Incidental findings on sonography of the breast: clinical significance and diagnostic workup

Contrast-Enhanced Mammography in Local Staging of Screen-Detected Breast Cancer

BACKGROUND

BreastScreen Australia, the population mammographic screening program for breast cancer, uses two-view digital screening mammography ± ultrasound followed by percutaneous biopsy to detect breast cancer. Secondary breast imaging for further local staging, not performed at BreastScreen, may identify additional clinically significant breast lesions. Staging options include further mammography, bilateral ultrasound, and/or contrast-based imaging (CBI) [magnetic resonance imaging (MRI) or contrast-enhanced mammography (CEM)]. CBI for local staging of screen-detected cancer was introduced at an academic hospital breast service in Melbourne, VIC, Australia. We report findings for otherwise occult disease and resulting treatment changes.

MATERIAL AND METHODS

Patients staged using CEM between November 2018 and April 2022 were identified from hospital records. Data were extracted from radiology, pathology, and breast unit databases. CEM-detected abnormalities were documented as true positive (TP) for invasive cancer or ductal carcinoma in situ (DCIS), or otherwise false positive (FP). The impact on surgical decisions was assessed.

RESULTS

Of 202 patients aged 44-84 years, 60 (30%) had 74 additional findings [34 (46%) TP, 40 (54%) FP]. These were malignant in 29/202 (14%) patients (79% invasive cancers, 21% DCIS). CEM resulted in surgical changes in 43/202 (21%) patients: wider resection (24/43), conversion to mastectomy (6/43), contralateral breast surgery (6/43), additional ipsilateral excision (5/43), and bracketing (2/43). Additional findings were more common for patients with larger index lesions and for invasive cancer, but there was no significant variation by age, breast density, or index lesion grade.

CONCLUSIONS

CEM for local staging of screen-detected breast cancers identified occult malignancy in 14% of patients. CEM improves local staging and may facilitate appropriate management of screen-detected breast cancers.

Supplemental Optoacoustic Imaging of Breast Masses: A Cost-Effectiveness Analysis

RATIONALE AND OBJECTIVES

To evaluate the cost-effectiveness of utilizing supplemental optoacoustic ultrasound (OA/US) versus gray-scale ultrasound (US) alone to differentiate benign and malignant breast masses in a diagnostic setting.

MATERIALS AND METHODS

We created a decision-tree model to compare the cost-effectiveness of OA/US and US from the perspective of the US healthcare system. We utilized diagnostic test performance parameters from the PIONEER-01(NCT01943916) clinical trial and cost parameters (USD) from the Truven Health MarketScan Databases. Utility (quality adjusted life year, QALY) values were determined following published patient-reported outcomes. Cost-effectiveness was calculated through incremental cost-effectiveness ratio (USD/QALY, ICER) and net monetary benefit (NMB) in a Markov chain model. Deterministic and probabilistic sensitivity analyses were performed to determine the significance of variation in input parameters. A willingness-to-pay (WTP) threshold of $100,000/QALY was used for the study.

RESULTS

OA/US had an estimated cumulative cost of $16,617.36 and the outcome of 16.85 QALYs in the 25-year period. The incremental NMB for OA/US was $1495.36, and the ICER was -$31,715.82/QALY, indicating that supplemental use of OA/US was more cost-effective than US alone. In the deterministic sensitivity analysis, when the cost of OA/US exceeded $1030.61 or the sensitivity of OA/US fell below 79.7%, or the specificity fell below 30.5%, the US alone strategy yielded higher NMB values compared to supplemental OA/US. According to probabilistic sensitivity analysis, OA/US was the better strategy in 98.69% of 10,000 iterations.

CONCLUSION

OA/US is more cost-effective than US to differentiate benign or malignant breast masses in the diagnostic setting. It can reduce costs while improving patients' quality of life, primarily by reducing false-positive results with consequent benign biopsies.

Joint localization and classification of breast masses on ultrasound images using an auxiliary attention-based framework

Multi-task learning (MTL) methods have been extensively employed for joint localization and classification of breast lesions on ultrasound images to assist in cancer diagnosis and personalized treatment. One typical paradigm in MTL is a shared trunk network architecture. However, such a model design may suffer information-sharing conflicts and only achieve suboptimal performance for individual tasks. Additionally, the model relies on fully-supervised learning methodologies, imposing heavy burdens on data annotation. In this study, we propose a novel joint localization and classification model based on attention mechanisms and a sequential semi-supervised learning strategy to address these challenges. Our proposed framework offers three primary advantages. First, a lesion-aware network with multiple attention modules is designed to improve model performance on lesion localization. An attention-based classifier explicitly establishes correlations between the two tasks, alleviating information-sharing conflicts while leveraging location information to assist in classification. Second, a two-stage sequential semi-supervised learning strategy is designed for model training to achieve optimal performance on both tasks and substantially reduces the need for data annotation. Third, the asymmetric and modular model architecture allows for the flexible interchangeability of individual components, rendering the model adaptable to various applications. Experimental results from two different breast ultrasound image datasets under varied conditions have demonstrated the effectiveness of the proposed method. Furthermore, we conduct comprehensive investigations into the impacts of various factors on model performance, gaining in-depth insights into the mechanism of our proposed framework. The code is available at https://github.com/comp-imaging-sci/lanet-bus.git.

Comparison of Ultrasound Features With Maximum Standardized Uptake Value Assessed by 18F-Fluorodeoxyglucose-Positron Emission Tomography/Computed Tomography for Prognosis of Estrogen Receptor+/Human Epithelial Growth Factor Receptor 2- Breast Cancer

ABSTRACT

estrogen receptor (ER)+/human epithelial growth factor receptor 2 (HER2)- breast cancers have less aggressive traits and a favorable prognosis when treated early. Prediction of prognosis for treatment outcome or survival in ER+/HER2- cancer is important. Ultrasound (US) is an effective and easy technique for breast cancer diagnosis and tumor characterization. Positron emission tomography/computed tomography (PET/CT) is widely used for diagnosis, staging, and therapeutic response in cancer evaluation, and a high maximum standardized uptake value (SUVmax) is associated with poor prognosis. The study aim was to compare the prognostic value of US features with that of the SUVmax assessed by PET/CT in ER+/HER- breast cancer patients. We retrospectively identified breast cancer patients in our institutional database who had undergone preoperative US and PET/CT, and 96 patients with invasive ductal carcinoma and ductal carcinoma in situ were included in this study. The US features of mass shape, margin, echo pattern, orientation, posterior features, boundary, and calcification in the mass were analyzed. We then analyzed the US features to look for correlations with SUVmax and associations with margins, boundaries, posterior features, histological grade, and ki-67 expression. High SUVmax was correlated with irregular shape, not-circumscribed margin, posterior acoustic enhancement, echogenic halo, and calcification in the mass (P < 0.05, all). Posterior acoustic enhancement was correlated with high ki-67 expression. Many US features of ER+/HER- breast cancer showed associations with SUVmax. Some US features of ER+/HER- breast cancer were useful for predicting prognosis.

