Mammography and subsequent whole-breast sonography of nonpalpable breast cancers: the importance of radiologic breast density

Evaluating clinical efficacy of hospital-based surveillance with mammography and ultrasonography for breast cancer

Periodic mammography and/or sonography examinations are conducted across numerous hospitals nationalwidely, especially for antedees with a positive mammography screening. Despite the regular practice, clinical efficacy of hospital-based breast cancer surveillance remains unclear. Specifically, the impact of surveillance interval upon survival and prognostic surrogates stratified by menopausal status, as well as malignant transition rate should be deciphered. We retrieved cancer registry to ascertain 841 breast cancers with surveillance history through administration data. Healthy controls underwent breast surveillance and were concurrently free of cancer. More benign diseases rather than cancers were identified from premenopausal women (age ≤50 years) with sonography alone within one year, as well as older women (age >50) with both mammography and sonography one to two years before a cancer or benign diagnosis. Among breast cancers, mammography alone during the antecedent one to two years had a protective effect for diagnosing carcinoma in situ rather than invasive cancer (age-adjusted odds ratio: 0.048, P = 0.016). Three-state time homogeneous Markov model showed that hospital-based breast surveillance within 2 years of disease onset reduced the malignant transition rate by 65.16% (59.79-76.74%). The clinical efficacy of breast cancer surveillance was evidenced.

The value of radiomics model based on ultrasound image features in the differentiation between minimal breast cancer and small benign breast masses

BACKGROUND

Female breast cancer has surpassed lung cancer as the most common cancer, and is also the main cause of cancer death for women worldwide. Breast cancer <1 cm showed excellent survival rate. However, the diagnosis of minimal breast cancer (MBC) is challenging.

OBJECTIVE

The purpose of our research is to develop and validate an radiomics model based on ultrasound images for early recognition of MBC.

METHODS

302 breast masses with a diameter of <10 mm were retrospectively studied, including 159 benign and 143 malignant breast masses. The radiomics features were extracted from the gray-scale ultrasound image of the largest face of each breast mass. The maximum relevance minimum reduncancy and recursive feature elimination methods were used to screen. Finally, 10 features with the most discriminating value were selected for modeling. The random forest was used to establish the prediction model, and the rad-score of each mass was calculated. In order to evaluate the effectiveness of the model, we calculated and compared the area under the curve (AUC) value, sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of the model and three groups with different experience in predicting small breast masses, and drew calibration curves and decision curves to test the stability and consistency of the model.

RESULTS

When we selected 10 radiomics features to calculate the rad-score, the prediction efficiency was the best, the AUC values for the training set and testing set were 0.840 and 0.793, which was significantly better than the insufficient experience group (AUC = 0.673), slightly better than the moderate experience group (AUC = 0.768), and was inferior to the experienced group (AUC = 0.877). The calibration curve and decision curve also showed that the radiomics model had satisfied stability and clinical application value.

CONCLUSION

The radiomics model based on ultrasound image features has a satisfied predictive ability for small breast masses, and is expected to become a potential tool for the diagnosis of MBC, and it is a zero cost (in terms of patient participation and imaging time).

Detection of microcalcifications using nonlinear beamforming techniques

OBJECTIVE

Abundant research demonstrates that early detection of cancer leads to improved patient prognoses. By detecting cancer earlier, when tumors are in their primary stages, treatment can be applied before metastases have occurred. The presence of microcalcifications (MCs) is indicative of malignancy in the breast, i.e., 30-50% of all nonpalpable breast cancers detected using mammograms are based on identifying the presence of MCs. Therefore, improving the ability to detect MCs with modern imaging technology remains an important goal. Specifically, improving the sensitivity of ultrasound imaging techniques to detect MCs in the breast will provide an important role for the early detection and diagnosis of breast cancer.

METHODS

In this work, a novel nonlinear beamforming technology for ultrasonic arrays is investigated for its ability to detect MCs. The beamforming technique, called null subtraction imaging (NSI), utilizes nulls in the beam pattern to create images using ultrasound. NSI provides improved lateral resolution, a reduction in side lobes, and an accentuation of bright singular targets. Therefore, it was hypothesized that the use of NSI would result in identification of more MCs in rat tumors having a speckle background. To test this hypothesis, rats with tumors were injected with Hydroxyapatite (HA) particles to mimic MCs. Ultrasound was used to scan the rat tumors and images were constructed using conventional delay and sum and using NSI beamforming. Three readers with experience in diagnostic ultrasound imaging examined the 1,344 images and scored the presence or absence of MCs.

DISCUSSION

In all, 336 different tumor image slices were recorded and each reconstructed using NSI or conventional delay and sum with Hann apodization. In every image where one or MCs were detected in the Hann reconstructions, MCs were detected in the NSI images. In nine rat tumor images, one or more MCs were detected in the NSI images but not in the Hann images.

CONCLUSIONS

Statistically, the results did support the hypothesis that NSI would increase the number of MCs detected in the rat tumors.

Screening Outcomes of Supplemental Automated Breast US in Asian Women with Dense and Nondense Breasts

Background Automated breast (AB) US effectively depicts mammographically occult breast cancers in Western women. However, few studies have focused on the outcome of supplemental AB US in Asian women who have denser breasts than Western women. Purpose To evaluate the performance of supplemental AB US on mammography-based breast cancer screening in Asian women with dense breasts and those with nondense breasts. Materials and Methods A retrospective database search identified asymptomatic Korean women who underwent digital mammography (DM) and supplemental AB US screening for breast cancer between January 2018 and December 2019. We excluded women without sufficient follow-up, established final diagnosis, or histopathologic results. Performance measures of DM alone and AB US combined with DM (hereafter AB US plus DM) were compared. The primary outcome was cancer detection rate (CDR), and the secondary outcomes were sensitivity and specificity. Subgroup analyses were performed based on mammography density. Results From 2785 screening examinations in 2301 women (mean age, 52 years ± 9 [SD]), 28 cancers were diagnosed (26 screening-detected cancers, two interval cancers). When compared with DM alone, AB US plus DM resulted in a higher CDR of 9.3 per 1000 examinations (95% CI: 7.7, 10.3) versus 6.5 per 1000 examinations (95% CI: 5.2, 7.2; P < .001) and a higher sensitivity of 90.9% (95% CI: 77.3, 100.0) versus 63.6% (95% CI: 40.9, 81.8; P < .001) but a lower specificity of 86.8% (95% CI: 85.2, 88.2) versus 94.6% (95% CI: 93.6, 95.5; P < .001) in women with dense breasts. In women with nondense breasts, AB US plus DM resulted in a higher CDR of 9.5 per 1000 examinations (95% CI: 7.1, 10.6) versus 6.3 per 1000 examinations (95% CI: 3.5, 7.1; P < .001), whereas specificity was lower at 95.2% (95% CI: 93.4, 96.8) versus 97.1% (95% CI: 95.8, 98.4; P < .001). Conclusion In Asian women, the addition of automated breast US to digital mammography showed higher cancer detection rates but lower specificities in both dense and nondense breasts. © RSNA, 2023 Supplemental material is available for this article.

