Indications For Breast MRI Research Articles

Breast MRI: State of the Art.

MRI of the breast has the highest sensitivity for breast cancer detection among current clinical imaging modalities and is indispensable for breast imaging practice. While the basis of breast MRI consists of T1-weighted contrast-enhanced imaging, T2-weighted, ultrafast, and diffusion-weighted imaging may be used to improve lesion characterization. Such multiparametric assessment of breast lesions allows for excellent discrimination between benign and malignant breast lesions. Indications for breast MRI are expanding. In preoperative staging, multiple studies confirm the superiority of MRI to other imaging modalities for tumor size estimation and detection of additional tumor foci in the ipsilateral and contralateral breast. Ongoing studies show that in experienced hands this can be used to improve breast cancer surgery, although there is no evidence of improved long-term outcomes. Screening indications are likewise growing as evidence is accumulating that OncologicRI depicts cancers at an earlier stage than mammography in all women. To manage the associated costs for screening, the use of abbreviated protocols may be beneficial. In patients treated with neoadjuvant chemotherapy, MRI is used to document response. It is essential to realize that oncologic and surgical response are different, and evaluation should be adapted to the underlying question.

The role of magnetic resonance imaging in the diagnosis of breast cancer

MR mammography is a highly sensitive (> 98%) and slightly lower specificity (> 80%) method of detecting breast cancer. The sensitivity of MR mammography in detecting low or medium grade DCIS is lower than in detecting inva­sive carcinomas and high grade DCIS. Achieving the high efficacy of MR mammography is only possible with a very good quality MR examination; this however is not always easy to accomplish. According to EUSOBI 2015 recommendations, the indications for breast MRI are: screening women with a high risk of breast cancer; preoperative staging of newly diagnosed breast cancer; evaluating the response to neoadjuvant chemotherapy; occult primary breast carcinoma (searching for breast cancer in patients with metastases and negative mammography and breast ultrasound); suspected local recurrence whenever needle biopsy proves impossible; assessing breast implants; further characterisation of equivocal lesions found by mammography/breast ultrasound, whenever needle biopsy proves impossible. The introduction of Digital Breast Tomosynthesis (DBT) and contrast-enhanced spectral mammography (CESM) into daily clinical practice in the recent years has created the need to re-analyse the indications for MR mammography and to develop a new breast cancer diagnostic imaging algorithm.

Comprehensive breast MRI: an update

With increasing use of clinical breast MRI and a plethora of novel techniques and sequences for lesion characterisation, a standardised approach to lesion description and reporting is increasingly important. This facilitates meaningful research and audit, particularly in the context of multicentre studies. To this end the American College of Radiology has recently published the 5th edition of the BI-RADS lexicon, with revision of the MRI section including addition of new descriptors, modification of others and deletion of some that were rarely helpful in practice, such as ‘stippled’ enhancement [1]. Categories for fibroglandular volume are now a to d, in line with the descriptors for mammography, thus avoiding confusion with assessment category. The degree of background parenchymal enhancement is now purely descriptive, from none/minimal to marked. A new descriptor is clustered rim enhancement (usually indicating DCIS). Non mass-like enhancement becomes non mass enhancement, whereas ‘ductal’ enhancement becomes linear. Overall the effect is of simplification and consistency with the mammography and ultrasound lexicons. The lexicon highlights the importance of a structured report, including the indication, scan technique, salient findings and critically, an overall assessment with a clear recommendation for further management. This approach has been validated in a number of studies correlating the assessment category with histopathological findings and/or long-term follow-up [2,3]. Use of a standardised lexicon, modified in the light of available evidence, has obviated some of the interpretative challenges of breast MRI. Use of supplemental diffusion weighted imaging may also be helpful [4]. Nonetheless, technical and clinical challenges remain. Artefacts are problematic, especially at 3T [5], and medical physics support is essential for good quality diagnostic scans, especially at higher field strength. Most importantly, it should be remembered that to date, despite the recognised superiority of breast MRI over any other modality for breast cancer detection and local staging, there is no hard evidence for improved patient outcomes. Two randomised controlled trials and seven comparative cohort studies have not shown any benefit for preoperative MRI in terms of re-excision rates; rather, there is a trend to higher mastectomy rates [6]. No convincing beneficial effects have been demonstrated in terms of in-breast tumour recurrence rates, disease-free survival or overall survival. Regarding assessment of response to neoadjuvant chemotherapy, MRI correlates better than mammography or ultrasound with final pathology, but false positive and negative studies are frequent, with underestimation of the amount of residual disease in up to 30% and overestimation in around 20% of cases [7,8]. Though evidence is accruing that MRI may be helpful in early response assessment, this is by no means standardised and is heavily dependent on many factors, not least tumour immunophenotype. Finally, though screening breast MRI for women at high risk has approximately double the sensitivity of mammography with encouraging stage shift and high rates of node negativity, there is as yet no evidence of a reduction in breast cancer mortality [9,10]. This workshop will provide an update on the BI-RADS lexicon and indications for breast MRI, with expert tuition in hands-on analysis of case studies.

