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

A twin convolutional neural network with hybrid binary optimizer for multimodal breast cancer digital image classification

There is a wide application of deep learning technique to unimodal medical image analysis with significant classification accuracy performance observed. However, real-world diagnosis of some chronic diseases such as breast cancer often require multimodal data streams with different modalities of visual and textual content. Mammography, magnetic resonance imaging (MRI) and image-guided breast biopsy represent a few of multimodal visual streams considered by physicians in isolating cases of breast cancer. Unfortunately, most studies applying deep learning techniques to solving classification problems in digital breast images have often narrowed their study to unimodal samples. This is understood considering the challenging nature of multimodal image abnormality classification where the fusion of high dimension heterogeneous features learned needs to be projected into a common representation space. This paper presents a novel deep learning approach combining a dual/twin convolutional neural network (TwinCNN) framework to address the challenge of breast cancer image classification from multi-modalities. First, modality-based feature learning was achieved by extracting both low and high levels features using the networks embedded with TwinCNN. Secondly, to address the notorious problem of high dimensionality associated with the extracted features, binary optimization method is adapted to effectively eliminate non-discriminant features in the search space. Furthermore, a novel method for feature fusion is applied to computationally leverage the ground-truth and predicted labels for each sample to enable multimodality classification. To evaluate the proposed method, digital mammography images and digital histopathology breast biopsy samples from benchmark datasets namely MIAS and BreakHis respectively. Experimental results obtained showed that the classification accuracy and area under the curve (AUC) for the single modalities yielded 0.755 and 0.861871 for histology, and 0.791 and 0.638 for mammography. Furthermore, the study investigated classification accuracy resulting from the fused feature method, and the result obtained showed that 0.977, 0.913, and 0.667 for histology, mammography, and multimodality respectively. The findings from the study confirmed that multimodal image classification based on combination of image features and predicted label improves performance. In addition, the contribution of the study shows that feature dimensionality reduction based on binary optimizer supports the elimination of non-discriminant features capable of bottle-necking the classifier.

Detection of microcalcifications using nonlinear beamforming techniques

OBJECTIVE

Abundant research demonstrates that early detection of cancer leads to improved patient prognoses. By detecting cancer earlier, when tumors are in their primary stages, treatment can be applied before metastases have occurred. The presence of microcalcifications (MCs) is indicative of malignancy in the breast, i.e., 30-50% of all nonpalpable breast cancers detected using mammograms are based on identifying the presence of MCs. Therefore, improving the ability to detect MCs with modern imaging technology remains an important goal. Specifically, improving the sensitivity of ultrasound imaging techniques to detect MCs in the breast will provide an important role for the early detection and diagnosis of breast cancer.

METHODS

In this work, a novel nonlinear beamforming technology for ultrasonic arrays is investigated for its ability to detect MCs. The beamforming technique, called null subtraction imaging (NSI), utilizes nulls in the beam pattern to create images using ultrasound. NSI provides improved lateral resolution, a reduction in side lobes, and an accentuation of bright singular targets. Therefore, it was hypothesized that the use of NSI would result in identification of more MCs in rat tumors having a speckle background. To test this hypothesis, rats with tumors were injected with Hydroxyapatite (HA) particles to mimic MCs. Ultrasound was used to scan the rat tumors and images were constructed using conventional delay and sum and using NSI beamforming. Three readers with experience in diagnostic ultrasound imaging examined the 1,344 images and scored the presence or absence of MCs.

DISCUSSION

In all, 336 different tumor image slices were recorded and each reconstructed using NSI or conventional delay and sum with Hann apodization. In every image where one or MCs were detected in the Hann reconstructions, MCs were detected in the NSI images. In nine rat tumor images, one or more MCs were detected in the NSI images but not in the Hann images.

CONCLUSIONS

Statistically, the results did support the hypothesis that NSI would increase the number of MCs detected in the rat tumors.

Diagnostic Performance of Contrast-Enhanced Digital Mammography versus Conventional Imaging in Women with Dense Breasts

The aim of this prospective study was to compare the diagnostic performance of contrast-enhanced mammography (CEM) versus digital mammography (DM) combined with breast ultrasound (BUS) in women with dense breasts. Between March 2021 and February 2022, patients eligible for CEM with the breast composition category ACR BI-RADS c-d at DM and an abnormal finding (BI-RADS 3-4-5) at DM and/or BUS were considered. During CEM, a nonionic iodinated contrast agent (Iohexol 350 mg I/mL, 1.5 mL/kg) was power-injected intravenously. Images were evaluated independently by two breast radiologists. Findings classified as BI-RADS 1-3 were considered benign, while BI-RADS 4-5 were considered malignant. In case of discrepancies, the higher category was considered for DM+BUS. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy were calculated, using histology/≥12-month follow-up as gold standards. In total, 51 patients with 65 breast lesions were included. 59 (90.7%) abnormal findings were detected at DM+BUS, and 65 (100%) at CEM. The inter-reader agreement was excellent (Cohen's k = 0.87 for DM+BUS and 0.97 for CEM). CEM showed a 93.5% sensitivity (vs. 90.3% for DM+BUS), a 79.4-82.4% specificity (vs. 32.4-35.5% for DM+BUS) (McNemar p = 0.006), a 80.6-82.9% PPV (vs. 54.9-56.0% for DM+BUS), a 93.1-93.3% NPV (vs. 78.6-80.0% for DM+BUS), and a 86.1-87.7% accuracy (vs. 60.0-61.5% for DM+BUS). The AUC was higher for CEM than for DM+BUS (0.865 vs. 0.613 for Reader 1, and 0.880 vs. 0.628, for Reader 2) (p < 0.001). In conclusion, CEM had a better diagnostic performance than DM and BUS alone and combined together in patients with dense breasts.

Advances in PET/CT Imaging for Breast Cancer

One out of eight women will be affected by breast cancer during her lifetime. Imaging plays a key role in breast cancer detection and management, providing physicians with information about tumor location, heterogeneity, and dissemination. In this review, we describe the latest advances in PET/CT imaging of breast cancer, including novel applications of 18F-FDG PET/CT and the development and testing of new agents for primary and metastatic breast tumor imaging and therapy. Ultimately, these radiopharmaceuticals may guide personalized approaches to optimize treatment based on the patient's specific tumor profile, and may become a new standard of care. In addition, they may enhance the assessment of treatment efficacy and lead to improved outcomes for patients with a breast cancer diagnosis.

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

BACKGROUND

Screening mammography can detect breast cancer at an early stage. Supporters of adding ultrasonography to the screening regimen consider it a safe and inexpensive approach to reduce false-negative rates during screening. However, those opposed to it argue that performing supplemental ultrasonography 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 alone for breast cancer screening for women at average risk of breast cancer.

