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Current Status of Breast MR Imaging

Part 2. Clinical Applications¹

¹ From the Department of Radiology, University of Bonn, Sigmund-Freud-Str 25, D-53105 Bonn, Germany. Received October 9, 2005; revision requested November 30; revision received January 8, 2006; final version accepted February 23. Final review and update by the author April 15, 2007. Address correspondence to the author (e-mail: kuhl{at}uni-bonn.de).

	ABSTRACT

TOP ABSTRACT INTRODUCTION MR IMAGING AS SECOND-LINE... MR IMAGING AS FIRST-LINE... ESSENTIALS References

 
Magnetic resonance (MR) imaging is emerging as the most sensitive modality that is currently available for the detection of primary or recurrent breast cancer. Although this technique has been shown to be an extremely powerful diagnostic tool, it is still relatively rarely used in clinical practice, as compared with other applications of MR imaging such as for musculoskeletal or brain and spine imaging. This is the second of a two-part series on the current status of breast MR. Part two provides an overview of the use of breast MR imaging in clinical patient care, the body of evidence that supports its use. A discussion is provided on the many controversies that exist regarding breast MR imaging for preoperative staging and for screening.

© RSNA, 2007

	INTRODUCTION

TOP ABSTRACT INTRODUCTION MR IMAGING AS SECOND-LINE... MR IMAGING AS FIRST-LINE... ESSENTIALS References

 
This is the second part of a two-part series on the state of the art of breast magnetic resonance (MR) imaging. In the first part (1), we explained the pathophysiologic basis of breast MR imaging, presented the current concepts for diagnosing breast cancer, listed typical imaging findings in benign and malignant breast lesions, and reviewed the sensitivity and specificity with which breast cancer diagnosis is achieved. We discussed the technical requirements for breast protocols and explained why the protocols have to compromise on the diverging demands of spatial and temporal resolution. We reviewed the advantages and disadvantages of different MR protocol parameter settings. We listed issues that, in the past, had been identified as interfering with the propagation of the clinical use of breast MR imaging, such as lack of standardization, lack of specificity, low positive predictive value, and lack of MR-guided biopsy facilities, and we analyzed the current status.

The conclusion was that although not all issues have been settled yet, substantial progress has been made in the past decade. Breast MR imaging is a mature technique that is ready for broad clinical use. Therefore, breast MR imaging should now be fully integrated into breast fellowship programs to allow breast radiologists to become competent MR users, and quality assurance programs have to be set up to guide the use of breast MR imaging in clinical practice. In this article, we will discuss how breast MR imaging should be used clinically, how it should be integrated into the work-up of an equivocal finding, and what the current level of evidence is regarding its use in the breast cancer patient.

	MR IMAGING AS SECOND-LINE MODALITY

TOP ABSTRACT INTRODUCTION MR IMAGING AS SECOND-LINE... MR IMAGING AS FIRST-LINE... ESSENTIALS References

 
MR Imaging to Clarify Inconclusive or Suspicious Conventional Imaging Findings
The use of breast MR in the case of a difficult-to-read mammogram with equivocal findings is probably the oldest indication for which breast MR imaging was suggested first (2–4). However, the scientific evidence regarding the effectiveness with which breast MR imaging can actually help solve mammographic problems is relatively weak, for two reasons.

First, substantial progress has been made to obtain histologic proof of equivocal lesions by means of a variety of minimally invasive biopsy procedures. Ultrasonography (US)- or mammography-guided core or vacuum core biopsy is widely available and allows safe and tissue-sparing definite diagnosis of suspicious lesions. So, if a lesion is equivocal, rather than perform MR imaging for clarification it is probably more efficient to offer imaging-guided biopsy. This is definitively the case if the mammographic or US abnormality is a solitary finding in an otherwise normal breast and can be targeted adequately for biopsy.

Second, even in the typical difficult-to-read mammogram with multiple findings, MR imaging for problem solving may be inefficient. An imaging modality with a high negative predictive value (NPV) is required to settle a diagnostic problem. For breast MR, NPVs have been reported to be as high as 98% in single-center studies (5,6), which is the highest published NPV of all breast imaging modalities that are currently available, including positron emission tomography (PET) and scintimammography (7–9). However, the NPV of any imaging modality will ultimately depend on the composition of the patient cohort and the interpreting radiologist's expertise. In a multicenter trial published relatively recently (10), the overall NPV of breast MR imaging was 85.4%, which is not high enough to clarify with sufficient confidence an equivocal or suspicious lesion seen at conventional imaging. The reason is that all breast imaging modalities have their "blind spots" or specific strengths and weaknesses. It is unlikely that the diagnostic accuracy of an imaging technique (eg, MR) will be superior to that of another (eg, mammography) in each and every clinical scenario. Accordingly, rather than compare overall NPVs of imaging modalities (ie, rather than lump together all the different clinical settings), one should identify specific clinical situations for which it may well be feasible to use breast MR imaging for problem solving and others for which the same is not attainable because the NPV is not high enough.

Indeed, there are clinical situations or specific constellations of conventional imaging findings in which the NPV of breast MR is high enough to be used for problem solving. First, in patients who are being followed up after breast-conserving surgery, it may be difficult (if not impossible) to distinguish a developing scar from recurrent cancer (3,11) (Fig 1). In this situation, breast MR imaging yields a high NPV and positive predictive value for recurrent cancer, and these excellent predictive values can be achieved even by readers with only limited experience.

View larger version (90K): [in this window] [in a new window] [Download PPT slide]   Figure 1a: (a–h) Breast MR for problem solving: scar versus recurrent cancer after breast-conserving therapy. (a–e) Local recurrence depicted at MR in a 60-year-old patient who underwent breast-conserving therapy 6 years previously. (a, b) Craniocaudal mammograms obtained in (a) August 2004 and (b) August 2005 reveal scar tissue, with discrete changes in scar appearance over 1-year follow-up. (c–e) Transverse T1-weighted gradient-echo breast MR images (repetition time msec/echo time msec, 290/4; flip angle, 90°) obtained in August 2005 (c) before and (d) after contrast material administration and (e) postcontrast subtracted image reveal scar as hypointense mass in c (arrow). Postcontrast images (d, e) show enhancement in medial aspect of the scar (upper arrow); a focus toward chest wall is also seen (lower arrow). MR-guided biopsy revealed multifocal recurrence in the scar and prepectoral focus. (f–j) Scar tissue in 43-year-old patient after breast-conserving therapy 3 years previously. (f, g) Two-view mammogram reveals spiculated mass (arrow) in upper outer quadrant at site of previous breast cancer. Lesion exhibits increased density compared with previous mammograms (not shown) and was interpreted as suspicious for recurrence (Breast Imaging Reporting and Data System [BI-RADS] category 4). (h) US image reveals hypoechoic mass (arrows) with posterior acoustic shadowing, compatible with both recurrent cancer and scar tissue. Transverse (i) T1-weighted gradient-echo precontrast (290/4; flip angle, 90°) and (j) postcontrast subtracted breast MR images reveal stellate mass (arrows) in upper outer quadrant. No contrast enhancement is seen on j. Patient did not undergo biopsy; absence of recurrent cancer was confirmed over 2-year follow-up.

