Three-dimensional helical CT of the breast: accuracy for measuring extent of breast cancer candidates for breast conserving surgery

Image quality of opportunistic breast examinations in photon-counting computed tomography: A phantom study

PURPOSE

To compare the breast imaging performance of a clinical whole-body photon-counting CT (PCCT) to that of a dedicated breast CT (BCT) to determine the image quality of opportunistic breast examinations in clinical PCCT.

MATERIALS AND METHODS

To quantify image quality for breast cancer applications, acquisitions of a breast phantom including representations of calcifications, fibers, and masses were performed using a clinical PCCT and a dedicated BCT. When imaging with the PCCT, the phantom was also combined with a thorax phantom to simulate realistic patient positioning, while only the breast phantom was imaged in the BCT. Images in BCT were acquired at 7.0 mGy (CTDI16cm) and using 2.6 mGy-25.0 mGy in the PCCT. Spatial resolution between the BCT and PCCT images was matched and data were reconstructed using the default methods of each system. The dose-normalized contrast-to-noise ratio (CNRD) of masses and the structural visibility of fibers and calcifications were evaluated as figures of merit for all reconstructions.

RESULTS

CNRD between masses and background was 0.56 mGy-½, on average with BCT and varied between 0.39 mGy-½ to 1.46 mGy-½ with PCCT over all dose levels, phantom configurations, and reconstruction algorithms. Calcifications down to a size of 0.29 mm and fibers down to a size of 0.23 mm could be reliably identified in the images of both systems.

CONCLUSIONS

Clinical PCCT provides an image quality superior to that obtained with BCT in terms of CNRD and allows for the identification of calcifications and fibers at comparable dose levels.

Is the prediction of one or two ipsilateral positive lymph nodes by computerized tomography and ultrasound reliable enough to restrict therapeutic neck dissection in oral squamous cell carcinoma (OSCC) patients?

INTRODUCTION

Proper management of the clinically involved neck in OSCC patients continues to be a matter of debate. Our aim was to analyze the accuracy of computerized tomography (CT) and ultrasound (US) in anticipating the exact location of lymph node (LN) metastases of OSCC patients across the AAO-HNS (American Academy of Otolaryngology-Head and Neck Surgery) levels ipsi- and contralaterally. Furthermore, we wanted to assess the suitability of therapeutic selective neck dissection (SND) in patients with one or two ipsilateral positive nodes upon clinical staging (cN1/cN2a and cN2b(2/x) patients).

METHODS

We prospectively analyzed the LN status of patients with primary OSCC using CT and US from 2007 to 2013. LNs were individually assigned to a map containing the AAO-HNS levels; patients bearing a single or just two ipsilateral positive nodes (designated cN1/cN2a or cN2b(2/x) patients either by CT (CT group) or US alone (US group) or in a group combining findings of CT and US (CTUS group)) received an ipsi-ND (I-V) and a contra-ND (I-IV). 78% of the LNs were sent individually for routine histopathological examination; the remaining were dissected and analyzed per neck level.

RESULTS

Upon the analysis of 1.670 LNs of 57 patients, the exact location of pathology proven LN metastases in cN1 patients was more precisely predicted by US compared to CT with confirmed findings only in levels IA, IB und IIA. Clearly decreasing the number of missed lesions, the findings in the CTUS group nearly kept the spatial reliability of the US group. The same analysis for patients with exactly two supposed ipsilateral lesions (cN2b(2/x)) yielded confirmed metastases from levels I to V for both methods individually and in combination and, therefore, render SND insufficient for these cases.

CONCLUSION

Our findings stress the importance of conducting both, CT and US, in patients with primary OSCC. Only the combination of their findings warrants the application of therapeutic SND in patients with a single ipsilateral LN metastasis (cN1/cN2a patients) but not in patients with more than one lesion upon clinical staging (≥ cN2b).

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.

