Interobserver and Intraobserver Agreement of Sonographic BIRADS Lexicon in the Assessment of Breast Masses

The application of computer-aided diagnosis in Breast Imaging Reporting and Data System ultrasound training for residents-a randomized controlled study

Background

The consistency of Breast Imaging Reporting and Data System (BI-RADS) classification among experienced radiologists is different, which is difficult for inexperienced radiologists to master. This study aims to explore the value of computer-aided diagnosis (CAD) (AI-SONIC breast automatic detection system) in the BI-RADS training for residents.

Methods

A total of 12 residents who participated in the first year and the second year of standardized resident training in Ningbo No. 2 Hospital from May 2020 to May 2021 were randomly divided into 3 groups (Group 1, Group 2, Group 3) for BI-RADS training. They were asked to complete 2 tests and questionnaires at the beginning and end of the training. After the first test, the educational materials were given to the residents and reviewed during the breast imaging training month. Group 1 studied independently, Group 2 studied with CAD, and Group 3 was taught face-to-face by experts. The test scores and ultrasonographic descriptors of the residents were evaluated and compared with those of the radiology specialists. The trainees' confidence and recognition degree of CAD were investigated by questionnaire.

Results

There was no statistical significance in the scores of residents in the first test among the 3 groups (P=0.637). After training and learning, the scores of all 3 groups of residents were improved in the second test (P=0.006). Group 2 (52±7.30) and Group 3 (54±5.16) scored significantly higher than Group 1 (38±3.65). The consistency of ultrasonographic descriptors and final assessments between the residents and senior radiologists were improved (κ3 > κ2 > κ1), with κ2 and κ3 >0.4 (moderately consistent with experts), and κ1 =0.225 (fairly agreed with experts). The results of the questionnaire showed that the trainees had increased confidence in BI-RADS classification, especially Group 2 (1.5 to 3.5) and Group 3 (1.25 to 3.75). All trainees agreed that CAD was helpful for BI-RADS learning (Likert scale score: 4.75 out of 5) and were willing to use CAD as an aid (4.5, max. 5).

Conclusions

The AI-SONIC breast automatic detection system can help residents to quickly master BI-RADS, improve the consistency between residents and experts, and help to improve the confidence of residents in the classification of BI-RADS, which may have potential value in the BI-RADS training for radiology residents.

Trial Registration

Chinese Clinical Trial Registry (ChiCTR2400081672).

The value of radiomics model based on ultrasound image features in the differentiation between minimal breast cancer and small benign breast masses

BACKGROUND

Female breast cancer has surpassed lung cancer as the most common cancer, and is also the main cause of cancer death for women worldwide. Breast cancer <1 cm showed excellent survival rate. However, the diagnosis of minimal breast cancer (MBC) is challenging.

OBJECTIVE

The purpose of our research is to develop and validate an radiomics model based on ultrasound images for early recognition of MBC.

METHODS

302 breast masses with a diameter of <10 mm were retrospectively studied, including 159 benign and 143 malignant breast masses. The radiomics features were extracted from the gray-scale ultrasound image of the largest face of each breast mass. The maximum relevance minimum reduncancy and recursive feature elimination methods were used to screen. Finally, 10 features with the most discriminating value were selected for modeling. The random forest was used to establish the prediction model, and the rad-score of each mass was calculated. In order to evaluate the effectiveness of the model, we calculated and compared the area under the curve (AUC) value, sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of the model and three groups with different experience in predicting small breast masses, and drew calibration curves and decision curves to test the stability and consistency of the model.

RESULTS

When we selected 10 radiomics features to calculate the rad-score, the prediction efficiency was the best, the AUC values for the training set and testing set were 0.840 and 0.793, which was significantly better than the insufficient experience group (AUC = 0.673), slightly better than the moderate experience group (AUC = 0.768), and was inferior to the experienced group (AUC = 0.877). The calibration curve and decision curve also showed that the radiomics model had satisfied stability and clinical application value.

