Comparison of magnetic resonance imaging, multidetector row computed tomography, ultrasonography, and mammography for tumor extension of breast cancer

Exploration of tumor size measurement methods in preoperative breast cancer assessment using whole-body silicon photomultiplier PET: feasibility and first results

PURPOSE

Whole-body silicon photomultiplier positron emission tomography (WB SiPM PET) could be used to diagnose breast cancer spread before lumpectomy. We aimed to investigate the method of measuring the tumor size by WB SiPM PET as a basis for diagnosing breast cancer spread in the breast.

MATERIALS AND METHODS

We retrospectively reviewed 35 breast cancer lesions in 32 patients who underwent WB SiPM PET/CT in the prone position as preoperative breast cancer examinations from September 2020 to March 2022. In all cases, a 20-mm spherical VOI was placed in the normal mammary gland to measure the mean standardised uptake value (SUVmean) and the standard deviation (SD) of 18F-fluorodeoxyglucose (FDG) uptake. We prepared four types of candidates (SUVmean + 2 SD, SUVmean + 3 SD, 1.5 SUVmean + 2 SD, 1.5 SUVmean + 3 SD) for thresholds for delineating tumor contours on PET images. On the semiautomatic viewer soft, the maximum tumor sizes were measured at each of the four thresholds and compared with the pathological tumor sizes, including the extensive intraductal component (EIC).

RESULTS

The lesion detection sensitivity was 97% for WB SiPM PET. PET detected 34 lesions, excluding 4-mm ductal carcinomas in situ (DCIS). PET measurements at the '1.5 SUVmean + 2 SD' threshold demonstrated values closest to the pathological tumor sizes, including EIC. Moreover, '1.5 SUVmean + 2 SD' had the highest concordance (63%).

CONCLUSIONS

The study demonstrated that among various PET thresholds, the '1.5 SUVmean + 2 SD' threshold exhibited the best performance. However, even with this threshold, the concordance rate was limited to only 63%.

Assignment of the biological value of solid breast masses based on quantitative evaluations of spectral CT examinations using electron density mapping, Zeffective mapping and iodine mapping

OBJECTIVE

We aimed to asses, in a clinical setting, whether the newly available quantitative evaluation of electron density (ED) in spectral CT examinations of the breast provide information on the biological identity of solid breast masses and whether ED maps yield added value to the diagnostic information of iodine maps and Zeff maps calculated from the same CT image datasets.

METHODS

All patients at the University Breast Cancer Center who underwent a clinically indicated Dual Layer Computed Tomography (DLCT) examination for staging of invasive breast cancer from 2018 to 2020 were prospectively included. Iodine concentration maps, Zeff maps and ED maps were automatically reconstructed from the DLCT datasets. Region of interest (ROI) based evaluations in the breast target lesions and in the aorta were performed semi-automatically in identical anatomical positions using dedicated evaluation software. Case-by-case evaluations were carried independently by 2 of 4 radiologists for each examination, respectively. Statistical analysis derived from the ROIs was done by calculating ROC/AUC curves and Youden indices.

RESULTS

The evaluations comprised 166 DLCT examinations. In the ED maps the measurements in the breast target lesions yielded Youden cutpoints of 104.0% (reader 1) and 103.8% (reader 2) resulting in AUCs of 0.63 and 0.67 at the empirical cutpoints. The variables "Zeff" and "iodine content" derived from the target lesions showed superior diagnostical results, with a Youden cutpoint of 8.0 mg/ml in the iodine maps and cutpoints of 1.1/1.2 in the Zeff maps the AUCs ranging from 0.84 to 0.85 (p = 0.023 to <0.000). The computational combination of Zeff and ED measurements in the target lesions yielded a slight AUC increase (readers 1: 0.85-0.87; readers 2: 0.84-0.94). The ratios of the measured values in the target lesions normalized to the values measured in the aorta showed comparable results. The AUCs of ED derived from the cutpoints showed inferior results to those derived from the Zeff maps and iodine maps (ED: 0.64 and 0.66 for reader 1 and 2; Zeff: 0.86 for both readers; iodine content: 0.89 and 0.86 for reader 1 and 2, respectively). The computational combination of the ED results and the Zeff measurements did not lead to a clinically relevant diagnostic gain with AUCs ranging from 0.86 to 0.88.

CONCLUSIONS

Quantitative assessments of Zeff, iodine content and ED all targeting the physical and chemical aspects of iodine uptake in solid breast masses confirmed diagnostically robust cutpoints for the differentiation of benign and malignant findings (Zeff < 7.7, iodine content of <0.8 mg/ml). The evaluations of the ED did not indicate any added diagnostic value beyond the quantitative assessments of Zeff and iodine content. Further research is warranted to develop suitable clinical indications for the use of ED maps.

Contrast-enhanced mammography (CEM) versus MRI for breast cancer staging: detection of additional malignant lesions not seen on conventional imaging

BACKGROUND

Contrast-enhanced mammography (CEM) is more available than MRI for breast cancer staging but may not be as sensitive in assessing disease extent. We compared CEM and MRI in this setting.

METHODS

Fifty-nine women with invasive breast cancer underwent preoperative CEM and MRI. Independent pairs of radiologists read CEM studies (after reviewing a 9-case set prior to study commencement) and MRI studies (with between 5 and 25 years of experience in breast imaging). Additional lesions were assigned National Breast Cancer Centre (NBCC) scores. Positive lesions (graded NBCC ≥ 3) likely to influence surgical management underwent ultrasound and/or needle biopsy. True-positive lesions were positive on imaging and pathology (invasive or in situ). False-positive lesions were positive on imaging but negative on pathology (high-risk or benign) or follow-up. False-negative lesions were negative on imaging (NBCC < 3 or not identified) but positive on pathology.

RESULTS

The 59 women had 68 biopsy-proven malignant lesions detected on mammography/ultrasound, of which MRI demonstrated 66 (97%) and CEM 67 (99%) (p = 1.000). Forty-one additional lesions were detected in 29 patients: six of 41 (15%) on CEM only, 23/41 (56%) on MRI only, 12/41 (29%) on both; CEM detected 1/6 and MRI 6/6 malignant additional lesions (p = 0.063), with a positive predictive value (PPV) of 1/13 (8%) and 6/26 (23%) (p = 0.276).

CONCLUSIONS

While MRI and CEM were both highly sensitive for lesions detected at mammography/ultrasound, CEM may not be as sensitive as MRI in detecting additional otherwise occult foci of malignancy.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registry: ACTRN 12613000684729.

Virtual monochromatic spectral CT imaging in preoperative evaluations for intraductal spread of breast cancer: comparison with conventional CT and MRI

PURPOSE

To investigate the efficacy of virtual monochromatic spectral computed tomography imaging (VMI) in the preoperative evaluation for intraductal spread of breast cancer.

MATERIALS AND METHODS

Twenty-four women who underwent spectral CT and were pathologically diagnosed with ductal carcinoma with a ≥ 2-cm noninvasive component were retrospectively enrolled in Group 1. Twenty-two women with 22 lesions pathologically diagnosed with ductal carcinoma in situ or microinvasive carcinoma were enrolled in Group 2. We compared the contrast-to-noise ratios (CNRs) of the lesions on conventional 120-kVp CT images and 40-keV VMIs in Group 1. Two board-certified radiologists measured the maximum diameters of enhancing areas on 120-kVp CT, 40-keV VMI, and MRI in Group 2 and compared with histopathological sizes.

