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28 February 2024, Volume 33 Issue 1
    

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  • CACA Guidelines for Holistic Integrative Management of Cancer: interpretation of the new mammography technology in X-rays examination
    YOU Chao , GU Yajia
    ZHONGLIU YINGXIANGXUE. 2024, 33(1): 1-5. https://doi.org/10.19732/j.cnki.2096-6210.2024.01.001
    Abstract ( ) Download PDF ( )   Knowledge map   Save
    The Oncology Imaging Professional Committee of the China Anti-Cancer Association organized experts to write the CACA Guidelines for Holistic Integrative Management of Cancer · X-rays Examination in 2023. The CACA guidelines emphasized that mammography has been proven to be the only imaging examination for detecting the early breast cancer and reducing the patients’ mortality. The new technologies of mammography, as its derivative methods, make up for the deficiency of traditional mammography to a certain extent, especially for Chinese women with dense breast. According to the guidelines, this paper introduced the core contents of the new technologies of mammography, which could provide an effective principle in the clinic.
  • Research progress of ultrasound radiomics based on artificial intelligence in the diagnosis and treatment of breast cancer 
    HUANG Yini , ZHOU Jianhua
    ZHONGLIU YINGXIANGXUE. 2024, 33(1): 6-12. https://doi.org/10.19732/j.cnki.2096-6210.2024.01.002
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    Accurate diagnosis and treatment of breast cancer significantly improve patient outcomes. Ultrasound is commonly used in the screening, diagnosis, and evaluation of therapeutic effects in breast cancer. Ultrasound radiomics uses high-throughput methods to extract numerous features from ultrasound images, reflecting the microscopic changes and biological behavior of the tumors. Ultrasound radiomics models based on artificial intelligence are gradually developed and applied in the diagnosis and treatment evaluation of breast cancer, aiming to facilitate the precise diagnosis and treatment of breast cancer. This article briefly introduced the research progress of ultrasound imaging based on artificial intelligence in breast cancer screening and diagnosis, molecular classification, axillary lymph node metastasis assessment, and neoadjuvant treatment efficacy assessment, summarized the limitations, challenges and the future development direction of the application of this technology.

  • The second edition of ultrasound BI-RADS published for a decade: retrospection and prospect
    WEI Minyan, ZHOU Jianqiao
    ZHONGLIU YINGXIANGXUE. 2024, 33(1): 13-19. https://doi.org/10.19732/j.cnki.2096-6210.2024.01.003
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    Since the American College of Radiology published the second edition of the Breast Imaging Reporting and Data System (BI-RADS) in 2013, both the clinical practice and scientific research of breast ultrasound have greatly benefited. This article summarized the clinical applications and innovations, existing issues and challenges, as well as future development opportunities of breast ultrasound imaging technology in the ten years since the publication of the second edition of Ultrasound BI-RADS in 2013. The aim was to provide valuable insights and assistance for clinical diagnosis and treatment, guideline promotion, and application.
  • The value of magnetic resonance imaging features in predicting 21-gene recurrence score of ER + /HER2 - breast
    CHEN Yang, TANG Wei, GU Yajia, PENG Weijun
    ZHONGLIU YINGXIANGXUE. 2024, 33(1): 20-30. https://doi.org/10.19732/j.cnki.2096-6210.2024.01.004
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    Objective: To explore the association between magnetic resonance imaging (MRI) features and the 21-gene recurrence score (RS), and to establish RS prediction models. Methods: Clinical and imaging data of estrogen receptor (ER) + / human epidermal growth factor receptor 2 (HER2) - breast cancer patients who underwent 21-gene expression assay in Fudan University Shanghai Cancer Center from April 2017 to March 2019 were collected. The patients who underwent preoperative breast MRI were selected. MRI images were evaluated according to the 2013 version of Breast Imaging Reporting and Data System lexicon. The univariate analyses were used to compare differences in MRI imaging features between the high-risk group (RS≥26) and the low-risk group (RS＜26) and multivariate logistic regression was used to construct a model. The patients