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Objectives: To assess whether no enhancement on pre-treatment MRI can rule out malignancy of additional US mass(es) initially assessed as BI-RADS 3 or 4 in women with newly diagnosed breast cancer., Methods: This retrospective study included consecutive women from 2010-2018 with newly diagnosed breast cancer; at least one additional breast mass (distinct from index cancer) assigned a BI-RADS 3 or 4 on US; and a bilateral contrast-enhanced breast MRI performed within 90 days of US. All malignant masses were pathologically proven; benign masses were pathologically proven or defined as showing at least 2 years of imaging stability. Incidence of malignant masses and NPV were calculated on a per-patient level using proportions and exact 95% CIs., Results: In 230 patients with 309 additional masses, 140/309 (45%) masses did not enhance while 169/309 (55%) enhanced on MRI. Of the 140 masses seen in 105 women (mean age, 54 years; range 28-82) with no enhancement on MRI, all had adequate follow-up and 140/140 (100%) were benign, of which 89/140 (63.6%) were pathologically proven and 51/140 (36.4%) demonstrated at least 2 years of imaging stability. Pre-treatment MRI demonstrating no enhancement of US mass correlate(s) had an NPV of 100% (95% CI 96.7-100.0)., Conclusions: All BI-RADS 3 and 4 US masses with a non-enhancing correlate on pre-treatment MRI were benign. The incorporation of MRI, when ordered by the referring physician, may decrease unnecessary follow-up imaging and/or biopsy if the initial US BI-RADS assessment and management recommendation were to be retrospectively updated., Key Points: • Of 309 BI-RADS 3 or 4 US masses with a corresponding mass on MRI, 140/309 (45%) demonstrated no enhancement whereas 169/309 (55%) demonstrated enhancement • All masses classified as BI-RADS 3 or 4 on US without enhancement on MRI were benign • MRI can rule out malignancy in non-enhancing US masses with an NPV of 100.

Background: Background parenchymal enhancement (BPE) on breast magnetic resonance imaging (MRI) may be associated with breast cancer risk, but previous studies of the association are equivocal and limited by incomplete blinding of BPE assessment. In this study, we evaluated the association between BPE and breast cancer based on fully blinded assessments of BPE in the unaffected breast., Methods: The Imaging and Epidemiology (IMAGINE) study is a multicenter breast cancer case-control study of women receiving diagnostic, screening, or follow-up breast MRI, recruited from three comprehensive cancer centers in the USA. Cases had a first diagnosis of unilateral breast cancer and controls had no history of or current breast cancer. A single board-certified breast radiologist with 12 years' experience, blinded to case-control status and clinical information, assessed the unaffected breast for BPE without view of the affected breast of cases (or the corresponding breast laterality of controls). The association between BPE and breast cancer was estimated by multivariable logistic regression separately for premenopausal and postmenopausal women., Results: The analytic dataset included 835 cases and 963 controls. Adjusting for fibroglandular tissue (breast density), age, race/ethnicity, BMI, parity, family history of breast cancer, BRCA1/BRCA2 mutations, and other confounders, moderate/marked BPE (vs minimal/mild BPE) was associated with breast cancer among premenopausal women [odds ratio (OR) 1.49, 95% CI 1.05-2.11; p = 0.02]. Among postmenopausal women, mild/moderate/marked vs minimal BPE had a similar, but statistically non-significant, association with breast cancer (OR 1.45, 95% CI 0.92-2.27; p = 0.1)., Conclusions: BPE is associated with breast cancer in premenopausal women, and possibly postmenopausal women, after adjustment for breast density and confounders. Our results suggest that BPE should be evaluated alongside breast density for inclusion in models predicting breast cancer risk.

Background: Differences in imaging parameters influence computer-extracted parenchymal enhancement measures from breast MRI., Purpose: To investigate the effect of differences in dynamic contrast-enhanced MRI acquisition parameter settings on quantitative parenchymal enhancement of the breast, and to evaluate harmonization of contrast-enhancement values with respect to flip angle and repetition time., Study Type: Retrospective., Phantom/populations: We modeled parenchymal enhancement using simulations, a phantom, and two cohorts (N = 398 and N = 302) from independent cancer centers., Sequence Field/strength: 1.5T dynamic contrast-enhanced T 1 -weighted spoiled gradient echo MRI. Vendors: Philips, Siemens, General Electric Medical Systems., Assessment: We assessed harmonization of parenchymal enhancement in simulations and phantom by varying the MR parameters that influence the amount of T 1 -weighting: flip angle (8°-25°) and repetition time (4-12 msec). We calculated the median and interquartile range (IQR) of the enhancement values before and after harmonization. In vivo, we assessed overlap of quantitative parenchymal enhancement in the cohorts before and after harmonization using kernel density estimations. Cohort 1 was scanned with flip angle 20° and repetition time 8 msec; cohort 2 with flip angle 10° and repetition time 6 msec., Statistical Tests: Paired Wilcoxon signed-rank-test of bootstrapped kernel density estimations., Results: Before harmonization, simulated enhancement values had a median (IQR) of 0.46 (0.34-0.49). After harmonization, the IQR was reduced: median (IQR): 0.44 (0.44-0.45). In the phantom, the IQR also decreased, median (IQR): 0.96 (0.59-1.22) before harmonization, 0.96 (0.91-1.02) after harmonization. Harmonization yielded significantly (P < 0.001) better overlap in parenchymal enhancement between the cohorts: median (IQR) was 0.46 (0.37-0.58) for cohort 1 vs. 0.37 (0.30-0.44) for cohort 2 before harmonization (57% overlap); and 0.35 (0.28-0.43) vs. .0.37 (0.30-0.44) after harmonization (85% overlap)., Data Conclusion: The proposed practical harmonization method enables an accurate comparison between patients scanned with differences in imaging parameters., Level of Evidence: 3 TECHNICAL EFFICACY STAGE: 4., (© 2020 The Authors. Journal of Magnetic Resonance Imaging published by Wiley Periodicals LLC on behalf of International Society for Magnetic Resonance in Medicine.)

Multishot multiplexed sensitivity-encoding diffusion-weighted imaging is a feasible and easily implementable routine breast MRI protocol that yields high-quality diffusion-weighted breast images. Purpose: To compare multiplexed sensitivity-encoding (MUSE) diffusion-weighted imaging (DWI) and single-shot DWI for lesion visibility and differentiation of malignant and benign lesions within the breast. Materials and Methods: In this prospective institutional review board-approved study, both MUSE DWI and single-shot DWI sequences were first optimized in breast phantoms and then performed in a group of patients. Thirty women (mean age, 51.1 years ± 10.1 [standard deviation]; age range, 27-70 years) with 37 lesions were included in this study and underwent scanning using both techniques. Visual qualitative analysis of diffusion-weighted images was accomplished by two independent readers; images were assessed for lesion visibility, adequate fat suppression, and the presence of artifacts. Quantitative analysis was performed by calculating apparent diffusion coefficient (ADC) values and image quality parameters (signal-to-noise ratio [SNR] for lesions and fibroglandular tissue; contrast-to-noise ratio) by manually drawing regions of interest within the phantoms and breast tumor tissue. Interreader variability was determined using the Cohen κ coefficient, and quantitative differences between MUSE DWI and single-shot DWI were assessed using the Mann-Whitney U test; significance was defined at P < .05. Results: MUSE DWI yielded significantly improved image quality compared with single-shot DWI in phantoms (SNR, P = .001) and participants (lesion SNR, P = .009; fibroglandular tissue SNR, P = .05; contrast-to-noise ratio, P = .008). MUSE DWI ADC values showed a significant difference between malignant and benign lesions ( P < .001). No significant differences were found between MUSE DWI and single-shot DWI in the mean, maximum, and minimum ADC values ( P = .96, P = .28, and P = .49, respectively). Visual qualitative analysis resulted in better lesion visibility for MUSE DWI over single-shot DWI (κ = 0.70). Conclusion: MUSE DWI is a promising high-spatial-resolution technique that may enhance breast MRI protocols without the need for contrast material administration in breast screening. Keywords: Breast, MR-Diffusion Weighted Imaging, Oncology Supplemental material is available for this article. © RSNA, 2020., Competing Interests: Disclosures of Conflicts of Interest: I.D.N. disclosed no relevant relationships. R.L.G. disclosed no relevant relationships. E.A.M. disclosed no relevant relationships. T.L. disclosed no relevant relationships. M.M.F. Activities related to the present article: disclosed no relevant relationships. Activities not related to the present article: is and employee of and holds stock in GE Healthcare. Other relationships: disclosed no relevant relationships. A.G. Activities related to the present article: disclosed no relevant relationships. Activities not related to the present article: is an employee of GE Healthcare. Other relationships: disclosed no relevant relationships. K.P. editorial board member for Radiology: Imaging Cancer. S.B.T. disclosed no relevant relationships., (2020 by the Radiological Society of North America, Inc.)