CONCLUSION

The radiomics model based on ultrasound image features has a satisfied predictive ability for small breast masses, and is expected to become a potential tool for the diagnosis of MBC, and it is a zero cost (in terms of patient participation and imaging time).

The feasibility of a novel computer-aided classification system for the characterisation and diagnosis of breast masses on ultrasound: a single-centre preliminary test study

AIM

To introduce a novel computer-aided classification (CAC) system and investigate the feasibility of characterising and diagnosing breast masses on ultrasound (US).

MATERIALS AND METHODS

A total of 246 breast masses were included. US features and the final assessment categories of the breast masses were analysed by a radiologist and the CAC system according to the Breast Imaging Reporting and Data System (BI-RADS) lexicon. The CAC system evaluated the BI-RADS assessment from the fusion of multi-view and colour Doppler US images without (SmartBreast) or with combining clinical variables (m-CAC system). The diagnostic performance and agreement of US characteristics between the radiologist and the CAC system were compared.

RESULTS

The agreement between the radiologist and the CAC system was substantial for mass shape (κ = 0.673), orientation (κ = 0.682), margin (κ = 0.622), posterior features (κ = 0.629), calcifications in a mass (κ = 0.709) and vascularity (κ = 0.745), fair for echo pattern (κ = 0.379), and moderate for BI-RADS assessment (κ = 0.575). With BI-RADS 4a as the cut-off value, the specificity (52.5% versus 25%, p<0.0001) and accuracy (73.98% versus 62.6%, p=0.0002) of the m-CAC system were improved without significant loss of sensitivity (94.44% versus 98.41%, p=0.1250) compared with the SmartBreast. The m-CAC system showed similar specificity (52.5% versus 45.83%, p=0.2430) and accuracy (73.98% versus 73.58%, p=1.0000) as the radiologist, but a lower sensitivity (94.44% versus 100%, p=0.0156).

CONCLUSION

The CAC system showed an acceptable agreement with the radiologist for characterisation of breast lesions. It has the potential to mimic the decision-making behaviour of radiologists for the classification of breast lesions.

Radiological predictive factors on preoperative multimodality imaging are related to Oncotype DX recurrence score in estrogen-positive/human epidermal growth factor receptor 2-negative invasive breast cancer: a cross-sectional study

OBJECTIVE

The Oncotype DX (ODX) estimates the 10-year risk of metastasis or recurrence of breast cancer and indicates whether chemotherapy is likely to be effective; however, the high cost of this test may limit its use for patients. The aim of this study was to evaluate the potential of preoperative imaging using mammography (MMG), ultrasonography (US), and dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI), and positron emission tomography/computed tomography (PET/CT) metabolic parameters in predicting the ODX recurrence score (ODXRS), which prognosticates estrogen receptor-positive (ER +)/human epidermal growth factor receptor 2-negative (HER2-) breast cancer.

METHODS

This retrospective study was conducted on 51 patients with ER+/ HER2- early-stage breast cancer with preoperative images available. Surgical specimens were sent for ODX assay and the ODXRS was categorized as low (<18) or intermediate/high (≥18). MMG/US findings were classified according to BI-RADS categories. For MRI analysis, tumor growth orientation was evaluated in addition to morphological assessment in BI-RADS. For PET/CT analysis, standardized uptake value (SUV) of the tumor were measured. Patient, tumor, and image characteristics were compared between the two groups, and predictors of the low ODXRS group were determined by logistic regression analysis. Two-sided P values less than 0.05 were considered statistically significant.

