Magnetic resonance imaging of the breast: recommendations from the EUSOMA working group

Mammary carcinoma - current diagnostic methods and symptomatology in imaging studies

Breast cancer is the most common neoplasm of the female population and its incidence is constantly rising. Social campaigns educating the public about the importance of the problem have been conducted for the past several years. Women are encouraged to self-examine on a monthly basis. Women aged 50-69 years can have an x-ray mammography performed once every 2 years as part of a prophylactic screening program. Ultrasound studies or MR mammography are adjuvant or, in some cases, alternative to x-ray mammography. Nuclear medicine techniques with application of oncophilic markers and receptor studies (this publication will not cover nuclear medicine methods) are not routinely used. Other techniques, such as computed tomography and conventional radiography are of no significance in the diagnostics of mammary cancer. However, together with isotopic methods, they are helpful in staging of the disease.X-ray mammography is, up to date, the only method with proven value in decreasing mortality. It is also the best available method for visualization of microcalicifications. Ultrasound examination is complementary to x-ray mammography as it is a cheap, easily available method of imaging mammary glands with higher glandular tissue content. It is also the most commonly used modality aiding in targeted biopsy of mammary gland. To date, MR mammography, characterized by the highest sensitivity in cancer diagnostics, remained a method reserved for "special tasks". MR is used for prophylaxis mainly in a population of women with particularly high risk of the disease and in cases where x-ray and ultrasound examinations are insufficient.Picture of mammary carcinoma in imaging studies is heterogeneous. However, it most often presents as an irregularly demarcated mass. Moreover, each modality can aid in visualization of additional features of a lesion such as typical shape of microcalcifications in x-ray mammography, characteristic pattern of contrast enhancement in MR examination or less strain in elastography.

Pre-treatment differences and early response monitoring of neoadjuvant chemotherapy in breast cancer patients using magnetic resonance imaging: a systematic review

OBJECTIVES

To assess whether magnetic resonance imaging (MRI) can identify pre-treatment differences or monitor early response in breast cancer patients receiving neoadjuvant chemotherapy.

METHODS

PubMed, Cochrane library, Medline and Embase databases were searched for publications until January 1, 2012. After primary selection, studies were selected based on predefined inclusion/exclusion criteria. Two reviewers assessed study contents using an extraction form.

RESULTS

In 15 studies, which were mainly underpowered and of heterogeneous study design, 31 different parameters were studied. Most frequently studied parameters were tumour diameter or volume, K(trans), K(ep), V(e), and apparent diffusion coefficient (ADC). Other parameters were analysed in only two or less studies. Tumour diameter, volume, and kinetic parameters did not show any pre-treatment differences between responders and non-responders. In two studies, pre-treatment differences in ADC were observed between study groups. At early response monitoring significant and non-significant changes for all parameters were observed for most of the imaging parameters.

CONCLUSIONS

Evidence on distinguishing responders and non-responders to neoadjuvant chemotherapy using pre-treatment MRI, as well as using MRI for early response monitoring, is weak and based on underpowered study results and heterogeneous study design. Thus, the value of breast MRI for response evaluation has not yet been established.

KEY POINTS

Few well-validated pre-treatment MR parameters exist that identify responders and non-responders. Eligible studies showed heterogeneous study designs which hampered pooling of data. Confounders and technical variations of MRI accuracy are not studied adequately. Value of MRI for response evaluation needs to be established further.

Comparison of 3- and 1.5-T dynamic breast MRI for visualization of spiculated masses previously identified using mammography

OBJECTIVE

The purpose of this article is to determine the effectiveness of MRI for visualizing spiculated breast cancer lesions that were previously identified using mammography and to compare the diagnostic quality of 3- and 1.5-T dynamic MRI by assessing the visualization of spiculation in such lesions.

MATERIALS AND METHODS

One hundred twenty MRI studies of breast cancers clearly identified as spiculated masses using mammography (71 MRI studies at 3 T that included both bilateral axial and unilateral sagittal images and 49 MRI studies at 1.5 T that included bilateral axial images only) were independently reviewed by three radiologists. The three different radiologists scored the visualization of the spiculation with respect to 3-T sagittal, 3-T axial, or 1.5-T axial images.

RESULTS

The diagnostic quality of sagittal 3-T dynamic MRI studies, as determined by assessing the visualization of spiculation, was significantly better than that of axial 3-T (p = 0.009) and 1.5-T (p = 0.004) studies. For small (< 1 cm) lesions, the diagnostic quality of sagittal 3-T studies determined by assessing the visualization of spiculation was significantly better than that of axial 1.5-T studies (p = 0.029).

CONCLUSION

Unilateral sagittal in-plane and through-plane high-spatial-resolution 3-T images can offer particularly higher spatial resolution for improved assessment of spiculation than do axial in-plane high-spatial-resolution images obtained at 1.5 and 3 T.

Contrast-enhanced MR imaging of the breast: association between asymmetric increased breast vascularity and ipsilateral cancer in a consecutive series of 197 patients

PURPOSE

This study was done to estimate the diagnostic performance of an asymmetric increase in breast vascularity (AIBV) for ipsilateral cancer.

