Current Breast Cancer Reports

, Volume 2, Issue 3, pp 159–165 | Cite as

Why Is Breast MRI so Controversial?

  • Basak E. DoganEmail author
  • Wei Tse Yang


Advances in dynamic contrast-enhanced (DCE) breast MRI over the past decade have led to significant improvements in the detection of early breast cancer and higher accuracy in the detection of multifocal and multicentric disease. This has resulted in the increased application of breast MRI in the diagnosis and management of breast cancer globally. Nonetheless, the true role of DCE breast MRI in the management of breast cancer patients remains controversial. This article discusses the strengths and limitations of DCE breast MRI by reviewing existing and emerging data from the past decade.


Breast cancer or neoplasm Magnetic resonance imaging Outcomes Breast conserving surgery 



No potential conflicts of interest relevant to this article have been reported.


Papers of particular interest, published recently have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Brekelmans CT, Seynaeve C, Bartels CC, et al.: Surveillance in BRCA1/2 gene mutation carriers and women with high familial risk. J Clin Oncol 2001, 19:924–930.PubMedGoogle Scholar
  2. 2.
    Scheuer L, Kauff N, Robson M, et al.: Outcome of preventive surgery and screening for breast and ovarian cancer in BRCA mutation carriers. J Clin Oncol 2002, 20:1260–1268.CrossRefPubMedGoogle Scholar
  3. 3.
    Komenaka IK, Ditkoff B, Joseph K, et al.: The development of interval breast malignancies in patients with BRCA mutations. Cancer 2004, 100:2079–2083.CrossRefPubMedGoogle Scholar
  4. 4.
    Saslow D, Boetes C, Burke W, et al.: American Cancer Society guidelines for breast screening with MRI as an adjunct to mammography. CA Cancer J Clin 2007, 57:75–89.CrossRefPubMedGoogle Scholar
  5. 5.
    Murphy CD, Lee JM, Drohan B, et al.: The American Cancer Society guidelines for breast screening with magnetic resonance imaging: an argument for genetic testing. Cancer 2008, 113:3116–3120.CrossRefPubMedGoogle Scholar
  6. 6.
    Kriege M, Brekelmans CT, Boetes C, et al.: Efficacy of MRI and mammography for breast-cancer screening in women with a familial or genetic predisposition. N Engl J Med 2004, 351:427–437.CrossRefPubMedGoogle Scholar
  7. 7.
    Warner E, Plewes DB, Hill KA, et al.: Surveillance of BRCA1 and BRCA2 mutation carriers with magnetic resonance imaging, ultrasound, mammography, and clinical breast examination. JAMA 2004, 292:1317–1325.CrossRefPubMedGoogle Scholar
  8. 8.
    Lehman CD, Blume JD, Weatherall P, et al.: Screening women at high risk for breast cancer with mammography and magnetic resonance imaging. Cancer 2005, 103:1898–1905.CrossRefPubMedGoogle Scholar
  9. 9.
    Kuhl CK, Schrading S, Leutner CC, et al.: Mammography, breast ultrasound, and magnetic resonance imaging for surveillance of women at high familial risk for breast cancer. J Clin Oncol 2005, 23:8469–8476.CrossRefPubMedGoogle Scholar
  10. 10.
    Leach MO, Boggis CR, Dixon AK, et al.: Screening with magnetic resonance imaging and mammography of a UK population at high familial risk of breast cancer: a prospective multicentre cohort study (MARIBS). Lancet 2005, 365:1769–1778.CrossRefPubMedGoogle Scholar
  11. 11.
    •• Lehman CD, Isaacs C, Schnall MD, et al.: Cancer yield of mammography, MR, and US in high-risk women: prospective multi-institution breast cancer screening study. Radiology 2007, 244:381–388. In this prospective screening study that included 171 high-risk women, the authors demonstrated that screening MRI detected more breast cancers than either mammography or ultrasound, although it resulted in a high biopsy rate. Ultrasound had the highest false-negative rate among the three modalities.Google Scholar
  12. 12.
    Mirza NQ, Vlastos G, Meric F, et al.: Predictors of locoregional recurrence among patients with early-stage breast cancer treated with breast conserving therapy. Ann Surg Oncol 2002, 9:256–265.CrossRefPubMedGoogle Scholar
  13. 13.
    Park CC, Mitsumori M, Nixon A, et al.: Outcome at 8 years after breast conserving surgery and radiation therapy for invasive breast cancer: influence of margin status and systemic therapy on local recurrence. J Clin Oncol 2000, 18:1668–1675.PubMedGoogle Scholar
  14. 14.
