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Background: Tumor heterogeneity and vascularity can be noninvasively quantified using histogram and perfusion analyses on computed tomography (CT) and magnetic resonance imaging (MRI). We compared the association of histogram and perfusion features with histological prognostic factors and progression-free survival (PFS) in breast cancer patients on low-dose CT and MRI. Methods: This prospective study enrolled 147 women diagnosed with invasive breast cancer who simultaneously underwent contrast-enhanced MRI and CT before treatment. We extracted histogram and perfusion parameters from each tumor on MRI and CT, assessed associations between imaging features and histological biomarkers, and estimated PFS using the Kaplan–Meier analysis. Results: Out of 54 histogram and perfusion parameters, entropy on T2- and postcontrast T1-weighted MRI and postcontrast CT, and perfusion (blood flow) on CT were significantly associated with the status of subtypes, hormone receptors, and human epidermal growth factor receptor 2 (p < 0.05). Patients with high entropy on postcontrast CT showed worse PFS than patients with low entropy (p = 0.053) and high entropy on postcontrast CT negatively affected PFS in the Ki67-positive group (p = 0.046). Conclusions: Low-dose CT histogram and perfusion analysis were comparable to MRI, and the entropy of postcontrast CT could be a feasible parameter to predict PFS in breast cancer patients.

Objective To determine survival outcomes in women with breast cancer detected at combined screening with breast MRI and mammography versus screening mammography alone. Methods This is an institutional review board-approved retrospective study, and the need for informed consent was waived. A total of 3002 women with an increased risk of breast cancer were screened between 2001 and 2004. Of the 3002 women, 1534 (51.1%) had 2780 combined screenings (MRI and mammography) and 1468 (48.9%) had 4811 mammography-only screenings. The Χ2 test and the Kaplan-Meier method were used to compare cancer detection rates and survival rates. Results The overall cancer detection rate was significantly higher in the MRI plus mammography group compared with the mammography-only group (1.4% [40 of 2780] vs 0.5% [23 of 4811]; P < 0.001). No interval cancers occurred in the MRI plus mammography group, whereas 9 interval cancers were found in the mammography-only group. During a median follow-up of 10.9 years (range: 0.7 to 15.2), a total of 11 recurrences and 5 deaths occurred. Of the 11 recurrences, 6 were in the MRI plus mammography group and 5 were in the mammography-only group. All five deaths occurred in the mammography-only group. Disease-free survival showed no statistically significant difference between the two groups (P = 0.32). However, overall survival was significantly improved in the MRI plus mammography group (P = 0.002). Conclusion Combined screening with MRI and mammography in women at elevated risk of breast cancer improves cancer detection and overall survival.

PURPOSE: To determine preoperative magnetic resonance imaging (MRI) features associated with positive or close margins in patients with breast cancer who underwent breast-conserving surgery (BCS). MATERIALS AND METHODS: A retrospective review identified 249 patients with invasive ductal carcinoma (IDC) who underwent preoperative MRI and BCS as a primary procedure between 2008 and 2010. The MR images were reviewed for descriptions of findings with no new interpretations made. Margins were defined as positive (tumor touching the inked specimen margin), close (< 2 mm tumor-free margin), or negative (≥ 2 mm tumor-free margin). Multivariate logistic regression analysis was performed to evaluate imaging and clinical factors predictive of positive or close margins. RESULTS: Of the 249 patients, 83 (33.3%) had positive or close margins and 166 (66.7%) had negative margins on the initial BCS specimen. Multivariate analysis showed that multifocal disease (odds ratio, 4.8; 95% CI, 1.9–12.2; p = 0.001), nonmass enhancement lesion (odds ratio, 3.0; 95% CI, 1.5–6.2, p = 0.003), greater background parenchymal enhancement (odds ratio, 2.5; 95% CI, 1.1–5.6; p = 0.023), larger lesion size (odds ratio, 1.3; 95% CI, 1.0–1.7, p = 0.032), and presence of ductal carcinoma in situ on needle biopsy (odds ratio, 2.4; 95% CI, 1.3–4.6; p = 0.008) were independent predictors of positive or close margins. CONCLUSIONS: Multifocal disease, nonmass enhancement lesion, or greater background parenchymal enhancement on preoperative breast MRI were significantly associated with positive or close margins. Identifying these MRI features before surgery can be helpful to reduce the reoperation rate in BCS.

