Faculty Bibliography

OBJECTIVE:The purpose of this article is to compare traditional versus machine learning-based computer-aided detection (CAD) platforms in breast imaging with a focus on mammography, to underscore limitations of traditional CAD, and to highlight potential solutions in new CAD systems under development for the future. CONCLUSION/CONCLUSIONS:CAD development for breast imaging is undergoing a paradigm shift based on vast improvement of computing power and rapid emergence of advanced deep learning algorithms, heralding new systems that may hold real potential to improve clinical care.

Although the majority of male breast problems are benign with gynecomastia as the most common etiology, men with breast symptoms and their referring providers are typically concerned about whether or not it is due to breast cancer. If the differentiation between benign disease and breast cancer cannot be made on the basis of clinical findings, or if the clinical presentation is suspicious, imaging is indicated. The panel recommends the following approach to breast imaging in symptomatic men. In men with clinical findings consistent with gynecomastia or pseudogynecomastia, no imaging is routinely recommended. If an indeterminate breast mass is identified, the initial recommended imaging study is ultrasound in men younger than age 25, and mammography or digital breast tomosynthesis in men age 25 and older. If physical examination is suspicious for a male breast cancer, mammography or digital breast tomosynthesis is recommended irrespective of patient age. 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 is a common complaint. However, in the absence any accompanying suspicious clinical finding (eg, lump or nipple discharge), the association with malignancy is very low (0%-3.0%). When malignancy-related, breast pain tends to be focal (less than one quadrant) and persistent. Pain that is clinically insignificant (nonfocal [greater than one quadrant], diffuse, or cyclical) requires no imaging beyond what is recommended for screening. In cases of pain that is clinically significant (focal and noncyclical), imaging with mammography, digital breast tomosynthesis (DBT), and ultrasound are appropriate, depending on the patient's age. 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.

BACKGROUND: Screening breast MRI has been shown to preferentially detect high-grade ductal carcinoma in situ (DCIS) and invasive carcinoma, likely due to increased angiogenesis resulting in early initial uptake of contrast. As interest grows in abbreviated screening breast MRI (AB-MRI), markers of early contrast washin that can predict tumor grade and potential aggressiveness are of clinical interest. PURPOSE: To evaluate the feasibility of using the initial enhancement ratio (IER) as a surrogate marker for tumor grade, hormone receptor status, and prognostic markers, as an initial step to being incorporated into AB-MRI. STUDY TYPE: Retrospective. SUBJECTS: In all, 162 women (mean 55.0 years, range 32.8-87.7 years) with 187 malignancies imaged January 2012-November 2015. FIELD STRENGTH/SEQUENCE: Images were acquired at 3.0T with a T1 -weighted gradient echo fat-suppressed-volume interpolated breath-hold sequence. ASSESSMENT: Subjects underwent dynamic contrast-enhanced breast MRI with a 7-channel breast coil. IER (% signal increase over baseline at the first postcontrast acquisition) was assessed and correlated with background parenchymal enhancement, washout curves, stage, and final pathology. STATISTICAL TESTS: Chi-square test, Spearman rank correlation, Mann-Whitney U-tests, Bland-Altman analysis, and receiver operating characteristic curve analysis. RESULTS: IER was higher for invasive cancer than for DCIS (R1/R2, P < 0.001). IER increased with tumor grade (R1: r = 0.56, P < 0.001, R2: r = 0.50, P < 0.001), as ki-67 increased (R1: r = 0.35, P < 0.001; R2 r = 0.35, P < 0.001), and for node-positive disease (R1/R2, P = 0.001). IER was higher for human epidermal growth factor receptor two-positive and triple negative cancers than for estrogen receptor-positive / progesterone receptor-positive tumors (R1 P < 0.001-0.002; R2 P = 0.0.001-0.011). IER had higher sensitivity (80.6% vs. 75.5%) and specificity (55.8% vs. 48.1%) than washout curves for positive nodes, higher specificity (48.1% vs. 36.5%) and positive predictive value (70.2% vs. 66.7%) for high ki-67, and excellent interobserver agreement (intraclass correlation coefficient = 0.82). DATA CONCLUSION: IER, a measurement of early contrast washin, is associated with higher-grade malignancies and tumor aggressiveness and might be potentially incorporated into an AB-MRI protocol. LEVEL OF EVIDENCE: 3 Technical Efficacy Stage 2 J. Magn. Reson. Imaging 2017.

Breast implant imaging varies depending on patient age, implant type, and symptoms. For asymptomatic patients (any age, any implant), imaging is not recommended. Rupture of saline implants is often clinically evident, as the saline is resorbed and there is a change in breast contour. With saline implants and equivocal clinical findings, ultrasound (US) is the examination of choice for patients less than 30 years of age, either mammography/digital breast tomosynthesis or US may be used for those 30 to 39 years of age, and mammography/digital breast tomosynthesis is used for those 40 years and older. For patients with suspected silicone implant complication, MRI without contrast or US is used for those less than 30 years of age; MRI without contrast, mammography/digital breast tomosynthesis, or US may be used for those 30 to 39 years of age; and MRI without contrast or mammography/digital breast tomosynthesis is used for those 40 years and older. Patients with unexplained axillary adenopathy and silicone implants (current or prior) are evaluated with axillary US. For patients 30 years and older, mammography/digital breast tomosynthesis is performed in conjunction with US. Last, patients with suspected breast implant-associated anaplastic large-cell lymphoma are first evaluated with US, regardless of age or implant type. 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.

