Diagnostic accuracy of supplemental three-dimensional breast ultrasound in the work-up of BI-RADS 0 screening recalls.

OBJECTIVE: To evaluate the diagnostic accuracy of supplemental 3D automated breast ultrasound (ABUS) in the diagnostic work-up of BI-RADS 0 recalls. We hypothesized that 3D ABUS may reduce the benign biopsy rate. MATERIALS AND METHODS: In this prospective multicenter diagnostic study, screening participants recalled after a BI-RADS 0 result underwent bilateral 3D ABUS supplemental to usual care: digital breast tomosynthesis (DBT) and targeted hand-held ultrasound (HHUS). Sensitivity, specificity, positive predictive value, and negative predictive value of 3D ABUS, and DBT plus HHUS, were calculated. New 3D ABUS findings and changes of management (biopsy or additional imaging) were recorded. RESULTS: A total of 501 women (median age 55 years, IQR [51-64]) with 525 BI-RADS 0 lesions were included between April 2018 and March 2020. Cancer was diagnosed in 45 patients. 3D ABUS sensitivity was 72.1% (95% CI [57.2-83.4%]), specificity 84.4% (95% CI [80.8-87.4%]), PPV 29.2% (95% CI [21.4-38.5%]), and NPV 97.1% 95.0-98.4%). Sensitivity of DBT plus HHUS was 100% (95% CI [90.2-100%]), specificity 71.4% (95% CI [67.2-75.2%]), PPV 23.8% (95% CI [18.1-30.5%]) and NPV 100% (95% CI [98.7-100%]). Twelve out of 43 (27.9%) malignancies in BI-RADS 0 lesions were missed on 3D ABUS, despite being detected on DBT and/or HHUS. Supplemental 3D ABUS resulted in the detection of 57 new lesions and six extra biopsy procedures, all were benign. CONCLUSION: 3D ABUS in the diagnostic work-up of BI-RADS 0 recalls may miss over a quarter of cancers detected with HHUS and/or DBT and should not be used to omit biopsy. Supplemental 3D ABUS increases the benign biopsy rate. TRIAL REGISTRATION: Dutch Trial Register, available via https://www.onderzoekmetmensen.nl/en/trial/29659 CRITICAL RELEVANCE STATEMENT: Supplemental 3D automated breast ultrasound in the work-up of BI-RADS 0 recalls may miss over a quarter of cancers detected with other methods and should not be used to omit biopsy; ABUS findings did increase benign biopsy rate. KEY POINTS: Automated breast ultrasound (ABUS) may miss over 25% of cancers detectable by alternative methods. Don't rely solely on 3D ABUS to assess indication for biopsy. New findings with supplemental 3D ABUS increase the benign biopsy rate.

The Facilitators and Barriers of the Implementation of a Clinical Decision Support System for Breast Cancer Multidisciplinary Team Meetings-An Interview Study.

BACKGROUND: AI-driven clinical decision support systems (CDSSs) hold promise for multidisciplinary team meetings (MDTMs). This study aimed to uncover the hurdles and aids in implementing CDSSs during breast cancer MDTMs. METHODS: Twenty-four core team members from three hospitals engaged in semi-structured interviews, revealing a collective interest in experiencing CDSS workflows in clinical practice. All interviews were audio recorded, transcribed verbatim and analyzed anonymously. A standardized approach, 'the framework method', was used to create an analytical framework for data analysis, which was performed by two independent researchers. RESULTS: Positive aspects included improved data visualization, time-saving features, automated trial matching, and enhanced documentation transparency. However, challenges emerged, primarily concerning data connectivity, guideline updates, the accuracy of AI-driven suggestions, and the risk of losing human involvement in decision making. Despite the complexities involved in CDSS development and integration, clinicians demonstrated enthusiasm to explore its potential benefits. CONCLUSIONS: Acknowledging the multifaceted nature of this challenge, insights into the barriers and facilitators identified in this study offer a potential roadmap for smoother future implementations. Understanding these factors could pave the way for more effective utilization of CDSSs in breast cancer MDTMs, enhancing patient care through informed decision making.

Long-term Survival in Breast Cancer Patients Is Associated with Contralateral Parenchymal Enhancement at MRI: Outcomes of the SELECT Study.