RESULTS

The quantitative assessment of Group 1 revealed that the mean ± SD of the CNRs in the 40-keV images were significantly greater than those in the 120-kVp images (5.5 ± 1.9 vs. 3.6 ± 1.5, p < 0.0001). The quantitative assessment of Group 2 demonstrated that the lesion size observed in the conventional 120-kVp CT images by both readers was significantly underestimated as compared to the histopathological size (p = 0.017, 0.048), whereas both readers identified no significant differences between the lesion size measured on 40-keV VMI and the histopathological data. In a comparison with MRI, 40-keV VMI provided measurement within a 10-mm error range in more lesions as compared to the conventional 120-kVp CT.

CONCLUSION

VMI improves the evaluation of intraductal spread and is useful for the preoperative evaluations of breast cancer.

Prospective Clinical Trial on Expanding Indications for Cryosurgery for Early Breast Cancers

INTRODUCTION

This is a prospective single arm clinical trial on cryosurgery for early breast cancers, to evaluate the expanded criteria to tumors larger than 1.5 cm and non-luminal breast cancers.

METHODS

Inclusion criteria include Solitary T1 breast cancers of any immunohistotypes. Cryosurgery was performed using the IceCure ProSense Cryoablation System. Lumpectomy of the cryoablated tumor was then performed 8 weeks after cryosurgery.

RESULTS

Fifteen patients underwent cryosurgery followed by lumpectomy (BCS). Median age was 53 years old 5 (33.3%) patients had ductal carcinoma in situ (DCIS), while 10 (66.7%) patients had invasive ductal carcinoma (IDC), of which 5 (50%) patients had luminal type cancers of which 3 (60%) were luminal A and 2 (40%) luminal B, 3 (30%) patients had HER2 enriched invasive carcinoma and 2 (20%) patients had triple negative IDC. Median tumor size was 13mm (Range 8.6-18mm). Seven (46.7%) patients were found to have residual cancer in the post-cryosurgery lumpectomy specimen. All residual cancers were found at the periphery of the cryoablated breast tissue. All breast cancers were otherwise completely ablated centrally as confirmed by routine histopathology, immunochemistry and TUNEL assay for evaluation of cell viability. None of the tumor factors such as tumor biology, as well as surgical factors such as ablation time and iceball size, were associated with risk of residual cancer. None of the 15 patients developed post-operative complications.

CONCLUSION

Residual cancer occurs at the periphery of the cryoablation site, careful pre-operative planning and intra-operative monitoring is crucial to ensure complete cryoablation.

The Effect of PACS in Breast Tumor Diagnosis Based on Numerical Analysis

The incidence and mortality rates are increasing year by year, and the incidence of the disease is gradually becoming younger. The purpose of this study was to investigate the clinical diagnostic value of PACS in breast tumor patients. Methods. 20 patients with breast tumor diagnosed by PACS were selected for the study, and the diagnosis was confirmed by pathological puncture or surgery. Results. The detection rates of breast tumor by MRI and CT were 94.44% and 96.67%, the sensitivities were 18.82% breast tumor and 96.67%, and the specificities were 53.84% and 54.54%, with no statistically significant difference ( $P>0.05$ ). There was no statistically significant difference in the detection rate of invasive lobular carcinoma (LDC) and PACS ( $P>0.05$ ). Conclusion. PACS has a greater detection rate for breast tumor and offers some diagnostic usefulness in diagnosing malignant breast tumor. The detection rate of breast tumors can be increased by selecting the most appropriate diagnostic tool for the patient’s current circumstances.

Breast Radiotherapy after Oncoplastic Surgery—A Multidisciplinary Approach

Simple Summary

This article aims to review and summarize the current evidence for the role of oncoplastic breast surgery and the implications this may have on other therapies, such as radiotherapy and chemotherapy.

Abstract

Oncoplastic breast surgery encompasses a range of techniques used to provide equitable oncological outcomes compared with standard breast surgery while, simultaneously, prioritizing aesthetic outcomes. While the outcomes of oncoplastic breast surgery are promising, it can add an extra complexity to the treatment paradigm of breast cancer and impact on decision-making surrounding adjuvant therapies, like chemotherapy and radiotherapy. As such, early discussions at the multidisciplinary team meeting with surgeons, medical oncologists, and radiation oncologists present, should be encouraged to facilitate best patient care.

Predictive value of ductal carcinoma in situ with invasive breast cancer in core needle biopsies for final pathologic size of intraductal elements

Preoperative evaluations of the size of ductal carcinoma in situ (DCIS) extension in invasive breast cancer (IBC) are problematic and markers of the actual size of DCIS remain elusive. This study aimed to quantify DCIS on core needle biopsy (CNB) and investigated its association with degree of DCIS extension on paired resection specimens, instead of with presence or absence of an extensive intraductal component or margin status as in earlier studies. This series examined 150 IBCs diagnosed from paired CNB and resection specimens. The DCIS/invasion ratio was calculated using the sum of each element size from CNB. In resection specimens, cases in which the greatest dimension of DCIS extension was longer than the greatest dimension of invasive size were defined as extended DCIS (Ext-DCIS). DCIS/invasion ratio level correlated positively with the degree of Ext-DCIS (P = 0.003). Using receiver operating characteristic curve analysis, setting cases with the subgroup of DCIS extension with greatest dimension > 2.5 times that of the invasive size in the resection specimen (Ext-DCIS > 2.5) as the positive class provided the best discrimination ability for DCIS/invasion ratio (0.375). In multivariate analysis, DCIS/invasion ratio > 0.375 was significantly associated with Ext-DCIS > 2.5 (P = 0.033). In conclusion, DCIS/invasion ratio > 0.375 in CNB was identified as a predictor of Ext-DCIS > 2.5 in resection specimens, suggesting that an approach combining DCIS/invasion ratio from CNB with preoperative staging may better predict the extent of DCIS and facilitate better surgical planning.

Added value of abbreviated breast magnetic resonance imaging for assessing suspicious microcalcification on screening mammography-a prospective study

OBJECTIVES

To investigate the added diagnostic value of abbreviated breast magnetic resonance imaging (MRI) for suspicious microcalcifications on screening mammography.

METHODS

This prospective study included 80 patients with suspicious calcifications on screening mammography who underwent abbreviated MRI before undergoing breast biopsy between August 2017 and September 2020. The abbreviated protocol included one pre-contrast and the first post-contrast T1-weighted series. MRI examinations were interpreted as either positive or negative based on the visibility of any significant enhancement. The positive predictive value (PPV) was compared before and after the MRI.

RESULTS

Of the 80 suspicious microcalcifications, 33.8% (27/80) were malignant and 66.2% (53/80) were false positives. Abbreviated MRI revealed 33 positive enhancement lesions, and 25 and two lesions showed true-positive and false-negative findings, respectively. Abbreviated MRI increased PPV from 33.8 (27 of 80 cases; 95% CI: 26.2%, 40.8%) to 75.8% (25 of 33 cases; 95% CI: 62.1%, 85.7%). A total of 85% (45 of 53) false-positive diagnoses were reduced after abbreviated MRI assessment.

CONCLUSIONS

Abbreviated MRI added significant diagnostic value in patients with suspicious microcalcifications on screening mammography, as demonstrated by a significant increase in PPV with a potential reduction in unnecessary biopsy.

KEY POINTS

• Abbreviated breast magnetic resonance imaging increased the positive predictive value of suspicious microcalcifications on screening mammography from 33.8 (27/80 cases) to 75.8% (25/33 cases) (p < .01). • Abbreviated magnetic resonance imaging helped avoid unnecessary benign biopsies in 85% (45/53 cases) of lesions without missing invasive cancer.

