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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
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IntroductionIntroduction
Timeline of Breast diagnosisTimeline of Breast diagnosis Role of MRI BreastRole of MRI Breast Recent advancesRecent advances Other modalitiesOther modalities ConclusionConclusion
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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
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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
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Spiculate mass left BreastSpiculate mass left Breast
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Right Breast Screening Right Breast Screening MammogramMammogram
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Coned viewConed view
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US Bx Invasive lobular cancerUS Bx Invasive lobular cancer
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Any more lesions ? Any more lesions ?
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MRI Breast with contrastMRI Breast with contrast
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MRI Breast with contrast and MRI Breast with contrast and subtractionsubtraction
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Colour mappingColour mapping
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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
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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
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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.
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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%
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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
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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
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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%
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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%
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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%
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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
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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
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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
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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
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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
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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
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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
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Multifocal 3 leisonsMultifocal 3 leisons
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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
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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
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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
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Extra capsular siliconExtra capsular silicon
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Silicon only image. Extra capsular Silicon only image. Extra capsular silicon with fluid collectionsilicon with fluid collection
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Normal sideNormal side
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US Extra capsular siliconUS Extra capsular silicon
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Extra capsular siliconExtra capsular silicon
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Silicon in Right axillary lymph nodeSilicon in Right axillary lymph node
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Coronal images to asses overall Coronal images to asses overall shapeshape
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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
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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)
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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
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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
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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
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Case 1Case 1
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SH 60 yrs. Recalled from screening for possible SH 60 yrs. Recalled from screening for possible ASD Right BreastASD Right Breast
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Further views showed normal mammogram.Further views showed normal mammogram.
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However, US 8mm IDM UOQ Biopsy B5b Invasive DCHowever, US 8mm IDM UOQ Biopsy B5b Invasive DC
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US localisation for WLE & SNBUS localisation for WLE & SNB
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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
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MRI Seroma with 23x14mm TumourMRI Seroma with 23x14mm Tumour
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MRI Seroma with 23x14 mm TumourMRI Seroma with 23x14 mm Tumour
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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
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CASE 2CASE 2
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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
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MRI: MRI: 53x49mm with axillary nodes 2.3cms53x49mm with axillary nodes 2.3cms
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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
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ResponseResponse to Chemotherapyto Chemotherapy
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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.
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Mammogram: Heterogeneously dense breastMammogram: Heterogeneously dense breastDiffuse stromal pattern with no focal massDiffuse stromal pattern with no focal mass
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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
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Pre chemo MRI: 80x 43 mm IDMPre chemo MRI: 80x 43 mm IDM
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MRI : MRI : After 2 courses of Chemotherapy: 6.4x4.5 cmAfter 2 courses of Chemotherapy: 6.4x4.5 cm
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Post Chemotherapy 11wks later: Few tiny enhancing nodulesPost Chemotherapy 11wks later: Few tiny enhancing nodules
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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
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CLINICAL AND IMAGING CLINICAL AND IMAGING DISCREPANCYDISCREPANCY
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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
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MRI : 7 cm IDM andMRI : 7 cm IDM and
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Second lesion found 2cmSecond lesion found 2cm
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Dynamic graph typical for cancerDynamic graph typical for cancer
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Post contrast colour mappingPost contrast colour mappingtreated by mastectomytreated by mastectomy
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Axillary lymphadenopathyAxillary lymphadenopathy
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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
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Non Contrast T1Non Contrast T1
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Non contrast T2Non contrast T2
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Post Contrast Subtraction imagesPost Contrast Subtraction images
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Post contrast subtractionPost contrast subtraction
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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
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Left Mammogram MLOLeft Mammogram MLO
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Coned compression viewConed compression view
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US: Vague area 20mm. Bx= B1US: Vague area 20mm. Bx= B1
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Stereo core Bx = B5b Lobular Stereo core Bx = B5b Lobular cancercancer
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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
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MRI: 60x25mmMRI: 60x25mm
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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
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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!
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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
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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
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MR spectroscopy 4TMR spectroscopy 4T
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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
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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
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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
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Thank youThank you