recent advances in mri breast and future

Recent advances in MRI Recent advances in MRI Breast and FutureBreast and Future

Dr.Rattehalli R RamachandraDr.Rattehalli R RamachandraConsultant RadiologistConsultant Radiologist

University Hospitals Coventry & University Hospitals Coventry & Warwick NHS trustWarwick NHS trust

IntroductionIntroduction

Timeline of Breast diagnosisTimeline of Breast diagnosis Role of MRI BreastRole of MRI Breast Recent advancesRecent advances Other modalitiesOther modalities ConclusionConclusion

Breast cancer UKBreast cancer UK

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

Timeline of Breast DiagnosisTimeline of Breast Diagnosis

1950’s – Breast Self Examination1950’s – Breast Self Examination 1960’s – BSE + Mammography1960’s – BSE + Mammography 1970’s – 1970’s – BSE + Mammography + BSE + Mammography +

Thermography+ UltrasoundThermography+ Ultrasound 1980’s – BSE + mammography + Better US1980’s – BSE + mammography + Better US 1990’s – BSE + mammo + US + MRI1990’s – BSE + mammo + US + MRI 2000’s – Digital mammo + US + MRI2000’s – Digital mammo + US + MRI 2010?? – Digital mammo + US + MRI + MR 2010?? – Digital mammo + US + MRI + MR

spectroscopy+Tomosynthesis + PEM + BSGIspectroscopy+Tomosynthesis + PEM + BSGI

Spiculate mass left BreastSpiculate mass left Breast

Right Breast Screening Right Breast Screening MammogramMammogram

Coned viewConed view

US Bx Invasive lobular cancerUS Bx Invasive lobular cancer

Any more lesions ? Any more lesions ?

MRI Breast with contrastMRI Breast with contrast

MRI Breast with contrast and MRI Breast with contrast and subtractionsubtraction

Colour mappingColour mapping

MRI Breast 2006 to 2010 AprilMRI Breast 2006 to 2010 April

MRI Breast 2006 to 2010 April

0

50

100

150

200

250

300

1 2 3 4 5 6

2005 2006 2007 2008 2009 2010

Series1

Timeline of Breast DiagnosisTimeline of Breast Diagnosis

1950’s – Breast Self Examination1950’s – Breast Self Examination 1960’s – BSE + Mammography1960’s – BSE + Mammography 1970’s – 1970’s – BSE + Mammography + BSE + Mammography +

Thermography+ UltrasoundThermography+ Ultrasound 1980’s – BSE + mammography + Better US1980’s – BSE + mammography + Better US 1990’s – BSE + mammo + US + MRI1990’s – BSE + mammo + US + MRI 2000’s – Digital mammo + US + MRI2000’s – Digital mammo + US + MRI 2010?? – Digital mammo + US + MRI + 2010?? – Digital mammo + US + MRI +

Tomosynthesis + PEM + BSGITomosynthesis + PEM + BSGI

Sensitivity & SpecificitySensitivity & SpecificityMammogram Vs Ultrasound Vs MRIMammogram Vs Ultrasound Vs MRI

SensitivitySensitivity SpecificitySpecificity

MammogramMammogram 81.85%81.85% 99%99%

UltrasoundUltrasound 86.4%86.4% 98.1%98.1%

MRI 3T MRI 3T 100%100% 93.9%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 PPV of Mammography for Breast cancercancer

For under 50 yrs ranges from 20%For under 50 yrs ranges from 20% For age 50-69 yrs 60-80%For age 50-69 yrs 60-80%

Sensitivity and Specificity of Annual MRI, Mammography, Ultrasound Sensitivity and Specificity of Annual MRI, Mammography, Ultrasound and 6 Monthly CBE in High Risk Womenand 6 Monthly CBE in High Risk Women

AUTHORAUTHOR MAMMOGRAPHYMAMMOGRAPHY ULTRASOUNDULTRASOUND MRIMRI CBECBE

SENSITIVITSENSITIVITY (%)Y (%)

SPECIFICITSPECIFICITY (%)Y (%)

SENSITIVISENSITIVITY (%)TY (%)

SPECIFICISPECIFICITY (%)TY (%)

SENSITIVISENSITIVITY (%)TY (%)

SPECIFICITSPECIFICITY (%)Y (%)

SENSITIVITSENSITIVITY (%)Y (%)

SPECIFICISPECIFICITY (%)TY (%)

