Imaging and management of nonpalpable lesions of the breast.

Mammography remains the primary imaging modality for the evaluation of breast disease. Its performance level is clearly related to strict quality control measures and comprehensive diagnostic imaging. Ultrasonography remains an adjunct tool for analysing nonpalpable and palpable masses; diagnostic criteria for benign lesions must be strictly applied. Reliable histologic diagnosis is possible with percutaneous large needle core biopsies; benign findings should always be correlated with imaging data and follow-up is essential to detect delayed false negatives. MR imaging is still under evaluation for most indications. Its high sensitivity and negative predictive value are of particular interest for the detection or elimination of breast cancer in selected populations.

Histological findings in surgical specimens after core biopsy of the breast.

Pathological changes induced by needling procedures found in breast surgical specimens are rare but can induce misinterpretation or compromise the definitive histological analysis. These abnormal findings depend on the interval between the core biopsy and excision. Early findings are local haemorrhage, disrupted tissue and epithelial cell displacement, whereas, fibrosis, fat necrosis and inflammatory reaction are observed later in time. The radiologists must be aware of these histological pitfalls and must consider the benefits of their core biopsies (indications, surgeon's question, number of samples).

Breast carcinoma in women previously treated for Hodgkin's disease: clinical and mammographic findings.

The aim of this study was to describe the radiological characteristics of breast cancers occurring after treatment of Hodgkin's disease (HD). This study identified 23 women (age range 28-70 years, mean age 40 years) with 29 breast cancers (22 infiltrating carcinomas, 5 in situ, 1 sarcoma, 1 indeterminate) who had previously undergone mantle irradiation (35-40 Gy) for HD. Clinical and mammographic data were reviewed by two radiologists. Dosimetry was available for 16 patients. Time from treatment of HD to the occurrence of breast cancer ranged from 15 months to 35 years (mean 18 years); 79% were younger than 45 years and 76% of cancers occurred between 10 and 25 years of follow-up. The physical examination was positive in 76% and 6 patients had bilateral tumors (synchronous, n = 2; metachronous, n = 4). Eighty-three percent of mammograms (n = 24) were abnormal (microcalcifications, n = 72%; opacity, n = 54%; two inflammatory breast cancers). Seven cancers were only detected by mammography, but mammograms were normal in 4 patients. Breast cancer was located beyond or was overlapping radiation fields in 75% of cases. Starting 10 years after mantle irradiation of women with HD, the follow-up should include annual clinical breast examination and mammography.

Differentiation between recurrent tumor and benign conditions after treatment of gynecologic pelvic carcinoma: value of dynamic contrast-enhanced subtraction MR imaging.

PURPOSE: To compare dynamic contrast material-enhanced subtraction and T2-weighted spin-echo (SE) magnetic resonance (MR) imaging in the differentiation of fibrosis from tumor recurrence during the follow-up of treated gynecologic pelvic malignancy. MATERIALS AND METHODS: Thirty-four patients (aged 24-82 years) with 18 benign and 35 malignant lesions confirmed by means of surgery (n = 18), biopsy (n = 25), or 18-month follow-up examination (n = 10) underwent dynamic contrast-enhanced subtraction and T2-weighted SE MR imaging. Contrast material enhancement of an abnormal pelvic structure within the first 90 seconds on dynamic contrast-enhanced subtraction images or high signal intensity on T2-weighted SE images was considered indicative of malignancy. RESULTS: The sensitivity, specificity, accuracy, and positive and negative predictive values were 91%, 67%, 83%, 86%, and 86%, respectively, for dynamic contrast-enhanced subtraction imaging and 91%, 22%, 68%, 70%, and 57%, respectively, for T2-weighted SE imaging. More lesions were correctly classified with dynamic contrast-enhanced subtraction imaging than with T2-weighted SE imaging (P < .01). CONCLUSION: Dynamic contrast-enhanced subtraction imaging is more accurate than T2-weighted SE imaging for differentiating fibrosis from tumor recurrence during the follow-up of treated gynecologic pelvic malignancy. However, use of both sequences is recommended.

Magnetic resonance imaging of the bone marrow in lymphomas and leukemias.

