Value of MRI in medicine: More than just another test?

Abstract

There is increasing scrutiny from healthcare organizations towards the utility and associated costs of imaging. MRI has traditionally been used as a high-end modality, and although shown extremely important for many types of clinical scenarios, it has been suggested as too expensive by some. This editorial will try and explain how value should be addressed and gives some insights and practical examples of how value of MRI can be increased. It requires a global effort to increase accessibility, value for money, and impact on patient management. We hope this editorial sheds some light and gives some indications of where the field may wish to address some of its research to proactively demonstrate the value of MRI. Level of Evidence: 5 Technical Efficacy: Stage 5 J. Magn. Reson. Imaging 2019;49:e14-e25.

Keywords: MR imaging; accessibility; costs; management; patient-centered; value.

FIGURE 1:

Paired study design.

FIGURE 2:

Modified marker strategy design.

FIGURE 3:

A 54-year old woman, no family history. Digital mammography exhibits heterogeneously dense breast (ACR 3 or C) (a). Breast MRI reveals invasive breast cancer in the right breast, plus a DCIS (b). MR-guided biopsy (c) revealed high-grade, ER/PR-negative, Her2-positive breast cancer plus high-grade DCIS.

FIGURE 4:

Screening of the liver for hepatocellular carcinoma (HCC) using dynamic contrast enhanced (DCE) MRI can be performed as part of a focused liver screening protocol. In this example from a 61-year-old woman with NASH, a 4.9 cm HCC in segment IV of the liver was identified and characterized as an OPTN 5b / LI-RADS 5 lesion using just four breath-holds requiring ~5 minutes of table time. All of the features needed to characterize this lesion can be ascertained from this exam, including arterial phase enhancement (late arterial T₁w), washout (2-min delayed T₁w), and capsular rim enhancement (portal venous T₁w).

FIGURE 5:

Pulmonary MRA can be performed to evaluate patients for pulmonary embolus in 3–4 15–20-second breath-holds: pre-contrast, arterial phase, and 1–2 delayed phase T1-weighted MRA acquisitions, requiring ~5–10 minutes of table time. In this example, right lower lobe pulmonary emboli are shown in a 22-year-old female presenting with acute chest pain and dyspnea (yellow arrows). Shown are the arterial phase images in coronal (acquired) orientation and axial and cropped double oblique multiplanar reformats (MPR).

FIGURE 6:

A 5-minute knee MRI protocol demonstrating morphometric and semiquantitative assessment of cartilage.

FIGURE 7:

Images from a prospectively performed biparametric prostate MRI exam consisting of T₂-weighted and diffusion imaging in a patient with prior negative biopsies. Imaging time was 11.9 minutes, table time 15 minutes. There is an anterior transition zone lesion that is Category 5 by PIRADs v. 2, with low T₂-weighted signal (left), persistent signal on b = 1400 s/mm² image (middle), and low apparent diffusion coefficient (right).

FIGURE 8:

A 69-year-old patient, prostate-specific antigen (PSA) 6.3 ng/ml, increasing. Underwent TRUS-guided biopsy four times, always with benign results. Abbreviated (biparametric) prostate MRI shows suspicious lesion in anterior zone (PIRADS-5). Histology on MR-guided targeted biopsy: prostate cancer, Gleason 8 (4 + 4).

FIGURE 9:

Comparison of 18F FDG-PET and arterial spin labeling MRI, demonstrating decreased metabolism corresponding with decreased perfusion (arrows). With permission from: Pizzini F, Smits M, Wesolowski R, et al. Arterial spin labelled MRI perfusion imaging techniques. In: Perfusion imaging in clinical practice: a multimodality diagnostic approach to tissue perfusion analysis. Saremi F (ed). Philadelphia: Wolters Kluwer; 2015. ISBN 978–1-4511–9316-9