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Table 1. Histopathologic Difference Between EIC Positive and EIC Negative Breast Cancer EIC positive (41) EIC negative (42) Total (83) Age (mean) 43.7 46.9 45.3 Diagnosis Pure IDC 00 11 11 IDC+DCIS 35 30 65 DCIS with microinvasion 04 00 04 ILC+LCIS 01 00 01 Metaplastic carcinoma 00 01 01 Mucinous carcinoma 01 00 01 Operation method Radical or MRM 25 25 50 Breast conserving surgery 16 17 33 Location Rt 23 23 46 Lt 18 19 37 T statue T1a 04 00 04 T1b 05 03 08 T1c 15 12 27 T2 17 25 42 T3 00 02 02 LN status N0 29 24 53 N1 12 18 30 Stage Stage I 16 09 25 Stage IIA 21 19 40 Stage IIB 04 14 18 Histologic grade I 08* 6 14* II 13* 16 29* III 15* 20 35* Nucler grade I 15* 24 39* II 17* 15 32* III 04* 03 07* Type of DCIS Comedo 23 02 25 Non-comedo 18 0 18 Grade of DCIS High grade 19 02 21 Low or intermediate 22 0 22 Estrogen receptor positive 28 28 56 negative 13 14 27 Progesteron receptor positive 23 26 49 negative 18 16 34 C-erb positive 20 19 39 negative 21 23 44 IDC: Infiltrating ductal carcinoma, DCIS: Ductal carcinoma in situ ILC: Infiltrating lobular carcinoma, EIC: Extensive intraductal component *: except cases with ILC, or DCIS with microinvasion : cases with available pathologic examination 544
Table 2. Comparison of Mammography, Ultrasonography and MRI For Detection of EIC in Cases with Invasive Breast Cancer Diagnostic method Sensitivity (%) Specificity (%) PPV (%) NPV (%) Accuracy (%) MMG 48.6 92.3 85.0 66.7 71.6 US 67.5 73.2 71.1 69.8 70.4 MRI 80.5 69.0 71.7 78.4 74.7 All combined 71.4 81.1 78.1 75.0 76.4 EIC: extensive intraductal component, MMG: mammography US: ultrasonography, MRI: magnetic resonance image PPV: positive predictive value, NPV: negative predictive value B A Fig. 1. 47-year-old women with ductal carcinoma in situ with microinvasion. A. Mammogram shows regional distributed pleomorphic microcalcifications (arrow) without mass density at upper portion of the right breast. C B. Sonogram shows tubular and nodular hypoechoic structure (arrow) with numerous hyperechoic foci representing calcifications and architectural distortion. C. MR axial subtraction image using contrast-enhanced 3D-FMP-SPGR sequence shows clumped, regional enhancement at right breast. All three diagnostic methods reveal positive findings of EIC. 545
C A B Fig. 2. 48-year-old women with invasive ductal carcinoma with EIC A, B. Mediolateral and craniocaudal views of mammogram show spiculated hyperdense mass (arrow) with architectural distortion at right upper outer breast with enlarged axillary lymph node. Microcalcifications are not present within or adjacent to the mass. D C. Sonogram shows ill-defined and irregular shaped hypoechoic mass at right breast. D. Subtraction MRI image shows linear ductal enhancement extending from main tumor at right breast. Although mammography and sonography cannot reveal positive finding of EIC, MRI diagnoses EIC of the breast cancer. 546
A Fig. 3. 48-year-old woman with with invasive ductal carcinoma with EIC A. Mammogram shows segmentally distributed irregular linear shaped calcifications (arrow) at right breast. B. Sonogram shows tubular hypoechoic structure (arrow) extending from the main tumor, and reveals calcifications within the main tumor C. Subtraction MRI image shows spiculated and round shaped enhancing mass at right breast. The mass doesn t have positive findings of EIC in MRI. B C 547
C A B Fig. 4. 43-year-old women with invasive ductal carcinoma with EIC negative. A, B. Mediolateral and craniocaudal views of mammogram show spiculated hyperdense mass (arrow) with architectural distortion at right upper outer breast. C. Sonogram shows spiculated irregular shaped hypoechoic mass at right breast. D. Subtraction MRI image shows linear ductal enhancement extending from main tumor at right breast. Despite histopathologic finding reveals intraductal component adjacent the invasive tu- D mor, intraductal component within the invasive lesion is less than 10% in total tumor volume. 548
