digital breast tomosynthesis (dbt)conplus.co.kr/~kcr2015/down/abstract_book/scientific... ·...

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14:00-14:30 Grand Ballroom 105

RC 06 BR-01 Advanced technique of breast imaging

Chairperson(s) : Hak Hee Kim University of Ulsan College of Medicine, Asan Medical Center, KoreaEun-Kyung Kim Yonsei University School of Medicine, Severance Hospital, Korea

Digital breast tomosynthesis (DBT)

Christopher E. ComstockMemorial Sloan Kettering Cancer Center, USA. [email protected]

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Ultrasound (US) elastography is an imaging techniquethat can show the tissue elasticity (stiffness) in vivo. Thefirst practical equipment was released in 2003, and manymanufacturers offer various kinds of commercial systemsthat are based on the following two US elastographytechniques: strain and shear-wave elastography. Themost common type of strain elastography displays therelative tissue displacement under compression, whereasshear-wave elastography displays an image of the shear-wave speed using acoustic radiation force excitation. USelastography is used to perform breast mass evaluationand characterization, and many studies have reportedthat it can increase the specificity of conventional B-mode

US in differentiating benign from malignant breastmasses and reduce unnecessary biopsies and short-termfollow-up induced by screening breast US. Recently, theUS elastographic features of breast masses have beenincorporated into the 2nd edition of Breast ImagingReporting and Data System (BI-RADS) US lexicon asassociated findings; hence, the use of elastography isexpected to increase. However, the technique can betime-consuming and give rise to both false positive andfalse negative results due to histology of the lesions aswell as inadequate data acquisition or interpretation. Theoperator should be well trained with sufficient experiencebefore maximum performance can be obtained.




Breast US elastography: pros and cons

Su Hyun Lee Seoul National University Hospital, Korea. [email protected]

Breast MRI is reported to have high sensitivity (94%-100%), variable specificity (37%-97%) and low positivepredictive value. To improve the specificity of breast MRI,several strategies have focused on either lesionmorphology or enhancement kinetics. In addition toimaging features, suspicious lesions may also becharacterized by detection of changes in the local biologicenvironment from Diffusion-weighted imaging (DWI).

DWI is used to visualize the degree of water moleculediffusion at in vivo MR imaging. The degree of waterdiffusion in biological tissue is inversely correlated to thetissue cellularity and the integrity of cell membranes. DWIuses motion-sensitizing gradients to measure theBrownian motion of water and DWI reflects themicroscopic cellular environment and is sensitive tocharacteristics such as cell density, membrane integrity,viscosity, and microstructure.

Diffusion is quantified by measuring apparent diffusioncoefficient (ADC) value. The ADC value is known as thein square millimeters per second, which defines theaverage area covered by a molecule per unit time andcan be calculated by assessing the signal attenuation thatoccurs at diffusion-weighted imaging performed atdifferent b values.

ADC value = -ln(SDW/SSE)/bSDW: the attenuated spin-echo signalSSE : the full spin-echo signal without diffusion

attenuationDWI can be used in evaluating breast cancer for

discriminating benign and malignant breast lesion.Reported the pooled sensitivity and specificity were 0.89(95% CI, 0.85-0.91) and 0.77 (95% CI, 0.69-0.84),respectively in a recent meta-analysis that evaluated thediagnostic value of ADC for predicting malignancy.

Other clinical applications are evaluation of specifictumor histologies and correlation between ADC value andprognostic factors, differentiation of cancer recurrencefrom surgical scar and assessing response toneoadjuvant chemotherapy.

DWI protocol optimization includes appropriate b-valueselection, sufficient signal-to-noise ratio (SNR), adequatefat suppression, and artifact reduction via shimming andparallel imaging. In addition, DWI analysis requiresstandard noise filtering, image registration, and consistentmethods for region of interest measurement for ADCcalculation. In vivo, ADC measures of malignant andbenign tumors and noncancerous breast tissue are

strongly dependent on the maximum b-value applied. Forlesion measurements, after identification on DCE-MRimage an ROI usually is manually defined at thecorresponding location on the high b-value DW images toencompass as much of the abnormality as possible whilestaying within the border of the hyperintense region.However, susceptibility-based echo planar imaging (EPI)-based distortions commonly causing pixel shifts on DWIcurrently limits the ability to propagate ROIs directly fromDCE-MRI.

One of the limitations of DWI is low spatial resolution,therefore small lesions may be difficult to visualize onDWI and an ADC map. Other one of limitation is thethreshold ADC value to discriminate benign frommalignant breast lesions is variable. In the literature, asubstantial amount of variability exists in the mean ADCvalues for lesions of specific histologies, suggestedabsolute ADC threshold values range from 1.1 × 10-3 to1.6 × 10-3 mm2/s. Also for measurement of ADC value,the appropriate b-value must be selected. Someliteratures reported a combined b-value protocol of b 0and 750 s/mm2 at 1.5 T and 50 and 850 s/mm2 at 3T wasoptimal. However, optimal b-value is not determined yet.

Although there are several limitations, the advantage ofDWI over conventional contrast enhanced MR imaging isits high sensitivity to change in the microscopic cellularenvironment without the need for intravenous contrastmaterial injection. DWI may have potential as an adjunctto conventional contrast-enhanced breast MR imaging forthe differentiation of malignant and benign lesions andhelping predict the effect of neoadjuvant chemotherapy.

References

1. Kuroki, Y, Nasu, K. Advances in breast MRI: diffusion-weighted imaging of the breast. Breast Cancer2008;15(3):212-217

2. Partridge SC, DeMartini WB, Kurland BF, et al.Quantitative diffusion-weighted imaging as an adjunct toconventional breast MRI for improved positive predictivevalue. AJR Am J Roentgenol 2009;193(6):1716-1722

3. Woodhams R, Ramadan S, Stanwell P, et al. Diffusion-weighted imaging of the breast: principles and clinicalapplications. Radiographics 2011;31(4):1059-1084

4. Thomassin-Naggara I, De Bazelaire C, Chopier J, et al.Diffusion-weighted MR imaging of the breast: advan-tages and pitfalls. Eur J Radiol 2013;82(3):435-443

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Diffusion-weighted imaging of breast MRI

Sun Mi Kim Seoul National University Bundang Hospital, Korea. [email protected]

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5. Partridge SC, McDonald ES. Diffusion weighted magnet-ic resonance imaging of the breast: protocol optimiza-

tion, interpretation, and clinical applications. MagnReson Imaging Clin N Am 2013;21(3):601-624

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SF 05 BR-01 Supplemental breast cancer screening

Chairperson(s) : Woo Kyung Moon Seoul National University Hospital, KoreaBoo-Kyung Han Samsung Medical Center, Sungkyunkwan University School of Medicine, Korea

Future direction of breast cancer screening

Christopher E. Comstock Memorial Sloan Kettering Cancer Center, USA. [email protected]

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1. Screening breast ultrasound: past,present, and future

Breast density is an increasingly pertinent issue inbreast cancer diagnosis.

Breast density results in a decrease in the sensitivity ofmammography for cancer detection, with a significantincrease in the risk of breast cancer. Ultrasound detectsadditional cancers.

1) Breast density- Mammography report given to patients required to

inform patients about their breast density- Report advises women with dense breast tissue that

they may benefit from supplemental screening withultrasound and/or MRI, depending on individual riskfactors

2) Screening breast ultrasound: controversial- ACR Appropriateness criteria: Prior to 2011- not listed as an indication for breast US: Current- indicated for high risk women who cannot

tolerate MRI, suggests it is an option for intermediate riskwomen with dense breasts

3) Advantages of breast ultrasound screening- Widely available- Inexpensive- No radiation, no contrast- Well tolerated by patients

4) Disadvantages of breast ultrasound screen-ing

- Limited ability to detect DCIS- Time consuming and operator dependent- Low PPV and high false positive- No proven long term mortality benefit to women

5) Handheld US vs. automated US

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Hendheld US Automated US

Variable standard image set Standard image setWhole breast and targeted US Some units only perform whole breast

Limit at subareolar, posterior, large breast (and axilla)Immediate (simultaneous) diagnostic US Need to recall patients for 2nd examOperator dependent Decreased operator dependentDecreased reproducibility Increased reproducibilityPerformance fatigue Time consuming review by radiologists

Study Aim No. of No. of Sensitivity Specificity PPV (%) Additional Ca. Screening Ultrasound- Yield From US Only Ca. (%) (%) US (1000)

Kaplan 3-4 density; 1862 6 - - 11.8 3Kolb et al. 2-4 13,547 37 97.3 - - 2.73US only 75.3 96.8 20.5Leconte et al. 3-4 4236 16 88 - 3.8Schaefer et al. 3-4 41,564 84 - - 25.4 2.02Berg et al. 3-4 2809 12 77.5 - 11.2 4.2Berg et al. 3-4 2809 32? 76 84 16 3.7

2. Summary of Findings in Reviewed Literature




Screening breast US

Bong Joo Kang The Catholic University of Korea, Seoul St. Mary’s Hospital, Korea. [email protected]

3. Comment in new BI-RADS aboutscreening US (Frequently Asked Questions)

1) Which type of breast imaging examination should Irecommend for my patients?

- When in doubt, refer to the ACR AppropriatenessCriteriaⓇ (http://www.acr.org/Quality-Safety/Appropri-ateness-Criteria/Diagnostic/Breast-Imaging). TheACR Appropriateness CriteriaⓇ provides recommen-dations for both screening and diagnostic breastimaging procedures.

2) When a woman is recalled from screening for anasymmetry, and spot-compression or spot compres-sion magnification views show no persistent abnor-mality, is it necessary to perform US?

- It is neither necessary nor appropriate to perform US- 80% of asymmetries: summation artifacts.- With spot-compression or spot-compression magnifi-

cation views depicting a focal asymmetry (non-masslesion visible on two different mammographic projec-tions) as the only imaging finding, then it would indeedbe appropriate to perform US targeted at the mammo-graphic lesion.

- Such cases would be assessed as probably benign(category 3) unless prior mammograms demonstratedat least 2-3 years of stability resulting in a benign (cat-egory 2) assessment.

3) Should assessment category 0 be applied to breastUS examinations?

- In general, assessment category 0 should not be as-

signed to diagnostic breast US examinations.- Assessment category 0 indeed is appropriate for

screening breast US examinations.4) For bilateral screening US performed either by the

technologist or the physician with no abnormalityidentified, what images should I record?

- In addition to demographics (patient’s name, uniqueidentifier, date of birth or age, facility name, and loca-tion), record one image in one plane (ordinarily radial)for each quadrant, and one image of the retroareolarregion just behind the nipple.

- The axilla could be scanned as well, but this was notrequired in the ACRIN 6666 protocol, nor was there arequirement to record a representative negative im-age. - - The standard set of five images per breastwas recorded.

References

1. Brem R, Lenihan M, Lieberman J, et al. Screeningbreast ultrasound: past, present, and future. AJR Am JRoentgenol 2015;204(2):234-240

2. Riedl C, Luft N, Bernhart C, et al. Triple-modality screen-ing trial for familial breast cancer underlines the impor-tance of magnetic resonance imaging and questions therole of mammography and ultrasound regardless of pa-tient mutation status, age, and breast density. J ClinOncol 2015;33(10):1128-1135

3. Breast Imaging Reporting and Data System: ACR BI-RADS - breast imaging atlas. Reston, VA: AmericanCollege of Radiology, 2003

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Weigert andSteenbergen 3-4 8647 28 96.6 94.9 6.7 3.25Hooley et al. 3-4 935 3 - - 6.5% 3.2Kelly et al. 3-4, automated 6425 23 81 98.7 38.4 3.6Automated only 67 89.9

Breast cancers that occur in the high risk women, es-pecially those women with genetic abnormalities, tend togrow more rapidly, tend to developed earlier in life, tendto be more difficult to identify at mammography, and maybe less responsive to therapy.

