Recent advances in MRI Breast and Future Dr.Rattehalli R Ramachandra Consultant Radiologist University Hospitals Coventry & Warwick NHS trust

Introduction Timeline of Breast diagnosis Role of MRI Breast Recent advances Other modalities Conclusion

Breast cancer UK Commonest cancer in women Accounts for 31% of all cancers in women Life time risk for men 1 in 1014 Life time risk for women 1 in 9 Ref: Cancer research UK Feb 2009

Timeline of Breast Diagnosis 1950’s – Breast Self Examination 1960’s – BSE + Mammography 1970’s – BSE + Mammography + Thermography+ Ultrasound 1980’s – BSE + mammography + Better US 1990’s – BSE + mammo + US + MRI 2000’s – Digital mammo + US + MRI 2010?? – Digital mammo + US + MRI + MR spectroscopy+Tomosynthesis + PEM + BSGI

Spiculate mass left Breast

Right Breast Screening Mammogram Recalled from screening

Coned view

US Bx Invasive lobular cancer

Any more lesions ?

MRI Breast with contrast

MRI Breast with contrast and subtraction

Colour mapping

MRI Breast 2006 to 2010 April

Timeline of Breast Diagnosis 1950’s – Breast Self Examination 1960’s – BSE + Mammography 1970’s – BSE + Mammography + Thermography+ Ultrasound 1980’s – BSE + mammography + Better US 1990’s – BSE + mammo + US + MRI 2000’s – Digital mammo + US + MRI 2010?? – Digital mammo + US + MRI + Tomosynthesis + PEM + BSGI

Sensitivity & Specificity Mammogram Vs Ultrasound Vs MRI 81.85% 99% Ultrasound 86.4% 98.1% MRI 3T 100% 93.9% Reference: Haitham Elsamaloty et al . AJR 2009; 192:1142-1148, Increasing the accuracy of detection of Breast Cancer with 3-T MRI.

PPV of Mammography for Breast cancer For under 50 yrs ranges from 20% For age 50-69 yrs 60-80%

Sensitivity and Specificity of Annual MRI, Mammography, Ultrasound and 6 Monthly CBE in High Risk Women AUTHOR MAMMOGRAPHY ULTRASOUND MRI CBE SENSITIVIT Y (%) SPECIFICIT Y (%) SENSITIVI TY (%) SPECIFICI TY (%) Kuhl et al 33 98 80 100 95 NS Tilanus- Linthorst et al - Stoutjesdij k et al 42 96 89 Podo et al 13 99 Morris et al 69 77 Kriege et al 40 71 90 18 Warner et al 36 9 Cancer Imaging 2005; 5(1): 32-38

MR Vs Mammogram Examples Netherlands study 1909 high risk patients 50 cancers 80% detected by MRI 33% detected by mammography

MR Vs Mammogram Examples UK 649 high risk women 35 cancers MRI found 77% Mammography found 40%

MR Vs Mammogram Examples Canada 236 Women at high risk 22 cancers MRI found 77% Mammo found 36%

MR Vs Mammogram Examples Bonn 529 Women at high risk 43 cancers MRI found 91% Mammography found 33%

Breast Ultrasound Not a screening test Good for lumps Good for clarification of abnormalities seen on mammography other than calcifications Good for taking biopsies

DIGITAL MAMMOGRAPHY DENSE BREASTS WOMEN UNDER 50 PREMENOPAUSAL WOMEN EQUAL OR SLIGHTLY REDUCED RADIATION DOSE Coventry is now fully digital Digital Tomosynthesis reduces the recall rate in dense breasts

Indications Staging newly diagnosed breast carcinoma ? Lobular cancer staging Unknown causes of axillary adenopathy Neo adjuvant chemotherapy Silicone implant rupture Screening high risk patients Radiation exposure at young age Difficult mammogram/ultrasound/physical examination, Problem solving

COMICE Trial Results Between 2001 to 2007 1625 patients,817 with 807 without MRI Re operation with in 6 months was 18.8% with MRI & 19.3% without MRI Result: No significant benefit by addition of MRI to conventional Triple assessment Comparitive effeciveness of MRI in Breast cancer trial Reference: L.Turnbul,Symposium Mammographicum 2008.Lille, France 06/07/2008, Also Lancet 13/2/2010