presentation predict the presence of an intensive intraductal component in early stage breast cancer? Int J Radiat Oncol Biol Phys 1989;12:1217-1221 12. Boetes C, Mus RD, Holland R, Barentsz JO, Strijk SP, Wobbes T, et al. Breast tumors: comparative accuracy of MR imaging relative to mammography and US for demonstrating extent. Radiology 1995;197:743-747 13. Solin LJ, Yeh IT, Kurtz J, Fourquet A, Recht A, Kuske R, et al. Ductal carcinoma in situ (intraductal carcinoma) of the breast treated with breast conserving surgery and definitive irradiation. Cancer 1993;71:2532-2542 14. Tsunoda-Shimazu H, Ueno E, Tohno E, Itai Y. Ultrasonographic evaluation for breast conservative therapy. Jpn J Breast Cancer 1996;11:649-655 15. Satake H, Shimamoto K, Sawaki A, Niimi R, Ando Y, Ishiguchi T, et al. Role of ultrasonography in the detection of intraductal spread of breast cancer: correlation with pathologic findings, mammography and MR imaging. Eur Radiol 2000;10:1726-1732 1. Holland R, Connolly JL, Gelman R, Mravunac M, Hendriks JH, Verbeek AL, et al. The presence of an extensive intraductal component following a limited excision correlateds with prominent 16. Mumtaz H, Hall-Craggs MA, Davidson T, Walmsley K, Thurell W, Kissin MW, et al. Staging of symptomatic primary breast cancer residual disease in the remainder of the breast. J Clin Oncol 1990; with MR imaging. AJR Am J Roentgenol 1997;169:417-424 8:113-118 17. Hiramatsu H, Enomoto K, Ikeda T, Mukai M, Furukawa J, 2. Abner AL, Recht A, Eberlein T, Come S, Shulman L, Hayes D, et Kikuchi K, et al. The role of contrast enhanced high resolution al. Prognosis following salvage mastectomy for recurrence in the MRI in the surgical planning of breast cancer. Breast Cancer breast after conservative surgery and radiation therapy for earlystage breast cancer. J Clin Oncol 1993;11:44-48 1997;4:285-290 18. Drew PJ, Chatterjee S, Turnbull LW, Read J, Carleton PJ, Fox JN, 3. Leborgne F, Leborgne JH, Ortega B, Dolan R, Zubizarreta E. Breast et al. Dynamic contrast enhanced magnetic resonance imaging of conservation treatment of early stage breast cancer: patterns of the breast is superior to triple assessment for the pre-operative detection of multifocal breast cancer. Ann Surg Oncol 1999;6:599-603 failure. Int J Radiat Oncol Biol Phys 1995;31:765-775 4. Veronesi U, Banfi A, Salvadori B, Luini A, Saccozzi R, Zucali R, et 19. Malur S, Wurdinger S, Moritz A, Michels W, Schneider A. al. Breast conservation is the treatment of choice in small breast Comparison of written reports of mammography, sonography and cancer; long-term results of a randomized trial. Eur J Cancer 1990; magnetic resonance mammography for preoperative evaluation of 26:668-670 breast lesions, with special emphasis on magnetic resonance mammography. Breast Cancer Res 2001;3:55-60 5. Fisher B, Redmond C, Poisson R, Margolese R, Wolmark N, Wickerham L, et al. Eight-year results of a randomized clinical trial 20. Neubauer H, Li M, Kuehne-Heid R, Schneider A, Kaiser WA. High comparing total mastectomy and lumpectomy with or without irradiation in the treatment of breast cancer. N Engl J Med 1989;320: grade and non-high grade ductal carcinoma in situ on dynamic MR mammography: characteristic findings for signal increase and morphological pattern of enhancement. Br J Radiol 2003;76:3-12 822-828 6. Gilles R, Zafrani B, Guinebretiere JM, Meunier M, Lucidarme O, 21. Weidner N, Folkman J, Pozza F, Bevilacqua P, Allred EN, Moore Tardivon AA, et al. Ductal carcinoma in situ; MR imaginghistopathologic correlation. Radiology 1995;196:415-419 DH, et al. Tumor angiogenesis: a new significant and independent prognostic indicator in early-stage breast carcinoma. J Natl Cancer 7. Schnitt SJ, Connolly JL, Harris JR, Hellman S, Cohen RB. Inst 1992;84:1875-1887 Pathologic predictors of early local recurrence in stage I and II 22. Revel D, Brasch RC, Paajanen H, Rosenau W, Grodd W, Engelstad breast cancer treated by primary radiation therapy. Cancer 1984; B, et al. Gd-DTPA contrast enhancement and tissue differentiation 53:1049-1057 in MR imaging of experimental breast carcinoma. Radiology 1986; 8. Boyages J, Recht A, Connolly