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Evolving Role of ImagingModalities in Inflammatory Breast Cancer

Carisa H. Le-Petross,a Luc Bidaut,b and Wei T. Yanga

Imaging plays several key roles in the diagnosis and assessment of inflammatory breast cancer (IBC).These include characterization of the known tumor, delineation of locoregional disease in theipsilateral and contralateral breast and regional lymph node basins, diagnosis of distant metastases,and evaluation of treatment response. We review the role of conventional imaging modalities,including mammography and sonography. We also discuss the potential of using evolving imagingmodalities such as magnetic resonance imaging (MRI), positron emission tomography with com-puted tomography (PET/CT), and more advanced or emerging imaging techniques in the assess-ment of IBC.Semin Oncol 35:51-63 © 2008 Elsevier Inc. All rights reserved.

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nflammatory breast cancer (IBC) is a rare but fre-quently lethal form of primary breast cancer, cate-gorized by the American Joint Committee on Can-

er as a T4d tumor.1-4 IBC is characterized by a rapidnset of swelling and enlargement of the breast, typi-ally within 3 months from the first symptom or sign toiagnosis.5-7 The common clinical presentation is dif-use skin erythema, edema, local tenderness, indura-ion, and warmth. IBC can present with or without aalpable breast mass and is usually a poorly differenti-ted infiltrating ductal carcinoma. The prognosis of IBCs poor because of the likelihood that it has already

icro-metastasized at diagnosis. Histological tissue di-gnosis may be problematic due to difficulty in definingn area for biopsy. Approximately 20% of patients withBC have gross distant metastases at the time of diag-osis.8

Imaging plays several key roles in the diagnosis andssessment of IBC. These include characterization ofhe known tumor, delineation of locoregional diseasen the ipsilateral and contralateral breast and regionalymph node basins, diagnosis of distant metastases, andvaluation of treatment response. We review here theole of conventional imaging modalities, includingammography and sonography, and discuss the poten-

ial of rapidly evolving imaging modalities, including

Department of Diagnostic Radiology, The University of Texas, M.D. AndersonCancer Center, Houston, TX.

Department of Imaging Physics, The University of Texas, M.D. Anderson CancerCenter, Houston, TX.

ddress correspondence to Wei T. Yang, MD, Department of Diagnostic Radiol-ogy, The University of Texas, M.D. Anderson Cancer Center, 1515 HolcombeBlvd, Houston, TX 77030.

270-9295/08/$ - see front matter
m2008 Elsevier Inc. All rights reserved. doi:10.1053/j.seminoncol.2007.11.016
eminars in Oncology, Vol 35, No 1, February 2008, pp 51-63

agnetic resonance imaging (MRI), positron emissionomography with computed tomography (PET/CT),nd advanced imaging techniques including co-registra-ion and hybrid imaging in the assessment of IBC.

MAGING TECHNIQUES

ammography

Standard imaging findings of IBC using mammographynd sonography have been previously described.9-17 Theargest study describing the mammography features ofBC was published in 2002.11 Uniformly, the most fre-uent and consistent imaging findings in IBC are skinhickening, trabecular and stromal thickening, and dif-use increased breast density (Figures 1A and 2A). Skinhickening and trabecular distortion are key to theiagnosis. Skin thickening is believed to be secondaryo infiltration of the dermal lymphatics by tumor cells,lthough pathologic proof of dermal lymphatic involve-ent is not necessary for the diagnosis of IBC. The

tromal and trabecular changes are presumed to beecondary to edema and obstruction of lymph vesselsnd capillaries. Increased size, density, trabeculations,nd skin changes may be subtle and detected only whenomparison with the contralateral breast is made. IBC isenerally a unilateral process.17 The higher percentage ofilateral cases reported in older studies of IBC18,19 likelyeflects the difference in case definition and the inclu-ion of locally advanced breast cancer patients in theseeries. Locally advanced breast cancer is the majorifferential diagnosis for IBC and can be excludedased on clinical history.

Although most patients present with a palpable
ass clinically, a corresponding mass is frequently not
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52 C.H. Le-Petross, L. Bidaut, and W.T. Yang

ammographically visible, likely due to overall in-reased density (Figure 1A), which masks underlyingasses and the infiltrative nature of the tumor. A pri-ary breast mass is the most variable finding on mam-ography (Figures 2A and 3A). Focal asymmetry or

rchitectural distortion is less common. Calcificationsre less common when compared to patients with

igure 1. (A) Right lateral mammogram in a 48-year-oldoman with IBC shows global asymmetry (long arrows)ith associated diffuse increased breast density and global

kin thickening (small arrows). No discrete mass or abnor-al microcalcifications are identified. Pathology showed

nvasive ductal carcinoma. (B) Longitudinal extended-field-f-view ultrasound shows global architectural distortionith marked posterior acoustic shadowing (arrows) involv-

ng the entire lateral right breast. No discrete mass is iden-ified.

