Developments in Breast Imaging: In Memory of Dr. …. Carolyn Kimme -Smith Enhancement Characteristics ... What are the new BIRADS MRI recommendations for 2010 ACR Atlas? What are

Developments in Breast Developments in Breast Imaging: In Memory of Imaging: In Memory of

Dr. Carolyn Dr. Carolyn KimmeKimme--SmithSmithEnhancement Characteristics Enhancement Characteristics of Cancer on Breast MRI and of Cancer on Breast MRI and

Biopsy TechniquesBiopsy TechniquesDebra M. Ikeda, M.D.Debra M. Ikeda, M.D.

Director of Breast ImagingDirector of Breast ImagingProfessor of RadiologyProfessor of Radiology

Stanford University, Stanford, CAStanford University, Stanford, CAImage courtesy of Bruce L. Daniel, M.D.Image courtesy of Bruce L. Daniel, M.D.

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

Professor of RadiologyProfessor of RadiologyStanford University, Stanford, CAStanford University, Stanford, CA

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

•• Images courtesy of American College of Radiology ACR BIImages courtesy of American College of Radiology ACR BI--RADS MRI, in RADS MRI, in American College of Radiology BIAmerican College of Radiology BI--RADS Imaging Atlas, Reston, VA, 2003, RADS Imaging Atlas, Reston, VA, 2003, ACR Breast MRI Lexicon Committee, International Working Group onACR Breast MRI Lexicon Committee, International Working Group on breast breast MRI, Bruce L. Daniel, M.D., MRI, Bruce L. Daniel, M.D., SunitaSunita Pal, M.D. and Pal, M.D. and AyaAya Kamaya, M.D.Kamaya, M.D.

Open Breast CoilOpen Breast Coil

MRI Devices4-coil phased array

Patient PositioningPatient Positioning IDCIDCRimRim SpiculatedSpiculated MicrolobulatedMicrolobulated


WellWell--defineddefined

FibroadenomaFibroadenomaSeptatedSeptated MacrolobulatedMacrolobulated


Breast MRI and MRIBreast MRI and MRI--BxBx

What is actually happening in US clinical practice?

What is breast MRI standard of care?

What are the new BIRADS MRI recommendations for 2010 ACR Atlas?

What are MRI breast biopsy results?

2008 National MRI Trends2008 National MRI TrendsBassett et al. AJRBassett et al. AJR

74% of practices offer MRI (557/754)

62% 5 MRI/wk (n=354), 10% >20/wk (n=54)

31.7% do no MRI Bx (n=173)

64% do screening MRI (n=359)

All soft copy read, 50% with CAD

48% never/29% rarely read outside MRIs

47% never/38% rarely read MRI w/o mammo/US

0

10

20

30

40

50

95

1st

95

2nd

95

3rd

95

4th

96

1st

96

2nd

96

3rd

96

4th

97

1st

97

2nd

97

3rd

97

4th

98

1st

98

2nd

98

3rd

98

4th

99

1st

99

2nd

99

3rd

99

4th

Quarter

UnilateralBilateral

Diagnostic Breast MRIUtilization at Stanford

MRI/MRI Biopsy Volumes*MRI/MRI Biopsy Volumes*MRI MRI BX TOTAL

2001 335 61 396

2002 827 105 932

2003 1120 172 1320

2004 1150 170 1320

2005 1120 172 1292

2006 1231 211 1442


What is breast MRI standard of care?

GadoliniumGadolinium--EnhancementEnhancement

Tumor AngiogenesisTumor Angiogenesis

Image courtesy Bruce L. Daniel MDImage courtesy Bruce L. Daniel MD

The Current Status of Breast MR The Current Status of Breast MR Imaging (Part 1 of 2 parts)Imaging (Part 1 of 2 parts)1. Spatial and temporal resolution are

important2. Understand perfusion and capilllary

leakage, tissue T1 and T2 relaxation3. Most sensitive for cancer; MRI and

Mammo offer complementary information

*Christiane Kuhl, M.D. Radiology 2007, August Vol 244; 2; 356-378 and Radiology 2007, September Vol 244; 3; 672-691