SEARCH METHODS

We searched the Cochrane Breast Cancer Group's Specialised Register, CENTRAL, MEDLINE, Embase, the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP), and ClinicalTrials.gov up until 3 May 2021.

SELECTION CRITERIA

For efficacy and harms, we considered randomised controlled trials (RCTs) and controlled non-randomised studies enrolling at least 500 women at average risk for breast cancer between the ages of 40 and 75. We also included studies where 80% of the population met our age and breast cancer risk inclusion criteria.

DATA COLLECTION AND ANALYSIS

Two review authors screened abstracts and full texts, assessed risk of bias, and applied the GRADE approach. We calculated the risk ratio (RR) with 95% confidence intervals (CI) based on available event rates. We conducted a random-effects meta-analysis.

MAIN RESULTS

We included eight studies: one RCT, two prospective cohort studies, and five retrospective cohort studies, enrolling 209,207 women with a follow-up duration from one to three years. The proportion of women with dense breasts ranged from 48% to 100%. Five studies used digital mammography; one study used breast tomosynthesis; and two studies used automated breast ultrasonography (ABUS) in addition to mammography screening. One study used digital mammography alone or in combination with breast tomosynthesis and ABUS or handheld ultrasonography. Six of the eight studies evaluated the rate of cancer cases detected after one screening round, whilst two studies screened women once, twice, or more. None of the studies assessed whether mammography screening in combination with ultrasonography led to lower mortality from breast cancer or all-cause mortality. High certainty evidence from one trial showed that screening with a combination of mammography and ultrasonography detects more breast cancer than mammography alone. The J-START (Japan Strategic Anti-cancer Randomised Trial), enrolling 72,717 asymptomatic women, had a low risk of bias and found that two additional breast cancers per 1000 women were detected over two years with one additional ultrasonography than with mammography alone (5 versus 3 per 1000; RR 1.54, 95% CI 1.22 to 1.94). Low certainty evidence showed that the percentage of invasive tumours was similar, with no statistically significant difference between the two groups (69.6% (128 of 184) versus 73.5% (86 of 117); RR 0.95, 95% CI 0.82 to 1.09). However, positive lymph node status was detected less frequently in women with invasive cancer who underwent mammography screening in combination with ultrasonography than in women who underwent mammography alone (18% (23 of 128) versus 34% (29 of 86); RR 0.53, 95% CI 0.33 to 0.86; moderate certainty evidence). Further, interval carcinomas occurred less frequently in the group screened by mammography and ultrasonography compared with mammography alone (5 versus 10 in 10,000 women; RR 0.50, 95% CI 0.29 to 0.89; 72,717 participants; high certainty evidence). False-negative results were less common when ultrasonography was used in addition to mammography than with mammography alone: 9% (18 of 202) versus 23% (35 of 152; RR 0.39, 95% CI 0.23 to 0.66; moderate certainty evidence). However, the number of false-positive results and necessary biopsies were higher in the group with additional ultrasonography screening. Amongst 1000 women who do not have cancer, 37 more received a false-positive result when they participated in screening with a combination of mammography and ultrasonography than with mammography alone (RR 1.43, 95% CI 1.37 to 1.50; high certainty evidence). Compared to mammography alone, for every 1000 women participating in screening with a combination of mammography and ultrasonography, 27 more women will have a biopsy (RR 2.49, 95% CI 2.28 to 2.72; high certainty evidence). Results from cohort studies with methodological limitations confirmed these findings. A secondary analysis of the J-START provided results from 19,213 women with dense and non-dense breasts. In women with dense breasts, the combination of mammography and ultrasonography detected three more cancer cases (0 fewer to 7 more) per 1000 women screened than mammography alone (RR 1.65, 95% CI 1.0 to 2.72; 11,390 participants; high certainty evidence). A meta-analysis of three cohort studies with data from 50,327 women with dense breasts supported this finding, showing that mammography and ultrasonography combined led to statistically significantly more diagnosed cancer cases compared to mammography alone (RR 1.78, 95% CI 1.23 to 2.56; 50,327 participants; moderate certainty evidence). For women with non-dense breasts, the secondary analysis of the J-START study demonstrated that more cancer cases were detected when adding ultrasound to mammography screening compared to mammography alone (RR 1.93, 95% CI 1.01 to 3.68; 7823 participants; moderate certainty evidence), whilst two cohort studies with data from 40,636 women found no statistically significant difference between the two screening methods (RR 1.13, 95% CI 0.85 to 1.49; low certainty evidence).

AUTHORS' CONCLUSIONS

Based on one study in women at average risk of breast cancer, ultrasonography in addition to mammography leads to more screening-detected breast cancer cases. For women with dense breasts, cohort studies more in line with real-life clinical practice confirmed this finding, whilst cohort studies for women with non-dense breasts showed no statistically significant difference between the two screening interventions. However, the number of false-positive results and biopsy rates were higher in women receiving additional ultrasonography for breast cancer screening. None of the included studies analysed whether the higher number of screen-detected cancers in the intervention group resulted in a lower mortality rate compared to mammography alone. Randomised controlled trials or prospective cohort studies with a longer observation period are needed to assess the effects of the two screening interventions on morbidity and mortality.

Supplemental Breast Cancer Screening in Women with Dense Breasts and Negative Mammography: A Systematic Review and Meta-Analysis

Background The best supplemental breast cancer screening modality in women at average risk or intermediate risk for breast cancer with dense breast and negative mammogram remains to be determined. Purpose To conduct systematic review and meta-analysis comparing clinical outcomes of the most common available supplemental screening modalities in women at average risk or intermediate risk for breast cancer in patients with dense breasts and mammography with negative findings. Materials and Methods A comprehensive search was conducted until March 12, 2020, in Medline, Epub Ahead of Print and In-Process and Other Non-Indexed Citations; Embase Classic and Embase; Cochrane Central Register of Controlled Trials; and Cochrane Database of Systematic Reviews, for Randomized Controlled Trials and Prospective Observational Studies. Incremental cancer detection rate (CDR); positive predictive value of recall (PPV1); positive predictive value of biopsies performed (PPV3); and interval CDRs of supplemental imaging modalities, digital breast tomosynthesis, handheld US, automated breast US, and MRI in non-high-risk patients with dense breasts and mammography negative for cancer were reviewed. Data metrics and risk of bias were assessed. Random-effects meta-analysis and two-sided metaregression analyses comparing each imaging modality metrics were performed (PROSPERO; CRD42018080402). Results Twenty-two studies reporting 261 233 screened patients were included. Of 132 166 screened patients with dense breast and mammography negative for cancer who met inclusion criteria, a total of 541 cancers missed at mammography were detected with these supplemental modalities. Metaregression models showed that MRI was superior to other supplemental modalities in CDR (incremental CDR, 1.52 per 1000 screenings; 95% CI: 0.74, 2.33; P < .001), including invasive CDR (invasive CDR, 1.31 per 1000 screenings; 95% CI: 0.57, 2.06; P < .001), and in situ disease (rate of ductal carcinoma in situ, 1.91 per 1000 screenings; 95% CI: 0.10, 3.72; P < .04). No differences in PPV1 and PPV3 were identified. The limited number of studies prevented assessment of interval cancer metrics. Excluding MRI, no statistically significant difference in any metrics were identified among the remaining imaging modalities. Conclusion The pooled data showed that MRI was the best supplemental imaging modality in women at average risk or intermediate risk for breast cancer with dense breasts and mammography negative for cancer. © RSNA, 2023 Supplemental material is available for this article. See also the editorial by Hooley and Butler in this issue.