ocally advanced invasive ductal breast cancer.9,12,14 In a i

ecent study of 80 patients with IBC, a mass or architec-ural distortion was the most common primary breastarenchymal feature.16 Calcifications were noted in 41%f patients16 and may emerge with an overall decrease

n density after therapy. A recent analysis of nine mam-ography studies over 18 years showed associated

xillary adenopathy in approximately 28% of patients.17

xillary adenopathy may be useful in differentiatingBC from possible confounders such as post radiationhange. In a recent single-institution retrospective anal-sis, mammography was the least sensitive and leastffective method in diagnosing breast disease in IBCatients.16 Mammography detected the lowest percent-ge of primary breast parenchymal lesions and theowest percentage of multicentric disease (43%).

onography

The role of sonography has been studied and rele-ated primarily to a localizing tool in the biopsy ofatients with identifiable masses.17 Even patients with-ut discrete masses may occasionally demonstrate ex-ensive areas of parenchymal architectural distortionhat are best captured and depicted on extended-field-f-view imaging (Figure 1B), which is a widely availableool on most sonography units today. Biopsy of theseegions of abnormality yields a cancer diagnosis in allases.16 When a mass is sonographically visible, it isost frequently an irregular hypoechoic mass with

ll-defined margins, and posterior acoustic shadowingFigures 2C and 3B). Skin thickening is evidenced bylurring of the transducer, skin, and dermal subcutane-us fat lines, which appear more hypoechoic, or, alter-atively, dilated lymphatic vessels representing edemaurrounding the breast lobules (Figure 2B). Edema canlso present as diffuse increased echogenicity of thereast (Figure 2B). In a recent retrospective review athe University of Texas M.D. Anderson Cancer CenterHouston, TX), sonography diagnosed a primary breastarenchymal lesion and skin thickening in 95% of le-ions16 (Figures 1B, 2C, and 3B). These findings suggesthat sonography is a reliable alternate imaging modalityhould the affected breast be too painful and edema-ous to undergo adequate compression during mam-ography. Furthermore, sonography also diagnosed aigher percentage of multicentric/multifocal disease72%).16

In our experience, sonography permits a more com-rehensive evaluation of the regional nodal basins (in-luding axillary, infraclavicular, internal mammary, andupraclavicular) than does any other modality.16,20,21

revious series have reported axillary adenopathy in2% to 56% of IBC cases (mean, 28%) (Figure 3C).1,3,4,17

ur recent study detected regional axillary nodal dis-ase in 93% of cases on sonography.16 Supraclavicular,
nfraclavicular, or internal mammary nodal disease was

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Evolving role of imaging modalities in IBC 53

iagnosed in at least 50% of patients on sonographyFigure 3C and D). Pretreatment nodal staging usingonography may affect locoregional therapeutic plan-ing, which is based on initial disease involvement.21

agnetic Resonance Imaging

MRI is an emerging breast imaging technique thatacks ionizing radiation and enjoys superior sensitivityn the diagnosis of invasive breast cancer. It also has theotential to characterize and quantify dynamic contrastgent enhancement in a region of interest. The majorunctions of MRI are in the diagnosis and staging ofreast cancer, and also in the monitoring of treatmentor patients with breast cancer.

To the best of our knowledge, findings of IBC onRI are scarce in the published literature15-17,22-24

Table 1). Most of the published data describe find-ngs performed on a 1-Tesla (T) or 1.5-T unit. Theallmark in the largest series described to date is skinhickening and skin enhancement.17 Enhancing ten-rils of tumor mass were noted extending to thekin. Breast deformity and enlargement, and enlargednhancing axillary nodes also were noted. A discreteecrotic mass was noted in 38%, followed by an

nfiltrative mass with a reticular dendritic pattern,ith extension to the pectoralis muscle. Tumorasses showed either wash-in with plateau or wash-

ut enhancement kinetics.In our institution, MRI of both breasts is performed

n magnetic resonance systems with field strength ofither 1.5 or 3.0 T (General Electric Medical Systems,aukesha, WI) and with standard dedicated bilateral

reast coils (four-channel phased array breast coil, In-ivo Corp, Orlando, FL; or eight-channel open phasedrray coil, General Electric Medical Systems). Prelimi-ary results on the MRI findings performed on a 3-Tystem of patients with IBC16,24 were recently reported.he imaging protocol included a sagittal fat-suppressed2-weighted fast spin-echo pulse sequence with fatuppression (TR/TE 4,000-6,000/85 ms), optional axial1-weighted fast spin-echo before dynamic imagingTR/TE 500/min), a dynamic series, and a delayed con-rast-enhanced axial or sagittal gradient echo sequence.he shape of the time-signal intensity curve was used

o characterize the enhancement pattern of a lesion.25

omputer-assisted detection (CAD) software was usedor providing a color-coded map of the pattern of en-ancement within areas of interest along with subtrac-ion and maximum intensity projection imaging.

