A survey by the European Society of Breast Imaging on radiologists' preferences regarding quality assurance measures of image interpretation in screening and diagnostic mammography

OBJECTIVES: Quality assurance (QA) of image interpretation plays a key role in screening and diagnostic mammography, maintaining minimum standards and supporting continuous improvement in interpreting images. However, the QA structure across Europe shows considerable variation. The European Society of Breast Imaging (EUSOBI) conducted a survey among the members to collect information on radiologists' preferences regarding QA measures in mammography. MATERIALS AND METHODS: An anonymous online survey consisting of 25 questions was distributed to all EUSOBI members and national breast radiology bodies in Europe. The questions were designed to collect demographic characteristics, information on responders' mammography workload and data about QA measures currently used in their country. Data was analysed using descriptive statistical analysis, the χ 2 test, linear regression, and Durbin-Watson statistic test. RESULTS: In total, 251 breast radiologists from 34 countries completed the survey. Most respondents were providing both screening and symptomatic services (137/251, 54.6%), working in an academic hospital (85/251, 33.9%) and reading 1000-4999 cases per year (109/251, 43.4%). More than half of them (133/251, 53%) had established QA measures in their workplace. Although less than one-third (71/251, 28.3%) had to participate in regular performance testing, the vast majority (190/251, 75.7%) agreed that a mandatory test would be helpful to improve their skills. CONCLUSION: QA measures were in place for more than half of the respondents working in screening and diagnostic mammography to evaluate their breast imaging performance. Although there were substantial differences between countries, the importance of having QA in the workplace and implemented was widely acknowledged by radiologists. CLINICAL RELEVANCE STATEMENT: Although several quality assurance (QA) measures of image interpretation are recommended by European bodies or national organisations, the QA in mammography is quite heterogenous between countries and reporting settings, and not always actively implemented across Europe. KEY POINTS: The first survey that presents radiologists' preferences regarding QA measures of image interpretation in mammography. Quality assurance measures in the workplace are better-established for breast screening compared to diagnostic mammography. Radiologists consider that performance tests would help to improve their mammography interpretation skills

Third International Consensus Conference on lesions of uncertain malignant potential in the breast (B3 lesions)

The heterogeneous group of B3 lesions in the breast harbors lesions with different malignant potential and progression risk. As several studies about B3 lesions have been published since the last Consensus in 2018, the 3rd International Consensus Conference discussed the six most relevant B3 lesions (atypical ductal hyperplasia (ADH), flat epithelial atypia (FEA), classical lobular neoplasia (LN), radial scar (RS), papillary lesions (PL) without atypia, and phyllodes tumors (PT)) and made recommendations for diagnostic and therapeutic approaches. Following a presentation of current data of each B3 lesion, the international and interdisciplinary panel of 33 specialists and key opinion leaders voted on the recommendations for further management after core-needle biopsy (CNB) and vacuum-assisted biopsy (VAB). In case of B3 lesion diagnosis on CNB, OE was recommended in ADH and PT, whereas in the other B3 lesions, vacuum-assisted excision was considered an equivalent alternative to OE. In ADH, most panelists (76%) recommended an open excision (OE) after diagnosis on VAB, whereas observation after a complete VAB-removal on imaging was accepted by 34%. In LN, the majority of the panel (90%) preferred observation following complete VAB-removal. Results were similar in RS (82%), PL (100%), and FEA (100%). In benign PT, a slim majority (55%) also recommended an observation after a complete VAB-removal. VAB with subsequent active surveillance can replace an open surgical intervention for most B3 lesions (RS, FEA, PL, PT, and LN). Compared to previous recommendations, there is an increasing trend to a de-escalating strategy in classical LN. Due to the higher risk of upgrade into malignancy, OE remains the preferred approach after the diagnosis of ADH

Arbeitsgemeinschaft Gynäkologische Onkologie Recommendations for the Diagnosis and Treatment of Patients with Early Breast Cancer: Update 2023

