Search

This study aimed to investigate the effect of calcifications on shear-wave elastography in evaluating breast lesions. We retrospectively reviewed ultrasound images of 673 breast lesions and compared the elasticity between lesions with and without calcifications in three subgroups: benign lesions, in situ carcinomas and invasive carcinomas. Breast lesions were confirmed histologically (n = 401) or by follow-up images for more than 2 y (n = 272). Calcifications were present in 25.3% (170/673) of the lesions. The Emean values with and without calcifications, respectively, were as follows: 62.8 and 29.8 kPa in benign lesions (p = 0.000), 114.6 and 52.8 kPa in in situ carcinomas (p = 0.037) and 171.9 and 146.4 kPa in invasive carcinomas (p = 0.018). The presence of calcifications significantly increased the Emean of breast lesions. Shear-wave elastography should be carefully interpreted in benign lesions with calcifications and in situ carcinomas without calcifications.

We studied the relationship between breast ultrasound background echotexture (BET) and magnetic resonance imaging (MRI) background parenchymal enhancement (BPE) and whether this relationship varied with hormonal status and amount of fibroglandular tissue (FGT) on MRI. Two hundred eighty-three Korean women (52.1 years; range = 27-79 years) with newly diagnosed primary breast cancer who underwent preoperative breast ultrasound and MRI were retrospectively studied. Background echotexture, BPE, and FGT were classified into 4 categories, and age, menopausal status, menstrual cycle regularity, and menstrual cycle stage at MRI were recorded. Background echotexture and BPE relationship was assessed overall, and in menopausal, FGT, menstrual cycle regularity, and menstrual cycle stage subgroups. Background echotexture and BPE correlated in women overall, and menopausal, FGT, and menstrual cycle subgroups and those in the first half of the cycle (all P < 0.001). Background echotexture reflects BPE, regardless of menopausal status, menstrual cycle regularity, and FGT and may be a biomarker of breast cancer risk.

Purpose Interest in unenhanced magnetic resonance imaging (MRI) screening for breast cancer is growing due to concerns about gadolinium deposition in the brain and the high cost of contrast-enhanced MRI. The purpose of this report is to describe the protocol of the Diffusion-Weighted Magnetic Resonance Imaging Screening Trial (DWIST), which is a prospective, multicenter, intraindividual comparative cohort study designed to compare the performance of mammography, ultrasonography, dynamic contrast-enhanced (DCE) MRI, and diffusion-weighted (DW) MRI screening in women at high risk of developing breast cancer. Methods A total of 890 women with BRCA mutation or family history of breast cancer and lifetime risk ≥ 20% are enrolled. The participants undergo 2 annual breast screenings with digital mammography, ultrasonography, DCE MRI, and DW MRI at 3.0 T. Images are independently interpreted by trained radiologists. The reference standard is a combination of pathology and 12-month follow-up. Each image modality and their combination will be compared in terms of sensitivity, specificity, accuracy, positive predictive value, rate of invasive cancer detection, abnormal interpretation rate, and characteristics of detected cancers. The first participant was enrolled in April 2019. At the time of manuscript submission, 5 academic medical centers in South Korea are actively enrolling eligible women and a total of 235 women have undergone the first round of screening. Completion of enrollment is expected in 2022 and the results of the study are expected to be published in 2026. Discussion DWIST is the first prospective multicenter study to compare the performance of DW MRI and conventional imaging modalities for breast cancer screening in high-risk women. DWIST is currently in the patient enrollment phase. Trial registration ClinicalTrials.gov Identifier: NCT03835897.

Background Data are limited regarding the performance of abbreviated screening breast MRI during consecutive years and the characteristics of breast cancers missed and detected with it. Purpose To assess the longitudinal diagnostic performance of abbreviated screening MRI and to determine whether the screening outcomes of abbreviated MRI differed between yearly time periods for 3 consecutive years. Materials and Methods This retrospective study included 1975 consecutive women who underwent abbreviated screening MRI between September 2015 and August 2018. Breast Imaging Reporting and Data System (BI-RADS) categories 3-5 defined positive results, and BI-RADS categories 1-2 defined negative results. Cancer detection rate (CDR), sensitivity, specificity, positive predictive value (PPV), abnormal interpretation rate (AIR), and interval cancer rate were assessed annually. Yearly performance measures were compared with the Fisher exact test by using the permutation method. Clinical-pathologic and imaging characteristics of the missed and detected cancers were compared by using the Fisher exact test and the Wilcoxon rank sum test. Results A total of 1975 women (median age, 49 years; interquartile range, 44-56 years) underwent 3037 abbreviated MRI examinations over 3 years. CDR (year 1 to year 3, 6.9-10.7 per 1000 examinations), positive predictive value for recall (9.7% [six of 62] to 15.6% [12 of 77]), positive predictive value for biopsy (31.6% [six of 19] to 63.2% [12 of 19]), sensitivity (75.0% [six of eight] to 80.0% [12 of 15]), and specificity (93.5% [807 of 863] to 94.1% [1041 of 1106]) were highest in year 3, and AIR (7.1% [62 of 871] to 6.9% [77 of 1121]) was lowest in year 3. However, all outcome measures did not differ statistically between years 1, 2, and 3 (all P > .05). The interval cancer rate was 0.66 per 1000 examinations (two of 3037). Thirty-eight breast cancers were identified in 36 women; 29 were detected with abbreviated MRI, but nine were missed. Of these, seven were detected with other imaging modalities after negative results at the last screening MRI examination, and two were interval cancers. All missed cancers were node-negative early-stage invasive cancers and were smaller (median size, 0.8 cm vs 1.2 cm; P = .01) than detected cancers. Conclusion Screening outcome measures of abbreviated MRI were sustained without significant differences between 3 consecutive years. All cancers missed at abbreviated MRI were node-negative invasive cancers and tended to be smaller than detected cancers. © RSNA, 2021 See also the editorial by Lee in this issue. Online supplemental material is available for this article.

A major limitation of screening breast ultrasound (US) is a substantial number of false-positive biopsy. This study aimed to develop a deep learning-based computer-aided diagnosis (DL-CAD)-based diagnostic model to improve the differential diagnosis of screening US-detected breast masses and reduce false-positive diagnoses. In this multicenter retrospective study, a diagnostic model was developed based on US images combined with information obtained from the DL-CAD software for patients with breast masses detected using screening US; the data were obtained from two hospitals (development set: 299 imaging studies in 2015). Quantitative morphologic features were obtained from the DL-CAD software, and the clinical findings were collected. Multivariable logistic regression analysis was performed to establish a DL-CAD-based nomogram, and the model was externally validated using data collected from 164 imaging studies conducted between 2018 and 2019 at another hospital. Among the quantitative morphologic features extracted from DL-CAD, a higher irregular shape score (P = .018) and lower parallel orientation score (P = .007) were associated with malignancy. The nomogram incorporating the DL-CAD-based quantitative features, radiologists’ Breast Imaging Reporting and Data Systems (BI-RADS) final assessment (P = .014), and patient age (P P P P = .317 in the development cohort; each 100% in the validation cohort). In conclusion, the proposed model showed good performance for differentiating screening US-detected breast masses, thus demonstrating a potential to reduce unnecessary biopsies.

With the increase in the number of cases of silicone implant insertion either for cosmetic surgery or breast reconstruction after mastectomy, it is not unusual to encounter patients with silicone implants in clinical settings. Recently, the first case of breast implant-associated anaplastic large cell lymphoma was reported in Korea. In addition to previously known complications, such as implant rupture or contracture, the number of implant-associated imaging examinations has also increased. Considering this background, radiologists should have sufficient knowledge about the type of examination required in patients who have undergone implant insertion and imaging findings to correctly identify implant-associated complications. In this article, various complications of silicone implants are discussed, including various imaging findings, which radiologists should know.