To retrospectively investigate the reasons for and features of undiagnosed cancers at previous supplemental screening ultrasonography (US) in women who subsequently received a diagnosis of breast cancer.The institutional review board approved this retrospective study and waived the requirement to obtain informed patient consent. The study consisted of 230 women (median age, 49 years; age range, 29-81 years) with 230 pairs of US examinations (prior and subsequent examinations) performed between December 2003 and August 2013 who were found to have cancer (median interval, 12 months; range, 2-24 months). The authors compared the clinical-pathologic features of patients with negative findings on prior images with those of patients with visible findings on prior images. Findings visible at prior US were classified as actionable or underthreshold by means of a blinded review by five radiologists. Lesions classified as Breast Imaging Reporting and Data System category 4 or 5 by fewer than three readers were determined to be underthreshold. Reasons for undiagnosed cancers and their imaging features were analyzed.Among the 230 prior US examinations, 72 (31.3%) showed visible findings and 158 (68.7%) showed negative findings. High-nuclear-grade cancers and triple-negative cancers were more common in patients with negative findings than in those with visible findings (P = .023 and P = .006, respectively). Blinded review revealed that 57 of the 72 visible findings (79%) were actionable. Misinterpretation (39% [28 of 72 lesions]) and multiple distracting lesions (17% [12 of 72 lesions]) were the two most common reasons for missing these actionable findings, which showed more noncircumscribed margins than did underthreshold findings (P = .028).At supplemental screening breast US, close attention should be paid to the presence of a margin that is not circumscribed, and multiple lesions should be separately assessed to reduce the number of missed breast cancers.

Importance Younger women (aged ≤50 years) who underwent breast conservation therapy may benefit from breast magnetic resonance imaging (MRI) screening as an adjunct to mammography. Objective To prospectively determine the cancer yield and tumor characteristics of combined mammography with MRI or ultrasonography screening in women who underwent breast conservation therapy for breast cancers and who were 50 years or younger at initial diagnosis. Design, Setting, and Participants This multicenter, prospective, nonrandomized study was conducted from December 1, 2010, to January 31, 2016, at 6 academic institutions. Seven hundred fifty-four women who were 50 years or younger at initial diagnosis and who had undergone breast conservation therapy for breast cancer were recruited to participate in the study. Reference standard was defined as a combination of pathology and 12-month follow-up. Interventions Participants underwent 3 annual MRI screenings of the conserved and contralateral breasts in addition to mammography and ultrasonography, with independent readings. Main Outcomes and Measures Cancer detection rate, sensitivity, specificity, interval cancer rate, and characteristics of detected cancers. Results A total of 754 women underwent 2065 mammograms, ultrasonography, and MRI screenings. Seventeen cancers were diagnosed, and most of the detected cancers (13 of 17 [76%]) were stage 0 or stage 1. Overall cancer detection rate (8.2 vs 4.4 per 1000; P = .003) or sensitivity (100% vs 53%; P = .01) of mammography with MRI was higher than that of mammography alone. After the addition of ultrasonography, the cancer detection rate was higher than that by mammography alone (6.8 vs 4.4 per 1000; P = .03). The specificity of mammography with MRI or ultrasonography was lower than that by mammography alone (87% or 88% vs 96%; P Conclusions and Relevance After breast conservation therapy in women 50 years or younger, the addition of MRI to annual mammography screening improves detection of early-stage but biologically aggressive breast cancers at acceptable specificity. Results from this study can inform patient decision making on screening methods after breast conservation therapy.

