The role of contrast-enhanced high resolution MRI in the surgical planning of breast cancer

The role of contrast-enhanced high resolution MRI for planning surgery in breast cancer was evaluated. Of 72 patients examined, 57 patients had invasive ductal carcinoma, 2 had mucinous carcinoma, 1 had medullary carcinoma, 7 had invasive lobular carcinoma, 2 had ductal carcinoma in situ (DCIS) and 3 had Paget’s disease. A 1.5 T Signa imager (GE Medical Systems, Milwaukee, WI) was used with a dedicated breast coil. The pulse sequence based on RARE (rapid acquisition with relaxation enhancement) was used with a fat suppression technique. After examining both breasts, the affected breast alone was examined with Gd enhancement. Linear and/or spotty enhancement on MRI was considered to suggest DCIS or intraductal spread in the area surrounding the invasive cancer. Of 72 patients, 50 showed linear and/or spotty enhancement on MRI and 41 of those 50 patients had DCIS or intraductal spread. In contrast, 22 of 72 patients were considered to have little or no intraductal spread on MRI and 17 of the 22 patients had no or little intraductal spread on pathological examination. The sensitivity, specificity and accuracy for detecting intraductal spread on MRI were 89%, 82% and 81%, respectively. Discrepancies in the estimated extent of intraductal spread were less than 2 cm in 90% of the patients according to pathological mapping. High resolution MRI was considered useful in detecting intraductal spread and in estimating its extent, however, larger study using precise correlation with pathology is necessary.     

The application of breast MRI in staging and screening for breast cancer

Contrast-enhanced breast magnetic resonance imaging (MRI) is a relatively new but increasingly used modality for the detection of breast cancer. MRI has demonstrated utility in identifying additional tumor foci and extent of disease in patients with known breast cancer. This is especially useful with invasive lobular carcinoma, which is difficult to evaluate on mammography. MRI has been found to identify the primary tumor in 70% to 86% of cases of occult breast cancer. Contrast-enhanced breast MRI has shown some usefulness in the detection of residual cancer following surgery but is limited by postoperative changes. In patients who have undergone neoadjuvant chemotherapy, breast MRI is most accurate in those patients in whom there is little or no response to chemotherapy. The use of contrast-enhanced breast MRlfor breast cancer screening is controversial. It has only been used in afew small studies of high-risk patients. The limitations of breast MRI include uptake in benign lesions and normal tissue, sensitivity for ductal carcinoma in situ, cost, and availability. This paper will discuss the uses, benefits, and limitations of contrast-enhanced breast MRI in the staging and screening of breast cancer.     

Diagnostic value of enhanced computed tomography in the detection of the widely spreading intraductal component of breast cancer: Case reports

We report cases of breast cancer with extensive intraductal component (EIC), the extent of which could be detected only by contrast-enhanced computed tomography (CT) scan. One case was a 32-year-old woman who presented left nipple bloody discharge without breast mass palpation. Mammography (MMG), galactography and ultrasonography (US) showed no abnormalities. Contrast helical CT scan revealed numerous patchy enhancement in the upper-outer quadrant of the left breast. Histological examnation revealed invasive ductal carcinoma with a predominant intraductal component. The second case was a 36- year-old woman who had noticed a left breast mass 2.4 cm in diameter. MMG and US suggested a localized breast cancer. Contrast helical CT scan revealed numerous patchy enhancement throughout the mammary gland in addition to the index tumor near the nipple. Histopathological results indicated invasive ductal carcinoma with widely spread ELC. In these two cases, the extent of intraductal cancer also correlated well with the CT findings. Breast CT scan can be an effective tool for determining the extent of the intraductal component of breast cancer, which is an important factor when considering breast-conserving therapy.     