RESULTS

Thirty-two (63%) and 19 (37%) patients were categorized as low and intermediate/high ODXRS, respectively. On univariate analysis, nuclear grade, tumor margin, and tumor growth orientation on MRI, and SUV_max on PET/CT were significantly associated with a low ODXRS. Multivariate analysis revealed that tumor growth orientation perpendicular to the Cooper's ligament on MRI (P = 0.031) and a low SUV_max on PET/CT (P = 0.016) were independent prognostic factors for a low ODXRS. As a predictor of low ODXRS, the receiver operating characteristic (ROC) analysis of the SUV_max showed that using 3.0 as the optimal cut-off value has a sensitivity and specificity of 94.4% and 73.0%, respectively, with an area under the curve (AUC) of 0.923.

CONCLUSIONS

The combination of perpendicular tumor growth orientation to Cooper's ligaments on MRI and a low SUV_max on PET/CT may predict a low ODXRS.

Can Pre-biopsy Second-Look Breast Ultrasound Affect Clinical Management? Experience From a Single Tertiary Hospital

Objectives

Interpretation discrepancy is a major disadvantage of breast imaging. This study aimed to determine the clinical benefit of the pre-biopsy second-look breast ultrasound (US).

Methods

Patients with suspicious breast masses referred to our tertiary hospital for US-guided breast biopsy were retrospectively reviewed between August 2017 and November 2019. Here, second-look assessments were performed by experienced specialized breast radiologists via performing a bilateral breast US scan plus reviewing former imaging studies, and results were compared with the initial assessment. Interpretation changes in terms of biopsy recommendation and surgical management (i.e., lumpectomy to mastectomy) were analyzed.

Results

A total of 537 patients were enrolled in this study. Interpretation discrepancies occurred in 109 patients (20%; 95% CI, 17%–24%). Among them, there were 84 patients (16%; 95% CI, 13%–19%) whose masses were re-classified as BI-RADS 3 by the second-look US and underwent 2-year follow-up, showing 82 benign, 1 malignant, and 1 high-risk lesions. On the other hand, 16 patients (3%; 95% CI, 2%–5%) undertook biopsy at an additional site, identifying 10 new malignant lesions, 3 high-risk lesions, and 3 benign lesions, resulting in surgical management changes in 12 patients. In addition, nine (2%; 95% CI, 1%–3%) patients received discrepant disease ranges, which also altered surgical management. Overall, 21 patients (4%; 95% CI, 3%–6%) got their surgical management altered by the second-look US.

Conclusion

Pre-biopsy second-look assessment of breast US can reduce unnecessary biopsies in 16% of patients and alter surgical management in 4% of patients, suggesting it is a practical and valuable method for patient care improvement.

Positive Predictive Value for the Malignancy of Mammographic Abnormalities Based on the Presence of an Ultrasound Correlate

Purpose To compare the outcomes of different mammographic lesions based on the presence of an ultrasound (US) correlate and to estimate how often targeted US can identify such lesions.

Materials and Methods This retrospective study included all consecutive cases from 2010 to 2016, with Breast Imaging Reporting and Database System (BI-RADS) categories 4 & 5 who underwent US as part of their diagnostic workup. We compared the incidence of malignancy between lesions comprising a US correlate that underwent US-guided core needle biopsy (CNB) and those without a correlate that underwent stereotactic CNB.

Results 833 lesions met the study criteria and included masses (64.3%), architectural distortion (19%), asymmetries (4.6%), and calcifications (12.1%). The CNB-based positive predictive value (PPV) was higher for lesions with a US correlate than for those without (40.2% [36.1, 44.4%] vs. 18.9% [14.5, 23.9%], respectively) (p<0.001). Malignancy odds for masses, asymmetries, architectural distortion, and calcifications were greater by 2.70, 4.17, 4.98, and 2.77 times, respectively, for the US-guided CNB (p<0.001, p=0.091, p<0.001, and p=0.034, respectively). Targeted US identified a correlate to 66.3% of the mammographic findings. The odds of finding a correlate were greater for masses (77.8%) than architectural distortions (53.8%) (p<0.001) or calcifications (24.8%) (p<0.001).

