Conventional Breast Imaging Research Articles

The accuracy of incremental pre-operative breast MRI findings – Concordance with histopathology in the Swedish randomized multicenter POMB trial

PurposeThe Pre-Operative MRI of the Breast (POMB) trial was a randomized, prospective, multicenter trial evaluating the impact of pre-operative breast MRI on treatment regimens and short-term surgical outcomes in women up to 56 years of age with breast cancer. The purpose of this study was to evaluate the performance of pre-operative breast MRI in the POMB trial with respect to incremental MRI findings - over conventional breast imaging methods – and their concordance with histopathology. Patients and methodsTwo-hundred and ten patients (n = 210) participating in the POMB trial underwent pre-operative breast MRI at two Swedish breast units.Positive predictive values (PPV) for the incremental MRI findings were calculated for three subgroups of patients with: 1. alteration/alterations of treatment plan; 2. no alteration of treatment plan; and, 3. MRI-related conversion from BCS to mastectomy.Area under the receiver operating characteristic curve (AUC) was calculated using in-breast BI-RADS based ratings for the whole MRI group. ResultsAfter exclusions a total number of 99 incremental findings in 78 patients were eligible for statistical analysis resulting in a PPV = 74%: (95% CI 60–84%) in 39 patients with MRI related alterations of initial treatment plans and 27%: (95% CI 14–44%) in 39 patients without.Positive predictive values of incremental findings decisive for specific treatment alteration/s were 83% (95% CI 68–92%) in patients with any alteration of initial treatment plans and 91% (95% CI 70–98%) for patients (n = 20/22) with conversion from breast conserving surgery to mastectomy.The empirical AUC for the incremental findings in the whole MRI group was 85% (95% CI 78–91%). ConclusionBreast MRI, performed and evaluated together with conventional breast imaging methods can provide relevant information at a high degree of accuracy in the pre-operative setting.

The Effects of Q Inside<sup>TM</sup> Safety Technology Micro Transponder on Routine Breast Implant Imaging

Objectives: A recent entry into the silicone gel-filled breast implant market from Motiva Implants (Establishment Labs Holdings Inc., NY, USA) contains a radio frequency identification device micro-transponder (RFID-M), known as the Q Inside Safety Technology, as an added safety feature embedded in the shell of its breast implant. This RFID-M device allows for the rapid unique identification of the implant. Concern for imaging voids due to the presence of the RFID device during MRI screening scans have arisen given its metallic components. Our investigation aims to determine whether the Q Inside Safety Technology RFID-M device in the Motiva Implants Limits the visualization of breast tissue in conventional breast imaging modalities. Methods: Seven patients with Motiva Implants were referred to dedicated diagnostic breast imaging centers for evaluation of their prostheses and surrounding breast parenchyma between January and May 2018. Imaging indications included routine evaluation of implant integrity, evaluation of significant breast symptoms, oncologic follow-up, and breast cancer screenings. Results: Under mammography, the Motiva Implants have a similar contour and mobility to other commonly used implants. The RFID-M is not visible and produces no artifact, allowing for proper visualization and screening of all visualized parenchymal tissues. Under ultrasound, the Motiva Implants are well-visualized in all patients. The RFID-M was not visible in vivo. No related ultrasound artifact was apparent within the lumen or behind the implant as shown in Figure 2(a). Five patients received MRI. The breast parenchyma and axillae were well-visualized in all 5 patients. The RFID-M was found to produce a “butterfly-shaped” susceptibility artifact that projects into the lumen of the breast implant and causes image distortion in some of the surrounding soft tissues and chest wall posterior to the implant. Conclusion: Aside from making its presence evident inside the implant, the Q Inside Safety Technology RFID-M does not interfere with the mammographic or sonographic exam, its results, or any consequent diagnosis made via their analysis. In the same respect using optimized MRI sequences to evaluate patients we were able to obtain satisfactory visualization of breast tissue in patients with the new Motiva Implants, and recommend using optimized study protocols for both early cancer detection and assessment of the implant’s integrity.

Predicting the molecular subtype of breast cancer based on mammography and ultrasound findings.