Three-Dimensional Helical CT of the Breast: Accuracy for Measuring Extent of Breast Cancer Candidates for Breast Conserving Surgery

Objective. To evaluate the accuracy of three-dimensional (3D) helical computed tomography (CT) for assessing the extent of breast cancer of candidates for breast conserving surgery. Methods. Results of helical CT were studied in 144 lesions of 144 patients with breast cancer before breast-conserving surgery. A lesion was defined as positive if focal enhancement was detected by CT within 100s after contrast material administration. After resection, tumors were histopathologically mapped and correlated with the extent of 3D images. Results. Helical CT enabled detection of 143 tumors but not of one ductal carcinoma in situ (DCIS). The median deviation of the tumor extension revealed by 3D helical CT images from pathological assessment was 7.7mm (range 0–60mm). The extent of tumors was significantly correlated with CT measurements (r=0.714, p<0.0001). By multivariate analysis, the presence of invasive tumors with intraductal extensions beyond the edge of the invasive tumor and histologic type (DCIS) were significant risk factors for deviation of the tumor extension revealed by 3D helical CT images from pathological assessment. Conclusion. Three dimensional helical CT of the breast is an accurate preoperative imaging modality for assessing the extent of breast cancer candidates for breast conserving surgery.     

Role of Breast MRI in Patients with Newly Diagnosed Breast Cancer

The role of breast MRI in patients with newly diagnosed breast cancer is controversial. Preoperative MRI is highly sensitive and accurate in assessing tumor size, extensive intraductal component (EIC), and in detection of additional sites of disease. It also has utility in assessing chest wall, nipple-areolar complex, and nodal involvement. Yet there are conflicting results in whether the use of preoperative MRI improves re-excision rate, local recurrence rate, and ultimately, survival. MRI has also been associated with overestimation of disease and increased mastectomy rates, and may contribute to treatment delay. Nevertheless, certain subgroups of patients may benefit more from preoperative MRI than others, including those with invasive lobular cancer (ILC), dense breasts, and those at elevated risk for breast cancer.     

3D imaging of intraductal spread of breast cancer and its clinical application for navigation surgery

BACKGROUND: To perform optimal tumor resection of breast cancer, preoperative information concerning intraductal spread of cancer (ISC) is very important. METHODS: To detect ISC, three-dimensional (3D) imaging methods including helical CT, MRI, and ultrasound were examined in patients with primary breast cancer by comparison with multi-sliced pathological specimens. RESULTS: The sensitivity of each modality for detecting ISC was 64.7%, 90.2% and 78.6%, and the specificity was 97.1%, 62.9% and 100%, respectively. Subsequently, the potential of each modality for navigation in breast conserving surgery was assessed. Three-dimensional helical CT navigation could reduce the positive rate of the specimen margins, and 3D MRI navigation using a special mapping sheet enabled removal of non-palpable breast cancer without positive margins in 66.7% of patients preliminarily. Real-time 3D ultrasound images correlated with the resected tumor size, with the difference between the two less than 2 cm in 72.7 % of the patients with ISC. CONCLUSION: Three-dimensional images from each modality were reliable enough for diagnosis of tumor spread, and surgical navigation using these images seemed to have potential clinical application for breast conserving surgery. Prospective studies for navigation surgery with more patients are needed.     

Predictors of local recurrence after breast-conservation therapy

Breast-conserving therapy (BCT) is a proven local treatment option for select patients with early-stage breast cancer. This paper reviews pathologic, clinical, and treatment-related features that have been identified as known or potential predictors for ipsilateral breast tumor recurrence in patients treated with BCT. Pathologic risk factors such as the final pathologic margin status of the excised specimen after BCT, the extent of margin involvement, the interaction of margin status with other adverse features, the role of biomarkers, and the presence of an extensive intraductal component or lobular carcinoma in situ all impact the likelihood of ipsilateral breast tumor recurrence. Predictors of positive repeat excision findings after conservative surgery include young age, presence of an extensive intraductal component, and close or positive margins in prior excision. Finally, treatment-related factors predicting ipsilateral breast tumor recurrence include extent of breast radiation therapy, use of a boost to the lumpectomy cavity, use of tamoxifen or chemotherapeutic agents, and timing of systemic therapy with irradiation. The ability to predict for an increased risk of ipsilateral breast tumor recurrence enhances the ability to select optimal local treatment strategies for women considering BCT.     