The most frequent MRI findings in two recent stud-es were multiple masses with irregular margins andeterogeneous internal enhancement associated with aash-out or plateau kinetic curve in 97% of pa-

ients.16,24 Skin thickening and skin enhancement wereeen in the majority of patients, ranging between 90%
o 100% on MRI15-17,22,24 (Figure 4). Chow et al com- l
ented that breasts with thicker skin demonstratedkin enhancement more frequently.17 Similar findingsere observed in our study24 (Figure 5A). In 39% of theatients with skin enhancement, tiny nodular enhance-ent was noted. Over half of the patients had breast

dema, which manifested as bright T2-weighted signalhroughout the affected breast16,17,24 (Figure 5B). Associ-ted breast enlargement and asymmetric breast enhance-ent also were observed, compatible with the inflamma-

ory process of this disease. On MRI, the primary breastesion may present as a mass-like or non–mass-like en-ancement (Figures 2D and 6). However, recent dataemonstrated that MRI revealed a primary breast lesion in00% of the cases (33/33) as compared to 96% withET/CT, 80% with mammogram, and 95% with ultra-ound.16 These new results are most likely due to techni-al advances in MRI, and suggest that MRI may presentlye the imaging modality of choice for this disease.

Heterogeneous or inhomogeneous and reticular orendritic internal enhancement (Figure 7) was com-only noted with both mass-like and non–mass-like

esions.15-17,22,24 Qualitative assessment of the primaryreast lesion enhancement demonstrated a wash-outattern in the majority of the cases.16,17,22,24 Axillary

nvolvement was identified in more than 80% ofases.16,17,22,24 The size and morphological characteris-ics of the lymph nodes are more useful, in our expe-ience, in differentiating between benign and malig-ant lymph nodes than using kinetic assessment. This isue to the fact that lymph nodes usually do enhancend often demonstrate a wash-out pattern.

The differential diagnosis of IBC is non-puerperalastitis, locally advanced breast cancer, and primary

reast lymphoma, all of which may result in skin thick-ning, diffuse breast enlargement, and diffuse in-reased mammographic density. The differential diag-osis between IBC and locally advanced breast cancerhould be excluded based on clinical history.17,26,27 MRIoes not allow sufficient differentiation between mas-itis and inflammatory carcinoma.22,23

Even though MRI is a powerful test in the diagnosisnd staging of IBC, this technique is not ideal for all IBCatients due to several technical limitations. Althoughhe breasts are not compressed during MRI, the in-reased duration of the study (approximately 40 min-tes on average) and the prone positioning add tootential patient discomfort and lack of tolerance.ommercially available breast coils currently come inne size only. Combining inflammation with a pre-xisting large breast may not allow the resulting en-arged breast to fit into a single sized breast coil. As aonsequence, MRI cannot be offered to all IBC pa-ients. Some patients may require pre-medication toinimize discomfort due to the pressure from the

reast coil against the inflamed breast and chest when
ying in a prone position.

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igure 2. (A) Right cranio-caudad digital mammogram in a 26-year-old woman with IBC shows an irregular high density massn the outer breast (long arrow) with associated global skin thickening (short arrows) and trabecular thickening. Pathologyhowed invasive ductal carcinoma. (B) Extended-field-of-view ultrasound of the right breast in the same patient demonstratesarked global skin thickening (arrows) and edema in the subcutaneous plane evidenced by diffuse hyperechogenicity. (C)

ransverse ultrasound of the right upper outer quadrant shows an area of architectural distortion (arrows) with markedosterior acoustic shadowing in the 10 o’clock position representing the primary breast parenchymal lesion. (D) Post-contrast

at suppressed axial VIBRANT (Volume Imaging for Breast Assessment by GE Healthcare) image in the same patient shows anrregular mass with spiculated margins (arrow) in the lateral right breast with heterogeneous enhancement and associatediffuse skin thickening (short arrows). (E) Coronal PET scan shows a hypermetabolic right breast mass (long arrow) withssociated right axillary adenopathy (short arrow). (F) Axial fusion PET/CT shows the hypermetabolic primary right breast
ancer (arrow).

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ET and PET/CT

18-Fluoro-deoxy-glucose (18-FDG)-PET has beensed in breast cancer with varying degrees of success.ecent reviews provide excellent background informa-

ion regarding techniques and protocols.28,29 Althoughrospective studies on the current use of FDG-PET inrimary breast cancer have suggested limited value invaluating local lymph nodal disease,28-30 these studiesave focused primarily on patients with early or small-olume disease for whom there is a low probability ofymph node involvement. These findings do not neces-arily apply to patients with IBC who frequently havextensive locoregional disease. Appropriate delinea-ion of disease extent is helpful for treatment planning,ncluding radiotherapy and chemotherapy16 (FiguresE, 3E, and 8A). A single study on seven patients de-cribed increased uptake in enlarged breasts, with as-ociated prominent skin uptake, and intense scatteredoci.31 There was associated ipsilateral axillary adenop-

Figure

thy in 86% of patients, infraclavicular and supraclavic- e

lar adenopathy in one patient, and bone metastases inne patient.31

PET/CT is an emerging imaging method that isidely gaining clinical acceptance because of its ability

o co-register both anatomic and functional informationn one image.32-34 PET/CT is developing a role in theomprehensive staging of breast cancer, particularly inhe determination of multicentric and or bilateral dis-ase, and of metastatic disease. The ability of PET/CT touantitate functional activity (eg, standardized uptakealue [SUV]) of known tumors or suspicious lesionsay improve the quality, definition and impact of im-

ging-based findings.28,35-38 PET/CT allows for a morennovative assessment of the anatomical environment,hereby permitting differentiation between specificnd non-specific uptake and even more so throughdvanced imaging paradigms.32,33,39,40 New more spe-ific PET tracers can lead to improved characterizationf a complex disease,41 which is critical in defining an