Utility of 70-kV single-energy CT in depicting the extent of breast cancer for preoperative planning

PURPOSE

To evaluate the detectability of breast cancer and visibility of the tumor extent using 70-kV single-energy contrast-enhanced (CE) breast computed tomography (70-kV CECT) compared with CE breast magnetic resonance imaging (CEMR).

METHODS

Between 2013 and 2015, 110 patients with 112 breast cancer lesions who underwent breast surgery after undergoing both 70-kV CECT and CEMR were enrolled. The major axis lengths of the breast lesion were measured and compared with the pathologically determined major axes. Agreement in the measured major axes was evaluated using the intra-class correlation coefficient (ICC).

RESULTS

Both 70-kV CECT and CEMR depicted all breast cancer lesions. The mean major axis was 3.0 (95% confidence interval [CI], 2.5-3.4) cm on CECT and 2.9 (2.6-3.3) cm on CEMR. The mean differences between the pathologically and radiologically measured major axes on 70-kV CECT and CEMR were 0.9 (0.7-1.1) and 1.0 (0.8-1.2) cm, respectively. The accuracy of the radiological major axes compared with the pathological major axes was 82.1% and 80.4% on CECT and CEMR, respectively (p = 0.81). The major axes on the two modalities demonstrated moderate agreement (ICC = 0.69, 95% CI 0.58-0.77). Pathologically and radiologically measured major axes on 70-kV CECT and CEMR demonstrated excellent agreement (ICC = 0.91, 95% CI 0.93-0.96).

CONCLUSIONS

Low-tube voltage (70-kV) CECT is the preferred modality to identify breast cancer lesions and tumor extent for preoperative planning because it has a similar diagnostic ability to CEMR and can be performed in the supine position.

Comparison of Mammography and Ultrasonography for Tumor Size of DCIS of Breast Cancer

OBJECTIVE

Accurate assessment of breast tumor size preoperatively is important for the initial decision-making in surgical approach. Therefore, we aimed to compare efficacy of mammography and ultrasonography in ductal carcinoma in situ (DCIS) of breast cancer.

METHODS

Preoperative mammography and ultrasonography were performed on 104 women with DCIS of breast cancer. We compared the accuracy of each of the imaging modalities with pathological size by Pearson correlation. For each modality, it was considered concordant if the difference between imaging assessment and pathological measurement is less than 0.5cm.

RESULTS

At pathological examination tumor size ranged from 0.4cm to 7.2cm in largest diameter. For mammographically determined size versus pathological size, correlation coefficient of r was 0.786 and for ultrasonography it was 0.651. Grouped by breast composition, in almost entirely fatty and scattered areas of fibroglandular dense breast, correlation coefficient of r was 0.790 for mammography and 0.678 for ultrasonography; in heterogeneously dense and extremely dense breast, correlation coefficient of r was 0.770 for mammography and 0.548 for ultrasonography. In microcalcification positive group, coeffient of r was 0.772 for mammography and 0.570 for ultrasonography. In microcalcification negative group, coeffient of r was 0.806 for mammography and 0.783 for ultrasonography.

CONCLUSION

Mammography was more accurate than ultrasonography in measuring the largest cancer diameter in DCIS of breast cancer. The correlation coefficient improved in the group of almost entirely fatty/ scattered areas of fibroglandular dense breast or in microcalcification negative group.

Comparison of postoperative CT- and preoperative MRI-based breast tumor bed contours in prone position for radiotherapy after breast-conserving surgery

Objectives

To compare the target volume of tumor bed defined by postoperative computed tomography (post-CT) in prone position registered with or without preoperative magnetic resonance imaging (pre-MRI).

Methods

A total of 22 patients were included with early-stage breast invasive ductal cancer, who have undergone breast-conservative surgery and received the pre-MRI and post-CT in prone position. The MRI sequences (T1W, T2W, T2W-SPAIR, DWI, dyn-eTHRIVE, sdyn-eTHRIVE) were delineated and manually registered to CT, respectively. The clinical target volumes (CTVs) and planning target volumes (PTVs) were contoured on CT and different MRI sequences, respectively. Differences were measured in terms of consistence index (CI), dice coefficient (DC), geographical miss index (GMI), and normal tissue index (NTI).

Results

The differences of delineation volumes among CT and MRIs were significant, both in the CTVs (p = 0.035) and PTVs (p < 0.001). The values of CI and DC for sdyn-eTHRIVE registration to CT were the largest among all MRI sequences, but GMI and NTI were the smallest. No obvious linear correlation (p > 0.05) between the CI derived from the registration of CT and sdyn-eTHRIVE of CTV with the breast volume, the cavity visualization score (CVS) of CT, time interval from surgery to CT simulation, the maximum diameter of the intraoperative mass, and the number of titanium clips, respectively.

Conclusions

The CTVs and PTVs in MRI sequences were all smaller than those in CT. The pre-MRI, especially the sdyn-eTHRIVE, could be used to optimize the post-CT-based target delineation of breast cancer.

Key Points

• Registered pre-MRI to post-CT in order to improve the accuracy of target volume delineation of breast cancer.

• The CTVs and PTVs in MRI sequences were all smaller than those in CT.

• The sdyn-eTHRIVE of pre-MRIs may be a better choice to improve the delineation of CT-based CTV and PTV.

Electronic supplementary material

The online version of this article (10.1007/s00330-020-07085-0) contains supplementary material, which is available to authorized users.

Preoperative tumor size measurement in breast cancer patients: which threshold is appropriate on computer-aided detection for breast MRI?

Background

Computer-aided detection (CAD) can detect breast lesions by using an enhancement threshold. Threshold means the percentage of increased signal intensity in post-contrast imaging compared to precontrast imaging. If the pixel value of the enhanced tumor increases above the set threshold, CAD provides the size of the tumor, which is calculated differently depending on the set threshold. Therefore, CAD requires the accurate setting of thresholds. We aimed to compare the diagnostic accuracy of tumor size measurement using MRI and CAD with 3 most commonly used thresholds and to identify which threshold is appropriate on CAD in breast cancer patients.

Methods

A total of 130 patients with breast cancers (80 invasive cancers and 50 ductal carcinoma in situ [DCIS]) who underwent preoperative MRI with CAD and surgical treatment were included. Tumor size was manually measured on first contrast-enhanced MRI and acquired by CAD using 3 different thresholds (30, 50, and 100%) for each tumor. Tumor size measurements using MRI and CAD were compared with pathological sizes using Spearman correlation analysis. For comparison of size discrepancy between imaging and pathology, concordance was defined as estimation of size by imaging within 5 mm of the pathological size. Concordance rates were compared using Chi-square test.

Results

For both invasive cancers and DCIS, correlation coefficient rho (r) between tumor size on imaging and pathology was highest at CAD with 30% threshold, followed by MRI, CAD with 50% threshold, and CAD with 100% threshold (all p <  0.05). For invasive cancers, the concordance rate of 72.5% at CAD with 30% threshold showed no difference with that of 62.5% at MRI (p = 0.213). For DCIS, the concordance rate of 30.0% at CAD with 30% threshold showed no difference with that of 36.0% at MRI (p = 0.699). Compared to MRI, higher risk of underestimation was noted when using CAD with 50% or 100% threshold for invasive cancers and when using CAD with 100% threshold for DCIS.