Conclusion The success of targeted US in identifying a correlate varies significantly according to the type of mammographic lesion. The PPV of lesions with a US correlate was significantly higher than that of those with no correlate. However, the PPV of lesions with no US correlate is high enough (18.9%) to warrant a biopsy.

Agreement in breast lesion assessment and final BI-RADS classification between radial and meander-like breast ultrasound

BACKGROUND

This study prospectively investigates the agreement between radial (r-US) and meander-like (m-US) breast ultrasound with regard to lesion location, lesion size, morphological characteristics and final BI-RADS classification of individual breast lesions.

METHODS

Each patient of a consecutive, unselected, mixed collective received a dual ultrasound examination.

RESULTS

The agreement between r-US and m-US for lesion location ranged from good (lesion to mammilla distance ICC 0.64; lesion to skin distance ICC 0.72) to substantial (clock-face localization κ 0.70). For lesion size the agreement was good (diameter ICC 0.72; volume ICC 0.69), for lesion margin and architectural distortion it was substantial (κ 0.68 and 0.70, respectively). Most importantly, there was a substantial agreement (κ 0.76) in the final BI-RADS classification between r-US and m-US.

CONCLUSIONS

Our recent comparison of radial and meander-like breast US revealed that the diagnostic accuracy of the two scanning methods was comparable. In this study, we observe a high degree of agreement between m-US and r-US for the lesion description (location, size, morphology) and final BI-RADS classification. These findings corroborate that r-US is a suitable alternative to m-US in daily clinical practice. Trial registration NCT02358837. Registered January 2015, retrospectively registered https://clinicaltrials.gov/ct2/results?cond=&term=NCT02358837&cntry=&state=&city=&dist =.

Reducing the number of unnecessary biopsies of US-BI-RADS 4a lesions through a deep learning method for residents-in-training: a cross-sectional study

OBJECTIVE

The aim of the study is to explore the potential value of S-Detect for residents-in-training, a computer-assisted diagnosis system based on deep learning (DL) algorithm.

METHODS

The study was designed as a cross-sectional study. Routine breast ultrasound examinations were conducted by an experienced radiologist. The ultrasonic images of the lesions were retrospectively assessed by five residents-in-training according to the Breast Imaging Report and Data System (BI-RADS) lexicon, and a dichotomic classification of the lesions was provided by S-Detect. The diagnostic performances of S-Detect and the five residents were measured and compared using the pathological results as the gold standard. The category 4a lesions assessed by the residents were downgraded to possibly benign as classified by S-Detect. The diagnostic performance of the integrated results was compared with the original results of the residents.

PARTICIPANTS

A total of 195 focal breast lesions were consecutively enrolled, including 82 malignant lesions and 113 benign lesions.

RESULTS

S-Detect presented higher specificity (77.88%) and area under the curve (AUC) (0.82) than the residents (specificity: 19.47%-48.67%, AUC: 0.62-0.74). A total of 24, 31, 38, 32 and 42 identified as BI-RADS 4a lesions by residents 1, 2, 3, 4 and 5 were downgraded to possibly benign lesions by S-Detect, respectively. Among these downgraded lesions, 24, 28, 35, 30 and 40 lesions were proven to be pathologically benign, respectively. After combining the residents' results with the results of the software in category 4a lesions, the specificity and AUC of the five residents significantly improved (specificity: 46.02%-76.11%, AUC: 0.71-0.85, p<0.001). The intraclass correlation coefficient of the five residents also increased after integration (from 0.480 to 0.643).

CONCLUSIONS

With the help of the DL software, the specificity, overall diagnostic performance and interobserver agreement of the residents greatly improved. The software can be used as adjunctive tool for residents-in-training, downgrading 4a lesions to possibly benign and reducing unnecessary biopsies.

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.