Comparative Study of Digital Breast Tomosynthesis (DBT) with and without Ultrasound versus Breast Magnetic Resonance Imaging (MRI) in Detecting Breast Lesion

Digital breast tomosynthesis (DBT) is a fairly recent breast imaging technique invented to overcome the challenges of overlapping breast tissue. Ultrasonography (USG) was used as a complementary tool to DBT for the purpose of this study. Nonetheless, breast magnetic resonance imaging (MRI) remains the most sensitive tool to detect breast lesion. The purpose of this study was to evaluate diagnostic performance of DBT, with and without USG, versus breast MRI in correlation to histopathological examination (HPE). This was a retrospective study in a university hospital over a duration of 24 months. Findings were acquired from a formal report and were correlated with HPE. The sensitivity of DBT with or without USG was lower than MRI. However, the accuracy, specificity and PPV were raised with the aid of USG to equivalent or better than MRI. These three modalities showed statistically significant in correlation with HPE (p < 0.005, chi-squared). Generally, DBT alone has lower sensitivity as compared to MRI. However, it is reassuring that DBT + USG could significantly improve diagnostic performance to that comparable to MRI. In conclusion, results of this study are vital to centers which do not have MRI, as complementary ultrasound can accentuate diagnostic performance of DBT.

Effects of deprivation and age on staging of breast, colon, rectum and prostate cancer in Umbria region, Italy: a multilevel approach

BACKGROUND

Early diagnosis of breast, colon, rectum and prostate cancers improves health outcomes. Low socioeconomic status (SES) is related to advanced stages at diagnosis; inequalities could explain differences in outcomes by age. The influence of SES, age and residence area on staging was explored in the Umbrian population.

METHODS

2001-2010 cases were geo-coded by census tract of residence. Stage distribution or Gleason score were analyzed by multilevel multinomial logistic regression with age and SES as the fixed effects and census tract as the random-effect.

RESULTS

For breast and colorectal cancers, the screening age class was advantaged. For breast, age effect was modulated by deprivation and census tract. In the elderly, the richest were advantaged, the poorest disadvantaged; issues emerged for the young. For colon, age effect is modulated by census tract in early stages and deprivation in late stages. The elderly were disadvantaged; the young and the deprived had more stages IV. About rectum, age effect was modulated by deprivation in the late stages. The elderly were disadvantaged; the young and the deprived presented more stages IV. For prostate, age effect was modulated by deprivation and census tract. The intermediate age class was advantaged, the elderly disadvantaged.

CONCLUSION

Age was not always the determinant of a delayed staging when SES was considered. For breast and colorectal cancers, issues of delayed diagnosis emerged in the young. If the care center was near the residence, the census tract modified the stage at diagnosis. These results are useful to reduce SES barriers by specific programs adapted to the age of the patient and area of residence.

ACR Appropriateness Criteria® Transgender Breast Cancer Screening

Breast cancer screening recommendations for transgender and gender nonconforming individuals are based on the sex assigned at birth, risk factors, and use of exogenous hormones. Insufficient evidence exists to determine whether transgender people undergoing hormone therapy have an overall lower, average, or higher risk of developing breast cancer compared to birth-sex controls. Furthermore, there are no longitudinal studies evaluating the efficacy of breast cancer screening in the transgender population. In the absence of definitive data, current evidence is based on data extrapolated from cisgender studies and a limited number of cohort studies and case reports published on the transgender community. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Added Value of the Vascular Index on Superb Microvascular Imaging for the Evaluation of Breast Masses: Comparison With Grayscale Ultrasound

OBJECTIVES

To evaluate the value of the vascular index (VI) on Superb Microvascular Imaging (SMI; Canon Medical Systems Corporation, Tokyo, Japan) in comparison with grayscale ultrasound (US) alone for assessing breast masses.

METHODS

We evaluated a total of 70 breast masses (36 malignant and 34 benign lesions) in 70 consecutive patients using grayscale US and SMI. Two breast radiologists analyzed grayscale US alone and the combination of grayscale US and SMI. They also measured the VI based on SMI. The diagnostic performance of grayscale US alone and the combination of grayscale US and SMI was compared. The VI was compared between benign and malignant masses, and the optimal cutoff value was determined. In addition, the interobserver agreement in imaging analyses and the VI was assessed.

RESULTS

The interobserver agreements in imaging analyses and the VI were almost perfect. The VI of malignant breast masses was significantly higher than that of benign lesions (P < .001). The optimal cutoff value of the VI for differentiating between malignant and benign breast masses was 2.95, with sensitivity of 86.1% and specificity of 91.2%. The diagnostic performance values of grayscale US alone and the combination of grayscale US and SMI were 0.824 and 0.912, respectively, for reader 1 (P = .028) and 0.795 and 0.853 for reader 2 (P = .101).

CONCLUSIONS

The VI on SMI was significantly higher for malignant breast masses than for benign lesions, with high interobserver agreement. Our study suggests that the combination of grayscale US and SMI with the VI could improve the characterization of breast masses.

Automated breast US as the primary screening test for breast cancer among East Asian women aged 40-49 years: a multicenter prospective study

OBJECTIVES

To prospectively evaluate the diagnostic performance of screening ABUS as the primary screening test for breast cancer among Korean women aged 40-49 years.

METHODS

This prospective, multicenter study included asymptomatic Korean women aged 40-49 years from three academic centers between February 2017 and October 2019. Each participant underwent ABUS without mammography, and the ABUS images were interpreted at each hospital with double-reading by two breast radiologists. Biopsy and at least 1 year of follow-up was considered the reference standard. Diagnostic performance of ABUS screening and subgroup analyses according to patient and tumor characteristics were evaluated.