Conclusion

For CAD analysis, 30% threshold is the most appropriate threshold whose accuracy is comparable to manual measurement on MRI for tumor size measurement. However, clinicians should be aware of the higher risk of underestimation when using CAD with 50% threshold for tumor staging in invasive cancers.

The Japanese Breast Cancer Society Clinical Practice Guidelines for Breast Cancer Screening and Diagnosis, 2018 Edition

This article updates readers as to what is new in the Japanese Breast Cancer Society Clinical Practice Guidelines for Breast Cancer Screening and Diagnosis, 2018 Edition. Breast cancer screening issues are covered, including matters of breast density and possible supplemental modalities, along with appropriate pre-operative/follow-up diagnostic breast imaging tests. Up-to-date clinical practice guidelines for breast cancer screening and diagnosis should help to provide patients and clinicians with not only evidence-based breast imaging options, but also accurate and balanced information about the benefits and harms of intervention, which ultimately enables shared decision making about imaging test plans.

Dual-energy computed tomography for evaluation of breast cancer: value of virtual monoenergetic images reconstructed with a noise-reduced monoenergetic reconstruction algorithm

PURPOSE

To evaluate the image quality and lesion visibility of virtual monoenergetic images (VMIs) reconstructed using a new monoenergetic reconstruction algorithm (nMERA) for evaluation of breast cancer.

MATERIALS AND METHODS

Forty-two patients with 46 breast cancers who underwent 4-phasic breast contrast-enhanced computed tomography (CT) using dual-energy CT (DECT) were enrolled. We selected the peak enhancement phase of the lesion in each patient. The selected phase images were generated by 120-kVp-equivalent linear blended (M120) and monoenergetic reconstructions from 40 to 80 keV using the standard reconstruction algorithm (sMERA: 40, 50, 60, 70, 80) and nMERA (40 +, 50 +, 60 +, 70 +, 80 +). The contrast-to-noise ratio (CNR) was calculated and objectively analyzed. Two independent readers subjectively scored tumor visibility and image quality each on a 5-point scale.

RESULTS

The CNR at 40 + and tumor visibility scores at 40 + and 50 + were significantly higher than those on M120. The CNR at 50 + was not significantly different from that on M120. However, the overall image quality score at 40 + was significantly lower than that at 50 + and on M120 (40 + vs M120, P < 0.0001 and 40 + vs 50 +, P = 0.0001).

CONCLUSIONS

VMI reconstructed with nMERA at 50 keV is preferable for evaluation of patients with breast cancer.

Low Breast Conserving Surgery (BCS) rates in public hospitals in Malaysia: The effect of stage and ethnicity

INTRODUCTION

Breast-conserving surgery (BCS) with radiation therapy is the procedure of choice for early-stage breast cancer. Survival and locoregional recurrence is non-inferior to mastectomy, with superior cosmetic and psycho-social outcomes. Differing health systems have demonstrated a wide variation in the rate of BCS. Little is known about the rate of BCS and factors influencing its practice in middle resource countries. This study aims to examine the BCS rates in Malaysia and to identify factors influencing its uptake.

METHODOLOGY

This is a multi-centre, cross-sectional study involving the University of Malaya Medical Centre (UMMC), Queen Elizabeth II Hospital (QEH), and Tengku Ampuan Rahimah Hospital (TARH). Patients diagnosed with invasive breast cancer from January 2014 to December 2015 were included, excluding stromal cancers and lymphomas. Univariate and multivariate analyses identified factors influencing BCS.

RESULTS

A total of 1005 patients were diagnosed with breast cancer in the allocated time frame. Excluding incomplete records and those who did not have surgery, 730 patients were analysed. Overall BCS rate was 32.9%. The BCS rate was highest at QEH (54.1%), followed by UMMC (29.5%), and TARH (17.4%). 16.9% had BCS after neoadjuvant therapy. Factors influencing BCS uptake included age, ethnic group, breast-surgeon led services, AJCC Stage, tumour size, HER-2 expression, and tumour grade.

CONCLUSIONS

The rate of BCS in Malaysia is low. A wide variation of rate exists among the studied hospitals. Younger age, earlier AJCC stage, and the presence of a Breast sub-specialist surgeon, would make it more likely that the patient has her breast conserved.

Magnetic resonance imaging of the breast: role in the evaluation of ductal carcinoma in situ

Ductal carcinoma in situ (DCIS) is a precursor mammary lesion whose malignant cells do not extend beyond the basement membrane and presents a risk of progression to malignant disease. Its early detection increased with screening mammography. The objective of this study was to review the literature on the main presentations of DCIS on magnetic resonance imaging (MRI), through searches of the Medline/PubMed, Latin-American and Caribbean Center on Health Sciences Information (Lilacs), and Scientific Electronic Library Online (SciELO) databases. DCIS can occur in its pure form or in conjunction with invasive disease, in the same lesion, in different foci, or in the contralateral breast. MRI has a high sensitivity for the detection of pure DCIS, being able to identify the non-calcified component, and its accuracy increases with the nuclear grade of the lesion. The most common pattern of presentation is non-nodular enhancement; heterogeneous internal structures; a kinetic curve showing washout or plateau enhancement; segmental distribution; and restricted diffusion. MRI plays an important role in the detection of DCIS, especially in the evaluation of its extent, contributing to more reliable surgical excision and reducing local recurrence.

Accuracy of Ultrasound for Preoperative Assessment of Tumor Size in Patients With Newly Diagnosed Breast Cancer: Is It Affected by the Background Parenchymal Echotexture?

OBJECTIVES

To assess the impact of the background parenchymal echotexture on the accuracy of tumor size estimation using breast ultrasound (US).

METHODS

A total of 140 women with newly diagnosed invasive breast cancer from January 2014 to December 2015 were enrolled in this study. Two radiologists retrospectively reviewed US images in consensus for background parenchymal echotexture interpretation. The maximum tumor diameter from static images was recorded. Tumor size measurements were considered as having agreement with histologic results if they were within ±5 mm compared to the pathologic size. The relationship between the accuracy of tumor size measurement by the background parenchymal echotexture and clinicopathologic characteristics was evaluated.

RESULTS

Of these 140 patients, 77 (55.0%) showed a homogeneous background parenchymal echotexture, whereas 63 (45.0%) showed a heterogeneous echotexture. The mean tumor size was 1.9 cm (range, 0.5-4.9 cm). The overall accuracy of tumor size measurement was 76.4% (104 of 140). Tumors of women with a homogeneous background parenchymal echotexture were more accurately measured than those of women with a heterogeneous echotexture (87.0% versus 63.5%; P = .001). Tumors with a small size (<2 cm; P = .018) and ductal carcinoma in situ-negative (P = .031), human epidermal growth factor receptor 2 (HER2)-negative (P = .053), and triple-negative (P = .016) types were also more accurately measured. The independent factors associated with inaccurate tumor size measurement were a heterogeneous background parenchymal echotexture, a large tumor size, and the HER2-enriched type (P < .05).

CONCLUSIONS

The background parenchymal echotexture affected the accuracy of tumor size estimation using breast US. Invasive breast cancers with large (≥2 cm) tumors and the HER2-enriched type showed significantly lower breast US accuracy compared to others.

Percutaneous cryoablation of breast tumours in patients with stable metastatic breast cancer: safety, feasibility and efficacy

PURPOSE

To evaluate safety, feasibility and efficacy of percutaneous cryoablation of breast tumours in patients with clinically stable metastatic breast cancer, and to compare the findings with reports on alternative procedures, namely surgery and local radiotherapy.