View larger version (84K): [in this window] [in a new window] [Download PPT slide]   Figure 1b: (a–h) Breast MR for problem solving: scar versus recurrent cancer after breast-conserving therapy. (a–e) Local recurrence depicted at MR in a 60-year-old patient who underwent breast-conserving therapy 6 years previously. (a, b) Craniocaudal mammograms obtained in (a) August 2004 and (b) August 2005 reveal scar tissue, with discrete changes in scar appearance over 1-year follow-up. (c–e) Transverse T1-weighted gradient-echo breast MR images (repetition time msec/echo time msec, 290/4; flip angle, 90°) obtained in August 2005 (c) before and (d) after contrast material administration and (e) postcontrast subtracted image reveal scar as hypointense mass in c (arrow). Postcontrast images (d, e) show enhancement in medial aspect of the scar (upper arrow); a focus toward chest wall is also seen (lower arrow). MR-guided biopsy revealed multifocal recurrence in the scar and prepectoral focus. (f–j) Scar tissue in 43-year-old patient after breast-conserving therapy 3 years previously. (f, g) Two-view mammogram reveals spiculated mass (arrow) in upper outer quadrant at site of previous breast cancer. Lesion exhibits increased density compared with previous mammograms (not shown) and was interpreted as suspicious for recurrence (Breast Imaging Reporting and Data System [BI-RADS] category 4). (h) US image reveals hypoechoic mass (arrows) with posterior acoustic shadowing, compatible with both recurrent cancer and scar tissue. Transverse (i) T1-weighted gradient-echo precontrast (290/4; flip angle, 90°) and (j) postcontrast subtracted breast MR images reveal stellate mass (arrows) in upper outer quadrant. No contrast enhancement is seen on j. Patient did not undergo biopsy; absence of recurrent cancer was confirmed over 2-year follow-up.

View larger version (131K): [in this window] [in a new window] [Download PPT slide]   Figure 1c: (a–h) Breast MR for problem solving: scar versus recurrent cancer after breast-conserving therapy. (a–e) Local recurrence depicted at MR in a 60-year-old patient who underwent breast-conserving therapy 6 years previously. (a, b) Craniocaudal mammograms obtained in (a) August 2004 and (b) August 2005 reveal scar tissue, with discrete changes in scar appearance over 1-year follow-up. (c–e) Transverse T1-weighted gradient-echo breast MR images (repetition time msec/echo time msec, 290/4; flip angle, 90°) obtained in August 2005 (c) before and (d) after contrast material administration and (e) postcontrast subtracted image reveal scar as hypointense mass in c (arrow). Postcontrast images (d, e) show enhancement in medial aspect of the scar (upper arrow); a focus toward chest wall is also seen (lower arrow). MR-guided biopsy revealed multifocal recurrence in the scar and prepectoral focus. (f–j) Scar tissue in 43-year-old patient after breast-conserving therapy 3 years previously. (f, g) Two-view mammogram reveals spiculated mass (arrow) in upper outer quadrant at site of previous breast cancer. Lesion exhibits increased density compared with previous mammograms (not shown) and was interpreted as suspicious for recurrence (Breast Imaging Reporting and Data System [BI-RADS] category 4). (h) US image reveals hypoechoic mass (arrows) with posterior acoustic shadowing, compatible with both recurrent cancer and scar tissue. Transverse (i) T1-weighted gradient-echo precontrast (290/4; flip angle, 90°) and (j) postcontrast subtracted breast MR images reveal stellate mass (arrows) in upper outer quadrant. No contrast enhancement is seen on j. Patient did not undergo biopsy; absence of recurrent cancer was confirmed over 2-year follow-up.

View larger version (128K): [in this window] [in a new window] [Download PPT slide]   Figure 1d: (a–h) Breast MR for problem solving: scar versus recurrent cancer after breast-conserving therapy. (a–e) Local recurrence depicted at MR in a 60-year-old patient who underwent breast-conserving therapy 6 years previously. (a, b) Craniocaudal mammograms obtained in (a) August 2004 and (b) August 2005 reveal scar tissue, with discrete changes in scar appearance over 1-year follow-up. (c–e) Transverse T1-weighted gradient-echo breast MR images (repetition time msec/echo time msec, 290/4; flip angle, 90°) obtained in August 2005 (c) before and (d) after contrast material administration and (e) postcontrast subtracted image reveal scar as hypointense mass in c (arrow). Postcontrast images (d, e) show enhancement in medial aspect of the scar (upper arrow); a focus toward chest wall is also seen (lower arrow). MR-guided biopsy revealed multifocal recurrence in the scar and prepectoral focus. (f–j) Scar tissue in 43-year-old patient after breast-conserving therapy 3 years previously. (f, g) Two-view mammogram reveals spiculated mass (arrow) in upper outer quadrant at site of previous breast cancer. Lesion exhibits increased density compared with previous mammograms (not shown) and was interpreted as suspicious for recurrence (Breast Imaging Reporting and Data System [BI-RADS] category 4). (h) US image reveals hypoechoic mass (arrows) with posterior acoustic shadowing, compatible with both recurrent cancer and scar tissue. Transverse (i) T1-weighted gradient-echo precontrast (290/4; flip angle, 90°) and (j) postcontrast subtracted breast MR images reveal stellate mass (arrows) in upper outer quadrant. No contrast enhancement is seen on j. Patient did not undergo biopsy; absence of recurrent cancer was confirmed over 2-year follow-up.

View larger version (143K): [in this window] [in a new window] [Download PPT slide]   Figure 1e: (a–h) Breast MR for problem solving: scar versus recurrent cancer after breast-conserving therapy. (a–e) Local recurrence depicted at MR in a 60-year-old patient who underwent breast-conserving therapy 6 years previously. (a, b) Craniocaudal mammograms obtained in (a) August 2004 and (b) August 2005 reveal scar tissue, with discrete changes in scar appearance over 1-year follow-up. (c–e) Transverse T1-weighted gradient-echo breast MR images (repetition time msec/echo time msec, 290/4; flip angle, 90°) obtained in August 2005 (c) before and (d) after contrast material administration and (e) postcontrast subtracted image reveal scar as hypointense mass in c (arrow). Postcontrast images (d, e) show enhancement in medial aspect of the scar (upper arrow); a focus toward chest wall is also seen (lower arrow). MR-guided biopsy revealed multifocal recurrence in the scar and prepectoral focus. (f–j) Scar tissue in 43-year-old patient after breast-conserving therapy 3 years previously. (f, g) Two-view mammogram reveals spiculated mass (arrow) in upper outer quadrant at site of previous breast cancer. Lesion exhibits increased density compared with previous mammograms (not shown) and was interpreted as suspicious for recurrence (Breast Imaging Reporting and Data System [BI-RADS] category 4). (h) US image reveals hypoechoic mass (arrows) with posterior acoustic shadowing, compatible with both recurrent cancer and scar tissue. Transverse (i) T1-weighted gradient-echo precontrast (290/4; flip angle, 90°) and (j) postcontrast subtracted breast MR images reveal stellate mass (arrows) in upper outer quadrant. No contrast enhancement is seen on j. Patient did not undergo biopsy; absence of recurrent cancer was confirmed over 2-year follow-up.

