BI-RADS Assessment Research Articles

Palpable breast abnormalities in women under age 40.

Although the prevalence of malignancy in average risk women under age 40 presenting with a palpable breast abnormality is low, the management of benign-appearing palpable abnormalities remains controversial. This study assesses the imaging evaluation, subsequent management, and outcomes of women under age 40 presenting with a palpable area of concern. This study also evaluates the costs, utility, and outcomes of BI-RADS 3 assessment in this patient population. A single institution retrospective case review from July 2010 through June 2013 identified women under age 40 presenting with a new palpable breast abnormality. Diagnostic imaging evaluation was performed. BI-RADS assessments and recommendations were recorded prospectively. Outcome was determined by tissue diagnosis, 2 years of surveillance, or search of the hospital tumor registry. Performance measures were calculated. Among 1440 cases, 1052 were initially assessed as BI-RADS 1 or 2 (73.1%), 184 as BI-RADS 3 (12.8%), 182 as BI-RADS 4 (12.6%), and 22 as BI-RADS 5 (1.5%). In all, 30 breast malignancies were diagnosed (cancer yield 2.1%). All 30 cancers were initially categorized as BI-RADS 4 or 5. No BI-RADS 1, 2, or 3 findings proved malignant. The imaging evaluation sensitivity was 100%, specificity was 87.7%, and accuracy was 87.9%. The negative predictive value was 100% and the positive predictive value was 14.7%. Average risk women under age 40 presenting with a palpable abnormality have a low prevalence of breast cancer. Imaging evaluation has a high sensitivity and negative predictive value, thereby allowing for confident characterization and appropriate management recommendations. For palpable solid masses with benign imaging features in women under age 40, short-term interval follow-up with subsequent periodic imaging or clinical examination for a total of 2 years is a cost-effective and safe alternative to biopsy.

Effectiveness of a Mobile Mammography Program.

Mobile mammography units have increasingly been used to address patient health care disparities; however, there are limited data comparing mobile units to stationary sites. This study aims to evaluate the characteristics of women who underwent mammography screening in a mobile unit versus those who underwent mammography screening at a cancer center. In this retrospective study, we analyzed all screening mammography examinations performed in a mobile unit in 2014 (n = 1433 examinations). For comparison, we randomized and reviewed an equivalent number of screening mammography examinations performed at our cancer center in 2014 (n = 1434 examinations). BI-RADS assessment, adherence to follow-up, biopsies performed, cancer detection rate, and sociodemographic variables were recorded. An independent-samples t test was conducted to identify potential differences in age between cancer center patients and mobile unit patients. Chi-square analyses were used to test for associations between location and factors such as health insurance, race, marital status, geographic area, adherence to screening guidelines, recall rate, adherence to follow-up, and cancer detection rates. Patients visiting our cancer center (mean = 57.74 years; SD = 10.55) were significantly older than those visiting the mobile unit (mean = 52.58 years; SD = 8.19; p < 0.001). There was a significant association between location and health insurance status (χ2 = 610.92; p < 0.001) with more uninsured patients undergoing screening in the mobile van (cancer center = 3.70%, mobile unit = 38.73%). There was a significant association between screening location and patient race (χ2 = 118.75, p < 0.001), with more white patients being screened at the cancer center (cancer center = 47.28%, mobile unit = 33.30%), more black patients being screened in the mobile van (cancer center = 49.30%, mobile unit = 54.15%), and more Hispanic patients being screened in the mobile van (cancer center = 1.05%, mobile unit = 6.77%). There was a significant association between location and patient marital status (χ2 = 135.61, p < 0.001), with more married patients screened at the cancer center (cancer center = 49.16%, mobile unit = 38.31%), more single patients screened in the mobile van (cancer center = 25.17%, mobile unit = 34.47%), and more widowed patients being screened at the cancer center (cancer center = 8.09%, mobile unit = 4.47%). There was a significant association between location and geographic area (χ2 = 33.33, p < 0.001), with both locations reaching more urban than rural patients (cancer center = 79.99%, mobile unit = 70.62%). There was a significant association between location and adherence to screening guidelines (χ2 = 179.60, p < 0.001), with patients screened at the cancer center being more compliant (cancer center = 56.90%, mobile unit = 34.47%). Finally, there was a significant association between location and recall rate (χ2 = 4.06, p < 0.001). The cancer center had a lower recall rate (13.32%) than the mobile van (15.98%). Of those patients with BI-RADS 0, there was a significant association between location and adherence to follow-up (χ2 = 22.75, p < 0.001) with patients using the mobile unit less likely to return for additional imaging (cancer center = 2.65%, mobile unit = 17.03%). Significant differences were found among patients visiting the cancer center versus the mobile mammography van. The cancer center's population is older and more adherent to guidelines, whereas the mobile mammography population exhibited greater racial and marital diversity, higher recall rate, and lack of adherence to follow-up recommendations. By identifying these characteristics, we can develop programs and materials that meet these populations' needs and behaviors, ultimately increasing mammography screening and follow-up rates among underserved populations.

