Clinical Feasibility of Dual-Layer CT With Virtual Monochromatic Image for Preoperative Staging in Patients With Breast Cancer: A Comparison With Breast MRI

OBJECTIVE

Dual-layer CT (DLCT) can create virtual monochromatic images (VMIs) at various monochromatic X-ray energies, particularly at low keV levels, with high contrast-to-noise ratio. The purpose of this study was to assess the clinical feasibility of contrast-enhanced chest DLCT with a low keV VMI for preoperative breast cancer staging, in comparison to breast MRI.

MATERIALS AND METHODS

A total of 152 patients with 155 index breast cancers were enrolled in the study. VMIs were generated from contrast-enhanced chest DLCT at 40 keV and maximum intensity projection (MIP) with three-dimensional (3D) reconstruction was performed for both bilateral breast areas. Two radiologists reviewed in consensus the 3D MIP images of the chest DLCT with VMI and breast MRI in separate sessions with a 3-month wash-out period. The detection rate and mean tumor size of the index cancer were compared between the chest DLCT with VMI and breast MRI. Additionally, the agreement of tumor size measurement between the two imaging modalities were evaluated.

RESULTS

Of all index cancers, 84.5% (131/155) were detected in the chest DLCT with VMI, while 88.4% (137/155) were detected in the breast MRI (P = 0.210). The Bland-Altman agreement between the chest DLCT with VMI and breast MRI was a mean difference of -0.05 cm with 95% limits of agreement of -1.29 to 1.19 cm. The tumor size in the chest DLCT with VMI (2.3 ± 1.7 cm) was not significantly different from that in the breast MRI (2.4 ± 1.6 cm) (P = 0.106).

CONCLUSION

The feasibility of chest DLCT with VMI was demonstrated for preoperative tumor staging in breast cancer patients, showing comparable cancer detectability and good agreement in tumor size measurement compared to breast MRI. This suggests that chest DLCT with VMI can serve as a potential alternative for patients who have contraindications to breast MRI.

Discrepancy between Tumor Size Assessed by Full-Field Digital Mammography or Ultrasonography (cT) and Pathology (pT) in a Multicenter Series of Breast Metaplastic Carcinoma Patients

Metaplastic breast cancer (BC-Mp) presents diagnostic and therapeutic complexities, with scant literature available. Correct assessment of tumor size by ultrasound (US) and full-field digital mammography (FFDM) is crucial for treatment planning.

METHODS

A retrospective cohort study was conducted on databases encompassing records of BC patients (2012-2022) at the National Research Institutes of Oncology (Warsaw, Gliwice and Krakow Branches). Inclusion criteria comprised confirmed diagnosis in postsurgical pathology reports with tumor size details (pT) and availability of tumor size from preoperative US and/or FFDM. Patients subjected to neoadjuvant systemic treatment were excluded. Demographics and clinicopathological data were gathered.

RESULTS

Forty-five females were included. A total of 86.7% were triple-negative. The median age was 66 years (range: 33-89). The median pT was 41.63 mm (6-130), and eight patients were N-positive. Median tumor size assessed by US and FFDM was 31.81 mm (9-100) and 34.14 mm (0-120), respectively. Neither technique demonstrated superiority (p > 0.05), but they both underestimated the tumor size (p = 0.002 for US and p = 0.018 for FFDM). Smaller tumors (pT1-2) were statistically more accurately assessed by any technique (p < 0.001). Only pT correlated with overall survival.

CONCLUSION

The risk of underestimation in tumor size assessment with US and FFDM has to be taken into consideration while planning surgical procedures for BC-Mp.

The Accuracy of Mammography, Ultrasound, and Magnetic Resonance Imaging For the Measurement of Invasive Breast Cancer With Extensive Intraductal Components

BACKGROUND

The precise preoperative evaluation of radiologic tumor size with extensive intraductal component (EIC) is important. This study compared the accuracy of mammography, ultrasound (US), and magnetic resonance imaging (MRI) to measure invasive breast cancer with EIC.

METHODS

Between 2007 and 2012, we collected data from 6816 patients who underwent surgery for invasive breast cancer at our institution. We reviewed the postoperative surgical reports of the tumors, in which the invasive tumor size and EIC were measured separately. Finally, we included 370 women who underwent preoperative mammography, US, and MRI. Each modality was retrospectively reviewed to measure the size of invasive breast cancer with EIC. The reference standard was surgical pathologic size and the accuracies of the image were evaluated.

