F. Thibault

Magnetic resonance imaging of the breast: Recommendations from the EUSOMA working group

The use of breast magnetic resonance imaging (MRI) is rapidly increasing. EUSOMA organised a workshop in Milan on 20-21st October 2008 to evaluate the evidence currently available on clinical value and indications for breast MRI. Twenty-three experts from the disciplines involved in breast disease management - including epidemiologists, geneticists, oncologists, radiologists, radiation oncologists, and surgeons - discussed the evidence for the use of this technology in plenary and focused sessions. This paper presents the consensus reached by this working group. General recommendations, technical requirements, methodology, and interpretation were firstly considered. For the following ten indications, an overview of the evidence, a list of recommendations, and a number of research issues were defined: staging before treatment planning; screening of high-risk women; evaluation of response to neoadjuvant chemotherapy; patients with breast augmentation or reconstruction; occult primary breast cancer; breast cancer recurrence; nipple discharge; characterisation of equivocal findings at conventional imaging; inflammatory breast cancer; and male breast. The working group strongly suggests that all breast cancer specialists cooperate for an optimal clinical use of this emerging technology and for future research, focusing on patient outcome as primary end-point.

Dual-energy contrast-enhanced digital mammography: initial clinical results of a multireader, multicase study

IntroductionThe purpose of this study was to compare the diagnostic accuracy of dual-energy contrast-enhanced digital mammography (CEDM) as an adjunct to mammography (MX) ± ultrasonography (US) with the diagnostic accuracy of MX ± US alone.MethodsOne hundred ten consenting women with 148 breast lesions (84 malignant, 64 benign) underwent two-view dual-energy CEDM in addition to MX and US using a specially modified digital mammography system (Senographe DS, GE Healthcare). Reference standard was histology for 138 lesions and follow-up for 12 lesions. Six radiologists from 4 institutions interpreted the images using high-resolution softcopy workstations. Confidence of presence (5-point scale), probability of cancer (7-point scale), and BI-RADS scores were evaluated for each finding. Sensitivity, specificity and ROC curve areas were estimated for each reader and overall. Visibility of findings on MX ± CEDM and MX ± US was evaluated with a Likert scale.ResultsThe average per-lesion sensitivity across all readers was significantly higher for MX ± US ± CEDM than for MX ± US (0.78 vs. 0.71 using BIRADS, p = 0.006). All readers improved their clinical performance and the average area under the ROC curve was significantly superior for MX ± US ± CEDM than for MX ± US ((0.87 vs 0.83, p = 0.045). Finding visibility was similar or better on MX ± CEDM than MX ± US in 80% of cases.ConclusionsDual-energy contrast-enhanced digital mammography as an adjunct to MX ± US improves diagnostic accuracy compared to MX ± US alone. Addition of iodinated contrast agent to MX facilitates the visualization of breast lesions.

Élastosonographie du sein : étude prospective de 122 lésions

Resume Objectif Evaluer l’elastosonographie dans la caracterisation des nodules mammaires Materiel et methodes L’elastosonographie (appareil Hitachi, sonde de 7,5-13 Mhz, classification de Ueno, scores 1-3 = benin et 4-5 = malin) a ete evaluee dans 125 lesions infra-cliniques chez 114 patientes. Les resultats ont ete compares a ceux des categories BI-RADS-echographie de l’ACR (benin = 2 et 3, malin = 4 et 5) et aux resultats des prelevements percutanes et/ou de la chirurgie (122 lesions evaluees, 59 % Resultats Il y a eu 3 echecs de la technique (2,4 %). L’elastographie etait concordante avec l’histologie pour 101 lesions, avec 13 faux negatifs et 8 faux positifs (sensibilite : 78,7 %, specificite : 86,9 %, VPP : 85,7 %, VPN : 80,3 %) ; versus pour la classification BI-RADS une concordance pour 98 lesions avec 1 faux negatif et 23 faux positifs (sensibilite : 98,4 %, specificite : 47,5 %, VPP : 65,2 %, VPN : 96,7 %). Conclusion L’elastographie est une methode complementaire simple et rapide permettant d’augmenter la specificite et la VPP de l’imagerie morphologique dans les nodules peu suspects (categories BI-RADS 3 et 4a) ce qui devrait diminuer le taux de prelevements benins inutiles.

