ACR Appropriateness Criteria ® Palpable Breast Masses

ACR Appropriateness Criteria® Imaging of Invasive Breast Cancer

As the proportion of women diagnosed with invasive breast cancer increases, the role of imaging for staging and surveillance purposes should be determined based on evidence-based guidelines. It is important to understand the indications for extent of disease evaluation and staging, as unnecessary imaging can delay care and even result in adverse outcomes. In asymptomatic patients that received treatment for curative intent, there is no role for imaging to screen for distant recurrence. Routine surveillance with an annual 2-D mammogram and/or tomosynthesis is recommended to detect an in-breast recurrence or a new primary breast cancer in women with a history of breast cancer, and MRI is increasingly used as an additional screening tool in this population, especially in women with dense breasts. 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 process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Canadian Association of Radiologists Breast Disease Imaging Referral Guideline

The Canadian Association of Radiologists (CAR) Breast Disease Expert Panel consists of breast imaging radiologists, a high-risk breast clinician, a patient advisor, and an epidemiologist/guideline methodologist. After developing a list of 20 clinical/diagnostic scenarios, a systematic rapid scoping review was undertaken to identify systematically produced referral guidelines that provide recommendations for one or more of these clinical/diagnostic scenarios. Recommendations from 30 guidelines and contextualization criteria in the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) for guidelines framework were used to develop 69 recommendation statements across the 20 scenarios. This guideline presents the methods of development and the recommendations for referring asymptomatic individuals, symptomatic patients, and other scenarios requiring imaging of the breast.

The Postoperative Breast: Imaging Findings and Diagnostic Pitfalls After Breast-Conserving Surgery and Oncoplastic Breast Surgery

Breast surgery is the cornerstone of treatment for early breast cancer. Historically, mastectomy and conventional breast-conserving surgery (BCS) were the main surgical techniques for treatment. Now, oncoplastic breast surgery (OBS), introduced in the 1990s, allows for a combination of BCS and reconstructive surgery to excise the cancer while preserving or enhancing the contour of the breast, leading to improved aesthetic results. Although imaging after conventional lumpectomy demonstrates typical postsurgical changes with known evolution patterns over time, OBS procedures show postsurgical changes/fat necrosis in locations other than the lumpectomy site. The purpose of this article is to familiarize radiologists with various types of surgical techniques for removal of breast cancer and to distinguish benign postoperative imaging findings from suspicious findings that warrant further work-up.

Triple assessment breast clinics: The value of clinical core biopsies

BACKGROUND

Triple Assessment Breast Clinics are designed for rapid diagnosis of symptomatic patients. When there is no concordance between clinical and radiological assessment, clinicians perform clinical core biopsies. In patients with a clinically suspicious examination (S4, S5) and normal imaging, clinically guided core biopsy should be performed as per NCCP guidelines. However, substantial research does not exist on the diagnostic value or use of clinical core biopsies in non-suspicious palpable (S3) lesions and practices differ in each health system.

AIMS

The aim of this research was to assess the diagnostic value of clinical core biopsies in nonsuspicious, probably benign palpable breast lesions (S3) where image guided cores were not indicated (R1/R2).

METHODS

The cohort consisted of patients undergoing clinical core biopsies at a Symptomatic Breast Unit from January 2014 to 2019. Data regarding patient demographics, outcome of triple-assessment and incidence of malignancy were obtained from a prospectively maintained database and results were analysed using Minitab 2018.

RESULTS

Three hundred and sixty patients had a clinical core biopsy performed in this period. Clinical examination scores for these patients were S1/S2 (66), S3 (277), S4 (15), and S5 (2). Radiology Scores were R1/R2 (355) and R3(5). Two patients with clinical score S3 (0.6%) were diagnosed with breast cancer due to their clinical cores. Both patients had normal mass imaging. There was no association between uncertain palpable breast lesions (S3), and atypia or malignancy on biopsy results when breast imaging was normal (P = 0.43, χ2 test).

CONCLUSION

Despite clinical core biopsies being used in triple assessment, there is no certainty in their value except that there is high clinical suspicion. Imaging modalities are constantly improving and are already well established. When the patient is assigned a clinical score of S3 and has normal radiology, a clinical core biopsy is not required in most cases.

Prediction of human epidermal growth factor receptor 2 (HER2) status in breast cancer by mammographic radiomics features and clinical characteristics: a multicenter study

OBJECTIVES

To preoperatively evaluate the human epidermal growth factor 2 (HER2) status in breast cancer using mammographic radiomics features and clinical characteristics on a multi-vendor and multi-center basis.

METHODS

This multi-center study included a cohort of 1512 Chinese female with invasive ductal carcinoma of no special type (IDC-NST) from two different hospitals and five devices (1332 from Institution A, used for training and testing the models, and 180 women from Institution B, as the external validation cohort). The Gradient Boosting Machine (GBM) was employed to establish radiomics and multiomics models. Model efficacy was evaluated by the area under the curve (AUC).

RESULTS

The number of HER2-positive patients in the training, testing, and external validation cohort were 245(26.3%), 105 (26.3.8%), and 51(28.3%), respectively, with no statistical differences among the three cohorts (p = 0.842, chi-square test). The radiomics model, based solely on the radiomics features, achieved an AUC of 0.814 (95% CI, 0.784-0.844) in the training cohort, 0.776 (95% CI, 0.727-0.825) in the testing cohort, and 0.702 (95% CI, 0.614-0.790) in the external validation cohort. The multiomics model, incorporated radiomics features with clinical characteristics, consistently outperformed the radiomics model with AUC values of 0.838 (95% CI, 0.810-0.866) in the training cohort, 0.788 (95% CI, 0.741-0.835) in the testing cohort, and 0.722 (95% CI, 0.637-0.811) in the external validation cohort.

