Management of breast magnetic resonance imaging-detected lesions

Breast magnetic resonance imaging (MRI) has become an essential component of breast imaging. Whether it is used as a problem-solving tool or a screening test or for staging patients with breast cancer, it detects many lesions in the breast. The challenge for the radiologist is to distinguish significant from insignificant lesions and to direct their management. A brief summary of the terminology according to the American College of Radiologists lexicon will be provided. This review article will cover the differential diagnosis of enhancing lesions, including masses and nonmass enhancement, from benign and malignant causes. Some of the specific morphologic and kinetic features that help to differentiate benign from malignant lesions will be illustrated, and positive predictive values of these features will be reviewed. The various methods of investigating enhancing lesions of the breast will be discussed, including second-look ultrasound, ultrasound-guided biopsy, stereotactic biopsy, and MRI-guided biopsy. A practical approach to the management of MRI-detected lesions will include timing of follow-up, when to biopsy and when to ignore enhancing lesions in the breast.     

MR imaging of the breast

The results of clinical investigation suggest that MR imaging can provide clinically important information that cannot be obtained with conventional imaging methods, and that this modality will, in the future, be an invaluable adjunctive breast imaging tool just as breast ultrasound is today. MR imaging appears to be the most accurate method for the detection of implant failure, and although it is the most costly of the available implant imaging techniques, it may be the study of choice when there is a question of implant integrity that cannot be answered with conventional methods. MR imaging as a method to detect, diagnose, and stage breast cancer remains in the investigational stage. The specificity of MR imaging appears limited because of the overlap in the enhancement kinetics and morphologic appearance of benign and malignant lesions. In selected cases, the identification of certain morphologic features, such as internal septations or the absence of enhancement, may be used to classify a lesion as benign, offering an alternative to percutaneous or excisional biopsy. MR imaging appears to be very sensitive for the visualization of both invasive carcinoma and DCIS. Perhaps most important, MR imaging can detect invasive and noninvasive breast carcinoma that is both mammographically and clinically occult, offering the potential for more accurate breast cancer staging and optimized treatment planning. MR imaging is emerging as perhaps the most promising imaging modality for breast cancer detection to date. Published results, however, are from studies with relatively small numbers of patients. The results of these studies should be validated in a large-scale clinical trial before MR imaging is implemented clinically, outside of research settings. This type of clinical investigation is needed to define the technical requirements for optimal imaging, to define interpretation criteria, to develop accurate MR imaging guided localization and biopsy systems, to define the clinical indications for which MR imaging should be used as an adjunct to conventional imaging methods, and to address the issue of cost-effectiveness. One such trial, an international, multi-institutional study funded by the National Cancer Institute, is presently underway.     

超声弹性成像与常规超声联合应用在乳腺病灶良恶性鉴别上的价值

目的：探讨超声弹性成像在鉴别乳腺病变良恶性上的价值。材料和方法：对随机来我院检查的400例患者共433个乳腺病灶分别进行常规超声及弹性超声检查，结果与病理对照。结果：常规超声成像和弹性成像在鉴别乳腺病灶良恶性上价值相当（灵敏度、特异度及正确率分别为84．8％、82．8％及83．6％和83．6％、78．2％及80．4％，P〉0．05），但联合应用2种技术灵敏度提高至93．0％，比常规超声检查显著提高（P≤0．01）。结论：超声弹性成像对乳腺恶性病变较敏感，能帮助诊断常规超声较难鉴别的良恶性病变，两者联合应用可进一步提高超声技术的鉴别诊断能力。     

The role of ultrasound in breast imaging

Sonography has become an important tool for evaluating breast abnormalities, including inflammatory processes, hematomas, ductal ectasia, cysts and solid lesions. This article describes protocols for ultrasound imaging of the breast and the sonographic appearance of common breast conditions, with particular attention to differentiating benign from malignant lesions. Ultrasound's role in interventional breast procedures and radiation therapy planning also are discussed.     

数字化X线钼靶检查对女性乳腺疾病诊断的价值

目的：研究乳腺良、恶性病变的钼靶影像学特征,评价钼靶影像学对乳腺良、恶性病变诊断的临床价值及早期发现乳腺癌的意义。方法对2010年2月至2011年3月100例经病理证实乳腺良恶性病变病例,进行回顾性钼靶影像学分析研究。结果乳腺良性病变64例,术前钼靶检查诊断符合51例,正确率为80％;乳腺恶性病变36例,术前钼靶检查诊断符合31例,正确率为86％。结论数字化钼靶摄影对乳腺良、恶性病变鉴别诊断优越于超声检查,诊断早期乳腺癌有其独特优势。     