Role of Multidetector Computed Tomography in Evaluating Incidentally Detected Breast Lesions

Aims and Background

Computed tomography (CT) does not represent the primary method for the evaluation of breast lesions; however, it can detect breast abnormalities, even when performed for other reasons related to thoracic structures. The aim of this study is to evaluate the potential benefits of 320-row multidetector CT (MDCT) in evaluating and differentiating incidentally detected breast lesions by using vessel probe and 3D analysis software with net enhancement value.

Methods and Study design

Sixty-two breast lesions in 46 patients who underwent 320-row chest CT examination were retrospectively evaluated. CT scans were assessed searching for the presence, location, number, morphological features, and density of breast nodules. Net enhancement was calculated by subtracting precontrast density from the density obtained by postcontrast values. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and diagnostic accuracy of CT were calculated for morphological features and net enhancement.

Results

Thirty of 62 lesions were found to be malignant at histological examination and 32 were found to be benign. When morphological features were considered, the sensitivity, specificity, accuracy, PPV, and NPV of CT were 87%, 100%, 88%, 100%, and 50%, respectively. Based on net enhancement, CT reached a sensitivity, specificity, accuracy, PPV, and NPV of 100%, 94%, 97%, 94%, and 100%, respectively.

Conclusions

MDCT allows to recognize and characterize breast lesions based on morphological features. Net enhancement can be proposed as an additional accurate feature of CT.

Multi-detector row CT-guided marking technique for breast-conserving therapy of early breast cancer: margin positivity and local control rates

BACKGROUND

In breast-conserving surgery (BCS), image-guided marking of the tumor border is important for preventing local recurrence and achieving a good cosmetic outcome. The purpose of this study was to evaluate the usefulness of multi-detector row computed tomography (MDCT)-guided marking technique before BCS in patients in whom ultrasound (US)-guided marking was not feasible.

METHODS

Between 2004 and 2010, 94 lesions underwent contrast-enhanced MDCT-guided marking. Margin positivity and local control rates were compared with those of 149 lesions undergoing US-guided marking during the same period.

RESULTS

In 21 lesions undergoing CT marking (22 %) and 20 lesions undergoing US marking (13 %), a negative resection margin could not be achieved, and hence the marking was judged as unsuccessful. Eighty-four lesions of the CT marking group and 119 of the US marking group received postoperative radiotherapy with 50 Gy in 25 fractions with or without an additional 10-Gy boost to the tumor bed. The remaining 10 and 30 patients, respectively, did not receive radiotherapy. The median follow-up period was 54 and 51 months for patients with CT marking and those with US marking, respectively. At 4 postoperative years, the local control rate was 96.5 % for patients with CT marking and 97.3 % for those with US marking (P = 0.89).

CONCLUSIONS

The MDCT marking technique appears to be a valuable tool for determining the surgical margin for BCS in patients in whom ultrasound marking cannot be performed. Combining this technique with appropriate postoperative radiation therapy is expected to yield reasonably high local control rates.

The value of chest CT for prediction of breast tumor size: comparison with pathology measurement

Background

Little information is available on the use of chest computed tomography (CT) to predict breast tumor size in breast cancer, despite the fact that chest CT examinations are being increasingly used. The purpose of this study was to evaluate the value of chest CT for predicting breast tumor size using pathology measurements as reference standards.

Methods

Tumor sizes (defined as greatest diameter) were retrospectively measured on the preoperative chest CT images of 285 patients with surgically proven unifocal, invasive breast carcinoma. Greatest tumor diameters as determined by chest CT and pathologic examinations were compared by linear regression and Spearman’s rho correlation analysis. Concordance between CT and pathology results was defined as a diameter difference of <5 mm. Subgroup analyses were also performed with respect to tumor size (<20 mm or ≥20 mm) and histological subtype (invasive ductal carcinoma(IDC) or non-IDC).