Usefulness of preoperative multidetector-row computed tomography in evaluating the extent of invasive lobular carcinoma in patients with or without neoadjuvant chemotherapy

Background  The present study was conducted to assess the clinical usefulness of multidetector-row CT (MDCT) in determining the extent of invasive lobular carcinoma (ILC) and especially the extent of residual tumor after neoadjuvant chemotherapy (NAC). Patients and methods  The subjects were 24 patients with primary ILC who underwent surgery without NAC and 17 patients with ILC who underwent surgery after NAC at National Cancer Center Hospital (NCCH) between April 1999 and December 2005. The extent of primary ILC was assessed by ultrasound, mammography, and MDCT before surgery, and the results obtained using each modality were compared with the results of pathological examination after surgery. In addition, the characteristic findings of ILC obtained by MDCT were assessed. Similarly, the extent of residual tumor after NAC was evaluated using ultrasound, mammography, and MDCT before surgery in the subjects who underwent NAC, and the results obtained by each modality were compared with the results of pathological examination after surgery. Results  The findings of primary ILC obtained by MDCT showed that the carcinoma was the non-localized type rather than the localized type in 63% of the subjects. In addition, with regard to the pattern of time-sequential contrast enhancement, the persistent pattern (in which tumor enhancement is strong in the late phase rather than in the early phase) was observed in 46% of the subjects, and the plateau pattern (in which contrast enhancement is weak in both the early phase and the late phase) was observed in 38% of the subjects. These trends were significant in the subjects who underwent NAC and in whom tumor enhancement could not be clearly observed by MDCT. Assessment of the extent of carcinoma showed that the diagnostic accuracy of MDCT was 79%, as compared with 71% for either ultrasound or mammography. Assessment of the extent of carcinoma after NAC also showed that the diagnostic accuracy of MDCT was 71%, as compared with 48% for ultrasound and 53% for mammography, indicating that MDCT provided the highest accuracy. It should be noted that for all modalities, the extent of ILC was not overestimated as compared with the tumor diameter measured during pathological examination. Conclusion  Assessment by MDCT showed that ILC tends to be diffuse, tumor enhancement tends to be very weak, and the rate of enhancement tends to be low. In addition, MDCT was found to be useful for determining the extent of carcinoma, and the diagnostic accuracy of MDCT, especially in determining the extent of carcinoma after NAC, was much higher than that of ultrasound or mammography.     

MRI导丝定位术对仅MRI显示的乳腺病变的诊断价值

目的:初步探索MRI导丝定位术对仅MRI显示的乳腺微小病变的诊断价值。方法:使用Toshiba 1.5T VISART超导MRI仪,八通道相控阵乳腺专用线圈,专用导丝及定位系统,对16例患者19处仅MRI显示、BI-RADS分类为4类及以上的乳腺微小隐匿病灶进行导丝定位术。根据MRI检查可疑病灶的部位,结合专用软件进行测量计算,选择外侧位、内侧位,精准定位进针,观察操作方式及定位准确性,准确划定手术区域位置及范围,定位结束后送病人行外科手术切除,结合手术病理结果进行对比分析。结果:16例患者19个病灶均一次定位成功,病理切片证实病变完全成功切除,成功率为100%。术前MRI综合诊断BI-RADS分类4A类5处,4B类6处,4C类6处,5类2处;病理包括:导管内多发乳头状瘤3处(其中1例伴不典型增生),中度不典型增生2处,重度不典型增生5处,导管内癌4例,导管内癌伴微浸润1例,浸润性乳腺癌1例,大汗腺化生伴导管上皮增生1例,硬化性腺病伴筛状增生1例,微小纤维腺瘤1例,术前MRI诊断结论与术后病理结果对照,诊断符合率为84.21%（16/19）。结论:对X线、超声无法检出,临床触及阴性,仅MRI显示的乳腺微小隐匿性病灶,应用MRI进行初步定性诊断,对BI-RADS分类4A类及以上的病灶进行MRI导丝定位术,是一种早期、安全、准确可靠的方法,弥补了X线、超声诊断的不足及假阴性的发生,提高了早期乳腺癌、导管内癌及不典型增生的精准诊治水平,是对乳腺X线和超声引导乳腺导丝定位术的重要补充。     

The presence of an extensive intraductal component following a limited excision correlates with prominent residual disease in the remainder of the breast

