ACR Breast MRI Accreditation Breast MRI: What’s New …€¢ Images courtesy of American College of Radiology ACR BI-RADS MRI, in American College of Radiology BI-RADS Imaging Atlas,

Breast MRI: What’s New in BI-RADS™, 5th Edition�

Orange County Radiological Society

September 13, 2014

Debra M. Ikeda, M.D. Director of Breast Imaging

Professor of Radiology Stanford University, Stanford, CA

Image courtesy of Bruce L. Daniel, M.D.

•  Images courtesy of American College of Radiology ACR BI-RADS MRI, in American College of Radiology BI-RADS Imaging Atlas, Reston, VA, 2003, ACR Breast MRI Lexicon Committee, Elizabeth Morris, Constance Lehman and Bruce L. Daniel, M.D.

ACR Breast MRI Accreditation and

Breast MRI BI-RADS® 2013 Personnel Initial and Continuing

Qualifications Equipment Clinical Images QA and QC Progam MRI Safety Guidance

ACR MRI Accreditation ACR Breast MRI Accreditation Program - Background Medicare Improvement for Patients and Providers Act of 2008(MIPPA)(not hospitals) – requires all providers billing for the MRI, CT, NM,PET technical component of part B of the Medicare Physician Fee Schedule to be accredited by January 1, 2012 to bill for Medicare beneficiaries No reimbursement if no accreditation CMS approval for ACR, IAC, JCHO

ACR Breast MRI Accreditation

http://www.acr.org/Quality-Safety/Accreditation/BreastMRI

Phone 800-227-6440 Email: [email protected] http://www.acr.org Updated June 19, 2014 – New system

allows electonic image submission

BREAST MRI ACCREDITATION http://www.acr.org/Quality-Safety/

Accreditation/BreastMRI FAQs Accreditation takes 4-5 months No survey but MIPPA facilities must

pariticpate in unannounced validation surveys by accrediting organization and/or Cneters for Medicare and Medicai Services (CMS)

ACR Breast MRI Accreditation program Clinical Image Review Clinical Image Review

Examination identification Pulse sequence and image contrast

Positioning and anatomic coverage Artifacts Spatial resolution Temporal resolution

ACR Breast MRI Accreditation program Clinical Image Review- Examination identification Patient’s first and last names Patient age or date of birth Patient Identification number Facility name Examination date *Laterality, left or right of midline section If laterality is absent or is incorrect, the case will fail accreditation. -

ACR Breast MRI Accreditation program – 4 Sequences T2-weighted/bright fluid series Three Multi-phase T1-weighted series all with matching technical factors 1) Precontrast T1 2) Early phase post contrast T1 –

completed within 4 minutes of injection

3) Delayed phase post contrast T1

2014 BI-RADS™ Mammography, Ultrasound and MRI Lexicon Expert concensus on Terms New information from literature since 2004 incorporated

with hyperlinks to literature Terms harmonize between the Lexicons US Lexicon includes 3D images, doppler, elastography MRI new images and implant chapter

2014 BI-RADS™ 5th Edition MRI REPORT FORMAT 1)  Clinical History and Indication 2)  Comparison to Previous Examinations 3)  Acquisition Reporting (see http://www.acr.org/-/

media/ACR/Documents/Accreditation/Breast MRI/Requirements.pdf)

4)  Overall Breast Composition and Background Parenchymal Enhancement (BPE)

5)  Clear description of Important Findings (Moprhology) 6)  Kinetic Curve Assessment 7)  Final Overall Assessment 8)  Management

2014 ACR BI-RADS™ MRI Reporting

Size and Location Mass or NME type and modifiers (shape margin density) Associated Findings How changed; if previously present Summary and BI-RADS™ Code (0-6) Management Use combined reporting (MRI/Mammmo/US)

Breast Lesion Locations Right or Left Breast Quadrant Clock position Depth in the breast - anterior, middle or posterior third Distance in cm from the nipple, skin, chest wall

*2013 ACR Breast Imaging Reporting and Data System, Reston, VA.

