PLASMINOGEN AND ANGIOSTATIN LEVELS IN FEMALE BENIGN BREAST LESIONS

It is known that benign breast tissue exhibit relatively low angiogenic capacity. Activation of angiogenesis in mammary pre-malignant lesions could be associated with disease progression and high risk of transformation into the breast cancer. However, insight into the underlying molecular mechanisms involved in angiogenesis regulation in non-cancerous breast pathologies is still poorly defined. The purpose of the present study was to determine levels of plasminogen and its proteolytic fragments (angiostatins) in mammary dysplasia (mastopathy and breast cyst) and benign neoplasms (fibroadenomas). Plasminogen and angiostatins were analyzed using immunoblotting and quantified by densitometric scanning. The significant increase in plasminogen levels was found in fibrocystic, cysts, and non-proliferatious fibroadenoma masses (4.7-, 3.7-, and 3.5-fold, respectively) compared to healthy breast tissues (control). In the same benign lesions, 6.7-, 4-, and 3.7-fold increase in plasminogen 50 kDa fragment (angiostatin) levels as compared with control were also observed. Activation of matrix metalloproteinase-9, which was detected using gelatine zymography, could be responsible for plasminogen cleavage and abundance of angiostatin infibrocystic and cyst masses. In contrast, dramatic decrease of both plasminogen and angiostatin levels (3.8- and 5.3-folds, respectively) was shown in tissues of proliferatious form of fibroadenoma in comparison with that of the dormant type of this neoplasm. Based on the obtained results, we concluded that angiostatin, a potent vessel growth inhibitor and anti-inflammatory molecule, can play a crucial role in pathophysiology of non-cancerous breast diseases. Further studies are needed to evaluate potential diagnostic and clinical implications of these proteins for prediction and therapy of benign breast pathologies.

[Expression and clinical significance of MTDH and VEGF in triple-negative breast cancer]

OBJECTIVE

To study the expression and clinical significance of MTDH and VEGF in triple-negative breast cancer (TNBC).

METHODS

Tissue samples of 168 breast cancers (including 112 TNBC tissue and 56 non-TNBC tissue), 10 breast fibroadenomas and 15 normal breast tissues were collected. Postoperative specimens were examined by immunohistochemistry for MTDH and VEGF expression. The correlation between the expression of MTDH and VEGF and clinicopathological features was analyzed.

RESULTS

MTDH and VEGF were expressed in 57.1% and 49.4% of breast cancer patients, 64.3% and 56.3% in TNBC patients, respectively, significantly higher than that in the non-TNBC tissues, breast fibroadenomas and normal breast tissues (P<0.05 for all). Statistically significant correlation was found between the MTDH and VEGF expressions (r=0.356, P<0.001). Moreover, MTDH expression was correlated with tumor size, BMI index, lymph node metastasis, pathological stage, recurrence and metastasis, and the expression of p53 and Ki-67 proteins (P<0.05 for all). The VEGF protein expression was correlated with lymph node metastasis, pathological staging, recurrence and metastasis, and the expression of Ki-67 protein (P<0.05 for all). The patients with high expression of MTDH and VEGF showed a lower DFS and OS (P<0.05 for both).

CONCLUSIONS

MTDH and VEGF expression may be correlated with tumor angiogenesis and progression and has the potential to be valuable prognostic factors in patients with TNBC.

Noninvasive In-Vivo Quantification of Mechanical Heterogeneity of Invasive Breast Carcinomas

Heterogeneity is a hallmark of cancer whether one considers the genotype of cancerous cells, the composition of their microenvironment, the distribution of blood and lymphatic microvasculature, or the spatial distribution of the desmoplastic reaction. It is logical to expect that this heterogeneity in tumor microenvironment will lead to spatial heterogeneity in its mechanical properties. In this study we seek to quantify the mechanical heterogeneity within malignant and benign tumors using ultrasound based elasticity imaging. By creating in-vivo elastic modulus images for ten human subjects with breast tumors, we show that Young's modulus distribution in cancerous breast tumors is more heterogeneous when compared with tumors that are not malignant, and that this signature may be used to distinguish malignant breast tumors. Our results complement the view of cancer as a heterogeneous disease on multiple length scales by demonstrating that mechanical properties within cancerous tumors are also spatially heterogeneous.

Autoantibodies against muscarinic receptors in breast cancer: their role in tumor angiogenesis

The presence of autoantibodies in cancer has become relevant in recent years. We demonstrated that autoantibodies purified from the sera of breast cancer patients activate muscarinic acetylcholine receptors in tumor cells. Immunoglobulin G (IgG) from breast cancer patients in T1N0Mx stage (tumor size≤2 cm, without lymph node metastasis) mimics the action of the muscarinic agonist carbachol stimulating MCF-7 cell proliferation, migration and invasion. Angiogenesis is a central step in tumor progression because it promotes tumor invasion and metastatic spread. Vascular endothelial growth factor-A (VEGF-A) is the main angiogenic mediator, and its levels have been correlated with poor prognosis in cancer. The aim of the present work was to investigate the effect of T1N0Mx-IgG on the expression of VEGF-A, and the in vivo neovascular response triggered by MCF-7 cells, via muscarinic receptor activation. We demonstrated that T1N0Mx-IgG (10(-8) M) and carbachol (10(-9) M) increased the constitutive expression of VEGF-A in tumor cells, effect that was reverted by the muscarinic antagonist atropine. We also observed that T1N0Mx-IgG and carbachol enhanced the neovascular response produced by MCF-7 cells in the skin of NUDE mice. The action of IgG or carbachol was reduced in the presence of atropine. In conclusion, T1N0Mx-IgG and carbachol may promote VEGF-A production and neovascularization induced by breast tumor cells via muscarinic receptors activation. These effects may be accelerating breast tumor progression.

Fine needle aspiration diagnosis of a spontaneously infarcted fibroadenoma mimicking carcinoma: a case report

BACKGROUND

Spontaneous infarction of fibroadenoma is an extremely rare complication in a nonpregnant/nonlactating female undergoing first-time aspiration. It can be misdiagnosed as carcinoma in all aspects of triple approach used for evaluation of patients with breast lesions.

CASE

A 37-year-old woman presented to the outpatient surgical clinic with a 6-month history of a breast lump that was slowly increasing in size and had become painful during the past month. There was no history of any trauma or fine needle aspiration, and she was not pregnant or lactating. Mammogram and ultrasound revealed a 2.9-cm heterogenous hypoechoic suspicious lesion. No lymph nodes were detected in the axilla. Fine needle aspiration cytology was performed, and a diagnosis of benign breast lesion with features of infarction was rendered on cytology. The lump was excised surgically, and a histological diagnosis of infarcted fibroadenoma was made.

CONCLUSION

Careful and diligent search for preserved benign epithelial cells on smears is the key to recognize this entity and avoid serious therapeutic implications.

Ultrasound characteristics of breast fibroadenomas are related to clinical and histological parameters

PURPOSE

We hypothesized that ultrasound characteristics of breast fibroadenomas (FA) vary in relation to the clinical and histological parameters: patient age, tumor size and histological classification.

MATERIALS AND METHODS

Eleven ultrasound characteristics frequently observed in breast tumors were defined before the onset of our study. These characteristics, as well as a semi-quantitative score for vascularization on color-coded Doppler ultrasound, were analyzed in a retrospective study. Histology revealed adult type differentiation in all FA. They were divided into florid, regressive and mixed subtypes. The examiner was blinded for the histological classification during image analysis.