CONCLUSIONS

Our study demonstrates that a model based on radiomics features and clinical characteristics has the potential to accurately predict HER2 status of breast cancer patients across multiple devices and centers.

CLINICAL RELEVANCE STATEMENT

By predicting the HER2 status of breast cancer reliably, the presented model built upon radiomics features and clinical characteristics on a multi-vendor and multi-center basis can help in bolstering the model's applicability and generalizability in real-world clinical scenarios.

KEY POINTS

• The mammographic presentation of breast cancer is closely associated with the status of human epidermal growth factor receptor 2 (HER2). • The radiomics model, based solely on radiomics features, exhibits sub-optimal performance in the external validation cohort. • By combining radiomics features and clinical characteristics, the multiomics model can improve the prediction ability in external data.

The Accuracy of Breast Cancer Diagnostic Tools

Background Breast cancer (BC) remains a significant health concern, leading to illness and death among women globally. It is essential to detect BC early using imaging techniques that accurately reflect the final pathology, guiding suitable intervention strategies. Objectives This study aimed to evaluate the agreement between radiological findings and histopathological results in BC cases. Methods We conducted a retrospective review of breast core needle biopsies (CNBs) in women over a six-year period (2017-2022) at Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia. The pathological diagnoses were compared with the findings from preceding radiological investigations. We also compared the tumour sizes in the resection specimens with their radiological counterparts. Results A total of 641 cases were included in the study. Ultrasound (US), mammography, and magnetic resonance imaging (MRI) yielded diagnostic accuracies of 85%, 77.9%, and 86.9%, respectively. MRI had the highest sensitivity at 72.2%, while US had the lowest at 61%. MRI provided the best agreement with the final resected tumor size. By contrast, mammography tended to overestimate the size (41.9%), and US most frequently underestimated it (67.7%). The connection between basal-like molecular subtypes and the Breast Imaging Reporting and Data System (BIRADS)-5 classifications was only statistically significant for MRI (p = 0.04). The luminal subtype was more likely to show speculation in mammography. Meanwhile, BIRADS-4 revealed a considerable number of benign pathologies across all the three modalities. Conclusions MRI demonstrated the highest accuracy, sensitivity, specificity, and positive predictive value (PPV) for diagnosing and estimating the tumor size. Mammography outperformed US in terms of sensitivity and yielded the highest negative predictive value (NPV). US, meanwhile, offered superior specificity, PPV, and accuracy. Therefore, combining these diagnostic methods could yield significant benefits.

Problem-solving Breast MRI

Breast MRI has high sensitivity and negative predictive value, making it well suited to problem solving when other imaging modalities or physical examinations yield results that are inconclusive for the presence of breast cancer. Indications for problem-solving MRI include equivocal or uncertain imaging findings at mammography and/or US; suspicious nipple discharge or skin changes suspected to represent an abnormality when conventional imaging results are negative for cancer; lesions categorized as Breast Imaging Reporting and Data System 4, which are not amenable to biopsy; and discordant radiologic-pathologic findings after biopsy. MRI should not precede or replace careful diagnostic workup with mammography and US and should not be used when a biopsy can be safely performed. The role of MRI in characterizing calcifications is controversial, and management of calcifications should depend on their mammographic appearance because ductal carcinoma in situ may not appear enhancing on MR images. In addition, ductal carcinoma in situ detected solely with MRI is not associated with a higher likelihood of an upgrade to invasive cancer compared with ductal carcinoma in situ detected with other modalities. MRI for triage of high-risk lesions is a subject of ongoing investigation, with a possible future role for MRI in decreasing excisional biopsies. The accuracy of MRI is likely to increase with the use of advanced techniques such as deep learning, which will likely expand the indications for problem-solving MRI. ©RSNA, 2023 Quiz questions for this article are available in the supplemental material.

Role of duct excision surgery in the treatment of pathological nipple discharge and detection of breast carcinoma: systematic review

BACKGROUND

The role of duct excision surgery is not clearly defined in patients with pathological nipple discharge without other clinical and radiological abnormalities. The primary aim of this systematic review was to determine the malignancy rate in patients with pathological nipple discharge after duct excision surgery (microdochectomy/major duct excision). The secondary aims were to determine the recurrence rate of pathological nipple discharge after surgery and to assess breast cancer development after surgery.

METHODS

MEDLINE and Embase were searched from inception to March 2023, using search terms related to 'nipple discharge', 'nipple fluid', 'microdochectomy', 'duct excision', and 'minimally invasive surgical procedure'. Studies reporting data about women who underwent duct excision surgery for pathological nipple discharge without clinical and radiological suspicion of breast cancer, as well as reporting data on women diagnosed with breast cancer after duct excision surgery, were included.

RESULTS

A total of 318 titles were identified, of which nine publications were included in the analysis. This resulted in 1108 patients with pathological nipple discharge who underwent a duct excision. The weighted mean rate of malignancy after duct excision surgery was 8.1 per cent (ranging from 2.3 to 13.5 per cent). Three studies described the recurrence rate of pathological nipple discharge (ranging from 0 to 12 per cent) and two studies reported breast cancer development in the follow-up in a total of three patients (less than 1 per cent).

CONCLUSION

The malignancy rate after duct excision surgery for pathological nipple discharge was low in patients with pathological nipple discharge without radiological and clinical abnormalities and approximately 9 of 10 patients undergo surgery for a benign cause. Improvement of the diagnostic and therapeutic workup is needed to prevent patients from undergoing (unnecessary) exploratory surgery.

