Zusammenfassung
Ziel: Ziel dieser Studie war es, herauszufinden, inwieweit die Verwendung der Gefäßmorphologie um und innerhalb einer anomalen B-Mode-Region von Nutzen ist, die diagnostische Genauigkeit bei 2 der häufigsten soliden Brustpathologien zu verbessern. Material und Methoden: Im Rahmen einer retrospektiven Studie wurden die B-Mode- und Doppler-Bilder von 117 Mammakarzinomen und 366 Fibrodadenomen und Fibroadenom-ähnlichen Läsionen untersucht. Beurteilt wurde dabei die Morphologie des Vaskularisationsmusters. Bei den Läsionen wurden der Quotient des Farbdopplerergebnis aus externen und internen Gefäßen, das externe Vaskularisationsmuster und die Verbindungsgefäße zu den internen Gefäßen untersucht und sodann eine Einteilung in benigne und maligne Vaskularisationsmuster vorgenommen. Diese Muster wurden wiederum mit dem histologischen Ergebnis korreliert. Ergebnisse: Ein Vaskularisationsnachweis gelang in 95 % der Karzinome und in 46 % der benignen Läsionen. Bei Karzinomen konnte ein Trend zu einer vermehrten Vaskularisation beobachtet werden. Dies führte bei Fibroadenomen beim Karzinomausschluss zu einer geringen Spezifität. Die Variationen der Vaskularisationsmuster wurden aufgezeichnet. Als benigne Vaskularisationsmuster wurden fehlende Vaskularität, Vaskularität in der Peripherie und periphere Grenzgefäße in Verbindung mit internen Gefäßen angesehen. Als maligne Gefäßmuster konnten radial ausgerichtete äußere Gefäße und ein Überwiegen von internen im Gegensatz zu externen Gefäßen, die mit den radialen Gefäßen in Verbindung standen, festgestellt werden (Fisher exact test p < 0,0001). Die Analyse der Vaskularisationsmorphologie verbesserte die Sensitivität, d. h. Karzinome zu identifizieren, von 97 % (B-Mode) auf 99 % (B-Mode und Farbdoppler), bei einem nur minimalen Rückgang der Spezifität (von 93,7 auf 92,6 %) oder der Genauigkeit (von 94,6 auf 94,2 %). Schlussfolgerung: Der Nachweis von Vaskularisation innerhalb von Läsionen kann für sich allein nicht mehr als guter Voraussageparameter gesehen werden, da der Anstieg der Dopplersensitivität mit Verbesserungen in der Ultraschalltechnologie einhergeht. Die morphologische Beurteilung des Gefäßmusters im Farbdoppler verbessert die Sensitivität der B-Mode-Diagnostik bei Mammakarzinomen und Fibroadenomen, wobei die Spezifität nur gering abnimmt. Im Vergleich zu den lediglich angrenzenden Gefäßen sollten alle radial angeordneten Verbindungsgefäße in einer Brustläsion als verdächtig eingestuft werden.
Abstract
Purpose: The aim of this study was to evaluate the use of vascular morphology, around and within the B-mode region of abnormality, for improving the diagnostic accuracy of two of the most common solid breast pathologies. Materials und Methods: The B-mode and Doppler images of 117 breast cancers and 366 fibroadenomas and lesions with a fibroadenoma-like appearance were reviewed retrospectively and the morphology of the vascular pattern was evaluated. The ratio of external to internal color Doppler, the external vascular pattern and the connecting vessels to internal vessels were assessed and differentiated into benign and malignant vascular patterns. These patterns were correlated with the histological diagnosis. Results: Vascularity was demonstrated in 95 % of cancers and in 46 % of benign lesions with a trend to increasing vascularity in cancers. This provided poor specificity for excluding cancer in fibroadenomas. Variations in vascular pattern were recorded. The observed benign vascular patterns were avascularity, vascularity in the periphery and peripheral marginal vessels connecting with internal vascularity. The observed malignant vascular patterns were radially aligned external vessels with internal vessels being more numerous than external vessels which connected to radial vessels. (Fisher exact test p < 0.0001). Analysis of the vascular morphology improved the sensitivity for identifying cancers from 97 % (B-mode) to 99 % (B-mode and color Doppler) with a minimal reduction in specificity (93.7 to 92.6 %) or accuracy (94.6 to 94.2 %). Conclusion: The presence of vascularity within a lesion, by itself, is no longer a good predictor of malignancy because of the increase in Doppler sensitivity associated with improvements in ultrasound technology. The color Doppler ultrasound vascular pattern morphology improves the accuracy and sensitivity of B-mode image diagnosis, breast cancers and fibroadenomas with a minimal loss of specificity. Any breast lesion with radial rather than marginal connecting vessels should be regarded with suspicion.
