Breast Implant Imaging Surveillance Practice: Survey of Breast Imaging Radiologists in the Society of Breast Imaging.

OBJECTIVE: The objectives of this Society of Breast Imaging (SBI)-member survey study were to assess the current imaging patterns for evaluation of symptomatic and asymptomatic breast implant integrity, including modalities used and imaging intervals. METHODS: A 12-question survey assessing the frequency of imaging modalities used to evaluate implant integrity, approximate number of breast implant integrity studies requested per month, intervals of integrity studies, and referring provider and radiology practice characteristics was distributed to members of the SBI. RESULTS: The survey response rate was 7.6% (143/1890). Of responding radiologists, 54.2% (77/142) were in private, 29.6% (42/142) in academic, and 16.2% (23/142) in hybrid practice. Among respondents, the most common initial examination for evaluating implant integrity was MRI without contrast at 53.1% (76/143), followed by handheld US at 46.9% (67/143). Of respondents using US, 67.4% (91/135) also evaluated the breast tissue for abnormalities. Among respondents, 34.1% (46/135) reported being very confident or confident in US for diagnosing implant rupture. There was a range of reported intervals for performing implant integrity studies: 39.1% (43/110) every 2-3 years, 26.4% (29/110) every 4-5 years, 15.5% (17/110) every 6-10 years, and 19.1% (21/110) every 10 years. CONCLUSION: For assessment of implant integrity, the majority of respondents (53.2%, 76/143) reported MRI as initial imaging test. US is less costly, but the minority of respondents (34.1%, 46/135) had confidence in US performance. Also, the minority of respondents (39.1%, 43/110) performed implant integrity evaluations every 2-3 years per the FDA recommendations for asymptomatic surveillance.

Assessing Diagnostic Performance Using the Transverse Plane Plus Coronal Plane Compared With the Transverse Plane Alone in Screening Automated Breast Ultrasound.

OBJECTIVES: The coronal plane is the unique display mode of automated breast (AB) ultrasound (US), which has valuable features of showing the entire breast anatomy and providing additional diagnostic value for breast lesions. However, whether adding the coronal plane could improve the diagnostic performance in screening breast cancer remains uncertain. This study aimed to evaluate the value of adding the coronal plane in interpretation for AB US screening. METHODS: In this retrospective study, AB US images from 644 women (396 in the no-finding group, 143 with benign lesions, and 105 with malignant lesions) aged 40-70 years were collected between January 2016 and October 2020. Four novice radiologists (with 1-5 years of experience with breast US) and four experienced radiologists (with >5 years of experience with breast US) were assigned to read all AB US images in the transverse plane plus coronal plane (T + C planes) and transverse plane (T plane) alone in separate reading sessions. Diagnostic performance, lesion conspicuity, and reading time were compared using analysis of variance. RESULTS: The mean reading time of all radiologists was significantly shorter in the T + C planes reading mode than in the T plane alone (115 ± 32 vs 128 ± 31 s, respectively; P < .05), and cancers had a higher conspicuity (odds ratio, 1.76; 95% confidence interval [CI], 1.00-3.08; P = .04). No significant differences were noted in the two reading modes (T + C planes vs T plane) in the sensitivity (82% [95% CI, 74-89%] vs 81% [95% CI, 74-88%], respectively; P = .68) and specificity (68% [95% CI, 62-75%] vs 70% [95% CI, 64-75%], respectively; P = .39) when Breast Imaging-Reporting and Data System (BI-RADS) 3 was set as the threshold. There were also no significant differences in the two reading modes (T + C planes vs T plane) in the sensitivity (70% [95% CI, 64-76%] vs 69% [95% CI, 63-75%], respectively; P = .39) and specificity (91% [95% CI, 87-96%] vs 91% [95% CI, 88-95%], respectively; P = .90) when BI-RADS 4 was set as the threshold. In addition, the mean areas under the receiver operating characteristic curves of all radiologists in the two reading modes (T + C planes vs T plane) were not significantly different (0.84 [95% CI, 0.79-0.89] vs 0.83 [95% CI, 0.78-0.89], respectively; P = .61). CONCLUSIONS: Adding a coronal plane in the AB US screening setting saved the reading time and improved the conspicuity of breast cancers but not the diagnostic performance.

The Impact of Virtual Reality on Anxiety and Pain During US-Guided Breast Biopsies: A Randomized Controlled Clinical Trial.

