Breast cancer is the most common cancer of American women and the second most common cause of cancer deaths.

Breast cancer is the most common cancer of American women and the second most common cause of cancer deaths. Extensive breast screening programs are currently effective worldwide. Mammography is the only imaging modality with proven effectiveness in the early detection of clinically occult breast cancer and remains the primary imaging modality for breast cancer screening.

Mammography however suffers with limitations in its ability to detect cancer with a reported sensitivity estimated at 80-85%. This limitation is often due to the obscuration of the tumor by superimposed fibroglandular tissue. Limitations in sensitivity have stimulated the evaluation of adjunctive imaging modalities for breast cancer screening. Breast MRI is one of these imaging tools.

The sensitivity for breast MRI in the detection of invasive breast cancers larger than 3 mm approaches 100%. There is greater variability in the sensitivity in the detection DCIS which ranges from 40-100%.

The main strengths of MRI include its exquisite delineation of soft tissue and its ability to image the breast in fine sections dynamically and in multiple planes thereby providing four-dimensional information. The basis of MR enhancement of breast cancer relates to vascularity of lesions and vessel permeability. Invasive breast cancer shows increased vascularity with an increased permeability of this neovascularity leading to an early uptake and early washout phenomenon. Invasive breast cancers tend to have increased vascularity at the periphery leading to a rim-enhancing pattern of lesions. The pattern of enhancement of DCIS can be variable including both ductal and regional enhancement.

Over the last 20 years, advances have been made in the field of breast MRI, however, even today there is no well-defined standard or optimal imaging technique for performing contrast-enhanced breast MRI . Additionally, there are no standardized interpretation criteria and no unified definition of what constitutes clinically important contrast enhancement.

Over the years, there have been 2 major approaches to image interpretation: 1) evaluation of enhancement kinetics or patterns of contrast enhancement 2) evaluation of lesion morphology or appearance. Early researchers from Europe demonstrated that malignant lesions consistently enhance and do so earlier and to a greater degree than benign lesions. Many authors utilized a quantitative approach to kinetic evaluation or enhancement patterns. Others have used a qualitative method for evaluation of the overall shape of the enhancement curve when attempting to distinguish benign from malignant lesions.

Three types of time/enhancement intensity curves have been described. Type I: steady enhancement where a persistent increase in signal intensity is present after 2 minutes . Type II: plateau, where the maximum signal intensity is achieved in 2 minutes and remains constant. Type III: washout, where the maximum achieved signal is demonstrated by 2 minutes and decreases with time. Benign lesions tend to demonstrate Type I curve and malignant lesions Type III.

Lesion morphology or architectural features identified on high spatial resolution images have been used to characterize lesions as to benign or malignant. Features that have been reported as suggestive of malignancy include a mass with irregular or spiculated borders and peripheral or ductal enhancement. Features of benignity include a mass with smooth or lobulated borders, no enhancement, nonenhancing internal septa and patchy parenchymal enhancement. In mammography, lesion margins represent the interface between the lesion and the adjacent parenchyma. The margin interface on MRI represents the interface between the area of vascularity and the surrounding tissue. It cannot be assumed that the mammographic features will necessarily be the same on mammography and MRI.

At the Center for Breast Care we have been performing breast MRI since 2000. We believe an integrated interpretation strategy where enhancement kinetics and morphologic features are used together obtaining superior outcomes compared to the use of either method alone. Despite the fact that there are differing approaches, there is still universal agreement that breast MRI is an extremely sensitive imaging technique for the detection of breast cancer.

Clinical Indications for Breast MRI

Invasive Lobular Cancer : This insidious cancer, difficult to detect by mammography and physical exam is commonly extensive, mutifocal or multicentric and can be bilateral in 10%. Patients with invasive lobular cancer more often have positive margins after lumpectomy. This potentially can be avoided with knowledge gained from preoperative breast MRI.

Breast Cancer Staging : One of the most common indications for breast MRI in our practice is for preoperative staging prior to lumpectomy. The extent of disease and its location is the effected breast and occult disease in the opposite breast will be found. 11% of patients can be expected to have unanticipated cancer in the opposite breast and 18% in the ipsilateral breast. We have found this exam will alter the treatment management in 25% of patients. MRI has a very high negative predictive value meaning that a negative breast MRI significantly improves the confidence that there is no occult invasive cancer in the ipsilateral or contralateral breast.