To retrospectively investigate whether the background parenchymal features around a tumor at preoperative dynamic contrast material-enhanced magnetic resonance (MR) imaging are associated with ipsilateral breast tumor recurrence (IBTR)-free survival in patients with ductal carcinoma in situ (DCIS) after breast conservation surgery.The institutional review board approved this study, and the requirement for informed consent was waived. Between 2004 and 2009, 215 consecutive women with pure DCIS who had undergone preoperative dynamic contrast-enhanced MR imaging and curative breast conservation surgery were identified. Clinical-pathologic features (age, menopausal status, presentation of clinical findings, biopsy method, tumor size, nuclear grade, hormonal receptor status, margin status, and adjuvant therapy) and MR imaging features (lesion size, background parenchymal enhancement grade, fibroglandular density, parenchymal signal enhancement ratio [SER] around the tumor, lesion type, and lesion kinetics) were analyzed. A Cox proportional hazards model was used to determine the association between MR imaging variables and IBTR-free survival after controlling for clinical-pathologic variables. Reproducibility of SER measurements was evaluated by using the intraclass correlation coefficient.There were 15 of 215 (7.0%) IBTR cases (nine DCIS cases and six invasive cases) at a median of 36 months (range, 11-61 months). Multivariate analysis showed that higher parenchymal SER (hazard ratio [HR] = 2.028, P.001 for reader 1; HR = 1.652, P.001 for reader 2) and larger histologic tumor size (HR = 1.360, P = .009 for reader 1; HR = 1.402, P = .006 for reader 2) were independent factors associated with worse IBTR-free survival. The intraclass correlation coefficient of SER measurements between two readers was 0.852 (95% confidence interval: 0.811, 0.885).Higher parenchymal SER around the tumor at preoperative dynamic contrast-enhanced MR imaging and larger histologic tumor size were independent factors associated with worse IBTR-free survival in patients with DCIS after breast conservation surgery.

Purpose To investigate whether pretreatment breast magnetic resonance (MR) imaging features are associated with pathologic complete response (PCR) and recurrence-free survival after neoadjuvant chemotherapy (NAC) in patients with triple-negative breast cancer. Materials and Methods Identified were 132 patients with primary triple-negative breast cancers who underwent NAC and pretreatment MR imaging between 2004 and 2010. Three breast radiologists independently reviewed the MR images based on the 2013 Breast Imaging Reporting and Data System lexicon. Presence of intratumoral high signal intensity and peritumoral edema on T2-weighted images was also evaluated. Association of PCR and recurrence-free survival with MR imaging features was assessed by using logistic regression and Cox regression. Bonferroni correction was applied to the P values. Results Among 132 patients, 18 (14%) underwent PCR. Round or oval masses (odds ratio, 3.5 [95% confidence interval: 1.3, 9.7]; P = .02), the absence of intratumoral T2 high signal intensity (odds ratio, 3.8 [95% confidence interval: 1.3, 11.0]; P = .01), and the absence of peritumoral edema (odds ratio, 3.4 [95% confidence interval: 1.2, 9.5]; P = .02) were associated with PCR, but not significantly. After 54 months of median follow-up, there were 41 (31% [41 of 132]) breast cancer recurrences. Peritumoral edema was the only significant variable associated with worse recurrence-free survival (hazard ratio, 4.9 [95% confidence interval: 1.9, 12.6]; P = .001). Conclusion Pretreatment MR imaging features may be associated with PCR and recurrence-free survival in patients with triple-negative breast cancer. © RSNA, 2016 Online supplemental material is available for this article.

