Faculty Bibliography

RATIONALE AND OBJECTIVES: To evaluate uptake, patterns of use, and perception of digital breast tomosynthesis (DBT) among practicing breast radiologists. MATERIALS AND METHODS: Institutional Review Board exemption was obtained for this Health Insurance Portability and Accountability Act-compliant electronic survey, sent to 7023 breast radiologists identified via the Radiological Society of North America database. Respondents were asked of their geographic location and practice type. DBT users reported length of use, selection criteria, interpretive sequences, recall rate, and reading time. Radiologist satisfaction with DBT as a diagnostic tool was assessed (1-5 scale). RESULTS: There were 1156 (16.5%) responders, 65.8% from the United States and 34.2% from abroad. Of these, 749 (68.6%) use DBT; 22.6% in academia, 56.5% private, and 21% other. Participants are equally likely to report use of DBT if they worked in academics versus in private practice (78.2% [169 of 216] vs 71% [423 of 596]) (odds ratio, 1.10; 95% confidence interval: 0.87-1.40; P = 1.000). Of nonusers, 43% (147 of 343) plan to adopt DBT. No US regional differences in uptake were observed (P = 1.000). Although 59.3% (416 of 702) of DBT users include synthetic 2D (s2D) for interpretation, only 24.2% (170 of 702) use s2D alone. Majority (66%; 441 of 672) do not perform DBT-guided procedures. Radiologist (76.6%) (544 of 710) satisfaction with DBT as a diagnostic tool is high (score >/= 4/5). CONCLUSIONS: DBT is being adopted worldwide across all practice types, yet variations in examination indication, patient selection, utilization of s2D images, and access to DBT-guided procedures persist, highlighting the need for consensus and standardization.

PURPOSE: To compare a novel multicoil compressed sensing technique with flexible temporal resolution, golden-angle radial sparse parallel (GRASP), to conventional fat-suppressed spoiled three-dimensional (3D) gradient-echo (volumetric interpolated breath-hold examination, VIBE) MRI in evaluating the conspicuity of benign and malignant breast lesions. MATERIALS AND METHODS: Between March and August 2015, 121 women (24-84 years; mean, 49.7 years) with 180 biopsy-proven benign and malignant lesions were imaged consecutively at 3.0 Tesla in a dynamic contrast-enhanced (DCE) MRI exam using sagittal T1-weighted fat-suppressed 3D VIBE in this Health Insurance Portability and Accountability Act-compliant, retrospective study. Subjects underwent MRI-guided breast biopsy (mean, 13 days [1-95 days]) using GRASP DCE-MRI, a fat-suppressed radial "stack-of-stars" 3D FLASH sequence with golden-angle ordering. Three readers independently evaluated breast lesions on both sequences. Statistical analysis included mixed models with generalized estimating equations, kappa-weighted coefficients and Fisher's exact test. RESULTS: All lesions demonstrated good conspicuity on VIBE and GRASP sequences (4.28 +/- 0.81 versus 3.65 +/- 1.22), with no significant difference in lesion detection (P = 0.248). VIBE had slightly higher lesion conspicuity than GRASP for all lesions, with VIBE 12.6% (0.63/5.0) more conspicuous (P < 0.001). Masses and nonmass enhancement (NME) were more conspicuous on VIBE (P < 0.001), with a larger difference for NME (14.2% versus 9.4% more conspicuous). Malignant lesions were more conspicuous than benign lesions (P < 0.001) on both sequences. CONCLUSION: GRASP DCE-MRI, a multicoil compressed sensing technique with high spatial resolution and flexible temporal resolution, has near-comparable performance to conventional VIBE imaging for breast lesion evaluation. LEVEL OF EVIDENCE: 3 J. Magn. Reson. Imaging 2016.

