Korean J Radiol.  2007 Dec;8(6):475-483. 10.3348/kjr.2007.8.6.475.

Targeted Ultrasound for MR-Detected Lesions in Breast Cancer Patients

• Shin JH
• Han BK
• Choe YH
• Ko K
• Choi N

• KMID: 1089434
• DOI: http://doi.org/10.3348/kjr.2007.8.6.475

Abstract

OBJECTIVE: To investigate the usefulness of targeted ultrasound (US) in the identification of additional suspicious lesions found by magnetic resonance (MR) imaging in breast cancer patients and the changes in treatment based on the identification of the lesions by the use of targeted US. MATERIALS AND METHODS: One-hundred forty nine patients who underwent breast MR imaging for a preoperative evaluation of breast cancer between January 2002 and July 2004 were included in the study. We searched all cases for any additional lesions that were found initially by MR imaging and investigated the performance of targeted US in identifying the lesions. We also investigated their pathological outcomes and changes in treatment as a result of lesion identification. RESULTS: Of the 149 patients with breast cancer, additional suspicious lesions were detected with MR imaging in 62 patients (42%). Of the 69 additional lesions found in those 62 patients, 26 (38%) were confirmed as cancers by histology. Thirty-eight lesions in 31 patients were examined with targeted US and were histologically revealed as cancers in 18 (47%), high risk lesions in two (5%), benign lesions in 15 (39%), and unidentified lesions in three (8%). The cancer rate was statistically higher in lesions with a US correlate than in lesions without a US correlate (p = 0.028). Of 31 patients, the surgical plan was altered in 27 (87%). The use of targeted US justified a change in treatment for 22 patients (81%) and misled five patients (19%) into having an unnecessary surgical excision. CONCLUSION: Targeted US can play a useful role in the evaluation of additional suspicious lesions detected by MR imaging in breast cancer patients, but is limited in lesions without a US correlate.

Keyword

Breast cancer; Magnetic resonance (MR); Ultrasound (US)

MeSH Terms

Adult
Aged
Biopsy
Breast/pathology
Breast Diseases/diagnosis/surgery
Breast Neoplasms/*diagnosis/surgery
Carcinoma, Ductal, Breast/*diagnosis/surgery
Carcinoma, Intraductal, Noninfiltrating/*diagnosis/surgery
Carcinoma, Lobular/*diagnosis/surgery
Contrast Media/administration & dosage
Diagnosis, Differential
False Negative Reactions
False Positive Reactions
Female
Humans
Image Enhancement/methods
Imaging, Three-Dimensional/methods
Magnetic Resonance Imaging/*methods
Middle Aged
Predictive Value of Tests
Sensitivity and Specificity
Ultrasonography, Mammary/*methods

Figure

• 

  Fig. 1 A 34-year-old woman with a 3-cm-sized palpable cancer of the right breast.A, B. A dynamic enhanced and subtracted T1-weighted sagittal MR image shows a 3 cm, irregular-shaped, enhancing malignant mass (arrow) (A). A small subareolar enhancing nodule (arrowhead) is additionally noted in the subareolar region in a different plane (B).C. A high signal intensity subareolar nodule (arrowhead) is noted on the reverse subtracted image.D. Targeted US depicts a 0.7 cm sized hypoechoic nodule (arrowhead) between the nipple and a palpable malignant mass (arrow). A US-guided biopsy of an additional lesion revealed an infiltrating ductal carcinoma. The surgical plan was changed from conservative breast surgery to a modified radical mastectomy with the consent of the patient.

• 

  Fig. 2 A 56-year-old woman with a nonpalpable US-detected cancer.A. A dynamic enhanced and subtracted T1-weighted sagittal MR image shows a spiculated malignant mass (arrow) in the upper outer portion of the right breast.B, C. Multiple aggregated enhancing nodules (arrowhead) (B) are additionally noted in the lower outer portion of the right breast. These nodules (arrowhead) show a high signal intensity on the reverse subtracted image (C).D. An initial US shows an irregular hypoechoic mass (arrow) in the upper outer portion of the right breast.E. On targeted US, a hypoechoic nodule (arrowhead) that was not detected at an initial US is noted at the 9 o'clock position of the right breast. The surgical biopsy after US-guided localization revealed an intraductal papilloma.

• 

  Fig. 3 A 40-year-old woman with a 1 cm palpable cancer of the left breast.A, B. Dynamic enhanced and subtracted T1-weighted sagittal MR images show a 1 cm intensely enhancing main mass (arrow) (A) in addition to a 5 cm clumped segmental enhancement with washout (arrowheads) (B) in a different plane.C. A high signal intensity (arrowheads) of a 5 cm clumped segmental enhancement is noted on the reverse subtracted image.D. Initial US shows only a 1 cm hypoechoic mass (arrow) at a palpable site.E. Targeted US shows a normal-looking, but slightly heterogeneous parenchyma. We interpreted that the additional enhancing lesion on MR had no US correlate. On a frozen section examination during the surgical operation, the additional enhancing lesion at the surrounding parenchyma revealed a malignancy, which was confirmed as an extensive intraductal carcinoma with an invasive ductal carcinoma following mastectomy. The surgical plan was changed from conservative breast surgery to mastectomy without the consent of the patient.

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  Fig. 4 A 43-year-old woman with a 1.5 cm palpable breast cancer.A. A dynamic enhanced and subtracted T1-weighted sagittal MR image shows a 1.8 cm, irregular-shaped, enhancing mass (arrow) at the upper outer portion of the left breast.B. Two additional suspicious enhancing lesions with washout (arrowheads) were noted at a different quadrant. Targeted US could not find a correlated lesion. Additional tissue excision and conserving surgery were performed due to this false positive finding of no US correlate. The final pathological diagnosis was fibrocystic change.C. High signal intensities of two additional lesions (arrowheads) are noted on the reverse subtracted image.

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