Occult Breast Cancer : Less than 1% of breast cancers present with malignant axillary nodes but without knowledge of the origin in the breast with normal breast exam and mammography. As the primary tumor is occult, standard treatment has been mastectomy. MRI has successfully located 75% of the primary breast cancers , which can allow treatment with breast conservation surgery.

Positive Surgical Margins : Incomplete resection of tumor results in positive surgical margins in a number of patients post lumpectomy requiring additional resection. MRI can locate residual and or additional tumor for surgical planning.

Neo-Adjuvant Chemotherapy : MRI can document tumor response to chemotherapy both with regards to size and tumor perfusion. Viable tumor however may remain with no abnormal enhancement after chemotherapy.
Post-operative scar vs. tumor recurrence : At 9 months or more after surgery, a mature scar, which may simulate cancer morphologically, does not enhance. Recurrent tumor shows the typical enhancement pattern and will be suspect on MRI.

Implants and known or suspected cancer : The diagnostic capabilities of MRI and ultrasound are not affected by the presence of implants as mammography is known to be. This permits more complete and accurate diagnosis and biopsy planning as needed.

Breast Cancer Screening: Although not currently practiced, several investigational studies are underway evaluating the efficacy of breast MRI in the diagnosis of unsuspected cancer in patients considered at high risk. Patients with a proven predisposition or a strong family history of breast cancer are at increased risk at a much younger age than the general population. Additionally, several pathologies result in increased risk of breast cancer development. These include such diagnosis as atypical ductal hyperplasia, lobular carcinoma insitu, and radial scar. Chest wall mantle radiation to the chest or mediastinum such as performed in patients with lymphoma can increase the risk to develop breast cancer. Certainly, the woman at greatest risk to develop new breast cancer is the patient with a history of breast cancer. In the next year, we would hope to be involved in a clinical investigational study, which would determine the incremental value of breast MRI over clinical exam and mammography in the detection of unsuspected breast cancer in the high-risk woman.

MRI Guided Breast Biopsy

As previously stated, breast MRI has become increasingly important in the detection and delineation of breast cancer in our practice. Many studies and our own experience show that MRI can reveal lesions that are both sonographically and mammographically occult. It is clearly the responsibility of the radiologist not only to detect and classify sub clinical lesions but also to ensure their accurate histologic verification. As tissue diagnosis of suspicious lesions is often required, the ability to perform MR guided breast biopsy or localization is an integral component of a dedicated breast MRI imaging program.

Since 2003, the Center for Breast Care has had the ability to perform MRI guided vacuum assisted breast biopsy utilizing a specialized MR compatible system (SUROS/ADEC). We believe we are able to deliver quantitatively and qualitatively satisfactory tissue specimens similar to the results we have achieved over the years with stereotactic and ultrasound guided breast biopsy. With our localization and biopsy equipment we also have the capability to place a tissue marker at the end of the procedure to document the location of the biopsy, being visible on conventional mammography.

We have encountered several technical challenges when performing MRI guided breast biopsy. There may be variation in the appearance of the lesion seen at the time of biopsy and the diagnostic MRI exam. This may be due to variation in positioning, compression of the breast or phase in the menstrual cycle. If the lesion cannot be definitively identified for biopsy, a follow-up exam is recommended.

Posterior and medial lesions have in the past been difficult to approach on MRI guided breast biopsy. However, with the acquisition of new localization technology (MRI Devices) there should be few inaccessible lesions in the future.

Another unique problem faced by the physician performing MRI guided breast biopsy is the "vanishing target" or the fading lesion visibility over time after Gadolinium injection. This should not be a problem once the stereotactic coordinates have been determined for the lesion assuming no lesion movement. Confirmation of needle positioning may be difficult particularly with small lesions due to the signal void artifact caused by the large core biopsy system.

As with any other clinically or technically challenging procedure, the patient should seek out that professional team with the most experience and dedication . At the Center for Breast Care we believe MRI is a relatively new imaging technique which allows almost unlimited sensitivity for the diagnosis of invasive breast cancer. However, this tool can best be used to the advantage of the patient if the small equivocal lesions detected become amenable to histologic evaluation. We have worked hard to bring forward an accurate safe and available program for our patients and their physicians.



