A systematic review of the effectiveness of magnetic resonance imaging (MRI) as an addition to mammography and ultrasound in screening young women at high risk of breast cancer

Recommendations for breast cancer surveillance for female survivors of childhood, adolescent, and young adult cancer given chest radiation: a report from the International Late Effects of Childhood Cancer Guideline Harmonization Group

Female survivors of childhood, adolescent, and young adult (CAYA) cancer who were given radiation to fields that include breast tissue (ie, chest radiation) have an increased risk of breast cancer. Clinical practice guidelines are essential to ensure that these individuals receive optimum care and to reduce the detrimental consequences of cancer treatment; however, surveillance recommendations vary among the existing long-term follow-up guidelines. We applied evidence-based methods to develop international, harmonised recommendations for breast cancer surveillance among female survivors of CAYA cancer who were given chest radiation before age 30 years. The recommendations were formulated by an international, multidisciplinary panel and are graded according to the strength of the underlying evidence.

Rapid increase in breast magnetic resonance imaging use: trends from 2000 to 2011

IMPORTANCE

Breast magnetic resonance imaging (MRI) is highly sensitive for detecting breast cancer. Low specificity, cost, and little evidence regarding mortality benefits, however, limit recommendations for its use to high-risk women. How breast MRI is actually used in community settings is unknown.

OBJECTIVE

To describe breast MRI trends and indications in a community setting.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective cohort study at a not-for-profit health plan and multispecialty group medical practice in New England of 10,518 women aged 20 years and older enrolled in the health plan for at least 1 year who had at least 1 breast MRI between January 1, 2000, and December 31, 2011.

MAIN OUTCOMES AND MEASURES

Breast MRI counts were obtained from claims data. Clinical indication (screening, diagnostic evaluation, staging or treatment, or surveillance) was determined using a prediction model developed from electronic medical records on a subset of participants. Breast cancer risk status was assessed using claims data and, for the subset, also through electronic medical record review. RESULTS; Breast MRI use increased more than 20-fold from 6.5 per 10,000 women in 2000 to 130.7 per 10,000 in 2009. Use then declined and stabilized to 104.8 per 10,000 by 2011. Screening and surveillance, rare indications in 2000, together accounted for 57.6% of MRI use by 2011; 30.1% had a claims-documented personal history and 51.7% a family history of breast cancer, whereas 3.5% of women had a documented genetic mutation. In the subset of women with electronic medical records who received screening or surveillance MRIs, only 21.0% had evidence of meeting American Cancer Society (ACS) criteria for breast MRI. Conversely, only 48.4% of women with documented deleterious genetic mutations received breast MRI screening.

CONCLUSIONS AND RELEVANCE

Breast MRI use increased steeply over 10 years and then stabilized, especially for screening and surveillance among women with family or personal history of breast cancer; most women receiving screening and surveillance breast MRIs lacked documented evidence of meeting ACS criteria, and many women with mutations were not screened. Efforts are needed to ensure that breast MRI use and documentation are focused on those women who will benefit most.

Cost-effectiveness of MRI for breast cancer screening in BRCA1/2 mutation carriers

Background

Women with mutations in BRCA1 or BRCA2 are at high risk of developing breast cancer and, in British Columbia, Canada, are offered screening with both magnetic resonance imaging (MRI) and mammography to facilitate early detection. MRI is more sensitive than mammography but is more costly and produces more false positive results. The purpose of this study was to calculate the cost-effectiveness of MRI screening for breast cancer in BRCA1/2 mutation carriers in a Canadian setting.

Methods

We constructed a Markov model of annual MRI and mammography screening for BRCA1/2 carriers, using local data and published values. We calculated cost-effectiveness as cost per quality-adjusted life-year gained (QALY), and conducted one-way and probabilistic sensitivity analysis.

Results

The incremental cost-effectiveness ratio (ICER) of annual mammography plus MRI screening, compared to annual mammography alone, was $50,900/QALY. After incorporating parameter uncertainty, MRI screening is expected to be a cost-effective option 86% of the time at a willingness-to-pay of $100,000/QALY, and 53% of the time at a willingness-to-pay of $50,000/QALY. The model is highly sensitive to the cost of MRI; as the cost is increased from $200 to $700 per scan, the ICER ranges from $37,100/QALY to $133,000/QALY.

Conclusions

The cost-effectiveness of using MRI and mammography in combination to screen for breast cancer in BRCA1/2 mutation carriers is finely balanced. The sensitivity of the results to the cost of the MRI screen itself warrants consideration: in jurisdictions with higher MRI costs, screening may not be a cost-effective use of resources, but improving the efficiency of MRI screening will also improve cost-effectiveness.

Establishing a program for individuals at high risk for breast cancer

Our need to create a program for individuals at high risk for breast cancer development led us to research the available data on such programs. In this paper, we summarize our findings and our thinking process as we developed our own program. Breast cancer incidence is increasing worldwide. Even though there are known risk factors for breast cancer development, approximately 60% of patients with breast cancer have no known risk factor, although this situation will probably change with further research, especially in genetics. For patients with risk factors based on personal or family history, different models are available for assessing and quantifying risk. Assignment of risk levels permits tailored screening and risk reduction strategies. Potential benefits of specialized programs for women with high breast cancer risk include more cost -effective interventions as a result of patient stratification on the basis of risk; generation of valuable data to advance science; and differentiation of breast programs from other breast cancer units, which can result in increased revenue that can be directed to further improvements in patient care. Guidelines for care of patients at high risk for breast cancer are available from various groups. However, running a high-risk breast program involves much more than applying a guideline. Each high-risk program needs to be designed by its institution with consideration of local resources and country legislation, especially related to genetic issues. Development of a successful high-risk program includes identifying strengths, weaknesses, opportunities, and threats; developing a promotion plan; choosing a risk assessment tool; defining "high risk"; and planning screening and risk reduction strategies for the specific population served by the program. The information in this article may be useful for other institutions considering creation of programs for patients with high breast cancer risk.

Towards non-invasive characterization of breast cancer and cancer metabolism with diffuse optics

We review recent developments in diffuse optical imaging and monitoring of breast cancer, i.e. optical mammography. Optical mammography permits non-invasive, safe and frequent measurement of tissue hemodynamics oxygen metabolism and components (lipids, water, etc.), the development of new compound indices indicative of the risk and malignancy, and holds potential for frequent non-invasive longitudinal monitoring of therapy progression.