Real-time sonography of palpable breast masses

In order to evaluate the clinical usefulness of an electronic real-time linear array scanner in breast diseases, ultrasonography was performed in 148 cases of histologically confirmed palpable breast masses. The real-time images were observed on a television monitor while moving the hand-held transducer probes over the masses. It took only a few minutes to examine and diagnose a palpable mass. Among 45 carcinomas, 39 lesions were correctly diagnosed, four lesions were not detected by ultrasound and two were misdiagnosed as fibroadenomas. On the other hand, ten benign lesions were falsely diagnosed as breast cancers: seven mastopathies (including four sclerosing adenosis), two fibroadenomas and one abscess. The sensitivity and specificity for diagnosing breast cancer were 0.87 and 0.90 respectively. Real-time sonography is a simple, time-saving and useful tool for examining palpable breast masses. However, it should be realised that some breast cancers are difficult to image and differentiate from benign lesions.     

Current uses of ultrasound in the evaluation of the breast

Ultrasound is an important imaging modality in evaluating the breast. One of the most common uses of ultrasound is to help distinguish benign from malignant breast disease, primarily with gray-scale ultrasound but also with Doppler ultrasound. Another common use is to provide guidance for interventional procedures. Less common uses include assisting in staging of breast cancer and evaluating patients with implants. Recently there has been an interest in using ultrasound to screen asymptomatic women for breast cancer, as is done with mammography. Further studies must be performed to assess if this reduces mortality from breast cancer. Although primarily used to image the female breast, ultrasound also can be used to evaluate breast-related concerns in men. Uses of contrast-enhanced ultrasound are still experimental and would add an invasive component to an otherwise noninvasive study.     

Elastographie als Zusatzmodalität der Mammasonographie

In recent years the use of elastography in addition to sonography has become a routine clinical tool for the characterization of breast masses. Whereas free hand compression elastography results in qualitative imaging of tissue stiffness due to induced compression, shear wave elastography displays quantitative information of tissue displacement. Recent studies have investigated the use of elastography in addition to sonography and improvement of specificity in differentiating benign from malignant breast masses could be shown. Therefore, additional use of elastography could help to reduce the number of unnecessary biopsies in benign breast lesions especially in category IV lesions of the ultrasound breast imaging reporting data system (US-BI-RADS).     

术前超声及钼靶BI-RADS分类对早期乳腺癌的诊断价值

 目的 探索术前超声及钼靶BI-RADS分类对早期乳腺癌的诊断价值。方法 收集2015-08至2017-08在医院确诊为早期乳腺癌(TNM分期为Ⅰ、Ⅱ期)且术前同时行超声及钼靶检查的43例患者资料,共44个病灶。以BI-RADS分类≤3判为良性,=4a为可疑恶性,≥4b判为恶性,回顾性分析超声、钼靶及两者联合对早期乳腺癌的诊断价值。结果 早期乳腺癌术前超声BI-RADS分类判为可疑恶性及恶性的比例为93.2%(41/44),明显高于钼靶75.0%(33/44),差异有统计学意义(P＜0.05),两者联合诊断比例为95.5%(42/44)。其中对于黏液腺癌,超声判读为可疑恶性及恶性的比例明显高于钼靶,而浸润性导管癌、导管内癌及其他类型乳腺癌超声与钼靶BI-RADS分类无差异。其中两者联合仍判为良性的2个病灶分别为导管内癌和髓样癌。结论 对于早期乳腺癌尤其是黏液腺癌,术前超声BI-RADS分类判为可疑恶性及恶性的比例较钼靶更高;术前超声和钼靶判为可疑恶性及恶性的比例与乳腺癌病理类型密切相关;而对于特殊类型的早期乳腺癌及导管内癌两者结合仍有可能漏诊。     

Small vascular lesions of the breast diagnosed by magnetic resonance imaging‐guided vacuum assisted biopsy: Report of 2 cases

Vascular lesions of the breast comprise a heterogeneous group that includes a variety of benign, atypical, and malignant lesions. These are a diagnostic challenge given variable clinical, radiological and pathological presentation, especially when they are small and asymptomatic. We present 2 cases of these rare lesions of the breast which were occult to mammographics and ultrasound studies. Both the lesions were detected only on magnetic resonance imaging, most helpful in the diagnosis of these rare tumor. Histopathological examinations following the magnetic resonance guided biopsies, were initially interpreted as negative for breast cancer in both cases. These turned out to be respectively a low grade angiosarcoma and a benign vascular lesion after a new histopathological examination following a larger magnetic resonance guided biopsies performed in light of the radiology-pathology discordance. Although rare, it is important to consider vascular tumours of the breast; radiologists need to be aware such tumors may present non-specific imaging features.     

