Screening Breast MRI in Patients Previously Treated for Breast Cancer: Diagnostic Yield for Cancer and Abnormal Interpretation Rate

ACR Appropriateness Criteria® Imaging of Invasive Breast Cancer

As the proportion of women diagnosed with invasive breast cancer increases, the role of imaging for staging and surveillance purposes should be determined based on evidence-based guidelines. It is important to understand the indications for extent of disease evaluation and staging, as unnecessary imaging can delay care and even result in adverse outcomes. In asymptomatic patients that received treatment for curative intent, there is no role for imaging to screen for distant recurrence. Routine surveillance with an annual 2-D mammogram and/or tomosynthesis is recommended to detect an in-breast recurrence or a new primary breast cancer in women with a history of breast cancer, and MRI is increasingly used as an additional screening tool in this population, especially in women with dense breasts. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Addition of Contrast-enhanced Mammography to Tomosynthesis for Breast Cancer Detection in Women with a Personal History of Breast Cancer: Prospective TOCEM Trial Interim Analysis

Background Digital breast tomosynthesis (DBT) is often inadequate for screening women with a personal history of breast cancer (PHBC). The ongoing prospective Tomosynthesis or Contrast-Enhanced Mammography, or TOCEM, trial includes three annual screenings with both DBT and contrast-enhanced mammography (CEM). Purpose To perform interim assessment of cancer yield, stage, and recall rate when CEM is added to DBT in women with PHBC. Materials and Methods From October 2019 to December 2022, two radiologists interpreted both examinations: Observer 1 reviewed DBT first and then CEM, and observer 2 reviewed CEM first and then DBT. Effects of adding CEM to DBT on incremental cancer detection rate (ICDR), cancer type and node status, recall rate, and other performance characteristics of the primary radiologist decisions were assessed. Results Among the participants (mean age at entry, 63.6 years ± 9.6 [SD]), 1273, 819, and 227 women with PHBC completed year 1, 2, and 3 screening, respectively. For observer 1, year 1 cancer yield was 20 of 1273 (15.7 per 1000 screenings) for DBT and 29 of 1273 (22.8 per 1000 screenings; ICDR, 7.1 per 1000 screenings [95% CI: 3.2, 13.4]) for DBT plus CEM (P < .001). Year 2 plus 3 cancer yield was four of 1046 (3.8 per 1000 screenings) for DBT and eight of 1046 (7.6 per 1000 screenings; ICDR, 3.8 per 1000 screenings [95% CI: 1.0, 7.6]) for DBT plus CEM (P = .001). Year 1 recall rate for observer 1 was 103 of 1273 (8.1%) for (incidence) DBT alone and 187 of 1273 (14.7%) for DBT plus CEM (difference = 84 of 1273, 6.6% [95% CI: 5.3, 8.1]; P < .001). Year 2 plus 3 recall rate was 40 of 1046 (3.8%) for DBT and 92 of 1046 (8.8%) for DBT plus CEM (difference = 52 of 1046, 5.0% [95% CI: 3.7, 6.3]; P < .001). In 18 breasts with cancer detected only at CEM after integration of both observers, 13 (72%) cancers were invasive (median tumor size, 0.6 cm) and eight of nine (88%) with staging were N0. Among 1883 screenings with adequate reference standard, there were three interval cancers (one at the scar, two in axillae). Conclusion CEM added to DBT increased early breast cancer detection each year in women with PHBC, with an accompanying approximately 5.0%-6.6% recall rate increase. Clinical trial registration no. NCT04085510 © RSNA, 2024 Supplemental material is available for this article.

Recommendations for the Screening of Breast Cancer of the Brazilian College of Radiology and Diagnostic Imaging, Brazilian Society of Mastology and Brazilian Federation of Gynecology and Obstetrics Association

OBJECTIVE

 To present the update of the recommendations of the Brazilian College of Radiology and Diagnostic Imaging, the Brazilian Society of Mastology and the Brazilian Federation of Associations of Gynecology and Obstetrics for breast cancer screening in Brazil.

METHODS

 Scientific evidence published in Medline, EMBASE, Cochrane Library, EBSCO, CINAHL and Lilacs databases between January 2012 and July 2022 was searched. Recommendations were based on this evidence by consensus of the expert committee of the three entities.

RECOMMENDATIONS

 Annual mammography screening is recommended for women at usual risk aged 40-74 years. Above 75 years, it should be reserved for those with a life expectancy greater than seven years. Women at higher than usual risk, including those with dense breasts, with a personal history of atypical lobular hyperplasia, classic lobular carcinoma in situ, atypical ductal hyperplasia, treatment for breast cancer or chest irradiation before age 30, or even, carriers of a genetic mutation or with a strong family history, benefit from complementary screening, and should be considered individually. Tomosynthesis is a form of mammography and should be considered in screening whenever accessible and available.

Recommendations for breast cancer screening in Brazil, from the Brazilian College of Radiology and Diagnostic Imaging, the Brazilian Society of Mastology, and the Brazilian Federation of Gynecology and Obstetrics Associations

Objective

To present an update of the recommendations of the Brazilian College of Radiology and Diagnostic Imaging, the Brazilian Society of Mastology, and the Brazilian Federation of Gynecology and Obstetrics Associations for breast cancer screening in Brazil.

Materials and Methods

Scientific evidence published between January 2012 and July 2022 was gathered from the following databases: Medline (PubMed); Excerpta Medica (Embase); Cochrane Library; Ebsco; Cumulative Index to Nursing and Allied Health Literature (Cinahl); and Latin-American and Caribbean Health Sciences Literature (Lilacs). Recommendations were based on that evidence and were arrived at by consensus of a joint committee of experts from the three entities.Recommendations: Annual mammographic screening is recommended for women between 40 and 74 years of age. For women at or above the age of 75, screening should be reserved for those with a life expectancy greater than seven years. Women at higher than average risk are considered by category: those with dense breasts; those with a personal history of atypical lobular hyperplasia, classical lobular carcinoma in situ, or atypical ductal hyperplasia; those previously treated for breast cancer; those having undergone thoracic radiotherapy before age 30; and those with a relevant genetic mutation or a strong family history. The benefits of complementary screening are also addressed according to the subcategories above. The use of tomosynthesis, which is an evolved form of mammography, should be considered in screening, whenever accessible and available.

