Antonella Roselli

A first evaluation of breast radiological density assessment by QUANTRA software as compared to visual classification

Breast radiological density is a determinant of breast cancer risk and of mammography sensitivity and may be used to personalize screening approach. We first analyzed the reproducibility of visual density assessment by eleven experienced radiologists classifying a set of 418 digital mammograms: reproducibility was satisfactory on a four (BI-RADS D1-2-3-4: weighted kappa = 0.694-0.844) and on a two grade (D1-2 vs D3-4: kappa = 0.620-0.851), but subjects classified as with dense breast would range between 25.1 and 50.5% depending on the classifying reader. Breast density was then assessed by computer using the QUANTRA software which provided systematically lower density percentage values as compared to visual classification. In order to predict visual classification results in discriminating dense and non-dense breast subjects on a two grade scale (D3-4 vs, D1-2) the best fitting cut off value observed for QUANTRA was ≤22.0%, which correctly predicted 88.6% of D1-2, 89.8% of D3-4, and 89.0% of total cases. Computer assessed breast density is absolutely reproducible, and thus to be preferred to visual classification. Thus far few studies have addressed the issue of adjusting computer assessed density to reproduce visual classification, and more similar comparative studies are needed.

Contrast-Enhanced MR Mammography: Improved Lesion Detection and Differentiation with Gadobenate Dimeglumine

OBJECTIVE The objective of our study was to intraindividually compare 0.1 mmol/kg doses of gadobenate dimeglumine and gadopentetate dimeglumine for contrast-enhanced breast MRI. SUBJECTS AND METHODS Forty-seven women (mean age +/- SD, 50.8 +/- 12.9 years) with breast lesions classified as BI-RADS category 3, 4, or 5 for suspicion of malignancy underwent two identical MR examinations at 1.5 T separated by 48-72 hours. T1-weighted gradient-echo images were acquired before contrast administration and at 2-minute intervals after the randomized injection of gadopentetate dimeglumine or gadobenate dimeglumine at 2 mL/s. Two blinded readers evaluated randomized image sets for lesion detection and differentiation as benign or malignant compared with histology. The McNemar exact test and the generalized estimating equation (GEE) were used to compare lesion detection rates and diagnostic performance in terms of sensitivity, specificity, accuracy, positive predictive value (PPV), and negative predictive value (NPV). RESULTS Histopathology data were available for 78 lesions. Significantly more lesions overall (75/78 [96%] vs 62/78 [79%], respectively; p = 0.0002) and significantly more malignant lesions (49/50 [98%] vs 38/50 [76%]; p = 0.0009) were detected with gadobenate dimeglumine than gadopentetate dimeglumine. All detected malignant lesions were correctly diagnosed with both agents. More detected benign lesions were correctly diagnosed with gadobenate dimeglumine than with gadopentetate dimeglumine (20/26 [77%] vs 17/24 [71%], respectively). Differentiation of lesions was significantly (p = 0.0001) better with gadobenate dimeglumine. Significantly better diagnostic performance was noted with gadobenate dimeglumine than with gadopentetate dimeglumine, respectively, for sensitivity (98.0% vs 76.0%; p = 0.0064), accuracy (88.5% vs 69.2%; p = 0.0004), PPV (86.0% vs 76.0%; p = 0.0321), and NPV (95.2% vs 57.1%; p = 0.0003). CONCLUSION Lesion detection and malignant-benign differentiation is significantly better with 0.1 mmol/kg gadobenate dimeglumine than 0.1 mmol/kg gadopentetate dimeglumine.

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

BackgroundDiagnostic 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.MethodsA 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.FindingsConventional 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.InterpretationCE-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.

The challenge of imaging dense breast parenchyma is magnetic resonance mammography the technique of choice? a comparative study with x-ray mammography and whole-breast ultrasound

