Assessment of breast cancer tumor size depends on method, histopathology and tumor size itself*

A Comprehensive Model Based on Dynamic Contrast-Enhanced Magnetic Resonance Imaging Can Better Predict the Preoperative Histological Grade of Breast Cancer Than a Radiomics Model

Background

Histological grade is an important prognostic factor for patients with breast cancer and can affect clinical decision-making. From a clinical perspective, developing an efficient and non-invasive method for evaluating histological grading is desirable, facilitating improved clinical decision-making by physicians. This study aimed to develop an integrated model based on radiomics and clinical imaging features for preoperative prediction of histological grade invasive breast cancer.

Methods

In this retrospective study, we recruited 211 patients with invasive breast cancer and randomly assigned them to either a training group (n=147) or a validation group (n=64) with a 7:3 ratio. Patients were classified as having low-grade tumors, which included grade I and II tumors, or high-grade tumors, which included grade III tumors. Three models were constructed based on basic clinical features, radiomics features, and the sum of the two. To assess diagnostic performance of the radiomics models, we employed measures such as receiver operating characteristic (ROC) curve, decision curve analysis (DCA), accuracy, sensitivity, and specificity, and the predictive performance of the three models was compared using the DeLong test and net reclassification improvement (NRI).

Results

The area under the curve (AUC) of the clinical model, radiomics model, and comprehensive model was 0.682, 0.833, and 0.882 in the training set and 0.741, 0.751, and 0.836 in the validation set, respectively. NRI analysis confirmed that the combined model was better than the other two models in predicting the histological grade of breast cancer (NRI=21.4% in the testing cohort).

Conclusion

Compared with the other models, the comprehensive model based on the combination of basic clinical features and radiomics features exhibits more significant potential for predicting histological grade and can better assist clinicians in optimal decision-making.

ACR Appropriateness Criteria® Monitoring Response to Neoadjuvant Systemic Therapy for Breast Cancer: 2022 Update

Imaging plays a vital role in managing patients undergoing neoadjuvant chemotherapy, as treatment decisions rely heavily on accurate assessment of response to therapy. This document provides evidence-based guidelines for imaging breast cancer before, during, and after initiation of neoadjuvant chemotherapy. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Surgical Planning after Neoadjuvant Treatment in Breast Cancer: A Multimodality Imaging-Based Approach Focused on MRI

Neoadjuvant chemotherapy (NACT) today represents a cornerstone in the treatment of locally advanced breast cancer and highly chemo-sensitive tumors at early stages, increasing the possibilities of performing more conservative treatments and improving long term outcomes. Imaging has a fundamental role in the staging and prediction of the response to NACT, thus aiding surgical planning and avoiding overtreatment. In this review, we first examine and compare the role of conventional and advanced imaging techniques in preoperative T Staging after NACT and in the evaluation of lymph node involvement. In the second part, we analyze the different surgical approaches, discussing the role of axillary surgery, as well as the possibility of non-operative management after-NACT, which has been the subject of recent trials. Finally, we focus on emerging techniques that will change the diagnostic assessment of breast cancer in the near future.

Three-dimensional ultrasound VOCAL combined with contrast-enhanced ultrasound: an alternative to contrast-enhanced magnetic resonance imaging for evaluating ablation of benign uterine lesions

OBJECTIVE

This study explores the feasibility and value of three-dimensional ultrasound virtual organ computer-aided analysis (3D-VOCAL) combined with contrast-enhanced ultrasound (CEUS) for measuring the non-perfused volume (NPV) after microwave ablation (MWA) of benign uterine lesions.

METHODS

Fifty-six patients with uterine myoma (UM) and adenomyosis (AM) treated with MWA were enrolled. NPV measurements were obtained postoperatively using two-dimensional CEUS (2D-CEUS), 3D-VOCAL combined with CEUS and three-dimensional contrast-enhanced magnetic resonance imaging (3D-CEMRI). Bland-Altman analysis and intraclass correlation coefficient (ICC) values were used to analyze the agreement of NPV measurements obtained via 2D-CEUS and the combined method with 3D-CEMRI. The inter- and intra-observer agreements of the NPV values obtained with all three methods were also analyzed.

RESULTS

Considering 3D-CEMRI as the standard, 3D-VOCAL showed greater agreement than 2D-CEUS and higher ICCs (ICC, 0.999 vs. 0.891) than 2D-CEUS for different lesion types and sizes of non-perfusion areas (p < 0.001 for all comparisons). NPV measurements obtained via 2 D-CEUS and 3 D-CEMRI differed significantly for AM and non-perfusion areas with maximum diameter ≥5 cm (p < 0.05) and showed no significant differences (p > 0.05) for UM and non-perfusion areas with maximum diameter <5 cm. The NPV measurements obtained via 3D-VOCAL and 3D-CEMRI did not differ significantly (p > 0.05). The intra- and inter-observer agreements of 3D-VOCAL measurements were better than those of 2D-CEUS and slightly lower than those of 3D-CEMRI.

CONCLUSIONS

3D-VOCAL combined with CEUS provides accurate estimates of NPV after MWA of benign uterine lesions, and offers a reliable, simple and efficient alternative to CEMRI.

Accuracy of conventional ultrasound, contrast-enhanced ultrasound and dynamic contrast-enhanced magnetic resonance imaging in assessing the size of breast cancer

OBJECTIVE

This study was performed to investigate the accuracy of conventional ultrasound (US), contrast-enhanced US (CEUS), and dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) in assessing the size of breast cancer.

METHODS

In total, 49 breast cancer lesions of 48 patients were included in this study. The inclusion criteria were the performance of total mastectomy or breast-conserving surgery for treatment of breast cancer in our hospital from January 2017 to December 2020 with complete pathological results, as well as the performance of conventional US, CEUS, and DCE-MRI examinations with complete results. The exclusion criteria were non-mass breast cancer shown on conventional US or DCE-MRI, including that found on CEUS with no boundary with surrounding tissues and no confirmed tumor scope; a tumor too large to be completely displayed in the US section, thus affecting the measurement results; the presence of two nodules in the same breast that were too close to each other to be distinguished by any of the three imaging methods; and treatment with preoperative chemotherapy. Preoperative conventional US, CEUS, and DCE-MRI examinations were performed. The postoperative pathological results were taken as the gold standard. The lesion size was represented by its maximum diameter. The accuracy, overestimation, and underestimation rates of conventional US, CEUS, and DCE-MRI were compared.