Added Value of Digital Breast Tomosynthesis Combined with Digital Mammography According to Reader Agreement: Changes in BI-RADS Rate and Follow-Up Management

Background: The aim of this study was to evaluate the added value of digital breast tomosynthesis (DBT) when combined with digital mammography (DM) in BI-RADS assessment and follow-up management. Methods: From February 2014 to January 2015, 214 patients underwent DM and DBT, acquired with a Siemens Mammomat Inspiration unit. 2 expert readers independently reviewed the studies in 2 steps: DM and DM+DBT, according to BI-RADS rate. Patients with BI-RADS 0, 3, 4, and 5 were recalled for work-up. Inter-reader agreement for BI-RADS rate and work-up rate were evaluated using Cohen's kappa. Results: Inter-reader agreement (κ value) for BI-RADS classification was 0.58 for DM and 0.8 for DM+DBT. DM+DBT increased the number of BI-RADS 1, 2, 4, 5 and reduced the number of BI-RADS 0 and 3 for both readers compared to DM alone. Regarding work-up rate agreement, κ was poor for DM and substantial (0.7) for DM+DBT. DM+DBT also reduced the work-up rate for both Reader 1 and Reader 2. Conclusion: DM+DBT increased the number of negative and benign cases (BI-RADS 1 and 2) and suspicious and malignant cases (BI-RADS 4 and 5), while it reduced the number of BI-RADS 0 and 3. DM+DBT also improved inter-reader agreement and reduced the overall recall for additional imaging or short-interval follow-up.

Application of BI-RADS Descriptors in Contrast-Enhanced Dual-Energy Mammography: Comparison with MRI

Background: Contrast-enhanced (CE) magnetic resonance imaging (MRI) BI-RADS descriptors are used in the evaluation of contrast-enhanced dual-energy mammography (CEDEM) images of mass lesions and are assumed to be applicable. Patients and Methods: Patients with suspicious mass lesions on mammography (BI-RADS 4 or 5) were included. CEDEM examinations were performed using a modified prototype unit. CE-MRI was performed using a high temporal and high spatial resolution imaging protocol. 2 blinded breast radiologists evaluated all images using criteria related to contrast enhancement intensity and morphology according to the BI-RADS lexicon (5th edition) in 2 sessions. Histopathology was used as the standard of reference. Results: 11 patients with 5 benign and 6 malignant index lesions were included. Enhancement characteristics were similar in the malignant cases. Enhancement of the benign lesions was moderate on CEDEM and strong on MRI. Discrepancies in the BI-RADS descriptors did not influence the final BI-RADS score. Overall, the BI-RADS assessment was almost identical in all cases. 1 malignant lesion was rated BI-RADS 4 with CEDEM and BI-RADS 5 with MRI, and 1 benign was rated BI-RADS 2 and BI-RADS 1, respectively. Conclusion: MRI BI-RADS descriptors of contrast-enhancing lesions can be applied for the morphologic analysis of mass lesions on CEDEM.

Fibroglandular Tissue Quantification in Mammography by Optimized Fuzzy C-Means with Variable Compactness

BackgroundMammography is a wordwild image modality used to diagnose breast cancer, even for asymptomatic women. Due to its large availability, mammograms can be used to measure breast density and to predict cancer development. MethodsWe developed a methodology to estimate breast density using post-processed digital mammogram. Our automatic approach utilizes an optimized Fuzzy C-Means with variable compactness algorithm to classify and quantify fibroglandular tissue in mammograms. ResultsFibroglandular tissue percentage estimation by our method has been compared with BI-RADS assessment from radiologist and achieved 67.8% of correct classification, with Spearman's correlation coefficient of ρ=0.618, for p<0.001. Furthermore, a Bland–Altman statistics showed no significant differences (bias of −0.20±1.52) between both methods, indicating that the assessment widely used in clinical routine is consistent with the results generated by the algorithms. Cohen's kappa coefficient comparing the performance of the algorithm with the visual assessment for the different BI-RADS scores was 0.47 suggesting a moderate agreement. ConclusionThen, our methodology showed to be robust and accurate when compared with visual assessment. Furthermore, our methodology is fully automatic and reproducible, avoiding inter and intra observers variation, which has a potential to be implemented in clinical routine.

