Reports of patients with axillary adenopathy identified on breast imaging after coronavirus disease (COVID-19) vaccination are rising. We propose a pragmatic management approach based on clinical ...presentation, vaccination delivery, and imaging findings. In the settings of screening mammography, screening MRI, and diagnostic imaging work-up of breast symptoms, with no imaging findings beyond unilateral axillary adenopathy ipsilateral to recent (prior six weeks) vaccination, we report the adenopathy as benign with no further imaging indicated if no nodes are palpable six weeks after the last dose. For patients with palpable axillary adenopathy in the setting of ipsilateral recent vaccination, clinical follow-up of the axilla is recommended. In all these scenarios, axillary ultrasound is recommended if clinical concern persists six weeks after vaccination. In patients with recent breast cancer diagnosis in the pre- or peri-treatment setting, prompt recommended imaging is encouraged as well as vaccination (in the thigh or contralateral arm). Our recommendations align with the ACR BI-RADS Atlas and aim to: 1) reduce patient anxiety, provider burden, and costs of unnecessary evaluation of enlarged nodes in the setting of recent vaccination, and 2) avoid further delays in vaccinations and breast cancer screening during the pandemic.
The purpose of this study is to compare the risk of malignancy associated with architectural distortion detected on 2D digital mammography (DM) versus digital breast tomosynthesis (DBT).
We performed ...a retrospective review of architectural distortion cases recommended for biopsy from September 2007 to February 2011, the period before DBT integration (hereafter known as the DM group), and from January 2013 to June 2016, the period after DBT integration (hereafter known as the DBT group). Medical records were reviewed for imaging findings and pathology results.
Architectural distortion was more commonly detected in the DBT group than the DM group (0.14% 274/202,438 examinations vs 0.07% 121/166,661 examinations; p < 0.001). The positive predictive value of architectural distortion for malignancy was significantly lower in the DBT group than the DM group (50.7% 139/274 cases vs 73.6% 89/121 cases; p < 0.001). Radial scar was the most common nonmalignant finding in both groups, but it was more common in the DBT group (33.2% 91/274 vs 11.6% 14/121; p < 0.001). In the DBT group, architectural distortion without correlative findings on ultrasound was less likely to represent malignancy than was architectural distortion with correlative findings on ultrasound (29.2% 31/106 vs 66.5% 105/158; p < 0.001).
Architectural distortion is more commonly detected on DBT than DM and is less likely to represent malignancy on DBT. Architectural distortion on DBT is less likely to represent malignancy if there is no sonographic correlate; however, biopsy is warranted even in the absence of a sonographic correlate, given the nearly 30% risk of malignancy in this setting.
To compare magnetic resonance (MR) imaging findings and clinical assessment for prediction of pathologic response to neoadjuvant chemotherapy (NACT) in patients with stage II or III breast cancer.
...The HIPAA-compliant protocol and the informed consent process were approved by the American College of Radiology Institutional Review Board and local-site institutional review boards. Women with invasive breast cancer of 3 cm or greater undergoing NACT with an anthracycline-based regimen, with or without a taxane, were enrolled between May 2002 and March 2006. MR imaging was performed before NACT (first examination), after one cycle of anthracyline-based treatment (second examination), between the anthracycline-based regimen and taxane (third examination), and after all chemotherapy and prior to surgery (fourth examination). MR imaging assessment included measurements of tumor longest diameter and volume and peak signal enhancement ratio. Clinical size was also recorded at each time point. Change in clinical and MR imaging predictor variables were compared for the ability to predict pathologic complete response (pCR) and residual cancer burden (RCB). Univariate and multivariate random-effects logistic regression models were used to characterize the ability of tumor response measurements to predict pathologic outcome, with area under the receiver operating characteristic curve (AUC) used as a summary statistic.
Data in 216 women (age range, 26-68 years) with two or more imaging time points were analyzed. For prediction of both pCR and RCB, MR imaging size measurements were superior to clinical examination at all time points, with tumor volume change showing the greatest relative benefit at the second MR imaging examination. AUC differences between MR imaging volume and clinical size predictors at the early, mid-, and posttreatment time points, respectively, were 0.14, 0.09, and 0.02 for prediction of pCR and 0.09, 0.07, and 0.05 for prediction of RCB. In multivariate analysis, the AUC for predicting pCR at the second imaging examination increased from 0.70 for volume alone to 0.73 when all four predictor variables were used. Additional predictive value was gained with adjustments for age and race.