RESULTS

The maximum lesion diameter on US, CEUS, DCE-MRI and pathology were 1.62±0.63 cm (range, 0.6-3.5 cm), 2.05±0.75 cm (range, 1.0-4.0 cm), 1.99±0.74 cm (range, 0.7-4.2 cm) and 1.92±0.83 cm (range, 0.5-4.0 cm), respectively. The lesion size on US was significantly smaller than that of postoperative pathological tissue (P <  0.05). However, there was no significant difference between the CEUS or DCE-MRI results and the pathological results. The underestimation rate of conventional US (55.1%, 27/49) was significantly higher than that of CEUS (20.4%, 10/49) and DCE-MRI (24.5%, 12/49) (P <  0.001 and P = 0.002, respectively). There was no significant difference in the accuracy of CEUS (36.7%, 18/49) and DCE-MRI (34.7%, 17/49) compared with conventional US (26.5%, 13/49); however, the accuracy of both groups tended to be higher than that of conventional US. The overestimation rate of CEUS (42.9%, 21/49) and DCE-MRI (40.8%, 20/49) was significantly higher than that of conventional US (18.4%, 9/49) (P = 0.001 and P = 0.015, respectively).

CONCLUSIONS

CEUS and DCE-MRI show similar performance when evaluating the size of breast cancer. However, CEUS is more convenient, has a shorter operation time, and has fewer restrictions on its use. Notably, conventional US is more prone to underestimate the size of lesions, whereas CEUS and DCE-MRI are more prone to overestimate the size.

Invasive Lobular Carcinoma-Correlation Between Imaging and Final Pathology: Is MRI Better?

BACKGROUND

Invasive lobular carcinoma (ILC) is associated with high re-excision rates following breast-conserving surgery (BCS). The correlation between lesion size on different imaging modalities and final tumor size has not been well characterized.

METHODS

A prospective database of patients with stage I-III breast cancer undergoing BCS between 2006 and 2016 was reviewed. Pearson correlation analysis was used to correlate tumor size on breast imaging to final pathology.

RESULTS

Of these, 111 patients with ILC were identified. Mean lesion size was 1.93 cm for MMG, 1.61 cm for US, and 2.51 cm for MRI. Mean tumor size on surgical excision was 2.64 cm. The correlation coefficient between pathology and the different imaging modalities were as follows: MMG .17, US 0.37, and MRI .58. Actual tumor size was underestimated by 1 cm in 27.1% of MMGs, 50% of USs, and in 13.3% of MRIs. 38 patients (34.2%) underwent re-excision. No differences in re-excision rates were noted in patients with and without MRI, 30.3% vs 40.0%, respectively (P = .31).

CONCLUSION

While MRI provides a better estimate of tumor size than MMG and US, the size of the tumor on imaging only weakly correlated with pathology. The use of MRI does not decrease re-excision rates.

Accurate Estimation of Breast Tumor Size: A Comparison Between Ultrasonography, Mammography, Magnetic Resonance Imaging, and Associated Contributing Factors

Objective

This study aimed to provide further evidence on the accuracy of tumor size estimates and influencing factors.

Materials and Methods

In this cross-sectional study, patients with a biopsy-proven diagnosis of breast cancer referred to our hospital to obtain a preoperative magnetic resonance imaging (MRI) between 2015 and 2016 were included. Data from 76 breast cancer patients with 84 lesions were collected. All participants underwent ultrasonography and MRI, and their mammograms (MGMs) were reevaluated for tumor size estimation. Measurements by the three imaging modalities were compared with the pathologically determined tumor size to assess their accuracy. Influencing factors such as surgical management, molecular and histopathological subtypes, and Breast Imaging Reporting and Data System enhancement types in MRI were also assessed.

Results

The rates of concordance with the gold standard were 64.3%, 76.2%, and 82.1% for MGM, ultrasound (US), and MRI measurements, respectively. Therefore, the highest concordance rate was observed in MRI-based estimates. Among the discordant cases, US and MGM underestimation were more prevalent (70%); nevertheless, MRI showed significant overestimation (80%). Tumor size estimates in patients whose MRIs presented with either non-mass enhancement [p=0.030; odds ratio (OR)=17.2; 95% confidence interval (CI): 1.3-225.9] or mass lesion with non-mass enhancement (p=0.001; OR=51.0; 95% CI: 5.0-518.4) were more likely to be discordant with pathological measurements compared with those in cases with only mass lesion on their MRIs.

Conclusion

MRI was more accurate than either US or MGM in estimating breast tumor size but had the highest overestimation rate. Therefore, caution should be practiced in interpreting data obtained from subjects whose MRIs present with non-mass enhancement or mass lesion with non-mass enhancement.

Accuracy of tumor size measurement on shear wave elastography (SWE): Correlation with histopathologic factors of invasive breast cancer

The aim of this study is to investigate the accuracy of tumor size assessment by shear wave elastography (SWE) in invasive breast cancer and also evaluated histopathologic factors influencing the accuracy.A total of 102 lesions of 102 women with breast cancers of which the size was 3 cm or smaller were included and retrospectively analyzed. Tumor size on B-mode ultrasound (US) and SWE were recorded and compared with the pathologic tumor size. If tumor size measurements compared to pathological size were within ±3 mm, they were considered as accurate. The relationship between the accuracy and histopathologic characteristics were evaluated.The mean pathologic tumor size was 16.60 ± 6.12 mm. Tumor sizes on SWE were significantly different from pathologic sizes (18.00 ± 6.71 mm, P < 0.001). The accuracy of SWE (69.6%) was lower than that by B-mode US (74.5%). There was more size overestimation than underestimation (23.5% vs 6.9%) using SWE. Conversely, there was more size underestimation than overestimation (18.6% vs 6.9%) using B-mode US. The accuracy of SWE was associated with ER positivity (P = .004), PR positivity (P = .02), molecular subtype (P = .02), and histologic grade (P = .03). In the multivariate analysis, ER positivity (P = .002) and molecular subtype (P = .027) significantly influenced the accuracy of tumor size measurement by SWE.In conclusion, the accuracy of the tumor size measured with SWE was lower than that measured with B-mode US and SWE tends to overestimate the size. ER positivity and molecular subtype are significantly associated with the accuracy of SWE in tumor size assessment.