Background: Each year the interdisciplinary Arbeitsgemeinschaft Gynäkologische Onkologie (AGO), German Gynecological Oncology Group Breast Committee on Diagnosis and Treatment of Breast Cancer provides updated state-of-the-art recommendations for early and metastatic breast cancer. Summary: The updated evidence-based treatment recommendation for early and metastatic breast cancer has been released in March 2023. Key Messages: This paper concisely captures the updated recommendations for early breast cancer chapter by chapter

AGO Recommendations for the Diagnosis and Treatment of Patients with Locally Advanced and Metastatic Breast Cancer: Update 2022

The Breast Committee of the Arbeitsgemeinschaft Gynakologische Onkologie (German Gynecological Oncology Group, AGO) presents the 2022 update of the evidence-based recommendations for the diagnosis and treatment of patients with locally advanced and metastatic breast cancer

AGO Recommendations for the Diagnosis and Treatment of Patients with Locally Advanced and Metastatic Breast Cancer: Update 2023

The Breast Committee of the Arbeitsgemeinschaft Gynakologische Onkologie (German Gynecological Oncology Group, AGO) presents the 2023 update of the evidence-based recommendations for the diagnosis and treatment of patients with locally advanced and metastatic breast cancer (mBC)

Third International Consensus Conference on lesions of uncertain malignant potential in the breast (B3 lesions)

The heterogeneous group of B3 lesions in the breast harbors lesions with different malignant potential and progression risk. As several studies about B3 lesions have been published since the last Consensus in 2018, the 3rd International Consensus Conference discussed the six most relevant B3 lesions (atypical ductal hyperplasia (ADH), flat epithelial atypia (FEA), classical lobular neoplasia (LN), radial scar (RS), papillary lesions (PL) without atypia, and phyllodes tumors (PT)) and made recommendations for diagnostic and therapeutic approaches. Following a presentation of current data of each B3 lesion, the international and interdisciplinary panel of 33 specialists and key opinion leaders voted on the recommendations for further management after core-needle biopsy (CNB) and vacuum-assisted biopsy (VAB). In case of B3 lesion diagnosis on CNB, OE was recommended in ADH and PT, whereas in the other B3 lesions, vacuum-assisted excision was considered an equivalent alternative to OE. In ADH, most panelists (76%) recommended an open excision (OE) after diagnosis on VAB, whereas observation after a complete VAB-removal on imaging was accepted by 34%. In LN, the majority of the panel (90%) preferred observation following complete VAB-removal. Results were similar in RS (82%), PL (100%), and FEA (100%). In benign PT, a slim majority (55%) also recommended an observation after a complete VAB-removal. VAB with subsequent active surveillance can replace an open surgical intervention for most B3 lesions (RS, FEA, PL, PT, and LN). Compared to previous recommendations, there is an increasing trend to a de-escalating strategy in classical LN. Due to the higher risk of upgrade into malignancy, OE remains the preferred approach after the diagnosis of ADH

Image-guided breast biopsy and localisation: recommendations for information to women and referring physicians by the European Society of Breast Imaging

Abstract: We summarise here the information to be provided to women and referring physicians about percutaneous breast biopsy and lesion localisation under imaging guidance. After explaining why a preoperative diagnosis with a percutaneous biopsy is preferred to surgical biopsy, we illustrate the criteria used by radiologists for choosing the most appropriate combination of device type for sampling and imaging technique for guidance. Then, we describe the commonly used devices, from fine-needle sampling to tissue biopsy with larger needles, namely core needle biopsy and vacuum-assisted biopsy, and how mammography, digital breast tomosynthesis, ultrasound, or magnetic resonance imaging work for targeting the lesion for sampling or localisation. The differences among the techniques available for localisation (carbon marking, metallic wire, radiotracer injection, radioactive seed, and magnetic seed localisation) are illustrated. Type and rate of possible complications are described and the issue of concomitant antiplatelet or anticoagulant therapy is also addressed. The importance of pathological-radiological correlation is highlighted: when evaluating the results of any needle sampling, the radiologist must check the concordance between the cytology/pathology report of the sample and the radiological appearance of the biopsied lesion. We recommend that special attention is paid to a proper and tactful approach when communicating to the woman the need for tissue sampling as well as the possibility of cancer diagnosis, repeat tissue sampling, and or even surgery when tissue sampling shows a lesion with uncertain malignant potential (also referred to as “high-risk” or B3 lesions). Finally, seven frequently asked questions are answered

