M. Van Goethem

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.

Pre-treatment differences and early response monitoring of neoadjuvant chemotherapy in breast cancer patients using magnetic resonance imaging: a systematic review.

ObjectivesTo assess whether magnetic resonance imaging (MRI) can identify pre-treatment differences or monitor early response in breast cancer patients receiving neoadjuvant chemotherapy.MethodsPubMed, Cochrane library, Medline and Embase databases were searched for publications until January 1, 2012. After primary selection, studies were selected based on predefined inclusion/exclusion criteria. Two reviewers assessed study contents using an extraction form.ResultsIn 15 studies, which were mainly underpowered and of heterogeneous study design, 31 different parameters were studied. Most frequently studied parameters were tumour diameter or volume, Ktrans, Kep, Ve, and apparent diffusion coefficient (ADC). Other parameters were analysed in only two or less studies. Tumour diameter, volume, and kinetic parameters did not show any pre-treatment differences between responders and non-responders. In two studies, pre-treatment differences in ADC were observed between study groups. At early response monitoring significant and non-significant changes for all parameters were observed for most of the imaging parameters.ConclusionsEvidence on distinguishing responders and non-responders to neoadjuvant chemotherapy using pre-treatment MRI, as well as using MRI for early response monitoring, is weak and based on underpowered study results and heterogeneous study design. Thus, the value of breast MRI for response evaluation has not yet been established.Key Points• Few well-validated pre-treatment MR parameters exist that identify responders and non-responders.• Eligible studies showed heterogeneous study designs which hampered pooling of data.• Confounders and technical variations of MRI accuracy are not studied adequately.• Value of MRI for response evaluation needs to be established further.

Risk factors of pain in mammographic screening.

Mammography is an important tool in the secondary prevention of breast cancer. However, earlier research has pointed out that an unpleasant experience during a previous mammography can deter women from returning for mammography screening. It is known that mammography can be a painful examination for some women. The research presented in this article focuses on the experience of pain during and after mammography (247 patients). Firstly, the study sets out to determine the extent to which women actually experience pain as a result of mammographic examination. Secondly, it focuses on identifying the factors that determine the risk of a painful experience during the screening procedure. A pain model was developed that takes into account a broad range of potential pain factors, including other than woman-related factors and factors associated with the actual examination. Special attention was paid to the examination context, the mammographic procedure and the screening staff. The research results show that the majority of women experience pain during mammography. With a logistic regression a number of women-related factors, staff-related and procedural factors were found significant in assessing the pain risk during mammography.

Breast MR imaging in a patient with unilateral axillary lymphadenopathy and unknown primary malignancy

Abstract. Bilateral invasive breast cancers were detected on MR imaging in a patient with left unilateral axillary lymphadenopathy and normal findings at physical examination, mammography, and ultrasound of both breasts. One spiculated and a second ill-defined enhancing lesion in the left breast as well as a superficial circumscribed lesion in the right breast were proven to be invasive malignancies. In patients with isolated axillary lymph nodes and occult primary malignancy, breast MRI can identify or exclude the breast as primary site, which proves the superiority and diagnostic benefit of this imaging method and also its contribution to the therapeutic approach.

Breast cancer and fat grafting: efficacy, safety and complications − A systematic review

Autologous fat grafting (AFG) or lipofilling is nowadays a popular technique for breast reconstruction after breast cancer surgery. There is debate regarding the oncological safety and risks of this procedure in breast cancer patients. A systematic review of the literature published between January first 1995 and October first 2016 was conducted regarding the efficacy, safety and complications of this technique in breast cancer patients after their cancer treatment. The databases PubMed, Science Direct and Thomson Reuters Web of Science were used to search for qualified articles. Inclusion criteria were women with a personal history of breast cancer and at least one lipofilling procedure. Only studies containing a minimum of 20 patients were included in this systematic review. The search yielded a total of 23 suitable articles: 18 case series, 4 retrospective cohort studies and one prospective cohort study. The systematic review encompassed a total of 2419 patients. Medical imaging was used in the majority of the studies to assess the follow-up. Mammography was the most popular technique (65.2%), followed by ultrasound (47.8%) and MRI (30.4%). The prevalence of complications was the following: fat necrosis in 5.31%, benign lesions, like cysts or calcifications in 8.78%, infections in 0.96% and local cancer recurrence in 1.69%. AFG or lipofilling appears to be an oncological safe technique with a low morbidity in women with a history of breast cancer. In order to have a better understanding and evidence of the oncological safety a randomised controlled trial is urgently needed. We further recommend that all AFG be registered in the cancer register.

