EDITORIAL
Magnetic Resonance Imaging in Breast Disease Laurie Margolies, MD, FACR
B
reast magnetic resonance imaging (MRI) is a constantly evolving technique for the early detection and evaluation of breast cancer. Screening MRI guidelines were published by the American Cancer Society in 20071 and, although widely adopted, do not extend screening to all who may benefit.2 Many breast imagers and surgeons routinely rely on it to assess disease burden in the newly diagnosed patient with the goal of decreasing reoperation rates and detecting synchronous cancers, whereas others bemoan its use and question the significance of breast MRI-detected cancers.3–6 Regardless of where a breast radiologist practices and with whom he or she practices, it is clear that proper breast MRI performance, interpretation, and biopsy is the responsibility of the breast imaging section, and those breast imagers practicing at the highest level must make breast MRI an integral component of their practice. Breast MRI is a relatively common adjunct to mammography. The Breast Cancer Surveillance Consortium (BCSC) using statistics from 3.6% of the US population collected data on breast MRI use from 2005 through 2009 and noted that the rate of breast MRI use increased from 4.2 to 11.5 breast MRI examinations per 1000 women. Screening breast MRI accounted for a large part of the increase, with it increasing from 0.8 to 4.3 breast MRI examinations per 1000 women. Screening accounted for 31.7% of the examinations, staging accounted for 16.2%, and a diagnostic workup of a non-MRI or clinical finding accounted for 40.3%.7 The latter group represents a very high percentage in relatively uncharted waters, as breast MRI is not thought to “have a sufficiently high negative predictive value to warrant its use for this purpose.”7 Women screened in the BCSC study are a heterogeneous group and are likely representative of the general US population. Forty-five percent had a personal history of breast cancer7—not considered by the American Cancer Society as warranting surveillance without confounding factors.1 In the BCSC cohort, only 25% had a lifetime risk of more than 20%, with the majority of screening MRI patients at intermediate or average risk as measured by the National Cancer Institute Breast Cancer Risk Assessment Tool, which encompasses age, race, previous biopsy results, age at menarche, age at first live birth, and family history of breast cancer in first-degree relatives. (http://www.cancer.gov/ bcrisktool). Similarly, Stout et al8 studying a large cohort in Massachusetts, Maine, and New Hampshire found that only 21% of those getting screening MRI had a documented more than 20% lifetime risk. Why women not at high risk are getting breast MRI is an interesting question. Patient preference? Perception of risk? Breast density? Equally interesting are those at high risk who limit their screening to mammography—or opt out of screening entirely. From Mount Sinai Medical Center, New York, NY. Reprints: Laurie Margolies, MD, FACR, Mount Sinai Medical Center, New York, NY (e‐mail: [email protected]). The author declares no conflict of interest. Copyright ©2014 by Lippincott Williams & Wilkins
This group has been studied,9,10 and reasons for declining MRI include claustrophobia, time, financial concerns, and lack of patient and/or referring physician interest. This issue of Topics in Magnetic Resonance Imaging walks the reader through the current status of breast MRI indications and discusses one of the most vexing challenges in breast MRI—the probably benign Breast Imaging Reporting and Data System category 3. The challenge of implant imaging with breast MRI is addressed as is the issue of extramammary findings on breast MRI. The issue continues with a review of breast MRI interventional procedures, which are integral to a well-run breast MRI program, and concludes with a discussion of technique, safety concerns, and future directions. Breast MRI is poised to continue to grow as an important adjunct to screening and diagnostic mammography; abbreviated noncontrast screening protocols, which are under investigation, may increase its use. Breast MRI used appropriately can be of substantial benefit; as breast imagers, we are responsible for high-quality images, careful interpretation, and its appropriate use. REFERENCES 1. Saslow D, Boetes C, Burke W, et al. American Cancer Society guidelines for breast screening with MRI as an adjunct to mammography. CA Cancer J Clin. 2007;57:75–89. 2. Hollingsworth AB, Stough RG. An alternative approach to selecting patients for high-risk screening with breast MRI. Breast J. 2014;20: 192–197. 3. Houssami N, Hayes DF. Review of preoperative magnetic resonance imaging (MRI) in breast cancer: should MRI be performed on all women with newly diagnosed, early stage breast cancer? CA Cancer J Clin. 2009; 59:290–302. 4. Lehman CD, DeMartini W, Anderson BO, et al. Indications for breast MRI in the patient with newly diagnosed breast cancer. J Natl Compr Canc Netw. 2009;7:193–201. 5. Houssami N, Turner R, Morrow M. Preoperative magnetic resonance imaging in breast cancer: meta-analysis of surgical outcomes. Ann Surg. 2013;257:249–255. 6. Sung JS, Li J, Da Costa G, et al. Preoperative breast MRI for early-stage breast cancer: effect on surgical and long-term outcomes. AJR Am J Roentgenol. 2014;202:1376–1382. 7. Wernli KJ, DeMartini WB, Ichikawa L, et al. Patterns of breast magnetic resonance imaging use in community practice. JAMA Intern Med. 2014; 174:125–132. 8. Stout NK, Nekhlyudov L, Li L, et al. Rapid increase in breast magnetic resonance imaging use: trends from 2000 to 2011. JAMA Intern Med. 2014; 174:114–121. 9. Berg WA, Blume JD, Adams AM, et al. Reasons women at elevated risk of breast cancer refuse breast MR imaging screening: ACRIN 6666. Radiology. 2010;254:79–87. 10. Brinton JT, Barke LD, Freivogel ME, et al. Breast cancer risk assessment in 64,659 women at a single high-volume mammography clinic. Acad Radiol. 2012;19:95–99.