Digital Breast Tomosynthesis: an Overview

Breast cancer is emerging as the most common malignancy in Indian women. Mammography is one of the few screening modalities available to the modern world that has proved itself of much use by aiding early detection and treatment of non-palpable, node-negative breast cancers. However, due to its two-dimensional nature, many cases of malignancies are still missed, to be detected at a later date or by an alternate modality. In 2011, FDA approved the supplemental use of digital breast tomosynthesis (DBT) in screening and diagnostic set ups. The acquisition of multiple low-dose projection images of the compressed parenchyma provided a 'third' dimension to the mammogram whereby the breast tissue could be seen layer by layer on the workstation. It improves cancer detection rate, and reduces recall rate and false-positive findings by improving lesion characterization. The current review discusses the principle of DBT with a comprehensive study of the literature.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13193-021-01310-y.

Advances in Ultrasound-Guided Vacuum-Assisted Biopsy of Breast Microcalcifications

Microcalcification is one of the significant indications for or can even be the sole mammographic feature of breast cancer, especially occult breast cancer. Biopsy and pathologic examination are the most important methods used to identify the nature of suspicious microcalcifications. Stereotactic vacuum-assisted breast biopsy (S-VAB) is the most commonly used biopsy method for microcalcifications currently because of the high detection rate of mammography for microcalcifications. However, in recent years, several clinical studies have gradually found that ultrasound-guided vacuum-assisted breast biopsy (US-VAB) could be an alternative to S-VAB for microcalcifications to some extent, and has its own advantages of flexibility, real-time performance, comfort and high accessibility compared with mammography. An overview of US-VAB of microcalcifications is provided with respect to success rate, diagnostic accuracy, advantages and limitations. On the basis of numerous studies and clinical experience, US-VAB proved to be a valid alternative to S-VAB, with comparable diagnostic accuracy if the microcalcification foci could be detected by ultrasound. And for patients with ultrasound-invisible microcalcifications who are not suitable for or tolerable of S-VAB, US-VAB combined with mammography localization of microcalcifications can also be considered.

Correlation of ultrasound, cytological, and histological features of 110 benign BI-RADS categories 4C and 5 nonpalpable breast lesions. The Institut Curie's experience

BACKGROUND

The purpose of this study was to determine the pathological and ultrasound (US) features of benign nonpalpable breast lesions (NPBLs) classified as Breast Imaging Reporting and Data System (BI-RADS) category 4C or 5.

METHODS

Between 2003 and 2007, 849 consecutive NPBLs detected at US and classified as BI-RADS category 4C (505) or 5 (344) initially underwent US-guided fine needle aspiration (FNA) at our institution. Benign diagnoses were established according to surgical excision findings or during a minimal 6-month imaging follow-up (mean, 3.7 years [SD, 2.6 years]). US BI-RADS features were reviewed and compared retrospectively using a chi-square test for the following pathological categories: epithelial and fibrous proliferation (EFP), cystic and papillary lesion (C&P), inflammatory lesion (IL), benign tumor (BT), intramammary lymph node (ILN), intraepithelial proliferative lesion (IPL), and nonspecific morphological alteration (NMA). The performance of FNA in the diagnosis of benignity was assessed.

RESULTS

Of 849 NPBLs, 110 (12.9%) NPBLs were benign: 88 (17.4%) were BI-RADS category 4C, and 22 (6.4%) were BI-RADS category 5. Forty-four (40%) were EFPs, 21 (19%) were C&Ps, 13 (12%) were NMAs, 11 (10%) were ILs, 11 (10%) were BTs, 8 (7%) were IPLs, and 2 (2%) were ILNs. Lesion shape, US pattern distribution, and posterior features showed statistically significant differences between these categories (P < .05): 33 (75%) EFPs exhibited posterior shadowing, 18 (86%) C&Ps were homogenous, 9 (82%) ILs were heterogeneous, 11 (100%) BTs were homogeneous, 9 (82%) BTs were oval, and 6 (75%) IPLs were irregularly shaped. Of the 110 benign NPBLs, FNA diagnosis was falsely positive in 7 (6%), suspicious in 10 (9%), and benign in 90 (82%), and 3 (3%) were inadequate for diagnosis.

CONCLUSION

A diverse array of benign NPBLs can be classified as BI-RADS category 4C or 5 on US, each showing specific imaging presentations.

The Role of Contrast-Enhanced Ultrasound in the Diagnosis and Pathologic Response Prediction in Breast Cancer: A Meta-analysis and Systematic Review

PURPOSE

To determine the overall performance of contrast-enhanced ultrasound (CEUS) in differentiating between benign and malignant breast lesions and in predicting the pathologic response to neoadjuvant chemotherapy (NAC) in patients with breast cancer (BC).

MATERIALS AND METHODS

Articles published up to April 2019 were systematically searched in Medline, Web of Science, and China National Knowledge Infrastructure. The sensitivities and specificities across studies, the calculations of positive and negative likelihood ratios (LR⁺ and LR^-), diagnostic odds ratio (OR), and constructed summary receiver operating characteristic curves were determined. Methodologic quality was assessed using the QUADAS (Quality Assessment of Diagnostic Accuracy Studies) tool. Subgroup analyses and metaregression were performed on prespecified study-level characteristics.

RESULTS

Fifty-one studies involving 4875 patients with 5246 breast lesions and 10 studies involving 462 patients with BC receiving NAC were included. Methodologic quality was relatively high, and no publication bias was detected. The overall sensitivity, specificity, diagnostic OR, LR⁺, and LR^- for CEUS were 0.88 (95% confidence interval [CI], 0.86-0.89), 0.82 (95% CI, 0.80-0.83), 30.55 (95% CI, 21.40-43.62), 4.29 (95% CI, 3.51-5.25), and 0.16 (95% CI, 0.13-0.21), respectively, showing statistical heterogeneity. Multivariable metaregression analysis showed contrast mode to be the most significant source of heterogeneity. The overall sensitivity, specificity, LR⁺, LR, and diagnostic OR of CEUS imaging in predicting the overall pathologic response to NAC in patients with BC were 0.89 (95% CI, 0.83-0.93), 0.83 (95% CI, 0.78-0.88), 4.49 (95% CI, 3.04-6.62), 0.16 (95% CI, 0.10-0.24,), and 32.21 (95% CI, 16.74-62.01), respectively, showing mild heterogeneity.

CONCLUSION

Our data confirmed the excellent performance of breast CEUS in differentiating between benign and malignant breast lesions as well as pathologic response prediction in patients with BC receiving NAC.

Multiple Bilateral Circumscribed Breast Masses Detected at Imaging: Review of Evidence for Management Recommendations

OBJECTIVE. Historically, management recommendations for multiple bilateral circumscribed breast masses encountered with breast imaging have varied. This article reviews the evidence and provides best-practice recommendations for managing these masses. CONCLUSION. Meticulous imaging technique and interpretation are required to correctly diagnose multiple bilateral circumscribed breast masses. Radiologists should classify such masses identified at mammography, digital breast tomosynthesis, or bilateral whole-breast sonography as benign and recommend annual follow-up. Elucidating the significance of these masses on MRI, contrast-enhanced mammography, or nuclear breast imaging requires further study.

Screening Breast Ultrasound Using Handheld or Automated Technique in Women with Dense Breasts

In women with dense breasts (heterogeneously or extremely dense), adding screening ultrasound to mammography increases detection of node-negative invasive breast cancer. Similar incremental cancer detection rates averaging 2.1-2.7 per 1000 have been observed for physician- and technologist-performed handheld ultrasound (HHUS) and automated ultrasound (AUS). Adding screening ultrasound (US) for women with dense breasts significantly reduces interval cancer rates. Training is critical before interpreting examinations for both modalities, and a learning curve to achieve optimal performance has been observed. On average, about 3% of women will be recommended for biopsy on the prevalence round because of screening US, with a wide range of 2%-30% malignancy rates for suspicious findings seen only on US. Breast Imaging Reporting and Data System 3 lesions identified only on screening HHUS can be safely followed at 1 year rather than 6 months. Computer-aided detection and diagnosis software can augment performance of AUS and HHUS; ongoing research on machine learning and deep learning algorithms will likely improve outcomes and workflow with screening US.

