Dinamik manyetik rezonans görüntüleme ve ultrason kontrast ajanlı power doppler ultrasonografi ile meme lezyonlarında benign ve malign ayrımı

Abstract

Özet lammografi meme kanserinin saptanmasında primer bir tarama yöntemidir. Mammografinin arama testi olarak kullanılması meme kanserinden ölümleri azaltmıştır. Ancak mammografinin ;pesifitesi benign ve malign lezyonlar arasında ayırım yapmakta yeterli değildir. Bu nedenle mammografiye yardımcı non invasiv tanı yöntemleri araştırılmaktadır. Jizim amacımız meme lezyonlarında malign ve benign lezyonların dinamik MR görüntüleme ve contrastlı power Doppler ultrasonogram ile ayırmak ve bu iki metodu birbiri ile karşılaştırmaktır. Jltrasonografik ve mammografik olarak saptanan şüpheli meme lezyonlarına, 100 olguda dinamik ^IR incelemesi yapıldı. Zaman-Sinyal intensite eğrileri oluşturuldu ve sınıflandırıldı. Opaklaşma Dranları değerlendirildi. 1. dakikada %70' in üzerinde 2. dakikada %100'ün üzerinde sinyal ntensitesinde artış olması malignite kriteri olarak kabul edildi. Lezyonlar ayrıca morfolojik Dzelliklerine göre değerlendirildi. Jltrasonografik ve mammografik olarak saptanan 30 şüpheli meme lezyonunada biyopsi öncesi <ontrastlı power Doppler inceleme uygulandı. Lezyon damarlanması derecelendirildi. Ayrıca jamarlanma şekli periferal, santral ve penetran olarak sınıflandırıldı. vR bulguları ile kontrastlı power Doppler sonuçları biyopsi sonrası elde edilen histopatolojik oulgular ile değerlendirildi. Dinamik MR incelemelerde malignite kriteri olarak kabul ettiğimiz opaklaşma oranı 1. dakikada %97,4 sensitivite - % 92,5 spesifite 2. dakikada % 100 sensitivite - % 90 spesifite, TIP III zaman- sinyal eğrisi (Wash-Out) % 49.2 sensitivite - % 94,2 spesifite, periferal opaklaşma % 54 sensitivite-%87 spesifite, spikuler kontur % 40.5 sensitivite - % 88 spesifite ile malign benign lezyon ayrımında yardımcı oldular. (Tablo 3) Benignite kriterleri olarak kabul ettiğimiz TIP I zaman - sinyal eğrisi % 66.6 sensitivite- % 95.4 spesifite, düzenli keskin kontur % 25.4 sensitivite - % 95.4 spesifite, interal septasyon varlığı %10.7 sensitivite-% 100 spesifite ile benign malign lezyon ayrımını yapabilmektedir ( tablo 3). Kontrastlı powerr Doppler incelemede malignite kriteri olarak kabul ettiğimiz 2. derece kanlanma ve/veya penetran damar varlığı levovist öncesi % 70 sensitivite - % 82.5 spesifite, levovist sonrası %91 sensitivite- % 78 spesifite ile meme lezyonlarında malign benign lezyon ayrımını sağladı (tablo5). Kontrastlı power Doppler incelemeye göre tümör saptanmasının belirgin olarak artırdığını saptadık. 60Ancak kontrastlı power Doppler incelemeler ile dinamik meme MR incelemelerin başarı oranları karşılaştırıldığında dinamik meme MR'ın hem daha sensitif hemde daha spesifik bir modalite olduğunu ve meme lezyonlarının karakterizasyonu için öncelikle tercih edilmesi gereken modalite olduğunu düşünmekteyiz. 61

