The role of contrast-enhanced MR mammography for determining candidates for breast conservation surgery

PURPOSE: The aim of this study was to assess the impact of preoperative magnetic resonance mammography (MRM) on the surgical determination of breast conservation treatment for breast cancer patients. METHODS: From September 1997 to March 2000, 57 consecutive breast conservation treatment candidates were prospectively evaluated with conventional imaging studies (mammography and ultrasonography) and preoperative MRM. RESULTS: In 47 of 54 (87% ) breast cancer patients breast conservation surgery (BCS) was indicated on the basis of mammography (MMG) and ultrasonography (US). However in 40 of the 54 (74% ) patients BCS was indicated on the basis of MRM. Thirty-eight of the 40 patients ultimately underwent BCS and only 1 showed a positive margin. There were 7 patients whose MRM findings suggested that more aggressive treatment than BCS was needed but for whom US/MMG suggested that BCS was appropriate. Five of the 7 patients underwent mastectomy rather than BCS based on the MRM findings, which were justified by post-surgical histological findings. Of the 2 remaining patients who underwent BCS, one had a positive histological margin and one had recurrence, both of which resulted in salvage mastectomy. CONCLUSION: Our study suggests that high resolution preoperative MRM provides more accurate information compared with US and MMG for selecting candidates for BCS. Using MRM as a routine staging tool may reduce unnecessary repeated excisions. A larger study will be required to confirm these findings and to define the patients most likely to benefit from breast MR imaging.     

MRI in the detection and management of breast cancer

Breast magnetic resonance imaging (MRI) is now at a stage where the evidence is suggesting widespread potential in the management of patients with known or suspected breast cancers. MRI is used as a supplementary tool to complement conventional methods of breast evaluation because it has excellent problem-solving capabilities. Many indications for clinical breast MRI are recognized, including resolving findings on mammography, staging of breast cancer when multiple or bilateral disease is suspected, and detecting the occult primary breast cancer presenting with malignant axillary lymphadenopathy but no detectable lesion on conventional breast examination. There is also encouraging ongoing research evaluating its role for the assessment of patients at high risk of breast cancer, for primary staging of cancers in radiographically dense breasts and for the assessment of response to chemotherapy. This article will review both the technical aspects of performing and interpreting breast MRI, as well as the current and possible future roles of breast MRI, comparing its strengths and weaknesses with conventional imaging.     

MRI in the detection and management of breast cancer

Breast magnetic resonance imaging (MRI) is now at a stage where the evidence is suggesting widespread potential in the management of patients with known or suspected breast cancers. MRI is used as a supplementary tool to complement conventional methods of breast evaluation because it has excellent problem-solving capabilities. Many indications for clinical breast MRI are recognized, including resolving findings on mammography, staging of breast cancer when multiple or bilateral disease is suspected, and detecting the occult primary breast cancer presenting with malignant axillary lymphadenopathy but no detectable lesion on conventional breast examination. There is also encouraging ongoing research evaluating its role for the assessment of patients at high risk of breast cancer, for primary staging of cancers in radiographically dense breasts and for the assessment of response to chemotherapy. This article will review both the technical aspects of performing and interpreting breast MRI, as well as the current and possible future roles of breast MRI, comparing its strengths and weaknesses with conventional imaging.     

乳腺钼靶超声和磁共振检查评估乳腺癌大小的准确性分析

目的分析乳腺钼靶、超声和磁共振检查评估乳腺癌大小的准确性。方法选择45例浸润性乳腺癌患者为研究对象,术前分别行乳腺钼靶、超声及磁共振检查,并且与术后切除的病理标本进行对比,分析其对预测乳腺癌大小的准确性。结果磁共振检查对病灶的检出率明显高于检查对肿瘤大小的诊断准确性检查,差异有统计学意义(P<0.05)。乳腺钼靶、超声及磁共振回归系数分别为-0.113、0.289和0.238,其中磁共振评估乳腺癌大小诊断标准误最低,为0.087。结论磁共振对乳腺癌检出率高,并且对肿瘤大小测量的准确度明显优于超声及乳腺钼靶,可以作为患者手术评估的依据。     

Assessment of residual tumour by FDG-PET: conventional imaging and clinical examination following primary chemotherapy of large and locally advanced breast cancer

Background:

The aim of this was to evaluate FDG-PET (2-(fluorine-18)-fluoro-2-deoxy-D-glucose positron emission tomography) for assessment of residual tumour after primary chemotherapy of large and locally advanced breast cancer in comparison with conventional imaging modalities.

