British Journal of Radiology 74 (2001),548-551 © 2001 The British Institute of Radiology
A method of coil localization for breast lesions seen only on MRI
R Warren, MD, FRCP1 and
P Kessar, PhD, FRCR2
1Department of Diagnostic Radiology, Box 97 Addenbrooke's Hospital, Cambridge CB2 2QQ and 2Magnetic Resonance Research Unit, The Royal Marsden Hospital, Downs Road, Sutton, Surrey SM2 5PT, UK
 |
Abstract
|
|---|
Breast lesions may be identified on MRI that are not shown on mammography or ultrasound owing to the high sensitivity and relatively poor specificity of contrast enhanced MRI. Techniques for diagnostic biopsy of such lesions are not widely available. A method is described that uses standard mammographic localization methods to place an MR compatible cerebral coil at the site of the suspect lesion. Confirmatory MRI can then be obtained before the lesion is surgically removed using a mammographic hook wire. This method is described and illustrated in detail for one case, and in summary for three further cases, to show the potential flexibility of application. The method is commended because it is simple and cheap, uses standard breast procedures and can be undertaken outside the MRI suite. The procedure will make full use of breast MRI possible to those who do not have dedicated localization equipment.
|
Introduction
|
|---|
Increasing use of contrast enhanced MRI in the diagnosis and management of breast cancer has established the need for a method of surgical biopsy of lesions that are shown on MRI but not on mammography and ultrasound. MRI, which has high sensitivity but relatively low specificity, is particularly applicable to dense breasts where false negatives may arise with mammography [1]. Although some cases are resolved by biopsy under ultrasound control, some cases that are not shown on any conventional imaging modality are finally found to have cancer. This is the subject of a recent review by our team in support of the UK study of MRI screening for breast cancer in women at high risk (MARIBS study) [2, 3]. Methods are becoming available for percutaneous localization needle biopsy under MR control and for the insertion of guidewires using specific coils that can be attached to the MRI equipment [4–6]. This equipment is still in the development stage and involves considerable expense for cases that are few in number. On the other hand, cases with suspicious contrast enhancement are being found in the MARIBS screening study [2, 7] and in other clinical situations. The present paper describes the use of an MR compatible cerebral coil [8], mounted for use in the breast and coupled with standard mammographic localization techniques. This has now been used on several occasions and the method is illustrated in this paper. Experience to date in a variety of situations gives confidence that the procedure can be deployed and varied on any occasion where a lesion requires surgical biopsy. The method is cheap and requires no complex equipment.
|
Method
|
|---|
When a decision has been made to proceed to localized surgical biopsy, the MRI study is re-assessed on the workstation. Cases described here have been undertaken using MRI protocol A of the MARIBS study, but omitting the proton density sequence and giving 1.6 mmol kg-1 of gadolinium contrast medium [9]. This includes a three-dimensional dynamic series of acquisitions before and at 90 s time points after injection of contrast medium. At a time separate from the original study following the decision for biopsy, multiplanar reconstruction of the second sequence, after contrast medium injection at 90 s, is performed on the workstation. For a malignant lesion, this will be the time of maximum contrast enhancement, giving the greatest clarity of the abnormality on the images. The contrast enhanced lesion is shown on images taken in three orthogonal planes (axial, coronal and sagittal). Craniocaudal (CC) and true lateral mammograms are obtained. By careful comparison of the topography of the breast on the images of the two modalities compared side by side, it is possible to put wax pencil marks on the CC and lateral mammograms, which correspond with the site of the contrast enhancing lesion in the two matched planes (axial and sagittal) (Figure 1b,e
). Although the mammogram is taken with the breast compressed and the MRI study is in the prone position with the pendant and uncompressed breast, it is usually possible to recognize matched shapes fairly accurately, by comparison of shapes rather than by measurement.
View larger version (125K):
[in this window]
[in a new window]
|
Figure 1. A 51-year-old woman (case 1 in text) with screen-detected ductal carcinoma in situ (DCIS) on the right side for pre-operative staging of the extent of DCIS. These images are from the contralateral (left) side to the screen-detected DCIS. The additional lesions have dynamic contrast medium uptake features similar to the histologically proven DCIS and suspicious of contralateral disease. (a) Sagittal reconstruction of three-dimensional (3D) dynamic T1 sequence at 90 s after gadolinium injection showing one of the suspect contrast enhancing areas (arrow). (b) Lateral mammogram marked to show both sites of contrast enhancement (arrows). (c) Sagittal 3D FSPGR sequence showing the coil at the site of lesion 1 (arrow). The susceptibility artefact is clearly seen, but the vessels show contrast enhancement and it is possible to undertake dynamic analysis of any lesion. (d). Axial reconstruction showing the position of lesion 1 at 90 s after gadolinium injection (arrow). (e) Craniocaudal mammogram showing pencil marks corresponding to the two lesions (arrows). (f) Craniocaudal mammogram showing coils in place and localizing wires inserted for surgery (arrows). Histology showed benign fibrocystic disease. NB Lesions 1 and 2 cannot be seen on the same tomographic slice of the MR image. They are of course both visible after marking with the coils on a mammogram. Images a–c are all sagittal/lateral views; (d–f) are all axial/craniocaudal views.
