breast imaging breast mri s taieb

New Breast MR Imaging

Sophie Taïeb, Luc Ceugnart

Anticancer center Oscar Lambret - Lille -

Ø  Perform in specialist breast units with experience in CI ü At least 150 MRI / year / centre ü MRI biopsy in house or agreement with another institution

Ø Use adequat sequences in adequat period of menstrual cycle (7-12)

Ø Respect indications

Ø Use Birads lexicon to describe lesions

Right Breast : Mass BiRads 5

•  US: mass 25 mm •  IDC grade 3 •  RE+, RP-, Her2 -, Ki67 25-30%

35 y-o. BRCa2. Yearly MRI

Right breast 6h : DCIS

•  Pas de traduction echo- mammographique

Right mastectomy

Ø IDC 16 mm Ø DCIS 11 mm

Ø 1N+ / 13 N

MRI allows to highlight carcinoma not

seen on mammo or US J

41 y-o - Nurse Normal physical examination Mother with breast carcinoma under 50 years-old 1st mammography

US : no lesions seen

BiRads 3 or MRI ?

BiRads 2

MRI = PROBLEM SOLVING J

CONTRALATERAL BREAST

3rd sequence postC T2FS

Ø  BiRads 3 Ø  US : not seen

Washin card

Follow up 4 months : Persistence of lesion Biopsy

Failure

2 Months later : SURGERY MRI wire localization

Ø HYPERPLASIA without atypical cells

MRI = Problem creating L

Ø Safe : No toxicity (gadolinium-chelates)

Ø High Sensitivity, Specificity, PPV, PNV : Even with low prevalence of disease

Ø Good reproducibility : Inter et Intra observers

Ø  Low coast : Money, Medical’s and Patient’s time

Ø  Easy comparison with gold standards ü  Mammo – US ü  Biopsy - Surgery ü  Histopathology

The breast MRI we need

MRI = Poor specificity

Ø  44 studies / 251 : 1985 - 2005

Ø Se : 90% [0.88-0.92]

Ø Sp : 72% [0.67-0.77]

Ø  11 studies (1994-2007) – No randomised studies Ø  2 mutations (727), 9 mutations + risk > 15% for all life (4939)

Ø  218 cancers : 3.5% (45) - 2% (171) - 20% DCIS - 60%N+ (126)

Ø  Se : Mammo 14-59% ; MRI 51-100% Ø  Sp : Mammo 91-100% ; MRI 79-98%

Ø  50 / 237 – 1996-2011 Ø  10811 women Ø  Extension surgery in 12,8% but useless in 6,3% of cases Ø Miss information about overall survival

Ø  MRI : ü  20% homolat lesions. PPV of cancer : 59-74% à need biopsy PPV : 75% if > 1,5T ; 59% if < 1,5T

ü  5,5% controlat. PPV of cancer : 27-47% à need biopsy PPV : 40% if > 1,5T ; 19% if < 1,5T

Ø Adequat sequences : 2nd Week of menstrual cycle ü At least one unenhanced high-contrast sequence (T2 FSE) ü  2D or 3D T1-w. dynamic seq. : pixel < 1,5 mm2, thickness

< 4mm, < 120 sec. ü Gado.-chelates 0,1mmol/kg – 2-3ml/s, saline flush (20-30ml)

Improve specificity : 3T MRI ?



Ø  Centre Oscar Lambret - 3T : 3D Vibrant (GE) ü  5 x 80 secondes ü  Pixel 0,66 mm2, Thickness 2,2mm, No Gap. ü S1 – begining injection 20sec. before the end, 4 post injection




Ø  Centre Oscar Lambret - 3T : 3D Vibrant (GE) ü  5 x 80 secondes ü  Pixel 0,66 mm2, Thickness 2,2mm, No Gap. ü S1 – begining injection 20sec. before the end, 4 post injection

Ø No studies demonstrate 3T > 1,5T ü  Best spatiale resolution

ü  Best temporal resolution : 15 - 20 mn T1 + T2 + DWI-w + 3D dynamic + Late Sequence (DCIS)


Improve specificity : DWI-MRI ?

Ø  à 2009 : 13 / 65 études Ø  615 Cancers, 349 LB Ø  b 1000 -Se : 0.84 [0.8-0.87]; Sp 0.84 [0.79-0.88]

ü  93 women, 101 lesions. 3T, b0, b600.

ü  33 BL : 9 FA, 3 intraductal Papillomas, 4 Fibrocystic L, 4 sclerosing aden. 2 ADHL, 11 areas of benign breast tissue

ü  68 K : 23 IDC, 26 IDC+DCIS, 9 DCIS, 6 ILC, 4 others

•  27 y-‐o. Pregnant : 8 Weeks •  Le6 B : IDC Grade 3 RE-‐, RP-‐, Her2 -‐.