Purpose: To compare annotation segmentation approaches and to assess the value of radiomics analysis applied to diffusion-weighted imaging (DWI) for evaluation of breast cancer receptor status and molecular subtyping., Procedures: In this IRB-approved HIPAA-compliant retrospective study, 91 patients with treatment-naïve breast malignancies proven by image-guided breast biopsy, (luminal A, n = 49; luminal B, n = 8; human epidermal growth factor receptor 2 [HER2]-enriched, n = 11; triple negative [TN], n = 23) underwent multiparametric magnetic resonance imaging (MRI) of the breast at 3 T with dynamic contrast-enhanced MRI, T2-weighted and DW imaging. Lesions were manually segmented on high b-value DW images and segmentation ROIS were propagated to apparent diffusion coefficient (ADC) maps. In addition in a subgroup (n = 79) where lesions were discernable on ADC maps alone, these were also directly segmented there. To derive radiomics signatures, the following features were extracted and analyzed: first-order histogram (HIS), co-occurrence matrix (COM), run-length matrix (RLM), absolute gradient, autoregressive model (ARM), discrete Haar wavelet transform (WAV), and lesion geometry. Fisher, probability of error and average correlation, and mutual information coefficients were used for feature selection. Linear discriminant analysis followed by k-nearest neighbor classification with leave-one-out cross-validation was applied for pairwise differentiation of receptor status and molecular subtyping. Histopathologic results were considered the gold standard., Results: For lesion that were segmented on DWI and segmentation ROIs were propagated to ADC maps the following classification accuracies > 90% were obtained: luminal B vs. HER2-enriched, 94.7 % (based on COM features); luminal B vs. others, 92.3 % (COM, HIS); and HER2-enriched vs. others, 90.1 % (RLM, COM). For lesions that were segmented directly on ADC maps, better results were achieved yielding the following classification accuracies: luminal B vs. HER2-enriched, 100 % (COM, WAV); luminal A vs. luminal B, 91.5 % (COM, WAV); and luminal B vs. others, 91.1 % (WAV, ARM, COM)., Conclusions: Radiomic signatures from DWI with ADC mapping allows evaluation of breast cancer receptor status and molecular subtyping with high diagnostic accuracy. Better classification accuracies were obtained when breast tumor segmentations could be performed on ADC maps.

Purpose: During MRI-guided breast biopsy, a metallic biopsy marker is deployed at the biopsy site to guide future interventions. Conventional MRI during biopsy cannot distinguish such markers from biopsy site air, and a post-biopsy mammogram is therefore performed to localize marker placement. The purpose of this pilot study is to develop dipole modeling of multispectral signal (DIMMS) as an MRI alternative to eliminate the cost, inefficiency, inconvenience, and ionizing radiation of a mammogram for biopsy marker localization., Methods: DIMMS detects and localizes the biopsy marker by fitting the measured multispectral imaging (MSI) signal to the MRI signal model and marker properties. MSI was performed on phantoms containing titanium biopsy markers and air to illustrate the clinical challenge that DIMMS addresses and on 20 patients undergoing MRI-guided breast biopsy to assess DIMMS feasibility for marker detection. DIMMS was compared to conventional MSI field map thresholding, using the post-procedure mammogram as the reference standard., Results: Biopsy markers were detected and localized in 20 of 20 cases using MSI with automated DIMMS post-processing (using a threshold of 0.7) and in 18 of 20 cases using MSI field mapping (using a threshold of 0.65 kHz)., Conclusion: MSI with DIMMS post-processing is a feasible technique for biopsy marker detection and localization during MRI-guided breast biopsy. With a 2-min MSI scan, DIMMS is a promising MRI alternative to the standard-of-care post-biopsy mammogram., (© 2019 International Society for Magnetic Resonance in Medicine.)

The rationale was to assess whether there are differences in multiparametric 18 F-FDG PET/MRI biomarkers of contralateral healthy breast tissue in patients with benign and malignant breast tumors. Methods: In this institutional review board-approved prospective single-institution study, 141 women with imaging abnormalities on mammography or sonography (BI-RADS 4/5) underwent combined 18 F-FDG PET/MRI of the breast at 3T with dynamic contrast-enhanced MRI, diffusion-weighted imaging, and the radiotracer 18 F-FDG. In all patients, the following imaging biomarkers were recorded for the contralateral (tumor-free) breast: breast parenchymal uptake (BPU) (from 18 F-FDG PET), mean apparent diffusion coefficient (from diffusion-weighted imaging), background parenchymal enhancement (BPE), and amount of fibroglandular tissue (FGT) (from MRI). Appropriate statistical tests were used to assess differences in 18 F-FDG PET/MRI biomarkers between patients with benign and malignant lesions. Results: There were 100 malignant and 41 benign lesions. BPE was minimal in 61 patients, mild in 56, moderate in 19, and marked in 5. BPE differed significantly ( P < 0.001) between patients with benign and malignant lesions, with patients with cancer demonstrating decreased BPE in the contralateral tumor-free breast. FGT approached but did not reach significance ( P = 0.055). BPU was 1.5 for patients with minimal BPE, 1.9 for mild BPE, 2.2 for moderate BPE, and 1.9 for marked BPE. BPU differed significantly between patients with benign lesions (mean, 1.9) and patients with malignant lesions (mean, 1.8) ( P < 0.001). Mean apparent diffusion coefficient did not differ between groups ( P = 0.19). Conclusion: Differences in multiparametric 18 F-FDG PET/MRI biomarkers, obtained from contralateral tumor-free breast tissue, exist between patients with benign and patients with malignant breast tumors. Contralateral BPE, BPU, and FGT are decreased in breast cancer patients and may potentially serve as imaging biomarkers for the presence of malignancy., (© 2020 by the Society of Nuclear Medicine and Molecular Imaging.)

Background: Small breast lesions are difficult to visually categorize due to the inherent lack of morphological and kinetic detail., Purpose: To assess the efficacy of radiomics analysis in discriminating small benign and malignant lesions utilizing model free parameter maps., Study Type: Retrospective, single center., Population: In all, 149 patients, with a total of 165 lesions scored as BI-RADS 4 or 5 on MRI, with an enhancing volume of <0.52 cm 3 ., Field Strength/sequence: Higher spatial resolution T 1 -weighted dynamic contrast-enhanced imaging with a temporal resolution of ~90 seconds performed at 3.0T., Assessment: Parameter maps reflecting initial enhancement, overall enhancement, area under the enhancement curve, and washout were generated. Heterogeneity measures based on first-order statistics, gray level co-occurrence matrices, run length matrices, size zone matrices, and neighborhood gray tone difference matrices were calculated. Data were split into a training dataset (~75% of cases) and a test dataset (~25% of cases)., Statistical Tests: Comparison of medians was assessed using the nonparametric Mann-Whitney U-test. The Spearman rank correlation coefficient was utilized to determine significant correlations between individual features. Finally, a support vector machine was employed to build multiparametric predictive models., Results: Univariate analysis revealed significant differences between benign and malignant lesions for 58/133 calculated features (P < 0.05). Support vector machine analysis resulted in areas under the curve (AUCs) ranging from 0.75-0.81. High negative (>89%) and positive predictive values (>83%) were found for all models., Data Conclusion: Radiomics analysis of small contrast-enhancing breast lesions is of value. Texture features calculated from later timepoints on the enhancement curve appear to offer limited additional value when compared with features determined from initial enhancement for this patient cohort., Level of Evidence: 4 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2019;50:1468-1477., (© 2019 International Society for Magnetic Resonance in Medicine.)

