Contrast-enhanced Breast MRI Research Articles

Fully automated detection of breast cancer in screening MRI using convolutional neural networks.

Current computer-aided detection (CADe) systems for contrast-enhanced breast MRI rely on both spatial information obtained from the early-phase and temporal information obtained from the late-phase of the contrast enhancement. However, late-phase information might not be available in a screening setting, such as in abbreviated MRI protocols, where acquisition is limited to early-phase scans. We used deep learning to develop a CADe system that exploits the spatial information obtained from the early-phase scans. This system uses three-dimensional (3-D) morphological information in the candidate locations and the symmetry information arising from the enhancement differences of the two breasts. We compared the proposed system to a previously developed system, which uses the full dynamic breast MRI protocol. For training and testing, we used 385 MRI scans, containing 161 malignant lesions. Performance was measured by averaging the sensitivity values between 1/8-eight false positives. In our experiments, the proposed system obtained a significantly ([Formula: see text]) higher average sensitivity ([Formula: see text]) compared with that of the previous CADe system ([Formula: see text]). In conclusion, we developed a CADe system that is able to exploit the spatial information obtained from the early-phase scans and can be used in screening programs where abbreviated MRI protocols are used.

MRI for the assessment of malignancy in BI-RADS 4 mammographic microcalcifications.

PurposeAssess the performance of breast MRI to diagnose breast cancer in BI-RADS 4 microcalcifications detected by mammography.Materials and methodsThis retrospective, IRB-approved study included 248 consecutive contrast-enhanced breast MRI (1.5T, protocol in accordance with EUSOBI recommendations) performed to further diagnose BI-RADS 4 microcalcifications detected at mammography during a 3-year period. Standard of reference had to be established by histopathology. Routine consensus reading results by two radiologists were dichotomized as positive or negative and compared with the reference standard (benign vs malignant) to calculate diagnostic parameters.ResultsThere were 107 malignant and 141 benign microcalcifications. Malignancy rates were 18.3% (23/126 BI-RADS 4a), 41.7% (25/60 BI-RADS 4b) and 95% (59/62 BI-RADS 4c). There were 103 true-positive, 116 true-negative, 25 false-positive, and 4 false-negative (one invasive cancer, three DCIS; 2 BI-RADS 4c, 1 BI-RADS 4b on mammography) breast MRI findings, effecting a sensitivity, specificity, PPV, and NPV of 96.3% (95%-CI 90.7–99.0%), 82.3% (95%-CI 75.0–88.2%), 80.5% (95%-CI 72.5–87.0%) and 96.7% (95%-CI 91.7–99.1%), respectively.ConclusionMRI is an accurate tool to further diagnose BI-RADS 4a and 4b microcalcifications and may be helpful to avoid unnecessary biopsies in BI-RADS 4a and 4b lesions. BI-RADS 4c microcalcifications should be biopsied irrespective of MRI findings.

Feasibility analysis of early temporal kinetics as a surrogate marker for breast tumor type, grade, and aggressiveness.

Screening breast MRI has been shown to preferentially detect high-grade ductal carcinoma in situ (DCIS) and invasive carcinoma, likely due to increased angiogenesis resulting in early initial uptake of contrast. As interest grows in abbreviated screening breast MRI (AB-MRI), markers of early contrast washin that can predict tumor grade and potential aggressiveness are of clinical interest. To evaluate the feasibility of using the initial enhancement ratio (IER) as a surrogate marker for tumor grade, hormone receptor status, and prognostic markers, as an initial step to being incorporated into AB-MRI. Retrospective. In all, 162 women (mean 55.0 years, range 32.8-87.7 years) with 187 malignancies imaged January 2012-November 2015. Images were acquired at 3.0T with a T1 -weighted gradient echo fat-suppressed-volume interpolated breath-hold sequence. Subjects underwent dynamic contrast-enhanced breast MRI with a 7-channel breast coil. IER (% signal increase over baseline at the first postcontrast acquisition) was assessed and correlated with background parenchymal enhancement, washout curves, stage, and final pathology. Chi-square test, Spearman rank correlation, Mann-Whitney U-tests, Bland-Altman analysis, and receiver operating characteristic curve analysis. IER was higher for invasive cancer than for DCIS (R1/R2, P < 0.001). IER increased with tumor grade (R1: r = 0.56, P < 0.001, R2: r = 0.50, P < 0.001), as ki-67 increased (R1: r = 0.35, P < 0.001; R2 r = 0.35, P < 0.001), and for node-positive disease (R1/R2, P = 0.001). IER was higher for human epidermal growth factor receptor two-positive and triple negative cancers than for estrogen receptor-positive / progesterone receptor-positive tumors (R1 P < 0.001-0.002; R2 P = 0.0.001-0.011). IER had higher sensitivity (80.6% vs. 75.5%) and specificity (55.8% vs. 48.1%) than washout curves for positive nodes, higher specificity (48.1% vs. 36.5%) and positive predictive value (70.2% vs. 66.7%) for high ki-67, and excellent interobserver agreement (intraclass correlation coefficient = 0.82). IER, a measurement of early contrast washin, is associated with higher-grade malignancies and tumor aggressiveness and might be potentially incorporated into an AB-MRI protocol. 3 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2018;47:1692-1700.