View larger version (110K): [in this window] [in a new window] [Download PPT slide]   Figure 1f: (a–h) Breast MR for problem solving: scar versus recurrent cancer after breast-conserving therapy. (a–e) Local recurrence depicted at MR in a 60-year-old patient who underwent breast-conserving therapy 6 years previously. (a, b) Craniocaudal mammograms obtained in (a) August 2004 and (b) August 2005 reveal scar tissue, with discrete changes in scar appearance over 1-year follow-up. (c–e) Transverse T1-weighted gradient-echo breast MR images (repetition time msec/echo time msec, 290/4; flip angle, 90°) obtained in August 2005 (c) before and (d) after contrast material administration and (e) postcontrast subtracted image reveal scar as hypointense mass in c (arrow). Postcontrast images (d, e) show enhancement in medial aspect of the scar (upper arrow); a focus toward chest wall is also seen (lower arrow). MR-guided biopsy revealed multifocal recurrence in the scar and prepectoral focus. (f–j) Scar tissue in 43-year-old patient after breast-conserving therapy 3 years previously. (f, g) Two-view mammogram reveals spiculated mass (arrow) in upper outer quadrant at site of previous breast cancer. Lesion exhibits increased density compared with previous mammograms (not shown) and was interpreted as suspicious for recurrence (Breast Imaging Reporting and Data System [BI-RADS] category 4). (h) US image reveals hypoechoic mass (arrows) with posterior acoustic shadowing, compatible with both recurrent cancer and scar tissue. Transverse (i) T1-weighted gradient-echo precontrast (290/4; flip angle, 90°) and (j) postcontrast subtracted breast MR images reveal stellate mass (arrows) in upper outer quadrant. No contrast enhancement is seen on j. Patient did not undergo biopsy; absence of recurrent cancer was confirmed over 2-year follow-up.

View larger version (96K): [in this window] [in a new window] [Download PPT slide]   Figure 1g: (a–h) Breast MR for problem solving: scar versus recurrent cancer after breast-conserving therapy. (a–e) Local recurrence depicted at MR in a 60-year-old patient who underwent breast-conserving therapy 6 years previously. (a, b) Craniocaudal mammograms obtained in (a) August 2004 and (b) August 2005 reveal scar tissue, with discrete changes in scar appearance over 1-year follow-up. (c–e) Transverse T1-weighted gradient-echo breast MR images (repetition time msec/echo time msec, 290/4; flip angle, 90°) obtained in August 2005 (c) before and (d) after contrast material administration and (e) postcontrast subtracted image reveal scar as hypointense mass in c (arrow). Postcontrast images (d, e) show enhancement in medial aspect of the scar (upper arrow); a focus toward chest wall is also seen (lower arrow). MR-guided biopsy revealed multifocal recurrence in the scar and prepectoral focus. (f–j) Scar tissue in 43-year-old patient after breast-conserving therapy 3 years previously. (f, g) Two-view mammogram reveals spiculated mass (arrow) in upper outer quadrant at site of previous breast cancer. Lesion exhibits increased density compared with previous mammograms (not shown) and was interpreted as suspicious for recurrence (Breast Imaging Reporting and Data System [BI-RADS] category 4). (h) US image reveals hypoechoic mass (arrows) with posterior acoustic shadowing, compatible with both recurrent cancer and scar tissue. Transverse (i) T1-weighted gradient-echo precontrast (290/4; flip angle, 90°) and (j) postcontrast subtracted breast MR images reveal stellate mass (arrows) in upper outer quadrant. No contrast enhancement is seen on j. Patient did not undergo biopsy; absence of recurrent cancer was confirmed over 2-year follow-up.

View larger version (108K): [in this window] [in a new window] [Download PPT slide]   Figure 1h: (a–h) Breast MR for problem solving: scar versus recurrent cancer after breast-conserving therapy. (a–e) Local recurrence depicted at MR in a 60-year-old patient who underwent breast-conserving therapy 6 years previously. (a, b) Craniocaudal mammograms obtained in (a) August 2004 and (b) August 2005 reveal scar tissue, with discrete changes in scar appearance over 1-year follow-up. (c–e) Transverse T1-weighted gradient-echo breast MR images (repetition time msec/echo time msec, 290/4; flip angle, 90°) obtained in August 2005 (c) before and (d) after contrast material administration and (e) postcontrast subtracted image reveal scar as hypointense mass in c (arrow). Postcontrast images (d, e) show enhancement in medial aspect of the scar (upper arrow); a focus toward chest wall is also seen (lower arrow). MR-guided biopsy revealed multifocal recurrence in the scar and prepectoral focus. (f–j) Scar tissue in 43-year-old patient after breast-conserving therapy 3 years previously. (f, g) Two-view mammogram reveals spiculated mass (arrow) in upper outer quadrant at site of previous breast cancer. Lesion exhibits increased density compared with previous mammograms (not shown) and was interpreted as suspicious for recurrence (Breast Imaging Reporting and Data System [BI-RADS] category 4). (h) US image reveals hypoechoic mass (arrows) with posterior acoustic shadowing, compatible with both recurrent cancer and scar tissue. Transverse (i) T1-weighted gradient-echo precontrast (290/4; flip angle, 90°) and (j) postcontrast subtracted breast MR images reveal stellate mass (arrows) in upper outer quadrant. No contrast enhancement is seen on j. Patient did not undergo biopsy; absence of recurrent cancer was confirmed over 2-year follow-up.

View larger version (109K): [in this window] [in a new window] [Download PPT slide]   Figure 1i: (a–h) Breast MR for problem solving: scar versus recurrent cancer after breast-conserving therapy. (a–e) Local recurrence depicted at MR in a 60-year-old patient who underwent breast-conserving therapy 6 years previously. (a, b) Craniocaudal mammograms obtained in (a) August 2004 and (b) August 2005 reveal scar tissue, with discrete changes in scar appearance over 1-year follow-up. (c–e) Transverse T1-weighted gradient-echo breast MR images (repetition time msec/echo time msec, 290/4; flip angle, 90°) obtained in August 2005 (c) before and (d) after contrast material administration and (e) postcontrast subtracted image reveal scar as hypointense mass in c (arrow). Postcontrast images (d, e) show enhancement in medial aspect of the scar (upper arrow); a focus toward chest wall is also seen (lower arrow). MR-guided biopsy revealed multifocal recurrence in the scar and prepectoral focus. (f–j) Scar tissue in 43-year-old patient after breast-conserving therapy 3 years previously. (f, g) Two-view mammogram reveals spiculated mass (arrow) in upper outer quadrant at site of previous breast cancer. Lesion exhibits increased density compared with previous mammograms (not shown) and was interpreted as suspicious for recurrence (Breast Imaging Reporting and Data System [BI-RADS] category 4). (h) US image reveals hypoechoic mass (arrows) with posterior acoustic shadowing, compatible with both recurrent cancer and scar tissue. Transverse (i) T1-weighted gradient-echo precontrast (290/4; flip angle, 90°) and (j) postcontrast subtracted breast MR images reveal stellate mass (arrows) in upper outer quadrant. No contrast enhancement is seen on j. Patient did not undergo biopsy; absence of recurrent cancer was confirmed over 2-year follow-up.

