Radiological Imaging for the High-Risk Patient

  • Erin Neuschler
  • Paula Grabler


In this chapter we will discuss the appropriate imaging techniques for women at high risk for breast cancer as well as accepted timelines for imaging. Mammography is the only imaging technique that has been proven to decrease breast cancer mortality as a screening modality. Given the limitations of mammography, other imaging techniques are recommended for the woman at high risk. We will discuss the utility of ultrasound and magnetic resonance imaging (MRI) as additional screening modalities. In addition emerging breast imaging technologies will be discussed.


Breast Cancer Dense Breast Digital Mammography Breast Magnetic Resonance Imaging Magnetic Resonance Imaging Lesion 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. 1.
    Smith RA, Cokkinides V, Brooks D, Saslow D, Brawley OW. Cancer screening in the United States, 2010: a review of current American Cancer Society guidelines and issues in cancer screening. CA Cancer J Clin. 2010;60(2):99–119.PubMedCrossRefGoogle Scholar
  2. 2.
    American Medical Association. Mammography screening in asymptomatic women forty years and older (AMA Policy H-525.993). Washington, DC: American Medical Association; 1999.Google Scholar
  3. 3.
    ACR Practice Guidelines for the Performance of Screening and Diagnostic Mammography. 2008. Available at:∼/media/ACR/Documents/PGTS/guidelines/Screening_Mammography.pdf. Accessed 1 Feb 2012.
  4. 4.
    Humphrey LL, Helfand M, Chan BK, Woolf SH. Breast cancer screening: a summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med. 2002;137(5 Pt 1):347–60.PubMedGoogle Scholar
  5. 5.
    Verbeek ALM, Hendricks JHCL, Holland R, Mravunac M, Sturmans F. Screening and breast cancer mortality, age specific effects in Nijmegen project, 1975–82. Lancet. 1985;1(8433):865–6.PubMedCrossRefGoogle Scholar
  6. 6.
    Shapiro S, Venet W, Strax P, Venet L. Periodic screening for breast cancer: the Health Insurance Plan Project and its sequelae, 1963–1986. Baltimore, MD: Johns Hopkins University Press; 1988.Google Scholar
  7. 7.
    Nystrom L, Rutqvist LE, Wall S, et al. Breast cancer screening with mammography: overview of Swedish randomized trials. Lancet. 1993;341(8851):973–8.PubMedCrossRefGoogle Scholar
  8. 8.
    Roberts MM, Alexander FE, Anderson TJ, et al. Edinburgh trial of screening for breast cancer: mortality at seven years. Lancet. 1990;335(8684):241–6.PubMedCrossRefGoogle Scholar
  9. 9.
    Miller AB, Baines CJ, To T, et al. Canadian national breast screening study: 1. Breast cancer detection and death rates among women aged 40 to 49 years. CMAJ. 1992;147:1459–76.PubMedGoogle Scholar
  10. 10.
    Moss SM, Summerley ME, Thomas BT, Ellman R, Chamberlain JOP. A case-control evaluation of the effect of breast cancer screening in the United Kingdom trial of early detection of breast cancer. J Epidemiol Community Health. 1992;46(10):362–4.PubMedCrossRefGoogle Scholar
  11. 11.
    Otto SJ, Fracheboud J, Looman CWN, et al. National Evaluation Team for breast cancer screening initiation of population-based mammography screening in Dutch municipalities and effect on breast-cancer mortality: a systematic review. Lancet. 2003;361(9367):411–7.CrossRefGoogle Scholar
  12. 12.
    Kerlikowske K, Grady D, Rubin SM, Sandrock C, Ernster VL. Efficacy of screening mammography. A meta-analysis. JAMA. 1995;273(2):149–54.PubMedCrossRefGoogle Scholar
  13. 13.
    Elwood JM, Cox B, Richardson AK. The effectiveness of breast cancer screening by mammography in younger women. Online J Curr Clin Trials. 1993; Doc No. 32.Google Scholar
  14. 14.
    Tabar L, Yen MF, Vitak B, Chen HH, Smith RA, Duffy SW. Mammography service screening and mortality in breast cancer patients: 20-year follow-up before and after introduction of screening. Lancet. 2003;361(9367):1405–10.PubMedCrossRefGoogle Scholar
  15. 15.
    U.S. Preventive Services Task Force. Screening for breast cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2009;151(10):716–26.Google Scholar
  16. 16.