Imaging of breast cancer-beyond the basics

Imaging of breast cancer is the backbone of breast cancer screening, diagnosis, preoperative/treatment assessment and follow-up. The main modalities are mammography, ultrasound and magnetic resonance imaging, each with its own advantages and disadvantages. New emerging technologies have also enabled each modality to improve on their weaknesses. Imaging-guided biopsies have allowed for accurate diagnosis of breast cancer, with low complication rates. The purpose of this article is to review the common modalities for breast cancer imaging in current practice with emphasis on the strengths and potential weaknesses, discuss the selection of the best imaging modality for the specific clinical question or patient population, and explore new technologies / future directions of breast cancer imaging.

Attitudes of Practicing Radiologists Toward the Management of Palpable Circumscribed Breast Masses

OBJECTIVE

To investigate the attitudes of radiologists toward palpable breast masses with benign features on US and to determine the factors influencing their decision.

METHODS

A 20-question online questionnaire was sent to radiologists with membership of the Iranian Society of Radiology and included questions regarding demographics, practice experience, and management approach to palpable circumscribed breast masses based on patient age and risk factors. Radiologists' management choice for masses in themselves or close relatives/friends was also queried.

RESULTS

In total, 151 radiologists participated (response rate 16%). For palpable breast masses with benign imaging features in women at high risk, the majority of radiologists selected MRI (95/151, 62.9%) and core-needle biopsy (110/151, 72.8%). In average-risk patients, radiologists with >5 years of practice experience selected biopsy more frequently (33/79, 41.8%) than less experienced radiologists (17/79, 23.6%) for patients ≥40 years old (P < 0.001) and patients <40 years old (20/79, 25.3%; 11/72, 15.3%, respectively) (P = 0.014). Similarly, selecting biopsy was more common in radiologists who completed a breast imaging fellowship for patients ≥40 years old (23/45, 51.1% vs 27/106, 25.5%) (P = 0.04), as well as for patients <40 years old (18/45, 40% vs 13/106, 12.3%) (P = 0.02). Radiologists who were <40 years old selected biopsy more frequently if evaluating a mass in themselves (22/86, 25.6%) compared to patients (15/86, 17.4%) (P < 0.001).

CONCLUSION

Radiologist experience and educational background, as well as patient baseline breast cancer risk, can predispose radiologists to choose biopsy for palpable breast masses despite a benign appearance on imaging.

Breast Ultrasound Volume Sweep Imaging: A New Horizon in Expanding Imaging Access for Breast Cancer Detection

OBJECTIVE

The majority of people in the world lack basic access to breast diagnostic imaging resulting in delay to diagnosis of breast cancer. In this study, we tested a volume sweep imaging (VSI) ultrasound protocol for evaluation of palpable breast lumps that can be performed by operators after minimal training without prior ultrasound experience as a means to increase accessibility to breast ultrasound.

METHODS

Medical students without prior ultrasound experience were trained for less than 2 hours on the VSI breast ultrasound protocol. Patients presenting with palpable breast lumps for standard of care ultrasound examination were scanned by a trained medical student with the VSI protocol using a Butterfly iQ handheld ultrasound probe. Video clips of the VSI scan imaging were later interpreted by an attending breast imager. Results of VSI scan interpretation were compared to the same-day standard of care ultrasound examination.

RESULTS

Medical students scanned 170 palpable lumps with the VSI protocol. There was 97% sensitivity and 100% specificity for a breast mass on VSI corresponding to 97.6% agreement with standard of care (Cohen's κ = 0.95, P < .0001). There was a detection rate of 100% for all cancer presenting as a sonographic mass. High agreement for mass characteristics between VSI and standard of care was observed, including 87% agreement on Breast Imaging-Reporting and Data System assessments (Cohen's κ = 0.82, P < .0001).

CONCLUSIONS

Breast ultrasound VSI for palpable lumps offers a promising means to increase access to diagnostic imaging in underserved areas. This approach could decrease delay to diagnosis for breast cancer, potentially improving morbidity and mortality.

Management of Intraductal Papilloma of the Breast Diagnosed on Core Needle Biopsy: Latest Controversies

Intraductal papillomas (IDPs), including central papilloma and peripheral papilloma, are common in the female population. Due to the lack of specific clinical manifestations of IDPs, it is easy to misdiagnose or miss diagnose. The difficulty of differential diagnosis using imaging techniques also contributes to these conditions. Histopathology is the gold standard for the diagnosis of IDPs while the possibility of under sample exists in the percutaneous biopsy. There have been some debates about how to treat asymptomatic IDPs without atypia diagnosed on core needle biopsy (CNB), especially when the upgrade rate to carcinoma is considered. This article concludes that further surgery is recommended for IDPs without atypia diagnosed on CNB who have high-risk factors, while appropriate imaging follow-up may be suitable for those without risk factors.

Artificial Intelligence for Breast US

US is a widely available, commonly used, and indispensable imaging modality for breast evaluation. It is often the primary imaging modality for the detection and diagnosis of breast cancer in low-resource settings. In addition, it is frequently employed as a supplemental screening tool via either whole breast handheld US or automated breast US among women with dense breasts. In recent years, a variety of artificial intelligence systems have been developed to assist radiologists with the detection and diagnosis of breast lesions on US. This article reviews the background and evidence supporting the use of artificial intelligence tools for breast US, describes implementation strategies and impact on clinical workflow, and discusses potential emerging roles and future directions.

