The aim of breast MRI is to obtain a reliable evaluation of any lesion within the breast. It is currently always used as an adjunct to the standard diagnostic procedures of the breast, i.e., clinical examination, mammography and ultrasound. Whereas the sensitivity of breast MRI is usually very high, specificity—as in all breast imaging modalities—depends on many factors such as reader expertise, use of adequate techniques and composition of the patient cohorts. Since breast MRI will always yield MR-only visible questionable lesions that require an MR-guided intervention for clarification, MRI should only be offered by institutions that can also offer a MRI-guided breast biopsy or that are in close contact with a site that can perform this type of biopsy for them. Radiologists involved in breast imaging should ensure that they have a thorough knowledge of the MRI techniques that are necessary for breast imaging, that they know how to evaluate a breast MRI using the ACR BI-RADS MRI lexicon, and most important, when to perform breast MRI. This manuscript provides guidelines on the current best practice for the use of breast MRI, and the methods to be used, from the European Society of Breast Imaging (EUSOBI).

/pdf/breast-mri-guidelines-from-the-european-society-of-breast-25bwn1furs.pdf

Breast MRI: guidelines from the European Society of Breast Imaging

Purpose: To determine, in a meta-analysis, the diagnostic performance of contrast material–enhanced magnetic resonance (MR) imaging in patients with breast lesions. Materials and Methods: Studies to assess the diagnostic performance of MR imaging in patients suspected of having breast cancer who underwent MR imaging and biopsy from January 1985 through March 2005 were reviewed for inclusion. A summary receiver operating characteristic curve was constructed, and pooled weighted estimates of sensitivity and specificity were calculated by using the recently developed bivariate approach for diagnostic meta-analysis. Results: Of 251 eligible studies, 44 were included in the meta-analysis (sample size range, 14–821; cancer prevalence, 23%–84%). Pooled weighted estimates of sensitivity and specificity were 0.90 (95% confidence interval: 0.88, 0.92) and 0.72 (95% confidence interval: 0.67, 0.77), respectively. The performance of breast MR imaging was influenced by the prevalence of cancer in the studied populatio...

Meta-Analysis of MR Imaging in the Diagnosis of Breast Lesions

Objective To examine changes in temporal trends in breast cancer mortality in women living in 30 European countries. Design Retrospective trend analysis. Data source WHO mortality database on causes of deaths Subjects reviewed Female deaths from breast cancer from 1989 to 2006 Main outcome measures Changes in breast cancer mortality for all women and by age group ( Results From 1989 to 2006, there was a median reduction in breast cancer mortality of 19%, ranging from a 45% reduction in Iceland to a 17% increase in Romania. Breast cancer mortality decreased by ≥20% in 15 countries, and the reduction tended to be greater in countries with higher mortality in 1987-9. England and Wales, Northern Ireland, and Scotland had the second, third, and fourth largest decreases of 35%, 29%, and 30%, respectively. In France, Finland, and Sweden, mortality decreased by 11%, 12%, and 16%, respectively. In central European countries mortality did not decline or even increased during the period. Downward mortality trends usually started between 1988 and 1996, and the persistent reduction from 1999 to 2006 indicates that these trends may continue. The median changes in the age groups were −37% (range −76% to −14%) in women aged Conclusions Changes in breast cancer mortality after 1988 varied widely between European countries, and the UK is among the countries with the largest reductions. Women aged

https://www.bmj.com/content/bmj/341/bmj.c3620.full.pdf

Disparities in breast cancer mortality trends between 30 European countries: retrospective trend analysis of WHO mortality database

Benign breast diseases constitute a heterogeneous group of lesions including developmental abnormalities, inflammatory lesions, epithelial and stromal proliferations, and neoplasms. In this review, common benign lesions are summarized and their relationship to the development of subsequent breast cancer is emphasized. The Oncologist 2006;11:435–449

Benign Breast Diseases: Classification, Diagnosis, and Management

This meta-analysis comprehensively addresses the issue of underestimation of invasive breast cancer and its predictors in the setting of diagnoses of ductal carcinoma in situ at core-needle biopsy, providing a pooled random effects estimate of underestimation (25.9%; 95% confidence interval: 22.5%, 29.5%).

https://pubs.rsna.org/doi/pdf/10.1148/radiol.11102368

Ductal Carcinoma in Situ at Core-Needle Biopsy: Meta-Analysis of Underestimation and Predictors of Invasive Breast Cancer

OBJECTIVE. Clinical trials to date into the use of full-field digital mammography (FFDM) for breast cancer screening have shown variable results. The aim of this study was to review the use of FFDM in a population-based breast cancer screening program and to compare the results with screen-film mammography.MATERIALS AND METHODS. The study included 188,823 screening examinations of women between 50 and 64 years old; 35,204 (18.6%) mammograms were obtained using FFDM. All films were double read using a 5-point rating scale to indicate the probability of cancer. Patients with positive scores were recalled for further workup. The recall rate, cancer detection rate, and positive predictive value (PPV) of FFDM were compared with screen-film mammography.RESULTS. The cancer detection rate was significantly higher for FFDM than screen-film mammography (6.3 vs 5.2 per 1,000, respectively; p = 0.01). The cancer detection rate for FFDM was higher than screen-film mammography for initial screening and subsequent scree...