PURPOSE: To assess the diagnostic utility of contrast kinetic analysis for breast lesions and background parenchyma of women undergoing MRI-guided biopsies, for whom standard clinical analysis had failed to separate benign and malignant lesions. MATERIALS AND METHODS: This study included 115 women who had indeterminate lesions based on routine diagnostic breast MRI exams and underwent an MRI (3 Tesla) -guided biopsy of one or more lesions suspicious for breast cancer. Breast dynamic contrast-enhanced (DCE)-MRI was performed using a radial stack-of-stars three-dimensional spoiled gradient echo pulse sequence and modified k-space weighted image contrast image reconstruction. Contrast kinetic model analysis was conducted to characterize the contrast enhancement patterns measured in lesions and background parenchyma (BP). The transfer rate (Ktrans ), interstitial volume fraction (ve ), and vascular volume fraction (vp ) estimated from the lesion and BP were used to separate malignant from benign lesions. RESULTS: The patients with malignant lesions had significantly (P < 0.05) higher median lesion-Ktrans (0.081 min-1 ), higher median BP-Ktrans (0.032 min-1 ), and BP-vp (0.020) than those without malignant lesions (0.056 min-1 , 0.017 min-1 and 0.012, respectively). The area under the receiver operating characteristic curve (AUC) of the BP-Ktrans (0.687) was highest among the single parameters and higher than that of the lesion-Ktrans (0.664). The combined logistic regression model of lesion-Ktrans , lesion-ve , BP-Ktrans , BP-ve , and BP-vp had the highest AUC of 0.730. CONCLUSION: Our results suggest that the contrast kinetic analysis of DCE-MRI data can be used to differentiate the malignant lesions from the benign and high-risk lesions among the indeterminate breast lesions recommended for MRI-guided biopsy exams. LEVEL OF EVIDENCE: 3 J. Magn. Reson. Imaging 2016.

Breast cancer is the most common female malignancy and the second leading cause of female cancer death in the United States. Although the majority of palpable breast lumps are benign, a new palpable breast mass is a common presenting sign of breast cancer. Any woman presenting with a palpable lesion should have a thorough clinical breast examination, but because many breast masses may not exhibit distinctive physical findings, imaging evaluation is necessary in almost all cases to characterize the palpable lesion. Recommended imaging options in the context of a palpable mass include diagnostic mammography and targeted-breast ultrasound and are dependent on patient age and degree of radiologic suspicion as detailed in the document Variants. There is little role for advanced technologies such as MRI, positron emission mammography, or molecular breast imaging in the evaluation of a palpable mass. When a suspicious finding is identified, biopsy is indicated. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Appropriate imaging evaluation of nipple discharge depends the nature of the discharge. Imaging is not indicated for women with physiologic nipple discharge. For evaluation of pathologic nipple discharge, multiple breast imaging modalities are rated for evidence-based appropriateness under various scenarios. For women age 40 or older, mammography or digital breast tomosynthesis (DBT) should be the initial examination. Ultrasound is usually added as a complementary examination, with some exceptions. For women age 30 to 39, either mammogram or ultrasound may be used as the initial examination on the basis of institutional preference. For women age 30 or younger, ultrasound should be the initial examination, with mammography/DBT added when ultrasound shows suspicious findings or if the patient is predisposed to developing breast cancer. For men age 25 or older, mammography/DBT should be performed initially, with ultrasound added as indicated, given the high incidence of breast cancer in men with pathologic nipple discharge. Although MRI and ductography are not usually appropriate as initial examinations, each may be useful when the initial standard imaging evaluation is negative. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Breast and whole-body PET/MR imaging is being used to detect local and metastatic disease and is being investigated for potential imaging biomarkers, which may eventually help personalize treatments and prognoses. This article provides an overview of breast and whole-body PET/MR exam techniques, summarizes PET and MR breast imaging for lesion detection, outlines investigations into multi-parametric breast PET/MR, looks at breast PET/MR in the setting of neo-adjuvant chemotherapy, and reviews the pros and cons of whole-body PET/MR in the setting of metastatic or suspected metastatic breast cancer.