Aim:To determine the correlation between mammography and ultrasound features of breast cancer with molecular subtypes and to calculate the predictive value of these features.Materials and Method:This is a prospective study of consecutive patients with breast cancer presenting between January 2016 and July 2017, who underwent mammography and/or ultrasound of breast and excision of the breast mass. Patients with contralateral breast mass, metastases, h/o prior cancer treatment, and other malignancies were excluded. On mammography, the presence or absence of microcalcification was noted. On ultrasound examination size, margins, microcalcification, posterior acoustic features, vascularity, and axillary nodes were assessed. Margins were categorized into circumscribed and non-circumscribed. Posterior acoustic features were classified into four categories: shadowing, enhancement, mixed, and no changes. Vascularity was assessed based on Adler's index into grades 0, 1, 2, and 3. Grades 0 and 1 were considered low and 2 and 3 were high.Results:Tumors with non-circumscribed margins and posterior acoustic shadowing were likely to be luminal A or B subtype of breast cancer [odds ratio (OR) 5.78; 95% confidence interval (CI) 3.68–9.80; P < 0.0001]. Tumors with non-circumscribed margins, posterior acoustic shadowing, and high vascularity were more likely to be luminal B subtype (OR 2.88; 95% CI 2–4.14; P- <0.0001). Tumors with microcalcification and posterior mixed acoustic pattern were strongly associated to be HER2-positive (OR 5.48; 95% CI 3.06–9.80; P < 0.0001). Tumors with circumscribed margins and posterior acoustic enhancement were highly suggestive of triple-negative breast cancer (OR 7.06; 95% CI 4.64–10.73; P < 0.0001).Conclusion:Microcalcification detected on mammography and certain ultrasound features such as circumscribed or non-circumscribed margins, posterior acoustic features, and vascularity are strongly correlated in predicting the molecular subtypes of breast cancer, and thus may further expand the role of conventional breast imaging.

Evaluating the Impact of Breast Density on Preoperative MRI in Invasive Lobular Carcinoma

The focus of this study was to assess the accuracy of breast MRI in predicting pathologic tumor size in invasive lobular carcinoma (ILC) and to evaluate the incidence and factors associated with the detection of additional MRI lesions in ILC patients. We retrospectively reviewed data from patients with stage I to III ILC diagnosed between 2010 and 2016 at our institution. Univariable and multivariable logistic regression were used to determine factors associated with detection of additional suspicious lesions on MRI. The cohort included 99 women with ILC who underwent preoperative MRI, with a median age of 61 years (range 35 to 80 years). The sensitivity of MRI for detecting invasive lobular carcinoma was 99%, higher than that of mammography (68%) and ultrasound (92%). Mammography and ultrasound had a tendency to underestimate ILC, and MRI estimates of final tumor size were concordant in the majority (58.6%) of cases, with a median discordance of-2 mm. Magnetic resonance imaging detected additional ipsilateral malignancy in 23.2%, occult contralateral disease in 3.0%, and altered surgical management in 29.3% of ILC cases. In multivariable analyses, factors significantly associated with additional suspicious findings on MRI included higher breast density (odds ratio 3.19; 95% CI 1.01 to 10.0) and lymph node-positive disease (odds ratio 4.02; 95% CI 0.96 to 16.9). Preoperative MRI is a useful adjunct to conventional breast imaging in ILC, particularly in women with dense breast tissue.

Preliminary Results of a New Auxiliary Mechatronic Near-Field Radar System to 3D Mammography for Early Detection of Breast Cancer.

Accurate and early detection of breast cancer is of high importance, as it is directly associated with the patients’ overall well-being during treatment and their chances of survival. Uncertainties in current breast imaging methods can potentially cause two main problems: (1) missing newly formed or small tumors; and (2) false alarms, which could be a source of stress for patients. A recent study at the Massachusetts General Hospital (MGH) indicates that using Digital Breast Tomosynthesis (DBT) can reduce the number of false alarms, when compared to conventional mammography. Despite the image quality enhancement DBT provides, the accurate detection of cancerous masses is still limited by low radiological contrast (about 1%) between the fibro-glandular tissue and affected tissue at X-ray frequencies. In a lower frequency region, at microwave frequencies, the contrast is comparatively higher (about 10%) between the aforementioned tissues; yet, microwave imaging suffers from low spatial resolution. This work reviews conventional X-ray breast imaging and describes the preliminary results of a novel near-field radar imaging mechatronic system (NRIMS) that can be fused with the DBT, in a co-registered fashion, to combine the advantages of both modalities. The NRIMS consists of two antipodal Vivaldi antennas, an XY positioner, and an ethanol container, all of which are particularly designed based on the DBT physical specifications. In this paper, the independent performance of the NRIMS is assessed by (1) imaging a bearing ball immersed in sunflower oil and (2) computing the heat Specific Absorption Rate (SAR) due to the electromagnetic power transmitted into the breast. The preliminary results demonstrate that the system is capable of generating images of the ball. Furthermore, the SAR results show that the system complies with the standards set for human trials. As a result, a configuration based on this design might be suitable for use in realistic clinical applications.

