Application value of MRI-guided wire localization to the non-palpable breast lesions only shown in Breast MRI

Introduction

Magnetic resonance imaging (MRI)-guided wire localization can be applied to assist to remove suspected breast lesions accurately. This study aimed to evaluate the clinical application value of this technique in Chinese women.

Methods

A total of 126 patients (131 lesions) who had underwent such technique in our hospital from April 2017 to June 2023 were enrolled. 1.5T MRI system and a wire localization device were used. Image characteristics, clinical features and postoperative pathology were collected and analyzed.

Results

All of 126 patients (131 lesions) were successfully localized by MRI and excised for biopsy. There were 39 malignant lesions (29.77%) and 92 benign lesions (70.23%). There was no significant correlation between the morphology of DCE-MRI and the ratio of malignant lesions (P=0.763), while there was a statistical correlation between the BPE, TIC curve and the malignancy rate (P<0.05). All the lesions were assessed according to BI-RADS category of MRI (C4A=77, C4B=40, C4C=12, C5=2). The malignancy rates were as follows: 16.88% for 4A lesions (13/77), 37.50% for 4B lesions (15/40), 75.00% for 4C lesions (9/12) and 100% for 5 lesions (2/2). There was a significant correlation between the BI-RADS category and the incidence of benign-to-malignant lesions (P<0.001).

Conclusion

MRI-guided wire localization can assist to remove suspected breast lesions early, safely and accurately. This technique makes up for the deficiency of X-ray and ultrasound, improves the accuracy of diagnosis and resection therapy in intraductal carcinoma and early invasive carcinoma, and helps to improve the the prognosis of breast cancer.

Mixed Reality Biopsy Navigation System Utilizing Markerless Needle Tracking and Imaging Data Superimposition

Exact biopsy planning and careful execution of needle injection is crucial to ensure successful procedure completion as initially intended while minimizing the risk of complications. This study introduces a solution aimed at helping the operator navigate to precisely position the needle in a previously planned trajectory utilizing a mixed reality headset. A markerless needle tracking method was developed by integrating deep learning and deterministic computer vision techniques. The system is based on superimposing imaging data onto the patient's body in order to directly perceive the anatomy and determine a path from the selected injection site to the target location. Four types of tests were conducted to assess the system's performance: measuring the accuracy of needle pose estimation, determining the distance between injection sites and designated targets, evaluating the efficiency of material collection, and comparing procedure time and number of punctures required with and without the system. These tests, involving both phantoms and physician participation in the latter two, demonstrated the accuracy and usability of the proposed solution. The results showcased a significant improvement, with a reduction in number of punctures needed to reach the target location. The test was successfully completed on the first attempt in 70% of cases, as opposed to only 20% without the system. Additionally, there was a 53% reduction in procedure time, validating the effectiveness of the system.

High-risk lesions in the breast diagnosed by MRI-guided core biopsy: upgrade rates and features associated with malignancy

PURPOSE

This study assessed the upgrade rates of high-risk lesions (HRLs) in the breast diagnosed by MRI-guided core biopsy and evaluated imaging and clinical features associated with upgrade to malignancy.

METHODS

This IRB-approved, retrospective study included MRI-guided breast biopsy exams yielding HRLs from August 1, 2011, to August 31, 2020. HRLs included atypical ductal hyperplasia (ADH), lobular carcinoma in situ (LCIS), atypical lobular hyperplasia (ALH), radial scar, and papilloma. Only lesions that underwent excision or at least 2 years of MRI imaging follow-up were included. For each HRL, patient history, imaging features, and outcomes were recorded.

RESULTS

Seventy-two lesions in 65 patients were included in the study, with 8/72 (11.1%) of the lesions upgraded to malignancy. Upgrade rates were 16.7% (2/12) for ADH, 100% (1/1) for pleomorphic LCIS, 40% (2/5) for other LCIS, 0% (0/19) for ALH, 0% (0/18) for papilloma, and 0% (0/7) for radial scar/complex sclerosing lesion. Additionally, two cases of marked ADH bordering on DCIS and one case of marked ALH bordering on LCIS, were upgraded. Lesions were more likely to be upgraded if they presented as T2 hypointense (versus isotense, OR 6.46, 95% CI 1.27-32.92) or as linear or segmental non-mass enhancement (NME, versus focal or regional, p = 0.008).

