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Breast MRI and MRIBreast MRI and MRI--guided guided Breast BiopsyBreast Biopsy
R. Edward R. Edward HendrickHendrick, PhD, FAAPM, FACR, PhD, FAAPM, FACRLynn Sage Comprehensive Breast CenterLynn Sage Comprehensive Breast CenterNorthwestern University Medical School Northwestern University Medical School
Chicago, IllinoisChicago, Illinois
Clinical Indications for ContrastClinical Indications for Contrast--enhanced Breast MRI:enhanced Breast MRI:
• Search for primary breast cancer in women with a positive axillary node
• Staging of tumor extent in women with a known breast cancer – MRI most accurate
• Search for multifocal, multicentric or bilateral breast cancer in women with a known breast cancer
• Search for residual tumor shortly after surgery in patients with + margins
• Evaluation for tumor recurrence after surgery and/or radiation
• Monitoring tumor size and extent in neoadjuvant chemotherapy
• Screening of high-risk women
Clinical Indications for ContrastClinical Indications for Contrast--enhanced Breast MRI:enhanced Breast MRI:
Technical RequirementsTechnical RequirementsFor Good Cancer Detection:For Good Cancer Detection:
•• HighHigh--field breast MRI (1.5T or >)field breast MRI (1.5T or >)•• GadoliniumGadolinium--DTPA injectionDTPA injection•• Dedicated bilateral breast coilDedicated bilateral breast coil•• Good fat suppression techniquesGood fat suppression techniques•• HighHigh--resolution 3D gradient echo resolution 3D gradient echo
pulse sequencepulse sequence
Technical RequirementsTechnical RequirementsFor Good Cancer Detection:For Good Cancer Detection:•• HighHigh--resolution 3D gradient echo resolution 3D gradient echo
pulse sequencepulse sequence–– Bilateral coverageBilateral coverage–– InIn--plane resolution < 1 mmplane resolution < 1 mm–– Slice thicknesses < 3 mm Slice thicknesses < 3 mm
•• Dynamic imaging with adequate Dynamic imaging with adequate temporal resolution (1temporal resolution (1--2 minutes) 2 minutes) T1WT1W--GradientGradient--echo Preecho Pre--
GdGd--chelatechelate
Why Why GdGd--chelateschelates Are Are EssentialEssentialfor Cancer Detectionfor Cancer Detection
T1W T1W ––GradientGradient--echoecho2 minute Post 2 minute Post GdGd
T1WT1W--GradientGradient--echo echo PrePre--GdGd--chelatechelate
Why Why GdGd--chelateschelates Are Are EssentialEssentialfor Cancer Detectionfor Cancer Detection
T1W T1W ––GradientGradient--echoecho2 minute Post 2 minute Post GdGd
SagittalSagittalMaximum Maximum Intensity Intensity Projection Projection (MIP)(MIP)
Siemens 2Siemens 2--channel Bilateral Breast Coil channel Bilateral Breast Coil Why Use a Dedicated Breast Coil?Why Use a Dedicated Breast Coil?Same STIR Pulse Sequence at 1.5TSame STIR Pulse Sequence at 1.5T
44--Channel Breast Coil Body Coil as ReceiverChannel Breast Coil Body Coil as Receiver
SNR = 190 SNR = 27
PrePre--ContrastContrast
3D T1W Scans without Fat Saturation
PostPost--ContrastContrast
Why Use FatWhy Use Fat--saturation in Contrast Series?saturation in Contrast Series?
