Rationale and Objectives
Breast MRI is an important new tool in the imaging armamentarium for the detection and characterization of breast carcinoma. Understanding the evidence-supported benefits and potential harms of breast MRI is important to ensure the appropriate utilization of this medical resource.
Materials and Methods
This article reviews the clinical settings in which MRI for breast cancer assessment has been shown to be advantageous. The evidence regarding the diagnostic accuracy of MRI and the impact of this imaging tool on clinical outcomes are described. Novel breast MRI techniques which may lead to future improvements in performance are discussed.
Results
Breast MRI has been shown in multiple studies to be advantageous for screening patients at high risk, evaluating patients with a new breast cancer diagnosis, monitoring treatment response in patients undergoing neoadjuvant chemotherapy and evaluating patients with metastatic axillary adenocarcinoma and unknown primary site. Among the limitations of MRI are its high cost and modest specificity resulting in false positive examinations.
Conclusions
When used in evidence-supported clinical settings, the high sensitivity of MRI results in earlier cancer detection or greater accuracy of detection compared to existing tests for breast carcinoma. Further scientific endeavors are crucial to optimize the future performance and application of breast MRI.
Breast magnetic resonance imaging (MRI) is an important new tool in the imaging armamentarium for the detection and characterization of breast carcinoma. In 2003, the first edition of the American College of Radiology (ACR) Breast Imaging Reporting and Data System (BI-RADS) MRI lexicon was published ( ), reflecting the significance of this imaging technique. Because of the enthusiasm for its benefits, there has been a rapid increase in the use of breast MRI over the last several years. Importantly, scientific evidence supports the use of breast MRI for specific clinical applications, although data are lacking to support MRI use for other clinical scenarios. An understanding of the current literature regarding breast MRI for cancer evaluation is necessary for evidence-based employment of this imaging tool. Use that is guided by prior studies of efficacy will optimize the clinical value of breast MRI and facilitate the appropriate utilization of this medical resource.
In this article, we first describe the clinical settings in which MRI for cancer assessment has been shown to be advantageous: screening patients at high risk, evaluating patients with a new breast cancer diagnosis, monitoring treatment response in patients undergoing neoadjuvant chemotherapy, and evaluating patients with metastatic axillary adenocarcinoma and unknown primary site. For each clinical setting, the evidence regarding the diagnostic accuracy of breast MRI is reviewed. Where study results exist for MRI efficacy based on effects on patient management or clinical outcomes, these findings are also presented. We then describe the clinical scenarios for which breast MRI is not currently well-supported by the literature. Finally, we discuss novel breast MRI techniques that may lead to future improvements in the performance of this imaging tool.
Background
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Current evidence-supported clinical applications
Screening Patients at High Risk for Breast Cancer
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Table 1
Results of MRI Screening in Women at High Risk for Breast Cancer with Comparative Sensitivities of Mammography, US, and MRI
Author, Year, Site Study Design No. Cancers Detected/Total No. Screened Sensitivity Cancer Yield from MRI Alone Biopsies Recommended Based on MRI PPV of Biopsies Performed Based on MRI Mammography US MRI Tilanus-Linthorst 2000, Netherlands P 2.8% (3/109) 0% ⁎ — 100% (3/3) 2.8% (3/109) 4.6% (5/109) 60.0% Podo (Italian Multi-Center Project) 2002, Italy P 7.6% (8/105) 12.5% (1/8) 12.5% (1/8) 100% (8/8) 6.7% (7/105) 8.6% (9/105) 88.9% Morris 2003, USA R 3.8% (14/367) 0% ⁎ — 100% (14/14) 3.8% (14/367) 16.1% (59/367) 23.7% Kriege (MRI Screening Study Group) 2004, Netherlands † P 2.4% (45/1909) 40.0% (18/45) — 71.1% (32/45) 1.2% (22/1909) 2.9% (56/1909) 57.1% Warner 2004, Canada P 9.3% (22/236) 36.4% (8/22) 33.3% (7/21) 77.3% (17/22) 3.0% ‡ (7/236) 15.7% (37/236) 46.0% Kuhl 2005, Germany P 8.1% (43/529) 32.6% (14/43) 39.5% (17/43) 90.7% (39/43) 3.6% (19/529) 14.7% (78/529) 50.0% Lehman (International Breast Magnetic Resonance Consortium) 2005, international P 1.1% (4/367) 25.0% (1/4) — 100% (4/4) 0.8% (3/367) 6.3% (23/367) 17.4% Leach (Magnetic Resonance Imaging in Breast Screening) 2005, UK P 5.1% (33/649) 40.0% (14/35) § — 77.1% (27/35) 2.9% (19/649) — 25.0% Lehman (International Breast Magnetic Resonance Consortium) 2007, USA P 3.5% (6/171) 33.3% (2/6) 16.7% (1/6) 100% (6/6) 2.3% (4/171) 8.2% (14/171) 42.9% Sardanelli 2007, Italy P 6.5% (18/278) 58.8% (10/17) 64.7% (11/17) 93.8% (15/16) 2.2% (6/278) 9.0% (25/278) 60.0%
MRI: magnetic resonance imaging; US: ultrasound; PPV: number of malignancies found at biopsy divided by total number of biopsies performed; P: prospective; R: retrospective.