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A preliminary study on the role of PET/CT in 24 pa-ients with IBC showed that PET/CT is accurate at dem-nstrating locoregional disease and distant metastases.16

ulticentric disease was documented in 63% of patients,

igure 3. (A) Left digital cranio-caudad mammogram of aass with spiculated margins (arrow) in the lateral brea

ltrasound of the left upper outer quadrant shows an irregulhadowing in the 2 to 3 o’clock position. (C) Transverse ultrndistinct margins and posterior acoustic shadowing. Thispsilateral supraclavicular fossa. (D) Ultrasound of the left suine-needle aspiration biopsy showed metastatic carcinomahe left breast (long arrow) and associated ipsilateral regionaET/CT shows multifocal hypermetabolic lesions (arrow)ypermetabolic left axillary and infraclavicular lymphadeno

egional nodal disease in 88%, and distant metastases in a

8% of patients. Distant metastasis primarily involved theiver, skeleton, and contralateral supraclavicular node inhis study16 (Figure 8B). This rate of metastatic disease isigher than that reported for breast cancers in general,

-old woman with IBC shows a solitary irregular high densityology showed invasive ductal carcinoma. (B) Transversemass (arrow) with indistinct margins and posterior acousticof the left axilla shows an irregular solid mass (arrow) with

t subjected to biopsy in view of suspicious findings in theicular fossa shows a solid round hypoechoic mass (arrow).ronal PET scan shows multifocal hypermetabolic lesions inllary and infraclavicular adenopathy (short arrows). (F) Axialleft breast. (G) Axial PET/CT at a different level showsrrows).

62-yearst. Pathar solidasoundwas nopraclav. (E) Col left axiin the

nd may reflect the aggressive nature of IBC.

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Such findings suggest that despite its cost, PET/CThould be considered in the initial staging of womeniagnosed with IBC. The cost of a PET/CT study is2,568 according to the Medicare fee schedule for oureographical area. This compares with $400 for CT of

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Table 1. MRI Findings of Patients With Inflamma

Rieber et al23 Lee et al15

No. of patients 10 9Skin thickening 90% 100%Skin enhancement 78%Breast edema 90% 22%Breast mass 22% 22%Kinetic curve

Wash-inPlateauWash-out

he thorax with contrast, $408 for CT of the abdomenith contrast, $387 for CT of the pelvis with contrast,

203 for whole-body bone imaging, $1,024, $1,008,nd $1,024 for MRI of the cervical spine, thoracicpine, and lumbar spine with contrast, respectively,

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ultimodality and Further Hybrid Imaging

While more traditional breast imaging modalitiesncluding mammography and MRI have evolved con-inuously to provide more detailed information,ewer more advanced imaging techniques have beeneveloped to take advantage of the unique physicalharacteristics of the breast from an imaging per-pective and to enable additional quantitative analy-is. While CAD software and paradigms have beenevised to extract the most pertinent diagnostic infor-ation from a single modality (eg, mammography,

onography, and MRI),42-44 uni-modality approaches areenerally insufficient to fully characterize complex dis-ases and response to therapy. A multimodality regis-ration imaging approach has the potential for indepen-ent sources of imaging each with its own complexifferential assessment of disease. Emerging hybrid im-ging systems such as PET/CT32,33 and single-photonmission computed tomography (SPECT)/CT45 haveeen put to increased use in this context. While intrin-ically superior for functional characterization of dis-ase, these systems still present problems or challengesor the meaningful and precise integration of all image-ased information available.46

Traditional multimodality imaging is defined as therocess of registering47-49 and exploiting39,40,50 datasets

igure 4. Non-contrast axial T1-weighted fast spin echomage in a 44-year-old patient with IBC shows markedlobal skin thickening (arrows) in the right breast. Skinunch biopsy confirmed carcinoma in dermal lymphatics.

hat have been produced on distinct modalities at dif- e

erent times. Registration is the process that identifieshe three-dimensional geometric transformation of oneataset into the spatial reference system of anotherne. Hybrid modalities improve upon the similarity ofhe data both in time and in space, which therefore

igure 5. (A) Post-contrast sagittal VIBRANT image of theight breast in a 56-year-old woman with IBC shows skinhickening and heterogeneous skin enhancement (arrows).kin punch biopsy demonstrated poorly differentiated car-inoma in dermis. (B) Pre-contrast fat suppressed T2-eighted image of the right breast in the same patient asbove demonstrates high signal intensity throughout thebroglandular tissue (medium arrow), skin (short arrows),nd chest wall (long arrow), compatible with extensive
dema. Biopsy showed invasive ductal carcinoma.