    Smitt MC, Nowels KW, Zdeblick MJ, et al.: The importance of the lumpectomy surgical margin status in long-term results of breast conservation. Cancer 1995, 76:259–267.CrossRefPubMedGoogle Scholar
  15. 15.
    Weinstein SP, Orel SG, Heller R, et al.: MR imaging of the breast in patients with invasive lobular carcinoma. AJR Am J Roentgenol 2001, 176:399–406.PubMedGoogle Scholar
  16. 16.
    Schelfout K, Van Goethem M, Kersschot E: Preoperative breast MRI in patients with invasive lobular breast cancer. Eur Radiol 2004, 14:1209–1216.CrossRefPubMedGoogle Scholar
  17. 17.
    Mann RM, Veltman J, Barentsz JO, et al.: The value of MRI compared to mammography in the assessment of tumour extent in invasive lobular carcinoma of the breast. Eur J Surg Oncol 2008, 34:135–142.PubMedGoogle Scholar
  18. 18.
    • Mann RM, Loo CE, Wobbes T, et al.: The impact of preoperative breast MRI on the re-excision rate in invasive lobular carcinoma of the breast. Breast Cancer Res Treat 2010, 119:415–422. This retrospective cohort study that included 267 women showed a significantly lower (9%) re-excision rate following breast conserving surgery for patients who underwent initial staging MRI as opposed to those who underwent only conventional imaging (mammography and ultrasound). Furthermore, preoperative MRI was not associated with an increased rate of initial mastectomies.Google Scholar
  19. 19.
    • Kuhl CK, Schrading S, Bieling HB, et al.: MRI for diagnosis of pure ductal carcinoma in situ: a prospective observational study. Lancet 2007, 11:485–492. In this prospective study, the authors investigated the sensitivity of mammography and breast MRI for the detection of DCIS and compared the biological profiles of DCIS detected by each modality. Forty-two percent of DCIS lesions detected by MRI were mammographically occult, whereas only 12% of the mammographically detected cases were occult by MRI. Biological profiles of detected DCIS lesions did not differ between the two groups.Google Scholar
  20. 20.
    Jansen SA, Newstead GM, Abe H, et al.: Pure ductal carcinoma in situ: kinetic and morphologic MR characteristics compared with mammographic appearance and nuclear grade. Radiology 2007, 245:684–691.CrossRefPubMedGoogle Scholar
  21. 21.
    Marcotte-Bloch C, Balu-Maestro C, Chamorey E: MRI for the size assessment of pure ductal carcinoma in situ (DCIS): A prospective study of 33 patients. Eur J Radiol 2009 [Epub ahead of print].Google Scholar
  22. 22.
    Morris EA, Schwartz LH, Drotman MB, et al.: Evaluation of pectoralis major muscle in patients with posterior breast tumors on breast MR images: early experience. Radiology 2000, 214:67–72.PubMedGoogle Scholar
  23. 23.
    Kazama T, Nakamura S, Doi O, et al.: Prospective evaluation of pectoralis muscle invasion of breast cancer by MR imaging. Breast Cancer 2005, 12:312–316.CrossRefPubMedGoogle Scholar
  24. 24.
    Offersen BV, Overgaard M, Kroman N, et al.: Accelerated partial irradiation as part of breast conserving therapy of early breast carcinoma: a systematic review. Radiother Oncol 2009, 90:1–13.CrossRefPubMedGoogle Scholar
  25. 25.
    Al-Hallaq HA, Mell LK, Bradley JA, et al.: Magnetic resonance imaging correctly identifies multifocal and multicentric disease in breast cancer patients who are ineligible for partial breast irradiation. Cancer 2008, 113:2408–2414.CrossRefPubMedGoogle Scholar
  26. 26.
    Orel SG, Schnall MD, Powell CM, et al.: Staging of suspected breast cancer: effect of MR imaging and MR guided biopsy. Radiology 1995, 196:115–122.PubMedGoogle Scholar
  27. 27.
    Fischer U, Kopka L, Grabbe E: Breast carcinoma: effect of preoperative contrast-enhanced MR imaging on the therapeutic approach. Radiology 1999, 213:881–888.PubMedGoogle Scholar
  28. 28.
    Bedrosian I, Mick R, Orel SG, et al.: Changes in the surgical management of patients with breast carcinoma based on preoperative magnetic resonance imaging. Cancer 2003, 98:468–473.CrossRefPubMedGoogle Scholar
  29. 29.
    Tan JE, Orel SG, Schnall MD, et al.: Role of magnetic resonance imaging and magnetic resonance-imaging guided surgery in the evaluation of patients with early-stage breast cancer for breast conservation treatment. Am J Clin Oncol 1999, 22:414–418.CrossRefPubMedGoogle Scholar
  30. 30.
    Tillman GF, Orel SG, Schnall MD, et al.: Effect of breast magnetic resonance imaging on the clinical management of women with early-stage breast carcinoma. J Clin Oncol 2002, 20:3413–3423.CrossRefPubMedGoogle Scholar
