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

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

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

4 Principles of Breast MRI
                                                                     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 AV shunting, pooling Abnormal endothelial permeability Cancers enhance early and intensely                  

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

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

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

9 Technique: MRI Sequences
Axial Stir Breast Lymph Nodes Edema 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 Other Masses Draining Veins Pre-Contrast Minute Post-Contrast Minutes Post-Contrast

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

12 Technique: MRI Sequences
Diffusion Imaging (DWI) 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 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
Washout Plateau (biphasic) Progressive (monophasic) Normal

15 Benign Enhancement Pattern
Progressive (monophasic) Normal

16 Malignant-like Enhancement
Washout Normal

17 Digital Mammography Primary tool for breast cancer screening
Breast MRI is an adjunct Mammogram is more sensitive in detection of Ductal Carcinoma in Situ (DCIS) 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 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 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

21 High Risk Screening Decisions should be made on a case by case basis.
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, that look at family history and other factors have lobular carcinoma in situ (LCIS) have atypical ductal hyperplasia (ADH) 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) Decisions should be made on a case by case basis.

22 Clinical Indications Pre-Operative Staging Index tumor Size
Multi-focality or multi-centricity Involvement of skin, pectoral muscle, chest wall Contralateral breast Lymph node status 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. 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 * 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 mammography and physical exam Multifocal / multi-centric in up to 35% of cases and bilateral in 10% 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 Mastectomy standard treatment for occult malignancy 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 MRI can locate residual or additional tumor foci Applied pre-operatively, MR significantly decreases re-operations

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

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

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

30 Clinical Indications Inappropriate Indications:
Screening for Average Risk Women Screening for Women with Less than 15% Lifetime Risk 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

31 Accuracy Varies Considerably with Different Techniques
Sensitivity: > 95-98% * Specificity: % 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 In the past, primarily employed as a problem-solving tool Now, central role in the diagnosis and staging of breast cancer Increasing use in the treatment of breast cancer Multi-modality approach makes it work


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