Trends in incidence of breast cancer among women under 40 in seven European countries: a GRELL cooperative study

Young women are not usually screened for breast cancer (BC). The trends in incidence in this population may better reflect changes in risk factors. However, studies on this subject are scarce and heterogeneous. The aim of this study was to describe the trends in incidence of BC in women under 40 from 1990 to 2008, using pooled European data. Thirty-seven European population-based cancer registries from Belgium, Bulgaria, France, Italy, Portugal, Spain and Switzerland participated in this study. World age-standardized incidence rates were first analyzed graphically and then using a Poisson regression model, in order to estimate average annual percent changes (AAPCs). The overall incidence rate of BC in the area covered increased linearly during the study period by 1.19% (0.93; 1.46) on average per year. This increase varied between countries from 0.20% (-0.53; 0.64) in Bulgaria to 2.68% (1.97; 3.40) in Portugal. In Italy, after a significant rise of 2.33% (1.14; 3.54) per year, BC incidence began decreasing in 2002 by -2.30% (-4.07; -0.50) yearly. The rise in incidence was greater for women under 35 and for ductal carcinomas. This increase can be due to a rise in risk factors and/or changes in diagnosis and surveillance practices, but we could not clearly distinguish between these two non-exclusive explanations.

Expression of aldehyde dehydrogenase after neoadjuvant chemotherapy is associated with expression of hypoxia-inducible factors 1 and 2 alpha and predicts prognosis in locally advanced breast cancer

OBJECTIVE

To analyze the expression of hypoxia-inducible factors (hypoxia-inducible factor 1A and hypoxia-inducible factor 2A) and aldehyde dehydrogenase proteins in patients with locally advanced breast carcinoma who were subjected to neoadjuvant chemotherapy.

METHODS

We included 90 patients with histologically confirmed stage II and III breast carcinoma who were treated with neoadjuvant chemotherapy between 2000 and 2005. Immunohistochemistry for aldehyde dehydrogenase, hypoxia-inducible factor 1A, and hypoxia-inducible factor 2A was performed before and after neoadjuvant chemotherapy. We analyzed the influence of clinical and pathological features on clinical and pathological response, disease-free survival, and overall survival.

RESULTS

An objective clinical response to neoadjuvant chemotherapy was observed in 80% of patients, with 12% showing a complete pathological response. Among all clinical and pathological parameters, only the expression of hypoxia-inducible factor 1A was associated with a pathological response. A positive association was found between expression of aldehyde dehydrogenase and that of hypoxia-inducible factor 1A before and after chemotherapy. Aldehyde dehydrogenase expression was associated with expression of hypoxia inducible-factor 2A in tumors after neoadjuvant treatment. In a univariate analysis, prognosis was influenced by age, pathological response, metastasis to axillary lymph nodes after neoadjuvant chemotherapy, overexpression of hypoxia-inducible factor 2, and the presence of aldehyde dehydrogenase-positive cells within the primary tumor after neoadjuvant chemotherapy. In a multivariate analysis, only age and the presence of aldehyde dehydrogenase-positive cells after chemotherapy were associated with reduced overall survival.

CONCLUSION

The presence of aldehyde dehydrogenase-positive cells within the residual tumor after neoadjuvant chemotherapy is associated with an increase in the expression of hypoxia-inducible factor 2A and with poor prognosis in patients with locally advanced breast cancer.

Which screening strategy should be offered to women with BRCA1 or BRCA2 mutations? A simulation of comparative cost-effectiveness

Background:

There is no consensus on the most effective strategy (mammography or magnetic resonance imaging (MRI)) for screening women with BRCA1 or BRCA2 mutations. The effectiveness and cost-effectiveness of the Dutch, UK and US screening strategies, which involve mammography and MRI at different ages and intervals were evaluated in high-risk women with BRCA1 or BRCA2 mutations.

Methods:

Into a validated simulation screening model, outcomes and cost parameters were integrated from published and cancer registry data. Main outcomes were life-years gained and incremental cost-effectiveness ratios. The simulation was situated in the Netherlands as well as in the United Kingdom, comparing the Dutch, UK and US strategies with the population screening as a reference. A discount rate of 3% was applied to both costs and health benefits.

Results:

In terms of life-years gained, the strategies from least to most cost-effective were the UK, Dutch and US screening strategy, respectively. However, the differences were small. Applying the US strategy in the Netherlands, the costs were €43 800 and 68 800 for an additional life-year gained for BRCA1 and BRCA2, respectively. At a threshold of €20 000 per life-year gained, implementing the US strategy in the Netherlands has a very low probability of being cost-effective. Stepping back to the less-effective UK strategy would save relatively little in costs and results in life-years lost. When implementing the screening strategies in the United Kingdom, the Dutch, as well as the US screening strategy have a high probability of being cost-effective.

Conclusion:

From a cost-effectiveness perspective, the Dutch screening strategy is preferred for screening high-risk women in the Netherlands as well as in the United Kingdom.

Preoperative magnetic resonance imaging in breast cancer: meta-analysis of surgical outcomes

BACKGROUND AND OBJECTIVE

The role of breast magnetic resonance imaging (MRI) in women newly diagnosed with breast cancer (BC) is controversial. This meta-analysis examines the effect of preoperative MRI compared with standard preoperative assessment on surgical outcomes, focusing on studies that used a controlled design.

METHODS

Using random-effects logistic meta-regression modeling, we estimated the proportion of women with each outcome in the MRI versus no-MRI groups, and calculated the odds ratio (OR) and adjusted OR (adjusted for study-level median age, and, where appropriate, for temporal effect) for each model.

RESULTS

There were 9 eligible studies (2 randomized trials; 7 comparative cohorts). Outcomes in 3112 patients with BC (any histological tumor type) for MRI versus no-MRI (referent) were as follows: initial mastectomy 16.4% versus 8.1% [OR, 2.22 (P < 0.001); adjusted OR, 3.06 (P < 0.001)]; re-excision after initial breast conservation 11.6% versus 11.4% [OR, 1.02 (P = 0.87); adjusted OR, 0.95 (P = 0.71)]; overall mastectomy 25.5% versus 18.2% [OR, 1.54 (P < 0.001); adjusted OR, 1.51 (P < 0.001)]. In 766 patients with invasive lobular cancer (ILC), outcomes were as follows: initial mastectomy 31.1% versus 24.9% [OR, 1.36 (P = 0.056); adjusted OR, 2.12 (P = 0.008)]; re-excision after initial breast conservation 10.9% versus 18.0% [OR, 0.56 (P = 0.031); adjusted OR, 0.56 (P = 0.09)]; overall mastectomy 43.0% versus 40.2% [OR, 1.12 (P = 0.45); adjusted OR, 1.64 (P = 0.034)].