Previous studies of patients with infiltrating ductal breast cancer treated with conservative surgery (ie, limited excision) and radiotherapy have indicated that the presence of an extensive intraductal component (EIC) in the excision specimen is highly associated with subsequent breast recurrence. The reason for this association is not clear, but possible explanations include the presence of more extensive disease in the breast or increased radiation resistance among tumors with an EIC (EIC+) compared with those without (EIC-) tumors. To investigate this association further, we related the presence or absence of an EIC in the primary tumors of 214 women who underwent mastectomy to the likelihood of finding additional foci of cancer in their mastectomy specimens using a correlated pathologic-radiologic mapping technique. Primary tumors that were EIC+ were significantly more likely to have carcinoma in the remainder of the breast than those which were EIC--(74% v 42%; P = .00001). This difference was primarily due to the presence of residual intraductal carcinoma. Seventy-one percent of EIC+ patients had residual intraductal carcinoma compared with 28% of EIC-patients (P less than .00001). In particular, 44% of EIC+ patients had "prominent" residual intraductal carcinoma compared with 3% of EIC-patients (P less than .00001). We conclude that patients whose tumors contain an EIC more frequently have a large subclinical tumor burden in the remainder of the breast compared with patients whose tumors do not contain an EIC. This observation may explain the association between EIC and subsequent breast recurrence when patients are treated with a limited excision before radiotherapy.     

Non-infiltrating intraductal carcinoma of the breast (author's transl)]

Non-infiltrating intraductal carcinoma may be considered a type of "carcinoma in situ" of the breast. In a review of 47 cases diagnosed and treated at Gustave-Roussy Institute between 1956--1972, it appears that the early symptoms of this rare type of breast carcinoma (it occurs only in 2.4% of all breast cancers) were a bloody discharge (38%) or Paget's disease of the nipple (11%). The histological examination was of the utmost importance in these cases due to the diagnostic uncertainties between benign hyperplastic lesions and authentic carcinomas as well as between infiltrating carcinomas and strictly intraductal carcinomas. Frozen section was only accurate in 30% of cases. The high frequency of multicentric foci (76%) contrasted with the absence of lymph node involvment (none of the 23 cases in which at least one node was excised, showed lymph node metastases). Treatment was only of ablation of the whole mammary gland, except in 6 patients who had a tumorectomy, two of whom also received radiotherapy. Local recurrence occurred in 4 patients, 3 of whom had only tumorectomy. The contralateral breast was affected in 2 cases. No patient under follow-up died of cancer within 5 years. The peculiar and highly favorable course of non-infiltrating intraductal carcinoma calls for an adequate therapy which could later be followed by a plastic reconstructive surgery should the patient wish to have this procedure.     

Utility of magnetic resonance imaging in the management of breast cancer: evidence for improved preoperative staging.

PURPOSE: The staging and treatment for breast cancer are changing; there is an increase in the incidence of ductal carcinoma-in-situ, the use of fine-needle aspiration and stereotactic biopsy for diagnosis, and the use of neoadjuvant chemotherapy. Thus, there is a need for a tool to assess more precisely the extent of cancer in the breast before surgery. To better plan surgical and chemotherapeutic interventions, we evaluated high-resolution magnetic resonance imaging (MRI) as such a tool. PATIENTS AND METHODS: Fifty-seven patients with 58 cases of breast cancer were evaluated preoperatively with MRI using a technique called the triple-acquisition rapid gradient echo technique to maximize anatomic detail. Imaging results were compared with mammography and subsequent pathology results. RESULTS: Magnetic resonance imaging correctly identified residual or primary cancer in 55 of 58 cases and accurately predicted the extent of the cancer in 54 of 58 cases. The anatomic extent was more accurately defined with MRI compared with mammography (98% v 55%). Magnetic resonance imaging added the greatest value in cases of multifocal disease. CONCLUSION: By applying MRI selectively to patients with a known diagnosis of cancer and focusing on defining the extent of malignant lesions, we were able to obtain clear and accurate anatomic information. Our results suggest that MRI could provide very valuable information for preoperative planning and single-stage resection in breast cancer. Based on preliminary data from our series, MRI would be valuable as a staging tool in the preoperative setting even if the cost is in the range of $1,300 to $2,000. It is already significantly less than the target cost, so it is reasonable to refine this technique for clinical use to help plan the most appropriate surgical intervention and possibly reduce costs as well. A careful prospective study is warranted to validate our findings.     