Rationale and objectives: To evaluate the diagnostic performance of abbreviated screening breast magnetic resonance imaging (AB-MRI) for screening in women with previously treated breast cancer. Materials and methods: This retrospective study included consecutive AB-MRI from September 2015 to December 2016 in patients with previously treated breast cancer. Longitudinal medical record of patients’ demographics, outcomes of imaging surveillance and results of biopsy was reviewed. Protocol consisted of T2-weighted scanning and dynamic contrast-enhanced imaging including one pre-contrast and two post-contrast scans. A positive examination was defined as final assessment of BI-RADS 4 or 5 and negative was defined as BI-RADS 1, 2, or 3. Abnormal interpretation rate, cancer detection rate (CDR), sensitivity, specificity, accuracy, positive predictive value (PPV), and negative predictive value (NPV) were analyzed. Results: Among total 1043 AB-MRI, 29 (2.8%) AB-MRI had suspicious findings including 26 (2.5%) BI-RADS 4 and 3 (0.3%) BI-RADS 5 assessments. CDR was 9.59 per 1000. Performance outcomes were as follows: sensitivity, 71.4%; specificity, 98.2%; accuracy, 97.8%; PPV 1, 35.7%; PPV3 50%; and NPV 99.6%. Four cancers with false negative MRI were all early cancers of

Purpose: To develop a radiomics signature based on preoperative MRI to estimate disease-free survival (DFS) in patients with invasive breast cancer and to establish a radiomics nomogram that incorporates the radiomics signature and MRI and clinicopathological findings. Experimental Design: We identified 294 patients with invasive breast cancer who underwent preoperative MRI. Patients were randomly divided into training (n = 194) and validation (n = 100) sets. A radiomics signature (Rad-score) was generated using an elastic net in the training set, and the cutoff point of the radiomics signature to divide the patients into high- and low-risk groups was determined using receiver-operating characteristic curve analysis. Univariate and multivariate Cox proportional hazards model and Kaplan–Meier analysis were used to determine the association of the radiomics signature, MRI findings, and clinicopathological variables with DFS. A radiomics nomogram combining the Rad-score and MRI and clinicopathological findings was constructed to validate the radiomic signatures for individualized DFS estimation. Results: Higher Rad-scores were significantly associated with worse DFS in both the training and validation sets (P = 0.002 and 0.036, respectively). The radiomics nomogram estimated DFS [C-index, 0.76; 95% confidence interval (CI); 0.74–0.77] better than the clinicopathological (C-index, 0.72; 95% CI, 0.70–0.74) or Rad-score–only nomograms (C-index, 0.67; 95% CI, 0.65–0.69). Conclusions: The radiomics signature is an independent biomarker for the estimation of DFS in patients with invasive breast cancer. Combining the radiomics nomogram improved individualized DFS estimation. Clin Cancer Res; 24(19); 4705–14. ©2018 AACR.

Purpose To evaluate the value of preoperative axillary ultrasonography (US) for preventing unnecessary axillary lymph node dissection after sentinel lymph node (SLN) biopsy in a large series of patients with early-stage breast cancers treated with both breast-conserving surgery and SLN biopsy. Materials and Methods From March 2009 to February 2013, 1802 patients who underwent breast-conserving surgery for clinical T1-2/N0 cancers and SLN biopsy with or without axillary lymph node dissection were included. Preoperative axillary US results and clinical-pathologic variables were compared according to the status of non-SLN metastasis. Multivariate logistic regression analysis was performed to find factors associated with non-SLN metastasis. Results Of 1802 patients, 397 (22.0%) underwent axillary lymph node dissection due to positive SLN biopsy and 76 (4.2%) had non-SLN metastasis at final histopathologic examination. Patients with non-SLN metastasis were younger and showed positive axilla at US and clinical T2 stage more frequently (P < .05). At multivariate analysis, positive axilla at US (P = .001), clinical T2 stage (P = .005), and lymphovascular invasion (P < .001) were significantly associated with non-SLN metastasis. Among 1284 patients with negative axilla at US and clinical T1 stage cancer, 1254 (97.7%) did not have non-SLN metastasis and 30 (2.3%) had non-SLN metastasis. Conclusion Preoperative axillary US results and clinical T stage are associated with the status of non-SLN metastasis in patients with early breast cancer. The results of this study suggest that preoperative axillary US can help select patients at minimal risk of non-SLN metastasis, for whom axillary lymph node dissection can be omitted. © RSNA, 2018 Online supplemental material is available for this article.

To compare the performance of synthetic mammography (SM) and digital mammography (DM) with digital breast tomosynthesis (DBT) or alone for the evaluation of microcalcifications. This retrospective study includes 198 mammography cases, all with DM, SM, and DBT images, from January to October 2013. Three radiologists interpreted images and recorded the presence of microcalcifications and their conspicuity scores and final BI-RADS categories (1, 2, 3, 4a, 4b, 4c, 5). Readers' area under the ROC curves (AUCs) were analyzed for SM plus DBT vs. DM plus DBT and SM alone vs. DM alone using the BI-RADS categories for the overall group and dense breast subgroup. Conspicuity scores of detected microcalcifications were neither significantly different between SM and DM with DBT nor alone (p>0.05). In predicting malignancy of detected microcalcifications, no significant difference was found between readers' AUCs for SM and DM with DBT or alone in the overall group or dense breast subgroup (p>0.05). Diagnostic performances of SM and DM for the evaluation of microcalcifications are not significantly different, whether performed with DBT or alone. • In DBT-imaging, SM and DM show comparable performances when evaluating microcalcifications. • For BI-RADS classification of microcalcifications, SM and DM show similar AUCs. • DBT with SM may be sufficient for diagnosing microcalcifications, without DM.

Background Ultrasonography (US) is an important tool to evaluate the status of internal mammary lymph node (IMN). US features of metastatic IMNs could help determine when biopsy should be performed. Purpose To compare US features of metastatic IMNs to those of benign entities. Material and Methods In women with suspected IMN metastasis on US, their intercostal space (ICS) abnormalities were classified into metastatic IMN, benign IMN, and lymph node (LN) mimickers. US features, distribution, and depth of abnormalities in one ICS and involved ICS level were analyzed. Results Among 66 ICS abnormalities in 53 women, 46 were metastatic IMNs, ten were benign IMNs, and ten were LN mimickers. For metastatic IMNs, the second ICS was the most commonly involved ICS (n = 22), followed by the first (n = 13), the third (n = 8), and the fourth (n = 3). ICS level distribution of metastatic IMNs was not significantly ( P = 0.5407) different from that of non-metastatic lesions. Metastatic IMNs were predominantly seen in the posterior layer of ICS, significantly ( P Conclusion Metastatic IMNs are more likely to be found in the posterior layer of ICS. This can help distinguish them from LN mimickers. Any part (upper, middle, or lower) of one ICS in craniocaudal direction could be involved. The second ICS was the most commonly involved level.

Purpose To determine the relationship between tumor heterogeneity assessed by means of magnetic resonance (MR) imaging texture analysis and survival outcomes in patients with primary breast cancer. Materials and Methods Between January and August 2010, texture analysis of the entire primary breast tumor in 203 patients was performed with T2-weighted and contrast material-enhanced T1-weighted subtraction MR imaging for preoperative staging. Histogram-based uniformity and entropy were calculated. To dichotomize texture parameters for survival analysis, the 10-fold cross-validation method was used to determine cutoff points in the receiver operating characteristic curve analysis. The Cox proportional hazards model and Kaplan-Meier analysis were used to determine the association of texture parameters and morphologic or volumetric information obtained at MR imaging or clinical-pathologic variables with recurrence-free survival (RFS). Results There were 26 events, including 22 recurrences (10 local-regional and 12 distant) and four deaths, with a mean follow-up time of 56.2 months. In multivariate analysis, a higher N stage (RFS hazard ratio, 11.15 [N3 stage]; P = .002, Bonferroni-adjusted α = .0167), triple-negative subtype (RFS hazard ratio, 16.91; P.001, Bonferroni-adjusted α = .0167), high risk of T1 entropy (less than the cutoff values [mean, 5.057; range, 5.022-5.167], RFS hazard ratio, 4.55; P = .018), and T2 entropy (equal to or higher than the cutoff values [mean, 6.013; range, 6.004-6.035], RFS hazard ratio = 9.84; P = .001) were associated with worse outcomes. Conclusion Patients with breast cancers that appeared more heterogeneous on T2-weighted images (higher entropy) and those that appeared less heterogeneous on contrast-enhanced T1-weighted subtraction images (lower entropy) exhibited poorer RFS.

PURPOSE To analyze the malignancy rate of ultrasound-guided core needle biopsy (US-CNB) for screen-detected breast lesions and to evaluate the results according to the mode of detection of the target lesions. METHODS This is a retrospective review of 703 consecutive women who underwent US-CNB for screen-detected breast lesions at a single tertiary hospital. Breast Imaging Reporting and Data System (BI-RADS) categories and histopathological results of the target lesions were assessed. The cases were divided into two groups: the mammography-based detected lesions (M-group) and the US-based detected lesions (U-group). The biopsy performances of the two groups were compared using the χ2 test. RESULTS The malignancy rate in the entire population was 22.0%: 0.8%, 12.3%, 65.2%, 89.3%, and 94.6% in BI-RADS categories 3, 4A, 4B, 4C, and 5, respectively. The malignancy rate was significantly higher in the M-group (54.1% [79/146]) than in the U-group (13.6% [76/557]) (p < 0.001). BI-RADS category 3 was the most common assessment overall that led to a US-CNB (362/703, 51.5%) and the rate of BI-RADS category 3 diagnoses that led to US-CNB was significantly higher in the U-group (p < 0.001). CONCLUSIONS The malignancy rate associated with US-CNB for screen-detected breast lesions was 22.0%. The breast lesions detected by mammography have a higher malignancy rate than those detected by US. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 45:261-266, 2017.

