(BQ) Part 1 book “Breast cancer - Diagnostic imaging and therapeutic guidance” has contents: Development, anatomy, and physiology of the mammary gland, tumor formation, pathology of benign and malignant changes in the breast, nonimaging diagnostics, breast ultrasonography,… and other contents.
Breast Cancer: Diagnostic Imaging and Therapeutic Guidance Uwe Fischer, MD Professor Women’s Health Care Center Göttingen, Germany Friedemann Baum, MD Women’s Health Care Center Göttingen, Germany Susanne Luftner-Nagel, MD Women’s Health Care Center Göttingen, Germany 545 illustrations Thieme Stuttgart • New York • Delhi • Rio de Janeiro Library of Congress Cataloging-in-Publication Data is available from the publisher This book is an authorized translation of the first German edition published and copyrighted 2014 by Georg Thieme Verlag, Stuttgart Title of the German edition: Diagnostik und Therapie des Mammakarzinoms Translators: Elizabeth Crawford, Göttingen, Germany; Alan Wiser, Ambler, PA, USA Illustrator: Barbara Gay, Bremen, Germany Important note: Medicine is an ever-changing science undergoing continual development Research and clinical experience are continually expanding our knowledge, in particular our knowledge of proper treatment and drug therapy Insofar as this book mentions any dosage or application, readers may rest assured that the authors, editors, and publishers have made every effort to ensure that such references are in accordance with the state of knowledge at the time of production of the book Nevertheless, this does not involve, imply, or express any guarantee or responsibility on the part of the publishers in respect to any dosage instructions and forms of applications stated in the book Every user is requested to examine carefully the manufacturers’ leaflets accompanying each drug and to check, if necessary in consultation with a physician or specialist, whether the dosage schedules mentioned therein or the contraindications stated by the manufacturers differ from the statements made in the present book Such examination is particularly important with drugs that are either rarely used or have been newly released on the market Every dosage schedule or every form of application used is entirely at the user’s own risk and responsibility The authors and publishers request every user to report to the publishers any discrepancies or inaccuracies noticed If errors in this work are found after publication, errata will be posted at www.thieme.com on the product description page Some of the product names, patents, and registered designs referred to in this book are in fact registered trademarks or proprietary names even though specific reference to this fact is not always made in the text Therefore, the appearance of a name without designation as proprietary is not to be construed as a representation by the publisher that it is in the public domain © 2018 Georg Thieme Verlag KG Thieme Publishers Stuttgart Rüdigerstrasse 14, 70469 Stuttgart, Germany +49 [0]711 8931 421, customerservice@thieme.de Thieme Publishers New York 333 Seventh Avenue, New York, NY 10001 USA +1 800 782 3488, customerservice@thieme.com Thieme Publishers Delhi A-12, Second Floor, Sector-2, Noida-201301 Uttar Pradesh, India +91 120 45 566 00, customerservice@thieme.in Thieme Publishers Rio de Janeiro, Thieme Publicaỗừes Ltda Edifớcio Rodolpho de Paoli, 25 andar Av Nilo Peỗanha, 50 Sala 2508 Rio de Janeiro 20020-906 Brasil +55 21 3172 2297 / +55 21 3172 1896 Cover design: Thieme Publishing Group Typesetting by DiTech Process Solutions Pvt Ltd., India Printed in China by Everbest Printing Ltd., Hong Kong ISBN 978-3-13-201931-7 Also available as an e-book: eISBN 978-3-13-201941-6 54321 This book, including all parts thereof, is legally protected by copyright Any use, exploitation, or commercialization outside the narrow limits set by copyright legislation without the publisher’s consent is illegal and liable to prosecution This applies in particular to photostat reproduction, copying, mimeographing or duplication of any kind, translating, preparation of microfilms, and electronic data processing and storage Contents Part 1: Anatomy, Physiology, and Pathology of the Breast Development, Anatomy, and Physiology of the Mammary Gland F Baum 1.1 Development 1.2 Anatomy 2 Physiology Bibliography Tumor Formation 1.3 F Baum 2.1 Mutation, Carcinogenesis, and Angiogenesis 2.2 Risk Factors 2.3 Genetic Risk Factors 2.4 Prevention 6 2.4.2 2.4.3 Secondary Prevention Tertiary Prevention 6 2.5 Epidemiology, Incidence, and Mortality Bibliography 2.4.1 Primary Prevention Pathology of Benign and Malignant Changes in the Breast J Rueschoff 3.1 Benign Changes 3.1.1 3.1.2 Histological Principles Nonneoplastic, Nonproliferative Diseases of the Breast Benign Tumor-Forming Diseases 3.1.3 24 25 26 29 3.2.8 Papillary Lesions Ductal Carcinoma In Situ Microinvasive and Invasive Breast Carcinoma Tumors of the Nipple Malignant Mesenchymal Tumors and Lymphomas of the Breast Metastatic Tumors 3.3 Acknowledgments 31 Bibliography 31 Nonimaging Diagnostics 34 3.2 Malignant Changes in the Breast 3.2.1 Classification of Malignant Breast Tumors (WHO Classification, B-Categories) Prognostic and Predictive Factors 3.2.2 11 3.2.3 3.2.4 3.2.5 3.2.6 3.2.7 29 30 19 19 20 Part 2: Breast Diagnostics U Fischer 4.1 History 34 4.4 Inspection 34 4.2 Informed Consent 34 4.5 Palpation 35 4.3 Self-Examination 34 Bibliography 40 Mammography 41 U Fischer 5.1 Technique and Methods 41 5.1.1 5.1.2 5.1.3 Principles of X-ray Mammography Components of a Mammography System Exposure Parameters 41 41 43 5.1.4 5.1.5 5.1.6 5.1.7 Image Quality Analog Mammography Digital Mammography Radiation Exposure 43 44 45 54 v Contents 5.2 Parameters and Positioning 55 5.2.1 5.2.2 5.2.3 5.2.4 5.2.5 Standard Projections Supplementary Views Galactography Mammography of the Male Breast Quality Assurance in Parameters and Positioning 55 57 58 61 61 5.3 Interpretation of Mammograms 62 5.3.1 5.3.2 Terminology Tissue Density in a Mammogram According to the ACR BI-RADS Atlas Interpretation Criteria BI-RADS Classification of Mammography Normal Findings in the Mammogram 63 64 68 74 Bibliography 74 Breast Ultrasonography 77 5.3.3 5.3.4 5.3.5 62 S Luftner-Nagel 6.1 Technique and Methods 77 6.1.1 6.1.2 6.1.3 6.1.4 6.1.5 Basic Principles Device Adjustments Examination Technique Ultrasound Techniques Quality Assurance 77 79 79 81 84 84 6.2.1 6.2.2 6.2.3 6.2.4 6.2.5 Terminology Tissue Type in Sonography Evaluation Criteria BI-RADS Classification of Breast Ultrasonography Normal Findings in Sonography 84 84 85 89 92 Bibliography 93 6.2 Evaluation Magnetic Resonance Imaging of the Breast 94 U Fischer 7.1 Technique and Methods 94 7.1.1 7.1.2 7.1.3 7.1.4 7.1.5 7.1.6 7.1.7 7.1.8 7.1.9 Basic Principles Tumor Detection Equipment Timing of the Examination Patient Positioning Measurement Parameters Image Postprocessing Implant Evaluation Nonestablished Examination Techniques 94 95 95 95 96 96 97 99 100 7.2 Evaluation 101 7.2.1 7.2.2 7.2.3 7.2.4 7.2.5 7.2.6 7.2.7 7.2.8 Terminology Perfusion Pattern Findings in the T1-Weighted Precontrast Image Findings in the T2-Weighted Image Findings in the T1-Weighted Contrast-Enhanced Image Evaluation Criteria BI-RADS Classification of MRI of the Breast Normal Findings