Clemens G. Kaiser

[Value of galactography for the diagnostic work-up of pathological nipple discharge in multimodal breast diagnostics. Part 2: a systematic review of the literature].

ZusammenfassungHintergrundDas Umfrageergebnis einer vorangegangenen Studie hat gezeigt, dass die Galaktographie in Deutschland heute selten eingesetzt wird und häufig neuere Verfahren angewendet werden. Die Evidenz der Galaktographie soll überprüft und der von Ultraschall (US) und MR-Mammographie (MRM) gegenübergestellt werden.Material und MethodenEs erfolgte eine Recherche in den Datenbanken PubMed und Cochrane unter Berücksichtigung englisch- und deutschsprachiger Studien. Der Evidenzgrad wurde gemäß des Oxford Centre for Evidence-based Medicine eingestuft.ErgebnisseEs konnten 19 Studien eingeschlossen werden, wovon 14 die Galaktographie, 10 den US und 5 die MRM beinhalten. Es handelt sich fast ausschließlich um retrospektive Studien mit einem Evidenzgrad von maximal „3b“. Die Zahlen zur diagnostischen Wertigkeit zeigen eine äußerst hohe Spannweite. Aufgrund sehr variabler Fallzahlen und Berücksichtigung verschiedener Pathologien sind die Studien nur eingeschränkt vergleichbar.ZusammenfassungGalaktographie, US und MRM weisen eine schwache Evidenz auf und für kein Verfahren lässt sich eine Überlegenheit ableiten. Die Galaktographie muss somit in der modernen multimodal ausgerichteten Diagnostik nicht mehr als obligater Standard angesehen werden. Empfehlungen zur Abklärung der pathologischen Sekretion müssen in gängige Leitlinien aufgenommen werden und diese Tatsachen berücksichtigen.AbstractBackgroundThe survey results of a previous study showed that galactography is now rarely used in Germany and newer methods are applied. The evidential value of galactography should be established and opposed to the evidential value of ultrasound (US) and magnetic resonance mammography (MRM).Materials and methodsA search was carried out in PubMed and Cochrane involving studies written in English or German. The level of evidence was measured according to the Oxford Centre for Evidence-based Medicine.ResultsA total of 19 studies were included, 14 with results on galactography, 10 on US and 5 on MRM. Almost all studies were retrospective with an evidence assigned to level 3b or lower. The results on the diagnostic values showed a very wide range. Because of very variable numbers of cases and consideration of various pathologies, the studies are only comparable to a limited extent.ConclusionGalactography, US and MRM all show a weak level of evidence and no superiority of a particular method can be derived. Therefore, galactography can no longer be considered as a mandatory standard in modern multimodal imaging of the breast. Recommendations for the diagnostic work-up of pathological nipple discharge have to be included in current guidelines and must consider these facts.BACKGROUND The survey results of a previous study showed that galactography is now rarely used in Germany and newer methods are applied. The evidential value of galactography should be established and opposed to the evidential value of ultrasound (US) and magnetic resonance mammography (MRM). MATERIALS AND METHODS A search was carried out in PubMed and Cochrane involving studies written in English or German. The level of evidence was measured according to the Oxford Centre for Evidence-based Medicine. RESULTS A total of 19 studies were included, 14 with results on galactography, 10 on US and 5 on MRM. Almost all studies were retrospective with an evidence assigned to level 3b or lower. The results on the diagnostic values showed a very wide range. Because of very variable numbers of cases and consideration of various pathologies, the studies are only comparable to a limited extent. CONCLUSION Galactography, US and MRM all show a weak level of evidence and no superiority of a particular method can be derived. Therefore, galactography can no longer be considered as a mandatory standard in modern multimodal imaging of the breast. Recommendations for the diagnostic work-up of pathological nipple discharge have to be included in current guidelines and must consider these facts.