RESULTS

Spearman's correlation coefficient for the size of invasive cancer with EIC was good between MRI (r = 0.741) and pathology, and moderate between mammography (r = 0.661) or US (r = 0.514) and pathology. Both mass and nonmass lesions showed good correlations (intraclass correlation coefficient [ICC] = 0.672 and 0.612, respectively) in MRI. Furthermore, the subgroup of tumors without microcalcifications showed a higher correlation with MRI (ICC = 0.796) than with mammography (ICC = 0.620). However, the subgroup with microcalcifications showed a good correlation with mammography (ICC = 0.702) compared to MRI (ICC = 0.680) and US (ICC = 0.532).

CONCLUSION

The lesion on mammography, US, and MRI reflected preoperative size of invasive cancer with EIC. MRI shows a higher correlation than mammography and US. However, cancer with calcifications of mammography shows a more accurate size than MRI or US.

Impact of preoperative magnetic resonance imaging on surgery and eligibility for intraoperative radiotherapy in early breast cancer

We looked at the usefulness of magnetic resonance imaging (MRI) in decision-making and surgical management of patients selected for intraoperative radiotherapy (IORT). We also compared lesion size measurements in different modalities (ultrasound (US), mammogram (MMG), MRI) against pathological size as the gold standard. 63 patients eligible for IORT based on clinical and imaging criteria over a 34-month period were enrolled. All had MMG and US, while 42 had additional preoperative MRI for locoregional preoperative staging. Imaging findings and pathological size concordances were analysed across the three modalities. MRI changed the surgical management of 5 patients (11.9%) whereby breast-conserving surgery (BCS) and IORT was cancelled due to detection of satellite lesion, tumor size exceeding 30mm and detection of axillary nodal metastases. Ten of 42 patients (23.8%) who underwent preoperative MRI were subjected to additional external beam radiotherapy (EBRT); 7 due to lymphovascular invasion (LVI), 2 due to involved margins, and 1 due to axillary lymph node metastatic carcinoma detected in the surgical specimen. Five of 21 (23.8%) patients without prior MRI were subjected to additional EBRT post-surgery; 3 had LVI and 2 had involved margins. The rest underwent BCS and IORT as planned. MRI and MMG show better imaging-pathological size correlation. Significant increase in the mean 'waiting time' were seen in the MRI group (34.1 days) compared to the conventional imaging group (24.4 days). MRI is a useful adjunct to conventional imaging and impacts decision making in IORT. It is also the best imaging modality to determine the actual tumour size.

Breast Magnetic Resonance Imaging for Patients With Newly Diagnosed Breast Cancer: A Review

Despite the high sensitivity and widespread use of preoperative magnetic resonance imaging (MRI), the American Cancer Society and the National Comprehensive Cancer Network guidelines do not recommend the routine use of preoperative MRI owing to the conflicting results and lack of clear benefit to the surgical outcome (reoperation and mastectomy) and long-term clinical outcomes (local recurrence and metachronous contralateral breast cancer). Preoperative MRI detects additional cancers that are occult at mammography and ultrasound but increases the rate of mastectomy. Concerns about overdiagnosis and overtreatment of preoperative MRI might be mitigated by adjusting the confounding factors when conducting studies, using the state-of-the-art image-guided biopsy technique, applying the radiologists’ cumulative experiences in interpreting MRI findings, and performing multiple lumpectomies in patients with multicentric cancer. Among the various imaging methods, dynamic contrast-enhanced MRI has the highest accuracy in predicting pathologic complete response after neoadjuvant chemotherapy. Prospective trials aimed at applying the MRI information to the de-escalation of surgical or radiation treatments are underway. In this review, current studies on the clinical outcomes of preoperative breast MRI are updated, and circumstances in which MRI may be useful for surgical planning are discussed.