Kuhl et alKuhl et al 3333 9898 3333 8080 100100 9595 NSNS NSNS

Tilanus-Tilanus-Linthorst Linthorst et alet al

00 100100 -- -- 100100 9595 NSNS NSNS

StoutjesdijStoutjesdijk et alk et al

4242 9696 -- -- 100100 8989 NSNS NSNS

Podo et alPodo et al 1313 100100 1313 100100 100100 9999 -- --

Morris et Morris et alal

NSNS NSNS -- -- 6969 7777 -- --

Kriege et alKriege et al 4040 9595 -- -- 7171 9090 1818 9898

Warner et Warner et alal

3636 100100 3333 9696 7777 9595 99 9999

Cancer Imaging 2005; 5(1): 32-38

MR Vs Mammogram Examples MR Vs Mammogram Examples

Netherlands studyNetherlands study

1909 high risk patients1909 high risk patients

50 cancers50 cancers

80% detected by MRI80% detected by MRI

33% detected by mammography33% detected by mammography

MR Vs Mammogram ExamplesMR Vs Mammogram Examples

UKUK649 high risk women649 high risk women

35 cancers35 cancers

MRI found 77%MRI found 77%

Mammography found 40%Mammography found 40%

MR Vs Mammogram ExamplesMR Vs Mammogram Examples

CanadaCanada236 Women at high risk236 Women at high risk

22 cancers22 cancers

MRI found 77%MRI found 77%

Mammo found 36%Mammo found 36%

MR Vs Mammogram ExamplesMR Vs Mammogram Examples

BonnBonn529 Women at high risk529 Women at high risk

43 cancers43 cancers

MRI found 91%MRI found 91%

Mammography found 33%Mammography found 33%

Breast UltrasoundBreast Ultrasound

Not a screening testNot a screening test Good for lumpsGood for lumps Good for clarification of abnormalities seen Good for clarification of abnormalities seen

on mammography other than calcificationson mammography other than calcifications Good for taking biopsiesGood for taking biopsies

DIGITAL MAMMOGRAPHYDIGITAL MAMMOGRAPHY

DENSE BREASTSDENSE BREASTS WOMEN UNDER 50WOMEN UNDER 50 PREMENOPAUSAL WOMENPREMENOPAUSAL WOMEN EQUAL OR SLIGHTLY REDUCED EQUAL OR SLIGHTLY REDUCED

RADIATION DOSERADIATION DOSE Coventry is now fully digitalCoventry is now fully digital Digital Tomosynthesis reduces the recall Digital Tomosynthesis reduces the recall

rate in dense breasts rate in dense breasts

IndicationsIndications

Staging newly diagnosed breast carcinoma ?Staging newly diagnosed breast carcinoma ? Lobular cancer stagingLobular cancer staging Unknown causes of axillary adenopathyUnknown causes of axillary adenopathy Neo adjuvant chemotherapyNeo adjuvant chemotherapy Silicone implant ruptureSilicone implant rupture Screening high risk patientsScreening high risk patients Radiation exposure at young ageRadiation exposure at young age Difficult mammogram/ultrasound/physical Difficult mammogram/ultrasound/physical

examination, Problem solvingexamination, Problem solving

COMICE Trial ResultsCOMICE Trial Results Between 2001 to 2007Between 2001 to 2007 1625 patients,817 with 807 without MRI1625 patients,817 with 807 without MRI Re operation with in 6 months wasRe operation with in 6 months was 18.8% with MRI & 19.3% without MRI18.8% with MRI & 19.3% without MRI Result: No significant benefit by addition of MRI to Result: No significant benefit by addition of MRI to

conventional Triple assessmentconventional Triple assessment

Comparitive effeciveness of MRI in Breast cancer trialComparitive effeciveness of MRI in Breast cancer trial

Reference: L.Turnbul,Symposium Mammographicum 2008.Lille, France Reference: L.Turnbul,Symposium Mammographicum 2008.Lille, France 06/07/2008, Also Lancet 13/2/201006/07/2008, Also Lancet 13/2/2010

IndicationsIndications

Staging newly diagnosed breast carcinoma ?Staging newly diagnosed breast carcinoma ? Lobular cancer stagingLobular cancer staging Unknown causes of axillary adenopathyUnknown causes of axillary adenopathy Neo adjuvant chemotherapyNeo adjuvant chemotherapy Silicone implant ruptureSilicone implant rupture Screening high risk patientsScreening high risk patients Difficult mammogram/ultrasound/physical Difficult mammogram/ultrasound/physical

examination, Problem solvingexamination, Problem solving Radiation exposure at young ageRadiation exposure at young age

