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. Author manuscript; available in PMC: 2021 Jun 17.
Published in final edited form as: Radiol Clin North Am. 2020 Nov 2;59(1):99–111. doi: 10.1016/j.rcl.2020.09.001

Abbreviated MR Imaging for Breast Cancer

Laura Heacock 1,*, Alana A Lewin 1, Hildegard K Toth 1, Linda Moy 1, Beatriu Reig 1
PMCID: PMC8211370  NIHMSID: NIHMS1712345  PMID: 33223003

INTRODUCTION

Breast MR imaging is the most sensitive imaging method for the detection of breast cancer.1,2 Although mammography remains the gold standard for breast cancer screening,3–5 numerous high-quality multicenter trials have demonstrated that breast MR imaging detects on average 3 to 4 times as many breast cancers as mammography in patients with a high (>20%–25%) lifetime risk of breast cancer, with cancer detection rates ranging from 14.7 to 16.0 per 1000 women6–8 (compared with 5.1 per 1000 women in screening mammography).9 Although traditionally breast MR imaging has been offered as supplemental screening for high-risk women only, increased cancer detection rates with breast MR imaging have been demonstrated in patients with intermediate (15%–20%) lifetime risk10,11 and even average (<15%) lifetime risk of breast cancer.12

Breast MR imaging offers superior cancer detection to screening mammography and ultrasound examination owing to the uptake of gadolinium intravenous contrast and improved tissue contrast. These features of MR imaging allow for the evaluation of real-time, functional wash-in and wash-out of contrast within the breast parenchyma. The increased angiogenesis and vessel permeability in invasive breast cancer13 results in avid uptake of contrast compared with the background parenchymal enhancement. Early uptake of contrast has also been demonstrated in high-grade ductal carcinoma in situ (DCIS), which may reflect pathologically increased permeability of the ductal membrane in higher grade DCIS owing to protease activity.14 The physiologic uptake of contrast in high-grade DCIS and invasive cancers explains the increased detection of these more aggressive malignancies on MR imaging when compared with mammography and ultrasound examination.15

Despite the clear advantages of breast MR imaging, it is traditionally recommended only to patients who have a high lifetime breast cancer risk.2 Recent guidelines have suggested a benefit for women an intermediate lifetime risk as well.11 Despite these recommendations, only 1.5% of women with a high lifetime risk in the community have ever had a breast MR imaging.16 This low use likely primarily reflects the traditional high cost of this examination, with cost-effectiveness studies previously showing maximum usefulness in high-risk patients. Other factors often cited in the low use of breast MR imaging include patient tolerance, accessibility, and patient claustrophobia.17,18

Abbreviated breast MR imaging, in which a limited number of breast imaging sequences are obtained, has been proposed as a way to solve both cost and patient tolerance issues while preserving the high cancer detection rate of breast MR imaging. Numerous studies have shown that abbreviated breast MR imaging screening can considerably decrease table time and reading time compared with a full breast MR imaging, while offering the same high positive predictive value and diagnostic accuracy.19–22 The recent Eastern Cooperative Oncology Group-American College of Radiology Imaging Network EA1141 multicenter trial has offered the first proof of the increased cancer detection rate of abbreviated breast MR imaging in average risk patients compared with digital breast tomosynthesis (DBT),19 paving the way for wider adoption of this screening method.

The purpose of this review is to discuss (1) the background of abbreviated MR imaging, (2) the various proposed abbreviated MR imaging protocols, (3) the known limitations of the modality, and (4) the challenges of clinical implementation.

IMAGING TECHNIQUE

Abbreviated breast MR imaging was first described by Kuhl and colleagues21 in 2014. In this landmark work, Kuhl and colleagues evaluated 443 women with average to intermediate lifetime risk in a series of 606 screening MR imaging and demonstrated that the diagnostic accuracy and positive predictive value were equivalent between an abbreviated protocol and a full breast imaging protocol. Kuhl’s protocol included a noncontrast T1-weighted and a single postcontrast T1-weighted sequence, with generated subtraction images (first postcontrast acquisition subtracted [FAST]) and maximum intensity projection (MIP) images. The average imaging time was 3 minutes compared with a full protocol time of 17 minutes table time; interpretation time was 28 seconds for the FAST images. Although Kuhl’s protocol consists of the stripped-down essentials for an abbreviated protocol, multiple iterations have been subsequently proposed (Table 1).

