mri for extent of cancer in the breast - bccbcckuwait.com/doc/bcc/pdf/2-03mh-dershaw.pdfbreast •...
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IMAGING ASSESSMENT OF LOCAL EXTENT OF BREAST CANCER
D DAVID DERSHAW MD
MEMORIAL SLOAN-KETTERING
NEW YORK, NEW YORK
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Mammographic determination of the extent of tumor depends on:
• Calcification: ductal cancer
– Only develop if there is tumor necrosis
– Reliably associated with comedo
– Does not always develop with non-comedo
• Mass: invasive cancer
– Rarely identified with DCIS
Mammography does not reliably demonstrate
the extent of non-comedo DCIS especially when
the identifiable lesion is > 2 cm
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MAMMOGRAPHIC FINDINGS IN DCIS(N=54)
N (%)
Microcalcifications without mass 37 (68)
Mass with microcalcifications 16 (30)
Mass without microcalcifications 1 (2)
Dershaw. Radiology 170;411;1989
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DCIS PathologyComedo
= Anaplastic cells with nuclear
pleomorphism and prominent mitoses
= Extensive necrosis, producing
calcification
= No skipped segments of the duct
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NECROSIS WITH MAMMOGRAPHIC CALCIFICATION
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CARCINOMA
INTERMITTENTLY
CONTAING
CALCIFICATIONS
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RESIDUAL TUMOR AT SURGICAL EXCISION
AFTER COMPLETE REMOVAL OF IMAGING
FINDINGS AT NEEDLE BIOPSYLiberman et al. Radiology 1998; 206:711
Needle Dx Total BX Residual Tumor
DCIS 12 8
IFDC 3 3
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MARGIN SIZE vs. TUMOR CLEARANCE FOR DCIS
Clear margin at surgery Residual tumor
1 cm 32%
2 cm 17%
3 cm 11%
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HISTOLOGIC SIGNIFICANCE OF TUMOR
SPICULES ON MAMMOGRAPHY
Spiculations caused by direct
tumor extension and by fibrotic
reaction have an identical
mammographic pattern and
cannot be differentiated on
mammography.
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INFILTRATING LOBULAR CARCINOMA
• 3-4% of infiltrating carcinomas
• Mass or ill-defined thickening on physical exam
• Calcifications are rare
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INVASIVE LOBULAR CARCINOMA
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MR assessment of invasive lobular carcinoma
Mammo MRI
Correct Assessment of 32 % 85%Extent of tumor
Rodenko et al. AJR 1996;167:1415
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MRI staging
• Size of known lesion
• Presence of other malignant sites in the breast
• Nodal involvement: axilla and internal mammary chain
• Chest wall involvement
• Nipple
• Contralateral disease
• Treatment response
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MRI staging
• Size of known lesion• Presence of other malignant sites in the
breast
• Nodal involvement: axilla and internal mammary chain
• Chest wall involvement
• Nipple
• Contralateral disease
• Treatment response
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Infiltrating lobular carcinoma - extent
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T3 Breast Cancer Normal Contralateral
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Diffuse infiltrating ductal carcinoma
2 minutes post 2 minutes post
left right
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Extensive carcinomas may be best appreciated
on 3D reconstruction
2D
3D
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MRI staging
• Size of known lesion
• Presence of other malignant sites in the breast
• Nodal involvement: axilla and internal mammary chain
• Chest wall involvement• Nipple• Contralateral disease• Treatment response
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Multifocal carcinoma
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Multicentric carcinoma
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Multicentric infiltrating ductal carcinoma
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MRI IS IMPERFECT AND CAN MISS OBVIOUS CANCERS ON MAMMOGRAM
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Axillary Nodal Metastases
• Central fat obliterated
• Same size as benign nodes
• Spiculation signifies perinodal tumor extension
• Microcalcifications very rare
• Number usually underestimated mammographically
• Hypertrophic nodes can have same pattern
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Disrupted Axillary Nodes Due to Metastatic
Breast Cancer: Sonographic Pattern
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SpiculatedAxillary Node: Extranodal
Extension of Metastatic Breast Cancer
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MRI staging
• Size of known lesion• Presence of other malignant sites in the
breast
• Nodal involvement: axilla and internal mammary chain
• Chest wall involvement• Nipple • Contralateral disease• Treatment response
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Pectoralis major
Pectoralis minor
AXILLARY NODE LEVEL
II I
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LEVEL I LEVEL II
AXILLARY NODAL STAGING
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LEVEL I LEVEL II
AXILLARY NODAL STAGING
PECTORALIS
major
minor
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Extensive tumor with axillary
nodal involvement
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Normal Internal Mammary Chain
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Internal mammary adenopathy
Post RxTumor