CONCLUSIONS

Our summary of the evidence showed that MRI significantly increased mastectomy rates and suggests an unfavorable harm-benefit ratio for routine use of preoperative MRI in BC. We found weak evidence that MRI reduced re-excision surgery in patients with ILC -although this was at the expense of increased mastectomies-and overall patient benefit from MRI in ILC is not clear from this study.

Mammographic screening for breast cancer: A review

In 2011, BreastScreen Australia celebrated 20 years of mammographic screening for breast cancer in Australia. There has been a reduction in mortality from breast cancer over the last two decades, coincident with mammographic screening. However, there are concerns that mammographic screening may result in overdiagnosis of breast cancer and that the reduction in mortality from breast cancer is the result of better treatment rather than screening. This article reviews the evidence on which mammographic screening for breast cancer is based, considers the issue of overdiagnosis of breast cancer by screening mammography, and assesses the role of screening mammography in the reduction in breast cancer mortality seen over the last two decades.

Breast MRI use uncommon among U.S. women

BACKGROUND

The goal of breast cancer screening is to reduce breast cancer mortality. Mammography is the standard screening method for detecting breast cancer early. Breast MRI is recommended to be used in conjunction with mammography for screening subsets of women at high risk for breast cancer. We offer the first study to provide national estimates of breast MRI use among women in the United States.

METHODS

We analyzed data from women who responded to questions about having a breast MRI on the 2010 National Health Interview Survey. We assessed report of having a breast MRI and reasons for it by sociodemographic characteristics and access to health care and computed five-year and lifetime breast cancer risk using the Gail model.

RESULTS

Among 11,222 women who responded, almost 5% reported ever having a breast MRI and 2% reported having an MRI within the 2 years preceding the survey. Less than half of the women who reported having a breast MRI were at increased risk. Approximately 60% of women reported having the breast MRI for diagnostic reasons. Women who ever had a breast MRI were more likely to be older, Black, and insured and to report a usual source of health care as compared with women who reported no MRI.

CONCLUSIONS

Breast MRI use may be underused or overused in certain subgroups of women.

IMPACT

As access to health care improves, the use of breast MRI and the appropriateness of its use for breast cancer detection will be important to monitor.

Trends in advanced imaging use for women undergoing breast cancer surgery

BACKGROUND

Evidence-based guidelines recommend limited perioperative diagnostic imaging for new breast cancer diagnoses. For patients aged >65 years, conventional imaging use (mammography, plain radiographs, and ultrasound) has remained stable, whereas advanced imaging (computed tomography [CT], nuclear medicine scans [positron emission tomography/bone scans], and magnetic resonance imaging [MRI]) use has increased. In this study, the authors evaluated traditional and advanced imaging use among younger patients (aged ≤ 65 years) undergoing breast cancer surgery.

METHODS

The MarketScan Commercial Claims and Encounters Research Database from 2005 through 2008 was analyzed to evaluate the use of conventional and advanced diagnostic imaging associated with surgery for ductal carcinoma in situ (DCIS) or stage I through III invasive breast cancer.

RESULTS

The study cohort included 52,202 women (13% with DCIS and 87% with stage I-III breast cancer). The proportion of patients undergoing conventional imaging remained stable, whereas the average number of conventional imaging tests per patient increased from 4.21 tests in 2005 to 4.79 tests per patient in 2008 (P < .0001). For advanced imaging, the proportion of women who underwent imaging increased from 48.8% in 2005 to 68.8% in 2008 (P < .0001), as did the number of tests per patient (from 1.53 tests in 2005 to 1.98 tests in 2008; P < .0001). MRI examinations accounted for nearly all of the increase in advanced imaging. Patients who underwent MRI examinations received significantly more traditional imaging tests compared with to those who did not, indicating that these tests are additive and are not replacing traditional imaging.

CONCLUSIONS

The current results demonstrate that the use of perioperative breast MRI has increased among women aged <65 years. Further study is indicated to determine whether the benefits of this procedure justify increased use.

Proteomic profile in familial breast cancer patients

OBJECTIVES

Breast cancer is the most common form of cancer affecting women, and the strongest risk factor remains family history. Although screening in asymptomatic women seems able to reduce breast-cancer related mortality, it is of limited usefulness in young women and patients with familial breast cancer syndrome. New diagnostic tools useful for breast cancer management are urgently needed. The aim of the present paper is to look for new candidate tumor markers useful for diagnosis in these patients.

DESIGN AND METHODS

In this prospective study 292 serum samples (100 from healthy people, 100 from sporadic breast cancer patients and 92 from familial breast cancer patients) were analyzed by SELDI-TOF-MS. All samples both from cancer patients and healthy subjects were run in duplicate and randomly spotted on CM10 and IMAC30 protein chip array. Data were analyzed using the expression differential mapping (EDM) tool, decisional tree and multivariate analysis. A further in silico investigation was performed in order to hypothesize the identity of evidenced peptides.

RESULTS

EDM highlighted thirteen and sixteen significant differentially expressed peaks by CM10 and IMAC30 protein chip respectively. Subsequent analysis showed that two peaks at m/z 11730 and 5066 were differentially expressed in sporadic and familial breast cancer patients respectively, while a peak at m/z 8127 was overexpressed only in familial breast cancer patients. The diagnostic power of protein peaks was tested by decisional tree; sensitivity and specificity ranged from 17% to 91.67%.

CONCLUSIONS

We show that the serum profile of familial breast cancer patients was different when compared with that of sporadic breast cancer patients. We hypothesized the identity of the most significant peaks, and further studies are now planned in order to definitively establish the identity.

EUSOMA criteria for performing pre-operative MRI staging in candidates for breast conserving surgery: hype or helpful?

Ongoing debate regarding the value of pre-operative MRI in staging patients with newly diagnosed breast cancer has resulted from the lack of evidence on its clinical efficacy, which contrasts MRIs capability for detecting additional disease (occult on conventional imaging) in the cancerous breast. We undertook a validation study of EUSOMA criteria that recommend selection of breast conserving surgery (BCS) candidates to pre-operative MRI. We examined whether these criteria were associated with a differential likelihood of a recommendation for mastectomy. In a cohort of 200 subjects, recommended for BCS following mammography (M) and ultrasound (US), and who also subsequently had pre-operative MRI, the proportions recommended for mastectomy based on MRI, where the criterion was present versus absent were: invasive lobular cancer (17.9% versus 17.4%; p=0.87); high familial risk (14.7% versus 18.1%; p=0.82); M/US tumour size discrepancy >1cm (32.1% versus 15.1%; p=0.05); and for any of these criteria versus none (21.6% versus 14.3%; p=0.24). These findings suggest that EUSOMA criteria for selection to pre-operative MRI may be inefficient as they do not appear to differentiate those at risk of having more extensive disease and likely to receive a mastectomy recommendation, with the exception of M/US tumour size discrepancy.