Summary Mammography is the primary screening test for breast carsinoma but specifity and sensitivity of mammography for differentation of malign benign breat leisons is low. Our purpose is : to differentatite malign-benign breast leisons with non-invasiv methods. For this reason: We use dynamic MRI and power Doppler ultrasonography with ultrason contrast agent. 100 patients were examined with dynamic MRI before biopsy was done. Time- signal intensity curves were obtained and classified. Enhancement rates were calculated and morphological features were evaluated. 30 patients before biopsy was done examined with power Doppler usg. before and after intravenous enjection of ultrasonographic contrast agent (Levovist) Leison's vascularisation were graded, also classified according to localization. MRI results and Doppler results compared with histopathological results. With the dynamic MRI, enhancement ratio had a sensitivitiy % 97.4 and specifity % 92,5 for the first minute; for the second minute had a sensitivitiy % 100 and specifity % 90. Time/signal intensity curves type III which represents `wash out` sign had a sensitivity % 49.2 specifity % 94.2. Peripheral enhancement had a sensitivity % 54 specifity % 87. Morphological features at dynamic MRI had high specifity ratios but their sensitivity ratios were low. With power Doppler ultrasonography before contrast agent we had % 70 sensitivity % 82,5 specifity. After IV ultrasonographic contrast agent (levovist) injection we had % 91 sensitivity % 78 specifity for differentiating malign and benign lesions. Although, power Doppler ultrasonography with contrast agent has a high sensitivity for differentiating malign and benign lesions, dynamic MRI has higher sensitivity and specifity ratios so we recommend dynamic MRI for the characterization of breast lesions. 1 Kelsey J.L. A rewiev of epidemiology human breast cancer Epidemiol Rew. 1979 ; 1:74-109 2 Hall FM, Screening Mammography; Poteatial problems on the horizon. N. Engl Jmed 1986; 314:53-55 3 Shapiro S. 10 to 14 year effect of screening on breast cancer mortality. J Natl Cancer Inst. 1982; 69: 349- 355 624 Pelican S, Moskowitz M. Effects of lead time, lenght bias, false negative assurance on screening for breath cancer Cancer 1993; 71:1998-2005 5 Tabar L. Dean P. Present state of screening for breath cancer. Semi Search Oncol. 1989; 5:94-101 6 Tabar L Dean P, Gad A. Screening for breath cancer: The Swedish trial radiology 1981; 138:219 7 Hanson D., Ries L Progress in early breast cancer detection. Cancer 1990; 65:2155-2158 8 Tabar L. Dean Gad. A. Homberg L.H. et al, Reduction immortality from breast cancer after mass screening with mammography. Lancet 1985; 1:829-832 9 Feig S.A. Decrease breast cancer mortality through mammography screening result of the clinical trials. Radilology 1988; 167:659-665 10 Chiatto S., Cateliotti L, Distante V. et al Non palpable leisons didacted by mammography: Review of 512 Consecutive cases, Radiology 1987; 165: 99-102 11 Breast masses: Mammographic and Tomographic evaluation, Radio. Clin. North Am. 1992; 30:67-92 12 Hommer MJ. Mammographic Interpretation : A practical approach New York, NY :McGraw-Hill, 1991; 4- 5 13 Kopans E.B., Swann C.A., Preoperative imaging guided needle placement and localization of clinicaly acud breast lesions. AJ.R. 1989 ; 152:1-9 14 Spibey G.H., Perry W.V., Clark V.A. et al Predicting rise of cancer at time of breast biopsy variation in oenign an malignant ratio. Am Surg 1982;48:326-332 15 Folkmann J. Induction of Angiogenesis & Cancer. Semin Cancer Biol 1992; 3:47-48 16 Folkmann J. What is the evidence that tumors are angiogenesis dependent? J. Natl. Cancer Inst. 1990; 32:4-6 7 Van Dijke F. Brasch R. Robert T. et al Mammary karsinomo model corelation of macromolecular contrast enhanced MR Imaging characterizations of tumor microvasculator and histolojik capillary densite. Radiology L996; 198:813-818 L8 Kaiser W.A. Zetler E. MR Imaging of the breast : Fast imaging sequences with and without Gd-DTPA Radiology 1989; 170:681-686 L9 Heywang S.H. Wolf A. MR Imaging of the breast, With Gd-DTPA Radiology 1989;171:195-203 10 Harms S.E., Flaming D.P. Hesley K.L et al MR Imaging of the breast with RODEO rezonance; Clinical experience with patological corelation. 