Accuracy of contrast-enhanced computed tomography in the prediction of residual breast cancer after neoadjuvant chemotherapy

Evaluation of Post-Neoadjuvant Chemotherapy Pathologic Complete Response and Residual Tumor Size of Breast Cancer: Analysis on Accuracy of MRI and Affecting Factors

목적

신보강화학요법을 시행한 유방암 환자에서 병리학적 관해와 잔류 암의 크기를 평가하는 데 있어 유방자기공명영상의 정확도를 분석하고 이에 영향을 미치는 인자들이 무엇인지 알아본다.

대상과 방법

2010년부터 2017년까지 본원에서 신보강화학요법 후 수술을 시행한 88명의 유방암 환자를 대상으로 하였다. 병리학적 관해는 수술 병리 결과에서 침윤성 유방암이 발견되지 않는 것으로 정의하였고 자기공명영상과 병리 조직의 잔류 암 크기 차이는 최대 직경으로 비교하였다. 병리학적 관해 및 자기공명영상과 병리 조직에서의 잔류 암 크기 차이에 영향을 미치는 인자를 알아보기 위해 통계분석을 시행하였다.

결과

전체 환자의 10%가 병리학적 관해에 도달하였다. 자기공명영상으로 관해를 예측할 때의 정확도와 곡선하부면적은 각각 90.91%, 0.8017이었다. 신보강화학요법 시행 후 유방자기공명영상과 병리 조직에서 측정한 잔류 암의 크기는 매우 강한 연관성을 보였고(r = 0.9, p < 0.001), 특히 영상에서 단일 종괴로 보였던 병변에서(p = 0.047) 그러하였다. 자기공명영상과 병리 조직 간의 잔류 암 크기는 내강형(p = 0.023), 그리고 자기공명영상에서 다초점 종괴 및 비종괴성 조영증강을 보인(p = 0.047) 환자군에서 유의미하게 큰 차이를 보였다.

결론

자기공명영상은 유방암의 병리학적 완전 관해와 잔류 암 크기의 평가에 있어서 정확도가 높은 검사이다. 유방암 아형과 병변의 영상의학적 소견이 자기공명영상의 정확도에 영향을 미친다.

Correlation between MRI morphological response patterns and histopathological tumor regression after neoadjuvant endocrine therapy in locally advanced breast cancer: a randomized phase II trial

PURPOSE

To correlate MRI morphological response patterns with histopathological tumor regression grading system based on tumor cellularity in locally advanced breast cancer (LABC)-treated neoadjuvant with third-generation aromatase inhibitors.

METHODS

Fifty postmenopausal patients with ER-positive/HER-2-negative LABC treated with neoadjuvant letrozole and exemestane given sequentially in an intra-patient cross-over regimen for at least 4 months with MRI response monitoring at baseline as well as after at least 2 and 4 months on treatment. The MRI morphological response pattern was classified into 6 categories: 0/complete imaging response; I/concentric shrinkage; II/fragmentation; III/diffuse; IV/stable; and V/progressive. Histopathological tumor regression was assessed based on the recommendations from The Royal College of Pathologists regarding tumor cellularity.

RESULTS

Following 2 and 4 months with therapy, the most common MRI pattern was pattern II (24/50 and 21/50, respectively). After 4 months on therapy, the most common histopathological tumor regression grade was grade 3 (21/50). After 4 months an increasing correlation is observed between MRI patterns and histopathology. The overall correlation, between the largest tumor diameter obtained from MRI and histopathology, was moderate and positive (r = 0.50, P-value = 2e-04). Among them, the correlation was highest in type IV (r = 0.53).

CONCLUSION

The type II MRI pattern "fragmentation" was more frequent in the histopathological responder group; and types I and IV in the non-responder group. Type II pattern showed the best endocrine responsiveness and a relatively moderate correlation between sizes obtained from MRI and histology, whereas type IV pattern indicated endocrine resistance but the strongest correlation between MRI and histology.