The Current Status of Breast MR The Current Status of Breast MR Imaging (Part 1 of 2 parts)Imaging (Part 1 of 2 parts)4. Specificity and PPV for MRI are

equivalent to Mammo5. Work-up for MRI findings are more

demanding than mammo or US, improvements for MRI are in great demand

6. Advances have been made in MRI interpretation guidelines

7. MRI biopsy is necessary*Christiane Kuhl, M.D. Radiology 2007,

August Vol 244; 2; 356-378

The Current Status of Breast MR The Current Status of Breast MR Imaging (Part 2)Imaging (Part 2)1. Clinical applications for MRI include

A. Problem Solving for equivocal mammo or US findings

B. MRI Biopsy necessary 40% US unseen C. Neoadjuvant chemotherapyD. Avoid over-treatment of MRI findings

Use MRI findings wisely - it is wrong totransfer mammo guidelines to MRI

E. High Risk screening

*Christiane Kuhl, M.D. Radiology 2007, September Vol 244; 3; 672-691

Screening ReferenceScreening Reference• Saslow D, Boetes C, Burke W, et al. American

Cancer Society Guidelines for Breast Screening with MRI as an Adjunct to Mammography. CA Cancer J Clin. 2007;57:75-89

MRI Breast Cancer ScreeningMRI Breast Cancer ScreeningAUTHOR YEAR #WOMEN #CANCERS %

KUHL 2000 192 HIGH RISK 9 4.6%

TILANUS-LINTHORP 2000 109 HIGH RISK 3 (6FP) 2.8%

WARNER 2001 196 BRCA1/2 7 3.6%

STOUTJESDIJK 2001 179 HIGH RISK13 (MRI ONLY) 7.3%

MORRIS 2003 367 HIGH RISK 14 (50 FP) 4%

LEE 2003182 (CA OPPOSITE)

7/ (8FP) 3.8%

HARTMAN 2004 41 HIGH RISK 1 2.4%

WARNER 2004 236 BRCA1/2 17/22 7.2%

KRIEGE 2004,06 1909 HIGH RISK 32/45 1.6%

LEHMAN 2005 367 HIGH RISK 4 (19FP,5%) 1.1%

MRI Breast Cancer ScreeningMRI Breast Cancer ScreeningAUTHOR YEAR #WOMEN #CANCERS %

PORT 2007 182 LCIS/ATYPIA 5 3%

TRECATE 2006 116 HIGH RISK 10 10%

LEHMAN 2007 171 HIGH RISK 6 3.5%

PEDICONI 2007118 CONTALATERAL OR HIGH RISK

22 5.3%

PORT 2007 182 LCIS/ATYPIA 5 3%

MRI Breast Cancer OppositeMRI Breast Cancer OppositeBreastBreast

AUTHOR YEAR #WOMEN #CANCERS %

RIEBEL 1998 34 3 11%

FISCHER 1999 463 19 4%

KUHL 2000 710 45 6%

SLANETZ 2002 17 4 24%

LIBERMAN 2002 223 12 5%

LEE 2003 182 7/ (8FP) 4%

VIEHWEG 2003 119 4 4%

LEHMAN 2007 969 30 3.1%


What are the new BIRADS MRI recommendations for 2010 ACR Atlas?

International Working Group for International Working Group for Breast MRIBreast MRI

and and American College of RadiologyAmerican College of RadiologyBreast MRI Lexicon CommitteeBreast MRI Lexicon Committee

19981998--20032003

ACR BIACR BI--RADS RADS -- MRIMRIImaging Atlas, Reston, VA 2003Imaging Atlas, Reston, VA 2003

2006/09 2006/09 Updates for ACR BIUpdates for ACR BI--RADSRADS™™1. Do bilateral studies2. Describe background enhancement3. Do T2-weighted non-contrast exams4. Check Kinetics5. Facilities doing breast MRI should be

able to do MRI-guided biopsy*6. Do combined reporting(MRI Screening advised for 20-25% lifetime risk

and women treated for Hodgkin disease**)*Christiane Kuhl, M.D. Radiology 2007, September