Purpose: To develop a multiparametric [ 18 F]FDG positron emission tomography/magnetic resonance imaging (PET/MRI) model for breast cancer diagnosis incorporating imaging biomarkers of breast tumors and contralateral healthy breast tissue., Methods: In this prospective study and retrospective data analysis, 141 patients (mean 57 years) with an imaging abnormality detected on mammography and/or ultrasound (BI-RADS 4/5) underwent combined multiparametric [ 18 F]FDG PET/MRI with PET/computed tomography and multiparametric MRI of the breast at 3 T. Images were evaluated and the following were recorded: for the tumor, BI-RADS descriptors on dynamic contrast-enhanced (DCE)-MRI, mean apparent diffusion co-efficient (ADCmean) on diffusion-weighted imaging (DWI), and maximum standard uptake value (SUVmax) on [ 18 F]FDG-PET; and for the contralateral healthy breast, background parenchymal enhancement (BPE) and amount of fibroglandular tissue (FGT) on DCE-MRI, ADCmean on DWI, and SUVmax. Histopathology served as standard of reference. Uni-, bi-, and multivariate logistic regression analyses were performed to assess the relationships between malignancy and imaging features. Predictive discrimination of benign and malignant breast lesions was examined using area under the receiver operating characteristic curve (AUC)., Results: There were 100 malignant and 41 benign lesions (size: median 1.9, range 0.5-10 cm). The multivariate regression model incorporating significant univariate predictors identified tumor enhancement kinetics (P = 0.0003), tumor ADCmean (P < 0.001), and BPE of the contralateral healthy breast (P = 0.0019) as independent predictors for breast cancer diagnosis. Other biomarkers did not reach significance. Combination of the three significant biomarkers achieved an AUC value of 0.98 for breast cancer diagnosis., Conclusion: A multiparametric [ 18 F]FDG PET/MRI diagnostic model incorporating both qualitative and quantitative parameters of the tumor and the healthy contralateral tissue aids breast cancer diagnosis.

MRI of the breast is the most sensitive test for breast cancer detection and outperforms conventional imaging with mammography, digital breast tomosynthesis, or ultrasound. However, the long scan time and relatively high costs limit its widespread use. Hence, it is currently only routinely implemented in the screening of women at an increased risk of breast cancer. To overcome these limitations, abbreviated dynamic contrast-enhanced (DCE)-MRI protocols have been introduced that substantially shorten image acquisition and interpretation time while maintaining a high diagnostic accuracy. Efforts to develop abbreviated MRI protocols reflect the increasing scrutiny of the disproportionate contribution of radiology to the rising overall healthcare expenditures. Healthcare policy makers are now focusing on curbing the use of advanced imaging examinations such as MRI while continuing to promote the quality and appropriateness of imaging. An important cornerstone of value-based healthcare defines value as the patient's outcome over costs. Therefore, the concept of a fast, abbreviated MRI exam is very appealing, given its high diagnostic accuracy coupled with the possibility of a marked reduction in the cost of an MRI examination. Given recent concerns about gadolinium-based contrast agents, unenhanced MRI techniques such as diffusion-weighted imaging (DWI) are also being investigated for breast cancer diagnosis. Although further larger prospective studies, standardized imaging protocol, and reproducibility studies are necessary, initial results with abbreviated MRI protocols suggest that it seems feasible to offer screening breast DCE-MRI to a broader population. This article aims to give an overview of abbreviated and fast breast MRI protocols, their utility for breast cancer detection, and their emerging role in the new value-based healthcare paradigm that has replaced the fee-for-service model. Level of Evidence: 1 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2019;49:e85-e100., (© 2018 International Society for Magnetic Resonance in Medicine.)

Full-field digital mammography (FFDM), the standard of care for breast cancer screening, has some limitations. With the advent of digital breast tomosynthesis (DBT), improvements including decreased recall rates and increased cancer detection rates have been observed. The quasi-three-dimensional capability of DBT reduces breast tissue overlap, a significant limitation of FFDM. However, early studies demonstrate that a few cancers detected at FFDM may not be diagnosed at DBT-only screening, and lesions with calcifications as the dominant feature may look less suspicious at DBT or not be visible at all. These findings support the use of combined FFDM and DBT protocols to optimize screening performance. However, this combination would approximately double the patient's radiation exposure. The development of computer algorithms that generate two-dimensional synthesized mammography (SM) views from DBT has improved calcification conspicuity and sensitivity. Therefore, SM may substitute for FFDM in screening protocols, reducing radiation exposure. DBT plus SM demonstrates significantly better performance than that of FFDM alone, although there are reports of missed malignant calcifications. Thus, some centers continue to perform FFDM with DBT. Use of DBT in breast imaging has also necessitated the development of DBT-guided biopsy. DBT-guided biopsy may have a higher success rate than that of stereotactic biopsy, with a shorter procedure time. While DBT brings substantial improvements to breast cancer imaging, it is important to be aware of its strengths and limitations regarding detection of calcifications. This article reviews the imaging appearance of breast calcifications at DBT, discusses calcification biopsy techniques, and provides an overview of the current literature. Online supplemental material is available for this article. © RSNA, 2019 An earlier incorrect version of this article appeared online. This article was corrected on February 13, 2019.

Objective: Prior to stereotactic breast biopsy, some radiologists obtain a mammogram image with an overlying alphanumeric grid to mark the skin overlying the target. Our purpose is to determine if this grid image affects stereotactic biopsy efficiency and accuracy, including total images obtained, procedure time and need for retargeting., Materials and Methods: IRB approved, HIPAA compliant retrospective review of prone stereotactic biopsy cases targeting calcifications 9/1/2015 to 9/1/2016 was performed. Images and reports were reviewed for number and type of images obtained, evidence of retargeting and biopsy table time. Attending radiologist, technologist and trainee involvement were recorded. Statistical analysis was performed utilizing SAS statistical software v 9.4 (SAS Institute, Cary, NC)., Results: Of 463 women (avg age 58.0 years, range 30-94), 392/463 (84.7%) had grid images obtained pre-biopsy. Grid patients had more images total than non-grid (avg 9.26 versus 8.44 images/patient; p < 0.0001) but spent less time on the biopsy table (avg 15 min 2 s versus 16 min 44 s/procedure; p < 0.0001). Non-grid patients were more likely to undergo initial retargeting (45% non-grid vs 30% of grid patients; p = 0.013); however, later retargeting after needle placement was comparable (p = 0.3)., Conclusion: Grid imaging increases images obtained but decreases retargeting and biopsy table time at the expense of mammogram room/technologist time to obtain the grid image. The overall result is longer total procedure time (grid time plus table time) for the patient/technologist. A grid image therefore has limited usefulness and should be used judiciously in cases where prone positioning is challenging to patients., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Purpose: Breast fibroglandular tissue (FGT), as visualized on a mammogram (mammographic density, MD), is one of the strongest known risk factors for breast cancer. FGT is also visible on breast MRI, and increased background parenchymal enhancement (BPE) in the FGT has been identified as potentially a major breast cancer risk factor. The aim of this exploratory study was to examine the biologic basis of BPE., Methods: We examined the unaffected contra-lateral breast of 80 breast cancer patients undergoing a prophylactic mastectomy before any treatment other than surgery of their breast cancer. BPE was classified on the BI-RADS scale (minimal/mild/moderate/marked). Slides were stained for microvessel density (MVD), CD34 (another measure of endothelial density), glandular tissue within the FGT and VEGF. Spearman correlations were used to evaluate the associations between BPE and these pathologic variables., Results: In pre-menopausal patients, BPE was highly correlated with MVD, CD34 and glandular concentration within the FGT, and the pathologic variables were themselves highly correlated. The expression of VEGF was effectively confined to terminal duct lobular unit (TDLU) epithelium. The same relationships of the four pathologic variables with BPE were seen in post-menopausal patients, but the relationships were much weaker and not statistically significant., Conclusion: The strong correlation of BPE and MVD together with the high correlation of MVD with glandular concentration seen in pre-menopausal patients indicates that increased breast cancer risk associated with BPE in pre-menopausal women is likely to result from its association with increased concentration of glandular tissue in the FGT. The effective confinement of VEGF expression to the TDLUs shows that the signal for MVD growth arises directly from the glandular tissue. Further studies are needed to understand the basis of BPE in post-menopausal women.