CONCLUSION

Our data support the recommendation that ADH and LCIS on MRI-guided biopsy warrant surgical excision due to high upgrade rates. HRLs that present as T2 hypointense, or as linear or segmental NME, should be viewed with suspicion as these were associated with higher upgrade rates to malignancy.

Challenges in MRI-Guided Breast Biopsy and Some Suggested Strategies: Case Based Review

With the increasing use of MRI in clinical practice, the need for MRI-guided intervention is also increasing. Indeterminate lesions identified on MRI without mammographic or sonographic correlates will need to be approached under MRI guidance. MRI-guided biopsy is a skill that can be acquired with proper training and guidance. These procedures have their own set of challenges and issues; some of them are specific to the patient habitus in this region. Adequate knowledge and understanding of the challenges can help the radiologist to be better equipped to face these issues and solve them promptly during the procedure, thus increasing the overall success rate of the procedure. Not much local data from Asian countries is available on this front. This paper aims to share common challenges one may face while performing MRI-guided biopsy and share some tips and tricks to address these problems. Hopefully, this will help the readers achieve a higher success rate for MRI-guided interventions in their clinical practice.

MRI-guided Breast Biopsy Case-based Review: Essential Techniques and Approaches to Challenging Cases

MRI-guided breast biopsy is often necessary to distinguish between benign and malignant lesions depicted at MRI, and meticulous preparation and radiologic-pathologic correlation aid in definitive diagnosis.

High-Risk Lesions Detected by MRI-Guided Core Biopsy: Upgrade Rates at Surgical Excision and Implications for Management

OBJECTIVE. The purpose of our study was to evaluate the upgrade rates of high-risk lesions (HRLs) diagnosed by MRI-guided core biopsy and to assess which clinical and imaging characteristics are predictive of upgrade to malignancy. MATERIALS AND METHODS. A retrospective review was performed of all women who presented to an academic breast radiology center for MRI-guided biopsy between January 1, 2015, and November 30, 2018. Histopathologic results from each biopsy were extracted. HRLs-that is, atypical ductal hyperplasia (ADH), lobular carcinoma in situ (LCIS), atypical lobular hyperplasia (ALH), radial scar, papilloma, flat epithelial atypia (FEA), benign vascular lesion (BVL), and mucocelelike lesion-were included for analysis. Clinical history, imaging characteristics, surgical outcome, and follow-up data were recorded. Radiologic-pathologic correlation was performed. RESULTS. Of 810 MRI-guided biopsies, 189 cases (23.3%) met the inclusion criteria for HRLs. Of the 189 HRLs, 30 cases were excluded for the following reasons: 15 cases were lost to follow-up, six cases were in patients who received neoadjuvant chemotherapy after biopsy, two lesions that were not excised had less than 2 years of imaging follow-up, and seven lesions had radiologic-pathologic discordance at retrospective review. Of the 159 HRLs in our study cohort, 13 (8.2%) were upgraded to carcinoma. Surgical upgrade rates were high for ADH (22.5%, 9/40) and FEA (33.3%, 1/3); moderate for LCIS (6.3%, 3/48); and low for ALH (0.0%, 0/11), radial scar (0.0%, 0/28), papilloma (0.0%, 0/26), and BVL (0.0%, 0/3). Of the upgraded lesions, 69.2% (9/13) were upgraded to ductal carcinoma in situ (DCIS) or well-differentiated carcinoma. ADH lesions were significantly more likely to be upgraded than non-ADH lesions (p = .005). CONCLUSION. ADH diagnosed by MRI-guided core biopsy warrants surgical excision. The other HRLs, however, may be candidates for imaging follow-up rather than excision, especially after meticulous radiologic-pathologic correlation.