Supplementary Breast Ultrasound Screening in Asian Women with Negative But Dense Mammograms—A Pilot Study

Introduction: Dense breasts are common in Asian women and they limit the sensitivity of mammography. This study evaluates the performance of supplementary breast ultrasound screening in Asian women with dense mammograms. Materials and Methods: The study was approved by the hospital’s Institutional Review Board. A prospective clinical trial was performed between September 2002 and November 2004. Asymptomatic Asian women with negative and dense mammograms were offered supplementary ultrasound screening for breast cancer. Ultrasound assessment was categorised as U1 to U4. U1 and U2 cases were recommended routine interval screening mammography. U3 cases were recommended follow-up ultrasound in 6 months and routine interval screening mammography and U4 cases were recommended biopsy. Results: One hundred and forty-one women with mean age of 45.1 years were enrolled into the study. Mean scan time was 13.0 minutes (± 5.6 minutes) for bilateral vs 11.0 minutes (± 1.4 minutes) for unilateral scans. There were 10 patients and 14 patients in the in the U3 and U4 categories, respectively. Two U4 category patients were diagnosed with malignancy—a-6 mm ductal carcinoma-in-situ and a 13-mm invasive ductal carcinoma. The breast cancer detection rate was 1.4%. Sensitivity and specificity were 100% (2/2) and 88.5% (92/104) respectively. The positive predictive value was 14.3% (2/14) and the negative predictive value was 100% (92/92). Conclusion: This pilot study reveals the usefulness of supplementary ultrasound screening in detecting early stage mammographically and clinically occult breast cancers in Asian women with dense breasts. A larger long-term study is, however, needed to assess its feasibility and impact on breast cancer prognosis. Key words: Asian, Breast, Dense, Screening, Ultrasound

Improvement of protein immobilization for the elaboration of tumor-associated antigen microarrays: application to the sensitive and specific detection of tumor markers from breast cancer sera

There is an urgent need to identify relevant tumor markers showing high sensitivity and specificity for early diagnosis and prognosis of breast cancer. Protein microarrays have demonstrated to be cost-effective, high through-put and powerful tools for screening and identifying tumor markers with only minute samples. Autoantibodies directed against tumor-associated antigens (TAAs) were shown to be relevant tumor markers. However, due to the variability of immune response from one individual to another and depending on the type of cancer, detection of only one type of anti-TAA autoantibody is not sufficient to give a reliable and precise diagnosis. It is necessary to use a set of several TAAs for determining specific autoimmune profiles. Therefore, combining various TAAs on different surfaces could improve sensitivity and specificity for anti-TAA autoantibody detection. Herein a panel of 10 proteins, including well-known tumor-associated antigens (TAAs) and potential new biomarkers of breast cancer, were immobilized onto microstructured microarray under optimized conditions (spotting pH buffer, surface chemistry, blocking procedure), in order to determine an autoimmune signature of breast cancer. Sera from 29 breast cancer patients and 28 healthy donors were screened in sandwich immunoassays on the miniaturized system to detect the eventual presence of anti-TAAs autoantibodies. Results indicated that the detection level of each anti-TAA autoantibody in a given serum sample was strongly dependant on the surface chemistry. Combining five TAAs (p53, Hsp60, Hsp70, Her2-Fc, NY-ESO-1) on two different surface chemistries (NHS and APDMES) allowed the significant detection of more than 82% breast cancer sera.

Differences in natural history between breast cancers in BRCA1 and BRCA2 mutation carriers and effects of MRI screening-MRISC, MARIBS, and Canadian studies combined

BACKGROUND

It is recommended that BRCA1/2 mutation carriers undergo breast cancer screening using MRI because of their very high cancer risk and the high sensitivity of MRI in detecting invasive cancers. Clinical observations suggest important differences in the natural history between breast cancers due to mutations in BRCA1 and BRCA2, potentially requiring different screening guidelines.

METHODS

Three studies of mutation carriers using annual MRI and mammography were analyzed. Separate natural history models for BRCA1 and BRCA2 were calibrated to the results of these studies and used to predict the impact of various screening protocols on detection characteristics and mortality.

RESULTS

BRCA1/2 mutation carriers (N = 1,275) participated in the studies and 124 cancers (99 invasive) were diagnosed. Cancers detected in BRCA2 mutation carriers were smaller [80% ductal carcinoma in situ (DCIS) or ≤10 mm vs. 49% for BRCA1, P < 0.001]. Below the age of 40, one (invasive) cancer of the 25 screen-detected cancers in BRCA1 mutation carriers was detected by mammography alone, compared with seven (three invasive) of 11 screen-detected cancers in BRCA2 (P < 0.0001). In the model, the preclinical period during which cancer is screen-detectable was 1 to 4 years for BRCA1 and 2 to 7 years for BRCA2. The model predicted breast cancer mortality reductions of 42% to 47% for mammography, 48% to 61% for MRI, and 50% to 62% for combined screening.

CONCLUSIONS

Our studies suggest substantial mortality benefits in using MRI to screen BRCA1/2 mutation carriers aged 25 to 60 years but show important clinical differences in natural history.

IMPACT

BRCA1 and BRCA2 mutation carriers may benefit from different screening protocols, for example, below the age of 40.

The effect of temporal sampling on quantitative pharmacokinetic and three-time-point analysis of breast DCE-MRI

The effects of temporal sampling on the previously published three-time-point (3TP) method are compared with those of a Tofts-Kety model using an arterial input function from the alternating minimization with model (AMM) method. Computer simulations are done to estimate the expected error in both the 3TP and Tofts-Kety models as a function of the temporal sampling rate of the data. The error in the 3TP model parameters remained essentially constant with respect to temporal sampling. The Tofts-Kety model showed a linear increase in parameter error with respect to temporal sampling. Both analysis methods were also applied to 87 clinically acquired breast scans. These scans were downsampled in time by a factor of 2 and 4, and the methods were reapplied. The spatial resolution was held constant throughout this study. At temporal resolutions less than 19.4 s, the Tofts-Kety model outperformed the 3TP model using receiver operating characteristic curve analysis (area under the ROC curve [AUC] of 0.94 compared to 0.91). As the temporal sampling rate decreased, the 3TP model outperformed the Tofts-Kety model (AUC of 0.89 versus 0.85). When the temporal sampling rate of the data was less than 20 s, the Tofts-Kety model with the AMM method had lower parameter error than the 3TP method.