Vol 244; 3; 672-691 **Saslow D et al. Ca Cancer J Clin 2007; 57 (2) 75-

78

2006 Improvements for 2006 Improvements for ACR BIACR BI--RADSRADS™™

1. Do bilateral studies**

Easier to compare symmetry ofbackground enhancement pattern

Less likely to miss DCIS

**November 2006 BIRADS Committee RSNA, Chicago, Illinois

FCCFCC ACR BIACR BI--RADSRADS™™BREAST MRI LexiconBREAST MRI Lexicon

MORPHOLOGY (FORM)

DISTRIBUTION

KINETICS (SI vs time)

C. NONC. NON--MASS LIKE ENHANCEMENTMASS LIKE ENHANCEMENTDuctal Enhancement:Ductal Enhancement:

Courtesy Courtesy ACR, ACR, IllustratedIllustratedBreast MRI Breast MRI Atlas, Atlas, BIRADSBIRADS--MRI, ACR, MRI, ACR, Reston,VAReston,VA20032003

DUCTAL enhancement. DCISDUCTAL enhancement. DCIS..

DCISDCIS

Pure DCIS Pure DCIS MAMMO – 90% CALCS (Ikeda 1988)

-10-20% MASS, NODULES

DETECTION RANGES 77-96% (MORRIS 2004)

SIZE, GRADE, ANGIOGENESIS, PROTOCOL

14-75% DCIS PROGESSES TO IDC, 22% RECURRENT (Leonard 2004)

AFTER Rx- 50% recurrences invasive (Bijiker 2004)

Accelerated Partial Breast Irradiation - extent

Pure DCIS Pure DCIS MORPHOLOGY mostly non-masslike, few masses

CLUMPED- cobblestone, occ confluent or HETEROGENEOUS

SEGMENTAL, DUCTAL , LINEAR

REGIONAL – large area , not ductal, randomFOCAL AREA – confined area <25% breast

KINETICS variable- MAY INDICATE HIGH GRADE DCIS IF PRESENT

Raza et al. AJR 2008; 191: 689

DCIS CharacteristicsDCIS CharacteristicsMORPHOLOGY IMPORTANT

SEGMENTAL

DUCTAL ENHANCEMENT

FOCAL AREALINEAR

CLUMPED (COBBLESTONE)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

Background Enhancement Background Enhancement

None/Minimal < 25%

Mild 25-50%

Moderate* 50-75%

Marked* >75%

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

ACR BIRADS Committee. Draft for Breast MRI Lexicon Update, November 2006

20032003 20012001

20052005 20042004

Image courtesy Aya Kamaya, M.D.Image courtesy Aya Kamaya, M.D.

Normal Hormone Normal Hormone Enhancement FluctuationsEnhancement Fluctuations

0202 0404

IDC MIP OUTER BREASTIDC MIP OUTER BREAST--11 IDC MIP OUTER BREASTIDC MIP OUTER BREAST--22








Kinetic DescriptionKinetic Description

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

Delayed slope after 2 minutes or after curve starts to change

SISI

InitialInitial DelayedDelayed

persistentpersistent

plateauplateau

washoutwashout

fastfast

mediummedium

slowslow



plateauplateau washoutwashoutPersistent

Heart CurveHeart Curve LN SpiralsLN Spirals

LN Spiral CurveLN Spiral Curve

DynamicDynamic(213 s)(213 s)

DynamicDynamic(277 s)(277 s)

High Res. High Res. (6 min 31 s)(6 min 31 s)

k=0k=0

Overview: Overview: ContrastContrast--enhanced MRI Protocol at Stanfordenhanced MRI Protocol at Stanford

T1T1 HighHigh--ResRes

InjectInjectGdGd

T2T2

Curve types, k21,Curve types, k21,parametric mapsparametric maps

MorphologyMorphologyACR MRI LexiconACR MRI Lexicon

Curve types, k21,Curve types, k21,parametric mapsparametric maps

Neoadjuvant ChemotherapyNeoadjuvant Chemotherapy30 patients undergoing neoadjuvant

chemotherapy, comparing response and surgical management before/post MRI

16 successful breast conservation

14 mastectomies

MRI would have helped therapy in 6 (20%) 5 mastectomy avoid chemotherapy,1 would avoid unsuccessful conservation

