mr mammography new
TRANSCRIPT
5/11/2006
Current & Potential Utility of MRI in Diagnosis & Management of Breast CancerBy:
Dr. Norran Hussein, MSCairo University
5/11/2006
Why MRI of the Breast?
• Imaging of the breast for cancer detection aims to fulfill two major goals:
-high sensitivity for detection of breast lesions -and reliable differentiation of benign from
malignant lesions (specificity).
• In the results of several large MRM studies, sensitivities of 83%-96% for detection of breast carcinomas were reported. However the specificity remains variable ranging from 37% to 89%.
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Post Post operative operative
BreastBreast Dense Dense Breast at Breast at high Riskhigh Risk
Evaluation of Evaluation of Prosthesis Prosthesis
Indications
6m of surgery6m silicone implants10m RT
Pre operative staging
Positive family history
Search for 1ry
Follow up after chemotherapy
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pre
1 min
2 min
3 min
4 min
5 min
A basic MRM
1) Dynamic1) Dynamic
2) Subtraction2) Subtraction
3) Curve3) Curve
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A basic MRM
1) Dynamic1) Dynamic
2) Subtraction2) Subtraction
3) Curve3) Curve
1 minute subtraction
pre1 min
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MRI BIRADS Lexicon
Is it a : Mass
Focus
Non mass like Enhancement
Other findings?
Kinetic Curve analysis
Shape
Margin
Distribution
Symmetrical/ Assymetrical
BIRADS
Category
Enhancement Pattern
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Post operative/ Radiated Breast
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Post Operative& Radiated58 year old woman who underwent left lumpectomy for Ca Breast 2 years before, followed by sessions of Radio & chemotherapy which were completed 3 months later.
Bilateral MLO Mammography
Ultrasonography of the
scar
L R
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Case 6 Axial Subtraction
Saggital T2
Axial T1
Axial T2 IR
MIP
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Axial Dynamic post contrast Fat suppressed FLASH, with signal-time analysis curve
Pathology: Recurrent Invasive Duct Carcinoma
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Dense Breast
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Malignant LN searching for a 1ry
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Pre operative evaluation47 year old patient presenting with Left breast lump.
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T2 IR
Subtraction
T1/ Gd
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Case 3
Diagnosis: Lt UOQ Invasive Duct Carcinoma
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Pre operative A 43 year old woman presenting with a left breast lump
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Pre operative
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Follow up chemotherapy
Pre treat. Post treat.
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MRI of Implant Failure
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Fibrous capsule
Fibrous capsule
Radial folds
Radial folds
Normal Implants
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MRI of Implant Failure
Suspicious Findings:
Loss of Round or Oval form
Contour Bulge
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MRI of Implant Failure
Diagnostic Findings:
Deflation
Capsular Contracture
Extracapsular Rupture
Intracapsular Rupture
Capsular contracture occurs when the AP diameter of the implant is nearly equal to the TS diameter.
(normally AP:TS ratio is 1:2)
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MRI of Implant Failure
Diagnostic Findings:
Deflation
Capsular Contracture
Extracapsular Rupture
Intracapsular Rupture
Axial T2 Fat Sat shows collapsed shell with residual salineThe saline is usually absorbed, and linguine sign is not visible in saline implants
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MRI of Implant Failure
Diagnostic Findings:
Deflation
Capsular Contracture
Extracapsular Rupture
Intracapsular Rupture
Saline outside fibrous capsule
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MRI of Implant Failure
Diagnostic Findings:
Deflation
Capsular Contracture
Extracapsular Rupture
Intracapsular Rupture
Inverted tear drop
C sign
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MRI of Implant Failure
Diagnostic Findings:
Deflation
Capsular Contracture
Extracapsular Rupture
Intracapsular Rupture
Key hole sign
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MRI of Implant Failure
Diagnostic Findings:
Deflation
Capsular Contracture
Extracapsular Rupture
Intracapsular Rupture
Linguine Sign
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MRI of Implant Failure
Diagnostic Findings:
Deflation
Capsular Contracture
Extracapsular Rupture
Intracapsular Rupture
In double lumen implants, if the inner shell ruptures, a mixture between the saline and silicone occurs: The salad oil phenomenon.
