negative, management is based on clinical suspicion. If additional imaging is warranted, MRI is preferred because of its increased sensitivity, specificity, and patient comfort. Although central duct excision is the current standard for evaluation of malignancy in patients with pathologic nipple discharge, studies suggest that, given the high negative predictive value of MRI, surveillance may be a reasonable alternative to surgery.

Three-dimensional Automated Breast US: Facts and Artifacts.

As automated breast (AB) US becomes more integrated into the daily practice of breast imaging, the need to address the artifacts that interfere with AB US image interpretation is becoming more important. Learning methods to detect and subsequently resolve artifacts such as shadowing can enhance the reader's confidence and ability to differentiate artifacts and true abnormalities. Understanding the basic principles of AB US and its image acquisition process are key elements in resolving artifacts. Gaining familiarity with the common patterns of AB US artifacts and placing them into categories of technical, software, physiologic, and breast lesion-related causes can aid in image interpretation. Recognizing specific artifacts, such as dropout and lack of contact, and the ability to distinguish them from true abnormalities, such as surgical scars and suspicious lesions, can help minimize preventable false-positive interpretations. Applying methods to confirm shadowing as artifactual, including the use of a second view, additional planes, and software-related tools such as the rotational tool, can aid the radiologist in resolving artifacts and avoiding preventable recalls, potentially resulting in increased specificity. Presented is a methodical approach to recognizing AB US artifacts and their causes; analyzing shadowing, a challenging entity in the interpretation of AB US imaging studies; differentiating artifact from true abnormality; and reviewing characteristic patterns and basic techniques to resolve artifacts. The goal of this article is to enable the radiologist in applying these methods to help reduce preventable false-positive recommendations and increase efficiency in AB US image interpretation. Online supplemental material is available for this article. ©RSNA, 2019.

Artificial Intelligence in Breast Imaging: Potentials and Limitations.

OBJECTIVE: The purpose of this article is to discuss potential applications of artificial intelligence (AI) in breast imaging and limitations that may slow or prevent its adoption. CONCLUSION: The algorithms of AI for workflow improvement and outcome analyses are advancing. Using imaging data of high quality and quantity, AI can support breast imagers in diagnosis and patient management, but AI cannot yet be relied on or be responsible for physicians' decisions that may affect survival. Education in AI is urgently needed for physicians.

MR imaging appearance of noncalcified and calcified DCIS.

To evaluate the MR appearance of noncalcified ductal carcinoma in situ (DCIS), with comparison to calcified DCIS. A retrospective, IRB-approved review of all DCIS diagnosed via MR biopsy between 2007 and 2011 was performed. DCIS was categorized as noncalcified based on the absence of calcifications on mammography and specimen radiography. MR morphology (focus, mass, nonmass enhancement [NME]) and enhancement kinetics (initial and delayed) for noncalcified DCIS were recorded and compared based on nuclear grade (1-3), size (<1.5 cm, 1.5-5 cm, >5 cm), and presence of necrosis. Imaging features of noncalcified and calcified DCIS were also compared. 115 cases of MR biopsy-proven DCIS were identified: 65 (56%) noncalcified and 50 (44%) calcified. For noncalcified DCIS, NME morphology was more common than mass or focus (60% vs 30.8% and 9.2%). There was a significant association between morphology and enhancement kinetics, with NME more likely demonstrating medium and persistent kinetics, and foci or masses demonstrating rapid and plateau or washout kinetics (P < .05). There was also a significant association between morphology and nuclear grade, with NME more likely seen with grade 3 DCIS (P = .024), and between size and initial enhancement, with lesions <1.5 cm more likely to have rapid initial enhancement (P = .0036). No significant difference was identified between calcified and noncalcified DCIS in terms of morphology, enhancement characteristics, nuclear grade, or presence of necrosis. The MR appearance of noncalcified DCIS closely mirrors that of calcified DCIS. Recognizing these imaging features may allow for improved identification of this MRI-detected abnormality, even in the absence of calcifications.

Value-Based Reimbursement: Impact of Curtailing Physician Autonomy in Medical Decision Making.

OBJECTIVE: In this article, we define value in the context of reimbursement and explore the effect of shifting reimbursement paradigms on the decision-making autonomy of a women's imaging radiologist. CONCLUSION: The current metrics used for value-based reimbursement such as report turnaround time are surrogate measures that do not measure value directly. The true measure of a physician's value in medicine is accomplishment of better health outcomes, which, in breast imaging, are best achieved with a physician-patient relationship. Complying with evidence-based medicine, which includes data-driven best clinical practices, a physician's clinical expertise, and the patient's values, will improve our science and preserve the art of medicine.