challenges, limitations and technical innovations

Das älteste Verfahren zur dedizierten Brustkrebsdiagnostik, die Röntgen- Mammographie, ist besonders bei Frauen mit dichtem Brustdrüsengewebe limitiert. Ihre Weiterentwicklung und die Etablierung alternativer Untersuchungsverfahren, die eine Verstärkung des Kontrasts zwischen Gewebe und Tumor, hauptsächlich durch den Einsatz von Kontrastmitteln erreichen wollen, stellt daher aktuell einen Schwerpunkt der radiologischen Forschung dar. Ziel dieser Arbeit war es zum einen, das Verhalten von modernen, ionischen und nicht-ionischen makrozyklischen gadoliniumhaltigen Kontrastmitteln in der MRT der Mamma zu vergleichen und zum anderen die Anwendbarkeit von jodhaltigen Kontrast¬mitteln in der Röntgen-Mammographie zu testen und den Einfluss auf die diagnostische Genauigkeit im Vergleich zur konventionellen MG und zur MRT zu überprüfen. Da die modernen makrozyklischen MRT-Kontrastmittel unterschiedliche Ladungseigenschaften besitzen und die Ladung einen Einfluss auf das Anreicherungsverhalten aufweist, war es Ziel unserer ersten Studien, das nicht-ionische Gadobutrol und das ionische Gd-DOTA bezüglich ihres dynamischen und quantitativen relativen Anreicherungsverhaltens bei benignen und malignen Mammaläsionen in einem intraindividuellen Vergleich zu untersuchen. Hier konnten wir sowohl in einer manuellen Auswertung, die die klinische Praxis widerspiegelt (Publikation 1), als auch mit einer vollautomatischen computerunterstützten Analyse (Publikation 2) zeigen, dass sich die beiden Kontrastmittel sowohl in der Signalintensität als auch in dem dynamischen Verhalten signifikant unterscheiden. So zeigte Gadobutrol ein signifikant höheres initiales Enhancement als Gd-DOTA (p<0,001) und mit 64,4 % im Vergleich zu 75,6 % ein signifikant geringeres Washout bei malignen Läsionen in der manuellen Auswertung. Auch in der computerassistierten Auswertung konnten diese Signifikanzen bestätigt werden. Daher ist es bei der dynamischen MRT der Mamma unverzichtbar, die Art des Kontrastmittels zu kennen und bei der Beurteilung der Ergebnisse auch die Besonderheiten der unterschiedlichen Kontrastmittel zu berücksichtigen. Die Entwicklungen in der Röntgenmammographie ermöglichen inzwischen die Darstellung der Aufnahme von jodhaltigem Kontrastmittel in Mammatumoren. Hier stellte sich primär die Frage nach der generellen Durchführbarkeit und sekundär nach dem Einfluss auf die diagnostische Genauigkeit. Da die kontrastmittelverstärkte Mammographie als komple-mentäres Verfahren zu der MRT gesehen wurde, wurde in unserer Publikation 3 zunächst ein dynamischer, temporaler Untersuchungsablauf evaluiert. Hier konnte eine deutliche Detektionsverbesserung von 19 % im Allgemeinen und von 24 % bei sehr dichtem Brustdrüsengewebe erreicht werden. In einer ROC-Analyse waren die Unter-schiede für alle Befunder signifikant. Die kinetische Information zeigt jedoch eine sehr große Variation und wurde als eine Herausforderung angesehen. Limitiert war dieser Untersuchungsansatz durch die Beschränkung auf die Untersuchung nur einer Brust in einer Ebene. Da es aber häufig auch kontralaterale Karzinome gibt oder in der Abklärung Fragen zur Gegenseite auftauchen, wurde ein Untersuchungsansatz mit der Möglichkeit der Darstellung beider Mammae gesucht. Hier konnte erfolgreich die spektrale dual-Energy-Mammographie eingesetzt werden, bei der eine Doppelbelichtung der Brust mit hoch- und niedrigenergetischen Röntgenspektren und anschließender Rekombination dieser Aufnahmen erfolgt. In der initialen Studie (Publikation 4) konnten wir bei 110 Frauen mit 148 Mammaläsionen eine signifikante Verbesserung der klinischen Performance durch Einsatz der CESM als Ergänzung zur Mammographie im Vergleich zur Mammographie inklusive Ultraschall erreichen. Die Sensitivität pro Läsion konnte von 71 % auf 78 % signifikant verbessert werden, ebenso die ROC Ergebnisse von 0,81 auf 0,87 (p=0,045). Da bisher die kontrastmittelverstärkte Mammographie immer als Ergänzung und nie als alleinige initiale diagnostische Methode eingesetzt wurde, war dies mit einer erhöhten Strahlenexposition für die Patientinnen verbunden. Da aber der größte Nutzen bei jungen Patientinnen mit dichtem Brustdrüsengewebe zu erwarten ist, und diese Patientengruppe sensibler auf Röntgenstrahlen reagiert, stellte sich die Frage, ob die CESM alleine ausreichend ist, eine Detektionsverbesserung zu erreichen und somit