Incidentally detected enhancing lesions found in breast MRI: analysis of apparent diffusion coefficient and T2 signal intensity significantly improves specificity.

To evaluate the value of adding T2- and diffusion-weighted imaging (DWI) to the BI-RADS® classification in MRI-detected lesions. This retrospective study included 112 consecutive patients who underwent 3.0T structural breast MRI with T2- and DWI on the basis of EUSOMA recommendations. Morphological and kinetic features, T2 signal intensity (T2 SI) and apparent diffusion coefficient (ADC) findings were assessed. Thirty-three (29.5%) patients (mean age 57.0 ± 12.7years) had 36 primarily MRI-detected incidental lesions of which 16 (44.4%) proved to be malignant. No single morphological or kinetic feature was associated with malignancy. Both low T2 SI (P = 0.009) and low ADC values (≤0.87 × 10-3 mm2s-1, P < 0.001) yielded high specificity (80.0%/80.0%). The BI-RADS classification supplemented with information from DWI and T2-WI improved the diagnostic performance of the BI-RADS classification as sensitivity remained 100% and specificity improved from 30% to 65.0%. The numbers of false positive lesions declined from 39% (N = 14) to 19% (N = 7). MRI-detected incidental lesions may be challenging to characterize as they have few specific malignancy indicating features. The specificity of MRI can be improved by incorporating T2 SI and ADC values into the BI-RADS assessment. • MRI-detected incidental lesions have few specific malignancy indicating features. • ≥ 1 suspicious morphologic or kinetic feature may warrant biopsy. • T2 signal intensity and DWI assessment are feasible in primarily MRI-detected lesions. • T2 SI and DWI assessment improve the BI-RADS specificity in MRI-detected lesions.

Abstract P6-10-12: Volumetric breast density better predicts tumour characteristics associated with poor prognosis compared to visual BI-RADS

Abstract Purpose: Early detection of breast cancer through mammography screening reduces breast cancer mortality. To improve outcomes from screening, more than half of invasive cancers and a third of high grade cancers should be small at detection (&amp;lt;15mm), and more than 70% of all cancers should be node negative at diagnosis. Although breast density is associated with reduced mammographic sensitivity, it is unclear whether certain tumor characteristics associated with poorer prognosis are more prevalent in women with denser breasts. The study investigated associations between visually- or volumetrically-assessed breast density and tumor characteristics related to poor prognosis. Methods: Our IRB-approved study included 755 DCIS, invasive ductal or invasive lobular breast cancers diagnosed in women (aged over 40) between January 2009 and December 2012. Information on the patients' tumor characteristics including stage, size, receptor, grade and lymph node status was collected retrospectively. Women were excluded if they had a previous history of breast cancer or breast surgery, or if they were missing tumour size data or raw digital mammograms taken within 24 months of the cancer diagnosis. For women with multiple cancers, only the first diagnosed cancer was included. Breast density was assessed using visual BI-RADS density categories and Volpara Density Grades (VDG; an automated equivalent to 4th Edition BI-RADS, assigned using preset cut-offs of volumetric breast density: 4.5, 7.5, 15.5 and &amp;gt;15.5%). VDG was calculated from both breasts if the prior negative mammogram was available, and the contralateral breast for positive mammograms. Results: Overall, 55% of invasive tumors and 33% of grade 3 tumors were smaller than 15 mm and 83% were node negative. Mean tumor size increased significantly with increasing VDG (VDG 1 = 12.8, 2 = 14.7, 3 = 16.1, 4 = 20.4 mm, p&amp;lt;0.001) and increasing BI-RADS (1 = 12.2, 2 = 13.9, 3 = 16.8, 4 = 18.2 mm, p=0.01). The proportion of node positive tumors also increased significantly with increasing VDG (5.1%, 12.8%, 19.3%, 26.1%, p&amp;lt;0.001) and BI-RADS (0%, 10.6%, 19.5%, 26%, p=0.01). There was a significant increase in grade 3 tumors (11%, 16.1%, 21.7%, 21.7%, p =0.02) and HER-2 positive tumors (5.6%, 10.5%, 13.3%, 14.3%, p=0.02) with increasing VDG that was not seen with visual BI-RADS assessment (p=0.4). Increasing VDG was also significantly associated with increased proportions of larger (i.e. &amp;gt;15mm) node positive cancers (1.7%, 6.3%, 10.5%, 16%, p=0.004) that were not seen with BI-RADS (p=0.2). Conclusion: We found that tumour size and node status differed significantly with breast density as measured by VDG and visual BI-RADS. However, grade 3, HER-2 positive and large/node-positive cancers were all significantly associated with increasing VDG, but not BI-RADS density grade. Further research is needed to investigate whether automated volumetric breast density can be used to predict which women are more likely to be diagnosed with tumours that have poorer prognostic features. Citation Format: Johnston L, Chan A, Arieno A, Morgan R, Highnam R, Destounis S. Volumetric breast density better predicts tumour characteristics associated with poor prognosis compared to visual BI-RADS. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P6-10-12.

