Breast Imaging: Diagnosis and Intervention

Preface
Contents
Mammography and Digital Breast Tomosynthesis: Technique
	1	 Introduction
	2	 Basics of X-Ray-Based Breast Imaging
		2.1	 Breast Lesions
		2.2	 Digital Mammography
		2.3	 Digital Breast Tomosynthesis
		2.4	 Mammographic Views
	3	 Imaging Systems
		3.1	 X-Ray Source
		3.2	 Compression Paddle
		3.3	 Anti-scatter Grid
		3.4	 Digital Detector
	4	 Breast Compression
	5	 Clinical Performance of Digital Breast Tomosynthesis
		5.1	 Lesion Visibility
		5.2	 Detection
		5.3	 Diagnosis
	6	 Population Screening with Digital Breast Tomosynthesis
	7	 Radiation Dose
		7.1	 Basics of Breast Dosimetry
		7.2	 Meaning of Breast Dose Estimates
		7.3	 Mammography vs. Tomosynthesis Dose
		7.4	 Radiation Dose vs. Clinical Performance
		7.5	 Total Breast Dose During a Screening Examination
	References
Contrast-Enhanced Mammography
	1	 Background
	2	 Techniques
		2.1	 Temporal Technique
		2.2	 Dual-Energy Technique
	3	 Clinical Studies
		3.1	 Comparisons of CEDM with Digital Mammography
		3.2	 Comparisons of CEDM with MRI
		3.3	 Comparisons of CEDM with Ultrasound
	4	 Current and Potential Indications for Contrast-Enhanced Mammography
	5	 Risks
		5.1	 Iodinated Contrast
		5.2	 Renal Toxicity
		5.3	 Radiation Dose
	6	 Conclusions
	References
Mammography Screening
	1	 Introduction
	2	 History of Mammography Screening
	3	 Scientific Basis for Current Screening: The Randomized Controlled Trials
	4	 Digital Mammography in Breast Cancer Screening
	5	 Recommendations for Organized Mammographic Screening
	6	 Guidelines and Quality Assurance of Screening Programs
		6.1	 Performance Indicators
		6.2	 Quality of the Mammographic Report
		6.3	 Single Versus Double Reading
	7	 Mammographic Diagnosis of Early Preclinical Breast Cancer
		7.1	 Ductal Carcinoma In Situ (DCIS)
		7.2	 Early Invasive Breast Cancer
	8	 Personalized Screening for Women at Average Risk
		8.1	 Ultrasound as Supplemental Imaging
		8.2	 Magnetic Resonance Imaging (MRI) as Supplemental Imaging
		8.3	 Digital Breast Tomosynthesis (DBT) as Supplemental Screening (Chapter “Mammography and Digital Breast Tomosynthesis: Technique”)
		8.4	 Other Imaging Modalities as Supplemental Screening
	9	 Screening for Women at Higher Risk
	10	 Adverse Effects of Mammography Screening
		10.1	 Radiation Exposure
		10.2	 False Positives
		10.3	 False Negatives and Interval Cancer
		10.4	 Overdiagnosis
	11	 The Future of Breast Cancer Screening
	References
Stereotactic Guided Breast Interventions
	1	 Indications for Stereotactic Breast Biopsy
	2	 Stereotactic Biopsy Systems
		2.1	 Prone Biopsy Tables
		2.2	 Add-On Biopsy Units
	3	 Pre-biopsy Evaluations
		3.1	 Lesion Evaluation
		3.2	 Needle Choice
			3.2.1	 Fine Needle Aspiration Cytology (FNAC)
			3.2.2	 Core Needle Biopsy (CNB)
			3.2.3	 Vacuum-Assisted Biopsy (VAB)
		3.3	 Patient Care
	4	 Biopsy Technique
		4.1	 Patient Positioning
		4.2	 Biopsy Preparations
		4.3	 Lesion Targeting and Biopsy
			4.3.1	 Stereotactic Guided Biopsy
			4.3.2	 Digital Breast Tomosynthesis-Guided Biopsy
		4.4	 Technical Limitations and Potential Remedies
		4.5	 Specimen Core Management
	5	 Post-biopsy Measures
		5.1	 Clip Positioning
		5.2	 Post-biopsy Mammography
		5.3	 Patient Care and Follow-Up
		5.4	 Pathological Result Management and Indications for Treatment
		5.5	 Presurgical Localization
		5.6	 Specimen Radiography
	6	 Summary
	References
How to Use Breast Ultrasound
	1	 Introduction
	2	 Equipment and Examination Technique
