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10.1245/s10434-006-9086-9
Annals of Surgical Oncology 13:1443-1449 (2006)
© 2006 Society of Surgical Oncology
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Original Article

Accuracy of the Combination of Mammography and Sonography in Predicting Tumor Response in Breast Cancer Patients After Neoadjuvant Chemotherapy

Florentia Peintinger, MD1,2, Henry M. Kuerer, MD, PhD1, Keith Anderson, MS3, Judy C. Boughey, MD1, Funda Meric-Bernstam, MD1, S. Eva Singletary, MD1, Kelly K. Hunt, MD1, Gary J. Whitman, MD4, Tanya Stephens, MD4, Aman U. Buzdar, MD5, Marjorie C. Green, MD5 and W. Fraser Symmans, MD2

1 Department of Surgical Oncology, The University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 444, Houston, Texas 77030, USA
2 Department of Pathology, The University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 85, Houston, Texas 77030, USA
3 Department of Biostatistics and Applied Mathematics, The University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 447, Houston, Texas 77030, USA
4 Department of Radiology, The University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1354, Houston, Texas 77030, USA
5 Department of Breast Medical Oncology, The University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1354, Houston, Texas 77030, USA

Correspondence: Address correspondence and reprint requests to: Henry M. Kuerer, MD, PhD; E-mail: hkuerer{at}mdanderson.org


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 PATIENTS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Background: Residual tumor size after neoadjuvant chemotherapy is an important consideration in surgical planning. We examined the accuracy of the combination of mammography and sonography in predicting pathologic residual tumor size.

Methods: Tumor size was evaluated by physical examination, mammography, and sonography at diagnosis and before surgery in 162 breast cancer patients who received neoadjuvant chemotherapy. Agreement between the predicted and the pathologic responses and the predicted and the pathologic tumor sizes was calculated. The effect of invasive lobular carcinoma, high nuclear grade, hormone receptor positivity, and the presence of an extensive intraductal component on the accuracy of mammography and sonography in predicting pathologic residual tumor size was analyzed.

Results: Forty-two patients (25.9%) had a pathologic complete response (pCR). Overall agreement between predicted and pathologic responses was 53% for physical examination, 67% for mammography plus sonography, and 63% for physical examination plus mammography and sonography. The sensitivity of mammography and sonography in predicting pCR was 78.6%, and the specificity was 92.5%; the accuracy was 88.9%. Residual tumor size determined by mammography and sonography correlated with pathologic residual tumor size (r = .662); pathologic tumor size was within .5 cm of predicted in 69.1% of patients. Multivariate analysis showed that pathologic residual tumor size was underestimated for lobular carcinoma and overestimated for poorly differentiated tumors.

Conclusions: The combination of mammography and sonography has a high accuracy in predicting pCR after neoadjuvant chemotherapy. Agreement of residual tumor size in mammography and sonography with pathologic residual tumor size was moderate.

Key Words: Mammography • Sonography • Breast cancer • Neoadjuvant chemotherapy


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
PATIENTS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Neoadjuvant chemotherapy is widely used in breast cancer treatment to induce tumor shrinkage and permit breast-conserving surgery, primarily in patients with more advanced disease.1–4 Because the response to neoadjuvant chemotherapy varies from patient to patient, regular evaluation of response during therapy is clinically indicated. Decisions about continuation of a current regimen and about the appropriate type and timing of surgery depend on the clinical and radiological assessment of tumor size during therapy. The traditional approach to monitoring tumor response in patients treated with neoadjuvant chemotherapy is to measure the tumor size by physical examination, mammography, and sonography before the initiation of chemotherapy and compare it with the tumor size before definitive surgical treatment. The quantification of response by using the categories of complete response (CR), partial response (PR), stable disease, and progressive disease (PD) serves as a gross estimate of chemosensitivity. However, exact residual tumor size is the desired information for surgical planning. A considerable number of investigations have shown moderate accuracy of physical examination and conventional imaging by mammography and sonography in predicting pathologic residual tumor size, but the results of those studies are controversial.5–11 In previous studies, correlation with the pathologic residual tumor size ranged from .42 to .68 for physical examination, from .33 to .84 for mammography, and from .29 to .89 for sonography. Some reports have suggested that physical examination and mammography are complementary in the assessment of tumor response; other reports have concluded that sonography correlates best with pathologic findings. The goals of this study were (1) to determine the accuracy of the combination of mammography and sonography in predicting pathologic tumor response, (2) to compare the accuracy of mammography and sonography with the accuracy of physical examination and physical examination plus mammography and sonography in predicting pathologic tumor response, and (3) to determine the accuracy of the combination of mammography and sonography in predicting pathologic residual tumor size.