Prediction of tumor size in patients with invasive ductal carcinoma using FT-IR spectroscopy combined with chemometrics: a preliminary study

Precise detection of tumor size is essential for early diagnosis, treatment, and evaluation of the prognosis of breast cancer. However, there are some errors between the tumor size of breast cancer measured by conventional imaging methods and the pathological tumor size. Invasive ductal carcinoma (IDC) is a common pathological type of breast cancer. In this study, serum Fourier transform infrared spectroscopy (FT-IR) combined with chemometric methods was used to predict the maximum diameter and maximum vertical diameter of tumors in IDC patients. Three models were evaluated based on the pathological tumor size measured after surgery and included grid search support vector machine regression (GS-SVR), back propagation neural network optimized by genetic algorithm (GA-BP-ANN), and back propagation neural network optimized by particle swarm optimization (PSO-BP-ANN). The results show that three models can accurately predict tumor size. The GA-BP-ANN model provided the best fitting quality of the largest tumor diameter with the determination coefficients of 0.984 in test set. And the GS-SVR model provided the best fitting quality of the largest vertical tumor diameter with the determination coefficients of 0.982 in test set. The GS-SVR model had the highest prediction efficiency and the lowest time complexity of the models. The results indicate that serum FT-IR spectroscopy combined with chemometric methods can predict tumor size in IDC patients. In addition, compared with traditional imaging methods, we found that the experimental results of the three models are better than traditional imaging methods in terms of correlation and fitting degree. And the average fitting error of PSO-BP-ANN and GA-BP-ANN models was less than 0.3 mm. The minimally invasive detection method is expected to be developed into a new clinical diagnostic method for tumor size estimation to reduce the diagnostic trauma of patients and provide new diagnostic experience for patients. Graphical Abstract.

Tumor size and focality in breast carcinoma: Analysis of concordance between radiological imaging modalities and pathological examination at a cancer center

CONTEXT

Accurate assessment of clinical and pathological tumor stage is crucial for patient treatment and prognosis.

OBJECTIVE

The aim of this study was to assess the concordance between the tumor size and focality between radiological studies and pathology and to evaluate the impact of discrepancies on staging.

DESIGN

Patients who underwent surgery for invasive breast carcinoma from January 1, 2014, to December 31, 2015, were identified.

RESULTS

Three imaging modalities (mammogram, ultrasound and MRI) were compared with gross examination and final pathology. 1152 preoperative radiological studies were evaluated for focality and 1019 were evaluated for tumor size. For all 3 radiographic modalities, there was a statistically significant difference between the mean tumor size on radiology and the final pathology report (mammogram, P < .001; ultrasound, P = .004; MRI, P < .001). In 29% of radiology studies, there was a discrepancy in stage. The error rate for determining focality was 28% for mammograms, 27% for ultrasounds, and 29% for MRIs. Tumor size from gross examination correlated with microscopic tumor size in 57% of cases, but gross examination had 88% concordance with the final pathology report in determining focality.

CONCLUSION

Our study revealed statistically significant differences in mean tumor size reported across all 3 imaging modalities when compared to the final pathology report. MRI had the highest error rate, with a tendency to overestimate tumor size and number of foci. Among all diagnoses, cases of invasive carcinoma with an extensive intraductal component were most prone to discrepancies with imaging.

Three-dimensional visualization technique in endoscopic breast-conserving surgery and pedicled omentum for immediate breast reconstruction

PURPOSE

To evaluate the three-dimensional visualization technique (3DVT) in endoscopic breast-conserving surgery (EBCS) and pedicled omentum for immediate breast reconstruction.

METHODS

Clinical data of 256-slice multi-detector CT scanning from 52 patients (group A) were introduced into self-developed Medical Imaging 3D Visualization Systems (MI-3DVS) for individualized segmentation, 3D reconstruction and volume calculation. The surgical process was designed according to the 3D model. Next, the EBCS and pedicled omentum breast reconstruction were performed according to the preoperative design. Finally, the operating time, blood loss, length of postoperative hospital stay, complications and cosmetic outcomes in group A were compared to 44 patients in group B, who underwent the same operation without 3DVT.

RESULTS

The 3DVT can be used to analyze the location of the breast tumors and determine the excision extension of the breast precisely. Compared to group B, group A had the advantage of less bleeding, shortened operating time and earlier discharge (p < 0.05). The cosmetic results of group A were more satisfactory than those of group B (p < 0.05). After a postoperative follow-up of 6-30 months, none of the patients in either group showed any signs of recurrence.

CONCLUSIONS

3DVT can be used to design the surgical process preoperatively and results in positive therapeutic and cosmetic outcomes in EBCS and pedicled omentum for immediate breast reconstruction.