Key words
breast - blood vessels - anatomy - neoplasms - ultrasound color Doppler
References
1
Jackson V P, Rothschild P A, Kreipke D L. et al .
The spectrum of sonographic findings of fibroadenoma of the breast.
Investigative Radiology.
1986;
21
34-40
2
Chao T C, Lo Y F, Chen S C. et al .
Prospective Sonographic Study of 3093 breast tumors.
Journal of Ultrasound Medicine.
1999;
18
363-370
3
Nigro D M, Organ C H.
Fibroadenoma of the female breast – Some epidemiologic surprises.
Postgraduate Medicine.
1976;
59
113-117
4
Sickles E A.
Periodic mammographic follow-up of probably benign lesions: results in 3,184 consecutive cases.
Radiology.
1991;
179
463-468
5
Chala Jr L, Endo E, Kim S. et al .
Gray-scale sonography of solid breast masses: Diagnosis of probably benign masses and reduction of the number of biopsies.
Journal of Clinical Ultrasound.
2007;
35
9-19
6
Jackson V P.
Management of solid breast nodules: what is the role of sonography?.
Radiology.
1995;
19
14-15
7
Sickles E A.
Probably benign breast lesions: when should follow-up be recommended and what is the optimal follow-up protocol?.
Radiology.
1999;
21
11-14
8
Bamber J C, De Gonzalez L, Cosgrove. et al .
Quantitative evaluation of real-time ultrasound features of the breast.
Ultrasound Medicine Biology.
1988;
14 (Suppl 1)
81-87
9
Kook S H, Park H W, Lee Y R. et al .
Evaluation of solid breast lesions with power Doppler sonography.
Journal of Clinical Ultrasound.
1999;
27
231-237
10
Stavros A T, Thickman D, Rapp C L. et al .
Solid breast nodules: use of sonography to distinguish between benign and malignant lesions.
Radiology.
1995;
196
123-134
11
Folkman J.
Tumor angiogenesis: therapeutic implications.
New England Journal of Medicine.
1971;
285
1182-1186
12
Mehta T S, Raza S, Baum J K.
Use of Doppler ultrasound in the evaluation of breast carcinoma.
Seminars in Ultrasound, CT and MR.
2000;
21
297-307
13
Feldman F.
Angiography of cancer of the breast.
Cancer.
1969;
23
803-808
14
Watt A C, Ackerman L V, Shetty P C.
Differentiation between benign and malignant disease of the breast using digital subtraction angiography of the breast.
Cancer.
1985;
56
1287-1292
15
Wells P T, Halliwell M. et al .
Tumor detection by ultrasonic Doppler blood- flow signals.
Ultrasonics.
1977;
15
231-232
16
Cosgrove D O, Kedar R P, Bamber J C. et al .
Breast diseases: Color Doppler US in differential diagnosis.
Radiology.
1993;
189
99-104
17
Lee S K, Lee T, Lee K R. et al .
Evaluation of breast tumors with color Doppler imaging: a comparison with image-directed Doppler ultrasound.
Journal of Clinical Ultrasound.
1995;
23
367-373
18
Wright I A, Pugh N D, Lyons K. et al .
Power Doppler in breast tumors: a comparison with conventional color Doppler imaging.
European Journal of Ultrasound.
1998;
7
175-181
19
Reinikainen H, Rissanen T, Paivansalo M. et al .
B-mode, power Doppler and contrast-enhanced power Doppler ultrasonography in the diagnosis of breast tumors.
Acta Radiologica.
2001;
42
106-113
20
Mehta T S, Raza S.
Power Doppler sonography of breast cancer: does vascularity correlate with node status or lymphatic vascular invasion?.
American Journal of Roentgenology.
1999;
173
303-307
21
Buadu L D, Murakami J, Murayama S. et al .
Color Doppler sonography of breast masses: a multiparameter analysis.
Clinical Radiology.
1997;
52
917-923
22
Youssefzadeh S, Eibenberger K, Helbich T. et al .
Use of resistance index for the diagnosis of breast tumors.
Clinical Radiology.
1996;
51
418-420
23
Madjar H, Sauerbrei W, Prompeler H J. et al .
Color Doppler and duplex flow analysis for classification of breast lesions.
Gynecological Oncology.