Methods:

In a prospective multicentre trial, 99 patients underwent one or more breast imaging modalities before surgery in addition to clinical examination, namely, FDG-PET (n=89), mammography (n=47), ultrasound (n=46), and magnetic resonance imaging (MRI) (n=46). The presence of residual tumour by conventional imaging, dichotomised as positive or negative, and the level of FDG uptake (standardised uptake values, SUV) were compared with histopathology, which served as the reference standard. Patients with no residual tumour or only small microscopic foci of residual tumour were classified as having minimal residual disease and those with extensive microscopic and macroscopic residual tumour tissue were classified as having gross residual disease.

Results:

By applying a threshold SUV of 2.0, the sensitivity of FDG-PET for residual tumour was 32.9% (specificity, 87.5%) and increased to 57.5% (specificity, 62.5%) at a threshold SUV of 1.5. Conventional imaging modalities were more sensitive in identifying residual tumour, but had a low corresponding specificity; sensitivity and specificity were as follows: MRI 97.6 and 40.0%, mammography 92.5 and 57.1%, ultrasound 92.0 and 37.5%, respectively. Breast MRI provided the highest accuracy (91.3%), whereas FDG-PET had the lowest accuracy (42.7%).

Conclusions:

FDG-PET does not provide an accurate assessment of residual tumour after primary chemotherapy of breast cancer. Magnetic resonance imaging offers the highest sensitivity, but all imaging modalities have distinct limitations in the assessment of residual tumour tissue when compared with histopathology.     

乳腺癌X线与MRI诊断价值比较分析

目的:比较X线及MR I两种影像学检查方法对于乳腺癌的诊断价值。方法:回顾分析48例经手术病理证实的乳腺癌患者的MR I及X线检查资料,进行对比分析。结果:MR I对于乳腺癌病灶的检出高于X线摄影,但存在假阳性,对于判断病变范围及淋巴结转移等方面MR I具有较大价值。结论:X线摄影与MR I联合应用有助于提高乳腺癌的诊断准确率。     

钼靶X线与高频B超联合检查乳腺疾病

目的:探讨钼靶X线摄影与高频B超联合检出乳腺良恶性病变的意义,提高早期乳腺疾病的诊断水平。方法:回顾分析385例乳腺病例影像学,依据美国乳腺影像报告方法、数据系统（BI-RADS）分类及高频B超。结果:X线钼靶对伴有微小钙化的早期乳腺癌的诊断具有明显的特异性。超声图像在显示1cm左右大小的乳腺肿块中有较高的准确性。结论:钼靶X线与高频B超联合检查乳腺疾病,具有极高的检出率及诊断符合率。     

全数字化乳腺X线摄影诊断中青年乳腺癌的价值

目的探讨全数字化乳腺X线摄影（FFDM）诊断中青年乳腺癌的应用价值。方法收集2008年9月至2011年6月进行FFDM检查并经病理证实的中青年乳腺癌与良性乳腺病患者共375例。X线诊断标准采用美国放射学会推荐的乳腺报告和数据系统（BI-RADS）：Ⅰ-Ⅲ级为良性,Ⅳ、Ⅴ级为恶性,并与病理结果对照;同时分析乳腺癌的X线表现。以致密型和多量腺体型为A组,少量腺体型和脂肪型为B组,两组灵敏度和特异度的比较采用χ^2检验。结果乳腺癌的X线征象包括肿块或结节、钙化、片状致密影、结构紊乱等。FFDM诊断的灵敏度为82．0％（91／111）,特异度为87．1％（230／264）,阳性预测值为72．8％（91／125）,阴性预测值为92．0％（230／250）,正确率为85．6％（321／375）。A、B两组的FFDM诊断灵敏度、特异度分别为74．5％（35／47）和87．5％（56／64）,84．4％（108／128）和89．7％（122／136）,其差异无统计学意义（P〉0．05）。结论全数字化乳腺X线摄影能及时发现乳腺病灶,对中青年乳腺癌具有较高的应用价值,X线诊断为BI—RADS—Ⅳ、Ⅴ级时建议行手术活组织检查。     

Utility of a serum tumour marker panel in the post-operative follow-up of breast cancer patients with equivocal conventional radiological examinations.