S3 Native 3

Diffusion b 1000 ADC

•  27 y-‐o. Pregnant : 8 Weeks •  Le6 B : IDC Grade 3 RE-‐, RP-‐, Her2 – •  Right B : ?

ADC: 2, ADC: 0,86.10-3 ADC: 1,26.10- 3

•  27 y-‐o. Pregnant : 8 Weeks •  LB : IDC Grade 3 RE-‐, RP-‐, Her2 – •  RB : ?

ADC: 2, ADC: 0,86.10-3 ADC: 1,26.10- 3

ADENOSIS

•  27 y-‐o. Pregnant : 8 Weeks •  LB : IDC Grade 3 RE-‐, RP-‐, Her2 – •  RB : ?

54 y-‐o. MulKfocalité on mammography ?

RB : 2nd lesion : Birads 5


LB :


LB : Lymph node

Artefacts fréquents….

Courtesy Dr C.Balleyguier

Improve specificity : Contrast media ?

Support: Bracco

Ø  Centers 17 : 07/2007 – 05/2009 Ø  162 Mammo ou US : Birads 3, 4, 5 (biopsy needed)

Ø  82 Gadobenate Dimeglumine / 80 Gadopentate Dimeglumine Ø  2nd MRI > 2 days; < 7 days

Ø  136 patients with both. GB : 7 atopic reactions, GP : 6 Ø  Independant 2nd reading : 3 readers + 4th review reader

Ø  136 double examinations : 216 lesions

Ø  144 cancers : ü  87 IDC, 30 ILC, 5 both, 5 others ü  13 DCIS, 3 LN, 1 mixte

Ø  52 Benign lesions

Ø  20 Birads3 : follow-up

Results : 3 readers Ø  Cancer detection rate : GB 91.7, 93, 94.4% > GP 79.9, 80.6, 83.3%

Ø  Se : GB 91.1, 94.5, 95.2% > GP 81.2, 82.6, 84.6%

Ø  Sp : GB 99, 98.2, 96.9% > GP 97.8, 96.9, 93.8%

50 y-o, DCIS

Use Birads to describe lesions

Objective : BiRads : 0? 1? 2? 3? 4? or 5?

1.  Density : 1 to 4 ≈ Mammography 2.  Background Parenchymal enhancement

Use Birads to describe lesions

Objective : BiRads : 0, 1, 2, 3, 4 ou 5 ?

1.  Density : 1 to 4 ≈ Mammography 2.  Background Parenchymal enhancement 3.  Lesion analysis – morphology

ü  Detection : 1st post contrast sequence (soust – MIP) ü  Analysis : 2nd post contrast sequence (native – MIP)

3 lesion types : Ø Foci Ø Masses Ø Non-Mass Enhancement

Conclusion:BiRads 0? 2? 3? 4? 5 ?

3T, GB

BiRads : 0, 2, 3, 4, 5 ?

45 y-o, 29 y-o, 54 y-o.

3T, GB

BiRads : 0, 2, 3, 4, 5 ?

3 lesion types : Ø Foci Ø Masses Ø Non-Mass Enhancement

BiRads Mammo & US : According to images alone BiRads MRI : According to MR images and CI

and 2nd look US and context (and intuition?)


45 y-o, BRCA2 2-2011

29 y-o, BRCA2 – 1st IRM – 1/2010

54 y-o. IDC bi-focal

BiRads : 0, 2, 3, 4, 5 ?

45 y-o, BRCA2, CI normal

2009 2-2011 BiRads 3

45 y-o, BRCA2 CI normal

2009 2-2011 BiRads 3 6-2011

1-2013

Birads 2

29 y-o, BRCA2 – 1st IRM – 1/2010

2nd look Mammo & US normal Birads3 D Birads3 G

29 y-o, BRCA2 – 1st IRM – 1/2010 4/2010

29 y-o, BRCA2 – 1st IRM – 1/2010 4/2010 : IDC, G3, ER+, PR-, Her2-, N-

8 mm – BiRads6- IDC BiRads 6 - IDC

§  54 y-o, Left breast : IDC

4,1mm

54 y-o Left breast : IDC

FOCUS Birads 4 : IDC 4,1mm

Retraction + lesions Birads 6 §  54 y-o, Left breast : IDC

Kinetic curves

Ø After morphological analysis (Kuhl, AJR 2005)

Ø After morphological analysis (Kuhl, 2005)

57% in carcinoma 5% in benign Lesion

Ø  (Kuhl, 1999)

Type 3

Kinetic curves

Ø After morphological analysis (Kuhl, 2005)

34 % : K 9% : K 12% : BL 83% : BL

Type 1

Type 2

Kinetic curves

Foci or UBO (unidentify bright object)

Ø  Birads2 if : ü  < 5 mm, ü  No associated findings ü  Not menopausal women, not after radiation therapy ü  Easier if multiple and bilateral : Background enhancement