RESULTS

Reference standard data were available for 959 women. The recall rate was 9.8% (95% confidence interval [CI]: 7.9%, 11.7%; 94 of 959 women) and the cancer detection yield was 5.2 per 1000 women (95% CI: -0.6, 11.1; 5 of 959 women). There was only one interval cancer. The sensitivity was 83.3% (95% CI: 53.5%, 100%; 5 of 6 cancers) and the specificity was 90.7% (95% CI: 88.8%, 92.5%; 864 of 95. women). The positive predictive values of biopsies performed (PPV₃) was 20.0% (95% CI: 4.3%, 35.7%; 5 of 25 women). Women with heterogeneous background echotexture had a higher recall rate (p = .009) and lower specificity (p = .036). Women with body mass index values < 25 kg/m² had a higher mean recall rate (p = .046).

CONCLUSION

In East Asia, screening automated breast US may be an alternative to screening mammography for detecting breast cancers in women aged 40-49 years.

KEY POINTS

• Automated breast US screening for breast cancer in asymptomatic women aged 40-49 is effective with 5.2 per 1000 cancer detection yield. • Women with heterogeneous background echotexture had a higher recall rate and lower specificity. • Women with body mass index < 25 kg/m² had a higher recall rate.

Mammographic Breast Density in Pakistani Women, Factors Affecting It, and Inter-Observer Variability in Assessment

Introduction Breast density on mammography can affect the sensitivity of breast cancer detection and is an independent risk factor for breast cancer. The incidence of breast cancer in Pakistani women is reported to be the highest among women in Asia. No published data is describing the patterns of mammographic breast density in this population. We undertook this study to assess the Breast Imaging Reporting and Data System (BI-RADS) patterns of breast density on mammography, factors that affect breast density, and inter-observer variability in breast density assessment. Methods Bilateral breast mammograms were retrospectively reviewed for breast density by two separate readers (resident and attending radiologist). Breast density was categorized into four types according to the BI-RADS lexicon. Types 1 and 2 were grouped into non-dense and types 3 and 4 into dense breasts. The association of patient factors with breast density was assessed, with p < 0.05 considered statistically significant. The inter-observer variability in breast density assessment between the two readers was calculated using Cohen's κ coefficient. Results A total of 612 women underwent mammography in the study period. Type 3 (heterogeneously dense breast parenchyma) was the most frequent pattern (51.6%) followed by type 2 (scattered fibroglandular) pattern (38.9%). Fatty parenchyma (type 1) and extremely dense parenchyma (type 4) were the least common. Breast density was inversely related to age (p < 0.001) and parity (p <0.002). Breast density was also lower in postmenopausal women (p < 0.001). There was no statistically significant difference in mean age at menarche, age at first delivery, family history of breast cancer, or presence of cancer among women with dense and non-dense breasts. The inter-observer agreement was almost perfect (κ = 0.86).  Conclusion The majority of women in our population (56.9%) had dense breasts (BI-RADS type 3 and 4) which decrease the sensitivity of breast cancer detection on mammography suggesting it may be insufficient as the sole screening/diagnostic tool in this population. Lower breast density was associated with increasing age, parity, and post-menopausal status. Breast density assessment was almost perfect among the resident and attending radiologist.

Follow-Up Intervals for Breast Imaging Reporting and Data System Category 3 Lesions on Screening Ultrasound in Screening and Tertiary Referral Centers

Objective

To assess the appropriate follow-up interval, and rate and timepoint of cancer detection in women with Breast Imaging Reporting and Data System (BI-RADS) 3 lesions on screening ultrasonography (US) according to the type of institution.

Materials and Methods

A total of 1451 asymptomatic women who had negative or benign findings on screening mammogram, BI-RADS 3 assessment on screening US, and at least 6 months of follow-up were included. The median follow-up interval was 30.8 months (range, 6.8–52.9 months). The cancer detection rate, cancer detection timepoint, risk factors, and clinicopathological characteristics were compared between the screening and tertiary centers. Nominal variables were compared using the chi-square or Fisher's exact test and continuous variables were compared using the independent t test or Mann-Whitney U test.

Results

In 1451 women, 19 cancers (1.3%) were detected; two (0.1%) were diagnosed at 6 months and 17 (1.2%) were diagnosed after 12.3 months. The malignancy rates were both 1.3% in the screening (9 of 699) and tertiary (10 of 752) centers. In the screening center, all nine cancers were invasive cancers and diagnosed after 12.3 months. In the tertiary center, two were ductal carcinomas in situ and eight were invasive cancers. Two of the invasive cancers were diagnosed at 6 months and the remaining eight cancers newly developed after 13.1 months.

Conclusion

One-year follow-up rather than 6-month follow-up may be suitable for BI-RADS 3 lesions on screening US found in screening centers. However, more caution is needed regarding similar findings in tertiary centers where 6-month follow-up may be more appropriate.

Computer-Aided Diagnosis Scheme for Distinguishing Between Benign and Malignant Masses on Breast DCE-MRI Images Using Deep Convolutional Neural Network with Bayesian Optimization

Although magnetic resonance imaging (MRI) has a higher sensitivity of early breast cancer than mammography, the specificity is lower. The purpose of this study was to develop a computer-aided diagnosis (CAD) scheme for distinguishing between benign and malignant breast masses on dynamic contrast material-enhanced MRI (DCE-MRI) by using a deep convolutional neural network (DCNN) with Bayesian optimization. Our database consisted of 56 DCE-MRI examinations for 56 patients, each of which contained five sequential phase images. It included 26 benign and 30 malignant masses. In this study, we first determined a baseline DCNN model from well-known DCNN models in terms of classification performance. The optimum architecture of the DCNN model was determined by changing the hyperparameters of the baseline DCNN model such as the number of layers, the filter size, and the number of filters using Bayesian optimization. As the input of the proposed DCNN model, rectangular regions of interest which include an entire mass were selected from each of DCE-MRI images by an experienced radiologist. Three-fold cross validation method was used for training and testing of the proposed DCNN model. The classification accuracy, the sensitivity, the specificity, the positive predictive value, and the negative predictive value were 92.9% (52/56), 93.3% (28/30), 92.3% (24/26), 93.3% (28/30), and 92.3% (24/26), respectively. These results were substantially greater than those with the conventional method based on handcrafted features and a classifier. The proposed DCNN model achieved high classification performance and would be useful in differential diagnoses of masses in breast DCE-MRI images as a diagnostic aid.

How can additional ultrasonography screening improve the detection of occult breast cancer in women with dense breasts?

Purpose

Although mammography is a gold standard for breast cancer screening, the number of cancers that cannot be detected with mammography is substantial, especially in dense-breast (DB) women. Breast sonography can be a useful and powerful screening tool in these cases. The aim of this study is to assess the application of whole-breast sonography in the evaluation of breast lesions in women with DB tissue and estimate its accuracy in comparison with mammography.