Factors affecting the concordance of radiologic and pathologic tumor size in breast carcinoma

Background

Radiologic assessment of tumor size is an integral part of the work-up for breast carcinoma. With improved radiologic equipment, surgical decision relies profoundly upon radiologic/clinical stage. We wanted to see the concordance between radiologic and pathologic tumor size to infer how accurate radiologic/clinical staging is.

Materials and methods

The surgical pathology and ultrasonography reports of patients with breast carcinoma were reviewed. Data were collected for 406 cases. Concordance was defined as a size difference within ±2 mm.

Results

The difference between radiologic and pathologic tumor size was within ±2 mm in 40.4% cases. The mean radiologic size was 1.73 ± 1.06 cm. The mean pathologic size was 1.84 ± 1.24 cm. A paired t-test showed a significant mean difference between radiologic and pathologic measurements (0.12 ± 1.03 cm, p = 0.03). Despite the size difference, stage classification was the same in 59.9% of cases. Radiologic size overestimated stage in 14.5% of cases and underestimated stage in 25.6% of cases. The concordance rate was significantly higher for tumors ≤2 cm (pT1) (51.1%) as compared to those greater than 2 cm (≥pT2) (19.7%) (p < 0.0001). Significantly more lumpectomy specimens (47.5%) had concordance when compared to mastectomy specimens (29.8%) (p < 0.0001). Invasive ductal carcinoma had better concordance compared to other tumors (p = 0.02).

Conclusion

Mean pathologic tumor size was significantly different from mean radiologic tumor size. Concordance was in just over 40% of cases and the stage classification was the same in about 60% of cases only. Therefore, surgical decision of lumpectomy versus mastectomy based on radiologic tumor size may not always be accurate.

Shear Wave Speed of the Lesion in Preoperative Breast Ultrasonography: Association with Disease-free Survival of Patients with Primary Operable Invasive Breast Cancer

RATIONALE AND OBJECTIVES

We aimed to investigate the relationship between shear wave speed (SWS) of the lesion on preoperative breast ultrasonography (US) and disease-free survival of patients with primary operable invasive breast cancer.

MATERIALS AND METHODS

This retrospective study was approved by our Institutional Review Board. The requirement for informed consent was waived. A total of 195 consecutive newly diagnosed invasive breast cancer patients (age 33-83 years; mean 54.0 years) with preoperative breast US with SWS measurement of the lesion were identified. They underwent surgery between May 2012 and May 2013. SWS was measured at the center and three marginal zones in the main tumors, and the maximum value was used for analyses. For 35 patients who underwent primary systemic therapy (PST), the maximum SWS before PST was used. Cox proportional hazards modeling was used to identify the relationship between clinical-pathologic factors and disease-free survival.

RESULTS

Fourteen recurrences occurred at 6-47 months (mean 22.3 months) after surgery. On multivariate analysis, a positive history of PST (hazard ratio [HR] = 4.93; 95% confidence interval [CI]: 1.66, 14.70; P = .004), adjuvant chemotherapy (HR = 3.67; 95% CI: 1.11, 12.1; P = .033), and higher maximum SWS (HR = 1.55; 95% CI: 1.07, 2.23; P = .020) were associated with poorer disease-free survival.

CONCLUSION

Higher maximum SWS on preoperative US, in addition to a positive history of PST and adjuvant chemotherapy, was significantly associated with poorer disease-free survival of patients with invasive breast cancer.

Assessment of breast mass morphology with diffusion-weighted MRI: Beyond apparent diffusion coefficient

BACKGROUND

Diffusion-weighted imaging (DWI) is a noncontrast-enhanced MRI technique. There are new promising studies on the use of DWI as a part of the enhanced or unenhanced abbreviated breast MRI protocols.

PURPOSE

To evaluate the ability of breast DWI in the assessment of mass morphology and determine the contribution of this morphologic evaluation in their characterization.

STUDY TYPE

Retrospective.

POPULATION

In all, 213 consecutive women were breast MR imaged and had a later confirmed diagnosis.

FIELD STRENGTH/SEQUENCE

Breast dynamic contrast-enhanced-MRI (DCE-MRI) and DWI at 1.5T.

