INTRODUCTION:We aimed to assess diagnostic performance and accuracy for local staging of CEM combined with DBT (CE + DBT) compared to digital mammography (DM) and MRI. METHODS:Female patients aged 18-70 years with clinical or sonographic suspicion of breast cancer had CE + DBT and breast MRI prior to treatment. Diagnostic accuracy, ability to identify additional disease foci, and disease extent estimations were compared for all imaging techniques. Histopathology was the reference standard. RESULTS:Eighty-seven participants were recruited; 80 included in the study; 69 had cancer. DBT had greater diagnostic sensitivity than DM, but lowest specificity. CEM and CE + DBT showed 100% sensitivity. Specificity was lower for CE + DBT than CEM alone. MRI sensitivity was higher than DM or DBT, but lower than CEM or CE + DBT. MRI specificity was lower than CE-DBT, both separately and in combination. Thirty-nine patients were included in exploratory subset analysis regarding identifying additional foci. DM missed the most cases (8/10); DBT had higher sensitivity but lower specificity; MRI s sensitivity but with more false positives; CEM had the greatest overall accuracy. Thirty patients were included in unifocal disease extent analysis. MRI, CEM, and CE-DBT all demonstrated strong correlation with pathological size, with MRI showing closest agreement. CONCLUSIONS:Combined CE + DBT is feasible within a one-stop clinic appointment and may obviate the need for MRI. CEM demonstrated comparable accuracy to MRI, both for diagnostic accuracy and in local staging. We showed no clear benefit to combining morphological information derived from DBT with functional data of CEM compared to CEM alone.

Oestrogen-receptor positive breast cancer patients are typically treated with adjuvant endocrine therapy (AET), some develop AET resistance. Previous research suggests mammographic density (MD) may represent an imaging biomarker, with fewer local or distant recurrences occurring with decreasing MD. We investigate whether reduction in MD after 1 and/or 3 years is associated with improved breast cancer specific survival (BCSS), metastasis-free survival (MFS) or disease-free survival (DFS). This retrospective cohort study was generated from a Mammo-50 trial subset. Participants taking AET (cases) and controls were included. MD was assessed in the AET group using a 0–100

Background and purpose. The average of two expert assessments of Mammographic Density (MD) using Visual Analogue Scales (VAS) has been related to risk of breast cancer, despite reader variability. Much of the evidence for this method of MD assessment came from a single-centre, single-mammography-vendor setting. We investigate the inter-observer agreement of readers assessing density in images from multiple vendors and its association with mean density and mammography vendor. Methods. We analysed MD assessments from 11 experienced readers who each assessed the cancer-free breast of 50 women with unilateral breast cancer at three time points, with 3-51 mammograms from 6 different vendors. The three vendors with the fewest were grouped. The standard deviation of VAS readings for each mammogram was used as a marker of agreement. Regression analysis was used to investigate agreement with vendor. To further investigate agreement, twenty mammograms showing Low Agreement (LA) between readers and 20 with High Agreement (HA) were selected. Results. Regression analysis found that vendor was not significantly associated with reader agreement (F(3,146) = 1.47, p = 0.225; R-2 = 0.029). Mammogram system vendor accounted for 3% of variability in reader agreement. There was a strong association between reader agreement and VAS density (p < 0.001). Standard deviations were 16.1-21.3% (LA) and 2.2-8.7% (HA). Discussion. Despite the very different appearance of mammograms from different vendors, disagreement was not found to be associated with vendor in this analysis, but it was found to be associated with density. Since reader agreement is low for some cases, averaging multiple visual assessments of breast density may be advisable if resources permit.

Objectives Individuals from deprived areas are less likely to attend breast screening. Inequalities in the coverage of breast screening are associated with poorer cancer outcomes. Individuals who have a positive first experience are more likely to attend subsequent mammograms. This work evaluates the provision of an additional telephone call to individuals who have never attended breast screening, to establish whether this increases attendance.Setting and Methods 1423 patients from four general practitioner practices within socially deprived areas of National Health Service Tayside (UK) comprised the study population. In addition to their standard appointment letter, individuals were to receive a call at least 24 h prior to their appointment. The call identified barriers to screening, and offered a supportive, problem-solving approach to overcoming these barriers. Data collected included: age, Scottish Index of Multiple Deprivation, first-time invite or previous non-attender, if contactable, duration of call, number of days prior to appointment, and confirmation appointment letter was received. The primary outcome was attendance at the screening.Results Contact by phone was made with 678 (47.6%) of the study population. Of those, 483 (71.2%) attended their appointment, 122 (18%) cancelled and 73 (10.8%) did not attend (DNA), versus 344 (46.2%) attending, 34 (4.6%) cancelling and 367 (49.3%) not attending among those who were not able to be contacted. Those who received a call were more likely to attend their appointment and less likely to DNA compared to individuals not receiving the call.Conclusion The intervention is simple and low cost; results indicate that the additional call may increase attendance and reduce DNA appointments at breast screening.

