I. Biltjes

MR mammography in the pre-operative staging of breast cancer in patients with dense breast tissue: comparison with mammography and ultrasound

The aim of this study was to determine whether pre-operative MR mammography could predict the extent of breast cancer in patients with dense breasts or whether dense parenchyma will lead to false-positive or inconclusive examinations. Sixty-seven patients with dense breasts with a malignant breast tumor planned for conservative surgery were reviewed. Detection rates of mammography, ultrasound, and MR mammography were studied, and the diameters of the lesions were measured and compared with pathological examination. Pathology revealed breast cancer in 65 patients. Sensitivity for detection of index lesions was 83% for mammography, 70.8% for ultrasound, and 98% for MR mammography. Mammography underestimated tumor extent in 37%, ultrasound in 40%, and MR in 12.5%. Of the 20 patients (31%) with multifocal or multicentric carcinoma, mammography detected the lesions in 35%, ultrasound in 30%, and MR in 100%, with a false-positive rate of 12.5, 14, and 23%. The MR mammography is more accurate in assessing tumor extent and multifocality in patients with dense breasts, but benign changes may lead to false-positive examinations.

Preoperative breast MRI in patients with invasive lobular breast cancer

To investigate the use of MRI in preoperative characterization of invasive lobular breast cancer (ILC) and in detection of multifocal/multicentric disease. We retrospectively reviewed T1-weighted FLASH 3D precontrast and postcontrast MR images together with subtraction images of 26 women with histopathologically proven invasive lobular cancer. Two experienced radiologists described tumor patterns of ILC independently. MR findings of unifocal, multifocal, single quadrant and multiquadrant disease were correlated with results of other imaging techniques and compared with histopathological findings as gold standard. Most ILC presented on MRI as a single spiculated/irregular, inhomogeneous mass (pattern 1, n=12) or as a dominant lesion surrounded by multiple small enhancing foci (pattern 2, n=8). Multiple small enhancing foci with interconnecting enhancing strands (pattern 3) and an architectural distortion (pattern 4) were both described in three cases. There was one case of a focal area of inhomogeneous enhancement (pattern 5) and one normal MR examination (pattern 6). Unifocal and multifocal lesions were identified on MRI in four patients with normal conventional imaging. In nine women, multiple additional lesions or more extensive multiquadrant disease were correctly identified only on MRI. MRI may play an important role in the evaluation of patients with ILC, which is often difficult to diagnose on clinical examination and conventional imaging and more likely occur in multiple sites and in both breasts. However, false-negative MR findings do occur in a small percentage of ILC.

MRI after successful lumbar discectomy

Our aim was to establish the normal range of MRI findings after successful lumbar discectomy. We prospectively examined 34 consecutive patients with an excellent clinical outcome by MRI 6 weeks and 6 months after surgery. All examinations included sagittal and axial spin-echo (SE) T1-weighted images before and after intravenous gadolinium-DTPA and fast SE T2-weighted images. Contrast enhancement along the surgical tract was seen in all patients 6 weeks and 6 months after surgery. After 6 months minimal or no mass effect on the dural sac by epidural scar was seen. In 20% of patients there was recurrent disc herniation, with mass effect. Enhancing nerve roots were seen in 20% of patients 6 weeks postoperatively, and half of these were associated with recurrent disc herniation at the same side. None of these patients still showed nerve root enhancement 6 months after surgery. Postoperative MRI studies must be interpreted with great care since the features described in the failed back surgery syndrome are also found, to some extent, in asymptomatic postoperative patients.

Role of Mri of the breast in the evaluation of the symptomatic patient

Purpose of review The role of MRI in breast pathology is still controversial. The technique has a high sensitivity for detection of breast carcinoma, but specificity is low. Therefore, it is only useful for right indications. Recent findings Studies are still performed to define the role of MRI. For diagnosis of a breast lesion, image-guided percutaneous core biopsy is the method of choice, and MRI is not indicated. It has a place in the detection of carcinoma in patients with nipple discharge. MRI has a role in the search of an occult primary breast carcinoma in patients with metastasis and primary unknown cancer. MRI is the best technique for locoregional staging of breast carcinoma. Its role in detection of recurrence is controversial, as image-guided biopsy has to be done if a suspicious lesion is seen. In dense breasts or difficult scar formation, MRI is able to detect recurrence. MRI is sensitive in detection of implant rupture in symptomatic augmented patients. Summary MRI has a role in well defined indications, but its role is still controversial even in some of these indications. MRI is not indicated in diagnosis in which image-guided percutaneous biopsy is the method of choice. Further studies must be performed.

MR is/is not a useful diagnostic tool for breast cancer management.

Dynamic Magnetic Resonance Imaging (MRI) of the breast has become an important complementary examination in breast cancer management, thanks to its high sensitivity of 98% for invasive breast cancer and of 80% for ductal carcinoma in situ (DCIS) (1-2). MR mammography is based on the enhancement of lesions after contrast injection. Interpretation of MR images is based on the morphology and dynamics of enhancement. As benign lesions also may enhance, specificity is low, with variable reported rates of 37-97%. Therefore, it may only be performed for selected indications.

MR mammography of a primary squamous cell carcinoma of the breast: a case report

A case of a primary squamous cell carcinoma of the breast in a patient with synchronous contralateral invasive ductal adenocarcinoma is reported. To our knowledge, no dynamic MR mammography of this pathology is described in the literature. On MR, it presented as a mainly non-enhancing, partially cystic mass with an enhancing irregular peripheral rim. In the differential diagnosis of a mass with unsharp margins and an irregular border of the cystic or the non-enhancing area on MR mammography, a primary squamous cell carcinoma must be included.

The fibrotic focus in MR-mammography.

A fibrotic focus (FF) is defined as a scar-like area, consisting mainly of fibroblasts and collagen fibres, that occupies various percentages of the centre of an invasive ductal carcinoma of the breast [1]. It shows many similarities with granulation tissue and subsequent scar-formation in wound repair and can be regarded as a focus of exaggerated reactive vascular stroma formation in a tumor [2]. It was first proposed in 1996 by Hasebe et al. as an indicator of tumor aggressiveness and subsequently confirmed as an independent prognostic factor in a prospective study of 439 patients [3]. It is correlated with tumor size, higher histological grade, higher frequency of tumor necrosis, c-erbB-2 overexpression, higher pathological stage, higher frequency of cases with more than three positive lymph node metastases and decreased shortand longterm survival [4,5]. FF characteristics can be the most important histologic factors for predicting metastasis to the bone [6]. Colpaert et al. have confirmed the independent prognostic significance of the FF, especially in early stage breast cancer [7]. Additionally they showed that the relative size (fibrotic focus/tumor ratio) of the FF is important for patient’s outcome and they emphasized the possible use of FF as a surrogate for quantifying angiogenesis [8]. FF is mentioned as a prognostic parameter in the WHO book on breast pathology [9]. Therefore, pre-operative detection of an FF could be important in planning the type of therapy in patients who will receive neoadjuvant therapy. Jitsuiki et al. reported that the presence of an FF was associated with a high microvessel density in both central and peripheral areas of the tumor and that microvessel count (MVC) significantly increased from the central to the peripheral zones in invasive ductal carcinoma [10]. In dynamic MR-mammography, lesion detection is based on enhancement of lesions after contrast injection. Degree of enhancement and enhancement pattern (homogeneous, non homogeneous or peripheral enhancement) largely depend on microvascular amount, density and distribution [11,12].