Overview of breast imaging

Efficacy of Second-Look Ultrasound with MR Coregistration for Evaluating Additional Enhancing Lesions of the Breast: Review of the Literature

Contrast enhanced magnetic resonance imaging (CE-MRI) has acquired a central role in the field of diagnosis and evaluation of breast cancer due to its high sensitivity; on the other hand, MRI has shown a variable specificity because of the wide overlap between the imaging features of benign and malignant lesions. Therefore, when an additional breast lesion is identified at CE-MRI, a second look with targeted US is generally performed because it provides additional information to further characterise the target lesion and makes it possible to perform US-guided biopsies which are costless and more comfortable for patients compared with MRI-guided ones. Nevertheless, there is not always a correspondence between CE-MR findings and targeted US due to several factors including different operator's experience and position of patients. A new technique has recently been developed in order to overcome these limitations: US with MR coregistration, which can synchronise a sonography image and the MR image with multiplanar reconstruction (MPR) of the same section in real time. The aim of our study is to review the literature concerning the second look performed with this emerging and promising technique, showing both advantages and limitations in comparison with conventional targeted US.

Surgical-office-based versus radiology-referral-based breast ultrasonography: a comparison of efficiency, cost, and patient satisfaction

BACKGROUND

The differences in efficiency, cost of care, and patient satisfaction between surgical-office-based (SB) breast ultrasonography by the surgeon and radiology-referral-based (RB) ultrasonography by the radiologist in the workup of lumps and imaging abnormalities have not been computed.

STUDY DESIGN

Charts of 61 consecutive patients requiring breast ultrasonography at the Comprehensive Breast Center from October through December 2005 were evaluated. The SB ultrasonography approach was compared with the RB approach. Matching variables were patient age, presenting complaint, Gail risk score, ultrasonography findings, interventional procedure, and histopathology reports. Outcomes variables were efficiency (time from presentation and establishment of diagnosis), cost of care, and patient satisfaction.

RESULTS

Twenty-nine patients had RB and 32 had SB breast ultrasonography. The RB and SB groups were similar in age, Gail risk, and ultrasonography findings. Median time to establish diagnosis in the RB group was 23 days, versus 1 day in the SB group (p < 0.0001). Median cost of care in the RB versus SB group was $659.00 versus $369.50 (p = 0.253), and net revenue generated was $85.00 versus $195.00 (p = 0.005), respectively. Forty-nine of 61 (80.3%) patients responded to the satisfaction survey. Forty-seven of 49 (96%) patients expect the diagnosis to be established within 48 hours. Twenty-eight of 28 (100%) patients in the SB group regarded their imaging study to be efficient, versus 5 of 21 patients in the RB group (p = 0.005); 16 of 21 in the RB group versus 26 of 28 in the SB group thought they adequately understood the ultrasonography findings at the time of study (p = 0.051). Twenty-four (86%) SB patients versus 14 (67%) RB patients rated overall experience as excellent (p = 0.055).

CONCLUSIONS

SB breast ultrasonography is an efficient, cost-effective, and patient-friendly approach to breast problems.

Updates in breast ultrasound

Ultrasound is becoming an indispensable tool for the surgeon in the diagnosis and treatment of a variety of breast problems. Hands-on ultrasound education for surgeons and the ongoing improvements in imaging technology have made surgeon-performed breast ultrasound an effective method of identifying and diagnosing breast lesions and have increased the surgeon's ability to perform ultrasound-guided interventional procedures. This article reviews the current state of surgeon-performed breast ultrasound.

Current status of PET in breast cancer imaging, staging, and therapy

The exact roles of PET in the imaging management of patients with known or suspected breast cancer are still in evolution. For assessing primary lesions, it is sometimes possible with PET to detect cancers occult on standard methods. This could be useful in high-risk patient populations, but in dense breasts, background FDG uptake is often higher than in women with fatty breasts, making identification of lesions < 1 cm in size improbable with current technologies. Distinguishing malignant from benign primary breast disease would seem better addressed by biopsy. With a positive predictive value of FDG PET for cancer over 96%, any FDG-avid breast lesion is highly suspicious and merits biopsy. Although PET in theory should be useful for depicting multifocal disease before surgery, the limitations in detecting small lesions in the breast limit the contribution of PET at present. It is most likely that PET will have a greater role in depicting primary breast lesions as dedicated PET imaging devices for the breast evolve. For axillary and internal mammary nodal staging, results with FDG PET are variable. Small nodal metastases < or = 5 mm will be missed by PET, whereas larger ones are more likely to be detected. PET can depict internal mammary nodes, but the accuracy of the method in this setting is not known, nor is there consensus on how identifying internal mammary node metastases will change treatment. Based on the available data, for pT1 breast lesions, PET, if negative, is not an adequate replacement for sentinel node surgery or axillary dissection. Results from the multicenter trial will be of great interest. Clearly PET can stage metastatic disease well. Bone scans with 18F- are exquisitely sensitive for metastases, and FDG is also very good. However, FDG PET can miss some blastic metastases to bone so at present FDG is not capable of excluding the presence of bone metastases. PET seems very well suited to detecting recurrences in soft tissues and the brachial plexus region in particular. The utility of PET in planning the treatment of individual patients appears promising. Although results must be confirmed in larger studies, it appears safe to conclude that failure of a chemotherapy regimen to decrease FDG uptake promptly in a breast cancer portends poor response. This does not hold true for hormonal therapy. At present, labeled estrogens are not widely available and cannot be recommended for clinical use. Thus, PET has shown considerable promise in breast cancer imaging, but in the author's experience is best applied to solve difficult imaging questions in specific patients and is not recommended for routine evaluation of the breast cancer patient. However, in larger primary tumors, the ability to use PET for staging and to plan treatment response suggest it will be more widely used. Additional studies with newer PET imaging devices and FDG and other tracers will help us better determine the role of PET in routine clinical care of the patient with known or suspected breast cancer. Certainly, this represent a fertile area for translational research studies over the next several years with the potential to significantly alter the way breast cancer is imaged and managed.