1997;
64
392-403
24
Peters-Engl, Medl C M, Leodolter S.
The use of color-coded and spectral Doppler ultrasound in the differentiation of benign and malignant breast lesions.
British Journal of Cancer.
1995;
71
137-139
25
Lee S W, Choi H Y, BaekSY. et al .
Role of color and power Doppler imaging in differentiating between malignant and benign solid breast masses.
Journal of Clinical Ultrasound.
2002;
30
459-464
26
Burns P N, Halliwell M, Wells P N. et al .
Ultrasonic Doppler studies of the breast.
Ultrasound Medical Biology.
1982;
8
127-143
27
Kedar R P, Cosgrove D O, McCready V R. et al .
Microbubble contrast agent for color Doppler US: effect on breast masses. Work in progress.
Radiology.
1996;
198
679-686
28
Yang W T, Metreweli C, Lam P K. et al .
Benign and malignant breast masses and axillary nodes: evaluation with echo-enhanced color power Doppler US.
Radiology.
2001;
220
795-802
29 Non-operative Diagnosis Subgroup of the National Coordinating Group for Breast Screening Pathology .Guidelines for Non-operative Diagnostic Procedures and Reporting in Breast Cancer Screening. Sheffield; NHSBSP Publications 2001 No 50
30 American College of Radiology .Breast Imaging Reporting and Data System: Ultrasound. Reston, VA; American College of Radiology 2003 4th ed
31 Sackett D L, Haynes R B, Guyatt G H. et al .Clinical Epidemiology. Little, Brown and Company 1991 2nd edition
32
Schoenberger S G, Sutherland C M, Robinson A E.
Breast neoplasms: duplex sonographic imaging as an adjunct in diagnosis.
Radiology.
1988;
168
665-668
33
Britton P D, Coulden R A.
The use of duplex Doppler ultrasound in the diagnosis of breast cancer.
Clinical Radiology.
1990;
42
399-401
34
Taylor K J, Merritt C, Piccoli R. et al .
Ultrasound as a complement to mammography and breast examination to characterize breast masses.
Ultrasound Medicine and Biology.
2002;
28
19-26
35
Cosgrove D O, Bamber J C, Davey J B. et al .
Color Doppler signals from breast tumors. Work in progress.
Radiology.
1990;
176
175-180
36
Dixon J M, Walsh J, Paterson D. et al .
Color Doppler ultrasonography studies of benign and malignant breast lesions.
British Journal of Surgery.
1992;
79
259-260
37
Kedar R P, Cosgrove D O, Bamber J C. et al .
Automated quantification of color Doppler signals: a preliminary study in breast tumors.
Radiology.
1995;
197
39-43
38
Chao T C, Lo Y F, Chen S C. et al .
Color Doppler ultrasound in benign and malignant breast tumors.
Breast Cancer Research and Treatment.
1999;
57
193-199
39
Birdwell R L, Ikeda D M, Jeffrey S S. et al .
Preliminary experience with power Doppler imaging of solid breast masses.
American Journal of Roentgenology.
1997;
169
703-707
40
Blohmer J U, Oellinger H, Schmidt C. et al .
Lichtenegger, Comparison of various imaging methods with particular evaluation of color Doppler sonography for planning surgery for breast tumors.
Arch Gynecological Obstetrics.
1999;
262
159-171
41
del Cura J L, Elizagaray E, Zabala L. et al .
The use of unenhanced Doppler sonography in the evaluation of solid breast lesions.
American Journal of Roentgenology.
2005;
184
1788-1794
42
Holcombe C N, Pugh N, Lyons K. et al .
Blood flow in breast cancer and fibroadenoma estimated by color Doppler ultrasonography.
British Journal of Surgery.
1995;
82
787-788
43
McNicholas M M, Mercer P M, Miller J C. et al .
Color Doppler sonography in the evaluation of palpable breast masses.
American Journal of Roentgenology.
1993;
161
765-771
44
Raza S, Baum J K.
Solid breast lesions: evaluation with power Doppler US.
Radiology.
1997;
203
164-168
45
Weind K L, Maier C F, Rutt B K. et al .
Invasive carcinomas and fibroadenomas of the breast: comparison of microvessel distributions – implications for imaging modalities.
Radiology.
1998;
208
477-483
Dr. William Edward Svensson
Nuclear Medicine, Charing Cross Hospital
Fulham Palace Road
W6 8RF London
UK
Phone: ++ 44/20/88 46 18 64
Fax: ++ 44/20/88 46 14 26
Email: william.svensson@imperial.nhs.uk