Table 1.

Summary of sequences included in various abbreviated MR imaging protocols and the reported sensitivity, specificity and area under the curve for that protocol

Standard Temporal Resolution
Reference Ultrafast Pre-T1W FAST T1W Second/Delayed Post T1W T2W Sub MIP Sens Spec Max Area Under the Curve
Platel et al,61 2014 Y Y Y N N Y Y NA NA 0.87
Kuhl et al,21 2014 N Y Y N N Y Y 100% 94.3% NA
Mann et al,28 2014 Y N N N N N N 90% 67% 0.812
Mango et al,22 2015 N Y Y N N Y Y 93%−98% NA NA
Grimm et al,32 2015 N Y Y Y Y Y N 86%−89% 45%−52% NA
Harvey et al,20 2016 N Y Y N N Y Y 100% 94% NA
Heacock et al,26 2016 N Y Y N Y Y N 97.8%−99.4% NA NA
Moschetta et al,33 2016 N Y Y N Y Y Y 89% 91% NA
Abe et al,39 2016 Y Y Y N N Y N 85% 79% 0.89
Machida et al,27 2017 Y Y Y N N N N 87.1%−93.5% 83.4%−91.7% NA
Chen et al,24 2017 N Y Y N N Y Y 92.9%−93.8% 86.5%−88.3% NA
Petrillo et al,62 2017 N Y Y N N Y Y 99.5% 75.4% NA
Panigrahi et al,29 2017 N Y Y N N Y Y 81.8% 97.2% NA
Romeo et al,63 2017 N Y Y N Y Y N 99% 93% NA
Oldrini et al,38 2017 Y Y Y N Y Y N 93.1% 70.8%−83.3% NA
Choi et al,25 2017 N Y Y N Y Y Y 100% 89.2% NA
Oldrini et al,64 2018 N Y Y N N Y N 100% 95.1% NA
Lee-Felker et al,65 2019 N Y Y N N Y Y 99% 97% NA
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Studies that used an ultrafast sequence had a temporal resolution of less than 10 s and were run both before and after contrast injection.

Abbreviations: FAST, first post contrast; Max, maximum; N, no; Pre, precontrast; Sens, sensitivity; Spec, specificity; Subs, subtraction images; T1W, T1-weighted; T2W, T2-weighted; Y, yes.

This initial abbreviated protocol can be compared with the American College of Radiology accreditation requirements for breast MR imaging, which include a scout localizer, T2-weighted images and precontrast and postcontrast T1-weighted images.23 Postcontrast images must include both early and delayed images; generally, at least 3 postcontrast series are acquired. Postprocessing often includes subtraction and MIP images. Additional specialized sequences may include diffusion weighted imaging (DWI), ultrafast (<10 second temporal resolution), and other multiparametric imaging sequences.10 For this full MR protocol, average table time is approximately 17 to 35 minutes, and this is generally scheduled in a 30-to 60-minute time slot (Fig. 1).

Fig. 1.

Fig. 1.

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Comparison of a typical abbreviated breast MR imaging protocol (AP) with a typical diagnostic breast MR imaging protocol (DP). At a minimum, the AP should include precontrast and first postcontrast T1-weighted images, with generated subtraction images and MIP image if desired. T2-weighted images are required for ACR MR imaging accreditation requirements. Ultrafast imaging and diffusion weighted imaging can be included in either AP or DP as part of a multiparametric protocol. FS, fat saturated; Post 1, first postcontrast T1-weighted; Pre T1W, precontrast T1-weighted; T2W, T2 weighted; UF, ultrafast.

SCREENING PROTOCOL LITERATURE

Overview

Since Kuhl and colleagues first evaluated abbreviated breast MR imaging, more than 5600 examinations in more than 8 countries have been evaluated in retrospective or prospective research studies, including a wide variety of patient populations including patients with average, intermediate, and high lifetime risks of breast cancer.20,24–29 Despite the heterogeneity of the protocols and patient populations, abbreviated breast MR imaging has consistently demonstrated excellent reproducibility with similar accuracy and sensitivity seen across these studies (see Table 1). These findings suggest that abbreviated breast MR imaging has the potential to increase breast MR imaging screening use by offering a less expensive, shorter examination that is well-tolerated by patients while preserving the high sensitivity of breast MR imaging for biologically aggressive breast cancer.15 Various sequences can be included in an abbreviated breast MR imaging protocol; the literature to date has explored the usefulness of which sequences should be included in this examination.

