Current and Future Directions of Breast MRI

Abstract

Magnetic resonance imaging (MRI) is the most sensitive exam for detecting breast cancer. The American College of Radiology recommends women with 20% or greater lifetime risk of developing breast cancer be screened annually with MRI. However, other high-risk populations would also benefit. Hartmann et al. reported women with atypical hyperplasia have nearly a 30% incidence of breast cancer at 25-year follow-up. Women with dense breast tissue have up to a 4-fold increased risk of breast cancer when compared to average-risk women; their cancers are more likely to be mammographically occult. Because multiple cohorts of women are at high risk for developing breast cancer, there has been a movement to develop an abbreviated MRI (abMRI) protocol to expand the availability of MRI screening. Studies on abMRI effectiveness have been promising, with Weinstein et al. demonstrating a cancer detection rate of 27.4/1000 in women with dense breasts after a negative digital breast tomosynthesis. Breast MRI is also used to evaluate the extent of disease as part of preoperative assessment in women with newly diagnosed breast cancer, and to assess a patient’s response to neoadjuvant chemotherapy. This paper aims to explore the current uses of MRI and propose future indications and directions.

Five decades of progress in surgical oncology: Breast

“…Lymphatic mapping has been integral to the evolution of SLNB. Dynamic imaging—especially magnetic resonance imaging—has been instrumental in high‐risk screening, management of occult breast cancer, clinical problem solving, and in the assessment of response pre‐ and post‐neoadjuvant chemotherapy (NAC) 62 . Studies of contrast‐enhanced digital mammography by MSK radiologist Maxine Jochelson suggest performance comparable to MRI but with improved specificity and lower cost 63 .…”

“…Dynamic imaging-especially magnetic resonance imaging-has been instrumental in high-risk screening, management of occult breast cancer, clinical problem solving, and in the assessment of response pre-and post-neoadjuvant chemotherapy (NAC). 62 Studies of contrastenhanced digital mammography by MSK radiologist Maxine Jochelson suggest performance comparable to MRI but with improved specificity and lower cost. 63 Fluorodeoxyglucose (FDG) PET is well established for staging and for follow-up of metastatic disease, and new imaging agents targeting ER promise improved performance for cancers with low FDG avidity.…”

Diagnostic performance of contrast‐enhanced mammography for suspicious findings in dense breasts: A systematic review and meta‐analysis

“…High breast density is considered an independent risk factor for breast cancer. Women with high fibroglandular content were shown to have a 4.6 times higher risk of breast cancer than the average risk 2 . More than 50% of women under 50 years of age have been reported to have dense breasts 3 .…”

“…Women with high fibroglandular content were shown to have a 4.6 times higher risk of breast cancer than the average risk. 2 More than 50% of women under 50 years of age have been reported to have dense breasts. 3 Superimposition of the dense glands has been shown to reduce the diagnostic performance of unenhanced breast imaging modalities, such as mammography.…”

Screening MRI in Patients with High-Risk Breast Lesions: More May Not Necessarily be More

“…Surveillance with MRI is therefore indicated primarily for patients who are at such elevated breast cancer risk that the risk of false-positive biopsies is outweighed by the benefits of potential early detection. 4 Given the established clinical pathways for high risk versus average risk, a lack of clarity exists for those patients who do not clearly fit the high-risk criteria but may potentially be at above-average risk due to a history of high-risk pathologies. It is in this space where Laws 5 focuses her research, an area where even among experts within an academic medical center there is variation in practice patterns.…”