DOI: 10.1148/radiol.2471071737
(Radiology 2008;247:295-296.)
© RSNA, 2008
Vascular Maps on Contrast-enhanced Breast MR Images: A New Approach Requiring Further Investigation
Francesco Sardanelli, MD
Department of Medical and Surgical Sciences, University of Milan School of Medicine, Unit of Radiology, IRCCS Policlinico San Donato, Via Morandi 30, 20097 San Donato Milanese, Milan, Italy
e-mail: f.sardanelli{at}grupposandonato.it
Editor:
I read with great interest the article by Christiane K. Kuhl (1) in the August 2007 issue of Radiology. I share with her most evaluations and opinions on the past, current, and future status of breast magnetic resonance (MR) imaging, in particular on the converging demand for high spatial and temporal resolution, the present relatively high levels of specificity and positive predictive value of breast MR, the need to include this technique among the tools available to radiologists expert in breast imaging, and the need to perform second-look sonography and MR-guided biopsy at centers that offer breast MR imaging.
However, I would like to comment on Dr Kuhl's opinion of our article (2), published in the June 2005 issue of Radiology, concerning the evaluation of vascular maps obtained with three-dimensional maximum intensity projections of subtracted early images from dynamic gadobenate dimeglumine–enhanced MR imaging. She disagrees on the use of "nonestablished descriptors for nonestablished criteria...in the attempt to, for example, assess the efficacy of a new contrast agent," in particular "if the study is designed as an interindividual comparison" (1).
As stated clearly in the Materials and Methods section of our report, our findings were retrospectively derived from the database of a previous multicenter European study (3) in which the diagnostic performance of three different doses (0.05, 0.1, and 0.2 mmol/kg) of gadobenate dimeglumine were compared with a standard dose (0.1 mmol/kg) of gadopentetate dimeglumine. Owing to the dose-finding design of the original study, an interindividual (and not intraindividual) scheme was necessary to avoid unethical practice—that is, to avoid the need for each enrolled woman to undergo four contrast material–enhanced MR examinations (and four injections of contrast agent). During the off-site blinded reading of this study, I noticed that in patients with probably malignant unilateral enhancing lesions, a larger number of larger vessels were present in the breast harboring the lesion—that is, a one-side increase of the whole vascular map seemed to be associated with an ipsilateral cancer. Thus, I started to think that a review of the cases in this study should be performed in order to verify this hypothesis. In the meantime, two articles (4,5) appeared in which the association between a one-side increase in vascular maps and ipsilateral cancer was found by using gadopentetate dimeglumine at 0.1 mmol/kg as a contrast agent. In this context, we wrote our article proposing a method to measure breast vascularity on the basis of vessel number, size, and length. This is the history of our article. Moreover, the association between increased whole-breast vascularity and ipsilateral cancer has also been observed in a study in which only patients with cancer were studied with gadopentetate dimeglumine at a fixed dose of 20 mL (6), and in a series of patients studied by us, with gadoterate meglumine at 0.1 mmol/kg (7). Finally, this approach has recently been used by Schmitz et al (8) at 3.0 T, with gadobutrol at 0.1 mmol/kg as a contrast agent, and these authors obtained a gain in specificity by using our vascular score. Anyway, this association certainly needs further investigation and cannot yet be considered an established descriptor or criterion. Moreover, differences between invasive versus intraductal cancers, the possible influence of cancer size, and altered vascular maps after neoadjuvant chemotherapy also require investigation. Further research is needed in order to fully answer the question raised by Liane E. Philpotts in the June 2005 issue of Radiology: "Will improved vascular mapping achieved with gadobenate dimeglumine aid in interpretation of breast MR images?" (9).
Finally, we agree completely with Dr Kuhl's opinion that "MR imaging belongs to the most rapidly evolving techniques of contemporary clinical medicine." By definition, we need a balance between the clinical need to establish methods, descriptors, and criteria and the scientific desire to investigate new findings and observations.
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References
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- Kuhl CK. Current status of breast MR imaging. I. Choice of technique, image interpretation, diagnostic accuracy, and transfer to clinical practice. Radiology 2007;244:672–691.
- Sardanelli F, Iozzelli A, Fausto A, Carriero A, Kirchin MA. Gadobenate dimeglumine-enhanced MR imaging breast vascular maps: association between invasive cancer and ipsilateral increased vascularity. Radiology 2005;235:791–797.[Abstract/Free Full Text]
- Knopp MV, Bourne MW, Sardanelli F, et al. Gadobenate dimeglumine in contrast-enhanced magnetic resonance imaging of the breast: a dose response analysis and comparison with gadopentetate dimeglumine. AJR Am J Roentgenol 2003;181:663–676.[Abstract/Free Full Text]
- Mahfouz AE, Sherif H, Saad A, et al. Gadolinium-enhanced MR angiography of the breast: is breast cancer associated with ipsilateral higher vascularity? Eur Radiol 2001;11:965–969.
- Carriero A, Di Credico A, Mansour M, Bonomo L. Maximum intensity projection analysis in magnetic resonance of the breast. J Exp Clin Cancer Res 2002;21(3 suppl):77–81.[Medline]
- Wright H, Listinsky J, Quinn C, Rim A, Crowe J, Kim J. Increased ipsilateral whole breast vascularity as measured by contrast-enhanced magnetic resonance imaging in patients with breast cancer. Am J Surg 2005;190:576–579.[CrossRef][Medline]
- Fausto A, Iozzelli A, Menicagli L, Sardanelli F. Contrast enhanced MR imaging of the breast: One-side increased vasculature as a predictor of invasive cancer [abstr]. In: Proceedings of the 12th European Congress of Radiology, Vienna, Austria. Eur Radiol 2006;16(suppl 1):210.
- Schmitz AC, Peters NH, Veldhuis WB, et al. Contrast-enhanced 3.0-T breast MRI for characterization of breast lesions: increased specificity by using vascular maps. Eur Radiol doi:10.1007/s00330-007-0766-z. Published online September 20, 2007.
- Philpotts LE. Will improved vascular mapping achieved with gadobenate dimeglumine aid in interpretation of breast MR images? Radiology 2005;235:717–718.[Free Full Text]
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