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Breast MRI: Technique and Indications Karen Dec M.D. Skagit Radiology, Inc.

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Presentation on theme: "Breast MRI: Technique and Indications Karen Dec M.D. Skagit Radiology, Inc."— Presentation transcript:

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2 Breast MRI: Technique and Indications Karen Dec M.D. Skagit Radiology, Inc.

3 Fundamentals of Contrast Enhanced Breast MRI Principles of Breast MRI Principles of Breast MRI Technique Technique Adjunctive Ultrasound Adjunctive Ultrasound Clinical Indications Clinical Indications Accuracy Accuracy

4 Principles of Breast MRI Angiogenesis = Abnormal tumor vessels produce neovascularity Top left: Implanted cancer cells glow with green fluorescence protein. Top right: Three of the original cancer cells have survived to begin replicating. Signals between the existing blood vessel and the growing cancer cells cause the cells to grow toward the vessel. Bottom left: The cancer cells have reached the existing blood vessel. Bottom right: When they number only , the cancer cells have created new, fully-functioning blood vessels. Graphic illustration by Stanley Coffman, Duke University Medical Center

5 Principles of Breast MRI Neovascularity characterized by: Low resistance, high flow Low resistance, high flow AV shunting, pooling AV shunting, pooling Abnormal endothelial permeability Abnormal endothelial permeability Cancers enhance early and intensely Cancers enhance early and intensely

6 Principles of Breast MRI Virtual Map of Angiogenesis Virtual Map of Angiogenesis Pre-Contrast Post -Contrast Pre-Contrast Post -Contrast

7 Technique Overview Prone positioning Prone positioning Breast placed in individual holders within coils Breast placed in individual holders within coils Images obtained prior to and following gadolinium administration Images obtained prior to and following gadolinium administration 6 imaging sequences 6 imaging sequences - Spatial resolution - Spatial resolution - Temporal resolution - Temporal resolution

8 Technique: MRI Sequences Coronal Stir Chest Lymph Nodes Lymph Nodes Axillary Axillary Supraclavicular Supraclavicular Internal mammary Internal mammary Lung Parenchyma Lung Parenchyma Liver Liver Bones Bones

9 Technique: MRI Sequences Axial Stir Breast Lymph Nodes Lymph Nodes Edema Edema Cysts Cysts STIR axial MR image shows marked asymmetry in appearance of breasts. Left breast has diffusely increased signal within parenchyma and skin, suggesting diffuse breast edema and skin thickening (arrow).

10 Technique: MRI Sequences Axial Pre-Contrast and Dynamic Post-Contrast 3D FLASH x 5 Cancers Cancers Other Masses Other Masses Draining Veins Draining Veins Pre-Contrast 1 Minute Post-Contrast 4 Minutes Post-Contrast Pre-Contrast 1 Minute Post-Contrast 4 Minutes Post-Contrast

11 Technique: MRI Sequences Axial VIEWS MIPS Volume Interpolated Exam under Water Stimulation High spatial resolution High spatial resolution Entire case can be displayed for clinicians Entire case can be displayed for clinicians

12 Technique: MRI Sequences Diffusion Imaging (DWI) Measures the mobility of water in tissue Measures the mobility of water in tissue Sensitive to characteristics often disrupted in malignant breast tissues, such as cell organization, density, extracellular space and cell membrane permeability Sensitive to characteristics often disrupted in malignant breast tissues, such as cell organization, density, extracellular space and cell membrane permeability DWI may be useful for detecting breast cancer in a wide age group of women, including young women with dense mammary glands.* DWI may be useful for detecting breast cancer in a wide age group of women, including young women with dense mammary glands.* *Radiation Medicine, 2007, Vol. 25:

13 Assessment Morphologic: Similar to mammography and ultrasound Dynamic: Blood flow physiology by evaluating dynamic enhancement curves