1st Post-Contrast Subtracted Image
Residual Signal Due to Motion Residual Signal Due to Motion Between PreBetween Pre-- and Postand Post--Contrast Images Mimics Contrast Images Mimics EnhancementEnhancement
Examples of Bad and Good Examples of Bad and Good Image QualityImage Quality
Old Old (BAD) (BAD) ScanningScanningProtocolProtocol
T2T2--FSE FSE or TSEor TSE
Old Old (BAD) (BAD) ScanningScanningProtocolProtocol
PrePre--GdGd
Old Old (BAD) (BAD) ScanningScanningProtocolProtocol
11stst
PostPost--GdGd
LargerLarger FOV than NecessaryFOV than Necessary
Low Matrix for Bilateral Axial ScanLow Matrix for Bilateral Axial Scan
Old Old (BAD) (BAD) ScanningScanningProtocolProtocol
11stst
SubtractedSubtracted
Motion Artifacts Motion Artifacts Obscure Lateral Obscure Lateral Breast TissueBreast Tissue
T2T2--TSETSE
New New ProtocolProtocol
Receiver Coil Has Better SNR
Breast Positioning Is Better
PrePre--GdGd
New New ProtocolProtocol
Fat Suppression Was Used
Spatial Resolution is Higher
11stst
PostPost--GdGd
New New ProtocolProtocol
11stst SubSub--tractedtractedImageImage
New New ProtocolProtocol
Fewer Motion Artifacts
Higher SNR
Higher Spatial Resolution
10 Ways to Tell That a Site Isn10 Ways to Tell That a Site Isn’’t Doing t Doing Good Breast MRIGood Breast MRI
•• Field strength < 1.5 TField strength < 1.5 T•• Images acquired unilaterally onlyImages acquired unilaterally only•• No fat saturation in CE imagesNo fat saturation in CE images•• Inadequate Inadequate GdGd--DTPA uptakeDTPA uptake•• InIn--plane resolution > 1 mm in CE imagesplane resolution > 1 mm in CE images•• Slice thickness > 3 mm in CE imagesSlice thickness > 3 mm in CE images•• No dynamic information obtainedNo dynamic information obtained•• Images interpreted from filmImages interpreted from film•• BIRADS for breast MRI not usedBIRADS for breast MRI not used•• Few or no vessels seen on 3D Few or no vessels seen on 3D MIPsMIPs
Looking at 3D Looking at 3D MIPsMIPs in the Acquired in the Acquired Projection Plane is a Good Way to Projection Plane is a Good Way to
Assess Overall Image QualityAssess Overall Image Quality
Excellent Axial MIP
Excellent Sagittal MIP from Same 3D Dataset
Good Sag MIP
Low SNR Sag MIP Poor Sag MIP
PrePre--GdGd PostPost--GdGd50 seconds post50 seconds post--injectioninjection
PostPost--GdGd Subtracted from PreSubtracted from Pre--GdGd
3D 3D 50 s50 sPostPost--GdGdSubtractedSubtracted
MaximumIntensityProjection (MIP)of Subtracted Images
Isotropic Imaging Permits Projection in Any Plane
MRI-GUIDED BREAST BIOPSYAppropriate for suspicious lesions found on MRI & not seen on mammography or USEquipment Needed:
A dedicated breast coil A biopsy guidance system compatible with the breast coil and tissue sampling deviceA MR-compatible tissue sampling device:
- 14 gauge cutting needle- 8-11 gauge vacuum-assisted sampling
device: Suros, Mammotome, etc.
