Rationale and Objectives
To compare the performance of two shortened breast magnetic resonance imaging (MRI) protocols to a standard MRI protocol for breast cancer screening.
Materials and Methods
In this Health Insurance Portability and Accountability Act compliant, institutional review board–approved pilot study, three fellowship-trained breast imagers evaluated 48 breast MRIs (24 normal, 12 benign, and 12 malignant) selected from a high-risk screening population. MRIs were presented in three viewing protocols, and a final Breast Imaging-Reporting and Data System assessment was recorded for each case. The first shortened protocol (abbreviated 1) included only fat-saturated precontrast T2-weighted, precontrast T1-weighted, and first pass T1-weighted postcontrast sequences. The second shortened protocol (abbreviated 2) included the abbreviated 1 protocol plus the second pass T1-weighted postcontrast sequence. The third protocol (full), reviewed after a 1-month waiting period, included a nonfat-saturated T1-weighted sequence, fat-saturated T2-weighted, precontrast T1-weighted, and three or four dynamic postcontrast sequences. Interpretation times were recorded for the abbreviated 1 and full protocols. Sensitivity and specificity were compared via a chi-squared analysis. This pilot study was designed to detect a 10% difference in sensitivity with a power of 0.8.
Results
There was no significant difference in sensitivity between the abbreviated 1 (86%; P = .22) or abbreviated 2 (89%; P = .38) protocols and the full protocol (95%). There was no significant difference in specificity between the abbreviated 1 (52%; P = 1) or abbreviated 2 (45%; P = .34) protocols and the full protocol (52%). The abbreviated 1 and full protocol interpretation times were similar (2.98 vs. 3.56 minutes).
Conclusions
In this pilot study, reader performance comparing two shortened breast MRI protocols to a standard protocol in a screening cohort were similar, suggesting that a shortened breast MRI protocol may be clinically useful, warranting further investigation.
Breast magnetic resonance imaging (MRI) has been shown to have the highest sensitivity of all imaging modalities for the detection of breast cancer, a critically important factor in screening . The high sensitivity of breast MRI is largely because of improved contrast over mammography, particularly in women with dense breast tissue . As a result, MRI has been increasingly used to help screen women at increased lifetime risk for breast cancer. The American College of Radiology Appropriateness Criteria gives contrast-enhanced MRI their highest rating for use in high-risk women (≥20% lifetime risk; genetic mutation carriers, strong family history, and prior chest radiation) when used in conjunction with mammography . Similar recommendations for MRI screening in high-risk women exist from the American Cancer Society and the National Comprehensive Cancer Care Network as well as health systems in the United Kingdom and Canada .
Although women with increased mammographic breast density have an increased risk of developing breast cancer compared to women with lower breast density, breast density alone as an independent risk factor confers less than the 20% risk threshold currently established to guide MRI use for high-risk screening . Nevertheless, many states require that radiologists notify women of their breast density and the limitations of screening mammography, prompting inquiries by some patients and referring physicians about the merits of other methods of breast cancer screening. Currently, there is no consensus about what additional screening modalities should be offered . However, in addition to several studies demonstrating that MRI has the highest sensitivity for breast cancer screening compared to ultrasound and mammography, , data from a recent study of a high-risk population have shown that MRI has the highest sensitivity regardless of breast density , suggesting that MRI may be a sensible additional screening option to offer women with dense breast tissue.
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Materials and methods
Study Patients
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MRI Protocol
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Reader Study
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Table 1
Breast Magnetic Resonance Imaging Sequences by Reader Protocol
Protocol T2 Dynamic Precontrast Dynamic 1st Pass Dynamic 2nd Pass Dynamic 3rd and 4th pass ∗ Nonfat-Saturated T1 Abbreviated 1 x x x Abbreviated 2 x x x x Full x x x x x x
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Data Analysis
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Results
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Table 2
Characteristics of Magnetic Resonance Imaging Examinations
Pathologic Diagnosis n % Normal 24 50.0 Benign 12 25.0 Fibrocystic changes 3 6.3 Fibroadenoma 4 8.3 Papilloma 2 4.2 Lymph node 1 2.1 Flat epithelial atypia 1 2.1 Atypical ductal hyperplasia 1 2.1 Malignant 12 25.0 Ductal carcinoma in situ 3 6.3 Invasive ductal carcinoma 8 8.3 Invasive lobular carcinoma 1 2.1
All studies had biopsy-proven abnormalities or two years of imaging follow-up.
Table 3
Sensitivity for Each Reader and Overall by Imaging Protocol
Protocol Reader 1 (%) Reader 2 (%) Reader 3 (%) Overall (%)P Value Sensitivity Abbreviated 1 92 83 83 86 .22 Abbreviated 2 92 83 92 89 .38 Full 92 92 100 95 Specificity Abbreviated 1 69 56 31 52 1 Abbreviated 2 67 44 25 45 .34 Full 58 58 39 52
Round three was used as the reference standard for P value calculations.
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Table 4
Interpretation Time for Each Reader and Overall by Imaging Protocol
Protocol Reader 1 (SD) Reader 2 (SD) Reader 3 (SD) Overall (SD)P Value Abbreviated 1 3.65 (2.68) 2.25 (0.73) 3.04 (1.34) 2.98 (1.86) <.01 Full 3.58 (2.22) 2.10 (0.67) 3.19 (1.08) 2.95 (1.59)
SD, standard deviation.
A two one-sided test for equivalence was used to calculate the P value.
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Discussion
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Conclusions
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