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Positron Emission Tomography
• Determination of axillary nodal status
– Sensitivity: 33-100%
– Specificity: 66-100%
– Best with larger tumor burden in axillary nodes
– Poor performance in women with T1 tumors
• Sensitivity reported as low as 25%
• Useful for determination of status of internal mammary and mediastinal nodes
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Breast cancer met
to axillary node
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MRI staging
• Size of known lesion• Presence of other malignant sites in the
breast• Nodal involvement: axilla and internal
mammary chain
• Chest wall involvement• Nipple
• Contralateral disease• Treatment response
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Invasion deep to fascia
chest wall involvement (stage IIIB)
ribs
intercostal muscles
serratus anterior muscle
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Determination of Chest Wall Involvement
Tumor free of chest wall
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Tumor abuts but does not invade chest wall
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Chest Wall
Invasion
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Pectoralis muscle and chest wall involvement
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Tumor extends through chest wall
Enlarged view
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MRI staging
• Size of known lesion
• Presence of other malignant sites in the breast
• Nodal involvement: axilla and internal mammary chain
• Chest wall involvement
• Nipple • Contralateral disease
• Treatment response
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Tumor extends toward without
involving nipple
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PAGETS DISEASE
Growth of ductal carcinoma in major ducts over the nipple and areola. Clinically evident as ectemoid change in nipple-areola complex.
Always accompanied by an intraductal carcinoma.May or may not be invasive.
Mammogram normal in 50%, but can show extensive tumor in underlying breast.
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PAGETS DISEASE: MAMMOGRAPHY
CALCIFICATIONS
AT THE NIPPLE NORMAL
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PAGETS DISEASE: MRI
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PAGETS DISEASE: MRI
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MRI staging
• Size of known lesion
• Presence of other malignant sites in the breast
• Nodal involvement: axilla and internal mammary chain
• Chest wall involvement
• Nipple
• Contralateral disease• Treatment response
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Study (year) #Pts Bx PPV #cancer %
Rieber 1998 34 --- 3 9
Fischer 1999 336 --- 15 4
Woo 2000 90 50% 5 6
Kuhl 2000 710 49% 45 6
Slanetz 2002 17 80% 4 24
Liberman 2003 223 20% 12 5
Lehman 2007 969 25% 30 3
Pediconi 2007 87 64% 18 21
TOTAL 2466 132 5
Synchronous, Contralateral Breast Cancer Found by MRI
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right breast left breast
Bilateral invasive lobular carcinoma with left found at time of right staging MRI
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Contralateral Findings
Right breast DCIS
Left breast
proliferative
changes
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MRI Assessment of Residual Disease After Neoadjuvant Chemotherapy
Partridge SC. AJR 2002; 179:1193
52 patients imaged pre- and post-chemo ; results compared to clinical exam
MR correlation with pathology was 0.89
CE correlation with pathology was 0.60
All cases with residual disease had positive MRI
5 cases with residual disease had negative CE
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MRI Assessement of Response to Neoadjuvant Chemotherapy
Chen JH. Cancer 2008; 112:17.
scanned before, during and after neoadj chemo
true+ true- false+ false-
HER-2 + (N=25) 20% 72% 4% 4%
HER-2 – (N=26) 34% 31% 4% 31%
Total (N=51) 27% 51% 4% 18%
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MRI Assessement of Response to Neoadjuvant Chemotherapy
Chen JH. Cancer 2008; 112:17.
CONCLUSION
MRI may be highly accurate for predicting
pathologic complete response in HER-2 +
women but has a high false-negative rate in
HER-2, particularly if they have been treated
with anti-angiogenic agents. Interpretation of
response, particularly if used to plan surgery,
should consider these factors.
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Pre chemo Post chemo
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Induction chemotherapy –evaluation of response
pre chemo 3 cycles: no response
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NECROTIC TUMOR
SHOWING RESPONSE
TO TREATMENT WITH
DEVELOPING FAT
NECROSIS
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MRI imaging patterns & likelihood of complete or partial response
• circumscribed mass 77%
• nodular tissue infiltration 37.5%
• diffuse tissue infiltration 37.5%
• patchy enhancement 20%
• septal spread 25%
AJR 2002;179:1193-9
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Dynamic curves change
• Contrast uptake (time of maximum enhancement) significantly reduced after chemotherapy
• Curves flatten & shift to the right
– May be seen after first cycle
Rieber et al BJR 1997;70:452-458
Wasser et al. Eur Radiol 2003;13:80-87
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MRI pattern of response may be predictive
may help set patients’ expectations about prognosis or potential for breast conservation
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