Who should a patient with abnormal breast MRI findings and a recommendation for targeted breast ultrasound (US) and biopsy be referred to?

Referral for Abnormal Breast MRI Requiring Targeted Ultrasound and Biopsy

Patients with abnormal breast MRI findings recommending targeted ultrasound and biopsy should be referred to a breast surgeon or a dedicated breast center with multidisciplinary capabilities including breast imaging specialists capable of performing image-guided biopsies. 1

Rationale for Specialist Referral

• Breast Imaging Specialists: Targeted ultrasound following MRI requires specialized expertise to correlate MRI findings with ultrasound imaging 2

  • Correlation rates vary significantly by lesion morphology: 49.3% for masses, 15% for non-mass enhancements, and 42.3% for foci 2
  • Requires dedicated breast imaging equipment and experienced personnel 3

• Breast Surgeons: Can coordinate comprehensive care if biopsy reveals malignancy

  • Provide surgical expertise if needed following diagnosis
  • Can manage both benign and malignant findings

Diagnostic Pathway Following Abnormal MRI

1. Targeted Ultrasound: First step for evaluating MRI-detected abnormalities 2

   • Allows for real-time imaging and potentially ultrasound-guided biopsy
   • More accessible and cost-effective than MRI-guided biopsy
   • Should be performed by radiologists experienced in breast imaging

2. Biopsy Options Based on Ultrasound Findings:

   • If ultrasound correlate found: Ultrasound-guided core needle biopsy (preferred over fine needle aspiration) 1
   • If no ultrasound correlate: MRI-guided biopsy will be necessary 3
     • Requires specialized equipment and expertise
     • Time-consuming and complex procedure 3

Importance of Specialized Care

• Diagnostic Accuracy: Proper correlation between MRI and ultrasound findings is crucial for accurate diagnosis

  • MRI has high sensitivity (88.1%) but moderate specificity (67.7%) for breast cancer 4
  • Targeted ultrasound improves specificity and guides appropriate biopsy method

• Comprehensive Management: Breast centers offer coordinated care including:

  • Advanced imaging capabilities
  • Image-guided biopsy expertise
  • Multidisciplinary treatment planning if malignancy is found

Common Pitfalls to Avoid

• Delayed Referral: Abnormal MRI findings classified as BI-RADS 4 or 5 require prompt tissue sampling 5

  • Delays in biopsy can lead to delayed diagnosis and treatment

• Inadequate Imaging Expertise: Not all radiologists have specialized training in breast imaging

  • Targeted ultrasound correlation requires specific expertise to locate MRI-detected lesions

• Fragmented Care: Referral to facilities without comprehensive breast imaging and biopsy capabilities may result in multiple appointments and delayed diagnosis

Special Considerations

• Occult Breast Cancer: For patients with suspicious MRI findings not visible on conventional imaging, referral to centers capable of performing MRI-guided biopsy is essential 5

• High-Risk Patients: Those undergoing MRI screening due to high breast cancer risk benefit from specialized breast centers with experience managing this population 6

By referring to a breast surgeon or dedicated breast center, patients receive coordinated care with appropriate expertise for both imaging correlation and potential surgical management if needed.