Breast Specimen Measurement Methodology and Its Potential Major Impact on Tumor Size

OBJECTIVE

Pathologic tumor size assessment highly depends on the gross specimen size once microscopic cancer size exceeds its macroscopic size, in particular if the dimension along the plane of sectioning is the greatest. We hypothesize that the method by which the specimen size is estimated can yield significantly different tumor size measurements and thus affect breast cancer staging and treatment.

METHODS

The size in the plane of sectioning of 50 lumpectomies over 4 cm was examined by 5 methods: measured grossly in the fresh state and postfixation, and calculated from the gross measurements by 3 different methods. For 15 mastectomies, we measured and calculated the span of the middle 4 and 6 slices using 3 methods.

RESULTS

For all 50 lumpectomies, fresh measurement yielded the largest size. The difference in size of lumpectomies was greater with increasing specimen size (P < .001). Using the method of adding 0.4 cm per each submitted sequential section yielded the smallest size in most cases. In mastectomies the span of the middle 4 and 6 slices was significantly larger if calculated from the average slice thickness based on the specimen size.

CONCLUSION

The method of specimen size measurement has implications in estimation of tumor size and patient management. It is essential that pathologists be aware of the technique used and its limitations. For individual slice thickness, we highly recommend using the measurements obtained at the time of grossing rather than calculating the average slice thickness from the specimen size.

Can conventional DWI accurately assess the size of endometrial cancer?

PURPOSE

To compare T2-weighted image (T2WI) and conventional Diffusion-weighted image (cDWI) of magnetic resonance imaging (MRI) for sensitivity of qualitative diagnosis and accuracy of tumor size (TS) measurement in endometrial cancer (EC). Meanwhile, the effect of the lesion size itself and tumor grade on the ability of T2WI and cDWI of TS assessment was explored. Ultimately, the reason of deviation on size evaluation was studied.

MATERIALS AND METHODS

34 patients with EC were enrolled. They were all treated with radical hysterectomy and performed MR examinations before operation. Firstly, the sensitivity of T2WI alone and T2WI-DWI in qualitative diagnosis of EC were compared according to pathology. Secondly, TS on T2WI and cDWI described with longitudinal (LD) and horizontal diameter (HD) were compared to macroscopic surgical specimen (MSS) quantitatively in the entire lesions and the subgroup lesions which grouped by postoperative tumor size itself and tumor grade. Thirdly, the discrepancy of mean ADC values (ADC mean) and range ADC values (ADC range) between different zones of EC were explored.

RESULTS

For qualitative diagnosis, the sensitivity of T2WI-DWI (97%) was higher than T2WI alone (85%) (p = 0.046).For TS estimation, no significant difference (PLD = 0.579; PHD = 0.261) was observed between T2WI (LDT2WI = 3.90 cm; HDT2WI = 2.88 cm) and MSS (LD = 4.00 cm; HD = 3.06 cm), whereas TS of cDWI (LDDWI = 3.01 cm; HDDWI = 2.54 cm) were smaller than MSS (PLD = 0.002; PHD = 0.002) in all lesions. In subgroup of tumor with G1 (grade 1) and small lesion (defined as maximum diameter < 3 cm), both T2WI and cDWI were not significantly different from MSS; In subgroup of tumor with G2 + 3 (grade 2 and grade 3) and big lesion (maximum diameter ≥ 3 cm), T2WI matched well with MSS still, but DWI lost accuracy significantly. The result of ADC values between different zones of tumor showed ADC mean of EC rose from central zone to peripheral zone of tumor gradually and ADC range widened gradually.

CONCLUSION

cDWI can detect EC very sensitively. The TS on cDWI was smaller than the fact for the ECs with G2/3 and big size. The TS of T2WI was in accordance with the actual size for all ECs. The heterogeneity may be responsible for the inaccuracy of cDWI.

Terminal digit preference: a source of measurement error in breast cancer diameter reporting

Objectives: Women diagnosed with breast cancer are offered treatment and therapy based on tumor characteristics, including tumor diameter. There is scarce knowledge whether tumor diameter is accurately reported, or whether it is unconsciously rounded to the nearest half-centimeter (terminal digit preference). This study aimed to assess the precision (number of digits) of breast cancer tumor diameters and whether they are affected by terminal digit preference. Furthermore, we aimed to assess the agreement between mammographic and histopathologic tumor diameter measurements.Material and Methods: This national registry study included reported mammographic and registered histopathologic tumor diameter information from the Cancer Registry of Norway for invasive breast cancers diagnosed during 2012-2016. Terminal digit preference was assessed using histograms. Agreement between mammographic and histopathologic measurements was assessed using the intraclass correlation coefficient (ICC) and Bland-Altman plots.Results: Mammographic, histopathologic, or both tumor measurements were available for 7792, 13,541 and 6865 cases, respectively. All mammographic and 97.2% of histopathologic tumor diameters were recorded using whole mm. Terminal digits of zero or five were observed among 38.7% and 34.8% of mammographic and histopathologic measurements, respectively. There was moderate agreement between the two measurement methods (ICC = 0.52, 95% CI: 0.50-0.53). On average, mammographic measurements were 1.26 mm larger (95% limits of agreement: -22.29-24.73) than histopathologic measurements. This difference increased with increasing tumor size.Conclusion: Terminal digit preference was evident among breast cancer tumor diameters in this nationwide study. Further studies are needed to investigate the potential extent of under-staging and under-treatment resulting from this measurement error.

Systematic review of agreement between tomosynthesis and pathologic tumor size for newly diagnosed breast cancer and comparison with other imaging tests

INTRODUCTION

Tomosynthesis is proposed to improve breast cancer assessment and staging as a complementary role to its detection capability. We examine the accuracy of tomosynthesis in measuring tumor size relative to pathology and compared with other tests.

AREAS COVERED

A systematic literature search identified studies of tomosynthesis in estimating the size of newly diagnosed breast cancers. Descriptive analyses were performed due to heterogeneity in patients, technology, and methods between studies. Eight studies were eligible (678 patients). Mean differences (MDs) between measurements (tomosynthesis-pathology) were generally small; overestimation (MDs of 1-3 mm) and underestimation (-1 mm) were reported. Limits of agreement (LOA) ranged between ±10 mm and ±28 mm. MDs did not differ in high and low breast densities. Large underestimation (-11 mm) and wide LOA (±41 mm) were reported for invasive lobular carcinoma. MDs and LOA were lower for tomosynthesis than mammography, but differences between tests were small.