OBJECTIVE: To investigate the efficacy of immersive virtual reality (VR) in combination with standard local anesthetic for mitigating anxiety and pain during US-guided breast biopsies compared to local anesthetic alone. METHODS: Patients scheduled for US-guided biopsy were invited to participate. Eligible patients were females 18 years of age or older. Patients were randomized to VR or control group at a 1:1 ratio. Patients in the VR group underwent biopsy with the addition of a VR experience and patients in the control group underwent usual biopsy. Patient-perceived levels of anxiety and pain were collected before and after biopsy via the State-Trait Anxiety Inventory (STAI) and Visual Analog Scale (VAS). Physiological data were captured during biopsy using a clinically validated wristband. Differences in anxiety, pain, and physiologic data were compared between the VR and control group. RESULTS: Sixty patients were enrolled. After excluding 2 patients with VR device malfunction, there were 29 patients in the VR and 29 patients in the control group for analysis. The VR group had reduced anxiety compared to the control group based on postintervention STAI (P <.001) and VAS (P = .036). The VR group did not have lower pain based on postintervention VAS (P = .555). Physiological measures showed higher RR intervals and decreased skin conductance levels, which are associated with lower anxiety levels in the VR group. CONCLUSION: Use of VR in addition to standard local anesthetic for US-guided breast biopsies was associated with reduced patient anxiety. Virtual reality may be a useful tool to improve the patient biopsy experience.

Nonmass Lesions on Breast US: An International Perspective on Clinical Use and Outcomes.

Nonmass lesions (NMLs) on breast US are defined as discrete areas of altered echotexture compared to surrounding breast tissue and lack the 3-dimensionality of a mass. They are not a component of American College of Radiology BI-RADS, but they are a finding type included in the Japan Association of Breast and Thyroid Sonology lexicon. Use of the NML finding is routine in many Asian practices, including the Samsung Medical Center and Seoul National University Hospital, and their features and outcomes have been investigated in multiple studies. Nonmass lesions are most often observed when US is used to evaluate mammographic asymmetries, suspicious calcifications, and nonmass enhancement on MRI and contrast-enhanced mammography. Nonmass lesions can be described by their echogenicity, distribution, presence or absence of associated calcifications, abnormal duct changes, architectural distortion, posterior shadowing, small cysts, and hypervascularity. Malignant lesions, especially ductal carcinoma in situ, can manifest as NMLs on US. There is considerable overlap between the US features of benign and malignant NMLs, and they also must be distinguished from normal variants. The literature indicates that NMLs with linear or segmental distribution, associated calcifications, abnormal duct changes, posterior shadowing, and hypervascularity are suggestive of malignancy, whereas NMLs with only interspersed small cysts are usually benign fibrocystic changes. In this article, we introduce the concepts of NMLs, illustrate US features suggestive of benign and malignant etiologies, and discuss our institutional approach for evaluating NMLs and an algorithm that we use to guide interpretation in clinical practice.

Granular Cell Tumor of the Breast: Radiologic-Pathologic Correlation.

Granular cell tumor (GCT) is an uncommon neoplasm arising from perineural Schwann cells that can arise anywhere in the body and is particularly rare in the breast. Imaging typically shows an irregular, noncalcified mass with high density on mammography and intense posterior shadowing on US that mimics malignancy. Benign GCTs can be locally aggressive and invade the skin or chest wall. Core biopsy is necessary for diagnosis. Polygonal- to spindle-shaped cells with prominent cytoplasmic eosinophilic granules show S-100 and CD68 staining on immunohistochemistry and lack cytokeratin, estrogen, or progesterone expression. The vast majority of GCTs are benign, albeit locally infiltrative, tumors cured by wide local excision.

ACR Appropriateness Criteria® Breast Cancer Screening.

Breast cancer screening recommendations are based on risk factors. For average-risk women, screening mammography and/or digital breast tomosynthesis is recommended beginning at age 40. Ultrasound (US) may be useful as an adjunct to mammography for incremental cancer detection in women with dense breasts, but the balance between increased cancer detection and the increased risk of a false-positive examination should be considered in the decision. For intermediate-risk women, US or MRI may be indicated as an adjunct to mammography depending upon specific risk factors. For women at high risk due to prior mantle radiation between the ages of 10 to 30, mammography is recommended starting 8 years after radiation therapy but not before age 25. For women with a genetic predisposition, annual screening mammography is recommended beginning 10 years earlier than the affected relative at the time of diagnosis but not before age 30. Annual screening MRI is recommended in high-risk women as an adjunct to mammography. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

ACR Appropriateness Criteria® Monitoring Response to Neoadjuvant Systemic Therapy for Breast Cancer.