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inimizes spatial and functional imaging discrepancieshead of the registration process. The advent of hybridmaging, eg, through PET/CT initially, has paved the

ay for multimodality applications in breast cancermaging and significant research is focused on combin-ng data extracted from multimodality datasets to de-ne the most relevant features for diagnosis, therapy

igure 6. Contrast enhanced T1-weighted fat-saturatedradient recalled echo (GRE) axial 3-T image of a 52-year-ld woman with IBC shows heterogeneous non mass-likenhancement involving the entire right breast (arrows) andarked global skin thickening (small arrows). Pathology

howed mixed invasive ductal and lobular carcinoma.

igure 7. Axial subtraction image of a 52-year-old womanith IBC shows heterogeneous non–mass-like enhance-ent with dendritic pattern (arrows) and marked global

kin thickening (small arrows). Pathology showed poorly
aifferentiated carcinoma.
ssessment, and intervention planning.39,40,50 For exam-le, Figure 9 shows the case of a 51-year-old womanresenting with a palpable left breast mass involvinghe left axillary and contralateral right axillary lymphodes, and low back pain. A single PET/CT scan with

igure 8. (A) Coronal PET scan in a 56-year-old womanith IBC shows multifocal left breast cancer (thick arrow),

ontralateral right axillary adneopathy (medium arrow),nd multiple hypermetabolic skeletal metastases involvinghe L5 vertebral body and the left hemipelvis (thin arrows).B) Coronal fusion PET/CT image in the same patient at aifferent level shows part of the hypermetabolic left breastancer (thick arrow) and bilateral iliac adenopathy (thinrrows).

dvanced image processing and visualization para-

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igms demonstrates the full extent and diffuse naturef the disease to both physician and patient. Standardssessment would have required a combination ofonography, CT of the chest and abdomen, MRI of thepine, and bone scan to demonstrate similarly the fullxtent of the disease.

A standard method of assessing response to therapy iserial measurement of lesion size. Trends are movingway from morphology-based serial size measurementsoward assessment of functional response,51 the rationaleeing the timeliness of such response that could permit aore efficient customization of therapy to specific canceratients. Sequential FDG-PET/CT acquisitions that haveeen co-registered on a similar scale demonstrate func-ional response to chemotherapy52 (Figure 10).

igure 9. Advanced FDG-PET/CT hybrid imaging in a 52-yisease and distant metastases. (A) Coronal fusion image thrimary left breast cancer (long arrow) and bilateral axillary aemonstrated in the left breast (medium arrow), right axendering” of PET/CT focused on skeletal lesions (3D) (longolors/items are PET.)

igure 10. (A) Baseline acquisition demonstrates hypermexillary (short arrow) and right internal mammary nodal diseemonstrates complete resolution of disease with no residua
ost-treatment shows absence of disease in the left breast and inc
Recent advances in MRI of the breast include higher-eld machines, new coils, faster electronics resulting inn increase in the signal to noise ratio and faster acqui-itions that enable more advanced sequences and bet-er tissue characterization through dynamic contrastnhancement, diffusion weighted imaging, and para-etric imaging.53-55 Much effort is focused on the de-

elopment of new tracers that are disease- or physiol-gy-specific.41

MR/PET is currently being developed56,57 and theurrent design involves a PET insert within a magneticesonance magnet and magnetic resonance gradients.58

urrently, combining PET and MRI in the breast cannly be achieved through what could be called “tradi-ional” multimodality approaches.59 Such approaches

woman with left IBC demonstrates extensive locoregionalhe spine (2D). (B) Coronal PET MIP (2.5D) image shows athy (small arrows). (C) Significant PET uptake bubbles (3D)rt arrow), and lumbar skeleton (long arrow). (D) “Cross-). (CT-derived skeleton in orange on A, B, and C. All other

primary left breast cancer (long arrow) with associated leftrt arrow). (B) Coronal PET/CT scan 75 days post-treatmentf hypermetabolism. (C) Further serial follow-up at 105 days

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equire discrete images and utilization of either intrin-ic or extrinsic landmarks to register a patient’s breastnd its contents across multiple modalities (Fig. 11).uch non-rigid registration is based on physical princi-les and models of varying complexity49 but cannotvercome all sources and effects of deformation in thentire volume of interest. Therefore, initiating the im-ging process with datasets that are as similar in loca-ion and positioning as possible is highly desirable foruccessful co-registration and fusion.60 With such aetup, the spatial registration errors between MRI (highpatial resolution) and PET (low spatial resolution) dueo the repositioning of the patient will generally remainegligible in regard to the gross matching of the twoatasets that can be achieved when patients are care-ully repositioned.

dvanced Breast Imaging Techniques

Cone-beam breast CT is being developed for spatialesolution and soft-tissue contrast characterization.61-63

edicated positron emission mammography (or evenull-blown PET) and SPECT machines64,65 are makingheir way toward clinical applications. Ultrasound to-ography is being actively developed66,67 either on its

wn or in combination with other modalities. Thereast also can be imaged using optical tomographytransmission, diffusion, emission or reflection). De-igning suitable reconstruction techniques for this spe-ific organ is still very much a work in progress, butrototype systems68,69 have already demonstrated theotential of such an approach, even for functional

maging and at a fraction of the cost of more estab-ished modalities (eg, MRI).