MRI in Invasive Lobular cancerMRI in Invasive Lobular cancer

MRI accurately assesses the size & extent MRI accurately assesses the size & extent of cancerof cancer

Detects cancer on other sideDetects cancer on other side Can change treatment plan in up to 28% of Can change treatment plan in up to 28% of

cases cases NICE guidelineNICE guideline

P W 2006 HISTORYP W 2006 HISTORY

55YRS OLD55YRS OLD P 3 R4 LUMP IN RIGHT BREASTP 3 R4 LUMP IN RIGHT BREAST US BIOPSY B5b LOBULAR SINGLE US BIOPSY B5b LOBULAR SINGLE

LESIONLESION MRI TO EXCLUDE ANY OTHER LESIONMRI TO EXCLUDE ANY OTHER LESION OTHERWISE SUITABLE FOR WLEOTHERWISE SUITABLE FOR WLE

Multifocal 3 leisonsMultifocal 3 leisons

IndicationsIndications

Staging newly diagnosed breast carcinoma ?Staging newly diagnosed breast carcinoma ? Lobular cancer stagingLobular cancer staging Unknown causes of axillary adenopathyUnknown causes of axillary adenopathy Neo adjuvant chemotherapyNeo adjuvant chemotherapy Silicone implant ruptureSilicone implant rupture Screening high risk patientsScreening high risk patients Difficult mammogram/ultrasound/physical Difficult mammogram/ultrasound/physical

examination, Problem solvingexamination, Problem solving Radiation exposure at young ageRadiation exposure at young age

Metastatic Nodes in Axilla With No Metastatic Nodes in Axilla With No Obvious Primary in BreastObvious Primary in Breast

< 2% of patients present with palpable < 2% of patients present with palpable axillary nodes and negative mammogram axillary nodes and negative mammogram and USand US

MRI finds the primary in up to 60-75% of MRI finds the primary in up to 60-75% of casescases

This should be confirmed by second look This should be confirmed by second look US or MR guided biopsyUS or MR guided biopsy

IndicationsIndications

Staging newly diagnosed breast carcinoma ?Staging newly diagnosed breast carcinoma ? Lobular cancer stagingLobular cancer staging Unknown causes of axillary adenopathyUnknown causes of axillary adenopathy Neo adjuvant chemotherapyNeo adjuvant chemotherapy Silicone implant ruptureSilicone implant rupture Screening high risk patientsScreening high risk patients Difficult mammogram/ultrasound/physical Difficult mammogram/ultrasound/physical

examination, Problem solvingexamination, Problem solving Radiation exposure at young ageRadiation exposure at young age

Extra capsular siliconExtra capsular silicon

Silicon only image. Extra capsular Silicon only image. Extra capsular silicon with fluid collectionsilicon with fluid collection

Normal sideNormal side

US Extra capsular siliconUS Extra capsular silicon

Extra capsular siliconExtra capsular silicon

Silicon in Right axillary lymph nodeSilicon in Right axillary lymph node

Coronal images to asses overall Coronal images to asses overall shapeshape

IndicationsIndications

Staging newly diagnosed breast carcinoma ?Staging newly diagnosed breast carcinoma ? Lobular cancer stagingLobular cancer staging Unknown causes of axillary adenopathyUnknown causes of axillary adenopathy Neo adjuvant chemotherapyNeo adjuvant chemotherapy Silicone implant ruptureSilicone implant rupture Screening high risk patientsScreening high risk patients Radiation exposure at young ageRadiation exposure at young age Difficult mammogram/ultrasound/physical Difficult mammogram/ultrasound/physical

examination, Problem solvingexamination, Problem solving

New ACS Guidelines for Annual New ACS Guidelines for Annual MRI Screening in addition to MRI Screening in addition to

MammoMammo(May, 2007)(May, 2007)

Any woman who has greater than 20% Any woman who has greater than 20% lifetime risk of developing breast cancerlifetime risk of developing breast cancer

(BRACAPRO, GAIL, BOADACEA)(BRACAPRO, GAIL, BOADACEA) BRCA mutation and untested relativesBRCA mutation and untested relatives Prior XRT (bet ages of 10-30)Prior XRT (bet ages of 10-30)

