Breast Cancer Screening
Savannah Partridge1

1University of Washington, United States

Synopsis

Abbreviated breast MRI protocols hold potential to reduce time and overall costs of breast MRI examinations, which could increase accessibility for more widespread screening. A growing number of studies have demonstrated that abbreviated MRI protocols can provide comparable diagnostic accuracy to that of conventional full MRI protocols for breast cancer screening. Current approaches and performance results will be reviewed, along with discussion of future directions.

OBJECTIVES:

  • Discuss potential role for abbreviated protocols in breast imaging
  • Review varying approaches and performance results for abbreviated breast MR protocols
  • Discuss the ongoing ECOG-ACRIN EA1141 prospective multicenter trial of abbreviated breast MRI and future directions

BACKGROUND:

Results of large screening trials have established breast MRI to be the most sensitive technique for detecting breast cancer [1-3]. It is currently recommended for screening of women with high lifetime risk (>20%) [4]. However, the lengthy scan times and associated high costs of conventional comprehensive breast MRI examinations limit accessibility of this screening tool for many women and reduce feasibility for expanded use in intermediate or lower risk cohorts who would benefit from supplemental breast MRI screening, such as women with elevated breast density. Initially demonstrated by Kuhl et al in 2014 [5], abbreviated breast MRI protocols have shown promise for increasing the efficiency and cost-effectiveness of breast screening by dramatically reducing scan and interpretation times. Advanced acquisition techniques may further improve diagnostic performance of abbreviated breast MRI protocols [6].

METHODS:

Conventional breast MRI protocols vary but typically consist of multiple sequences including a localizer, water-sensitive sequence (T2-weighted and/or STIR) and dynamic series of T1-weighted pre- and post-contrast scans, and also may include other sequences such as non-fat-suppressed T1-weighted and diffusion-weighted imaging (DWI) sequences. Abbreviated breast MRI protocols also vary considerably across studies in the literature [7-20]. The common goal is to increase throughput by reducing overall scan time to ~10 minutes or less. Most frequently this is achieved by obtaining at minimum a pre-contrast and single post-contrast T1-weighted acquisition, critical for retaining sensitivity, and eliminating extra post-contrast T1-weighted acquisitions and any other non-essential sequences. Without the additional post-contrast T1-weighted sequences, typical abbreviated protocols only allow for assessment of morphology of enhancing lesions but not kinetics, which can be helpful for differential diagnosis [21]. Novel ‘ultrafast’ dynamic contrast-enhanced (DCE) MRI protocols are being explored to extract valuable early kinetic information within the shortened time window of abbreviated MR [22-24]. These techniques use accelerated imaging strategies to provide both high spatial and high temporal resolution, which could allow optimal evaluation of both the morphologic characteristics and kinetics of lesions.

RESULTS:

There have been studies from several institutions investigating the performance of abbreviated MRI protocols for breast cancer screening. For the most part, their findings have been in agreement, demonstrating that abbreviated breast MRI provides comparable diagnostic accuracy to full diagnostic protocols. Across all studies, abbreviated protocols had substantially shorter acquisition times (average, 8 minutes) compared with the full diagnostic protocols (average, 25 minutes). In studies that compared performance of abbreviated versus full diagnostic protocols, the shorter acquisition time and faster interpretation did not significantly affect sensitivity (ranging 88–100%) or [5, 7, 11, 12, 14-17, 20]. Most studies also found no difference in specificity using abbreviated protocols, although lower specificity was reported in one study (88% for abbreviated vs. 95% for the full protocol, p=0.036) [12]. Multiple ultrafast DCE-MRI studies have reported the early kinetics metrics including maximum relative enhancement slope and time to enhancement to be valuable kinetics metrics for discriminating benign and malignant enhancing breast lesions [22-25]. One study using an abbreviated breast MRI protocol found ultrafast DCE-MRI to improve the specificity (averaged for two readers) from 60% to 77%, which was also higher than the specificity achieved using a full protocol (59%) [14]. This higher specificity was achieved without any decrease in sensitivity (93% for abbreviated MRI with and without ultrafast DCE-MRI and also for the full protocol).

DISCUSSION/CONCLUSION:

Abbreviated breast MRI protocols hold potential to increase throughput and reduce overall costs of breast MRI, which could increase accessibility for more widespread screening. A growing number of studies have demonstrated that abbreviated MRI protocols can provide comparable diagnostic accuracy to that of the conventional full MRI protocol at reduced scan and interpretation times. Additionally, preliminary investigations of abbreviated MRI protocols incorporating ultrafast DCE-MRI sequences show promise for obtaining diagnostically useful kinetic information within the shortened imaging timeframe. In future directions, these promising and mostly concordant results of single-center studies have prompted a multicenter trial currently underway to investigate the utility of abbreviated breast MRI as a low cost supplemental screening test for females with dense breast tissue (ECOG-ACRIN EA1141) [26, 27]. Also, emerging research on non-contrast/unenhanced methods, relying primarily on diffusion-weighted imaging (DWI) for cancer detection, may also hold potential to further eliminate the associated time, costs and toxicities of gadolinium administration in abbreviated breast MR protocols. As growing evidence and results of multicenter trials confirm the accuracy to be comparable to that of conventional breast MRI protocols, it is likely that abbreviated MRI protocols will quickly become the standard approach for breast MRI screening and may increase feasibility for screening a wider population of women with intermediate or lower risk.

Acknowledgements

Funding support: NIH/NCI R01CA207290

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Proc. Intl. Soc. Mag. Reson. Med. 26 (2018)