nahezu 50 % der Strahlendosis eingespart werden kann. Dieser Frage gingen wir in der als Publikation 5 eingeschlossenen Studie nach. Hier wurde die CESM+/-Mammographie mit der MG alleine verglichen. Die erreichten Sensitivitäten von 94,7 % in der CESM versus 95 % in der CESM+MG unterschieden sich nicht, beide Varianten waren jedoch der MG mit einer Sensitivität von 77,9 % signifikant überlegen. Die mittlere AGD betrug 1,89 mGy für die CESM, 1.78 mGy für die MG und 3.67 mGy für die Kombination von beiden. Bei sehr dichtem Drüsengewebe war die AGD der CESM signifikant niedriger als die der MG. Diese Daten bestätigen die initiale These, dass besonders bei Patienten mit dichtem Brustdrüsengewebe auf die zusätzliche konventionelle Mammographie verzichtet werden kann. Somit kann folglich bis zu 61 % der Parenchymdosis eingespart werden. Die erfolgversprechenden Ergebnisse der kontrastmittelverstärkten Mammographie führten zu der Frage, inwieweit diese Methode mit der MRT, dem Goldstandard der kontrastmittelverstärkten Bildgebung der Brust, vergleichbar sind und konkurrieren können. Hierzu wurden die MG, CESM und MRT in einem Vergleich der diagnostischen Genauig-keit bezogen auf Indexläsionen untersucht (Publikation 6). In dieser abschließenden Untersuchung wurde bei 80 Frauen die MRT mit der bilateralen CESM ohne dynamische Information und der MG in Bezug auf die korrekte Detektion und Größenbestimmung histologisch gesicherter Mammakarzinome verglichen. Hier zeigte die CESM eine Sensitivität von 100 % und die MRT von 97,4 %. Beide waren der MG mit 83,5 % signifikant überlegen. Die CESM wies die beste Korrelation der Tumorgröße mit der postoperativen Histologie auf. Zusammenfassend zeigen die vorgelegten Studien, dass aufgrund unterschiedlicher Eigenschaften von Kontrastmitteln in der MRT der Mamma, die Art des verwendeten Kontrastmittels bei der Beurteilung von Befunden berücksichtigt werden muss, da sie unterschiedlichen Einfluss auf das dynamische Anreicherungsverhalten haben. Inwieweit dies die Sensitivität und Spezifität der Methode beeinflusst, bleibt Gegenstand weiterer Untersuchungen. Die kontrastmittelverstärkte Mammographie und hier besonders die CESM stellt ein gutes und verlässliches Verfahren als Ergänzung zu den bisherigen Methoden der Mammabildgebung dar. Die bilaterale Darstellung bietet praktische Vorteile gegenüber der zeitlich aufgelösten kontrastmittelverstärkten Mammographie einer Seite in nur einer Ebene. Erste Ergebnisse im Vergleich zur MRT zeigen die bilaterale CESM mit vergleichbar guten Resultaten wie die MRT, sodass die Indikationen für die CESM ähnlich zu denen der MRT erwartet werden können. Auch stellt die CESM eine gute Alternative zur MRT dar, wenn diese aus den unterschiedlichsten Gründen nicht durchführbar ist. Der primäre Einsatz der CESM unter Verzicht auf die MG bietet ein erhebliches Dosis-einsparpotential. Die vorgestellten Studien bieten zahlreiche Anregungen für weitere wissenschaftliche Forschungsprojekte zur Verbesserung der diagnostischen Genauigkeit und Behandlungs-planung bei der Suche nach und Therapie des Mammakarzinoms.The oldest technique dedicated to breast-cancer diagnosis, x-ray mammography, has considerable limitations in patients with dense breast tissue. Therefore it is a central focus of current research on breast cancer to increase the contrast between tissue and tumor, primarily with the use of contrast-agents. The main goal of this body of work was to compare modern ionic and non-ionic macrocyclic gadolinium-containing contrast-agents when used for breast MRI and to research the applicability of iodine-containing contrast-agents for x-ray mammography. Furthermore their effect on accuracy in diagnostics when compared to conventional mammograms and MRIs was investigated. Modern macrocyclic MRI contrast-agents have differing electrical properties, specifically their charge significantly influences their enhancement. Because of this, a goal of our first studies was to evaluate both the non-ionic Gadobutrol and the ionic Gd-DOTA for their relative enhancement in benign and malignant breast lesions. For publication 1 we investigated a setup similar to clinical practice (manual examination) and for publication 2 a fully automated computer-aided analysis. Here we demonstrated a statistically significant difference in contrast-agent intensity and dynamics. In the manual examination Gabobutrol showed a significantly