![Page 1: MRI in breast cancer: diagnosis and intervention](https://reader033.vdocuments.us/reader033/viewer/2022042302/625a67e2b8e35965193684e9/html5/thumbnails/1.jpg)
MRI in breast cancer: diagnosis and intervention
Dr Sue Barter Addenbrookes Hospital, Cambridge UK
![Page 2: MRI in breast cancer: diagnosis and intervention](https://reader033.vdocuments.us/reader033/viewer/2022042302/625a67e2b8e35965193684e9/html5/thumbnails/2.jpg)
Intervention will be discussed in High Risk Screening!
![Page 3: MRI in breast cancer: diagnosis and intervention](https://reader033.vdocuments.us/reader033/viewer/2022042302/625a67e2b8e35965193684e9/html5/thumbnails/3.jpg)
Indications UK and Europe:
Breast MRI is well established as a tool for certain recognised indications which include:
� Mammographically occult lesions in dense breasts�Discrepancy in size (mammography/ultrasound/clinical)�Suspected multifocal disease�Lobular carcinomas�Axillary lymphadenopathy, primary unknown�Evaluation of response to primary chemotherapy �Assessment of breast implant integrity �High risk screening
EUSOBI 2008Eusoma 2010: Evidence based
![Page 4: MRI in breast cancer: diagnosis and intervention](https://reader033.vdocuments.us/reader033/viewer/2022042302/625a67e2b8e35965193684e9/html5/thumbnails/4.jpg)
Indications US:
USA 12 indications
�Lesion characterization�Neoadjuvant chemotherapy� Infiltrating lobular and ductal carcinoma�Axillary adenopathy, primary unknown�Postoperative tissue reconstruction�Silicone and non-silicone breast augmentation� Invasion deep to the fascia�Contralateral breast examination in patients with breast
malignancy�Postlumpectomy for residual disease�Surveillance of high-risk patients�Recurrence of breast cancer
![Page 5: MRI in breast cancer: diagnosis and intervention](https://reader033.vdocuments.us/reader033/viewer/2022042302/625a67e2b8e35965193684e9/html5/thumbnails/5.jpg)
Dynamic CE MRI
�Angiogenesis closely correlated with invasive cancer�Neo capillaries ++�Enlarged fenestrations�Capillary leakage�AV shunting
![Page 6: MRI in breast cancer: diagnosis and intervention](https://reader033.vdocuments.us/reader033/viewer/2022042302/625a67e2b8e35965193684e9/html5/thumbnails/6.jpg)
How we do it:
Dedicated breast coil mandatoryMultichannelAccess to prior conventional imagingDouble reporting
![Page 7: MRI in breast cancer: diagnosis and intervention](https://reader033.vdocuments.us/reader033/viewer/2022042302/625a67e2b8e35965193684e9/html5/thumbnails/7.jpg)
Cambridge MR protocols
�1.5T GE �10/week (30 – 40 min) (High burden)�Normal parenchymal enhancement
least mid cycle�Optimum imaging window day 6 to 16
of cycle�No evidence stopping HRT reduces
background parenchymal enhancement�Iv Gd 1.5mmol/kg 3ml/sec (pink cannula)
![Page 8: MRI in breast cancer: diagnosis and intervention](https://reader033.vdocuments.us/reader033/viewer/2022042302/625a67e2b8e35965193684e9/html5/thumbnails/8.jpg)
Positioning
�Prone�Feet first�weight < 105kg�No padding, allowing gravity to elongate
breasts�Discomfort: neck and arm ache
![Page 9: MRI in breast cancer: diagnosis and intervention](https://reader033.vdocuments.us/reader033/viewer/2022042302/625a67e2b8e35965193684e9/html5/thumbnails/9.jpg)
Side marking�Transposing sides is a common reporting
error�Fish oil capsule marker�We mark left breast�Correlate with other imaging�Viewing
![Page 10: MRI in breast cancer: diagnosis and intervention](https://reader033.vdocuments.us/reader033/viewer/2022042302/625a67e2b8e35965193684e9/html5/thumbnails/10.jpg)
Sequences�Axial T1 & T2�DWI�Axial 3D dynamic “VIBRANT” –T1 FSPGR fat