La pratique de l’IRM mammaire au centre hospitalier de Chambéry

ObjectiveTo determine indications, technique and results of breast MRI performed at Chambery hospital (CH). Patients and methodsAnalytical retrospective study of 12 months, conducted at CH. It involved the analyzing of 100 breast MRI examinations performed in 84 patients using a brand device Siemens Magneton Area®. ResultsThe mean age of patients was 56.2 years. The indications for breast MRI were the assessment of local and regional extension of breast cancer (28%), the results of monitoring of neoadjuvant chemotherapy (22%), the research of local recurrence after conservative treatment (14%) and cases of diagnostic discrepancies (13%). The most commonly used sequences were axial T1 ES (91%), axial T2 STIR (91%) and axial T1 with gadolinium injection (97%). The assessment of locoregional extension revealed multifocal invasion in 14 cases, pectoral in 3 cases, lymph node in 7 cases and skin in 4 cases. Concerning the monitoring of neoadjuvant chemotherapy, tumor involution was found in 10 patients and stability in 3 others. The distinction between tumor recurrence and postoperative scar showed 10 negative cases and 4 cases of tumor recurrence. ConclusionBreast MRI is an excellent non-invasive method for studying fully and satisfactorily within. It is mainly practiced in the CH to the extension of cancer and monitoring neoadjuvant chemotherapy balance.

The “perirenal edema sign” as a hint towards hypertension - Preliminary observations on cofindings in MRI breast cancer staging

The role of MRI concerning imaging modalities of the breast (MR-mammography: MRM) has over the last 20 years evolved to be increasingly important. So far current ACR guidelines list among the specific indications for breast MRI mainly: 1. Patients after operation or radiation 2. Preoperative staging 3. Cancer of unknown primary (CUP Syndrome) 4. High-Risk patients (e.g. BRCA1 or 2) In case of previous cancer history or the detection of a malignant lesion, a body array coil was placed onto the back of patients in order to cover the upper half of the body from the neck to the upper lumbar region (Fig. 1). By incidental finding, some patients would show diffuse perirenal edema around both kidneys in the T2-weighted images (Fig. 2). Upon inquiry, patients confirmed a history of hypertension. These incidental findings initiated a specific observation with the aim to address the question as to how often this new sign is associated with a hypertensive anamnesis and possibly to explain the pathophysiological background of the finding.

High-risk lesions diagnosed at MRI-guided vacuum-assisted breast biopsy: can underestimation be predicted?

To evaluate the frequency of diagnosis of high-risk lesions at MRI-guided vacuum-assisted breast biopsy (MRgVABB) and to determine whether underestimation may be predicted. Retrospective review of the medical records of 161 patients who underwent MRgVABB was performed. The underestimation rate was defined as an upgrade of a high-risk lesion at MRgVABB to malignancy at surgery. Clinical data, MRI features of the biopsied lesions, and histological diagnosis of cases with and those without underestimation were compared. Of 161 MRgVABB, histology revealed 31 (19%) high-risk lesions. Of 26 excised high-risk lesions, 13 (50%) were upgraded to malignancy. The underestimation rates of lobular neoplasia, atypical apocrine metaplasia, atypical ductal hyperplasia, and flat epithelial atypia were 50% (4/8), 100% (5/5), 50% (3/6) and 50% (1/2) respectively. There was no underestimation in the cases of benign papilloma without atypia (0/3), and radial scar (0/2). No statistically significant differences (p > 0.1) between the cases with and those without underestimation were seen in patient age, indications for breast MRI, size of lesion on MRI, morphological and kinetic features of biopsied lesions. Imaging and clinical features cannot be used reliably to predict underestimation at MRgVABB. All high-risk lesions diagnosed at MRgVABB require surgical excision.

Indications for Breast MRI in the Patient with Newly Diagnosed Breast Cancer

Use of breast MRI in the preoperative evaluation of patients recently diagnosed with breast cancer has increased significantly over the past 10 years because of its well-documented high sensitivity for detecting otherwise occult breast cancer in the affected and contralateral breasts. However, published research reports on the impact of this improved cancer detection are limited. Equally important are growing concerns that the quality of breast MRI may vary significantly across practice sites, and therefore the published value of MRI may not be achieved for many patients. This article describes the peer-reviewed, published clinical research trials evaluating breast MRI in patients with newly diagnosed breast cancer on which the National Comprehensive Cancer Network (NCCN) practice guidelines are based. The current NCCN guidelines recommend that breast MRI be considered for patients with a newly diagnosed breast cancer to evaluate the extent of ipsilateral disease and to screen the contralateral breast, particularly for women at increased risk for mammographically occult disease. In addition, the guidelines indicate that breast MRI may be used for patients with axillary nodal adenocarcinoma to identify the primary malignancy. The guidelines stress the importance of having proper equipment, imaging technique, and provider training necessary to achieve high-quality breast MRI, and emphasize that MRI practice sites should have the ability to perform MRI-guided biopsy or needle localization. In addition to describing the data regarding use of breast MRI in women with newly diagnosed cancer, this article provides recommendations for the performance of high-quality breast MRI and suggestions for future research.