RESULTS

Histological type: florid FA: more frequent in younger women (age group < 30 years; p < 0.001), and bigger than regressive FA (larger than 16 mm: p = 0.007). Statistically significant differences between florid and regressive FA regarding the ultrasound features: enhanced posterior ultrasound transmission (p < 0.001), homogenous echo pattern (p = 0.003) and lobulated margin contour (p = 0.042). Tumor size: patients with larger tumors (> 16 mm) were younger (mean age 35 vs. 43 years, p < 0.001). More often in bigger FA: enhanced dorsal ultrasound transmission (p < 0.001), hyperechoic spots (p < 0.001), strong vascularization (p < 0.001), inhomogeneous echo pattern (p = 0.001), horizontal axis (p = 0.009), lobulated margin contour (p = 0.009), lateral shadowing (p = 0.047). Age: more often in older patients (age group > 30 years): dorsal ultrasound shadowing (p = 0.008), irregular margin contour (p = 0.038), homogenous echo pattern (p = 0.047).

CONCLUSION

Histological type, tumor size and patient age significantly influence ultrasound characteristics of breast FA. This might be helpful to consider when breast lesions are classified and decisions for biopsies are made.

The use of breast ultrasound color Doppler vascular pattern morphology improves diagnostic sensitivity with minimal change in specificity

PURPOSE

The aim of this study was to evaluate the use of vascular morphology, around and within the B-mode region of abnormality, for improving the diagnostic accuracy of two of the most common solid breast pathologies.

MATERIALS AND METHODS

The B-mode and Doppler images of 117 breast cancers and 366 fibroadenomas and lesions with a fibroadenoma-like appearance were reviewed retrospectively and the morphology of the vascular pattern was evaluated. The ratio of external to internal color Doppler, the external vascular pattern and the connecting vessels to internal vessels were assessed and differentiated into benign and malignant vascular patterns. These patterns were correlated with the histological diagnosis.

RESULTS

Vascularity was demonstrated in 95 % of cancers and in 46 % of benign lesions with a trend to increasing vascularity in cancers. This provided poor specificity for excluding cancer in fibroadenomas. Variations in vascular pattern were recorded. The observed benign vascular patterns were avascularity, vascularity in the periphery and peripheral marginal vessels connecting with internal vascularity. The observed malignant vascular patterns were radially aligned external vessels with internal vessels being more numerous than external vessels which connected to radial vessels. (Fisher exact test p < 0.0001). Analysis of the vascular morphology improved the sensitivity for identifying cancers from 97 % (B-mode) to 99 % (B-mode and color Doppler) with a minimal reduction in specificity (93.7 to 92.6 %) or accuracy (94.6 to 94.2 %).

CONCLUSION

The presence of vascularity within a lesion, by itself, is no longer a good predictor of malignancy because of the increase in Doppler sensitivity associated with improvements in ultrasound technology. The color Doppler ultrasound vascular pattern morphology improves the accuracy and sensitivity of B-mode image diagnosis, breast cancers and fibroadenomas with a minimal loss of specificity. Any breast lesion with radial rather than marginal connecting vessels should be regarded with suspicion.

[Hemodynamic changes in benign and malignant breast tumors and the mechanism]

OBJECTIVE

To compare the histological morphology, hemodynamics and angiogenesis-related molecules between benign and malignant breast tumor and investigate their variation in different perfusion regions in the same type of tumors.

METHODS

Thirty patients with malignant breast carcinoma and 30 with breast fibroadenoma underwent contrast-enhanced ultrasound examination with time-intensity quantitative analysis. The perfusion indices including peak intensity (PI), area under the curve (AUC), time to peak (TTP) and wash-out time (WOT) were measured both inside and on the margin of the foci. The expressions of CD34, vascular endothelial growth factor (VEGF), and Flk-1/KDR in both groups were measured immuhistochemically.

RESULTS

The time-intensity curve (TIC) of malignant tumor group was characterized by rapid ascent and slow descent, while that of the benign group presented with slow ascent and rapid descent. The AUC and WOT of the malignant tumor group were significantly higher than those of the benign group, while the PI and TTP showed no significant difference. In malignant tumor group, PI, AUC and WOT on the margin of the foci were significantly higher those of the inside region, while TTP showed a reverse pattern. No significant differences were found in the perfusion parameters between the inside and outside of the foci in the benign group. The distribution of CD34 was heterogeneous in breast carcinoma, and the micro-vessels were densely distributed especially on the margin of the cancer nest. The microvessel density of the malignant group (34.48-/+8.34) was significantly higher than that of the benign group (18.65-/+4.69). Diffuse or focal high VEGF expression was found on the margin of the cancer nest and necrotic tissue, but hardly detected in the benign group. Flk-1/KDR expressed diffusely or focally in breast carcinoma with especial high expression on the margin of the cancer nest and necrotic tissue, but was virtually undetectable in the benign group.

CONCLUSION

The perfusion pattern, TIC, mean perfusion parameter and variation of the regional perfusion parameters provide valuable evidence for differential diagnoses between benign and malignant breast tumors. Molecular imaging targeting VEGF and Flk-1/KD shed light on new approaches to early diagnosis of breast carcinoma.

[Heterogeneity of angioarchitecture and their hemodynamic changes in benign and malignant breast tumors]

OBJECTIVE

To explore the differences between the angioarchitecture, hemodynamics, ultrastructure of neovasculr endothelial cells, and vascular distribution in different perfusion regions in benign and malignant breast tumors.

METHODS

30 cases of breast carcinoma (33 lesions) and 30 cases of breast fibroadenoma (34 lesions) were examined by contrast enhanced microvascular imaging (MVI), and perfusion indexes were collected both inside and at the margin of each focus according to time-intensity quantitative analysis, including peak intensity (PI), area under the curve (AUC), time to peak (TTP) and wash-out time (WOT). The ultrastructure of neovascular endothelial cells was examined by transmission electron microscopy. The expression of CD34, VEGF, Flk-1/KDR in both two groups were detected by immuhistochemistry.

RESULTS

Significant differences were found between the two groups characterized with filling defect, vascular distortion, dilatation and uneven enhancement. Most of the curves of malignant group (87.9%, 29/33) ascended rapidly and dropped slowly while those of the benign group (79.4%, 27/34) ascended slowly and dropped rapidly. The AUC and WOT of malignant tumor group were significantly higher than those of benign group, while the PI and TTP had statistically no significant difference. In the malignant tumor group, PI, AUC and WOT collected from the margin of foci were significantly different from those collected inside the foci, however, there was no significant difference in the benign group. The margin of foci was characterized with dilated and distorted vessels, and the center of the foci was occupied by narrow or occluded blood vessels, sometimes with contracted endothelial cells and pericytes. Abundant microvascular areas located at the margin of foci. The ultrastructure of endothelial cells in the newly formed blood vessels of malignant group showed strong ability to divide, which was different from normal endothelium cells.

CONCLUSION

The perfusion pattern, mode of time-intensity curve, mean perfusion parameter and variation of regional perfusion parameters provide a valuable diagnostic basis in distinguishing benign and malignant breast tumors. The density, morphology, distribution, structure and function of newly formed microvessels in tumor foci are also crucial factors when tumors are assessed by imaging examination.

[Relationship between serum VEGF level and VEGF, COX-2 and MVD expression in breast cancer tissues]

OBJECTIVE

To investigate the relationship between serum VEGF (sVEGF) level and VEGF, COX-2 and MVD expression in breast cancer, and to discuss their role in angiogensis of breast cancer.

METHODS

sVEGF level was detected by ELISA in 68 preoperative breast cancer, 35 benign breast disease and 20 healthy women. The expression of VEGF, COX-2 and MVD was detected by immunohistochemical method in tissues of breast cancer and breast benign diseases, and to analyze the relationship of sVEGF, VEGF, COX-2 and MVD.

