View
3
Download
0
Category
Preview:
Citation preview
Elizabeth Morris MD FACR
Chief, Breast Imaging Service
Professor of Radiology
Memorial Sloan Kettering Cancer
Center
The New MRI BI-RADS®
Prior to BI-RADS, Some Mammography
Reports Looked Like This
Unintelligible descriptions; ambiguous recommendations
BI-RADS® is de facto standard for
research -drives advancement of breast
cancer care
• Universally known
• BI-RADS® used for 2 decades
• 5th edition for Mammography
• 2nd editions for US and MRI
• Translated into 8 languages (French,
Spanish, German, Portugese, Croatian,
Russian, Mandarin, Romanian)
• Over 1000 pubmed citations
On-line version available
4
ACR BI-RADS® 2013 Chairs
• Carl D’Orsi, MD – Chair, ACR
Committee on BI-RADS
• Subcommittee chairs
• Ed Sickles, MD – Mammography
• Ellen Mendelson, MD – Ultrasound
• Elizabeth Morris, MD - MRI
BI-RADS® Follow-Up and
Outcome Monitoring section for all
modalities
• Overall Assessment
– If there are different recommendations,
assessment for each breast favored
– If same recommendation for each breast,
single overall assessment adequate
Important Points about Final
Assessment Categories • Assessment is based on imaging findings
– Markers/Hardware are not BI-RADS® 2
– In a patient with known cancer if there are no
imaging findings then it is BI-RADS 1 or 2
– If the patient has a palpable benign cyst &
wants aspiration BI-RADS is still 2
• OK to add additional sentence suggesting
aspiration/biopsy based on clinical findings
Amount of Fibroglandular
Parenchyma
Almost entirely fat
Scattered fibroglandular
tissue
Heterogeneous
Fibroglandular tissue
Extreme
Fibroglandular tissue
Section on Non-enhancing findings
added • Hi contrast on pre C+ in duct
• Simple cyst
• Non-simple cyst
• Hematoma/seroma
• Edema
• Non-enhancing mass
• Dilated ducts
• Skin thickening
• Architectural distortion
• Signal void from clips, foreign bodies
Fat containing lesions added
• Lymph node
– Normal
– abnormal
• Fat necrosis
• Hamartoma
• Postoperative seroma with fat
New – Implants
11
Background Parenchymal Enhancement
(BPE)
• BI-RADS MRI Lexicon
• Minimal, mild, moderate, marked
•
Native breast tissue
• Amount of fibroglandular tissue
• Background parenchymal enhancement
4 – 6 X risk
No two breasts look alike
Background parenchymal enhancement patterns
and intensities vary
MRI BI-RADS® Lexicon – 2nd
edition
Minimal
Mild
Moderate
Marked
minimal mild
moderate
marked
BPE related to the volume
of the FGT that enhances
Patterns are not yet
included ( not enough
robust data )
When do you image BPE?
• First post contrast image following IV
gadolinium injection for routine breast MRI
• Delayed imaging assessment may not
discriminate different categories
• Assess Increase in signal intensity (SI)
– Variable intensity
– Variable patterns
Background Parenchymal
Enhancement patterns in MRI
screening • Qualitative analysis on Subtracted images
– Homogeneous 46/335 (14%)
– Heterogeneous 80/335 (24%)
– Nodular (stippled) 71/335 (21%)
• Young women < 45 y
– Nodular BPE (p<0.0001)
Jansen SA et al Eur Radiol 2011
Pathologically what does stippled
BPE correspond to?
Is BPE a surrogate for the breast
microenvironment?