   PATIENTS AND METHODS
TOP
 ABSTRACT
 INTRODUCTION
 PATIENTS AND METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
The medical records of 162 patients treated with neoadjuvant chemotherapy in a phase III randomized trial for clinical T1–3 breast cancer between November 1998 and July 2001 at The University of Texas M. D. Anderson Cancer Center were reviewed and analyzed. Patients with extensive diffuse micro-calcifications, multicentric/multifocal disease, or a history of incisional biopsy were not included in this study. The diagnosis of invasive cancer was made on the basis of either core biopsy or fine-needle aspiration. Patients were randomly assigned to receive either (1) paclitaxel once a week for 12 weeks, with the dose based on the nodal status (80 mg/m2 for node-negative and 150 mg/m2 for node-positive patients), followed by four cycles of fluorouracil (500 mg/m2), doxorubicin (50 mg/m2), and cyclophosphamide (500 mg/m2) or (2) paclitaxel 225 mg/m2 once every 3 weeks for 4 weeks, followed by the same regimen of four cycles of fluorouracil, doxorubicin, and cyclophosphamide. All patients underwent a physical examination, mammography, and sonography at diagnosis and after the completion of neoadjuvant chemotherapy, before surgery, to estimate tumor size. In this retrospective study, the mammographic and sonographic measurements were obtained from the radiology reports. Tumor measurements by physical examination were obtained from the medical records. All measurements were performed at the time of treatment. For spiculated masses in mammography, the sizes of the central nidus were recorded. For each method of assessment, tumor size was recorded in centimeters as the largest diameter measured. For patients deemed to undergo breast-conserving surgery after completion of chemotherapy, metallic coils were placed in the tumor bed under ultrasound guidance to mark the primary tumor site.

After definitive surgery (breast-conserving surgery or mastectomy), pathologic tumor size was determined prospectively by one of the dedicated breast pathologists at M. D. Anderson Cancer Center. In cases of eccentric tumor shrinkage or residual tumor cells scattered over a fibrotic tumor bed, the tumor size was defined as the largest diameter of the tumor bed rather than the largest cellular focus. The pathologist also examined the surgical specimen for the presence of an extensive intraductal component (EIC), defined as at least 25% ductal carcinoma-in-situ or the presence of ductal carcinoma-in-situ outside the main tumor. Pathologic CR (pCR) was defined as the absence of invasive cancer.

The most frequently used system for classifying tumor response is the World Health Organization system,12 which defines response in terms of the percentage change in tumor size. Recently, the Response Evaluation Criteria in Solid Tumors (RECIST) have been introduced for solid tumors—the RECIST guidelines—that simplify the response-evaluation procedure. The RECIST classification13 is based on unidimensional measurement of the largest tumor diameter instead of the previously used bidimensional measurement. According to the RECIST guidelines, PR is defined as a decrease of at least 30%, and PD is defined as an increase of at least 20% in the longest tumor diameter. On the basis of the clinical and the mammographic and sonographic tumor measurements, which we derived from the corresponding report forms, each patient’s tumor response was classified as CR, PR, stable disease, or PD according to the RECIST guidelines.13

We compared three different methods of predicting response to neoadjuvant chemotherapy: (1) physical examination only, with findings recorded by the observing surgeon; (2) the combination of mammography and sonography; and (3) physical examination plus mammography and sonography.

For each of these three methods, tumor size was defined as the largest measurement obtained by any of the modalities included. The baseline tumor sizes and the postchemotherapy tumor sizes according to physical examination, mammography, and sonography were compared individually.