View larger version (106K): [in this window] [in a new window] [Download PPT slide]   Figure 1j: (a–h) Breast MR for problem solving: scar versus recurrent cancer after breast-conserving therapy. (a–e) Local recurrence depicted at MR in a 60-year-old patient who underwent breast-conserving therapy 6 years previously. (a, b) Craniocaudal mammograms obtained in (a) August 2004 and (b) August 2005 reveal scar tissue, with discrete changes in scar appearance over 1-year follow-up. (c–e) Transverse T1-weighted gradient-echo breast MR images (repetition time msec/echo time msec, 290/4; flip angle, 90°) obtained in August 2005 (c) before and (d) after contrast material administration and (e) postcontrast subtracted image reveal scar as hypointense mass in c (arrow). Postcontrast images (d, e) show enhancement in medial aspect of the scar (upper arrow); a focus toward chest wall is also seen (lower arrow). MR-guided biopsy revealed multifocal recurrence in the scar and prepectoral focus. (f–j) Scar tissue in 43-year-old patient after breast-conserving therapy 3 years previously. (f, g) Two-view mammogram reveals spiculated mass (arrow) in upper outer quadrant at site of previous breast cancer. Lesion exhibits increased density compared with previous mammograms (not shown) and was interpreted as suspicious for recurrence (Breast Imaging Reporting and Data System [BI-RADS] category 4). (h) US image reveals hypoechoic mass (arrows) with posterior acoustic shadowing, compatible with both recurrent cancer and scar tissue. Transverse (i) T1-weighted gradient-echo precontrast (290/4; flip angle, 90°) and (j) postcontrast subtracted breast MR images reveal stellate mass (arrows) in upper outer quadrant. No contrast enhancement is seen on j. Patient did not undergo biopsy; absence of recurrent cancer was confirmed over 2-year follow-up.

A clinical scenario in which the NPV of breast MR is known to be insufficient involves the patient with suspicious mammographic calcifications. The sensitivity of breast MR imaging for demonstrating ductal carcinoma in situ (DCIS) that exhibits calcifications on a mammogram is only about 85%. Accordingly, the decision about whether to perform biopsy of suspicious calcifications must be based on their mammographic appearance alone. Nevertheless, MR imaging is useful in patients with calcifications: It can help (a) demonstrate or exclude underlying invasive cancer, which can be accomplished with high confidence because of the high NPV for invasive cancer, and/or (b) demonstrate the extent of (possible) DCIS. In this context, it is important to understand that mammography and MR imaging are complementary for diagnosis of DCIS: While MR does not depict all DCIS cases that manifest as calcifications on a mammogram, mammography in turn does not depict all DCIS cases that manifest as contrast material enhancement on breast MR images. On the basis of current research, it appears that indeed the overall sensitivity of MR for high-grade DCIS is substantially higher than that of mammography (16).

MR in Women with Normal Conventional Imaging Studies but with Clinical Signs or Symptoms of Breast Cancer
Carcinoma of unknown primary.—Each year, about 2%–7% of all new cases of solid cancer are diagnosed primarily by noting their metastatic spread, without evidence of the primary cancer (17,18). In about 5% of these patients, the site of metastases are the axillary lymph nodes, which suggests the breast as the site of the primary cancer. Compared with other sites of metastasis, axillary lymph nodes are associated with a relatively favorable prognosis (19). Owing to the relatively low incidence of the carcinoma of unknown primary situation, published studies on this topic report on relatively small numbers of subjects. On the basis of this limited evidence, it seems that breast MR helps identify the primary breast cancer if the mammogram and US studies remain normal and that, importantly, a negative breast MR image can be used to alleviate the indication for mastectomy (20–25). In view of the high NPV of MR imaging, oncologists advocate radiation therapy only or no local therapy at all in women with negative MR images.

Pathologic nipple discharge.—Pathologic nipple discharge may be a symptom of breast cancer, although in the majority of cases (80%–90%) ductal ectasia and/or solitary or multiple papillomas will be the underlying cause (26). Imaging studies are performed not only to demonstrate (or exclude) breast cancer but also to locate benign lesions that cause these symptoms. Mammography and breast US are complementary for this purpose (27,28), yet in the majority of cases both imaging studies will be normal. Galactography may be helpful (27–29) but is not always technically feasible in patients with only intermittent discharge or in patients with discharge from more than one orifice. Even in experienced hands, technical failures will occur in up to 10% of cases (27). More important, the diagnostic yield is limited. In a larger series of patients presenting with nipple discharge and normal mammogram, the sensitivity for demonstrating a malignant lesion at galactography was reported to range between 0% and 55% (30–32). Last, even if the galactogram does reveal a lesion, it may not be removed by means of subsequent excisional biopsy in up to 20% of cases (33,34), owing to the difficulty of preoperative localization. MR imaging can help detect an intraductal lesion in women with nipple discharge and normal conventional imaging findings (35–37). However, differentiation between a papilloma and a small invasive cancer or DCIS is usually not attainable with breast MR imaging (Fig 2).

View larger version (118K): [in this window] [in a new window] [Download PPT slide]   Figure 2a: Images in 60-year-old patient with 2-month history of bloody nipple discharge. (a, b) Two-view mammogram and (c) breast US image reveal dilated milk duct immediately behind the nipple and hypoechoic material filling the milk duct 10 mm behind the nipple, which was found to be blood clot and detritus. Transverse (d) T1-weighted gradient-echo precontrast (290/4.6; flip angle, 90°) and (e) and postcontrast subtracted MR images reveal ductal enhancement (arrow) in 12-o'clock position, 40 mm cephalad to nipple. MR-guided biopsy confirmed papilloma.

View larger version (111K): [in this window] [in a new window] [Download PPT slide]   Figure 2b: Images in 60-year-old patient with 2-month history of bloody nipple discharge. (a, b) Two-view mammogram and (c) breast US image reveal dilated milk duct immediately behind the nipple and hypoechoic material filling the milk duct 10 mm behind the nipple, which was found to be blood clot and detritus. Transverse (d) T1-weighted gradient-echo precontrast (290/4.6; flip angle, 90°) and (e) and postcontrast subtracted MR images reveal ductal enhancement (arrow) in 12-o'clock position, 40 mm cephalad to nipple. MR-guided biopsy confirmed papilloma.

View larger version (132K): [in this window] [in a new window] [Download PPT slide]   Figure 2c: Images in 60-year-old patient with 2-month history of bloody nipple discharge. (a, b) Two-view mammogram and (c) breast US image reveal dilated milk duct immediately behind the nipple and hypoechoic material filling the milk duct 10 mm behind the nipple, which was found to be blood clot and detritus. Transverse (d) T1-weighted gradient-echo precontrast (290/4.6; flip angle, 90°) and (e) and postcontrast subtracted MR images reveal ductal enhancement (arrow) in 12-o'clock position, 40 mm cephalad to nipple. MR-guided biopsy confirmed papilloma.

View larger version (102K): [in this window] [in a new window] [Download PPT slide]   Figure 2d: Images in 60-year-old patient with 2-month history of bloody nipple discharge. (a, b) Two-view mammogram and (c) breast US image reveal dilated milk duct immediately behind the nipple and hypoechoic material filling the milk duct 10 mm behind the nipple, which was found to be blood clot and detritus. Transverse (d) T1-weighted gradient-echo precontrast (290/4.6; flip angle, 90°) and (e) and postcontrast subtracted MR images reveal ductal enhancement (arrow) in 12-o'clock position, 40 mm cephalad to nipple. MR-guided biopsy confirmed papilloma.

