A Simple Ultrasound Based Classification Algorithm Allows Differentiation of Benign from Malignant Breast Lesions by Using Only Quantitative Parameters.

PURPOSE: We hypothesized that different quantitative ultrasound (US) parameters may be used as complementary diagnostic criteria and aimed to develop a simple classification algorithm to distinguish benign from malignant breast lesions and aid in the decision to perform biopsy or not. PROCEDURES: One hundred twenty-four patients, each with one biopsy-proven, sonographically evident breast lesion, were included in this prospective, IRB-approved study. Each lesion was examined with B-mode US, Color/Power Doppler US and elastography (Acoustic Radiation Force Impulse-ARFI). Different quantitative parameters were recorded for each technique, including pulsatility (PI) and resistive Index (RI) for Doppler US and lesion maximum, intermediate, and minimum shear wave velocity (SWVmax, SWVinterm, and SWVmin) as well as lesion-to-fat SWV ratio for ARFI. Receiver operating characteristic curve (ROC) analysis was used to evaluate the diagnostic performance of each quantitative parameter. Classification analysis was performed using the exhaustive chi-squared automatic interaction detection method. Results include the probability for malignancy for every descriptor combination in the classification algorithm. RESULTS: Sixty-five lesions were malignant and 59 benign. Out of all quantitative indices, maximum SWV (SWVmax), and RI were included in the classification algorithm, which showed a depth of three ramifications (SWVmax ≤ or > 3.16; if SWVmax ≤ 3.16 then RI ≤ 0.66, 0.66-0.77 or > 0.77; if RI ≤ 0.66 then SWVmax ≤ or > 2.71). The classification algorithm leads to an AUC of 0.887 (95 % CI 0.818-0.937, p < 0.0001), a sensitivity of 98.46 % (95 % CI 91.7-100 %), and a specificity of 61.02 % (95 % CI 47.4-73.5 %). By applying the proposed algorithm, a false-positive biopsy could have been avoided in 61 % of the cases. CONCLUSIONS: A simple classification algorithm incorporating two quantitative US parameters (SWVmax and RI) shows a high diagnostic performance, being able to accurately differentiate benign from malignant breast lesions and lower the number of unnecessary breast biopsies in up to 60 % of all cases, avoiding any subjective interpretation bias

Virtual Touch IQ elastography reduces unnecessary breast biopsies by applying quantitative "rule-in" and "rule-out" threshold values.

Our purpose was to evaluate Virtual Touch IQ (VTIQ) elastography and identify quantitative "rule-in" and "rule-out" thresholds for the probability of malignancy, which can help avoid unnecessary breast biopsies. 189 patients with 196 sonographically evident lesions were included in this retrospective, IRB-approved study. Quantitative VTIQ images of each lesion measuring the respective maximum Shear Wave Velocity (SWV) were obtained. Paired and unpaired, non-parametric statistics were applied for comparisons as appropriate. ROC-curve analysis was used to analyse the diagnostic performance of VTIQ and to specify "rule-in" and "rule-out" thresholds for the probability of malignancy. The standard of reference was either histopathology or follow-up stability for >24 months. 84 lesions were malignant and 112 benign. Median SWV of benign lesions was significantly lower than that of malignant lesions (p 98% with a concomitant significant (p = 0.032) reduction in false positive cases of almost 15%, whereas a "rule-in" threshold of 6.5 m/s suggested a probability of malignancy of >95%. In conclusion, VTIQ elastography accurately differentiates malignant from benign breast lesions. The application of quantitative "rule-in" and "rule-out" thresholds is feasible and allows reduction of unnecessary benign breast biopsies by almost 15%

Breast lesion detection and characterization with contrast-enhanced magnetic resonance imaging: Prospective randomized intraindividual comparison of gadoterate meglumine (0.15 mmol/kg) and gadobenate dimeglumine (0.075 mmol/kg) at 3T.