No sonographer, no radiologist: Assessing accuracy of artificial intelligence on breast ultrasound volume sweep imaging scans

Breast ultrasound provides a first-line evaluation for breast masses, but the majority of the world lacks access to any form of diagnostic imaging. In this pilot study, we assessed the combination of artificial intelligence (Samsung S-Detect for Breast) with volume sweep imaging (VSI) ultrasound scans to evaluate the possibility of inexpensive, fully automated breast ultrasound acquisition and preliminary interpretation without an experienced sonographer or radiologist. This study was conducted using examinations from a curated data set from a previously published clinical study of breast VSI. Examinations in this data set were obtained by medical students without prior ultrasound experience who performed VSI using a portable Butterfly iQ ultrasound probe. Standard of care ultrasound exams were performed concurrently by an experienced sonographer using a high-end ultrasound machine. Expert-selected VSI images and standard of care images were input into S-Detect which output mass features and classification as "possibly benign" and "possibly malignant." Subsequent comparison of the S-Detect VSI report was made between 1) the standard of care ultrasound report by an expert radiologist, 2) the standard of care ultrasound S-Detect report, 3) the VSI report by an expert radiologist, and 4) the pathological diagnosis. There were 115 masses analyzed by S-Detect from the curated data set. There was substantial agreement of the S-Detect interpretation of VSI among cancers, cysts, fibroadenomas, and lipomas to the expert standard of care ultrasound report (Cohen's κ = 0.73 (0.57-0.9 95% CI), p<0.0001), the standard of care ultrasound S-Detect interpretation (Cohen's κ = 0.79 (0.65-0.94 95% CI), p<0.0001), the expert VSI ultrasound report (Cohen's κ = 0.73 (0.57-0.9 95% CI), p<0.0001), and the pathological diagnosis (Cohen's κ = 0.80 (0.64-0.95 95% CI), p<0.0001). All pathologically proven cancers (n = 20) were designated as "possibly malignant" by S-Detect with a sensitivity of 100% and specificity of 86%. Integration of artificial intelligence and VSI could allow both acquisition and interpretation of ultrasound images without a sonographer and radiologist. This approach holds potential for increasing access to ultrasound imaging and therefore improving outcomes related to breast cancer in low- and middle- income countries.

Approach to the patient with a palpable breast mass

ABSTRACT

Breast mass is a common finding in patients presenting to primary care, women's health, or urgent care clinics. There are multiple etiologies that can cause a palpable breast mass both benign and malignant. PAs must know how to approach a patient with a palpable breast mass as well as what appropriate diagnostic evaluation is needed.

Comparison of emergency pediatric breast ultrasound interpretations and management recommendations between pediatric radiologists and breast imaging radiologists

PURPOSE

Pediatric patients with breast-related symptoms often initially present to the emergency department for evaluation. While pediatric radiologists are accustomed to evaluating acute infectious and traumatic etiologies, they may be less familiar with breast-specific findings. This study compares management recommendations of pediatric breast ultrasounds performed in the emergency setting between pediatric and breast imaging radiologists.

METHODS

This retrospective cohort study reviewed data from all pediatric breast ultrasounds performed in the emergency setting from a single academic institution from 1/1/14 to 12/31/19. During the study period, 12 pediatric radiologists with experience ranging from 1 to 33 years interpreted pediatric breast ultrasounds. Three breast imaging radiologists (with 3, 8, and 25 years of experience) retrospectively reviewed each case and recorded whether further management was recommended. Differences in recommendations were compared using Fisher's exact test. Cohen's kappa was used to assess agreement between subspecialty radiologists.

RESULTS

This study included 75 pediatric patients, with mean age 13 ± 5.6 years and malignancy rate of 1.3% (1/75). Pediatric radiologists and the most experienced breast imaging radiologist had moderate agreement in management recommendations (k = 0.54). There was no significant difference in recommendations for further management between pediatric radiologists (22/75 [29.3%]) and the most experienced breast imaging radiologist (15/75 [20.0%]), p = 0.26.

CONCLUSION

Recommendations for pediatric breast complaints in the emergency setting are comparable between subspecialties.

ACR Appropriateness Criteria® Imaging of the Axilla

This publication reviews the current evidence supporting the imaging approach of the axilla in various scenarios with broad differential diagnosis ranging from inflammatory to malignant etiologies. Controversies on the management of axillary adenopathy results in disagreement on the appropriate axillary imaging tests. Ultrasound is often the appropriate initial imaging test in several clinical scenarios. Clinical information (such as age, physical examinations, risk factors) and concurrent complete breast evaluation with mammogram, tomosynthesis, or MRI impact the type of initial imaging test for the axilla. Several impactful clinical trials demonstrated that selected patient's population can received sentinel lymph node biopsy instead of axillary lymph node dissection with similar overall survival, and axillary lymph node dissection is a safe alternative as the nodal staging procedure for clinically node negative patients or even for some node positive patients with limited nodal tumor burden. This approach is not universally accepted, which adversely affect the type of imaging tests considered appropriate for axilla. This document is focused on the initial imaging of the axilla in various scenarios, with the understanding that concurrent or subsequent additional tests may also be performed for the breast. 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.

Non-BRCA Early-Onset Breast Cancer in Young Women

The incidence of breast cancer in younger women is rising. Although early-onset breast cancer is highly associated with biologically aggressive tumors such as triple-negative and human epidermal growth factor 2 (HER2)-positive cancers, the more recent increase is disproportionately driven by an increase in the incidence of luminal cancer. In particular, the increase in de novo stage IV disease and the inherent age-based poorer survival rate among younger women with even early-stage luminal cancers suggest underlying distinct biologic characteristics that are not well understood. Further contributing to the higher number of early-onset breast cancers is pregnancy-associated breast cancer (PABC), which is attributed to persistent increases in maternal age over time. Although guidelines for screening of patients who carry a BRCA1 or BRCA2 gene mutation are well established, this population comprises only a fraction of those with early-onset breast cancer. A lack of screening in most young patients precludes timely diagnosis, underscoring the importance of early education and awareness. The disproportionate disease burden in young women of certain racial and ethnic groups, which is further exacerbated by socioeconomic disparity in health care, results in worse outcomes. An invited commentary by Monticciolo is available online. ^©RSNA, 2022.