Material and methods

A total of 207 asymptomatic DB women participated in this study. The breast tissue density was assessed using ACR BI-RADS. Patients underwent high-resolution ultrasonography of the breast in addition to physical examination and mammography. Different risk factors were also assessed.

Results

152 of 207 (73.4%) cases who had mammography performed had DB, and 55 (26.6%) cases had very dense breasts (very DBs). None of the cases had a positive history of malignancy, while 19% of them had a positive history of breast cancer in first- or second-degree relatives.

Conclusions

All findings were higher in cases with DB compared to very DBs except for fibroadenoma, which was detected more in cases with very DBs. Our study showed that the prevalence of different breast lesions had a significant relationship with the density of the breast. In our study, 48.3% of the cases were diagnosed with a lesion in their sonography result, although 81.0% of them were benign lesions, and the other 19.0% needed follow-up or biopsy evaluation. A substantial number of mammographically occult breast lesions, either benign or malignant, could be detected by ultrasound in DB tissue.

Supplemental breast cancer-screening ultrasonography in women with dense breasts: a systematic review and meta-analysis

Background

Mammography is not effective in detecting breast cancer in dense breasts.

Methods

A search in Medline, Cochrane, EMBASE and Google Scholar databases was conducted from January 1, 1980 to April 10, 2019 to identify women with dense breasts screened by mammography (M) and/or ultrasound (US). Meta-analysis was performed using the random-effect model.

Results

A total of 21 studies were included. The pooled sensitivity values of M alone and M + US in patients were 74% and 96%, while specificity of the two methods were 93% and 87%, respectively. Screening sensitivity was significantly higher in M + US than M alone (risk ratio: M alone vs. M + US = 0.699, P < 0.001), but the slight difference in specificity was statistically significant (risk ratio = 1.060, P = 0.001). Pooled diagnostic performance of follow-up US after initial negative mammography demonstrated a high pooled sensitivity (96%) and specificity (88%). The findings were supported by subgroup analysis stratified by study country, US method and timing of US.

Conclusions

Breast cancer screening by supplemental US among women with dense breasts shows added detection sensitivity compared with M alone. However, US slightly decreased the diagnostic specificity for breast cancer. The cost-effectiveness of supplemental US in detecting malignancy in dense breasts should be considered additionally.

A review of various modalities in breast imaging: technical aspects and clinical outcomes

Background

Nowadays, breast cancer is the second cause of death after cardiovascular diseases. In general, about one out of eight women (about 12%) suffer from this disease during their life in the USA and European countries. If breast cancer is detected at an early stage, its survival rate will be very high. Several methods have been introduced to diagnose breast cancer with their clinical advantages and disadvantages.

Main text

In this review, various methods of breast imaging have been introduced. Furthermore, the sensitivity and specificity of each of these methods have been investigated. For each of the imaging methods, articles that were relevant to the past 10 years were selected through electronic search engines, and then the most relevant papers were selected. Finally, about 40 articles were studied and their results were categorized and presented in the form of a report as follows. Various breast cancer imaging techniques were extracted as follows: mammography, contrast-enhanced mammography, digital tomosynthesis, sonography, sonoelastography, magnetic resonance imaging, magnetic elastography, diffusion-weighted imaging, magnetic spectroscopy, nuclear medicine, optical imaging, and microwave imaging.

Conclusion

The choice of these methods depends on the patient’s state and stage, the age of the individual and the density of the breast tissue. Hybrid imaging techniques appear to be an acceptable way to improve detection of breast cancer. This review article can be useful in choosing the right method for imaging in people suspected of breast cancer.

A Prospective Study of Automated Breast Ultrasound Screening of Women with Dense Breasts in a Digital Breast Tomosynthesis-based Practice

OBJECTIVE

To assess prospectively the interpretative performance of automated breast ultrasound (ABUS) as a supplemental screening after digital breast tomosynthesis (DBT) or as a standalone screening of women with dense breast tissue.

METHODS

Under an IRB-approved protocol (written consent required), women with dense breasts prospectively underwent concurrent baseline DBT and ABUS screening. Examinations were independently evaluated, in opposite order, by two of seven Mammography Quality Standards Act-qualified radiologists, with the primary radiologist arbitrating disagreements and making clinical management recommendations. We report results for 1111 screening examinations (598 first year and 513 second year) for which all diagnostic workups are complete. Imaging was also retrospectively reviewed for all cancers. Statistical assessments used a 0.05 significance level and accounted for correlation between participants' examinations.

RESULTS

Of 1111 women screened, primary radiologists initially "recalled" based on DBT alone (6.6%, 73/1111, CI: 5.2%-8.2%), of which 20 were biopsied, yielding 6/8 total cancers. Automated breast ultrasound increased recalls overall to 14.4% (160/1111, CI: 12.4%-16.6%), with 27 total biopsies, yielding 1 additional cancer. Double reading of DBT alone increased the recall rate to 10.7% (119/1111), with 21 biopsies, with no improvement in cancer detection. Double reading ABUS increased the recall rate to 15.2% (169/1111, CI: 13.2%-17.5%) of women, of whom 22 were biopsied, yielding the detection of 7 cancers, including one seen only on double reading ABUS. Inter-radiologist agreement was similar for recall recommendations from DBT (κ = 0.24, CI: 0.14-0.34) and ABUS (κ = 0.23, CI: 0.15-0.32). Integrated assessments from both readers resulted in a recall rate of 15.1% (168/1111, CI: 13.1%-17.4%).

CONCLUSION

Supplemental or standalone ABUS screening detected cancers not seen on DBT, but substantially increased noncancer recall rates.

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.

Supplemental Screening for Women with Dense Breasts: What Do Practicing Radiologists Recommend?

OBJECTIVE

To evaluate radiologists' supplemental screening recommendations for women with dense breasts, at average, intermediate, or high risk of breast cancer, and to determine if there are differences between their recommendations for their patients, their friends and family, and themselves.

METHODS

This is an anonymous survey of Society of Breast Imaging (SBI) members. Demographics, knowledge of breast density as a risk factor, and recommendations for screening with digital breast tomosynthesis (DBT), ultrasound (US), and magnetic resonance imaging (MRI) in women with dense breasts, at average, intermediate, or high- risk of breast cancer were assessed. The likelihood of their recommending the screening test for their patients, their family and friends, and themselves was assessed on a Likert scale from 0 to 4 (0 = "not at all likely" to 4 = "extremely likely").

RESULTS

There were 295 responses: 67% were women, and breast imaging comprised 95% of their practice. Among participants, 53% correctly answered the question on relative risk of breast cancer when comparing extremely dense versus fatty breasts, and 57% when comparing heterogeneously dense versus scattered breasts. US is recommended at a relatively low rate (1.0-1.4 on the 0-4 scale), regardless of risk. DBT is recommended at a relatively high rate (2.5-3.0 on the 0-4 scale), regardless of risk status. MR is recommended mainly for those at high risk (3.6 on the 0-4 scale). Radiologists were more likely to recommend additional imaging for themselves than for their patients and their family and friends.