Imaging breast cancer response during neoadjuvant systemic therapy

Neoadjuvant systemic therapy is used to enable breast-conserving surgery in patients with large primary operable breast cancers. It is important to be able to accurately assess response to systemic therapy, both to assist the surgeon and for prognostic purposes. Moreover, a proportion of women will fail to respond to treatment and would potentially benefit from either a change in therapy or earlier surgery rather than continuing completion of the planned course of treatment. Conventional techniques of assessing response (clinical examination, x-ray mammography and breast ultrasound) rely on changes in tumor size, which are often delayed and do not always correlate with pathologic response. This review examines the evidence for functional imaging techniques including scintimammography, functional computed tomography, dynamic magnetic resonance imaging, spectroscopy and positron emission tomography. These techniques measure changes in tumor vasculature, metabolism or proliferation and may prove to be earlier and more sensitive measures of response to systemic therapy, thus enabling tailoring of an individual's treatment.

Evaluation of the usefulness of breast CT imaging in delineating tumor extent and guiding surgical management: a prospective multi-institutional study

OBJECTIVE

The aim of the present study was to evaluate the usefulness of computed tomographic (CT) imaging in delineating tumor extent and guiding surgical management.

BACKGROUND

The routine use of preoperative magnetic resonance imaging (MRI) is a controversial issue in breast cancer management. Negative studies with regard to the utility of MRI might be due to differences in positioning during imaging and subsequent surgery.

METHODS

Candidates for breast-conserving surgery were eligible for the study. The surgeons marked the line of planned excision on the skin, which was also recorded on the CT image. Contrast-enhanced breast CT was performed in the supine surgical position. The CT results were used to help determine the extent of resection. The pathological findings were then compared with the CT-guided surgical plans.

RESULTS

A total of 297 patients were involved. The surgeons widened the extent of resection in 42 (14.1%, 95% confidence interval 10.1%-18.1%) patients on the basis of the CT findings. Among the 6 patients whose procedures were changed to mastectomy, 4 had pathologically multicentric tumors and 2 had widely spread intraductal components. The remaining 36 patients underwent quadrantectomy instead of wide excision on the basis of the CT images. There were 3 patients in whom conversion from wide excision to quadrantectomy resulted in overexcision. Preoperative breast CT may have reduced the positive margin rate and also correctly changed the extent of surgery in 13.1% of patients.

CONCLUSIONS

This prospective study suggests that breast CT, carried out in the supine position, is useful in the preoperative determination of the optimal surgical procedure.

Color Doppler ultrasonography for treatment response prediction and evaluation in breast cancer

Primary systemic therapy is a well-established modality of treatment in locally advanced breast cancer. Assessment of tumor response to chemotherapy not only helps in assessing the efficacy of the regimen used but also predicts the overall outcome of the patient. The tumor vascularity is a surrogate marker of tumor burden and this can be readily assessed by color Doppler ultrasound using various indices (resistivity index, pulsatility index and maximum flow velocity). The pre- and post-chemotherapy indices can be compared with in order assess the response to chemotherapy. Among various imaging modalities, MRI and PET have the highest sensitivity in detecting the tumor response, but they are not cost effective. Color Doppler ultrasound is a promising alternative for tumor response assessment owing to its availability, reproducibility and cost–effectiveness.

Is radiotherapy an option for early breast cancers with complete clinical response after neoadjuvant chemotherapy?

PURPOSE

To determine whether the exclusive use of radiotherapy (ERT) could be a treatment option after complete clinical response (cCR) to neoadjuvant chemotherapy (NCT) for early breast cancer (EBC).

METHODS AND MATERIALS

Between 1985 and 1999, 1,477 patients received NCT for EBC considered too large for primary conservative surgery. Of 165 patients with cCR, 65 patients were treated with breast surgery (with radiotherapy) and 100 patients were treated with ERT.