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• There is an overlap between benign and malignant lesions in the pattern of contrast uptake.
• DW MRI provides information about the state of molecular translational motion of water.
• As the cellularity of malignant breast tumours is known from histological examinations to be hypercellular compared to benign, these differences should be reflected in DWI.
• The mean value of the Apparent Diffusion Coefficient (ADC) of the malignant tumours is reduced compared to that of the benign lesions and normal tissues (due to their increased cellularity).
MR Diffusion
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MR DiffusionADC maps in a patient with a malignant breast Tumour. Images are shown in 8 spatial locations with the tumour seen as a hypointense area on the last 2 images.
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Hyperintense region of in the ADC map representing a cyst.
MRI T2WI
ADC Map
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ADC maps in a patient with a malignant breast lesion. Images of 8 spatial locations show the decreased ADC values of the tumour. Other hypointense areas were attributed to fat.
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Normal MRS of the Breast
7 6 5 4 3 2 1 0 -1 Frequency (ppm)
FatCholine
Water
Un Sat FA
Un Sat FA
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Normal MRS of the Breast
7 6 5 4 3 2 1 0 -1 Frequency (ppm)
Water
•Located at 4.77 ppm
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Normal MRS of the Breast
7 6 5 4 3 2 1 0 -1 Frequency (ppm)
Un Sat FA
Un Sat FA
•Their peak is located at 1.97 to 2.77 ppm 5.3 ppm
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Normal MRS of the Breast
7 6 5 4 3 2 1 0 -1 Frequency (ppm)
Fat•Their peak is located at 1.4 ppm
•Water to fat ratios: The ratio of water/ fat, and water to unsaturated fatty acids was found to vary between healthy women and women with breast cancer.
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Normal MRS of the Breast
7 6 5 4 3 2 1 0 -1 Frequency (ppm)
Choline
•The Cho peak is located at 3.2 ppm and contains contributions from glycerophosphocholine, phosphocholine, and free Cho.
•The molecules are located in the cell membranes and reflect the phospholipid membrane turnover, and the peak is elevated in neoplastic diseases. •It is caused by rapid cell membrane turnover, and increased cellular density
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However…..
70
80
90
100
< 2.5 2.5 – 4.9> 5.0(cm3)
Pro
babili
ty (
%)
The Probability to Detect Choline in Breast Cancer is Higher in the Larger Lesions
Lesion size
Magnet strength
Lactating breast
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Step 1:Quality assurance(is this an adequate spectrum)
1. Make sure there is good water and Fat suppression.
2. Stay away from hgic, cystic areas.
3. Make sure your voxel does not contain fat.
How to analyse a spectrum
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How to analyse a spectrum
Step 1:Quality assurance(is this an adequate spectrum)
Step 2: check quantities of metabolites
1. choline: present or absent2. Water to lipid ratio
-Peak at 3.2ppm -SNR >2 -At least 2 of 3 spectra
acquired at different TE values.
H2O Fat
Cho
Cho
1H-MRS of Breast Carcinoma
Mastopathy in a 48-year-old woman
Response to chemotherapy
A promising application is the use of breast MRS for predicting response to cancer treatment. Current clinically available methods such as palpation and imaging rely on changes in tumor size, which take several weeks before any changes are detectable.
Breast MRS, in contrast, reflects changes in intracellular metabolism that would occur before any gross morphological change.
Response to chemotherapy
In the results of a study presented in RSNA 2003 meeting:12 women with biopsy proven Ca, were examined with MRS before and within 24hrs of chemotherapy.Patients which showed decreased choline within 24hrs showed a tumour reduction size, after 12 wks of ttt.Patients with cte or elevated choline within 24hrs, failed to have anatomic response to therapy.