Multidetector row computed tomography for diagnosing intraductal extension of breast carcinoma

OBJECTIVES: Several reports supported the association of higher ipsilateral breast tumor recurrence rates with positive or intermediate margins compared with negative pathologic margins. Precise evaluation of intraductal component and adequate surgical margin are important factors affecting the tumor recurrence after breast conserving surgery. Numerous studies have reported the utility of magnetic resonance imaging for diagnosing developing intraductal extension of breast cancer, but few have investigated multidetector-row computed tomography (MD-CT). The present study evaluated the clinical utility of MD-CT for detecting intraductal extension of breast carcinoma, and analyzed clinical parameters affecting the detection of intraductal extension under MD-CT. METHODS: Subjects comprised 44 patients grouped into three categories according to degree of intraductal extension of the main tumor under MD-CT (Intraductal spread grade 1 approximately 3: IDS 1 approximately 3). Tumors were also categorized histopathologically (p-IDS 0 approximately 3), and CT-pathological correlations were examined retrospectively. Clinical parameters were evaluated to determine the affect on detection of intraductal components. RESULTS: MD-CT detected 44 breast lesions (100%). Sensitivity for detection of intraductal component was 81.2%, specificity was 67.8%, and accuracy was 72.7%. Regarding extent of intraductal components, significant correlations were found between histopathological and MD-CT findings. A strong correlation was found in postmenopausal women between T2 tumor and high histological grade. CONCLUSIONS: MD-CT findings of intraductal extension from breast carcinoma correlate with histological degree of intraductal extension, and MD-CT may be useful for preoperative assessment of breast-conserving surgery, particularly for postmenopausal women with histological high nuclear grade and T2 tumor.     

Imaging preoperatively for pancreatic adenocarcinoma

Pancreatic cancer is a highly lethal malignancy which is increasing in incidence and mortality. The fourth leading cause of cancer death in the U.S., pancreatic cancer is projected to become the second leading cause of cancer death by 2020. Patients with pancreatic cancer have an abysmal 5-year survival of 6%, and 90% of these patients eventually die from the disease. This is in large part due to the commonly advanced stage of disease at the time of diagnosis. Currently, the only potentially curative therapy for pancreatic carcinoma is complete surgical resection. Patients who undergo incomplete resection with residual disease have similar survival rates to those patients with metastatic disease and should be spared this relatively morbid surgery. Thus, the key to impacting prognosis is the detection of smaller and earlier stage lesions, and the key to optimal management is accurately determining which patients have potentially resectable surgery and which patients would not benefit from surgery. Cross-sectional imaging plays an essential role in both the diagnosis and appropriate staging of pancreatic carcinoma. The diagnosis and staging of pancreatic adenocarcinoma is performed with cross-sectional imaging. Multi-detector computed tomography (MDCT) is the most commonly used, best-validated imaging modality for the diagnosis and staging of pancreatic cancer. Modern contrast-enhanced magnetic resonance imaging (MRI) has been demonstrated to be equivalent to MDCT in detection and staging of pancreatic cancer. Endoscopic ultrasound (EUS) is very sensitive for detecting pancreatic masses; however, due to limitations in adequate overall abdominal staging, it is generally used in addition to or after MDCT. Transabdominal ultrasound and positron emission tomography/computed tomography (PET/CT) have limited roles in the diagnosis and staging of pancreatic cancer. Preoperative imaging is used to characterize patients as having resectable disease, borderline resectable disease, locally advanced disease (unresectable) and metastatic disease (unresectable). As the definitions of borderline resectable and unresectable may vary from institution to institution and within institutions, it is essential to accurately assess and describe the factors relevant to staging including: local extent of tumor, vascular involvement, lymph node involvement and distant metastatic disease. To facilitate this, standardized reporting templates for pancreatic ductal adenocarcinoma have been created and published. Structured reporting for pancreatic cancer has been reported to provide superior evaluation of pancreatic cancer, facilitate surgical planning, and increase surgeons’ confidence about tumor resectability.     