MATERIALS AND METHODS

A total of 197 patients without previous breast interventions underwent bilateral contrast-enhanced (gadoterate meglumine, 0.1 mmol/kg) magnetic resonance (MR) imaging. Vessels >-2 mm in diameter and ≥ 3 cm in length were counted on maximum intensity projections: a difference ≥ 2 in number between the two breasts was considered AIBV. Pathology or ≥ 1 year follow-up served as a reference standard. The difference in sensitivity of AIBV between invasive and ductal carcinoma in situ (DCIS) as well as the association between AIBV and the diameter of invasive lesions or the histological grade were evaluated using χ(2) test.

RESULTS

Pathology revealed 82 malignancies and 20 benign lesions: 70 invasive carcinomas (57 ductal, nine lobular, three mucinous, one papillary) and 12 DCIS: 10 fibroadenomas, two papillomas, two atypical ductal hyperplasias and six other benign lesions. The remaining 95 patients were negative at follow-up. Sensitivity of AIBV was 74% (61/82), specificity 94% (108/115), accuracy 86% (169/197), positive predictive value 90% (61/68) and negative predictive value 84% (108/129). Sensitivity for invasive cancers (80%; 56/70) was significantly higher than that for DCIS (42%; 5/12) (p<0.001). For invasive cancers, sensitivity was 40% (2/5) for lesions ≤ 9 mm in diameter, 69% (9/13) for those 10-14 mm, 79% (15/19) for those 15-19 mm and 91% (30/33) for those ≥ 20 mm (p<0.001). The G3 lesion rate was 49% (27/55) among true positives and only 7% (1/14) among false negatives (p=0.009).

CONCLUSIONS

An association between AIBV and ipsilateral cancer exists, particularly for invasive cancers ≥ 20 mm or with high pathologic grade.

Early prediction of pathologic response to neoadjuvant therapy in breast cancer: systematic review of the accuracy of MRI

Magnetic resonance imaging (MRI) has been proposed to have a role in predicting final pathologic response when undertaken early during neoadjuvant chemotherapy (NAC) in breast cancer. This paper examines the evidence for MRI's accuracy in early response prediction. A systematic literature search (to February 2011) was performed to identify studies reporting the accuracy of MRI during NAC in predicting pathologic response, including searches of MEDLINE, PREMEDLINE, EMBASE, and Cochrane databases. 13 studies were eligible (total 605 subjects, range 16-188). Dynamic contrast-enhanced (DCE) MRI was typically performed after 1-2 cycles of anthracycline-based or anthracycline/taxane-based NAC, and compared to a pre-NAC baseline scan. MRI parameters measured included changes in uni- or bidimensional tumour size, three-dimensional volume, quantitative dynamic contrast measurements (volume transfer constant [Ktrans], exchange rate constant [k(ep)], early contrast uptake [ECU]), and descriptive patterns of tumour reduction. Thresholds for identifying response varied across studies. Definitions of response included pathologic complete response (pCR), near-pCR, and residual tumour with evidence of NAC effect (range of response 0-58%). Heterogeneity across MRI parameters and the outcome definition precluded statistical meta-analysis. Based on descriptive presentation of the data, sensitivity/specificity pairs for prediction of pathologic response were highest in studies measuring reductions in Ktrans (near-pCR), ECU (pCR, but not near-pCR) and tumour volume (pCR or near-pCR), at high thresholds (typically >50%); lower sensitivity/specificity pairs were evident in studies measuring reductions in uni- or bidimensional tumour size. However, limitations in study methodology and data reporting preclude definitive conclusions. Methods proposed to address these limitations include: statistical comparison between MRI parameters, and MRI vs other tests (particularly ultrasound and clinical examination); standardising MRI thresholds and pCR definitions; and reporting changes in NAC based on test results. Further studies adopting these methods are warranted.

Ductal carcinoma in situ of the breast

Ductal carcinoma in situ (DCIS) of the breast represents a complex, heterogeneous pathologic condition in which malignant epithelial cells are confined within the ducts of the breast without evidence of invasion. The increased use of screening mammography has led to a significant shift in the diagnosis of DCIS, accounting for approximately 27% of all newly diagnosed cases of breast cancer in 2011, with an overall increase in incidence. As the incidence of DCIS increases, the treatment options continue to evolve. Consistent pathologic evaluation is crucial in optimizing treatment recommendations. Surgical treatment options include breast-conserving surgery (BCS) and mastectomy. Postoperative radiation therapy in combination with breast-conserving surgery is considered the standard of care with demonstrated decrease in local recurrence with the addition of radiation therapy. The role of endocrine therapy is currently being evaluated. The optimization of diagnostic imaging, treatment with regard to pathological risk assessment, and the role of partial breast irradiation continue to evolve.

Detection of incidental vertebral fractures in breast imaging: the potential role of MR localisers

OBJECTIVES

Incidental diagnosis of vertebral fractures (VFs) may represent a key point in the assessment of bone health status. Our purpose was to retrospectively evaluate localisation sequences (MR-loc) of breast MRI as a potential tool to detect osteoporotic VFs.

METHODS

MR-loc sagittal images of 856 breast MRIs were reviewed by three expert musculoskeletal radiologists with a semiquantitative approach to detecting VFs. Anamnesis and data of patients were investigated. Official breast MRI and previous imaging reports were checked to understand if VFs or other relevant bone findings were known in patients' clinical history.