The sensitivity of breast MRI has been reported from71% to 100% compared with 16% to 40% for mammog-raphy.

There have been many studies that adding MRI as anadjunct to the screening mammography resulted in greatincrease of sensitivity by detecting mammographically oc-cult breast cancer in high risk patients. Even though thehigher sensitivity of MRI is at the cost of a higher biopsyrate, lower specificity, and a lack of data demonstratingthat screening MRI will result in improved survival forthese patients.

It is now well accepted that annual screening with MRIshould be recommended for women with BRCA1 orBRCA2 gene mutations. For other women at high risk forbreast cancer, there is currently no consensus on howMRI should be incorporated into clinical practice.

The American Cancer Society screening guidelinesinclude annual MRI screening for

Women with known BRCA1 or BRCA2 mutations, Untested first-degree relatives of a known mutation

carrier,Women with a greater than 20% - 25% lifetime risk-

based assessment models.

Based on expert consensus opinion, annual MRIscreening in also recommended for

Patients (and first-degree relatives of patients) withCowden, Bannayan-Riley-Ruvalcaba, or Li-fraumenisyndromes,

Women who received radiation therapy to the chestbetween ages of 10 - 30 years

For the women with personal history of breast cancer,previous biopsy proven LCIS, ALH or ADH, dense breasttissue and lifetime risk level of 15% - 20%, it is notconclusive regarding screening MRI.

MRI is not recommended for women with a less than15% lifetime risk of breast cancer.

Screening breast MRI in women with personal historyof breast cancer does not have consensus. However,some studies supporting the role of screening MRI inwomen with personal history of breast cancer, report thatmammography is limited in evaluation of the conserved

breast in areas of postoperative distortion. Breast MRIhas a high sensitivity in the detection of breast cancerand, in particular, a high sensitivity and specificity indifferentiating scar from recurrent tumor.

Screening breast MRI in women previously treated forbreast cancer

Detected cancer in 1.0% of examinations, with a 10.7%abnormal interpretation rate, and a PPV for malignancy of17.9%.

Found malignancies in 12%, with a reasonable biopsyrate (PPV, 39%), More than half of the MRI-detectedcancers were minimal breast cancers.

There are many limitations in screening breast MRI.Even in ACS guidelines, it is unclear how to integrate

MRI into the current screening programs. It is alsounclear if at this level of lifetime risk the additional benefitfrom annual MRI screening outweighs the additionalcosts, or whether a longer screening interval for MRI (e.g.2 years) is more cost-effective.

Screening breast MRI has risk of false positives,additional imaging, biopsy, anxiety, and cost. ScreeningMRI does not prevent breast cancer, is not proven toreduce deaths due to breast cancer yet.

Many studies have proven the cost-effectiveness ofscreening breast MRI, especially in Women with knownBRCA1 or BRCA2 mutations. In other high risk group,MRI screening may also be cost effective, depending onthe expected prevalence of undiagnosed breast cancer atthe time of screening.

Abbreviated breast MRI for screening can be anothersolution. Abbreviated breast MRI is feasible withoutcompromising sensitivity or specificity compared with theregular full diagnostic MRI protocol. It could increaseaccess to breast MRI and decrease the cost of existingMRI screening programs.

References

1. Weinstein S, Rosen M. Breast MR imaging: current indi-cations and advanced imaging techniques. Radiol ClinNorth Am 2010;48(5);1013-1042

2. Saslow D, Boetes C, Burke W, et al. American CancerSociety guidelines for breast screening with MRI as anadjunct to mammography. CA Cancer J Clin2007:57(2):75-89

3. Giess CS, Poole PS, Chikarmane SA, et al. Screeningbreast MRI in patients previously treated for breast can-

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Screening breast MRI

Eun Young KoSamsung Medical Center, Sungkyunkwan University School of Medicine, Korea. [email protected]

cer: diagnostic yield for cancer and abnormal interpreta-tion rate. Acad Radiol 2015 [Epub ahead of print]

4. Brennan S, Liberman L, Dershaw DD, et al. Breast MRIscreening of women with a personal history of breastcancer. AJR Am J Roentgenol 2010;195(2):510-516

5. Taneja, C, Edelsberg J, Weycker D, et al. CostEffectiveness of breast cancer screening with contrast-enhanced MRI in high-risk women. J Am Coll Radiol2009;6(3):171-179

6. Plevritis SK, Kurian AW, Sigal BM, et al. Cost-effective-ness of screening BRCA1/2 mutation carriers with breast

magnetic resonance imaging. JAMA 2006;295(20):2374-2384

7. Cott Chubiz JE, Lee JM, Gilmore ME, et al. Cost-effec-tiveness of alternating magnetic resonance imaging anddigital mammography screening in BRCA1 and BRCA2gene mutation carriers. Cancer 2013;119(6):1266-1276

8. Kuhl CK, Schrading S, Strobel K, et al. Abbreviatedbreast magnetic resonance imaging (MRI): first postcon-trast subtracted images and maximum-intensity projec-tion?a novel approach to breast cancer screening withMRI. J Clin Oncol 2014;32(22):2304-2310

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Breast08:00-09:30 203

Mammography

Chairperson(s)Shin-Ho Kook Kangbuk Samsung Hospital,

Sungkyunkwan University School ofMedicine, Korea

Seong Ku Woo Keimyung University Dongsan MedicalCenter, Korea

SS 16 BR-01 08:00 Diagnostic accuracies and affecting factors ofmammography in the National Cancer ScreeningProgram in KoreaEun Hye Lee1, Dong-rock Shin2, Keum Won Kim3,Young Joong Kim3, Hyo Soon Lim4, Young Mi Park5,Jeong Seon Park6, Hye-won Kim7, You Me Kim8,Hye Jung Kim9, Jae Kwan Jun10

1Soonchunhyang University Bucheon Hospital,2GangNeung Asan Hospital, 3Konyang UniversityHospital, 4Chonnam National University Hospital, 5InjeUniversity Busan Paik Hospital, 6Hanyang UniversityMedical Center, 7Wonkwang University Hospital,8Dankook University Hospital, 9Kyungpook NationalUniversity Hospital, 10National Cancer Center, Korea. [email protected]

PURPOSE: To evaluate diagnostic accuracies and affect-ing factors of mammography in the National CancerScreening Program in Korea.MATERIALS AND METHODS: Ten university-affiliatedhospitals participating in National Cancer ScreeningProgram (NCSP) were enrolled in this retrospectivestudy. We collected results of mammography performedbetween 2005 and 2010 and matched them with database of National Health Insurance Service. We extractedbreast cancer (including DCIS) patients registered within1 year after screening. Existing breast cancer patients,examinees performed interstitial mammoplasty, andunmatched cases were excluded. We calculated recallrate (RR), cancer detection rate (CDR), positive predictivevalue (PPV1), sensitivity and specificity and comparedthem according to types of breast density, equipmentsand readers.RESULTS: 128,756 cases were valid among 130,537cases. Age groups of examinees were 45,445 in 40’s(35.3%), 47,354 in 50’s (36.8%), 28,336 in 60’s (22.0%),and 7,621 in 70 and over (5.9%). Breast densities werealmost entirely fatty in 18,145 (14.1%), scattered fibrog-landular in 40,054 (31.1%), heterogeneously dense in59,271 (46.0%), and extremely dense in 11,286 (8.8%).Types of mammography were film in 33,976 (26.4%), CRin 41,690 (32.4%), and digital in 53,090 (41.2%). Generaland breast radiologists read 40,058 (31.1%) and 88,698(68.9%) cases, respectively. RR was 19.1% (range, 8.9-26.7% according to hospital) and higher in dense breast(28.7 vs. 7.5%), film and CR mammography (24.8 and19.8 vs. 14.8%), and general radiologists (32.0 vs.13.3%) (p < 0.001). CDR per 1,000 screening was 2.69(range, 1.75-5.23) and higher in dense breast (3.39 vs.

1.84%) and digital mammography (3.43 vs. 2.11 and2.24%) (p < 0.05). PPV1 was 1.4% (range, 0.8-2.0%)and higher in fatty breast (2.5 vs. 1.2%), digital mammog-raphy (2.3 vs. 1.1 and 0.9%), and breast radiologists (2.2vs. 0.7%) (p < 0.05). Sensitivity was 86.5% (range, 75.6-94.6%) and showed no difference in all factors. Specificitywas 81.1% (range, 73.5-91.2%) and higher in fatty breast(92.7 vs. 71.5%), digital and CR mammography (85.4 and80.3 vs. 75.3%), and breast radiologists (87.0 vs. 68.2%)(p < 0.001).CONCLUSION: Diagnostic accuracies, except sensitivity,of mammography in the NCSP were suboptimal. Densebreast, film and CR mammography, and general radiolo-gists affects diagnostic accuracies of screening mam-mography. Sensitivity, however, was not affected bythese factors.

SS 16 BR-02 08:10Mammographic and clinicopathologicalcharacteristics of breast cancer diagnosedwithin a National Cancer Screening Program inKorea: results from a multicentric studyYoung Mi Park1, Eun Hye Lee2, Young Joong Kim3,Dong-Rock Shin4, Jeong Seon Park5, Youme Kim6,Hye-Won Kim7, Hyo Soon Lim8, Hye Jung Kim9, Jae Kwan Jun10

1Inje University Busan Paik Hospital, 2SoonchunhyangUniversity College of Medicine, 3Konyang UniversityHospital, 4GangNeung Asan Hospital, 5HanyangUniversity Medical Center, 6Dankook UniversityHospital, 7Wonkwang University Hospital, 8ChonnamNational University Hospital, 9Kyungpook NationalUniversity Hospital, 10National Cancer Center, Korea. [email protected]

PURPOSE: To analyze mammographic and clinicopatho-logical characteristics of breast cancer diagnosed inwomen enrolled in a National Cancer Screening Programfrom ten university-affiliated hospitals in 2005-2010.MATERIALS AND METHODS: After Institutional ReviewBoard approval of each hospital, we collected consecu-tive patients who had undergone screening mammogra-phy in a National Cancer Screening Program between2005 and 2010 using database of PACS. We matchedthe results of mammography with the database ofNational Health Insurance Service to extract the list ofbreast cancer. Information on age, tumor size, histologicaltype, grade, lymph node status, metastasis at diagnosis,and biomarkers of the cancers was obtained from clinicaland pathological reports. Mammographic findings werereviewed as per the ACR BIRADS lexicon (5th edition).Clinicopathologic, and mammographic characteristics ofscreen-detected and missed cancers were analyzedusing Cochran Mantel Haenzel test.RESULTS: Out of 409 cancers, a total of 336 breast can-cers (265 invasive cancers [78.9%] and 71 ductal carci-noma in situ [21.1%]) in 331 women (5 bilateral cancers)aged 38-79 (mean 52.5) which had been confirmedpathologically were enrolled. The tumor size ranged from1 mm to 80 mm (mean 17.4 mm). Lymph node metasta-sis was positive in 19.3%, and no one had metastasis atdiagnosis of cancer. Among them, 267 true positive (TP)cancers (79.5%), 19 false negative (FN) cancers (5.7%),

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10 true interval (TI) cancers (3.0%), 29 mammographical-ly occult (MO) cancers (8.6%), and 11 TI or MO cancers(3.3%) were identified. The patients with TP cancer hadmammographically fatty parenchyma in 33.7% and denseparenchyma in 66.3%, whereas the patients with TI orMO cancers had 24% and 76% respectively (p = 0.0001).TP cancers most frequently showed mass (88 out of 260,33.8%) on mammography, whereas FN cancers asym-metry (9 out of 18, 50%, p = 0.0029). Clinical andhistopathologic features did not show significantly differ-ences between screen-detected and interval cancers.CONCLUSION: Our results showed that the patients withTI or MO cancers had more frequently dense parenchy-ma as compared with screen-detected cancers. TP can-cers most commonly showed mass whereas FN cancersshowed asymmetry on mammography.