Implications for surveillance for breast cancer patients based on the internally and externally validated BRENDA-metastatic recurrence score

PURPOSE

Although the incidence of distant relapse is decreasing, 20-30% of patients with early breast cancer die of metastasis. The aim of this study is to characterize patients with metastasis-free survival(MFS) less than 5 years, to analyze the most probable site of metastases according to the internally and externally validated BRENDA-score. The BRENDA-score is a combination of the biological subtype and clinical staging.

METHOD

3832 patients with primary diagnosis of breast cancer and either distant metastatic recurrence within 5 years or MFS ≥ 5 years were assigned to this study. Patients were classified for metastatic recurrence according to the BRENDA-score. 1765 patients were in a validation set. Statistical methods were Kaplan-Meier curves, Cox regression analysis, Exhausted CHAID, likelihood-ratio tests and the Nearest Neighbor Estimation method.

RESULTS

There was a significant(p < 0.001) difference between the Kaplan-Meier MFS-functions of M0-patients stratified by BRENDA-score. The BRENDA score outperforms intrinsic subtypes and the Nottingham prognostic score. It fits the original data and the validation set equally well (p = 0.179).There was a significant(p < 0.001) difference between mean BRENDA-Index for patients with MFS < 5y(21.0 ± 9.0) and patients with MFS ≥ 5y(mean BRENDA-Index 11.7 ± 8.2). 55.6% of the very high risk patients(BRENDA-Index ≥ 27) had metastases within 5 years. The most likely primary metastatic site was bone(30%) followed by liver(19%) and lung(18%). The discriminatory ability(areas under the time dependent ROC curve) of the BRENDA score is good to acceptable for the first 5 years. In the very low/low risk (intermediate, high/very high) risk group 50% of all metastases were diagnosed within 26 months. Guideline adherence had a highly significant influence on outcome independent of the risk group.

CONCLUSION

The evaluation showed that the BRENDA-Score is a robust predictive tool for breast cancer recurrence and site of metastases in the first five years after diagnosis. It outperforms intrinsic subtypes and the Nottingham prognostic score. The BRENDA-score could be a tool for a risk orientated and targeted follow up.

Challenges and Changes of the Breast Cancer Screening Paradigm

Since four decades mammography is used for early breast cancer detection in asymptomatic women and still remains the gold standard imaging modality. However, population screening programs can be personalized and women can be divided into different groups based on risk factors and personal preferences. The availability of new and evolving imaging modalities, for example, digital breast tomosynthesis, dynamic-contrast-enhanced magnetic resonance imaging (MRI), abbreviated MRI protocols, diffusion-weighted MRI, and contrast-enhanced mammography leads to new challenges and perspectives regarding the feasibility and potential harms of breast cancer screening. The aim of this review is to discuss the current guidelines for different risk groups, to analyze the recent published studies about the diagnostic performance of the imaging modalities and to discuss new developments and future perspectives. LEVEL OF EVIDENCE: 1 TECHNICAL EFFICACY: Stage 6.

ACR Appropriateness Criteria® Imaging After Breast Surgery

Given that 20% to 40% of women who have percutaneous breast biopsy subsequently undergo breast surgery, knowledge of imaging women with a history of benign (including high-risk) disease or breast cancer is important. For women who had surgery for nonmalignant pathology, the surveillance recommendations are determined by their overall risk. Higher-than-average risk women with a history of benign surgery may require screening mammography starting at an earlier age before 40 and may benefit from screening MRI. For women with breast cancer who have undergone initial excision and have positive margins, imaging with diagnostic mammography or MRI can sometimes guide additional surgical planning. Women who have completed breast conservation therapy for cancer should get annual mammography and may benefit from the addition of MRI or ultrasound to their surveillance regimen. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

R, D. GK, Yalla V. Improvement of Segmentation Efficiency in Mammogram Images Using Dual-ROI Method

Mammogram segmentation utilizing multi-region of intrigue is a standout amongst the most rising exploration territory in the medical image analysis. The steps engaged with the research are grouped into two kinds: 1) segmentation of mammogram images and 2) extraction of texture features from mammogram images. To overcome these difficulties, a compelling technique is proposed in this paper that comprises of three phases. In the principal arrangement, mammogram images from INbreast database are selected and improved utilizing Laplacian filtering. At that point, the pre-processed mammogram images are utilized for segmentation utilizing modified adaptively regularized kernel-based fuzzy C means (M-ARKFCM). After segmentation, statistical texture FE is connected for recognizing the patterns of cancer and non-cancer regions in mammogram images. Finally, the experimental outcome demonstrated that the proposed approach enhanced the segmentation efficiency by methods of statistical parameters contrasted with the existing operating procedures.

Abbreviated Screening MRI for Women with a History of Breast Cancer: Comparison with Full-Protocol Breast MRI

Background Few studies have compared abbreviated breast MRI with full-protocol MRI in women with a personal history of breast cancer (PHBC), and they have not adjusted for confounding variables. Purpose To compare abbreviated breast MRI with full-protocol MRI in women with PHBC by using propensity score matching to adjust for confounding variables. Materials and Methods In this single-center retrospective study, women with PHBC who underwent full-protocol MRI (January 2008-August 2017) or abbreviated MRI (September 2017-April 2019) were identified. With use of a propensity score-matched cohort, screening performances were compared between the two MRI groups with the McNemar test or a propensity score-adjusted generalized estimating equation. The coprimary analyses were sensitivity and specificity. The secondary analyses were the cancer detection rate, interval cancer rate, positive predictive value for biopsies performed (PPV3), and Breast Imaging Reporting and Data System (BI-RADS) category 3 short-term follow-up rate. Results There were 726 women allocated to each MRI group (mean age ± SD, 50 years ± 8 for both groups). Abbreviated MRI and full-protocol MRI showed comparable sensitivity (15 of 15 cancers [100%; 95% CI: 78, 100] vs nine of 13 cancers [69%; 95% CI: 39, 91], respectively; P = .17). Abbreviated MRI showed higher specificity than full-protocol MRI (660 of 711 examinations [93%; 95% CI: 91, 95] vs 612 of 713 examinations [86%; 95% CI: 83, 88], respectively; P < .001). The cancer detection rate (21 vs 12 per 1000 examinations), interval cancer rate (0 vs five per 1000 examinations), and PPV3 (61% [14 of 23 examinations] vs 41% [nine of 22 examinations]) were comparable (all P < .05). The BI-RADS category 3 short-term follow-up rate of abbreviated MRI was less than half that of full-protocol MRI (5% [36 of 726 examinations] vs 12% [84 of 726 examinations], respectively; P < .001). Ninety-three percent (14 of 15) of cancers detected at abbreviated MRI were node-negative T1-invasive cancers (n = 6) or ductal carcinoma in situ (n = 8). Conclusion Abbreviated breast MRI showed comparable sensitivity and superior specificity to full-protocol MRI in breast cancer detection in women with a personal history of breast cancer. © RSNA, 2022 Online supplemental material is available for this article.

