A Deep Learning Decision Support Tool to Improve Risk Stratification and Reduce Unnecessary Biopsies in BI-RADS 4 Mammograms.

Purpose: To evaluate the performance of a biopsy decision support algorithmic model, the intelligent-augmented breast cancer risk calculator (iBRISK), on a multicenter patient dataset. Materials and Methods: iBRISK was previously developed by applying deep learning to clinical risk factors and mammographic descriptors from 9700 patient records at the primary institution and validated using another 1078 patients. All patients were seen from March 2006 to December 2016. In this multicenter study, iBRISK was further assessed on an independent, retrospective dataset (January 2015-June 2019) from three major health care institutions in Texas, with Breast Imaging Reporting and Data System (BI-RADS) category 4 lesions. Data were dichotomized and trichotomized to measure precision in risk stratification and probability of malignancy (POM) estimation. iBRISK score was also evaluated as a continuous predictor of malignancy, and cost savings analysis was performed. Results: The iBRISK model's accuracy was 89.5%, area under the receiver operating characteristic curve (AUC) was 0.93 (95% CI: 0.92, 0.95), sensitivity was 100%, and specificity was 81%. A total of 4209 women (median age, 56 years [IQR, 45-65 years]) were included in the multicenter dataset. Only two of 1228 patients (0.16%) in the "low" POM group had malignant lesions, while in the "high" POM group, the malignancy rate was 85.9%. iBRISK score as a continuous predictor of malignancy yielded an AUC of 0.97 (95% CI: 0.97, 0.98). Estimated potential cost savings were more than $420 million. Conclusion: iBRISK demonstrated high sensitivity in the malignancy prediction of BI-RADS 4 lesions. iBRISK may safely obviate biopsies in up to 50% of patients in low or moderate POM groups and reduce biopsy-associated costs.Keywords: Mammography, Breast, Oncology, Biopsy/Needle Aspiration, Radiomics, Precision Mammography, AI-augmented Biopsy Decision Support Tool, Breast Cancer Risk Calculator, BI-RADS 4 Mammography Risk Stratification, Overbiopsy Reduction, Probability of Malignancy (POM) Assessment, Biopsy-based Positive Predictive Value (PPV3) Supplemental material is available for this article. Published under a CC BY 4.0 license.See also the commentary by McDonald and Conant in this issue.

Mid-treatment Ultrasound Descriptors as Qualitative Imaging Biomarkers of Pathologic Complete Response in Patients with Triple-Negative Breast Cancer.

This study aimed to investigate mid-treatment breast tumor ultrasound characteristics that may predict eventual pathologic complete response (pCR) in triple-negative breast cancer; specifically, we examined associations between pCR and two parameters: tumor response pattern and tumor appearance. Ultrasound was performed at mid-treatment, defined as the completion of four cycles of anthracycline-based chemotherapy and before receiving taxane-based chemotherapy. Consensus imaging review was performed while blinded to pathology results (i.e., pCR/non-pCR) from surgery. Tumor response pattern was described as "complete," "concentric," "fragmented," "stable" or "progression." Tumor appearance was designated as "mass," "architectural distortion," "flat tumor bed" or "clip only." Univariate and multivariate regression analyses of 144 participants showed significant associations between mid-treatment response pattern and pCR (p = 0.0348 and p = 0.0173, respectively), with complete and concentric response patterns more likely to achieve pCR than other patterns. Univariate and multivariate regression analyses further showed significant associations between mid-treatment tumor appearance and pCR (p < 0.0001 for both), with persistent appearance of mass less likely than other appearances to achieve pCR. To conclude, our study demonstrated strong associations between pCR and both tumor response pattern and tumor appearance, thereby suggesting that these parameters have potential as qualitative imaging biomarkers of pCR in triple-negative breast cancer.

BI-RADS Ultrasound Lexicon Descriptors and Stromal Tumor-Infiltrating Lymphocytes in Triple-Negative Breast Cancer.