EXPERT COMMENTARY

Although tomosynthesis is a promising technology for assessing breast cancer size, few studies in that context had limitations (small sample sizes, heterogeneous populations, and technologies). Studies using current technology and appropriate statistical methods are required to establish the magnitude of improvement in measurement accuracy, and patients for whom the test may be of most benefit.

ACR Appropriateness Criteria® Monitoring Response to Neoadjuvant Systemic Therapy for Breast Cancer

Patients with locally advanced invasive breast cancers are often treated with neoadjuvant chemotherapy prior to definitive surgical intervention. The primary aims of this approach are to: 1) reduce tumor burden thereby permitting breast conservation rather than mastectomy; 2) promptly treat possible metastatic disease, whether or not it is detectable on preoperative staging; and 3) potentially tailor future chemotherapeutic decisions by monitoring in-vivo tumor response. Accurate radiological assessment permits optimal management and planning in this population. However, assessment of tumor size and response to treatment can vary depending on the modality used, the measurement technique (such as single longest diameter, 3-D measurements, or calculated tumor volume), and varied response of different tumor subtypes to neoadjuvant chemotherapy (such as concentric shrinkage or tumor fragmentation). As discussed in further detail, digital mammography, digital breast tomosynthesis, US and MRI represent the key modalities with potential to help guide patient management. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Estimation of tumor size in breast cancer comparing clinical examination, mammography, ultrasound and MRI-correlation with the pathological analysis of the surgical specimen

BACKGROUND

To evaluate the best method in our center to measure preoperative tumor size in breast tumors, using as reference the tumor size in the postoperative surgical specimen. We compared physical examination vs. mammography vs. resonance vs. ultrasound. There are different studies in the literature with disparate results.

METHODS

This is a retrospective study. All the included patients have been studied by clinical examination performed by gynecologist or surgeon specialists in senology, and radiological tests (mammography, ultrasound and magnetic resonance imaging). The correlation of mammary examination, ultrasound, mammography and resonance with pathological anatomy was studied using the Pearson index. Subsequently, the results of such imaging tests were compared with the tumor size of the infiltrating component measured by anatomopathological study using a student's t test for related variables. The level of significance was set at 95%. Statistical package R. was used.

RESULTS

A total of 73 cases were collected from October 2015 to July 2016 with diagnosis of infiltrating breast carcinoma. Twelve cases of carcinoma in situ and seven cases of neoadjuvant carcinoma are excluded. Finally, a total of 56 cases were included in the analysis. The mean age of the patients is 57 years. The histology is of infiltrating ductal carcinoma in 46 patients (80.7%), lobular in 8 (14%) and other carcinomas in 3 cases (5.2%). We verified the relationship between preoperative tumor size by physical examination, mammography, ultrasound (US) and magnetic resonance imaging (MRI), and the final size of the surgical specimen by applying a Pearson correlation test. A strong correlation was found between the physical examination results 0.62 (0.43-0.76 at 95% CI), ultrasound 0.68 (0.51-0.8 at 95% CI), mammography 0.57 (0.36-0.72 at 95% CI) and RM 0.51 (0.29-0.68 at 95% CI) with respect to pathological anatomy. The mean tumor size of the surgical specimen was 16.1 mm. Mean of tumor size by physical examination was 12.1 mm (P<0.05), by 14 mm US (P<0.05), by mammography of 14.3 (P<0.05) and by MRI of 22.53 mm (P>0.05).

CONCLUSIONS

Ultrasonography is the best predictor of tumor size in breast cancer, compared with clinical examination, mammography, and resonance. Our work could help the decision-making process such as the type of conservative surgery, the possible need for oncoplastic surgery or the decision to start treatment with neoadjuvant therapy, in patients with unifocal tumors.

Variations in the sonographic measurement techniques of BI-RADS 3 breast masses

OBJECTIVE

To evaluate the differences in sonographic (US) distance and volume measurements from different sonologists and identify the optimal parameters to avoid clinically relevant variations in the measurement of BI-RADS 3 breast masses.

METHODS

For this cross-sectional study with prospectively collected data, four physicians with various levels of experience in US, herein called sonologists, performed distance and volume US measurements of 80 masses classified as BI-RADS 3. The Cochran Q test was used to compare the matched sets of rates of clinically relevant variability between all pairs of sonologists' measurements.

RESULTS

There were clinically relevant differences between sonologists in the measurements of the longest diameter (range, 17.5-43.7%, p = 0.003), the longest diameter perpendicular to the previous one (anteroposterior diameter) (17.5-33.7%, p = 0.06), the third diameter orthogonal to the plane defined by the previous two (transverse diameter) (28.7-55%, p = 0.001), and at least two of those three diameters (18.7-38.7%, p = 0.015). The smallest clinically relevant differences were observed with volume measurements (range of differences, 6.2-13.7%, p = 0.51).

CONCLUSIONS

Volume measurement technique was associated with the least variations, whereas distance measurements, which are used routinely, were associated with unacceptable rates of clinically relevant variations. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 45:252-260, 2017.

Accuracy of Tumor Sizing in Breast Cancer: A Comparison of Strain Elastography, 3-D Ultrasound and Conventional B-Mode Ultrasound with and without Compound Imaging

The objective of this study was to compare the accuracy of strain elastography (SE), 3-D ultrasound (US), B-mode US with compound imaging (CI) and B-mode US without compound imaging for lesion sizing in breast cancer. The prospective study included 93 patients with invasive breast cancer. The largest tumor diameters measured by B-mode US, B-mode US with CI, SE and 3-D US were compared in Bland-Altman plots versus pathology as reference. A general linear model repeated measures (GLM Rep) was applied to investigate factors influencing tumor sizing. All methods underestimated pathologic size, with SE (-0.08 ± 7.7 mm) and 3-D US (-1.4 ± 6.5 mm) having the smallest mean differences from pathology. Bland-Altman plots revealed that B-mode US, B-mode US with CI and 3-D US systematically underestimated large tumor sizes, and only SE was technically comparable to pathology. The study indicates that sonographic underestimation of tumor size occurs mainly in tumors >20 mm; in this subgroup, SE is superior to other ultrasound methods.