CONCLUSION

For women with dense breasts, radiologists are "somewhat likely" to recommend US and "likely" to "very likely" to recommend DBT regardless of risk group. They are "very likely" to recommend MRI for high-risk groups.

Comparison of variability in breast density assessment by BI-RADS category according to the level of experience

Background Only few studies have assessed variability in the results obtained by the readers with different experience levels in comparison with automated volumetric breast density measurements. Purpose To examine the variations in breast density assessment according to BI-RADS categories among readers with different experience levels and to compare it with the results of automated quantitative measurements. Material and Methods Density assignment was done for 1000 screening mammograms by six readers with three different experience levels (breast-imaging experts, general radiologists, and students). Agreement level between the results obtained by the readers and the Volpara automated volumetric breast density measurements was assessed. The agreement analysis using two categories-non-dense and dense breast tissue-was also performed. Results Intra-reader agreement for experts, general radiologists, and students were almost perfect or substantial (k = 0.74-0.95). The agreement between visual assessments of the breast-imaging experts and volumetric assessments by Volpara was substantial (k = 0.77). The agreement was moderate between the experts and general radiologists (k = 0.67) and slight between the students and Volpara (k = 0.01). The agreement for the two category groups (nondense and dense) was almost perfect between the experts and Volpara (k = 0.83). The agreement was substantial between the experts and general radiologists (k = 0.78). Conclusion We observed similar high agreement levels between visual assessments of breast density performed by radiologists and the volumetric assessments. However, agreement levels were substantially lower for the untrained readers.

Natural history of luminal A breast invasive ductal carcinoma in an elderly

An elderly woman, with no clinically palpable breast lump, presented with an initially benign-appearing lesion on ultrasound. She was followed up to reveal the natural history of luminal A breast cancer.

BI-RADS 3: Current and Future Use of Probably Benign

PURPOSE OF REVIEW

Probably benign (BI-RADS 3) causes confusion for interpreting physicians and referring physicians and can induce significant patient anxiety. The best uses and evidence for using this assessment category in mammography, breast ultrasound, and breast MRI will be reviewed; the reader will have a better understanding of how and when to use BI-RADS 3.

RECENT FINDINGS

Interobserver variability in the use of BI-RADS 3 has been documented. The 5th edition of the BI-RADS atlas details the appropriate use of BI-RADS 3 for diagnostic mammography, ultrasound, and MRI, and discourages its use in screening mammography. Data mining, elastography, and diffusion weighted MRI have been evaluated to maximize the accuracy of BI-RADS 3.

SUMMARY

BI-RADS 3 is an evolving assessment category. When used properly, it reduces the number of benign biopsies while allowing the breast imager to maintain a high sensitivity for the detection of early stage breast cancer.

Radiologic findings of screen-detected cancers in an organized population-based screening mammography program in Turkey

PURPOSE

Bahçeşehir Breast Cancer Screening Program is a population based organized screening program in Turkey, where asymptomatic women aged 40-69 years are screened biannually. In this prospective study, we aimed to determine the mammographic findings of screen-detected cancers and discuss the efficacy of breast cancer screening in a developing country.

METHODS

A total of 6912 women were screened in three rounds. The radiologic findings were grouped as mass, focal asymmetry, calcification, and architectural distortion. Masses were classified according to shape, border, and density. Calcifications were grouped according to morphology and distribution. Cancers were grouped according to the clinical stage.

RESULTS

Seventy cancers were detected with an incidence of 4.8/1000. Two cancers were detected in other centers and three were not visualized mammographically. Mammographic presentations of the remaining 65 cancers were mass (47.7%, n=31), calcification (30.8%, n=20), focal asymmetry (16.9%, n=11), architectural distortion (3.1%, n=2), and skin thickening (1.5%, n=1). The numbers of stage 0, 1, 2, 3, and 4 cancers were 13 (20.0%), 34 (52.3%), 14 (21.5%), 3 (4.6%), and 1 (1.5%), respectively. The numbers of interval and missed cancers were 5 (7.4%) and 7 (10.3%), respectively.

CONCLUSION

A high incidence of early breast cancer has been detected. The incidence of missed and interval cancers did not show major differences from western screening trials. We believe that this study will pioneer implementation of efficient population-based mammographic screenings in developing countries.

Medical auditing of whole-breast screening ultrasonography

Since breast ultrasonography (US) has been used as an adjunctive screening modality in women with dense breasts, the need has arisen to evaluate and monitor its possible harm and benefits in comparison with other screening modalities such as mammography. Recently, the fifth edition of the Breast Imaging Reporting and Data System published by the American College of Radiology has suggested auditing methods for screening breast US. However, the method proposed therein is slightly different from how diagnostic performance was calculated in previous studies on screening breast US. In this article, the background and core aspects of medical audits of breast cancer screening will be reviewed to provide an introduction to the medical auditing of screening breast US, with the goal of helping radiologists to understand and identify potential ways to improve outcomes.

A Review of Supplemental Screening Ultrasound for Breast Cancer: Certain Populations of Women with Dense Breast Tissue May Benefit

Breast density has been shown to be a strong, independent risk factor for breast cancer. Unfortunately, mammography is less accurate on dense breast tissue compared to fattier breast tissue. Multiple studies suggest a solution to this by demonstrating the ability of supplemental screening ultrasound to detect additional malignant lesions in women with dense breast tissue but negative mammography. In particular, supplemental screening ultrasound may be beneficial to women with dense breast tissue and intermediate or average risk for breast cancer, women in specific ethnic populations with greater prevalence of dense breast tissue, and women living in resource-poor healthcare environments. Although magnetic resonance imaging is currently recommended for women with high risk for breast cancer, not all women can access or tolerate a magnetic resonance imaging examination. Notably, ultrasound does not require intravenous gadolinium and may be an alternative for women with socioeconomic or medical restrictions, which limit their access to magnetic resonance imaging. Limitations of supplemental screening ultrasound include a substantial rate of false-positives, increased cost, and limited resource availability, particularly in regard to the time required for image interpretation. Additional clinical experience with this application of ultrasound, improved patient selection criteria, and new technology, such as the promising results seen with automated whole breast ultrasound, may address these limitations. In light of recent legislation in some states that has called for discussing supplemental imaging with patients who have dense breast tissue, the optimal role for supplemental screening ultrasound merits further exploration.