1993; 187:493-501 ;1 Kedar R.P., Cosgrove D. McCrede V.R. et al Micro bubble contrast agent for color Doppler US effect on jreast muscles. Radiology 1996; 198:679-686 2 Kumar V. Cotran R. Robbins S. et al Basic Pathology 1992 620-641 3 American College of Radiology : BI-RADS at 3. Reston, V.A., American College of Radiology, 1998 4 Basset L.W., Gold R.H., Cove H.C. et al Mammographic spectrum of traumatic fat necrosis, the allibility of pathognomonic sign of karsinoma. AJR. 1987: 130: 119-122 6325 Edeiken S., Mammography in the symptomatic woman, Cancer 1989; 63:1412-1414 26 Evans W.P., Breast Masses: Appropriate evaluation. Radiol Clin. Nort Am. 1995; 33: 1085-1108 27 Sickles E.A., Non-palpable, circumscribe, non-calsified, solid breast masses: likelyhood of malignancy based on leison side and age of patient. Radilogy 1994 ;192:439-442 28 Sickles E.A. Periodic, mammographic follow up of probably benign leisons result in 3184 consecutive cases. Radiology 1991; 179:463-468 29 Sickles E.A. Probably benign breast leisons, when should follow up be recomended and what is the optimum follow up protocol. Radiology 1999; 213:11-14 30 Svane G., Franzen S., Radiological apperance of nonpalpable intramamary lymph notes. Acda. Radiol 1993; 34:577-580 J1 Crothers C.G., Butler N.F. Fibroadenolipoma of the breast. Br. J Radiol 1985; 48:191-202 î2 Hilton S.V., Leopold G.R., Olson L.K. et al, realtime breast sonography: Application in 300 consecutive Datients. AJR 1986; 147:479-486 i3 Giatto S. Carriaggi P. Bularessi P. et al The value of routine cytologic examination of breast cyst Fluds !/CTA Cytol 1987; 31:301-34 14 Soo M.S., Willyford M.E., Walsh R. et al Papilary karsinoma of the breast imaging findings. AJR 1995:164:321-326 15 Yang W.T., Suen M.Metrwelli C. et al Sonographic futures of benign populary neoplazms of the breast eviewed of 22 patients. J Ultrasound Med. 1997 16:161-168 6 Stavros AT. Thickman D. Rapp C.L. et al Solid Breast Nodules distingiushed between benign and malign esions. Radiology 1995; 196:123-134 7 Skaan P. Engedal K. Analyzes of sonographic features in differentation of fibroadoma and invasiv lubdal :arsinoma ACR 1998 170:109-114 8 Rahbar G. Sie A.C. Hansen G.C. et al Ultrasongraphic differentation of benign vs malignant solid breast nasses. Radiology 1999 213:889-894 9 Berkowitz J.E. Gatewood M.B., Gaylor B.W. et al Equivocal mammographic findings: Evaluation with spot :ompression Radiology 1989; 171 :369-371 0 Fornage B.D., Coan J.D., David C.L. et al Ultrasound guided needle biopsy of the breast and other interventional procedures. Radiol Clean Nort.Am. 1992; 30: 167-185 1 Parker S.H., Job W.E. Dennis V.A. et al US guided automated large core breast biopsy Radiology 1993;.87:507-511 2 Bonn B. Henteg Z. Perbec L. et al Diagnostic accuracy of mammograpy and contrast enhanced MR naging in 238 histologically verified press leisons. ACDA Radiol 1997; 38:489-496 3 Boetes C, Barentsz J.O., Mus R.D. et al MR characterization