The Utility of Breast MRI as a Problem-Solving Tool

The Utility of Breast MRI as a Problem-Solving Tool
Edwin J. Yau, Robert L. Gutierrez, Wendy B. DeMartini, Peter R. Eby, Sue Peacock and Constance D. Lehman
The Breast Journal 17;3:273–280

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Breast magnetic resonance imaging (MRI) is routinely used as a problem-solving tool, but its benefit for this indication remains unclear. The records of 3001 consecutive breast MR examinations between January 1, 2003 and June 6, 2007 were reviewed to identify all those performed for the clinical indication of problem solving. Details of clinical presentation, mammography and ultrasound (US) findings, follow-up recommendations, and pathology outcomes were recorded. Benign versus malignant outcomes were determined by biopsy or 12 months of follow-up imaging and linkage with the regional tumor registry. Problem solving was the clinical indication for 204 of 3001 (7%) of all examinations. Forty-two of 204 examinations (21%) had suspicious or highly suspicious MRI assessments with recommendation for biopsy and 62 of 204 (79%) examinations were assessed as negative, benign, or probably benign. Thirty-six biopsies were performed based on MRI findings and 14 cancers were diagnosed. Biopsy was indicated for 11 of 14 (79%) cancers based on suspicious mammographic or US findings identified prior to MRI. One incidental cancer was detected by MRI alone in a patient at high risk for breast cancer, and two cancers were detected in patients with suspicious nipple discharge and negative mammogram and US. A single false-negative MRI occurred in a patient whose evaluation for a palpable lump prompted biopsy. 

Problem-solving breast MRI rarely identifies otherwise occult cancer and can be falsely negative in patients with suspicious findings on mammogram and US. Until the benefits and risks of problem-solving MRI are clarified, it should be used judiciously.

Increase in Mastectomies Performed in Patients in the Community Setting Undergoing MRI

Increase in Mastectomies Performed in Patients in the Community Setting Undergoing MRI
Ayodele Ayoola, Suganthi Alagarsamy, Jerry Jaboin and Suman Rao
The Breast Journal 17;3:256-259

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This study is designed to determine whether the use of magnetic resonance imaging (MRI) leads to an increased number of unnecessary mastectomies in breast cancer patients in the community setting. This is a retrospective study of the records of 178 patients from the local offices of three community physicians. The medical records of patients over the age of 18 with breast cancer who underwent both MRI and mammogram imaging were reviewed. MRI detected more lesions than mammogram; however, these lesions were not cancerous. The lesions detected by mammogram correlated more with pathologic lesions. Of the 59 patients who underwent mastectomies, 78% had MRI and 22% did not have the imaging. Of the 100 patients who had both MRI and mammogram, 48% underwent lumpectomy and 46% had mastectomy. More patients who had both imaging modalities underwent mastectomies compared to those who had mammogram alone. The addition of MRI evaluation in patients with breast cancer is related to increased unnecessary mastectomies.

Overview of Gynecomastia in the Modern Era and the Leeds Gynaecomastia Investigation Algorithm

Overview of Gynecomastia in the Modern Era and the Leeds Gynaecomastia Investigation Algorithm
Samir Rahmani, Philip Turton, Abeer Shaaban and Barbara Dall
The Breast Journal 17;3:246-255
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Gynecomastia is a benign enlargement of male breast glandular tissue. At least a third of males are affected at some time during their lifetime. Idiopathic causes exceed other etiologies and relate to an imbalance in the ratio of estrogen to androgen tissue levels or end-organ responsiveness to these hormones. Assessment must include a thorough history and clinical examination, specific blood investigations and usually tissue sampling and/or breast imaging. Management consists of a combination of measures that may include simple reassurance, pharmacological manipulation, medical treatment or surgery. Hormone therapy may help to abort the acute proliferative phase of gynecomastia with a 30% response rate but should not be considered in chronic established cases. Surgical treatment may comprise simple liposuction for a predominant fatty component or direct excision when glandular tissue is predominant. The main aim is to control the patient’s symptoms and to exclude other etiological factors.

Predictors of Invasion and Axillary Lymph Node Metastasis in Patients with a Core Biopsy Diagnosis of Ductal Carcinoma In Situ: An Analysis of 255 Cases

Predictors of Invasion and Axillary Lymph Node Metastasis in Patients with a Core Biopsy Diagnosis of Ductal Carcinoma In Situ: An Analysis of 255 Cases
Jeong S. Han, Kyle H. Molberg and Venetia Sarode
The Breast Journal 17;3:223–229

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The diagnosis of ductal carcinoma in situ (DCIS) using core biopsy does not ensure the absence of invasion on final excision. We performed a retrospective analysis of 255 patients with DCIS who had subsequent excision. Clinical, radiologic, and pathologic findings were correlated with risk of invasion and sentinel lymph node (SLN) metastasis. Of 255 patients with DCIS, 199 had definitive surgery and 52 (26%) had invasive ductal carcinoma (IDC) on final excision. Extent of abnormal microcalcification on mammography, and presence of a radiologic/palpable mass and solid type of DCIS were significantly associated with invasion on final excision. Sentinel lymph node biopsy was performed in 131 (65.8%) patients of whom 18 (13.4%) had metastasis. Size of IDC and extent of DCIS on final pathology were significantly associated with positive SLN. Micrometastasis and isolated tumor cells comprised majority (71.4%) of the metastases in DCIS. SLN biopsy should be considered in those with high risk DCIS