Intraoperative Ultrasound Localization of Nonpalpable Breast Cancers

BackgroundPreoperative localization of nonpalpable breast cancers requires good coordination between imaging and surgery departments, and insertion of a guide wire can be traumatic for the patient. This study was designed to evaluate the efficacy of intraoperative ultrasound localization of nonpalpable breast cancers directly by the surgeon.MethodsThis prospective study was conducted from June 2006 to October 2006 in 70 patients who underwent surgery for nonpalpable invasive breast cancer. Ultrasound was performed in the operating room by the surgeon with the patient in the operative position. Tumor identification, the correlation with tumor diameter on preoperative ultrasound, analysis of resection margins, and the need to perform surgical re-excision were analyzed.ResultsIntraoperative ultrasound identified the target in 67 (95.7%) of 70 patients. Two of the three lesions not detected by intraoperative ultrasound were ≤5 mm in diameter in patients with a body mass index of ≥25 (normal range, 19–24). The correlation with diagnostic ultrasound for tumor dimensions was satisfactory (correlation coefficient r = .80). Resection margins free of invasive lesions were obtained in 66 cases (94.3%). Three patients (4.3%) required surgical re-excision, one mastectomy due to multifocal cancer, and two lumpectomy due to positive resection margins.ConclusionsIntraoperative ultrasound localization of nonpalpable breast cancers is feasible and effective, with a sensitivity of 98.3% for tumors >5 mm. It spares the patient the discomfort of a radiological and/or supplementary examination with insertion of a guide wire. It also saves time and money for hospital teams.

Digital detectors for mammography: the technical challenges

This paper reviews the different techniques available and competing for full-field digital mammography. The detectors are described in their principles: photostimulable storage phosphor plates inserted as a cassette in a conventional mammography unit, dedicated active matrix detectors (i.e., flat-panel, thin-film transistor-based detectors) and scanning systems, using indirect and direct X-ray conversion. The main parameters that characterize the performances of the current systems and influence the quality of digital images are briefly explained: spatial resolution, detective quantum efficiency and modulation transfer function. Overall performances are often the result of compromises in the choice of technology.

Monitoring therapeutic efficacy in breast carcinomas

The aim of imaging during and after neoadjuvant therapy is to document and quantify tumor response: has the tumor size been accurately measured? Certainly, the most exciting information for the oncologists is: can we identify good or nonresponders, and can we predict the pathological response early after the initiation of treatment? This review article will discuss the role and the performance of the different imaging modalities (mammography, ultrasound, magnetic resonance imaging and FDG-PET imaging) for evaluating this therapeutic response. It is important to emphasize that, at this time, clinical examination and conventional imaging (mammography and ultrasound) are the only methods recognized by the international criteria. Magnetic resonance imaging and FDG-PET imaging are very promising for predicting the response early after the initiation of neoadjuvant chemotherapy.

How to optimize breast ultrasound

Breast cancer is the most common female cancer, and the second cause of cancer-related mortality of women in our society. Mammography is the gold-standard method of breast imaging. However it is not an optimal screening tool, especially in cases of dense breast parenchyma. Even when optimally performed, its sensitivity ranges between 69 and 90%. Ultrasound represents an additional diagnostic tool that raises the detection rate of benign and malignant breast lesions. It is the method of choice for differentiating solid from cystic lesions, for further characterizing mammographic findings and better appreciating palpable breast lesions. B-mode ultrasonography is used in every day practice. Harmonic imaging and compound imaging can be used to ameliorate the image contrast and resolution. Colour Doppler is used for studying lesion vascularization however there is no consensus as to whether it really permits to differentiate malignancies from benign lesions. New technical developments such as breast elastography, 3D ultrasound and dedicated ultrasound computed aided diagnosis (CAD) are promising methods for the future.

Contrast enhanced spectral mammography: better than MRI?

The initial method developed for contrast enhanced mammography used temporal acquisitions of high-energy images before and after intravenous injection of iodinated contrast medium [1–4]. The patient had to be primarily positioned for breast compression, using minimal pressure not to alter diffusion of contrast agent. A baseline image (mask) was obtained before injection. Following contrast administration, serial images were acquired over several minutes. Logarithmic subtraction of pre and post-contrast images was applied. Initial experience with such dynamic imaging showed the clinical feasibility of the technique. Further work investigated the diagnostic benefits offered by this modality over conventional mammography, showing a gain in sensitivity for the detection of cancer particularly in dense breasts [4]. The technique, however, proved sensitive to motion artifacts. It also posed the issue of the additional radiation exposure applied for an examination limited to one breast at a time in a single projection view. The second method developed for contrast enhanced mammography was based on dual energy acquisition. Physical and clinical research currently focuses on this technology also referred to as spectral imaging or contrast enhanced spectral mammography (CESM). To allow visualization of low concentration of iodine with only a modest increase in radiation exposure, the x-ray spectrum delivers energies just above the K-edge of iodine (33.2 keV) while using a high voltage range of 45–50kVp [5]. In that setting the patient receives contrast administration first and then is positioned for mammography with normal compression of the breast. A typical protocol goes from obtaining the mediolateral oblique (MLO) view on one breast – typically 2 min after the start of injection – to the MLO view on the other breast, then from the craniocaudal (CC) view on the first side – 4 min after the start of injection – to the CC view on the other side. For each view, a pair of low and highenergy images is acquired. The two images are combined so that the areas of iodine enhancement are highlighted from background parenchyma. Two views of both breasts can be obtained after a single injection of contrast medium.