RESULTS

A total of 780/856 female patients (91.1 %) undergoing MRI for oncological reasons and 76/856 (8.9 %) with non-oncological aims were recruited into the study (54.7 ± 12.2 years old, 21-89 years); 57/856 MR-loc images (6.7 %) were considered inadequate for diagnostic purposes and were excluded from the analysis. MR-loc detected VFs in 71/799 patients (8.9 %). VFs were neither reported nor previously known in the clinical history of 63/71 patients (88.7 %; P < 0.001). No mention of VFs was found in any breast MR reports. In four patients MR-loc identified vertebral metastases.

CONCLUSIONS

A systematic evaluation of MR-loc may offer additional clinical information to prevent unrecognised VFs. MR-loc may screen for VFs in other imaging settings.

KEY POINTS

Vertebral fractures are usually a hallmark of osteoporosis. Localisation sequences before breast MR examinations can identify vertebral fractures. MR localisers should be inspected for vertebral fractures in other clinical settings.

[Guideline for the prevention and early detection of breast and ovarian cancer in high risk patients, particularly in women from HBOC (hereditary breast and ovarian cancer) families]

The Austrian guideline for prevention and early detection of breast and ovarian cancer in high risk patients--particularly in women from hereditary breast and ovarian cancer families--were established with particular consideration of the most recent position paper of the European Society of Breast Cancer Specialists (EUSOMA) by the authors mentioned above. The guideline is aimed at facilitating and standardizing the care and early detection strategies in women with an elevated life time risk for breast and ovarian cancer.

Readout-segmented echo-planar imaging improves the diagnostic performance of diffusion-weighted MR breast examinations at 3.0 T

PURPOSE

To qualitatively and quantitatively compare the diagnostic value of diffusion-weighted (DW) magnetic resonance (MR) imaging based on standard single-shot echo-planar imaging and readout-segmented echo-planar imaging in patients with breast cancer at 3.0 T.

MATERIALS AND METHODS

Institutional review board approval and written informed consent were obtained. Forty-seven patients with 49 histopathologically verified lesions were included in this study. In all patients, DW imaging, with single-shot echo-planar imaging and readout-segmented echo-planar imaging with comparable imaging parameters, was performed with a 3.0-T MR imager. Two independent readers visually assessed image quality and lesion conspicuity, and image properties (ie, signal-to-noise ratio, contrast, geometric distortions) were quantified. Regions of interest were drawn in all lesions (28 malignant, 21 benign) and in the normal breast parenchyma to investigate differences in apparent diffusion coefficient (ADC). Diagnostic accuracy was calculated on the basis of an ADC threshold of 1.25 × 10(-3) mm(2)/sec.

RESULTS

Each reader found a higher diagnostic accuracy for readout-segmented (96%) than for single-shot (90%) echo-planar imaging. The area under the curve for readout-segmented echo-planar imaging (0.981) was significantly larger than for single-shot echo-planar imaging (0.867) (P = .026). There was no significant difference in the ADC obtained by using either DW imaging method. Lesion conspicuity and image quality of readout-segmented echo-planar imaging were rated superior to those of single-shot echo-planar imaging (P < .001). Readout-segmented echo-planar imaging reduced geometric distortions by a factor of three.

CONCLUSION

DW imaging based on readout-segmented echo-planar imaging provided significantly higher image quality and lesion conspicuity than single-shot echo-planar imaging by reducing geometric distortions, image blurring, and artifact level with a clinical high-field-strength MR imager. Thereby, readout-segmented echo-planar imaging reached a higher diagnostic accuracy for the differentiation of benign and malignant breast lesions.

[Breast cancer screening in high risk populations]

We aim to define which patients make up the populations with high and intermediate risk of developing breast cancer, to review the studies of screening with magnetic resonance imaging in addition to mammography in high risk patients (describing the imaging characteristics of the cancers in this group), to review the studies of screening with magnetic resonance imaging in patients with intermediate risk, and to update the guidelines for screening in patients with high or intermediate risk (based on the recent recommendations of the main scientific societies/American and European guidelines).

Diffusion tensor magnetic resonance imaging of the normal breast: reproducibility of DTI-derived fractional anisotropy and apparent diffusion coefficient at 3.0 T

PURPOSE

Diffusion-weighted imaging (DWI) may improve the diagnostic performance of conventional breast magnetic resonance imaging (MRI). Diffusion tensor imaging (DTI) is an extension of DWI. If DTI-derived measurements are to be clinically useful, particularly for predicting and/or monitoring therapeutic effects, they must be robust and reliable. The purpose of this study was to assess intra- and interobserver reproducibility of DTI-derived fractional anisotropy (FA) and apparent diffusion coefficient (ADC) at 3.0 T.

MATERIALS AND METHODS

This prospective study was approved by the Institutional Review Board, and participants provided written informed consent. Sixty normal contralateral breasts of 60 patients (28-85 years, median 57) were analysed with a DWI sequence following a standard MRI protocol. Four authors performed all postprocessing and analyses independently and in different sessions. The same authors, blinded to the initial results, repeated the image postprocessing and analysis 4 weeks after the initial session.