SS 16 BR-03 08:20First application of the radiation dosemanagement system (RadimetricsTM) in full fielddigital mammography (FFDM)Ji Eun Baek, Bong Joo Kang, Sung Hun Kim, Hyun Sil Lee The Catholic University of Korea, Seoul St. Mary’sHospital, Korea. [email protected]

PURPOSE: In the perspectives on radiation dose, thereare consensus of importance on radiation dose manage-ment for patient safety and trends to reduce radiationdose for patient safety. Radiation dose management sys-tem like RadimetricsTM helps radiologists optimize proto-cols and reduce radiation dose. RadimetricsTM is useful forquality assurance. Eventually, radiologists are able to doquality management in radiology. There is no previousdata applying the radiation dose management system inmammography. We investigated the clinical usefulness ofthe radiation dose management system in full field digitalmammography (FFDM) using RadimetricsTM.MATERIALS AND METHODS: We did radiation dosetracking, monitoring, and statistics through the existedradiation dose management system (RadimetricsTM). Theutilization data, parameter, and dose report were sent tothe conventional picture archiving and communicationsystem (PACS) and the Radiometrics enterprise flat form.And we could review the data under the web base. Weanalyzed the correlation of the age, kVp, mAs, breastthickness, compression force, and breast compositionwith organ dose of breast using the Pearson’s product-moment correlation. Additionally, in patients with abovediagnostic reference level (4th quarter, ≥ 75%) of radia-tion dose, the causes were analyzed.RESULTS: From February to May 2015, 2543 sets ofFFDM were performed and sent to PACS and the radia-

tion dose management system (RadimetricsTM). In total2543 sets, 2182 were routine bilateral FFDM with 4views. The mean glandular dose of 4 views was 6.64 ±3.06 mGy (2.78-17.55). In the correlation analysis, theage had moderate negative linear relationship with organdose. The mAs and breast composition had moderatepositive linear relationship with organ dose. The kVp,breast thickness, and compression force had weak posi-tive linear relationship with organ dose. Patients withabove diagnostic reference level (4th quarter, ≥ 75%) ofradiation dose showed dense breast composition andthicker breast.CONCLUSION: The radiation dose management systemis useful in FFDM. Patients with thick and dense breastsshould be carefully managed to maintain the constantradiation dose.

SS 16 BR-04 08:30Can mammographic density guess bone mineraldensity?Ah rhm Woo, Youn jeong Kim, Se jin Nam, Mi young Kim, Yeo ju Kim, Soon gu Cho Inha University Hospital, Korea. [email protected]

PURPOSE: Mammographic breast density and bonemineral density (BMD) are markers of cumulative expo-sure to estrogen. 5th BI-RADS estimates quartile rangesof breast density to reflect clinical experience. The pur-pose of this study is to evaluate which is correlated withBMD better.MATERIALS AND METHODS: 373 Korean women,aged 35-89 years (mean, 56 years) with mammographyand BMD data were collected in this study. Breast densitywas assigned to mammographic assessment by clinicalpattern and automatic volumetric breast density measure-ment (AVBD) methods. BMD was obtained from femoralneck and lumbar spine. The association between BMDand breast density was evaluated. Osteoporosis wasdiagnosed based on the mean and standard deviation of20-29 years. Our data did not include physical activity,parity, smoking, and use of hormone or vitamin therapy.RESULTS: The agreement between breast density eval-uations by BI-RADS and AVBD was good (kappa value =0.695, p = 0.000). AVBD were consistent with BI-RADS in298 cases and showed insignificant difference in 75cases by one grade (undergrade, 16 cases; overgrade,59 cases) from BI-RADS. The breast density by twomethods were negatively correlated with age, body massindex (BMI), BMD of femur and lumbar spine (p < 0.05).Particularly, osteoporosis was related to lower grade thanupper grade of breast density (p = 0.003, p = 0.000).CONCLUSION: New BI-RADS breast density and AVBDcan infer BMD, regardless of any physical or medical

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Table 1.

Automatic volumetric breast density measurement(AVBD)

1 (N=10) 2 (N=83) 3(N=182) 4 (N=98) Total(373) p

Breast tissue vol (cm3) 701.47 243.29 586.62 213.59 457.26 251.19 306.86 178.97 453.0.7 248.64 0.0047Fibroglandular vol (cm3) 28.27 8.88 34.10 12.21 49.14 34.40 64.52 41.93 49.28 34.55 0.000Breast density (%) 4.14 0.21 6.05 0.76 10.79 2.19 21.00 4.03 12.24 6.18 0.000

information. Therefore, people with non-dense breastsare recommended for regular BMD checkup, whethermenopausal or not.

SS 16 BR-05 08:40“Category 4a” microcalcifications: how shouldthis category be applied in malignancy riskstratification and patient management? Jihee Kim, Eun-Kyung Kim, Min Jung Kim, Hee Jung Moon, Jung Hyun Yoon Severance Hospital, Korea. [email protected]

PURPOSE: Although the subcategory of category 4Amicrocalcifications are commonly used in daily practice,the descriptor for category 4A microcalcifications are notyet specified in the Breast Imaging Reporting and DataSystem (BI-RADS). The purpose of this study is to inves-tigate how category 4A assessment is applied to micro-calcifications detected on mammography and the appro-priate calcification descriptors for the category 4A lesions.MATERIALS AND METHODS: From June 2008 toNovember 2011, 296 women with microcalcifications

detected on mammography assessed as BI-RADS cate-gory 4a who underwent imaging-guided biopsy or surgerywere included. Pre-biopsy mammograms were reviewedretrospectively, and imaging features were analyzedaccording to the revised morphology and distributiondescriptors of the 5th edition of BI-RADS. Pathologicalresults of stereotactic biopsy and surgical excision wereconsidered as the reference standard. Positive predictivevalues (PPVs) were calculated and compared using thex2 test or Fisher’s exact test.RESULTS: The overall PPV of category 4a microcalci-fications was 17.7%. PPVs of individual morphologydescriptors were as follows: amorphous 7.2%, coarseheterogeneous 12.8%, fine pleomorphic or fine linear/finelinear branching 91.4% (p < 0.001). PPVs of distributiondescriptors were as follows: regional 13.2%, grouped16.1%, linear/segmental 54.5% (p < 0.001). For morphol-ogy and distribution descriptors combinations, PPVs foramorphous/regional and amorphous/grouped microcalci-fications were 6.8% and 6.9%, while PPVs of other com-binations were higher than 10%, respectively.CONCLUSION: PPVs of amorphous microcalcificationsin regional or grouped distribution are suitable for catego-ry 4A assessment, while PPVs in other combinations

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Table 2.

BI-RADS density Total

Fat Fibroglandular (FG) Heterogeneously Dense (HD) Extremely Dense (ED)

Volpara 1 9 1 0 0 102 14 62 7 0 833 0 29 145 8 1824 0 0 16 82 98

BI-RADS total 23 92 168 90 373

kappa value: 0.695 p=0.000

Table 3.

Automatic volumetric breast density measurement(AVBD) Total (373) p

1 (N=10) 2 (N=83) 3(N=182) 4 (N=98)

Age (year) 63.4 10.03 63.14 10.03 55.22 8.75 49.78 7.53 55.77 9.99 0.019*

Body mass index (BMI) 26.40 4.74 25.86 2.98 24.19 3.13 22.16 2.75 24.1 3.33 0.000*

Lumbar BMD (g/cm2) 1.01 0.15 0.99 0.15 1.06 0.16 1.06 0.16 1.04 0.16 0.013*Femur BMD (g/cm2) 0.93 0.16 0.85 0.19 0.92 0.15 0.88 0.14 0.89 0.16 0.024*BMD 0.003*

Normal 3 (30.0) 19 (22.9) 70 (38.5) 40 (40.8) 132 (35.4)Osteopenia 5 (50.0) 45 (54.2) 91 (50.0) 48 (49.0) 189 (50.7)Osteoporosis 2 (20.0) 19 (22.9) 21(11.5) 10 (10.2) 52 (13.9)

BI-RADS density

Fat(N=23) FG(N=92) HD(N=168) ED(N=90) Total (373) p

Age (year) 67.3 9.84 60.7 9.26 55.05 9.09 49.10 6.72 55.77 9.99 0.000*

Body mass index (BMI) 26.81 3.51 25.22 3.12 24.12 3.08 22.19 2.93 24.09 3.33 0.000*

Lumbar BMD (g/cm2) 0.99 0.16 0.99 0.16 1.06 0.16 1.07 0.16 1.04 0.16 0.004Femur BMD (g/cm2) 0.88 0.14 0.85 0.92 0.92 0.16 0.89 0.14 0.88 0.16* 0.015*BMD 0.000*

Normal 6(26.1) 18(19.6) 70(41.7) 38(42.2) 132(35.4)Osteopenia 11(47.8) 53(57.6) 81(48.2) 44(48.9) 189(50.7)Osteoporosis 6(26.1) 21(22.8) 17(10.10 8(8.9) 52(13.9)

ranged in higher levels of malignancy risk. Subcategori-zation is required for the suspicious microcalcificationsdescribed in the 5th edition of BI-RADS for appropriate riskstratification and further patient management.

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Table 1. Final pathology of the 305 category 4A microcalcifications according to individual morphology and distribution descrip-tors seen on mammography

Descriptors Final pathology Total PPV (%) P

Benign (n=251) Malignant (n=54)

Benign High-risk Total DCIS Invasive Totalcarcinoma

Morphology <0.001Amorphous 175 (83.3%) 32 (78.0%) 207 (82.5%) 13 (29.5%) 3 (30.0%) 16 (29.6%) 223 (73.1%) 7.2 (16/223)Coarse heterogeneous 32 (15.2%) 9 (22.0%) 41 (16.3%) 6 (13.6%) 0 (0.0%) 6 (11.1%) 47 (15.4%) 12.8 (6/47)Fine pleomorphic/fine linear branching 3 (1.4%) 0 (0.0%) 3 (1.2%) 25 (56.8%) 7 (70.0%) 32 (59.3%) 35 (11.5%) 91.4 (32/35)Distribution <0.001Diffuse 11 (5.2%) 2 (4.9%) 13 (5.2%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 13 (4.3%) 0.0 (0/13)Regional 42 (20.0%) 4 (9.8%) 46 (18.3%) 6 (13.6%) 1 (10.0%) 7 (13.0%) 53 (17.4%) 13.2 (7/53)Grouped 149 (71.0%) 33 (80.5%) 182 (72.5%) 31 (70.5%) 4 (40.0%) 35 (64.8%) 217 (71.1%) 16.1 (35/217)Linear/segmental 8 (3.8%) 2 (4.9%) 10 (4.0%) 7 (15.9%) 5 (50.0%) 12 (22.2%) 22 (7.2%) 54.5 (12/22)

Total 210 41 251 44 10 54 305 17.7 (54/305)

PPV: positive predictive value, DCIS: ductal carcinoma in situ

Table 2. PPV of the 305 category 4A microcalcifications in combination of morphology and distribution descriptors

Descriptors Final pathology Total PPV (%) P

Benign (n=251) Malignant (n=54)

