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Recent developments in the magnetic resonance community have shown an increased trend toward the implementation of breast MR imaging as a method of screening for breast cancer. In May 2007, the American Cancer Society (ACS) released new guidelines regarding the type of patients who should receive annual breast magnetic resonance imaging (MRI) scans in addition to mammograms. The revised guidelines are the first to recommend MRIs for screening women who show no signs of cancer. The combination of yearly mammograms and MRIs will improve the ability of doctors to detect breast cancer at an earlier stage, when it is easier to treat. The American Cancer Society recommendation was issued as the result of an expert panel review of the relevant breast MR literature and research studies performed.

Who Should Receive Breast MRI Screening

According to the ACS journal CA: A Cancer Journal for Clinicians, MRI screening in addition to mammograms is recommended for women who meet at least one of the following conditions:

• they have a BRCA1 or BRCA2 mutation
• they have a first-degree relative (parent, sibling, child) with a BRCA1 or BRCA2 mutation, even if they have yet to be tested themselves
• their lifetime risk of breast cancer has been scored at 20-25% or greater, based on one of several accepted risk assessment tools that take family history and other factors into account
• they had radiation to the chest between the ages of 10 and 30
• they have Li-Fraumeni syndrome, Cowden syndrome, or Bannayan-Riley-Ruvalcaba syndrome, or may have one of these syndromes based on a family history in a first-degree relative Screening MRIs are not recommended for women with a lifetime risk of breast cancer below 15%.

It is important to note that the MRI as a screening method should be used with care. Christy Russell, MD is chair of the ACS Breast Cancer Advisory Group and co-author of the new guideline. “As with other cancer screening tests, MRI is not perfect and in fact leads to many more false-positive results than mammography,” she explains. “Those false positives, which can lead to a high number of avoidable biopsies, can create fear, anxiety, and adverse health effects, making it imperative to carefully select those women who should be screened using this technology.”

There are several risk subgroups for which the available data is insufficient to recommend for or against screening, including women with:

• a personal history of breast cancer
• carcinoma in situ
• atypical hyperplasia
• extremely dense breasts on mammography

For women at average risk, the ACS recommends getting annual mammograms and breast exams by a physician, beginning at age 40. Most high-risk women should begin getting MRIs and mammograms at age 30, the new guideline says, unless they and their doctor determine it is better to begin at a different age.

Further Findings

There are several articles that support MR imaging for the detection of breast cancer. One such study, published in the March 29, 2007 issue of the New England Journal of Medicine, by Dr. Constance Lehman et al., of the University of Washington Medical Center, provided some interesting results. Dr. Lehman and her research team studied almost 1,000 women who were recently diagnosed with cancer in one breast, but had no detected cancer in the contralateral (other) breast). The team imaged these women using MRI.

The study revealed that the MRI scan of these women detected breast cancer in the contralateral breast in 30 of 969 women who were enrolled in the study (3.1%). The sensitivity of MRI in the contralateral breast was 91%, and the specificity was 88%. The negative predictive value of MRI was 99%. A biopsy was performed on the basis of a positive MRI finding in 121 of the 969 women (12.5%), 30 of whom had specimens that were positive for cancer (24.8%); 18 of the 30 specimens were positive for invasive cancer. The mean diameter of the invasive tumors detected was 10.9 mm. The additional number of cancers detected was not influenced by breast density, menopausal status, or the histologic features of the primary tumor.

This is an important finding since cancer is found in the contralateral breast in up to 10 percent of the women who have already received treatment for unilateral breast cancer.

The Importance Of Contrast

The use of a contrast agent in MRI breast imaging is an important component. Dynamic Contrast Enhanced (DCE) MRI is the acquisition of sequential images during the passage of a contrast agent within a region of interest. Clinicians are interested in the enhancement kinetics or the wash-in and wash-out of the contrast from the region of interest. DCE MRI can help determine differential diagnosis (malignant vs. benign) of enhancing lesions through the post processing signal intensity curve. A rapid wash-out may indicate a malignant lesion while a slower wash-out may suggest a benign lesion. Precautions should be taken to identify patients that have contrast sensitivity or may be at risk for developing nephrogenic systemic fibrosis (NSF).

It is important to note that breast MRI, while an exciting and evolving technology, should be regarded as an additional method of diagnosis, and should never replace appropriate standard screening and diagnostic tools, such as:

• breast self-examination
• physical examination of the breast by a qualified professional
• screening and diagnostic mammography
• fine needle aspiration or biopsy

All of these latest developments clearly illustrate the evolving needs of the magnetic resonance world, and further demonstrate the increasing importance of achieving accreditation in breast MRI through the ICAMRL program.

ICAMRL Breast Accreditation

The ICAMRL offers accreditation for breast MR either as part of the whole body testing area or as a separate breast imaging module, and is comprised of several separate, yet integrated aspects of quality assurance in the laboratory. The process of accreditation is one of initial and ongoing self-evaluation. It emphasizes the strengths of the facility and identifies areas where improvement is needed, with the ultimate goal of providing quality patient care and high quality diagnostic images.

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