ONCLUSION

In conclusion, mammography is the least sensitive

igure 11. Registration and fusion between a parametricRI data set (multiphase subtraction) and FDG-PET/CT

mage on the same patient as in Figure 9. The externalreast surface that is easily identified on MRI and PET/CTas used as a deformable bubble to register the breast from

he prone MR data set to the supine PET/CT. The diseasedeft breast is the main focus of the non-rigid registrationhat clearly demonstrates the link between increased FDGptake and MR perfusion (arrow).

maging modality for diagnosis of parenchymal abnor-

alities in the assessment of IBC. Sonography is usefuln localizing areas for biopsy and histological confirma-ion, and also in the comprehensive evaluation of theegional nodal basins (including axillary, infraclavicu-ar, internal mammary, and supraclavicular). MRI dem-nstrates parenchymal breast abnormality in virtuallyll patients with IBC and provides the advantage ofxquisite anatomical detail and functional informationhrough kinetic evaluation. PET/CT is accurate at dem-nstrating locoregional disease and distant metastases.he evolving, emerging, and advanced imaging tech-iques and approaches described herein are obviouslyot exhaustive and not necessarily specific to IBC. As aeneral point, the evolution of multimodality imageegistration and fusion in particular should not be con-trued as a rationale for acquiring more datasets thatill remain separate, but rather as a way to foster the

ntegration of complementary information (includingarameters derived from the source imaging datasets),he sum of which should always be greater than itsarts. Based on our preliminary experience, such evo-

ution and innovations should prove extremely relevanto a disease as complex as IBC.

EFERENCES1. Levine PH, Steinhorn SC, Ries LG, et al. Inflammatory

breast cancer: the experience of the Surveillance, Epide-miology, and End Results (SEER) program. J Natl CancerInst. 1985;74:291-7.

2. Chang S, Parker SL, Pham T, et al. Inflammatory breastcarcinoma incidence and survival: the Surveillance, Epi-demiology, and End Results program of the NationalCancer Institute, 1975-1992. Cancer. 1998;82:2366-72.

3. Hance KW, Anderson WF, Devesa SS, et al. Trends ininflammatory breast carcinoma incidence and survival:the Surveillance, Epidemiology, and End Results programat the National Cancer Institute. J Natl Cancer Inst. 2005;97:966-75.

4. Greene FL, Page DL, Fleming ID, et al. American JointCancer Committee cancer staging manual. 6th ed. NewYork: Springer-Verlag; 2002. p. 221-40.

5. Lee B, Tannenbaum N. Inflammatory carcinoma of thebreast: a report of twenty-eight cases from the breastclinic of Memorial Hospital. Surg Gynecol Obstet. 1924;39:580-5.

6. Jaiyesimi IA, Buzdar AU, Hortobagyi G. Inflammatorybreast cancer: a review. J Clin Oncol. 1992;10:1014-24.

7. Dirix LY, Dam PV, Prove A, et al. Inflammatory breastcancer: current understanding. Curr Opin Oncol. 2006;18:563-71.

8. Wingo PA, Jamison PM, Young JL, et al. Population-basedstatistics for women diagnosed with inflammatory breastcancer (United States). Cancer Causes Control. 2004;15:321-8.

9. Dershaw DD, Moore MP, Liberman L, et al. Inflammatorybreast carcinoma: mammographic findings. Radiology.1994;190:831-4.

0. Droulias CA, Sewell CW, McSweeney MB, et al. Inflam-
matory carcinoma of the breast: a correlation of clinical,

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1

2

2

2

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2

2

2

2

3

3

3

3

3

3

3

3

3

3

4

4

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radiologic and pathologic findings. Ann Surg. 1976;184:217-22.

1. Gunhan-Bilgen I, Ustun EE, Memis A. Inflammatorybreast carcinoma: mammographic, ultrasonographic,clinical, and pathologic findings in 142 cases. Radiology.2002;223:829-38.

2. Kushwaha AC, Whitman GJ, Stelling CB, et al. Primaryinflammatory carcinoma of the breast: retrospective re-view of mammographic findings. AJR Am J Roentgenol.2000;174:535-8.

3. Caumo F, Gaioni MB, Bonetti F, et al. Occult inflamma-tory breast cancer: review of clinical, mammographic,US and pathologic signs. Radiol Med (Torino). 2005;109:308-20.

4. Tardivon AA, Viala J, Corvellec Rudelli A, et al. Mammo-graphic patterns of inflammatory breast carcinoma: aretrospective study of 92 cases. Eur J Radiol. 1997;24:124-30.

5. Lee KW, Chung SY, Yang I, et al. Inflammatory breastcancer: imaging findings. Clin Imaging. 2005;29:22-5.

6. Yang WT, Le-Petross HT, Macapinlac H, et al. Inflamma-tory breast cancer: PET/CT, MRI, mammography, andsonography findings. Breast Cancer Res Treat. Epub2007 Jul 26.

7. Chow CK. Imaging in inflammatory breast carcinoma.Breast Dis. 2005;22:45-54.

8. Haagensen CD. Diseases of the breast. 2nd Edition. Phil-adelphia: Saunders; 1971. p. 576-84.

9. Taylor GW, Meltzer A. Inflammatory carcinoma of thebreast. Am J Cancer. 1938;133:33-49.

0. Yang WT, Ahuja A, Tang A, et al. High resolution sono-graphic detection of axillary lymph node metastases inbreast cancer. J Ultrasound Med. 1996;16:241-6.