Axillary lymph node characterization in breast cancer patients using magnetic resonance mammography: A prospective comparative study with FDG PET-CT and healthy women

OBJECTIVE The aim of this study was to evaluate the capability of dynamic contrast enhanced MR-mammography (MRM) for the interpretation of axillary lymph nodes (LNs) in patients with breast cancer. MATERIAL AND METHODS 25 patients with breast cancer preoperatively underwent both FDG positron emission computed tomography (PET-CT) and dynamic contrast enhanced MRM. The maximum signal increase (SImax) and curve shape (types I-III) of contrast enhanced LNs ≥ 0.5 cm (short-axis) were analyzed in MRM and correlated to the maximum standard uptake value (SUVmax) of FDG PET-CT. 29 healthy women with MRM served as control group. Enhancement kinetics of all malignant LNs were compared to LN findings of the healthy control group. RESULTS Overall 33 contrast enhanced LNs on preoperative MRM had a corresponding FDG uptake on PET-CT. 30 of the PET positive LNs were classified as surely malignant (mean SUVmax 7.3 (± 5.4)). The mean SImax of these LNs was not significantly different to the control group (222% vs 197%), but malignant LNs had a significantly higher rate of type III curves with rapid washout (93% vs 66%, p = 0.008). CONCLUSION The maximum signal increase is not capable of differentiating malignant from benign axillary LNs. However, since malignant LNs showed a higher frequency of rapid washout curves (type III curves) on corresponding MRM future studies should concentrate on the analysis of this parameter. In clinical routine the curve shape still should be taken with care as there is a high overlap with benign LNs.

Magnetic resonance imaging of intraductal papillomas: typical findings and differential diagnosis.

Objective Even upon core biopsy, accurate classification of benign intraductal papillomas (IPs) can be difficult. Accordingly, IPs are still frequently surgically resected. Therefore, accurate classification of IP by magnetic resonance mammography (MRM) would potentially optimize patient management. However, the few investigations assessing MRM of IP included small patient collectives, and overall accuracy is still unknown. We performed this investigation to analyze the morphologic and dynamic MRM profiles of IP in more detail and to identify the overall accuracy of MRM for differential diagnosis of IP versus malignant breast lesions. Methods Consecutive patients scheduled for MRM (standardized scanning protocols: dynamic T1-weighted gradient echo before/after Gd-DTPA [gadolinium diethylenetriamine pentaacetate; 0.1 mmol/kg body weight]; T2-weighted turbo spin echo) with subsequent surgicopathologic verification were enrolled. For the detailed assessment of morphologic and dynamic profiles, 2 experienced radiologists (>500 MRM examinations; blinded to surgicopathologic verification) performed prospective evaluation of MRM, in consensus, applying 17 predefined MRM descriptors. From this database, all patients showing IP (n = 83) or malignant breast lesions (n = 648) were further evaluated statistically: univariate analyses (association of single descriptors with IP/breast cancer: contingency table statistics) and multivariate analyses were performed to identify accurate descriptor combinations (CHAID [CHi-squared Automatic Interaction Detection]) and overall accuracy of MRM for differential diagnosis of IP versus malignant breast lesions (logistic regression; receiver operating characteristics [ROC], area under the ROC curve). Results There were 82.4% of MRM descriptors significantly associated with IP (n = 14; P < 0.05). The accuracy of single descriptors (odds ratio [OR], ⩽10.6) could be further increased by descriptor combinations (double combination: OR ⩽12.7; triple combination: OR ⩽15.0). With area under the ROC curve = 0.90, there was a high overall accuracy of MRM for the differential diagnosis of IP versus malignant breast lesions. Conclusions A detailed assessment of MRM allows precise characterization of benign IPs and accurate differentiation from malignant breast lesions.