    Lee CH, Dershaw DD, Kopans D, et al. Breast cancer screening with imaging: recommendations from the Society of Breast Imaging and the ACR on the use of mammography, breast MRI, breast ultrasound, and other technologies for the detection of clinically occult breast cancer. J Am Coll Radiol. 2010;7(1):18–27.PubMedCrossRefGoogle Scholar
  17. 17.
    American Cancer Society. Breast cancer: early detection. 2011. Available at: Accessed 1 Feb 2012.
  18. 18.
    National Comprehensive Cancer Network. NCCN clinical practice guidelines in oncology: NCCN guidelines TM. Breast cancer screening and diagnosis, version 1.2011. Scholar
  19. 19.
    Brewster AM, Hortobagyi GN, Broglio KR, Kau S, Santa-Maria CA. Residual risk of breast cancer recurrence 5 years after adjuvant therapy. J Natl Cancer Inst. 2008;100(16):1179–83.PubMedCrossRefGoogle Scholar
  20. 20.
    Hartman M, Czene K, Reilly M, Adolfsson J, Bergh J, Adami HO, et al. Incidence and prognosis of synchronous and metachronous bilateral breast cancer. J Clin Oncol. 2007;25(27):4210–6.PubMedCrossRefGoogle Scholar
  21. 21.
    ACR-ACS-CAP-SSO practice guideline for the management of ductal carcinoma in-situ of the breast (DCIS). Revised 2006 (Resolution 21). Available at:∼/media/ACR/Documents/PGTS/guidelines/DCIS.pdf. Accessed 1 Feb 2012.
  22. 22.
    ACR-ACS-CAP-SSO practice guideline for breast conservation therapy in the management of invasive breast carcinoma. Revised 2006 (Resolution 20). Available at:∼/media/ACR/Documents/PGTS/guidelines/Invasive_Breast_Carcinoma.pdf. Accessed 1 Feb 2012.
  23. 23.
    Khatcheressian JL, Wolff AC, Smith TJ, Grunfeld E. American Society of Clinical Oncology 2006 update of the breast cancer follow-up and management guideline in the adjuvant setting. J Clin Oncol. 2006;24(31):5091–7.PubMedCrossRefGoogle Scholar
  24. 24.
    Grann A, Abdou JC, Dragman N, Goodman R. The value of postexcision preradiation mammography in patients with early-stage breast cancer. Am J Clin Oncol. 2004;27(3):285–8.PubMedCrossRefGoogle Scholar
  25. 25.
    Link K, Eradat J, Mehta NH, Bent C. Is a short-interval postradiation mammogram necessary after conservative surgery and radiation in breast cancer? Int J Radiat Oncol Biol Phys. 2008;72(4):1041–7.CrossRefGoogle Scholar
  26. 26.
    Hymas RV, Gaffney DK, Parkinson BT, Belnap T. Is short interval mammogram necessary after breast-conservation surgery and radiation treatment in breast cancer patients? J Clin Oncol. 2010;28(15 Suppl):603.Google Scholar
  27. 27.
    Elder EE, Kennedy CW, Gluch L, Carmalt HL. Patterns of breast cancer relapse. Eur J Surg Oncol. 2006;32(9):922–7.PubMedCrossRefGoogle Scholar
  28. 28.
    MacLachlan TK, Somasundaram K, Sgagias M, et al. BRCA1 effects on the cell cycle and the DNA damage response are linked to altered gene expression. J Biol Chem. 2000;275(4):2777–85.PubMedCrossRefGoogle Scholar
  29. 29.
    Jansen-van der Weide MC, Greuter MJ, Jansen L, Oosterwijk JC, Pijnappel RM, de Bock GH. Exposure to low-dose radiation and the risk of breast cancer among women with a familial or genetic predisposition: a meta-analysis. Eur Radiol. 2010;20(11):2547–56.CrossRefGoogle Scholar
  30. 30.
    Brekelmans CT, Seynaeve C, Bartels CC, et al. Effectiveness of breast cancer surveillance in BRCA ½ gene mutation carriers and women with high familial risk. J Clin Oncol. 2001;19(4):924–30.PubMedGoogle Scholar
  31. 31.
    Komenaka IK, Ditkoff BA, Joseph KA, et al. The development of interval breast malignancies in patients with BRCA mutations. Cancer. 2004;100(10):2079–83.PubMedCrossRefGoogle Scholar
  32. 32.