Effect of dependent errors in the assessment of diagnostic or screening test accuracy when the reference standard is imperfect

When no gold standard is available to evaluate a diagnostic or screening test, as is often the case, an imperfect reference standard test must be used instead. Furthermore, the errors of the test and its reference standard may not be independent. Some authors have opined that positively dependent errors will lead to overestimation of test performance. Although positive dependence does increase agreement between the test and the reference standard, it is not clear if test accuracy will necessarily be overestimated in this situation, and the case of negatively associated test errors is even less clear. To examine this issue in more detail, we derive the apparent sensitivity, specificity, and overall accuracy of a test relative to an imperfect reference standard and the bias in these parameters. We demonstrate that either positive or negative bias can occur if the reference standard is imperfect. The type and magnitude of bias depend on several components: the disease prevalence, the true test sensitivity and specificity, the covariance between the false-negative test errors among the true disease cases, and the covariance between the false-positive test errors among the true noncases. If, for example, sensitivity and specificity are 0.8 for both the test and reference standard and the errors have a moderate positive dependence, test sensitivity is then underestimated at low prevalence but overestimated at high prevalence, while the opposite occurs for specificity. We illustrate these ideas through general numerical calculations and an empirical example of screening for breast cancer with magnetic resonance imaging and mammography.

Breast cancers detected by breast MRI screening and ultrasound in asymptomatic Asian women: 8 years of experience in Taiwan

BACKGROUND

This study investigated one-stop breast screening combining magnetic resonance imaging (MRI) and ultrasound (US) in asymptomatic Asian women.

METHODS

3,586 asymptomatic women (mean age, 45.3 years) were retrospectively analyzed by breast MRI followed by US. US-guided biopsy was performed when the MRI-detected lesion was confirmed by US. When the lesion was not detected on the initial US, a second-look US guided by MRI findings was performed. Then biopsy was done. MRI-positive and US-negative patients were followed up according to MRI lesion size, MRI lesion morphology, and mammographic diagnosis.

RESULTS

In total, 115 subjects had suspicious malignant lesions and received US-guided biopsy, and 47 malignant lesions, including 35 invasive cancers and 12 carcinoma in situ (CIS) lesions, were diagnosed. More than half (22/35, 63%) of the women with invasive cancer were <50 years of age, and 27 (57.4%) of the 47 cancer cases had early breast cancers. Two invasive cancers (5.7%) and 7 CIS lesions (58.3%) were found at the second-look US. The overall cancer incidence was 1.31% (47/3,586) and increased to 2.2% (78/3,586) if precancerous lesions were included. Subjects aged 41-50 years had the highest incidence of cancer detection (1.97%). Five MRI and US-negative cases had cancers found 1 year after the screening.

CONCLUSIONS

The results from the one-stop breast screening in this study showed that combining MRI and US is an efficient multimodality tool for screening asymptomatic Asian women in a metropolitan area of Taiwan who had concerns about the diagnosis and radiation of mammography.

[Breast cancer after Hodgkin disease]

Secondary breast cancer represents 6 to 9% of secondary neoplasia after treatments for Hodgkin Disease (HD). Mostly, they appear 10 years after the end of treatments for HD. The most important risk factors are mantle field irradiation and the young age. The means of screening and treatments are still in discussion. We report a case of bilateral intraductal and invasive carcinoma that occurred 16 years after treatments for HD, developing its particularities in diagnosis and treatment, particularly place of conservative treatments and sentinel lymph node biopsy.

Statistical comparison of dynamic contrast-enhanced MRI pharmacokinetic models in human breast cancer

By fitting dynamic contrast-enhanced MRI data to an appropriate pharmacokinetic model, quantitative physiological parameters can be estimated. In this study, we compare four different models by applying four statistical measures to assess their ability to describe dynamic contrast-enhanced MRI data obtained in 28 human breast cancer patient sets: the chi-square test (χ(2)), Durbin-Watson statistic, Akaike information criterion, and Bayesian information criterion. The pharmacokinetic models include the fast exchange limit model with (FXL_v(p)) and without (FXL) a plasma component, and the fast and slow exchange regime models (FXR and SXR, respectively). The results show that the FXL_v(p) and FXR models yielded the smallest χ(2) in 45.64 and 47.53% of the voxels, respectively; they also had the smallest number of voxels showing serial correlation with 0.71 and 2.33%, respectively. The Akaike information criterion indicated that the FXL_v(p) and FXR models were preferred in 42.84 and 46.59% of the voxels, respectively. The Bayesian information criterion also indicated the FXL_v(p) and FXR models were preferred in 39.39 and 45.25% of the voxels, respectively. Thus, these four metrics indicate that the FXL_v(p) and the FXR models provide the most complete statistical description of dynamic contrast-enhanced MRI time courses for the patients selected in this study.

Diffuse optical imaging and spectroscopy of the breast: a brief outline of history and perspectives

Breast cancer is the most common cancer among women in industrialized countries. At present, X-ray mammography is the gold standard for breast imaging, but has limitations, especially when dense breasts are imaged, as typically occurs in young women. Optical imaging can non-invasively provide information on tissue composition, structure and physiology that can be beneficially exploited for breast lesion detection and identification. In the last few decades optical breast imaging has been investigated, using different geometries (projection imaging and tomography) and measurement techniques (continuous wave, frequency resolved and time resolved approaches). Also, data analysis and display varies significantly, ranging from intensity images to maps of the optical properties (absorption and scattering), tissue composition, and physiological parameters (typically blood volume and oxygenation). This paper outlines the historical evolution of optical imaging and spectroscopy of the breast, highlighting potentialities and limitations, and presents an overview of the main applications and perspectives of the field.