Results

CT and pathology measured diameters were found to be linearly related (size at pathology = 1.086 × CT determined tumor size - 1.141; Spearman’s rho correlation coefficient = 0.84, P<0.001). Most tumors (n = 228, 80.0%) were concordant by chest CT and pathology, but 36 tumors (12.7%) were underestimated by CT (average underestimation, 11 mm; range, 6–36 mm) and 21 tumors (7.4%) were overestimated (average overestimation by CT, 10 mm; range, 6–19 mm). The concordance rate between the two sets of measurements was greater for tumor of <20 mm and for IDC (P<0.001 and P = 0.011, respectively).

Conclusions

Tumor size by chest CT is well correlated with pathology determined tumor size in breast cancer patients, and the diameters of the majority of tumors by chest CT and pathology differed by <5 mm. In addition, the concordance rate was higher for breast tumors of <20 mm and for tumors of the IDC histologic subtype.

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.

The emergence of diagnostic imaging technologies in breast cancer: discovery, regulatory approval, reimbursement, and adoption in clinical guidelines

In this article, we trace the chronology of developments in breast imaging technologies that are used for diagnosis and staging of breast cancer, including mammography, ultrasonography, magnetic resonance imaging, computed tomography, and positron emission tomography. We explore factors that affected clinical acceptance and utilization of these technologies from discovery to clinical use, including milestones in peer-reviewed publication, US Food and Drug Administration approval, reimbursement by payers, and adoption into clinical guidelines. The factors driving utilization of new imaging technologies are mainly driven by regulatory approval and reimbursement by payers rather than evidence that they provide benefits to patients. Comparative effectiveness research can serve as a useful tool to investigate whether these imaging modalities provide information that improves patient outcomes in real-world settings.

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.

Diagnosis of breast cancer with multidetector computed tomography: analysis of optimal delay time after contrast media injection

PURPOSE

The aim of this study was to investigate the optimal delay time after a contrast media injection for multidetector computed tomography (MD-CT) images in the diagnosis of breast cancer patients.

MATERIALS AND METHODS

Thirty-one patients who underwent MD-CT for their preoperative examination and who had postoperatively confirmed pathology were enrolled. Four-phase images of dynamic contrast enhanced study were acquired using four-detector MDCT. All cases were mammographically classified into two groups according to BI-RADS: nondense and dense groups. The CT value of the background mammary gland, background breast enhancement (BBE), and tumor-background mammary gland contrast (TBC) were compared between the two groups.

RESULTS

The CT value of the dense group was significantly higher than that of the nondense group in all phases. BBE in both nondense and dense groups showed no significant differences in any of the phases. In the nondense group, TBC was significantly higher in both the second and the third phases than in the first phase, while in the dense group, TBC was significantly higher in the second phase than in the first and third phases.

CONCLUSION

The optimal delay time to depict breast cancer is 80 s after a contrast media injection, regardless of the density level of the background mammary gland.

Usefulness of lesion image mapping with multidetector-row helical computed tomography using a dedicated skin marker in breast-conserving surgery

To investigate the usefulness of computed tomography (CT) with skin-marker placement in determining the excision area and decreasing the positive or close margin rates in breast-conserving surgery (BCS). Multidetector-row helical computed tomography (MDCT) mapping images were reconstructed in subjects (n = 117) diagnosed with primary breast cancer who had undergone MDCT using CT skin markers. Serial 5-mm-thick slices prepared from the surgical specimen were used for pathological analyses. A "positive margin" was defined as the presence of malignant cells at the surgical margin, and a "close margin" as a tumor within 5 mm of the surgical margin. The rates of positive and close margins were calculated. We identified the lesions in 111 of 117 cases (94.9%) on MDCT. Of these, 93 underwent BCS under the guidance of MDCT mapping and the remaining 18 underwent mastectomy. Among the 93 cases, 6 (6.5%) had positive or close margins and were diagnosed with ductal carcinoma in situ of low nuclear grade. MDCT mapping with a CT skin marker is feasible for simulating surgical positioning and determining the excision area. MDCT mapping could decrease the positive and close margin rates in BCS.

