Supplementary screening sonography in mammographically dense breast: pros and cons

Breast Cancer Detection on Dual-View Sonography via Data-Centric Deep Learning

Goal: This study aims to enhance AI-assisted breast cancer diagnosis through dual-view sonography using a data-centric approach. Methods: We customize a DenseNet-based model on our exclusive dual-view breast ultrasound dataset to enhance the model's ability to differentiate between malignant and benign masses. Various assembly strategies are designed to integrate the dual views into the model input, contrasting with the use of single views alone, with a goal to maximize performance. Subsequently, we compare the model against the radiologist and quantify the improvement in key performance metrics. We further assess how the radiologist's diagnostic accuracy is enhanced with the assistance of the model. Results: Our experiments consistently found that optimal outcomes were achieved by using a channel-wise stacking approach incorporating both views, with one duplicated as the third channel. This configuration resulted in remarkable model performance with an area underthe receiver operating characteristic curve (AUC) of 0.9754, specificity of 0.96, and sensitivity of 0.9263, outperforming the radiologist by 50% in specificity. With the model's guidance, the radiologist's performance improved across key metrics: accuracy by 17%, precision by 26%, and specificity by 29%. Conclusions: Our customized model, withan optimal configuration for dual-view image input, surpassed both radiologists and existing model results in the literature. Integrating the model as a standalone tool or assistive aid for radiologists can greatly enhance specificity, reduce false positives, thereby minimizing unnecessary biopsies and alleviating radiologists' workload.

Exploring age-standardized cancer incidence rates and regional disparities: A retrospective cohort study of 8 major cancers in South Korea

BACKGROUND

We analyzed trends in cancer incidence and regional disparities of eight major types of cancer in Korea.

METHODS

This retrospective cohort study used the data of 17 cities/provinces from the Korea Central Cancer Registry (1999-2020) in South Korea. Age-standardized incidence rates (per 100,000 person-years), between-group variance (per 100,000 person-years)2, and annual percentage changes ( %) were calculated for the eight most common malignancies. Joinpoint regression was utilized to identify the points at which significant changes occur in cancer incidence or regional disparity trends over time to characterize these trends.

RESULTS

The incidence of stomach cancer decreased as regional disparity decreased and that of colorectal cancer initially increased but recently declined, showing fluctuations in regional disparity. The incidence and regional disparity in liver cancer decreased. The incidence of lung cancer remained stable, with reduced regional disparities. The incidence of breast cancer rose with increasing regional disparity, whereas the incidence of cervical cancer decreased, accompanied by decreased regional disparity. A significant increase in prostate cancer was found, with initially reduced regional disparities but later showed a resurgence. The incidence of thyroid cancer fluctuated alongside variations in regional disparities.

CONCLUSION

This study revealed cancer incidence and regional variations in each cancer type in Korea. More studies are needed to understand the underlying factors and potential interventions for reducing cancer incidence and addressing regional disparity.

Evaluation of the Value of Multiplex MicroRNA Analysis as a Breast Cancer Screening in Korean Women under 50 Years of Age with a High Proportion of Dense Breasts

This study was conducted to confirm the performance of the microRNA (miRNA) biomarker combination as a new breast cancer screening method in Korean women under the age of 50 with a high percentage of dense breasts. To determine the classification performance of a set of miRNA biomarkers (miR-1246, 202, 21, and 219B) useful for breast cancer screening, we determined whether there was a significant difference between the breast cancer and healthy control groups through box plots and the Mann–Whitney U-test, which was further examined in detail by age group. To verify the classification performance of the 4 miRNA biomarker set, 4 classification methods (logistic regression, random forest, XGBoost, and generalized linear model plus random forest) were applied, and 10-fold cross-validation was used as a validation method to improve performance stability. We confirmed that the best breast cancer detection performance was achievable in patients under 50 years of age when the set of 4 miRNAs were used. Under the age of 50, the 4 miRNA biomarkers showed the highest performance with a sensitivity of 85.29%, specificity of 93.33%, and area under the curve (AUC) of 0.961. Examining the results of 4 miRNA biomarkers was found to be an effective strategy for diagnosing breast cancer in Korean women under 50 years of age with dense breasts, and hence has the potential as a new breast cancer screening tool. Further validation in an appropriate screening population with large-scale clinical trials is required.