To investigate factors related to false shear wave elastography (SWE) results for breast non-mass lesions (NMLs) detected by B-mode US. This retrospective study enrolled 152 NMLs detected by B-mode US and later pathologically confirmed (79 malignant, 73 benign). All lesions underwent B-mode US and SWE. Quantitative (mean elasticity [E mean]) and qualitative (maximum stiffness colour) SWE parameters were assessed, and ‘E mean > 85.1 kPa’ or ‘stiff colour (green to red)’ determined malignancy. Final SWE results were matched to pathology results. Multivariate logistic regression analysis identified factors associated with false SWE results for diagnosis of breast NMLs. Associated calcifications (E mean: odds ratio [OR] = 7.60, P

Objective: To compare the diagnostic performance of breast MRI with abbreviated protocol (AB-MRI) and full ddiagnostic protocol (FDP-MRI) for surveillance of females with a personal history of breast cancer Methods: In this retrospective study, we analyzed the outcomes of total 1312 post-operative screening breast MRI matched from 1045 AB-MRI and 677 FDP-MRI, which had histologic confirmation for suspicious MRI findings or 1 year negative follow-up images. This study was approved by the institutional review board and informed patient consent was waved. AB-MRI consists of T2 weighted scanning and dynamic contrast-enhanced imaging including one pre-contrast and two post-contrast scans. We compared the diagnostic performance for recurrent breast cancer in terms of sensitivity, specificity, positive-predictive value, negative-predictive value, and accuracy and area under the curve between the screening AB-MRI and FDP-MRI. Results: Overall, 13 recurrent tumors among 1312 post-operative cases screened with breast MRI (1.0%) were detected including 8 invasive cancer, 2 cases of in situ cancer, and 3 cases of metastatic lymph nodes. The sensitivity and negative predictive value were 70 vs 100 and 99.5% vs 100% in AB-MRI and FDP-MRI. Specificity, positive predictive value, accuracy, and area under the curve of AB-MRI and FDP-MRI were 98.0% vs 96.9%, 35.0% vs 23.1%, 97.6% vs 97.0%, and 0.840 vs 0.985, respectively. Conclusion: The performance of AB-MRI was comparable to that of FDP-MRI in detecting recurrent breast cancer and decreased false positive cases. Advances in knowledge: AB-MRI provides a reliable alternative with similar diagnostic performance and shorter MRI acquisition time.

Summary: Background: Mammography is the current standard for breast cancer screening. This study aimed to develop an artificial intelligence (AI) algorithm for diagnosis of breast cancer in mammography, and explore whether it could benefit radiologists by improving accuracy of diagnosis. Methods: In this retrospective study, an AI algorithm was developed and validated with 170 230 mammography examinations collected from five institutions in South Korea, the USA, and the UK, including 36 468 cancer positive confirmed by biopsy, 59 544 benign confirmed by biopsy (8827 mammograms) or follow-up imaging (50 717 mammograms), and 74 218 normal. For the multicentre, observer-blinded, reader study, 320 mammograms (160 cancer positive, 64 benign, 96 normal) were independently obtained from two institutions. 14 radiologists participated as readers and assessed each mammogram in terms of likelihood of malignancy (LOM), location of malignancy, and necessity to recall the patient, first without and then with assistance of the AI algorithm. The performance of AI and radiologists was evaluated in terms of LOM-based area under the receiver operating characteristic curve (AUROC) and recall-based sensitivity and specificity. Findings: The AI standalone performance was AUROC 0·959 (95% CI 0·952–0·966) overall, and 0·970 (0·963–0·978) in the South Korea dataset, 0·953 (0·938–0·968) in the USA dataset, and 0·938 (0·918–0·958) in the UK dataset. In the reader study, the performance level of AI was 0·940 (0·915–0·965), significantly higher than that of the radiologists without AI assistance (0·810, 95% CI 0·770–0·850; p

To develop a classification system using imaging features to interpret breast non-mass lesions (NMLs) detected on US and to stratify their cancer risk. This retrospective study included 715 patients with 715 breast NMLs detected on breast US from 2012 to 2016. Each patient underwent mammography at the time of diagnosis. Radiologists assessed US and mammographic features and final BI-RADS categories. Multivariable logistic regression was used to find imaging features associated with malignancy in a development dataset (n = 460). A system to classify BI-RADS categories (3 to 5) was developed based on the odds ratios (ORs) of imaging features significantly associated with malignancy and validated in a distinct validation dataset (n = 255). Among 715 NMLs, 385 (53.8%) were benign and 330 (46.2%) were malignant. In the development dataset, the following B-mode US features were associated with malignancy (all p < 0.001): segmental distribution (OR = 3.03; 95% confidence interval [CI], 1.50–6.15), associated calcifications (OR = 4.26; 95% CI, 1.62–11.18), abnormal ductal change (OR = 4.91; 95% CI, 2.07–11.68), and posterior shadowing (OR = 20.20; 95% CI, 6.46–63.23). The following mammographic features were also associated with malignancy (all p < 0.001): calcifications (OR = 7.98; 95% CI, 3.06–20.81) and focal asymmetry (OR = 4.75; 95% CI, 1.90–11.88). In the validation dataset, our classification system using US and mammography showed a higher area under the curve (0.951–0.956) compared to when it was not applied (0.908–0911) to predict malignancy with BI-RADS categories (p < 0.05). Our classification system which incorporates US and mammographic features of breast NMLs can help interpret and manage all NMLs detected on breast US by stratifying cancer risk according to BI-RADS categories. • When diagnosing breast NMLs detected on US, suspicious US features are segmental distribution, associated abnormal ductal change, calcifications, and posterior shadowing within or around the NML on B-mode US, while a probably benign US feature is the presence of multiple small cysts. • Corresponding suspicious mammographic features of breast NMLs detected on US are associated calcifications and focal asymmetry. • Our classification system which incorporates US features with and without mammography can potentially be used to interpret and manage any NMLs detected on breast US in clinical practice.

Background The relationship between method of breast cancer screening (mammography or US) and survival outcome in patients with screening-detected ductal carcinoma in situ (DCIS) has not been determined. Purpose To investigate whether different methods of breast cancer screening are associated with different survival outcomes in patients with screening-detected DCIS and to evaluate clinical-pathologic and imaging factors associated with second breast cancer. Materials and Methods We retrospectively identified women who underwent surgery to treat DCIS initially detected with screening mammography or US between July 2004 and December 2011 in a single institution. Overall survival (OS) and disease-free survival (DFS) were assessed. Factors associated with second breast cancer (invasive carcinoma or DCIS) were found with multivariable Cox proportional hazards regression analysis. Subgroups were analyzed according to screening method. Results A total of 814 women (median age, 47 years; age range, 25-81 years) were included; 627 underwent treatment for screening mammography-detected DCIS (mammography-detected group), and 187 underwent treatment for screening US-detected DCIS (US-detected group). During follow-up (median, 7 years; interquartile range, 5-8 years), 26 ipsilateral and 26 contralateral second breast cancers (6.4%, 52 of 814) were found, with 44 in the mammography-detected group and eight in the US-detected group. The overall 5-year OS and DFS rates were 100% and 95.3%, respectively. DFS rates did not differ according to screening method (P = .21, 5-year DFS rates were 94.9% in the mammography-detected group and 96.5% in the US-detected group). In the mammography-detected group, higher nuclear grade (intermediate grade: hazard ratio [HR], 5.7; 95% confidence interval [CI]: 1.3, 24.3; P = 0.02) (high grade: HR, 8.0; 95% CI: 1.9, 34.2; P = .01) and dense breast (HR, 3.5; 95% CI: 1.1, 11.4; P = 0.04) were associated with second breast cancer. In the US-detected group, human epidermal growth factor receptor 2 positivity was associated with second breast cancer (HR, 9.2; 95% CI: 2.2, 38.5; P = .002). Conclusion Disease-free survival of patients who underwent treatment for screening-detected ductal carcinoma in situ (DCIS) did not differ according to screening detection method. In patients with screening mammography-detected DCIS, higher nuclear grade and dense breast were associated with second breast cancer, and in patients with screening US-detected DCIS, human epidermal growth factor 2 positivity was associated with second breast cancer. © RSNA, 2019 Online supplemental material is available for this article. See also the editorial by Fowler in this issue.