sat� 2mm thick; FOV 34 X 34� 1 test: coverage, shimming for fat sat� 1 pre� 5 post contrast� Automatic Subtraction processing
�Research – diffusion, spectroscopy, other dynamic acquisition sequences, 3T
![Page 11: MRI in breast cancer: diagnosis and intervention](https://reader033.vdocuments.us/reader033/viewer/2022042302/625a67e2b8e35965193684e9/html5/thumbnails/11.jpg)
Problems with fat sat
�Contralateral implants�Recent biopsy (?metal)�Portacaths (NB ruin DWI)
�Coils/clips – ok if Titanium – small local bloom
![Page 12: MRI in breast cancer: diagnosis and intervention](https://reader033.vdocuments.us/reader033/viewer/2022042302/625a67e2b8e35965193684e9/html5/thumbnails/12.jpg)
Post processing
�Subtraction�MIP�Multiplanar reconstruction�Curve analysis (Functool)�Spectroscopy�Diffusion�CAD (Cadstream)
![Page 13: MRI in breast cancer: diagnosis and intervention](https://reader033.vdocuments.us/reader033/viewer/2022042302/625a67e2b8e35965193684e9/html5/thumbnails/13.jpg)
Reporting: BI-RADS�The ACR BI-Rads Lexicon widely used� 5th Edition published 2013� Standardised:
•Imaging findings terminology•Report organisation•Assessment structure• Classification of findings
Some differences in Europe Eg no category 0, 4 abc in UK
no category 0,3,4ab in GermanyCambridge Breast Unit
![Page 14: MRI in breast cancer: diagnosis and intervention](https://reader033.vdocuments.us/reader033/viewer/2022042302/625a67e2b8e35965193684e9/html5/thumbnails/14.jpg)
BIRADS�BIRADS 0 (Needs additional imaging
evaluation)�BIRADS 1 (Normal)�BIRADS 2 (Benign finding)�BIRADS 3 (Probably benign finding - short
interval follow-up) AVOID IF POSSIBLE�BIRADS 4 Suspicious finding; further
assessment and biopsy should be considered�BIRADS 5 (Highly suggestive of malignancy;
biopsy mandatory)�BI-RADS 6 Known biopsy proven malignancy
Cambridge Breast Unit
![Page 15: MRI in breast cancer: diagnosis and intervention](https://reader033.vdocuments.us/reader033/viewer/2022042302/625a67e2b8e35965193684e9/html5/thumbnails/15.jpg)
Interpretation: BI-RADS descriptors�Density (amount of FG tissue)�Background enhancement
� none/minimal: <25%�mild: 25-50%�moderate: 50-75%�marked : >75%
![Page 16: MRI in breast cancer: diagnosis and intervention](https://reader033.vdocuments.us/reader033/viewer/2022042302/625a67e2b8e35965193684e9/html5/thumbnails/16.jpg)
Reporting:First stepMass or non-mass?
![Page 17: MRI in breast cancer: diagnosis and intervention](https://reader033.vdocuments.us/reader033/viewer/2022042302/625a67e2b8e35965193684e9/html5/thumbnails/17.jpg)
BI-RADS descriptors: MorphologyMass
3 dimensional space occupying lesion <5mm Convex margin separate from surrounding FGT
Shape:round, oval, (Inc lobulated,)irregular
Focus < 5 mm: To small to characterize margins, etc Heywang-Köbrunner et al. Eur Rad 2001
Margins:smooth, irregular,
spiculated
Internal EH characteristics: homogenous, heterogenous, rim, dark or enhancement,internal septations, central (target)
![Page 18: MRI in breast cancer: diagnosis and intervention](https://reader033.vdocuments.us/reader033/viewer/2022042302/625a67e2b8e35965193684e9/html5/thumbnails/18.jpg)
BI-RADS descriptors:EnhancementKinetics
washout, plateau, persistent(caveat: papillomas and lymph nodes washout)
~ 70% of invasive cancers wash out~ 9% of DCIS washes out
Non Mass EnhancementSymmetric or assymetric?
focal, linear ductal, linear clumped, segmental patchy/clumped, regional, diffusestippled, punctate,
Linear Enhancement, Rare, beware movement artifact
![Page 19: MRI in breast cancer: diagnosis and intervention](https://reader033.vdocuments.us/reader033/viewer/2022042302/625a67e2b8e35965193684e9/html5/thumbnails/19.jpg)
Interpretation: you do these!