PURPOSE: Increased levels of stromal tumor-infiltrating lymphocytes (sTILs) have recently been considered a favorable independent prognostic and predictive biomarker in triple-negative breast cancer (TNBC). The purpose of this study was to determine the relationship between BI-RADS (Breast Imaging Reporting and Data System) ultrasound lexicon descriptors and sTILs in TNBC. MATERIALS AND METHODS: Patients with stage I-III TNBC were evaluated within a single-institution neoadjuvant clinical trial. Two fellowship-trained breast radiologists used the BI-RADS ultrasound lexicon to assess pretreatment tumor shape, margin, echo pattern, orientation, posterior features, and vascularity. sTILs were defined as low <20 or high ≥20 on the pretreatment biopsy. Fisher's exact tests were used to assess the association between lexicon descriptors and sTIL levels. RESULTS: The 284 patients (mean age 52 years, range 24-79 years) were comprised of 68% (193/284) with low-sTIL tumors and 32% (91/284) with high-sTIL tumors. TNBC tumors with high sTILs were more likely to have the following features: (1) oval/round shape than irregular shape (p = 0.003), (2) circumscribed or microlobulated margins than spiculated, indistinct, or angular margins (p = 0.0005); (3) complex cystic and solid pattern than heterogeneous pattern (p = 0.006); and (4) posterior enhancement than shadowing (p = 0.002). There was no significant association between sTILs and descriptors for orientation and vascularity (p = 0.06 and p = 0.49, respectively). CONCLUSION: BI-RADS ultrasound descriptors of the pretreatment appearance of a TNBC tumor can be useful in discriminating between tumors with low and high sTIL levels. Therefore, there is a potential use of ultrasound tumor characteristics to complement sTILs when used as stratification factors in treatment algorithms for TNBC.

Retrospective Review of a Mobile Mammography Screening Program in an Underserved Population within a Large Metropolitan Area.

RATIONALE AND OBJECTIVES: Mobile mammography units provide preventive health care to patients facing barriers to annual screening. This study reviews the outcomes of a mobile mammography service during a recent 5-year period. MATERIALS AND METHODS: This retrospective study analyzed the examinations by mobile mammography during a 5-year period (9327 examinations). The patients recalled, biopsies performed, and cancers detected were tallied. The race, age, breast cancer size, lymph node involvement, and metastases were recorded. The positive predictive value (PPV) and cancer detection rate metrics were calculated as outlined by the American College of Radiology Breast Imaging Reporting and Data System Atlas. RESULTS: The program identified cancer in 14 cases (cancer detection rate = 1.5 per 1000 examinations [95% confidence interval [CI], 0.9-2.5]) with 11 being invasive. The majority of these cancers were small and of low stage. Lymph node status was determined in 11 of the 14 cases (1 as N1mi, 5 as N0, 4 as N1,1 as N2a). Abnormalities led to 1686 examinations recalled (Recall Rate = 17.8%; PPV 1 = 0.8% [95% CI, 0.5%-1.4%]). One hundred and one were recommended for biopsy (PPV 2 = 13.9% [95% CI, 8.4%-21.9%]), and 98 pursued biopsy (PPV 3 = 14.3% [95% CI, 8.7%-22.6%]). Patient age ranged from 41 to 67 years with an average of 50.6 years. CONCLUSION: The program detected many cancers in an asymptomatic population facing barriers to breast cancer screening. These findings are underscored by the cancers detected at an early stage with a favorable prognosis and support the need for the development of similar programs.

Functional Tumor Volume by Fast Dynamic Contrast-Enhanced MRI for Predicting Neoadjuvant Systemic Therapy Response in Triple-Negative Breast Cancer.

BACKGROUND: Dynamic contrast-enhanced (DCE) MRI is useful for diagnosis and assessment of treatment response in breast cancer. Fast DCE MRI offers a higher sampling rate of contrast enhancement curves in comparison to conventional DCE MRI, potentially characterizing tumor perfusion kinetics more accurately for measurement of functional tumor volume (FTV) as a predictor of treatment response. PURPOSE: To investigate FTV by fast DCE MRI as a predictor of neoadjuvant systemic therapy (NAST) response in triple-negative breast cancer (TNBC). STUDY TYPE: Prospective. POPULATION/SUBJECTS: Sixty patients with biopsy-confirmed TNBC between December 2016 and September 2020. FIELD STRENGTH/SEQUENCE: A 3.0 T/3D fast spoiled gradient echo-based DCE MRI ASSESSMENT: Patients underwent MRI at baseline and after four cycles (C4) of NAST, followed by definitive surgery. DCE subtraction images were analyzed in consensus by two breast radiologists with 5 (A.H.A.) and 2 (H.S.M.) years of experience. Tumor volumes (TV) were measured on early and late subtractions. Tumors were segmented on 1 and 2.5-minute early phases subtractions and FTV was determined using optimized signal enhancement thresholds. Interpolated enhancement curves from segmented voxels were used to determine optimal early phase timing. STATISTICAL TESTS: Tumor volumes were compared between patients who had a pathologic complete response (pCR) and those who did not using the area under the receiver operating curve (AUC) and Mann-Whitney U test. RESULTS: About 26 of 60 patients (43%) had pCR. FTV at 1 minute after injection at C4 provided the best discrimination between pCR and non-pCR, with AUC (95% confidence interval [CI]) = 0.85 (0.74,0.95) (P < 0.05). The 1-minute timing was optimal for FTV measurements at C4 and for the change between C4 and baseline. TV from the early phase at C4 also yielded a good AUC (95%CI) of 0.82 (0.71,0.93) (P < 0.05). DATA CONCLUSION: FTV and TV measured at 1 minute after injection can predict response to NAST in TNBC. LEVEL OF EVIDENCE: 1 TECHNICAL EFFICACY: 4.