in MRI of the Breast 101 101 101 102 Bibliography 107 102 103 104 107 Imaging of Breast Lesions 110 U Fischer and S Luftner-Nagel vi 8.1 Benign Findings 110 8.1.1 8.1.2 8.1.3 8.1.4 8.1.5 8.1.6 8.1.7 8.1.8 8.1.9 8.1.10 8.1.11 8.1.12 8.1.13 8.1.14 8.1.15 8.1.16 Cysts Inflamed Cysts Complex Cysts Myxoid Fibroadenoma Fibrotic Fibroadenoma Adenoma Hamartoma Lipoma Mammary Fibrosis Adenosis of the Breast Fibrocystic Condition of the Breast Adenomyoepithelioma Acute Nonpuerperal Mastitis Chronic Nonpuerperal Mastitis Intramammary Lymph Nodes Pseudoangiomatous Stromal Hyperplasia 110 110 111 112 114 116 116 117 119 120 121 122 124 125 125 126 8.1.17 8.1.18 8.1.19 8.1.20 8.1.21 Seroma Hematoma Fat Necrosis (Oil Cyst) Abscess Postoperative Scars 128 129 130 131 132 8.2 Findings with Ambiguous Biological Potential 133 8.2.1 8.2.2 8.2.3 8.2.4 8.2.5 8.2.6 Papillomas Radial Scars Atypical Ductal Hyperplasia Phyllodes Tumors Cysts with Intracystic Proliferation Lobular Intraepithelial Neoplasia 133 135 135 136 138 139 8.3 Intraductal Carcinoma 141 8.3.1 Ductal Carcinoma In Situ (Low Grade) 141 Contents 8.3.2 8.3.3 Ductal Carcinoma In Situ (Intermediate Type) Ductal Carcinoma In Situ (High Grade) 141 141 8.4 Invasive Tumors 143 8.4.1 8.4.2 8.4.3 8.4.4 Invasive Ductal Carcinoma Invasive Lobular Carcinoma Tubular Carcinoma Medullary Carcinoma 143 145 147 147 8.4.5 8.4.6 8.4.7 8.4.8 8.4.9 8.4.10 8.4.11 Mucinous Carcinoma Invasive Papillary Carcinoma Sarcomas Triple-Negative Carcinoma Paget’s Disease of the Nipple Inflammatory Carcinoma Systemic Diseases Involving the Breast 148 150 152 152 152 154 155 Breast Intervention 158 F Baum 9.1 Biopsy 158 9.1.1 9.1.2 Objective of Percutaneous Tissue Sampling Percutaneous Tissue Sampling Equipment and Implementation Interventional Imaging Classification of Findings Tumor Seeding and Mechanical Tumor Induction Quality Assurance 158 9.2 Localization 166 158 161 164 166 166 9.2.1 9.2.2 9.2.3 Objective of Pretherapeutic Localization Equipment and Implementation Quality Assurance 166 170 172 Bibliography 173 9.1.3 9.1.4 9.1.5 9.1.6 Part 3: Prevention and Therapy of Breast Cancer 10 Examination Concepts 176 U Fischer 10.1 Prevention 176 10.4 Pretherapeutic Local Staging 183 10.2 Early Breast Cancer Detection (Secondary Prevention) 176 10.5 Pretherapeutic Peripheral Staging 184 10.2.1 10.2.2 10.2.3 10.2.4 Mammography Screening Individualized Examination Concepts Early Detection in Women with a High-Risk Profile Future Concepts of Early Breast Cancer Detection 177 180 181 182 10.6 Follow-up Care 184 10.7 Implant Evaluation 185 10.8 Evaluation of the Male Breast 185 10.3 Diagnostic Work-up 183 Bibliography 185 11 Surgical Treatment of Breast Carcinoma 187 T Kuehn 11.1 Significance of Surgery in the Context of Multimodal Treatment of Breast Carcinoma 187 11.2 Types of Breast Carcinoma 187 11.2.1 11.2.3 Lesions of Uncertain Biological Potential (B3 Lesions) Preinvasive Carcinoma (Ductal Carcinoma in Situ; B5a) Invasive Carcinoma (B5b) 187 187 11.3 Surgical Treatment of the Primary Lesion 189 11.3.1 11.3.2 Oncologic Aspects Technical Aspects 189 189 11.4 Lymph Node Surgery 192 11.2.2 187 11.4.1 11.4.2 11.4.3 Procedure for Clinically Negative Node Status Procedure for Clinically Positive Nodal Status Procedure for Clinically Negative Node Status and Positive Sentinel Node 195 195 11.5 Secondary Breast Reconstruction 196 11.5.1 Timing the Reconstruction: Primary vs Secondary Reconstruction Alloplastic Reconstruction (Implant Reconstruction) Autologous Reconstruction (Reconstruction Using Endogenous Tissue) Nipple Reconstruction 11.5.2 11.5.3 11.5.4 Bibliography 195 196 197 197 199 200 vii Contents 12 Medical Treatment of Breast Cancer 201 M Hellriegel and G Emons 12.1 Basic Principles and Objectives 201 12.4.1 12.2 Adjuvant Drug Therapy 201 12.4.2 12.2.1 12.2.2 12.2.3 12.2.4 Adjuvant Chemotherapy Neoadjuvant Therapy Adjuvant Endocrine Therapy Antibody Therapy 201 202 204 207 12.5 12.3 Medical Treatment in Locoregional Recurrence 12.4 Medical Treatment of Distant Metastases 13 Radiotherapy of Breast Cancer 212 Endocrine Therapy in Premenopausal Patients with Distant Metastases 208 Endocrine Therapy in Postmenopausal Patients with Distant Metastases 208 Endocrine Maintenance Therapy after Completing Chemotherapy 209 207 Chemotherapy of Metastatic Breast Cancer Combined with New Agents 209 208 Bibliography 210 12.6 C F Hess 13.1 Adjuvant Radiotherapy after Breast-Conserving Surgery 212 13.2 Adjuvant Radiotherapy after Mastectomy 212 13.3 Effectiveness of Adjuvant Radiation Therapy: Prognostic Factors 213 Integration of Adjuvant Radiotherapy into the Multimodal Treatment Concept 213 13.5 Target Volume and Dose Concept 213 13.5.1 13.5.2 Clinical Target Volume: Former Tumor Region, Mammary Gland, Chest Wall, and Regional Lymph Channels Partial Breast Irradiation 14 Management of a Diagnostic Breast Center 220 13.4 13.5.3 214 215 Shortened Treatment Time: Alternative Fractionation Schemes 215 Acute Side Effects and Complications of Adjuvant Radiation Therapy 216 13.6.1 13.6.2 Acute Side Effects Late Complications of Radiation Therapy 216 216 13.7 Planning and Implementing Radiation Therapy 217 13.8 Radiotherapy in Primarily Inoperable Tumors, Recurrences, and Metastatic Disease 218 Summary 218 Bibliography 218 13.6 13.9 F Baum 14.1 Expertise 220 14.2 Equipment 220 14.3.3 14.3.4 222 14.3.5 Breast MRI Room Rooms for a Second Ultrasound Unit and for Interventional Procedures Recovery Room 14.4 Ambiance 223 14.5 Communication 223 222 223 14.3 Facility Design 221 14.3.1 14.3.2 Doctor’s Consultation Room Mammography and Sonography Rooms 221 221 15 Logistics in an Interdisciplinary Breast Center 225 G Emons 15.1 Background 225 15.2 Structure of a Certified Breast Center 225 15.3 Treatment Pathways in a Breast Center 225 16 15.4 Outlook 225 Bibliography 227 Counseling Techniques and Psychosocial Support 228 H Lorch, A Kuechemann, and J Rueschoff 16.1 viii Compliance 228 16.1.1 Quality of the Medical Services 228 7.1 Technique and Methods rapid image acquisition and a weaker signal yield In comparison with SE sequences, GRE sequences show higher sensitivity for artifacts caused by susceptibility differences in tissues (bone, air) or through metal deposits Correspondingly, the sensitivity of GRE sequences to paramagnetic contrast media is greater Signal intensity in MRI imaging can be modified by the administration of contrast materials Paramagnetic substances are primarily used for this purpose, but superparamagnetic substances can also be used Substances of both these groups exhibit the property of changing the relaxation times of the anatomical structures being imaged Paramagnetic contrast media shorten the T1 and T2 relaxation times Contrast-enhanced breast MRI takes advantage of this shortening effect on the T1 relaxation time to increase the signal intensity in the T1W sequences Superparamagnetic substances have no utility for breast MR imaging a 7.1.2 Tumor Detection MRI of the breast has high sensitivity for the detection of hypervascularized areas in the breast through the depiction of the intramammary structures in very thin layers before and after intravenous administration of a contrast agent suitable for MRI Contrast-enhancing areas are characterized by increased