breast mri bx talk - department of radiologyradiology.uthscsa.edu/grad/presentations/breast mri bx...

Breast MRI and MRIBreast MRI and MRI--guided guided Breast BiopsyBreast Biopsy

R. Edward R. Edward HendrickHendrick, PhD, FAAPM, FACR, PhD, FAAPM, FACRLynn Sage Comprehensive Breast CenterLynn Sage Comprehensive Breast CenterNorthwestern University Medical School Northwestern University Medical School

Chicago, IllinoisChicago, Illinois

Clinical Indications for ContrastClinical Indications for Contrast--enhanced Breast MRI:enhanced Breast MRI:

• Search for primary breast cancer in women with a positive axillary node

• Staging of tumor extent in women with a known breast cancer – MRI most accurate

• Search for multifocal, multicentric or bilateral breast cancer in women with a known breast cancer

• Search for residual tumor shortly after surgery in patients with + margins

• Evaluation for tumor recurrence after surgery and/or radiation

• Monitoring tumor size and extent in neoadjuvant chemotherapy

• Screening of high-risk women

Clinical Indications for ContrastClinical Indications for Contrast--enhanced Breast MRI:enhanced Breast MRI:

Technical RequirementsTechnical RequirementsFor Good Cancer Detection:For Good Cancer Detection:

•• HighHigh--field breast MRI (1.5T or >)field breast MRI (1.5T or >)•• GadoliniumGadolinium--DTPA injectionDTPA injection•• Dedicated bilateral breast coilDedicated bilateral breast coil•• Good fat suppression techniquesGood fat suppression techniques•• HighHigh--resolution 3D gradient echo resolution 3D gradient echo

pulse sequencepulse sequence

Technical RequirementsTechnical RequirementsFor Good Cancer Detection:For Good Cancer Detection:•• HighHigh--resolution 3D gradient echo resolution 3D gradient echo

pulse sequencepulse sequence–– Bilateral coverageBilateral coverage–– InIn--plane resolution < 1 mmplane resolution < 1 mm–– Slice thicknesses < 3 mm Slice thicknesses < 3 mm

•• Dynamic imaging with adequate Dynamic imaging with adequate temporal resolution (1temporal resolution (1--2 minutes) 2 minutes) T1WT1W--GradientGradient--echo Preecho Pre--

GdGd--chelatechelate

Why Why GdGd--chelateschelates Are Are EssentialEssentialfor Cancer Detectionfor Cancer Detection

T1W T1W ––GradientGradient--echoecho2 minute Post 2 minute Post GdGd

T1WT1W--GradientGradient--echo echo PrePre--GdGd--chelatechelate

Why Why GdGd--chelateschelates Are Are EssentialEssentialfor Cancer Detectionfor Cancer Detection

T1W T1W ––GradientGradient--echoecho2 minute Post 2 minute Post GdGd

SagittalSagittalMaximum Maximum Intensity Intensity Projection Projection (MIP)(MIP)

Siemens 2Siemens 2--channel Bilateral Breast Coil channel Bilateral Breast Coil Why Use a Dedicated Breast Coil?Why Use a Dedicated Breast Coil?Same STIR Pulse Sequence at 1.5TSame STIR Pulse Sequence at 1.5T

44--Channel Breast Coil Body Coil as ReceiverChannel Breast Coil Body Coil as Receiver

SNR = 190 SNR = 27

PrePre--ContrastContrast

3D T1W Scans without Fat Saturation

PostPost--ContrastContrast

Why Use FatWhy Use Fat--saturation in Contrast Series?saturation in Contrast Series?

