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10/4/10
1
Diagnosis of Breast Lesions with MRI
George Trilikis, M.D.
October 2, 2010
Overview
Breast MRI Indications Is breast MRI the best test?
Key concepts to high quality breast MRI What are some things a technologist can do to
improve the chances of answering the clinical question?
Breast MRI findings What is the radiologist looking for?
Is Breast MRI the Best Test?
Indications Guiding principles
Alternatives
Controversies
Indications
The best test depends on what clinical problem one is trying to solve.
Clinical Problem #1
Does my ASYMPTOMATIC patient have breast cancer?
Screening.
Screening bMRI
Principle #1: Earlier detection reduces the risk of dying of breast cancer.
Principle #2: Any test is more accurate when the disease is more common. Therefore, higher risk groups are favored populations for screening.
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High Risk Indications
BRCA1 & BRCA2 & other genetic Mutations
Strong family history of breast and/or ovarian cancer without known mutations—risk models
Prior mantle XRT between 10 & 30 yrs old
Personal history of breast cancer
Personal history of LCIS, ALH or ADH
Mammographic density
Robson M and Offit K. N Engl J Med 2007;357:154-162
Probability of Breast Cancer and Ovarian Cancer during a 10-Year Period
ACS Recommendations Screening bMRI
Alternatives & Controversies: Do nothing
Self breast exam
Clinical breast exam
Mammography
Ultrasound
Clinical Problem #2
Does my SYMPTOMATIC patient have breast cancer? Lump
Skin changes like dimpling, redness, thickening
Nipple discharge Bloody
Clear
Serous
Pain
Symptomatic bMRI
Alternatives & Controversies: Do nothing
Self breast exam
Clinical breast exam
Mammography
Ultrasound
Surgical consultation
Breast MR should not be used as a first line problem solving tool.
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Clinical Problem #3
How much breast cancer is present in my patient with a NEW breast cancer diagnosis?
Local Staging
This use of breast MR for staging varies from surgeon to surgeon and hospital to hospital.
Staging bMRI
Principle #1: Studies show detection of previously undetected contralateral breast cancer in 4% of cases.
Principle #2: MRI detects more breast cancer than mammography and ultrasound.
Principle #3: No studies have proved change in mortality.
Staging bMRI
Alternatives & Controversies: Do nothing
Self breast exam
Clinical breast exam
Mammography
Ultrasound
Surgical consultation
Clinical Problem #4
My patient has breast cancer in an axillary lymph node or distant metastatic disease without any physical, mammographic or other evidence of cancer in the breast—occult primary breast cancer.
Where is the primary breast cancer?
Occult Primary bMRI
Principle #1: MRI can find the tumor about 2/3 of the time.
Principle #2: Gross pathology/Histology can find the tumor about 2/3 of the time.
Occult Primary bMRI
Alternatives & Controversies: Do nothing
Self breast exam
Clinical breast exam
Mammography
Ultrasound
Surgical consultation
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Clinical Problem #5
My patient is getting neoadjuvant chemotherapy. Is the tumor is responding?
Response to therapy.
Response to Therapy bMRI
Principle #1: In theory, if the chemo isn’t working, you could stop it or change to something different.
Pre / Post Example
Demonstrates importance of clip
Response to Therapy bMRI
Alternatives & Controversies: Do nothing
Self breast exam
Clinical breast exam
Mammography
Ultrasound
Surgical consultation
MRI can give us functional information by showing a decrease in the degree of enhancement before a decrease in size.
Clinical Problem #6
Does my patient have recurrent breast cancer?
Similar to SCREENING and SYMPTOMATIC bMRI.
Recurrence
Alternatives & Controversies: Do nothing
Self breast exam
Clinical breast exam
Mammography
Ultrasound
Surgical consultation
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Clinical Problem #7
Are my patient’s SILICONE breast implants intact or ruptured?
Silicone implant rupture
Information for Women About the Safety of Silicone Breast Implants Edited by Martha Grigg, Stuart Bondurant, Virginia L Ernster, and Roger Herdman, Washington (DC): National Academies Press (US); 2000. ISBN: 0-309-06593-3 http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=nap9618 Accessed 10/2/10
• Sagittal T2-weighted short-T1 inversion-recovery MR image (3,000/60 [repetition time msec/echo time msec]) obtained with
fat suppression
• shows intracapsular rupture of a silicone breast implant, as
demonstrated by the linguine sign (arrow).
Safvi A Radiology 2000;216:838-839
©2000 by Radiological Society of North America Copyright © 2007 by the American Roentgen Ray Society
Berg, W. A. et al. Am. J. Roentgenol. 2002;178:465-472
45-year-old woman with extracapsular rupture of 15-year-old subpectoral single-lumen silicone gel implant
Summary of Indications
Most Accepted High Risk Screening
Occult Primary
Silicone Implant Evaluation
Less Widespread Agreement Staging
Response to Therapy
Recurrence Evaluation
Symptomatic Workup
Questions?