-
InVivoInVivo 44--channel Bilateral Breast Coilchannel Bilateral Breast Coil
MRI Devices New Breast MRI CAD
InVivoInVivo 77--channel Imaging & Biopsy Coilchannel Imaging & Biopsy Coil
GE 8 Channel Breast Coil
MR-GUIDED BIOPSY
Grid Guidance Grid Guidance DeviceDevice
Grid Biopsy Guidance Devices
Reusable
Disposable
Guidance for Biopsy - Pillar/Post
Disposable
Reusable
Biopsy NeedlesBiopsy NeedlesFront ViewFront View
14g Cutting 14g Cutting 11g VA 11g VA 10g VA10g VA 8g VA 8g VA
Biopsy NeedlesBiopsy NeedlesSide ViewSide View
14g Cutting 14g Cutting 11g VA 11g VA 10g VA10g VA 8g VA 8g VA
1414--gauge gauge Cutting Cutting NeedleNeedle
14 Gauge spring14 Gauge spring--loaded biopsy gunloaded biopsy gun
Suros 9G MR-compatible Biopsy System
SurosSuros –– ATEC ATEC now now HologicHologic
Suros 9G MR-compatible Biopsy System Suros 9G Biopsy Samples
MRMR--guided Vacuumguided Vacuum--assisted Biopsy Setup assisted Biopsy Setup Breast Biopsy Sample WeightsBreast Biopsy Sample Weights
DeviceDevice Sample Sample WeightWeight
14 g Cutting Needle14 g Cutting Needle 18 mg18 mg
14 g 14 g MammotomeMammotome 37mg37mg
12 g 12 g SurosSuros ATECATEC 49 mg49 mg
11 g 11 g MammotomeMammotome 95 mg95 mg
9 g 9 g SurosSuros ATECATEC 118 mg118 mg
8 8 MammotomeMammotome 300 mg300 mg
Core Biopsy Sample SizesCore Biopsy Sample Sizes
100 mg each 12-17 mg eachAXIAL PLANE
MR-GUIDED BIOPSY
MRMR--guided Breast Biopsyguided Breast Biopsy
PrePre--ContrastContrast PostPost--ContrastContrast
MRMR--guided Breast Biopsyguided Breast Biopsy
External Marker External Marker Targeted LesionTargeted Lesion
MRMR--guided Breast Biopsyguided Breast Biopsy
Grid at Skin of Lateral Breast Targeted LesionGrid at Skin of Lateral Breast Targeted Lesion
∆x
∆y
∆z is found by the slice location difference from skinline to lesion
SurosSuros 9G Vacuum Biopsy System9G Vacuum Biopsy System
Suros 9G Biopsy Needle and Inserter SurosSuros 9G Biopsy Needle and Localizer9G Biopsy Needle and Localizer
MRMR--guided Breast Biopsyguided Breast Biopsy
Grid After Needle Placement Targeted LesionGrid After Needle Placement Targeted Lesion
Stylus Track Stylus Track
MRMR--guided Breast Biopsyguided Breast Biopsy
Targeted Lesion Before Targeted Lesion Before Targeted Lesion AfterTargeted Lesion AfterTissue SamplingTissue Sampling Tissue SamplingTissue Sampling
Stylus Track
Ethicon Micromark Applicator with Clip
MRMR--guided Breast Biopsyguided Breast Biopsy
Targeted Lesion Before Targeted Lesion Before Targeted Lesion AfterTargeted Lesion AfterTissue SamplingTissue Sampling Tissue SamplingTissue Sampling
Marker Clip Marker Clip ArtifactArtifact
Biopsy Markers & MR ArtifactsSenoRxSenoRx UltracorUltracor
FFDM ImageFFDM Image
SenoRxSenoRx GelmarkGelmark
SenoRxSenoRx GM UltraGM Ultra
MammomarkMammomark
MammomarkMammomark
InradInrad
MicromarkMicromark
MRI Image MRI Image 3D 3D -- GREGRE
Biopsy Markers & MR ArtifactsSenoRxSenoRx UltracorUltracor
FFDM ImageFFDM Image MRI Image MRI Image 2D T2 TSE2D T2 TSE
SenoRxSenoRx GelmarkGelmark
SenoRxSenoRx GM UltraGM Ultra
MammomarkMammomark
MammomarkMammomark
InradInrad
MicromarkMicromark
Digital Radiograph T2 FSE
ConclusionsConclusions
•• MRIMRI--guided breast biopsy is guided breast biopsy is appropriate for suspicious enhancing appropriate for suspicious enhancing lesions seen on MRI and not seen on lesions seen on MRI and not seen on mammography or breast USmammography or breast US
•• Breast MRI has an important role in Breast MRI has an important role in the search for and evaluation of breast the search for and evaluation of breast cancer cancer
ConclusionsConclusions
•• MRIMRI--guided breast biopsy usually gets guided breast biopsy usually gets sufficient samples, but can sufficient samples, but can underestimate diseaseunderestimate disease
•• It is harder to confirm correct sampling It is harder to confirm correct sampling with MRIwith MRI--guided breast biopsy than guided breast biopsy than with xwith x--ray or US guidanceray or US guidance
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