    Harvey JA, Bovbjerg VE. Quantitative assessment of mammographic breast density: relationship with breast cancer risk. Radiology. 2004;230(1):29–41.PubMedCrossRefGoogle Scholar
  33. 33.
    Boyd NF, Guo H, Martin LJ, Sun L. Mammographic density and the risk and detection of breast cancer. N Engl J Med. 2007;356(3):227–36.PubMedCrossRefGoogle Scholar
  34. 34.
    Pisano ED, Gatsonis C, Hendrick E, Yaffe M. Diagnostic performance of digital versus film mammography for breast-cancer screening. N Engl J Med. 2005;356(17):1773–83.CrossRefGoogle Scholar
  35. 35.
    Lakhani SR, Jacquemier J, Sloane JP, et al. Multifactorial analysis of differences between sporadic breast cancers and cancers involving BRCA1 and BRCA2 mutations. J Natl Cancer Inst. 1998;90(15):1138–45.PubMedCrossRefGoogle Scholar
  36. 36.
    Breast Cancer Linkage Consortium. Pathology of familial breast cancer: differences between breast cancers in carriers of BRCA1 or BRCA2 mutations and sporadic cases. Lancet. 1997;349(9064):1505–10.CrossRefGoogle Scholar
  37. 37.
    Tilanus-Linthorst M, Verhoog L, Obdeign IM, et al. A BRCA ½ mutation, high breast density and prominent pushing margins of a tumor independently contribute to a frequent false-negative mammography. Int J Cancer. 2002;102(1):91–5.PubMedCrossRefGoogle Scholar
  38. 38.
    Hamilton LJ, Evans AJ, et al. Breast imaging findings in women with BRCA1 and BRCA2 associated breast carcinoma. Clin Radiol. 2004;59(10):895–902.PubMedCrossRefGoogle Scholar
  39. 39.
    Schrading S, Kuhl C. Mammographic, US, and MR imaging phenotypes of familial breast cancer. Radiology. 2008;246(1):58–70.PubMedGoogle Scholar
  40. 40.
    O’Connell A, Conover DL, Zhang Y. Cone-beam CT for breast imaging: radiation dose, breast coverage, and image quality. AJR Am J Roentgenol. 2010;195(2):496–509.PubMedCrossRefGoogle Scholar
  41. 41.
    ACR. BI-RADS mammography. In: American College of Radiology Breast Imaging Reporting and Data System Atlas. 4th ed. Reston, VA: American College of Radiology; 2003.Google Scholar
  42. 42.
    Mammography Quality Standards Act. Available at: Accessed 1 Feb 2012.
  43. 43.
    Madjar H, Mendelson EB. The practice of breast ultrasound. 2nd ed. Stuttgart, Germany: Thieme; 2008.Google Scholar
  44. 44.
    Berg WA. Supplemental screening sonography in dense breasts. Radiol Clin North Am. 2004;42(5):845–51.PubMedCrossRefGoogle Scholar
  45. 45.
    Berg WA, Blume JD, Cormack JB, et al.; ACRIN 6666 Investigators. Combined screening with ultrasound and mammography vs mammography alone in women at elevated risk of breast cancer. JAMA. 2008;299(18):2151–63.Google Scholar
  46. 46.
    Berg WA. Tailored supplemental screening for breast cancer: what now and what next? AJR Am J Roentgenol. 2009;192(2):390–9.PubMedCrossRefGoogle Scholar
  47. 47.
    Warner E, Causer PA, Wong JW, et al. Improvement in DCIS detection rates by MRI over time in a high-risk breast screening study. Breast J. 2011;17(1):9–17.PubMedCrossRefGoogle Scholar
  48. 48.
    Kelly KM, Dean J, Comulada WS, Lee SJ. Breast cancer detection using automated whole breast ultrasound and mammography in radiographically dense breasts. Eur Radiol. 2010;20(3):734–42.PubMedCrossRefGoogle Scholar
  49. 49.
    Kelly KM, Dean J, Lee SJ, Comulada WS. Breast cancer detection: radiologists’ performance using mammography with and without automated whole-breast ultrasound. Eur Radiol. 2010;20(11):2557–64.PubMedCrossRefGoogle Scholar
  50. 50.
    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(2):381–8.PubMedCrossRefGoogle Scholar
  51. 51.
    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(11):1317–25.PubMedCrossRefGoogle Scholar
  52. 52.
    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(33):8469–76.PubMedCrossRefGoogle Scholar
  53. 53.