Stellenwert der Galaktographie zur Abklärung pathologischer Sekretion in der komplementären Mammadiagnostik

ZusammenfassungHintergrundDie Galaktographie wird seit Jahrzehnten zur Abklärung der pathologischen Sekretion eingesetzt. Zwischenzeitlich haben sich neuere Verfahren wie der hochauflösende Ultraschall (US) und die MR-Mammographie (MRM) in der multimodalen Mammadiagnostik etabliert. Eine Umfrage an Brustzentren soll klären, inwieweit die Galaktographie oder neuere Verfahren der multimodalen Mammadiagnostik angewandt werden.Material und MethodenEine anonyme Onlineumfrage wurde deutschlandweit an 342 radiologischen Einheiten zertifizierter Brustzentren durchgeführt.ErgebnisseEs nahmen 177 Einheiten (52 %) teil. Dreizehn Prozent bieten keine Galaktographie an, 33 % führen maximal 5 Galaktographien pro Jahr durch, 24 % 6–10, 18 % 11–20, 8 % 21–50 und 5 % 51–100. 53 % siedeln die Methode in der Stufendiagnostik nach dem US und vor der MRM an, 32 % würden auch die MRM vorziehen. Nur 4 % setzen die Galaktographie initial ein.SchlussfolgerungDie Galaktographie ist an den Brustzentren heute kein obligater Standard mehr, und neuere Methoden werden bevorzugt. Es sollte anhand der Literatur überprüft werden, welche Evidenz der Galaktographie im Vergleich zu den anderen Verfahren bei dieser Fragestellung zukommt. Dies wird Thema des zweiten Teils dieser Arbeit sein.AbstractPurposeGalactography has been used in cases of pathological discharge for decades. Meanwhile other methods, such as high-resolution ultrasound (US) and magnetic resonance mammography (MRM) have been established for modern multimodal breast imaging. A survey among certified German breast care centers aimed to investigate to what extent galactography is currently used and whether newer techniques in multimodal imaging are preferred.Materials and methodsAn anonymous online survey was carried out nationwide and open to 342 radiology units in certified German breast care centers.ResultsA total of 177 units (52 %) participated in the survey of which 13 % generally do not provide galactography, 33 % conduct a maximum of 5 galactographies per year, 24 % conduct 6–10, 18 % 11–20, 8 % 21–50 and 5 % 51–100. Of the participants 53 % give first priority to US and prefer galactography to MRM in stepwise diagnosis and 32 % prefer MRM to galactography. Only 4 % use galactography initially.ConclusionCurrently galactography is no longer a mandatory standard and newer methods are preferred. The evidential value of galactography in comparison to other techniques should be established on the basis of the literature. The second part of this paper will deal with this question.

Automated Semi-Quantitative Analysis of Breast MRI: Potential Imaging Biomarker for the Prediction of Tissue Response to Neoadjuvant Chemotherapy

Background: We aimed to investigate an automated semi-quantitative software as an imaging biomarker for the prediction of tissue response (TR) after completion of neoadjuvant chemotherapy (NAC). Methods: Breast magnetic resonance imaging (MRI) (1.5T, protocol according to international recommendations) of 67 patients with biopsy-proven invasive breast cancer were examined before and after NAC. After completion of NAC, histopathologic assessments of TR were classified according to the Chevallier grading system (CG1/4: full/non-responder; CG2/C3: partial responder). A commercially available fully automatic software (CADstream) extracted MRI parameters of tumor extension (tumor diameter/volume: TD/TV). Pre- versus post-NAC values were compared (ΔTV and ΔTD). Additionally, the software performed volumetric analyses of vascularization (VAV) after NAC. Accuracy of MRI parameters to predict TR were identified (cross-tabs, ROC, AUC, Kruskal-Wallis). Results: There were 37 (34.3%) CG1, 7 (6.5%) CG2, 53 (49.1%) CG3, and 11 (10.2%) CG4 lesions. The software reached area under the curve levels of 79.5% (CG1/complete response: ΔTD), 68.6% (CG2, CG3/partial response: VAV), and 88.8% to predict TR (CG4/non-response: ΔTV). Conclusion: Semi-quantitative automated analysis of breast MRI data enabled the prediction of tissue response to NAC.

[Value of galactography for the diagnostic work-up of pathological nipple discharge in multimodal breast diagnostics : Part 1: An online survey among German breast care centers.]