Axilla
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Addition of MRS to MRI improved specificity from 62.5% to 87.5% (Huang et al,2004)
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Conclusion• improving the diagnostic sensitivity
and specificity and hence reducing the un-necessary intervention.
• to monitor response to neoadjuvant therapy.
• Metastatic axillary nodes
• A potential application of in vivo 1H MR spectroscopy may be the noninvasive evaluation of the sentinel node for prognostic and surgical planning purposes.
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Conclusion: Limitations
• Ductal carcinoma in situ.• Small lesions.• Breast-feeding women
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Conclusion
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Technique:• Freehand or Stereotactic• Needles and wires should be MR compatibleFreehand:• MRI done in supine position before and after iv CM • 2skin markers: tube filled with diluted Gd-DTPA & vit E capsule (reference TS slice)• Based on these 2 markers and the position of the
lesion, an exact entrance and needle path can be planned.
Stereotactic• Devices must allow1. sufficient fixation of the breast 2. accurate stereotactic system to allow pinpoint
accuracy of the needle 3.access to the entire breast parenchyma 4. integration to an imaging coil• The breast is compressed between 2 perforated
plates with multiple horizontal holes that have MR visible markers serving as coordinates to calculate lesion location. The coil allows horizontal access to the breast either medially or laterally.
Biopsy: Mr Guided
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MR guided Stereotactic Biopsy
Prone biopsy apparatus
Supine biopsy apparatus
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MR guided Biopsy
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RadiofrequencyIndications:
• Single tumours• Not more than 1.5cm• Visible on US• Away from skin to avoid burns
Advantages:• Destroys small cancers before surgery• Shrinks tumours to avoid mastectomy• Reduce need for harsh systemic treatment• Provides a treatment option when surgery is not
available or too risky.
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Radiofrequency• Under general anesthesia, an U/S guided needle-
thin probe is inserted directly into the breast tumor and numerous prongs are deployed around the tumor. The prongs look like the ribs of an umbrella when fully deployed. Five of the prongs have thermometers at their tips. Electrical currents run through the device causing breast cancer molecules surrounding the tumor to move back and forth creating heat.
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Radiofrequency• Treatment is initiated at 10 watts of power for
2mins, after which power is increased in 5 watt increments every min until tissue impedence rises rapidly and power drops below 10 watts thus indicating complete coagulative necrosis of the lesion.
• After 30 sec pause, a 2nd phase of ttt is applied.
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Thank You
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Why MRS of the Breast?
• Imaging of the breast for cancer detection aims to fulfill two major goals:
-high sensitivity for detection of breast lesions -and reliable differentiation of benign from malignant
lesions (specificity).
• In the results of several large MRM studies, sensitivities of 83%-96% for detection of breast carcinomas were reported. However the specificity remains variable ranging from 37% to 89%.
• MR spectroscopy offers an adjunctive tool for lesion characterization in an effort to decrease unnecessary biopsy.
• Although not a tool for screening an entire breast, it can play a role in improving specificity.
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Post operative Post operative BreastBreast
Dense Breast Dense Breast at high Riskat high Risk
Evaluation of Evaluation of axillary nodesaxillary nodes
MRSMRS
Indications
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Specificity Specificity
Calcifications Calcifications
DCISDCIS
MRIMRI
Limitations
Inflammation Inflammation vs Cavs Ca
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MassSurrounding Non mass like Enhancement
Morphology:
Shape: round
Margin: spiculated
Enhancement pattern: rim
Other: skin thickening, oedema
Kinetic curve:
Initial Rise: slow
Delayed Phase: persistent
Category : BIRADS 4
Pathology: Recurrent Invasive Duct Carcinoma
Morphology:
Distribution: diffuse
Enhancement pattern: heterogenous
asymmetrical
Kinetic curve:
Initial : rapid
Delayed : persistent
Category: BIRADS 4
Left Breast
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Case 9: Lexicon
Mass
Focus
Non mass like Enhancement
Morphology:
Shape: irregular
Margin: spiculated
Enhancement pattern: thick rim
Other: skin thickening
Kinetic curve:
Initial Rise: rapid
Delayed Phase: persistent
Category : BIRADS 5
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Case 8: LexiconMultiple Masses & FociMorphology:
Shape: irregular
Margin: spiculated
Enhancement pattern: heterogeneous
Other: skin thickening, mammary edema, chest wall edema, Lymph nodes
Kinetic curve:
Initial Rise: rapid
Delayed Phase: plateau & persistent
Category : BIRADS 5
Diagnosis: Recurrent Left Multicentric Invasive Ductal Ca
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Follow up chemotherapyA 55 year old woman who underwent left conservative surgery 1year & 4 months ago followed by radio& chemotherapy.