Tumor Size of Invasive Breast Cancer on Magnetic Resonance Imaging and Conventional Imaging (Mammogram/Ultrasound): Comparison with Pathological Size and Clinical Implications

BACKGROUND AND AIM

In Landspitali University Hospital, magnetic resonance imaging is used non-selectively in addition to mammogram and ultrasound in the preoperative assessment of breast cancer patients. The aim of this study was to assess invasive tumor size on imaging, compare with pathological size and evaluate the impact of magnetic resonance imaging on the type of surgery performed.

MATERIAL AND METHODS

All women with invasive breast cancer, diagnosed in Iceland, between 2007 and 2009 were reviewed retrospectively. In all, 438 of 641 (68%) patients diagnosed had preoperative magnetic resonance imaging. Twelve patients treated with neoadjuvant chemotherapy were excluded and 65 patients with multifocal or contralateral disease were assessed separately.

RESULTS

Correlations between microscopic and radiologic tumor sizes were relatively weak. All imaging methods were inaccurate especially for large tumors, resulting in an overall underestimation of tumor size for these tumors. Magnetic resonance imaging under- and overestimated pathological tumor size by more than 10 mm in 16/348 (4.6%) and 26/348 patients (7.5%), respectively. In 19 patients (73%), overestimation of size was seen exclusively on magnetic resonance imaging. For tumors under- or overestimated by magnetic resonance imaging, the mastectomy rates were 56% and 65%, respectively, compared to an overall mastectomy rate of 43%. Of 51 patients diagnosed with multifocal disease on pathology, 19 (37%) were diagnosed by mammogram or ultrasound and 40 (78%) by magnetic resonance imaging resulting in a total detection rate of 84% (43 patients). Fourteen (3%) patients were diagnosed preoperatively with contralateral disease. Of those tumors, all were detected on magnetic resonance imaging but seven (50%) were also detected on mammogram or ultrasound or both.

CONCLUSION

Our results suggest that routine use of magnetic resonance imaging may result in both under- and overestimation of tumor size and increase mastectomy rates in a small proportion of patients. Magnetic resonance imaging aids in the diagnosis of contralateral and multifocal disease.

Surgical Resection Margins after Breast-Conserving Surgery: Senonetwork Recommendations

This paper reports findings of the “Focus on Controversial Areas” Working Party of the Italian Senonetwork, which was set up to improve the care of breast cancer patients. After reviewing articles in English on the MEDLINE system on breast conserving surgery for invasive carcinoma, the Working Party presents their recommendations for identifying risk factors for positive margins, suggests how to manage them so as to achieve the highest possible percentage of negative margins, and proposes standards for investigating resection margins and therapeutic approaches according to margin status. When margins are positive, approaches include re-excision, mastectomy, or, as second-line treatment, radiotherapy with a high boost dose. When margins are negative, boost administration and its dose depend on the risk of local recurrence, which is linked to biopathological tumor features and surgical margin width. Although margin status does not affect the choice of systemic therapy, it may delay the start of chemotherapy when further surgery is required.

Comparative accuracy of preoperative tumor size assessment on mammography, sonography, and MRI: Is the accuracy affected by breast density or cancer subtype?

PURPOSE

To compare the accuracy of preoperative breast tumor size measurements obtained on three imaging modalities (mammography [MM], sonography [US], and MRI) with those obtained on final pathologic examination for different breast densities and various tumor types.

METHODS

Records from patients who underwent breast cancer lumpectomy between 2008 and 2012 and in whom tumor was seen on all three imaging modalities were retrospectively reviewed for maximum tumor size measurements. Patients with positive tumor margins and those who had undergone neoadjuvant chemotherapy were excluded. Tumor size measurements obtained on the three imaging modalities were compared for accuracy with those obtained during the final pathologic examination. Differences were analyzed for the whole group and for subgroups according to breast density and tumor type.

RESULTS

In total, 57 patients were included, in whom wire-localization lumpectomy was performed without neoadjuvant chemotherapy; negative surgical margins for tumor were obtained, and tumor was preoperatively visualized on all three imaging modalities. The mean (± SEM) tumor size measured on MRI was significantly greater than that measured on pathology (p < 0.001), whereas the sizes measured on US and MM were not statistically significantly different from that measured on pathology (p = 0.62 and p = 0.57). Tumor size measured on MRI was greater than that measured on both US and MM (p = 0.003 and p < 0.001). Compared with the measurements obtained on pathology, that obtained on US showed moderate agreement (Lin concordance correlation coefficient [CCC], 0.71; 95% confidence interval [CI], 0.56-0.82); poorer agreement was found for the sizes obtained on MM (CCC, 0.58; 95% CI, 0.38-0.72) and MRI (CCC, 0.50; 95% CI, 0.31-0.65). No difference in comparative accuracy of size measurement was noted between dense and nondense breast tissue. MRI overestimated tumor size in ductal cancers (p < 0.001) and slightly underestimated it in lobular cancers.

CONCLUSIONS

Preoperative MRI significantly overestimated tumor size. Measurements obtained on US and MM were more accurate irrespective of breast density, with US measurements being slightly more accurate than MM measurements.

Shear Wave Elastography (SWE): An Analysis of Breast Lesion Characterization in 83 Breast Lesions

Qualitative and quantitative shear wave elastography (SWE) criteria were assessed to differentiate between malignant and benign breast lesions. This prospective study included 83 lesions. SWE features measured included maximal stiffness values inside the lesion (E(lesion)) and in the peri-lesion area (E(perilesion)) and ratio values (R(lesion) and R(perilesion)) according to the formula E(lesion) or E(perilesion)/E(fat), with E(fat) corresponding to normal fatty tissue. We compared ultrasonography (B-mode), SWE and histologic sizes. With qualitative and quantitative SWE analysis, sensitivity was 94% and specificity 73%. Malignant lesions appeared more heterogeneous, with higher stiffness and ratio values than benign lesions (p < 0.001). For malignant lesions, SWE size was better correlated to histologic size than B-mode size. Using benign SWE signs to selectively downgrade category 4a and 4b lesions, the specificity improved from 13% to 51% without loss in sensitivity (100%) compared to ultrasound.

Comparison of primary breast cancer size by mammography and sonography

PURPOSE

To compare tumor size by mammography and sonography and align with pathological results in primary breast cancer cases.

MATERIALS AND METHODS

We retrospectively reviewed 95 primary breast cancer patients who underwent mammography and sonography from January 2011 to June 2012. The largest tumor diameter was chosen as sizing reference for each imaging modality. The measurements of mammography and sonography were considered concordant if they were within the measurement of pathological results±0.5 cm. Pearson's correlation coefficient was calculated for imaging results.