were divided into the training group and the validation group in a 7∶3 ratio. Pearson correlation coefficient screening method and recursive feature elimination method were used for feature screening, the synthetic minority oversampling technique was used for balancing the training dataset, four different machine learning algorithms (linear support vector machine, random forest, decision tree and K-nearest neighbor) were used to construct the models, and the model performance was evaluated by receiver operating characteristic (ROC) curve. Results: A total of 159 patients were enrolled, with 58 in the low-risk group and 101 in the high-risk group. In clinical characteristics, progesterone receptor (PR) status showed difference (P=0.017), and the proportion of patients with positive PR expression was higher in the low- risk group than in the high-risk group. In the MRI characteristics, the distribution of tumor margins showed difference between groups (P=0.008). The tumors in the low-risk group were mostly characterized by spiculated margins (64.8%), and the tumors in the high-risk group were mostly characterized by irregular margins (54.7%). Incorporating PR status and tumor margin into the multivariate logistic regression model, PR positive patients had a lower risk of recurrence than PR negative patients, with an OR value of 0.110 (P=0.038); the recurrence risk of spiculated margins was relatively lower than that of irregular margins, with an OR value of 0.343 (P=0.004). The area under curve (AUC) was 0.667. The calibration curve and decision curve indicated that the model had good calibration performance and certain clinical practicability. 111 patients were included in the training group (34 in low- risk group and 77 in high-risk group) and 48 patients were included in the validation group (24 in low-risk group and 24 in high-risk group). The AUC range of the four machine learning models was 0.64-0.69, and the AUCs of support vector machine and random forest models were relatively higher. Conclusion: Breast MRI features have a potential role in assessing the recurrence risk of ER + / HER -  breast cancer patients.
  • Development of a nomogram for differentiation between pure mucinous breast carcinomas and fibroadenomas based on DCE-MRI features 
    QU Ning, LUO Yahong
    ZHONGLIU YINGXIANGXUE. 2024, 33(1): 31-38. https://doi.org/10.19732/j.cnki.2096-6210.2024.01.005
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    Objective: To develop a nomogram to differentiate pure mucinous breast carcinoma (PMBC) from fibroadenoma (FA) with high signal intensity on T2-weighted imaging (T2WI) based on dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) features, in order to improve the accuracy of differential diagnosis between them. Methods: DCE-MRI features of 64 PMBC lesions and 137 FA lesions with T2WI were analyzed retrospectively. The Breast Imaging Reporting and Data System (BI-RADS) classification from the original report was recorded. DCE-MRI features with statistical difference in univariate analysis were included in multivariate logistic regression analysis to develop DCE-MRI nomogram. Area under curve (AUC), sensitivity, specificity, accuracy, positive predictive value (PPV) and negative predictive value (NPV) of receiver operating characteristic (ROC) curve were used to evaluate DCE-MRI nomogram. The calibration curves were drawn to show the consistency between the predictive value and the true value. Decision curve analysis (DCA) was conducted to determine the clinical usefulness of DCE-MRI nomogram. Results: Sensitivity, specificity, accuracy, PPV and NPV calculated according to the BI-RADS classification from the original report were 76.56%, 73.00%, 74.13%, 56.98% and 86.96%, respectively. Multivariate analysis showed that age, margin, delayed enhancement pattern, enhancing internal septation and extent of lobulation were independent predictors for differentiating PMBC from FA. AUC, sensitivity, specificity, accuracy, PPV and NPV of DCE-MRI nomogram were 96.24%, 87.50%, 94.89%, 92.54%, 88.89% and 94.20%, respectively. According to the calibration curve, the predicted and true values showed good consistency. Based on decision curve analysis, the net benefit of using DCE-MRI nomogram to differentiate PMBC from FA was greater than treat-all or treat-none scheme. Conclusion: The nomogram based on DCE-MRI features for differentiation between PMBC and FA was superior to the BI-RADS classification from the original report and improved the accuracy of differential diagnosis of PMBC and FA.
