The central role of imaging for breast cancer patients

Abstract

This thesis describes the essential role of imaging in breast cancer diagnostics and treatment.

Part I describes the impact of same-day diagnosis for breast cancer. Same-day diagnosis was introduced in the University Medical Center Utrecht in November 2011 with the aim to reduce patient anxiety by providing a histologically proven diagnosis in patients referred to our outpatient breast clinic. We evaluated feasibility, diagnostic accuracy, and impact on stress and anxiety of the patient. Between November 2011 and March 2013, 759 patients visited the same-day clinic for evaluation of their breast lesion. We were able to provide a final diagnosis within one day in 606/759 (79.8%) patients without impairing diagnostic accuracy (3/759 discordant findings). A strong and fast reduction in anxiety was observed in patients with benign disease. Anxiety did not decrease in patients with a malignant diagnosis, nor did anxiety increase in these patients. We concluded that same-day diagnosis was feasible and accurate. Anxiety decreased rapidly after communication of the diagnosis.

Part II describes the diagnostic value of diffusion-weighted (DWI) MRI in patients with a suspicion of breast cancer. We compared conventional bilateral DWI to a new technique: high-resolution targeted DWI. The techniques were compared quantitatively and qualitatively in 21 patients. Both techniques were able to differentiate between benign and malignant tumors based on the apparent diffusion coefficient. The qualitative analysis showed that rFOV DWI images were significantly sharper than bilateral DWI and radiologists were better able to predict a malignancy for rFOV DWI compared to bilateral DWI.

There are various ways to localize non-palpable breast lesions. In Part III we evaluated new methods localization of non-palpable breast tumors and the sentinel node. First, a direct comparison between intraoperative ultrasound (IOUS) and guidewire localization (GWL) was performed in 258 patients. Tumor free resection margins were obtained in >93% of patients and were similar between GWL and IOUS, leading to the conclusion that IOUS is a reliable alternative to GWL. In a systematic overview of the literature on radioactive seed localization (RSL), we showed that RSL is a safe and accurate technique for localization of non-palpable breast cancer. Finally, we described an innovative approach for image-guided sentinel lymph node (SLN) localization, where we combined contrast-enhanced ultrasound with microbubbles for sentinel lymph node identification with the placement of an I-125 seed in the SLN in a series of fifteen patients. Lymph nodes were visualized in twelve and an I-125 seed was placed. In nine patients the seed was placed within 0.5 cm of the sentinel node, of which four were found inside the node. Since only 9/15 procedures were partly successful and 4/15 perfectly successful, we concluded that this novel approach is not ready for clinical practice and cannot replace the current standard sentinel lymph node localization with technetium-99m nanocolloid.