1st Post-Contrast Subtracted Image

Residual Signal Due to Motion Residual Signal Due to Motion Between PreBetween Pre-- and Postand Post--Contrast Images Mimics Contrast Images Mimics EnhancementEnhancement

Examples of Bad and Good Examples of Bad and Good Image QualityImage Quality

Old Old (BAD) (BAD) ScanningScanningProtocolProtocol

T2T2--FSE FSE or TSEor TSE


PrePre--GdGd


11stst

PostPost--GdGd

LargerLarger FOV than NecessaryFOV than Necessary

Low Matrix for Bilateral Axial ScanLow Matrix for Bilateral Axial Scan


11stst

SubtractedSubtracted

Motion Artifacts Motion Artifacts Obscure Lateral Obscure Lateral Breast TissueBreast Tissue

T2T2--TSETSE

New New ProtocolProtocol

Receiver Coil Has Better SNR

Breast Positioning Is Better

PrePre--GdGd


Fat Suppression Was Used

Spatial Resolution is Higher

11stst

PostPost--GdGd


11stst SubSub--tractedtractedImageImage


Fewer Motion Artifacts

Higher SNR

Higher Spatial Resolution

10 Ways to Tell That a Site Isn10 Ways to Tell That a Site Isn’’t Doing t Doing Good Breast MRIGood Breast MRI

•• Field strength < 1.5 TField strength < 1.5 T•• Images acquired unilaterally onlyImages acquired unilaterally only•• No fat saturation in CE imagesNo fat saturation in CE images•• Inadequate Inadequate GdGd--DTPA uptakeDTPA uptake•• InIn--plane resolution > 1 mm in CE imagesplane resolution > 1 mm in CE images•• Slice thickness > 3 mm in CE imagesSlice thickness > 3 mm in CE images•• No dynamic information obtainedNo dynamic information obtained•• Images interpreted from filmImages interpreted from film•• BIRADS for breast MRI not usedBIRADS for breast MRI not used•• Few or no vessels seen on 3D Few or no vessels seen on 3D MIPsMIPs

Looking at 3D Looking at 3D MIPsMIPs in the Acquired in the Acquired Projection Plane is a Good Way to Projection Plane is a Good Way to

Assess Overall Image QualityAssess Overall Image Quality

Excellent Axial MIP

Excellent Sagittal MIP from Same 3D Dataset

Good Sag MIP

Low SNR Sag MIP Poor Sag MIP

PrePre--GdGd PostPost--GdGd50 seconds post50 seconds post--injectioninjection

PostPost--GdGd Subtracted from PreSubtracted from Pre--GdGd

3D 3D 50 s50 sPostPost--GdGdSubtractedSubtracted

MaximumIntensityProjection (MIP)of Subtracted Images

Isotropic Imaging Permits Projection in Any Plane

MRI-GUIDED BREAST BIOPSYAppropriate for suspicious lesions found on MRI & not seen on mammography or USEquipment Needed:

A dedicated breast coil A biopsy guidance system compatible with the breast coil and tissue sampling deviceA MR-compatible tissue sampling device:

- 14 gauge cutting needle- 8-11 gauge vacuum-assisted sampling

device: Suros, Mammotome, etc.

-

InVivoInVivo 44--channel Bilateral Breast Coilchannel Bilateral Breast Coil

MRI Devices New Breast MRI CAD

InVivoInVivo 77--channel Imaging & Biopsy Coilchannel Imaging & Biopsy Coil

GE 8 Channel Breast Coil

MR-GUIDED BIOPSY

Grid Guidance Grid Guidance DeviceDevice

Grid Biopsy Guidance Devices

Reusable

Disposable

Guidance for Biopsy - Pillar/Post

Disposable

Reusable

Biopsy NeedlesBiopsy NeedlesFront ViewFront View

14g Cutting 14g Cutting 11g VA 11g VA 10g VA10g VA 8g VA 8g VA

Biopsy NeedlesBiopsy NeedlesSide ViewSide View

14g Cutting 14g Cutting 11g VA 11g VA 10g VA10g VA 8g VA 8g VA

1414--gauge gauge Cutting Cutting NeedleNeedle

14 Gauge spring14 Gauge spring--loaded biopsy gunloaded biopsy gun

Suros 9G MR-compatible Biopsy System

SurosSuros –– ATEC ATEC now now HologicHologic

Suros 9G MR-compatible Biopsy System Suros 9G Biopsy Samples

MRMR--guided Vacuumguided Vacuum--assisted Biopsy Setup assisted Biopsy Setup Breast Biopsy Sample WeightsBreast Biopsy Sample Weights