MR imaging assessment of the breast after breast conservation therapy: distinguishing benign from malignant lesions

Dynamic contrast material-enhanced magnetic resonance (MR) imaging has emerged as a valuable tool in evaluation of women who have undergone lumpectomy and whole-breast radiation therapy for breast cancer. Early diagnosis of local recurrence by means of close clinical and imaging follow-up is an important component of a breast-conserving strategy, as it may improve survival. In the post-breast conservation therapy (BCT) breast, resolving edema, fat necrosis, a small focal area of non-masslike enhancement (NMLE), and thin linear NMLE at the lumpectomy site can all be expected findings. In contrast, masslike enhancement or NMLE of ductal or segmental distribution can indicate recurrence. Therefore, at MR imaging of the post-BCT breast, it is important to identify lesions that are benign or appropriate for short-interval imaging surveillance to minimize unnecessary intervention, as well as to discern suspicious lesions and optimize the diagnosis of recurrence.     

乳腺肿瘤血管生成与DCE-MRI参数的相关性研究

新生血管在乳腺癌的发生发展中起着重要的作用,抗肿瘤血管生成是临床上治疗乳腺癌的一种重要方法,因此需要一种能够在活体中准确评估乳腺癌肿瘤血管生成、肿瘤血管结构及功能状态、抗血管治疗疗效的成像方法。目前,多种成像方法均可以用于显示肿瘤血管状态,其中动态增强MRI(DCE-MRI)是一种较常用的无创、无电离辐射的检查方法,具有MRI多序列、多参数、多方位以及高的软组织分辨力的成像特点,在乳腺癌的诊断、术前分期及治疗效果评估中具有重要的价值。就DCE-MRI参数对乳腺良、恶性病变的鉴别诊断及乳腺癌新辅助化疗的疗效评估及预后监测予以综述。     

ACR Appropriateness Criteria Evaluation of the Symptomatic Male Breast

Most male breast problems are benign, and men with typical symptoms of gynecomastia or pseudogynecomastia do not usually need imaging. When a differentiation between benign disease and breast cancer cannot be made on the basis of clinical findings or when the clinical findings are suspicious for breast cancer, imaging is indicated. Mammography is useful in both identifying cancer and obviating the need for biopsy in patients for whom a benign mammographic impression confirms the clinical impression. However, because of the relationship of breast cancer to increasing age, age-based protocols that do not include mammography have been developed. For men with an indeterminate palpable mass, begin with ultrasound if the patient is <25 years of age, because breast cancer is highly unlikely. Mammography should be performed if ultrasound is suspicious. For men ≥25 years of age or having a highly concerning physical examination, usually begin with mammography; ultrasound is useful if mammography is inconclusive or suspicious.The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 3 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals, and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.     

Magnetization transfer ratio as a predictor of malignancy in breast lesions: preliminary results.

MRI is an important tool for investigating breast cancer. Although recognized as the method of choice for screening high-risk patients, and for other indications the role of MRI for lesion characterization remains controversial. Recently some authors have advocated the use of morphologic and postcontrast features for this purpose. Quantitative breast MRI techniques have not been applied extensively in breast diseases. Magnetization transfer (MT) is a quantitative MR technique commonly used to investigate neurological diseases. In breast diseases the use of MT has been limited to improving visualization of areas of enhancement in postcontrast images. The purpose of this study was to evaluate the feasibility and utility of MT in discriminating benign from malignant breast lesions. Fifty-two lesions, BIRADS 4 and 5, from 49 patients, were prospectively evaluated using the MT ratio (MTR). Patients were divided into two groups: benign and malignant lesions. The MTR of fat, pectoralis major muscle, fibroglandular tissue, and breast lesions were calculated. A statistically significant difference was found between MTR from benign and malignant lesions (P < 0.001). Preliminary results suggest that MT can be used to evaluate breast lesions. Further studies are necessary to better define the utility and applicability of this technique.     