OBJECTIVE: To assess the value of the serum carcinoembryonic antigen (CEA), tissue polypeptide antigen (TPA) and breast cancer-associated antigen CA15.3 (CEA-TPA-CA15.3) tumour marker panel in selecting from a group of patients with equivocal bone scintigraphy, chest X-ray or liver echography, those with skeletal, thoracic or liver metastases. Clinical data of 427 breast cancer patients submitted to an intensive follow-up after mastectomy between January 1986 and December 2000 were retrospectively reviewed. METHODS: Among the 427 patients operated on for breast cancer, 221 patients with a total of 332 equivocal instrumental examinations (bone scintigraphy, n = 286; chest X-ray, n = 29; liver echography, n = 17) were reviewed. All 221 patients were followed up clinically, biochemically and instrumentally until there was a clear definition of their condition, metastatic or not, for an average time of 35 months. Positive and negative predictive values of the tumour marker panel in patients with equivocal bone scintigraphy, chest X-ray and liver echography were evaluated; concomitant clinical symptoms were also taken into consideration. RESULTS: Among the 221 patients with equivocal bone scintigraphy, chest X-ray and liver echography, tumour markers showed a positive predictive value of 69, 93 and 83% and a negative predictive value of 98, 86 and 91%, respectively, for the indication of the metastatic or benign origin of the equivocal instrumental imaging. Clinical symptoms were not helpful in predicting metastatic disease (sensitivity, specificity and accuracy of 60, 53 and 54%, respectively). CONCLUSIONS: These data suggest that a short monitoring with the CEA-TPA-CA15.3 tumour marker panel is an important tool to confirm or exclude metastatic disease in those patients who are suspected to have metastases following common instrumental investigations, and it is particularly important to avoid false positive diagnoses.     

超声光散射乳腺成像诊断乳腺癌假阳性率分析

目的:超声光散射乳腺成像系统（OPTIMUS）是多模式的可以进行早期乳腺癌普查、诊断及疗效检测的系统。本研究回顾经手术后病理证实的160 例乳腺肿瘤的OPTIMUS系统表现与病理结果对比分析,评价OPTIMUS系统的临床应用价值。方法:对160 例乳腺肿瘤患者进行OPTIMUS系统检查,将检查结果及手术病理进行总结,并与相应的钼靶及超声结果进行对比,用卡方检验分析结果有无统计学差异。结果:OPTIMUS系统诊断良性病变42例,恶性病变118 例。术后病理诊断良性病变60例,恶性病变100 例。假阳性率为30.0% ,假阴性率为0。OPTIMUS系统诊断乳腺癌准确性88.8%（142/160）,敏感性100.0%（100/100）;相应超声及钼靶检测准确性分别为87.6% 和87.1% ,无统计学差异;敏感性分别为86.8% 和87.1% ,与OPTIMUS系统有统计学差异。结论:OPTIMUS系统对诊断乳腺恶性肿瘤的准确性及敏感性较高,是提高乳腺良恶性病变鉴别诊断的有效方法。      

Diagnostic accuracy of mammography, ultrasonography and magnetic resonance imaging in the detection of intraductal spread of breast cancer following neoadjuvant chemotherapy

The purpose of this study is to evaluate the accuracy of mammography, ultrasonography, and contrast-enhanced magnetic resonance imaging for the diagnosis of intraductal spread of breast cancer following preoperative neoadjuvant chemotherapy. We evaluated a total of 168 areas of normal breast tissue outside the mass in 42 consecutive female patients with breast cancer using each imaging modality both before and after neoadjuvant chemotherapy. Neoadjuvant chemotherapy comprised two to four cycles of adriamycin-based CAF regimen. Multivariate analysis indicated that calcification on mammography and size of hypoechoic structures on ultrasonography prior to neoadjuvant chemotherapy shows a correlation with intraductal spread on pathologic study. Our study reveals that mammography and ultrasonography are useful in avoiding residual cancer cells caused by intraductal spread following conservative breast surgery.     

