Breast MRI: Technique and Indications Karen Dec M.D. Skagit Radiology, Inc.
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Transcript of Breast MRI: Technique and Indications Karen Dec M.D. Skagit Radiology, Inc.
Breast MRI:Breast MRI:
Technique and IndicationsTechnique and Indications
Karen Dec M.D.Karen Dec M.D.Skagit Radiology, Inc.Skagit Radiology, Inc.
FundamentalsFundamentals of Contrastof ContrastEnhanced Breast MRIEnhanced Breast MRI
Principles of Breast MRIPrinciples of Breast MRI TechniqueTechnique Adjunctive UltrasoundAdjunctive Ultrasound Clinical IndicationsClinical Indications AccuracyAccuracy
Principles of Breast MRIPrinciples of Breast MRI Angiogenesis = Abnormal tumor Angiogenesis = Abnormal tumor vessels produce neovascularityvessels produce neovascularity
Top left:Top left: Implanted cancer cells glow with Implanted cancer cells glow with green fluorescence protein.green fluorescence protein.
Top right:Top right: Three of the original cancer cells Three of the original cancer cells have have
survived to begin replicating. Signals between survived to begin replicating. Signals between the the
existing blood vessel and the growing cancer existing blood vessel and the growing cancer cells cells
cause the cells to grow toward the vessel.cause the cells to grow toward the vessel.
Bottom left:Bottom left: The cancer cells have reached The cancer cells have reached the the
existing blood vessel.existing blood vessel.
Bottom right:Bottom right: When they number only 100- When they number only 100-300, 300,
the cancer cells have created new, fully-the cancer cells have created new, fully-functioning functioning
blood vessels.blood vessels.
Graphic illustration byGraphic illustration by Stanley Coffman, Duke Stanley Coffman, Duke University Medical CenterUniversity Medical Center
PrinciplesPrinciples of Breast MRIof Breast MRI
Neovascularity characterized Neovascularity characterized by:by:
Low resistance, high flowLow resistance, high flow AV shunting, poolingAV shunting, pooling Abnormal endothelial Abnormal endothelial
permeabilitypermeability
Cancers enhance early and Cancers enhance early and intenselyintensely
Principles of Breast MRIPrinciples of Breast MRI
Virtual Map of AngiogenesisVirtual Map of Angiogenesis Pre-Contrast Post -ContrastPre-Contrast Post -Contrast
TechniqueTechnique OverviewOverview
Prone positioningProne positioning
Breast placed in Breast placed in individual holders within individual holders within coilscoils
Images obtained prior to Images obtained prior to and following gadolinium and following gadolinium administrationadministration
6 imaging sequences6 imaging sequences - Spatial resolution- Spatial resolution - Temporal resolution- Temporal resolution
Technique: MRI Technique: MRI SequencesSequences
Coronal Stir ChestCoronal Stir Chest
Lymph NodesLymph Nodes
AxillaryAxillary
SupraclavicularSupraclavicular
Internal mammaryInternal mammary Lung ParenchymaLung Parenchyma LiverLiver BonesBones
Technique: MRI Technique: MRI SequencesSequences
Axial Stir BreastAxial Stir Breast Lymph NodesLymph Nodes EdemaEdema CystsCysts
STIR axial MR image shows marked asymmetry in appearance of breasts. Left breast has diffusely increased signal within parenchyma andskin, suggesting diffuse breast edema and skin thickening (arrow).