Breast density and risk of breast cancer

Early studies reported a 4- to 6-fold risk of breast cancer between women with extremely dense and fatty breasts. As most early studies were case-control studies, we took advantage of a population-based screening program to study density and breast cancer incidence in a cohort design. In the Capital Region, Denmark, women aged 50 to 69 are invited to screening biennially. Women screened November 2012 to December 2017 were included, and classified by BI-RADS density code, version 4, at first screen after recruitment. Women were followed up for incident breast cancer, including ductal carcinoma in situ (DCIS), to 2020 in nationwide pathology data. Rate ratios (RRs) and 95% confidence intervals (CI) were compared across density groups using Poisson-regression. We included 189 609 women; 1 067 282 person-years; and 4110 incident breast cancers/DCIS. Thirty-three percent of women had BI-RADS density code 1; 38% code 2; 24% code 3; 4.7% code 4; and missing 0.3%. Using women with BI-RADS density code 1 as baseline; women with code 2 had RR 1.69 (95% CI 1.56-1.84); women with code 3, RR 2.06 (95% CI 1.89-2.25); and women with code 4, RR 2.37 (95% CI 1.05-2.74). Results differed between observations accumulated during screening and above screening age. Our results indicated less difference in breast cancer risk across level of breast density than normally stated. Translated into absolute risk of breast cancer after age 50, we found a 6.2% risk for the one-third of women with lowest density, and 14.7% for the 5% of women with highest density.

Ultrasound classification of breast masses using a comprehensive Nakagami imaging and machine learning framework

In this study we investigate the potential of parametric images formed from ultrasound B-mode scans using the Nakagami distribution for non-invasive classification of breast lesions and characterization of breast tissue. Through a sliding window technique, we generated seven types of Nakagami images for each patient scan in our dataset using basic and as well as derived parameters of the Nakagami distribution. To determine the suitable window size for image generation, we conducted an empirical analysis using 4 windows, which includes 3 column windows of lengths 0.1875 mm, 0.45 mm and 0.75 mm and widths of 0.002 mm, along with the standard square window with sides equal to three times the pulse length of incident ultrasound. From the parametric image sets generated using each window, we extracted a total of 72 features that consisted of morphometric, elemental and hybrid features. To our knowledge no other literature has conducted such a comprehensive analysis of Nakagami parametric images for the classification of breast lesions. Feature selection was performed to find the most useful subset of features from each of the parametric image sets for the classification of breast cancer. Analyzing the classification accuracy and Area under the Receiver Operating Characteristic (ROC) Curve (AUC) of the selected feature subsets, we determined that the selected features acquired from Nakagami parametric images generated using a column window of length 0.75 mm provides the best results for characterization of breast lesions. This optimal feature set provided a classification accuracy of 93.08%, an AUC of 0.9712, a False Negative Rate (FNR) of 0%, and a very low False Positive Rate (FPR) of 8.65%. Our results indicate that the high accuracy of such a procedure may assist in the diagnosis of breast cancer by helping to reduce false positive diagnoses.

The Impact of Dense Breasts on the Stage of Breast Cancer at Diagnosis: A Review and Options for Supplemental Screening

The purpose of breast cancer screening is to find cancers early to reduce mortality and to allow successful treatment with less aggressive therapy. Mammography is the gold standard for breast cancer screening. Its efficacy in reducing mortality from breast cancer was proven in randomized controlled trials (RCTs) conducted from the early 1960s to the mid 1990s. Panels that recommend breast cancer screening guidelines have traditionally relied on the old RCTs, which did not include considerations of breast density, race/ethnicity, current hormone therapy, and other risk factors. Women do not all benefit equally from mammography. Mortality reduction is significantly lower in women with dense breasts because normal dense tissue can mask cancers on mammograms. Moreover, women with dense breasts are known to be at increased risk. To provide equity, breast cancer screening guidelines should be created with the goal of maximizing mortality reduction and allowing less aggressive therapy, which may include decreasing the interval between screening mammograms and recommending consideration of supplemental screening for women with dense breasts. This review will address the issue of dense breasts and the impact on the stage of breast cancer at the time of diagnosis, and discuss options for supplemental screening.

Positive Predictive Value for the Malignancy of Mammographic Abnormalities Based on the Presence of an Ultrasound Correlate

Purpose To compare the outcomes of different mammographic lesions based on the presence of an ultrasound (US) correlate and to estimate how often targeted US can identify such lesions.

Materials and Methods This retrospective study included all consecutive cases from 2010 to 2016, with Breast Imaging Reporting and Database System (BI-RADS) categories 4 & 5 who underwent US as part of their diagnostic workup. We compared the incidence of malignancy between lesions comprising a US correlate that underwent US-guided core needle biopsy (CNB) and those without a correlate that underwent stereotactic CNB.

Results 833 lesions met the study criteria and included masses (64.3%), architectural distortion (19%), asymmetries (4.6%), and calcifications (12.1%). The CNB-based positive predictive value (PPV) was higher for lesions with a US correlate than for those without (40.2% [36.1, 44.4%] vs. 18.9% [14.5, 23.9%], respectively) (p<0.001). Malignancy odds for masses, asymmetries, architectural distortion, and calcifications were greater by 2.70, 4.17, 4.98, and 2.77 times, respectively, for the US-guided CNB (p<0.001, p=0.091, p<0.001, and p=0.034, respectively). Targeted US identified a correlate to 66.3% of the mammographic findings. The odds of finding a correlate were greater for masses (77.8%) than architectural distortions (53.8%) (p<0.001) or calcifications (24.8%) (p<0.001).