Role of elastography for downgrading BI-RADS category 4a breast lesions according to risk factors

BACKGROUND

Elastography has been introduced as an additional diagnostic tool to ultrasonography (US) which helps clinicians decide whether or not to perform biopsy on US-detected lesions.

PURPOSE

To evaluate the role of strain elastography in downgrading Breast Imaging Reporting and Data System (BI-RADS) category 4a breast lesions according to personal risk factors for breast cancer in asymptomatic women.

MATERIAL AND METHODS

Strain elastography features of a total of 255 asymptomatic category 4a lesions were classified as soft and not soft (intermediate and hard). Malignancy was confirmed by surgery or biopsy, and benignity was confirmed by surgery or biopsy with no change on US for at least six months. Malignancy rates of lesions with soft and not soft elastography were calculated according to the presence of risk factors.

RESULTS

Of 255 lesions, 25 (9.8%) were malignant and 230 (90.2%) were benign. Of 195 lesions in average-risk women, the malignancy rate of lesions with soft elastography was 1.5% (1/68), which was significantly lower than the 14.2% (18/127) of lesions with not soft elastography ( P = 0.004). Of 60 lesions in increased-risk women, the malignancy rate of lesions with soft elastography was 15.0% (3/20), which was not significantly different from the 7.5% (3/40) of lesions with not soft elastography ( P = 0.390).

CONCLUSION

In average-risk women, category 4a lesions with soft elastography could be followed up with US because of a low malignancy rate of 1.5%.

Interobserver agreement in breast ultrasound categorization in the Mammography and Ultrasonography Study for Breast Cancer Screening Effectiveness (MUST-BE) trial: results of a preliminary study

Purpose

The purpose of this study was to record and evaluate interobserver agreement as quality control for the modified categorization of screening breast ultrasound developed by the Alliance for Breast Cancer Screening in Korea (ABCS-K) for the Mammography and Ultrasonography Study for Breast Cancer Screening Effectiveness (MUST-BE) trial.

Methods

Eight breast radiologists with 4-16 years of experience participated in 2 rounds of quality control testing for the MUST-BE trial. Two investigators randomly selected 125 and 100 cases of breast lesions with different ratios of malignant and benign lesions. Two versions of the modified categorization were tested. The initially modified classification was developed after the first quality control workshop, and the re-modified classification was developed after the second workshop. The re-modified categorization established by ABCS-K added size criteria and the anterior-posterior ratio compared with the initially modified classification. After a brief lecture on the modified categorization system prior to each quality control test, the eight radiologists independently categorized the lesions using the modified categorization. Interobserver agreement was measured using kappa statistics.

Results

The overall kappa values for the modified categorizations indicated moderate to substantial degrees of agreement (initially modified categorization and re-modified categorization: κ=0.52 and κ=0.63, respectively). The kappa values for the subcategories of category 4 were 0.37 (95% confidence interval [CI], 0.24 to 0.52) and 0.39 (95% CI, 0.31 to 0.49), respectively. The overall kappa values for both the initially modified categorization and the re-modified categorization indicated a substantial degree of agreement when dichotomizing the interpretation as benign or suspicious.

Conclusion

The preliminary results demonstrated acceptable interobserver agreement for the modified categorization.

Breast ultrasonography for detection of metachronous ipsilateral breast tumor recurrence

BACKGROUND

Early detection of recurrence improves the survival rate of patients treated with breast conservation therapy (BCT). Therefore, ultrasonography (US) may be useful for metachronous ipsilateral breast tumor recurrence (MIBTR) obscured on mammography by dense breast tissue and distortion.