Benign High-risk DCIS Invasive carcinoma

Amorphous 0.269Diffuse 10(5.7%) 1(3.1%) 0(0.0%) 0(0.0%) 11 (4.9%) 0 (0/11)Regional 38 (21.7%) 3 (9.4%) 3 (23.1%) 0 (0.0%) 44 (19.7%) 6.8 (3/44)Grouped 122 (69.7%) 26 (81.3%) 9 (69.2%) 2 (66.7%) 159 (71.3%) 6.9 (11/159)Linear/segmental 5 (2.9%) 2 (6.3%) 1 (7.7%) 1 (33.3%) 9 (4.0%) 22.2 (2/9)Coarse heterogeneous 0.659Diffuse 1 (3.1%) 1 (11.1%) 0 (0.0%) 0 (0.0%) 2 (4.3%) 0 (0/2)Regional 4 (12.5%) 1 (11.1%) 1 (16.7%) 0 (0.0%) 6 (12.8%) 16.7 (1/6)Grouped 25 (78.1%) 7 (77.8%) 4 (66.7%) 0 (0.0%) 36 (76.6%) 11.1 (4/36)Linear/segmental 2 (6.3%) 0 (0.0%) 1 (16.7%) 0 (0.0%) 3 (6.4%) 33.3 (1/3)Fine pleomorphic/fine linear branching 0.854Diffuse 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0/0)Regional 0 (0.0%) 0 (0.0%) 2 (8.0%) 1 (14.3%) 3 (8.6%) 100.0 (3/3)Grouped 2 (66.7%) 0 (0.0%) 18 (72.0%) 2 (28.6%) 22 (62.9%) 90.9 (20/22)Linear/segmental 1 (33.3%) 0 (0.0%) 5 (20.0%) 4 (57.1%) 10 (28.6%) 90.0 (9/10)

Total 210 41 44 10 305 17.7 (54/305)

PPV: positive predictive value, DCIS: ductal carcinoma in situ

Breast MRI

SS 16 BR-06 08:50Early surveillance using breast MR imaging inwomen after breast conservation therapy - apreliminary studyJi Eun Baek1, Bong Joo Kang1, Sung Hun Kim1,Yeong Yi An2, Hyun Sil Lee1

1The Catholic University of Korea, Seoul St. Mary’sHospital, 2The Catholic University of Korea, St.Vincent’s Hospital, Korea. [email protected]

PURPOSE: To prospectively investigate the outcomes ofearly surveillance (12 months or less) including breastmagnetic resonance (MR) imaging in women who had ahistory of breast conservation therapy (BCT) for breastcancers.MATERIALS AND METHODS: Between April 2014 andApril 2015, 237 consecutive women (mean age, 51.3 ±9.7 years; age range, 21-81 years) with 240 breast can-cers who underwent breast MR imaging for early surveil-lance (mean, 8.2 ± 2.9 months; range, 5-12 months)after BCT for breast cancer were studied. Of the studypopulation, 225 (94.9%) patients underwent preoperativeMR examinations. We assessed cancer detection rate,positive predictive value (PPV), sensitivity, and specificityand evaluated the clinicopathological characteristics ofthe detected cancer including pathologic subtype ofbreast cancer and surgical margin status. In addition, weassessed the cancer detection ability in other imagingmodalities such as ultrasound and mammography at thesame time.RESULTS: 1.7% (4/240) cancers (1 invasive ductal carci-noma (IDC), 3 ductal carcinoma in situ (DCIS); meansize, 3 ± 3.1 cm; range, 0.4-8 cm; all node negative)were detected with MR imaging. PPV for recall (4/15),PPV for biopsy (4/13), sensitivity, and specificity were27%, 31%, 80%, and 95%, respectively. Three of the fourMR detected cancers showed close surgical margin (<0.2 cm) and the other one cancer 0.2 cm in surgical mar-gin. 3 patients among entire 51 patients with DCIS wererecurred (5.9%), and only one patient among entire 153patients with IDC was recurred (0.1%). None of therecurred cases was detected on ultrasound and mam-mography.CONCLUSION: Preliminary data suggest that single-screening MR imaging can be used for early surveillanceafter BCT. Early surveillance using MR imaging could bemore useful for patients with close surgical margin andDCIS.

SS 16 BR-07 09:00 Clinical utility of real-time MRI navigated US inpreoperative second-look US examination inbreast cancer patientsAh Young Park1, Bo Kyoung Seo1, Kyu Ran Cho2,Ok Hee Woo3, Jaehyung Cha1

1Korea University Ansan Hospital, 2Korea UniversityAnam Hospital, 3Korea University Guro Hospital,Korea. [email protected]

PURPOSE: To investigate the clinical utility of real-timeMRI navigated US for preoperative second-look examina-tion in breast cancer patients.MATERIALS AND METHODS: Fifty-five consecutivebreast cancer patients underwent second-look US exami-nation with real-time MRI navigated US to evaluate pre-operative MRI-detected lesions between October 2013and February 2015 and were enrolled in this study. Of atotal of 67 breast lesions, 41 lesions were detected onboth conventional US and MRI navigated US, 23 weredetected only on MRI navigated US, and the remainingtwo were not found. The detection rates of conventionalUS and MRI navigated US were compared withMcNemar test. Clinical data (age and change of surgicalplan), US features (background echotexture, distancefrom nipple, and mass characteristics) and MRI features(size, depth, type, characteristics, and kinetics of lesions)were compared between the following two groups withStudent’s T, chi-square, or Fisher’s exact test; 41 lesionsdetected on both conventional US and MRI navigated US(Group 1) and 23 lesions detected with only MRI navigat-ed US (Group 2).RESULTS: The detection rate of MRI navigated US wasstatistically higher than that of conventional US, 95.5%(65/67) versus 61.2% (41/67) (p < 0.0001). Heterogene-ous background echotexture (69.6% [16/23] vs. 34.1%[14/41], p = 0.012), isoechoic masses on US (65.2%[15/23] vs. 7.3% [3/41], p < 0.0001), and deep location onMRI (26.1% [6/23] vs. 14.6% [6/41], p = 0.041) were morecommon in Group 2. The change in surgical plan wasmore common in Group 2, although there was less statis-tical significance (43.5% [10/23] vs. 22.0% [9/41], p =0.071). In 10 patients with change of surgical plan inGroup 2, four underwent mastectomy due to multicentriccancers and six underwent additional excision due toconcurrent high-risk lesions.CONCLUSION: Real-time MRI navigated US is useful todetect breast lesions on second-look US examination,which can affect treatment plan. It could be more helpfulto identify the lesions with heterogeneous backgroundechotexture, iso-echogenicity, or deep location.

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SS 16 BR-08 09:10 Estimation of T2* relaxation time of breastcancer: correlation with clinical and pathologicalfeaturesMirinae Seo1, Jung Kyu Ryu2, Geon-Ho Jahng2, Sun Jung Rhee2, Jang-Hoon Oh3, Hyug-Gi Kim3

1Chung-Ang University Hospital, 2Kyung Hee UniversityHospital at Gangdong, 3College of Electronics andInformation, Kyung Hee University, Yongin, Korea. [email protected]

PURPOSE: The purposes of this study are the estimationof the T2* relaxation time in breast cancer of breast MRIand evaluation of the relationship of the T2* value withclinical and pathological features.MATERIALS AND METHODS: Between January 2011and July 2013, a total of 72 MR images of 72 invasiveductal carcinomas (IDCs) in 72 women were collectedusing a three-dimensional multi-echo gradient-echosequence with 7 echo times. After T2* were mapped foreach patient, volumetric regions of interest (ROI) weredefined at the cancer areas for each patient. Student’s t-test and one-way analysis of variance (ANOVA) test wereused to compare T2* values in different cancer character-istic groups according to clinical, and pathological fea-tures. In addition, multivariate linear regression analysiswas performed to find independent predictive factorsassociated with T2* values in cancer.RESULTS: In the 72 cancers involved in the study, themean T2* relaxation time for high-grade cancer groupwas longer than that for low or indeterminate-grade can-cer group (33.51 ± 11.20 ms vs. 26.75 ± 7.89 ms, p =0.004). There was also statistically significant differencein mean T2* relaxation time between the low-staining Ki-67 group and the high-staining Ki-67 group (26.13 ± 7.00ms vs. 31.21 ± 10.91 ms, p = 0.027). Clinical factorsincluding age, menopausal status, and family historywere not statistically significant correlations to T2* values.Multivariate analysis showed that the high-grade cancerwas an independent predictor of longer T2* relaxationtime (p = 0.050).CONCLUSION: T2* relaxation time in high-grade cancerwas found to be significantly longer than that in low orindeterminate-grade cancer. Quantitative measurementof T2* relaxation time might provide new diagnostic para-meter to breast MRI.

SS 16 BR-09 09:20 Analysis of factors influencing the detectabilityon diffusion-weighted MRI and diffusionbackground signals in invasive breast cancerpatients Eun Sook Ko, Boo-Kyung Han, Eun Young Ko Samsung Medical Center, Korea. [email protected]

PURPOSE: To determine the factors influencing thedetectability of diffusion-weighted (DW) magnetic reso-nance imaging (MRI) and diffusion background signals ininvasive breast cancer.MATERIALS AND METHODS: Institutional ReviewBoard approval was obtained and patient consent waswaived. 167 patients with newly diagnosed invasive duc-tal carcinoma, not otherwise specified (IDC NOS), whounderwent preoperative breast MRI with diffusion-weight-ed imaging (DWI) were included in this study.Detectability on DWI and contrast-enhanced subtractedT1-weighted images, background parenchymal enhance-ment (BPE) and diffusion background signal were qualita-tively rated. Detectability on DWI was compared with clini-copathologic findings including menopausal status, mam-mographic density, and molecular subtype. Multivariateordinal logistic regression analysis was performed todetermine variables independently associated withdetectability on DWI and diffusion background signals.RESULTS: In multivariate analysis, the diffusion back-ground signal (odds ratio = 0.23, p < 0.001), histologicgrade (adjusted odds ratio = 1.91, p = 0.004), tumor size(adjusted odds ratio = 1.06, p = 0.004) and lymphovascu-lar invasion (adjusted odds ratio = 2.30, p = 0.019) wereindependently correlated with the detectability on DWI ininvasive breast cancer. Only BPE was independently cor-related with the amount of diffusion background signalson DWI.CONCLUSION: In invasive breast cancers, detectabilityon DWI was significantly affected by diffusion backgroundsignal.

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Breast16:00-18:00 Grand Ballroom 105

Axilla

Chairperson(s)Min Jung Kim Yonsei University School of Medicine,

Severance Hospital, KoreaNariya Cho Seoul National University Hospital, Korea

SS 23 BR-01 16:00 Evaluation of lymph node status afterneoadjuvant chemotherapy in breast cancerpatients: comparison of diagnostic performanceof US, MRI and PET/CTSeulgi You, Doo Kyoung Kang, Tae Hee Kim Ajou University Hospital, Korea. [email protected]

PURPOSE: To evaluate the diagnostic performance ofultrasound (US), magnetic resonance imaging (MRI) andF-18 fluorodeoxyglucose positron emission tomography/computed tomography (FDG PET/CT) for the diagnosisof metastatic axillary lymph node (ALN) after neoadjuvantchemotherapy (NAC) and to find out histopathologic fac-tors affecting the diagnostic performance of these imag-ing modalities.MATERIALS AND METHODS: From January 2012 toNovember 2014, 191 consecutive patients with breastcancer who underwent NAC before surgery were retro-spectively reviewed. We included 139 patients with axil-lary lymph node metastasis which was confirmed on fineneedle aspiration or core needle biopsy at initial diagno-sis.RESULTS: After NAC, 39 (28%) patients showed nega-tive conversion of axillary lymph node on surgical speci-mens of sentinel lymph node or axillary lymph node. Thesensitivity of US, MRI and PET/CT was 50% (48/96),72% (70/97) and 22% (16/73), respectively. The specifici-ty of US, MRI and PET-CT was 77% (30/39), 54%(21/39) and 85% (22/26), respectively. The Az value ofcombination of US and PET/CT was highest (0.634) fol-lowed by US (0.626) and combination of US, MRI andPET/CT (0.617). The size of tumor deposit in lymph nodeand estrogen receptor were significantly associated withthe diagnostic performance of US (p < 0.001 and p =0.009, respectively) and MRI (p = 0.045 and p = 0.036respectively). The % diameter decrease, size of tumordeposit in lymph node, progesterone receptor, HER2 andhistologic grade were significantly associated with thediagnostic performance of PET/CT (p = 0.023, p = 0.002,p = 0.036, p = 0.044 and p = 0.008, respectively). Onmultivariate logistic regression analysis, size of tumordeposit within lymph node was identified as being inde-pendently associated with diagnostic performance of US(odds ratio, 13.07; 95% confidence interval [CI], 2.95-57.96) and PET/CT (odds ratio, 6.47; 95% CI, 1.407-29.737).CONCLUSION: Combination of three imaging modalitiesshowed highest sensitivity and PET/CT showed highestspecificity for the evaluation of ALN metastasis after NAC.US alone or combination of US and PET/CT showed

highest positive predictive value. The size of tumordeposit within ALN was significantly associated with diag-nostic performance of US and PET/CT.