DCIS: Non-masslikeLinear clumped enhancementSegmental, or ductal asymmetric pattern
Invasive Ductal CancerIrregular or spiculate massHeterogenous enhancementFast uptake and washout
![Page 20: MRI in breast cancer: diagnosis and intervention](https://reader033.vdocuments.us/reader033/viewer/2022042302/625a67e2b8e35965193684e9/html5/thumbnails/20.jpg)
MRI features and PPV
�Mass� spiculated mass : 80 %� irregular shape : 32 %� < 5 mm mass : 3 %
�Non mass� Linear (rare) � segmental : 67 %� clumped ductal : 31 %
![Page 21: MRI in breast cancer: diagnosis and intervention](https://reader033.vdocuments.us/reader033/viewer/2022042302/625a67e2b8e35965193684e9/html5/thumbnails/21.jpg)
MRI features and PPVEnhancement � Lack of enhancement has high negative predictive value (NPV) for
malignancy (88%–96%)� Type I curve: progressive enhancement pattern
� considered benign ~9% malignant� Type II curve: plateau pattern
� concerning for malignancy 34% malignant� Type III curve: washout pattern
� rapid uptake and washout� strongly suggestive of malignancy 57%
![Page 22: MRI in breast cancer: diagnosis and intervention](https://reader033.vdocuments.us/reader033/viewer/2022042302/625a67e2b8e35965193684e9/html5/thumbnails/22.jpg)
Scar tissue:
�Mass or non-masslike� Irregular lesion�No enhancement�Low T2 signal
No indication for MRI routinely for scar tissue. It should NOT replace conventional assessment and core biopsy.
![Page 23: MRI in breast cancer: diagnosis and intervention](https://reader033.vdocuments.us/reader033/viewer/2022042302/625a67e2b8e35965193684e9/html5/thumbnails/23.jpg)
Indications UK and Europe:
� Mammographically occult lesions in dense breasts
�Problem solving: Discrepancy in size or position (mammography/ultrasound/clinical)
�Suspected multifocal disease�Lobular carcinomas�Axillary lymphadenopathy, primary unknown�Evaluation of response to primary
chemotherapy �Assessment of breast implant integrity
![Page 24: MRI in breast cancer: diagnosis and intervention](https://reader033.vdocuments.us/reader033/viewer/2022042302/625a67e2b8e35965193684e9/html5/thumbnails/24.jpg)
Cambridge Breast Unit
Occult lesion, Dense breast
![Page 25: MRI in breast cancer: diagnosis and intervention](https://reader033.vdocuments.us/reader033/viewer/2022042302/625a67e2b8e35965193684e9/html5/thumbnails/25.jpg)
Cambridge Breast Unit
Occult lesion, Dense breast
![Page 26: MRI in breast cancer: diagnosis and intervention](https://reader033.vdocuments.us/reader033/viewer/2022042302/625a67e2b8e35965193684e9/html5/thumbnails/26.jpg)
Cambridge Breast Unit
Problem Solving �MRI to assess screen detected abnormality right
breast�original mammographic lesion appeared to be
upper inner quadrant. Ultrasound lesion (B2) seemed to be a bit too lateral for true correlation.
![Page 27: MRI in breast cancer: diagnosis and intervention](https://reader033.vdocuments.us/reader033/viewer/2022042302/625a67e2b8e35965193684e9/html5/thumbnails/27.jpg)
Cambridge Breast Unit
Problem solving
�MRI RIGHT shows a unifocal irregular area with rapid enhancement measuring 12 mm x 12 mm x 8 mm situated in the lower inner quadrant. On review of mammograms there is faint change in this area on the MLO film
�LEFT: normal�needs second look u/sound
![Page 28: MRI in breast cancer: diagnosis and intervention](https://reader033.vdocuments.us/reader033/viewer/2022042302/625a67e2b8e35965193684e9/html5/thumbnails/28.jpg)
Lobular carcinoma�Mass or non-masslike enhancement�Heterogenous enhancement�Variable curve type�T2 isointense to fibroglandular tissue
![Page 29: MRI in breast cancer: diagnosis and intervention](https://reader033.vdocuments.us/reader033/viewer/2022042302/625a67e2b8e35965193684e9/html5/thumbnails/29.jpg)
Lobular carcinoma
�22mm grade2 invasive lobular ca
�MR detected multifocality
2nd lesion inferiorlylobular ca on US biopsy
![Page 30: MRI in breast cancer: diagnosis and intervention](https://reader033.vdocuments.us/reader033/viewer/2022042302/625a67e2b8e35965193684e9/html5/thumbnails/30.jpg)