RESULTS

(1) sVEGF level in preoperative breast cancers was 306.51 pg/ml (interquartile range from 190.44 to 442.04 pg/ml), in benign diseases was 150.82 pg/ml (interquartile range from 82.36 to 212.34 pg/ml), and in healthy control was 105.93 pg/ml (interquartile range from 78.54 to 157.77 pg/ml). The sVEGF level of preoperative breast cancer group was significantly higher than that of breast benign disease group and healthy women (P = 0.001). (2) The VEGF expression positive rate in breast cancer (67.65%) was significantly higher than that in breast benign disease (44.12%) (P = 0.015). The COX-2 expression positive rate in breast cancer (42.86%) was significantly higher than that in breast benign disease (11.43%) (P = 0.002). (3) the COX-2 expression positive rate in sVEGF high level patients (56.00%) was significantly higher than that in sVEGF normal level patients (11.11%) (P = 0.024), and MVD in sVEGF high level patients (27.32 +/- 3.40) was also higher than that in sVEGF normal level patients (15.31 +/- 6.16) (P = 0.011). (4) The sVEGF level (322.09 +/- 79.31) of 68 breast cancer patients whose VEGF was positive in breast cancer tissues was significantly higher than that in VEGF negative group (222.47 +/- 73.53) (P = 0.017). (5) The COX-2 expression positive rate in VEGF positive expression group (65.21%) was significantly higher than that in VEGF negative expression group (18.18%) (P = 0.017). The MVD expression in COX-2 positive expression group (22.94 +/- 5.51) was significantly higher than that in COX-2 negative expression group (10.30 +/- 4.42) (P = 0.027).

CONCLUSION

sVEGF level in breast cancer is significantly higher than that in breast benign disease and healthy women, and is correlated with the expression of COX-2 and MVD in breast cancer tissues.

CD105/smooth muscle actin double immunostaining discriminate between immature and mature tumor blood vessels

The aim of the study was to demonstrate the value of the double immunostaining for endothelial and perivascular cell to discriminate mature from immature tumor-associated blood vessels in mammary carcinoma. We used the specific endothelial marker CD105 to highlight the activated endothelial cells and antibodies against smooth muscle cell actin (SMA) for perivascular cells, applying Envision Doublestain system (HRP/DAB-APAAP/Fast Red). We found an inverse correlation between the immunoexpression of CD105 and SMA in normal vessels and a strong positive signal for CD105 in the intratumor single endothelial cells and immature vessels. Only few blood vessels were positive for both CD105 and SMA within the tumor area. The signal for the endothelial marker was weak and inconstant, and significantly diminished when the SMA immunoexpression was increased for the same vessel. The differentiation between vessels with and without perivascular cells coverage using double immunostaining for CD105/SMA may be an important step in the selection of the mammary tumors, which could have a high grade of responsiveness to antiangiogenic therapy with monoclonal antibodies against CD105 antigen.

Videodensitometry in the examination of focal breast lesions after injection of an ultrasound contrast agent

BACKGROUND

The present investigation aimed at assessing the possibility of distinguishing between malignant and benign breast lesions by measuring the signal intensity in vessels of the suspect lesions over time after administration of the ultrasound contrast agent Levovist.

MATERIALS AND METHODS

Levovist was administered intravenously to 21 patients with breast cancer and 12 patients with a benign breast lesion. In the subsequent ultrasound investigation (Color Power Angiography) the resulting increase in brightness over time in the vessels of the lesions was measured using the videodensitometry method. From the calculated time-brightness curves, the time to maximum brightness (T(max)), time to 90% of maximum brightness (T(90%)), maximum brightness and other time and brightness parameters were determined. The data were analyzed by means of the Mann-Whitney-Wilcoxon test. Additionally, the sensitivity and specificity were calculated for a sequence of cut-off levels for T(90%), T(max) maximum brightness and wash-in wash-out parameters.

RESULTS

The differences between the benign and the malignant lesions for the parameters T(max) and T(90%) were statistically significant. The malignant foci showed a significantly more rapid in-flow of the contrast agent (p = 0.006) than the benign lesions. The wash-in wash-out time for Levovist was significantly shorter for the malignant lesions than for the benign lesions (p = 0.02). The time difference in attaining maximum brightness was not significant (p = 0.14). The specificity and sensitivity made a more precise differentiation between benign and malignant tumors possible.

CONCLUSION

The use of a contrast agent in Doppler ultrasound enhances the diagnostic reliability in distinguishing between malignant and benign lesions, justifying the use of a contrast agent with a high specificity (92%) such as Levovist. However, invasive pre-operative methods such as punch biopsy are not, thereby, rendered unneccessary. It is possible that the combination of Levovist and videodensitometry will make it possible to increase the specificity of breast cancer diagnosis.

[Values of color Doppler flow imaging and imaging changes of breast fascia and ligament in differential diagnosis of small breast neoplasms]

BACKGROUND & OBJECTIVE

Color Doppler flow imaging (CDFI) has been widely applied to the diagnosis of breast neoplasms. But combined use of CDFI and imaging changes of breast fascia and ligament (superficial and deep fascia, and Cooper's ligament) on the differential diagnosis of small breast neoplasms (< or =2 cm) has rarely been reported. This study was to explore the value of combined use of CDFI and imaging changes of breast fascia and ligament in differential diagnosis of small breast neoplasms.

METHODS

CDFI was performed on 110 patients with small breast neoplasms. Among them, 52 cases were diagnosed to be benign by pathologic examination after surgery, while the rest 58 were malignant. The blood flow and Doppler image inside and around the breast lesions were analyzed. Four grades were classified according to blood flow imaging. The infiltration of breast fascia and ligament was also considered. The CDFI result was compared with that of pathologic examination.

RESULTS

The correct diagnosis rates of CDFI in diagnosing benign and malignant small breast neoplasms were 90.4% and 84.5%, respectively. The false-positive and false-negative rates of CDFI were 9.6% and 15.5%, respectively. There were obvious differences in blood flow grading, systolic maximum velocity (V(max)), resistance index (RI), and imaging changes of superficial, deep fascia and Cooper's ligament between benign and malignant small breast neoplasms.

CONCLUSION

Combination of CDFI with imaging changes of breast fascia and ligament is valuable in clinical diagnosis and differential diagnosis of small breast neoplasms.

Expression of hypoxia-inducible factor 1 alpha and its downstream targets in fibroepithelial tumors of the breast

Introduction

Hypoxia-inducible factor 1 (HIF-1) alpha and its downstream targets carbonic anhydrase IX (CAIX) and vascular endothelial growth factor (VEGF) are key factors in the survival of proliferating tumor cells in a hypoxic microenvironment. We studied the expression and prognostic relevance of HIF-1α and its downstream targets in phyllodes tumors and fibroadenomas of the breast.

Methods

The expression of HIF-1α, CAIX, VEGF and p53 was investigated by immunohistochemistry in a group of 37 primary phyllodes tumors and 30 fibroadenomas with known clinical follow-up. The tumor microvasculature was visualized by immunohistochemistry for CD31. Proliferation was assessed by Ki67 immunostaining and mitotic counts. Being biphasic tumors, immunoquantification was performed in the stroma and epithelium.

Results

Only two fibroadenomas displayed low-level stromal HIF-1α reactivity in the absence of CAIX expression. Stromal HIF-1α expression was positively correlated with phyllodes tumor grade (P = 0.001), with proliferation as measured by Ki67 expression (P < 0.001) and number of mitoses (P < 0.001), with p53 accumulation (P = 0.003), and with global (P = 0.015) and hot-spot (P = 0.031) microvessel counts, but not with CAIX expression. Interestingly, concerted CAIX and HIF-1α expression was frequently found in morphologically normal epithelium of phyllodes tumors. The distance from the epithelium to the nearest microvessels was higher in phyllodes tumors as compared with in fibroadenomas. Microvessel counts as such did not differ between fibroadenomas and phyllodes tumors, however. High expression of VEGF was regularly found in both tumors, with only a positive relation between stromal VEGF and grade in phyllodes tumors (P = 0.016). Stromal HIF-1α overexpression in phyllodes tumors was predictive of disease-free survival (P = 0.032).

Conclusion

These results indicate that HIF-1α expression is associated with diminished disease-free survival and may play an important role in stromal progression of breast phyllodes tumors. In view of the absence of stromal CAIX expression in phyllodes tumors, stromal upregulation of HIF-1α most probably arises from hypoxia-independent pathways, with p53 inactivation as one possible cause. In contrast, coexpression of HIF-1α and CAIX in the epithelium in phyllodes tumors points to epithelial hypoxia, most probably caused by relatively distant blood vessels. On the other hand, HIF-1α and CAIX seem to be of minor relevance in breast fibroadenomas.