Background Several single-center studies found that high contralateral parenchymal enhancement (CPE) at breast MRI was associated with improved long-term survival in patients with estrogen receptor (ER)-positive and human epidermal growth factor receptor 2 (HER2)-negative breast cancer. Due to varying sample sizes, population characteristics, and follow-up times, consensus of the association is currently lacking. Purpose To confirm whether CPE is associated with long-term survival in a large multicenter retrospective cohort, and to investigate if CPE is associated with endocrine therapy effectiveness. Materials and Methods This multicenter observational cohort included women with unilateral ER-positive HER2-negative breast cancer (tumor size ≤50 mm and ≤three positive lymph nodes) who underwent MRI from January 2005 to December 2010. Overall survival (OS), recurrence-free survival (RFS), and distant RFS (DRFS) were assessed. Kaplan-Meier analysis was performed to investigate differences in absolute risk after 10 years, stratified according to CPE tertile. Multivariable Cox proportional hazards regression analysis was performed to investigate whether CPE was associated with prognosis and endocrine therapy effectiveness. Results Overall, 1432 women (median age, 54 years [IQR, 47-63 years]) were included from 10 centers. Differences in absolute OS after 10 years were stratified according to CPE tertile as follows: 88.5% (95% CI: 88.1, 89.1) in tertile 1, 85.8% (95% CI: 85.2, 86.3) in tertile 2, and 85.9% (95% CI: 85.4, 86.4) in tertile 3. CPE was independently associated with OS, with a hazard ratio (HR) of 1.17 (95% CI: 1.0, 1.36; P = .047), but was not associated with RFS (HR, 1.11; P = .16) or DRFS (HR, 1.11; P = .19). The effect of endocrine therapy on survival could not be accurately assessed; therefore, the association between endocrine therapy efficacy and CPE could not reliably be estimated. Conclusion High contralateral parenchymal enhancement was associated with a marginally decreased overall survival in patients with estrogen receptor-positive and human epidermal growth factor receptor 2-negative breast cancer, but was not associated with recurrence-free survival (RFS) or distant RFS. Published under a CC BY 4.0 license. Supplemental material is available for this article. See also the editorial by Honda and Iima in this issue.

Mapping Current Organizational Structure and Improvement Points of Breast Cancer Multidisciplinary Team Meetings - An Interview Study.

Purpose: The aim of the study was to map current organization, and document potential improvement points of breast cancer multidisciplinary team meetings (MDTMs), in order to support the optimization of the present breast cancer MDTM organization. Methods: From January 2019 to February 2021, 24 core team members of the breast cancer multidisciplinary team (MDT) in three hospitals were interviewed. Semi-structured interviews were performed based on an interview guide. All interviews were recorded and transcribed verbatim. Deductive coding was performed on the transcripts by two independent researchers. The codes were organized in categories and themes. Results: In total 24 healthcare professionals; surgeons, medical oncologists, radiotherapists, pathologists, radiologists, and specialized nurses, from three different hospitals were interviewed. According to the participants, improving efficiency before and during MDTMs is possible by ensuring proper preparation of attendees, implementing more structure during discussions, improving access to and availability of patient data and optimizing general meeting discipline. Conclusion: Preparation, structure, data availability and meeting discipline were highlighted as essential factors for efficient breast cancer MDTM improvement. These topics seem to be applicable to other types of oncology MDTMs as well. Improving MDTM efficiency on the long term ensures high-quality discussions for all breast cancer patients.

Optoacoustic imaging of the breast: correlation with histopathology and histopathologic biomarkers.

AIM: This study was conducted in order to investigate the role of gray-scale ultrasound (US) and optoacoustic imaging combined with gray-scale ultrasound (OA/US) to better differentiate between breast cancer molecular subtypes. MATERIALS AND METHODS: All 67 malignant masses included in the Maestro trial were retrospectively reviewed to compare US and OA/US feature scores and histopathological findings. Kruskal-Wallis tests were used to analyze the relationship between US and OA/US features and molecular subtypes of breast cancer. If a significant relationship was found, additional Wilcoxon-Mann-Whitney tests were used to identify the differences between molecular subtype groups. RESULTS: US sound transmission helped to differentiate between LUMA and LUMB, LUMB and TNBC, and LUMB and all other molecular subtypes combined (p values < 0.05). Regarding OA/US features, the sum of internal features helped to differentiate between TNBC and HER2-enriched subtypes (p = 0.049). Internal vessels (p = 0.025), sum of all internal features (p = 0.019), and sum of internal and external features (p = 0.028) helped to differentiate between LUMA and LUMB. All internal features, the sum of all internal features, the sum of all internal and external features, and the ratio of internal and external features helped to differentiate between LUMA and TNBC. The same features also helped to differentiate between LUMA and TNBC from other molecular subtypes (p values < 0.05). CONCLUSIONS: The use of OA/US might help radiologists to better differentiate between breast cancer molecular subtypes. Further studies need to be carried out in order to validate these results. KEY POINTS: • The combination of functional and morphologic information provided by optoacoustic imaging (OA) combined with gray-scale US helped to differentiate between breast cancer molecular subtypes.

