This year, the main theme of the International Day of Radiology is breast imaging. To get some insight into the field, we spoke to Prof. Boris Brkljačić, professor of radiology and Vice-Dean at the University of Zagreb School of Medicine, Croatia, and Chairman of the ESR Communications and External Affairs Committee.

European Society of Radiology: Breast imaging is widely known for its role in the detection of breast cancer. Could you please briefly outline the advantages and disadvantages of the various modalities used in this regard?
Boris Brkljačić: Mammography, ultrasound and MRI are three modalities used for the detection of breast cancer. Mammography has been used for many decades, and the introduction of full flat panel digital mammography has enabled image acquisition with a lower radiation dose, and other advantages in image processing and biopsies. Mammography is used widely in breast cancer screening and has been validated through decades of screening. It is also the initial imaging method in women older than 40 and it enables the detection of microcalcifications, the early signs of ductal cancer in situ, and the majority of breast cancers, depending on the radiographic density of the breast. It can also be used to guide biopsy of microcalcifications. The denser the breasts are, the lower the sensitivity of mammography in detecting breast lesions, which is the disadvantage of mammography. The new mammographic method, digital tomosynthesis, improves the detection rate of cancer in dense breasts. Mammography exposes patients to radiation and is therefore not recommended in young women because their breasts are very radiosensitive.

Prof. Boris Brkljačić, Professor of Radiology and Vice-Dean at the University of Zagreb School of Medicine, Croatia, and Chairman of the ESR Communications and External Affairs Committee.

Ultrasound is an imaging method that provides images based on the acoustic properties of tissues. The blood flow in lesions can be analysed by colour Doppler ultrasound, and elasticity of lesions can be analysed and quantified by sonoelastography. The advantage of ultrasound is that it is completely harmless; it does not expose patients to radiation, and is an excellent method for the guidance of biopsies of all sonographically visible lesions. Ultrasound can demonstrate cancers that are not visible in mammographically dense breasts, and is the complementary imaging modality to mammography, both in diagnosis and in screening. Some U.S. states legally oblige physicians to inform women about mammographic density and advise them of additional methods of examination in dense breasts. Among many advantages in ultrasound technology are the automated whole-breast ultrasound systems that have recently been introduced to the market. The disadvantage of ultrasound is that it increases the number of false-positive findings.

Magnetic resonance imaging (MRI) of the breast has gained considerable importance over the last two decades and is used more and more in breast imaging. It is used in high-risk screening, in the detection of occult cancer with positive lymph nodes, and in the evaluation of implants, and it is the best method for detecting the presence of and assessing the distribution and extent of cancer. It can also be used to monitor the success of neoadjuvant chemotherapy, and is an excellent method for looking for residual cancer or recurrence after treatment. MRI is relatively expensive and time consuming, although abbreviated MRI protocols have recently been introduced.

For treatment planning and monitoring it is very important to know the exact type and grade of cancer, and its immunohistochemical profile. Image guided biopsy is crucial in relation to that, and all imaging methods enable precise, image-guided biopsy to obtain an adequate sample from the breast cancer and other breast lesions.
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This year, the main theme of the International Day of Radiology is breast imaging. To get some insight into the field, we spoke to Dr. Ilse Vejborg, head of radiology at the University Hospital of Copenhagen, Rigshospitalet and head of the Capital Mammography Screening programme in Denmark.

European Society of Radiology: Breast imaging is widely known for its role in the detection of breast cancer. Could you please briefly outline the advantages and disadvantages of the various modalities used in this regard?
Ilse Vejborg: Mammography is a fast examination, showing the whole breast, if performed properly. Mammography has a high sensitivity to fatty tissue but the sensitivity can be compromised in dense breasts. Ultrasonography is an important supplementary examination which should be used in diagnostic examinations of women with palpable lumps or other symptoms in the breast. In experienced hands, ultrasound is the best examination for distinguishing a solid from cystic palpable lump but often also for evaluating whether the lump looks benign or malignant. Ultrasonography offers the possibility of evaluating the blood flow (Doppler) and stiffness (elastography) in a process and can be used to perform ultrasound-guided interventions.

MR Mammography has the highest sensitivity of all the imaging modalities but a more varying specificity; the latter is probably partly explained by the fact that in contrast to mammography screening, where high volume readers reading more than 5,000 examinations a year are mandatory, high volume readers of MR mammography are rarer.