• Independent of mammographic
density
• Doesn’t act like “density”
• Mammographic breast density does not
correlate with the degree of background
enhancement in MRI
• Scores for background enhancement were
– lower than mammographic scores in 371/468
(79.3%)
– equivalent in 90/468 (19.2%)
– higher in 7/468 (1.5%)
JMRI 2014
BPE likely is a quantifiable functional
assessment of the breast parenchyma
This is BPE – NOT “multiple foci”
“Stippled” is a retired term
BPE & hormonal status relationship has
been recognized for several decades
Kuhl CK, Bieling HB, Gieseke J, et al. Healthy premenopausal breast
parenchyma in dynamic contrast-enhanced MR imaging of the breast: normal
contrast medium enhancement and cyclical-phase dependency. Radiology
1997
Muller-Schimpfle M, Ohmenhauser K, Stoll P, Dietz K, Claussen CD. Menstrual
cycle and age: influence on parenchymal contrast medium enhancement in MR
imaging of the breast. Radiology 1997
Day 25 Day 12
Mastalgia/post Mx
Led to recommendations to only perform
breast MRI in week 2 to eliminate any
spurious enhancement
• Recommendation formulated in a period
where all enhancement was thought to be
suspicious
– Contributed to high false positive rate of
breast MRI
• Background parenchymal enhancement
had not yet been recognized
• Correlation between mammographic breast density and background enhancement (p = 0.011) (n=146) – 9/9 predominately fatty breasts showed minimal (78%) or
mild (12%) BPE
• Inverse correlation between age and BPE (p < 0.0001) – Younger patients with dense breasts were more likely to
demonstrate moderate/marked BPE
• “All premenopausal women should be imaged by breast MRI during the second week, or at least when in the middle of their menstrual cycle, whenever possible”
Eur J Radiol 2012
When should you image patients
based on their cycle?
• Recommendations are based on observation of enhancement
• We now know that BPE is a normal phenomenon
• If we are going to make recommendations we need outcome data
– Are call backs higher
– Are less cancers detected
– Are there too many false positive biopsies?
Hormonal Fluctuation
Focus
• Bright fluid imaging can help in the evaluation of
a focus. Benign lesions are generally very high
in signal intensity (cyst-like).
MIP T1W Imaging
Post Contrast Subtraction T2W Imaging
“Multiple foci” should not be used as this means a pattern of BPE
Mass
• Round
• Oval (includes lobulated)
• Irregular
• Shape descriptors adapted from
mammography BI-RADS for uniformity
Margin
• The edge or border of the lesion
• The margin may be described as
circumscribed or not circumscribed
Margin descriptors adapted from
mammography & US BI-RADS for
uniformity
Circumscribed
• Sharply demarcated with an abrupt
transition between lesion and surrounding
tissue. For MRI, the entire margin must be
well-defined for a mass to qualify as
circumscribed.
Fibroadenoma
Postcontrast
Invasive Ductal
Carcinoma Hematoma
Not circumscribed-irregular
• composed of edges either round or jagged
but not spiculated. Implies suspicious
finding.
Not Circumscribed-spiculated
Invasive Ductal Carcinoma.
Note pectoralis muscle
invasion(arrow)
Invasive Ductal
Carcinoma Invasive Lobular
Carcinoma
Characterized by lines radiating from the mass. Implies a suspicious finding.
Non-Mass Enhancement (NME)
• Non-mass enhancement describes an area that is not a mass
• Includes enhancement patterns extending over small or large regions
• internal enhancing characteristics described as a pattern discrete from normal surrounding background parenchymal enhancement
• Non-mass-like enhancement may have areas or spots of normal glandular tissue or fat between the abnormally enhancing components
NME
internal enhancement
• Homogeneous
• Heterogeneous
• Clumped
• Clustered ring
• Stippled removed as this is a type of BPE
• Clustered ring added as seen more now at high resolution
Clustered Ring
• Thin rings of enhancement clustered together
around the ducts. Enhancement in the
periductal stroma. Best seen on high resolution
images; implies a suspicious finding.
Clustered ring(ROI). Pathology:
Ductal Carcinoma In Situ
Clustered ring. Pathology:
Ductal Carcinoma In Situ
When deciding if you have a focus or
not
First question to ask:
Is it a unique finding or is it part of BPE?
What is a focus?
A focus is UNIQUE and stands out from BPE
but otherwise has no suspicious features
Focus or mass?
A small IDC is able to be detected
despite marked BPE
Follow up of a unique focus without suspicious features
on an initial screening examination is recommended
What is this? A small mass or focus?
