Rationale and Objectives
The BI-RADS Atlas 5th Edition includes screening breast magnetic resonance imaging (MRI) outcome benchmarks. However, the metrics are from expert practices and clinical trials of women with hereditary breast cancer predispositions, and it is unknown if they are appropriate for routine practice. We evaluated screening breast MRI audit outcomes in routine practice across a spectrum of elevated risk patients.
Materials and Methods
This Institutional Review Board-approved, Health Insurance Portability and Accountability Act-compliant retrospective study included all consecutive screening breast MRI examinations from July 1, 2010 to June 30, 2013. Examination indications were categorized as gene mutation carrier (GMC), personal history (PH) breast cancer, family history (FH) breast cancer, chest radiation, and atypia/lobular carcinoma in situ (LCIS). Outcomes were determined by pathology and/or ≥12 months clinical and/or imaging follow-up. We calculated abnormal interpretation rate (AIR), cancer detection rate (CDR), positive predictive value of recommendation for tissue diagnosis (PPV2) and biopsy performed (PPV3), and median size and percentage of node-negative invasive cancers.
Results
Eight hundred and sixty examinations were performed in 566 patients with a mean age of 47 years. Indications were 367 of 860 (42.7%) FH, 365 of 860 (42.4%) PH, 106 of 860 (12.3%) GMC, 14 of 860 (1.6%) chest radiation, and 8 of 22 (0.9%) atypia/LCIS. The AIR was 134 of 860 (15.6%). Nineteen cancers were identified (13 invasive, 4 DCIS, two lymph nodes), resulting in CDR of 19 of 860 (22.1 per 1000), PPV2 of 19 of 88 (21.6%), and PPV3 of 19 of 80 (23.8%). Of 13 invasive breast cancers, median size was 10 mm, and 8 of 13 were node negative (61.5%).
Conclusions
Performance outcomes of screening breast MRI in routine clinical practice across a spectrum of elevated risk patients met the American College of Radiology Breast Imaging Reporting and Data System benchmarks, supporting broad application of these metrics. The indication of a personal history of treated breast cancer accounted for a large proportion (42%) of our screening examinations, with breast MRI performance in this population at least comparable to that of other screening indications.
Introduction
Breast magnetic resonance imaging (MRI) is currently the most sensitive imaging test for identifying breast cancer, and detects malignancy that is occult to the clinical examination and other imaging modalities . Several prospective studies have demonstrated an increase in the detection of breast cancer with breast MRI over mammography alone in patients with a familial or genetic predisposition for breast cancer . This has led to a rapid increase in the use of breast MRI across the country , particularly in those patients at high risk for the development of breast cancer .
In 2007, the American Cancer Society (ACS) published the first guidelines for breast MRI as an adjunct to mammography to screen patients for breast cancer . These guidelines recommend screening breast MRI in patients with a known genetic predisposition to breast cancer (BRCA mutation or Li-Fraumeni, Cowden, Bannayan-Riley-Ruvalcaba syndromes and their first-degree relatives), a lifetime risk for breast cancer ~20%–25% or greater, and radiation to the chest between the ages of 10 and 30 years old . Similar guidelines were subsequently enacted by the American College of Radiology (ACR) and the National Comprehensive Cancer Network (NCCN) .
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Materials and Methods
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Breast MRI Indications
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Breast MRI Technique
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Breast MRI Interpretation and Data Collection
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Calculations
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Results
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TABLE 1
Screening Breast MRI Indications
Breast MRI Examination Indications Patients, N % Cancer Yield CDR PPV3 Genetic mutation carrier 106 12.3 1 Family history of breast cancer 367 42.7 6 Personal history of treated breast cancer 365 42.4 11 History of chest radiation 14 1.6 0 Prior biopsy with atypia or LCIS 8 0.9 1 Total screening 860 100.0 19 22.1 23.8
CDR, cancer detection rate (per 1000 examinations); LCIS, lobular carcinoma in situ; MRI, magnetic resonance imaging; PPV3, positive predictive value 3 (biopsy performed).