Association between ultrasound findings, tumor type, grade, and biological markers in patients with breast cancer

Background

This prospective study included 65 female patients with primary breast cancer. Ultrasound was performed for all patients. Ultrasound findings were analyzed according to the ACR BI-RADS lexicon 5th edition and correlated with tumor type, grade, and biological markers (ER, PR, HER-2/neu, and Ki67). The purpose of this study is to assess the association between ultrasound findings, tumor type, grade, and the state of biological markers in patients with breast cancer.

Results

Irregular shape and speculated margins are more frequently associated with invasive duct carcinoma than DCIS (p value < 0.001). There were no association between the ultrasound findings (shape, margin, orientation, echopattern, and posterior features) and the tumor grade (p value 1.0, 0, 0.544, 1.0, and 1.0), respectively. Irregular shape is more frequently seen in ER and PR positive breast cancers (p value = 0.036 and 0.026, respectively). Non-circumscribed margins were frequently seen in PR positive breast cancers (p value = 0.068). No statistically significant difference between US descriptors and HER-2/neu-positive cases.

Conclusion

Irregularly shaped tumors with speculated margins are frequently seen in invasive duct carcinoma and also more frequently seen in ER-, PR-, and Ki67-positive cases. No relation between ultrasound descriptors and the tumor grade of invasive duct carcinoma. Also, there were no relation between ultrasound descriptors and the state of HER-2/neu.

Asymptomatic Complicated Cysts in Postmenopausal Women: Is Tissue Sampling Unnecessarily High?

RATIONALE AND OBJECTIVES

To determine the malignancy rate of complicated cysts in postmenopausal women and to discuss appropriate (Breast Imaging Reporting and Data System assessment and recommendation.

MATERIALS AND METHODS

This study was approved by our institutional review board and informed consent was waived. One hundred fourteen postmenopausal patients with 183 complicated cysts as defined by the newest Breast Imaging Reporting and Data System edition were identified retrospectively between January 2013 and December 2015 (to allow for 2 years follow-up period). One hundred eight complicated cysts were assessed as probably benign and 75 as suspicious. Prospective review of all images and pathology was performed and patient's age, breast density, risk factors, use of hormone replacement therapy, and family history of breast cancer were recorded. A total of 30 symptomatic patients and lesions not meeting criteria for complicated cysts were excluded from our cohort. Benignity was determined by aspiration, biopsy, resolution, recategorization to a simple cyst, or adequate follow-up.

RESULTS

None of our complicated cysts proved malignant. Fifteen of 108 probably benign complicated cysts were aspirated yielding benign fluid in 10 and 5 were biopsied yielding benign pathology (only 2 with atypical cells). Twenty-nine of 75 complicated cysts categorized as suspicious were aspirated and fluid was discarded in 25 and 4 sent for cytology yielding benign pathology. The other 41 complicated cysts thought to be suspicious were biopsied with benign pathology (only 1 atypical).

CONCLUSION

This study supports the use of a probably benign assessment of asymptomatic complicated cysts irrespective of age. The sensitivity for malignancy was 100% in our cohort.

Attributes, Performance, and Gaps in Current & Emerging Breast Cancer Screening Technologies

Background:

Early detection of breast cancer, combined with effective treatment, can reduce mortality. Millions of women are diagnosed with breast cancer and many die every year globally. Numerous early detection screening tests have been employed. A wide range of current breast cancer screening methods are reviewed based on a series of searchers focused on clinical testing and performance. </P><P> Discussion: The key factors evaluated centre around the trade-offs between accuracy (sensitivity and specificity), operator dependence of results, invasiveness, comfort, time required, and cost. All of these factors affect the quality of the screen, access/eligibility, and/or compliance to screening programs by eligible women. This survey article provides an overview of the working principles, benefits, limitations, performance, and cost of current breast cancer detection techniques. It is based on an extensive literature review focusing on published works reporting the main performance, cost, and comfort/compliance metrics considered.

Conclusion:

Due to limitations and drawbacks of existing breast cancer screening methods there is a need for better screening methods. Emerging, non-invasive methods offer promise to mitigate the issues particularly around comfort/pain and radiation dose, which would improve compliance and enable all ages to be screened regularly. However, these methods must still undergo significant validation testing to prove they can provide realistic screening alternatives to the current accepted standards.

Initial clinical results with a fusion prototype for mammography and three-dimensional ultrasound with a standard mammography system and a standard ultrasound probe

BACKGROUND

Combinations *Equal contributors. of different imaging techniques in fusion devices appear to be associated with improvements in diagnostic assessment.

PURPOSE

The aim of this study was to test the feasibility of using an automated standard three-dimensional (3D) ultrasound (US) device fused with standard mammography for the first time in breast cancer patients.

MATERIAL AND METHODS

Digital mammograms and 3D automated US images were obtained in 23 patients with highly suspicious breast lesions. A recently developed fusion machine consisting of an ABVS 3D US transducer from an Acuson S2000 machine and a conventional Mammomat Inspiration device (both Siemens Healthcare GmbH, Erlangen, Germany) were used for the purpose. The feasibility of the examinations, imaging coverage, and patients' experience of the procedure were examined.

RESULTS

In 15 out of 19 patients, the region of interest (ROI) with the tumor marked in the mammogram was visible on US. The examination was experienced positively by the patients, with no unexpected pain or injury. The examination was time-saving and well tolerated.

CONCLUSION

In conclusion, we have shown initial clinical feasibility of an US/radiography fusion prototype with good localization and evaluation of the ROIs. The combined examination was well tolerated. The simultaneous evaluation with mammography and US imaging may be able to improve detection and reduce examiner-related variability.

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

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

Negligible Advantages and Excess Costs of Routine Addition of Breast Ultrasonography to Mammography in Dense Breasts

Aim

To assess the role of breast ultrasonography as a complement to negative mammography in radiologically dense breasts.

Material and methods

Out of a total series of 49,044 consecutive mammograms reported as negative in asymptomatic women, 25,665 (52.3%) were coded as dense (BI-RADS D3–4) and ultrasonography was recommended. Due to organizational problems, ultrasonography was performed immediately or within 1 month only in 5,227 cases, representing the study series.

Results

Two cancers were detected at immediate ultrasonography (0.03%). The cancer detection rate in women aged 40–49 and 50–69 years was 0.002% and 0.07%, respectively. The benign biopsy rate was 0.5% for core biopsies and 0.02% for surgical biopsies. The cost per ultrasonography-assessed woman was € 56.05, whereas the cost per additional mammographically occult but ultrasonography-detected cancer was € 146,496.53. The mammograms of the 2 cancer cases underwent blind review by an expert reader and were confirmed as negative.

Discussion

Our findings show a low cancer detection rate, substantially lower compared to other clinical studies of ultrasonography in dense breasts, though in accordance with preliminary evidence from an Italian randomized clinical trial within a population-based screening program. The policy of adding ultrasonography to negative mammography in dense breasts seems to have very limited cost-effectiveness, and should not be adopted in routine practice before results of ongoing clinical trials are available.