OBJECTIVE:Contrast-enhanced digital breast tomosynthesis (CE-DBT) is a novel imaging technique, combining contrast-enhanced spectral mammography and tomosynthesis. This may offer an alternative imaging technique to breast MRI for monitoring of response to neoadjuvant chemotherapy. This paper addresses patient experience and preference regarding the two techniques.METHODS:Conducted as part of a prospective pilot study; patients were asked to complete questionnaires pertaining to their experience of CE-DBT and MRI following pre-treatment and end-of-treatment imaging. Questionnaires consisted of eight questions answered on a categorical scale, two using a visual analogue scale (VAS), and a question to indicate preference of imaging technique. Statistical analysis was performed with Wilcoxon signed rank test and McNemar test for related samples using SPSS v. 25.RESULTS:18 patients were enrolled in the pilot study. Matched CE-DBT and MRI questionnaires were completed after 22 patient episodes. Patient preference was indicated after 31 patient episodes. Overall, on 77% of occasions patients preferred CE-DBT with no difference between pre-treatment and end-of-treatment imaging. Overall experience (p = 0.008), non-breast pain (p = 0.046), anxiety measured using VAS (p = 0.003), and feeling of being put at ease by staff (p = 0.023) was better for CE-DBT. However, more breast pain was experienced during CE-DBT when measured on both VAS (p = 0.011) and categorical scale (p = 0.021).CONCLUSION:Our paper suggests that patients prefer CE-DBT to MRI, adding further evidence in favour of contrast-enhanced mammographic techniques.ADVANCES IN KNOWLEDGE:Contrast mammographic techniques offer an alternative, more accessible imaging technique to breast MRI. Whilst other studies have addressed patient experience of contrast-enhanced spectral mammography, this is the first study to directly explore patient preference for CE-DBT over MRI in the setting of neoadjuvant chemotherapy, finding that overall, patients preferred CE-DBT despite the relatively long breast compression.

Objectives To identify associations between baseline ultrasound (US) and mammographic features and metastasis free survival (MFS) in women receiving neo-adjuvant chemotherapy (NACT) for breast cancer. Methods The data were collected as part of an ethically approved prospective study. Women with invasive breast cancer receiving NACT who were metastasis free at diagnosis were included. Baseline US and mammography were performed. Imaging was assessed by an experienced breast radiologist who was blinded to outcomes. US imaging features documented included posterior effect, skin thickening, size and stiffness using shear wave elastography (SWE). The mammographic features documented were spiculation and microcalcification. The development of metastatic disease was ascertained from computer records. Statistical analysis was performed using Kaplan Meier survival curves and Receiver Operator Characteristic (ROC) analysis. Results 171 women with 172 cancers were included in the study and 55 developed metastatic disease. Mean follow-up was 6.0 years. Women with mammographic calcification had significantly poorer metastasis free survival (MFS) compared to women without calcification (p = 0.043, 6 yr MFS 50 % vs 69 %). Women bearing cancer with distal shadowing had poorer MFS than women without shadowing (p = 0.025, 6 yr MFS 47 % vs. 73 %). Women with US skin thickening had poorer MFS compared to women without skin thickening (p = 0.032, 6 yr MFS 52 % vs. 68 %). Mammographic spiculation, US size and stiffness at SWE had no significant association with MFS. Conclusion We have identified mammographic and US features associated with MFS in women receiving NACT. Such information may be useful when counselling patients about the benefits and risks of NACT.

Purpose The primary aim was to develop and validate a novel mammography positioning measure, specifically incorporating parameters which might relate to mammography pain. We then explored relationships between the new adverse positioning score and (1) pain; (2) patient and technique factors. Methods A 15-item instrument incorporating positioning features with potential to relate to mammography pain was developed. Participants’ mammograms (n = 310) were reviewed for presence of these features. Validity was investigated using the Rasch model. Scores produced by the resultant measure were investigated for associations with patients’ pain scores and relevant patient and technique factors, using Pearson correlation, analysis of variance, and multiple linear regression. Results Statistical indices within the Rasch measurement framework provided good evidence that the measure reflected a coherent construct of adverse positioning. Thus, the scores produced with the measurement instrument were valid for use in further statistical analysis. There is, however, scope for improvement of the measure’s discriminatory properties. Adverse positioning scores were higher for greater breast volumes (r = 0.12, p=.0391) and body mass index (BMI) (r = 0.13, p=.0349), and varied by mammographer (F(11,298) 2.38, p = .0078). The relationships with BMI and mammographer persisted in regression modelling. No relationship was found between adverse positioning and pain. Conclusions Evidence from Rasch analysis suggests that this novel measure is valid for quantifying a coherent “adverse positioning” construct in mammography. Adverse positioning scores varied by mammographer and were related to higher patient BMI but not to mammography pain. The measure warrants expansion, further refinement, and testing in larger studies.