BACKGROUND: Contrast-enhanced magnetic resonance imaging (CE-MRI) of the breast is highly sensitive for breast cancer detection. Multichannel coils and 3T scanners can increase signal, spatial, and temporal resolution. In addition, the T1 -reduction effect of a gadolinium-based contrast agent (GBCA) is higher at 3T. Thus, it might be possible to reduce the dose of GBCA at 3T without losing diagnostic information. PURPOSE: To compare a three-quarter (0.075 mmol/kg) dose of the high-relaxivity GBCA gadobenate dimeglumine, with a 1.5-fold higher than on-label dose (0.15 mmol/kg) of gadoterate meglumine for breast lesion detection and characterization at 3T CE-MRI. STUDY TYPE: Prospective, randomized, intraindividual comparative study. POPULATION: Eligible were patients with imaging abnormalities (BI-RADS 0, 4, 5) on conventional imaging. Each patient underwent two examinations, 24-72 hours apart, one with 0.075 mmol/kg gadobenate and the other with 0.15 mmol/kg gadoterate administered in a randomized order. In all, 109 patients were prospectively recruited. FIELD STRENGTH/SEQUENCE: 3T MRI with a standard breast protocol (dynamic-CE, T2 w-TSE, STIR-T2 w, DWI). ASSESSMENT: Histopathology was the standard of reference. Three blinded, off-site breast radiologists evaluated the examinations using the BI-RADS lexicon. STATISTICAL TESTS: Lesion detection, sensitivity, specificity, and diagnostic accuracy were calculated per-lesion and per-region, and compared by univariate and multivariate analysis (Generalized Estimating Equations, GEE). RESULTS: Five patients were excluded, leaving 104 women with 142 histologically verified breast lesions (109 malignant, 33 benign) available for evaluation. Lesion detection with gadobenate (84.5-88.7%) was not inferior to gadoterate (84.5-90.8%) (P ≥ 0.165). At per-region analysis, gadobenate demonstrated higher specificity (96.4-98.7% vs. 92.6-97.3%, P ≤ 0.007) and accuracy (96.3-97.8% vs. 93.6-96.1%, P ≤ 0.001) compared with gadoterate. Multivariate analysis demonstrated superior, reader-independent diagnostic accuracy with gadobenate (odds ratio = 1.7, P < 0.001 using GEE). DATA CONCLUSION: A 0.075 mmol/kg dose of the high-relaxivity contrast agent gadobenate was not inferior to a 0.15 mmol/kg dose of gadoterate for breast lesion detection. Gadobenate allowed increased specificity and accuracy. LEVEL OF EVIDENCE: 1 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2019;49:1157-1165

Microstructural breast tissue characterization: A head-to-head comparison of Diffusion Weighted Imaging and Acoustic Radiation Force Impulse elastography with clinical implications

Abstract Purpose Head-to-head comparison of Diffusion Weighted Imaging (DWI) and Acoustic Radiation Force Impulse (ARFI) elastography regarding the characterization of breast lesions in an assessment setting. Method Patients undergoing an ultrasound examination including ARFI and an MRI protocol including DWI for the characterization of a BI-RADS 3–5 breast lesion between 06/2013 and 10/2016 were eligible for inclusion in this retrospective, IRB-approved study. 60 patients (30–84 years, median 50) with a median lesion size of 16 mm (range 5–55 mm) were included. The maximum shear wave velocity (SWVmax) and mean apparent diffusion coefficient (ADCmean) for each lesion were retrospectively evaluated by a radiologist experienced in the technique. Histology was the reference standard. Diagnostic performances of ARFI and DWI were assessed using ROC curve analysis. Spearman's rank correlation coefficient and multivariate logistic regression were used to investigate the independence of both tests regarding their diagnostic information to distinguish benign from malignant lesions. Results Corresponding areas under the ROC curve for differentiation of benign (n = 16) and malignant (n = 49) lesions were 0.822 (ARFI) and 0.871 (DWI, p-value = 0.48). SWVmax and ADCmean values showed a significant negative correlation (ρ = −0.501, p-value Conclusion Significant correlation between quantitative findings of ARFI and DWI in breast lesions exists. Thus, ARFI provides similar diagnostic information as a DWI-including protocol of an additional "problem-solving" MRI for the characterization of a sonographically evident breast lesion, improving the immediate patient management in the assessment setting

A simple classification system (the Tree flowchart) for breast MRI can reduce the number of unnecessary biopsies in MRI-only lesions.