of suspicous breast leisons with gadolinium- mhanced turbo flash substraction technique Radiology 1994; 193: 777-781 6444 Hylotn NM, Franken S.D., Imaging techniques for breast MR imaging, Magn. Rezon. Imaging Clin. North Am. 1994; 2:511-524 45 Foben E., Rubi. C, Kaliswer L. et al Breast MR Imaging with commercialy available technics radiologic, pathologic correlation. Radiology 1995 ;196: 143-152 45 Orell S.G., Schnall M.D., Livolsi V.A. et al Suspicous breast leisons: MR Imaging with radiologic-pathologic correlation. Radiology 1994; 195:485-493 47 Gilles R., Guinebretiere J.M., Lucidarme O. et al, Non palpable breast tumors diagnosis with contrast enhance substraction dynamic MR imaging Radiology 1994;191:625-631 48 Hulka C.A., Smith B.L., Sgroi D.C. et al, Benign and malignnant breast leisons differentation with echoplanar MR imaging Radiology 1995;197:33-38 49 Orel S.G., Schnall M.D., Powell CM. et al, Staging of suspected breast cancer: effect on MR imaging and MR guided biopsy.,0 Kopans D.B. Preoperative imaging-guided needle placement and localization of clinically occult leisons in Kopans DB (ed) breast imaging Philadelphia CB lippincott 1989 pp320-341 '* Hochman F.Y. Orel S.G. Schmall M.D. The variable MRI appearence of fibroadonemas with radiologic, Dathologic correlation Radiology 1997; 204:123-129 >2 Kuhl C.K., Mielcarek P., Klaschiek S. et al: Dynamic Breast MR imaging: Are signal time course data usefull :or differenational diagnosis of enhancing leisons? Radiology 1999;211:101-110,3 Sherif H., Mafouz A.E., Oellinger H. et al: Peripheral washout sign on contrast enhance MR images of the Dreast. Radiology ; 1997 205:209-213) '4 Stamper P.C., Herman S., Suspect breast leisons finding at dynamic gadolinium - enhanced MR imaging :orrelated with mammographic and pathologic features. Radiology 1995 197:387-395 '5 Bone B., Aspelin P., Bronge L. et al, Sensitivity and spesifity of MR Mammografi with histopathological rorrelation in 250 breast. ACDA Radiol 1996 37:208-213 '6 Orel S.G. Differentiating benign from malignant enhancing leisons idetified MR imaging of the breast. Are :ime intensity curves and accurad predictor. Radiology 1999; 211:5-7 7 Gilles R., Zafrani D., Guinnebretere J. et al, Duckdal karsinoma insitu : MR Imaging - Histopathologic rorrelation Radiology 1995;196:415-419 8 Orel S.G., Mendonca M.H., Reynolds C. et al, MR Imaging of DCIS Radiology 1997; 202: 9 Soderstrom C.E., Harms S.E., Copit D.S., Three dimensional rodeo breast MRI imaging of leisons rontaining D CIS Radiology 1996;201:427-431 0 Orel S.G., Schnall M.D. Powell G.M. et al, Staging of suspected breats cancer. Effect of MR Imaging and *1R guided biopsy Radiology 1995; 196:115-122 1 Orel S.G., Reynolds C, Shnall M.D. et al Breast Karsinoma MR Imaging before re execisional biopsy. Radiology 1997; 205:402-436 6562 Rodenko G.N., Harms S.E:, Pruneda CM. et al: MR Imaging in the management before surgery of lobüler karsinoma of the breast correlation with patology. AJR 1996; 167:1415-1419 63 Lynch H.T. Albano W.A. Danes B.S. Genetic predipositions to breast cancers. Cancer 1984 53:612-622 64 Miki Y. Swenssen J. Shattuck D. et al A strock canditate for the breast and ovarian cancer susseptibility gen BRCA-I. Science 1994 266:66-71 65 Wooster R. Bigner G. Lancashter et al Identification of the breast cancer susseptibility gen BRCA-II Nature 1995 