Can T2-weighted 3-T breast MRI predict clinically occult inflammatory breast cancer before pathological examination? A single-center experience

The Role of MRI in Breast Cancer and Breast Conservation Therapy

Contrast-enhanced breast MRI has an established role in aiding in the detection, evaluation, and management of breast cancer. This article discusses MRI sequences, the clinical utility of MRI, and how MRI has been evaluated for use in breast radiotherapy treatment planning. We highlight the contribution of MRI in the decision-making regarding selecting appropriate candidates for breast conservation therapy and review the emerging role of MRI-guided breast radiotherapy.

Breast cancer dermal lymphatic invasion recurrence and contralateral axillary lymph nodes metastasis after complete response to neoadjuvant therapy: A case report

INTRODUCTION AND IMPORTANCE

Non-luminal type breast cancer patients with pathological complete response (pCR) by neoadjuvant chemotherapy (NAC) usually have a good prognosis, but occasionally recurrence occurs.

CASE PRESENTATION

A 61-year-old woman was diagnosed with breast cancer T2N2aM0 stage IIIA and its intrinsic type was non-luminal type. After NAC, the patient achieved pCR and underwent breast-conserving surgery and axillary lymph node dissection (ALND). Radiotherapy and trastuzumab of one-year duration was added. However, six years and two months later, local recurrence and contralateral axillary lymph node (CLALN) metastasis were identified. After resection, anti-human epidermal growth factor receptor 2 (HER-2) therapy was done, however, six months after operation, purpura was observed on the right chest and tended to increase. One and a half years after re-operation, dermal lymphatic invasion (DLI) recurrence without clinical inflammatory signs was diagnosed. A skin resection was performed >1.5 cm away from the purpura, and the surgical margins were negative but four months later, a recurrence re-emerged.

CLINICAL DISCUSSION

CLALN metastasis is considered distant metastasis based on the current TNM classification. However, as previous ALND or radiotherapy can change lymphatic flow, the resulting CLALN may not be distant metastasis. DLI recurrence without clinical inflammatory signs is likely to be resistant to anti-HER2 even in non-luminal type, and even a 2-cm margin for skin surgical lines may result in positive margins.

CONCLUSION

There are cases where CLALN after ALND should also be considered possible metastasis. In DLI recurrence, the skin excision margin line should be set very generously.

Assessment and Response to Neoadjuvant Treatments in Breast Cancer: Current Practice, Response Monitoring, Future Approaches and Perspectives

Neoadjuvant treatments (NAT) for breast cancer (BC) consist in the administration of chemotherapy-more rarely endocrine therapy-before surgery. Firstly, it was introduced 50 years ago to downsize locally advanced (inoperable) BCs. NAT are now widespread and so effective to be used also at the early stage of the disease. NAT are heterogeneous in terms of therapeutic patterns, class of used drugs, dosage, and duration. The poly-chemotherapy regimen and administration schedule are established by a multi-disciplinary team, according to the stage of disease, the tumor subtype and the age, the physical status, and the drug sensitivity of BC patients. Consequently, an accurate monitoring of treatment response can provide significant clinical advantages, such as the treatment de-escalation in case of early recognition of complete response or, on the contrary, the switch to an alternative treatment path in case of early detection of resistance to the ongoing therapy. Future is going toward increasingly personalized therapies and the prediction of individual response to treatment is the key to practice customized care pathways, preserving oncological safety and effectiveness. To gain such goal, the development of an accurate monitoring system, reproducible and reliable alone or as part of more complex diagnostic algorithms, will be promising.

Accelerated 3D high-resolution T2-weighted breast MRI with deep learning constrained compressed sensing, comparison with conventional T2-weighted sequence on 3.0 T

PURPOSE

To evaluate the feasibility of isotropic 3D high-resolution T2-weighted imaging (T2WI) MRI sequences and compare the images reconstructed by integrating artificial intelligence-compressed sensing (AI-CS), compressed sensing (CS), and conventional 2D T2WI sequences for quality.

MATERIALS AND METHODS

Fifty-two female patients (ages: 26-80 years) with suspected breast cancer were enrolled. They underwent breast MRI examinations using three sequences: conventional T2WI, CS 3D T2WI, and AI-CS 3D T2WI. Image quality, signal-to-noise ratio (SNR), contrast-to-noise ratio, tumor volume, and maximal tumor diameter were compared using the Friedman test. Image quality was scored on a 5-point scale, with 1 indicating nonassessable quality and 5 indicating excellent quality. Tumor volume and maximal tumor diameter were compared based on AI-CS 3D T2WI (slightly high signal), conventional T2WI, and dynamic contrast-enhanced (DCE) sequences.