DeviceDevice Sample Sample WeightWeight

14 g Cutting Needle14 g Cutting Needle 18 mg18 mg

14 g 14 g MammotomeMammotome 37mg37mg

12 g 12 g SurosSuros ATECATEC 49 mg49 mg

11 g 11 g MammotomeMammotome 95 mg95 mg

9 g 9 g SurosSuros ATECATEC 118 mg118 mg

8 8 MammotomeMammotome 300 mg300 mg

Core Biopsy Sample SizesCore Biopsy Sample Sizes

100 mg each 12-17 mg eachAXIAL PLANE

MR-GUIDED BIOPSY

MRMR--guided Breast Biopsyguided Breast Biopsy

PrePre--ContrastContrast PostPost--ContrastContrast


External Marker External Marker Targeted LesionTargeted Lesion


Grid at Skin of Lateral Breast Targeted LesionGrid at Skin of Lateral Breast Targeted Lesion

∆x

∆y

∆z is found by the slice location difference from skinline to lesion

SurosSuros 9G Vacuum Biopsy System9G Vacuum Biopsy System

Suros 9G Biopsy Needle and Inserter SurosSuros 9G Biopsy Needle and Localizer9G Biopsy Needle and Localizer


Grid After Needle Placement Targeted LesionGrid After Needle Placement Targeted Lesion

Stylus Track Stylus Track


Targeted Lesion Before Targeted Lesion Before Targeted Lesion AfterTargeted Lesion AfterTissue SamplingTissue Sampling Tissue SamplingTissue Sampling

Stylus Track

Ethicon Micromark Applicator with Clip


Targeted Lesion Before Targeted Lesion Before Targeted Lesion AfterTargeted Lesion AfterTissue SamplingTissue Sampling Tissue SamplingTissue Sampling

Marker Clip Marker Clip ArtifactArtifact

Biopsy Markers & MR ArtifactsSenoRxSenoRx UltracorUltracor

FFDM ImageFFDM Image

SenoRxSenoRx GelmarkGelmark

SenoRxSenoRx GM UltraGM Ultra

MammomarkMammomark

MammomarkMammomark

InradInrad

MicromarkMicromark

MRI Image MRI Image 3D 3D -- GREGRE

Biopsy Markers & MR ArtifactsSenoRxSenoRx UltracorUltracor

FFDM ImageFFDM Image MRI Image MRI Image 2D T2 TSE2D T2 TSE

SenoRxSenoRx GelmarkGelmark

SenoRxSenoRx GM UltraGM Ultra

MammomarkMammomark

MammomarkMammomark

InradInrad

MicromarkMicromark

Digital Radiograph T2 FSE

ConclusionsConclusions

•• MRIMRI--guided breast biopsy is guided breast biopsy is appropriate for suspicious enhancing appropriate for suspicious enhancing lesions seen on MRI and not seen on lesions seen on MRI and not seen on mammography or breast USmammography or breast US

•• Breast MRI has an important role in Breast MRI has an important role in the search for and evaluation of breast the search for and evaluation of breast cancer cancer

ConclusionsConclusions

•• MRIMRI--guided breast biopsy usually gets guided breast biopsy usually gets sufficient samples, but can sufficient samples, but can underestimate diseaseunderestimate disease

•• It is harder to confirm correct sampling It is harder to confirm correct sampling with MRIwith MRI--guided breast biopsy than guided breast biopsy than with xwith x--ray or US guidanceray or US guidance

breast mri bx talk - department of radiologyradiology.uthscsa.edu/grad/presentations/breast mri bx...

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