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Rationale and Objectives: To determine if background parenchymal enhancement (BPE) on screening breast magnetic resonance imaging (MRI) in high-risk women correlates with future cancer., Materials and Methods: All screening breast MRIs (n = 1039) in high-risk women at our institution from August 1, 2004, to July 30, 2013, were identified. Sixty-one patients who subsequently developed breast cancer were matched 1:2 by age and high-risk indication with patients who did not develop breast cancer (n = 122). Five fellowship-trained breast radiologists independently recorded the BPE. The median reader BPE for each case was calculated and compared between the cancer and control cohorts., Results: Cancer cohort patients were high-risk because of a history of radiation therapy (10%, 6 of 61), high-risk lesion (18%, 11 of 61), or breast cancer (30%, 18 of 61); BRCA mutation (18%, 11 of 61); or family history (25%, 15 of 61). Subsequent malignancies were invasive ductal carcinoma (64%, 39 of 61), ductal carcinoma in situ (30%, 18 of 61) and invasive lobular carcinoma (7%, 4of 61). BPE was significantly higher in the cancer cohort than in the control cohort (P = 0.01). Women with mild, moderate, or marked BPE were 2.5 times more likely to develop breast cancer than women with minimal BPE (odds ratio = 2.5, 95% confidence interval: 1.3-4.8, P = .005). There was fair interreader agreement (κ = 0.39)., Conclusions: High-risk women with greater than minimal BPE at screening MRI have increased risk of future breast cancer., (Copyright © 2018 The Association of University Radiologists. Published by Elsevier Inc. All rights reserved.)

Objectives: To determine the malignancy rate overall and for specific BI-RADS descriptors in women ≥70 years who undergo stereotactic biopsy for calcifications., Methods: We retrospectively reviewed 14,577 consecutive mammogram reports in 6839 women ≥70 years to collect 231 stereotactic biopsies of calcifications in 215 women. Cases with missing images or histopathology and calcifications associated with masses, distortion, or asymmetries were excluded. Three breast radiologists determined BI-RADS descriptors by majority. Histology, hormone receptor status, and lymph node status were correlated with BI-RADS descriptors., Results: There were 131 (57 %) benign, 22 (10 %) atypia/lobular carcinomas in situ, 55 (24 %) ductal carcinomas in situ (DCIS), and 23 (10 %) invasive diagnoses. Twenty-seven (51 %) DCIS cases were high-grade. Five (22 %) invasive cases were high-grade, two (9 %) were triple-negative, and three (12 %) were node-positive. Malignancy was found in 49 % (50/103) of fine pleomorphic, 50 % (14/28) of fine linear, 25 % (10/40) of amorphous, 20 % (3/15) of round, 3 % (1/36) of coarse heterogeneous, and 0 % (0/9) of dystrophic calcifications., Conclusions: Among women ≥70 years that underwent stereotactic biopsy for calcifications only, we observed a high rate of malignancy. Additionally, coarse heterogeneous calcifications may warrant a probable benign designation., Key Points: • Cancer rates of biopsied calcifications in women ≥70 years are high • Radiologists should not dismiss suspicious calcifications in older women • Coarse heterogeneous calcifications may warrant a probable benign designation.

Purpose: To assess the interobserver variability of readers when outlining breast tumors in MRI, study the reasons behind the variability, and quantify the effect of the variability on algorithmic imaging features extracted from breast MRI., Methods: Four readers annotated breast tumors from the MRI examinations of 50 patients from one institution using a bounding box to indicate a tumor. All of the annotated tumors were biopsy proven cancers. The similarity of bounding boxes was analyzed using Dice coefficients. An automatic tumor segmentation algorithm was used to segment tumors from the readers' annotations. The segmented tumors were then compared between readers using Dice coefficients as the similarity metric. Cases showing high interobserver variability (average Dice coefficient <0.8) after segmentation were analyzed by a panel of radiologists to identify the reasons causing the low level of agreement. Furthermore, an imaging feature, quantifying tumor and breast tissue enhancement dynamics, was extracted from each segmented tumor for a patient. Pearson's correlation coefficients were computed between the features for each pair of readers to assess the effect of the annotation on the feature values. Finally, the authors quantified the extent of variation in feature values caused by each of the individual reasons for low agreement., Results: The average agreement between readers in terms of the overlap (Dice coefficient) of the bounding box was 0.60. Automatic segmentation of tumor improved the average Dice coefficient for 92% of the cases to the average value of 0.77. The mean agreement between readers expressed by the correlation coefficient for the imaging feature was 0.96., Conclusions: There is a moderate variability between readers when identifying the rectangular outline of breast tumors on MRI. This variability is alleviated by the automatic segmentation of the tumors. Furthermore, the moderate interobserver variability in terms of the bounding box does not translate into a considerable variability in terms of assessment of enhancement dynamics. The authors propose some additional ways to further reduce the interobserver variability.