Diagnosis of breast cancer: MDCT versus MRI

In Japan, helical CT has been applied to breast cancers for the accurate determination of cancer extent before surgery. In recent years, multidetector CT (MDCT) has become commercially available. Compared with mammography and ultrasonography, MDCT of the breast is thought to be useful for preoperative assessment of breast-conserving surgery. In contrast, magnetic resonance imaging (MRI) is extremely accurate in the diagnosis of intraductal carcinoma and multicentricity of breast cancer. A real problem related to the use of CT is X-ray exposure. Therefore, it is controversial whether the use of CT for the patients with breast cancer is appropriate or not. Recent studies that compared the use of MDCT and MRI in the same patients concluded that MRI was more accurate for the detection and evaluation of the extent of intraductal carcinoma. We should consider the pitfalls and limitations of CT for assessing the breast cancer extent.     

Dynamic contrast enhanced magnetic resonance imaging aids the surgical management of invasive lobular breast cancer.

AIMS: Infiltrating Lobular Carcinoma (ILC) accounts for 5-10% of all breast cancers and is associated with subtle clinical and mammographic changes. It is also frequently multifocal and traditional diagnostic methods are unable to reliably detect this preoperatively. The aim of the study was to evaluate the efficacy of current imaging modalities compared with dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) in the evaluation of ILC. METHODS: Data from women with ILC treated between 1996 and 2000 who had undergone preoperative triple assessment and DCE-MRI was analysed. The diagnostic accuracy and the detection of multifocal disease for each modality was assessed and any changes in clinical management following DCE-MRI were recorded. RESULTS: Twenty-one women (mean age 57, range 43-72 years) were recruited. The sensitivity of X-ray mammography, ultrasound, clinical assessment, fine needle aspiration cytology or core biopsy and DCE-MRI was 90.5, 87.5, 76.2, 85.7 and 95.2% respectively. DCE-MRI identified all the patients with subsequently histologically proven multifocal disease (n=11) with PPV and NPV of 100 and 95.2% respectively. X-ray mammography and ultrasound combined identified only 27% (n=3/11) with PPV and NPV of 100 and 55.6% respectively. Management was changed in 24% (5/21) of the cases following DCE-MRI. CONCLUSION: DCE-MRI has a higher sensitivity than other imaging modalities and is able to accurately delineate multifocal disease not evident on conventional imaging. DCE-MRI should therefore be used for accurate staging prior to surgery for invasive lobular breast cancer.     

Developments toward diagnostic breast cancer imaging using near-infrared optical measurements and fluorescent contrast agents

The use of near-infrared (NIR) light to interrogate deep tissues has enormous potential for molecular-based imaging when coupled with NIR excitable dyes. More than a decade has now passed since the initial proposals for NIR optical tomography for breast cancer screening using time-dependent measurements of light propagation in the breast. Much accomplishment in the development of optical mammography has been demonstrated, most recently in the application of time-domain, frequency-domain, and continuous-wave measurements that depend on endogenous contrast owing to angiogenesis and increased hemoglobin absorbance for contrast. Although exciting and promising, the necessity of angiogenesis-mediated absorption contrast for diagnostic optical mammography minimizes the potential for using NIR techniques to assess sentinel lymph node staging, metastatic spread, and multifocality of breast disease, among other applications. In this review, we summarize the progress made in the development of optical mammography, and focus on the emerging work underway in the use of diagnostic contrast agents for the molecular-based, diagnostic imaging of breast.     