MRI-guided breast biopsy based on diffusion-weighted imaging: a feasibility study

Objectives

This study evaluated the feasibility of DWI for lesion targeting in MRI-guided breast biopsies. Furthermore, it assessed device positioning on DWI during biopsy procedures.

Methods

A total of 87 biopsy procedures (5/87 bilateral) consecutively performed between March 2019 and June 2020 were retrospectively reviewed: in these procedures, a preliminary DWI sequence (b = 1300 s/mm²) was acquired to assess lesion detectability. We included 64/87 procedures on lesions detectable at DWI; DWI sequences were added to the standard protocol to localize lesion and biopsy device and to assess the site marker correct positioning.

Results

Mass lesions ranged from 5 to 48 mm, with a mean size of 10.7 mm and a median size of 8 mm. Non-mass lesions ranged from 7 to 90 mm, with a mean size of 33.9 mm and a median size of 31 mm. Positioning of the coaxial system was confirmed on both T1-weighted and DWI sequences. At DWI, the biopsy needle was detectable in 62/64 (96.9%) cases; it was not visible in 2/64 (3.1%) cases. The site marker was always identified using T1-weighted imaging; a final DWI sequence was acquired in 44/64 cases (68.8%). In 42/44 cases (95.5%), the marker was recognizable at DWI.

Conclusions

DWI can be used as a cost-effective, highly reliable technique for targeting both mass and non-mass lesions, with a minimum size of 5 mm, detectable at pre-procedural DWI. DWI is also a feasible technique to localize the biopsy device and to confirm the deployment of the site marker.

Key Points

• MRI-guided breast biopsy is performed in referral centers by an expert dedicated staff, based on prior MR imaging; contrast agent administration is usually needed for lesion targeting.

• DWI represents a feasible, highly reliable technique for lesion targeting, avoiding contrast agent administration.

• DWI allows a precise localization of both biopsy needle device and site marker.

A Review on Advances in Intra-operative Imaging for Surgery and Therapy: Imagining the Operating Room of the Future

With the advent of Minimally Invasive Surgery (MIS), intra-operative imaging has become crucial for surgery and therapy guidance, allowing to partially compensate for the lack of information typical of MIS. This paper reviews the advancements in both classical (i.e. ultrasounds, X-ray, optical coherence tomography and magnetic resonance imaging) and more recent (i.e. multispectral, photoacoustic and Raman imaging) intra-operative imaging modalities. Each imaging modality was analyzed, focusing on benefits and disadvantages in terms of compatibility with the operating room, costs, acquisition time and image characteristics. Tables are included to summarize this information. New generation of hybrid surgical room and algorithms for real time/in room image processing were also investigated. Each imaging modality has its own (site- and procedure-specific) peculiarities in terms of spatial and temporal resolution, field of view and contrasted tissues. Besides the benefits that each technique offers for guidance, considerations about operators and patient risk, costs, and extra time required for surgical procedures have to be considered. The current trend is to equip surgical rooms with multimodal imaging systems, so as to integrate multiple information for real-time data extraction and computer-assisted processing. The future of surgery is to enhance surgeons eye to minimize intra- and after-surgery adverse events and provide surgeons with all possible support to objectify and optimize the care-delivery process.

Recent Progress for the Techniques of MRI-Guided Breast Interventions and their applications on Surgical Strategy

With a high sensitivity of breast lesions, MRI can detect suspicious lesions which are occult in traditional breast examination equipment. However, the lower and variable specificity of MRI makes the MRI-guided intervention, including biopsies and localizations, necessary before surgery, especially for patients who need the treatment of breast-conserving surgery (BCS). MRI techniques and patient preparation should be first carefully considered before the intervention to avoid lengthening the procedure time and compromising targeting accuracy. Doctors and radiologists need to reconfirm the target of the lesion and be very familiar with the process approach and equipment techniques involving the computer-aided diagnosis (CAD) tools and the biopsy system and follow a correct way. The basic steps of MRI-guided biopsy and localization are nearly the same regardless of the vendor or platform, and this article systematically introduces detailed methods and techniques of MRI-guided intervention. The two interventions both face different challenging situations during procedures with solutions given in the article. Post-operative statistics show that the complications of MRI-guided intervention are infrequent and mild, and MRI-guided biopsy provides the pathological information for the subsequent surgical decisions and MRI-guided localization fully prepared for follow-up surgical biopsy. New techniques for MRI-guided intervention are also elaborated in the article, which leads to future development. In a word, MRI-guided intervention is a safe, accurate, and effective technique with a low complication rate and successful MRI-guided intervention is truly teamwork with efforts from patients to surgeons, radiologists, MRI technologists, and nurses.