Indications Staging newly diagnosed breast carcinoma ? Lobular cancer staging Unknown causes of axillary adenopathy Neo adjuvant chemotherapy Silicone implant rupture Screening high risk patients Difficult mammogram/ultrasound/physical examination, Problem solving Radiation exposure at young age

MRI in Invasive Lobular cancer MRI accurately assesses the size & extent of cancer Detects cancer on other side Can change treatment plan in up to 28% of cases NICE guideline Example next slide

P W 2006 HISTORY 55YRS OLD P 3 R4 LUMP IN RIGHT BREAST US BIOPSY B5b LOBULAR SINGLE LESION MRI TO EXCLUDE ANY OTHER LESION OTHERWISE SUITABLE FOR WLE

Multifocal 3 leisons Patricia Waters 12/10/2006 D19600

Indications Staging newly diagnosed breast carcinoma ? Lobular cancer staging Unknown causes of axillary adenopathy Neo adjuvant chemotherapy Silicone implant rupture Screening high risk patients Difficult mammogram/ultrasound/physical examination, Problem solving Radiation exposure at young age

Metastatic Nodes in Axilla With No Obvious Primary in Breast < 2% of patients present with palpable axillary nodes and negative mammogram and US MRI finds the primary in up to 60-75% of cases This should be confirmed by second look US or MR guided biopsy Examples later

Indications Staging newly diagnosed breast carcinoma ? Lobular cancer staging Unknown causes of axillary adenopathy Neo adjuvant chemotherapy Silicone implant rupture Screening high risk patients Difficult mammogram/ultrasound/physical examination, Problem solving Radiation exposure at young age

Extra capsular silicon B 18196 Claire Geraghty 23/11/1979 8/4/2009

Silicon only image. Extra capsular silicon with fluid collection

Normal side

US Extra capsular silicon

Extra capsular silicon B73005 Michelle Wright 15/9/1975 15/4/2009

Silicon in Right axillary lymph node

Coronal images to asses overall shape

Indications Staging newly diagnosed breast carcinoma ? Lobular cancer staging Unknown causes of axillary adenopathy Neo adjuvant chemotherapy Silicone implant rupture Screening high risk patients Radiation exposure at young age Difficult mammogram/ultrasound/physical examination, Problem solving

New ACS Guidelines for Annual MRI Screening in addition to Mammo (May, 2007) Any woman who has greater than 20% lifetime risk of developing breast cancer (BRACAPRO, GAIL, BOADACEA) BRCA mutation and untested relatives Prior XRT (bet ages of 10-30)

NICE Guideline MRI annual surveillance From 30-39 yrs: To women at a 10 year risk >8% From 40-49 yrs: To women at 10 year risk of > 20% or To women at a 10 year risk of > 12% where mammography has shown a dense breast pattern

Radiation exposure at young age Hodgkin's disease treated with Mantle radiation Risk of BC increases beginning about 7-8yrs after treatment peaking at about 15yrs post treatment Younger age at treatment = Higher risk Many unaware of risk Begin intensive screening 6-7 yrs after treatment

Indications Staging newly diagnosed breast carcinoma ? Lobular cancer staging Unknown causes of axillary adenopathy Neo adjuvant chemotherapy Silicone implant rupture Screening high risk patients Radiation exposure at young age Difficult mammogram/ultrasound/physical examination, Problem solving

Problem solving Case 1

SH 60 yrs. Recalled from screening for possible ASD Right Breast

Further views showed normal mammogram.