RESULTS

All three T2WI were successfully performed in all patients. 3D CS and AI-CS were significantly better than conventional T2WI in terms of lesion conspicuity and morphology, structural details, overall image quality, diagnostic information for breast lesions, and breast tissue delineation (P < 0.001). The SNR of conventional T2WI was significantly higher for 3D T2WI sequences. The contrast-to-noise ratio was significantly higher for AI-CS 3D T2WI than for conventional T2WI sequence. There was no significant difference in tumor volume between DCE (8.08 ± 16.51) and AI-CS 3D T2WI (8.25 ± 16.29) sequences and no significant differences in tumor diameter among DCE, AI-CS 3D T2WI, and conventional T2WI sequences.

CONCLUSION

Isotropic-resolution 3D T2WI sequences can be acquired using AI-CS while maintaining image quality and diagnostic value, which may pave the way for isotropic 3D high-resolution T2WI for clinical application.

MRI Changes in Breast Skin Following Preoperative Therapy for Patients with Inflammatory Breast Cancer

RATIONALE AND OBJECTIVES

Preoperative systemic therapy (PST) followed by mastectomy and radiation improves survival for patients with inflammatory breast cancer (IBC). Residual disease within the skin post-PST adversely impacts surgical outcome and risk of local-regional recurrence (LRR). We aimed to assess magnetic resonance imaging (MRI) breast skin changes post-PST with pathologic response and its impact on surgical resectability.

MATERIALS AND METHODS

We retrospectively reviewed 152 baseline and post-PST breast MRIs of 76 patients with IBC. Using the ACR-BIRADS MRI lexicon, we correlated skin thickness, qualitative enhancement, and kinetic analysis with pathologic response in the skin at mastectomy.

RESULTS

Baseline MRI showed skin thickening in all 76 patients, 75/76 (99%) showed skin enhancement, 54/75 (72%) had medium/fast initial kinetics, usually with persistent delayed kinetics in 49/54 (91%). Following PST, 66/76 (87%) had residual skin thickening with 64/76 (84%) showing a decrease; 33/76 (43%) had persistent enhancement. The median thickness post-PST was 4.7 mm with residual tumor in the skin, and 3.0 mm without residual tumor (p = 0.008). Regardless of pathologic response, the majority of patients had persistent skin thickening on MRI following PST (100% [14/14] with residual tumor and 84% [52/62] without residual tumor). There was no association between post-PST skin thickness on breast MRI and rate of LRR.

CONCLUSION

Patients with IBC have skin thickening and enhancement on baseline breast MRI, with a statistically significant reduction in skin thickness following successful PST. Despite persistent skin changes on MRI, patients achieving a partial or complete parenchymal response to PST may proceed to mastectomy with low LRR rates.

Intramammary edema of invasive breast cancers on MRI T2-weighted fat suppression sequence: Correlation with molecular subtypes and clinical-pathologic prognostic factors

OBJECTIVE

To investigate the associations between different patterns of intramammary edema on preoperative 3.0 T magnetic resonance imaging (MRI) T₂-weighted fat suppression sequence and invasive breast cancer molecular subtypes and clinical-pathologic prognostic factors.

METHODS

Between May 2014 and December 2020, 191 patients with invasive breast cancer who had undergone preoperative MRI and mastectomy or breast-conserving surgery were retrospectively enrolled. The relationships between different patterns of intramammary edema and invasive breast cancer molecular subtypes and clinical-pathologic features were evaluated using the Student's t-test or Mann-Whitney U test and the χ2 test or Fisher's exact test.

RESULTS

Patients with luminal B (HER2 positive), HER2-enriched and triple negative breast cancers respectively had different patterns of intramammary edema (P < 0.001). There was a significant association between intramammary edema and clinical-pathologic factors, including larger tumor size, higher Ki-67 index, lymph node metastasis and lymphovascular invasion (all P < 0.001).

CONCLUSIONS

Intramammary edema may provide added values of predicting molecular subtypes and clinical-pathologic prognosis, enhancing the ability to individualize the treatment of patients with invasive breast cancer.

