Best Practice Guidelines for Breast Imaging, Breast Imaging Society, India: Part—1

Breast imaging is one of the prerequisites for providing high quality breast health care. Choosing the appropriate investigation is central to diagnosing breast disease in women and men who present to health professionals for treatment. Patients with breast disease present to doctors of different subspecialties as well as general practitioners in our country. It is important therefore to provide uniform guidance to doctors in different health care setups of our country, urban and rural, government and private, for breast diseases to be diagnosed and treated optimally. These guidelines framed by the task group set up by the Breast Imaging Society, India have been formulated focusing primarily on the Indian patients and health care infrastructures. These guidelines aim to provide a framework for the referring doctors and practicing radiologists, to enable them to choose the appropriate investigation for patients with breast symptoms and signs. The aim has been to keep this framework simple and practical so that it can guide not only subspecialists in breast care but also help doctors who do not routinely deal with breast diseases, so that breast cancer is not missed. Overall, the aim of this document is to provide a holistic approach to standardize breast care imaging services in India. Part 1 of these guidelines focuses on the best practice principles for mammography, breast ultrasound and breast magnetic resonance imaging. In the absence of a population-based screening program in India, the guidelines to be followed for those women who wish to be screened by mammography have been provided. The key points of these guidelines include the recommendations that mammography is the modality of choice for breast screening and investigation of symptomatic women aged over forty years. Screening is advised annually from the age of forty. Ultrasound is the investigation of choice for pregnant and lactating women and women less than thirty years of age. For women between thirty to thirty-nine years of age, ultrasound can be used initially followed by mammography in presence of clinical or sonographic suspicion of breast cancer. All women diagnosed with breast cancer should have ultrasound and mammography. Breast MRI is useful for assessment of disease extent, problem solving, evaluation of response to neo-adjuvant chemotherapy, identifying occult breast primary and evaluation of augmented breasts.

Primary Angiosarcoma of the Breast: MRI Findings

We present image findings, especially rare MRI of a primary breast angiosarcoma with its histopathology, and also analyze the relevant medical literature reports in terms of the MRI findings. As our patient had unique features of a primary breast angiosarcoma, this case could be very helpful for future diagnosis of this rare breast malignancy by MRI.

Comparison of Cartesian and radial acquisition on short-tau inversion recovery (STIR) sequences in breast MRI / Comparação de aquisições cartesiana e radial nas sequências short tau inversion recovery (STIR) na RM de mama

Abstract Objective: The purpose of this study was to compare two short-tau inversion recovery (STIR) sequences, Cartesian and radial (BLADE) acquisitions, for breast magnetic resonance imaging (MRI) examinations. Materials and Methods: Ninety-six women underwent 1.5 T breast MRI exam (48 Cartesian and 48 BLADE). Qualitative analysis including image artifacts, image quality, fat-suppression, chest-wall depiction, lesion detection, lymph node depiction and overall impression were evaluated by three blinded readers. Signal to noise ratios (SNRs) were calculated. Cronbach's alpha test was used to assess inter-observer agreement. Subanalyses of image quality, chest-wall depiction and overall impression in 15 patients with implants and image quality in 31 patients with clips were correlated using Pearson test. Wilcoxon rank sum test and t-test were performed. Results: Motion artifacts were present in 100% and in 0% of the Cartesian and the BLADE exams, respectively. Chemical-shift artifacts were present in 8% of the Cartesian exams. Flow artifacts were more frequent on BLADE. BLADE sequence was statistically superior to Cartesian for all qualitative features (p < 0.05) except for fat-suppression (p = 0.054). In the subanalysis, BLADE was superior for implants and clips (p < 0.05). SNR was statistically greater for BLADE (48.35 vs. 16.17). Cronbach ranged from 0.502 to 0.813. Conclusion: BLADE appears to be superior to Cartesian acquisition of STIR imaging as measured by improved image quality, fewer artifacts, and improved chest wall and lymph node depiction.