  • Prediction value of breast MRI in ipsilateral breast tumor recurrence after breast-conserving surgery and distant metastasis following secondary surgery
    LI Jinhui , QU Feilin , YOU Chao , GU Yajia , PENG Weijun
    ZHONGLIU YINGXIANGXUE. 2024, 33(1): 39-48. https://doi.org/10.19732/j.cnki.2096-6210.2024.01.006
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    Objective: To examine the prognostic value of magnetic resonance imaging (MRI) characteristics for ipsilateral breast tumor recurrence (IBTR) patients following breast-conserving surgery (BCS) and the risk of distant metastasis following secondary surgery in patients with IBTR. Methods: A retrospective analysis was conducted on 6 807 breast cancer patients who underwent BCS in Fudan University Shanghai Cancer Center between January 2010 and December 2018. Among them, 67 cases experienced IBTR and underwent preoperative MRI examination at our institution. Using a 1∶2 ratio, they were matched with 134 control patients without recurrence based on age, clinical stage, and fibro glandular density. Univariate analysis was used to compare the MRI characteristics and clinical pathological data of the two groups. Multivariate logistic regression was performed to identify independent factors for IBTR. Furthermore, among the 67 patients with IBTR, 47 patients underwent secondary surgery and had MR images of the recurrent tumor. The median follow-up time was 22.0 months (range from 1.9 to 101.1 months), with 15 cases developing distant metastasis and 32 cases without distant metastasis. Univariate and multivariate Cox regression analyses were conducted to determine independent predictive factors associated with distant metastasis following secondary surgery. Results: Univariate analysis revealed a significant association between histological grade, negative margin distance, molecular subtype, receipt of postoperative adjuvant radiotherapy, background parenchymal enhancement (BPE), lesion enhancement type, suspicion of involvement of the nipple skin on preoperative MRI, and postoperative IBTR (P＜0.05). Additionally, multivariate logistic regression analysis demonstrated that high BPE, non-mass lesions, nipple or skin thickening with indentation, molecular subtypes of human epidermal growth factor receptor 2 (HER2) + and triple-negative breast cancer, as well as not receiving radiotherapy after surgery, were independent risk factors for IBTR. Among the 47 patients who underwent secondary surgery and had MRI images of the recurrent tumor, univariate and multivariate Cox regression analysis indicated that negative HER2 status and high BPE levels on preoperative MRI were associated with a higher risk of distant metastasis after secondary surgery. Conclusion: Preoperative MRI provides valuable assistance in the auxiliary clinical management and prognostic prediction of patients undergoing breast-conserving surgery and experiencing IBTR. High BPE, non-mass lesions, and nipple or skin thickening with indentation on preoperative MRI indicate a high risk of local recurrence after breast-conserving surgery. In addition, high BPE on MRI of recurrent lesions is associated with the occurrence of distant metastasis after secondary surgery.
  • Diagnostic value of ultrasound-assisted mammography in dense breast screening
    CHEN Jing , WU Rong , DIAO Xuehong , HE Zhiyan , YAO Minghua , LI Chunxiao , SHAO Sihui
    ZHONGLIU YINGXIANGXUE. 2024, 33(1): 49-56. https://doi.org/10.19732/j.cnki.2096-6210.2024.01.007
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    Objective: To analyze the diagnostic value of ultrasound-assisted mammography in dense breast screening. Methods: A retrospective analysis of 1 096 patients with dense breast masses, who underwent both conventional ultrasound and mammography in Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine from January 2013 to August 2019. According to age, tumor size and with or without calcification, the patients were divided into several groups. Taking the pathological results as the gold standard, the influence of combined examination on the classification of Breast Imaging Reporting and Data System (BI-RADS) versus mammography was discussed. At the same time, area under curve (AUC), malignant detection rate, sensitivity, and specificity of mammography alone and mammography combined with conventional ultrasound in the diagnosis of dense breast masses were obtained and compared. Results: The increased rate of breast cancer in BI-RADS 0 and 1-3 categories by combined examination were 14.8% and 15.1%, respectively. The AUCs of mammography and mammography combined with conventional ultrasound in the diagnosis of dense breast mass were 0.774 and 0.937 (Z=13.757, P＜0.001), respectively. Regardless of the dense breast masses with different age groups, different size groups and groups with or without calcification, AUC of mammography combined with conventional ultrasound was significantly higher than that of mammography alone, and the differences were statistically significant (P＜0.05). The sensitivity of mammography alone and mammography combined with conventional ultrasound were 65.6% and 93.3% (χ 2 = 54.955, P＜0.001); the specificity were 89.3% and 94.1% (χ 2 =353.013, P＜0.001); the detection rate of breast cancer increased from 24.3% (266/1 096) to 34.6% (379/1 096, χ 2 = 293.450, P＜0.001). In different age groups, different size groups and groups with or without calcification, the sensitivity and specificity of mammography combined with conventional ultrasound in the diagnosis of dense breast mass were significantly higher than mammography, with statistical significance (P＜0.05). Conclusion: Compared with mammography alone, ultrasound-assisted mammography can improve the detection rate of malignant tumors in patients with dense mammary glands. In particular, ultrasound-assisted mammography is of great significance for breast cancer screening in people with dense breast, whose age over 55 years or whose mass diameter ＜2 cm.

