Magnetic resonance-guided, vacuum-assisted breast biopsy: results from a European multicenter study of 538 lesions

MRI-visualized T2 hyperintense breast lesions: identifying clinical and imaging factors linked to malignant biopsy outcomes

PURPOSE

To determine the malignancy rate for MRI-guided breast biopsies performed for T2 hyperintense breast lesions and to assess additional clinical and MRI characteristics that can predict benign and malignant outcomes.

METHODS

A retrospective chart review of consecutive MRI-guided breast biopsies performed in two tertiary hospitals was conducted over two years. Biopsies performed for T2 hyperintense lesions were selected, and further lesion imaging characteristics and patient risk factors were collected. Univariate and multivariate modeling regression were used to determine additional imaging and patient factors associated with malignant outcomes for biopsies of T2 hyperintense lesions.

RESULTS

Out of 369 MRI-guided breast biopsies, 100 (27%) were performed for T2 hyperintense lesions. Two biopsy-proven benign lesions were excluded as the patient was lost on follow-up. With a study cohort of 98 lesions, the final pathology results were benign for 80 (80%) of these lesions, while 18 (18%) were malignant. Using multivariate logistic modeling, patient age > 50 (OR 5.99 (1.49, 24.08 95% CI), p < 0.05) and lesion size > 3 cm (OR 5.54 (1.54-18.7), p < 0.01) were found to be important predictors of malignant outcomes for MRI biopsies performed for T2 hyperintense lesions.

CONCLUSION

Our study observed a high malignancy rate, challenging the assumption that T2 hyperintensity can be considered a benign imaging characteristic for otherwise suspicious MRI-detected lesions. Decision-making regarding tissue sampling should be made based on a thorough evaluation of more reliable additional demographic and imaging factors, including patient age and lesion size.

MRI only detected lesions: Can contrast enhanced mammography guided biopsy be an alternative method: Initial clinical findings

OBJECTIVE

This study aims to analyze our initial findings regarding CEM-guided stereotactic vacuum-assisted biopsy for MRI-only detected lesions and compare biopsy times by MRI-guided biopsy.

MATERIALS AND METHODS

In this retrospective analysis, CEM-guided biopsies of MRI-only detected breast lesions from December 2021 to June 2023were included. Patient demographics, breast density, lesion size, background parenchymal enhancement on CEM, lesion positioning, procedure duration, and number of scout views were documented. Initially, seven patients had CEM imaging before biopsy; for later cases, CEM scout views were used for simultaneous lesion depiction and targeting.

RESULTS

Two cases were excluded from the initial 28 patients with 29 lesions resulting in a total of 27 lesions in 26 women (mean age:44.96 years). Lesion sizes ranged from 4.5 to 41 mm, with two as masses and the remaining as non-mass enhancements. Histopathological results identified nine malignancies (33.3 %, 9/27), including invasive cancers (55.6 %, 5/9) and DCIS (44.4 %, 4/9). The biopsy PPV rate was 33.3 %. Benign lesions comprised 66.7 %, with 22.2 % high-risk lesions. The biopsy success rate was 93.1 % (27/29), and minor complications occurred in seven cases (25.9 %, 7/27), mainly small hematomas and one vasovagal reaction (3.7 %, 1/27). Median number of scout views required was 2, with no significant differences between cases with or without prior CEM (P = 0.8). Median duration time for biopsy was 14 min, significantly shorter than MRI-guided bx at the same institution (P < 0.001) by 24 min with predominantly upright positioning of the patient (88.9 %) and horizontal approach of the needle (92.6 %).

CONCLUSION

This study showed that CEM-guided biopsy is a feasible and safe alternative method and a faster solution for MRI-only detected enhancing lesions and can be accurately performed without the need for prior CEM imaging.

Contrast-Enhanced Mammography-Guided Biopsy: Preliminary Results of a Single-Center Retrospective Experience

Background: CEM-guided breast biopsy is an advanced diagnostic procedure that takes advantage of the ability of CEM to enhance suspicious breast lesions. The aim pf this paper is to describe a single-center retrospective experience on CEM-guided breast biopsy in terms of procedural features and histological outcomes. Methods: 69 patients underwent the procedure. Patient age, breast density, presentation, dimensions, and lesion target enhancement were recorded. All the biopsy procedures were performed using a 7- or 10-gauge (G) vacuum-assisted biopsy needle. The procedural approach (horizontal or vertical) and the decubitus of the patient (lateral or in a sitting position) were noted. Results: A total of 69 patients underwent a CEM-guided biopsy. Suspicious lesions presented as mass enhancement in 35% of cases and non-mass enhancement in 65% of cases. The median size of the target lesions was 20 mm. The median procedural time for each biopsy was 10 ± 4 min. The patients were placed in a lateral decubitus position in 52% of cases and seated in 48% of cases. The most common approach was horizontal (57%). The mean AGD was 14.8 mGy. At histology, cancer detection rate was 28% (20/71). Conclusions: CEM-guided biopsy was feasible, with high procedure success rates and high tolerance by the patients.

Contrast-enhanced breast imaging: Current status and future challenges

BACKGROUND

Contrast-enhanced breast MRI and recently also contrast-enhanced mammography (CEM) are available for breast imaging. The aim of the current overview is to explore existing evidence and ongoing challenges of contrast-enhanced breast imaging.

METHODS

This narrative provides an introduction to the contrast-enhanced breast imaging modalities breast MRI and CEM. Underlying principle, techniques and BI-RADS reporting of both techniques are described and compared, and the following indications and ongoing challenges are discussed: problem-solving, high-risk screening, supplemental screening in women with extremely dense breast tissue, breast implants, neoadjuvant systemic therapy (NST) response monitoring, MRI-guided and CEM- guided biopsy.

RESULTS

Technique and reporting for breast MRI are standardised, for the newer CEM standardisation is in progress. Similarly, compared to other modalities, breast MRI is well established as superior for problem-solving, screening women at high risk, screening women with extremely dense breast tissue or with implants; and for monitoring response to NST. Furthermore, MRI-guided biopsy is a reliable technique with low long-term false negative rates. For CEM, data is as yet either absent or limited, but existing results in these settings are promising.

CONCLUSION

Contrast-enhanced breast imaging achieves highest diagnostic performance and should be considered essential. Of the two contrast-enhanced modalities, evidence of breast MRI superiority is ample, and preliminary results on CEM are promising, yet CEM warrants further study.

Pathology of MRI and second-look ultrasound detected multifocal breast cancer

INTRODUCTION

Targeted second-look ultrasound (US) is often performed following MRI of the breast to determine if an MRI-detected lesion is visible on US and thus amenable to US-guided biopsy. This study aimed to assess the pathology of lesions detected and biopsied on the second-look US. In particular, for multifocal cancers, whether the pathology of additional lesions detected by second-look US is different to the index lesion.

METHODS

Multicentre single-institution retrospective study of 300 consecutive cases of second-look US biopsies from August 2017 to April 2022 was performed, with their histopathology and imaging characteristics recorded. For multifocal cancers, Wilcoxon Signed Ranks Tests were used to compare differences between the index and additional lesions in the histopathology category (i.e., high-risk benign, precursor or malignant) and BRE grade.

RESULTS

69 multifocal cancers were detected. For the purposes of this study, additional lesions were considered more invasive if they were of a higher histopathological category or BRE grade, or demonstrated lymphovascular invasion when the primary lesion did not. 15/69 additional lesions were not seen on the initial mammogram/tomography or ultrasound, seen on subsequent MRI and second look US, and were less invasive than the index lesion. 3/69 additional lesions were more invasive than their index lesions. Wilcoxon Signed Ranks test showed additional lesions were of either similar or lesser invasiveness compared to index lesions (z= -3.207, p = 0.001) in the histopathological category, and the same or lower BRE grade (z= -2.972, p = 0.003).

CONCLUSION

In multifocal breast cancers, additional lesions detected on MRI and second-look US have the same or less invasive histopathology compared to the index lesion.