PURPOSE

To evaluate clinical, radiologic, and pathologic findings of MIBTR retrospectively, and to assess the role of surveillance US additional to mammography for MIBTR detection.

MATERIAL AND METHODS

During 2000 to 2012, 28 MIBTR were collected and reviewed among 2958 women treated for primary breast cancer with conservation surgery. The detection rates of imaging studies for identifying metachronous ipsilateral lesions were assessed and compared. MIBTR tumor staging was evaluated according to imaging modality for detection of MIBTR, palpability, and recent imaging surveillance.

RESULTS

No significant difference was observed in the detection rate between mammography and US for overall MIBTR (84.2% vs. 85.7%; P = 0.898) or non-palpable MIBTR (88.2% vs. 81.0%; P = 0.566). US alone identified 33.3% of non-palpable MIBTRs (seven of 21). Among these cases, two had negative mammograms. All 14 MIBTRs with recent imaging surveillance were stage T2 or less, and all seven MIBTRs detected by US alone were in situ or T1; 33% of MIBTRs without recent imaging surveillance were T3 or T4.

CONCLUSION

The overall MIBTR detection rate by US was not higher than the detection rate of mammography, although combined surveillance with US and mammography found MIBTRs slightly earlier than mammography alone.

Contrast enhanced dual energy spectral mammogram, an emerging addendum in breast imaging

OBJECTIVE

To assess the role of contrast-enhanced dual-energy spectral mammogram (CEDM) as a problem-solving tool in equivocal cases.

METHODS

44 consenting females with equivocal findings on full-field digital mammogram underwent CEDM. All the images were interpreted by two radiologists independently. Confidence of presence was plotted on a three-point Likert scale and probability of cancer was assigned on Breast Imaging Reporting and Data System scoring. Histopathology was taken as the gold standard. Statistical analyses of all variables were performed.

RESULTS

44 breast lesions were included in the study, among which 77.3% lesions were malignant or precancerous and 22.7% lesions were benign or inconclusive. 20% of lesions were identified only on CEDM. True extent of the lesion was made out in 15.9% of cases, multifocality was established in 9.1% of cases and ductal extension was demonstrated in 6.8% of cases. Statistical significance for CEDM was p-value <0.05. Interobserver kappa value was 0.837.

CONCLUSION

CEDM has a useful role in identifying occult lesions in dense breasts and in triaging lesions. In a mammographically visible lesion, CEDM characterizes the lesion, affirms the finding and better demonstrates response to treatment. Hence, we conclude that CEDM is a useful complementary tool to standard mammogram. Advances in knowledge: CEDM can detect and demonstrate lesions even in dense breasts with the advantage of feasibility of stereotactic biopsy in the same setting. Hence, it has the potential to be a screening modality with need for further studies and validation.

The Use of Ultrasound in Breast Cancer Screening of Asymptomatic Women with Dense Breast Tissue: A Narrative Review

INTRODUCTION

Mammography is the standard screening modality for breast cancer; however, sensitivity reduces with increasing breast density, resulting in the potential for masking of cancer. Ultrasound is a potential supplemental screening tool, but its routine use is controversial.

METHODS

A database search was performed with keywords "ultrasound" and "breast density and screening", including variations. Articles were included if they assessed the use of hand-held ultrasound as a supplemental screening modality in women with dense breasts.

DISCUSSION

Twelve articles were identified. No high-level evidence articles were identified. Cancer detection rates increased with the addition of ultrasound-to-mammography screening protocols. However, this was associated with increased costs per cancer detected, an increased biopsy rate, and a low positive predictive value. The survival benefit, cost versus benefit, and psychological impact of the addition of ultrasound is unknown.

CONCLUSIONS

The addition of ultrasound to a screening program in an asymptomatic population of women with dense breast tissue detects additional cancers compared with mammography alone. Knowledge regarding a survival or cost benefit associated with increased cancer detection, and the psychological impact of the addition of ultrasound is unknown. Further research is needed to assess whether the addition of ultrasound is cost-effective with respect to clinical outcome and survival.