Ø  Birads3 if ü  1st MRI in BRACx women ü  Post menopausal or post radiation therapy ü Unique or few or in not glandular zone of breast. ü  Breast cancer or Birads 5 Lesion in contralateral breast Follow up : 3/4 months, 6/8 months, 12 months



Ø  Birads3 if ü  1st MRI in BRACx women ü  Post menopausal or post radiation therapy ü Unique or few or in not glandular zone of breast. ü  Breast cancer or Birads 5 Lesion in contralateral breast Follow up : 3/4 months, 6/8 months, 12 months

Ø  Birads 4 Lesion Birads 5 or 6 in same breast = biopsy PPV of cancer : 3 à 95% If < 4mm : PPV of biopsy : 0 ; If > 4 mm : PPV of biopsy 20-30%


3 lesion types : Ø Foci Ø Masses : MARGIN Ø Non-Mass Enhancement


Ø  2003-2005 : 1523 MRI / 1128 p Ø  258 L BiRads 4,5 – 196 p : 186 LB, 72 Cancers (21 DCIS, 34 DIC

11 LIC, 6 others) Ø  95 NME

ü  27 M ü  68 B

NME

NME

Ø  2008-2009 : 131 NME / 115 p – Breast cancer 46, HR 29, PS 40 Ø  63 BL, 12 FL, 56 Cancers

NME symmetric, focal, bilateral : BiRads 2

NME, asymmetric : not so easy

NME, asymmetric : not so easy

Radiation therapy of the Left B 5 years ago … BiRads2

49 y-o, BRCA2, first MRI ACR4 : DCIS

2mn 6mn

T2 T1

4/5 4/5

4/5 4/5

3

4/5 4/5

4/5 4/5

131 L 31 Birads 3 : 1 C 100 BiRads 4/5 : 56 C ou FL FP : 74/131 (55%)

2nd look US - Biopsies

Ø Visibility : Masses 57- 62%, NME 12-31 %


Ø Visibility : Masses 57- 62%, NME 12-31 % Ø  PPV of K if lesions seen on 2nd look US or not

ü  Demartini, 2009 : (167) 36% - 22% ü  Abe, 2010 : (202) 29% - 13% If MRI + and US - : 13 à 35% K à Biopsy always ++


Ø Visibility : Masses 57- 62%, NME 12-31 % Ø  PPV of K if lesions seen on 2nd look US or not

ü  Demartini, 2009 : (167) 36% - 22% ü  Abe, 2010 : (202) 29% - 13% If MRI + and US - : 13 à 35% K à Biopsy always ++

Ø  Meissniger, 2009 : Corrélation MRI / US : 519 ü  56% ok : 62% if masses – 31% if NME ü  80 US Biopsy for BL 10 lesions not same on MRI and US : 9 cancers

Thomassin et al. Breast Cancer Res Treat. 2012 A plea for the biopsy marker: how, why and why not clipping after breast biopsy?

Ø Safe : No toxicity (gadolinium-chelates)

Ø High Sensitivity, Specificity, PPV, PNV : Even with low prevalence of disease

Ø Good reproducibility : Inter et Intra observers

Ø  Low coast : Money, Medical’s and Patient’s time

Ø  Easy comparison with gold standards ü  Biopsy ü  Surgery ü  Histopathology

The breast MRI we need

The breast MRI we dream

Ø No contra indications

Ø Suppine position likes US, Surgery and radiotherapy

Ø No contrast need

Ø  Few sequences to characterize (without doubts) ü  Lesions ü  Treatment response

Ø Uncertainties of radiological analysis easy to explain to referent collegues and patients …

(with color and arrows to help them to find target – may be a need for radiologist also)

ü  ECR 2013 : B- 0325 = Meilleure délimitation pour le boost de radiothérapie

SUPPINE POSITION

Real-time US Pre-contrast T1WI

Early phase T1WI Late phase T1WI

SUPPINE POSITION Nakano et al. Breast Cancer Research and Treatment 2012 ü  196 patients MRI in suppine position. 67 lesions in 55p. ü  24M, 43B ü  2nd look sonogrphy : real-time virtual sonography

ü  B- 0453 = FSET2 ideal + Diff (3T, 31 cas) No contrast needed for response assessment after

neoadjuvant Chemotherapy

ü  B- 0954 = Multi spectral sequences with T1 and T2 cartography §  46 lesions (18 B, 28 M) §  Ratio T1/T2 élevé dans K

ECR 2013 : No contrast

Key points

1.  Respect indications 2.  Respect technical conditions 3.  Use BiRads lexicon (allowed Birads 0) 4.  3T, Contrast-media, DWI-MRI helpfull

No more problems after MRI than before ü  Explain it to referent collegues ü  Explain it to patients Before to perform Breast MRI

Thank you

breast imaging breast mri s taieb

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