RESULTS

Mean ADC and FA for DTI sequences were, respectively, 1.92±0.30 and 0.32±0.09. Intra- and interobserver agreement of the four radiologists for ADC and FA were good (acceptable). Kappa values for ADC were intra-R1=0.82; intra-R2=0.84; intra-R3=0.89; intra-R4=0.88; inter-R1-R2=0.73; inter-R1-R3=0.74; inter-R1-R4=0.81; inter-R2-R3=0.76; inter-R2-R4=0.77; inter-R3-R4=0.83. Kappa values for FA were intra-R1=0.60; intra-R2=0.72; intra-R3=0.84; intra-R4 = 0.66; inter-R1-R2=0.64; inter-R1-R3=0.69; inter-R1-R4=0.72; inter-R2-R3=0.80; inter-R2-R4=0.71; inter-R3-R4=0.73. Within-subject coefficient of variation was 15% for ADC and 30% for FA. Repeatability with α=0.05 was 0.37×10-3 mm(2)/s for ADC and 0.112 for FA.

CONCLUSIONS

ADC and FA measurements obtained with DTI are reproducible and may be valid, reliable and sensitive to change. ADC values obtained with DTI are more reproducible than FA.

Outcome of MRI-guided vacuum-assisted breast biopsy - initial experience at Institute of Oncology Ljubljana, Slovenia

BACKGROUND

Like all breast imaging modalities MRI has limited specificity and the positive predictive value for lesions detected by MRI alone ranges between 15 and 50%. MRI guided procedures (needle biopsy, presurgical localisation) are mandatory for suspicious findings visible only at MRI, with potential influence on therapeutic decision. The aim of this retrospective study was to evaluate our initial clinical experience with MRI-guided vacuum-assisted breast biopsy as an alternative to surgical excision and to investigate the outcome of MRI-guided breast biopsy as a function of the MRI features of the lesions. PATIENTS AND METHODS.: In 14 women (median age 51 years) with 14 MRI-detected lesions, MRI-guided vacuum-assisted breast biopsy was performed. We evaluated the MRI findings that led to biopsy and we investigated the core and postoperative histology results and follow-up data.

RESULTS

The biopsy was technically successful in 14 (93%) of 15 women. Of 14 biopsies in 14 women, core histology revealed 6 malignant (6/14, 43%), 6 benign (6/14, 43%) and 2 high-risk (2/14, 14%) lesions. Among the 6 cancer 3 were invasive and 3 were ductal carcinoma in situ (DCIS). The probability of malignancy in our experience was higher for non-mass lesion type and for washout and plateau kinetics.

CONCLUSIONS

Our initial experience confirms that MRI-guided vacuum-assisted biopsy is fast, safe and accurate alternative to surgical biopsy for breast lesions detected at MRI only.

Small masses on breast MR: is biopsy necessary?

RATIONALE AND OBJECTIVES

To evaluate outcome of magnetic resonance (MR)-detected biopsied breast lesions ≤5 mm by correlating imaging characteristics with pathology.

METHODS AND MATERIALS

Institutional review board-approved retrospective review of 565 lesions biopsied with MR guidance between March 2004 and February 2009 found 68 lesions ≤5 mm in 61 patients. Lesions evaluated were those prospectively recommended for biopsy based on clinical setting, suspicious lesion morphology, and kinetics. Two study radiologists, blinded to final pathology, reviewed MR exams recording patient age, exam indication (staging, surveillance, diagnostic, or follow-up), mass location, size, morphology, T2-weighted signal, and kinetics. Chart review provided final pathology.

RESULTS

Of 68 masses ≤5 mm, 14 (20.6%) were malignant. Of 32 <5 mm, 32 (28.1%) were malignant. Of 14 malignancies, 7 (50%) were in patients with recently diagnosed breast cancer, 6 in the same breast, of which 4 (66.7%) were in same quadrant. Higher likelihood of malignancy based on proximity to known cancer was statistically significant (P = .01). No significant difference in proportion of malignancies was found based on age, T2-weighted signal, morphology, or kinetics.

CONCLUSION

For MR-detected biopsied masses, the positive predictive value for malignancy of those ≤5 mm was 20.6%. The highest prevalence of cancers was in the same quadrant as a newly diagnosed breast cancer. The decision to biopsy small masses should be based on carefully assessed MR features, and in the context of exam indication, not solely on size.

Correlations between diffusion-weighted imaging and breast cancer biomarkers

OBJECTIVE

We evaluated whether the apparent diffusion coefficient (ADC) provided by diffusion-weighted imaging (DWI) varies according to biological features in breast cancer.

METHODS

DWI was performed in 190 patients undergoing dynamic contrast-enhanced magnetic resonance imaging (MRI) for local staging. For each of the 192 index cancers we studied the correlation between ADC and classical histopathological and immunohistochemical breast tumour features (size, histological type, grade, oestrogen receptor [ER] and Ki-67 expression, HER2 status). ADC was compared with immunohistochemical surrogates of the intrinsic subtypes (Luminal A; Luminal B; HER2-enriched; triple-negative). Correlations were analysed using the Mann-Whitney U and Kruskal-Wallis H tests.

RESULTS

A weak, statistically significant correlation was observed between ADC values and the percentage of ER-positive cells (-0.168, P = 0.020). Median ADC values were significantly higher in ER-negative than in ER-positive tumours (1.110 vs 1.050 × 10(-3) mm(2)/s, P = 0.015). HER2-enriched tumours had the highest median ADC value (1.190 × 10(-3) mm(2)/s, range 0.950-2.090). Multiple comparisons showed that this value was significantly higher than that of Luminal A (1.025 × 10(-3) mm(2)/s [0.700-1.340], P = 0.004) and Luminal B/HER2-negative (1.060 × 10(-3) mm(2)/s [0.470-2.420], P = 0.008) tumours. A trend towards statistical significance (P = 0.018) was seen with Luminal B/HER2-positive tumours.

