Korean J Radiol.  2016 Oct;17(5):695-705. 10.3348/kjr.2016.17.5.695.

Real-Time MRI Navigated Ultrasound for Preoperative Tumor Evaluation in Breast Cancer Patients: Technique and Clinical Implementation

• Park AY
• Seo BK

• KMID: 2458061
• DOI: http://doi.org/10.3348/kjr.2016.17.5.695

Abstract

Real-time magnetic resonance imaging (MRI) navigated ultrasound is an image fusion technique to display the results of both MRI and ultrasonography on the same monitor. This system is a promising technique to improve lesion detection and analysis, to maximize advantages of each imaging modality, and to compensate the disadvantages of both MRI and ultrasound. In evaluating breast cancer stage preoperatively, MRI and ultrasound are the most representative imaging modalities. However, sometimes difficulties arise in interpreting and correlating the radiological features between these two different modalities. This pictorial essay demonstrates the technical principles of the real-time MRI navigated ultrasound, and clinical implementation of the system in preoperative evaluation of tumor extent, multiplicity, and nodal status in breast cancer patients.

Keyword

Breast neoplasm; Magnetic resonance imaging; Ultrasonography; Navigation; Image correlation

MeSH Terms

Adult
Aged
Breast Neoplasms/*diagnostic imaging/pathology/surgery
Combined Modality Therapy/methods
Female
Humans
Image-Guided Biopsy/methods
Lymphatic Metastasis
Magnetic Resonance Imaging/instrumentation/methods
Middle Aged
Preoperative Care/methods
Ultrasonography, Interventional/instrumentation/methods

Figure

• 

  Fig. 1 Equipment of MRI navigated ultrasound. A. Two electromagnetic sensors (arrows) are attached to tip of transducer. B, C. Portable electromagnetic transmitter (white arrowhead) is positioned near patient undergoing examination. Position-sensing unit (black arrowhead) connects electromagnetic sensors and transmitter, which allows tracking probe position and orientation within electromagnetic field.

• 

  Fig. 2 43-year-old female with multiple cancers in ipsilateral breast. Breast ultrasound (A) and contrast-enhanced axial T1-weighted MRI (B) images show biopsy-proven invasive ductal carcinoma (arrows) in 1 o'clock direction on left breast. MRI image (C) depicts another 19 mm-sized heterogeneous non-mass enhancement (white arrowheads) in 3 o'clock direction on left breast. Real-time MRI navigated ultrasound (D) identified indistinct irregular isoechoic mass (arrowheads). Mass was diagnosed as invasive ductal carcinoma, and patient underwent breast conserving surgery for multifocal breast cancers.

• 

  Fig. 3 37-year-old female with multiple cancers in ipsilateral breast. Breast ultrasound (A) and contrast-enhanced axial T1-weighted MRI (B) images show biopsy-proven invasive ductal carcinoma (arrows) in 1 o'clock direction on right breast. MRI and computer-aided detection images (C) depict another 6 mm-sized circumscribed oval mass (white arrowhead) with early fast and delayed plateau enhancement pattern in right subareolar area. Real-time MRI navigated ultrasound (D) identified microlobulated oval isoechoic mass (arrowheads) in right subareolar area. Ultrasound-guided core needle biopsy verified this mass as ductal carcinoma in situ, and patient underwent modified radical mastectomy. Final pathologic result was multiple invasive ductal carcinomas.

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  Fig. 4 49-year-old female with bilateral synchronous cancers. Contrast-enhanced axial T1-weighted MRI image (A) shows diffuse heterogeneous non-mass enhancement (arrows) in right breast, biopsy-proven invasive ductal carcinoma, and multiple enhancing masses (arrowheads) in left breast. Real-time MRI navigated ultrasound transverse (B) and longitudinal (C) images depict irregular indistinct hypoechoic mass (arrowheads) in left breast 2 o'clock direction. Mass was diagnosed as invasive ductal carcinoma, and patient underwent bilateral modified radical mastectomy.

• 

  Fig. 5 40-year-old female with concurrent high-risk lesion in ipsilateral breast. Breast ultrasound (A) and contrast-enhanced T1-weighted MRI (B) images show biopsy-proven invasive ductal carcinoma (arrows) in 2 o'clock direction on left breast. MRI (C) depicts another 10 mm-sized focal non-mass enhancement (white arrowheads) in left inner mid portion. Real-time MRI navigated ultrasound (D) identified irregular isoechoic mass (arrowheads) in left 9 o'clock direction. Lesion was diagnosed as atypical ductal hyperplasia. Patient underwent breast conserving surgery for invasive ductal carcinoma, and excisional biopsy for atypical ductal hyperplasia.

• 

  Fig. 6 46-year-old female with ductal carcinoma in situ showing discordant tumor extent on mammography, ultrasound, and MRI. Magnification mammography (A) shows grouped fine pleomorphic calcifications in right breast. Ultrasound image (B) shows 12 mm-sized focal ductal change with microcalcifications (arrows) in 9 o'clock direction on right breast. Contrast-enhanced T1-weighted MRI image (C) shows 50 mm-sized segmental non-mass-enhancement (white arrowheads) in right mid outer breast, which was not well correlated with mammographic or ultrasound features. Real-time MRI navigated ultrasound (D) identified 45 mm-sized ductal change (arrowheads) in right 9 o'clock direction. Patient underwent ultrasound-guided wire localization at proximal and distal ends of lesion, and breast conserving surgery. Pathological tumor size was 40 mm.

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  Fig. 7 30-year-old female with invasive ductal carcinoma on right breast and ipsilateral axillary lymph node metastasis. Real-time MRI navigated ultrasound image (A) shows biopsy-proven invasive ductal carcinoma (arrows) in 11 o'clock direction on right breast. MRI (B) depicts ill-defined lymph node (white arrowhead) in right axilla, which was not detected on initial ultrasound examination. Real-time MRI navigated ultrasound (C) identified 11 mm-sized lymph node with cortical thickening (arrowheads). Ultrasound-guided core needle biopsy for this lymph node verified metastasis.

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