Purpose To determine additional cancer yield of magnetic resonance (MR) imaging in women with breast cancer detected at screening ultrasonography (US) and to identify a subgroup of women who are likely to benefit from preoperative MR imaging. Materials and Methods This study was approved by the institutional review board, and the requirement for informed consent was waived. A retrospective review of 374 women (median age, 48 years; age range, 30-74 years) with breast cancer detected at screening US (invasive, n = 321) who underwent preoperative breast MR imaging between 2007 and 2013 was performed. Cancer yield and positive predictive value of biopsy were calculated. Multivariate logistic regression analysis was performed to identify clinical-pathologic features associated with additional cancer detected at MR imaging. Results Of 374 women, 21 (5.6%; 95% confidence interval [CI]: 3.5%, 8.5%) were diagnosed with additional cancer (positive predictive value of biopsy, 42.0% [21 of 50 women]; 95% CI: 28%, 57%). Index invasive lobular cancer (ILC) histologic type was significantly associated with additional cancer detected at MR imaging (odds ratio, 4.0; 95% CI: 1.2, 13.6; P = .03). In women with index invasive cancer, premenopausal status (odds ratio, 5.7; 95% CI: 1.2, 35.8; P = .03) and lobular histologic type (odds ratio, 3.9; 95% CI: 1.1, 12.3; P = .03) were factors associated with additional cancer detected at MR imaging. Conclusion Preoperative MR imaging helped to detect additional sites of cancer in 5.6% of women with breast cancer detected at screening US. Women with index ILC and premenopausal women are more likely to benefit from preoperative MR imaging.

Screening ultrasound (US) can increase the detection of breast cancer. However, little is known about the clinicopathologic characteristics of breast cancers detected by screening US. A search of the database for patients with breast cancer yielded a dataset in 6837 women who underwent breast surgery at Seoul National University Hospital (Korea). Of 6837 women, 1047 were asymptomatic and had a non-palpable cancer. Two hundred fifty-four women with 256 cancers detected by US (US-detected cancer) and 793 women with 807 cancers detected by mammography (MG-detected cancer) were identified. The imaging, clinicopathologic, and molecular data were reviewed. Univariate and multivariate analyses were carried out. Women with US-detected cancer were younger and were more likely to undergo breast-conserving surgery and to have node-negative invasive cancer (P0.0001). By multivariate analysis, the significant independent characteristics were tumor size, mammographic density, final assessment category according to the American College of Radiology Breast Imaging Reporting and Data System, progesterone receptor (PR), human epidermal growth factor receptor 2 (HER2), and molecular subtype. Compared to tumors that were2 cm in size, tumors that were ≤ 1 cm in size were 2.2-fold more likely to be US-detected cancers (P = 0.02). Compared to the luminal A subtype tumors (estrogen receptor [ER]+, PR+, HER2-), luminal B subtype tumors (ER+, PR+, HER2+) were less likely to be in the US-detected cancer group (P0.01). Women with dense breasts were more likely to have US-detected cancer (P0.01) versus those with non-dense breasts. Screening US-detected cancers were less likely to be diagnosed as category 5 instead of category 4 (P0.01). In conclusion, women with US-detected breast cancer are more likely to have small-sized invasive cancer and more likely associated with the luminal A subtype.

To determine the imaging and clinical-pathologic factors associated with recurrence in patients with early stage triple-negative breast cancer.This study was approved by the institutional review board, and the requirement to obtain informed consent was waived. The authors evaluated 398 patients with stage I or II triple-negative breast cancer (median age, 48 years; range, 21-81 years) who were treated between January 2003 and December 2008. Data collected included preoperative breast magnetic resonance (MR) images, mammographic density, patient age, symptoms, family history of breast cancer, histologic tumor characteristics, tumor grade, tumor size, lymphovascular invasion, lymph node involvement, surgery type, margin status, and adjuvant treatment received. Multivariate analysis was performed by using a Cox proportional hazards model, and recurrence-free survival was estimated with the adjusted Kaplan-Meier method.Of the 398 patients, 63 (15.8%) had recurrent disease after a median follow-up of 6.1 years. The absence of preoperative MR imaging (hazard ratio [HR] with multivariate analysis = 2.66; 95% confidence interval = 1.49, 4.75; P.001), dense breast tissue (HR = 2.77; 95% confidence interval = 1.39, 5.51; P = .004), family history of breast cancer (HR = 2.32; 95% confidence interval = 1.10, 4.90; P = .028), and lymphovascular invasion (HR = 1.83; 95% confidence interval = 1.11, 3.03; P = .019) were found to be independently associated with recurrence. These same factors were also found to be associated with recurrence-free survival.The absence of preoperative MR imaging and the presence of dense breast tissue at mammography were associated with an increased risk of recurrence in patients with triple-negative breast cancer.