Sensitivity and specificity of mammography and adjunctive ultrasonography to screen for breast cancer in the Japan Strategic Anti-cancer Randomized Trial (J-START): a randomised controlled trial

BACKGROUND

Mammography is the only proven method for breast cancer screening that reduces mortality, although it is inaccurate in young women or women with dense breasts. We investigated the efficacy of adjunctive ultrasonography.

METHODS

Between July, 2007, and March, 2011, we enrolled asymptomatic women aged 40-49 years at 42 study sites in 23 prefectures into the Japan Strategic Anti-cancer Randomized Trial (J-START). Eligible women had no history of any cancer in the previous 5 years and were expected to live for more than 5 years. Randomisation was done centrally by the Japan Clinical Research Support Unit. Participants were randomly assigned in 1:1 ratio to undergo mammography and ultrasonography (intervention group) or mammography alone (control group) twice in 2 years. The primary outcome was sensitivity, specificity, cancer detection rate, and stage distribution at the first round of screening. Analysis was by intention to treat. This study is registered, number UMIN000000757.

FINDINGS

Of 72,998 women enrolled, 36,859 were assigned to the intervention group and 36,139 to the control group. Sensitivity was significantly higher in the intervention group than in the control group (91·1%, 95% CI 87·2-95·0 vs 77·0%, 70·3-83·7; p=0·0004), whereas specificity was significantly lower (87·7%, 87·3-88·0 vs 91·4%, 91·1-91·7; p<0·0001). More cancers were detected in the intervention group than in the control group (184 [0·50%] vs 117 [0·32%], p=0·0003) and were more frequently stage 0 and I (144 [71·3%] vs 79 [52·0%], p=0·0194). 18 (0·05%) interval cancers were detected in the intervention group compared with 35 (0·10%) in the control group (p=0·034).

INTERPRETATION

Adjunctive ultrasonography increases sensitivity and detection rate of early cancers.

FUNDING

Ministry of Health, Labour and Welfare of Japan.

The Values of Combined and Sub-Stratified Imaging Scores with Ultrasonography and Mammography in Breast Cancer Subtypes

Background and Objectives

The Breast Imaging Reporting and Data System (BI-RADS) of Mammography (MG) and Ultrasonography (US) were equivalent to the “5-point score” and applied for combined and sub-stratified imaging assessments. This study evaluated the value of combined and sub-stratified imaging assessments with MG and US over breast cancer subtypes (BCS).

Materials and Methods

Medical records of 5,037 cases having imaging-guided core biopsy, performed from 2009 to 2012, were retrospectively reviewed. This study selected 1,995 cases (1,457 benign and 538 invasive cancer) having both MG and US before biopsy. These cases were categorized with the “5-point score” for their MG and US, and applied for combined and sub-stratified imaging assessments. Invasive cancers were classified on the basis of BCS, and correlated with combined and sub-stratified imaging assessments.

Results

These selected cases were evaluated by the “5-point score.” MG, US, and combined and sub-stratified imaging assessments all revealed statistically significant (P < 0.001) incidence of malignancy. The sensitivity was increased in the combined imaging score (99.8%), and the specificity was increased in the sub-stratified combined score (75.4%). In the sub-stratified combined imaging assessment, all BCS can be classified with higher scores (abnormality hierarchy), and luminal B subtype showed the most salient result (hierarchy: higher, 95%; lower, 5%).

Conclusions

Combined and sub-stratified imaging assessments can increase sensitivity and specificity of breast cancer diagnosis, respectively, and Luminal B subtype shows the best identification by sub-stratified combined imaging scoring.

2D mammography, digital breast tomosynthesis, and ultrasound: which should be used for the different breast densities in breast cancer screening?

PURPOSE

To determine which modalities [2D mammography (2D), digital breast tomosynthesis (DBT), whole breast sonography (WBS)] are optimal for screening depending on breast density.

METHODS

Institutional retrospective cohort study of 2013 screening mammograms (16,789), sorted by modalities and density.

RESULTS

Cancer detection is increased by adding WBS to 2D (P=.02) for the overall study population. Recall rate was lowest with 2D+DBT (10.2%, P<.001) and highest with 2D+DBT+WBS (23.6%, P<.001) for the overall study population as well.

CONCLUSION

Women with dense and nondense breasts benefit from reduced recall rate with the addition of DBT; however, this benefit is negated with the addition of WBS.

Will supplemental screening ultrasound increase breast cancer overdiagnosis?

Overdiagnosis refers to the detection of cancers that would never come to light in a patient's lifetime and are only identified by means of screening. Exactly how much overdiagnosis currently exists with screening mammography is uncertain. Because we do not know for certain which tumors would ultimately lead to death if left untreated and which would not, we cannot directly measure overdiagnosis and how best to estimate it is a matter of controversy. A conservative estimate of overdiagnosis with mammography would be on the order of 10%, but estimates have ranged as high as 54%. We know from multiple studies that ultrasound (US) screening mostly detects small, invasive, node-negative cancers; and in the ACRIN 6666 study, there was a greater tendency for US-only-detected tumors to be low grade than those detected with mammography. However, the population of patients undergoing screening US can be expected to differ from the average screening mammography population in that they will have higher breast density, they will be younger, and they may also have higher breast cancer risk than the population undergoing screening mammography. These factors may be associated with more aggressive tumors. There is no way to know whether we will be increasing overdiagnosis without performing a large randomized controlled study with very long-term follow-up. Even if some cancers are overdiagnosed with US, there will be a greater proportion of lethal breast cancers that are successfully treated because of screening US. The more important task is to learn how to correctly diagnose and appropriately treat nonlethal cancers.

Initial experience with the New York State breast density inform law at a community-based breast center

OBJECTIVES

The purpose of this study was to review our initial experience with the New York State breast density inform law (New York public health law, S2404-C) at our outpatient breast center. We sought to review the findings in patients returning for screening breast sonography after a screening mammogram revealed heterogeneously dense or extremely dense breast tissue.

METHODS

From January 1, 2013, through May 31, 2014, 102,841 patients who underwent screening mammography were seen at our institution. Of these, 35,153 were determined to have heterogeneously dense breast tissue, and 11,864 were determined to have extremely dense breast tissue. Due to the New York State breast density inform law, these 47,017 patients were notified of their breast density, with 935 patients (2%) returning for 971 screening breast sonographic examinations.

RESULTS

Heterogeneously dense breast tissue was noted in 66% of the patients (619), and extremely dense breast tissue was noted in 34% (316). Thirty-one percent of the patients (290) reported no additional risk factors; 68% (635) presented with 1 or more additional risk factors; and 1% (10) were adopted, and the risk status could not be assessed. Twenty-five procedures (2.6%) were performed after screening breast sonography, resulting in 22 benign findings, 1 atypical finding, and 2 malignancies. The overall positive predictive value was 8% (2 of 25), and the overall cancer detection rate was 2.1 per 1000 (2 of 935).