SS 23 BR-02 16:10 The diagnosis of axillary lymph node metastasisin breast cancer: comparison withultrasonography, MRI, PET/CT, and CTYoue Ree Kim, Hye-Won Kim Wonkwang University Hospital, Korea. [email protected]

PURPOSE: To evaluate the diagnostic performance ofultrasonography (US), magnetic resonance imaging(MRI), 18F-Fluorodeoxyglucose positron emission tomog-raphy/computed tomography (PET/CT), and computedtomography (CT) for axillary lymph node metastasis inpatients with breast cancer.MATERIALS AND METHODS: Retrospectively, weenrolled 109 axillary lymph nodes from 105 consecutivewomen (including bilateral breast cancer, n = 4) who werediagnosed with pathologically proven invasive breast can-cer and who underwent preoperative breast US, MRI,PET/CT and chest CT. The largest ipsilateral axillarylymph nodes were evaluated on this study. We assessedthe diagnostic accuracy of each modality and significantimaging findings of metastatic axillary lymph nodes.RESULTS: A total of 28 patients had axillary lymph nodemetastasis on pathology. The sensitivity, specificity, posi-tive predictive value, negative predictive value, and diag-nostic accuracy were 46%, 94%, 71%, 85%, 83% for US(AUC = 0.710, p = 0.002), 58%, 88%, 60%, 87%, 81% forMRI (AUC = 0.739, p < 0.001), 50%, 96%, 81%, 86%,85% for PET/CT (AUC = 0.742, p < 0.001), and 48%,90%, 60%, 85%, 80% for CT (AUC = 0.691, p = 0.004),respectively. PET/CT was more accurate than MRI (p =0.039) for prediction of metastatic axillary lymph nodes.The enhancement degree on CT/MRI and kinetic patternson MRI of metastatic axillary lymph nodes were not statis-tically significant compared to those of non-metastaticlymph nodes. Among imaging variables of each modality,both the cortical thickness and the ratio of short axis tolong axis of axillary lymph node on US showed statistical-ly significant on receiver operating curve analysis (AUC=0.875, p < 0.001, AUC = 0.742, p < 0.001 respectively).The cutoff value for the cortical thickness of lymph nodeon US with 3.6 mm yielded 72% sensitivity, 87% specifici-ty, and the cutoff value for the ratio of short axis to longaxis of lymph node on US with 0.49 showed 64% sensi-tivity, 70% specificity.CONCLUSION: The diagnostic performances of metasta-tic axillary lymph nodes detection using US, MRI,PET/CT, and CT are comparable. The cortical thicknessand the ratio of short axis to long axis of lymph node onUS demonstrates statistically significant as a single para-meter for assessment of metastatic axillary lymph nodes.

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SS 23 BR-03 16:20 Early-stage invasive ductal breast cancer:association of tumor apparent diffusioncoefficient values with axillary lymph nodemetastasisJin You Kim, Hie Bum Seo Pusan National University Hospital, Korea. [email protected]

PURPOSE: To evaluate any association between tumorapparent diffusion coefficient (ADC) values and axillarynode metastasis in early-stage invasive ductal breastcancer.MATERIALS AND METHODS: The Institutional ReviewBoard approved this retrospective study, and waived theneed for informed consent. Between May 2013 andNovember 2014, the records of 270 invasive ductalbreast cancer patients (mean age, 51.3 years; range, 23-85 years) with stages T1 and T2 disease who underwentpreoperative breast magnetic resonance imaging, includ-ing diffusion-weighted (DW) imaging with b values of 0and 1,000 s/mm2 were reviewed. The ADC values of thebreast tumors were measured and compared with clinico-pathological variables. Receiver operating characteristic(ROC) curve and multivariate regression analyses wereused to test the predictive power of the tumor ADC valueswith regard to axillary node metastasis.RESULTS: Of the 270 patients, 58 (21.5%) experiencedaxillary lymph node metastasis. The mean tumor ADCvalues were significantly lower in patients with axillarynode metastasis versus those without metastasis (0.880× 10-3 vs. 0.999 × 10-3 mm2/s; p < 0.001). A ROC curvedemonstrated a tumor ADC value of 0.991 × 10-3 mm2/sto be the optimal cut-off for predicting axillary nodemetastasis. Multivariate regression analysis revealed thatlower tumor ADC value (≤ 0.991 × 10-3 mm2/s; adjustedodds ratio (OR) = 5.861, p < 0.001) was an independentvariable associated with axillary node metastasis, alongwith large tumor size (> 2 cm; adjusted OR = 3.156, p =0.002) and presence of lymphovascular invasion (adjust-ed OR = 4.125, p < 0.001). When tumor ADC value wasadded to known risk factors (i.e., tumor size and lympho-vascular invasion), a significant improvement in the accu-racy of risk prediction for axillary node metastasis wasachieved (c-statistic = 0.758 vs. 0.816, p = 0.026).CONCLUSION: Tumor ADC values obtained at DWimaging may be an independent predictive factor for axil-lary lymph node metastasis in patients with early-stageinvasive ductal breast cancer.

Advanced technique of mammography

SS 23 BR-04 16:30 Dual energy contrast enhanced digitalmammography (CEDM) for screening:preliminary resultsJanice Sung, Carol Lee, Girard Gibbons,Christopher Comstock Memorial Sloan Kettering Cancer Center, USA. [email protected]

PURPOSE: To evaluate early results of an on-goingprospective trial assessing the accuracy and cancerdetection rate of dual energy contrast enhanced digitalmammography (CEDM) for breast cancer screening.MATERIALS AND METHODS: All women scheduled forscreening CEDM were considered for inclusion.Exclusion criteria were: age < 30, symptomatic patients,newly diagnosed breast cancer, breast surgery or biopsyin within 90 days, lumpectomy for breast cancer in past 3years, prior MRI within past 3 years, breast implants,patients with contraindications to use of iodinated contrastagent. Studies were performed on dedicated digital mam-mography units (General Electric). After the intravenousadministration of 525 mg/kg iodinated contrast (iohexol),two images in each projection (MLO and CC) one at lowenergy and one at high energy, were obtained. The lowenergy images served as the standard digital mammo-grams (DM). Recall rate for both DM and CEDM, addi-tional work-up and biopsy, and cancer detection ratewere noted.RESULTS: From December 2014 through April, 2015, 52patients were enrolled ranging in age from 30 to 69 years(mean, 52 years). All patients were at increased risk forbreast cancer. The recall rate for findings seen only onDM was 6% with 4 lesions seen in 3 patients (3 calcifica-tions, 1 asymmetry). Two of these lesions were assessedas probably benign (BI-RADS 3) after additional imagingand two underwent stereotactic biopsy yielding atypicalductal hyperplasia in one case and benign results in theother. Recall rate for findings seen only on CEDM was17% with 11 lesions seen in 9 patients. All 11 were mass-es. Four were found on targeted ultrasound; biopsy yield-ed 2 cancers in one patient and two benign results. MRIwas recommended in the remaining 6 patients withCEDM only findings for further evaluation. MR was nega-tive or benign in 2 patients. In the other 4, an MR corre-late was identified, and MR guided biopsy yielded malig-nancy in 2 and benign results in 2. No cancers weredetected by DM alone. For CEDM, 4 cancers in 3 patientswere diagnosed giving a cancer detection rate of57/1000.CONCLUSION: Very early results of CEDM for screeningshowed an in increase in recall but also increased cancerdetection. CEDM is a promising screening tool and maybe useful as supplemental screening in patients withincreased breast cancer risk.

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SS 23 BR-05 16:40 Comparison of diagnostic efficacy betweensynthesized 2D mammography and full-fileddigital mammography (FFDM) for evaluation ofbreast lesionsGayoung Choi1, Ok Hee Woo1, Hye Seon Shin1,Seonah Jang2, Kyu Ran Cho3, Bo Kyoung Seo4

1Korea University Guro Hospital, 2Korea Cancer CenterHospital, 3Korea University Anam Hospital, 4KoreaUniversity Ansan Hospital, Korea. [email protected]

PURPOSE: To compare diagnostic efficacy of synthe-sized 2D mammography from digital breast tomosynthe-sis (DBT) and conventional FFDM in patients undergoneDBT for evaluation of breast cancer.MATERIALS AND METHODS: A retrospective observerperformance study on blindly paired synthesized 2Dmammography from DBT and FFDM was performed by 3radiologists specialized in breast imaging (12 years, 5years, and 3 years of experience each). Images of biopsyconfirmed 257 breast lesions in 229 patients were collect-ed from April 21, 2014 to February 28, 2015 in our institu-tion. The diagnostic sensitivities of both synthesized 2Dmammography and FFDM were calculated and com-pared by McNemar’s test and the interobserver agree-ment on both exams was evaluated by kappa value. Also,detailed lesion characterization by DBT, synthesized 2Dmammography, FFDM, US, and MRI was done accordingto BI-RADS 2013 and each observer chose the bettermodality between synthesized 2D mammography andFFDM blindly, then statistically analyzed by Fisher’s exacttest.RESULTS: All patients were female and the mean agewas 51.6 years (range, 22-87 years). Among total 257lesions, 212 were malignant and 45 were benign. Thediagnostic sensitivity for malignant lesion of synthesized2D mammography was 82.5% and FFDM was 83.5%,and specificity was 91.1% in both. AUC of diagnosticaccuracy for synthesized 2D mammography was 0.876and FFDM was 0.868, which showed no statistically sig-nificant difference (p = 0.89). Kappa values for the inter-observer agreement evaluation were 0.973 for observer 1and 2, 0.944 for 2 and 3, and 0.972 for 1 and 3 whichshowed almost perfect interobserver agreement. Theobservers chose the synthesized 2D mammography as abetter modality in 27.6%, FFDM in 5.45%, and equal in66.9%, and especially spiculated margin was more clear-ly detectable in synthesized 2D mammography (p <0.05).CONCLUSION: Synthesized 2D mammography showedequivalent diagnostic values as compared with FFDM.Overall characterization of the lesion was better in syn-thesized 2D mammography, and especially it showed sta-tistically significant superiority in evaluation of spiculatedmargin and architectural distortion.