For each of the three methods of predicting response to neoadjuvant chemotherapy, we compared the predicted responses with the pathologic responses determined on the basis of the corresponding baseline measurements. The percentage agreement between the predicted and the pathologic responses was calculated for each comparison. To determine the accuracy of the combination of mammography and sonography in predicting pCR, we determined the sensitivity and the specificity of this combination with respect to the detection of pCR. We also performed a detailed analysis of agreement between the tumor size defined on the basis of mammography and sonography and the pathologic residual tumor size, considering four size categories: 0, .1 to 1, 1.1 to 2, and >2 cm. Finally, on the basis of the hypothesis that tumor-associated factors may influence tumor size estimation, we examined whether invasive lobular carcinoma, EIC, high nuclear grade, and hormone-receptor status (positivity for both estrogen receptor and progesterone receptor or for only one of these receptors) affected the accuracy of the combination of mammography and sonography in predicting pathologic residual tumor size.

All statistical analyses were performed by using S-PLUS software (Insightful Corp., Seattle, WA). The concordance correlation coefficient was used instead of Pearson correlation because the concordance correlation coefficient can account for the difference from exact agreement.14 Chi-squared tests of equal proportions were used to compare rates of agreement. Paired t-tests were used to test whether the tumor size as predicted by mammography and sonography differed from the pathologic tumor size. A multivariate linear model was used to assess whether invasive lobular carcinoma, EIC, high nuclear grade, and hormone receptor status influenced the estimation of pathologic tumor size on the basis of imaging findings.


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 PATIENTS AND METHODS
 RESULTS
DISCUSSION
 REFERENCES
 
Patient characteristics are summarized in Table 1Go. The median tumor size at presentation was 3 cm as measured by physical examination alone, 2.5 cm as measured by mammography and sonography, and 3 cm as measured by the combination of physical examination and mammography and sonography. On pathologic examination after surgery, 42 patients (25.9%), had a pCR, and 120 patients had residual disease (RD). Sixteen patients (9.9%) had an EIC.


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  		TABLE 1. Pretreatment patient characteristics
 
The agreement between predicted responses and actual pathologic responses for each of the three methods of predicting response is presented in Table 2Go. The combination of mammography and sonography was associated with the best overall agreement (67%) between predicted responses and pathologically determined responses. The combination of mammography and sonography accurately predicted pCR in 33 of the 42 patients with pCR; in comparison, physical examination alone accurately predicted pCR in 34 of the 42 patients with pCR. The findings of a clinical CR did not predict pCR in 42 patients. The overall agreement was significantly better for the combination of mammography and sonography than for physical examination alone (P = .012; 95% confidence interval, .030–.253).


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  		TABLE 2. Agreement between predicted responses and pathologic responses
 
The combination of mammography and sonography had a sensitivity of 78.6% and a specificity of 92.5% in predicting pCR (vs. RD), and this resulted in an accuracy of 88.9% in distinguishing pCR from RD. Combined imaging measurements in nine patients falsely predicted pCR. In four of these cases, the residual tumor size was between .2 and .5 cm. In two cases, the patients had scattered tumor cells in a fibrotic area, and in the remaining two false pCR cases, the patients had solid residual tumors.

The analysis of agreement between the residual tumor size as determined by mammography and sonography and the residual tumor size determined pathologically revealed that the best agreement was for residual tumor sizes of 0 cm (78.6%) and 1.1 to 2 cm (74%) (Table 3Go). The solid line in Fig. 1Go corresponds to cases with exact agreement between tumor size on imaging and pathologic tumor size. The probability that the tumor size on imaging would accurately predict the pathologic tumor size within .5 cm was 69.1% (the area within the dotted lines); the probability that the tumor size on imaging would accurately predict the pathologic tumor size within 1 cm was 82.7% (the area within the dashed lines). These results indicated a decrease in accuracy when the residual tumor size was smaller than 1 cm or larger than 2 cm. Although the concordance correlation coefficient was r = .662, 42.6% (69 of 162) of the pathologic tumor sizes were underestimated by the combination of mammography and sonography, and 33.9% (55 of 162) were overestimated. On average, the residual tumor size on imaging underestimated the pathologic residual size by .168 cm (P = .03).


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  		TABLE 3. Agreement between residual tumor size predicted by the combination of mammography (MG) and sonography (US) and pathologic residual tumor size
 

Figure 1
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  		FIG. 1. Concordance between imaging tumor size determined by mammography and sonography and pathologic tumor size. The concordance correlation coefficient was .662. The solid line indicates exact size agreement. The area between dotted lines indicates agreement with pathologic tumor size within .5 cm (69.1% of cases). The area between dashed lines indicates agreement with pathologic tumor size within 1 cm (82.7% of cases). The area below the solid line underestimates pathologic tumor size.