Spontaneous “healing” of breast cancer

BACKGROUND: Healing is a phenomenon by which the intraductal component of breast cancer disappears and is replaced by fibrous tissue. Focally localized healing often prevents confirmation of the continuity of intraductal carcinoma. OBJECTIVE: To clarify the clinicopathological characteristics of breast cancer with healing. PATIENTS AND METHODS: At our hospital, 308 patients (311 breasts) underwent breast conservation therapy without neoadjuvant chemotherapy for breast cancer in 2000. These surgical specimens were histopathologically investigated with 5 mm serial sections. We assessed the proportion and the characteristics of breast cancer with healing. RESULTS: (1) The proportion of breast cancer with healing was 7% (21/311). (2) In the 21 patients, the mean age was 59.2 years, and the mean diameter was 2.8 cm. (3) The histological type of the breast cancer varied: noninvasive ductal carcinoma in 2 cases, papillotubular carcinoma in 5, solid-tubular carcinoma in 8, scirrhous carcinoma in 5, invasive lobular carcinoma in 1, and Paget's disease in 1. However in all cases, the histologic type of the intraductal carcinoma foci was the comedo/solid type and the nuclear grade of cancer cells was high. (4) In cases with healing, areas of healing were seen in an average of 5 (1-26) blocks, compared with intraductal carcinoma foci in 13 blocks (2-40). Healing was located on the nipple side of the main lesion in 8 cases, the peripheral side in 9, and both sides in 4. In 3 cases, healing was seen at the surgical margin of the partial mastectomy specimen. CONCLUSION: The proportion of breast cancer cases with healing was 7% and these cases were intraductal carcinoma of the comedo/solid type, consisting of highly malignant cancer cells.     

The role of magnetic resonance imaging in early breast cancer

Despite recent evidence that fails to detect a benefit in surgical and local recurrence outcomes in those who receive optimal surgery and adjuvant systemic and radiotherapy, magnetic resonance imaging (MRI) is still being employed. We review the recent literature to clarify the role in the use of MRI in early breast cancer. A literature search using the Medline and Ovid databases was conducted between 2004 and 2011 using the terms "magnetic resonance imaging' and 'early breast cancer'. Only articles with clinical trials published in English in adult humans with available abstracts were included. Articles on high-risk women, response to neoadjuvant therapy, advanced breast cancer, the occult primary, the contralateral breast and technical articles were excluded. Articles examining the role of MRI in the staging of early breast cancer were retained. Over 260 articles regarding breast MRI have been published in the last 5 years. Additional foci may be found in 16% of patients but the impact on the extent of surgery and local recurrence rate is yet to be defined. Certain sub-groups who may benefit include those with invasive lobular carcinoma and mammographically dense breasts and those for consideration of partial breast irradiation. With standard adjuvant radiotherapy, there is no benefit in routine MRI with respect surgical extent and local recurrence. Should MRI be used, pre-operative biopsy to confirm additional disease must be undertaken prior to a change in surgical extent of resection. However, MRI may be useful in the evaluation of those who can be considered for partial breast irradiation. Centres undertaking breast MRI must have MRI-biopsy capabilities and constantly audit the reporting of MRI with correlation to the final pathology.     

Does pre-operative breast magnetic resonance imaging in addition to mammography and breast ultrasonography change the operative management of breast carcinoma?

Magnetic resonance imaging (MRI) has been used for the local staging of breast cancer, especially to determine the extent of multiple lesions and to identify occult malignancies. The aim of this study was to evaluate the effect of pre-operative MRI on the surgical treatment of breast cancer. Between January 2006 and May 2007, 535 newly diagnosed breast cancer patients who planned to undergo breast conserving surgery had clinical examinations, bilateral mammography, breast ultrasonography, and breast MRI. The radiologic findings and clinicopathologic data were reviewed retrospectively. Ninety-eight (18.3%) patients had additional lesions, shown as suspicious lesions on breast MRI, but not detected with conventional methods. Eighty-four (15.7%) of these patients had a change in surgical treatment plans based on the MRI results. Forty-seven (8.8%) of the 84 patients had additional malignancies; the other 37 patients (6.9%) had benign lesions. The positive predictive value for MRI-based surgery was 56.0% (47 of 84 patients). During the period of study, the use of pre-operative MRI was increased with time (OR 1.20; 95% CI 1.16–1.23; P < 0.001), but the mastectomy rate did not change significantly (OR 0.98; 95% CI 0.95–1.00; P = 0.059). Multiple factors were analyzed to identify the patients more likely to undergo appropriate and complete surgery based on the additional findings of the pre-operative MRI, but the results were not statistically significant. This research suggests that a pre-operative MRI can potentially lower the rate of incompletely excised malignancies by identifying additional occult cancer prior to surgery and does not lead to an increase in the mastectomy rate; however, because some benign lesions are indistinguishable from suspicious or malignant lesions, excessive surgical procedures are unnecessarily performed in a significant portion of patients. In the future, the criteria for the use of MRI in local staging of breast cancer should be established.     