The evolving role of new imaging methods in breast screening

The potential to avert breast cancer deaths through screening means that efforts continue to identify methods which may enhance early detection. While the role of most new imaging technologies remains in adjunct screening or in the work-up of mammography-detected abnormalities, some of the new breast imaging tests (such as MRI) have roles in screening groups of women defined by increased cancer risk. This paper highlights the evidence and the current role of new breast imaging technologies in screening, focusing on those that have broader application in population screening, including digital mammography, breast ultrasound in women with dense breasts, and computer-aided detection. It highlights that evidence on new imaging in screening comes mostly from non-randomised studies that have quantified test detection capability as adjunct to mammography, or have compared measures of screening performance for new technologies with that of conventional mammography. Two RCTs have provided high-quality evidence on the equivalence of digital and conventional mammography and on outcomes of screen-reading complemented by CAD. Many of these imaging technologies enhance cancer detection but also increase recall and false positives in screening.

A genetic strategy for combined screening and localized imaging of breast cancer

PURPOSE

Improvements are needed for the early detection of breast cancer, as current imaging methods lack sensitivity to detect small tumors and assess their disease phenotype.

PROCEDURES

To address this issue, the dual reporter adenoviral vector (Ad5/3-Id1-SEAP-Id1-mCherry) was produced with a cancer-specific Id1 promoter driving expression of a blood-based screening reporter (secreted embryonic alkaline phosphatase, SEAP) and a fluorescent imaging reporter (mCherry). This diagnostic system was assessed for its screening potential on breast cancer cell lines of various aggressive phenotypes. Reporter expression was measured and correlated with promoter level expression using Western blot. Adenovirus receptor expression was normalized against reporter expression with luciferase infectivity assays. Ad5/3-Id1-SEAP-Id1-mCherry infected MDA-MB-231 cells combined with uninfected cells were implanted into the mammary fat pad of athymic nude mice to recapitulate low-dose tumor delivery. Id1 driven SEAP expression and mCherry imaging were monitored to validate diagnostic sensitivity and efficacy.

RESULTS

Infected breast cancer cell lines displayed SEAP levels in the media that were 10-fold above background by 2 days after infection. Ad5/3-Id1-SEAP-Id1-mCherry infected cells (multiplicity of infection = 10) implanted in athymic nude mice demonstrated a 14-fold increase in serum SEAP levels over baseline when as little as 2.5% of the tumor contained infected cells. This robust response was also found for the mCherry reporter, which was clearly visible in tumor xenografts on day 2 post implantation.

CONCLUSIONS

This diagnostic system that combines screening with imaging for early detection and monitoring of breast cancer can be easily extended to other reporters/modalities and cancer-targeting methods. Combining screening with imaging in a genetic, cancer-specific mechanism allows sensitive multi-modal detection and localization of breast cancer.

Searching for early breast cancer biomarkers by serum protein profiling of pre-diagnostic serum; a nested case-control study

Background

Serum protein profiles have been investigated frequently to discover early biomarkers for breast cancer. So far, these studies used biological samples collected at or after diagnosis. This may limit these studies' value in the search for cancer biomarkers because of the often advanced tumor stage, and consequently risk of reverse causality. We present for the first time pre-diagnostic serum protein profiles in relation to breast cancer, using the Prospect-EPIC (European Prospective Investigation into Cancer and nutrition) cohort.

Methods

In a nested case-control design we compared 68 women diagnosed with breast cancer within three years after enrollment, with 68 matched controls for differences in serum protein profiles. All samples were analyzed with SELDI-TOF MS (surface enhanced laser desorption/ionization time-of-flight mass spectrometry). In a subset of 20 case-control pairs, the serum proteome was identified and relatively quantified using isobaric Tags for Relative and Absolute Quantification (iTRAQ) and online two-dimensional nano-liquid chromatography coupled with tandem MS (2D-nanoLC-MS/MS).

Results

Two SELDI-TOF MS peaks with m/z 3323 and 8939, which probably represent doubly charged apolipoprotein C-I and C3a des-arginine anaphylatoxin (C3a_desArg), were higher in pre-diagnostic breast cancer serum (p = 0.02 and p = 0.06, respectively). With 2D-nanoLC-MS/MS, afamin, apolipoprotein E and isoform 1 of inter-alpha trypsin inhibitor heavy chain H4 (ITIH4) were found to be higher in pre-diagnostic breast cancer (p < 0.05), while alpha-2-macroglobulin and ceruloplasmin were lower (p < 0.05). C3a_desArg and ITIH4 have previously been related to the presence of symptomatic and/or mammographically detectable breast cancer.

Conclusions

We show that serum protein profiles are already altered up to three years before breast cancer detection.

Clinical Considerations of BRCA1- and BRCA2-Mutation Carriers: A Review

Individuals who carry an inherited mutation in the breast cancer 1 (BRCA1) and BRCA2 genes have a significant risk of developing breast and ovarian cancer over the course of their lifetime. As a result, there are important considerations for the clinician in the counseling, followup and management of mutation carriers. This review outlines salient aspects in the approach to patients at high risk of developing breast and ovarian cancer, including criteria for genetic testing, screening guidelines, surgical prophylaxis, and chemoprevention.

Time for a re-evaluation of mammography in the young? Results of an audit of mammography in women younger than 40 in a resource restricted environment

Mammography in younger women is considered to be of limited value. In a resource restricted environment without access to magnetic resonance imaging (MRI) and with a high incidence of breast cancer in the young, mammography remains an important diagnostic tool. Recent technical advances and better regulation of mammography make a reassessment of its value in these conditions necessary. Data of all the mammograms performed at a tertiary hospital and private breast clinic between January 2003 and July 2009 in women less than 40 years of age were collected. Indications were the presence of a mass, follow-up after primary cancer therapy, and screening for patients perceived at high risk due to a family history or the presence of atypical hyperplasia. Data acquired were as follows: Demographics, prior breast surgery, indication for mammography, outcome of mammography, diagnostic procedures, and their results. Of 2,167 mammograms, 393 were performed for a palpable mass, diagnostic mammography. In these, the overall cancer detection rate was 40%. If the mammography was reported as breast imaging reporting and data system (BIRADS(®)) 5 versus BIRADS(®) 3 and 4 versus BIRADS(®) 1 and 2, a final diagnosis of malignancy was established in 96, 48, and 5%, respectively. Of 367 mammograms done for the follow-up after primary treatment of breast cancer, seven cancers were diagnosed for a detection rate of 1.9%. Of 1,312 mammograms performed for screening, the recall rate was 4%; the biopsy rate 2%, and the cancer diagnosis rate 3/1,000 examinations. In contrast to past series, this series has shown that recent advances in mammography have made it a useful tool in the management of breast problems in young women, notably in a resource-restricted environment. Women for screening should be selected carefully.