Revisiting Nonmass Enhancement in Breast MRI: Analysis of Outcomes and Follow-Up Using the Updated BI-RADS Atlas.

The purpose of this study is to assess the frequency of reclassification of nonmass enhancement (NME) as background parenchymal enhancement (BPE) and to determine positive predictive values (PPVs) of NME descriptors using the revised BI-RADS atlas. A retrospective review of our institution's MRI database from January 1, 2009, through March 30, 2012, identified 6220 contrast-enhanced breast MRI examinations. All findings prospectively assessed as NME and rated as BI-RADS categories 3, 4, and 5 (n = 386) were rereviewed in consensus by two radiologists who were blinded to pathologic findings with the fifth edition of the BI-RADS lexicon. Findings considered as postsurgical, associated with known cancers, NME given a BI-RADS category 3 assessment before 2009, previously biopsied, and those reclassified as BPE, focus, or mass were excluded (n = 181). Medical records were reviewed for demographics and outcomes. Two hundred five women were included (mean age, 48.8 years; range, 21-84 years). Seventy-seven of 386 findings (20.0%) were reclassified as BPE, and patients with BPE were younger than those with NME (mean age, 43.9 years; range, 31-62 years) (p = 0.003). Pathology results for 144 of 205 (70.2%) patients included 52 malignant, 11 high-risk, and 81 benign lesions. The highest PPVs for distribution patterns were 34.5% (10/29) for segmental and 100.0% (3/3) for diffuse distribution. The highest PPVs for internal enhancement patterns were 36.7% (11/30) for clustered ring enhancement and 27.5% (11/40) for clumped enhancement. No difference for NME malignancy rate was noted according to BPE (10/52 [19.2%] marked or moderate; 42/153 [27.5%] mild or minimal, p = 0.24). Thirty-two percent (17/52) of malignant NMEs had high T2 signal. Careful assessment of findings as BPE versus NME can improve PPVs, particularly in younger women. Although clustered ring enhancement had one of the study's highest PPVs, this number falls below previously published rates. Reliance on T2 signal as a benign feature may be misleading, because one-third of malignancies had T2 signal.

Abstract 3742: Exposure burden for patients during an experimental study using a dual-energy contrast-enhanced spectral mammography