CONCLUSIONS

Handheld screening breast sonography performed in women with dense breast tissue can aid in the detection of otherwise occult breast cancer, as we found 2 cancers in the study population, with an overall positive predictive value of 8%. The addition of screening sonography in this cohort did lead to an increase in minimally invasive procedures in 2.6%.

Limitations of mammography in the diagnosis of breast diseases compared with ultrasonography: a single-center retrospective analysis of 274 cases

BACKGROUND

The aim of this study is to compare X-ray mammography (MG) and ultrasonography (US) in the diagnosis of breast diseases in Chinese women.

METHODS

We retrospectively analyzed X-ray mammograms of 274 patients with US and surgical/pathological results of breast diseases diagnosed at The Second Affiliated Hospital of Anhui Medical University (Hefei, China) between March 2011 and November 2014. The MG and US data were compared to surgical records using the results from post-surgical pathological examinations as the gold standard.

RESULTS

The overall sensitivity, specificity, accuracy, false-positive, false-negative, positive predictive value, and negative predictive value for the detection of breast cancer were 88.5%, 57.9%, 73.7%, 42.1%, 11.5%, 69.2%, and 82.5%, respectively, for MG and 95.9%, 66.7%, 81.8%, 33.3%, 4.1%, 75.5%, and 93.8%, respectively, for US. Of the 274 cases, lesion size by MG agreed with surgery in 133 (48.5%) patients compared with 216 (78.8%) by US (P < 0.01). Lesion location by MG agreed with surgery in 146 (53.3%) patients compared with 257 (93.8%) by US (P < 0.01). These values were then stratified according to age, menstrual status, breast density, and breast volume, and the agreement rates of MG with surgery were lower than that of US (all P < 0.01), except when the lesion size was >5 cm (P > 0.05).

CONCLUSIONS

US was better than MG in the preoperative evaluation of breast diseases of Chinese women. These results suggest that US could be more useful for detecting breast lesions in China, especially for younger women with dense breasts.

Analysis of prior mammography with negative result in women with interval breast cancer

PURPOSE

The purpose of our study was to review mammographic findings which were previously negative in women with interval breast cancer and to analyze the histopathological features of the interval breast cancer.

MATERIALS AND METHODS

A total of 5521 women underwent surgery for breast cancer between January 2009 and December 2011. Among them, 240 women who had undergone available, previous mammography studies reported as normal or benign (mean interval between examinations, 9.7 months) were included in our study. We reviewed the previous mammographic features and categorized as true interval breast cancer, minimal sign, and missed interval breast cancer. Histopathological findings were also reviewed.

RESULTS

Of the 240 diagnosed cancers, 78 (32.5 %) were classified as true interval breast cancer, 78 (32.5 %) as minimal sign, and 84 (35 %) as missed interval breast cancer. True interval breast cancer occurred in a younger age and showed dense breast compared with missed breast cancer. The breast density of 169 patients (70.4 %) was dense. In the minimal sign group, the most common finding was normal appearing tissue (61/78), followed by benign-appearing calcification (17/78). There were no significant differences in the histopathological findings in each of the three groups and tended to have smaller tumor size, negative nodal status, a lower AJCC stage, and frequent luminal A subtype.

CONCLUSION

The majority of interval breast cancers was not detectable in patients with dense breast or showed subtle mammographic findings on previous mammography. Although the majority of breast cancers showed a low grade in the histopathological findings, a better understanding of the mammographic findings will influence the sensitivity of mammography.

Changing patterns of microcalcification on screening mammography for prediction of breast cancer

BACKGROUND

The presence of microcalcification on mammography is one of the earliest signs in breast cancer detection. However, it is difficult to distinguish malignant calcifications from benign calcifications. The aim of this study is to evaluate correlation between changing patterns of microcalcification on screening mammography and malignant breast lesions.

METHODS

Medical records and diagnostic images of 67 women who had previously undergone at least two digital mammograms at least 6 months apart and underwent mammography-guided needle localization and surgical excision between 2011 and 2013 were retrospectively reviewed and analyzed.

RESULTS

Breast cancer was detected in the surgical specimens of 20 patients (29.9 %). Annual change of extent of microcalcification on mammography showed statistically significant correlation with pathologic outcome (P = 0.023). The changing pattern of new appearance or increased extent of microcalcification on mammography had positive predictive value of 54.8 % for breast cancer, and it was a statistically significant predictor for breast cancer (P = 0.012). Shape or number change of microcalcification without increased extent had less accurate predictive value for breast cancer, particularly in women younger than 50 years (P < 0.001).

CONCLUSIONS

This study showed that the pattern of increased extent of microcalcification on screening mammography was a significant predictor for breast cancer. We suggest that mammography-guided needle localization and surgical excision should be considered when increased extent of microcalcification is observed on screening mammography and closed follow-up without pathologic confirmation can be permitted if absence of extension of microcalcification was confirmed in women younger than 50 years.

A multiparametric serum marker panel as a complementary test to mammography for the diagnosis of node-negative early-stage breast cancer and DCIS in young women

BACKGROUND

The sensitivity of mammography for the detection of small lesions, including node-negative early-stage (T1N0) primary breast cancer (PBC) and ductal carcinoma in situ (DCIS), is significantly decreased in young patients. From a clinical standpoint, an inconclusive mammogram reflects the inability of clinicians to confidently decide whether patients should be referred for biopsy or for follow-up with repeat imaging.

METHODS

Specific ELISAs were developed for a panel of 13 well-recognized breast autoantigens (HSP60, FKBP52, PRDX2, PPIA, MUC1, GAL3, PAK2, P53, CCNB1, PHB2, RACK1, RUVBL1, and HER2). Circulating autoantibody levels were measured in a cohort of 396 serum samples from histologically confirmed DCIS (n = 87) or T1N0 PBC (n = 153) and healthy controls (n = 156).

RESULTS

Individually, antibodies against CCNB1, FKBP52, GAL3, PAK2, PRDX2, PPIA, P53, and MUC1 demonstrated discriminatory power between breast cancer and healthy control groups. At 90% sensitivity, the overall combined specificity of the autoantibody serum screening test was 42%. Adjustment for higher sensitivities of 95% and 99% resulted in 30% and 21% specificities, respectively (33% and 18% in T1N0 PBC and 28% and 21% in DCIS). Finally, in patients with node-negative early-stage breast cancer younger than 50 years, the autoantibody assay exhibited 59% specificity with a fixed sensitivity at 90%.

CONCLUSIONS

Our autoantibody panel allows accurate detection of early breast cancer and DCIS, notably in younger patients.

IMPACT

Clinical assessment of this autoantibody panel displays a potential to facilitate clinical management of early-stage breast cancer detection in cases of inconclusive mammogram.