Combined Reporting Make a final BIRADS Assessment 0 - Incomplete Additional Imaging Needed 1 - Negative (routine f/u) 2 - Benign (routine f/u) 3   - Probably Benign - Short Interval Follow-up

( <2% cancer)

1 month f/u for hormones 6 month f/u NOT background enhancement

ACR MRI Lexicon 2nd Edition

Combined Reporting BIRADS Assessment 4   - Suspicious Tissue diagnosis “Biopsy should be performed in

the absence of clinical contraindication” Recommend Bx and How Guided, by US, Mammo, MRI

5   - Highly Suggestive of Malignancy - Tissue diagnosis “Biopsy should be performed in

the absence of clinical contraindication” 6 - Known Biopsy Proven Malignancy - Surgical excision when clinically appropriate MRI Lexicon 2nd Edition, ACR MRI Accreditation

Program

Important

Assessment is based on imaging findings OK to add additional sentence suggesting

biopsy based on clinical findings even if exam is BI-RADS® 1 or 2

16�

Slide courtesy ACR www.acr.org �

2014 BIRADS Reporting Cut-offs for BIRADS 4 4a = 2%-10% 4b = 11%-50%

4c = 51-95%) BIRADS Assessment and Management

are separated to treat the patient, not the BIRADS code

ACR BI-RADS™ MRI LEXICON ACR Subcommittee on BI-RADS MRI American College of Radiology 1891 Preston White Drive Reston, VA 20191 FAX: 703-648-9176 Email: [email protected] Elizabeth A. Morris, M.D., Chair, Subcomimittee on BI-

RADS MRI

American College of Radiology (ACR) ACR BI-RADS™ MRI LEXICON

New Web-based format (hardcopy on demand) Mammo/US/MRI compatibility Evidence based information with hyperlinks to

references

BI-RADS™ MRI Lexicon Changes New Quality Assessment Section Includes

Technical Parameters and Kinetic/Functional Considerations – influence images; standardization results in consistent architecture & kinetic reporting

BI-RADS™ MRI Lexicon Changes Morphology and kinetics are still both

important, add T2 weighted non-con Terms added (BPE) or deleted as better

terms identified, other terms clarified New Section on Non-enhancing Findings New Implant Section Clarify BIRADS 0 and BIRADS 3 Need for Combined Reporting

Kinetic Description (Unchanged)

Initial slope within 2 minutes or when curve starts to change. Delayed slope after 2 minutes or after curve starts to change

SI

Initial Delayed persistent

plateau

washout

fast

medium

slow

Kinetic Description: Signal Intensity/Time Intensity Curve

Persistent - 6% cancer Plateau - 64% cancer

Washout - 87% cancer Sensitivity 91% Specificity 83%

PPV 77% Kuhl et al. Radiology 1999

BI-RADS™ MRI Lexicon- Kinetics Initial phase – enhancement pattern in the first 2 minutes or when the curve starts to change Initial Slow – increase of <50% Initial Medium – increase of 50-100% Initial Fast/rapid - >100% increase

BI-RADS™ MRI Lexicon- Kinetics Delayed phase – enhancement pattern after 2 minutes or when the curve starts to change Persistent – continued > 10% increase Plateau – SI does not change after initial

rise, flat Washout – SI decreases >10% after rise

Breast MRI BI-RADS® 2013 Contrast Bolus w saline flush Contrast dose based on weight (Use a power injector) Timing so first post contrast scan is at 90

seconds to 2 minutes after injection, center of scan is ½ way through peak contrast

Dynamic Images High Spatial Resolution

k=0

Overview: Contrast-enhanced MRI Protocol at Stanford

T1 DWI

Inject Gd

T2

Curve types Morphology ACR MRI Lexicon

parametric maps

Chart courtesy of Bruce L. Daniel, M.D.

Kinetic Description


SI

Initial >100%

50 – 100%

<50%

fast

medium

slow

Kinetic Description


SI

Initial Delayed Persistent

> 10%increase

plateau

Washout

>10%increase

fast

medium

slow

Kinetic Description


SI

Initial Delayed persistent

plateau

washout

fast

medium

slow

BI-RADS™ MRI Lexicon Changes Literature on morphology and dynamic curve

interpretation for benign and malignant lesions advanced (2004)

Variations on MRI technique influence what is observed and reported

New Quality Assessment Section Includes Technical Parameters and Kinetic/Functional Considerations – influence images; standardization results in consistent architecture & kinetic reporting




ALMOST ENTIRELY FAT SCATTERED FIBROGLANDULAR TISSUE HETEROGENEOUS FIBROGLANDULAR TISSUE EXTREME FIBROGLANDULAR TISSUE

*2013 ACR BIRADS Breast Imaging Reporting and Data System, Reston, VA. Released 2/2014 .