ZusammenfassungHintergrundDie Galaktographie wird seit Jahrzehnten zur Abklärung der pathologischen Sekretion eingesetzt. Zwischenzeitlich haben sich neuere Verfahren wie der hochauflösende Ultraschall (US) und die MR-Mammographie (MRM) in der multimodalen Mammadiagnostik etabliert. Eine Umfrage an Brustzentren soll klären, inwieweit die Galaktographie oder neuere Verfahren der multimodalen Mammadiagnostik angewandt werden.Material und MethodenEine anonyme Onlineumfrage wurde deutschlandweit an 342 radiologischen Einheiten zertifizierter Brustzentren durchgeführt.ErgebnisseEs nahmen 177 Einheiten (52 %) teil. Dreizehn Prozent bieten keine Galaktographie an, 33 % führen maximal 5 Galaktographien pro Jahr durch, 24 % 6–10, 18 % 11–20, 8 % 21–50 und 5 % 51–100. 53 % siedeln die Methode in der Stufendiagnostik nach dem US und vor der MRM an, 32 % würden auch die MRM vorziehen. Nur 4 % setzen die Galaktographie initial ein.SchlussfolgerungDie Galaktographie ist an den Brustzentren heute kein obligater Standard mehr, und neuere Methoden werden bevorzugt. Es sollte anhand der Literatur überprüft werden, welche Evidenz der Galaktographie im Vergleich zu den anderen Verfahren bei dieser Fragestellung zukommt. Dies wird Thema des zweiten Teils dieser Arbeit sein.AbstractPurposeGalactography has been used in cases of pathological discharge for decades. Meanwhile other methods, such as high-resolution ultrasound (US) and magnetic resonance mammography (MRM) have been established for modern multimodal breast imaging. A survey among certified German breast care centers aimed to investigate to what extent galactography is currently used and whether newer techniques in multimodal imaging are preferred.Materials and methodsAn anonymous online survey was carried out nationwide and open to 342 radiology units in certified German breast care centers.ResultsA total of 177 units (52 %) participated in the survey of which 13 % generally do not provide galactography, 33 % conduct a maximum of 5 galactographies per year, 24 % conduct 6–10, 18 % 11–20, 8 % 21–50 and 5 % 51–100. Of the participants 53 % give first priority to US and prefer galactography to MRM in stepwise diagnosis and 32 % prefer MRM to galactography. Only 4 % use galactography initially.ConclusionCurrently galactography is no longer a mandatory standard and newer methods are preferred. The evidential value of galactography in comparison to other techniques should be established on the basis of the literature. The second part of this paper will deal with this question.

The "perirenal edema sign" as a hint towards hypertension--preliminary observations on cofindings in MRI breast cancer staging.

The role of MRI concerning imaging modalities of the breast (MR-mammography: MRM) has over the last 20 years evolved to be increasingly important. So far current ACR guidelines list among the specific indications for breast MRI mainly: 1. Patients after operation or radiation 2. Preoperative staging 3. Cancer of unknown primary (CUP Syndrome) 4. High-Risk patients (e.g. BRCA1 or 2) In case of previous cancer history or the detection of a malignant lesion, a body array coil was placed onto the back of patients in order to cover the upper half of the body from the neck to the upper lumbar region (Fig. 1). By incidental finding, some patients would show diffuse perirenal edema around both kidneys in the T2-weighted images (Fig. 2). Upon inquiry, patients confirmed a history of hypertension. These incidental findings initiated a specific observation with the aim to address the question as to how often this new sign is associated with a hypertensive anamnesis and possibly to explain the pathophysiological background of the finding.

The Assessment of Background Parenchymal Enhancement (BPE) in a High-Risk Population: What Causes BPE?

OBJECTIVE: To investigate promoting factors for background parenchymal enhancement (BPE) in MR mammography (MRM). METHODS: 146 patients were retrospectively evaluated, including 91 high-risk patients (50 BRCA patients, 41 patients with elevated lifetime risk). 56 screening patients were matched to the high-risk cases on the basis of age. The correlation of BPE with factors such as fibroglandular tissue (FGT), age, menopausal status, breast cancer, high-risk precondition as well as motion were investigated using linear regression. RESULTS: BPE positively correlated with FGT (P < .001) and negatively correlated with menopausal status (P < .001). Cancer did not show an effect on BPE (P > .05). A high-risk precondition showed a significant impact on the formation of BPE (P < .05). However, when corrected for motion, the correlation between BPE and a high-risk precondition became weak and insignificant, and a highly significant association between BPE and motion was revealed (P < .01). CONCLUSION: BPE positively correlated with FGT and negatively correlated with age. Cancer did not have an effect on BPE. A high-risk precondition appears to have a negative effect on BPE. However, when corrected for motion, high-risk preconditions became insignificant. Technical as well as physiological influences seem to play an important role in the formation of BPE.