The phosphorylated form of connexin43 is up-regulated in breast hyperplasias and carcinomas and in their neoformed capillaries

We applied an antiserum (SA226P) specifically recognizing the phosphorylated form of connexin43 (P-Cx43) to human breast samples including normal breast samples, with fibrocystic disease (FCD), fibroadenomas (FA), in situ and infiltrating carcinomas of all major types, and miscellaneous extramammary tumors. The findings were compared with those obtained with commercial antisera recognizing all Cx43 forms (pan-Cx43). A subset of samples was stained for Her2-neu and p44/42 to mitogen-activated protein kinase. Paraffin step sections were used. Immunoblots were performed on frozen samples of a representative subset of cases. In the normal breast, FCD, and FA, SA226P stained strongly and extensively most myoepithelial cells (MECs); luminal cells remained unstained. In proliferative FCD and some cellular FA, SA226P stained MEC and the capillary endothelium (CE). In ductal and lobular in situ carcinomas, SA226P reacted strongly and diffusely with the remaining MEC, the CE, and the transformed luminal cells. SA226P stained all infiltrating carcinomas except the tubular variant. In all breast carcinomas, the CE within and adjacent to tumors and some myofibroblasts stained with SA226P. By contrast, pan-Cx43 stained weakly and sporadically the MEC and rare samples of invasive carcinomas. Notably, Mab p44/42 reacted in parallel with the samples stained with SA226P, whereas reactions with Her2 were negative. Immunoblot findings paralleled those obtained immunohistochemically. We conclude that P-Cx43, restricted to MEC in the normal breast, is up-regulated in the same cells in hyperplasias and dysplasias and FA and is strongly up-regulated in invasive carcinomas. Notably, in some proliferative FCD and in most in situ and infiltrating carcinomas, P-Cx43 is strongly expressed in CE within and adjacent to the lesions but not away from them. These findings were paralleled by the strong nuclear reactions noted with Mab p44/42. These phenomena, although not exclusive to malignancy, are particularly conspicuous in breast carcinomas and seemingly reflect active proliferation associated with abnormal gap junctional intercellular communication.

Color Doppler imaging of fibroadenomas of the breast with histopathologic correlation

PURPOSE

This study was conducted to characterize the spatial distribution of blood vessels in breast fibroadenomas.

METHODS

We performed a prospective study to map the anatomic distribution of the vessels in 29 fibroadenomas of the breast using color Doppler sonography. We categorized the detected vessels according to their location in or on the fibroadenoma, counted the different types of vessels, and tested for correlations between vessel distributions or numbers and histopathologic findings.

RESULTS

Blood flow was demonstrated in 24/29 (83%) of fibroadenomas. We found 3 vessel types: feeding vessels, which are prominent vessels leading from the surrounding breast tissue into the fibroadenoma; capsular vessels, which are located within the tissue capsule; and segmental vessels, which are located within the fibrous septa of the fibroadenoma. Capsular and segmental vessels were demonstrated in 23/24 (96%) and 24/24 (100%) of the cases, respectively. Feeding vessels were seen in 12/24 (50%) of the cases. Histopathologic analysis revealed the same location and distribution of the vessels as color Doppler imaging. However, there was no correlation between numbers of vessels counted on sonograms and on histopathologic specimens.

CONCLUSIONS

Examination of the vascularity demonstrated on color Doppler imaging helps in the diagnosis of benign breast neoplasms such as fibroadenomas.

Analysis of the microvasculature and tissue type ratios in normal vs. benign and malignant breast tissue

OBJECTIVE

To analyze the microvasculature and tissue type ratios in normal vs. benign and malignant breast tissue to establish a baseline for expected values against which future imaging studies can be benchmarked.

STUDY DESIGN

Using computer-assisted techniques on immunostained breast tissue (normal [n = 28], fibrocystic [n = 37], fibroadenomas [n = 19], invasive carcinomas [n = 19]), values were obtained for microvessel density (MVD), mean vessel area (MVA), vessel orientation (shape) and epithelial:stromal ratio (E:S). Measurement reproducibility and the effects of fibroadenoma stromal hyalinization and fibrocystic disease severity were also tested.

RESULTS

Value ranges for the 4 diagnostic groups were significantly different (P < .001). For invasive breast carcinomas, E:S and MVD were significantly higher (P < .001) but MVA was smaller as compared to that in fibroadenomas. Peripherally vs. centrally there was no significant difference in MVD, MVA or vessel shape in the neoplasms. Decreases in E:S and MVD correlated with fibroadenoma stromal hyalinization. Increases in E:S and MVA correlated with more severe fibrocystic disease. Correlation coefficients for measurement reproducibility were high across the diagnostic categories.

CONCLUSION

This study established a specific, reproducible, computer-assisted technique and baseline of expected values for morphologic criteria in normal, benign and malignant breast tissue that may be used in the future to correlate new breast imaging responses with these underlying biologic properties.

Raised plasma endostatin levels correlate inversely with breast cancer angiogenesis

BACKGROUND

Angiogenesis is essential for solid tumors, such as breast cancer, to grow. The effect of surgical removal of breast tumors on plasma endostatin and vascular endothelial growth factor (VEGF) levels was evaluated. Tumor tissues were analyzed for expression of Intratumoral microvessel density (IMVD) and endostatin. The effect of VEGF and endostatin in inducing apoptosis on human liver microvascular endothelial cells (HLMVEC) was investigated.

MATERIALS AND METHODS

Plasma from healthy volunteers, patients with fibroadenomas and breast cancer patients were assayed for endostatin and VEGF via immunoassay, pre-operatively and four weeks post-operatively. Expression of endostatin in tumor tissue was determined by Western blotting. IMVD was assessed following immunohistochemical staining with anti-CD34 antibody.

RESULTS

Plasma endostatin levels, in breast cancer patients, were significantly elevated (P = 0.015) in the post-operative (60.59 +/- 7.70 etag/ml) compared with the pre-operative group (30.62 +/- 4.54 etag/ml) and with normal age-matched controls (34.97 +/- 3.76 etag/ml). In patients with high pre-operative plasma endostatin value, IMVD was decreased to 20.1 +/- 3.2 counts compared with 41.9 +/- 5.4 counts in those with low pre-operative endostatin value (P = 0.006). Neither plasma endostatin nor VEGF levels correlated with routine clinico-pathological parameters. Endostatin induced endothelial cell apoptosis and modulated the cytoprotective effect of VEGF in HLMVEC survival.

CONCLUSIONS

Plasma endostatin levels are increased in patients following surgical removal of the primary tumor. The decreased IMVD seen in patients with higher endostatin levels may be due to the apoptosis-inducing effect of endostatin on microvascular endothelial cells.

Evaluation of tumor angiogenesis with contrast-enhanced dynamic magnetic resonance mammography

The goal of this research was to correlate dynamic magnetic resonance (MR) mammographic contrast enhancement and microvessel densities in breast masses. Forty-six female patients with breast masses detected by mammography and/or ultrasonography were included in the study. MR contrast enhancements of the lesions were investigated dynamically using axial three-dimensional fast low-angle shot sequences. After excisional biopsy or mastectomy, immunohistochemical staining with factor VIII-RA was performed, followed by microvessel density measurements. Contrast enhancement patterns in dynamic MR mammography were compared with microvessel density measurements using Student's t-test, Pearson's moment correlation coefficients, and one-way analysis of variance (ANOVA). Malignant lesions exhibited three different enhancement patterns: 1) a peak enhancement within 120 seconds (early phase), followed by a decrease in the delayed phase (25 cases); 2) an increase in the early phase, followed by a plateau in the delayed phase (9 cases); and 3) an increase throughout the examination without any peak (5 cases). In benign lesions, signal intensity did not exhibited a peak in five cases, whereas in two cases enhancement was increased in the early phase and made a plateau in the delayed phase. A significant correlation was found between microvessel density and the percentage of maximal signal increase following paramagnetic contrast administration (r=0.322, p<0.05). Dynamic enhancement patterns and rates of maximal signal increase predict microvessel density in breast malignancies and may possibly be used as prognostic indicators.