SS 23 BR-06 16:50 Replacement single-view mediolateral oblique(MLO) digital mammography to synthesizedmammography with digital breast tomosynthesis(DBT) image: comparison of radiation dose anddiagnostic performanceHyo-Jin Kang, Sung Eun Song, Won Hwa Kim, Min Sun Bae, Jung Min Chang, Woo Kyung Moon Seoul National University Hospital, Korea. [email protected]

PURPOSE: To evaluate the diagnostic performance andradiation dose of single-view cranio-caudal (CC) digitalmammography (DM) plus mediolateral oblique (MLO)synthesized mammography (SM) with digital breasttomosynthesis (DBT) in comparison with two-view digitalmammography (DM) and two views DM with MLO DBT.MATERIALS AND METHODS: This study was approvedby our Institutional Review Board and informed consentwas obtained in all patients. Between October andNovember 2014, paired two-view DM and single MLODBT images were obtained from 130 women (medianage, 52.1 years). Four independent retrospective readingsessions (two-view DM, single-view CC DM with MLOSM, two-view DM with DBT, and single-view CC DM andMLO SM with DBT) were performed in random order by 3blinded radiologists and the likelihood of malignancy (%)and BI-RADS categories of each lesion were assessed.Areas under receiver operating characteristic curve(AUC), sensitivities, and specificities were compared foreach arm using histopathologic results as the referencestandard. Average glandular dose (AGD) of DM and MLODBT were calculated from DICOM headers for imagesobtained with automatic exposure settings.RESULTS: Among 159 lesions in 130 patients, 27 weremalignant (mean tumor size, 3.27 ± 2.5 cm). When usingMLO SM and DBT instead of MLO DM, mean AGDrevealed a less than 10% increase (mean ± SD, 5.78mGy ± 1.07). A slight higher mean AUC was noted com-pared to two-view DM, but it was statistically not signifi-cant (p = 0.302). Mean AGD of two-view DM with MLODBT was 8.45 mGy ± 1.32 per patient, which was 60%higher than that of two-view DM alone (5.3 mGy ± 0.6, p< 0.001). Mean AUCs for two-view DM and DM+SM was0.881 and 0.848, respectively (p = 0.142). When DBTwas added, the mean AUC increased to 0.914 (p =0.016) and 0.907 (p = 0.073), and sensitivities increasedto 82.7%, and 81.5%, respectively (all p < 0.009), albeitwith minimal specificity increment (p > 0.05).CONCLUSION: Diagnostic performance can beimproved with the addition of MLO DBT to two-view DM.Replacement of MLO DM with SM and DBT showed asmall increase in radiation dose, but no gain in diagnosticperformance to two-view DM.

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SS 23 BR-07 17:00 Comparison of model-based perfusionparameters on dynamic contrast-enhanced MRIaccording to the dominant stroma type of breastcancerYoolim Baek, Doo Kyoung Kang, Tae Hee Kim Ajou University Hospital, Korea. [email protected]

PURPOSE: To evaluate imaging findings of breast can-cers according to the dominant stroma type by usingkinetic curve analysis and model-based perfusion para-meters from DCE-MRI.MATERIALS AND METHODS: From March 2011 toSeptember 2011, 64 patients were included for dataanalysis. Kinetic curve analysis and model based perfu-sion parameters (Ktrans, Kep and Ve) were obtainedusing DCEMRI and post-processing software. Imagingcharacteristics were analyzed according to the tumor-stroma ratio and dominant stroma type.RESULTS: Ve values were significantly lower in tumorswith more than 50% cellularity (0.37 vs. 0.48, p = 0.021).Mean Kep values were different between collagen domi-nant, fibroblast dominant and lymphocyte dominantgroups. By post hoc comparisons, mean Kep values weresignificantly higher in lymphocyte dominant group thancollagen dominant group (p = 0.003). In multivariateregression analysis, nuclear grade (p = 0.021) and domi-nant stroma type (collagen dominant, p = 0.017) wereindependently correlated with Kep values. In terms of thedominant stroma type, the collagen dominant typeshowed a decrease of 0.247 in Kep values, comparedwith the fibroblast-dominant type (p = 0.017).CONCLUSION: Kep values were significantly lower inbreast cancers with dominant collagen type and higher incancers with high nuclear grade.KEY POINTS: Breast cancer can be classified into 3 cat-egories according to the dominant stroma type. There arecollagen dominant type, fibroblast dominant type and lym-phocyte dominant type. Kep means the vessel permeabil-ity and Kep was significantly lower in collagen dominanttype of breast cancer. Breast cancers with high nucleargrade had higher Kep values than breast cancer with lownuclear grade.

Breast MRI

SS 23 BR-08 17:10 The predictive factors associated with the earlyand late recurrence in breast cancer: predictivefactors on radiography andimmunohistopathologyBoram Kim, Eun Jung Choi, Sin Ae Choi, Young Sun Lee, Su Bin Chon Chonbuk National University Medical School, Korea. [email protected]

PURPOSE: To evaluate the radiologic and immuno-histopathologic factors influencing recurrence period inthe cases of the patients who experienced recurrenceafter first treatment of breast cancerMATERIALS AND METHODS: From January 2007 toDecember 2013, we retrospectively reviewed 1122 breastcancer patients who had undergone surgery at our hospi-tal. Among them, we analyzed the MRI findings andimmunohistopathologic findings of 122 recurrent breastcancer patients. We evaluated the MRI enhancementparameters (kinetic curve types, background parenchy-mal enhancement (BPE), the number of vessels perbreast as a representation of ipsilateral whole-breast vas-cularity, semiquantitative parameters of tumors), morpho-logic features and histopathologic findings (operation andtreatment methods, stage, nodal status, histologic grade,nuclear grade, extensive intraductal carcinoma compo-nent (EIC), hormone receptor, p53, c-erB-2, Ki-67, andmolecular subtype). We had attempted to compare therecurrent patients within 2 years after the completion ofcurative surgery and adjuvant chemotherapy as the earlyrecurrence with those over 2 years as the late recurrence.RESULTS: Among 1122 women with breast cancers, 80(7.1%) had early recurrence and 42 (3.7%) had laterecurrence. In terms of immunohistopathologic findings,HER2 positivity (OR, 13.66; 95% CI, 7.65-24.39), Ki 67positivity (OR, 3.32; 95% CI, 1.80-6.12), and nodal status(OR, 1.91; 95% CI, 1.42-2.56) affected early recurrence.HER2 positivity (OR, 6.89; 95% CI, 3.48-13.63) andnodal status (OR, 1.18; 95% CI, 1.21-2.45) affected laterecurrence. According to MRI findings, increased ipsilat-eral whole breast vascularity (OR, 2.00; 95% CI, 1.57-2.55), adjacent vessel sign (OR, 1.88; 95% CI, 1.02-3.43), and BPE (OR, 1.45; 95% CI, 1.12-1.88) affectedearly recurrence. Adjacent vessel sign (OR, 0.500; 95%CI, 0.26-0.94), BPE (OR, 1.40; 95% CI, 1.03-1.90), lowerEpeak (OR, 0.99; 95% CI, 0.99-1.00), and lower E1 (OR,0.99; 95% CI, 0.99-1.00) affected late recurrence.CONCLUSION: Increased ipsilateral whole breast-vascu-larity, adjacent vessel sign, BPE were the predictor asso-ciated with early recurrence of breast cancer in conjunc-tion with HER2 positivity, Ki-67 positivity, and nodal sta-tus.

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SS 23 BR-09 17:20Radiogenomic analysis for breast cancer withmicrocalcificationsSung Ui Shin1, Wonhwa Kim1, A-jung Chu2, Sung Eun Song1, Wonsik Han1, Woo Kyung Moon1

1Seoul National University Hospital, 2SMG-SNUBoramae Medical Center, Korea. [email protected]

PURPOSE: To investigate relationships between micro-calcifications and gene expression patterns usingmicroarray analysis in breast cancer.MATERIALS AND METHODS: The Institutional ReviewBoard approved this study and waived the informed con-sent. Clinicopathologic finding, mammographic features,and gene expression data were evaluated in 133 women(mean age, 50.1 years; range, 21-79 years) with stage I-IIIbreast cancer. Thirty-three patients had suspicious micro-calcifications and 100 had no microcalcification on mam-mography. Global gene expression analyses were per-formed using Affymetrix GeneChipⓇ Human Gene 2.0 STArray (53,427 probes). Independent sample t-test wasperformed and differentially expressed genes were identi-fied (> 1.5-fold difference and p < 0.05). To correct forfalse positive results in multiple testing, significance analy-sis of microarrays (SAM) method was used and adjustedp-value < 0.05 was selected. To explore biological mean-ing behind differentially expressed genes, we usedDatabase for Annotation, Visualization and IntegratedDiscovery (DAVID) v6.7 Bioinformatics tool and IngenuityPathway Analysis. In addition, genes included in the pre-diction analysis of PAM50, MammaPrintⓇ andOncotypeDXⓇ were also compared between two groups(microcalcifications versus no calcification).RESULTS: HER2 positivity (p < 0.001) and presence ofcomedo necrosis (p = 0.024) are significantly higher in thecalcification group. The other clinicopathologic findingsare not significantly different between two groups.Differentially expressed genes (n = 128) were associatedwith response to wound, coagulation, inflammation,immune response, cell motility, ossification, blood vesseldevelopment. Among known gene signatures, GRB7 (foldchange = 2.264, p = 0.006) and ERBB2 (fold change =2.132, p < 0.001) which are associated with recurrence,cell invasion and poor survival were highly expressed. Incontrast, ZNF385B (fold change = 2.584, p = 0.001)which is associated with p53-mediated apoptosis andgood prognosis was underexpressed in calcificationgroup.CONCLUSION: Gene expression patterns are differentaccording to microcalcifications status in breast cancer.Cancers with mammographic microcalcifications areassociated with metabolic aggressiveness and poor prog-nosis.

SS 23 BR-10 17:30 Perfusion parameters in dynamic contrastenhanced MRI and apparent diffusion coefficient(ADC) value in diffusion-weighted MRI:correlation with prognostic factors in breastcancerHyun Sil Lee, Sung Hun Kim, Bong Joo Kang, Ji Eun Baek The Catholic University of Korea, Seoul St. Mary’sHospital, Korea. [email protected]

PURPOSE: To evaluate the correlation of prognostic fac-tors and subtypes of breast cancer with perfusion para-meters in dynamic contrast-enhanced (DCE) magneticresonance imaging (MRI) and apparent diffusion coeffi-cient (ADC) value in diffusion-weighted MRI.MATERIALS AND METHODS: Quantitative perfusionparameters (Ktrans, kep, ve and iAUC) and ADC value in theentire tumor volume were obtained using histogramanalysis in 52 invasive ductal carcinomas. Six measures(25th percentile, mean, median, 75th percentile, skewness,kurtosis) were calculated for each parameter and ADCvalue. Correlations of perfusion parameters and ADC val-ues with prognostic factors (tumor size, axillary lymphnode metastasis, histologic grade, expression of estrogenreceptor (ER), progesterone receptor (PR), Ki-67 andhuman epidermal growth factor receptor 2 [HER2]) andtumor subtypes were analyzed.RESULTS: In histogram analysis, iAUCmean andiAUCmedian were higher in tumors larger than 2 cm (8.23± 2.33, 8.64 ± 2.67×104) than in tumors smaller than 2cm (6.99 ± 1.92, 7.04 ± 2.15×104; p = 0.046, 0.023). Ve

median was higher in tumors with PR positivity (0.54 ±0.18) than those with PR negativity (0.44 ± 0.1, p =0.041). There was a significant correlation between ADCvalues and HER2 positivity for ADCmean and ADCmedian,with higher ADC values in tumors with HER2 positivity(1.306 and 1.278×10-3 mm2/s) than those with HER2negativity (1.078 and 1.053×10-3 mm2/s; p = 0.012 and0.020). ADCmean and ADCmedian for PR positive groupsshowed lower ADC values (1.070 and 1.045×10-3 mm2/s)than PR negative group (1.240 and 1.212×10-3 mm2/s; p= 0.018 and 0.028). ADCmean and ADCmedian for tumorswith ER positivity showed lower ADC values (1.089 and1.068×10-3 mm2/s) than tumors with ER negativity (1.260and 1.222×10-3 mm2/s; p = 0.011 and 0.024). There wasa significant difference between luminal and HER2enriched type in ADCmean and ADCmedian, higher ADCvalue in HER2 enriched type (1.404 and 1.378 × 10-3

mm2/s) than in luminal type (1.096 and 1.073 × 10-3

mm2/s; p = 0.030 and 0.045).CONCLUSION: Of perfusion parameters, iAUC correlat-ed with tumor size and ve median correlated with PR positiv-ity. Various ADC value measurements showed positivecorrelation with tumors with HER2 positivity and HER2enriched subtype and negative correlation with tumorswith ER/PR positivity.