This study aimed to compare the accuracy and inter- and intra-observer reproducibility of the measured elasticity between 2 shear wave elastography systems. Three breast radiologists examined 8 targets of 4 different levels of stiffness (size: 11 mm, 4 mm) in an elasticity phantom (Customized 049A Elasticity QA Phantom, CIRS, Norfolk, VA, USA) using 2 different shear wave ultrasound elastography systems: SuperSonic Imagine (SSI) (SSI, Aix en Provence, France) and ShearScan (RS-80A, Samsung Medison, Seoul, Korea). Three radiologists performed ultrasound (US) elastography examinations for the phantom lesions using 2 equipment over a 1-week interval. Intra- and inter-observer reproducibility and the accuracy of the measured elasticity were analyzed and compared between the 2 systems. The accuracy of shape was also analyzed by shape-matching between B-mode and elastography color image. Intra-class correlation coefficients (ICC) were used in statistical analysis. For measured elasticity, the intra-observer and inter-observer reproducibility were excellent in both SSI and ShearScan (0.994 and 0.998). The overall accuracy was excellent in both systems, but the accuracy in small lesions (4 mm target) was lower in SSI than ShearScan (0.780 vs 0.967). The accuracy of shape-matching on the elastography image was 59.0% and 81.4% in the SSI and ShearScan, respectively. In conclusion, the SSI and ShearScan showed excellent intra- and inter-observer reproducibility. The accuracy of the Young's modulus was high in both the SSI and ShearScan, but the SSI showed decreased accuracy in measurement of elasticity in small targets and poor shape-matching between the B-mode image and color-coded elastography image.

Purpose: This study assessed the incidence and cancer rate of probably benign lesions detected on bilateral whole-breast screening ultrasound (US), which corresponded to US Breast Imaging Reporting and Data System (BI-RADS) category 3, and evaluated the proper management of those lesions. Methods: This study was approved by the Institutional Review Board in our institution, which waived informed patient consent. We retrospectively reviewed US images of 1,666 patients who underwent bilateral whole-breast screening US as a supplemental screening test to negative screening mammography or screening US only. The incidence, clinical course, and cancer rate of screening USdetected probably benign lesions corresponding to US BI-RADS category 3 were investigated, and the size and multiplicity of screening US-detected category 3 lesions were evaluated. Results: Probably benign lesions corresponding to US BI-RADS category 3 were detected in 689 of 1,666 patients (41.4%) who underwent screening US. Among them, 653 had follow-up US images for at least 24 months, and among these 653, 190 (29.1%) had multiple bilateral category 3 lesions. Moreover, 539 of 1,666 patients (32.4%) had lesions ≤ 1 cm in size and 114 of 1,666 (6.8%) had lesions > 1 cm (median, 0.82 cm; range, 0.3– 4.2 cm). Four of the 653 patients (0.6%) showed suspicious interval changes and were categorized into BI-RADS category 4. Biopsy analysis confirmed only one lesion as invasive ductal carcinoma at the 6-month follow-up; another lesion was an intraductal papilloma and the remaining two were fibroadenomas. Overall cancer rate of the screening US-detected BI-RADS category 3 lesions was 0.2%. Conclusion: The incidence of category 3 lesions detected on screening US only was very high, but the cancer rate was very low. Therefore, in an average-risk population, routine screening US is preferable over short-term followup for BI-RADS category 3 lesions detected on whole-breast screening US.

Purpose To evaluate the accuracy of magnetic resonance imaging (MRI)-guided breast biopsy. Methods We retrospectively reviewed the clinical data of 111 consecutive patients referred for MRI-guided breast biopsy after mammography and breast ultrasound between May 2009 and April 2019. After excluding 37 patients without follow-up images (> 2 years), 74 patients (74 lesions) were finally included. We reviewed the histologic results of MRI-guided biopsy and subsequent surgery, post-biopsy management, and breast cancer development during follow-up. We investigated the false-negative rate, ductal carcinoma in situ (DCIS) underestimation, atypical ductal hyperplasia (ADH) underestimation rate, and technical failure rate of MRI-guided biopsy. Results Among 74 scheduled MRI-guided biopsies, six were canceled because biopsy was deemed unnecessary, while three failed due to technical difficulties (technical failure rate: 3/68, 4.4%). MRI-guided biopsy was performed in 65 patients, of which 18 patients were diagnosed with malignant lesions, 46 with benign lesions, and one with ADH bordering on DCIS. Subsequent surgery (n = 27) showed DCIS underestimation in three cases (3/7, 43%), ADH underestimation in two cases (1/2, 50%), as well as seven concordant benign and 11 concordant malignant lesions. The overall false-negative rate was 4.3% (2/46). Thirty-eight out of 48 benign lesions were followed-up (median period, 5.8 years; interquartile range, 4.1 years) without subsequent surgery. Thirty-seven concordant benign lesions were stable (n = 27) or disappeared (n = 10); however, the size of one discordant benign lesion increased on follow-up MRI and it was diagnosed as DCIS after 1 year. Conclusion MRI-guided biopsy is an accurate method for exclusion of malignancy with a very low false-negative rate.

Axillary ultrasonography (US) is the most commonly used imaging modality for nodal evaluation in patients with breast cancer. No Axillary Surgical Treatment in Clinically Lymph Node-Negative Patients after Ultrasonography (NAUTILUS) is a prospective, multicenter, randomized controlled trial investigating whether sentinel lymph node biopsy (SLNB) can be safely omitted in patients with clinically and sonographically node-negative T1-2 breast cancer treated with breast-conserving therapy. In this trial, a standardized imaging protocol and criteria were established for the evaluation of axillary lymph nodes. Women lacking palpable lymph nodes underwent axillary US to dismiss suspicious nodal involvement. Patients with a round hypoechoic node with effaced hilum or indistinct margins were excluded. Patients with T1 tumors and a single node with a cortical thickness ≥ 3 mm underwent US-guided biopsy. Finally, patients with negative axillary US findings were included. The NAUTILUS axillary US nodal assessment criteria facilitate the proper selection of candidates who can omit SLNB. Trial Registration: ClinicalTrials.gov Identifier: NCT04303715.

Objective To investigate whether a computer-aided diagnosis (CAD) system based on a deep learning framework (deep learning-based CAD) improves the diagnostic performance of radiologists in differentiating between malignant and benign masses on breast ultrasound (US). Materials and Methods B-mode US images were prospectively obtained for 253 breast masses (173 benign, 80 malignant) in 226 consecutive patients. Breast mass US findings were retrospectively analyzed by deep learning-based CAD and four radiologists. In predicting malignancy, the CAD results were dichotomized (possibly benign vs. possibly malignant). The radiologists independently assessed Breast Imaging Reporting and Data System final assessments for two datasets (US images alone or with CAD). For each dataset, the radiologists' final assessments were classified as positive (category 4a or higher) and negative (category 3 or lower). The diagnostic performances of the radiologists for the two datasets (US alone vs. US with CAD) were compared. Results When the CAD results were added to the US images, the radiologists showed significant improvement in specificity (range of all radiologists for US alone vs. US with CAD: 72.8–92.5% vs. 82.1–93.1%; p < 0.001), accuracy (77.9–88.9% vs. 86.2–90.9%; p = 0.038), and positive predictive value (PPV) (60.2–83.3% vs. 70.4–85.2%; p = 0.001). However, there were no significant changes in sensitivity (81.3–88.8% vs. 86.3–95.0%; p = 0.120) and negative predictive value (91.4–93.5% vs. 92.9–97.3%; p = 0.259). Conclusion Deep learning-based CAD could improve radiologists' diagnostic performance by increasing their specificity, accuracy, and PPV in differentiating between malignant and benign masses on breast US.

To evaluate the interpretative performance of two-dimensional (2D) synthetic mammography (SM) reconstructed from digital breast tomosynthesis (DBT) in the detection of T1-stage invasive breast cancers, compared to 2D full-field digital mammography (FFDM).This retrospective study enrolled 214 patients. For each patient, FFDM and DBT were performed between January and June 2013, and SM was reconstructed from DBT data. Three radiologists interpreted images and recorded visibility scores and morphologies of cancers. Diagnostic performances of SM and FFDM were compared. Percentages of detected cancers and visibility scores were compared for tumour size, and presence of calcifications for each observer.Observer sensitivity showed no difference for detection with SM and FFDM (P 0.05). One observer showed a higher specificity (P = 0.02) and higher positive predictive value with SM (95 % CI 0.6-16.4), but the differences in the corresponding values between SM and FFDM for the other observers were not statistically significant. In subgroup analyses according to tumour size and presence of calcifications, percentages of detected cancers and visibility scores were not significantly different.Diagnostic performances of SM and FFDM are comparable for detecting T1-stage breast cancers. Therefore, our results indicate that SM may eliminate the need for additional FFDM during DBT-based imaging.• DBT plus FFDM increases radiation dose compared to FFDM alone. • Detecting T1-stage cancers with only SM is comparable to detection with FFDM. • Two-dimensional SM may replace dose-requiring FFDM in DBT-based imaging.