Differential diagnosis of breast masses in South Korean premenopausal women using diffuse optical spectroscopic imaging

Young patients with dense breasts have a relatively low-positive biopsy rate for breast cancer (∼1 in 7). South Korean women have higher breast density than Westerners. We investigated the benefit of using a functional and metabolic imaging technique, diffuse optical spectroscopic imaging (DOSI), to help the standard of care imaging tools to distinguish benign from malignant lesions in premenopausal Korean women. DOSI uses near-infrared light to measure breast tissue composition by quantifying tissue concentrations of water (ctH2O), bulk lipid (ctLipid), deoxygenated (ctHHb), and oxygenated (ctHbO2) hemoglobin. DOSI spectral signatures specific to abnormal tissue and absent in healthy tissue were also used to form a malignancy index. This study included 19 premenopausal subjects (average age 41±9), corresponding to 11 benign and 10 malignant lesions. Elevated lesion to normal ratio of ctH2O, ctHHb, ctHbO2, total hemoglobin (THb=ctHHb+ctHbO2), and tissue optical index (ctHHb×ctH2O/ctLipid) were observed in the malignant lesions compared to the benign lesions (p<0.02). THb and malignancy index were the two best single predictors of malignancy, with >90% sensitivity and specificity. Malignant lesions showed significantly higher metabolism and perfusion than benign lesions. DOSI spectral features showed high discriminatory power for distinguishing malignant and benign lesions in dense breasts of the Korean population.

Diagnostic Yield of Fine-Needle Aspiration for Axillary Lymph Nodes During Screening Breast Ultrasound

The purpose of our study was to assess the positive predictive value (PPV) of ultrasound (US)-guided fine-needle aspiration (FNA) and the cancer detection rate for incidentally detected abnormal axillary lymph node (LN) in patients who underwent screening US. We retrospectively reviewed 72 LNs of 69 patients (mean age, 44.9 years) who underwent US-FNA for incidentally detected abnormal axillary LNs on 50,488 screening US from January 2005 to December 2011. The PPV of US-FNA and the cancer detection rate were calculated. We evaluated US images for lymph node size, abnormal findings (hilum loss, eccentric cortical thickening, round shape, extranodal extension, or marked hypoechoic cortex), and mammography for the identification of abnormal LNs. The PPV of each finding was also calculated. The PPV of US-FNA and the cancer detection rate were 2.8% (2/72) and 0.004% (2/50,488), respectively. The mean (SD) measurements for long-axis, short-axis, and cortical thickening of the LNs were 14.9 (5.9) mm, 8.5 (3.5) mm, and 5.8 (2.8) mm, respectively. Of the positive LNs, US findings of hilum loss, eccentric cortical thickening, and extranodal extension were found, and each corresponding PPV was 6.3% (1/16), 1.8% (1/56), and 14.3% (1/7), respectively. The PPV of mammography was 14.3% (1/7). Our results suggest that the PPVs of US-FNA and the cancer detection rate for incidentally detected abnormal axillary LNs during screening US are too low to recommend axillary US during breast US screening and that follow-up is acceptable for abnormal LNs detected during screening breast US that do not have extranodal extension or are negative on mammography.

Mammographic Breast Density Evaluation in Korean Women Using Fully Automated Volumetric Assessment

The purpose was to present mean breast density of Korean women according to age using fully automated volumetric assessment. This study included 5,967 screening normal or benign mammograms (mean age, 46.2 ± 9.7; range, 30-89 years), from cancer-screening program. We evaluated mean fibroglandular tissue volume, breast tissue volume, volumetric breast density (VBD), and the results were 53.7 ± 30.8 cm(3), 383.8 ± 205.2 cm(3), and 15.8% ± 7.3%. The frequency of dense breasts and mean VBD by age group were 94.3% and 19.1% ± 6.7% for the 30s (n = 1,484), 91.4% and 17.2% ± 6.8% for the 40s (n = 2,706), 72.2% and 12.4% ± 6.2% for the 50s (n = 1,138), 44.0% and 8.6% ± 4.3% for the 60s (n = 89), 39.1% and 8.0% ± 3.8% for the 70s (n = 138), and 39.1% and 8.0% ± 3.5% for the 80s (n = 12). The frequency of dense breasts was higher in younger women (n = 4,313, 92.3%) than older women (n = 1,654, 59.8%). Mean VBD decreased with aging or menopause, and was about 16% for 46-year-old-Korean women, much higher than in other countries. The proportion of dense breasts sharply decreases in Korean women between 40 and 69 years of age.