Abstract Mammography provides early micro-calcification recognition, that is important for further breast cancer (BC) diagnosis. Imaging choice for BC detection is X-ray mammography (MG) with the use of high-resolution digital modality combined with iodinated contrast agents. However, a conventional MG has some sensitivity limitations, especially in patients with densely treated breasts. Moreover, MG contributes radiation risk for BC that is correlated with an exposure to ionizing radiation. Patients, for whom MG study does not give a clear interpretation are often further diagnosed by contrast-enhanced breast MRI, the most sensitive BC detection technique. Alternatively, it is limited by higher costs, lower availability and increased false positives. Dual-energy contrast-enhanced spectral mammography (CESM) is a new method applied in BC that enables accurate detection of malignant breast lesions similar to breast MRI. The aim of this study was to compare the usefulness of CESM versus MG in BC detection. Additionally, doses given to the BC patients during imaging were compared. In this study, 250 consecutive women (144 MG vs. 105 CESM), that were screened using mammography between 2011 and 2014 were retrospectively enrolled in the study. The comparison of entrance surface air kerma and mean glandular dose values for both options were recorded, respectively and analyzed using different statistical and retrospective approach. Results of presented study showed that CESM might be a new diagnostic tool allowing an accurate detection of BC lesions, giving results similar to those received from magnetic resonance imaging. A good agreement found between sensitivity of the method and tumour diameters measurements based on CESM, supports this tool as a potential replacement for breast MRI in the preoperative evaluation of BC patients. However, a radiation burden for patients might be significantly higher than that for a standard full-field digital mammography procedure. In summary, each method has its own benefits with respect to specific applications that are further discussed in the study. Citation Format: Kamila Rawojc, Kamil Kisielewicz, Anna Dziecichowicz, Monika Tomaszuk, Anna Cepiga, Jankowska Anna, Cieśla Izabela, Najberg Dominika, Luczynska Elzbieta, Bartosz Kieltyka. Exposure burden for patients during an experimental study using a dual-energy contrast-enhanced spectral mammography [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 3742. doi:10.1158/1538-7445.AM2017-3742

Cylindrical Inversion Pulse for the Reduction of Cardiac Motion Artifacts in Contrast-enhanced Breast MRI.

We proposed a simple technique for reduction of cardiac-related motion artifacts on contrast-enhanced images in the breast by using cylindrical regional-suppression technique (CREST) that can directly suppress the heart signals. The purpose of this study was to select the optimal scan parameters and to evaluate the feasibility in the breast. We demonstrated that the optimized CREST could dramatically reduce the cardiac-related flow artifacts without any penalty to the acquisition time, signal-to-noise ratio and contrast-enhanced lesion-to-parenchyma contrast.

Clinical Utility of Breast MRI in the Diagnosis of Malignancy After Inconclusive or Equivocal Mammographic Diagnostic Evaluation.

The purpose of this study was to determine the clinical utility of breast MRI for diagnosing malignancy in women with equivocal mammographic findings but no symptoms. Retrospective review of an institutional MRI database of 7332 contrast-enhanced breast MRI examinations from January 1, 2009, through December 31, 2012, yielded the records of 296 (4.0%) examinations of 294 women without symptoms who underwent MRI for mammographic findings uncertain at diagnostic evaluation. Imaging findings, histopathologic results, and patient demographics were obtained from the electronic medical record. The mean patient age was 55 years (range, 29-83 years). Mammographic lesion type (n = 294) included 89 focal asymmetries, 76 asymmetries, 64 masses, 44 architectural distortions, 17 surgical scar versus lesion, and four miscellaneous lesions. Diagnostic ultrasound, performed on 286 of 294 (97.3%) lesions at mammographic evaluation, showed an ultrasound correlate in 37 (12.9%) lesions, equivocal correlate in 48 (16.8%), and no ultrasound correlate in 201 (70.3%). MRI examination of 294 index lesions showed a correlate in 133 (45.2%) and no correlate in 161 (54.8%). Forty of 294 (13.6%) index lesions were malignant, 37 (92.5%) with an MRI correlate and three (7.5%) without an MRI correlate. Among 250 patients who underwent biopsy or had 2 or more years of imaging stability, the sensitivity, specificity, negative predictive value, and positive predictive value of breast MRI for malignancy were 92.5%, 62.4%, 97.8%, and 31.9%. Forty-four of 294 (15.0%) patients had lesions incidentally found at MRI; 7 of 41 (17.1%) lesions that were biopsied or were stable for at least 1 year were malignant. Problem-solving breast MRI for inconclusive mammographic findings helps identify malignancies with high sensitivity and a high negative predictive value.

Prediction of malignancy by a radiomic signature from contrast agent-free diffusion MRI in suspicious breast lesions found on screening mammography.