METHODS

17 female patients (average age of 54.8 years ± 10.8; range 37-72) with primary breast tumour not surgically treated because of metastatic disease were included. Patients were treated for their primary lesion by percutaneous cryotherapy in period of stable disease. This minimally intervention was performed using ultrasound or CT scan guidance. All patients had clinical and breast-MRI evaluation before and at 1, 3, 6 and 12 months after the procedure.

RESULTS

All procedures were performed under local anaesthesia and technically successful. The mean largest diameter of the primary lesions was 16 ± 12 mm (size range 5-45 mm). In 15 patients, we obtained a complete regression of the primary breast lesion without recurrence during the follow-up period. Two patients with lesions measured at 40 and 45 mm had recurrence in follow up period. A second session of cryotherapy was performed for these 2 patients, not included in this study. Five patients had painful masses before cryotherapy. All were immediately relieved after the intervention and durably during all follow-up.

CONCLUSION

These results show that the cryoablation of primary breast lesions seems to be well suited to the palliative care of metastatic patients, particularly because of its good tolerance, low complication rate and ability to provide local or analgesic control. Advances in knowledge: Therapies are limited for these symptomatic patients at metastatic state of primary breast tumour. This study shows that cryoablation in palliative care is achievable in common practice, is effective in local control of the tumour and can provide immediate and long-term analgesic control.

Contrast Enhancement in Breast Cancer and Background Mammary-Gland Tissue During the Super-Early Phase of Dynamic Breast Magnetic Resonance Imaging

RATIONALE AND OBJECTIVES

We aimed to compare the contrast enhancement between tumor and mammary-gland tissue to distinguish lesions in the super-early phase, during which minimal contrast media uptake is observed in mammary-gland tissue.

MATERIALS AND METHODS

Dynamic magnetic resonance imaging, including the super-early phase with bolus tracking (BT) method (to determine the optimal imaging start time), was performed by using identical parameters to obtain transverse fat-suppressed T1-weighted images of both breasts. The percent enhancement (PE) and the contrast ratio (CR) indicators for tumor and mammary-gland tissue were assessed in each dynamic phase.

RESULTS

The PE values of the tumor were 62.4% and 151.6%, and those of the mammary gland were 0.3% and 20.7% in the super-early and early phases, respectively. Therefore, virtually no background parenchymal enhancement was observed in the super-early phase. The variation in the PE values during the super-early phase was significantly smaller when the values were determined with the BT method (P < .05). The CR was highest in the early phase, and the CR in the super-early phase was lower than in the other phases. Early-phase PE and CR were significantly higher in invasive cancer cases than in noninvasive cancer cases (P < .01). A significant difference in the imaging start time was observed for the anatomic side factor by the BT method.

CONCLUSION

Background parenchymal enhancement almost never appeared in the super-early phase, but the CR was lower in the super-early phase than in the early phase. The BT method allowed for an optimal imaging start time for the super-early phase and yielded images with less deviation of contrast enhancement.

Abbreviated breast magnetic resonance protocol: Value of high-resolution temporal dynamic sequence to improve lesion characterization

PURPOSE

To evaluate the added value of ULTRAFAST-MR sequence to an abbreviated FAST protocol in comparison with FULL protocol to distinguish benign from malignant lesions in a population of women, regardless of breast MR imaging indication.

MATERIALS AND METHODS

From March 10th to September 22th, 2014, we retrospectively included a total of 70 consecutive patients with 106 histologically proven lesions (58 malignant and 48 benign) who underwent breast MR imaging for preoperative breast staging (n=38), high-risk screening (n=7), problem solving (n=18), and nipple discharge (n=4) with 12 time resolved imaging of contrast kinetics (TRICKS) acquisitions during contrast inflow interleaved in a regular high-resolution dynamic MRI protocol (FULL protocol). Two readers scored MR exams as either positive or negative and described significant lesions according to Bi-RADS lexicon with a TRICKS images (ULTRAFAST), an abbreviated protocol (FAST) and all images (FULL protocol). Sensitivity, specificity, positive and negative predictive values, and accuracy were calculated for each protocol and compared with McNemar's test.

RESULTS

For all readers, the combined FAST-ULTRAFAST protocol significantly improved the reading with a specificity of 83.3% and 70.8% in comparison with FAST protocol or FULL protocol, respectively, without change in sensitivity. By adding ULTRAFAST protocol to FAST protocol, readers 1 and 2 were able to correctly change the diagnosis in 22.9% (11/48) and 10.4% (5/48) of benign lesions, without missing any malignancy, respectively. Both interpretation and image acquisition times for combined FAST-ULTRAFAST protocol and FAST protocol were shorter compared to FULL protocol (p<0.001).

CONCLUSION

Compared to FULL protocol, adding ULTRAFAST to FAST protocol improves specificity, mainly in correctly reclassifying benign masses and reducing interpretation and acquisition time, without decreasing sensitivity.

Multimodal ultrasound computer-assisted tomography: An approach to the recognition of breast lesions

The research here presented aims at developing a new, promising method for the imaging diagnostics of breast lesions - ultrasound tomography (UST). A currently implemented device enables the reconstruction three complementary images for each coronal breast section. Based on in vivo breast examination, the authors developed an approach to breast diagnostics which employs ultrasound transmission and reflection tomography imaging. The obtained transmission images of ultrasound speed distribution show good correlation of glandular tissue areas with their visualization on MRI images. The results also allow a prediction that the implemented UST device offering fusion of reconstructed images may contribute to achieving a new standard for breast cancer diagnostics through non-invasive, fast and cheap screening tests.

Clinical accuracy of preoperative breast MRI for breast cancer

BACKGROUND

It is unclear if breast magnetic resonance imaging (MRI) is more accurate than mammography (MGM) and ultrasound (U/S) in aggregate for patients with invasive cancer.

METHODS

We compared concordance of combined tumor size and tumor foci between MRI and MGM and U/S combined to pathological tumor size and foci as the gold standard from 2009 to 2015. Tumor size was nonconcordant if it differed from the pathologic size by ≥33% and tumor foci was nonconcordant if >1 foci were seen. If one or both of the MGM or U/S was nonconcordant and the MRI was concordant, MRI provided greater accuracy.

RESULTS

Of 471 patients with MGM, US, and MRI, MRI was more accurate for 32.9% of patients for tumor size and for 21.9% for tumor foci. Patients for whom MRI had greater accuracy were compared to those who did not for clinical and tumor factors. The only significant factor was calcifications on mammography. Tumor size, stage, molecular subtype, histology, grade, patient BMI, age, mammographic density, and use of hormone replacement therapy were not significantly different.

CONCLUSIONS

Breast MRI provides greater accuracy for a third of patients undergoing preoperative MGM and U/S. Mammographic calcifications were associated with MRI clinical accuracy for patients with invasive cancer.

A comparison study between gross tumor volumes defined by preoperative magnetic resonance imaging, postoperative specimens, and tumor bed for radiotherapy after breast-conserving surgery

BACKGROUND

The identification and contouring of target volume is important for breast-conserving therapy. The aim of the study was to compare preoperative magnetic resonance imaging (MRI), postoperative pathology, excised specimens' (ES) size, and tumor bed (TB) delineation as methods for determining the gross tumor volume (GTV) for radiotherapy after breast-conserving surgery (BCS).