View larger version (112K): [in this window] [in a new window] [Download PPT slide]   Figure 2e: Images in 60-year-old patient with 2-month history of bloody nipple discharge. (a, b) Two-view mammogram and (c) breast US image reveal dilated milk duct immediately behind the nipple and hypoechoic material filling the milk duct 10 mm behind the nipple, which was found to be blood clot and detritus. Transverse (d) T1-weighted gradient-echo precontrast (290/4.6; flip angle, 90°) and (e) and postcontrast subtracted MR images reveal ductal enhancement (arrow) in 12-o'clock position, 40 mm cephalad to nipple. MR-guided biopsy confirmed papilloma.

To avoid harm and costs due to inefficient treatment, it is desirable to predict response to neoadjuvant chemotherapy as early as possible, ideally immediately after the first cycle. Imaging during this early phase is aimed at demonstrating the presence (or absence) of a metabolic response to treatment rather than a change in tumor size. Metabolic response can only be assessed on imaging studies that offer functional information on tumor perfusion and metabolic turnover. PET is such a technique and has an established role for the early assessment of response behavior, although the published evidence is limited to a total of 180 patients who were investigated in as many as eight nonrandomized studies (38–46).

There is now increasing evidence that the same functional information may also be obtained by using dynamic contrast material–enhanced MR imaging, MR spectroscopy, and/or diffusion-weighted MR imaging. In a total 74 patients, dynamic contrast-enhanced breast MR imaging has been used to identify responders 6 weeks after the first chemotherapy cycle (47–50). As the earliest sign of response, a change of enhancement kinetics was observed (slower wash-in rate, absence of a washout pattern—ie, flattening of the enhancement curve), which preceded a change in tumor morphology by several weeks.

Proton MR spectroscopy, in particular at higher magnetic field strength, and diffusion-weighted imaging can help distinguish responders and nonresponders even earlier, as soon as 24 hours after the first cycle of chemotherapy (51–55). In proton MR spectroscopy, breast cancers typically exhibit an elevated choline resonance; choline is a metabolite implicated in cellular membrane turnover and, thus, is a marker of cellular proliferation. A reduction of the choline peak seems to provide a very early sign of response. In addition, there is also evidence that the baseline (before neoadjuvant chemotherapy) signal intensity of the choline peak provides predictive information—that is, helps assess the likelihood with which a given cancer will respond to treatment. Diffusion-weighted imaging helps detect cytotoxic effects of neoadjuvant chemotherapy by demonstrating changes in the free interstitial water diffusion rates.

Since assessing response to chemotherapy should have a substantial impact on clinical decision making, it may emerge as one of the most important indications for breast MR. To obtain more and higher-level evidence for this indication, the American College of Radiology Imaging Network (ACRIN) has sponsored a multi-institutional prospective clinical trial (ACRIN 6657) to evaluate the role of MR for predicting response to treatment.

After neoadjuvant chemotherapy, MR is used to depict residual disease. Several studies have investigated the confidence with which residual disease is demonstrated with different imaging modalities, and all are concordant that breast MR imaging is superior to conventional imaging and clinical breast assessment (Fig 3). MR findings correlate significantly better with pathologic response, with correlation coefficients ranging between 0.72 and 0.93, compared with 0.30–0.52 for conventional imaging and about 0.19 for clinical assessment (57–67). Although MR imaging may be superior to other methods, the correlation is not a perfect 100%. In other words, even if an MR study is negative, vital tumor remnants may be identified in up to 30% of patients.

View larger version (80K): [in this window] [in a new window] [Download PPT slide]   Figure 3a: Monitoring primary neoadjuvant chemotherapy in 35-year-old patient with invasive ductal cancer who had presented with a palpable mass in upper outer quadrant of right breast and right-sided axillary lymphadenopathy. (a) Diagnostic mammogram reveals very dense (American College of Radiology category 4) tissue and pleomorphic calcifications (arrow) at site of the palpable lump. (b) US of right breast at patient's first visit demonstrates large hypoechoic mass at site of the palpable lump. US-guided biopsy revealed ductal invasive cancer, grade III. (d) Breast MR image (290/4.6, 90° flip angle) obtained at first visit reveals huge cancer (arrows) that infiltrated almost entire right breast including the upper outer, upper inner, and lower outer quadrants (not shown). Patient was considered a candidate for neoadjuvant chemotherapy and received epirubicine, cyclophosphamide and taxane. Follow-up revealed complete response on clinical, as well as mammographic (not shown), grounds and at (c) breast US. (e) Breast MR image (290/4.6, 90° flip angle) obtained after therapy reveals residual enhancing tissue in upper outer and lower outer quadrants (arrows). Mastectomy was performed and confirmed residual vital tumor disseminated in both outer quadrants of the right breast.

View larger version (93K): [in this window] [in a new window] [Download PPT slide]   Figure 3b: Monitoring primary neoadjuvant chemotherapy in 35-year-old patient with invasive ductal cancer who had presented with a palpable mass in upper outer quadrant of right breast and right-sided axillary lymphadenopathy. (a) Diagnostic mammogram reveals very dense (American College of Radiology category 4) tissue and pleomorphic calcifications (arrow) at site of the palpable lump. (b) US of right breast at patient's first visit demonstrates large hypoechoic mass at site of the palpable lump. US-guided biopsy revealed ductal invasive cancer, grade III. (d) Breast MR image (290/4.6, 90° flip angle) obtained at first visit reveals huge cancer (arrows) that infiltrated almost entire right breast including the upper outer, upper inner, and lower outer quadrants (not shown). Patient was considered a candidate for neoadjuvant chemotherapy and received epirubicine, cyclophosphamide and taxane. Follow-up revealed complete response on clinical, as well as mammographic (not shown), grounds and at (c) breast US. (e) Breast MR image (290/4.6, 90° flip angle) obtained after therapy reveals residual enhancing tissue in upper outer and lower outer quadrants (arrows). Mastectomy was performed and confirmed residual vital tumor disseminated in both outer quadrants of the right breast.

View larger version (116K): [in this window] [in a new window] [Download PPT slide]   Figure 3c: Monitoring primary neoadjuvant chemotherapy in 35-year-old patient with invasive ductal cancer who had presented with a palpable mass in upper outer quadrant of right breast and right-sided axillary lymphadenopathy. (a) Diagnostic mammogram reveals very dense (American College of Radiology category 4) tissue and pleomorphic calcifications (arrow) at site of the palpable lump. (b) US of right breast at patient's first visit demonstrates large hypoechoic mass at site of the palpable lump. US-guided biopsy revealed ductal invasive cancer, grade III. (d) Breast MR image (290/4.6, 90° flip angle) obtained at first visit reveals huge cancer (arrows) that infiltrated almost entire right breast including the upper outer, upper inner, and lower outer quadrants (not shown). Patient was considered a candidate for neoadjuvant chemotherapy and received epirubicine, cyclophosphamide and taxane. Follow-up revealed complete response on clinical, as well as mammographic (not shown), grounds and at (c) breast US. (e) Breast MR image (290/4.6, 90° flip angle) obtained after therapy reveals residual enhancing tissue in upper outer and lower outer quadrants (arrows). Mastectomy was performed and confirmed residual vital tumor disseminated in both outer quadrants of the right breast.