  31. 31.
    Berg WA, Gutierrez L, NessAiver MS, et al.: Diagnostic accuracy of mammography, clinical examination, US and MR imaging in preoperative assessment of breast cancer. Radiology 2004, 233:830–849.CrossRefPubMedGoogle Scholar
  32. 32.
    Schelfout K, Van Goethem M, Kersschot E, et al.: Contrast-enhanced MR imaging of breast lesions and effect on treatment. Eur J Surg Oncol 2004, 30:501–507.CrossRefPubMedGoogle Scholar
  33. 33.
    • Houssami N, Ciatto S, Macaskill P, et al.: Accuracy and surgical impact of magnetic resonance imaging in breast cancer staging: systematic review and meta-analysis in detection of multifocal and multicentric cancer. J Clin Oncol 2008, 26:3248–3258. This meta-analysis of 19 studies on MRI staging of the affected breast in women with primary breast cancer showed that MRI detected additional disease in 16% of women with breast cancer and led to more extensive surgery in an important proportion of women by identifying additional foci of cancer not evident on conventional imaging and clinical examination.Google Scholar
  34. 34.
    Fischer U, Zachariae O, Baum F, et al.: The influence of preoperative MRI of the breasts on recurrence rate in patients with breast cancer. Eur Radiol 2004, 14:1725–1731.PubMedGoogle Scholar
  35. 35.
    •• Solin LJ, Orel SG, Hwang WT, et al.: Relationship of breast magnetic resonance imaging to outcome after breast conserving therapy with radiation for women with early stage breast carcinoma or ductal carcinoma in situ. J Clin Oncol 2008, 26:352–353. This single-center retrospective study of 756 patients with primary breast cancer scheduled for breast conserving therapy included 215 women who had breast MRI as part of their initial evaluation for primary breast cancer and 541 who did not. No benefit of MRI in reducing the local recurrence rate (extremely uncommon) and no difference in the incidence of contralateral breast cancer in the MRI and non-MRI groups was observed at 8 years.Google Scholar
  36. 36.
    Schaapveid M, Visser O, Louwman WJ, et al.: The impact of adjuvant therapy on contralateral breast cancer risk and the prognostic significance of contralateral breast cancer. A population based study in the Netherlands. Breast Cancer Res Treat 2008, 110:189–197.CrossRefGoogle Scholar
  37. 37.
    Montgomery DA, Krupa K, Jack WJL, et al.: Changing pattern of the detection of locoregional relapse in breast cancer: the Edinburgh experience. Br J Cancer 2007, 96:1802–1807.CrossRefPubMedGoogle Scholar
  38. 38.
    Carmichael AR, Bendall S, Lockerbie L, et al.: The long-term outcome of synchronous bilateral breast cancer is worse than metachronous or unilateral tumors. Eur J Surg Oncol 2002, 28:388–391.CrossRefPubMedGoogle Scholar
  39. 39.
    Lee SG, Orel SG, Woo IJ, et al.: MR imaging screening of the contralateral breast in patients with newly diagnosed breast cancer: preliminary results. Radiology 2003, 226:773–778.CrossRefPubMedGoogle Scholar
  40. 40.
    Lehman CD, Blume JD, Thickman D, et al.: Added cancer yield of MRI in screening the contralateral breast of women recently diagnosed with breast cancer: results from the International Breast Magnetic Resonance Consortium (IBMC) trial. J Surg Oncol 2005, 92:9–15.CrossRefPubMedGoogle Scholar
  41. 41.
    • Lehman CD, Gatsonis C, Kuhl CK, et al.: MRI evaluation of the contralateral breast in women with recently diagnosed breast cancer. N Engl J Med 2007, 356:1295–1303. The authors demonstrate that MRI can identify small cancers in the contralateral breast that are missed by mammography and clinical examination in 3.1% of the women at the time of the initial ipsilateral breast cancer diagnosis. MRI showed a high sensitivity (91%), specificity (88%), and negative-predictive value (99%) for the contralateral breast in patients with known ipsilateral breast cancer.Google Scholar
  42. 42.
    Renz DM, Böttcher J, Baltzer PA, et al.: The contralateral synchronous breast carcinoma: a comparison of histology, localization, and magnetic resonance imaging characteristics with the primary index cancer. Breast Cancer Res Treat. 2010 [Epub ahead of print].Google Scholar
  43. 43.