The Impact of Tumor Edema on T2-Weighted 3T-MRI Invasive Breast Cancer Histological Characterization: A Pilot Radiomics Study

Simple Summary

Breast cancer is the most common cancer in women worldwide. Currently the use of MR is mandatory in staging phase. The standard protocol includes T2-weighted sequences for morphology and signal analysis, T1-weighted images for adding information (i.e., ematic or adipous components), diffusion-weighted sequences which provide information on tissue cellularity, and dynamic post-contrast sequences useful for detecting and locating lesions. Although not considered among the main prognostic factors in current guidelines, tumor-associated edema provides useful information on tumor aggressiveness, and has been shown to be associated with the main histological tumor characteristics. With this work, entitled “The Impact of Tumor Edema on T2-weighted 3T-MRI Invasive Breast Cancer Histological Characterization: a Pilot Radiomics Study”, we want to demonstrate that radiomics edema, based on algorithms that allow the extraction of imaging features not visible to the human eye, can further increase the accuracy in the prediction of histological factors compared to the use of traditional information only.

Abstract

Background: to evaluate the contribution of edema associated with histological features to the prediction of breast cancer (BC) prognosis using T2-weighted MRI radiomics. Methods: 160 patients who underwent staging 3T-MRI from January 2015 to January 2019, with 164 histologically proven invasive BC lesions, were retrospectively reviewed. Patient data (age, menopausal status, family history, hormone therapy), tumor MRI-features (location, margins, enhancement) and histological features (histological type, grading, ER, PgR, HER2, Ki-67 index) were collected. Of the 160 MRI exams, 120 were considered eligible, corresponding to 127 lesions. T2-MRI were used to identify edema, which was classified in four groups: peritumoral, pre-pectoral, subcutaneous, or diffuse. A semi-automatic segmentation of the edema was performed for each lesion, using 3D Slicer open-source software. Main radiomics features were extracted and selected using a wrapper selection method. A Random Forest type classifier was trained to measure the performance of predicting histological factors using semantic features (patient data and MRI features) alone and semantic features associated with edema radiomics features. Results: edema was absent in 37 lesions and present in 127 (62 peritumoral, 26 pre-pectoral, 16 subcutaneous, 23 diffuse). The AUC-classifier obtained by associating edema radiomics with semantic features was always higher compared to the AUC-classifier obtained from semantic features alone, for all five histological classes prediction (0.645 vs. 0.520 for histological type, 0.789 vs. 0.590 for grading, 0.487 vs. 0.466 for ER, 0.659 vs. 0.546 for PgR, and 0.62 vs. 0.573 for Ki67). Conclusions: radiomic features extracted from tumor edema contribute significantly to predicting tumor histology, increasing the accuracy obtained from the combination of patient clinical characteristics and breast imaging data.

Evaluation of Breast Edema Findings at T2-weighted Breast MRI Is Useful for Diagnosing Occult Inflammatory Breast Cancer and Can Predict Prognosis after Neoadjuvant Chemotherapy

Background Prediction of occult inflammatory breast cancer (IBC) and breast cancer prognosis based on breast edema findings on T2-weighted MRI scans, even for patients without clinical signs of IBC, would be useful in both pretreatment planning and prognosis and may elucidate the underlying biologic mechanisms. Purpose To evaluate whether classification of breast edema on T2-weighted MRI scans is useful for predicting the prognosis of patients with breast cancer treated with neoadjuvant chemotherapy (NAC). Materials and Methods A retrospective evaluation was performed of women with breast cancer who underwent breast MRI and were treated with NAC between January 2011 and December 2018. Breast edema on T2-weighted images was scored on a scale of 1 to 4, as follows: (a) breast edema score (BES) 1, no edema; (b) BES 2, peritumoral edema; (c) BES 3, prepectoral edema; and (d) BES 4, subcutaneous edema (suspicious for occult IBC). Clinically evident IBC was classified as BES 5 (without MRI). The log-rank test was performed, and hazard ratios were calculated using the Cox hazard model to evaluate associations between BES and progression-free survival (PFS) and overall survival (OS). PFS rate at 100 months after initiation of therapy was also evaluated. Results Of 408 patients (median age, 53 years; range, 28-80 years), 65 (16%) had a recurrence and 27 (7%) died. The log-rank test revealed differences in PFS for BES 4 versus 1, BES 5 versus 1, BES 5 versus 2, and BES 5 versus 3 (adjusted P < .05 for all). PFS rates for BES 1-5 were 0.92, 0.85, 0.80, 0.62, and 0.58, respectively, and the corresponding OS rates at 100 months were 0.98, 0.91, 0.92, 0.77, 0.86, respectively. Conclusion Classification of breast edema findings on T2-weighted MRI scans using a breast edema score was related to the prognosis of patients after neoadjuvant chemotherapy. © RSNA, 2021 Online supplemental material is available for this article.