Downgrading of Breast Masses Suspicious for Cancer by Using Optoacoustic Breast Imaging.

Purpose To assess the ability of optoacoustic (OA) ultrasonography (US) to help correctly downgrade benign masses classified as Breast Imaging Reporting and Data System (BI-RADS) 4a and 4b to BI-RADS 3 or 2. Materials and Methods OA/US technology uses laser light to detect relative amounts of oxygenated and deoxygenated hemoglobin in and around suspicious breast masses. In this prospective, multicenter study, results of 209 patients with 215 breast masses classified as BI-RADS 4a or 4b at US are reported. Patients were enrolled between 2015 and 2016. Masses were first evaluated with US with knowledge of previous clinical information and imaging results, and from this information a US imaging-based probability of malignancy (POM) and BI-RADS category were assigned to each mass. The same masses were then re-evaluated at OA/US. During the OA/US evaluation, radiologists scored five OA/US features, and then reassigned an OA/US-based POM and BI-RADS category for each mass. BI-RADS downgrade and upgrade percentages at OA/US were assessed by using a weighted sum of the five OA feature scores. Results At OA/US, 47.9% (57 of 119; 95% CI: 0.39, 0.57) of benign masses classified as BI-RADS 4a and 11.1% (three of 27; 95% CI: 0.03, 0.28) of masses classified as BI-RADS 4b were correctly downgraded to BI-RADS 3 or 2. Two of seven malignant masses classified as BI-RADS 4a at US were incorrectly downgraded, and one of 60 malignant masses classified as BI-RADS 4b at US was incorrectly downgraded for a total of 4.5% (three of 67; 95% CI: 0.01, 0.13) false-negative findings. Conclusion At OA/US, benign masses classified as BI-RADS 4a could be downgraded in BI-RADS category, which would potentially decrease biopsies negative for cancer and short-interval follow-up examinations, with the limitation that a few masses may be inappropriately downgraded.

Dynamic Contrast-Enhanced Magnetic Resonance Imaging in the Assessment of Inflammatory Breast Cancer Prior to and After Neoadjuvant Treatment.

BACKGROUND: The aim of this study was to describe the dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) features of inflammatory breast cancer (IBC) and to assess the value of DCE-MRI for the prediction of pathological complete response (pCR). METHODS: Image analysis was performed in 15 patients with IBC (cT4d) and 12 patients with non-IBC (cT2), and included the assessment of BIRADS characteristics, skin alterations, enhancement characteristics, and changes post chemotherapy. Sensitivity and specificity of DCE-MRI for the presence of residual disease were obtained. Pearson's correlation coefficients were calculated comparing the (preoperative) tumor size with the histological size. RESULTS: Skin thickening/enhancement (80%) and non-mass-like enhancement (66.7%) occurred more often in IBC (16.7 vs. 8.3% in non-IBC). In 2 of 3 cases of IBC, pCR was correctly predicted (sensitivity 92%, specificity 67%), compared to 3 of 5 cases in non-IBC (sensitivity 86%, specificity 40%). Lower peak enhancement might be associated with a higher likelihood of pCR in IBC. No other parameters predicted eventual pCR. In IBC, no correlation between preoperative tumor size and histological size was found (r = 0.22, p = 0.50), whereas in non-IBC, size estimations were more accurate (r = 0.75, p = 0.03). CONCLUSION: IBC is characterized on MRI by skin changes and non-mass-like enhancement. Radiological complete response seems indicative of pCR in IBC and non-IBC. Size estimation of residual disease in IBC appears to be inaccurate.

MR-guided breast biopsy at 3T: diagnostic yield of large core needle biopsy compared with vacuum-assisted biopsy.

OBJECTIVE: The purpose of this study was to evaluate two MR-guided biopsy techniques at 3 T, large core needle breast biopsy (LCNB) and vacuum-assisted breast biopsy (VAB) and to compare the diagnostic yield and rate of complications to determine the optimal biopsy technique at 3 T. METHODS: 55 LCNB and 64 VAB were consecutively performed. Benign biopsy results were verified by retrospective correlation of histology, with pre-interventional, post-interventional MRI studies and follow-up and were classified as representative or non-representative. Time to follow-up was up to 2 years for the considered non-representative benign lesions. Statistical analysis was performed using the Chi-squared test. RESULTS: LCNB was technically successful in 100% of patients (55/55) and VAB in 98% of patients (63/64). Histopathological analysis resulted in 45 (82%) benign, 3 (5%) high-risk and 7 (13%) malignant lesions for LCNB and 43 (67%) benign, 3 (5%) high-risk and 18 (28%) malignant lesions. Distribution was significantly different (p < 0.001), favouring VAB over LCNB. CONCLUSION: Because of the substantially higher diagnostic yield and certainty of a benign diagnosis, VAB is the optimal biopsy technique at 3 T. LCNB should be considered when VAB is not feasible.