View larger version (95K): [in this window] [in a new window] [Download PPT slide]   Figure 3d: Monitoring primary neoadjuvant chemotherapy in 35-year-old patient with invasive ductal cancer who had presented with a palpable mass in upper outer quadrant of right breast and right-sided axillary lymphadenopathy. (a) Diagnostic mammogram reveals very dense (American College of Radiology category 4) tissue and pleomorphic calcifications (arrow) at site of the palpable lump. (b) US of right breast at patient's first visit demonstrates large hypoechoic mass at site of the palpable lump. US-guided biopsy revealed ductal invasive cancer, grade III. (d) Breast MR image (290/4.6, 90° flip angle) obtained at first visit reveals huge cancer (arrows) that infiltrated almost entire right breast including the upper outer, upper inner, and lower outer quadrants (not shown). Patient was considered a candidate for neoadjuvant chemotherapy and received epirubicine, cyclophosphamide and taxane. Follow-up revealed complete response on clinical, as well as mammographic (not shown), grounds and at (c) breast US. (e) Breast MR image (290/4.6, 90° flip angle) obtained after therapy reveals residual enhancing tissue in upper outer and lower outer quadrants (arrows). Mastectomy was performed and confirmed residual vital tumor disseminated in both outer quadrants of the right breast.

View larger version (88K): [in this window] [in a new window] [Download PPT slide]   Figure 3e: Monitoring primary neoadjuvant chemotherapy in 35-year-old patient with invasive ductal cancer who had presented with a palpable mass in upper outer quadrant of right breast and right-sided axillary lymphadenopathy. (a) Diagnostic mammogram reveals very dense (American College of Radiology category 4) tissue and pleomorphic calcifications (arrow) at site of the palpable lump. (b) US of right breast at patient's first visit demonstrates large hypoechoic mass at site of the palpable lump. US-guided biopsy revealed ductal invasive cancer, grade III. (d) Breast MR image (290/4.6, 90° flip angle) obtained at first visit reveals huge cancer (arrows) that infiltrated almost entire right breast including the upper outer, upper inner, and lower outer quadrants (not shown). Patient was considered a candidate for neoadjuvant chemotherapy and received epirubicine, cyclophosphamide and taxane. Follow-up revealed complete response on clinical, as well as mammographic (not shown), grounds and at (c) breast US. (e) Breast MR image (290/4.6, 90° flip angle) obtained after therapy reveals residual enhancing tissue in upper outer and lower outer quadrants (arrows). Mastectomy was performed and confirmed residual vital tumor disseminated in both outer quadrants of the right breast.

MR Imaging in Patients with Breast Implants
Breast MR imaging in patients with breast implants is performed to investigate the integrity of the implant shell and delineate breast cancer around or behind the implant. To evaluate breast implant integrity, no contrast agent is needed, although it may be helpful to depict chronic inflammatory changes around the implant due to what clinically appears as "capsulitis" or implant fibrosis. Unlike mammography, MR imaging enables the diagnosis of breast cancers arising behind an implant, particularly if the implant was placed in the prepectoral or retroglandular location. Therefore, MR imaging should be considered the method of choice for help in diagnosing breast cancers in this subset of women.

MR Imaging in Drug Development and Discovery
Usually, the efficacy of a new drug has been evaluated by assessing treatment response either on clinical and/or pathologic grounds. While the former is prone to error and may be inaccurate, the latter is relatively difficult to obtain on a serial basis and, if obtained in vivo (eg, with core biopsy), may in turn suffer from sampling errors. With the ever increasing speed of drug development, there is an ever increasing demand for an alternate noninvasive surrogate marker of treatment success that is sensitive and more accurate than clinical assessment and that is more readily available, less traumatic, and more representative than serial core biopsy. Imaging techniques such as MR that provide both morphologic and functional information will, in the foreseeable future, play an important role for this purpose. With the wealth of tissue information that is already provided by MR-based techniques today (morphology, contrast-enhancement kinetics, perfusion volume and vessel permeability, diffusion rates, and metabolic information at proton or phosphorus MR spectroscopy), MR is ideally suited to help assess treatment response on a tissue level. Accordingly, it would be reasonable to integrate functional breast MR into the planning of phase I and phase II clinical trials. With the rapidly advancing technologies of molecular imaging, MR-based technologies will allow an even more targeted approach for evaluating treatment and will probably allow assessment of treatment on a cellular level (56).

Staging Known Breast Cancer
According to the European guidelines, at least 80% of women with newly diagnosed breast cancer should be treated with breast-conserving surgery plus radiation therapy (71). Since, in most patients, breast cancer surgery is performed with curative intent, an accurate delineation of disease extent is of key importance (Figs 4–7). This provides a road map to help the surgeon achieve clear margins with only one surgical intervention (identification of additional multifocal or multicentric breast cancer foci, presence of an intraductal component around an invasive cancer); identify contraindications for breast conservation, such as infiltration of the chest wall or areola; and identify breast cancer in the opposite breast.

View larger version (94K): [in this window] [in a new window] [Download PPT slide]   Figure 4a: Preoperative staging with breast MR imaging in 45-year-old patient who had undergone mastectomy for left breast cancer 5 years previously. Follow-up (a) mediolateral oblique, (b) craniocaudal, and (c) spot magnification mammographic views of right breast reveal mass (arrow) between lower quadrants that is highly suspicious for contralateral cancer (BI-RADS category 5). (d) Whole-breast US was performed for core biopsy of known lesion (arrow), which confirmed presence of cancer, and for further staging but did not reveal additional lesions. Transverse (e) T1-weighted gradient-echo precontrast (290/4.6; flip angle, 90°) and (f, g) postcontrast subtracted breast MR images depict known cancer (arrow in e and f) between lower quadrants (BI-RADS category 6) and another enhancing mass (arrow in g) in upper inner quadrant (BI-RADS category 4). MR-guided biopsy results confirmed additional small (6-mm) stage pT1b breast cancer plus adjacent DCIS. Patient underwent mastectomy.

View larger version (60K): [in this window] [in a new window] [Download PPT slide]   Figure 4b: Preoperative staging with breast MR imaging in 45-year-old patient who had undergone mastectomy for left breast cancer 5 years previously. Follow-up (a) mediolateral oblique, (b) craniocaudal, and (c) spot magnification mammographic views of right breast reveal mass (arrow) between lower quadrants that is highly suspicious for contralateral cancer (BI-RADS category 5). (d) Whole-breast US was performed for core biopsy of known lesion (arrow), which confirmed presence of cancer, and for further staging but did not reveal additional lesions. Transverse (e) T1-weighted gradient-echo precontrast (290/4.6; flip angle, 90°) and (f, g) postcontrast subtracted breast MR images depict known cancer (arrow in e and f) between lower quadrants (BI-RADS category 6) and another enhancing mass (arrow in g) in upper inner quadrant (BI-RADS category 4). MR-guided biopsy results confirmed additional small (6-mm) stage pT1b breast cancer plus adjacent DCIS. Patient underwent mastectomy.