Conclusion The success of targeted US in identifying a correlate varies significantly according to the type of mammographic lesion. The PPV of lesions with a US correlate was significantly higher than that of those with no correlate. However, the PPV of lesions with no US correlate is high enough (18.9%) to warrant a biopsy.

Second-Generation 3D Automated Breast Ultrasonography (Prone ABUS) for Dense Breast Cancer Screening Integrated to Mammography: Effectiveness, Performance and Detection Rates

In our study, we added a three-dimensional automated breast ultrasound (3D ABUS) to mammography to evaluate the performance and cancer detection rate of mammography alone or with the addition of 3D prone ABUS in women with dense breasts. Our prospective observational study was based on the screening of 1165 asymptomatic women with dense breasts who selected independent of risk factors. The results evaluated include the cancers detected between June 2017 and February 2019, and all surveys were subjected to a double reading. Mammography detected four cancers, while mammography combined with a prone Sofia system (3D ABUS) doubled the detection rate, with eight instances of cancer being found. The diagnostic yield difference was 3.4 per 1000. Mammography alone was subjected to a recall rate of 14.5 for 1000 women, while mammography combined with 3D prone ABUS resulted in a recall rate of 26.6 per 1000 women. We also observed an additional 12.1 recalls per 1000 women screened. Integrating full-field digital mammography (FFDM) with 3D prone ABUS in women with high breast density increases and improves breast cancer detection rates in a significant manner, including small and invasive cancers, and it has a tolerable impact on recall rate. Moreover, 3D prone ABUS performance results are comparable with the performance results of the supine 3D ABUS system.

The concordance in lesion detection and characteristics between the Anatomical Intelligence and conventional breast ultrasound Scan method

Background

The aim of this study was to investigate the concordance in lesion detection, between conventional Handhold Ultrasound (HHUS) and The Anatomical Intelligence for Breast ultrasound scan method.

Result

The AI-breast showed the absolute agreement between the resident and an experienced breast radiologist. The ICC for the scan time, number, clockface location, distance to the nipple, largest diameter and mean diameter of the lesion obtained by a resident and an experienced breast radiologist were 0.7642, 0.7692, 0.8651, 0.8436, 0.7502, 0.8885, respectively. The ICC of the both practitioners of AI-breast were 0.7971, 0.7843, 0.9283, 0.8748, 0.7248, 0.8163, respectively. The k value of Anatomical Intelligence breast between experienced breast radiologist and resident in these image characteristics of boundary, morphology, aspect ratio, internal echo, and BI-RADS assessment were 0.7424, 0.7217, 0.6741, 0.6419, 0.6241, respectively. The k value of the two readers of AI-breast were 0.6531, 0.6762, 0.6439, 0.6137, 0.5981, respectively.

Conclusion

The anatomical intelligent breast US scanning method has excellent reproducibility in recording the lesion location and the distance from the nipple, which may be utilized in the lesions surveillance in the future.

Suspicious breast lesions incidentally detected on chest computer tomography with histopathological correlation

OBJECTIVE

To evaluate incidental breast lesions on chest computed tomography with histopathological correlation. It is important for general radiologist to characterize a breast lesion as benign, indetermined, or sufficiently suspicious to warrant further work-up.

METHODS

A total of 35.000 chest CT examinations were performed between January 2016 and December 2020. 27 patients (mean age 70 years, age range 48-87 years) with incidental breast lesions were identified in this retrospective study. Two radiologists scored incidental breast lesions independently regarding their morphology, and the results were compared to histopathology which was obtained by an ultrasound-guided core needle biopsy or a surgical excision.

RESULTS

Out of 35.000 chest CT examinations, a total of 31 incidental breast lesions in 27 patients were detected. Among the 31 lesions, 23 were malignant and 8 benign. The malignant lesions included 17 carcinomas and 6 metastases (4 lymphomas and 2 melanomas). The benign lesions contained 2 hematomas, 4 fat necrosis, and 2 fibrosis lumps.

CONCLUSION

Chest computed tomography as a standard imaging technique is helpful for evaluation of suspicious breast lesions. This may ultimately influence patient management and lead to further imaging.

Automated breast ultrasound: Supplemental screening for average-risk women with dense breasts

OBJECTIVE

We review ultrasound (US) options for supplemental breast cancer screening of average risk women with dense breasts.

CONCLUSION

Performance data of physician-performed handheld US (HHUS), technologist-performed HHUS, and automated breast ultrasound (AUS) indicate that all are appropriate for adjunctive screening. Volumetric 3D acquisitions, reduced operator dependence, protocol standardization, reliable comparison with previous studies, independence of performance and interpretation, and whole breast depiction on coronal view may favor selection of AUS. Important considerations are workflow adjustments for physicians and staff.

Automated whole breast segmentation for hand-held ultrasound with position information: Application to breast density estimation

BACKGROUND AND OBJECTIVE

Women with higher breast densities have a relatively higher risk to be diagnosed with breast cancer. Hand-held ultrasound (HHUS) can provide precise screening results and detect masses in dense breasts. However, its lack of position information and automatic extraction of breast area hinder the implementation of density estimation. To facilitate reliable breast density evaluation, this study proposed an upgraded version of our whole-breast ultrasound (WBUS) system, which not only can provide precise position information, but also can extract precise breast area automatically based on deep learning method.

METHODS

WBUS images with probe position information were collected from 117 women. For each case, an automatic breast region segmentation by DeepResUnet was conducted, then fibroglandular tissues were extracted from breast region using fuzzy c-mean (FCM) classifier. Finally, the percentage of breast density and breast area of the DeepResUnet predicted region and the breast region of the ground truth were calculated and compared.

RESULTS

The average and standard deviation of each breast case for DeepResUnet predicted breast region of 10-fold in Accuracy (ACC) was 0.963±0.054. Sensitivity (SENS) was 0.928±0.11. Specificity (SPEC) was 0.967±0.054. Dice coefficient (Dice) was 0.916±0.98. Region intersection over union (IoU) was 0.856±0.134. Significant and very high correlations of breast density, fibroglandular tissue area and breast area (R = 0.843, R= 0.822 and R = 0.984, all p values < 0.001) were found between the ground truth and the result of the proposed method for ultrasound images.