MRI-guided diffuse optical spectroscopy of malignant and benign breast lesions

We present the clinical implementation of a novel hybrid system that combines magnetic resonance imaging (MRI) and near-infrared (NIR) optical measurements for the noninvasive study of breast cancer in vivo. Fourteen patients were studied with a MR-NIR prototype imager and spectrometer. A diffuse optical tomographic scheme employed the MR images as a priori information to implement an image-guided NIR localized spectroscopic scheme. All patients who entered the study also underwent gadolinium-enhanced MRI and biopsy so that the optical findings were cross-validated with MR readings and histopathology. The technique quantified the oxy- and deoxyhemoglobin of five malignant and nine benign breast lesions in vivo. Breast cancers were found with decreased oxygen saturation and higher blood concentration than most benign lesions. The average hemoglobin concentration ([H]) of cancers was 0.130+/-0.100 mM, and the average hemoglobin saturation (Y) was 60+/-9% compared to [H]=0.018+/-0.005 mM and Y=69+/-6% of background tissue. Fibroadenomas exhibited high hemoglobin concentration [H]=0.060+/-0.010 mM and mild decrease in oxygen saturation Y=67+/-2%. Cysts and other normal lesions were easily differentiated based on intrinsic contrast information. This novel optical technology can be a significant add-on in MR examinations and can be used to characterize functional parameters of cancers with diagnostic and treatment prognosis potential. It is foreseen that the technique can play a major role in functional activation studies of brain and muscle as well.

Magnetic resonance image-guided focused ultrasound surgery

The powerful union of focused ultrasound and magnetic resonance imaging (MRI) has created a new approach to noninvasive surgery. By using this integrated therapy delivery system, the physician can correctly localize tumors, optimally target acoustic energy, monitor energy deposition in real time, and accurately control the deposited thermal dose within the entire tumor volume. This satisfies the requirements for "ideal surgery." In a real sense, MRI provides the "road map" by which focused ultrasound surgery (FUS) is followed. The advantages of MRI over ultrasound guidance in controlling FUS lie in the more sensitive detection of tumor target, the real-time detection of tissue temperature, and the confirmation of thermally induced tissue changes-powerful features that eventually can replace the traditional surgical approach. Applying software that connects the therapy and imaging system (the "Dosimetry Workstation"), the physician can generate an entire treatment plan from quantifying temperature changes to positioning the therapy transducer. The noninvasive debulking of tumors without disturbing adjacent, functionally intact structures is thereby accomplished.

Measuring microvascular density in tumors by digital dissection

OBJECTIVE

To develop and validate a digital dissection techniquefor measuring the cross-sectional area of blood vessels in histologic sections of tumors routinely stained with hematoxylin and eosin.

STUDY DESIGN

The procedure was first validated in four experimental tumors in rats by comparing the results of the digital dissection technique to functional estimates of the blood volume in the tumors as measured by dynamic, contrast-enhanced magnetic resonance imaging. The method was then tested on a variety of experimental and human tumors.

RESULTS

The digital dissection technique yielded results that exactly matched the functional measurements of blood volume infour experimental tumors. Digital dissection of 40 additional tumors in rats showed that 21 infiltrating ductal carcinomas had significantly greater microvascular density (MVD) than 19 benign fibroadenomas (12% vs. 7.9%, P=.028 by two-tailed t test). In 10 human breast carcinomas the MVD was consistently greater than the measurement of blood vessel density as identified by immunohistochemical staining for factor VIII. The between-run coefficients of variation for the MVD assay were 12% (n = 5) for a human breast cancer and 18% (n = 5)for an experimental rat tumor.

CONCLUSION

The digital dissection technique is a reproducible, objective and accurate method of measuring MVD in sections of tumors that are routinely stained with hematoxylin and eosin.

Contrast-enhanced color Doppler ultrasound characteristics in hypervascular breast tumors: comparison with MRI

The aim of this study was to evaluate the accuracy of contrast-enhanced color Doppler ultrasound (CE-US) in comparison with contrast-enhanced MR imaging (CE-MRI) in the discrimination of hypervascularized breast tumors. An additional CE-US of the breast was preoperatively performed in 40 patients with a hypervascular breast lesion detected on CE-MRI. The presence of blood flow signals and the morphological characteristics of the vessels in the breast lesions were evaluated pre- and post-contrast administration, as well as the dynamic aspects of the Doppler signal, including time interval to maximum signal enhancement and persistence of the signal enhancement. Twenty-three carcinomas and 17 fibroadenomas were explored. Considering initial signal enhancement > 100% after the administration of contrast material as a criterion suggesting malignancy, CE-MRI showed a sensitivity of 100% and a specificity of 76.5% in the detection of malignant breast tumors. Color Doppler signals were consistently demonstrated in all carcinomas and in 68.7% of fibroadenomas after the administration of Levovist, with CE-US showing a sensitivity of 95.6% and a specificity of 5.9%. Neither the mean number of vessels per tumor, nor the location of vessels, the time to maximum increase of the Doppler signal or the persistence of signal enhancement showed significant differences between benign and malignant lesions. Additional CE-US does not increase the low specificity of MRI in patients with hypervascularized breast tumors.

Diagnostic difficulties in spontaneous infarction of a fibroadenoma in an adolescent: case report

Spontaneous infarction is an uncommon complication occurring in fibroadenoma of the breast. Although infarction following fine-needle aspiration has been reported in the literature, to the best of our knowledge this is the first reported case where infarction was encountered on first-time aspiration. It is necessary to distinguish infarcted fibroadenoma from mastitis, duct ectasia, mammary tuberculosis, and carcinoma on cytology smears. Lack of knowledge of this entity may lead to an erroneous diagnosis of inflammatory lesion or carcinoma. We report the first case of cytological and histological findings in spontaneous infarction of fibroadenoma in 13-yr-old female.

Dynamic contrast-enhanced MRI using Gd-DTPA: interindividual variability of the arterial input function and consequences for the assessment of kinetics in tumors

Gd-DTPA kinetics in arterial blood was investigated by dynamic MRI in 47 patients with malignant and benign mammary tumors. Signal enhancement was monitored for 10 min after the beginning of a 1-min infusion of 0.1 mmol/kg Gd-DTPA. Kinetics in blood was biexponential with median half-lives of 21 sec and 11.1 min, respectively. Peak signal enhancement and the area under the signal enhancement-time curve varied 2.5- and 3.7-fold between patients. The shortest mean residence time in one of up to three tumor compartments, MRT*, was estimated using either the individual (reference) or a mean population (surrogate) arterial input function (AIF). MRT* (reference estimate) was 1.0 (0-1.5), 1.9 (1.5-2.3), and 2.5 (2.3-2.8) min in carcinomas, fibroadenomas, and mastopathies, respectively (median and interquartile distance). Surrogate estimates were unbiased but differed from the reference estimates 1.5-fold or more in 23% of cases. AIFs should be monitored individually if accurate estimates of individual MRT* are desired.

[Vascularization of fibroadenomas: contrast harmonic imaging compared with contrast-enhanced power doppler]

PURPOSE

To compare contrast material-enhanced harmonic power Doppler ultrasonography (CHI) with conventional contrast-enhanced power Doppler ultrasound (CPD) in depicting the vascularity of fibroadenomas.

MATERIALS AND METHODS

Forty patients with fibroadenomas (aged 19-61 years) underwent conventional contrast-enhanced and harmonic power Doppler US. According to a standardized examination protocol, serial dynamic scans were obtained before and at 30, 90 and 150 seconds after injection of contrast agent. Video-taped scans were independently reviewed by three blinded readers with regard to parameter artifacts, degree of Doppler signal enhancement, demarcation of vessels and extent of vessel visualization.

