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Canceled MRI-guided Breast Biopsies Due to Nonvisualization

Posted Aug 31, 2018 Updated Apr 10, 2023
By Niveditha Pinnamaneni MD , Linda Moy MD , Yiming Gao MD , Amy N. Melsaether MD , James S. Babb PhD , Hildegard K. Toth MD , Samantha L. Heller MD PhD
12 min read

Rationale and Objective

The objective of this study was to evaluate breast lesion outcomes in patients after canceled MRI-guided breast biopsy due to lesion nonvisualization.

Materials and Methods

Electronic medical records (January 2007–December 2014) were searched for patients with canceled magnetic resonance imaging (MRI)-guided breast biopsies due to lesion nonvisualization. A total of 1403 MRI-detected lesions were scheduled for MRI-guided biopsy and 89 were canceled because of nonvisualization. Imaging studies and medical records were reviewed for patient demographics, lesion characteristics, and subsequent malignancy. Patients without adequate MRI follow-up imaging were excluded. Statistical analysis was employed to determine if patient demographics or lesion characteristics were predictive of lesion resolution or lesion biopsy after subsequent follow-up.

Results

Eighty-nine (6.3% [89/1403]; 95% confidence interval, 5.2%–7.7%) biopsies in 89 women were canceled because of nonvisualization. Follow-up MRIs greater than 5.5 months were available for 60.7% (54/89) of women. In 74.1% (40/54) of these patients, the lesions completely resolved on follow-up. In 25.9% (14/54) of the patients, the lesion persisted on follow-up; 42.9% (6/14) of these patients underwent biopsy. One case (1.9% [1/54]) yielded ductal carcinoma in situ with microinvasion at the 6-month follow-up. No patient demographics or lesion features were associated with lesion resolution or lesion biopsy.

Conclusions

The majority of canceled MRI-guided biopsy lesions resolved on later follow-up; however, because of the small possibility of a missed malignancy, follow-up MRI imaging at 6 months is recommended.

Introduction

Numerous studies have demonstrated the diagnostic utility of magnetic resonance imaging (MRI) breast cancer detection compared to mammography and ultrasound, particularly in high-risk patient populations . Additionally, the advent of MRI-guided vacuum-assisted biopsy has provided a relatively quick and safe method of sampling tissue, sparing patients the time and invasiveness of a surgical biopsy . In some instances, however, MRI-guided biopsies may be canceled; reported rates of biopsy cancellation have ranged from 8% to 13%, most often because of nonvisualization of the initial biopsy target on the scheduled day of biopsy . Lesions may not be visualized because the lesion has resolved at the time of biopsy and may have only been due to background parenchymal enhancement (BPE), now no longer seen. In other cases, however, lesions may be canceled for technical reasons such as poor patient positioning or compression, which may impede contrast delivery to the breast. These canceled biopsies can thus be a source of confusion and frustration for both clinicians and patients. Only a few studies have specifically investigated the clinical course of these nonvisualized lesions; the reported frequency of subsequent malignancy has ranged from 0% to 10% .

A better understanding of the longer term outcomes after nonvisualization of an MRI-guided biopsy target is warranted to help guide decisions regarding appropriate follow-up and treatment. The purpose of the present study, therefore, was to evaluate outcomes—including subsequent development of ipsilateral quadrant malignancy—in patients who had a canceled MRI-guided breast biopsy due to nonvisualization of the lesion on the day of biopsy. A secondary purpose was to determine if any patient demographics or lesion characteristics were predictive of lesion resolution or lesion biopsy after subsequent follow-up.

Materials and Methods

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Figure 1, Patient outcomes after canceled MRI-guided biopsy. DCIS, ductal carcinoma in situ; MRI, magnetic resonance imaging.

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MRI Technique

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MRI-Biopsy Imaging Technique

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Patient Characteristics

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Imaging Findings

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Follow-up

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Data Collection and Statistical Analysis

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Results

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Patient Characteristics

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TABLE 1

Patient Demographics and Lesion Characteristics in the Initial Diagnostic Study

Patient/Lesion Characteristics ( n = 54)n (%) Patient age (y) 45.5 (range, 23.0–67.0) Menopausal status Premenopausal 38 (70.3) Postmenopausal 16 (29.6) Family history of breast cancer Yes 26 (48.1) No 28 (51.9) Personal history of breast cancer Yes 27 (50.0) Prior 9 (33.3) Current 18 (66.7) No 27 (50.0) Indication for MRI Screening 34 (63.0) Diagnostic 20 (37.0) Background enhancement Minimal 12 (22.2) Mild 16 (29.6) Moderate 22 (40.7) Marked 4 (7.4) Lesion type on initial MRI Focus 1 (1.9) Nonmass enhancement 38 (70.4) Mass 15 (27.8) Lesion size (cm) on initial MRI Mean 2.2 Median 1.0 Range 0.3–8.0 Lesion kinetics on initial MRI Persistent 40 (74.1) Plateau 12 (22.2) Washout 2 (3.7) BI-RADS (lesion) 3 1 (1.9) 4a 33 (61.1) 4b 20 (37.0) 4c 0 (0) 5 0 (0)

BI-RADS, Breast Imaging Reporting and Data Systems; MRI, magnetic resonance imaging.