Purpose: To determine if real-time breast ultrasound (RTUR) after second opinion reinterpretation of submitted static ultrasound images at a comprehensive cancer center impacts clinical management, specifically by detecting additional cancer and preventing unnecessary biopsy., Materials and Methods: In this IRB-approved and HIPAA-compliant retrospective study, 209 patients were included who had breast ultrasound studies from outside facilities submitted for second opinion review between January 2013 and May 2014, and who subsequently underwent RTUR at our institution within three months of the outside study. Findings on submitted exams were compared with those on RTUR and disagreements between them were annotated to indicate the presence or absence of suspicious lesions and recommendation for biopsy. Changes in management were defined as any additional biopsies performed or biopsies averted after RTUR and reported as frequencies and percentages using 95% confidence intervals., Results: Following RTUR, 49 additional biopsies were performed in 43/209 patients (20.6%; 95% CI 15.1-26.1%). Additional cancer was found in 12/49 (24.5%) biopsies in 11/209 patients (5.3%; 95% CI 2.2-8.2%). Forty biopsies in 31/209 (14.8%; CI 10.0-19.7%) patients originally recommended were canceled after RTUR. Overall, a change in management after RTUR was observed in 68/209 patients (32.5%; 95% CI 26.1-38.9%), including patients with either additional biopsies performed or biopsies averted., Conclusion: RTUR was found to be an important tool in the management of patients at our comprehensive cancer center. Although additional false-positive lesions may be detected on RTUR, a great number of patients will benefit from RTUR in finding additional cancers or avoiding unnecessary biopsies., (Copyright © 2018 Elsevier Inc. All rights reserved.)

MRI is an essential tool in breast imaging, with multiple established indications. Dynamic contrast-enhanced MRI (DCE-MRI) is the backbone of any breast MRI protocol and has an excellent sensitivity and good specificity for breast cancer diagnosis. DCE-MRI provides high-resolution morphological information, as well as some functional information about neoangiogenesis as a tumour-specific feature. To overcome limitations in specificity, several other functional MRI parameters have been investigated and the application of these combined parameters is defined as multiparametric MRI (mpMRI) of the breast. MpMRI of the breast can be performed at different field strengths (1.5-7 T) and includes both established (diffusion-weighted imaging, MR spectroscopic imaging) and novel MRI parameters (sodium imaging, chemical exchange saturation transfer imaging, blood oxygen level-dependent MRI), as well as hybrid imaging with positron emission tomography (PET)/MRI and different radiotracers. Available data suggest that multiparametric imaging using different functional MRI and PET parameters can provide detailed information about the underlying oncogenic processes of cancer development and progression and can provide additional specificity. This article will review the current and emerging functional parameters for mpMRI of the breast for improved diagnostic accuracy in breast cancer.

Objective: To evaluate effects of fibroglandular tissue (FGT) composition and background parenchymal enhancement (BPE) on diffusion tensor imaging (DTI) parameters in normal breast tissue., Methods: DTI analysis was performed on 35 breasts with regions of interest drawn to include only normal tissue. Breasts were dichotomized by FGT composition and by BPE; DTI parameters were compared., Results: The λ1 principal diffusion coefficient was lower in breasts with moderate/marked BPE versus those with minimal/mild BPE (P=.039). All other parameters were unaffected., Conclusion: λ1 is sensitive to differences in BPE within normal breast tissue that should be taken into account in DTI evaluation., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Pathologic evaluation of breast specimens requires a fixation and staining procedure of at least 12 hours duration, delaying diagnosis and post-operative planning. Here we introduce an MRI technique with a custom-designed radiofrequency resonator for imaging breast and lymph tissue with sufficient spatial resolution and speed to guide pathologic interpretation and offer value in clinical decision making. In this study, we demonstrate the ability to image breast and lymphatic tissue using 7.0 Tesla MRI, achieving a spatial resolution of 59 × 59 × 94 μm(3) with a signal-to-noise ratio of 15-20, in an imaging time of 56 to 70 minutes. These are the first MR images to reveal characteristic pathologic features of both benign and malignant breast and lymph tissue, some of which were discernible by blinded pathologists who had no prior training in high resolution MRI interpretation.

Objective: To evaluate the ability of an abbreviated breast magnetic resonance imaging (MRI) protocol, consisting of a precontrast T1 weighted (T1W) image and single early post-contrast T1W image, to detect breast carcinoma., Materials and Methods: A HIPAA compliant Institutional Review Board approved review of 100 consecutive breast MRI examinations in patients with biopsy proven unicentric breast carcinoma. 79% were invasive carcinomas and 21% were ductal carcinoma in situ. Four experienced breast radiologists, blinded to carcinoma location, history and prior examinations, assessed the abbreviated protocol evaluating only the first post-contrast T1W image, post-processed subtracted first post-contrast and subtraction maximum intensity projection images. Detection and localization of tumor were compared to the standard full diagnostic examination consisting of 13 pre-contrast, post-contrast and post-processed sequences., Results: All 100 cancers were visualized on initial reading of the abbreviated protocol by at least one reader. The mean sensitivity for each sequence was 96% for the first post-contrast sequence, 96% for the first post-contrast subtraction sequence and 93% for the subtraction MIP sequence. Within each sequence, there was no significant difference between the sensitivities among the 4 readers (p=0.471, p=0.656, p=0.139). Mean interpretation time was 44s (range 11-167s). The abbreviated imaging protocol could be performed in approximately 10-15 min, compared to 30-40 min for the standard protocol., Conclusion: An abbreviated breast MRI protocol allows detection of breast carcinoma. One pre and post-contrast T1W sequence may be adequate for detecting breast carcinoma. These results support the possibility of refining breast MRI screening protocols., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

Purpose: To evaluate the influence of the amount of fibroglandular breast tissue (FGT) and background-parenchymal enhancement (BPE) on lesion detection, quantitative analysis of normal breast tissue and of breast lesions on DWI., Materials and Methods: IRB approved this retrospective study on focal findings at contrast-enhanced (CE)breast MR and DWI performed during July-December 2011. Patients with cysts, previous irradiation,silicone implants and current chemotherapy were excluded. DWI with fat suppression was acquired before dynamic acquisition (b factors: 0.1000 s/mm2) using 1.5 and 3 T scanners. Using correlation with dynamic and T2 images, ROIs were drawn free-hand within the borders of any visible lesion and incontralateral normal breast. Fisher's exact test to evaluate visibility and Wilcoxon-rank-sum test for comparison of ADC values were used. The amount of FGT and BPE was visually assessed by concurrent MRI. Analysis was stratified by menopausal status., Results: 25/127 (20%) lesions were excluded for technical reasons. 65/102 (64%) lesions were visible on DWI (median diameter: 1.85 cm). Mass lesions (M) were more visible (43/60 = 72%) than non-mass enhancement (NME) (22/42 = 52%) and malignant lesions were more visible (55/72 = 76%) than benign(10/30 = 33%). BPE and FGT did not influence visibility of M (p = 0.35 and p = 0.57 respectively) as well as of NME (p = 0.54 and p = 0.10). BPE and FGT did not influence visibility of malignant (p = 0.96 and p = 1.0)and benign lesions (p = 1.0 and p = 0.10). Results were confirmed adjusting for menopausal status. The ADC value of normal breast tissue was not influenced by BPE, while it was lower in predominantly fatty breasts compared to dense ones (p = 0.002)., Conclusions: FGT affects the quantitative evaluation of ADC in normal breast tissue whereas BPE does not.Furthermore, both BPE and FGT do not influence visibility of benign or malignant findings, including both mass lesions and non-mass enhancement, on DWI., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