Benefit of digital breast tomosynthesis in symptomatic young women (≤30 years) diagnosed with BI-RADS category 4 or 5 on ultrasound

AIM

To evaluate the addition of digital breast tomosynthesis (DBT) in the diagnosis of breast lesions in symptomatic young Chinese women (≤30 years) diagnosed with Breast Imaging Reporting and Data System (BI-RADS) category 4 or 5 on ultrasound, and demonstrate the potential use of combining DBT with ultrasound.

MATERIALS AND METHODS

This retrospective analysis included 5 years of digital mammography (DM) and DBT data (January 2015 to July 2020). In total, 768 DBT and DM examinations were performed in 713 young women. The results were determined by pathological assessment. Diagnostic performance was measured based on the sensitivity, specificity, accuracy, positive predictive value (PPV), negative predictive value (NPV), and receiver operating characteristic area under the curve (AUC).

RESULTS

Compared with DM alone, DBT + DM increased the sensitivity from 82.5% to 93.2%, specificity from 70.8% to 84%, accuracy from 74% to 86.5%, NPV from 93.6% to 97.4% (all p<0.01). The AUC of DBT + DM (0.946, 95% confidence interval [CI]: 0.927-0.960) was greater than that of DM (0.884, 95% CI: 0.859-0.905; p<0.001). The differences in the BI-RADS category distributions of malignant and benign lesions were both statistically significant (p<0.001). DM alone led to 36 false-negative diagnoses, whereas the inclusion of DBT identified breast cancer in 22 of those cases. There were 4.9% (10/206) false-negative diagnoses in ultrasound. After adding DBT, four breast cancers were detected. An additional six breast cancers were diagnosed by biopsy based on an assessment of BI-RADS 4A by DBT/DM.

CONCLUSION

DBT + DM significantly improves the diagnostic performance in this young population, especially in young people with higher breast density. Moreover, DBT is an effective supplementary examination to ultrasound.

ACR Appropriateness Criteria® Transgender Breast Cancer Screening

Breast cancer screening recommendations for transgender and gender nonconforming individuals are based on the sex assigned at birth, risk factors, and use of exogenous hormones. Insufficient evidence exists to determine whether transgender people undergoing hormone therapy have an overall lower, average, or higher risk of developing breast cancer compared to birth-sex controls. Furthermore, there are no longitudinal studies evaluating the efficacy of breast cancer screening in the transgender population. In the absence of definitive data, current evidence is based on data extrapolated from cisgender studies and a limited number of cohort studies and case reports published on the transgender community. 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.

Can Ultrasound Elastography Help Better Manage Mammographic BI-RADS Category 4 Breast Lesions?

BACKGROUND

To assess the performance of conventional ultrasound (US) combined with strain elastography (SE) in the Breast Imaging Reporting and Data System (BI-RADS) category 4 lesions on mammography.

MATERIALS AND METHODS

Women with breast lesions identified as having mammography BI-RADS 4 lesions and underwent US examination were included in China. US features and US BI-RADS assessment were recorded in real-time and prospectively reported. The pathological result was referred to as the gold standard. The performance of US in the mammographic BI-RADS category 4 lesions was evaluated. Diagnostic performances of US BI-RADS, SE and combined both were compared.

RESULTS

A total of 751 women with 751 breast lesions classified as mammographic BI-RADS category 4 were included. For mammographic findings, 530 (70.6%) were true positive and 221 (29.4%) were false positive. Conventional US achieved higher positive predictive value (PPV) than mammography (78.5% vs. 70.6%, P=.001). The specificity increased from 34.4% to 47.1% (P< .001) without any loss in sensitivity and the PPV increased to 81.9% (P = .122) when conventional US was used in combination with SE. For conventional US combined with SE, it led to a correct diagnosis of no breast cancer in 104 of the 221 false-positive findings (47.1%) and achieved higher PPV than mammography regardless of patient age and lesion size.

CONCLUSION

Conventional US combined with SE is a helpful tool for the noninvasive examination of breast lesions classified as BI-RADS category 4 on mammography. It helped increase the PPV and had the potential to avoid unnecessary biopsies of BI-RADS category 4 lesions detected on mammography.

Breast development in pediatric patients from birth to puberty: physiology, pathology and imaging correlation

Breast tissue undergoes a series of changes from birth to puberty. The majority of the changes are transient, related to physiological hormonal changes. Although the breast is identical in both sexes at birth, its histology and development will eventually differ. It is important for radiologists to have a basic understanding of endocrinological changes and appearance on imaging to avoid potential pitfalls, particularly on ultrasound, which is the primary modality used to evaluate the breast.

Ectopic mammary tissue in vulva: case report and systematic literature review

Objective

To report the case of a patient diagnosed with ectopic mammary tissue in the vulva, and to conduct a literature review of the diagnosis, treatment and prognosis of this condition in that location.

Materials and Methods

A 49-year-old patient who presented with a painful vulvar mass to a private intermediate complexity center in Bogotá, Colombia. The lesion was assessed on ultrasound and then surgically excised; histopathology showed ectopic mammary tissue with absence of malignancy. A search was conducted in the PubMed, Embase, Cochrane, LILACS and Scielo databases using the keywords “Vulva,” “Breast” and “Ectopic.” Case reports and case series of women with histopathology-confirmed mammary tissue in the vulva were included.

Results

Overall, 184 titles were identified and, of these, 94 were ultimately included, for a total of 126 cases, with 57.9% being benign tumors, 95% in women under 50 years of age, and 42.06% being malignant tumors, 92% in women over 50 years of age. Diagnosis was made on the basis of the clinical findings, with ancillary diagnostic imaging, tumor markers and immunohistochemistry in some cases. Local excision was performed in 91% of cases with benign pathology and in 43% of cases with malignant pathology, with the diagnostic method being therapeutic.

