European Radiology: How to reduce the rate of benign biopsies of breast BI-RADS 4A lesions?

Currently, breast cancer is one of the most common cancers in women and the leading cause of cancer-related deaths in women (accounting for 25% of all cancer deaths in women).

Digital mammography (DM) and digital breast tomography (DBT) have been widely used in breast cancer screening and diagnosis to reduce breast cancer mortality and improve prognosis
.
According to the Breast Imaging-Reporting and Data System (BI-RADS), Category 4 covers a wide range of malignant potentials, ranging from 2 to 95%, further subdivided into 4A, 4B, and 4C
.
However, the risk of malignancy for Class 4A lesions is low (only 2% to 10%), and these lesions are mostly benign, resulting in a lot of unnecessary biopsies
.

Traditionally, dynamic contrast-enhanced MRI (DCE-MRI) has been the most sensitive test
for detecting breast cancer.
However, MRI is expensive and takes a long time to examine, so it cannot be widely used in clinical practice
.
Contrast-enhanced mammography (CEM) is a new imaging technique developed in recent years to assess morphology and angiogenesis
associated with breast cancer.
Previous studies have shown that CEM has diagnostic performance comparable to MRI in diagnosing breast cancer, and even more specific.

Until now, however, there is no BI-RADS dictionary
dedicated to CEM.
The Kaiser score (KS) is a machine learning clinical decision rule that combines MRI BI-RADS features to provide diagnostic scoring of enhanced lesions Indicates the possibility of
malignancy.
KS values range from 1 to 11, with a biopsy
greater than 4.

Recently, a study published in the journal European Radiology explored the diagnostic performance of CEM combined with KS in DBT BI-RADS 4A lesions, providing technical support
for reducing unnecessary breast biopsies.

This retrospective study evaluated 109 DBT BI-RADS 4A lesions
in 106 patients from June 2019 to June 2021 。 For lesions without enhancement on CEM, they were downgraded to BI-RADS 3; for lesions with enhancement, the reader was asked to classify
all enhancement lesions on breast MRI with reference to KS.
Diagnostic performance
was assessed using subject operating specificity (ROC) curve analysis.
Two readers scored all cases and assessed readership through Cohen's kappa coefficient
.

There were 95 benign lesions and 14 malignant lesions
.
The accuracy of CEM combined with KS is expressed in terms of the area under the curve (AUC), which is between
0.
880 and 0.
906.
The use of KS improved performance with a significant statistical difference (P < 0.
001)
compared to a single BI-RADES or US.
CEM using KS had higher specificity (p < 0.
001) than CEM using BI-RADS or US, while there was no difference in sensitivity (p > 0.
05).

CEM combined with KS avoided 72 (75.
8%) to 78 (82.
1%) unnecessary benign biopsies of 95 benign lesions previously classified by DBT as BI-RADS 4A
.
There was a high degree of agreement among KS readers (kappa: 0.
727).

A 53-year-old patient with a mass (a) on the DBT is classified as BI-RADS 4A
.
CEM (early and late recombination images of b, c) shows a ring-shaped mass with enhanced internal heterogeneity, manifested as a continuous curve corresponding to KS of 1
.
Histopathology shows fibroadenoma

This study suggests that CEM combined with KS can be used for the reclassification of DBT BI-RADS 4A lesions, providing evidence to
reduce unnecessary benign biopsies.

Original source:

Xiaocui Rong,Yihe Kang,Jing Xue,et al.
Value of contrast-enhanced mammography combined with the Kaiser score for clinical decision-making regarding tomosynthesis BI-RADS 4A lesions.
DOI:10.
1007/s00330-022-08810-7.