The purpose of this article is to provide raw data and measure-validation data pertaining to a co-submission published in European Journal of Radiology and entitled: Development and validation of a novel measure of adverse patient positioning in mammography. This Data in Brief article serves not only to provide greater detail than its companion article but also as an educational worked example of the Rasch measurement framework. Rasch measurement is a form of modern psychometric technique and our articles provide the first known example of its use in the evaluation of clinical radiological image quality. The data consist of observations of mammographic images, plus limited participant parameters relevant to the measure validation process. Also provided are validation indices produced by subjecting the primary data to Rasch analysis. An expert observer generated the primary data by reviewing mammographic images to judge the presence or absence of a set of features developed through theory and consultation with other experts. The validation data were generated through Rasch analysis, performed using Winsteps® software, which mathematically models the probability of having a correct response (or a present feature in this dataset) to an item in a given measurement instrument (e.g. questionnaire), as a function of the participant's ability/position on the underlying construct under study. The data can be reused by anyone wishing to learn and practice psychometric validation techniques. They can also form a basis for researchers wishing to build on our preliminary measure for the assessment of mammographic clinical image quality.

OBJECTIVE:Full-field digital mammography (FFDM) has limited sensitivity for cancer in younger women with denser breasts. Digital breast tomosynthesis (DBT) can reduce the risk of cancer being obscured by overlying tissue. The primary study aim was to compare the sensitivity of FFDM, DBT and FFDM-plus-DBT in women under 60 years old with clinical suspicion of breast cancer.METHODS:This multicentre study recruited 446 patients from UK breast clinics. Participants underwent both standard FFDM and DBT. A blinded retrospective multireader study involving 12 readers and 300 mammograms (152 malignant and 148 benign cases) was conducted.RESULTS:Sensitivity for cancer was 86.6% with FFDM [95% CI (85.2-88.0%)], 89.1% with DBT [95% CI (88.2-90%)], and 91.7% with FFDM+DBT [95% CI (90.7-92.6%)]. In the densest breasts, the maximum sensitivity increment with FFDM +DBT over FFDM alone was 10.3%, varying by density measurement method. Overall specificity was 81.4% with FFDM [95% CI (80.5-82.3%)], 84.6% with DBT [95% CI (83.9-85.3%)], and 79.6% with FFDM +DBT [95% CI (79.0-80.2%)]. No differences were detected in accuracy of tumour measurement in unifocal cases.CONCLUSIONS:Where available, DBT merits first-line use in the under 60 age group in symptomatic breast clinics, particularly in women known to have very dense breasts.ADVANCES IN KNOWLEDGE:This study is one of very few to address the accuracy of DBT in symptomatic rather than screening patients. It quantifies the diagnostic gains of DBT in direct comparison with standard digital mammography, supporting informed decisions on appropriate use of DBT in this population.

AIM: To assess the safety of a policy of not biopsying presumed fibroadenomas with benign ultrasound and shear-wave elastography findings in women aged 25-39 years. MATERIALS AND METHODS: Patients aged 25-39 years were included after attending a one -stop clinic before 01/05/2019 where clinical and ultrasound greyscale findings suggested a benign mass and shear-wave elastography showed a mean stiffness of <50 kPa. Such patients were reassured and discharged without biopsy or follow-up. The archived ultrasound images were reviewed subsequently by a second radiologist who could recall patients for biopsy if he deemed the imaging findings to be not definitively benign. Local and national electronic records were reviewed to identify whether these patients later re-presented with breast problems. RESULTS: Seventy-six women with a mean age of 33 years were included. The minimum follow-up was 12 months and the mean follow-up was 2 years. Three (4%) of patients were recalled after review of the ultrasound images by a second radiologist. Five (7%) patients represented with the same lump. Three (4%) patients re-presented with a different benign problem. Two patients presented with breast cancer in the ipsilateral breast but at a different location from the assessed benign lesion. CONCLUSION: Early audit results of a policy of not biopsying or following up clinically benign masses with benign ultrasound greyscale appearances and shear wave stiffness <50 kPa in women aged 25-39 years suggest that this approach may be safe and acceptable. (c) 2020 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.