Resumo Objetivo: Comparar duas sequências de aquisição, cartesiana e radial (BLADE) ponderadas em short-tau inversion recovery (STIR), em exames de ressonância magnética de mama. Materiais e Métodos: Noventa e seis pacientes foram submetidas a exame de ressonância magnética de mama em 1,5 T (48 aquisições STIR cartesianas e 48 aquisições STIR BLADE). A análise qualitativa incluindo artefatos, qualidade de imagem, supressão de gordura, avaliação da parede torácica, detecção de lesões, linfonodos e impressão geral foi avaliada independentemente por três leitores. Os signal to noise ratios (SNRs) foram calculados. Foi utilizado o teste alfa de Cronbach para avaliar a concordância interobservador. Subanálises da qualidade de imagem, avaliação da parede torácica e impressão geral em 15 pacientes com implantes e qualidade de imagem em 31 pacientes com clipes cirúrgicos foram correlacionadas aplicando o teste de Pearson. Os testes de Wilcoxon rank sum test e Student t foram utilizados para comparação qualitativa e quantitativa entre as duas sequências. Resultados: Os artefatos de movimento estavam presentes em 100% e 0% dos exames de aquisição cartesiana e de BLADE, respectivamente. Os artefatos de desvio químico estavam presentes em 8% dos exames cartesianos. Artefatos de fluxo foram mais frequentes nas sequências BLADE. A sequência BLADE foi estatisticamente superior para todos os atributos qualitativos (p < 0,05), exceto na supressão de gordura (p = 0,054). O BLADE foi superior na avaliação dos implantes e clipes cirúrgicos (p < 0,05). O SNR foi estatisticamente superior na sequência BLADE (48,35 versus 16,17). Cronbach variou entre 0,502 e 0,813. Conclusão: A sequência BLADE foi superior à sequência de aquisição cartesiana de imagens na ponderação STIR, comprovada por uma melhor qualidade de imagem, menos artefatos e melhor avaliação da parede torácica e de linfonodos.

Biopsias mamarias bajo resonancia magnética, experiencia preliminar / Breast biopsies performed under MRI, preliminary experience

La resonancia magnética (RM) mamaria se está convirtiendo en una herramienta de trabajo frecuentemente utilizada en nuestro medio. Existe un grupo de lesiones que sólo pueden ser identificadas por esta técnica, RMI only. Entre 14 a 20 por ciento de ellas serán malignas, según las diferentes series publicadas. Este tipo de lesiones requieren de biopsia guiada bajo RM. Pacientes y Métodos: se realizó revisión retrospectiva descriptiva de las biopsias asistidas por vacío realizadas en nuestra institución (período entre agosto de 2008 y junio de 2013). Resultados: El 0,3 por ciento (11) de las biopsias realizadas en nuestra institución fueron realizadas bajo RM, en 9 mujeres. En el 55 por ciento de los casos la indicación de la resonancia en la que se detectó la lesión biopsiada, fue etapificación de cáncer mamario recientemente diagnosticado; en el 100 porciento de los casos se realizó ultrasonido de segunda mirada, las lesiones tenían un tamaño promedio de 15 mm (4-29), un 63,6 por ciento fueron nódulos y el resto captaciones tipo no masa. La duración de la biopsia varió entre 40 y 130 minutos, un 27,2 por ciento resultaron lesiones malignas; 36,4 por ciento lesiones de alto riesgo; y 36,4 por ciento benignas. En el 45,5 por ciento el resultado de la biopsia bajo resonancia cambia la conducta quirúrgica. De las 7 lesiones operadas hubo subestimación en un caso de cáncer ductal in situ, que resultó cáncer ductal infiltrante. En el resto la histología quirúrgica fue idéntica a la de la biopsia bajo resonancia. Conclusión: Las biopsias bajo resonancia son infrecuentes, consumen un tiempo considerable, su correlación histológica es muy confiable y cambia la conducta quirúrgica casi en la mitad de los casos, lo cual tiene implicancias en el pronóstico de la paciente.