  • Ultrasonic features of different molecular subtypes of breast cancer in young women 
    DU Wenna, DONG Weilu, CAI Ting, WU Yiyun
    ZHONGLIU YINGXIANGXUE. 2024, 33(1): 57-61. https://doi.org/10.19732/j.cnki.2096-6210.2024.01.008
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    Objective: To investigate ultrasound sonographic characteristics of different molecular subtypes of breast cancer in young women under the age of 40 years. Methods: A retrospective analysis of 60 young patients diagnosed in The Affiliated Hospital of Nanjing University of Chinese Medicine from January 2019 to May 2023 was conducted, who had received breast ultrasound examination and breast cancer resection, then they were pathologically confirmed as breast cancer after surgery. The cases were divided into type Luminal A, type Luminal B, triple-negative type and human epidermal growth factor receptor 2 (HER2) overexpression type according to immunohistochemistry. The ultrasound characteristics of different subtypes in the maximum diameter, the orientation, the aspect ratio, the shape, the boundary, marginal spiculate, internal echo, calcification, posterior echo, the blood flow grade, and the elastic score of the mass were analyzed. Results: In 60 breast cancer cases, Luminal A type was relatively common (40.0%), while the HER2 overexpression type was the rarest (15.0%). Among different molecular subtypes, the differences in the marginal burr, calcification and posterior echo of the mass were statistically significant (P＜0.05), among which the Luminal A type and Luminal B type mainly showed marginal spiculate (79.2%, 55.3%), the triple-negative type mainly showed enhancement or with no change (91.7%), and HER2 overexpression type mainly showed calcification (88.9%). However, there was no statistical significance in the maximum diameter, the orientation, the aspect ratio, the shape, the boundary, internal echo, the blood flow grade, and the elasticity score of the mass (P＞0.05). Conclusion: The ultrasound sonographic characteristics of young female patients with breast cancer are associated with their molecular subtypes, which can provide a valuable reference for predicting the molecular subtypes of breast cancers before a surgery.
  • The value of ultrasound elastography combined with UGCNB in the diagnosis of breast lesions
    ZHONG Liping, HUANG Xuemei, WANG Shuyu, XU Qin
    ZHONGLIU YINGXIANGXUE. 2024, 33(1): 62-68. https://doi.org/10.19732/j.cnki.2096-6210.2024.01.009
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    Objective: To investigate the value of ultrasound elastography (UE) combined with ultrasound-guided core needle biopsy (UGCNB) in the diagnosis of benign and malignant breast lesions, and the consistency with postoperative pathological findings. Methods: A total of 98 patients with suspected breast cancer from October 2020 to October 2022 were selected and examined by UE and UGCNB, and the postoperative pathological findings were used as the “gold standard”. The quantitative parameters of UE ［strain ratio (SR) and area ratio (AR)］ were compared between benign breast tumors and breast cancer patients, and the correlation between quantitative parameters of UE and clinical characteristics of breast cancer was analyzed. The receiver operating characteristic (ROC) curve was used to analyze the value of UE quantitative parameters in diagnosing the benign and malignant breast lesions, and to analyze the consistency of UE and UGCNB alone and in combination with postoperative pathological findings. Results: In 98 cases of suspected breast cancer, 53 cases of breast cancer were detected by postoperative pathology, 46 cases of breast cancer were detected by UE, and 50 cases of breast cancer were detected by UGCNB. SR and AR of breast cancer patients were higher than benign breast tumor patients (P<0.05). The expression of SR and AR in breast cancer patients with different clinical stages, lymph node metastasis status, the positive expression of estrogen receptor (ER), progesterone receptor (PR) and human epidermal growth factor receptor 2 (HER2), Ki-67 proliferation index were significantly different (P<0.05). SR and AR were positively correlated with the high clinical stage, lymph node metastasis, HER2 + , Ki-67 proliferation index of breast cancer, and negatively correlated with ER + and PR + (P<0.05). The area under curves (AUCs) for individual diagnosis of SR and AR were 0.715 and 0.682, respectively, while the AUC for combined diagnosis was 0.849. The consistency between UE alone diagnosis of benign and malignant breast lesions and postoperative pathologic examination results was 0.655, and the consistency between UGCNB alone diagnosis and postoperative pathologic examination results was 0.939, and the consistency between the combined diagnosis and postoperative pathologic examination results was 0.979, and the accuracy of the combined diagnosis was higher than that of UE alone (P<0.05). Conclusion: UE combined with UGCNB examination can effectively improve the accuracy of preoperative diagnosis of breast cancer, and provide a basis for early clinical qualitative diagnosis, disease assessment and intervention plan formulation.

