Surveillance of BRCA1 and BRCA2 mutation carriers with magnetic resonance imaging, ultrasound, mammography, and clinical breast examination

Auditing Abbreviated Breast MR Imaging: Clinical Considerations and Implications

Abbreviated breast MR (AB-MR) imaging is a relatively new breast imaging tool, which maintains diagnostic accuracy while reducing image times compared with full-protocol breast MR (FP-MR) imaging. Breast imaging audits involve calculating individual and organizational metrics, which can be compared with established benchmarks, providing a standard against which performance can be measured. Unlike FP-MR imaging, there are no established benchmarks for AB-MR imaging but studies demonstrate comparable performance for cancer detection rate, positive predictive value 3, sensitivity, and specificity with T2. We review the basics of performing an audit, including strategies to implement if benchmarks are not being met.

Clinical breast exam contribution to breast cancer diagnosis in BRCA mutation carriers vs. average to intermediate risk women

PURPOSE

The contribution of clinical breast exam (CBE) to breast cancer diagnosis in average risk women undergoing regular screening mammography is minimal. To evaluate the role of CBE in high-risk women, we compared BC diagnosis by CBE in BRCA mutation carriers undergoing regular BC surveillance to average to intermediate risk women undergoing regular breast cancer screening.

METHODS

A retrospective chart review of all consecutive screening visits of BRCA mutation carriers (January 2012-October 2022) and average to intermediate risk women (November 2016-December 2022) was completed. Women with histologically confirmed BC diagnosis were included. Additional CBE yield for BC diagnosis, defined as the percentage of all BC cases detected by CBE alone, was assessed in both groups.

RESULTS

Overall, 12,997 CBEs were performed in 1,328 BRCA mutation carriers in whom 134 BCs were diagnosed. In 7,949 average to intermediate risk women who underwent 15,518 CBEs, 87 BCs were diagnosed. CBE contributed to BC diagnosis in 3 (2%) BRCA mutation carriers and 3 (4%) non-carriers. In both groups, over 4,000 CBEs were needed in order to diagnose one cancer. In all 3 BRCA mutation carriers BC was palpated during the surveillance round that did not include MRI. In the average to intermediate risk group, 2 of 3 cancers diagnosed following CBE findings were in a different location from the palpable finding.

CONCLUSIONS

The contribution of CBE to BC diagnosis is marginal for all women including BRCA mutation carriers. In BRCA mutation carriers, CBE appears redundant during the MRI surveillance round.

Decoding the Prevalent High-Risk Breast Cancers: Demographics, Pathological, Imaging Insights, and Long-Term Outcome

Objective: To investigate the features and outcomes of breast cancer in high-risk subgroups. Materials and Methods: REB approved an observational study of women diagnosed with breast cancer from 2010 to 2019. Three radiologists, using the BI-RADS lexicon, blindly reviewed mammogram and MRI screenings without a washout period. Consensus was reached with 2 additional reviewers. Inter-rater agreement was measured by Fleiss Kappa. Statistical analysis included Mann-Whitney U, Chi-square tests for cohort analysis, and Kaplan-Meier for survival rates, with a Cox model for comparative analysis using gene mutation as a reference. Results: The study included 140 high-risk women, finding 155 malignant lesions. Significant age differences noted: chest radiation therapy (median age 44, IQR: 37.0-46.2), gene mutation (median age 49, IQR: 39.8-58.0), and familial risk (median age 51, IQR: 44.5-56.0) (P = .007). Gene mutation carriers had smaller (P = .01), higher-grade tumours (P = .002), and more triple-negative ER- (P = .02), PR- (P = .002), and HER2- (P = .02) cases. MRI outperformed mammography in all subgroups. Substantial to near-perfect inter-rater agreement observed. Over 10 years, no deaths occurred in chest radiation group, with no significant survival difference between gene mutation and familial risk groups, HR = 0.93 (95% CI: 0.27, 3.26), P = .92. Conclusion: The study highlights the importance of age and specific tumour characteristics in identifying high-risk breast cancer subgroups. MRI is confirmed as an effective screening tool. Despite the aggressive nature of cancers in gene mutation carriers, early detection is crucial for survival outcomes. These insights, while necessitating further validation with larger studies, advocate for a move toward personalized medical care, strengthening the existing healthcare guidelines.

Fertility Preservation in BRCA1/2 Germline Mutation Carriers: An Overview

BRCA1 and BRCA2 mutations are responsible for a higher incidence of breast and ovarian cancer (from 55% up to 70% vs. 12% in the general population). If their functions have been widely investigated in the onset of these malignancies, still little is known about their role in fertility impairment. Cancer patients treated with antineoplastic drugs can be susceptible to their gonadotoxicity and, in women, some of them can induce apoptotic program in premature ovarian follicles, progressive depletion of ovarian reserve and, consequently, cancer treatment-related infertility (CTRI). BRCA variants seem to be associated with early infertility, thus accelerating treatment impairment of ovaries and making women face the concrete possibility of an early pregnancy. In this regard, fertility preservation (FP) procedures should be discussed in oncofertility counseling-from the first line of prevention with risk-reducing salpingo-oophorectomy (RRSO) to the new experimental ovarian stem cells (OSCs) model as a new way to obtain in vitro-differentiated oocytes, several techniques may represent a valid option to BRCA-mutated patients. In this review, we revisit knowledge about BRCA involvement in lower fertility, pregnancy feasibility, and the fertility preservation (FP) options available.

BRCA testing and management of BRCA-mutated early-stage breast cancer: a comprehensive statement by expert group from GCC region

BReast CAncer (BRCA)1 and BRCA2 gene pathogenic variants account for most hereditary breast cancers (BC). Identification of BRCA mutations can significantly influence both prognosis and treatment outcomes. Furthermore, it enables the identification of individuals who are at heightened risk of developing BC due to inherited genetic mutations. Many developing countries rely on western guidelines for BRCA testing and BC management; however, there exist wide disparities in the prevalence of risk factors, availability of medical resources, and practice patterns. Guidelines tailored to specific regions can help mitigate healthcare variations, promote consistency in treatment, and aid healthcare providers in identifying effective therapies for improving patient outcomes. Hence, oncologists from the Gulf Cooperation Council (GCC) congregated virtually in March 2023 and reviewed existing data on the epidemiology of BC, BRCA mutations, practices and challenges associated with BRCA testing and management of BRCA mutated early-stage BC in the GCC region. They also provided insights on the real-world diagnostic and treatment practices and challenges in the GCC region in the BRCA-mutated early-stage BC domain and suggested some variations to international guidelines to aid their uptake in this region.

MRI Surveillance and Breast Cancer Mortality in Women With BRCA1 and BRCA2 Sequence Variations

Importance

Magnetic resonance imaging (MRI) surveillance is offered to women with a pathogenic variant in the BRCA1 or BRCA2 gene who face a high lifetime risk of breast cancer. Surveillance with MRI is effective in downstaging breast cancers, but the association of MRI surveillance with mortality risk has not been well defined.

Objective

To compare breast cancer mortality rates in women with a BRCA1 or BRCA2 sequence variation who entered an MRI surveillance program with those who did not.

Design, Setting, and Participants

Women with a BRCA1 or BRCA2 sequence variation were identified from 59 participating centers in 11 countries. Participants completed a baseline questionnaire between 1995 and 2015 and a follow-up questionnaire every 2 years to document screening histories, incident cancers, and vital status. Women who had breast cancer, a screening MRI examination, or bilateral mastectomy prior to enrollment were excluded. Participants were followed up from age 30 years (or the date of the baseline questionnaire, whichever was later) until age 75 years, the last follow-up, or death from breast cancer. Data were analyzed from January 1 to July 31, 2023.

Exposures

Entrance into an MRI surveillance program.

Main Outcomes and Measures

Cox proportional hazards modeling was used to estimate the hazard ratios (HRs) and 95% CIs for breast cancer mortality associated with MRI surveillance compared with no MRI surveillance using a time-dependent analysis.

Results

A total of 2488 women (mean [range] age at study entry 41.2 [30-69] years), with a sequence variation in the BRCA1 (n = 2004) or BRCA2 (n = 484) genes were included in the analysis. Of these participants, 1756 (70.6%) had at least 1 screening MRI examination and 732 women (29.4%) did not. After a mean follow-up of 9.2 years, 344 women (13.8%) developed breast cancer and 35 women (1.4%) died of breast cancer. The age-adjusted HRs for breast cancer mortality associated with entering an MRI surveillance program were 0.20 (95% CI, 0.10-0.43; P < .001) for women with BRCA1 sequence variations and 0.87 (95% CI, 0.10-17.25; P = .93) for women with BRCA2 sequence variations.

Conclusion and Relevance

Results of this cohort study suggest that among women with a BRCA1 sequence variation, MRI surveillance was associated with a significant reduction in breast cancer mortality compared with no MRI surveillance. Further studies of women with BRCA2 sequence variations are needed to ascertain these women obtain the same benefits associated with MRI surveillance.

MRI only detected lesions: Can contrast enhanced mammography guided biopsy be an alternative method: Initial clinical findings

OBJECTIVE

This study aims to analyze our initial findings regarding CEM-guided stereotactic vacuum-assisted biopsy for MRI-only detected lesions and compare biopsy times by MRI-guided biopsy.

MATERIALS AND METHODS

In this retrospective analysis, CEM-guided biopsies of MRI-only detected breast lesions from December 2021 to June 2023were included. Patient demographics, breast density, lesion size, background parenchymal enhancement on CEM, lesion positioning, procedure duration, and number of scout views were documented. Initially, seven patients had CEM imaging before biopsy; for later cases, CEM scout views were used for simultaneous lesion depiction and targeting.