Motion artifacts, lesion type, and parenchymal enhancement in breast MRI: what does really influence diagnostic accuracy?

Background Motion artifacts can reduce image quality of breast magnetic resonance imaging (MRI). There is a lack of data regarding their effect on diagnostic estimates. Purpose To evaluate factors that potentially influence readers’ diagnostic estimates in breast MRI: motion artifacts; amount of fibroglandular tissue; background parenchymal enhancement; lesion size; and lesion type. Material and Methods This Institutional Review Board-approved, retrospective, cross-sectional, single-center study included 320 patients (mean age = 55.1 years) with 334 histologically verified breast lesions (139 benign, 195 malignant) who underwent breast MRI. Two expert breast radiologists evaluated the images considering: motion artifacts (1 = minimal to 4 = marked); fibroglandular tissue (BI-RADS FGT); background parenchymal enhancement (BI-RADS BPE); lesion size; lesion type; and BI-RADS score. Univariate (Chi-square) and multivariate (Generalized Estimation Equations [GEE]) statistics were used to identify factors influencing sensitivity, specificity, and accuracy. Results Lesions were: 230 mass (68.9%) and 59 non-mass (17.7%), no foci. Forty-five lesions (13.5%) did not enhance in MRI but were suspicious or unclear in conventional imaging. Sensitivity, specificity, and accuracy were 93.8%, 83.4%, and 89.8% for Reader 1 and 95.4%, 87.8%, and 91.9% for Reader 2. Lower sensitivity was observed in case of increased motion artifacts (P = 0.007), non-mass lesions (P < 0.001), and small lesions ≤ 10 mm (P < 0.021). No further factors (e.g. BPE, FGT) significantly influenced diagnostic estimates. At multivariate analysis, lesion type and size were retained as independent factors influencing the diagnostic performance (P < 0.033). Conclusion Motion artifacts can impair lesion characterization with breast MRI, but lesion type and small size have the strongest influence on diagnostic estimates.

Differentiation of ductal carcinoma in situ versus fibrocystic changes by magnetic resonance imaging: are there pathognomonic imaging features?

Background In breast magnetic resonance imaging (MRI), the diagnosis of ductal carcinoma in situ (DCIS) remains controversial; the most challenging cause of false-positive DCIS diagnosis is fibrocystic changes (FC). Purpose To search for typical and pathognomonic patterns of DCIS and FC using a standard clinical MRI protocol. Material and Methods Consecutive patients scheduled for breast MRI (standardized protocols @ 1.5T: dynamic-T1-GRE before/after Gd-DTPA [0.1 mmol/kg body weight (BW)]; T1-TSE), with subsequent pathological sampling, were investigated. Sixteen MRI descriptors were prospectively assessed by two experienced radiologists in consensus (blinded to pathology) and explored in patients with DCIS (n = 77) or FC (n = 219). Univariate and multivariate statistics were performed to identify the accuracy of descriptors (alone, combined). Furthermore, pathognomonic descriptor-combinations with an accuracy of 100% were explored (χ2 statistics; decision trees). Results Six breast MRI descriptors significantly differentiated DCIS from FC (Pcorrected < 0.05; odds ratio < 7.9). Pathognomonic imaging features were present in 33.8% (n = 100) of all cases allowing the identification of 42.9% of FC (n = 94). Conclusion Pathognomonic patterns of DCIS and FC were frequently observed in a standard clinical MRI protocol. Such imaging patterns could decrease the false-positive rate of breast MRI and hence might help to decrease the number of unnecessary biopsies in this clinically challenging subgroup.