CONCLUSIONS

ADC values vary significantly according to biological tumour features, suggesting that cancer heterogeneity influences imaging parameters.

KEY POINTS

DWI may identify biological heterogeneity of breast neoplasms. • ADC values vary significantly according to biological features of breast cancer. • Compared with other types, HER2-enriched tumours show highest median ADC value. • Knowledge of biological heterogeneity of breast neoplasm may improve imaging interpretation.

Magnetic resonance imaging of radial sclerosing lesions (radial scars) of the breast

PURPOSE

To identify magnetic resonance (MR) imaging (MRI) features of radial sclerosing lesions (RSLs) of the breast.

METHODS AND MATERIALS

The radiologic and pathologic records for 4629 consecutive patients undergoing MR examinations of the breast were retrospectively reviewed. Patients who received a pathologic diagnosis of RSL without atypia or carcinoma at surgical excision were identified. The MR images were evaluated according to the BI-RADS-MRI lexicon by two experienced breast radiologists. The frequency of morphologic and kinetic patterns and of BI-RADS-MRI assessment categories was calculated.

RESULTS

Twenty-nine patients with 29 surgically excised RSL were identified. Nine (31%) RSL were MR-occult; the remaining 20 (69%) RSL presented as masses (10/20, 50%), architectural distortions (5/20, 25%), non-mass lesions (4/20, 20%), and focus (1/20, 5%). Kinetic analysis was performed in 18 RSL: enhancement features were benign in 9 (50%) cases, suspicious in 7 (39%) cases and indeterminate in 2 (11%) cases. Twelve (41%) MR examinations were assessed as suspicious (BI-RADS-MRI 4 and 5), and 17 (59%) as negative (BI-RADS-MRI 1) or benign (BI-RADS-MRI 2 and 3).

CONCLUSION

RSLs are often visualized on MR imaging. Just as in mammography and sonography, RSL can have variable morphologic and kinetic features, and not infrequently they can mimic invasive carcinoma of the breast.

The role of magnetic resonance imaging in early breast cancer

Despite recent evidence that fails to detect a benefit in surgical and local recurrence outcomes in those who receive optimal surgery and adjuvant systemic and radiotherapy, magnetic resonance imaging (MRI) is still being employed. We review the recent literature to clarify the role in the use of MRI in early breast cancer. A literature search using the Medline and Ovid databases was conducted between 2004 and 2011 using the terms "magnetic resonance imaging' and 'early breast cancer'. Only articles with clinical trials published in English in adult humans with available abstracts were included. Articles on high-risk women, response to neoadjuvant therapy, advanced breast cancer, the occult primary, the contralateral breast and technical articles were excluded. Articles examining the role of MRI in the staging of early breast cancer were retained. Over 260 articles regarding breast MRI have been published in the last 5 years. Additional foci may be found in 16% of patients but the impact on the extent of surgery and local recurrence rate is yet to be defined. Certain sub-groups who may benefit include those with invasive lobular carcinoma and mammographically dense breasts and those for consideration of partial breast irradiation. With standard adjuvant radiotherapy, there is no benefit in routine MRI with respect surgical extent and local recurrence. Should MRI be used, pre-operative biopsy to confirm additional disease must be undertaken prior to a change in surgical extent of resection. However, MRI may be useful in the evaluation of those who can be considered for partial breast irradiation. Centres undertaking breast MRI must have MRI-biopsy capabilities and constantly audit the reporting of MRI with correlation to the final pathology.

The inflammatory breast: management, decision-making algorithms, therapeutic principles

Inflammatory syndrome is one of the rare emergency breast situations. Its etiology is benign, infectious in most cases. The clinical examination is often self-evident and suggests the diagnosis. But alone it is insufficient, and diagnostic tests are necessary to guide therapy. As essential as it is, mammography's limitations reinforce the benefit of ultrasonography, which in all cases reveals an abscess and has greater sensitivity for detecting a malignant tumor. If the etiology is benign, clinical signs will disappear with medical treatment, with no need for further investigation. While it is legitimate to initiate a trial treatment, it must not delay oncologic management, because of the severity of inflammatory cancer.

Imaging inflammatory breast cancer

Carcinomatous mastitis is a severe form of breast cancer and its diagnosis is essentially clinical and histological. The first examination to perform is still mammography, not only to provide evidence supporting this diagnosis but also to search for a primary intramammary lesion and assess local/regional spread. It is essential to study the contralateral breast for bilaterality. Ultrasound also provides evidence supporting inflammation, but appears to be better for detecting masses and analysing lymph node areas. The role of MRI is debatable, both from a diagnostic point of view and for monitoring during treatment, and should be reserved for selected cases. An optimal, initial radiological assessment will enable the patient to be monitored during neoadjuvant chemotherapy.

Effect of contrast agent on the results of in vivo ¹H MRS of breast tumors - is it clinically significant?