RESULTS

Two cases were excluded from the initial 28 patients with 29 lesions resulting in a total of 27 lesions in 26 women (mean age:44.96 years). Lesion sizes ranged from 4.5 to 41 mm, with two as masses and the remaining as non-mass enhancements. Histopathological results identified nine malignancies (33.3 %, 9/27), including invasive cancers (55.6 %, 5/9) and DCIS (44.4 %, 4/9). The biopsy PPV rate was 33.3 %. Benign lesions comprised 66.7 %, with 22.2 % high-risk lesions. The biopsy success rate was 93.1 % (27/29), and minor complications occurred in seven cases (25.9 %, 7/27), mainly small hematomas and one vasovagal reaction (3.7 %, 1/27). Median number of scout views required was 2, with no significant differences between cases with or without prior CEM (P = 0.8). Median duration time for biopsy was 14 min, significantly shorter than MRI-guided bx at the same institution (P < 0.001) by 24 min with predominantly upright positioning of the patient (88.9 %) and horizontal approach of the needle (92.6 %).

CONCLUSION

This study showed that CEM-guided biopsy is a feasible and safe alternative method and a faster solution for MRI-only detected enhancing lesions and can be accurately performed without the need for prior CEM imaging.

The Japanese breast cancer society clinical practice guidelines for breast cancer screening and diagnosis, 2022 edition

This article provides updates to readers based on the newly published Japanese Breast Cancer Society Clinical Practice Guidelines for Breast Cancer Screening and Diagnosis, 2022 Edition. These guidelines incorporate the latest evaluation of evidence from studies of diagnostic accuracy. For each clinical question, outcomes for benefits and harms were established, and qualitative or quantitative systematic reviews were conducted. Recommendations were determined through voting by a multidisciplinary group, and guidelines were documented to facilitate shared decision-making among patients and medical professionals. The guidelines address screening, surveillance, and pre- and postoperative diagnosis of breast cancer. In an environment that demands an integrated approach, decisions are needed on how to utilize modalities, such as mammography, ultrasound, MRI, and PET/CT. Additionally, it is vital to understand the appropriate use of new technologies, such as tomosynthesis, elastography, and contrast-enhanced ultrasound, and to consider how best to adapt these methods for individual patients.

Risk-reducing mastectomy and breast cancer mortality in women with a BRCA1 or BRCA2 pathogenic variant: an international analysis

BACKGROUND

Risk-reducing mastectomy (RRM) is offered to women with a BRCA1 or BRCA2 pathogenic variant, however, there are limited data on the impact on breast cancer mortality.

METHODS

Participants were identified from a registry of women with BRCA1/2 pathogenic variants. We used a pseudo-randomised trial design and matched one woman with a RRM to one woman without a RRM on year of birth, gene, and country. We estimated the hazard ratio (HR) and 95% confidence intervals (CI) for dying of breast cancer in the follow-up period.

RESULTS

There were 1654 women included; 827 assigned to the RRM arm and 827 assigned to the control arm. After a mean follow-up of 6.3 years, there were 20 incident breast cancers (including 15 occult cancers) and two breast cancer deaths in the RRM arm, and 100 incident breast cancers and 7 breast cancer deaths in the control arm (HR = 0.26; 95% CI 0.05-1.35; p = 0.11). The probability of dying of breast cancer within 15 years after RRM was 0.95%.

CONCLUSIONS

In women with a BRCA1 or BRCA2 pathogenic variant, RRM reduces the risk of breast cancer, and the probability of dying of breast cancer is low.

Outcomes of High-Risk Breast MRI Screening in Women Without Prior History of Breast Cancer: Effectiveness Data from a Tertiary Care Center

OBJECTIVE

To evaluate the diagnostic performance outcomes of a breast MRI screening program in high-risk women without prior history of breast cancer.

METHODS

Retrospective cohort study of 1 405 consecutive screening breast MRI examinations in 681 asymptomatic women with high risk of breast cancer without prior history of breast cancer from January 1, 2015, to December 31, 2019. Outcomes (sensitivity, specificity, positive predictive value, negative predictive value, false-negative rate [FNR], cancer detection rate [CDR]) and characteristics of cancers were determined based on histopathology or 12-month follow-up. MRI examinations performed, BI-RADS assessments, pathology outcomes, and CDRs were analyzed overall and by age decade. Results in incidence screening round (MRI in last 18 months) and nonincidence round were compared.

RESULTS

Breast MRI achieved CDR 20/1000, sensitivity 93.3% (28/30), and specificity 83.4% (1 147/1375). Twenty-eight (28/1 405, CDR 20/1000) screen-detected cancers were identified: 18 (64.3%, 18/28) invasive and 10 (35.7%, 10/28) ductal carcinoma in situ. Overall, 92.9% (26/28) of all cancers were stage 0 or 1 and 89.3% (25/28) were node negative. All 14 incidence screening round malignancies were stage 0 or 1 with N0 disease. Median size for invasive carcinoma was 8.0 mm and for ductal carcinoma in situ was 9.0 mm. There were two false-negative exams for an FNR 0.1% (2/1 405).

CONCLUSION

High-risk screening breast MRI was effective at detecting early breast cancer and associated with favorable outcomes.

Screening in Women With BRCA Mutations Revisited

Patients with BRCA1 or BRCA2 gene mutations are at high risk for the development of breast cancer. This article reviews the current evidence for breast cancer screening of patients with BRCA1 or BRCA2 pathogenic gene mutations if they have not undergone prophylactic mastectomy. It will review the current evidence-based imaging recommendations for different modalities and ages of screening initiation in screening this patient population at high risk. Special considerations in transgender BRCA1 and BRCA2 mutation carriers are also discussed.

Psychosocial outcomes after varying risk management strategies in women at increased familial breast cancer risk: a mixed methods study of patient and partner outcomes

INTRODUCTION

Female carriers of BRCA1/2 genes have an increased lifetime risk of breast cancer. Options for managing risk include imaging surveillance or risk-reducing surgery (RRS). This mixed methods study aimed to identify factors affecting risk-management decisions and the psychosocial outcomes of these decisions for high-risk women and their partners.

METHODS

Semi-structured qualitative interviews were performed with women at high breast cancer risk who had faced these choices. Partners were also interviewed. Analysis used a framework approach. A bespoke questionnaire was developed to quantify and explore associations.

RESULTS

A total of 32 women were interviewed. Of these, 27 had partners of whom 7 (26%) agreed to be interviewed. Four main themes arose: perception of risk and impact of increased risk; risk-management strategy decision-making; impact of risk-management strategy; support needs and partner relationship issues. The questionnaire response rate was 36/157 (23%). Decision satisfaction was high in both surveillance and RRS groups. Relationship changes were common but not universal. Common causes of distress following RRS included adverse body image changes. Both groups experienced generalised and cancer-specific anxiety. Drivers for surgery included having children, deaths of close family from breast cancer and higher levels of cancer anxiety.

CONCLUSIONS

Levels of psychosocial and decision satisfaction were high for women choosing both RRS and surveillance but, for a minority, risk-reducing measures result in long-term psychosocial morbidity. Efforts to recognise women at increased risk of psychological morbidity may allow targeted support.

The Accuracy of Breast Cancer Diagnostic Tools

Background Breast cancer (BC) remains a significant health concern, leading to illness and death among women globally. It is essential to detect BC early using imaging techniques that accurately reflect the final pathology, guiding suitable intervention strategies. Objectives This study aimed to evaluate the agreement between radiological findings and histopathological results in BC cases. Methods We conducted a retrospective review of breast core needle biopsies (CNBs) in women over a six-year period (2017-2022) at Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia. The pathological diagnoses were compared with the findings from preceding radiological investigations. We also compared the tumour sizes in the resection specimens with their radiological counterparts. Results A total of 641 cases were included in the study. Ultrasound (US), mammography, and magnetic resonance imaging (MRI) yielded diagnostic accuracies of 85%, 77.9%, and 86.9%, respectively. MRI had the highest sensitivity at 72.2%, while US had the lowest at 61%. MRI provided the best agreement with the final resected tumor size. By contrast, mammography tended to overestimate the size (41.9%), and US most frequently underestimated it (67.7%). The connection between basal-like molecular subtypes and the Breast Imaging Reporting and Data System (BIRADS)-5 classifications was only statistically significant for MRI (p = 0.04). The luminal subtype was more likely to show speculation in mammography. Meanwhile, BIRADS-4 revealed a considerable number of benign pathologies across all the three modalities. Conclusions MRI demonstrated the highest accuracy, sensitivity, specificity, and positive predictive value (PPV) for diagnosing and estimating the tumor size. Mammography outperformed US in terms of sensitivity and yielded the highest negative predictive value (NPV). US, meanwhile, offered superior specificity, PPV, and accuracy. Therefore, combining these diagnostic methods could yield significant benefits.

Economic evaluation of breast MRI in screening - a systematic review and basic approach to cost-effectiveness analyses

Background

Economic evaluations have become an accepted methodology for decision makers to allocate resources in healthcare systems. Particularly in screening, where short-term costs are associated with long-term benefits, and adverse effects of screening intermingle, cost-effectiveness analyses provide a means to estimate the economic value of screening.

Purpose

To introduce the methodology of economic evaluations and to review the existing evidence on cost-effectiveness of MR-based breast cancer screening.

Materials and methods

The various concepts and techniques of economic evaluations critical to the interpretation of cost-effectiveness analyses are briefly introduced. In a systematic review of the literature, economic evaluations from the years 2000-2022 are reviewed.

Results

Despite a considerable heterogeneity in the reported input variables, outcome categories and methodological approaches, cost-effectiveness analyses report favorably on the economic value of breast MRI screening for different risk groups, including both short- and long-term costs and outcomes.

Conclusion

Economic evaluations indicate a strongly favorable economic value of breast MRI screening for women at high risk and for women with dense breast tissue.