Purpose: To study the differentiation of malignant breast lesions from benign lesions and fibroglandular tissue (FGT) using apparent diffusion coefficient (ADC) and intravoxel incoherent motion (IVIM) parameters., Materials and Methods: This retrospective study included 26 malignant and 14 benign breast lesions in 35 patients who underwent diffusion-weighted MRI at 3.0T and nine b-values (0-1000 s/mm(2) ). ADC and IVIM parameters (perfusion fraction fp , pseudodiffusion coefficient Dp , and true diffusion coefficient Dd ) were determined in lesions and FGT. For comparison, IVIM was also measured in 16 high-risk normal patients. A predictive model was constructed using linear discriminant analysis. Lesion discrimination based on ADC and IVIM parameters was assessed using receiver operating characteristic (ROC) and area under the ROC curve (AUC)., Results: In FGT of normal subjects, fp was 1.1 ± 1.1%. In malignant lesions, fp (6.4 ± 3.1%) was significantly higher than in benign lesions (3.1 ± 3.3%, P = 0.0025) or FGT (1.5 ± 1.2%, P < 0.001), and Dd ((1.29 ± 0.28) × 10(-3) mm(2) /s) was lower than in benign lesions ((1.56 ± 0.28) × 10(-3) mm(2) /s, P = 0.011) or FGT ((1.86 ± 0.34) × 10(-3) mm(2) /s, P < 0.001). A combination of Dd and fp provided higher AUC for discrimination between malignant and benign lesions (0.84) or FGT (0.97) than ADC (0.72 and 0.86, respectively)., Conclusion: The IVIM parameters provide accurate identification of malignant lesions., (© 2013 Wiley Periodicals, Inc.)

Objective: The objective of this study was to evaluate the effect of bilateral salpingo-oophorectomy (BSO) on background parenchymal enhancement (BPE) and the amount of fibroglandular tissue (FGT) seen on breast MRI., Methods: Retrospective review identified 21 BRCA mutation carriers who underwent breast MRI before and after elective BSO. After exclusion of patients placed on postoperative hormone replacement therapy, there were 18 eligible patients. Blinded to surgical status, three independent readers used categorical scales to rate BPE (minimal, mild, moderate, marked) and the amount of FGT (fatty, scattered, heterogeneously dense, dense) on pre- and post-BSO MRI examinations. The sign test was used to assess for changes in the categorical ratings of BPE and FGT., Results: Significant proportions of women demonstrated decreases in BPE and in the amount of FGT following oophorectomy (P = 0.004 and 0.02, respectively.) BPE decreases were larger and seen earlier than FGT changes. There was no significant relationship between age/body mass index and changes in BPE and FGT., Conclusions: BPE and the amount of FGT seen on breast MRI are significantly decreased by oophorectomy; BPE decreases to a greater extent and earlier than FGT., Key Points: • Background parenchymal enhancement significantly decreases at breast MRI following oophorectomy. • Fibroglandular tissue significantly decreases on breast MRI following oophorectomy. • Decrease in background parenchymal enhancement is greater than in fibroglandular tissue. • Decrease in background parenchymal enhancement occurs earlier than in fibroglandular tissue.

Purpose: To compare total choline concentrations ([Cho]) and water-to-fat (W/F) ratios of subtypes of malignant lesions, benign lesions, and normal breast parenchyma and determine their usefulness in breast cancer diagnosis. Reference standard was histology., Materials and Methods: In this HIPPA compliant study, proton MRS was performed on 93 patients with suspicious lesions (>1 cm) who underwent MRI-guided interventional procedures, and on 27 prospectively accrued women enrolled for screening MRI. (W/F) and [Cho] values were calculated using MRS data., Results: Among 88 MRS-evaluable histologically-confirmed lesions, 40 invasive ductal carcinoma (IDC); 10 invasive lobular carcinoma (ILC); 4 ductal carcinoma in situ (DCIS); 3 invasive mammary carcinoma (IMC); 31 benign. No significant difference observed in (W/F) between benign lesions and normal breast tissue. The area under curve (AUC) of receiver operating characteristic (ROC) curves for discriminating the malignant group from the benign group were 0.97, 0.72, and 0.99 using [Cho], (W/F) and their combination as biomarkers, respectively. (W/F) performs significantly (P < 0.0001;AUC = 0.96) better than [Cho] (AUC = 0.52) in differentiating IDC and ILC lesions., Conclusion: Although [Cho] and (W/F) are good biomarkers for differentiating malignancy, [Cho] is a better marker. Combining both can further improve diagnostic accuracy. IDC and ILC lesions have similar [Cho] levels but are discriminated using (W/F) values., (Copyright © 2011 Wiley-Liss, Inc.)

Objective: This study was performed to identify characteristics of suspicious lesions seen on breast MRI that are most likely to have an ultrasound correlate and to determine how often the presumed ultrasound correlate actually corresponds to the MRI finding., Materials and Methods: From September 2005 through December 2007, targeted ultrasound was performed for 519 suspicious MRI-detected lesions in 361 women. Retrospective review was performed to determine lesion type (mass vs nonmass), lesion descriptors, lesion size, BI-RADS category, indication for MR examination, patient age, and biopsy outcome. The results of 80 follow-up MRI examinations among 154 cases with concordant benign results on ultrasound-guided biopsy were noted., Results: A presumed ultrasound correlate was found in 290 (56%) of the 519 lesions with masses more likely than nonmass lesions to be seen with ultrasound (62% of masses and 31% of nonmass lesions). Increasing lesion size, assessment of BI-RADS category 5 versus BI-RADS category 4, rim enhancement in masses, and clumped enhancement in nonmass lesions were also significantly more likely to have an ultrasound correlate. On follow-up imaging in 80 benign, concordant ultrasound-guided biopsies, the sonographic lesion did not correspond to the MRI finding in 10. Nine of these 10 lesions underwent subsequent MRI-guided biopsy and five cancers were diagnosed., Conclusion: The MR characteristics of lesions most likely to be seen with an ultrasound correlate were mass versus nonmass, increasing size, and increased level of suspicion of the lesion. Clip placement and follow-up imaging after ultrasound-guided biopsy that yields benign concordant results should be performed to detect cases in which the presumed ultrasound correlate is inaccurate to detect unsuspected false-negative biopsies.

Background: Although carcinoma presenting as axillary metastases is assumed to be due to breast cancer, identification of the primary lesion may prove problematic. We investigated the ability of breast magnetic resonance imaging (MRI) to identify the primary tumor, thereby confirming the diagnosis and broadening treatment options., Methods: From 1995 to 2001, 69 patients at our institution presented with occult primary breast cancer. All patients had negative breast examinations and mammograms and underwent breast MRI., Results: Of 69 patients, 55 had axillary adenopathy without evidence of distant disease (stage II); 14 had stage IV disease. In patients with stage II disease, MRI revealed suspicious lesions in 76% (42 of 55). In 62% (26 of 42), the MRI finding proved to be the occult primary tumor. Of these, 58% (15 of 26) were candidates for breast conservation. MRI did not identify the primary tumor in 25 women; 12 underwent mastectomy. Cancer was found in 33% (4 of 12) of these. Thirteen patients were treated with primary breast irradiation; three were lost to follow-up, one developed distant disease, and nine were without evidence of disease with a median follow-up of 4.5 years. In women with stage IV disease, MRI identified the primary tumor in 5 of 9 patients with regional adenopathy and 2 of 5 patients with distant disease (overall 50%; 7 of 14). MRI identified the primary tumor in women with both mammographically dense (19 of 44; 43%) and less dense (10 of 20; 50%) breasts., Conclusions: Breast MRI detects mammographically occult cancer in half of women with axillary metastases, regardless of breast density. MRI is a powerful tool for stage II and stage IV patients with occult primary breast cancer.