ASSESSMENT

After Institutional Review Board approval, two radiologists first independently, and later in consensus, evaluated the visibility and morphology of the 143 malignant, 70 benign masses on DWI and DCE-MRI in separate sessions, blindly. Shape, margin, and internal pattern of the masses were evaluated according to BI-RADS lexicon. Apparent diffusion coefficient (ADC) and tumor size were measured by one radiologist.

STATISTICAL TESTS

Consistency between imaging methods and readers was evaluated with Cohen's kappa statistics. Multivariate analysis was applied to find the best predictors of malignancy.

RESULTS

Tumor visibility on DWI was high to moderate in at least 88% of cases. Consistency between DWI and DCE-MRI was substantial (kappa ≥0.757) for shape and margin and moderate (kappa = 0.505) for internal pattern. Interobserver agreement was substantial to moderate for all morphologic parameters (kappa ≥0.596). Morphology evaluated on DWI provided 83-84% accuracy in discriminating malignant from benign masses. ADC alone provided 90-91% accuracy. Both morphologic parameters and ADC were significantly associated with malignancy on multivariate analysis and provided 91-93% accuracy.

DATA CONCLUSION

DWI might be used not only for ADC evaluation but also for the morphological evaluation of breast masses to characterize them.

LEVEL OF EVIDENCE

3 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2018;48:1668-1677.

Invasive Breast Carcinoma Tumor Size on Core Needle Biopsy: Analysis of Practice Patterns and Effect on Final Pathologic Tumor Stage

INTRODUCTION

In the absence of nodal metastasis, pathologic tumor (pT) size remains one of the most important factors in adjuvant treatment decisions and patient prognosis in breast cancer. The aim of this study was to evaluate the effect of core needle biopsy (CNB) tumor size on final pT stage.

MATERIALS AND METHODS

Our information system was searched to identify all patients who underwent excisional procedures for invasive breast carcinoma from January 1^, 2014 to December 31, 2015. The tumor size on CNB and final excision, the number of cases in which the CNB size was larger, and the percentage of cases in which using the CNB tumor size changed the final pT stage were recorded.

RESULTS

From 1380 primary breast excisions/mastectomies, a total of 870 cases were included. In 82 (9.4%) the CNB tumor size was larger (63 of 82 cases) or no residual tumor was identified on excision (19 of 82 cases). From these 82 cases, 40 (48.7%) were properly staged on the basis of CNB tumor size, 16 (19.5%) were not staged, and 26 (31.7%) were staged using the final excision tumor size. Change in stage occurred in 7 of these 26 patients.

CONCLUSION

Our study revealed that in most cases, the largest tumor size is found in the excision/mastectomy specimen. However, in 9.4% (82 of 870), the CNB contains the most accurate tumor size for pT staging. On the basis of our results, including the largest linear tumor extent on the CNB report is recommended.

Tumor Size in Breast Carcinoma: Gross Measurement Is Important!

Introduction. The staging of breast carcinoma is mainly dependent on tumor size and lymph node status. Small increments in tumor size upstage the patient. An accurate determination of the tumor size is therefore critically important. Although the final staging is based on microscopic size, pathologists rely on gross measurements in a considerable number of cases. Methods. We investigated the concordance between gross and microscopic measurements of breast carcinoma as well as factors affecting this concordance. This study is a retrospective review of surgical pathology reports of invasive breast carcinomas. Data were collected for 411 cases. Concordance was defined as a size difference within ±2 mm. Results. Gross and microscopic sizes were identical in 33.1% of cases. Gross and microscopic size difference was within ±2 mm in 56% of cases. Despite the size difference, stage classification ended up being the same in 68.6% of cases. Tumor stage was over estimated by gross measurement in 17.0% of cases and underestimated in 14.4% of cases. The concordance was significantly higher for those tumors in which final pathologic tumor (pT) size was greater than 2 cm (≥pT2) as compared with those less than or equal to 2 cm (≤pT1; P < .0001). A higher proportion of mastectomy specimens (61.4%) were concordant as compared with lumpectomy specimens (52.1%). Conclusion. Gross and microscopic tumor sizes were concordant in 56% of cases. Stage classification based on gross and microscopic tumor size was different in nearly one third (31.4%) of cases. Gross tumor size is critically important in accurate staging at least in cases where tumor size cannot be confirmed microscopically.