Objective To determine what percentage of cancers, detected by screening ultrasonography (US), were detectable by full-field digital mammography (FFDM) and digital breast tomosynthesis (DBT). Materials and methods Eighty-four consecutive women in whom mammography was negatively interpreted and supplementary screening US initially detected breast cancers at outside hospitals underwent both FFDM and DBT. We excluded cases with overt suspicious findings on repeat mammography and ineligible cases. In the remaining 41 cases, three radiologists who were blinded to tumor location, even though they were aware that they had breast cancers independently reviewed both FFDM and DBT. The reference standard was the reference FFDM made by two unblinded reviewers who were aware of the tumor location and shape on DBT, US, and magnetic resonance imaging (MRI). The visibility score based on the correct marking was compared between FFDM and DBT. Results Among the 41 cases, the cancers were visible in 25 (61.0%) on FFDM and in 34 (82.9%) on DBT ( P = 0.047) by the unblinded review. In the blinded analysis, the cancers were significantly more "constantly visible" in the three radiologists on DBT than on FFDM [53.7% (22/41) vs. 26.8% (11/41), respectively, P = 0.013]. The dominant lesion type was "focal asymmetry" on DBT (39.0%) and "asymmetry" on FFDM (31.7%). Conclusions Our analysis suggests that 54% of cancers that were detected by US and were not evident on 2D mammography were detectable by screening using DBT. Additional 29% of cancers were visualized on DBT, when the area of concern was known.

Two automated volumetric breast density analyses of 44 patients who underwent image-guided needle localization in one breast were compared to calculate the agreement of assessment parameters in short-term digital mammography reimaging. The outputs of the automated volumetric breast density method included four parameters [fibroglandular tissue volume (Vfg), total breast volume (Vb), volumetric breast density (Vbd), and area breast density (Abd)]. The variability and agreement of each parameter were calculated in serial mammograms. There was no significant difference in mean Vfg, Vb, Vbd, or Abd between two mammograms (P = .249, .053, .727, and .603, respectively).

Background Further information is needed regarding whether histopathological characteristics affect breast tumor elasticity. Purpose To determine whether maximum elasticity values vary according to tumor-stroma ratio, dominant stroma type, or presence of fibrosis in invasive breast cancer. Material and Methods This study included 71 patients with invasive ductal carcinoma not otherwise specified (IDC NOS) who underwent breast shear-wave elastography (SWE). Maximum elasticity (Emax) values were retrospectively correlated with pathological findings that included tumor-stroma ratio, dominant stroma type (collagen, fibroblast, lymphocyte), and fibrosis. Multiple linear regression analysis was performed to determine variables independently associated with Emax. Results High histologic grade was significantly correlated with higher Emax ( P = 0.042). Estrogen receptor and progesterone receptor expression negatively correlated with high elasticity values ( P = 0.013 and P = 0.03, respectively). Breast cancers that exhibited higher cellularity demonstrated a greater level of stiffness that was not statistically significant (ρ = 0.153; P = 0.193). While dominant stroma type and fibrosis did not affect Emax ( P = 0.197 and P = 0.598, respectively), lesion size was significantly associated with Emax (ρ = 0.474, P max ( P Conclusion The composition of tumors did not affect their Emax.

The purpose of this study was to determine whether the apparent diffusion coefficient (ADC) and tumor detectability based on diffusion-weighted imaging (DWI) are affected by the menstrual cycle or menopausal status in breast cancer patients. Institutional review board approval was obtained, and the requirement for informed consent was waived. A total of 124 women with invasive ductal carcinoma not otherwise specified (IDC NOS) who underwent breast MRI with DWI were included in this study. Two radiologists retrospectively measured the ADCs of tumor and contralateral normal glandular tissue and scored the tumor detectability. The ADCs and detectability were compared to menstrual cycle and menopausal status, based on patient questionnaires. ADCs of tumors and contralateral tissue were significantly lower in postmenopausal women than in premenopausal women (P = 0.006 and P < 0.001, respectively). Tumor detectability did not differ significantly between the premenopausal and postmenopausal groups (P = 0.454). Normalized ADCs were not significantly lower in postmenopausal women compared to premenopausal women (P = 0.880). There was no statistically significant difference in the absolute, contralateral, and normalized ADCs (P = 0.091, 0.809, and 0.299, respectively), and the tumor detectability (P = 0.680) according to the menstrual cycle. Although ADCs of the IDC and normal glandular tissue in postmenopausal women were significantly lower than those in premenopausal women, the menstrual cycle did not affect tumor detectability and ADCs of IDC.

PURPOSE The purpose of this study was to investigate the final outcomes of magnetic resonance imaging (MRI)-identified additional lesions (MRALs) in breast cancer patients and the role of second-look ultrasound (SLUS) and imaging-guided interventions. METHODS We analyzed breast cancer patients with MRALs on preoperative MRI between January and June 2012. MRALs were defined as additional lesions suspected on MRI but not suspected on mammograms or ultrasound. The malignancy rate of MRALs, MRI-based Breast Imaging Reporting and Database System (BI-RADS) category, positional relationship with the index cancer, MRI-concordant lesion visibility on SLUS, performance of imaging-guided interventions, and total mastectomy (TM) rates were evaluated for the confirmed lesions. RESULTS Among the 119 confirmed lesions, SLUS and imaging-guided interventions were performed in 94 (79.0%) and 82 cases (68.9%), respectively. The malignancy rate was 68.1% (81 of 119), and was significantly higher in BI-RADS 4C-5 lesions than in 4A-4B lesions (94.6% vs. 56.1%, P

Objectives To evaluate whether preoperative breast dynamic contrast-enhanced (DCE) magnetic resonance (MR) imaging kinetic features, assessed using computer-aided diagnosis (CAD), can predict survival outcome and tumor aggressiveness in patients with invasive breast cancer. Materials and methods Between March and December 2011, 301 women who underwent preoperative DCE MR imaging for invasive breast cancer, with CAD data, were identified. All MR images were retrospectively evaluated using a commercially available CAD system. The following kinetic parameters were prospectively recorded for each lesion: initial peak enhancement, the proportion of early phase medium and rapid enhancement, and the proportion of delayed phase persistent, plateau, and washout enhancement. The Cox proportional hazards model was used to determine the association between the kinetic features assessed by CAD and disease-free survival (DFS). The peak signal intensity and kinetic enhancement profiles were compared with the clinical-pathological variables. Results There were 32 recurrences during a mean follow-up time of 55.2 months (range, 5–72 months). Multivariate analysis revealed that a higher peak enhancement (DFS hazard ratio, 1.004 [95% confidence interval (CI): 1.001, 1.006]; P = .013) on DCE MR imaging and a triple-negative subtype (DFS hazard ratio, 21.060 [95% CI: 2.675, 165.780]; P = .004) were associated with a poorer DFS. Higher peak enhancement was significantly associated with a higher tumor stage, clinical stage, and histologic grade. Conclusions Patients with breast cancer who showed higher CAD-derived peak enhancement on breast MR imaging had worse DFS. Peak enhancement and volumetric analysis of kinetic patterns were useful for predicting tumor aggressiveness.