RESULTS

The range of the maximum diameter was 0.6 cm-10.5 cm and mean value was 3.81±2.04 cm by pathological results, 0.7 cm-12.4 cm and 3.99±2.19 cm by mammography, and 0.9 cm-11.0 cm and 3.63±2.01 cm by sonography, respectively. Sonography (R: 0.754), underestimated tumor size, but had a better correlation with pathological tumor size compared to mammography (R: 0.676), which overestimated tumor size.

CONCLUSIONS

Sonography is superior to mammography in assessment of primary breast cancer.

Breast contrast-enhanced ultrasound: is a scoring system feasible? A preliminary study in China

OBJECTIVES

Although many studies about breast contrast-enhanced ultrasound had been conducted, clear diagnostic criteria for evaluating enhancement patterns are still lacking. This study aims to identify significant indicators for breast contrast-enhanced ultrasound and to establish an initial scoring system.

MATERIALS AND METHODS

Totally 839 patients were included in the study. This study was divided into two parts. 364 patients were included in part 1 while 475 in part 2. Conventional ultrasound and contrast-enhanced ultrasound were used to examine each lesion. Only the cases in part 2 were also examined by elastography. In part 1, Logistic regression analysis was performed to predict significant variables. A 5-point scoring system was developed based on the results. In part 2, the scoring system was used to evaluate all the breast lesions. To evaluate the diagnostic efficacy of the new scoring system, it was compared with the system established for elastography and conventional ultrasound (BI-RADS).

RESULTS

Three independent variables, namely, lesion scope, margin, and shape were selected in the final step of the logistic regression analysis in part 1. In part 2, the area under the ROC (receiver operating characteristic) curve for the contrast-enhanced scoring system was 0.912. The difference in the diagnostic capabilities of the contrast-enhanced scoring system and elastography was not statistically significant (P = 0.17). The difference in the diagnostic capabilities of the contrast-enhanced scoring system and BI-RADS was statistically significant (P<0.001).

CONCLUSIONS

The contrast-enhanced patterns of benign and malignant breast tumors are different. The application of a 5-point scoring system for contrast-enhanced ultrasound is clinically promising.

Freehand elastography for determination of breast cancer size: comparison with B-mode sonography and histopathologic measurement

OBJECTIVES

Elastography assesses the strain of soft tissues and is used to enhance diagnostic accuracy in evaluating breast tumors, but minimal data exist on its ability to accurately assess tumor size. This study was performed to assess the preoperative accuracy of measuring the size of biopsyproven breast cancer lesions with elastography and conventional B-mode sonography compared with the reference standard size measured by histopathologic examination.

METHODS

Elastography and conventional B-mode sonography were performed on 69 women with histologically proven breast cancer, and tumor sizes on both modalities were recorded. These measurements were compared with the final pathologic size, which was used as the reference standard. The sizes and differences between sonographic, elastographic, and pathologic measurements were statistically tested, and an analysis of equivalence to the reference standard was performed using Bland-Altman plots.

RESULTS

There was a significant difference between sizes on elastography and pathologic examination, with elastography overestimating the tumor size (P = .0187). Sonography slightly underestimated the tumor size, but this finding was not significant (P = .36). Bland-Altman plots confirmed that sonography but not elastography was an acceptable standard compared with the pathologic size.

CONCLUSIONS

Breast elastography but not B-mode sonography overestimates the size of breast tumors compared with the final pathologic size.

FemZone trial: a randomized phase II trial comparing neoadjuvant letrozole and zoledronic acid with letrozole in primary breast cancer patients

BACKGROUND

The objective of this prospectively randomized phase II trial (Trial registration: EUCTR2004-004007-37-DE) was to compare the clinical response of primary breast cancer patients to neoadjuvant therapy with letrozole alone (LET) or letrozole and zoledronic acid (LET + ZOL).

METHODS

Patients were randomly assigned to receive either LET 2.5 mg/day (n = 79) or the combination of LET 2.5 mg/day and a total of seven infusions of ZOL 4 mg every 4 weeks (n = 89) for 6 months. Primary endpoint was clinical response rate as assessed by mammogram readings. The study was terminated prematurely due to insufficient recruitment. We report here on an exploratory analysis of this data.

RESULTS

Central assessment of tumor sizes during the treatment period was available for 131 patients (66 LET, 65 LET + ZOL). Clinical responses (complete or partial) were seen in 54.5% (95% CI: 41.8-66.9) of the patients in the LET arm and 69.2% (95% CI: 56.6-80.1) of those in the LET + ZOL arm (P = 0.106). A multivariate model showed an OR of 1.72 (95% CI: 0.83-3.59) for the experimental arm.

CONCLUSION

No increase in the clinical response rate was observed with the addition of ZOL to a neoadjuvant treatment regimen with LET. However a trend towards a better reponse in the LET + ZOL arm could be observed. This trend is consistent with previous studies that have investigated the addition of ZOL to chemotherapy, and it may support the evidence for a direct antitumor action of zoledronic acid.

Comparison of Breast Cancer Screening Results in Korean Middle-Aged Women: A Hospital-based Prospective Cohort Study

Objectives

The aim of this hospital-based prospective study was to evaluate the diagnostic ability of breast cancer screening in Korean middle-aged women using age, ultrasonography, mammography, and magnification mammography, which are commonly used in most hospitals.

Methods

A total of 21 patents were examined using ultrasonography, mammography, and magnification mammography, and their data were prospectively analyzed from August 2011 to March 2013. All patients were divided into benign and malignant groups and the screening results were classified using the American College of Radiology Breast Imaging Reporting and Data System (BI-RADS). The final pathology report was used as the reference standard and the sensitivity and specificity of ultrasonography, mammography, and magnification mammography were evaluated using receiver-operating characteristics (ROC) analysis.

Results

The analysis included 21 patients who underwent biopsy. Among them, three (14.3%) were positive and 18 (85.7%) negative for breast cancer. The average age was 50.5 years (range = 38–61 years). The sensitivity was the same for ultrasonography and magnification mammography and the specificity of magnification mammography was higher than that of ultrasonography. The highest area under the ROC curve (AUC) was observed in the combination of age and magnification mammography (1.000) and the decreasing order of AUC in others was magnification mammography (0.833), ultrasonography (0.787), mammography (0.667), and age (0.648).