1. Vlastos G, Fornage BD, Mirza NQ, et al. The correlationof axillary ultrasonography with histologic breast cancerdownstaging after induction chemotherap. Am J Surg.2000;179:446-52.

2. Belli P, Costantini M, Romani M, et al. Role of magneticresonance imaging in inflammatory carcinoma of thebreast. Rays. 2002;27:299-305.

3. Rieber A, Tomczak RJ, Mergo PJ, et al. MRI of the breastin the differential diagnosis of mastitis versus inflamma-tory carcinoma and follow-up. J Comput Assist Tomogr.1997;21:128-32.

4. Le-Petross HT, Charnsangavej C, Cristofanilli C, et al.Inflammatory breast cancer (IBC): Magnetic resonanceimaging (MRI) characteristics at 1.5 and 3.0T. Presentedat the Annual Meeting of the Radiological Society ofNorth America; 2007 November 26-30; Chicago, IL.

5. Kuhl CK, Mielcareck P, Klaschik S, et al. Dynamic breastMR imaging: are signal intensity time course data usefulfor differential diagnosis of enhancing lesions? Radiol-ogy. 1999;211:101-10.

6. Anderson WF, Chu KC, Chang S. Inflammatory breastcarcinoma and noninflammatory locally advanced breastcarcinoma: distinct clinicopathologic entities? J Clin On-col. 2003;21:2254-9.

7. Walshe JM, Swain SM. Clinical aspects of inflammatorybreast cancer. Breast Dis. 2005;22:35-44.

8. Wahl RL, Siegel BA, Coleman RE, et al. Prospective mul-
ticenter study of axillary nodal staging by positron emis-
sion tomography in breast cancer: a report of the StagingBreast Cancer With PET Study Group. J Clin Oncol.2004;2:277-85.

9. Eubank WB, Mankoff DA. Evolving role of positron emis-sion tomography in breast cancer imaging. Semin NuclMed. 2005;35:84-99.

0. Osman MM, Cohade C, Nakamoto Y, et al. Clinicallysignificant inaccurate localization of lesions with PET/CT: frequency in 300 patients. J Nucl Med. 2003;44:240-3.

1. Baslaim MM, Bakheet SM, Bakheet R, et al. 18-Fluorode-oxyglucose-positron emission tomography in inflamma-tory breast cancer. World J Surg. 2003;27:1099-104.

2. Beyer T, Townsend DW, Brun T, et al. A combinedPET/CT scanner for clinical oncology. J Nucl Med. 2000;41:1369-79.

3. Townsend DW, Beyer T. A combined PET/CT scanner:the path to true image fusion. Br J Radiol. 2002;75Suppl:24-30.

4. Fueger BJ, Weber WA, Quon A, et al. Performance of2-deoxy-2-[F-18]fluoro-D-glucose positron emission to-mography and integrated PET/CT in restaged breast can-cer patients. Mol Imaging Biol. 2005;7:369-76.

5. Rousseau C, Devillers A, Sagan C, et al. Monitoring of earlyresponse to neoadjuvant chemotherapy in stage II and IIIbreast cancer by [18F] fluorodeoxyglucose positron emis-sion tomography. J Clin Oncol. 2006;24:5366-72.

6. Larson SM, Erdi Y, Akhurst T, et al. Tumor treatmentbased on visual and quantitative changes in global tumorglycolysis using PET-FDG imaging: the visual responsescore and the change in total lesion glycolysis. ClinPositron Imaging. 1999;2:159-71.

7. Krak NC, Hoekstra OS, Lammertsma AA. Measuring re-sponse to chemotherapy in locally advanced breast can-cer: methodological considerations. Eur J Nuc Med MolImaging. 2004;31 Suppl 1:S103-11.

8. Tatsumi M, Cohade C, Mourtzikos KA, et al. Initial expe-rience with FDG-PET/CT in the evaluation of breast can-cer. Eur J Nuc Med Mol Imaging. 2006;33:254-62.

9. Bidaut L. Multisensor imaging and virtual simulation forassessment, diagnosis, therapy planning and navigation.Simulation Gaming. 2001;32:370-90.

0. Bidaut L, Akhurst T, Downey RJ. Advanced imaging in-cluding PET/CT for cardiothoracic surgery. Semin Tho-rac Cardiovasc Surg. 2004;16:272-82.

1. Linden HM, Stekhova SA, Link JM, et al. Quantitativefluoroestradiol positron emission tomography imagingpredicts response to endocrine treatment in breast can-cer. J Clin Oncol. 2006;24:2793-9.

2. Giger ML. Computerized analysis of images in the detec-tion and diagnosis of breast cancer. Semin Ultrasound CTMR. 2004;25:411-8.

3. Sahiner B, Chan HP, Roubidoux MA, et al. Malignant andbenign breast masses on 3D US volumetric images: effectof computer-aided diagnosis on radiologist accuracy. Ra-diology. 2007;242:716-24.