To assess radiomics as a tool to determine how well lesions found suspicious on breast cancer screening X-ray mammography can be categorized into malignant and benign with unenhanced magnetic resonance (MR) mammography with diffusion-weighted imaging and T2 -weighted sequences. From an asymptomatic screening cohort, 50 women with mammographically suspicious findings were examined with contrast-enhanced breast MRI (ceMRI) at 1.5T. Out of this protocol an unenhanced, abbreviated diffusion-weighted imaging protocol (ueMRI) including T2 -weighted, (T2 w), diffusion-weighted imaging (DWI), and DWI with background suppression (DWIBS) sequences and corresponding apparent diffusion coefficient (ADC) maps were extracted. From ueMRI-derived radiomic features, three Lasso-supervised machine-learning classifiers were constructed and compared with the clinical performance of a highly experienced radiologist: 1) univariate mean ADC model, 2) unconstrained radiomic model, 3) constrained radiomic model with mandatory inclusion of mean ADC. The unconstrained and constrained radiomic classifiers consisted of 11 parameters each and achieved differentiation of malignant from benign lesions with a .632 + bootstrap receiver operating characteristics (ROC) area under the curve (AUC) of 84.2%/85.1%, compared to 77.4% for mean ADC and 95.9%/95.9% for the experienced radiologist using ceMRI/ueMRI. In this pilot study we identified two ueMRI radiomics classifiers that performed well in the differentiation of malignant from benign lesions and achieved higher performance than the mean ADC parameter alone. Classification was lower than the almost perfect performance of a highly experienced breast radiologist. The potential of radiomics to provide a training-independent diagnostic decision tool is indicated. A performance reaching the human expert would be highly desirable and based on our results is considered possible when the concept is extended in larger cohorts with further development and validation of the technique. 1 Technical Efficacy: Stage 2 J. MAGN. RESON. IMAGING 2017;46:604-616.

Baseline results from the UK SIGNIFY study: a whole-body MRI screening study in TP53 mutation carriers and matched controls

In the United Kingdom, current screening guidelines for TP53 germline mutation carriers solely recommends annual breast MRI, despite the wide spectrum of malignancies typically seen in this group. This study sought to investigate the role of one-off non-contrast whole-body MRI (WB MRI) in the screening of asymptomatic TP53 mutation carriers. 44 TP53 mutation carriers and 44 population controls were recruited. Scans were read by radiologists blinded to participant carrier status. The incidence of malignancies diagnosed in TP53 mutation carriers against general population controls was calculated. The incidences of non-malignant relevant disease and irrelevant disease were measured, as well as the number of investigations required to determine relevance of findings. In TP53 mutation carriers, 6 of 44 (13.6, 95% CI 5.2–27.4%) participants were diagnosed with cancer during the study, all of which would be considered life threatening if untreated. Two were found to have two primary cancers. Two participants with cancer had abnormalities on the MRI which were initially thought to be benign (a pericardial cyst and a uterine fibroid) but transpired to be sarcomas. No controls were diagnosed with cancer. Fifteen carriers (34.1, 95% CI 20.5–49.9%) and seven controls (15.9, 95% CI 6.7–30.1%) underwent further investigations following the WB MRI for abnormalities that transpired to be benign (p = 0.049). The cancer detection rate in this group justifies a minimum baseline non-contrast WB MRI in germline TP53 mutation carriers. This should be adopted into national guidelines for management of adult TP53 mutation carriers in addition to the current practice of contrast enhanced breast MRI imaging.

Dynamic Contrast-Enhanced MRI Perfusion Parameters as Imaging Biomarkers of Angiogenesis.

Hypoxia in the tumor microenvironment is the leading factor in angiogenesis. Angiogenesis can be identified by dynamic contrast-enhanced breast MRI (DCE MRI). Here we investigate the relationship between perfusion parameters on DCE MRI and angiogenic and prognostic factors in patients with invasive ductal carcinoma (IDC). Perfusion parameters (Ktrans, kep and ve) of 81 IDC were obtained using histogram analysis. Twenty-fifth, 50th and 75th percentile values were calculated and were analyzed for association with microvessel density (MVD), vascular endothelial growth factor (VEGF) and conventional prognostic factors. Correlation between MVD and ve50 was positive (r = 0.33). Ktrans50 was higher in tumors larger than 2 cm than in tumors smaller than 2 cm. In multivariate analysis, Ktrans50 was affected by tumor size and MVD with 12.8% explanation. There was significant association between Ktrans50 and tumor size and MVD. Therefore we conclude that DCE MRI perfusion parameters are potential imaging biomarkers for prediction of tumor angiogenesis and aggressiveness.