MRI would hinder therapy in 3: not prevent unsuccessful conservation (1) or prevent successful conservation (3)

Thibault F et al. AJR 2004; 183:1159-68

NonNon--Spic (CR) preSpic (CR) pre-- chemochemo

NonNon--Spic (CR) postSpic (CR) post--chemochemo ChemotherapyChemotherapyPre Post Pre Post

Images courtesy of Dr. Bruce L. DanielImages courtesy of Dr. Bruce L. Daniel

T2T2--weighted images*weighted images*Fluid (cysts) bright against fat

Normal fluid in ducts

Lymph nodes (UOQ, vessel,fat)

Cellular FA (bright, sclerotic dark)

Lactating patients bright glands, cancers dark

Breast edema

Beware mucinous cancers (pitfall)** Kuhl CK et al JMRI 1999; 9: 187-96, Yuen et al. JMRI 2007;25:502-10,

Espinosa et al. Radiology 2005;237:249-36

Breast CA with High Signal Breast CA with High Signal Intensity on T2Intensity on T2--weighted Imagesweighted Images30/480 breast cancers had high T2-weighted SI (8 mucinous; 22 nonmucinous cancers) compared 19 FA

Hi SNR and enhancing septations in mucinous cancers and irregular border, no dark septations and rim enhancement in non-mucinous cancers separated them from FA

Yuen et al JRMI 2007;25;502-10

Case 2007Case 2007-- UK4UK4

T2 FSE Fat SatT2 FSE Fat Sat T1 3D SPGR Fat T1 3D SPGR Fat Sat Sat -- Post GadPost Gad

T1 Spiral 10 seconds after Gd arrival in Breast

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

What are TP biopsy rates for What are TP biopsy rates for MRI?MRI?

Current MRI sequences/hardware make high resolution/kinetic scans now more available

Several vendors offer CAD, dedicated breast coils, MRI-compatible grids, needles and vacuum assisted biopsy probes

MRI-guided pre-operative needle localization and vacuum assisted core availability increasing

Reported TP biopsy rates comparable to mammography

Right Breast in Left CoilRight Breast in Left Coil

Courtesy Bruce Daniel, MDCourtesy Bruce Daniel, MD

4-Coil Phased-ArrayOpen Platform Breast Coil, MRI-Devices Inc,Waukesha, WI

MRI Breast Lesion Marking System, E-Z-EM Inc., Westbury, NY

CT-MRI Topographic Marker, Radionics / Z-Medical Inc., Baltimore

Freehand / InteractiveNeedle Placement

VacuumVacuum--Assisted Core Needle Assisted Core Needle Biopsy Apparatus*Biopsy Apparatus*

ATEC MRI CompatibleVacuum Breast Biopsy SystemSuros Surgical Instruments Inc., Indianapolis, IN

2.8 cm

*MR Safe

Confirmation on Orthogonal ViewsConfirmation on Orthogonal Views

Axial ReformatAxial Reformat1.5T 3DSSMT1.5T 3DSSMT

Axial 0.5T 3Axial 0.5T 3--Pt Pt Dixon SPGRDixon SPGR

Sagittal 0.5T 3Sagittal 0.5T 3--Pt Pt Dixon SPGRDixon SPGR

Courtesy Bruce Daniel, MDCourtesy Bruce Daniel, MD

MRIMRI--guided Breast guided Breast Needle Localization BiopsyNeedle Localization Biopsy

AUTHOR YEAR #WOMEN %

OREL 1994 10 40%

FISCHER 1995 15 33%

KUHL 1997 97 54%

DANIEL 1998 19 42%

FISCHER 1998 130 48%

OREL 1999 137 43%

MORRIS 2001 115 31%

LEHMAN 2004 38 40%

VAN DEN BOSCH 2005 304 34%

MRIMRI--guided Breast guided Breast Needle Localization BiopsyNeedle Localization Biopsy

