breast mri: technique and indications karen dec m.d. skagit radiology, inc

Breast MRI:Breast MRI:

Technique and IndicationsTechnique and Indications

Karen Dec M.D.Karen Dec M.D.Skagit Radiology, Inc.Skagit Radiology, Inc.

FundamentalsFundamentals of Contrastof ContrastEnhanced Breast MRIEnhanced Breast MRI

Principles of Breast MRIPrinciples of Breast MRI TechniqueTechnique Adjunctive UltrasoundAdjunctive Ultrasound Clinical IndicationsClinical Indications AccuracyAccuracy

Principles of Breast MRIPrinciples of Breast MRI Angiogenesis = Abnormal tumor Angiogenesis = Abnormal tumor vessels produce neovascularityvessels produce neovascularity

Top left:Top left: Implanted cancer cells glow with Implanted cancer cells glow with green fluorescence protein.green fluorescence protein.

Top right:Top right: Three of the original cancer cells Three of the original cancer cells have have

survived to begin replicating. Signals between survived to begin replicating. Signals between the the

existing blood vessel and the growing cancer existing blood vessel and the growing cancer cells cells

cause the cells to grow toward the vessel.cause the cells to grow toward the vessel.

Bottom left:Bottom left: The cancer cells have reached The cancer cells have reached the the

existing blood vessel.existing blood vessel.

Bottom right:Bottom right: When they number only 100- When they number only 100-300, 300,

the cancer cells have created new, fully-the cancer cells have created new, fully-functioning functioning

blood vessels.blood vessels.

Graphic illustration byGraphic illustration by Stanley Coffman, Duke Stanley Coffman, Duke University Medical CenterUniversity Medical Center

PrinciplesPrinciples of Breast MRIof Breast MRI

Neovascularity characterized Neovascularity characterized by:by:

Low resistance, high flowLow resistance, high flow AV shunting, poolingAV shunting, pooling Abnormal endothelial Abnormal endothelial

permeabilitypermeability

Cancers enhance early and Cancers enhance early and intenselyintensely

Principles of Breast MRIPrinciples of Breast MRI

Virtual Map of AngiogenesisVirtual Map of Angiogenesis Pre-Contrast Post -ContrastPre-Contrast Post -Contrast

TechniqueTechnique OverviewOverview

Prone positioningProne positioning

Breast placed in Breast placed in individual holders within individual holders within coilscoils

Images obtained prior to Images obtained prior to and following gadolinium and following gadolinium administrationadministration

6 imaging sequences6 imaging sequences - Spatial resolution- Spatial resolution - Temporal resolution- Temporal resolution

Technique: MRI Technique: MRI SequencesSequences

Coronal Stir ChestCoronal Stir Chest

Lymph NodesLymph Nodes

AxillaryAxillary

SupraclavicularSupraclavicular

Internal mammaryInternal mammary Lung ParenchymaLung Parenchyma LiverLiver BonesBones


Axial Stir BreastAxial Stir Breast Lymph NodesLymph Nodes EdemaEdema CystsCysts

STIR axial MR image shows marked asymmetry in appearance of breasts. Left breast has diffusely increased signal within parenchyma andskin, suggesting diffuse breast edema and skin thickening (arrow).


Axial Pre-Contrast and Dynamic Post-Contrast 3D FLASH x 5Axial Pre-Contrast and Dynamic Post-Contrast 3D FLASH x 5 CancersCancers Other Masses Other Masses Draining VeinsDraining Veins

Pre-Contrast 1 Minute Post-Contrast 4 Minutes Post-ContrastPre-Contrast 1 Minute Post-Contrast 4 Minutes Post-Contrast


Axial “VIEWS” MIPSAxial “VIEWS” MIPS Volume Interpolated Exam under Water Volume Interpolated Exam under Water

StimulationStimulation

High spatial resolutionHigh spatial resolution Entire case can be Entire case can be

displayed for cliniciansdisplayed for clinicians


Diffusion Imaging (DWI)Diffusion Imaging (DWI)