Screening MRI in Women at Intermediate Breast Cancer Risk: An Update of the Recent Literature

Guidelines issued by the American Cancer Society (ACS) in 2007 recommend neither for nor against screening MRI in women at intermediate breast cancer risk (15%-20%), including those with dense breast tissue, a history of lobular neoplasia or atypical ductal hyperplasia (ADH), or a prior breast cancer, because of scarce supporting evidence about the utility of MRI in these specific patient populations. However, since the issuance of the ACS guidelines in 2007, multiple investigations have found that women at intermediate risk may be suitable candidates for screening MRI, given the high detection rates of early-stage cancers and acceptable false-positive rates. For women with dense breast tissue, the Dense Tissue and Early Breast Neoplasm Screening trial reported that the incremental cancer detection rate (CDR) by MRI exceeded 16 cancers per 1000 examinations but decreased in the second round of screening; this decrease in CDR, however, occurred alongside a marked decrease in the false-positive rate. For women with lobular neoplasia or ADH, single-institution retrospective analyses have shown CDRs mostly ranging from 11 to 16 cancers per 1000 MRI examinations, with women with lobular carcinoma in situ benefitting more than women with atypical lobular hyperplasia or ADH. For patients with a prior breast cancer, the cancer yield by MRI varies widely but mostly ranges from 8 to 20 cancers per 1000 examinations, with certain subpopulations more likely to benefit, such as those with dense breasts. This article reviews and summarizes more recent studies on MRI screening of intermediate-risk women.

Current and Future Directions of Breast MRI

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

Imaging surveillance for the detection of ipsilateral local tumor recurrence in patients who underwent oncoplastic breast-conserving surgery with acellular dermal matrix: abbreviated MRI versus conventional mammography and ultrasonography

BACKGROUND

To evaluate the usefulness of surveillance-abbreviated magnetic resonance imaging (AB-MRI) for the detection of ipsilateral local tumor recurrence (LTR) in patients who underwent oncoplastic breast-conserving surgery (BCS) with acellular dermal matrix (ADM) by comparing its diagnostic performance with that of mammography (MG) and ultrasonography (US).

METHODS

The postoperative MG, US, and AB-MRI findings of the ipsilateral breast and pathological results of 324 patients who underwent oncoplastic BCS using ADM were reviewed. The cancer detection rate (CDR), sensitivity, specificity, positive predictive value (PPV) for biopsy, accuracy, and area under the curve (AUC) for each imaging modality were calculated.

RESULTS

A total of 8 ipsilateral LTRs were diagnosed, and most cancers (87.5%) were stage 0 or 1 (median size of invasive cancer, 1.44 cm; range, 0.7-2 cm). The CDRs of MG, US, MG + US, and AB-MRI were 0.009, 0.012, 0.015, and 0.025 per woman, respectively. Three cancers were detectable on only AB-MRI, and the additional CDR of AB-MRI was 0.010. The sensitivity and specificity of MG, US, MG + US, and AB-MRI were 37.5%, 50%, 62.5%, and 100% and 99.7%, 98.4%, 98.1%, and 97.8%, respectively. The PPVs for biopsy were 75%, 44.4%, 45.5%, and 53.3%, respectively. The AUC was significantly higher for AB-MRI (0.989) than for MG alone (0.686, P = 0.0009), US alone (0.742, P = 0.009), and MG + US (0.803, P = 0.04). A total of 66.7% of cancers visible on only AB-MRI were located at the deep posterior portion of the excision cavity, which might have been missed with MG or MG + US due to masking by the ADM filler.

CONCLUSION

AB-MRI can improve the detection of ipsilateral LTR despite postoperative changes caused by ADM fillers compared to conventional MG and US. Patients who undergo BCS with ADM can be candidates for AB-MRI surveillance considering improved cancer detection and high sensitivity.

Screening Breast MRI Primer: Indications, Current Protocols, and Emerging Techniques

Breast dynamic contrast-enhanced MRI (DCE-MRI) is the most sensitive imaging modality for the detection of breast cancer. Screening MRI is currently performed predominantly in patients at high risk for breast cancer, but it could be of benefit in patients at intermediate risk for breast cancer and patients with dense breasts. Decreasing scan time and image interpretation time could increase cost-effectiveness, making screening MRI accessible to a larger group of patients. Abbreviated breast MRI (Ab-MRI) reduces scan time by decreasing the number of sequences obtained, but as multiple delayed contrast enhanced sequences are not obtained, no kinetic information is available. Ultrafast techniques rapidly acquire multiple sequences during the first minute of gadolinium contrast injection and provide information about both lesion morphology and vascular kinetics. Diffusion-weighted imaging is a noncontrast MRI technique with the potential to detect mammographically occult cancers. This review article aims to discuss the current indications of breast MRI as a screening tool, examine the standard breast DCE-MRI technique, and explore alternate screening MRI protocols, including Ab-MRI, ultrafast MRI, and noncontrast diffusion-weighted MRI, which can decrease scan time and interpretation time.