乳腺疾病术前影像学评估价值探讨

目的:比较彩色多普勒超声、钼靶和MRI在乳腺良恶性疾病诊断中的作用.方法:以术后病理结果为金标准,比较术前3种检查方法的诊断准确性.结果:共计465例乳腺疾病患者接受检查,其中乳腺恶性病变339例,乳腺良性病变126例.乳腺癌彩超、钼靶和MRI的灵敏度分别为88.3%、85.3%和92.3%,特异度分别为88.6%、90.4%和91.7%,诊断符合率分别为88.5%、89.5%和92.0%,其中MRI 的各项诊断指标均为最高,对≤2cm的乳腺癌,钼靶的特异度最高(96.2%),但对于<45岁的年轻女性的致密性乳腺内的病变诊断,具有较低灵敏度.对乳腺炎性病变和导管瘤,钼靶及彩超较MRI诊断率高(66.6%,66.7%).结论:彩色多普勒超声和钼靶及MRI 3种乳腺影像诊断方法对乳腺病变的诊断均有各自优势,联合三种检查方法可对术前乳腺病变有更高的诊断价值.     

Incorporating new imaging models in breast cancer management

Opinion statement Mammography is the only screening test proven to decrease breast cancer morbidity and mortality. Although mammography is an effective screening tool, it does have limitations, particularly in women with dense breasts. New imaging techniques are emerging to overcome these limitations and enhance cancer detection, improving patient outcome. Digital mammography, computer aided detection, breast ultrasound and breast magnetic resonance imaging (MRI) are frequently used adjuncts to mammography in today’s clinical practice. Recent studies have shown that these techniques can enhance the radiologist’s ability to detect cancer and assess disease extent, which is crucial in treatment planning and staging. Positron emission tomography (PET) also plays an important role in staging breast cancer and monitoring treatment response. Other modalities such as tomosynthesis and MR lymphangiography show promise in overcoming the problems related to dense breast tissue and the lack of noninvasive methods to assess lymph node status. Imaging-guided, minimally invasive therapies are also emerging as alternatives to surgical biopsy for breast lesions. As imaging techniques improve, the role of imaging will continue to evolve with the goal remaining a decrease in breast cancer morbidity and mortality.     

乳腺疾病术前影像学评估价值探讨

目的：比较彩色多普勒超声、钼靶和MRI在乳腺良恶性疾病诊断中的作用。方法：以术后病理结果为金标准,比较术前3种检查方法的诊断准确性。结果：共计465例乳腺疾病患者接受检查,其中乳腺恶性病变339例,乳腺良性病变126例。乳腺癌彩超、钼靶和MRI的灵敏度分别为88.3%、85.3%和92.3%,特异度分别为88.6%、90.4%和91.7%,诊断符合率分别为88.5%、89.5%和92.0%,其中MRI的各项诊断指标均为最高,对≤2cm的乳腺癌,钼靶的特异度最高（96.2%）,但对于〈45岁的年轻女性的致密性乳腺内的病变诊断,具有较低灵敏度。对乳腺炎性病变和导管瘤,钼靶及彩超较MRI诊断率高（66.6%,66.7%）。结论：彩色多普勒超声和钼靶及MRI 3种乳腺影像诊断方法对乳腺病变的诊断均有各自优势,联合三种检查方法可对术前乳腺病变有更高的诊断价值。     

Contrast-enhanced magnetic resonance mammography: does it affect surgical decision-making in patients with breast cancer?