American College of Radiology Imaging Network 6667 Research Protocol

We are very excited to have received approval to participate in the American College of Radiology Imaging Network 6667 Research Protocol in February of 2004, "MRI Evaluation of the Contralateral Breast in Women with a Recent Diagnosis of Breast Cancer". We are one of 22 sites in th USA, Canada and Europe who look to evaluate 1000 women.

The primary aim of this study is to determine how frequently patients with a known cancer of one breast are found by MRI to have cancer in the contralateral breast. All women will undergo MR evaluation of the contralateral breast within 60 days of diagnosis of breast cancer. Truth regarding breast cancer status will be determined through the results of a breast biopsy or as a result of a 24 month follow up without clinical evidence of disease.

Secondary aims include assessing sensitivity, specificity and positive predictive values and ROC curves of MRI in evaluating the contralateral breast in women with recent diagnosis of breast cancer. In addition, preliminary evaluation of the influence of breast mammographic density, age, and tumor histology on the yield of MRI will be performed.

Eligibility criteria include:

1. Women > 18 years of age

2. Recent history of unilateral breast cancer in the non-study breast, DCIS or invasive cancer within 60 days prior to MRI.

3. Negative clinical exam and mammogram of the study breast within 90 days of MRI and no new clinical symptoms.

4. No history of breast biopsy of the study breast within 6 months.

5. No current or recent history of chemotherapy for cancer.

6. Signed study informed consent prior to registration.

7. No contraindication to MRI.

8. No current history of hormonal therapy, tamoxifen or aromatase inhibitors for therapeutic measures.

9. No prior MRI of study breast within 12 months prior to study MRI.

10. No initial biopsy proven breast cancer diagnosis in either breast more than 60 days prior to the MRI.

We believe the results of such a study will positively affect patient care in our own community and across the world in the future and hope to accrue significant numbers of patients with the help of members of our medical community.

Breast Cancer: MRI

Breast MRI (magnetic resonance imaging) is a test that may be used to distinguish between benign (noncancerous) and malignant (cancerous) lesions. Performing this test may reduce the number of breast biopsies done to evaluate a suspicious breast mass. Although MRI can detect tumors in dense breast tissue, it cannot detect tiny specks of calcium (known as microcalcifications), which account for half of the cancers detected by mammography.

Is the Breast MRI Test Safe?
Yes. MRI examination poses no risk to the average patient if appropriate safety guidelines are followed.

People who have had heart surgery and people with the following medical devices can be safely examined with MRI:
Surgical clips or sutures.
Artificial joints.
Staples.
Most heart valve replacements.
Disconnected medication pumps.
Vena cava filters.
Brain shunt tubes for hydrocephalus.

Some conditions may make an MRI examination inadvisable. Tell your doctor if you have any of the following conditions:

• Heart pacemaker
• Cerebral aneurysm clip (metal clip on a blood vessel in the brain)
• Implanted insulin pump (for treatment of diabetes), narcotics pump (for pain medication), or implanted nerve stimulators ("TENS") for back pain
• Metal in the eye or eye socket
• Cochlear (ear) implant for hearing impairment
• Implanted spine stabilization rods
• Severe lung disease
• Uncontrolled gastroesophageal reflux (a condition causing severe heartburn)
• In addition, tell your doctor if you:
  Are pregnant.
• Weigh more than 300 pounds.
• Are not able to lie on your back for 30 to 60 minutes.
• Have claustrophobia (fear of closed or narrow spaces).

How Long Is the Breast MRI Test?
Allow 1 1/2 hours for your MRI exam. In most cases, the procedure takes 45 to 60 minutes, during which time several dozen images may be obtained.

What Happens Before the Exam?
Personal items such as your watch, wallet -- including any credit cards with magnetic strips (they will be erased by the magnet) -- and jewelry should be left at home if possible, or removed prior to the MRI scan. Hearing aids should be removed before the test since they can be damaged by the magnetic field. Secured lockers are typically available to store personal possessions.