A) Amount of Fibroglandular Tissue (FGT)– ON MRI -

B) Normal “background” parenchymal enhancement (BPE)

percentage of normal enhancing fibroglandular tissue

background dependent on breast density (% fibroglandular tissue by volume)

Background Parenchymal Enhancement (BPE)

ENHANCEMENT SYMMETRIC None ASYMMETRIC

Minimal Mild Moderate*

Marked* *Moderate and Marked Background Enhancement can hide invasive cancer noninvasive cancer

*2013 ACR BIRADS Breast Imaging Reporting and Data System, Reston, VA. Released 2/2014

C. NON-MASS LIKE ENHANCEMENT: now NME Diffuse enhancement: Now marked BPE

Image # NH5

DIFFUSE enhancement.

C. NON-MASS LIKE ENHANCEMENT: now NME Multiple Regions: Now moderate BPE

Image # 012

MULTIPLE REGIONS of heterogeneous enhancement. Fibrocystic change.

C. NON-MASS LIKE ENHANCEMENT: now NME Diffuse enhancement: Now mild BPE

Image # 005

DIFFUSE stippled enhancement. Fibrocystic changes.

Normal Background Parenchymal Enhancement (BPE) Previously all enhancement was thought

to be abnormal Normal breast parenchyma enhances

and fluctuates with hormonal cycles or exogenous hormones

2003 2001

2005 2004

Image courtesy Aya Kamaya, M.D.

None/Minimal BPE

Minimal BPE (in scattered breast )

MILD BPE (in scattered breast) Moderate BPE (in hetero/dense breast)

Marked BPE (in dense breast) Findings that are NOT “background enhancement”

DCIS - in appropriate clinical setting focal area linear linear branching (historic ductal) segmental asymmetric

- especially if in setting of known cancer

or if “clumped”

MRI Enhancement in Stromal Tissue Surrounding Breast Tumors: Association with Recurrence Free Survival following

Neoadjuvant Chemotherapy

Jones, E.F., et al. PLoS One, 2013. 8(5): p. e61969.

Fifty patients with locally-advanced breast cancer were imaged with dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) before (V1) and after one cycle (V2) of adriamycin-cytoxan therapy.�

Results: The mixed effects model displayed a decreasing radial trend in PE at both V1 and V2. An increasing trend was less pronounced in SER. Survival analysis showed that the hazard ratio estimates for each unit decrease in global SER was statistically significant at V1 [estimated hazard ratio = 0.058, 95% Wald CI (0.003, 1.01), likelihood ratio p = 0.03]; but was not so for V2.�

MRI Enhancement in Stromal Tissue Surrounding Breast Tumors�

Jones, E.F., et al. PLoS One, 2013. �

Conclusions: stromal tissue outside the tumor can be quantitatively characterized by DCE-MRI, and stromal enhancement measurements may be further developed for use as a potential predictor of recurrence/disease-free survival following therapy.�

MRI Enhancement in Stromal Tissue Surrounding Breast Tumors�

Jones, E.F., et al. PLoS One, 2013. �

MRI Findings (> BPE) Focus

Mass Shape – Oval/Round/Irregular Margin – Circumscribed Not circumscribed : Irregular/Spiculated Internal Enhancement Homogeneous/Heterogeneous Rim

Dark Internal Septations ACR BIRADS Breast MRI Lexicon Update

MASS DESCRIPTORS MARGIN SHAPE

Circumscribed

Not Circumscribed

Irregular

Spiculated

Homogeneous

Heterogeneous

Rim

Dark septations

Oval Round

Irregular

INTERNAL ENHANCEMENT

MRI Findings (> BPE) Non-mass Enhancement (NME)

Distribution Internal Enhancement Focus Focal NME Homogeneous Linear Heterogeneous