Comparative Analysis of Diagnostic Performance of Automatic Breast Ultrasound, Full-Field Digital Mammography and Contrast-Enhanced Mammography in Relation to Breast Composition

This single center study includes a comparative analysis of the diagnostic performance of full-field digital mammography (FFDM), contrast-enhanced mammography (CEM) and automatic breast ultrasound (ABUS) in the group of patients with breast American College of Radiology (ACR) categories C and D as well as A and B with FFDM. The study involved 297 patients who underwent ABUS and FFDM. Breast types C and D were determined in 40% of patients with FFDM and low- energy CEM. CEM was performed on 76 patients. Focal lesions were found in 131 patients, of which 115 were histopathologically verified. The number of lesions detected in patients with multiple lesions were 40 from 48 with ABUS, 13 with FFDM and 21 with CEM. Compliance in determining the number of foci was 82% for FFDM and 91% for both CEM and ABUS. In breast types C and D, 72% of all lesions were found with ABUS, 56% with CEM and 29% with FFDM (p = 0.008, p = 0.000); all invasive cancers were diagnosed with ABUS, 83% with CEM and 59% with FFDM (p = 0.000, p = 0.023); 100% DCIS were diagnosed with ABUS, 93% with CEM and 59% with FFDM. The size of lesions from histopathology in breast ACR categories A and B was 14-26 mm, while in breast categories C and D was 11-37 mm. In breast categories C and D, sensitivity of ABUS, FFDM and CEM was, respectively, 78.05, 85.37, 92.68; specificity: 40, 13.33, 8.33; PPV (positive predictive value): 78.05, 72.92, 77.55; NPV (negative predictive value): 40, 25, 25, accuracy: 67.86, 66.07, 73.58. In breast categories A and B, sensitivity of ABUS, FFDM and CEM was, respectively, 81.25, 93.75, 93.48; specificity: 18.18, 18.18, 16.67; PPV: 81.25, 83.33, 89.58; NPV: 18.18, 40, 25; accuracy: 69.49, 79.66, 84.62. The sensitivity of the combination of FFDM and ABUS was 100 for all types of breast categories; the accuracy was 75 in breast types C and D and 81.36 in breast types A and B. The study confirms the predominance of C and D breast anatomy types and the low diagnostic performance of FFDM within that group and indicates ABUS and CEM as potential additive methods in breast cancer diagnostics.

Young Women with Breast Cancer: The Current Role of Precision Oncology

Young adults aged 40 years and younger with breast cancer represent less than 5% of all breast cancer cases, yet it is the leading cause of death among young women with cancer worldwide. Breast cancer that develops at a young age is more aggressive and has biological features that carry an increased risk of relapse and death. Young adults are more likely to have a genetic predisposition and key biomarkers, including endocrine receptors, the HER2 receptor, and proliferation biomarkers, that appear different compared to older adults. Despite being more aggressive, management strategies are largely the same irrespective of age. Given the higher rates of genetic predisposition, fast access to genetic counselling and testing is a necessity. In this review, the biological differences in young adult breast cancer and the current role precision medicine holds in the treatment of young adults with breast cancer are explored. Given the relatively high risk of relapse, developing novel genomic tools to refine the treatment options beyond the current standard is critical. Existing predictive genomic tests require careful interpretation with consideration of the patient's clinical and pathological features in the young patient cohort. Careful evaluation is also required when considering extended endocrine therapy options. Improved characterization of mutations occurring in tumors using next-generation sequencing could identify important driver mutations that arise in young women. Applying the advances of precision medicine equitably to patients in resource-rich and low- and middle-income countries will be critical to impacting the survival of young adults with breast cancer worldwide.

Clinical and imaging modality factors impacting radiological interpretation of breast screening in young women with neurofibromatosis type 1

Young women with Neurofibromatosis type 1 (NF1) have a high risk of developing breast cancer and poorer survival following breast cancer diagnosis. International guidelines recommend commencing breast screening between 30 and 35 years; however, the optimal screening modality is unestablished, and previous reports suggest that breast imaging may be complicated by the presence of intramammary and cutaneous neurofibromas (cNFs). The aim of this study was to explore potential barriers to implementation of breast screening for young women with NF1.Twenty-seven women (30-47 years) with NF1 completed breast screening with breast MRI, mammogram and breast ultrasound. Nineteen probably benign/suspicious lesions were detected across 14 women. Despite the presence of breast cNFs, initial biopsy rate for participants with NF1 (37%), were comparable to a BRCA pathogenic variant (PV) cohort (25%) (P = 0.311). No cancers or intramammary neurofibromas were identified. Most participants (89%) returned for second round screening.The presence of cNF did not affect clinician confidence in 3D mammogram interpretation, although increasing breast density, frequently seen in young women, impeded confidence for 2D and 3D mammogram. Moderate or marked background parenchymal enhancement on MRI was higher in the NF1 cohort (70.4%) than BRCA PV carriers (47.3%), which is an independent risk factor for breast cancer.Breast MRI was the preferred mode of screening over mammogram, as the majority (85%) with NF1 demonstrated breast density (BI-RADS 3C/4D), which hinders mammogram interpretation. For those with high breast density and high cNF breast coverage, 3D rather than 2D mammogram is preferred, if MRI is unavailable.

Diagnostic accuracy of intravoxel incoherent motion (IVIM) and dynamic contrast-enhanced (DCE) MRI to differentiate benign from malignant breast lesions: A systematic review and meta-analysis

PURPOSE

Magnetic resonance imaging (MRI) can reduce the need for unnecessary invasive diagnostic tests by nearly half. In this meta-analysis, we investigated the diagnostic accuracy of intravoxel incoherent motion modeling (IVIM) and dynamic contrast-enhanced (DCE) MRI in differentiating benign from malignant breast lesions.

METHOD

We systematically searched PubMed, EMBASE, and Scopus. We included English articles reporting diagnostic accuracy for both sequences in differentiating benign from malignant breast lesions. Articles were assessed by quality assessment of diagnostic accuracy studies-2 (QUADAS-2) questionnaire. We used a bivariate effects model for standardized mean difference (SMD) analysis and diagnostic test accuracy analysis.

RESULTS

Ten studies with 537 patients and 707 (435 malignant and 272 benign) lesions were included. The D, f, Ktrans, and Kep mean values significantly differ between benign and malignant lesions. The pooled sensitivity (95 % confidence interval) and specificity were 86.2 % (77.9 %-91.7 %) and 70.3 % (56.5 %-81.1 %) for IVIM, and 93.8 % (85.3 %-97.5 %) and 68.1 % (52.7 %-80.4 %) for DCE, respectively. Combined IVIM and DCE depicted the highest area under the curve of 0.94, with a sensitivity and specificity of 91.8 % (82.8 %-96.3 %) and 87.6 % (73.8 %-94.7 %), respectively.

CONCLUSIONS

Combined IVIM and DCE had the highest diagnostic accuracy, and multiparametric MRI may help reduce unnecessary benign breast biopsy.

Defining features of hereditary lobular breast cancer due to CDH1 with magnetic resonance imaging and tumor characteristics

Women with germline pathogenic variants in CDH1, which encodes E-cadherin protein, are at increased lifetime risk of invasive lobular carcinoma (ILC). The associated tumor characteristics of hereditary lobular breast carcinoma (HLBC) in this high-risk population are not well-known. A single-center prospective cohort study was conducted to determine the imaging and pathologic features of HLBC compared to population-based ILC using Surveillance, Epidemiology, and End Results (SEER) data. One hundred fifty-eight women with CDH1 variants were evaluated, of whom 48 (30%) also had an ILC diagnosis. The median age at CDH1 diagnosis was 45 years [interquartile range, IQR 34-57 years] whereas the median age at diagnosis of CDH1 with concomitant ILC (HLBC) was 53 [IQR 45-62] years. Among women with HLBC, 83% (40/48) were identified with CDH1 mutation after diagnosis of ILC. Among 76 women (48%, 76/158) undergoing surveillance for ILC with breast magnetic resonance imaging (MRI), 29% (22/76) had an abnormal MRI result with available biopsy data for comparison. MRI detected ILC in 7 out of 8 biopsy-confirmed cases, corresponding with high sensitivity (88%), specificity (75%), and negative predictive value (98%); however, false-positive and false-discovery rates were elevated also (25% and 68%, respectively). HLBC was most frequently diagnosed at age 40-49 years (44%, 21/48), significantly younger than the common age of diagnosis of ILC in SEER general population data (most frequent age range 60-69 years, 28%; p < 0.001). HLBC tumors were smaller than SEER-documented ILC tumors (median 1.40 vs. 2.00 cm; p = 0.002) and had a higher incidence of background lobular carcinoma in situ (88% vs. 1%; p < 0.001) as well as progesterone receptor positivity (95% vs. 81%, p = 0.032). These findings suggest that HLBC is often detected via conventional screening methods as an early-stage hormone receptor-positive tumor, thus the clinical benefit of intensive screening with MRI may be limited to a subset of women with germline CDH1 variants.