Multicenter surveillance of women at high genetic breast cancer risk using mammography, ultrasonography, and contrast-enhanced magnetic resonance imaging (the high breast cancer risk italian 1 study): final results

OBJECTIVES

: To prospectively compare clinical breast examination, mammography, ultrasonography, and contrast-enhanced magnetic resonance imaging (MRI) in a multicenter surveillance of high-risk women.

MATERIALS AND METHODS

: We enrolled asymptomatic women aged ≥ 25: BRCA mutation carriers; first-degree relatives of BRCA mutation carriers, and women with strong family history of breast/ovarian cancer, including those with previous personal breast cancer.

RESULTS

: A total of 18 centers enrolled 501 women and performed 1592 rounds (3.2 rounds/woman). Forty-nine screen-detected and 3 interval cancers were diagnosed: 44 invasive, 8 ductal carcinoma in situ; only 4 pT2 stage; 32 G3 grade. Of 39 patients explored for nodal status, 28 (72%) were negative. Incidence per year-woman resulted 3.3% overall, 2.1% <50, and 5.4% ≥ 50 years (P < 0.001), 4.3% in women with previous personal breast cancer and 2.5% in those without (P = 0.045). MRI was more sensitive (91%) than clinical breast examination (18%), mammography (50%), ultrasonography (52%), or mammography plus ultrasonography (63%) (P < 0.001). Specificity ranged 96% to 99%, positive predictive value 53% to 71%, positive likelihood ratio 24 to 52 (P not significant). MRI showed significantly better negative predictive value (99.6) and negative likelihood ratio (0.09) than those of the other modalities. At receiver operating characteristic analysis, the area under the curve of MRI (0.97) was significantly higher than that of mammography (0.83) or ultrasonography (0.82) and not significantly increased when MRI was combined with mammography and/or ultrasonography. Of 52 cancers, 16 (31%) were diagnosed only by MRI, 8 of 21 (38%) in women <50, and 8 of 31 (26%) in women ≥ 50 years of age.

CONCLUSION

: MRI largely outperformed mammography, ultrasonography, and their combination for screening high-risk women below and over 50.

Psychological impact and acceptability of magnetic resonance imaging and X-ray mammography: the MARIBS Study

Background:

As part of the Magnetic Resonance Imaging for Breast Screening (MARIBS), Study women with a family history of breast cancer were assessed psychologically to determine the relative psychological impact and acceptability of annual screening using magnetic resonance imaging (MRI) and conventional X-ray mammography (XRM).

Methods:

Women were assessed psychologically at baseline (4 weeks before MRI and XRM), immediately before, and immediately after, both MRI and XRM, and at follow-up (6 weeks after the scans).

Results:

Overall, both procedures were found to be acceptable with high levels of satisfaction (MRI, 96.3% and XRM, 97.7% NS) and low levels of psychological morbidity throughout, particularly at 6-week follow-up. Low levels of self-reported distress were reported for both procedures (MRI, 13.5% and XRM, 7.8%), although MRI was more distressing (P=0.005). Similarly, higher anticipatory anxiety was reported before MRI than before XRM (P=0.003). Relative to XRM, MRI-related distress was more likely to persist at 6 weeks after the scans in the form of intrusive MRI-related thoughts (P=0.006) and total MRI-related distress (P=0.014). More women stated that they intended to return for XRM (96.3%) than for MRI (88% P<0.0005). These effects were most marked for the first year of screening, although they were also statistically significant in subsequent years.

Conclusion:

Given the proven benefits of MRI in screening for breast cancer in this population, these data point to the urgent need to provide timely information and support to women undergoing MRI.

Growth of breast cancer recurrences assessed by consecutive MRI

Background

Women with a personal history of breast cancer have a high risk of developing an ipsi- or contralateral recurrence. We aimed to compare the growth rate of primary breast cancer and recurrences in women who had undergone prior breast magnetic resonance imaging (MRI).

Methods

Three hundred and sixty-two women were diagnosed with breast cancer and had undergone breast MRI at the time of diagnosis in our institution (2005 - 2009). Among them, 37 had at least one prior breast MRI with the lesion being visible but not diagnosed as cancer. A linear regression of tumour volume measured on MRI scans and time data was performed using a generalized logistic model to calculate growth rates. The primary objective was to compare the tumour growth rate of patients with either primary breast cancer (no history of breast cancer) or ipsi- or contralateral recurrences of breast cancer.

Results

Twenty women had no history of breast cancer and 17 patients were diagnosed as recurrences (7 and 10 were ipsi- and contralateral, respectively). The tumour growth rate was higher in contralateral recurrences than in ipsilateral recurrences (growth rate [10^-3 days^-1] 3.56 vs 1.38, p < .001) or primary cancer (3.56 vs 2.09, p = 0.01). Differences in tumour growth were not significant for other patient-, tumour- or treatment-related characteristics.

Conclusions

These findings suggest that contralateral breast cancer presents accelerated growth compared to ipsilateral recurrences or primary breast events.

Perspectives and potential applications of nanomedicine in breast and prostate cancer

Nanomedicine is a branch of nanotechnology that includes the development of nanostructures and nanoanalytical systems for various medical applications. Among these applications, utilization of nanotechnology in oncology has captivated the attention of many research endeavors in recent years. The rapid development of nano-oncology raises new possibilities in cancer diagnosis and treatment. It also holds great promise for realization of point-of-care, theranostics, and personalized medicine. In this article, we review advances in nano-oncology, with an emphasis on breast and prostate cancer because these organs are amenable to the translation of nanomedicine from small animals to humans. As new drugs are developed, the incorporation of nanotechnology approaches into medicinal research becomes critical. Diverse aspects of nano-oncology are discussed, including nanocarriers, targeting strategies, nanodevices, as well as nanomedical diagnostics, therapeutics, and safety. The review concludes by identifying some limitations and future perspectives of nano-oncology in breast and prostate cancer management.

Detection of non-palpable breast cancer in asymptomatic women by using unenhanced diffusion-weighted and T2-weighted MR imaging: comparison with mammography and dynamic contrast-enhanced MR imaging

OBJECTIVE

To compare the detectability of non-palpable breast cancer in asymptomatic women by using mammography (MMG), dynamic contrast-enhanced MR imaging (DCE-MRI) and unenhanced MR imaging with combined diffusion-weighted and T2-weighted images (DWI+T2WI).