|
|
This point is then localized with the breast coil needle using the alpha numeric plate in the mammography room. This can be done through a standard needle, for example a lumbar puncture needle. A prepared set manufactured by William Cook Europe A/S (MREYETM Breast Localisation Coil Ref IDLC-19.5-9.0-4-U-DM; Bjaeverskov, Denmark) uses an MR compatible needle. The lengths of all the parts of the set are matched. This small kit allows an MR compatible cerebral embolisation coil to be inserted at a point accurately selected in the CC and lateral projections.
Check mammograms clearly show the radio-opaque coil (Figure 1f
). A contrast enhanced MR study is undertaken at a later time to show the relationship between the coil and the lesion (Figure 1c). This particular cerebral coil, adapted for breast use, gives an unmistakable susceptibility artefact, but does not prevent view and analysis of contrast medium uptake. The position of the coil in relation to the lesion cannot be changed at this time, but it has usually been possible to place the coil within 5–10 mm of the lesion.
At a later date, the tissue can be removed surgically using a standard hook wire. Specimen mammography will show the coil removed. Quality standards in the UK National Health Service Breast Screening Programme require that a diagnostic biopsy should not exceed 20 g [10], a degree of accuracy permitted in the cases described here.
|
Contralateral lesions
|
|---|
A 51-year-old woman was found to have an area of calcification in the right breast on mammography screening. Core biopsy of this area showed papillary ductal carcinoma in situ (DCIS). MRI showed the DCIS to be more extensive than expected, a finding confirmed at surgery where a wide local excision had to be converted to a mastectomy on account of involved margins. The MRI study showed two lesions in the contralateral breast, with enhancement features resembling those on the right (Figure 1a) but with no corresponding mammographic finding. Using the reconstructed MRI study in the sagittal and axial plane at 90 s from the injection of contrast medium (Figure 1a,d), two coils were inserted and their position checked by a repeat contrast enhanced MRI study (Figure 1c). One coil was readily found and removed at surgery. The surgeon had difficulty in finding the central coil because the hook wire, although threaded through the coil, extended several centimetres beyond in a large and mobile breast. Histology showed that the MR features were due to benign breast disease.
|
Recurrent DCIS
|
|---|
A 69-year-old woman had surgery 5 years before for high grade DCIS. A surveillance mammogram showed fatty breasts and no radiological abnormality, although there was clinical suspicion of recurrence at the site of surgery. MRI showed contrast medium uptake at another site in the breast. A cerebral localizing coil was inserted by the method described above and the tissue removed contained high grade DCIS.
|
Screen-detected query
|
|---|
A 42-year-old woman carrying the BRCA1 mutation attended for MRI screening in the UK MRC study of MRI screening for breast cancer in high-risk women (MARIBS). Her breasts were dense and featureless on mammography. An enhancing lesion, 1 cm deep to the right nipple, was still present on repeat studies at 2 weeks and 4 months. The enhancing lesion could not be identified by ultrasound, but had an enhancement curve that was suspicious of carcinoma. The lesion was removed surgically by the above method and histology showed a benign hamartoma.
|
Screen-detected query in Tp53 patient resolved without mammography
|
|---|
A patient who had an MR query in the MARIBS study carried a p53 gene mutation, and a corresponding feature was seen on ultrasound. Mammography was not undertaken because of the radiation sensitivity associated with this mutation. The method described can be adapted for such a patient, by ultrasound insertion of a coil followed by contrast enhanced MRI to check the position. This case illustrates how the coil method has the flexibility to be adapted for use with ultrasound and no mammogram.
|
Discussion
|
|---|
When using breast MRI in the management of breast disease, there is a perceived need to find methods that enable care to be based upon histology in the same way as other breast modalities [11]. Although attempts are being made to achieve tissue characterization by analytical methods of contrast medium enhancement and morphology [12], this will always be less reliable than the information obtained by the biopsy techniques used with mammography and ultrasound [13–16]. Although substantial developments with a variety of creative ideas and inventions has taken place, it is still not possible to purchase anything other than a prototype. Systems are becoming available commercially, but their commercial use is in an early phase. The costs are high for the number of cases on which they are likely to be used. Changes in the main MRI equipment on which they are used can render an expensive localizing device useless. The advantages of our technique are as follows:- The procedure takes place in the breast unit and not in the MRI suite.
- It uses standard localization techniques familiar to any breast radiologist.
- It can be sufficiently accurate to obtain a diagnostic biopsy comprising less than 20 g of breast tissue [10].
- There is no wire extending from the breast so there is no urgency to undertake surgery.
- The procedure can be done at a site distant from the MRI or surgical suite, or even at another hospital.