  • The diagnostic value of CEUS combined with 2DUS in the diagnosis of differentiating benign and malignant breast lesions 
    ZHANG Shen , LIU Yunyun , ZHANG Yifeng , XU Huixiong 　
    ZHONGLIU YINGXIANGXUE. 2024, 33(1): 69-74. https://doi.org/10.19732/j.cnki.2096-6210.2024.01.010
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    Objective: To assess the diagnostic accuracy of contrast-enhanced ultrasound (CEUS) in conjunction with 2D ultrasound (2DUS) in the diagnosis of the breast benign and malignant lesions, with pathological histological analysis serving as the gold standard. Methods: A total of 1 299 female breast lesions patients who underwent breast 2DUS and CEUS in Tenth People’s Hospital of Tongji University from February 2018 to August 2023, with pathological histological examination were included in this study, and patients underwent examination with 2DUS Breast Imaging Reporting and Data System (BI-RADS) and CEUS combined with 2DUS, and were compared and analyzed for the CEUS features of breast benign and malignant lesions as well as the sensitivity, specificity, accuracy, positive predictive value, and negative predictive value under the two examination modalities. Results: Based on the findings from pathological histological examinations, the 1 299 patients were distributed into two groups, with 807 cases falling under the benign lesion group and 492 cases classified as malignant lesions group. 2DUS BI- RADS and CEUS combined with 2DUS examination were performed respectively, the sensitivity (96.1%) and accuracy rate (88.8%) of CEUS combined with 2DUS examination was significantly higher than the 2DUS BI-RADS examination, which suggested that the diagnostic value of CEUS combined with 2DUS was higher, and it also had a high sensitivity (95.9%) for the detection of benign and malignant 4 types of BI-RADS lesions. Conclusion: CEUS combined with 2DUS can be used together in the differential diagnosis of breast benign and malignant lesions, and the combined detection of the two has a high diagnostic value and can improve the diagnostic accuracy.
  • Association between the characteristics of conventional ultrasound combined with CEUS and the recurrence or metastasis of postoperative breast cancer
    LIN Minjia, ZHA Hailing, ZHANG Manqi, DU Liwen, PING Jieyi, LI Cuiying 　
    ZHONGLIU YINGXIANGXUE. 2024, 33(1): 75-81. https://doi.org/10.19732/j.cnki.2096-6210.2024.01.011
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    Objective: To investigate the value of characteristics of conventional ultrasound combined with contrast-enhanced ultrasound (CEUS) in predicting the recurrence or metastasis of postoperative breast cancer patients. Methods: A total of 139 patients with breast cancer in Nanjing Medical University First Hospital confirmed by pathology and subsequently underwent surgical resection from January 2016 to December 2017 were selected in this study, and the recurrence or metastasis of these patients within five years were analyzed, including 126 patients without recurrence or metastasis and 13 patients with recurrence or metastasis (3 patients with recurrence and 10 patients with metastasis). The correlation between the characteristics of conventional ultrasound combined with CEUS and the recurrence or metastasis of postoperative breast cancer in the two groups was determined by univariate analyses. Logistic regression was used to screen out the risk factors and establish a model to analyze its diagnostic efficacy. Results: Univariate analysis showed that the uniformity of enhancement (uneven), lesion edges after enhancement (blurry), tumor orientation (vertical) and lymph node blood flow (non-lymphoid portal type) were correlated with the recurrence or metastasis of postoperative breast cancer. Multivariable logistic regression showed that the uniformity of enhancement (OR=5.686, P=0.047), tumor orientation (OR=5.190, P=0.015) and lymph node blood flow (OR=6.725, P=0.006) were independent risk factors for recurrence or metastasis in postoperative breast cancer patients. Logistic regression analysis was used to screen out the risk factors and establish conventional ultrasound combined with CEUS model. The area under the receiver operating characteristic (ROC) curve for uniformity of enhancement, tumor orientation, lymph node blood flow and conventional ultrasound combined with CEUS model were 0.677, 0.677, 0.685 and 0.841 respectively. Conclusion: The conventional ultrasound combined with CEUS model established in this study has certain application value in predicting the recurrence or metastasis of postoperative breast cancer. It provides the reference basis for breast surgeons to improve the treatment plan for patients with recurrence risk before treatment.