Clinical utility of the radiation dose management system for full field digital mammography (FFDM): In Asian women with dense breast tissue.

70 Background: In the perspectives on radiation dose, there are consensus of importance on radiation dose management for patient safety and trends to reduce radiation dose for patient safety. Radiation dose management system like Radimetrics helps radiologists optimize protocols and reduce radiation dose. There is no previous data applying the radiation dose management system in mammography.We investigated the clinical usefulness of the radiation dose management system in full field digital mammography (FFDM) using commercial Radiation dose management system. Methods: We did radiation dose tracking, monitoring, and statistics through the existed radiation dose management system (Radimetrics). The utilization data, parameter, and dose report were sent to the conventional picture archiving and communication system (PACS) and the Radimetrics enterprise flat form. And we could review the data including age, kVp, mAs, breast thickness, and compression force under the web base. We analyzed the breast composition depending on the BI-RADS assessment categories. We evaluated the correlation of the age, kVp, mAs, breast thickness, compression force, and breast composition with organ dose of breast. Additionally, in patients with above diagnostic reference level ( ≥ 75%) of radiation dose, the causes were analyzed. Results: From February to May 2015, 3076 sets of FFDM were performed and sent to PACS and the radiation dose management system (Radimetrics). In total 3076 sets, 2520 were routine bilateral FFDM with 4 views. The mean glandular dose was 6.59± 2.87 mGy (2.63-18.46). In the correlation analysis, the age had moderate negative linear relationship with organ dose. The mAs and breast composition had moderate positive linear relationship with organ dose. The kVp, breast thickness, and compression force had weak positive linear relationship with organ dose. Patients with above diagnostic reference level ( ≥ 75%) of radiation dose showed dense breast composition and thicker breast. Conclusions: The radiation dose management system is useful in FFDM. Especially in Asian women with thick and dense breasts, radiation dose should be carefully managed.

Contrast-enhanced dual energy mammography with a novel anode/filter combination and artifact reduction: a feasibility study.

To demonstrate the feasibility of contrast-enhanced dual-energy mammography (CEDEM) using titanium (Ti) filtering at 49 kVp for high-energy images and a novel artefact reducing image-subtraction post-processing algorithm. Fifteen patients with suspicious findings (ACR BI-RADS 4 and 5) detected with digital mammography (MG) that required biopsy were included. CEDEM examinations were performed on a modified prototype machine. Acquired HE and low-energy raw data images were registered non-rigidly to compensate for possible subtle tissue motion. Subtracted CEDEM images were generated via weighted subtraction, using a fully automatic, locally adjusted tissue thickness-dependent subtraction factor to avoid over-subtraction at the breast border. Two observers evaluated the MG and CEDEM images according to ACR BI-RADS in two reading sessions. Results were correlated with histopathology. Seven patients with benign and eight with malignant findings were included. All malignant lesions showed a strong contrast enhancement. BI-RADS assessment was altered in 66.6% through the addition of CEDEM, resulting in increased overall accuracy. With CEDEM, additional lesions were depicted and false-positive rate was reduced compared to MG. CEDEM using Ti filtering with 49 kVp for HE exposures is feasible in a clinical setting. The proposed image-processing algorithm has the potential to reduce artefacts and improve CEDEM images. • CEDEM with a titanium filter is feasible in a clinical setting. • Breast thickness-dependent image subtraction has the potential to improve CEDEM images. • The proposed image-processing algorithm reduces artefacts.

Abstract P5-02-10: Factors influencing agreement of Ki67 labeling index between core needle biopsy and surgical resection specimens