Patients with locally advanced invasive breast cancers are often treated with neoadjuvant chemotherapy prior to definitive surgical intervention. The primary aims of this approach are to: 1) reduce tumor burden thereby permitting breast conservation rather than mastectomy; 2) promptly treat possible metastatic disease, whether or not it is detectable on preoperative staging; and 3) potentially tailor future chemotherapeutic decisions by monitoring in-vivo tumor response. Accurate radiological assessment permits optimal management and planning in this population. However, assessment of tumor size and response to treatment can vary depending on the modality used, the measurement technique (such as single longest diameter, 3-D measurements, or calculated tumor volume), and varied response of different tumor subtypes to neoadjuvant chemotherapy (such as concentric shrinkage or tumor fragmentation). As discussed in further detail, digital mammography, digital breast tomosynthesis, US and MRI represent the key modalities with potential to help guide patient management. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

The image quality and lesion characterization of breast using automated whole-breast ultrasound: A comparison with handheld ultrasound.

OBJECTIVE: To prospectively evaluate the image quality of automated whole breast ultrasonography (AWUS) in the characterization of breast lesions compared with handheld breast ultrasonography (HHUS). MATERIALS AND METHODS: This prospective study included a total of 411 lesions in 209 women. All patients underwent both HHUS and AWUS prior to biopsy. An evaluation of identical image pairs of 411 lesions obtained from both modalities was performed, and the image quality of AWUS was compared with that of HHUS as a reference standard. The overall image quality was evaluated for lesion coverage, lesion conspicuity, and artifact effect using a graded score. Additionally, the factors that correlated with differences in image quality between the two modalities were analyzed. RESULTS: In 97.1%, the image quality of AWUS was identical or superior to that of HHUS, whereas AWUS was inferior in 2.9%. In only 0.5%, the poor quality of AWUS images caused by incomplete lesion coverage and shadowing due to a contact artifact inhibited precise interpretations. The two main causes resulting in degraded AWUS image quality were blurring of the margin (83.3%) and acoustic shadowing by Cooper's ligament or improper compression pressure of the transducer (66.7%). Among various factors, peripheral location from the nipple (p=0.01), lesion size (p=0.02), shape descriptor (p=0.02), and final American College of Radiology Breast Imaging Reporting and Data System (BI-RADS) category (p=0.001) were correlated with differences in image quality between AWUS and HHUS. CONCLUSION: Although the image quality of AWUS was comparable to that of HHUS for lesion interpretation, HHUS was clearly superior to AWUS for analyzing lesions with a peripheral location, an irregular shape, a non-circumscribed margin and BI-RADS category 4 or 5.

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.

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.

Isolated post-transplantation lymphoproliferative disease involving the breast and axilla as peripheral T-cell lymphoma.

Post-transplantation lymphoproliferative disorders (PTLDs) are a heterogeneous group of diseases that represent serious complications following immunosuppressive therapy for solid organ or hematopoietic-cell recipients. In contrast to B-cell PTLD, T-cell PTLD is less frequent and is not usually associated with Epstein Barr Virus infection. Moreover, to our knowledge, isolated T-cell PTLD involving the breast is extremely rare and this condition has never been reported previously in the literature. Herein, we report a rare case of isolated T-cell PTLD of the breast that occurred after a patient had been treated for allogeneic peripheral blood stem cell transplantation due to acute myeloblastic leukemia.

Isolated Post-Transplantation Lymphoproliferative Disease Involving the Breast and Axilla as Peripheral T-cell Lymphoma

Post-transplantation lymphoproliferative disorders (PTLDs) are a heterogeneous group of diseases that represent serious complications following immunosuppressive therapy for solid organ or hematopoietic-cell recipients. In contrast to B-cell PTLD, T-cell PTLD is less frequent and is not usually associated with Epstein Barr Virus infection. Moreover, to our knowledge, isolated T-cell PTLD involving the breast is extremely rare and this condition has never been reported previously in the literature. Herein, we report a rare case of isolated T-cell PTLD of the breast that occurred after a patient had been treated for allogeneic peripheral blood stem cell transplantation due to acute myeloblastic leukemia.

Standards of the Polish Ultrasound Society - update. Sonomammography examination.