99Tcm-3PRGD2整合素受体显像鉴别乳腺良恶性病变的价值及与超声检查的对比研究

目的探讨99Tcm-3PRGD₂整合素受体显像鉴别乳腺良恶性病变的价值及与超声检查的对比研究。方法收集2016年10月至2017年6月因乳腺结节或肿块拟行穿刺或手术治疗的女性患者,行乳腺超声检查,选取超声提示病灶直径>1 cm的45例患者经肘静脉注射99Tcm-3PRGD₂（740~925 MBq）后行早期15 min SPECT静态显像及2 h SPECT/CT俯卧位显像。以病理结果为“金标准”,采用半定量分析指标T/NT值建立诊断阈值并进行诊断效能分析。组间比较采用独立样本非参数检验Mann-Whitney U方法;诊断效能比较采用χ2检验。结果45例患者经病理学检查共发现56个病灶,其中,35个病灶为乳腺癌,21个病灶为良性病变。99Tcm-3PRGD₂ 2 h SPECT/CT显像的乳腺恶性病灶T/NT值（3.92±1.67）高于良性病灶T/NT值（2.04±0.46）,且差异有统计学意义（Z=-3.77,P=0.00）。取约登指数最大时的临界值2.9,99Tcm-3PRGD₂ SPECT/CT显像的灵敏度、特异度、准确率分别为82.9%、71.4%、78.6%,诊断乳腺良恶性病变受试者工作特征（ROC）曲线下面积为0.77;超声诊断乳腺良恶性病变ROC曲线下面积为0.76,其灵敏度、特异度、准确率分别为85.7%、66.7%、78.6%。99Tcm-3PRGD₂ SPECT/CT与超声诊断效能相近（χ2=0.05,P>0.05）。超声+99Tcm-3PRGD₂ SPECT/CT联合检查可提高乳腺良恶性诊断的准确率（92.9%）,分别与二者比较差异均有统计学意义（χ2=77.17、74.87,均P < 0.05）。结论99Tcm-3PRGD₂整合素受体显像可以从肿瘤血管生成角度鉴别乳腺良恶性病变,提供解剖及功能信息,尤其对于超声声像图表现不典型时,可进一步鉴别良恶性,减少患者不必要的穿刺等有创性检查。     

Breast scintigraphy today: indications and limitations

Breast carcinoma is the most common neoplasm found among women in the Western world. Mammography (MM) is the most widely used diagnostic imaging method for screening and diagnosing breast cancer. However, despite technical improvements in recent years, MM has known diagnostic limits; consequently not all breast carcinomas are identified on mammograms, especially if the breast is dense, there is a breast prosthesis or the patient has previously undergone radiation, surgery or biopsy. In addition, the mammographic images of benign and malignant lesions can be similar. Therefore, abnormalities detected on MM frequently result in negative biopsies. Scintimammography (SM) is the functional imaging study of the breast using primarily the radiopharmaceuticals (99m)Tc-sestamibi and (99m)Tc-tetrofosmin. The main advantage of SM is that its functional basis makes this technique a useful complement to MM. SM resolves some of the main limitations of MM as it is not affected by changes in breast morphology. Several single-site and multi-centre studies have demonstrated that SM has an improved specificity compared with MM, because it is better able to distinguish malignant from benign breast lesions. Interestingly, except in smaller lesions, a higher sensitivity has been recorded for SM than for MM in most of these studies as well. Adjunctive use of SM when MM is equivocal can reduce the number of unnecessary breast biopsies and identify previously unexpected sites of breast cancer. SM appears unaffected by the anatomical changes seen following chemotherapy and radiotherapy, and so this technique can be particularly useful in monitoring the treatment of breast cancer patients, especially when breast-conserving treatment is given. The main limitation to SM has been the sub-optimal resolution of the standard Anger gamma camera, which makes it difficult to detect lesions of less than 10 mm; however, the development of high-resolution breast-dedicated gamma cameras may offer improvements in this respect. This review will look at the evidence for SM and show how it can become part of the clinical care algorithm in breast cancer.     

Papillary lesions of the breast: MRI, ultrasound, and mammographic appearances

OBJECTIVE: The purpose of this article is to describe the different imaging appearances of benign and malignant papillary lesions of the breast as well as to point out potential errors of interpretation that can lead to misdiagnosis. CONCLUSION: There is a wide spectrum of appearances of papillary lesions of the breast on MRI, ultrasound, and mammography. This variable appearance of papillary lesions makes differentiation of benign from malignant pathologies difficult on imaging, and tissue sampling is usually warranted.     

Breast lesions examined by digital angiography. Work in progress

Differentiation of benign from malignant lesions in screening for breast cancer is usually arrived at via surgical biopsy, an invasive and costly procedure. Digital subtraction angiography (DSA) of the breast is a less invasive procedure. DSA imaging patterns from 22 patients with malignant and benign lesions were compared with surgical biopsy findings. DSA examinations were performed with the breast in an immobilization device and contrast medium was injected into the superior vena cava. Images were produced with a low kilovoltage (50 kVp) to enhance contrast, and a technique yielding an average dose to the breast of less than 2 rad (0.02 Gy) was used. Preliminary clinical results demonstrate the potential of DSA for differentiation of benign and malignant lesions and justify further investigations of its use as an alternative to surgical biopsy.     

增强MRI诊断乳腺良恶性病变的价值

目的评价增强ＭＲＩ对乳腺良、恶性病变的诊断价值。方法对４８例乳腺病变患者进行ＭＲＩ平扫和增强扫描，并对照Ｘ线、Ｂ超及手术病理结果，分析比较了病变强化后形状、边界、内部信号、强化速度与程度以及强化消失快慢等特征。结果４８例乳腺病变患者８１个病灶的良、恶性诊断准确率为９２．６％。结论增强ＭＲＩ是鉴别乳腺良、恶性病变的一种有效的影像学诊断方法