Cambridge Breast Unit
Unknown primary47 year old presented with axillary lymphadenopathy
![Page 31: MRI in breast cancer: diagnosis and intervention](https://reader033.vdocuments.us/reader033/viewer/2022042302/625a67e2b8e35965193684e9/html5/thumbnails/31.jpg)
Cambridge Breast Unit
Unknown primary
![Page 32: MRI in breast cancer: diagnosis and intervention](https://reader033.vdocuments.us/reader033/viewer/2022042302/625a67e2b8e35965193684e9/html5/thumbnails/32.jpg)
Cambridge Breast Unit
Neoadjuvant baseline
![Page 33: MRI in breast cancer: diagnosis and intervention](https://reader033.vdocuments.us/reader033/viewer/2022042302/625a67e2b8e35965193684e9/html5/thumbnails/33.jpg)
Cambridge Breast Unit
Neoadjuvant Mid Rx
![Page 34: MRI in breast cancer: diagnosis and intervention](https://reader033.vdocuments.us/reader033/viewer/2022042302/625a67e2b8e35965193684e9/html5/thumbnails/34.jpg)
Cambridge Breast Unit
Comparison – response
![Page 35: MRI in breast cancer: diagnosis and intervention](https://reader033.vdocuments.us/reader033/viewer/2022042302/625a67e2b8e35965193684e9/html5/thumbnails/35.jpg)
ImplantsMRI is indicated for problem solving focal abnormalitieswhere triple assessment has failed to resolve the diagnosis.It is considered by many as the “gold standard” for assessment of implant rupture.
![Page 36: MRI in breast cancer: diagnosis and intervention](https://reader033.vdocuments.us/reader033/viewer/2022042302/625a67e2b8e35965193684e9/html5/thumbnails/36.jpg)
Implants:EUSOMA Guidance
� MRI not recommended for screening for implant rupture in asymptomatic women.
�Symptoms suggestive of implant rupture, etc.after conventional imaging, non-contrast MRI is recommended to confirm or exclude rupture.
�Signs/symptoms of parenchymal disease (e.g. breast lump), when conventional imaging is not diagnostic, non-contrast MRI and DCE MRI is indicated
� In symptomatic patients that have undergone breast augmentation with direct polyacrylamide gel injection, non-contrast MRI and dynamic contrast-enhanced MRI are indicated.
(Sardanelli 2010):
![Page 37: MRI in breast cancer: diagnosis and intervention](https://reader033.vdocuments.us/reader033/viewer/2022042302/625a67e2b8e35965193684e9/html5/thumbnails/37.jpg)
Sequences Implants
�Single breast (less chemical shift)�Axial STIR�Axial stir water sat (silicone only)�Sagittal STIR�Axial VIBRANT single phase
![Page 38: MRI in breast cancer: diagnosis and intervention](https://reader033.vdocuments.us/reader033/viewer/2022042302/625a67e2b8e35965193684e9/html5/thumbnails/38.jpg)
Implant failure
�Linguini�Noose�Keyhole�Silicone leak�Salad oil
![Page 39: MRI in breast cancer: diagnosis and intervention](https://reader033.vdocuments.us/reader033/viewer/2022042302/625a67e2b8e35965193684e9/html5/thumbnails/39.jpg)
Pre-operative MRI
�MRI improves diagnosis of breast cancer, but does it reduce rates of reoperation and recurrence?
�COMICE and MONET trials suggested not�Preoperative Breast MRI in Clinical Practice:
Multicenter International Prospective Meta-Analysis (MIPA) of Individual Woman Data An EIBIR-EuroAIM/EUSOBI Study (due 2018)(Sardinelli)
![Page 40: MRI in breast cancer: diagnosis and intervention](https://reader033.vdocuments.us/reader033/viewer/2022042302/625a67e2b8e35965193684e9/html5/thumbnails/40.jpg)
Take home messages� Mass: Shape, margins etc do not override
enhancement kinetics�Lobular cancers may not show typical malignant type
enhancement� NME: distribution, symmetry key�MRI is not needed to assess a tumour before surgery
for biopsy-proven invasive breast cancer or DCIS except in specific clinical situations.
�Carrying out an unnecessary preoperative MRI scan may cause additional stress without any benefit and waste healthcare resources
�Do not substitute for conventional imaging and biopsy unless specific indications
![Page 41: MRI in breast cancer: diagnosis and intervention](https://reader033.vdocuments.us/reader033/viewer/2022042302/625a67e2b8e35965193684e9/html5/thumbnails/41.jpg)
Thank you