vascularization, increased vessel permeability, and an enlarged interstitial space (tissue matrix) These tissue characteristics are found in almost all invasive cancers and in a majority of intraductal breast carcinomas (keyword: tumor neoangiogenesis) Some benign breast lesions, however, are also associated with an increased perfusion pattern, so that there is an overlap in the imaging characteristics of benign and malignant processes Technical and methodological aspects of a high-quality breast MRI are discussed in the following sections b 7.1.3 Equipment Breast MRI is generally performed in a whole-body magnet with field strengths of 1.5 and 3.0 T (tesla) (▶ Fig 7.1a) It is no longer acceptable to use systems with 0.5 T Special bilateral surface coils are required for breast MRI to achieve a sufficiently high spatial resolution These are adapted to fit the shape of the female breast and should preferably be open to enable optimal support and positioning of the breast, and to allow for carrying out interventional procedures when required (▶ Fig 7.1b) Dedicated compression plates can be integrated into such open breast coils to reduce the occurrence of motion artifacts (▶ Fig 7.1c) c Fig 7.1 Breast MRI (a) 1.5 T Examination unit (CE Healthcare, Milwaukee, Wl, USA) with the surface coil in place (b) Open surface coil with integrated compression plates (Noras, Höchberg, Germany) (c) Compression device with superior-inferior fixation of the breast (Noras, Höchberg, Germany) Note Open breast surface coils with integrated compression plates are an essential requirement for excellent breast MRI quality 7.1.4 Timing of the Examination The parenchymal perfusion pattern, and thus the contrast enhancement in the mammary gland, fluctuates with the changing hormonal influences on the female breast during the menstrual cycle The degree of disturbing signal enhancement on breast MRI imaging is least in the second week of the menstrual cycle Thus, when circumstances allow, an examination should be scheduled between the 7th and 14th days of the cycle Examinations performed in the third week of the menstrual cycle are generally still acceptable, but the first and fourth weeks should be avoided If the imaging has to be done during this unfavorable period, the potential diagnostic disadvantage from increased enhancement must be taken into account 95 Magnetic Resonance Imaging of the Breast Practical Tip 7.1.6 Measurement Parameters The best time to perform breast MRI is in the second week of the menstrual cycle Technique After menopause, there are no concerns related to the menstrual cycle when planning a breast MRI examination appointment Occasionally, however, there can be undesirable early parenchymal contrast enhancement due to hormone replacement therapy (HRT), necessitating a repeat examination after stopping HRT for 4–6 weeks As a general principle, however, it is not justifiable to stop hormone substitution before performing a breast MRI examination An MRI examination can be performed without restriction after a previous fine needle puncture, and after a core needle biopsy without significant hematoma After a vacuum-assisted biopsy, there is typically a large resection cavity with reactive, hyperemic changes around the edge and hematoma in the center In general, it is better to undertake MRI before rather than after such an interventional procedure Subsequent to an open biopsy, no breast MRI should be performed within an interval of months so as to avoid interference from increased enhancement associated with wound healing After tumor resection (as breast-conserving therapy [BCT]) and radiation therapy, this interval is increased to about 12 months after termination of the radiotherapy There is, however, pronounced variability between individuals with respect to the extent and duration of the reactive changes after a course of radiation therapy 7.1.5 Patient Positioning The examination is performed with the examinee in the prone position with the arms along the sides, preferably tucked into the belt of a bath robe (▶ Fig 7.2) As an alternative, the arms can be crossed above the head, although in this position the breasts are often not completely visualized in the axial slice orientation The use of a cushioned head support on which the forehead rests has proven value, allowing the woman to view a picture motif by way of an angled mirror during the procedure Note The key to a high-quality breast MRI examination is patient comfort Contrast-enhanced breast MRI can be performed with the 2D and 3D techniques Each technique has advantages and disadvantages that not significantly affect the assessability or sensitivity of the MRI examination The decision as to which technique should be used should be based on the experience of the examiner; it is not advisable, however, to alternate techniques frequently Recently, parallel imaging has optimized image acquisition speed and spatial resolution This is essentially simultaneous acquisition of image data over two or more receiving coils with different spatial sensitivities Sequences T1-weighted (T1W) GRE sequences still represent the heart of the breast MRI examination (▶ Fig 7.3a) Essentially, they allow sensitive capture of an enhancement after administration of an MR-appropriate paramagnetic contrast agent These T1W sequences are typically performed once before and several times after the peripheral venous administration of contrast medium To allow clear visualization of contrastenhancing areas, it is necessary to eliminate or suppress interfering intramammary fat signals This can be accomplished in two ways: ● By the subtraction of identical slice images before and after administration of contrast material (“European school”) ● By the acquisition of sequences with primary fat suppression, i.e., saturation (FAT-SAT) (“American school”) The additional acquisition of a T2 weighted (T2W) sequence is recommended in order to obtain a signal-intense visualization of water-containing or grossly edematous structures (▶ Fig 7.3b) For this, breast MRI primarily employs T2W SE or TSE (turbo spin echo) sequences, or IR (inversion recovery) sequences, combined with simultaneous fat saturation The T2W measurement is not for tumor detection, but rather to characterize suspicious findings found in the contrastenhanced T1W measurement Notes ● ● Fig 7.2 Prone patient positioning for breast MRI Frontal headrest with angled mirror and picture motif for viewing during the examination Headphones for listening to recorded music Compression plates with positioned and fixed breast Arms along the body with the arms tucked into the belt of the bath robe and relaxed pectoral muscles Alarm bulb to terminate the examination if necessary 96 a In the T1W image, contrast media, fat, protein, and blood appear white (signal intense) In the T2W image, water-containing substances appear white (signal intense) b Fig 7.3 T1W and T2W sequences in breast MRI (a) Precontrast T1W image (b) T2W image 7.1 Technique and Methods Orientation MRI allows examinations in any slice orientation In Europe, the transverse (i.e., axial) plane is usually preferred when contrastenhanced breast MRI is used for tumor detection; in North America, the sagittal plane is preferred For implant