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BREAST MR IMAGING

Volume 14 � Number 3 � August 2006

Contents

Preface xi

Christiane K. Kuhl

Breast MR Imaging Lexicon Updated 293

Elizabeth A. Morris

The American College of Radiology Breast Imaging and Reporting Data System MRimaging lexicon incorporates morphologic and kinetic features of lesions identified onbreast MR imaging. This brief article is aimed at introducing this material and shouldnot be used as a definitive guide. Because the breast MR imaging lexicon is a work inprogress, there are many areas that need exploring and better characterization. It ishoped that the radiologist uses the terms and concepts presented here as a template towhich future lexicon terminology can be added.

Concepts for Differential Diagnosis in Breast MR Imaging 305

Christiane K. Kuhl

There is broad agreement in that breast MR imaging, compared with all othercontemporary breast imaging techniques, offers the highest sensitivity for primary andrecurrent invasive breast cancer. For a long time, however, the modality suffered fromthe reputation of offering only a limited specificity. In addition, the allegedly lowsensitivity for intraductal breast cancer hampered the more widespread use of breast MRimaging. More recent results, however, suggest that the specificity and positive predictivevalue of breast MR imaging are at least equivalent to those of mammography andthat the sensitivity for ductal carcinoma in situ (DCIS) is at least comparable tomammography, if not higher. Apart from increasing reader experience, this progress ismainly attributable to the fact that in parallel with improved MR imaging technology,more refined interpretation criteria became available. These criteria allow a substantiallyimproved diagnosis of malignant masses and of DCIS. This article provides an overviewon the current status of the diagnostic criteria that are used for differential diagnosis inbreast MR imaging and on the diagnostic accuracy that is achievable with breast MRimaging.

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Breast MR Imaging in the Diagnostic Setting 329

Mitchell Schnall and Susan Orel

The role of MR imaging as an adjunct in the diagnostic evaluation of findings onmammography or clinical examination continues to evolve. Clearly, the use of MRimaging to evaluate all suspicious screening findings is not reasonable or effective. Inparticular, the role of MR imaging in the setting of mammographic microcalcifications islimited. MR imaging may be used in cases of one or more mammographically detectedmasses or asymmetric density in an effort to avoid biopsy. Optimized MR imagingtechnique; careful mammography, ultrasound, and MR imaging correlation; andadherence to interpretation guidelines are important to avoid false-negative diagnoses.

Breast MR Imaging in Assessing Extent of Disease 339

Laura Liberman

Breast MR imaging is valuable in assessment of extent of disease in the ipsilateral andcontralateral breast in women who have breast cancer. In the ipsilateral breast, MRimaging depicts otherwise unsuspected sites of cancer in 16% (range, 6%–34%). In thecontralateral breast, MR imaging depicts otherwise unsuspected sites of cancer in 6%(range, 3%–24%). MR imaging is most likely to depict additional sites of cancer inwomen with invasive lobular cancer and a family history of breast cancer. MR imagingcan also assist in evaluating involvement of skin, pectoral muscle, and chest wall.Disadvantages of breast MR imaging include cost and additional procedures (follow-upand biopsy); furthermore, no data as yet show that breast MR imaging in the extent ofdisease evaluation improves disease-free or overall survival. If breast MR imaging is usedin evaluating extent of disease, it is necessary to have the capability to perform biopsy oflesions detected by MR imaging only.

Preoperative MR Imaging in Patients with Breast Cancer: Preoperative Staging,Effects on Recurrence Rates, and Outcome Analysis 351

Uwe Fischer, Friedemann Baum, and Susanne Luftner-Nagel

As well documented for other diseases (ie, lymphoma), an accurate pretherapeuticassessment of the extent of breast cancer is essential for planning the appropriatetreatment to get the best long-term results, decrease recurrence rates, and increasepatient survival. This article presents an overview of the effects of preoperative localstaging with MR imaging in breast cancer patients.