Measures the mobility of Measures the mobility of water in tissuewater in tissue

Sensitive to characteristics Sensitive to characteristics often disrupted in malignant often disrupted in malignant breast tissues, such as cell breast tissues, such as cell organization, density, organization, density, extracellular space and cell extracellular space and cell membrane permeabilitymembrane permeability

DWI may be useful for DWI may be useful for detecting breast cancer in a detecting breast cancer in a wide age group of women, wide age group of women, including young women with including young women with dense mammary glands.*dense mammary glands.*

*Radiation Medicine, 2007, Vol. 25:218-*Radiation Medicine, 2007, Vol. 25:218-223223

AssessmentAssessment

Morphologic:Morphologic: Similar to Similar to mammography and ultrasoundmammography and ultrasound

Dynamic:Dynamic: Blood flow physiology by Blood flow physiology by evaluating dynamic enhancement evaluating dynamic enhancement curvescurves

Dynamic Enhancement Dynamic Enhancement PatternsPatterns

0

20

40

60

80

100

120

0 1 2 3 4 5Minutes

Dynam

ic E

nhance

ment

NormNormalal

Progressive (monophasic)Progressive (monophasic)

PlateauPlateau (biphasic)(biphasic)

WashoutWashout

Benign Enhancement Benign Enhancement PatternPattern

0

20

40

60

80

100

120

0 1 2 3 4 5Minutes

Dyn

amic

Enh

ance

men

t

NormNormalal

Progressive (monophasic)Progressive (monophasic)

Malignant-like Malignant-like EnhancementEnhancement

0

20

40

60

80

100

120

0 1 2 3 4 5Minutes

Dyn

amic

Enh

ance

men

t

NormNormalal

WashoutWashout

Digital MammographyDigital Mammography

Primary tool for breast cancer screeningPrimary tool for breast cancer screening Breast MRI is an adjunct Breast MRI is an adjunct Mammogram is more sensitive in Mammogram is more sensitive in

detection of Ductal Carcinoma in Situ detection of Ductal Carcinoma in Situ (DCIS)(DCIS)

Can determine if lesion amenable to Can determine if lesion amenable to stereotactic guided biopsy stereotactic guided biopsy

Adjunctive Breast Adjunctive Breast UltrasoundUltrasound

Accurate, high Accurate, high resolution resolution

breast sonography breast sonography essential essential

in localizing lesions for in localizing lesions for

potential percutaneous potential percutaneous

needle tissue samplingneedle tissue sampling

Clinical IndicationsClinical Indications

Screening of High-Risk WomenScreening of High-Risk WomenPre-Operative StagingPre-Operative StagingContralateral Breast Cancer in Newly Contralateral Breast Cancer in Newly

Diagnosed Breast CancerDiagnosed Breast CancerLobular CancerLobular CancerOccult Breast CancerOccult Breast CancerClose or Positive Surgical MarginsClose or Positive Surgical MarginsPost-operative Scar vs. Tumor RecurrencePost-operative Scar vs. Tumor RecurrenceNeo-Adjuvant ChemotherapyNeo-Adjuvant ChemotherapyImplants and Known or Suspected CancerImplants and Known or Suspected CancerProblematic MammogramProblematic Mammogram

High Risk ScreeningHigh Risk Screening

Annual Breast MRI and Mammography Screening is Annual Breast MRI and Mammography Screening is Recommended Recommended

for Women Who Have:for Women Who Have:

BRCA1 or BRCA2 gene mutation BRCA1 or BRCA2 gene mutation First degree relative with BRCA1 or BRCA2 gene mutation and First degree relative with BRCA1 or BRCA2 gene mutation and

have not been tested themselveshave not been tested themselves Lifetime risk of breast cancer has been scored at 20-25% or Lifetime risk of breast cancer has been scored at 20-25% or

greater, based on one of several accepted risk assessment tools greater, based on one of several accepted risk assessment tools that look at family history and other factorsthat look at family history and other factors

