Julia Krammer

First description of MR mammographic findings in the tumor bed after intraoperative radiotherapy (IORT) of breast cancer

The aim was to investigate changes in the tumor bed on magnetic resonance mammography (MRM) after intraoperative radiotherapy (IORT) and whether they would limit the diagnostic value of posttherapeutic MRM. We retrospectively investigated 36 patients undergoing MRM after IORT (median interval 2.8 years, range 0.4-7.1). Wound cavities with fat necrosis were common after IORT (81%). They were associated with persisting contrast enhancement, i.e., enhancement was mostly seen irrespective of the posttherapeutic interval. It normally presented as rim enhancement and did not cause any diagnostic uncertainty if viewed together with other tissue characteristics. We do not expect a limited diagnostic value of MRM after IORT.

[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.

Characteristics of axillary lymph nodes apparent on dynamic contrast-enhanced breast MRI in healthy women.

The study was initiated to characterize and better understand the natural characteristics of axillary lymph nodes (LNs) apparent on dynamic breast magnetic resonance imaging (MRI). The most important finding in 71 subjects that included healthy women was that 41% showed strong enhanced axillary LNs. The dynamic curves of these LNs revealed an initial mean signal increase of 197% (±58%), all of them with a following plateau (34%) or washout (66%). Our study points out that the previous understanding of contrast enhancement in breast lesions should be taken with care when assessing axillary LNs. This has to be considered especially in preoperative breast MRI.

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.

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.

[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 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.

Impact of Tumor Localization and Method of Preoperative Biopsy on Sentinel Lymph Node Mapping After Periareolar Nuclide Injection.

Background To evaluate whether tumor localization and method of preoperative biopsy affect sentinel lymph node (SLN) detection after periareolar nuclide injection in breast cancer patients. Methods and Findings 767 breast cancer patients were retrospectively included. For lymphscintigraphy periareolar nuclide injection was performed and the SLN was located by gamma camera. Patient and tumor characteristics were correlated to the success rate of SLN mapping. SLN marking failed in 9/61 (14.7%) patients with prior vacuum-assisted biopsy and 80/706 (11.3%) patients with prior core needle biopsy. Individually evaluated, biopsy method (p = 0.4) and tumor localization (p = 0.9) did not significantly affect the SLN detection rate. Patients with a vacuum-assisted biopsy of a tumor in the upper outer quadrant had a higher odds ratio of failing in SLN mapping (OR 3.8, p = 0.09) compared to core needle biopsy in the same localization (OR 0.9, p = 0.5). Conclusions Tumor localization and preoperative biopsy method do not significantly impact SLN mapping with periareolar nuclide injection. However, the failure risk tends to rise if vacuum-assisted biopsy of a tumor in the upper outer quadrant is performed.

The value of “constant sharpness” as a diagnostic sign in MR-Mammography

Purpose To examine “constant lesion sharpness” as a morphological diagnostic sign in the differential diagnosis between benign and malignant lesions. Material and methods This prospective study had institutional review board approval and was HIPAA compliant. In total 1014 consecutive patients were examined (mean age 55 years ± 13 years) and evaluated in our University hospital towards the morphological shape of the lesion borders. The “Constant sharpness Sign” was defined as a lesion remaining continuously sharp for the duration of the dynamic scan. Inclusion criteria were unclear findings (e.g. BIRADS III/IV), Preoperative staging (BRIDAS IV/V), and referred patients from local clinic of gynecology. Exclusion criteria were MRM-examination ≤1 year before, status after surgery and/or biopsy, chemotherapy and/or radiation therapy. Reference Standard was histological verification. Images were diagnosed by two experienced radiologists in consensus, blinded to the standard of reference. Results 1014 patients with 1084 lesions (436 benign, 648 malignant lesions) were included into the study. 41.5% of benign lesions and 6.8% (181/436) of malignant lesions displayed a constant sharpness as an accompanying morphological sign (P < 0.001). This resulted in a sensitivity of 41.5%, specificity of 93.2%, a positive likelihood ratio of 6.1%, a negative likelihood ratio of 0.63 and an odd’s ratio of 9,7%. Summary and conclusion The constant sharpness sign seems to be an accurate predictor of benign breast lesions, which may help to increase the accuracy of MRM as a morphological sign.