AUTHOR YEAR #WOMEN %CA

VAN DEN BOSCH 2006 304 34%

VIEHWEG 2006

97 LESIONS/63 WOMEN +FH/87 BX

(9 IDC/12 DCIS)

10 DISAPPEARED

24%

CARLSON 2007 85 24%

MRIMRI--guided Vacuumguided Vacuum--Assisted Core Assisted Core Needle Breast BiopsyNeedle Breast Biopsy

AUTHOR YR # NOTES %CA

LEHMAN 2005 38AV 38 MIN FOR 1 BX, 59 MIN FOR MULT, BILATER 64 MIN

37%

LIBERMAN 2005 112

14/112 (12%) CANCELLED (GONE)

24/95 (25%) CANCER, 9/95 WERE DISCORDANT (10%)

CLIP DEPLOYED IN 86?91 LESIONS

24%

OREL 2006 85

35 IDC/ 17 DCIS,

4 DCIS WAS IDC, 2 ADH WERE DCIS

2 DISCORDANT (2%) FN

61%

(52/75)

PERLET 2006 538

517/538 SUCCESSFUL

17 ADH (3%), 362 BENIGN (70%)

PPV VARIED DEPENDING ON INDICATION

27%

138/517

GEBAUER 2007 42 4224%

(11/42)

2007 Breast MRI and MRI2007 Breast MRI and MRI--guided guided Needle Localization BiopsyNeedle Localization Biopsy

FACILITY

#MRI

PER

YR

TIME

TO DO MRI (MIN)

# MRI READPER

DAY

#MRI

BX

PER

YR

TIME TO DO BX (MIN)

HOW

MRI

BX DONE

HOW MANY

MRI BX/

DAY

MIDWEST

ACADEMIC- K1500 45 8-20 85 45-60

GRID/

VACUUUP TO 2 PER DAY

MID EAST COAST - P 714 30 6-8 100

40

(60 MIN)

GRID/

VACUU

1 AT

6:30 AM

NORTHWEST

-P 2000 30

10

(8-15)150

60

(60-90 MIN)

GRID/

VACUU

60-90 MIN

1,2 SITES

STANFORD 1225 60 8-25 23590-120

(2-3 SITES)

FREE-

HAND/VACUU

3 PTS/AM

MULTIPLE

SITES

2008 Breast MRI and MRI2008 Breast MRI and MRI--guided guided Needle Localization BiopsyNeedle Localization Biopsy

FACILITY

#MRI

PER

YR

TIME

TO DO MRI (MIN)

# MRI READPER

DAY

#MRI

BX

PER

YR

TIME TO DO BX (MIN)

HOW

MRI

BX DONE

HOW MANY

MRI BX/

DAY

M MIDWEST

ACADEMIC1000 40 3-6 50 90

GRID/

VACUU

1/ DAY

AS NEED

MID WEST COAST - BR

1200 45 3-8 7090 GRID/

VACUU

1/DAY

2X/WK

MID EAST COAST-B

1000 60 3-6 100 90GRID/

VACUU

3-4/1DAY

7-2 PM

MIDWEST ACADEMIC=H

300 60 2 12 90PILLAR/POST

VACUU

1/DAY

SLOTS FOR 2

Breast MRI and MRIBreast MRI and MRI--BxBxWhat is actually happening in US clinical

practice? – screening, 70% bx

What is breast MRI standard of care?-bilat high spatial and temporal resolution

What are the new BIRADS MRI recommendations for 2010 ACR Atlas?-bilat scans, T2-weighted, background,

kinetics, do bx and combined reporting

What are MRI breast biopsy results? 30-40% TP for cancer

Axial T1 SEAxial T1 SESag DynamicSag Dynamic3D spiral3D spiral

Sag HiSag Hi--Res CentricRes Centric3DSSMT3DSSMT

Axial ReformatAxial Reformat3DSSMT3DSSMT

Methods: 1.5T Diagnostic MRIMethods: 1.5T Diagnostic MRI

Cho

Thank You!Thank You!

Documents

Developments in Breast Imaging: In Memory of Dr. …. Carolyn Kimme -Smith Enhancement Characteristics ... What are the new BIRADS MRI recommendations for 2010 ACR Atlas? What are