Conclusions

In Korean women, the diagnostic accuracy of magnification mammography was better than that of ultrasonography and mammography. The combination of age and magnification mammography increased the sensitivity and diagnostic accuracy.

The effect of accompanying in situ ductal carcinoma on accuracy of measuring malignant breast tumor size using B-mode ultrasonography and real-time sonoelastography

Objectives. Clinical estimation of malignant breast tumor size is critical for preoperative planning and is crucial for following up the tumor's response to the therapy in case she receives a neoadjuvant chemotharapy. Ductal carcinoma in situ (DCIS) accompanies about 25.4% of detected invasive breast cancers. The aim of this study was to examine the effect of the presence of DCIS on the accuracy of the ultrasonographic measuring malignant breast tumor size using B-mode and real time elastography. Materials and Methods. We recruited histologically confirmed breast cancer patients in a prospective observational study. Results. We recruited 50 breast cancer patients with a median age of 57.5 years. DCIS was confirmed to accompany 42% (n = 21) of the cases. Tumor size estimation using B-mode sonography (P < 0.001) as well as using real time elastography (P < 0.001). was statistically significant correlated to the actual tumor size. Presence of DCIS in 42% of our recruited patients affected the tumor size estimation using both methods thus losing the correlation between both estimations (P = 0.794). Conclusion. This study shows that the presence of DCIS significantly affects the accuracy of measuring the sizes of malignant breast tumors when using either B-mode ultrasonography or real time elastography.

Do patients with invasive lobular breast cancer benefit in terms of adequate change in surgical therapy from a supplementary preoperative breast MRI?

BACKGROUND

Breast magnetic resonance imaging (MRI) has been introduced in the preoperative management of invasive lobular breast cancer (ILC). We analysed if MRI leads to adequate changes in surgical management.

PATIENTS AND METHODS

We carried out a single-centre retrospective confirmatory analysis of 92 patients with ILC and a preoperative breast MRI. By applying a blinded tumour board method, we analysed if surgical procedures were altered due to breast MRI. In case of alteration, we analysed whether the change was adequate according to the postoperative pathology findings. We considered an adequate rate of change>5% to be a clinically relevant benefit.

RESULTS

A change in surgical therapy due to the MRI findings occurred in 23 of 92 patients (25%). According to the postoperative pathology findings, this change was adequate for 20 of these patients (22%; 95% confidence interval [CI] 14%-31%, P<0.0001). An overtreatment occurred for three patients (3%; 95% CI 0%-6%) who underwent a mastectomy following the results of breast MRI. Patients with larger tumours did likely benefit more from preoperative breast MRI.

CONCLUSIONS

Patients with ILC might benefit from a preoperative breast MRI. Possible harm from overtreatment should be minimised by diligent use of preoperative histological clarification.

Assessment of breast cancer tumour size using six different methods

OBJECTIVES

Tumour size estimates using mammography (MG), conventional ultrasound (US), compound imaging (CI) and real-time elastography (RTE) were compared with histopathological specimen sizes.

METHODS

The largest diameters of 97 malignant breast lesions were measured. Two US and CI measurements were made: US1/CI1 (hypoechoic nucleus only) and US2/CI2 (hypoechoic nucleus plus hyperechoic halo). Measurements were compared with histopathological tumour sizes using linear regression and Bland-Altman plots.

RESULTS

Size prediction was best with ultrasound (US/CI/RTE: R (2) 0.31-0.36); mammography was poorer (R(2) = 0.19). The most accurate method was US2, while US1 and CI1 were poorest. Bland-Altman plots showed better size estimation with US2, CI2 and RTE, with low variation, while mammography showed greatest variability. Smaller tumours were better assessed than larger ones. CI2 and US2 performed best for ductal tumours and RTE for lobular cancers. Tumour size prediction accuracy did not correlate significantly with breast density, but on MG tumours were more difficult to detect in high-density tissue.

CONCLUSIONS

The size of ductal tumours is best predicted with US2 and CI2, while for lobular cancers RTE is best. Hyperechoic tumour surroundings should be included in US and CI measurements and RTE used as an additional technique in the clinical staging process.

Identifying factors contributing to reduced breast tumor size: a longitudinal study

AIM

This study examines the trends and outcomes of breast cancer patients who have undergone surgical procedures at the Department of Surgical Sciences, University of Insubria, Varese, Italy. It also identifies the factors that contributed to the reduction of the breast tumor size over a 13-year period at a tertiary referral center.

METHODS

All breast cancer operations performed at the Department of Surgical Sciences, University of Insubria, Varese, Italy, from January 1992 to June 2005 were examined and data from their surgical pathology reports were also analyzed, using a prospective database. A longitudinal study was performed to compare and analyze the pathological data during three consecutive time periods. The periods were from 1992 to 1996, 1997 to 1999, and 2000 to 2005. Surgical and pathological outcomes included age of the patient at the time of the diagnosis, partial breast resections, mastectomies, axillary lymphadenectomies, tumor size, histological type and stage, and lymph node status.

RESULTS

The study group was comprised of 3050 patients who underwent breast resection between 1992 and 2005. Quadrantectomy was the preferred surgical approach in 1759 patients (58%). Throughout the longitudinal study, the tumors measuring less than 1cm increased from 13.4% to 15.4%; the number of tumors diagnosed at stage I increased from 44.1% to 56.8%; the most frequent histological type was ductal carcinoma; the number of ductal carcinomas in situ (DCIS) increased from 4% to 6%; and the incidence of lymphadenectomies decreased from 71.6% to 52.5%. Perioperative factors that correlated with the decreased size of the tumor over time were: screening, improvement of diagnostic and therapeutic techniques, and the increased operative use of sentinel lymph node biopsy (SLNB).

CONCLUSIONS

There has been an evolving refinement in surgical technique and perioperative management of breast cancer patients undergoing surgical resection at the Department of Surgical Sciences, University of Insubria, Varese, Italy, during the past decades. The present longitudinal study on 3050 surgical breast cancer patients confirmed the progressive reduction of tumor size at the time of the diagnosis. Perioperative factors that correlated with the decreased tumor size over time were mammography screening, improvement of diagnostic and therapeutic techniques, and the use of SLNB. Furthermore, the study showed that the progressive reduced number of useless axillary lymphadenectomies was mainly due to the increased intraoperative use of axillary SLNB.