METHODS

Thirty-three patients with breast cancer who underwent preoperative MRI and radiotherapy after BCS were enrolled. The GTVs determined by MRI, pathology, and the ES were defined as GTVMRI, GTVPAT, and GTVES, respectively. GTVMRI+1 was defined as a 1.0-cm margin around the GTVMRI. The radiation oncologist delineated GTV of the TB (GTVTB) using planning computed tomography according to ≥5 surgical clips placed in the lumpectomy cavity (LC).

RESULTS

The median GTVMRI, GTVMRI+1, GTVPAT, GTVES, and GTVTB were 0.97 cm (range, 0.01-6.88), 12.58 cm (range, 3.90-34.13), 0.97 cm (range, 0.01-6.36), 15.46 cm (range, 1.15-70.69), and 19.24 cm (range, 4.72-54.33), respectively. There were no significant differences between GTVMRI and GTVPAT, GTVMRI+1 and GTVES, GTVES and GTVTB (P = 0.188, 0.070, and 0.264, respectively). GTVMRI is positively related with GTVPAT. However, neither GTVES nor GTVTB correlated with GTVMRI (P = 0.071 and 0.378, respectively). Furthermore, neither GTVES nor GTVTB correlated with GTVMRI+1 (P = 0.068 and 0.375, respectively).

CONCLUSION

When ≥5 surgical clips were placed in the LC for BCS, the volume of TB was consistent with the volume of ES. Neither the volume of TB nor the volume of ES correlated significantly with the volume of tumor defined by preoperative MRI.

Breast Tuberculosis after Chest Trauma - a Case Report and Review of the Literature

BACKGROUND

Breast involvement of tuberculosis (TB) is well known but uncommon. It can resemble other diseases, including breast cancer, and diagnosis is quite difficult. So, when facing a breast lesion, a possible tubercular etiology should always be born in mind, relying on qualified laboratories to confirm the diagnosis.

CASE REPORT

We describe a 42-year-old woman with a mammary fistula complicating a post-traumatic lump. A critical analysis of the diagnostic process was performed together with a review of the literature, also considering the potential role of trauma in inducing such a rare complication.

The need for supplemental breast cancer screening modalities: a perspective of population-based breast cancer screening programs in Japan

PURPOSE

This article discusses possible supplemental breast cancer screening modalities for younger women with dense breasts from a perspective of population-based breast cancer screening program in Japan.

CONCLUSION

Supplemental breast cancer screening modalities have been proposed to increase the sensitivity and detection rates of early stage breast cancer in women with dense breasts; however, there are no global guidelines that recommend the use of supplemental breast cancer screening modalities in such women. Also, no criterion standard exists for breast density assessment. Based on the current situation of breast imaging in Japan, the possible supplemental breast cancer screening modalities are ultrasonography, digital breast tomosynthesis, and breast magnetic resonance imaging. An appropriate population-based breast cancer screening program based on the balance between cost and benefit should be a high priority. Further research based on evidence-based medicine is encouraged. It is very important that the ethnicity, workforce, workflow, and resources for breast cancer screening in each country should be considered when considering supplemental breast cancer screening modalities for women with dense breasts.

Differentiation of Malignant and Benign Incidental Breast Lesions Detected by Chest Multidetector-Row Computed Tomography: Added Value of Quantitative Enhancement Analysis

To retrospectively determine the association between breast lesion morphology and malignancy and to determine the optimal value of lesion enhancement (HU, Hounsfield units) to improve the diagnostic accuracy of breast cancer in patients with incidental breast lesions (IBLs). A total of 97 patients with 102 IBLs detected from July 2009 to December 2012 were enrolled in this study. Two radiologists analyzed CT images for the presence of malignancy based on the morphology of the lesions alone and in combination with an enhancement value (HU) analysis. There were 36 malignant and 66 benign IBLs. When the morphology and enhancement values were combined, the sensitivity, specificity, and accuracy were 92%, 97%, and 95%, respectively, for reader 1 and 89%, 94%, and 92%, respectively, for reader 2. The addition of HU values led to correct changes in the diagnosis; specifically, the accuracy of the diagnosis of reader 1 and reader 2 improved by 6.9% and 11.8%, respectively. The addition of the enhancement value (HU) to the CT morphology improved the diagnostic accuracy in the differentiation of malignant from benign IBLs by using the region of interest (ROI) to measure the HU within the most suspicious part of the lesion.

Computer-aided detection (CAD) system for breast MRI in assessment of local tumor extent, nodal status, and multifocality of invasive breast cancers: preliminary study

Background

We aimed to investigate the efficacy of computer-aided detection (CAD) for MRI in the assessment of tumor extent, lymph node status, and multifocality in invasive breast cancers in comparison with other breast imaging modalities.

Methods

Two radiologists measured the maximum tumor size, as well as, analyzed lymph node status and multifocality in 86 patients with invasive breast cancers using mammography, ultrasound, CT, MRI with and without CAD, and 18-fludeoxyglucose positron emission tomography (FDG-PET). The assessed data were compared with pathology.

Results

For tumor extent, there were no significant differences between pathological size and measured size using mammography, ultrasound, CT, or MRI with and without CAD (P > 0.05). For evaluation of lymph node status, ultrasound had the best kappa coefficients (0.522) for agreement between imaging and pathology, and diagnostic performance with 92.1% specificity and 90.0% positive predictive value. For multifocality, MRI with CAD had the highest area under the receiver operating characteristic curve (AUC = 0.888).

Conclusions

CAD for MRI is feasible to assess tumor extent and multifocality in invasive breast cancer patients. However, CAD is not effective in evaluation of nodal status.

Use of contrast-enhanced spectral mammography for intramammary cancer staging: preliminary results

RATIONALE AND OBJECTIVES

To prospectively evaluate and compare the accuracy of contrast-enhanced spectral mammography (CESM) and ultrasound (US) in size measurement of breast cancer with histologic tumor sizes as gold standard.

MATERIALS AND METHODS

Twenty women aged between 40-73 years (mean age, 57 ± 10 years) with histologically proven invasive ductal/lobular carcinomas were included in the study. Agreement between imaging tumor size (CESM and US) and histopathologic tumor size was evaluated with Bland-Altman analysis. Stereotactically guided vacuum biopsy was performed in four patients after CESM. Two independent reviewers described artifacts of CESM.

RESULTS

Motion artifacts did not occur in the study. CESM-specific artifacts caused by scattered radiation mostly occurred in oblique view of CESM. Background enhancement of breast tissue was seen in four patients. Mean difference of tumor sizes was 0.3 mm (6.34%) between CESM and histology and -2.2 mm (-7.59%) between US and histology. Limits of agreement ranged from -18.9 to 19.48 mm for CESM and from -17.1 to 12.7 mm with US. Especially smaller tumors with a size <23 mm were measured more precisely with CESM. Enhancement of breast tissue around microcalcifications correlated with abnormalities.

CONCLUSIONS

CESM is accurate in size measurements of small breast tumors. On average CESM leads to a slight overestimation of tumor size, whereas US tends to underestimate tumor size. Assessment of the breast tissue can be limited by the scattered radiation artifact and background enhancement of breast tissue. CESM seems to be helpful in the characterization of breast tissue around microcalcifications.