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Evaluation of Patients with a New Breast Cancer Diagnosis
Extent of disease in the ipsilateral breast
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Table 2
Frequency of Magnetic Resonance Imaging Detected Unsuspected Malignancy in the Ipsilateral Breast in Patients with a Recent Diagnosis of Breast Cancer
Author, Year Number of Malignant Cases Number (%) with Additional Unsuspected Ipsilateral Magnetic Resonance Imaging Malignancy Number (%) Multifocal Number (%) Multicentric Harms, 1993 29 breasts 10 (34.5%) 3 (10.3%) 7 (24.1%) Orel, 1995 64 women 13 (20.3%) — — Mumtaz, 1997 92 breasts 11 (12.0%) 1 (1.1%) 10 (10.9%) Fischer, 1999 336 women 54 (16.1%) 30 (8.9%) 24 (7.1%) Bedrosian, 2003 267 women 49 (18.4%) — — Liberman, 2003 70 women 19 (27.1%) 14 (20.0%) 5 (7.1%) Schelfout, 2004 170 women 33 (19.4%) 12 (7.1%) 17 (10.0%) Schnall (International Breast Magnetic Resonance Consortium), 2005 423 women 41 (9.7%) — — Total 1451 230 (15.9%) 60 (8.6% ⁎ ) 63 (9.0% ⁎ )
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Table 3
Frequency of Impact on Surgical Management of Magnetic Resonance Imaging Detected Malignancy in the Ipsilateral Breast in Patients with a Recent Diagnosis of Breast Cancer
Author, Year Number of Malignant Cases Number (%) with Additional Ipsilateral Magnetic Resonance Imaging Malignancy Impacting Surgical Management ⁎ Orel, 1995 64 7 (10.9%) Fischer, 1999 336 51 (15.2%) Tan, 1999 83 5 (6.0%) Tillman, 2002 207 18 (8.7%) Bedrosian, 2003 267 49 (18.4%) Shelfout, 2004 170 42 (24.7%) Berg, 2004 111 29 (26.1%) Total 1238 201 (16.2%)
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Screening of the contralateral breast
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Table 4
Frequency of Magnetic Resonance Imaging Detected Unsuspected Malignancy in the Contralateral Breast in Patients with a Recent Diagnosis of Breast Cancer
Author, Year Number of Patients Number (%) with Contralateral Magnetic Resonance Imaging Malignancy Rieber, 1997 34 3 (8.8%) Fischer, 1999 463 15 (3.2%) Slanetz, 2002 17 4 (23.5%) Liberman, 2003 223 12 (5.4%) Lee, 2003 182 7 (3.9%) Viehweg, 2004 119 4 (3.4%) Berg, 2004 111 3 (2.7%) Lehman, 2005 103 4 (3.9%) Pediconi, 2007 118 22 (18.6%) Lehman, 2007 969 30 (3.1%) Total 2,339 104 (4.4%)
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Monitoring Treatment Response in Patients Undergoing Neoadjuvant Chemotherapy
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Evaluating Patients with Metastatic Axillary Adenocarcinoma and Unknown Primary
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Table 5
Frequency of Magnetic Resonance Imaging–Detected Breast Malignancy in Patients with Axillary Adenopathy and Unknown Primary Site
Author, Year Number of Patients Number (%) with Magnetic Resonance Imaging–Detected Malignancy Stomper, 1999 8 2 (25.0%) Henry-Tillman, 1999 8 8 (100%) Orel, 1999 22 19 (86.4%) Obdeijn, 2000 20 8 (40.0%) Olson, 2000 40 28 (70.0%) Buchanan, 2005 64 31 (48.4%) Total 162 96 (59.3%)
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Clinical applications not supported by the evidence
Problem Solving for Clinical or Mammographic Findings
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Future of breast MRI
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High-Field Strength Scanners
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Diffusion-Weighted Imaging
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MRS
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Conclusions
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