Radiology Breast Imaging

[Breast Imaging] Cutaneous Caves and Subcutaneous Adipose Columns in the Breast: Radiologic-Pathologic Correlation

Kopans, D. B., Rusby, J. E. — 2008-11-14

Purpose: To investigate the histologic correlations of the innumerable 2–3-mm radiolucencies that project over the breast, as seen on mammograms.

Materials and Methods: With institutional review board approval and HIPAA compliance, this work involved detailed x-ray imaging of discarded tissue from two mastectomy specimens, together with histologic examination of the skin and subcutaneous fat and evaluation of the skin during reduction mammoplasty surgery in two patients.

Results: Comparison of the histologic findings with the findings on x-ray images demonstrated that the lucencies seen by using mammography are cutaneous caves in the underside of the dermis into which insert columns of fat projecting up from the subcutaneous adipose tissue. This finding was confirmed with evaluation of the skin during reduction surgery.

Conclusion: As far as is known, this is the first description of a complex of anatomic structures that explain radiolucencies evident by using mammography.

[Breast Imaging] Screening Mammography: Does Ethnicity Influence Patient Preferences for Higher Recall Rates Given the Potential for Earlier Detection of Breast Cancer?

Jafri, N. F., Ayyala, R. S., Ozonoff, A., Jordan-Gray, J., Slanetz, P. J. — 2008-11-14

Purpose: To prospectively survey the preferences of an underserved and predominantly minority population of women regarding their understanding of screening mammography, desire for recall and early detection, and willingness to continue with annual screening mammography once given a false-positive result.

Materials and Methods: A total of 1011 women who were going to undergo mammography completed a HIPAA-compliant, Institutional Review Board–approved, validated survey in one of three languages: English, Spanish, or Haitian-Creole. Data were analyzed across three groups (ie, white, black, Hispanic) by using ² analysis.

Results: Of 911 women included in the final analysis, 378 (41%) were white, 439 (48%) were black, and 94 (10%) were Hispanic. Income and education levels varied significantly across ethnicities (P < .0001). A higher percentage of white women (40%) correctly identified the sensitivity of mammography (P < .0001), while black (42%) and Hispanic (50%) participants thought mammography to have a higher sensitivity than it truly does. After a false-positive result, only 80% of black women and 71% of Hispanic women were likely to continue with screening in the future, compared with 93% of white women (P < .0001). Only 54% of black women and 59% of Hispanic women were willing to return for a second noninvasive procedure despite the possibility of a higher cancer detection rate, compared with 76% of white women (P < .0001). Black women (53%) were also more reluctant to be recalled for invasive studies, and Hispanic women (65%) were slightly less willing to take this risk than were white women (75%) (P < .0001).

Conclusion: Differences in ethnic background appear to influence women's understanding of mammography, compliance with recall, and preference for early detection of breast cancer.

[Breast Imaging] Suspicious Breast Lesions: Assessment of 3D Doppler US Indexes for Classification in a Test Population and Fourfold Cross-Validation Scheme

2008-10-20

Purpose: To assess the diagnostic performance of various Doppler ultrasonographic (US) vascularity measures in conjunction with grayscale (GS) criteria in differentiating benign from malignant breast masses, by using histologic findings as the reference standard.

Materials and Methods: Institutional Review Board and HIPAA standards were followed. Seventy-eight women (average age, 49 years; range, 26–70 years) scheduled for breast biopsy were included. Thirty-eight patient scans were partially analyzed and published previously, and 40 additional scans were used as a test set to evaluate previously determined classification indexes. In each patient, a series of color Doppler images was acquired and reconstructed into a volume encompassing a suspicious mass, identified by a radiologist-defined ellipsoid, in which six Doppler vascularity measures were calculated. Radiologist GS ratings and patient age were also recorded. Multivariable discrimination indexes derived from the learning set were applied blindly to the test set. Overall performance was also confirmed by using a fourfold cross-validation scheme on the entire population.

Results: By using all cases (46 benign, 32 malignant), the area under the receiver operating characteristic curve (A_z) values confirmed results of previous analyses: Speed-weighted pixel density (SWPD) performed the best as a diagnostic index, although statistical significance (P = .01) was demonstrated only with respect to the normalized power-weighted pixel density. In both learning and test sets, the three-variable index (SWPD-age-GS) displayed significantly better diagnostic performance (A_z = 0.97) than did any single index or the one two-variable index (age-GS) that could be obtained without the data from the Doppler scan. Results of the cross validation confirmed the trends in the two data sets.