New York State Breast Density Mandate: Follow-up Data With Screening Sonography

OBJECTIVES

To evaluate the impact on breast cancer detection from screening breast sonography performed in women with mammographically dense breasts.

METHODS

This study used a retrospective chart review. Data collected included total number of screening mammograms, total number of dense breast screening sonograms, total number of procedures performed, biopsy results, and demographic data. Data were obtained from January 1, 2013, through August 31, 2015. During this period, there were a total of 195,982 screening mammographic examinations performed at our facility. Of these, 83,234 patients (42.5%) were informed that their breast tissue was heterogeneously dense or extremely dense. We specifically reviewed cases to identify those with findings on sonography only. The positive predictive value, biopsy rate, and cancer detection rate were determined.

RESULTS

During the study period, 5434 screening sonographic examinations were performed in 4898 women with heterogeneously dense or extremely dense breasts. Most (95.7%) of the sonographic examinations resulted in an American College of Radiology Breast Imaging Reporting and Data System (BI-RADS) category 1 or 2 designation. A total of 101 lesions were given a BI-RADS 3 designation; 134 suspicious findings were given a BI-RADS 4 or 5 designation; and 100 of these were seen on sonography only, all of which underwent tissue sampling, resulting in the diagnosis of 18 malignancies; all were invasive. In evaluating screening sonographic findings, we found a positive predictive value of 18.0%, with an overall biopsy rate of 2.0% and a cancer detection rate of 3.3 per 1000.

CONCLUSIONS

The results of our continued evaluation of our screening sonography program confirm that screening breast sonography in women with dense breast tissue can detect otherwise occult malignancy, with a low biopsy rate.

Pilot Investigation into the Use of an Anthropomorphic Breast Sonography Phantom as a Training and Assessment Tool

A device for the training and quantitative assessment of the competency of trainee radiologists in the technically challenging area of breast sonography was developed and evaluated. Currently, suitable commercially available devices are lacking, and there is a growing realization that the reliance on direct exposure to patients for learning may not represent best practice from either the trainees' or patients' perspective. Three devices (PI, PII and PIII) were designed to produce very realistic sonographic images of breast morphology with a range of embedded pathologies. The pilot evaluation used a case study research design to evaluate the role of the anthropomorphic breast sonography training device in training and assessment in a clinical environment. Through the case study, it was possible to evaluate the process and relationships when using this type of training intervention for a small group of radiology resident trainees. The investigation involved a baseline assessment of trainees' (n = 4) ability to detect and characterize all lesions in PI, followed by a 4-wk training period on PII and a post-training assessment using PIII. The evaluation revealed an improvement of 30% ± 8% in the trainee's performance from pre- to post-training. It was expected that the performance of the trainees would improve as the training phantom described in this study aligns with the learning theory of constructivism and fits the ideal specifications of a medical training device in terms of its realism and facilitation of self-directed learning and deliberate practice of the trainees. The device provides a useful platform upon which training and assessment can be facilitated.

Breast Imaging Reporting and Data System Category 3 Lesions Detected on Whole-Breast Screening Ultrasound

Purpose

This study assessed the incidence and cancer rate of probably benign lesions detected on bilateral whole-breast screening ultrasound (US), which corresponded to US Breast Imaging Reporting and Data System (BI-RADS) category 3, and evaluated the proper management of those lesions.

Methods

This study was approved by the Institutional Review Board in our institution, which waived informed patient consent. We retrospectively reviewed US images of 1,666 patients who underwent bilateral whole-breast screening US as a supplemental screening test to negative screening mammography or screening US only. The incidence, clinical course, and cancer rate of screening US-detected probably benign lesions corresponding to US BI-RADS category 3 were investigated, and the size and multiplicity of screening US-detected category 3 lesions were evaluated.

Results

Probably benign lesions corresponding to US BI-RADS category 3 were detected in 689 of 1,666 patients (41.4%) who underwent screening US. Among them, 653 had follow-up US images for at least 24 months, and among these 653, 190 (29.1%) had multiple bilateral category 3 lesions. Moreover, 539 of 1,666 patients (32.4%) had lesions ≤1 cm in size and 114 of 1,666 (6.8%) had lesions >1 cm (median, 0.82 cm; range, 0.3–4.2 cm). Four of the 653 patients (0.6%) showed suspicious interval changes and were categorized into BI-RADS category 4. Biopsy analysis confirmed only one lesion as invasive ductal carcinoma at the 6-month follow-up; another lesion was an intraductal papilloma and the remaining two were fibroadenomas. Overall cancer rate of the screening US-detected BI-RADS category 3 lesions was 0.2%.

Conclusion

The incidence of category 3 lesions detected on screening US only was very high, but the cancer rate was very low. Therefore, in an average-risk population, routine screening US is preferable over short-term follow-up for BI-RADS category 3 lesions detected on whole-breast screening US.

Personal History of Premenopausal Breast Cancer as a Risk Factor for Referral to Screening Breast MRI

RATIONALE AND OBJECTIVES

The purpose of this study was to examine whether patients with premenopausal breast cancer history only can benefit from screening breast magnetic resonance imaging (MRI) by comparing them to patients with both a personal and a family history of breast cancer.

MATERIALS AND METHODS

With Institutional Review Board approval and waiver of informed consent, a retrospective review was conducted to determine patients previously diagnosed with premenopausal breast cancer undergoing screening MRI. From December 2003 to October 31, 2014, a total of 4436 screening MRI examinations were performed; 381 examinations were performed in 131 patients with a personal history (PH) of premenopausal breast cancer. This cohort was evaluated further and revealed 146 examinations in 52 patients with PH only, and 235 examinations in 79 patients with personal history and family history (PHFH). Fisher's exact test was used to compare the distribution between the groups.

RESULTS

Total number of MRI examinations performed per patient ranged from 1 to 10, with an average of 2.9 in the PHFH group and 2.8 in the PH only group. Patient age at time of original diagnosis was significantly different between the groups (P = 0.0391). There were 74 (19.4%) suspicious MRI findings: 27 in the PH only group and 47 in the PHFH group. Fifty-two had needle biopsy tissue sampling performed; three additional lesions were sampled at excision. Malignancy was detected in 27.3%: 53.3% in the PHFH group and 46.7% in the PH only group (P = 0.7963). There was no significant difference when the pathology between the PH only group and the PHFH group was compared (P = 0.5692). Of those diagnosed with cancer, average time between diagnoses was 6.9 years for the PHFH group and 7.1 for the PH only group (range 2-16).

CONCLUSIONS

Patients with a PH only are at a similar risk level as those with additional family history for the development of a subsequent breast cancer and therefore benefit from screening breast MRI, as a similar rate of cancer detection was found in both groups.

US-localized diffuse optical tomography in breast cancer: comparison with pharmacokinetic parameters of DCE-MRI and with pathologic biomarkers

BACKGROUND

To correlate parameters of Ultrasonography-guided Diffuse optical tomography (US-DOT) with pharmacokinetic features of Dynamic contrast-enhanced (DCE)-MRI and pathologic markers of breast cancer.