4. Meinel LA, Stolpen AH, Berbaum KS, et al. Breast MRIlesion classification: improved performance of human read-ers with a backpropagation neural network computer-aided diagnosis (CAD) system. J Magn Reson Imaging.
2007;25:89-95.

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5. Hasegawa BH, Wong KH, Iwata K, et al. Dual-modalityimaging of cancer with SPECT/CT. Technol Cancer ResTreat. 2002;1:449-58.

6. Vogel WV, Oyen WJG, Barentsz JO, et al. PET/CT: pan-acea, redundancy, or something in between? J Nucl Med.2004;45 Suppl 1:15S-24S.

7. Van Den Elsen PA, Pol EJD, Viergever MA. Medical imagematching—A review with classification. IEEE Engineer-ing Med Biol Magazine. 1993;1:26-39.

8. Crum WR, Griffin LD, Hill DLG, et al. Zen and the art ofmedical image registration: correspondence, homologyand quality. Neuroimage. 2003;20:1425-37.

9. Crum WR, Hartkens T, Hill DLG. Non-rigid image reg-istration: theory and practice. Br J Radiol. 2007;77:S140-53.

0. Sonka M, Fitzpatrick M, editors: Handbook of medicalimaging. Vol. 2. Medical image processing and analysis.Bellingham, WA: SPIE—The International Society for Op-tical Engineering; 2000.

1. Jaffe CC. Measures of response: RECIST, WHO, and newalternatives. J Clin Oncol. 2006;24:3245-51.

2. Cristofanilli M, Boussen H, Ben Ayed F, et al. A phase IIcombination study of lapatinib (TYKERB(®) and pacli-taxel as neoadjuvant therapy in patients with newlydiagnosed inflammatory breast cancer (IBC). Presentedat the 29th San Antonio Breast Cancer Symposium; 2006December 14-17; San Antonio, TX.

3. Wedam SB, Low JA, Yang SX, et al. Antiangiogenic andantitumor effects of Bevacizumab in patients with inflam-matory and locally advanced breast cancer. J Clin Oncol.2006;24:769-77.

4. Hylton N. Dynamic contrast-enhanced magnetic reso-nance imaging as an imaging biomarker. J Clin Oncol.2006;24:3293-8.

5. Hamstra DA, Rehemtulla A, Ross BD. Diffusion magneticresonance imaging: a biomarker for treatment responsein oncology. J Clin Oncol. 2007;25:4104-9.

6. Shao Y, Cherry SR, Farahani K, et al. Simultaneous PETand MR imaging. Physics Med Biol. 1997;42:1965-70.

7. Catana C, Wu Y, Judenhofer MS, et al. Simultaneousacquisition of multislice PET and MR images: initial re-sults with an MR compatible PET scanner. J Nucl Med.
2006;47:1968-76.
8. Judenhofer MS, Catana C, Swann BK, et al. PET/MRimages acquired with a compact MR-compatible PETdetector in a 7-T magnet. Radiology. 2007;244:807-14.

9. Schmidt GP, Kramer H, Reiser MF, et al. Whole-bodymagnetic resonance imaging and positron emission to-mography-computed tomography in oncology. TopicsMagn Reson Imag. 2007;18:193-202.

0. Moy L, Ponzo F, Noz ME, Maguire GQ, et al. Improvingspecificity of breast MRI using prone PET and fused MRIand PET 3D volume datasets. J Nucl Med. 2007;48:528-37.

1. Shaw CC, Chen L, Altunbas MC, et al. Cone beam breastCT with a flat panel detector—simulation, implementa-tion and demonstration. Proceedings of the 27th AnnualInternational Conference of the Engineering in Medicineand Biology Society; 2005; p 4461-4464.

2. Gong XJ, Glick S, Liu B, et al. A computer simulationstudy comparing lesion detection accuracy with digitalmammography, breast tomosynthesis, and cone beamCT breast imaging. Med Physics. 2006;33:1041-52.

3. Kwan ALC, Boone JM, Yang K, et al. Evaluation of thespatial resolution characteristics of a cone-beam breastCT scanner. Med Physics. 2007;34:275-81.

4. Levine EA, Freimanis RI, Perrier ND, et al. Positron emis-sion mammography: initial clinical results. Ann Surg On-col. 2003;10:86-91.

5. Rosen EL, Turkington TG, Soo MS, et al. Detection ofprimary breast carcinoma with a dedicated, large-field-of-view FDG PET mammography device: initial experi-ence. Radiology. 2005;234:527-34.

6. Duric N, Littrup P, Poulo L, et al. Detection of breastcancer with ultrasound tomography: first results withthe Computed Ultrasound Risk Evaluation (CURE) pro-totype. Med Physics. 2007;34:773-85.

7. Glide C, Duric N, Littrup P. Novel approach to evaluatingbreast density utilizing ultrasound tomography. MedPhysics. 2007;34:744-53.

8. Yates TD, Hebden JC, Gibson AP, et al. Optical tomog-raphy of the breast using a multi-channel time-resolvedimager. Physics Med Biol. 2005;50:2503-17.

9. Enfield LC, Gibson AP, Everdell NL, et al. Three-dimen-sional time-resolved optical mammography of the un-
compressed breast. Applied Optics. 2007;46:3628-38.

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