    Sardanelli F, Podo F, Santoro F, et al.; High Breast Cancer Risk Italian 1 (HIBCRIT-1) Study. Multicenter surveillance of women at high genetic breast cancer risk using mammography, ultrasonography, and contrast-enhanced magnetic resonance imaging (the high breast cancer risk Italian 1 study): final results. Invest Radiol. 2011;46(2):94–105.Google Scholar
  54. 54.
    Mendelson EB, Baum JK, Berg WA, Merritt CRB, Rubin E. Breast imaging reporting and data system, BI-RADS: ultrasound. Reston, VA: American College of Radiology; 2003.Google Scholar
  55. 55.
    Marcus JN, Watson P, Page DL, et al. Hereditary breast cancer: pathobiology, prognosis, and BRCA1 and BRCA2 gene linkage. Cancer. 1996;77(4):697–709.PubMedCrossRefGoogle Scholar
  56. 56.
    Lamb PM, Perry NM, Vinnicombe SJ, Wells CA. Correlation between ultrasound characteristics, mammographic findings and histological grade in patients with invasive ductal carcinoma of the breast. Clin Radiol. 2000;55(1):40–4.PubMedCrossRefGoogle Scholar
  57. 57.
    Kaiser WA, Zeitler E. MR imaging of the breast: fast imaging sequences with and without Gd-DTPA. Preliminary observations. Radiology. 1989;170(3 Pt 1):681–6.PubMedGoogle Scholar
  58. 58.
    Heywang SH, Wolf A, Pruss E, et al. MR imaging of the breast with Gd-DTPA: use and limitations. Radiology. 1989;171(1):95–103.PubMedGoogle Scholar
  59. 59.
    Kuhl CK, Bieling HB, Gieseke J, et al. Healthy premenopausal breast parenchyma in dynamic contrast-enhanced MR imaging of the breast: normal contrast medium enhancement and cyclical-phase dependency. Radiology. 1997;203(1):137–44.PubMedGoogle Scholar
  60. 60.
    ACR MRI accreditation program requirements. Available at:∼/media/ACR/Documents/PGTS/guidelines/MRI_Breast.pdf. Accessed 1 Feb 2012.
  61. 61.
    Lehman CD. Role of MRI in screening women at high risk for breast cancer. J Magn Reson Imaging. 2006;24(5):964–70.PubMedCrossRefGoogle Scholar
  62. 62.
    American College of Radiology. ACR BI-RADS: magnetic resonance imaging, in ACR Breast Imaging Reporting and Data System: Breast Imaging Atlas. Reston, VA: American College of Radiology; 2003.Google Scholar
  63. 63.
    Kuhl CK, Mielcareck P, Klaschik S, et al. Dynamic breast MR imaging: are signal intensity time course data useful for differential diagnosis of enhancing lesions? Radiology. 1999;211(1):101–10.PubMedGoogle Scholar
  64. 64.
    Weinstein S, Rosen M. Breast MR imaging: current indications and advanced imaging techniques. Radiol Clin North Am. 2010;48(5):1013–42.PubMedCrossRefGoogle Scholar
  65. 65.
    Kuhl C. Dynamic breast magnetic resonance imaging. In: Morris EA, Liberman L, editors. Breast MRI: diagnosis and intervention. New York, NY: Springer; 2005. p. 79–139.Google Scholar
  66. 66.
    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(2):75–89.PubMedCrossRefGoogle Scholar
  67. 67.
    Kuhl CK, Schmutzler RK, Leutner CC, et al. Breast MR imaging screening in 192 women proved or suspected to be carriers of a breast cancer susceptibility gene: preliminary results. Radiology. 2000;215(1):267–79.PubMedGoogle Scholar
  68. 68.
    Friedlander LC, Roth SO, Gavenonis SC. Results of MR imaging screening for breast cancer in high-risk patients with lobular carcinoma in situ. Radiology. 2011;261(2):421–7.PubMedCrossRefGoogle Scholar
  69. 69.
    Le-Petross HT, Whitman GJ, Atchley DP, et al. Effectiveness of alternating mammography and magnetic resonance imaging for screening women with deleterious BRCA mutations at high risk of breast cancer. Cancer. 2011;117(17):3900–7.PubMedCrossRefGoogle Scholar
  70. 70.
    Kriege M, Brekelmans CT, Boetes C, et al. Magnetic Resonance Imaging Screening Study Group. Efficacy of MRI and mammography for breast-cancer screening in women with a familial or genetic predisposition. N Engl J Med. 2004;351(5):427–37.Google Scholar
  71. 71.