Conclusions

Ectopic mammary tissue in the vulva must be considered as part of the differential diagnosis of vulvar masses, prognosis being different in pre and postmenopausal women. Further studies are needed to enhance the characterization of this condition and define the ideal course of treatment in terms of relapse and survival.

Invasive lobular carcinoma mammographic findings: correlation with age, breast composition, and tumour size

Purpose

The aim of this study was to evaluate mammographic findings associated with invasive lobular carcinoma in different age groups, taking into account breast composition and tumour size.

Material and methods

A total of 1023 invasive lobular carcinoma preoperative mammograms were evaluated. According to the American College of Radiology Breast Imaging Reporting and Data System, cancer mammographic findings were classified as mass, calcifications, architectural distortion, and asymmetry, and breasts were assessed as dense (C or D breast composition) or non-dense (A or B). The patient cohort was subdivided into 3 age groups (< 50, 50-69, ≥ 70 years of age). In order to make the size and age groups dichotomous variables and to perform multiple regression analysis, a cut-off of 10 mm was chosen for tumour size, and < 50-years-old and 50-69-years-old age groups were grouped together (< 70-years-old age group).

Results

Significant results of multivariate analysis were the association between mass finding and non-dense breasts and size ≥ 10 mm (p < 0.0001), between calcifications, and dense breasts, size < 10 mm and < 70-years-old age group (p < 0.0001), between distortion and < 70-years-old age group (p = 0.0366), and between asymmetry and ≥ 70-years-old age group (p = 0.0090).

Conclusions

Various mammographic findings are differently associated with age group, breast composition, and tumour size.

Metastatic Breast Cancer Masked as Constipation

Even though screening mammography has been attributed to decreased mortality in recent decades, breast cancer is one of the leading causes of death among women in the United States. Disruption of screening protocols and variation in the presentation may alter the course of detection and management. We report a case of hormone receptor-positive breast cancer that presented as vague gastrointestinal symptoms in a patient with a delayed workup for a self-discovered breast lump during the coronavirus disease global pandemic.

A 48-year-old woman with a history of gastroesophageal reflux and hypertension presented to the emergency department with primary complaints of constipation and abdominal distention with associated flatus and nausea. Vitals were within normal limits, and physical examination was notable for abdominal distention and diffuse tenderness to palpation. Labs demonstrated hypercalcemia and an unremarkable complete blood count. A chest X-ray showed a right hilar mass, and a CT chest revealed multiple lytic bone lesions diffusely scattered throughout the entire skeleton; no hilar mass was noted on the CT chest. A CT scan of the abdomen and pelvis incidentally revealed a right breast mass. A bone marrow biopsy identified invasive ductal carcinoma. Mammography and biopsy of the breast mass identified estrogen receptor/progesterone receptor-positive invasive ductal carcinoma, consistent with the bone marrow biopsy, confirming the diagnosis of metastatic breast cancer.

Unpredicted disruptions in screening processes may result in delayed cancer diagnoses. This case illustrates the importance of routine self-breast examinations, screening mammography, and maintaining a broad differential diagnosis.

Breast cancer in young women: Imaging and clinical course

The purpose of this study was to characterize presenting imaging findings in women younger than 40 diagnosed with invasive breast cancer in the context of pathology and clinical course. Retrospective chart and imaging reviews were performed in patients under 40 diagnosed with breast cancer between July 1, 2004, and December 31, 2013. Patient demographic, imaging, pathology, and clinical data were collected. Overall and recurrence-free survival were estimated using the Kaplan-Meier method. Univariate Cox proportional hazards models were performed to identify factors associated with recurrence-free survival. Our study cohort consisted of 110 patients with invasive mammary carcinoma. One hundred one (91.8%) presented with a palpable mass. The mean size of all lesions on imaging was 3.5 cm ± 2.9 cm. Malignant calcifications were present in 54 (49.1%) cases. Imaging demonstrated multifocal or multicentric disease in 45 (40.9%) cases. Seventy four (67.3%) cancers were high grade. Luminal genomic subtypes were the most common (n = 61, 55.5%). At presentation, 4 (3.6%) patients had bilateral malignancy and 8 (7.3%) patients had distant metastatic disease. Ninety seven (88.2%) underwent neoadjuvant chemotherapy and 67 (60.9%) underwent radiation therapy. Seventy five (68.2%) of the patients underwent mastectomy. The restricted mean time to recurrence was 9.01 years (standard error 3.162 months). ER positivity was associated with compromised recurrence-free survival. The overall survival rate was 0.962 at 10 years. Young patients diagnosed with breast cancer typically present with advanced breast imaging findings and undergo aggressive treatment. Recurrence often occurs >5 years from diagnosis, and ER positive subtypes are at increased risk for recurrence.

Incidental Breast Findings on Computed Tomography and MR Imaging

Computed tomography (CT) and magnetic resonance (MR) imaging may demonstrate a wide variety of incidental findings in the breast, including primary breast carcinoma, the second most common cancer in women. It important to recognize the spectrum of pathologic conditions in order to properly assess the need for further workup. Some findings may be diagnosed as benign on the basis of CT/ MR imaging and clinical history alone, whereas others will require evaluation with dedicated breast imaging and possibly biopsy. This article serves to guide radiologists' management of the wide spectrum of incidental breast findings encountered on cross-sectional imaging.

