Hyeong-Gon Moon

Clinical application of shear wave elastography (SWE) in the diagnosis of benign and malignant breast diseases

Shear wave elastography (SWE) is an emerging technique which can obtain quantitative elasticity values in breast disease. We therefore evaluated the diagnostic performance of SWE for the differentiation of breast masses compared with conventional ultrasound (US). Conventional US and SWE were performed by three experienced radiologists for 158 consecutive women who had been scheduled for US-guided core biopsy or surgical excision in 182 breast masses (89 malignancies and 93 benign; mean size, 1.76xa0cm). For each lesion, quantitative elasticity was measured in terms of the Young’s modulus (in kilopascals, kPa) with SWE, and BI-RADS final categories were assessed with conventional US. The mean elasticity values were significantly higher in malignant masses (153.3xa0kPaxa0±xa058.1) than in benign masses (46.1xa0kPaxa0±xa042.9), (Pxa0<xa00.0001). The average mean elasticity values of invasive ductal (157.5xa0±xa057.07) or invasive lobular (169.5xa0±xa061.06) carcinomas were higher than those of ductal carcinoma in situ (117.8xa0kPaxa0±xa054.72). The average mean value was 49.58xa0±xa043.51 for fibroadenoma, 35.3xa0±xa031.2 for fibrocystic changes, 69.5xa0±xa063.2 for intraductal papilloma, and 149.5xa0±xa0132.4 for adenosis or stromal fibrosis. The optimal cut-off value, yielding the maximal sum of sensitivity and specificity, was 80.17xa0kPa, and the sensitivity and specificity of SWE were 88.8% (79 of 89) and 84.9% (79 of 93). The area under the ROC curve (Az value) was 0.898 for conventional US, 0.932 for SWE, and 0.982 for combined data. In conclusion, there were significant differences in the elasticity values of benign and malignant masses as well as invasive and intraductal cancers with SWE. Our results suggest that SWE has the potential to aid in the differentiation of benign and malignant breast lesions.

Age and HER2 expression status affect MRI accuracy in predicting residual tumor extent after neo-adjuvant systemic treatment

BACKGROUNDnAlthough recent studies suggest high accuracy of breast magnetic resonance imaging (MRI) in predicting residual tumor extent after neo-adjuvant systemic treatment (NST), its use is still controversial. In this study, we aimed to identify predictive factors of MRI accuracy after NST to determine a subgroup of patients in whom the use of MRI provides best additional benefit.nnnMATERIALS AND METHODSnClinicopathologic and molecular profiles of breast cancer patients were investigated and their relationships with MRI accuracy were analyzed.nnnRESULTSnFrom January 2006 to February 2008, 195 patients received NST and preoperative MRI. In overall, MRI predicted residual tumor extent with higher accuracy than ultrasonography. Triple-negative (TN) tumors showed highest correlation between MRI-measured and pathologic tumor size (r = 0.781) when compared with other subtypes. Multivariate analysis showed age and HER2 expression status as independent factors predicting MRI accuracy. When patients were classified based on their age and HER2 status, relatively older patients (>45) with HER2-negative tumors showed highest MRI accuracy. This finding was further validated using an independent cohort of 63 consecutive patients.nnnCONCLUSIONnAge and HER2 status independently affected MRI accuracy after NST. This observation may guide more tailored approach in using MRI in breast cancer patients undergoing NST.

Limited value and utility of breast MRI in patients undergoing breast-conserving cancer surgery.

BackgroundOur aim was to compare the accuracy of magnetic resonance imaging (MRI) and ultrasonography (US) in measuring the size of invasive breast cancer (IBC) and carcinoma in situ (CIS). We also examined the utility of routinely performing MRI in addition to US before breast-conserving surgery (BCS).Patients and MethodsData from 1558 consecutive patients diagnosed with IBC and/or CIS between 2003 and 2005 were reviewed. For comparing the accuracy of US and MRI, paired t test was done comparing pathologic and imaging (US and MRI) tumor size in 821 patients who received both breast US and MRI. In instance of attempted BCS (nxa0=xa0794), operative approach, resection margins, and clinical outcomes of non-MRI and MRI groups were compared.ResultsFor CIS, IBC without CIS, and IBC with CIS, MRI was more accurate in estimating tumor size than US. When BCS was attempted (nxa0=xa0794), the rate of tumor involvement in initial resection margins did not differ between non-MRI and MRI groups (23.0% and 23.4%, Pxa0=xa0.926). Similarly, rates of re-excision (13.1% vs 17.5%, Pxa0=xa0.130) and conversion to mastectomy (2.3% vs 2.1%, Pxa0=xa0.893) were comparable, as were ipsilateral breast tumor recurrence, locoregional recurrence, and disease-free survival (log rank Pxa0=xa0.284, .950, and .955, respectively).ConclusionsBreast MRI provided more accurate estimates of tumor size, correlating better with pathologic tumor size than US for both IBC and CIS. However, no clear benefit in terms of lower re-excision rate, higher breast conservation success, or reduced recurrence emerged for routine use of breast MRI before BCS.