Abstract Reliable determination of Ki67 labeling index (Ki67 LI) on core needle biopsy specimens (CNB) is essential for determining breast cancer intrinsic subtype (IST), preoperative treatment decisions and short-term treatment response during neoadjuvant therapy. However, analyses investigating robustness of Ki67 LI assessment upon repeated tumor biopsies are scarce and results of studies investigating agreement of KI67 LI between CNB and surgical resection (SR) specimens are conflicting. In the present study, we analysed the role of clinical and pathological factors in influencing concordance of Ki67 LI between CNB and SR specimens. 502 matched pairs of CNB and SR specimens of patients with invasive ER-positive, HER2-negative breast cancer were included in our study. Ki67 LI was determined according to recent recommendations. Luminal B disease was defined by Ki67 LI &amp;gt; 20% according to SR. Ki67 LI values were considered concordant by a divergence of 10% points. Agreement was calculated by Cohen's kappa. Associations with clinicopathological factors were analyzed by Chi square test and logistic regression. Factors investigated included age, menopausal status, CNB method, BIRADS assessment category of imaging abnormality, time between CNB and SR, extent of surgery, histological grade (including individual grading score components according to Elston and Ellis), tumor size, lymph node stage, estrogen- (ER), progesterone- (PR) and HER2-receptor status. A cutoff value of 20% for KI67 LI in SR demonstrated a sensitivity of 90% and a specificity of 60% for identifying luminal B breast cancer in CNB. Upon investigating measurement agreement, we found substantial agreement of Ki67 LI between CNB and SR specimens with a weighted kappa value of 0.837. IST assesment in CNB and SR showed only moderate concordance with a kappa value of 0.587. Concordant diagnosis of IST in CNB and SR was significantly associated with PR expression and histological grade (p&amp;gt;0.05). Agreement of Ki67 LI was higher in tumors expressing low and high levels of PR compared to tumors with intermediate PR score. 27% and 22% of low and intermediate grade breast cancers showed discordant IST in CNB and SR, respectively. In contrast, only 3% of high grade breast cancers differed regarding IST upon repeated measurements. Interestingly, concordance of IST was significantly associated with all separate grading score components in CNB samples such as extent of glandular differentiation (p=0.015), nuclear polymorphism (p=0.005) and number of mitotic figures (p&amp;gt;0.001). We conclude that agreement of breast cancer IST according to Ki67 LI between CNB and SR specimens is significantly influenced by histological tumor grade and PR status. These factors, including all three grading score components are likely to mirror tumor heterogeneity that might compromise obtaining a CNB sample representative of the entire tumor. Our results cast a doubt upon robustness of single CNB-driven measurements of prognostic indicators and outcome predictors in estrogen-receptor positive breast cancer of low or intermediate histological grade. Whether molecular testing of CNB specimens improves classification of luminal breast cancer and helps resolve diagnostic disparities remains to be determined. Citation Format: Zsuzsanna Bago-Horvath, Fabian Roessler, Philipp Wimmer, Martina Mittlboeck, Nicolas Kozakowski, Katja Pinker-Domenig, Rupert Bartsch, Peter Dubsky, Martin Filipits, Margaretha Rudas. Factors influencing agreement of Ki67 labeling index between core needle biopsy and surgical resection specimens [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P5-02-10.

A detailed criterion of BI-RADS assessment category based on US-BI-RADS: a preliminary study

Objective To set up an objective criterion for BI-RADS assessment. Methods The breast sonograms of 1 938 female cases were retrospectively studied which had been confirmed by pathology from January to September 2011 and 2012 January. 1 660 cases during 2011 were model cases, and the importance of each single feature in distinguishing between benign and malignant was obtained with Chi square and OR value. A detailed criterion of BI-RADS assessment category was set up based on US-BI-RADS. Results Eighteen of 24 lexicons were statistically significant distinguished between benign and malignant breast masses(P<0.05). The lexicons were divided into major suspicious signs, middle ones and minor ones assigned 3 points, 2 points and 1 point, and a scoring model was established as follows: Score=3*(X1+ X2+ …+ X6)+ 2*(X7+ X8+ …+ X12)+ (X9+ X10+ …+ X18). Based on BI-RADS, the positive predictive value of model cases was 1.5%, 6.9%, 22.1%, 62.5%, 96.1% followed by category 3, 4A, 4B, 4C and 5, and it was 1.4%, 3.4%, 21.1%, 69.4%, 92.7% in test cases. Conclusions The scoring model could be useful for BI-RADS final assessment more objectively, and could make it more convenient to predict the risk of breast cancer. Key words: Ultrasonography; Breast diseases; Breast imaging reporting and data system

Non-mass-like breast lesions at ultrasonography: Feature analysis and BI-RADS assessment