CASE: Strong family history of breast
cancer & BRCA 1 positive
2004 High risk screening MRI
• 4/11/04 BILATERAL BREAST MR: CLINICAL STATEMENT: 29-year-old BRCA positive woman with strong family history of breast cancer status post benign left breast biopsy in 2002. Follow-up to last MRI which showed nodular enhancement on the left and stippled parenchymal enhancement on the right. TECHNIQUE: Fat suppressed sagittal T2-weighted, non-fat suppressed sagittal T1-weighted, fat suppressed sagittal T1-weighted pre and post Gadolinium intravenous administration and subtraction images of bilateral breasts were performed using a 1.5 Tesla GE magnet and dedicated breast coil. Additional MIP images were also performed using the first T1-weighted contrast enhanced subtraction imaging series. FINDINGS: Comparison is made with a prior bilateral breast MRI dated 9/2/03. The breasts contain an extreme amount of fibroglandular tissue with marked background parenchymal enhancement. In the upper inner quadrant of the left breast in the region of prior benign biopsy, the previously identified areas of enhancement are less prominent, suggesting that these are postoperative or hormonally related changes (series 12, image 18). There has been no interval development of abnormal enhancement within the left breast. Within the right breast, marked background parenchymal enhancement is again noted and appears unchanged since the prior exam. No suspicious focal areas of enhancement are identified within the right breast. IMPRESSION: LESS PROMINENT AREA OF ENHANCEMENT IN THE UPPER INNER QUADRANT OF THE LEFT BREAST AT THE SITE OF PRIOR BENIGN BIOPSY, SUGGESTING POSTOPERATIVE OR HORMONALLY RELATED CHANGE. BI-RADS 2: BENIGN FINDINGS. RECOMMEND ANNUAL MRI SCREENING.
Continued yearly screening
6 years later…new mass in left breast
Right breast Left breast
What is your assessment?
1. BI-RADS® 0 – Recommend US
2. BI-RADS® 2 – Benign
2. BI-RADS® 3 – 6 month follow up
3. BI-RADS® 4 - biopsy
What is your assessment?
1. BI-RADS® 0 – Recommend US
2. BI-RADS® 2 – Benign
2. BI-RADS® 3 – 6 month follow up
3. BI-RADS® 4 - biopsy
Targeted US performed to
determine method of biopsy
INVASIVE DUCTAL CARCINOMA
The decision to biopsy has already been made prior to the US
47 yo contralateral mastectomy 10
years ago
High risk screen – the NEW focus
What is your assessment?
1. BI-RADS® 0 – Recommend US
2. BI-RADS® 2 – Benign
2. BI-RADS® 3 – 6 month follow up
3. BI-RADS® 4 - biopsy
What is your assessment?
1. BI-RADS® 0 – Recommend US
2. BI-RADS® 2 – Benign
2. BI-RADS® 3 – 6 month follow up
3. BI-RADS® 4 - biopsy
Targeted US negative
MR biopsy
3 mm IDC
Post biopsy cavity
New focus
Biopsy
trocar
Postop MRI for positive margins
What is your assessment?
1. BI-RADS® 0 – Recommend US
2. BI-RADS® 2 – 1 year follow up
2. BI-RADS® 3 – 6 month follow up
3. BI-RADS® 4/5 – biopsy
4. BI-RADS® 6 – Known cancer
What is your assessment?
1. BI-RADS® 0 – Recommend US
2. BI-RADS® 2 – 1 year follow up
2. BI-RADS® 3 – 6 month follow up
3. BI-RADS® 4/5 – biopsy
4. BI-RADS® 6 – Known cancer
Postop MRI for positive margins
What is your assessment?
1. BI-RADS® 0 – Recommend US
2. BI-RADS® 2 – Benign
2. BI-RADS® 3 – 6 month follow up
3. BI-RADS® 4/5 – biopsy
4. BI-RADS® 6 – Known cancer
What is your assessment?
1. BI-RADS® 0 – Recommend US
2. BI-RADS® 2 – Benign
2. BI-RADS® 3 – 6 month follow up
3. BI-RADS® 4/5 – biopsy
4. BI-RADS® 6 – Known cancer
What is BI-RADS after NAC with
complete response on MRI?
Path: Isolated nests of IDC
scattered throughout
What is your assessment?
1. BI-RADS® 1 – Negative
2. BI-RADS® 2 – Benign
2. BI-RADS® 3 – 6 month follow up
3. BI-RADS® 4/5 – biopsy
4. BI-RADS® 6 – Known cancer
What is your assessment?
1. BI-RADS® 1 – Negative
2. BI-RADS® 2 – Benign
2. BI-RADS® 3 – 6 month follow up
3. BI-RADS® 4/5 – biopsy
4. BI-RADS® 6 – Known cancer
Use of BI-RADS 0 for MRI
• Used for retrieval of old exams that are
currently unavailable
• Need additional imaging
– Example: Possible lymph node on MRI – US
or mammography recommended to confirm
benign
– Example: Possible fibroadenoma on MRI –
US recommended for further characterization
Recommending US to prove
something benign
Appropriate use of BI-RADS 0
Use of BI-RADS: 0 OK
Trying to prove something benign
Characteristic “black hole” sign of fat necrosis
Known cancer
MRI performed for staging shows
additional suspicious lesion
MR detected additional lesion
Known cancer
What is your assessment?
