Mumtaz, Hamid; (1997) Magnetic resonance imaging in the staging and treatment of breast tumours. Doctoral thesis (Ph.D), UCL (University College London).

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Abstract

Conventional X-ray mammography is the imaging modality most commonly used to diagnose breast cancer. However, there are limitations to its accuracy for assessing the locoregional extent of disease, the diagnosis of suspected tumour recurrence within the breast, and assessment of response to neoadjuvant treatment. Locoregional disease staging is important as it affects the choice of treatment and ultimately clinical outcome. Breast-conserving surgery has been developed to improve the cosmetic results of an otherwise deforming surgery. It is widely accepted to be a safe option in selected patients when coupled with appropriate adjuvant treatment. Preliminary experience with interstitial laser photocoagulation (ILP) as a minimally invasive treatment of primary breast cancer has shown promise, but the technique has lacked a suitable imaging modality to demonstrate the treatment effects. Within this thesis, there are two major themes. The first explores whether magnetic resonance (MR) (a non-ionising imaging modality with an intrinsic high soft tissue contrast and spatial resolution) is of value in addressing the limitations of X-ray mammography. The second theme explores ILP as a means of percutaneously ablating benign and malignant breast tumours, and to develop MR imaging to monitor the response to therapy. The results have shown an overall improved accuracy of contrast-enhanced MR imaging compared to mammography in (a) the local staging of primary breast cancer with regards to invasive tumour size measurement, multicentricity, detection of extensive intraductal component, assessment of nipple-retroareolar involvement with tumour, and axillary node metastases, (b) the diagnosis of local tumour recurrence and, (c) the assessment of residual disease after neoadjuvant therapy. In the studies evaluating ILP, techniques enabling larger diameter of tissue necrosis to be achieved were developed allowing in some cases complete ablation of benign and malignant breast tumours. Contrast-enhanced MR images obtained 24 h or more after treatment demonstrated the laser-induced necrosis as a new area of non-enhancement, findings which correlated accurately with histological extent of tissue necrosis. The residual tumour after treatment of malignant tumours was accurately shown on MR when imaged 24 h after ILP in cases treated with a single fibre and 48 h in cases treated with multiple fibres. Real time MR imaging showed an evolving zone of signal loss, which at the end of ILP correlated closely with histological extent of laser induced necrosis. This thesis has shown that MR imaging is a promising technique for the locoregional staging of breast cancer and for monitoring ILP therapy to breast tumours. However, many technical modifications are necessary before the results based on MR imaging can be used as the definitive guide in selecting surgical treatment or to confirm complete tumour ablation with percutaneous therapies. These issues and some potential solutions are discussed within this thesis.

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