higher initial enhancement than Gd-DOTA (p<0.001) and a significantly decreased wash-out for malignant lesions in the manual examination (64.4% / 75.6%). We showed similar results in the computer-aided analysis. It is therefore essential to be aware of the properties of the different contrast-agents for dynamic breast-MRI. Breast mammography allows the display of iodine-containing contrast agent uptake in breast tumors. The main questions here are the feasibility of the examination and how much this influences diagnostic accuracy. Because contrast-enhanced mammography is seen as a complementary technique to MRI, we first evaluated a dynamic temporal examination procedure for publication 3. Here, significant increases in detection rates were observed, 19% total and 24% for very dense breast tissue. The ROC analysis resulted in statistical significance for each reader. Kinetic information showed significant variation and proved challenging. The sole examination of one plane in one breast per patient was the main limitation of this study. As contralateral carcinomas are common and both breasts should be evaluated we looked for the ability to examine both breasts. Low-dose dual- energy spectral mammography examines both low- and high energy x-rays and recombines them for analysis. This approach was successfully used and in our initial study (publication 4) we were able to measure a significant improvement of clinical performance when comparing mammography + CESM to mammography + ultrasound. The study included 110 women with 148 breast lesions. The sensitivity for detecting breast lesions was increased from 71% to 78%, the ROC results from 0.81 to 0.87 (p=0.045). As contrast-enhanced mammography was always used in addition to regular diagnostics, it resulted in an increased radiation dosage to the patient. As the most significant utility was shown for women with dense breast-tissue, and because these women react more strongly to x-rays, the question arises if CESM alone would be sufficient for an increased detection-rate while decreasing radiation exposure by nearly 50%. We evaluated this question in publication 5, here we compared CESM+/-mammography with mammography. Sensitivities of 94.6% for CESM and 95% for CESM+MG were not significantly different, both options however were significantly better than mammography alone with a sensitivity of 77.9%. The AGD was 1.89 mGy for CESM, 1.78 mGy for mammography and 3.67 mGy for the combination. The AGD was significantly lower for CESM than in mammography for very dense breast tissue. This confirms the initial hypothesis that for patients with very dense breast tissue conventional mammography can be avoided which results in a reduction of 61% in parenchymal radiation dosage. These promising results lead us to question how well this method fares in comparison to MRI, the gold standard of contrast-enhanced imaging of the breast. Here we compared the diagnostic accuracy of mammography, CESM and MRI for index lesions (publication 6). In this final examination we compared MRI with bilateral CESM without dynamic information and mammography in 80 women to study detection rates and size-measurements in histologically verified breast- carcinoma. CESM resulted in a sensitivity of 100%, MRI in 97.4% - both were statistically significant improvements over mammography with a sensitivity of 83.5%. CESM showed the best correlation between tumor size and post-operative histology. In summary these studies show the importance of evaluating the contrast-agents for breast-MRI as they interact differently with breast lesions and show different enhancement. How much this influences sensitivity and specificity needs to be studied further. Contrast-enhanced breast mammography and specifically CESM has been established as a reliable technique to supplement current methods in breast imaging. Bilateral imaging provides advantages over one-sided imaging for time series of contrast-enhanced mammography. Comparing MRI to bilateral CESM showed similar results and similar indications should lead towards CESM imaging. CESM is a suitable alternative for MRI in settings without access to MRI. The initial usage of CESM without a conventional mammogram allows a significant reduction in radiation exposure. The presented studies provide ample suggestions for further research to improve diagnostic accuracy and therapeutic management of breast cancer