evaluation, at least one complementary sagittal angulation is expressly recommended Temporal Resolution In the vast majority of cases, contrast enhancement occurs more rapidly in hypervascularized breast tumors than in the surrounding glandular parenchyma This is particularly true for invasive breast carcinomas, in which the maximum signal intensity peak is usually reached approximately minutes after the intravenous administration of the contrast agent However, some carcinomas can exhibit their maximum signal intensity peak as early as minute after the administration of the contrast agent, followed by a “washout” effect In contrast, the signal intensity of parenchyma displays a continuous increase during the entire examination time of to 10 minutes, and there is a considerable degree of variation between individuals Because early and strong contrast enhancement of parenchyma may occur (e.g., in areas of adenosis or due to hormonal stimulation), pathological processes can be masked (masking effect) Generally, a temporal resolution of maximally to 2.5 minutes/sequence over a period of at least minutes after contrast agent administration is required for dynamic measurements Spatial Resolution Various factors and setting parameters affect the spatial resolution of breast MRI Specifically, these are the matrix (depending on the chosen field of view), the slice thickness, and the magnitude of the resulting volume For examinations in axial orientation, the field of view is predetermined by the patient’s proportions (usually 300–350 mm) Recommendations advise a matrix size of at least 256 × 256 pixels Ideally, however, a matrix of 512 × 512 pixels should be used, which should not be the result of interpolation Although general recommendations are for a slice thickness between and mm, breast MRI should be performed with single slice thicknesses of 1.5 to 2.5 mm Indisputably, the best results are obtained by high-resolution breast MRI with a matrix of 512 × 512 pixels and a single slice thickness of 1.5 to mm Contrast Medium Intravenous administration of an extracellular paramagnetic contrast agent allows visualization of the vascularization within the breast Repetitive measurement after the administration of contrast media gives information about the uptake and clearance of the contrast material over time For dynamic breast MRI (1.5 T), the recommended dose of contrast agent is 0.1 mmol Gd-DTPA (gadopentetate dimeglumine) per kg body weight The contrast agent is mechanically injected at a rate of to mL/s via a venous access previously placed in the cubital fossa Gd-DTPA is cleared quickly and completely by way of renal excretion Tubular reabsorption has not been demonstrated The half-life of Gd-DTPA in the blood is approximately 90 minutes After 24 hours, more than 90% of the substance has been excreted Gd-DTPA is very well tolerated From available data, the rate of side effects is considered to be less than 2%, and approximately 80% of side effects are classified as mild Adequate and clear information must be provides to the patient to allow written consent to be obtained before starting the examination The use of Gd-DTPA during pregnancy has not been established as innocuous, so contrast-enhanced breast MRI in pregnant women should be avoided on principle The use of gadoliniumbased contrast material can lead to nephrogenic systemic fibrosis in patients with renal insufficiency This risk is especially high in patients with acute or chronic renal insufficiency and a glomerular filtration rate less than 30 mL/min per 1.73 m3, and in patients with acute renal insufficiency in conjunction with hepatorenal syndrome or a history of liver transplantation Phase-Encoding Gradient Spatial orientation in three-dimensions is achieved in MRI by way of phase encoding and frequency encoding of selected slice planes For the axial view of breast MRI, as is commonly used in Europe, the phase-encoding gradient is typically positioned in a mediolateral direction However, this occasionally impairs the ability to evaluate the axillary aspects of the breast, with the overlapping artifacts usually being worse in the vicinity of the heart (left axillary area) than on the right side This problem has been resolved by modifying the examination protocol to feature alternation of the phase-encoding gradient As signal curve analysis in high-resolution breast MRI becomes less significant, revision of the established examination protocols should take new considerations into account Zebra Protocol The zebra protocol (▶ Fig 7.4) involves sequentially alternating the phase-encoding gradient Before administration of contrast medium, one measurement is made with the phase-encoding gradient along the mediolateral or horizontal direction, and one with it along the frontoposterior or vertical direction These serve as the base measurements for the later image subtraction After administration of contrast medium, two measurements are performed with the phase-encoding gradient along the mediolateral direction followed by one measurement with it along the frontoposterior direction Subsequent image postprocessing yields three subtracted images: ● Earliest subtraction with mediolateral phase-encoding gradient ● Early subtraction with mediolateral phase-encoding gradient ● Late subtraction with frontoposterior phase-encoding gradient The zebra protocol enables complete visualization of all the parenchymal segments, including the potential “dead spaces” in the left axillary tail region while preserving a very high temporal resolution 7.1.7 Image Postprocessing The multitude of images acquired in dynamic MR mammography necessitates additional postprocessing to help in the detection of contrast-enhancing lesions, the further characterization of findings, and the optimal presentation of lesions 97 Magnetic Resonance Imaging of the Breast a b c d e f g Fig 7.4 Zebra protocol Acquisition of dynamic T1 sequence slices with alternating phase-encoding gradients (a) Precontrast examination with anteroposterior phase-encoding gradient (b) Precontrast examination with mediolateral phase-encoding gradient (c, d) After administration of contrast medium, two T1 image sequences with mediolateral phase-encoding gradients are acquired: first for performing the earliest subtraction (c), and second for performing the early subtraction (d) (e) After these postcontrast T1W images for the earliest and the early subtraction postprocessing are acquired, the third postcontrast T1W sequence is acquired with anteromedial phase-encoding gradient for the late image subtractions (f) Maximum intensity projection with mediolateral phase-encoding gradient (g) Maximum intensity projection with anteroposterior phase-encoding gradient 98 7.1 Technique and Methods Image Subtraction Maximum Intensity Projection The subtraction of precontrast images from postcontrast images with identical slice positions serves to eliminate the signalintense adipose tissue and facilitates detection of hypervascularized areas of tissue (▶ Fig 7.5a) It is mandatory to subtract the precontrast examination series from the first (earliest subtraction) and the second (early subtraction) postcontrast series on a pixel-to-pixel basis Within the zebra protocol, an additional subtraction of the