Objective: The purpose of this study was to determine the prevalence and positive predictive value of ductal enhancement among MR imaging-detected breast lesions that had biopsy and to assess the histologic findings associated with ductal enhancement., Materials and Methods: Retrospective review was performed of 427 nonpalpable, mammographically occult lesions that had MR imaging-guided needle localization and surgical biopsy. Lesions were reviewed by one radiologist who was unaware of the histologic outcomes and were classified according to a standardized lexicon. MR imaging and histologic findings of ductal enhancing lesions were reviewed., Results: Ductal enhancement accounted for 88 (21%) of 427 lesions and 88 (59%) of 150 nonmass lesions. Histologic finding in these 88 lesions were ductal carcinoma in situ (DCIS) in 18 (20%); infiltrating carcinoma in five (6%), including three with DCIS; lobular carcinoma in situ (LCIS) in nine (10%); atypical ductal hyperplasia in eight (9%); and benign in 48 (55%). Among the 48 benign lesions, the dominant histologic findings were fibrocystic change (n = 16); ductal hyperplasia (n = 8); fibrosis (n = 8); postbiopsy change (n = 5); benign breast tissue (n = 3); sclerosing adenosis (n = 2); and single cases of fibroadenoma, fibroadenomatoid change, lymph node, mastitis, papilloma, and radial scar. Factors associated with a trend toward a higher frequency of carcinoma included clumped enhancement (p = 0.05) and synchronous ipsilateral cancer (p = 0.07)., Conclusion: Ductal enhancement accounted for 21% of MR imaging-detected lesions that had biopsy and had a positive predictive value of 26%. Differential diagnosis of ductal enhancement includes carcinoma (usually DCIS); atypical ductal hyperplasia; LCIS; and benign findings such as fibrocystic change, ductal hyperplasia, and fibrosis.

The purpose of this study was to determine whether different histologic findings are obtained from different areas of breast masses seen on mammography when targeted on stereotactic breast biopsy. Twenty-one masses (mean size, 1.8 cm; range, 0.7-5.5 cm) underwent stereotactic biopsy using a 14-gauge directional vacuum-assisted biopsy probe (Mammotome, Biopsys/Ethicon Endo-Surgery, Cincinnati, OH). The central and peripheral areas of the mass were targeted and biopsied separately, and histologic findings from the targeted center and periphery were compared. Six of 21 masses (29%) were heterogeneous, yielding different histologic results from the targeted center and periphery. In 4 heterogeneous masses, which constituted 4 of 21 masses (19%) in this study, surgical biopsy was recommended on the basis of findings obtained from only the center (n = 2) or the periphery (n = 2). Stereotactic biopsy findings in these 4 masses were atypia in 3 and radial scar in 1; none of these 4 masses had carcinoma at surgery. In all 4 masses that proved to be malignant, the diagnosis of carcinoma was made in specimens obtained from both the targeted center and the periphery of the mass. Breast masses can be heterogeneous, yielding different histologic findings from different areas of the mass. Our data suggest that sampling part but not all of a mass may miss certain histologic components of the mass, but should not result in a failure to diagnose carcinoma.

System design and initial results are presented from a new unilateral MR-guided breast lesion localization and core biopsy system. Over 150 imaging studies, an accuracy study on phantoms with 50 localization wire deployments and 33 core biopsy trials, and 19 clinical procedures are reported. The mean spatial accuracy from the lesion center for a 20-gauge (G) needle (N = 13) was within 1.2 +/- 1.4 mm (SD) and for a 14G biopsy (N = 4) 0.8 +/- 1.1 mm. For sampling using a 16G core through a 14G needle, the mean accuracy was 5.6 mm (N = 2). The needle guide geometry imposed a small, calculable targeting error. For phantom measurements using the 20G device, the mean geometry-induced error was 0.73 +/- 0.43 mm. However, this contribution was, on average, 42% of the mean measured 2.35 +/- 1.65 mm offset. The new device design provided an accurate and simple guidance method for localization or core biopsy of MR-visible breast lesions., (Copyright 2001 Wiley-Liss, Inc.)

Objective: The objective of this study was to evaluate the learning curve for stereotactic breast biopsy., Materials and Methods: Retrospective review was performed of 923 consecutive lesions that underwent stereotactic breast biopsy performed by one of six radiologists. Four hundred fourteen lesions had 14-gauge automated core biopsy, and 509 subsequent lesions had vacuum-assisted biopsy (14-gauge in 163 and 11-gauge in 346). Medical records were reviewed to determine the technical success rate and false-negative rate as a function of operator experience., Results: For 14-gauge automated core biopsy, a significantly lower technical success rate was seen for the first five cases of each radiologist than for subsequent cases (25/30 = 83.3% versus 366/384 = 95.3%, p < 0.02) and for the first 20 cases than for subsequent cases (90/100 = 90% versus 284/296 = 95.9%, p < 0.05). For 11-gauge vacuum-assisted biopsy, a significantly lower technical success rate was seen for the first five cases than for subsequent cases (17/20 = 85.0% versus 310/322 = 96.3%, p < 0.05) and for the first 15 cases than for subsequent cases (54/60 = 90.0% versus 273/283 = 96.5%, p = 0.03). The false-negative rate was higher for the first 15 cases compared with subsequent cases both for stereotactic 14-gauge automated core biopsy (4/31 = 12.9% versus 3/115 = 2.6%, p < 0.04) and for stereotactic 11-gauge vacuum-assisted biopsy (2/27 = 7.4% versus 0/85 = 0%, p < 0.06)., Conclusion: A learning curve exists for stereotactic breast biopsy. Significantly higher technical success rates and lower false-negative rates were observed after the first five to 20 cases for 14-gauge automated core biopsy and after the first five to 15 cases for 11-gauge vacuum-assisted biopsy. Even after a radiologist has experience with stereotactic biopsy, changes in equipment may result in a new learning curve.

Background: The purpose of the current study was to determine the frequency of imaging-histologic discordance at percutaneous breast biopsy and to assess the likelihood of carcinoma in these discordant lesions., Methods: Percutaneous imaging guided breast biopsy was performed on 1785 consecutive lesions during a 7-year period under stereotactic (n = 1205) or sonographic (n = 580) guidance, using an automated needle (n = 1044) or directional vacuum-assisted probe (n = 741). Lesions were prospectively classified according to the Breast Imaging Reporting and Data System (BI-RADS) as Category 3 (probably benign), Category 4 (suspicious), or Category 5 (highly suggestive of malignancy). Imaging-histologic discordance was considered to have occurred when the percutaneous biopsy histology did not provide a sufficient explanation for the imaging features; in such cases, repeat biopsy was recommended. Medical records, imaging studies, and histologic findings were reviewed., Results: Imaging-histologic discordance was present in 56 of 1785 (3.1%) lesions. The frequency of discordance was significantly higher in our first 2 years of experience with percutaneous biopsy than in later years (18 of 361 = 5.0% vs. 38 of 1424 = 2.7%; P < 0.04) and was significantly higher for lesions that were BI-RADS Category 5 rather than BI-RADS Category 4 (20 of 416 = 4.8% vs. 36 of 1366 = 2. 6%; P < 0.04). The frequency of discordance was significantly lower with the 11-gauge vacuum-assisted probe than other devices for calcifications (7 of 414 = 1.7% vs. 16 of 251 = 6.8%; P = 0.001) but not for masses (6 of 161 = 3.7% vs. 26 of 959 = 2.7%; P = 0.44). Repeat biopsy, performed in 45 discordant lesions revealed carcinoma in 11 (24.4%; 95% confidence intervals, 12.9-39.5%). The frequency of carcinoma was significantly higher among discordant BI-RADS Category 5 than discordant BI-RADS Category 4 lesions (7 of 16 = 43. 8% vs. 4 of 29 = 13.7%; P < 0.04)., Conclusions: Imaging-histologic discordance occurred in 3.1% of lesions that had percutaneous breast biopsy. Imaging-histologic discordance was an indication for surgical excision because of the high (24.4%) prevalence of carcinoma in these lesions., (Copyright 2000 American Cancer Society.)

