Preoperative Breast Magnetic Resonance Imaging: An Ontario Health (Cancer Care Ontario) Clinical Practice Guideline.

BACKGROUND: The use of preoperative breast magnetic resonance imaging (MRI) after the diagnosis of breast cancer by mammography and/or ultrasound is inconsistent. METHODS: After conducting a systematic review and meta-analysis comparing preoperative breast MRI versus no MRI, we reconvened to prepare a clinical practice guideline on this topic. RESULTS: Based on the evidence that MRI improved recurrence, decreased the rates of reoperations (re-excisions or conversion mastectomy), and increased detection of synchronous contralateral breast cancer, we recommend that preoperative breast MRI should be considered on a case-by-case basis in patients diagnosed with breast cancer for whom additional information about disease extent could influence treatment. Based on stronger evidence, preoperative breast MRI is recommended in patients diagnosed with invasive lobular carcinoma for whom additional information about disease extent could influence treatment. For both recommendations, the decision to proceed with MRI would be conditional on shared decision-making between care providers and the patient, taking into account the benefits and risks of MRI as well as patient preferences. Based on the opinion of the Working Group, preoperative breast MRI is also recommended in the following more specific situations: (a) to aid in surgical planning of breast conserving surgery in patients with suspected or known multicentric or multifocal disease; (b) to identify additional lesions in patients with dense breasts; (c) to determine the presence of pectoralis major muscle/chest wall invasion in patients with posteriorly located tumours or when invasion of the pectoralis major muscle or chest wall is suspected; (d) to aid in surgical planning for skin/nipple-sparing mastectomies, autologous reconstruction, oncoplastic surgery, and breast conserving surgery with suspected nipple/areolar involvement; and (e) in patients with familial/hereditary breast cancer but who have not had recent breast MRI as part of screening or diagnosis.

Optimizing Digital Mammographic Image Quality for Full-Field Digital Detectors: Artifacts Encountered during the QC Process.

Early detection of breast cancer through routine mammographic screening has been shown to reduce mortality from breast cancer by up to 30% in multiple studies. However, this reduction of mortality is possible only with careful attention to image quality by the medical physicist, radiologic technologist, and interpreting radiologist. The accepted quality control (QC) processes for analog mammography are well established. However, now that use of digital units is widespread in both the United States and internationally, information regarding the necessary steps and the inherent challenges that might be encountered at each step needs to be elucidated. In this review, the essential steps of the QC process for digital mammography are reviewed, with special attention to the possible problems that can occur during the QC process, many of which can lead to image artifacts. For each of the daily, weekly, monthly, and semiannual QC tests, we review the steps and expected performance and provide examples of some of the common artifacts that may be encountered. Understanding the components of the QC process and recognizing problems that may result in a suboptimal image is critical to ensure optimal image quality in an effort to maximize early detection of breast cancer.

Imaging approaches to diagnosis and management of common ductal abnormalities.

Ductal disease is an important, often overlooked, and poorly understood issue in breast imaging that results in delays in diagnosis and patient care. The differential diagnosis for an intraductal mass is broad and includes inspissated secretions, infection, hemorrhage, solitary or multiple papillomas, and malignancy. Each breast is composed of eight or more ductal systems, with most disease arising in the terminal ductal-lobular unit. Imaging evaluation of the ductal system usually entails a combination of mammography, galactography, ultrasonography (US), and in some cases magnetic resonance (MR) imaging. The most common finding with all modalities is ductal dilatation with a focal or diffuse abnormality. Benign diseases of the ducts include duct ectasia, blocked ducts, inflammatory infiltrates, periductal mastitis, apocrine metaplasia, intraductal papillomas, and papillomatosis. Malignant diseases of the ducts include ductal carcinoma in situ, invasive ductal carcinoma, and Paget disease. Most commonly performed with US or MR imaging guidance, percutaneous biopsy methods are helpful in diagnosis and management of ductal findings. Because most findings are smaller than 1 cm, located within a duct, and thus sometimes not visible after a single pass, vacuum-assisted devices help improve the accuracy of sampling.

Spectrum of diseases presenting as architectural distortion on mammography: multimodality radiologic imaging with pathologic correlation.

Architectural distortion is the third most-common appearance of breast cancer and often is a subtle finding on mammography. In this article, we review a variety of breast diseases that may present as architectural distortion on mammography; review the utility of correlative imaging, such as ultrasound and magnetic resonance; and review appropriate management for these diagnoses. Primary causes include breast cancer, ductal carcinoma in situ, radial scar, complex sclerosing lesion, and fat necrosis. Secondary etiologies include previous breast surgery, trauma, and infection. Familiarity with imaging findings presenting as distortion on multimodality imaging will optimize detection and management of this subtle-yet-significant finding.