Prognostic influence of BCL2 expression in breast cancer

Although BCL2 has occasionally been suggested as a candidate prognostic factor for breast cancer, it is still not accepted as a prognostic factor. We attempted to validate the role of BCL2 as a prognostic factor of breast cancer. Data on 7,230 primary breast cancer patients from the Seoul National University Hospital Breast Care Center were analyzed. Three current prognostic models, including the St. Gallen model, the Nottingham prognostic index (NPI) model and the TNM model, were used for analysis of the prognostic influence of BCL2. The positive BCL2 group showed more favorable features with regard to clinicopathologic parameters than the BCL2 negative group and a strong correlation was observed between BCL2 and the hormonal receptor. The positive BCL2 group showed better prognosis in overall survival and disease free survival (log‐rank test, both p < 0.001), even in all subgroups, than the BCL2 negative group. BCL2 was a significant prognostic factor in both univariate (hazard ratio [HR], 0.361; 95% confidence interval (CI), 0.306–0.426; p < 0.001) and multivariate analyses (HR, 0.417; 95% CI, 0.417–0.705; p < 0.001). BCL2 had a strong influence on the established prognostic models, including the St. Gallen model, the NPI model and the TNM model. BCL2 was a powerful independent prognostic factor for breast cancer and had a strong influence on the current prognostic models. Favorable clinicopathologic features and a strong correlation with the hormonal receptor are suggested as the causes of superior survival in patients with BCL2 positive breast cancer.

Breast-Conserving Surgery After Tumor Downstaging by Neoadjuvant Chemotherapy is Oncologically Safe for Stage III Breast Cancer Patients

BackgroundWe conducted a retrospective study to evaluate the local recurrence (LR) rate depending on the use of neoadjuvant chemotherapy (NCT) and to determine the oncologic safety of breast-conserving surgery (BCS) after NCT by comparing LR between patients treated with BCS and mastectomy in clinical stage III breast cancer patients.Patients and MethodsBetween 2004 and 2007, 166 patients underwent BCS or mastectomy after NCT (NCT group) and 193 patients underwent surgery first (surgery group) in clinical stage III breast cancer patients. Patients whose tumor size became ≤4xa0cm after NCT, 57 patients underwent mastectomy (mastectomy group) 39 patients underwent preplanned BCS (preplanned BCS group), and 33 patients underwent downstaged BCS (downstaged BCS group). The recurrence rates between the groups and risk factors for LR were analyzed.ResultsThe 5-year LR-free survival rates were 93.6xa0% in the NCT group and 95.9xa0% in the surgery group (Pxa0=xa00.108). In the NCT group, the 5-year LR-free survival rates were 96.3xa0% in the mastectomy group, 94.7xa0% in the preplanned BCS group and 90.9xa0% in the downstaged BCS group (Pxa0=xa00.669). High expression of Ki-67 was a predictor of LR in patients in three groups (Hazard ratio 8.300, Pxa0=xa00.049).ConclusionsOur findings suggest that BCS after NCT in clinical stage III patients is oncologically safe in terms of LR if breast tumor size is ≤4xa0cm after NCT and Ki-67 is a predictor of LR after NCT.

Adenoid cystic carcinoma of the breast: a case series of six patients and literature review.

Adenoid cystic carcinoma (ACC) of the breast is a very rare and indolent tumor with a favorable prognosis, despite its triple-negative status. Due to its rarity, there has been no consensus regarding treatments, and treatment guidelines have not been established. Here, we report on six patients with ACC of the breast. All of the patients initially presented with localized disease and no axillary lymph node metastases. Although some of our patients developed local recurrence or distant metastases, all patients had a favorable clinical course, and to date, none of the patients has died from complications of her disease. Here, we described the clinicopathologic features of ACC of the breast and review the current literature.

Evaluation of tumor extent in breast cancer patients using real-time MR navigated ultrasound: Preliminary study

OBJECTIVESnTo evaluate the accuracy of real-time MR navigated ultrasound (MRnav US) for tumor extent measurements in breast cancer and to investigate variables influencing the accuracy of MRnav US in comparison with US alone.nnnMETHODSnFifty-three patients with 60 malignancies underwent preoperative breast MRI and US with or without MRI navigation. Maximum lesion sizes based on MRnav US and US alone were measured, and their relationship with the pathology was analyzed considering the differences in the clinicopathologic variables of the patients.nnnRESULTSnAmong 60 breast cancers, mean lesion size at initial breast US without MRI navigation and at MRI-navigated US was 19 mm and 24 mm, respectively, compared with 28 mm on the histopathology. Overall, the tumor size estimated with MRnav US was more strongly correlated with the histologic tumor size than with US alone. Accurate measurements by MRnav US were significantly more frequent in the lesions that were presented as a mass type on MRI. In addition, the accurate measurement of mass extent was improved with MRnav US in patients who had non-mass type lesions on MRI and who had undergone neoadjuvant systemic chemotherapy when compared with US alone.nnnCONCLUSIONnMRnav US was more accurate for tumor extent estimation than US alone, and specific clinicopathologic variables can affect the accuracy of MRnav US.