What Happens During the Exam?
You will be asked to wear a hospital gown during your breast MRI.
As the MRI scan begins, you will hear the equipment making a muffled thumping sound that will last for several minutes. Other than the sound, you should experience no unusual sensations during the scanning.
Certain MRI exams require that you receive an injection of a contrast material. This helps identify certain anatomic structures on the scan images.
Feel free to ask questions or tell the technologist or the physician if you have any concerns.
What Happens After the Exam?
Generally, you can resume your usual activities and normal diet immediately.
Your physician will discuss the test results with you.

What About After the Test?

There are no side- or after-effects with MRI, so you can resume your normal activities as soon as your exam is over. The radiologist will interpret your MRI scan and report the findings to your doctor.

How Do I Prepare for the Test?

No special preparation is required. You can eat and drink as you normally would, engage in regular activities, and take any prescription medication.
Plan to arrive about 30 minutes before your appointment time. You'll be asked to change into a gown since belts, zippers, snaps and thread in clothing may contain metal that disturbs MRI signals. We'll ask you questions before you enter the MRI exam room to confirm that you don't have any metal in or on your body. You'll have to remove all metallic objects such as jewelry, glasses, hairpins and dentures (personal belongings can be locked in a locker). Please be sure to tell the technologist if you have metal implants, a cardiac pacemaker, permanent dental bridges, braces or other metal objects.

What Is Magnetic Resonance Imaging?

MRI is a sophisticated technology that uses a computer, magnetic field and radio waves - instead of x-rays - to produce images of the soft tissues in the body. MRI has been safely used for decades to provide information to help in the early diagnosis and treatment of disease.
MRI of the breasts has emerged as a new technique in the evaluation of breast disease. When used in conjunction with conventional x-ray mammography, breast MRI can provide valuable information for the detection and characterization of breast disease. MRI doesn't replace mammography - it's a different imaging technique that provides additional information.
Nationally recognized breast centers currently perform breast MRI for a number of reasons including: · Diagnosis of breast implant rupture · Surgical planning· Staging of breast cancer and treatment planning · Post-surgery and post-radiation follow-up · Dense breast tissue evaluation · Monitoring of high-risk patients with a non-radiation alternative

MRI Breast Cancer Screening; Don’t Forget About Colon Cancer!

by Kevin Knopf, MDTuesday, April 3, 2007
An article on the use of MRI to detect breast cancer sparked a change in the American Cancer Society screening guidelines, and this will be a useful test – particularly in younger women where the ability of mammography to detect cancer is limited by the density of the breasts.We have been using MRI in breast cancer patients for several years now, and these new guidelines will help this use become more appropriate. It is a welcome change.But the American Cancer Society guidelines reminded me again about another screening test – Colonoscopy. The very word strikes fear in many people; but now is a good time to reiterate what a great and important test a screening colonoscopy is.
Colon cancer is the second most common cancer and the second most common cause of cancer death in women who don’t smoke. And there is very effective screening available for colon cancer. A screening colonoscopy is a potentially embarrassing thing, but getting over that embarrassment and having one is a great thing to do.Not only can colonoscopy tell you if you are free of colon cancer, or detect colon cancer at an earlier and more curable stage – it can do something even better – it can prevent colon cancer. We estimate it can take 10 years from the start of a polyp in the colon to develop into a cancer – with a colonoscopy polyps can be detected, removed, and in effect cure you of colon cancer without requiring surgery. Thus it is a fabulous screening test. A little diarrhea the night before with the prep, the test is done under sedation the next day, a little embarrassment, and your fears of developing colon cancer can be allayed.The American Cancer Society recommends screening starting at age 50 – the American Gastroenterology Society recommends that African Americans start screening at 45. If you have had a relative with colon or rectal cancer you should start screening at roughly 10 years before that relative's cancer was diagnosed.Sadly, many of my breast cancer patients put off getting a colonoscopy. I can understand why, but if you’ve gone through so much to cure yourself of breast cancer, consider how little you need to go through to prevent yourself from getting colon cancer.

Should MRI Be Performed to Detect Contralateral Breast Cancer?