 
Multivariate analysis (R2 = .60) of factors possibly affecting the accuracy of the combination of mammography and sonography in predicting pathologic residual tumor size showed that invasive lobular carcinoma was associated with a 1.2-cm average underestimation of pathologic residual tumor size (P < .001), whereas poorly differentiated tumors were associated with a .61-cm average overestimation of pathologic residual tumor size (P < .001) (Table 4Go). Hormone-receptor positivity and EIC were associated with overestimation only on univariate analysis.


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  		TABLE 4. Factors predicting the accuracy of the combination of mammography and sonography in predicting pathologic residual tumor size
 

   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 PATIENTS AND METHODS
 RESULTS
 DISCUSSION
REFERENCES
 
Our findings show that the combination of mammography and sonography is more accurate than physical examination alone or physical examination plus mammography and sonography in predicting the pathologic response to neoadjuvant chemotherapy. The combination of mammography and sonography had a sensitivity of 78.6%, a specificity of 92.5%, and an accuracy of 88.9% in predicting pCR (vs. RD). To our knowledge, only one other study has examined the accuracy of the combination of mammography and sonography in predicting tumor response, and it showed that pathologic response correlated better with physical examination than mammography or sonography and that the combination of both imaging modalities does not correlate better to pathologic tumor size than physical examination alone (r = .62 vs. r = .68).15 However, these results were based on a total of 3 patients with a pCR in a study population of 141 patients treated within 2 different trials.

Bonadonna et al.16 indicated that it is difficult to interpret published results from studies of neoadjuvant chemotherapy because of differences in the assessment or lack of information about the method of assessment of tumor response. Furthermore, because of the different criteria used to evaluate response, there is a wide range (16%–66%) of reported clinical rates of CR to neoadjuvant chemotherapy. Our study, in which we used different measurements at baseline (physical examination vs. physical examination plus imaging vs. imaging) as the reference by which to judge objective tumor response, showed, as did previous studies, that different assessment methods are associated with different response rates.

Selection criteria for breast conservation after completion of neoadjuvant chemotherapy include the ability to achieve negative margins and to maintain optimal cosmesis. Pathologic CR is the desirable result after neoadjuvant chemotherapy because it is associated with improved survival17–19 and an increased likelihood for undergoing breast conservation. As more effective drugs and regimens have become available, pCR rates ranging from 25% to 66.7% have been achieved,17,20 and the proportion of women eligible for breast conservation is expected to increase. Accurate preoperative assessment of CR and RD is crucial for planning the extent of surgery. In patients undergoing neoadjuvant chemotherapy, the main two questions to be answered before surgery are (1) Was a CR obtained? and (2) If a CR was not obtained, what is the size of the residual tumor? We found that the combination of mammography and sonography accurately predicted a pCR in 33 (78.6%) of the 42 patients. Nine patients predicted by the combined imaging measurements as having a pCR actually had RD. In four of these cases, the RD was probably missed because of the small residual tumor size (.2–.5 cm). In two other false pCR cases, the patients had scattered tumor cells in fibrotic areas. In the remaining two false pCR cases, the patients had solid residual tumors. In patients with RD, small residual tumors up to 1 cm were accurately identified by the combination of mammography and sonography in 60.6% of cases, and residual tumors up to 2 cm were identified in 74% of cases. The accuracy of mammography and sonography was affected by the invasive lobular histological type, which was associated with an underestimation of residual tumor size, thus indicating the limitations of mammography and sonography to predict the extent of disease before surgery in invasive lobular cancer. Although 1 additional patient was predicted as having a pCR by physical examination, 42 patients were falsely predicted as having a pCR. In general, physical examination is associated with interobserver variability, which may be enhanced in a multidisciplinary setting.