Breast Cancer Screening with Abbreviated Breast MRI: 3-year Outcome Analysis

Background Data are limited regarding the performance of abbreviated screening breast MRI during consecutive years and the characteristics of breast cancers missed and detected with it. Purpose To assess the longitudinal diagnostic performance of abbreviated screening MRI and to determine whether the screening outcomes of abbreviated MRI differed between yearly time periods for 3 consecutive years. Materials and Methods This retrospective study included 1975 consecutive women who underwent abbreviated screening MRI between September 2015 and August 2018. Breast Imaging Reporting and Data System (BI-RADS) categories 3-5 defined positive results, and BI-RADS categories 1-2 defined negative results. Cancer detection rate (CDR), sensitivity, specificity, positive predictive value (PPV), abnormal interpretation rate (AIR), and interval cancer rate were assessed annually. Yearly performance measures were compared with the Fisher exact test by using the permutation method. Clinical-pathologic and imaging characteristics of the missed and detected cancers were compared by using the Fisher exact test and the Wilcoxon rank sum test. Results A total of 1975 women (median age, 49 years; interquartile range, 44-56 years) underwent 3037 abbreviated MRI examinations over 3 years. CDR (year 1 to year 3, 6.9-10.7 per 1000 examinations), positive predictive value for recall (9.7% [six of 62] to 15.6% [12 of 77]), positive predictive value for biopsy (31.6% [six of 19] to 63.2% [12 of 19]), sensitivity (75.0% [six of eight] to 80.0% [12 of 15]), and specificity (93.5% [807 of 863] to 94.1% [1041 of 1106]) were highest in year 3, and AIR (7.1% [62 of 871] to 6.9% [77 of 1121]) was lowest in year 3. However, all outcome measures did not differ statistically between years 1, 2, and 3 (all P > .05). The interval cancer rate was 0.66 per 1000 examinations (two of 3037). Thirty-eight breast cancers were identified in 36 women; 29 were detected with abbreviated MRI, but nine were missed. Of these, seven were detected with other imaging modalities after negative results at the last screening MRI examination, and two were interval cancers. All missed cancers were node-negative early-stage invasive cancers and were smaller (median size, 0.8 cm vs 1.2 cm; P = .01) than detected cancers. Conclusion Screening outcome measures of abbreviated MRI were sustained without significant differences between 3 consecutive years. All cancers missed at abbreviated MRI were node-negative invasive cancers and tended to be smaller than detected cancers. © RSNA, 2021 See also the editorial by Lee in this issue. Online supplemental material is available for this article.

Supplemental Screening for Patients at Intermediate and High Risk for Breast Cancer

The sensitivity of mammography is more limited in patients with dense breasts and some patients at higher risk for breast cancer. Patients with intermediate or high risk for breast cancer may begin screening earlier and benefit from supplemental screening techniques beyond standard 2-dimensional mammography. A patient's individual risk factors for developing breast cancer, their breast density, and the evidence supporting specific modalities for a given clinical scenario help to determine the need for supplemental screening and the modality chosen. Additional factors include the availability of supplemental screening techniques at an individual institution, cost, insurance coverage, and state-specific breast density legislation.

Percentage volume of delayed kinetics in computer-aided diagnosis of MRI of the breast to reduce false-positive results and unnecessary biopsies

AIM

To investigate the best cut-off percentage volume of delayed kinetics using magnetic resonance imaging (MRI) with computer-aided diagnosis (CAD) to reduce unnecessary biopsies in patients with newly diagnosed breast cancer.

MATERIALS AND METHODS

Between January 2017 and December 2018, 94 malignant and 56 benign masses were analysed using MRI CAD. All malignant and benign masses measured <2 cm and were confirmed histopathologically. The optimal cut-off values for washout, plateau, and persistent components were determined using the maximum Youden Index. The positive predictive value (PPV) was analysed using morphological descriptors and combining the percentage volume of delayed kinetics.

RESULTS

The area under the curve (AUC) was highest at ≤73% persistent component (AUC=0.759). In the subgroup analyses of masses <1 cm, the AUC was highest a plateau of >26% (AUC=0.697). When the persistent ≤73% criterion was applied to the lesions of C4a, the positive predictive value (PPV) increased from 61.9% to 72.44% with reduced false-negative cases and when applied to the lesions of C4a and C4b, the PPV increased from 61.9% to 78.1% with slightly increased false-negative cases. For subcentimetre lesions, the PPV increased from 46.77% to 54.72% with the same number of false-negative cases, when a plateau of >26% was applied to C4a, and the PPV increased from 46.77% to 61.36% with five false-negative cases when applied to C4a and C4b.

CONCLUSION

The percentage volume of delayed kinetics has the potential to improve the PPV of breast MRI. When suspicious masses <2 cm do not show ≤73% persistence, follow-up rather than biopsy could be considered; however, to avoid increasing false-negative cases, delayed kinetic information should be used with caution and accurate margin assessment is essential.

The utility of magnetic resonance imaging in early-stage breast cancer survivors-An institutional experience and literature review

The role of breast magnetic resonance imaging (MRI) in the screening of breast cancer survivors with remaining breast tissue is not well studied. We sought to evaluate the outcomes of screening breast MRI in a cohort of breast cancer survivors. A population of patients with history of stage I-IIIa breast cancer and ≥1 MRI a year or later from diagnosis between 2006-2008 were identified using the National Comprehensive Cancer Network data base from two large Boston-area cancer centers. Patient and disease characteristics were obtained from the data base, and medical records were reviewed to identify the index MRI (first eligible), indications, and two-year outcomes. Overall, 647 patients had breast MRI scans during the study period including 342 eligible patients whose index MRIs were done for breast screening purposes. 47/342 (13.7%) were abnormal, and 3.8% (13/342) underwent biopsy, resulting in the detection of 3 cases of locoregional recurrence or new primary breast cancer (0.9%, 95% CI = 0.2%-2.5%). Of 295 patients with a normal index screening MRI, 12 had a breast cancer recurrence diagnosed within 2 years (4.1% 95%CI = 2.1%-7.0%), and 5 of these recurrences were limited to MRI-screened breast tissue. No statistically significant difference in the rate of 2-year locoregional or distant recurrence was observed between patients with an abnormal screening MRI and those with a normal scan. Adjunct single breast MRI surveillance in a general population of breast cancer survivors one year after diagnosis detected few recurrences, and its effect on short-term outcomes was unclear.

Surveillance for second breast cancer events in women with a personal history of breast cancer using breast MRI: a systematic review and meta-analysis

PURPOSE

Women with personal history of breast cancer (PHBC) are currently recommended to receive annual mammography for surveillance of breast cancer recurrence or new primary. However, given issues in accuracy with mammography, there is a need for evolving evidence-based surveillance recommendations with supplemental imaging. In this systematic review, we compiled and compared existing studies that describe the test performance of surveillance breast MRI among women with PHBC.