Choline (Cho) signal identification and quantification in (1)H MRS are used in breast cancer diagnosis. However, an influence of the gadolinium-based contrast agent on the Cho amplitude has been reported experimentally. This study aims to identify the impact of gadolinium-based contrast agents on Cho detection and quantification in postcontrast breast MRS. Consecutive patients were recruited prospectively and randomly allocated to two groups. Group A received a neutral (gadolinium diethylenetriaminepentaacetic acid bis-methylamide) and group B an ionic (gadolinium diethylenetriaminepentaacetic acid) contrast agent, each at a dosage of 0.1 mmol/kg. First, the presence of Cho was identified visually. Then, the normalized Cho intensity in malignant lesions was quantified. Multivariate analysis was applied to identify independent influencing factors on Cho. Sixty-three lesions were investigated [A, n = 34; B, n = 29; 43 malignant (one bilaterally malignant), 20 benign]. Cho was identified visually in 14 of 20 malignant tumors in group A and 12 of 22 malignant tumors in group B (p = 0.477). Normalized Cho differed significantly (p = 0.001) between groups A (mean, 26.8 ± 6.0 AU) and B (mean, 18.2 ± 12.5 AU). No linewidth differences were identified (p > 0.05). Multivariate analysis revealed only group membership (A versus B) as an independent predictor of Cho (p = 0.017). The results suggest stronger negative effects of an ionic relative to a neutral gadolinium-based contrast agent on breast tumor MRS in vivo. These results should be considered when conducting and comparing quantitative Cho measurements in the breast.

Do patients with invasive lobular breast cancer benefit in terms of adequate change in surgical therapy from a supplementary preoperative breast MRI?

BACKGROUND

Breast magnetic resonance imaging (MRI) has been introduced in the preoperative management of invasive lobular breast cancer (ILC). We analysed if MRI leads to adequate changes in surgical management.

PATIENTS AND METHODS

We carried out a single-centre retrospective confirmatory analysis of 92 patients with ILC and a preoperative breast MRI. By applying a blinded tumour board method, we analysed if surgical procedures were altered due to breast MRI. In case of alteration, we analysed whether the change was adequate according to the postoperative pathology findings. We considered an adequate rate of change>5% to be a clinically relevant benefit.

RESULTS

A change in surgical therapy due to the MRI findings occurred in 23 of 92 patients (25%). According to the postoperative pathology findings, this change was adequate for 20 of these patients (22%; 95% confidence interval [CI] 14%-31%, P<0.0001). An overtreatment occurred for three patients (3%; 95% CI 0%-6%) who underwent a mastectomy following the results of breast MRI. Patients with larger tumours did likely benefit more from preoperative breast MRI.

CONCLUSIONS

Patients with ILC might benefit from a preoperative breast MRI. Possible harm from overtreatment should be minimised by diligent use of preoperative histological clarification.

DNA damage induced by mammography in high family risk patients: only one single view in screening

Women with high risk of breast or ovarian cancers might be more susceptible to radiation-induced cancer because most of tumor suppressor genes are also implicated in the radio-induced DNA damage repair and signaling. Recent radiobiological advances may help to re-consider the potential cellular and molecular consequences of the standard two-view mammographic screening. A major radiobiological effect exacerbated in high family risk women caused by mammographic repeated doses was pointed out on relevant cellular model (untransformed and non tumoral human breast epithelial cells): the Low and Repeated Dose (LORD) effect. In parallel, while magnetic resonance imaging (MRI) is reported to be less sensitive than mammography for detection of ductal carcinoma in situ, a recent study highlighted the increased ability of MRI to detect them related to the experience both of radiologists and MRI centers. Hence, along with studies confirming improvement of the sensitivity of MRI to detect ductal carcinoma in situ, the supra-additivity effect induced by the two-view mammographic screening in high family risk patients suggests that mammographic exposures can be limited seriously. Consequently, a single view (oblique) per breast in association with annual MRI, with the sole aim to detect calcifications reflecting carcinoma in situ non detectable by MRI, might represent currently a compromise.

Indicações de ressonância magnética das mamas em um centro de referência em oncologia

OBJETIVO: Avaliar e discutir as indicações de ressonância magnética das mamas em um centro de referência oncológico. MATERIAIS E MÉTODOS: Estudo retrospectivo, aprovado pelo Comitê de Ética e Pesquisa da instituição, conduzido através da revisão de prontuários e laudos médicos. Foram incluídos todos os exames de ressonância magnética das mamas realizados no período de julho de 2008 a julho de 2009 (n = 529). RESULTADOS: A idade média das pacientes foi de 49 anos, variando de 17 a 86 anos. História familiar de câncer de mama e/ou ovário esteve presente em 162 pacientes (30,6%). As indicações mais comuns de ressonância magnética das mamas foram esclarecimento de achados inconclusivos na mamografia e/ou ultrassom (48,8%), avaliação de recorrência tumoral/cicatriz cirúrgica (15,1%), estadiamento/planejamento cirúrgico (11,7%) e rastreamento de pacientes de alto risco (8,5%). CONCLUSÃO: Apesar de achados inconclusivos nos exames convencionais serem a indicação mais comum de ressonância magnética das mamas, não há evidências que justifiquem esta conduta na literatura. Em razão da sua alta sensibilidade e percentual de falso-positivos, este exame deve ser adequadamente indicado, para evitar a realização de procedimentos desnecessários. Se bem indicada, a ressonância magnética pode contribuir para o processo de tomada de decisão e constitui uma ferramenta fundamental na avaliação de lesões mamárias.