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TABLE 2
Breast MRI Screen Detected Cancers
Age Screening Indication Histology Location Invasive size (cm) Node status MRI Finding Type BI-RADS 1 51 Personal history Invasive recurrence Axillary node Positive Lymph node 0 2 41 Personal history IDC, ILC, DCIS Breast 1.3 Positive NME 4 3 55 Family history DCIS Breast N/A Mass 4 4 48 Family history DCIS Breast N/A Mass 4 5 59 Personal and Family history DCIS Breast N/A NME 4 6 62 Family history IDC Breast 0.5 Negative Mass 4 7 57 Personal history IDC, DCIS Breast 0.5 Positive Mass 4 8 55 LCIS IDC Breast 0.9 Negative NME 4 9 57 Family history IDC, DCIS Breast 0.4 Negative Mass 4 10 58 Personal history IDC Breast 0.4 Negative NME 4 11 43 Personal history IDC, DCIS Breast 2.2 Negative Mass 4 12 50 Gene mutation (BRCA1) DCIS Breast N/A NME 4 13 40 Family history IDC Breast 1 Positive Mass 4 14 60 Personal history IDC Breast 1.4 Positive Mass 4 15 54 Family history IDC Breast 1 Negative Mass 4 16 63 Personal history IDC Breast 1.9 Negative Mass 4 17 41 Personal history Invasive recurrence Internal mammary node Positive Lymph node 4 18 47 Personal history IDC Breast 0.8 Positive Mass 5 19 65 Personal history Invasive recurrence Chest wall 1.6 Negative Mass 5
BI-RADS, Breast Imaging Reporting and Data System; DCIS, ductal carcinoma in situ; IDC, invasive ductal carcinoma; ILC, invasive lobular carcinoma; MRI, magnetic resonance imaging; NME, nonmass enhancement; N/A, not applicable.
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TABLE 3
BI-RADS Edition 5 Breast MRI Screening Benchmarks
Category Benchmark ‘ Our Results Cancer detection rate (per 1000 examinations) 20–30 22.1 Median size of invasive cancers (in mm) TBD 10.0 Percentage of node-negative invasive cancers >80% 61.5% Percentage of minimal cancer \* >50% 70.6% (12 of 17) PPV2 (recommendation for biopsy) 15% 21.6% (19 of 88) PPV3 (biopsy performed) 20%–50% 23.8% (19 of 80)
BI-RADS, Breast Imaging Reporting and Data System; MRI, magnetic resonance imaging; PPV, positive predictive value; TBD, to be determined.
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Discussion
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Acknowledgments
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References
1. DeMartini W., Lehman C.: A review of current evidence-based clinical applications for breast magnetic resonance imaging. Top Magn Reson Imaging 2008; 19: pp. 143-150.
2. Kuhl C.: The current status of breast MR imaging. Part I. Choice of technique, image interpretation, diagnostic accuracy, and transfer to clinical practice. Radiology 2007; 244: pp. 356-378.
3. Lehman C.D., Isaacs C., Schnall M.D., et. al.: Cancer yield of mammography, MR, and US in high-risk women: prospective multi-institution breast cancer screening study. Radiology 2007; 244: pp. 381-388.
4. Kriege M., Brekelmans C.T., Boetes C., et. al.: Efficacy of MRI and mammography for breast-cancer screening in women with a familial or genetic predisposition. N Engl J Med 2004; 351: pp. 427-437.
5. Kuhl C., Weigel S., Schrading S., et. al.: Prospective multicenter cohort study to refine management recommendations for women at elevated familial risk of breast cancer: the EVA trial. J Clin Oncol 2010; 28: pp. 1450-1457.
6. Leach M.O., Boggis C.R., Dixon A.K., et. al.: Screening with magnetic resonance imaging and mammography of a UK population at high familial risk of breast cancer: a prospective multicentre cohort study (MARIBS). Lancet 2005; 365: pp. 1769-1778.
7. Lehman C.D., Blume J.D., Weatherall P., et. al.: Screening women at high risk for breast cancer with mammography and magnetic resonance imaging. Cancer 2005; 103: pp. 1898-1905.
8. Passaperuma K., Warner E., Causer P.A., et. al.: Long-term results of screening with magnetic resonance imaging in women with BRCA mutations. Br J Cancer 2012; 107: pp. 24-30.
9. Rijnsburger A.J., Obdeijn I.M., Kaas R., et. al.: BRCA1-associated breast cancers present differently from BRCA2-associated and familial cases: long-term follow-up of the Dutch MRISC Screening Study. J Clin Oncol 2010; 28: pp. 5265-5273.
10. Sardanelli F., Podo F., D’Agnolo G., et. al.: Multicenter comparative multimodality surveillance of women at genetic-familial high risk for breast cancer (HIBCRIT study): interim results. Radiology 2007; 242: pp. 698-715.
11. DeMartini W.B., Ichikawa L., Yankaskas B.C., et. al.: Breast MRI in community practice: equipment and imaging techniques at facilities in the Breast Cancer Surveillance Consortium. J Am Coll Radiol 2010; 7: pp. 878-884.
12. Elmore L., Margenthaler J.A.: Use of breast MRI surveillance in women at high risk for breast cancer: a single-institutional experience. Ann Surg Oncol 2010; 17: pp. 263-267.
13. Stout N.K., Nekhlyudov L.: Early uptake of breast magnetic resonance imaging in a community-based medical practice, 2000–2004. J Womens Health (Larchmt) 2011; 20: pp. 631-634.
14. 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: pp. 75-89.