Intra-operative measurement of tumour size in breast cancer and its comparison with other methods: a prospective study

Accurate measurement of breast tumour size determines staging and prognosis. Discrepancies amongst clinical examination (CE), ultrasonography (USG), mammography, pathological examination (PE) and magnetic resonance imaging have been reported. However, few studies have evaluated changes in breast tumour size from the operating table to the laboratory.

A decision tool for predicting sentinel node accuracy from breast tumor size and grade

The ability to predict axillary lymph node involvement in breast cancer patients in the preoperative setting is invaluable. This study provides a simple set of formulae to enable clinicians to make informed decisions in the management of screen-detected breast cancer. The tumor pathology reports were obtained of all 4,585 women identified between 1996 and 1999 in New South Wales (NSW) with T1 or T2 breast cancer by the statewide co-ordinated breast screening service (BreastScreen NSW). Equations predicting node positivity were calculated by linear regression analysis and, from published sentinel node false-negative rates, the probability of retrieval of a false-negative axillary lymph node by sentinel node biopsy was calculated for tumors of different size and grade. Node involvement was identified in 1,089 (23.8%) of women. A linear relationship for tumor size, grade, and nodal involvement was predicted by: frequency (%) = 1.5 x tumor size (mm) + 2 (or 6 or 10) for grade I (or II or III) tumors. Assuming a 7.5% false-negative rate, the probability of retrieving a false-negative sentinel node ranged from 0.8% for a patient with a 5 mm, grade I carcinoma to 6.0% for a 50 mm, grade III tumor. These simple formulae are easy to use in a clinical setting. The reference table enables breast surgeons to inform a patient about the absolute probability of false-negative sentinel biopsy rates for patients with screen-detected carcinomas when size can be estimated from preoperative imaging and when tumor grade is often available from preoperative core biopsy. Patients with large, T2 breast tumors may be best treated with axillary dissection rather than sentinel node biopsy alone due to the risk of under-staging the woman's disease and also the high probability of finding a positive sentinel node.

Molecular response to aromatase inhibitor treatment in primary breast cancer

Background

Aromatase inhibitors such as anastrozole and letrozole are highly effective suppressants of estrogen synthesis in postmenopausal women and are the most effective endocrine treatments for hormone receptor positive breast cancer in such women. Little is known of the molecular effects of these agents on human breast carcinomas in vivo.

Methods

We randomly assigned primary estrogen receptor positive breast cancer patients to treatment with anastrozole or letrozole for 2 weeks before surgery. Expression profiling using cDNA arrays was conducted on pretreatment and post-treatment biopsies. Sample pairs from 34 patients provided sufficient RNA for analysis.

Results

Profound changes in gene expression were seen with both aromatase inhibitors, including many classical estrogen-dependent genes such as TFF1, CCND1, PDZK1 and AGR2, but also many other genes that are likely to represent secondary responses; decrease in the expression of proliferation-related genes were particularly prominent. Many upregulated genes are involved in extracellular matrix remodelling, including collagens and members of the small leucine-rich proteoglycan family (LUM, DCN, and ASPN). No significant differences were seen between letrozole and anastrozole in terms of molecular effects. The gene changes were integrated into a Global Index of Dependence on Estrogen (GIDE), which enumerates the genes changing by at least twofold with therapy. The GIDE varied markedly between tumours and related significantly to pretreatment levels of HER2 and changes in immunohistochemically detected Ki67.

Conclusion

Our findings identify the transcriptional signatures associated with aromatase inhibitor treatment of primary breast tumours. Larger datasets using this approach should enable identification of estrogen-dependent molecular changes, which are the determinants of benefit or resistance to endocrine therapy.

The value of MRI compared to mammography in the assessment of tumour extent in invasive lobular carcinoma of the breast

AIMS

Invasive lobular carcinoma of the breast (ILC) is known to be substantially underestimated by mammography, which makes correct planning of treatment difficult. MRI has been proposed as a valuable adjunct to mammography. The purpose of the current study is to evaluate its value, compare it to mammography and assess the possible causes of over- and underestimation of lesion size on MRI.

METHOD

The mammograms and MRI scans of 67 consecutive patients with ILC were retrieved and re-evaluated. Size measurements were correlated to the sizes extracted from the pathology report.

RESULTS

MRI measurements correlated better to pathologic size (r=0.85) than mammographic measurements (r=0.27). Underestimation of tumour size was more common on mammography (p<0.001); overestimation occurred with equal frequency (p=0.69). Overestimation on MRI, caused by non-malignant findings, was attributed to enhancing lobular carcinoma in situ.

CONCLUSION

MRI is a more accurate modality for determining tumour size in patients with ILC than mammography. The typical underestimation of lesion size by mammography can be prevented with the aid of MRI, without increasing the risk of lesion overestimation.

Accuracy of contrast-enhanced breast ultrasound for pre-operative tumor size assessment in patients diagnosed with invasive ductal carcinoma of the breast

Our aim was to assess the feasibility and accuracy of contrast-enhanced ultrasound (CEUS) of the breast with SonoVue microbubbles for pre-operative size measurement of invasive breast carcinomas. Seven patients diagnosed with nine invasive breast carcinomas prospectively underwent gray-scale ultrasound and CEUS of the breast according to a standardized protocol. CEUS of the breast was performed by a Philips iU22 scanner equipped with a 4-8 MHz linear array transducer. We used a single dose of 2.4 ml SonoVue as contrast agent. Breast lesion morphology was scored according to the sonographic BI-RADS lexicon criteria and classified accordingly. The greatest tumor dimensions on gray-scale ultrasound and CEUS of the breast were finally compared with the greatest histopathologic tumor sizes. Gray-scale ultrasound underestimated the histopathologic tumor size in 6/9 cases (67%), whereas CEUS of the breast underestimated tumor size in only 3/9 (33%) cases. CEUS of the breast was significantly more accurate for tumor size assessment. Greatest tumor dimension as measured with gray-scale ultrasound of the breast was within 2 mm of the pathologic tumor size in only 2/9 cases (22%), whereas CEUS of the breast accurately assessed tumor size within 2 mm of pathologic tumor size in 6/9 (67%) of the cases (P<0.05). CEUS of the breast proved to be a feasible and safe procedure. It is more accurate than gray-scale ultrasound of the breast for pre-operative size assessment of invasive ductal breast carcinomas.