	3	 Sonographic Anatomy of the Normal Breast
	4	 Types of Breast Lesions and Their Sonographic Features as per the ACR BI-RADS Atlas
		4.1	 BI-RADS Final Assessment Categories
	5	 Sonographic Features of Benign Breast Lesions
	6	 Sonographic Features of Breast Lesions
	7	 Sonographic Features of Malignant Breast Lesions
	8	 Further Ultrasound Applications: After Treatment, Screening, Intervention
	9	 Summary
	References
Breast Ultrasound: Advanced Techniques
	1	 Introduction
	2	 Elastography
		2.1	 Introduction
		2.2	 Strain Elastography
		2.3	 Shear Wave Elastography
			2.3.1	 Technique
			2.3.2	 Number of Images
			2.3.3	 Region of Interest Size and Data Extraction
			2.3.4	 Qualitative Evaluation and Artifacts
			2.3.5	 3D Shear Wave
			2.3.6	 Normal Breast Tissue
			2.3.7	 Benign Lesions at SWE
			2.3.8	 Malignant Lesions at SWE
				2.3.8.1 DCIS
				2.3.8.2 Invasive Cancer
			2.3.9	 Benign Malignant Differentiation
				2.3.9.1 Nodal Metastasis and SWE
			2.3.10	 SWE Elastography in Women Receiving Neoadjuvant Chemotherapy (NACT)
			2.3.11	 SWE and Neoadjuvant Hormone Therapy
			2.3.12	 SWE and the Prognosis of Breast Cancer
			2.3.13	 Fibroepithelial Lesions
			2.3.14	 Unusual Breast Malignancies
	3	 Ultrasound Assessment of Lesion Vascularity
		3.1	 Doppler
		3.2	 Contrast-Enhanced Ultrasound
		3.3	 Superb Microvascular Imaging
	References
Automated Breast Ultrasound
	1	 Technique
	2	 Image Evaluation
		2.1	 Normal Findings and Artifacts
		2.2	 Characteristics of Breast Lesions
	3	 Potential in Screening
	4	 Potential in Staging and Therapy Monitoring
	5	 AI for ABUS
	6	 Future Perspectives
	References
Ultrasound-Guided Interventions
	1	 Indications
	2	 Biopsy Guidance Method
		2.1	 Role of a Second-Look Ultrasound
			2.1.1	 Visible at Ultrasound
			2.1.2	 Visible at Ultrasound and Mammography
			2.1.3	 Visible at MRI
			2.1.4	 Very Small or Subtle Correlating Findings at Ultrasound
	3	 Types of Biopsy Procedures
		3.1	 Cytological Sampling
			3.1.1	 Fine Needle Aspiration (FNA): Cytological Sampling
		3.2	 Histological Sampling
			3.2.1	 Core Needle Biopsy: Histological Sampling
			3.2.2	 Vacuum-Assisted Biopsy: Histological Sampling
	4	 Considerations Regarding Lesion Type
		4.1	 Cystic Lesions
		4.2	 Solid Lesions
		4.3	 Calcifications
	5	 Patient Information
		5.1	 Patient History
		5.2	 Allergy
		5.3	 Anticoagulation Medication and Handling
		5.4	 Endocarditis Prophylaxis
	6	 Preparation of the System and Material
	7	 Patient Preparation
		7.1	 Local Anesthesia
	8	 Biopsy Technique
		8.1	 Indications for Clip Marking
		8.2	 Preoperative Wire Localization
	9	 Reporting and Probe Handling and Pathology Information
	10	 Radiological-Histopathological Correlation
	11	 Summary
	References
Breast MRI: Techniques and Indications
	1	 Introduction
	2	 The Standard Acquisition Protocol
	3	 Post-processing: Image Subtraction and MIP Reconstructions
	4	 Post-processing: Dynamic Analysis
	5	 Diffusion-Weighted Imaging
	6	 Abbreviated CE Protocols
	7	 High-Risk Screening
		7.1	 Assessing the Response to Neoadjuvant Therapy (NAT)
		7.2	 Preoperative
		7.3	 Occult Primary Breast Cancer
	8	 Equivocal/Inconclusive Findings at Conventional Imaging Including Suspicion of Breast Cancer Recurrence
	9	 Evaluation of Breast Implant Integrity
	10	 Pathologic Nipple Discharge
	11	 Borderline (B3) Lesions at Mammography/US-Guided Needle Biopsy
	12	 Conclusions
	References
Abbreviated Breast MRI: Short and Sweet?