1H-MR spectroscopy of suspicious breast mass lesions at 3T: a clinical experience.

To test 3T proton magnetic resonance spectroscopy (1H-MRS) for breast mass lesions. Patients with BI-RADS 4-5 lesions at mammography/ultrasound were prospectively enrolled. After contrast-enhanced breast MRI, single-voxel MRS (point-resolved volume selection, PRESS); pencil-beam shimming; volume of interest 1cm3; TR/TE=3000/135ms) was performed. Spectra were considered reliable if the full width at half maximum (FWHM) of the water peak was ≤45Hz. A signal-to-noise ratio of the total choline (tCho) peak at 3.21ppm ≥2 was used as cutoff for malignancy. All lesions underwent needle sampling. Final pathology was available for all malignant lesions; for benign lesions the reference standard was final pathology or at least 1-year negative follow-up. Reliable spectra were obtained in 115/127 lesions (91%), with a mean FWHM of 32.4Hz (range 8-45Hz). A tCho peak SNR ≥2 was detected in 66 malignant lesions (62 invasive cancers; 4 ductal carcinoma in situ) and in 3 benign lesions. Excluding lesions located ≤1cm from the skin (n=3) or pectoral muscle (n=11), sensitivity was 65/73 [89%, 95% confidence interval (CI): 80-95%], and specificity 25/28 (89%) (95% CI: 72-98%). Considering only invasive cancers, sensitivity reached 61/68 (90%, 95% CI: 81-96%). MRS additional time was 8min. When lesions close to the skin or pectoral muscle are excluded, 3T 1H-MRS of mass lesions ≥1cm showed a high diagnostic performance, however, insufficient to avoid needle biopsy.

Breast MRI Screening: Benefits and Limitations

Multiple studies have demonstrated screening mammography’s ability to decrease mortality in average risk women. It is also recognized that women at high risk for breast cancer who choose surveillance benefit from additional imaging strategies for cancer detection in addition to mammography alone. Contrast-enhanced breast MRI has become a standard and accepted tool in the screening evaluation of women with a high risk of breast cancer. However, despite recognition of MRI’s ability to detect breast cancer in the screening setting in a high-risk population, there are still questions surrounding the use of breast MRI in the screening environment. This chapter will provide an overview of breast screening MRI indications and current guidelines and will also review the evidence supporting the use of screening breast MRI.

Diagnostic investigation of breast magnetic resonance imaging in malignant and benign mass lesions.

IntroductionBreast magnetic resonance imaging (BMRI) has been identified as a valuable modality in the diagnosis of breast cancer and monitoring the response to chemotherapy. The aim of this study was to evaluate the relative importance of different descriptors of breast masses in contrast-enhanced breast MRI.Material and methodsIn a database of pathologically proven breast lesions, in total 433 masses in 312 patients detected by contrast-enhanced breast MRI were selected. All images were assessed according to the MRI BI-RADS lexicon and those with significant positive MRI findings (BI-RADS categories 3, 4, 5) were enrolled in the study.ResultsMean age of patients was 45.09 ±10.5 years. The most frequent BI-RADS score was 4 (60.7%), followed by 3 (27%). Among the morphologic descriptors of the enhancing masses, the findings most strongly associated with malignancy included spiculated margin (60.6%) and irregular shape (38%). Considering the dynamic descriptors, a wash-out pattern in the time-intensity curve was the most powerful finding associated with malignancy (27.9%). Among all breast MRI descriptors, the best odds ratio (OR) in association with malignancy was noted for speculated margin (OR = 10.2) followed by wash-out or plateau curves (OR = 6.1), size greater than 1 cm (OR = 4.3) and irregular shape (OR = 3.1).ConclusionsIt seems that morphologic descriptors of MRI BI-RADS for enhancing masses are quite specific, while dynamic descriptors of the masses are highly sensitive. Appropriate consideration and combination of different BI-RADS findings could help in better characterization of enhancing masses on breast MRI, lowering the rate of false positive reports and avoiding unnecessary biopsies.