Ultrasonography of the right breast
Mammography
LR
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Case 8
Axial T1
Axial T2 IR
Saggital T2
Axial Subtraction
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Case 8
MIPAxial Dynamic post contrast Fat suppressed FLASH, with signal-time analysis curve
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Pre operative:a 43 year old lady presenting with a right breast lump & axillary swelling. The examination was performed during the 2nd week of the menstrual cycle.
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Normal implants have a smooth, clearly defined margin, With a homogenous appearance.
Implants are encompassed by a thin fibrous capsule with low signal intensity.
Many implants show radial folds on MR which should not be confused with implant rupture . Very thin slices are needed to identify leaks from the implant shell.
Fibrous capsule
Fibrous capsule
Radial folds
Radial folds
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MRI Appearance of Various Implants
Single lumen
Silicone
Saline
Water suppressed T2 WIs of single lumen silicon implant
Axial T2 Fat Sat
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MRI Appearance of Various Implants
Single lumen
Double lumen
silicone
saline
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MRI Appearance of Various Implants
Single lumen
Double lumen
Fat suppressed T2 W
water suppressed T2 W
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MRI Appearance of Various Implants
Single lumen
Double lumen
Multicompartmental
Outer saline & 2 inner silicone comaprtments
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MRI Appearance of Various Implants
Single lumen
Double lumen
Multicompartmental
Single lumen silicone with saline Injection
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MRI of Implant Failure
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Fibrous capsule
Fibrous capsule
Radial folds
Radial folds
Normal Implants
5/11/2006
MRI of Implant Failure
Suspicious Findings:
Loss of Round or Oval form
Contour Bulge
5/11/2006
MRI of Implant Failure
Diagnostic Findings:
Deflation
Capsular Contracture
Extracapsular Rupture
Intracapsular Rupture
Capsular contracture occurs when the AP diameter of the implant is nearly equal to the TS diameter.
(normally AP:TS ratio is 1:2)
5/11/2006
MRI of Implant Failure
Diagnostic Findings:
Deflation
Capsular Contracture
Extracapsular Rupture
Intracapsular Rupture
Axial T2 Fat Sat shows collapsed shell with residual salineThe saline is usually absorbed, and linguine sign is not visible in saline implants
5/11/2006
MRI of Implant Failure
Diagnostic Findings:
Deflation
Capsular Contracture
Extracapsular Rupture
Intracapsular Rupture
Saline outside fibrous capsule
5/11/2006
MRI of Implant Failure
Diagnostic Findings:
Deflation
Capsular Contracture
Extracapsular Rupture
Intracapsular Rupture
Inverted tear drop
C sign
5/11/2006
MRI of Implant Failure
Diagnostic Findings:
Deflation
Capsular Contracture
Extracapsular Rupture
Intracapsular Rupture
Key hole sign
5/11/2006
MRI of Implant Failure
Diagnostic Findings:
Deflation
Capsular Contracture
Extracapsular Rupture
Intracapsular Rupture
Linguine Sign
5/11/2006
MRI of Implant Failure
Diagnostic Findings:
Deflation
Capsular Contracture
Extracapsular Rupture
Intracapsular Rupture
In double lumen implants, if the inner shell ruptures, a mixture between the saline and silicone occurs: The salad oil phenomenon.