Comparison of Two Different Ultrasound Devices Using Strain Elastography Technology in the Diagnosis of Breast Lesions Related to the Histologic Results

This study was conducted to provide evidence that elastograms of two different devices and different manufacturers using the same technical approach provide the same diagnoses. A total of 110 breast lesions were prospectively analysed by two experts in ultrasound, using the strain elastography function from two different manufacturers (Hitachi HI-RTE, Hitachi Medical Systems, Wiesbaden, Germany; and Siemens eSie Touch, Siemens Medical Systems, Erlangen, Germany). Results were compared with the histopathologic results. Applying the Bowker test of symmetry, no statistically significant difference between the two elastography functions of these two devices was found (p = 0.120). The Cohen's kappa of k = 0.591 showed moderate strength of agreement between the two elastograms. The two examiners yielded moderate strength of agreement analysing the elastograms (Hitachi HI-RTE, k = 0.478; Siemens eSie Touch, k = 0.441). In conclusion, evidence is provided that elastograms of the same lesion generated by two different ultrasound devices equipped with a strain elastography function do not significantly differ.

Sonographic features of invasive ductal breast carcinomas predictive of malignancy grade

Context:

Assessment of individual sonographic features provides vital clues about the biological behavior of breast masses and can assist in determining histological grade of malignancy and thereby prognosis.

Aims:

Assessment of individual sonographic features of biopsy proven invasive ductal breast carcinomas as predictors of malignancy grade.

Settings and Design:

A retrospective analysis of sonographic findings of 103 biopsy proven invasive ductal breast carcinomas.

Materials and Methods:

Tumor characteristics on gray-scale ultrasound and color flow were assessed using American College of Radiology (ACR) Breast Imaging Reporting and Data System (BI-RADS) Atlas Fifth Edition. The sonographic findings of masses were individually correlated with their histopathologic grades.

Statistical Analysis Used:

Chi square test, ordinal regression, and Goodman and Kruskal tau test.

Results:

Breast mass showing reversal/lack of diastolic flow has a high probability of belonging to histological high grade tumor (β 1.566, P 0.0001). The masses with abrupt interface boundary are more likely grade 3 (β 1.524, P 0.001) in comparison to masses with echogenic halos. The suspicious calcifications present in and outside the mass is a finding associated with histologically high grade tumors. The invasive ductal carcinomas (IDCs) with complex solid and cystic echotexture are more likely to be of high histological grade (β 1.146, P 0.04) as compared to masses with hypoechoic echotexture.

Conclusions:

Certain ultrasound features are associated with tumor grade on histopathology. If the radiologist is cognizant of these sonographic features, ultrasound can be a potent modality for predicting histopathological grade of IDCs of the breast, especially in settings where advanced tests such as receptor and molecular analyses are limited.

An Evaluation of Ultrasound Features of Breast Fibroadenoma

Background

Breast cancer is among the most common cancers in the world. Ultrasound evaluations of breast have come into attention as an alternative route. Ultrasound features of benign lesions such as fibroadenoma can be overlapping with those in a malignant tumor. Here, we assessed the reports of breast ultrasound in patients with pathologic diagnosis of fibroadenoma.

Materials and Methods

We conducted a cross-sectional study and enrolled female patients with confirmed histologic diagnosis of fibroadenoma. Ultrasound studies were performed on the participants to see which sonographic patterns are more frequent in such lesions.

Results

In 92 patients with 40.4 ± 9.2 years of age, all participants were classified as stage 4 on Breast Imaging-Reporting and Data System scale. The mean ± standard deviation of size for the lesions was 167.4 ± 101.4 mm². Upper outer quadrants in the breasts had the most number of lesions. Almost lesions were round with only 2.2% were oval. When assessed for the margin definition, 57.8% were circumscribed. Noncircumscribed masses were reported in 21.7%. About 91.3% of cases were hypoechoic in the ultrasound evaluation. Lobulated masses were in 28.3% of the cases. 8.7% of the masses were spongy whereas 9.8% and 2.2% of them had calcification and heterogenic appearance, respectively.