378: 789-792 66 Hoskins K.F. Stopfer J.E. Kalzon K.E. et al Assesment and Consiling for woman with a family history of breast cancer. Jama 1995 273:577-585 67 Claus E.B. Schildkraut J.M. Thompson V.D. et al The genetic attributable risk of breast and ovarian cancer.Cancer 1996 77:2318-2324 68 Campane R. Calliada F. Bottinelli 0. et al Contrast enhancing agence in ultrasonography : Clinical applications European Journal of Radiology 1998 27: 161-170 69 Goldberg B.B. Liu J.B. Forsberg F. et al Ultrasound Contrast Agence A rewiev Ultrasound in Medicine and Biology 1994 Volume 20 No:4 319-333 70 Lin E. Mc Ardie C.S. Ul rasound contrast agence in liver imaging Clin. Radiol. Suppl. 1996 1: 35-39 71 Mouaaouy A. Becker H. Schlief R. et al Rat liver model for testing intraoperativ echo contrast sonography Surg. Endosc. 1990 4: 114-117 72 Robin M.L. Ulrasound Contrast Agence 2001 Radiol. Clin. North Am. Volume 39 3: 399-414 73 El Yousef S.J., Alfidi R.J., Dukhesnu R. et al: Initial experience with NMR imaging of the woman breastJ Comp. Assist Tomog 1983; 7:215-218 74 El Yousef S.J., Alfidi R.J., Dukhesnu R. et al, Mr Imaging of the breast Radiology 1984; 150: 761-766 75 Stellîng C.B., Wang B.C., Liebherr A. et al, Prototype coil of MR Imaging of the female breast disease. Radiology 1985, 154:457-462 76 Dash N., Luppetiin A.R:, Daffner R.H. et al, MR imaging of the diagnostic of breast disease. AJR 1986; 146:119-125 77 Heywang S., Hakka D. Schmidt E. et al: MR Imaging of the breast using dadenilium DTPA, J. Comput. assist. Tomogr. 1986; 10:199-204 78 Gribbestadt IS Nielsen G. Fujosne H. et al: Contrast Enhanced MR Imaging of breats ACTA Radiolagica 1992; 31:833-842 79 Turkat K.J., Klein B.D., Polan R.L. et al: Dynamic MR mammography ; A technique for potaentially educing biyopsy rate for benign breast diases J. Magne. Res. Image. 1994; 4:563-538 w Kaiser W.A. MR Mammography Radiologe 1993 35:292-299 11 Kaiser W.A. Dynamic MR Breast Imaging using a double breast coil an important step towards routine examination of the breast. Front Eur. Radiol. 1990 7:40-67 6682 Algire GH Chalkley H.W. Vaskuler reactions of normal and malignent tissues invivo vasculer reactions of miles to wounds and to normal neoplastic transplants J.Natl. Cancer Inst. 1945 6: 73-85 83 Folkmann J. Watson K. Inger D. et al: Induction of angiogenesis during the transition from hyperplesia to neoplesia Nature 1989; 339:58-61 84 Silmann F., Boyce J., Fruhder R. et al: The significance of atypical vessels and neovasculariztion in cervical neoplesia. AMJ Obsted Gyncol. 1981 139:154-159 85 Jensen H.M., Abgiogenesis induced by normal human breast issue mechanism and pathology current communications in molecular biology. Cold Spring Harbour N.Y. Cold Spring Harbour Lab. 1987: 155-157 86 Weidner N., Semple J. P., Welch W.R. et al: Tumor Angiogenesis and metastasis- correleation in invaziv breast karsinoma The New England Journal of Medicine 1991; Volume 324 Nol 1-7 87 Fiddler I.J., Gersten D.M., Hart I.R. et al: The biology of cancer invasion of cancer and metastasis. Adv. Cancer Res. 1978: 28; 149-250 88 Nicholson G.L., Cancer Metastasis Sci Am. 1979 240; 66-76 89 Weiss L. Ed Fundamental aspects of metastasis Amsterdam : North Holland 1976; 51-70 90 Liotta L.A., Saidel G., Kleinerman J. et al: The significance of hematogenous tumor cell clumps in the metastatic process. Cancer Res. 1976; 26:889-894 91 Weidner N. Folkmann J. Pozza F. et al: Tumor angiogenesis a new significant and independent problostic indicator in early stage breast karsinoma J.Natl. Cancer Inst. 1992; 84: 1875-1887 92 Weidner N. In the tumoral microvasculer density as prognostic factor in cancer Am J. Pathol. 