METHODS

We searched PubMed and EMBASE using MeSH terms for studies (2000-2019) that described the diagnostic characteristics of breast MRI in women with PHBC. Search results were reviewed and included based on PICOTS criteria; quality of included articles was assessed using QUADAS-2. Meta-analysis of single proportions was conducted for diagnostic characteristics of breast MRI, including tests of heterogeneity.

RESULTS

Our review included 11 articles in which unique cohorts were studied, comprised of a total of 8338 women with PHBC and 12,335 breast MRI done for the purpose of surveillance. We predict intervals (PI) for cancer detection rate per 1000 examinations (PI 9-15; I² = 10%), recall rate (PI 5-31%; I² = 97%), sensitivity (PI 58-95%; I² = 47%), specificity (PI 76-97%; I² = 97%), and PPV3 (PI 16-40%; I² = 44%).

CONCLUSIONS

Studies addressing performance of breast MRI are variable and limited in population-based studies. The summary of evidence to date is insufficient to recommend for or against use of breast MRI for surveillance among women with PHBC.

Screening in patients with increased risk of breast cancer (part 1): pros and cons of MRI screening

Screening plays an important role in women with a high risk of breast cancer. Given this population's high incidence of breast cancer and younger age of onset compared to the general population, it is recommended that screening starts earlier. There is ample evidence that magnetic resonance imaging (MRI) is the most sensitive diagnostic tool, and American and the European guidelines both recommend annual MRI screening (with supplementary annual mammography) as the optimum screening modality. Nevertheless, the current guidelines do not totally agree about the recommendations for MRI screening in some subgroups of patients. The first part of this article on screening in women with increased risk of breast cancer reviews the literature to explain and evaluate the advantages of MRI screening compared to screening with mammography alone: increased detection of smaller cancers with less associated lymph node involvement and a reduction in the rate of interval cancers, which can have an impact on survival and mortality (with comparable effects to other preventative measures). At the same time, however, we would like to reflect on the drawbacks of MRI screening that affect its applicability.

Diagnostic performance of abbreviated breast MRI for screening of women with previously treated breast cancer

RATIONALE AND OBJECTIVES

To evaluate the diagnostic performance of abbreviated screening breast magnetic resonance imaging (AB-MRI) for screening in women with previously treated breast cancer.

MATERIALS AND METHODS

This retrospective study included consecutive AB-MRI from September 2015 to December 2016 in patients with previously treated breast cancer. Longitudinal medical record of patients' demographics, outcomes of imaging surveillance and results of biopsy was reviewed. Protocol consisted of T2-weighted scanning and dynamic contrast-enhanced imaging including one pre-contrast and two post-contrast scans. A positive examination was defined as final assessment of BI-RADS 4 or 5 and negative was defined as BI-RADS 1, 2, or 3. Abnormal interpretation rate, cancer detection rate (CDR), sensitivity, specificity, accuracy, positive predictive value (PPV), and negative predictive value (NPV) were analyzed.

RESULTS

Among total 1043 AB-MRI, 29 (2.8%) AB-MRI had suspicious findings including 26 (2.5%) BI-RADS 4 and 3 (0.3%) BI-RADS 5 assessments. CDR was 9.59 per 1000. Performance outcomes were as follows: sensitivity, 71.4%; specificity, 98.2%; accuracy, 97.8%; PPV 1, 35.7%; PPV3 50%; and NPV 99.6%. Four cancers with false negative MRI were all early cancers of <1.0 cm with node negative. One was palpable interval cancer while the others were alternative screening modality-detected asymptomatic cancers before the next MRI screening.

CONCLUSION

AB-MRI showed high accuracy and NPV for detecting cancer recurrence in women with previously treated breast cancer. Missed cancers were all minimal cancers with node negative.

Feasibility of abbreviated magnetic resonance imaging (AB-MRI) screening in women with a personal history (PH) of breast cancer

PURPOSE

To investigate the feasibility of abbreviated magnetic resonance imaging (AB-MRI) in women with a personal history (PH) of breast cancer as a screening tool.

MATERIALS AND METHODS

We retrospectively reviewed 1880 screening AB-MRIs in 763 women with a PH of breast cancer (median age, 55 years; range, 23-89 years) between October 2015 and October 2016. The total acquisition times of AB-MRI were 8.3 min and 2.8 min with and without T2-weighted imaging, respectively. The tissue diagnosis or one-year follow-up status was used as the reference standard. The characteristics of tumor recurrences detected on AB-MRI screenings were analyzed. The cancer detection rates (CDRs) and additional CDRs for the 1st round and overall rounds of AB-MRI screening were calculated. The recall rate, sensitivity, specificity, positive predictive values for recall (PPV1) and biopsy (PPV3) for the 1st round of AB-MRI screening were calculated. The diagnostic performance of the combination of mammography and ultrasonography was compared with that of AB-MRI by receiver operating characteristic (ROC) curve analysis.

RESULTS

Fifteen of a total of 21 recurrences were detected on the 1st round of AB-MRI screening: 93.3% were node-negative T1 tumors (median tumor size, 1.02 cm; range, 0.1-2 cm) or Tis; 66.7% were high-grade tumors; 8 of these 15 were mammographically and ultrasonographically occult. The CDR and additional CDR for the 1st round of AB-MRI screening were 0.019 and 0.010 per woman, respectively. The sensitivity, specificity, recall rate, PPV1 and PPV3 for the 1st round of AB-MRI screening were 100%, 96.0%, 14.3%, 13.8% and 58.3%, respectively. For detecting secondary cancer, AB-MRI showed a higher sensitivity and PPV than the combination of mammography and ultrasonography (95.2%, 57.1% vs 47.6%, 38.5%). The area under the ROC curve was higher for AB-MRI (0.966; 95% CI: 0.951-0.978) than the combination of mammography and ultrasonography (0.727; 95% CI: 0.694-0.759) (P<0.0001).

CONCLUSION

AB-MRI improved cancer detection with a high specificity, sensitivity and PPV in women with a PH of breast cancer. AB-MRI could be a useful screening tool for detecting secondary cancer considering its high diagnostic performance and short examination time.