ObjectiveTo analyze the features of non-mass-like (NML) breast lesions on ultrasound (US) and determine their corresponding malignancy rate and to stratify these lesion patterns according to US BI-RADS categories. Materials and methodsOne hundred sixty-four consecutive lesions were retrospectively classified into four types according to the US features, the corresponding positive predictive values (PPVs) were obtained. Clinical, imaging, and histopathological findings were reviewed. ResultsAmong the 164 lesions, 39 (24%) were classified as type Ia, 14 (8%) as type Ib, 39 (24%) as type IIa, 19 (12%) as type IIb, 19 (12%) as type III, and 34 (21%) as type IV. The PPVs for malignancy were 21% for type Ia, 79% for type Ib, 10% for type IIa, 58% for type IIb, 16% for type III, and 21% for type IV. All NML lesions were classified as BI-RADS category 4a (type IIa), 4b (type Ia, III and IV) and 4c (type Ib and IIb) according to their PPVs. There was a significantly higher frequency of malignancy among lesions of type Ib and type IIb compared with the other types (P<0.01 for each). Lesions with associated calcifications, presence of abnormal axillary nodes, or a mammographic finding of suspected malignancy had a higher probability of malignancy (P<0.05 for each). ConclusionUS is useful in clarifying the indication for biopsy of NML lesions. The types of US classifications used in our study establish reliable references for the NML patterns when stratified according to the BI-RADS categories.

Adding 3D Breast Tomosynthesis to Digital Mammography: Values and Limitations

INTRODUCTION: The technology of 3D breast Tomosynthesis (BT) promises elimination of effect of overlapping tissue seen on full field digital mammography (DM).This is by its ability to create 1mm slice thickness images of the breast, that are reviewed on a dedicated work station. OBJECTIVES: To assess the value of adding BT to DM, for improving lesion visibility, characterization and BIRADS assessment. METHODS AND MATERIALS: 929 cases were evaluated with DM and BT in a dedicated breast imaging unit with diagnostic and screening services. Both DM and BT were performed in craniocaudal and mediolateral oblique views in different exposures. Evaluation and BIRADS scoring was given to DM followed by BT. A final BIRADS score considering both interpretations and any additional information by ultrasound was later decided. RESULTS: 70.8 % of cases were screening and 29.2 % were diagnostic. According to the final assessment categories; 25.3%, 53.3%, 11.2%, 5.5%, 4.7% of cases were given a BIRADS score of 1, 2, 3, 4, 5 respectively. +PP, -PP and Accuracy of DM alone were 89.71, 97.33, 96.77%. On adding BT results were 87.5, 99.17, 98.06 % respectively. Agreement between BT BIRADS and final BIRADS score was 91.8% (kappa 0.872). Between DM and Final BIRADS was 81.1% (Kappa 0.710). Regarding the cancers detected in very dense breasts (more than 75% glandular tissue) DBT could diagnose 76.4%, while only 5.8% were diagnosed by DM. CONCLUSION: Adding BT to DM improves accuracy by analysis of margins, focal asymmetry, number of lesions, however, it did not show additional information in evaluation of microcalcifications.

Updated breast MRI lexicon

The American College of Radiology (ACR) BI-RADS Breast Imaging Lexicon was developed over a 5 year period, initially organized in 1999 by a Breast MRI “Lesion Diagnosis Working Group” and later by the ACR. This work resulted in a lexicon (dictionary) of terms to describe breast lesions on contrast-enhanced breast magnetic resonance imaging studies. The first publication was developed when breast MRI was first being used and referencing the little data available to produce the lexicon of terms in describing lesions seen on breast MRI. Even though the ACR Lexicon has proved robust for the most part, since its publication there have been technical advances in breast MRI hardware, coils and pulse sequences, resulting in new information on breast cancer morphology and kinetic behavior. Publication on MRI studies using the new hardware and software resulted in increases in cancer sensitivity and specificity in published literature. As a result, information is now available on technical parameters required to obtain both high spatial and temporal resolution on breast MRI scans that resulted in high sensitivity and specificity. These advances and scientific data were used in developing and updating the new Lexicon. The new breast MRI Lexicon is chaired by Elizabeth A Morris, M.D and is expected to be published in the fall of 2012. The new ACR Lexicon includes a web-based format (hardcopy is also available), recommends mammography/US/MRI correlation, and has evidence based information with hyperlinks to references. The Lexicon also includes sections on Quality Assessment with technical parameters and kinetic/functional considerations that influence MRI images. There is a new section on audit recommendations. The ACR also lists a separate ACR Breast MRI Accreditation Program that accredits breast MRI facilities in the United States with technical, outcome and personnel credentialing criteria. Breast MRI Lexicon recommendations include adding T2weighted non-contrast sequences, and combined reporting of MRI with mammographic and ultrasound findings. Finally, simultaneous bilateral MRI scans are recommended and are considered standard of care. There is a new section on breast implants, with a lexicon describing the implant type, location, and findings commonly seen in intact and ruptured implants. In silicone breast implant studies, imaging terms include normal radial folds, subcapsular line, linguine and keyhole/teardrop. Importantly, there is a new section describing background parenchymal enhancement (BPE) that describes how much of the normal breast parenchyma enhances, which in turn can influence the sensitivity of breast MRI to detect cancer. The BPE can be described as none, minimal, mild, moderate or marked. Terms that previously were used to describe findings seen on breast MRI such as “diffuse stippled enhancement” may actually represent moderate BPE, which is a normal finding. As before, both morphology and kinetic information is considered important. There are no changes to the kinetic terminology. Morphology terms in the lexicon have been added or deleted, adding terms that were commonly used, and deleting those that were not used in the scientific literature. Deleted terms include central and septal enhancement, and enhancing septations. Morphology additions include clustered ring enhancement in contrast-enhanced studies. Morphology terms that have been revised include “non-masslike” to “non-mass” enhancement, and “irregular” mass margins to “uneven” mass margins in masses that have an irregular shape. Last, the Lexicon recommends a final BIRADS assessment including BIRADS codes 0 – Incomplete, Need Additional Imaging Evaluation, 1 – Negative, 2 – Benign, 3 – Probably Benign, 4 – Suspicious, 5 – Highly Suggestive of Malignancy, and 6 – Known Biopsy Proven Malignancy. The ACR Breast MRI Lexicon publication also includes an atlas that illustrates the key findings described in the lexicon. Because the contributors to the atlas were based both in the USA and around the world, there are a wide variety of techniques and pulse sequences that were used to generate the images. Variability in the examples include axial, sagittal, multi-planar reconstructions, fatsuppressed and non-fat-suppressed images chosen as state-of-theart, providing the reader with the rare chance to view MRI studies of specific findings using high-quality, varying techniques.