Low-grade adenosquamous carcinoma of the breast: a review with focus on imaging and management

Low-grade adenosquamous carcinoma is a less frequent variant of metaplastic breast carcinoma, incidentally detected during screening and has an age distribution similar to other breast carcinomas. It shares characteristics with both benign and malignant carcinomas: its mammographic and sonographic features are therefore nonspecific. Breast conserving surgery with adjuvant radiation therapy is currently the preferred therapeutic approach. The aim of this review is to describe the imaging and clinical features of low-grade adenosquamous carcinoma for appropriate identification and diagnosis. The associated pitfalls, histopathologic and epidemiologic factors, natural course, and management of low-grade adenosquamous carcinoma are also discussed.

Mastitis and More: A Pictorial Review of the Red, Swollen, and Painful Breast

Clinically, acute mastitis presents as a red, swollen, and painful breast. Targeted ultrasound can be performed to evaluate the extent of infection and for an underlying abscess. Noncomplicated mastitis or a small fluid collection may respond to oral antibiotics without further intervention, but a larger or more complex abscess may require single or serial percutaneous aspiration. Breast infections, particularly those complicated by an abscess, can have a prolonged clinical course, and close follow-up is required. Since the clinical presentation and imaging features of acute infectious mastitis can overlap with other etiologies, such as inflammatory breast cancer and idiopathic granulomatous mastitis, a percutaneous biopsy may be indicated to accurately diagnose patients.

US as the Primary Imaging Modality in the Evaluation of Palpable Breast Masses in Breastfeeding Women, Including Those of Advanced Maternal Age

Background Women are increasingly delaying childbearing, and thus lactation, into their 30s and 40s, when mammography would typically be the initial imaging modality to evaluate palpable masses in the general population. Current guidelines recommend US as the first-line imaging modality for palpable masses in pregnant and lactating women, but data regarding breastfeeding women age 30 years and older are near nonexistent. Purpose To evaluate the diagnostic performance of targeted US as the primary imaging modality for the evaluation of palpable masses in lactating women, including those of advanced maternal age. Materials and Methods Lactating women with palpable breast masses evaluated at targeted US over a 17-year period (January 2000 to July 2017) were retrospectively identified. All US evaluations were performed at diagnostic evaluation, and mammography was performed at the discretion of the interpreting radiologist. Breast Imaging Reporting and Data System assessments, imaging, and pathology results were collected. Descriptive statistics and 2 × 2 contingency tables were assessed at the patient level. Results There were 167 women (mean age, 35 years ± 5 [standard deviation]), 101 of whom (60%) were of advanced maternal age (≥35 years). All women underwent targeted US, and 98 (59%) underwent mammography in addition to US. The frequency of malignancy was five of 167 (3.0%). Targeted US demonstrated a sensitivity and specificity of five of five (100%; 95% confidence interval [CI]: 48%, 100%) and 114 of 162 (70%; 95% CI: 63%, 77%), respectively. Negative predictive value, positive predictive value of an abnormal examination, and positive predictive value of biopsy were 114 of 114 (100%; 95% CI: 97%, 100%), five of 53 (9.4%; 95% CI: 3%, 21%), and five of 50 (10%; 95% CI: 3%, 22%), respectively. In the subset of 98 women who underwent mammography in addition to US, mammography depicted seven incidental suspicious findings, which lowered the specificity from 62 of 93 (67%; 95% CI: 56%, 76%) to 57 of 93 (61%; 95% CI: 51%, 71%) (P = .02). Conclusion Targeted US depicted all malignancies in lactating women with palpable masses. Adding mammography increased false-positive findings without any additional cancer diagnoses. © RSNA, 2020 See also the editorial by Newell in this issue.

Current Recommendations for Breast Imaging of the Pregnant and Lactating Patient

During pregnancy and lactation, the breast undergoes unique changes that manifest as varied clinical and imaging findings. Understanding the expected physiologic changes of the breast as well as recognizing the best imaging modalities for a given clinical scenario can help the radiologist identify the abnormalities arising during this time. Discussion with the patient about the safety of breast imaging can reassure patients and improve management. This article reviews the physiologic changes of the breast during pregnancy and lactation; the safety and utility of various imaging modalities; upto-date consensus on screening guidelines; recommendations for diagnostic evaluation of breast pain, palpable abnormalities, and nipple discharge; and recommendations regarding advanced modalities such as breast MRI. In addition, the commonly encountered benign and malignant entities affecting these patients are discussed.

Primum non nocere: Utility and outcomes of pediatric breast ultrasound

PURPOSE

To assess the use and outcomes of ultrasound for the evaluation of breast signs and symptoms in pediatric females.

METHODS

A retrospective database review identified all patients ≤18-years-old who underwent breast ultrasound at an academic institution over a 20-year period. Each symptomatic site was designated a case and analyses were performed on each case. Imaging findings were obtained from the radiology reports. Clinical and pathology data were obtained from the medical records. Descriptive statistics were performed.

RESULTS

The final cohort comprised 124 cases in 101 patients. Mean age was 15 years (range 1-18). The most common indication for ultrasound was a palpable lump (71%). Thirty-seven cases (30%) demonstrated no sonographic correlate to the symptom; 36 (29%) had a benign correlate. The most common benign correlates were abscess/phlegmon and cyst. All cases of abscess/phlegmon had infectious symptoms. Fifty-one cases (41%) demonstrated a sonographic mass that was not characteristically benign. Of these indeterminate masses, 27 were recommended for biopsy, 13 for short-interval follow-up, and 6 had no recommendation. Of 27 biopsied masses, 63% were fibroadenomas. No symptoms were due to malignancy. Therefore, the NPV of ultrasound was 100% and the PPV 0%.