Breast MRI - The champion in the millimeter league: MIO breast MRI - The method of choice in women with dense breasts

We perform MRI of the breast as a first pass technique. We successfully established 10-minute-protocols (including T2 images) with a fixed dosage of 5 ml 1 M CM. A high spatial resolution of 526 × 526, better 672 × 672 or maximum (1.024 × 1.024, MIO MRI) is vital to achieve best results. We use fixation tools to avoid motion artifacts. Motion correction algorithms can, however, often eliminate such artifacts when they are present. In initial breast MRI exams, morphologic features are the most important criteria for lesion evaluation. If previous exams are available for comparison, the main criteria indicating a suspicious lesion are an increase in lesion size or the depiction of new lesions. High quality HR MRI of the breast is the method of choice in women with dense or extremely dense breasts in all cases (screening, assessment, follow up). In density type A or B, MRI can be helpful in defined constellations, e.g. when MX and US are limited or contraindicated. According to our experience, 95% or more of all carcinomas of the breast are detectable on MRI. The remaining 5% of MRI-occult lesions are intraductal tumors or very small invasive carcinomas depicted with mammography due to associated microcalcifications. MRI is, however, superior to all other imaging modalities in the detection of the clinically relevant DCIS (high risk DCIS, intermediate type). Consecutive MRI examinations in intervals of 12 to 24 months allow a reliable detection of invasive breast cancer with an average size of 7-8 mm. This corresponds to a rate of metastasis-free locoregional lymph nodes in >95% of cases. The rate of interval cancers is <2%. In conclusion, this strategy may increase the overall-lifetime survival of breast cancer patients to more than 95%. Inversely, mortality may be reduced to <5%. Taking these improvements in early breast cancer detection and survival that can be achieved through the implementation of QA HR MRI of the breast into account, it should be discussed to modify oncologic guidelines for the treatment of breast cancer. MRI is the best diagnostic tool we have and according to our experience, a first pass, quality-assured high-resolution breast MRI protocol provides best diagnostic results at minimal procedural effort.

Reducing False Negatives in Biopsy of Suspicious MRI Findings

Breast MRI is a highly sensitive imaging modality that often detects findings that are occult on mammography and US. Given the overlap in appearance of benign and malignant lesions, an accurate method of tissue sampling for MRI-detected findings is essential. Although MRI-directed US and correlation with mammography can be helpful for some lesions, a correlate is not always found. MRI-guided biopsy is a safe and effective method of tissue sampling for findings seen only on MRI. The unique limitations of this technique, however, contribute to false negatives, which can result in delays in diagnosis and adverse patient outcomes; this is of particular importance as most MRI examinations are performed in the high-risk or preoperative setting. Here, we review strategies to minimize false negatives in biopsy of suspicious MRI findings, including appropriate selection of biopsy modality, use of meticulous MRI-guided biopsy technique, management after target nonvisualization, assessment of adequate lesion sampling, and determination of radiology-pathology concordance. A proposed management algorithm for MRI-guided biopsy results will also be discussed.

False-positive incidental lesions detected on contrast-enhanced breast MRI: clinical and imaging features

PURPOSE

To identify demographic and imaging features of MRI-detected enhancing lesions without clinical, ultrasound, and mammographic correlation associated with false-positive outcomes, impacting patient care.

MATERIALS AND METHODS

A retrospective multi-institutional study of imaging studies and patient's chart review of consecutive women with MRI-detected enhancing lesions without clinical, mammogram, or ultrasound correlation between January and December 2018, who underwent MRI-guided biopsy. According to the BI-RADS lexicon, lesions' frequency and imaging features were recorded. The demographic and imaging characteristics variables were correlated with histopathology as the gold standard and an uneventful follow-up of at least one year. Univariate logistic regression analysis was used to explore the correlation between the baseline variables such as age, genetic mutation, family history of breast cancer, personal history of breast cancer, MRI indication, background parenchymal enhancement, and MRI characteristic of the lesion with the false-positive results in main data and subgroup analysis.

RESULTS

Two hundred nineteen women (median age 49 years; range 26-85 years) with 219 MRI-detected enhancing lesions that underwent MRI-guided vacuum-assisted biopsy during the study period fulfilled the study criteria and formed the study cohort. Out of 219, 180 lesions (82.2%) yielded benign pathology results, including 137 benign outcomes (76%) and 43 high-risk lesions (24%). Most demographic and imaging characteristics variables did not help to differentiate malignant from benign lesions. The variables that showed statistically significant association with true-positive results in univariate analyses were age (OR 1.05; 95% CI 1.02-1.08; p = 0.0015), irregular mass-lesion shape when compared with oval/round mass lesion (OR 11.2; 95% CI 1.6-78.4; p = 0.015), and clumped and clustered ring of enhancement when compared with homogeneous (OR 3.22, 95% CI 1.40-7.40; p = 0.0058). For participants with mass breast lesion, the hyperintense signal on the T2-weighted sequence (compared to the normal fibroglandular signal) was significantly related to the false-positive result (OR 0.13; 95% CI 0.02-0.76; p = 0.024).

CONCLUSION

Young patients, oval/round mass-lesion shape, and homogeneous pattern of non-mass enhancement showed the strongest association with false-positive results of enhancing lesions depicted by MRI. For participants with mass breast lesion, T2-bright mass lesion showed significant association with false-positive result. It may impact the patient's management with a suggestion of follow-up rather than interventional procedure when these demographic and imaging parameters are present, consequently decreasing the patient's anxiety and health care costs.

Contrast-enhanced mammography-guided biopsy: technical feasibility and first outcomes

OBJECTIVES

To evaluate the feasibility of contrast-enhanced mammography (CEM)-guided biopsy at Hospital del Mar, a Spanish university hospital.

METHODS

We retrospectively reviewed all consecutive women with a suspicious enhancing finding eligible for CEM-guided biopsy, who were prospectively enrolled in a pre-marketing clinical validation and feasibility study (October 2019 to September 2021). CEM-guided biopsy is a stereotactic-based procedure that, by using intravenous iodinated contrast media administration and dual-energy acquisition, provides localisation of enhancing lesions. All the biopsies were performed using a vacuum-assisted device. We collected procedural characteristics (patient position and type of approach), and histopathological results. Feasibility endpoints included success (visualisation of the enhancing lesion, post-procedural biopsy changes and clip placement), procedural time, number of scout acquisitions and complications.

RESULTS

A total of 66 suspicious enhancing lesions (18.0% foci, 44.0% mass, 38.0% non-mass enhancement; median size 8.5 mm) in 64 patients (median age 59 years, mostly minimal [48.4%] or mild [32.8%] background parenchymal enhancement) were referred for CEM-guided biopsy in the study period. The success rate was 63/66 (95.4%). Amongst successful procedures, patients were most frequently seated (52/63, 82.5%) and the preferred approach was horizontal (48/63, 76.2%). Median total time per procedure was 15 min. Median number of acquisitions needed before targeting was 2 (range 1-4). Complications consisted of hematoma (17/63, 27%) and vasovagal reaction (2/63, 3.2%). At histology, the malignancy rate was 25/63 (39.7%).

CONCLUSION

In this first patient series, CEM-guided breast biopsy was feasible, with success and complication rates similar to those previously reported for magnetic resonance guidance.

KEY POINTS

• CEM may be used to guide biopsy of enhancing lesions through a stereotactic-based procedure combined with intravenous iodinated contrast media administration and dual-energy acquisition. • In this first patient series (n = 64), the success rate of CEM-guided biopsy was above 95%, the only complications were hematoma (22.2%) and vasovagal reaction (3.2%), and median total time per procedure was 15 min. • CEM-guided biopsy is feasible and could potentially be a widely available biopsy technique for enhancing-only lesions.

A case report of breast cancer in silicone-injected breasts diagnosed by an emerging technique of contrast-enhanced mammography-guided biopsy

Background

Breast cancer in silicone-injected breasts is often obscured in conventional mammography and sonography. Contrast-enhanced magnetic resonance imaging (CE-MRI) is an optimal modality for cancer detection. This case report demonstrates the use of contrast-enhanced spectral mammography (CESM) and CESM-guided biopsy (CESM-Bx) to diagnose breast cancer in silicone-injected breasts. However, there is no relevant report in the literature.

Case Presentation

A 59-year-old woman who received a liquid silicone injection for breast augmentation 30 years ago was transferred to our hospital for a CE-MRI-guided biopsy due to a suspicion of cancer in her right breast. The CE-MRI showed a 3.1-cm irregular enhanced mass and a 1.1-cm circumscribe mass in the upper outer quadrant of the right breast. Unfortunately, the CE-MRI-guided biopsy had to wait for 1 month due to a busy schedule. The CESM revealed two masses that were consistent with CE-MRI findings. CESM-Bx was performed, and the patient was diagnosed with invasive lobular carcinoma with an irregular mass and fibroadenoma of the circumscribed mass. The patient underwent substantial surgery.

Conclusions

CESM-Bx is a simple emerging technique that can be used feasibly to obtain tissue proof on the concerned enhanced lesion on CESM. In such cases of silicone-injected breasts, the CESM-Bx can be used as an alternative to MRI-guided biopsy for cancer diagnosis.

Assessment of MRI-Detected Breast Lesions: A Benign Correlate on Second-Look Ultrasound Can Safely Exclude Malignancy

Introduction

Due to the increasing use of dynamic breast MRI and the limited availability of MR-guided interventions, MRI-detected lesions usually undergo a second-look ultrasound (SLUS). We investigated the safety of a negative SLUS and a benign SLUS correlate in excluding malignant and high-risk lesions (B3) and evaluated criteria for the rate of detection on SLUS.

