Tumor texture parameters of invasive ductal breast carcinoma in neoadjuvant chemotherapy: early identification of non-responders on breast MRI.

PURPOSE: Texture analysis (TA) parameters (variance of SI, mean of gradient, variance of gradient, kurtosis of SI, and entropy) in patients with invasive ductal carcinoma (IDC) contribute to objective assessment of neoadjuvant chemotherapy (NACT) activity. The objective was to assess TA parameters in early identification of non-responders (NR) in NACT, after the 2nd cycle of NACT. MATERIAL AND METHODS: Fifty patients (N = 50) were included in the retrospective analysis of baseline and MRI following the 2nd cycle of NACT. TA parameters were computed and correlated to the lesion size and DWI-ADC in NR (N1 = 25). Additional matched responders (R, N2 = 25) assessed for the same parameters, served as the control group. RESULTS: Tumor size and ADC did not change significantly in NR after the 2nd cycle of NACT (2.88 ± 0.38 vs. 2.76 ± 0.36 [cm], p = 0.131; 1.01 ± 0.14 vs. 1.05 ± 0.13 [mm2/s × 10-3], p = 0.363), but TA parameters changed significantly: variance of gradient (346.5 ± 12.6 vs. 355.6 ± 16.9, p = 0.01), kurtosis of SI (1.47 ± 0.09 vs. 1.54 ± 0.11, p = 0.02), entropy LH (60.39 ± 4.34 vs. 64.42 ± 3.05, p = 0.001) and entropy HL (61.02 ± 5.51 vs. 65.63 ± 3.63, p < 0.00001). TA parameters, particularly entropy (EN LH 64.42 ± 3.05 vs. 61.59 ± 1.76, p < 0.0001; EN HL 65.63 ± 3.63 vs. 62.89 ± 2.05, p < 0.0001), significantly differ between NR and R in early response assessment. CONCLUSION: Entropy, kurtosis of SI and variance of gradient tend to increase in NR. TA parameters significantly differ between NR and R after the 2nd cycle of NACT. TA parameters, related to morpho-functional parameters may contribute to early NR identification.

Relative apparent diffusion coefficient (rADC) in breast lesions of uncertain malignant potential (B3 lesions) and pathologically proven breast carcinoma (B5 lesions) following breast biopsy.

PURPOSE: To assess relative apparent diffusion coefficient (rADC) and ADC in B3 and B5 lesions in premenopausal female patients, added to standard morpho-dynamic breast contrast-enhanced MRI. METHODS: 104 patients with histologically confirmed B3 (N1 = 52) and matched B5 lesions (N2 = 52), were examined on MRI (1.5 T, full diagnostic protocol, diffusion weighted imaging - b50, b850) in a retrospective analysis following the IRB approval: Atypical ductal hyperplasia (ADH, n1 = 20), Flat epithelial atypia (FEA, n2 = 11), Classic lobular neoplasia (CLN, n3 = 8), Papillary lesion (PL, n4 = 6) and Phyllodes tumor (PT, n5 = 7). rADC and ADC were computed for each lesion. The two-tailed Mann-Whitney U test was used for comparison with B5 lesions. RESULTS: Mean rADC value for B3 lesions, (N1 = 52): 0.81+/-0.08 mm2/s x 10-3 and B5 lesions, (N2 = 52): 0.58+/-0.07 mm2/s x 10-3 is statistically different (p < 0.00001). Mean rADC values [mm2/s x 10-3], per entity in B3 are: ADH, 0.82+/-0.06; FEA, 0.75+/-0.03; CLN, 0.73+/-0.03; PL, 0.94+/-0.02; PT 0.86+/-0.05. CONCLUSIONS: Although morpho-dynamic features of borderline and malignant lesions may overlap, the initial results in this research, suggest the highly significant difference in both ADC and rADC between B3 and B5 lesions. Larger trials are needed to confirm the initial data.

Breast Dynamic Contrast Enhanced MRI: Fibrocystic Changes Presenting as a Non-mass Enhancement Mimicking Malignancy.