This article reviews MRI techniques and results in the assessment of bone marrow in patients with lymphoma. MRI is more sensitive than blind biopsy (BB) in detecting bone marrow invasion. False-negative results have been reported in low-grade non Hodgkin's lymphoma (NHL) and chronic lymphocytic leukemia. Bone marrow imaging is particularly indicated in patients with Hodgkin's disease, high grade NHL or myelocytic leukemia, with a negative BB and abnormal clinical (stage B, bone pains) or biochemical data (elevated alkaline phosphatase) and who have relapsed. During treatment. MR imaging is a valuable tool for the evaluation of response and the diagnosis of benign bone marrow complications. Knowledge of post-therapeutic patterns is essential to avoid misinterpretations. The main drawback with this technique is its inability to differentiate residual lesions from fibrosis and needle guided-biopsy is mandatory if treatment decision-making relies on the MR result, alone.

Mammographic patterns of inflammatory breast carcinoma: a retrospective study of 92 cases.

OBJECTIVE: To quantitate initial mammographic signs and to describe post-therapeutic patterns of inflammatory breast cancer. MATERIAL AND METHODS: Two radiologists retrospectively analyzed the initial clinical and mammographic findings of 92 patients with inflammatory breast carcinoma. The post-therapeutic mammogram (n = 75) was considered abnormal when focal opacity and or malignant-type microcalcifications were still visible. RESULTS: Redness of the skin, "peau d'orange' and increased temperature were the most common findings. A palpable mass was noted in 97% with axillary lymph node involvement in 83% of cases. All initial mammograms were abnormal. Isolated inflammatory signs were observed in 14% and malignant signs in 86% of patients (opacity = 77% and/or malignant-type microcalcifications = 47%). Skin thickening was seen in 93.5%, nipple inversion in 56.5%, increased breast density in 93.5%, stromal coarsening in 85% and hypervascularisation in 32.5% of mammograms. On post-therapeutic mammograms, 35 patients (46.5%) were suspected of having residual disease. During follow-up, 19 patients (25.3%) relapsed locally: 75% had abnormal post-therapeutic mammograms. CONCLUSION: The presence of isolated inflammatory signs on the mammogram is sufficient to suspect inflammatory breast carcinoma and biopsy must be performed in doubtful cases. Radical surgery is indicated when persistent malignant signs are still visible on mammogram after conservative treatment.

MR imaging during intracavitary brachytherapy of vaginal and cervical cancer: preliminary results.

Intracavitary brachytherapy is an effective treatment for gynecologic cancers. Twelve magnetic resonance (MR) imaging studies were performed during intracavitary brachytherapy (10 initial studies and two during repeat brachytherapy) in 10 patients with clear cell adenocarcinoma (n = 9) or epithelioma (n = 1). Fifty percent of the vaginal lesions did not demonstrate high signal intensity on T2-weighted images. Individually tailored molded applicators allowed easy detection of abnormal vaginal parietal thickening on T1-weighted images: Results in seven cases were concordant with results of clinical examination, and there were no false-negative results. MR imaging was useful in controlling the relationships between the tumor and the applicator and facilitated treatment planning, since the radiation dose to the tumor volume and adjacent critical organs could be calculated accurately. Limitations of MR imaging were underestimation of superficial vaginal tumors and the inability to differentiate between tumor and inflammation after recent surgery or repeat intracavitary brachytherapy. MR imaging during intracavitary brachytherapy appears to be a useful adjunct to clinical examination.

Dynamic contrast-enhanced subtraction versus T2-weighted spin-echo MR imaging in the follow-up of colorectal neoplasm: a prospective study of 41 patients.

PURPOSE: To compare dynamic contrast-enhanced subtraction (DCES) and T2-weighted spin-echo (SE) magnetic resonance (MR) imaging in the differentiation of fibrosis from recurrence during the follow-up of treated colorectal neoplasms. MATERIALS AND METHODS: Forty-one patients with 39 malignant and 16 benign lesions confirmed by means of surgery (n = 23), biopsy (n = 24), or 12-month follow-up examination (n = 8) underwent DCES MR imaging and T2-weighted SE MR imaging. Enhancement of an abnormal pelvic structure within the first 90 seconds on DCES images or high signal intensity on T2-weighted SE images was considered indicative of malignancy. RESULTS: Sensitivity, specificity, and positive and negative predictive values were, respectively, 97%, 81%, 93%, and 100% for DCES MR imaging and 77%, 56%, 81%, and 56% for T2-weighted MR imaging. The number of correctly classified lesions was significantly higher with DCES imaging compared with T2-weighted imaging (P < or = .006). CONCLUSION: DCES imaging is more accurate than T2-weighted SE imaging for differentiating fibrosis from recurrence during the follow-up of treated colorectal neoplasms.