https://www.ajronline.org/doi/pdf/10.2214/AJR.08.2157

Comparison of Digital Mammography and Screen-Film Mammography in Breast Cancer Screening: A Review in the Irish Breast Screening Program

Radial scar (RS) is a benign, well recognised, radiological and pathological entity. Histologically, it is characterised by a fibroelastotic core with entrapped ducts and surrounding radiating ducts and lobules. Postmortem studies indicate that these lesions are present commonly in the population, especially in association with benign breast disease. In recent years, their clinical relevance has assumed more importance with the introduction of population based screening programmes. The exact pathogenesis of RS is unknown. Accumulating evidence indicates that they are associated with atypia and/or malignancy and, in addition, may be an independent risk factor for the development of carcinoma in either breast. In view of the association with atypia and malignancy, excision biopsy is justified in RS, although it has been argued that core biopsy evaluation and surveillance may be appropriate in selected patients.

https://jcp.bmj.com/content/jclinpath/56/10/721.full.pdf

Pathology and clinical relevance of radial scars: a review.

The primary purpose of this study was to evaluate the impact of digital mammography screening on breast dose by analysing the results of a patient dose survey of the Irish breast screening programme. Results from the survey were used to determine a dose reference level for the screening programme. Approximately, 100 examinations were acquired for each of the digital mammography systems operational in the screening programme. Each examination consisted of two standard views of each breast. The mean glandular dose for each acquired image was calculated. The dose reference level was established by calculating the 95th percentile of the average mean glandular dose for the average compressed breast thickness of the mediolateral oblique views. The overall average mean glandular dose per examination was 2.72 ± 0.04 mGy. The average compressed breast thickness was 61.4 ± 0.03 mm. The average compression force was 109 ± 7 N. A dose reference level value of 1.75 mGy was established for the screening programme. The results of this clinical dose survey provide a valuable indication of the dose performance of modern full field digital mammographic imaging systems. The results demonstrate clearly the dose benefits of digital mammography. The dose benefit of digital screening was further demonstrated by the establishment of a comparatively lower diagnostic reference level for the screening programme. The comparison of the dose performance of individual X-ray systems with the diagnostic reference level highlights the need for more optimisation within the service.

Comprehensive dose survey of breast screening in Ireland.

Aims: Radial scars (RS) are benign entities, frequently identified on screening mammography, which may be associated with malignancy Much debate has been generated with regard to the optimum management of RS We present our experience of RS in the first 5 years of a screening programme The aim was to evaluate (i) the incidence of atypia and malignancy and (ii) the value of the preoperative core biopsy We also further characterize the histological features



Methods and results:  One hundred and twenty-five histologically confirmed cases of RS were reviewed (111 had preoperative biopsies) Thirty-one (248%) patients had a final malignant diagnosis (11 with invasive malignancy) and 28 (224%) showed atypia (including lobular carcinoma in situ) In those with core biopsies and a final malignant diagnosis, 12 cases were categorized as B5 (413%), three as B4 (103%), 12 as B3 (413%) and two as B2 (7%) Common histological features included obliterated ducts and chronic inflammation with, less frequently, neural hyperplasia (168%) and perineural invasion (32%)



Conclusions:  The high incidence of atypia and malignancy identified in our study justifies our policy of removing all mammographically detected RS We emphasize the utility of preoperative core biopsy evaluation in permitting one-stage surgical therapy in those with B5 diagnoses

Radial scars/complex sclerosing lesions and malignancy in a screening programme: incidence and histological features revisited.

Background The role of sentinel lymph node biopsy (SLNB) for ductal carcinoma in situ (DCIS) is poorly defined. However, up to 20% of patients with DCIS will have invasive carcinoma; these patients require staging for axillary metastasis. The aim of this study was to identify patients with a core biopsy diagnosis of DCIS who may benefit from SLNB. Methods In a prospective study, we performed SLNB on patients with a preoperative diagnosis of >2.5 cm of high-grade DCIS or DCIS when mastectomy was indicated. Results Sixty-two patients underwent surgery for high-grade DCIS, and 35 of these patients underwent SLNB. Postsurgical excision histology revealed invasive disease in 20 patients, 19 of whom had undergone SLNB. Before the adoption of SLNB in selected DCIS patients, all 20 with occult invasive disease would have required second surgery axillary staging ( P Conclusions SLNB should not be performed routinely for all patients with an initial diagnosis of DCIS. However, selective lymphadenectomy may be a useful clinical adjuvant in selected high-risk DCIS patients.

F. Flanagan

Papers

Comparison of Digital Mammography and Screen-Film Mammography in Breast Cancer Screening: A Review in the Irish Breast Screening Program

Pathology and clinical relevance of radial scars: a review.

Comprehensive dose survey of breast screening in Ireland.

Radial scars/complex sclerosing lesions and malignancy in a screening programme: incidence and histological features revisited.

Role of sentinel lymph node biopsy in high-risk ductal carcinoma in situ patients.