15. Lee C.H., Dershaw D.D., Kopans D., et. al.: Breast cancer screening with imaging: recommendations from the Society of Breast Imaging and the ACR on the use of mammography, breast MRI, breast ultrasound, and other technologies for the detection of clinically occult breast cancer. J Am Coll Radiol 2010; 7: pp. 18-27.
16. National Comprehensive Cancer Network® : Genetic/Familial High-Risk Assessment: Breast and Ovarian. Version 2. 2016. NCCN Clinical Practice Guidelines in Oncology. Available at: http://NCCN.org Accessed July 18, 2016
17. National Comprehensive Cancer Network® : Breast Cancer Screening and Diagnosis. Version 1.2015. NCCN Clinical Practice Guidelines in Oncology. Available at: http://NCCN.org Accessed July 18, 2016
18. National Comprehensive Cancer Network® : Breast Cancer. Version 2.2016. NCCN Clinical Practice Guidelines in Oncology. Available at: http://NCCN.org Accessed July 18, 2016
19. Lehman C.D., Lee J.M., DeMartini W.B., et. al.: Screening MRI in women with a personal history of breast cancer. J Natl Cancer Inst 2016; 108:
20. Niell B.L., Gavenonis S.C., Motazedi T., et. al.: Auditing a breast MRI practice: performance measures for screening and diagnostic breast MRI. J Am Coll Radiol 2014; 11: pp. 883-889.
21. Ikeda D.M., Hylton N.M., Kuhl C.K., et. al.: BI-RADS: magnetic resonance imaging.D’Orsi C.J.Mendelson E.B.Ikeda D.M. et. al.Breast imaging reporting and data system: ACR BI-RADS—breast imaging atlas.2003.American College of RadiologyReston, VA:
22. D’Orsi C.J., Sickles E.A., Mendelson E.B., et. al.: ACR BI-RADS® atlas, breast imaging reporting and data system.2013.American College of RadiologyReston, VA
23. Sickles E.A., D’Orsi C.: Follow-up and outcome monitoring.ACR BI-RADS® atlas, breast imaging and reporting and data system.2013.American College of RadiologyReston, VA:
24. American College of Radiology : Breast magnetic resonance imaging (MRI) accreditation program requirements. Available at: http://www.acraccreditation.org/~/media/ACRAccreditation/Documents/Breast-MRI/Requirements.pdf?la=en Accessed December 14, 2015
25. Carney P.A., Parikh J., Sickles E.A., et. al.: Diagnostic mammography: identifying minimally acceptable interpretive performance criteria. Radiology 2013; 267: pp. 359-367.
26. Carney P.A., Sickles E.A., Monsees B.S., et. al.: Identifying minimally acceptable interpretive performance criteria for screening mammography. Radiology 2010; 255: pp. 354-361.
27. Rosenberg R.D., Yankaskas B.C., Abraham L.A., et. al.: Performance benchmarks for screening mammography. Radiology 2006; 241: pp. 55-66.
28. Ehsani S., Strigel R.M., Pettke E., et. al.: Screening magnetic resonance imaging recommendations and outcomes in patients at high risk for breast cancer. Breast J 2015; 21: pp. 246-253.
29. Warner E., Plewes D.B., Hill K.A., et. al.: Surveillance of BRCA1 and BRCA2 mutation carriers with magnetic resonance imaging, ultrasound, mammography, and clinical breast examination. JAMA 2004; 292: pp. 1317-1325.
30. Kuhl C.K., Schrading S., Leutner C.C., et. al.: Mammography, breast ultrasound, and magnetic resonance imaging for surveillance of women at high familial risk for breast cancer. J Clin Oncol 2005; 23: pp. 8469-8476.
31. Sickles E.A., D’Orsi C.: Follow-up and outcome monitoring.ACR BI-RADS® atlas, breast imaging and reporting and data system.2013.American College of RadiologyReston, VA: Footnote (a), page 27
32. Morris E.A., Comstock C.E., Lee C.H., et. al.: ACR BI-RADS® magnetic resonance imaging.ACR BI-RADS® atlas, breast imaging reporting and data system.2013.American College of RadiologyReston, VA:
33. Berg W.A.: Tailored supplemental screening for breast cancer: what now and what next?. AJR Am J Roentgenol 2009; 192: pp. 390-399.
34. Lee C.I., Ichikawa L., Rochelle M.C., et. al.: Breast MRI BI-RADS assessments and abnormal interpretation rates by clinical indication in US community practices. Acad Radiol 2014; 21: pp. 1370-1376.
35. Schacht D.V., Yamaguchi K., Lai J., et. al.: Importance of a personal history of breast cancer as a risk factor for the development of subsequent breast cancer: results from screening breast MRI. AJR Am J Roentgenol 2014; 202: pp. 289-292.
36. Brennan S., Liberman L., Dershaw D.D., et. al.: Breast MRI screening of women with a personal history of breast cancer. AJR Am J Roentgenol 2010; 195: pp. 510-516.