Preoperative MRI features associated with lymphovascular invasion in node-negative invasive breast cancer: A propensity-matched analysis

PURPOSE

In node-negative disease, the presence of lymphovascular invasion (LVI) is reported to be an unfavorable prognostic factor. Thus, the aim of this study was to evaluate whether preoperative breast MRI features are associated with LVI in patients with node-negative invasive breast cancer by a propensity-matched analysis.

MATERIALS AND METHODS

Among 389 patients with node-negative invasive ductal breast cancer who had preoperative breast 3.0 Tesla MRI with precontrast T2-weighted fat-suppressed, pre- and dynamic postcontrast T1-weighted fat-suppressed sequences, 61 patients with LVI (LVI group) were matched with 183 patients without LVI (no LVI group) at a ratio of 1:3 in terms of age, histologic grade, tumor size, and hormone receptor status. Two radiologists reviewed the MRI features, following profiles of focal breast edema (peritumoral, prepectoral, subcutaneous), intratumoral T2 signal intensity, adjacent vessel sign, and increased ipsilateral whole-breast vascularity, in addition to 2013 Breast Imaging Reporting and Data System lexicon.

RESULTS

The presence of peritumoral edema (45.9% [28/61] versus 30.6% [56/183], P = 0.030) and adjacent vessel sign (82.0% [50/61] versus 68.3% [125/183], P = 0.041) was significantly associated with LVI. Prepectoral edema was also more frequently observed in the LVI group than in the no LVI group with borderline significance (26.2% [16/61] versus 15.3% [28/183], P = 0.055). In cases of nonmass enhancement, regional enhancement was more frequently found in the LVI group than in the no LVI group (60.0% [3/4] versus 5.9% [1/4], P = 0.042).

CONCLUSION

Preoperative breast MRI features may be associated with LVI in patients with node-negative invasive breast cancer.

LEVEL OF EVIDENCE

3 Technical Efficacy: Stage 3 J. Magn. Reson. Imaging 2017;46:1037-1044.

Is "prepectoral edema" a morphologic sign for malignant breast tumors?

RATIONALE AND OBJECTIVES

A variety of morphologic and kinetic signs of benign or malignant breast lesions contribute to a final diagnosis and differential diagnosis in magnetic resonance (MR) mammography (MRM). As a new sign, prepectoral edema (PE) in patients without any history of previous biopsy, operation, radiation, or chemotherapy was detected during routine breast MR examinations. The purpose of this study was to retrospectively evaluate the role of this morphologic sign in the differential diagnosis of breast lesions.

MATERIALS AND METHODS

Between January 2005 and October 2006, a total of 1109 consecutive MRM examinations have been performed in our institution. In this study, only patients who would later be biopsied or operated in our own hospital were included. They had no previous operation, biopsy, intervention, chemotherapy, hormone replacement therapy, or previous mastitis. In total, 162 patients with 180 lesions were included, histologically correlated later-on by open biopsy (124 patients and 136 lesions) or core biopsy (38 patients and 44 lesions). The evaluations were performed by four experienced radiologists in consensus.

RESULTS

One hundred eighty evaluated lesions included 104 malignant lesions (93 invasive and 11 noninvasive cancers) and 76 benign lesions. PE was detected in 2.6% of benign lesions (2 of 76), in none of the Ductal cacinoma in situ (DCIS) cases (0 of 11), and in 25.8% of malignant lesions (24 of 93; P < .000). PE was found significantly more frequently in presence of malignant tumors >2 cm in diameter (48.5%, 17 of 35 vs. 13.8%, 8 of 58; P < .001). PE was not statistically associated to malignant tumor type, presence or absence of additional DCIS, and number of lesions. This resulted in the following diagnostic parameters for PE as an indicator for malignancy: sensitivity of 19.3%, specificity of 97.3%, positive predictive value (PPV) of 92.3%, negative predictive value of 48%, and accuracy of 57.7%.

CONCLUSIONS

In case of occurrence, the "PE sign" seems to be a specific indicator for malignant tumors with a high PPV, independent from its entity.