METHODS

Our institutional review board approved this retrospective study and waived the requirement for informed consent. Thirty seven breast cancer patients received US-DOT and DCE-MRI with less than two weeks in between imaging sessions. The maximal total hemoglobin concentration (THC) measured by US-DOT was correlated with DCE-MRI pharmacokinetic parameters, which included K(trans), k ep and signal enhancement ratio (SER). These imaging parameters were also correlated with the pathologic biomarkers of breast cancer.

RESULTS

The parameters THC and SER showed marginal positive correlation (r = 0.303, p = 0.058). Tumors with high histological grade, negative ER, and higher Ki-67 expression ≥ 20% showed statistically higher THC values compared to their counterparts (p = 0.019, 0.041, and 0.023 respectively). Triple-negative (TN) breast cancers showed statistically higher K(trans) values than non-TN cancers (p = 0.048).

CONCLUSION

THC obtained from US-DOT and K(trans) obtained from DCE-MRI were associated with biomarkers indicative of a higher aggressiveness in breast cancer. Although US-DOT and DCE-MRI both measured the vascular properties of breast cancer, parameters from the two imaging modalities showed a weak association presumably due to their different contrast mechanisms and depth sensitivities.

Recommendations for screening and early detection of common cancers in India

Cancers of the breast, uterine cervix, and lip or oral cavity are three of the most common malignancies in India. Together, they account for about 34% of more than 1 million individuals diagnosed with cancer in India each year. At each of these cancer sites, tumours are detectable at early stages when they are most likely to be cured with standard treatment protocols. Recognising the key role that effective early detection and screening programmes could have in reducing the cancer burden, the Indian Institute for Cytology and Preventive Oncology, in collaboration with the US National Cancer Institute Center for Global Health, held a workshop to summarise feasible options and relevant evidence for screening and early detection of common cancers in India. The evidence-based recommendations provided in this Review are intended to act as a guide for policy makers, clinicians, and public health practitioners who are developing and implementing strategies in cancer control for the three most common cancers in India.

Screening breast ultrasound: past, present, and future

OBJECTIVE. This article discusses breast ultrasound for the detection of breast cancer in the screening environment, as well as strategies for integrating screening breast ultrasound, including automated breast ultrasound. CONCLUSION. Breast density is an increasingly pertinent issue in breast cancer diagnosis. Breast density results in a decrease in the sensitivity of mammography for cancer detection, with a significant increase in the risk of breast cancer. Ultrasound detects additional cancers.

Hybrid algorithm for elastography to visualize both solid and fluid-filled lesions

We propose a novel strain estimation technique that can produce reliable strain images of both solid and fluid-filled lesions. In our method, a kernel-based correlation coefficient technique and a speckle tracking-based strain estimation technique are combined into a single algorithm. The elegance of our algorithm is that fluid-filled lesions are first automatically identified by three selection criteria, and strain in those parts is estimated using the kernel-based correlation coefficient technique. Strain where fluid-filled lesions have not been detected is estimated using a speckle tracking-based algorithm, and then these two estimates are merged to form the final image. Any speckle tracking algorithm can be used in our proposed technique; however, we used a modified version of the direct average spectral strain estimation technique to describe our algorithm. We modified the direct average spectral strain estimation algorithm to track smaller strain variation and to facilitate strain calculation from multiple frames. We describe the performance of our proposed hybrid algorithm using in vivo patient data. Both the solid and fluid-filled lesions are clearly visible in the strain images produced by our proposed approach and are of better quality in terms of contrast-to-noise ratio and border sharpness than the strain images generated by other reported techniques. We also validate the performance of our proposed multiframe technique using experimental phantom data and in vivo patient data. The results reveal that the quality of the strain image can be improved using the multiframe technique compared with its dual-frame counterpart.

Comparison of lesion detection in the transverse and coronal views on automated breast sonography

OBJECTIVES

The purpose of our study was to compare the accuracy of detection of lesions in the coronal and transverse views on automated breast sonography.

METHODS

Three breast radiologists independently interpreted automated breast sonograms from 113 women: 14 with negative findings and 99 with known breast lesions (99 benign and 53 malignant findings). The readers were asked to detect the presence or absence of the abnormalities using the transverse and coronal views in different reading sessions. If a lesion was detected, we evaluated its location, sonographic features, including shape, orientation, margin, boundary type, and echo pattern, and final American College of Radiology Breast Imaging Reporting and Data System assessment category. The reading time was also evaluated.

RESULTS

Of 456 potential detections (152 lesions with 3 readers), 80.5% of the detections were made with the transverse view, and 67.3% were made with the coronal view. The detection rates for both malignant and benign lesions were significantly higher for the transverse view than for the coronal view (P < .001). The reading time for the coronal view was less than that for the transverse view (mean ± SD, 3.83 ± 1.71 versus 5.57 ± 2.21 minutes). The intraclass correlation coefficient values for lesion location, distance from the nipple, and lesion size for both views all exceeded 0.7.

CONCLUSIONS

Although the coronal view on automated breast sonography showed comparable reliability and a shorter reading time, the detection rate for the coronal view was significantly lower than that for the transverse view in both benign and malignant lesions. It is preferable to reserve the coronal view as an additional method to the transverse view.

Improving breast cancer detection using ultrasonography in asymptomatic women with non-fatty breast density

BACKGROUND

Mammography (MX) is a reliable modality for detection of breast cancer in asymptomatic women. Use of additional whole breast ultrasonography (US) for breast cancer screening is widely recognized, in particular in women with dense breast parenchyma.

PURPOSE

To determine the subgroup of women, according to breast density and age, who receive most benefit from US following MX for detection of breast cancer in an asymptomatic condition.

MATERIAL AND METHODS

The study was conducted in asymptomatic women who had non-fatty breast parenchyma using MX and US during January 2006 and December 2007. Mammographic breast density was classified as recommended by ACR BI-RADS lexicon. Non-fatty breast referred to D2, D3, and D4. US was performed by the same radiologists who interpreted MX with a handheld machine during the same visit. Data on demographics, cancer detection rate (CDR), and incremental cancer detection rate (ICDR) were analyzed using 95% confident interval (CI).

RESULTS

Of 14,483 breast cancer screenings in women who had non-fatty breast density, 115 cancers were documented. The mean age of cancer patients was 49.6 years. Of 115 cancers, 105 were evidenced on images (31 with MX alone, 19 with US alone, and 55 with both MX and US). Overall CDR was 7.9 per 1000 examination (95% CI, 6.5-9.5). CDR for MX only (MX-CDR) was 6.5 per 1000 examinations (95% CI, 5.2-7.9). Additional US could significantly improve CDR (P < 0.001; 95% CI, 0.9-2.2); US-ICDR was 1.4 per 1000 examinations. According to age group, the group of 40-59 years had statistically significant improvement of ICDR (P < 0.001). The ICDR was highest in D4 breast density (D4) (US-ICDR = 2.5 per 1000 examinations).

CONCLUSION

Use of US adjunct to MX for detection of breast cancer in asymptomatic non-fatty, average-risk women for detection of breast cancer is a promising diagnostic procedure. A significant benefit was documented, in particular, in women aged 40-59 years old, and in women with D4 breast density.

Comparison of mammography in combination with breast ultrasonography versus mammography alone for breast cancer screening in asymptomatic women

AIM

To compare the agreement of screening breast mammography plus ultrasound and reviewed mammography alone in asymptomatic women.