At present, conventional imaging with mammography alone or sonography alone shows low to moderate accuracy in the prediction of RD, and there is already extensive literature about the effectiveness of alternative modalities, such as magnetic resonance imaging,21–24 dynamic magnetic resonance imaging, magnetic resonance spectroscopy, and positron emission tomography25 for monitoring response. Magnetic resonance imaging and positron emission tomography measure changes in tumor vascularity and metabolism, respectively, and these techniques may prove to be more sensitive for assessing tumor response. Sometimes three imaging modalities—mammography, sonography, and magnetic resonance imaging—are performed to obtain the necessary response information. However, at present, it is not known whether and under which circumstances these modalities are complementary and which one is the most accurate. Whereas previous reports have shown conflicting results for the accuracy of mammography and sonography, our observations suggest that the combination of both modalities may accurately predict pCR; this allows the opportunity for breast-conserving surgery and indicates the size underestimation in lobular cancers, which may influence surgical planning. Furthermore, for tumors with RD, the combination of mammography and sonography will estimate residual tumor size within .5 cm in 69% of cases. These results cannot be generalized for patients with extensive calcifications and multifocal/multicentric disease because they were not included in this study, but they may be useful for comparative studies investigating new imaging modalities.

In daily clinical practice, conventional and cost-effective imaging approaches are useful if they are shown to have a high sensitivity. In contrast to the changes associated with adjuvant chemotherapy, residual tumors and tumor changes associated with neoadjuvant chemotherapy are not easy to identify with conventional imaging. Scattered tumor cells in a fibrotic area, remaining intraductal carcinoma after the disappearance of the invasive component, and the invasive lobular histological type are some examples of features that may not be accurately characterized by conventional imaging. As long as it is not clear which is the optimal imaging modality to predict tumor response, we suggest that the combination of mammography and sonography is a practical approach to estimate residual tumor size and to plan surgery for unifocal breast cancer without extensive microcalcifications. Newer, more precise imaging modalities are needed to monitor residual cancer after neoadjuvant chemotherapy, to standardize imaging, and to simplify surgical planning.


   FOOTNOTES
 
Presented in part at the American Society of Breast Surgeons Seventh Annual Meeting, Baltimore, Maryland, April 5–9, 2006.

Received for publication May 15, 2006. Accepted for publication May 18, 2006.


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 PATIENTS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 