Positive predictive value of breast MRI in cancer detection.

Abstract Abstract #4007 Purpose: 
 Positive predictive values (PPVs) are among the performance benchmarks which have been reported when examining clinical outcomes related to mammography. Breast MRI is increasingly being used as a tool for screening and diagnostic purposes and current performance benchmarks for breast MRI have yet to be established. The purpose of this study is to assess breast MRI performance in our academic clinical practice via comparison of breast MRI PPVs with reported PPV values for mammography. Specifically, we sought to determine the abnormal interpretation rate of breast MRI examinations, and then to calculate the PPVs related to recommendations for further diagnostic evaluation and to recommendations for biopsy of breast lesions visualized on MRI.
 Materials and Methods: 
 This study was approved by our institutional review board and its methodology is in compliance with federal HIPAA regulations. A retrospective search of our institutional breast imaging database identified all breast MRI examinations performed 4/1/07 - 3/31/08. Data abstracted included: patient age, clinical indication for breast MRI, Breast Imaging Reporting and Data System (BI-RADS) assessments for all breast imaging examinations, clinical follow-up, and pathology results. Positive exams were defined as those with an initial BI-RADS 0, 4, or 5. Exams with suspicious findings were defined as those with a final BI-RADS 4 or 5 after additional workup. PPVs were calculated based on American College of Radiology recommendations and using the following definitions: PPV1 = exams with cancer/positive exams, PPV 2 = exams with cancer/exams with suspicious findings, and PPV 3 = cancers/biopsied lesions.
 Results:
 2,600 breast MRI examinations were performed during the study period. After exclusion criteria were applied, 285 positive exams (BI-RADS 0, 4 or 5) were identified for further analysis. The abnormal interpretation rate was 10.96% (285/2600, 95% CI: 9.7% - 12.2%). After non-invasive workup, including mammographic and sonographic correlation, 186 lesions on 177 exams had biopsy recommendations (final BI-RADS 4 or 5). Following biopsy, 55 malignancies were diagnosed (35 invasive carcinomas, 18 DCIS, 2 phyllodes/sarcoma). The overall PPV for a positive breast MRI exam (PPV1) was 17.2% (49/285). The PPV for suspicious findings after non-invasive workup (PPV2) was 27.7% (49/177). The PPV for biopsied lesions (PPV3) was 29.6% (55/186). When stratified by MRI indication, the cancer yield was lower in the screening setting (PPV1 = 9.7%, PPV2 = 19.7%, PPV3 = 19.4%) than in the diagnostic setting (PPV1 = 23.0%, PPV2 = 31.9%, PPV3 = 34.7%).
 Conclusions:
 Diagnostic breast MRI PPVs are comparable to published benchmarks for diagnostic mammography. Screening breast MRI PPVs are lower than published values for screening mammography, and lower when compared with reports from high-risk screening breast MRI trials. This may reflect characteristics of the population undergoing screening breast MRI in our academic clinical practice. Factors such as cancer detection rate and the population risk for breast cancer should be considered when examining PPVs for breast MRI. Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 4007.

MRI and interventional MRI in breast cancer

Objectifs To introduce modern techniques of breast MRI and MR-guided breast intervention. Indications for breast MRI should be stated. Furthermore value of breast MRI and MR-guided breast intervention in different settings will be illustrated. Typical examples of breast cancer patients and their MR images will be presented. Points cles To understand techniques and indications of breast MRI and MR-guided breast interventions. To realize the value of breast MRI and MR-guided breast intervention in breast cancer. Resume Breast cancer is the most frequent cancer of women in industrialized countries. Early detection can save lives and enhance the cosmetic result. Breast MRI is more sensitive than mammography and ultrasound in the detection of invasive and non-invasive carcinoma. Therefore breast MRI should be performed in patients with known cancer for exclusion of additional foci of carcinoma and for prediction of tumour extent. After neoadjuvant therapy breast MRI is helpful to predict therapy response. In case of only MR-detected suspicious lesions MR-guided intervention is necessary. This means either MR-guided lesion localization and following surgical biopsy or MR-guided needle biopsy.

Role of MRI in screening, diagnosis and management of breast cancer

Screening and early diagnosis has an important role in reducing the morbidity and mortality associated with breast cancer. Mammography has an established role and has been approved for routine screening. MRI is an emerging tool and has the highest sensitivity of current breast imaging techniques. Although low specificity and high cost of MRI restricted its use in routine screening, it has been increasingly used in the screening of high-risk individuals, diagnosing occult cases, staging and assessing the response to chemotherapy. MRI-guided techniques, including needle-localization biopsy and vacuum-assisted breast biopsy, have a special role in diagnosis and management. This article focuses on the role of MRI in diagnosis, screening and management of breast cancer, and reviews the current indications for breast MRI.

Clinical Indications for Breast MRI

Clinical Indications for Breast MRI