precontrast series from the third series after administration of contrast medium (late subtraction) is performed, allowing an evaluation of the tissue in the axillary tails (see ▶ Fig 7.4) The maximum intensity projection technique yields a comprehensive three-dimensional view of both breasts Based on the subtraction images generated by postprocessing, which only take into account image pixels having a certain signal intensity (threshold algorithm), the representation of image information gives the impression of a “transparent breast” which can be viewed from different angles (▶ Fig 7.5c) Curve Analysis The analysis of time–signal intensity curves (TICs) within representative areas of contrast enhancement has lost importance with the increasing optimization of the spatial resolution of breast MRI The analysis remains useful for mass lesions with defined volumes, but it does not provide any additional information in the case of multiple foci or non-space-occupying lesions TIC measurements should be made in defined measurement areas (ROIs, regions of interest), which are selected such that they include the greatest possible proportion of the maximally enhancing area while disregarding less vascularized areas (e.g., central necrotic tissue areas) The size of the field of view here should be between and pixels and the selection of three ROIs per lesion is recommended The numerical results of the time–signal intensity measurements are expressed as percentage increase over the initial signal intensity values (▶ Fig 7.5b) Computer-Assisted Image Analysis Various models of CAD (computer-assisted diagnosis) for dynamic MRI examinations of the breast have been presented in the literature These range from color-coded parameter images (▶ Fig 7.5d) over automatically defined regions of interest, and from pulsating playback sequences with a repetition rate of or images per second to the use of pharmacokinetic models ▶ Table 7.1 shows the breast examination protocol used at the Göttingen Women’s Health Care Center (BZG [Diagnostisches Brustzentrum Göttingen]) 7.1.8 Implant Evaluation Examinations that target the detection of complications related to prosthetic implants differ fundamentally from examinations designed to rule out carcinoma For one thing, implant diagnostics not require a dynamic examination, so that IV administration of contrast medium is unnecessary For another, special sequences come into use that allow the selective evaluation of the different prosthesis components (e.g., silicone or saline) Fig 7.5 Image postprocessing in breast MRI (a) Subtraction (b) Curve analysis (c) Maximum intensity projection (d) Computer-assisted diagnosis (CAD) a c b d 99 Magnetic Resonance Imaging of the Breast Table 7.1 Examination protocol at the BZG (Göttingen Diagnostic Breast Center, 2013) Parameter Setting Field strength 1.5 T Surface coil Bilateral, open Breast stabilization Dedicated breast compression plates, superoinferior Angulation Axial Technique 3D Phase-encoding gradient Zebra protocol (see ▶ Fig 7.4) Sequences T1W GRE repetitive, T2W inversion recovery with fat saturation Dynamics Two measurements before, three measurements following administration of contrast media (zebra protocol) Contrast agent Gd-DTPA 0.1 mmol/kg body weight Contrast agent injection Cubital fossa; automated injection (3 mL/s); followed by 20 mL saline solution Spatial resolution 1.5–2.5 mm Field of view 300–350 mm Matrix 512 × 512, noninterpolated a Temporal resolution 87 s/sequence TR 8.4 ms TE 4.1 ms (in-phase) Fig 7.7 Breast implant with intracapsular rupture on MRI (a) Examination with silicone-sensitive sequences and suppression of the water signal Evidence of rupture of the implant shell and collapse with incipient linguine sign (b) Examination with water-sensitive sequence and silicone signal suppression Visualization of aqueous inclusions within the silicone (“salad oil sign”) As opposed to contrast-enhanced breast MRI for early tumor detection, MRI examination of breast prostheses requires the acquisition of images in multiple planes In addition to the usual axial slice orientation, sagittal images are acquired to detect any silicone located outside the superior and inferior circumference of the prosthesis, as well as to evaluate any deformation of the prosthesis in a superoinferior direction (▶ Fig 7.6) A good prosthesis examination requires extremely high spatial resolution (1–2 mm), but this is unproblematic as there is no need for administration of contrast medium, and thus the measurement protocol has plenty of leeway regarding the temporal resolution Fat-suppressing inversion recovery sequences are usually used, because they are most effective in differentiating between the various prosthetic fluids By additionally suppressing the water signal, such inversion recovery sequences allow a signal-intense visualization of silicone (siliconesensitive measurement), while the signal of the saline components and the surrounding adipose tissue is suppressed (▶ Fig 7.7) Conversely, inversion recovery sequences combined with silicone suppression allow the selective visualization of the saline components (water-sensitive measurement), so that, especially in the case of double-lumen prostheses (silicone/saline), the two prosthetic lumina can be visualized separately 100 Fig 7.6 Breast implant MRI Visualization of an implant in the usual T1W sequence with normal findings b 7.1.9 Nonestablished Examination Techniques Additional examination techniques have been investigated and will continue to be investigated to further characterize conspicuous findings on MRI These include MR spectroscopy, MR elastography, and diffusion-weighted imaging techniques The usefulness of these methods has yet to be clearly established MR Spectroscopy Magnetic resonance spectroscopy (MRS) investigates the interactions between molecules and electromagnetic fields In addition to allowing the characterization of molecular properties such as bond lengths and bond strengths, it also enables the identification of atomic constituents The observed molecular spectra differ from conventional atomic spectra by having very many more, usually overlapping spectral lines (“bands”) The choline peak has particular significance in tumor diagnosis and characterization, because carcinomas commonly exhibit a high concentration of choline There continue to be problems with the placement of measuring volumes and the associated partial volume fraction contaminated by adjacent or endotumoral necroses, parenchyma, or adipose tissue 7.2 Evaluation MR Elastography The goal of MR elastography (MRE) is to present a visual image of the viscoelastic tissue properties (hardness, elasticity, and cushioning effect) and derived parameters, such as anisotropy and elasticity tensor of the intramammary tissue structures This makes it possible to distinguish between benign and malignant tumors on the basis of their differing elastic properties Performance of this examination requires a breast surface coil with an integrated oscillator capable of sending low-frequency sound waves (e.g., 60 Hz) into the tissues The wave pattern is then measured, and, through calculation, translated into a color scale that enables a slice-by-slice analysis of the elasticity and hardness