Automated breast volume scanner (ABVS) in assessing breast cancer size: A comparison with conventional ultrasound and magnetic resonance imaging

OBJECTIVES

To compare automated breast volume scanner (ABVS), ultrasound (US) and MRI in measuring breast cancer size, and evaluate the agreement between ABVS and US in assessing lesion location and sonographic features.

METHODS

We retrospectively included 98 women with 100 index cancers who had undergone US and ABVS followed by 1.5T MRI. Images were interpreted by a pool of readers reporting lesion size, location and breast imaging reporting and data system (BI-RADS) features. Bland-Altman analysis (with logarithmic data transformation), intraclass correlation coefficient (ICC) and Cohen's kappa statistic were used for statistical analysis.

RESULTS

MRI showed the best absolute agreement with histology in measuring cancer size (ICC 0.93), with LOA comparable to those of ABVS (0.63-1.99 vs. 0.52-1.73, respectively). Though ABVS and US had highly concordant measurements (ICC 0.95), ABVS showed better agreement with histology (LOA 0.52-1.73 vs. 0.45-1.86, respectively), corresponding to a higher ICC (0.85 vs. 0.75, respectively). Except for posterior features (k=0.39), the agreement between US and ABVS in attributing site and BI-RADS features ranged from substantial to almost perfect (k=0.68-0.85).

CONCLUSIONS

ABVS performs better than US and approaches MRI in predicting breast cancer size. ABVS performs comparably to US in sonographic assessment of lesions.

KEY POINTS

• ABVS approaches MRI in predicting breast cancer size. • ABVS is equivalent to US in localising and characterising breast cancer. • ABVS is more accurate than US in assessing breast cancer size. • ABVS has the potential to replace US in breast cancer staging.

Accuracy of contrast-enhanced spectral mammography for estimating residual tumor size after neoadjuvant chemotherapy in patients with breast cancer: a feasibility study

Objective

To assess the feasibility of contrast-enhanced spectral mammography (CESM) of the breast for assessing the size of residual tumors after neoadjuvant chemotherapy (NAC).

Materials and methods

In breast cancer patients who underwent NAC between 2011 and 2013, we evaluated residual tumor measurements obtained with CESM and full-field digital mammography (FFDM). We determined the concordance between the methods, as well as their level of agreement with the pathology. Three radiologists analyzed eight CESM and FFDM measurements separately, considering the size of the residual tumor at its largest diameter and correlating it with that determined in the pathological analysis. Interobserver agreement was also evaluated.

Results

The sensitivity, specificity, positive predictive value, and negative predictive value were higher for CESM than for FFDM (83.33%, 100%, 100%, and 66% vs. 50%, 50%, 50%, and 25%, respectively). The CESM measurements showed a strong, consistent correlation with the pathological findings (correlation coefficient = 0.76-0.92; intraclass correlation coefficient = 0.692-0.886). The correlation between the FFDM measurements and the pathological findings was not statistically significant, with questionable consistency (intraclass correlation coefficient = 0.488-0.598). Agreement with the pathological findings was narrower for CESM measurements than for FFDM measurements. Interobserver agreement was higher for CESM than for FFDM (0.94 vs. 0.88).

Conclusion

CESM is a feasible means of evaluating residual tumor size after NAC, showing a good correlation and good agreement with pathological findings. For CESM measurements, the interobserver agreement was excellent.

Relevance of breast MRI in determining the size and focality of invasive breast cancer treated by mastectomy: a prospective study

Background

The aim of this study was the evaluation of breast MRI in determining the size and focality of invasive non-metastatic breast cancers.

Methods

The prospective, single-centre study conducted in 2015 compared preoperative MRI with histological analysis of mastectomy.

Results

One hundred one mastectomies from 98 patients were extensively analysed. The rates of false-positive and false-negative MRI were 2 and 4% respectively. The sensitivity of breast MRI was 84.7% for the detection of all invasive foci, 69% for single foci and 65.7% for multiple foci. In the evaluation of tumour size, the Spearman rank correlation coefficient r between the sizes obtained by MRI and histology was 0.62. The MRI-based prediction of a complete response to neoadjuvant chemotherapy was 75%.