1995; 147; 9-19 93 Bosari S., Lee A., Dellis R. et al: Micro vessel quantification and prognosis in invaziv breast karsinoma Hum Pathol. 1992; 23: 755-761 34 Samejima N. Yamazaki N. A Study on the vascular proliferation in tissues around the tumor in breast cancer. Jpn. J. Surg. 1988 12;235-242 95 Jensen H.M., Chen I. Devault M.R. et al: Angiogenesis indused by noram human breast issue a probable marker for frequency. Science 1982; 218: 293-295 35 Brem S. Jensen H. Gulliano I. et al: Angiogenesis a marker of preneoplastic breast leisons. Cancer 1978; 41:239-244 37 Papadimitrau J.M.. Woods A.E. et al: Structral and functional characteristics of microcirculation of neoplasms Journal of Pathology 1975: 116:65-72 38 Froudge C, Guinnebteire J.M., Contesso G. et al: Correlation between contrast enhancement in dynamic magnetic resinance imaging of the breast and tumor angiogenesis. Invest Radiol 1994; Volume:29 Mol2: 1043-1048 39 Hulka C.A., Edmister W.B., Smith B.L. et al: Dynamic Echoplanar imaging of the breast experience in diagnosis breast karsinoma correlation with tumor angiogenesis. Radiology 1997: 205: 837-842 6700 Van Dijke C.F., Brasch R.C. Roberts T.P. et al: Mammary karsinoma model: correlation of nacromolecular contrast enhanced MR imaging characterizations tumor microvasculature and histologic :apillary density. Radiology 1996 198: 813-818 101 Dvorak H., Brown L. Detmann M. et al: Vaskuler permeability factor -Vascular endothelial growth factor. Micro vasculer hiperpermeability and angiogenesis. Am J. Pathol 1995; 146: 1029-1039 102 Blood J. Zetter B. Tumor interaction with vasculatur angiogenesis and tumor metastasis. Bio Chem.-Bio 3hys. ACTA 1990; 1032: 89-118 103 Heywang-Kobruner S.H. Haustein J. et al: Contrast enhanced MR imaging of the breast comparison of :wo different gadopentat- dimeglumine Radiology 1994 191: 639-646 04 Heibert E.V., Perman W.H., Herrman W.H. et al: A fast 3-d imaging technique for performing dynamic gadolinium enhanced MRI of breast leisons. Magnetic Resonance Imaging 1996 14:337-348 105 ChenevertT.L, Helvie M.A., Aisen A.M. et al: Dynamic Three -Dimensional Imaging with parcial k-space sampling in issue application for gadolinium enhanced rate characterization of breast leisons. Radiology L995 196:135-142 05 Perman W.H., Heiberg E.V., Herrman V.M. et al: Half Fourier 3-D technique for dynamic contrast enhanced MR imaging of both breast and axxilla : Initial characterization of breast leisons. Rdaiology 1996 '00:263-269 07 Bishop J.E., Santry G.E., Keltz F. et al: Accuracy of keyhole data accusation in quantatif analyses of dynamic contrast enhanced breast MRI Society of Magnetic Resonance 1995 : 639 08 Kinkel K. Helbich T.H., Essermann LJ. et al: Dynamic High Spatial resolution MR imaging of suspicious jreast leisons: Diagnostic criteria and interobserver variability AJR 2000 175: 35-43 09 Danielle B.L, Yen Y.F., Glower G.H. et al: Breast disease dynamic spiral Mr imaging. Radiology 1998 209: 199-509 10 Degani H. Gussis V. Weinstien D. et al:Mapping pathofizyological futures of breast tumors by MRI