Background: Nipple-areola complex (NAC) and skin flap ischemia and necrosis can occur after nipple-sparing mastectomy (NSM). The purpose of this study was to correlate vascular findings on MRI with outcomes in patients who underwent NSM., Study Design: Female patients at a single institution who underwent NSM and had a preoperative breast MRI between 2010 and 2014 were identified. Medical records were reviewed for patient demographics, surgical factors, and complications. Magnetic resonance images were reviewed by 2 radiologists, blinded to outcomes, for the presence of dual vs single blood supply to the breast. The association between blood supply on MRI with ischemic and necrotic complications after NSM was analyzed., Results: One hundred and sixty-four NSM procedures were performed in 105 patients (mean age 45.5 years, range 25 to 69 years) who had a preoperative MRI. The majority of procedures were performed for malignancy (89 of 164 [54.3%]) or prophylaxis (73 of 164 [44.5%]). Nipple-areola complex or skin flap ischemia or necrosis occurred in 40 (24.4%) breasts. Ischemia or necrosis after NSM was less likely to occur in breasts with dual compared with single blood supply (20.8% vs 38.2%; p = 0.03). There was no association between surgical complications and age, BMI, smoking history, previous radiation therapy, indication for NSM, surgical specimen weight, surgical incision type, reconstruction approach, or operating surgeon on univariate analysis., Conclusions: Preoperative MRI characterization of breast vascularity can be considered when planning NSM. The presence of a dual blood supply to the breast on MRI is associated with a decreased risk of nipple-areola complex and skin flap ischemia and necrosis after NSM., (Copyright © 2016 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Purpose: The purpose of this study is to investigate the association between breast cancer recurrence-free survival and breast magnetic resonance imaging (MRI) tumor enhancement dynamics which are quantified semi-automatically using computer algorithms., Methods: In this retrospective IRB-approved study, we analyzed data from 275 breast cancer patients at a single institution. Recurrence-free survival data were obtained from the medical record. Routine clinical pre-operative breast MRIs were performed in all patients. The tumors were marked on the MRIs by fellowship-trained breast radiologists. A previously developed computer algorithm was applied to the marked tumors to quantify the enhancement dynamics relative to the automatically assessed background parenchymal enhancement. To establish whether the contrast enhancement feature quantified by the algorithm was associated with recurrence-free survival, we constructed a Cox proportional hazards regression model with the computer-extracted feature as a covariate. We controlled for tumor grade and size (major axis length), patient age, patient race/ethnicity, and menopausal status., Results: The analysis showed that the semi-automatically obtained feature quantifying MRI tumor enhancement dynamics was independently predictive of recurrence-free survival (p=0.024)., Conclusion: Semi-automatically quantified tumor enhancement dynamics on MRI are predictive of recurrence-free survival in breast cancer patients., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Rationale and Objectives: To compare the performance of two shortened breast magnetic resonance imaging (MRI) protocols to a standard MRI protocol for breast cancer screening., Materials and Methods: In this Health Insurance Portability and Accountability Act compliant, institutional review board-approved pilot study, three fellowship-trained breast imagers evaluated 48 breast MRIs (24 normal, 12 benign, and 12 malignant) selected from a high-risk screening population. MRIs were presented in three viewing protocols, and a final Breast Imaging-Reporting and Data System assessment was recorded for each case. The first shortened protocol (abbreviated 1) included only fat-saturated precontrast T2-weighted, precontrast T1-weighted, and first pass T1-weighted postcontrast sequences. The second shortened protocol (abbreviated 2) included the abbreviated 1 protocol plus the second pass T1-weighted postcontrast sequence. The third protocol (full), reviewed after a 1-month waiting period, included a nonfat-saturated T1-weighted sequence, fat-saturated T2-weighted, precontrast T1-weighted, and three or four dynamic postcontrast sequences. Interpretation times were recorded for the abbreviated 1 and full protocols. Sensitivity and specificity were compared via a chi-squared analysis. This pilot study was designed to detect a 10% difference in sensitivity with a power of 0.8., Results: There was no significant difference in sensitivity between the abbreviated 1 (86%; P = .22) or abbreviated 2 (89%; P = .38) protocols and the full protocol (95%). There was no significant difference in specificity between the abbreviated 1 (52%; P = 1) or abbreviated 2 (45%; P = .34) protocols and the full protocol (52%). The abbreviated 1 and full protocol interpretation times were similar (2.98 vs. 3.56 minutes)., Conclusions: In this pilot study, reader performance comparing two shortened breast MRI protocols to a standard protocol in a screening cohort were similar, suggesting that a shortened breast MRI protocol may be clinically useful, warranting further investigation., (Copyright © 2015 AUR. Published by Elsevier Inc. All rights reserved.)