JL, Schnitt SJ, Gelman R, Kooy H, et 158:319-323 al. Early breast cancer: predictors of breast recurrence for patients 23. Folkman J, Watson K, Ingber D, Hanahan D. Induction of angiogenesis during the transition from hyperplasia to neoplasia. Nature treated with conservative surgery and radiation therapy. Radiother Oncol 1990;19:29-41 1989;339:58-61 9. Lagios MD, Margolin FR, Westdahl PR, Rose MR. 24. Silverberg SG, Chitale AR. Assessment of significance of proportions of intraductal and infiltrating tumor growth in ductal carcino- Mammographically detected duct carcinoma in situ, Frequency of local recurrence following tylectomy and prognostic effect of nuclear grade on local recurrence. Cancer 1989;63:618-624 ma of the breast. Cancer 1978;32:830-837 25. Jing X, Kakudo K, Murakami M, Nakamura Y, Nakamura M, 10. Stomper PC, Connolly JL. Mammographic features predicting an Yokoi T, et al. Intraductal spread of invasive breast carcinoma has extensive intraductal component in early stage infiltrating ductal a positive correlation with c-erb B-2 overexpression and vascular carcinoma. AJR Am J Roentgenol 1992;158:269-272 invasion. Cancer 1999;86:439-448 11. Healey EA, Osteen RT, Schnitt SJ, Gelman R, Stomper PC, Connolly JL, et al. Can the clinical and mammographic findings at 549
Usefulness of Breast MRI for Diagnosing an Extensive Intraductal Component of Breast Cancer: Comparison with Mammography and Ultrasonography 1 Tae Hee Kim, M.D., Doo Kyung Kang, M.D.,Yong Sik Jung, M.D. 2, Hyunee Yim, M.D. 3 1 Department of Diagnostic Radiology, Ajou University, College of Medicine 2 Department of General Surgery, Ajou University, College of Medicine 3 Department of Pathology, Ajou University, College of Medicine Purpose: An extensive intraductal component of breast cancer is a principal risk factor for local recurrence, and this is difficult to diagnose with performing only mammography. We investigated the usefulness of breast MRI for evaluating an extensive intraductal component of breast cancer, and we compared this modality with mammography and ultrasonography (US). Materials and Methods: From March 2003 to July 2004, 90 patients underwent breast MRI among all the patients who were suffering with breast cancer and for whom an EIC was ultimately revealed to be present or not. A total 83 patients with stage I and II breast cancer were finally included in this study. EIC positivity was defined according to the imaging data as follows: 1) microcalcifications beyond the tumor shadow or malignant microcalcifications without a tumor mass on mammography, 2) tubular hypoechoic structures adjacent to the tumor or architectural distortion with calcifications beyond the tumor on US, and 3) linear or ductal enhancement, segmental or regional clumped enhancement, and spotty nodular or reticular enhancement adjacent to the tumor on MRI. EIC was present in 41 patients and this finding was negative in 42 patients. The results were then compared those results from mammography and US. Results: The sensitivities of detecting EIC by mammography, US and MRI were 48.6%, 67.5% and 80.5%, respectively, and the corresponding specificities were 92.3%, 73.2% and 69.0%, respectively. In the cases that were suspected to be EIC positive on more than two imaging modality, the positive predictive value (PPV) was 78.1%. In cases that were suspected of being EIC positive on just one imaging modality, the negative predictive value (NPV) was 75.0%. Conclusion: Breast MRI provides good information about an EIC of breast cancer and it is a more sensitive study than mammography and US, yet the specificity for the detection of EIC is highest on mammography. A combined evaluation by mammography, US and MRI is the most accurate way to diagnose an EIC of breast cancer. Index words : Breast Magnetic resonance (MR) Ultrasound (US) Mammography Address reprint requests to : Doo Kyung Kang, M.D., Department of Diagnostic Radiology, Ajou University, College of Medicine 5 Wonchon-dong, Youngtong-gu, Suwon 442-719, Korea. Tel. 82-31-219-5114 Fax. 82-31-219-5862 E-mail: kdklsm@ajou.ac.kr 550