Breast Imaging Outcomes following Abnormal Thermography

The study aimed to determine the outcome of patients presenting for evaluation of abnormal breast thermography. Following Institutional Review Board approval, retrospective search identified 38 patients who presented for conventional breast imaging following a thermography-detected abnormality. Study criteria included women who had mammogram and/or breast ultrasound performed for evaluation of a thermography-detected abnormality between January 1, 2000, and December 31, 2015. Patients whose mammograms and ultrasounds were initiated at an outside institution or who did not have imaging at our institution were excluded. Records were reviewed for clinical history, thermography results, mammogram and/or ultrasound findings, and pathology. Mammograms and ultrasounds were prospectively interpreted by one of 14 Mammography Quality Standards Act-certified breast imaging radiologists with 3-30 years of experience. Patient outcomes were determined by biopsy or at least 1 year of follow-up. Patient ages ranged from 23 to 70 years (mean = 50 years). Ninety-five percent (36 of 38) of patients did not have breast cancer. The two patients diagnosed with breast cancer had suspicious clinical symptoms including palpable mass and erythema. No asymptomatic woman had breast cancer. Negative predictive value was 100%. Of 38 patients, 79% (30 of 38) had Breast Imaging Reporting and Data System (BI-RADS) 1 or 2 assessments; 5% (2 of 38) had BI-RADS 3; and 16% (6 of 38) had BI-RADS 4 (n = 5) or BI-RADS 5 (n = 1) assessments. Two of six patients with biopsy recommendations were diagnosed with breast cancer (Positive predictive value 2 = 33.3%). All findings recommended for biopsy were ipsilateral to the reported thermography abnormality. No cancer was diagnosed among asymptomatic women. The 5% of patients diagnosed with cancer had co-existing suspicious clinical findings. Mammogram and/or ultrasound were useful in accurately characterizing patients with abnormal thermography.

Does Breast Magnetic Resonance Imaging Combined With Conventional Imaging Modalities Decrease the Rates of Surgical Margin Involvement and Reoperation?: A Case-Control Comparative Analysis.

The objective of this study was to assess whether preoperative breast magnetic resonance imaging (MRI) combined with conventional breast imaging techniques decreases the rates of margin involvement and reexcision.Data on patients who underwent surgery for primary operable breast cancer were obtained from the Changhua Christian Hospital (CCH) breast cancer database. The rate of surgical margin involvement and the rate of reoperation were compared between patients who underwent conventional breast imaging modalities (Group A: mammography and sonography) and those who received breast MRI in addition to conventional imaging (Group B: mammography, sonography, and MRI).A total of 1468 patients were enrolled in this study. Among the 733 patients in Group A, 377 (51.4%) received breast-conserving surgery (BCS) and 356 (48.6%) received mastectomy. Among the 735 patients in Group B, 348 (47.3%) received BCS and 387 (52.7%) received mastectomy. There were no significant differences in operative method between patients who received conventional imaging alone and those that received MRI and conventional imaging (P = 0.13). The rate of detection of pathological multifocal/multicentric breast cancer was markedly higher in patients who received preoperative MRI than in those who underwent conventional imaging alone (14.3% vs 8.6%, P < 0.01). The overall rate of surgical margin involvement was significantly lower in patients who received MRI (5.0%) than in those who received conventional imaging alone (9.0%) (P < 0.01). However, a significant reduction in rate of surgical margin positivity was only observed in patients who received BCS (Group A, 14.6%; Group B, 6.6%, P < 0.01). The overall BCS reoperation rates were 11.7% in the conventional imaging group and 3.2% in the combined MRI group (P < 0.01). There were no significant differences in rate of residual cancer in specimens obtained during reoperation between the 2 preoperative imaging groups (Group A, 50%; Group B, 81.8%, P = 0.09). In multivariate analysis, multifocal/multicentric breast cancer (odds ratio = 2.38, P = 0.02) and without MRI use (odds ratio = 2.35, P < 0.01) were the major predisposing factors to margin involvement in patients received BCS.Preoperative breast MRI combined with conventional breast imaging results in a lower rate of surgical margin involvement and reoperations in patients who receive BCS.