MRI appears useful in detecting occult contralateral tumors in women recently diagnosed with breast cancer.
Women with a diagnosis of unilateral breast cancer have increased risk for developing cancer in the other breast. Investigators at 25 U.S. sites assessed the role of contralateral breast magnetic resonance imaging in women with recently diagnosed breast cancer who had had normal clinical and mammographic findings in the contralateral breast within 90 days of study enrollment. Contralateral breast MRI was performed no later than 2 months after diagnosis, and cancer status was followed for 1 year after the study MRI.
Of the 969 evaluable women (mean age, 53 years; 91% white; 80% with no family history of breast cancer), 121 women underwent recommended biopsies based on positive MRI findings. As a result, 30 tumors were detected, including 18 invasive carcinomas and 12 ductal carcinomas in situ (DCIS). Three additional contralateral breast cancers were diagnosed within 1 year of study entry. These three tumors, which represent false-negative MRI findings, were all DCIS (diameter range, 1–4 mm). The diagnostic yield of contralateral breast MRI was 3.1%, with an estimated sensitivity of 91% and a specificity of 88%. The negative predictive value of MRI was 99%, and the estimated positive predictive value was 21%.
Comment: In this landmark study, the estimated risk for detection of contralateral breast cancer 1 year after a negative breast MRI was well under 1%, and the few contralateral tumors to be detected at that time were small and contained. Thus, for a woman recently diagnosed with unilateral breast cancer and considering contralateral prophylactic mastectomy, negative MRI findings might provide sufficient reassurance to forgo this surgery. An editorialist notes that the American Cancer Society now recommends breast MRI for women with a 20% or greater lifetime risk for breast cancer. The ACS also states that there is insufficient evidence to make a recommendation for or against MRI screening for women with a personal history of breast cancer or for those with radiologically dense breasts (CA Cancer J Clin 2003; 53:141). As breast MRI becomes more widely available, clinicians and patients should recognize that the quality of such examinations varies widely. Furthermore, some facilities offer breast MRI but lack the means to perform biopsies of abnormalities detected with this technology. The ACS guidelines recommend that breast MRI should not be performed in this setting.
— Andrew M. Kaunitz, MD
Published in Journal Watch Women's Health March 29, 2007

