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A biopsy guided by magnetic resonance imaging can find breast cancers that mammography and ultrasound can't see, and Regina Hamilton is grateful for that.
Hamilton had been having yearly mammograms since age 28 because her dense, fibrocystic breasts often produced new lumps. She had already had two biopsies, the first at age 20. So when she felt an unusual thickening more than a year ago, it didn't raise concerns, but it brought the St. Mary's, Ga., resident back to Mayo Clinic in Jacksonville for an unplanned mammogram.
MR-guided breast biopsies are a much-needed, long-awaited technology, says Dr. Elizabeth DePeri.
The X-ray showed a subtle change but nothing specific. Dense tissue and abnormal tissue both show up white on X-ray mammography, and it's sometimes difficult to tell them apart. An ultrasound scan, which can see through dense tissue and is used to distinguish a cyst from a solid mass, is usually done when mammography doesn't provide all the answers. Hamilton's ultrasound wasn't specific for cancer.
The final option, when mammography and ultrasound aren't conclusive, is a magnetic resonance (MR) scan of the breasts. MR scans take about 45 minutes and produce hundreds of pictures, each showing a thin slice of breast tissue, which a computer compiles into images that can be studied from all directions. MR scans look for masses like the other imaging techniques do. But breast tissue density doesn't matter, since MR focuses on increased vascularization, or new blood vessels, that feed tumors. Highlighted by the injection of a special dye, breast tumors "light up" on MR scans.
Radiologist Dr. Elizabeth DePeri saw what she called a "mild enhancement" but nothing definitely abnormal on Hamilton's MR scans. Six months later, her mammogram showed a slight change, but the ultrasound and MR were unchanged. "It was worrisome enough that we wanted short-term follow-up," says Dr. Betty Mincey, director of Mayo's Multispecialty Breast Clinic in Jacksonville. With some changes to watch but no definite abnormality to target for biopsy, patients are typically followed closely, as Hamilton was. In early 2003, the area being watched showed concerning changes on the MR scans.
MR-guided breast biopsies can streamline care, says Dr. Elizabeth DePeri.
Normally, this would have posed a problem for physicians. Clearly there was something changing in Hamilton's breast, and that called for a biopsy. The preferred method is to obtain tissue samples using a hollow needle inserted through the skin and guided to the suspicious area via mammography or ultrasound. Such needle biopsies leave minimal scarring and no deformity. They cost less than surgical biopsies, require only a topical anesthetic, can be done in less than an hour and have virtually no complications. They are just as reliable as surgical biopsies but much easier on the patient.
However, when the suspicious area isn't clearly visible on mammography or ultrasound,the radiologist has no means to sample the area with a needle or mark it for a surgeon to remove for testing.
Fortunately, in late April, Mayo Clinic in Jacksonville was one of four centers in the country that had special equipment to take a biopsy in the MR suite. The specially fabricated, vacuum-assisted needle works in the presence of the magnetic field created by MR because it's powered pneumatically, not electrically.
Thanks to that technology, Hamilton was able to have a simple, through-the-skin biopsy. Laboratory analysis of the tissue detected cancer. At age 36, the wife and mother of two teenaged children was diagnosed with ductal carcinoma in situ, the earliest form of cancer.
"I was upset, of course," Hamilton says. "I wasn't prepared for it." But, she adds, "I'm glad they found it."
"Ductal carcinoma in situ is a frightening diagnosis," Mincey says. "It is breast cancer, but it's cancer in its earliest form, while it's still confined to the milk ducts of the breast. It's the earliest breast cancer we can detect.
"In her case, there was no other way this cancer could have been diagnosed," Mincey says.
Regina Hamilton wasn't prepared for a diagnosis of cancer but feels blessed that it was found so early.
Women with a family or personal history of breast cancer, those who've had previous breast surgery and those with dense breast tissue are often evaluated with MR when mammography is inconclusive. About 250 breast MR scans are done at Mayo in Jacksonville every year. Nineteen MR-guided breast biopsies were done in the first two months the technology was available; five showed cancer. "Those are cancers we couldn't have seen otherwise," DePeri says.
"This is a much-needed, long-awaited technology," DePeri says. 'It's really a shortcut to diagnosis, and it streamlines care quite a bit. "For patients, that means quicker answers and less worry.
"Before we had to find the same problem on ultrasound or mammography, mark it with a wire and send the patient for a biopsy or surgery," DePeri says. "Now we can avoid multiple appointments and possibly a surgical biopsy, get a more definitive sample of the tissue, and there's no question that you're getting the right spot."
No one can say when Hamilton's cancer would have been found otherwise. She has no history of the disease in her family, and although her dense breast tissue makes mammography more challenging, it doesn't by itself increase her risk of developing cancer.
"Had we not followed this potential problem area with MR, the cancer likely would have advanced much more by the time we could see it on mammography," DePeri says.
Although Hamilton's cancer was confined, it had spread in a duct, so a conservative lumpectomy wasn't an option. She had a mastectomy, but no follow-up chemotherapy or radiation was required.
"Having all this work done in one place gave me reassurance," says Hamilton, who had been coming to Mayo for mammograms for several years. "They had all the records, and the radiologists were very good about showing me the scans.
"Before these last problems started, I was hoping to get to 40 without having another mammogram," Hamilton says. "If I hadn't checked my breasts and gone back for tests, it could have been five years before I was diagnosed.
"I look at it as a blessing," she says.
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