Clinical application of multidetector row computed tomography in patient with breast cancer

Although multidetector row computed tomography is not the primary method of evaluating breast cancer, it could be performed as an excellent alternative, especially in the presence of magnetic resonance contraindications. Moreover, computed tomography can still have an important role in evaluation of nodal status, thoracic invasion, and distant metastasis because of the large area covered in a single examination. Our experience together with literature indicates that multidetector row computed tomography is a powerful supplementary method for evaluation of patients with breast cancer.

MDCT of the breast

OBJECTIVE

The purpose of this study was to evaluate retrospectively the accuracy of low-dose MDCT in the differentiation of breast lesions suspected on mammography and sonography.

MATERIALS AND METHODS

MDCT was performed on 61 patients with mammographic or sonographic findings suggestive of breast cancer who could not undergo MR mammography. For each lesion, morphologic features, attenuation, and time-attenuation curve pattern were evaluated. The 1-minute cut point of attenuation was analyzed on the images. CT findings were compared with histopathologic results, which were the reference standard.

RESULTS

Forty-seven of 61 patients underwent surgery, and the pathologic findings revealed 27 malignant and 20 benign lesions. With CT 25 of 27 malignant lesions and all 20 benign lesions were diagnosed correctly. CT had a sensitivity of 92.6%, specificity of 100%, positive predictive value of 100%, negative predictive value of 90.9%, and accuracy of 95.74%. The cutoff attenuation value, which had the best validity for differentiating malignant and benign lesions, was calculated to be 90 H on the 1-minute images.

CONCLUSION

Our results confirm and strengthen the importance of all imaging parameters and not one in particular. Dynamic MDCT can be used in the evaluation of selected patients with suspected breast tumors.

Breast CT

Breast cancer is a serious disease that accounts for approximately 40,000 deaths per year in the United States. Unfortunately, there is no known cause of breast cancer, and therefore the best way to prevent mortality is early detection. In the past 15 years, breast cancer mortality has been reduced significantly, which is in part due to screening with film-screen mammography. Nonetheless, conventional mammography lacks sensitivity, especially for certain subgroups of women such as those with dense breast tissue, those under 50 years old, and pre- or perimenopausal women. In addition, mammography has a very poor positive predictive value for biopsy, with 70%-90% of biopsies performed turning out negative. By improving visualization of breast tissue, X-ray computerized tomography (CT) of the breast can potentially provide improvements in diagnostic accuracy over conventional mammography. Owing to recent technological developments in digital detector technology, flat-panel CT imagers dedicated to imaging of the breast are now feasible. A number of academic groups are currently researching dedicated breast CT and prototype systems are currently being evaluated in the clinical setting.

Multidetector computed tomography assessment on tumor size and nodal status in patients with locally advanced breast cancer before and after neoadjuvant chemotherapy

AIMS

To evaluate the utility of multidetector computed tomography (MCT) in assessing tumor size and nodal status in patients with advanced breast cancers before and after the neoadjuvant chemotherapy.

METHODS

Twenty-eight proven locally advanced breast cancer patients with 30 tumors were enrolled in this study. MCT was used to assess tumor size and axillary lymph nodes before and after the neoadjuvant chemotherapy. The correlation between tumor size on MCT and gross tumor size was tested.

RESULTS

The MCT measurements documented complete response in 3, partial response in 18, non-response in 8 and progressed in 1. The mean tumor diameters on pathology and post-chemotherapy MCT were 3.6cm (S.D.=+/-2.9cm) and 3.1cm (S.D.=+/-2.6cm), respectively. The Pearson correlation coefficient was 0.76 (p<0.001). The sensitivity, specificity, positive predictive valve, negative predictive valve and accuracy of MCT in diagnosing the axillary lymph node metastases after pre-operative neoadjuvant chemotherapy were counted, respectively, to 72%, 40%, 85.7%, 22.2% and 66.7%. All the 5 downstaged axillary nodal statuses from node-positive to node-negative on MCT had micrometastases.