Clustered breast microcalcifications: evaluation by dynamic contrast-enhanced subtraction MRI.

OBJECTIVE: Our goal was to evaluate dynamic contrast-enhanced subtraction MRI in the diagnosis of isolated clustered calcifications of the breast. MATERIALS AND METHODS: One hundred seventy-two patients underwent surgical biopsy for isolated clustered breast calcifications. Their mammograms showed round (n = 88) or linear/irregular (n = 84) microcalcifications. All patients had a preoperative Gd-DOTA-enhanced subtraction dynamic study. Any early contrast enhancement in the breast parenchyma concomitant with early enhancement of normal vessels was considered positive. RESULTS: Fifty-eight in situ carcinomas, 22 invasive carcinomas, and 92 benign lesions were found at histological analysis. Dynamic MR sequences showed early contrast enhancement in 76 of 80 malignant lesions (sensitivity 95%) and in 45 of 92 benign lesions (specificity 51%). Two invasive and two intraductal carcinomas did not show early contrast enhancement. Three independent observers agreed in rating early contrast enhancement in 143 of 172 lesions. CONCLUSION: Poor specificity limits the diagnostic accuracy of dynamic contrast-enhanced subtraction MRI in distinguishing benign from malignant microcalcifications on mammography.

Can clinical data help to screen patients with lymphoma for MR imaging of bone marrow?

BACKGROUND: Previous studies have suggested combining magnetic resonance (MR) imaging and biopsy in patients with lymphoma but association between MR results and clinical symptoms have never been investigated. The purpose of this retrospective study was to better delineate patients profiles requiring bone marrow (BM) imaging in lymphoma. MATERIAL AND METHODS: 50 MR studies and blind biopsies (BB) were reviewed in 40 patients with lymphoma. MR results were compared to clinical, laboratory-based and BM follow-up data to determine potential associations between MR results and these parameters. RESULTS: 46% of MR studies were abnormal with a normal BB; 2% were normal with an abnormal BB. Abnormal MR results were significantly associated with subsequent bone marrow involvement (p < 0.01). Abnormal MR studies were significantly associated with constitutional symptoms, bone pains (p < 0.05) and an elevated alkaline phosphatase level (p < 0.01). MR imaging excluded malignancy in three patients and caused therapy to be modified in three. CONCLUSION: Abnormal clinical and laboratory-based data should be used to screen patients with normal BB for MR imaging, especially in patients with Hodgkin's disease and high grade non-Hodgkin's lymphoma.

Ductal carcinoma in situ: MR imaging-histopathologic correlation.

PURPOSE: To correlate histopathologic and magnetic resonance (MR) imaging findings of ductal carcinoma in situ (DCIS). MATERIALS AND METHODS: Thirty-six women with DCIS underwent preoperative contrast material-enhanced subtraction dynamic MR imaging. Concomitant early contrast enhancement in the breast parenchyma with normal vessels was considered a positive finding. The size and shape of early enhancement were correlated with the size and density packing of ducts involved by DCIS. Tumor angiogenesis in the stroma that surrounded the ducts was evaluated with immunoperoxidase staining. RESULTS: Early contrast enhancement was demonstrated in 34 patients with DCIS but not in two patients with comedo-type DCIS. Tumor angiogenesis was demonstrated in the stroma. The size and morphology of contrast-enhanced lesions significantly correlated with the size (P = .0085) and density packing of ducts involved by DCIS (P = .012). CONCLUSION: Contrast enhancement on dynamic MR images of DCIS may be due to the presence of tumor angiogenesis in the stroma.

[Diagnosis of local breast cancer recurrences by magnetic resonance imaging]. / Diagnostic des récidives locales du cancer du sein par imagerie par résonance magnétique.