CONCLUSIONS

Breast density, fibroglandular tissue, and breast volume evaluated based on the proposed method and WBUS system have significant correlations with ground truth, indicating that the proposed method and WBUS system has the potential to be an alternative modality for breast screening and density estimation in clinical use.

Clinicopathological features of breast cancer without mammographic findings suggesting malignancy

Background

Mammography (MG) is widely used for screening examinations. Dense breast reduces MG screening sensitivity, possibly delaying diagnosis. However, little is known about the characteristics of breast cancers without MG findings indicative of malignancy. Hence, we investigated breast cancer patients with tumors not detected by MG.

Patients and methods

In total, 1758 Japanese patients with breast cancer, undergoing curative surgery between 2012 and 2018 without neo-adjuvant chemotherapy, were retrospectively investigated. Clinicopathological features were compared between patients without (MG-negative) and with (MG-positive) cancer-specific findings on MG. The current study included cases who came to our hospital after experiencing subjective symptoms, or whose tumors were detected by MG and/or US-screening. We reviewed results of both MG and US conducted at our institution.

Results

There were 201 MG-negative cases (11.4%). In patients with invasive disease, multivariate analysis revealed MG-negative patients to have higher breast density on MG (p < 0.001). Tumors of MG-negative patients were smaller (p < 0.001), showed less lymph node involvement (p = 0.011), and were of lower grade (p = 0.027). The majority of MG-negative tumors were found by ultrasound screening, being smaller than tumors in patients with subjective symptoms. In the MG-negative group, tumor characteristics such as tumor grade did not differ between those detected by screening versus subjective symptoms.

Conclusion

Most tumors in MG-negative group patients were identified by US screening and the diseases were found at early stages with low malignancy. The usefulness of additional ultrasound with MG-screening might merit further investigations.

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Breast cancers without cancer-specific findings on mammograms were pathologically at early stages and low-grade .

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The majority of mammogram-negative tumors were found by ultrasound screening.

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Mammogram-negative tumors were low-grade regardless of motives for visiting the hospital.

Screening Breast Ultrasound Using Handheld or Automated Technique in Women with Dense Breasts

In women with dense breasts (heterogeneously or extremely dense), adding screening ultrasound to mammography increases detection of node-negative invasive breast cancer. Similar incremental cancer detection rates averaging 2.1-2.7 per 1000 have been observed for physician- and technologist-performed handheld ultrasound (HHUS) and automated ultrasound (AUS). Adding screening ultrasound (US) for women with dense breasts significantly reduces interval cancer rates. Training is critical before interpreting examinations for both modalities, and a learning curve to achieve optimal performance has been observed. On average, about 3% of women will be recommended for biopsy on the prevalence round because of screening US, with a wide range of 2%-30% malignancy rates for suspicious findings seen only on US. Breast Imaging Reporting and Data System 3 lesions identified only on screening HHUS can be safely followed at 1 year rather than 6 months. Computer-aided detection and diagnosis software can augment performance of AUS and HHUS; ongoing research on machine learning and deep learning algorithms will likely improve outcomes and workflow with screening US.

Sensitivity of screening mammography by density and texture: a cohort study from a population-based screening program in Denmark

Background

Screening mammography works better in fatty than in dense breast tissue. Computerized assessment of parenchymal texture is a non-subjective method to obtain a refined description of breast tissue, potentially valuable in addition to breast density scoring for the identification of women in need of supplementary imaging. We studied the sensitivity of screening mammography by a combination of radiologist-assessed Breast Imaging Reporting and Data System (BI-RADS) density score and computer-assessed parenchymal texture marker, mammography texture resemblance (MTR), in a population-based screening program.

Methods

Breast density was coded according to the fourth edition of the BI-RADS density code, and MTR marker was divided into quartiles from 1 to 4. Screening data were followed up for the identification of screen-detected and interval cancers. We calculated sensitivity and specificity with 95% confidence intervals (CI) by BI-RADS density score, MTR marker, and combination hereof.

Results

Density and texture were strongly correlated, but the combination led to the identification of subgroups with different sensitivity. Sensitivity was high, about 80%, in women with BI-RADS density score 1 and MTR markers 1 or 2. Sensitivity was low, 67%, in women with BI-RADS density score 2 and MTR marker 4. For women with BI-RADS density scores 3 and 4, the already low sensitivity was further decreased for women with MTR marker 4. Specificity was 97–99% in all subgroups.

Conclusion

Our study showed that women with low density constituted a heterogenous group. Classifying women for extra imaging based on density only might be a too crude approach. Screening sensitivity was systematically high in women with fatty and homogenous breast tissue.

Breast density implications and supplemental screening

Digital breast tomosynthesis (DBT) has been widely implemented in place of 2D mammography, although it is less effective in women with extremely dense breasts. Breast ultrasound detects additional early-stage, invasive breast cancers when combined with mammography; however, its relevant limitations, including the shortage of trained operators, operator dependence and small field of view, have limited its widespread implementation. Automated breast sonography (ABS) is a promising technique but the time to interpret and false-positive rates need to be improved. Supplemental screening with contrast-enhanced magnetic resonance imaging (MRI) in high-risk women reduces late-stage disease; abbreviated MRI protocols may reduce cost and increase accessibility to women of average risk with dense breasts. Contrast-enhanced digital mammography (CEDM) and molecular breast imaging improve cancer detection but require further validation for screening and direct biopsy guidance should be implemented for any screening modality. This article reviews the status of screening women with dense breasts. KEY POINTS: • The sensitivity of mammography is reduced in women with dense breasts. Supplemental screening with US detects early-stage, invasive breast cancers. • Tomosynthesis reduces recall rate and increases cancer detection rate but is less effective in women with extremely dense breasts. • Screening MRI improves early diagnosis of breast cancer more than ultrasound and is currently recommended for women at high risk. Risk assessment is needed, to include breast density, to ascertain who should start early annual MRI screening.