Dr. Ilse Vejborg, head of radiology at the University Hospital of Copenhagen, Rigshospitalet and head of the Capital Mammography Screening programme in Denmark.

ESR: Early detection of breast cancer is the most important issue for reducing mortality, which is one reason for large-scale screening programmes. What kind of programmes are in place in your country and where do you see the advantages and possible disadvantages?
IV: In Denmark we have nationwide, organised, population-based mammography screening. Mammography screening is offered every second year free of charge in the target age group of women aged 50–69 years. Mammography screening is the only imaging modality proven to reduce breast cancer mortality. It is a fast and inexpensive examination which can be performed without the presence of the physicians. In Denmark, all screening centres have digital mammography equipment and RIS and PACS systems.

Nationwide mammography screening in Denmark was implemented rather late compared to our Nordic neighbours and Denmark has had a higher mortality of breast cancer than the other Nordic countries. Mammography screening started in Copenhagen municipality in 1991, in the county of Fyn in 1993 and in the municipality of Frederiksberg (close to Copenhagen) in 1994. These programmes offering screening only to around 20% of the target population were for many years the only screening programmes in Denmark. Not until 2010 did we have a nationwide roll out of mammography screening.

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This year, the main theme of the International Day of Radiology is breast imaging. To get some insight into the field, we spoke to Dr. Viera Lehotská, Associate Professor and Head of the 2nd Radiology Department of the Faculty of Medicine Comenius University and St. Elizabeth’s Cancer Institute, Bratislava, Slovakia.

European Society of Radiology: Breast imaging is widely known for its role in the detection of breast cancer. Could you please briefly outline the advantages and disadvantages of the various modalities used in this regard?
Viera Lehotská: Mammography, including recent trends (e.g. tomosynthesis), is considered to be an essential, highly sensitive and representative method in the diagnostics of non-palpable breast lesions, especially those with the presence of microcalcifications. Based on this fact, mammography is generally accepted as the only proper method for active detection of breast cancer in the screening process. One disadvantage is the use of ionising radiation, and some patients might also consider the need for breast compression during imaging another disadvantage. But its contribution to the diagnosis of early stages of breast cancer significantly outweighs these limitations.

Dr. Viera Lehotská, Associate Professor and Head of the 2nd Radiology Department of the Faculty of Medicine Comenius University and St. Elizabeth’s Cancer Institute, Bratislava, Slovakia.

Ultrasound examination of the breast and the axilla serves as the main complementary method to mammography: for differentiation between cystic and solid lesions as well as for the elimination of occult lesions in dense breast glands. For younger women (under 40), pregnant women, or women during lactation, as well as for women with inflammatory breast disease or impaired mammary implants, ultrasound is used as the first choice examination method. Its benefit is not only its low cost but also its repeatability and non-risk character. Together with newer trends such as US-elastography and contrast-enhanced ultrasound (CEUS), it contributes to the assessment of lesions dignity (whether it is benign or malignant). It is very helpful in the follow-up of operated and irradiated breast and is therefore an important part of the monitoring of patients after surgery for breast cancer.

MR-mammography has strictly defined indications, which, if they are kept to, makes it a robust method. It has high sensitivity in the diagnosis of invasive breast carcinoma. Its specificity can be increased by using functional MRI methods such as diffusion-weighted imaging (DWI) and dynamic contrast-enhanced (DCE) MRI, and MR-spectroscopy. In addition, its potential is not only in the assessment of the extent of breast cancer (multiplicity, etc.) or in the assessment of early response to neoadjuvant chemotherapy, but also in its high sensitivity in high risk groups.

Interventional methods also play a very important role, whether under the MG-stereotactic, ultrasound or MR-navigation. Preoperative histologisation of breast lesions by standard vacuum-assisted biopsy or by the Intact BLES (Breast Lesion Excision System) is an indispensable part of the exact diagnosis of the character of breast lesions. Similarly, image-guided localisation techniques enable effective surgical treatment of breast cancer.

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This year, the main theme of the International Day of Radiology is breast imaging. To get some insight into the field, we spoke to Dr. Sophie Dellas, assistant professor of radiology and division head of breast imaging and diagnostics at the University Hospital Basel, Switzerland, and a core team member of the certified breast centre at the same institution.