AIM:To assess whether ultrasound features of breast cancer are associated with breast cancer specific survival (BCSS). MATERIALS AND METHODS:Within a single breast service, data was collected prospectively (April 2010-April 2012) from 319 consecutive women (mean age 63 years) with 335 ultrasound-visible invasive breast cancers. Ultrasound features were evaluated retrospectively from the recorded images according to the Breast Imaging Reporting and Data System (BI-RADS) lexicon by a radiologist blinded to outcomes. Survival and cause of death were ascertained from local and national sources. Kaplan-Meier survival curves were generated, and statistical significance tested using the log-rank test. RESULTS:Mean follow-up in those alive was 80.9 months. Thirty breast cancer deaths and 45 non-breast cancer deaths occurred. Five-year BCSS in the presence of distal acoustic enhancement was 76% compared to 88%, 96%, and 100% for those with distal shadowing, no distal effect or combined effect respectively (p<0.0002). Patients with sonographic skin involvement had 73% 5-year BCSS compared to 92% for no skin involvement (p<0.0001). Focal oedema was associated with 56% 5-year BCSS compared to 89% for those without (p=0.0002). A significant association was demonstrated between ultrasound tumour size and BCSS (p<0.0001). At multivariate analysis, skin changes, distal enhancement, and focal oedema maintained prognostic significance. CONCLUSION:Distal enhancement, focal oedema, and skin involvement have strong associations with breast cancer death. These factors could be taken into account, along with lesion size and other commonly used preoperative prognostic features, when considering management of women with breast cancer.

Aims: to assess the feasibility and acceptability of large-gauge percutaneous removal of the axillary sentinel lymph node (SLN) using dual gamma probe and ultrasound guidance. Materials and Methods: Technetium nanocolloid was administered the day before surgery. On the day of surgery, potential SLNs were identified with gamma probe and ultrasound scanning. A 7G vacuum assisted biopsy (VAB) device was inserted percutaneously deep to the target node and the node(s) removed. The gamma probe was used to confirm removal of radiolabelled tissue. At surgery, any residual radiolabelled or blue nodes were removed. Morbidity was assessed via (i) a pain questionnaire immediately after the percutaneous procedure, (ii) relevant items from the FACT B+4 questionnaire 7-10 days after surgery, and (iii) case note review one month after surgery. Results: Twenty-two patients consented and 20 patients underwent the procedure. Radiolabelled nodal tissue was obtained in 18/20 (90%). The mean procedure time was 11 minutes. Four of 18 patients had metastatic disease identified in the VAB excision tissue with 100% sensitivity for axillary metastasis. At axillary surgery, additional intact SLN or fragments were found in 14 patients. No additional metastatic disease was found at surgery. One patient suffered a pneumothorax during instillation of local anaesthetic. The median pain score was 10/100 by visual analogue scale. Immediate post procedure haematoma was common (14 of 20) and prolonged manual compression frequent. Conclusion: VAB removal of sentinel nodes using dual scanning is feasible. Although preliminary sensitivity and specificity levels are encouraging, complications may discourage widespread implementation.

AIMS: To assess the feasibility and acceptability of large-gauge percutaneous removal of the axillary sentinel lymph node (SLN) using dual gamma probe and ultrasound guidance. MATERIALS AND METHODS: Technetium nanocolloid was administered the day before surgery. On the day of surgery, potential SLNs were identified with gamma probe and ultrasound scanning. A 7 G vacuum-assisted biopsy (VAB) device was inserted percutaneously deep to the target node and the node(s) removed. The gamma probe was used to confirm removal of radiolabelled tissue. At surgery, any residual radiolabelled or blue nodes were removed. Morbidity was assessed via (1) a pain questionnaire immediately after the percutaneous procedure, (2) relevant items from the FACT B+4 questionnaire 7-10 days after surgery, and (3) case note review 1 month after surgery. RESULTS: Twenty-two patients consented and 20 patients underwent the procedure. Radiolabelled nodal tissue was obtained in 18/20 (90%). The mean procedure time was 11 minutes. Four of 18 patients had metastatic disease identified in the VAB excision tissue with 100% sensitivity for axillary metastasis. At axillary surgery, additional intact SLN or fragments were found in 14 patients. No additional metastatic disease was found at surgery. One patient suffered a pneumothorax during instillation of local anaesthetic. The median pain score was 10/100 by visual analogue scale. Immediate post-procedure haematoma was common (14 of 20) and prolonged manual compression frequent. CONCLUSION: VAB removal of sentinel nodes using dual scanning is feasible. Although preliminary sensitivity and specificity levels are encouraging, complications may discourage widespread implementation. (C) 2018 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.