BACKGROUND: We aimed to analyse the morphokinetic features of breast fibrocystic changes (nonproliferative lesions, proliferative lesions without atypia and proliferative lesions with atypia) presenting as a non-mass enhancement (NME)in dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) examination. PATIENTS AND METHODS: Forty-six patients with histologically proven fibrocystic changes (FCCs) were retrospectively reviewed, according to Breast Imaging Reporting and Data System (BI-RADS) lexicon. Prior to DCE-MRI examination, a unilateral breast lesion suspicious of malignancy was detected clinically, on mammography or breast ultrasonography. RESULTS: The predominant features of FCCs presenting as NME in DCE-MRI examination were: unilateral regional or diffuse distribution (in 35 patients or 76.1%), heterogeneous or clumped internal pattern of enhancement (in 36 patients or 78.3%), plateau time-intensity curve (in 25 patients or 54.3%), moderate or fast wash-in (in 31 patients or 67.4%).Nonproliferative lesions were found in 11 patients (24%), proliferative lesions without atypia in 29 patients (63%) and lesions with atypia in six patients (13%), without statistically significant difference of morphokinetic features, except of the association of clustered microcysts with proliferative dysplasia without atypia. CONCLUSIONS: FCCs presenting as NME in DCE-MRI examination have several morphokinetic features suspicious of malignancy, therefore requiring biopsy (BI-RADS 4). Nonproliferative lesions, proliferative lesions without atypia and proliferative lesions with atypia predominantly share the same predefined DCE-MRI morphokinetic features.

Vaginal packing volume impact on dose parameters during radiography and computed tomography based postoperative brachytherapy of cervical carcinoma.

PURPOSE: To investigate the influence of the vaginal packing volume on the registered dose parameters evaluated by radiography (2D) and computed tomography (CT) (3D) based brachytherapy planning in cervical cancer patients treated with postoperative radiotherapy. METHODS: The postoperative radiotherapy was performed in 40 cervical cancer patients with increased risk for disease relapse. Both, radiography and CT based brachytherapy planning were done in all patients. Vaginal packing volume was evaluated by clinical target volume (CTV)uk, assessed on CT scans and analyzed according to the registered dose parameters: doses delivered to the organs at risk (OAR) and the defined CTV, using both planning methods. RESULTS: CTVuk volume had statistically significant influence on CTV coverage with the prescribed brachytherapy doses D90 (p<0.01) and D100 (p<0.01), revealing a CTVuk cut-off value of 25.6 cm3. Dividing the patients into two groups according to the cutoff value, we found a statistical significance in the registered doses to the rectal wall and no significance in the bladder wall doses between the groups. Also, a statistically significant, negative correlation was found between CTVuk and following doses: Rmax (rho= -0.34, p<0.05), D0.1cc (rho= -0.76, p<0.01), D1cc (rho= -0.74, p<0.01) and D2cc (rho= -0.72, p<0.01), D90 (rho= -0.80, p<0.01), D100 (rho= -0.7, p<0.01). CONCLUSION: If the brachytherapy vaginal packing is of a large volume (more than 25.6 cm3), an asymmetric deformation of the proximal part of the vaginal cavity might appear, leading to inappropriate dose coverage of the CTV part of the vaginal mucosa. Also, making a vaginal packing volume larger than 25.6 cm3 made no further reduction in the bladder dose, but it made a statistically significant further reduction in the rectal doses.

Positive enhancement integral values in dynamic contrast enhanced magnetic resonance imaging of breast carcinoma: ductal carcinoma in situ vs. invasive ductal carcinoma.