of suspicious lesions Table 7.2 Density types on breast MRI Description and sensitivity of breast MRI according to the level of enhancement in the early phase of the examination ACR MRM density type Description Sensitivity of breast MRI I No early parenchymal enhancement 98% II Mild early parenchymal enhancement ~90% III Moderate early paren- ~70% chymal enhancement IV Intense early parenchymal enhancement ~50% Diffusion-Weighted MR Imaging Diffusion-weighted MRI (DWI) produces an image representing the diffusional movement of water molecules in body tissue The technique is used primarily to examine the brain, because for some diseases of the central nervous system the diffusion pattern is changed in characteristic ways In the breast too, the diffusion rate of water molecules depends upon the nature and extent of the pathological changes at the cellular level Thus diffusion measurements are made to obtain an additional criterion for differentiating between benign and malignant changes on the basis of such disturbances in the cellular structure of the tumor a b c d 7.2 Evaluation 7.2.1 Terminology Breast MR images are described and categorized according to the BI-RADS lexicon, which presents a standardized terminology for the description and characterization of MRI findings Currently, the 5th edition of the BI-RADS lexicon (2013) is available from the American College of Radiology (ACR) Fig 7.8 Density types on breast MRI Examples of MRI examinations (early subtraction) with different MRM density types: (a) type I; (b) type II; (c) type III; (d) type IV 7.2.2 Perfusion Pattern The sensitivity of the breast MRI examination is determined to a significant extent by the physiologic vascularization of the parenchyma Early parenchymal enhancement hinders the detection of hypervascularized lesions In analogy to the density types on Xray mammography, a categorization of the density on breast MRI has also been devised (MRM density = magnetic resonance mammography density) to express the transparency of the breast (▶ Table 7.2, ▶ Fig 7.8) The greater the transparency of the glandular structures, the more sensitive the method is for the detection breast lesions at a smaller size and at an earlier stage The range of sensitivity here spans from about 50% (MRM density type IV) to almost 100% (MRM density type I), depending on the physiologic perfusion (see ▶ Table 5.1) There are no defined criteria for assigning an MRM density level to a corresponding MRI examination Ultimately, it is a subjective decision made by the evaluator In any case, the reference parameter for this is the early-subtraction image, i.e., subtraction from the second measurement after administration of contrast medium Note The assignment of the breast MRI density type makes a statement about the reliability with which the particular breast MRI can detect breast cancer 7.2.3 Findings in the T1-Weighted Precontrast Image Important information that can be important in characterizing suspicious lesions and in evaluating an individual examinee’s breast medical history or composition can be obtained from the T1W image findings before administration of contrast medium (T1W precontrast image) Thus the detection of adipose tissue within a mass lesion usually argues in favor of a benign condition, e.g., an intramammary lymph node (▶ Fig 7.9a) The contents of cystic lesions (e.g., blood or proteinaceous fluid) can also be more 101 Magnetic Resonance Imaging of the Breast a c b d Fig 7.9 Findings in the precontrast T1W MR image of the breast Examples (a) Lymph nodes (prepectoral and intramammary) (b) Postoperative hematoma (c) Postoperative susceptibility artifacts (d) Postoperative scarring precisely defined using the T1W information (▶ Fig 7.9b) After previous surgical interventions, one often finds “susceptibility artifacts” as a consequence of electrocautery (▶ Fig 7.9c) In addition, postoperative scars (▶ Fig 7.9d), fat necrosis, and oil cysts can also be localized and evaluated on the precontrast images However, the use of precontrast T1W image findings for the initial detection of breast cancer is appropriate only in exceptional cases, such as when a spiculated lesion lies within surrounding adipose tissue and can thus be easily identified based on its morphology a c b d Fig 7.10 Findings in the T2W MR image of the breast Examples (a) Cyst (b) Seroma (c) Area of adenosis (d) Fibroadenoma Fig 7.11 Typical MRI subtraction image Physiologic early contrast enhancement of the vessels and the nipple as well as suspicious enhancement within breast cancer in the left breast (arrow) Note In the breast MRI examination, T1W images serve primarily to characterize suspicious findings; only occasionally they aid in their initial detection 7.2.4 Findings in the T2-Weighted Image T2W images give a signal-intense visualization of fluid-containing structures As a rule, they are not suitable for detection of carcinoma However, information about the water content in a lesion can contribute important differential diagnostic information in the characterization of ambiguous hypervascularized masses or areas (▶ Fig 7.10) Thus, invasive carcinomas frequently exhibit a lower endotumoral fluid content than, for example, myxomatous fibroadenomas or papillomas (Invasive medullary or mucinous carcinomas are exceptions to this rule.) Nevertheless, assessment of the fluid content per se does not permit reliable differentiation between benign and malignant changes 102 Note In the breast MRI examination, T2W images serve primarily to characterize but not to detect suspicious findings Practical Tip In the breast MRI, T2W- and T1W images should be performed with identical slice thickness and position 7.2.5 Findings in the T1-Weighted Contrast-Enhanced Image Suspicious findings on breast MRI are detected by T1W images after administration of contrast medium; the visualization of contrast-enhancing findings is best in the subtraction images of identical precontrast and postcontrast slices (▶ Fig 7.11) As well as the conspicuous enhancement of a lesion, morphological criteria are of particular diagnostic importance for its characterization 7.2 Evaluation The significance of the kinetic curve assessment has declined due to the continuing improvement of the spatial resolutionof breast MRI and dynamic measurements Note Contrast enhanced T1W breast MRI images, especially after subtraction postprocessing, serve the primary technique for the detection of suspicious mammary findings, but also in their characterization, based on morphological criteria 7.2.6 Evaluation Criteria The BI-RADS lexicon differentiates between three primary findings on breast MRI: ● Focus or foci ● Mass lesion ● Lesion without space-occupying characteristics (nonmasslike enhancement) Foci A focus is a tiny spot of enhancement within the parenchyma, exhibiting a maximum size of < mm A solitary focus can be an expression of hormonal stimulation (▶ Fig 7.12a), but one must also include the very early stage of a malignant process in the differential diagnosis, so a follow-up MRI after months is the strategic recommendation The occurrence of multiple foci typically suggests a physiologic increase in perfusion (▶ Fig 7.12b) In this case, no targeted follow-up is indicated Mass Lesions