14 Dynamic Enhancement Patterns Normal Progressive (monophasic) Plateau (biphasic) Washout

15 Benign Enhancement Pattern Normal Progressive (monophasic)

16 Malignant-like Enhancement Normal Washout

17 Digital Mammography Primary tool for breast cancer screening Primary tool for breast cancer screening Breast MRI is an adjunct Breast MRI is an adjunct Mammogram is more sensitive in detection of Ductal Carcinoma in Situ (DCIS) Mammogram is more sensitive in detection of Ductal Carcinoma in Situ (DCIS) Can determine if lesion amenable to stereotactic guided biopsy Can determine if lesion amenable to stereotactic guided biopsy

18 Adjunctive Breast Ultrasound Accurate, high resolution breast sonography essential in localizing lesions for potential percutaneous needle tissue sampling

19 Clinical Indications Screening of High-Risk Women Pre-Operative Staging Contralateral Breast Cancer in Newly Diagnosed Breast Cancer Lobular Cancer Occult Breast Cancer Close or Positive Surgical Margins Post-operative Scar vs. Tumor Recurrence Neo-Adjuvant Chemotherapy Implants and Known or Suspected Cancer Problematic Mammogram

20 High Risk Screening Annual Breast MRI and Mammography Screening is Recommended for Women Who Have: BRCA1 or BRCA2 gene mutation BRCA1 or BRCA2 gene mutation First degree relative with BRCA1 or BRCA2 gene mutation and have not been tested themselves First degree relative with BRCA1 or BRCA2 gene mutation and have not been tested themselves Lifetime risk of breast cancer has been scored at 20-25% or greater, based on one of several accepted risk assessment tools that look at family history and other factors Lifetime risk of breast cancer has been scored at 20-25% or greater, based on one of several accepted risk assessment tools that look at family history and other factors Chest wall radiation between the ages of 10 and 30 at dosages above 4 Gy Chest wall radiation between the ages of 10 and 30 at dosages above 4 Gy Li-Fraumeni syndrome, Cowden syndrome, or Bannayan-Riley-Ruvalcaba syndrome, or may have one of these syndromes based on a history in a first-degree relative Li-Fraumeni syndrome, Cowden syndrome, or Bannayan-Riley-Ruvalcaba syndrome, or may have one of these syndromes based on a history in a first-degree relative

21 High Risk Screening Currently there is insufficient evidence to recommend for or against annual breast MRI screening in women who: have a lifetime risk of 15-24% as defined by several accepted risk assessment tools, such as BRACAPRO, have a lifetime risk of 15-24% as defined by several accepted risk assessment tools, such as BRACAPRO, that look at family history and other factors that look at family history and other factors have lobular carcinoma in situ (LCIS) have lobular carcinoma in situ (LCIS) have atypical ductal hyperplasia (ADH) have atypical ductal hyperplasia (ADH) have heterogeneously or extremely dense breasts on mammography (refer to first line of report) have heterogeneously or extremely dense breasts on mammography (refer to first line of report) Have a personal history of breast cancer including ductal carcinoma in situ (DCIS) Have a personal history of breast cancer including ductal carcinoma in situ (DCIS) Decisions should be made on a case by case basis. Decisions should be made on a case by case basis.

22 Clinical Indications Pre-Operative Staging Index tumor Size Index tumor Size Multi-focality or multi-centricity Multi-focality or multi-centricity Involvement of skin, pectoral muscle, chest wall Involvement of skin, pectoral muscle, chest wall Contralateral breast Contralateral breast Lymph node status Lymph node status Hematogenous metastases Hematogenous metastases

23 Clinical Indications Detection of Contralateral Breast Cancer in Newly Diagnosed Breast Cancer As many as 10% of women with breast cancer will develop a new tumor in the opposite breast with a negative mammogram and physical exam at the initial time of diagnosis. As many as 10% of women with breast cancer will develop a new tumor in the opposite breast with a negative mammogram and physical exam at the initial time of diagnosis. Finding cancers earlier may help women make treatment decision, potentially sparing additional surgery, radiation therapy and chemotherapy later. Finding cancers earlier may help women make treatment decision, potentially sparing additional surgery, radiation therapy and chemotherapy later. UW Researchers performed breast MRI on 969 patients with newly diagnosed breast cancer and detected 30 early stage tumors not detected on mammogram or physical exam * UW Researchers performed breast MRI on 969 patients with newly diagnosed breast cancer and detected 30 early stage tumors not detected on mammogram or physical exam * Memorial Sloan Kettering found contralateral breast cancer more often identified when index cancer was infiltrating lobular carcinoma **\ Memorial Sloan Kettering found contralateral breast cancer more often identified when index cancer was infiltrating lobular carcinoma **\ * NEJM 2007 vol. 356,No. 13: ** AJR 2003, vol. 180:

24 Clinical Indications Lobular Infiltrating Carcinoma Insidious cancer- Difficult to detect on Insidious cancer- Difficult to detect on mammography and physical exam Multifocal / multi-centric in up to 35% of cases and bilateral in 10% Multifocal / multi-centric in up to 35% of cases and bilateral in 10% Frequent cause of positive lumpectomy margins Frequent cause of positive lumpectomy margins

25 Clinical Indications Occult Breast Cancer About 0.3% of breast cancers present with malignant axillary lymph nodes, but normal breast exams and mammograms About 0.3% of breast cancers present with malignant axillary lymph nodes, but normal breast exams and mammograms Mastectomy standard treatment for occult malignancy Mastectomy standard treatment for occult malignancy Up to 2/3 can be localized with MRI allowing breast conservation surgery Up to 2/3 can be localized with MRI allowing breast conservation surgery

26 Clinical Indications Close or Positive Surgical Margins Up to 50% of lumpectomies have inadequate margins, requiring additional resection Up to 50% of lumpectomies have inadequate margins, requiring additional resection MRI can locate residual or additional tumor foci MRI can locate residual or additional tumor foci Applied pre-operatively, MR significantly decreases re-operations Applied pre-operatively, MR significantly decreases re-operations

27 Clinical Indications Post-operative Scar vs. Tumor Recurrence At 6 months or more after surgery At 6 months or more after surgery Mature scar, which may simulate cancer morphologically, does not enhance Mature scar, which may simulate cancer morphologically, does not enhance Recurrent tumor shows malignant-like enhancement curve Recurrent tumor shows malignant-like enhancement curve

28 Clinical Indications Neo-adjuvant Chemotherapy MRI improves the T classification as well as staging MRI improves the T classification as well as staging Can document tumor response to chemotherapy Can document tumor response to chemotherapy

29 Clinical Indications Implants and Known or Suspected Cancer MRI is not affected by implants or silicone MRI is not affected by implants or silicone Improves diagnostic confidence Improves diagnostic confidence Allows U/S guided needle biopsy prn Allows U/S guided needle biopsy prn Women with history of silicone injections can benefit from MRI screening Women with history of silicone injections can benefit from MRI screening

30 Clinical Indications Inappropriate Indications: Screening for Average Risk Women Screening for Average Risk Women Screening for Women with Less than 15% Lifetime Risk Screening for Women with Less than 15% Lifetime Risk As a Replacement for Mammography or Sonography As a Replacement for Mammography or Sonography To Biopsy or Determine the Need for Biopsy of a Suspicious Lesion Detected by Other Methods: Mammography, Ultrasound, and Physical Exam To Biopsy or Determine the Need for Biopsy of a Suspicious Lesion Detected by Other Methods: Mammography, Ultrasound, and Physical Exam

31 Accuracy Varies Considerably with Different Techniques Sensitivity: > 95-98% * Specificity: 37-97% Negative Predictive Value: > 95% Positive Predictive Value: ~ 65-75% * For DCIS sensitivity is lower, especially for low or intermediate grade lesions

32 Conclusions Bilateral, dynamic and high-spatial resolution breast MRI is widely accepted Bilateral, dynamic and high-spatial resolution breast MRI is widely accepted In the past, primarily employed as a problem-solving tool In the past, primarily employed as a problem-solving tool Now, central role in the diagnosis and staging of breast cancer Now, central role in the diagnosis and staging of breast cancer Increasing use in the treatment of breast cancer Increasing use in the treatment of breast cancer Multi-modality approach makes it work Multi-modality approach makes it work

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