3-T breast magnetic resonance imaging in patients with suspicious microcalcifications on mammography.

OBJECTIVE: To investigate the diagnostic value of 3-Tesla (T) breast MRI in patients presenting with microcalcifications on mammography. METHODS: Between January 2006 and May 2009, 123 patients with mammographically detected BI-RADS 3­5 microcalcifications underwent 3-T breast MRI before undergoing breast biopsy. All MRIs of the histopathologically confirmed index lesions were reviewed by two breast radiologists. The detection rate of invasive carcinoma and ductal carcinoma in situ (DCIS) was evaluated, as well as the added diagnostic value of MRI over mammography and breast ultrasound. RESULTS: At pathology, 40/123 (33%) lesions proved malignant; 28 (70%) DCIS and 12 (30%) invasive carcinoma. Both observers detected all invasive malignancies at MRI, as well as 79% (observer 1) and 86% (observer 2) of in situ lesions. MRI in addition to conventional imaging led to a significant increase in area under the receiver operating characteristic (ROC) curve from 0.67 (95% CI 0.56­0.79) to 0.79 (95% CI 0.70­0.88, observer 1) and to 0.80 (95% CI 0.71­0.89, observer 2), respectively. CONCLUSIONS: 3-T breast MRI was shown to add significant value to conventional imaging in patients presenting with suspicious microcalcifications on mammography. KEY POINTS: • 3-T MRI is increasingly used for breast imaging in clinical practice. • On 3-T breast MRI up to 86% of DCIS lesions are detected. • 3-T MRI increases the diagnostic value in patients with mammographically detected microcalcifications.

Assessment of ovarian movement on consecutive pelvic MRI examinations in patients with gynaecological malignancies: what is the planning organ-at-risk volume for radiotherapy?

OBJECTIVES: The aims of this study are to assess the extent of ovarian movement on consecutive MRI examinations in patients with gynaecological malignancies and to define potential safety volumes around the ovaries that may avoid ovarian ablation during pelvic irradiation. METHODS: Patients with cervical, vaginal and endometrial cancer who underwent MRI examinations of the pelvis before and during radiotherapy were included in the study. The position of the ovaries was retrospectively determined on two consecutive axial and sagittal T(2) weighted MRI examinations of the pelvis. Ovarian movement was determined in craniocaudal, anteroposterior and mediolateral directions. Safety volumes were calculated by computing elliptical volumes based on the derived 95% and 99% reference intervals. RESULTS: 30 patients with a gynaecological malignancy were included. Both ovaries could be identified on the MRI examinations in all cases. The safety volumes around the ovaries encompassing 95% and 99% of ovarian movement were 11 and 25 cm(3) (95%), and 24 and 54 cm(3) (99%), for the left and right ovary, respectively. CONCLUSION: Adding a safety volume around the ovaries may reduce the high radiation dose to the ovaries. This could potentially avoid ovarian ablation, reducing significant fertility morbidity.

Preoperative MRI and surgical management in patients with nonpalpable breast cancer: the MONET - randomised controlled trial.

BACKGROUND: We evaluated whether performing contrast-enhanced breast MRI in addition to mammography and/or ultrasound in patients with nonpalpable suspicious breast lesions improves breast cancer management. METHODS: The MONET - study (MR mammography of nonpalpable breast tumours) is a randomised controlled trial in patients with a nonpalpable BIRADS 3-5 lesion. Patients were randomly assigned to receive routine medical care, including mammography, ultrasound and lesion sampling by large core needle biopsy or additional MRI preceding biopsy. Patients with cancer were referred for surgery. Primary end-point was the rate of additional surgical procedures (re-excisions and conversion to mastectomy) in patients with a nonpalpable breast cancer. FINDINGS: Four hundred and eighteen patients were randomised, 207 patients were allocated to MRI, and 211 patients to the control group. In the MRI group 74 patients had 83 malignant lesions, compared to 75 patients with 80 malignant lesions in the control group. The primary breast conserving surgery (BCS) rate was similar in both groups; 68% in the MRI group versus 66% in the control group. The number of re-excisions performed because of positive resection margins after primary BCS was increased in the MRI group; 18/53 (34%) patients in the MRI group versus 6/50 (12%) in the control group (p=0.008). The number of conversions to mastectomy did not differ significantly between groups. Overall, the rate of an additional surgical intervention (BCS and mastectomy combined) after initial breast conserving surgery was 24/53 (45%) in the MRI group versus 14/50 (28%) in the control group (p=0.069). INTERPRETATION: Addition of MRI to routine clinical care in patients with nonpalpable breast cancer was paradoxically associated with an increased re-excision rate. Breast MRI should not be used routinely for preoperative work-up of patients with nonpalpable breast cancer.

Surgical outcome of patients with core-biopsy-proven nonpalpable breast carcinoma: a large cohort follow-up study.