View larger version (87K): [in this window] [in a new window] [Download PPT slide]   Figure 4c: Preoperative staging with breast MR imaging in 45-year-old patient who had undergone mastectomy for left breast cancer 5 years previously. Follow-up (a) mediolateral oblique, (b) craniocaudal, and (c) spot magnification mammographic views of right breast reveal mass (arrow) between lower quadrants that is highly suspicious for contralateral cancer (BI-RADS category 5). (d) Whole-breast US was performed for core biopsy of known lesion (arrow), which confirmed presence of cancer, and for further staging but did not reveal additional lesions. Transverse (e) T1-weighted gradient-echo precontrast (290/4.6; flip angle, 90°) and (f, g) postcontrast subtracted breast MR images depict known cancer (arrow in e and f) between lower quadrants (BI-RADS category 6) and another enhancing mass (arrow in g) in upper inner quadrant (BI-RADS category 4). MR-guided biopsy results confirmed additional small (6-mm) stage pT1b breast cancer plus adjacent DCIS. Patient underwent mastectomy.

View larger version (181K): [in this window] [in a new window] [Download PPT slide]   Figure 4d: Preoperative staging with breast MR imaging in 45-year-old patient who had undergone mastectomy for left breast cancer 5 years previously. Follow-up (a) mediolateral oblique, (b) craniocaudal, and (c) spot magnification mammographic views of right breast reveal mass (arrow) between lower quadrants that is highly suspicious for contralateral cancer (BI-RADS category 5). (d) Whole-breast US was performed for core biopsy of known lesion (arrow), which confirmed presence of cancer, and for further staging but did not reveal additional lesions. Transverse (e) T1-weighted gradient-echo precontrast (290/4.6; flip angle, 90°) and (f, g) postcontrast subtracted breast MR images depict known cancer (arrow in e and f) between lower quadrants (BI-RADS category 6) and another enhancing mass (arrow in g) in upper inner quadrant (BI-RADS category 4). MR-guided biopsy results confirmed additional small (6-mm) stage pT1b breast cancer plus adjacent DCIS. Patient underwent mastectomy.

View larger version (77K): [in this window] [in a new window] [Download PPT slide]   Figure 4e: Preoperative staging with breast MR imaging in 45-year-old patient who had undergone mastectomy for left breast cancer 5 years previously. Follow-up (a) mediolateral oblique, (b) craniocaudal, and (c) spot magnification mammographic views of right breast reveal mass (arrow) between lower quadrants that is highly suspicious for contralateral cancer (BI-RADS category 5). (d) Whole-breast US was performed for core biopsy of known lesion (arrow), which confirmed presence of cancer, and for further staging but did not reveal additional lesions. Transverse (e) T1-weighted gradient-echo precontrast (290/4.6; flip angle, 90°) and (f, g) postcontrast subtracted breast MR images depict known cancer (arrow in e and f) between lower quadrants (BI-RADS category 6) and another enhancing mass (arrow in g) in upper inner quadrant (BI-RADS category 4). MR-guided biopsy results confirmed additional small (6-mm) stage pT1b breast cancer plus adjacent DCIS. Patient underwent mastectomy.

View larger version (76K): [in this window] [in a new window] [Download PPT slide]   Figure 4f: Preoperative staging with breast MR imaging in 45-year-old patient who had undergone mastectomy for left breast cancer 5 years previously. Follow-up (a) mediolateral oblique, (b) craniocaudal, and (c) spot magnification mammographic views of right breast reveal mass (arrow) between lower quadrants that is highly suspicious for contralateral cancer (BI-RADS category 5). (d) Whole-breast US was performed for core biopsy of known lesion (arrow), which confirmed presence of cancer, and for further staging but did not reveal additional lesions. Transverse (e) T1-weighted gradient-echo precontrast (290/4.6; flip angle, 90°) and (f, g) postcontrast subtracted breast MR images depict known cancer (arrow in e and f) between lower quadrants (BI-RADS category 6) and another enhancing mass (arrow in g) in upper inner quadrant (BI-RADS category 4). MR-guided biopsy results confirmed additional small (6-mm) stage pT1b breast cancer plus adjacent DCIS. Patient underwent mastectomy.

View larger version (78K): [in this window] [in a new window] [Download PPT slide]   Figure 4g: Preoperative staging with breast MR imaging in 45-year-old patient who had undergone mastectomy for left breast cancer 5 years previously. Follow-up (a) mediolateral oblique, (b) craniocaudal, and (c) spot magnification mammographic views of right breast reveal mass (arrow) between lower quadrants that is highly suspicious for contralateral cancer (BI-RADS category 5). (d) Whole-breast US was performed for core biopsy of known lesion (arrow), which confirmed presence of cancer, and for further staging but did not reveal additional lesions. Transverse (e) T1-weighted gradient-echo precontrast (290/4.6; flip angle, 90°) and (f, g) postcontrast subtracted breast MR images depict known cancer (arrow in e and f) between lower quadrants (BI-RADS category 6) and another enhancing mass (arrow in g) in upper inner quadrant (BI-RADS category 4). MR-guided biopsy results confirmed additional small (6-mm) stage pT1b breast cancer plus adjacent DCIS. Patient underwent mastectomy.

View larger version (70K): [in this window] [in a new window] [Download PPT slide]   Figure 5a: Preoperative staging with breast MR imaging in 53-year-old patient whose core biopsy results proved invasive lobular cancer in right breast. Contralateral cancer was identified on preoperative breast MR images. (a–d) Two-view bilateral mammograms reveal large mass (arrow) in upper outer quadrant of right breast. Left breast appears normal (BI-RADS category 1). At breast US for staging (not shown), left breast appeared normal. (e–g) Transverse postcontrast subtracted MR images depict known cancer in right breast (arrow in e) and two enhancing foci, 3 and 4 mm in size, in contralateral breast in the lower outer quadrant (IL 1, arrow in f) and upper inner quadrant (IL 2, arrow in g). (h–j) For further work-up of incidental lesions, (h, i) spot compression mammographic views and (j) second-look US images were obtained. A correlate for the lesion in f was identified on i (IL 1?, arrow) while a correlate for the lesion in g was seen on j (IL 2?, arrow). Histologic analysis of lesion on f revealed 4-mm stage pT1aN0 invasive lobular cancer, and that of lesion on g revealed 3-mm area of focal adenosis.

View larger version (76K): [in this window] [in a new window] [Download PPT slide]   Figure 5b: Preoperative staging with breast MR imaging in 53-year-old patient whose core biopsy results proved invasive lobular cancer in right breast. Contralateral cancer was identified on preoperative breast MR images. (a–d) Two-view bilateral mammograms reveal large mass (arrow) in upper outer quadrant of right breast. Left breast appears normal (BI-RADS category 1). At breast US for staging (not shown), left breast appeared normal. (e–g) Transverse postcontrast subtracted MR images depict known cancer in right breast (arrow in e) and two enhancing foci, 3 and 4 mm in size, in contralateral breast in the lower outer quadrant (IL 1, arrow in f) and upper inner quadrant (IL 2, arrow in g). (h–j) For further work-up of incidental lesions, (h, i) spot compression mammographic views and (j) second-look US images were obtained. A correlate for the lesion in f was identified on i (IL 1?, arrow) while a correlate for the lesion in g was seen on j (IL 2?, arrow). Histologic analysis of lesion on f revealed 4-mm stage pT1aN0 invasive lobular cancer, and that of lesion on g revealed 3-mm area of focal adenosis.