Segmental Clumped Regional Clustered Ring

Multiple Regions Diffuse ACR BIRADS Breast MRI Lexicon Update

Breast MRI Lexicon

Non-Mass Enhancement NME

Focus Focal NME

Linear

Segmental

Clustered Ring Ducts vs Microcysts

DCIS Clumped non-masslike enhancement in a

ductal, linear, segmental, or regional distribution

14% show no enhancement! Kinetics not helpful

Usually rapid uptake, but can demonstrate persistent, plateau, or washout

Mimics normal breast parenchyma on T1 and T2

Kuhl CK et al. Lancet 2007 Aug 11:370(9586):485-92

DCIS Characteristics

MORPHOLOGY IMPORTANT SEGMENTAL {DUCTAL ENHANCEMENT} LINEAR (FOCAL AREA} FOCAL NME LINEAR CLUMPED (COBBLESTONE)

(BIRADS 2013 think Clustered Ring) PROXIMITY TO IDC KINETICS LESS IMPORTANT- MAY INDICATE

HIGH GRADE DCIS IF PRESENT Kuhl CK et al. Lancet 2007 Aug 11:370(9586):

485-92

Anatomy and Pathology Explain DCIS Appearances Segmental,Regional, Linear

Focal NME

Breast MRI Non-Mass Enhancement Distribution

REGIONAL Enhancement not confined to single duct; may be in multiple ducts

MULTIPLE REGIONS Multiple areas of regional enhancement

DIFFUSE Scattered enhancement throughout the breast

Asymmetric

(Septal -thickened trabeculae)

Associated Features Nipple retraction

Nipple invasion Skin retraction Skin thickening Skin invasion –a) Direct invasion b) Inflammatory cancer Axillary adenopathy Pectoralis muscle invasion Chest wall invasion Architectural distortion *2013 ACR BIRADS Breast Imaging Reporting and Data System, Reston, VA.

Released 2/2014

Fat Containing Lesions Lymph nodes – a) Normal b) Abnormal

Fat necrosis Hamartoma Postoperative seroma/hematoma with fat *2013 ACR BIRADS Breast Imaging Reporting and Data

System, Reston, VA. Released 2/2014

Location of Lesion

Location Depth *2013 ACR BIRADS Breast Imaging Reporting and Data


MRI Findings (> BPE) Intramammary Lymph Node

Skin Lesion *2013 ACR BIRADS Breast Imaging Reporting and

Data System, Reston, VA. Released 2/2014




Non-enhancing Findings Ductal high signal on T1W

Cyst –simple and complicated Post-operative fluid collections (Hematoma/seroma) Post-therapy skin thickening and trabecular thickening (w

skin thickening, post XRT, edema) Non-enhancing mass Architectural distortion Signal void from clips, foreign bodies *2013 ACR BIRADS Breast Imaging Reporting and Data





IMPLANTS IMPLANT TYPE – Saline, silicone, other LOCATION – subpectoral, subglandular INTACT – radial folds INTRACAPSULAR FINDINGS –

keyhole (teardrop, noose) subcapsular line linguine

EXTRACAPSULAR RUPTURE Abnormal Implant Contour – focal bulge, Globular Water Droplets, Peri-implant fluid

IMPLANTS Implant Material and Type– Saline, silicone (intact or

ruptured), other material, lumen type Implant Location – Retroglandular, Retropectoral Abnormal Implant Contour – Focal Bulge Intracapsular Silicone Findings– Radial folds,

subcapsular line, keyhole sign (teardrop, noose), linguine sign

Extracapsular silicone – Breast, Lymph Nodes Water Droplets Peri-implant fluid




BIRADS 0 - Additional Imaging Needed

USED ONLY TO STOP A BIOPSY - mammo or US to confirm a benign lymph node that would otherwise undergo MRI biopsy

- US for fibroadenoma

ACR BIRADS Breast MRI Lexicon 2nd Edition, 2013

BIRADS 3

BACKGROUND PARENCHYMAL ENHANCEMENT

Should NOT fall into this category except for 1 month follow-up for hormones

Usually 6-month follow up for benign findings

Few studies on BIRADS 3 for follow up or showing < 2% malignancy (Marshall et al 2012)

Descriptors adapted from Mammography BI-RADS for

uniformity ACR BIRADS Breast MRI Lexicon 2nd Edition 2013




Multifocal Disease (2)

calcs 4 cm from nipple 1.4 cm from nipple

3 cm from nipple

Thank You!