Conclusion: Quantitative Doppler US vascularity measurements considerably contribute to malignant breast tissue identification beyond subjective GS evaluation alone. The SWPD-age-GS index has high performance (A_z = 0.97), regardless of incidental performance variations in its single variable components.

[Breast Imaging] Deconvolution-based Dynamic Contrast-enhanced MR Imaging of Breast Tumors: Correlation of Tumor Blood Flow with Human Epidermal Growth Factor Receptor 2 Status and Clinicopathologic Findings--Preliminary Results

2008-10-20

Purpose: To prospectively determine whether breast carcinomas possess characteristic values of tumor blood flow (TBF) that correlate with pathologic and molecular prognostic markers.

Materials and Methods: The institutional ethics committee approved this study. After informed consent was obtained, 57 women (age range, 31–80 years) with histologically proved breast cancer underwent routine magnetic resonance (MR) mammography, which included a whole-breast dynamic contrast material–enhanced (DCE) sequence. A second contrast material bolus was injected during dynamic single-section turbo field-echo imaging of the section where the lesion was maximally enhanced. The relative signal intensity changes were deconvolved in a pixelwise fashion to yield the TBF. Formalin-fixed paraffin-embedded tumor specimens on slides were evaluated for histologic size and grade, as well as for estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor 2 (HER2) protein. In patients with a HER2 protein score of 2+ or 3+, HER2 gene status was assessed. For all prognostic parameters, the Mann-Whitney U test was used to compare median TBF in the HER2-positive group with that in the HER2-negative group.

Results: Significantly higher TBF was observed in tumors larger than 2 cm in diameter and in PR-negative and HER2 gene–amplified tumors (P < .05). In the HER2-positive and HER2-negative groups, ER-positive PR-positive tumors had a lower median TBF than did ER-negative PR-negative tumors, and the difference was significant in the HER2-positive group (P < .05).

Conclusion: Pixelwise deconvolution analysis of DCE MR data in patients with breast cancer can provide preoperative information regarding TBF. These results also support the hypothesis that there is increased TBF in HER2-positive tumors.

[Breast Imaging] The "Laboratory" Effect: Comparing Radiologists' Performance and Variability during Prospective Clinical and Laboratory Mammography Interpretations

2008-09-16

Purpose: To compare radiologists' performance during interpretation of screening mammograms in the clinic with their performance when reading the same mammograms in a retrospective laboratory study.

Materials and Methods: This study was conducted under an institutional review board–approved, HIPAA-compliant protocol; the need for informed consent was waived. Nine experienced radiologists rated an enriched set of mammograms that they had personally read in the clinic (the "reader-specific" set) mixed with an enriched "common" set of mammograms that none of the participants had previously read in the clinic by using a screening Breast Imaging Reporting and Data System (BI-RADS) rating scale. The original clinical recommendations to recall the women for a diagnostic work-up, for both reader-specific and common sets, were compared with their recommendations during the retrospective experiment. The results are presented in terms of reader-specific and group-averaged sensitivity and specificity levels and the dispersion (spread) of reader-specific performance estimates.

Results: On average, the radiologists' performance was significantly better in the clinic than in the laboratory (P = .035). Interreader dispersion of the computed performance levels was significantly lower during the clinical interpretations (P < .01).

Conclusion: Retrospective laboratory experiments may not represent either expected performance levels or interreader variability during clinical interpretations of the same set of mammograms in the clinical environment well.

[Breast Imaging] Direct MR Galactography: Feasibility Study

2008-09-16

Purpose: To compare T1- and T2-weighted direct magnetic resonance (MR) galactography, indirect MR galactography, and conventional galactography in women with pathologic nipple discharge.

Materials and Methods: The study was approved by the institutional review board. Written informed consent was obtained from all patients. Twenty-three women (age range, 30–85 years) with pathologic nipple discharge and pathologic conventional galactographic findings underwent physical examination, ultrasonography, and MR imaging before surgery. A T2-weighted sequence of the affected breast was performed before (indirect MR galactography), and T1- and T2-weighted sequences were performed after (direct MR galactography), gadopentetate dimeglumine was injected into the discharging duct. MR galactographic findings were analyzed and compared with conventional galactographic findings. Sequences used were T2-weighted three-dimensional constructive interference in steady state (CISS), T1-weighted volumetric interpolated breath-hold examination (VIBE), and T1-weighted fast low-angle shot (FLASH).