However, US 8mm IDM UOQ Biopsy B5b Invasive DC

US localisation for WLE & SNB

MDM Specimen X ray normal Breast tissue HP: No tumour in the specimen SNB positive Repeat US: Post operative changes only with lot of oedema and seroma. No tumour seen Decision: To do MRI to try and Identify the tumour

MRI Seroma with 23x14mm Tumour

MRI Seroma with 23x14 mm Tumour

Second look Ultrasound Guided by MRI location of the lesion Tumour identified by US and localised again Tumour excised during ANC HP report: 22 mm IDC with clear margin

Occult on Conventional Imaging CASE 2 Occult on Conventional Imaging

MC 72yrs Clinical: P3 nodularity Left Breast Normal Mammogram Normal Ultrasound Clinical core biopsy HP: Invasive carcinoma mixed Ductal and Lobular MDM Decision: For MRI to asses exact size Marion Chapman 72 yrs D32436 55

MRI: 53x49mm with axillary nodes 2.3cms 56

Surgery Mastectomy with axillary node clearance HP: 50mm Invasive carcinoma mixed Ductal and Lobular Grade 2 3 out of 13 nodes positive for metastases

Response to Chemotherapy Case 3 Response to Chemotherapy

44yr SD H/o LIRB.O/E swelling in right breast with some inflammatory changes. Susan Daly T88166 59

Mammogram: Heterogeneously dense breast Diffuse stromal pattern with no focal mass

Ultrasound: Increased vascularity & mixed echogenicity Ultrasound: Increased vascularity & mixed echogenicity. IDM in UOQ 2cm from right nipple. Axillary nodes up to 3 cm Bx IDC

Pre chemo MRI: 80x 43 mm IDM

MRI : After 2 courses of Chemotherapy: 6.4x4.5 cm

Post Chemotherapy 11wks later: Few tiny enhancing nodules

Post operative finding Four foci of residual grade 2 invasive ductal carcinoma No realistic tumour size can be estimated

CLINICAL AND IMAGING DISCREPANCY CASE 4 CLINICAL AND IMAGING DISCREPANCY

39 yrs JM H/o Lump in Left Breast O/E 1cm lump in left breast UOQ Imaging: About 3 cm lump in UOQ B5b Suitable for WLE MDM: For MRI to confirm the size JILL MIDDLETON P80903 from Warwick 11/9/2008 67

MRI : 7 cm IDM and

Second lesion found 2cm

Dynamic graph typical for cancer

Post contrast colour mapping treated by mastectomy

Axillary lymphadenopathy

LB. 47Yrs. Right axillary nodes Biopsy: Metastatic carcinoma from Breast Mammogram: Dense breast. Extensive benign changes with cysts US: No obvious primary in the Breast

Non Contrast T1 Lynnett Barlow 1/4/2010 AA1311993

Non contrast T2

Post Contrast Subtraction images

Post contrast subtraction

LF 51yrs H/o Suspicious lump in left breast Nipple changes Fullness Ill defined lumpy area inner aspect of left nipple Leslie Fielding A32796 DOB: 16/7/1958

Left Mammogram MLO

Coned compression view

US: Vague area 20mm. Bx= B1

Stereo core Bx = B5b Lobular cancer

MDT Patient very reluctant for mastectomy For MRI to asses the actual size of lesion Exclude multi focal nature

MRI: 60x25mm MRI 28/10/09

Mammoplasty histology 70mm Grade 2 Lobular cancer Probably multi focal Difficult to asses size Lateral margin involved

Why not screen everybody????? Hey, a normal MRI virtually excludes invasive breast cancer!

Limitations of MRI False positives: Overlap of Benign & malignant lesions Incidental enhancing lesions About 30% Needs further assessment with second look US,Bx, ? MR guided

False Negatives Invasive lobular cancer Low grade Ductal cancers eg Tubular DCIS: Presents as MC in 73-98% MRI sensitivity: 40-100% Small lesions < 3mm difficult to detect Enhancing pattern often atypical MR spectroscopy may help in future

MR spectroscopy 4T Breast cancer research

Inappropriate uses of MRI Should not be substituted for Mammography or Ultrasound Should not be used as substitute for a histological diagnosis No studies proving efficacy of MRI as a screening tool in the general population

Conclusion 1 MRI is not a screening tool for women over 50yrs MRI with Mammogram is good for high risk women MRI is indicated for staging in invasive lobular cancer MRI is not required for routine staging MRI should be used as problem solving tool in difficult circumstances

Conclusion 2 We Await new tools like Tomosynthesis, Improved software on Spectroscopy for breast imaging, Future : CT mammography, BSGI,PEM MR Ductography

Thank you