RESULTS

The two groups were comparable in terms of baseline characteristics, except for larger initial tumor sizes in the ERT group. There were no significant differences in overall, disease-free and metastasis-free survival rates. Five-year and 10-year overall survival rates were 91% and 77% in the no-surgery group and 82% and 79% in the surgery group, respectively (p = 0.9). However, a nonsignificant trend toward higher locoregional recurrence rates (LRR) was observed in the no-surgery group (31% vs. 17% at 10 years; p = 0.06). In patients with complete responses on mammography and/or ultrasound, LRR were not significantly different (p = 0.45, 10-year LRR: 21% in surgery vs. 26% in ERT). No significant differences were observed in terms of the rate of cutaneous, cardiac, or pulmonary toxicities.

CONCLUSIONS

Surgery is a key component of locoregional treatment for breast cancers that achieved cCR to NCT.

Accuracy of clinical evaluation of locally advanced breast cancer in patients receiving neoadjuvant chemotherapy

BACKGROUND

Physical examination (PE), mammography (MG), breast magnetic resonance imaging (MRI), fluorodeoxyglucose positron emission tomography (PET), and pathologic evaluation are used to assess primary breast cancer. To the authors' knowledge, their accuracy has not been well studied in patients receiving neoadjuvant chemotherapy. Accuracies of each modality in tumor and lymph node assessment in patients with T3/T4 tumors receiving neoadjuvant chemotherapy were compared.

METHODS

Forty-five patients of a prospective clinical trial studying T3-T4M0 tumors were included. Patients received neoadjuvant chemotherapy: docetaxel/carboplatin with or without trastuzumab before and/or after surgery (depending on HER-2/neu status and randomization). Tumor measurements by PE, MG, and MRI and lymph node status by PE and PET were obtained before and after neoadjuvant chemotherapy. Concordance among different clinical measurements was assessed and compared with the tumor and lymph node staging by pathology. Spearman correlation (r) and root mean square error (RMSE) were used to measure the accuracy of measurements among all modalities and between modalities and pathologic tumor size.

RESULTS

Compared with the tumor size measured by PE, MRI was more accurate than MG at baseline (r=0.559, RMSE=35.4% vs r=0.046, RMSE=66.1%). After neoadjuvant chemotherapy, PE correlated better with pathology than MG or MRI (r=0.655, RMSE=88.6% vs r=0.146, RMSE=147.1% and r=0.364, RMSE=92.6%). Axillary lymph node assessment after neoadjuvant chemotherapy demonstrated high specificity but low sensitivity by PET and PE.

CONCLUSIONS

Findings suggested that MRI was a more accurate imaging study at baseline for T3/T4 tumor, and PE correlated best with pathology finding. PET and PE both correctly predicted positive axillary lymph nodes but not negative lymph nodes.

[18F]FDG-PET predicts complete pathological response of breast cancer to neoadjuvant chemotherapy

PURPOSE

To evaluate, in breast cancer patients treated by neoadjuvant chemotherapy, the predictive value of reduction in FDG uptake with regard to complete pathological response (pCR).

METHODS

Forty-seven women with non-metastatic, non-inflammatory, large or locally advanced breast cancer were included. Tumour uptake of FDG was evaluated before and after the first course of neoadjuvant chemotherapy. Four indices were used: maximal and average SUV without or with correction by body surface area and glycaemia (SUV(max), SUV(avg), SUV(max-BSA-G) and SUV(avg-BSA-G), respectively). The predictive value of reduction in FDG uptake with respect to pCR was studied by logistic regression analysis. Relationships between baseline [(18)F]FDG uptake and prognostic parameters were assessed.

RESULTS

The relative decrease in FDG uptake (DeltaSUV) after the first course of neoadjuvant chemotherapy was significantly greater in the pCR group than in the non-pCR group (p < 0.000066). The four FDG uptake indices were all strongly correlated with each other. A decrease in SUV(max-BSA-G) of 85.4% +/- 21.9% was found in pCR patients, versus 22.6% +/- 36.6% in non-pCR patients. DeltaSUV(max-BSA-G) <-60% predicted the pCR with an accuracy of 87% and DeltaSUVs were found to be only factors predictive of the pCR at multivariate analysis. An elevated baseline SUV was associated with high mitotic activity (p < 0.0016), tumour grading (p < 0.004), high nuclear pleomorphism score (p < 0.03) and negative hormonal receptor status (p < 0.005).