Methods

In the retrospective analysis, all breast MRIs performed between 2011 and 2013 were screened for newly detected lesions. We analyzed the SLUS detection rate dependent on breast density, mass character, lesion size, and histology. We calculated the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of a negative and benign SLUS for malignant lesions (B5) and lesions requiring surgical excision (including high-risk and B5 lesions).

Results

We successfully correlated 110 of 397 lesions. The detection rate was significantly higher for mass than for non-mass lesions and correlated with lesion size for mass lesions only. Lesions without/with a benign SLUS correlate were more frequently benign (including B3) or required no further procedure (B2). The sensitivity of SLUS in the detection of B3 and B5 lesions was 58%, and 73% in the detection of B5 lesions. The NPV of a negative or benign SLUS for B3 and B5 lesions was 89%, and 96% for B5 lesions.

Discussion

SLUS is a safe diagnostic tool for the management of MRI-detected lesions and can spare patients from undergoing invasive procedures.

Magnetic Resonance Imaging-Guided Breast Biopsy in Korea: A 10-Year Follow-Up Experience

Purpose

To evaluate the accuracy of magnetic resonance imaging (MRI)-guided breast biopsy.

Methods

We retrospectively reviewed the clinical data of 111 consecutive patients referred for MRI-guided breast biopsy after mammography and breast ultrasound between May 2009 and April 2019. After excluding 37 patients without follow-up images (> 2 years), 74 patients (74 lesions) were finally included. We reviewed the histologic results of MRI-guided biopsy and subsequent surgery, post-biopsy management, and breast cancer development during follow-up. We investigated the false-negative rate, ductal carcinoma in situ (DCIS) underestimation, atypical ductal hyperplasia (ADH) underestimation rate, and technical failure rate of MRI-guided biopsy.

Results

Among 74 scheduled MRI-guided biopsies, six were canceled because biopsy was deemed unnecessary, while three failed due to technical difficulties (technical failure rate: 3/68, 4.4%). MRI-guided biopsy was performed in 65 patients, of which 18 patients were diagnosed with malignant lesions, 46 with benign lesions, and one with ADH bordering on DCIS. Subsequent surgery (n = 27) showed DCIS underestimation in three cases (3/7, 43%), ADH underestimation in two cases (1/2, 50%), as well as seven concordant benign and 11 concordant malignant lesions. The overall false-negative rate was 4.3% (2/46). Thirty-eight out of 48 benign lesions were followed-up (median period, 5.8 years; interquartile range, 4.1 years) without subsequent surgery. Thirty-seven concordant benign lesions were stable (n = 27) or disappeared (n = 10); however, the size of one discordant benign lesion increased on follow-up MRI and it was diagnosed as DCIS after 1 year.

Conclusion

MRI-guided biopsy is an accurate method for exclusion of malignancy with a very low false-negative rate.

Long-term MRI-guided vacuum-assisted breast biopsy results of 600 single-center procedures

OBJECTIVES

The objective of this study is to report on the performance of the MRI-guided VABB in our center and to look at the long-term outcome of biopsies with benign histology over a period of 19 years.

METHODS

In a single-center retrospective review study, data of 600 VABB procedures performed between September 1999 and March 2017 were evaluated. We collected patient demographics, histopathological diagnosis at MRI-VABB, and basic lesion characteristics (size, location). Data from the Belgian Cancer Registry was cross-referenced with our database to find out which patients with benign MRI-VABB results developed a malignant lesion over time.

RESULTS

These 600 VABB procedures were performed in 558 women with a mean patient age of 51.8 years (range 18-82 years). Our technical success rate was 99.3%. We found 27.67% B5 lesions, 9.82% B3 lesions, and 0.17% B4 lesions. Of 362 benign MRI-guided VABBs, follow-up data was available for a mean follow-up period of 7.6 years (0.8-18.3). Only one (0.3%) biopsy was a false negative lesion after MRI-guided VABB during follow-up. Short-term FU-MRI provided no increase in detection rate.

CONCLUSION

The accuracy of MRI-guided VABB is high with a very low false negative rate of 0.3% on long-term follow-up. The value of short-term FU-MRI for every case after MRI-guided VABB may be questioned.

KEY POINTS

• MRI-guided vacuum-assisted breast biopsies yield a large portion of clinically relevant lesions (9.82% B3, 0.17% B4, and 27.67% B5 lesions). • The false negative biopsy rate of MRI-guided VABB in this study with a mean follow-up time of 7.6 years was only 0.3%. • Performing a short-term follow-up MRI after a benign MRI-guided VABB concordant to the MRI appearance may be questioned.

Utility and Diagnostic Performance of Automated Breast Ultrasound System in Evaluating Pure Non-Mass Enhancement on Breast Magnetic Resonance Imaging

Objective

To compare the utility and diagnostic performance of automated breast ultrasound system (ABUS) with that of hand-held ultrasound (HHUS) in evaluating pure non-mass enhancement (NME) lesions on breast magnetic resonance imaging (MRI).

Materials and Methods

One hundred twenty-six consecutive MRI-visible pure NME lesions of 122 patients with breast cancer were assessed from April 2016 to March 2017. Two radiologists reviewed the preoperative breast MRI, ABUS, and HHUS images along with mammography (MG) findings. The NME correlation rate and diagnostic performance of ABUS were compared with that of HHUS, and the imaging features associated with ABUS visibility were analyzed.

Results

Among 126 pure NME lesions, 100 (79.4%) were malignant and 26 (20.6%) were benign. The overall correlation rate was 87.3% (110/126) in ABUS and 92.9% (117/126) in HHUS. The sensitivity and specificity were 87% and 50% for ABUS and 92% and 42.3% for HHUS, respectively, with no significant differences (p = 0.180 and 0.727, respectively). Malignant NME was more frequently visualized than benign NME lesions on ABUS (93% vs. 65.4%, p = 0.001). Significant factors associated with the visibility of ABUS were the size of NME lesions on MRI (p < 0.001), their distribution pattern (p < 0.001), and microcalcifications on MG (p = 0.027).

Conclusion

ABUS evaluation of pure NME lesions on MRI in patients with breast cancer is a useful technique with high visibility, especially in malignant lesions. The diagnostic performance of ABUS was comparable with that of conventional HHUS in evaluating NME lesions.

MR imaging-guided vacuum assisted breast biopsy: Radiological-pathological correlation and underestimation rate in pre-surgical assessment

BACKGROUND

Magnetic Resonance(MR) guided percutaneous procedures(MRgVABB) have been developed and largely employed to reduce the need of surgical biopsies for suspicious lesions which can be detected only by MR(MR-only lesion). The present study aims to investigate correlation between imaging, histological features of MRgVABB and surgical specimens of MR-only lesions.

METHODS

We retrospectively enrolled 56 patients with a total of 61 lesions. Each finding was defined as Mass-Enhancement(ME) or Non-ME(NME) and classified according to BI-RADS. MRgVABB and surgical data were collected. Concordance between MR, MRgVABB and open biopsy was calculated. Underestimation Rate(UR) of MRgVABB with surgery was obtained.

RESULTS

B2 and B5b lesions were statistically associated with NME and ME, respectively. No statistical association was found to B3 nor to B5a with radiological features. UR was 10 %; underestimated lesions were strongly associated with the presence of a ME on MR imaging. Moreover, B3 lesions are associated with higher UR.

CONCLUSION

Radiological features should influence patient management aiming to construct a correct diagnostic and therapeutic plan. When MR is prescribed for breast cancer staging for ME-MR-only lesions, we suggest surgical open biopsy instead of MRgVABB when upfront surgery is the treatment of choice.

Current status of MRI-guided vacuum-assisted breast biopsy in Japan

In April 2018, the national health insurance coverage of MRI-guided vacuum-assisted breast biopsy (VAB) was instituted with the application of the Japan Breast Cancer Society. Although MRI-guided VAB has been considered as a special procedure for a long time, having an access to this procedure should be recommended for facilities performing breast MRI as in Western countries. From now on, relevant societies should make efforts in data collection and quality control of MRI-guided VAB in Japan. We must avoid the following. To delay the early diagnosis of breast cancer in the judgment of an inaccurate indication, perform unnecessary biopsy due to overestimation of diagnosis, and reduce the success rate of MRI-guided VAB with immature techniques. This review explains the current status of MRI-guided VAB in Japan and shares procedure and biopsy data as a future reference from an experienced facility.