Objective: Displaced epithelial fragments at percutaneous biopsy of ductal carcinoma in situ (DCIS) may mimic stromal invasion. This study was undertaken to determine the frequency of epithelial displacement in DCIS lesions of patients who underwent stereotactic 11-gauge directional vacuum-assisted breast biopsy., Materials and Methods: We retrospectively reviewed 28 consecutive DCIS lesions in patients who underwent stereotactic 11-gauge directional vacuum-assisted breast biopsy followed by surgery. Surgical specimens were examined for histologic evidence of epithelial displacement, consisting of fragments of epithelium in artifactual spaces in breast parenchyma or in lymphovascular channels, accompanied by hemorrhage, fat necrosis, inflammation, hemosiderin-laden macrophages, or granulation tissue., Results: The median number of specimens obtained per lesion was 14 (range, seven to 45). The median interval from stereotactic biopsy to surgery was 27 days (range, 10-59 days). Surgery revealed DCIS in 19 (68%) of 28 lesions, DCIS and infiltrating carcinoma in four lesions (14%), and no residual carcinoma in five lesions (18%). Reactive changes at the biopsy site were identified in all cases. Displacement of benign epithelium into granulation tissue at the stereotactic biopsy site was identified in two cases (7%). We found no evidence of displacement of malignant epithelium., Conclusion: Epithelial displacement is uncommon after stereotactic 11-gauge directional vacuum-assisted biopsy of the breast. We observed displacement of benign epithelium in two (7%) of 28 DCIS lesions and no displacement of malignant epithelium.

Objective: This study was undertaken to assess the accuracy of percutaneous large-core biopsy in evaluating papillary breast lesions., Materials and Methods: A retrospective review of imaging-guided large-core breast biopsy of 1077 consecutive lesions revealed that papillary lesions were diagnosed in 34 (3%) cases. Surgical correlation (n = 22) or minimum 2 years' mammographic follow-up (n = 4) were available for 26 papillary lesions. Mammographic and histologic findings in these 26 cases were reviewed., Results: Percutaneous biopsy histology had benign findings in nine lesions, atypical in 10, and malignant in seven. Of seven lesions yielding benign papilloma at percutaneous biopsy, none (0%) had carcinoma at surgery or mammographic follow-up. Surgery revealed carcinoma in one of two lesions yielding papillomatosis at percutaneous biopsy. This lesion was a spiculated mass; surgical biopsy, recommended because of mammographic-histologic discordance, revealed a radial sclerosing lesion and ductal carcinoma in situ (DCIS). Of 10 papillary lesions with atypical ductal hyperplasia at percutaneous biopsy, surgery revealed DCIS in three (30%). Of seven lesions in which percutaneous biopsy yielded papillary DCIS, surgery revealed DCIS in all seven; three (43%) also had invasive carcinoma., Conclusion: Among our patients, diagnosis by percutaneous core biopsy of benign papillary lesions proved to be accurate when concordant with imaging findings. Surgical excision was indicated when diagnosis by percutaneous biopsy revealed atypical papillary lesions or papillary DCIS. A larger series with longer follow-up is required to assess the clinical course of benign papillary lesions without atypia that are not excised after percutaneous large-core breast biopsy.

Purpose: To determine the frequency with which ultrasonographically (US) guided core biopsy obviated diagnostic surgical biopsy of nonpalpable breast masses, to calculate the cost savings of diagnosis attributable to US-guided core biopsy, and to compare the costs of US-guided versus stereotactically guided core biopsy., Materials and Methods: US-guided core biopsy was performed in 151 consecutive solitary, nonpalpable breast masses in 151 women (age range, 23-80 years) by using a 14-gauge automated gun and needle. Clinical follow-up data were obtained. Cost savings were assessed by using national Medicare reimbursement costs of +385 for US-guided core biopsy, +610 for stereotactic core biopsy, and +1,332 for needle localization and surgical biopsy., Results: US-guided core biopsy obviated a surgical procedure in 128 (85%) of 151 women. The mean adjusted direct cost saving per US-guided core biopsy was +744 per case. Use of US-guided biopsy decreased the cost of diagnosis by 56% (+744/+1,332) over the cost of surgical biopsy. If biopsy had been performed with stereotactic rather than with US guidance, the mean adjusted direct cost saving would have been +519 per case, a 39% (+519/1,332) decrease in the cost of diagnosis compared with the cost of surgical biopsy., Conclusion: Percutaneous biopsy of a nonpalpable breast mass with either US or stereotactic guidance is less expensive than surgery, but cost savings are greater with US-guided biopsy.

Purpose: To determine whether complete percutaneous removal of a malignant lesion detected at mammography ensures complete excision of the carcinoma histopathologically., Materials and Methods: A retrospective review was performed of 135 lesions in which stereotactic biopsy was performed with a directional, vacuum biopsy instrument and an 11-gauge probe followed by mammography. Carcinoma was diagnosed at stereotactic biopsy in 51 (38%) lesions. In 15 (29%) carcinomas, the lesion seen at mammography was removed at stereotactic biopsy. Surgical findings were available for correlation with biopsy and imaging findings in all 15 cases. Mammographic and histopathologic findings were reviewed., Results: Mammographic findings were calcifications in 11 lesions and a mass in four lesions. The median lesion size was 0.7 cm (range, 0.2-1.4 cm), and the median number of biopsy specimens was 15 (range, 10-22 specimens). Histopathologic findings at stereotactic biopsy were ductal carcinoma in situ in 12 lesions and infiltrating ductal carcinoma in three. Surgery revealed residual carcinoma in 11 (73%) of 15 lesions, including all three infiltrating ductal carcinomas and eight of 12 ductal carcinoma in situ lesions., Conclusion: Complete removal of the mammographic lesion does not ensure complete excision of the carcinoma.

Purpose: To evaluate the utility of contrast material-enhanced magnetic resonance (MR) imaging of the breast for localization of the site of primary breast carcinoma in patients with isolated ipsilateral axillary metastasis, without other focal findings at physical examination or mammography., Materials and Methods: Twelve women with biopsy-proved metastatic adenocarcinoma to axillary lymph nodes and occult primary tumor underwent MR imaging at 1.5 T with a three-dimensional spoiled gradient-echo pulse sequence before and after administration of gadopentetate dimeglumine. Enhancing areas were correlated with histopathologic findings at mastectomy (n = 8) or breast-conserving treatment (n = 4)., Results: In nine (75%) of the 12 patients, enhancement was seen on MR images that represented the site of the primary tumor at surgery. Eight had focal masses, and one had an area of regional enhancement. Two patients had negative MR findings, and no tumor was found at mastectomy. One patient with regional enhancement on MR images had no corresponding tumor at surgery., Conclusion: Breast MR imaging enables identification of the site of primary tumor in most patients suspected of having occult primary breast cancer, and MR findings can influence surgical treatment.