Use of Maximum Intensity Projection Images

Early studies of abbreviated MR imaging first determined the minimum number of images that needed to be included in a screening protocol. Kuhl and colleagues evaluated the diagnostic accuracy of MIP images alone compared with FAST images and the full diagnostic protocol, with 11 cancers evaluated in 606 screening MR imaging examinations. Although MIP interpretation time was substantially shorter at 2.8 seconds, 10 of 11 cancers were identified. FAST image interpretation was 28 seconds and all 11 cancers were seen, equivalent to the full diagnostic protocol (Fig. 2). The specificity and positive predictive value were also equivalent between FAST images and full diagnostic protocol (94.3% vs 93.9% and 24.4% vs 23.4%, respectively; P = .56321). Kuhl and colleagues concluded that FAST image interpretation may be preferable to MIP alone. This finding was reinforced by Mango and colleagues,22 who evaluated 100 biopsy-proven unicentric breast cancers in a 4-reader study using the same sequences as Kuhl and associates. The first postcontrast subtraction image interpretation had a sensitivity of 96% compared with 93% for MIP images. Abbreviated MR imaging acquisition time was 10 to 15 minutes compared with a full protocol of 30 to 40 minutes, with an average interpretation time of 44 seconds (Fig. 3). In this study evaluating only known cancers, missed lesions were more likely to be low-grade invasive cancer or DCIS. Although MIP evaluation can be useful for a quick overview, FAST images should be reviewed carefully to detect subtle lesions.

Fig. 2.

Fig. 2.

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A 73-year-old woman with a strong family history of breast cancer. MR imaging performed for intermediate-risk screening. In the left breast at 3:00 there is a 1.0-cm linear nonmass enhancement (arrow), seen on both MIP image (A) and corresponding first postcontrast subtraction images (B). There is no correlate on T2-weighted images (C). MR imaging guided biopsy yielded high-grade DCIS. The arrowhead denotes an incidental, stable, intramammary lymph node with corresponding increased T2-weighted signal.

Fig. 3.

Fig. 3.

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A 45-year-old woman with a strong family history of breast cancer presenting for high-risk screening. Annual mammogram demonstrates heterogeneously dense breasts (A). MIP image (B) and corresponding first postcontrast image (C) are negative. Compared with routine diagnostic breast MR imaging, abbreviated breast MR imaging interpretation time has been reported as less than 2 minutes on average.

Usefulness of Additional Postcontrast Sequences

The most commonly described abbreviated MR protocol includes only a single early postcontrast sequence, and there are few studies of later postcontrast sequences. In the American College of Radiology Breast Imaging and Reporting Data System lexicon, enhancement of breast lesions is broken into the initial phase, which represents peak enhancement in the first 2 minutes, and the delayed phase, which occurs after 2 minutes.30 The signal intensity over time creates a time intensity curve, which may show persistent, plateau, or washout enhancement. The time–intensity curves are known to be differently distributed among malignant and benign lesions, with significant overlap.31 In adding additional postcontrast sequences to the abbreviated protocol, investigators seek to capture some of the kinetic information that is available in the full MR imaging protocol.

A reader study of 48 high-risk screening MR imaging studies comparing a full protocol with abbreviated protocols with only the first postcontrast sequence versus with the addition of the second postcontrast sequence found no significant difference in sensitivity and specificity between the protocols.32 In fact, the addition of the second postcontrast sequence resulted in a nonsignificant trend toward a lower specificity compared with the first postcontrast sequence only. In this study, scan time for each sequence was 2 minutes, such that the second postcontrast sequence was in the early delayed phase (or intermediate phase).

Seeking to capture information from the intermediate phase of the postcontrast period, Moschetta and colleagues33 evaluated an abbreviated protocol using a more delayed single postcontrast sequence obtained 3 minutes after injection. In comparison with the full dynamic contrast-enhanced MR imaging, there was no difference in sensitivity, specificity, or accuracy. The authors argue that, rather than attempt to evaluate dynamic enhancement over time, their protocol preferentially evaluated the presence of enhancement and the morphology of lesions on high-resolution postcontrast images. However, note that the authors did not compare their abbreviated protocol with this delayed sequence with a more abbreviated protocol using only an earlier postcontrast sequence.

