Original contribution
Comparing Contrast-Enhanced Color Flow Imaging and Pathological Measures of Breast Lesion Vascularity

https://doi.org/10.1016/j.ultrasmedbio.2008.02.010Get rights and content

Abstract

This study was conducted to compare quantifiable measures of vascularity obtained from contrast-enhanced color flow images of breast lesions to pathologic vascularity measurements. Nineteen patients with solid breast masses received Levovist® Injection (10 mL at 300 mg/mL; Berlex Laboratories, Montville, NJ, USA). Color flow images of the mass pre and post contrast were obtained using an HDI 3000 scanner (Philips Medical Systems, Bothell, WA, USA) optimized for clinical scanning on an individual basis. After surgical removal, specimens were sectioned in the same planes as the ultrasound images and stained with an endothelial cell marker (CD31). Microvessel area (MVA) and intratumoral microvessel density (MVD) were determined for vessels 10–19 μm, 20–29 μm, 30–39 μm, 40–49 μm and ≥50 μm in diameter using a microscope and image processing software. From the ultrasound images, the number of color pixels before and after contrast administration relative to the total area of the breast mass was calculated as a first-order measure of fractional tumor vascularity. Vascularity measures were compared using reverse stepwise multiple linear regression analysis. In total, 58 pathology slides (with 8,106 frames) and 185 ultrasound images were analyzed. There was a significant increase in flow visualization pre to post Levovist injection (p = 0.001), but no differences were found between the 11 benign and the eight malignant lesions (p > 0.35). Ultrasound vascularity measurements post contrast correlated significantly with pathology (0.15 ≤ r2 ≤ 0.46; p < 0.03). The 30–39 μm vessel range contributed most significantly to the MVD relationship (p < 0.001), whereas the MVA was mainly influenced by vessels 20–29 μm (p < 0.004). Precontrast ultrasound only correlated with pathology for relative MVA (r2 = 0.16; p = 0.01). In conclusion, contrast-enhanced color flow imaging provides a noninvasive measure of breast tumor neovascularity, corresponding mainly to vessels 20–39 μm in diameter, when used in a typical clinical setting.

Introduction

Mammography is the imaging mode of choice for screening, detecting and diagnosing breast lesions (Kopans 1998, Tabár & Dean 2003). Nonetheless, the vast majority of breast biopsies performed in clinical practice (between 65 and 90%) are found to be benign when assessed histopathologically (Kopans 1998, Zonderland et al 1999). Hence, a reliable and quantifiable technique for improved characterization of malignant and benign breast masses is needed.

Ultrasound imaging is an important adjunct to mammography that quite easily differentiates between cystic and solid lesions (Stavros et al 1995, Taylor et al 2002, Zonderland et al 1999). It can also provide real-time guidance of breast biopsies. Moreover, ultrasound imaging of anatomical features has been shown to improve the characterization of solid breast lesions as benign or malignant (Stavros et al 1995, Taylor et al 2002, Zonderland et al 1999). Another important and independent predictor of malignancy is the angiogenic vascular morphology associated with breast tumors (de Jong et al 2000, Gasparini and Harris 1995, Weidner et al 1991, Weidner et al 1992). Tumor angiogenesis is the development of a new vascular network out of preexisting vessels and is considered essential for the progression of solid tumors (Carmeliet and Jain 2000, Folkman 1990, Li 2000). However, breast lesion characterization based on Doppler ultrasound flow measurements have produced mixed results, because of overlap between flow measurements in benign and malignant tumors (Adler et al 1990, Bohm-Velez and Mendelson 1989, Taylor et al 2002). One problem may be the lack of sensitivity to detecting flow in small tumor vessels using standard ultrasound techniques (Ferrara et al. 2000).

Microbubble-based ultrasound contrast agents produce 15–25 dB increases in the echo intensities of blood flow signals (especially when combined with power Doppler imaging), thus markedly improving the sensitivity of ultrasonic flow imaging (Ferrara et al 2000, Forsberg et al 1998, Goldberg et al 2001). Consequently, we hypothesized that quantitative measures of breast lesion vascularity could be obtained noninvasively from contrast-enhanced color flow images, and this was confirmed in our small, preliminary evaluation of 10 patients (Chaudhari et al. 2000). Hence, the purpose of our current study was to prospectively compare noninvasive, quantitative measures of vascularity obtained from contrast-enhanced ultrasound color flow imaging to invasive pathologic vascularity measurements in a larger patient group. As a secondary objective, this project attempted to establish the size of the vessels that contribute most to the ultrasound results obtained with real-time color flow imaging.

Section snippets

Materials and Methods

Nineteen patients were enrolled in this prospective study between September 1996 and October 1997. These were women older than 21 years who were scheduled for an excisional biopsy of a breast mass. All patients were referred after palpation and/or X-ray mammography identified a solid mass. Subjects had to be medically stable, whereas pregnant or nursing women were excluded. The study was approved by the university's Institutional Review Board and was compliant with the Health Insurance

Results

The 19 subjects enrolled in this study were predominantly Caucasian (11 women, 58%), five subjects (26%) were African American, one participant (5%) was Asian and two women requested to be listed as “other.” The mean age was 54 y (range 24 to 81). There were eight cancers and 11 benign lesions in this population (i.e., 8 of 19 [42%] of the breast masses were malignant), with average diameters of 14 and 12 mm, respectively, as measured by ultrasound (p = 0.55). A statistically significant

Discussion

In total, 19 patients with eight cancers and 11 benign lesions were evaluated in this study, which corresponds to 185 ultrasound images and 8,106 frames from 58 pathology slides. This is almost double the number of patients and images evaluated in our previous study (Chaudhari et al. 2000), but it is still a relatively small patient population. When analyzing the entire dataset (Table 1), a significant but not very strong, linear relationship was found between the ultrasonic FV obtained post

Acknowledgments

This project was supported by the U.S. Army Medical Research Material Command under DAMD17–97–1–7116, by the National Institutes of Health (NIH) through grants NIH CA60854 and NIH CA48010, as well as by Berlex Laboratories, Montville, NJ, USA. We gratefully acknowledge the assistance provided by C. Dascenzo and C. Slotoroff in recruiting patients for this study, as well as the efforts of Y. Lee, F. N. Saikali, A. Voodarla, R. Yoon and A. Yu with regards to the image analysis.

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