Comparison of the Diagnostic Accuracy of Mammogram-based Deep Learning and Traditional Breast Cancer Risk Models in Patients Who Underwent Supplemental Screening with MRI

Background Access to supplemental screening breast MRI is determined using traditional risk models, which are limited by modest predictive accuracy. Purpose To compare the diagnostic accuracy of a mammogram-based deep learning (DL) risk assessment model to that of traditional breast cancer risk models in patients who underwent supplemental screening with MRI. Materials and Methods This retrospective study included consecutive patients undergoing breast cancer screening MRI from September 2017 to September 2020 at four facilities. Risk was assessed using the Tyrer-Cuzick (TC) and National Cancer Institute Breast Cancer Risk Assessment Tool (BCRAT) 5-year and lifetime models as well as a DL 5-year model that generated a risk score based on the most recent screening mammogram. A risk score of 1.67% or higher defined increased risk for traditional 5-year models, a risk score of 20% or higher defined high risk for traditional lifetime models, and absolute scores of 2.3 or higher and 6.6 or higher defined increased and high risk, respectively, for the DL model. Model accuracy metrics including cancer detection rate (CDR) and positive predictive values (PPVs) (PPV of abnormal findings at screening [PPV1], PPV of biopsies recommended [PPV2], and PPV of biopsies performed [PPV3]) were compared using logistic regression models. Results This study included 2168 women who underwent 4247 high-risk screening MRI examinations (median age, 54 years [IQR, 48-60 years]). CDR (per 1000 examinations) was higher in patients at high risk according to the DL model (20.6 [95% CI: 11.8, 35.6]) than according to the TC (6.0 [95% CI: 2.9, 12.3]; P < .01) and BCRAT (6.8 [95% CI: 2.9, 15.8]; P = .04) lifetime models. PPV1, PPV2, and PPV3 were higher in patients identified as high risk by the DL model (PPV1, 14.6%; PPV2, 32.4%; PPV3, 36.4%) than those identified as high risk with the TC (PPV1, 5.0%; PPV2, 12.7%; PPV3, 13.5%; P value range, .02-.03) and BCRAT (PPV1, 5.5%; PPV2, 11.1%; PPV3, 12.5%; P value range, .02-.05) lifetime models. Conclusion Patients identified as high risk by a mammogram-based DL risk assessment model showed higher CDR at breast screening MRI than patients identified as high risk with traditional risk models. © RSNA, 2023 Supplemental material is available for this article. See also the editorial by Bae in this issue.

Artificial intelligence to support person-centred care in breast imaging - A scoping review

AIM

To overview Artificial Intelligence (AI) developments and applications in breast imaging (BI) focused on providing person-centred care in diagnosis and treatment for breast pathologies.

METHODS

The scoping review was conducted in accordance with the Joanna Briggs Institute methodology. The search was conducted on MEDLINE, Embase, CINAHL, Web of science, IEEE explore and arxiv during July 2022 and included only studies published after 2016, in French and English. Combination of keywords and Medical Subject Headings terms (MeSH) related to breast imaging and AI were used. No keywords or MeSH terms related to patients, or the person-centred care (PCC) concept were included. Three independent reviewers screened all abstracts and titles, and all eligible full-text publications during a second stage.

RESULTS

3417 results were identified by the search and 106 studies were included for meeting all criteria. Six themes relating to the AI-enabled PCC in BI were identified: individualised risk prediction/growth and prediction/false negative reduction (44.3%), treatment assessment (32.1%), tumour type prediction (11.3%), unnecessary biopsies reduction (5.7%), patients' preferences (2.8%) and other issues (3.8%). The main BI modalities explored in the included studies were magnetic resonance imaging (MRI) (31.1%), mammography (27.4%) and ultrasound (23.6%). The studies were predominantly retrospective, and some variations (age range, data source, race, medical imaging) were present in the datasets used.

CONCLUSIONS

The AI tools for person-centred care are mainly designed for risk and cancer prediction and disease management to identify the most suitable treatment. However, further studies are needed for image acquisition optimisation for different patient groups, improvement and customisation of patient experience and for communicating to patients the options and pathways of disease management.

Breast Cancer Screening for Women at Higher-Than-Average Risk: Updated Recommendations From the ACR

Early detection decreases breast cancer death. The ACR recommends annual screening beginning at age 40 for women of average risk and earlier and/or more intensive screening for women at higher-than-average risk. For most women at higher-than-average risk, the supplemental screening method of choice is breast MRI. Women with genetics-based increased risk, those with a calculated lifetime risk of 20% or more, and those exposed to chest radiation at young ages are recommended to undergo MRI surveillance starting at ages 25 to 30 and annual mammography (with a variable starting age between 25 and 40, depending on the type of risk). Mutation carriers can delay mammographic screening until age 40 if annual screening breast MRI is performed as recommended. Women diagnosed with breast cancer before age 50 or with personal histories of breast cancer and dense breasts should undergo annual supplemental breast MRI. Others with personal histories, and those with atypia at biopsy, should strongly consider MRI screening, especially if other risk factors are present. For women with dense breasts who desire supplemental screening, breast MRI is recommended. For those who qualify for but cannot undergo breast MRI, contrast-enhanced mammography or ultrasound could be considered. All women should undergo risk assessment by age 25, especially Black women and women of Ashkenazi Jewish heritage, so that those at higher-than-average risk can be identified and appropriate screening initiated.

Analytic Hierarchy Process Analysis of Patient Preferences for Contrast-Enhanced Mammography Versus MRI as Supplemental Screening Options for Breast Cancer

OBJECTIVE

To guide implementation of supplemental breast screening by assessing patient preferences for contrast-enhanced mammography (CEM) versus MRI using analytic hierarchy process (AHP) methodology.

METHODS

In an institutional review board-approved, HIPAA-compliant protocol, from March 23 to June 3, 2022, we contacted 579 women who had both CEM screening and MRI. Women were e-mailed an invitation to complete an online survey developed using an AHP-based model to elicit preferences for CEM or MRI. Methods for categorical data analysis were used to evaluate factors affecting preferences, under the Bonferroni correction for multiplicity.

RESULTS

Complete responses were received from 222 (38.3%) women; the 189 women with a personal history of breast cancer had a mean age 61.8 years, and the 34 women without a personal history of breast cancer had a mean age of 53.6 years. Of 222 respondents, 157 (70.7%, confidence interval [CI]: 64.7-76.7) were determined to prefer CEM to MRI. Breast positioning was the most important criterion for 74 of 222 (33.3%) respondents, with claustrophobia, intravenous line placement, and overall stress most important for 38, 37, and 39 women (17.1%, 16.7%, and 17.6%), respectively, and noise level, contrast injection, and indifference being emphasized least frequently (by 10 [4.5%], 11 [5.0%], and 13 [5.9%] women, respectively). CEM preference was most prevalent (MRI least prevalent) for respondents emphasizing claustrophobia (37 of 38 [97%], CI: 86.2-99.9); CEM preference was least prevalent (MRI most prevalent) for respondents emphasizing breast positioning (40 of 74 [54%], CI: 42.1-65.7).

CONCLUSIONS

AHP-based modeling reveals strong patient preferences for CEM over MRI, with claustrophobia favoring preference for CEM and breast positioning relatively favoring preference for MRI. Our results should help guide implementation of screening CEM and MRI.

Predictors of nonadherence to breast cancer screening guidelines in a United States urban comprehensive cancer center

BACKGROUND

This study aimed to identify predictors of nonadherence to breast cancer screening guidelines in an urban screening clinic among high- and average-risk women in the United States.

METHODS

We reviewed records of 6090 women who received ≥2 screening mammograms over 2 years at the Karmanos Cancer Institute to examine how breast cancer risk and breast density were associated with guideline-concordant screening. Incongruent screening was defined as receiving supplemental imaging between screening mammograms for average-risk women, and as not receiving recommended supplemental imaging for high-risk women. We used t-tests and chi-square tests to examine bivariate associations with guideline-congruent screening, and probit regression to regress guideline-congruence unto breast cancer risk, breast density, and their interaction, controlling for age and race.

RESULTS

Incongruent screening was more likely among high- versus average-risk women (97.7% vs. 0.9%, p < 0.01). Among average-risk women, incongruent screening was more likely among those with dense versus nondense breasts (2.0% vs. 0.1%, p < 0.01). Among high-risk women, incongruent screening was more likely among those with nondense versus dense breasts (99.5% vs. 95.2%, p < 0.01). The significant main effects of density and high-risk on increased incongruent screening were qualified by a density by high-risk interaction, showing a weaker association between risk and incongruent screening among women with dense breasts (simple slope = 3.71, p < 0.01) versus nondense breasts (simple slope = 5.79, p < 0.01). Age and race were not associated with incongruent screening.

CONCLUSIONS

Lack of adherence to evidence-based screening guidelines has led to underutilization of supplementary imaging for high-risk women and potential overutilization for women with dense breasts without other risk factors.

An Unenhanced Breast MRI Protocol Based on Diffusion-Weighted Imaging: A Retrospective Single-Center Study on High-Risk Population for Breast Cancer

PURPOSE

This study aimed to investigate the use of contrast-free magnetic resonance imaging (MRI) as an innovative screening method for detecting breast cancer in high-risk asymptomatic women. Specifically, the researchers evaluated the diagnostic performance of diffusion-weighted imaging (DWI) in this population.

METHODS

MR images from asymptomatic women, carriers of a germline mutation in either the BRCA1 or BRCA2 gene, collected in a single center from January 2019 to December 2021 were retrospectively evaluated. A radiologist with experience in breast imaging (R1) and a radiology resident (R2) independently evaluated DWI/ADC maps and, in case of doubts, T2-WI. The standard of reference was the pathological diagnosis through biopsy or surgery, or ≥1 year of clinical and radiological follow-up. Diagnostic performances were calculated for both readers with a 95% confidence interval (CI). The agreement was assessed using Cohen's kappa (κ) statistics.

RESULTS

Out of 313 women, 145 women were included (49.5 ± 12 years), totaling 344 breast MRIs with DWI/ADC maps. The per-exam cancer prevalence was 11/344 (3.2%). The sensitivity was 8/11 (73%; 95% CI: 46-99%) for R1 and 7/11 (64%; 95% CI: 35-92%) for R2. The specificity was 301/333 (90%; 95% CI: 87-94%) for both readers. The diagnostic accuracy was 90% for both readers. R1 recalled 40/344 exams (11.6%) and R2 recalled 39/344 exams (11.3%). Inter-reader reproducibility between readers was in moderate agreement (κ = 0.43).