Topics in Magnetic Resonance Imaging • Volume 23, Number 6, December 2014
www.topicsinmri.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
327
Magnetic Resonance Imaging in Breast Disease Laurie Margolies, MD, FACR
B
reast magnetic resonance imaging (MRI) is a constantly evolving technique for the early detection and evaluation of breast cancer. Screening MRI guidelines were published by the American Cancer Society in 20071 and, although widely adopted, do not extend screening to all who may benefit.2 Many breast imagers and surgeons routinely rely on it to assess disease burden in the newly diagnosed patient with the goal of decreasing reoperation rates and detecting synchronous cancers, whereas others bemoan its use and question the significance of breast MRI-detected cancers.3–6 Regardless of where a breast radiologist practices and with whom he or she practices, it is clear that proper breast MRI performance, interpretation, and biopsy is the responsibility of the breast imaging section, and those breast imagers practicing at the highest level must make breast MRI an integral component of their practice. Breast MRI is a relatively common adjunct to mammography. The Breast Cancer Surveillance Consortium (BCSC) using statistics from 3.6% of the US population collected data on breast MRI use from 2005 through 2009 and noted that the rate of breast MRI use increased from 4.2 to 11.5 breast MRI examinations per 1000 women. Screening breast MRI accounted for a large part of the increase, with it increasing from 0.8 to 4.3 breast MRI examinations per 1000 women. Screening accounted for 31.7% of the examinations, staging accounted for 16.2%, and a diagnostic workup of a non-MRI or clinical finding accounted for 40.3%.7 The latter group represents a very high percentage in relatively uncharted waters, as breast MRI is not thought to “have a sufficiently high negative predictive value to warrant its use for this purpose.”7 Women screened in the BCSC study are a heterogeneous group and are likely representative of the general US population. Forty-five percent had a personal history of breast cancer7—not considered by the American Cancer Society as warranting surveillance without confounding factors.1 In the BCSC cohort, only 25% had a lifetime risk of more than 20%, with the majority of screening MRI patients at intermediate or average risk as measured by the National Cancer Institute Breast Cancer Risk Assessment Tool, which encompasses age, race, previous biopsy results, age at menarche, age at first live birth, and family history of breast cancer in first-degree relatives. (http://www.cancer.gov/ bcrisktool). Similarly, Stout et al8 studying a large cohort in Massachusetts, Maine, and New Hampshire found that only 21% of those getting screening MRI had a documented more than 20% lifetime risk. Why women not at high risk are getting breast MRI is an interesting question. Patient preference? Perception of risk? Breast density? Equally interesting are those at high risk who limit their screening to mammography—or opt out of screening entirely. From Mount Sinai Medical Center, New York, NY. Reprints: Laurie Margolies, MD, FACR, Mount Sinai Medical Center, New York, NY (e‐mail: [email protected]). The author declares no conflict of interest. Copyright ©2014 by Lippincott Williams & Wilkins
This group has been studied,9,10 and reasons for declining MRI include claustrophobia, time, financial concerns, and lack of patient and/or referring physician interest. This issue of Topics in Magnetic Resonance Imaging walks the reader through the current status of breast MRI indications and discusses one of the most vexing challenges in breast MRI—the probably benign Breast Imaging Reporting and Data System category 3. The challenge of implant imaging with breast MRI is addressed as is the issue of extramammary findings on breast MRI. The issue continues with a review of breast MRI interventional procedures, which are integral to a well-run breast MRI program, and concludes with a discussion of technique, safety concerns, and future directions. Breast MRI is poised to continue to grow as an important adjunct to screening and diagnostic mammography; abbreviated noncontrast screening protocols, which are under investigation, may increase its use. Breast MRI used appropriately can be of substantial benefit; as breast imagers, we are responsible for high-quality images, careful interpretation, and its appropriate use. REFERENCES 1. Saslow D, Boetes C, Burke W, et al. American Cancer Society guidelines for breast screening with MRI as an adjunct to mammography. CA Cancer J Clin. 2007;57:75–89. 2. Hollingsworth AB, Stough RG. An alternative approach to selecting patients for high-risk screening with breast MRI. Breast J. 2014;20: 192–197. 3. Houssami N, Hayes DF. Review of preoperative magnetic resonance imaging (MRI) in breast cancer: should MRI be performed on all women with newly diagnosed, early stage breast cancer? CA Cancer J Clin. 2009; 59:290–302. 4. Lehman CD, DeMartini W, Anderson BO, et al. Indications for breast MRI in the patient with newly diagnosed breast cancer. J Natl Compr Canc Netw. 2009;7:193–201. 5. Houssami N, Turner R, Morrow M. Preoperative magnetic resonance imaging in breast cancer: meta-analysis of surgical outcomes. Ann Surg. 2013;257:249–255. 6. Sung JS, Li J, Da Costa G, et al. Preoperative breast MRI for early-stage breast cancer: effect on surgical and long-term outcomes. AJR Am J Roentgenol. 2014;202:1376–1382. 7. Wernli KJ, DeMartini WB, Ichikawa L, et al. Patterns of breast magnetic resonance imaging use in community practice. JAMA Intern Med. 2014; 174:125–132. 8. Stout NK, Nekhlyudov L, Li L, et al. Rapid increase in breast magnetic resonance imaging use: trends from 2000 to 2011. JAMA Intern Med. 2014; 174:114–121. 9. Berg WA, Blume JD, Adams AM, et al. Reasons women at elevated risk of breast cancer refuse breast MR imaging screening: ACRIN 6666. Radiology. 2010;254:79–87. 10. Brinton JT, Barke LD, Freivogel ME, et al. Breast cancer risk assessment in 64,659 women at a single high-volume mammography clinic. Acad Radiol. 2012;19:95–99.
Topics in Magnetic Resonance Imaging • Volume 23, Number 6, December 2014
www.topicsinmri.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
327