RESULTS

The number of intratumoral power Doppler signals depicted was similar with both techniques at 30-90 seconds after contrast administration; however, after 90 seconds, CPD depicted significantly more intratumoral signals than did CHI (p < 0.0001). CHI was superior to CPD with regard to "blooming" or motion-related artifacts (p < 0.0001).

CONCLUSION

CHI balances the increased susceptibility of CPD to interference from clutter artifacts and thus allows the depiction of vessels that may have been obscured on CPD at similar system settings.

Significance of resistive index in color Doppler ultrasonogram: differentiation between benign and malignant breast masses

The objective of this article is to evaluate the significance of resistive index in differentiation between benign and malignant breast lesions on duplex ultrasonographic examination. Resistive indices obtained in 106 breast lesions of 104 patients were included. Sixty-four were benign (mean age: 32.4 +/- 11.1 years), and 42 were malignant lesions (mean age: 47.8 +/- 11.4 years). The resistive index was classified as follows: below 0.49, from 0.5 to 0.59, 0.6 to 0.69, 0.7 to 0.79, and above 0.8. We analyzed and defined the optimal threshold value of RI between benign and malignant lesions. The mean values of the RI of benign and malignant lesions were 0.62 +/- 0.095 (range 0.44-0.86) and 0.74 +/- 0.097 (range, 0.50-0.92), respectively. The resistive index exceeded 0.7 in 80% of malignant lesions. The difference of the RI between malignant and benign lesions was statistically significant when the threshold value was 0.7 (P < 0.001). A resistive index over 0.7 may suggest malignant lesions. Due to the considerable overlap of the range of the RI, it may not be diagnostic in any single patient; however, it may be helpful in conjunct with gray-scale image.

Multicompartment analysis of gadolinium chelate kinetics: blood-tissue exchange in mammary tumors as monitored by dynamic MR imaging

The blood-tissue exchange kinetics of gadopentetate were studied in 49 malignant and benign mammary tumors. Signal enhancement was monitored simultaneously in the aorta and in tumor for 10.5 minutes after the beginning of a 1 minute i.v. infusion of the contrast medium (CM). Kinetic analysis was based on a model with two compartments for systemic pharmacokinetics and up to three kinetically distinct compartments for tumor. Kinetic heterogeneity, ie, two or more compartments with different exchange rate constants in a given tumor, was found in 85% of carcinomas, 38% of fibroadenomas, and 14% of mastopathic tumors. The within-tumor average of CM exchange rates was 1.22 (0.62-1.65) min(-1) in carcinomas, 0.38 (0.26-0.60) min(-1) in fibroadenomas, and 0.16 (0. 12-0.20) min(-1) in mastopathies (median and interquartile distances). The area under the signal enhancement-time curve of the aorta varied 4.5-fold between individuals. It is concluded that individual CM kinetics in arterial blood should be taken into account when CM exchange rates between blood and tumor are to be determined and that a kinetic model for potentially malignant tumors should allow for kinetic heterogeneity.

Gigantomastia during pregnancy: a case report

Gigantomastia during pregnancy is a rare occurrence that is usually resolved by postpartum involution or surgical reduction. The authors present a patient that illustrates rapid enlargement of the breast that caused decreased fetal growth and skin breakdown, and ultimately resulted in total surgical removal of the breast tissue and reconstruction.

Proliferative activity and tumor angiogenesis is closely correlated to stromal cellularity of fibroadenoma: proposal fibroadenoma, cellular variant

Fibroadenoma (FA) is the most common benign tumor of the breast in adult women. Some FA have a highly cellular stroma, making it difficult to differentiate from phyllodes tumors (PT). Forty-three FA were grouped into: (i) 27 conventional type (FACT) median stromal cellularity (SC) of highest cellular area (HCA), < or = 125 cells/1 high-power field (HPF); and (ii) 16 cellular variant (FACV) median SC of HCA, > 125 cells/1 HPF. These were studied for the proliferative activity of their stromal cells. Expression of c-fos, p53, basic fibroblast growth factor (bFGF), fibroblast growth factor receptor (FGFR), and vascular endothelial growth factor (VEGF) in the stromal cells were examined in the FA and 12 PT to determine whether it is possible to separate FACV from FACT. The proliferative activity of stromal cells was evaluated by the labeling index (LI) of proliferating cell nuclear antigen (PCNA). Conventional type fibroadenoma stromal cells had the lowest frequency of c-fos, p53, bFGF, FGFR and VEGF protein expression; PT stromal cells had the highest frequency of expression; and FACV stromal cells had an intermediate frequency of expression. Multivariate analysis demonstrated that bFGF and FGFR expression are significantly correlated with SC of FA. Separation of FACV from FACT by SC seems appropriate in revealing the phenotypic and biological differences of FA. The SC of FA seems to be regulated by bFGF and FGFR expression.

D-galactose-based signal-enhanced color Doppler sonography of breast tumors and tumorlike lesions

RATIONALE AND OBJECTIVES

This study sought to evaluate prospectively the diagnostic potential of unenhanced and enhanced color Doppler and power Doppler for the differentiation of tumors and tumorlike lesions of the breast.

METHODS

Ninety-two patients with 110 tumors or tumorlike lesions of the breast were investigated by unenhanced and enhanced color and power Doppler ultrasound. The sonomorphologic aspects of vascularization were analyzed. In addition, maximal systolic frequency shift, resistance, and pulsatility indices were determined.

RESULTS

In 15 (24%) of 63 primary carcinomas, 15 (68%) of 22 fibroadenomas, and all (100%) of 14 postoperative lesions, the sonomorphologic analysis for the differential diagnosis of breast tumors was improved after contrast enhancement in color Doppler mode. In comparing unenhanced color Doppler to power Doppler, the latter was found to be slightly superior (sensitivity, 60% vs. 67%; specificity, 39% vs. 45%, respectively); after enhancement, both modes were equivalent (sensitivity, 100% vs. 100%; specificity, 95% vs. 95%, respectively). Signal enhancement resulted in a significant improvement in sensitivity and specificity (P < 0.01). Typical signs of malignancy were irregular vessel calibers, serpiginous courses, penetration of the tumor's margin, and irregular reticular vascularization. The quantitative parameters proved not to be helpful for the differential diagnosis of breast tumors.

CONCLUSIONS

By improved analysis of the vascularization pattern, d-galactose-enhanced color Doppler sonography was found to provide more reliable differential diagnostic information than unenhanced Doppler ultrasound in tumors and tumorlike lesions of the breast.

[Significance of resistance index and pulsatility index in differential diagnosis of breast neoplasm]

OBJECTIVE

To investigate the significance of the resistance index (RI) and pulsatility index (PI) in differential diagnosis between the benign and malignant breast neoplasms.

METHODS

Forty-seven cases of malignant breast tumors, sixty-nine cases of fibroadenomas, seven cases of inflammatory masses and twenty-two cases of mammiplasia were demonstrated on color Doppler flow imaging (CDFI). The measurements of RI and PI of the four groups were recorded respectively and the comparison between benign and malignant neoplasms was made by applying Doppler quantitative analysis.

RESULTS

The color flow was detected in 59.4% of benign breast neoplasms and in 89% of malignant ones respectively (chi 2-test, P < 0.001). There were significant difference between benign and malignant neoplasms on the RI and PI. The malignant neoplasms were characteristic of higher RI (> or = 0.70) and PI (> or = 1.30), which were of satisfactory value for differential diagnosis, amounting to 95.5% of accuracy.

CONCLUSIONS

Combination of both color Doppler analysis and 2D-US might remarkably increase the sensitivity and specificity of differential diagnosis of breast neoplasms. Our results confirmed the significance of color Doppler flow imaging and Doppler quantitative analysis on the differential diagnosis of breast neoplasms.