Abstract. Breast MRI is becoming a frequently used working tool in our environment. A group of lesions exist that can only be identified by this technique, "MRI only". Between 14-20 % of these will be malignant, according to various published series. Such lesions require biopsy guided under MRI. Patients and Methods: A descriptive retrospective review of vacuum-assisted biopsies was performed at our institution (period between August 2008 and June 2013). Results: 0.3 % (11) of the biopsies performed at our institution were done so under MRI, in 9 women. In 55% of the cases the resonance indication in which the biopsied lesion was detected, was newly diagnosed staging of breast cancer; in 100% of the cases a second-look ultrasound was performed, the lesions had an average size of 15 mm (4-29), 63.6% were nodules and the remainder other non-mass type deposits. The duration of the biopsy varied between 40 and 130 min, 27.2% were malignant lesions, 36.4 % high-risk lesions, and 36.4 % benign. In 45.5% the result of the biopsy performed under MRI changed the surgical procedure. Of the 7 operated lesions there was an underestimation in one case of ductal carcinoma in situ, which resulted being invasive ductal carcinoma. In the remainder, the surgical histology was identical to that of the biopsy performed under magnetic resonance. Conclusion: Biopsies performed under MRI are infrequent, they take considerable time, their histological correlation is very reliable and it changes the surgical procedure in almost half of the cases, which has implications in the prognosis of the patient.

Investigation of Correlations of Double Inversion Recovery and MR Spectroscopy on Breast MR Imaging

PURPOSE: To evaluate the correlation of lesion-to-normal ratio (LNR) of signal intensity from double inversion recovery MR imaging and total choline-containing compound (tCho) resonance from single voxel MR spectroscopy in breast cancers. MATERIALS AND METHODS: Between August 2008 and December 2009, 28 patients who were diagnosed as breast cancer and had undergone both double inversion recovery (DIR) MR imaging and MR spectroscopy (MRS) were included in this study. The signal intensities of the lesion (L) and ipsilateral normal breast tissue (N) were measured in region of interest of each breast cancer in DIR and contrast enhance MR image (CE-T1WI) to calculate the LNR value for each technique. MRS was performed using single-voxel MR spectroscopy. The height, width and area of tCho resonance were compared with each LNR of DIR and CE-T1WI. We used Pearson's correlation coefficient (r) for correlation analysis and the significance level was p=0.05. RESULTS: There was no statistically significant correlation between LNR of CE-T1WI and height (r=-0.322, p=0.094), width (r=-0.233, p=0.232) and area (r=-0.309, p=0.109) of MRS tCho. There was no statistically significant correlation between LNR of DIR and height (r=0.067, p=0.735), width (r=-0.287, p=0.139) and area (r=0.012, p=0.953) of MRS tCho, either. The Pearson's correlation coefficient was 0.186 between LNRs of CE-T1WI and DIR (p=0.344). CONCLUSION: There was no statistically significant correlation between LNR of DIR and relative amount of tCho resonance of MRS.

US-guided Clip Implantation for Tumor Localization in Breast Cancer Patients Who Undergo Neoadjuvant Chemotherapy: Feasibility Study

PURPOSE: The purpose of our study was to investigate the feasibility of US-guided clip implantation in patients receiving neoadjuvant chemotherapy for treatment of breast cancer. MATERIALS AND METHODS: From January to May 2012, marker clips were inserted with US guidance in or adjacent to 23 tumors in 20 female patients receiving neoadjuvant chemotherapy for treatment of breast cancer at our institution. One radiologist performed a retrospective review of the identification of tumors on US, mammography,and breast MRI, and MRI artifact caused by a marker clip. Clip migration was evaluated using the clip-to-nipple distance on mammography obtained immediately after clip insertion and ithin one week before breast surgery. Complication associated with clip insertion was also observed. RESULTS: After completion of neoadjuvant chemotherapy, all tumors showed a decrease in size, and 13 of 23 (56.5%) tumors were no longer palpable and thus required preoperative localization. In addition, marker clips were the only remaining evidence of the original tumor site in three of 23 (13.0%) tumors at the time of preoperative localization. All signal voids caused by a marker clip on breast MRI were less than 1 cm, which did not have a significant effect on detection and evaluation of the extent of the breast cancer. The mean change of the clip-to-nipple distance was 2.11 mm on a craniocaudal, and 2.67 mm on a mediolateral mammogram. No complication associated with clip insertion was observed in any case. CONCLUSION: US-guided clip implantation in or adjacent to a breast cancer is safe and feasible for patients with anticipation of complete or near complete response to neoadjuvant chemotherapy.