Clinician-performed ultrasound in hemodynamic and cardiac assessment: a synopsis of current indications and limitations

Accurate hemodynamic and intravascular volume status assessment is essential in the diagnostic and therapeutic management of critically ill patients. Over the last two decades, a number of technological advances were translated into a variety of minimally invasive or non-invasive hemodynamic monitoring modalities. Despite the promise of less invasive technologies, the quality, reliability, reproducibility, and generalizability of resultant hemodynamic and intravascular volume status data have been lacking. Since its formal introduction, ultrasound technology has provided the medical community with a more standardized, higher quality, broadly applicable, and reproducible method of accomplishing the above-mentioned objectives. With the advent of portable, hand-carried devices, the importance of sonography in hemodynamic and volume status assessment became clear. From basic venous collapsibility and global cardiac assessment to more complex tasks such as the assessment of cardiac flow and tissue Doppler signals, the number of real-life indications for sonology continues to increase. This review will provide an outline of the essential ultrasound applications in hemodynamic and volume status assessment, focusing on evidence-based uses and indications.

Computer-aided detection system for masses in automated whole breast ultrasonography: development and evaluation of the effectiveness

Purpose:

The aim of this study was to evaluate the performance of a proposed computer-aided detection (CAD) system in automated breast ultrasonography (ABUS).

Methods:

Eighty-nine two-dimensional images (20 cysts, 42 benign lesions, and 27 malignant lesions) were obtained from 47 patients who underwent ABUS (ACUSON S2000). After boundary detection and removal, we detected mass candidates by using the proposed adjusted Otsu's threshold; the threshold was adaptive to the variations of pixel intensities in an image. Then, the detected candidates were segmented. Features of the segmented objects were extracted and used for training/testing in the classification. In our study, a support vector machine classifier was adopted. Eighteen features were used to determine whether the candidates were true lesions or not. A five-fold cross validation was repeated 20 times for the performance evaluation. The sensitivity and the false positive rate per image were calculated, and the classification accuracy was evaluated for each feature.

Results:

In the classification step, the sensitivity of the proposed CAD system was 82.67% (SD, 0.02%). The false positive rate was 0.26 per image. In the detection/segmentation step, the sensitivities for benign and malignant mass detection were 90.47% (38/42) and 92.59% (25/27), respectively. In the five-fold cross-validation, the standard deviation of pixel intensities for the mass candidates was the most frequently selected feature, followed by the vertical position of the centroids. In the univariate analysis, each feature had 50% or higher accuracy.

Conclusion:

The proposed CAD system can be used for lesion detection in ABUS and may be useful in improving the screening efficiency.

Mammography and ultrasonography reports compared with tissue diagnosis--an evidence based study in Iran, 2010

BACKGROUND

Breast cancer is the most prevalent cancer and the fifth cause of cancer death in Iranian women. Early detection and treatment are important for appropriate management of this disease. Mammography and ultrasonography are used for screening and evaluation of symptomatic cases and the main diagnostic test for breast cancer is pathological. In this study we evaluated mammography and ultrasonography as diagnostic tools.

METHODS

In this cross-sectional study 384 mammography and ultrasonography reports for 255 women were assessed, divided into benign and malignant groups. Suspected cases were referred for pathology evaluation. The radiologic and pathologic reports were compared and also comparison was performed based on age groups (more and less than 50 years old), history of breastfeeding and gravidity. Statistical analysis was performed by SPSS.