CT-guided biopsy of breast lesions: When should it be considered?

Mammography, ultrasound, and magnetic resonance imaging (MRI) are the most commonly used modalities for interventional radiology procedures involving the breast. Computed tomography (CT) is rarely used for breast imaging yet it is able to detect breast lesions and can often provide safe and effective access to breast lesions. The aim of this study was to demonstrate situations in which CT should be considered as an alternative guidance method for the biopsy of breast lesions that are not accessible with conventional imaging modalities.

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.

Analytical derivation of elasticity in breast phantoms for deformation tracking

PURPOSE

Patient-specific biomedical modeling of the breast is of interest for medical applications such as image registration, image guided procedures and the alignment for biopsy or surgery purposes. The computation of elastic properties is essential to simulate deformations in a realistic way. This study presents an innovative analytical method to compute the elastic modulus and evaluate the elasticity of a breast using magnetic resonance (MRI) images of breast phantoms.

METHODS

An analytical method for elasticity computation was developed and subsequently validated on a series of geometric shapes, and on four physical breast phantoms that are supported by a planar frame. This method can compute the elasticity of a shape directly from a set of MRI scans. For comparison, elasticity values were also computed numerically using two different simulation software packages.

RESULTS

Application of the different methods on the geometric shapes shows that the analytically derived elongation differs from simulated elongation by less than 9% for cylindrical shapes, and up to 18% for other shapes that are also substantially vertically supported by a planar base. For the four physical breast phantoms, the analytically derived elasticity differs from numeric elasticity by 18% on average, which is in accordance with the difference in elongation estimation for the geometric shapes. The analytic method has shown to be multiple orders of magnitude faster than the numerical methods.

CONCLUSION

It can be concluded that the analytical elasticity computation method has good potential to supplement or replace numerical elasticity simulations in gravity-induced deformations, for shapes that are substantially supported by a planar base perpendicular to the gravitational field. The error is manageable, while the calculation procedure takes less than one second as opposed to multiple minutes with numerical methods. The results will be used in the MRI and Ultrasound Robotic Assisted Biopsy (MURAB) project.

Stormram 4: An MR Safe Robotic System for Breast Biopsy

Suspicious lesions in the breast that are only visible on magnetic resonance imaging (MRI) need to be biopsied under MR guidance with high accuracy and efficiency for accurate diagnosis. The aim of this study is to present a novel robotic system, the Stormram 4, and to perform preclinical tests in an MRI environment. Excluding racks and needle, its dimensions are 72 × 51 × 40 mm. The Stormram 4 is driven by two linear and two curved pneumatic stepper motors. The linear motor is capable of exerting 63 N of force at a pressure of 0.65 MPa. In an MRI environment the maximum observed stepping frequency is 30 Hz (unloaded), or 8 Hz when full force is needed. The Stormram 4’s mean positioning error is 0.73 ± 0.47 mm in free air, and 1.29 ± 0.59 mm when targeting breast phantoms in MRI. Excluding the off-the-shelf needle, the robot is inherently MR safe. The robot is able to accurately target lesions under MRI guidance, reducing tissue damage and risk of false negatives. These results are promising for clinical experiments, improving the quality of healthcare in the field of MRI-guided breast biopsies.

Is there a Role for Contrast-enhanced Ultrasound in the Detection and Biopsy of MRI Only Visible Breast Lesions?

Background

This study aimed to evaluate the feasibility of contrast-enhanced ultrasound (CEUS) and CEUS-guided interventions in the diagnostics of MRI visible targeted US occult breast lesions.