Purpose: Physical phantoms are essential for the development, optimization, and evaluation of x-ray breast imaging systems. Recognizing the major effect of anatomy on image quality and clinical performance, such phantoms should ideally reflect the three-dimensional structure of the human breast. Currently, there is no commercially available three-dimensional physical breast phantom that is anthropomorphic. The authors present the development of a new suite of physical breast phantoms based on human data., Methods: The phantoms were designed to match the extended cardiac-torso virtual breast phantoms that were based on dedicated breast computed tomography images of human subjects. The phantoms were fabricated by high-resolution multimaterial additive manufacturing (3D printing) technology. The glandular equivalency of the photopolymer materials was measured relative to breast tissue-equivalent plastic materials. Based on the current state-of-the-art in the technology and available materials, two variations were fabricated. The first was a dual-material phantom, the Doublet. Fibroglandular tissue and skin were represented by the most radiographically dense material available; adipose tissue was represented by the least radiographically dense material. The second variation, the Singlet, was fabricated with a single material to represent fibroglandular tissue and skin. It was subsequently filled with adipose-equivalent materials including oil, beeswax, and permanent urethane-based polymer. Simulated microcalcification clusters were further included in the phantoms via crushed eggshells. The phantoms were imaged and characterized visually and quantitatively., Results: The mammographic projections and tomosynthesis reconstructed images of the fabricated phantoms yielded realistic breast background. The mammograms of the phantoms demonstrated close correlation with simulated mammographic projection images of the corresponding virtual phantoms. Furthermore, power-law descriptions of the phantom images were in general agreement with real human images. The Singlet approach offered more realistic contrast as compared to the Doublet approach, but at the expense of air bubbles and air pockets that formed during the filling process., Conclusions: The presented physical breast phantoms and their matching virtual breast phantoms offer realistic breast anatomy, patient variability, and ease of use, making them a potential candidate for performing both system quality control testing and virtual clinical trials.

Mammography is currently the most widely utilized tool for detection and diagnosis of breast cancer. However, in women with dense breast tissue, tissue overlap may obscure lesions. Digital breast tomosynthesis can reduce tissue overlap. Furthermore, imaging with contrast enhancement can provide additional functional information about lesions, such as morphology and kinetics, which in turn may improve lesion identification and characterization. The performance of these imaging techniques is strongly dependent on the structural composition of the breast, which varies significantly among patients. Therefore, imaging system and imaging technique optimization should take patient variability into consideration. Furthermore, optimization of imaging techniques that employ contrast agents should include the temporally varying breast composition with respect to the contrast agent uptake kinetics. To these ends, we have developed a suite of 4-D virtual breast phantoms, which are incorporated with the kinetics of contrast agent propagation in different tissues and can realistically model normal breast parenchyma as well as benign and malignant lesions. This development presents a new approach in performing simulation studies using truly anthropomorphic models. To demonstrate the utility of the proposed 4-D phantoms, we present a simplified example study to compare the performance of 14 imaging paradigms qualitatively and quantitatively.