OBJECTIVE To retrospectively evaluate the features of undiagnosed breast cancers on prior screening breast magnetic resonance (MR) images in patients who were subsequently diagnosed with breast cancer, as well as the potential utility of MR-computer-aided evaluation (CAE). MATERIALS AND METHODS Between March 2004 and May 2013, of the 72 consecutive pairs of prior negative MR images and subsequent MR images with diagnosed cancers (median interval, 32.8 months; range, 5.4-104.6 months), 36 (50%) had visible findings (mean size, 1.0 cm; range, 0.3-5.2 cm). The visible findings were divided into either actionable or underthreshold groups by the blinded review by 5 radiologists. MR imaging features, reasons for missed cancer, and MR-CAE features according to actionability were evaluated. RESULTS Of the 36 visible findings on prior MR images, 33.3% (12 of 36) of the lesions were determined to be actionable and 66.7% (24 of 36) were underthreshold; 85.7% (6 of 7) of masses and 31.6% (6 of 19) of non-mass enhancements were classified as actionable lesions. Mimicking physiologic enhancements (27.8%, 10 of 36) and small lesion size (27.8%, 10 of 36) were the most common reasons for missed cancer. Actionable findings tended to show more washout or plateau kinetic patterns on MR-CAE than underthreshold findings, as the 100% of actionable findings and 46.7% of underthreshold findings showed washout or plateau (p = 0.008). CONCLUSION MR-CAE has the potential for reducing the number of undiagnosed breast cancers on screening breast MR images, the majority of which are caused by mimicking physiologic enhancements or small lesion size.

Computer-aided diagnosis (CAD) systems in gray-scale breast ultrasound images have the potential to reduce unnecessary biopsy of breast masses. The purpose of our study is to develop a robust CAD system based on the texture analysis. First, gray-scale invariant features are extracted from ultrasound images via multi-resolution ranklet transform. Thus, one can apply linear support vector machines (SVMs) on the resulting gray-level co-occurrence matrix (GLCM)-based texture features for discriminating the benign and malignant masses. To verify the effectiveness and robustness of the proposed texture analysis, breast ultrasound images obtained from three different platforms are evaluated based on cross-platform training/testing and leave-one-out cross-validation (LOO-CV) schemes. We compare our proposed features with those extracted by wavelet transform in terms of receiver operating characteristic (ROC) analysis. The AUC values derived from the area under the curve for the three databases via ranklet transform are 0.918 (95% confidence interval [CI], 0.848 to 0.961), 0.943 (95% CI, 0.906 to 0.968), and 0.934 (95% CI, 0.883 to 0.961), respectively, while those via wavelet transform are 0.847 (95% CI, 0.762 to 0.910), 0.922 (95% CI, 0.878 to 0.958), and 0.867 (95% CI, 0.798 to 0.914), respectively. Experiments with cross-platform training/testing scheme between each database reveal that the diagnostic performance of our texture analysis using ranklet transform is less sensitive to the sonographic ultrasound platforms. Also, we adopt several co-occurrence statistics in terms of quantization levels and orientations (i.e., descriptor settings) for computing the co-occurrence matrices with 0.632+ bootstrap estimators to verify the use of the proposed texture analysis. These experiments suggest that the texture analysis using multi-resolution gray-scale invariant features via ranklet transform is useful for designing a robust CAD system.