CONCLUSIONS

In female carriers of a BRCA1/2 mutation, breast DWI supplemented with T2-WI allowed breast cancer detection with high sensitivity and specificity by a radiologist with extensive experience in breast imaging, which is comparable to other screening tests. The findings suggest that DWI and T2-WI have the potential to serve as a stand-alone method for unenhanced breast MRI screening in a selected population, opening up new perspectives for prospective trials.

Clinicopathological and ultrasound characteristics of breast cancer in BRCA1 and BRCA2 mutation carriers

PURPOSE

BRCA1 and BRCA2 tumors exhibit different characteristics. This study aimed to assess and compare the ultrasound findings and pathologic features of BRCA1 and BRCA2 breast cancers. To our knowledge, this is the first study to examine the mass formation, vascularity, and elasticity in breast cancers of BRCA-positive Japanese women.

METHODS

We identified patients with breast cancer harboring BRCA1 or BRCA2 mutations. After excluding patients who underwent chemotherapy or surgery before the ultrasound, we evaluated 89 cancers in BRCA1-positive and 83 in BRCA2-positive patients. The ultrasound images were reviewed by three radiologists in consensus. Imaging features, including vascularity and elasticity, were assessed. Pathological data, including tumor subtypes, were reviewed.

RESULTS

Significant differences in tumor morphology, peripheral features, posterior echoes, echogenic foci, and vascularity were observed between BRCA1 and BRCA2 tumors. BRCA1 breast cancers tended to be posteriorly accentuating and hypervascular. In contrast, BRCA2 tumors were less likely to form masses. In cases where a tumor formed a mass, it tended to show posterior attenuation, indistinct margins, and echogenic foci. In pathological comparisons, BRCA1 cancers tended to be triple-negative subtypes. In contrast, BRCA2 cancers tended to be luminal or luminal-human epidermal growth factor receptor 2 subtypes.

CONCLUSION

In the surveillance of BRCA mutation carriers, radiologists should be aware that the morphological differences between tumors are quite different between BRCA1 and BRCA2 patients.

Comprehensive Care of Women With Genetic Predisposition to Breast and Ovarian Cancer

Women at risk for hereditary breast and ovarian cancer syndromes are frequently seen in primary care and gynecology clinics. They present with a distinctive set of clinical and emotional needs that revolve around complex risk management discussions and decision making. The care of these women calls for the creation of individualized care plans that facilitate adjustment to the mental and physical changes associated with their choices. This article provides an update on comprehensive evidence-driven care of women with hereditary breast and ovarian cancer. The aim of this review is to aid clinicians in identifying those at risk for hereditary cancer syndromes and provide practical advice on patient-centered medical and surgical risk management. Topics of discussion include enhanced surveillance, preventive medications, risk-reducing mastectomy and reconstruction, risk-reducing bilateral salpingo-oophorectomy, fertility, sexuality, and menopausal management, with attention to the importance of psychological support. High-risk patients may benefit from a multidisciplinary team that provides realistic expectations with consistent messaging. The primary care provider must be aware of the special needs of these patients and the consequences of their risk management interventions.

Counselling of path_BRCA carriers who are considering risk-reducing oophorectomy

path_BRCA 1/2 increases a woman's lifetime risk of breast and ovarian cancer. Interventions can be offered which manage cancer risk; annual breast screening from age 30, chemoprevention and, once a woman's family is complete, risk-reducing surgery. The latter is the most effective method of reducing cancer in path_BRCA carriers; salpingo-oophorectomy reduces breast and ovarian cancer, respectively, by up to 50% and 95%. Factors affecting a woman's decision to undergo risk-reducing surgery are complex; dominant factors include risks of surgery, effect on cancer outcomes and menopausal sequelae. Specific information relating to hormone replacement and non-hormonal alternatives are an important consideration for women but, are often overlooked. Informative counselling is required to enable satisfaction with the chosen intervention whilst improving survival outcomes. This review paper outlines the current data pertaining to these decision-making factors and provides a proforma to enable effective counselling.

Challenges and Changes of the Breast Cancer Screening Paradigm

Since four decades mammography is used for early breast cancer detection in asymptomatic women and still remains the gold standard imaging modality. However, population screening programs can be personalized and women can be divided into different groups based on risk factors and personal preferences. The availability of new and evolving imaging modalities, for example, digital breast tomosynthesis, dynamic-contrast-enhanced magnetic resonance imaging (MRI), abbreviated MRI protocols, diffusion-weighted MRI, and contrast-enhanced mammography leads to new challenges and perspectives regarding the feasibility and potential harms of breast cancer screening. The aim of this review is to discuss the current guidelines for different risk groups, to analyze the recent published studies about the diagnostic performance of the imaging modalities and to discuss new developments and future perspectives. LEVEL OF EVIDENCE: 1 TECHNICAL EFFICACY: Stage 6.

Supplemental Breast Cancer Screening in Women with Dense Breasts and Negative Mammography: A Systematic Review and Meta-Analysis

Background The best supplemental breast cancer screening modality in women at average risk or intermediate risk for breast cancer with dense breast and negative mammogram remains to be determined. Purpose To conduct systematic review and meta-analysis comparing clinical outcomes of the most common available supplemental screening modalities in women at average risk or intermediate risk for breast cancer in patients with dense breasts and mammography with negative findings. Materials and Methods A comprehensive search was conducted until March 12, 2020, in Medline, Epub Ahead of Print and In-Process and Other Non-Indexed Citations; Embase Classic and Embase; Cochrane Central Register of Controlled Trials; and Cochrane Database of Systematic Reviews, for Randomized Controlled Trials and Prospective Observational Studies. Incremental cancer detection rate (CDR); positive predictive value of recall (PPV1); positive predictive value of biopsies performed (PPV3); and interval CDRs of supplemental imaging modalities, digital breast tomosynthesis, handheld US, automated breast US, and MRI in non-high-risk patients with dense breasts and mammography negative for cancer were reviewed. Data metrics and risk of bias were assessed. Random-effects meta-analysis and two-sided metaregression analyses comparing each imaging modality metrics were performed (PROSPERO; CRD42018080402). Results Twenty-two studies reporting 261 233 screened patients were included. Of 132 166 screened patients with dense breast and mammography negative for cancer who met inclusion criteria, a total of 541 cancers missed at mammography were detected with these supplemental modalities. Metaregression models showed that MRI was superior to other supplemental modalities in CDR (incremental CDR, 1.52 per 1000 screenings; 95% CI: 0.74, 2.33; P < .001), including invasive CDR (invasive CDR, 1.31 per 1000 screenings; 95% CI: 0.57, 2.06; P < .001), and in situ disease (rate of ductal carcinoma in situ, 1.91 per 1000 screenings; 95% CI: 0.10, 3.72; P < .04). No differences in PPV1 and PPV3 were identified. The limited number of studies prevented assessment of interval cancer metrics. Excluding MRI, no statistically significant difference in any metrics were identified among the remaining imaging modalities. Conclusion The pooled data showed that MRI was the best supplemental imaging modality in women at average risk or intermediate risk for breast cancer with dense breasts and mammography negative for cancer. © RSNA, 2023 Supplemental material is available for this article. See also the editorial by Hooley and Butler in this issue.

Clinicopathological and imaging features of ductal carcinoma in situ in BRCA1/2 mutation carriers

BACKGROUND

BRCA1/2-associated invasive breast cancer has been extensively studied. However, there are few reports of ductal carcinoma in situ (DCIS).

OBJECTIVE

This study aimed to investigate the clinicopathological and imaging findings of DCIS in patients with BRCA1/2 mutations.

METHODS

This was a single-institution, retrospective study. We identified patients diagnosed with DCIS with BRCA mutations between September 2003 and December 2020. Clinicopathological data and mammography (MG), magnetic resonance imaging (MRI), and ultrasound (US) findings were reviewed.

RESULTS

We identified 30 cancers in 28 patients; 7 (25.0%) patients had BRCA1 mutations, and 21 (75.0%) had BRCA2 mutations. The median patient age was 42 years. Screening was the most common reason for the detection of DCIS (50.0%), followed by occult cancer diagnosed by pathological examination after risk-reducing mastectomy (26.7%). The nuclear grade was most often 1 (46.7%), and 93.3% were estrogen and/or progesterone receptor positive. The detection rates of MG, MRI, and US were 64.3%, 72.0%, and 64.0%, respectively. The most common imaging findings were calcification (100%) on MG, non-mass enhancement (88.9%) on MRI, and hypoechoic area (75.0%) on US.

CONCLUSION

BRCA-associated DCIS was more strongly associated with BRCA2, and imaging features were similar to those of sporadic DCIS. Our results are helpful in informing surveillance strategies based on genotypes in women with BRCA mutations.

Health Benefits and Cost-Effectiveness of Children's Oncology Group Breast Cancer Screening Guidelines for Chest-Irradiated Hodgkin Lymphoma Survivors

PURPOSE

To evaluate the outcomes and cost-effectiveness of the Children's Oncology Group Guideline recommendation for breast cancer (BC) screening using mammography (MAM) and breast magnetic resonance imaging (MRI) in female chest-irradiated childhood Hodgkin lymphoma (HL) survivors. Digital breast tomosynthesis (DBT), increasingly replacing MAM in practice, was also examined.

METHODS

Life years (LYs), quality-adjusted LYs (QALYs), BC mortality, health care costs, and false-positive screen frequencies of undergoing annual MAM, DBT, MRI, MAM + MRI, and DBT + MRI from age 25 to 74 years were estimated by microsimulation. BC risks and non-BC mortality were estimated from female 5-year survivors of HL in the Childhood Cancer Survivor Study and the US population. Test performance of MAM and MRI was synthesized from HL studies, and that of DBT from the general population. Costs (2017 US dollars [USD]) and utility weights were obtained from the medical literature. Incremental cost-effectiveness ratios (ICERs) were calculated.