Complex cystic lesions of the breast on ultrasonography: Feature analysis and BI-RADS assessment

Complex cystic lesions of the breast on ultrasonography: Feature analysis and BI-RADS assessment

Shear wave elastography for breast masses is highly reproducible.

ObjectivesTo evaluate intra- and interobserver reproducibility of shear wave elastography (SWE) for breast masses.MethodsFor intraobserver reproducibility, each observer obtained three consecutive SWE images of 758 masses that were visible on ultrasound. 144 (19%) were malignant. Weighted kappa was used to assess the agreement of qualitative elastographic features; the reliability of quantitative measurements was assessed by intraclass correlation coefficients (ICC). For the interobserver reproducibility, a blinded observer reviewed images and agreement on features was determined.ResultsMean age was 50 years; mean mass size was 13 mm. Qualitatively, SWE images were at least reasonably similar for 666/758 (87.9%). Intraclass correlation for SWE diameter, area and perimeter was almost perfect (ICC ≥ 0.94). Intraobserver reliability for maximum and mean elasticity was almost perfect (ICC = 0.84 and 0.87) and was substantial for the ratio of mass-to-fat elasticity (ICC = 0.77). Interobserver agreement was moderate for SWE homogeneity (κ = 0.57), substantial for qualitative colour assessment of maximum elasticity (κ = 0.66), fair for SWE shape (κ = 0.40), fair for B-mode mass margins (κ = 0.38), and moderate for B-mode mass shape (κ = 0.58), orientation (κ = 0.53) and BI-RADS assessment (κ = 0.59).ConclusionsSWE is highly reproducible for assessing elastographic features of breast masses within and across observers. SWE interpretation is at least as consistent as that of BI-RADS ultrasound B-mode features.Key Points• Shear wave ultrasound elastography can measure the stiffness of breast tissue • It provides a qualitatively and quantitatively interpretable colour-coded map of tissue stiffness • Intraobserver reproducibility of SWE is almost perfect while intraobserver reproducibility of SWE proved to be moderate to substantial • The most reproducible SWE features between observers were SWE image homogeneity and maximum elasticity

Accuracy of Diagnostic Mammography and Breast Ultrasound During Pregnancy and Lactation

The purpose of this article is to determine the accuracy of mammography and sonography in evaluating pregnant, lactating, and postpartum women. We retrospectively reviewed diagnostic breast imaging examinations of 155 pregnant, lactating, and postpartum women with 164 lesions presenting to our breast imaging department from 2004 to 2005. Records were reviewed for clinical presentation, reported sonographic or mammographic findings with BI-RADS assessment, histologic results, and clinical outcomes. Examinations rated as BI-RADS categories 4 and 5 were considered positive. One hundred thirty-four (82%) of 164 lesions had pathology results available or longer than 12 months follow-up in our study group. Of these lesions, 12 (9%) were evaluated by mammography alone, 49 (37%) were evaluated by ultrasound alone, and 73 (54%) were evaluated by both techniques. Of 134 lesions, 87 (65%) were in patients who presented during lactation, 34 (25%) who presented during pregnancy, and 13 (10%) who presented postpartum. The presenting symptom for 86 lesions (64%) was a palpable mass. Biopsies were performed for 40 lesions. Of these lesions, four were malignant and 36 were benign. Mammograms were dense or heterogeneously dense in 88% of patients. All four malignancies were BI-RADS category 4 or 5 according to both mammography and ultrasound. For the 85 lesions evaluated with mammography, there was 100% sensitivity, 93% specificity, 40% positive predictive value, and 100% negative predictive value. For the 122 lesions evaluated with sonography, there was 100% sensitivity, 86% specificity, 19% positive predictive value, and 100% negative predictive value. Among lactating and pregnant women, both mammography and sonography had a negative predictive value of 100% and accurately revealed the few cancers that were present in our study group.