MATERIALS AND METHODS

All breast imaging data were obtained for women who presented for routine medical checkup at National Cancer Institute (NCI), Thailand from January 2010 to June 2013. A radiologist performed masked interpretations of selected mammographic images retrieved from the computer imaging database. Previous mammography, ultrasound reports and clinical data were blinded before film re-interpretation. Kappa values were calculated to assess the agreement between BIRADS assessment category and BIRADS classification of density obtained from the mammography with ultrasound in imaging database and reviewed mammography alone.

RESULTS

Regarding BIRADS assessment category, concordance between the two interpretations were good. Observed agreement was 96.1%. There was moderate agreement in which the Kappa value was 0.58% (95%CI; 0.45, 0.87). The agreement of BI-RADS classification of density was substantial, with a Kappa value of 0.60 (95%CI; 0.54, 0.66). Different results were obtained when a subgroup of patients aged ≥60 years were analyzed. In women in this group, observed agreement was 97.6%. There was also substantial agreement in which the Kappa value was 0.74% (95%CI; 0.49, 0.98).

CONCLUSIONS

The present study revealed that concordance between mammography plus ultrasound and reviewed mammography alone in asymptomatic women is good. However, there is just moderate agreement which can be enhanced if age- targeted breast imaging is performed. Substantial agreement can be achieved in women aged ≥60. Adjunctive breast ultrasound is less important in women in this group.

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

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

Positive predictive value of additional synchronous breast lesions in whole-breast ultrasonography at the diagnosis of breast cancer: clinical and imaging factors

Purpose:

To evaluate the positive predictive value (PPV) of bilateral whole-breast ultrasonography (BWBU) for detection of synchronous breast lesions on initial diagnosis of breast cancer and evaluate factors affecting the PPV of BWBU according to varying clinicoimaging factors.

Methods:

A total of 75 patients who had synchronous lesions with pathologic confirmation at the initial diagnosis of breast cancer during January 2007 and December 2007 were included. The clinical factors of the patients were evaluated. One observer retrospectively reviewed the imaging studies of the index breast cancer lesion and the synchronous lesion. The PPV for additional biopsy was calculated for BWBU and various clinical and imaging factors affecting the PPV for BWBU were evaluated.

Results:

The overall PPV for additional biopsy was 25.7% (18 of 70). The PPV for synchronous lesions detected both on mammography and BWBU, and detected only on BWBU, was 76.9% (10 of 13) and 14.3% (7 of 49), respectively. There was no clinical factor affecting the PPV for BWBU. Among the imaging factors, ipsilateral location of the synchronous lesion to the index lesion (P=0.06) showed a marginal statistically significant correlation with malignancy in the synchronous breast lesion. A mass with calcification on mammography presentation (P<0.01), presence of calcification among the ultrasonography findings (P<0.01), and high Breast Imaging Reporting and Data System final assessment (P<0.01) were imaging factors that were associated with malignancy in the additional synchronous lesion.

Conclusion:

BWBU can detect additional synchronous malignancy at the diagnosis of breast cancer with a relatively high PPV, especially when mammography findings are correlated with ultrasonographic findings.

Ultrasonography alone for diagnosis of breast cancer in women under 40

INTRODUCTION

Recent guidelines suggest that ultrasonography should be used as the primary imaging modality in women under 40 years of age with mammography being offered if further imaging is required. The aim of this study was to assess the adequacy of ultrasonography and the utility of mammography in this patient group by reviewing the role these imaging techniques had in the diagnosis of breast cancer in our unit.

METHODS

All breast cancers diagnosed in patients 39 years or younger from June 2009 to June 2011 were reviewed. This was a retrospective review of presentation, clinical findings, imaging modality (ultrasonography, mammography, magnetic resonance imaging [MRI]) and histology. Mammography was the primary imaging modality until May 2011 in women between 35 and 39 years of age. Both invasive and intraductal carcinoma were included in the study but lobular carcinoma in situ was excluded.

RESULTS

A total of 2,495 patients were referred to the symptomatic breast clinic in this age group during the study period. Thirty women were identified with either invasive cancer (n=27) or ductal carcinoma in situ (n=3). Twenty-eight patients underwent mammography, graded as uncertain, suspicious or malignant in the majority. Malignancy was missed in one patient. All 30 patients underwent ultrasonography, reported as uncertain, suspicious or malignant, an indication for diagnostic core biopsy. Ultrasonography alone did not miss any cancers but did fail to detect multifocal disease in one patient.

CONCLUSIONS

In this study group, ultrasonography was reliable as the primary imaging modality for women under 40, identifying all cancers in this cohort. Mammography and/or MRI remain essential adjuncts to accurately determine multifocality and/or the extent of disease.

Cystic breast lesions by conventional ultrasonography: sonographic subtype-pathologic correlation and BI-RADS Assessment

INTRODUCTION

Appropriate categorization is very important because the clinical management of each subtype of cystic breast lesions (CBLs) differs. The purpose was to evaluate the sonographic subtype-pathologic correlation, and to identify the effectiveness of the Breast Imaging Reporting and Data System (BI-RADS)-ultrasound (US) for differentiation of benign and malignant CBLs.

MATERIAL AND METHODS

A database from December 1, 2007 and November 30, 2009 was identified in the Department of Diagnostic Ultrasound, Rui Jin Hospital, School of Medicine, Shanghai Jiao Tong University, China. Those patients with palpable or clinical symptomatic breast masses were associated with a cystic component in lesions on breast US. All patients underwent a subsequent fine-needle/core-needle biopsy or surgical excision. The sonographic findings were analyzed according to the BI-RADS-US, and were categorized by two different methods of subtype categorization compared with the pathologic results.

RESULTS

Ninety-nine breast cystic lesions in 83 women were included, among whom 16 patients were identified with bilateral cystic lesions. The total malignancy rate of CBLs was 14.1% (95% confidence interval 7.3-21.0%). Among 99 CBLs, 14 malignant lesions were associated with sonographic appearances of complex cystic lesions, while the remaining subtypes were benign. Shape, margin, echo pattern, orientation, calcification, and vascularity were statistically significantly different between the benign and malignant lesions (p = 0.010, p = 0.004, p < 0.001, p < 0.001, p = 0.036, and p < 0.001, respectively) (degrees of freedom = 1).

CONCLUSIONS

By comparison of the two different methods of subtype categorization of CBLs, the appropriate 5-variety classification should be suggested. The BI-RADS-US was useful for differentiating benign from malignant cystic lesions.

Accuracy of an automated breast volume ultrasound system for assessment of the pre-operative extent of pure ductal carcinoma in situ: comparison with a conventional handheld ultrasound examination

The goal of the study described here was to compare the accuracy of an automated breast volume scanner (ABVS) with that of hand-held ultrasound (HHUS) in assessing the pre-operative extent of pure ductal carcinoma in situ (DCIS). This prospective study consisted of 33 patients with histopathologically proven pure DCIS who received conventional HHUS and ABVS examinations. The discrepancy and correlation coefficients were calculated to assess differences in sizes determined by imaging and histopathologic examination. Mean age was 51.8 y. Mean lesion size as assessed with the ABVS did not differ significantly from that determined by histopathology. Lesion size was adequately estimated, under-estimated or over-estimated with the ABVS in 64%, 15% and 21% of patients, and with HHUS in 42%, 15% and 42%, respectively (p < 0.05). The coefficient of correlation between histopathologic and ABVS measurements was higher than that between histopathologic and HHUS measurements. The ABVS appears to assess the extent of the lesion better than HHUS and can provide more accurate information pre-operatively.