Ultrasound as the Primary Screening Test for Breast Cancer: Analysis From ACRIN 6666.

BACKGROUND: Mammography is not widely available in all countries, and breast cancer incidence is increasing. We considered performance characteristics using ultrasound (US) instead of mammography to screen for breast cancer. METHODS: Two thousand eight hundred nine participants were enrolled at 20 sites in the United States, Canada, and Argentina in American College of Radiology Imaging 6666. Two thousand six hundred sixty-two participants completed three annual screens (7473 examinations) with US and film-screen (n = 4351) or digital (n = 3122) mammography and had biopsy or 12-month follow-up. Cancer detection, recall, and positive predictive values were determined. All statistical tests were two-sided. RESULTS: One hundred ten women had 111 breast cancer events: 89 (80.2%) invasive cancers, median size 12 mm. The number of US screens to detect one cancer was 129 (95% bootstrap confidence interval [CI] = 110 to 156), and for mammography 127 (95% CI = 109 to 152). Cancer detection was comparable for each of US and mammography at 58 of 111 (52.3%) vs 59 of 111 (53.2%, P = .90), with US-detected cancers more likely invasive (53/58, 91.4%, median size 12 mm, range = 2-40 mm), vs mammography at 41 of 59 (69.5%, median size 13 mm, range = 1-55 mm, P < .001). Invasive cancers detected by US were more frequently node-negative, 34 of 53 (64.2%) vs 18 of 41 (43.9%) by mammography (P = .003). For 4814 incidence screens (years 2 and 3), US had higher recall and biopsy rates and lower PPV of biopsy (PPV3) than mammography: The recall rate was 10.7% (n = 515) vs 9.4% (n = 453, P = .03), the biopsy rate was 5.5% (n = 266) vs 2.0% (n = 97, P < .001), and PPV3 was 11.7% (31/266) vs 38.1% (37/97, P < .001). CONCLUSIONS: Cancer detection rate with US is comparable with mammography, with a greater proportion of invasive and node-negative cancers among US detections. False positives are more common with US screening.

Quantitative Maximum Shear-Wave Stiffness of Breast Masses as a Predictor of Histopathologic Severity.

OBJECTIVE: The objective of our study was to compare quantitative maximum breast mass stiffness on shear-wave elastography (SWE) with histopathologic outcome. SUBJECTS AND METHODS: From September 2008 through September 2010, at 16 centers in the United States and Europe, 1647 women with a sonographically visible breast mass consented to undergo quantitative SWE in this prospective protocol; 1562 masses in 1562 women had an acceptable reference standard. The quantitative maximum stiffness (termed "Emax") on three acquisitions was recorded for each mass with the range set from 0 (very soft) to 180 kPa (very stiff). The median Emax and interquartile ranges (IQRs) were determined as a function of histopathologic diagnosis and were compared using the Mann-Whitney U test. We considered the impact of mass size on maximum stiffness by performing the same comparisons for masses 9 mm or smaller and those larger than 9 mm in diameter. RESULTS: The median patient age was 50 years (mean, 51.8 years; SD, 14.5 years; range, 21-94 years), and the median lesion diameter was 12 mm (mean, 14 mm; SD, 7.9 mm; range, 1-53 mm). The median Emax of the 1562 masses (32.1% malignant) was 71 kPa (mean, 90 kPa; SD, 65 kPa; IQR, 31-170 kPa). Of 502 malignancies, 23 (4.6%) ductal carcinoma in situ (DCIS) masses had a median Emax of 126 kPa (IQR, 71-180 kPa) and were less stiff than 468 invasive carcinomas (median Emax, 180 kPa [IQR, 138-180 kPa]; p = 0.002). Benign lesions were much softer than malignancies (median Emax, 43 kPa [IQR, 24-83 kPa] vs 180 kPa [IQR, 129-180 kPa]; p < 0.0001). Usual benign lesions were soft, including 62 cases of fibrocystic change (median Emax, 32 kPa; IQR, 24-94 kPa), 51 cases of fibrosis (median Emax, 36 kPa; IQR, 22-102 kPa), and 301 fibroadenomas (median Emax, 45 kPa; IQR, 30-79 kPa). Eight lipomas (median Emax, 14 kPa; IQR, 8-15 kPa), 154 cysts (median Emax, 29 kPa; IQR, 10-58 kPa), and seven lymph nodes (median Emax, 17 kPa; IQR, 9-40 kPa) were softer than usual benign lesions (p < 0.0001 for lipomas and cysts; p = 0.007 for lymph nodes). Risk lesions were slightly stiffer than usual benign lesions (p = 0.002) but tended to be softer than DCIS (p = 0.14). Fat necrosis and abscesses were relatively stiff. Conclusions were similar for both small and large masses. CONCLUSION: Despite overlap in Emax values, maximum stiffness measured by SWE is a highly effective predictor of the histopathologic severity of sonographically depicted breast masses.