Systematic review and meta-analysis of the diagnostic accuracy of ductoscopy in patients with pathological nipple discharge.

Invasive surgery remains the standard for diagnosis of pathological nipple discharge (PND). Only a minority of patients with nipple discharge and an unsuspicious finding on conventional breast imaging have cancer. Ductoscopy is a minimally invasive alternative for evaluation of PND. This systematic review and meta-analysis was designed to evaluate the diagnostic accuracy of ductoscopy in patients with PND. A systematic search of electronic databases for studies addressing ductoscopy in patients with PND was conducted. Two classification systems were assessed. For DSany , all visualized ductoscopic abnormalities were classified as positive, whereas for DSsusp , only suspicious findings were considered positive. After checking heterogeneity, pooled sensitivity and specificity of DSany and DSsusp were calculated. The search yielded 4642 original citations, of which 20 studies were included in the review. Malignancy rates varied from 0 to 27 per cent. Twelve studies, including 1994 patients, were eligible for meta-analysis. Pooled sensitivity and specificity of DSany were 94 (95 per cent c.i. 88 to 97) per cent and 47 (44 to 49) per cent respectively. Pooled sensitivity and specificity of DSsusp were 50 (36 to 64) and 83 (81 to 86) per cent respectively. Heterogeneity between studies was moderate to large for sensitivity (DSany : I2 = 17·5 per cent; DSsusp : I2 = 37·9 per cent) and very large for specificity (DSany : I2 = 96·8 per cent; DSsusp : I2 = 92·6 per cent). Ductoscopy detects about 94 per cent of all underlying malignancies in patients with PND, but does not permit reliable discrimination between malignant and benign findings.

MRI findings of radiation‐associated angiosarcoma of the breast (RAS)

To describe the magnetic resonance imaging (MRI) characteristics of radiation-associated breast angiosarcomas (RAS). In this Institutional Review board (IRB)-approved retrospective study, 57 women were diagnosed with pathologically confirmed RAS during the study period (January 1999 to May 2013). Seventeen women underwent pretreatment breast MRI (prior to surgical resection or chemotherapy), of which 16 studies were available for review. Imaging features, including all available mammograms, ultrasounds, and breast MRIs, of these patients were evaluated by two radiologists independently and correlated with clinical management and outcomes. The median age of patients at original breast cancer diagnosis was 69.3 years (range 42-84 years), with average time from initial radiation therapy to diagnosis of RAS of 7.3 years (range 5.1-9.5 years). Nine women had mammograms (9/16, 56%) and six had breast ultrasound (US) (6/16, 38%) prior to MRI, which demonstrated nonsuspicious findings in 5/9 mammograms and 3/6 ultrasounds. Four patients had distinct intraparenchymal masses on mammogram and MRI. MRI findings included diffuse T2 high signal skin thickening (16/16, 100%). Nearly half (7/16, 44%) of patients had T2 low signal intensity lesions; all lesions rapidly enhanced on postcontrast T1 -weighted imaging. All women underwent surgical resection, with 8/16 (50%) receiving neoadjuvant chemotherapy. Four women died during the study period. Clinical, mammographic, and sonographic findings of RAS are nonspecific and may be occult on conventional breast imaging; MRI findings of RAS include rapidly enhancing dermal and intraparenchymal lesions, some of which are low signal on T2 weighted imaging.