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Chairperson(s)Eun Young Ko Samsung Medical Center,

Sungkyunkwan University School ofMedicine, Korea

Bo Kyoung Seo Korea University Ansan Hospital, Korea

SS 32 BR-01 09:50 Supplemental screening US in combination withelastography and color Doppler US: interimresults of a prospective multicenter studySu Hyun Lee1, Jung Min Chang1, Nariya Cho1, Ann Yi1, A jung Chu2, Ji Hyun Youk3, Eun Ju Son3,Seon Hyeong Choi4, Shin Ho Kook4, Chung Jin5, Eun Suk Cha5, Hye Ryoung Koo6, Jeong Seon Park6, Kyung Hee Ko7, Hye Young Choi8, Eun Bi Ryu9, Woo Kyung Moon1

1Seoul National University Hospital, 2SMG-SNUBoramae Medical Center, 3Gangnam SeveranceHospital, 4Kangbuk Samsung Hospital, 5Ewha WomansUniversity Mokdong Hospital, 6Hanyang UniversityMedical Center, 7Bundang CHA General Hospital,8Gyeongsang National University Hospital, 9DongnamInstitute of Radiological and Medical Science, Korea. [email protected]

PURPOSE: To validate the added value of elastographyand color Doppler ultrasonography (US) for supplementalscreening US in a multicenter study.MATERIALS AND METHODS: This study was conduct-ed with Institutional Review Board approval, and writteninformed consent was obtained. From November 2013 toDecember 2014, 1241 women (mean age, 46 years;range, 26-84 years) with breast masses (mean size, 1.0cm; range, 0.3-4.1 cm) detected on supplemental screen-ing US and assessed as BI-RADS category 3 or higherwere prospectively recruited from 10 tertiary care centers.After identifying the mass of interest on B-mode US, elas-tography (strain elastography was used in 4 sites andshear-wave elastography was used in 6 sites) and colorDoppler US were performed. Investigators assessed thelikelihood of malignancy as a percentage at the time ofenrollment using the four data sets: B-mode US alone, B-mode US with elastography, B-mode US with colorDoppler US, and B-mode US with elastography and colorDoppler US. Using the reference standard of biopsy (n =822) or at least 1 year of follow-up (228 of 419), the areasunder the receiver operating characteristics curve (AUC)were compared between the four data sets.RESULTS: Seventy-one of 1,241 breast masses (5.7%)were malignant. The AUC of B-mode US increased from0.891 to 0.931 (p = 0.044) and 0.924 (p = 0.136) whenelastography or color Doppler US was added, respective-ly. When both elastography and color Doppler US wereadded to B-mode US, the highest AUC (0.963) wasachieved (p < 0.001). The majority of breast masses inour cohort (93% [1152 of 1241]) was assessed as BI-RADS category 3 or 4A on B-mode US and included 25

malignancies (9 ductal carcinoma in situ [DCIS], 16 inva-sive carcinoma). None of invasive cancers but only oneDCIS showed negative findings on both elastography andcolor Doppler US. If the BI-RADS category 3 or 4A mass-es with negative findings on both elastography and colorDoppler US were managed with 1-year diagnostic follow-up, a considerable number of unnecessary biopsies(80.6% [608 of 754]) and short-term follow-up (88.2%[367 of 416]) can be reduced.CONCLUSION: Combined use of elastography and colorDoppler US can increase the specificity of supplementalscreening US for breast cancer detection.

SS 32 BR-02 10:00 Stiffness value measured by shear-waveelastography: preoperative predictor of invasivebreast cancer in patients with biopsy-confirmedductal carcinoma in situJae Seok Bae, Su Hyun Lee, Sung Ui Shin, Jung Min Chang, Woo Kyung Moon Seoul National University Hospital, Korea. [email protected]

PURPOSE: To investigate whether lesion stiffness mea-sured by shear-wave elastography (SWE) could predicthistologic upgrade of ductal carcinoma in situ (DCIS) con-firmed by ultrasound (US)-guided core needle biopsy(CNB).MATERIALS AND METHODS: This retrospective studywas conducted with Institutional Review Board approval,and informed consent was waived. From January 2012 toFebruary 2015, database search revealed 120 biopsy-confirmed DCIS in patients (mean age, 52.4) who under-went B-mode US and SWE prior to surgery.Clinicopathologic results, B-mode findings, size on US,mean and maximum elasticity values on SWE wererecorded. Three radiologists independently analyzedqualitative color scores on SWE images using 5 pointscale. To identify the preoperative factors associated withupgrade to invasive cancer, B-mode US findings, SWEinformation, and clinical variables were analyzed usingunivariate and multivariate logistic regression analysis.Qualitative color scores assessed by individual radiolo-gists were analyzed to identify correlation with clinico-pathologic variables, lesion size, and findings on B-modeUS using multiple linear regression analysis.Interobserver agreements among radiologists on qualita-tive color score were assessed using multi-rater kappastatistic.RESULTS: The overall upgrade rate was 41.7% (50 of120). Mean, maximum stiffness values, qualitative colorscores, and lesion size showed significant differences inupgrade and non-upgrade groups. Multivariate logisticregression analysis revealed mean (p = 0.012), maximumstiffness (p = 0.039), and lesion size (p < 0.001) were sig-nificantly correlated with histologic upgrade. In readerstudy, color scores were correlated with the histologicupgrade, mammographic density, and B-mode categoryin all three radiologists (p value < 0.04). The overall inter-observer agreement for elasticity score was excellent (κ=0.814-0.887).CONCLUSION: Breast lesion stiffness measured bySWE could be helpful to predict the upgrade to invasive

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cancer in US-guided biopsy proven DCIS patients, andtherefore aid in planning the type of operation when surgi-cal excision is performed.

SS 32 BR-03 10:10 Combined shear wave elastography and colorDoppler US in Characterization of breast lesions:the diagnostic effect on B-mode US Mi Ran Jeon, Inyoung Youn, Seon Hyeong Choi,Yoon Jung Choi, Shin Ho Kook, Mi Yeon Lee Kangbuk Samsung Hospital, Korea. [email protected]

PURPOSE: To evaluate the diagnostic effect of com-bined shear-wave elastography (SWE) and color DopplerUS in addition to B-mode US in characterization of breastlesions.MATERIALS AND METHODS: From January 2011 toDecember 2013, 996 lesions (795 benign, 201 malignant)of 980 patients (mean age, 49.5) who underwent B-modeUS and combined SWE and color Doppler US beforebiopsy were included. The size (< 1 cm, 1-2 cm, 2 cm ≤)and BI-RADS assessment of B-mode US of each lesionwere recorded. SWE with maximum visual color stiffnessand vascular signal on Doppler US were retrospectivelyassessed. As for SWE, blue to green (≤ 80 kPs) wasused as benign reference point and as for color DopplerUS, amount (≤ 3 vascular signals in or around lesion) orpattern (penetrating) were used to differentiate frommalignant lesions. Diagnostic performance (sensitivity,specificity, PPV, NPV and diagnostic accuracy) of eachB-mode, and combination modalities were statisticallyevaluated. RESULTS: Among 795 benign lesions, 337 fibroadeno-mas and 66 papillary lesions, 11 lesions with atypia andamong 201 malignant lesions, 35 in situ carcinomas wereenrolled. About 85% of lesions were smaller than 2 cm(T1) and B-mode assessment of the lesions met the likeli-hood of malignancy on BI-RADS system. The sensitivityand NPV of B-mode US were improved by adding colorDoppler and SWE together (p < 0.001). The sensitivity,specificity, PPV, NPV and diagnostic accuracy of B-modeonly and combination of color Doppler, SWE on B-modeare as follows; 83.6%, 93.2%, 75.7%, 95.7% and 91.2%for B-mode only, 90%, 72.6%, 45.4%, 96.6% and 76.1%for combination respectively. The lesion larger than 2cmin size and fibroadenoma, papilloma, and lesion withatypia among benign pathology showed more false posi-tive and the lesion smaller than 1 cm in size, and DCIS,other invasive rather than invasive ductal carcinomashowed more false negative on both (color Doppler andSWE) combination study (p < 0.01). CONCLUSION: Color Doppler and SWE added to B-mode US revealed improvement of sensitivity and NPV (p< 0.001), without improvement of specificity, PPV anddiagnostic accuracy.

SS 32 BR-04 10:20 Categorization of focal breast lesions accordingto the Ultrasound breast imaging reporting anddata system (BI-RADS US) lexicon: role of acomputer aided decision making support (S-Detect)Tommaso Vincenzo Bartolotta, Alessia Orlando,Adele Taibbi, Margherita Safina, Alessandra Cirino,Raffaele Ienzi University of Palermo, Italy. [email protected]

PURPOSE: To assess the role of a computer-guideddecision-making support (S-Detect) in the categorizationof focal breast lesions (FBLs) according to the UltrasoundBreast Imaging Reporting and Data System (BI-RADSUS) lexicon.MATERIALS AND METHODS: According to the BI-RADS US descriptors (shape, orientation, margin of themass, boundary, echo pattern and posterior acoustic fea-ture) two radiologists classified by consensus into 4 cate-gories (BI-RADS 2: benign; BI-RADS 3: probably benign;BI-RADS 4: suspicious; BI-RADS 5: highly suggestive ofmalignancy) 150 FBLs (size range, 3-25.6 mm; mean,12.2 ± 6.6 mm SD) detected by means of high resolutionUS in 114 patients (M:F = 2:112; age range, 20-79 years;mean, 49.5 ±14.1 years SD). An independent readeralso assessed off-line the same 150 FBLs by means of S-Detect, a built-in dedicated software for US-BIRADS clas-sification, capable of a semi-automated lesion extractionand guided classification according to same above-men-tioned BI-RADS US descriptors. US-guided core-biopsyacted as standard of reference (SOR) for all the FBLsclassified as BI-RADS 4 or 5. Sensitivity, Specificity,Positive (PPV) and Negative (NPV) predictive valueswere calculated considering BI-RADS 4 or 5 FBLs asmalignant and BI-RADS 2 or 3 FBLs as benign mass.RESULTS: The two reviewers classified the 150 FBLs asBI-RADS 2 (n = 70), BI-RADS 3 (n = 52), BI-RADS 4 (n =17), BI-RADS 5 (n = 11), with Sensitivity, Specificity, PPVand NPV of 76.7%, 95.8%, 82.1% and 94.3% respective-ly. S-Detect assisted radiologist classified the 150 FBLsas BI-RADS 2 (n = 70), BI-RADS 3 (n = 47), BI-RADS 4(n = 22), BI-RADS 5 (n = 11), with Sensitivity, Specificity,PPV and NPV of 100%, 97.5%, 90.9% and 100% respec-tively. S-Detect changed the initial BI-RADS classificationin 13 of 150 (8.7%) FBLs: 9 FBLs were up-graded fromBI-RADS 3 to BI-RADS 4 whereas 4 FBLs were down-graded from BI-RADS 4 to BI-RADS 3. S-Detect re-clas-sification was correct in 11 of 13 (84.6%) cases: 7/9malignant FBLs were properly up-graded from BI-RADS3 to BI-RADS 4, but 2/9 benign FBLs were erroneouslyup-graded to BI-RADS 4. All the 4 FBLs down-graded toBI-RADS 3 were benign. No differences were noted inclassification of FBLs BI-RADS 2 and 5.CONCLUSION: Our experience validated S-Detect as aneffective computer-aided decision-making tool for classifi-cation of FBLs according to BI-RADS US lexicon.