Background Most of the breast lesions show hypoechogenicity relative to fat on ultrasonography. The frequency and malignancy rate of hyperechoic lesions are not investigated in a large series. Purpose To evaluate the frequency and malignancy rate of hyperechoic lesions on breast sonography and to investigate sonographic characteristics that may predict malignancy in hyperechoic breast lesions. Material and Methods Radiologic reports of 16,416 patients who underwent breast sonography between 2007 and 2008 were searched using “hyperechoic”, “echogenic” or “heterogeneous echoic” to describe lesions. Sonographic findings were evaluated according to the Breast Imaging Reporting and Data System lexicon. Clinical records including follow-up and pathologic findings were also reviewed. We calculated the frequency of hyperechoic lesions and their malignancy rate. Differences in sonographic appearances between benign and malignant lesions were also investigated. Results Among the 16,416 patients, 103 (0.6%) hyperechoic lesions were identified (mean size, 1.79 cm). Of these 103 lesions, 27 (26.2%) were pathologically evaluated and five (4.9%, 4 invasive ductal carcinoma and 1 mucinous carcinoma) were confirmed as malignant. Among the 819 malignant lesions diagnosed using sonography-guided core needle biopsy, five (0.6%) were hyperechoic. In benign lesions, fat necrosis and fibroadenoma were common pathologic diagnoses. Malignant lesions were more likely to have irregular shape ( P = 0.003), non-parallel orientation ( P = 0.002), non-circumscribed margin ( P = 0.007), and a hypoechoic area ( P = 0.027) than benign lesions. All hyperechoic carcinomas were seen as suspicious masses on mammograms. Conclusion Hyperechoic masses are very rare and mostly benign. As an adjunct to mammography, the imaging findings reported here could help to avoid misdiagnosis for malignant hyperechoic lesion.

Importance Younger women (aged ≤50 years) who underwent breast conservation therapy may benefit from breast magnetic resonance imaging (MRI) screening as an adjunct to mammography. Objective To prospectively determine the cancer yield and tumor characteristics of combined mammography with MRI or ultrasonography screening in women who underwent breast conservation therapy for breast cancers and who were 50 years or younger at initial diagnosis. Design, Setting, and Participants This multicenter, prospective, nonrandomized study was conducted from December 1, 2010, to January 31, 2016, at 6 academic institutions. Seven hundred fifty-four women who were 50 years or younger at initial diagnosis and who had undergone breast conservation therapy for breast cancer were recruited to participate in the study. Reference standard was defined as a combination of pathology and 12-month follow-up. Interventions Participants underwent 3 annual MRI screenings of the conserved and contralateral breasts in addition to mammography and ultrasonography, with independent readings. Main Outcomes and Measures Cancer detection rate, sensitivity, specificity, interval cancer rate, and characteristics of detected cancers. Results A total of 754 women underwent 2065 mammograms, ultrasonography, and MRI screenings. Seventeen cancers were diagnosed, and most of the detected cancers (13 of 17 [76%]) were stage 0 or stage 1. Overall cancer detection rate (8.2 vs 4.4 per 1000; P = .003) or sensitivity (100% vs 53%; P = .01) of mammography with MRI was higher than that of mammography alone. After the addition of ultrasonography, the cancer detection rate was higher than that by mammography alone (6.8 vs 4.4 per 1000; P = .03). The specificity of mammography with MRI or ultrasonography was lower than that by mammography alone (87% or 88% vs 96%; P Conclusions and Relevance After breast conservation therapy in women 50 years or younger, the addition of MRI to annual mammography screening improves detection of early-stage but biologically aggressive breast cancers at acceptable specificity. Results from this study can inform patient decision making on screening methods after breast conservation therapy.

Purpose To determine the survival rates and clinical-pathologic and imaging factors associated with recurrence in women with breast cancer detected at screening ultrasonography (US). Materials and Methods This study was approved by the institutional review board, and the requirement to obtain informed consent was waived. A retrospective review of the databases of four institutions identified 501 women (median age, 47 years; range, 27-74 years) with breast cancer (425 invasive cancers and 76 ductal carcinoma in situ) detected at screening US between January 2004 and March 2011. Five-year overall survival (OS) and recurrence-free survival (RFS) rates were estimated, and the clinical-pathologic and imaging data were collected. Multivariate analysis was performed by using Cox proportional hazard regression to determine factors associated with recurrence. Results At a median follow-up of 7.0 years (range, 5.0-12.1 years), 15 (3.0%) recurrences were detected: five in ipsilateral breast and 10 in contralateral breast. The 5-year OS and RFS rates were 100% and 98.0% (95% confidence interval [CI]: 96.8%, 99.2%), respectively. In patients with invasive cancers, age younger than 40 years (hazard ratio: 3.632 [95% CI: 1.099, 11.998]; P = .032), the triple-negative subtype (hazard ratio: 7.498 [95% CI: 2.266, 24.816]; P = .001), and Breast Imaging Reporting and Data System (BI-RADS) category 4A lesions (hazard ratio: 5.113 [95% CI: 1.532, 17.195]; P = .008) were associated with recurrence. Conclusion Women with breast cancers detected at screening US have excellent outcomes, with a 5-year RFS rate of 98.0%. However, in patients with invasive breast cancer, age younger than 40 years, the triple-negative subtype, and BI-RADS category 4A lesions were associated with recurrence. © RSNA, 2017 Online supplemental material is available for this article.

Background This study investigated which zonal tissue would be more secure from the risk of fat necrosis between Holm zones II and III and examined the risk factors of fat necrosis in a clinical series of medial row perforator-based deep inferior epigastric artery perforator (DIEP) flaps. Patients and Methods A retrospective chart review was performed for patients undergoing unilateral breast reconstructions with medial row perforator DIEP flaps. Data regarding patients, operation-related characteristics, and complications including fat necrosis were collected. Fat necrosis was mainly diagnosed by ultrasound examination, and its location was also assessed. Results A total of 103 cases were analyzed. Fat necrosis was diagnosed in 13.6% of patients and developed more frequently in zone III (7.8%) than in zone II (4.9%). In risk factor analysis, the inset rate, the weight ratio of the inset flap to harvested flap, was significantly associated with the development of fat necrosis. The flaps with inset rates more than 79% showed 16 times higher risk of fat necrosis than those below 79% in multivariate analysis. The incidence of fat necrosis in zone III was significantly increased in the high inset rate group when compared with the low inset rate group, whereas the incidence in zone II did not change. Conclusions In unilateral breast reconstruction using medial row perforator DIEP flaps, fat necrosis developed more frequently in zone III than in zone II, and this tendency was more prominent in high inset rate group. Not transferring excessive contralateral tissue including lateral zone III tissue might be helpful for reducing the risk of fat necrosis. © 2014 Wiley Periodicals, Inc. Microsurgery 35:272–278, 2015.

The goal of this study was to analyze the differences in ultrasound characteristics of papillary thyroid carcinoma (PTC) originating in the thyroid isthmus versus that originating from the lobes.From a retrospective review of our institution's database of records dated between January 2007 and December 2008, we identified 48 patients with classic PTCs located in the isthmus. All the patients had undergone preoperative ultrasound imaging, total thyroidectomy with bilateral central lymph node dissection, and postoperative follow-up for at least 2 years. As a control group, 96 patients with classic PTCs located in the lobe who had undergone total thyroidectomy with bilateral central lymph node dissection during the same period were randomly matched to the study patients for age, sex, and tumor size.According to the clinicopathologic analyses, the incidence of extrathyroidal extension was higher in the patients with a tumor originating in the isthmus than in the control group (p = 0.026). According to the imaging analyses, the tumors originating in the isthmus more frequently had a circumscribed margin (p = 0.030), a wider-than-tall shape (p0.001), and the suspicion of extrathyroidal extension (p0.001) than those originating from the lobes.The results of this study showed that PTCs originating in the isthmus were more likely to have extrathyroidal extension than those originating from the lobes. Therefore, careful ultrasound evaluation should be performed on masses in the thyroid isthmus even if ultrasound shows a circumscribed mass with a wider-than-tall shape.

Background Stromal fibrosis in the breast is a non-specific benign pathologic entity with wide spectrum of imaging finding. The false-negative rates (number of cancers missed) previously reported have limited value because short follow-up period and small number of populations. Purpose To describe the mammographic and sonographic findings of stromal fibrosis of the breast diagnosed by imaging-guided biopsy and to determine the false-negative rate at percutaneous biopsy. Material and Methods Between January 2007 and December 2008, 3097 consecutive imaging-guided breast core biopsies were performed. Patients were included in our study if stromal fibrosis was the predominant pathologic finding. Patients who had received 2 years and histologic data were reviewed to evaluate lesion stability. Results Stromal fibrosis was diagnosed in 187 (6.0%) of 3097 imaging-guided biopsies among patients with >2 years of follow-up (mean, 41.9 months). Among them, 91 (49%) of 187 lesions were not visible on mammography and calcifications were the most common findings, being identified in 33 lesions (17.6%). The most common sonographic finding was an oval hypoechoic mass with a circumscribed margin. Forty-two lesions (22.5%) were excised. Four false-negative lesions (2.1%, 4/187) were identified; all false-negative lesions were diagnosed within 6 months because of imaging-pathology discordance (75%, 3/4) or disease progression (25%, 1/4). Conclusion Stromal fibrosis diagnosed by imaging-guided biopsy has a wide spectrum of imaging finding and can be managed safely with radiologic-pathologic correlation and subsequent short-term imaging follow-up.