Low rates of additional cancer detection by magnetic resonance imaging in newly diagnosed breast cancer patients who undergo preoperative mammography and ultrasonography.

Purpose We evaluated the efficacy of breast magnetic resonance imaging (MRI) for detecting additional malignancies in breast cancer patients newly diagnosed by breast ultrasonography and mammography. Methods We retrospectively reviewed the records of 1,038 breast cancer patients who underwent preoperative mammography, bilateral breast ultrasonography, and subsequent breast MRI between August 2007 and December 2010 at single institution in Korea. MRI-detected additional lesions were defined as those lesions detected by breast MRI that were previously undetected by mammography and ultrasonography and which would otherwise have not been identified. Results Among the 1,038 cases, 228 additional lesions (22.0%) and 30 additional malignancies (2.9%) were detected by breast MRI. Of these 228 lesions, 109 were suspected to be malignant (Breast Imaging-Reporting and Data System category 4 or 5) on breast MRI and second-look ultrasonography and 30 were pathologically confirmed to be malignant (13.2%). Of these 30 lesions, 21 were ipsilateral to the main lesion and nine were contralateral. Fourteen lesions were in situ carcinomas and 16 were invasive carcinomas. The positive predictive value of breast MRI was 27.5% (30/109). No clinicopathological factors were significantly associated with additional malignant foci. Conclusion Breast MRI was useful in detecting additional malignancy in a small number of patients who underwent ultrasonography and mammography.

Comparison of the diagnostic performance of digital breast tomosynthesis and magnetic resonance imaging added to digital mammography in women with known breast cancers.

AbstractObjectivesTo compare the diagnostic performance of digital breast tomosynthesis (DBT) and magnetic resonance imaging (MRI) added to mammography in women with known breast cancers.MethodsThree radiologists independently reviewed image sets of 172 patients with 184 cancers; mammography alone, DBT plus mammography and MRI plus mammography, and scored for cancer probability using the Breast Imaging Reporting and Data System (BI-RADS). Jack-knife alternative free-response receiver-operating characteristic (JAFROC), which allows diagnostic performance estimation using single lesion as a statistical unit in a cancer-only population, was used. Sensitivity and positive predictive value (PPV) were compared using the McNemar and Fisher-exact tests.ResultsThe JAFROC figures of merit (FOMs) was lower in DBT plus mammography (0.937) than MRI plus mammography (0.978, Pu2009=u20090.0006) but higher than mammography alone (0.900, Pu2009=u20090 .0013). The sensitivity was lower in DBT plus mammography (88.2xa0%) than MRI plus mammography (97.8xa0%) but higher than mammography alone (78.3xa0%, both Pu2009<u20090 .0001). The PPV was significantly higher in DBT plus mammography (93.3xa0%) than MRI plus mammography (89.6xa0%, Pu2009=u20090 .0282).ConclusionsDBT provided lower diagnostic performance than MRI as an adjunctive imaging to mammography. However, DBT had higher diagnostic performance than mammography and higher PPV than MRI.Key Points• Digital breast tomosynthesis (DBT) plus mammography was compared with MRI plus mammography.n • DBT had lower sensitivity and higher PPV than MRI.n • DBT had higher diagnostic performance than mammography.

Residual Mammographic Microcalcifications and Enhancing Lesions on MRI After Neoadjuvant Systemic Chemotherapy for Locally Advanced Breast Cancer: Correlation with Histopathologic Residual Tumor Size

PurposeTo evaluate the accuracy of residual microcalcifications on mammogram (MG) in predicting the extent of the residual tumor after neoadjuvant systemic treatment (NST) in patients with locally advanced breast cancer and to evaluate factors affecting the accuracy of MG microcalcifications using magnetic resonance imaging (MRI) as a reference.MethodsThe patients who underwent NST and showed suspicious microcalcifications on MG comprised our study population. Clinicopathologic and imaging (MG, MRI) findings were investigated. Agreement between image findings and pathology was assessed and factors affecting the discrepancy were analyzed.ResultsAmong 207 patients, 196 had residual invasive ductal carcinoma or ductal carcinoma-in-situ (mean size, 3.78xa0cm). The overall agreement of residual microcalcifications on MG predicting residual tumor extents was lower than MRI in all tumor subtypes (intraclass correlation coefficient [ICC]xa0=xa00.368 and 0.723, pxa0<xa00.0001). The agreement of residual MG microcalcifications and pathology was highest in HR+/HER2+ tumors and lowest in the triple-negative tumors (ICCxa0=xa00.417 and 0.205, respectively). Multivariate linear regression analysis revealed that a size discrepancy between microcalcifications and histopathology was correlated with molecular subtype (pxa0=xa00.005). In HR+/HER2− and triple-negative subtypes, the mean extents of residual microcalcification were smaller than residual cancer, and overestimation of tumor extent was more frequent in HR+/HER2+ and HR−/HER2+ tumors.ConclusionsThe extent of microcalcifications on MG after NST showed an overall lower correlation with the extent of the pathologic residual tumor than enhancing lesions on MRI. The accuracy of residual tumor evaluation after NST with MG and MRI is affected by their molecular subtype.