CONCLUSION

MCT can be used to evaluate tumor size and nodal status in patients with advanced breast cancer. As there is a baseline MCT before chemotherapy for comparison, we are potentially aware of the possibility of false negative nodal micrometastases on the post-chemotherapy MCT.

Non-palpable and non-invasive ductal carcinoma with bloody nipple discharge successfully resected after cancer spread was accurately diagnosed with three-dimensional computed tomography and galactography

A case of ductal carcinoma in situ (DCIS) that was treated by partial mastectomy is reported. The operation was performed after accurate estimation of cancer spread by three-dimensional computed tomography (3D-CT). The patient was a 39-year-old woman without a palpable lump who had a bloody nipple discharge. Ultrasonography showed distended mammary ducts with intraductal components. Fine needle aspiration cytology revealed ductal carcinoma. Galactography showed two subsegmental ducts and peripheral branches in the upper-inner quadrant of the right breast. 3D-CT depicted a well enhanced segmental-clumped lesion including two subsegments of a duct lobular system shown in galactograms. DCIS was diagnosed and partial mastectomy following the video assisted thoracoscopic surgery (VATS) marker insertion was performed, after cancer spread was accurately diagnosed by 3D-CT guidance. DCIS resected by minimally sufficient partial mastectomy with negative surgical margins was diagnosed histopathologically.

Comparison of MDCT and MRI for Evaluating the Intraductal Component of Breast Cancer

OBJECTIVE

The purpose of our study was to compare the accuracy of MDCT and MRI for evaluating the intraductal component of breast cancer.

MATERIALS AND METHODS

Sixty-nine patients with histologically proven invasive carcinoma underwent MDCT and MRI. Retrospectively, two radiologists performed a blinded review of the MDCT and MRI. Cases with intraductal component enhancement were classified into two morphologic types: ductal extension and segmental distribution. The lengths of the main tumor and of the intraductal component were measured in cases with ductal extension. For cases with segmental distribution, only the maximum length of the tumor was measured.

RESULTS

The sensitivity, specificity, and accuracy in detecting the intraductal component were 61%, 88%, and 71%, respectively, using MDCT; and 75%, 88%, and 80%, respectively, using MRI. MRI revealed the presence of the intraductal component with significantly higher sensitivity than did MDCT (p = 0.031). In the analysis of the length of the intraductal component in cases with ductal extension, which had relatively small intraductal components, underestimation by 15 mm or more was significantly less frequent with MRI than with MDCT (p = 0.008). There was no significant difference between MDCT and MRI in the evaluation of the maximum length of tumors in cases with segmental distribution, which had relatively large intraductal components.

CONCLUSION

Compared with MDCT, MRI revealed the presence of the intraductal component with higher sensitivity and equivalent specificity. In cases with ductal extension, MRI is more precise than MDCT for determination of the margin for surgical removal, with less underestimation of the extent of the intraductal component.

Assessing the extent of breast cancer using multidetector row helical computed tomography

OBJECTIVE

The aim of the study was to evaluate the usefulness of multidetector row helical computed tomography (MD-CT) in assessing the local extent of breast cancer.

METHODS

Seventy-five breast cancer patients were examined using MD-CT with scanning performed in the supine position at 1-mm collimation. The extent of the breast tumors determined using CT was compared with that based on histopathologic mapping with continuous 5-mm slices.

RESULTS

The CT evaluation of the maximum diameter of the extent of breast cancer was much better correlated with the histopathologic diagnosis (correlation coefficient=0.90) than the pre-CT diagnosis (correlation coefficient=0.46). Computed tomography correctly detected mammographically and clinically occult cancer other than the index lesion in 14 of 15 patients. The sensitivity, specificity, and accuracy in the diagnosis of the additional lesions were 93.3%, 98.3%, and 97.3%, respectively. Because the images were obtained in the supine position, they were useful for surgical planning.