Purpose The purpose of this study was to assess the value of adding digital breast tomosynthesis (DBT) to full-field digital mammography (FFDM) in the diagnostic workup of breast cancer and to determine which lesion variables affect cancer detectability in the combined modality. Methods Between March and May 2012, paired FFDM and DBT images were obtained from 203 women as part of a diagnostic workup for breast cancer. Images from FFDM alone, DBT alone, and DBT combined with FFDM were reviewed in separate sessions by six blinded readers. Jackknife alternative free-response receiver operating characteristic (JAFROC) figure of merit (FOM), sensitivity, and specificity were compared between the modalities. Lesion characteristics affecting the cancer detection rate when using the combined modality were also analyzed. Results Among the 203 women, 126 women had a total of 129 malignancies and 77 women had total of 77 benign lesions. The overall JAFROC FOM of the combined modality was higher than that of FFDM alone (0.827 vs. 0.775, p

Automated whole breast ultrasound (ABUS) is an emerging screening tool for detecting breast abnormalities. In this study, a computer-aided detection (CADe) system based on multi-scale blob detection was developed for analyzing ABUS images. The performance of the proposed CADe system was tested using a database composed of 136 breast lesions (58 benign lesions and 78 malignant lesions) and 37 normal cases. After speckle noise reduction, Hessian analysis with multi-scale blob detection was applied for the detection of tumors. This method detected every tumor, but some nontumors were also detected. The tumor like lihoods for the remaining candidates were estimated using a logistic regression model based on blobness, internal echo, and morphology features. The tumor candidates with tumor likelihoods higher than a specific threshold (0.4) were considered tumors. By using the combination of blobness, internal echo, and morphology features with 10-fold cross-validation, the proposed CAD system showed sensitivities of 100%, 90%, and 70% with false positives per pass of 17.4, 8.8, and 2.7, respectively. Our results suggest that CADe systems based on multi-scale blob detection can be used to detect breast tumors in ABUS images.

Rhinocerebral mucormycosis is an acute fulminant opportunistic fungal infection usually seen in diabetic or immunocompromised patients. The fungi that cause mucormycosis inoculate the nasal mucosa and may spread to the paranasal sinuses, orbit, and brain. Our patient initially presented with mild ethmoid sinusitis. At that time, brain MRI and contrast-enhanced MR angiography were grossly normal. However, aggravation of sinusitis with extension to the right orbit and anterior cranial fossa rapidly developed within two months. Moreover, an occlusion of the right internal carotid artery was combined. We report a case of a pathologically-proven rhino-orbital-cerebral mucormycosis with serial follow-up imaging for over one year.

Purpose: To evaluate the feasibility of peripheral bone densitometry for the assessment of bone density, and to compare it with dual energy X-ray absorptiometry (DXA). Materials and Methods: Radiographic absorptiometry (RA) of the middle phalange, peripheral DXA (pDXA) of the calcaneus, and the DXA were performed for two groups: Group 1 was a normal group of 54 healthy young women and group 2 was a group of 54 postmenopausal women considered to be at a high risk for osteoporosis. For the normal group, RA and pDXA were scanned twice to assess the repeatability of the methods. The Tscores were compared to determine whether there was a correlation between the peripheral and axial bone densitometries. The cutoff values of RA and pDXA for the diagnosis of osteopenia were determined. Results: Each examination showed different T-scores for a given person. The T-scores of RA were higher than those of pDXA for the normal group, whereas the T-scores of pDXA were higher for high-risk group. The coefficients of repeatability were 0.88 in RA and 1.53 in pDXA. The correlation coefficient for DXA was higher in RA than in pDXA. The cutoff values for osteopenia were -1.773 for RA and -1.75 for pDXA, as compared to -1.0 for DXA. Conclusion: The data suggests that RA is a viable screening method for osteoporosis. However, there should be consideration for the fact that bone density depends on examination methods or sites.