CONCLUSION

In breast cancer patients, after only one course of neoadjuvant chemotherapy the reduction in FDG uptake is an early and powerful predictor of pCR.

Current Trends and Controversies over Pre-operative Chemotherapy for Women with Operable Breast Cancer

The multi-disciplinary approach, including surgery, chemotherapy, endocrine therapy and radiation therapy, has become the standard treatment for primary breast cancer patients. The indication of pre-operative chemotherapy has been extended to women with potentially operable breast cancer based on the results of large randomized studies and has become an attractive option that extends the chance of breast conservation. The clinical and pathological responses to pre-operative chemotherapy correlates with long-term outcome. The anthracycline-containing regimen is now considered the standard. Sequential administration of non-cross-resistant drugs, namely taxanes, improves local tumor response but its long-term benefit has been controversial. Prediction of response to pre-operative chemotherapy still remains a challenge. Identification of useful predictive markers and development of molecular-targeted drugs is the key to individualized therapy in the future.

Accuracy of physical examination, ultrasonography, and mammography in predicting residual pathologic tumor size in patients treated with neoadjuvant chemotherapy

OBJECTIVE

To assess the accuracy of physical examination, ultrasonography, and mammography in predicting residual size of breast tumors following neoadjuvant chemotherapy.

BACKGROUND

Neoadjuvant chemotherapy is an accepted part of the management of stage II and III breast cancer. Accurate prediction of residual pathologic tumor size after neoadjuvant chemotherapy is critical in guiding surgical therapy. Although physical examination, ultrasonography, and mammography have all been used to predict residual tumor size, there have been conflicting reports about the accuracy of these methods in the neoadjuvant setting.

METHODS

We reviewed the records of 189 patients who participated in 1 of 2 protocols using doxorubicin-containing neoadjuvant chemotherapy, and who had assessment by physical examination, ultrasonography, and/or mammography no more than 60 days before their surgical resection. Size correlations were performed using Spearman rho analysis. Clinical and pathologic measurements were also compared categorically using the weighted kappa statistic.

RESULTS

Size estimates by physical examination, ultrasonography, and mammography were only moderately correlated with residual pathologic tumor size after neoadjuvant chemotherapy (correlation coefficients: 0.42, 0.42, and 0.41, respectively), with an accuracy of +/-1 cm in 66% of patients by physical examination, 75% by ultrasonography, and 70% by mammography. Kappa values (0.24-0.35) indicated poor agreement between clinical and pathologic measurements.

CONCLUSION

Physical examination, ultrasonography, and mammography were only moderately useful for predicting residual pathologic tumor size after neoadjuvant chemotherapy.

A case of mucinous carcinoma of the breast that demonstrated a good pathological response to neoadjuvant chemotherapy despite a poor clinical response

A 30-year-old woman presented with a right breast tumor. Mucinous carcinoma was diagnosed by core needle biopsy (T2: 5 cm N1 M0). Despite receiving a neoadjuvant anthracycline and taxane regimen, the patient demonstrated no clinical response (NC). Based on the patient's strong preference, we performed breast-conserving surgery. On histological examination, we observed widespread mucus and a few viable malignant cells, a Grade 2 therapeutic response. Neither optimal management procedures nor guidelines for chemotherapy for primary mucinous carcinoma of the breast have been established. It is a reasonable assumption, however, that discordance between the clinical response and therapeutic response to neoadjuvant chemotherapy may occur in cases of mucinous carcinoma.