Diagnostic Performance of Breast Magnetic Resonance Imaging in Non-Calcified Equivocal Breast Findings: Results from a Systematic Review and Meta-Analysis.

ObjectivesTo evaluate the performance of MRI for diagnosis of breast cancer in non-calcified equivocal breast findings.Materials and MethodsWe performed a systematic review and meta-analysis of peer-reviewed studies in PubMed from 01/01/1986 until 06/15/2015. Eligible were studies applying dynamic contrast-enhanced breast MRI as an adjunct to conventional imaging (mammography, ultrasound) to clarify equivocal findings without microcalcifications. Reference standard for MRI findings had to be established by histopathological sampling or imaging follow-up of at least 12 months. Number of true or false positives and negatives and other characteristics were extracted, and possible bias was determined using the QUADAS-2 applet. Statistical analyses included data pooling and heterogeneity testing.ResultsFourteen out of 514 studies comprising 2,316 lesions met our inclusion criteria. Pooled diagnostic parameters were: sensitivity (99%, 95%-CI: 93–100%), specificity (89%, 95%-CI: 85–92%), PPV (56%, 95%-CI: 42–70%) and NPV (100%, 95%-CI: 99–100%). These estimates displayed significant heterogeneity (P<0.001).ConclusionsBreast MRI demonstrates an excellent diagnostic performance in case of non-calcified equivocal breast findings detected in conventional imaging. However, considering the substantial heterogeneity with regard to prevalence of malignancy, problem solving criteria need to be better defined.

Erratum to: Dynamic contrast-enhanced breast MRI at 7T and 3T: an intra-individual comparison study

[This corrects the article DOI: 10.1186/s40064-015-1654-7.].

Multiparametric breast MRI with 3T: Effectivity of combination of contrast enhanced MRI, DWI and 1H single voxel spectroscopy in differentiation of Breast tumors

ObjectivesTo evaluate the diagnostic accuracy of dynamic contrast enhanced breast MRI (DCE-MRI) combined with diffusion weighted imaging (DWI) and 1H single-voxel magnetic resonance spectroscopy (1HMRS) in differentiating malignant from benign breast lesions. MethodsOne hundred twenty-nine patients with 138 lesions were included in the study. Multiparametric MRI of the breast was performed with a 3T unit. A DWI is followed by DCE-MRI and 1HMRS. All lesions were biopsied within one week after MRI. Histopathologic findings were accepted as the standard of reference. Probability of malignancy was assessed according to BI-RADS for DCE-MRI. ADC values were measured for DWI and choline peaks were assessed using a semi-quantitative method in 1HMRS. Two blinded radiologists evaluated findings in consensus. Diagnostic performance of DCE-MRI, DWI and 1HMRS alone or in combination for multiparametric imaging were statistically evaluated. ResultsHistopathology revealed malignancy in 54.4% of lesions (75/138). DCE-MRI showed the highest AUC (0.978), sensitivity (97.33%) and specificity (88.89%) compared to DWI and 1HMRS. Sensitivity was 100% when a positive result from any one of three techniques was accepted as malignancy, albeit with a trade-off for 65.1% specificity. Highest specificity (98.4%) was attained when all three techniques were required to be positive, though with a lower sensitivity (82.7%) as trade-off. Logistic regression analysis confirmed significant association with DCE-MRI (p<0.001) and 1H MRS (p=0.009) but not with DWI (p=0.127). There was one case of fat necrosis which was false positive in all three techniques. ConclusionsMultiparametric imaging with combination of DCE-MRI, DWI and 1HMRS does not improve, and may even reduce the diagnostic accuracy of breast MRI. Although, the specificity may be improved with a trade-off for lower sensitivity, we have not set a convenient algorithm for the combined use of these techniques.