Evaluation of the diagnostic value of a computed radiography system by comparison of digital hard copy images with screen–film mammography: results of a prospective clinical trial

The purpose of the study was to determine prospectively the diagnostic value of a computed radiography (CR) system by comparing mammographic hard copy images with screen–film mammography (SFM). A series of 100 patients, who came for diagnostic investigation, underwent two-view SFM (Lorad M-IV Platinum) and digital mammography with a CR system (AGFA CR system). The images were obtained by double exposure, i.e. same view without removing compression of the corresponding breast. The CR images were processed with dedicated processing for mammography. Six radiologists read sets of SFM and CR images. The primary efficacy parameter was the overall diagnostic value. The secondary efficacy parameters were lesion conspicuity and lesion details (for masses and micro-calcifications), tissue visibility at chest wall and at skin line, axillary details, overall density and sharpness impression and the overall noise impression. These parameters were scored by a 7-point scoring system. “CR non-inferior to SFM” was concluded if the lower confidence interval bound exceeded 80%. The confidence interval for the overall diagnostic value was between 96.4% and 100%. Pooled analysis of the ten features for image quality comparison demonstrated for all but one feature (lesion details of the calcifications) CR non-inferiority to SFM.

Abstract P2-01-02: The predictive value of sentinel node biopsy (SNB) in early breast cancer after neo-adjuvant chemotherapy (NACT): A prospective study

Background SNB has replaced axillary lymph node dissection (ALND) in those patients (pts) with clinically node negative axilla. This has reduced the morbidity, in particular lymphedema considerable. SLN after NACT is feasible but not accurate in clinically node positive (cN1-3) pts (false negative rate around 10%). Therefore, continuous efforts have to been made in randomized prospective studies to improve the detetion rate of SNB in order to avoid the morbidity of ALND. The purpose of this study is to determine the negative predictive value of the sentinel node in breast cancer after NACT. Method A single institution prospective study regarding the negative predictive value of the sentinel node in breast cancer after NACT was conducted in the Multidisciplinary Breast Clinic of the Antwerp University Hospital from 29/03/2010 untill 12-2015 (Study number: B30020108368). Inclusion criteria for study participation were: breast cancer, age above 18 years, female, tumor stages T2-T4 N0-3 or T1N1-N3. All pts were staged by a mammography, ultrasound of the axilla, MRI of the breast, 18F-fluoro-2-deoxy-glucose( 18 F-FDG) positron emission tomography (PET-CT) scan and bone scintigraphy. They received NACT consisting of 12 cycles of Paclitaxel or 4 cycles of Docetaxel followed by dose dense doxorubicin or epirubicin/cyclofosfamide or vice versa as a standard initial treatment. After 6 weeks a 18 F-FDG PET-CT scan was performed for early tumor response evaluation. At the day of operation, all the pts had a preoperative injecting with a 99mTC-labelled nanocolloid in the peri-areolar region. A gamma detector was used to localize the SLN(s). All SLN(s) were removed and a complete ALND was performed. Results A total of 150 pts were enrolled in our study of which 129 were eligible for analysis. 53 pts had a positive SLN of which 32 have a positive axillary lymph nodes (ALN) (PPV 60%); 76 pts has a negative SLN of which 6 had a positive ALN (NPV 92%). The sensitivity is 84% and the specificity 76% with a false omission rate (FOR) of 8%. 45 pts had an initial clinical N0 (cN0 is defined as clinical negative and no suspect lymph nodes on ultrasound, on MRI breast and 18 F-FDG-PET CT scan). 45 pts had negative SLN, with no ALN and 2 pts had a positive SNL of which 1 pts had axillary involvement (NPV 100%). The FOR of cN1: 5%, cN2: 37%, cN3 33%. A total of 22 pts out of 84 pts (26%) of which 15/49 cN1 (30%), 6/23 (26%) cN2, 1/12 (8%)have after 6 weeks of chemotherapy, 18 F-FDG normalization on 18 F-FDG PET-CT scan. A total of 17 pts had a negative SLN and ALN. The FOR was 0% Conclusion SNB after NACT in case of cN0 is very reliable with high NPV and low FOR. In case of 18 F-FDG-PET CT normalization after 6 weeks of chemotherapy and a negative SLN, no ALND has to be performed. Citation Format: Huizing M, Najim O, Dockx Y, Huyghe I, Van den Wyngaert T, van Goethem M, Verslegers I, Papadimitriou K, Altintas S, Baldewijns M, Trinh B, van Dam P, Tjalma W. The predictive value of sentinel node biopsy (SNB) in early breast cancer after neo-adjuvant chemotherapy (NACT): A prospective study [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P2-01-02.