Diagnosis of complete response to neoadjuvant chemotherapy using diagnostic imaging in primary breast cancer patients

Advances in the therapeutic agents used for neoadjuvant chemotherapy (NAC) have recently achieved higher response rates and induced a greater number of pathologic complete responses (pCR) than ever before. The aim of this study is the diagnosis of pCR after NAC by diagnostic imaging of clinical complete response (cCR) patients. This study included 35 breast cancer patients who demonstrated cCR after receiving NAC with a combination of anthracycline and taxane from May 1998 to August 2003. Surgical treatment included breast-conserving therapy followed by radiotherapy or mastectomy. The identity of post-NAC lesions as either a complete response (CR) or partial response (PR) were made by mammography, ultrasonography, and contrast-enhanced computed tomography (CT). Among the 35 patients, 11 achieved pCR, including the disappearance of both invasive and intraductal components. Of the patients achieving pCR, eight were defined as CR and three were determined to be PR by CT. There was a significant relationship between the pCR and the determination of CR by CT. The determination of CR by ultrasonography was indicative of the disappearance of pathologic invasive components. While mammography appeared to reflect the observed histologic results, we did not observe any statistical differences. A subset of cases exhibited discrepancies between the imaging and pathologic results, likely due to the replacement of destroyed tumor cells by fibrosis and granulomatous tissue. The evaluation of CR by CT was significantly indicative of pCR. The positive predictive value, however, was not large enough to avoid surgical treatment. Further studies will be needed to establish a diagnosis of pCR.

Imaging in evaluation of response to neoadjuvant breast cancer treatment

The role of imaging for patients treated with neoadjuvant therapy for breast cancer is not only to evaluate the therapeutic response in terms of tumour shrinkage, but also to predict the histological response to chemotherapy, which is correlated to survival. Surgery and histopathological analysis after neoadjuvant therapy allow for an objective assessment of the accuracy of imaging techniques in evaluating response. The aim of this study is to compare the value of the different conventional and functional imaging techniques for determining response to neoadjuvant chemotherapy in breast cancer treatment.

The use of contrast-enhanced computed tomography before neoadjuvant chemotherapy to identify patients likely to be treated safely with breast-conserving surgery

OBJECTIVE

To select suitable candidates for breast-conserving treatment (BCT) after neoadjuvant chemotherapy (NAC), based on the classification of tumors into localized or diffuse types using contrast-enhanced computed tomography (CE-CT).

SUMMARY BACKGROUND DATA

A relatively high rate of loco-regional failure after BCT has been reported with breast cancer downstaged by NAC. Accurate assessment of the suitability of BCT and the response to NAC, before the initiation of NAC, will allow the optimal selection of an appropriate therapeutic course.

METHODS

We evaluated 110 consecutive patients with operable breast carcinomas measuring 3-cm or more in diameter by CE-CT after NAC treatment with doxorubicin and docetaxel at National Cancer Center Hospital, Tokyo, from May 1998 to November 2001. Lesions were classified as either localized or diffuse types by mammography (MMG), ultrasonography (US), and CE-CT.

RESULTS

Tumors designated as localized type by MMG, US, and CE-CT were reduced to tumors less than 3.0 cm (P < 0.0001) in a concentric circle (P < 0.0001). Localized tumors by CE-CT were treated safely with BCT maintaining a negative margin status (P = 0.01). In contrast, diffuse type tumors shrunk into a mosaic pattern consisting of tumors larger than 3.1 cm. Tumors classified as localized by CE-CT responded better pathologically than diffuse tumors (P = 0.0365). Multivariate analysis demonstrated that morphologic type by CE-CT and histologic type were significant predictors of candidates for safe BCT.

CONCLUSIONS

The classification of tumors into either localized or diffuse types, using CE-CT before NAC administration, accurately predicts which tumors will be suitable candidates for BCT after NAC.