Digital breast tomosynthesis versus mammography and breast ultrasound: a multireader performance study.

AbstractObjectivesTo compare the diagnostic performance of single-view breast tomosynthesis (BT) with that of dual-view mammography (MX); to assess the benefit of adding the craniocaudal (CC) mammographic view to BT, and of adding BT to MX plus breast ultrasound, considered to be the reference work-up.MethodsOne hundred and fifty-five consenting patients with unresolved mammographic and/or ultrasound findings or breast symptoms underwent conventional work-up plus mediolateral oblique-view BT of the affected breast. The final study set in 130 patients resulted in 55 malignant and 76 benign and normal cases. Seven breast radiologists rated the cases through five sequential techniques using a BIRADS-based scale: MX, MX + ultrasound, MX + ultrasound + BT, BT, BT + MX(CC). Multireader, multicase receiver operating characteristic (ROC) analysis was performed and performance of the techniques was assessed from the areas under ROC curves. The performance of BT and of BT + MX(CC) was tested versus MX; the performance of MX + ultrasound + BT tested versus MX + ultrasound.ResultsTomosynthesis was found to be non-inferior to mammography. BT + MX(CC) did not appear to be superior to MX, and MX + ultrasound + BT not superior to MX + ultrasound.ConclusionsOverall, none of the five techniques tested outperformed the others. Further clinical studies are needed to clarify the role of BT as a substitute for traditional work-up in the diagnostic environment.Key Points• Digital breast tomosynthesis is a new adjunct to mammography and breast ultrasound. • We compared the diagnostic performance of these investigations in an experimental observer study. • Single-view breast tomosynthesis was confirmed as non-inferior to dual-view mammography. • None of the investigations (or combinations) tested outperformed the others. • Further prospective studies are needed to clarify precise role of tomosynthesis for diagnostic application.

Preoperative radio-chemotherapy in early breast cancer patients: long-term results of a phase II trial.

PURPOSE This phase II trial aimed to investigate the efficacy of concurrent radio- (RT) and chemotherapy (CT) in the preoperative setting for operable, non-metastatic breast cancer (BC) not amenable to initial breast-conserving surgery (BCS). PATIENTS AND METHODS From 2001 to 2003, 59 women were included. CT consisted of four cycles of 5-FU, 500 mg/m(2)/d, continuous infusion (d1-d5) and vinorelbine, 25 mg/m(2) (d1 and d6). Starting concurrently with the second cycle, RT delivered 50 Gy to the breast and 46 Gy to the internal mammary and supra/infra-clavicular areas. Breast surgery and lymph node dissection were then performed. Adjuvant treatment consisted of a 16 Gy boost to the tumor bed after BCS, FEC (four cycles of fluorouracil 500 mg/m(2), cyclophosphamide 500 mg/m(2), and epirubicin 100 mg/m(2), d1; d21) for pN1-3 and hormone-therapy for positive hormone receptors BC. RESULTS The in-breast pathological complete response rate was 27%. BCS was performed in 41 (69%) pts. Overall and distant-disease free survivals at 5 years were respectively 88% [95% CI 80-98] and 83% [95% CI 74-93] whereas locoregional and local controls were 90% [95% CI 82-97] and 97% [95% CI 92-100]. Late toxicity (CTCAE-V3) was assessed in 51 pts (86%) with a median follow-up of 7 years [5-8]. Four (8%) experienced at least one grade III toxicities (one telangectasia and three fibroses). Cosmetic results, assessed in 35 of the 41 pts (85%) who retained their breasts, were poor in four pts (11%). CONCLUSION Preoperative concurrent administration of RT and CT is an effective regimen. Long-term toxicity is moderate. This association deserves further evaluations in prospective trials.