© 2004 Foundation for Promotion of Cancer Research
Comparison of Intraductal Spread on Dynamic Contrast-enhanced MRI with Clinicopathologic Features in Breast Cancer
1 Department of Surgery, 2 Department of Pathology and 3 Department of Radiology, Kyoto First Red Cross Hospital, Kyoto and 4 Department of Digestive Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
For reprints and all correspondence: Shuhei Komatsu, Department of Digestive Surgery, Kyoto Prefectural University of Medicine, 465 Kawaramachihirokoji, Kamigyo-ku, Kyoto, 602-8566, Japan. E-mail: syuhei{at}mx.biwa.ne.jp
Received February 9, 2004; accepted June 13, 2004
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Abstract |
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 TOP Abstract INTRODUCTIONSUBJECTS AND METHODSRESULTSDISCUSSIONReferences |
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Objective: Contrast-enhanced magnetic resonance imaging (CE-MRI) has emerged as a new diagnostic technology in various breast cancer treatments. However, little is known about the correlation between intraductal spread on CE-MRI and clinicopathologic features. This study was designed to evaluate these correlations for the surgical planning of breast cancer.
Methods: Twenty-six breast cancer lesions (in 26 female patients) treated by breast conserving surgery between March 2001 and March 2003 were evaluated retrospectively. CE-MRI was performed with a 1.5 T unit using a dedicated bilateral breast coil.
Results: In detecting intraductal spread of breast cancer, the sensitivity, specificity and accuracy of CE-MRI were 82.4%, 60.0% and 77.3%, respectively. On mammography (MMG), these were 21.1%, 100.0% and 42.3%, respectively. Therefore, CE-MRI has a higher sensitivity and accuracy, although with a lower specificity than MMG. Compared with breast cancer lesions without intraductal spread on CE-MRI, lesions with intraductal spread on CE-MRI were found more frequently in larger-sized tumors (P = 0.0088).
Conclusion: Preoperative evaluation for intraductal spread by CE-MRI should be more useful than by MMG for breast cancer. When making the surgical decision regarding excision range, particular attention should be paid to this consideration for patients with larger-sized cancer tumors.
Key Words: breast cancer • breast conserving surgery • contrast-enhanced MRI • intraductal spread • MRI
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INTRODUCTION |
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Recent technological advances in diagnosis, the use of routine mammographic screening, and increasing patient awareness of breast cancer have led to breast cancer detection at earlier clinical stages (1). Consequently, breast conserving surgery has gained wide acceptance and become more common. During breast conserving surgery, it is important to avoid positive margins, which is a risk factor for local recurrence and has the potential to decrease survival (2,3). Therefore, in making decisions regarding excision range, accurate information is necessary to predict the extent of intraductal spread and the development of devices. This study was designed to determine the correlation between clinicopathological features and the extent of intraductal spread of breast cancer and to re-evaluate the utility of contrast-enhanced magnetic resonance imaging (CE-MRI) in diagnosing it.
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SUBJECTS AND METHODS |
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Between March 2001 and March 2003, 26 lesions were evaluated in 26 females who were suspected of having breast tumors on the basis of clinical findings or conventional imaging studies such as mammography (MMG) and ultrasonography (US). All lesions demonstrated malignancy on open or needle biopsy before surgery.
At our institution, diagnostic CE-MRI was performed using a 1.5 T Signa scanner system (Signa; General Electric Medical Systems, Milwaukee, WI). Patients were scanned in the prone position without breast compression in a dedicated bilateral breast coil. Our imaging sequence included a localizing sequence followed by an axial fat-suppressed T2-weighted sequence (TR/TE, 4000/85; FSE, FOV, 300 mm; slice thickness, 4.0 mm; spacing, 1.0 mm). A T1-weighted coronal three-dimensional dynamic (FOV, 320 mm, TR Min Full; slice thickness, 6.0 mm; flip angle, 40°; Locpar, Bw 31.25, slab 16) and axial T1-weighted fat-suppressed (FSE, FOV, 32 mm; slice thickness, 4.0 mm; spacing, 1.0 mm) fast radio frequency spoiled gradient-echo sequence (fast SPGR) were then performed after a rapid intravenous bolus injection of 0.1 mmol/kg body weight of gadolinium-diethylene triamine pentaacetic acid (Gd-DTPA), delivered through an indwelling i.v. catheter.