AIM: To assess the value of post-treatment shear-wave elastography (SWE) parameters (maximum stiffness [Emax], mean stiffness [Emean], and standard deviation [SD]) compared to greyscale ultrasonography (US) and magnetic resonance imaging (MRI) in identifying pathological complete response (pCR) to neoadjuvant chemotherapy (NACT) in breast cancer. MATERIALS AND METHODS: In a prospective cohort study, 80 patients receiving NACT for breast cancer underwent baseline and post-treatment US, SWE, and MRI examinations. Four SWE images in two orthogonal planes were obtained. Maximum greyscale US diameter and maximum diameter of lesion enhancement on MRI were measured. Percentage reductions between baseline and post-treatment scans were calculated for MRI and greyscale US diameter, and Emean, Emax, and SD. The percentage reduction in Emean and US diameter were also analysed as a combination. Analysis was undertaken using receiver operating characteristic (ROC) curves and the chi-squared test. RESULTS: pCR occurred in 21 of 80 (26%) women. The area under the ROC curve (AUC) for pCR of percentage reductions in Emean, Emax, SD, and greyscale US diameter were 0.89, 0.85, 0.75, and 0.86, respectively. The combination of percentage reductions in Emean and greyscale ultrasound diameter yielded an AUC of 0.92, which is similar to the AUC for MRI of 0.96 (p=0.28). CONCLUSIONS: SWE combined with greyscale US shows promise for end-of-treatment identification of response to NACT in women with breast cancer, with accuracies similar to breast MRI. This technique could be used to inform surgical decision-making after NACT. (C) 2018 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.

BACKGROUND:Prediction of pathological complete response (pCR) of primary breast cancer to neoadjuvant chemotherapy (NACT) may influence planned surgical approaches in the breast and axilla. The aim of this project is to assess the value of interim shear wave elastography (SWE), ultrasound (US) and magnetic resonance imaging (MRI) after 3 cycles in predicting pCR. METHODS:64 patients receiving NACT had baseline and interim US, SWE and MRI examinations. The mean lesion stiffness at SWE, US and MRI diameter was measured at both time points. We compared four parameters with pCR status: a) Interim mean stiffness ≤ or > 50 kPa; b) Percentage stiffness reduction; c) Percentage US diameter reduction and d) Interim MRI response using RECIST criteria. The Chi square test was used to assess significance. RESULTS:Interim stiffness of ≤ or > 50 kPa gave the best prediction of pCR with pCR seen in 10 of 14 (71 %) cancers with an interim stiffness of ≤ 50 kPa, compared to 7 of 50 (14 %) of cancers with an interim stiffness of > 50 kPa, (p < 0.0001) (sensitivity 59 %, specificity 91 %, PPV 71 %, NPV 86 % and diagnostic accuracy 83 %). Percentage reduction in stiffness was the next best parameter (sensitivity 59 %, specificity 85 %, p < 0.0004) followed by reduction in MRI diameter of > 30 % (sensitivity 50 % and specificity 79 %, p = 0.03) and % reduction in US diameter (sensitivity 47 %, specificity 81 %, p = 0.03). Similar results were obtained from ROC analysis. CONCLUSION:SWE stiffness of breast cancers after 3 cycles of NACT and changes in stiffness from baseline are strongly associated with pCR after 6 cycles.

The purpose is to develop and validate an automated method for detecting image unsharpness caused by patient motion blur in digital mammograms. The goal is that such a tool would facilitate immediate re-taking of blurred images, which has the potential to reduce the number of recalled examinations, and to ensure that sharp, high-quality mammograms are presented for reading. To meet this goal, an automated method was developed based on interpretation of the normalized image Wiener Spectrum. A preliminary algorithm was developed using 25 cases acquired using a single vendor system, read by two expert readers identifying the presence of blur, location, and severity. A predictive blur severity score was established using multivariate modeling, which had an adjusted coefficient of determination, R2 =0.63±0.02, for linear regression against the average reader-scored blur severity. A heatmap of the relative blur magnitude showed good correspondence with reader sketches of blur location, with a Spearman rank correlation of 0.70 between the algorithmestimated area fraction with blur and the maximum of the blur area fraction categories of the two readers. Given these promising results, the algorithm-estimated blur severity score and heatmap are proposed to be used to aid observer interpretation. The use of this automated blur analysis approach, ideally with feedback during an exam, could lead to a reduction in repeat appointments for technical reasons, saving time, cost, potential anxiety, and improving image quality for accurate diagnosis.