Breast Imaging: Current Trends and Future Applications

Terry Duggan-Jahns, RT(R)(CT)(MR)(M)
*Manager, Outpatient Diagnostic Imaging, St. Joseph Medical Center, Tacoma, Washington. Address correspondence to: Terry Duggan-Jahns, RT(R)(CT)(MR)(M), Manager, Outpatient Diagnostic Imaging, St. Joseph Medical Center, 1717 South J Street, Tacoma, WA 98401. E-mail: tdugganjahns@mac.com.
Breast cancer is the most common cancer in women after skin cancer; 1 in 7 women will be diagnosed with breast cancer in her lifetime. The American Cancer Society (ACS) estimates that there are 213 000 new cases per year and that the disease accounts for 41 000 deaths per year in the United States. Of these new cases, the ACS estimates that only 63% will be diagnosed at the localization stage when the survival rate is 97%.1 Recent advancements in breast imaging technology have improved the ability to find breast cancer earlier when it is most treatable, helped to distinguish cancerous lesions from benign lesions, shown the true extent of the disease for surgical and therapeutic planning, and assisted in the treatment and follow-up management of patients with breast cancer.
Analog (Film-Screen) MammographyMammography imaging technology debuted in the late 1960s and remains the gold standard for breast cancer detection today. Mammography imaging technology can reliably image calcifications, which are often associated with early stage breast cancers such as ductal carcinoma in situ. The decline in mortality for breast cancer has been attributed to early detection through screening mammography and improved therapy. Age 40 is the recommended age for breast cancer screening and, because of the growing population of women over 40, every year more women are getting annual mammograms, according to the National Research Council.2
Full-Field Digital MammographyPublished in the New England Journal of Medicine in October 2005, the Digital Imaging Screening Trial found that digital mammography is a better imaging tool and more accurate than conventional film mammography in: (1) women under the age of 50 years; (2) women who are premenopausal or perimenopausal of age; and (3) women with radiographically dense breasts.3 The examination time is decreased and it provides the radiologist with higher quality images than analog film-screen mammography. Most mammograms are still performed on analog systems. It is estimated that less than 10% of all mammograms currently use digital mammography technology, but its availability to patients is expected to increase in the future.3
Magnetic Resonance Imaging Magnetic resonance imaging (MRI) of the breast was approved in 1991 by the US Food and Drug Administration (FDA) as a supplemental tool to mammography to aid in the diagnosis of breast cancer.4 It is the second fastest growing MRI procedure in the United States. MRI is considered a problem-solving technology, especially for patients with very dense breasts, those who have suspected lesions found on mammography or ultrasound, and patients with augmented breasts. It is highly sensitive to small abnormalities that can sometimes be missed with other breast imaging techniques. It can also help determine the type of surgery (lumpectomy or mastectomy) indicated when breast cancer is found. There are limitations with MRI because it cannot image calcifications, which are tiny calcium deposits that can indicate breast cancer.
Historically, MRI breast imaging guidelines were as follows4:
Suspicious mass found on mammography and ultrasound imaging
Positive axillary nodes—negative mammograms and ultrasound-unknown primary
High-risk factors—known BRCA1 or BRCA2 genetic mutation
Extremely dense breasts—on mammography
Staging/treatment planning-known cancer—bilateral study; 5% will have contralateral involvement
Management of known breast cancer—follow-up chemotherapy or radiation therapy
Implant rupture, implant integrity
For women at average risk, the ACS recommends getting annual mammograms and breast examinations by a physician, beginning at age 40. The ACS recently recommended that high-risk women should begin getting MRIs and mammograms at age 30.5
The new guidelines for MRI breast imaging published by the ACS recommends MRI breast screening of high-risk patients, in addition to mammograms for women who meet at least 1 of the following criteria:
BRCA1 or BRCA2 mutation
First-degree relative (eg, parent, sibling, or child) with a BRCA1 or BRCA2 mutation, even if they have yet to be tested themselves
Lifetime risk of breast cancer scored at 20% to 25% or greater based on one of several accepted risk assessment tools that look at family history and other factors
Radiation to the chest between the ages of 10 and 30
Li-Fraumeni syndrome, Cowden syndrome, Bannayan-Riley-Ruvalcaba syndrome, or a history of one of these syndromes in a first-degree relative
The disadvantages of MRI breast imaging are that it remains an expensive imaging modality and it is not always readily available.
Click here to see MRI breast images
Magnetic Resonance Imaging-Guided Breast BiopsyMRI-guided breast biopsy vacuum-assisted technique has been proven to be a beneficial and successful option if a lesion cannot be identified or is not visible on ultrasound. This technique can be expensive because specialized equipment is needed and well-trained users are absolutely necessary.
Ultrasound and Ultrasound-Guided BiopsyUltrasound is increasingly being utilized to image the breast and guide biopsies (core and fine needle) of suspected breast cancer. It has excellent contrast resolution. Ultrasound is frequently used to evaluate breast abnormalities found on screening mammograms, diagnostic mammograms, or a physician-performed clinical breast examination. It can differentiate between solid and cystic lesions or lymph nodes. Limitations of ultrasound include a lack of good spatial resolution, its effectiveness is operator dependent, it cannot reliably detect calcifications, and the whole breast cannot be imaged at one time.