European Society of Radiology: Breast imaging is widely known for its role in the detection of breast cancer. Could you please briefly outline the advantages and disadvantages of the various modalities used in this regard?
Sophie Dellas: Mammography is the imaging modality of choice for breast cancer screening, but also for diagnosis, evaluation, and follow-up of people who have had breast cancer. Long-term results of randomised controlled trials of mammography screening on average show a decrease in breast cancer mortality of 22% in women aged 50 to 74 years. The main problem of mammography is that it is not a perfect method. Mammography generates 2D images based on the density of tissue for penetrating x-rays. The compression of the breast that is required during a mammogram can be uncomfortable. The compression is necessary to reduce overlapping of the breast tissue. A breast cancer can be hidden in the overlapping tissue and not visible on the mammogram. This is called a false negative mammogram. Mammography is associated with a false negative rate in the order of 10% to 20%. On the other hand, mammography can identify an abnormality that looks like a cancer, but turns out to be normal. This is called a false positive mammogram. Besides worrying about being diagnosed with breast cancer, a false positive means more tests and follow-up examinations. Furthermore, at least some of the cancers found with screening mammography would never otherwise be diagnosed in a patient’s lifetime. The magnitude of such overdiagnosis is a topic of much debate. It is likely to represent up to 10% of breast cancers found on screening mammography and results in potentially unnecessary treatments.

Dr. Sophie Dellas, assistant professor of radiology and division head of breast imaging and diagnostics at the University Hospital Basel, Switzerland.

Breast ultrasound is complementary to both mammography and magnetic resonance imaging (MRI) of the breast. It does not use radiation. It is therefore the initial diagnostic method of choice if breast imaging is required below the age of 40. It allows the confident characterisation of not only benign cysts but also benign and malignant solid masses and the characterisation of palpable abnormalities. The high spatial and contrast resolution of modern breast ultrasound equipment allows the detection of subtle lesions at the size of terminal duct lobular units such as DCIS and small invasive cancers. In women with dense breasts and a negative mammogram, ultrasound therefore is increasingly used as a supplemental screening tool. The major disadvantage of ultrasound as a screening tool is the high risk of false positive findings resulting in unnecessary biopsies. The rate of false positives is much higher with screening ultrasound than with mammography or screening MRI.

Unlike mammography, MRI of the breast does not use radiation. It is safe even though it does require an intravenous injection of a contrast medium. It has a sensitivity exceeding 90% for detecting breast cancer and is superior to mammography and ultrasound. Annual MRI screening is recommended for women with a high lifetime risk of getting breast cancer. Although breast MR imaging is extremely sensitive, its specificity is limited, leading to additional workups and benign biopsies. Good quality breast MR imaging is expensive, time-consuming, and not universally available. Patients with pacemakers, certain aneurysm clips or other metallic hardware, an allergy to contrast agents, or severe claustrophobia are unable to undergo MR imaging.

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B-0951 Comparison of contrast-enhanced dual-energy mammography (CEDEM) with contrast-enhanced magnetic resonance imaging (CE-MRI) in breast lesions: a prototype report

T. Knogler, R. Leithner, M. Hörnig, M. Waitzbauer, F. Semturs, G. Langs, P. Homolka, K. Pinker-Domenig, T.H. Helbich | Monday, March 11, 14:00 – 15:30 / Room F1

Purpose: To test the feasibility of CEDEM, by comparing its results with CE-MRI in breast lesions.
Methods and Materials: Fifteen female patients with 15 breast lesions were included in this study. CEDEM was performed with a Mammomat Inspiration prototype (Siemens, Germany) before and after i.v. administration of 2 ml Iomeron® 400 (Bracco, Italy) per kg b.w. at a rate of 3.5ml/sec. The same lesions were assessed with CE-MRI (Tim Trio, Siemens, Erlangen, Germany) using a standard protocol and the administration of 0.2mmol Dotarem® (Guerbet, France) per kg b.w. Images of both modalities were assessed by two readers with respect to morphology and enhancement characteristics. A histological work-up was performed in all lesions.
Results: Histopathology revealed eight malignant and seven benign lesions (size range from 8 to 38mm). Morphology and enhancement characteristics were similar and comparable with both techniques. All malignant lesions showed strong contrast uptake and suspicious morphologic signs, whereas benign lesions tend to enhance less strong on both techniques. Based on the morphologic and enhancement characteristics CEDEM and CE-MRI allowed accurate differentiation of benign and malignant breast lesions.
Conclusion: CEDEM allows adequate differentiation of benign and malignant breast lesions using morphologic and enhancement characteristics. CEDEM imaging features are comparable to those of CE-MRI. CEDEM offers a feasible and low cost alternative to CE-MRI in breast lesions.