Technique: MRI Technique: MRI SequencesSequences
Axial Pre-Contrast and Dynamic Post-Contrast 3D FLASH x 5Axial Pre-Contrast and Dynamic Post-Contrast 3D FLASH x 5 CancersCancers Other Masses Other Masses Draining VeinsDraining Veins
Pre-Contrast 1 Minute Post-Contrast 4 Minutes Post-ContrastPre-Contrast 1 Minute Post-Contrast 4 Minutes Post-Contrast
Technique: MRI Technique: MRI SequencesSequences
Axial “VIEWS” MIPSAxial “VIEWS” MIPS Volume Interpolated Exam under Water Volume Interpolated Exam under Water
StimulationStimulation
High spatial resolutionHigh spatial resolution Entire case can be Entire case can be
displayed for cliniciansdisplayed for clinicians
Technique: MRI Technique: MRI SequencesSequences
Diffusion Imaging (DWI)Diffusion Imaging (DWI)
Measures the mobility of Measures the mobility of water in tissuewater in tissue
Sensitive to characteristics Sensitive to characteristics often disrupted in malignant often disrupted in malignant breast tissues, such as cell breast tissues, such as cell organization, density, organization, density, extracellular space and cell extracellular space and cell membrane permeabilitymembrane permeability
DWI may be useful for DWI may be useful for detecting breast cancer in a detecting breast cancer in a wide age group of women, wide age group of women, including young women with including young women with dense mammary glands.*dense mammary glands.*
*Radiation Medicine, 2007, Vol. 25:218-*Radiation Medicine, 2007, Vol. 25:218-223223
AssessmentAssessment
Morphologic:Morphologic: Similar to Similar to mammography and ultrasoundmammography and ultrasound
Dynamic:Dynamic: Blood flow physiology by Blood flow physiology by evaluating dynamic enhancement evaluating dynamic enhancement curvescurves
Dynamic Enhancement Dynamic Enhancement PatternsPatterns
0
20
40
60
80
100
120
0 1 2 3 4 5Minutes
Dynam
ic E
nhance
ment
NormNormalal
Progressive (monophasic)Progressive (monophasic)
PlateauPlateau (biphasic)(biphasic)
WashoutWashout
Benign Enhancement Benign Enhancement PatternPattern
0
20
40
60
80
100
120
0 1 2 3 4 5Minutes
Dyn
amic
Enh
ance
men
t
NormNormalal
Progressive (monophasic)Progressive (monophasic)
Malignant-like Malignant-like EnhancementEnhancement
0
20
40
60
80
100
120
0 1 2 3 4 5Minutes
Dyn
amic
Enh
ance
men
t
NormNormalal
WashoutWashout
Digital MammographyDigital Mammography
Primary tool for breast cancer screeningPrimary tool for breast cancer screening Breast MRI is an adjunct Breast MRI is an adjunct Mammogram is more sensitive in Mammogram is more sensitive in
detection of Ductal Carcinoma in Situ detection of Ductal Carcinoma in Situ (DCIS)(DCIS)
Can determine if lesion amenable to Can determine if lesion amenable to stereotactic guided biopsy stereotactic guided biopsy
Adjunctive Breast Adjunctive Breast UltrasoundUltrasound
Accurate, high Accurate, high resolution resolution
breast sonography breast sonography essential essential
in localizing lesions for in localizing lesions for
potential percutaneous potential percutaneous
needle tissue samplingneedle tissue sampling
Clinical IndicationsClinical Indications
Screening of High-Risk WomenScreening of High-Risk WomenPre-Operative StagingPre-Operative StagingContralateral Breast Cancer in Newly Contralateral Breast Cancer in Newly
Diagnosed Breast CancerDiagnosed Breast CancerLobular CancerLobular CancerOccult Breast CancerOccult Breast CancerClose or Positive Surgical MarginsClose or Positive Surgical MarginsPost-operative Scar vs. Tumor RecurrencePost-operative Scar vs. Tumor RecurrenceNeo-Adjuvant ChemotherapyNeo-Adjuvant ChemotherapyImplants and Known or Suspected CancerImplants and Known or Suspected CancerProblematic MammogramProblematic Mammogram