Training and standards for performance, interpretation, and structured reporting for supplemental breast cancer screening.

OBJECTIVE. To compensate for the reduction of mammography's sensitivity in women with dense breasts, supplemental screening can increase the cancer detection rate. The modalities suggested are MRI, which is the most sensitive and is indicated for women with the highest risk of breast cancer, and ultrasound, which is suggested for dense-breasted average-risk women. CONCLUSION. For decades, ultrasound has been a focused examination. Extending a handheld ultrasound examination to depict the entire breast requires formal didactic training and hands-on scanning to learn suitable, efficient methods. Automated options also require intensive training in performance and interpretation.

Clinical outcomes with the MammoSite radiation therapy system: results of a prospective trial.

OBJECTIVE: The purpose of this study was to report the treatment-induced adverse events and cosmetic and treatment outcomes of accelerated partial breast irradiation (APBI) delivered with the MammoSite radiation therapy system (RTS) in breast cancer patients undergoing breast-conserving therapy (BCT). METHODS: This is a prospective clinical trial that was approved by the institutional review board. The study included female breast cancer patients undergoing breast-conserving therapy in the form of surgery and APBI delivered with the MammoSite RTS. Patients and tumor characteristics, treatment-induced acute adverse events based on the Common Toxicity Criteria for Adverse Events (CTCAE) version 2.0, chronic AEs according to Radiation Therapy Oncology Group (RTOG) scale, treatment outcomes (including local control, disease-free survival, and overall survival), and cosmetic outcomes are reported. RESULTS: The study included 36 eligible patients treated consecutively in our institution between November 2003 and August 2009. The age range was 45-83 years. A total of 29 patients had invasive disease (median size 1.1 cm), while 7 patients had in situ disease only (median size 0.8 cm). The skin distance in most of the patients (91.7 %) was ≥1 cm; only three patients (8.3 %) had skin distance <1 cm. The median balloon diameter was 5 cm (range 4-6 cm). At a median follow-up of 42 months (range 4-65 months), local control, disease-free survival, and overall survival were 100 %. None of the patients experienced any grade 3 or 4 toxicities; 16.7 and 5.6 % of the patients had late grade 2 fibrosis and telangiectasia, respectively. At last follow-up, cosmetic outcome was rated as good or excellent in 94 % of the patients. CONCLUSION: APBI delivered with the MammoSite RTS is a feasible, tolerable, and effective treatment modality. Multicenter, randomized, controlled clinical trials with a larger number of patients are required for verification.

Technologist-performed handheld screening breast US imaging: how is it performed and what are the outcomes to date?

Breast density-inform legislation is increasing the need for data on outcomes of tailored screening. Dense parenchyma can mask cancers, and denser tissue is also more likely to develop breast cancer than fatty tissue. Digital mammography is standard for women with dense breasts. Supplemental screening magnetic resonance imaging should be offered to women who meet high-risk criteria. Supplemental screening ultrasonographic (US) imaging may be appropriate in the much larger group of women with dense breasts. Both physician- and technologist-performed screening US imaging increases detection of node-negative invasive breast cancer. To meet anticipated demand in the United States, screening US images will most likely be acquired by trained technologists rather than physicians. While automated US offers standard documentation, there are few data on outcomes. US has been used diagnostically for decades to characterize masses seen by using mammography, but training specific to screening has been lacking. Standard approaches to training and documentation of technologist-performed handheld screening US imaging are needed. This article reviews the current status of technologist-performed handheld screening breast US imaging.

Update on screening breast ultrasonography.

This article includes current recommendations for screening breast ultrasonography, a review of the literature, a discussion of problems associated with the implementation of screening breast ultrasonography, and a brief discussion of the political and economic factors influencing the use of screening breast ultrasonography.