B-0950 Clinical feasibility of contrast-enhanced dual-energy mammography (CEDEM) with a tungsten (W)/titanium (Ti) anode/filter combination: a prototype report

T. Knogler, R. Leithner, M. Hörnig, F. Semturs, M. Waitzbauer, G. Langs, P. Homolka, K. Pinker-Domenig, T.H. Helbich | Monday, March 11, 14:00 – 15:30 / Room F1

Purpose: To test the feasibility of CEDEM with a W/Ti anode/filter combination for high energy images in a clinical setting.
Methods and Materials: Fifteen female patients with 15 breast lesions were included in this study. CEDEM was performed with a Mammomat Inspiration prototype (Siemens, Germany) before and after i.v. administration of 2-ml Iomeron® 400 (Bracco, Italy) per kg b.w. at a rate of 3.5ml/sec. Dual-energy images were acquired with 28-32kVp and a W/Rhodium (Rh) anode/filter combination for low-energy and 49 kVp and a W/Ti anode filter combination for high energy. Weighted subtraction images were computed for diagnostic work-up. Images were assessed by two readers with respect to lesion-enhancement and image quality. A histological work-up was performed in all lesions.
Results: Histopathology revealed eight malignant lesions and seven benign lesions (size range from 8 to 38mm). All malignant lesions enhanced and were seen from both readers on weighted subtraction images. Benign lesions did not enhance thus they were not visualised on weighted subtraction images. Image quality was rated excellent from both readers. Based on the visibility of the lesion CEDEM allowed an accurate differentiation of benign and malignant breast lesions.
Conclusion: CEDEM with a W/Ti anode/filter combination is suitable and feasible. Lesion visibility and image quality were excellent. Further research is needed to determine the value of CEDEM in a clinical setting.

B-0962 First experiences with a self-test for Dutch breast screening radiologists as a quality assurance tool

J. Timmers, A. Verbeek, R. Pijnappel, M. Broeders, G. den Heeten | Monday, March 11, 14:00 – 15:30 / Room F2

Purpose: To evaluate the use of a self-test as a quality assurance tool for screening radiologists in the Dutch breast cancer screening programme.
Methods and Materials: 144 screening radiologists were invited to voluntarily complete a test set of 60 screening mammograms. The following grading criteria were assigned regarding the most suspicious lesion: location, level of suspicion, BI-RADS, laterality, type (well defined mass, ill defined mass, spiculated mass, microcalcification clusters, architectural distortion and asymmetric density) and mammographic density are assigned. Also, several reader characteristics, such as years of experience and number of cases read per year, were to be completed. Case and lesion sensitivity and specificity were determined for all readers. The spearman correlation coefficient was used to determine correlation between reader characteristics and performance measured by the area under the receiver operator characteristics (ROC) curve (AUC).
Results: 112 radiologists completed the test set (78%). The mean age was 49 (range 33-68) and on radiologists read on average 10,000 (range 700-60,000) screening mammograms per year. The median AUC value was 0.91, case sensitivity 91 %, lesion sensitivity was 91 % and specificity 94 %. The AUC was not correlated to reader characteristics. The test-set revealed interobserver variation in assigning lesion types.
Conclusion: Overall, a good performance was seen among all screening radiologists. Readers are able to determine their educational needs and compare it with peers during training or audits. It is therefore a useful quality assurance tool. Medical education should be dedicated to reducing interobserver variation.

B-0687 Does the adjunct of digital breast tomosynthesis (DBT) increase inter-reader reproducibility of two-dimensional digital mammography (2D-DM)?