    • Brennan ME, Houssami N, Lord S, et al.: Magnetic resonance imaging screening of the contralateral breast in women with newly diagnosed breast cancer: systematic review and meta-analysis of incremental cancer detection and impact on surgical management. J Clin Oncol 2009, 27:5640–5649. A review of 22 studies reporting on contralateral MRI in women with newly diagnosed invasive breast cancer found MRI-only visible malignancies in 131 (4%) of 3253 women. The relatively high incremental cancer detection rate may reflect selection bias, and concerns regarding the potential harms of MRI screening leading to additional work-up and surgery without clear clinical benefit are raised, as MRI does not reliably differentiate benign from malignant lesions.Google Scholar
  44. 44.
    • Berg WA, Blume JD, Adams AM, et al.: Reasons women at elevated risk of breast cancer refuse Breast MR imaging screening: ACRIN 6666. Radiology 2010, 254:79–87. This study aims to determine the reasons for non-participation in a trial of supplemental MRI breast screening after mammography and ultrasound for women at increased risk of breast cancer who enrolled in the ACRIN 6666 ultrasound screening trial. Of 1215 women with analyzable data, only 57.9% of women agreed to participate in breast MRI screening. The primary reasons for non-participation in 512 women were claustrophobia (25.4%), time constraints (18.2%), and financial concerns (12.1%).Google Scholar
  45. 45.
    •• Turnbull L, Brown S, Harvey I, et al.: Comparative effectiveness of MRI in breast cancer (COMICE) trial: a randomised controlled trial. Lancet 2010, 375:563–571. This study was an open parallel trial with 45 participating centers in the United Kingdom that assessed the clinical efficacy of DCE MRI in 1623 women aged 18 years or older with primary breast cancer who were scheduled for wide local excision after triple assessment. The findings showed that the addition of MRI to conventional triple assessment did not significantly decrease the reoperation rate; 153 (19%) of 816 of the MRI group needed repeat surgery compared with 156 (19%) of 807 of the no-MRI group.Google Scholar
  46. 46.
    Morris EA: Should we dispense with preoperative breast MRI? Lancet 2010, 375:528–530.CrossRefPubMedGoogle Scholar
  47. 47.
    Partridge SC, Gibbs JE, Lu Y, et al.: MRI measurements of breast tumor volume predict response to neoadjuvant chemotherapy and recurrence-free survival. AJR Am J Roentgenol 2005, 184:1774–1781.PubMedGoogle Scholar
  48. 48.
    Padani AR, Hayes C, Assersohn L, et al.: Prediction of clinicopathological response of breast cancer to primary chemotherapy at contrast-enhanced MR imaging: initial clinical results. Radiology 2006, 239:361–374.CrossRefGoogle Scholar
  49. 49.
    Owen HW, Dockerty MB, Grey HK: Occult carcinoma of the breast. Surg Gynecol Obstet 1954, 98:302–308.PubMedGoogle Scholar
  50. 50.
    Baron PL, Moore MP, Kinne DW, et al.: Occult breast cancer presenting with axillary metastases. Arch Surg 1990, 125:210–214.PubMedGoogle Scholar
  51. 51.
    Jackson B, Scott-Conner C, Moulder J: Axillary metastasis from occult breast carcinoma: diagnosis and management. Am J Surg 1995, 61:431–434.Google Scholar
  52. 52.
    Obdeijn IM, Brouwers-Kuyper EM, Tilanus-Linthorst MM, et al.: MR imaging-guided sonography followed by fine-needle aspiration cytology in occult carcinoma of the breast. AJR Am J Roentgenol 2000, 174:1079–1084.PubMedGoogle Scholar
  53. 53.
    Olson JA Jr, Morris EA, Van Zee KJ, et al.: Magnetic resonance imaging facilitates breast conservation for occult breast cancer. Ann Surg Oncol 2000, 7:411–415.CrossRefPubMedGoogle Scholar
  54. 54.
    Orel SG, Weinstein SP, Schnall MD, et al.: Breast MR imaging in patients with axillary node metastases and unknown primary malignancy. Radiology 1999, 212:543–549.PubMedGoogle Scholar
  55. 55.
    McMahon K, Medoro L, Kennedy D: Breast magnetic resonance imaging: an essential role in malignant axillary lymphadenopathy of unknown origin. Aust Radiol 2005, 49:382–389.CrossRefGoogle Scholar
  56. 56.
    Bassett LW, Dhaliwal SG, Eradat J, et al.: National trends and practices in breast MRI. AJR Am J Roentgenol 2008, 191:332–339.CrossRefPubMedGoogle Scholar

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© Springer Science+Business Media, LLC 2010

Authors and Affiliations

  1. 1.Department of Diagnostic RadiologyThe University of Texas M.D. Anderson Cancer CenterHoustonUSA

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