A Clinical Oncology Perspective on the Use of Breast MR 363

Monica Morrow and Gary Freedman

MR imaging of the breast detects additional carcinoma in as many as 30% of womenthought to have localized disease by clinical examination and mammography. This hasled some to advocate its routine use in the preoperative evaluation of breast cancerpatients. However, local failure rates in patients selected for breast conservation byconventional methods are less than 5% at 10 years, suggesting that the majority of thisdisease is controlled with radiotherapy. The potential role of MR in the preoperativeevaluation and postoperative follow-up of patients with early-stage breast cancer isdiscussed.

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MR Imaging Evaluation of Cancer Extent: Is There Clinical Relevance? 379

Mitchell Schnall

The traditional methods for selecting women for breast conservation therapy (BCT),coupled with adjuvant radiation therapy, have reduced recurrence rates of BCT toacceptable levels. These recurrence rates are still significant, however. They may befurther affected by the application of more anatomically targeted radiation therapy.Preoperative MR imaging should theoretically reduce the local failure rate of BCT by atleast 5%, with only a modest increase in the mastectomy rate. The evolution of BCT toinclude more targeted radiation therapy and ablation should place an even largeremphasis on accurate tumor localization and has the potential to allow BCT to becomemore prevalent and effective.

MR Imaging for Assessment of Breast Cancer Response to NeoadjuvantChemotherapy 383

Nola Hylton

Contrast-enhanced MR imaging is being used increasingly because of its high sensitivityto breast cancer and superior ability to demonstrate the extent and distribution ofdisease. In addition to this direct clinical use, MR imaging in the neoadjuvant treatmentsetting allows exploration of its potential value in quantifying primary tumor response.The high sensitivity and staging accuracy of MR imaging may yield more accurateclassification of objective tumor response using RECIST criteria than clinicalexamination or mammography. Functional measurements hold the promise of greatersensitivity for detecting biologic effects of targeted treatments than simple anatomicmethods.

MR Imaging for Surveillance of Women at High Familial Risk for Breast Cancer 391

Christiane K. Kuhl

The adequate management of individuals who carry a high lifetime risk for breast canceris still an unsettled issue. This holds especially true for subjects with documented orsuspected germline mutation of a breast cancer susceptibility gene. These women facea lifetime risk for breast cancer of up to 80%, which is, of course, significant. Still, thismeans that approximately one fifth of women never develop the disease. The perceivedmutilating effects of preventive mastectomy make the decision for surgical preventiondifficult for most women. Secondary prevention aims at identifying familial breastcancer at the earliest possible stage. During recent years, considerable evidence has beenaccumulated that breast MR imaging is substantially more sensitive than mammographyand breast ultrasound regarding the identification of familial breast cancer. It should beconsidered an integral part of a surveillance program for women at increased familialrisk for breast cancer, be it with or without documented mutation of a breast cancersusceptibility gene.

Do We Need Randomized Controlled Clinical Trials to Evaluate the ClinicalImpact of Breast MR Imaging? 403

Bruce J. Hillman

MR imaging of the breast has been shown to identify breast cancers that have goneundetected by mammography. There are a number of potential designs that can be used

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to further evaluate breast MR imaging, particularly with respect to its impact on clinicalcare. Determination of whether using breast MR imaging to screen healthy individualsfor breast cancer actually reduces breast cancer–specific mortality—and whether this canbe accomplished at an acceptable cost—probably requires randomized, controlledclinical.

MRI-Guided Percutaneous Biopsy of Breast Lesions: Materials, Techniques,Success Rates, and Management in Patients with SuspectedRadiologic-Pathologic Mismatch 411

Daniel Floery and Thomas H. Helbich

MR imaging of the breast allows the detection of suspicious breast lesions that are occultat mammography and ultrasound. For the histologic verification of such lesions,percutaneous MR imaging–guided biopsy techniques can now be offered as analternative to open breast biopsy. This review focuses on the currently available devicesand techniques for MR imaging–guided percutaneous breast biopsy and reports theirachievable diagnostic accuracy. Technical success rates and strategies for patientmanagement are also outlined. In addition, new developments in MR imaging–guidedminimally invasive therapeutic interventions are discussed, as well as the potential forresearch opportunities and directions.

Index 427