MRI-guided core needle biopsy of the breast: Radiology-pathology correlation and impact on clinical management

OBJECTIVE

Breast MRI is used to screen high-risk patients and determine extent of disease in breast cancer (BC) patients. The goal of this study was to determine the pathologic correlates of breast MRI abnormalities biopsied under MRI guidance.

METHODS

We retrospectively identified 101 MRI-guided core needle biopsies (CNB) of the breast from 79 women over a 4-year period. MRI-detected lesions biopsied with ultrasound or stereotactic guidance were excluded. MRI studies and pathology were reviewed by breast radiologists and pathologists.

RESULTS

Of the 79 patients, 72 (91%) had a history of prior (n = 13) or concurrent (n = 59) BC. There were 101 MRI abnormalities: 60 (59%) with non-mass enhancement (NME) and 41 (41%) with mass enhancement. Pathology was benign in 83/101 (82%), including in the majority of NME lesions (43/60, 72%). The most common benign findings were: fibrocystic changes (FCC) (49%), sclerosing lesions (13%), and fibroadenoma (FA) (9%). There were 18 (18%) malignant diagnoses: 8 (44%) invasive lobular carcinoma (ILC), 7 (39%) ductal carcinoma in situ (DCIS), and 3 (17%) invasive ductal carcinoma (IDC). Of the 18 malignant diagnoses, 16 (89%) occurred in 14 unique patients with concurrent BC. Based on the malignant MRI-guided CNB, 6 (46%) of these patients had additional (sentinel lymph node biopsy or contralateral breast surgery) or more extensive (wider lumpectomy) surgery.

CONCLUSION

In this series, most MRI-guided CNB of the breast were benign. The vast majority of malignant diagnoses occurred in patients with concurrent BC and frequently resulted in changes in clinical management.

MRI-guided vacuum-assisted breast biopsy: experience of a single tertiary referral cancer centre and prospects for the future

MRI-guided vacuum-assisted breast biopsy (VABB) is used for suspicious breast cancer (BC) lesions which are detectable only with MRI: because the high sensitivity but limited specificity of breast MRI it is a fundamental tool in breast imaging divisions. We analyse our experience of MRI-guided VABB and critically discuss the potentialities of diffusion-weighted imaging (DWI) and artificial intelligence (AI) in this matter. We retrospectively analysed a population of consecutive women underwent VABB at our tertiary referral BC centre from 01/2011 to 01/2019. Reference standard was histological diagnosis or at least 1-year negative follow-up. McNemar, Mann-Whitney and χ² tests at 95% level of significance were used as statistical exams. 217 women (mean age = 52, 18-72 years) underwent MRI-guided VABB; 11 were excluded and 208 MRI-guided VABB lesions were performed: 34/208 invasive carcinomas, 32/208 DCIS, 8/208 LCIS, 3/208 high-risk lesions and 131/208 benign lesions were reported. Accuracy of MRI-guided VABB was 97%. The predictive features for malignancy were mass with irregular shape (OR 8.4; 95% CI 0.59-31.6), size of the lesion (OR 4.4; 95% CI 1.69-9.7) and mass with irregular/spiculated margins (OR 5.4; 95% CI 6.8-31.1). Six-month follow-up showed 4 false-negative cases (1.9%). Invasive BC showed a statistically significant higher hyperintense signal at DWI compared to benign lesions (p = 0.03). No major complications occurred. MR-guided VABB showed high accuracy. Benign-concordant lesions should be followed up with breast MRI in 6-12 months due to the risk of false-negative results. DWI and AI applications showed potential benefit as support tools for radiologists.

Image-guided breast biopsy and localisation: recommendations for information to women and referring physicians by the European Society of Breast Imaging

We summarise here the information to be provided to women and referring physicians about percutaneous breast biopsy and lesion localisation under imaging guidance. After explaining why a preoperative diagnosis with a percutaneous biopsy is preferred to surgical biopsy, we illustrate the criteria used by radiologists for choosing the most appropriate combination of device type for sampling and imaging technique for guidance. Then, we describe the commonly used devices, from fine-needle sampling to tissue biopsy with larger needles, namely core needle biopsy and vacuum-assisted biopsy, and how mammography, digital breast tomosynthesis, ultrasound, or magnetic resonance imaging work for targeting the lesion for sampling or localisation. The differences among the techniques available for localisation (carbon marking, metallic wire, radiotracer injection, radioactive seed, and magnetic seed localisation) are illustrated. Type and rate of possible complications are described and the issue of concomitant antiplatelet or anticoagulant therapy is also addressed. The importance of pathological-radiological correlation is highlighted: when evaluating the results of any needle sampling, the radiologist must check the concordance between the cytology/pathology report of the sample and the radiological appearance of the biopsied lesion. We recommend that special attention is paid to a proper and tactful approach when communicating to the woman the need for tissue sampling as well as the possibility of cancer diagnosis, repeat tissue sampling, and or even surgery when tissue sampling shows a lesion with uncertain malignant potential (also referred to as "high-risk" or B3 lesions). Finally, seven frequently asked questions are answered.

High-risk lesions diagnosed at MRI-guided vacuum-assisted breast biopsy: imaging characteristics, outcome of surgical excision or imaging follow-up

BACKGROUND

To evaluate imaging characteristics, outcome of surgical excision or imaging follow-up on high-risk lesions diagnosed at MRI-guided vacuum-assisted breast biopsy (MRI-VABB).

METHODS

We retrospectively reviewed 598 lesions undergoing 9-gauge MRI-VABB from January 2015 to April 2018 to identify high risk breast lesions. We collected patient demographics, breast MRI BI-RADS descriptors, histopathological diagnosis at MRI-VABB and surgical excision, frequency of upgrade to malignancy and imaging follow-up of high-risk lesions. The x² test and Fisher exact tests were performed for univariate analysis.

RESULTS

114 patients with 124/598 findings (20.7%) had high-risk lesions at MRI-VABB, including atypical ductal hyperplasia (ADH) (21/124, 16.9%), lobular neoplasia (40/124, 32.3%), radial scar/complex sclerosing lesion (RS/CSL) (13/124, 10.5%), papillary lesions (49/124, 39.5%), and flat epithelial atypia (FEA) (1/124, 0.8%). 84/124 (67.7%) high-risk lesions were excised. 19/84 (22.6%) were upgraded to malignancy (7 invasive cancer, 12 DCIS). The upgrade rate for ADH and lobular neoplasia was 7/18 (38.9%) and 9/31 (29.0%), respectively. The upgrade rate for RS/CSL was 1/10 (10%). Of the 25 papillary lesions excised, 2 (8%) demonstrated pathologic atypia and were upgraded to DCIS. The other 23 papillary lesions had no upgrade or atypia. Excised high-risk lesions showing upgrade varied from 0.4 to 6 cm in length (mean 1.6 cm). There was a non-significant trend (p = 0.054) between larger lesion and upgrade to malignancy; however, there were no other specific imaging features to predict malignancy upgrade.

CONCLUSIONS

There were no specific MRI imaging characteristics of high-risk lesions to predict malignancy upgrade. Therefore, surgical excision is recommended for high-risk lesions, especially ADH or lobular neoplasia.

Minimally Invasive Breast Procedures: Practical Tips and Tricks

OBJECTIVE. The purpose of this article is to review the literature regarding image-guided breast procedures, including helpful tips and tricks to guide the practicing interventional breast radiologist. CONCLUSION. The successful diagnosis and treatment of breast cancer involves coordination of the multidisciplinary breast team. Optimal procedural skills for image-guided biopsy and preoperative lesion localization are paramount to the radiologists' success.

Preoperative assessment of breast cancer: Multireader comparison of contrast-enhanced MRI versus the combination of unenhanced MRI and digital breast tomosynthesis

PURPOSE

To compare the sensitivity for breast cancer (BC) and BC size estimation of preoperative contrast-enhanced magnetic resonance imaging (CEMRI) versus combined unenhanced magnetic resonance imaging (UMRI) and digital breast tomosynthesis (DBT).

PATIENTS AND METHODS

We retrospectively included 56 women who underwent DBT and preoperative 1.5 T CEMRI between January 2016-February 2017. Three readers with 2-10 years of experience in CEMRI and DBT, blinded to pathology, independently reviewed CEMRI (diffusion-weighted imaging [DWI], T2-weighted imaging, pre- and post-contrast T1-weighted imaging) and a combination of UMRI (DWI and pre-contrast T1-weighted imaging) and DBT. We calculated per-lesion sensitivity of CEMRI and UMRI + DBT, and the agreement between CEMRI, UMRI and DBT versus pathology in assessing cancer size (Bland-Altman analysis). Logistic regression was performed to assess features predictive of cancer missing.