Music, Movement, and Mind: Use of Drumming to Improve Strength, Balance, Proprioception, Stamina, Coordination, and Emotional Status in a 12-Year-Old With Agenesis of the Corpus Callosum: A Case Study.

The purpose of this article is to report a case study of the effect of therapeutic drumming on motor, communication skills, and behavior of a preteen diagnosed with agenesis of the corpus callosum. This 12-year-old participated in 30- to 45-minute weekly sessions over a 12-month period in which rudimentary drumming exercises were used to analyze and then measure any changes in equilibrium reactions, postural transfers, and trunk control. Measurable documentation evidenced marked improvement in motor skills while suggesting communication and behavioral improvement. The findings support the theory that therapeutic drumming would benefit preteens with agenesis of the corpus callosum, which provides promising evidence to other neurologic developmental diagnoses and therefore indicates a need for further research. While the therapeutic nature of music is well documented, how the listener participates can influence the effect of the music. For example, passive music listening can improve pain or anxiety, however, active music listening with expected intentional action may improve physical, mental, behavioral, and spiritual healing. Active music listening could be a valuable holistic nursing intervention.

Association of Retrospective Peer Review and Positive Predictive Value of Magnetic Resonance Imaging-Guided Vacuum-Assisted Needle Biopsies of Breast.

OBJECTIVE: To evaluate the association between retrospective peer review of breast magnetic resonance imaging-guided vacuum-assisted needle biopsies and positive predictive value of subsequent magnetic resonance imaging-guided biopsies. MATERIALS AND METHODS: In January, 2015, a weekly conference was initiated in our institution to evaluate all breast magnetic resonance imaging-guided vacuum-assisted needle biopsies performed over January 1, 2014-December 31, 2015. During this weekly conferences, breast dynamic contrast-enhanced magnetic resonance imaging findings of 6 anonymized cases were discussed and then the faculty voted on whether they agree with the biopsy indication, accurate sampling and radiology-pathology correlation. We retrospectively reviewed and compared the magnetic resonance imaging indication, benign or malignant pathology rates, lesion types and the positive predictive value of magnetic resonance imaging-guided vacuum-assisted needle biopsy in the years before and after initiating this group peer review. RESULTS: The number of dynamic contrast-enhanced magnetic resonance imaging and magnetic resonance imaging-guided vacuum-assisted needle biopsies before and after initiating the review were 1447 vs 1596 (p=0.0002), and 253 (17.5%) vs 203 (12.7%) (p=0.04), respectively. There was a significant decrease in the number of benign biopsies in 2015 (n=104) compared to 2014 (n=154, p=0.04). The positive predictive value of magnetic resonance imaging-guided biopsy significantly increased after group review was implemented (Positive predictive value in 2014=%39.1 and positive predictive value in 2015=%48.8) (p=0.03), although the indications (p=0.49), history of breast cancer (p=0.14), biopsied magnetic resonance imaging lesion types (p=0.53) were not different. Less surgical excision was performed on magnetic resonance imaging-guided vacuum-assisted needle biopsy identified high-risk lesions in 2015 (p=0.25). CONCLUSION: Our study showed an association between retrospective peer review of past biopsies and increased positive predictive value of magnetic resonance imaging-guided vacuum-assisted needle biopsies in our institution.