The Sequence Application Of X-ray, CT And Mammary MRI On Breast Cancer Diagnosis And Evaluation Before Breast-conserving Surgery

BACKGROUNDBreast cancer (breast cancer, BC) is one of the serious malignant tumors threating to women’ health. From detection to treatment, the patients experience3stages, screening, diagnosis, preoperative evaluation. Mammography, ultrasound, CT and MRI are applied commonly as imaging examination. It is very important to master a variety of indications for imaging examination, and to undergo sequentially applying various imaging methods.①Mammography is the first choice for breast cancer screening and diagnosis. Microcalcifications (MC) is the most specific signs for diagnosis of breast cancer. It is important to improve MC detection rate and explore the relations between MC imaging features and pathology.②CT is currently only used for detect breast cancer metastasis in the chest. It is worth noting that breast cancer is found by chest CT scan due to other diseases. Therefore, it is necessary to differential understand the CT imaging signs of breast cancer.③With the rise of breast-conserving surgery (BCS) for early breast cancer, it is urgent for doctors to determine the extent of resection, maximize retention normal glands surrounding the tumor. The traditional X-ray mammography, ultrasound has been unable to meet the special assessment requirements. Mammary MRI can more accurately assess the size, infiltration range, lesions surrounding of tumor. PART1Quantity analysis on breast micro calcifications in X-rays and the clinical evaluationObjectives1. To evaluate the innovation of X-ray photography technique for breast wire-oriented biopsy specimen.2. To evaluate the relations between mammography MC features and pathology in breast lesions.Methods1. SubjectsFrom May2010to October2012,106women with breast disease were collected, aged25-68years old, average age41.9years, median age41years old. FFDM images were characterized as MC lesions. Pathology diagnosis results were obtained by biopsy or tumor resection. Specimens were undergone mammography routinely, which determines MC lesions had been totally removed.2. EquipmentsFFDM underwent all the patients before operation, equipped with a high-definition digital rapid acquisition station and X-ray induced biopsy system (GIOTTO Corp., Italy). Patients were examined standing or sitting. Mammography regularly shot bilateral breast, included craniocaudal (CC) and mediolateral oblique (MLO) projection, besides side or special projection if necessary. Computer system implemented automatic X-ray exposure conditions, and breast X-ray images must be acquired conforming to mammography image quality standard, stored with standard DICOM file format and imported into PACS.3. Problems in DR routine photography for wire-oriented biopsy specimens were analyzed. Photography technique was reformed to improve image quality. Detection rate of calcification was compared between the two photography techniques (Routine Group and Reforming Group).4. MC image featuresMC image features in FFDM were recorded, included breast density, MC shape, distribution, quantity (number of per unit area), MC Density, location and whether accompanying by mass, etc.(?)MC shape was divided into4types, referring Le Gal classification in1984. And type I was typical benign calcification, followed with no intervention in clinic. Consequently, type I was not explored in this study.㎝C distribution, was classified into cluster, linear, segmental, regional, and diffuse, according to Brest Imaging Reporting and Data System (BI-RADS), formulated by American Radiology Association in2003(?)MC quantity, was calculated by counting the MC numbers in a unit area (usually1cm2) in the most concentrated area, and was divided into4groups,0～10,11～20,21～30, and>30.(?)MC Density was divided into high density and low density (hidden calcification).(?) MC location is in left or in right breast,.(?)Whether accompanied by mass:yes or not.4. Statistical processingSPSS13.0software was applied for statistical analysis. Single factor analysis was utilized by x2test (Fisher’s exact test), and multiple factors analysis by Logistic regression analysis. Comparison difference is statistically significant when P<0.05.Results1. Shortages of breast specimens DR images and innovationThe shortages of breast specimens DR images included signs overlap, poor contrast, calcification or glandular with blurred details. The best images were obtained by using the background sets, appropriate pressure, manually adjustment of exposure parameters. Routine Group had a high calcification detection rate than Reforming Group (100%vs.83.3%, P<0.05)2. Pathology of106patients with MC111MC lesions were found