BACKGROUND: Breast-conserving surgery (BCS) is the preferred treatment for nonpalpable breast carcinoma. The outcome, however, may be disappointing. In this study surgical outcome in a large cohort of patients diagnosed with nonpalpable breast carcinoma is evaluated. METHODS: In 833 patients with 841 nonpalpable breast carcinomas the number of re-excisions and type of surgical procedures was calculated and summed per patient. Subsequently, the number of conversions to mastectomy and the number of days until complete tumor removal were analyzed. In a subgroup analysis the patients with an in situ carcinoma were compared with the patients with an invasive carcinoma. RESULTS: The initial surgery consisted of BCS for 589 tumors (70%) and of mastectomy for 242 tumors (29%). For ten tumors (1%) the initial surgery was unknown. After BCS, 158/589 tumors (27%) required a re-excision: 116/337 (34%) for the in situ carcinomas and 63/504 (13%) for the invasive carcinomas (p = 0.0001). The number of conversions from BCS to mastectomy was 106/589 (18%): 66/241 (28%) in patients diagnosed with an in situ carcinoma versus 40/348 (11%) in patients with an invasive carcinoma (p = 0.0001). The median number of days until complete tumor removal was 28, being 38 days for the in situ carcinomas and 25 days for the invasive carcinomas (p = 0.0001). CONCLUSIONS: There is room for improvement in the surgical treatment of nonpalpable breast carcinoma, especially the relatively favorable in situ carcinoma, as it requires significantly more excisions, mastectomies, conversions to mastectomy, and days for complete removal.

Contrast-enhanced 3.0-T breast MRI for characterization of breast lesions: increased specificity by using vascular maps.

PURPOSE: To assess the diagnostic accuracy of contrast-enhanced 3.0-T breast magnetic resonance imaging (MRI) for differentiating benign from malignant breast masses and subsequently to test if specificity could be further improved by scoring of the overall ipsilateral breast vascularity. MATERIALS AND METHODS: Fifty-four patients were prospectively enrolled in the study and underwent contrast-enhanced 3.0-T breast MRI. MR images were evaluated and classified according to the MRI BI-RADS lexicon criteria. Lesion size, number of lesions, and localization in the breast were systematically assessed. Maximum intensity projections (MIPS) were obtained by using high-resolution contrast-enhanced (0.1 mmol/kg gadobutrol) fat-saturated T1-weighted images. Breast vascularization was scored according to the methods from Sardanelli et al. by measuring the number, diameter, and length of the vessels on the MIPS. The score ranged from 0 (indicating absent or low breast vascularity) to 3 (indicating high breast vascularity). RESULTS: Final analysis of 56 lesions revealed 25 (45%) malignant lesions and 31 (55%) benign lesions. Correlation with the MRI BI-RADS classification revealed cancer in none (0%) of the BI-RADS II lesions, in 1 (12%) of the BI-RADS III lesions, in 5 (83%) of the BI-RADS IV lesions, and in 19 (100%) of the BI-RADS V lesions. Based on morphologic and kinetic data analysis, the sensitivity and specificity of 3.0-T breast MRI was 100% (25/25) and 74% (23/31), respectively. After adjustment for the breast vascularity score, specificity significantly (p = 0.048) increased to 87% (27/31) without affecting sensitivity. CONCLUSION: Diagnostic accuracy of contrast-enhanced 3.0-T breast MRI increased significantly when the vascularity score was added to the standard morphologic and kinetic data analysis, resulting in a specificity of 87% without affecting sensitivity, which remained 100%.

Targeting difficult accessible breast lesions: MRI-guided needle localization using a freehand technique in a 3.0 T closed bore magnet.

PURPOSE: To report the accuracy of magnetic resonance imaging (MRI)-guided needle localization for diagnosis of MRI detected suspicious breast lesions located in difficult accessible regions of the breast, using the freehand method in a 3.0 T closed bore magnet. MATERIALS AND METHODS: In five patients with five MRI-only breast lesions underwent MRI-guided needle localization for histopathologic evaluation of the lesions. All interventional procedures were performed in a 3.0 T MRI system with the patient in prone position and by using a dedicated phased array breast coil. MRI-guided needle localizations were performed by using a freehand technique. In our study, the high-resolution scan allowed preprocedural localization of all lesions without use of contrast enhancement. In all cases contrast-enhanced MRI was performed after insertion of the wire to confirm the tip of the wire in direct contact with the enhancing lesion. RESULTS: Needle localizations were performed in five patients. Histopathologic evaluation of tissue after surgery excision biopsy revealed one lymph node, three invasive ductal carcinoma and one ductal carcinoma in situ. Lesion size varied from 6 to 30 mm. Mean duration time was 25 min. No complications occurred during the intervention method. In the patient with the benign lesion control MRI of the breast after 6 months confirmed lesion removal. CONCLUSIONS: MRI-guided needle localization by using a freehand technique in a 3.0 T closed bore magnet is a safe and accurate method for diagnosis of difficult accessible breast lesions only visible on MRI.