Purpose: To assess accuracy and usefulness of placement of a localizing clip after stereotactic, vacuum-assisted breast biopsy., Materials and Methods: Retrospective review was performed of 57 lesions that underwent placement of a localizing clip after stereotactic vacuum-assisted biopsy with an 11-gauge (n = 42) or 14-gauge (n = 15) probe. The clip was placed when images obtained after stereotactic biopsy suggested that the lesion seen at mammography was removed. Coordinates of the clip on stereotactic images obtained after placement were compared with lesion coordinates determined before biopsy. Surgery was performed in 25 cases. Mammographic and histopathologic findings were reviewed., Results: The distance from clip to lesion site was less than 1 cm in 40 (95%) of 42 lesions that underwent clip placement with the 11-gauge probe versus 11 (73%) of 15 lesions that underwent clip placement after 14-gauge biopsy (P < .04). The biopsy site was identified in the surgical specimen in 19 (100%) lesions with clips after 11-gauge biopsy and five (83%) of six lesions with clips after 14-gauge biopsy. No complications occurred., Conclusion: A localizing clip can be placed in proximity to the stereotactic biopsy site through an 11-gauge probe. Clip placement can enable accurate localization for surgical excision.

Purpose: To evaluate mammographic findings after stereotactic 14-gauge vacuum biopsy., Materials and Methods: Retrospective review was performed of results at stereotactic 14-gauge vacuum biopsy in 108 lesions in 100 women. The median number of specimens obtained per lesion was 12 (mean, 14; range, 1-50). In all cases, mammography was performed immediately after vacuum biopsy. Pre- and postbiopsy mammograms were reviewed., Results: Postbiopsy mammograms depicted air at the biopsy site in 78 (72%) of 108 lesions and hematoma in 65 (60%) of 108 lesions. Of 55 lesions depicted as calcifications, postbiopsy mammograms depicted a decrease in the number of calcifications in 45 (82%), including nine cases in which all calcifications were removed. No residual lesion was identified on postbiopsy mammograms in 14 (13%) of 108 lesions; 11 (58%) of 19 mammographic lesions that measured 0.5 cm or less in maximal dimension were completely removed. Nineteen patients underwent a needle localization procedure, at a median 14 days (range, 6-51 days) after vacuum biopsy. In one patient a hematoma was depicted at mammography 10 days after biopsy; in the remaining 18 (95%) patients, mammograms obtained during needle localization depicted no hematoma or air., Conclusion: Air and hematoma were often present on mammograms immediately after stereotactic vacuum biopsy, but these changes resolved rapidly. Stereotactic vacuum biopsy provided wide sampling of calcifications and allowed complete removal of the mammographic lesion in some cases.

Purpose: To evaluate the mammographic and histopathologic features of carcinomas not diagnosed at stereotactic core biopsy., Materials and Methods: A retrospective review revealed 144 surgically confirmed carcinomas preoperatively sampled with stereotactic core biopsy. Diagnosis at stereotactic core biopsy was carcinoma in 116 (81%) lesions, atypical hyperplasia in 21 (15%), and benign findings discordant with those from mammography in seven (5%). Mammographic and histopathologic findings in the latter 28 cases were reviewed., Results: Prompt repeat biopsy was recommended in all 28 cases. The frequency with which a cancer yielded atypical hyperplasia at stereotactic core biopsy was higher for calcifications than masses (30% vs 5%, P < .0001), ductal carcinoma in situ (DCIS) than infiltrating carcinoma (33% vs 7%, P = .0002), and noncomedo than comedo DCIS (60% vs 9%, P = .0008). No significant difference was observed in the likelihood of benign core biopsy findings without atypia in malignant calcifications versus masses (7% vs 3%, P = .43), DCIS versus infiltrating carcinoma (7% vs 4%, P = .43), or noncomedo versus comedo DCIS (0% vs 9%, P = .49)., Conclusion: The likelihood of not diagnosing carcinoma was highest for calcifications and for noncomedo DCIS. Discordance in mammographic and histopathologic findings or the presence of atypical hyperplasia may enable the radiologist to identify missed or underestimated carcinomas prospectively and avoid a delay in diagnosis.

Objective: The purpose of this study was to compare impalpable breast carcinomas revealed by core biopsy with those revealed by surgical biopsy with respect to the frequency of performing a single surgical procedure and finding tumor at the margins of the lumpectomy specimen., Materials and Methods: Retrospective review found 197 solitary impalpable breast carcinomas revealed by core biopsy using a 14-gauge needle (n = 90) or surgical biopsy after needle localization (n = 107). Lumpectomy was the surgical treatment in 62 (69%) of the 90 cancers revealed by core biopsy and in 74 (69%) of the 107 cancers revealed by surgical biopsy. Records were reviewed to determine the number and type of surgeries performed on each patient and the histopathologic findings at surgery. Lumpectomy margins were considered positive if tumor was present at the inked margins of a lumpectomy performed as a separate procedure after the diagnostic biopsy., Results: A single surgical procedure was performed 76 (84%) of the 90 patients who underwent core biopsy versus 31 (29%) of the 107 patients who underwent surgical biopsy. This difference was statistically significant (p < .00001). Tumor was present at the lumpectomy margins in five (8%) of the 62 cancers revealed by core biopsy versus four (5%) of the 74 cancers diagnosed by surgical biopsy. This difference was not statistically significant (p = .7)., Conclusion: A single surgical procedure was performed significantly more often in patients in whom impalpable breast cancer was revealed by core biopsy. The likelihood of obtaining tumor-free margins at lumpectomy did not differ significantly for cancers revealed by either method. These data indicate that core biopsy provides the information necessary to plan surgical treatment and could decrease the number of surgical procedures required in patients with impalpable breast cancer.

Objective: The purpose of this study was to evaluate the role of core biopsy in the diagnosis of multiple synchronous ipsilateral breast lesions and to determine the impact of this information on patients' management., Materials and Methods: Of 371 patients who underwent core-needle breast biopsy under stereotaxic (n = 278) or sonographic (n = 93) guidance, 20 (5%) underwent core biopsy of two mammographically separate lesions in the ipsilateral breast on the same date. Fourteen of these 20 patients subsequently underwent surgery. We retrospectively reviewed the medical, radiographic, and histopathologic records in these 14 patients and in 91 patients with single mammographic lesions diagnosed as carcinoma by means of core biopsy during the same period., Results: In 11 patients, core biopsy revealed two sites of carcinoma. Core biopsy findings in these 11 patients were two areas of infiltrating ductal carcinoma (n = 5), one infiltrating ductal carcinoma and one infiltrating lobular carcinoma (n = 2), one infiltrating ductal carcinoma and one ductal carcinoma in situ (n = 1), and two foci of ductal carcinoma in situ (n = 3). All 11 patients with two core biopsy-proven foci of carcinoma underwent mastectomy. Patients were significantly more likely to be treated with mastectomy if core biopsy revealed two rather than one site of carcinoma (100% versus 38%, p < .001)., Conclusion: Core-needle biopsy is useful in diagnosing multiple synchronous ipsilateral breast lesions. By showing whether carcinoma is present in one or more sites in the breast, core biopsy can provide information of critical importance in making treatment decisions.

Purpose: To determine the clinical implication of recommendation for repeat biopsy after large-core stereotaxic breast biopsy., Materials and Methods: Repeat biopsy was recommended in 56 (18%; mean age, 51.0 years) of 314 consecutive women who underwent stereotaxic core biopsy. Biopsy was performed by using a dedicated prone stereotaxic table and digital imaging. When calcifications were present, specimen radiography was performed. Fifty of the 56 women underwent follow-up biopsy., Results: Repeat biopsy was recommended because of ductal atypia in 30 patients, discordant imaging and histopathologic results in 15, diagnoses for which more tissue was required in 10, and radial scar in one. Twenty-two (39%) of the 56 had carcinoma. Carcinoma was detected in 15 women (50%) with ductal atypia and in seven women (47%) with discordant histopathologic and imaging findings. No other cancer was detected., Conclusion: Rebiopsy of those lesions for which results are nonconcordant or with a high incidence of coexistent malignancy is necessary for stereotaxic core biopsy to be optimally effective. Among the 56 patients, 39% had malignancy.