Cancer screening and early diagnosis in low and middle income countries : Current situation and future perspectives

Limited health system capacities and competing health priorities in low and middle income countries (LMICs) necessitate a pragmatic approach to population-based cancer screening. Thus, the challenges faced by LMICs to implement a 'western' model of screening for common cancers and the possible means to overcome these challenges are presented. Breast cancer is the number one cancer with a rising trend in the majority of LMICs. Implementation of mass-scale mammography-based screening is not feasible and sustainable in most of them. While some LMICs have introduced breast cancer screening based on clinical breast examination (CBE), the programs need to be of appropriate quality. All LMICs should improve the capacity for early diagnosis of breast cancer along with other common cancers through community education, training of frontline health workers, facilitating prompt referrals and improving the infrastructure for cancer diagnosis and treatment. Resources permitting, the LMICs with high burden of cervical cancer may consider human papillomavirus (HPV) detection-based screening; a simple low-cost alternative is visual inspection with acetic acid (VIA). Regardless of the choice, a strong linkage should be established between screening and treatment with implementation of robust quality assurance. The few LMICs with a rising trend of colorectal cancers and adequate resources may implement demonstration projects to screen with fecal immunochemical tests (FIT). Oral cancer screening of habitual tobacco and/or alcohol users using oral visual examination (OVE) may be implemented in countries with high burden of the cancer, but primary prevention (i.e., tobacco/alcohol cessation) should be prioritized. Screenings for other cancers are not recommended for LMICs.

Mammographic breast density in recent and longer-standing ethiopian immigrants to israel

High breast density is associated with an increased risk of breast cancer development. Little is known concerning ethnic variations in breast density and its relevant contributing factors. We aimed to study breast density among Ethiopian immigrants to Israel in comparison with Israeli-born women and to determine any effect on breast density of the length of residency in the immigrant population. Mammographic breast density using the BI-RADS system was estimated and compared between 77 women of Ethiopian origin who live in Israel and 177 Israeli-born controls. Logistic regression analysis was performed to estimate the odds ratios (OR) for high density (BI-RADS score ≥ 3) vs low density (BI-RADS score < 3) cases, comparing the 2 origin groups. Ethiopian-born women had a crude OR of 0.15 (95% CI: 0.08-0.26) for high breast density compared with Israeli-born women. Adjustments for various cofounders did not affect the results. Time since immigration to Israel seemed to modify the relationship, with a stronger association for women who immigrated within 2 years prior to mammography (OR:0.07, 95% CI: 0.03-0.17) as opposed to women with a longer residency stay in Israel (OR:0.23, 95% CI:0.10-0.50). Adjustments of various confounders did not alter these findings. Breast density in Ethiopian immigrants to Israel is significantly lower than that of Israeli-born controls. Our study suggests a positive association between time since immigration and breast density. Future studies are required to define the possible effects of dietary change on mammographic density following immigration.

Correlation Between Mammographic Breast Density, Breast Tissue Type in Ultrasonography, Fibroglandular Tissue, and Background Parenchymal Enhancement in Magnetic Resonance Imaging

Objective

Breast cancer is the most common malignancy in the female population, and imaging studies play a critical role for its early detection. Mammographic breast density (MBD) is one of the markers used to predict the risk stratification of breast cancer in patients. We aimed to assess the correlations among MBD, ultrasound breast composition (USBC), fibroglandular tissue (FGT), and the amount of background parenchymal enhancement (BPE) in magnetic resonance imaging, after considering the subjects' menopausal status.

Methods

In this retrospective cross-sectional study, the medical records' archives in a tertiary referral hospital were reviewed. Data including age, menopausal status, their mammograms, and ultrasound assessments were extracted from their records. All of their imaging studies were reviewed, and MBD, USBC, FGT, and BPE were determined, recorded, and entered into SPSS software for analysis.

Results

A total of 121 women (mean age = 42.7 ± 11.0 years) were included, of which 35 out of 115 (30.4%) had reached menopause. Using the Jonckheere-Terpstra test for evaluating the trends among above mentioned 4 radiologic characteristics in the total sample population, a significant positive relation was found between each of these paired variables: (1) USBC-MBD (P = .006), (2) FGT-MBD (P = .001), (3) USBC-BPE (P = .046), (4) USBC-FGT (P = .036), and (5) BPE-FGT (P < .001). These trends were not found to be significant among premenopausal subjects.

Conclusions

Considering the trends between different measures of breast density in the 3 radiologic modalities, these factors can be used interchangeably in certain settings.

Downgrading of Breast Masses Suspicious for Cancer by Using Optoacoustic Breast Imaging

Purpose To assess the ability of optoacoustic (OA) ultrasonography (US) to help correctly downgrade benign masses classified as Breast Imaging Reporting and Data System (BI-RADS) 4a and 4b to BI-RADS 3 or 2. Materials and Methods OA/US technology uses laser light to detect relative amounts of oxygenated and deoxygenated hemoglobin in and around suspicious breast masses. In this prospective, multicenter study, results of 209 patients with 215 breast masses classified as BI-RADS 4a or 4b at US are reported. Patients were enrolled between 2015 and 2016. Masses were first evaluated with US with knowledge of previous clinical information and imaging results, and from this information a US imaging-based probability of malignancy (POM) and BI-RADS category were assigned to each mass. The same masses were then re-evaluated at OA/US. During the OA/US evaluation, radiologists scored five OA/US features, and then reassigned an OA/US-based POM and BI-RADS category for each mass. BI-RADS downgrade and upgrade percentages at OA/US were assessed by using a weighted sum of the five OA feature scores. Results At OA/US, 47.9% (57 of 119; 95% CI: 0.39, 0.57) of benign masses classified as BI-RADS 4a and 11.1% (three of 27; 95% CI: 0.03, 0.28) of masses classified as BI-RADS 4b were correctly downgraded to BI-RADS 3 or 2. Two of seven malignant masses classified as BI-RADS 4a at US were incorrectly downgraded, and one of 60 malignant masses classified as BI-RADS 4b at US was incorrectly downgraded for a total of 4.5% (three of 67; 95% CI: 0.01, 0.13) false-negative findings. Conclusion At OA/US, benign masses classified as BI-RADS 4a could be downgraded in BI-RADS category, which would potentially decrease biopsies negative for cancer and short-interval follow-up examinations, with the limitation that a few masses may be inappropriately downgraded.