G. Di Leo, L.A. Carbonaro, M. Bazzocchi, V. Londero, A. Dal Col, R.M. Trimboli, F. Sardanelli | Sunday, March 10, 10:30 – 12:00 / Room F2

Purpose: To estimate the inter-reader reproducibility of DBT added to 2D-DM in comparison to that of 2D-DM alone.
Methods and Materials: A series of 65 breasts (65 women, aged 58±9 years) underwent DBT (Giotto, IMS, Italy) as an adjunct to 2D-DM. After an agreement on how to report 2D-DM and DBT, 3 independent readers (R1, R2, R3) with >6 years of experience in 2D-DM and >1 year of experience in DBT evaluated all studies. Each reader evaluated the breast density and assigned a BI-RADS score using only 2D-DM. After 30 days, they repeated the evaluation adding DBT to 2D-DM. The inter-reader reproducibility was estimated using the quadratically weighted Cohen’s kappa.
Results: The breast density reported at 2D-DM by the most experienced reader was: 75 % in 1 (1%). Considering the B1, B2, B3, B4, and B5 BI-RADS scores, the same reader assigned the followings: 25, 0, 10, 20, and 10 using 2D-DM; 31, 1, 7, 13, and 13 using 2D-DM plus DBT. For each pair of readers, 2D-DM plus DBT resulted in a higher inter-reader reproducibility than that of 2D-DM alone: kappa value for 2D-DM ranged from 0.418 to 0.566 while that for 2D-DM plus DBT ranged from 0.656 to 0.758.
Conclusion: While the inter-reader reproducibility of 2D-DM resulted only moderate, the adjunction of DBT allowed to reach a substantial reproducibility. The use of DBT added to 2D-DM can reduce inter-reader variability and allow for more reliable readings from different radiologists.

B-0816 Breast tomosynthesis versus digital mammography: evaluation of diagnostic potential in women with abnormal screening mammograms

M. Mohamed Aly | Monday, March 11, 10:30 – 12:00 / Room F2

Purpose: To compare the diagnostic potential of digital mammography with tomosynthesis.
Methods and Materials: 100 women with abnormal screening mammograms,187 findings, and definite imaging or histopathological diagnosis were included. The screening mammography interpretation consisted of direct comparison of the tomosynthesis (DBT) examination with full field digital mammography (FFDM) images. The study radiologists subjectively rated the equivalence of the image quality of both the DBT and the FFDM examinations with no use of additional mammography, magnification views or comparison mammography. The next step was categorising the findings in both FFDM and DBT separately according to BIRADS classification and the statistical analysis evaluated the p values of DBT and FFDM as well as their sensitivities.
Results :All findings categorised as BIRADS 3 according to mammography showed reduction in number,particularly for masses, when examined with tomosynthesis. The image quality of tomosynthesis was subjectively rated as equivalent (53.5%) or superior (43.3%) to digital mammography in 96.8% of the total of findings; the test was highly significant (p <0.001). For masses, tomosynthesis image quality was rated as equivalent in 40.5% or superior in 58.1% of findings. Masses were 53 % of findings in which tomosynthesis had superior image quality. The FFDM Sensitivity was of 91.9 % compared with 95.2% for DBT.
Conclusion: The diagnostic potential of digital breast tomosynthesis is superior to that of full-field digital mammography by evaluating their image quality and their sensitivity. Based on a subjective analysis, DBT showed a significantly higher image quality compared with digital mammography in all finding types, especially in the characterisation of masses.

A-508 Clinical aspects of computer aided detection and diagnosis in DBT

H.-P. Chan | Sunday, March 10, 16:00 – 17:30 / Room F2

Digital breast tomosynthesis (DBT) can potentially increase the sensitivity and reduce recall rate in breast cancer screening. However, the chance of oversight may not be negligible because of the very large search space (~50-80 slices per view) and the increased workload and possibly fatigue to the radiologists. CAD has been shown to reduce radiologists’ false negatives in screening mammography. It can be expected that CAD may be useful for DBT interpretation. DBT in clinical use is still at an early stage. Although the impact of CAD on DBT interpretation has not been reported, some important issues associated with CAD use can be expected based on the experiences in screening mammography. In this talk, the potential usefulness of CAD in DBT and the issues as observed from the reported prospective studies of CAD use in the clinic will be discussed, including the potential impact of off-label use (i.e., CAD systems approved as second reader used as concurrent or first reader), user training, and quality assurance of CAD performance. Because of the increased reading time for DBT, there will be an even stronger tendency that radiologists may want to use CAD as a concurrent or even first reader to improve workflow. To have a CAD system for such intended use, much more stringent requirements for the standalone performance of the CAD system and properly designed studies to evaluate its impact as a concurrent or first reader should be required before the CAD system can be approved for clinical use with DBT.