Comparison of Gadoteric Acid and Gadobutrol for Detection as Well as Morphologic and Dynamic Characterization of Lesions on Breast Dynamic Contrast-Enhanced Magnetic Resonance Imaging

In contrast to conventional breast imaging techniques, one major diagnostic benefit of breast magnetic resonance imaging (MRI) is the simultaneous acquisition of morphologic and dynamic enhancement characteristics, which are based on angiogenesis and therefore provide insights into tumor pathophysiology. The aim of this investigation was to intraindividually compare 2 macrocyclic MRI contrast agents, with low risk for nephrogenic systemic fibrosis, in the morphologic and dynamic characterization of histologically verified mass breast lesions, analyzed by blinded human evaluation and a fully automatic computer-assisted diagnosis (CAD) technique. Institutional review board approval and patient informed consent were obtained. In this prospective, single-center study, 45 women with 51 histopathologically verified (41 malignant, 10 benign) mass lesions underwent 2 identical examinations at 1.5 T (mean time interval, 2.1 days) with 0.1-mmol kg doses of gadoteric acid and gadobutrol. All magnetic resonance images were visually evaluated by 2 experienced, blinded breast radiologists in consensus and by an automatic CAD system, whereas the morphologic and dynamic characterization as well as the final human classification of lesions were performed based on the categories of the Breast imaging reporting and data system MRI atlas. Lesions were also classified by defining their probability of malignancy (morpho-dynamic index; 0%-100%) by the CAD system. Imaging results were correlated with histopathology as gold standard. The CAD system coded 49 of 51 lesions with gadoteric acid and gadobutrol (detection rate, 96.1%); initial signal increase was significantly higher for gadobutrol than for gadoteric acid for all and the malignant coded lesions (P < 0.05). Gadoteric acid resulted in more postinitial washout curves and fewer continuous increases of all and the malignant lesions compared with gadobutrol (CAD hot spot regions, P < 0.05). Morphologically, the margins of the malignancies were different between the 2 agents, whereas gadobutrol demonstrated more spiculated and fewer smooth margins (P < 0.05). Lesion classifications by the human observers and by the morpho-dynamic index compared with the histopathologic results did not significantly differ between gadoteric acid and gadobutrol. Macrocyclic contrast media can be reliably used for breast dynamic contrast-enhanced MRI. However, gadoteric acid and gadobutrol differed in some dynamic and morphologic characterization of histologically verified breast lesions in an intraindividual, comparison. Besides the standardization of technical parameters and imaging evaluation of breast MRI, the standardization of the applied contrast medium seems to be important to receive best comparable MRI interpretation.

The Added Diagnostic Value of Dynamic Contrast-Enhanced MRI at 3.0 T in Nonpalpable Breast Lesions

ObjectiveTo investigate the added diagnostic value of 3.0 Tesla breast MRI over conventional breast imaging in the diagnosis of in situ and invasive breast cancer and to explore the role of routine versus expert reading.Materials and MethodsWe evaluated MRI scans of patients with nonpalpable BI-RADS 3–5 lesions who underwent dynamic contrast-enhanced 3.0 Tesla breast MRI. Initially, MRI scans were read by radiologists in a routine clinical setting. All histologically confirmed index lesions were re-evaluated by two dedicated breast radiologists. Sensitivity and specificity for the three MRI readings were determined, and the diagnostic value of breast MRI in addition to conventional imaging was assessed. Interobserver reliability between the three readings was evaluated.ResultsMRI examinations of 207 patients were analyzed. Seventy-eight of 207 (37.7%) patients had a malignant lesion, of which 33 (42.3%) patients had pure DCIS and 45 (57.7%) invasive breast cancer. Sensitivity of breast MRI was 66.7% during routine, and 89.3% and 94.7% during expert reading. Specificity was 77.5% in the routine setting, and 61.0% and 33.3% during expert reading. In the routine setting, MRI provided additional diagnostic information over clinical information and conventional imaging, as the Area Under the ROC Curve increased from 0.76 to 0.81. Expert MRI reading was associated with a stronger improvement of the AUC to 0.87. Interobserver reliability between the three MRI readings was fair and moderate.Conclusions3.0 T breast MRI of nonpalpable breast lesions is of added diagnostic value for the diagnosis of in situ and invasive breast cancer.

The role of magnetic resonance imaging in preoperative planning for patients undergoing therapeutic mammoplasty.