Diagnostic performance of automated breast ultrasound as a replacement for a hand-held second-look ultrasound for breast lesions detected initially on magnetic resonance imaging

To evaluate the diagnostic performance of automated breast ultrasound (ABUS) after breast magnetic resonance imaging (MRI) as a replacement for hand-held second-look ultrasound (HH-SLUS), we evaluated 58 consecutive patients with breast cancer who had additional suspicious lesions on breast MRI. All patients underwent HH-SLUS and ABUS. Three breast radiologists evaluated the detectability, location, characteristics and conspicuity of lesions on ABUS. We also evaluated inter-observer variability and compared the results with HH-SLUS results. Eighty additional suspicious lesions were identified on breast MRI. Fifteen of the 80 lesions (19%) were not detected on HH-SLUS. Eight of the 15 lesions (53%) were detected on ABUS, whereas the remaining 7 were not detected on ABUS. Among the 65 lesions detected on HH-SLUS, only 3 lesions were not detected on ABUS. The intra-class correlation coefficients for lesion location and size all exceeded 0.70, indicating high reliability. Moderate to fair agreement was found for mass shape, orientation, margin and Breast Imaging Reporting and Data System (BI-RADS) final assessment. Therefore, ABUS can reliably detect additional suspicious lesions identified on breast MRI and may help in the decision on biopsy guidance method (US vs. MRI) as a replacement tool for HH-SLUS.

Breast ultrasonography: state of the art

Ultrasonography (US) is an indispensable tool in breast imaging and is complementary to both mammography and magnetic resonance (MR) imaging of the breast. Advances in US technology allow confident characterization of not only benign cysts but also benign and malignant solid masses. Knowledge and understanding of current and emerging US technology, along with the application of meticulous scanning technique, is imperative for image optimization and diagnosis. The ability to synthesize breast US findings with multiple imaging modalities and clinical information is also necessary to ensure the best patient care. US is routinely used to guide breast biopsies and is also emerging as a supplemental screening tool in women with dense breasts and a negative mammogram. This review provides a summary of current state-of-the-art US technology, including elastography, and applications of US in clinical practice as an adjuvant technique to mammography, MR imaging, and the clinical breast examination. The use of breast US for screening, preoperative staging for breast cancer, and breast intervention will also be discussed.

Probably benign lesions at screening breast US in a population with elevated risk: prevalence and rate of malignancy in the ACRIN 6666 trial

PURPOSE

To prospectively validate predefined breast ultrasonographic (US) Breast Imaging Reporting and Data System (BI-RADS) category 3 criteria in a multicenter setting in an elevated-risk population.

MATERIALS AND METHODS

The American College of Radiology Imaging Network 6666 database was reviewed for prospectively defined BI-RADS category 3 lesions. Patient characteristics, lesion US features at initial detection, and work-up recommendations were analyzed with descriptive statistics. Exact 95% confidence intervals (CIs) were given, where appropriate. Lesion reference standard was biopsy or a minimum of 1-year follow-up. In addition, malignancy rate for lesions that had at least 2 years of follow-up data or that had biopsy data was calculated.

RESULTS

Of 2662 participants, 519 (19.5%) had 745 BI-RADS category 3 lesions (25.5% of 2916 US lesions other than simple cysts), with a median size of 7 mm (range, 2-135 mm). The number of new BI-RADS category 3 lesions decreased with year 2-3 screening, but the percentage of new BI-RADS category 3 lesions was stable at 26.4% (506 of 1920 lesions), 23.6% (142 of 601 lesions), and 24.6% (97 of 395 lesions), respectively. Of 745 BI-RADS category 3 lesions, 124 (16.6%) were ultimately sampled for biopsy. Six malignancies (0.8% of BI-RADS category 3 lesions; 95% confidence interval [CI]: 0.3%, 1.7%) occurred in five (1.0%) of 519 participants: Five malignancies were invasive (median size, 10 mm; size range, 2-18 mm), and one was node positive. When the analysis is limited to lesions with at least 2-year follow-up or biopsy, the malignancy rate among BI-RADS category 3 lesions is 0.9% (95% CI: 0.3%, 2.0%). Three malignant BI-RADS category 3 lesions were sampled for biopsy because of a suspicious change at follow-up (two N0 lesions, one each at 6- and 12-month follow-up; one N1 lesion at 24-month follow-up), one was sampled for biopsy because of an upgrade after additional mammography (NX), one was found at mastectomy for another cancer (N0), and one was found at prophylactic contralateral mastectomy in the same patient (NX).

CONCLUSION

As BI-RADS category 3 lesions have a low malignancy rate (0.8%; 95% CI: 0.3%, 1.7%) and only 0.1% of the cancers had suspicious changes at 6-month follow-up and only one (17%; 95% CI: 0.4%, 64%) of six malignancies were node positive at detection (24-month follow-up), a recommendation of 1-year diagnostic follow-up may be appropriate for BI-RADS category 3 lesions detected at screening US. Online supplemental material is available for this article.

Evaluation of screening whole-breast sonography as a supplemental tool in conjunction with mammography in women with dense breasts

OBJECTIVES

The purpose of this study was to evaluate the use and performance of supplemental screening whole-breast sonography in conjunction with mammography in asymptomatic women with dense breast tissue.

METHODS

A total of 28,796 asymptomatic women underwent screening mammography. Among 20,864 women with dense breasts (72%), 8359 underwent additional sonography as part of their screening examinations. We classified women with mammographically dense breasts into mammography-only and mammography-plus-sonography groups. The reference standard was a combination of pathologic results and clinical follow-up at 2 years. We compared the recall rate, cancer detection yield, sensitivity, specificity, and positive predictive value in each group.

RESULTS

Among the 20,864 women with dense breasts, 35 cancers were diagnosed, with a mean size of 13 mm. The cancer detection yield was 0.480 per 1000 women in the mammography-only group and increased to 2.871 in the mammography-plus-sonography group. Of 24 cancers detected in the mammography-plus-sonography group, the mean size was 11 mm, and the axillary lymph nodes were negative in 19 of 20. The sensitivity was significantly higher in the mammography-plus-sonography group than the mammography-only group (100% versus 54.55%; P = .002). The positive predictive values of sonographically prompted biopsy were 11.1% for the mammography-plus-sonography group and 50% for the mammography-only group.

CONCLUSIONS

Supplemental screening whole-breast sonography increases the cancer detection yield by 2.391 cancers per 1000 women with dense breast tissue over that of mammography alone. It is beneficial for increased detection of breast cancers that are predominantly small and node negative; however, it also raises the number of false-positive results.

Sonoelastography in distinguishing benign from malignant complex breast mass and making the decision to biopsy

Objective

To evaluate the additional effect of sonoelastography on the radiologist's ability for distinguishing benign from malignant complex breast masses and to decide whether to perform biopsy by B-mode US.

Materials and Methods

One hundred eighteen complex breast masses (15 malignant lesions, 103 benign lesions) were included. Five blinded readers independently assessed the likelihood of the malignancy score from 1 to 5 for two data sets (B-mode ultrasound alone and B-mode ultrasound with sonoelastography). Elasticity scores were categorized as 0, 1, or 2 based on the degree and distribution of strain of the echogenic component within complex masses. The readers were asked to downgrade the likelihood of the malignancy score when an elasticity score of 0 was assigned and to upgrade the likelihood of the malignancy score when an elasticity score of 2 was assigned. The likelihood of the malignancy score was maintained as it was for the lesions with an elasticity score of 1. The Az values, sensitivities, and specificities were compared.