RESULTS

With 100% screening adherence, annual BC screening extended LYs by 0.34-0.46 years over no screening. If the willingness-to-pay threshold to gain a quality-adjusted LY was ICER < $100,000 USD, annual MAM at age 25-74 years was the only cost-effective strategy. When nonadherence was taken into consideration, only annual MAM at age 30-74 years (ICER = $56,972 USD) was cost-effective. Supplementing annual MAM with MRI costing $545 USD was not cost-effective under either adherence condition. If MRI costs were reduced to $300 USD, adding MRI to annual MAM at age 30-74 years could become more cost-effective, particularly in the reduced adherence condition (ICER = $133,682 USD).

CONCLUSION

Annual BC screening using MAM at age 30-74 years is effective and cost-effective in female chest-irradiated HL survivors. Although annual adjunct MRI is not cost-effective at $545 USD cost, it could become cost-effective as MRI cost is reduced, a plausible scenario with the emergent use of abbreviated MRI.

Screening MRI Does Not Increase Cancer Detection or Result in an Earlier Stage at Diagnosis for Patients with High-Risk Breast Lesions: A Propensity Score Analysis

BACKGROUND

Guidelines recommend consideration of screening MRI for patients with high-risk breast lesions (HRLs), acknowledging limited data for this moderate-risk population.

METHODS

This study identified patients with atypical ductal/lobular hyperplasia (ADH/ALH), lobular carcinoma in situ, (LCIS) or both evaluated at our high-risk clinic. Patients were categorized as having received screening mammography (MMG) alone vs. MMG and breast MRI (MMG+MRI). Inverse probability weighting based on propensity scores (PS) representing likelihood of MRI use was applied to Kaplan-Meier and Cox regression analyses to determine cancer detection and biopsy rates by screening group.

RESULTS

Among 908 eligible patients, 699 (77%) patients with available follow-up data were analyzed (542 with ADH/ALH and 157 with LCIS). Of the 699 patients, 540 (77%) received MMG alone, and 159 (23%) received MMG + MRI. The median follow-up period was 25 months, during which a median of two MRIs were performed. After PS-weighting, the characteristics of each screening group were well-balanced with respect to age, race, body mass index (BMI), menopausal status, breast density, family history, HRL type, and chemoprevention use. The 4 year breast cancer detection rate was 3.6% with both MMG alone and MMG+MRI (p = 0.89). The breast biopsy rates were significantly higher with MMG+MRI (30.5% vs12.6%; hazard ratio [HR], 2.67; p < 0.001). All breast cancers were clinically node-negative and pathologic stage 0 or 1. Among five cancers in the MMG+MRI group, two were MRI-detected, two were MMG-detected, and one was detected on clinical exam.

CONCLUSIONS

Screening MRI did not improve cancer detection, and cancer characteristics were favorable whether screened with MMG alone or MMG + MRI. These findings question the benefit of MRI for patients with HRL, although longer-term follow-up study is needed.

Comprehensive clinical characterization of patients with BRCA1: c.5017_5019del germline variant

Purpose

We provide evidence for the reclassification of the BRCA1:c.5017_5019del variant by presenting the clinicopathological characteristics, clinical outcomes, and family history of breast or ovarian cancer in 17 patients with this variant.

Methods

This study included breast or ovarian cancer patients tested for BRCA1/2 genes between January 2008 and June 2020 at 10 medical centers in Korea. We retrospectively reviewed 17 probands from 15 families who had the BRCA1:c.5017_5019del variant according to the electronic medical records.

Results

We present 10 breast cancer patients and 7 ovarian cancer patients from 15 families identified as having BRCA1:c.5017_5019del and a total of 19 cases of breast cancer and 14 cases of ovarian cancer in these families. The ratio of breast-to-ovarian cancer was 1.3:1. Breast cancer patients with this variant showed a rich family history of breast or ovarian cancer, 8 patients (80.0%). The mean age at diagnosis was 45.4 years and 6 patients (60.0%) were categorized into hormone-receptor-negative breast cancer. Also, the ovarian cancer patients with this variant showed strong family histories of breast and/or ovarian cancer in 4 patients (57.1%).

Conclusion

We presented clinical evidence for the reclassification of BRCA1:c.5017_5019del as a likely pathogenic variant (LPV). Reclassification as LPV could result in the prophylactic treatment and medical surveillance of probands, family testing recommendations, and appropriate genetic counseling of their families.

High Risk Breast Cancer Screening is a Double Edged Sword: A Qualitative Study of Patient Perspectives on the Ontario High Risk Breast Cancer Screening Program

BACKGROUND

MRI-based breast cancer screening for high-risk women has been associated with false positives. This study explored the benefits and drawbacks of MRI-based screening using in-depth patient interviews.

METHODS

This was a qualitative study of interviews with women participating in the High Risk Ontario Breast Screening Program. Women enrolled at two centers who had completed at least one round of screening were invited to participate. Recruitment was suspended when thematic saturation was reached. Semi-structured telephone interviews were conducted and transcribed verbatim. Emergent themes were identified and a coding framework established.

RESULTS

21 women (median age 41 years) participated in telephone interviews. Women had been in the program a median of 4 years (IQR 1-5), and 71% had experienced at least one abnormal screen. Eight participants (38%) had undergone biopsies. Six women (29%) were BRCA mutation carriers. MRIs were described as intimidating, uncomfortable, and claustrophobic. Participants were concerned about long-term exposure to gadolinium contrast. Compared to MRI, mammography alone was viewed as painful, less sensitive, and a "useless…waste of time." MRI provided a "psychological safety net" that outweighed the distress associated with abnormal screens. Many women accepted this trade-off as a "two-edged sword" that was "worth it" and provided a sense of control. Suggestions for improvement included more information regarding the risks of MRI, and access to counselling.

CONCLUSIONS

Women participating in MRI-based screening strongly value reassurance from a highly sensitive screening test. This outweighed the distress of abnormal screens. There are areas for improvement around patient communication and psychosocial support.

MRI Breast: Current Imaging Trends, Clinical Applications, and Future Research Directions

Magnetic Resonance Imaging (MRI) is the most sensitive and advanced imaging technique in diagnosing breast cancer and is essential in improving cancer detection, lesion characterization, and determining therapy response. In addition to the dynamic contrast-enhanced (DCE) technique, functional techniques such as magnetic resonance spectroscopy (MRS), diffusion-weighted imaging (DWI), diffusion kurtosis imaging (DKI), and intravoxel incoherent motion (IVIM) further characterize and differentiate benign and malignant lesions thus, improving diagnostic accuracy. There is now an increasing clinical usage of MRI breast, including screening in high risk and supplementary screening tools in average-risk patients. MRI is becoming imperative in assisting breast surgeons in planning breast-conserving surgery for preoperative local staging and evaluation of neoadjuvant chemotherapy response. Other clinical applications for MRI breast include occult breast cancer detection, investigation of nipple discharge, and breast implant assessment. There is now an abundance of research publications on MRI Breast with several areas that still remain to be explored. This review gives a comprehensive overview of the clinical trends of MRI breast with emphasis on imaging features and interpretation using conventional and advanced techniques. In addition, future research areas in MRI breast include developing techniques to make MRI more accessible and costeffective for screening. The abbreviated MRI breast procedure and an area of focused research in the enhancement of radiologists' work with artificial intelligence have high impact for the future in MRI Breast.

Ductal Carcinoma In Situ (DCIS) Diagnosed by MRI-Guided Biopsy among BRCA1/BRCA2 Mutation Carriers

Background

While BRCA1/BRCA2 pathogenic sequence variants (PSVs) clearly confer an increased risk for invasive breast cancer, the extent to which these mutant alleles increase DCIS risk is less clear.

Objective

To assess the rate of detection over a 5-year period, and MRI imaging features of pure noncalcified DCIS in a cohort of Israeli BRCA1/BRCA2 PSV carriers attending a high-risk clinic from 2015 to 2020.

Materials and Methods

All female BRCA1/BRCA2 PSV-carriers followed at the Meirav High-risk clinic from 2015 to 2020 were eligible if they underwent semiannual breast imaging (MRI/mammography) and MRI-guided biopsy-proven pure DCIS. Clinical data, pathology information, and imaging characteristics were retrieved from the computerized archiving system.

Results

18/121 (15.2%) participating BRCA1 PSV carriers and 8/81 (10.1%) BRCA2 PSV-carriers who underwent MRI-guided biopsy were diagnosed with DCIS. The median age of BRCA1 carriers and BRCA2 carriers was 49.8 years and 60.6 years, respectively (p = 0.55). Negative estrogen-receptor tumors were diagnosed in 13/18 (72%) BRCA1 and 2/8 (25%) BRCA2 PSV carriers (p < 0.05). Thirteen (13/18–72%) BRCA1 carriers had intermediate to high-grade or high-grade DCIS compared with 4/8 (50%) of BRCA2 carriers (p = 0.03). Over the 5-year study period, 29/1100 (2.6%) BRCA1/BRCA2 PSV carriers were diagnosed with DCIS seen on MRI only.

Conclusion

MRI-detected noncalcified DCIS is more frequent in BRCA1 PSV carriers compared with BRCA2 carriers, unlike the BRCA2 predominance in mammography-detected calcified DCIS. BRCA1-related DCIS is diagnosed earlier, more likely to be estrogen receptor-negative and of higher grade compared with BRCA2-related DCIS. Future prospective studies should validate these results and assess the actual impact they might have on clinical management of BRCA PSV carriers.