	1	 Introduction
	2	 Abbreviated Breast MRI
		2.1	 How?
		2.2	 Why?
		2.3	 Who?
		2.4	 What?
		2.5	 Limitations
		2.6	 Future Directions
	3	 Conclusion
	References
Breast MRI: Multiparametric and Advanced Techniques
	1	 Introduction
	2	 State of the Art of Breast MRI
	3	 Advanced Techniques
		3.1	 Advanced DWI Approaches
		3.2	 MR Spectroscopy
		3.3	 Emerging Techniques
	4	 Screening MRI: Abbreviated MRI Protocols and Non-contrast mpMRI
	5	 Breast MRI Radiomics and Radiogenomics
	6	 Conclusions
	References
MRI-Guided Breast Interventions
	1	 Introduction
	2	 Breast MRI-Guided Biopsy
		2.1	 Indications
		2.2	 Pre-procedure
			2.2.1	 Patient Preparation, Counseling, and Consent
			2.2.2	 Equipment
			2.2.3	 Imaging Protocol
		2.3	 Procedure
			2.3.1	 Planning
			2.3.2	 Positioning (Fig. 3a, b)
			2.3.3	 Imaging
			2.3.4	 Localization
			2.3.5	 Biopsy
			2.3.6	 Sampling
			2.3.7	 Post-biopsy Care
			2.3.8	 Assessment of Sampling Accuracy and Technical Limitations
	3	 MRI-Guided Wire Localization
	4	 MRI-Guided Percutaneous Ablative Treatment
		4.1	 Radiofrequency Ablation (RFA)
		4.2	 Laser Interstitial Thermal Therapy (LITT)
		4.3	 Cryoablation (Pediconi et al. 2018; Gombos et al. 2015)
		4.4	 High-Intensity Focused Ultrasound Ablation (HIFU)
	5	 Conclusion
	References
Imaging the Axilla
	1	 Indications for Axillary Imaging and Clinical Relevance
	2	 Anatomy and Ultrasound Examination Technique
	3	 US Features of Morphologically Normal and Abnormal Lymph Nodes
	4	 US-Guided Biopsy Technique of Axillary Lymph Nodes
	5	 Clinical Utility of Axillary US
	6	 Neoadjuvant Chemotherapy and Imaging of Axillary Lymph Nodes
	7	 Multimodality Imaging of Axillary Lymph Nodes
	8	 Summary
	References
Imaging of Ductal Carcinoma In Situ (DCIS)
	1	 Background
	2	 Diagnosis of DCIS
		2.1	 Mammography and Digital Breast Tomosynthesis
		2.2	 Ultrasound
		2.3	 Contrast-Enhanced Breast Magnetic Resonance Imaging and Contrast-Enhanced Mammography
	3	 Comparative Sensitivity of Mammography and MRI
	4	 Risk Stratification in DCIS
	5	 Preoperative and Intraoperative Management of DCIS
	6	 Conclusion
	References
Cystic and Complex Cystic and Solid Lesions
	1	 Introduction: About the Nature of Cystic Lesions of the Breast
	2	 Imaging Classification of Cystic Lesions of the Breast
		2.1	 Simple Cysts
			2.1.1	 Imaging Findings
				2.1.1.1 Ultrasound
				2.1.1.2 Mammography
				2.1.1.3 Magnetic Resonance Imaging
			2.1.2	 Management
		2.2	 Complicated Cysts
			2.2.1	 Imaging Findings
				2.2.1.1 Ultrasound
				2.2.1.2 Mammography
				2.2.1.3 Magnetic Resonance Imaging
			2.2.2	 Management
		2.3	 Complex Cystic and Solid Lesions
			2.3.1	 Imaging Findings
				2.3.1.1 Ultrasound
				2.3.1.2 Mammography
				2.3.1.3 Magnetic Resonance Imaging
			2.3.2	 Management
		2.4	 Clustered Microcysts
			2.4.1	 Imaging Findings
				2.4.1.1 Ultrasound
				2.4.1.2 Mammography
				2.4.1.3 Magnetic Resonance Imaging
			2.4.2	 Management
	3	 Differential Diagnosis of Cystic Breast Lesions
		3.1	 Benign Lesions