Background. Assessment of the ratio between tumour volume and breast volume in therapeutic mammoplasty is paramount. Traditionally based on clinical assessment and conventional breast imaging, the role of breast magnetic resonance imaging (MRI) in this context has not been established. Methods. Data was collected from all women undergoing therapeutic mammoplasty (TM) between 2006 and 2011. Each case was discussed at an MDT where MRI was considered to facilitate surgical planning. The contribution of MRI to disease assessment and surgical outcome was then reviewed. Results. 35 women underwent TM, 15 of whom had additional MRI. 33% of patients within the MRI subgroup had abnormalities not seen on either mammography or USS. Of those undergoing MRI, 1/15 patients required completion mastectomy versus 3 patients requiring completion mastectomy and 1 patient requiring further wide local excision (4/20) in the conventional imaging group. No statistical difference was seen between size on MRI and size on mammography versus final histological size, but a general trend for greater correlation between size on MRI and final histological size was seen. Conclusion. MRI should be considered in selected patients undergoing therapeutic mammoplasty. Careful planning can identify those who are most likely to benefit from MRI, potentially reducing the need for further surgery.

Avoiding preoperative breast MRI when conventional imaging is sufficient to stage patients eligible for breast conserving therapy

AimTo determine when preoperative breast MRI will not be more informative than available breast imaging and can be omitted in patients eligible for breast conserving therapy (BCT). MethodsWe performed an MRI in 685 consecutive patients with 692 invasive breast tumors and eligible for BCT based on conventional imaging and clinical examination. We explored associations between patient, tumor, and conventional imaging characteristics and similarity with MRI findings. Receiver operating characteristic (ROC) analysis was employed to compute the area under the curve (AUC). ResultsMRI and conventional breast imaging were similar in 585 of the 692 tumors (85%). At univariate analysis, age (p<0.001), negative preoperative lymph node status (p=0.011), comparable tumor diameter at mammography and at ultrasound (p=0.001), negative HER2 status (p=0.044), and absence of invasive lobular cancer (p=0.005) were significantly associated with this similarity. At multivariate analysis, these factors, except HER2 status, retained significant associations. The AUC was 0.68. ConclusionsIt is feasible to identify a subgroup of patients prior to preoperative breast MRI, who will most likely show similar results on conventional imaging as on MRI. These findings enable formulation of a practical consensus guideline to determine in which patients a preoperative breast MRI can be omitted.

ClearPEM, un TEP dédié au sein

Conventional breast imaging (mammography, ultrasound, MRI) relies on the analysis of anatomical characteristics. Whole-body positron emission tomography (PET) allows for the acquisition of a metabolic image, yet is limited by its poor spatial resolution. The Crystal Clear Collaboration developed a PET dedicated for breast imaging, the ClearPEM, in order to offer a high-resolution nuclear imaging technique. The patient is installed in the prone position on the exam bed, with two detector plates rotating around to breast to acquire a 3-dimensional image. Two prototypes were built and installed in hospitals. We summarize the technical solutions necessary for the development of this system and present a summary of its performances as well as an outlook on preclinical and clinical tests.

Breast MRI as a Problem Solving Tool in Paget’s Disease of the Nipple

Paget’s disease of the nipple is a rare breast malignancy. It is usually, but not always, associated with an underlying ductal carcinoma in situ or invasive ductal carcinoma. Conventional breast imaging studies often fail to detect underlying breast malignancy when present. The following article will discuss the role of breast MRI as a problem solving tool in Paget’s disease of the nipple-areolar complex in patients with no abnormality on clinical examination and normal mammography. doi:10.4021/jcs80w

P2-08-04: Computer-Derived Breast MRI Features Have Complementary Value for Preoperative Selection of Systemic Drug Therapy in Node-Negative Stage-I/II Breast Cancer Patients.

