Douek, Michael; (2000) Contrast-enhanced imaging in the biological and functional assessment of breast cancer. Doctoral thesis (M.D), UCL (University College London).

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Abstract

Contrast-enhanced MRI and ultrasound have emerged as additional imaging modalities in the management of breast cancer. This thesis examines the role these modalities currently play in the surgical management of breast cancer. Ways in which MRI may contribute to staging, diagnosis, treatment and prognosis are investigated. It was demonstrated that small additional enhancing foci on MRI, away from the primary tumour, represent in-situ or invasive cancer foci. Although their resection may result in extended wide local excisions or even unnecessary mastectomies, it was demonstrated that MRI findings do not currently influence the amount of tissue removed during breast conservation surgery. Volumetric analysis of breast MRI was proposed as an accurate objective assessment of the extent of surgery required for a particular tumour. Breast MRI was shown to be useful in the assessment of extent of residual disease during primary medical therapy but not in the detection of axillary lymph node metastases. In the second section of this thesis, the clinical application of pre-operative MRI in providing prognostic as well as diagnostic information was evaluated. Contrast- enhancement with both MRI and ultrasound is believed to depend on tumour angiogenesis but only a weak correlation was demonstrated between contrast- enhancement intensity and tumour angiogenesis. The detection of angiogenesis was applied to Doppler ultrasound using a novel microbubble ultrasound contrast agent (Levovist). Within a multicentre prospective study, Doppler ultrasound was shown to be a powerful discriminator of malignancy in suspected local recurrence. A strong correlation was found between MRI and histological assessment of tumour size but there was no correlation between enhancement intensity and other pathological prognostic variables. This thesis has shown that breast MRI is useful in pre-operative planning of surgery and provides diagnostic as well as limited prognostic information. Future proposed studies to determine the effect of MRI on patient management and patient outcome in breast cancer are considered.

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