The role of computed tomography in the selection of breast cancer treatment

Contrast-enhanced computed tomography (CE-CT) is one of the most sensitive imaging modalities. CE-CT plays a role in the following: (1) to determine the extent of breast cancer to select the appropriate breast conserving treatment (BCT). The sensitivity and specificity for the detection of extensive intraductal component (EIC) by CE-CT were 82-88% and 75-89%, respectively. The pathological extent of tumors significantly correlated with the extension revealed by CE-CT; (2) to determine the extent of resection following neoadjuvant chemotherapy, which is difficult to assess by other modalities; (3) to diagnose axillary lymph node metastasis. The sensitivity and specificity are 79-90% and 70-89%, respectively; (4) to identify occult breast cancer with axillary metastasis and to diagnose local recurrence after BCT.

Current limits of knowledge in adjuvant and neoadjuvant endocrine therapy of breast cancer: the need for more clinical research

Adjuvant endocrine therapy following surgical resection of early, endocrine sensitive breast cancer has proven benefits in reducing risk of recurrence and death, as demonstrated in many mature well controlled clinical trials. The introduction of new endocrine therapies as potential alternatives to tamoxifen or ovarian ablation and the incorporation of neoadjuvant endocrine therapy into the overall management strategy continue to provide exciting challenges for clinical research. In this article the focus is on as yet unanswered questions pertinent to adjuvant or neoadjuvant endocrine therapy for breast cancer. In the process, we broadly outline the current limits of knowledge as we understand it. Many relevant and current clinical trials are ongoing and a list of these with contact details or references are provided. Definitive data is urgently needed in many areas and, when available, will provide important evidence on which the management of breast cancer patients in future can be based. Participation in relevant clinical trials is vital for future progress.

Emerging role of taxanes in adjuvant and neoadjuvant therapy for breast cancer: the potential and the questions

Adjuvant chemotherapy has gained increasing prominence in the treatment of nonmetastatic breast cancer, producing gradual improvement in the survival of these patients. The taxanes offer great hope for adding to the progress in adjuvant treatment, but data have been conflicting. Early results of multi-center trials testing the sequential addition of paclitaxel to anthracycline-based adjuvant chemotherapy have perhaps been prematurely reported, but have already made a major impact on patterns of care for node-positive and even some node-negative patients. The early dramatic improvements in CALG 9344 are fading with time, however, and have not been confirmed by a second similar trial, NSABP B-28. Moreover, it cannot be stated with certainty whether the modest improvements observed by sequential addition of paclitaxel reflect the ability of this drug to kill anthracycline-resistant cancer cells or the increased total duration and amount of treatment. By contrast, the early results of the BCIRG 001 trial suggest that combining docetaxel with doxorubicin may significantly increase survival, but these early results should be viewed with caution and do not necessarily mean that docetaxel is superior to paclitaxel. The role of neoadjuvant chemotherapy for breast cancer has also expanded over the past 2 decades, from its initial use for inoperable locally advanced breast cancer (LABC) to its current use for patients with large operable tumors to make BCT feasible. The neoadjuvant approach also has an important role in clinical trials, where it will allow more rapid comparison of treatment regimens than can be accomplished in the adjuvant setting and provides an opportunity to analyze biologic markers as predictors of response. The value of this approach, however, will ultimately depend on a clear demonstration, not yet available, that a change in therapy that increases primary tumor response will also lead to improved long-term survival. The roles of docetaxel and paclitaxel in the neoadjuvant setting has been actively investigated over the past 5 to 10 years, and exciting results are beginning to emerge. Clearly, docetaxel has potent antitumor activity against breast cancer. Several preliminary results suggest that addition of docetaxel to an anthracycline-based regimen, particularly when added sequentially, as in NASBP B-27 and the Aberdeen trial, results in higher clinical and pathologic response rates. Whether this will translate into increased long-term survival, as suggested by the early results of the Aberdeen trial, remains to be seen. Whether sequential addition of docetaxel to doxorubicin is more or less effective than combining these drugs also has not been established. The results from M.D. Anderson suggesting that paclitaxel given on a weekly schedule was more effective than the same drug given every 3 weeks are particularly intriguing, and they may help to explain why the adjuvant studies with paclitaxel given every 3 weeks have not produced more dramatic results, whereas several studies with docetaxel (also given every 3 weeks) seem so positive. It may be that paclitaxel, with activity that is highly schedule-dependent and for which cell killing is more dependent on the duration of exposure, works best when given weekly, whereas the efficacy of docetaxel depends less on scheduling. If this is the case, then weekly paclitaxel may turn out to be equally effective as docetaxel appears to be even when given every 3 weeks. Alternatively, if docetaxel is simply a more active drug, then giving docetaxel weekly may be the most effective taxane regimen. Whether routine use of weekly chemotherapy administration in the adjuvant or neoadjuvant setting is practical or not is largely subjective, but at least it appears that the toxicity of this approach is acceptable. These issues are also being addressed in ongoing trials. Finally, taxanes have produced dramatic increases in response rates in the neoadjuvant setting, but, except for the Aberdeen trial, survival benefits have not yet been shown. If, however, the high pCR rates do translate into overall survival benefits that are greater than adding taxanes to postoperative adjuvant therapy, it might suggest that, unlike other drugs, taxanes are actually more effective before surgery than after, as predicted originally based on laboratory experiments. Clearly, much work remains to be done in this area of research on breast cancer therapy.