OBJECTIVES: The aim of this study was to contribute to the standardization of the numeric positive enhancement integral (PEI) values in breast parenchyma, ductal carcinoma in situ (DCIS) and invasive ductal carcinoma (IDC) and to evaluate the significance of the difference in PEI values between IDC and parenchyma, DCIS and parenchyma and IDC and DCIS. MATERIALS AND METHODS: In the prospective trial, we analyzed the dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) of 60 consecutive patients with histologically confirmed unilateral DCIS (n=30) and IDC (n=30) and defined the PEI values (range; mean ± SD) for the lesions and the breast parenchyma. Tumor-to-non-tumor (T/NT) ratios were calculated for DCIS and IDC and compared. PEI color maps (PEICM) were created. The differences in PEI values between IDC and parenchyma and between DCIS and parenchyma were tested according to t-test. Analysis of variance (ANOVA) was used to test the differences between the mean PEI values of parenchyma, DCIS and IDC. RESULTS: IDC showed highly statistically different PEI numeric values compared to breast parenchyma (748.7 ± 32.2 vs. 74.6 ± 17.0; p<0.0001). The same applied to the differences in the group of patients with DCIS (428.0 ± 25.0 vs. 66.0 ± 10.6; p<0.0001). The difference between IDC, DCIS and parenchyma were also considered highly statistically significant (p<0.0001) and so were the T/NT ratios for IDC and DCIS (10.1 ± 2.4 vs. 6.6 ± 1.4; p<0.0001). CONCLUSIONS: PEI numeric values may contribute to differentiation between invasive and in situ breast carcinoma.

MRI in the evaluation of breast cancer patient response to neoadjuvant chemotherapy: predictive factors for breast conservative surgery.

PURPOSE: We aimed to prospectively assess the role of dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) in the evaluation of predictive factors for breast conservative surgery during neoadjuvant chemotherapy. MATERIALS AND METHODS: Sixty-six patients were evaluated before the first treatment cycle, after the second cycle, and upon the completion of neoadjuvant chemotherapy according to largest tumor diameter, tumor volume, postcontrast enhancement, and tumor regression pattern. The patients were divided into responders (pathologic complete and near complete response) and nonresponders. Each subgroup was re-evaluated according to morphokinetic criteria for identification of candidates for breast conservative surgery. RESULTS: In responders (n=27), the lesion size upon the completion of neoadjuvant chemotherapy was significantly smaller compared to nonresponders (1.5 ± 0.6 vs. 3.2 ± 0.9 cm; P < 0.001), as was the volume (1.2 vs. 11.0 cm(3); P < 0.001). The measured lesion size did not differ from the histologic size (1.5 ± 0.6 vs. 1.2 ± 0.6 cm; P = 0.09) and had a high correlation (r=0.93). In responders, the following parameters were significantly different before and after neoadjuvant chemotherapy: size (3.6 ± 1.4 to 1.5 ± 0.6 cm; P < 0.001), volume (17.6 to 1.2 cm(3); P < 0.001), predominant concentric regression, plateau and continuous time-intensity curves (P < 0.001). DCE-MRI has the sensitivity of 87% and the accuracy of 77% to identify candidates for breast conservative surgery. CONCLUSION: Selected morphokinetic DCE-MRI parameters may contribute to the multidisciplinary decision when considering the selection of candidates for breast conservative surgery.

Breast ductal carcinoma in situ: morphologic and kinetic MRI findings.

BACKGROUND: Adequate diagnosis of ductal carcinoma in situ (DCIS) could lead to efficacious treatment. Due to the fact that DCIS lesions can progress to invasive carcinomas and that the sensitivity of the standard examination - mammography - is between 70 and 80%, use of a more sensitive diagnostic tool was needed. In detection of DCIS, contrast-enhanced magnetic resonance imaging (CE-MRI) has the sensitivity up to 96%. OBJECTIVES: Morphological features and kinetic parameters were evaluated to define the most regular morphological, kinetic and morpho-kinetic patterns on MRI assessment of breast ductal carcinoma in situ (DCIS). PATIENTS AND METHODS: We retrospectively assessed eighteen patients with 23 histologically confirmed lesions (mean age, 52.4 ± 10.5 years). All patients were clinically and mammographically examined prior to MRI examination. RESULTS: DCIS appeared most frequently as non-mass-like lesions (12 lesions, 52.17%). The differences in the frequency of lesion types were statistically significant (P<0.05). The following morphological patterns were detected: A: no specific morphologic features, B: linear/branching enhancement, C: focal mass-like enhancement, D: segmental enhancement, E: segmental enhancement in triangular shape, F: diffuse enhancement, G: regional heterogeneous enhancement in one quadrant not conforming to duct distribution and H: dotted or granular type of enhancement with patchy distribution. The difference in the frequency of the proposed patterns was statistically significant (P<0.05). There were eight lesions with mass enhancement, and six with segmental lesions: regional and triangular. There was no statistically significant difference in the frequency of enhancement curve types (P>0.05). There was no significant difference in the frequency of morpho-kinetic patterns. CONCLUSION: Non-mass-like lesions, lesions with focal or segmental distribution, with a "plateau" enhancement curve type were the most frequent findings of DCIS lesions on MRI.