CONCLUSION

In this cohort of pediatric and adolescent patients, malignancy was never the cause of breast symptoms. Imaging yielded false positives with a biopsy recommendation in 22% of cases. Ultrasound provided value in evaluating infectious symptoms. Given the extreme rarity of breast cancer in this population, surveillance may be a safe alternative for most indeterminate lesions.

Contrast-enhanced spectral mammography (CESM) in women presenting with palpable breast findings

OBJECTIVE

Palpable breast abnormalities in women warrant diagnostic evaluation. Contrast-enhanced spectral mammography (CESM) is a novel technique which has demonstrated early promising results in the diagnostic imaging setting. The purpose of this study was to evaluate the role of CESM for imaging of palpable breast abnormalities and compare it to the current routine imaging work-up.

MATERIALS AND METHODS

This retrospective study included women with palpable breast masses who underwent diagnostic CESM and ultrasound between 2012 and 2019. Diagnostic parameters for low-energy images, CESM and targeted ultrasound were calculated and compared. Analysis was performed at the lesion level. Additional incidental findings were reported separately.

RESULTS

Included in this study were 138 women with 147 palpable breast abnormalities, of which 38 were cancers. Standard 2D mammography revealed 36/38 cancers (sensitivity 94.7%). All 38 cancers (100%) were detected at CESM and at targeted ultrasound. Negative predictive value for 2D mammography was 97.8% (91/93), and 100% for both ultrasound (74/74) and for CESM (80/80). None of the palpable masses that were negative at CESM but positive at ultrasound (n = 13) were malignant. Two additional incidental cancers were detected with CESM at the contralateral breast to the palpable lump.

CONCLUSION

CESM could be useful for assessment of palpable breast abnormalities, potentially decreasing the number of unnecessary benign biopsies performed.

Artificial Intelligence for Mammography and Digital Breast Tomosynthesis: Current Concepts and Future Perspectives

Although computer-aided diagnosis (CAD) is widely used in mammography, conventional CAD programs that use prompts to indicate potential cancers on the mammograms have not led to an improvement in diagnostic accuracy. Because of the advances in machine learning, especially with use of deep (multilayered) convolutional neural networks, artificial intelligence has undergone a transformation that has improved the quality of the predictions of the models. Recently, such deep learning algorithms have been applied to mammography and digital breast tomosynthesis (DBT). In this review, the authors explain how deep learning works in the context of mammography and DBT and define the important technical challenges. Subsequently, they discuss the current status and future perspectives of artificial intelligence-based clinical applications for mammography, DBT, and radiomics. Available algorithms are advanced and approach the performance of radiologists-especially for cancer detection and risk prediction at mammography. However, clinical validation is largely lacking, and it is not clear how the power of deep learning should be used to optimize practice. Further development of deep learning models is necessary for DBT, and this requires collection of larger databases. It is expected that deep learning will eventually have an important role in DBT, including the generation of synthetic images.

Locoregional Cancer Recurrence after Breast Reconstruction: Detection, Management, and Secondary Reconstructive Strategies

BACKGROUND

Locoregional recurrence of the previously reconstructed breast poses a diagnostic and operative challenge. This study examines detection, management, and reconstructive strategies of locoregional recurrence following postmastectomy breast reconstruction.

METHODS

A retrospective review of records was performed on patients treated within the health system for breast cancer from January of 2000 to July of 2014. Of these patients, descriptive factors and operative details were collected for those that developed locoregional recurrence. Subsequent reconstructive operations were also examined. Using a multidisciplinary team, a surveillance/management algorithm was generated.

RESULTS

A total of 41 patients with locoregional recurrence were identified (mean time to recurrence, 4.6 years). Two- and 5-year survival following locoregional recurrence was 88 percent and 39 percent, respectively. Locoregional recurrence was found to occur in the following tissue planes: subcutaneous (27 percent), subcutaneous/pectoralis (24 percent), chest wall (37 percent), and axillary (12 percent). The most frequent method of detection was patient concern leading to examination. Older age at the time of locoregional recurrence (p = 0.028), increased time to recurrence/detection (p = 0.024), and chemotherapy before locoregional recurrence (p = 0.014) were associated with the need for a secondary salvage flap. Patients who experienced a subcutaneous recurrence were far less likely to undergo a secondary flap (p = 0.011). Factors associated with loss of the index reconstruction included lower body mass index (p = 0.009), pectoralis invasion (p = 0.05), and implant reconstruction (p = 0.03).

CONCLUSIONS

Detection and management of locoregional recurrence requires appropriate physical examination and imaging. Significant factors associated with failure to salvage the initial reconstruction included body mass index, plane of recurrence, and type of initial reconstruction.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

ABM Clinical Protocol #30: Breast Masses, Breast Complaints, and Diagnostic Breast Imaging in the Lactating Woman

A central goal of The Academy of Breastfeeding Medicine is the development of clinical protocols, free from commercial interest or influence, for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient.

ACR Appropriateness Criteria® Breast Imaging of Pregnant and Lactating Women

Breast imaging during pregnancy and lactation is challenging due to unique physiologic and structural breast changes that increase the difficulty of clinical and radiological evaluation. Pregnancy-associated breast cancer (PABC) is increasing as more women delay child bearing into the fourth decade of life, and imaging of clinical symptoms should not be delayed. PABC may present as a palpable lump, nipple discharge, diffuse breast enlargement, focal pain, or milk rejection. Breast imaging during lactation is very similar to breast imaging in women who are not breast feeding. However, breast imaging during pregnancy is modified to balance both maternal and fetal well-being; and there is a limited role for advanced breast imaging techniques in pregnant women. Mammography is safe during pregnancy and breast cancer screening should be tailored to patient age and breast cancer risk. Diagnostic breast imaging during pregnancy should be obtained to evaluate clinical symptoms and for loco-regional staging of newly diagnosed PABC. 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.