Abstract P4-01-01: A case series of the Milky Way sign: A diagnostic finding of ductal carcinoma in situ (DCIS) and invasive breast carcinoma (IDC) on digital breast tomosynthesis (DBT)

Abstract Purpose: we have previously described the "Milky Way Sign", which manifests as microcalcifications overlying noncalcified band-like density, best seen in digital breast tomosynthesis (DBT), in a patient with ductal carcinoma in situ (DCIS). Here, we describe a series of patients with DCIS, IDC, and rarely, Atypical Ductal Hyperplasia (ADH) with this sign. Materials and Methods: we performed a systemic search of all stereotactic core biopsies for suspicious calcifications performed at our institution from April 15, 2014, when we first implemented DBT with synthesized 2D mammogram, to October 2, 2014, and identified all cases that were diagnosed as DCIS, IDC, or high-risk lesions (such as ADH, atypical lobular hyperplasia (ALH), and intraductal papilloma) on pathology. From 89 biopsied performed in 87 patients, a total of 13 cases of DCIS, IDC, or IDC with DCIS were identified in 12 patients. 17 cases of high-risk lesions were identified in 16 patients, including 10 ADH in 9 patients, 4 ALH, two intraductal papillomas, and one atypical columnar cell change. Results: Among the 30 cases of suspicious calcifications with a diagnosis of DCIS, IDC, or high-risk lesions, 37% demonstrated the Milky Way Sign (11/30), including 71% of DCIS cases (5/7), 60% of cases of IDC (3/5), 100% of DCIS/IDC (1/1), and 12% of high-risk lesions (2/17). Both high-risk lesions with the Milky Way sign were ADH from the same patient. Among the 11 cases with the Milky Way sign, the breast density at the site of calcifications is either scattered (6/11) or heterogeneously dense (5/11), whereas the density at 1 cm surrounding the calcifications is either fatty (8/11) or scattered (3/11). The breast is less dense surrounding the calcifications in all but one case. The calcifications seen in the Milky Way cases are predominantly fine pleomorphic calcifications except one case of fine linear and linear branching calcifications. The calcifications are grouped (6/11), linear (3/11), or segmental (2/11) in distribution. Five patients also had contrast-enhanced breast MRIs. Among them, three (one each with the diagnosis of DCIS, IDC or DCIS/IDC) had non-mass enhancement on breast MRI that correlated to the Milky Way sign seen on mammogram. The other two patients (one with DCIS and one with IDC) had post biopsy change instead of Non-mass enhancement were seen in the corresponding areas. Conclusion: The Milky Way sign, in the context of DBT, is a novel diagnostic sign for both DCIS and IDC. It may occasionally be seen in ADH cases as well. Features that often associate with the Milky Way sign include less dense tissue surrounding the calcifications, calcifications that are fine pleomorphic in morphology and grouped or linear in distribution. Preliminary results also suggest that the Milky Way sign may correspond to non-mass enhancement seen on contrast-enhanced breast MRI. Clinical Relevance Statement: We hope that the Milky Way sign will facilitate detection of both DCIS and IDC in the context of DBT. Citation Format: Allison K, Xu Y, Liu YI, Miyake KK, Downey JR, Lipson JA, Ikeda DM. A case series of the Milky Way sign: A diagnostic finding of ductal carcinoma in situ (DCIS) and invasive breast carcinoma (IDC) on digital breast tomosynthesis (DBT). [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 P4-01-01.

Dynamic contrast-enhanced breast MRI at 7T and 3T: an intra-individual comparison study.

The aim of this study is to compare the current state of lesion identification, the BI-RADS classification and the contrast-enhancement behavior at 7T and 3T breast MRI in the same patient group. Twenty-seven patients with thirty suspicious lesions were selected for this prospective study and underwent both 7T and 3T MRI. All examinations were rated by two radiologists (R1 and R2) independently on image quality, lesion identification and BI-RADS classification. We assessed sensitivity, specificity, NPV and PPV, observer agreement, lesion sizes, and contrast-enhancement-to-noise ratios (CENRs) of mass lesions. Fifteen of seventeen histopathological proven malignant lesions were detected at both field strengths. Image quality of the dynamic series was good at 7T, and excellent at 3T (P = 0.001 for R1 and P = 0.88 for R2). R1 found higher rates of specificity, NPV and PPV at 7T when compared to 3T, while R2 found the same results for sensitivity, specificity, NPV and PPV for both field strengths. The observers showed excellent agreement for BI-RADS categories at 7T (κ = 0.86) and 3T (κ = 0.93). CENRs were higher at 7T (P = 0.015). Lesion sizes were bigger at 7T according to R2 (P = 0.039). Our comparison study shows that 7T MRI allows BI-RADS conform analysis. Technical improvements, such as acquisition of T2w sequences and adjustment of B1+ field inhomogeneity, are still necessary to allow clinical use of 7T breast MRI.