CONCLUSION

The extent of breast cancer can be determined accurately using MD-CT.

Low-dose multidetector dynamic CT in the breast

This study investigated the feasibility of using low-dose multidetector dynamic computed tomography (CT) scan for imaging breast. We measured the radiation dose using a phantom at low- and standard-dose CT. To compare the image quality at low- and standard-dose CT, we evaluated normal breasts in 57 cases. In 44 cases with breast cancer, we assessed the staging and time-enhancement curves of breast cancer. In conclusion, the low-dose multidetector dynamic CT scan is feasible for the evaluation of the breast, with reduced radiation dose and with similar image quality when compared with standard-dose CT scan. In breast cancers, low-dose dynamic CT could be used for the staging of breast cancer before surgery.

Three-dimensional ultrasound imaging of breast cancer by a real-time intraoperative navigation system

BACKGROUND

In order to achieve a good cosmetic result without increasing the risk of ipsilateral breast cancer recurrence after breast conserving surgery, it is very important to minimize the resection volume of the breast without compromising the negativity of the surgical margin. For this purpose, it is necessary to obtain precise information on tumor extension. We therefore developed a three-dimensional (3-D) ultrasound navigation system for breast cancer surgery, which can be performed in the operating room just before surgery.

METHODS

We obtained 3-D breast tumor images by the 3-D ultrasound navigation system in 40 patients with primary breast cancer (stage 0-II) who underwent mastectomy or breast conserving surgery. The tumor size was measured in a coronal view of the 3-D tumor image and compared with the tumor size obtained from a pathological map of the tumor extension.

RESULTS

We obtained 3-D tumor images in 38 patients (success rate=95%). The tumor size in the images showed a very strong correlation with the pathological tumor size (r=0.898). The difference in tumor size between the 3-D images and pathology was less than 1 cm in 29 tumors (76.3%) and less than 2 cm in 36 (94.7%). On the other hand, the difference in tumor size between palpation and pathology was less than 1 cm in 19 out of 38 tumors (50.0%) and less than 2 cm in 29 tumors (76.3%). The absolute difference between the 3-D images and pathology was significantly less than that between palpation and pathology (p=0.0197).

CONCLUSIONS

Our 3-D ultrasound navigation system is useful in visualizing breast tumor extension and is more accurate than palpation. The system is expected to be helpful in deciding on the appropriate surgical margin in breast cancer surgery, resulting in a better cosmetic outcome without increasing the risk of surgical margin positivity.

Usefulness of three-dimensional multidetector-row CT images for preoperative evaluation of tumor extension in primary breast cancer patients

PURPOSE

Usefulness of three dimensional (3D) multidetector-row CT (MDCT) images for preoperative evaluation of tumor extension was studied in primary breast cancer patients.

METHODS

3D-MDCT tumor images of 143 tumors in 143 patients with primary breast cancer were created with the volume rendering method. The transverse tumor size (TS) and vertical tumor size (VS) were then measured in an anterior-posterior view of the 3D-MDCT images. The pathological tumor size was determined according to a map of the tumor spread prepared by pathologists using multi-sliced (3-5 mm intervals) surgical specimens and compared with the tumor size on 3D-MDCT images.

RESULTS

First, the optimal method for creating 3D-MDCT tumor images was determined for the first 40 patients (learning set), resulting in a fairly good correlation of tumor size on 3D-MDCT images with pathological tumor size (r = 0.983 for TS and r = 0.958 for VS). We then carried out a validation study on the next 103 patients (validation set). The 3D-MDCT tumor size's strong correlation with the pathological tumor size demonstrated a high rate of accuracy (r = 0.974 for TS and r = 0.977 for VS). Subset analyses according to histological type showed that correlation coefficients were r = 0.979 for TS and r = 0.981 for VS of invasive ductal carcinomas (n = 88), r = 0.948 for TS and r = 0.970 for VS of ductal carcinomas in situ (n = 10), and r = 0.984 for TS and r = 0.976 for VS of invasive lobular carcinomas (n = 5).