Two special types of breast cancer presenting as progressive disease after neoadjuvant chemotherapy with docetaxel plus doxorubicin

Seventy-eight patients with primary breast cancer over 3 cm in diameter in stages II A, II B, III A and III B according to the UICC classification received neoadjuvant chemotherapy from August 1, 1998 to June 30, 2000 at the Breast Division of the National Cancer Center Hospital. Neoadjuvant chemotherapy consisted of doxorubicin (Adriamycin: ADM) 50 mg/m(2) and docetaxel (Taxotere: DOC) 60 mg/m(2) every three weeks. The overall clinical response to this regimen was 88% (69/78). Although neoadjuvant chemotherapy with this regimen achieved good responses in patients with breast cancer, 2 patients presented with progressive disease (PD) after treatment. One patient had inflammatory breast cancer (IBC) and the other had primary squamous cell carcinoma (SCC) of the breast. There were 4 cases of IBC and one case of SCC of the breast who received neoadjuvant chemotherapy in this series. Our observations suggest that this regimen might not be effective for these types of breast cancer.

Assessment of response by breast helical computed tomography to neoadjuvant chemotherapy in large inflammatory breast cancer

Breast helical computed tomography (CT) was evaluated for use in assessing response to neoadjuvant chemotherapy and residual tumor volume. Forty-three patients with large, inflammatory breast cancers (stage IIA, 12; IIB, 13; IIIA, 9; IIIB, 9), all histologically confirmed by core biopsy, were evaluated prior to and following neoadjuvant chemotherapy. The breast helical CT procedure involved patients in the prone position using single acquisition during quiet respiration following intravenous injection of nonionic contrast material. Helical CT results (3.2-mm slices and maximum intensity projections) were compared to clinical and mammographic evaluations, as well as to pathologic findings. All tumors were clearly visible by breast helical CT, showing important tumor enhancement. Helical CT evaluation of response to chemotherapy (using World Health Organization criteria) corresponded better with mammography (78%, Cohen's kappa statistic (kappa) = 0.65) than with clinical examination (53%, kappa = 0.30). Helical CT measurement of residual tumor volume after neoadjuvant chemotherapy and correlation with pathologic findings were globally satisfactory. The intraclass correlation coefficient was 0.69 (excellent for rounded opacities [0.97], but not as good for diffuse, scattered or multinodular opacities [0.60]). By contrast, clinical and mammographic correlations were globally unsatisfactory (0.49 and 0.28, respectively). Breast helical CT can be very useful in the quantitative assessment of response to neoadjuvant chemotherapy and preoperative determination of residual tumor volume. For this reason, it can be considered an alternative to breast magnetic resonance imaging because of its simplicity, rapidity, and accessibility.