Background Diagnostic imaging in women with suspected breast cancer should accurately detect and diagnose malignant tumors and facilitate the correct choice of therapy. Contrast-enhanced magnetic resonance mammography (CE-MRM) is potentially the imaging modality of choice for accurate patient management decisions. Methods A total of 164 women with suspected breast cancer based on clinical examination, conventional mammography and/or ultrasound each underwent preoperative bilateral CE-MRM using an axial 3D dynamic T1-weighted gradient-echo sequence and gadobenate dimeglumine as contrast agent. Images were evaluated by two readers in consensus. Histological evaluation of detected lesions was performed on samples from core biopsy or surgery. Determinations were made of the sensitivity, accuracy and positive predictive value of CE-MRM compared to mammography/ultrasound for the detection of malignant lesions and of the impact of CE-MRM for surgical decision-making. Findings Conventional mammography/ultrasound detected 175 lesions in the 164 evaluated patients. CE-MRM revealed 51 additional lesions in 34/164 patients; multifocal and multicentric cancer was detected in 7 and 4 additional patients, respectively, contralateral foci in 21 additional patients and pectoral muscle infiltration in 2 additional patients. CE-MRM also confirmed the absence or benignity of 3 and 1 lesions suspected of malignancy on mammography/ultrasound. The sensitivity and accuracy for malignant lesion detection and identification was 100% and 93.4%, respectively, for CE-MRM compared to 77.3% and 72.1% for mammography/ultrasound, respectively. Patient management was altered for 32/164 (19.5%) patients as a result of CE-MRM. Interpretation CE-MRM positively impacts patient management decisions and should be performed in all women with suspected breast cancer based on clinical examination, mammography and/or ultrasound.     

Tc-99m MIBI in suspected recurrent breast cancer

A prospective trial was performed to assess the accuracy of Tc-99m MIBI scintimammography in 63 women (mean age 65, range 33-85 years) with suspected recurrent breast cancer in the breast and/or loco-regional tissues. All patients had been diagnosed with breast cancer 1-23 years before the scintimammography. A total of 27 breasts had been removed by mastectomy so scintimammography was compared with mammography in the remaining 99 breasts. Pathological follow-up of patients confirmed 33 sites of recurrent disease within the breast, 26 (78%) were identified by scintimammography and 14 (42%) by mammography; 30 (90%) were positive on one test or the other. In addition Tc-99m MIBI scintimammography identified 10/16 (63%) of axillary lymph nodes with recurrent tumour and 4/6 sites of recurrent tumour present elsewhere. Tc-99m MIBI scintimammography is more accurate in identifying recurrent disease in the breast than mammography and can identify loco-regional recurrence outside of the breast.     

彩色超声联合 X 线钼靶摄影在乳腺癌诊断中的价值

目的：研究彩色超声联合X线钼靶摄影在乳腺癌诊断中的价值。方法回顾性分析270例乳腺癌患者的彩色超声、X线钼靶摄影以及二者联合的检查结果,并与术后或者是病理学分析结果进行对比。从阳性诊断符合率、乳腺类型、恶性肿瘤的肿块粒径、癌的类型4个方面的结果进行分析。结果单用彩色超声、单用X线钼靶摄影和彩色超声联合X线钼靶摄影的阳性诊断符合度分别为86．1％、87．9％和96．5％,单用彩色超声和单用X线钼靶摄影的阳性诊断符合度均明显低于彩色超声联合X线钼靶摄影,差异具有统计学意义（P＜0．05）;对于不同的乳腺类型,则单用彩色超声、单用X线钼靶摄影和彩色超声联合X线钼靶摄影的正确诊断率分别为72．2％、77．1％和91．1％,单用彩色超声、单用X线钼靶摄影的正确诊断率明显低于彩色超声联合X线钼靶摄影,差异具有统计学意义（ P＜0．05）;对于不同的肿块粒径,单用彩色超声、单用X线钼靶摄影和彩色超声联合X线钼靶摄影的正确诊断率分别为79．2％、74．4％、92．6％,彩色超声联合X线钼靶摄影诊断准确率明显高于单用彩色超声和单用X线钼靶摄影,差异具有统计学意义（ P＜0．05）;在不同类型的癌方面,单用彩色超声、单用X线钼靶摄影和彩色超声联合X线钼靶摄影的正确诊断率分别为77．2％、76．3％、93．1％,彩色超声联合X线钼靶摄影的准确率均明显高于单用彩色超声、单用X线钼靶摄影的诊断准确率,差异具有统计学意义（P＜0．05）。结论彩色超声和X线钼靶摄影在检查乳腺癌过程中,都具有各自的优势和劣势,二者联合之后能显著提高乳腺癌的诊断准确率,提高对乳腺肿瘤的早期发现率,具有较大实用价值。