No Diagnostic Concerns With Cardiovascular Magnetic Resonance Imaging in Patients With Breast Cancer and Breast Implants

Abstract

To the Editor We welcome the Viewpoint from Oren et al 1 highlighting the importance of ensuring high-quality cardiovascular (CV) imaging for patients living with (or survivors of) breast cancer with breast implants. Patients commonly require functional CV imaging to establish CV safety during or after receiving cancer treatment for screening for cancer treatment-related cardiac dysfunction (CTRCD) in line with available guidelines and consensus statements. 2 Echocardiography has long been known to be challenging in patients with breast implants, 3 and inaccurate imaging risks not only late detection of potentially life-threatening cardiotoxic effects but also inappropriate withholding of cancer treatments. Alternative imaging modalities are therefore commonly required to ensure accurate diagnosis and appropriate clinical decisionmaking. Investigation and monitoring of incident CV toxic effects also requires optimal CV noninvasive imaging, and the spectrum of disease demands a multimodality approach, with false-positive results reported in this patient group with both electrocardiography 4 and nuclear (single-photon emission computed tomography) imaging. 5 The authors state that the diagnostic performance of cardiovascular magnetic resonance imaging (CMR) may be impaired by the presence of breast prostheses. They propose that formal evaluation of the sensitivity and specificity of CMR in patients with breast cancer and implants is required, notably for investigation of immune checkpoint inhibitor-related myocarditis.We strongly refute that suggestion. There is no evidence to suggest that the presence of a breast implant should impact tissue characterization-either for late gadolinium enhancement fibrosis imaging or for parametric mapping for measurement of T1, T2, or T2*. The constituent components of the implants (silicone, saline) are nonferromagnetic and have no impact on relaxometry. Many thousands of patients globally have undergone CMR with breast implants, and there are no published or anecdotal reports of artifacts.The only area where care should be taken with patients with breast cancer undergoing CMR is for patients with some tissue expanders with MAGNA-SITE injection ports, which are labelled as MR-Unsafe. Tissue expanders are temporary devices used prior to breast implantation following mastectomy. All breast implants are labelled as MR-Safe and many new tissue expanders are labelled MR-Conditional.Options for quality diagnostic CV imaging in patients with breast cancer with implants may be limited, and for these specific patients, the impact of not evaluating for CTRCD or other cardiotoxic effects is high. Suggesting that either CMR or computed tomography be inaccurate is not only incorrect but also potentially harmful to patients. On behalf of the cardiooncology community and patients, we would strongly advocate that this Viewpoint article be amended to correct this statement.