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SS 32 BR-05 10:30 Tumor growth rate during wait times for surgeryin women with breast cancers assessed by USSu Hyun Lee, Jung Min Chang, Nariya Cho, Woo Kyung Moon Seoul National University Hospital, Korea. [email protected]

PURPOSE: To evaluate tumor growth rate (TGR) duringthe wait times for surgery in women with invasive breastcancers and to identify clinicopathologic factors associat-ed with TGR.MATERIALS AND METHODS: This study was approvedby our Institutional Review Board and the requirement forwritten informed consent was waived. A retrospectivechart review in a tertiary care center identified 1580women who had breast surgery for invasive carcinomabetween August 1, 2013 and August 31, 2014. Amongthem, a total of 307 consecutive women (mean age, 53years; range, 27-81 years) with T1-2 breast cancers eligi-ble for TGR assessment by using ultrasonography (US)were included. All women underwent serial breast US atthe time of initial diagnosis and one day before surgery asa routine protocol in our hospital. The three perpendiculardiameters of tumors were measured on US images ateach time point and the maximum diameter and volumeof tumors were compared using paired samples t-test.TGR was quantified using the parameter of specificgrowth rate (SGR; %/day) and was compared with clini-copathologic variables using univariate and multivariateanalyses.RESULTS: The median time from diagnosis to surgerywas 31 days (range, 8-78 days). The maximum diameterand volume of tumors at surgery (mean, 15.8 ± 6.8 mmand 1.73 ± 2.6 cc) were significantly larger than those atdiagnosis (15.0 ± 6.5 mm and 1.47 ± 2.3 cc) (p < 0.001,both). Tumor subtype (ER-positive [n = 206], HER2-posi-tive [n = 35], and triple negative cancers [n = 66]) was theonly independent clinicopathologic factor associated withSGR on multivariate analysis (p = 0.006). Triple negativecancers showed the highest SGR (0.980 ± 1.071) fol-lowed by HER2-positive (0.550 ± 1.219) and ER-positivecancers (0.192 ± 0.995) (p < 0.001). Clinical T stage wasnot significantly changed between diagnosis and surgeryin ER- and HER2-positive cancers, however, higher Tstage at surgery was more frequent in triple negative can-cers (p = 0.027).CONCLUSION: Triple negative cancers showed thehighest TGR during the wait times for surgery and clinicalT stage can be upgraded between diagnosis and surgeryin triple negative cancers.

SS 32 BR-06 10:40 Management of clinically and mammographicallyoccult benign papillary lesions diagnosed at US-guided 14G breast core needle biopsySung Mo Moon, Hae Kyoung Jung, Kyung Hee Ko Bundang CHA General Hospital, Korea. [email protected]

PURPOSE: Our study was to determine how to manageclinically and mammographically occult benign papillarylesions diagnosed at ultrasound (US)-guided 14G breastcore needle biopsy (CNB) by evaluating their upgraderates.MATERIALS AND METHODS: Subsequent excisionalfindings (surgery or vacuum-assisted removal (VAR) withadditional ultrasonographic (US) follow-up (≥ 2 years)) orUS follow-up (≥ 2 years) were available in 75 patientswith 80 benign papillary lesions diagnosed at US-guided14G breast CNB between March 2009 February 2013.Two patients with a breast cancer history were excluded.Finally, 73 patients with 78 benign papillary lesions diag-nosed at US-guided 14G breast CNB (69 benign papillo-mas (BPs) in 64 patients and 9 atypical papillomas (APs)in 9 patients) were included in this study. We analyzedtheir upgrade rates using excisional findings or US follow-up results with no change at 2 years as the referencestandard. Association with patient age, lesion size, lesiondistance from the nipple, multiplicity, and imaging-histo-logic concordance for upgrade of BPs was examinedusing logistic regression statistics.RESULTS: Surgical excision was performed in 53(67.9%) of 78 lesions and revealed 5 upgrades (11.4%)to APs in 44 BPs and 2 (22.2%) upgrades to ductal carci-noma in situ in 9 APs. Among 12 (15.4%) BPs removedby vacuum-assisted device and US followed up (≥ 2years), 1 (8.3%) was upgraded to AP. The remaining 13(16.7%) BPs were US followed up and were stable at the2 year follow-up period. Patient age, lesion size, distancefrom a nipple, multiplicity and imaging-histologic concor-dance were not associated with upgrade of incidentalBPs diagnosed at US-guided 14G breast CNB.CONCLUSION: Clinically and mammographically occultBPs diagnosed at US-guided 14G breast CNB were notassociated with malignancy. They may be managed byclose US follow-up or VAR with additional US follow-upinstead of immediate surgical excision. Incidental APsdiagnosed at US-guided 14G breast CNB should be sur-gically excised due to the high upgrade rate to malignan-cy (22.2%).

SS 32 BR-07 10:50 US features and characteristics of minimal size(≤≤ 5 mm) breast cancerJin Chung, Eun Suk Cha, Jee Eun Lee, Jeoung Hyun Kim Ewha Womans University Mokdong Hospital, Korea. [email protected]

PURPOSE: To investigate ultrasonographic (US) fea-tures and clinical characteristics of minimal size (≤ 5mm, Tis, Tmi, T1a) breast cancer.MATERIALS AND METHODS: Of 824 breast cancerpatients, 59 patients (7.2%) had minimal size breast can-

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cers (n = 67). Among them, 42 lesions were multifocallesions. Clinical characteristics were evaluated with com-paring primary group and multifocal group. We also eval-uate US features according to the BI-RADS US lexicon,for two groups.RESULTS: In 67 lesions, DCIS were 13 lesions and 54lesions were invasive breast cancers (including 2 microin-vasive cancers). Mean size of cancer was 3.54 mm.There was no size and age difference between primarygroup and multifocal group. The most of multifocal groupwas invasive breast cancer, except one DCIS. The mostcommon features of minimal size breast cancer showedirregular shape, parallel orientation, microlobulated mar-gin, hypo/isoecho, no posterior enhancement and mini-mal vascularity. The most common final assessment wascategory 4a. Axillary node positive was more frequent inmultifocal group (23.8% vs. 12%).CONCLUSION: Minimal size breast cancer showed dif-ferent US findings. Although the small size, if breast masson ultrasound shows irregular shape, microlobulated mar-gin and vascularity, biopsy may be required.

SS 32 BR-08 11:00 Interval cancer rate at combined mammographyand breast US screeningSung Eun Song, Nariya Cho, Jung Min Chang, Ann Yi, Min Sun Bae, Su Hyun Lee, Woo Kyung Moon Seoul National University Hospital, Korea. [email protected]

PURPOSE: One of the most important surrogate indica-tors of the effectiveness of breast screening program isthe interval cancer rate. Previous research had focusedon interval cancer rate of mammography screening.Thus, we aimed to investigate the interval cancer rate ofcombined mammography and breast ultrasonography(US) screening.MATERIALS AND METHODS: Between 2011 and 2012,19004 consecutive women underwent 20907 combinedscreening mammography and physician-performed USexaminations including 19680 prevalent and 1227 inci-dent examinations in our institution. Cancer detectionrate, interval cancer rate, positive predictive value3(PPV3), and recall rate were calculated. Clinicopathologicfeatures of detected cancers and interval cancers wererecorded and differences were analyzed according to theage and mammographic density.RESULTS: Cancer detection rate was 3.11/1000 in allexaminations: 3.28/1000 in women < 50 years and3.01/1000 in women ≥ 50 years (p = 1.000): 2.68/1000in women with non-dense breasts and 3.31/1000 inwomen with dense breasts (p = 0.504). Interval cancerrate was 0.72/1000 negative screens: 1.91/1000 inwomen < 50 years and 0.08 /1000 in women ≥ 50 years(p < 0.001): 0.16/1000 in women with non-dense breastsand 1.00/1000 in women with dense breasts (p = 0.074).PPV3 was 13.56% (65/479) and recall rate was 13.13%(2745/20907). Compared with screen-detected cancers,interval cancers were significantly associated withyounger age (p < 0.001), palpable symptom (p < 0.001),premenopausal state (p = 0.001) and family history ofbreast cancer (p = 0.002). No differences were found in

personal history of breast cancer, hormone therapy, histo-logic grade, tumor stage, LN metastasis, Ki-67, cancersubtypes, mammographic density and presentation (p >0.05).CONCLUSION: Given the acceptable cancer detectionrate, low interval cancer rate, PPV3, and recall rate, com-bined mammography and US screening was an effectivescreening program. However, close attention should bepaid to premenopausal women younger than 50 yearsdue to their higher interval cancer rate.

SS 32 BR-09 11:10 Superb microvascular imaging in evaluation ofsolid breast masses: can it improve thediagnostic performance for the differentiation ofbenign and malignant breast masses?Ah Young Park1, Bo Kyoung Seo1, Kyu Ran Cho2,Ok Hee Woo3, Kyoonsoon Jung4, Jaehyung Cha1

1Korea University Ansan Hospital, 2Korea UniversityAnam Hospital, 3Korea University Guro Hospital,4Hallym University Sacred Heart Hospital, Korea. [email protected]

PURPOSE: To evaluate the utility of Superb Microvascul-ar Imaging (SMI) for evaluation of solid breast masses bycomparing with color and power Doppler imaging.MATERIALS AND METHODS: Between February 2014and March 2015, consecutive 169 patients with 191 sus-picious solid breast masses underwent US-guided coreneedle biopsy and performed color Doppler (CDI), powerDoppler (PDI) and SMI before the procedure. Three radi-ologists retrospectively analyzed number, distribution(peripheral, central, or both), and morphology (dot, linear,branching or tortuous/penetrating) of vessels within themasses, and assessed BI-RADS categories on B-modeimaging and each vascular imaging. Interobserver vari-ability in vascular imaging analyses was evaluated withintraclass correlation and vascular imaging findings werecompared among three modalities with Kruskal-Wallistest. Finally, diagnostic performance for differentiationbetween benign and malignant masses was comparedbetween B-mode imaging only and combined use of B-mode with each vascular imaging modality using receiveroperating characteristic (ROC) curve analysis.RESULTS: Ninety-two lesions were malignant and 99were benign. Interobserver variability in assessment ofBI-RADS categories and vascular imaging analyses wasexcellent with range of intraclass correlation coefficients,0.86-0.98. SMI depicted more number of vessels andmore frequent central or both distribution and branchingor tortuous/penetrating morphology, compared with CDIand PDI (p < 0.0001). The area under the ROC curve(AUC) in combined use of B-mode with SMI (AUC =0.815) was higher than those of B-mode only (AUC =0.774), B-mode with CDI (AUC = 0.789), and B-modewith PDI (AUC = 0.791) with statistical significance (p <0.0001).CONCLUSION: SMI is superior to CDI or PDI in the sen-sitivity and characterization of vascularity in solid breastmasses. It could be a supplementary tool on B-mode USfor the differentiation between benign and malignantbreast masses.

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