1. BI-RADS® 1 – Negative
2. BI-RADS® 2 – Benign
2. BI-RADS® 3 – 6 month follow up
3. BI-RADS® 4/5 – biopsy
4. BI-RADS® 6 – Known cancer
What is your assessment?
1. BI-RADS® 1 – Negative
2. BI-RADS® 2 – Benign
2. BI-RADS® 3 – 6 month follow up
3. BI-RADS® 4/5 – biopsy
4. BI-RADS® 6 – Known cancer
BI-RADS 4 or 5 trumps BIRADS 6
as there is an actionable finding
Conclusions
• BI-RADS® 5th edition is more user friendly
• Increased content
• Uniformity across modalities
• Assessment & Recommendation Uncoupled
• Outcomes section
• Electronic version planned
Question 1
A new unique 6 mm mass with
homogeneous enhancement is a BI-RADS 2
lesion
A. False
B. True
Question 1
A new unique 6 mm mass with
homogeneous enhancement is a BI-RADS 2
lesion
A. False
B. True
Reference: D’Orsi CJ, Sickles EA, Mendelson EB, Morris EA, et al.
ACR BI-RADS Atlas: Breast Imaging Reporting and Data System. 5 ed.
Reston, VA, American College of Radiology, 2013
Question 2
What imaging features would make a focus
suspicious on MRI?
A. Homogeneous enhancement, high signal on
bright fluid imaging, washout kinetics
B. New, homogeneous enhancement and iso on
bright fluid imaging, plateau kinetics
C. Stable, homogeneous enhancement, iso on
bright fluid imaging, persistent kinetics
Question 2
What imaging features would make a focus
suspicious on MRI?
A. Homogeneous enhancement, high signal on
bright fluid imaging, washout kinetics
B. New, homogeneous enhancement and iso on
bright fluid imaging, plateau kinetics
C. Stable, homogeneous enhancement, iso on
bright fluid imaging, persistent kinetics
Reference: D’Orsi CJ, Sickles EA, Mendelson EB, Morris EA, et al.
ACR BI-RADS Atlas: Breast Imaging Reporting and Data System. 5 ed.
Reston, VA, American College of Radiology, 2013
Question 3
Q.1 Which of the following is a BI-RADS 4
finding?
a. Fat necrosis following surgical biopsy
b. Peripherally enhancing cyst that is high in signal
on T2W imaging
c. Multiple foci of enhancement
d. Postoperative seroma cavity
e. New unique 6 mm mass with homogenous
enhancement
Question 3
Q.1 Which of the following is a BI-RADS 4
finding?
a. Fat necrosis following surgical biopsy
b. Peripherally enhancing cyst that is high in signal
on T2W imaging
c. Multiple foci of enhancement
d. Postoperative seroma cavity
e. New unique 6 mm mass with homogenous
enhancement
Reference: D’Orsi CJ, Sickles EA, Mendelson EB, Morris EA, et al.
ACR BI-RADS Atlas: Breast Imaging Reporting and Data System. 5 ed.
Reston, VA, American College of Radiology, 2013
Question 4
Q. 2 Breast MRI biopsy should NOT be performed:
a. to evaluate BI-RADS 4 or 5 lesions not
identified on targeted ultrasound
b. to evaluate BI-RADS 3 lesions if the patient is
anxious and requests biopsy
c. to evaluate BI-RADS 0 lesions
d. clumped segmental enhancement
e. rim enhancing irregular mass with plateau
kinetics
Question 4
Q. 2 Breast MRI biopsy should NOT be performed:
a. to evaluate BI-RADS 4 or 5 lesions not
identified on targeted ultrasound
b. to evaluate BI-RADS 3 lesions if the patient is
anxious and requests biopsy
c. to evaluate BI-RADS 0 lesions
d. clumped segmental enhancement
e. rim enhancing irregular mass with plateau
kinetics
Reference: D’Orsi CJ, Sickles EA, Mendelson EB, Morris EA, et al.
ACR BI-RADS Atlas: Breast Imaging Reporting and Data System. 5 ed.
Reston, VA, American College of Radiology, 2013
THANK YOU!
Evelyn Lauder Outpatient
Breast Center MSKCC Hospital MSKCC
THANK YOU!!
Recommended