OBJECTIVES: To assess whether using the Tree flowchart obviates unnecessary magnetic resonance imaging (MRI)-guided biopsies in breast lesions only visible on MRI. METHODS: This retrospective IRB-approved study evaluated consecutive suspicious (BI-RADS 4) breast lesions only visible on MRI that were referred to our institution for MRI-guided biopsy. All lesions were evaluated according to the Tree flowchart for breast MRI by experienced readers. The Tree flowchart is a decision rule that assigns levels of suspicion to specific combinations of diagnostic criteria. Receiver operating characteristic (ROC) curve analysis was used to evaluate diagnostic accuracy. To assess reproducibility by kappa statistics, a second reader rated a subset of 82 patients. RESULTS: There were 454 patients with 469 histopathologically verified lesions included (98 malignant, 371 benign lesions). The area under the curve (AUC) of the Tree flowchart was 0.873 (95% CI: 0.839-0.901). The inter-reader agreement was almost perfect (kappa: 0.944; 95% CI 0.889-0.998). ROC analysis revealed exclusively benign lesions if the Tree node was ≤2, potentially avoiding unnecessary biopsies in 103 cases (27.8%). CONCLUSIONS: Using the Tree flowchart in breast lesions only visible on MRI, more than 25% of biopsies could be avoided without missing any breast cancer. KEY POINTS: • The Tree flowchart may obviate >25% of unnecessary MRI-guided breast biopsies. • This decrease in MRI-guided biopsies does not cause any false-negative cases. • The Tree flowchart predicts 30.6% of malignancies with >98% specificity. • The Tree's high specificity aids in decision-making after benign biopsy results

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

Is the Level of Contrast Enhancement on Contrast-Enhanced Mammography (CEM) Associated with the Presence and Biological Aggressiveness of Breast Cancer?

There is limited information about whether the level of enhancement on contrast-enhanced mammography (CEM) can be used to predict malignancy. The purpose of this study was to correlate the level of enhancement with the presence of malignancy and breast cancer (BC) aggressiveness on CEM. This IRB-approved, cross-sectional, retrospective study included consecutive patients examined with CEM for unclear or suspicious findings on mammography or ultrasound. Excluded were examinations performed after biopsy or during neoadjuvant treatment for BC. Three breast radiologists who were blinded to patient data evaluated the images. The enhancement intensity was rated from 0 (no enhancement) to 3 (distinct enhancement). ROC analysis was performed. Sensitivity and negative likelihood ratio (LR-) were calculated after dichotomizing enhancement intensity as negative (0) versus positive (1–3). A total of 156 lesions (93 malignant, 63 benign) in 145 patients (mean age 59 ± 11.6 years) were included. The mean ROC curve was 0.827. Mean sensitivity was 95.4%. Mean LR- was 0.12%. Invasive cancer presented predominantly (61.8%) with distinct enhancement. A lack of enhancement was mainly observed for ductal carcinoma in situ. Stronger enhancement intensity was positively correlated with cancer aggressiveness, but the absence of enhancement should not be used to downgrade suspicious calcifications

Virtual Touch IQ elastography reduces unnecessary breast biopsies by applying quantitative “rule-in” and “rule-out” threshold values

Our purpose was to evaluate Virtual Touch IQ (VTIQ) elastography and identify quantitative “rule-in” and “rule-out” thresholds for the probability of malignancy, which can help avoid unnecessary breast biopsies. 189 patients with 196 sonographically evident lesions were included in this retrospective, IRB-approved study. Quantitative VTIQ images of each lesion measuring the respective maximum Shear Wave Velocity (SWV) were obtained. Paired and unpaired, non-parametric statistics were applied for comparisons as appropriate. ROC-curve analysis was used to analyse the diagnostic performance of VTIQ and to specify “rule-in” and “rule-out” thresholds for the probability of malignancy. The standard of reference was either histopathology or follow-up stability for >24 months. 84 lesions were malignant and 112 benign. Median SWV of benign lesions was significantly lower than that of malignant lesions (p<0.001). The application of a “rule-out” threshold of 1.9m/s lead to a sensitivity of >98% with a concomitant significant (p=0.032) reduction in false positive cases of almost 15%, whereas a “rule-in” threshold of 6.5m/s suggested a probability of malignancy of >95%. In conclusion, VTIQ elastography accurately differentiates malignant from benign breast lesions. The application of quantitative “rule-in” and “rule-out” thresholds is feasible and allows reduction of unnecessary benign breast biopsies by almost 15%.(VLID)464138