High Risk ScreeningHigh Risk Screening
Annual Breast MRI and Mammography Screening is Annual Breast MRI and Mammography Screening is Recommended Recommended
for Women Who Have:for Women Who Have:
BRCA1 or BRCA2 gene mutation BRCA1 or BRCA2 gene mutation First degree relative with BRCA1 or BRCA2 gene mutation and First degree relative with BRCA1 or BRCA2 gene mutation and
have not been tested themselveshave not been tested themselves Lifetime risk of breast cancer has been scored at 20-25% or Lifetime risk of breast cancer has been scored at 20-25% or
greater, based on one of several accepted risk assessment tools greater, based on one of several accepted risk assessment tools that look at family history and other factorsthat look at family history and other factors
Chest wall radiation between the ages of 10 and 30 at dosages Chest wall radiation between the ages of 10 and 30 at dosages above 4 Gyabove 4 Gy
Li-Fraumeni syndrome, Cowden syndrome, or Bannayan-Riley-Li-Fraumeni syndrome, Cowden syndrome, or Bannayan-Riley-Ruvalcaba syndrome, or may have one of these syndromes Ruvalcaba syndrome, or may have one of these syndromes based on a history in a first-degree relativebased on a history in a first-degree relative
High Risk ScreeningHigh Risk Screening
Currently there is insufficient evidence to recommend for or Currently there is insufficient evidence to recommend for or against annual against annual
breast MRI screening in women who:breast MRI screening in women who:
have a lifetime risk of 15-24% as defined by several accepted risk have a lifetime risk of 15-24% as defined by several accepted risk assessment tools, such as BRACAPRO,assessment tools, such as BRACAPRO,
that look at family history and other factorsthat 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 have heterogeneously or extremely dense breasts on mammography
(refer to first line of report)(refer to first line of report) Have a personal history of breast cancer including ductal carcinoma in Have a personal history of breast cancer including ductal carcinoma in
situ (DCIS)situ (DCIS)
Decisions should be made on a case by case basis.Decisions should be made on a case by case basis.
Clinical IndicationsClinical Indications
Pre-Operative StagingPre-Operative Staging Index tumor SizeIndex tumor Size Multi-focality or multi-centricityMulti-focality or multi-centricity Involvement of skin, pectoral muscle, Involvement of skin, pectoral muscle,
chest wallchest wall Contralateral breastContralateral breast Lymph node statusLymph node status Hematogenous metastasesHematogenous metastases
Clinical IndicationsClinical Indications
Detection of Contralateral Breast Cancer in Newly Detection of Contralateral Breast Cancer in Newly Diagnosed Breast CancerDiagnosed Breast Cancer
As many as 10% of women with breast cancer will develop a new As many as 10% of women with breast cancer will develop a new tumor in the opposite breast with a negative mammogram and tumor in the opposite breast with a negative mammogram and physical exam at the initial time of diagnosis.physical exam at the initial time of diagnosis.
Finding cancers earlier may help women make treatment decision, Finding cancers earlier may help women make treatment decision, potentially sparing additional surgery, radiation therapy and potentially sparing additional surgery, radiation therapy and chemotherapy later.chemotherapy later.