Effectiveness of multi-detector row computed tomography in detection of the presence and extent of ductal carcinoma in situ

Background

As ductal carcinoma in situ (DCIS) lesions can spread widely in the ductal-lobular segment, often without palpable tumor, complete resection of the lesion in breast-conserving surgery requires establishment of the precise location and extent of the lesion during preoperative imaging studies. We investigated the potential of multi-detector row computed tomography (MDCT) in detecting and delineating DCIS lesions.

Methods

Overall, 74 patients with 75 DCIS lesions underwent breast MDCT. The size of the DCIS lesion in each patient was measured in the volume rendering images and compared to the size obtained by pathological mapping. The differences between the actual tumor size and that obtained from MDCT (L-Path and L-CT) were calculated, and the relationships between these differences and tumor characteristics were investigated.

Results

DCIS was detected fully or partially in 64 (84.9 %) of 75 lesions, whereas the detection rate of magnetic resonance imaging (MRI) was 90 %. The detection rate was not influenced by comedo/non-comedo status, but the detection rate of higher nuclear grade DCIS lesions tended to be higher than that of low grade lesions (p = 0.089), while the estimated size was also more accurate in the former (p = 0.046). Hormone receptor and Her2 status did not affect MDCT findings.

Conclusion

MDCT is highly effective for detecting DCIS, especially the more aggressive types of DCIS. Moreover, the patient’s position during MDCT imaging is more similar to that during surgery than that during MRI, making MDCT a highly useful presurgical imaging technique for the assessment of DCIS.     

Endoscopic diagnosis of extrahepatic bile duct carcinoma: Advances and current limitations

The accurate diagnosis of extrahepatic bile duct carcinoma is difficult, even now. When ultrasonography (US) shows dilatation of the bile duct, magnetic resonance cholangiopancreatography followed by endoscopic US (EUS) is the next step. When US or EUS shows localized bile duct wall thickening, endoscopic retrograde cholangiopancreatography should be conducted with intraductal US (IDUS) and forceps biopsy. Fluorescence in situ hybridization increases the sensitivity of brush cytology with similar specificity. In patients with papillary type bile duct carcinoma, three biopsies are sufficient. In patients with nodular or infiltrating-type bile duct carcinoma, multiple biopsies are warranted, and IDUS can compensate for the limitations of biopsies. In preoperative staging, the combination of dynamic multi-detector low computed tomography (MDCT) and IDUS is useful for evaluating vascular invasion and cancer depth infiltration. However, assessment of lymph nodes metastases is difficult. In resectable cases, assessment of longitudinal cancer spread is important. The combination of IDUS and MDCT is useful for revealing submucosal cancer extension, which is common in hilar cholangiocarcinoma. To estimate the mucosal extension, which is common in extrahepatic bile duct carcinoma, the combination of IDUS and cholangioscopy is required. The utility of current peroral cholangioscopy is limited by the maneuverability of the "baby scope". A new baby scope (10 Fr), called "SpyGlass" has potential, if the image quality can be improved. Since extrahepatic bile duct carcinoma is common in the Far East, many researchers in Japan and Korea contributed these studies, especially, in the evaluation of longitudinal cancer extension.     

Staging of palpable tl-2 invasive breast cancer with helical ct

BACKGROUND: The purpose of this study was to evaluate the accuracy of contrast-enhanced high resolution helical computed tomography (CT) for assessing locoregional staging of palpable T1-2 invasive breast cancer. METHODS: Helical CT studies of 156 lesions from 156 patients with invasive breast cancer before breast-conserving surgery were examined. A lesion was defined as positive if focal enhancement was detected by CT within 100 seconds after contrast material administration. After resection, tumors were histopathologically mapped and comparison made with the extent of contrast enhancement. RESULTS: Helical CT enabled detection of all 156 index tumors. CT enabled detection of 28 of 43 multifocal lesions (65%) and five of five multicentric lesions (100%). In 24 of 33 lesions (73%), CT revealed additional cancers not seen on mammography. The extent of tumor significantly correlated with CT measurements (r=0.76, p<0.0001). CONCLUSION: Helical CT of the breast is an accurate preoperative imaging modality for assessing the locoregional staging of T1-2 invasive breast cancer.