CONCLUSION

3D-MDCT images can assess breast cancer tumor extension highly accurately, and thus seems to be useful for planning the extent of resection in breast conserving surgery.

Multidetector row computed tomography for diagnosing intraductal extension of breast carcinoma

OBJECTIVES

Several reports supported the association of higher ipsilateral breast tumor recurrence rates with positive or intermediate margins compared with negative pathologic margins. Precise evaluation of intraductal component and adequate surgical margin are important factors affecting the tumor recurrence after breast conserving surgery. Numerous studies have reported the utility of magnetic resonance imaging for diagnosing developing intraductal extension of breast cancer, but few have investigated multidetector-row computed tomography (MD-CT). The present study evaluated the clinical utility of MD-CT for detecting intraductal extension of breast carcinoma, and analyzed clinical parameters affecting the detection of intraductal extension under MD-CT.

METHODS

Subjects comprised 44 patients grouped into three categories according to degree of intraductal extension of the main tumor under MD-CT (Intraductal spread grade 1 approximately 3: IDS 1 approximately 3). Tumors were also categorized histopathologically (p-IDS 0 approximately 3), and CT-pathological correlations were examined retrospectively. Clinical parameters were evaluated to determine the affect on detection of intraductal components.

RESULTS

MD-CT detected 44 breast lesions (100%). Sensitivity for detection of intraductal component was 81.2%, specificity was 67.8%, and accuracy was 72.7%. Regarding extent of intraductal components, significant correlations were found between histopathological and MD-CT findings. A strong correlation was found in postmenopausal women between T2 tumor and high histological grade.

CONCLUSIONS

MD-CT findings of intraductal extension from breast carcinoma correlate with histological degree of intraductal extension, and MD-CT may be useful for preoperative assessment of breast-conserving surgery, particularly for postmenopausal women with histological high nuclear grade and T2 tumor.

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.

Value of Three-Dimensional Helical CT Image-Guided Planning for Made-to-Order Lumpectomy in Breast Cancer Patients

The authors reviewed Niigata Cancer Center Hospital's experience treating patients with lumpectomy to evaluate the utility of three-dimensional helical computed tomography (3D-CT) image-guided made-to-order lumpectomy and determine a positive margin rate. From April 1993 to September 2000, 251 breasts in 248 patients were treated with lumpectomy with a 1 cm macroscopic free margin. In 213 breasts (85%), 3D-CT image-guided made-to-order lumpectomy was performed. Thirty-eight breasts (15%) underwent a lumpectomy without 3D-CT. The lumpectomy specimen was sectioned at 5 mm intervals. Margin status was classified as negative (no invasive or ductal carcinoma in situ (DCIS) within 2 mm from the cut surface) or positive. Positive margins were classified as focally positive (invasive or DCIS transected at the margin within 5 mm or one slide) or massively positive. With 3D-CT image-guided lumpectomy, 21% (45/213) of lesions had a positive margin and 42% (16/38) of lesions without 3D-CT image-guided lumpectomy had a positive margin (p = 0.0055). For lesions with massively positive margins, the rates were 9% (4/45) for 3D-CT image-guided lumpectomy and 38% (6/16) for lumpectomy without 3D-CT (p = 0.0152). 3D-CT image-guided made-to-order lumpectomy decreased the positive surgical margin rate. Among patients with positive margins, those with 3D-CT image-guided lumpectomy have less residual cancer than those without 3D-CT.

3D imaging of intraductal spread of breast cancer and its clinical application for navigation surgery

BACKGROUND

To perform optimal tumor resection of breast cancer, preoperative information concerning intraductal spread of cancer (ISC) is very important.