Choudhery and colleagues34 compared full dynamic contrast-enhanced MR imaging with an abbreviated MR imaging protocol composed of 2 postcontrast sequences. These sequences were centered at 60 to 75 seconds and 180 to 205 seconds after injection and the investigators generated time–intensity curves. They found no significant differences in the time–intensity curve types of benign versus malignant lesions as obtained with either the full or abbreviated protocol. Malignant lesions seen on the abbreviated protocol demonstrated persistent time–intensity curve in 60.7% of lesions, plateau curve in 24.6%, and washout in 14.8%, which was not significantly different from the full protocol. However, with the full protocol, there was a nonsignificant trend toward more washout and fewer plateau curves in malignant lesions as compared with the abbreviated protocol, similar to the findings of Partridge and colleagues.35 Note that this was not a reader study and the clinical usefulness of the time– intensity curves was not assessed. However, this study demonstrated significant overlap between worst curve types seen in benign and malignant lesions, suggesting kinetic information may not have improved lesion characterization.

Park and colleagues36 compared screening women with a personal history of breast cancer with a full MR imaging protocol versus an abbreviated protocol composed of 2 postcontrast sequences, each of which was 1 minute long. The investigators found the abbreviated MR imaging protocol resulted in decreased sensitivity, increased specificity, and similar accuracy compared with the full MR imaging protocol. In this study, the inclusion of the second sequence was likely important to the sensitivity of the abbreviated examination given that this sequence was timed within the initial phase of lesion enhancement. Therefore, in determining the usefulness of multiple postcontrast sequences, the postcontrast acquisition time of each sequence must be specified given the variability in MR imaging protocols. Overall, adding additional postcontrast sequences beyond the FAST acquisition seems to lengthen imaging time without clinical benefit.

Ultrafast Imaging

An essential premise of abbreviated breast MR imaging is that the first postcontrast images are when cancers are most visible compared with background parenchymal enhancement and that more delayed postcontrast imaging does not increase sensitivity. However, omission of the delayed postcontrast acquisitions also limits kinetic analysis of gadolinium wash-out, which can provide important information for lesion characterization.31 A proposed substitute is to instead evaluate the wash-in of contrast on abbreviated MR imaging, using new ultrafast and accelerated breast MR imaging techniques. These imaging sequences exploit various k-space undersampling and view-sharing techniques to continuously sample the center of k-space while sparsely sampling peripheral regions of k-space over time, allowing for temporal resolution of 10 frames per second or less with relative preservation of spatial resolution.28,37,38 Ultrafast sequences can therefore image the wash-in of contrast every 1 to 10 seconds during the first 1 to 2 minutes postcontrast, compared with a standard temporal resolution of 2 to 3 minutes in routine diagnostic breast MR imaging. This protocol allows for early visualization of angiogenic lesions with minimization of background parenchymal enhancement (Fig. 4).

Fig. 4.

Fig. 4.

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A 42-year-old woman with BRCA1 mutation presenting for high-risk screening while breastfeeding. MIP images (A) and first postcontrast T1-weighted images (B) demonstrate diffuse marked background parenchymal enhancement consistent with lactational changes and limiting sensitivity for breast cancer detection. However, ultrafast time-resolved angiography with interleaved stochastic trajectories images with 4-second temporal resolution after contrast injection performed on a 3.0T magnet (C) demonstrate no early wash-in of contrast in either breast at 12-second postcontrast injection, consistent with a negative study. Use of ultrafast imaging to evaluate early wash-in of contrast allows for evaluation of the breasts at optimal timing to minimize background parenchymal enhancement. In this abbreviated protocol, ultrafast imaging is performed with a slightly decreased spatial resolution and then followed by a high spatial resolution volumetric interpolated breath-hold examination sequence to allow for lesion characterization.