The use of BIRADS classification has been recommended in sonomammography examinations in Poland since the year 2010. It was developed by the Polish Ultrasound Society and published in Ultrasound Examinations Standards of the Polish Ultrasound Society. Standards, based on BIRADS-usg classification, introduced uniformity in breast ultrasound examination descriptions and in the terminology of pathological lesions in breasts. BIRADS-usg classification takes into account breast morphological structure elements and pathological focal lesions in them. It enables the distinction between benign lesions and lesions suspected of being malignant. It contains information on the malignancy risk of focal lesions and proposals of diagnostic-therapeutic algorithms (including biopsy) in relation to lesions of different character. The Polish Ultrasound Society recommends performing prophylactic sonomammography examinations every 12 months in women over the age of 30 because of the increasing breast cancer morbidity in women from all age groups. In this article a spectrum of focal changes in breasts are presented within the relevant BIRADS-usg classification categories. The features of ultrasound morphology, enabling them to be classified to particular categories of BIRADS-usg classification are discussed. Management algorithms which may help clinicians to diagnose breast cancer and to treat it are proposed. Elements of medical history, physical examination, recommended techniques of sonomammography examination performance, technical parameters of ultrasound machine and examination description standards are presented. This article was prepared based on the Ultrasound Examination Standards of the Polish Ultrasound Society which was published in 2011 and updated. It contains numerous pictures visualizing BIRADS-usg classification.

Errors and mistakes in breast ultrasound diagnostics.

Sonomammography is often the first additional examination performed in the diagnostics of breast diseases. The development of ultrasound imaging techniques, particularly the introduction of high frequency transducers, matrix transducers, harmonic imaging and finally, elastography, influenced the improvement of breast disease diagnostics. Nevertheless, as in each imaging method, there are errors and mistakes resulting from the technical limitations of the method, breast anatomy (fibrous remodeling), insufficient sensitivity and, in particular, specificity. Errors in breast ultrasound diagnostics can be divided into impossible to be avoided and potentially possible to be reduced. In this article the most frequently made errors in ultrasound have been presented, including the ones caused by the presence of artifacts resulting from volumetric averaging in the near and far field, artifacts in cysts or in dilated lactiferous ducts (reverberations, comet tail artifacts, lateral beam artifacts), improper setting of general enhancement or time gain curve or range. Errors dependent on the examiner, resulting in the wrong BIRADS-usg classification, are divided into negative and positive errors. The sources of these errors have been listed. The methods of minimization of the number of errors made have been discussed, including the ones related to the appropriate examination technique, taking into account data from case history and the use of the greatest possible number of additional options such as: harmonic imaging, color and power Doppler and elastography. In the article examples of errors resulting from the technical conditions of the method have been presented, and those dependent on the examiner which are related to the great diversity and variation of ultrasound images of pathological breast lesions.

Comparison of Diagnostic Performance of US Elastography and Conventional B-mode US in Differentiation of Breast Lesions

PURPOSE: The purpose of this study was to compare the diagnostic performance of ultrasound (US) elastography and conventional B-mode US for discrimination between benign and malignant breast lesions. MATERIALS AND METHODS: During a 13-month period, 277 women with 335 sonographically visible breast lesions who were scheduled to undergo biopsy were examined with US elastography. Elastographic findings were classified as benign or malignant based on the area ratio, with 1.00 as the threshold. Findings on conventional B-mode US were classified according to the BI-RADS category, as follows: lesions of BI-RADS categories 2 and 3 were considered benign, while those in categories 4 and 5 were considered malignant. Statistical analysis included sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), accuracy, and ROC curve analysis for comparison of the diagnostic performance of US elastography and conventional B-mode US. RESULTS: Of the 335 breast lesions, 85 (25.4%) showed malignancy on pathology. Findings on B-mode US showed malignancy in 264 (78.8%) and elastographic findings showed malignancy in 102 (30.4%). The sensitivity, specificity, PPV, NPV, and accuracy of B-mode US and elastography were 98.8%, 28.0%, 31.8%, 98.6%, and 79.4% and 69.4%, 81.2%, 57.8%, 88.8%, and 79.4%, respectively. Elastography showed significantly higher specificity and PPV and lower sensitivity and NPV, compared with B-mode US (p < 0.001). The area under the ROC curve (AUC value) was 0.761 for elastography, and 0.634 for B-mode US (p < 0.001). CONCLUSIONS: US elastography can improve specificity and PPV of B-mode US, but with significant sacrifice of sensitivity and NPV. Therefore, US elastography may complement B-mode US for differentiation of breast masses.

Current Trends in Breast Ultrasonography

In the last 30 years, technical improvements have directly contributed to expanding sonographic breast imaging applications into the most important adjunctive imaging modality for breast evaluation. Most of these advances have related to improvements in sonographic gray-scale image resolution and contrast, but some applications such as color Doppler imaging, elastography, optical imaging, or three-dimensional ultrasounds have resulted in sonographic information that is uniquely different from grayscale imaging. The current spectrum of new breast sonographic techniques not only offers information uniquely different from gray-scale imaging but also involves hardware advances that affect the method of image production. In this article, we discuss the current trends in breast ultrasonography focusing on the advances to further improve accuracy for breast lesion diagnosis.