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sings in MRI-Mammography.pdf Werner A. Kaiser Signs in MR-Mammography 123 Werner Alois Kaiser, M.D., M.S. Professor and Chairman Department of Diagnostic and Interventional Radiology Friedrich-Schiller University Hospital Erlanger Allee 101 07740 Jena Germany www.mediteach.de www.uni-jena.de/med/idir werner.kaiser@med.uni-jena.de Received: 8 May 2007; Corrected: 27 September 2007 ISBN 978-3-540-73292-1 Springer Berlin Heidelberg New York Library of Congress Control Number: 2007933374 This work is subject to copyright. All rights are reserved, wether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broad-casting, reproduction on microfilm or any other way, and storage in data banks. 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Editor: Dr. Ute Heilmann, Heidelberg, Germany Desk Editor: Wilma McHugh, Heidelberg, Germany Reproduction, typesetting and production: LE-TEX Jelonek, Schmidt & Vöckler GbR, Leipzig, Germany Cover design: Frido Steinen-Broo, eStudio, Calamar, Spain Printed on acid-free paper 21/3180/YL 5 4 3 2 1 0 SPIN 12078301    Preface A teacher of mine once said, “If we had a diagnostic method that enabled us to detect and remove all breast cancers 5 to 10 mm in size, we could practically eliminate breast cancer deaths.” Large screen- ing studies in Scandinavia and other countries have documented the truth of this statement. The 20-year survival rate is very high (over 95%) when the initial tumor size is less than 1 cm. We are faced with a major medical problem. Breast cancer is the leading cause of cancer-related deaths in women, and its incidence and prevalence have been steadily rising in recent decades. It commonly affects young women and the mothers of small children – a segment of the population that “ought not to die.” The medical problem becomes even more tragic when we consider the rela- tively slow growth rates of most breast carcinomas. As a rule, breast cancers are very slow-growing tumors that take years or decades to reach a size of 1 cm. Nature has actually given us a very large time window for detecting and treating breast cancer. This is quite different from pancreatic cancer or glioblastoma, where almost all patients die within a year after diagnosis. Magnetic resonance imaging (MRI) of the breast, known also as magnetic resonance mammog- raphy (MRM), can solve the problem of high breast cancer mortality. MRM is sensitive enough to detect breast tumors as small as 3 mm in diameter. The problem with MRM is its long learning curve. The method is still relatively new, somewhat complicated, has numerous pitfalls, and requires experience in analyzing more than 1000 images per breast. Benjamin Franklin once said, “Beware of young doctors and old barbers.” I have had to learn a great deal since 1983. It has been like a long trek through the jungle, where you first hack out a path with a machete, then make a road, and finally build a highway. Sometimes I wonder why it took me so long to make these discoveries. But today I understand the many mistakes that have been made in the past, and I know that we are still making mistakes that will have to be un- derstood and corrected in the future. Albert Salomon first described the x-ray appearance of breast cancer in 1913. When I consider how far modern x-ray mammography has come with special x-ray tubes, compression, digital technology, very high spatial resolution, computer postprocessing, etc., I realize that even after 20 years, MRM is still in its infancy. There is still a long way to go before MRM becomes an established, routine imaging procedure throughout the world. I wrote my first book (MR Mammography, Springer, 1993) 10 years after I began working with this modality, but even then it was much too soon. Scarcely any book was criticized as harshly as mine: “By the time readers buy this book, probably all of the material will prove to be obsolete” (Radiology 191,1:148 1994). In the years since then, however, MRI has become widely utilized in the diagnosis of breast cancer. More than 3000 publications on breast MRI are listed in PubMed, and I know of no publication during the past 5 years that has not documented the substantial value of MRM relative to conventional mammograms or even the combination of mammograms and breast ultrasound. Nevertheless, I am struck by the problem that there are still no recognized international standards for performing MRM, and that much of the morphologic and dynamic information contained in breast MR images has not yet been adequately explored or utilized. Too many women today are still I   undergoing unnecessary breast biopsies and excisions that may cause significant disfigurement and distress, not to mention the tremendous costs. The experience of the past 20 years has shown that when the information supplied by MRM is fully utilized, this modality can detect even small lesions and can reliably discriminate between benign and malignant tumors. The goal of this book is to describe and qualitatively interpret all previously known morphologic and kinetic signs in breast MRI. I am well aware that some indications are well evaluated through numerous investigations and studies, while others are based on observations of relatively small num- bers of patients. Most of these indications should have been published by now, so many diagnosti- cians can find them on the images, and thus a faster global evaluation can ensue. There is a saying: „You only see what you know“. The quantitative accuracy of these signs will be addressed in future publications, with the object of making our interpretations as accurate as possible and minimizing the rates of false-negative and false-positive diagnoses. Unnecessary biopsies, with their attendant costs, complications and distress, should be reduced to an absolute minimum. Basically, MRM images a breast with the highest possible spatial and temporal resolution follow- ing the injection of a contrast agent so that early morphologic and pathophysiologic signs of malig- nancy, such as tumor angiogenesis, can be recognized and identified. A consistent scheme is used throughout this book for describing the morphologic and kinetic signs of a breast lesion: 1. Definition of the sign 2. Explanatory diagram 3. Clinical example 4. Medical interpretation The sequence in which the signs are described is purely arbitrary and is simply based on the method- ology that I have followed over the years when reading breast images. MR mammography is still evolving, but at a relatively slow pace – typical of any evolutionary pro- cess in medicine. Yet women deserve a better and more expeditious application of this technology so that they can live longer, happier lives free of breast cancer. This book is intended to help broaden and expedite the clinical application of MRM so that as many physicians as possible can make more accurate and confident diagnoses. In the future, the results of MRM will be subjected to a computer- based data analysis to further improve its accuracy. I have to express sincere thanks to: – my wife Ursula for her love and patience during the past 34 years and for her constant support and discussions both as a partner and as a patient, even at times when I was heavily engaged in scientific debates. – my children Clemens, Simon, Daniel, Birgit, and Ulrich for our wonderful family life, past and present. – I especially received many valuable suggestions from my son Clemens, who studies medicine with utmost interest. All of my former and present colleagues at the Nuremberg Hospital, Bonn Uni- versity Hospital, Würzburg University Hospital, and Jena University Hospital. a Preface II   – my secretary Mrs. Maren Mihlan for her valuable help in typing this manuscript. – Springer Publishers for their support in the publication and layout of this book. I hope that my readers will enjoy this book and that as many patients as possible will benefit from its use. Jena, May 2007 Werner Alois Kaiser, M.D., M.S. ...