From the patient to the population: Use of genomics for population screening

Genomic medicine is expanding from a focus on diagnosis at the patient level to prevention at the population level given the ongoing under-ascertainment of high-risk and actionable genetic conditions using current strategies, particularly hereditary breast and ovarian cancer (HBOC), Lynch Syndrome (LS) and familial hypercholesterolemia (FH). The availability of large-scale next-generation sequencing strategies and preventive options for these conditions makes it increasingly feasible to screen pre-symptomatic individuals through public health-based approaches, rather than restricting testing to high-risk groups. This raises anew, and with urgency, questions about the limits of screening as well as the moral authority and capacity to screen for genetic conditions at a population level. We aimed to answer some of these critical questions by using the WHO Wilson and Jungner criteria to guide a synthesis of current evidence on population genomic screening for HBOC, LS, and FH.

Comparison of Abbreviated Breast MRI vs Digital Breast Tomosynthesis for Breast Cancer Detection among Women with a History of Breast Cancer

RATIONALE AND OBJECTIVES

To compare the diagnostic performance of abbreviated breast MRI (AB-MRI) and digital breast tomosynthesis (DBT) in women with a personal history (PH) of breast cancer as a postoperative screening tool.

MATERIALS AND METHODS

A total of 471 patients who completed both DBT and AB-MRI examinations were included in this study (median age, 54.5 years). The detected cancer characteristics were analyzed. The cancer detection rate (CDR), sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), accuracy, and area under the curve (AUC) were calculated by receiver operating characteristic (ROC) curve analysis.

RESULTS

Eleven malignancies were diagnosed, and most of the detected cancers were stage I (7 of 11, 63.6%). Eight were invasive ductal carcinomas (IDC), and 3 were ductal carcinoma in situ (DCIS). Of the 11 recurrences, 6 malignancies were detected by DBT, and 11 were detected by AB-MRI. AB-MRI detected all 8 IDC and 3 DCIS lesions, and DBT detected 6 of 8 IDC lesions. The CDRs for DBT and AB-MRI screenings were 12.7 and 23.4 per 1,000 women, respectively. The sensitivity, specificity, PPV, NPV, and accuracy of DBT versus AB-MRI were 54.6% versus 100%, 97.6% versus 96.5%, 35.3% versus 40.7%, 98.9% versus 100%, and 96.6% versus 96.6%, respectively. AB-MRI showed a higher AUC value (0.983) than DBT (0.761) (p = 0.0049).

CONCLUSION

AB-MRI showed an improved CDR, especially for invasive cancer. The diagnostic performance of AB-MRI was superior to that of DBT with high sensitivity and PPV without sacrificing specificity in women with a PH of breast cancer.

Controversies and Open Questions in Management of Cancer-Free Carriers of Germline Pathogenic Variants in BRCA1/BRCA2

Females harboring germline BRCA1/BRCA2 (BRCA) P/LPV are offered a tight surveillance scheme from the age of 25−30 years, aimed at early detection of specific cancer types, in addition to risk-reducing strategies. Multiple national and international surveillance guidelines have been published and updated over the last two decades from geographically diverse countries. We searched for guidelines published between 1 January 2015 and 1 May 2022. Differences between guidelines on issues such as primary prevention, mammography screening in young (<30 years) carriers, MRI screening in carriers above age 65 years, breast imaging (if any) after risk-reducing bilateral mastectomy, during pregnancy, and breastfeeding, and hormone-replacement therapy, are just a few notable examples. Beyond formal guidelines, BRCA carriers’ concerns also focus on the timing of risk-reducing surgeries, fertility preservation, management of menopausal symptoms in cancer survivors, and pancreatic cancer surveillance, issues that, for some, there are no data to support evidence-based recommendations. This review discusses these unsettled issues, emphasizing the importance of future studies to enable global guideline harmonization for optimal surveillance strategies. Moreover, it raises the unmet need for personalized risk stratification and surveillance in BRCA P/LPV carriers.

Breast cancer detection by analyzing the volatile organic compound (VOC) signature in human urine

A rising number of authors are drawing evidence on the diagnostic capacity of specific volatile organic compounds (VOCs) resulting from some body fluids. While cancer incidence in society is on the rise, it becomes clear that the analysis of these VOCs can yield new strategies to mitigate advanced cancer incidence rates. This paper presents the methodology implemented to test whether a device consisting of an electronic nose inspired by a dog’s olfactory system and olfactory neurons is significantly informative to detect breast cancer (BC). To test this device, 90 human urine samples were collected from control subjects and BC patients at a hospital. To test this system, an artificial intelligence-based classification algorithm was developed. The algorithm was firstly trained and tested with data resulting from gas chromatography-mass spectrometry (GC–MS) urine readings, leading to a classification rate of 92.31%, sensitivity of 100.00%, and specificity of 85.71% (N = 90). Secondly, the same algorithm was trained and tested with data obtained with our eNose prototype hardware, and class prediction was achieved with a classification rate of 75%, sensitivity of 100%, and specificity of 50%.

Clinical Impact of Pathogenic Variants in DNA Damage Repair Genes beyond BRCA1 and BRCA2 in Breast and Ovarian Cancer Patients

Simple Summary

The clinical utility of positive findings in DNA damage-repair (DDR) genes BRCA1 and BRCA2 for the treatment of patients with breast or ovarian cancer is well established. However, multigene panel genetic testing for patients with breast and ovarian cancer now commonly includes DDR genes in addition to BRCA1 and BRCA2, a number of which are considered moderate or low-risk genes. This study aimed to describe the clinical utility of positive results from genetic testing when the findings were in one of these other DDR genes. In a group of 101 women with positive findings in a cancer gene other than BRCA1 or BRCA2 (often in a DDR gene), nearly three-fifths (58%) had a clinical recommendation made based on their positive genetic test result and two-thirds (65%) had the clinician make recommendations for family members that may be at risk. This real-world data provides evidence that positive findings from genetic testing for moderate and low-risk genes, including DDR genes, can have clinical utility and can impact a patient’s clinical management.

Abstract

Consensus guidelines for hereditary breast and ovarian cancer include management recommendations for pathogenic/likely pathogenic (P/LP) variants in ATM, CHEK2, PALB2, and other DNA damage repair (DDR) genes beyond BRCA1 or BRCA2. We report on clinical management decisions across three academic medical centers resulting from P/LP findings in DDR genes in breast/ovarian cancer patients. Among 2184 patients, 156 (7.1%) carried a P/LP variant in a DDR gene. Clinical follow-up information was available for 101/156 (64.7%) patients. Genetic test result-based management recommendations were made for 57.8% (n = 59) of patients and for 64.7% (n = 66) of patients’ family members. Most recommendations were made for moderate-to-high risk genes and were consistent with guidelines. Sixty-six percent of patients (n = 39/59) implemented recommendations. This study suggests that P/LP variants in DDR genes beyond BRCA1 and BRCA2 can change clinical management recommendations for patients and their family members, facilitate identification of new at-risk carriers, and impact treatment decisions. Additional efforts are needed to improve the implementation rates of genetic-testing-based management recommendations for patients and their family members.

Contralateral Breast Screening with Preoperative MRI: Long-Term Outcomes for Newly Diagnosed Breast Cancer

Background The diagnostic value of screening the contralateral breast with MRI in patients with newly diagnosed breast cancer is poorly understood. Purpose To assess the impact of MRI for screening the contralateral breast on long-term outcomes in patients with newly diagnosed breast cancer and to determine whether subgroups with unfavorable prognoses would benefit from MRI in terms of survival. Materials and Methods Data on consecutive patients with newly diagnosed breast cancer seen from January 2008 to December 2010 were reviewed retrospectively. Patients with neoadjuvant chemotherapy, previous breast cancer, distant metastasis, absence of contralateral mammography at diagnosis, and no planned surgical treatment were excluded. Groups that did and did not undergo preoperative MRI were compared. Survival analysis was performed using the Kaplan-Meier method for propensity score-matched groups to estimate cause-specific survival (CSS) and overall survival (OS). A marginal Cox proportional hazards model was used to evaluate association of MRI and clinicopathologic variables with OS. Results Of 1846 patients, 1199 fulfilled the inclusion criteria. Median follow-up time was 10 years (range, 0-14 years). The 2:1 matched sample comprised 705 patients (470 in the MRI group and 235 in the no-MRI group); median ages at surgery were 59 years (range, 31-87 years) and 64 years (range, 37-92 years), respectively. MRI depicted contralateral synchronous disease more frequently (27 of 470 patients [5.7%] vs five of 235 patients [2.1%]; P = .047) and was associated with a higher OS (hazard ratio [HR], 2.51; 95% CI: 1.25, 5.06; P = .01). No differences were observed between groups in metachronous disease rate (MRI group: 21 of 470 patients [4.5%]; no-MRI group: 10 of 235 patients [4.3%]; P > .99) or CSS (HR, 1.34; 95% CI: 0.56, 3.21; P = .51). MRI benefit was greater in patients with larger tumor sizes (>2 cm) (HR, 2.58; 95% CI: 1.11, 5.99; P = .03) and histologic grade III tumors (HR, 2.94; 95% CI: 1.18, 7.32; P = .02). Conclusion Routine MRI screening of the contralateral breast after first diagnosis of breast cancer improved overall survival; the most pronounced benefit was found in patients with larger primary tumor size and primary tumors of histologic grade III. © RSNA, 2022 Online supplemental material is available for this article. See also the editorial by Taourel in this issue.

Multiparametric Magnetic Resonance Imaging in Evaluation of Benign and Malignant Breast Masses with Pathological Correlation

Background

Dynamic contrast-enhanced (DCE) MRI sequences plays a vital role in diagnosing breast masses with high sensitivity and specificity as compared to other diagnostic modalities. The addition of diffusion-weighted imaging (DWI) and apparent diffusion coefficient (ADC) values significantly improves diagnostic accuracy. This study aimed to study the breast masses on DCE-MRI, restricted diffusion on DWI, ADC values, and choline peak on spectroscopy in breast cancer diagnosis.