[Estimation of vascular blood flow velocity in the breast neoplasms]

Based on examinations of 133 females having the normal breast, benign and malignant tumors, the potentialities of color Doppler mapping of breast vessels are shown. Cancers showed an increased vascularity in the peritumor areas and high flow velocity (Vmax' Vmean) in the surrounding tumor vessels. These criteria are not related to the size of a malignant tumor.

A new elastographic method for estimation and imaging of lateral displacements, lateral strains, corrected axial strains and Poisson's ratios in tissues

A major disadvantage of the current practice of elastography is that only the axial component of the strain is estimated. The lateral and elevational components are basically disregarded, yet they corrupt the axial strain estimation by inducing decorrelation noise. In this paper, we describe a new weighted interpolation method operating between neighboring RF A-lines for high precision tracking of the lateral displacement. Due to this high lateral-tracking precision, quality lateral elastograms are generated that display the lateral component of the strain tensor. These precision lateral-displacement estimates allow a fine correction for the lateral decorrelation that corrupts the axial estimation. Finally, by dividing the lateral elastogram by the axial elastogram, we are able to produce a new image that displays the distribution of Poisson's ratios in the tissue. Results are presented from finite-element simulations and phantoms as well as in vitro and in vivo experiments.

3-D color Doppler image quantification of breast masses

In this article, new measures obtained from color Doppler images are introduced and a pilot study is described, in which these and previously published indices are evaluated for use in future work. Twenty women with breast masses observed on mammography and going to surgical biopsy were studied. Of the masses, 11 proved to be benign and 9 were malignant. Both 3-D mean frequency shift (f-CDI) and power mode Doppler (p-CDI) imaging were performed. To identify the mass and other regions of interest, vessels were displayed as rotatable 3-D color volumes, superimposed on selectable grey-scale/color flow slices. Doppler signals were recorded in each of 6 ellipsoidal regions of interest in and around the mass and 2 in normal tissues. Seven measures were computed in each region, three from power mode, two from mean frequency and two from combinations of both. Radiologists rated the grey-scale appearances of the masses on a scale of 1 to 5 (5=most suspicious) for each of 6 conventional grey-scale criteria. Of the individual vascularity measures in individual ROIs, the log speed-weighted pixel density and log power-weighted pixel density in the lesion internal periphery showed the greatest discrimination of malignancy, although neither was statistically significant nor as good as the peak variables described below. The mean visual grey-scale rating was the best discriminator overall, but two peak vascularity measures each made promising scatterplots in conjunction with the average visual grey-scale rating. These two vascularity measures were the log peak normalized power-weighted pixel density (peak NPD) and log of peak mean Doppler frequency times the peak NPD (vM x NPD(M)). Each of these two values was the maximum in any one of the five chosen ROIs closely associated with the mass. A possible rationale for the relative success of these peak values is the blood signal's normalization and the inhomogeneity of most breast cancers and the expectation that the highest velocities (shunting) and largest collections of blood are not necessarily in the same region in and around the tumor. Peak NPD of cancers varied with age, decreasing by a factor of 45 from 33 to 77 y.

Invasive carcinomas and fibroadenomas of the breast: comparison of microvessel distributions--implications for imaging modalities

PURPOSE

To compare spatial patterns of blood vessels between invasive breast carcinomas and fibroadenomas to improve the diagnostic specificity of noninvasive vascular magnetic resonance imaging and color Doppler ultrasound.

MATERIALS AND METHODS

Nineteen invasive ductal carcinomas and 20 fibroadenomas from 39 patients were stained for factor VIII-related antigen. Vessels smaller than 40 microns were counted in x200 fields defined in peripheral and central areas of the tumor and in normal tissue adjacent to fibroadenomas. Significant differences in vessel density were determined with Student t tests and one-way analyses of variance. Distributions of vessels 40 microns or larger were qualitatively evaluated.

RESULTS

There were 9-105 vessels (mean, 31.4 vessels) smaller than 40 microns per x200 peripheral and 4-57 vessels (mean, 20.1 vessels) smaller than 40 microns per x200 central carcinoma field. There was no significant difference in vessel density between the two groups. Peripheral microvessel density was significantly higher (P < .01) than central microvessel density in 15 (79%) of the 19 carcinomas and in three (16%) of 19 fibroadenomas. (A Student t test could not be performed in one case of fibroadenoma; size permitted only one countable field according to the authors' criteria.) The 18 cases with normal tissue had 21-229 vessels (mean, 80.5 vessels) per field; in 16 (89%) of the 18 cases, these vessel counts were significantly higher (P < .01) than those in the fibroadenoma cases. Vessels 40 microns or larger were found mainly in the periphery of carcinomas and were more uniformly distributed in fibroadenomas.

CONCLUSION

Evaluation of the spatial distribution of vessels and the ability to resolve vessel sizes may add valuable information to the imaging-based diagnostic work-up of indeterminate solid breast lesions.

Effects of a microbubble contrast agent on breast tumors: computer-assisted quantitative assessment with color Doppler US--early experience

PURPOSE

To evaluate objectively the effects of a microbubble contrast agent on the color Doppler ultrasound (US) examination of breast lesions.

MATERIALS AND METHODS

Forty-seven patients aged 23-71 years underwent color Doppler US before and after intravenous injection of a microbubble contrast agent. A 3-minute computer-assisted assessment of the color pixel density (CPD) was used to evaluate objectively the increase in the number of color Doppler US signals, the transit time of the microbubble bolus, and the potential additional differential diagnostic information.

RESULTS

Peak CPD at contrast agent-enhanced color Doppler US was 14.3% +/- 8.1 (mean +/- 1 standard deviation) for carcinomas and 9.3% +/- 4.9 for benign lesions (P = .04). The time to peak enhancement was shorter in carcinomas (38 seconds +/- 20) than in benign tumors (71 seconds +/- 48, P = .02). Final CPD was close or equal to baseline values. With the median of 13% for peak CPD as a threshold, the sensitivity for this parameter was 55%, the specificity was 79%, and the accuracy was 62% (P = .04). For a median time to peak of 50 seconds, the sensitivity was 84%, the specificity was 57%, and the accuracy was 76%.

CONCLUSION

After microbubble contrast agent injection, carcinomas and benign lesions behave differently in degree, onset, and duration of Doppler US enhancement. High interindividual variability and temporal variations in the Doppler US signal still limit the value of these criteria for prospective diagnosis.

Immunohistochemical studies on expression of human vascular smooth muscle myosin heavy chain isoforms in normal mammary glands, benign mammary disorders and mammary carcinomas

The expression of myosin in normal and diseased mammary glands of 199 Japanese women was evaluated immunohistochemically by the avidin-biotin peroxidase complex method using antibodies to three human smooth muscle myosin heavy chain isoforms derived from the vascular smooth muscle: myosin SM1 is expressed consistently from fetal stage to adulthood, myosin SM2 appears only in well-differentiated smooth muscle after birth, and myosin SMemb is more abundant in embryonic aortas. SM1 was expressed in myoepithelial cells of normal mammary glands and fibrocystic diseases and in myoepithelial-like tumor cells in the basal layer of fibroadenomas and phyllodes tumors. SM2 was expressed only in the myoepithelial cells of mammary glands in breastfeeding women. SMemb was expressed more intensely in the cytoplasm of luminal epithelial cells in larger fibroadenomas (P< 0.01), or in the cytoplasm of carcinoma cells in invasive ductal carcinomas with metastasized lymph nodes (P< 0.001) and in those of higher histological grade (P<0.0001). Multivariate logistic analysis showed a significant correlation only between the expression of SMemb and histological grade (P< 0.0001), which is a prognostic factor of mammary carcinomas. These findings suggested the possible prognostic value of SMemb.