  1. Fisher B, Bryant J, Wolmark N, et al. Effect of preoperative chemotherapy on the outcome of women with operable breast cancer. J Clin Oncol 1998; 16:2672–85.[Abstract]
  2. Newman LA, Buzdar AU, Singletary SE, et al. A prospective trial of preoperative chemotherapy in resectable breast cancer: predictors of breast-conservation therapy feasibility. Ann Surg Oncol 2002; 9:228–34.[Abstract/Free Full Text]
  3. Kuerer HM, Singletary SE, Buzdar AU, et al. Surgical conservation planning after neoadjuvant chemotherapy for stage II and operable stage III breast carcinoma. Am J Surg 2001; 182:601–8.[CrossRef][Medline]
  4. Vlastos G, Mirza NQ, Lenert JT, et al. The feasibility of minimally invasive surgery for stage IIA, IIB, and IIIA breast carcinoma patients after tumor downstaging with induction chemotherapy. Cancer 2000; 88:1417–24.[CrossRef][Medline]
  5. Chagpar AB, Middleton LP, Sahin AA, et al. Accuracy of physical examination, ultrasonography, and mammography in predicting residual pathologic tumor size in patients treated with neoadjuvant chemotherapy. Ann Surg 2006; 243:257–64.[CrossRef][Medline]
  6. Pierce L, Adler D, Helvie M, et al. The use of mammography in breast preservation in locally advanced breast cancer. Int J Radiat Oncol Biol Phys 1996; 34:571–7.[CrossRef][Medline]
  7. Helvie MA, Joynt LK, Cody RL, et al. Locally advanced breast carcinoma: accuracy of mammography versus clinical examination in the prediction of residual disease after chemotherapy. Radiology 1996; 198:327–32.[Abstract/Free Full Text]
  8. Loehberg CR, Lux MP, Ackermann S, et al. Neoadjuvant chemotherapy in breast cancer: which diagnostic procedures can be used?. Anticancer Res 2005; 25:2519–25.[Medline]
  9. Herrada J, Iyer RB, Atkinson EN, et al. Relative value of physical examination, mammography, and breast sonography in evaluating the size of the primary tumor and regional lymph node metastases in women receiving neoadjuvant chemotherapy for locally advanced breast carcinoma. Clin Cancer Res 1997; 3:1565–9.[Abstract]
  10. Dershaw DD, Drossman S, Liberman L, Abramson A. Assessment of response to therapy of primary breast cancer by mammography and physical examination. Cancer 1995; 75:2093–8.[CrossRef][Medline]
  11. Fornage BD, Toubas O, Morel M. Clinical, mammographic, and sonographic determination of preoperative breast cancer size. Cancer 1987; 60:765–71.[CrossRef][Medline]
  12. Miller AB, Hoogstraten B, Staquet M, Winkler A. Reporting results of cancer treatment. Cancer 1981; 47:207–14.[CrossRef][Medline]
  13. Therasse P, Arbuck SG, Eisenhauer EA, et al. New guidelines to evaluate the response to treatment in solid tumors. European Organization for Research and Treatment of Cancer, National Cancer Institute of the United States, National Cancer Institute of Canada. J Natl Cancer Inst 2000; 92:205–16.[Abstract/Free Full Text]
  14. Lin LI. A concordance correlation coefficient to evaluate reproducibility. Biometrics 1989; 45:255–68.[CrossRef][Medline]
  15. Fiorentino C, Berruti A, Bottini A, et al. Accuracy of mammography and echography versus clinical palpation in the assessment of response to primary chemotherapy in breast cancer patients with operable disease. Breast Cancer Res Treat 2001; 69:143–51.[CrossRef][Medline]
  16. Bonadonna G, Valagussa P, Zucali R, Salvadori B. Primary chemotherapy in surgically resectable breast cancer. CA Cancer J Clin 1995; 45:227–43.[Abstract]
  17. Green MC, Buzdar AU, Smith T, et al. Weekly paclitaxel improves pathologic complete remission in operable breast cancer when compared with paclitaxel once every 3 weeks. J Clin Oncol 2005; 23:5983–92.[Abstract/Free Full Text]
  18. Kuerer HM, Newman LA, Smith TL, et al. Clinical course of breast cancer patients with complete pathologic primary tumor and axillary lymph node response to doxorubicin-based neo-adjuvant chemotherapy. J Clin Oncol 1999; 17:460–9.[Abstract/Free Full Text]
  19. Bear HD, Anderson S, Brown A, et al. The effect on tumor response of adding sequential preoperative docetaxel to pre-operative doxorubicin and cyclophosphamide: preliminary results from National Surgical Adjuvant Breast and Bowel Project Protocol B-27. J Clin Oncol 2003; 21:4165–74.[Abstract/Free Full Text]
  20. Buzdar AU, Ibrahim NK, Francis D, et al. Significantly higher pathologic complete remission rate after neoadjuvant therapy with trastuzumab, paclitaxel, and epirubicin chemotherapy: results of a randomized trial in human epidermal growth factor receptor 2-positive operable breast cancer. J Clin Oncol 2005; 23:3676–85.[Abstract/Free Full Text]
  21. Davis PL, Staiger MJ, Harris KB, et al. Breast cancer measurements with magnetic resonance imaging, ultrasonography, and mammography. Breast Cancer Res Treat 1996; 37:1–9.[CrossRef][Medline]
  22. Yeh E, Slanetz P, Kopans DB, et al. Prospective comparison of mammography, sonography, and MRI in patients undergoing neoadjuvant chemotherapy for palpable breast cancer. AJR Am J Roentgenol 2005; 184:868–77.[Abstract/Free Full Text]
  23. Warren RM, Bobrow LG, Earl HM, et al. Can breast MRI help in the management of women with breast cancer treated by neoadjuvant chemotherapy? Br J Cancer 2004; 90:1349–60.[CrossRef][Medline]
  24. Schott AF, Roubidoux MA, Helvie MA, et al. Clinical and radiologic assessments to predict breast cancer pathologic complete response to neoadjuvant chemotherapy. Breast Cancer Res Treat 2005; 92:231–8.[CrossRef][Medline]
  25. Beresford M, Padhani AR, Goh V, Makris A. Imaging breast cancer response during neoadjuvant systemic therapy. Expert Rev Anticancer Ther 2005; 5:893–905.[CrossRef][Medline]



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