Conclusion

The most frequent features include a hypoechoic mass with a circumscribed border; however, complex presentations that overlap malignant masses are also detectable including noncircumscribed margin, lobulation, presence of a posterior shadow, heterogenicity, and micro calcification.

Inter- and Intra-Observer Agreement in Ultrasound BI-RADS Classification and Real-Time Elastography Tsukuba Score Assessment of Breast Lesions

Our aim was to prospectively evaluate inter- and intra-observer agreement between Breast Imaging Reporting and Data System (BI-RADS) classifications and Tsukuba elasticity scores (TSs) of breast lesions. The study included 164 breast lesions (63 malignant, 101 benign). The BI-RADS classification and TS of each breast lesion was assessed by the examiner and twice by three reviewers at an interval of 2 months. Weighted κ values for inter-observer agreement ranged from moderate to substantial for BI-RADS classification (κ = 0.585-0.738) and was substantial for TS (κ = 0.608-0.779). Intra-observer agreement was almost perfect for ultrasound (US) BI-RADS (κ = 0.847-0.872) and TS (κ = 0.879-0.914). Overall, individual reviewers are highly self-consistent (almost perfect intra-observer agreement) with respect to BI-RADS classification and TS, whereas inter-observer agreement was moderate to substantial. Comprehensive training is essential for achieving high agreement and minimizing the impact of subjectivity. Our results indicate that breast US and real-time elastography can achieve high diagnostic performance.

Reducing Costs of Breast Examination: Ultrasound Performance and Inter-Observer Variability of Expert Radiologists Versus Residents

AIM

To compare efficiency levels between radiologist and radiology resident and any significant or clinically relevant differences in breast ultrasound diagnosis, thus reducing extra costs.

MATERIAL AND METHODS

100 patients attending for breast ultrasound were included. Each patient was examined by a radiologist, and subsequently by a resident of the radiology department. Both operators noted their findings and wrote a concluding report. Reports were compared for histological and biological analysis.

RESULTS

100 female patients with a mean age about 49 years were examined. The proportions of correct diagnoses of lesions individuated by radiologist and resident were 26.90 > 13.71% (p-value = 10.7), i.e. the radiologist was more accurate in comparison to resident in the individuation of breast lesions.

CONCLUSIONS

The radiologist was more accurate in comparison to radiology resident in the evaluation of breast pathology in ultrasonography diagnoses, and this could reduce cost and/or in-depth analysis.

Contrast-enhanced ultrasound improved performance of breast imaging reporting and data system evaluation of critical breast lesions

AIM: To determine whether contrast-enhanced ultrasound (CEUS) can improve the precision of breast imaging reporting and data system (BI-RADS) categorization.

METHODS: A total of 230 patients with 235 solid breast lesions classified as BI-RADS 4 on conventional ultrasound were evaluated. CEUS was performed within one week before core needle biopsy or surgical resection and a revised BI-RADS classification was assigned based on 10 CEUS imaging characteristics. Receiver operating characteristic curve analysis was then conducted to evaluate the diagnostic performance of CEUS-based BI-RADS assignment with pathological examination as reference criteria.

RESULTS: The CEUS-based BI-RADS evaluation classified 116/235 (49.36%) lesions into category 3, 20 (8.51%), 13 (5.53%) and 12 (5.11%) lesions into categories 4A, 4B and 4C, respectively, and 74 (31.49%) into category 5. Selecting CEUS-based BI-RADS category 4A as an appropriate cut-off gave sensitivity and specificity values of 85.4% and 87.8%, respectively, for the diagnosis of malignant disease. The cancer-to-biopsy yield was 73.11% with CEUS-based BI-RADS 4A selected as the biopsy threshold compared with 40.85% otherwise, while the biopsy rate was only 42.13% compared with 100% otherwise. Overall, only 4.68% of invasive cancers were misdiagnosed.