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Imaging Findings

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Follow-up—Benign Lesions

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Figure 2, Forty-one-year-old woman with a recently diagnosed left invasive ductal carcinoma who underwent a diagnostic breast MRI. (a) On sagittal dynamic contrastenhanced right breast MRI with subtraction, a 1.0-cm region of clumped nonmass enhancement with type 2 kinetics was seen within the retroareolar breast ( white arrow ); an MRI-guided biopsy was recommended. (b) On sagittal dynamic contrast-enhanced right breast MRI with subtraction performed on the day of biopsy 10 days later, the MRI target was not seen ( white arrow ); the biopsy was canceled and a 6-month follow-up was recommended. (c) On sagittal dynamic contrast-enhanced right breast MRI followup 2.5 years later, the MRI target was again not seen ( white arrow ). This lesion was also not seen on the first follow-up MRI at 6 months (not shown). MRI, magnetic resonance imaging.

TABLE 2

Characteristics of Lesions Undergoing Subsequent Biopsy

Case Size on Initial MRI Lesion Morphology on Initial MRI Lesion Kinetics on Initial MRI BI-RADs on Initial MRI Time to Subsequent Bx (mo) Lesion Size on Fup MRI Lesion Morphologyon Fup MRI Lesion Kinetics on Fup MRI Lesion Features on Fup MRI BI-RADs on Fup MRI MRI-guided Bx Pathology Result 1 1.0 Mass 3 4b 5.6 1.0 Mass 3 Lesion revisualized, new calcs on mammo 4b DCIS with microinvasion 2 0.7 Mass 1 4a 38.9 0.8 Mass 1 Increased in size 4a FCC 3 \* 2.5 NME 1 3 24.2 2.5 NME 1 Lesion revisualized, stable 3 FCC 4 1.5 NME 2 4a 21.2 3.5 NME 2 Increased in size 4a FCC 5 1.3 NME 1 4a 26.9 1.3 NME 1 Lesion revisualized, stable 4a FCC 6 2.5 NME 1 4a 12.1 2.5 NME 1 Lesion revisualized, stable 4a FCC

BI-RADS, Breast Imaging Reporting and Data System; Bx, biopsy; calcs, calcifications; DCIS, ductal carcinoma in situ; FCC, fibrocystic change; Fup, follow-up; mammo, mammogram; MRI, magnetic resonance imaging; NME, nonmass enhancement.

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Follow-up—Malignancy

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Figure 3, Thirty-seven-year-old woman with a history of right ADH and a recently diagnosed right ductal carcinoma in situ who underwent a diagnostic breast MRI. (a) On sagittal dynamic contrast-enhanced breast MRI with subtraction, a 1.0-cm mass with type 3 kinetics was seen within the posterior right breast ( white arrow ). MRI-guided biopsy was recommended. (b) On sagittal dynamic contrast-enhanced right breast MRI with subtraction performed on the day of biopsy performed 2 weeks later, this lesion appeared to have resolved ( white arrow ); the MRI biopsy was thus canceled. On review, it is likely that compression, as well as grid positioning factors, in light of the far posterior location of the lesion, contributed to nonvisualization. (c) Sagittal dynamic contrast-enhanced right breast MRI with subtraction performed 6 months later revealed a conspicuous 1.0-cm mass within the posterior right breast ( white arrow ). A mammogram performed on the same day showed new calcifications that correlated with the mass; a stereotactic biopsy was performed, yielding ductal carcinoma in situ with microinvasion. MRI, magnetic resonance imaging.

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Discussion

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TABLE 3

Frequency of Malignancy After Canceled MRI-guided Biopsy

Study/Year Number of Lesions Recommended for MRI-guided Biopsy Number (%) of Lesions Canceled Because of Nonvisualization Number of Lesions with Fup Imaging Number of Lesions with Pathology Fup Reported Median Fup Times Number (%) of Malignancies in Ipsilateral Quadrant Malignant Pathology Perlet et al. (2002) 413 46 (10) 46 0 1–4 d 0 (0) Hefler et al. (2003) 291 37 (13) 29 0 4–24 h 3 (10) One IDC and one ILC on short-term follow-up without compression; one IDC after biopsy on the day of the scheduled biopsy, despite the lack of contrast enhancement Liberman et al. (2005) 112 14 (13) 13 0 5 mo 0 (0) Viehweg et al. (2006) 83 10 (10) 10 0 6 mo 0 (0) Han et al. (2008) 172 22 (13) 18 0 Not reported 0 (0) Brennan et al. (2011) 911 74 (8) 58 3 12 mo 1 (2) One DCIS after mastectomy Johnson et al. (2013) 117 15 (13) 11 3 19.5 mo 0 (0) Niell et al. (2014) 445 56 (13) 41 8 154 d 5 (10) One IDC and one DCIS after mastectomy, one IDC after excisional biopsy, and one IDC and one DCIS on follow-up at 6 wk and 6 mo This study (2017) 1403 89 (6) 54 0 21.9 mo 1 (2) One DCIS on follow-up at 6 mo

DCIS, ductal carcinoma in situ; Fup, follow-up; IDC, invasive ductal carcinoma; ILC, invasive lobular carcinoma; MRI, magnetic resonance imaging.

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Academic Radiology, Volume 25, Issue 9
Journals General Radiology
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