Chest wall radiation between the ages of 10 and 30 at dosages Chest wall radiation between the ages of 10 and 30 at dosages above 4 Gyabove 4 Gy

Li-Fraumeni syndrome, Cowden syndrome, or Bannayan-Riley-Li-Fraumeni syndrome, Cowden syndrome, or Bannayan-Riley-Ruvalcaba syndrome, or may have one of these syndromes Ruvalcaba syndrome, or may have one of these syndromes based on a history in a first-degree relativebased on a history in a first-degree relative

High Risk ScreeningHigh Risk Screening

Currently there is insufficient evidence to recommend for or Currently there is insufficient evidence to recommend for or against annual against annual

breast MRI screening in women who:breast MRI screening in women who:

have a lifetime risk of 15-24% as defined by several accepted risk have a lifetime risk of 15-24% as defined by several accepted risk assessment tools, such as BRACAPRO,assessment tools, such as BRACAPRO,

that look at family history and other factorsthat look at family history and other factors have lobular carcinoma in situ (LCIS)have lobular carcinoma in situ (LCIS) have atypical ductal hyperplasia (ADH)have atypical ductal hyperplasia (ADH) have heterogeneously or extremely dense breasts on mammography have heterogeneously or extremely dense breasts on mammography

(refer to first line of report)(refer to first line of report) Have a personal history of breast cancer including ductal carcinoma in Have a personal history of breast cancer including ductal carcinoma in

situ (DCIS)situ (DCIS)

Decisions should be made on a case by case basis.Decisions should be made on a case by case basis.


Pre-Operative StagingPre-Operative Staging Index tumor SizeIndex tumor Size Multi-focality or multi-centricityMulti-focality or multi-centricity Involvement of skin, pectoral muscle, Involvement of skin, pectoral muscle,

chest wallchest wall Contralateral breastContralateral breast Lymph node statusLymph node status Hematogenous metastasesHematogenous metastases


Detection of Contralateral Breast Cancer in Newly Detection of Contralateral Breast Cancer in Newly Diagnosed Breast CancerDiagnosed Breast Cancer

As many as 10% of women with breast cancer will develop a new As many as 10% of women with breast cancer will develop a new tumor in the opposite breast with a negative mammogram and tumor in the opposite breast with a negative mammogram and physical exam at the initial time of diagnosis.physical exam at the initial time of diagnosis.

Finding cancers earlier may help women make treatment decision, Finding cancers earlier may help women make treatment decision, potentially sparing additional surgery, radiation therapy and potentially sparing additional surgery, radiation therapy and chemotherapy later.chemotherapy later.

UW Researchers performed breast MRI on 969 patients with newly UW Researchers performed breast MRI on 969 patients with newly diagnosed breast cancer and detected 30 early stage tumors not diagnosed breast cancer and detected 30 early stage tumors not detected on mammogram or physical exam *detected on mammogram or physical exam *

Memorial Sloan Kettering found contralateral breast cancer more often Memorial Sloan Kettering found contralateral breast cancer more often identified when index cancer was infiltrating lobular carcinoma **\identified when index cancer was infiltrating lobular carcinoma **\

* NEJM 2007 vol. 356,No. 13:1295-1303* NEJM 2007 vol. 356,No. 13:1295-1303** AJR 2003, vol. 180:333-341** AJR 2003, vol. 180:333-341


Lobular Infiltrating CarcinomaLobular Infiltrating Carcinoma Insidious cancer- Difficult to detect Insidious cancer- Difficult to detect

onon

mammography and physical exammammography and physical exam Multifocal / multi-centric in up to Multifocal / multi-centric in up to