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Keys to High Quality (HQ) bMRI
Technologist
Sequences and Resolution
Appropriate clinical history and timing
Patient positioning, comfort and cooperation
HQ: Sequences & Resolution
Breast Cancer Sequences Axial, simultaneous acquisition with FOV & matrix to
allow for sub-millimeter in-plane resolution
Slice width close to 1 mm. No greater than 3 mm.
T1 Non-Fat-Sat
T1 Fat-Sat—Dynamic (Pre & Post)
Subtraction & Reconstruction
T2 Fat-Sat
+/- Diffusion (research)
+/- Spectroscopy (research)
T1 Pre
T1 fat sat
sub
pre post
MIP
HQ: Sequences & Resolution
Breast Implant Sequences Two plane acquisition (axial and sagittal)
T1 for basic anatomy
Axial & Sagittal SILICONE SENSITIVE WATER SAT – ACTIVE
FAT-SAT – INVERSION RECOVERY
T2 for incidentals
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HQ: Clinical History & Timing
Why is the study being done? Screening vs Symptom New Cancer vs Response vs Recurrence Implant Evaluation
What prior imaging has been done? Mammography Ultrasound Comparison MRIs
When & Where was prior imaging done? Outside films Local films
HQ: Technologist
How can I help answer the clinical question? Make sure you know the clinical question!
Document family history if High-Risk Screening
Document Last Menstrual Period if Screening
Mark site of symptoms with fiducial
Mark site of cancer if known/palpable
HQ: Technologist
How can I help speed and accuracy of interpretation?
Document/Clarify Clinical History
Ask about previous imaging and get signed release form
HQ: Patient Factors
Positioning
Comfort
Cooperation
HQ: Positioning
Make sure the coil is adequately open
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HQ: Positioning
Make sure the breast is pulled down into the coil and centered.
HQ: Patient Comfort & Cooperation
Explain how motion can decrease the effectiveness of the exam.
Explain how we want the best exam possible.
Help the patient understand that it’s best to hold still passively rather than actively.
Help the patient get comfortable so they can “relax still.”
Assess patient’s anxiety/buy in/cooperation.
sub MIP
BI-RADS MR Lexicon
Focus/Foci
Mass
Non-Mass-Like Enhancement
Internal Enhancement Patterns
Associated Findings
Lesion Location
Kinetic Curve Assessment
Morphology
Mass = 3D, space occupying lesion Shape
Round
Oval
Lobulated
Irregular
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Morphology
Mass = 3D, space occupying lesion
Shape
Round
Oval
Lobulated
Irregular
Margin Smooth
Irregular
Spiculated
Morphology Mass = 3D, space occupying lesion
Shape
Round
Oval
Lobulated
Irregular
Margin
Smooth
Irregular
Spiculated
Internal Enhancement Characteristics Non Homogeneous Heterogeneous Rim Dark internal septations Enhancing internal septations Central Enhancement
Nunes LW, Schnall MD, Orel SG. Radiology 2001; 219: 484-494.
Morphology?
Nunes LW, Schnall MD, Orel SG. Radiology 2001; 219: 484-494.
Non-Mass Findings Enhancement
Distribution Focal area
Linear
Ductal
Segmental
Regional
Multiple regions
Diffuse
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Non-Mass Findings Enhancement
Distribution
Focal area
Linear
Ductal
Segmental
Regional
Multiple regions
Diffuse
Pattern Homogeneous or inheterogeneous
Heterogeneous or inhomogeneous
Stippled / Punctate
Clumped / Cobblestone
Reticular / Dendritic
Non-Mass Findings Enhancement
Distribution
Focal area
Linear
Ductal
Segmental
Regional
Multiple regions
Diffuse
Pattern
Homogeneous or inheterogeneous
Heterogeneous or inhomogeneous
Stippled / Punctate
Clumped / Cobblestone
Reticular / Dendritic
Symmetry / Asymmetry Laterality
Non-mass Morphology?
Nunes LW, Schnall MD, Orel SG. Radiology 2001; 219: 484-494.
Non-mass Morphology?
Nunes LW, Schnall MD, Orel SG. Radiology 2001; 219: 484-494.
Non-mass Morphology?
Nunes LW, Schnall MD, Orel SG. Radiology 2001; 219: 484-494.
Non-mass Morphology?
Nunes LW, Schnall MD, Orel SG. Radiology 2001; 219: 484-494.
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Non-mass Morphology?
Nunes LW, Schnall MD, Orel SG. Radiology 2001; 219: 484-494.
Non-mass Morphology?
Nunes LW, Schnall MD, Orel SG. Radiology 2001; 219: 484-494.
Nunes LW, Schnall MD, Orel SG, et. al. RadioGraphics 1999; 19: 79-92.
Associated Findings
Nipple retraction or inversion
Pre-contrast high duct signal
Skin retraction
Skin thickening
Skin invasion
Edema
Lymphadenopathy
Pectoralis invasion
Chest wall invasion
Hematoma
Abnormal signal void
Cyst
“Corners” Liver mets, etc.
MR Guided Biopsies
Plan ahead
Touch base with mammo technologists and radiologist performing the biopsy, preferably in the day or two prior to the biopsy, often scheduled early
Double check equipment and expiration dates
Questions?