The Role of Ultrasound in Screening Dense Breasts-A Review of the Literature and Practical Solutions for Implementation

Breast cancer is the second leading cause of cancer death in women. Estimates indicate a nearly 40% breast cancer mortality reduction when screening women annually starting at age 40. Although mammography is well known to be a powerful screening tool in the detection of early breast cancer, it is imperfect, particularly for women with dense breasts. In women with dense breast tissue, the sensitivity of mammography is reduced. Additionally, women with dense breasts have an increased risk of developing breast cancer while mammography has a lower sensitivity. Screening ultrasound, both handheld and automated, is effective in detecting mammographically occult cancer in women with dense tissue. Studies have shown that ultrasound significantly increases detection of clinically important, small, largely invasive, node-negative cancers. The purpose of this review article is to summarize the literature to date regarding screening breast ultrasound, emphasizing differences in cancer detection in high risk and intermediate risk women, and to discuss practical ways to implement screening ultrasound in clinical practice, including automated whole breast ultrasound, as a viable solution to the increasing need for additional screening.

Negligible Advantages and Excess Costs of Routine Addition of Breast Ultrasonography to Mammography in Dense Breasts

Aim

To assess the role of breast ultrasonography as a complement to negative mammography in radiologically dense breasts.

Material and methods

Out of a total series of 49,044 consecutive mammograms reported as negative in asymptomatic women, 25,665 (52.3%) were coded as dense (BI-RADS D3–4) and ultrasonography was recommended. Due to organizational problems, ultrasonography was performed immediately or within 1 month only in 5,227 cases, representing the study series.

Results

Two cancers were detected at immediate ultrasonography (0.03%). The cancer detection rate in women aged 40–49 and 50–69 years was 0.002% and 0.07%, respectively. The benign biopsy rate was 0.5% for core biopsies and 0.02% for surgical biopsies. The cost per ultrasonography-assessed woman was € 56.05, whereas the cost per additional mammographically occult but ultrasonography-detected cancer was € 146,496.53. The mammograms of the 2 cancer cases underwent blind review by an expert reader and were confirmed as negative.

Discussion

Our findings show a low cancer detection rate, substantially lower compared to other clinical studies of ultrasonography in dense breasts, though in accordance with preliminary evidence from an Italian randomized clinical trial within a population-based screening program. The policy of adding ultrasonography to negative mammography in dense breasts seems to have very limited cost-effectiveness, and should not be adopted in routine practice before results of ongoing clinical trials are available.

Breast density: why all the fuss?

The term "breast density" or mammographic density (MD) denotes those components of breast parenchyma visualised at mammography that are denser than adipose tissue. MD is composed of a mixture of epithelial and stromal components, notably collagen, in variable proportions. MD is most commonly assessed in clinical practice with the time-honoured method of visual estimation of area-based percent density (PMD) on a mammogram, with categorisation into quartiles. The computerised semi-automated thresholding method, Cumulus, also yielding area-based percent density, is widely used for research purposes; however, the advent of fully automated volumetric methods developed as a consequence of the widespread use of digital mammography (DM) and yielding both absolute and percent dense volumes, has resulted in an explosion of interest in MD recently. Broadly, the importance of MD is twofold: firstly, the presence of marked MD significantly reduces mammographic sensitivity for breast cancer, even with state-of-the-art DM. Recognition of this led to the formation of a powerful lobby group ('Are You Dense') in the US, as a consequence of which 32 states have legislated for mandatory disclosure of MD to women undergoing mammography. Secondly, it is now widely accepted that MD is in itself a risk factor for breast cancer, with a four-to sixfold increased relative risk in women with PMD in the highest quintile compared to those with PMD in the lowest quintile. Consequently, major research efforts are underway to assess whether use of MD could provide a major step forward towards risk-adapted, personalised breast cancer prevention, imaging, and treatment.

Usefulness of Organ Electrodermal Diagnostics in Detection of Breast Pathology: A Multicenter, Randomized, Double-Blinded Clinical Study

Objective: Pathology of an internal organ/body part causes corresponding skin areas-organ projection areas/acupuncture points-to rectify applied electrical currents (a diode phenomenon) once the resistance "breakthrough effect" has been induced in these specific, and sometimes remote, skin zones. The aim of this study was to estimate the diagnostic accuracy-as well as the scope of utilization-for detection of breast pathology of organ electrodermal diagnostics (OED), which utilizes this electrophysiologic phenomenon. Materials and Methods: A multicenter randomized, double-blinded comparative study of OED results and clinical diagnoses, as the criteria standards, was done on 400 female volunteers, with a mean age of 39 (standard deviation: 9 years), at three academic breast clinics. Participants were divided into 7 groups: (1) a control group; (2) a cancer-survivor group; (3) a breast-fibroadenoma group; (4) a mastitis group; (5) a breast-abscess group; (6) a preinvasive breast-cancer group; and (7) an invasive breast-cancer group. Results: The OED overall detection rate was 88.8%, the sensitivity rate was 92.7%, and the specificity rate was 76.5%. The predictive value for positive OED results equaled 92.4% and, for negative OED results, equaled 77.3%. However, both sensitivity and specificity rates varied among specific groups. The highest sensitivity rates were shown by OED in groups with serious pathologies, such as invasive cancer (94.2%), preinvasive cancer (90.0%), breast abscess (94.4%), and mastitis (95.9%). The OED results correlated with the intensity of the pathologic process within breasts but were not affected by either the type or the etiology of the disease. Conclusions: OED appears to be a reliable method for detecting breast pathology; this method might also estimate the intensity of a breast pathologic process but cannot explain the cause of the disease directly.

Comparison of mammography and ultrasonography findings with pathology results in patients with breast cancer in Birjand, Iran

Background

Early diagnosis of breast cancer, the incidence of which among Iranian women is about a decade earlier than in developed countries, is important.

Objective

To compare mammography and ultrasonography findings with those of pathology in patients with breast cancer.