in106cases with breast disease, including5cases with MC in both side breasts. There were50malignant lesions (45.0%) and61benign lesions (55.0%), confirmed by pathology.3. Single factor analysisMC features factors, including shape, distribution, and whether accompanied by mass, number of per unit area, had significant influence on proportions of malignance. Furthermore, as the elevations classification of MC shape and number per unit area, proportions of malignance is increasing, in turn, respectively29.6%,30.1%,87.0%,30.1%and87.0%,48.0%,58.5%,75.8%. When MC is accompanied with mass, malignant lesion rate was75.7%, significantly higher than without mass29.7%(P<0.001). But MC density and mammary gland density type had no significant effect for calcification identification.Conclusions1.Full digital mammography, computer-aided detection and X-ray innovation will improve the detection rate of calcification.2. MC image features, including shape, distribution, density and whether accompanied by mass, is valuable for breast cancer differential diagnosis.3. Le Gal classification of micro calcification is highly relative to malignancy. Diagnosis accuracy will be improved if combining with other imaging signs. PART2Application of multi-sliced CT on breast cancer and related factors analysis such as molecular typing on lymph node metastasisObjectives1. To investigate the application of multi-sliced CT on breast cancer and early lymph node metastasis (LNM).2. To investigate the relation between molecular typing and lymph node metastasis.Methods1.30cases with infiltrative ductal carcinoma (IDC) confirmed by pathology were collected and set as Study Group, with an average age(49.7±11.8)yr, and30fibromas as Control Group, with an average age(48.6±10.2)yr. There was no significant difference in age. In addition,20breast cancer cases without lymph node metastasis were collected.2. Equipments.128-slice CT plain scan and2phrase enhance was undergone. Image signs of mass of two groups were compared. Image signs of early lymph node metastasis were analyzed.ResultsIn MSCT images, IDC masses had irregular shape, burr rim.2-phrase MSCI demonstrated obvious enhancement in artery phrase, persistence enhancement in vein phrase and ring shape enhancement. There were significant different between2groups in mass shape, rim and enhancement mode (P<0.05). MSCT demonstrated22LNM, but6of them had no swelling but obvious enhancement. Lymph node (LN) metastasis showed round performance, lost of normal lymph node gate structure and enhanced significantly, including15in axillary LN,2in internal mammary chain,2in supraclavicular LN,8in mediastinal LN.Conclusions1. MSCT2-phrase enhance scan plays an important role in assessing breast cancer and early lymph node metastasis.2. There is relation between molecular typing and lymph node metastasis. Part3Application of preoperative MRI on breast cancer diagnosis and evaluation before breast-conserving surgeryObjectivesTo evaluate the influence of preoperative MRI on tumor-positive rate of resection margins and surgery treatment programs in breast cancer patients eligible for breast-conserving surgery.MethodsFrom Mar2012to May2013,64cases with breast cancer eligible for breast-conserving surgery (BCS) were collected as STUDY GROPU (SG). From Jun2010to Aug2011,73cases with breast cancer eligible for BCS were collected as history CONTROL GROUP (CG). The two groups were undergone with mammography and ultrasound, and were eligible for BCS after assessment. In addition, SG was undergone with breast MRI preoperatively.ResultsSG included64patients, with a total of77lesions, mean age40.19±0.91yr; historical SG included73patients, with a total of81lesions, mean age39.14±0.92yr. Tumor size differences between the two groups (P=0.020), between the two groups infiltrating ductal carcinoma (Infiltrating ductal carcinoma, IDC), there are differences in the size (P=0.022). While age, the gland type, whether positive palpation, mammography is showing malignant calcification, pathologic type between the two groups did not show a significant difference. Compared with the historical CG, SG had lower positive margin rate (9.6%and24.7%; P=0.04). In addition, preoperative MRI demonstrated multiple lesions in12cases (18.8%), peritumoral infiltration and contralateral lesions. Therefore, the original surgical resection plan was changed.Conclusions1. Preoperative MRI, demonstrating the size, infiltration range of breast cancer, therefore effectively reduces positive margin rate for the patients who underwent breast-conserving surgery.2. Preoperative MRI, demonstrating more multiple lesions, peritumoral infiltration and contralateral lesions, therefore changes the original surgical resection plan.