To determine whether apparent diffusion coefficient (ADC) values vary according to tumor-stroma ratio, dominant stroma type, or presence of central fibrosis in estrogen receptor-positive breast cancer.Institutional review board approval was obtained, and patient consent was waived. Sixty-one patients with estrogen receptor-positive invasive ductal carcinoma-not otherwise specified who underwent breast magnetic resonance (MR) imaging with diffusion-weighted (DW) imaging were included in this study. The ADC values of the lesions were measured. Two pathologists evaluated the tumor-stroma ratio, dominant stroma type (collagen, fibroblast, lymphocyte), and central fibrosis. Detectability on DW images was compared between the two groups according to the tumor-stroma ratio (stroma rich or stroma poor). Mean ADC values were retrospectively compared with the tumor-stroma ratio, dominant stroma type, and presence of a central fibrosis. Multiple linear regression analysis was performed to determine variables independently associated with ADC.On DW images, detectability was not significantly different between stroma-rich and stroma-poor groups (P = .244). ADC values were significantly lower in the stroma-poor group (P.001). The mean ADC values in the collagen-dominant type were lower than in fibroblast-dominant or lymphocyte-dominant types (P = .021). In multiple linear regression analysis, tumor-stroma ratio (P = .007), tumor size (P = .007), and dominant stroma type (collagen dominant, P = .029) were independently correlated with ADC.In estrogen receptor-positive breast cancers, ADC values showed significant differences according to the tumor-stroma ratio and dominant stroma type.

BRAF(V600E) mutation (valine-to-glutamate substitution at residue 600 of the B-type Raf kinase gene) analysis from thyroid aspirates is increasingly used as a prognostic or diagnostic marker. However, it is limited under some conditions. The purpose of this study was to assess the incidence and predictive factors of thyroid nodules with specimens inadequate for BRAF(V600E) mutation analysis.We performed a retrospective cohort study of consecutive patients who underwent ultrasound-guided fine-needle aspiration (FNA) and molecular testing of aspiration specimens. Patients who had inadequate specimens in both allele-specific polymerase chain reaction and direct DNA-sequencing methods were selected. Univariate and multivariate logistic regression analyses were performed to identify predictive factors of specimens inadequate for molecular tests.Specimens inadequate for BRAF(V600E) mutation analysis were seen in 168 of 7001 (2.4%) patients. Factors, including patient age and sex, nodule size, ultrasound diagnosis, the presence of calcification, and cystic changes within thyroid nodules, were not significant predictors of inadequate mutation analysis. Oval-to-round or irregular shapes (e.g., not taller-than-wide) and final benign results were significant factors in univariate analysis (p = 0.0002 and p = 0.0013, respectively). However, nodules aspirated by operators with less than 1 year of experience (odds ratio [OR], 3.005; p = 0.0070), and those that had spiculated margins (OR, 6.139; p = 0.0142), isoechogenicity (OR, 10.374; p = 0.0442), or nondiagnostic cytologic findings (OR, 73.637; p = 0.0055) remained significant risk factors after adjustment in multivariable analysis.Thyroid nodule specimens inadequate for BRAF(V600E) mutation analysis were frequently associated with FNA aspiration performed by inexperienced operators, nondiagnostic cytologic findings, benign nodules on final diagnosis, and probably benign ultrasound findings, such as isoechogenicity and not-taller-than-wide shape.

Breast metastases from extramammary malignancies are uncommon. The most common sources are lymphomas/leukemias and melanomas. Some of the less common sources include carcinomas of the lung, ovary, and stomach, and infrequently, carcinoid tumors, hypernephromas, carcinomas of the liver, tonsil, pleura, pancreas, cervix, perineum, endometrium and bladder. Breast metastases from extramammary malignancies have both hematogenous and lymphatic routes. According to their routes, there are common radiological features of metastatic diseases of the breast, but the features are not specific for metastases. Typical ultrasound (US) features of hematogenous metastases include single or multiple, round to oval shaped, well-circumscribed hypoechoic masses without spiculations, calcifications, or architectural distortion; these masses are commonly located superficially in subcutaneous tissue or immediately adjacent to the breast parenchyma that is relatively rich in blood supply. Typical US features of lymphatic breast metastases include diffusely and heterogeneously increased echogenicities in subcutaneous fat and glandular tissue and a thick trabecular pattern with secondary skin thickening, lymphedema, and lymph node enlargement. However, lesions show variable US features in some cases, and differentiation of these lesions from primary breast cancer or from benign lesions is difficult. In this review, we demonstrate various US appearances of breast metastases from extramammary malignancies as typical and atypical features, based on the results of US and other imaging studies performed at our institution. Awareness of the typical and atypical imaging features of these lesions may be helpful to diagnose metastatic lesions of the breast.

Purpose To investigate the detectability and imaging characteristics of primary tumors according to imaging modalities and to identify clinical features and histological prognostic factors for axillary metastases in patients with small (≤1cm, T1a and T1b) invasive breast cancer. Materials and methods A total of 221 patients with histologically confirmed small invasive cancers were included for the statistical analysis. At mammography, ultrasonography and MRI, the detectability, and imaging characteristics of primary tumors were compared in patients with or without axillary metastases. Clinical features and histological prognostic factors for axillary metastases were investigated. Results Of 221 patients examined, axillary metastasis was found in 42 (19%) at the time of surgery. There was no significant difference in detectability of small tumors using ultrasonography and MRI between patients with and without axillary metastasis. However, mammography had a higher positive rate of primary tumors in patients with axillary metastasis than without metastasis (92.9% vs. 77.1%, p =0.023). Patients with axillary metastasis in small cancers showed more common architectural distortion than negative ( p =0.0147) or mass ( p =0.0356) on mammography. Clinical features were not different in the two groups. Only lymphovascular invasion was independently associated with axillary metastasis ( p =0.0051, 95% CI, 1.527–11.597). Conclusion The detectability of small invasive breast cancers among patients with and without axillary metastasis is different with mammography, but not with US and MRI. Lymphovascular invasion is only a predictor for axillary metastasis in small invasive cancers.

Purpose To investigate the characteristic sonographic (US) findings of pure ductal carcinoma in situ (DCIS) in a large series. Methods We retrospectively reviewed the US findings of 126 cases of pure DCIS in 123 consecutive patients who underwent surgery for breast cancer in our hospital. We analyzed the US findings of the lesions according to mass or nonmass abnormality, shape, margin, orientation, echogenicity, echotexture, boundary echo, posterior acoustic features, presence of associated ductal dilatation, presence of intralesional cystic focus, and presence of microcalcifications on US. We compared the US characteristics of pure DCIS with and without mammographic microcalcifications. Results Seventy-eight cases of pure DCIS had microcalcifications and 48 had no microcalcifications on mammography (MG). Overall, 109 cases (86.5%) of pure DCIS were demonstrated on US. DCIS with microcalcifications on MG showed positive US findings in 79.5% of cases. The most common US finding was heterogeneous hyper- or isoechoic parenchyma with intralesional microcalcifications and without posterior acoustic features. DCIS without microcalcifications on MG showed positive US findings in 97.9% of cases. The most common US findings were masses with round or oval shape, microlobulated margin, parallel orientation, heterogeneous mild hypoechogenicity, and without boundary echo or posterior acoustic features. Ductal dilatations and intralesional cystic foci were present in 17.5% (22/126) and 23.8% (30/126) of pure DCIS, respectively. Conclusions Overall, US could demonstrate 85.7% of pure DCIS cases, including 16 (12.7%) cases of clinically and mammographically occult pure DCIS. DCIS with and without microcalcifications on MG showed different US characteristics. © 2013 Wiley Periodicals, Inc. J Clin Ultrasound, 41:465–471, 2013

The aim of this study was to evaluate whether pleomorphic invasive lobular carcinoma (PILC) is different from classic invasive lobular carcinoma (CILC) in terms of radiologic and clinicopathologic features. We compared the radiologic and clinicopathologic features of 22 surgically confirmed PILCs in 21 patients from 2004 to 2009 and 47 CILCs from 47 consecutive patients. For all cases, we reviewed the imaging findings, medical records and pathological results. PILC had a higher T stage, N stage, nuclear and histologic grade compared to CILC. PILC was more commonly negative for estrogen receptors and positive for HER2 than CILC (all p 0.05). However, there were no significant differences in age, symptoms, tumor size, extensive intraductal component, lymphovascular invasion, triple negative profile, or multiplicity between the two groups. PILC was not detected on mammography in 1 (4.5%) of 22 cases, whereas CILC was not detected on mammography in 7 (14.9%) of 47 cases and on MRI in 2 (5.0%) of 40 (p = 0.42 and p = 1.000, respectively). MRI identified more frequent multiplicity than mammography for both PILC and CILC (p 0.001), but was similar to US (p = 0.066). Most lesions showed a spiculated mass or architectural distortion with or without calcifications on mammography and ultrasound. No differences in mass and/or non-mass lesions or kinetics on MRI were observed between the two groups. PILC shows more pathologically aggressive features, but cannot be differentiated from CILC based on imaging findings.

