HomeAbout UsLocationsContact UsOur PhysiciansLinksNewsEmployment
  

Many challenges remain to improve the detection of breast cancer, and guiding appropriate therapy. Despite the effectiveness of mammography and ultrasound in the diagnosis of breast cancer, mammography may miss 15% of breast cancers. This is particularly true in patients with dense breasts. Additional challenges for early detection are presented with the identification of high risk patients such as those with lobular carcinoma in situ (LCIS) or brca1 and brca2 genetic markers. Challenges also remain to insure negative surgical margins, reduce local recurrence rates and appropriately select patients for lumpectomy or mastectomy depending on histology and local staging.

Breast MRI has now matured to be able to play an increasing role worldwide in these situations.

click on picture to view full size

Maximum intensity projection of an enhancing mass of the breast (dense white oval on left side of image)

Technical Details

The detection of breast cancer with MRI is based on the fact that nearly 100% of invasive cancers will enhance with the administration of I.V. gadolinium. This is probably on the basis of invasive tumor angiogenesis. The true false negative rate however, is probably not known. For in situ cancers, MRI detects only 40-100% of lesions. The variability of sensitivity here reflects: the inclusion of some tumors with microinvasion, some series with small numbers of reported cases, and variable histology. Realistically, sensitivity for DCIS is probably in the 50% range (6,9).

In the past, the price for high sensitivity in detecting invasive cancer was suboptimal specificity. Normal breast tissue during late cycle and various benign breast pathologies demonstrate enhancement with MRI. Reported specificity rates of breast MRI are highly variable (37-97%), depending on the source and methodology. Improvements in specificity have recently been made. Morphologic analysis and enhancement kinetics are the two main methods of evaluation. Specificity of 83% has been achieved by Kuhl (2, 4) using a combination of these methods (91% sensitivity, 77% positive predictive value, 94% negative predictive value, accuracy 86%). Similar results have been shown by other groups.

Having established reasonable accuracy, the specific situations in which breast MRI may be utilized is growing. Of recent interest is the ability of breast MRI to improve cancer detection rates in high-risk patients such as those with BrCa1 and BrCa2 genetic markers. In these patients who do not elect preventive mastectomy, breast MRI is a surveillance option. Indeed, recent data from Kuhl (3) and others (7, 10) have shown increased detection rates of cancers in women who are Brca1 and Brca2 positive.

Additional proven areas of the utility of breast MRI include: discriminating post treatment change from tumor, the determination of multifocality, and more accurate assessment of the local extent of tumor (local staging) (1,8). Indeed, Weinstein (11) found that in patients with invasive lobular carcinoma, 39% of patients had more extensive disease at MRI than predicted through traditional methods.

References

  1. Frei K, et al. MR imaging of the breast in patients with positive margins after lumpectomy: Influence of the time interval between lumpectomy and MR imaging. AJR 2000; 175:1577
  2. Kuhl CK, et al, Dynamic gadolinium enhanced breast MR: Are signal intensity time course data useful for diagnosis?, Radiology 1999, 211:101
  3. Kuhl CK, et al, Breast MR imaging screening in 192 women proved or suspected to be carriers of a breast cancer susceptibility gene: Preliminary results. Radiology 2000, 215:267
  4. Kuhl CK, et al, Dynamic image interpretation of MRI of the breast. JMRI 2001, 12:965
  5. Kuhl CK, et al. Healthy premenopausal breast parenchyma in dynamic contrast enhanced MR imaging of the breast: Normal contrast medium enhancement and cyclical phase dependency. Radiology 1997; 203: 137-144
  6. Orel-Greenstein S, et al. MR imaging of ductal carcinoma in situ. Radiology 1997; 202:413
  7. Meijers-Heijjboer H, et al. Breast cancer after prophylactic bilateral mastectomy in women with a BrCa1 or BrCa2 mutation. NEJM 2001; 345:159-164
  8. Soderstrom CE, et al, Detection with MR imaging of residual tumor in the breast soon after surgery. AJR 1997, 168: 485
  9. Soderstrom CE, et al. Three-dimensional RODEO breast MRI imaging of lesions containing ductal carcinoma in situ. Radiology 1996; 201:427-432
  10. Stoutjesdijk MJ, et al. Magnetic resonance imaging and mammography in women with hereditary risk of breast cancer. JNCI 2001; 93(14):1095
  11. Weinstein S, et al. MR imaging of the breast in invasive lobular carcinoma. AJR 2001;176:399

Other Services


 
Core Biopsy
Stereotactic and ultrasound guided needle biopsy of the breast as an alternative to open surgical biopsy - Our experience at Dean - St. Mary's
 

 
Screening Mammography
Mammography saves lives: Current recommendations, questions and controversies
 

 
Breast Ultrasound
Breast ultrasound plays important role in distinguishing benign from possible cancerous lesions
 

 
Ductography
Procedure to evaluate cause of nipple discharge
 

 
Breast Sentinel Node Mapping
Allows less extensive lymph gland removal during surgery for breast cancer
 

 
MRI of the Pelvis
The role of MRI in benign and malignant disease of the uterus, cervix and ovaries