Women and health care professionals generally prefer intensive follow-up after a diagnosis of breast cancer. However, there are no survival differences between women who obtain intensive surveillance with imaging and laboratory studies compared with women who only undergo testing because of the development of symptoms or findings on clinical examinations. American Society of Clinical Oncology and National Comprehensive Cancer Network guidelines state that annual mammography is the only imaging examination that should be performed to detect a localized breast recurrence in asymptomatic patients; more imaging may be needed if the patient has locoregional symptoms (eg, palpable abnormality). Women with other risk factors that increase their lifetime risk for breast cancer may warrant evaluation with breast MRI. Furthermore, the quality of life is similar for women who undergo intensive surveillance compared with those who do not. There is little justification for imaging to detect or rule out metastasis in asymptomatic women with newly diagnosed stage I breast cancer. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Breast pain (or tenderness) is a common symptom, experienced by up to 80% of women at some point in their lives. Fortunately, it is rarely associated with breast cancer. However, breast pain remains a common cause of referral for diagnostic breast imaging evaluation. Appropriate workup depends on the nature and focality of the pain, as well as the age of the patient. Imaging evaluation is usually not indicated if the pain is cyclic or nonfocal. For focal, noncyclic pain, imaging may be appropriate, mainly for reassurance and to identify treatable causes. Ultrasound can be the initial examination used to evaluate women under 30 with focal, noncyclic breast pain; for women 30 and older, diagnostic mammography, digital breast tomosynthesis, and ultrasound may all serve as appropriate initial examinations. However, even in the setting of focal, noncyclic pain, cancer as an etiology is rare. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer-reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Recent advances in deep learning for object recognition in natural images has prompted a surge of interest in applying a similar set of techniques to medical images. Most of the initial attempts largely focused on replacing the input to such a deep convolutional neural network from a natural image to a medical image. This, however, does not take into consideration the fundamental differences between these two types of data. More specifically, detection or recognition of an anomaly in medical images depends significantly on fine details, unlike object recognition in natural images where coarser, more global structures matter more. This difference makes it inadequate to use the existing deep convolutional neural networks architectures, which were developed for natural images, because they rely on heavily downsampling an image to a much lower resolution to reduce the memory requirements. This hides details necessary to make accurate predictions for medical images. Furthermore, a single exam in medical imaging often comes with a set of different views which must be seamlessly fused in order to reach a correct conclusion. In our work, we propose to use a multi-view deep convolutional neural network that handles a set of more than one high-resolution medical image. We evaluate this network on large-scale mammography-based breast cancer screening (BI-RADS prediction) using 103 thousand images. We focus on investigating the impact of training set sizes and image sizes on the prediction accuracy. Our results highlight that performance clearly increases with the size of training set, and that the best performance can only be achieved using the images in the original resolution. This suggests the future direction of medical imaging research using deep neural networks is to utilize as much data as possible with the least amount of potentially harmful preprocessing

OBJECTIVES: This study was performed to determine the frequency, predictors, and outcomes of ultrasound (US) correlates for non-mass enhancement. METHODS: From January 2005 to December 2011, a retrospective review of 5837 consecutive breast magnetic resonance imaging examinations at our institution identified 918 non-mass enhancing lesions for which follow-up or biopsy was recommended. Retrospective review of the images identified 879 of 918 lesions (96%) meeting criteria for non-mass enhancement. Patient demographics, pathologic results, and the presence of an adjacent landmark were recorded. Targeted US examinations were recommended for 331 of 879 cases (38%), and 284 of 331 women (86%) underwent US evaluations. RESULTS: The US correlate rate for non-mass enhancement was 23% (64 of 284). An adjacent landmark was significantly associated with a US correlate (P < .001). Biopsy was recommended for 43 of 64 correlates (67%). Ultrasound-guided biopsy was performed on 39 of 43 (91%); 7 of 39 (18%) were malignant. No correlate was seen for 220 of 284 lesions (77%). At magnetic resonance imaging-guided biopsy, 14 of 117 (12%) were malignancies. For all biopsied non-mass enhancements, the malignancy rate was 18% (55 of 308) and was significantly more prevalent in the setting of a known index cancer (P < .001), older age (P < .001), the presence of a landmark (P = .002), and larger lesion size (P = .019). CONCLUSIONS: Non-mass enhancement with an adjacent landmark is more likely to have a US correlate compared to non-mass enhancement without an adjacent landmark. Non-mass enhancement in the setting of a known index cancer, older age, a landmark, and larger lesion size is more likely to be malignant. However, no statistical difference was detected in the rate of malignancy between non-mass enhancement with (18%) or without (12%) a correlate. Absence of a correlate does not obviate the need to biopsy suspicious non-mass enhancement.