CONCLUSION: This pilot study suggests that evaluation of BI-RADS 4 breast lesions with CEUS results in reduced biopsy rates and increased cancer-to-biopsy yields.

Shear-wave elastography and greyscale assessment of palpable probably benign masses: is biopsy always required?

OBJECTIVE

To establish if palpable breast masses with benign greyscale ultrasound features that are soft on shear-wave elastography (SWE) (mean stiffness <50 kPa) have a low enough likelihood of malignancy to negate the need for biopsy or follow-up.

METHODS

The study group comprised 694 lesions in 682 females (age range 17-95 years, mean age 56 years) presenting consecutively to our institution with palpable lesions corresponding to discrete masses at ultrasound. All underwent ultrasound, SWE and needle core biopsy. Static greyscale images were retrospectively assigned Breast Imaging Reporting and Data System (BI-RADS) scores by two readers blinded to the SWE and pathology findings, but aware of the patient's age. A mean stiffness of 50 kPa was used as the SWE cut-off for calling a lesion soft or stiff. Histological findings were used to establish ground truth.

RESULTS

No cancer had benign characteristics on both modalities. 466 (99.8%) of the 467 cancers were classified BI-RADS 4a or above. The one malignant lesion classified as BI-RADS 3 was stiff on SWE. 446 (96%) of the 467 malignancies were stiff on SWE. No cancer in females under 40 years had benign SWE features. 74 (32.6%) of the 227 benign lesions were BI-RADS 3 and soft on SWE; so, biopsy could potentially have been avoided in this group.

CONCLUSION

Lesions which appear benign on greyscale ultrasound and SWE do not require percutaneous biopsy or short-term follow-up, particularly in females under 40 years.

ADVANCES IN KNOWLEDGE

None of the cancers had benign characteristics on both greyscale ultrasound and SWE, and 32% of benign lesions were BI-RADS 3 and soft on SWE; lesions that are benign on both ultrasound and SWE may not require percutaneous biopsy or short-term follow-up.

Variability in Observer Performance Between Faculty Members and Residents Using Breast Imaging Reporting and Data System (BI-RADS)-Ultrasound, Fifth Edition (2013)

Background

Ultrasonography (US) is a useful tool for breast imaging, yet is highly operator-dependent.

Objectives

We evaluated inter-observer variability and performance discrepancies between faculty members and radiology residents when describing breast lesions, by the fifth edition of breast imaging reporting and data system (BI-RADS)-US lexicon, and then attempted to identify whether inter-observer variability could be improved after one education session.

Patients and Methods

In total, 50 malignant lesions and 70 benign lesions were considered in our retrospective study. Two faculty members, two senior residents, and two junior residents separately assessed the US images. After the first assessment, the readers received one education session, and then reassessed the images in a random order. Inter-observer variability was measured using the kappa coefficient (κ). Performance discrepancy was evaluated by receiver operating characteristic (ROC) curves.

Results

For the faculty members, fair-to-good agreement was obtained in all descriptors and final assessment, while for residents, poor-to-moderate agreement was obtained. The areas under the ROC curves were 0.78 for the faculty members, 0.59 for the senior residents, and 0.52 for the junior residents, respectively. Diagnostic performance was significantly higher in the faculty members than the senior and junior residents (P = 0.0001 and < 0.0001, respectively). After one education session, the agreement in the final assessment was one level higher in the faculty members and senior residents, yet in the senior residents, the degree of agreement was still only fair. Moreover, in the junior residents, there was no improvement.

Conclusion

Investigative assessment of breast US by residents is inadvisable. We recommend continued professional resident training to improve the degree of agreement and performance.

Association of Different MRI BIRADS Descriptors With Malignancy in Non Mass-Like Breast Lesions

Background:

Several studies on the diagnostic efficacy of MRI has not real consensus for the accuracy of MRI characteristics in non mass like breast lesions, and the number of malignant lesions in different studies is insufficient.