NICE Guideline NICE Guideline MRI annual surveillance MRI annual surveillance

From 30-39 yrs:From 30-39 yrs: To women at a 10 year risk >8%To women at a 10 year risk >8% From 40-49 yrs:From 40-49 yrs: To women at 10 year risk of > 20% orTo women at 10 year risk of > 20% or To women at a 10 year risk of > 12% To women at a 10 year risk of > 12%

where mammography has shown a dense where mammography has shown a dense breast patternbreast pattern

Radiation exposure at young ageRadiation exposure at young age

Hodgkin's disease treated with Mantle Hodgkin's disease treated with Mantle radiationradiation

Risk of BC increases beginning about 7-Risk of BC increases beginning about 7-8yrs after treatment peaking at about 8yrs after treatment peaking at about 15yrs post treatment15yrs post treatment

Younger age at treatment = Higher riskYounger age at treatment = Higher risk Many unaware of riskMany unaware of risk Begin intensive screening 6-7 yrs after Begin intensive screening 6-7 yrs after

treatmenttreatment

IndicationsIndications

Staging newly diagnosed breast carcinoma ?Staging newly diagnosed breast carcinoma ? Lobular cancer stagingLobular cancer staging Unknown causes of axillary adenopathyUnknown causes of axillary adenopathy Neo adjuvant chemotherapyNeo adjuvant chemotherapy Silicone implant ruptureSilicone implant rupture Screening high risk patientsScreening high risk patients Radiation exposure at young ageRadiation exposure at young age Difficult mammogram/ultrasound/physical Difficult mammogram/ultrasound/physical

examination, Problem solvingexamination, Problem solving

Case 1Case 1

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

Further views showed normal mammogram.Further views showed normal mammogram.

However, US 8mm IDM UOQ Biopsy B5b Invasive DCHowever, US 8mm IDM UOQ Biopsy B5b Invasive DC

US localisation for WLE & SNBUS localisation for WLE & SNB

MDMMDM

Specimen X ray normal Breast tissueSpecimen X ray normal Breast tissue HP: No tumour in the specimenHP: No tumour in the specimen SNB positiveSNB positive Repeat US: Post operative changes only with Repeat US: Post operative changes only with

lot of oedema and seroma. No tumour seenlot of oedema and seroma. No tumour seen Decision: To do MRI to try and Identify the Decision: To do MRI to try and Identify the

tumourtumour

MRI Seroma with 23x14mm TumourMRI Seroma with 23x14mm Tumour

MRI Seroma with 23x14 mm TumourMRI Seroma with 23x14 mm Tumour

Second look UltrasoundSecond look Ultrasound Guided by MRI location of the lesion Guided by MRI location of the lesion Tumour identified by US and localised Tumour identified by US and localised

again again Tumour excised during ANCTumour excised during ANC HP report: 22 mm IDC with clear marginHP report: 22 mm IDC with clear margin

CASE 2CASE 2

MC 72yrsMC 72yrs Clinical: P3 nodularity Left BreastClinical: P3 nodularity Left Breast Normal MammogramNormal Mammogram Normal UltrasoundNormal Ultrasound Clinical core biopsyClinical core biopsy HP: Invasive carcinoma mixed Ductal and HP: Invasive carcinoma mixed Ductal and

LobularLobular MDM Decision: For MRI to asses exact MDM Decision: For MRI to asses exact

sizesize

MRI: MRI: 53x49mm with axillary nodes 2.3cms53x49mm with axillary nodes 2.3cms

SurgerySurgery

Mastectomy with axillary node clearanceMastectomy with axillary node clearance HP: 50mm Invasive carcinoma mixed HP: 50mm Invasive carcinoma mixed

Ductal and Lobular Grade 2Ductal and Lobular Grade 2 3 out of 13 nodes positive for metastases3 out of 13 nodes positive for metastases

ResponseResponse to Chemotherapyto Chemotherapy

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

Mammogram: Heterogeneously dense breastMammogram: Heterogeneously dense breastDiffuse stromal pattern with no focal massDiffuse stromal pattern with no focal mass

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

Pre chemo MRI: 80x 43 mm IDMPre chemo MRI: 80x 43 mm IDM

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

Post Chemotherapy 11wks later: Few tiny enhancing nodulesPost Chemotherapy 11wks later: Few tiny enhancing nodules