Discussion

MRI exhibits high sensitivity in the detection of invasive breast cancers. False positives were linked to the inflammatory nature of the tumour bed. False negatives were associated with small or low-grade tumours and their retro-areolar location. The size of T1 tumours was overestimated by an average of 7%, but MRI was the most efficient procedure. The sensitivity of MRI for the diagnosis of unifocal tumours was higher than that for multifocal sites. Our study confirmed the positive contribution of preoperative MRI for invasive lobular carcinomas and complete response predictions after neoadjuvant chemotherapy.

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.

The impact of breast cancer biological subtyping on tumor size assessment by ultrasound and mammography - a retrospective multicenter cohort study of 6543 primary breast cancer patients

BACKGROUND

Mammography and ultrasound are the gold standard imaging techniques for preoperative assessment and for monitoring the efficacy of neoadjuvant chemotherapy in breast cancer. Maximum accuracy in predicting pathological tumor size non-invasively is critical for individualized therapy and surgical planning. We therefore aimed to assess the accuracy of tumor size measurement by ultrasound and mammography in a multicentered health services research study.

METHODS

We retrospectively analyzed data from 6543 patients with unifocal, unilateral primary breast cancer. The maximum tumor diameter was measured by ultrasound and/or mammographic imaging. All measurements were compared to final tumor diameter determined by postoperative histopathological examination. We compared the precision of each imaging method across different patient subgroups as well as the method-specific accuracy in each patient subgroup.

RESULTS

Overall, the correlation with histology was 0.61 for mammography and 0.60 for ultrasound. Both correlations were higher in pT2 cancers than in pT1 and pT3. Ultrasound as well as mammography revealed a significantly higher correlation with histology in invasive ductal compared to lobular cancers (p < 0.01). For invasive lobular cancers, the mammography showed better correlation with histology than ultrasound (p = 0.01), whereas there was no such advantage for invasive ductal cancers. Ultrasound was significantly superior for HR negative cancers (p < 0.001). HER2/neu positive cancers were also more precisely assessed by ultrasound (p < 0.001). The size of HER2/neu negative cancers could be more accurately predicted by mammography (p < 0.001).

CONCLUSION

This multicentered health services research approach demonstrates that predicting tumor size by mammography and ultrasound provides accurate results. Biological tumor features do, however, affect the diagnostic precision.

Comparative accuracy of preoperative tumor size assessment on mammography, sonography, and MRI: Is the accuracy affected by breast density or cancer subtype?

PURPOSE

To compare the accuracy of preoperative breast tumor size measurements obtained on three imaging modalities (mammography [MM], sonography [US], and MRI) with those obtained on final pathologic examination for different breast densities and various tumor types.

METHODS

Records from patients who underwent breast cancer lumpectomy between 2008 and 2012 and in whom tumor was seen on all three imaging modalities were retrospectively reviewed for maximum tumor size measurements. Patients with positive tumor margins and those who had undergone neoadjuvant chemotherapy were excluded. Tumor size measurements obtained on the three imaging modalities were compared for accuracy with those obtained during the final pathologic examination. Differences were analyzed for the whole group and for subgroups according to breast density and tumor type.

RESULTS

In total, 57 patients were included, in whom wire-localization lumpectomy was performed without neoadjuvant chemotherapy; negative surgical margins for tumor were obtained, and tumor was preoperatively visualized on all three imaging modalities. The mean (± SEM) tumor size measured on MRI was significantly greater than that measured on pathology (p < 0.001), whereas the sizes measured on US and MM were not statistically significantly different from that measured on pathology (p = 0.62 and p = 0.57). Tumor size measured on MRI was greater than that measured on both US and MM (p = 0.003 and p < 0.001). Compared with the measurements obtained on pathology, that obtained on US showed moderate agreement (Lin concordance correlation coefficient [CCC], 0.71; 95% confidence interval [CI], 0.56-0.82); poorer agreement was found for the sizes obtained on MM (CCC, 0.58; 95% CI, 0.38-0.72) and MRI (CCC, 0.50; 95% CI, 0.31-0.65). No difference in comparative accuracy of size measurement was noted between dense and nondense breast tissue. MRI overestimated tumor size in ductal cancers (p < 0.001) and slightly underestimated it in lobular cancers.

CONCLUSIONS

Preoperative MRI significantly overestimated tumor size. Measurements obtained on US and MM were more accurate irrespective of breast density, with US measurements being slightly more accurate than MM measurements.