Surveillance Magnetic Resonance Imaging in Detecting the Second Breast Cancer in Women With a Personal History of Breast Cancer

OBJECTIVE

The objective of this study was to evaluate the diagnostic performance of magnetic resonance imaging (MRI) in detecting the secondary breast cancer among women with a personal history of the lesion.

MATERIALS AND METHODS

We retrospectively reviewed breast MRI examinations performed between 2007 and 2011. A total of 798 women with a history of breast cancer were included in the study. Cancer detection rate, positive predictive value (PPV), recall rate, sensitivity, and specificity were assed. Cancer detection rate was stratified by interval after surgery of the primary breast cancer. Also, we derived 1 comparison group from the women for comparing the performance of x-ray mammography, ultrasound, and MRI in detecting the second breast cancer.

RESULTS

Of the 798 patients, 47 of the 49 secondary breast carcinomas were detected by MRI. The sensitivity and specificity of MRI in detecting the secondary lesions were 95.9% and 96.3%, respectively. The recall rate was 9.5%, and the PPV was 61.8%. Cancer detection rate of MRI examinations performed at more than 36 months after initial surgery was significantly higher than that at 36 months or less after initial surgery (13.7% vs 3.6, P < 0.001). In comparison group, the sensitivity and specificity of MRI, mammography, and ultrasound were 96.7% and 96.1%, 48.4% and 93.9%, and 77.4% and 96.1%, respectively.

CONCLUSIONS

Surveillance MRI for women with a personal history of breast cancer has high sensitivity in finding the secondary malignancies with a reasonable recall rate and PPV.

Surveillance Breast MRI and Mammography: Comparison in Women with a Personal History of Breast Cancer

Background There is lack of consensus regarding the use of breast MRI for routine surveillance for second breast cancer events in women with a personal history of breast cancer. Purpose To compare performance of surveillance mammography with breast MRI. Materials and Methods This observational cohort study used prospectively collected data and included 13 266 women age 18 years and older (mean age, 60 years ± 13) with stage 0-III breast cancer who underwent 33 938 mammographic examinations and 2506 breast MRI examinations from 2005 to 2012 in the Breast Cancer Surveillance Consortium. Women were categorized into two groups: mammography alone (n = 11 745) or breast MRI (n = 1521). Performance measures were calculated by using end-of-day assessment and occurrence of second breast cancer events within 1 year of imaging. Logistic regression was used to compare performance for breast MRI versus mammography alone, adjusting for women, examination, and primary breast cancer characteristics. Analysis was conducted on a per-examination basis. Results Breast MRI was associated with younger age at diagnosis, chemotherapy, and higher education and income. Raw performance measures for breast MRI versus mammography were as follows, respectively: cancer detection rates, 10.8 (95% confidence interval [CI]: 6.7, 14.8) versus 8.2 (95% CI: 7.3, 9.2) per 1000 examinations; sensitivity, 61.4% (27 of 44; 95% CI: 46.5%, 76.2%) versus 70.3% (279 of 397; 95% CI: 65.8%, 74.8%); and biopsy rate, 10.1% (253 of 2506; 95% CI: 8.9%, 11.3%) versus 4.0% (1343 of 33 938; 95% CI: 3.7%, 4.2%). In multivariable models, breast MRI was associated with higher biopsy rate (odds ratio [OR], 2.2; 95% CI: 1.9, 2.7; P < .001) and cancer detection rate (OR, 1.7; 95% CI: 1.1, 2.7; P = .03) than mammography alone. However, there were no differences in sensitivity (OR, 1.1; 95% CI: 0.4, 2.9; P = .84) or interval cancer rate (OR, 1.1; 95% CI: 0.6, 2.2; P = .70). Conclusion Comparison of the performance of surveillance breast MRI with mammography must account for patient characteristics. Whereas breast MRI leads to higher biopsy and cancer detection rates, there were no significant differences in sensitivity or interval cancers compared with mammography. © RSNA, 2019 Online supplemental material is available for this article. See also the editorial by Newell in this issue.

Breast density implications and supplemental screening

Digital breast tomosynthesis (DBT) has been widely implemented in place of 2D mammography, although it is less effective in women with extremely dense breasts. Breast ultrasound detects additional early-stage, invasive breast cancers when combined with mammography; however, its relevant limitations, including the shortage of trained operators, operator dependence and small field of view, have limited its widespread implementation. Automated breast sonography (ABS) is a promising technique but the time to interpret and false-positive rates need to be improved. Supplemental screening with contrast-enhanced magnetic resonance imaging (MRI) in high-risk women reduces late-stage disease; abbreviated MRI protocols may reduce cost and increase accessibility to women of average risk with dense breasts. Contrast-enhanced digital mammography (CEDM) and molecular breast imaging improve cancer detection but require further validation for screening and direct biopsy guidance should be implemented for any screening modality. This article reviews the status of screening women with dense breasts. KEY POINTS: • The sensitivity of mammography is reduced in women with dense breasts. Supplemental screening with US detects early-stage, invasive breast cancers. • Tomosynthesis reduces recall rate and increases cancer detection rate but is less effective in women with extremely dense breasts. • Screening MRI improves early diagnosis of breast cancer more than ultrasound and is currently recommended for women at high risk. Risk assessment is needed, to include breast density, to ascertain who should start early annual MRI screening.

Contrast-enhanced MRI for breast cancer screening

Multiple studies in the first decade of the 21^st century have established contrast-enhanced breast MRI as a screening modality for women with a hereditary or familial increased risk for the development of breast cancer. In recent studies, in women with various risk profiles, the sensitivity ranges between 81% and 100%, which is approximately twice as high as the sensitivity of mammography. The specificity increases in follow-up rounds to around 97%, with positive predictive values for biopsy in the same range as for mammography. MRI preferentially detects the more aggressive/invasive types of breast cancer, but has a higher sensitivity than mammography for any type of cancer. This performance implies that in women screened with breast MRI, all other examinations must be regarded as supplemental. Mammography may yield ~5% additional cancers, mostly ductal carcinoma in situ, while slightly decreasing specificity and increasing the costs. Ultrasound has no supplemental value when MRI is used. Evidence is mounting that in other groups of women the performance of MRI is likewise superior to more conventional screening techniques. Particularly in women with a personal history of breast cancer, the gain seems to be high, but also in women with a biopsy history of lobular carcinoma in situ and even women at average risk, similar results are reported. Initial outcome studies show that breast MRI detects cancer earlier, which induces a stage-shift increasing the survival benefit of screening. Cost-effectiveness is still an issue, particularly for women at lower risk. Since costs of the MRI scan itself are a driving factor, efforts to reduce these costs are essential. The use of abbreviated MRI protocols may enable more widespread use of breast MRI for screening. Level of Evidence: 1 Technical Efficacy: Stage 5 J. Magn. Reson. Imaging 2019;50:377-390.