RESULTS

We included 70 lesions (64% invasive BC, 36% ductal carcinoma in situ or invasive BC with in situ component). UMRI + DBT showed lower sensitivity (86-89%) than CEMRI (94-100%), with a significant difference for the most experienced reader only (p = 0.008). False-positives were fewer with UMRI + DBT (4-5) than with CEMRI (18-25), regardless of the reader (p = 0.001-0.005). For lesion size, UMRI showed closer limits of agreement with pathology than CEMRI or DBT. Cancer size ≤1 cm was the only independent predictor for cancer missing for both imaging strategies (Odds ratio 8.62 for CEMRI and 19.16 for UMRI + DBT).

CONCLUSIONS

UMRI + DBT showed comparable sensitivity and less false-positives than CEMRI in the preoperative assessment of BC. UMRI was the most accurate tool to assess cancer size.

Association of Retrospective Peer Review and Positive Predictive Value of Magnetic Resonance Imaging-Guided Vacuum-Assisted Needle Biopsies of Breast

Objective

To evaluate the association between retrospective peer review of breast magnetic resonance imaging-guided vacuum-assisted needle biopsies and positive predictive value of subsequent magnetic resonance imaging-guided biopsies.

Materials and Methods

In January, 2015, a weekly conference was initiated in our institution to evaluate all breast magnetic resonance imaging-guided vacuum-assisted needle biopsies performed over January 1, 2014-December 31, 2015. During this weekly conferences, breast dynamic contrast-enhanced magnetic resonance imaging findings of 6 anonymized cases were discussed and then the faculty voted on whether they agree with the biopsy indication, accurate sampling and radiology-pathology correlation. We retrospectively reviewed and compared the magnetic resonance imaging indication, benign or malignant pathology rates, lesion types and the positive predictive value of magnetic resonance imaging-guided vacuum-assisted needle biopsy in the years before and after initiating this group peer review.

Results

The number of dynamic contrast-enhanced magnetic resonance imaging and magnetic resonance imaging-guided vacuum-assisted needle biopsies before and after initiating the review were 1447 vs 1596 (p=0.0002), and 253 (17.5%) vs 203 (12.7%) (p=0.04), respectively. There was a significant decrease in the number of benign biopsies in 2015 (n=104) compared to 2014 (n=154, p=0.04). The positive predictive value of magnetic resonance imaging-guided biopsy significantly increased after group review was implemented (Positive predictive value in 2014=%39.1 and positive predictive value in 2015=%48.8) (p=0.03), although the indications (p=0.49), history of breast cancer (p=0.14), biopsied magnetic resonance imaging lesion types (p=0.53) were not different. Less surgical excision was performed on magnetic resonance imaging-guided vacuum-assisted needle biopsy identified high-risk lesions in 2015 (p=0.25).

Conclusion

Our study showed an association between retrospective peer review of past biopsies and increased positive predictive value of magnetic resonance imaging-guided vacuum-assisted needle biopsies in our institution.

Clinical Value of Shear Wave Elastography Added to Targeted Ultrasound (Second-Look Ultrasound) in the Evaluation of Breast Lesions Suspicious of Malignancy Detected on Magnetic Resonance Imaging

OBJECTIVES

To determine the value of shear wave elastography (SWE) added to targeted ultrasound (US) after breast magnetic resonance imaging (MRI).

METHODS

From July 2015 to October 2017, 40 patients who underwent targeted US evaluations of suspicious MRI-detected American College of Radiology Breast Imaging Reporting and Data System category 4 lesions (mass or nonmass enhancement) were enrolled in this prospective study. B-mode US and SWE examinations were performed to detect US correlates to MRI-detected lesions; their Breast Imaging Reporting and Data System categories were recorded; lesions that were dark blue on a 6-point color scale or had maximum elasticity of 30 kPa or less were categorized as soft. Biopsy was performed with US or MRI guidance, with the pathologic findings correlated with MRI, US, and SWE findings. The value of SWE for lesion detection and identification of benign lesions was determined.

RESULTS

The mean age of the 40 patients was 51.1 years. There were 48 MRI-detected lesions (20 cancers, 3 high-risk lesions, and 25 benign lesions). Ultrasound correlates (8 category 3 and 25 category 4) were shown for 33 lesions (69%; P < .0001), with 16 cancers (80%; P < .0001) and 17 benign lesions. Shear wave elastography assisted detection of 3 (19%) cancers on US imaging. All 7 soft US category 3 lesions were benign (7 of 33 [21%]; P = .0014).

CONCLUSIONS

Shear wave elastography was useful with targeted US after breast MRI to increase cancer detection by US. A significant number of US correlates to MRI-detected lesions could have been identified as benign (category 3 and soft) before biopsy, with the potential of short-interval follow-up of MRI-detected lesions with benign US correlates instead of biopsy.

The clinical impact of MRI screening for BRCA mutation carriers: the first report in Japan

BACKGROUND

There is no consensus on the appropriate surveillance for high-risk women with breast cancer in Japan. We investigated their imaging features and pathological characteristics to build a proper surveillance system for asymptomatic high-risk individuals in the future.

METHODS

We retrospectively reviewed 93 female (median age 43 years) BRCA1 and BRCA2 mutation carriers from our institutional clinical database from 2011 to 2017. The study population was composed of 112 breast cancers. Mammography and MRI were reviewed by examiners blinded to patients' clinical history. Final surgical or biopsy histopathology served as the reference standard in all the patients.

RESULTS

Fifty-nine breast cancers met selection criteria; of these, 30 were BRCA1-associated tumors, and 29 were BRCA2-associated tumors. Invasive ductal carcinoma was the most prevalent type in both BRCA1 and BRCA2. There were statistically significant differences in phenotype, nuclear grade, and Ki-67 labeling index between BRCA1 and BRCA2 mutation carriers. Additionally, imaging findings on mammography and MRI were statistically different. Tumors in BRCA2 carriers demonstrated mammographic calcifications more frequently, while those in BRCA1 carriers demonstrated a mass or architectural distortion (P < 0.001). Enhancement pattern on MRI also significantly differed between the two subgroups (P = 0.006). The size of MRI-detected lesions was statistically smaller than the size of those detected by other modalities (P = 0.004).

CONCLUSIONS

The imaging and histological characteristics of BRCA1/2 mutation carriers were consistent with other countries' studies. MRI-detected lesions were significantly smaller than lesions detected by non-MRI modality. All lesions in BRCA1 mutation carriers could be detected by MRI.

Magnetic resonance imaging-guided vacuum-assisted breast biopsy: experience and preliminary results of 205 procedures

Objective

To demonstrate the frequency of malignancy and histological characteristics of lesions in patients submitted to vacuum-assisted breast biopsy guided by magnetic resonance imaging (MRI).

Materials and Methods

This was a retrospective study of MRI-guided vacuum-assisted breast biopsies performed between April 2008 and December 2016, in which we analyzed clinical and epidemiological data, as well as the BI-RADS classification and histopathological results. We compared nodules and non-nodular enhancements, in terms of their correlation with malignancy, using chi-square test.

Results

Among 215 cases referred for MRI-guided vacuum-assisted breast biopsy, the procedure was contraindicated in 10 cases (5%) and was technically feasible in the remaining 205 (95%). Non-nodular enhancements were observed in 135 cases (66%), and nodules were observed in 70 (34%), with a mean diameter of 2.2 cm (range, 0.5-9.6 cm) and 0.97 cm (range, 0.5-2.2 cm), respectively. Of the 205 lesions analyzed, 43 (21%) were malignant, 129 (63%) were benign, and 33 (16%) were classified as high-risk lesions. The most common histological findings were invasive ductal carcinoma and, in high-risk cases, lobular neoplasia. There was no significant difference between nodules and non-nodular enhancements in terms of the rate of malignancy (p = 0.725).

Conclusion

In our sample, the overall malignancy rate was 21%. However, to improve the assessment of these results, it is necessary to correlate them with the surgical data and with data from the follow-up of benign cases.

High risk breast lesions identified on MRI-guided vacuum-assisted needle biopsy: outcome of surgical excision and imaging follow-up

OBJECTIVE:

To determine whether breast MRI-guided vacuum-assisted biopsy (MRI-VAB) high-risk lesion histology influences surgical or long-term imaging follow-up outcomes.

METHODS:

Patients with imaging-concordant high-risk findings on 9-gauge breast MRI-VAB between January 2007 and July 2012 who had surgical histopathology or 2 year imaging follow-up were retrospectively reviewed.