Results: The 23 patients had a total of 57 findings at conventional galactography. Indirect MR galactography with CISS showed pathologic findings in eight (42%) of 19 patients and showed 15 (33%) of 46 of all findings. Direct MR galactography with CISS showed pathologic findings in 23 (100%) of 23 patients and 47 (82%) of 57 of all findings, that with VIBE showed pathologic findings in 19 (83%) of 23 patients and 38 (67%) of 57 of all findings, and that with FLASH showed pathologic findings in 16 (100%) of 16 patients and 31 (80%) of 39 of all findings. There was a significant (P < .01) difference between indirect MR galactography and all direct MR galactography sequences in the detection of ductal disease. Eight (35%) of 23 women showed additional findings at direct MR galactography in comparison with standard MR imaging sequences.

Conclusion: MR galactography has the potential to be used in the diagnostic work-up of pathologic nipple discharge. Direct MR galactography shows more disease than does indirect MR galactography. The highest detection rate for ductal disease compared with that at conventional galactography was found with the direct MR galactography CISS and FLASH sequences.

[Breast Imaging] Premedication to Reduce Discomfort during Screening Mammography

Lambertz, C. K., Johnson, C. J., Montgomery, P. G., Maxwell, J. R. — 2008-08-18

Purpose: To test the hypothesis that premedication with acetaminophen, ibuprofen, and/or 4% lidocaine gel would decrease discomfort and improve satisfaction with screening mammography in women who expect a higher level of discomfort.

Materials and Methods: In this HIPAA-compliant, institutional review board–approved, prospective, double-blinded, placebo-controlled clinical trial, 418 women aged 32–89 years who expected substantial discomfort with screening mammography were randomly divided to receive premedication with acetaminophen, ibuprofen, and/or 4% lidocaine gel. Subjects provided informed written consent. The primary outcome was discomfort. Secondary outcomes were satisfaction and plans for future mammography on the basis of discomfort. Subjects completed structured questionnaires with visual analog scales to measure discomfort and satisfaction. A generalized linear mixed-models framework was used to assess the effect of medications on discomfort during mammography, and satisfaction with technologist and machine combinations was included as a random effect. The "plans for mammography next year" outcome was modeled by using a binary distribution and logit link function.

Results: Discomfort was significantly lower in the lidocaine gel group (P = .01). Satisfaction was significantly negatively correlated with discomfort (P < .001). Satisfaction and whether or not the subject had delayed her mammography because of fear of discomfort had significant effects on plans to undergo mammography next year (P < .001 for both). There were significant differences in discomfort between different combinations of technologists and machines.

Conclusion: Premedication with 4% lidocaine gel significantly reduced discomfort during screening mammography, and reduced discomfort may improve the likelihood of future mammographic screening and early detection of breast cancer.

[Breast Imaging] BI-RADS 3, 4, and 5 Lesions: Value of US in Management--Follow-up and Outcome

Raza, S., Chikarmane, S. A., Neilsen, S. S., Zorn, L. M., Birdwell, R. L. — 2008-08-18

Purpose: To evaluate the use, final outcome, and positive biopsy rate of American College of Radiology ultrasonographic (US) Breast Imaging Reporting and Data System (BI-RADS) categories 3, 4, and 5 recommended for breast masses.

Materials and Methods: At US, consecutive masses, palpable and nonpalpable, categorized as BI-RADS 3, 4, and 5 between January 1, 2003, and December 31, 2004, were retrospectively reviewed with institutional review board approval. Medical records provided imaging and histologic information.

Results: After patients lost to follow-up were excluded, the study population was 767 patients with 926 masses (476 palpable, 450 nonpalpable). In BI-RADS 3 masses (n = 356), imaging follow-up of 252 masses documented stability for 6–24 months. Aspiration of 24 masses revealed cysts. Biopsy in 80 masses revealed three malignancies, all of which were diagnosed within 6 months of the index examination, were smaller than 1 cm, and were node negative (negative predictive value = 99.2%). In BI-RADS 4 masses (n = 524), aspiration results indicated 35 cysts; biopsy in 455 revealed 85 malignancies (positive predictive value [PPV] = 16.2%). Imaging follow-up only in 34 revealed no cancers 2 and more years later. Among BI-RADS 5 masses (n = 46), 43 were malignant and three benign (PPV = 93.4%).

Conclusion: Inconsistent use of BI-RADS category 3 occurred in 14.0% of cases when biopsy was recommended. Although biopsy was performed in almost equal numbers of palpable and nonpalpable masses, only 11% of palpable BI-RADS 3 and 4 masses were malignant, as compared with 22% of nonpalpable masses. Strict adherence to lexicon characteristics of probably benign lesions should improve specificity.