		3.2	 Malignant Lesions
	4	 Conclusion
	References
High-Risk Lesions of the Breast: Diagnosis and Management
	1	 Introduction
	2	 Histopathologic Characteristics, Prognosis, Diagnosis, and Management of High-Risk Lesions of the Breast
		2.1	 Atypical Ductal Hyperplasia
		2.2	 Flat Epithelial Atypia
		2.3	 Lobular Neoplasia
		2.4	 Papillary Lesions
		2.5	 Phyllodes Tumor
		2.6	 Radial Scar and Complex Sclerosing Lesion
	3	 Chemoprevention in High-Risk Lesions
	4	 Conclusion
	References
Minimal Invasive Therapy
	1	 Introduction
	2	 Cryotherapy
		2.1	 Cryotherapy in Fibroadenomas
		2.2	 Cryotherapy in Breast Cancer
	3	 Radiofrequency Ablation
	4	 Microwave Ablation
	5	 High-Intensity Focused Ultrasound Ablation
	6	 Potential Complications of Minimally Invasive Therapies for Breast Tumors
		6.1	 Cryotherapy
		6.2	 Radiofrequency Ablation
		6.3	 Microwave Ablation
		6.4	 High-Intensity Focused Ultrasound Ablation
	7	 Potential Advantages
	8	 Limitations
	9	 Summary and Outlook
	References
Post-therapy Evaluation (Including Breast Implants)
	1	 Introduction
	2	 Post-therapy Changes Without Reconstruction
		2.1	 The Basis for Iatrogenic Changes in the Breast
			2.1.1	 Changes Due to Fluid Collections
			2.1.2	 Changes Due to Fat Necrosis
		2.2	 Timeline for Iatrogenic Changes in Breast
		2.3	 Mastectomy
			2.3.1	 Radiological Tests and Findings
			2.3.2	 Recurrence and Follow-Up
		2.4	 Breast-Conserving Treatment
			2.4.1	 Radiological Tests and Findings
			2.4.2	 Recurrence and Follow-Up
	3	 Heterologous and Implant-Based Breast Reconstruction (IBR)
		3.1	 Breast Implants
			3.1.1	 Radiological Tests
			3.1.2	 Normal Findings
			3.1.3	 Intracapsular Rupture
			3.1.4	 Extracapsular Rupture
			3.1.5	 Recurrence and Follow-Up
		3.2	 Complementary Meshes
	4	 Autologous Breast Reconstruction (ABR)
		4.1	 Autologous Flaps
			4.1.1	 Classification
			4.1.2	 Radiological Tests
			4.1.3	 Normal Findings
			4.1.4	 Complications
			4.1.5	 Recurrence and Follow-Up
		4.2	 Lipofilling, Lipomodeling, or Free-Fat Injection
			4.2.1	 Radiological Tests
			4.2.2	 Radiological Findings
			4.2.3	 Recurrence and Follow-Up
	References
Impact and Assessment of Breast Density
	1	 Introduction
	2	 Breast Density and the Risk for Breast Cancer
		2.1	 Masking Effect
		2.2	 Independent Risk Factor
	3	 Assessment Methods
		3.1	 Mammography
			3.1.1	 Subjective Qualitative Assessment
			3.1.2	 Objective Automated Quantitative Assessment
		3.2	 Ultrasound
		3.3	 Magnetic Resonance Imaging
	4	 New Avenues for Risk-Adapted Screening
	5	 Summary
	References
Artificial Intelligence in Breast Imaging
	1	 Introduction
	2	 A Brief Overview: From Conventional CAD to Deep Learning Based—A More Comprehensive Range of Applications
	3	 AI Systems in Various Clinical Applications
		3.1	 Breast Cancer Risk Assessment for Screening: Mainly in Mammography
		3.2	 Lesion Detection and Classification for Diagnosis
		3.3	 Therapy Selection and Outcome Prediction for Interventions
	4	 Challenges and Future Directions
	References