RESULTS:

90 patients with 99 lesions were included. Lesions were atypical ductal hyperplasia (ADH) (n = 21), lobular neoplasia [n = 36; atypical lobular hyperplasia (ALH) (n = 22), lobular carcinoma in situ (LCIS) (n = 6), and ALH plus LCIS (n = 8)], and other high-risk lesion (n = 42; papillary lesions, radial scar, flat epithelial atypia, atypia unspecified). Of 53 excised lesions, 6 (11%) were upgraded to invasive cancer or ductal carcinoma in situ (DCIS). 4 of 21 (19%) ADH lesions were upgraded to DCIS. 2 of 36 (6%) lobular neoplasia lesions, both combined ALH and LCIS, were upgraded to DCIS, and invasive lobular carcinoma, respectively. The remaining 46 lesions were managed conservatively with imaging follow-up: 17 (37%) had mammography only, while 29 (63%) had mammography and MRI follow-up. There was no evidence of breast cancer development at the site of MRI-VAB in the cases with only imaging follow-up.

CONCLUSION:

We conclude that the upgrade rate for high-risk lesions at MRI-VAB at surgical excision is low. Surgical excision is warranted for ADH and combined ALH-LCIS lesions. For other lesions, a multidisciplinary approach to decide on personalized management may be appropriate.

ADVANCES IN KNOWLEDGE:

Surgical excision is warranted for ADH lesions and combined ALH-LCIS lesions identified at breast MRI-VAB. A multidisciplinary approach to patient management of other high-risk lesions may be appropriate.

MRI-guided breast biopsy: a review of technique, indications, and radiological-pathological correlations

Breast magnetic resonance imaging (MRI) is the technique of choice in detection, local staging, and monitoring of breast cancer; however, breast MRI results in the detection of more indeterminate/suspicious lesions that need to be histopathologically proven to guide patient management than any other breast imaging method. If such abnormalities are not detectable in any of the conventional imaging tools (mammography (MMG) or ultrasound) then an MRI-guided biopsy needs to be performed to obtain a diagnosis. Breast MRI-guided biopsy is a time-consuming and complex procedure that requires specific equipment and experienced, well-trained staff. This review article explores and illustrates the indications, the currently available technologies, and the technique of breast MRI-guided biopsy, and explains the importance of careful imaging review and selection of cases. We correlate the radiological-pathological findings and highlight the impact on patient management in a multidisciplinary setting.

Lesion characteristics, histopathologic results, and follow-up of breast lesions after MRI-guided biopsy

PURPOSE

We aimed to assess the effectiveness of magnetic resonance imaging (MRI)-guided vacuum-assisted breast biopsy (VABB), evaluate and compare the characteristics and histopathologic findings of lesions, and overview the follow-up results of benign lesions.

METHODS

MRI findings and histopathologic results of breast lesions biopsied by MRI-guided VABB between 2013 and 2016 were retrospectively analyzed. MRI findings closely related with malignancy were investigated in particular. Follow-up results of benign lesions were evaluated.

RESULTS

MRI-guided VABB was applied to 116 lesions of 112 women. Of the lesions, 75 (65%) were benign, while 41 (35%) were malignant. Segmental (94%), clustered (89%), and clustered ring (67%) non-mass-like enhancement patterns were found to be more related with malignancy. False-negative rate of MRI-guided VABB was 12%, underestimation rate was 21%. One of the 54 followed-up benign lesions had a malignant result.

CONCLUSION

MRI-guided VABB is a reliable method for the diagnosis of breast lesions that are positive only on MRI. Follow-up results show that cancer detection rate is low for radio-pathologically concordant lesions. Further multicenter studies with larger patient population are needed to elucidate these results.

A survey by the European Society of Breast Imaging on the utilisation of breast MRI in clinical practice

OBJECTIVES

While magnetic resonance imaging (MRI) is considered a helpful diagnostic tool in breast imaging, discussions are ongoing about appropriate protocols and indications. The European Society of Breast Imaging (EUSOBI) launched a survey to evaluate the utilisation of breast MRI in clinical practice.

METHODS

An online survey reviewed by the EUSOBI board and committees was distributed amongst members. The questions encompassed: training and experience; annual breast MRI and MRI-guided-intervention workload; examination protocols; indications; reporting habits and preferences. Data were summarised and subgroups compared using χ² test.

RESULTS

Of 647 EUSOBI members, 177 (27.4%) answered the survey. The majority were radiologists (90.5%), half of them based in academic centres (51.9%). Common indications for MRI included cancer staging, treatment monitoring, high-risk screening and problem-solving, and differed significantly between countries (p≤0.03). Structured reporting and BI-RADS were mostly used. Breast radiologists with ≤10 years of experience preferred inclusion of additional techniques, such as T2/STIR (p=0.03) and DWI (p=0.08) in the scan protocol. MRI-guided interventions were performed by a minority of participants (35.4%).

CONCLUSIONS

The utilisation of breast MRI in clinical practice is generally in line with international recommendations. There are substantial differences between countries. MRI-guided interventions and functional MRI parameters are not widely available.

KEY POINTS

• MRI is commonly used for the detection and characterisation of breast lesions. • Clinical practice standards are generally in line with current recommendations. • Standardised criteria and diagnostic categories (mainly BI-RADS) are widely adopted. • Younger radiologists value additional techniques, such as T2/STIR and DWI. • MRI-guided breast biopsy is not widely available.

Safety and Efficacy of Magnetic Resonance-Guided Vacuum-Assisted Large-Volume Breast Biopsy (MR-Guided VALB)

OBJECTIVE

Magnetic resonance (MR)-guided vacuum-biopsy is technically demanding and may fail depending on target-lesion size or breast size, and location of lesions within the breast. We developed an MR-guided vacuum-assisted biopsy protocol that collects larger amounts of tissue, aiming at an at least partial or complete ablation of the target-lesion, just as it is intended during surgical (excisional) biopsy. Rationale is to avoid biopsy failures (false-negative results due to undersampling) by collecting larger amounts of tissue. We report on our experience with MR-guided vacuum-assisted large-volume breast biopsy (VALB) (MR-guided VALB) with regard to clinical success and complication rates.

MATERIALS

Institutional review board-approved analysis of 865 patients with 1414 MR imaging (MRI)-only breast lesions who underwent tissue sampling under MRI guidance. Magnetic resonance-guided VALB was performed on a 1.5 T-system with a 9G system. Per target lesion, we collected at least 24 samples, with the biopsy notch directed toward the position of the target until on postbiopsy control imaging the target lesion appeared completely or at least greatly removed. The standard-of-reference was established by at least 24-months follow-up (for benign biopsy results), or results of surgical histology (for malignant or borderline results). We investigated the technical success rates as a function of factors that usually interfere with MR-guided vacuum biopsy.

RESULTS

Target lesions were located in the central versus peripheral parts of the breast in 66.6% (941/1414) versus 33.6% (473/1414), occurred in large, intermediate, or small breasts in 22.7% (321/1414), 56.4% (797/1414), or 20.9% (296/1414), corresponded to nonmass enhancement (NME) versus mass enhancement (ME) in 64.0% (905/1414) vs. 36.0% (509/1414), with an average size of 23 mm for NME versus 9 mm for ME, respectively. Primary technical failures, that is, inability to reach the target lesion occurred in 0.2% of patients (2/865) and 0.1% of target lesions (2/1414). Successful biopsy, that is, an MR-guided VALB diagnosis matching with the standard of reference, was achieved in 99.5% (859/863) of patients and 99.7% (1408/1412) target lesions that had been amenable to MR-guided VALB. In 0.5% of patients (4/863) and 0.3% of target lesions (4/1412), a radiologic-pathologic mismatch suggested a false-negative biopsy, confirmed by secondary excisional biopsy. The likelihood of failure was independent of the lesion's location in the breast, breast size, target lesion size, or target lesion type (NME vs ME). None of the patients with benign MR-guided VALB diagnoses developed breast cancer at the biopsy site during follow-up of 2 years. None of the patients developed major complications.

CONCLUSION

Magnetic resonance-guided VALB is a safe procedure that is associated with a high success rate (99.7%) that is independent of the size, type, or location of a target lesion, or the size of the breast, and is associated with a very low complication rate.

A simple classification system (the Tree flowchart) for breast MRI can reduce the number of unnecessary biopsies in MRI-only lesions

OBJECTIVES

To assess whether using the Tree flowchart obviates unnecessary magnetic resonance imaging (MRI)-guided biopsies in breast lesions only visible on MRI.

METHODS

This retrospective IRB-approved study evaluated consecutive suspicious (BI-RADS 4) breast lesions only visible on MRI that were referred to our institution for MRI-guided biopsy. All lesions were evaluated according to the Tree flowchart for breast MRI by experienced readers. The Tree flowchart is a decision rule that assigns levels of suspicion to specific combinations of diagnostic criteria. Receiver operating characteristic (ROC) curve analysis was used to evaluate diagnostic accuracy. To assess reproducibility by kappa statistics, a second reader rated a subset of 82 patients.