    Tilanus-Linthorst MM, Bartels CC, Obdeijn AI, Oudkerk M. Earlier detection of breast cancer by surveillance of women at familial risk. Eur J Cancer. 2000;36(4):514–9.PubMedCrossRefGoogle Scholar
  72. 72.
    Warner E, Hill K, Causer P, et al. Prospective study of breast cancer incidence in women with a BRCA1 or BRCA2 mutation under surveillance with and without magnetic resonance imaging. J Clin Oncol. 2011;29(13):1664–9.PubMedCrossRefGoogle Scholar
  73. 73.
    Leung JW. Utility of second-look ultrasound in the evaluation of MRI-detected breast lesions. Semin Roentgenol. 2011;46(4):260–74.PubMedCrossRefGoogle Scholar
  74. 74.
    Abe H, Schmidt RA, Shah RN, et al. MR-directed (“second-look”) ultrasound examination for breast lesions detected initially on MRI: MR and sonographic findings. AJR Am J Roentgenol. 2010;194(2):370–7.PubMedCrossRefGoogle Scholar
  75. 75.
    Tabár L, Vitak B, Chen HH, et al. The Swedish two-county trial twenty years later. Updated mortality results and new insights from long-term follow-up. Radiol Clin North Am. 2000;38(4):625–51.PubMedCrossRefGoogle Scholar
  76. 76.
    Baldwin P. Digital breast tomosynthesis. Radiol Technol. 2009;81(1):57M–74.PubMedGoogle Scholar
  77. 77.
    Sarkar A, Shi C, Rassiah-Szegedi P, Diaz A, Eng T, Papanikolaou N. The effect of a limited number of projections and reconstruction algorithms on the image quality of megavoltage digital tomosynthesis. J Appl Clin Med Phys. 2009;10(3):2970.PubMedCrossRefGoogle Scholar
  78. 78.
    Hologic Selenia Dimensions 3D System, Sponsor executive summary. 2010;40–1. Available at: Accessed 14 March 2011.
  79. 79.
    Poplack SP, Tosteson TD, Kogel CA, Nagy HM. Digital breast tomosynthesis: initial experience in 98 women with abnormal digital screening mammography. AJR Am J Roentgenol. 2007;189(3):616–23.PubMedCrossRefGoogle Scholar
  80. 80.
    Andersson I, Ikeda DM, Zackrisson S, et al. Breast tomosynthesis and digital mammography: a comparison of breast cancer visibility and BIRADS classification in a population of cancers with subtle mammographic findings. Eur Radiol. 2008;18(12):2817–25.PubMedCrossRefGoogle Scholar
  81. 81.
    Förnvik D, Zackrisson S, Ljungberg O, et al. Breast tomosynthesis: accuracy of tumor measurement compared with digital mammography and ultrasonography. Eur Radiol. 2008;18(3):2817–25.Google Scholar
  82. 82.
    Boone JM, Kwan AL, Yang K, Burkett GW, Lindfors KK, Nelson TR. Computed tomography for imaging the breast. J Mammary Gland Biol Neoplasia. 2006;11(2):103–11.PubMedCrossRefGoogle Scholar
  83. 83.
    Lindfors KK, Boone JM, Nelson TR. Dedicated breast CT: initial clinical experience. Radiology. 2008;246(3):725–33.PubMedCrossRefGoogle Scholar
  84. 84.
    Brem RF, Floerke AC, Rapelyea JA, Teal C, Kelly T, Mathur V. Breast-specific gamma imaging as an adjunct imaging modality for the diagnosis of breast cancer. Radiology. 2008;247(3):651–7.PubMedCrossRefGoogle Scholar
  85. 85.
    Berg WA, Weinberg IN, Narayanan D, et al. High-resolution fluorodeoxyglucose positron emission tomography with compression (“positron emission mammography”) is highly accurate in depicting primary breast cancer. Breast J. 2006;12(4):309–23.PubMedCrossRefGoogle Scholar
  86. 86.
    Hendrick RE. Radiation doses and cancer risks from breast imaging studies. Radiology. 2010;257(1):246–53.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2013

Authors and Affiliations

  1. 1.Department of Breast ImagingNorthwestern Memorial HospitalChicagoUSA
  2. 2.Department of RadiologyNorthwestern Memorial HospitalChicagoUSA

Personalised recommendations