Investigation of early contrast wash-in as measured by ultrafast techniques has demonstrated important differences between malignant and benign lesions. One such ultrafast abbreviated breast MR imaging protocol by Mann and colleagues28 used time-resolved angiography with interleaved stochastic trajectories imaging to evaluate 160 patients, with maximum slope of contrast wash-in demonstrating higher area under the curve (0.829) than standard Breast Imaging and Reporting Data System criteria (AUC, 0.692). In addition to maximum slope, enhancement ratios also differ between benign and malignant lesions; Abe and colleagues39 evaluated the initial enhancement rate and signal enhancement ratio in 62 lesions and found increased initial enhancement rate and signal enhancement ratio correlated with malignancy. Although ultrafast kinetic information remains experimental, it seems to offer valuable supplemental information similar to the role of kinetic curve wash-out information in full diagnostic breast MR imaging.

T2-Weighted Imaging

Although T1-weighted precontrast and postcontrast images are the mainstay of abbreviated breast MR imaging, T2-weighted images are considered a minimal requirement for American College of Radiology breast MR imaging recommendation23 and are often included in abbreviated MR imaging protocols. In early studies of diagnostic breast MR imaging, T2-weighted images were shown to improve lesion characterization and showed40,41 usefulness in distinguishing benign from malignant lesions. More recent studies evaluating modern breast MR imaging have shown mixed usefulness.10 However, a perceived drawback of abbreviated MR imaging is that it may result in more short-term follow-up studies than full diagnostic breast MR imaging.21,42 As such, inclusion of T2-weighted imaging may be of interest in future studies to decrease Breast Imaging and Reporting Data System 3 recommendations and decrease unnecessary short-term follow-up (Fig. 5).

Fig. 5.

Fig. 5.

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A 32-year-old BRCA-positive woman presenting for high-risk screening. A mammogram performed 6 months earlier (A) demonstrates heterogeneously dense breasts with no mammographic abnormality. An oval circumscribed mass (arrow) in the right breast at 10:00 anterior depth is seen on MIP image (B) and first postcontrast subtraction images (C) with no correlate on T2-weighted images (D). Although the addition of T2-weighted sequences has not been demonstrated to increase cancer detection rates, it improves reader confidence in diagnosis and may decrease short-term follow-up recommendations in the screening setting. MR imaging-guided biopsy found invasive ductal carcinoma.

Heacock and colleagues26 found the addition of T2-weighted imaging did not change cancer detection rate in a series of 107 known unilateral breast cancers. However, all 3 readers reported that reviewing the T2-weighted images increased lesion conspicuity. Adding T2-weighted images increased scan time to 5 minutes, but only increased reader interpretation time by 5 to 10 seconds. The authors noted that, because the study was performed in a population of known breast cancers, the usefulness of T2-weighted imaging may be limited in changing diagnostic accuracy; T2-weighted imaging is likely most helpful in the screening setting. In a subsequent study, Strahle and colleagues43 evaluated various protocol combinations in evaluating 452 mixed benign and malignant lesions. Statistical analysis demonstrated that the most effective sequence order and inclusion was T2-weighted images, T1-weighted precontrast, and T1-weighted first and late postcontrast breast MR imaging had the greatest sensitivity and specificity in breast cancer screening. The total scan time for this protocol was 7.5 minutes.

Although abbreviated MR imaging both with and without T2-weighted imaging demonstrate similar accuracy, many early studies were not performed in pure screening populations. Numerous studies have subsequently included T2-weighted imaging without specifically evaluating the impact of this sequence, including the recent Eastern Cooperative Oncology Group-American College of Radiology Imaging Network 1141 multicenter trial. Standardized MR imaging interpretation in EA1141 specifically includes the presence or absence of T2-weighted imaging in determining whether or not to biopsy or follow an enhancing lesion on screening MR imaging.19 It remains undetermined if the inclusion of T2-weighted imaging changes breast cancer detection, but similar to full diagnostic imaging, it likely is most valuable in increasing specificity and biopsy positive predictive value.

Noncontrast, Diffusion-Weighted Imaging, and Multiparametric Imaging

With the concerns about safety of gadolinium containing contrast agents and the recommendation that gadolinium-based contrast should only be administered when necessary,44 noncontrast protocols have been studied with some encouraging results. DWI is a noncontrast MR technique that measures the random motion of water molecules in tissue, reflecting the cellular microenvironment. Studies of noncontrast abbreviated MR protocols with combinations of DWI with T1-weighted and/ or T2-weighted sequences yielded sensitivities of 45% to 78% for the detection of malignancy.45,46 These sensitivities are at least similar to46 or higher than mammography,45 but do not compare favorably with the higher sensitivity for cancer detection of contrast-enhanced MR imaging. This finding suggests that DWI may not be ready for use as a stand-alone screening technique. However, DWI has shown promise in lesion characterization, demonstrating similar accuracy for characterizing benign from malignant lesions as contrast-enhanced MR imaging.47–49 A study of patients with mammographically detected suspicious lesions used an abbreviated MR imaging protocol of DWI and T2-weighted imaging to characterize the lesions, with a negative predictive value of 0.92 and a positive predictive value of 0.93, which were higher than an abbreviated protocol of the first postcontrast sequence.47