MR imaging findings are a stronger predictor of pathologic response to NACT than clinical assessment, with the greatest advantage observed with the use of volumetric measurement of tumor response early in treatment.
Purpose To develop a machine learning model that allows high-risk breast lesions (HRLs) diagnosed with image-guided needle biopsy that require surgical excision to be distinguished from HRLs that are ...at low risk for upgrade to cancer at surgery and thus could be surveilled. Materials and Methods Consecutive patients with biopsy-proven HRLs who underwent surgery or at least 2 years of imaging follow-up from June 2006 to April 2015 were identified. A random forest machine learning model was developed to identify HRLs at low risk for upgrade to cancer. Traditional features such as age and HRL histologic results were used in the model, as were text features from the biopsy pathologic report. Results One thousand six HRLs were identified, with a cancer upgrade rate of 11.4% (115 of 1006). A machine learning random forest model was developed with 671 HRLs and tested with an independent set of 335 HRLs. Among the most important traditional features were age and HRL histologic results (eg, atypical ductal hyperplasia). An important text feature from the pathologic reports was "severely atypical." Instead of surgical excision of all HRLs, if those categorized with the model to be at low risk for upgrade were surveilled and the remainder were excised, then 97.4% (37 of 38) of malignancies would have been diagnosed at surgery, and 30.6% (91 of 297) of surgeries of benign lesions could have been avoided. Conclusion This study provides proof of concept that a machine learning model can be applied to predict the risk of upgrade of HRLs to cancer. Use of this model could decrease unnecessary surgery by nearly one-third and could help guide clinical decision making with regard to surveillance versus surgical excision of HRLs.
RSNA, 2017.
To evaluate volumetric magnetic resonance (MR) imaging for predicting recurrence-free survival (RFS) after neoadjuvant chemotherapy (NACT) of breast cancer and to consider its predictive performance ...relative to pathologic complete response (PCR).
This HIPAA-compliant prospective multicenter study was approved by institutional review boards with written informed consent. Women with breast tumors 3 cm or larger scheduled for NACT underwent dynamic contrast-enhanced MR imaging before treatment (examination 1), after one cycle (examination 2), midtherapy (examination 3), and before surgery (examination 4). Functional tumor volume (FTV), computed from MR images by using enhancement thresholds, and change from baseline (ΔFTV) were measured after one cycle and before surgery. Association of RFS with FTV was assessed by Cox regression and compared with association of RFS with PCR and residual cancer burden (RCB), while controlling for age, race, and hormone receptor (HR)/ human epidermal growth factor receptor type 2 (HER2) status. Predictive performance of models was evaluated by C statistics.
Female patients (n = 162) with FTV and RFS were included. At univariate analysis, FTV2, FTV4, and ΔFTV4 had significant association with RFS, as did HR/HER2 status and RCB class. PCR approached significance at univariate analysis and was not significant at multivariate analysis. At univariate analysis, FTV2 and RCB class had the strongest predictive performance (C statistic = 0.67; 95% confidence interval CI: 0.58, 0.76), greater than for FTV4 (0.64; 95% CI: 0.53, 0.74) and PCR (0.57; 95% CI: 0.39, 0.74). At multivariate analysis, a model with FTV2, ΔFTV2, RCB class, HR/HER2 status, age, and race had the highest C statistic (0.72; 95% CI: 0.60, 0.84).
Breast tumor FTV measured by MR imaging is a strong predictor of RFS, even in the presence of PCR and RCB class. Models combining MR imaging, histopathology, and breast cancer subtype demonstrated the strongest predictive performance in this study.
Reports are rising of patients with unilateral axillary lymphadenopathy, visible on diverse imaging examinations, after recent coronavirus disease 2019 vaccination. With less than 10% of the US ...population fully vaccinated, we can prepare now for informed care of patients imaged after recent vaccination. The authors recommend documenting vaccination information (dates of vaccinations, injection site left or right, arm or thigh, type of vaccine) on intake forms and having this information available to the radiologist at the time of examination interpretation. These recommendations are based on three key factors: the timing and location of the vaccine injection, clinical context, and imaging findings. The authors report isolated unilateral axillary lymphadenopathy (i.e., no imaging findings outside of visible lymphadenopathy), which is ipsilateral to recent (prior 6 weeks) vaccination, as benign with no further imaging indicated. Clinical management is recommended, with ultrasound if clinical concern persists 6 weeks after the final vaccination dose. In the clinical setting to stage a recent cancer diagnosis or assess response to therapy, the authors encourage prompt recommended imaging and vaccination (possibly in the thigh or contralateral arm according to the location of the known cancer). Management in this clinical context of a current cancer diagnosis is tailored to the specific case, ideally with consultation between the oncology treatment team and the radiologist. The aim of these recommendations is to (1) reduce patient anxiety, provider burden, and costs of unnecessary evaluation of enlarged nodes in the setting of recent vaccination and (2) avoid further delays in vaccinations and recommended imaging for best patient care during the pandemic.