Patients and methods

This retrospective study examined 10 females with 10 occult, MRI only detected breast lesions between July 2014 and April 2017. Targeted second look US followed by CEUS with 2.4 ml of SonoVue® were performed for all of the lesions. After positive CEUS localization the same dose was repeated for confirmation and CEUS-guided interventions were performed.

Results

MRI revealed 8 mass lesions with a mean size of 9 mm (range 5–16 mm) and 2 non-mass enhancing lesions of 10 and 20 mm in largest diameters. Targeted US revealed no morphological correlate for the lesions. Five out of 10 lesions (50%) were visible on CEUS. CEUS-guided core biopsy was performed on 4 lesions and 1 was marked with a clip for later surgical removal. Histopathological analysis confirmed 4 of them to be malignant. Three out of 5 nonvisible lesions on CEUS underwent MRI-guided interventions, 1 lesion was scheduled for follow-up as it was non-amenable for MRI biopsy, and 1 lesion was biopsied under US-guidance. Three of these nonvisible lesions on CEUS were confirmed to be malignant.

Conclusions

Based on our preliminary results, CEUS is a feasible tool for detecting many MRI only visible breast lesions, resulting in a more cost effective and less time-consuming practice. It is a more convenient alternative than MRI guided biopsy and has the potential to be included in the diagnostic algorithm which evaluates MRI only visible breast lesions.

Utility of BI-RADS Assessment Category 4 Subdivisions for Screening Breast MRI

OBJECTIVE

BI-RADS for mammography and ultrasound subdivides category 4 assessments by likelihood of malignancy into categories 4A (> 2% to ≤ 10%), 4B (> 10% to ≤ 50%), and 4C (> 50% to < 95%). Category 4 is not subdivided for breast MRI because of a paucity of data. The purpose of the present study is to determine the utility of categories 4A, 4B, and 4C for MRI by calculating their positive predictive values (PPVs) and comparing them with BI-RADS-specified rates of malignancy for mammography and ultrasound.

MATERIALS AND METHODS

All screening breast MRI examinations performed from July 1, 2010, through June 30, 2013, were included in this study. We identified in medical records prospectively assigned MRI BI-RADS categories, including category 4 subdivisions, which are used routinely in our practice. Benign versus malignant outcomes were determined by pathologic analysis, findings from 12 months or more clinical or imaging follow-up, or a combination of these methods. Distribution of BI-RADS categories and positive predictive value level 2 (PPV2; based on recommendation for tissue diagnosis) for categories 4 (including its subdivisions) and 5 were calculated.

RESULTS

Of 860 screening breast MRI examinations performed for 566 women (mean age, 47 years), 82 with a BI-RADS category 4 assessment were identified. A total of 18 malignancies were found among 84 category 4 and 5 assessments, for an overall PPV2 of 21.4% (18/84). For category 4 subdivisions, PPV2s were as follows: for category 4A, 2.5% (1/40); for category 4B, 27.6% (8/29); for category 4C, 83.3% (5/6); and for category 4 (not otherwise specified), 28.6% (2/7).

CONCLUSION

Category 4 subdivisions for MRI yielded malignancy rates within BI-RADS-specified ranges, supporting their use for benefits to patient care and more meaningful practice audits.

MRI-guided breast vacuum biopsy: Localization of the lesion without contrast-agent application using diffusion-weighted imaging

OBJECTIVE

In magnetic resonance-guided breast vacuum biopsies, the contrast agent for targeting suspicious lesions can typically be applied only once during an intervention, due to the slow elimination of the gadolinium chelate from the extracellular fluid space. This study evaluated the feasibility of diffusion-weighted imaging (DWI) for lesion targeting in vacuum assisted magnetic resonance imaging (MRI) biopsies.

CONCLUSION

DWI may be used as an alternative to dynamic contrast-enhanced MRI with the advantage of reproducibility. However, the targeted lesion requires the characteristics of a mass-like lesion, substantial diffusion restriction, and a minimum size of approximately 1cm.

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.