at high »patiel resolution Nat Med 1997 3:780-782 11 Tofts F.S. Berkowitz B. Schnall M.D. et al: Quantatif analyses of dynamic Gd-DTPA enhancement in breast :umors using permiability model. Magn Rezon. Med. 1995 ; 33:564-568 112 Musurakis S. Buckley D.L. Drew P J. et aUDynamic MR Imaging of the breast combined with analyses of :ontrast agent kinetics in the differentation of primary breast tumors. Clinical radiology 1997 52:516-526 113 Mafouz A.E., Hamn B. Wolf KJ. et al: Periferal wash out: a sign of malignancy on dynamic gadolinium enhanced MR Images of focal liver leisons. Radiology 1994 190: 49-52 114 Buadu L.D. Murakami J. Murayama S. et al: Breast leisons of correlation of contrast medium enhancement patterns in MR Images with histopathologic findings and tumor angiogenesis Radiology 1996 200:639-649 68115 Schwickert H.C. Stiskal M. Robert T.P. et al: Contrast enhanced MR Imaging assestment tumor capillary permiabiiity effect of irradiation on delivery of Chemothrapy Radiology 1996 198:893-898 116 Feldmann H J., Molls M., Hoederath A. et al: Blood flow and study state temperatures in deep seated tumors and normal tissues. Ind. J. Radiat. Onkol. Biol. Phys. 1992: 23:1003-1008 117 Baxter L.T., Jain R.K. et al: Transport of floud and macromoleculs in tumors role of binding and methabolism Microvasc. Res. 1991 41:5-23 118 Jain R.K. Hemodynamic and transport barriers to the treatment of solid tumors. Int. J. Radiat. Bio. 1991 60:85-100 119 Less J.R. Posner M.C. Boucher Y. et al: Intestio hypertension in human breast and colorectal tumor. Cancer Res. 1992 52:6371-6374 120 Kuhl C.K. Mielcarek P. Shild K.H. et al: Sensitivity 2-D and 3-D GRE sequences in dynamic breast imaging systemic control study with two individual comparison. Radiology 1996 201: 121-130 121 Kuhl C.K. Kreft B.P. Bielling H.R. et al: Dynamic Breast MRI in premenepozal healthy volunteers noraml i/alue of contrast enhancement and cycle face dependency. Radiology 1997 203: 1-9 122 Nunes L.W. Schnall M.D. Orell S.G. et al: Breast Mr imaging interpretation model Radiology 1997 202:833-841 123 Tavasolli F.A. Pathology of the breast Page 293 124 Brown C.F. Bense B. Sackman R.W.V. et al: Expression of vascular permiabiiity factor (vasculer îndothalial growth factor ) and its receptors in breast cancer Hum. Patho. 1995 26: 86-91 25 Brix G. Kenze M. Knoop M.V. et ahComparison of farmokinetic MRI and 18 (F) PET in the diagnosis of jreast cancer initial experience Eur Radiol. 2001 11: 2050-2057 26 Dixson J.M., Walsh S. Paterson D. et al: Color Doppler Us. Studies of benign and malignent breast leisons. 3r. J. Search. 1992; 79:259-260 27 Schoenberger S.G. Sutherland CM. Robin A.E. et al: Breast neoplasms duplex sonographic imaging as an îdjant in diagnosis. Radiology 1988 168: 665-668 28 Britton P.D. Coulden R.A. The use of duplex Doppler us. in the diagnosis of breast cancer. Clin. Radiol. L990; 42:339-401 29 Cosgrove D. Kedar R.P. Bamber J.C. et al: Breast diseases color Doppler us. in differential diagnosis Radiology 1993 189: 93-104 30 Lee S..K. Lee T. Lee K.R. et al: Evaluation of breast tumors with color Doppler imaging. A comparison vith image directed Doppler us. J. Clin. Ultrasound 1995 23:367-373 31 Jain R.K., determinent of tumor blood flow ; A rewiev Cancer Res. 1988 51: 2641-2658 32 Less J.R. Shalak T.C. Sevichk E.M. et al: Microvasculer architecture in a mammary karsinoma branching ratterns and vessel dimensions Cancer Res. 1991 51:265-273 69133 Konishi Y., Hamada M, Schimadu K. et al: Doppler spectra analyses of the intratumorel wave form in the breeast diseases. Imaging 1993 60:18-22 134 John C. Stolzt W. Gritsche E.M. et al: Die Dopplersonographiche untersuchung von mamatumoren mit hilfe der farbdoppler Sonographicke der dupplex sonographicke und des cw -Doppler ; Zantrabl Gynakol. 