Abstract Background: Typical guidelines for adjuvant systemic drug therapy require assessment of lymph node status, tumor extent and grade. Increasing interest exists, however, for preoperative therapy (neoadjuvant drug therapy and preoperative partial breast irradiation). Here, representative excision specimens are not available to assess eligibility for systemic therapy. Moreover, tumor grade may be difficult to assess in core biopsies resulting in underestimation rates up to 40%. Contrast-enhanced MRI has been shown to correlate with underlying tumor biology, but it is unknown whether it can complement eligibility criteria for systemic drug therapy. Purpose: To assess the complementary value of MRI to determine eligibility for systemic drug therapy prior to breast-conserving surgery in node-negative stage-I/II breast cancer patients. Materials and methods: Patients with preoperative node-negative invasive breast cancer ≥1.0 cm and eligible for breast-conserving therapy after conventional breast imaging and MRI were consecutively included between February 2000 and March 2007. Informed consent was obtained from all patients. Eligibility to systemic therapy was determined on the basis of national guidelines using age, size, tumor grade, as well as axillary lymph node status at final pathology. Twenty temporal and morphological features of contrast uptake at MRI were automatically analyzed by a previously build CAD workstation1,2. Preoperative lymph node status was derived from ultrasound-guided fine-needle aspiration. Multivariate logistic regression and receiver-operating characteristics (ROC) analysis was used to assess associations between preoperative features (age, ER status, computer-extracted MRI features) and eligibility to systemic therapy based on post-operative features (tumor size, grade, lymph node status). Results: Three-hundred-and-eighty-six patients were included. The mean patient age was 58 years. The mean tumor size at pathology was 1.6 cm. Tumor grade was I, II and III in 128 (33%), 163 (42%), and 94 (24%) of tumors, respectively. Post-operative lymph node status was positive in 115/386 (30%) patients. In total, 262/386 (68%) patients were eligible for systemic drug therapy based on post-operative pathology. Multivariate analysis of preoperatively available features yielded ER status, and principle components 1, 6, 8 and 15 of the computer-extracted features. These components describe tumor volume and shape, heterogeneity of contrast uptake, late-enhancement kinetics, and probability of malignancy. The resulting model correlated with the Adjuvant! program (R=0.55, p&amp;lt;0.0001). The area under the ROC curve was 0.82 (p&amp;lt;0.0001). Without the model, agreement between preoperative and postoperative assessment of eligibility to drug therapy was 232/386 (60%) at 15/124 (12%) overestimation rate. With the MRI model, it increased to 258/386 (67%) (p=0.004) without increasing overestimation rate. Conclusion: Computer-analysis of contrast-enhanced MRI has potential to complement preoperative selection of stage I/II node-negative breast-cancer patients for systemic drug therapy. Ref: 1. Gilhuijs et al., Radiology 2002; 225: 907–916 2. Deurloo et al., Radiology 2005; 234: 693–701 Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P2-08-04.

Multifocal, multicentric and contralateral breast cancers: breast MR imaging in the preoperative evaluation of patients with newly diagnosed breast cancer

This study was done to verify the usefulness of preoperative breast magnetic resonance (MR) imaging in patients with newly diagnosed breast cancer. A retrospective analysis of 291 patients with invasive breast cancer newly diagnosed with conventional breast imaging (mammography and ultrasound) was performed. All patients underwent MR imaging prior to surgery. The MR imaging detection rate of additional malignant cancers occult to mammography and ultrasound was calculated. Data were analysed with Fisher's exact test (p<0.05) according to the following parameters: histopathological features of the index tumour (histological type and size) and mammographic density [according to the Breast Imaging Reporting and Data System (BI-RADS) classification from 1 fatty to 4 dense). The gold standard was the histological examination on the surgical specimen. MR imaging identified 40 mammographically and sonographically occult malignant lesions other than the index cancer in 27/291 patients (9%). These additional cancers were located in the same quadrant as the index cancer in 13 women (4%), in a different quadrant in 12 (4%) and in the contralateral breast in the remaining two (1%). The cancer detection rate in the subgroup of index cancers with lobular histological type was 25%, significantly higher (p=0.03) than the detection rate of 11% recorded in the subgroup of ductal cancers. The cancer detection rate in the subgroup of index cancers >2 cm was 27%, significantly higher (p=0.001) than the rate of 8% found in the subgroup of index cancers <2 cm. Mammographic density was not correlated (p=0.48) with MR detection of additional cancer, with 14% of additional malignancies being detected in both dense and fatty breasts. In patients with newly diagnosed invasive breast cancer, preoperative MR imaging is useful for detecting additional synchronous malignancies that are not detected on conventional breast imaging. The cancer detection rate is 9%. The use of preoperative MR imaging as an adjunct to conventional breast imaging in women with an infiltrating lobular index cancer and an index cancer >2 cm is especially beneficial.