After surgery, the resected breast cancer specimens were fixed in buffered formalin and embedded in paraffin for pathologic examination using standard methods. The specimen was serially sectioned and mapping was performed for more precise studies such as comparison of intraductal spread on both CE-MRI and MMG with pathological intraductal spread, and examination of the correlation between intraductal spread on CE-MRI and clinicopathological features. The macroscopic and microscopic classifications of breast cancers were based on the Japanese Breast Cancer Society (JBCS) (4).
Discrete variables were analyzed using the Fisher's exact probability test, and continuous variables were compared using the Student t-test. P values of <0.05 were considered to indicate statistically significant differences.
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RESULTS |
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Age ranged from 35 to 69 with a mean age of 52.9 years. Mean lesion size was 15.8 mm (range, 6.0–30.0 mm). According to the JBCS (4), 25 lesions had invasive ductal carcinoma, comprising 11 papillotubular carcinomas, eight solid-tubular carcinomas and six scirrhous carcinomas. One had apocrine carcinoma.
Table 1 shows the correlation between CE-MRI, MMG and pathological findings regarding intraductal spread. Of these 26 breast cancer lesions, 19 (73.1%) showed linear and/or spotty enhancement on CE-MRI, suggesting the presence of intraductal spread of invasive carcinoma (Fig. 1). On the other hand, of the 26 lesions, 19 lesions (73.1%) showed pathological intraductal spread. In 16 (84.2%) of these lesions, pathological intraductal spread could be detected on CE-MRI prior to surgery. Therefore, the sensitivity, specificity and accuracy for detecting intraductal spread on CE-MRI were 84.2%, 57.1% and 76.9%, respectively. With respect to MMG, only four (21.1%) of the 19 lesions with pathological intraductal spread showed linear and/or spotty calcifications suggesting the presence of intraductal spread on MMG before surgery. The sensitivity, specificity and accuracy for detecting intraductal spread on MMG were 21.1%, 100.0%, and 42.3%, respectively. Therefore, CE-MRI has a higher sensitivity and accuracy, but a lower specificity than MMG in the detection of intraductal spread of breast cancer.
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Table 2 demonstrates the comparison of intraductal spread on CE-MRI with clinicopathologic factors. There were statistically significant differences in tumor size (P = 0.0088) between lesions with a positive pattern of intraductal spread and those with a negative pattern on CE-MRI.
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DISCUSSION |
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To remove the main lesions completely in a single procedure for breast cancer should have apparent benefits, such as avoiding additional surgery to re-excise for positive or close margins and increasing the possibility of removing a satellite lesion or lesions during a single surgery while conserving the breast. Therefore, more detailed information about the extent and distribution of cancer is a requirement of breast conserving surgery (5,6).
CE-MRI uses morphological and physiological properties, allowing assessment of tumors that cause no architectural distortion. On the other hand, MMG and US depend on architectural distortion to detect tumors. In detecting tumors and estimating the extent of intraductal spread, if calcifications are not present, MMG is not very helpful. Moreover, MMG in patients with dense breasts is generally more difficult to interpret, and tumors can be masked by dense breast tissue (7). US is also considered useful for detecting intraductal spread (8). Linear hypo-echoic structures extending from the main tumor have been considered suggestive of intraductal spread of invasive carcinoma on US. However, US can be impaired by inhomogeneous tissues, as is seen in breasts with extensive fibrocystic changes (8). Moreover, the utility of US may be greatly dependent on the skill of the examiner. Therefore, there are limits to the evaluation of the extent of intraductal spread in breast cancer by such conventional modalities as MMG and US, and increasing interest should be paid to CE-MRI for breast cancer diagnosis.
Several studies have suggested that CE-MRI is superior to MMG in delineating the extent of disease in the breast (9–11). Indeed, CE-MRI has higher sensitivity and accuracy, but lower specificity than MMG, especially in the detection of intraductal spread of breast cancer in our study (Table 1).
We hypothesized that the enhancing effect of intraductal spread on CE-MRI might have a correlation with clinicopathologic factors in breast cancer, because the rapid uptake enhancing effect of CE-MRI is mainly due to microvessel status (12,13) and increased angiogenesis in breast cancer tumors (14–16). In our study, compared with lesions without intraductal spread on CE-MRI, breast cancer lesions with intraductal spread on CE-MRI were found more frequently in larger-sized tumors (P = 0.0088) (Table 2). Therefore, the larger a tumor becomes, the more angiogenesis might increase, leading to the intraductal spread. However, the detailed mechanisms comprise a highly complex series, the details of which remain unclear.