The combination of a contrast-enhanced sequence for cancer detection and a DWI sequence for lesion characterization seems to show the most promising results for sensitivity and specificity.50 A study of screening MR imaging in 356 women found that an abbreviated protocol including DWI had higher sensitivity and specificity than an abbreviated protocol without DWI, with similar sensitivity and specificity as the full protocol.24 The limitations of DWI have been shown to be in the detection of invasive lobular carcinoma, mucinous cancers, invasive cancers presenting as diffuse nonmass enhancement, and lesions smaller than 12 mm.50

EASTERN COOPERATIVE ONCOLOGY GROUP-AMERICAN COLLEGE OF RADIOLOGY IMAGING NETWORK TRIAL RESULTS AND TRIALS IN DEVELOPMENT

The recently published EA1141 trial (Comparison of abbreviated breast MR imaging and DBT in breast cancer screening in women with dense breasts) is a study comparing abbreviated MR imaging against DBT.19 The investigators enrolled 1510 asymptomatic, average-risk women with dense breasts to undergo both DBT and abbreviated MR imaging screening examinations on the same day. The results of the first round of screening showed that the invasive cancer detection rate of abbreviated MR imaging was more than double that of DBT (11.8 per 1000 compared with 4.8 per 1000). Of the 23 cancers identified, abbreviated MR imaging identified 22 cancers (17 invasive and 4 DCIS) and missed a case of DCIS. DBT identified only 9 cancers (7 invasive and 2 DCIS). Of the 17 total invasive cancers identified in the study, 3 were high grade and all of these were only identified by MR imaging and were missed on DBT. This result is consistent with the prior observation by Sung and colleagues15 that MR imaging detects higher grade tumors than mammography.

The first-round results of EA1141 show the promise of abbreviated MR imaging as an adjunct screening test in average-risk women. Follow-up is ongoing; patients will undergo a second round of DBT and abbreviated MR imaging screening at the 1-year mark, as an incidence screening round. The EA1141 investigators will also evaluate the types of detected invasive and in situ cancers by genomic profiling, to gain further insight into whether abbreviated MR imaging may identify more biologically aggressive tumors than DBT.

An ongoing large multicenter trial in the United Kingdom, the Breast Screening—Risk Adaptive Imaging for Density (BRAID) trial, will randomize women found to have dense breasts on screening mammography to supplemental screening with either automated breast ultrasound examination, contrast-enhanced spectral mammography, or abbreviated MR imaging (clinicaltrial.gov identifier NCT04097366). There are currently no large trials of abbreviated MR imaging underway in which patients are randomized to be screened with abbreviated MR imaging only, without mammography.

NONSCREENING APPLICATION: EXTENT OF DISEASE EVALUATION

The value of abbreviated MR imaging in the setting of a newly diagnosed cancer has been evaluated by a few small studies. A retrospective reader study of 81 MR imaging studies performed for extent of disease evaluation compared the full protocol MR with an abbreviated MR consisting of precontrast, and first postcontrast T1, MIP, and subtraction sequences.51 Investigators found no difference between the protocols in detecting multifocal, multicentric, contralateral malignancy, or axillary nodal metastasis. A similar study of 87 patients with known cancer found no difference between readers’ additional lesion detection rate between the full protocol and the abbreviated protocol of precontrast and first postcontrast T1 with MIP image.52 In both of these studies, out of a total of 9 false-negative lesions missed on abbreviated MR imaging but detected on full protocol MR imaging, all were DCIS and low-grade invasive carcinomas, other than one 5-mm high-grade IDC missed by 1 reader.52 This outcome suggests that lesions missed by abbreviated MR imaging may not be as clinically relevant in patients who will be treated with locoregional radiation and systemic therapy. Additional research in this area is needed.