Can conventional breast imaging accurately determine the extent of screen detected high grade ductal carcinoma in situ (DCIS)?

Introduction: Calcified DCIS is frequently detected by screening mammography. The extent of microcalcification is a determinant for treatment with breast conserving surgery (BCS). However, DCIS can be uncalcified, and indeed nationally almost one quarter (23%) of patients with DCIS treated initially by BCS require a second operation. A similar proportion (22%) are found to have unexpected invasive disease following surgery. More accurate identification of these cases pre-operatively would greatly improve surgical planning.

Counterview: Pre-operative breast MRI (magnetic resonance imaging) is not recommended for all patients with newly diagnosed breast cancer

For the woman with a newly diagnosed early stage breast cancer, the routine use of pre-operative breast MRI (magnetic resonance imaging) is not indicated beyond conventional breast imaging (i.e., mammography with correlation ultrasound as indicated). There is no consistent evidence that a pre-operative breast MRI confers a benefit to the patient by improving clinical outcomes or surgical procedures. In a meta-analysis of studies reporting on the use of pre-operative breast MRI for the patient with an established index cancer, multifocal or multicentric disease was found on breast MRI in 16% of the patients, a rate substantially higher than the rate of local recurrence after breast conserving surgery plus definitive radiation treatment. In the largest retrospective study of patients treated with breast conserving surgery plus radiation, no gain was found for adding a breast MRI to conventional breast imaging. No randomized clinical trial has been designed to evaluate long term clinical outcomes associated with adding a pre-operative breast MRI. Adding pre-operative breast MRI can alter clinical management in ways that are potentially harmful to patients, for example, increased ipsilateral mastectomies, increased contralateral prophylactic mastectomies, increased work-ups, and delay to definitive surgery. In summary, the routine use of pre-operative breast MRI is not warranted for the typical patient with a newly diagnosed early stage breast cancer.

Visualization of invasive breast cancer and its subclinical disease spread within the breast: Precise correlation between MR imaging findings and histopathologic findings

610 Background: Magnetic Resonance Imaging (MRI) of the breast shows superior ability to visualize the extent of invasive breast cancer compared to conventional breast imaging. Nonetheless, MRI may under- or overestimate the extent of invasive disease, and the ability of MRI to depict components of disease around the primary invasive tumor is not well established. The purpose of this study was to precisely correlate MRI findings with histopathologic findings in breast cancer patients and to establish the incidence and quantity of surrounding MRI occult disease in breast cancer patients that are scheduled for breast-conserving therapy (BCT). Methods: Patients were prospectively included if they had biopsy-proven invasive breast cancer and the choice of treatment was BCT after pre-operative MRI. Pathology findings were spatially reconstructed and correlated with preoperative MRI. Tumors were stratified by absence or presence of an extensive intraductal component (EIC- or EIC+). The largest diameter of the MRI-visible lesion was compared with the largest diameter of the primary invasive tumor at pathology. Distances (mm) between the edge of the MRI-visible lesion and surrounding subclinical tumor foci (i.e., DCIS, invasive foci) were measured. At various distances from the edge of the MRI-visible tumor, the incidence of disease was determined. Results: 53 patients with 54 breast tumors were included. 42 tumors were EIC- and 12 were EIC+. The mean size (± SD) of the primary invasive tumor was 18.1 ± 7.5 mm on MRI and 19.5 ± 8.2 mm on pathology (Pearson's correlation coefficient: 0.75). The MRI-visible lesion was larger than or equal to the primary invasive tumor on pathology in 21 (39%) cases. Underestimation of the primary invasive tumor occurred up to 7 mm from the edge of the MRI-visible lesion. Beyond 10 mm, subclinical tumor foci were found in 48% off all tumors, in 36% and 92% of EIC- and EIC+ tumors (p &lt; 0.001). Beyond 20 mm these rates were 19%, 7% and 67%, respectively (p &lt; 0.001). Conclusions: Disease around MRI-visible lesions may be more extensive than assumed prior to treatment, especially in EIC+ tumors. This may have consequences for treatment margins in MRI-guided therapy of localized breast cancer. No significant financial relationships to disclose.