RESULTS

There were 454 patients with 469 histopathologically verified lesions included (98 malignant, 371 benign lesions). The area under the curve (AUC) of the Tree flowchart was 0.873 (95% CI: 0.839-0.901). The inter-reader agreement was almost perfect (kappa: 0.944; 95% CI 0.889-0.998). ROC analysis revealed exclusively benign lesions if the Tree node was ≤2, potentially avoiding unnecessary biopsies in 103 cases (27.8%).

CONCLUSIONS

Using the Tree flowchart in breast lesions only visible on MRI, more than 25% of biopsies could be avoided without missing any breast cancer.

KEY POINTS

• The Tree flowchart may obviate >25% of unnecessary MRI-guided breast biopsies. • This decrease in MRI-guided biopsies does not cause any false-negative cases. • The Tree flowchart predicts 30.6% of malignancies with >98% specificity. • The Tree's high specificity aids in decision-making after benign biopsy results.

Post-clip placement MRI following second-look US-guided core biopsy for suspicious lesions identified on breast MRI

OBJECTIVES

To evaluate whether the post-clip placement MRI following second-look ultrasound (US)-guided core biopsy is useful to confirm the adequate sampling of suspicious lesions identified on breast MRI.

METHODS

Between 2014 and 2016, 31 consecutive women with 34 suspicious lesions that had not been identified on previous mammography or US were detected using MRI. Among them, 26 women with 29 lesions (mean size 1.5 cm, range 0.5-5.8 cm) found by second-look US underwent US-guided biopsy, subsequent clip insertion and post-clip placement MRI. Five women with five lesions that were not found by second-look US underwent MRI-guided biopsy. The technical success rate and lesion characteristics were described.

RESULTS

The technical success rate was 96.6% (28/29). One failure case was a benign, 1.1-cm non-mass enhancement. Of the 28 success cases, 23 (82.1%) were masses and 5 (17.9%) were non-mass enhancements; 17 (60.7%) were benign, 4 (14.3%) were high-risk and 7 (25.0%) were malignant lesions. The technical success rate was 100% (28/28) for masses and 83.3% (5/6) for non-mass enhancements.

CONCLUSIONS

Post-clip placement MRI following US-guided biopsy is useful in confirming the adequate sampling of lesions identified on MRI. This method could be an alternative to MRI-guided biopsy for lesions visible on US.

KEY POINTS

• Post-clip MRI is useful for confirming adequate sampling of US-guided biopsy. • Post-clip MRI following US-guided biopsy revealed a 96.6 % technical success rate. • One technical failure case was a benign, 1.1-cm non-mass enhancement. • The technical success rate of US-guided biopsy for non-mass enhancements was 83.3 %.

MRI-guided breast interventions

Magnetic resonance imaging (MRI)-guided interventions, including biopsies and wire localizations, are fundamental to any breast imaging practice due to the high sensitivity but limited specificity of breast MRI. The basic steps of MRI-guided biopsies are similar regardless of the vendor or platform, and technical considerations include approach planning, patient preparation and positioning, lesion targeting, and directional sampling using a vacuum-assisted biopsy technique. Unique challenges related to MRI-guided biopsies include vanishing lesions due to contrast washout, obscuration of the biopsy site due to susceptibility artifacts, and limited access to posteromedial lesions. A careful approach to planning, patient positioning, and lesion targeting will maximize the chances for a successful biopsy. Due to overlapping imaging features between benign and malignant lesions, radiologic-pathologic concordance is difficult and essential for further patient management.

LEVEL OF EVIDENCE

5 Technical Efficacy: Stage 3 J. MAGN. RESON. IMAGING 2017;46:631-645.

Predictive detection areas for identifying additional MRI-detected breast lesions on second-look ultrasonography

PURPOSE

Identifying an additional MRI-detected breast lesion on second-look ultrasonography (US) is technically challenging because of lesion displacement with the patient's position change. The aim of this study is to help identify MRI-detected lesions on second-look US by developing a probing area, called "the predictive detection area" (PDA), and by assessing the PDA.

METHODS

We measured the nipple-to-lesion distances (NLDs) for 16 breast lesions on prone- and supine-position MRI sets and calculated the difference and angle between the two NLD vectors, representing the lesion displacement. The minimum and maximum differences and angles were chosen to form the PDA. Another 22 breast lesions, detected in the prone MRI, were identified on US by probing the PDA to evaluate the probability of existence.

RESULTS

The width between the minimum and maximum differences in two NLDs and the angle to form the PDA for the upper-inner, upper-outer, and lower-outer quadrants were 23.0 mm and 95.0°, 29.0 mm and 41.0°, and 18.0 mm and 17.0°, respectively. The respective probabilities of existence were 100, 80, and 100%.

CONCLUSIONS

The PDA had a high probability of existence and was acceptably accurate; therefore, the PDA in a second-look US has the potential to help operators to quickly identify additional MRI-detected lesions.

Volume Navigation Technique for Ultrasound-Guided Biopsy of Breast Lesions Detected Only at MRI

OBJECTIVE

The purpose of this study is to assess the utility of a volume navigation technique (VNT) for ultrasound-guided biopsy of MRI-detected, but sonographically ambiguous or occult, breast lesions.

SUBJECTS AND METHODS

Within a recruitment period of 13 months (January 1, 2014, through February 1, 2015), 22 patients with 26 BI-RADS category 4 or 5 lesions that were detected at MRI but missed at second-look ultrasound were reimaged using a rapid sequence and a flexible body coil in a 3-T MRI scanner. Patients were supine, with three skin markers placed on the breasts. MRI volume data were coregistered to real-time ultrasound in a dedicated platform, and MRI-detected lesions (six masses, 11 nonmass enhancements, eight foci, and one architectural distortion) were sought using VNT-guided ultrasound. Five needle biopsy specimens were obtained either from each sonographically detected lesion (n = 11) or from VNT-guided sonographically localized breast volume corresponding to the MRI-detected, but still ultrasound-occult, lesions (n = 15).

RESULTS

Histopathologic analysis revealed 18 benign and six malignant lesions. The remaining two lesions, both of which appeared as masses at MRI, were high risk and were upgraded to carcinoma after excisional biopsy. All malignant lesions underwent curative surgery; the final histopathologic diagnoses remained unchanged. Of the six malignant lesions, one was a mass, three were nonmass enhancements, and two were enhancing foci at MRI. Three malignant lesions were occult at ultrasound, and three were discerned as subtle hypoechoic changes. No benign lesion was sonographically visualized as a mass, and none progressed, with 56% disappearing at MRI performed during the follow-up period (mean, 14 months).

CONCLUSION

Coregistration of MRI and real-time ultrasound enables sonographic localization of breast lesions detected at MRI only. VNT is a feasible alternative to MRI-guided biopsy of ultrasound-occult breast lesions.

Separation of benign and malignant breast lesions using dynamic contrast enhanced MRI in a biopsy cohort

PURPOSE

To assess the diagnostic utility of contrast kinetic analysis for breast lesions and background parenchyma of women undergoing MRI-guided biopsies, for whom standard clinical analysis had failed to separate benign and malignant lesions.

MATERIALS AND METHODS

This study included 115 women who had indeterminate lesions based on routine diagnostic breast MRI exams and underwent an MRI (3 Tesla) -guided biopsy of one or more lesions suspicious for breast cancer. Breast dynamic contrast-enhanced (DCE)-MRI was performed using a radial stack-of-stars three-dimensional spoiled gradient echo pulse sequence and modified k-space weighted image contrast image reconstruction. Contrast kinetic model analysis was conducted to characterize the contrast enhancement patterns measured in lesions and background parenchyma (BP). The transfer rate (K^trans ), interstitial volume fraction (v_e ), and vascular volume fraction (v_p ) estimated from the lesion and BP were used to separate malignant from benign lesions.

RESULTS

The patients with malignant lesions had significantly (P < 0.05) higher median lesion-K^trans (0.081 min^-1 ), higher median BP-K^trans (0.032 min^-1 ), and BP-v_p (0.020) than those without malignant lesions (0.056 min^-1 , 0.017 min^-1 and 0.012, respectively). The area under the receiver operating characteristic curve (AUC) of the BP-K^trans (0.687) was highest among the single parameters and higher than that of the lesion-K^trans (0.664). The combined logistic regression model of lesion-K^trans , lesion-v_e , BP-K^trans , BP-v_e , and BP-v_p had the highest AUC of 0.730.

CONCLUSION

Our results suggest that the contrast kinetic analysis of DCE-MRI data can be used to differentiate the malignant lesions from the benign and high-risk lesions among the indeterminate breast lesions recommended for MRI-guided biopsy exams.