Three-dimensional, space-occupying areas of increased enhancement of mm and larger are designated “mass lesions.” One should evaluate mass lesions based on the criteria “shape,” “margins”, and “endotumoral contrast media distribution,” as well as certain dynamic criteria in representative regions of interest (ROIs): “initial rise” and “delayed phase” or “postinitial” uptake of contrast medium To help translate findings based on these criteria into a BI-RADS assessment category, a system has been developed that assigns a points value to each criteria (the Goettingen score, ▶ Table 7.3) In this system, phenomena that strongly suggest malignancy—such as ring enhancement and washout effect—are given a higher score than findings that are more likely to be Table 7.3 Goettingen score for the evaluation of mass lesions on breast MRI Assignment of points (0–2) for each criterion, depending on the specified findings Maximal achievable point score is Evaluation criterion Score Shape Round, oval Irregular, spiculated - Margin Circumscribed Indistinct - Contrast media distribution Homogeneous Inhomogeneous Rim sign Initial signal increase (1st–3rd minute) Mild (< 50%) Moderate (50– 100%) Strong (> 100%) Post-initial signal sequence Continuous increase Plateau phase Washout phenomenon Table 7.4 Assignment of an MR BI-RADS category according to the Goettingen score Mass lesions with an overall score of < points are typically considered to be benign, while lesions with a sore of ≥ points are considered to be potentially suspicious for malignancy Mass lesions with a score of points are assigned to MR BI-RADS Total point count in the Goettingen score MR BI-RADS category 1 2 3 and 6, 7, and associated with benign findings, such as smooth margins and slight initial signal increase The sum of all the points makes up the overall score for a mass lesion, which can range from to points This overall score enables a fairly reliable evaluation of a mass lesion and its assignment to a BI-RADS assessment category (▶ Table 7.4, ▶ Fig 7.13) Individual work groups have expanded the Goettingen Score to include the criteria “endotumoral water content” in the T2W measurement, and the presence of “endotumoral septations.” Note Neither any individual criterion (“shape,” “margins”, “contrast media distribution”) nor either of the dynamic criteria, considered alone, enables reliable assessment of a mass lesion in breast MRI Non-Space-Occupying Changes a b Fig 7.12 Foci on breast MRI (a) Solitary focus in the early subtraction image (maximum intensity projection) (b) Multiple foci in the early subtraction image (maximum intensity projection) Areas of increased enhancement that not exhibit spaceoccupying characteristics are termed “nonmasslike enhancement.” Such findings are typically associated with enhancement of the parenchymal or tumor matrix, whereas the intramammary adipose tissue does not enhance (▶ Fig 7.14) The application of the Goettingen score here makes little sense, especially given that the ROIs used to determine the dynamic characteristics will often 103 Magnetic Resonance Imaging of the Breast a b Fig 7.13 Mass lesions on breast MRI (a) Benign mass in the early subtraction image (fibroadenoma) (b) Malignant mass lesion in the early subtraction image (carcinoma) Seven categories are distinguished, whereby the categories BIRADS and BI-RADS are of special significance The BI-RADS assessment categories to are used to encode the probability that an abnormality is a malignant process (▶ Table 7.5); these prescribe concrete recommendations for the further course of action (▶ Table 7.6) a b Fig 7.14 Non-masslike lesions on breast MRI A non-space-occupying process (invasive, lobular breast carcinoma): adipose tissue is not infiltrated by the tumor process (single-file infiltration pattern) Secondary characteristics: postoperative susceptibility artifacts from a previous surgery (a) T1W precontrast image (b) Subtraction image following administration of contrast medium include lipomatous regions, thus complicating the interpretation Aside from a regional physiologic increase in perfusion (a normal finding), the differential diagnosis should consider intraductal tumors, invasive lobular carcinomas, radial scars, and inflammatory changes Note Microcalcifications, whether carcinoma-associated or not, are not depicted on breast MRI MRI is very sensitive, however, in the detection of the increased vascularization associated with proliferating tumor processes 7.2.7 BI-RADS Classification of MRI of the Breast The final assessment of a breast MRI examination must always be in accordance with the ACR MRI BI-RADS classification system 104 MR BI-RADS As for the other modalities, the BI-RADS category is assigned when no conclusive assessment of the MRI examination is possible and further diagnostic procedures are required For breast MRI, this primarily involves examinations that are deemed to be technically or methodologically inadequate and must be repeated, e.g., as a consequence of artifacts caused by patient movement The BI-RADS category may also be assigned when it is necessary to acquire additional information from other imaging modalities (mammography, sonography) or when past medical history information must be obtained Table 7.5 BI-RADS classification for breast MRI findings (MR BI-RADS) Description of findings and corresponding risk of malignancy MR BI-RADS category Description Risk of carcinoma (%) Normal Definitely benign Probably benign > 0% – ≤ 2% Suspicious > 2% – < 95%a Highly suggestive of malignancy ≥ 95% aDue to the large risk range within the category MR BI-RADS (> 2– < 95%), subdivisions may be used: subcategory MR BI-RADS 4A (> 2– ≤ 10%), 4B (> 10– ≤ 50%) and 4C (> 50– < 95%) 7.2 Evaluation Table 7.6 Recommended management according to the MR BI-RADS category MR BI-RADS category Recommended management Next examination within the routine screening interval Next examination within the routine screening interval Follow-up after months Histological work-up by percutaneous biopsy Pretherapeutic histological work-up by percutaneous biopsy Fig 7.15 MR BI-RADS Unremarkable visualization of both breasts on breast MRI (maximum intensity projection) Within the concept of individualized examinations, the BIRADS category should not have to be used at all Ambiguous findings can be conclusively evaluated by promptly carrying out appropriate supplementary examinations and assigning a BIRADS category to while the patient is still on site MR BI-RADS The BI-RADS category is assigned when an examination is determined to be complete and adequate for assessment Findings are normal and without abnormalities to comment on (▶ Fig 7.15) This signifies that both breasts are visualized symmetrically and that there are no mass lesions with increased vascularization, architectural distortions, or suspicious areas of enhancement Depending on the individual breast cancer risk, further examinations are recommended at appropriate screening intervals a b Fig 7.16 MR BI-RADS Typical examples Both images show T1W precontrast examination No enhancement is seen after administration of contrast material (not shown) (a) Fibrotic fibroadenoma (b) Oil cyst MR BI-RADS BI-RADS categorization also conveys that the breast MRI examination is