Local and regional staging of invasive breast cancer with sonography: 25 years of practice at MD Anderson Cancer Center

At The University of Texas MD Anderson Cancer Center, we have used sonography (US) extensively for more than 2 decades to refine the local and regional staging of invasive breast cancer. Although magnetic resonance imaging is superior to all other imaging modalities in the measurement of the primary tumor and detection of additional foci of malignancy, in our experience US has shown sufficient accuracy in clinical practice to stage most invasive breast cancers. The exceptions are ill-defined tumors such as invasive lobular cancers and tumors in breasts containing extensive diffuse benign disease. An advantage of US is that multifocality or multicentricity can be confirmed via US-guided fine-needle aspiration within 15 minutes and the information shared immediately with the patient and the breast surgeon or medical oncologist. US has also proved indispensable in the evaluation of lymphatic spread because it can evaluate more nodal basins (e.g., the supraclavicular fossa and low neck) than magnetic resonance imaging can and because it can guide needle biopsy to confirm the status of any indeterminate node (including internal mammary nodes) within minutes.

Comparison of ductoscopy, galactography, and imaging modalities for the evaluation of intraductal lesions: a critical review

BACKGROUND

Today, in cases of nipple discharge of unclear origin, the abundance of diagnostic procedures - a, diagnostic dilemma' - becomes apparent, because unequivocal indications and a current, standardized examination sequence are presently not available. The diagnostic workup of patients with nipple discharge usually includes the clinical history, physical examination, mammography, ultrasonography, galactography, and nipple discharge cytology, but not ductoscopy.

METHODS

In this review we analyze and discuss the possible role of ductoscopy in evaluating intraductal pathologies and its combined use with diagnostic imaging modalities. For this purpose, we reviewed and compared the results of the radiological, pathological, and surgical studies independently.

CONCLUSIONS

Currently, there is no solitary accurate modality to reach our definitive purpose. Being aware of the capability of each diagnostic modality may take us closer to our target. Therefore, adjunct and appropriate use of multiple imaging modalities and ductoscopy is necessary to evaluate patients with nipple discharge.

Accuracy of tumour size assessment in the preoperative staging of breast cancer: comparison of digital mammography, tomosynthesis, ultrasound and MRI

PURPOSE

Accurate measurement of breast tumour size is fundamental for treatment planning. We compared the accuracy of digital mammography (DM), digital breast tomosynthesis (DBT), ultrasound (US) and magnetic resonance imaging (MRI) for the preoperative evaluation of breast cancer size.

MATERIALS AND METHODS

We retrospectively reviewed 149 breast cancers in 110 patients who underwent DM, DBT, US and MRI between January 2010 and December 2011, before definitive surgery. The lesions were measured by two radiologists, without knowledge of the final histological examination, considered the gold standard. For each imaging modality, the maximum tumour size was measured to the nearest millimetre; the measurements were considered concordant if they were within ± 5 mm. Pearson's correlation coefficient was calculated for each imaging modality.

RESULTS

The median pathological tumour size was 22.3 mm. MRI and DBT had a level of concordance with pathology of 70% and 66%, respectively, which was higher than that of DM (54%). DBT and MRI measurements had a better correlation with pathological tumour size (R:0.89 and R:0.92, respectively) compared to DM (R:0.83) and US (R:0.77).

CONCLUSIONS

DBT and MRI are superior to DM and US in the preoperative assessment of breast tumour size. DBT seems to improve the accuracy of DM, although MRI remains the most accurate imaging modality for breast cancer extension.

Incidental detection of clinically unexpected breast lesions by computed tomography

BACKGROUND

Increased use of computed tomography (CT) has resulted in greater detection of incidental breast lesions unrelated to the primary diagnostic inquiry.

PURPOSE

To investigate the morphology and clinical significance of breast abnormalities detected incidentally by conventional CT.

MATERIAL AND METHODS

A total of 2945 female patients underwent CT examinations of the body, including the chest, from May 2006 to April 2010. Two radiologists interpreted these CT scans independently and pointed out a mass or non-mass-like lesion as abnormalities in the breast. Patients who incidentally showed breast lesions on CT scans were identified by a computer-based search of the diagnostic reports and were enrolled in this study. The morphology and enhancement patterns of CT-detected breast lesions were evaluated according to BI-RADS-MRI.

RESULTS

In total, 32 clinically unexpected abnormal breast lesions were found in 31 (1.1%) patients. Twenty-nine of the 32 lesions were detected by contrast-enhanced CT and three by unenhanced CT. Ten breast cancers were found in 10 patients (0.34%), which yielded the prevalence for malignancy of 31% (10/32). Invasive ductal carcinomas accounted for eight lesions, while two were ductal carcinomas in situ (DCIS). Nine lesions were depicted as a mass and one DCIS was a non-mass-like lesion. Good morphological predictors of breast cancers for a mass were an irregular shape, a lobulated shape, and an irregular margin. Benign lesions accounted for 22 lesions from 21 patients (0.71%). Of these, 13 lesions in 13 patients were depicted as a mass and nine lesions in nine patients as a non-mass-like lesion.

CONCLUSION

Unexpected breast lesions can be identified as a mass or non-mass-like lesion on conventional chest CT scans. Among these, breast cancers that are not clinically apparent occur with considerable prevalence. We suggest that careful interpretation of the breast should be a routine part of CT examinations.

The potential for an enhanced role for MRI in radiation-therapy treatment planning

The exquisite soft-tissue contrast of magnetic resonance imaging (MRI) has meant that the technique is having an increasing role in contouring the gross tumor volume (GTV) and organs at risk (OAR) in radiation therapy treatment planning systems (TPS). MRI-planning scans from diagnostic MRI scanners are currently incorporated into the planning process by being registered to CT data. The soft-tissue data from the MRI provides target outline guidance and the CT provides a solid geometric and electron density map for accurate dose calculation on the TPS computer. There is increasing interest in MRI machine placement in radiotherapy clinics as an adjunct to CT simulators. Most vendors now offer 70 cm bores with flat couch inserts and specialised RF coil designs. We would refer to these devices as MR-simulators. There is also research into the future application of MR-simulators independent of CT and as in-room image-guidance devices. It is within the background of this increased interest in the utility of MRI in radiotherapy treatment planning that this paper is couched. The paper outlines publications that deal with standard MRI sequences used in current clinical practice. It then discusses the potential for using processed functional diffusion maps (fDM) derived from diffusion weighted image sequences in tracking tumor activity and tumor recurrence. Next, this paper reviews publications that describe the use of MRI in patient-management applications that may, in turn, be relevant to radiotherapy treatment planning. The review briefly discusses the concepts behind functional techniques such as dynamic contrast enhanced (DCE), diffusion-weighted (DW) MRI sequences and magnetic resonance spectroscopic imaging (MRSI). Significant applications of MR are discussed in terms of the following treatment sites: brain, head and neck, breast, lung, prostate and cervix. While not yet routine, the use of apparent diffusion coefficient (ADC) map analysis indicates an exciting future application for functional MRI. Although DW-MRI has not yet been routinely used in boost adaptive techniques, it is being assessed in cohort studies for sub-volume boosting in prostate tumors.

MR-guided high-intensity focused ultrasound ablation of breast cancer with a dedicated breast platform

Optimizing the treatment of breast cancer remains a major topic of interest. In current clinical practice, breast-conserving therapy is the standard of care for patients with localized breast cancer. Technological developments have fueled interest in less invasive breast cancer treatment. Magnetic resonance-guided high-intensity focused ultrasound (MR-HIFU) is a completely noninvasive ablation technique. Focused beams of ultrasound are used for ablation of the target lesion without disrupting the skin and subcutaneous tissues in the beam path. MRI is an excellent imaging method for tumor targeting, treatment monitoring, and evaluation of treatment results. The combination of HIFU and MR imaging offers an opportunity for image-guided ablation of breast cancer. Previous studies of MR-HIFU in breast cancer patients reported a limited efficacy, which hampered the clinical translation of this technique. These prior studies were performed without an MR-HIFU system specifically developed for breast cancer treatment. In this article, a novel and dedicated MR-HIFU breast platform is presented. This system has been designed for safe and effective MR-HIFU ablation of breast cancer. Furthermore, both clinical and technical challenges are discussed, which have to be solved before MR-HIFU ablation of breast cancer can be implemented in routine clinical practice.