Methods

This descriptive cross-sectional study was performed using medical records of 79 patients with breast malignancies, who were referred to Imam Reza Hospital and private laboratories of Birjand, Iran, from December 2012 to December 2014. The patients’ information was recorded using a checklist, which included name, code, age, ultrasonography, and mammography results and pathology reports. The results of ultrasonography and mammography were compared with pathology findings as the gold standard. SPSS Version 21 was used for data analysis.

Results

The mean age of the patients was 46.94 ± 11.76 years. The results showed that 74.7%, 16.5%, and 7.6% of the patients had ductal carcinoma, lobular carcinoma, and mixed carcinoma, respectively. About 72.5%, 24.6%, and 2.9% of the patients had stage 2, 3, and 1 breast cancer, respectively. In addition, both breasts were involved in 1.3% of the patients. The ultrasound findings were positive and false negative in 97.5% and 2.5% of the cases. Moreover, the mammography results were positive and false negative in 98.7% and 1.3% of the patients.

Conclusion

This study showed that mammography is the preferred modality in screening breast cancer patients; the use of complementary tests such as ultrasonography is recommended, especially in high-risk women.

Interaction of mammographic breast density with menopausal status and postmenopausal hormone use in relation to the risk of aggressive breast cancer subtypes

PURPOSE

We examined the associations of mammographic breast density with breast cancer risk by tumor aggressiveness and by menopausal status and current postmenopausal hormone therapy.

METHODS

This study included 2596 invasive breast cancer cases and 4059 controls selected from participants of four nested case-control studies within four established cohorts: the Mayo Mammography Health Study, the Nurses' Health Study, Nurses' Health Study II, and San Francisco Mammography Registry. Percent breast density (PD), absolute dense (DA), and non-dense areas (NDA) were assessed from digitized film-screen mammograms using a computer-assisted threshold technique and standardized across studies. We used polytomous logistic regression to quantify the associations of breast density with breast cancer risk by tumor aggressiveness (defined as presence of at least two of the following tumor characteristics: size ≥2 cm, grade 2/3, ER-negative status, or positive nodes), stratified by menopausal status and current hormone therapy.

RESULTS

Overall, the positive association of PD and borderline inverse association of NDA with breast cancer risk was stronger in aggressive vs. non-aggressive tumors (≥51 vs. 11-25% OR 2.50, 95% CI 1.94-3.22 vs. OR 2.03, 95% CI 1.70-2.43, p-heterogeneity = 0.03; NDA 4th vs. 2nd quartile OR 0.54, 95% CI 0.41-0.70 vs. OR 0.71, 95% CI 0.59-0.85, p-heterogeneity = 0.07). However, there were no differences in the association of DA with breast cancer by aggressive status. In the stratified analysis, there was also evidence of a stronger association of PD and NDA with aggressive tumors among postmenopausal women and, in particular, current estrogen+progesterone users (≥51 vs. 11-25% OR 3.24, 95% CI 1.75-6.00 vs. OR 1.93, 95% CI 1.25-2.98, p-heterogeneity = 0.01; NDA 4th vs. 2nd quartile OR 0.43, 95% CI 0.21-0.85 vs. OR 0.56, 95% CI 0.35-0.89, p-heterogeneity = 0.01), even though the interaction was not significant.

CONCLUSION

Our findings suggest that associations of mammographic density with breast cancer risk differ by tumor aggressiveness. While there was no strong evidence that these associations differed by menopausal status or hormone therapy, they did appear more prominent among current estrogen+progesterone users.

Improved Performance of Adjunctive Ultrasonography After Mammography Screening for Breast Cancer Among Chinese Females

INTRODUCTION

Until now, no studies have investigated whether women other than those with dense breasts are suitable for adjunctive ultrasonography after negative mammography, and investigated whether all women with negative mammography are suitable for adjunctive ultrasonography.

METHODS

Based on the Multi-modality Independent Screening Trial in China, a total of 31,918 women aged 45 to 65 years underwent both ultrasonography and mammography. Physicians performed ultrasonography and mammography separately and were blinded to each other's findings until their interpretations had been recorded. For both ultrasonography and mammography, suspicious results and those highly suggestive of a malignancy were confirmed by pathologic examination, whereas other results were confirmed by 1-year follow-up after initial screening.

RESULTS

Based on Breast Imaging Reporting and Data System (BIRADS) assessments, 84 (84.8%) of 99 cancers were identified on mammography (detection rate, 2.6/1000), and 61 (61.6%) of 99 cancers were identified on ultrasonography (detection rate, 1.9/1000). Integrated mammography with ultrasonography identified 94 (95.0%) of 99 cancers, with an increment of 11.9% in cancer detection rate (from 2.6/1000 to 2.9/1000) (P < .05). Moreover, among women with BIRADS 3, adjunctive ultrasonography detected no cancers. All 10 additional cancers detected by adjunctive ultrasonography were from women with BIRADS 0 to 2, at a cost of 207 women with false positives. Additionally, dense breasts and benign breast disease were significantly associated with positive ultrasonography after BIRADS 0 to 2 (all P values < .05).

CONCLUSIONS

After negative mammography, adjunctive ultrasonography should only be recommended for BIRADS 0 to 2 but not BIRADS 3, especially for women with dense breasts or benign breast disease.

Inter-rater reliability and double reading analysis of an automated three-dimensional breast ultrasound system: comparison of two independent examiners

PURPOSE

Breast ultrasound could be a valuable tool complementary to mammography in breast cancer screening. Automated 3D breast ultrasound (ABUS) addresses challenges of hand-held ultrasound and could allow double reading analysis of ultrasound images. This trial assesses the inter-rater reliability and double reading analysis of an ABUS system.

METHODS

To assess the reproducibility and diagnostic validity of the ABUS system, SomoV™, a blinded double reading analysis, was performed in 1019 patients (2038 breasts) by two examiners (examiner A/B) and compared to single reading results, as well as to the reference standard regarding its diagnostic validity. Cohen's kappa coefficients were calculated to measure the inter-rater reliability and agreement of the different diagnostic modalities. Patient comfort and time consumption for image acquisition and reading were analyzed descriptively as secondary objectives.