Purpose:To establish the value of magnetic resonance imaging (MRI) of the breast in comparison to x-ray mammography and ultrasound for breast cancer evaluation in women with dense breast parenchyma. Materials and Methods:Two hundred thirty-eight women with dense breast parenchyma who were suspicious for breast cancer or inconclusive for the presence of breast lesions based on clinical examination, ultrasound or x-ray mammography, and who underwent breast MRI at 1.5 T before and after administration of 0.1 mmol/kg gadobenate dimeglumine were evaluated. Lesions considered malignant (Breast Imaging Reporting and Data System (BI-RADS) 4 or 5) on x-ray mammography and/or ultrasound and as BI-RADS 3, 4, or 5 on MRI were evaluated histologically. Other lesions were followed up at 6 and/or 18 months. The diagnostic performance (sensitivity, specificity, accuracy, and positive and negative predictive values) of each technique was determined and compared using a general linear mixed model with appropriate correction for multiplicity. Results:At final diagnosis 121 of 238 (50.8%) women had one or more confirmed malignant lesions, whereas 117 (49.2%) had benign lesions or no lesions. Among 97 women who underwent all 3 techniques more lesions (malignant and benign) were detected with breast MRI (n = 135) than with x-ray mammography (n = 85) or ultrasound (n = 107) and diagnostic confidence was greater. In terms of patient-based diagnostic accuracy breast MRI was significantly (P[r] < 0.0001) superior to both x-ray mammography and ultrasound (96.9% accuracy for MRI vs. 60.8% for mammography and 66.0% for US). Malignant lesions were histologically confirmed in 55 of 97 women who underwent all 3 techniques. Breast MRI detected more cases of multifocal, multicentric, and contralateral disease and fewer misdiagnoses occurred. Overall, breast MRI led to a modification of the surgical approach for 28 (23.1%) of the 121 women with diagnosed malignant disease. Conclusion:Breast MRI should be considered for routine breast cancer evaluation in women with dense breast parenchyma.

Color-coded automated signal intensity curves for detection and characterization of breast lesions: preliminary evaluation of a new software package for integrated magnetic resonance-based breast imaging.

Objectives:The objective of this study was to evaluate the value of a color-coded automated signal intensity curve software package for contrast-enhanced magnetic resonance mammography (CE-MRM) in patients with suspected breast cancer. Materials and Methods:Thirty-six women with suspected breast cancer based on mammographic and sonographic examinations were preoperatively evaluated on CE-MRM. CE-MRM was performed on a 1.5-T magnet using a 2D Flash dynamic T1-weighted sequence. A dosage of 0.1 mmol/kg of Gd-BOPTA was administered at a flow rate of 2 mL/s followed by 10 mL of saline. Images were analyzed with the new software package and separately with a standard display method. Statistical comparison was performed of the confidence for lesion detection and characterization with the 2 methods and of the diagnostic accuracy for characterization compared with histopathologic findings. Results:At pathology, 54 malignant lesions and 14 benign lesions were evaluated. All 68 (100%) lesions were detected with both methods and good correlation with histopathologic specimens was obtained. Confidence for both detection and characterization was significantly (P ≤ 0.025) better with the color-coded method, although no difference (P > 0.05) between the methods was noted in terms of the sensitivity, specificity, and overall accuracy for lesion characterization. Excellent agreement between the 2 methods was noted for both the determination of lesion size (kappa = 0.77) and determination of SI/T curves (kappa = 0.85). Conclusions:The novel color-coded signal intensity curve software allows lesions to be visualized as false color maps that correspond to conventional signal intensity time curves. Detection and characterization of breast lesions with this method is quick and easily interpretable.

Unenhanced MRI at 3T in neo-adjuvant chemotherapy

Over the past two decades, systemic neoadjuvant chemotherapy (NAC) has been used in patients with non-metastatic breast cancers [1]. The concept of NAC for operable breast cancers evolved from experience in locally advanced inoperable breast cancer. The goals of NAC in breast cancer are to treat occult systemic disease, decrease the tumor volume reducing the extent of local surgery, and increase long term survival. There are several reasons that support the advantages of NAC. First of all, systemic therapy given prior to surgery might sterilize areas of micrometastases and prevent further cancer growth after the primary tumor is resected [2]. This would be especially true considering the hypothesis that breast surgery could release tumor cells and stimulate the growth of occult micro-metastases through mechanisms such as angiogenesis [3,4]. Another positive aspect of NAC is the possibility to reduce the size of the primary tumor, which allows higher rates of breast-conserving surgery and/or reduces local recurrence rates. Last, the efficacy of NAC can be used as an in vivo assay of drug sensitivity/resistance. In fact, NAC requires an optimal assessment of response to cytotoxic drugs in vivo, which is not only clinically relevant but also critical in terms of research efforts directed to the assessment of chemo resistance and response. Accurate assessment of the neoadjuvant response is a critical element in monitoring and assessing treatment strategies. Considering the high toxicity of chemotherapeutic drugs, early assessment of therapeutic response of the tumor is essential for patient management, as NAC is associated with significant morbidity and reduced quality of life [5,6]. Nowadays, contrast enhanced MRI is considered the most reliable imaging technique in the early assessment of response to NACand it is commonly used in many centers in monitoring NACresponse in patients affected by breast cancer. Several studies have