- It does not use expensive add-on equipment. The only additional cost is the small kit, which is marketed at under £50 ($75).
The disadvantages of this method are that it prepares the patient for open surgical biopsy rather than percutaneous biopsy, and that the level of accuracy is not as great as the procedures undertaken with breast localization coils. There will certainly still be a need for the more complex equipment and this paper does not provide the complete solution.
|
Acknowledgments
|
|---|
Our patients were under the care of Mr A Purushotham, Mr G Wishart and Mr G Querci della Rovere. William Cook Europe A/S supplied the localization coils free of charge for developmental use. The procedures are covered by Ethical Committee approval of the Cambridge Health Authority and the Royal Marsden Hospital for the studies in which the patients received their MRI scans, and in specific approval for prototype localization procedures.
Received for publication August 18, 2000.
Revision received January 31, 2001.
Accepted for publication April 4, 2001.
|
References
|
|---|
-
Kuhl CK. MRI of breast tumors. Eur Radiol 2000;10:46–58.[Medline]
-
Brown J, Coulthard A, Dixon A, Dixon J, Easton D, et al. Protocol for a national multi-centre study of magenetic resonance imaging screening in women at genetic risk of breast cancer. UK MRI Breast Screening Study Advisory Group. The Breast 2000;9:78–82.
-
Warren RML, Hayes C, Advisory Group of the UK study of MRI screening for breast cancer. Localization of breast lesions shown only on MRI—a review for the UK study of MRI screening for breast cancer. Br J Radiol 2000;73:123–32.[Abstract]
-
Heywang-Kobrunner S, Heinig A, Schaumloffel U, Viehweg P, Buchmann J, Lampe D, et al. MR-guided percutaneous excisional and incisional biopsy (PEIB) of breast lesions. Eur Radiol 1999;9:1656–65.[Medline]
-
Kuhl CK, Elevelt A, Leutner CC, Gieseke J, Pakos E, Schild HH. Interventional breast MR imaging: clinical use of a stereotactic localization and biopsy device. Radiology 1997;204:667–75.[Abstract/Free Full Text]
-
Daniel BL, Birdwell RL, Ikeda DM, Jeffrey SS, Black JW, Block WF, et al. Breast lesion localization: a freehand, interactive MR imaging-guided technique. Radiology 1998;207:455–63.[Abstract/Free Full Text]
-
Brown J, Coulthard A, Dixon A, Dixon J, Easton D, et al. Rationale for a national multi-centre study of magnetic resonance imaging screening in women at genetic risk of breast cancer. UK MRI Breast Screening Study Advisory Group. The Breast 2000;9:72–7.
-
Braeuning MP, Burke ET, Pisano ED. Embolization coils as tumor markers for mammography in patients undergoing neoadjuvant chemotherapy for carcinoma of the breast. AJR 2000;174:251–2.[Free Full Text]
-
Brown J, Buckley D, Coulthard A, Dixon AK, Dixon JM, Easton DF, et al. Magnetic resonance imaging screening in women at genetic risk of breast cancer: imaging and analysis protocol for the UK multicentre study. Magn Reson Imaging 2000;18:765–76.[Medline]
-
Screening Nc-ogfswibc. Quality assurance guidelines for surgeons working in breast cancer screening, Report No. 20. Sheffield: NHS Breast Screening Programme, 1996.
-
Hall Craggs MA, Mumtaz H. Keeping abreast of magnetic resonance: developments in breast cancer imaging. Clin Radiol 1997;52:253–5.[Medline]
-
Orel SG. Differentiating benign from malignant enhancing lesions identified at MR imaging of the breast: are time-signal intensity curves an accurate predictor? Radiology 1999;211:5–7.[Free Full Text]
-
Parker SH, Burbank F, Jackman RJ, Aucreman CJ, Cardenosa G, Cink TM, et al. Percutaneous large-core breast biopsy: a multi-institutional study [see comments]. Radiology 1994;193:359–64.[Abstract/Free Full Text]
-
Parker SH, Stavros AT, Dennis MA. Needle biopsytechniques. Radiol Clin North Am 1995;33:1171–86.[Medline]
-
Parker SH, Klaus AJ. Performing a breast biopsy with a directional, vacuum-assisted biopsy instrument. Radiographics 1997;17:1233–52.[Abstract]
-
Fornage BD. Sonographically guided needle biopsy of nonpalpable breast lesions. J Clin Ultrasound 1999;27:385–98.[Medline]
This article has been cited by other articles:
|
|
|
|
 
C. C. Genson, C. E. Blane, M. A. Helvie, S. A. Waits, and T. L. Chenevert
Effects on Breast MRI of Artifacts Caused by Metallic Tissue Marker Clips
Am. J. Roentgenol.,
February 1, 2007;
188(2):
372 - 376.
[Abstract]
[Full Text]
[PDF]
|
|
|
Top
Abstract
Introduction