Intraoperative micro-computed tomography (micro-CT): a novel method for determination of primary tumour dimensions in breast cancer specimens

OBJECTIVES

Micro-CT is a promising modality to determine breast tumour size in three dimensions in intact lumpectomy specimens. We compared the accuracy of tumour size measurements using specimen micro-CT with measurements using multimodality pre-operative imaging.

METHODS

A tabletop micro-CT was used to image breast lumpectomy specimens. The largest tumour dimension on three-dimensional reconstructed micro-CT images of the specimen was compared with the measurements determined by pre-operative mammography, ultrasound and MRI. The largest dimension of pathologic invasive cancer size was used as the gold standard reference to assess the accuracy of imaging assessments.

RESULTS

50 invasive breast cancer specimens in 50 patients had micro-CT imaging. 42 were invasive ductal carcinoma, 6 were invasive lobular carcinoma and 2 were other invasive cancer. Median patient age was 63 years (range 33-82 years). When compared with the largest pathologic tumour dimension, micro-CT measurements had the best correlation coefficient (r = 0.82, p < 0.001) followed by MRI (r = 0.78, p < 0.001), ultrasound (r = 0.61, p < 0.001) and mammography (r = 0.40, p < 0.01). When compared with pre-operative modalities, micro-CT had the best correlation coefficient (r = 0.86, p < 0.001) with MRI, followed by ultrasound (r = 0.60, p < 0.001) and mammography (r = 0.54, p < 0.001). Overall, mammography and ultrasound tended to underestimate the largest tumour dimension, while MRI and micro-CT overestimated the largest tumour dimension more frequently.

CONCLUSION

Micro-CT is a potentially useful tool for accurate assessment of tumour dimensions within a lumpectomy specimen. Future studies need to be carried out to see if this technology could have a role in margin assessment.

ADVANCES IN KNOWLEDGE

Micro-CT is a promising new technique which could potentially be used for rapid assessment of breast cancer dimensions in an intact lumpectomy specimen in order to guide surgical excision.

Complexities and challenges in the pathologic assessment of size (T) of invasive breast carcinoma

Size (the "T" in the TNM System) of invasive breast carcinoma is a proven independent prognostic factor; however, its accurate determination can be challenging. The purpose of this review is to discuss the complexities inherent in determining "T"-including those encountered in the clinical measurement ("cT", ie, physical and radiologic assessment) as well as pathologic determination (pT) of invasive breast carcinomas. Pathologic estimation of tumor size, macroscopic, as well as microscopic, can be problematic due to the complexity of multiple situations, seeming confusion regarding staging guidelines, and interobserver variation in interpretation. Additional problematic scenarios in determination of "T" include those incurred in excisions performed after the performance of needle core biopsies, and in cases wherein there are multiple foci of invasive carcinoma, as well as in carcinomas status post-neoadjuvant chemotherapy. It can also be difficult to determine "T" in certain types of invasive carcinoma, particularly those of the lobular type. In this communication, some of the complexities and challenges in determing "T" are discussed, and modest suggestions are offered to assist in optimizing such assessments.

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.

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.

Breast cancer size estimation with MRI in BRCA mutation carriers and other high risk patients

OBJECTIVE

To assess the value of breast MRI in size assessment of breast cancers in high risk patients, including those with a BRCA 1 or 2 mutation. Guidelines recommend invariably breast MRI screening for these patients and therapy is thus based on these findings. However, the accuracy of breast MRI for staging purposes is only tested in sporadic cancers.

METHODS

We assessed concordance of radiologic staging using MRI with histopathology in 49 tumors in 46 high risk patients (23 BRCA1, 12 BRCA2 and 11 Non-BRCA patients). The size of the total tumor area (TTA) was compared to pathology. In invasive carcinomas (n=45) the size of the largest focus (LF) was also addressed.

RESULTS

Correlation of MRI measurements with pathology was 0.862 for TTA and 0.793 for LF. TTA was underestimated in 8(16%), overestimated in 5(10%), and correctly measured in 36(73%) cases. LF was underestimated in 4(9%), overestimated in 5(11%), and correctly measured in 36(80%) cases. Impact of BRCA 1 or 2 mutations on the quality of size estimation was not observed.

CONCLUSIONS

Tumor size estimation using breast MRI in high risk patients is comparable to its performance in sporadic cancers. Therefore, breast MRI can safely be used for treatment planning.