LIMITATIONS

Given the lack of delayed postcontrast sequences in most abbreviated MR imaging protocols, slow-enhancing malignancies may be missed. These neoplasms include invasive lobular carcinoma, DCIS, and invasive ductal carcinoma presenting as nonmass enhancement.22,26

In addition, residual invasive or in situ cancer after neoadjuvant therapy may be missed. Neoadjuvant chemotherapy or endocrine therapy, which is administered before breast surgery, may be used in selected patients to shrink tumor size in the breast and axilla. Post-treatment MR imaging is the most sensitive modality to evaluate extent of residual disease and enable accurate surgical planning.53 The antiangiogenic effects of chemotherapy may result in delayed enhancement of residual invasive disease.54 Residual DCIS may also demonstrate delayed enhancement55 and its extent is important to delineate to achieve negative surgical margins and avoid re-excision. For these reasons, the use of abbreviated MR in post-treatment imaging may not be successful and has not been prospectively studied.10

For abbreviated MR imaging protocols that rely on evaluation of the MIP image, lesions at the periphery of the field of view may be missed, such as those in the axilla22,26 and chest wall32 (Fig. 6).

Fig. 6.

Fig. 6.

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A 56-year-old woman with a personal history of atypia and a strong family history of breast cancer, presenting for high-risk screening. An oval, homogenously enhancing 0.8-cm mass in the left breast at 2:00 (arrow) seems to be a benign axillary lymph node on MIP image (A), but is slightly anterior to axillary lymph nodes on corresponding first postcontrast subtraction images (B). However, the mass is new compared with prior MR imaging (C). MR imaging-guided biopsy yielded metaplastic carcinoma. Arrowhead denotes a previously biopsied left breast benign masses. Axillary lesions are a known pitfall of MIP interpretation; this area should be reviewed carefully on first postcontrast images.

CLINICAL IMPLEMENTATION

Research to date has demonstrated that abbreviated breast MR imaging has promise in increasing the use of screening MR imaging. Radiologists are increasingly expected to demonstrate the quality and appropriateness of advanced imaging techniques such as breast MR imaging, particularly as reimbursement and health care policy shift from a fee-for-service model to value-based health care.56 To gain widespread acceptance for supplemental screening, abbreviated breast MR imaging will need to demonstrate that it decreases costs while improving patient outcomes. One ongoing secondary analysis of the recently completed EA1141 study is a cost-effectiveness analysis comparing abbreviated MR imaging with DBT.19It is anticipated that the projected lower cost of this examination combined with its high diagnostic accuracy will result in favorable cost-effectiveness analysis compared with a standard breast MR imaging. Practices seeking to offer abbreviated breast MR imaging in the meantime have important reimbursement and workflow considerations that must be addressed.

Reimbursement

There is currently no Current Procedural Terminology code for abbreviated MR imaging and thus most imaging facilities offering abbreviated breast MR imaging inform patients up front that the study is self-pay and not covered by insurance. Although individual facilities have various inclusion criteria, abbreviated breast MR imaging is often offered to patients at average risk with dense breasts or patients with intermediate lifetime risk as a supplemental screening examination,42 because these women may not meet insurance coverage requirements for MR imaging screening (reserved for high-risk women) and thus have higher out-of-pocket costs. In contrast, patients who have a high lifetime risk of breast cancer usually have routine insurance coverage for breast MR imaging and can undergo the standard diagnostic examination. If a high-risk patient has a high-deductible health insurance plan, however, the patient may also prefer the up-front cost of the abbreviated MR imaging to that of their deductible for the full examination. Considerations when establishing the cost of the examination can include regional pricing for other breast screening examinations and similar screening examinations, such as unhenanced lung cancer computed tomography scans and cardiac calcium scoring.42 In limited states, such as Michigan, abbreviated breast MR imaging is covered by health maintenance organizations.