Purpose To evaluate the menstrual cycle and breast composition influence on background parenchymal enhancement of breast magnetic resonance imaging (MRI) and to investigate the optimal time for breast MR examinations. Materials and Methods We evaluated the dynamic contrast-enhanced breast MR images of 238 women who had completed a questionnaire survey about menstrual status. On MRI, the degree of enhancement (DE) of normal parenchyma was measured in the images 2 minutes and 6 minutes after contrast injection. A comparison between premenopausal and postmenopausal women and a separate comparison between dense breasts and fatty breasts were analyzed according to the premenopausal women's menstrual cycle. Results Premenopausal women showed significantly higher DE than the postmenopausal women (P

Background It remains uncertain whether MRI identification of additional foci of disease leads to improved outcome. We undertook a study to evaluate the influence of breast MRI on early and long-term outcome. Methods Among 1,271 patients undergone breast cancer surgery between January 2005 and December 2006, 785 patients were attempted for BCS. Operative approach and radiologic findings were compared according to MRI use. We reselected 615 patients with unilateral early-stage breast cancer treated with BCS including RT. We compared the histopathologic characteristics and outcomes according to MRI use. Results In patients attempted for BCS (n = 785), re-excision rates were not significantly different according to MRI use (P = 1.000). Conversion to mastectomy or bilateral cancer surgery were higher in MRI group (P = 0.002). The IBTR rate was higher in the non-MRI group (P = 0.020). Difference in contralateral cancer rate and total recurrence rates failed to reach statistical significance (P = 0.168, 0.383, respectively). Multivariate study after adjustment showed no difference in recurrence rates and IBTR rates between the two groups (hazard ratios 1.34, 6.37 Ps = 0.385, 0.076). Conclusion Use of MRI in patients with early-stage breast cancer did not result in improvement of a patient's outcome. J. Surg. Oncol. 2013;107:815–821. © 2013 Wiley Periodicals, Inc.

To determine whether BPE in preoperative breast MRI influences patients’ recurrence-free survival (RFS). Between February 2010 and December 2011, 804 consecutive women with invasive breast cancer who had undergone preoperative breast MRI and curative cancer surgery were identified. BPE was visually graded by two reviewers. We determined the correlation between BPE grade and other clinicopathological variables, including age, adjuvant therapy, menopausal status, histologic grade, T stage, N stage, lymphovascular invasion, molecular subtype, surgical margin status, and mammographic density. A Cox proportional hazards model was used to analyze the effects of clinicopathological variables and radiological findings (BPE grade, mammographic density) on RFS. High BPE was associated with premenopausal status (Ps

The cribriform-morular variant of papillary thyroid carcinoma (cmvPTC) is rare. There are few if any studies of the ultrasonographic (US) features of cmvPTC. The aim of this study was to determine the characteristic US and clinical features of the cmvPTC.A retrospective review of the US and clinical features was performed on 18 surgically confirmed cmvPTCs in five patients who were seen at our institution between January 2000 and December 2010.All patients were female with a mean age of 28 years (range, 19-46 years). Two patients presented with palpable lesions, and the other patients were incidentally detected during screening US. On US, the majority of nodules had well-defined, oval to round shapes, and were hypoechoic and solid without calcifications. However, 6 (33.3%) of 18 nodules did have a cystic change. The size of the lesions varied from 0.3 to 3.0 cm (mean, 1.11 cm). None of the nodules were diagnosed as malignant based on the US criteria, but all except one patient had a cytology of their thyroid nodules that was read as malignant, without revealing the subtype of their PTC. Two of the five patients had familial adenomatous polyposis (FAP), and they had bilateral multiple nodules. No metastatic lymph nodes or extrathyroidal extension were identified. To date, none of the patients has had recurrence or metastasis during their mean follow-up of 25 months after thyroidectomy.It appears that most cases of cmvPTC do not have features of malignancy on US and that they are indolent tumors as far as their clinical and histological features are concerned.

Background We evaluated shear-wave elastography (SWE) and color Doppler ultrasonography (US) features for fibroepithelial lesions (FELs), and to evaluate their utility to differentiate fibroadenomas (FAs) and phyllodes tumors (PTs). Methods This retrospective study included 67 FELs pathologically confirmed (49 FAs, 18 PTs). B-mode US, SWE and color Doppler US were performed for each lesion. Mean elasticity (Emean), maximum elasticity (Emax), and vascularity were determined by SWE and Doppler US. Diagnostic performances were calculated to differentiate FAs and PTs. Equivocal FELs diagnosed by core needle biopsy (CNB) were further analyzed. Results Median Emean and Emax were significantly lower for FAs than PTs (Emean, 15.7 vs. 66.7 kPa; Emax, 21.0 vs. 76.7 kPa, P43.9 kPa, 89.8%; Emax >46.1 kPa, 79.6%) than B-mode US (42.9%) (P0.05). The combination of SWE and Doppler US with ‘Emean>43.9 kPa or high vascularity (≥2 vessel flows)’ showed a higher area under the curve (0.786 vs. 0.687) and higher diagnostic values than B-mode US (sensitivity, 100 vs. 94.4%; specificity, 57.1 vs. 42.9%; positive predictive value, 46.2 vs. 37.8%; negative predictive value, 100 vs. 95.5%), without statistical significance (P>0.05). Of the 30 equivocal FELs, all lesions with ‘Emean≤43.9 kPa and low vascularity (0–1 vessel flow)’ (23.3%, 7/30) were finally confirmed as FAs by excision. Conclusion FAs have a tendency to have less stiffness and lower vascularity than PTs. Combined SWE and color Doppler US may help patients with equivocal FELs diagnosed by CNB avoid unnecessary excision.

To determine the factors influencing the degree of detectability of lesions and diffusion background signals on magnetic resonance diffusion-weighted imaging (DWI) in invasive breast cancer. Institutional review board approval was obtained and patient consent was waived. Patients with newly diagnosed invasive ductal carcinoma, who underwent preoperative breast magnetic resonance imaging with DWI were included in this study (n = 167). Lesion detectability on DWI and contrast-enhanced subtracted T1-weighted images, the degree of background parenchymal enhancement (BPE), and diffusion background signal were qualitatively rated. Detectability of lesions on DWI was compared with clinicopathological findings including menopausal status, mammographic density, and molecular subtype of breast cancer. Multivariate linear regression analysis was performed to determine variables independently associated with detectability of lesions on DWI and diffusion background signals. Univariate analysis showed that the detectability of lesions on DWI was significantly associated with lesion size (P = 0.001), diffuse background signal (P

To retrospectively investigate whether background parenchymal enhancement (BPE) of the contralateral breast on preoperative dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) is associated with therapeutic outcomes following neoadjuvant chemotherapy (NAC) in unilateral invasive breast cancer. The institutional review board approved this study, and informed consent was waived. Between 2009 and 2011, 93 women with unilateral invasive breast cancer (43 premenopausal women who performed pre-NAC MRI between days 7 and 20 of the menstrual cycle and 50 postmenopausal women) underwent NAC with pre- and post-NAC DCE-MRI before surgery. MRI features (BPE [minimal, mild, moderate, marked] of the contralateral breast, lesion size and number, lesion kinetics, and changes in lesion size) and clinicopathologic features were analyzed. Patients were grouped according to BPE category (high [moderate or marked] or low [minimal or mild]). Cox regression modeling was used to determine associations between MRI features and recurrence-free survival (RFS) after controlling for clinicopathologic variables. The mean follow-up period was 48.2 months. Twenty-three recurrences occurred (2 ipsilateral breasts, 6 regional, and 15 distant). On multivariate analysis, high BPE on pre-NAC MRI (hazard ratio [HR] = 3.851, P = 0.006) and triple-negative cancer (HR = 3.192, P = 0.002) were independent factors associated with worse RFS. A greater reduction of lesion size on post-NAC MRI (HR = 0.984, P = 0.021) was associated with better RFS. High BPE on pre-NAC MRI is significantly associated with worse RFS in an NAC setting. This study suggests that BPE on pre-NAC DCE-MRI may have potential as a predictor of long-term outcomes in breast cancer patients who undergo NAC.