Use of a Volume Navigation Technique for Combining Real-Time Ultrasound and Contrast-Enhanced MRI: Accuracy and Feasibility of a Novel Technique for Locating Breast Lesions.

The objective of this study was to evaluate the accuracy of the volume navigation technique for combining real-time ultrasound and contrast-enhanced MRI (CE-MRI) of breast lesions. Thirty-eight women with single breast lesions underwent 3-T MRI. A 3.5-minute CE-MRI sequence was used, as was a flexible body coil. Patients underwent imaging in the supine position, with three markers placed on their breasts. Real-time sonographic images were coregistered to the preloaded breast CE-MRI volume by coupling skin markers, with the use of an electromagnetic transmitter positioned next to the subjects. The transmitter detected the spatial positions of the two electromagnetic sensors mounted on the transducer bracket. After this fusion process in 3D space was completed, divergences in the location of the center of each lesion on CE-MRI and ultrasound images were analyzed. The mean lesion size was 17.4 mm on ultrasound and 17.9 mm on MRI, whereas the mean (± SD) misalignment of the lesion centers on CE-MRI and ultrasound was 3.9 ± 2.5 mm on the x-axis (mediolateral view), 3.6 ± 2.7 mm on the y-axis (anteroposterior view), and 4.3 ± 2.6 mm on the z-axis (craniocaudal view). No lesion had a misalignment greater than 10 mm on any of three axes. The accuracy of volume navigation was independent of patient age and the lesion size, location, and histopathologic findings (p > 0.05). Intermediate lesions, which had a depth of center of 11-20 mm on ultrasound had a mean misalignment of 2.6 ± 1.9 mm, compared with 5.5 ± 2.2 mm for deep lesions, which had a depth of center greater than 20 mm (p = 0.049). The volume navigation technique is an accurate method for coregistration of CE-MRI and sonographic images, enabling lesion localization within a limited volume.

Clinical evaluation of contrast-enhanced digital mammography and contrast enhanced tomosynthesis—Comparison to contrast-enhanced breast MRI

PurposeTo compare the diagnostic accuracy of contrast-enhanced digital mammography (CEDM) and contrast-enhanced tomosynthesis (CET) to dynamic contrast enhanced breast MRI (DCE-MRI) using a multireader-multicase study. MethodsInstitutional review board approval and informed consents were obtained. Total 185 patients (mean age 51.3) with BI-RADS 4 or 5 lesions were evaluated before biopsy with mammography, tomosynthesis, CEDM, CET and DCE-MRI. Mediolateral-oblique and cranio-caudal views of the target breast CEDM and CET were acquired at 2 and 4min after contrast agent injection. A mediolateral-oblique view of the non-target breast was taken at 6min. Each lesion was scored with forced BI-RADS categories by three readers. Each reader interpreted lesions in the following order: mammography, tomosynthesis, CEDM, CET, and DCE-MRI during a single reading session. ResultsHistology showed 81 cancers and 144 benign lesions in the study. Of the 81 malignant lesions, 44% (36/81) were invasive and 56% (45/81) were non-invasive. Areas under the ROC curve, averaged for the 3 readers, were as follows: 0.897 for DCE-MRI, 0.892 for CET, 0.878 for CEDM, 0.784 for tomosynthesis and 0.740 for mammography. Significant differences in AUC were found between the group of contrast enhanced modalities (CEDM, CET, DCE-MRI) and the unenhanced modalities (all p<0.05). No significant differences were found in AUC between DCE-MRI, CET and CEDM (all p>0.05). ConclusionCET and CEDM may be considered as an alternative modality to MRI for following up women with abnormal mammography. All three contrast modalities were superior in accuracy to conventional digital mammography with or without tomosynthesis.