35% of cases and bilateral in 10%35% of cases and bilateral in 10% Frequent cause of positive Frequent cause of positive

lumpectomy margins lumpectomy margins


Occult Breast CancerOccult Breast Cancer About 0.3% of breast cancers present About 0.3% of breast cancers present

with malignant axillary lymph nodes, with malignant axillary lymph nodes, but normal breast exams and but normal breast exams and mammogramsmammograms

Mastectomy standard treatment for Mastectomy standard treatment for occult malignancyoccult malignancy

Up to 2/3 can be localized with MRI Up to 2/3 can be localized with MRI allowing breast conservation surgeryallowing breast conservation surgery


Close or Positive Surgical MarginsClose or Positive Surgical Margins Up to 50% of lumpectomies have Up to 50% of lumpectomies have

inadequate margins, requiring inadequate margins, requiring additional resectionadditional resection

MRI can locate residual or MRI can locate residual or additional tumor fociadditional tumor foci

Applied pre-operatively, MR Applied pre-operatively, MR significantly decreases re-significantly decreases re-operationsoperations


Post-operative Scar vs. Tumor Post-operative Scar vs. Tumor RecurrenceRecurrence

At 6 months or more after surgeryAt 6 months or more after surgery ““Mature scar”, which may simulate Mature scar”, which may simulate

cancer morphologically, does not cancer morphologically, does not enhanceenhance

Recurrent tumor shows malignant-Recurrent tumor shows malignant-like enhancement curvelike enhancement curve


Neo-adjuvant ChemotherapyNeo-adjuvant Chemotherapy

MRI improves the “T” MRI improves the “T” classification as well as stagingclassification as well as staging

Can document tumor response to Can document tumor response to chemotherapychemotherapy


Implants and Known or Suspected CancerImplants and Known or Suspected Cancer MRI is not affected by implants or MRI is not affected by implants or

siliconesilicone Improves diagnostic confidenceImproves diagnostic confidence Allows U/S guided needle biopsy prnAllows U/S guided needle biopsy prn Women with history of silicone Women with history of silicone

injections can benefit from MRI injections can benefit from MRI screeningscreening


Inappropriate Indications:Inappropriate Indications:

Screening for Average Risk WomenScreening for Average Risk Women Screening for Women with Less than 15% Screening for Women with Less than 15%

Lifetime RiskLifetime Risk As a Replacement for Mammography or As a Replacement for Mammography or

SonographySonography To Biopsy or Determine the Need for Biopsy To Biopsy or Determine the Need for Biopsy

of a Suspicious Lesion Detected by Other of a Suspicious Lesion Detected by Other Methods: Mammography, Ultrasound, and Methods: Mammography, Ultrasound, and Physical ExamPhysical Exam

AccuracyAccuracy

Varies Considerably with Different Varies Considerably with Different TechniquesTechniques

Sensitivity: Sensitivity: >> 95-98% 95-98% **

Specificity: 37-97%Specificity: 37-97%

Negative Predictive Value: Negative Predictive Value: >> 95% 95%

Positive Predictive Value: ~ 65-75%Positive Predictive Value: ~ 65-75%

* For DCIS sensitivity is lower, especially for low or intermediate * For DCIS sensitivity is lower, especially for low or intermediate grade lesionsgrade lesions

ConclusionsConclusions

Bilateral, dynamic and high-spatial Bilateral, dynamic and high-spatial resolution breast MRI is widely resolution breast MRI is widely acceptedaccepted

In the past, primarily employed as a In the past, primarily employed as a problem-solving toolproblem-solving tool

Now, central role in the diagnosis and Now, central role in the diagnosis and staging of breast cancerstaging of breast cancer

Increasing use in the treatment of Increasing use in the treatment of breast cancerbreast cancer

Multi-modality approach makes it workMulti-modality approach makes it work

breast mri: technique and indications karen dec m.d. skagit radiology, inc

Documents

left breast

minutes postcontrast

coils breast

minute postcontrast

veins precontrast

dynamic postcontrast

diffuse breast edema

malignant breast tissues