Screening women with a personal history of breast cancer: overview of the evidence on breast imaging surveillance

This work reviews the evidence on breast imaging for screening (surveillance) in women with a history of breast cancer (BC). Early detection of second BCs in these women improves their prognosis based on studies using mammography (usually with clinical examinations) for surveillance. Cohort studies have estimated that mammography surveillance has moderate sensitivity (65.4%) and good specificity (98.3%), and have shown that these women are at a higher risk of interval BC than age- and breast density-matched women without a history of BC. Studies of adjunct imaging (ultrasound, magnetic resonance imaging) for surveillance that have reported detection and accuracy measures have generally shown that adjunct imaging detected more second BCs than mammography and added substantially to the amount of false-positive results; however, little evidence exists regarding screening efficacy of adjunct imaging as part of routine surveillance.

Impact of Advancing Technology on Diagnosis and Treatment of Breast Cancer

New emerging breast imaging techniques have shown great promise in breast cancer screening, evaluation of extent of disease, and response to neoadjuvant therapy. Tomosynthesis, allows 3-dimensional imaging of the breast, and increases breast cancer detection. Fast abbreviated MRI has reduced time and costs associated with traditional breast MRI while maintaining cancer detection. Diffusion-weighted imaging is a functional MRI technique that does not require contrast and has shown potential in screening, lesion characterization and also evaluation of treatment response. New image-guided preoperative localizations are available that have increased patient satisfaction and decreased operating room delays.

Developments in Breast Imaging: Update on New and Evolving MR Imaging and Molecular Imaging Techniques

This article reviews new developments in breast imaging. There is growing interest in creating a shorter, less expensive MR protocol with broader applicability. There is an increasing focus on and consideration for the additive impact that functional analysis of breast pathology have on identifying and characterizing lesions. These developments apply to MR imaging and molecular imaging. This article reviews evolving breast imaging techniques with attention to strengths, weaknesses, and applications of these approaches. We aim to give the reader familiarity with the state of current developments in the field and to increase awareness of what to expect in breast imaging.

Breast magnetic resonance imaging for surveillance of women with a personal history of breast cancer: outcomes stratified by interval between definitive surgery and surveillance MR imaging

Background

Women with a personal history of breast cancer are at increased risk of future breast cancer events, and may benefit from supplemental screening methods that could enhance early detection of subclinical disease. However, current literature on breast magnetic resonance (MR) imaging surveillance is limited. We investigated outcomes of surveillance breast magnetic resonance (MR) imaging in women with a personal history of breast cancer.

Methods

We reviewed 1053 consecutive breast MR examinations that were performed for surveillance in 1044 women (median age, 53 years; range, 20–85 years) previously treated for breast cancer between August 2014 and February 2016. All patients had previously received supplemental surveillance with ultrasound. Cancer detection rate (CDR), abnormal interpretation rate and characteristics of MR-detected cancers were assessed, including extramammary cancers. We also calculated the PPV₁, PPV₃, sensitivity and specificity for MR-detected intramammary lesions. Performance statistics were stratified by interval following initial surgery.

Results

The CDR for MR-detected cancers was 6.7 per 1000 examinations (7 of 1053) and was 3.8 per 1000 examinations (4 of 1053) for intramammary cancers. The overall abnormal interpretation rate was 8.0%, and the abnormal interpretation rate for intramammary lesions was 7.2%. The PPV₁, PPV₃, sensitivity and specificity for intramammary lesions was 5.3% (4 of 76), 15.8% (3 of 19), 75.0% (3 of 4) and 98.3% (1031 of 1049), respectively. For MR examinations performed ≤36 months after surgery, the overall CDR was 1.4 per 1000 examinations. For MR examinations performed > 36 months after surgery, the overall CDR was 17.4 per 1000 examinations.

Conclusions

Surveillance breast MR imaging may be considered in women with a history of breast cancer, considering the low abnormal interpretation rate and its high specificity. However, the cancer detection rate was low and implementation may be more effective after more than 3 years after surgery.

Usefulness of abbreviated breast MRI screening for women with a history of breast cancer surgery

PURPOSE

We investigated the usefulness of abbreviated breast MRI (AB-MRI), including fat-suppressed T2-weighted imaging, pre- and postcontrast image acquisition, and subtracted maximum-intensity projection imaging, for the screening of women with a history of breast cancer surgery.

METHODS

Between October 2014 and March 2016, a total of 799 AB-MRI examinations were performed for 725 women with a history of breast cancer surgery. The image acquisition time was 8.5 min. Screening mammography, ultrasound, and AB-MRI were generally performed around the same time. The cancer detection rate, positive predictive values for recall and biopsy, sensitivity and specificity of screening MRI, and rate of malignancy belonging to each breast imaging reporting and data system (BI-RADS) category were assessed.

RESULTS

AB-MRI detected 12 malignancies in 12 women (15.0 cancers per 1000 cases). Seven of these 12 malignancies were initially invisible on ultrasound and mammography, although subsequent targeted ultrasound revealed lesions corresponding to the MRI-detected lesions. The positive predictive values for recall and biopsy and sensitivity and specificity values for screening MRI were 12.4, 61.5, 100, and 89.2%, respectively. The rates of malignancies belonging to categories 1, 2, 3, and 4 of the BI-RADS were 0, 0, 4.8, and 57.1%, respectively.

CONCLUSIONS

The diagnostic performance of screening AB-MRI for women with a history of breast cancer surgery is acceptable, with the advantages of short examination and interpretation times and low costs. Thus, it could be used as a main screening modality that may replace conventional imaging in breast cancer survivors.