IMPORTANCE: After the US Food and Drug Administration (FDA) approved computer-aided detection (CAD) for mammography in 1998, and the Centers for Medicare and Medicaid Services (CMS) provided ...increased payment in 2002, CAD technology disseminated rapidly. Despite sparse evidence that CAD improves accuracy of mammographic interpretations and costs over $400 million a year, CAD is currently used for most screening mammograms in the United States. OBJECTIVE: To measure performance of digital screening mammography with and without CAD in US community practice. DESIGN, SETTING, AND PARTICIPANTS: We compared the accuracy of digital screening mammography interpreted with (n = 495 818) vs without (n = 129 807) CAD from 2003 through 2009 in 323 973 women. Mammograms were interpreted by 271 radiologists from 66 facilities in the Breast Cancer Surveillance Consortium. Linkage with tumor registries identified 3159 breast cancers in 323 973 women within 1 year of the screening. MAIN OUTCOMES AND MEASURES: Mammography performance (sensitivity, specificity, and screen-detected and interval cancers per 1000 women) was modeled using logistic regression with radiologist-specific random effects to account for correlation among examinations interpreted by the same radiologist, adjusting for patient age, race/ethnicity, time since prior mammogram, examination year, and registry. Conditional logistic regression was used to compare performance among 107 radiologists who interpreted mammograms both with and without CAD. RESULTS: Screening performance was not improved with CAD on any metric assessed. Mammography sensitivity was 85.3% (95% CI, 83.6%-86.9%) with and 87.3% (95% CI, 84.5%-89.7%) without CAD. Specificity was 91.6% (95% CI, 91.0%-92.2%) with and 91.4% (95% CI, 90.6%-92.0%) without CAD. There was no difference in cancer detection rate (4.1 in 1000 women screened with and without CAD). Computer-aided detection did not improve intraradiologist performance. Sensitivity was significantly decreased for mammograms interpreted with vs without CAD in the subset of radiologists who interpreted both with and without CAD (odds ratio, 0.53; 95% CI, 0.29-0.97). CONCLUSIONS AND RELEVANCE: Computer-aided detection does not improve diagnostic accuracy of mammography. These results suggest that insurers pay more for CAD with no established benefit to women.
Conventional breast MRI is highly sensitive for cancer detection but prompts some false positives. We performed a prospective, multicenter study to determine whether apparent diffusion coefficients ...(ADCs) from diffusion-weighted imaging (DWI) can decrease MRI false positives.
A total of 107 women with MRI-detected BI-RADS 3, 4, or 5 lesions were enrolled from March 2014 to April 2015. ADCs were measured both centrally and at participating sites. ROC analysis was employed to assess diagnostic performance of centrally measured ADCs and identify optimal ADC thresholds to reduce unnecessary biopsies. Lesion reference standard was based on either definitive biopsy result or at least 337 days of follow-up after the initial MRI procedure.
Of 107 women enrolled, 67 patients (median age 49, range 24-75 years) with 81 lesions with confirmed reference standard (28 malignant, 53 benign) and evaluable DWI were analyzed. Sixty-seven of 81 lesions were BI-RADS 4 (
= 63) or 5 (
= 4) and recommended for biopsy. Malignancies exhibited lower mean in centrally measured ADCs (mm
/s) than benign lesions 1.21 × 10
vs.1.47 × 10
;
< 0.0001; area under ROC curve = 0.75; 95% confidence interval (CI) 0.65-0.84. In centralized analysis, application of an ADC threshold (1.53 × 10
mm
/s) lowered the biopsy rate by 20.9% (14/67; 95% CI, 11.2%-31.2%) without affecting sensitivity. Application of a more conservative threshold (1.68 × 10
mm
/s) to site-measured ADCs reduced the biopsy rate by 26.2% (16/61) but missed three cancers.
DWI can reclassify a substantial fraction of suspicious breast MRI findings as benign and thereby decrease unnecessary biopsies. ADC thresholds identified in this trial should be validated in future phase III studies.
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