Post operative findingPost operative finding

Four foci of residual grade 2 invasive Four foci of residual grade 2 invasive ductal carcinomaductal carcinoma

No realistic tumour size can be estimatedNo realistic tumour size can be estimated

CLINICAL AND IMAGING CLINICAL AND IMAGING DISCREPANCYDISCREPANCY

39 yrs JM 39 yrs JM H/o Lump in Left BreastH/o Lump in Left Breast O/E 1cm lump in left breast UOQO/E 1cm lump in left breast UOQ Imaging: About 3 cm lump in UOQImaging: About 3 cm lump in UOQ B5bB5b Suitable for WLESuitable for WLE MDM: For MRI to confirm the sizeMDM: For MRI to confirm the size

MRI : 7 cm IDM andMRI : 7 cm IDM and

Second lesion found 2cmSecond lesion found 2cm

Dynamic graph typical for cancerDynamic graph typical for cancer

Post contrast colour mappingPost contrast colour mappingtreated by mastectomytreated by mastectomy

Axillary lymphadenopathyAxillary lymphadenopathy

LB. 47Yrs.LB. 47Yrs.

Right axillary nodesRight axillary nodes Biopsy: Metastatic carcinoma from BreastBiopsy: Metastatic carcinoma from Breast Mammogram: Dense breast. Extensive Mammogram: Dense breast. Extensive

benign changes with cystsbenign changes with cysts US: No obvious primary in the BreastUS: No obvious primary in the Breast

Non Contrast T1Non Contrast T1

Non contrast T2Non contrast T2

Post Contrast Subtraction imagesPost Contrast Subtraction images

Post contrast subtractionPost contrast subtraction

LF 51yrs LF 51yrs

H/o Suspicious lump in left breastH/o Suspicious lump in left breast Nipple changesNipple changes FullnessFullness Ill defined lumpy area inner aspect of left Ill defined lumpy area inner aspect of left

nipplenipple

Left Mammogram MLOLeft Mammogram MLO

Coned compression viewConed compression view

US: Vague area 20mm. Bx= B1US: Vague area 20mm. Bx= B1

Stereo core Bx = B5b Lobular Stereo core Bx = B5b Lobular cancercancer

MDTMDT

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

MRI: 60x25mmMRI: 60x25mm

Mammoplasty histologyMammoplasty histology

70mm Grade 2 Lobular cancer70mm Grade 2 Lobular cancer Probably multi focalProbably multi focal Difficult to asses sizeDifficult to asses size Lateral margin involvedLateral margin involved

Why not screen Why not screen everybody?????everybody?????

Hey, a normal MRI virtually excludes Hey, a normal MRI virtually excludes invasive breast cancer!invasive breast cancer!

Limitations of MRILimitations of MRI

False positives:False positives: Overlap of Benign & malignant lesionsOverlap of Benign & malignant lesions Incidental enhancing lesionsIncidental enhancing lesions About 30%About 30% Needs further assessment with second Needs further assessment with second

look US,Bx, ? MR guidedlook US,Bx, ? MR guided

False NegativesFalse Negatives

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

MR spectroscopy 4TMR spectroscopy 4T

Inappropriate uses of MRIInappropriate uses of MRI

Should not be substituted for Should not be substituted for Mammography or UltrasoundMammography or Ultrasound

Should not be used as substitute for a Should not be used as substitute for a histological diagnosishistological diagnosis

No studies proving efficacy of MRI as a No studies proving efficacy of MRI as a screening tool in the general populationscreening tool in the general population

Conclusion 1Conclusion 1 MRI is not a screening tool for women over MRI is not a screening tool for women over

50yrs50yrs MRI with Mammogram is good for high risk MRI with Mammogram is good for high risk

womenwomen MRI is indicated for staging in invasive MRI is indicated for staging in invasive

lobular cancerlobular cancer MRI is not required for routine stagingMRI is not required for routine staging MRI should be used as problem solving MRI should be used as problem solving

tool in difficult circumstancestool in difficult circumstances

Conclusion 2Conclusion 2

We Await new tools like Tomosynthesis, We Await new tools like Tomosynthesis, Improved software on Spectroscopy for Improved software on Spectroscopy for breast imaging,breast imaging,

Future : CT mammography, BSGI,PEMFuture : CT mammography, BSGI,PEM MR DuctographyMR Ductography

Thank youThank you