  • Clinical significance of ultrasonic myocardial work index in evaluating cancer therapy-related cardiac dysfunction after breast cancer chemotherapy
    BAO Chengming , RAN Hong , JIA Hui , CHEN Xiaoyuan , QIAN Xiaofeng , LU Ankui , ZHANG Renmin
    ZHONGLIU YINGXIANGXUE. 2024, 33(1): 82-88. https://doi.org/10.19732/j.cnki.2096-6210.2024.01.012
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    Objective: To explore the clinical significance of ultrasonic myocardial work index in evaluating cancer therapy-related cardiac dysfunction (CTRCD) after breast cancer chemotherapy. Methods: A total of 45 women with human epidermal growth factor receptor 2 (HER2) + breast cancer who received anthracycline sequential therapy participated in Nanjing Lishui District People’s Hospital from January 2021 to June 2022 were selected, including 33 patients with non-CTRCD and 12 patients with CTRCD. All patients were examined by two-dimensional transthoracic echocardiography and two-dimensional speckle tracking imaging (STI) before starting anthracycline therapy (T 0 ), after 2 cycles of anthracycline chemotherapy (T 1 ), after 4 cycles (T 2 ) and at the end of the whole chemotherapy cycle (T 3 ). Results: In patients without CTRCD, the trajectories of GLS, GWI and GCW were significantly different (P＜0.001, 0.017 and 0.006, respectively). During the whole chemotherapy period, GLS, GWI and GCW of patients with CTRCD decreased in a time-dependent manner (P＜0.05), and reached the lowest level at T 3 . Multivariate analysis showed that GLS ［OR (95% CI)=1.94 (1.02-3.69), P=0.044］ and GWI ［OR (95% CI)=1.78 (1.05-3.03), P=0.032］ was independently related to CTRCD. The area under curve (AUC) of GLS and GWI in T 1 as independent predictors of CTRCD were 0.749 (95% CI 0.550-0.948) and 0.837 (95% CI 0.675-0.998), respectively. When GLS and GWI were combined in T 1 phase, the AUC of diagnosing CTRCD increased to 0.942 (95% CI 0.878-1.000), and the sensitivity and specificity were 74.7% and 92.1% respectively. Conclusion: Left ventricular GLS and GWI can be used as independent predictors of anthracycline-induced CTRCD.

  • The progress of breast MRI in evaluating breast conservation therapy and ipsilateral breast tumor recurrence
    LI Jinhui , YOU Chao , QU Feilin , GU Yajia , PENG Weijun
    ZHONGLIU YINGXIANGXUE. 2024, 33(1): 89-95. https://doi.org/10.19732/j.cnki.2096-6210.2024.01.013
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    Breast conservation therapy (BCT) is one of standard treatments for early breast cancer. Ipsilateral breast tumor recurrence (IBTR) after BCT remains a matter of great concern in clinical practice. Positive surgical margins and lack of radiotherapy or systemic therapy have been confirmed to be high-risk factors for IBTR. Due to the prognosis varying from patient to patient, further risk stratification assessment is still needed. Early prediction and accurate diagnosis of IBTR are important guarantees for improving the prognosis and survival rate of patients. Breast magnetic resonance imaging (MRI) has extremely high soft tissue resolution and spatial resolution, which would be of significant clinical value in preoperative evaluation and postoperative follow-up. This article reviewed the research status and progress of MRI in BCT and IBTR.
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