View larger version (84K): [in this window] [in a new window] [Download PPT slide]   Figure 5c: Preoperative staging with breast MR imaging in 53-year-old patient whose core biopsy results proved invasive lobular cancer in right breast. Contralateral cancer was identified on preoperative breast MR images. (a–d) Two-view bilateral mammograms reveal large mass (arrow) in upper outer quadrant of right breast. Left breast appears normal (BI-RADS category 1). At breast US for staging (not shown), left breast appeared normal. (e–g) Transverse postcontrast subtracted MR images depict known cancer in right breast (arrow in e) and two enhancing foci, 3 and 4 mm in size, in contralateral breast in the lower outer quadrant (IL 1, arrow in f) and upper inner quadrant (IL 2, arrow in g). (h–j) For further work-up of incidental lesions, (h, i) spot compression mammographic views and (j) second-look US images were obtained. A correlate for the lesion in f was identified on i (IL 1?, arrow) while a correlate for the lesion in g was seen on j (IL 2?, arrow). Histologic analysis of lesion on f revealed 4-mm stage pT1aN0 invasive lobular cancer, and that of lesion on g revealed 3-mm area of focal adenosis.

View larger version (85K): [in this window] [in a new window] [Download PPT slide]   Figure 5d: Preoperative staging with breast MR imaging in 53-year-old patient whose core biopsy results proved invasive lobular cancer in right breast. Contralateral cancer was identified on preoperative breast MR images. (a–d) Two-view bilateral mammograms reveal large mass (arrow) in upper outer quadrant of right breast. Left breast appears normal (BI-RADS category 1). At breast US for staging (not shown), left breast appeared normal. (e–g) Transverse postcontrast subtracted MR images depict known cancer in right breast (arrow in e) and two enhancing foci, 3 and 4 mm in size, in contralateral breast in the lower outer quadrant (IL 1, arrow in f) and upper inner quadrant (IL 2, arrow in g). (h–j) For further work-up of incidental lesions, (h, i) spot compression mammographic views and (j) second-look US images were obtained. A correlate for the lesion in f was identified on i (IL 1?, arrow) while a correlate for the lesion in g was seen on j (IL 2?, arrow). Histologic analysis of lesion on f revealed 4-mm stage pT1aN0 invasive lobular cancer, and that of lesion on g revealed 3-mm area of focal adenosis.

View larger version (112K): [in this window] [in a new window] [Download PPT slide]   Figure 5e: Preoperative staging with breast MR imaging in 53-year-old patient whose core biopsy results proved invasive lobular cancer in right breast. Contralateral cancer was identified on preoperative breast MR images. (a–d) Two-view bilateral mammograms reveal large mass (arrow) in upper outer quadrant of right breast. Left breast appears normal (BI-RADS category 1). At breast US for staging (not shown), left breast appeared normal. (e–g) Transverse postcontrast subtracted MR images depict known cancer in right breast (arrow in e) and two enhancing foci, 3 and 4 mm in size, in contralateral breast in the lower outer quadrant (IL 1, arrow in f) and upper inner quadrant (IL 2, arrow in g). (h–j) For further work-up of incidental lesions, (h, i) spot compression mammographic views and (j) second-look US images were obtained. A correlate for the lesion in f was identified on i (IL 1?, arrow) while a correlate for the lesion in g was seen on j (IL 2?, arrow). Histologic analysis of lesion on f revealed 4-mm stage pT1aN0 invasive lobular cancer, and that of lesion on g revealed 3-mm area of focal adenosis.

View larger version (113K): [in this window] [in a new window] [Download PPT slide]   Figure 5f: Preoperative staging with breast MR imaging in 53-year-old patient whose core biopsy results proved invasive lobular cancer in right breast. Contralateral cancer was identified on preoperative breast MR images. (a–d) Two-view bilateral mammograms reveal large mass (arrow) in upper outer quadrant of right breast. Left breast appears normal (BI-RADS category 1). At breast US for staging (not shown), left breast appeared normal. (e–g) Transverse postcontrast subtracted MR images depict known cancer in right breast (arrow in e) and two enhancing foci, 3 and 4 mm in size, in contralateral breast in the lower outer quadrant (IL 1, arrow in f) and upper inner quadrant (IL 2, arrow in g). (h–j) For further work-up of incidental lesions, (h, i) spot compression mammographic views and (j) second-look US images were obtained. A correlate for the lesion in f was identified on i (IL 1?, arrow) while a correlate for the lesion in g was seen on j (IL 2?, arrow). Histologic analysis of lesion on f revealed 4-mm stage pT1aN0 invasive lobular cancer, and that of lesion on g revealed 3-mm area of focal adenosis.

View larger version (115K): [in this window] [in a new window] [Download PPT slide]   Figure 5g: Preoperative staging with breast MR imaging in 53-year-old patient whose core biopsy results proved invasive lobular cancer in right breast. Contralateral cancer was identified on preoperative breast MR images. (a–d) Two-view bilateral mammograms reveal large mass (arrow) in upper outer quadrant of right breast. Left breast appears normal (BI-RADS category 1). At breast US for staging (not shown), left breast appeared normal. (e–g) Transverse postcontrast subtracted MR images depict known cancer in right breast (arrow in e) and two enhancing foci, 3 and 4 mm in size, in contralateral breast in the lower outer quadrant (IL 1, arrow in f) and upper inner quadrant (IL 2, arrow in g). (h–j) For further work-up of incidental lesions, (h, i) spot compression mammographic views and (j) second-look US images were obtained. A correlate for the lesion in f was identified on i (IL 1?, arrow) while a correlate for the lesion in g was seen on j (IL 2?, arrow). Histologic analysis of lesion on f revealed 4-mm stage pT1aN0 invasive lobular cancer, and that of lesion on g revealed 3-mm area of focal adenosis.

View larger version (90K): [in this window] [in a new window] [Download PPT slide]   Figure 5h: Preoperative staging with breast MR imaging in 53-year-old patient whose core biopsy results proved invasive lobular cancer in right breast. Contralateral cancer was identified on preoperative breast MR images. (a–d) Two-view bilateral mammograms reveal large mass (arrow) in upper outer quadrant of right breast. Left breast appears normal (BI-RADS category 1). At breast US for staging (not shown), left breast appeared normal. (e–g) Transverse postcontrast subtracted MR images depict known cancer in right breast (arrow in e) and two enhancing foci, 3 and 4 mm in size, in contralateral breast in the lower outer quadrant (IL 1, arrow in f) and upper inner quadrant (IL 2, arrow in g). (h–j) For further work-up of incidental lesions, (h, i) spot compression mammographic views and (j) second-look US images were obtained. A correlate for the lesion in f was identified on i (IL 1?, arrow) while a correlate for the lesion in g was seen on j (IL 2?, arrow). Histologic analysis of lesion on f revealed 4-mm stage pT1aN0 invasive lobular cancer, and that of lesion on g revealed 3-mm area of focal adenosis.

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