Breast-Specific Gamma ImagingBreast-specific gamma imaging (BSGI) is a functional imaging technique designed to assess changes in tissue function rather than in anatomical structure. It is most commonly used for patients who have equivocal mammography or ultrasound findings. It is also used to help determine the extent of breast cancer involvement and to help clarify lymph-node involvement.6 The breast is compressed between 2 camera heads and a small dose of radioactive material is injected intravenously (Sestamibi). BSGI is capable of helping to differentiate cancer from other structures.
Computer-Aided DetectionComputer-aided detection (CAD) technology uses a computer to provide a second read or assist radiologists in making an accurate diagnosis. CAD systems have been approved by the US FDA for use in mammography, lung computed tomography, virtual colonoscopy, and breast MRI. CAD systems for mammography became commercially available in June 1998. They help increase the sensitivity for detecting small lesions and calcifications in the breast. CAD systems used in MRI allow the radiologist to view up to 2000 images at one time. After the injection of contrast material and dynamic imaging, these systems color code the enhancement kinetics of various tissue areas of the breast. CAD systems help analyze enhancement patterns of tumor angiogenesis of invasive tumors versus normal fibroglandular tissue.
The Future of Breast Imaging: Where Are We Going?The following are new technologies that are emerging in breast imaging:
MRI breast spectroscopy—The June 2006 issue of Journal of Radiology reported on a preliminary study by Memorial Sloan-Kettering Cancer Center in New York about the potential of using MRI breast spectroscopy. Researchers found that patients with proven positive biopsies had an elevated choline marker on magnetic resonance spectroscopy imaging mapping. This study also indicated the potential of utilizing magnetic resonance spectroscopy to eliminate the need for conventional breast biopsy techniques in the future.7
Positron emission tomography (PET) imaging, PET mammography (PEM), and PET/CT—These are currently the most useful noninvasive tests for staging or restaging breast cancer and monitoring metastatic disease throughout the whole body. A few research centers across the country are evaluating dedicated PEM devices that may potentially improve the identification of small breast cancers.8 This technology has the potential to detect breast cancers as small as 2 mm. Additionally, new PET targeting agents other than fluorodeoxyglucose are currently being developed.
Digital breast tomosynthesis (DBT) is an emerging imaging technology that is a cross between mammography and CT, which provides a 3-dimensional, digital X ray of the breast. This imaging technology allows the radiologist to look at slices or individual layers of the breast. DBT takes multiple X-ray pictures of each breast from many angles. The goal is to overcome patient discomfort from compression, detect cancer hiding within overlapping tissue, and reduce the number of views needed. Early results with DBT have shown promise. Researchers believe that this new breast imaging technique will make it easier to see breast cancers in dense breast tissue and make breast screening more comfortable.9
Breast Imaging Informational Web Sites
http://www.breastcancer.org/
http://www.cancernews.com/
http://www.cancer.org/
http://www.womenshealth.gov/
ConclusionsContinuously emerging advancements in breast imaging technology present new challenges and possibilities for the field of radiology. Such innovations in technology are helping clinicians detect and diagnose breast cancer in its earliest stage, thus saving the lives of countless women yearly. Recent revision of ACS breast cancer early detection guidelines for MRI breast imaging have been a critical step for screening of high-risk patients.
As the population of women over the age of 40 continues to grow, it will create more of a demand for breast imaging. There will also be more of a demand for highly trained, dedicated, experienced, and skilled radiologists and technologists to specialize in this imaging arena. Currently, there is a shortage of breast imagers. The Institute of Medicine and the National Research Council report that there are approximately 20 000 radiologists in the United States who can interpret mammograms, but only 2000 actually subspecialize in the field of breast imaging. The American Registry of Radiologic Technologists Web site reports that there are 47 384 technologists with advanced certification in mammography imaging.2 These glaring statistics beg the question: Will we be prepared to accept the future challenges presented to us?
References1. American Cancer Society. Available at: http://www.cancer.org/. Accesssed November 13, 2006.
2. Orenstein BW. Happily ever after. Radiology Today. Available at: http://www.radiologytoday.net/archive/rt31306p34.shtml. Accessed November 13, 2006.
3. Pisano ED, Gatsonis C, Hendrick E, et al. Diagnostic performance of digital versus film mammography for breast-cancer screening. N Engl J Med. 2005;353:1773-1783.
4. Imaginis. Breast cancer diagnosis. Available at: http://www.imaginis.com/breasthealth/mei.asp. Accessed November 13, 2006.
5. ACS advises MRIs for some at high risk of breast cancer. American Cancer Society Web site. Available at: http://www.cancer.org/docroot/NWS/content/NWS_1_1x_Society_Advises_MRIs_for_Some_Women_at_High_Risk_of_Breast_Cancer.asp. Accessed July 2, 2007.
6. Applied Radiology. October 2006 issue. Available at: http://www.appliedradiology.com/backissues/issue.asp?ID=160. Accessed November 13, 2006.
7. Bartella L, Morris EA, Dershaw DD, et al. Proton MR spectroscopy with choline peak as malignant marker improves positive predictive value for breast cancer diagnosis: preliminary study. Radiology. 2006;239:686-692.
8. Kumar R, Alavi A. Fluorodeoxyglucose-PET in the management of breast cancer. Radiolol Clin North Am. 2004;42:1113-1122, ix.
9. Breastcancer.org. Digital tomosynthesis. Available at: http://www.breastcancer.org/digital_tomosynthesis.html. Accessed November 13, 2006