Purpose To assess adherence with annual or biennial screening mammography after a diagnosis of high-risk lesion(s) at stereotactic biopsy with or without surgical excision and to identify clinical factors that may affect screening adherence after a high-risk diagnosis. Materials and Methods This institutional review board-approved HIPAA-compliant retrospective study included 208 patients who underwent stereotactic biopsy between January 2012 and December 2014 that revealed a high-risk lesion. Whether the patient underwent surgical excision and/or follow-up mammography was documented. Adherence of these women to a protocol of subsequent mammography within 1 year (9-18 months) or within 2 years (9-30 months) was compared with that of 45 508 women with normal screening mammograms who were imaged during the same time period at the same institution. Possible factors relevant to postdiagnosis management and screening adherence were assessed. Consultation with a breast surgeon was identified by reviewing clinical notes. Uptake of pharmacologic chemoprevention following diagnosis (patient decision to take chemopreventive medications) was assessed. The Fisher exact test was used to compare annual or biennial screening adherence rates. Binary logistic regression was used to identify factors predictive of whether women returned for screening within selected time frames. Results In total, 913 (1.3%) of 67 874 women were given a recommendation to undergo stereotactic biopsy, resulting in diagnosis of 208 (22.8%) of 913 high-risk lesions. Excluding those with a prior personal history of breast cancer or upgrade to cancer at surgery, 124 (66.7%) of 186 women underwent surgery and 62 (33.3%) did not. Overall post-high-risk diagnosis adherence to annual or biennial mammography was similar to that in control subjects (annual, 56.4% vs 50.8%, P = .160; biennial, 62.0% vs 60.1%, P = .630). Adherence was significantly better in the surgical group than in the nonsurgical group for annual mammography (70.0% vs 32.0%; odds ratio [OR] = 5.0; 95% confidence interval [CI]: 2.4, 10.1; P < .001) and for biennial mammography (74.3% vs 40.0%; OR = 4.3; 95% CI: 2.1, 8.8; P < .001). Among the patients in the nonsurgical group, those adherent to annual or biennial mammography were significantly more likely to have seen a breast surgeon than the nonadherent women (annual, 77.3% vs 35.7%, P = .005; biennial, 67.9% vs 36.4%, P = .045). All patients receiving chemopreventive agents underwent a surgical consultation (100%; n = 21). Conclusion Although diagnosis of a high-risk lesion at stereotactic breast biopsy did not compromise overall adherence to subsequent mammographic screening, patients without surgical excision, particularly those who did not undergo a surgical consultation, had significantly lower imaging adherence and chemoprevention uptake as compared with their counterparts who underwent surgery, suggesting that specialist care may be important in optimizing management. © RSNA, 2018.

PURPOSE/OBJECTIVE:To evaluate whether false-positive stereotactic vacuum-assisted breast biopsy (SVAB) affects subsequent mammographic screening adherence. MATERIALS AND METHODS/METHODS:tests. RESULTS:There were 913 SVABs performed in 2012 to 2014 for imaging detected lesions; of these, malignant or high-risk lesions or biopsies resulting in a recommendation of surgical excision were excluded, leaving 395 SVABs yielding benign pathology in 395 women. Findings were matched with a control population consisting of 45,126 women who had a BI-RADS 1 or 2 screening mammogram and did not undergo breast biopsy. In all, 191 of 395 (48.4%) women with a biopsy with benign results and 22,668 of 45,126 (50.2%) women without biopsy returned for annual follow-up >9 months and ≤18 months after the index examination (P = .479). In addition, 57 of 395 (14.4%) women with a biopsy with benign results and 3,336 of 45,126 (7.4%) women without biopsy returned for annual follow-up >18 months after the index examination (P < .001). Older women, women with personal history of breast cancer, and women with postbiopsy complication after benign SVAB were more likely to return for screening (P = .026, P = .028, and P = .026, respectively). CONCLUSION/CONCLUSIONS:The findings in our study suggest that SVABs with benign results do not negatively impact screening mammography adherence. The previously described "harms" of false-positive mammography and biopsy may be exaggerated.

Patients with locally advanced invasive breast cancers are often treated with neoadjuvant chemotherapy prior to definitive surgical intervention. The primary aims of this approach are to: 1) reduce tumor burden thereby permitting breast conservation rather than mastectomy; 2) promptly treat possible metastatic disease, whether or not it is detectable on preoperative staging; and 3) potentially tailor future chemotherapeutic decisions by monitoring in-vivo tumor response. Accurate radiological assessment permits optimal management and planning in this population. However, assessment of tumor size and response to treatment can vary depending on the modality used, the measurement technique (such as single longest diameter, 3-D measurements, or calculated tumor volume), and varied response of different tumor subtypes to neoadjuvant chemotherapy (such as concentric shrinkage or tumor fragmentation). As discussed in further detail, digital mammography, digital breast tomosynthesis, US and MRI represent the key modalities with potential to help guide patient management. 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 cancer screening recommendations are based on risk factors. For average-risk women, screening mammography and/or digital breast tomosynthesis is recommended beginning at age 40. Ultrasound (US) may be useful as an adjunct to mammography for incremental cancer detection in women with dense breasts, but the balance between increased cancer detection and the increased risk of a false-positive examination should be considered in the decision. For intermediate-risk women, US or MRI may be indicated as an adjunct to mammography depending upon specific risk factors. For women at high risk due to prior mantle radiation between the ages of 10 to 30, mammography is recommended starting 8 years after radiation therapy but not before age 25. For women with a genetic predisposition, annual screening mammography is recommended beginning 10 years earlier than the affected relative at the time of diagnosis but not before age 30. Annual screening MRI is recommended in high-risk women as an adjunct to mammography. 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.