Abstract P1-01-24: Preoperative ultrasound staging of the axilla superfluous peroperative examination of the sentinel node

Background: Axillary surgery in breast cancer is tailored. The current standard is to perform a frozen section or dep examination of the sentinel node during surgery. If the sentinel node is found positive (≥ macrometastases) a complete axilliary resection is recommended. Preoperative identification of positive nodes will lead to a further improvement of the tailored therapy. Hypothesis: A percentage of less than 5% of patients who would needed an additional operation is considered acceptable. Material and Method: From 2010 – 2012 all breast cancer patients of the Multidisciplinary Breast Clinic Antwerpen had an ultrasound evaluation of the axilla as part of their staging. Fine needle aspiration cytology was performed of suspicious lymph nodes. If this showed to be positive, sentinel node biopsy was bypassed. Patients with normal nodes or benign/non diagnostic biopsy had removal of the sentinel node(s) without peroperative pathological examinations. Results: A total of 275 breast patients had an ultrasound staging (table 1). The sensitivity, specificity, positive predictive value and negative predictive value was respectively 90%, 85%, 77% and 94%. Ten of the 275 patients (3.6%) needed an axillary clearance as a second procedure. Discussion Preoperative detection of invaded lymph nodes has several advantages. First of all it will allow you to identify patients with positive nodes, who can participate in neoadjuvant trial. Secondly it will save operating time and avoid overloading of the system for direct examination and reduces tissue loss. This approach will reduce costs for the health system and anesthetic time for the patient, with an acceptable reoperation rate. Conclusion Preoperative evaluation ultrasound staging of the axillare lymph nodes will avoid peroperative examination of the sentinel node at an acceptable reoperation rate. It is better for the patient, the physicians and the health care system. Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P1-01-24.

96 A Retrospective Analysis of Follow-up in Patients with Suspicion of Breast Tissue Superposition in Digital Screening Mammograms

concentration during NAC, while no trend was observed in oxyhemoglobin, deoxyhemoglobin, and bulk lipid. The percent change in water after two to three months of chemotherapy correlates strongly with age (r=0.752, p = 0.0019). Conclusion: Water concentration correlated with the MRI fibroglandular density. Ovarian suppression induced by NAC may be responsible for the reduced breast density, explaining the significant water concentration reduction in premenopausal subjects. No significant changes were noted in bulk lipid in any subject. This suggests that relatively fast changes in breast density induced by NAC occur due to the reduction of fibroglandular tissue rather than by increases or replacement by bulk lipid. These results suggest that DOSI is a low-cost, bed-side imaging modality capable of monitoring breast density as a prognostic marker.