determined to be complete and adequate for assessment In contrast to the MR BI-RADS category, in BI-RADS a finding is present that is worth describing but is clearly benign Examples of such findings on MRI include: ● Fibrotic fibroadenoma without enhancement (▶ Fig 7.16a) ● Cysts ● Old scars without enhancement ● Findings with lipomatous inclusions, such as lipomas, oil cysts (▶ Fig 7.16b), galactoceles, or hamartomas ● Implants with no indication of malignant changes All the itemized entities exhibit a characteristic appearance on MRI that excludes them from the differential diagnoses of malignant tumors The risk of cancer is assessed to be 0%, and further examinations should be performed at appropriate screening intervals MR BI-RADS The category BI-RADS is assigned if an examination is determined to be complete and adequate for assessment, and a lesion is present that has a high probability of being benign By definition, the residual risk of malignancy is ≤ 2% The BI-RADS lexicon does not describe any concrete examples of this, so the classification of a lesion to the MR BI-RADS category ultimately remains a b Fig 7.17 MR BI-RADS (a) Solitary focus in the right breast (arrow) (b) Findings initially categorized as MR BI-RADS Follow-up MRI months later showed identical findings (arrow) intuitive On principle, it appears prudent to avoid using the BIRADS category, because this leads to a high false-positive rate for benign findings (overdiagnosis), while, on the other hand, there is a risk that the definitive diagnosis of a malignant lesion might be delayed From the author’s personal experience, however, there are two concrete constellations in which it makes sense to use the MR BI-RADS category without risk of any appreciable worsening of prognosis if the lesion does correspond to a carcinoma: ● Solitary focus (▶ Fig 7.17) ● Small mass lesion with points on the Goettingen score (presupposing that a second-look ultrasound is unremarkable) In any case, as for the other modalities, all imaging possibilities should be exploited to clarify the finding before a lesion is classified as BI-RADS This is especially true for the targeted second-look ultrasound, which is performed with exact information on the localization, size, and configuration of the MRI finding 105 Magnetic Resonance Imaging of the Breast A short-term follow-up examination after an interval of months is usually recommended for findings in the MR BI-RADS category As an alternative, if the patient desires, a prompt diagnostic work-up with a percutaneous biopsy can be performed If short-term follow-up shows enlargement of the lesion being followed, then the lesion is upgraded and reclassified as an MR BIRADS lesion, and a percutaneous biopsy for diagnostic work-up is should be done Here, too, the supplementary performance of a second-look ultrasound examination is indicated, in particular to clarify whether the finding can be biopsied by means of an ultrasound-guided core needle biopsy In retrospective monitoring, the rate of carcinoma found in the MR BI-RADS group within the recommended follow-up examination period should be less than 2% MR BI-RADS The BI-RADS category (▶ Fig 7.18) is assigned if an examination is determined to be complete and adequate for assessment, and a lesion is present that has sufficient probability of being malignant to warrant biopsy These findings not have the classic appearance of a malignant lesion but, by definition, carry a > to < 95% risk of malignancy For MRI, as for the other modalities, it is possible to subclassify MR BI-RADS into the subcategories MR BI-RADS 4A (carcinoma risk > 2– ≤ 10%), MR BI-RADS 4B (> 10– ≤ 50%) and MR BI-RADS 4C (> 50– < 95%), but the BI-RADS lexicon does not present concrete examples for the corresponding subclassifications As a rule, an interventional diagnostic work-up, i.e., a percutaneous biopsy, is recommended for findings in the MR BI-RADS category With knowledge of the MRI findings, however, the mammographic images should be reviewed again and a secondlook ultrasound performed When no corresponding findings are seen on the mammogram and/or ultrasound, then diagnostic a work-up is indicated in the form of an MRI-guided, vacuumassisted biopsy If, after the biopsy, the lesion is found to be histopathologically benign, then the compatibility between the histology and imaging must be reviewed If it appears probable that the lesion was missed, re-biopsy or an open biopsy should be considered, in accordance with appropriate guidelines If no re-biopsy is performed, a repeat MRI examination after to 12 months is recommended MR BI-RADS The BI-RADS category designates those lesions that exhibit the typical MRI appearance of breast cancer (▶ Fig 7.19) In the Goettingen score, these mass lesions typically receive or points The probability of malignancy is statistically between 95 and 100% Here also, the ACR does not specify any concrete examples for this category Findings in the MR BI-RADS category are clarified by means of an MRI-guided, vacuum-assisted biopsy, as long as there are no corresponding findings on mammography or sonography The course of action is essentially that for findings in the MR BI-RADS category MR BI-RADS Lesions are placed in this category once histology has confirmed a malignancy corresponding to a lesion in the histological Bclassifications B5a (DCIS: ductal carcinoma in situ), B5b (invasive carcinoma), B5c, or B5d The classification of a lesion to this category is thus independent of the morphological criteria in the image findings The BI-RADS category is only to be used until the malignant lesion has been surgically excised Postoperatively, classification is made according to the pT staging of the TNM system of the UICC (Union for International Cancer Control) b Fig 7.18 MR BI-RADS Typical examples (a) Nonmasslike lesion (differential diagnosis: adenosis, mastitis, ductal carcinoma in situ [DCIS], invasive lobular carcinoma [ILC]) (b) Hypervascularized mass lesion (differential diagnosis: nodular adenosis, fibroadenoma, papilloma, invasive carcinoma) 106 7.2 Evaluation a b Fig 7.19 MR BI-RADS Classic carcinoma of the breast (a) Irregular shape and spiculations (b) Indistinct margins with ring enhancement and increased central enhancement Note ● ● ● In the overall assessment, the final diagnosis stands at the end of an examination chain (clinical examination, mammography, ultrasonography, breast MRI) Here, taking the specific reliability of each method into consideration, a summarizing evaluation of all image findings is assigned in the form of a final combined BIRADS score to category 1, 2, 3, 4, or Assuming that the histological result 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Pseudoangiomatous Stromal Hyperplasia 11 0 11 0 11 1 11 2 11 4 11 6 11 6 11 7 11 9 12 0 12 1 12 2 12 4 12 5 12 5 12 6 8 .1. 17 8 .1. 18 8 .1. 19 8 .1. 20 8 .1. 21 Seroma ... Benign Findings 11 0 8 .1. 1 8 .1. 2 8 .1. 3 8 .1. 4 8 .1. 5 8 .1. 6 8 .1. 7 8 .1. 8 8 .1. 9 8 .1. 10 8 .1. 11 8 .1. 12 8 .1. 13 8 .1. 14 8 .1. 15 8 .1. 16 Cysts ... China by Everbest Printing Ltd., Hong Kong ISBN 97 8-3 -1 3-2 019 3 1- 7 Also available as an e-book: eISBN 97 8-3 -1 3-2 019 4 1- 6 543 21 This book, including all parts thereof, is legally protected by copyright