UW Researchers performed breast MRI on 969 patients with newly UW Researchers performed breast MRI on 969 patients with newly diagnosed breast cancer and detected 30 early stage tumors not diagnosed breast cancer and detected 30 early stage tumors not detected on mammogram or physical exam *detected on mammogram or physical exam *
Memorial Sloan Kettering found contralateral breast cancer more often Memorial Sloan Kettering found contralateral breast cancer more often identified when index cancer was infiltrating lobular carcinoma **\identified when index cancer was infiltrating lobular carcinoma **\
* NEJM 2007 vol. 356,No. 13:1295-1303* NEJM 2007 vol. 356,No. 13:1295-1303** AJR 2003, vol. 180:333-341** AJR 2003, vol. 180:333-341
Clinical IndicationsClinical Indications
Lobular Infiltrating CarcinomaLobular Infiltrating Carcinoma Insidious cancer- Difficult to detect Insidious cancer- Difficult to detect
onon
mammography and physical exammammography and physical exam Multifocal / multi-centric in up to Multifocal / multi-centric in up to
35% of cases and bilateral in 10%35% of cases and bilateral in 10% Frequent cause of positive Frequent cause of positive
lumpectomy margins lumpectomy margins
Clinical IndicationsClinical Indications
Occult Breast CancerOccult Breast Cancer About 0.3% of breast cancers present About 0.3% of breast cancers present
with malignant axillary lymph nodes, with malignant axillary lymph nodes, but normal breast exams and but normal breast exams and mammogramsmammograms
Mastectomy standard treatment for Mastectomy standard treatment for occult malignancyoccult malignancy
Up to 2/3 can be localized with MRI Up to 2/3 can be localized with MRI allowing breast conservation surgeryallowing breast conservation surgery
Clinical IndicationsClinical Indications
Close or Positive Surgical MarginsClose or Positive Surgical Margins Up to 50% of lumpectomies have Up to 50% of lumpectomies have
inadequate margins, requiring inadequate margins, requiring additional resectionadditional resection
MRI can locate residual or MRI can locate residual or additional tumor fociadditional tumor foci
Applied pre-operatively, MR Applied pre-operatively, MR significantly decreases re-significantly decreases re-operationsoperations
Clinical IndicationsClinical Indications
Post-operative Scar vs. Tumor Post-operative Scar vs. Tumor RecurrenceRecurrence
At 6 months or more after surgeryAt 6 months or more after surgery ““Mature scar”, which may simulate Mature scar”, which may simulate
cancer morphologically, does not cancer morphologically, does not enhanceenhance
Recurrent tumor shows malignant-Recurrent tumor shows malignant-like enhancement curvelike enhancement curve
Clinical IndicationsClinical Indications
Neo-adjuvant ChemotherapyNeo-adjuvant Chemotherapy
MRI improves the “T” MRI improves the “T” classification as well as stagingclassification as well as staging
Can document tumor response to Can document tumor response to chemotherapychemotherapy
Clinical IndicationsClinical Indications
Implants and Known or Suspected CancerImplants and Known or Suspected Cancer MRI is not affected by implants or MRI is not affected by implants or
siliconesilicone Improves diagnostic confidenceImproves diagnostic confidence Allows U/S guided needle biopsy prnAllows U/S guided needle biopsy prn Women with history of silicone Women with history of silicone
injections can benefit from MRI injections can benefit from MRI screeningscreening
Clinical IndicationsClinical Indications
Inappropriate Indications:Inappropriate Indications:
Screening for Average Risk WomenScreening for Average Risk Women Screening for Women with Less than 15% Screening for Women with Less than 15%
Lifetime RiskLifetime Risk As a Replacement for Mammography or As a Replacement for Mammography or
SonographySonography To Biopsy or Determine the Need for Biopsy To Biopsy or Determine the Need for Biopsy
of a Suspicious Lesion Detected by Other of a Suspicious Lesion Detected by Other Methods: Mammography, Ultrasound, and Methods: Mammography, Ultrasound, and Physical ExamPhysical Exam
AccuracyAccuracy
Varies Considerably with Different Varies Considerably with Different TechniquesTechniques
Sensitivity: Sensitivity: >> 95-98% 95-98% **
Specificity: 37-97%Specificity: 37-97%
Negative Predictive Value: Negative Predictive Value: >> 95% 95%
Positive Predictive Value: ~ 65-75%Positive Predictive Value: ~ 65-75%
* For DCIS sensitivity is lower, especially for low or intermediate * For DCIS sensitivity is lower, especially for low or intermediate grade lesionsgrade lesions
ConclusionsConclusions
Bilateral, dynamic and high-spatial Bilateral, dynamic and high-spatial resolution breast MRI is widely resolution breast MRI is widely acceptedaccepted
In the past, primarily employed as a In the past, primarily employed as a problem-solving toolproblem-solving tool
Now, central role in the diagnosis and Now, central role in the diagnosis and staging of breast cancerstaging of breast cancer
Increasing use in the treatment of Increasing use in the treatment of breast cancerbreast cancer
Multi-modality approach makes it workMulti-modality approach makes it work