RESULTS

The mean ages of malignant and benign cases were 49±11.6 and 43±11.2 years, respectively. Sensitivity and specificity for mammography were 73% and 45%, respectively. Sensitivity and specificity for ultrasonography were 69% and 49%, respectively. There were statistical differences between specificity of mammography in patients based on factors such as history of gravidity, breastfeeding and sensitivity in patients equal or more than 50 years old and less.

CONCLUSION

Factors affecting different results in mammography and ultrasonography reports were classified into three groups, consisting of skill, experience and training of medical staff, and setting of instruments. It is recommended that health managers in developing countries pay attention the quality of setting and man power more than current status. Policy-makers and managers must establish guidelines regarding breast imaging in Iran.

Earlier detection of breast cancer with ultrasound molecular imaging in a transgenic mouse model

While there is an increasing role of ultrasound for breast cancer screening in patients with dense breast, conventional anatomical ultrasound lacks sensitivity and specificity for early breast cancer detection. In this study, we assessed the potential of ultrasound molecular imaging using clinically translatable vascular endothelial growth factor receptor type 2 (VEGFR2)-targeted microbubbles (MB(VEGFR2)) to improve the diagnostic accuracy of ultrasound in earlier detection of breast cancer and ductal carcinoma in situ (DCIS) in a transgenic mouse model [FVB/N-Tg(MMTV-PyMT)634Mul]. In vivo binding specificity studies (n = 26 tumors) showed that ultrasound imaging signal was significantly higher (P < 0.001) using MB(VEGFR2) than nontargeted microbubbles and imaging signal significantly decreased (P < 0.001) by blocking antibodies. Ultrasound molecular imaging signal significantly increased (P < 0.001) when breast tissue (n = 315 glands) progressed from normal [1.65 ± 0.17 arbitrary units (a.u.)] to hyperplasia (4.21 ± 1.16), DCIS (15.95 ± 1.31), and invasive cancer (78.1 ± 6.31) and highly correlated with ex vivo VEGFR2 expression [R(2) = 0.84; 95% confidence interval (CI), 0.72-0.91; P < 0.001]. At an imaging signal threshold of 4.6 a.u., ultrasound molecular imaging differentiated benign from malignant entities with a sensitivity of 84% (95% CI, 78-88) and specificity of 89% (95% CI, 81-94). In a prospective screening trail (n = 63 glands), diagnostic performance of detecting DCIS and breast cancer was assessed and two independent readers correctly diagnosed malignant disease in more than 95% of cases and highly agreed between each other [intraclass correlation coefficient (ICC) = 0.98; 95% CI, 97-99]. These results suggest that VEGFR2-targeted ultrasound molecular imaging allows highly accurate detection of DCIS and breast cancer in transgenic mice and may be a promising approach for early breast cancer detection in women.

Mammographic density in asymptomatic menopausal women: correlation with clinical and sonographic findings

OBJECTIVE: To evaluate mammographic breast density in asymptomatic menopausal women in correlation with clinical and sonographic findings. MATERIALS AND METHODS: Mammograms and clinical and sonographic findings of 238 asymptomatic patients were retrospectively reviewed in the period from February/2022 to June/2006. The following variables were analyzed: mammographic density patterns, sonographic findings, patients' age, parity, body mass index and use of hormone replacement therapy. RESULTS: Age, parity and body mass index showed a negative correlation with breast density pattern, while use of hormone replacement therapy showed a positive correlation. Supplementary breast ultrasonography was performed in 103 (43.2%) patients. Alterations which could not be visualized at mammography were found in 34 (33%) of them, most frequently in women with breast density patterns 3 and 4. CONCLUSION: The authors concluded that breast density patterns were influenced by age, parity, body mass index and time of hormone replacement therapy. Despite not having found any malignant abnormality in the studied cases, the authors have observed a predominance of benign sonographic abnormalities in women with high breast density patterns and without mammographic abnormalities, proving the relevance of supplementary ultrasonography to identify breast lesions in such patients.