Objectives:

In this study we aimed to analyze the diagnostic role of MRI BIRADS features for diagnosis of malignancy in non mass like breast lesions.

Patients and Methods:

All patients with positive findings (BIRADS 3, 4, 5), which had either biopsy proved pathology or follow-up MRI data at least for 12 months were included in the study. Finally, 213 breasts MRI that showed non mass like enhancing lesions among our patients were assessed in study. One experienced breast radiologist who was unaware of any clinical information or the histopathologic diagnosis evaluated all images retrospectively. The morphologic parameters evaluated consisted of distribution modifiers and pattern of internal enhancement. The kinetic enhancement parameters were assessed as showing washout, plateau, or persistent patterns. In the enhancement kinetic analysis, thew most worrisome curve type in each lesion was considered for interpretation, if it was more than 2% enhancement. We have evaluated the visual findings by comparison of the signal intensity on the first and third dynamic series. Data for the study were extracted from the breast MRI database and analyzed using SPSS version 16 statistical software.

Results:

Totally 188 patients had 213 non mass like lesions. Mean age of the patients was 44.9 ± 8.3 years (24-63). Totally 46 of lesions were malignant (21.6%). The most common BIRADS score was 4 (116; 54.5%). The most prevalent feature of distribution, internal enhancement and curve type were focal (59.2%), clumped (27.2%) and washout (34.3%). Distribution of different subgroups of MR BIRADS features was different among benign and malignant lesions (All Pvalues < 0.05). Regarding association with malignancy, odds ratio of lesions with segmental or ductal linear distribution was 3.4 (95% CI = 1.7-6.8), Clumped, Reticular and Dendritic internal enhancement was 2.5 (95% CI = 1.3-5) and wash out curve type was 5.4 (95% CI = 2.7-10.9). Sensitivity of higher MR BIRADS (4,5) for diagnosis of malignancy was 100%. Specificity of segmental or ductal linear distribution in diagnosis of malignancy was 81%. Specificity of BIRADS 5 for diagnosis of malignancy was 98%. In a multivariate logistic regression analysis for diagnosis of malignancy in which distribution, internal enhancement and curve type were considered as independent variables, distribution and curve type remained significant in the model while the internal enhancement showed a borderline P-value.

Conclusions:

Although in our study washout pattern was the most powerful indicator for malignant pathology in non mass like enhancing lesions, more studies with larger sample size needs in this regard.

Uterine artery embolization for treatment of symptomatic fibroids: a review of the evidence

Fibroids are the most common benign tumors of the uterus during female reproductive age. Uterine artery embolization (UAE) using embolic particles (PVA, Gelfoam) to occlude the uterine arteries, have been reported as a relatively safe, effective, and durable nonsurgical alternative to hysterectomy in diminishing fibroid-related symptoms. To block the arterial blood supply to the fibroid completely, UAE is typically performed in both uterine arteries by an experienced interventional radiologist. Reduction in menorrhagia has been reported as 80-93 percent and the mean decrease in fibroid size varies from 50-78% in the literature. In our center improvement in menstrual bleeding after 6 months was 80.3%, and uterine fibroids underwent shrinkage of 63.7±33.7% after12 months. Complication rate including amenorrhea ranges from 1% - 7% in the literature. UAE may be followed by menopause in 1% of cases. Nevertheless, it is usually encountered in women in their late 40s. It seems that the future of UAE depends on optimal selection of patients according to volume-shrinkage prediction and fertility outcome. Although pregnancy is possible after embolization, however neither fertility preservation nor improvement can be guaranteed following UAE. Indeed, Women who desire to become pregnant should be cautioned about potential complications during pregnancy. The aim of this review is to discuss about the efficacy, safety, technique, and choice of embolic agent. Also we present the effects of this technique on fertility and pregnancy outcome and also methods for dose reduction during this procedure.