Pearls and pitfalls in breast MRI

At our academic institution, we have noticed repeated examples of both false-positive and false-negative MR diagnoses in breast cancer. The most common diagnostic errors in interpreting MRI of the breast are discussed in this review and experience-based advice is provided to avoid similar mistakes. The most common reasons for false-positive diagnoses are misinterpretation of artefacts, confusion between normal enhancing structures and tumours and, above all, insufficient use of the American College of Radiology breast imaging reporting and data system lexicon, whereas false-negative diagnoses are made as a result of missed tiny enhancement, a background-enhancing breast, or enhancement interpreted as benign rather than malignant.

[Neoadjuvant treatment of breast cancer: implications for the pathologist]

These past few years, neoadjuvant strategy has taken an increasing place in the management of breast cancer patients. This strategy is mainly indicated to obtain a tumour bulk regression allowing a breast conserving surgery in patients that otherwise would have undergone mastectomy. Of note, development of new chemotherapy agents and targeted therapies has critically helped in the progress of neoadjuvant strategy as it is currently associated with better pathological response rates. In this context, the pathologist is at the crossroad of this multidisciplinary process. First, he provides on the initial core needle biopsy the tumour pathological characteristics that are critical for the choice of treatment strategy, i.e. histological type, histological grade, proliferative activity (mitotic count and Ki67/MIB1 index labeling), hormone receptor status (oestrogen receptor and progesterone receptor) and HER2 status. Secondly, the pathologist evaluates the pathological response and the status of surgical margins with regards to the residual tumour on the surgical specimen after neoadjuvant treatment. These parameters are important for the management of the patient, since it has been shown that complete pathological response is associated with improved disease free survival. Several grading systems are used to assess the pathological response in breast and axillary lymph nodes. The most frequently used in France are currently the systems described by Sataloff et al. and Chevallier et al. In this review, we detail the different steps involving the pathologist in neoadjuvant setting, with special regards to the quality process and future perspectives such as emerging predictive biomarkers.

Mammography: EUSOBI recommendations for women's information

This paper summarises the basic information to be offered to women who undergo mammography. After a delineation of the general aim of early diagnosis of breast cancer, the main difference between screening mammography and diagnostic mammography is explained. The best time for scheduling mammography in fertile women is defined. The need to bring images and reports from the previous mammogram (and from other recent breast imaging examinations) is highlighted. The technique and procedure of mammography are briefly described with particular attention to discomfort and pain experienced by a fraction of women who undergo the test. Information is given on the recall during a screening program and on the request for further work-up after a diagnostic mammography. The logic of the diagnostic mammography report and of classification systems such as BI-RADS and R1-R5 is illustrated, and brief but clear information is given about the diagnostic performance of the test, with particular reference to interval cancers. Moreover, the breast cancer risk due to radiation exposure from mammography is compared to the reduction in mortality obtained with the test, and the concept of overdiagnosis is presented. Finally, five frequently asked questions are answered.

Should breast cancer survivors be excluded from, or invited to, organised mammography screening programmes?

BACKGROUND

The prevalence of breast cancer in developed countries has steadily risen over recent decades. Immediate and long-term health needs of patients, including preventive care and screening services, are receiving increasing attention. A question still unresolved is whether breast cancer survivors should receive mammographic surveillance in the clinical or screening setting and, thus, whether they should be excluded from, or invited to, organised mammography screening programmes. The objective of this article is to discuss the many contradictory aspects of this matter.

DISCUSSION

Problems with mammographic surveillance of breast cancer survivors include: weak evidence of a reduction in mortality; lack of evidence in favour of one setting or the other; lack of evidence-based guidelines for the frequency and duration of surveillance; disproportionate emphasis placed on the first few years post-treatment, probably dictated by surgical and oncological priorities; a variety of screening policies, as these women are permanently or temporarily or partially excluded from many - but not all - organised screening programmes worldwide; an even greater disparity in follow-up protocols used in the clinical setting; a paucity of data on compliance to mammographic surveillance in both settings; and a difficulty in coordinating the roles of health care providers. In the future, the use of mammography in breast cancer survivors will be influenced by the inclusion of women aged > 69 years in organised screening programmes and the implementation of multidisciplinary breast units, and will probably be investigated by research activities on individual risk assessment and risk-tailored screening. In the interim, current problems can be partially alleviated with some technical solutions in screening data recording, patient flows, and care coordination.

SUMMARY

Mammographic surveillance of breast cancer survivors is situated at the crossroads of numerous different specialist areas of breast cancer control and management. The solutions for current problems probably lie in some important modifications in the conventional screening procedure that are underway or under study. These developments appear to be directed towards a partial modification of the screening rationale, with an adaptation to meet the diversified breast care needs of women. The complexity of the matter constitutes a call to action for several entities to eliminate the barriers to effective research in this field.

Performance of a fully automatic lesion detection system for breast DCE-MRI

PURPOSE

To describe and test a new fully automatic lesion detection system for breast DCE-MRI.