A survey by the European Society of Breast Imaging on radiologists’ preferences regarding quality assurance measures of image interpretation in screening and diagnostic mammography

Objectives: Quality assurance (QA) of image interpretation plays a key role in screening and diagnostic mammography, maintaining minimum standards and supporting continuous improvement in interpreting images. However, the QA structure across Europe shows considerable variation. The European Society of Breast Imaging (EUSOBI) conducted a survey among the members to collect information on radiologists’ preferences regarding QA measures in mammography. Materials and methods: An anonymous online survey consisting of 25 questions was distributed to all EUSOBI members and national breast radiology bodies in Europe. The questions were designed to collect demographic characteristics, information on responders’ mammography workload and data about QA measures currently used in their country. Data was analysed using descriptive statistical analysis, the χ 2 test, linear regression, and Durbin-Watson statistic test. Results: In total, 251 breast radiologists from 34 countries completed the survey. Most respondents were providing both screening and symptomatic services (137/251, 54.6%), working in an academic hospital (85/251, 33.9%) and reading 1000–4999 cases per year (109/251, 43.4%). More than half of them (133/251, 53%) had established QA measures in their workplace. Although less than one-third (71/251, 28.3%) had to participate in regular performance testing, the vast majority (190/251, 75.7%) agreed that a mandatory test would be helpful to improve their skills. Conclusion: QA measures were in place for more than half of the respondents working in screening and diagnostic mammography to evaluate their breast imaging performance. Although there were substantial differences between countries, the importance of having QA in the workplace and implemented was widely acknowledged by radiologists. Clinical relevance statement: Although several quality assurance (QA) measures of image interpretation are recommended by European bodies or national organisations, the QA in mammography is quite heterogenous between countries and reporting settings, and not always actively implemented across Europe. Key Points: The first survey that presents radiologists’ preferences regarding QA measures of image interpretation in mammography. Quality assurance measures in the workplace are better-established for breast screening compared to diagnostic mammography. Radiologists consider that performance tests would help to improve their mammography interpretation skills