In breast conserving surgery with CE-MRI diagnosis, the main problem is likely to be false positive and false negative findings regarding intraductal spread, and discrepancy between the estimated extent of intraductal spread on CE-MRI and the pathological extent may result in unnecessary resection with an additional tissue defecit or an insufficient resection with positive margins. Larger and further studies are necessary. Reviewing more clinical data and making more precise correlations with pathology using higher magnetic field CE-MRI, as well as mapping and scanning in a position such as that in operation may solve these issues. These issues are currently under evaluation at our institute.
In conclusion, our present study clearly demonstrates that preoperative evaluation for intraductal spread by CE-MRI should be more useful than that by MMG in breast cancer. When making the surgical decision regarding excision range, particular attention should be paid to this consideration for patients with larger-sized cancer tumors.
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Acknowledgments |
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We thank radioactive ray engineers Mr Yusuke Inoue and Mr Hiroki Kanazawa for their assistant in the implementation of this study.
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References |
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1 Nystrom L, Larsson LG, Rutqvist LE, et al. Determination of cause of death among breast cancer cases in the Swedish randomized mammography screening trials. A comparison between official statistics and validation by an endpoint committee. Acta Oncol 1995;34:145–52.[Web of Science][Medline]
2 Anscher MS, Jones P, Prosnitz LR, et al. Local failure and margin status in early-stage breast carcinoma treated with conservation surgery and radiation therapy. Ann Surg 1993;218:22–8.[Web of Science][Medline]
3 Fortin A, Larochelle M, Laverdiere J, Lavertu S, Tremblay D. Local failure is responsible for the decrease in survival for patients with breast cancer treated with conservative surgery and postoperative radiotherapy. J Clin Oncol 1999;17:101–9.
4 The Japanese Breast Cancer Society: general rules for clinical and pathological recording of breast cancer, 14th Edition. Tokyo: Kanehara & Co, 2000 (in Japanese).
5 Osteen RT. Strategies for breast-conserving surgery. An unresolved dilemma. Cancer 1995;75:1563–5.[CrossRef][Web of Science][Medline]
6 Voogd AC, Nab HW, Crommelin MA, van der Heijden LH, Kluck HM, Coebergh JW. Comparison of breast-conserving therapy with mastectomy for the treatment of early breast cancer in community hospitals. Eur J Surg Oncol 1996;22:13–6.[CrossRef][Web of Science][Medline]
7 Kerlikowske K, Grady D, Barclay J, Sickles EA, Ernster V. Effect of age, breast density, and family history on the sensitivity of first screening mammography. J Am Med Assoc 1996;276:33–8.
8 Hlawatsch A, Teifke A, Schmidt M, Thelen M. Preoperative assessment of breast cancer: sonography versus MR imaging. Am J Roentgenol 2002;179:1493–501.
9 Harms SE, Flamig DP, Hesley KL, et al. MR imaging of the breast with rotating delivery of excitation off response: clinical experience with pathologic correlation. Radiology 1993;187:493–501.
10 Fisher U, Kopka L, Grabbe E. Breast carcinoma: effect of preoperative contast-enhanced MR imaging on the therapic approach. Radiology 1999;213:881–8.
11 Esserman L, Hylton N, Yassa L, Barclay J, Frankel S, Sickles E. Utility of magnetic resonance imaging in the management of breast cancer: evidence for improved preoperative staging. J Clin Oncol 1999;17:110–9.
12 Buckley DL, Drew PJ, Mussurakis S, Monson JR, Horsman A. Microvessel density of invasive breast cancer assessed by dynamic Gd-DTPA enhanced MRI. J Magn Reson Imaging 1997;7:461–4.[Web of Science][Medline]
13 van Dijke CF, Brasch RC, Roberts TP, et al. Mammary carcinoma model: correlation of macromolecular contrast-enhanced MR imaging characterizations of tumor microvasculature and histologic capillary density. Radiology 1996;198:813–8.
14 Furman-Haran E, Margalit R, Grobgeld D, Degani H. Dynamic contrast-enhanced magnetic resonance imaging reveals stress-induced angiogenesis in MCF7 human breast tumors. Proc Natl Acad Sci USA 1996;93:6247–51.
15 Degani H, Furman E, Fields S. Magnetic resonance imaging and spectroscopy of MCF7 human breast cancer: pathophysiology and monitoring of treatment. Clin Chim Acta 1994;228:19–33.[CrossRef][Web of Science][Medline]
16 Weinreb JC, Newstead G. MR imaging of the breast. Radiology 1995;196:593–610.
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