LEVEL OF EVIDENCE

3 J. MAGN. RESON. IMAGING 2017;45:1385-1393.

An image-guided automated robot for MRI breast biopsy

BACKGROUND

The IGAR (Image-guided Automated Robot) is a robotic platform capable of performing highly accurate clinical interventions under image guidance. The IGAR is unique in that it demonstrates MRI compatibility and maintains safe operation, adequate shielding, high image quality, and accurate robotic control even while in an imaging environment. The IGAR is initially intended for breast biopsy.

METHODS

Tests for projectile hazards, heating, signal-to-noise ratio loss, and geometric distortion were used to demonstrate MR compatibility. Accuracy and repeatability of the robotic system were tested on benchtop models to establish a baseline of precision.

RESULTS

The IGAR averaged an accuracy of 0.34 mm and a repeatability of 0.2 mm. There was no significant distortion attributable to the robot, no projectile risk, and no unacceptable levels of heating.

CONCLUSION

The IGAR system is safe and effective in an MRI environment Copyright © 2016 John Wiley & Sons, Ltd.

Outcomes of Preoperative MRI-Guided Needle Localization of Nonpalpable Mammographically Occult Breast Lesions

OBJECTIVE

MRI-guided needle localization allows access to MRI-detected mammographically occult breast lesions that are not amenable to MRI-guided biopsy. The purpose of this study was to examine the safety and outcomes of MRI-guided needle localization.

MATERIALS AND METHODS

Ninety-nine consecutive breast lesions that underwent preoperative MRI-guided needle localization were identified. Clinical indications for breast MRI, reasons for performing MRI-guided needle localization, and surgical pathology results were recorded. Lesion characteristics, procedure time, and complications were assessed.

RESULTS

Of 99 lesions, 60 (60.6%) were in a location inaccessible for MRI biopsy, necessitating MRI-guided needle localization. Histologic evaluation revealed 38 (38.4%) carcinomas, 31 (31.3%) high-risk lesions, and 30 (30.3%) benign lesions. Carcinoma was more likely to be found in women with known cancer (31/61 [50.8%]; p = 0.003) than in women undergoing imaging for high-risk screening (2/18 [11.1%]) or problem solving (6/20 [30%]). Masses (p = 0.013) and foci (p < 0.001) were more likely to be malignant than were lesions with nonmass enhancement. Foci were significantly more often malignant compared with all other lesion types (9/10 [90%]; p < 0.001). The mean (± SD) procedure time was 32.9 ± 9.39 minutes. All lesions were occult on specimen radiographs. There were no procedure-related complications.

CONCLUSION

The positive predictive value of MRI-guided needle localization (38.4%) is comparable to that of mammography- and tomosynthesis-guided localizations and is highest in women with a known diagnosis of cancer. It is highly accurate in targeting small enhancing lesions, thereby improving surgical management. MRI-guided needle localization is a safe, accurate, and time-efficient procedure.

Vacuum-assisted breast biopsies (VAB) carried out on an open 1.0T MR imager: Influence of patient and target characteristics on the procedural and clinical results

PURPOSE

The study was conducted in order to assess the clinical impact of MRI-guided vacuum-assisted breast biopsies carried out using an open 1.0T open MRI-system.

MATERIAL AND METHODS

The clinical, imaging, interventional and histological data of all 132 patients with a first MRI-guided vacuum-assisted breast biopsy carried out between 07/2005 and 03/2012at the Radiological Department were extracted from the clinical files. The clinical outcome of patients with benign histological findings was assessed based on the clinical files and queries of the local gynecologists in charge. In the 103 interventional image data sets available target localization and target size were evaluated by two board-certified senior radiologists. Clinical data, lesion characteristics and interventional results were evaluated statistically using subgroup analyses.

RESULTS

131 of 132 MRI-guided breast biopsies (99.2%) were carried out successfully. The median interventional duration was 30min (25%-percentile 25min, 75%-percentile 35min, maximum 75min). Minor complications occurred in 12 interventions of the 131 (9.2%). The histological work-up of the biopsy specimen showed benign results in 98 of 131 interventions (74.8%), lesions with uncertain biological potential in 5 biopsies (3.8%) and malignant findings in 28 biopsies (21.4%). There were 2 false negative histological findings. Neither the patient age nor the medical history nor the anticipated risk of developing breast cancer had an impact on the success rates and the complication rates. In the 103 interventions with available image data sets the maximum target lesion diameters were 1-5mm in 16 lesions (15.5%), 6-10mm in 41 lesions (39.8%) and 11-15mm in 29 lesions (28.2%). There was a positive correlation between the maximum diameters and the rate of malignancy of the target lesions (p=0.020) as well as a trend towards longer interventional procedure durations in smaller target lesions (p=0.183).

CONCLUSION

MRI-guided vacuum-assisted breast biopsy for suspicious breast lesions is a clinically safe and feasible method even in small target lesions when using an open high-field MRI-system.

MR-guided vacuum-assisted breast biopsy of MRI-only lesions: a single center experience

PURPOSE

The purpose of this study was to compare three different biopsy devices on false-negative and underestimation rates in MR-guided, vacuum-assisted breast biopsy (VABB) of MRI-only lesions.

METHODS

This retrospective, single-center study was IRB-approved. Informed consent was waived. 467 consecutive patients underwent 487 MR-guided VABB using three different 8-10-gauge-VABB devices (Atec-9-gauge,A; Mammotome-8-gauge,M; Vacora-10-gauge,V). VABB data (lesion-type, size, biopsy device, histopathology) were compared to final diagnosis (surgery, n = 210 and follow-up, n = 277). Chi-square, and Kruskal-Wallis tests were applied. P values < 0.05 were considered significant.

RESULTS

Final diagnosis was malignant in 104 (21.4 %), high risk in 64 (13.1 %) and benign in 319 (65.5 %) cases. Eleven of 328 (3.4 %) benign-rated lesions were false-negative (1/95, 1.1 %, A; 2/73, 2.7 %, M; 8/160 5.0 % V; P = 0.095). Eleven high-risk (11/77, 14.3 %) lesions proved to be malignant (3/26, 11.5 % A; 4/12, 33.3 % M; 4/39, 10.3 % V; P = 0.228). Five of 34 (14.7 %) DCIS were upgraded to invasive cancer (2/15, 13.3 %, A; 1/6, 16.6 % M; 2/13, 15.3 %, V; P = 0.977). Lesion size (P = 0.05) and type (mass vs. non-mass, P = 0.107) did not differ significantly.

CONCLUSION

MR-guided VABB is an accurate method for diagnosis of MRI-only lesions. No significant differences on false-negative and underestimation rates were observed between three different biopsy devices.

KEY POINTS

• MR-guided VABB is an accurate procedure for the diagnosis of MRI-only lesions. • Similar false-negative and underestimation rates allow all three different MR-guided VABB devices for clinical application. • High-risk lesions should undergo surgery due to a substantial underestimation rate. • Agreement between MR-guided VABB and final diagnosis (benign/malignant) was 95.5% (465/487).

MRI-guided wire localization open biopsy is safe and effective for suspicious cancer on breast MRI

BACKGROUND

Magnetic resonance imaging of breast, reported to be a high sensitivity of 94% to 100%, is the most sensitive method for detection of breast cancer. The purpose of this study was to investigate our clinical experience in MRI-guided breast lesion wire localization in Chinese women.

MATERIALS AND METHODS

A total of 44 patients with 46 lesions undergoing MRI-guided breast lesion localization were prospectively entered into this study between November 2013 and September 2014. Samples were collected using a 1.5-T magnet with a special MR biopsy positioning frame device. We evaluated clinical lesion characteristics on pre-biopsy MRI, pathologic results, and dynamic curve type baseline analysis.

RESULTS

Of the total of 46 wire localization excision biopsied lesions carried out in 44 female patients, pathology revealed fourteen malignancies (14/46, 30.4%) and thirty-two benign lesions (32/46, 69.6%). All lesions were successfully localized followed by excision biopsy and assessed for morphologic features highly suggestive of malignancy according to the American College of Radiology Breast Imaging Reporting and Data System (BI-RADS) category of MRI (C4a=18, C4b=17, C4c=8,C5=3). Of 46 lesions, 37 were masses and 9 were non-mass enhancement lesions. Thirty-two lesions showed a continuous kinetics curve, 11 were plateau and 3 were washout.

CONCLUSIONS

Our study showed success in MRI-guided breast lesion wire localization with a satisfactory cancer diagnosis rate of 30.4%. MRI-guided wire localization breast lesion open biopsy is a safe and effective tool for the workup of suspicious lesions seen on breast MRI alone without major complications. This may contribute to increasing the diagnosis rate of early breast cancer and improve the prognosis in Chinese women.