1992; 114: 249-253 135 Foumier D. Dreger J.L. Hessler C. et al: Color Doppler sonography in the breast diseases; Is it so cold tumorel flow specific? Imaging 1993 60:52-56 136 Rubin J.M. Bude R.O. Carson P.L et al: Power Doppler us. A potentialy useful alternative to mean frequency based color Doppler us. Radiology 1994 190: 853-856 137 Bude R.O. Rubin J.M. Adler R.S. et al: Power versus conventional color Doppler sonography comparison in the normal intravenal vasculature radiology 1994 192: 777-780 138 Rubin J.M. Bude R.O. Carson P.L. et al: Power Doppler expense standart color capability diagnostic imaging 1993 15:66-71 139 Raza J. Baum J.K. Solid breast leisons evaluation with power Doppler us Radiology 1997 203:164-168 140 Cheng W.F. Lee. C.N. Chu J.S. et al: Vascularity index as a novel parameter for the vivo assisment of angiogenesis in patients with cervical karsinoma Cancer 1999 85: 651 141 Wells P.T. Halliwell M. Skidmore R. et al: Tumor detection of us Doppler bloodflow signal. Ultrasonics 1997 15: 231 142 Kedar R.P., Cosgrove D. Bamber J. et al: Automated quantification of color Doppler signal and Dreminilary study in breast issue. Radiology 1995 197:39-43 143 Huber S. Delorme S. Knopp M.V. et al: Breast tumors computer assistant quantatif assesment with color Doppler us. Radiology 1994 192:797-801 144 Huber S. Hellbich T. Kettenbach J. et al: Effects of microbuble contrast agent on breast tumors computer assisted quantatif assesment with color Doppler us.- early experience Radiology 1998:208:485-489 145 Robin M.L. Weber T.M. The potential role of ultrasound contrast agent. Appl. Radiol. Supp.1997 26:13-19 146 Forceberg F. Liu J.B. Burns P.N. et al: Artifacts in ultrasonic agent studies. J.UItrasound Med. 1994 13:357-365 147 Schroeder R. Maeuer J. Voel T.S. et al: D-Galaktose based signal enhanced color -power Doppler sonography of breast tumors and tumor like leisons. Invest Radiol 1998; Vol34 No:2 109-115 148 Moon K.W. Im J.G. Noh D.Y. et al Non Palpable breast leisons evaluation with power Doppler us and a nicrobubble contrast agent initial experience Radiology 2000 ; 217: 240-146 149 Alamo C. Fischer K. Contrast et al: enhanced color Doppler ultrasound characteristic in Hypervasculer oreast tumors comparison with MRI Euro Radiol 2001 11:970-977 150 Kubek K.A. Chan L. Fraiser T. et al: Color Doppler flow as an indicator of nodal metastasis in solid breast Tiasses. Journal of Ultrasound Medicine 1996 15: 835-841 70151 Birdwell R.L Ikeda M.D. Jeffrey S.S. et al: Preliminary experience with power Doppler imaging of solid breast masses. AJR 1997 169:703-707 152 Weind H.L. Maier C..F. Rutt B.K. et al: Invasiv carsinomas and fibroadenomas of the breast comparison of microvessel distributions. Implications for imaging modelities. Radiology 1998 ; 208: 477-483 153 Holcombe C. Pagh N. Lyon K. et al: Blood flow breast cancer and fibroadenoma estimated by color Doppler us Br. J. Surg. 1995 82:787-788