MRI-guided breast biopsy at 3T using a dedicated large core biopsy set: feasibility and initial results.

OBJECTIVE: The increasing importance of breast MRI in the diagnostic processes concerning breast cancer yield often lesions that are visible on MRI only. To assess the nature of these lesions, pathologic analysis is necessary. Therefore, MR-guided biopsy should be available. Breast MRI at 3T has shown advantage over 1.5T. Unfortunately, current equipment for MR-guided biopsy is better suited for intervention at 1.5T due to the danger of heating titanium co-axial sleeves and large susceptibility artifacts. We evaluated a dedicated 3T breast biopsy set that uses plastic coaxial needles to overcome these problems. MATERIALS AND METHODS: We performed MRI-guided breast biopsy in 23 women with 24 MRI-only visible breast lesions at 3T. Biopsy procedures were performed with plastic coaxial needles in a closed bore 3T clinical MR system on a dedicated phased array breast coil with a commercially available add-on stereotactic biopsy device. RESULTS: Width of the needle artifact was 2mm in all 24 cases. Biopsy procedure was completed between 35 and 67 min. The procedure was judged moderately easy in 12 and normal in 10 cases. One procedure was judged difficult and there was one technical failure. CONCLUSION: MRI-guided breast biopsy at 3T is a fast and accurate procedure. The plastic coaxial needles reduce the susceptibility artifact largely and do not increase the difficulty of the procedure. The diagnostic yield is at least equal to the diagnostic yield of the same procedure at 1.5T. Therefore, this technique can be safely used for lesions only visible at 3T MRI.

Computer-aided detection (CAD) for breast MRI: evaluation of efficacy at 3.0 T.

OBJECTIVE: The purpose of the study was to evaluate the accuracy of 3.0-T breast MRI interpretation using manual and fully automated kinetic analyses. MATERIAL AND METHODS: Manual MRI interpretation was done on an Advantage Workstation. Retrospectively, all examinations were processed with a computer-aided detection (CAD) system. CAD data sets were interpreted by two experienced breast radiologists and two residents. For each lesion automated analysis of enhancement kinetics was evaluated at 50% and 100% thresholds. Forty-nine malignant and 22 benign lesions were evaluated. RESULTS: Using threshold enhancement alone, the sensitivity and specificity of CAD were 97.9% and 86.4%, respectively, for the 50% threshold, and 97.9% and 90%, respectively, for the 100% threshold. Manual interpretation by two breast radiologists showed a sensitivity of 84.6% and a specificity of 68.8%. For the same two radiologists the mean sensitivity and specificity for CAD-based interpretation was 90.4% (not significant) and 81.3% (significant at p < 0.05), respectively. With one-way ANOVA no significant differences were found between the two breast radiologists and the two residents together, or between any two readers separately. CONCLUSION: CAD-based analysis improved the specificity compared with manual analysis of enhancement. Automated analysis at 50% and 100% thresholds showed a high sensitivity and specificity for readers with varying levels of experience.

Feasibility of MRI-guided large-core-needle biopsy of suspiscious breast lesions at 3 T.

The feasibility of large-core-needle magnetic resonance imaging (MRI)-guided breast biopsy at 3 T was assessed. Thirty-one suspicious breast lesions shown only by MRI were detected in 30 patients. Biopsy procedures were performed in a closed-bore 3-T clinical MR system on a dedicated phased-array breast coil with a commercially available add-on stereotactic biopsy device. Tissue sampling was technically successful in 29/31 (94%) lesions. Median lesion size (n = 29) was 9 mm. Histopathological analysis showed 19 benign lesions (66%) and one inconclusive biopsy result (3%). At follow-up of these lesions, 15 lesions showed no malignancy, no information was available in three patients and two lesions turned out to be malignant (one lesion at surgical excision 1 month after biopsy and one lesion at a second biopsy because of a more malignant enhancement curve at 12-months follow-up MRI). Nine biopsy results showed a malignant lesion (31%) which were all surgically removed. No complications occurred. MRI-guided biopsy at 3 T is a safe and effective method for breast biopsy in lesions that are occult on mammography and ultrasound. Follow-up MRI at 6 months after the biopsy should be performed in case of a benign biopsy result.