Rationale and Objectives: Spectroscopy signal of a breast lesion may be disrupted by the presence of metal from a biopsy marking clip. This study compares the size of magnetic resonance (MR) susceptibility artifacts and degree of local spectroscopy signal disturbance created by conventional titanium tissue marker clips to that of a novel carbon coated ceramic breast tissue marker clip., Materials and Methods: Five breast tissue marker clips were embedded in a gelatin breast phantom. The phantoms were imaged on a 3T MR scanner, and three-dimensional T1-weighted gradient echo images were obtained. The area of the susceptibility artifact was calculated and compared for each clip. Single voxel point resolved spectroscopy spectra (SVS) were acquired for three ceramic clips aligned along the superoinferior, anteroposterior, and left-right axes, respectively. Measurements were repeated for an area of pure gelatin and for one similarly sized titanium clip located arbitrarily in the main field. Water spectra were obtained, and line widths and areas of the water peaks were compared., Results: All five clips were easily visible on MR imaging. The ceramic marker clip produced less apparent artifact when compared with the metallic clips. Spectral analysis demonstrated local frequency shifts around all clips. Line widths varied from 7 to 92 Hz in the voxels on and around the titanium clip and from 4 to 18 Hz around the ceramic clips., Conclusion: The ceramic breast tissue marker clip produced less susceptibility artifact and less line broadening on 3T MR imaging than conventional titanium clips. This tissue marker may reduce artifact and improve consistency of breast MR spectroscopy., (Copyright © 2011 AUR. Published by Elsevier Inc. All rights reserved.)

Objective: The purpose of this study was to evaluate a compact portable 10-gauge handheld battery-operated vacuum-assisted biopsy system for MRI-guided breast biopsy., Conclusion: The compact portable battery-operated biopsy system can be used successfully for MRI-guided core breast biopsy and is an alternative to current systems.

Rationale and Objectives: The aim of this study was to determine if core biopsy–proven benign papillomas of the breast need to be surgically excised. Materials and methods: Mammographic and pathologic database review from January 1994 to January 2004 revealed 178 papillary lesions diagnosed by core biopsy in 176 women (mean age, 59 years). All lesions had ≥24 months of imaging follow-up (n = 75) or surgical correlation (n = 103). Details regarding core biopsy technique, lesion appearance, pathologic results, imaging-histopathologic concordance, and follow-up imaging were recorded. Core and surgical pathologic results were correlated. Results: Of the 178 papillary lesions diagnosed at core needle biopsy, 120 (67%) were initially diagnosed as benign without atypia. The core biopsy diagnoses of benignity were confirmed for all 120 lesions by either surgical excision (n = 45) or stability after ≥2 years of imaging follow-up (n = 75). Of the remaining 58 papillary lesions, 50 were found to be atypical at core needle biopsy; 15 of those 50 (29%) were upgraded to malignancies at surgical excision. Eight of the 178 lesions (5%) were initially diagnosed as malignant papillary lesions at core needle biopsy. Seven of these eight (88%) were confirmed malignant at excision. None of the surgically proven cancers was diagnosed as benign at core biopsy. Conclusions: Close imaging follow-up rather than excision of core biopsy–proven benign papillomas was adequate given careful imaging-histopathologic correlation and excision of all atypical and discordant lesions. Individual centers should evaluate their own data and tailor their practices accordingly. [Copyright &y& Elsevier]

The purpose of this study is to identify predictors of tumor-positive surgical margins after breast-conserving surgery on dynamic contrast-enhanced (DCE) MRI. We conducted a retrospective study of consecutive women who underwent DCE MRI before breast-conserving surgery from 2005 to 2014. Patient demographics, indication for surgery, MRI findings, biopsy pathology results, and surgical outcomes were reviewed. The unpaired t -test and chi -square test were used to compare the positive and negative margins groups. 554 women (mean age, 56; range, 26–90) underwent DCE MRI before 575 breast-conserving surgeries for invasive carcinoma (n = 473) or ductal carcinoma in situ (DCIS) (n = 102). Positive margins requiring re-excision occurred in 19.7% (93/473) of surgeries for invasive carcinoma and 31.4% (32/102) of surgeries for DCIS. For invasive carcinoma surgeries, positive margins were more common when MRI demonstrated the finding of non-mass enhancement (NME) rather than the finding of enhancing mass (33.8% [22/65] versus 16.9% [61/360], p < 0.01). Tumor size on MRI was significantly larger in the positive margins group (2.5 cm versus 1.9 cm, p < 0.001). Positive margins were more common with invasive lobular rather than invasive ductal histology at core biopsy (38.3% [18/47] versus 16.0% [56/350], p < 0.001). For DCIS surgeries, there were no significant differences in positive margin rates related to MRI features. For invasive carcinoma surgeries, positive margins are associated with NME on MRI, larger tumor size on MRI, and lobular histology at core biopsy. These findings may be used to predict which patients are at risk for positive margins after breast-conserving surgery. • MRI can predict which patients are at risk for positive margins after lumpectomy. • Non-mass enhancement on breast MRI is associated with tumor-positive surgical margins. • Large tumor size on breast MRI is associated with tumor-positive surgical margins. [ABSTRACT FROM AUTHOR]