Material and methods

This study was a prospective observational study which involved subjects with breast lumps. Baseline data was collected from the patients along with pertinent clinical history and relevant laboratory investigations. MR mammography (MRM) was performed on a 1.5 Tesla MR Scanner (MAGNETOM® Avanto, Siemens AG, Munich Germany) using a dedicated double breast coil.

Results

Forty-one subjects were included with a total of 54 breast masses in them. The mean age of the study population was 47.1±14.7 years. From the MRI final diagnosis, the majority (53.70%) were diagnosed as malignant lesions and 46.30% as benign. Out of 20 lesions diagnosed as benign on histopathology, only five percent had ADC value <1.3 ×10⁻³mm²/s, and the majority (95%) had ADC value >1.3 ×10⁻³mm²/s. All 20 lesions were circumscribed, ovoid, or round in shape showing no restricted diffusion on DWI, with corresponding ADC value of >1.3×10⁻³mm²/s, homogeneous post-contrast enhancement, or with dark internal septations, type I kinetic enhancement curve, and they showed no choline peak on spectroscopy. Out of 34 malignant lesions diagnosed on histopathology, the majority (85.29%) displayed restricted diffusion on DWI and had an ADC value of <1.3×10⁻³mm²/s, most of them had spiculated margins, type II/ III kinetic curve with choline peak on spectroscopy.

Conclusion

Multiparametric MR mammography, which included DCE-MRM, DWI, ADC values, and spectroscopy, correlated well with the histopathological diagnosis of benign and malignant breast masses.

Missed Breast Cancers on MRI in High-Risk Patients: A Retrospective Case–Control Study

Purpose: To determine if MRI features and molecular subtype influence the detectability of breast cancers on MRI in high-risk patients. Methods and Materials: Breast cancers in a high-risk population of 104 patients were diagnosed following MRI describing a BI-RADS 4–5 lesion. MRI characteristics at the time of diagnosis were compared with previous MRI, where a BI-RADS 1–2–3 lesion was described. Results: There were 77 false-negative MRIs. A total of 51 cancers were overlooked and 26 were misinterpreted. There was no association found between MRI characteristics, the receptor type and the frequency of missed cancers. The main factors for misinterpreted lesions were multiple breast lesions, prior biopsy/surgery and long-term stability. Lesions were mostly overlooked because of their small size and high background parenchymal enhancement. Among missed lesions, 50% of those with plateau kinetics on initial MRI changed for washout kinetics, and 65% of initially progressively enhancing lesions then showed plateau or washout kinetics. There were more basal-like tumours in BRCA1 carriers (50%) than in non-carriers (13%), p = 0.0001, OR = 6.714, 95% CI = [2.058–21.910]. The proportion of missed cancers was lower in BRCA carriers (59%) versus non-carriers (79%), p < 0.05, OR = 2.621, 95% CI = [1.02–6.74]. Conclusions: MRI characteristics or molecular subtype do not influence breast cancer detectability. Lesions in a post-surgical breast should be assessed with caution. Long-term stability does not rule out malignancy and multimodality evaluation is of added value. Lowering the biopsy threshold for lesions with an interval change in kinetics for a type 2 or 3 curve should be considered. There was a higher rate of interval cancers in BRCA 1 patients attributed to lesions more aggressive in nature.

Radiologist-Level Performance by Using Deep Learning for Segmentation of Breast Cancers on MRI Scans

Purpose

To develop a deep network architecture that would achieve fully automated radiologist-level segmentation of cancers at breast MRI.

Materials and Methods

In this retrospective study, 38 229 examinations (composed of 64 063 individual breast scans from 14 475 patients) were performed in female patients (age range, 12–94 years; mean age, 52 years ± 10 [standard deviation]) who presented between 2002 and 2014 at a single clinical site. A total of 2555 breast cancers were selected that had been segmented on two-dimensional (2D) images by radiologists, as well as 60 108 benign breasts that served as examples of noncancerous tissue; all these were used for model training. For testing, an additional 250 breast cancers were segmented independently on 2D images by four radiologists. Authors selected among several three-dimensional (3D) deep convolutional neural network architectures, input modalities, and harmonization methods. The outcome measure was the Dice score for 2D segmentation, which was compared between the network and radiologists by using the Wilcoxon signed rank test and the two one-sided test procedure.

Results

The highest-performing network on the training set was a 3D U-Net with dynamic contrast-enhanced MRI as input and with intensity normalized for each examination. In the test set, the median Dice score of this network was 0.77 (interquartile range, 0.26). The performance of the network was equivalent to that of the radiologists (two one-sided test procedures with radiologist performance of 0.69–0.84 as equivalence bounds, P < .001 for both; n = 250).

Conclusion

When trained on a sufficiently large dataset, the developed 3D U-Net performed as well as fellowship-trained radiologists in detailed 2D segmentation of breast cancers at routine clinical MRI.

Keywords: MRI, Breast, Segmentation, Supervised Learning, Convolutional Neural Network (CNN), Deep Learning Algorithms, Machine Learning Algorithms

Published under a CC BY 4.0 license.

Supplemental material is available for this article.

MRI Screening of BRCA Mutation Carriers: Comparison of Standard Protocol and Abbreviated Protocols With and Without T2-Weighted Images

Background: Increasing evidence supports the role of abbreviated MRI protocols for breast cancer detection. However, abbreviated protocols have been poorly studied in patients who are BRCA1 or BRCA2 mutation carriers. Further, the need for T2-weighted (T2W) sequences in abbreviated protocols remains controversial. Objective: To compare the diagnostic performance of a standard full breast MRI protocol and of abbreviated protocols with and without inclusion of the T2W sequence in patients with BRCA mutations. Methods: This retrospective study included a total of 292 patients (mean age, 47.9 years) who were BRCA1 or BRCA2 mutation carriers and who underwent a total of 427 screening breast MRI examinations using a standard full protocol that could be classified as having benign (n=407) or malignant (n=20) findings based on histopathology or imaging follow-up. Four readers independently assessed examinations in three separate sessions [theoretical abbreviated protocol (which included the first postcontrast acquisition), theoretical abbreviated protocol with addition of T2W sequence, and the standard full protocol], assigning BI-RADS categories. Categories of 3-5 were considered to represent positive examinations. Interreader agreement was assessed, and diagnostic performance was compared using pooled reader data. Results: Interreader agreement for BI-RADS category, expressed as kappa, was 0.55 for standard, 0.45 for abbreviated, and 0.57 for abbreviated+T2. Pooled sensitivity was 94% for standard, 92% for abbreviated, and 90% for abbreviated+T2 (all p>.001). Pooled specificity was 80% for standard, 71% for abbreviated, and 83% for abbreviated+ T2 (p<.001 for abbreviated+T2 compared with both standard and abbreviated). Pooled PPV was 19% for standard, 14% for abbreviated, and 20% for abbreviated+T2 (p<.001 for abbreviated compared with both standard and abbreviated). Pooled NPV was 100% for standard, 99% for abbreviated, and 99% for abbreviated+T2 (all p>.001). Pooled accuracy was 80% for standard, 73% for abbreviated, and 83% for abbreviated+T2 (p<.001 for abbreviated compared with both standard and abbreviated+T2). Conclusion: The abbreviated protocol without T2W images had suboptimal performance. However, addition of T2W sequence yielded comparable sensitivity and accuracy, and small increase in specificity, compared with the full protocol. Clinical Impact: The findings support implementation of abbreviated MRI with T2W imaging for breast cancer screening in patients with BRCA mutations.

Comparing breast cancer imaging characteristics of CHEK2 with BRCA1 and BRCA2 gene mutation carriers

PURPOSE

Breast cancer gene (BRCA) 1 and 2 mutations are frequently studied gene mutations (GM); the incidence of checkpoint kinase 2 (CHEK2) is increasing. We describe the imaging features of breast cancer (BC) in CHEK2 mutations, compared to BRCA 1 and 2 using mammography, ultrasound (US) and magnetic resonance imaging (MRI).

METHOD

Inclusion criteria were primary BC in GM carriers, treated in the same hospital. Age at diagnosis, histology, hormone receptor and human epidermal growth factor receptor 2 (HER2) status were retrieved. Mammography descriptors were mass, asymmetry and suspicious microcalcifications. The enhancement pattern (MRI), shape and border, architectural distortion, the presence of a hyperechoic rim and cystic complex structure (US) were documented. Analyses were performed using SAS software (version 9.4). Fishers' exact test was used to test associations between two categorical variables.

RESULTS

In 191 women, 233 malignant lesions were diagnosed (78 in BRCA1, 109 in BRCA2, 46 in CHEK2). In CHEK2 carriers, mammographically, suspicious microcalcifications (54%) were more prevalent (BRCA2 (48%) and BRCA1 carriers (33%)) (p-value = 0.057) compared to mass lesions (35%). On US, lesions were most frequently ill-defined (86%) (p = 0.579) and irregular (94.5%) (p = 0.098) compared to BRCA2 (77% and 80% resp.) and BRCA1 carriers (71% and 72% resp.). On MRI, mass lesions showed a type 3 curve in CHEK2 (67%) compared to BRCA1 (36%) and BRCA2 (50%) (p = 0.056).

CONCLUSIONS

Malignant radiological characteristics of breast cancer, more specifically suspicious microcalcifications, were more frequently seen in CHEK2 and BRCA2 compared to BRCA1 mutation carriers (without a significant difference) indicating the importance of mammography in follow-up of CHEK2 carriers.