MATERIALS AND METHODS

Studies were collected from two institutions adopting different DCE-MRI sequences, one with and the other one without fat-saturation. The detection pipeline consists of (i) breast segmentation, to identify breast size and location; (ii) registration, to correct for patient movements; (iii) lesion detection, to extract contrast-enhanced regions using a new normalization technique based on the contrast-uptake of mammary vessels; (iv) false positive (FP) reduction, to exclude contrast-enhanced regions other than lesions. Detection rate (number of system-detected malignant and benign lesions over the total number of lesions) and sensitivity (system-detected malignant lesions over the total number of malignant lesions) were assessed. The number of FPs was also assessed.

RESULTS

Forty-eight studies with 12 benign and 53 malignant lesions were evaluated. Median lesion diameter was 6 mm (range, 5-15 mm) for benign and 26 mm (range, 5-75 mm) for malignant lesions. Detection rate was 58/65 (89%; 95% confidence interval [CI] 79%-95%) and sensitivity was 52/53 (98%; 95% CI 90%-99%). Mammary median FPs per breast was 4 (1st-3rd quartiles 3-7.25).

CONCLUSION

The system showed promising results on MR datasets obtained from different scanners producing fat-sat or non-fat-sat images with variable temporal and spatial resolution and could potentially be used for early diagnosis and staging of breast cancer to reduce reading time and to improve lesion detection. Further evaluation is needed before it may be used in clinical practice.

DNA double-strand breaks induced by mammographic screening procedures in human mammary epithelial cells

PURPOSE

To assess in vitro mammographic radiation-induced DNA damage in mammary epithelial cells from 30 patients with low (LR) or high (HR) family risk of breast cancer.

MATERIALS AND METHODS

Spontaneous and radiation-induced DNA double-strand breaks (DSB) were quantified by using immunofluorescence of the phosphorylated H2AX histone (γH2AX) in different conditions of mammography irradiation (2, 4, 2 + 2 mGy).

RESULTS

HR patients showed significantly more spontaneous γH2AX foci than LR patients (p = 0.014). A significant dose-effect was observed, with an exacerbation in HR patients (p = 0.01). The dose repetition (2 + 2 mGy) provided more induced and more unrepaired DSB than 2 mGy and 4 mGy, and was exacerbated in HR (p = 0.006).

CONCLUSIONS

This study highlights the existence of DSB induced by mammography and revealed by γH2AX assay with two major radiobiological effects occurring: A low-dose effect, and a LOw and Repeated Dose (LORD) effect. All these effects were exacerbated in HR patients. These findings may lead us to re-evaluate the number of views performed in screening using a single view (oblique) in women whose mammographic benefit has not properly been proved such as HR patients.

Feasibility of 7 Tesla breast magnetic resonance imaging determination of intrinsic sensitivity and high-resolution magnetic resonance imaging, diffusion-weighted imaging, and (1)H-magnetic resonance spectroscopy of breast cancer patients receiving neoadjuvant therapy

OBJECTIVES

To evaluate the feasibility of 7T breast magnetic resonance imaging (MRI) by determining the intrinsic sensitivity gain compared with 3T in healthy volunteers and to explore clinical application of 7T MRI in breast cancer patients receiving neoadjuvant chemotherapy (NAC).

MATERIALS AND METHODS

In 5 volunteers, the signal-to-noise ratio (SNR) was determined on proton density MRI at 3T using a conventional 4-channel bilateral breast coil and at 7T using a dedicated 2-channel unilateral breast coil, both obtained at identical scan parameters. Subsequently, consecutive breast cancer patients on NAC were included. The 7T breast MRI protocol consisted of diffusion-weighted imaging, 3D high-resolution (450 μm isotropic) T1-weighted fat-suppressed gradient-echo sequences and quantified single voxel (1)H-magnetic resonance spectroscopy. Morphology was scored according to the MRI Breast Imaging-Reporting and Data System (BI-RADS)-lexicon, and the images were compared with 3T and histopathologic findings. Image quality was evaluated using a 5-point scale.

RESULTS

A 5.7-fold higher SNR was measured at 7T than at 3T, which reflects the advantages of a higher field strength and the use of optimized radiofrequency coils. Three breast cancer patients were included and received a total of 13 7T MRI examinations. The image quality of the high-resolution examinations was at least satisfactory, and good to excellent in 9 of the 13 examinations performed. More anatomic detail was depicted at 7T than at 3T. In 1 case, a fat plane between the muscle and tumor was visible at 7T, but not at the clinically performed 3T examination, suggesting that there was no muscle invasion, which was confirmed by pathology. Changes in tumor apparent diffusion coefficient values could be monitored in 2 patients and were found to increase during NAC, consistent with published results from studies at lower field strengths. Apparent diffusion coefficient values increased respectively from 0.33 × 10(-3) mm(2)/s to 1.78 × 10(-3) mm(2)/s after NAC and from 1.20 × 10(-3) mm(2)/s to 1.44 × 10(-3) mm(2)/s during NAC. Choline concentrations as low as 0.77 mMol/kg(water) could be detected. In 1 patient, choline levels showed an overall decrease from 4.2 mMol/kw(water) to 2.6 mMol/kg(water) after NAC and the tumor size decreased correspondingly from 3.9 × 4.1 × 5.6 cm(3) to 2.0 × 2.7 × 2.4 cm(3). All 7T MRI findings were consistent with pathology analysis.

CONCLUSION

Dedicated 7T breast MRI is technically feasible, can provide more SNR than at 3T, and has diagnostic potential.