Targeted Ultrasound in Women Younger Than 30 Years With Focal Breast Signs or Symptoms: Outcomes Analyses and Management Implications

The purpose of this article is to assess the accuracy of targeted breast ultrasound in women younger than 30 years presenting with focal breast signs or symptoms. Retrospective review of the electronic medical records identified all ultrasound examinations from January 1, 2002, through August 30, 2006, performed for focal breast signs or symptoms in women younger than 30 years. BI-RADS assessments were recorded. Outcomes were determined by biopsy, 24 months of ultrasound surveillance, and linkage with the regional tumor registry. The overall cancer yield, sensitivity, specificity, negative predictive value (NPV), positive predictive value (PPV) 2, and PPV3 of ultrasound were calculated. Among 830 study patients, lesions were assessed as BI-RADS category 1 or 2 in 526 (63.4%), BI-RADS category 3 in 140 (16.9%), BI-RADS category 4 in 163 (19.6%), and BI-RADS category 5 in one (0.1%) patient. Three malignancies were detected, for a cancer yield of 0.4%. No BI-RADS category 3 lesions, two BI-RADS category 4 lesions, and the single BI-RADS category 5 lesion were malignant. Ultrasound sensitivity was 100%, specificity was 80.5%, NPV was 100%, PPV2 was 1.8%, and PPV3 was 1.9%. Women younger than 30 years with focal breast signs or symptoms have a very low (0.4%) incidence of malignancy. The 100% sensitivity and NPV of targeted ultrasound in our study substantiates its use as an accurate primary imaging test in this clinical setting. We found no malignancies in BI-RADS category 3 lesions, supporting ultrasound surveillance over biopsy in this patient population.

First clinical experience of contrast enhanced digital mammography (CEDM) for the detection of breast carcinomas.

Abstract Abstract #5001 Purpose: CEDM is a recent development of digital mammography using the intra-venous injection of an iodinated contrast agent in conjunction with a mammography examination. The objective of this paper is to present two techniques developed to perform CEDM examinations, the preliminary clinical experiences and potential clinical applications of this new breast imaging procedure.&amp;#x2028; Material and methods: Between 2005 and 2008, 140 consenting women with suspicious findings on mammography and or ultrasonography underwent CEDM using modified full-field digital mammography systems (GE Healthcare, Chalfont St-Giles, UK). A temporal subtraction sequence with acquisition of high-energy images before and after contrast medium injection was used for the first 20 patients. A dual energy technique with acquisition of a pair of low and high-energy images only after contrast medium injection was used for the other 120 patients.&amp;#x2028; Results: CEDM, either using temporal or dual energy technique, improved the probability of malignancy and the BIRADS assessment compared to conventional mammography alone. The temporal subtraction technique offered the possibility to analyze the kinetic curve of enhancement of breast lesions, similar to breast MRI. Dual energy technique did not provide information about the kinetic of tumor enhancement but allowed the acquisition of multiples views of the same breast or bilateral examination and was less sensitive to patient motion than temporal CEDM. The potential clinical applications are the determination of the extent of disease, the assessment of recurrent disease, the clarification of mammographically equivocal lesions, the detection of occult lesions on standard mammography, particularly in dense breast, and the monitoring of the response to chemotherapy.&amp;#x2028; &amp;#x2028; &amp;#x2028; &amp;#x2028; Conclusion: Initial clinical experience has shown the ability of CEDM to map the distribution of neovasculature induced by cancer using mammography. CEDM should result in a simple way to enhance the detection and the characterization of breast lesions and to provide some prognostic factors of breast carcinomas. Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 5001.

Breast imaging and reporting data system (BIRADS) magnetic resonance imaging illustrated cases

Illustrated cases are presented here, for training the reader to BIRADS MRI. This article offers guidance in integrating findings from the different MR sequences, morphology and kinetics of an abnormal enhancement: report organization, use of lexicon for describing the detected lesion, final assessment with BI-RADS assessment categories.