[Dynamic assessment of contrast medium enhancement in Doppler ultrasound imaging. Current status]

Findings in previous investigations have indicated that contrast-enhanced colour Doppler can be used to improve the demonstration of characteristic features of neovascularization in malignancies. However, the quantification of the increase in colour Doppler signals after Levovist in the cited study relied only on descriptive criteria defined by the investigator, resulting in a subjective scoring system. A computer-assisted method for quantitative analysis of colour pixel density is a novel approach for objective assessment of colour Doppler signal after contrast media administration. After microbubble contrast medium injection in 47 patients, carcinomas and benign lesions behaved differently regarding degree, onset and duration of Doppler enhancement. However, the high interindividual variability and the temporal variations of the Doppler signal still limit the value of these criteria for prospective diagnosis. Rapid image-acquisition techniques are needed in order to apply the necessary mathematical processing before the contrast kinetics can be used for diagnostic purposes.

Optimized differential diagnosis of breast lesions by combined B-mode and color Doppler sonography

To optimize the sensitivity and specificity of gray-scale imaging and color Doppler in breast tumor diagnosis, alone and in combination, 89 women with palpable breast masses were scanned preoperatively and standard parameters were determined in both modes. Parameters significant for differentiation of benign and malignant tumors identified using univariate analysis were combined and weighted using multivariate analysis (multiple logistic regression). Histologically 59 tumors were malignant and 30 benign. Gray-scale sonography alone achieved a sensitivity of 88% and a specificity of 96% using the parameters of wall structure and posterior acoustic attenuation. Color Doppler achieved a sensitivity of 85% and a specificity of 79% using resistance index and pulsatility index as parameters. Combination of both methods yielded an accurate diagnosis in 84/87 patients (sonographic lesion correlates were absent in two cases), equivalent to a sensitivity of 97% and a specificity of 96%. Thus the individual diagnostic performance of gray-scale imaging and color Doppler sonography in palpable breast disease is further enhanced using multiple logistic regression to combine independently significant parameters.

Vascular expression of E-selectin is increased in estrogen-receptor-negative breast cancer: a role for tumor-cell-secreted interleukin-1 alpha

Angiogenesis plays an important role in breast cancer growth and metastasis. Multiple adhesion molecules have been shown to perform critical functions in the process of angiogenesis. In this study, we analyzed 15 benign and 22 malignant estrogen-receptor-negative and estrogen-receptor-positive breast specimens for the presence of the endothelial cell adhesion molecules E-selectin and P-selectin. We found that E-selectin's expression was increased in the malignant breast tumors compared with their benign counterparts (23.86% of blood vessels versus 2.47%; P = 0.0005). Furthermore, E-selectin staining was found to be significantly increased in the estrogen-receptor-negative carcinomas compared with the estrogen-receptor-positive ones (P = 0.005). In vitro findings strongly correlated with the in vivo findings and showed a higher degree of E-selectin induction in endothelial cells exposed to conditioned media from estrogen-receptor-negative breast cancer cell lines than from estrogen-receptor-positive ones. The degree of E-selectin induction correlated with the amount of interleukin-1 alpha in the tumor-conditioned media. Neutralizing antibodies to interleukin-1 alpha significantly inhibited the E-selectin expression in endothelial cells exposed to tumor-conditioned media. The results indicate that the endothelial E-selectin expression during angiogenesis is related to breast carcinoma progression in vivo and that this component of angiogenesis may be due directly to tumor-cell-secreted interleukin-1 alpha.

Is there a correlation in breast carcinomas between tumor size and number of tumor vessels detected by gadolinium-enhanced magnetic resonance mammography?

Tumor vessels are known as a sign of malignancy in breast tumors. Is there a correlation between tumor size and the number of vessels in cases of breast tumor examined by dynamic gadolinium (Gd)-enhanced MR imaging? Eighteen patients (mean age, 46 +/- 7 years) underwent dynamic Gd-enhanced MR imaging of the breast by three-dimensional gradient echo sequence using thin-layer technique (2.5 mm) at 1.5T. The dynamic study included one precontrast and four postcontrast sequences (every 90 seconds) in coronal slices. Postprocessing by subtraction method and reconstruction in both transverse and sagittal planes were performed. All carcinomas showed rapid Gd enhancement. Tumor size (0.5 to 31.5 cm3; mean, 6.3 +/- 3.7 cm3) and number of vessels (1 to 10; mean, 3 +/- 2.1) were detected in summation of all three directions. A significant correlation was found between number of vessels and tumor size (r = 0.787, p < or = 0.01). Breast tumor size significantly correlated with the number of vessels detected by Gd-enhanced MR mammography. The introduced method is a further important step in differentiating a carcinoma from a benign lesion.

New signs of breast cancer: high resistance flow and variations in resistive indices evaluation by color Doppler sonography

In a prospective study, color Doppler sonograms (CDS) were performed in 142 patients with solid breast lesions (64 carcinomas, 53 fibroadenomas, 25 miscellaneous breast diseases). Exclusively intratumoral RI were determined, with only the highest and lowest value in the various vessels of a tumor being considered. We found that an RI < 0.80 is typical for benign breast conditions, but also frequently occurs in malignant lesions. A significant difference was seen for higher RIs. An RI > or = 0.80 was seen to be an indicator of malignancy with high specificity (96%) and a sensitivity of 55%. Moreover, RI differences in malignant lesions were markedly greater than in benign lesions. An RI difference > or = 0.20 among vessels of one tumor was a malignancy indicator with very high specificity (97%) but relatively low sensitivity (39%). An RI > or = 0.80 and RI differences > or = 0.20 are specific Doppler ultrasound (US) malignancy indicators.

Endothelial Tie growth factor receptor provides antigenic marker for assessment of breast cancer angiogenesis

Breast cancer prognosis has previously been linked to the degree of tumour vascularisation. In order to establish additional markers for tumour angiogenesis, we have used monoclonal antibodies against the endothelial Tie receptor tyrosine kinase to study the degree of vascularisation of breast carcinomas and the regulation of Tie expression in the vascular endothelial cells. Antibodies were used for Tie detection and the results were correlated with other prognostic markers. Of four monoclonal antibodies directed against different epitopes of the Tie extracellular domain, two reacted against Tie in unfixed histopathological sections of breast carcinomas. One of these antibodies (clone 7e8) was specific for the endothelial cells whereas the other (clone 10f11) also reacted with basement membranes and occasional carcinoma cells. When Tie expression was studied with the antibody clone 7e8, all 27 carcinomas, two in situ carcinomas, samples of histologically normal breast tissue (n = 16) or normal skin or lymph node tissue (n = 5) showed staining. Microvessel counts were higher in carcinomas (median 14; range 3-27) than in fibrodenomas (median 10; range 5-18) or histologically normal breast tissue (median 7; range 3-15, P = 0.0006). A similar result was obtained using antibodies against the CD31 (PECAM) antigen. Microvessel counts in 7e8 staining were not significantly associated with primary tumour size, axillary nodal status, histological grade or staining for oestrogen receptor, progesterone receptor, Ki-67 proliferation marker or p53 oncoprotein.

Blood flow in breast cancer and fibroadenoma estimated by colour Doppler ultrasonography

Blood flow was measured by colour Doppler ultrasonography in 33 fibroadenomas of size 5-31 mm and 28 malignant breast masses of 8-37 mm visible on ultrasonography. There was detectable blood flow in 11 fibroadenomas and 21 cancers (P < 0.01). The median peak systolic frequency was 1.0 (range 0.25-2.0) kHz in malignant tumours and 0.5 (range 0.2-1.25) kHz in fibroadenomas. Blood flow was not detected in the eight fibroadenomas of less than 13 mm but was present in five of seven cancers smaller than this. Five of six carcinomas with three or more detectable vessels were classified as grade III on histological examination, compared with two of 11 carcinomas with one or two vessels. Similarly, five of seven cancers with three or more detectable vessels had axillary lymph node metastases compared with two of 13 with only one or two vessels. Detectable blood flow in breast masses is more common in cancer than in fibroadenoma and is highly suggestive of malignancy if the mass is less than 13 mm in size. Malignant tumours with a larger number of vessels are more likely to be of high grade and to have associated axillary node metastases.