The aim of this study is to determine the diagnostic value of magnetic resonance imaging in the diagnosis of local recurrence of breast cancer. From 1991 to 1994, 61 women were studied prospectively using magnetic resonance imaging. All examinations were made on a 1.5 Testa machine with T1 weighted images and after gadolium-dota injection and dynamic images (T1 weighted sequences every 47 seconds during injection of a gadolinium-dota bolus). All the pre-injection, images in the dynamic series were subtracted from the images after injection. A surgical biopsy was obtained in 39 patients yielding a diagnosis of local recurrence (n = 28) or a benign lesion (n = 11). Among the 28 local recurrences, pathology examination reported invasive cancer in 22 and intra-ductal carcinoma in 6. In 22 patients with normal magnetic resonance imaging, follow-up examinations were performed every 6 months. There were no local recurrences within a delay of 6 to 36 months. Twenty-six of the 28 patients with a local recurrence, cystosteatonecrosis and surgery scar tissue less than 6 months old showed contrast uptake 1 min and 34 s after gadolinium injection during the dynamic sequence. This product uptake yielded nodular images within the invasive carcinomas and linear images in the intraductal cancers. In all cases, it is easier to visualize this contrast uptake in subtraction images. In conclusion, magnetic resonance imaging is a simple reliable method for the diagnosis of local recurrence of breast cancer.

Quantification of hemodynamics in primary pulmonary hypertension with magnetic resonance imaging.

The aims of this study were first to analyze pulmonary flow differences between patients with primary pulmonary hypertension (PPH) and volunteers, and second to determine whether magnetic resonance (MR) 3D Fourier encoding velocity imaging is capable of assessing hemodynamics in PPH. Pulmonary and aortic flows were quantified with MR imaging in 13 patients with PPH confirmed by right heart catheterization (RHC) within the same week and in 10 volunteers. MR pulmonary antegrade velocities, acceleration time (defined as the time from the onset of flow to the peak velocity), and arterial distensibility (maximal surface-minimal surface/minimal surface) were significantly different in patients (p < 0.05). MR pulmonary and aortic flow volumes correlated well with each other in the two populations (r = 0.98). Agreement between MR and RHC data was low: for the right cardiac output (mean difference) the 95% confidence interval was -0.88 to -0.22 L/min and for the right stroke volume 2.83 to 9.71 ml. However, the high coefficient correlations found between the two techniques showed that MR data could be used as indicators of right hemodynamics. 3D Fourier encoding-velocity sequence is a reliable noninvasive flow measurement method for the quantification of right hemodynamics in patients with PPH.

Focal areas of increased opacity in ductal carcinoma in situ of the comedo type: mammographic-pathologic correlation.

PURPOSE: To determine a histopathologic explanation for focal areas of increased opacity on mammograms of ductal carcinoma in situ of the comedo type (comedocarcinoma). MATERIALS AND METHODS: From January 1991 to January 1993, mammograms from 36 patients with comedocarcinomas were reviewed. Each mammogram was screened for microcalcifications and/or any focal area of increased opacity. The presence or absence of infiltrating components was confirmed at pathologic examination, with particular emphasis placed on the search for any stromal reaction. RESULTS: The clinical examination revealed a palpable tumor in five patients (14%) and a bloody discharge from the nipple in two (5%). Isolated clusters of microcalcifications were seen at mammography in 24 patients (67%). Nine patients (25%) had clusters associated with focal areas of increased opacity; three patients (8%) had no microcalcifications. Histologic analysis demonstrated an intense, periductal, inflammatory reaction in all 12 patients with focal areas of increased opacity. CONCLUSION: Focal areas of increased opacity are not always indicative of an infiltrating component and may merely represent intense stromal reaction.

Role of CT in chronic pulmonary embolism: comparison with pulmonary angiography.

To assess the value of CT in chronic pulmonary embolism (CPE), CT scans and pulmonary angiograms of 21 consecutive patients were reviewed. Computed tomography was better than angiography in assessing proximal clots (three thrombi not seen by angiography, three angiographic false-positives confirmed by surgery). Furthermore, CT was able to analyze pulmonary arteries distal to angiographic amputations. Computed tomography was less sensitive than angiography for vascular distortions (38 vs. 50%) and stenosis (35 vs. 71.8%). Pulmonary infarctions were better detected and characterized by CT than by angiography. Isolated parenchymal ground-glass opacities were seen by CT in 18 patients, especially in those with right cardiomegaly. High resolution CT delineated them better than did standard CT. Computed tomography may be a useful adjunct to angiography in the assessment of CPE.