[The role of breast magnetic resonance imaging in the diagnosis of ductal carcinoma in situ].

Ductal carcinoma in situ (DCIS), the noninvasive breast malignant tumor originates from the terminal ductal-lobular units (TDLU). The typical feature of DCSI is the formation of calcifications. Up to 90% of DCIS are diagnosed on mammographic examinations, as clinically asymptomatic. Between 10% and 20% of DCIS remain mammographically occult due to the lack of calcifications and/ or small tumor dimensions. Contrast-enhanced breast magnetic resonance imaging (MRI) detects mammographically occult breast lesions, thus defining morphologic features of the lesion and the dynamics of signal intensity changes due to contrast enhancement. Distribution of contrast enhancement - signal intensity increase in DCIS most frequently includes segmental, ductal and linear patterns, followed by regional enhancement pattern, while the intralesional contrast uptake most frequently includes the nodular pattern with the areas of confluence. Postcontrast signal intensity increase in DCIS is most frequently fast in the initial phase (wash-in), while the whole dynamic of contrast-enhancement includes either of the three possible time-intensity curve (TIC) types (persistent, plateau or washout), although the plateau TIC is considered to be more frequent. Breast MRI has high sensitivity in the diagnosis of invasive breast cancer, varying from 90% to 100%; the sensitivity in the diagnosis of DCIS is lower (77-96%). For the time being, the primary role of MRI in DCIS is planning of breast-conserving surgery (BCS) for the evaluation of lesion extension. Further development of MRI in the diagnosis of DCIS includes the implementation of the principles of functional and molecular imaging.

Posterior breast cancer - mammographic and ultrasonographic features.

BACKGROUND/AIM: Posterior breast cancers are located in the prepectoral region of the breast. Owing to this distinctive anatomical localization, physical examination and mammographic or ultrasonographic evaluation can be difficult. The purpose of the study was to assess possibilities of diagnostic mammography and breast ultrasonography in detection and differentiation of posterior breast cancers. METHODS: The study included 40 women with palpable, histopathological confirmed posterior breast cancer. Mammographic and ultrasonographic features were defined according to Breast Imaging Reporting and Data System (BI-RADS) lexicon. RESULTS: Based on standard two-view mammography 87.5%, of the cases were classified as BI-RADS 4 and 5 categories, while after additional mammographic views all the cases were defined as BI-RADS 4 and 5 categories. Among 96 mammographic descriptors, the most frequent were: spiculated mass (24.0%), architectural distortion (16.7%), clustered micro-calcifications (12.6%) and focal asymmetric density (12.6%). The differentiation of the spiculated mass was significantly associated with the possibility to visualize the lesion at two-view mammography (p = 0.009), without the association with lesion diameter (p = 0.083) or histopathological type (p = 0.055). Mammographic signs of invasive lobular carcinoma were significantly different from other histopathological types (architectural distortion, p = 0.003; focal asymmetric density, p = 0.019; association of four or five subtle signs of malignancy, p = 0.006). All cancers were detectable by ultrasonography. Mass lesions were found in 82.0% of the cases. Among 153 ultrasonographic descriptors, the most frequent were: irregular mass (15.7%), lobulated mass (7.2%), abnormal color Doppler signals (20.3%), posterior acoustic attenuation (18.3%). Ultrasonographic BI-RADS 4 and 5 categories were defined in 72.5% of the cases, without a significant difference among various histopathological types (p = 0.109). CONCLUSION: Standard two-view mammography followed by additional mammographic projections is an effective way to demonstrate the spiculated mass and to classify the prepectoral lesion as category BI-RADS 4 or 5. Additional ultrasonography can overcome the mimicry of invasive lobular breast carcinoma at mammography.