Performance Benchmarks for Screening Breast MR Imaging in Community Practice

Purpose To compare screening magnetic resonance (MR) imaging performance in the Breast Cancer Surveillance Consortium (BCSC) with Breast Imaging Reporting and Data System (BI-RADS) benchmarks. Materials and Methods This study was approved by the institutional review board and compliant with HIPAA and included BCSC screening MR examinations collected between 2005 and 2013 from 5343 women (8387 MR examinations) linked to regional Surveillance, Epidemiology, and End Results program registries, state tumor registries, and pathologic information databases that identified breast cancer cases and tumor characteristics. Clinical, demographic, and imaging characteristics were assessed. Performance measures were calculated according to BI-RADS fifth edition and included cancer detection rate (CDR), positive predictive value of biopsy recommendation (PPV2), sensitivity, and specificity. Results The median patient age was 52 years; 52% of MR examinations were performed in women with a first-degree family history of breast cancer, 46% in women with a personal history of breast cancer, and 15% in women with both risk factors. Screening MR imaging depicted 146 cancers, and 35 interval cancers were identified (181 total-54 in situ, 125 invasive, and two status unknown). The CDR was 17 per 1000 screening examinations (95% confidence interval [CI]: 15, 20 per 1000 screening examinations; BI-RADS benchmark, 20-30 per 1000 screening examinations). PPV2 was 19% (95% CI: 16%, 22%; benchmark, 15%). Sensitivity was 81% (95% CI: 75%, 86%; benchmark, >80%), and specificity was 83% (95% CI: 82%, 84%; benchmark, 85%-90%). The median tumor size of invasive cancers was 10 mm; 88% were node negative. Conclusion The interpretative performance of screening MR imaging in the BCSC meets most BI-RADS benchmarks and approaches benchmark levels for remaining measures. Clinical practice performance data can inform ongoing benchmark development and help identify areas for quality improvement. © RSNA, 2017.

Breast cancer screening: updated recommendations of the Brazilian College of Radiology and Diagnostic Imaging, Brazilian Breast Disease Society, and Brazilian Federation of Gynecological and Obstetrical Associations

Objective

To present the current recommendations for breast cancer screening in Brazil, as devised by the Brazilian College of Radiology and Diagnostic Imaging, the Brazilian Breast Disease Society, and the Brazilian Federation of Gynecological and Obstetrical Associations.

Materials and methods

We analyzed scientific studies available in the Medline and Lilacs databases. In the absence of evidence, the recommendations reflected the consensus of a panel of experts.

Recommendations

Annual mammography screening is recommended for women 40-74 years of age. Among women ≥ 75 years of age, annual mammography screening should be reserved for those with an expected survival > 7 years. Complementary ultrasound should be considered for women with dense breasts. Complementary magnetic resonance imaging is recommended for women at high risk. When available, an advanced form of mammography known as tomosynthesis can be considered as a means of screening for breast cancer.

Utility of surveillance MRI in women with a personal history of breast cancer

PURPOSE

To determine the utility and rate of biopsy in women with a positive history of breast cancer screened with MRI.

METHODS

Retrospective review of 491 breast MRI screening examinations in women with a personal history of breast cancer.

RESULTS

In total, 107 biopsies were performed, an average of 0.09 biopsies per person year. The positive predictive value for biopsies prompted by MRI findings was 0.24 (95% C.I. 0.10-0.38). Eight of the nine subsequent cancers were initially identified on screening MRI alone.

CONCLUSION

Surveillance MRI in breast cancer survivors may increase detection of subsequent cancers while increasing rate of biopsy.

Unenhanced magnetic resonance screening using fused diffusion-weighted imaging and maximum-intensity projection in patients with a personal history of breast cancer: role of fused DWI for postoperative screening

PURPOSE

To assess the diagnostic performance of unenhanced abbreviated protocol (AP) comprising fused diffusion-weighted imaging (DWI) using T1-weighted imaging (T1WI) with DWI maximum-intensity projections (DWI MIPs) for screening patients with a personal history of breast cancer (PHBC).

METHODS

This institutional review board-approved retrospective observational study included 343 patients with PHBC who underwent 3T breast magnetic resonance imaging (MRI) between November 2013 and September 2015. Three breast radiologists reviewed the DWI MIPs of the AP to identify lesions, and the remaining axial AP images to characterize the detected lesions and establish the breast imaging reporting and data system final assessment. The conventional protocol (CP) images were also evaluated in the same way. The decision-making times were recorded.

RESULTS

MRI acquisition time was approximately 5 min for AP. The mean times to read MIPs and remaining images were shorter in AP than in CP (5.5 and 22.1 s vs. 7.8 and 29.6 s). On DWI MIPs, the readers detected 9, 8, and 9 of 9 pathologically proven cancers, with negative predictive values (NPVs) of 100.0, 99.6, and 100.0%. Complete AP showed sensitivities of 88.9, 100.0, and 88.9% and specificities of 94.8, 93.4, and 95.1%. Complete CP showed sensitivities of 100.0, 100.0, and 88.9% and specificities of 93.4, 94.0, and 96.3%.

CONCLUSIONS

An unenhanced AP had a short acquisition time of 5 min, and DWI MIPs showed NPVs greater than 99% across readers. The diagnostic performance of complete AP was equivalent to that of CP for screening patients with PHBC.

Imaging Surveillance After Primary Breast Cancer Treatment

OBJECTIVE

Current clinical guidelines are consistent in supporting annual mammography for women after treatment of primary breast cancer. Surveillance imaging beyond standard digital mammography, including digital breast tomosynthesis (DBT), breast ultrasound, and MRI, may improve outcomes. This article reviews the evidence on the performance and effectiveness of breast imaging modalities available for surveillance after treatment of sporadic unilateral primary breast cancer and identifies additional factors to be considered when selecting an imaging surveillance regimen.

CONCLUSION

Evidence review supports the use of mammography for surveillance after primary breast cancer treatment. Variability exists in guideline recommendations for surveillance initiation, interval, and cessation. DBT offers the most promise as a potential modality to replace standard digital mammography as a front-line surveillance test; a single published study to date has shown a significant decrease in recall rates compared with standard digital mammography alone. Most guidelines do not support the use of whole-breast ultrasound in breast cancer surveillance, and further studies are needed to define the characteristics of women who may benefit from MRI surveillance. The emerging evidence about surveillance imaging outcomes suggests that additional factors, including patient and imaging characteristics, tumor biology and gene expression profile, and choice of treatment, warrant consideration in selecting personalized posttreatment imaging surveillance regimens.