Using MRI To Diagnose Breast Cancer In Its Intraductal Stage May Stem Development Of Invasive Cancer

By using MRI (magnetic resonance imaging) it may be possible to prevent the development of invasive cancer by diagnosing breast caner in its intraductal stage, according to an article in The Lancet. A Comment in The Lancet believes that these findings demonstrate that MRI should now be used as another method, in its own right, to detect early stage breast cancer. Professor Christiane Kuhl, Department of Radiology, University of Bonn, Germany, and team examined details on 7,319 women over a period of five years. They had all been referred to an academic breast center. As well as conventional mammography for diagnostic assessment and screening they all received MRI as well. The aim here being to find out how sensitive each method was in diagnosing DCIS (ductal carcinoma in situ). Different radiologists then assessed the mammograms and MRI scans. They assessed the relative sensitivity of each detection method by comparing the biological profiles of mammography-detected DCIS with those of MRI-detected DCIS. The scientists found that:-- Of 167 women who had a DCIS diagnosis, 92% were diagnosed with MRI-- Of 167 women who had a DCIS diagnosis, 56% were diagnosed by mammography-- MRI sensitivity for diagnosing DCIS increased with nuclear grade-- Mammography sensitivity for diagnosing DCIS decreased with nuclear grade-- Of 89 women with high grade DCIS diagnosis, 98% were diagnosed by MRI-- Of 89 women with high grade DCIS diagnosis, 52% were diagnosed by mammography-- 48% were missed by mammography but diagnosed by MRI aloneThe MRI's higher sensitivity was not linked to a significantly higher number of false positive diagnoses. "Our study suggests that the sensitivity of film screen or digital mammography for diagnosing DCIS is limited. MRI could help improve the ability to diagnose DCIS, especially DCIS with high nuclear grade," the authors conclude. "These findings can only lead to the conclusion that MRI outperforms mammography in tumour detection and diagnosis. MRI should thus no longer be regarded as an adjunct to mammography but as a distinct method to detect breast cancer in its earliest stage. A large-scale multicentre breast-screening trial with MRI in the general population is essential," Dr Carla Boetes and Dr Ritse Mann, Radboud University Nijmegen Medical Centre, Netherlands, wrote in the accompanying Comment. http://www.thelancet.comWritten by: Christian Nordqvist Copyright: Medical News Today Not to be reproduced without permission of Medical News Today

MRI Might Improve Breast Cancer Screening in High-Risk Women

Findings of a British study indicate that MRI might be a useful adjunct to mammography in high-risk women, especially those with BRCA1 mutations.
Women who are at high risk for breast cancer because of genetic predisposition are advised to have annual mammograms starting at age 30, but mammograms are relatively insensitive in young women with dense breasts. Contrast-enhanced magnetic resonance imaging (MRI) is more sensitive but less specific than mammography in such women.
Investigators in the U.K. performed 1881 paired mammograms and contrast-enhanced MRI studies on 649 asymptomatic women (age at entry, 31–55) with known BRCA1, BRCA2, or TP53 mutations or a strong family history of breast cancer. Suspicious findings were evaluated until malignancy was confirmed (35 exams) or excluded (244 exams).
MRI was significantly more sensitive (77% vs. 40%) but less specific (81% vs. 93%) than mammography. Combined, the two tests had a sensitivity of 94% but a specificity of only 77%. When women or their first-degree relatives had BRCA1 mutations, MRI was much more sensitive than mammography (92% vs. 23%). In women with other risk factors, MRI was not significantly more sensitive than mammography.
Comment: Like results from two other studies (Journal Watch Oct 5 2004 and Journal Watch Aug 10 2004), these results suggest that MRI might be a useful adjunct for breast cancer screening in high-risk women, particularly those with BRCA1 mutations. Because no evidence yet exists showing that MRI screening will reduce breast cancer mortality in this population, the uncertain value of MRI must be weighed against its high cost and the excess diagnostic procedures that result from its lower specificity.
— Bruce Soloway, MD
Published in Journal Watch General Medicine June 21, 2005