Perfusion curve f (t) analysis of breast cancer by contrast-enhanced ultrasonography

BACKGROUND

Imaging the perfusion of contrast media in breast tumors may allow improved diagnosing and treating breast cancer.

PURPOSE

To compare the perfusion curve f (t) characteristics of contrast-enhanced ultrasonography in benign and malignant breast tumors.

MATERIAL AND METHODS

Patients with breast tumors (n = 87) were evaluated with contrast-enhanced ultrasonography and the perfusion curve f (t) parameters were calculated using Sonoliver(®) software to compare analysis (tumor) and reference (normal) tissue areas. Differences between breast and breast tumors were assessed.

RESULTS

Compared to benign tumors, malignant tumors had faster enhancement time and a shorter mean transit time (all P values < 0.05). The intensity of the signal was also greater for malignant compared with benign tumors.

CONCLUSION

Perfusion curve f (t) parameter measurements can distinguish differences in vascular flow between malignant and benign breast tumors and may provide a new quantitative indicator of breast tumor.

Ductal carcinoma in situ of the breast: a surgical perspective

Ductal carcinoma in situ (DCIS) of the breast is a heterogeneous neoplasm with invasive potential. Risk factors include age, family history, hormone replacement therapy, genetic mutation, and patient lifestyle. The incidence of DCIS has increased due to more widespread use of screening and diagnostic mammography; almost 80% of cases are diagnosed with imaging with final diagnosis established by biopsy and histological examination. There are various classification systems used for DCIS, the most recent of which is based on the presence of intraepithelial neoplasia of the ductal epithelium (DIN). A number of molecular assays are now available that can identify high-risk patients as well as help establish the prognosis of patients with diagnosed DCIS. Current surgical treatment options include total mastectomy, simple lumpectomy in very low-risk patients, and lumpectomy with radiation. Adjuvant therapy is tailored based on the molecular profile of the neoplasm and can include aromatase inhibitors, anti-estrogen, anti-progesterone (or a combination of antiestrogen and antiprogesterone), and HER2 neu suppression therapy. Chemopreventive therapies are under investigation for DCIS, as are various molecular-targeted drugs. It is anticipated that new biologic agents, when combined with hormonal agents such as SERMs and aromatase inhibitors, may one day prevent all forms of breast cancer.

Visualizing breast cancer using the Twente photoacoustic mammoscope: what do we learn from twelve new patient measurements?

We acquired images of breast malignancies using the Twente photoacoustic mammoscope (PAM), to obtain more information about the clinical feasibility and limitations of photoacoustic mammography. Results were compared with conventional imaging and histopathology. Ten technically acceptable measurements on patients with malignancies and two measurements on patients with cysts were performed. In the reconstructed volumes of all ten malignant lesions, a confined region with high contrast with respect to the background could be seen. In all malignant cases, the PA contrast of the abnormality was higher than the contrast on x-ray mammography. The PA contrast appeared to be independent of the mammographically estimated breast density and was absent in the case of cysts. Technological improvements to the instrument and further studies on less suspicious lesions are planned to further investigate the potential of PAM.

Breast ultrasound tomography versus MRI for clinical display of anatomy and tumor rendering: preliminary results

OBJECTIVE

The objective of our study was to determine the clinical display thresholds of an ultrasound tomography prototype relative to MRI for comparable visualization of breast anatomy and tumor rendering.

SUBJECTS AND METHODS

Thirty-six women were imaged with MRI and our ultrasound tomography prototype. The ultrasound tomography scan generated reflection, sound-speed, and attenuation images. The reflection images were fused with the components of the sound-speed and attenuation images that achieved thresholds to represent parenchyma or solid masses using an image arithmetic process. Qualitative and quantitative comparisons of MRI and ultrasound tomography clinical images were used to identify anatomic similarities and optimized thresholds for tumor shapes and volumes.

RESULTS

Thresholding techniques generated ultrasound tomography images comparable to MR images for visualizing fibrous stroma, parenchyma, fatty tissues, and tumors. In 25 patients, tumors were cancerous and in 11, benign. Optimized sound-speed thresholds of 1.46±0.1 and 1.52±0.03 km/s were identified to best represent the extent of fibroglandular tissue and solid masses, respectively. An arithmetic combination of attenuation images using a threshold of 0.16±0.04 dB/cm (mean±SD) further characterized benign from malignant masses. No significant difference in tumor volume was noted between benign or malignant masses by ultrasound tomography or MRI (p>0.1) using these universal thresholds.

CONCLUSION

Ultrasound tomography is able to image and render breast tissues in a manner comparable to MRI. Using universal ultrasound tomography threshold values for rendering the size and distribution of benign and malignant tissues appears feasible without IV contrast material.

The role of breast MR imaging in pre-operative determination of invasive disease for ductal carcinoma in situ diagnosed by needle biopsy

OBJECTIVES

To evaluate whether magnetic resonance (MR) imaging features can predict the presence of occult invasion in cases of biopsy-proven pure ductal carcinoma in situ (DCIS).

METHODS

We retrospectively reviewed 92 biopsy-proven pure DCIS in 92 women who underwent MR imaging. The following MR imaging findings were compared between confirmed DCIS and invasive breast cancer (IBC): lesion size, type, morphological and kinetic assessments by ACR BI-RADS MRI, and findings of fat-suppressed T2-weighted (FS-T2W) imaging.

RESULTS

Sixty-eight of 92 (74%) were non-mass-like enhancements (NMLE) and 24 were mass lesions on MR imaging. Twenty-one of 68 (31%) NMLE and 13 of 24 (54%) mass lesions were confirmed as IBC. In NMLE lesions, large lesions (P = 0.007) and higher signal intensities (SI) on FS-T2W images (P = 0.032) were significantly associated with IBC. Lesion size remained a significant independent predictor of invasion in multivariate analysis (P = 0.032), and combined with FS-T2W SIs showed slightly higher observer performances (area under the curve, AUC, 0.71) than lesion size alone (AUC 0.68). There were no useful findings that enabled the differentiation of mass-type lesions.

CONCLUSIONS

Breast MR imaging is potentially useful to predict the presence of occult invasion in biopsy-proven DCIS with NMLE.

KEY POINTS

MR mammography permits more precise lesion assessment including ductal carcinoma in situ A correct diagnosis of occult invasion before treatment is important for clinicians This study showed the potential of MR mammography to diagnose occult invasion Treatment and/or aggressive biopsy can be given with greater confidence MR mammography can lead to more appropriate management of patients.

Preoperative CT evaluation of intraductal spread of breast cancer and surgical treatment

It is always a challenge to accurately determine the appropriate extent of resection in breast-conserving surgery (BCS), in order to reduce the need for re-excision, prevent local recurrence, and optimize cosmetic results. Detecting intraductal spread alone with high sensitivity may not be enough to realize safe BCS. Computed tomography carried out with the patient in the supine position accompanied by adequate marking is effective for preoperative determination of the optimum extent of BCS.