METHODS

Forty-two lesions in 42 patients with non-palpable breast cancer in asymptomatic women were enrolled. For the reading test, we prepared a control including 13 normal and 8 benign cases. Each imaging set included biplane MMG, DCE-MRI and DWI+T2WI. Five readers were asked to rate the images on a scale of 0 to 100 for the likelihood of the presence of cancer and the BI-RADS category. Confidence level results were used to construct receiver operating characteristic analysis. Sensitivity and specificity were calculated for each technique.

RESULTS

DWI+T2WI showed higher observer performances (area under the curve, AUC, 0.73) and sensitivity (50%) for the detection of non-palpable breast cancer than MMG alone (AUC 0.64; sensitivity 40%) but lower than those of DCE-MRI (AUC 0.93; sensitivity 86%). A combination of MMG and DWI+T2WI exhibited higher sensitivity (69%) compared with that of MMG alone (40%).

CONCLUSION

DWI+T2WI could be useful in screening breast cancer for patients who cannot receive contrast medium and could be used as a new screening technique for breast cancer.

Age at diagnosis of breast cancer in Arab nations

The impression among Arab Physicians dealing with breast cancer is that it presents at an earlier age and at a more advanced stage as compared to western countries. However, the statistical data to support this impression is remarkably scarce.

METHOD

We performed a comprehensive literature review of reports of breast cancer in Arab countries. Articles were identified from Saudi Arabia, Bahrain, Qatar, Kuwait, Emirate, Oman, Yemen, Iraq, Syria, Jordan, Lebanon, Egypt, Libya, Algeria, Tunis, Morocco, and Sudan.

RESULTS

Twenty eight articles were identified and reviewed. The average age at diagnosis of breast cancer was available in 18 articles; the average age was 48 (SD = 2.8), range 43-52, median 48.5 and mode 45 years among the 7455 patients included. The median age of diagnosis of breast cancer was available in 8 articles; here, the average age was 45.4 (SD = 4.8), range 40-54.5, median 44.5 years among the 5379 patients included. The percentage of patients that were younger than 50 years old was reported in 11 articles from 8 countries and included 5144 patients; 65.5% (SD = 11) were less than 50 years old (range 49-78%, median = 66%).

DISCUSSION

In this literature review, the average age at presentation of breast cancer in Arab countries appears to be a decade earlier than in western countries. If this is true, this has important implications for screening and cancer management strategies in these countries, including the ideal age at which to begin screening. Adoption of Western guidelines "without critical amendment" in planning breast cancer programs will waste resources without achieving desired outcomes. Determination of the true frequency and age of onset of breast cancer in Arab women should be an important research priority.

Role of fusion of prone FDG-PET and magnetic resonance imaging of the breasts in the evaluation of breast cancer

The purpose of this study is to report further about the statistically significant results from a prospective study, which suggests that fusion of prone F-18 Fluoro-deoxy-glucose (FDG) positron emission tomography (PET) and magnetic resonance (MR) breast scans increases the positive predictive value (PPV) and specificity for patients in whom the MR outcome alone would be nonspecific. Thirty-six women (mean age, 43 years; range, 24-65 years) with 90 lesions detected on MR consented to undergo a FDG-PET scan. Two blinded readers evaluated the MR and the computer tomography (CT) attenuation-corrected prone FDG-PET scans side-by-side, then after the volumes were superimposed (fused). A semiautomatic, landmark-based program was used to perform nonrigid fusion. Pathology and radiologic follow-up were used as the reference standard. The sensitivity, specificity, PPV, negative predictive value (NPV), and accuracy (with 95% confidence intervals) for MR alone, FDG-PET alone, and fused MR and FDG-PET were calculated. The median lesion size measured from the MR was 2.5 cm (range, 0.5-10 cm). Histologically, 56 lesions were malignant, and 15 were benign. Nineteen lesions were benign after 20-47 months of clinical and radiologic surveillance. The sensitivity of MR alone was 95%, FDG-PET alone was 57%, and fusion was 83%. The increase in PPV from 77% in MR alone to 98% when fused and the increase in specificity from 53% to 97% were statistically significant (p < 0.05). The false-negative rate on FDG-PET alone was 26.7%, and after fusion this number was reduced to 9%. FDG-PET and MR fusions were helpful in selecting which lesion to biopsy, especially in women with multiple suspicious MR breast lesions.

Recommendations for research priorities in breast cancer by the coalition of cancer cooperative groups scientific leadership council: imaging and local therapy

Imaging and local therapy are important modalities for detection and management of localized breast cancer. Improvements in screening and local therapy have contributed to reduced breast cancer-associated morbidity and mortality. The Coalition of Cancer Cooperative Groups (CCCG) convened the Scientific Leadership Council (SLC) in breast cancer, an expert panel, to identify priorities for future research and current trials with greatest practice-changing potential. Panelists formed a consensus on research priorities for breast imaging and locoregional therapy, and also identified six trials judged to be of high priority. Current high priority trials included trials determining: (1) the role of accelerated partial breast versus whole-breast radiation (B39), (2) the feasibility, safety, and local and systemic control of small localized breast cancers treated with tumor ablation (Z1072), (3) the role of removal of the primary cancer in selected patients with metastatic disease (E2108), and (4) the clinical and biological effects of pre-operative anti-HER2-directed and ER-directed therapies in localized or locally advanced breast cancer (B41, Z1031, Z1041). Ongoing and future trials will further refine optimal locoregional management, and additional research is required to develop improved screening methods and identify high risk populations most likely to benefit from targeted screening.

Magnetic resonance imaging of the breast: recommendations from the EUSOMA working group

The use of breast magnetic resonance imaging (MRI) is rapidly increasing. EUSOMA organised a workshop in Milan on 20-21st October 2008 to evaluate the evidence currently available on clinical value and indications for breast MRI. Twenty-three experts from the disciplines involved in breast disease management - including epidemiologists, geneticists, oncologists, radiologists, radiation oncologists, and surgeons - discussed the evidence for the use of this technology in plenary and focused sessions. This paper presents the consensus reached by this working group. General recommendations, technical requirements, methodology, and interpretation were firstly considered. For the following ten indications, an overview of the evidence, a list of recommendations, and a number of research issues were defined: staging before treatment planning; screening of high-risk women; evaluation of response to neoadjuvant chemotherapy; patients with breast augmentation or reconstruction; occult primary breast cancer; breast cancer recurrence; nipple discharge; characterisation of equivocal findings at conventional imaging; inflammatory breast cancer; and male breast. The working group strongly suggests that all breast cancer specialists cooperate for an optimal clinical use of this emerging technology and for future research, focusing on patient outcome as primary end-point.