¿Es concordante el tamaño tumoral medido en resonancia magnética mamaria y el de la biopsia quirúrgica en pacientes con cáncer de mama, tratadas con quimioterapia neoadyuvante? / Is breast MRI concordant with pathologic tumor size in breast cancer patients treated with neo-adjuvant chemotherapy?

Neoadjuvant chemotherapy (NACT) is a treatment used in those breast cancers initially inoperable due to their size, and also in operable breast cancers where NACT could increase the rate of conservative breast surgery. To assess tumor response to treatment, clinical examination, mammography, ultrasound, and breast MRI are used, the latter being the modality that yields the best correlation with histologic tumor volume. We evaluated the correlation of tumor sizes as measured by MRI versus surgical pathological specimen in breast cancers treated with NACT. Eighteen patients underwent MRI to monitor NACT; in 15 (83 percent) of them the final biopsy was obtained. In this group a very good correlation was observed, with a mean difference between MRI and histology of 4 mm regarding tumor volumen, which has allowed an adequate management of patients in our daily practice.

La quimioterapia neoadyuvante (QTNA) es un tratamiento usado en aquellos cánceres mamarios cuyo tamaño los hace inoperables al momento del diagnóstico y en cánceres mamarios operables, pero cuyo uso podría permitir una cirugía conservadora. Para evaluar la respuesta al tratamiento, se ha utilizado el examen clínico, la mamografía, el ultrasonido y la resonancia magnética mamaria, siendo ésta última la que mejor correlación tiene con el tamaño tumoral histológico. Quisimos evaluar la concordancia del tamaño tumoral medido en resonancia magnética con el de la biopsia quirúrgica, en cánceres mamarios tratados con QTNA. Dieciocho pacientes se realizaron resonancia magnética para monitorización de QTNA, en 15 (83 por ciento) de ellas se obtuvo la biopsia definitiva. En este grupo observamos una muy buena correlación, con una diferencia promedio de 4 mm, entre el tamaño de la resonancia y el de la histología, lo que permitió en nuestro medio un adecuado manejo de las pacientes.

Breast Cancer Screening with MRI

Breast MRI is the most accurate adjunctive to the mammography for the screening of breast cancer. Despite lack of randomized controlled trials on the effectiveness of MRI screening, it is now recommended for the women at high risk for breast cancer by the American Cancer Society and the National Comprehensive Cancer Network based on several prospective observational studies. In Korea, a retrospective study reported that preoperative MRI screening of the contralateral breast in women with unilateral breast cancer was associated with reduced metachronous cancer incidence. To introduce breast MRI as a supplemental modality to screening mammography in Korea, standardization and education of interpretation, establishment of MR-guided biopsy and adequate indication, and evaluation of cost-effectiveness and should be preceded.

Resonancia magnética mamaria preoperatoria: la gran polémica / Preoperative breast MRI: the great controversy

Preoperative examination intended to detect multifocality, multicentricity and bilaterality-once considered the strongest indication of breast magnetic resonance imaging (MRI)-is currently being strongly questioned in medical literature. This paper aims at evaluating, based on our experience at Clínica Alemana, Santiago, Chile, breast MRI ability to improve preoperative radiological tumour staging by conventional methods, as well as to determine the proportion of patients in which this diagnostic procedure generated changes in the surgical management. We retrospectively reviewed preoperative MRI studies carried out between January 2009 and June 2010. Classification: Group 1: MRI provided no new information. Group 2: by detecting additional lesions, MRI improved radiological staging without changing the type of surgery planned. Group 3: MRI showed new benign lesions and caused unnecessary surgery. Group 4: MRI successfully changed the type of surgery planned based on conventional studies. A total of 419 breast MRI scans were performed during a 18-month period; 39 percent of them were carried out preoperatively. For the analysis, 128 patients were enrolled and distributed in the following categories: Group 1 (66 percent), Group 2 (20 percent), Group 3 (2 percent) and Group 4 (12 percent). In 95.3 percent of the patients, a single surgery with clear margins was performed. This work demonstrated the usefulness of preoperative MRI in our practice, i.e., it allowed for a better radiological staging in one third of the patients and even successfully changed the surgical approach in 12 percent of cases.