Clinical Workflow

Clinical workflow implementation remains a key consideration in offering abbreviated breast MR imaging. Of note, the majority of research studies evaluate abbreviated MR imaging time or scan time, which is not equivalent with “table time” or the complete time it takes to evaluate a patient. This time includes preparing the patient for the examination, the scan time, and the time to turn around the room for the next patient. Borthakur and colleagues57 evaluated scan time and complete study time between abbreviated breast MR imaging and full breast MR imaging screening studies and found that scan time for their abbreviated protocol was 17.5 minutes with a total study time of 36 minutes; this compared with scan time of 28.8 minutes for the full protocol and total study time of 50 minutes. When comparing total study time, the abbreviated protocol had only a 38% greater patient flow rate than the standard breast MR imaging despite a 65% decrease in scan time, with increased technologist activity time explaining the discrepancy between scan and study time savings.57 This finding emphasizes that workflow must be optimized to maximize efficiency when implementing abbreviated breast MR imaging, because this information is critical to estimating the price point for an abbreviated study and assessing feasibility for widespread implementation.

A critical look at current and projected workflow for breast MR imaging is therefore important to adding value when implementing an abbreviated protocol. One easy to implement solution is to batch schedule abbreviated breast MR imaging patients in consecutive slots, as suggested by Marshall and colleagues.42 Imaging abbreviated breast MR imaging patients consecutively allows for the technologist workstation setup and breast coil to remain in place, maximizing patient turnaround efficiency. A more challenging solution to implement is to critically evaluate general MR imaging workflow. Space and funds permitting, dockable tables, duplication of coils, and optimizing the patient’s path to the scanner can result in time savings even when scanning a heterogeneous set of daily protocols.58 Finally, workflow considerations need also include radiologist interpretation time. Although reported abbreviated breast MR imaging interpretation time is generally reported to be less than 5 minutes in the research setting,21 this time does not include a review of patient history and prior examinations, both of which can be expected to increase interpretation time.

FUTURE DIRECTIONS

Although it is clear that abbreviated breast MR imaging has promise as a screening examination, identifying the populations most likely to benefit from this examination is ongoing. The use of abbreviated breast MR imaging in preoperative breast MR imaging for assessment of breast cancer extent of disease, in problem solving, and in assessment of neoadjuvant chemotherapy response remain underexplored. Other directions of current research involve the incorporation of ultrafast and other multiparametric sequences10 into abbreviated breast MR imaging to increase both its sensitivity and specificity. Another ongoing area of research is the implementation of deep learning techniques, which may be useful both in the interpretation of screening abbreviated MR imaging59 and in MR imaging reconstruction to provide additional information and further decrease scan time.60

SUMMARY

MR imaging is the most sensitive imaging modality for the detection of breast cancer, far outperforming full-field digital mammography, tomosynthesis, and ultrasound examination. However, the long examination time of breast MR imaging increases the cost and decreases examination availability, making it impractical as a large-scale screening examination. Abbreviated MR imaging has been shown to have similar diagnostic accuracy as full protocol MR imaging, with significantly shortened examination time. Further studies are still needed to standardize the abbreviated protocol, to refine the patient population most likely to benefit from abbreviated MR imaging, and to evaluate outcomes in patients with abbreviated MR imaging -detected cancers.

KEY POINTS.

  • Studies have demonstrated that abbreviated breast MR imaging diagnostic accuracy and sensitivity for breast cancer detection is comparable with that of a full diagnostic protocol in screening populations.

  • Abbreviated breast MR imaging protocols remain under development, but include, at a minimum, precontrast and postcontrast T1-weighted images.

  • Current limitations of abbreviated breast MR imaging include nonscreening applications and the evaluation of invasive lobular carcinomas and low-grade ductal carcinoma in situ.

  • Clinical implementation challenges include the current lack of Current Procedural Terminology coding and minimizing turnaround time as well as imaging time.

  • Future directions include the implementation of ultrafast and multiparametric protocols.

CLINICS CARE POINTS.

  • Abbreviated breast MR imaging has diagnostic accuracy and sensitivity for breast cancer detection comparable to that of a full diagnostic protocol in screening populations

  • Minimal protocol requirements for abbreviated breast MR imaging include precontrast and postcontrast T1-weighted images. T2-weighted imaging may be necessary to meet American College of Radiology breast MR imaging accreditation requirements.

  • The use of abbreviated breast MR imaging in nonscreening applications (eg, known breast cancer extent of disease evaluation, problem solving, and postneoadjuvant chemotherapy evaluation) remains under investigation.

  • Clinical challenges to implementation include reimbursement considerations and optimization of workflow to maximize patient turnaround.

Footnotes

DISCLOSURE

The authors state no relevant conflict of interest or financial disclosures.

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