RESULTS

Analysis of inter-rater reliability yielded agreement in 81.6% (κ = 0.37; p < 0.0001) showing fair agreement. Single reading analysis of SomoV™ exams (examiner A/examiner B) compared to reference standard showed good specificity (examiner A: 88.3%/examiner B: 84.5%), fair inter-rater agreement (examiner A: κ = 0.31/examiner B: κ = 0.31), and adequate sensitivity (examiner A: 53.1%/examiner B: 64.2%). Double reading analysis yielded good sensitivity and specificity (73.7 and 77.7%). Mammography (n = 1911) alone detected 160 of 176 carcinomas (sensitivity 90.1%). Adding SomoV™ to mammography would have detected 12 additional carcinomas, resulting in a higher sensitivity of 97.7%.

CONCLUSION

SomoV™ is a promising technique with good sensitivity, high patient comfort, and fair inter-examiner reliability. It allows double reading analysis that, in combination with mammography, could increase detection rates in breast cancer screening.

Analysis of false-negative readings of automated breast ultrasound studies

BACKGROUND

To assess the reasons for false-negative readings of automated breast ultrasound (ABUS) studies.

METHODS

Between 2012 and 2015, 1,890 ABUS studies were performed at our tertiary medical center. Those for which false-negative results were documented in the initial ABUS report against the corresponding hand-held ultrasound (HHUS) scan were reviewed by three specialized breast radiologists. Key images of specific lesions were marked on the ABUS and HHUS scans and compared for quality (equal, better with HHUS, better with ABUS). Readers were also asked to identify the reasons for the differences in image quality between the scans: poor visibility, lesion location, or fibroglandular tissue shadowing.

RESULTS

Twenty-two ABUS studies met the study criteria. Two of the three readers found that most lesions were better demonstrated with HHUS. Overall agreement among the readers was moderate (kappa 0.36, SD 0.15, p = 0.002). Highest agreement was found for better image quality for HHUS than ABUS (kappa 0.4, SD 1.3, p = 0.0007). Of the four biopsy-proven carcinomas, three were found by all three readers to be better depicted with HHUS; two were located peripherally and were not seen by ABUS. For all readers, the most common reason for false-negative readings was poor visibility, followed by peripheral lesion location and shadowing obscuring the lesion.

CONCLUSIONS

Several factors may make reading ABUS images difficult. Resolution can be diminished by imperfect transducer-breast contact, and fibrotic breasts can cause artifacts such as marked shadowing. Peripheral lesions may be missed because of blind spots. Reader training and experience may play an important role in managing these issues. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 45:245-251, 2017.

Whole-Breast Ultrasound for Breast Screening and Archiving

The incidence of breast cancer is increasing worldwide, reinforcing the importance of breast screening. Conventional hand-held ultrasound (HHUS) for breast screening is efficient and relatively easy to perform; however, it lacks systematic recording and localization. This study investigated an electromagnetic tracking-based whole-breast ultrasound (WBUS) system to facilitate the use of HHUS for breast screening. One-hundred nine breast masses were collected, and the detection of suspicious breast lesions was compared between the WBUS system, HHUS and a commercial automated breast ultrasound (ABUS) system. The positioning error between WBUS and ABUS (1.39 ± 0.68 cm) was significantly smaller than that between HHUS and ABUS (1.62 ± 0.91 cm, p = 0.014) and HHUS and WBUS (1.63 ± 0.9 cm, p = 0.024). WBUS is a practical clinical tool for breast screening that can be used instead of the often unavailable and costly ABUS.

Ultrasonography and histology correlation in BI-RADS 4/5 small breast lesions among Thai patients

Background: Ultrasonography is an important imaging tool in detection of small breast cancers, particularly in younger women with dense breasts. Among the ultrasonographic characteristics for the malignancy, it is unclear which are common or more predictive.

Objective: Analyze breast ultrasonograms and determine the common and predictive characteristics of the BIRADS 4/5 small breast lesions that were correlated with histology-proved carcinoma among Thai patients.

Methods: Data were collected retrospectively between November 2006 and September 2007 at King Chulalongkorn Memorial Hospital. Forty-five BI-RADS 4 or 5 small breast lesions from 41 patients were reviewed for ultrasonographic characteristics and for correlation between each of these features and histology-proved malignancy.

Results: There were 15 out of 30 lesions of BI-RADS 4 and 14 out of 15 of BI-RADS 5 that were histologically proven breast carcinoma. The lesion dimension ranged from 0.27 cm to 1.5 cm (mean: 0.98 cm). The malignant signs that were common consisted of irregular shapes (70%) and posterior shadowing (35.6%). However, the most correlating signs for malignancy were vascularity of the lesion 100%, and spiculated margins 100%. The other characteristics for malignancy, in descending order, were marked hypoechoicity 88.9%, microcalcifications within mass 85.7%, echogenic halo 83.3%, shadowing 81.3%, branched pattern 77.8%, duct extension 75%, irregular shape72.2%, and taller than wide orientation 70%.

Conclusion: Irregular shape and shadowing were the two most common malignant signs that characterized BI-RADS 4, 5 small breast lesions by ultrasonography. However, the most predictive signs were increases in vascularity and spiculated margins.

Improved cancer detection in automated breast ultrasound by radiologists using Computer Aided Detection

OBJECTIVE

To investigate the effect of dedicated Computer Aided Detection (CAD) software for automated breast ultrasound (ABUS) on the performance of radiologists screening for breast cancer.

METHODS

90 ABUS views of 90 patients were randomly selected from a multi-institutional archive of cases collected between 2010 and 2013. This dataset included normal cases (n=40) with >1year of follow up, benign (n=30) lesions that were either biopsied or remained stable, and malignant lesions (n=20). Six readers evaluated all cases with and without CAD in two sessions. CAD-software included conventional CAD-marks and an intelligent minimum intensity projection of the breast tissue. Readers reported using a likelihood-of-malignancy scale from 0 to 100. Alternative free-response ROC analysis was used to measure the performance.

RESULTS

Without CAD, the average area-under-the-curve (AUC) of the readers was 0.77 and significantly improved with CAD to 0.84 (p=0.001). Sensitivity of all readers improved (range 5.2-10.6%) by using CAD but specificity decreased in four out of six readers (range 1.4-5.7%). No significant difference was observed in the AUC between experienced radiologists and residents both with and without CAD.

CONCLUSIONS

Dedicated CAD-software for ABUS has the potential to improve the cancer detection rates of radiologists screening for breast cancer.