El estudio preoperatorio en búsqueda de multifocalidad, multicentricidad y bilateralidad -antes considerada la indicación más sólida de la resonancia magnética (RM) mamaria- hoy se encuentra fuertemente cuestionada en la literatura. En este trabajo nos propusimos evaluar la capacidad de la RM mamaria en nuestro centro para mejorar la etapificación radiológica preoperatoria realizada por métodos convencionales y determinar la proporción de las pacientes en que genera cambio en el enfoque quirúrgico. Hemos revisado retrospectivamente las RM preoperatorias entre enero de 2009 y junio de 2010. Clasificación: Grupo1: la RM no aportó información nueva. Grupo 2: al detectar lesiones adicionales, mejoró la etapificación radiológica, sin cambiar el tipo de la cirugía planificada. Grupo3: demostró nuevas lesiones no malignas y causó cirugía inútil. Grupo 4: cambió correctamente el tipo de cirugía planeada en base a los estudios convencionales. En los 18 meses se realizaron 419 RM mamarias, el 39 por ciento de ellas en preoperatorio. Para el análisis se han reclutado 128 pacientes con la siguiente distribución en los grupos predeterminados: Grupo 1(66 por ciento), Grupo 2(20 por ciento), Grupo 3(2 por ciento) y Grupo 4(12 por ciento). En el 95,3 por ciento de las pacientes se logró realizar una sola cirugía con márgenes libres. Este trabajo demostró la utilidad de la RM preoperatoria en nuestra práctica: permite una mejor etapificación radiológica en el tercio de las pacientes e incluso cambia correctamente el enfoque quirúrgico en el 12 por ciento de los casos.

Diagnostic Value of 3D Fast Low-Angle Shot Dynamic MRI of Breast Papillomas

PURPOSE: To evaluate the value of breast MRI in analysis of papillomas of the breast. MATERIALS AND METHODS: From 1996 to 2004, 94 patients underwent surgery due to papillomas of the breast. Among them, 21 patients underwent 3D fast low angle shot (FLASH) dynamic breast MRI. Eight masses were palpable and 11 of 21 patients had nipple discharge. Two radiologists indifferently analyzed the location, size of the lesions and shape, margin of the masses, multiplicity and ductal relation. The MRI findings were categorized according to breast imaging reporting and data system (BI-RADS) lexicon. The amount and pattern of enhancement and associated findings were also evaluated according to BI-RADS. We then compared the MRI findings with galactography, mammography and breast ultrasonography (US) and examined histopathologic correlation. RESULTS: On breast MRI, the lesion size was 0.4-1.59 cm, and 18 patients showed subareolar location. On 4.25 cm (mean 1.54) dynamic enhanced images, imaging findings showed mass (n = 10), intracystic mass (n = 3), focus (n = 5), ductal enhancement (n = 2), and segmental enhancement (n = 1). In cases of the masses, the shapes of the masses were round (n = 4), lobulated (n = 3), and irregular (n = 6), and margins were circumscribed (n = 6), microlobulated (n = 5), and indistinct (n = 2). The enhancement patterns were homogeneous enhancement (n = 7), heterogeneous (n = 3) or rim enhancement (n = 3). CONCLUSION: The contrast enhanced dynamic breast MRI was highly sensitive for diagnosis of breast papillomas. MRI could play a key role in the pre-operative work-up for multiple papillomas and papillomatosis.

Clinical Applications of Breast MRI

Breast MRI is a cutting-edge technology in the diagnosis and intervention of breast abnormalities. Over the last decade, breast MRI has evolved from a research field to a clinical field. Radiologists should understand the indications, how to obtain adequate images, and how to interpret and report their findings. Breast MRI is now used in the differentiation of benign from malignant mass, preoperative staging of breast cancer patients, assessment of tumor response to neoadjuvant chemotherapy, and evaluation of women with breast implants. It can also be used as a supplemental screening modality for high-risk women. Qualified radiologists and adequate MRI technique are crucial for the success of these purposes. This review is focused on the indication, standardized use of lexicon and categorization of breast MRI.