Results

The Az value of B-mode ultrasound with sonoelastography (mean, 0.863) was greater than that of B-mode ultrasound alone (mean, 0.731; p = 0.001-0.007) for all authors. The specificity of B-mode ultrasound with sonoelastography (mean, 37.1%) was greater than that of B-mode ultrasound alone (mean, 3.8%; p < 0.001) for all readers. The addition of sonoelastography led to changes in decisions. A mean of 33.6% of benign masses were recommended for follow-up instead of biopsy.

Conclusion

For complex breast masses, sonoelastography allows increase in both the accuracy in distinguishing benign from malignant lesions and the specificity in deciding whether to perform biopsy.

Mammography in combination with breast ultrasonography versus mammography for breast cancer screening in women at average risk

BACKGROUND

Breast cancer is the most common malignant disease diagnosed in women worldwide. Screening with mammography has the ability to detect breast cancer at an early stage. The diagnostic accuracy of mammography screening largely depends on the radiographic density of the imaged breasts. In radiographically dense breasts, non-calcified breast cancers are more likely to be missed than in fatty breasts. As a consequence, some cancers are not detected by mammography screening. Supporters of adjunct ultrasonography to the screening regimen for breast cancer argue that it might be a safe and inexpensive approach to reduce the false negative rates of the screening process. Critics, however, are concerned that performing supplemental ultrasonography on women at average risk will also increase the rate of false positive findings and can lead to unnecessary biopsies and treatments.

OBJECTIVES

To assess the comparative effectiveness and safety of mammography in combination with breast ultrasonography versus mammography for breast cancer screening for women at average risk of breast cancer.

SEARCH METHODS

We searched the Cochrane Breast Cancer Group's Specialised Register, MEDLINE (via OvidSP) and EMBASE up until February 2012.To detect ongoing or unpublished studies, we searched the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP), ClinicalTrials.gov and the National Cancer Institute's clinical trial database until June 2012. In addition, we conducted grey literature searches using the following sources: OpenGrey; National Institute of Health RePORTER; Health Services Research Projects in Progress (HSRPROJ); Hayes, Inc. Health Technology Assessment; The New York Academy of Medicine's Grey Literature Index and Conference Papers Index.

SELECTION CRITERIA

For efficacy, we considered randomised controlled trials (RCTs), with either individual or cluster randomisation, and prospective, controlled non-randomised studies with a low risk of bias and a sample size of at least 500 participants.In addition to studies eligible for efficacy, we considered any controlled, non-randomised study with a low risk of bias and a study size of at least 500 participants for the assessment of harms.Our population of interest were women between the ages of 40 and 75 years who were at average risk for breast cancer.

DATA COLLECTION AND ANALYSIS

Two review authors screened abstracts and full-text publications against the inclusion criteria. None of the studies met our inclusion criteria.

MAIN RESULTS

Our review did not detect any controlled studies on the use of adjunct ultrasonography for screening in women at average risk for breast cancer. One ongoing randomised controlled trial was identified (J-START, Japan).

AUTHORS' CONCLUSIONS

Presently, there is no methodologically sound evidence available justifying the routine use of ultrasonography as an adjunct screening tool in women at average risk for breast cancer.

Multiple bilateral circumscribed masses at screening breast US: consider annual follow-up

PURPOSE

To determine prospectively the prevalence and rate of malignancy of multiple bilateral (MB) circumscribed breast masses detected at screening ultrasonography (US) compared with those of other US-depicted masses.

MATERIALS AND METHODS

This institutional review board-approved, HIPAA-compliant prospective trial included women at elevated risk for breast cancer, who gave written informed consent to participate in a study evaluating cancer detection rates for three rounds of annual supplemental screening US at 21 international sites. After exclusions, 2662 participants and 7473 screening studies were included. Physician-performed US studies were interpreted, with blinding to mammography results. Simple cysts were noted. Breast Imaging Reporting and Data System features of all other findings were recorded, with addition of the descriptor MB similar-appearing circumscribed masses (minimum of three total and at least one in each breast), with details of the largest such mass recorded. Rates of malignancy were determined after biopsy or mammographic and US follow-up at a minimum of 11 months. For this analysis, 490 women (1370 screenings) with prior mastectomy were excluded. Descriptive statistics and exact 95% confidence intervals (CIs) were generated.

RESULTS

Of 2172 evaluable participants (6103 screening studies; median age at study entry, 54.0 years; range, 25-91 years), 1454 had unique findings at US. One hundred thirty-five (6.2%) participants had 153 unique MB circumscribed masses, with no malignancies (0% [95% CI: 0%, 2.4%]; 95% CI: 0%, 2.9% for the 127 masses with at least 2 years of follow-up). There were 1319 (60.7%) participants with 2464 non-MB lesions, including 1038 solitary circumscribed masses with a malignancy rate of 0.8% (eight of 1038). Of 836 solitary circumscribed masses with at least 2 years of follow-up, the malignancy rate was 0.4% (three of 836; 95% CI: 0.1%, 1.0%). Of the 135 women with MB circumscribed masses, 82 (60.7%) also had a solitary lesion. Two of these 82 women (2.4%) had cancer.

CONCLUSION

MB similar-appearing circumscribed masses seen at screening US are almost always benign, with no malignancies found among such lesions in this prospective, multicenter experience. These lesions are suitable for diagnostic follow-up in 1 year, with resumption of screening thereafter if they are stable.

Volumetric breast ultrasound as a screening modality in mammographically dense breasts

This investigation is part of an ongoing large scale study using volumetric breast ultrasound (VBUS) as a screening modality in mammographically dense breasts, offering a substantial benefit to MR imaging of the breast in terms of cost and efficiency. The addition of VBUS to mammography in women with greater than 50% breast density resulted in the detection of 12.3 per 1,000 breast cancers, compared to 4.6 per 1,000 by mammography alone with an overall attributable risk of breast cancer of 19.92 (95% confidence level, 16.75–23.61) in our screened population. These preliminary results may justify the cost benefit of implementing the judicious use of VBUS as an alternative to MR imaging of the breast in conjunction with mammography in the dense breast screening population.

Histological analysis of benign breast imaging reporting and data system categories 4c and 5 breast lesions in imaging study

PURPOSE

The objective of this study was to analyze the histology of breast lesions categorized as Breast Imaging Reporting and Data System (BI-RADS) 4c or 5 breast lesions during the imaging evaluation, but diagnosed as benign during the histological evaluation.

MATERIALS AND METHODS

We retrospectively reviewed 71 breast lesions categorized as BI-RADS 4c or 5 during imaging study, but diagnosed as benign upon histological evaluation.

RESULTS

Breast lesions were classified into six groups upon histological analysis: intraductal papilloma (18 cases), inflammatory group (15 cases), fibroepithelial tumor (14 cases), clustered microcalcification (10 cases), minimal histological alteration (10 cases), and adenosis (4 cases). Sclerosis and architectural complexity were associated with most of the biopsies that were morphologically similar to malignancy.

CONCLUSION

Among 71 cases categorized as 4c or 5 during the imaging study, but diagnosed as benign upon histological examination, intraductal papilloma was the most frequently identified histological lesion. These 71 cases exhibited histological characteristics of sclerosis and/or complex/complicated features that should be histologically differentiated from malignancy during evaluation.