METHODS

To detect ISC, three-dimensional (3D) imaging methods including helical CT, MRI, and ultrasound were examined in patients with primary breast cancer by comparison with multi-sliced pathological specimens.

RESULTS

The sensitivity of each modality for detecting ISC was 64.7%, 90.2% and 78.6%, and the specificity was 97.1%, 62.9% and 100%, respectively. Subsequently, the potential of each modality for navigation in breast conserving surgery was assessed. Three-dimensional helical CT navigation could reduce the positive rate of the specimen margins, and 3D MRI navigation using a special mapping sheet enabled removal of non-palpable breast cancer without positive margins in 66.7% of patients preliminarily. Real-time 3D ultrasound images correlated with the resected tumor size, with the difference between the two less than 2 cm in 72.7 % of the patients with ISC.

CONCLUSION

Three-dimensional images from each modality were reliable enough for diagnosis of tumor spread, and surgical navigation using these images seemed to have potential clinical application for breast conserving surgery. Prospective studies for navigation surgery with more patients are needed.

False-positive helical CT findings of multifocal and multicentric breast cancer: is attenuation of tumor useful for diagnosing enhanced lesions?

OBJECTIVE

To analyze helical CT false-positive multifocal breast cancers and to assess the relevance of the attenuation of tumors for diagnosing enhanced lesions.

METHODS

Helical CT studies of 156 invasive breast cancers before breast conserving surgery were examined. A lesion was defined as positive if focal enhancement was detected by CT within 100 seconds after contrast material administration. The attenuation and enhancement percent ratio [(post-contrast value/pre-contrast value)%] were obtained. Attenuation of false-positive and malignant lesions was compared.

RESULTS

Helical CT enabled the detection of all 156 invasive tumors with 95 intraductal tumor extensions. The sensitivity and specificity of multifocal/multicentric disease detection by helical CT were 69% and 90%, respectively. False-positive multifocal/multicentric findings were obtained in 11 (7%) of 156 cases. The mean value of the enhancement percent ratio of the index tumors was 237%. Significant differences in the attenuation on post-contrast enhanced scans between the enhanced lesions (index tumors; mean, 82 HU), the true-positive multifocal/multicentric lesions (mean, 73 HU), the false-positive multifocal/multicentric lesions (mean, 87 HU) and normal breast tissue (mean, 32 HU) were found (p<0.0001). The attenuation of the true-positive multifocal/multicentric lesions on post-contrast enhanced scans was significantly less than that of the false-positive multifocal/multicentric lesions (p=0.03).

CONCLUSION

Attenuation of tumor is not useful for differential diagnosis of enhanced lesions on helical CT of the breast. The presence of enhancement alone does not always indicate a malignant lesion.

Comparison between high-resolution helical CT and pathology in breast examination

PURPOSE

To determine whether high-resolution helical CT can show the architectural features of breast carcinomas of non-limited extent (non-BCLE) and to establish the CT characteristic morphology of non-BCLE.

MATERIAL AND METHODS

We prospectively studied high-resolution helical CT of 136 invasive breast carcinomas before breast-conserving surgery. Non-BCLE were defined as ductal carcinomas in situ and invasive carcinomas beyond 1 cm from the edge of the dominant mass. Non-BCLE were defined as positive if enhanced beyond 1 cm from the edge of the focal enhancement on CT. After surgical resection, specimens were sliced in serial sections at 5-mm intervals, and the gross morphology and histology were correlated with the appearance of the preoperative CT lesion images.

RESULTS

Non-BCLE were present in 47 invasive carcinomas. The sensitivity and specificity of non-BCLE evaluation by high-resolution helical CT were 70% and 89%, respectively. The morphology of non-BCLE on CT agreed with histologic findings. The morphological pattern on CT significantly correlated with intraductal tumor density adjacent to invasive tumor.

CONCLUSION

Comparison of high-resolution helical CT with histologic data suggests that demonstration of a non-BCLE morphology can make the CT breast carcinoma local staging more accurate.